严重创伤病人的麻醉

,*,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,严重创伤病人的麻醉,Anesthesia for Trauma,In advanced countries,injury ranks as the fourth leading cause of death following heart disease,cancer,and cerebrovascular disease.,Preoperative Assessment,For trauma patients,in addition to the ordinary preanesthetic evaluation,the severity of the trauma should be evaluated.The commonly used scoring system including:,1.ASA physical status score,It is not very useful for discriminating small difference,in severely injured patients.,2.Glasgow coma score scale（GCS）,Indicators:Eye opening,Spontaneous 4,To voice 3,To pain,2,None 1,Verbal response,Oriented 5,Confused 4,Inappropriate words 4,Incomprehensible words 2,None 1,Motor responses,Obeys Command 6,Localizes pain 5,Withdraws（pain）4,Flexion（pain）3,Extension（pain）2,None 1,Numeric range：315,Lower score more serious coma,3.Revised Trauma Score（RTS）,Indicators：Systolic blood pressure,89mmHg 4,7689mmHg 3,5075mmHg 2,149mmHg 1,No pulse 0,Weight0.7326,Respiratory rate,1029/min4,29/min3,69/min2,15/min1,None0,Weight0.2908,Glasgow Coma Scale,1315 4,912 3,68 2,45 1,3 0,Weight 0.9368,Numeric range 00.784,SBPwgt+RRwgt+GCSwgt=TS,Lower Score more serious injury,4.Others Refer to the text.,Mechanisms of Injury,The mechanism of injury determines the pattern of,injury,and the knowledge focuses the treatment priorities,for the patient.,For example:,Penetrating thoracic trauma,Blunt Chest trauma,The therapeutic approach is quite different.,Blunt trauma results in widespread energy transfer to the body.When the limits of lord tolerance are exceeded,Tissues are disrupted depending on the amount of energy transfer.,Penetrating trauma injures as the energy behind,the penetrating instrument causes stretching and,crushing of tissues.The energy dissipation profiles of different weapons（Knives and bullets determine the anatomic depth and extent of maximum injury.,Trauma patients death demonstrate a trimodal distribution.In the first and largest peak of distribution curve,death from either blunt or penetrating trauma occurs immediately following widespread laceration of the brain or major blood vessels,including the heart.Such patients can rarely be saved.,In the second peak,exsanguinations from vascular injuries causes death within a few hours without medical treatment.,Inadequate or delayed shock resuscitation or surgical treatment leads to late death from infection,sepsis,or multiorgan failure,.,麻醉前准备,对于严重创伤病人，必须首先考虑其病情特点：,病情紧急；病情严重；,病情复杂；有剧烈疼痛；,应一律视作“饱胃”病人，慎重处理。,复苏是应优先采取的措施。,Parr和Grande建议了一个对创伤病人的处理程序。,I.Overview,A.Perform visual scan of patient for obvious injures.,B.Obtain history from prehospital personnel and,patient（if able）,.Primary survey（ascertain“ABCDEs”）,A.Airway maintenance（with cervical spine control）,1.Look for chest wall movements,retraction and,nasal flaring,2.Listen for breath sound,stridor,and obstructed,ventilation.,3.Feel for air movement,B.Breathing（give supplemental oxygen）,1.Determine whether ventilation is adequate,2.Inspect chest to exclude open pneumothorax,sucking chest wound,or flail segment,3.Ausculate for bilateral breath sounds,4.Provide assisted ventilation for ventilatory,failure,C.Circulation（establish venous access）,1.Check peripheral pulses,capillary refill,and blood pressure,2.Obtain electrocardiogram,3.Grade shock according to vital signs,4.Correct hypovolemia and obtain blood,samples,D.Disability（determine neurologic status）,1.Evaluate central function,A：alertV：responds to vocal stimulus,P：responds to painful stimulus,U：Unresponsive,2.Evaluate pupil response to light,E：Expose patient for complete examination,.Resuscitation phase,.Secondary surrey,.Definitive care phase,麻醉前的复苏治疗是提高麻醉、手术安全性的,重要环节。,主要包括：,1保存中枢神经系统功能。维持良好的脑,血流供应；注意避免造成继发性脊髓损伤；对,昏迷病人一般在药物治疗（如用甘露醇）前作气管,内插管和轻度过度通气。在作气管内插管时应注意,保持颈椎的稳定。,2保持气道通畅，充分供氧,（1）使用肌松药作经口腔气管内插管是最常用,的方法。,正确进行环状软骨加压。,对疑有颈椎损伤病人，插管时应由助手人工,固定病人头颈部以稳定颈椎。,（2）某些情况下行紧急气管内插管,（3）喉罩（LMA）可用于快速建立通,气途径,（4）纤支镜的应用,（5）气管造口术,3休克的复苏,建立能快速输液、输血的静脉通路。,对需输入大量液体或血液者，应注意,对输入的液体或血液加温。,对输入液体的选择：首先是恢复血容量，其次,考虑必需的血红蛋白浓度，最后是保持凝血机,制正常或基本正常。应注意晶、胶体比例，血,液的合理应用，必要时辅用血管活性药物。,75%氯化钠与胶体液的混合液的应用。,4应注意纠正酸碱平衡和电解质方面的紊乱。,5其他 如适当止痛，进行必要的监测等。,Changes in vital signs with percent blood volume lost in hemorrhage,Vital signs,15%,15%30%,30%40%,40%,Heart rate,100,120,120,140,Systolic blood pressure,Normal,Normal,Decreased,Decreased,Pulse pressupe,Normal,to,increased,Decreased,Decreased,Decreased,Capillary refill,Normal,Delayed,Delayed to,Absent,Absent,Respiratory rate,1420,2030,3040,35,CNS-mental status,Anxious,More anxious,Anxious,and,Confused,Confused,to,lethargic,麻醉处理要点,一、必须充分认识此类病人的麻醉特点,1严重创伤病人不能耐受深的全身麻醉，也,不能耐受其麻醉平面或范围可对病人的血流动力学,造成明显影响的椎管内麻醉。,2凡经肝代谢、经肾排泄的麻醉用药其作用,时间明显延长。,3应一律按“饱胃”病人处理。,4了解其麻醉前复苏情况，以便进一步处理。,5往往难于合作或已昏迷。,二、麻醉前用药与麻醉选择,1,麻醉用药,镇痛、镇静药物,抗胆碱药物,昏迷或危重病人免用或麻醉过程中酌用,小量，经静脉,2麻醉选择,（1）全身麻醉：多处伤或其他严重创伤、气管内插,管应避免采用在某些情况下不宜采,用的药物：,氯胺酮,琥珀胆碱,氧化亚氮,安氟醚、异氟醚等如用于脑外伤病人应用时采,用轻度过度通气，临床上多用异氟醚。,（,2）椎管内麻醉：椎管内麻醉所致的交感阻滞削,弱失血病人稳定其血流动力学的代偿能力。,（3）部位麻醉：较适用于肢体创伤手术的麻醉。,休克病人对局麻药的耐量降低。,三、适当的监测,有人将对创伤病人的监测汇总如下：,M