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1、严重创伤病人的麻醉Anaesthesia for Critical Trauma Patients1几个概念w创伤w多发伤w多部位伤w复合伤轻伤中等伤重伤严重创伤2Why should we learn trauma anesthesia?wAnesthesiologists are being faced with anesthetizing an increasing number of trauma patientwAll anesthesiologists will likely have significant and unpredictable exposure to trauma
2、 patients3wIn 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 record4wIn the same year there were an estimated 18,200,000 disabling accidental injuries, or about 2,080 injuri
3、es 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 homicides5wInjury ranks as the fourth leading cause of death in the U.S.wCurrently, for American younger th
4、an 40 years, trauma is the most common cause of death, following heart disease, cancer, and cerebrovascular disease6Potential roles of the anesthesiologist in this areawTrauma team memberwTrauma team leaderwAnesthesiologistwCritical care physician7wPain relief physician wProhospital care physician w
5、Critical care transport physician or director wDisaster planning consultant8病情评估9病情评估w评分系统（scoring system) w创伤机制 (mechanisms of injury)10Scoring systemwASAPS wGCS: a useful prognostic tool for patient with acute head injuries wTS, RTS(revised trauma score) and PTS(pediatric trauma score): used to pr
6、edict outcome and direct patients to appropriate facilities. wCRAMS Score11ASA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级前加“E”表示急诊诊手术术患者分级级，如EIII级级12GCS（Glasgow coma score)wEye opening (41)wVerbal responses (51)wMotor r
7、esponses (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 openingwSpontaneous- 4wTo voice- 3wTo pain- 2wTo none- 114Verbal reponseswOriented- - 5wConfused- 4wInappropriate- 3wIncomprehensive words- 2wNone- 115Motor responsewObeys command- 6wLocalizes pain- 5wWithdraws
8、(pain)- 4wFlexion(pain)- 3wExtension(pain)- 2wNone- 116创伤机制w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 w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胸部创伤w闭合性头部损伤与开放性股骨骨折1718严重创伤病人的病情特点w病情紧急，伤情复杂w生理紊乱重，并发症多，死亡率高w疼痛剧烈w饱胃19严重创伤病人的麻醉处理特点w不能耐受深麻醉w难以配合局部麻醉w麻醉药物作用时间明显延长w容易误吸w常需支持循环
9、功能20术前准备Preoperative Preparation21原则w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 w在经过3045s的病情判断后应立即开 始创伤救治 w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)wOverviewwPerform visual scan of patient for obvious injurieswObtain history from prehospital personnel and patient(if able) wPrimary sur
10、vey(ascertain “ABCDEs”)wAirway maintenance (with cervical spine control)wLook for chest wall movements, retraction ,and nasal flaringwListen for breath sounds, stridor, and obstucted ventilationwFeel for air movement 23wPrimary survey(ascertain “ABCDEs”)wBreathing (give supplemental oxygen)wDetermin
11、e whether ventilation is adequatewInspect chest to exclude open pneumothoraxwAuscultate for bilateral breath soundswProvide assisted ventilation for ventilatory failure wCirculation (establish venous access)wCheck peripheral pulses, capillary refill, and blood pressurewObtain electrocardiogramwGrade
12、 shock according to vital signswCorrect hypovolemia and obtain blood samples24wPrimary survey(ascertain “ABCDEs”)wDisability (determine neurologic status)wEvaluate central function A: alert V: responds to vocal stimulus P: responds to painful stimulus U: unresponsivewEvaluate pupil response to light
13、 wExpose patient for complete examination w Resuscitation phase w Secondary survey w Definitive care phase25气管插管术w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（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 w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%1
14、530%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w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 匿性损伤 w了解既往疾病史、过敏史、手术史和药物 服用史 w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 w注意酗酒、药物成瘾可能40麻醉前检诊w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
15、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, EtCO2(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w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w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
