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休克临床表现和治疗休克(Shock)的定义•休克是指任何原因引起有效循环血量减少,导致组织和器官氧合血液灌流不足,从而发生的代谢障碍和功能细胞受损的病理过程•Shockisaconditioninwhichthecardiovascul

arsystemfailstoperfusetissuesadequately.Inadequatetissueperfusioncanresultin:–generalizedcellularhypoxia(starvation)–widespreadim

pairmentofcellularmetabolism–tissuedamage–organfailure–death•维持有效循环血量的必要因素:•充足的血容量Sufficientbloodvolume•有效的心排出量Ef

fectivecardiacpump•良好的周围血管张力UpstandingperipheralangiotasisEffectivecirculatingbloodvolume休克临床表现和治疗2休克的分类（Type

sofShock）•分类疾病举例•低血容量性休克创伤出血、上消化道出血（hypovolemicshock）烧伤、肠梗阻•感染性休克胆道感染等•（SepticShock）•心源性休克心梗•（CardiogenicShock）

•过敏性休克青霉素过敏、血清过敏•（Anaphylacticshock）•神经源性休克疼痛刺激、脊髓损伤•（NeurogenicShock）••hemorrhageshockandtraumaticshock.休

克临床表现和治疗3PATHOPHYSIOLOGYOFSHOCKSYNDROME•微循环改变MicrocirculationChange•代谢变化MetabolismChange•内脏器官的继发性损害Secondarydamageoninternal

organs休克临床表现和治疗4MicrocirculationChangeDecompensatedphaseCompensatedphaseIrreversiblephaseDeath休克临床表现和治疗5•Sympatheticnervoussystemactivates•Car

diaceffectsIncreasedforceofcontractionsIncreasedheartrateIncreasedcardiacoutput•PeripheraleffectsArteriolar

constrictionPre-/post-capillarysphinctercontractionIncreasedperipheralresistanceShuntingofbloodtocoreorgans•Decreased

renalbloodflow–Reninreleasedfromkidneyarteriole–Renin&Angiotensinogencombine–ConvertstoAngiotensinI–AngiotensinI

convertstoAngiotensinII•Peripheralvasoconstriction•Increasedaldosteronerelease(adrenalcortex)•Peripheralcap

illariescontainminimalblood•Stagnation•AerobicmetabolismchangestoanaerobicCompensatoryMechanisms休克临床表现和治疗6休克的病理生理过程--微循环的

变化•微循环收缩期(休克代偿期)的特点:心跳中枢、血管舒缩中枢、交感神经兴奋→心跳加快，心排出量增加，儿茶酚胺大量释放•儿茶酚胺的作用：促使外周和内脏小、微血管和毛细血管前括约肌强烈收缩，动静脉短路和直捷通道开放•收缩期结果:外周血管阻力增加和回心血量增加；低灌注、缺氧状态。休克临床表现和

治疗7Continuedanaerobicmetabolism•Relaxationofprecapillarysphincters•Continuedcontractionofpostcapillarysphincters•Peripheralpoolingofbl

oodDecreasedbloodflowtothetissuescausescellularhypoxia•Decreasedcoronarybloodflow•Myocardialischemia•

Decreasedforceofcontraction•DecreasedbloodpressureDecompensatedShock休克临床表现和治疗8休克的病理生理过程--微循环的变化•微循环扩张期(休克抑制期)的特点:组织灌流不足，乏氧代

谢，酸性物质增多，微动脉和毛细血管前括约肌扩张，但毛细血管后静脉仍收缩肥大细胞释放组胺,缓激肽,毛细血管扩张范围增加•扩张期结果：毛细血管多灌少流，容积增加，血液浓缩，回心血大减，心排血量减少，血压下降，心脑灌注不足，休克加重。休克临床表现和治疗9IfLowPerfusionStatespe

rsists:IRREVERSIBLEDEATHIMMINENT!!!休克临床表现和治疗10•Decreasedperfusioncausestissuedamage/necrosis•Tissuenecrosistriggersdiffuseclotting•D

iffuseclottingconsumesclottingfactors•Fibrinolysisbegins•Severe,uncontrolledsystemichemorrhageoccursDis

seminatedIntravascularCoagulation(DIC)休克临床表现和治疗11休克的病理生理过程--微循环的变化•微循环衰竭期（DIC期）的特点：毛细血管内形成微血栓，DIC，细胞缺氧，组织自溶，由于凝血因子消耗，

