休克-英語解讀第一頁，共43頁。Westernrecordviolentimpactorblow,1743physiologicinstability,1815Easternrecord厥脫，內閉外脫I.HistoricalAspectInitialrecordsofshock第二頁，共43頁。InitialExplanationofshockWesternThomasLatta,1831PatientswithCholeraInfusionoffluids→improvementHypovolemiaEastern邪毒內陷氣隨血脫陰虧氣脫氣機郁閉陰絕陽脫第三頁，共43頁。withtheRiseofPhysiologyBurgeoningofCardiovascularphysiologyintheendof19CN,CrileCVPdroppedafterhemorrhageAnimalsurvivalwasincreasedaftertheinfusionofsalinetheUseofCardiacCatheterizationBloodvolumeloss→fallinCardiacOutput第四頁，共43頁。withtheCombinationof

PhysiologyandBiochemistryToxintheoryofshock,Cannon&Baylissimpairmentofoxygentransportdevelopmentofacidosistoxininseveremuscleinjury→lossofvasomotortone→venoussequestrationofblood→hypotension第五頁，共43頁。AntedatetheEraofCriticalCareMedicineExtensivephysiologicresearchofWigger,inearly1940sintegratingtheConceptsofimpairedoxygendeliveryoxygendebttissueinjury/deaththeconceptofirreversibleshockprogressivesystemiccirculatorydecompensation第六頁，共43頁。ControversyonLung&KidneyARDS

Introductionoftheflowdirectedpulmonaryarterycatheter,in1970

Noncardiogenicnature

NotduetovolumeoverloadARFMorepromptandaggressiveresuscitationIncidence↓ATNhappens:hypoperfusionARDShappens:DefectsinCellMembraneFunctionandVascularPermeabilityHypovolemia/Toxin/CytokineHypoxiaARDS第七頁，共43頁。Asyndromethatresultsfrominadequateperfusionoftissuesinsufficienttomeetmetabolicdemandleadtocellulardysfunction,elaborationofinflammatorymediators,andcelluarinjurywhichmaybelimited,orwidespread

Acontinuum,rangingfromsubclinicaldeficitsinperfusiontoMODSorfrankorganfailure.Tissuehypoxia

duetohypoperfusionDefectsInjuryII.Definitionofshock

第八頁，共43頁。

A.組織低灌注所致細胞缺氧

B.低血壓

C.酸中毒

D.心功能不全

E.以上都不對休克的根本問題是:第九頁，共43頁。ImpairedtissueperfusionWiderspectrumofshockpresentationsRangingfromocculttissuehypoxiatofull-blowncardiovascularcollapseorMultipleorgandysfunctionImplicationalarmearliertreatearlierExplanation第十頁，共43頁。Tissuehypoperfusiontissuehypoxiaanaerobicmetabolism,acidosisinflammatorymediaterscirculatoryredistributionearlyinvolvementofsplanchniccirculationcellularinjurysepticcomplicationsMODSExplanation第十一頁，共43頁。O2DebtWhetherDO2critisincreased

inARDS,orsepsis?Delivery-dependentoxygenuptake=HypoxiacauseMODSsupranormallevelssupplyofO2preventtheprogressionofMODS?ProvidingopportunityforinterventionProvidingtimeforthediseasetosubsiderOxygenconsumption(vO)2Oxygendelivery(DO2)O2DebtExplanation第十二頁，共43頁。CirculatoryredistributionConceptHomeostaticresponsetohypoperfusiontopreserveoxygendeliverytoheartandbrainbyselectivedivertingbloodMechanismcatechols,angiotensionII,Vasopressin,endothelin,TXA2

ConsequenceCellularandorganderangement→MODSBreakdownoftheintestinalepithelialbarrierbacterialandtoxintranslocation→SIRS→MODSExplanation第十三頁，共43頁。intrinsicobstructionofcap.Bedlow-flowstates,hypothermia,andincreasedviscositycap.Sludging:intravascularcoagulation,plateletaggregation,otherintraluminaldebrispreventingRBCfromreachingthetissuesextrinsicobstructionofcap.Bedlocaltissueinflammation,edema,orhemorrhage,ACSvesselwallpermeabilitydeficitThechangesinMicrocirculatary

