上海交大外科學(xué)休克pbl課件

外科休克

ShockTerm“choc”

–Frenchfor“push”orimpactwasfirstpublishedin1743bythephysicianLeDranAboutmyselfName:費(fèi)健Email:feijian@Mobile:137-0176-9798開始了大家要專心啊A22yearoldmanwasdrivingdrunkandwithouthisseatbeltfastenedwhenhewasinvolvedinasingle-vehicleautomobileaccident.WhenattendedbyEMT（abbr.emergencymedicaltechnician急診醫(yī)士）personnel,noinformationwasavailableaboutthetimeoftheaccident.Hewasfoundagitatedandcomplainingofabdominalpain.

Hisairwaywaspatent.Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Hewasplacedinahardcervicalcollarandonabackboardandtransportedtoyouremergencyroom.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage（灌洗）revealsgrossblood.

Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage（灌洗）revealsgrossblood.

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(guò)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(dòng)力學(xué)的特點(diǎn)低排高阻型休克（低動(dòng)力型休克，冷休克）高排低阻型休克（高動(dòng)力型休克，暖休克）StudyQuestions2:

Whatalterationsinoxygendeliveryarepresent?

Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage（灌洗）revealsgrossblood.

單位時(shí)間內(nèi)通過(guò)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Section2.Localfeedbackregulationofcapillaryperfusion：

ConstrictionofPre-capillaryDecreasedbloodLocalaccumulationofsphincterandPost-arterioleflowofproductsandhistaminetruecapillarynet

IncreasedresponseDecreasedresponseofSMCtoofSMCtoVasoconstrictiveagentsVasoconstrictiveagents

IncreasedbloodClearanceofhistamineandflowofRelaxationofpre-capillarymetabolicproductstruecapillarynetsphincterandpost-arteriole

Constriction

Relaxation真毛細(xì)血管開放調(diào)節(jié)示意圖后微動(dòng)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,腺苷增多平滑肌對(duì)縮血管物質(zhì)反應(yīng)性升高后微動(dòng)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(duì)縮血管物質(zhì)反應(yīng)性降低

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

氧代謝動(dòng)力學(xué)監(jiān)測(cè)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)：?jiǎn)挝粫r(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(dòng)脈血氧飽和度和氧分壓)、血紅蛋白、心臟指數(shù)。正常值，500-600ml/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。Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage（灌洗）revealsgrossblood.

氧代謝障礙組織細(xì)胞缺氧是休克的本質(zhì)問(wèn)題缺氧無(wú)氧代謝增加

ATP生成減少肝功能下降乳酸大量產(chǎn)生 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

MODSStudyQuestions4:

Whatistheeffectofthiskindofshockonthekidneys,theheart,thelungs,thebrain,theintestine?

Atthescene,hewasbreathingat20perminutewithabloodpressureof90/60andapulseof130.Uponarrivalhisvitalsignsarethesame,withatemperatureof36oC.

Hisabdomenismarkedlydistended.Hishandsandfeetarecold,hislegsmottled.Anasogastrictuberevealsgreenliquid.Aurinarycatheterrevealsdarkyellowurine.Hishemoglobinis7.Hisabdominallavage（灌洗）revealsgrossblood.

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(wú)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(guò)快而舒張期過(guò)短或舒張期壓力下降時(shí)，冠狀動(dòng)脈的血流減少，由此引起的