急診上消化道出血共識(shí)解讀王仲

1、2011-03,急性上消化道出血急診診治專家共識(shí),中國(guó)醫(yī)師協(xié)會(huì)急診醫(yī)師分會(huì),急診科特點(diǎn)-多界面的學(xué)科,人多開(kāi)放輕重不一各種病人多項(xiàng)技術(shù)時(shí)間依賴性強(qiáng)……,EMD,消化科,呼吸科,外科,ICU,手術(shù)室,院前急救,保命是我們的第一任務(wù),先開(kāi)槍，后瞄準(zhǔn),急診判斷處理診斷治療,,門(mén)診診斷治療,固定靶射擊與雙向飛碟,上消化道出血概述,急診常見(jiàn)病之一潛在危險(xiǎn)大定義：指屈氏韌帶以上的消化道(食管,胃,十二指腸,

2、 胰腺,膽道)的急性出血,是臨床常見(jiàn)急癥分類：非靜脈曲張性出血、靜脈曲張性出血常見(jiàn)病因：十二指腸潰瘍、胃潰瘍和食管靜脈曲張1,,概述,大多數(shù)急性上消化道出血病人首診于急診科，病人常以頭暈、乏力、暈厥等不典型癥狀就診急診醫(yī)師的職責(zé)：正確、迅速、合理地判斷和診治,哪些病人應(yīng)當(dāng)考慮急性上消化道出血,急性上消化道出血（或疑似）,以典型癥狀就診的患者，容易診斷（嘔血、黑便或血便，伴有周圍循環(huán)功能衰竭） 以不典型癥狀（頭暈

3、、乏力、暈厥等）就診的患者，急診醫(yī)師應(yīng)保持高度警惕，積極明確或排除上消化道出血的診斷2-4,急診就診病人大出血比例高于門(mén)診病人門(mén)脈高壓病人出血更兇猛（6%）部分沒(méi)有肝病史的EVB病人上消化道出血病人以消化性潰瘍居多即使有肝病的病人，70%為潰瘍病出血……,輕與重——我們知道嗎？,大出血病人的緊急處理應(yīng)當(dāng)綜合考慮,他們多長(zhǎng)時(shí)間死亡,即刻數(shù)分鐘數(shù)分鐘至小時(shí)小時(shí)至數(shù)天數(shù)天至數(shù)月數(shù)月至數(shù)十月,心源性猝死窒息大出血（內(nèi)、外

4、）重癥感染腫瘤免疫病,緊急評(píng)估（即刻完成）,患者意識(shí)喪失、呼吸停止及大動(dòng)脈搏動(dòng)不能觸及立即開(kāi)始心肺復(fù)蘇5,,,緊急評(píng)估,對(duì)未出現(xiàn)呼吸心跳停止的病人，首先進(jìn)行意識(shí)狀態(tài)判斷Glassgow評(píng)分≤ 8分，表示病人昏迷，應(yīng)對(duì)呼吸道采取保護(hù)措施,意識(shí)判斷,意識(shí)狀態(tài)評(píng)分表（Glassgow 評(píng)分）,急性血色素下降的結(jié)果,昏迷：自我保護(hù)能力的喪失，包括對(duì)氣道的保護(hù),緊急評(píng)估,A. 氣道,B. 呼吸,C. 循環(huán),急性上消化道出血急診診治流程

5、,急性上消化道出血（或疑似）,緊急處置（2分鐘內(nèi)完成）,心電、血壓、血氧飽和度持續(xù)監(jiān)測(cè)對(duì)嚴(yán)重出血的病人，開(kāi)放靜脈通路，配血，液體復(fù)蘇意識(shí)障礙、排尿困難及所有休克患者留置尿管，記錄尿量患者絕對(duì)臥床，意識(shí)障礙患者將頭偏向一側(cè)，避免誤吸意識(shí)清楚，能夠配合的病人可留置胃管并沖洗肝硬化，食道胃底靜脈曲張出血及配合度差的病人留置胃管時(shí)慎重，避免加重出血7,常規(guī)處理,急性失血的循環(huán)影響,處理原則——保證灌注,,大出血的緊急處置,常用復(fù)蘇液體

6、：生理鹽水、平衡液、人工膠體和血液制品,液體復(fù)蘇,大出血的緊急處置,藥物治療是急性上消化道出血的首選治療手段,病情危重患者，特別是初次發(fā)病，既往病史不詳患者,靜脈應(yīng)用生長(zhǎng)抑素＋質(zhì)子泵抑制劑（PPI）7，17,病因明確之前，可經(jīng)驗(yàn)性聯(lián)合用藥9，12，16,上消化道大出血及高度懷疑靜脈曲張性出血時(shí),血管加壓素＋抗生素14，18，19,以上基礎(chǔ)上聯(lián)用,明確病因后，再根據(jù)具體情況調(diào)整治療方案,初始藥物治療,大出血的緊急處置,常用藥物,,生長(zhǎng)抑

7、素及其類似物,抑酸藥物,血管加壓素及其類似物,抗菌藥物,止血藥物,初始藥物治療,減少血流促進(jìn)凝血,控制損害促進(jìn)凝血,減少血流,促進(jìn)凝血,大出血的緊急處置,生長(zhǎng)抑素——14肽,減少內(nèi)臟血流、降低門(mén)靜脈阻力抑制胃酸和胃蛋白酶分泌抑制胃腸道及胰腺肽類激素分泌,作用機(jī)制,肝硬化急性食道胃底靜脈曲張出血的首選藥物之一20，21急性非靜脈曲張出血的治療9,臨床應(yīng)用,,大出血的緊急處置,A. 可迅速有效控制急性上消化道出血21B.

