Prognosis and Treatment

预后及治疗

Untreated shock is usually fatal. Even when treated, mortality from cardiogenic shock after MI and from septic shock is high (60 to 65%). Prognosis depends on the cause, preexisting or complicating illness, time between onset and diagnosis, and promptness and adequacy of therapy.

休克不治疗可致命。即使加以治疗，心肌梗塞后的心源性休克和败血症性休克的死亡率也很高（60－65%)。预后取决于病因、现有或并发症、起病诊断间隔时间及治疗的及时性和正确性。

General management: First aid involves keeping the patient warm. Hemorrhage is controlled, airway and ventilation checked, and respiratory assistance given if necessary. Nothing is given by mouth, and the patient's head is turned to one side to avoid aspiration if emesis occurs.

一般处理：急救措施包括病人保暖、控制出血、检查气道及通气，必要时提供呼吸支持；禁止口腔进食，病人头部转向一侧以避免吸入呕吐物。

Treatment begins simultaneously with evaluation. Supplemental O2 by face mask is provided. In severe shock or if ventilation is inadequate, airway intubation with mechanical ventilation is necessary. Two large (16- to 18-gauge) IV catheters are inserted into separate peripheral veins. A central venous line or an intraosseous needle, especially in children, provides an alternative when peripheral veins cannot promptly be accessed.医学全在线www.med126.com

评估与治疗要同步进行。通过面罩补充氧气。严重休克或换气不足者有必要行气管插管进行机械通气。将两根大规格（16－18)静脉管分别插入　外周静脉。如无法获取外周静脉，可用中心静脉插管或骨内针（尤其是儿童)替代。

Typically, 1 L (or 20 mL/kg in children) of 0.9% saline is infused over 15 min. In major hemorrhage, Ringer's lactate is commonly used. Unless clinical parameters return to normal, the infusion is repeated. Smaller volumes (eg, 250 to 500 mL) are used for patients with signs of high right-sided pressure (eg, distention of neck veins) or acute MI. A fluid challenge should probably not be given to a patient with signs of pulmonary edema. Further fluid therapy is based on the underlying condition and may require monitoring of CVP or PAOP.

十五分钟注入0.9%生理盐水1L（儿童20 mL/kg)。大出血时常用林格氏乳酸盐。继续输液至临床参数恢复正常。右侧高压（如颈静脉怒张)或急性MI病人可用较小剂量（如250 - 500 mL)。肺水肿病人不宜输液。根据潜在疾病决定是否继续输液，要进行CVP或PAOP监测。

Patients in shock are critically ill and should be admitted to an ICU. Monitoring includes ECG; systolic, diastolic, and mean BP, preferably by intra-arterial catheter; respiratory rate and depth; pulse oximetry; urine flow by indwelling bladder catheter; body temperature; and clinical status, including sensorium (eg, Glasgow Coma Scale—see Table 2: Stupor and Coma: Glasgow Coma Scale*), pulse volume, skin temperature, and color. Measurement of CVP, PAOP, and thermodilution cardiac output using a balloon-tipped pulmonary arterial catheter may be helpful for diagnosis and initial management of patients with shock of uncertain or mixed etiology or with severe shock, especially when accompanied by oliguria or pulmonary edema. Echocardiography (bedside or transesophageal) is a less invasive alternative. Serial measurements of ABGs, Hct, electrolytes, serum creatinine, and blood lactate are obtained. Sublingual CO2 measurement, if available, is a noninvasive monitor of visceral perfusion. A well-designed flow sheet is helpful.

休克病人都属危重病人，应收住ICU病房。监测内容包括ECG；收缩、舒张和平均血压，最好用动脉内插管测得；呼吸速率和深度；脉氧测定；内置导尿管尿流测定；体温；及临床状况，包括感觉（如Glasgow昏迷等级表－见表2：木僵和昏迷：Glasgow昏迷表)、脉量、皮肤温度和肤色等。采用肺动脉球囊导管测定CVP、PAOP和热稀释心排血量有助于病因不明或多种病因引起的休克病人或严重休克并伴少尿或肺水肿病人的诊断与初期处理。超声心动图（床边或经食管)侵入性较小，连续测定ABG、Hct、电解质、血清肌酸酐和血乳酸盐。若可行，舌下CO2测定不失为测定内脏灌注情况的一种非入侵性方法。设计良好的流程表很有用。

Because tissue hypoperfusion makes intramuscular absorption unreliable, all parenteral drugs are given IV. Opioids generally are avoided because they may cause vasodilation, but severe pain may be treated with morphine 1 to 4 mg IV given over 2 min and repeated q 10 to 15 min if necessary. Although cerebral hypoperfusion may cause anxiety, sedatives or tranquilizers are not routinely given.

组织灌注不足造成肌内吸收不可靠，非肠道药物都经静脉输入。阿片类药物可引起血管扩张，一般应避免使用。疼痛剧烈时可用吗啡1－4 mg，两分钟IV治疗，必要时可每10－15分钟重复一次。虽然大脑灌注不足可导致焦虑，但按常规也不使用镇静剂或安定药。

After initial resuscitation, specific treatment is directed at the underlying condition. Additional supportive care is guided by the type of shock.

初期复苏后，特定疗法主要针对潜在病情，其他支持性治疗则根据休克类型而定。