顱腦損傷英文版

“Boy,doIhaveanExcedrinheadache!!”

managingtheheadinjuredpatientLeaugeayWebreBS,CCEMT-P,NREMT-P第1頁(yè)ScenarioWhiledescendingMtHoodinOregon,Bobtumbledheadoverheels,andcametoastopdanglingoffaprecipicebyhisTelemarkskiat11,000ft.OnarrivaltheskipatrolparamedicsBob’sbreathingwassonorousandshallow,andhehadaGCSof3-4.Theonlyobviousinjuriesweretohishead.HisBPwas87/55,HR100andRR16第2頁(yè)

Howshouldtheparamedicstreatthispatient?Shouldhebeintubated?Shouldhebefluidresuscitated?第3頁(yè)Commonmajortrauma4millionpeopleexperienceheadtraumaannuallySevereheadinjuryismostfrequentcauseoftraumadeathGSWtocranium:75-80%mortalityAtRiskpopulationMales15-24InfantsYoungChildrenElderlyIntroductiontoHead,Facial,

&NeckInjuries第4頁(yè)TIMEISCRITICALIntracranialHemorrhageProgressingEdemaIncreasedICPCerebralHypoxiaPermanentDamageSeverityisdifficulttorecognizeSubtlesignsImprovedifferentialdiagnosisImprovessurvivabilityIntroductiontoHead,Facial,

&NeckInjuries第5頁(yè)ScalpStrongFlexiblemassofSkinFasciaMuscularTissueHighlyVascularHairprovidesInsulationStructuresBeneathGaleaAponeuroticaBetweenscalpandskullFibrousconnectivesheathSubaponeurotica(Areolar)TissuePermitsvenousbloodflowfromtheduralsinusestothevenousvesselsofscalpEmissaryVeins:PotentialrouteforInfectionAnatomy&Physiology

oftheHead第6頁(yè)P(yáng)arietalSutureLineFrontalTemporalOrbitsMaxillaeMandibleTemporalMandibularJointOcciptalNasalBonesZygomaticArchSphenoidForamenMagnum(HoleinBase)Cranium第7頁(yè)第8頁(yè)第9頁(yè)BrainOccupies80%ofcraniumComprisedof3MajorStructuresCerebrumCerebellumBrainstemHighmetabolicrateReceives15%ofcardiacoutputConsumes20%ofbody’soxygenRequiresconstantcirculationIFBloodsupplystopsUnconsciouswithin10secondsDeathin4-6minutesAnatomy&Physiology

oftheHead第10頁(yè)CerebralPerfusionPressurePressurewithincranium(ICP)resistsbloodflowandgoodperfusiontotheCNSPressureusuallylessthan10mmHgMeanArterialPressure(MAP)Mustbeatleast50mmHgtoensureadequateperfusionMAP=DBP+1/3PulsePressureCerebralPerfusionPressure(CPP)PressuremovingbloodthroughthecraniumCPP=MAP-ICPAnatomy&Physiology

oftheHead第11頁(yè)CalculatingMAP(meanarterialpressure)DBP+1/3PPPP(pulsepressure)=SBP-DBPSBP+2(DBP)3CalculatingCPP(cerebralperfusionpressure)MAP–ICPICPnormally<10Anatomy&Physiology

oftheHead第12頁(yè)CerebralPerfusionPressureAutoregulationChangesinICPresultincompensationIncreasedICP=IncreasedBPThiscausesICPtorisehigherandBPtoriseBraininjuryanddeathbecomeimminentExpandingmassinsidecranialvaultDisplacesCSFIfpressureincreases,braintissueisdisplacedAnatomy&Physiology

oftheHead第13頁(yè)FaceMusclesMChewingmusclesMPosteriorpalateandpharynxMFaceMusclesMSightSOpticIIPupilConst,Rectus&ObliquesMOculomotorIIIOpthalmic(FH),Maxillary(cheek)Mandible(chin)STrigeminalVLateralrectusmuscleMAbducensVITastetoposteriortongueSVagusXTongueMHypoglossalXIITrapezius&Sternocleido.MusclesMAccessoryXIHearingbalanceSAcousticVIIISuperiorObliquesMTrochlearIVTongueSFacialVIIPosteriorpharynx,tastetoanteriortongueSGlossopharyn-

