休克英文课件.pptx
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休克英文课件.pptx
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SHOCK,ShenHongZhejiangUniversitySchoolofMedicine.,HistoricalAspects,Theconceptofshockhasevolvedoverthecenturiesfromtheearliestdescriptioninantiquityoftraumaticwoundsandhemorrhage.Hippocraticfacies(460380B.C.):
tourniguet.BloodlettingGalen(A.D.130200):
erroneousknowledgeofanatomy.Ligationofbleedingvessels,Vesalius.WilliamHarvey(16centuries):
anatomyandcirculationofthecardiovascularsystemAFrenchmilitarysurgeon:
theuseofsimplebandagesThomasLatta:
in1831.infusionofintravenousfluidsintohypo-volemicpatientsinflictedwithcholeracausedclinicalimprovent.,Pathogenesis:
vasomotorexhaustion:
neurogenictheorytraumatictoxemia:
cannon.Bay(WorldWarI)hypovolemia:
Keith,Blalock(experimentsondogs)fatembolism;acidosisadrenaldysfunction,Pathogenesis:
resuscitation,individualargandysfunction,cellularderangements(Korean,Vietnamconflict).Shocklung.ARDSmolecularbiology,inflammatorymediator,metabolicsupport,oxygendelivery,organischemia,sepsis.,II.Definitionofshock,Asyndromeresultsfrominadequateperfusionoftissuesalterationsincellularmetabolism,cellulardysfunctionandcellularinjury,MODSduetotissuehyperfusion,hypoxia.Oxygendelivery;oxygendebt;oxygendemandexceedstheoxygensupply.,III.Cause,classificationofshock,1.hypovolemicshock,1)hemorrhagiclosses:
trauma,gastrointestinalbleedingrupturedaneurysm.2)plasmavolumelosses:
extravascularfluidsequestration,pancreatitis,burns,bowelobstruction.,2.cardiogenicshock,dinminishedcardiacoutputintrinsiccauseextrinsiccausemyocardialinfarctioncardiacrhythmdisturbances.Tensionpneumothoraxpericardialtamponade,3.neurogenicshock,failureofthesympatheticnervoussystemtomaintainnormalvasculartone.Spinalcordinjury,severeheadinjury.Spinalanesthesia,4.vasogenic,endogenousorexogenousvaso-activemediatorssystemicinflammatoryresponsesyndrome(SIRS)sepsis(infectious)noninfectiousAnaphylacticHypoadrenaltraumatic,IV.Pathophysiologyofshock,ImpairedtissueperfusionTissuehypoxia,AnaerobicmetabolismAcidosis,CellulardysfunctionSIRS/SepsisMultipleorgandysfunctionsyndrome,InflammatoryMediators,CirculatoryredistributionIschemia/Reperfusion,Pathophysiology:
RoleofhypoxiaAnaerobicmetabolismandacidosisHyperlactatemiaCirculatoryredistributionImpairmentofgutperfusion,Anaerobicmetabolismandacidosis,Glucose,Glycogen,lactate,Pyruvate,AcetylCoA,CitricAcidcycle,cytosolmitochondria,Aerobicglycolysis,Anaerobicglycolysis,Circulatoryredistribution,Vaso-constrictivefactors:
Catechol,angiotensinII,vasopressin,endothelin,thromboxanA2Vaso-dilatory:
Nitricoxide,prostaglandinE2,prostacyclin,interleukin-2,bradykinin.,Impairmentofgutperfusion:
SubsequentbacterialortoxintranslocationSystemicinflammatoryresponse,MODS,I.baroreceptors,Vasomotorcenter(medulla)SympatheticneuraloutputIncreasedsystemicvascularresistanceIncreasedvenousreturntotheheartArteriolarvasoconstriction(cutaneoustissue.Skeletalmuscle.Renalandsplanchnicvascularbeds),II.adrenalmedullaryoutput,tachycardia,enhancedcardiaccontractility,III.Antidiuretichormone(posteriorpituitary),VasoconstrictionWaterreabsorptioninthedistaltubuleofthekidney,IV.rennin(kidney),AngiotensinI(liver)AngiotensinII(lungs)vasoconstrictoraldosterone(adrenalcortex)reabsorptionofsodium,V.microcirculatoryautoregulation,Mediatorofshockandsepsis,EndotoxinComplementfragmentsEicosanoidsLeukotrienes,Prostaglandins,ThrobomxanesCytokines:
Interleukins(IL1,IL2,IL6);TNF-a;CSF,GCSF,GM-CSF;IFN-rNeuroendocrinemediators:
catechols,cortisol,glucagons,V.diagosisandmanagementofshock:
Generalapproach,KeepSaO290%,OptimizecardiacindexMayneedearlyhemodynamicmonitoring,OptimizeHb11-13g/dl,supplysupplementalO2mechanicalventilation,ifnecessaryAssessvolumestatus(preload),PCWP15volumeexpansion,PCWP15considervolumeifPCWP18,Reassesstokeep:
PCWP15-18mmHgMAP60-80mmHg,SvO265-70%,consumptionGoalsmetTreatincitingcauseofshockcontrolinflammatoryresponsenutritionalsupport,GoalsnotmetInotropicsupport(bagonism)DobutamineDopamineEpinephrine,注:
