病情危重的判斷醫(yī)務(wù)科

1、1會(huì)計(jì)學(xué)病情危重的判斷醫(yī)務(wù)科病情危重的判斷醫(yī)務(wù)科病史查體輔助檢查診斷治療時(shí)間病史查體可能的診斷復(fù)蘇緊急的問(wèn)題病史查體可能的診斷潛在的問(wèn)題治療反應(yīng)針對(duì)病因治療繼續(xù)復(fù)蘇病史查體輔助檢查修正診斷治療反應(yīng)在病人穩(wěn)定之前，千萬(wàn)不要離開病人平均動(dòng)脈壓？血管收縮心率血管擴(kuò)張心率低高Adapted from: Bone RC et al. Chest. 1992;101:1644-55.Opal SM et al. Crit Care Med. 2000;28:S81-2.非特異性損傷引起的臨床反應(yīng), 滿足 2條標(biāo)準(zhǔn): T 38 C or 90 bpmRR 20 bpmWCC 12,000/mm3or 10%

2、桿狀核SIRS = systemic inflammatory response syndrome SIRS及及可疑或明確的感染Chest 1992;101:1644. 全身性感染伴器官衰竭頑固性低血壓SIRSSepsisSevere SepsisSeptic Shock氧氧是是生命之源生命之源一尖一尖兩底兩底兩面外側(cè)面、內(nèi)側(cè)面兩面外側(cè)面、內(nèi)側(cè)面三緣前緣、后緣、下緣三緣前緣、后緣、下緣細(xì)、長(zhǎng)，較水平細(xì)、長(zhǎng)，較水平短、粗，較垂直短、粗，較垂直上端第上端第6頸椎與頸椎與 環(huán)狀軟骨相連環(huán)狀軟骨相連下端第下端第4、5胸椎胸椎 交界處交界處自然呼吸氣道壓力氣道壓力呼氣期吸氣期0FiO2吸氧裝置低 80

3、mmHg-股動(dòng)脈股動(dòng)脈 SBP 70 mmHg-頸總動(dòng)脈頸總動(dòng)脈 SBP 60 mmHgFG：濾過(guò)梯度（跨腎小球的壓力）GFP：腎小球?yàn)V過(guò)壓PTP：近端小管壓015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)Autoregulatory thresholdSubautoregulatory slope肋骨骨折（每根）肋骨骨折（每根）150 ml骨盆骨折骨盆骨折 3000 ml股骨閉合性骨折股骨閉合性骨折15002000 ml脛骨閉合性骨折脛骨閉合性骨折 500 ml手掌大小傷口手掌大小傷口

4、500 ml胸膜腔可隱藏胸膜腔可隱藏2000 ml腹腔至少可隱藏腹腔至少可隱藏2000 ml腹膜后間隙可隱藏腹膜后間隙可隱藏 1500-3000 ml時(shí)間（小時(shí)）時(shí)間（小時(shí)） 2 4 6 8 10 20 29Hb15 g%Hb的真實(shí)水平的真實(shí)水平 失血量的估計(jì)：Hb /HCT并不能及時(shí)準(zhǔn)確的反應(yīng)失血量02040608010012014013001400150016001700180019002000血壓：紅柱；心率：虛線；CVP：藍(lán)線02040608010012014013001400150016001700180019002000輸血新鮮血漿膠體液容量缺乏更為嚴(yán)重低容量表現(xiàn)低容量表現(xiàn)心動(dòng)過(guò)速

5、心動(dòng)過(guò)速低血壓低血壓(嚴(yán)重者嚴(yán)重者)高乳酸高乳酸(嚴(yán)重者嚴(yán)重者)肢端溫度降低肢端溫度降低脫水表現(xiàn)脫水表現(xiàn)皮膚充盈下降皮膚充盈下降口渴口渴口干口干腋窩干燥腋窩干燥高血鈉高血鈉高蛋白血癥高蛋白血癥高血紅蛋白高血紅蛋白高血球壓積高血球壓積體位性低血壓體位性低血壓動(dòng)脈血壓或每動(dòng)脈血壓或每搏輸出量的呼搏輸出量的呼吸波動(dòng)吸波動(dòng)下肢被動(dòng)抬高下肢被動(dòng)抬高容量負(fù)荷試驗(yàn)容量負(fù)荷試驗(yàn)結(jié)果陽(yáng)性結(jié)果陽(yáng)性腎臟灌注減少腎臟灌注減少濃縮尿濃縮尿(低尿鈉低尿鈉,高尿滲高尿滲)BUN升高升高(與肌酐升高不與肌酐升高不成比例成比例)持續(xù)性代謝性持續(xù)性代謝性酸中毒酸中毒動(dòng)態(tài)指標(biāo)動(dòng)態(tài)指標(biāo)靜態(tài)指標(biāo)靜態(tài)指標(biāo)容量狀態(tài)評(píng)價(jià)容量狀態(tài)評(píng)價(jià)參數(shù)參數(shù)

