医学--临床危象双语课件.ppt

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1、第十章第十章常见临床危象常见临床危象Chapter 10Chapter 10 Common Emergency CrisisCommon Emergency CrisisDefinition of Common Emergency CrisisDefinition of Common Emergency Crisis Clinical crisis is not an independent disease but a Clinical crisis is not an independent disease but a group of syndromes manifested progre

2、ss of certain group of syndromes manifested progress of certain disease.disease.It can threaten the vital organs,particularly the It can threaten the vital organs,particularly the brain.brain.是指某一疾病在进展中所表现的一组综合征。死亡率和致是指某一疾病在进展中所表现的一组综合征。死亡率和致是指某一疾病在进展中所表现的一组综合征。死亡率和致是指某一疾病在进展中所表现的一组综合征。死亡率和致残率较高残率较高

3、残率较高残率较高 The mortality and morbidity would be high The mortality and morbidity would be high The common precipitating factors of the crisis:The common precipitating factors of the crisis:常见诱因：常见诱因：Exhaustion,infection,trauma,surgery,delivery Exhaustion,infection,trauma,surgery,delivery The crisis ca

4、n be controlled The crisis can be controlled DefinitionDefinitionDefinitionDefinition：is an excessive and unusual elevation of body is an excessive and unusual elevation of body temperature greater than 41temperature greater than 41.It is medical It is medical emergencyemergency,accompanied by convu

5、lsion,coma,accompanied by convulsion,coma,shock,hemorrhage,etcshock,hemorrhage,etc a medical emergencya medical emergency 是指体温异乎寻常升高至是指体温异乎寻常升高至是指体温异乎寻常升高至是指体温异乎寻常升高至41414141以上，是一种医疗急症。以上，是一种医疗急症。以上，是一种医疗急症。以上，是一种医疗急症。高热同时伴随抽搐、昏迷、休克、出血等，通常是致高热同时伴随抽搐、昏迷、休克、出血等，通常是致高热同时伴随抽搐、昏迷、休克、出血等，通常是致高热同时伴随抽搐、昏迷、休

6、克、出血等，通常是致命的，需紧急处理。命的，需紧急处理。命的，需紧急处理。命的，需紧急处理。Section1 hyperpyrexia crisis第一节第一节 超高热危象超高热危象一、病因一、病因 EtiologyEtiology.Infectious HyperpyrexiaInfectious HyperpyrexiaInfectious HyperpyrexiaInfectious Hyperpyrexia 感染性发热感染性发热.Non-infectious Hyperpyrexia Non-infectious Hyperpyrexia Non-infectious Hyperpyr

7、exia Non-infectious Hyperpyrexia 非非非非感染性发热感染性发热 1.1.Allergic reactionAllergic reaction 变态反应变态反应 Such as serum Such as serum disease,infusion reactions disease,infusion reactions 2.2.Dysfunction of the body Dysfunction of the bodys temperature s temperature regulation center regulation center 体温调节中枢异

8、常体温调节中枢异常 3.3.Endocrine and metabolic diseases Endocrine and metabolic diseases 内分泌和代谢性疾病内分泌和代谢性疾病.First Aid Care.First Aid Care 救治和护理救治和护理（一）严密观察病情（一）严密观察病情（一）严密观察病情（一）严密观察病情.MonitoringMonitoringMonitoringMonitoring1.1.Monitor the changes of vital signs,Monitor the changes of vital signs,such as co

9、nsciousness,breathing,blood such as consciousness,breathing,blood pressure,pulse,temperature and peripheral pressure,pulse,temperature and peripheral circulation,particular the changes of circulation,particular the changes of temperature falls too fast as this may lead temperature falls too fast as

10、this may lead to collapse of the patient.to collapse of the patient.2.2.Observe for the changes of concomitant Observe for the changes of concomitant symptoms symptoms 伴随症状伴随症状that can assist the physician that can assist the physician to make diagnosis.to make diagnosis.3.3.Record intake and output

11、 of the patient.Record intake and output of the patient.Adequate fluids should be supplemented.Adequate fluids should be supplemented.First Aid Care（二）降温（二）降温.Cooling.Cooling.Cooling.Cooling It is vitalIt is vital （关键）（关键）to decrease the body temperature to decrease the body temperature to 38.5 quic

