严重创伤病人麻醉

1、1,严重创伤病人的麻醉,Anaesthesia for Critical Trauma Patients,2,几个概念,创伤 多发伤 多部位伤 复合伤,轻伤 中等伤 重伤,严重创伤,3,Why should we learn trauma anesthesia?,Anesthesiologists are being faced with anesthetizing an increasing number of trauma patient All anesthesiologists will likely have significant and unpredictable exposure to trauma patients,4,In 1993, approximately 90,000 individuals in the U.S died of accidental injuries , for a rate of 34.9 deaths per 100, 000 population, the second lowest accidental death rate on

2、record,5,In the same year there were an estimated 18,200,000 disabling accidental injuries, or about 2,080 injuries every hour, and the 90,000 accidental deaths amounted to 1 every 6 minutes-and these numbers excluded the rising level of intentional injuries caused by attempted or successful suicides and homicides,6,Injury ranks as the fourth leading cause of death in the U.S. Currently, for American younger than 40 years, trauma is the most common cause of death, following heart disease, cancer

3、, and cerebrovascular disease,7,Potential roles of the anesthesiologist in this area,Trauma team member Trauma team leader Anesthesiologist Critical care physician,8,Pain relief physician Prohospital care physician Critical care transport physician or director Disaster planning consultant,9,病情评估,10,病情评估,评分系统（scoring system) 创伤机制 (mechanisms of injury),11,Scoring system,ASAPS GCS: a useful prognostic tool for patient with acute head injuries TS, RTS(revised trauma score) and PTS(pediatric trauma

4、score): used to predict outcome and direct patients to appropriate facilities. CRAMS Score,ASA分级,13,GCS（Glasgow coma score),Eye opening (41) Verbal responses (51) Motor responses (61),轻型：1315分，意识障碍20min以内 中型：912分，意识障碍20min 6h 重型：38分，伤后昏迷至少6h以上或伤后24h内情况再次恶化者,14,Eye opening,Spontaneous- 4 To voice- 3 To pain- 2 To none- 1,15,Verbal reponses,Oriented- - 5 Confused- 4 Inappropriate- 3 Incomprehensive words- 2 None- 1,16,Motor response,Obeys command- 6 Localizes pain- 5 Withdraws(pain)- 4 Flexion(pai

5、n)- 3 Extension(pain)- 2 None- 1,17,创伤机制,虽然创伤的原因多种多样，但各种创伤导致的损伤机制是相同的，因此可以用创伤性疾病（traumatic disease)来概括各种创伤导致的机体损害 了解创伤的损伤机制是创伤治疗的前提 钝性损伤与穿透性损伤 颈部与气道创伤 胸部创伤 闭合性头部损伤与开放性股骨骨折,19,严重创伤病人的病情特点,病情紧急，伤情复杂 生理紊乱重，并发症多，死亡率高 疼痛剧烈 饱胃,20,严重创伤病人的麻醉处理特点,不能耐受深麻醉 难以配合局部麻醉 麻醉药物作用时间明显延长 容易误吸 常需支持循环功能,21,术前准备,Preoperative Preparation,22,原则,按步骤获取病史、体检、诊断和治疗的程序不适用于创伤病人 在经过3045s的病情判断后应立即开始创伤救治 经过初期复苏治疗后，应除外一切可能的隐匿损伤,23,程序（sequence of management of trauma patients),Overview Perform visual scan of patient for obvious inj

6、uries Obtain history from prehospital personnel and patient(if able) Primary survey(ascertain “ABCDEs”) Airway maintenance (with cervical spine control) Look for chest wall movements, retraction ,and nasal flaring Listen for breath sounds, stridor, and obstucted ventilation Feel for air movement,24,Primary survey(ascertain “ABCDEs”) Breathing (give supplemental oxygen) Determine whether ventilation is adequate Inspect chest to exclude open pneumothorax Auscultate for bilateral breath sounds Prov

7、ide assisted ventilation for ventilatory failure Circulation (establish venous access) Check peripheral pulses, capillary refill, and blood pressure Obtain electrocardiogram Grade shock according to vital signs Correct hypovolemia and obtain blood samples,25,Primary survey(ascertain “ABCDEs”) Disability (determine neurologic status) Evaluate central function A: alert V: responds to vocal stimulus P: responds to painful stimulus U: unresponsive Evaluate pupil response to light Expose patient for

8、complete examination Resuscitation phase Secondary survey Definitive care phase,26,气管插管术,需要立即行气管插管的适应症 GCS 9的头部创伤病人 休克 气道阻塞 需要镇静的躁动病人 全麻病人 胸部创伤伴低血容量时 复苏后低氧血症 心跳骤停,27,插管时应注意以下问题,使用肌松剂有助于气管插管实施，但需注意颈椎不稳定和大范围软组织损伤病人 对于颈椎不稳定的病人应在插管时手法控制头、颈稳定。有研究显示，使用肌松剂经口明视和盲探鼻插管相比，后者发生误吸兵法症的比例更高 正确应用环状软骨压迫方法有助于减少误吸 面罩通气时避免气体进入胃内,29,插管时应注意以下问题,非特异性抗酸药物、H2受体拮抗剂、胃复安（metoclopramide)插管前0.51h前静注 提高胃内pH，减少胃容量 平稳的诱导过程和拔管时良好的气道发射是防止误吸的最好方法,30,插管时应注意以下问题,喉罩通气为困难气管插管的解决途径之一 下颌骨骨折和颧骨骨折病人通常不能使用面罩通气，清醒插管常是解除气道梗阻的最佳方法。由于情况紧急且出血影响

9、视野，纤维支气管镜通常不能使用,31,插管时应注意以下问题,气管切开是建立气道的最后途径 穿透伤导致的口底毁损 喉或颈部气管破裂 训练有素的麻醉医师可以减少气管切开的数量，不得已时也可经环甲膜使用针状或气管切开导管建立气道，最大程度地减少创伤,32,休克复苏液体通道,出血性休克的复苏需要迅速恢复有效血容量以保证心、脑和重要脏器的氧供 如果开始使所有外周静脉均萎陷时可经髓内针向骨髓内输液以补充由此大量的血液丢失，但必须迅速经皮或静脉造口建立大口径的静脉通道，或者经皮穿刺置入用于肺动脉置管的导管鞘（sheath),33,休克复苏液体通道,可使用机械泵或空气加压装置加速输液 需注意液体通道的建立应保证液体能输向心脏 即需注意胸部或腹部严重创伤时有上腔或下腔静脉破裂的情况 大量输血、输液时需注意液体加热,34,休克复苏液体选择,首先恢复血容量，然后恢复血红蛋白浓度，最后恢复凝血功能 较早的研究表明，从血液流变学（rheologic)和氧运输能力的关系看，HCT 0.280.30最适合于氧在细胞水平的释放 近来的观点认为，HCT 0.18 0.22对部分病人也可耐受，但是否适合于孕妇、高龄和低容量休克恢复期病人尚有待阐明,35,休克复苏液体选择,使用胶体的支持者认为其较晶体液能更有效地补充细胞外液，可以使用较晶体液少得多的量而更好地维持血管内和微循环容量、增加心排量和氧释放，同时升高血压。相反，晶体液只能恢复血压而不能增加心排出量 有争议的是，有研究发现创伤患者在外科止血前使用大量胶体液使血压正常

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