此图表太大,一个幻灯页面不,DeliveryindependentO2能全部显示,Reassess,GoalsmetTreatincitingcauseofshockcontrolinflammatoryresponsenutritionalsupport,注:
此图表太大,一个幻灯页面不,能全部显示GoalsnotmetConsidervasodilatorsNitroglyceninNitroprussideConsideraagonistNorepinephrineEpinephrineNeosynephrinePlusDopamine,SPECIFICSHOCKSYNDROMES,icalsignsandsymptomsofhemorrhagicshockbasedonseverityofbl,注:
此图表太大,一个幻灯页面不能全部显示,Traumaticshock,Hypovolemicshockwith1.largervolumelosses2.greaterfluidsequestrationintheextravascularcompartments3.moreintenseactivationofinflammatorymediatorsdevelopmentofSIRS4.microcirculatoryderangements5.MODSfrequentlyoccur,Traumaticshock,treatment1.excessivefluidrequirements2.mechanicalventilation3.pulmonaryarterycathetermonitoring4.cardiovascularsupport,ShockAssociatedwithSIRS,Sepsis,andMODS,SIRS:
twoormoreoffollowing1.temperaturegreaterthan38orlessthan362.heartrategreaterthan90beatsperminute3.respiratoryrategreaterthan20breathsperminuteorPaCO2lessthan32mmHg4.whitebloodcellcountgreaterthan12,000percumm,lessthan4000percummorgreaterthan10%bandforms,VII.Diagnosisofhypovolemicshock,1.clinicalhistory;2.physicalfindings;3.bloodtests.4.characteristichemodynamics1.lowrightandleftsidedfillingpressures(lowcentralvenouspressure,lowPCWP)2.decreasedcardiacoutput,decreasedSvO23.increasedsystemicvascularresistance,VIII.Treatment,Patientsairway;adequateventilation,oxygenationFluidreplacementisotonicelectrolytesolutionsCrystalloid-RingerslactatesolutionBloodtransfusion-type-specifictypeOpackedredbloodcellsGuidetreatmentIfabsentmonitorthecentralvenouspressurePlaceapulmonaryarterycatheterThen:
urinaryoutputrateof0.5to1.0ml/kg/hourThepneumaticanti-shockgarmentColloidsolution;hyper-tonicsaline(controversy),SEPSIS,Sepsis:
thepresenceofSIRSinassociationwithculture-proveninfectionSepticshock:
sepsiswithhypotensiondespiteadequatefluidresuscitation,alongwiththepresenceofmanifestationsofhypoperfusion,including,butnotlimitedto,lacticacidosis,oliguria,oranacutealterationinmentalstatus.Mutipleorgandysfunctionsyndrome(MODS):
thepresenceofalteredorganfunctioninanacutelyillpatientsuchthathomeostasiscannotbemaintainedwithoutintervention.,Mortalityrate,26%SIRSSepsisMortalityrate:
7%16%4%SepsisSepticshockMortalityrate:
7%46%MODSmortalityrangefrom20%to100%dependingonthenumberoffailedorgansseverityofillnessscoringsystems,MODS,PrimaryMODSIschemicReperfussiondirectinsultSecondaryMODS(two-hitmodel)exaggerateduncontrolledsystemicinflammatoryresponse,clinicalfeatures:
fever,tachycardia,hypotension,oliguria(obtundation,coma)alteredmentalstatus.Leukocytosisorleukopeniaincreasedordecreasedsystemicvascularresistance.Positivemicrobialculturesgram-negativebacteriaescherichiacoli,klebsiellapseudomonasstaphylococcusstreptococcusspices,fungal,viral,protozoalpneumonia,gastrointestinalperforationbiliarytractinfection,urinarytractinfectionburnwounds,TheTwo-hitTheoryofMODS,FirstHit,1MODS,Death,Recovery,SystemicInflammatoryresponse,SecondHit,AmplifiedSystemicInflammationresponse,2MODS,Recovery,Death,1.PulmonaryfailureARDS,Mortalityexceeds50%ventilationperfusionabnormalitiespulmonaryedemahypoxemiadecreasedfunctionalresidualcapacitydecreasedinfiltratesonchestX-rays,2.Gastrointestinaldysfunction,Gastritis.Ulcerations.Pancreatitis;cholesystitis,mal-absorption,mucosalatrophy,translocationofbacteriaortoxins.,3.Renaldysfunction,TissuehypoperfusionTissuedamagebyactivatedinfalammatorycellsandtheirmediatorsUremiaelectrolytedisturbancesdialysis,4.Cardiacdysfunction,1depreesedcoronarybloodflow2directendotoxintoxicity3myocardiadepressantfactor(TNF),5.CNSmanifestationofMODS,GCSscoring;mentalstatusthepatientsbesteyeopening,verbalandmotorresponses,Treatment,TopreventtheprogressiontoMODS.ToimproveoxygendeliveryandoxygencomsumptionOxygendelivery:
Volumeexpansion;Provisionofredbloodcellmass;Useofpharmacologicagents:
Betaagonists&VasodilatorsFormonitoring:
e.g.pulmonaryarterycatheterForhemodynamicandotherphysiologicevaluationAntibiotics:
todetectpossiblesourcesofinfection(culture)SurgicaldebridementDrainageNutritionalsupport,TheEnd,Thankyou!
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