外科学休克pbl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,第二级,第三级,第四级,第五级,*,About myself,Name:,费 健,Email:feijianhotmail,Mobile:137-0176-9798,About myselfName:费 健,1,开始了,大家要专心啊,开始了,2,一个例子八大问题,一个例子八大问题,3,A 22 year old man was driving drunk and without his seatbelt fastened when he was involved in a single-vehicle automobile accident.When attended by EMT,（,abbr.emergency medical technician,急诊医士,）,personnel,no information was available about the time of the accident.He was found agitated and complaining of abdominal pain.,A 22 year old man was driving,4,His airway was patent.At the scene,he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130.He was placed in a hard cervical collar and on a back board and transported to your emergency room.Upon arrival his vital signs are the same,with a temperature of 36,o,C.,His airway was patent.At the,5,His abdomen is markedly distended.His hands and feet are cold,his legs mottled.A nasogastric tube reveals green liquid.A urinary catheter reveals dark yellow urine.His hemoglobin is 7.His abdominal lavage,（,灌洗,）,reveals gross blood.,His abdomen is markedly disten,6,Study Questions 1:What type of shock does this patient exhibit?,Study Questions 1:What type,7,At the scene,he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130.Upon arrival his vital signs are the same,with a temperature of 36,o,C.His abdomen is markedly distended.His hands and feet are cold,his legs mottled.A nasogastric tube reveals green liquid.A urinary catheter reveals dark yellow urine.His hemoglobin is 7.His abdominal lavage,（,灌洗,）,reveals gross blood.,At the scene,he was breathing,8,休克的原因和分类,按,病因学,分类,一、失血失液性休克,:,二、创伤性休克：,三、感染性休克：,四、心源性休克：,五、过敏性休克：,六、神经源性休克：,大出血，腹泻，剧烈呕吐等,疼痛和失血,内毒素,大面积心肌梗死，心包填塞,青霉素，血清制剂或疫苗,高位脊髓麻醉或损伤,休克的原因和分类按病因学分类大出血，腹泻，剧烈呕吐等疼痛和失,9,按,血流动力学,的特点,低排高阻型休克（低动力型休克，冷休克）,高排低阻型休克（高动力型休克，暖休克）,按血流动力学的特点,10,低血容量性休克,失血性休克,损伤性休克,感染性休克,心源性休克,神经源性休克,过敏性休克,休克的分类,外科休克,低血容量性休克休克的分类外科休克,11,Study Questions 2:What alterations in oxygen delivery are present?,Study Questions 2:What alt,12,At the scene,he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130.Upon arrival his vital signs are the same,with a temperature of 36,o,C.His abdomen is markedly distended.His hands and feet are cold,his legs mottled.A nasogastric tube reveals green liquid.A urinary catheter reveals dark yellow urine.His hemoglobin is 7.His abdominal lavage,（,灌洗,）,reveals gross blood.,At the scene,he was breathing,13,单位时间内通过心血管系统进行循环的血量,-,有效循环血量,不包括贮存在肝、脾、淋巴血窦、淤滞于毛细血管中的血量,单位时间内通过心血管系统进行循环的血量-,14,依赖于,充足的血容量,有效的心排量,良好的周围血管张力,有效循环血量,休 克,代谢障碍细胞受损,组织血液灌注不足,有效循环血量锐减,依赖于有效循环血量休 克代谢障碍细胞受损组织血,15,微循环障碍,微循环收缩期,微循环扩张期,DIC,期,休克的病理生理,微循环障碍休克的病理生理,16,Section 2.,Local feedback regulation,of capillary perfusion,：,Constriction of Pre-capillary Decreased blood Local accumulation of,sphincter and Post-arteriole flow of products and histamine,true capillary net,Increased response Decreased response,of SMC to of SMC to,Vasoconstrictive agents Vasoconstrictive agents,Increased blood,Clearance of histamine and flow of Relaxation of pre-capillary,metabolic products true capillary net,s,phincter and post-arteriole,Constriction,Relaxation,Section 2.Local feedback r,17,真毛细血管开放调节示意图,后微动脉与毛细血管前括约肌收缩,真毛细血管血流量减少,局部组织激肽,组胺,乳酸,腺苷增多,平滑肌对缩血管物质反应性升高,后微动脉与毛细血管前括约肌舒张,局部组织激肽,组胺,乳酸,腺苷减少,真毛细血管血流量增多,平滑肌对缩血管物质反应性降低,真毛细血管开放调节示意图后微动脉与毛细血管前括约肌收缩真毛细,18,休克,期（缺血性缺氧期）,微循环变化：,微血管、毛细血管前括约肌痉挛性,收缩,毛细血管缺血、缺氧,动,-,静,脉短路、直捷通路开放,少灌少流 灌少于流,休克期（缺血性缺氧期）,19,外科学休克pbl课件,20,休克,期（淤血性缺氧期）,微循环变化：,微血管扩张，毛细血管前括约肌,松弛，静脉内血流缓慢、淤滞，,毛细血管淤血,、缺氧,多灌少流，灌大于流,休克期（淤血性缺氧期）,21,外科学休克pbl课件,22,休克,期（,微循环衰竭期、,DIC,期,）,微循环变化：,微血管麻痹性扩张，毛细血管内,血流停滞，出现大量的微血栓。,不灌不流,休克期（微循环衰竭期、DIC期）,23,外科学休克pbl课件,24,氧代谢动力学监测,1.,全身氧代谢：氧输送、氧耗量、氧摄取及混合静脉血 氧分压,氧输送,(DO,2,),：单位时间内心脏泵血提供给组织细胞的氧量。受三个因素影响，呼吸功能,(,动脉血氧饱和度和氧分压,),、血红蛋白、心脏指数。正常值，,500-600ml/min.m,2,氧耗量,(VO,2,):,单位时间内组织器官所消耗的氧量。,160-220,ml/min.m,2,。,氧摄取率(,O,2,ER):,单位时间内组织的氧耗量占氧输送,的比率，正常20-30%.,氧 需,:,机体单位时间内维持组织细胞正常代谢 所需的氧量。,氧代谢动力学监测1.全身氧代谢：氧输送、,25,氧债：机体的氧耗量不能满足正常代谢，即氧需与氧耗量的差值。,血乳酸浓度：血乳酸越高，表示微循环障碍越重。,混合静脉血氧饱和度,(SvO,2,),或血氧分压,(PvO,2,):,正常值,65%,和,40mmHg,经皮动脉血氧饱和度,(SaO,2,):94%,氧债：机体的氧耗量不能满足正常代谢，即氧需与氧耗量的差,26,Study Questions 3:What acid/base category would be expected?,Study Questions 3:What aci,27,At the scene,he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130.Upon arrival his vital signs are the same,with a temperature of 36,o,C.His abdomen is markedly distended.His hands and feet are cold,his legs mottled.A nasogastric tube reveals green liquid.A urinary catheter reveals dark yellow urine.His hemoglobin is 7.His abdominal lavage,（,灌洗,）,reveals gross blood.,At the scene,he was breathing,28,氧代谢障碍,组织细胞缺氧是休克的本质问题,缺氧,无氧代谢增加,ATP,生成减少,肝功能下降,乳酸大量产生,乳酸代谢降低 代谢性酸中毒,组织细胞器功能降低,组织功能降低,MODS,氧代谢障碍组织细胞缺氧是休克的本质问题,29,Study Questions 4:What is the effect of this kind of shock on the kidneys,the heart,the lungs,the brain,the intestine?,Study Questions 4:What is t,30,At the scene,he was breathing at 20 per minute with a blood pressure of 90/60 and