最新急诊超声对于休克患者的鉴别诊断(刘继海)课件PPT.ppt 106页

'急诊超声对于休克患者的鉴别诊断(刘继海) 主要内容急诊超声和普通超声的区别？以不明原因休克患者RUSH检查为例进一步阐释急诊超声的重要性急诊超声的未来发展方向？ 急诊超声技术的开展带来的冲击“争地盘”或“抢饭碗”——该不该做？“资质问题”与“收费问题”——如何做？“难做吗”与“做得准吗”——培训与质量控制如何解决？ 可能的诊断LeftventricularfailureTensionpneumothoraxHemoperitoneumAnaphylaxisSeveredehydrationNeurogenicshockCardiactamponadeValvulardysfunctionPulmonaryembolusOccultmedicationerrororoverdoseSepsisRupturedaneurysmAorticdissectionMyocardialischemia/infarctionThyrotoxicosisAdrenalfailureDysrhythmiaAutonomicdysfunctionOccultgastrointestinalbleedMesentericischemiaAbdominalinflammation RUSHExamThistechnologyisidealinthecareofthecriticalpatientinshock,andthemostrecentACEPguidelinesfurtherdelineateanewcategoryof‘‘resuscitative’’ultrasound.Step1:Thepump（泵）Step2:Thetank（血容量）Step3:Thepipes（血管） Step1—EvaluationofthePump‘‘Effusionaroundthepump’’:evaluationofthepericardium‘‘Squeezeofthepump’’:determinationofgloballeftventricularfunction‘‘Strainofthepump’’:assessmentofrightventricularstrain EvaluationofthePump Normalsubxiphoid Normalparasternallong NormalparasternalshortLateralwall Normalparasternalshortatlevelofaorticvalve Normalapical4Lateralwall Normalapical2Anteriorwall Pericardialeffusion Cardiactamponade ‘‘Squeezeofthepump’’determinationof‘‘howstrongthepumpis?”avisualcalculationofthepercentagechangefromdiastoletosystoleMotionofanteriorleafletofthemitralvalvecanalsobeusedtoassesscontractility. Normalparasternallong NormalparasternalshortLateralwall AneasysystemofgradingTojudgethestrengthofcontractionsasgood,withthewallsoftheventriclecontractingwellduringsystole;Poor,withtheendocardialwallschanginglittleinpositionfromdiastoletosystole;Intermediate,withthewallsmovingwithapercentagechangeinbetweentheprevious2categories. BenefitsKnowingthestrengthofleftventricularcontractilitywillgivetheEPabetterideaofhowmuchfluid‘‘thepump’’orheartofthepatientcanhandle,beforemanifestingsignsandsymptomsoffluidoverload.Incardiacarrest,theclinicianshouldspecificallyexamineforthepresenceorabsenceofcardiaccontractions. ‘‘Strainofthepump’’Onbedsideechocardiography,thenormalratioofthelefttorightventricleis1:0.6.Theoptimalcardiacviewsfordeterminingthisratioofsizebetweenthe2ventriclesaretheparasternallongandshort-axisviewsandtheapical4-chamberview. RightVentricleStrain ThrombusinRA DifferentialDiagnosisMassivePESmallerandrecurrentpulmonaryemboliCorpulmonalePrimarypulmonaryarteryhypertensionAcuterightheartstrainthusdiffersfromchronicrightheartstraininthatalthoughbothconditionscausedilationofthechamber,theventriclewillnothavethetimetohypertrophyifthetimecourseissudden.‘‘Evaluationofthepipes” Step2:EvaluationoftheTank‘‘Fullnessofthetank’’:evaluationoftheinferiorcavaandjugularveinsforsizeandcollapsewithinspiration‘‘Leakinessofthetank’’:FASTexamandpleuralfluidassessment‘‘Tankcompromise’’:pneumothorax‘‘Tankoverload’’:pulmonaryedema EvaluationoftheTank ‘‘Fullnessofthetank’’ M-modeDoppler Howtodetermine？