Wani lokaci yana da kyau mu yi mamakin ko abubuwan da muke ji, gani da ji sun yi daidai da yadda muke zato. Dokta Alan Garner yana kallon hankalin ku lokacin da kuka shiga cikin ƙirji kuma yana mamakin ko duk yana nan gaba kamar yadda muke son tunani?

Bari mu fara wannan sakon ta hanyar bayyana a gaba cewa wannan game da raunukan kirji ne. Idan ba shine abin da kuke tunani ba to lokaci ya yi don duba wani wuri.

Abin da nake so in tattauna shi ne ganewar asibiti na tashin hankali pneumothorax a cikin filin. Dalilin tattaunawar shi ne na yi imanin an fi gano cutar. Lokacin da na yi aiki a Burtaniya shekaru 6 da suka gabata, kamar ana bincikar tashin hankali akai-akai kuma dalilin da aka bayar shine sauti yayin da suke keta pleura da ƙarfi. Yayin da majinyacin ya kasance tabbataccen matsa lamba a lokacin sannan sautin dole ne ya kasance iska yana gudu daga sararin samaniya kamar yadda matsa lamba na intrathoracic ya kasance tabbatacce a duk lokacin sake zagayowar numfashi daidai?

Ka tuna yadda ba za mu iya dogara da sautunan da ke cikin gwajin asibiti a cikin yanayin asibiti ba saboda sun kasance marasa aminci? To an gaya mani wannan yana daidai. 'Koyaushe' babbar kalma ce a magani

Ina kuma sane da aƙalla shari'ar guda ɗaya inda majiyyaci mai raunin harbin bindiga guda ɗaya daga ƙaramin makami mai ƙarfi yana da intubation sannan kuma thoracostomies na yatsan hannu biyu. Bayanin da aka yi a lokacin shi ne cewa likitan prehospital, wanda babu shakka ya shiga ciki duka da aminci, ya bayyana cewa a lokacin thoracostomies sun sami pneumothorax a gefe guda kuma tashin hankali a gefe guda.

Duk da haka akan hoto da tiyata, mashin ɗin ya koma kai tsaye zuwa cikin pancreas kuma babu inda kusa da hemithorax ko diaphragm. Lallai raunin da aka gano ga kowane ɓangaren ƙirjin shine raunin thoracostomy da kansu. Sake mai intubated haƙuri don haka intrathoracic matsa lamba dole ne ya kasance tabbatacce daidai? Idan huhu ya yi ƙasa to dole ne ya zama pneumothorax? Kuma idan akwai sauti a kan ƙetare pleura tabbas ya kasance tashin hankali?

A bayyane yake a cikin yanayi na biyu alamun sun kasance masu ɓarna to me ke faruwa a nan? Bari mu ajiye na biyu na ƙalubalen farkon ganewar asali na pneumothorax kuma mu mai da hankali kan ji tare da yatsa da sauti zuwa kunnuwa. Shin zai iya zama wasu shaidun da aka kai mu ga imani sun gaya mana muna fama da pneumothorax na iya yaudarar ƙwararrun likitocin da aka horar da su?

Diving In

Wataƙila na yi ƴan magudanar ruwa fiye da yawancin. Wani bangare wannan shine saboda fiye da shekaru 20 a cikin filin asibiti amma tabbas na yi ma fiye da haka lokacin da nake mai rejista shekaru 25 da suka wuce. Na shafe watanni 6 ina aiki ga likitocin biyu na numfashi kuma na sanya magudanar ruwa da yawa (mafi yawan zubar da jini) a cikin marasa lafiya waɗanda ba su da pneumothorax kafin in fara. An saba jin hayaniya yayin da aka karya pleura yayin da iska ta shiga cikin sauri. Amma wannan ba shakka ya kasance yana ba da iska ne kawai ga marasa lafiya kuma wannan ya bambanta ko?

Babu shakka muna bukatar mu koma fannin ilmin halitta domin mu ga abin da ke motsa iska ko dai shiga ko fita daga cikin ramin da muka yi domin sanin ko sautin da muke ji iskar ce ke shiga, ko kuma iska ce ke fita.

