严重创伤病人的麻醉 1 overview Inadvancedcountries injuryranksasthethirdleadingcauseofdeathfollowingheartdiseaseandcancer 2 Treatmentprincipletocriticallyillpatients AssessmenttoorganfunctionanddiseasestatesPreoperativetreatmentSelectiontoanesthesiawayandanestheticsCloseintra operativemonitoringandcorrectiontoabnormalityofpathophysiologicalstatePositivepreventionandtreatmenttoPostoperativecomplications 3 PreoperativeAssessment 4 5 6 7 8 9 10 11 12 心功能分级及意义级别屏气临床表现临床意义麻醉试验I级 30s能耐受日常体力活动心功能正常耐受力活动后无心慌良好气短等不适II级20 30s日常体力活动有一定不适 心功能较差如处理适当自行控制活动量 耐受仍好不能作跑步或用力的工作III级10 20s轻度或一般体力活动后心功能不全麻醉前应充分准备心悸 气短明显 应避免增加心脏负担只能胜任极轻微的体力活动或静息IV级10s以内不能耐受任何体力活动 心功能衰竭极差 一般需推迟静息时也感气短 不能平卧 有端坐呼吸 心动过速等表现 13 5 5AssesstobloodlossofdamageindifferentpartsEstimationtobloodloss ml PositionModeratedamageSeveredamageUpperlimb5001000Calf5002000Thigh10003500Pelvis10004000Abdomen10005000Chest10004000 14 15 Characteristicsofseveretraumapatient scondition 1病情紧急注意检查和治疗的矛盾2病情严重失血性休克发生率可达95 3病情复杂复合伤居多4疼痛剧烈5饱胃急诊病人一律视为饱胃病人 16 anesthesiacharacteristicsofSeveretraumapatients 1不能耐受深麻醉2难以配合麻醉3难于避免呕吐误吸4麻醉药作用时间明显延长5常伴有不同程度脱水 酸中毒6常需支持循环功能 疼痛剧烈病情严重病情复杂 病情严重病情复杂 病情紧急饱胃 病情严重 17 Firstaidandtreatmentbeforeanesthesia 原则积极准备而不延误手术时机 确保呼吸道通畅及充分供氧 导致缺氧的原因通常有 呼吸道梗阻 神志不清 昏迷 舌后坠 分泌物 呕吐 中枢性呼吸抑制 颅脑损伤 胸外伤 处理方法 通畅呼吸道 吸引 口咽通气道 气管插管 气管切开 充分供氧 鼻导管 面罩 机械通气 多发伤病人应假定有颈椎损伤而做颈椎固定 18 19 20 Principlesofanesthesia PremedicationAnalgesic Sedative AnticholinergicsMethodofanesthesia1 localanesthesia itissuitabletoSuperficialsurgeryanddosesshouldbenoted intravertebralanesthesia Caution generalanesthesia Common Lightanesthesiaisappropriate 21 Methodofgeneralanesthesia1anesthesiainduction1 1PreventivemeasuresofrefluxandaspirationLargediameterofgastrictubeAntacids Cemitidine200 400mgAwaketrachealintubationaftertopicalanesthesiaCricoidpressurebeforeintubationInflateendotrachealtubecuffAppropriatedoseanti cholinergicdrugsInjectenon depolarizingmusclerelaxantsbeforeSuccinylcholin 22 23 24 25 5Circulationandrespiratorymanagementduringanesthesia5 1Circulationmanagement5 1 1maintainbloodpressurebloodvolumesupplement Crystalloid colloid blood plasmaVasoactivedrugs dopamine3 15 g kg min 26 5 1 2AntiarrhythmicDrugsslowdowntheheartrateafterensuringventilationandoxygensupply andeliminatinglowbloodvolume5 1 3heartfunctionCedilanid5 1 4MicrocirculationDextran scopolamine 654 2 corticosteroids etc 27 28 胸部创伤病人的麻醉处理 危险因素及处理1气胸 麻醉前需胸腔闭式引流2大血管破裂 导致休克或死亡3心包填塞 麻醉前宜心包穿刺4严重缺氧 可因反常呼吸 气胸 合并颅脑损伤 肺挫伤及低血压等引起 对肺挫伤者 应严格控制输血输液 29 30 31 32 33 Thankyou 34