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1、严重创伤病人的麻醉Anesthesia for TraumanIn advanced countries, injury ranks as the fourth leading cause of death following heart disease, cancer, and cerebrovascular disease.Preoperative Assessment For For trauma trauma patients, patients, in in addition addition to to the the ordinary ordinary preanesthetic
2、preanesthetic evaluation, evaluation, the the severity severity of of the the trauma trauma should should be evaluated. The commonly used scoring system including:be evaluated. The commonly used scoring system including:1. ASA physical status score1. ASA physical status score It is not very useful f
3、or discriminating small difference It is not very useful for discriminating small difference in severely injured patients. in severely injured patients.2. Glasgow coma score scale2. Glasgow coma score scale（GCSGCS） Indicators: Eye opening Indicators: Eye opening Spontaneous 4 Spontaneous 4 To voice
4、3 To voice 3 To pain To pain 2 2 None None 1 1 Verbal response Verbal response Oriented Oriented 5 5 Confused Confused 4 4 Inappropriate words 4 Inappropriate words 4 Incomprehensible words 2 Incomprehensible words 2 None None 1 1 Motor responsesMotor responses Obeys Command Obeys Command 6 6 Locali
5、zes pain Localizes pain 5 5 Withdraws Withdraws（painpain） 4 4 Flexion Flexion（painpain） 3 3 Extension Extension（painpain） 2 2 None None 1 1Numeric rangeNumeric range：3 31515 Lower score more serious coma Lower score more serious coma3. Revised Trauma Score3. Revised Trauma Score（RTSRTS） IndicatorsIn
6、dicators：Systolic blood pressureSystolic blood pressure89mmHg89mmHg 4 4767689mmHg89mmHg 3 3505075mmHg75mmHg 2 21 149mmHg49mmHg 1 1No pulseNo pulse 0 0WeightWeight0.73260.7326Respiratory rateRespiratory rate101029/min29/min4 429/min29/min3 36 69/min9/min2 21 15/min5/min1 1NoneNone0 0WeightWeight0.290
7、80.2908 Glasgow Coma ScaleGlasgow Coma Scale13131515 4 49 91212 3 36 68 8 2 24 45 5 1 13 3 0 0 Weight Weight 0.9368 0.9368 Numeric range Numeric range 0 00.7840.784 SBPwgt+RRwgt+GCSwgtSBPwgt+RRwgt+GCSwgt=TS=TS Lower Score more serious injury Lower Score more serious injury4. Others Refer to the text
8、.4. Others Refer to the text. Mechanisms of Injury The mechanism of injury determines the pattern of The mechanism of injury determines the pattern of injury, and the knowledge focuses the treatment priorities injury, and the knowledge focuses the treatment priorities for the patient. for the patien
9、t. For example: For example: Penetrating thoracic trauma Penetrating thoracic trauma Blunt Chest trauma Blunt Chest trauma The therapeutic approach is quite different. The therapeutic approach is quite different. Blunt trauma results in widespread energy transfer to the body. When the limits of lord
10、 tolerance are exceeded, Tissues are disrupted depending on the amount of energy transfer. Penetrating trauma injures as the energy behind the penetrating instrument causes stretching and crushing of tissues. The energy dissipation profiles of different weapons（Knives and bullets determine the anato