纤维蛋白溶解系统激活，出现严重的出血倾向休克临床表现和治疗12休克的病理生理变化—体液代谢的改变•能量不足(Energydeficiency)•乏氧代谢(Anonicmetabolism)致乳酸(Lacticacid)和丙酮酸(Pyruv

icacid)积聚，造成酸中毒(Metabolicacidosis)•钠泵(Sodium-pump)和钙泵(Calciumpump)功能异常，致细胞肿胀，甚至死亡休克临床表现和治疗13休克的病理生理变化

—内脏器官的继发性损害•多器官衰竭(MultipleOrganSystemsFailure,MOSF):几个脏器相继或同时受损：1.呼吸窘迫综合征,（ARDS:Adultrespiratorydistresssyndrome）2.肾衰(Renalfailure):

肾皮质内肾小管上皮变性坏死3.心：心肌受损，局灶性坏死4.肝功能衰竭(Hepaticfailure)：小叶中央坏死5.胃肠道：粘膜糜烂、出血6.脑：脑水肿(cerebraledema)、脑疝(cerebralhernia)休克临床表现和治疗14Sta

gesofShockInitialstage-tissuesareunderperfused,decreasedCO,increasedanaerobicmetabolism,lacticacidisbui

ldingCompensatorystage-Reversible.SNSactivatedbylowCO,attemptingtocompensateforthedecreasetissueperfusion.Progressivestage-Faili

ngcompensatorymechanisms:profoundvasoconstrictionfromtheSNSISCHEMIALacticacidproductionishighanaerobicmetabolicacidosisIrreversibleorrefract

orystage-CellularnecrosisandMultipleOrganDysfunctionSyndromemayoccurDEATHISIMMINENT!!!!休克临床表现和治疗15•Hy

potension<90mmHg(maybenormallevelorincreaseduetocompensatorymechanism)•Meanarterialpressure(MAP)<60mmHg•Tachycardia:weakandthreadypulse•Tachyp

nea:blowoffCO2respiratoryalkalosis•DecreasedurineoutputGenerallyClinicalPresentation休克临床表现和治疗16休克的临床表现•休克代偿期：丧

失血容量<20%;交感神经活动增强1.神清(consciousness)，但烦躁(restlessness)，呼吸加快(quickenrespiration)2.皮肤苍白(Paleskin)，手足厥冷(Coldhan

dsandfeet)3.心率快(Rapidrate)，血压正常(NormalBP)或稍升高(IncreasingBP)，舒张压(diastolicbloodpressure)升高，脉压缩小(narrowp

ulsepressure)4.尿量(urineoutput)正常或减少休克临床表现和治疗17•休克抑制期：丧失血容量>20%1.神志淡漠(Disturbanceofconsciousness)→昏迷(Coma)2.口唇(Orallip)、

肢端(Limb)发绀(Cyanosis)，出冷汗(Coldsweat)3.脉细速(Rapidrateandthread/weakpulse)，血压下降(FallingBP)，脉压差(Pulsepressur

edifference)明显缩小4.5.尿量减少或无尿(Anuria)休克的临床表现休克临床表现和治疗18•重度休克：血容量丧失>40%1.昏迷(Coma)2.全身皮肤粘膜紫绀(Cyanosis)，四肢冰冷3.脉搏摸不到，血压测不出4.无尿(Anuria

)5.器官功能衰竭的表现休克的临床表现休克临床表现和治疗19休克的诊断DiagnosisofShock•早期诊断:病史：失血、失液、创伤等临床表现：兴奋或烦躁，出冷汗，心率快，脉压缩小，尿少•抑制期诊断：依靠典型表现——神志淡漠，反应迟钝，皮肤