gealIXSmellSOlfactoryIInnervationFNameCN第14頁(yè)TypesofTraumaSofttissueSkullfracturePrimarybraininjuriesSecondarybraininjuries第15頁(yè)Thepatientpresentedtotheemergencydepartmentwiththegolfcubinhishead,whichwasremovedintheoperatingroom第16頁(yè)Lateralskullx-rayofapatientwhopresentedwithasevereintracranialinjuryproducedbyagolfclub第17頁(yè)ScalpInjuryContusionsLacerationsAvulsionsSignificantHemorrhageALWAYSReconsiderMOIforsevereunderlyingproblems第18頁(yè)BrainInjuryAsdefinedbytheNationalHeadInjuryFoundation“atraumaticinsulttothebraincapableofproducingphysical,intellectual,emotional,socialandvocationalchanges.”ClassificationDirectPrimaryinjurycausedbyforcesoftraumaIndirectSecondaryinjurycausedbyfactorsresultingfromtheprimaryinjury第19頁(yè)DirectBrainInjuryTypesCoupInjuryatsiteofimpactContrecoupInjuryonoppositesidefromimpact第20頁(yè)IntracranialPerfusionReviewCranialvolumefixed80%=Cerebrum,cerebellum&brainstem12%=Bloodvessels&blood8%=CSFIncreaseinsizeofonecomponentdiminishessizeofanotherInabilitytoadjust=increasedICP第21頁(yè)IntracranialPerfusionCompensatingforPressureCompressvenousbloodvesselsReductioninfreeCSFPushedintospinalcordDecompensatingforPressureIncreaseinICPRiseinsystemicBPtoperfusebrainFurtherincreaseofICPDangerouscycleICPBP第22頁(yè)IntracranialPressureRoleofCarbonDioxideIncreaseofCO2inCSFCerebralVasodilationEncouragebloodflowReducehypercarbiaReducehypoxiaContributesto

ICPCausesclassicHyperventilation&HypertensionReducedlevelsofCO2inCSFCerebralvasoconstrictionResultsincerebralanoxia第23頁(yè)FactorsAffectingICPVasculatureConstrictionCerebralEdemaSystolicBloodPressureLowBP=PoorCerebralPerfusionHighBP=IncreasedICPCarbonDioxideReducedrespiratoryefficiency第24頁(yè)IncreasedpressureCompressesbraintissueAgainst&aroundFalxCerebriTentoriumCerebelliHerniatesbrainstemCompromisesbloodsupplySigns&SymptomsUpperBrainstemVomitingAlteredmentalstatusPupillarydilationMedullaOblongataRespiratoryCardiovascularBloodPressuredisturbancesPressure&StructuralDisplacement第25頁(yè)AlteredMentalStatusAlteredorientationAlterationinpersonalityAmnesiaRetrogradeAntegradeCushing’sReflexIncreasedBPBradycardiaErraticrespirationsSigns&Symptoms

ofBrainInjuryVomitingWithoutnauseaProjectileBodytemperaturechangesChangesinpupilreactivityDecorticateposturing第26頁(yè)P(yáng)athophysiologyofChangesFrontalLobeInjuryAlterationsinpersonalityOccipitalLobeInjuryVisualdisturbancesCorticalDisruptionReducementalstatusorAmnesiaRetrogradeUnabletorecalleventsbeforeinjuryAntegradeUnabletorecalleventsaftertrauma“RepetitiveQuestioning”FocalDeficitsHemiplegia,WeaknessorSeizuresSigns&Symptoms

ofBrainInjury第27頁(yè)UpperBrainstemCompressionIncreasingbloodpressureReflexbradycardiaVagusnervestimulationCheyne-StokesrespirationsPupilsbecomesmallandreactiveDecorticateposturingNeuralpathwaydisruptionSigns&SymptomsofBrainInjury

PhysiologicalChanges第28頁(yè)MiddleBrainstemCompressionWideningpulsepressureIncreasingbradycardiaCNSHyperventilationDeepandRapidBilateralpupilsluggishnessorinactivityDecerebrateposturingSigns&SymptomsofBrainInjury

PhysiologicalChanges第29頁(yè)LowerBrainstemInjuryPupilsdilatedandunreactiveAtaxicrespirationsErraticwithnopatternIrregularanderraticpulserateECGChangesHypotensionLossofresponsetopainfulstimuliSigns&SymptomsofBrainInjury

