• / 61
  • 下载费用:25 金币  

【医学ppt课件】休克的诊断与治疗

关 键 词:
医学ppt课件 休克的诊断与治疗 休克的诊断和治疗 休克的诊断与治疗PPT课件 PPT医学课件 休克诊断和治疗 休克的诊断和治疗ppt课件 休克PPT课件 休克的诊断与
资源描述:
单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *1 休克的诊断与治疗 • 中南大学湘雅二医院 • 博士、教授、心内科副主任 • 李向平 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 定 义 • 休克是指机体在各种强烈致病因素作用下, 引起有效循环血量急剧减少,导致全身微循 环功能障碍,使脏器血流灌注不足,引起缺 血、缺氧、代谢障碍及重要脏器损害,直到 细胞死亡为特征的临床综合征。 • 休克是病情危重的征象之一,是濒死的一个 可逆转阶段,如不及时诊治死亡率极高。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 休克的病因及分类 • 低容量性休克: – 失血性、大量液体丢失 • 心源性休克: • 血管源性休克 – 感染性休克 – 过敏性休克 – 创伤性休克 – 神经性休克:麻醉药或扩管药、中枢及外周神 经损伤等 • 其他 – 急、慢性肾上腺皮质功能不全,急性胰腺炎等 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 休克的临床表现与分期 第一期 (轻度) 第二期 (中度) 第三期 (重度) 收缩压 脉压 心率 呼吸频率 皮肤 毛细血管再充盈 尿量 意识 正常、↓ ↓ ↑ 正常 冷、苍白 0-1秒 正常、↓ 烦躁 ↓ ↓↓ ↑↑ ↑ 湿、苍灰 1-3秒 ↓↓ 淡漠 ↓↓ ↓↓ ↑↑→↓↓ ↑↑→↓↓ 紫色斑纹 3秒 无尿 极淡漠、昏迷 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 休克的诊断标准 ⑴有诱发休克的病因; ⑵意识异常; ⑶脉搏细速,100次/分或不能触及; ⑷四肢湿冷,胸骨部位皮肤指压阳性(指压后再充盈 时间2秒),皮肤出现花纹,粘膜苍白或发绀,尿 量2秒 (胸骨部,甲床,小鱼际) 皮肤冰凉、苍白、潮湿 休克? 颈静脉 萎陷 充盈 低血容量休克 血管源性休克 心源性休克 四肢视触诊 休克的快速目测识别 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 休克的治疗 • 一般治疗 • 病因治疗 • 扩容治疗 • 血管活性药物的应用 • 纠正酸中毒 • 其他 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 休克的一般治疗 • 体位:平卧位或头胸部与下肢均抬高30° 。 • 给氧:使氧分压保持在70mmHg以上(氧饱和度90%以上)。 •监护和实验室检查: – 常规监测BP、P、R、心率、血氧饱和度、尿量、尿比重; – 查血常规、电解质、肝肾功能、动脉血气分析; – 酌情选择下列项目:⑴中心静脉压(CVP),正常值为 5~12cmH2O;⑵肺毛细血管楔压(PCWP),正常值为 8~12mmHg(1.07~1.60kPa);⑶心肌酶、血培养、细菌学 检查、DIC相关检查等。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 休克的扩容治疗 扩容是休克治疗最重要的环节 • 补液量:头30~60分钟可输500~1000ml,24小 时约2500~4000ml。 • 补液种类:可先输生理盐水、糖盐水或平衡盐溶 液(乳酸林格液)。然后酌情选下列制剂:⑴多 糖类血浆代用液,如右旋糖酐、羟乙基淀粉(贺 斯、万汶、“706”代血浆等)、明胶多肽类( 佳乐施、菲克雪浓和海脉素等);⑵人血胶体物 质,包括血浆、白蛋白、全血等。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 休克的扩容治疗 • 血容量是否补足的判断: –血容量不足:口渴、外周静脉充盈不良、脉 搏细速、收缩压1.020、CVP100mmHg、脉压 30mmHg、四肢温暖、休克指数=0.5左右、尿 量30ml/h且比重50×10-3/L(推荐级别:E级)。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 感染所致ALI和(或)ARDS的机械通气 • ALI和(或)ARDS患者应避免高潮气量和高 气道平台压,早期应采用较低的潮气量(如 在理想体重下6ml/kg),使吸气末平台压不 超过30cmH2O(推荐级别:B级)。 • 采用小潮气量通气和限制气道平台压力, 允许动脉血二氧化碳分压(PaCO2)高于正 常,即达到允许性高碳酸血症(推荐级别:C 级)。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 感染所致ALI和(或)ARDS的机械通气 • 采用能防止呼气末肺泡塌陷的最低呼气 末正压(PEEP)(推荐级别:E级)。 • 机械通气的患者应采用45°角半卧位,以 防止呼吸机相关肺炎的发生(推荐级别:C 级) Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 控制血糖 • 严重感染患者早期病情稳定后应维持血糖水平 低于8.3mmol/L(150mg/dl)。研究表明,可通过 持续静脉输注胰岛素和葡萄糖来维持血糖水平 。早期应每隔30~60min测定一次血糖,稳定后 每4h测定一次(推荐级别:D级)。 • 严重的脓毒症患者的血糖控制需制订肠内营养 方案(推荐级别:E级)。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 肾脏替代治疗 • 并发急性肾功能衰竭时,持续静脉-静脉 血液滤过与间断血液透析治疗效果相同 。但对于血流动力学不稳定的全身性感 染患者,持续血液滤过能够更好地控制液 体平衡(推荐级别:B级)。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 碳酸氢盐治疗 • pH≥7.15时不推荐应用碳酸氢盐治疗(推 荐级别:C级)。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 深静脉血栓(DVT)的预防 • 严重感染患者应使用小剂量肝素或低分子肝素 预防DVT。有肝素使用禁忌证(血小板减少、重 度凝血病、活动性出血、近期脑出血)者,推荐 使用物理性的预防措施(弹力袜、间歇压缩装 置)。