8、 預(yù)防早期再出血的發(fā)生22，23C. 有效預(yù)防內(nèi)鏡治療后的肝靜脈壓力梯度（HVPG）升高， 從而提高內(nèi)鏡治療的成功率24D. 可顯著降低消化性潰瘍出血患者的手術(shù)率E. 對(duì)于高?；颊撸x用高劑量生長(zhǎng)抑素在改善患者內(nèi)臟血流 動(dòng)力學(xué)、出血控制率和存活率方面均優(yōu)于常規(guī)劑量20，23,特點(diǎn),生長(zhǎng)抑素,大出血的緊急處置,生長(zhǎng)抑素用法,,,用法,大出血的緊急處置,生長(zhǎng)抑素類似物,血管加壓素及其類似物,包括垂體后葉素

9、血管加壓素特利加壓素,抑酸藥物,PPI針劑埃索美拉唑：80mg bolus 80mg/h奧美拉唑: 80mg bolus 80mg/h泮妥拉唑蘭索拉唑雷貝拉唑H2RA雷尼替丁法莫替丁等,提高胃腸道內(nèi)pH值促進(jìn)血凝塊的形成，防止血凝塊溶解促進(jìn)病變部位愈合,緊急處理中的其他藥物,抗菌藥物喹諾酮類抗菌素對(duì)喹諾酮類耐藥者也可使用頭孢類 抗菌素止血藥物：止血藥物的療效尚未證實(shí)，不推薦作為一線藥物使用,急性

10、上消化道大出血急診診治流程,急性上消化道出血（或疑似）,,二次評(píng)估——病因評(píng)估,在解除危及生命的情況、液體復(fù)蘇和初始經(jīng)驗(yàn)治療開(kāi)始后；或初次評(píng)估判斷病情較輕，生命體征穩(wěn)定的病人，開(kāi)始進(jìn)行二次評(píng)估——全面評(píng)估,病史 詳細(xì)詢問(wèn)病史有助于對(duì)出血病因的初步判斷全面查體 重點(diǎn)注意血流動(dòng)力學(xué)狀態(tài)、腹部、慢性肝臟疾病或 門(mén)脈高壓體征、直腸指診實(shí)驗(yàn)室和輔助檢查 血

11、細(xì)胞分析、肝功能、腎臟功能和電解質(zhì)、 凝血功能、血型、心電圖、胸片、腹部超聲,二次評(píng)估,病情嚴(yán)重程度的評(píng)估 病情嚴(yán)重度與失血量呈正相關(guān)。如根據(jù)血容量減少導(dǎo)致周圍循環(huán)的改變來(lái)判斷失血量，休克指數(shù)（心率/收縮壓）是判斷失血量的重要指標(biāo)之一6，15,上消化道出血病情嚴(yán)重程度分級(jí),注：休克指數(shù)=心率/收縮壓,二次評(píng)估,是否存在活動(dòng)性出血的評(píng)估

12、 臨床上出現(xiàn)下列情況考慮有活動(dòng)性出血,,,嘔血或黑便次數(shù)增多，嘔吐物呈鮮紅色或排出暗紅血便，或伴有腸鳴音活躍,經(jīng)快速輸液輸血，周圍循環(huán)衰竭的表現(xiàn)未見(jiàn)明顯改善，或雖暫時(shí)好轉(zhuǎn)而又再惡化，中心靜脈壓仍有波動(dòng)，稍穩(wěn)定又再下降,,,,紅細(xì)胞計(jì)數(shù)、血紅蛋白測(cè)定與Hct 繼續(xù)下降，網(wǎng)織紅細(xì)胞計(jì)數(shù)持續(xù)增高,補(bǔ)液與尿量足夠的情況下，血尿素氮持續(xù)或再次增高,胃管抽出物有較多新鮮血,1,2,3,4,5,二次評(píng)估,出血預(yù)后的評(píng)估,急性上消化道出血急診診治流程,

13、急性上消化道出血（或疑似）,藥物治療,,內(nèi)鏡,內(nèi)鏡檢查為上消化道出血病因診斷的關(guān)鍵檢查47，應(yīng)盡量在出血后24～48h內(nèi)進(jìn)行；藥物與內(nèi)鏡聯(lián)合治療是目前首選的治療方式24，26，47，48，內(nèi)鏡治療方法的選擇請(qǐng)參加消化專業(yè)有關(guān)指南8，13，14，19,急性上消化道出血急診診治流程,急性上消化道出血（或疑似）,緊急處置,二次評(píng)估,藥物治療+內(nèi)鏡聯(lián)合治療,,,,,治療后再次評(píng)估,經(jīng)上述治療后再次評(píng)估患者出血是否得到有效控制。若仍可能存在活動(dòng)性

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