I kekahi manawa pono e noʻonoʻo inā like nā mea a mākou e lohe ai, ʻike ai a manaʻo ai e like me kā mākou i manaʻo ai. Ke nānā nei ʻo Dr Alan Garner i kou mau manaʻo ke komo ʻoe i loko o ka umauma a noʻonoʻo inā he pololei ia i mua e like me kā mākou e noʻonoʻo ai?

E hoʻomaka kākou i kēia pou ma ka ʻōlelo ʻana i mua e pili ana kēia i nā ʻeha umauma. Inā ʻaʻole ʻo ia ka mea āu e noʻonoʻo ai a laila ka manawa e nānā i kahi ʻē aʻe.

ʻO kaʻu mea e makemake ai e kūkākūkā ʻo ia ka maʻi maʻi o ka tension pneumothorax ma ke kula. ʻO ke kumu o ke kūkākūkā ʻana ʻo ia kaʻu i manaʻoʻiʻo he ala over-diagnosed. I koʻu hana ʻana ma UK 6 mau makahiki i hala aku nei, ua ʻike pinepine ʻia ke ʻano haʻalulu a ʻo ke kumu i hāʻawi ʻia ʻo ke kani ʻana i ka wā i uhaki ai lākou i ka pleura me nā forceps. E like me ka mea maʻi ua maikaʻi puʻe ventilated i ka manawa a laila ka leo e holo wikiwiki ana i waho o ka pleural wahi e like me kā lākou intrathoracic puʻe ua maikaʻi i loko o ka respiratory pōʻaiapuni pololei?

E hoʻomanaʻo pehea ʻaʻole hiki iā mākou ke hilinaʻi i nā kani e pili ana i ka hoʻokolohua lapaʻau ma ke ʻano prehospital no ka mea hiki ʻole ke hilinaʻi ʻia? ʻAe, ua haʻi ʻia iaʻu he pololei mau kēia. ʻO 'mau' kahi huaʻōlelo nui i ka lāʻau lapaʻau

Ua ʻike nō hoʻi au i hoʻokahi hihia i loaʻa ai i ka mea maʻi me ka ʻeha pu epigastric hoʻokahi mai kahi mea kaua haʻahaʻa haʻahaʻa i hoʻokomo ʻia a laila bilateral finger thoracostomies. ʻO ka ʻōlelo i kēlā manawa ʻo ke kauka prehospital, ʻaʻohe kānalua i komo i loko o ia mea me ka manaʻo maikaʻi, i ka manawa o ka thoracostomies ua loaʻa iā lākou kahi pneumothorax ma kekahi ʻaoʻao a me kahi ʻāʻī ma kekahi ʻaoʻao.

Eia nō naʻe ma ke kiʻi ʻana a me ke ʻoki ʻana, ua hoʻi pololei ka projectile i loko o ka pancreas a ʻaʻohe wahi kokoke i ka hemithorax a i ka diaphragm. ʻOiaʻiʻo, ʻo nā ʻeha wale nō i ʻike ʻia ma kekahi ʻāpana o ka umauma, ʻo ia ka ʻeha thoracostomy iā lākou iho. Eia hou ka mea maʻi intubated no laila ua maikaʻi ke kaomi intrathoracic? Inā hāʻule ka māmā a laila he pneumothorax? A inā he leo ma ka haʻi ʻana i ka pleura, he haʻalulu paha ia?

Akaka ma ka hihia ʻelua ua alakaʻi hewa nā hōʻailona no laila he aha ka mea e hana nei? E hoʻokaʻawale i kekona i nā pilikia o ka ʻike mua ʻana o ka pneumothorax a nānā i ka manaʻo me ka manamana lima a me ke kani i nā pepeiao. Hiki paha i kekahi o nā hōʻike i alakaʻi ʻia iā mākou e manaʻoʻiʻo e haʻi iā mākou e pili ana mākou i kahi pneumothorax hiki ke alakaʻi hewa i nā kauka lapaʻau i aʻo maikaʻi ʻia?

