1、第十章常见临床危象Chapter 10 Common Emergency Crisis,Definition of Common Emergency Crisis,Clinical crisis is not an independent disease but a group of syndromes manifested progress of certain disease. It can threaten the vital organs, particularly the brain. 是指某一疾病在进展中所表现的一组综合征。死亡率和致残率较高 The mortality and m
2、orbidity would be high The common precipitating factors of the crisis: 常见诱因： Exhaustion, infection, trauma, surgery, delivery The crisis can be controlled,Definition： is an excessive and unusual elevation of body temperature greater than 41.It is medical emergency , accompanied by convulsion, coma,
3、shock, hemorrhage, etc a medical emergency 是指体温异乎寻常升高至41以上，是一种医疗急症。高热同时伴随抽搐、昏迷、休克、出血等，通常是致命的，需紧急处理。,Section1 hyperpyrexia crisis第一节 超高热危象,一、病因 Etiology,.Infectious Hyperpyrexia 感染性发热.Non-infectious Hyperpyrexia 非感染性发热1.Allergic reaction 变态反应 Such as serum disease , infusion reactions 2. Dysfunction
4、of the bodys temperature regulation center 体温调节中枢异常3. Endocrine and metabolic diseases 内分泌和代谢性疾病,.病情评估 Assessment,(一)病史收集 Collecting Medical History 1.Epidemiological data 流行病学资料 2.The characteristics of fever 发热特点 Many febrile发热的 illnesses have a specific fever pattern （二）体格检查 Physical Examination
5、the patients face , skin rash or petechia瘀点 , enlargement of lymph node or liver and spleen. （三）实验室检查Laboratory Inspection Blood routine, urine routine , stool routine , and cerebrospinal fluid routine test,.First Aid Care 救治和护理,（一）严密观察病情.Monitoring1. Monitor the changes of vital signs , such as con
6、sciousness , breathing , blood pressure , pulse , temperature and peripheral circulation , particular the changes of temperature falls too fast as this may lead to collapse of the patient.2.Observe for the changes of concomitant symptoms 伴随症状that can assist the physician to make diagnosis.3. Record
7、intake and output of the patient. Adequate fluids should be supplemented.,.First Aid Care,（二）降温.CoolingIt is vital （关键）to decrease the body temperature to 38.5 quickly and effectively in hyperpyrexia crisis.1.Physical cooling物理降温 is a preferred simple（首选） , safe and effective measure. （1）方法：冰水擦浴；温水擦
8、浴；酒精擦浴；冰敷。 （2）注意事项： 2. Cooling with medication 3. Hibernation therapy冬眠降温,.Identify Causes寻找病因,1.Choose appropriate antibiotics合理选用抗生素2.To the disease highly suspected 诊断性治疗diagnostic treatment can be provided. 3. For unexplained fever, continuous observation and further examinations are required. 对
9、原因不明者-进一步观察,（四）加强基础护理. Strengthen Primary Care,a quiet environment 休息环境provide sufficient water , nutrition, vitamins; 充足的营养、水份、维生素protect normal function of vital organs sedate patients 镇静administer oxygen to patients who have dyspnea 吸氧endotracheal intubations 机械通气,（五）对症护理 Symptomatic Care,1. Ice
10、pack need to be replaced in time 及时更换冰袋2.Skin Care 皮肤护理3. Oral care 口腔护理4.Strengthen management of respiratory tract 加强呼吸道管理5. Patients who are irritable or having convulsion should be placed bed with side rails up, and may need limbs constraint to prevent falling from the bed or self-injury. 保护及约束,