11、mic depth and extent of maximum injury. Trauma patients death demonstrate a trimodal distribution. In the first and largest peak of distribution curve, death from either blunt or penetrating trauma occurs immediately following widespread laceration of the brain or major blood vessels, including the
12、heart. Such patients can rarely be saved. In the second peak, exsanguinations from vascular injuries causes death within a few hours without medical treatment. Inadequate or delayed shock resuscitation or surgical treatment leads to late death from infection, sepsis, or multiorgan failure.麻醉前准备麻醉前准备
13、对于严重创伤病人，必须首先考虑其病情特点：对于严重创伤病人，必须首先考虑其病情特点：病情紧急；病情紧急；病情严重；病情严重；病情复杂；病情复杂；有剧烈疼痛；有剧烈疼痛；应一律视作应一律视作“ “饱胃饱胃” ”病人，慎重处理。病人，慎重处理。复苏是应优先采取的措施。复苏是应优先采取的措施。ParrParr和和GrandeGrande建议了一个对创伤病人的处理程序。建议了一个对创伤病人的处理程序。I. OverviewI. OverviewA. Perform visual scan of patient for obvious injures.A. Perform visual scan of
14、patient for obvious injures.B. Obtain history from B. Obtain history from prehospitalprehospital personnel and personnel and patient patient（if ableif able）. Primary survey. Primary survey（ascertain“ABCDEsascertain“ABCDEs” ”）A. Airway maintenanceA. Airway maintenance（with cervical spine controlwith
15、cervical spine control） 1. Look for chest wall movements, retraction and 1. Look for chest wall movements, retraction and nasal flaring nasal flaring 2. Listen for breath sound, 2. Listen for breath sound, stridorstridor, and obstructed, and obstructed ventilation. ventilation. 3. Feel for air movem
16、ent 3. Feel for air movement B. Breathing（give supplemental oxygen） 1. Determine whether ventilation is adequate 2. Inspect chest to exclude open pneumothorax, sucking chest wound, or flail segment 3. Ausculate for bilateral breath sounds 4. Provide assisted ventilation for ventilatory failure C. Ci
17、rculation（establish venous access） 1. Check peripheral pulses, capillary refill, and blood pressure 2. Obtain electrocardiogram 3. Grade shock according to vital signs 4. Correct hypovolemia and obtain blood samples D. DisabilityD. Disability（determine determine neurologicneurologic status status） 1
18、. Evaluate central function1. Evaluate central functionA A：alertalertV V：responds to vocal stimulusresponds to vocal stimulusP P：responds to painful stimulusresponds to painful stimulusUU：UnresponsiveUnresponsive 2. Evaluate pupil response to light 2. Evaluate pupil response to light E E：Expose pati
19、ent for complete examinationExpose patient for complete examination . Resuscitation phase. Resuscitation phase . Secondary surrey. Secondary surrey . Definitive care phase. Definitive care phase 麻醉前的复苏治疗是提高麻醉、手术安全性的麻醉前的复苏治疗是提高麻醉、手术安全性的重要环节。重要环节。 主要包括：主要包括： 1 1保存中枢神经系统功能。保存中枢神经系统功能。维持良好的脑维持良好的脑血流供应；血