苍白或紫绀，四肢湿冷，脉细速，呼吸浅快，收缩压下降至12kPa（90mmHg）以下，尿少或无尿休克临床表现和治疗20神志状态(Mentalstatus)肢体温度、色泽(Limbtemperatureandcolor)血压(Bloodpr

essure)脉率(Pulse)尿量(Urineoutput)休克的监测—一般监测GeneralMonitor休克临床表现和治疗21休克的监测—特殊监测SpecialMonitor•中心静脉压(CentralVenousPressure,CVP)

:血容量和心功能正常值：0.49-0.98kPa(5-10cmH2O)CVP↓，——血容量不足CVP↑，——心功能不全或过度收缩（﹥1.47kPa)充血性心力衰竭(CongestiveHeartFai

lure)(>1.96kPa)休克临床表现和治疗22休克的监测—特殊监测SpecialMonitor•肺动脉楔压(PulmonaryCapillaryWedgePressure,PCWP)：可直接反映肺静脉、左心房和左心室的压力，了解肺循环阻力正常值：0.8-2.0kPa,

低于正常值，提示血容量不足，>4.0kPa，表示肺水肿•心排出量和心脏指数：心排出量难以准确测定，临床应用少•动脉血气分析(ArterialBloodGasAnalysis)：可了解呼吸功能和酸碱平衡的变化。PaO280-100mmHg,PaCO236-44mmHg,PaCO2>60mmH

g,PaO2<60mmHg,休克临床表现和治疗23休克的监测—特殊监测SpecialMonitor•动脉血乳酸盐测定：反映细胞血液灌流情况。正常值：1-2mmol/L，浓度越高，休克越严重。>8mmol/L,死亡率100%。•DIC的实验室

检查—确诊依据：Plat<80×109/L;纤维蛋白原<1.5g/LPTT延长>3`,副凝实验(+);3P试验阳性；血涂片中破碎红细胞超过2%。休克临床表现和治疗24休克的治疗TreatmentofShock•一般紧急措施控制活动性大出血休克体位:头和躯干抬高20-30度,下肢抬高5-

20度吸氧，6-8L/min；保持呼吸道通畅保持安静，避免搬动保暖，可用休克服休克临床表现和治疗25休克的治疗TreatmentofShock•补充血容量(Restorecirculatingvolumeandtis

sueperfusion)：是抗休克的根本措施补充量：可根据CVP调节，应补充丧失量和已扩大的毛细血管床容量•积极处理原发病(TreatReversibleCauses)：在恢复有效血容量后积极手术处理外科原发病。在原发病不除，休克不能纠正时，应抗休克

的同时，积极手术处理，以免丧失抢救时机休克临床表现和治疗26Shocktreatment“Arudeunhingingofthemachineryoflife”“Abriefpauseintheactofdying”休克临床表现和治疗27休克的治疗TreatmentofSh

ock•纠正酸碱平衡失调：主要是酸中毒酸中毒的纠正有赖于休克的根本好转补充血容量，改善组织灌流，休克严重者，应给予碱性药物如碳酸氢钠•心血管药物的应用(CirculatorySupport)Vasoconstrictor：去

甲肾上腺素；间羟胺；苯肾上腺素；苯苄胺；苄胺唑啉；多巴胺；异丙肾上腺素；西地兰等•治疗DIC改善微循环•皮质类固醇和其他药物的应用休克临床表现和治疗28Insummary,TreatmentofShock•Identifythepatientathighriskforsho

ck•Controloreliminatethecause•Implementmeasurestoenhancetissueperfusion•Correctacidbaseimbalance•Treatcardiacdysrhythmias休克临床表现和治疗

29失血性休克的治疗(TreatmentofHemorrhagicShock)•补充血容量：根据情况输入晶体或/和胶体溶液出血量少，无活动性出血者，输入晶体液出血量大，有活动性出血者，先输晶体液，后输血根据中心静脉压调整输液量和速度•止血：在补充血容量的同时