12、kly and effectively in hyperpyrexia to 38.5 quickly and effectively in hyperpyrexia crisis.crisis.1.1.Physical coolingPhysical cooling物理降温物理降温物理降温物理降温 is a preferred simple is a preferred simple（首选）（首选）,safe and effective measure.,safe and effective measure.（1 1 1 1）方法：冰水擦浴；温水擦浴；酒精擦浴；冰敷。）方法：冰水擦浴；温水擦

13、浴；酒精擦浴；冰敷。）方法：冰水擦浴；温水擦浴；酒精擦浴；冰敷。）方法：冰水擦浴；温水擦浴；酒精擦浴；冰敷。（2 2 2 2）注意事项：）注意事项：）注意事项：）注意事项：2.2.Cooling with medication Cooling with medication 3.3.Hibernation therapy Hibernation therapy冬眠降温冬眠降温.Identify Causes.Identify Causes寻找病因寻找病因1.1.Choose appropriate antibioticsChoose appropriate antibiotics合理选用抗合理

14、选用抗合理选用抗合理选用抗生素生素生素生素2.2.To the disease highly suspected To the disease highly suspected 诊断性治诊断性治诊断性治诊断性治疗疗疗疗diagnostic treatment can be provided.diagnostic treatment can be provided.3.3.For unexplained fever,continuous For unexplained fever,continuous observation and further examinations are observ

15、ation and further examinations are required.required.对原因不明者对原因不明者对原因不明者对原因不明者-进一步观察进一步观察进一步观察进一步观察（五）对症护理（五）对症护理 Symptomatic CareSymptomatic Care1.Ice pack need to be replaced in time1.Ice pack need to be replaced in time 及时更换冰袋及时更换冰袋及时更换冰袋及时更换冰袋2.2.Skin Care Skin Care 皮肤护理皮肤护理皮肤护理皮肤护理3.3.Oral care

16、Oral care 口腔护理口腔护理口腔护理口腔护理4.4.Strengthen management of respiratory Strengthen management of respiratory tracttract 加强呼吸道管理加强呼吸道管理加强呼吸道管理加强呼吸道管理5.5.Patients who are irritable or having Patients who are irritable or having convulsion should be placed bed with convulsion should be placed bed with side

17、side railsrails up,and may need limbs constraint to up,and may need limbs constraint to prevent falling from the bed or self-injury.prevent falling from the bed or self-injury.保护及约束保护及约束保护及约束保护及约束Section 3 Hyperthyroidism CrisisSection 3 Hyperthyroidism Crisis甲亢危象甲亢危象 DefinitionDefinitionDefinitionD

18、efinition Hyperthyroidism crisis(also known as thyrotoxic Hyperthyroidism crisis(also known as thyrotoxic storm)is an uncommon medical emergency caused by an storm)is an uncommon medical emergency caused by an exacerbation of primary hyperthyroidism exacerbation of primary hyperthyroidism characteri

19、zed by decompensationcharacterized by decompensation代偿不全代偿不全 of one or of one or more organ systems.more organ systems.甲亢危象是一种由甲状腺功能亢进恶化的，以一个或多个器甲亢危象是一种由甲状腺功能亢进恶化的，以一个或多个器甲亢危象是一种由甲状腺功能亢进恶化的，以一个或多个器甲亢危象是一种由甲状腺功能亢进恶化的，以一个或多个器官功能失代偿为特征的罕见的医疗急症。官功能失代偿为特征的罕见的医疗急症。官功能失代偿为特征的罕见的医疗急症。官功能失代偿为特征的罕见的医疗急症。.Prec

20、ipitants and PathogenesisPrecipitants and Pathogenesis诱因与发病机制诱因与发病机制 Precipitants can be divided into two categories:Precipitants can be divided into two categories:i.i.i.i.Medical PrecipitantsMedical PrecipitantsMedical PrecipitantsMedical Precipitants 内科性诱因内科性诱因内科性诱因内科性诱因 Medical precipitants refe

21、r to precipitants other Medical precipitants refer to precipitants other than surgical factors.than surgical factors.1.1.Serious infections:Serious infections:严重感染，临床上最常见的因素严重感染，临床上最常见的因素严重感染，临床上最常见的因素严重感染，临床上最常见的因素 2.stress 2.stress 2.stress 2.stress 应激：过度紧张、高热、过度疲劳、情绪激动。应激：过度紧张、高热、过度疲劳、情绪激动。应激：过度紧

