外科休克

ShockTerm“choc〞–Frenchfor“push〞orimpactwasfirstpublishedin1743bythephysicianLeDranAboutmyselfName:費健Mobile:137-0176-9798開始了大家要專心啊一個例子

八大問題

A22yearoldmanwasdrivingdrunkandwithouthisseatbeltfastenedwhenhewasinvolvedinasingle-vehicleautomobileaccident.WhenattendedbyEMT〔abbr.emergencymedicaltechnician急診醫(yī)士〕personnel,noinformationwasavailableaboutthetimeoftheaccident.Hewasfoundagitatedandcomplainingofabdominalpain.

Hisairwaywaspatent.Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Hewasplacedinahardcervicalcollarandonabackboardandtransportedtoyouremergencyroom.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage〔灌洗〕revealsgrossblood.

StudyQuestions1:

Whattypeofshockdoesthispatientexhibit?

Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage〔灌洗〕revealsgrossblood.

休克的原因和分類按病因?qū)W分類一、失血失液性休克:二、創(chuàng)傷性休克：三、感染性休克：四、心源性休克：五、過敏性休克：六、神經(jīng)源性休克：大出血，腹瀉，劇烈嘔吐等疼痛和失血內(nèi)毒素大面積心肌梗死，心包填塞青霉素，血清制劑或疫苗高位脊髓麻醉或損傷按血流動力學的特點低排高阻型休克〔低動力型休克，冷休克〕高排低阻型休克〔高動力型休克，暖休克〕低血容量性休克失血性休克損傷性休克感染性休克

心源性休克神經(jīng)源性休克過敏性休克休克的分類外科休克StudyQuestions2:

Whatalterationsinoxygendeliveryarepresent?

Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage〔灌洗〕revealsgrossblood.

單位時間內(nèi)通過心血管系統(tǒng)進行循環(huán)的血量--

有效循環(huán)血量不包括貯存在肝、脾、淋巴血竇、淤滯于毛細血管中的血量依賴于充足的血容量有效的心排量良好的周圍血管張力有效循環(huán)血量休克代謝障礙細胞受損組織血液灌注缺乏有效循環(huán)血量銳減微循環(huán)障礙微循環(huán)收縮期微循環(huán)擴張期DIC期休克的病理生理Section2.Localfeedbackregulationofcapillaryperfusion：

ConstrictionofPre-capillaryDecreasedbloodLocalaccumulationofsphincterandPost-arterioleflowofproductsandhistaminetruecapillarynet

IncreasedresponseDecreasedresponseofSMCtoofSMCtoVasoconstrictiveagentsVasoconstrictiveagents

IncreasedbloodClearanceofhistamineandflowofRelaxationofpre-capillarymetabolicproductstruecapillarynetsphincterandpost-arteriole

Constriction

Relaxation真毛細血管開放調(diào)節(jié)示意圖后微動脈與毛細血管前括約肌收縮真毛細血管血流量減少平滑肌對縮血管物質(zhì)反響性升高后微動脈與毛細血管前括約肌舒張真毛細血管血流量增多平滑肌對縮血管物質(zhì)反響性降低休克Ⅰ期〔缺血性缺氧期〕微循環(huán)變化：微血管、毛細血管前括約肌痙攣性收縮,毛細血管缺血、缺氧,動-靜脈短路、直捷通路開放 少灌少流灌少于流

休克Ⅱ期〔淤血性缺氧期〕微循環(huán)變化：微血管擴張，毛細血管前括約肌松弛，靜脈內(nèi)血流緩慢、淤滯，毛細血管淤血、缺氧多灌少流，灌大于流

休克Ⅲ期〔微循環(huán)衰竭期、DIC期〕微循環(huán)變化：微血管麻痹性擴張，毛細血管內(nèi)血流停滯，出現(xiàn)大量的微血栓。

不灌不流

氧代謝動力學監(jiān)測1.全身氧代謝：氧輸送、氧耗量、氧攝取及混合靜脈血 氧分壓①氧輸送(DO2)：單位時間內(nèi)心臟泵血提供給組織細胞的氧量。受三個因素影響，呼吸功能(動脈血氧飽和度和氧分壓)、血紅蛋白、心臟指數(shù)。正常值，500-600ml/min.m2②氧耗量(VO2):單位時間內(nèi)組織器官所消耗的氧量。 160-220ml/min.m2。③氧攝取率(O2ER):單位時間內(nèi)組織的氧耗量占氧輸送 的比率，正常20-30%.④氧需:機體單位時間內(nèi)維持組織細胞正常代謝 所需的氧量。

⑤氧債：機體的氧耗量不能滿足正常代謝，即氧需與氧耗量的差值。⑥血乳酸濃度：血乳酸越高，表示微循環(huán)障礙越重。⑦混合靜脈血氧飽和度(SvO2)或血氧分壓(PvO2):正常值>65%和>40mmHg⑧經(jīng)皮動脈血氧飽和度(SaO2):>94%StudyQuestions3:

Whatacid/basecategorywouldbeexpected?

Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage〔灌洗〕revealsgrossblood.

氧代謝障礙組織細胞缺氧是休克的本質(zhì)問題缺氧無氧代謝增加

ATP生成減少肝功能下降乳酸大量產(chǎn)生 乳酸代謝降低 代謝性酸中毒

組織細胞器功能降低 組織功能降低

MODSStudyQuestions4:

Whatistheeffectofthiskindofshockonthekidneys,theheart,thelungs,thebrain,theintestine?

Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyel