Idan aka sami zubar jini mai yawa, kula da zubar da jini lokaci zuwa lokaci da jijiyoyin bugun jini na iya haifar da bambanci tsakanin rayuwa da mutuwar mai haƙuri. A cikin wannan labarin, za mu bayar da rahoton binciken shari'ar Italiya akan amfani da hanyar shakatawa da shiga ciki.

Tsarin kulawa da gaggawa na 118 na Trieste (Italiya) ya yanke shawarar sanya EZ-IO® na'urar shiga cikin intraosseous ga duk sabis na motar asibiti ALS na yankin. Manufar shine a ba da kayan aiki ambulances idan akwai zubar jini mai tsanani da kuma horar da likitocin da ke aiki a wuraren da ake kula da marasa lafiya a asibiti wajen kula da manyan zubar jini na junctional da na hannu. Sun shiga cikin yaƙin neman zaɓe na "Dakatar da zubar da jini", wanda Cibiyar Nazarin Likita ta Amurka ta inganta kuma Società Italiana di Chirurgia d'Urgenza e del Trauma (Società Italiana di Chirurgia d'Urgenza e del Trauma) ta shigo da shi zuwa Italiya. Amfani da a yawon shakatawa kuma shiga cikin ciki na iya nufin wani muhimmin canji a cikin magance irin wannan rikitarwar zubar jini.

Mawallafa: Andrea Clemente, Mauro Milos, Alberto Peratoner SSD 118 Trieste - Ma'aikatar Gaggawa (attività integrata di Emergenza, Urgenza ed Accettazione). Azienda Sanitaria Jami'ar Giuliano Isontina

 

Shigar shiga ciki: yawon shakatawa da yawan zubar jini

Kowace shekara, rauni yana da alhakin ƙarancin mace-mace a duniya. Hukumar Kiwon Lafiya ta Duniya ta kiyasta cewa a cikin 2012, mutane miliyan 5.1 sun mutu saboda bala'i, wanda yayi kama da 9.2% na mace-mace a duniya (an tabbatar da yawan mace-mace a cikin shari'o'i 83 cikin mazaunan 100,000). 50% na mutuwar sun kasance tsakanin shekaru 15 zuwa 44, yayin da adadin mace-macen maza ya ninka na mata sau biyu (1).

A Italiya, abubuwan da suka faru na rauni suna da alhakin 5% na adadin mutuwar shekara-shekara (2). Ya dace da kusan mutuwar 18,000, wanda:

• Hatsarin hanya: mutuwar mutane 7,000
• Hatsarorin cikin gida: mutuwar 4,000
• haɗari a wurin aiki: mutuwar 1,300
• ayyukan rashin hankali / ko cutar da kai: 5,000 mutuwar

Yawancinsu ana haifar da su ta hanyar yawan asibiti miliyan 1, daidai yake da kusan 10% na yawan adadin shekara-shekara (3).

Cutar Haemorrhagic ita ce ta biyu da ke haifar da mutuwa bayan raunin da ya faru a tsakiya, ba tare da la’akari da inji ba na rauni. Cututtukan jini suna da alhakin 30-40% na mutuwar rauni kuma 33-56% yana faruwa a cikin waje-asibiti (4).

Domin samun inganci kamar yadda zai yiwu, tilas ne a bayar da maganin zubar jinin da wuri-wuri bayan lalacewa. Zub da jini na hanzari zai iya haifar da abin da ake kira "trauma triad of death" ko "na mutuwa triad": hypothermia, coagulopathy da acidosis metabolic.

Zub da jini mai yawa yana rage jigilar oxygen kuma zai iya haifar da hypothermia tare da canza canji na coagulation cascade. Idan babu isashshen sunadarin oxygen da abubuwan gina jiki da ake jigilar su ta hanyar jini (hypoperfusion), sel suna canzawa zuwa metabolism anaerobic, suna haifar da sakin lactic acid, jikin ketone da sauran abubuwan acid wanda ke rage jinin pH wanda ke haifar da acidosis na metabolism. Acidara yawan acidity yana lalata kyallen takarda da gabobin jiki a cikin jiki kuma yana iya rage ƙarfin motsa jiki ta hanyar yin jigilar oxygen.

 

Yawon shakatawa da kuma damar shiga ciki: mawuyacin ceton rai

Daga rikice-rikicen Iraki da Afghanistan, mun koya cewa amfani da tim din ɗakin shakatawa da bandeji masu mahimmanci suna cikin mahimmanci hanyoyin tseratar da rayuwa. Hanyar da ta dace sosai don ba da amsa, wanda Kwamitin Sojojin Amurka ke yin nazari akai game da Tsarin Kulawa da Kayayyakin Kayayyaki (C-TCCC). Aiwatar da ka’idodin TCCC ya haifar da raguwa sosai a yawan masu cutar hauka masu iya yawan jini (5).

Godiya ga ƙwarewa mai zurfi da aka haɓaka a matakin soja, waɗannan hanyoyin kulawa sun fara yadu a cikin farar hula, sama da duka, sakamakon hare-haren ta'addanci kamar waɗanda suka faru a lokacin Marathon Boston a 2013 (6).

Ayyukan ceton rai na gaggawa don kula da cututtukan hauka ta hanyar masu amsawa na farko, waɗanda suka nuna mahaɗan, na iya ma'anar muhimmiyar ma'ana ga rage mutuwar hanawa (7). A cikin Amurka, daya daga cikin dabarun da suka tabbatar da ingancin rage mace-macen masu zubar da jini shine a samar da duk ma'aikatan kiwon lafiya da kuma wadanda suka fara bayar da amsa ('yan sanda da masu kashe wuta) tare da na'urorin kula da zubar jini da horo (8).

A cikin sabis na gaggawa na yau da kullun da na yau da kullun, bandeji na damfara da ake amfani dashi a yawan zubar jini shine yawanci bai isa ba. Yana da tasiri kawai lokacin da za'ayi matsi na kai tsaye, wanda ba za'a iya garantin koyaushe yayin haɗarin rauni ko haɗarin haɗari (5).

Wannan shine ya sa yawancin kungiyoyin gaggawa ke amfani da tsarin shakatawa. Yana da manufa guda ɗaya ne kawai: hana fashewar basir da yawan zubar jini daga wani reshe. An tabbatar dashi a kimiyance cewa aikace-aikacen sa ko shakka babu yana da ceton rai. Marasa lafiya waɗanda suka ɗanɗani tashin hankali mai ɗora damuwa suna da ƙididdigar mummunan halin ƙididdiga tare da ƙarancin rayuwa. Shaida da aka tattara a fagen soji ta nuna cewa mutanen da suka ji rauni waɗanda aka shafa wa dansu kafin farawar girgiza kai suna da darajar 90%, idan aka kwatanta da 20% lokacin da aka yi amfani da wannan bajintar bayan alamun farko na girgiza (9).

Amfani da farko na yawon shakatawa yana rage buƙatar sake haifar da yanayin motsa jiki tare da klallisos a cikin yanayin karin-asibiti (haemodilution, hypothermia) da hemoderivatives a cikin yanayin asibiti (coagulopathies), guje wa kara dagula abubuwan da ke tattare da haɗarin haɗarin cutar (10).

A lokacin rikici na Vietnam, 9% na mutuwar ya faru ne ta hanyar zub da jini. A cikin rikice-rikicen yau, an rage shi zuwa 2% godiya ga horarwa kan amfani da yawon shakatawa da yaduwarsa. Adadin rayuwa tsakanin sojoji da aka yi garkuwa da su tare da waɗanda ba a yi amfani da su ba shine 87% vs. 0% (9). Binciken bincike na kasa da kasa 6 ya ba da rahoton rage adadin kashi 19% na gabobin da ke ciki.

