急診上消化道出血共識解讀王仲

1、2011-03,急性上消化道出血急診診治專家共識,中國醫(yī)師協(xié)會急診醫(yī)師分會,急診科特點-多界面的學科,人多開放輕重不一各種病人多項技術時間依賴性強……,EMD,消化科,呼吸科,外科,ICU,手術室,院前急救,保命是我們的第一任務,先開槍，后瞄準,急診判斷處理診斷治療,,門診診斷治療,固定靶射擊與雙向飛碟,上消化道出血概述,急診常見病之一潛在危險大定義：指屈氏韌帶以上的消化道(食管,胃,十二指腸,

2、 胰腺,膽道)的急性出血,是臨床常見急癥分類：非靜脈曲張性出血、靜脈曲張性出血常見病因：十二指腸潰瘍、胃潰瘍和食管靜脈曲張1,,概述,大多數(shù)急性上消化道出血病人首診于急診科，病人常以頭暈、乏力、暈厥等不典型癥狀就診急診醫(yī)師的職責：正確、迅速、合理地判斷和診治,哪些病人應當考慮急性上消化道出血,急性上消化道出血（或疑似）,以典型癥狀就診的患者，容易診斷（嘔血、黑便或血便，伴有周圍循環(huán)功能衰竭） 以不典型癥狀（頭暈

3、、乏力、暈厥等）就診的患者，急診醫(yī)師應保持高度警惕，積極明確或排除上消化道出血的診斷2-4,急診就診病人大出血比例高于門診病人門脈高壓病人出血更兇猛（6%）部分沒有肝病史的EVB病人上消化道出血病人以消化性潰瘍居多即使有肝病的病人，70%為潰瘍病出血……,輕與重——我們知道嗎？,大出血病人的緊急處理應當綜合考慮,他們多長時間死亡,即刻數(shù)分鐘數(shù)分鐘至小時小時至數(shù)天數(shù)天至數(shù)月數(shù)月至數(shù)十月,心源性猝死窒息大出血（內、外

4、）重癥感染腫瘤免疫病,緊急評估（即刻完成）,患者意識喪失、呼吸停止及大動脈搏動不能觸及立即開始心肺復蘇5,,,緊急評估,對未出現(xiàn)呼吸心跳停止的病人，首先進行意識狀態(tài)判斷Glassgow評分≤ 8分，表示病人昏迷，應對呼吸道采取保護措施,意識判斷,意識狀態(tài)評分表（Glassgow 評分）,急性血色素下降的結果,昏迷：自我保護能力的喪失，包括對氣道的保護,緊急評估,A. 氣道,B. 呼吸,C. 循環(huán),急性上消化道出血急診診治流程

5、,急性上消化道出血（或疑似）,緊急處置（2分鐘內完成）,心電、血壓、血氧飽和度持續(xù)監(jiān)測對嚴重出血的病人，開放靜脈通路，配血，液體復蘇意識障礙、排尿困難及所有休克患者留置尿管，記錄尿量患者絕對臥床，意識障礙患者將頭偏向一側，避免誤吸意識清楚，能夠配合的病人可留置胃管并沖洗肝硬化，食道胃底靜脈曲張出血及配合度差的病人留置胃管時慎重，避免加重出血7,常規(guī)處理,急性失血的循環(huán)影響,處理原則——保證灌注,,大出血的緊急處置,常用復蘇液體

6、：生理鹽水、平衡液、人工膠體和血液制品,液體復蘇,大出血的緊急處置,藥物治療是急性上消化道出血的首選治療手段,病情危重患者，特別是初次發(fā)病，既往病史不詳患者,靜脈應用生長抑素＋質子泵抑制劑（PPI）7，17,病因明確之前，可經(jīng)驗性聯(lián)合用藥9，12，16,上消化道大出血及高度懷疑靜脈曲張性出血時,血管加壓素＋抗生素14，18，19,以上基礎上聯(lián)用,明確病因后，再根據(jù)具體情況調整治療方案,初始藥物治療,大出血的緊急處置,常用藥物,,生長抑

7、素及其類似物,抑酸藥物,血管加壓素及其類似物,抗菌藥物,止血藥物,初始藥物治療,減少血流促進凝血,控制損害促進凝血,減少血流,促進凝血,大出血的緊急處置,生長抑素——14肽,減少內臟血流、降低門靜脈阻力抑制胃酸和胃蛋白酶分泌抑制胃腸道及胰腺肽類激素分泌,作用機制,肝硬化急性食道胃底靜脈曲張出血的首選藥物之一20，21急性非靜脈曲張出血的治療9,臨床應用,,大出血的緊急處置,A. 可迅速有效控制急性上消化道出血21B.