PhysiologicalChanges第30頁(yè)DifferentpathologythanolderpatientsSkullcandistortduetoanteriorandposteriorfontanellesBulgingSlowsprogressionofincreasingICPIntracranialhemorrhagecontributestohypovolemiaDecreasedbloodvolumeinped’sGeneralManagementAvoidhyperextensionofheadTonguepushessoftpalletclosedVentilatethroughmouthandnoseSigns&SymptomsofBrainInjury

PediatricHeadTrauma第31頁(yè)Signs&SymptomsofBrainInjury

GlasgowComaScale第32頁(yè)P(yáng)hysiologicalIssuesIndicatepressureonCN-II,CN-III,CN-IV,&CN-VICN-III(OculomotorNerve)Pressureonnervecauseseyestobesluggish,thendilated,andfinallyfixedReducedperipheralbloodflowPupilSize&ReactivityReducedPupillaryResponsivenessDepressantdrugsorCerebralHypoxiaFixed&DilatedExtremeHypoxiaSigns&SymptomsofBrainInjury

EyeSigns第33頁(yè)SkullFracturesTheskullwillnotfracturewithoutextremeforceClosed/openlineardepressedcomminutedbasilarimpaledobject第34頁(yè)CranialInjuryTraumamustbeextremetofractureLinearDepressedOpenImpaledObjectBasalSkullUnprotectedSpacesweaken

structureRelatively

easiertofracture第35頁(yè)CranialInjuryBasalSkullFractureSignsBattle’sSignsRetroauricularEcchymosisAssociatedwithfractureof

auditorycanalandlower

areasofskullRaccoonEyesBilateralPeriorbital

EcchymosisAssociatedwithorbital

fractures第36頁(yè)CranialInjuryBasilarSkullFractureMaytearduraPermitCSFtodrainthroughanexternalpassagewayMaymediateriseofICPEvaluatefor“Target”or“Halo”sign第37頁(yè)BasilarSkullFractureCribiformplatefractureBattle’ssignPeriorbitalecchymosisCSFleakage第38頁(yè)P(yáng)rimaryBrainInjuryResultsfromdirecttraumaFocalDiffuse第39頁(yè)DirectBrainInjuryCategoriesFocalOccurataspecificlocationinbrainDifferentialsCerebralContusionIntracranialHemorrhageEpiduralhematomaSubduralhematomaIntracerebralHemorrhageSubarachnoidHemorrhageDiffuseConcussionModerateDiffuseAxonalInjurySevereDiffuseAxonalInjury第40頁(yè)FocalContusionsIntracerebralhematomaSubduralhematomaSubarachnoidhematomaEpiduralhematoma第41頁(yè)ContusionsLOCwithresultantcellulardamage“bruising”Temporalinjuryoftenpresentswithrepetitivequestioning第42頁(yè)Ayoungmalearrivedintheemergencydepartmentafterexperiencingagunshotwoundtothebrain.Theentrancewasontheleftoccipitalregion.ACTscanshowstheskullfractureandalargeunderlyingcerebralcontusion.Thepatientwastakentotheoperatingroomfordebridementofthewoundandskullfracture,withrepairoftheduramater第43頁(yè)FocalBrainInjuryCerebralContusionBlunttraumatolocalbraintissueCapillarybleedingintobraintissueCommonwithbluntheadtraumaConfusionNeurologicdeficitPersonalitychangesVisionchangesSpeechchangesResultsfromCoup-contrecoupinjury第44頁(yè)EpiduralHematomaLocatedbetweenskullandduramaterUsuallyinvolvesarterialbleeding-middlemeningealarterySharplydefinededgesonCTUsuallynounderlyingbraininjuryClassicalpresentationis“l(fā)ucidinterval”Mayquicklyevolveintoherniation第45頁(yè)LucidIntervaltransientLOCfollowedbyalucidperiodwherepatientisneurologicallyintactfollowedbyasecondaryonsetofHAanddecreasingLOC第46頁(yè)EpiduralHematomaBleedingbetweenduramaterandskullInvolvesarteriesMiddlemeningealarterymostcommonRapidbleeding&reductionofoxygentotissuesHerniatesbraintowardforamenmagnumFocalBrainInjury