Wataƙila waɗannan yankanin ya haifar da raunin raunin farko kuma ba a bayyana shi azaman rikitarwa na biyu ba game da amfani da yawon shakatawa (11). A cikin manyan nazarin soja guda biyu, an gano cewa yawan rikice-rikice sakamakon amfani da yawon shakatawa ya tashi daga 0.2% (12) zuwa 1.7% (9). Sauran karatun sun nuna babu rashi game da yanayin yawon shakatawa wanda ya rage a wurin tsakanin 3 zuwa 4 hours (13.14).

Dole ne muyi la'akari da awanni 6 a matsayin matsakaicin matsakaicin iyakar rayuwa (15). Workingungiyar aiki tsakanin Ma'aikatar tsaron cikin gida da ke tattare da “Ma’aikatar Tsaro ta ƙasa” na Fadar White House, ta haɓaka ƙaddamar da "Dakatar da Zub da jini" a cikin Amurka, tare da maƙasudin gina ƙarfin hali tsakanin jama'ar ta hanyar ƙaruwa wayar da kan al'amuran yau da kullun don dakatar da zubar da jini da ke haifar da rayuwa wanda ke haifar da haɗari ta hanyar haɗari na rayuwar yau da kullun da kuma mummunan lamari na yanayi ko yanayin ta'addanci.

“Kwamitin Rage” na Kwalejin Bincike na Amurka da Yarda da Hartford suna daga cikin manyan masu tallata wannan kamfen. Ana la'akari da zubar da jini da ba a kulawa da shi ba shine farkon abin da ke haifar da mutuwa ta hanyar rauni, yayin da tushen jigilar lokaci shine amfani da mahaɗa a matsayin masu amsawa na farko don gudanar da zubar da jini har zuwa lokacin da masu ƙwararru suka ceto, bayan sun tabbatar da cewa tsoma bakin yana da tasiri a cikin farko 5 -10 minti.

Wadanda ke koyar da tsarin Trieste 118 sun shiga cikin aikin "Dakatar da Zub da jini", wanda aka shigo da Italiya ta Italiya ta Chirurgia d'Urgenza e del Trauma. Manufar ita ce daidaita dabi'un yadda ya kamata a kan hanyar amfani da yawon shakatawa, a halin yanzu ana kan duk motocin ceto na lardin.

 

Game da yawon shakatawa da kuma damar shiga ciki

A wurin da ake gabatar da asibiti, sau da yawa yana da mahimmanci don tabbatar da saurin jijiyoyin bugun gini, amma jigilar yanayi yawanci matsala (16,17). Accessarfin nesa na remainsabi'a ya kasance ma'auni, amma idan aka lalata mahimman ayyukan, dawo da shi na iya zama da wahala ko yana iya ɗaukar tsawo.

Abubuwan da suka shafi muhalli kamar haske mara kyau, iyakataccen sarari, mawuyacin hali mai haƙuri ko dalilai na asibiti kamar yanayin vasoconstriction a cikin rawar jiki ko marassa lafiya, ƙarancin dukiyar da ke tattare da cutar sankara ko kiba na iya yin wahalar samun damar mahalli na mazauni.

Wadanda ke fama da rauni tare da kara karfin gwiwa, kamuwa da bugun zuciya ko kuma rufewa na iya buƙatar samun dama na jijiyoyin jiki kai tsaye.
A cikin marasa lafiyar yara, samun damar jijiyoyin jiki na iya zama da wahala a zahiri (18). Theimar nasarar da aka samu a cikin sanya madaidaiciyar maganin ɓarna a farkon ƙoƙari a waje da asibiti shine kashi 74% (19.20) kuma an rage shi zuwa ƙasa da 50% idan har aka sami bugun zuciya (20). Marasa lafiya a cikin basur suna buƙatar, a matsakaita, mintina 20 don samun damar buɗe ciki (21).

