休克与失血性休克-课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,休克与失血性休克,休克与失血性休克,1,Case,1,午夜,1,9,岁男性 自行入院,左侧背部刀刺伤,Awake,but,sluggish,双侧呼吸音都存在,HR140,BP80/50,SPO,2,100%,T,3,6.1,Case1午夜,2,then,2,L,saline,B,P,110,/,75,Xr,ay,B,P,75/55,Short,of,breath,a,nd.,then2L saline,3,Case2,50min,后,2,4,岁男性 步行入院,车祸伤,Awake,and,angry,右胸部及腹部疼痛,HR125,BP120/80,RR20,SPO,2,94%,10min,BP,80/40,Case250min后,4,Then.,2L,l,actated,ringer,solution,FAST,BP,75/40,And,more.,Then.2L lactated ringer solu,5,内容提纲,休克分类及机制,休克通常处理方案,失血性休克机制,失血性休克综合方案,失血性休克液体管理,失血性休克输血事项,内容提纲休克分类及机制,6,内容提纲,休克分类及机制,休克通常处理方案,失血性休克机制,失血性休克综合方案,失血性休克液体管理,失血性休克输血事项,内容提纲休克分类及机制,7,休克的分类,常规病因分类,病生分类,休克的分类常规病因分类,8,休克的病生分类,动力性休克,容量性休克,分布性休克,梗阻性休克,休克的病生分类动力性休克,9,容量是什么,广义的容量：循环系统内的血容积（这是一个开放的系统）,狭义（经典意义）容量：左心室前负荷,广义和狭义的容量概念存在相关性，也存在差异,容量是什么广义的容量：循环系统内的血容积（这是一个开放的系统,10,心功能,前负荷,治疗,优化氧供和氧耗,监测,重症治疗的目标,组织氧供是维持正常功能的前提,心功能前负荷治疗优化氧供和氧耗监测重症治疗的目标组织氧供是维,11,关于循环功能到底需要知道哪些,脏器组织得到相适应的血液供给,通过前阻力血管调控各部位的流量,提供相应的动力和容量,结果,循环目标,分配,神经内分泌及局部调控,心脏搏血,基础,关于循环功能到底需要知道哪些脏器组织得到相适应的血液供给通过,12,评价容量的目的,容量是循环系统目标实现的前提,循环系统的目标：组织灌注,失,代偿的结果：休克,MOF,容量正常 循环功能良好,容量异常 循环功能异常,评价容量的目的容量是循环系统目标实现的前提,13,改善心输出量,前负荷,收缩力,后负荷,心率变异性,Frank-Starling mechanism,容量是实现有效心输出量的基础,改善心输出量前负荷收缩力后负荷心率变异性Frank-Star,14,SV,Preload,V,V,V,SV,SV,SV,Normal contractility,Preload, CO and Frank-Starling Mechanism,target area,volume responsive,volume overloaded,15,改善心输出（,CO,）,SVPreloadVVVSVSVSVNormal contr,15,V,V,SV,SV,SV,Preload,Poor contractility,Normal contractility,target area,volume responsive,volume overloaded,16,Preload, CO and Frank-Starling Mechanism,改善心输出（,CO,）,VVSVSVSVPreloadPoor contractil,16,V,V,SV,SV,SV,Preload,Preload, CO and Frank-Starling Mechanism,High contractility,Normal Contractility,target area,volume responsive,volume overloaded,Poor contractility,17,改善心输出（,CO,）,VVSVSVSVPreloadPreload, CO and,17,V,V,V,SV,SV,SV,Preload, CO and Frank-Starling Mechanism,target area,volume responsive,volume overloaded,Preload,SV,改善心输出（,CO,）,VVVSVSVSVPreload, CO and Frank,18,循环系统失代偿的表现形式,终极表现形式（死亡）,描述心输出量与组织灌注之间的矛盾（心衰）,组织系统性低灌注状态（休克）,循环系统失代偿的表现形式终极表现形式（死亡）,19,休克的表现形式,系统性,各,功能系统之间存在差异,与基础病相关,代偿也是一种表现,休克的表现形式系统性,20,早期出现的：代偿,在循环系统没有严重受损的前提下，代偿是最早出现的,代偿的形式：,心律,心率,心肌收缩,血压,血,容量调节,早期出现的：代偿在循环系统没有严重受损的前提下，代偿是最早出,21,早期出现的：哪些是最早被舍弃,皮肤、肌肉,胃肠道,肾脏,被,忽视的问题：精神状态,早期出现的：哪些是最早被舍弃皮肤、肌肉,22,休克的重型表现：衰竭,由于灌注不足而导致的功能障碍,信号,肌肉 皮肤： 乏力 虚弱 肢端 色泽 温度,胃肠道：食欲下降 腹胀 蠕动异常,损害,肾功能：肾小管功能异常至滤过障碍,肝功能：肝细胞损害并功能异常,典型,循环失代偿：血压下降 心律失常（快 慢）,脑部灌注异常：昏迷 躁狂,休克的重型表现：衰竭由于灌注不足而导致的功能障碍信号肌肉 皮,23,内容提纲,休克分类及机制,休克通常处理方案,失血性休克机制,失血性休克综合方案,失血性休克液体管理,失血性休克输血事项,内容提纲休克分类及机制,24,休克与失血性休克-课件,25,休克与失血性休克-课件,26,休克与失血性休克-课件,27,休克与失血性休克-课件,28,休克与失血性休克-课件,29,休克与失血性休克-课件,30,凝血过程,血管因素,血小板,凝血因子,凝血过程血管因素血小板凝血因子,31,Hemostasis:,Vasoconstriction,& Plug Formation,Figure 16-12: Platelet plug formation,Hemostasis: Vasoconstriction,32,Figure 16-10c: Megakaryocytes and platelets,Coagulate, form plug, prevent blood loss,Formed by fragmentation from,megakaryoctyes,Half-life 9-10days,Figure 16-10c: Megakaryocytes,33,Overview of Hemostasis: Clot Formation & Vessel Repair,Figure 16-11: Overview of hemostasis and tissue repair,Overview of Hemostasis: Clot,34,Hemostasis: Coagulation & Clot Stabilization,Figure 16-13: The coagulation cascade,Prothrombin,Ca+,Fibrinogen,Fibrin,Polymerization,Hemostasis: Coagulation & Clot,35,Dissolving the Clot and Anticoagulants,Figure 16-14: Coagulation and fibrinolysis,Dissolving the Clot and Antico,36,休克与失血性休克-课件,37,休克与失血性休克-课件,38,Advance,Treatment,and,Life,S,upport,Classification,Advance Treatment and Life Sup,39,内容提纲,休克分类及机制,休克通常处理方案,失血性休克机制,失血性休克综合方案,失血性休克液体管理,失血性休克输血事项,内容提纲休克分类及机制,40,暴力性损伤救治特点,原因容易辨识但损伤部位判定困难,分为：,生命支持,神经系统损伤（头部,脊髓）,胸部外伤（心,肺）,功能保全,神经系统损伤,肢体损伤,暴力性损伤救治特点原因容易辨识但损伤部位判定困难,41,暴力性损伤救治程序,损伤部位判断,意识判断,意识丧失循环衰竭（,CPR,）,意识清醒,根据患者描述判断损伤部位,意识丧失,根据外伤部位初步判断但需要按全身损害进行处理,暴力性损伤救治程序损伤部位判断意识判断意识丧失循环衰竭（C,42,救治方法,整体搬运,功能位放置,固定,保持气道通畅,止血（压迫,止血带）,救治方法整体搬运,43,ATLS,management,Clinicians should be familiar with the clinical signs of hem-,orrhagic,shock. (III-B),Clinicians should be familiar with the stages of hemorrhagic,shock,. (III-B),Clinicians should assess each womans risk for hemorrhagic,shock,and prepare for the procedure accordingly. (III-B),ATLS managementClinicians shou,44,ATLS,management,Resuscitation from hemorrhagic shock should include ade-,quate,oxygenation. (II-3A),Resuscitation from hemorrhagic shock should include,restoration,of circulating volume by placement of two large- bore IVs, and rapid infusion of a balanced crystalloid solu- tion. (I-A),?,ATLS managementResuscitation f,45,ATLS,management,Vasoactive agents are rarely indicated in the management of hemorrhagic shock and should be considered only when vol- ume replacement is complete, hemorrhage is arrested, and hypotension continues. They should be administered in a critical care setting with the assistance of a multidisciplinary team. (III-B),ATLS managementVasoactive agen,46,ATLS,management,In hemorrhagic shock, prompt recognition and arrest of the source of hemorrhage, while implementing resuscitative mea- sures, is recommended. (III-B),ATLS managementIn hemorrhagic,47,院前急救策略,A,prospective multicenter Canadian study,9405,patients,showed,increased,mortality,with ATLS interventions in the field when compared to “,scoop and run,.,”,For,each procedure, the risk of death increased 2.63 times (odds ratio OR 0.38, 95% confidence interval CI, 0.18-0.79,P, 0.0096).,院前急救策略A prospective multicente,48,内容提纲,休克分类及机制,休克通常处理方案,失血性休克机制,失血性休克综合方案,失血性休克液体管理,失血性休克输血事项,内容提纲休克分类及机制,49,Fluid resuscitation of septic shock,2001 EGDT,2004 initial guidelines,2008 updated version guidelines,2010 severe sepsis bundles,Fluid resuscitation of septic,50,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,In-hospital mortality was,30.5 percent,in the group assigned to,early goal-directed therapy, as compared with,46.5,percent in the group assigned to,standard therapy,(,P=0.009,).,Emanuel Rivers et al.N Engl J,51,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,Emanuel Rivers et al.N Engl J,52,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,Emanuel Rivers et al.N Engl J,53,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,Emanuel Rivers et al.N Engl J,54,Additions to Fluid Therapy Recommendations,（,2012,）,With regard to