AsmallercaliberIVC(<2cmdiameter)withaninspiratorycollapsegreaterthan50%roughlycorrelatestoaCVPoflessthan10cmofwater.Thisphenomenonmaybeobservedinhypovolemicanddistributiveshockstates.AlargersizedIVC(>2cmdiameter)thatcollapseslessthan50%withinspirationcorrelatestoaCVPofmorethan10cmofwater。Thisphenomenonmaybeseenincardiogenicandobstructiveshockstates. Highcardiacfillingpressure TwocaveatstothisruleexistThefirstisinpatientswhohavereceivedtreatmentwithvasodilatorsand/ordiureticspriortoultrasoundevaluationinwhomtheIVCmaybesmallerthanpriortotreatment,alteringtheinitialphysiologicalstate.Thesecondcaveatexistsinintubatedpatientsreceivingpositivepressureventilation,inwhichtherespiratorydynamicsoftheIVCarereversed. ‘‘Leakinessofthetank’’FASTexamandpleuralfluidassessmentIntraumaticconditions,asaresultofa‘‘holeinthetank,’’leadingtohypovolemicshock.Innontraumaticconditions,accumulationofexcessfluidintotheabdominalandchestcavitiesoftensignifies‘‘tankoverload,’’Ininfectiousstates,pneumoniamaybeaccompaniedbyacomplicatingparapneumonicpleuraleffusion,andascitesmayleadtospontaneousbacterialperitonitis. Rightupperquatrant Leftupperquadrant Pelvicfreefluid ‘‘Tankcompromise’’:pneumothorax pneumothorax ‘‘Tankoverload’’:pulmonaryedemaToassessforpulmonaryedemawithultrasound,thelungsarescannedwiththephased-arraytransducerintheanterolateralchestbetweenthesecondandfifthribinterspaces.ThepresenceofBlinescoupledwithdecreasedcardiaccontractilityandaplethoricIVConfocusedsonographicevaluationshouldpromptthecliniciantoconsiderthepresenceofpulmonaryedemaandinitiateappropriatetreatment. B-lines Step3—EvaluationofthePipes‘‘Ruptureofthepipes’’:aorticaneurysmanddissection‘‘Cloggingofthepipes’’:venousthromboembolism AAAAmeasurementofgreaterthan3cmisabnormalanddefinesanabdominalaorticaneurysm AorticDissectionTheparasternallong-axisviewoftheheartpermitsanevaluationoftheproximalaorticroot,andameasurementofmorethan3.8cmisconsideredabnormal. AorticDissection ‘‘Cloggingofthepipes’’:venousthromboembolism Summary 病例224岁女性，58公斤，既往健康，仅口服避孕药。因“晕倒”被急救车送入院。病人意识模糊，病史有限。GCS（格拉斯哥昏迷评分）5-6，BP73/42，脉搏80次/分，体温38.3℃，SpO292%（在吸氧4升/分钟的情况下），呼吸26次/分，大汗，右小腿及脚部明显肿胀。胸片无明显异常。心电图——窦性心律，血糖4.3mM/L。 急诊超声评估结果（1）心脏收缩力好，未见明显心包积液，无右室劳损表现；下腔静脉直径<2cm，吸气变异率>50%，无浆膜腔积液主动脉正常，下肢静脉未见血栓，右下肢腹股沟区明显红肿右下肢蜂窝织炎，感染性休克 急诊超声评估结果（2）心脏收缩力好，未见明显心包积液，无右室劳损表现；下腔静脉直径<2cm，吸气变异率>50%，盆腔积液，超声引导下穿刺抽出不凝血主动脉正常，下肢静脉未见血栓宫外孕破裂出血 急诊超声评估结果（3）心脏收缩力好，未见明显心包积液，可见右室扩大表现，右室心肌不肥厚；下腔静脉直径=2cm，吸气变异率<50%，未见多浆膜腔积液表现主动脉正常，下肢静脉可见血栓大面积肺栓塞可能 急诊超声未来发展方向超声技术的发展带来变革更加注重脏器功能连续评估被越来越多的急诊医师所掌握并指导临床 急诊医学的明天更美好 SAT语法 考试时间和分项组成TypeofQsNo.ofQsTimeAllottedImprovingSentences2535mins(includingone25-minsectionandone10-minsection)IdentifyingSentenceErrors18ImprovingParagraphs6TotalQs49 动词哪些词可以做主语(subject)?哪些词可以做谓语(predicate)？ 主谓一致一、就前原则1）N1+介词+N2+verbIntheearlytwentiethcentury,newthinkingabout(A)symbolismandtheunconsciouswere(B)greatlyinspiredby(C)thewritingsof(D)SigmundFreudandCarlJung.Noerror.