IntracranialHemorrhage第47頁(yè)CTscanofanacuteleft-sidedepiduralhematoma.Notethetypicalconvexorlens-shapedappearance.Thehematomatakesthisshapeasthedurastripsfromtheundersurfaceofthecranium,limitedbythesuturelines.Amidline

shiftoftheventricularsystemexists.第48頁(yè)SubduralHematomaLocatedbetweentheduramaterandpiamaterAllvenousbleeds,usuallypresentwithslowonsetIndistinctonCTUnderlyingbraininjuryMaynotpresentwithSxforhoursordays第49頁(yè)SubduralHematomaBleedingwithinmeningesBeneathduramater&withinsubarachnoidspaceAbovepiamaterSlowbleedingSuperiorsagitalsinusSignsprogressoverseveraldaysSlowdeteriorationofmentationFocalBrainInjury

IntracranialHemorrhage第50頁(yè)Acutesubduralhematoma:notethebright(white)imagepropertiesofthebloodonthisnoncontrastcranialCTscan.Notealsothemidlineshift.第51頁(yè)Subacutesubduralhematoma:thecrescent-shapedclotislesswhitethanonCTscanofacutesubduralhematoma

第52頁(yè)IntracerebralHemorrhageRupturebloodvesselwithinthebrainPresentationsimilartostrokesymptomsSignsandsymptomsworsenovertimeFocalBrainInjury

IntracranialHemorrhage第53頁(yè)IntracerebralHematoma LocatedinthebrainparenchymaDifficulttodistinguishfromcontusion第54頁(yè)Intracranialhemorrhage.CTscanofrightfrontalintracerebralhemorrhagecomplicatingthrombolysisofanischemicstroke.第55頁(yè)SubarachnoidHemorrhageMaynotpresentwithphysicalfindingsHAstiffnecknuchalrigidityBloodinCSF第56頁(yè)BrainCTscanshowssubtlefindingofbloodattheareaofthecircleofWillisconsistentwithacutesubarachnoidhemorrhage.第57頁(yè)DiffuseBrainInjuryDuetostretchingforcesplacedonaxonsPathologydistributedthroughoutbrainTypesConcussionModerateDiffuseAxonalInjurySevereDiffuseAxonalInjury第58頁(yè)ConcussionTransientLOCUsuallycompleterecoveryMildformofdiffuseinjuryOftenpresentswithabriefperiodofconfusionPtmayexhibitretrogradeorposttraumaticamnesia第59頁(yè)DiffuseAxonalInjuryRapid,profound,prolongedunconsciousnessOftenleadstoincreasedICP第60頁(yè)MildtomoderateformofDiffuseAxonalInjury(DAI)NervedysfunctionwithoutanatomicdamageTransientepisodeofConfusion,Disorientation,EventamnesiaSuspectifpatienthasamomentarylossofconsciousnessManagementFrequentreassessmentofmentationABC’sDiffuseBrainInjury

Concussion第61頁(yè)“ClassicConcussion”SamemechanismasconcussionAdditional:MinutebruisingofbraintissueUnconsciousnessIfcerebralcortexandRASinvolvedMayexistwithabasilarskullfractureSigns&SymptomsUnconsciousnessorPersistentconfusionLossofconcentration,disorientationRetrograde&AntegradeamnesiaVisualandsensorydisturbancesMoodorPersonalitychangesDiffuseBrainInjury

ModerateDiffuseAxonalInjury第62頁(yè)BrainstemInjurySignificantmechanicaldisruptionofaxonsCerebralhemispheresandbrainstemHighmortalityrateSigns&SymptomsProlongedunconsciousnessCushing’sreflexDecorticateorDecerebrateposturingDiffuseBrainInjury

