四种休克与脓毒症的第一个小时

🧠 为什么重要

休克是组织灌注不足。COMPENSATORY（代偿）期：心动过速、脉压变窄、皮肤凉而湿冷、焦虑、尿量减少；血压仍可看起来正常。PROGRESSIVE（进展）和 REFRACTORY（难治）期：低血压（MAP 低于 65）、意识混乱、少尿、代谢性酸中毒伴 lactate 升高，以及器官衰竭。HYPOVOLEMIC（低血容量性，源于出血、烧伤、脱水）：给予等渗液体和血液，止住丢失。CARDIOGENIC（心源性，源于大面积 MI、心力衰竭）：泵衰竭，所以液体加重肺淤血；使用正性肌力药、利尿剂，有时用机械支持，但右心室梗死除外，在这种情况下衰竭的右心室需要前负荷：要谨慎给予液体推注，且不用硝酸盐或利尿剂。OBSTRUCTIVE（梗阻性，源于张力性气胸、心包填塞、大面积肺栓塞）：填充或流出的物理性阻塞使心输出量下降，常伴颈静脉怒张；通过针刺减压或胸腔引流管、心包穿刺，或溶栓或取栓来解除阻塞，因为单靠液体无法解决它。DISTRIBUTIVE（分布性）休克有三种类型。SEPTIC（感染性）：sepsis（脓毒症）是由对感染的失调反应引起的器官功能障碍；septic shock（感染性休克）是需要血管加压药维持 MAP 在 65 或更高，且在充分补液后 lactate 仍高于 2 的脓毒症；第一个小时的集束化措施包括测量 lactate（如果高于 2 则复测）、在抗生素之前抽血培养、在一小时内给予广谱抗生素、快速给予 30 mL/kg 的 crystalloid 以治疗低血压或 lactate 达到 4 或更高的情况，以及在补液期间或之后开始使用血管加压药（norepinephrine 为首选），以维持 MAP 在 65 或更高。ANAPHYLACTIC（过敏性）：先肌内注射 epinephrine，然后补液和气道支持。NEUROGENIC（神经源性，T6 或以上脊髓损伤）：这是经典的伴有 BRADYCARDIA（心动过缓）和皮肤温暖干燥的休克，源于交感张力丧失；用液体、血管加压药和 atropine 治疗。通用的护理措施包括给氧、建立两条大口径 IV 通路、每小时尿量至少 0.5 mL/kg/hr（成人约 30 mL/hr）、持续监测，并保持患者温暖。

Shock is inadequate tissue perfusion. COMPENSATORY stage: tachycardia, narrowing pulse pressure, cool clammy skin, anxiety, decreased urine output; the blood pressure can still look normal. PROGRESSIVE and REFRACTORY stages: hypotension (MAP below 65), confusion, oliguria, metabolic acidosis with rising lactate, and organ failure. HYPOVOLEMIC (hemorrhage, burns, dehydration): isotonic fluids and blood, stop the loss. CARDIOGENIC (massive MI, heart failure): the pump fails, so fluids worsen pulmonary congestion; inotropes, diuretics and sometimes mechanical support, except in right ventricular infarction, where the failing right ventricle needs preload: cautious fluid boluses and no nitrates or diuretics. OBSTRUCTIVE (tension pneumothorax, cardiac tamponade, massive pulmonary embolism): a physical block to filling or outflow drops cardiac output, often with distended neck veins; relieve the block with needle decompression or a chest tube, pericardiocentesis, or thrombolysis or embolectomy, because fluids alone will not fix it. DISTRIBUTIVE shock has three types. SEPTIC: sepsis is organ dysfunction caused by a dysregulated response to infection; septic shock is sepsis that needs vasopressors to keep MAP 65 or higher and has a lactate above 2 despite adequate fluids; the first hour bundle is lactate measurement (remeasure if above 2), blood cultures drawn before antibiotics, broad-spectrum antibiotics within one hour, rapid 30 mL/kg of crystalloid for hypotension or a lactate of 4 or more, and vasopressors (norepinephrine first), started during or after fluids, to keep MAP 65 or higher. ANAPHYLACTIC: intramuscular epinephrine first, then fluids and airway support. NEUROGENIC (spinal cord injury at or above T6): the classic shock with BRADYCARDIA and warm dry skin, from lost sympathetic tone; treat with fluids, vasopressors and atropine. Universal nursing care: oxygen, two large-bore IVs, hourly urine output of at least 0.5 mL/kg/hr (about 30 mL/hr in adults), continuous monitoring, and keeping the client warm.

🏥 真实场景

🧊 一位术后出血的患者血压为 118/88，心率为 126，皮肤凉，过去一小时尿量为 15 mL。一位新护士把这个血压读作没问题。经验丰富的护士把 30 的脉压、心动过速和少尿读作代偿性失血性休克，患者在血压下降之前就被送回手术室。血压是最后一个变化的数字。

🧊 A client bleeding after surgery has a blood pressure of 118/88 and a heart rate of 126, with cool skin and 15 mL of urine in the last hour. A new nurse reads the pressure as fine. The experienced nurse reads a pulse pressure of 30, tachycardia and oliguria as compensated hemorrhagic shock, and the client goes back to the operating room before the pressure ever falls. The blood pressure is the last number to move.

📌 要点总结

• 早期休克：心动过速、脉压窄、皮肤凉、尿量低、BP 正常Early shock: tachycardia, narrow pulse pressure, cool skin, low urine, normal BP
• 脓毒症第一个小时：培养、抗生素、30 mL/kg 液体、lactate，MAP 低于 65 时用 norepinephrineSepsis hour one: cultures, antibiotics, 30 mL/kg fluids, lactate, norepinephrine if MAP under 65
• 心源性休克用正性肌力药和利尿剂，不用液体推注；梗阻性需要解除阻塞；神经源性有心动过缓Cardiogenic shock gets inotropes and diuretics, not fluid boluses; obstructive needs the block relieved; neurogenic is bradycardic

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