外科休克

Surgicalshock外科總論胡寅2006-12-11HUYIN第一節(jié)概論休克SHOCK:

機(jī)體有效循環(huán)血容量減少、組織灌注不足，細(xì)胞代謝紊亂和功能受損的綜合征本質(zhì)：氧供障礙\需求增加

→恢復(fù)有效供氧2006-12-11HUYIN現(xiàn)代的觀念序貫性事件亞臨床的灌注不足

——?

多器官功能障礙(MODS)或衰竭(MOF)2006-12-11HUYINDefinition

Shockisasevereconditionthatoccurswhennotenoughbloodflowsthroughthebody,causingverylowbloodpressure,alackofurine,andcellandtissuedamage.

Thiscandamagemultipleorgans.ShockrequiresIMMEDIATEmedicaltreatmentandcangetworseveryrapidly.2006-12-11HUYIN分類心源性休克Cardiogenic

shock低血容量性休克Hypovolemicshock感染中毒性休克Toxicshock過敏性休克Allergicshock神經(jīng)性休克Nervousshock2006-12-11HUYINConsiderations

Majorclassesofshockinclude:Cardiogenicshock

(associatedwithheartproblems)Hypovolemicshock

(causedbyinadequatebloodvolume)Anaphylacticshock

(causedbyallergicreaction)Septicshock

(associatedwithinfections)Neurogenicshock

(causedbydamagetothenervoussystem)2006-12-11HUYINCauses

Heartproblems(suchasheartattackorheartfailure)Lowbloodvolume(aswithheavybleedingordehydration)Changesinbloodvessels(aswithinfectionorsevereallergicreactions)Shockisoftenassociatedwithheavyexternalorinternalbleedingfromaseriousinjury.Spinalinjuriescanalsocauseshock.Toxicshocksyndromeisanexampleofatypeofshockfromaninfection.2006-12-11HUYIN病理生理

微循環(huán)變化

微循環(huán)收縮期

periodofmicrocirculatorycontraction

微循環(huán)擴(kuò)張期

microcirculatoryexpandingperiod

微循環(huán)衰竭期

microcirculatoryfailure2006-12-11HUYIN病理生理

微循環(huán)收縮期神經(jīng)內(nèi)分泌反應(yīng)主動脈弓和頸動脈竇交感-腎上腺素/兒茶酚胺球旁小體腎素-血管緊張素心跳加快、心排出量增加2006-12-11HUYIN病理生理

微循環(huán)收縮期選擇性血管收縮血流重新分配小動、靜脈血管平滑肌/毛細(xì)血管前括約肌毛細(xì)血管后括約肌回心血量下降迷走神經(jīng)抑制的降低滲透壓升高抗利尿激素增加垂體腎上腺皮質(zhì)激素醛固酮分解代謝2006-12-11HUYIN微循環(huán)三條通道動靜脈短路直捷通道營養(yǎng)通路兒茶酚胺乳酸、丙酮酸兒茶酚胺微血栓DIC2006-12-11HUYIN病理生理

微循環(huán)擴(kuò)張期缺氧動靜脈短路/直捷通道開放組織灌注下降更缺氧炎性物質(zhì)血液滯留血漿外滲休克加重2006-12-11HUYIN病理生理

微循環(huán)衰竭期血液滯留酸性環(huán)境高凝狀態(tài)DIC缺氧缺能溶酶體破裂酶釋放細(xì)胞自溶器官功能受損2006-12-11HUYIN病理生理

代謝改變無氧代謝→乳酸鹽/丙酮酸鹽→代謝性酸中毒能量代謝障礙應(yīng)急→兒茶酚胺/腎上腺皮質(zhì)激素→蛋白分解→糖異生血糖升高2006-12-11HUYIN病理生理