LevelExplanation第十四頁，共43頁。HypovolemicShockHemorrhage-Plasmalosses-CardiogenicShockIntrinsic-ExtrinsicCompressive-Obstructive-III.ClassificaionofShockTraumaGIBleedingRupturedaneurysmsBurnBowelobstructionMyocardialinfarctionCardiomyopathyValvularHeartDiseaseCardiacRhythmdisturbanceMyocardialdepressionTensionpneumothoraxPericardialtamponadeHighlevelofpositive-pressureventilationPulmonaryembolismSurgicalShock1第十五頁，共43頁。NeurogenicShocke.g.VasogenicShockSIRS,toxin

SepticdespiteadequatefluidresucitationTraumatic

AnaphylacticandAnaphylactoidHypoadrenalSpinalcordinjurySevereheadinjurySpinalcordanesthesiaSurgicalShock2第十六頁，共43頁。TheothersTheremaybea“

”tobefilled.but“cellularshock”,suchaspoisoning,hypoxia,hypoglycemia,isnotthesyndrome,continuum,ortissuehypoxiaduetohypoperfusion,maybeexcludedfromthecategoryofshock.第十七頁，共43頁。各型休克的共同特點是：

A.血壓下降

B.中心靜脈壓下降

C.脈壓縮小

D.尿量減少

E.有效循環血量銳減第十八頁，共43頁。Secondaryvisceralimpairement

Microcirculatorychanges

MetabolicchangesIV.Pathophysiologicstagingofshock第十九頁，共43頁。

MicrocirculatoryStagingMicrocirculatoryconstrictivephaseMicrocirculatorydilatationphaseMicrocirculatoryfailurephase第二十頁，共43頁。后微A微V前括約肌A－V吻合支微動脈微靜脈加重過程——只出不進/只過不進只進不出/進多出少MicrocirculatoryStructure第二十一頁，共43頁。

MetabolicChangesenergymetabolicabnormality無氧糖酵解，產能減少metabolicacidosis引起微血管擴張，等barrierfunctiondefectsofmembrane累及基底膜，細胞膜，溶酶體膜第二十二頁，共43頁。

SecondaryVisceralImpairmentHeartKidneyLungBrainGastrointestinaltractLiver第二十三頁，共43頁。ClinicalStagingShockcompensatorystagenervous,restless,agitation,cool,pale,thirsty,tachycardia,shortofbreathBPnormalorincreased,pulsepressuredecreased,urinaryoutputnormalordecreasedBloodloss<20%，<800ml第二十四頁，共43頁。Shockinhibitingstagefaint,dullness,confusion,comacyanosis,dyspneaextremitiescoldandwet,pulsefastandweakoliguria,anuriaBPdecreased

Bloodloss>20%，>800ml第二十五頁，共43頁。關于休克代償期微循環改變，

下列那一項是錯誤的：

A.動靜脈短路開放

B.直捷通道開放

C.微動脈收縮

D.微靜脈收縮

E.毛細血管內血液淤積第二十六頁，共43頁。V.DiagnosisandpatientmonitoringCausesandPredictionConventionalmonitoringMentalstatusSkintemperatureBloodpressure,PulserateUrinaryoutput(30ml/hr)SpecialmonitoringCVP(<5,5~10cmH2O,>15,>20)Bloodroutinetest/Arterialbloodgasanalysis/ElectrolytesPCWP(6~15mmHg)COCISerumlactateconcentrationArterialbloodgasanalysisDIC:PLT/FDP第二十七頁，共43頁。VI.MeasurementofShock一般緊急處理Urgentmeasurement補充血容量Resuscitation積極處理原發病Treatincitingcauseofshock糾正酸堿平衡失調Controlelectrolytes,andacidbasederangement血管活性藥物的應用Inotropicagent治療DIC，改善微循環TreatDIC,improvemicrocirculation皮質類固醇和其它藥物的應用Corticosteroids心理支持與呵護第二十八頁，共43頁。PCWPCVP<15,Volumeexpansion<10cmH2O<18,Considervolume<14>18Diurese>14Reestablishmentofurinaryoutputtoarateof0.5-1.0mlperkg.PerhourAnormalheartrateandbloodpressureAdequatecapillaryrefillNormalsensoriumNormalCVPandPWCPi.VolumeResuscitation&Initialend-pointsFluidresuscitationEnd-pointreaching第二十九頁，共43頁。OptimizeOxygenDeliveryKeepSaO2>90%

