美国重症医学(FCCM)的基础教程 休克的诊断与治疗
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SSHHKK 77
®
Od cardiac output • Increased systemic vascular
resistance • Variable filling pressures
dependent on etiology • Cardiac tamponade, tension
Diagnosis and Management of Shock
SHK 1
®
Objectives
• Identify the major types of shock and principles of management
• Review fluid resuscitation and use of vasopressor and inotropic agents
pneumothorax, massive pulmonary embolus
SHK 8
®
Cardiogenic Shock Management
• Treat arrhythmias • Diastolic dysfunction may
require increased filling pressures • Vasodilators if not hypotensive • Inotrope administration
• Initial crystalloid choices – Lactated Ringer’s solution – Normal saline (high chloride may produce hyperchloremic acidosis)
• Match fluid given to fluid lost – Blood, crystalloid, colloid
• Understand concepts of O2 supply and demand • Discuss the differential diagnosis of oliguria
SHK 2
®
Shock
• Always a symptom of primary cause • Inadequate blood flow to meet tissue
• Preload and afterload reduction to improve hypoxemia if blood pressure adequate
SHK 10
®
Hypovolemic Shock Management
• Volume resuscitation – crystalloid, colloid
oxygen demand • May be associated with hypotension • Associated with signs of hypoperfusion:
mental status change, oliguria, acidosis
SHK 3
®
Shock Categories
SHK 13
®
Fluid Therapy
• Crystalloids – Lactated Ringer’s solution – Normal saline
• Colloids – Hetastarch – Albumin – Gelatins
• Cardiogenic • Hypovolemic • Distributive • Obstructive
SHK 4
®
Cardiogenic Shock
• Decreased contractility • Increased filling pressures,
decreased LV stroke work, decreased cardiac output • Increased systemic vascular resistance – compensatory
SHK 9
®
Cardiogenic Shock Management
• Vasopressor agent needed if hypotension present to raise aortic diastolic pressure
• Consultation for mechanical assist device
SSHHKK 1111
®
Distributive Shock Therapy
• Restore intravascular volume • Hypotension despite volume therapy
– Inotropes and/or vasopressors • Vasopressors for MAP < 60 mm Hg • Adjunctive interventions dependent
on etiology
SHK 12
®
Obstructive Shock Treatment
• Relieve obstruction – Pericardiocentesis – Tube thoracostomy – Treat pulmonary embolus
• Temporary benefit from fluid or inotrope administration
SHK 5
®
Hypovolemic Shock
• Decreased cardiac output • Decreased filling pressures • Compensatory increase in
systemic vascular resistance
SHK 6
®
Distributive Shock
• Normal or increased cardiac output • Low systemic vascular resistance • Low to normal filling pressures • Sepsis, anaphylaxis, neurogenic,
and acute adrenal insufficiency
®
Od cardiac output • Increased systemic vascular
resistance • Variable filling pressures
dependent on etiology • Cardiac tamponade, tension
Diagnosis and Management of Shock
SHK 1
®
Objectives
• Identify the major types of shock and principles of management
• Review fluid resuscitation and use of vasopressor and inotropic agents
pneumothorax, massive pulmonary embolus
SHK 8
®
Cardiogenic Shock Management
• Treat arrhythmias • Diastolic dysfunction may
require increased filling pressures • Vasodilators if not hypotensive • Inotrope administration
• Initial crystalloid choices – Lactated Ringer’s solution – Normal saline (high chloride may produce hyperchloremic acidosis)
• Match fluid given to fluid lost – Blood, crystalloid, colloid
• Understand concepts of O2 supply and demand • Discuss the differential diagnosis of oliguria
SHK 2
®
Shock
• Always a symptom of primary cause • Inadequate blood flow to meet tissue
• Preload and afterload reduction to improve hypoxemia if blood pressure adequate
SHK 10
®
Hypovolemic Shock Management
• Volume resuscitation – crystalloid, colloid
oxygen demand • May be associated with hypotension • Associated with signs of hypoperfusion:
mental status change, oliguria, acidosis
SHK 3
®
Shock Categories
SHK 13
®
Fluid Therapy
• Crystalloids – Lactated Ringer’s solution – Normal saline
• Colloids – Hetastarch – Albumin – Gelatins
• Cardiogenic • Hypovolemic • Distributive • Obstructive
SHK 4
®
Cardiogenic Shock
• Decreased contractility • Increased filling pressures,
decreased LV stroke work, decreased cardiac output • Increased systemic vascular resistance – compensatory
SHK 9
®
Cardiogenic Shock Management
• Vasopressor agent needed if hypotension present to raise aortic diastolic pressure
• Consultation for mechanical assist device
SSHHKK 1111
®
Distributive Shock Therapy
• Restore intravascular volume • Hypotension despite volume therapy
– Inotropes and/or vasopressors • Vasopressors for MAP < 60 mm Hg • Adjunctive interventions dependent
on etiology
SHK 12
®
Obstructive Shock Treatment
• Relieve obstruction – Pericardiocentesis – Tube thoracostomy – Treat pulmonary embolus
• Temporary benefit from fluid or inotrope administration
SHK 5
®
Hypovolemic Shock
• Decreased cardiac output • Decreased filling pressures • Compensatory increase in
systemic vascular resistance
SHK 6
®
Distributive Shock
• Normal or increased cardiac output • Low systemic vascular resistance • Low to normal filling pressures • Sepsis, anaphylaxis, neurogenic,
and acute adrenal insufficiency