介質(zhì)體液因子神經(jīng)內(nèi)分泌因子補體系統(tǒng)激肽系統(tǒng)前列腺素類細(xì)胞因子炎性介質(zhì)（白介素、腫瘤壞死因子氧自由基2006-12-11HUYIN炎癥介質(zhì)釋放和缺血再灌注損傷;releaseofmediatorsofinflammationreperfusioninjury2006-12-11HUYIN病理生理

細(xì)胞與器官內(nèi)臟器官的繼發(fā)性損害

微循環(huán)障礙＞1O小時

多系統(tǒng)器官衰竭M(jìn)SOFMultipleSystemOrganFailure2006-12-11HUYIN肺

內(nèi)皮細(xì)胞—肺間質(zhì)水腫肺泡上皮細(xì)胞——局限性肺不張

—————ARDS腎

抗利尿激素\醛固酮——水鈉潴留腎皮質(zhì)腎小管壞死——腎衰心

冠脈血流少——心肌損害腦、胃腸道、肝2006-12-11HUYIN細(xì)胞的變化膜線粒體內(nèi)質(zhì)網(wǎng)溶酶體2006-12-11HUYIN臨床表現(xiàn)ClinicalManifestation

休克代償期

CompensatoryStageofShock﹝早期休克pre-shockstage﹞煩燥口渴面色蒼白呼吸增快心率80～120次/分收縮壓9.33～12kPa(70～90mmH)脈壓2.6～4.0kPa尿量正常\減少(<25ml/h)比重增高中心靜脈壓(CVP)0.5～10kPa2006-12-11HUYIN臨床表現(xiàn)休克抑制期

inhibitorystageofshock

煩渴面色蒼黃肢體涼濕\\意識模糊昏迷紫紺心率100～140次/分呼吸>25次/分\\脈博細(xì)速>140次/分收縮壓6.67～9.33kPa(50～70mmH)\\呼吸窘迫

脈壓縮小\\收縮壓0～6.6kPa

尿量減少15～25ml/h比重增高\\尿量0～15ml/h

中心靜脈壓(CVP)<0.49kPa\\或>1.96kPa

2006-12-11HUYINSymptoms

Apersoninshockhasextremelylowbloodpressure.Dependingonthespecificcauseandtypeofshock,symptomswillincludeoneormoreofthefollowing:2006-12-11HUYINAnxietyoragitationConfusion

Pale,cool,clammyskin2006-12-11HUYINLowornourineoutput

Bluishlipsandfingernails

Dizziness,light-headedness,orfaintness

2006-12-11HUYINProfusesweating,moistskinRapidbutweakpulseShallowbreathing

Chestpain

Unconsciousness

2006-12-11HUYIN診斷diagnosis病史casehistory臨床表現(xiàn)clinicalsituation2006-12-11HUYIN一般監(jiān)測generamonitoring

意識呼吸腦血流灌注/腦血氧皮溫色澤末梢血循環(huán)

脈率血壓血容量平均動脈壓=舒張壓+1/3脈壓12±0.6kPa

休克指數(shù)=脈率÷收縮壓(mmHg)

尿量腎灌流\血容量

2006-12-11HUYIN一般監(jiān)測generamonitoring精神狀態(tài)mentalstatus皮膚溫度\色澤skintemperature\colour血壓bloodpressure脈率pulserate尿量urinaryvolume2006-12-11HUYIN特殊監(jiān)測specialmonitoring中心靜脈壓

回心血量\右心搏出量肺毛細(xì)血管楔壓

心排出量(CO)心臟指數(shù)(CI)