积极止血要处理好休克和止血手术间的辨证关系休克临床表现和治疗30中心静脉压和补液的关系•CVPBP原因处理原则•低低血容量严重不足充分补液•低正常血容量不足适当补液•高低心功能不全强心药，纠酸，•或血容量相对过多舒血管•高正常容量血管过度收缩舒张血管•正

常低心功能不全补液实验•或血容量不足休克临床表现和治疗31损伤性休克的治疗(TreatmentofTraumaticShock)•补充血容量：应根据监测指标的变化来决定补液量•纠正酸碱平衡失调：碱中毒→酸中毒适当应用碱性药物•手术治疗：应根据病情判断是否需要手

术以及手术时机的选择•药物治疗：大量抗生素，复合维生素等休克临床表现和治疗32HypovolemicShock•Managementgoal:–Restorecirculatingvolumeandtissueperfusion:–Controlhemorrhage–Re

storecirculatingvolume–Optimizeoxygendelivery–VasoconstrictorifBPstilllowaftervolumeloading休克临床表现和治疗33Ai

medatimprovementtissuehypoperfusion•InsertFoleycathetertomonitortheurineflow;•Augmentsystolicbpto›100mmHg:1.PlaceinreverseTrendelenbur

gposition;2.IVvolumeinfusion(500-1000mlbolus),unlesscardiogenicshocksuspected(beginwithnormalsaline,thenwholeblood,dextran,orpackedRBCs,ifanemic),con

tinuevolumereplacementasneededtorestorevascularvolume;•Addvasoactivedrugsafterintrvascularvolumeisopmtimized;administerv

asopressorsifsystemicvascularresistanceisdecreased.•Ifseveremetabolicacidosisispresented(pH<7.15),administerNaHCO3

;•Identifyandtreattheunderlyingcauseofshock.休克临床表现和治疗34感染性休克的类型TypesofSepticShock•高排低阻型（高动力型）：“Warm”shockh

yperdynamicresponse,原因：感染灶释放扩血管物质特点：周围血管阻力降低，心排出量增加•低排高阻型（低动力型）“Cold”shockhypodynamicresponse原因：血容量减少+

继发感染活性因子：儿茶酚胺、5-羟色胺、组织胺、缓激肽特点：周围血管阻力增加，心排出量降低休克临床表现和治疗36感染性休克的两种临床表现•临床表现冷休克(高阻力型)暖休克(低阻力型)•神志躁动、淡漠或嗜睡清醒•皮肤色泽苍白、紫绀或花斑样紫绀淡红或潮红•皮肤温度湿冷或

冷汗温暖、干燥•毛细血管充盈时间延长1-2秒•脉搏细速慢、有力•脉压（kPa）<4>4•尿量(每小时)<25ml>30ml休克临床表现和治疗37SepticShockTreatment:–Prevention–Findandkillthesourceoftheinfection–

Fluidresuscitation–Vasoconstrictors–Inotropicdrugs–MaximizeO2deliverySupport–NutritionalSupport休克临床表现和治疗38TreatmentofSepticShock•Antibiotictrea

tment;•Removalordrainageofafocalsourceofinfection:Removeindwellingintravascularcathetersandsendtipsforquantitativeculture;replaceFoleyandotherd

rainagecatheters;•Hemodynamic,respiratory,andmetabolicsupport:⑴.MaintainintravascularvolumewithIVfluids.Initiatetreatmentw

ith1-2Lofnormalsalineadministeredover1-2h,keepingpulmonarycapillarywedgepressureat12-16mmHgorcentralvenouspressureat8-12cmH2O,ur

ineoutputat>30mlperhour,meanarterialbloodpressureat>65mmHg.休克临床表现和治疗39Addinotropicandvasopressortherapyifneeded.Maintaincent

ralvenousoxygensaturationat>70%.⑵.Maintainoxygenationwithventilatorsupportasindicated.•Othertreatments:Antiendotoxin,

anti-inflammatory,andanticoagulantdrugsarebeingstudiedinseveresepsistreatment.•AnticoagulantrecombinantactivatedproteinC(aPC):constanti

nfusionof24ug/kgperhourfor96h.TreatmentofSepticShock休克临床表现和治疗40感染性休克的治疗•补充血容量：以平衡盐溶液为主，配合适量的血浆和全血；并根据CVP调节输液量和速度•控制感染：处理原发感染灶；应用抗菌药物；