Back to Basics

Matsin huhu shine matsi mai matsa lamba wanda ke tafiyar da iska ta al'ada. Shi ne bambanci tsakanin matsa lamba na alveolar da matsa lamba intrapleural a cikin huhu.

P_tp =P_alv - P_ip. Ku P_tp matsa lamba na transpulmonary, P_alv matsa lamba na alveolar, da kuma P_ip matsa lamba intrapleural ne.

(Idan kuna son ƙarin ƙari akan wannan kyakkyawar rayuwa a cikin Fast Lane tana da ɗan matsananciyar bugun jini. nan.)

Hakanan ya zama cewa zaku iya samun samfoti na google na babban littafin karatu na John West akan ilimin halin numfashi. Ɗauki ɗan lokaci don tafiya ku ji daɗi Hoto na 4-9 a shafi na 59. 

Kuna iya gani daga panel B (Na nufi shi, je ku duba) cewa matsa lamba na intrapleural ya bambanta tsakanin -5 da -8 cmH.₂O a tsakiyar huhu yayin numfashi na al'ada. Koyaushe ba shi da kyau kuma hakan yana faruwa ne saboda koma baya na huhu wanda bangon ƙirji ke adawa da shi. Yana da ƙasa mara kyau a yankunan da suka dogara da huhu (rage girman alveolar) kuma mafi mummunan a koli (ƙara girman alveolar).

Mu Ƙara Iska

A cikin yanayin ƙananan pneumothorax, iska a cikin sararin samaniya yana sa matsa lamba na intrapleural ba ta da kyau kuma an rage bambancin matsa lamba don samun iska. Idan pneumothorax yana buɗewa gaba ɗaya zuwa iska kamar tare da buɗaɗɗen thoracostomy rauni matsa lamba na intrapleural daidai yake da matsa lamba na yanayi, farfadowa na huhu na huhu yana haifar da rushewa cikakke kuma samun iska ta hanyar faɗaɗa ƙirji ba zai yiwu ba - dole ne a yi amfani da matsa lamba mai kyau na iska.

Ba yanayin pneumothorax ba ne ya shafe ni musamman. Idan sun kasance hypoxic ko hypotensive kuma mai haƙuri yana da pneumothorax kirji ya kamata a rage shi - cikakken rashin hankali. Tambayar ita ce me yasa likitocin asibiti masu kyau suna rage ƙirji na al'ada kuma suna tunanin akwai pneumothorax ko ma tashin hankali lokacin da babu? Shin ilimin lissafi ya kai mu can?

Mara lafiya Daya

Da farko bari mu yi la'akari da mara lafiyar mara lafiya tare da numfashi na al'ada kuma babu pneumothorax. Wannan shi ne halin da marasa lafiya da ke fama da mummunan zubar da jini da nake sanya magudanar ruwa a cikin shekaru da suka wuce. Anan matsi na alveolar bai taɓa wuce cmH ba₂O ko biyu tabbatacce ko korau. Matsalolin intrapleural duk da haka shine -5 zuwa -8 cmH₂O. Don haka ba komai ko wane lokaci na numfashi kuka keta ma'auni, matsin matsa lamba tsakanin sararin samaniya da yanayi mara kyau ne kuma iska zata shiga cikin gaggawa.

Matsakaicin ya fi girma cikin wahayi lokacin da matsa lamba na alveolar ba shi da kyau (sabili da haka jimlar matsa lamba yana kusa da -8 cmH).₂O) da ƙasa mara kyau yayin ƙarewa lokacin da ya fi kamar -5 cmH₂O. Duk da haka ko da yaushe mara kyau. Komai wani bangare na sake zagayowar numfashin da kuka karya pleura, iska za ta gudana zuwa cikin sararin sararin samaniya kuma jujjuyawar huhu zai sa ta ruguje. Idan kun ji hayaniya kamar yadda na yi sau da yawa, iska ce ke tasowa, raunin ƙirji na tsotsa. Wani iatrogenic.

