美国重症医学（FCCM）基础指导特殊情况处理.ppt

Special Considerations Objectives Understand management principles of severe gastrointestinal hemorrhage Discuss diagnosis and management of pulmonary embolism Review recognition and management of aortic dissection List principles of poisoning management Identify management principles of temperature-related injury A 49-yr-old male is admitted after bloody emesis. He has a history of heavy alcohol use.  Blood pressure 90/40 mm Hg  Heart rate 116 beats/min  Hematocrit 24% He is confused and diaphoretic. Severe GI Hemorrhage –Management Principles Assess adequacy of airway Intravenous access Prompt initial resuscitation Monitor availability of blood products Monitor for secondary consequences of hypotension and anemia Rapid diagnostic evaluation, surgical consultation, transfer  Severe Upper GI Hemorrhage Endoscopy after lavage to establish diagnosis Endoscopic therapy Variceal bleeding Endoscopic therapy Vasopressin Octreotide Severe Lower GI Bleeding Rectal examination Consider upper GI source Endoscopy Angiography + embolization Surgery Pediatric Considerations – GI Hemorrhage Upper GI bleeding rare Causes of lower GI bleeding 1 mo–1 yr: Meckel’s diverticulum 1–2 yrs: intussusception 2–12 yrs: polyps, child abuse, inflammatory bowel disease Pulmonary Embolism An obese diabetic patient is at bedrest with lower extremity cellulitis. She had the sudden onset of dyspnea and palpitations. She is en route to the ED. Risk Factors for Pulmonary Embolism Heart failure Advanced age Trauma Obesity Estrogens, pregnancy Risk Factors for Pulmonary Embolism Malignancy Surgery Immobility, paralysis Prior embolism, thrombosis Hypercoagulable disorders Pulmonary Embolism – Diagnosis Nonspecific signs/symptoms Nonspecific chest radiograph ECG nonspecific Hypoxemia common but normal PaO2 possible Level of clinical suspicion important Diagnosis of Pulmonary Embolism Diagnosis of Pulmonary Embolism Diagnosis of Pulmonary Embolism Diagnosis