6、預(yù)測(cè)正確比例預(yù)測(cè)正確比例預(yù)測(cè)正確百分比預(yù)測(cè)正確百分比PAWP31/10230CO49/9751SVR39/8844RAP54/9855Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553心輸出量PAWPConnors(NEJM 83)ICU pts44% 42%E

7、isenberg(CCM 84)ICU pts50% 33%Bayliss(BMJ 83)CCU pts71% 62%35-30-25-20-15-10-5-0-CO (l/min)-5 0 5 10 15 20 25 30 35 40CVP (mmHg)Notarius et al Am Heart J 1998Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124132Bellomo R, Chapman M,

8、 Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000 Dec 23-30; 356(9248): 2139-43多巴胺(n = 161)安慰劑(n = 163)P值Scr峰值245 144249 1470.93Scr差值62 107

9、66 1080.82Scr 300的患者數(shù)56560.92需要RRT的患者數(shù)35400.55ICU住院日13 1414 150.67總住院日29 2733 390.29死亡人數(shù)6966Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Tr

10、ials Group. Lancet 2000 Dec 23-30; 356(9248): 2139-43Leone M, Vallet B, Teboul JL, et al. Survey of the use of catecholamines by French physicians. Intensive Care Med. 2004 Mar 3 Epub ahead of print Leone M, Vallet B, Teboul JL, et al. Survey of the use of catecholamines by French physicians. Intens

11、ive Care Med. 2004 Mar 3 Epub ahead of print Leone M, Vallet B, Teboul JL, et al. Survey of the use of catecholamines by French physicians. Intensive Care Med. 2004 Mar 3 Epub ahead of print Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103:

12、1826-31Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103: 1826-31NEDOPA劑量(g/kg/min)1.5 1.210 25有效率93% (15/16)31% (5/16)換用藥物后有效率0% (0/1)91% (10/11)存活率59%17%出院病人數(shù)96Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic se

13、ptic shock. Chest 1993; 103: 1826-31Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103: 1826-31ICU放射影像十問(wèn)放射影像十問(wèn)【1】先問(wèn)病史再照片子【2】處置要針對(duì)患者而非針對(duì)片子【3】沒(méi)看過(guò)患者就不要對(duì)片子下最后結(jié)論【4】讀片要讀好片：注意明暗、解析度、大小【5】片子要全看，不要只看部份，不要跳著看【6】讀片有疑惑時(shí)，先重新評(píng)估病人【7】記得rule of 2：2角度、2關(guān)節(jié)、2側(cè)、2張

14、、2次【8】做完 procedure （中心靜脈置管、氣管插管、胸管）后再照一張【9】懷疑氣胸要在48h內(nèi)評(píng)估23張【10】新入ICU患者要在72h內(nèi)有CT影像（在病情允許情況下）ICU BOOK貼片與皮膚接觸處需要用水或肥皂清洗，禁用酒精，因會(huì)增加皮膚阻力；Cuff的選擇：袖帶中間有兩個(gè)白線，最邊上的有一條細(xì)白線，袖帶在綁的時(shí)候，最邊上的細(xì)白線一定要在兩條白線中間，否則就不是適當(dāng)?shù)男鋷?，需要更換氧合下降胸廓運(yùn)動(dòng)?調(diào)FiO2=1.0氧合下降胸廓運(yùn)動(dòng)?調(diào)FiO2=1.0人工通氣通氣容易?呼吸機(jī)故障ETT/患者問(wèn)題氣道阻力升高或順應(yīng)性降低治療病因 調(diào)整呼吸機(jī)設(shè)置YesNo檢查設(shè)置與功能No氧合下降

15、胸廓運(yùn)動(dòng)?調(diào)FiO2=1.0體格檢查特別注意:單側(cè)插管氣胸肺不張肺水腫支氣管痙攣治療病因 調(diào)整呼吸機(jī)設(shè)置Yes氧合下降胸廓運(yùn)動(dòng)?調(diào)FiO2=1.0人工通氣通氣容易?呼吸機(jī)故障ETT/患者問(wèn)題氣道阻力升高或順應(yīng)性降低體格檢查特別注意:單側(cè)插管氣胸肺不張肺水腫支氣管痙攣治療病因 調(diào)整呼吸機(jī)設(shè)置YesNo檢查設(shè)置與功能YesNo觀察是最積極的治療！Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991

16、; 99: 492493Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers P

17、L, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers PL, Schlichtig R, Miro A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493Rogers PL, Schlichtig R, Mir

18、o A, Pinsky M. Auto-PEEP during CPR: an “occult” cause of electromechanical dissociation? Chest 1991; 99: 492493敏感性, 特異性, 陽(yáng)性預(yù)期值(PPV)和陰性預(yù)期值(NPV)的四格表檢查結(jié)果患病無(wú)病總計(jì)+aba + bcdc + d合計(jì)a + cb + da + b + c + d敏感性 = a / (a + b)PPV = a / (a + c) 特異性 = d / (c + d) NPV = d / (b + d)abcdefghijklm12345678910 11 12 13nopqrstuvwxyz14 15 1