國(guó)際創(chuàng)傷生命支持ITLS-05-休克的評(píng)估及處理Chapter8-Shock-SC

Chapter8ShockEvaluationandManagementShockEvaluationandManagement

休克的評(píng)估及處理Overview概要FourvascularsystemcomponentsofperfusionProgressionofshocksignsandsymptoms休克征狀之改變Threecommonclinicalshocksyndromes常見(jiàn)休克種類之征狀Hemorrhagicandneurogenicshockpathophysiology

出血性及神經(jīng)性休克之病理生理2Shock-Overview概要Controllableanduncontrollablehemorrhage,nonhemorrhagicshocksyndromesHemostaticagents凝血?jiǎng)〤urrentindicationsforfluidadministration

補(bǔ)充體液的指標(biāo)3Shock-Shock休克Shock-4Perfusionoftissueswithoxygen(組織灌注,electrolytes(電解質(zhì)),glucose(血糖份),andfluid(體液)becomesinadequate.PreparedbyHarrisLam(A&ETrainingCentre,R&TSKH)5“Fick”P(pán)rinciple空氣中的氧氣注入人體細(xì)胞可用”FickPrinciple”說(shuō)明如下：暢通的氣道Airway

足夠的呼吸Breathing

有效的血循環(huán)Circulation紅血球釋放氧氣到各細(xì)胞OnloadOxygenDeliveryOxygenOffloadOxygen“Steadystate”activityNormalPerfusion正常的灌注6Shock-氣體交挽心臟血管網(wǎng)絡(luò)液量NormalPerfusionShock-7HeartRatexStrokeVolume=CardiacOutput

心跳x每次收縮的輸出量=心輸出量CardiacOutputxPVR=BloodPressure心輸出量x血管阻力=血壓PerfusionPreservation保存灌注Basicrulesofshockmanagement:Maintainairway維持氣道暢通Maintainoxygenationandventilation

維持足夠供氣及換氣Controlbleedingwherepossible制止出血Maintaincirculation維持足夠血液循環(huán)Adequateheartrateandintravascularvolume

足夠之心跳及血量8Shock-ShockProgression休克進(jìn)程Shock-9Beginswithinjury,

spreadsthroughoutbody,

multisysteminsulttomajororgans開(kāi)始時(shí)身體受傷,繼而影響全身,導(dǎo)致各器官受傷害ShockProgression休克進(jìn)程10Shock-灌注不足無(wú)氧呼吸加速缺氧細(xì)胞死亡腎上腺分泌增加紅血球減少ShockShockisacontinuum.休克一開(kāi)始后持續(xù)發(fā)生Signsandsymptomsareprogressive.

征狀會(huì)慢慢演變出來(lái)Manysymptomsduetocatecholamines.

大部征狀是因腎上腺素泌造成Cellularprocesshasclinicalmanifestations.當(dāng)細(xì)胞受影響時(shí)會(huì)有明顯臨床征狀11Shock-ShockCompensatedanddecompensated補(bǔ)嘗期及非保嘗期:Older,hypertensive,and/orheadinjurycannottoleratehypotensionforevenshorttime年老,血壓高及/或頭部受傷者都不能短暫處于血壓低12Shock-PreparedbyHarrisLam(A&ETrainingCentre,R&TSKH)13HypovolemicShockCompensatedprogression補(bǔ)嘗期進(jìn)程Weaknessandlightheadedness軟弱及頭暈Thirst口渴Pallor蒼白Tachycardia心跳加速Diaphoresis皮膚淺濕泠Tachypnea呼吸加速Urinaryoutputdecreased尿量減少Peripheralpulsesweakened周?chē)}搏減弱14Shock-ShockProgressionCompensatedtodecompensated由補(bǔ)嘗期到非保嘗期Initialriseinbloodpressureduetoshunting血壓升高Initialnarrowingofpulsepressure脈搏壓收窄Diastolicraisedmorethansystolic收縮壓上升較舒張壓上怏Prolongedhypoxialeadstoworseningacidosis酸中毒Ultimatelossofcatecholamineresponse對(duì)腎上腺無(wú)返應(yīng)Compensatedshocksuddenly“crashes”補(bǔ)嘗失敗15Shock-HypovolemicShockDecompensatedprogression非保嘗期進(jìn)程Hypotension血壓低Hypovolemiaand/ordiminishedcardiacoutputAlteredmentalstatus意識(shí)紊亂Decreasedcerebralperfusion腦組織灌注,

acidosis,hypoxia,catecholaminestimulationCardiacarrest心跳停止CriticalorganfailureSecondarytobloodorfluidloss,hypoxia(缺氧),arrhythmia(心律不齊)16Shock-ClassicShockPatternEarlyshock早期休克15–25%bloodvolume失血15-20%Tachycardia心跳加速Pallor蒼白Narrowedpulsepressure脈搏壓收窄Thirst口渴Weakness軟弱Delayedcapillaryrefill

