國際創(chuàng)傷生命支持itls休克的評估及處理

1、Chapter 8Shock Evaluation and Management,Shock Evaluation and Management休克的評估及處理,Overview概要,Four vascular system components of perfusionProgression of shock signs and symptoms休克征狀之改變Three common clinical shock syndr

2、omes常見休克種類之征狀Hemorrhagic and neurogenic shock pathophysiology 出血性及神經(jīng)性休克之病理生理,2,Shock -,Overview概要,Controllable and uncontrollable hemorrhage, nonhemorrhagic shock syndromesHemostatic agents凝血劑Current indications

3、for fluid administration 補充體液的指標,3,Shock -,Shock休克,Shock -,4,Perfusion of tissues with oxygen(組織灌注, electrolytes (電解質(zhì)),glucose(血糖份), and fluid(體液) becomes inadequate.,Prepared by Harris Lam (A&E Training Centr

4、e, R&TSKH),5,“Fick” Principle,空氣中的氧氣注入人體細胞可用 ”Fick Principle”說明如下：暢通的氣道Airway 足夠的呼吸Breathing 有效的血循環(huán)Circulation紅血球釋放氧氣到各細胞,,,,,On load Oxygen,,Delivery Oxygen,,Off load Oxygen,“Steady state” activity,N

5、ormal Perfusion正常的灌注,6,Shock -,氣體交挽,心臟,血管網(wǎng)絡,液量,Normal Perfusion,Shock -,7,Heart Rate x Stroke Volume = Cardiac Output 心跳x每次收縮的輸出量=心輸出量Cardiac Output x PVR = Blood Pressure心輸出量x血管阻力 =血壓,Perfusion Preservation保存

6、灌注,Basic rules of shock management:Maintain airway維持氣道暢通Maintain oxygenation and ventilation 維持足夠供氣及換氣Control bleeding where possible制止出血Maintain circulation維持足夠血液循環(huán)Adequate heart rate and intravascular volume

7、 足夠之心跳及血量,8,Shock -,Shock Progression休克進程,Shock -,9,Begins with injury, spreads throughout body, multisystem insult to major organs開始時身體受傷,繼而影響全身,導致各器官受傷害,Shock Progression休克進程,10,Shock -,灌注不足,無氧呼吸,加速缺氧,細胞死亡,腎上腺分泌增加,

8、紅血球減少,Shock,Shock is a continuum.休克一開始后持續(xù)發(fā)生Signs and symptoms are progressive. 征狀會慢慢演變出來Many symptoms due to catecholamines. 大部征狀是因腎上腺素泌造成Cellular process has clinical manifestations.當細胞受影響時會有明顯臨床征狀,11,Shock -

9、,Shock,Compensated and decompensated補嘗期及非保嘗期:Older, hypertensive, and/or head injury cannot tolerate hypotension for even short time年老,血壓高及/或頭部受傷者都不能短暫處于血壓低,12,Shock -,Prepared by Harris Lam (A&E Training Centre,

10、R&TSKH),13,Hypovolemic Shock,Compensated progression補嘗期進程Weakness and lightheadedness軟弱及頭暈Thirst口渴Pallor蒼白Tachycardia心跳加速Diaphoresis皮膚淺濕泠Tachypnea呼吸加速Urinary output decreased尿量減少Peripheral pulses weakened周圍脈搏

11、減弱,14,Shock -,Shock Progression,Compensated to decompensated由補嘗期到非保嘗期Initial rise in blood pressure due to shunting血壓升高Initial narrowing of pulse pressure脈搏壓收窄Diastolic raised more than systolic收縮壓上升較舒張壓上怏Prolonged

12、hypoxia leads to worsening acidosis酸中毒Ultimate loss of catecholamine response對腎上腺無返應Compensated shock suddenly “crashes”補嘗失敗,15,Shock -,Hypovolemic Shock,Decompensated progression非保嘗期進程Hypotension血壓低Hypovolemia and/o

13、r diminished cardiac outputAltered mental status意識紊亂Decreased cerebral perfusion腦組織灌注, acidosis, hypoxia, catecholamine stimulationCardiac arrest心跳停止Critical organ failureSecondary to blood or fluid loss, hypoxia (

14、缺氧), arrhythmia (心律不齊),16,Shock -,Classic Shock Pattern,Early shock早期休克,15–25% blood volume失血15-20%Tachycardia心跳加速Pallor蒼白Narrowed pulse pressure脈搏壓收窄Thirst口渴Weakness軟弱Delayed capillary refill 毛細管再充時問延遲,Late

