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Hemorrhagic shock: In hemorrhagic shock, surgical control of bleeding is primary. Vigorous volume replacement accompanies rather than precedes surgical control. Blood transfusion is used for hemorrhagic shock unresponsive to 2 L (or 40 mL/kg in children) of crystalloid. Failure to respond usually indicates insufficient volume administration or unrecognized ongoing hemorrhage. Vasopressor agents are not indicated for treatment of hemorrhagic shock unless cardiogenic, obstructive, or distributive causes are also present. |
出血性休克：出血性休克病人主要通過外科手術(shù)控制出血。大容量補液應(yīng)在手術(shù)控制期間而不是控制前進行。輸血用于2L（或兒童40mL)類晶體無反應(yīng)的出血性休克病人。無反應(yīng)通常表明輸入容量不足或存在隱匿性出血。治療出血性休克不需要血管加壓藥，除非同時存在心源性、阻塞性或分布性病因。 | |
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Distributive shock: Distributive shock with profound hypotension after initial fluid replacement with 0.9% saline may be treated with inotropic or vasopressor agents (eg, dopamine - see Table 3: Shock and Fluid Resuscitation: Inotropic and Vasoactive Catecholamines). Patients with septic shock also receive at least two broad-spectrum antibiotics. Patients with anaphylactic shock unresponsive to fluid challenge (especially if accompanied by bronchoconstriction) receive epinephrine 0.05 to 0.1 mg IV, followed by epinephrine infusion of 5 mg in 500 mL 5% D/W at 10 mL/h or 0.02 μg/kg/min.醫(yī)學(xué)全在線m.zxtf.net.cn |
分布性休克：用0.9%生理鹽水初步補液后的低血壓分布性休克病人可用收縮性或血管加壓藥治療（如多巴胺－見表3：休克和液體復(fù)蘇：收縮性和血管加壓兒茶酚胺類藥)。敗血癥性休克病人至少也要服用兩種廣譜抗生素。輸液無效的過敏性休克病人（尤其是伴有支氣管收縮者)可先靜脈給注腎上腺素0.05至0.1 mg，然后再用5 mg 腎上腺素加500 mL 5%葡萄糖液滴注，滴速10 mL/h or 0.02 μg/kg/min。 | |
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Cardiogenic shock: In cardiogenic shock, structural disorders (eg, valvular dysfunction, septal rupture) are repaired surgically. Coronary thrombosis is treated either by percutaneous interventions (angioplasty, stenting), coronary artery bypass surgery, or thrombolysis. Tachydysrhythmia (eg, rapid atrial fibrillation, ventricular tachycardia) is slowed by cardioversion or with drugs. Bradycardia is treated with a transcutaneous or transvenous pacemaker; atropine 0.5 mg IV up to 4 doses q 5 min may be given pending pacemaker placement. Isoproterenol (2 mg/500 mL 5% D/W at 1 to 4 μg/min [0.25 to 1 mL/min]) may occasionally be useful if atropine is ineffective, but it is not advised in patients with myocardial ischemia due to coronary artery disease. |
心源性休克：心源性休克病人的的結(jié)構(gòu)性病癥（如瓣膜功能異常、室間隔破裂等)可通過手術(shù)修復(fù)。冠狀動脈栓塞采用經(jīng)皮手術(shù)（血管成形術(shù)、支架)、冠狀動脈旁路手術(shù)或溶栓治療。節(jié)律異�？焖伲ㄈ缈焖�心房顫動、室性心動過速)通過心臟復(fù)律或藥物緩解。心動過緩則用經(jīng)皮或經(jīng)靜脈起搏器治療，并根據(jù)起搏器使用情況IV補充阿托品0.5mg，每5分鐘4次劑量。若阿托品無效，亦可偶爾使用異丙腎上腺素（2 mg5%葡萄糖液500 mL滴速1 to 4 μg/min [0.25 to 1 mL/min])。冠狀動脈疾病引起的心肌缺血者不宜使用。 | |