改善病人的一般状况；维持呼吸功能等•纠正酸中毒：酸中毒发生早，严重，及早应用碱性药物•心血管药物应用：西地兰；B-受体兴奋剂和a受体抑制剂联合应用•减轻细胞损害：皮质类固醇，大剂量应用；SOD，抑肽酶，PGI2，试用中休克临床表现和治疗41THEEND休克临床表现和治

疗42Clinicalexamples-1•An82-year-oldmanwasbroughttotheemergencyroombyhisgrandson,whoreportedthatthema

nhadbeeneatingpoorlyfor2daysandhadbeendifficulttoarousethatmorning.Thepatienthadnospecificcomplaints

.Onexam,thepatientwouldopenhiseyesandmumbleincoherentlyinresponsetopain.Histemperaturewas38.6℃,BP75/40,HR124reg

ular,respirations26.Hislungswereclear.Nomurmursorextrasoundswereappreciatedoncardiacexam.休克临床表现和治疗43Clinicalexamples-1•Hisskinwaswarm,withboundingpe

ripheralpulses.HischestradiographandEKGwerenormal.Laboratorydata:whitebloodcellcount19500(normallessthan10000).Abladdercatheterwasinserted(withdiffi

culty)andyieldedcloudyurine,whichwasnotedtocontainmanywhitecellsandbacteria.Urinewassentforculture.休克临床表现和治疗44Clinicalexamples-2•An35

-year-oldwomanpresentedtoanemergencyroomcomplainingofaheadachepresentsinceamyelogramwhichhadbeenperformed4daysbefore.Herpastmedicalh

istorywasunremarkableandherphysicalexaminationwasnormal.Shewasgivenaninjectionofmeperidineforherpain.Aftertheinjectionshebegant

ocomplainofnumbnessandtinglinginherfingertips,lightheadedness,shortnessofbreathanddiffuseitching.休克临床表现和治疗45Clinicalexamples-2•Herpulsew

asnotedtobe140andbloodpressurewaspalpableat70/0mmHg.Faintwheezeswerenotedthroughoutthelungs.Althoughshehadinitiallydenieddrugallergies,shenowre

memberedsimilarsymptomswhichhadfollowedaninjectionof‘painmedicine”2yearsbefore.休克临床表现和治疗46Clinicalexamples-3•An67-year-oldfemalearrivedinth

eemergencyroomcomplainingofchestpainandsevereweaknessfor12hours.Thesesymptomshadbeenprecededbyseveraldaysofnauseaandvomiting,poorappetite,and

subjectivefever.Onexamination,shehadapulserateof110andBP85/50.Therewasnojugularvenousdistension.Herlungswereclearandnomurmurorgallopwereheardo

nauscultationoftheheart.Therewasnoextremityedema.休克临床表现和治疗47Clinicalexamples-3•EKGshowednewSTelevationintheinferiorle

ads,suggestinganevolvinginferiormyocardialinfarction.RightprecordialleadsdidnotshowevidenceofRVinfarctionatthattime.•Thepatientwasgivensu

blingualnitroglycerinandwithinminutesbecameconfusedandunabletoresponsetoquestions.Systolicbloodpress

uredroppedto60andpulseslowedto70.herlegswereelevatedandrapidinfusionofintravenousfluidswasbegun.休克临床表现和治疗48Clinicalexamples-3•Her

mentalstatusimprovedbutsheremainedhypotensive.Thedecisionwasmadetoplaceapulmonaryarterycathetertohelpwithma

nagementofcardiogenicshock.•InitialHemodynamicData:◆BP:80/50,mean60◆RA:4mmHg,RV22/3,PA22/10,PAOP6◆Cardiacoutput:1.9liters/min◆S

VR:2350dynes-cm-5-sec(normal400-1900)休克临床表现和治疗49