发热的急诊科处理—香港大学课件-(精品课件).pptVIP

SEPTIC SHOCK MANAGEMENT Ventilation Establishing adequate ventilation to correct hypoxemia and pH and to reduce systemic oxygen consumption and LV work. Ventilator therapy is indicated for progressive hypoxemia, hypercapnia, neurologic deterioration or respiratory muscle failure. RSI is preferred with anesthetic agent, such as ketamine or etomidate. * SEPTIC SHOCK MANAGEMENT Volume Replacement Intravenous access: Peripheral( 2?18- or 1?16-gauge) vs CVP Initially administer 20 ml/kg of crystalloid or 5ml/kg colloid In sepsis and trauma patients hydroxyethyl starch solutions resulted in less tissue edema and better preserved microcapillary integrity Because both ventricles tend to stiffen during shock, a high CVP ( 10-15 mmH2O ) is often needed * SEPTIC SHOCK MANAGEMENT Vasopressor Support Dopamine as the most often appropriate first choice Combination of dobutamine and norepinephrine increase both CO and SVR and to improved indices of tissue oxygenation in patients with severe sepsis * SEPTIC SHOCK MANAGEMENT Antimicrobial Therapy If an focus is found, the antibiotics can be directed by clinical experience Removal or drainage of a focal source is essential When no focus can be found, a semisynthetic penicillin with ?-lactamase inhibitor with an aminoglycoside or monotherapy with imipenem-cilastatin is a rational empiric choice * SEPTIC SHOCK MANAGEMENT No evidence supports empiric treatment of metabolic acidosis with bicarbonate and only consider when severe metabolic acidosis (pH 7.2 ) Blood transfusion is indicated if low Hb ( 8-10 g/dL) Adrenal insufficiency should be suspected in septic patients with refractory hypotension ( hydrocortisone 50 mg IV q6h ) * Key Points Early recognition A-B-C O2-IV-Monitor Eradicate infection source * Case 5 * Name 陳XX Age 35 Y/O Sex Male Triage Class II 90/08/14 10:26 AM 由診所護士陪同步入 AVPU BT 38.5oC PR 153 RR 18 BP 83/43 O2 sat 94 % * Chief Complaint SOB