Luʻu i loko

Malia paha ua hana au i kekahi mau pahu wai ʻoi aʻe ma mua o ka hapa nui. ʻO kekahi hapa ma muli o 20 mau makahiki i ka prehospital space akā ua hana hou au i ka wā i kākau inoa ai au i ka makahiki 25 i hala. Ua hoʻohana au i 6 mau mahina e hana ana no kekahi mau kauka hanu a ua hoʻokomo au i nā kahawai he nui (no ka maʻi maʻi ʻino) i nā maʻi i loaʻa ʻole ka pneumothorax ma mua o koʻu hoʻomaka ʻana. He mea maʻamau ka lohe ʻana i kahi walaʻau ʻoiai ua haki ka pleura i ka holo ʻana o ka ea.

Pono kākou e hoʻi i ka physiology e ʻike ai i ka mea e hoʻoneʻe nei i ka neʻe ʻana o ka ea i loko a i waho paha o ka lua a mākou i hana ai no ka hoʻoholo ʻana inā he ea e komo ana ka leo a mākou e lohe nei.

E hoʻi i nā kumuhana

ʻO ke kaomi transpulmonary ka gradient kaomi e hoʻokele i ka ea maʻamau. ʻO ia ka ʻokoʻa ma waena o ka kaomi alveolar a me ka kaomi intrapleural i ka ka umauma.

P_tp = P_alv - P_ip. Ma kahi o P_tp ʻO ke kaomi transpulmonary, P_alv ʻO ke kaomi alveolar, a ʻo P_ip ʻo ke kaomi intrapleural.

(Inā makemake ʻoe i mea hou aʻe e pili ana i kēia, ʻo Life in the Fast Lane kahi mea liʻiliʻi i ke kaomi transpulmonary. maanei.)

ʻIke ʻia hiki iā ʻoe ke kiʻi i kahi Google preview o ka puke haʻawina maʻamau a John West ma ka physiology hanu. E hoʻomaha iki e hele a hauʻoli Kiʻi 4-9 ma ka ʻaoʻao 59. 

Hiki iā ʻoe ke ʻike mai ka panel B (ʻo wau i ʻōlelo ai, e hele a nānā) ʻokoʻa ke kaomi intrapleural ma waena o -5 a me -8 cmH.₂ʻO ma ka pae waena-māmā i ka manawa o ka hanu maʻamau. ʻAʻole maikaʻi mau ia a ma muli o ka elastic recoil o ka māmā e kūʻē ʻia ana e ka paia o ka umauma. ʻAʻole ʻoi aku ka maikaʻi ʻole ma nā ʻāpana hilinaʻi o ka māmā (e hoʻemi ana i ka nui alveolar) a ʻoi aku ka maikaʻi ʻole ma ka piko (e hoʻonui ana i ka nui alveolar).

E Hoʻohui Ea

Ma ke kūlana o kahi pneumothorax liʻiliʻi, ʻo ka ea i loko o ka pleural space e hoʻemi ʻole ʻia ke kaomi intrapleural a no laila ua hoʻemi ʻia ka ʻokoʻa o ka hoʻokele ʻana no ka ea. Inā hāmama loa ka pneumothorax i ka lewa e like me ka ʻeha thoracostomy hāmama, ua like ke kaomi intrapleural me ke kaomi o ka lewa, ʻo ka hoʻihoʻi hou ʻana o ka māmā e hāʻule piha a ʻaʻole hiki ke hoʻokuʻu ʻia ma ka hoʻonui ʻana o ka umauma - pono e hoʻopili ʻia ke kaomi ea maikaʻi.

ʻAʻole pili iaʻu i ke kūlana o ka pneumothorax. Inā he hypoxic a i ʻole hypotensive lākou a he pneumothorax ka mea maʻi, pono e hoʻokaʻawale ʻia ka pahu - ʻaʻohe-brainer piha. ʻO ka nīnau no ke aha e hoʻokaʻawale ai nā kauka maikaʻi i nā umauma maʻamau a noʻonoʻo aia he pneumothorax a i ʻole ka ʻāʻī inā ʻaʻole? Ke alakaʻi nei ka physiology iā mākou i laila?

