1、About myselfAbout myselfName:费费 健健Email:feijianhotmailMobile:137-0176-9798开始了大家要专心啊 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
2、was available about 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 placed in a hard cervical collar and on a back board and transported to y
3、our emergency room.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 liquid.A urinary catheter reveals dark yellow urine.His hemoglobin is 7.His abdominal lavage（灌洗）reve
4、als gross blood.Study Questions 1:What type of 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 markedly distended.His hands and feet ar
5、e 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.按按病因学病因学分类分类一、失血失液性休克一、失血失液性休克:二、创伤性休克：二、创伤性休克：三、感染性休克：三、感染性休克：四、心源性休克：四、心源性休克：五、过敏性休克：五、过敏性休克：六、神经源性休克：六、神经源性休克：大出血，腹泻，剧烈呕吐等大出
6、血，腹泻，剧烈呕吐等疼痛和失血疼痛和失血内毒素内毒素大面积心肌梗死，心包填塞大面积心肌梗死，心包填塞青霉素，血清制剂或疫苗青霉素，血清制剂或疫苗高位脊髓麻醉或损伤高位脊髓麻醉或损伤按血流动力学的特点1.低排高阻型休克（低动力型休克，冷休克）2.高排低阻型休克（高动力型休克，暖休克）外科休克外科休克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 p
7、ulse 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 liquid.A urinary catheter reveals dark yellow urine.His hemoglobin is 7.His abdominal lavage（灌洗）reveals gro
8、ss blood.代谢障碍代谢障碍细胞受损细胞受损组织血液组织血液灌注不足灌注不足有效循环有效循环血量锐减血量锐减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
9、 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 sphincter and post-arteriole Constriction Relaxation 真毛细血管开放调节示意图真毛细血管开放调节示意图后微动脉与毛细血后微动脉与毛细血管前括约肌收缩管前括约肌收缩真毛细血管真毛
10、细血管血流量减少血流量减少局部组织激肽局部组织激肽,组组胺胺,乳酸乳酸,腺苷增多腺苷增多平滑肌对缩血管平滑肌对缩血管物质反应性升高物质反应性升高后微动脉与毛细血后微动脉与毛细血管前括约肌舒张管前括约肌舒张局部组织激肽局部组织激肽,组组胺胺,乳酸乳酸,腺苷减少腺苷减少真毛细血管真毛细血管血流量增多血流量增多平滑肌对缩血管平滑肌对缩血管物质反应性降低物质反应性降低 少灌少流 灌少于流 、缺氧 多灌少流，灌大于流 不灌不流 1.全身氧代谢：氧输送、氧耗量、氧摄取及混合静脉血全身氧代谢：氧输送、氧耗量、氧摄取及混合静脉血 氧分压氧分压氧输送氧输送(DO2)：单位时间内心脏泵血提供给组织细胞：单位时间内
11、心脏泵血提供给组织细胞的氧量。受三个因素影响，呼吸功能的氧量。受三个因素影响，呼吸功能(动脉血氧饱和动脉血氧饱和度和氧分压度和氧分压)、血红蛋白、心脏指数。正常值，、血红蛋白、心脏指数。正常值，500-600ml/min.m2氧耗量氧耗量(VO2):单位时间内组织器官所消耗的氧量。单位时间内组织器官所消耗的氧量。160-220ml/min.m2。氧摄取率氧摄取率(O2ER):单位时间内组织的氧耗量占氧输送单位时间内组织的氧耗量占氧输送 的比率，正常的比率，正常20-30%.氧氧 需需:机体单位时间内维持组织细胞正常代谢机体单位时间内维持组织细胞正常代谢 所需的氧量。所需的氧量。氧债：机体的氧耗
12、量不能满足正常代谢，即氧氧债：机体的氧耗量不能满足正常代谢，即氧需与氧耗量的差值。需与氧耗量的差值。血乳酸浓度：血乳酸越高，表示微循环障碍越血乳酸浓度：血乳酸越高，表示微循环障碍越重。重。混合静脉血氧饱和度混合静脉血氧饱和度(SvO2)或血氧分压或血氧分压(PvO2):正常值正常值65%和和 40mmHg经皮动脉血氧饱和度经皮动脉血氧饱和度(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
13、 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 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 abdom
14、inal lavage（灌洗）reveals gross blood.氧代谢障碍氧代谢障碍 组织细胞缺氧是休克的本质问题组织细胞缺氧是休克的本质问题缺氧缺氧无氧代谢增加无氧代谢增加 ATP生成减少生成减少 肝功能下降肝功能下降 乳酸大量产生乳酸大量产生 乳酸代谢降低乳酸代谢降低 代谢性酸中毒代谢性酸中毒 组织细胞器功能降低组织细胞器功能降低 组织功能降低组织功能降低 MODSStudy Questions 4:What is the effect of this kind of shock on the kidneys,the heart,the lungs,the brain,the int
15、estine?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 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.休克失代偿休克失代偿 内脏缺血、缺氧内脏缺血、缺氧 内脏血管内皮细胞受损内脏血管内皮细胞受损全身炎症反应综合征全身炎症反应综合征 MODS：