11、Section 3 Hyperthyroidism Crisis甲亢危象,Definition Hyperthyroidism crisis (also known as thyrotoxic storm) is an uncommon medical emergency caused by an exacerbation of primary hyperthyroidism characterized by decompensation代偿不全 of one or more organ systems. 甲亢危象是一种由甲状腺功能亢进恶化的，以一个或多个器官功能失代偿为特征的罕见的医疗急症。
12、,发病率,甲亢危象一般可占住院甲亢病人数的1%2%，女性明显高于男性本症可发生于任何年龄，儿童少见。甲亢危象在老年人较多见。主要并发症有严重的心律失常心力衰竭、休克等,. Precipitants and Pathogenesis诱因与发病机制,Precipitants can be divided into two categories:i. Medical Precipitants 内科性诱因 Medical precipitants refer to precipitants other than surgical factors. 1.Serious infections: 严重感染，
13、临床上最常见的因素 2.stress 应激：过度紧张、高热、过度疲劳、情绪激动。 3. Emotional stimulus: 精神刺激：对诱发本症有明显作用 4. Suddenly withdrawal of or non-compliance with anti-thyroid medication 忽然停用或不适应抗甲状腺药物 5.Others: Squeezing the thyroid excessively results in massive thyroxin released into blood. 挤压甲状腺,(二)外科性诱因 Surgical precipitants,If
14、 hyperthyroidism crisis developed in a patient with hyperthyroidism during the operation of 416 hours after surgery 与术前准备不充分，肾上腺皮质激素分泌不足有关。常发生于手术时和术后4-16小时,（三）发病机制Pathogenesis,The pathogenesis of hyperthyroidism crisis is not clearly defined. The possible key factors may include:甲亢危象发病机制尚不清楚，可能相关的主要
15、因素包括：1.Massive thyroid hormone releasing into blood 大量甲状腺素释放入血2.Blood concentration of free thyroid hormone increasing.血游离甲状腺素浓度增加3 Activation of adrenaling increasing 肾上腺素活力增加,二、病情评估 Assessment,1. Primary hyperthyroidism aggravated.原有甲状腺功能亢进进一步加重2.Systemic symptoms 全身症状 The body temperature increas
16、es sharply. A lethal high fever may develop within 2428 hours. Skin presents red and moist accompanied by massive perspiration, then turns to no sweat. It is followed by obviously dehydration or collapse, dyspnea or even shock. 高热、皮肤潮湿红润、大汗、明显脱水、呼吸困难、休克 3. CNS symptoms 中枢神经系统症状 It manifests as anxie
17、ty, indifferent expression, restless, and even coma. 焦虑、表情淡漠、躁动不安、昏迷。,二、病情评估 Assessment,4. Cardiovascular system symptoms 心血管症状5.Digestive system symptoms 消化系统症状：厌食、恶心、呕吐、腹泻6. Water and electrolyte imbalance 水与电解质紊乱：代谢性酸中毒、低血钠。7.Other manifestations 胸痛、呼吸急促、后期可出现呼吸窘迫综合征,三、救治与护理 First Aid Care,i. Mon
18、itoring changes of the level of consciousness , body temperature, pulse, breath, blood pressure , blood oxygen saturation.严密观察 患者神志、体温、脉搏、呼吸、血压、血氧饱和度,三、救治与护理 First Aid Care,（二）急救措施1、原则维持基本生命 迅速降温 补充体液 消除诱因 治疗病因对症处理2、措施： 降低血循环中甲状腺素的浓度抑制甲状腺素的合成-丙硫氧嘧啶（PTU）抑制甲状腺素的释放。 PTU+碘液降低组织对甲状腺素-儿茶酚胺的反应 普萘洛尔利血平各胍乙啶氢
19、化可的松糖皮质激素的应用降温其它对症处理,（三）加强基础护理 Strengthen Primary Nursing Care,1. Absolute bed rest; maintain a quiet and comfortable environment. 绝对卧床休息2. Provide primary nursing care: offer high energy, high protein , and high vitamin diet; encourage the patient to drink more water.做好生活护理 3.Psychological care 精神护
20、理 Concern and comfort the patient; eliminate the fear and encourage confidence to confront the disease.,（四）对症护理 Symptomatic Care,1. Administer sedative such as diazepam to the manic（狂躁） patient. 镇静2. Keep various rescue equipment ready; prevent complications such as aspiration pneumonia etc. 做好各种抢救准