20、流供应；注意避免造成继发性脊髓损伤；注意避免造成继发性脊髓损伤；对对昏迷病人一般在药物治疗（如用甘露醇）前作气管昏迷病人一般在药物治疗（如用甘露醇）前作气管内插管和轻度过度通气。在作气管内插管时应注意内插管和轻度过度通气。在作气管内插管时应注意保持颈椎的稳定。保持颈椎的稳定。2 2保持气道通畅，充分供氧保持气道通畅，充分供氧 （1 1）使用肌松药作经口腔气管内插管是最常用）使用肌松药作经口腔气管内插管是最常用的方法。的方法。 正确进行环状软骨加压。正确进行环状软骨加压。 对疑有颈椎损伤病人，插管时应由助手人工对疑有颈椎损伤病人，插管时应由助手人工 固定病人头颈部以稳定颈椎。固定病人头颈部以稳定
21、颈椎。 （2）某些情况下行紧急气管内插管 （3）喉罩（LMA）可用于快速建立通 气途径 （4）纤支镜的应用 （5）气管造口术3休克的复苏 建立能快速输液、输血的静脉通路。 对需输入大量液体或血液者，应注意 对输入的液体或血液加温。 对输入液体的选择：首先是恢复血容量，其次对输入液体的选择：首先是恢复血容量，其次 考虑必需的血红蛋白浓度，最后是保持凝血机考虑必需的血红蛋白浓度，最后是保持凝血机 制正常或基本正常。应注意晶、胶体比例，血制正常或基本正常。应注意晶、胶体比例，血 液的合理应用，必要时辅用血管活性药物。液的合理应用，必要时辅用血管活性药物。 75% 75%氯化钠与胶体液的混合液的应用。
22、氯化钠与胶体液的混合液的应用。4 4应注意纠正酸碱平衡和电解质方面的紊乱。应注意纠正酸碱平衡和电解质方面的紊乱。5 5其他其他 如适当止痛，进行必要的监测等。如适当止痛，进行必要的监测等。Changes in vital signs with percent blood volume lost in hemorrhageVital signs15%15%30%30%40%40%Heart rate100120120140Systolic blood pressureNormalNormalDecreasedDecreasedPulse pressupeNormaltoincreasedDecr
23、easedDecreasedDecreasedCapillary refillNormalDelayedDelayed toAbsentAbsentRespiratory rate14202030304035CNS-mental statusAnxiousMore anxiousAnxiousandConfusedConfusedtolethargic麻醉处理要点麻醉处理要点 一、必须充分认识此类病人的麻醉特点一、必须充分认识此类病人的麻醉特点一、必须充分认识此类病人的麻醉特点一、必须充分认识此类病人的麻醉特点 1 1严重创伤病人不能耐受深的全身麻醉，也严重创伤病人不能耐受深的全身麻醉，也不能
24、耐受其麻醉平面或范围可对病人的血流动力学不能耐受其麻醉平面或范围可对病人的血流动力学造成明显影响的椎管内麻醉。造成明显影响的椎管内麻醉。 2 2凡经肝代谢、经肾排泄的麻醉用药其作用凡经肝代谢、经肾排泄的麻醉用药其作用时间明显延长。时间明显延长。 3 3应一律按应一律按“ “饱胃饱胃” ”病人处理。病人处理。 4 4了解其麻醉前复苏情况，以便进一步处理。了解其麻醉前复苏情况，以便进一步处理。 5 5往往难于合作或已昏迷。往往难于合作或已昏迷。二、麻醉前用药与麻醉选择1麻醉用药 镇痛、镇静药物 抗胆碱药物 昏迷或危重病人免用或麻醉过程中酌用 小量，经静脉2 2麻醉选择麻醉选择（1 1）全身麻醉：多
25、处伤或其他严重创伤、气管内插）全身麻醉：多处伤或其他严重创伤、气管内插 管应避免采用在某些情况下不宜采管应避免采用在某些情况下不宜采 用的药物：用的药物： 氯胺酮氯胺酮 琥珀胆碱琥珀胆碱 氧化亚氮氧化亚氮 安氟醚、异氟醚等如用于脑外伤病人应用时采安氟醚、异氟醚等如用于脑外伤病人应用时采 用轻度过度通气，临床上多用异氟醚。用轻度过度通气，临床上多用异氟醚。（2 2）椎管内麻醉：椎管内麻醉所致的交感阻滞削）椎管内麻醉：椎管内麻醉所致的交感阻滞削 弱失血病人稳定其血流动力学的代偿能力。弱失血病人稳定其血流动力学的代偿能力。（3 3）部位麻醉：较适用于肢体创伤手术的麻醉。）部位麻醉：较适用于肢体创伤手
26、术的麻醉。 休克病人对局麻药的耐量降低。休克病人对局麻药的耐量降低。三、适当的监测 有人将对创伤病人的监测汇总如下：Montoring choices for Trauma PatientsNoninvasive EssentialECG for heart rate and rhythm,noninvasive blood pressure, respiratory rate,Temperature, SaO2, ETCO2 with waveform Optional Concentrations of anesthetic and respiratory gases（e.g. Mass
27、spectrometry, Transcutaneous）InvasiveFoley catheter urine output, intra-arterial pressure catheter, central venous pressure catheterTransesophageal echocardiographyIndications for Massive hemorrhagePulmonary Pretraumatic heart diseasearteryMultiple systems injuries/Mechanism of injurycatheterMonitor
28、ing of cardiac output and oxygen consumptionOptimization of fluid therapy in head-injured patient 四、麻醉注意事项四、麻醉注意事项 1检查在麻醉前复苏中所置气管内导管，如 未行气管内插管，应注意在麻醉诱导及苏 过程中避免出现误吸。 2施行全麻时，应选用对心血管系统抑制最 小，不升高或不明显升高颅内压的药物。 耐受量小，宜采用“滴定”（Titration）的方 法。 3. 除维持平顺的麻醉外，应注意维护、支持重要 的脏器功能和维持电解质、酸碱平衡等内环境的稳定。（注意监测、处理），例如呼吸、循环、尿
29、量4. 除注意创伤病人的共性外，还应注意不同病人的病理特点（个性），进行相应处理。 如：张力性气胸 心脏挫伤 并存肺挫伤 腹腔内大量失血5术中可能遇到的问题（1）手术时间延长：注意全面照顾、处理 病人。（2）体温降低：特别易发生于多处伤病 人。应注意从各方面保持体温和减少 体热的丢失。 （3 3）大量输血：常可出现稀释性血小板减少、凝血因）大量输血：常可出现稀释性血小板减少、凝血因 子不足、凝血时间延长、离子钙浓度降低等。子不足、凝血时间延长、离子钙浓度降低等。 需适当补充血小板、凝血因子，依据离子钙浓度需适当补充血小板、凝血因子，依据离子钙浓度 补充钙剂。补充钙剂。 保持正常体温对保持凝血功能正常非常重要。保持正常体温对保持凝血功能正常非常重要。（4 4）低氧血症：往往是由于未被发现的气胸加重或是）低氧血症：往往是由于未被发现的气胸加重或是 由于肺部的脂肪栓塞。由于肺部的脂肪栓塞。
