上海交大外科学 上血PBL PPT课件.pptVIP

医学课件 上消化道大出血Massive Upper Gastrointestinal Bleeding 上海交通大学医学院 瑞金临床医学院 2009 Introduce Ourselves Dr. Yang Dr. Li 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 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 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 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 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 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) 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 Massive or Minor UGIB or LGIB Estimation of Blood Loss occult blood stool – 5-10ml/24h melena – 50-100ml/24h hematemesis – 250-300ml in stomach CNS change – 500ml hypovolemia – 1000ml/short period Child-Pugh Classification 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 ABC airway保持气道通畅 breathing维持呼吸和供氧 circulation维持循环 bilateral intravenous access (at least)双路静脉通路 short, large pore短而粗 fast fluid replace