21、备，预防吸入性肺炎,第四节 高血糖危象 Hyperglycemic Crisis,概念及特征,概念：高血糖危象指糖尿病昏迷diabetic coma 基本病理生理变化 胰岛素分泌不足至糖代谢紊乱 特征性病理改变：高血糖、高酮血症、代谢性酸中毒 hyperglycemic, hyperketonemia and metabolic acidosis. 分类：酮症酸中毒昏迷、高渗性非酮症昏迷 Ketoacidosis coma 、 hyperosmolar nonketotic coma,一、糖尿病酮症酸中毒,概 述是糖尿病急性并发症之一可作为糖尿病首发表现由于胰岛素绝对或相对缺乏引起以高血糖（
22、hyperglycemia） 、高酮血症（hyperketonemia ）、代谢性酸中毒（ metabolic acidosis ）为特征,三联征。 英文（DKA Diabetic ketoacidosis,）,（一）诱因与发病机制Precipitants and Pathogenesis,1、引起糖升高的因素：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。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 2、引起失水、脱水的因素 利尿药物、水摄入不足、透析、 大面积烧伤3、肾功能不全,高血糖,DKA发病机制,(二)、病情评估面 Asse
23、ssment,1、症状Symptoms：原有糖尿病症状加重；极度软弱无力，意识改变2、体征Signs：体征：失水征、呼吸深而速有酮味，血压下降、休克3、实验室检查 Laboratory investigations ： 血:血糖明显升高， 16-33.3mmol/L CO2CP降低，血PH降低,代谢性酸中毒 尿：尿糖、尿酮体阳性,临床表现,(三)救治与护理 First Aid Care,1.严密观察病情 Monitoring (1) Strictly observe for the changes of temperature, pulse, breathing, BP and conscio
24、usness; (2) Promptly draw blood sample and take urine sample (3) Accurately record the intake and output of 24 hours.,(三)救治与护理 First Aid Care,2、补液，纠正电解质及酸碱失衡： Fluid resuscitation and correction of electrolytes or acid-base imbalance 补液：首选生理盐水1000ml/第1小时纠正电解质及酸碱失衡 胰岛素应用：小剂量胰岛素治疗，根据血糖、尿糖调节剂量 治疗中避免血糖下降
25、过快、过低，以免发生脑水肿 一般护理：加强生活护理。,二、糖尿病高渗性非酮症昏迷 Hyperosmolar Nonketotic Diabetic Coma,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、进行性意识障碍为特点。无明显酮症酸中毒多见老年人，约2/3病人发病前无糖尿病史或仅有轻症（不多食、不消瘦）(HNDC) is another acute complication of diabetic. It is a clinical syndrome characterized by severe hyperglycemia, hypertonic dehydration,
26、 and progressively mental disorder.HNDC is a medical emergency with a high morbidity and mortality,（一）诱因与发病机制Precipitants and Pathogenesis,发病机制 Pathogenesis 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,但血酮增加不明显。诱因 Precipitants 1、引起血糖增高的因素1）各种感染性并发症和应激因素2）各种引起高血糖的药物3）糖摄入过多4）合并影响糖代谢的内分泌疾病2、引起失水、脱水的因素3、肾功能
27、不全,(二)病情评估 Assessment,临床表现： Clinical presentation1、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、进行性意识障碍，多见老年人，部分病人无糖尿病史2、实验室检查：高血糖、高血浆渗透压，伴有高血钠、氮质血症。3、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。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、多尿多食不明显,失水加重,神经、精神症状,昏 迷,（三）救治与护理 First Aid Care,1、严密观察病情2、补液：输入等渗盐水，快速扩张微循环，补充 血
28、容量，纠正血压，容量稳定后低渗盐水缓注。 3、纠正电解质紊乱：主要补充钾盐4、胰岛素应用：一般用普通胰岛素小剂量治疗法，定时测血糖，血糖13.9MMOL/L停用胰岛素，改用5%GS5、治疗诱因及伴随症状,第五节 低血糖危象 Hypoglycemia Crisis,概 念:某些病理和生理原因使血糖降低，引起交感神经兴奋和中枢神经异常的症状及体征。,(一)病因与发病机制,（一）病因 1、空腹低血糖：内分泌性、肝源性、营养障碍2、餐后低血糖3、药物引起的低血糖,(一)病因与发病机制,（二）发病机制 正常血糖状态下，糖分解代谢与合成代谢保持动态平衡血糖浓度相对稳定（空腹血糖3.5-6.5mmol/L
29、异常情况下， 当血糖低于2.8mmol/L时，一方面引起交感神经兴奋，大量儿茶酚胺释放，另一方面由于能量供应不足使大脑皮层功能抑制，皮层功能下功能异常，即表现为中枢神经低糖症状和交交感神经兴奋两组症状。,(二)病情评估,（一）临床表现 交感神经过度兴奋的表现 中枢神经系统功能障碍的表现（二）诊断要点1、有低血糖危象的表现2、既刻测血糖低于2.88mmol/L3、立即给予葡萄糖后可消除症状4、鉴别诊断：,三、救治与护理,（一）严密观察病情生命体征、观察尿量、记录出入量、观察治疗前后的病情变化。（二）急救措施1、血糖测定2、补充葡萄糖（三）一般护理（四）病因治疗小结：甲状腺功能亢进、高血糖、低血糖危象的护理措施,