血氣分析動脈血乳酸鹽

DIC的檢測胃腸黏膜內(nèi)pH值2006-12-11HUYINFirstAid

Call911forimmediatemedicalhelp.Checktheperson'sairway,breathing,andcirculation.Ifnecessary,beginrescuebreathingandCPR.2006-12-11HUYINFirstAidEvenifthepersonisabletobreatheonhisorherown,continuetocheckrateofbreathingatleastevery5minutesuntilhelparrives.2006-12-11HUYINFirstAidIfthepersonisconsciousandDOESNOThaveaninjurytothehead,leg,neck,orspine,placethepersonintheshockposition.Laythepersononthebackandelevatethelegsabout12inches.DONOTelevatethehead.Ifraisingthelegswillcausepainorpotentialharm,leavethepersonlyingflat.2006-12-11HUYINFirstAidGiveappropriatefirstaidforanywounds,injuries,orillnesses.Keepthepersonwarmandcomfortable.Loosentightclothing.2006-12-11HUYINFirstAidIFTHEPERSONVOMITSORDROOLSTurntheheadtoonesidesoheorshewillnotchoke.DothisaslongasthereisNOsuspicionofspinalinjury.Ifaspinalinjuryissuspected,"logroll"himorherinstead.Keeptheperson'shead,neckandbackinlineandrollhimorherasaunit.2006-12-11HUYIN治療treatment;一般緊急治療體位：軀干抬高1O一15°

下肢抬高2O一30°呼吸道通暢吸氧保溫防暑急救2006-12-11HUYIN2006-12-11HUYINDoNot

DONOTgivethepersonanythingbymouth,includinganythingtoeatordrink.DONOTmovethepersonwithaknownorsuspectedspinalinjury.DONOTwaitformildershocksymptomstoworsenbeforecallingforemergencymedicalhelp.2006-12-11HUYIN治療

補充血容量

恢復(fù)有效循環(huán)血量量:

喪失量＋補充量(擴(kuò)大的毛細(xì)血管床質(zhì):

晶體

(等滲液、平衡液)

膠體

(全血、血漿、白蛋白)補液恢復(fù)的標(biāo)準(zhǔn)

(CVP

脈博、血壓、尿量、皮溫、神志)2006-12-11HUYIN治療積極處理原發(fā)病2006-12-11HUYIN治療糾正酸堿失衡低碳酸血癥高乳酸血癥高碳酸血癥碳酸氫鈉的應(yīng)用2006-12-11HUYIN治療

血管活性物質(zhì)的應(yīng)用vasoactivedrugs血管收縮藥

﹝大計量多巴胺多巴酚丁胺去甲腎上腺素

間羥安﹞血管擴(kuò)張藥

﹝酚妥拉明阿托品

硝普鈉小計量多巴胺﹞強(qiáng)心藥

﹝西地蘭﹞2006-12-11HUYIN治療治療DIC改變微循環(huán)

（肝素/氨甲苯酸/阿司匹林）皮質(zhì)類固醇（五大作用）其他

2006-12-11HUYIN治療維護(hù)重要器官的功能防治感染粘膜屏障↓---→腸菌移位2006-12-11HUYIN第二節(jié)低血容量性休克

Hypovolemicshock

定義:

短時間內(nèi)丟失大量全血、血漿或其它液體，超過機(jī)體的代償限度即導(dǎo)致休克綜合征2006-12-11HUYINHypovolemicshock

Hypovolemicshockisanemergencyconditioninwhichseverebloodandfluidlossmakestheheartunabletopumpenoughbloodtothebody.Thistypeofshockcancausemanyorganstostopworking.2006-12-11HUYIN包括:失血性休克

(>20%總血量)

靜脈曲張出血、肝癌破裂、宮外孕…失液性休克

腸梗阻、燒傷…損傷性休克2006-12-11HUYINCauses,incidence,andriskfactors

Losingabout1/5ormoreofthenormalamountofbloodinyourbodycauseshypovolemicshock.Bloodlosscanbeduetobleedingfromcutsorotherinjuryorinternalbleedingsuchasgastrointestinaltractbleeding.Theamountofbloodinyourbodymaydropwhenyoulosetoomanyotherbodyfluids,whichcanhappenwithdiarrhea,vomiting,burns,andotherconditions.2006-12-11HUYINThegreaterandmorerapidthebloodloss,themoreseveretheshocksymptoms.2006-12-11HUYIN病理血容量驟減神經(jīng)內(nèi)分泌心搏加強(qiáng)加快外周/內(nèi)臟血管收縮保持心腦血供腎水鈉儲留口渴少尿失液→細(xì)胞外液丟失血液濃縮創(chuàng)傷感染2006-12-11HUYINSymptoms