OptimizeCardiacIndex

OptimizeHbSupplysupplementalO2Earlyhemodynamicmonitoring11-13g/dlVentilator,ifnecessaryAssessvolumestatus(preload)ReassessKeep:PCWP15-18mmHg,MAP60-80mmHg,DeliveryindependentO2consumptionGoalmeetGoalnotmeetTreatincitingcauseofshockControlSIRSNutritionalsupportInotropicsupportbetaagonismGoalmeetGoalnotmeetConsiderVasodilator,alphaagonistInitialresuscitationofpatientsinShockPCWP<15,Volumeexpansion<18,Considervolume;>18Diurese第三十頁，共43頁。

A.心功能不全B.血容量不足C.血容量過多D.血管張力升高E.以上都不是休克病人經補液后，血壓仍低。5~10min內經靜脈注入等滲鹽水250ml，如血壓上升，而中心靜脈壓不變，提示：第三十一頁，共43頁。ShockMODSDisturbanceDeath?Timing&Strategy!!!Effort&Effectii.CurrentStrategyforShockSolution第三十二頁，共43頁。Prevention,earlyIdentification,

earlyandspecifictreatmentforShockandMODS感染創傷燒傷SAPSIRS代謝紊亂低氧乏氧代謝休克復蘇失敗痊愈MODS好轉MODS第二次打擊心源性、神經源性因素低血容量血管源性PrimarySecondary（感染）(24h)死亡第三十三頁，共43頁。1.HypovolemicshockSymptomadecreaseinpulsepressuretachycaridaandhypotensionurineoutputfallsnormalskinturgorislostmentalstatuschanges-inaprogressivefashionapprehension,anxiety,completeobtundationCVPdecreaseTreatmentResuscitation&ControltheincitingcauseofshockSpecific第三十四頁，共43頁。2.TraumaticshockTypeVasogenicshockthatbeginsashypovolemicshockCharacter-refractorytofluidreplacementtherapyLargervolumelosses,greaterfluidsequestrationMoreintenseactivationofinflammatorymediatorsDevelopmentofSIRSDevastatingsofttissueinjuriesMachanismincreasingmicrovascularpermeability,ExcessivefluidrequirementFrequentlyRequiremechanicalventilation,PulmonaryarterycathetermonitoringCardiovascularsupportOperationSpecific第三十五頁，共43頁。3.SepticshockTypeVasogenicshock,RefractorytofluidreplacementtherapyDefinitionSepsiswithhypotensiondespiteadequatefluidresuscitationalongwiththepresenceofmanifestationsofhypoperfutionsuchaslacticacidosis,obliguria,oracutealterationinmentalstatusMechanismCytokinesVasodilatation,Increasingmicrovascularpermeability,ExcessivefluidrequirementSpecific第三十六頁，共43頁。

TreatmentofSepticshockResuscitationControlinfectionNormalizationofelectrolytes,acidbasedearangementInotropicagentCorticosteroidsNutritionalsupport,dealwithDIC,organfunctionsupportSpecific第三十七頁，共43頁。4.Anaphylactic

andAnaphylactoidshockMechanismInflammatorymediatorsC3a,C5a,Histamine,Kinnins,ProstaglandinssymptomsVasodilatation,increasedcapillarypermeabilitybronchospasm,airwayedema,circulatorycollapseTreatment縮血管AminophyllineCorticosteroidsAntihistamineImmunologicallyMediated:byIgEantibodyNotImmunologicallyMediated:Radiographiccontrastdyes,narcoticsSpecific第三十八頁，共43頁。

5.CardiogenicShockSymptomWeakorslowpuls