Tourniquet da intraosseous damar: ingantacciyar hanyar samun damar shiga jijiyar jijiyoyi shine damar shiga ciki: ana samun shi da sauri fiye da dawo da jijiya ta gefe (50± 9 s vs 70± 30 s) (22). A cikin saitin asibiti a cikin marasa lafiya na ACR tare da jijiyoyin jijiyoyin da ba su samuwa, samun damar shiga cikin ciki ya nuna ƙimar nasara mafi girma a cikin ƙasa da lokaci fiye da CVC sanyawa (85% vs 60%; 2 min vs 8 min) (23), haka kuma hanyar ba ta buƙatar katsewar matsawar ƙirji kuma saboda haka zai iya inganta rayuwar mai haƙuri (24).

Majalisar Resuscitation ta Turai ta ba da shawarar yin amfani da hanyoyin shiga ciki azaman madadin ingantacce idan aka gaza gano labulen mahaifa a cikin majinyacin (25) kuma a matsayin farkon zabi a cikin mara lafiyar yara (26).
Tun daga watan Afrilun 2019, tsarin IZ-IO® Intraosseous Access System an yi shi a duk ASUITS 118 Advanced Rescue Ambulances bayan horar da ma’aikatan jinya da watsa hanyoyin aiki, a baya kawai tsarin magani na kai ne ya kasance sanye da kayan.

Yaduwar sarrafawa ga dukkanin ambulances yana sa ya yiwu a hanzarta ba da izinin shigowar jijiyoyin jiki, rage lokutan jiyya da kuma ƙara haɓaka ayyukan sabis don citizensan ƙasa. Yawancin karatu sun nuna cewa EZ-IO® ingantaccen tsarin dawo da ciki ne: yawan nasarar nasarar yana da girma sosai (99.6% 27; 98.8% 28; 90% 29) kazalika da nasarar nasara a ƙoƙarin farko ( 85.9% 27; 94% 28; 85% 23) kuma an san shi da yanayin saurin karatu (29). Abun shiga ciki yayi daidai da damar shiga cikin mahaifa dangane da harhada magunguna da ingancin aikin asibiti (30) kuma matsalar rikicewar kasa da 1% (24).

Game da damar shiga cikin ciki da kuma amfani da yawon shakatawa, rahoton shari'ar

Rahoton hali:

6.35 na yamma: Tsarin 118 Trieste ya kunna ta FVG Yanki na Asibitin Ayyukan Gaggawa na gaggawa don amsa lambar rawaya mai rauni a gida.

6.44 pm: motar asibiti ta isa wurin kuma ma'aikatan suna tare da dangin marasa lafiya a cikin gidan wanka. Wata tsohuwa 'yar shekara 70, mai kiba, zaune a bandaki ta sume (GCS 7 E 1 V2 M 4). Numfashin huci, kodadde, diaphoretic, bugun bugun carotid da kyar ake iya gane shi, lokacin cika capillary> 4 seconds. Babban slick na jini a ƙafafun majiyyaci; ciwon jijiyoyi sun bayyana a cikin ƙananan gaɓoɓin kuma an nannade wani tawul, wanda kuma jiƙa a cikin jini a kusa da maraƙi na dama.

6.46 na yamma: lambar ja. An nemi magani na kai kuma dole ne su yi kira don samar da agajin wuta don taimakawa jigilar mai haƙuri, la'akari da yanayin nauyinta da iyakataccen sararin samaniya da ake da shi. Lokacin da aka cire tawul, za a gano zubar jinni daga cikin jijiyoyin bugun jini a cikin ulcuscruris, wanda yake cikin sashin bayan maraƙi.

Ba shi yiwuwa a tabbatar da ingancin matsi kai tsaye da kuma sadaukar da wani ma'aikaci don wannan dalili. Don haka, nan da nan suka yi amfani da Combat Application Tourniquet (CAT), suna dakatar da zubar jini. Bayan haka, ba a gano sauran bakin bakin jini ba.

Shugaban ya hau kanshi kuma yayi amfani da O2 da 100% FiO2 tare da bacewar numfashi.
Ganin yanayin rawar jiki da kiba, ba shi yiwuwa a sami damar ɓoye mahalli, don haka, bayan yunƙurin farko, an sanya damar shiga cikin ɗakin da ke daidai da tsarin EZ-IO® tare da allurar 45mm.

An tabbatar da daidaiton wurin shigowa: kwanciyar hankali na allura, burin fitar jini da sauƙaƙin injin girman mil 10 SF. Magani na jiki 500 ml jiko tare da huhun jakar an fara shi kuma an yi amfani da an sanya shi tare da mitella. Lokacin da aka sanya ECG saka idanu, rhythmic HR, PA da SpO80 ba a iya gano su.

Sannan sai anyi amfani da rigar likita mai cike da damuwa a wurin zubar jini. Tarin tarin aiki mai saurin lalacewa ya nuna cewa mara lafiyar yana fama da cutar hawan jini, hauhawar jini, dyslipidemia, OSAS a cikin nocturnal CPAP, atrial fibrillation in TAO. Hakanan an bi ta Aikin Fuskokin Filastik da Cututtukan Cutar cututtukan ƙananan ƙwayar cuta tare da dermohypodermite ta MRSA, P. Mirabilis da P. Aeruginosa kuma a cikin maganin tapazole 5mg 8 hours, bisoprolol 1.25mg h 8, diltiazem 60mg kowane 8 hours, coumadin bisa ga INR.

6.55 na yamma; da mai zaman kansa ya iso wurin. Mai haƙuri ya gabatar tare da GCS 9 (E 2, V 2, M 5), FC 80r, PA 75/40, SpO2 98% tare da FiO2 100%. 1000mg EV tranexamic acid an gudanar dashi. Tare da taimakon Gobarar Wuta, an tattara mara lafiyar tare da kujera sannan kuma akan mai shimfiɗa.

A cikin motar asibiti, an gabatar da mai haƙuri tare da GCS 13 (E 3, V 4, M 6), PA 105/80, FC 80r da SpO2 98% tare da FiO2 100%. Dama ankarar da damar shiga cikin kabari da dama lokacinda aka tattara aikin, don haka aka sami nasarar shiga wata dama ta kai tsaye a kujerar jana'izar hagu kuma ana ci gaba da samar da ruwa mai gudana.

Ganin ingantaccen sigogi masu mahimmanci, an yi maganin analgesic tare da fentanest 0.1mg da jimillar 500ml na saline da 200ml na ringeracetate. A 7.25 na yamma motar asibiti, tare da likita a kunne hukumar, hagu a lambar ja zuwa Cattinara gaggawa Room.

Surgeon, resuscitation sashen da jini banki da aka faɗakar. Motar asibiti ta isa PS da karfe 7.30 na dare
Kidaya jini na farko ya nuna: haemoglobin 5 g / dL, ƙwayoyin jini 2.27 x 103µL, hematocrit 16.8%, yayin da coagulation: INR 3.55, 42.3 seconds, Ratio 3.74. An shigar da mai haƙuri zuwa maganin gaggawa da kuma halayen hemotransfusions na jimlar 7 raka'a na ƙwaƙwalwar ƙwayar jini da sake zagayowar ƙwayoyin cuta tare da dalbavancin da cefepime.

 

Yawon shakatawa, yawan zubar jini da hanyoyin shiga ciki: KARANTA TARIHIN ITALI

 

KARANTA ALSO

Yawon shakatawa: Dakatar da zub da jini bayan raunin bindiga

Ganawa tare da AURIEX - Ficewa ta hanyar lafiya, horo da kuma kula da zubar jini

Yawon shakatawa ne ko babu yawon shakatawa? Kwararrun orthopedics guda biyu sunyi magana akan jimlar maye

Kulawa na Kula da Ta'ida: Yaya ya kamata a kiyaye lafiyar dabbobi don fuskantar filin yaki?

 

Yawon shakatawa, yawan zub da jini da samun damar shiga cikin SARAUNIYA

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