Mara lafiya Biyu

Ba na jin wani zai sami matsala da abubuwa ya zuwa yanzu. Don haka bari mu matsa zuwa ga majinyacin ciki wanda ba shi da pneumothorax. Zan ɗauka a nan cewa babu juriya mai yawa na iska a cikin majinyacin mu na rauni (wanda ba a ce ba su da cututtukan huhu na huhu, anaphylaxis ga magungunan shigar da ka ba ko kuma jini yana zaune a cikin babban bronchus. /ETT) yayin da yake sa tattaunawar ta ɗan yi sauƙi a ɗauka cewa juriya ba ta da yawa (ba ta da amfani bisa ga Daleks) kuma matsin lamba da kuke gani akan ma'aunin injin ku yana watsawa kai tsaye zuwa alveoli.

Duban ma'auni na ma'aunin bugun jini, sai dai idan matsi na iska kuma saboda haka matsa lamba na alveolar ya fi kusan 5 cmH.₂To, gradient a lokacin da ka bude pleura yana nufin iska tana zuwa shigar kumburin pleural. (Idan suna da mahimmancin juriya na iska wannan na iya faruwa tare da matsi mafi girma na iska).

Kawai samun saurin bugun ido na wannan matsi na ma'aunin ma'auni mai jujjuyawar iska ba tare da PEEP ba (kuma jakar kuɗa kai za ta samar da irin wannan ko da yake ƙarin alamar canji). Kuma da gangan ba ni da PEEP a cikin wannan ginshiƙi. PEEP ba zai yiwu ya zama abu na farko da za mu kai ga majiyyacin rauni na hypotensive da muka shiga kawai inda muke damuwa game da yiwuwar pneumothorax.

Tare da huhu na yau da kullun, matsa lamba mafi girma anan yana yiwuwa kusan 20 cmH₂O. Menene rabo na jimlar zagaye na numfashi shine matsin lamba na iska (saboda haka matsi na alveolar a cikin majiyyatan mu tare da ƙananan juriya na iska) mai yiwuwa ya kasance ƙasa da 5 cmH₂Ya? Idan ɗan ƙaramin injin ku na asibiti yana da kusan 1:2 I: E rabo kamar yadda yawancin ke yi, to amsar ita ce mafi yawansa.

A wasu kalmomi sai dai idan kuna da PEEP na akalla 5 cmH₂Ko ma a cikin majinyacin ku da aka saka majinar jini mara kyau ne ga rabin zagayen numfashi mara kyau. Yayin da aƙalla rabin zagayen numfashi, idan kun ji hayaniya yayin da kuke keta ma'auni, kuna jin saurin iska. IN

Ragewar huhu shine dalilin da kake jin huhu ya rushe ta lokacin da ka zare karfin ka sanya yatsa sai dai idan kana da PEEP a cikin wasa.

Yanzu ba na ce ba a taɓa samun lokacin da iska ba ta shiga ba. Ban yi tunanin kalmar "ko da yaushe" a cikin magani ba, tuna? Ina ba da shawarar cewa abin da muka sani game da ilimin lissafi zai yi jayayya cewa akwai aƙalla ƙaƙƙarfan kaso na lokacin da wannan matsi na bugun jini ba shi da kyau lokacin da kuka keta pleura, wanda ke nufin cewa akwai yuwuwar samun adadi mai kyau na lokuta inda. waɗancan “tabbas” alamun asibiti sun zama marasa abin dogaro.

Don nunin wannan tare da mahaifiyar duk buɗewar thoracotomy (a cikin cadaver) duba wannan bidiyo.

An shigar da cadaver, an halicci rauni mai rauni na "karimci", kuma a kowane ƙarewar huhu yana rushewa daidai sai dai idan an yi amfani da PEEP. Kuma lura da rugujewar ya cika akan kowace karewa.