(E)Thebright(A)fiberglasssculpturesofLuisJimenezhasreceived(B)criticalacclaimnotonly(C)inhishomestate,NewMexico,butalsoin(D)NewYork.Noerror(E) 主谓一致一、就前原则2）N1+插入语/doing/done+N2+verbThegovernor"saidesareconvinced(A)thattheannouncementoftheinvestigation,comingjustdays(B)beforethefilingdeadline,werecalculated(C)todiscouragethegovernorfromrunning(D)forreelection.Noerror(E)Thegroovedandbarbedspearsoftheboxjellyfish,each(A)trailedby(B)apoisonthread,isreleased(C)when(D)theanimalisthreatened.Noerror(E) 固定用法anumberof+n+复数verbthenumberof+n+单数verbarowof/alistof/alineof+n+单数verb 二、就后原则：倒装结构1）only+状语置于句首AirpollutioncausedbyIndustrialfumeshasbeenstudied(A)foryears,but(B)onlyrecentlyhas(C)theharmfuleffectsofnoisepollutionbecome(D)known.Noerror(E)2）句首出现表地点或表否定的特殊介词（短语）或副词（短语）Among(A)themostdangerousenvironmentalthreatsthatwefaceare(B)“compu-garbage”,thenonbiodegradableandoftentoxic(C)wasteresultingfromtheimproperdisposalof(D)obsoletepersonalcomputers.Noerror(E) 二、就后原则：倒装结构3）当主语较长时，表语前置Alsosupported(A)bythecommissionwas(B)theproposedhealthclinicsandtheproposedcenter(C)todistributeinformationonjob-training(D)opportunities.Noerror(E) 三、就近原则1）therebe2)NeitherAnorB,eitherAorB,notonlyAbutalsoBSincethereis(A)twopencils,apadofpaper,andaruleroneachdesk,studentsdonothave(B)tobring(C)theirown(D)supplies.Noerror(E) 练习题Theregularlyscheduled（A）conferencebetweenmytutorandme（B）is（C）setforFriday,butmylowgradesinchemistryrequires（D）metoarrangeanearliermeeting.Noerror（E）D Althoughtheexactcauseoftype2diabetesisunknown,expertssaythatforsomepeopleimproperdietandlackofexercisecontributestotheonsetofthedisease.(A)exercisecontributes(B)exercise,theycontribute(C)exercisecontribute(D)exercise,contributing(E)exercisehasbeencontributing Absentfromthecurtaincall,toourdisappointment,was(A)thedirectorandtheproducer,bothofwhom(B)haddone(C)somuchtobringabout(D)thistriumphantopeningnight.Noerror(E)A Alongsidethetrailonwhichwerideourbikeseachmorningrunacrookedlineofruggedoldoaktrees.(A)runacrookedlineofruggedoldoaktrees(B)runsacrookedlineofruggedoldoaktrees(C)runsruggedoldoaktreesinacrookedline(D)thererunsruggedoldoaktreesinacrookedline(E)thererunacrookedlineofruggedoldoaktrees ThescientificwritingsofEdwardO.Wilson,StephenJayGould,andRichardDawkins,which(A)hascontinued(B)thediscussionofgeneticissuesraisedby(C)CharlesDarwin,are(D)familiartomanyhighschoolandcollegestudents.Noerror（E）B Peter"sseeminglyeffortless(A)flights,achievedthrough(B)theuseofsophisticatedtechnicalequipment,continues(C)todelightthosewho(D)seetheplayPeterPan.Noerror（E）C Thenumberofawardsgiventhisyear(A)tobiochemistsaccentuate(B)thesignificantgains(C)beingmadein(D)thestudyofthechemistryoflivingorganisms.Noerror（E）B LangstonHughesmaybebestknownfor(A)hispoetry,but(B)includedamong(C)hismanypublishedworksare(D)asizablecollectionofshortstories.Noerror（E）D Extending(A)alongseveralcityblocksare(B)arowofginkgotrees,theirleaves(C)turning(D)abrilliantyellownowthatsummerisover.Noerror（E）B Theideasforsongs,games,andskitsthatfilltheCubScoutLeader"sGuideisinvaluableforscoutleaderswhentheytrytofindcreativeactivitiesforthechildren.