fluid therapy, the use of,crystalloids,in the initial fluid resuscitation in severe sepsis,is recommended,(,strong recommendation; Grade 1A,).,Additions to Fluid Therapy Rec,55,Additions to Fluid Therapy Recommendations,（,2012,）,We recommend that initial fluid challenge in patients with sepsis-induced tissue perfusion with suspicion of hypovolemnic be 1,000 mL of crystalloids or more to achieve,a minimum of 30 mL/kg of crystalloids in the first four to six hours.,Additions to Fluid Therapy Rec,56,Additions to Fluid Therapy Recommendations,（,2012,）,The researchers also suggest,adding albumin,to the initial fluid resuscitation for severe sepsis and septic shock (,weak recommendation; Grade 2B,).,Additions to Fluid Therapy Rec,57,怎么补,怎么补,58,失血性休克的复苏历程,早期认识：迅速补充容量至正常或稍高,近,30,年的变化源自于战争,失血性休克的复苏历程早期认识：迅速补充容量至正常或稍高,59,从何而来,Beginning in the 1960s, work pioneered by Fogelman and Wilson6 and consolidated by Shires7 and others showed that trauma and,hemorrhage,led,to extracellular volume losses beyond the blood lost and that the addition of crystalloid to blood replacement could lead to improved survival.,The ubiquitous American Trauma Life Support (ATLS) course recommends 2 liters of crystalloid be infused, and this maxim has been extrapolated so that it is “.now common that all trauma patients (not just patients in shock) are infused with 2 or more liters of LR solution.”,从何而来Beginning in the 1960s, wo,60,问题的提出,By the early 1980s, new concerns developed about the side effects of large-volume crystalloid infusion.,n a landmark study by Bickell et al in 1994, 598 hypotensive patients with penetrating torso injuries were randomized to either,standard,or,delayed,fluid resuscitation,. The results of the study showed that survival was 62% for those who received immediate fluid resuscitation and 70% in the delayed resuscitation group (,P,= 0.04).,问题的提出By the early 1980s, new c,61,误区,1,：,Resuscitation,injury,误区1：Resuscitation injury,62,休克与失血性休克-课件,63,休克与失血性休克-课件,64,误区,2,误区2,65,几个概念,延迟液体复苏,delayed resuscitation,DR,复苏损伤,resuscitation,injury,R,I,允许性低血压,permissive,h,ypotension,PH,几个概念延迟液体复苏 delayed resuscitati,66,与,Sepsis,的区别,丢失的成分,丢失的部位,丢失的机制,发生的原因,与Sepsis的区别丢失的成分,67,What is resuscitation injury?,What fluid is best for resuscitation,?,When should fluid resuscitation start, and once,initiated, what should the endpoints be,?,How should the coagulopathy of trauma be,managed,?,What is resuscitation injury?,68,终点在哪里,终点在哪里,69,MAP,:,65,mmHg,MAP,:,85,mmHg,MAP,:,75,mmHg,tonometry,PCO,2,gap,red cell,velocity,capillary,flow,urine,output,150,100,50,13,%,*,*,*,NE dose,cardiac,index,SVR,150,100,50,200,%,lactate,3.1,4.7,998,*,LeDoux D et al.Crit Care Med. 2000;28(8):2729-32.,MAP: 65 mmHgMAP: 85 mmHgMAP: 7,70,Mean arterial pressure,Organ,Blood,flow,mmHg,65,Mean arterial pressureOrganmmH,71,Mean arterial pressure,Organ,Blood,flow,mmHg,no prior hypertension,with prior hypertension,65,Strandgaard S et al.Br Med J.1973;1(5852):507-10,Mean arterial pressureOrganmmH,72,ScvO,2,70%?,ScvO2 70%?,73,Variable and,Treatment group,Base Line,0 hr,CVP,mmHg,Standard therapy,6,8,EGDT,5,9,MAP,mmHg,Standard