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Shock after acute MI is treated with volume expansion if PAOP is low or normal; 15 to 18 mm Hg is considered optimal. If a pulmonary artery catheter is not in place, cautious volume infusion (250- to 500-mL bolus of 0.9% saline) may be tried while auscultating the chest frequently for signs of fluid overload. Shock after right ventricular MI will usually respond partially to volume expansion; however, vasopressor agents may be needed. |
如PAOP低或正常，急性MI休克行擴容治療，15－18 mm Hg較理想。如未配置肺動脈導(dǎo)管，可謹慎采用容量輸液（0.9%生理鹽水150－500 mL推注)，同時經(jīng)常聽診胸部觀察液體過剩體癥。右室MI休克通常會對容量擴張起反應(yīng)，但可能需要血管加壓藥。 | |
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If hypotension is moderate (eg, mean arterial pressure [MAP] 70 to 90 mm Hg), dobutamine infusion may be used to improve cardiac output and reduce left ventricular filling pressure. Tachycardia and arrhythmias occasionally occur during dobutamine administration, particularly at higher doses, necessitating dose reduction. Vasodilators (eg, nitroprusside, nitroglycerin), which increase venous capacitance or lower systemic vascular resistance, reduce the workload on the damaged myocardium and may increase cardiac output in patients without severe hypotension. Combination therapy (eg, dopamine or dobutamine with nitroprusside or nitroglycerin) may be particularly useful but requires close ECG and pulmonary and systemic hemodynamic monitoring. |
中度低血壓病人（MAP 70-90 mm Hg)可用多巴酚丁胺改善心排量，減少左室充盈壓。作用多巴酚丁胺有時會引起心動過速和心律異常，特別是大劑量時，此時應(yīng)減少劑量。血管擴張藥（如硝普鹽、硝酸甘油)增加靜脈容量或減少全身血管阻力，減輕受損心肌負擔，可增加無嚴重低血壓病人的心排量。聯(lián)合療法（如多巴胺或多巴酚丁胺加硝普鹽或硝酸甘油)尤為有效，但需要密切進行ECG、肺動脈和體循環(huán)血液動力學(xué)監(jiān)測。 | |
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For more serious hypotension (MAP < 70 mm Hg), norepinephrine or dopamine may be given, with a target systolic pressure of 80 to 90 mm Hg (and not > 110 mm Hg). Intra-aortic balloon counterpulsation is valuable for temporarily reversing shock in patients with acute MI. This procedure should be considered as a bridge to permit cardiac catheterization and coronary angiography before possible surgical intervention in patients with acute MI complicated by ventricular septal rupture or severe acute mitral regurgitation who require vasopressor support for > 30 min. |
低血壓較重（MAP < 70 mm Hg)病人可用去國甲腎上腺素或多巴胺，使收縮壓保持在80－90 mm Hg（不> 110 mm Hg)。主動脈內(nèi)球囊反搏對臨時逆轉(zhuǎn)急性MI性休克很重要，它是急性MI并發(fā)室間隔破裂病人或嚴重急性二尖瓣反流需要＞30 min血管加壓藥支持病人術(shù)前進行心導(dǎo)管和冠狀動脈造影的過渡橋梁。 | |
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In obstructive shock, cardiac tamponade requires immediate pericardiocentesis, which can be done at the bedside. Tension pneumothorax should be immediately decompressed with a catheter inserted into the second intercostal space, midclavicular line. Massive pulmonary embolism resulting in shock is treated with thrombolysis or surgical embolectomy. |
阻塞性休克病人若出現(xiàn)心臟壓塞，需立即進行心包穿刺術(shù)。該手術(shù)可以在床邊進行。張力性氣胸應(yīng)立即在第二肋間隙、鎖骨中線插管降壓。肺動脈大塊栓塞引起休克則采用溶栓或栓子切除術(shù)療法。 |