Hookahi Hoomanawanui

E noʻonoʻo mua kākou i ka mea maʻi i hoʻopaʻa ʻole ʻia me ka hanu maʻamau a ʻaʻohe pneumothorax. ʻO kēia ke kūlana me ka poʻe maʻi me nā maʻi maʻi maʻi aʻu e waiho nei i nā kahawai i nā makahiki i hala. ʻAʻole ʻoi aku ka nui o ke kaomi alveolar ma mua o ka cmH₂ʻO a ʻelua paha maikaʻi a maikaʻi ʻole paha. ʻO ke kaomi intrapleural naʻe -5 a -8 cmH₂O. No laila, ʻaʻohe mea pili i ke ʻano o ka hanu ʻana āu e uhaʻi ai i ka pleura, ʻo ka ʻemi kaomi ma waena o ka pleural space a me ka lewa he ʻino a e holo wikiwiki ka ea.

ʻOi aku ka nui o ka gradient i ka hoʻoulu ʻana inā ʻino ke kaomi alveolar (a no laila ʻo ka nui o ke kaomi ma kahi o -8 cmH.₂ʻO) a emi mai ka maikaʻi ʻole i ka wā e pau ai ke ʻano like -5 cmH₂O. He ino nae nae. ʻAʻole pili i ka ʻāpana o ka ʻōpū hanu e uhaʻi ai ʻoe i ka pleura, e kahe ana ka ea i loko o ka lumi pleural a ʻo ka hoʻihoʻi ʻana o ka māmā e hāʻule ai. Inā lohe ʻoe i ka walaʻau e like me kaʻu i hana pinepine ai, ʻo ke ea e holo mai ana i loko, ka ʻeha umauma omo maʻamau. ʻO kahi iatrogenic.

Hoomanawanui Elua

Manaʻo wau ʻaʻole pilikia kekahi me nā mea i kēia manawa. No laila e neʻe kākou i ka mea maʻi i hoʻopaʻa ʻia ʻaʻohe pneumothorax. Ke manaʻo nei au ma ʻaneʻi ʻaʻole nui ka pale ʻana i ke ala ea i ko mākou maʻi trauma (ʻaʻole ia he ʻōlelo ʻaʻole lākou i loaʻa i lalo o ka maʻi pulmonary obstructive, anaphylaxis i nā lāʻau induction āu i hāʻawi ai a i ʻole kahi clot e noho ana i loko o kahi bronchus nui. /ETT) no ka mea he mea maʻalahi ke kūkākūkā e manaʻo ʻia he liʻiliʻi ke kūʻē ʻana (mea ʻole e like me ka Daleks) a ʻo ke kaomi āu e ʻike nei ma kāu ana ventilator e lawe pololei ʻia i ka alveoli.

Ke nānā nei mākou i kā mākou hoʻohālikelike puʻe transpulmonary, ke ʻole ke kiʻekiʻe o ke ea a no laila ke kiʻekiʻe o ke kaomi alveolar ma mua o 5 cmH.₂A laila, ʻo ka gradient i ka manawa e wehe ai ʻoe i ka pleura, ʻo ia ka mea e hele ana ka ea komo ka lua pleural. (Inā loaʻa iā lākou ke kūʻē ʻana i ke ala ea, hiki ke hana ʻia me ka ʻoi aku ka nui o ke kaomi ea).

E kiʻi wale i ka maka maka o kēia pakuhi kaomi manawa o ka ventilator cycled volume maʻamau me ka PEEP ʻole (a e hāʻawi ka ʻeke hoʻonui ponoʻī i kahi ʻano like a ʻoi aku ka loli). A ʻaʻohe oʻu PEEP ma kēia pakuhi. ʻAʻole paha ʻo PEEP ka mea mua a mākou e loaʻa ai i ka maʻi maʻi trauma hypotensive a mākou i hoʻokomo ai i kahi a mākou e hopohopo nei e pili ana i kahi pneumothorax.