SevereDiffuseAxonalInjury第63頁(yè)第64頁(yè)P(yáng)athwayofDeteriorationCranialinsultTissueedemaIncreasingICPCompressionofarteriesDecreasedcerebralbloodflowDecreasedO2withcellulardeathEdemaaroundnecrotictissue第65頁(yè)Con’tIncreasingICPwithcompressionofbrainstemandrespiratorycenterAccumulationofCO2resultinginvasodilationIncreasingbloodvolumefurtherincreasingICPDeath第66頁(yè)AnyswellingorbleedingdecreasesthecirculatingbloodvolumeandcerebralbloodflowDecreasedcerebralbloodflowresultsinhypoxiaandCO2risesHypercarbiadilatescerebralbloodvesselscausingincreasingBPAttemptstoperfusebrainresultinginincreasedICP第67頁(yè)HerniationDepressionof3rdcranialnerveresultsinpupillarydilation-aniscoriaLateralparesisCushing’striadDecorticateposturingDecerebrateposturing第68頁(yè)DecorticatePosturingResultsfromlesionsofinternalcapsules,basalganglia,thalamusorcerebralhemisphereInterruptscorticospinalpathwaysPresentswithflexedarmsandextendedlowerextremities第69頁(yè)DecerebratePosturingResultsfrominjurytomidbrainandponsIndicativeofbrainstemdysfunctionPresentswithextendedupperextremitiesandpronationExtendedlowerextremitiesUsuallyindicativeofgraverinjury第70頁(yè)Cushing’sReflexLatesignofincreasingICPBradycardiaWideningpulsepressure/increasingBPChangesinrespiratorypatterns第71頁(yè)RespiratoryPatternsMaybeindicativeofinjurylocationinthebrainCheyne-StokesCentralNeurogenichyperventilationApneusticClusterbreathingAtaxicbreathing第72頁(yè)Cheyne-StokesRespirationsPeriodicbreathinginwhichdepthofeachbreathincreasestopeakthendecreasestoaperiodofapneaHyperpneicstageusuallylastslongerthanapneicphaseBilaterallesionsincerebralhemispheres第73頁(yè)CentralNeurogenicRespirationsSustainedregular,rapidanddeepbreathingMidbrainandupperponsinjury第74頁(yè)ApneusticRespirationsBreathingwithalongpauseatfullinspirationorfullexpirationRespiratoryfunctionpresentatbrainstemlevelonly第75頁(yè)ClusterBreathingGaspingbreathswithirregularpausesLesionhighmedullaorlowpons第76頁(yè)AtaxicBreathingTotallyirregularconsistingofbothdeepandshallowbreathsassociatedwithirregularpausesConsistentwithmedullainjurysincetheinspiratoryandexpiratorycentersarelocatedhere第77頁(yè)GlascowComaScaleWidelyusedtomeasureseverityofinjuryinapatientandprognosisUsebestpossibleresponseMostpredictivesubsequenttoresuscitation第78頁(yè)GCSEyeopening1-4Verbalresponse1-5Motorresponse1-6第79頁(yè)TraumaScoreRespiratoryrateBloodpressureMaybeincorporatedintotheGCS第80頁(yè)SecondaryBrainInjuryHYPOXIAHYPOTENSION

AnemiaHyperglycemiaHypoglycemiaHyperthermiaIntracranialmass第81頁(yè)SignificanceSurvivingtheinitialinjuryisasmallpartofthebattleforthetraumaticbraininjuredpersonSecondaryinjurymayhaveagreaterinfluenceoverthefinaloutcomethantheprimaryinjuryTwomostcommonhypoxiaandhypotensionandmaybeasdevastatingastheprimaryinjury第82頁(yè)HypotensionSinglemostprognosticfactorAsingleepisodeofdecreasedBPhasbeencorrelatedwithpooreroutcomeBrainrequiresbloodflowforperfusionKeepBP>90systolicCPP=MAP-ICPMostimportanttokeepMAP=/>70第83頁(yè)HypotensioninthefaceofcerebraledemaresultsindecreasedCPP(cerebralperfusionpressure)第84頁(yè)MAP(2)DBP+SBP

