小兒急癥課件

TheSickChildBeverlyYoung,MD2010TheWarrenAlpertMedicalSchoolofBrownUniversity小兒急癥Haveyouseenchildrendie?

你見過兒童死亡嗎？

Discusswithyourpartner:

與你周圍的人討論：Whatwasthecauseofdeath?死因是什么？Whattreatmentdidthechildreceive?孩子接受過什么治療？Whatworked,andwhatdidn’t?哪些治療有效，哪些無效？小兒急癥Childrendiein2ways:

兒童死亡的兩個原因：Respiratoryfailure呼吸衰竭Inadequatetissueperfusion體液丟失小兒急癥3causesforinadequatetissueperfusion

體液缺乏的3個因素:Hypovolemia血容量不足Poordistributionofbodyfluids體液分布異常Heartdysfunction心臟功能障礙小兒急癥Majorcausesofchilddeath兒童死亡的主要原因:CardiacDysfunction心臟功能障礙

Congenitalheartdisease先天性心臟病Myocarditis心肌炎RespiratoryFailure呼吸衰竭InadequatePerfusion體液不足Blockageofmajorairways氣管堵塞

Choking氣管異物-Epiglottitis會厭炎

Abscess膿腫

Mass腫塊Blockageof

smallAirways小氣道堵塞

Asthma哮喘

Bronchiolitis支氣管炎Lungdisease肺疾病

Pneumonia肺炎

Heartdisease心臟疾病Hypovolemia血容量不足*Mostcommon*Hemorrhage出血

Dehydration脫水Maldistributionofbodyfluids體液分布不良

Massiveinfection

腫塊感染(septicshock感染性休克)

Anaphylaxis

過敏反應

Severeburns

燒傷小兒急癥Children’sRespiratoryRate

兒童呼吸頻率Theyoungerthechild,thefastertherespiratoryrate.孩子越小，呼吸頻率越快Fastbreathingisasignofrespiratorydistressorotherillness.呼吸加快是呼吸窘迫或其它疾病的跡象Ifasickchild’srespiratoryratedrops,itmaysignalimpendingrespiratoryfailure.如果患兒的呼吸頻率急速下跌，可能預示著即將發(fā)生呼吸衰竭。Age0–1歲year2–4歲years4–10歲years>10歲yearsNormalRespiratoryRate20-4020-3020-2512-20小兒急癥IdentifyingRespiratoryDistress

判斷呼吸窘迫Increasedrespiratoryrate呼吸頻率加快Nasalflaring鼻翼扇動Retractions–abovethesternalnotch,belowtheribs凹陷—胸骨上窩，膈肌凹陷Decreasedairmovementonauscultation聽診呼吸音減弱Wheezing,cracklesonauscultation哮鳴音、濕啰音Lethargy嗜睡Cyanosis紫紺Sometimesthereisanobviouscause–choking,historyofasthma,knownpneumoniaorheartdisease有時會有一個明顯的病因—窒息、哮喘史、肺炎或心臟疾病小兒急癥IdentifyingInadequatePerfusion

辨認體液不足HeartRate心率SystemicPerfusion體循環(huán)BloodPressure血壓小兒急癥Children’sHeartRates兒童心率Age年齡Birth–3mos3mos–2yrs2yrs–10yrs>10yrsNormalHeartRate正常心率85–205100–19060–14060-100Theyoungerthechild,thefastertheheartrate.孩子越小，心率越快Whenachildissick,theheartrateincreasesasthebodytriestoincreaseperfusion.當孩子生病時，心率增快，因為機體努力改善體循環(huán)Alowheartrateindicatesthattheheartisalreadyfailingandisasignofveryseriousillness.心率減低說明心臟已經(jīng)衰竭，是嚴重疾病的跡象。小兒急癥IdentifyingDecreasedSystemicPerfusion

辨認體循環(huán)減弱WeakpulsesOR“bounding”pulses脈搏減弱或彈跳脈搏（水沖脈）Decreasedskinperfusion皮膚循環(huán)減少Cool冰涼Capillaryrefilltime>2seconds毛細充盈時間大于2秒Mottlingandpallor(peripheralbeforecentral)斑影與蒼白（先周圍，后中央）小兒急癥IdentifyingDecreasedSystemicPerfusion