22、张、高热、过度疲劳、情绪激动。应激：过度紧张、高热、过度疲劳、情绪激动。3.Emotional stimulus:3.Emotional stimulus:精神刺激：对诱发本症有明显作用精神刺激：对诱发本症有明显作用精神刺激：对诱发本症有明显作用精神刺激：对诱发本症有明显作用 4.4.Suddenly withdrawal of or non-compliance with anti-Suddenly withdrawal of or non-compliance with anti-thyroid medication thyroid medication 忽然停用或不适应抗甲状腺药物忽然停

23、用或不适应抗甲状腺药物忽然停用或不适应抗甲状腺药物忽然停用或不适应抗甲状腺药物 5.Others:Squeezing the thyroid excessively results in 5.Others:Squeezing the thyroid excessively results in massive thyroxin released intomassive thyroxin released into blood.blood.挤压甲状腺挤压甲状腺挤压甲状腺挤压甲状腺 （三）发病机制（三）发病机制PathogenesisPathogenesis The pathogenesis of

24、 hyperthyroidism crisis is not The pathogenesis of hyperthyroidism crisis is not clearly defined.The possible key factors may clearly defined.The possible key factors may include:include:甲亢危象发病机制尚不清楚，可能相关的主要因素包括：甲亢危象发病机制尚不清楚，可能相关的主要因素包括：甲亢危象发病机制尚不清楚，可能相关的主要因素包括：甲亢危象发病机制尚不清楚，可能相关的主要因素包括：1.1.Massive t

25、hyroid hormone releasing into blood Massive thyroid hormone releasing into blood 大量大量甲状腺素释放入血甲状腺素释放入血甲状腺素释放入血甲状腺素释放入血 2.2.Blood concentration of free thyroid hormone Blood concentration of free thyroid hormone increasing.increasing.血游离甲状腺素浓度增加血游离甲状腺素浓度增加血游离甲状腺素浓度增加血游离甲状腺素浓度增加 3 3 Activation of adren

26、aling increasing Activation of adrenaling increasing 肾上腺素活力增加肾上腺素活力增加肾上腺素活力增加肾上腺素活力增加二、病情评估二、病情评估 Assessment Assessment 1.1.Primary hyperthyroidism aggravated.Primary hyperthyroidism aggravated.原有甲状腺功能亢进进一步加重原有甲状腺功能亢进进一步加重原有甲状腺功能亢进进一步加重原有甲状腺功能亢进进一步加重 2.2.Systemic symptoms Systemic symptoms 全身症状全身症状

27、The body temperature increases sharply.A lethal high fever The body temperature increases sharply.A lethal high fever may develop within 2428 hours.Skin presents red and moist may develop within 2428 hours.Skin presents red and moist accompanied by massive perspiration,then turns to no sweat.accompa

28、nied by massive perspiration,then turns to no sweat.It is followed by obviously dehydration or collapse,dyspnea or It is followed by obviously dehydration or collapse,dyspnea or even shock.even shock.高热、皮肤潮湿红润、大汗、明显脱水、呼吸困难、休克高热、皮肤潮湿红润、大汗、明显脱水、呼吸困难、休克高热、皮肤潮湿红润、大汗、明显脱水、呼吸困难、休克高热、皮肤潮湿红润、大汗、明显脱水、呼吸困难、休克

29、 3.CNS symptoms 3.CNS symptoms 中枢神经系统症状中枢神经系统症状中枢神经系统症状中枢神经系统症状 It manifests as anxiety,indifferent expression,It manifests as anxiety,indifferent expression,restless,and even coma.restless,and even coma.焦虑、表情淡漠、躁动不安、昏迷。焦虑、表情淡漠、躁动不安、昏迷。焦虑、表情淡漠、躁动不安、昏迷。焦虑、表情淡漠、躁动不安、昏迷。三、救治与护理三、救治与护理 First Aid CareFir

30、st Aid Care i.Monitoring i.Monitoring i.Monitoring i.Monitoring changes of the level of consciousness,changes of the level of consciousness,body temperature,pulse,breath,blood body temperature,pulse,breath,blood pressure,blood oxygen saturation.pressure,blood oxygen saturation.严密观察严密观察严密观察严密观察 患者神志、

