??(shock)

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??(shock)

• ???

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Case

• ??,?,23?,?????????,?????.
• ??
• ??120?/?,???????????120/90mmHg???,????\??????160
  0m1.
• ???????????????
• ?????????

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• ??-???????
• The theory of microcirculation
  Sympathetic-adrenal medulla hypersympathetic

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• ????
• ????????????????,??????????,???????????
  ???????

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• ?? ?????(Etiology and classification of shock )
• ?) ????(Etiology)
• 1??????(Blood loss and body fluid loss )
• ??
• ?? (fluid loss vomit. diarrhea)
• 2????(infectious shock )
• G-,???,?????
• warm shock ?????
• cold shock

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• 3????(Cardiogenic shock)
• ??
• ??? ?????
• 4?????(Neurogenic shock)
• ?????
• 5????(anaphylaxic shock )
• ????
• 6 ??????(Burn)

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• ?)??????
• 1.???????(Hypovolemic shock)
• 2.??????(Vasogenic shock)
• 3.?????(Cardiogenic shock)

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• ?)?????
• 1.???????
• 2.???????

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• ?????????(Periods and pathogenesis)
• ?)?????(ischemic phase)
• ?????(changes of the microcirculation)
• 1???????????????
• ?????????
• 2?????????,?????
• ?-? ??????

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• 3? ????,?lt?(perfusion flow perfusion lt
  flow)
• ??(mechanism)
• 1???-????? ????
• 2?????
• 1)??????
• 2)???(TXA2 )
• 3)??????
• 4)???
• 5)?????

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• ??(compensation)
• 1???????( return to heart)
• ???? self-blood transfusion ??? ???
• ???? self-transfusion
• 2?????
• 3??????(redistribution of blood flow )

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• ????(Manifestations)
• ??(mental status )????,
• ??(skin)?????
• ??
• ??(urine)??,500ml/24h

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• ?)?????(stage of stagnant anoxia)
• ???(changes of microcirculation )
• 1???????????????
• ?????????
• ??????gt???
• 2?????,?gt?(perfusion flow perfusion
  gt flow)

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??

• 1?????acidosis ,?????? ?????
• 2???Hypoxia ,????????,?????
• 3?????concentration,RBC?? stack
• 4???????????
• 5?P-selectin\E- selectin
• ICAM-1,VCAM

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• ????
• ??mental status ??faint coma
• ???????
• ?????
• ???? 100ml/24h

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• ?)???( refractory shockstage,irreversible
• stage )
• ???
• VSMC ??
• 1???????
• 2??????
• 3????(no-reflow)
• ???? WBC??

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• ?? DIC??
• 1?????concentration
• 2??????????????
• ( extrinsic blood coagulation)
  ?
• 3????????????
• (intrinsic blood coagulation)
• 4???????
• 5??????

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extrinsic blood coagulation
intrinsic blood coagulation
? ?
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????

• 1?????
• 2???(bleeding) ???

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• ????
• 1????? ?????
• 2?????????
• 3?????

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• ???????????
• (?) ????
• ????
• ????? ATP
• ????? ??

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mitochondria
free radical
lysosome
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• (?)???????
• 1??? ??? ??
• ???
• 2?ATP ???? ??
• ??? ???

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• (?)????
• 1???????????
• 2?????
• 3??????

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• ????????
• 1?????
• ???????????????
• a-??,?V?? ß- ??
• ????? NO, PGI

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• 2???
• ???????????????
• H1 -?? ?????, cap???
• H2 -?? ???,cap??
• 3???????
• ???????????
• ??????-????,???????

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• 4??????
• ??-??????????AT-?
• ????
• 5????
• ????O2 ???????????

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??????(systemic inflammatory response
syndrome,SIRS)

• 1.?????
• 2.??????
• 3.????????
• 4.??-????????

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????????

• 1????
• ????????? GFR
• ????? ATN
• ??,??

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• 2????
• ????,????

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• ??(congestion)
• ??edema
• ????(thrombosis)
• ???(atelectasis)
• ?????(formation of hyalinemembrane)
• ???(lung bleeding )

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• Grade of respiratory dysfunction
• ? PaCO2 lt 33mmHg, PaO2 gt 60mmHg
• ? PaO2 lt 60mmHg ,cyanosis
• ? O2 50 ,???(breathing apparatus
• assist)
• PaO2 lt 50mmHg , PaCO2

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• 3????
• early stage ??
• late stage
• coronary blood flow
• acidosis(???)?ATP
• hyperkalemia (???) heart failure
• MDF(??????)
• DIC of myocardium

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• Grade of cardial dysfunction
• CI(cardiac index) 3.0-3.5L/min/ m2
• ?CIlt3.0 L/min/ m2
• ?CIlt2.0 L/min/ m2
• ?CIlt1.5L/min/ m2 ,

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• 4 ???? Brain function
• early stage ????
• late stage ischemia hypoxia
•  
• brain edema faint?coma

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• 5 ? ?????Hepatic dysfunction
• a. Kupffers cell IL-8
  PMN
• ??( sequestration)
• b. xanthine oxidase(??????) release O2 -
• c. liver function
• acidosis,
• ?????(endotoxemia)
• icterus(??)

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• Grade of liver dysfunction
• ???(Bilirubin)
• ?gt 2.0 mg/dl icterus(??)
• ? gt 4.0 mg/dl
• ? gt 8.0 mg/dl

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• 6) Digestive tract
• ?(stomach) ??(ischemia), DIC, congestion (??)
  
• 
  stress ulcer
• ?(intestine) perfusion
  barrier function
• microthrombus
  (??)
• 
  ??bacteria\??toxin
• 
  get into blood

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• ????
• 1?????????,???
• What will be transfused?
• Blood , Blood plasma
• water 10 GDW
• 0.9 NaCl

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• 2??????
• pressors drugs mortality(???)
• vasodilation drugs?
• From Lab to bedside, from bedside to Lab
• 3??????
• SOD O2 -

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• 1.??????,????????????????????????
• 2.?????????????????????????????