Symptoms and Signs

症状体征

Lethargy, confusion, and somnolence are common. The hands and feet are pale, cool, clammy, and often cyanotic, as are the earlobes, nose, and nail beds. Capillary filling time is prolonged, and except in distributive shock, the skin appears grayish or dusky and moist. Overt diaphoresis may occur. Peripheral pulses are weak and typically rapid; often, only femoral or carotid pulses are palpable. Tachypnea and hyperventilation may be present. BP tends to be low (< 90 mm Hg systolic) or unobtainable; direct measurement by intra-arterial catheter, if done, often gives higher and more accurate values. Urine output is low.

常见症状有倦怠、意识模糊和瞌睡；手足苍白、发冷、冷湿、常常伴有发绀，耳叶、鼻子和指甲床也是如此。毛细血管充盈时间延长，除分布性休克外，还可出现皮肤浅灰或灰黑潮湿症状。出汗明显。周围脉搏细速，通常只可扪及股或颈动脉。可能呼吸急促和换气过度。血压低（收缩压＜90mm Hg)或测不到。但动脉直接插管所测得的血压明显较高较准确。排尿量少。

Distributive shock produces similar symptoms, except the skin may appear warm or flushed, especially during sepsis. The pulse may be bounding rather than weak. In septic shock, fever, usually preceded by chills, is generally present. Some patients with anaphylactic shock have urticaria or wheezing.医学全在线www.med126.com

分布性休克症状类似，但皮肤温暖或潮红，尤其是败血症期间。脉搏洪大而不弱。败血症性休克通常先出现寒战，然后发烧。有些过敏性休克病人会有荨麻疹或喘鸣。

Numerous other symptoms (eg, chest pain, dyspnea, abdominal pain) may occur due to the underlying disease or secondary organ failure.

由于潜在疾病或继发性器官衰竭，还可出现其他多种症状（如胸痛、呼吸困难腹痛等)。

Diagnosis

诊断

Diagnosis is mostly clinical, based on evidence of insufficient tissue perfusion (obtundation, oliguria, peripheral cyanosis) and signs of compensatory mechanisms (tachycardia, tachypnea, diaphoresis). Specific criteria include obtundation, heart rate > 100, respiratory rate > 22, hypotension (systolic BP < 90 mm Hg) or a 30 mm Hg fall in baseline BP, and urine output < 0.5 mL/kg/h. Laboratory findings that support the diagnosis include lactate > 3 mmol/L, base deficit < −5 mEq/L, and Paco2 < 32 mm Hg. However, none of these findings alone is diagnostic, and each is evaluated in the overall clinical context, including physical signs. Recently, measurement of sublingual PCO2 has been introduced as a noninvasive and rapid measurement of the severity of shock.

诊断以临床诊断为主，可根据组织灌注不足（迟钝、少、周围发绀)和代偿机制方面的一些症状（心动过速、呼吸急促、出冷汗)作出诊断。特殊标准包括迟钝、心率＞100、呼吸率＞22、低血压（收缩压＜90 mm Hg)或比基线血压低30 mm Hg，排尿量＜0.5 mL/kg/h.。支持诊断的化验结果包括乳酸盐＞3 mmol/L，　碱缺失＜−5 mEq/L，Paco2＜mm Hg。不过，单项检验结果都不能作为诊断依据，每项检验结果都应结合总的临床情况加以评价，包括身体症状。最近，有一种无创性快速检测手段，即舌下PCO2测定法，已被引进用于测定休克的严重程度。

Diagnosis of cause: Recognizing the underlying cause of shock is more important than categorizing the type. Often, the cause is obvious or can be recognized quickly by history and physical examination, aided by simple testing.医学全在线www.med126.com

病因诊断：确定休克的潜在病因比给休克分类更重要。病因常常是明显的，可以通过病史及体格检查快速识别，并用简单的检验加以确诊。

Chest pain (with or without dyspnea) suggests MI, aortic dissection, or pulmonary embolism. A systolic murmur may indicate ventricular septal rupture or mitral insufficiency from acute MI. A diastolic murmur may indicate aortic regurgitation from aortic dissection involving the aortic root. Cardiac tamponade is suggested by jugular venous distention, muffled heart sounds, and a paradoxical pulse. Pulmonary embolism severe enough to produce shock typically produces decreased O2 saturation and occurs more often in special settings, including prolonged bed rest and after a surgical procedure. Tests include ECG, troponin I, chest x-ray, ABG measurements, lung scan, helical CT, and/or echocardiography.