(A)isinvaluableforscoutleaderswhentheytrytofindcreativeactivities(B)areinvaluableforscoutleaderstryingtofindcreativeactivities(C)arethosewiththeinvaluablecreativeactivitiesscoutleadertrytofind(D)forscoutleaderstryingtofindcreativeactivities,isinvaluable(E)andwhichisinvaluableforscoutleaderswhotrytofindcreativeactivities Aneconomicalandefficient(A)recyclingcenterisAccessible(B)tothepublic,responsivetocommunityneeds,andcomplywith(C)currentfederalregulationsgoverning(D)wastedisposal.Noerror（E）C Evidencefromsurveysandinterviewsshowfriendshipsmadeinhighschooltendtolastlongerthanthosemadeincollege.(A)showfriendshipsmadeinhighschooltendtolast(B)showhighschoolfriendshipsthattendtolast(C)isshowinghighschoolfriendshipstendingtolast(D)showsthatfriendshipsmadeinhighschooltendtolast(E)showsfriendshipsinhighschooltendstolast Oneofthemostpopularandattractivenewcarswereavailableforsolittlemoneythatpeoplethoughtsomethingwaswrong.(A)wereavailableforsolittlemoneythatpeoplethoughtsomethingwas(B)wasavailableforsolittlemoneythatpeoplethoughtsomethingwere(C)wasavailableforsolittlemoneythatpeoplethoughtsomethinghasgone(D)wasavailableforsolittlemoneythatpeoplethoughtsomethingwas(E)wassellingforverylittlemoneysopeoplethoughtofitassomethingwas NotoneofthestudentsintheadvancedchemistryclasshavepassedasingletestwithagradebetterthanaC,butthesecondhalfofthecoursewillbeeasier.(A)havepassedasingletestwithagradebetterthanaC(B)havemanagedtopassasingletestwithbetterthanaCgrade(C)havepassedasingletestanybetterthanagradeofC(D)haspassedhavingbetterthanaCgradeonssingletest(E)haspassedasingletestwithbetterthanaCgrade Notwoofthespecimenswassufficientlyaliketowarrantthembeingcalledmembersofasinglespecies.(A)wassufficientlyaliketowarrantthembeingcalled(B)wassufficientlyaliketowarrantthecallingofthem(C)wassufficientlyaliketowarranttheirbeingcalled(D)weresufficientlyaliketowarrantthecallingofthem(E)weresufficientlyaliketowarrantcallingthem 时态一、表时间的连词AsIenteredthePantheon,abuildingthathasexistedinRomesinceancienttimes,mybrotheristurningtometowhisperthatthegreatrotundaofthePantheonwasahavenofpeaceandharmony.(A)isturningtometowhisper(B)turnedtomeandwhispered(C)turnstomeandiswhispering(D)turnsandalsowhisperstome(E)wouldturnandwhispertome 时态Beforeshewrotethefamousaccountofherexperiencesas(A)aBuddhistnuntraveling(B)acrossJapan,LadyNijohaslived(C)atthecourtoftheJapaneseEmperorforover(D)twentyyears.Noerror（E）C 时态Dr.Chien-ShiungWuhasdisprovedawidelyacceptedtheoryofphysicswhensheshowedthatidenticalnuclearparticlesdonotalwaysactalike.(A)hasdisproved(B)havingdisproved(C)disproved(D)disproves(E)disproving 时态Bythebeginningof1755,eventsarereachingastagethatmadewarbetweenBritainandFranceallbutinevitable.(A)arereaching(B)willreach(C)couldreach(D)havingreached(E)hadreached 时态二、根据未划线部分动词时态或者表示时间的短语判断Nomatter(A)wheretheycamefromorwhat(B)theirpreviouslifestyleis(C),therefugeesweregrateful(D)forhavingbeengrantedpoliticalasylumintheUnitedStates.Noerror（E）C 时态二、根据未划线部分动词时态或者表示时间的短语判断Inthebeliefthatcrosswordpuzzlesstimulatedhermind,Doloreswillspendhoursonthemeveryweek.