急诊上消化道出血共识解读-王仲

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,急诊上消化道出血共识解读-王仲,急诊科特点-多界面的学科,人多,开放,轻重不一,各种病人,多项技术,时间依赖性强,EMD,消化科,呼吸科,外科,ICU,手术室,院前急救,保命是我们的第一任务,先开枪，后瞄准,急诊,判断,处理,诊断,治疗,门诊,诊断,治疗,固定靶射击与,双向飞碟,上消化道出血概述,急诊常见病之一,潜在危险大,定义,：指屈氏韧带以上的消化道,(,食管,胃,十二指肠,胰腺,胆道,),的急性出血,是临床常见急症,分类,：非静脉曲张性出血、静脉曲张性出血,常见病因,：,十二指肠溃疡、胃溃疡和食管静脉曲张,1,概述,大多数急性上消化道出血病人首诊于急诊科，,病人常以头晕、乏力、晕厥等不典型症状就诊,急诊医师的职责：正确、迅速、合理地判断和诊治,中国医师协会急诊分会，推荐使用,“急性上消化道出血急诊诊治流程,”,对患者进行评估、治疗和管理,哪些病人应当考虑急性上消化道出血,急性上消化道出血（或疑似）,紧急评估,以典型症状就诊的患者，容易诊断,（呕血、黑便或血便，伴有周围循环功能衰竭）,以不典型症状（头晕、乏力、晕厥等）就诊的患者，急诊医师应保持高度警惕，积极明确或排除上消化道出血的诊断,2-4,急诊就诊病人大出血比例高于门诊病人,门脉高压病人出血更凶猛（6%）,部分没有肝病史的EVB病人,上消化道出血病人以消化性溃疡居多,即使有肝病的病人，70%为溃疡病出血,轻与重,我们知道吗？,大出血病人的紧急处理应当综合考虑,他们多长时间死亡,即刻,数分钟,数分钟至小时,小时至数天,数天至数月,数月至数十月,心源性猝死,窒息,大出血（内、外）,重症感染,肿瘤,免疫病,紧急评估（即刻完成）,患者意识丧失、呼吸停止及大动脉搏动不能触及,立即开始心肺复苏,5,紧急评估,对未出现呼吸心跳停止的病人，首先进行意识状态判断,Glassgow,评分,8,分，表示病人昏迷，应对呼吸道采取保护措施,意识,判断,眼睛运动,语言,肢体运动,6,按要求活动肢体,5,准确对答,疼痛能定位躲避,4,自主睁眼,文不对题,疼痛躲避运动,3,呼唤时可睁眼,能说断续词语,疼痛刺激肢体屈曲,2,刺痛时可睁眼,能发音，不成词,疼痛刺激肢体强直,1,不睁眼,无语言,无运动,意识状态评分表（,Glassgow,评分）,急性血色素下降的结果,Hb,结果,7.0,晕厥发作,6.0,定向力障碍,5.0,淡漠,4.0,昏迷、中枢障碍,昏迷：自我保护能力的丧失，包括对气道的保护,紧急评估,A.,气道,B.,呼吸,C.,循环,急性上消化道出血急诊诊治流程,急性上消化道出血（或疑似）,紧急评估,紧急处置,紧急处置（,2,分钟内完成）,心电、血压、血氧饱和度持续监测,对严重出血的病人，开放静脉通路，配血，液体复苏,意识障碍、排尿困难及所有休克患者留置尿管，记录尿量,患者绝对卧床，意识障碍患者将头偏向一侧，避免误吸,意识清楚，能够配合的病人可留置胃管并冲洗,肝硬化，食道胃底静脉曲张出血及配合度差的病人留置胃管时慎重，避免加重出血,7,常规处理,急性失血的循环影响,Hb,结果,7.0,细胞氧供边缘,6.0,诱发心绞痛,5.0,细胞功能障碍,4.0,？