Me nā māmā maʻamau, ʻoi aku ka nui o ke kaomi ma kahi o 20 cmH₂O. He aha ka hapa o ka huina hanu o ke ea (a no laila ke kaomi alveolar i ko kakou ma'i me ke ku ea ha'aha'a) aia ma lalo o 5 cmH₂O? Inā he 1:2 I:E ka nui o kāu ventilator prehospital e like me ka hapa nui, a laila ʻo ka hapa nui o ia mea.

Ma nā huaʻōlelo ʻē aʻe ke ʻole ʻoe he PEEP ma kahi o 5 cmH₂ʻOiai i loko o kāu mea maʻi i hoʻopili ʻia, ʻaʻole maikaʻi ke kaomi transpulmonary no ka hapalua maikaʻi o ka pōʻai hanu. I loko o ka hapa liʻiliʻi o ka pōʻai hanu, inā lohe ʻoe i ka walaʻau ʻoiai ʻoe e haki ana i ka pleura, lohe ʻoe i ka lele ʻana o ka ea. IN.

ʻO ka hoʻihoʻi ʻana o ke akemāmā ke kumu i manaʻo ai ʻoe ua hāʻule ka māmā i ka manawa āu e huki ai i nā pū i waho a hoʻokomo i kou manamana lima ke ʻole ʻoe e pāʻani i kahi PEEP.

I kēia manawa, ʻaʻole wau e ʻōlelo ʻaʻole i hiki mai ka manawa i holo ʻole ai ka ea. Ke manaʻo wale nei au e hoʻopaʻapaʻa ka mea a mākou e ʻike ai i ka physiology aia ma kahi liʻiliʻi o kahi māhele paʻa o ka manawa kahi i maikaʻi ʻole ai kēlā gradient puʻe transpulmonary i ka wā e haki ai ʻoe i ka pleura, ʻo ia hoʻi he hapa maikaʻi o nā hihia kahi. ʻaʻole hiki ke hilinaʻi ʻia kēlā mau hōʻailona "kekahi" maʻi.

No ka hōʻike ʻana o kēia me ka makuahine o nā thoracotomies hāmama (i loko o kahi cadaver) e nānā kēia wikiō.

Hoʻokomo ʻia ke kupapaʻu, ua hana ʻia kahi ʻeha decompression pleural "ʻoluʻolu", a i kēlā me kēia pau ʻana e hāʻule ka māmā i lalo ke ʻole e hoʻohana ʻia ka PEEP. A e hoʻomaopopo ua pau ka hāʻule ʻana i kēlā me kēia pau ʻana.

I ka lōʻihi o ka nui o ka thoracostomy e kamaʻilio manuahi me ka lewa (a inā ʻoe e hilinaʻi nei i ka ʻenehana "manamana" hāmama ma mua o ka hoʻokomo ʻana i loko o kahi kahawai, pono ia e nui a i ʻole hiki ke hoʻopaneʻe hou lākou), ke kau ʻoe i kāu lima i ka wā o ka pau ʻana e hāʻule ka māmā ke ʻole ka nui kūpono o ka PEEP splinting mea wehe nani loa.

E hāʻule ʻo ia inā ma mua o kou hana ʻana i ka ʻeha a i ʻole i ka wā i hohola ai ʻoe i nā pū a hana i ka lua kamaʻilio. ʻO ka manawa ma waena o ka hana ʻana i ka lua a me ka loaʻa ʻana o kēlā ʻano o ke akemāmā i luna a i ʻole ka māmā i lalo me ka manamana lima he manawa kūpono ia e hāʻule ai ka māmā. Me he mea lā ʻaʻole haʻi paha kēia hōʻailona lapaʻau iā ʻoe e pili ana i ke kūlana o ka pāʻani ma mua o ka hana ʻia ʻana o ka ʻeha.