15、 shock后早期休克,17,Shock -,30–45% blood volume失血130-45%Hypotension血壓下降First sign of “l(fā)ate shock”后早期休克時最早出現(xiàn)征狀Weak orno peripheral pulse 周圍脈搏變?nèi)趸騿适rolonged capillary refill毛細管再充時問進一步延遲長,Capillary Refill毛細管再充時問進一步延遲長,18,S

16、hock -,Capillary Refill,19,Shock -,Tachycardia心跳加速,Early sign of illness—most common最見的疾患早期征狀:Transient rise with anxiety, quickly to normal間歇性Determine underlying causeEarly sign of shock為早期休克征狀:Suspect hemorrhage懷疑

17、出血: sustained rate >100Red flag for shock休克的危儉狀態(tài):pulse rate >120No tachycardia does not rule out shock.無脈搏加速并不能排徐休克“Relative bradycardia”相對性心跳過慢,20,Shock -,Capnography,Level ofexhaled CO2 as waveform (EtCO2)呼氣C

18、O2 含量Typically ~35–40 mmHgFalling EtCO2 Hyperventilation呼吸過速 or decreased oxygenationEtCO2 <20mmHgMay indicate circulatory collapse血循環(huán)失敗Warning sign of worsening shock休克變差訊號,21,Shock -,Shock Syndromes,Low-v

19、olume shock血溶積減少性休克,Absolute hypovolemiaHemorrhagic or other fluid loss,Mechanical shock機械性休克,22,Shock -,Obstructive阻塞性Cardiac tamponadeTension pneumothoraxMassive pulmonary embolismCardiogenic心原性Myocardial contu

20、sionMyocardial infarction,High-space shock容量增大性休克,Relative hypovolemiaNeurogenic shock精神性Vasovagal syncopeSepsis毒血性Drug overdose藥物中毒,Low-Volume Shock,Absolute hypovolemia血溶積減少Large vascular space血管內(nèi)容積Blood vessel

21、s hold more than actually flows.Catecholamines cause vasoconstriction血管收縮.Minor blood loss: vasoconstriction sufficientSevere blood loss: vasoconstriction insufficientClinical presentation臨床表現(xiàn)“Thready” pulse脈搏柔弱, ta

22、chycardia脈速, pale蒼白, flat neck veins頸靜脈扁平,23,Shock -,High-Space Shock,Relative hypovolemia相對性低血溶量“Vasodilatory shock”血管澎脹Large intact vascular spaceInterruption of sympathetic nervous system 交感神經(jīng)受阻Loss of normal v

23、asoconstriction失去血管收縮力; vascular space becomes much “too large”血管內(nèi)容量增大Clinical presentation臨床表現(xiàn)Varies dependent on type of high-space shock,24,Shock -,High-Space Shock Types,Neurogenic shock神經(jīng)性休克Most typically after

24、injury to spinal cord脊椎受傷Injury prevents additional catecholamine release阻礙腎上腺分泌Circulating catecholamines may briefly preserveSepsis syndrome細菌入血Drug overdoses藥物過量and chemical exposures中毒Such as nitroglycerin, calc

25、ium channel blockers, antihypertensive medications降血壓藥, cyanide山埃,25,Shock -,High-Space Shock,Neurogenic shock,HypotensionHeart rate normal or slowSkin warm, dry, pinkParalysis or deficitNo chest movement 無胸部起伏,

26、simple diaphragmatic隔式呼吸,Drug overdose, sepsis,26,Shock -,TachycardiaSkin pale or flushed 血色潮紅Flat neck veins 頸靜脈扁平,Mechanical Shock機械性休克,Obstructs blood flow to or through heartSlows venous return靜脈回流Decreas

27、es cardiac output心輸出Clinical presentationDistended neck veinsCyanosisCatecholamine effects腎上腺素刺激Pallor, tachycardia, diaphoresis,27,Shock -,Current Shock Research,Prehospital management researchHemorrhagic shock du

28、e to trauma and traumatic brain injury in prehospital environmentIntravenous solutionsHypertonic saline高濃度鹽水may support vascular status by pulling interstitial fluid into vascular space. Artificial blood人造血products c