毛細(xì)管再充時(shí)問(wèn)延遲Lateshock后早期休克17Shock-30–45%bloodvolume失血130-45%Hypotension血壓下降Firstsignof“l(fā)ateshock”后早期休克時(shí)最早出現(xiàn)征狀Weakor

noperipheralpulse

周?chē)}搏變?nèi)趸騿适rolongedcapillaryrefill毛細(xì)管再充時(shí)問(wèn)進(jìn)一步延遲長(zhǎng)CapillaryRefill

毛細(xì)管再充時(shí)問(wèn)進(jìn)一步延遲長(zhǎng)18Shock-CapillaryRefill19Shock-Tachycardia心跳加速Earlysignofillness—mostcommon最見(jiàn)的疾患早期征狀:Transientrisewithanxiety,quicklytonormal間歇性DetermineunderlyingcauseEarlysignofshock為早期休克征狀:Suspecthemorrhage懷疑出血:sustainedrate>100Redflagforshock休克的危儉狀態(tài):pulserate>120Notachycardiadoesnotruleoutshock.無(wú)脈搏加速并不能排徐休克“Relativebradycardia”相對(duì)性心跳過(guò)慢20Shock-CapnographyLevelofexhaledCO2aswaveform(EtCO2)呼氣CO2含量Typically~35–40mmHgFallingEtCO2

Hyperventilation呼吸過(guò)速ordecreasedoxygenationEtCO2<20mmHgMayindicatecirculatorycollapse血循環(huán)失敗Warningsignofworseningshock休克變差訊號(hào)21Shock-ShockSyndromesLow-volumeshock血溶積減少性休克AbsolutehypovolemiaHemorrhagic

orotherfluidlossMechanicalshock機(jī)械性休克22Shock-Obstructive阻塞性CardiactamponadeTensionpneumothoraxMassivepulmonaryembolismCardiogenic心原性MyocardialcontusionMyocardialinfarctionHigh-spaceshock容量增大性休克RelativehypovolemiaNeurogenicshock精神性VasovagalsyncopeSepsis毒血性Drugoverdose藥物中毒Low-VolumeShockAbsolutehypovolemia血溶積減少Largevascularspace血管內(nèi)容積Bloodvesselsholdmorethanactuallyflows.Catecholaminescausevasoconstriction血管收縮.Minorbloodloss:vasoconstrictionsufficientSeverebloodloss:vasoconstrictioninsufficientClinicalpresentation臨床表現(xiàn)“Thready”pulse脈搏柔弱,tachycardia脈速,pale蒼白,flatneckveins頸靜脈扁平23Shock-High-SpaceShockRelativehypovolemia相對(duì)性低血溶量“Vasodilatoryshock”血管澎脹LargeintactvascularspaceInterruptionofsympatheticnervoussystem交感神經(jīng)受阻Lossofnormalvasoconstriction失去血管收縮力;

vascularspacebecomesmuch“toolarge”血管內(nèi)容量增大Clinicalpresentation臨床表現(xiàn)Variesdependentontypeofhigh-spaceshock24Shock-High-SpaceShockTypesNeurogenicshock神經(jīng)性休克Mosttypicallyafterinjurytospinalcord脊椎受傷Injurypreventsadditionalcatecholaminerelease阻礙腎上腺分泌CirculatingcatecholaminesmaybrieflypreserveSepsissyndrome細(xì)菌入血Drugoverdoses藥物過(guò)量andchemicalexposures中毒Suchasnitroglycerin,calciumchannelblockers,antihypertensivemedications降血壓藥,cyanide山埃25Shock-High-SpaceShockNeurogenicshockHypotensionHeartratenormal

orslowSkinwarm,dry,pinkParalysisordeficitNochestmovement

無(wú)胸部起伏,simplediaphragmatic

隔式呼吸Drugoverdose,sepsis26Shock-TachycardiaSkinpaleorflushed血色潮紅Flatneckveins

頸靜脈扁平MechanicalShock

機(jī)械性休克ObstructsbloodflowtoorthroughheartSlowsvenousreturn靜脈回流Decreasescardiacoutput心輸出ClinicalpresentationDistendedneckveinsCyanosisCatecholamineeffects腎上腺素刺激Pallor,tachycardia,diaphoresis27Shock-CurrentShockResearchPrehospitalmanagementresearchHemorrhagicshockduetotraumaand

traumaticbraininjuryinprehospitalenvironmentIntravenoussolutionsHypertonicsaline高濃度鹽水maysupportvascularstatusbypullinginterstitialfluidintovascularspace.Artificialblood人造血productscarryoxygen.28Shock-PASGResearchPneumaticantishockgarment抗休克褲Uncontrollableinternalhemorrhage

duetopenetratinginjury胸部受傷Mayincreasemortality,

especiallyintrathoracicProbablyincreasesbleeding,

deathduetoexsanguination29Shock-FluidAdministrationUncontrollablehemorrhageMayincreasebleedinganddeathDilutesclottingfactors凝血因子減少Earlybloodtransfusion輸血inseverecasesIVfluidscarryalmostnooxygenMoribundtraumapatientsFluidmaybeindicatedtomaintainsomecirculationLocalmedicaldirection30Shock-FluidAdministrationUncontrollablehemo