No laila hiki ke hoʻopunipuni nā leo a me ka manaʻo ʻana i ka hāʻule ʻana o ke akemāmā, ʻo ia wale nō ka hoʻihoʻi ʻana o ka māmā i ka wehe ʻana o ka pleura. Hiki iā ʻoe ke hōʻoiaʻiʻo i ka manawa hea o ka pōʻai hanu i loaʻa i ka mea maʻi i ka wā i hana ai ʻoe i kēlā lua? Inā ʻaʻole i loaʻa iā ʻoe ma kahi o 5 cmH₂ʻO (a ʻoi aku paha) PEEP ma ka manawa āu i uhaki ai i ka pleura ʻaʻole pono kekahi o kēia mau hōʻailona.

Ano, pehea?

Eia hou, ʻaʻole wau e ʻōlelo i nā mea e like me "mau" a "ʻaʻole loa". ʻO kaʻu e ʻōlelo nei, ʻoi aku ka nui o ka hina a puni kēia mau hōʻailona lapaʻau ma mua o ka mea i ʻike mua ʻia.

No laila pehea ʻoe e ʻike ai inā he pneumothorax ko lākou? Noʻu ʻaneʻane ma ka ultrasound i kēia manawa. ʻAʻole maopopo iaʻu pehea wau i mālama ai no 15 o kēlā mau makahiki 20+ o ka mālama prehospital me ka ʻole. ʻO kekahi manawa ʻoiaʻiʻo he equivocal ka scan a pono ʻoe e kelepona ma muli o nā hōʻailona āu e ʻike ai a me ke ʻano o ka mea maʻi akā ʻike wau he mea maʻamau loa kēia me kahi kiʻekiʻe kiʻekiʻe linear probe.

A no ka hoʻopaʻapaʻa, ʻo ka hōʻailona he physiology abnormal, ʻoi aku ke koko. Inā hoʻoponopono ka decompressing i ka umauma i ka physiology a laila ua pilikia lākou. Inā ʻaʻole, ua loaʻa iā lākou kahi pneumothorax maʻalahi - a ʻaʻole loa. No ka mea, ʻo ka walaʻau āu i lohe ai i kou uhaki ʻana i ka pleura he ea paha i ke komo ʻana a i ʻole ka haʻalele ʻana i ka hale, ʻaʻole kōkua ka lohe ʻana i kahi walaʻau iā ʻoe. Aia ʻo Elvis i loko o ka hale?

Notes:

Ua loaʻa iaʻu ka loiloi maikaʻi ʻo Dr Blair Munford i kahi puʻupuʻu o ka physiology ma aneʻi e hōʻoia i ke kūlike.

Ma hope o kēlā loulou i ka bit LITFL ma ke kaomi transpulmonary hou? A laila hele pololei maanei.

A ʻo ka hana nui a John West (ma ka liʻiliʻi o ka ʻaoʻao i ʻōlelo ʻia). maanei.

Ua kau ʻia kēlā kiʻi o Nahni me nā pepeiao nui i ka Creative Nā Kāhua ʻāpana o ka flickr na Allan Henderson a ʻaʻole i hoʻololi ʻia ma ʻaneʻi.

ʻAe, a inā ʻaʻole ʻoe i ʻike i ka mea kupaianaha maoli ʻo John West, ua hoʻopaʻa ʻia ke keiki ʻo Adelaide ʻo kāna mau haʻiʻōlelo holoʻokoʻa na ʻoe e hele e nānā. No ka mea, aia ʻoe i kou mau makahiki 80 e hāʻawi paha ʻoe i ka hoʻonaʻauao olakino e like me ia, ʻeā?

E heluhelu pū nō hoʻi:

Tracheal Intubation: I ka manawa, pehea a no ke aha e hana ai i kahi ala kaʻaima no ka mea maʻi

He aha ka Transient Tachypnoea o ke keiki hou, a i ʻole Neonatal Wet Lung Syndrome?

Source:

Mālama lele Collettive