31、体温、脉搏、呼吸、血压、血氧饱和度患者神志、体温、脉搏、呼吸、血压、血氧饱和度患者神志、体温、脉搏、呼吸、血压、血氧饱和度患者神志、体温、脉搏、呼吸、血压、血氧饱和度三、救治与护理三、救治与护理 First Aid CareFirst Aid Care（二）急救措施（二）急救措施（二）急救措施（二）急救措施 1 1 1 1、原则、原则、原则、原则维持基本生命维持基本生命维持基本生命维持基本生命 迅速降温迅速降温迅速降温迅速降温 补充体液补充体液补充体液补充体液 消除诱因消除诱因消除诱因消除诱因 治疗病因对症处理治疗病因对症处理治疗病因对症处理治疗病因对症处理 2 2 2 2、措施：、措施：、措

32、施：、措施：降低血循环中甲状腺素的浓度降低血循环中甲状腺素的浓度降低血循环中甲状腺素的浓度降低血循环中甲状腺素的浓度抑制甲状腺素的合成抑制甲状腺素的合成抑制甲状腺素的合成抑制甲状腺素的合成-丙硫丙硫丙硫丙硫氧嘧啶（氧嘧啶（氧嘧啶（氧嘧啶（PTUPTUPTUPTU）抑制甲状腺素的释放。抑制甲状腺素的释放。抑制甲状腺素的释放。抑制甲状腺素的释放。PTU+PTU+PTU+PTU+碘液碘液碘液碘液 降低组织对甲状腺素降低组织对甲状腺素降低组织对甲状腺素降低组织对甲状腺素-儿茶酚胺的反应儿茶酚胺的反应儿茶酚胺的反应儿茶酚胺的反应 普萘洛尔普萘洛尔普萘洛尔普萘洛尔利血平各胍乙啶利血平各胍乙啶利血平各胍乙啶

33、利血平各胍乙啶氢化可的松氢化可的松氢化可的松氢化可的松 糖皮质激素的应用糖皮质激素的应用糖皮质激素的应用糖皮质激素的应用 降温降温降温降温 其它对症处理其它对症处理其它对症处理其它对症处理（三）加强基础护理（三）加强基础护理（三）加强基础护理（三）加强基础护理 Strengthen Primary Nursing CareStrengthen Primary Nursing CareStrengthen Primary Nursing CareStrengthen Primary Nursing Care 1.1.Absolute bed rest;maintain a quiet and A

34、bsolute bed rest;maintain a quiet and comfortable fortable environment.绝对卧床休息绝对卧床休息 2.2.Provide primary nursing care:offer high Provide primary nursing care:offer high energy,high protein,and high vitamin diet;energy,high protein,and high vitamin diet;encourage the patient to drink more waterencoura

35、ge the patient to drink more water.做好生活护做好生活护理理 3.3.Psychological care Psychological care 精神护理精神护理 Concern and comfort the patient;eliminate the Concern and comfort the patient;eliminate the fear and encourage confidence to confront the fear and encourage confidence to confront the disease.disease.（

36、四）对症护理（四）对症护理 Symptomatic CareSymptomatic Care1.1.Administer sedative such as Administer sedative such as diazepam to the manicdiazepam to the manic（狂躁）（狂躁）patientpatient.镇静镇静镇静镇静2.2.Keep various rescue equipment Keep various rescue equipment ready;prevent complications such as ready;prevent complic

37、ations such as aspiration pneumonia etc.aspiration pneumonia etc.做好各种抢救准备，预防吸入性肺炎做好各种抢救准备，预防吸入性肺炎做好各种抢救准备，预防吸入性肺炎做好各种抢救准备，预防吸入性肺炎 第四节第四节 高血糖危象高血糖危象 Hyperglycemic Crisis Hyperglycemic Crisis一、糖尿病酮症酸中毒一、糖尿病酮症酸中毒概概概概 述述述述是糖尿病急性并发症之一是糖尿病急性并发症之一是糖尿病急性并发症之一是糖尿病急性并发症之一可作为糖尿病首发表现可作为糖尿病首发表现可作为糖尿病首发表现可作为糖尿病首发

