国际创伤生命支持ITLS休克的评估及处理.ppt

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1、Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJInternational Trauma International Trauma Life SupportLife Supportfor Prehospital Care Providersfor Prehospital Care ProvidersSixth Edition Sixth Edition Patricia M.Hicks,MS,NREMTPPatricia M.Hicks,MS,N

2、REMTPRoy Alson,PhD,MD,FACEPRoy Alson,PhD,MD,FACEPDonna Hastings,EMT-PDonna Hastings,EMT-PJohn Emory Campbell,MD,FACEPJohn Emory Campbell,MD,FACEPand Alabama Chapter,and Alabama Chapter,American College of Emergency PhysiciansAmerican College of Emergency PhysiciansChapter 8Chapter 8Shock Evaluation

3、and ManagementShock Evaluation and ManagementCampbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJShock Evaluation and Shock Evaluation and ManagementManagement休克的评估及处理休克的评估及处理休克的评估及处理休克的评估及处理Campbell,International Trauma Life Support,6th Ed.2008 Pearson

4、 Education,Inc.,Upper Saddle River,NJOverview概要概要Four vascular system components of perfusionProgression of shock signs and symptoms休克征状之改变休克征状之改变Three common clinical shock syndromes常见休克种类之征状常见休克种类之征状Hemorrhagic and neurogenic shock pathophysiology 出血性及神经性休克之病理生理2Shock-Campbell,International Trauma

5、 Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJOverview概要概要Controllable and uncontrollable hemorrhage,nonhemorrhagic shock syndromesHemostatic agents凝血剂Current indications for fluid administration 补充体液的指标3Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Edu

6、cation,Inc.,Upper Saddle River,NJShock休克休克Shock-4Perfusion of tissues with oxygenPerfusion of tissues with oxygen(组织灌注组织灌注组织灌注组织灌注,electrolytes(,electrolytes(电解质电解质电解质电解质),),glucose(glucose(血糖份血糖份血糖份血糖份),and fluid),and fluid(体液体液体液体液)becomes inadequate.)becomes inadequate.Campbell,International Trau

7、ma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJPrepared by Harris Lam(A&E Training Centre,R&TSKH)5“Fick”Principle空气中的氧气注入人体细胞可用空气中的氧气注入人体细胞可用”Fick Principle”说明如下：说明如下：畅通的气道畅通的气道Airway 足够的呼吸Breathing 有效的血循环有效的血循环Circulation红血球释放氧气到各细胞红血球释放氧气到各细胞On load OxygenDelivery OxygenOf

8、f load OxygenCampbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJ“Steady state”activityNormal Perfusion正常的灌注正常的灌注6Shock-气体交挽心脏血管网络液量Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJNormal PerfusionShock-

9、7Heart Rate x Stroke Volume =Cardiac OutputHeart Rate x Stroke Volume =Cardiac Output 心跳心跳心跳心跳x x每次收缩的输出量每次收缩的输出量每次收缩的输出量每次收缩的输出量=心输出量心输出量心输出量心输出量Cardiac Output x PVR =Blood PressureCardiac Output x PVR =Blood Pressure心输出量心输出量心输出量心输出量x x血管阻力血管阻力血管阻力血管阻力=血压血压血压血压Campbell,International Trauma Life Sup

10、port,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJPerfusion Preservation保存灌注保存灌注Basic rules of shock management:Maintain airway维持气道畅通Maintain oxygenation and ventilation 维持足够供气及换气Control bleeding where possible制止出血Maintain circulation维持足够血液循环Adequate heart rate and intravascular volume 足够

11、之心跳及血量8Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJShock Progression休克进程休克进程Shock-9Begins with injury,Begins with injury,spreads throughout body,spreads throughout body,multisystem insult to major organsmultisystem insult to major organs开始

12、时身体受伤开始时身体受伤开始时身体受伤开始时身体受伤,继而影响全身继而影响全身继而影响全身继而影响全身,导致各器官受伤害导致各器官受伤害导致各器官受伤害导致各器官受伤害Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJShock Progression休克进程休克进程10Shock-Red blood cells decreasedInadequate perfusionAnaerobic processesHypoxia worsensCatec

13、holamine increasesCell death灌注不足灌注不足无氧呼吸无氧呼吸加速缺氧加速缺氧细胞死亡细胞死亡肾上腺分肾上腺分泌增加泌增加红血球减少红血球减少Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJShockShock is a continuum.休克一开始后持续发生休克一开始后持续发生Signs and symptoms are progressive.征状会慢慢演变出来Many symptoms due to catech

