1、嚴重創傷病人的麻醉嚴重創傷病人的麻醉1嚴重創傷病人的麻醉嚴重創傷病人的麻醉1overviewIn advanced countries, injury ranks as the third leading cause of death following heart disease and cancer.嚴重創傷病人的麻醉2overviewIn advanced countriesTreatment principle to critically ill patients Assessment to organ function and disease states Preoperative

2、treatment Selection to anesthesia way and anesthetics Close intra-operative monitoring and correction to abnormality of pathophysiological state Positive prevention and treatment toPostoperative complications 嚴重創傷病人的麻醉3Treatment principle to critiPreoperative Assessment For trauma patients, in addit

3、ion to the ordinary preanesthetic evaluation, the severity of the trauma should be evaluated. The commonly used scoring system including:嚴重創傷病人的麻醉4Preoperative Assessment嚴重創傷病人的1.ASA physical status classification system It is divided into 5 levels According to medical history, Physical examination

4、and laboratory examination Level 1 and Level 2 :normal organ function Level 3: compensation, need sufficient preoperative preparation Level 4 decompensation, High mortality Level 5 dying嚴重創傷病人的麻醉51.ASA physical status classifi2. Glasgow coma score scale（GCS） Indicators: Eye opening Spontaneous 4 To

5、voice 3 To pain 2 None 1 Verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible words 2 None 1 嚴重創傷病人的麻醉62. Glasgow coma score scale（GC Motor responses Obeys Command 6 Localizes pain 5 Withdraws（pain） 4 Flexion（pain） 3 Extension（pain） 2 None 1嚴重創傷病人的麻醉7 Motor responses嚴重創傷病人的麻醉

6、 Injury classificationLight : 1315 Consciousness obstacle in 20min Medium: 912 Consciousness obstacle between 20min and 6hSevere: 38 Coma more than 6 hours or the second coma in 24h嚴重創傷病人的麻醉8 Injury classification嚴重創3. Revised Trauma Score（RTS） Indicators：Systolic blood pressure89mmHg 47689mmHg 3507

7、5mmHg 2149mmHg 1No pulse 0Weight0.7326Respiratory rate1029/min429/min369/min215/min1None0Weight0.2908嚴重創傷病人的麻醉93. Revised Trauma Score（RTS）嚴重 Glasgow Coma Scale1315 4912 368 245 13 0 Weight 0.9368 Numeric range 07.84 SBPwgt+RRwgt+GCSwgt=TS Lower Score more serious injury嚴重創傷病人的麻醉10嚴重創傷病人的麻醉104 CRAMS

8、 Score CRAMS is constituted by five words including Circulation ,Rspiration,Abdomen,Motor and SpeakIt is a comprehensive according to physiological indexes and traumatic parts Score7 minor injurie mortality 0.15%Score6 serious injury mortality 62%sensitivity 83%91.7%, higher than TS嚴重創傷病人的麻醉114 CRAM

9、S Score嚴重創傷病人的麻醉115Assessment to organ function5.1 cardiac function:performance After activity ,Breathless test 5.2 pulmonary function:Measuring chest diameter method Blowing matches testblcod gas analysis and Pulmonary function test5.3 Liver functionSerum bilirubin , transaminase , albumin ,PT,APTT

10、5.4 renal functionUrine , Urea nitrogen , creatinine 嚴重創傷病人的麻醉125Assessment to organ function嚴心功能分級及意義級 別 屏氣 臨 床 表 現 臨床意義 麻醉 試驗I級 30s 能耐受日常體力活動 心功能正常 耐受力 活動后無心慌 良好 氣短等不適II級 2030s 日常體力活動有一定不適， 心功能較差 如處理適當 自行控制活動量， 耐受仍好 不能作跑步或用力的工作III級 1020s 輕度或一般體力活動后 心功能不全 麻醉前應充分準備 心悸、氣短明顯， 應避免增加心臟負擔 只能勝任極輕微的體力 活動或靜

11、息IV級 10s以內 不能耐受任何體力活動， 心功能衰竭 極差，一般需推遲 靜息時也感氣短，不能平臥， 有端坐呼吸、心動過速等表現嚴重創傷病人的麻醉13心功能分級及意義嚴重創傷病人的麻醉135.5 Assess to blood loss of damage in different parts Estimation to blood loss （ml） Position Moderate damage Severe damage Upper limb 500 1000Calf 500 2000Thigh 1000 3500 Pelvis 1000 4000Abdomen 1000 5000

12、Chest 1000 4000嚴重創傷病人的麻醉145.5 Assess to blood loss of da嚴重創傷病人的麻醉15嚴重創傷病人的麻醉15Characteristics of severe trauma patients condition 1 病情緊急 注意檢查和治療的矛盾 2病情嚴重 失血性休克發生率可達95% 3病情復雜 復合傷居多 4疼痛劇烈 5飽胃 急診病人一律視為飽胃病人 嚴重創傷病人的麻醉16Characteristics of severe trauanesthesia characteristics of Severe trauma patients 1不能