(A)Doloreswillspendhoursonthemeveryweek(B)Doloreswouldspendhoursonthemeveryweek(C)hoursofeveryweekarespentonthembyDolores(D)theyoccupiedhoursofeveryweekforDolores(E)everyweekwillfindDoloresspendinghoursonthem 时态二、根据未划线部分动词时态或者表示时间的短语判断Untilrecently,mostpeopleentering(A)politicsfeel(B)thatlossofprivacywasafairprice(C)topayfor(D)thechancetoparticipateinpolicymaking.Noerror(E)B 时态三、did,done的拼写问题Conflictsbetweenlanddevelopersandconservationistshaverepeatedlyarose(A),causing(B)Congresstoreconsiderlegislationthatprohibits(C)buildingwithinhabitats(D)ofendangeredspecies.Noerror（E）In1988aSovieticebreakingshiphelpedfree(A)threegraywhalesthathadbecometrapped(B)intheArcticiceaftertheyhadswam(C)intothecoastalwatersofAlaskatofeed(D).Noerror（E） 时态三、did,done的拼写问题Afterthegrueling(A)rehearsal,thepianistfeltwore(B)outandwantedonly(C)tosleep(D).Noerror(E)Ancientdocumentswroteon(A)vellum,aformoffineparchmentmadeofanimalhides,mustbestoredundercarefully(B)controlledconditionsbecausechangesinhumidity(C)canbedamaging(D).Noerror(E) 课堂练习Ihavegoneto(A)onlyone(B)footballgameafter(C)Igraduated(D)fromhighschool.Noerror(E)NextMondayacommitteechosenby(A)theschoolboardmet(B)toreview(C)thefinallistofapplicantsforthepositionof(D)principalatthenewhighschool.Noerror(E) Fourteenyearsafter(A)theGalileospaceprobewaslaunchedfromthespaceshuttleAtlantis,themissionwaspurposelyendedwhen(B)theGalileodisintegrates(C)inthedense(D)atmosphereoftheplanetJupiter.Noerror(E)By(A)theearly1920"s,LouisArmstrongrecordedhisfirst(B)solosasamemberofKingOliver"sCreoleJazzBandinsuchpiecesas(C)"ChimesBlues"and"Tears,"which(D)hecomposedwithpianistLilHardin.Noerror(E) Whiledescribinghisfirstattempttolearnsurfing,Jamalwouldbepleasedbytheinteresthisclassmateswereshowing.Whiledescribinghisfirstattempttolearnsurfing,Jamalwouldbepleased(B)Ashewasdescribinghisfirstattempttolearnsurfing,Jamalwaspleased(C)Jamal,describinghisfirstattempttolearnsurfing,hewaspleased(D)Whenhedescribedhisfirstattempttolearnsurfing,Jamal,pleased(E)Atthesametimewhenhedescribedhisfirstattempttolearnsurfing,Jamalwaspleased Topersuadehisparentstolethimstudyabroad,Kennethdescribedotherstudents"positiveexperiences,explainshowforeignstudywouldbenefithisfuturecareer,andassuredthemthathecouldgetfinancialaid.(A)explainshowforeignstudywouldbenefithisfuturecareer,andassured(B)explainedhowforeignstudywouldbenefithisfuturecareer,andassured(C)explaininghowforeignstudyisbeneficialtohisfuturecareer,andassures(D)heexplainedhowforeignstudywouldbenefithisfuturecareer,andassuring(E)inexplaininghowforeignstudywouldbenefithisfuturecareer,andheassures SamuelAdamswasbynomeansthefirstAmericantoespousethedemocraticcause,buthehasbeenthefirstwhoconceivedthepartymachinerythatmadeitpractical.