14、olamines.大部征状是因肾上腺素泌造成Cellular process has clinical manifestations.当细胞受影响时会有明显临床征状11Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJShockCompensated and decompensated补尝期及非保尝期补尝期及非保尝期:Older,hypertensive,and/or head injury cannot tolerate hypote

15、nsion for even short time年老,血压高及/或头部受伤者都不能短暂处于血压低12Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJPrepared by Harris Lam(A&E Training Centre,R&TSKH)13Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle R

16、iver,NJHypovolemic ShockCompensated progression补尝期进程补尝期进程Weakness and lightheadedness软弱及头晕Thirst口渴Pallor苍白Tachycardia心跳加速Diaphoresis皮肤浅湿泠Tachypnea呼吸加速Urinary output decreased尿量减少Peripheral pulses weakened周围脉搏减弱14Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Uppe

17、r Saddle River,NJShock ProgressionCompensated to decompensated由补尝期到非保尝期由补尝期到非保尝期Initial rise in blood pressure due to shunting血压升高Initial narrowing of pulse pressure脉搏压收窄Diastolic raised more than systolic收缩压上升较舒张压上怏Prolonged hypoxia leads to worsening acidosis酸中毒Ultimate loss of catecholamine respo

18、nse对肾上腺无返应Compensated shock suddenly“crashes”补尝失败15Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJHypovolemic ShockDecompensated progression非保尝期进程非保尝期进程Hypotension血压低Hypovolemia and/or diminished cardiac outputAltered mental status意识紊乱Decreas

19、ed cerebral perfusion脑组织灌注,acidosis,hypoxia,catecholamine stimulationCardiac arrest心跳停止Critical organ failureSecondary to blood or fluid loss,hypoxia(缺氧),arrhythmia(心律不齐)16Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJClassic Shock PatternEa

20、rly shock早期休克早期休克1525%blood volume失血15-20%Tachycardia心跳加速Pallor苍白Narrowed pulse pressure脉搏压收窄Thirst口渴Weakness软弱Delayed capillary refill 毛细管再充时问延迟Late shock后早期休克后早期休克17Shock-3045%blood volume失血130-45%Hypotension血压下降First sign of“late shock”后早期休克时最早出现征状Weak orno peripheral pulse 周围脉搏变弱或丧失Prolonged cap

21、illary refill毛细管再充时问进一步延迟长Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJCapillary Refill毛细管再充时问进一步延迟毛细管再充时问进一步延迟长长18Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJCapillary Refill19Shock-Ca

22、mpbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJTachycardia心跳加速心跳加速Early sign of illnessmost common最见的疾患早期最见的疾患早期征状征状:Transient rise with anxiety,quickly to normal间歇性Determine underlying causeEarly sign of shock为早期休克征状为早期休克征状:Suspect hemorrhage怀疑出血:su

23、stained rate 100Red flag for shock休克的危俭状态:pulse rate 120No tachycardia does not rule out shock.无脉搏加速无脉搏加速并不能排徐休克并不能排徐休克“Relative bradycardia”相对性心跳过慢20Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJCapnographyLevel ofexhaled CO2 as waveform(Et

24、CO2)呼气呼气CO2 含量含量Typically 3540 mmHgFalling EtCO2 Hyperventilation呼吸过速 or decreased oxygenationEtCO2 75%with penetrating cardiac injury“Becks triad”Shock,muffled heart tones,distended neck veinsManagementRapid safe transport to appropriate facilityCardiac arrest can occur in minutesFluid administrati

25、on by local medical direction38Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJMechanical Shock CausesMyocardial contusionHeart muscle injury and/or cardiac dysrhythmiasRarely causes shock;mostly little or no signsSevere may cause acute heart

26、failure急性心脏衰竭ManagementRapid safe transportCardiac arrest may occur in 510 minutesCardiac monitoring and treat arrhythmiasFluid administration may worsen condition39Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJSpecial SituationsSevere head

27、injury hypovolemic shockGlasgow Coma Score of 8 or lessFluid administrationBP of 120 mmHg systolic to maintain cerebral perfusion pressure of at least 60 mmHg 非出血性的血溶积减少性休克Nonhemorrhagic hypovolemic shockGeneral management same as controllableFluid administration for volume replacement40Shock-Campbe

28、ll,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJSummaryKnowledge about pathophysiology and treatment of shock is essential.Critical condition that leads to death.Assessment and intervention must be rapid.Monitor closely for early signs.Be aware of management controversies.Rely on local medical direction.41Shock-Campbell,International Trauma Life Support,6th Ed.2008 Pearson Education,Inc.,Upper Saddle River,NJDiscussion42Shock-