上海交大外科学上血(ppt)

Massive or Minor
Class I
Class II
Class III
Class IV
Blood Loss ml
≤750
750-1500 1500-2000 ＞2000
Blood
≤15
Loss %
15-30
30-40
＞40
Pulse Rate bpm
≤100
＞100
＞120
＞140
Blood Pressure
上海交大外科学上血(ppt)
（优选）上海交大外科学 上血
Basic Concepts
What Is Massive Bleeding
>20% (>800ml) blood loss Hemodynamic instability血流动力学不稳 Clinical signs of poor perfusion组织灌注差
Let’s have a problem!
Patient Come
45-yr female first episode of hematemesis呕血 transferred from a small hospital 2 units of packed erythrocyte红细胞 tranfused nasogastric tube胃管 introduced with active bleeding pulse 120 bpm, BP 80/40 mmHg
systolic blood pressure (SBP)收缩压 ≤ 90mmHg postural hypotension体位性低血压 SBP decrease
≥15mmHg or pulse rate increase ≥10 bpm cool extremities四肢厥冷 syncope晕厥 ongoing brisk hematemesis进行性/活跃地呕血 maroon stool枣红便
Is it a massive or minor bleeding? Where is the most probable bleeding site?
Worrisome clinical signs and symptoms
tachycardia心动过速 more than 100 beats per minute (bpm)
Please Remember
UGIB is not uncommon in the emergency room Mortality rate is about 10% UGIB is a series of diseases mainly treated by internal
medicine. 3-15% require a surgical procedure
LGIB
Hematemesis呕血 Almost certain Rare
Melena黑便
Probable
Possible
Hematochezia 便血
Possible
Blood-streak stool Rare 便中带血丝
Occult blood stool Possible 大便隐血
Probable Almost certain Possible
What Is Your Decision
What is your intuition直觉?
For Reference
Does the patient have life-threatening situation?
– hypovolemic shock低血容量性休克 – low body temperature体温降低 – anemia/hypoxemia贫血/低氧血症 – comorbidities并存病
Slight
>Moderate
Encephalopathy 脑病
None
Slight
>Moderate
Grade A=5-8 points, Grade B=9-11 points, Grade C= 12-15 points
What Is Your Decision
What are the management priorities优先 顺序 to this patient?
For Reference
Resuscitation复苏 Hemostasis止血 Differential diagnosis鉴别诊断 Basic disease treatment治疗原发病 Comorbidity management处理并存病
Initial Resuscitation
Child-Pugh Classification
No. of Points
1
2
3
Bilirubin(μmol/L)
<34
34-51
>51
总胆红素
Albumin(g/L)
>35
28-35
<28
白蛋白
Prothrombin Time
≤14
15-17
≥18
凝血酶原时间(s)
Ascites 腹水
None
normal
normal
decrease decrease
CNS 神经 Slightly
Mildly
Anxious, Confused,
系统症状 anxious轻度 anxious中度 confused焦 lethargic意识
焦虑
焦虑 虑/意识模糊 模糊/嗜睡
UGIB or LGIB
Manifestation症状 UGIB
Estimation of Blood Loss
occult blood stool melena hematemesis CNS change hypovolemia
– 5-10ml/24h – 50-100ml/24h – 250-300ml in stomach – >500ml – >1000ml/short period
来自百度文库
What Is UGI
Esophagus食道 Stomach胃 Duodenum十二指肠
Jejunum空肠 Ileum回肠 Ascending Colon升结肠 Transverse Colon横结肠 Descending Colon降结肠 Sigmoid Colon乙结肠 Rectum直肠 Anus肛门