13、耐受深麻醉2難以配合麻醉3難于避免嘔吐誤吸4麻醉藥作用時間明顯延長5常伴有不同程度脫水、酸中毒6常需支持循環功能 疼痛劇烈 病情嚴重病情復雜病情嚴重病情復雜病情緊急飽胃病情嚴重嚴重創傷病人的麻醉17anesthesia characteristics of First aid and treatment before anesthesia 原則 積極準備而不延誤手術時機確保呼吸道通暢及充分供氧 導致缺氧的原因通常有： 呼吸道梗阻：神志不清、昏迷、舌后墜、分泌物、嘔吐 中樞性呼吸抑制：顱腦損傷 胸外傷處理方法： 通暢呼吸道：吸引、口咽通氣道、氣管插管、氣管切開 充分供氧：鼻導管、面罩、機械通氣

14、多發傷病人應假定有頸椎損傷而做頸椎固定嚴重創傷病人的麻醉18First aid and treatment before嚴重創傷病人的麻醉19嚴重創傷病人的麻醉19 快速補充血容量建立輸液通道： 常需穿刺中心靜脈輸液種類 平衡液 右旋糖酐、羥乙基淀粉萬汶、血定安輸血 ：成份輸血或全血糾正代謝性酸中毒 5%NaHCO2解除病人疼痛 度冷丁5075mg監測 呼吸、循環、體溫、出凝血監測等嚴重創傷病人的麻醉20 快速補充血容量嚴重創傷病人的麻醉20Principles of anesthesiaPremedicationAnalgesic ，Sedative ，Anticholinergics Me

15、thod of anesthesia 1. local anesthesia-it is suitable to Superficial surgery and doses should be noted intravertebral anesthesia-Caution！general anesthesia -Common ，Light anesthesia is appropriate嚴重創傷病人的麻醉21Principles of anesthesiaPremedMethod of general anesthesia 1 anesthesia induction 1.1 Prevent

16、ive measures of reflux and aspiration Large diameter of gastric tube Antacids :Cemitidine200400mgAwake tracheal intubation after topical anesthesiaCricoid pressure before intubationInflate endotracheal tube cuff Appropriate dose anti-cholinergic drugsInjecte non-depolarizing muscle relaxants before

17、Succinylcholin 嚴重創傷病人的麻醉22Method of general anesthesia 嚴2 drugs of anesthesia Induction2.1 intravenous anestheticdrugs of little effect on blood pressure are usually selected ,such asetomidateMidazolamgamma OH） Ketamine it is suitable to hypotension2.2 muscle relaxantnot directly lower blood pressur

18、e，Succinylcholine banned from large areas of contusion in patients with renal dysfunction 嚴重創傷病人的麻醉232 drugs of anesthesia Inductio3 keep of general anesthesia 3.1 superficial anesthesia3.2 balanced anesthesia3.3 inhalation anestheticEnfluorine,isoflurane sevenflurane and nitrous oxide3.4intravenous

19、 anesthesiagive priority to ketamine , fentanyl and Sufentanil3.5 muscle relaxant Pancuronium, vecuronium, atracurium and cisatracurium嚴重創傷病人的麻醉243 keep of general anesthesia 嚴4 Anesthesia Monitoring objective: understand patients condition and guide treatment 4.1Blood pressure and pulse Pressure de

20、pend on arterial puncture4.2 urine volume4.3 central venous pressure,CVP)and (pulmonary capillary wedge pressure，PCWP)4.4Temperature monitoring 4.5Hematocrit 2530%4.6 arterial blood Lactic Acid4.7blood gas and electrolure嚴重創傷病人的麻醉254 Anesthesia Monitoring objec5Circulation and respiratory management

21、 during anesthesia5.1Circulation management5.1.1maintain blood pressure blood volume supplement:Crystalloid, colloid, blood, plasmaVasoactive drugs: dopamine315g/kg/min嚴重創傷病人的麻醉265Circulation and respiratory m5.1.2AntiarrhythmicDrugs slow down the heart rate after ensuring ventilation and oxygen sup

22、ply,and eliminating low blood volume5.1.3 heart function Cedilanid5.1.4Microcirculation Dextran, scopolamine ,654-2, corticosteroids, etc. 嚴重創傷病人的麻醉275.1.2Antiarrhythmic嚴重創傷病人的麻醉275.2 Respiratory management General principles: to maintain airway patency and adequate oxygen supply Monitoring SpO2PaO2

23、PETCO2PACO2PaCO2嚴重創傷病人的麻醉28嚴重創傷病人的麻醉28胸部創傷病人的麻醉處理危險因素及處理1氣胸: 麻醉前需胸腔閉式引流2大血管破裂:導致休克或死亡3心包填塞:麻醉前宜心包穿刺4嚴重缺氧:可因反常呼吸、氣胸、合并顱腦損傷、肺挫傷及低血壓等引起-對肺挫傷者，應嚴格控制輸血輸液嚴重創傷病人的麻醉29胸部創傷病人的麻醉處理危險因素及處理嚴重創傷病人的麻醉29嚴重創傷病人的麻醉30嚴重創傷病人的麻醉30Prevention of postoperative complications 1 disseminated inravascular coagulation1.1Diagnosis 1.1.1Have the cause of DIC, such as shock, infection, trauma, etc. 1.1.2 Multiple bleeding tendency 嚴重創傷病人的麻醉31Preve