therapy,76,24,EGDT,74,27,6 hrs after the start of therapy,Total fluids,(mL),Any vasopressor,(%),12, 7,14,4,3499, 2438,4981,2984,81, 18,95,19,66, 16,77,10,30.3,27.4,ScvO,2,%,Standard therapy,49,13,EGDT,49,11,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,Variable and Base LineCVP mmHg,74,其他指标,?,Lactate clearance,Passive leg raising,PPV,Dynamic measures of echocardiographic function,其他指标?Lactate clearance,75,真正的终点,维持生命体征,有效止血,真正的终点维持生命体征,76,补什么,补什么,77,几种选择,晶体液,胶体液（人工,or,白蛋白）,混合型,高张,等张,几种选择晶体液,78,Sepsis,液体选择,Sepsis液体选择,79,Delaney AP et al. Crit Care Med. 2011;39(2):386-91.,Delaney AP et al. Crit Care Me,80,Brochard L et al. Am J Respir Crit Care Med.2010 ;181(10):1128-55.,Brochard L et al. Am J Respir,81,Panel recommendations,We consider fluid resuscitation with crystalloids to be as effective and safe as fluid resuscitation with hypooncotic colloids (gelatins and 4% albumin).,Based on current knowledge, we recommend that hyperoncotic,solutions (dextrans, hydroxyethylstarches, or 20-,25% albumin) not be used for routine fluid resuscitation because they carry a risk for renal dysfunction.,Brochard L et al. Am J Respir Crit Care Med.2010 ;181(10):1128-55.,Panel recommendationsWe consid,82,Decreased glomerular filtration pressure due to increased intracapillary oncotic pressure and (direct) colloid nephrotoxicity (osmotic nephrosis) are the two purported mechanisms responsible for the higher incidence of renal dysfunction with hyperoncotic colloids than with crystalloids or hypooncotic colloids .,Brochard L et al. Am J Respir Crit Care Med.2010 ;181(10):1128-55.,Decreased glomerular filtratio,83,休克与失血性休克-课件,84,休克与失血性休克-课件,85,休克与失血性休克-课件,86,休克与失血性休克-课件,87,休克与失血性休克-课件,88,休克与失血性休克-课件,89,休克与失血性休克-课件,90,休克与失血性休克-课件,91,液体复苏-2004年,SAFE,研究,随机对照多中心研究,共6997例需要液体复苏的,ICU,病人,观察28天的结果,组别：,干预组：3497,4%人血白蛋白,对照组：3500,生理盐水,N Engl J Med 2004;350:2247-56.,液体复苏-2004年SAFE研究随机对照多中心研究N Eng,92,结论,在液体复苏时,应,用4%白蛋白与生理盐水在28天内效果相当；,N Engl J Med 2004;350:2247-56.,结论N Engl J Med 2004;350:2247-5,93,SAFE study,亚组分析,脓毒性休克：死亡率有减少趋势,（,30.7% vs 35.3%,，,P=0.09,）,创伤病人，特别是脑外伤病人：死亡率有增加趋势,（,13.6% vs 10.0%,，,P=0.06,）,N Engl J Med 2004;350:2247-56.,SAFE study亚组分析N Engl J Med 200,94,乳酸林格氏液的区别,为什么乳酸,什么样的乳酸,现在用什么,L-type,乳酸林格氏液的区别为什么乳酸,95,内容提纲,休克分类及机制,休克通常处理方案,失血性休克机制,失血性休克综合方案,失血性休克液体管理,失血性休克输血事项,内容提纲休克分类及机制,96,2007,2007,97,输血的问题,MOF,SIRS,Infection,TRALI,transfusion,related,ALI,输血的问题MOF,98,ET:,early,transfusion,965 trauma admissions 91 (9%) required ET (76% male, median age:,38,ET was initiated in ED (52%), OR (38%) or ICU (10%,),MTP transfusions were started at a median of 0.5h (0.5-4, IQR: 0.5-1.5),Injury. 2013 May;44(5):581-6.,ET: early transfusion965 traum,99,MTP,Massive Transfusion Protocol (MTP),以往：成分输血,RBC,+,液体,resort to 1:1:1 ratio of major components (RBC, Plasma and Platelets),MTPMassive Transfusion Protoco,100,休克与失血性休克-课件,101,休克与失血性休克-课件,102,November 2011 ,November 2011 www.ebmedicine,103,Bougl et al. Annals of Intensive Care 2013, 3:1,Bougl et al. Annals of Intens,104,最需要分辨的出血,外科处理后稳定性 与 未处理非稳定性,是否合并,TBI,最需要分辨的出血外科处理后稳定性 与 未处理非稳定性,105,休克与失血性休克-课件,106,休克与失血性休克-课件,107,