,处理原则保证灌注,大出血的紧急处置,常用复苏液体：生理盐水、平衡液、人工胶体和血液制品,病情危重时，输液、输血相继或同时进行,输血,门脉高压食管静脉曲张出血患者避免过度输血或输液,11,，,12,；避免仅用生理盐水扩容；高龄、伴心肺肾疾病患者防止输液量过多,2,，,3,限制性液体复苏与液体控制,收缩压,90,120,mmHg,；脉搏,100,次,/min,；尿量,40 ml/h,、血,Na+,140 mmol/L,；神智清楚或好转，无明显脱水貌,血容量充足及输血目标,积极补液后患者血压仍不能提升到正常水平，可适当地选用血管活性药物，使用方法参见相关指南,15,血管活性药物的使用,液体复苏,大出血的紧急处置,药物治疗是急性上消化道出血的首选治疗手段,病情危重患者,，特别是初次发病，既往病史不详患者,静脉应用生长抑素,质子泵抑制剂（,PPI,）,7,，,17,病因明确之前，可经验性联合用药,9,，,12,，,16,上消化道大出血及高度怀疑静脉曲张性出血时,血管加压素抗生素,14,，,18,，,19,以上基础上联用,明确病因后，再根据具体情况调整治疗方案,初始药物治疗,大出血的紧急处置,常用药物,生长抑素及其类似物,抑酸药物,血管加压素及其类似物,抗菌药物,止血药物,初始药物治疗,减少血流,促进凝血,控制损害,促进凝血,减少血流,促进凝血,大出血的紧急处置,生长抑素,14,肽,减少内脏血流、降低门静脉阻力,抑制胃酸和胃蛋白酶分泌,抑制胃肠道及胰腺肽类激素分泌,作用,机制,肝硬化急性食道胃底静脉曲张出血的首选药物之一,20,，,21,急性非静脉曲张出血的治疗,9,临床,应用,大出血的紧急处置,A.,可迅速有效控制急性上消化道出血,21,B.,预防早期再出血的发生,22,，,23,C.,有效预防内镜治疗后的肝静脉压力梯度（,HVPG,）升高，,从而提高内镜治疗的成功率,24,D.,可显著降低消化性溃疡出血患者的手术率,E.,对于高危患者，选用高剂量生长抑素在改善患者内脏血流,动力学、出血控制率和存活率方面均优于常规剂量,20,，,23,特点,生长抑素,大出血的紧急处置,生长抑素用法,1,2,用法,首剂量,250 g,快速静脉滴注（或缓慢推注）后，持续进行,250 g/h,静脉滴注（或泵入），疗程,5,天,高危,患者,高剂量输注（,500g/h,）生长抑素在改善患者内脏血流,动力学、出血控制率和存活率方面均优于常规剂量,20,，,23,可根据患者病情多次重复,250 g,冲击剂量快速静脉滴注，,最多可达,3,次,大出血的紧急处置,生长抑素类似物,生长抑素,类似物,奥曲肽对非静脉曲张出血的治疗作用尚待进一步研究证实,生长抑素类似物可作为急性静脉曲张出血的常用药物,奥曲肽是人工合成的八肽生长抑素类似物,血管加压素及其类似物,包括垂体后叶素,血管加压素,特利加压素,抑酸药物,PPI,针剂,埃索美拉唑：,80mg bolus 80mg/h,奥美拉唑,: 80mg bolus 80mg/h,泮妥拉唑,兰索拉唑,雷贝拉唑,H,2,RA,雷尼替丁,法莫替丁等,提高胃肠道内,pH,值,促进血凝块的形成，防止血凝块溶解,促进病变部位愈合,紧急处理中的其他药物,抗菌药物,喹诺酮类抗菌素,对喹诺酮类耐药者也可使用头孢类,抗菌素,止血药物,：止血药物的疗效尚未证实，不推荐作为一线药物使用,急性上消化道大出血急诊诊治流程,急性上消化道出血（或疑似）,紧急评估,紧急处置,二次评估,二次评估,病因评估,在解除危及生命的情况、液体复苏和初始经验治疗开始后；或初次评估判断病情较轻，生命体征稳定的病人，开始进行二次评估,全面评估,病史,详细询问病史有助于对出血病因的初步判断,全面查体,重点注意血流动力学状态、腹部、慢性肝脏疾病或,门脉高压体征、直肠指诊,实验室和辅助检查,血细胞分析、肝功能、肾脏功能和电解质、,凝血功能、血型、心电图、胸片、腹部超声,二次评估,病情严重程度的评估,病情严重度与失血量呈正相关。