Muddin thoracostomy ya isa ya isa sadarwa tare da iska (kuma idan kuna dogara ga fasahar "yatsa" budewa maimakon sanyawa a cikin magudana yana buƙatar zama babba ko kuma za su iya sake tayar da hankali), lokacin da kuka sanya ku Yatsa a lokacin karewa huhun zai rushe sai dai idan akwai isasshen adadin abubuwan PEEP da ke buɗewa sosai.

Za a ruguje ko ya riga ya kasance kafin ka yi rauni ko kuma ya faru yayin da kake yada karfi da kuma sanya ramin sadarwa. Lokacin da ke tsakanin yin rami da samun wannan ma'anar huhu sama ko huhu ƙasa da yatsa shine isasshen lokacin da huhu ya faɗi ƙasa. Da alama wannan alamar ta asibiti mai yiwuwa ba ta gaya muku kome ba game da yanayin wasan kafin a yi rauni.

Don haka surutai na iya zama yaudara da jin faɗuwar huhu kawai yana nufin cewa huhu ya koma baya yayin da aka buɗe pleura. Shin za ku iya ba da garantin ko wane lokaci na sake zagayowar numfashi da majiyyaci ke ciki lokacin da kuka yi wannan rami? Sai dai idan kuna da aƙalla 5 cmH₂O (kuma watakila ƙari) PEEP akan lokacin da kuka keta ma'aunin pleura ba daga cikin waɗannan alamun ba yana nufin komai.

Yanzu me?

Har ila yau, ba na son yin magana kamar "ko da yaushe" ko "ba". Abin da nake ba da shawara shi ne cewa za a iya samun launin toka da yawa a kusa da waɗannan alamun asibiti fiye da yadda ake iya fara ganin lamarin.

Don haka ta yaya za ku san idan suna da pneumothorax? A gare ni kusan ko da yaushe ta hanyar duban dan tayi yanzu. Ban san yadda na gudanar da 15 na waɗannan shekaru 20+ na kulawa da asibiti ba tare da ɗaya ba. Wani lokaci ba shakka scan ɗin yana da daidaito kuma kuna buƙatar yin kira bisa la'akari da alamun da kuke gani da yanayin majiyyaci amma na ga wannan ba shi da yawa tare da ingantaccen bincike na layin mitoci mai kyau.

Kuma game da tashin hankali, alamar alama ita ce ilimin halittar jiki mara kyau, musamman hawan jini. Idan decompressing ƙirji ya gyara ilimin lissafi to suna da tashin hankali. Idan ba haka ba to suna da pneumothorax mai sauƙi - ko babu. Domin hayaniyar da kuka ji yayin da kuka keta pleura na iya zama iska ko dai shiga ko fita daga ginin, jin hayaniya ba zai taimake ku ba. Shin Elvis ya taɓa kasancewa a cikin ginin kwata-kwata?

Notes:

Na sami ƙwararren Dr Blair Munford ya sake duba tarin ilimin halittar jiki a nan don tabbatar da ya dace.

Bayan waccan hanyar haɗin zuwa bitL na LITFL akan matsi na transpulmonary kuma? Sannan tafi dama nan.

Kuma babban aikin John West (aƙalla shafin da aka ambata) shine nan.

Wannan hoton Nahni mai manyan kunnuwa an buga wa Creative Commons Wani ɓangare na flicker na Allan Henderson kuma ba a canza shi a nan.

Oh, kuma idan ba ku san ainihin abin ban mamaki John West ba, ɗan Adelaide ya yi kyau, ya yi rikodin gaba daya jerin karatunsa ku je ku kalla. Domin lokacin da kake cikin shekarunka 80 za ka iya ba da gudummawa ga ilimin likitanci haka ma, daidai?

Karanta Har ila yau:

Maganin Tracheal: Yaushe, Ta yaya Kuma Me yasa Za a Kirkiro Jirgin Sama Na Maɗaukaki Ga Mai Haƙuri

Menene Tachypnoea Mai Raɗaɗi Na Jariri, Ko Ciwon Huhu Na Neonatal?

Source:

Kula da Jirgin Jirgin Kulawa