辨認體循環(huán)減弱Mentalstatuschanges精神面貌改變Early:irritability,slightconfusion早期：煩躁，輕度迷糊Late:lethargy,lossofconsciousness后期：嗜睡，意識不清Decreasedurineoutput尿量減少Infants(<1year):nourinefor>6hours嬰兒（小于1歲）：無尿超過6小時Olderchildren(>1year):nourinefor>12hours稍大的兒童（大于1歲）：無尿超過12小時小兒急癥Children’sBloodPressure兒童血壓Theolderthechild,thehigherthebloodpressure孩子越大，血壓越高Approximatesystolicbloodpressureforchildren1–10yearsold:90mmHg+(2×ageinyears) Diastolicbloodpressureshouldbeapproximately2/3ofthesystolicbloodpressure.1-10歲的兒童的收縮壓大約是：90+（2×年齡），舒張壓大約是收縮壓的2/3Lowbloodpressureinachildisasignofveryseriousillness!兒童低血壓是嚴重疾病的跡象小兒急癥IdentifyingHypovolemia

辨認血容量不足Historyofbloodorfluidloss出血或體液丟失:Traumaticinjurycausingexternalorinternalbleeding

創(chuàng)傷導致內(nèi)或外出血Diarrhea/vomiting

腹瀉/嘔吐Excessiveurination

過度排尿Lackoffluidintake

液體攝入不足Sunkeneyes眼睛凹陷小兒急癥IdentifyingHypovolemia

辨認血容量不足Drymucousmembranes(mouth,lips)&absenceoftearsifcrying粘膜干燥（口腔、嘴唇），哭時無淚Weakpulses脈搏弱Poorskinturgor皮膚彈性減弱Peripheralcapillaryrefill>2seconds末梢回血時間大于2秒Infants:sunkenfontanel嬰兒：前囟凹陷Decreasedurineoutput尿量減少<1yearold:nourinefor>6hours小于1歲的孩子：超過6小時無尿>1yearold:nourinefor>12hours大于1歲的孩子：超過12小時無尿小兒急癥IdentifyingSepticShock辨認感染性休克Thismaylookdifferentfromotherkindsofshock:

它不同于其它種類的休克Increasedheartrate

心率增加Fever

發(fā)熱Boundingpulses

水沖脈Increaseddistancebetweensystolicanddiastolicbloodpressures(>1/3systolic)

脈壓差增大（大于收縮壓的1/3）Theremaybeanobvioussourceofinfection(ortheremaynot)可能會有明顯的感染源（也可能沒有）小兒急癥Majorcausesofchilddeath兒童死亡的主要原因:CardiacDysfunction心臟功能障礙

Congenitalheartdisease先天性心臟病Myocarditis心肌炎RespiratoryFailure呼吸衰竭InadequatePerfusion體液不足Blockageofmajorairways氣管堵塞

Choking氣管異物-Epiglottitis會厭炎

Abscess膿腫

Mass腫塊Blockageof

smallAirways小氣道堵塞

Asthma哮喘

Bronchiolitis支氣管炎Lungdisease肺疾病

Pneumonia肺炎

Heartdisease心臟疾病Hypovolemia血容量不足*Mostcommon*Hemorrhage出血

Dehydration脫水Maldistributionofbodyfluids體液分布不良

Massiveinfection

腫塊感染(septicshock感染性休克)

Anaphylaxis

過敏反應

Severeburns

燒傷小兒急癥TreatingRespiratoryFailure

治療呼吸衰竭Treattheunderlyingcause(i.e.,asthma)治療潛在的病因（如：哮喘）Bag-maskventilation呼吸氣囊小兒急癥TreatingInadequatePerfusion治療體液不足Giveoxygen,ifavailable如有可能，吸氧GetIVaccess–usealarge-boreneedle靜脈輸液—用大號針3.Give20ml/kgofnormalsalineasfastaspossible:over5–10minutes

在5-10分鐘內(nèi)按每公斤體重20毫升，補充生理鹽水4.Reassessheartrate,perfusion,bloodpressure

重新測心率、體循環(huán)、血壓小兒急癥TreatingInadequatePerfusion治療體液不足5.Ifthesearestillabnormal:repeat20ml/kgnormalsaline+reassessment–asmanytimesasneeded!

如果仍然不正常：再次按每公斤體重20毫升，補充生理鹽水，再重新測量，只要需要，重復。6.Stillnoresponse?Dopamineorepinephrineifyouhaveit7.Getthechildtothehospitalimmediately!

仍然沒效果，可以給多巴胺或腎上腺素；建議盡快送醫(yī)院小兒急癥#1A5yearoldboycomestoyouwith2daysofsorethroatandrunnynose.Todayhehadafeverto38degreesinthemorning.Hehasbeenabitsleepyandcrankysincehehashadthefever.Hismothergavehimparacetamol2hoursagoanditbroughthisfeverdownandhehasbeenactingnormalsincethen.Hisheartrateis110andhisrespiratoryrateis23.Heiseatinganddrinkingandurinatingasusual.一個5歲男孩，喉痛流涕2天，今天發(fā)熱，上午38度，發(fā)熱后他有一點嗜睡和煩躁，2小時前他媽媽讓他服用撲熱息痛，現(xiàn)在體溫正常，孩子活動正常，他的心率是110次/分，呼吸頻率是23次/分，食納可，二便正常。小兒急癥#1A5yearoldboycomestoyouwith2daysofsorethroatandrunnynose.Todayhehadafeverto38degreesinthemorning.Hehasbeenabitsleepyandcrankysincehehashadthefever.Hismothergavehimparacetamol2hoursagoanditbroughthisfeverdownandhehasbeenactingnormalsincethen.Hisheartrateis110（60－

