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1、心血管系統評估,器官/系統在維持生命功能中的角色,心血管身體評估-循環功能,心臟功能評估 動脈功能評估溫度（冰冷）、顏色（發紺）、脈搏強度(無脈搏) 靜脈功能評估-腫脹、發紺 微血管功能評估-Capillary refilling,心臟功能評估-組織灌流,決定組織灌流之主要三因素 Blood volume: intravascular fluid， 脫水及出血等影響血液容量，可反應: PCWP、Basal rales-left heartCVP(JVP)-right atrium Cardiac pumping:心肌收縮能力 反應: :SBP、HR、Cardiac Output/ Cardia
2、c index Vascular tone 反應: DBP、SVR、 PVR處理順序: Volume pumping vascular tone,組織灌流不足徵象,Brain：change of Level Of ConsciousnessKidney：U/O Heart：myocardial ischemia Lung：poor oxygenation vascular constriction Liver：congestion & 心源性肝小葉壞死 GI tract：ischemic Limbs：pale & cold、poor capillary refilling,循環功能失常見的症狀
3、與徵候,Low cardiac output：heart failure、shock、心包填塞等 pale、cold limbs、urine output、irritable poor activity tolerance（weak）、 pulmonary edema、dyspnea、rales、 limb edema Pulsus pressure narrow（systolicdiastolic）：正常為50 mmHg。 congestive liver & spleen change of consciousness Palpitation：arrhythmia Chest pain：心
4、肌缺氧、受損,Basic Circulation,Cardiac output= stroke volume X heart ratesstroke volumePreload Afterload contractility,Preload Afterload,Preload: Tension on the muscle before contractile consider to LVEDPAfterload: Load against the contractile forceconsider to the ascending aorta systolic BP,心血管系統評估,測量：HR
5、、Pulse 、BP、CVP(JVP) 、 CO、SVR、SVO2、SPO2（ Vital sign always first response） 外觀：顏色、溫度、矢狀指、水腫、腹水 症狀： 病史： 檢驗：,Low cardiac output,Decreased cardiac output caused by cardiac factor Decrease in cardiac output caused by peripheral factors-decrease venous return Decrease blood volume Decrease venous dilatatio
6、n Obstruction of the large veins,high cardiac output,high cardiac output is almost always caused by reduced total peripheral resistance beriberi aeteriovenous fistula(shunt) Hyperthyrodism Anemia,心臟評估HR,PMI (point maximal impulse，localized in -5 intercostal space) S3、S4: 左心衰竭 Heart Murmur,評估工具-聽診器、血
7、壓計、皮尺、,長度3046 cm,description of heart murmurs,Intensitygrade Timingearly 、mind 、late (systolic diastolic) Characterrumbling 、blowing Shapecrescendo、 decrescendo Location Radiation,心雜音分級,脈搏觸診,測量適應症：動脈粥狀硬化、用主動脈弓導管(ECMO)、冠狀動脈移植手術 脈搏強弱：無：- 、 弱：+、正常：+ 、 強 ：+) 測量位置：,anterior (脛前)A,pedal(足背) A,posterior (脛
8、後) A,Pulse evaluation,Pulsus alternus pulsus paradoxus：exaggerated inspiratory fall (10mmhg) in systolic Pulsus paevus Pulsus tardus Pulsus bisferiences Bounding Pulsus,Pulsus paradoxus,Severe Constrictive lung disease pericardial tamponade Tension pneumothorax,Pulsus alternans,An alteration in dias
9、tolic volume leading tobeat-to-beat variation in preload A sign of decreased myocardial contractility (deletion of the number of myocardial cells contracting on alternate beats) Severe LV dysfunction,Pulsus bisferens,Double systolic pulsation,Pulsus bisferens,Hypertrophic cardiomyopathy Aortic regur
10、gitation,Pulsus parvus,Weak upstroke due to decrease stroke volume Hypovolemia L V failure Aortic or mitral stenosisi,Pulsus tardus(遲緩),Delay upstroke Aortic stenosisi,Bounding Pulsus,Hyperkinetic circulation Aortic regulation Patent ductus arteriosus Vasolilation,Hyperdynamic pulse,Aortic regurgita
11、tion AV fistula Thyrotoxicosis Anemia Pregnancy sepsis,Basic Circulation,Blood pressure= cardiac output X systemic resistance 收縮壓：左心室射出血量施加於血管璧壓力 舒張壓：血液於動脈管腔（璧）所遭受阻力,血壓-組織灌流,Perfusion pressure(灌流壓): 向前引起組織系統灌流的趨力壓差 (pressure gradient) Systemic perfusion pressureMBP-CVP Cerebral perfusion pressureMBP
12、-ICP (30 mmHg, in injured brain50 mmHg at least Myocardial perfusion pressureDBP-CVP (50 mmHg) Glomerular filtration pressure MBP-膠質滲透壓-鮑式囊內壓BP低時供應器官血流減少之順序：肺腎臟肝心臟(hypoxemia)及腦（hypoxia）,心血管系統評估-成人血壓分級,Assessment of blood loss,BP、CO 、 PCWP、CVP 、cold skin,血量:70cc/kg 身體反應: 肝臟收縮交感神經代償低容積休克 未控制出血：MBP 不需超
13、過90 mmHg 大量出血：輸全血,Hypertensive,Hypertensive Encephalopathy MBP150 mmHg，超過腦部自我調節機轉vasospasm、ischemia、edema、hemorrhage seizureMalignant hypertension DBP130 mmHg end organ damage LV hypertrophy， hematuria， proteinuria，溶血性貧血,Advantages and disadvantages on various cannulation sites,Radial artery Brachia
14、l artery Femoral arteryAxillary artery Dorsalis pedal artery,Six “s”( Acute Arterial Occlusion)Pallor（lose flowing blood in the capillary bed then white color） Pain Paresthesia(皮膚感覺異常) ParalysisPulselessness Poikilothermia (溫度變冷)hardness :壓力2530 mmHgSwelling(小腿周圍長),compartment syndrome,C.V P,head up
15、 300,Jugular vein enlargement (+),C.V P高原因,右心衰竭 體液過多 限制性心包炎 左到右分流 三尖辦狹窄 心包填塞 測量時避免假性升高 咳嗽、用力、呼吸器使用、藥物輸入,周邊血管阻力(SVR),SVR:血管收縮、LVH、hypovolema cardiogenic shock、血液粘稠(B-擴張藥物)SVR：血管擴張、moderate hypolexmia、Anemia (L-收縮藥物),Artery Blood oxygen（Hb 、 PaO2） C.O (normal 47 L)/ C.I.(2.54L/min， C.O/體表面積) Tissure O
16、2 comsumption influence SVO2之因素SVO2：pathological shunt (L-R shunt) 、sepsis 、 cyanidetoxicity 抑粒線體使用O2）、 Mitral regurgitation SVO2：Arrythmia 、 shivering 、 hypothermia 、Anemia 、C .O 、 Hypoxia ,increased tissue O2 consumption,SVO2,CYANOSIS,CENTRAL CYANOSIS（hypoxia） Impaired pulmonary function Anatomic vascular shunting Decreased inspired O2 Abnormal hemoglobins peripheral cyanosis Reduced cardiac output Cold exposure Redistribution of blood flow from extremities Arterial obstruction Venous obstruction,