8、 預防早期再出血的發(fā)生22，23C. 有效預防內鏡治療后的肝靜脈壓力梯度（HVPG）升高， 從而提高內鏡治療的成功率24D. 可顯著降低消化性潰瘍出血患者的手術率E. 對于高危患者，選用高劑量生長抑素在改善患者內臟血流 動力學、出血控制率和存活率方面均優(yōu)于常規(guī)劑量20，23,特點,生長抑素,大出血的緊急處置,生長抑素用法,,,用法,大出血的緊急處置,生長抑素類似物,血管加壓素及其類似物,包括垂體后葉素

9、血管加壓素特利加壓素,抑酸藥物,PPI針劑埃索美拉唑：80mg bolus 80mg/h奧美拉唑: 80mg bolus 80mg/h泮妥拉唑蘭索拉唑雷貝拉唑H2RA雷尼替丁法莫替丁等,提高胃腸道內pH值促進血凝塊的形成，防止血凝塊溶解促進病變部位愈合,緊急處理中的其他藥物,抗菌藥物喹諾酮類抗菌素對喹諾酮類耐藥者也可使用頭孢類 抗菌素止血藥物：止血藥物的療效尚未證實，不推薦作為一線藥物使用,急性

10、上消化道大出血急診診治流程,急性上消化道出血（或疑似）,,二次評估——病因評估,在解除危及生命的情況、液體復蘇和初始經(jīng)驗治療開始后；或初次評估判斷病情較輕，生命體征穩(wěn)定的病人，開始進行二次評估——全面評估,病史 詳細詢問病史有助于對出血病因的初步判斷全面查體 重點注意血流動力學狀態(tài)、腹部、慢性肝臟疾病或 門脈高壓體征、直腸指診實驗室和輔助檢查 血

11、細胞分析、肝功能、腎臟功能和電解質、 凝血功能、血型、心電圖、胸片、腹部超聲,二次評估,病情嚴重程度的評估 病情嚴重度與失血量呈正相關。如根據(jù)血容量減少導致周圍循環(huán)的改變來判斷失血量，休克指數(shù)（心率/收縮壓）是判斷失血量的重要指標之一6，15,上消化道出血病情嚴重程度分級,注：休克指數(shù)=心率/收縮壓,二次評估,是否存在活動性出血的評估

12、 臨床上出現(xiàn)下列情況考慮有活動性出血,,,嘔血或黑便次數(shù)增多，嘔吐物呈鮮紅色或排出暗紅血便，或伴有腸鳴音活躍,經(jīng)快速輸液輸血，周圍循環(huán)衰竭的表現(xiàn)未見明顯改善，或雖暫時好轉而又再惡化，中心靜脈壓仍有波動，稍穩(wěn)定又再下降,,,,紅細胞計數(shù)、血紅蛋白測定與Hct 繼續(xù)下降，網(wǎng)織紅細胞計數(shù)持續(xù)增高,補液與尿量足夠的情況下，血尿素氮持續(xù)或再次增高,胃管抽出物有較多新鮮血,1,2,3,4,5,二次評估,出血預后的評估,急性上消化道出血急診診治流程,

13、急性上消化道出血（或疑似）,藥物治療,,內鏡,內鏡檢查為上消化道出血病因診斷的關鍵檢查47，應盡量在出血后24～48h內進行；藥物與內鏡聯(lián)合治療是目前首選的治療方式24，26，47，48，內鏡治療方法的選擇請參加消化專業(yè)有關指南8，13，14，19,急性上消化道出血急診診治流程,急性上消化道出血（或疑似）,緊急處置,二次評估,藥物治療+內鏡聯(lián)合治療,,,,,治療后再次評估,經(jīng)上述治療后再次評估患者出血是否得到有效控制。若仍可能存在活動性

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