29、arry oxygen.,28,Shock -,PASG Research,Pneumatic antishock garment抗休克褲Uncontrollable internal hemorrhage due to penetrating injury胸部受傷May increase mortality, especially intrathoracicProbably increases bleeding, deat

30、h due to exsanguination,29,Shock -,Fluid Administration,Uncontrollable hemorrhageMay increase bleeding and deathDilutes clotting factors凝血因子減少Early blood transfusion輸血in severe casesIV fluids carry almost no oxygenM

31、oribund trauma patientsFluid may be indicated to maintain some circulationLocal medical direction,30,Shock -,Fluid Administration,Uncontrollable hemorrhageMaintain peripheral perfusion 維持足夠周圍血管血液灌注Peripheral pulse

32、周圍脈搏Higher systolic may be required with increased ICP or with history of hypertensionMaintaining consciousness維持傷者清醒In absence of traumatic brain injury“Adequate blood pressure”足夠血壓Controversial with ongoing resea

33、rchLocal medical direction,31,Shock -,Fluid Administration,Internal hemorrhage內(nèi)出血from blunt trauma挫傷Large-bone fractures主要骨折Usually self-limiting bleed自行止血, except pelvisFluid administration for volume expansion補充體液

34、Large internal blood vessel tear,嚴重內(nèi)臟血管撕裂or laceration or avulsion of internal organ器官撕裂Fluid may increase bleeding and death輸液可增加內(nèi)出血及死亡率Fluid administration to maintain peripheral perfusion保持輸液量至僅維持周圍脈搏Local medical

35、 direction,32,Shock -,Controllable Hemorrhage,ManagementControl bleeding制止出血Shock positionHigh-flow oxygen給高濃度氧氣Rapid safe transport速送醫(yī)院Large-bore IV access用粗靜脈輸液管Fluid bolus 20 ml/kg rapidly快速輸液, repeat if necessa

36、ryCardiac monitor監(jiān)察心跳, SpO2血含氧量 , EtCO2CO2 呼出量Ongoing Exam持續(xù)監(jiān)察,33,Shock -,Uncontrollable Hemorrhage,Management: ExternalControl bleedingShock positionHigh-flow oxygenRapid safe transportLarge-bore IV accessFlui

37、d administrationCardiac monitor, SpO2, EtCO2Ongoing Exam,34,Shock -,Uncontrollable Hemorrhage無法制止之出血,Management: InternalRapid safe transportShock positionHigh-flow oxygenLarge-bore IV accessFluid administration

38、Cardiac monitor, SpO2, EtCO2Ongoing Exam,35,Shock -,High-Space Shock,ManagementHigh-flow oxygenShock positionRapid safe transportLarge-bore IV accessFluid bolus 20 ml/kg rapidlyConsider vasopressors血管加壓素for vasodi

39、latory shockCalcium channel blocker overdose or sepsisOngoing Exam,36,Shock -,Mechanical Shock,Tension pneumothoraxVena cava collapses下腔靜脈阻塞, prevents venous returnMediastinal shift中隔移位lowers venous returnTracheal d

40、eviation away from affected side 氣管移位到對側(cè)Decreased cardiac outputManagementChest decompressionPrompt decompression of pleural pressure,37,Shock -,Mechanical Shock Causes,Cardiac tamponadeBlood fills “potential” s

41、pace; prevents heart fillingMay occur >75% with penetrating cardiac injury“Beck’s triad”Shock, muffled heart tones, distended neck veinsManagementRapid safe transport to appropriate facilityCardiac arrest can oc

42、cur in minutesFluid administration by local medical direction,38,Shock -,Mechanical Shock Causes,Myocardial contusionHeart muscle injury and/or cardiac dysrhythmiasRarely causes shock; mostly little or no signsSevere

43、 may cause acute heart failure急性心臟衰竭ManagementRapid safe transportCardiac arrest may occur in 5–10 minutesCardiac monitoring and treat arrhythmiasFluid administration may worsen condition,39,Shock -,Special Situatio

44、ns,Severe head injury hypovolemic shockGlasgow Coma Score of 8 or lessFluid administrationBP of 120 mmHg systolic to maintain cerebral perfusion pressure of at least 60 mmHg 非出血性的血溶積減少性休克Nonhemorrhagic hypovolemi

45、c shockGeneral management same as controllableFluid administration for volume replacement,40,Shock -,Summary,Knowledge about pathophysiology and treatment of shock is essential.Critical condition that leads to death.