Rapidpulse

Pulsemaybeweak(thready)Rapidbreathing

Anxietyoragitation2006-12-11HUYINCool,clammyskin

Weakness

Paleskincolor(pallor)Sweating,moistskin2006-12-11HUYINDecreasedornourineoutput

Lowbloodpressure

Confusion

Unconsciousness

2006-12-11HUYINtests

CBC

CTscanoranx-rayofsuspectedareasEndoscopy

Echocardiogram(heartultrasound)Rightheart(Swan-Ganz)catheterization--canhelptellthedifferencebetweenhypovolemicandanothertypeofshockcalledcardiogenicshock2006-12-11HUYINGastricendoscopy2006-12-11HUYINSwanGanzcatheterization

2006-12-11HUYINCBC(completebloodcount)Thenumberofredbloodcells(RBCs)Thenumberofwhitebloodcells(WBCs)ThetotalamountofhemoglobininthebloodThefractionofthebloodcomposedofredbloodcells(hematocrit)MCV(meancorpuscularvolume)--thesizeoftheredbloodcellsMCH(meancorpuscularhemoglobin)MCHC(meancorpuscularhemoglobinconcentration)plateletcount2006-12-11HUYIN一、失血性休克和失液性休克治療﹙一﹚補充血容量

治療﹙二﹚藥物治療

治療﹙三﹚病因治療

2006-12-11HUYINTreatment

Getimmediatemedicalhelp.Inthemeantime,followthesesteps:Keepthepersoncomfortableandwarm(toavoidhypothermia).Havethepersonlieflatwiththefeetliftedupabout12inchestoincreasecirculation.However,ifthepersonhasfromahead,neck,back,orleginjury,leavehimorherinthepositioninwhichtheywerefoundunlessdoingsoposesotherimmediatedanger.2006-12-11HUYINDonotgivefluidsbymouth.Ifpersonishavinganallergicreaction,treattheallergicreaction,ifyouknowhow.Ifthepersonmustbecarried,trytokeephimorherflat,withtheheaddownandfeetliftedup.Stabilizetheheadandneckbeforemovingapersonwithasuspectedspinalinjury.2006-12-11HUYINThegoalofhospitaltreatmenttoreplacebloodandfluids.Anintravenous(IV)linewillbeputintothepersonsarmtoallowbloodorbloodproductstobegiven.Medicinessuchasdopamine,dobutamine,epinephrine,andnorepinephrinemaybeneededtoincreasebloodpressureandtheamountofbloodpumpedoutoftheheart(cardiacoutput).2006-12-11HUYINOthermethodsthatmaybeusedCardiacmonitoring,includingSwan-GanzcathertizationUrinarycathetertocollectandmonitorhowmuchurineisproduced2006-12-11HUYIN補充血容量依據(jù)休克的程度或休克指數(shù)(血壓、cvp)紅細(xì)胞比積(3O%)血清白蛋白(白蛋白＜3g／dl)2006-12-11HUYIN中心靜脈壓和動脈壓變化的處理原則2006-12-11HUYIN成人(體重50~70公斤)45分鐘內(nèi)平衡鹽液(等滲鹽水)1000~1500ml中分子右旋糖酐、羥乙基淀粉(<1000ml)血漿、白蛋白2006-12-11HUYIN補液方法:先晶體后膠體交替補液2006-12-11HUYIN藥物應(yīng)用

5%碳酸氫鈉→酸中毒

1O%氯化鉀→胃腸梗阻葡萄糖酸鈣→大量輸血血管活性藥高滲鹽水→“頑固性”休克

5～7﹒5%氯化鈉(50ml×8.v.q1/2h)

