心血管系统评估

Pulsus tardus(遲緩)
Delay upstroke
Aortic stenosisi
Bounding Pulsus
Hyperkinetic circulation Aortic regulation Patent ductus arteriosus Vasolilation
➢ Decrease blood volume ➢ Decrease venous dilatation ➢ Obstruction of the Байду номын сангаасarge veins
high cardiac output
high cardiac output is almost always caused by reduced total peripheral resistance
➢ beriberi ➢ aeteriovenous fistula(shunt) ➢ Hyperthyrodism ➢ Anemia
心臟評估—HR
PMI (point maximal impulse，
localized in -5 intercostal space) S3、S4: 左心衰竭
收縮壓：左心室射出血量施加於血管璧壓力 舒張壓：血液於動脈管腔（璧）所遭受阻力
血壓---組織灌流
Perfusion pressure(灌流壓): 向前引起組織系統灌流的趨 力壓差 (pressure gradient)
Systemic perfusion pressure MBP-CVP
Digestion, absorption, regulation Perfusion Regulation Urea formation Urea excretion transport
H2O
Fluid balance
負責器官/系統 Lung Hgb-O (circulation) Heart
G-I Heart Liver Liver Kidney Heart (pumping) Volume Kidney
溶血性貧血
Advantages and disadvantages on various cannulation sites
Radial artery Brachial artery Femoral artery Axillary artery Dorsalis pedal artery
Low cardiac output
Decreased cardiac output caused by cardiac factor
Decrease in cardiac output caused by peripheral factors --decrease venous return
Hypertensive
Hypertensive Encephalopathy
MBP>150 mmHg，超過腦部自我調節機轉 →vasospasm、ischemia、edema、 hemorrhage→ seizure
Malignant hypertension
DBP>130 mmHg →end organ damage LV hypertrophy， hematuria， proteinuria，
Pulsus alternans
An alteration in diastolic volume leading to beat-to-beat variation in preload
A sign of decreased myocardial contractility (deletion of the number of myocardial cells contracting on alternate beats)
Volume of blood Change of vital signs
loss
BP
HR RR
capillary refilling
<15% 20~25% 40~45%
微降 快
快 <2 sec
降
>100 >25 >5 sec
量不到 >110 >25 >5 sec
血量:70cc/kg 身體反應: 肝臟收縮→交感神經代償→低容積休克 未控制出血：MBP 不需超過90 mmHg 大量出血：輸全血
心血管系統評估
台大醫院外科加護病房 陳 淑 卿 督導長
器官/系統在維持生命功能中的角色
生命功能 Oxygenation
and CO2 removal
Perfusion
Nutrients intake
NH4 removal
組成因素 Ventilation & diffusion Carrying Perfusion Pump Volume Vascular tone
正常為50 mmHg。 congestive liver & spleen change of consciousness Palpitation：arrhythmia Chest pain：心肌缺氧、受損
Basic Circulation
Cardiac output= stroke volume X heart rates
循環功能失常見的症狀與徵候
Low cardiac output：heart failure、shock、心包填塞等
pale、cold limbs、urine output↓、irritable poor activity tolerance（weak）、 pulmonary edema、dyspnea、rales、 limb edema Pulsus pressure narrow（systolic－diastolic）：
處理順序: Volume → pumping → vascular tone
組織灌流不足徵象
Brain：change of Level Of Consciousness
Kidney：U/O↓ Heart：myocardial ischemia Lung：poor oxygenation →vascular constriction Liver：congestion & 心源性肝小葉壞死 GI tract：ischemic Limbs：pale & cold、poor capillary refilling
MBP-膠質滲透壓-鮑式囊內壓
BP低時供應器官血流減少之順序： 肺→腎臟→肝→心臟(hypoxemia)及腦（hypoxia）
心血管系統評估-成人血壓分級
Category
Normal High Normal Mild Hypertension Moderate Hypertension Severe Hypertension Crisis Hypertension
Severe LV dysfunction
Pulsus bisferens
Double systolic pulsation
Pulsus bisferens
Hypertrophic cardiomyopathy Aortic regurgitation
Pulsus parvus
Weak upstroke due to decrease stroke volume Hypovolemia L V failure Aortic or mitral stenosisi
心雜音分級
grade 1/6 2/6 3/6 4/6 5/6 6/6
volume 非常輕微, 僅在特殊狀況聽到 可以清楚聽到 比第二級大聲 比第三級大聲 聽診器部份抵著胸壁即可聽到 聽診器不用抵住胸壁即可聽到
Thrill 無 無 無 無 有 有
脈搏觸診
測量適應症：動脈粥狀硬化、用主動脈弓導管(ECMO)、冠
心血管身體評估--循環功能
心臟功能評估 動脈功能評估—
溫度（冰冷）、顏色（發紺）、脈搏強度(無脈搏)
靜脈功能評估--腫脹、發紺
微血管功能評估--Capillary refilling
心臟功能評估----組織灌流
決定組織灌流之主要三因素 Blood volume: intravascular fluid， 脫水及出血等影響血液容 量，可反應: ➢ PCWP、Basal rales---left heart ➢ CVP(JVP)---right atrium Cardiac pumping:心肌收縮能力 反應: :SBP、HR、Cardiac Output/ Cardiac index Vascular tone 反應: DBP、SVR、 PVR
Pulsus paevus Pulsus tardus Pulsus bisferiences Bounding Pulsus
Pulsus paradoxus
Severe Constrictive lung disease pericardial tamponade Tension pneumothorax
stroke volume ➢ Preload ➢ Afterload ➢ contractility
Preload Afterload
Preload: Tension on the muscle before contractile consider to LVEDP
Afterload: Load against the contractile force
Systolic ＜130 130-139 140-150 160-179 180-209 ＞210
Diastolic ＜85 85-89 90-99 100-109 110-119 ＞120
Assessment of blood loss
BP↓、CO ↓、 PCWP↓、CVP ↓、cold skin
Heart Murmur
評估工具-聽診器、血壓計、皮尺、
聽診器 膜面(diaphragm) 鐘面(bell)
適用
高頻 低頻
S1、S2、systolic clicks、腸音
S3、S4、diastolic murmur
長度30~46 cm
description of heart murmurs
Intensity—grade Timing—early 、mind 、late (systolic diastolic) Character—rumbling 、blowing Shape—crescendo、 decrescendo Location Radiation
狀動脈移植手術
脈搏強弱：無：- 、 弱：+、正常：++ 、 強 ：+++)
測量位置： anterior (脛前)A pedal(足背) A posterior (脛後) A
Pulse evaluation
Pulsus alternus pulsus paradoxus：
exaggerated inspiratory fall (＞10mmhg) in systolic
consider to the ascending aorta systolic BP
心血管系統評估
測量：HR、Pulse 、BP、CVP(JVP) 、 CO、SVR、SVO2、SPO2
（ Vital sign always first response） 外觀：顏色、溫度、矢狀指、水腫、腹水 症狀： 病史： 檢驗：
Hyperdynamic pulse
Aortic regurgitation AV fistula Thyrotoxicosis Anemia Pregnancy sepsis
Basic Circulation
Blood pressure= cardiac output X systemic resistance
Cerebral perfusion pressure MBP-ICP (30 mmHg, in injured brain>50 mmHg at least
Myocardial perfusion pressure DBP-CVP (>50 mmHg)
Glomerular filtration pressure