严重创伤病人的麻醉答辩.ppt

* For example, acute oxygen deprivation from drowning requires immediate attention to restoring oxygen delivery to the cardiopulmonary system, to prevent massive cellular necrosis. Penetrating thoracic trauma requires immediate placement of a chest tube to drain extrapulmonary pleural air and blood. Such a patient may often require no further surgery. * Cutdown 早期复苏通道的建立有两点，一是发现创伤部位的血管，二是胸大肌注射升压药（如多巴胺、麻黄素） * Volume of fluid replacement and hemoglobin concentration consumption---a plateau in the curve of oxygen consumption versus oxygen delivery. Normalization of the base excess(deficit) on arterial blood gases is another indicator that oxygen debt has been repaid. Levels of mixed venous lactate have been used in a similar fashion. Coagulation function is monitored, and appropriate replacement therapy is prescribed. * Anxious, more anxious, anxious and confused, confused to lethargic * Oxygen consumption can be calculated from from the pulmonary artery catheter measurements by using the product of cardiac output times the difference between the arterial oxygen pressure(PaO2) and pulmonary artery oxygen content. Mortality from trauma varies inversely with post-traumatic oxygen consumption. Therefore, early placement of a pulmonary artery catheter in appropriate patients cannot be overemphasized. * Dantrolene,常用剂量为2mg/kg。由于改药的水溶性很低给临床应用带来困难。近年发现与dantrolene化学结构相似的azumolene（EU4093），药效两者也很相似，但后者的水溶性为dantrolene的30倍，室有应用前途的药物。其他药物包括大剂量地塞米松或氢化考地松 * 插管时应注意以下问题 气管切开是建立气道的最后途径 穿透伤导致的口底毁损 喉或颈部气管破裂 训练有素的麻醉医师可以减少气管切开的数量，不得已时也可经环甲膜使用针状或气管切开导管建立气道，最大程度地减少创伤 * 休克复苏——液体通道 出血性休克的复苏需要迅速恢复有效血容量以保证心、脑和重要脏器的氧供 如果开始使所有外周静脉均萎陷时可经髓内针向骨髓内输液以补充由此大量的血液丢失，但必须迅速经皮或静脉造口建立大口径的静脉通道，或者经皮穿刺置入用于肺动脉置管的导管鞘（sheath) * 休克复苏——液体通道 可使用机械泵或空气加压装置加速输液 需注意液体通道的建立应保证液体能输向心脏 即需注意胸部或腹部严重创伤时有上腔或下腔静脉破裂的情况 大量输血、输液时需注意液体加热 * 休克复苏——液体选择 首先恢复血容量，然后恢复血红蛋白浓度，最后恢复凝血功能 较早的研究表明，从血液流变学（rheologic)和氧运输能力的关系看，HCT 0.28￣0.30最适合于氧在细胞水平的释放 近来的观点认为，HCT 0.18 ￣ 0.22对部分病人也可耐受，但是否适合于孕妇、高龄和低容量休克恢复期病人尚有待阐明 * 休克复苏——液体选择 使用胶体的支持者认为其较