38、表现由于胰岛素绝对或相对缺乏引起由于胰岛素绝对或相对缺乏引起由于胰岛素绝对或相对缺乏引起由于胰岛素绝对或相对缺乏引起以高血糖（以高血糖（以高血糖（以高血糖（hyperglycemiahyperglycemiahyperglycemiahyperglycemia）、高酮血症、高酮血症、高酮血症、高酮血症（hyperketonemiahyperketonemiahyperketonemiahyperketonemia ）、代谢性酸中毒（）、代谢性酸中毒（）、代谢性酸中毒（）、代谢性酸中毒（metabolic metabolic metabolic metabolic acidosisacidosi

39、sacidosisacidosis ）为特征）为特征）为特征）为特征,三联征。三联征。三联征。三联征。英文（英文（英文（英文（DKA Diabetic ketoacidosisDKA Diabetic ketoacidosisDKA Diabetic ketoacidosisDKA Diabetic ketoacidosis）（一）诱因与发病机制（一）诱因与发病机制Precipitants and PathogenesisPrecipitants and Pathogenesis1 1 1 1、引起糖升高的因素：、引起糖升高的因素：、引起糖升高的因素：、引起糖升高的因素：感染：最常见，占一半以

40、上，泌尿道、肺部感染。最常见感染：最常见，占一半以上，泌尿道、肺部感染。最常见感染：最常见，占一半以上，泌尿道、肺部感染。最常见感染：最常见，占一半以上，泌尿道、肺部感染。最常见胰岛素治疗中断或不适当减量。胰岛素治疗中断或不适当减量。胰岛素治疗中断或不适当减量。胰岛素治疗中断或不适当减量。应激状态：心肌梗死、外伤、手术、妊娠分娩、精神刺激。应激状态：心肌梗死、外伤、手术、妊娠分娩、精神刺激。应激状态：心肌梗死、外伤、手术、妊娠分娩、精神刺激。应激状态：心肌梗死、外伤、手术、妊娠分娩、精神刺激。各种引起糖升高的药物各种引起糖升高的药物各种引起糖升高的药物各种引起糖升高的药物 2 2 2 2、引起

41、失水、脱水的因素、引起失水、脱水的因素、引起失水、脱水的因素、引起失水、脱水的因素 利尿药物、水摄入不足、透析、利尿药物、水摄入不足、透析、利尿药物、水摄入不足、透析、利尿药物、水摄入不足、透析、大面积烧伤大面积烧伤大面积烧伤大面积烧伤3 3 3 3、肾功能不全、肾功能不全、肾功能不全、肾功能不全高血糖胰岛素绝对或相对不足胰岛素对抗性调节激素升高脂肪分解蛋白质分解葡萄糖利用游离脂肪酸甘油酮体碱储备酮症酸中毒氨基酸糖异生渗透性利尿水电解质丢失脱水高渗DKADKA发病机制发病机制临床表现(三三)救治与护理救治与护理 First Aid Care 1.严密观察病情 Monitoring(1)(1)S

42、trictly observe for the changes of Strictly observe for the changes of temperature,pulse,breathing,BP and temperature,pulse,breathing,BP and consciousness;consciousness;(2)(2)Promptly draw blood sample and take Promptly draw blood sample and take urine sampleurine sample(3)(3)Accurately record the i

43、ntake and Accurately record the intake and output of 24 hours.output of 24 hours.二、糖尿病高渗性非酮症昏迷二、糖尿病高渗性非酮症昏迷二、糖尿病高渗性非酮症昏迷二、糖尿病高渗性非酮症昏迷 Hyperosmolar Nonketotic DiabeticHyperosmolar Nonketotic DiabeticHyperosmolar Nonketotic DiabeticHyperosmolar Nonketotic Diabetic ComaComaComaComa 是糖尿病另外一种急性并发症是糖尿病另外一

44、种急性并发症是糖尿病另外一种急性并发症是糖尿病另外一种急性并发症 特点：重度高血糖，、高渗性脱水、进行性意识特点：重度高血糖，、高渗性脱水、进行性意识特点：重度高血糖，、高渗性脱水、进行性意识特点：重度高血糖，、高渗性脱水、进行性意识障碍为特点。无明显酮症酸中毒多见老年人，约障碍为特点。无明显酮症酸中毒多见老年人，约障碍为特点。无明显酮症酸中毒多见老年人，约障碍为特点。无明显酮症酸中毒多见老年人，约2/32/32/32/3病人发病前无糖尿病史或仅有轻症（不多食、病人发病前无糖尿病史或仅有轻症（不多食、病人发病前无糖尿病史或仅有轻症（不多食、病人发病前无糖尿病史或仅有轻症（不多食、不消瘦）不消瘦

