早期识别危重患者.ppt

* * * * * * * * * * * * * * * * * 胸片正常 胸片大致正常的急性呼吸困难 肺源性 气道病变，神经肌肉病变，早期病变 心源性 血管病变 其他原因 代谢性酸中毒，贫血，心理疾患 你看到了刚查的动脉血气 动脉血气 结果 pH 7.21 PaO2 （mmHg） 236 PaCO2 （mmHg） 24 HCO3 （ mmol/L） 10 Lac （ mmol/L ） 9.6 Hb （g/L） 125 你怎样判断病情 免疫力低下的患者 Physician’s skill 住院期间发热 严重代谢性酸中毒 脓毒症休克！ 处 理 立即抽取血培养，给予广谱抗生素； 迅速开放通路，积极补液； 2小时后患者呼吸困难好转…… 8小时血培养报警：E.Coli 重复床旁查体 物理检查 处理前结果 处理后结果 体温 38.6 ℃ 38.3 ℃ 心率 118 次/min 102 次/min 呼吸频率 36 次/min 24 次/min 血压 105 / 65 125 / 75 SpO2 100% 100% 一般情况 神清，急性病容 较前好转 皮肤 出汗多 基本同前 心肺 心率偏快 基本同前 复查血气 动脉血气 处理前结果 处理后结果 pH 7.21 7.32 PaO2 （mmHg） 236 186 PaCO2 （mmHg） 24 32 HCO3 （ mmol/L） 10 18 Lac （ mmol/L ） 9.6 5.2 Hb （g/L） 125 121 总 结 患者病情一般不会“突然”变化，突然变化是因为医生“突然”发现其变化； 重视新出现的难以解释的症状，尤其是报警症状； 循环衰竭可以表现为呼吸症状，反之亦然； 血压变化是危重症的晚期表现； 动脉血气对于判断危重患者病情意义重大。 Thanks * * * * * * * Unfortunately this model is only appropriate when there is sufficient time, which almost never occurs with seriously ill patients. * During resuscitation further history taking and examination to determine underlying problem, probable underlying diagnosis and to assess response to resuscitation. Definitive therapy started and resuscitation continued * In addition certain groups of patients are difficult to assess. These include the immunosuppressed and elderly (inflammatory response blunted), young adults (decompensation occurs very late) and trauma patients (high potential for multiple injuries) * * * Airway management can be divided into BASIC AND ADVANCED MANAGEMENT Basic airway maneuvers Relieving obstruction by the head tilt is easy and effective. A hand firmly placed on the forehead tilts the head backward on the atlanto-occipital joint The chin lift is completed by placing the fingers of the one hand under the bony part of the lower jaw and lifting the chin forward. Note The tongue and posterior pharynx is lifted away from the posterior pharynx * The head tilt, jaw thrust, mouth open (triple airway maneuver) is used when other methods have failed to open the airway. The head is t