既往有DVT史的严重感染患者,应联合应 用抗凝药物和物理性预防措施(推荐级别:A级) 。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 应激性溃疡的预防 • 所有严重感染患者都需预防应激性溃疡 。H2受体阻滞剂比硫糖铝更为有效。在提 高胃液pH值方面,质子泵抑制剂可能优于 H2受体抑制剂(推荐级别:A级)。 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *51 失血性休克复苏研究进展 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 失血性休克复苏存在的争议 • 采用快速输液还是限制输液? • 采用复温还是降温? Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 是充分还是限制性液体复苏? • 传统观念:对于失血性休克应给予充分液体复 苏或积极液体复苏,以恢复有效血容量和使血 压恢复至正常,保证脏器和组织的灌注,阻止 休克的进一步发展。 • 新观点:1992年以来,有动物和临床研究观察 到,在活动性出血控制前积极地进行液体复苏 会增加出血量,使并发症和病死率增加。因此 提出限制性复苏(limited resuscitation)的概念 ,即在活动性出血控制前应限制液体复苏。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 限制性液体复苏的依据 在有活动性出血存在的情况下: • 开放血管口的出血量与主动脉根部和此部位 的压力差明显相关; • 血压恢复后,小血管内已形成的血栓被冲掉 ,使已停止的出血重新开始; • 随着血压回升,保护性血管痉挛解除,使血 管扩张; • 输入的液体降低了血液的粘稠度,使出血量 增加。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 限制性输液的研究 • 有研究在主动脉撕裂的出血动物模型中,分别 输注出血量0、1、2、3倍乳酸林格氏液。结果 :远端主动脉流量分别为基础值的39%、41%、 56%和56%,输注2倍和3倍量组有再出血发生, 输注1倍和2倍量组存活率最高。因此认为以中 等量液体复苏为宜。 • 另有报道,用针刺破大鼠下段主动脉,使平均 动脉压降低,然后以1.5ml/min或3.0ml/min速度输 注乳酸林格氏液,总量60ml/kg。结果1.5ml/min 输液组动物失血量显著少于3.0ml/min组,死亡 率也显著低于3.0ml/min组。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 限制性输液的研究 • Bickell等对598例躯干穿透伤的低血压患 者进行立即输液和延迟到患者进手术室 后再补液的对照研究,结果延迟补液患 者的死亡率降低(30%比38%)、住院时间 短、脏器功能失常少(23%比30%)。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 如何评价和应用这些结果? • 是充分还是限制性输液虽仍存在争议,但在失血 性休克动物和人不接受液体复苏会增加死亡率和 并发症这一点上似乎已达成共识,止血之前限制 补液(仅补到休克逆转时)也已得到很大程度认同。 • 临床上患者的出血量、出血速度不一,休克的程 度也不同。因此,无论是输液量和输液速度都不 能千篇一律。 • 在失血性休克期间,机体通过自身调整进行代偿 ,然而代偿是有限的。有人认为有效的代偿是1小 时,称为“金小时”,而大血管或心脏等破裂甚至 当场死亡。因此,对所谓的延迟性复苏要分别对 待。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 是复温还是低温休克复苏? • 低体温是指中心体温低于35℃。 • 低温是失血性休克患者的常见临床体征,其原 因是多方面的。 • 通常认为低体温主要的不利作用是:引起外周 血管收缩及诱发心律失常、心脏抑制、寒战和 增加氧消耗;改变血粘度、加重脏器缺血、影 响出凝血机制,从而增加死亡率。 • 在失血性休克患者复苏时,为了避免低体温的 发生,通常采用保温措施。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 复温还是低温休克复苏的研究 •Kim等分别使动物中心体温维持于37.5℃和30.0℃2小时, 结果:不输液正常体温动物1小时左右全部死亡,低体温 动物5/10只存活;输少量液体正常体温组1/10只存活,低 体温组7/10只存活,有显著性差异。 •Takasu采用体表降温使未控制出血鼠中心温度降至34℃ 、30℃,并与正常体温(38℃)比较。结果:各组平均 存活时间分别为119分钟、132分钟和51分钟。 总之,对于低温休克复苏的研究尚处于初期阶段, 有许多问题尚不清楚,如低温的程度、开始时间及持续 的时间仍值得研究。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 小 结 • 休克是临床上常见的危急症 • 早期诊断、早期治疗是抢救成功的关键 • 除了针对病因进行治疗外,及时上氧、 监护、扩容、升压、纠酸、并发症的防 治均是休克救治的基本措施 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development.
展开阅读全文
  麦档网所有资源均是用户自行上传分享,仅供网友学习交流,未经上传用户书面授权,请勿作他用。
0条评论

还可以输入200字符

暂无评论,赶快抢占沙发吧。

关于本文
本文标题:【医学ppt课件】休克的诊断与治疗
链接地址:https://www.maidoc.com/p-15695445.html

当前资源信息

范文库

编号: 20181006020655813180

类型: 共享资源

格式: PPT

大小: 176.50KB

上传时间: 2019-11-08

关于我们 - 网站声明 - 网站地图 - 资源地图 - 友情链接 - 网站客服 - 联系我们

[email protected] 2018-2020 maidoc.com版权所有  文库上传用户QQ群:3303921 

麦档网为“文档C2C模式”,即用户上传的文档所得金币直接给(下载)用户,本站只是中间服务平台,本站所有文档下载所得的金币归上传人(含作者)所有。
备案号:蜀ICP备17040478号-3  
川公网安备:51019002001290号 


收起
展开