(A)hasbeenthefirstwhoconceived(B)hadbeenthefirstwhoconceived(C)wasthefirsthavingconceived(D)wasthefirsttoconceive(E)havingbeenthefirsttoconceive Firstrunin1867andstilltakingplaceeverysummer,theBelmontStakes,ahorseraceforthoroughbredthree-year-olds,wasoneoftheoldestracesintheUnitedStates.(A)was(B)is(C)were(D)are(E)hasbeen Forthepast(A)hundredyearsormore,YellowstoneNationalParkwas(B)akindofsociologicallaboratoryinwhich(C)NorthAmericanshavebeenexploringthemeaningof(D)thenational-parkconcept.Noerror(E)Duringthelast(A)fiftyyears,wecome(B)totake(C)radiocommunicationforgranted,butthemeresuggestionthatwecouldcommunicateinsuch(D)afashionmustoncehaveseemedoutlandish.Noerror(E)Katherinefeltthatshehasnothad(A)anyunderstandingof(B)thehighlyintricateworkings(C)ofthestockmarketuntil(D)heruncletookhertotheNewYorkStockExchange.Noerror(E) Setin(A)SouthCarolinain1964,thenovelTheSecretLifeofBeesis(B)notaboutbeesbutabout(C)Lily,afourteenyearoldwhoruns(D)awayfromhome.Noerror(E)Thosewho(A)defendsequoiatreesfrom(B)loggersjustified(C)doingso(D)onthegroundsthatsuchtreesareirreplaceable.Noerror(E)Despite(A)itsculturalimportance,theDailyGazettelost(B)70percentofitssubscriberssince1920and,by1955,waslosing(C)asmuchas(D)$200,000ayear.Noerror(E) 虚拟语气时间从句谓语形式主句谓语形式对将来动词过去式(be用were)should+动词原形wereto+动词原形would/should/might/could+动词原形对现在动词过去式(be用were)would/should/might/could+动词原形对过去had+动词过去分词would/should/might/couldhave+动词过去分词 虚拟语气Hewasconvincedthatifpropertytaxeswouldhaveroseanyhigher,hewouldhavehadtomovetoadifferentarea.(A)ifpropertytaxeswouldhaverose(B)ifpropertytaxeswouldrise(C)ifpropertytaxeshadrisen(D)hadpropertytaxesrose(E)werepropertytaxestorise 虚拟语气ProfessorBrownstarted(A)yesterday"slecturebysuggesting(B)thatif(C)BenjaminFranklinwerealivetoday,heprobablyworked(D)foranadvertisingagency.Noerror(E)Someoftheworkerswhoresent(A)thesupervisor"sauthoritywouldprobably(B)feeluncomfortableif(C)theyweretoacquiretheindependencethattheydemand(D).Noerror(E) 虚拟语气倒装IfIhaddoneHadIdoneIfIshoulddoShouldIdoHadIknown(A)thatthelinetogetintothemoviewouldbe(B)solong,Iwouldof(C)leftearliertogettothetheaterorbought(D)myticketonline. 虚拟语气真假错综Iftherehadbeenapowerfailure,thehospitalwillrunonelectricityfromitsowngenerators,whichcanoperatefor200hours.(A)Iftherehadbeen(B)Iftherewere(C)Hadtherebeen(D)Shouldtherebe(E)Therehasbeen 课堂练习Hewasconvincedthatifpropertytaxeswouldhaveroseanyhigher,hewouldhavehadtomovetoadifferentarea.(A)ifpropertytaxeswouldhaverose(B)ifpropertytaxeswouldrise(C)ifpropertytaxeshadrisen(D)hadpropertytaxesrose(E)werepropertytaxestorise Ellenwouldcallmeifshehadrememberedmyphonenumber.wouldcallmeifshehadrememberedwouldcallmeifsheweretohaverememberedwouldcalledmehadsherememberedwouldhavecalledmeifshewouldrememberwouldhavecalledmeifshehadremembered HadNightingaledieduponherreturntoEngland,herreputationwouldhardlyhavebeendifferentandherlegendwouldhavecomedowntousalmostasweknowittoday.HadNightingaledieduponherreturntoEnglandIfNightingaledieduponherreturntoEnglandNightingale,ifshehaddied,uponherreturntoEnglandHavingdieduponherreturntoEnglandAsaresultofherhavingdieduponherreturntoEngland'