如根据血容量减少导致周围循环的改变来判断失血量，休克指数（心率,/,收缩压）是判断失血量的重要指标之一,6,，,15,分级,失血量（,ml）,血压（,mmHg）,心率,（次,/min）,血红蛋白（,g/L）,症状,休克,指数,轻度,500,基本正常,正常,无变化,头昏,0.5,中度,500-1000,下降,100,70-100,晕厥、口渴、,少尿,1.0,重度,1500,收缩压,80,120,70,肢冷、少尿、,意识模糊,1.5,上消化道出血病情严重程度分级,注：休克指数,=,心率,/,收缩压,二次评估,是否存在活动性出血的评估,临床上出现下列情况考虑有活动性出血,呕血或黑便次数增多，呕吐物呈鲜红色或排出暗红血便，或伴有肠鸣音活跃,经快速输液输血，周围循环衰竭的表现未见明显改善，或虽暂时好转而又再恶化，中心静脉压仍有波动，稍稳定又再下降,红细胞计数、血红蛋白测定与,Hct,继续下降，网织红细胞计数持续增高,补液与尿量足够的情况下，血尿素氮持续或再次增高,胃管抽出物有较多新鲜血,1,2,3,4,5,二次评估,出血预后的评估,急性上消化道出血急诊诊治流程,急性上消化道出血（或疑似）,紧急评估,紧急处置,二次评估,药物治疗,+,内镜联合治疗,药物治疗,内镜,内镜检查为上消化道出血病因诊断的关键检查,47,，应尽量在出血后,24,48h,内进行；药物与内镜联合治疗是目前首选的治疗方式,24,，,26,，,47,，,48,，内镜治疗方法的选择请参加消化专业有关指南,8,，,13,，,14,，,19,急性上消化道出血急诊诊治流程,急性上消化道出血（或疑似）,紧急评估,紧急处置,二次评估,药物治疗,+,内镜联合治疗,治疗后再评估,病情稳定，门诊或住院治疗,介入、外科手术治疗,治疗后再次评估,经上述治疗后再次评估患者出血是否得到有效控制。若仍可能存在活动性出血，可根据患者病情选择重复内镜治疗或外科手术治疗。对严重出血患者或因脏器低灌注而引起相应并发症者应尽快收入监护病房进行加强监护治疗,急性上消化道出血,（或疑似）,紧急评估,：,意识状态评估,A,气道：气道是否缺乏保护，如：意识水平的下降,B,呼吸：记录呼吸频率，呼吸质量和氧饱和度,C,循环：测量血压、脉搏、毛细血管再充盈时间,紧急处置,：,气道保护，机械通气,液体复苏、输血,经验性联合用药：,静脉生长抑素,PPI,；考虑静脉曲张出血者再联用血管加压素广谱抗生素,二次评估,：,病史、查体、实验室和辅助检查,病情严重程度评估,是否存在活动性出血,预后的评估,药物内镜联合治疗,无反应，大动脉,搏动消失,心肺复苏,病情稳定，门诊或住院治疗,介入、外科手术治疗,治疗后再次评估,紧急评估病情稳定,不稳定,急性上消化道出血急诊诊治流程,小结,参考文献,1.Henrion, J., et al.,Upper gastrointestinal bleeding: what has changed during the last 20 years?,Gastroenterol Clin Biol, 2008. 32(10): p. 839-47.,2.Alkhatib, A.A. and F.A. 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