45、）不消瘦）不消瘦）(HNDC)is another acute complication of diabetic.(HNDC)is another acute complication of diabetic.It is a clinical syndrome characterized by severe It is a clinical syndrome characterized by severe hyperglycemia,hypertonic dehydration,and hyperglycemia,hypertonic dehydration,and progressively

46、 mental disorder.progressively mental disorder.HNDC is a medical emergency with a high morbidity HNDC is a medical emergency with a high morbidity and mortalityand mortality （一）诱因与发病机制（一）诱因与发病机制Precipitants and PathogenesisPrecipitants and Pathogenesis发病机制发病机制 PathogenesisPathogenesis 患者已存在不同程度的糖代谢障

47、碍，在诱因的作用下患者已存在不同程度的糖代谢障碍，在诱因的作用下加重原有糖代谢障碍，导致严重高血糖加重原有糖代谢障碍，导致严重高血糖,但血酮增加不但血酮增加不明显。明显。诱因诱因 Precipitants Precipitants 1 1、引起血糖增高的因素、引起血糖增高的因素1 1）各种感染性并发症和应激因素）各种感染性并发症和应激因素2 2）各种引起高血糖的药物）各种引起高血糖的药物3 3）糖摄入过多）糖摄入过多4 4）合并影响糖代谢的内分泌疾病）合并影响糖代谢的内分泌疾病2 2、引起失水、脱水的因素、引起失水、脱水的因素3 3、肾功能不全、肾功能不全(二)病情评估评估 Assessmen

48、tAssessment 临床表现：临床表现：临床表现：临床表现：Clinical presentationClinical presentation 1 1 1 1、症状体征：先有多尿、多饮、体重下降，可有发热。重、症状体征：先有多尿、多饮、体重下降，可有发热。重、症状体征：先有多尿、多饮、体重下降，可有发热。重、症状体征：先有多尿、多饮、体重下降，可有发热。重度高血糖，无明显酮症酸中毒、高渗性脱水、进行性意识度高血糖，无明显酮症酸中毒、高渗性脱水、进行性意识度高血糖，无明显酮症酸中毒、高渗性脱水、进行性意识度高血糖，无明显酮症酸中毒、高渗性脱水、进行性意识障碍，多见老年人，部分病人无糖尿病史

49、障碍，多见老年人，部分病人无糖尿病史障碍，多见老年人，部分病人无糖尿病史障碍，多见老年人，部分病人无糖尿病史 2 2 2 2、实验室检查：高血糖、高血浆渗透压，伴有高血钠、氮、实验室检查：高血糖、高血浆渗透压，伴有高血钠、氮、实验室检查：高血糖、高血浆渗透压，伴有高血钠、氮、实验室检查：高血糖、高血浆渗透压，伴有高血钠、氮质血症。质血症。质血症。质血症。3 3 3 3、诊断要点：糖尿病原有症状加重，表情迟钝。中老年人、诊断要点：糖尿病原有症状加重，表情迟钝。中老年人、诊断要点：糖尿病原有症状加重，表情迟钝。中老年人、诊断要点：糖尿病原有症状加重，表情迟钝。中老年人出现以上临床表现如极度高血糖。

50、实验室检查结果证实出现以上临床表现如极度高血糖。实验室检查结果证实出现以上临床表现如极度高血糖。实验室检查结果证实出现以上临床表现如极度高血糖。实验室检查结果证实。糖尿病高渗性非酮症昏迷临床表现多饮、多尿多饮、多尿多饮、多尿多饮、多尿多食不明显多食不明显多食不明显多食不明显失水加重失水加重失水加重失水加重神经、精神神经、精神神经、精神神经、精神症状症状症状症状昏昏昏昏 迷迷迷迷（三）救治与护理（三）救治与护理 First Aid CareFirst Aid Care1 1 1 1、严密观察病情、严密观察病情、严密观察病情、严密观察病情2 2 2 2、补液：输入等渗盐水，快速扩张微循环，、补液：