国际创伤生命支持ITLS-05-休克的评估及处理Chapter8_Shock_SC

Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJInternationalTraumaLifeSupportforPrehospitalCareProvidersSixthEditionPatriciaM.Hicks,MS,NREMTPRoyAlson,PhD,MD,FACEPDonnaHastings,EMT-PJohnEmoryCampbell,MD,FACEPandAlabamaChapter,AmericanCollegeofEmergencyPhysiciansChapter8ShockEvaluationandManagementCampbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJShockEvaluationandManagement休克的评估及处理Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJOverview概要FourvascularsystemcomponentsofperfusionProgressionofshocksignsandsymptoms休克征状之改变Threecommonclinicalshocksyndromes常见休克种类之征状•Hemorrhagicandneurogenicshockpathophysiology出血性及神经性休克之病理生理2Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJOverview概要Controllableanduncontrollablehemorrhage,nonhemorrhagicshocksyndromes•Hemostaticagents凝血剂•Currentindicationsforfluidadministration补充体液的指标3Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJShock休克Shock-4Perfusionoftissueswithoxygen(组织灌注,electrolytes(电解质),glucose(血糖份),andfluid(体液)becomesinadequate.Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJPreparedbyHarrisLam(A&ETrainingCentre,R&TSKH)5“Fick”Principle空气中的氧气注入人体细胞可用”FickPrinciple”说明如下：畅通的气道Airway足够的呼吸Breathing有效的血循环Circulation红血球释放氧气到各细胞OnloadOxygenDeliveryOxygenOffloadOxygenCampbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJ“Steadystate”activityNormalPerfusion正常的灌注6Shock-气体交挽心脏血管网络液量Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJNormalPerfusionShock-7HeartRatexStrokeVolume=CardiacOutput心跳x每次收缩的输出量=心输出量CardiacOutputxPVR=BloodPressure心输出量x血管阻力=血压Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJPerfusionPreservation保存灌注Basicrulesofshockmanagement:•Maintainairway维持气道畅通•Maintainoxygenationandventilation维持足够供气及换气•Controlbleedingwherepossible制止出血•Maintaincirculation维持足够血液循环•Adequateheartrateandintravascularvolume足够之心跳及血量8Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJShockProgression休克进程Shock-9Beginswithinjury,spreadsthroughoutbody,multisysteminsulttomajororgans开始时身体受伤,继而影响全身,导致各器官受伤害Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJShockProgression休克进程10Shock-RedbloodcellsdecreasedInadequateperfusionAnaerobicprocessesHypoxiaworsensCatecholamineincreasesCelldeath灌注不足无氧呼吸加速缺氧细胞死亡肾上腺分泌增加红血球减少Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJShockShockisacontinuum.休克一开始后持续发生•Signsandsymptomsareprogressive.征状会慢慢演变出来•Manysymptomsduetocatecholamines.大部征状是因肾上腺素泌造成•Cellularprocesshasclinicalmanifestations.当细胞受影响时会有明显临床征状11Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJShockCompensatedanddecompensated补尝期及非保尝期:•Older,hypertensive,and/orheadinjurycannottoleratehypotensionforevenshorttime•年老,血压高及/或头部受伤者都不能短暂处于血压低12Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJPreparedbyHarrisLam(A&ETrainingCentre,R&TSKH)13Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJHypovolemicShockCompensatedprogression补尝期进程•Weaknessandlightheadedness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•Urinaryoutputdecreased尿量减少•Peripheralpulsesweakened周围脉搏减弱14Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJShockProgressionCompensatedtodecompensated由补尝期到非保尝期•Initialriseinbloodpressureduetoshunting血压升高•Initialnarrowingofpulsepressure脉搏压收窄•Diastolicraisedmorethansystolic收缩压上升较舒张压上怏•Prolongedhypoxialeadstoworseningacidosis酸中毒•Ultimatelossofcatecholamineresponse对肾上腺无返应•Compensatedshocksuddenly“crashes”补尝失败15Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJHypovolemicShockDecompensatedprogression非保尝期进程•Hypotension血压低•Hypovolemiaand/ordiminishedcardiacoutput•Alteredmentalstatus意识紊乱•Decreasedcerebralperfusion脑组织灌注,acidosis,hypoxia,catecholaminestimulation•Cardiacarrest心跳停止•Criticalorganfailure–Secondarytobloodorfluidloss,hypoxia(缺氧),arrhythmia(心律不齐)16Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJClassicShockPatternEarlyshock早期休克•15–25%bloodvolume失血15-20%•Tachycardia心跳加速•Pallor苍白•Narrowedpulsepressure脉搏压收窄•Thirst口渴•Weakness软弱•Delayedcapillaryrefill毛细管再充时问延迟Lateshock后早期休克17Shock-•30–45%bloodvolume失血130-45%•Hypotension血压下降•Firstsignof“lateshock”后早期休克时最早出现征状•Weakornoperipheralpulse周围脉搏变弱或丧失•Prolongedcapillaryrefill毛细管再充时问进一步延迟长Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonEducation,Inc.,UpperSaddleRiver,NJCapillaryRefill毛细管再充时问进一步延迟长18Shock-Campbell,InternationalTraumaLifeSupport,6thEd.©2008PearsonE