140）

andhisrespiratoryrateis23（20－25）.Heiseatinganddrinkingandurinatingasusual.一個5歲男孩，喉痛流涕2天，今天發(fā)熱，上午38度，發(fā)熱后他有一點嗜睡和煩躁，2小時前他媽媽讓他服用撲熱息痛，現(xiàn)在體溫正常，孩子活動正常，他的心率是110次/分（60－140），呼吸頻率是23次/分（20－25），食納可，二便正常。小兒急癥＃2A1yearoldgirlcomestoyouwith2daysofrunnynoseandcongestionandcough.Thismorningshehasbeenwheezingabit.Sheisfebrileto38.4degrees,herheartrateis190,andherrespiratoryrateis60.Shehasretractionsabovethesternalnotchandbelowtheribs,andsheisflaringhernostrilswhenshebreathes.Shelookstiredandirritable.Shehasnotbeenfeedingwell.1歲的女孩，流涕、鼻塞和咳嗽2天，今天早上有一點喘，體溫38.4度，心率190次/分，呼吸頻率是60次/分，胸骨上窩和膈肌凹陷，呼吸時鼻翼扇動，她看上去很累，煩躁，食欲不振。小兒急癥＃2A1yearoldgirlcomestoyouwith2daysofrunnynoseandcongestionandcough.Thismorningshehasbeenwheezingabit.Sheisfebrileto38.4degrees,herheartrateis190（100－

190）,andherrespiratoryrateis60（20－40）.Shehasretractionsabovethesternalnotchandbelowtheribs,andsheisflaringhernostrilswhenshebreathes.Shelookstiredandirritable.Shehasnotbeenfeedingwell.1歲的女孩，流涕、鼻塞和咳嗽2天，今天早上有一點喘，體溫38.4度，心率190次/分，呼吸頻率是60次/分，胸骨上窩和膈肌凹陷，呼吸時鼻翼扇動，她看上去很累，煩躁，食欲不振。小兒急癥＃3A7yearoldboycomestoyouwith5daysofvomitinganddiarrhea.Hehashadafeverto38degreesfor2days.Hisheartrateis120andhisrespiratoryrateis24.Heappearslethargic,hiseyesappearsunken,hislipsaredry,andhiscapillaryrefilltimeis4seconds.Hehasbeeneatinganddrinkingverylittleandhehasnoturinatedfor24hours.7歲男孩，嘔吐和腹瀉5天，發(fā)熱38℃有2天，心率120次/分，呼吸頻率24次/分，嗜睡、眼睛凹陷、嘴唇干，末梢充血時間是4秒，吃得很少，喝一點，24小時無尿。小兒急癥＃3A7yearoldboycomestoyouwith5daysofvomitinganddiarrhea.Hehashadafeverto38degreesfor2days.Hisheartrateis120（60－

140）andhisrespiratoryrateis24（20－25）.Heappearslethargic,hiseyesappearsunken,hislipsaredry,andhiscapillaryrefilltimeis4seconds.Hehasbeeneatinganddrinkingverylittleandhehasnoturinatedfor24hours.7歲男孩，嘔吐和腹瀉5天，發(fā)熱38℃有2天，心率120次/分（60－140）

，呼吸頻率24次/分

（20－25），嗜睡、眼睛凹陷、嘴唇干，末梢充血時間是4秒，吃得很少，喝一點，

24小時無尿。小兒急癥＃4A4yearoldgirlcomestoyouwith4daysofdiarrhea.Shehasnothadafeverandhasbeeneatinganddrinkingasusual.Herheartrateis100andherrespiratoryrateis21.Sheisalertandplayfulandherlipsappearmoist.Shehasbeenurinatingasusual.4歲女孩，腹瀉4天，不發(fā)熱，吃喝正常，心率100次/分，呼吸頻率21次/分，精神好，玩耍，嘴唇濕潤，尿量正常。小兒急癥＃4A4yearoldgirlcomestoyouwith4daysofdiarrhea.Shehasnothadafeverandhasbeeneatinganddrinkingasusual.Herheartrateis100（60－

140）andherrespiratoryrateis21（20－25）.Sheisalertandplayfulandherlipsappearmoist.Shehasbeenurinatingasusual