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1、1严重创伤病人的麻醉Anaesthesia for Critical Trauma Patients2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3Why should we learn trauma anesthesia?Anesthesiologists are being faced with anesthetizing an increasing number of trauma patientAll anesthesiologists will likely have significant and unpredictable exposure to trauma pati
2、ents4In 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 record5In the same year there were an estimated 18,200,000 disabling accidental injuries, or about 2,080 injuries ever
3、y 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 homicides6Injury ranks as the fourth leading cause of death in the U.S.Currently, for American younger than 40 yea
4、rs, trauma is the most common cause of death, following heart disease, cancer, and cerebrovascular disease7Potential roles of the anesthesiologist in this areaTrauma team memberTrauma team leaderAnesthesiologistCritical care physician8病情评估9病情评估评分系统（scoring system) 创伤机制 (mechanisms of injury)10Scorin
5、g systemASAPS GCS: a useful prognostic tool for patient with acute head injuries TS, RTS(revised trauma score) and PTS(pediatric trauma score): used to predict outcome and direct patients to appropriate facilities. CRAMS ScoreASA分级I 级重要器官、系统功能正常II级轻微的系统性疾病，但代偿完全III级有严重的系统性疾病，功能受损但未丧失 工作能力 IV级有严重系统性疾
6、病，丧失工作能力，持续 威胁生命 V级濒死（moribund）患者，不做手术预计24 小时内死亡者在分级前加“E”表示急诊手术患者分级，如EIII级12GCS（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13Eye openingSpontaneous- 4To voice- 3To pain- 2To none- 114Verbal repons
7、esOriented- - 5Confused- 4Inappropriate- 3Incomprehensive words- 2None- 115Motor responseObeys command- 6Localizes pain- 5Withdraws(pain)- 4Flexion(pain)- 3Extension(pain)- 2None- 116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w钝性损伤与穿透性损伤w颈部与气道创伤w
8、胸部创伤w闭合性头部损伤与开放性股骨骨折18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19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20术前准备Preoperative Preparation21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22程序（sequence of management of trauma patients)I.OverviewA.Perform visua
9、l scan of patient for obvious injuriesB.Obtain history from prehospital personnel and patient(if able) II.Primary survey(ascertain “ABCDEs”)A.Airway maintenance (with cervical spine control)1.Look for chest wall movements, retraction ,and nasal flaring2.Listen for breath sounds, stridor, and obstuct
10、ed ventilation3.Feel for air movement23II.Primary survey(ascertain “ABCDEs”)B.Breathing (give supplemental oxygen)1.Determine whether ventilation is adequate2.Inspect chest to exclude open pneumothorax3.Auscultate for bilateral breath sounds4.Provide assisted ventilation for ventilatory failure C.Ci
11、rculation (establish venous access)1.Check peripheral pulses, capillary refill, and blood pressure2.Obtain electrocardiogram3.Grade shock according to vital signs4.Correct hypovolemia and obtain blood samples24II.Primary survey(ascertain “ABCDEs”)D.Disability (determine neurologic status)1.Evaluate
12、central function A: alert V: responds to vocal stimulus P: responds to painful stimulus U: unresponsive1.Evaluate pupil response to light E.Expose patient for complete examination III.Resuscitation phase IV.Secondary survey V.Definitive care phase25气管插管术需要立即行气管插管的适应症nGCS 30%或出血继续，应输胶体和血，另外再加 13倍的晶体液
13、（根据临床表现和监测判断），这 部分病人同时需要纯氧通气以增加氧向组织中的释 放，直至血红蛋白恢复w 失血量40%，立即输入浓缩红细胞，再加胶体和 晶体液 初期复苏完成后，应结合监测及病人对治 疗的反应进行进一步液体治疗休克复苏输液方案38不同程度失血引起的生命体征改变15%1530%3040%40%心 率100120120140收 缩 压正常正常下降下降脉 压正常或增加下降下降下降毛细血管 充盈时间正常延长延长或消失消失呼吸频率14202030304035意识状态焦虑更加焦虑焦虑、错乱错乱到昏睡39麻醉前病史获取病史的获取对象包括目击者和病人本人， 需要了解创伤发生的场景以判断可能的隐 匿性
14、损伤 了解既往疾病史、过敏史、手术史和药物 服用史 虽然所有创伤病人都应视为饱胃状态，但 仍应尽可能了解进食时间、量和种类以了 解胃内容物性质 注意酗酒、药物成瘾可能40麻醉前检诊同其他外科手术病人一样需要体检和实验室 检查，但应特别注意呼吸、循环和神经系统 检查 w意识状态（GCS） w瞳孔对光反应 w肢体运动 w未插管病人应评估气管插管的困难程度 w注意是否存在颈椎骨折及是否固定 w是否存在气胸、心肌挫伤、心包填塞 w失血量评估（根据生命体征） w血气、血红蛋白计数、血球压积、血糖、血肌酐、 ECG、颈椎X线等41创伤病人的监测项目无 创基本ECG（HR），NBP，R，T，SaO2, Et
15、CO2(趋势图）备选麻醉药浓度和呼吸气体监测有 创尿量监测（Foley 导尿管），ABP，CVP， TEE置入肺动脉导 管的适应证大量出血 既往有心脏疾患 多发伤或或复合伤 监测氧供氧耗 颅脑损伤患者液体管理42术中管理Intraoperative Management43麻醉选择全身麻醉是多发伤病人的第一选择n严重创伤病人需要气管插管和呼吸支持n长时间手术过程中病人不能始终安静合作n不会影响出血引起的代偿机制局部麻醉有其特殊的吸引力，但通常只适 用于单一肢体的创伤n对心血管功能影响较小，避免了建立气道可能 的困难44麻醉计划（Anesthesia Plan)1.选择对心血管抑制较小同时不引起颅 内压升高的药物w小剂量的硫喷妥钠、依托米酯、舒芬太尼w肌松药的剂量通常并不减少 2.通常静脉应用极小剂量的药物就