2006-12-11HUYIN病因治療非手術(shù)止血法三腔管氣囊口服硫酸高鐵靜滴垂體后葉素手術(shù)止血法2006-12-11HUYINExpectations(prognosis)

Hypovolemicshockisalwaysamedicalemergency,butthereiswidevariationinbothsymptomsandoutcomesdependingupontheamountofbloodvolumelost,therateofloss,theunderlyingillnessorinjurycausingtheloss,andotherfactors.2006-12-11HUYINIngeneral,patientswithmilderdegreesofshocktendtodobetterthanthosewithmoresevereshock.However,incasesofseverehypovolemicshock,deathispossibleevenwithimmediatemedicalattention.Theelderlyareatincreasedriskofhavingpooroutcomesfromshock.2006-12-11HUYIN二、創(chuàng)傷性休克

traumaticshock病因和預(yù)防急性出血炎性腫脹滲出擠壓傷心血管功能障礙氣胸心包填塞其它

脊癱2006-12-11HUYIN治療

輸液輸血/肺水腫糾正酸堿失衡藥物治療血管活性藥利尿劑碳酸氫鈉抗生素

創(chuàng)傷處理2006-12-11HUYIN第三節(jié)

感染性休克septicshock定義:

急性嚴(yán)重感染引起的休克

(革蘭氏陰性菌革蘭氏陽性菌霉菌、病毒)2006-12-11HUYINAlternativenames

Bacteremicshock;Endotoxicshock;Septicemicshock;Warmshock2006-12-11HUYINDefinitionSepticshockisaseriousconditionthatoccurswhenanoverwhelminginfectionleadstolowbloodpressureandlowbloodflow.Thebrain,heart,kidneys,andlivermaynotworkproperlyormayfail.2006-12-11HUYINCauses,incidence,andriskfactors

Septicshockoccursmostoftenintheveryoldandtheveryyoung.Italsooccursinpeoplewhohaveotherillnesses.2006-12-11HUYINCauses,incidence,andriskfactors

Anytypeofbacteriacancausesepticshock.Fungiand(rarely)virusesmayalsocausethecondition.Toxinsreleasedbythebacteriaorfungusmaycause

tissuedamage,andmayleadtolowbloodpressureandpoororganfunction.Manyresearchersbelievethatabnormalbloodclotsinsmallarteriescausethelackofbloodflowandpoororganfunction.2006-12-11HUYIN病理

Gˉ桿菌→內(nèi)毒素━━━━━━━━━━┓↓←補體、抗體↓

交感神經(jīng)組胺激肽前列腺素

↓↓

血管痙攣內(nèi)皮損傷炎性反應(yīng)

↓↓

微循環(huán)障礙代謝紊亂器官功能障礙2006-12-11HUYINThetoxinsalsocauseastronginflammatoryresponsefromthebody,whichcontributestosepticshock.

2006-12-11HUYIN全身炎性反應(yīng)綜合征SIRS體溫>38OR<36心率>90次/分呼吸急促>20次/分PaCO2<4.3kPa白細(xì)胞計數(shù)>12*109/L

SystemicInflammatoryResponseSyndrome

2006-12-11HUYINRiskfactorsforsepticshockincludeDiabetes

DiseasesthatweakentheimmunesystemsuchasAIDSLymphomaLeukemiaDiseasesofthegenitourinarysystem,biliarysystem,orintestinalsystemRecentinfectionLong-termuseof

antibioticsRecentsurgery

ormedicalprocedure.2006-12-11HUYINSymptomsHighorverylowtemperature,chillsLightheadednessShortnessofbreathPalpitationsCool,paleextremitiesRestlessness,agitation,lethargy,orconfusionRapidheartrateLowbloodpressure,especiallywhenstandingLowurineoutput(duetokidneyfailure)2006-12-11HUYIN臨床表現(xiàn)原有的感染病變(敗血癥)休克表現(xiàn)冷休克低排高阻型熱休克高排低阻型并發(fā)系統(tǒng)器官衰竭(DIC、ARDS)

2006-12-11