上海交大外科學(xué)休克pbl

1、外科休克Shock,Term “choc” – French for “push” or impact was first published in 1743 by the physician LeDran,About myself,Name: 費(fèi) 健Email: feijian@hotmail.comMobile:137-0176-9798,開始了大家要專心啊,一個(gè)例子八大問題,,A 22 year old man

2、 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 急診醫(yī)士） personnel, no information was available ab

3、out the time of the accident. He was found agitated and complaining of abdominal pain.,,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

4、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 36oC.,,His abdomen is markedly distended. His hands and feet

5、 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.,,Study Questions 1:What type of

6、 shock does this patient exhibit?,,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 36oC. His abdomen is

7、 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 b

8、lood.,,休克的原因和分類,按病因?qū)W分類　一、失血失液性休克:　二、創(chuàng)傷性休克：　三、感染性休克：　四、心源性休克：　五、過敏性休克：　六、神經(jīng)源性休克：,大出血，腹瀉，劇烈嘔吐等,疼痛和失血,內(nèi)毒素,大面積心肌梗死，心包填塞,青霉素，血清制劑或疫苗,高位脊髓麻醉或損傷,按血流動力學(xué)的特點(diǎn)低排高阻型休克（低動力型休克，冷休克）高排低阻型休克（高動力型休克，暖休克）,低血容量性休克失血性休克損傷性休克感染性休克

9、心源性休克神經(jīng)源性休克過敏性休克,休克的分類,,,,外科休克,,Study Questions 2: What alterations in oxygen delivery are present?,,At the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. Upon arrival h

10、is vital signs are the same, with a temperature of 36oC. 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 yell

11、ow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood.,,單位時(shí)間內(nèi)通過心血管系統(tǒng)進(jìn)行循環(huán)的血量-- 有效循環(huán)血量不包括貯存在肝、脾、淋巴血竇、淤滯于毛細(xì)血管中的血量,依賴于充足的血容量有效的心排量良好的周圍血管張力,,,有效循環(huán)血量,休 克,代謝障礙細(xì)胞受損,組織血液灌注不足,有效循環(huán)血量銳減,,

12、微循環(huán)障礙微循環(huán)收縮期微循環(huán)擴(kuò)張期DIC期,休克的病理生理,,,,,,,,,,,,,,,,,,,Section 2.,,,Local feedback regulation of capillary perfusion： Constriction of Pre-capillary Decreased blood Local accumulation of sphincter an

13、d Post-arteriole flow of products and histamine true capillary net   Inc

14、reased response Decreased response of SMC to of SMC to Vasoconstrictive

15、 agents Vasoconstrictive agents  Increased blood Clearance of histamine and flow of

16、 Relaxation of pre-capillary metabolic products true capillary net sphincter and post-arteriole,Constriction,Relaxation,真毛細(xì)血管開放調(diào)節(jié)示意圖,后微動脈與毛細(xì)血管前括約肌收縮,真毛細(xì)血管血流量減少,局部組織激肽,組胺,乳酸,腺苷增多,平

17、滑肌對縮血管物質(zhì)反應(yīng)性升高,后微動脈與毛細(xì)血管前括約肌舒張,局部組織激肽,組胺,乳酸,腺苷減少,真毛細(xì)血管血流量增多,平滑肌對縮血管物質(zhì)反應(yīng)性降低,,,,,,,,,休克Ⅰ期 （缺血性缺氧期） 微循環(huán)變化： 微血管、毛細(xì)血管前括約肌痙攣性 收縮,毛細(xì)血管缺血、缺氧,動-靜 脈短路、直捷通路開放

18、 少灌少流 灌少于流,,,,休克Ⅱ期（淤血性缺氧期） 微循環(huán)變化： 微血管擴(kuò)張，毛細(xì)血管前括約肌 松弛，靜脈內(nèi)血流緩慢、淤滯， 毛細(xì)血管淤血、缺氧 多灌少流，灌大于流,,,,休克Ⅲ期（微循環(huán)衰竭期、DIC期） 微循環(huán)變化： 微血管麻痹性擴(kuò)張，毛細(xì)血

19、管內(nèi) 血流停滯，出現(xiàn)大量的微血栓。 　　　　　　　　　　　　　不灌不流,,,,氧代謝動力學(xué)監(jiān)測,1.全身氧代謝：氧輸送、氧耗量、氧攝取及混合靜脈血 氧分壓①氧輸送(DO2)：單位時(shí)間內(nèi)心臟泵血提供給組織細(xì)胞的氧量。受三個(gè)因素影響，呼吸功能(動脈血氧飽和度和氧分壓)、血紅蛋白、心臟指數(shù)。正常值，500

20、-600ml/min.m2②氧耗量(VO2):單位時(shí)間內(nèi)組織器官所消耗的氧量。 160-220ml/min.m2。③氧攝取率(O2ER):單位時(shí)間內(nèi)組織的氧耗量占氧輸送 的比率，正常20-30%.④氧 需: 機(jī)體單位時(shí)間內(nèi)維持組織細(xì)胞正常代謝 所需的氧量。,,⑤氧債：機(jī)體的氧耗量不能滿足正常代謝，即氧需與氧耗量的差值。⑥血乳酸濃度：血乳酸越高，表

21、示微循環(huán)障礙越重。⑦混合靜脈血氧飽和度(SvO2)或血氧分壓(PvO2):正常值>65%和 >40mmHg⑧經(jīng)皮動脈血氧飽和度(SaO2):>94%,Study Questions 3: What acid/base category would be expected?,,At the scene, he was breathing at 20 per minute with a blood pressur

22、e of 90/60 and a pulse of 130. Upon arrival his vital signs are the same, with a temperature of 36oC. His abdomen is markedly distended. His hands and feet are cold, his legs mottled. A nasogastric tube reveals green

23、liquid. A urinary catheter reveals dark yellow urine. His hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood.,,氧代謝障礙,組織細(xì)胞缺氧是休克的本質(zhì)問題缺氧無氧代謝增加 ATP生成減少 肝功能下降 乳酸大量產(chǎn)生

24、 乳酸代謝降低 代謝性酸中毒 組織細(xì)胞器功能降低 組織功能降低 MODS,,,,,,,,,,,Study Questions 4:What is the

25、 effect of this kind of shock on the kidneys, the heart, the lungs, the brain, the intestine?,,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 sig

26、ns are the same, with a temperature of 36oC. 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. H

27、is hemoglobin is 7. His abdominal lavage（灌洗）reveals gross blood.,,內(nèi)臟器官損傷,休克失代償 內(nèi)臟缺血、缺氧 內(nèi)臟血管內(nèi)皮細(xì)胞受損全身炎癥反應(yīng)綜合征 MODS,,,,,,內(nèi)臟器官的繼發(fā)性損害⒈肺：,⒉腎：休克時(shí)由于腎血

28、管收縮、血流量減少、引起急性腎衰竭，表現(xiàn)少尿（每日尿量＜400ml）嚴(yán)重者無尿（每日尿量＜100ml）。,,⒊心：由于冠脈灌流量的80％發(fā)生于舒張期，當(dāng)心率過快而舒張期過短或舒張期壓力下降時(shí)，冠狀動脈的血流減少，由此引起的缺氧和酸中毒可導(dǎo)致心肌損害。當(dāng)心肌微循環(huán)內(nèi)血栓形成，還可引起心臟局灶性壞死，此外，電解質(zhì)的失衡也將加重心臟損害 。,⒋腦：休克早期，腦血流影響不大，但當(dāng)動脈血壓持續(xù)性下降，最終也會引起腦灌注壓和血流量