3Normal(70-100)第85頁(yè)HypoxiaDefinedasSpO2<90%LeadstocelldamageandresultantswellingCloselyfollowshypotensionininfluenceRSIfasterandmorereliableLessthan8intubate第86頁(yè)TreatmentProvideadequateventilationProvideadequatefluidresuscitationContinuallymonitorVSHOB@30degreesandheadmidlineConsidermannitolandhyperventilationifherniationimminentProphylacticseizuremedicationisnotindicated第87頁(yè)VentilationRSIandventilateataratetomaintainEtCo2between35-45mmHgLidocaine1mg/kgpriortoanyintubationattempt第88頁(yè)HyperventilationHasbecomeverycontroversialrecentlyandisnolongerautomaticallyrecommendedMayexacerbatebraininjuryinallbuttheherniatingpatientReceptorsrespondtoincreasedO2withvasoconstrictionInjuredtissueisnolongerperfusedResultsinincreasededemaandnecrosis第89頁(yè)FluidResuscitationInitiateIVinfusiontomaintainSBP=/>90PreferablyMap>70mmHGFluidofchoiceLRorNSGlucosecausesfluidtobepulledintocellsresultingincerebraledema第90頁(yè)MonitorContinuouslymonitorVSforSxofrisingICPChangesinbreathingpatternsIncreasingBPDecreasingHRUnequalpupilsPosturing第91頁(yè)P(yáng)ositionElevatedHOBMidlineheadplacementAssistswithvenousdrainagefromtheheadwhichdecreasesICP第92頁(yè)HyperthermiaCausesanincreaseinICPandshouldberegulatedHeadinjuredpatientsoftensufferfromincreasedbodytemperaturesandshouldbemonitoredAcetaminophenandothercoolingtechniquesmaybeusedDonotinducehypothermiawhichmayleadtoshiveringwhichresultsinincreasedICP第93頁(yè)SeizuresIntheeventofseizurestreatmentshouldbeinitiatedimmediatelyduetoresultanthypoxiaandincreasedICPTreatmentmayincludetheuseofValiumandCerebyxValiumdoesnotterminateabnormalelectricaldischargeasfosphenytoindoesPatientsmayneedtobeinaninducedbarbituratecoma第94頁(yè)TreatmentinHerniationHyperventilatetoEtCo2ofno<30mmHgMannitol-osmoticdiureticwhichmaybeusefulindecreasingICP1-1.5mg/kgLasixisaloopdiureticandnotusefulPurposeistokeepthepatientalivefordefinitivetreatmentsurgicalevacuationdrainplaced第95頁(yè)Medications:OxygenPrimary1stlinedrugAdministerhighflowHyperventilationiscontraindicatedReducescirculatingCO2levelsNRB:15LPMBVM:12-20timesperminuteKeepSaO2>95%第96頁(yè)Medications:DiureticsMannitol(osmotrol)MOALargeglucosemoleculeDoesnotleavebloodstreamOsmoticDiureticEffectiveindrawingfluidfrombrainContraindicationHypovolemia&HypotensionCHFDose1gm/kgCAUTIONFormscrystalsatlowtemperaturesReconstitutewithrewarming&gentleagitationUSEIN-LINEfilter&PREFLUSHline第97頁(yè)Medications:DiureticsFurosemide(Lasix)MOALoopDiureticInhibitsreabsorptionofNa+inKidneysIncreasedsecretionofwaterandelectrolytesNa+,Cl–,Mg++,Ca++.Venousdilation&ReducescardiacpreloadMaybegivenincombinationwithMannitolNoteffectiveinreducingcerebraledemaContraindicationPregnancy:fetalabnormalitiesDoseSlowIVPorIMover1-2minutes0.5-1mg/kg:Commonly40or80mg第98頁(yè)Medications:ParalyticsSuccinylcholine(Anectine)MOADepolarizingMedicationCausesFasciculationsOnset&DurationOnset:30-60secondsDuration:2-3minutesPrecautionParalyzesALLmusclesincludingthoseofrespirationIncreasesintraocculareyepressureContraindicationPenetratingeyeinjury&DigitalisDose1-1.5mg/kgIVConsideradministrationofdefasiculatingdoseofparalyticUsewithlidocaine1mg/kginheadinjuredpatients第99頁(yè)Medications:ParalyticsPancuronium(Pavulon)MOANon-depolarizingagentDoesnotaffectLOCOnset&DurationOnset:3-5minDuration:30-60minDoseMustpremedwithsedative0.04-0.1mg/kgVecuronium(Norcuron)MOANon-depolarizingagentDoesnotaffectLOCOnset&DurationOnset:<1minDuration:25-40minDoseConsiderpremedwithsedative0.08-0.1mg/kg第100頁(yè)Medications:SedativesDiazepam(Valium)MOABenzodiazepineAnti-anxietyMusclerelaxantOnset&DurationOnset:1-15minDuration:15-60minDose5-10mgMidazolam(Versed)MOABenzodiazepine3-4xpotentthanvaliumDoseSLOWIVP1mg/min1-2.5mgtitrated第101頁(yè)Medications:SedativeMorphineMOAOpiumalkaloidAnalgesicSedationAnti-anxietyReducesvascularvolume&cardiacpreloadIncreasesvenouscapacitanceSide