胸痛（伴或无呼吸困难)提示心肌梗死、主动脉破裂或肺栓塞。收缩期杂音表明室中隔破裂或急性心肌梗死引起的二尖瓣闭锁不全。舒张期杂音表明因主动脉破裂而引起的主动脉返流，累及主动脉根部。颈静脉怒张、心音低沉、及奇脉提示心包填塞。严重的肺动脉栓塞产生典型的休克，可导致氧饱和度下降，某些情况下及术后较为常见，包括卧床休息时候延长。诊断检查包括ECG、肌钙蛋白I、胸透、ABG、肺部扫描、螺旋式计算机体层造影和或超声心动图等。

Abdominal or back pain or a tender abdomen suggests pancreatitis, ruptured abdominal aortic aneurysm, peritonitis, and, in women of childbearing age, ruptured ectopic pregnancy. A pulsatile midline mass suggests ruptured abdominal aortic aneurysm. A tender adnexal mass suggests ectopic pregnancy. Testing typically includes abdominal CT (if the patient is unstable, bedside ultrasound can be helpful), CBC, amylase, and lipase, and, for women of childbearing age, urine pregnancy test.

腹痛或背痛或腹部触痛提示胰腺炎、腹主动脉瘤破裂、腹膜炎和育龄期妇女的异位妊娠破裂。正中线搏动性肿块提示腹主动脉瘤破裂。附件触痛肿块提示异位妊娠。主要生化检查包括腹部CT（如病人状态不稳，床边超声检查有助于诊断)、CBC、淀粉酶检查和脂酶检查等，育龄期妇女则应再作尿妊娠试验。

Fever, chills, and focal signs of infection suggest septic shock, particularly in immunocompromised patients. Isolated fever, contingent on history and clinical settings, may point to heat stroke. Tests include chest x-ray; urinalysis; CBC; and cultures of wounds, blood, urine, and other relevant body fluids.

发烧、寒战和局部感染症状提示败血症性休克，特别是免疫代偿病人。无病史及临床突发性单纯发烧可指向热性休克，检查包括胸透、尿分析、CBC及伤口、血液、尿液及其他相关体液的培养。

In a few patients, the cause is occult. Patients with no focal signs or symptoms indicative of cause should have ECG, cardiac enzymes, chest x-ray, and ABG. If results of these tests are normal, the most likely causes include drug overdose, occult infection (including toxic shock), and obstructive shock.

有些病人的病因不易发现。病人没有出现显示病因的局部性或症状体征时就应作ECG、心酶、胸透和ABG检查。如检查结果正常，最可能的原因包括药物过量、隐匿性感染（包括中毒性休克)和阻塞性休克。

Ancillary testing: If not already obtained, ECG, chest x-ray, CBC, serum electrolytes, BUN, creatinine, PT, PTT, liver function tests, and fibrinogen and fibrin split products are done to monitor patient status and serve as a baseline. If the patient's volume status is difficult to determine, monitoring of central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP) may be useful. CVP < 5 mm Hg (< 7 cm H2O) or PAOP < 8 mm Hg may indicate hypovolemia, although CVP may be greater in hypovolemic patients with preexisting pulmonary hypertension.

辅助检查：如未曾获得检查结果，则ECG、胸透、CBC、血清电解质分析、BUN、肌酑、PT、PTT、肝功检查、纤维蛋白素原和纤维蛋白裂解产物等都可用以检测病人状况并充当对照标准。如难以确定病人容量状况，检测中心静脉压（CVP)或肺动脉闭塞压（PAOP)可能有用。CVP < 5 mm Hg (< 7 cm H2O)或PAOP < 8 mm Hg可能提示血容量不足，虽然原先患有肺动脉高血压的低血容量性病人的CVP也可能较高。