Haemodynamic changes in trauma
Haemodynamic changes in trauma
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DOI：
10.1093/bja/aeu232
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发表时间：
2014-08-01
影响因子：
9.8
通讯作者：
Watts, S.
中科院分区：
文献类型：
--
作者：
Kirkman, E.;Watts, S.
在发达国家，创伤是生命最初40年的主要死因。它的血流动力学反应支持患者最初的生存能力，以及对治疗和随后的发病率和解决率的反应。创伤造成许多侮辱，包括出血、组织损伤(伤害性伤害)，主要是军事人员伤亡，爆炸造成的爆炸。这篇文章讨论了对这些侮辱的血液动力学反应和后续治疗。单纯性出血(失血但无明显组织损伤)引起双相反应：平均动脉压(MBP)最初由压力反射(心动过速和血管阻力增加，第一阶段)维持，随后由第二反射(血管阻力和心动过缓下降，第二阶段)引起MAP突然下降。第二阶段可能是保护性的。对组织损伤的反应会减弱第二阶段，并可能导致有害的血流动力学重新分配，从而影响流向某些重要器官的血液。相比之下，胸部冲击波暴露增加了对出血的第二阶段反应。然而，肺损伤引起的低氧通过增加伴随的休克状态而限制了低血压复苏的有效性。另一种替代策略(“混合复苏”)，即在降压复苏的第一个小时后，通过采用修订的正常血压目标来增加组织灌注量，可能会改善这些问题。最后，吗啡还减弱了某些物种(但不是所有物种)对出血的第二阶段反应，这与不良结局有关。对人类患者的影响目前尚不清楚，目前是一项生理调查的主题。
Trauma is the leading cause of death during the first four decades of life in the developed countries. Its haemodynamic response underpins the patient's initial ability to survive, and the response to treatment and subsequent morbidity and resolution. Trauma causes a number of insults including haemorrhage, tissue injury (nociception) and, predominantly, in military casualties, blast from explosions. This article discusses aspects of the haemodynamic responses to these insults and subsequent treatment. 'Simple' haemorrhage (blood loss without significant volume of tissue damage) causes a biphasic response: mean arterial blood pressure (MBP) is initially maintained by the baroreflex (tachycardia and increased vascular resistance, Phase 1), followed by a sudden decrease in MAP initiated by a second reflex (decrease in vascular resistance and bradycardia, Phase 2). Phase 2 may be protective. The response to tissue injury attenuates Phase 2 and may cause a deleterious haemodynamic redistribution that compromises blood flow to some vital organs. In contrast, thoracic blast exposure augments Phase 2 of the response to haemorrhage. However, hypoxaennia from lung injury limits the effectiveness of hypotensive resuscitation by augmenting the attendant shock state. An alternative strategy ('hybrid resuscitation') whereby tissue perfusion is increased after the first hour of hypotensive resuscitation by adopting a revised normotensive target may ameliorate these problems. Finally, morphine also attenuates Phase 2 of the response to haemorrhage in some, but not all, species and this is associated with poor outcome. The impact on human patients is currently unknown and is the subject of a current physiological investigation.