Hluav taws, nqus pa, thiab hlawv: lub hom phiaj ntawm kev kho thiab kev kho mob

By Cristiano Antonino On Apr 8, 2023

Cov kev puas tsuaj tshwm sim los ntawm kev nqus pa los ntawm kev haus luam yeeb txiav txim siab qhov kev tuag ntawm cov neeg mob kub hnyiab: nyob rau hauv cov ntaub ntawv no, qhov kev puas tsuaj los ntawm kev nqus pa nqus tau ntxiv rau cov neeg los ntawm qhov kub hnyiab, feem ntau ua rau tuag taus.

Kab lus no tau mob siab rau kev kho mob kub hnyiab, nrog rau kev siv tshwj xeeb rau kev mob ntsws thiab kev puas tsuaj hauv cov neeg uas tau nqus pa, thaum cov kab mob dermatological yuav raug tshawb nrhiav lwm qhov.

Haus luam yeeb inhalation thiab hlawv, lub hom phiaj ntawm kev kho

Lub hom phiaj ntawm kev pab ua pa hauv cov neeg mob kub hnyiab yog kom ntseeg tau tias:

airway patency,
Qhov cua zoo,
txaus oxygenation,
tswj xyuas kua qaub-puag tshuav,
tswj cov hlab plawv stability,
kev kho mob sai sai.

Qee qhov xwm txheej, ua qhov excartomy yog qhov tseem ceeb los tiv thaiv cov ntaub so ntswg hauv siab los ntawm kev cuam tshuam lub hauv siab.

Lub hom phiaj ntawm kev kho mob ntawm daim tawv nqaij yog:

tshem tawm cov tawv nqaij tsis tseem ceeb,
kev siv cov ntaub qhwv tshuaj nrog tshuaj tua kab mob,
qhov txhab kaw nrog kev hloov ntawm daim tawv nqaij ib ntus thiab hloov pauv ntawm daim tawv nqaij los ntawm cov chaw noj qab haus huv lossis cov qauv cloned mus rau qhov chaw hlawv,
txo cov kua dej thiab kev pheej hmoo kis mob.

Cov ntsiab lus yuav tsum tau muab cov caloric ntau dua cov basal sawv daws yuav, txhawm rau pab txhawb kev kho qhov txhab thiab tsis txhob catapolism.

Kev kho mob ntawm cov neeg mob kub hnyiab nrog pa luam yeeb inhalation

Hlawv cov neeg raug tsim txom me me uas cuam tshuam rau cov hlab cua sab saud, lossis muaj cov tsos mob ntawm kev ua pa tsis zoo lossis, txawm li cas los xij, kev koom tes hauv pulmonary, yuav tsum tau saib xyuas kom zoo.

Nws yog ib qho tsim nyog los muab cov pa oxygen ntxiv, los ntawm lub qhov ntswg cannula, thiab kom tus neeg mob xav tau siab Fowler txoj hauj lwm, txhawm rau txo qis kev ua pa.

Bronchospasm yog kho nrog aerosolized β-agonists (xws li orciprenaline lossis albuterol).

Yog tias muaj kev cuam tshuam ntawm txoj hlab ntsws, nws yuav tsum tau muab kev ruaj ntseg nrog lub raj endotracheal uas tsim nyog.

Early mob ntsws feem ntau tsis pom zoo rau cov neeg raug mob kub hnyiab vim tias cov txheej txheem no cuam tshuam nrog kev kis tus kab mob ntau dua thiab muaj kev tuag ntau ntxiv, txawm hais tias nws yuav tsim nyog rau kev txhawb nqa ua pa mus ntev.

Thaum ntxov intubation tau raug tshaj tawm tias ua rau muaj kev kub ntxhov nyob rau hauv pulmonary edema nyob rau hauv qee cov neeg mob uas ua pa raug mob.

Daim ntawv thov ntawm 5 los yog 10 cm H2O nruam zoo cua siab (CPAP) tuaj yeem pab txo qis pulmonary edema thaum ntxov, khaws lub ntsws ntim, txhawb nqa txoj hlab ntsws oedematous, txhim kho qhov cua / perfusion piv, thiab txo cov neeg tuag ntxov.

Kev tswj hwm ntawm cortisone rau kev kho mob ntawm edema tsis pom zoo, vim tias muaj kev pheej hmoo ntawm kev kis kab mob.

Kev kho mob ntawm cov neeg mob comatose yog coj mus rau hypoxia hnyav los ntawm kev nqus pa pa thiab CO lom thiab ua raws li kev tswj hwm ntawm oxygen.

Lub dissociation thiab tshem tawm ntawm carboxyhemoglobin yog nrawm los ntawm kev tswj hwm cov tshuaj oxygen.

Cov neeg uas tau nqus cov pa luam yeeb, tab sis tsuas muaj qhov nce me ntsis hauv Hbco (tsawg dua 30%) thiab tswj cov kev ua haujlwm ntawm lub plawv, yuav tsum tau kho nrog kev xa 100% oxygen los ntawm lub ntsej muag nruj nruj, xws li "tsis ua pa" ( uas tsis tso cai rau koj nqus cov pa uas koj nyuam qhuav exhaled dua), nrog rau 15 litres / feeb, ua kom lub tank cia tag nrho.

Kev kho cov pa oxygen yuav tsum txuas ntxiv mus txog thaum qib Hbco poob qis dua 10%.

Daim npog ntsej muag CPAP nrog 100% oxygen xa tuaj yeem yog qhov kev kho mob tsim nyog rau cov neeg mob uas mob hypoxemia thiab tsis muaj lossis tsuas yog mob me me ntawm lub ntsej muag thiab cov pa sab saud.

Cov neeg mob uas muaj refractory hypoxemia los yog aspiration raug mob txuam nrog coma los yog cardiopulmonary instability yuav tsum tau intubation thiab ua pa kev pab nrog 100% oxygen thiab raug xa mus sai rau kev kho mob hyperbaric oxygen.

Cov kev kho mob tom kawg tau txhim kho kev thauj mus los oxygen sai sai thiab ua kom cov txheej txheem tshem tawm CO los ntawm cov ntshav.

Cov neeg mob uas muaj mob pulmonary edema thaum ntxov, ARDS, los yog mob ntsws feem ntau xav tau qhov zoo kawg-kawg siab (NCOO) Kev txhawb nqa ua pa thaum muaj ABGs qhia txog kev ua pa tsis ua haujlwm (PaO2 tsawg dua 60 mmHg, thiab / lossis PaCO2 siab dua 50 mmHg, nrog pH qis dua 7.25).

NCOO Yog tias PaO2 poob qis dua 60 mmHg thiab FiO2 xav tau tshaj 0.60.

Kev pab cuam ua pa yuav tsum tau ua kom ntev, vim tias cov neeg mob kub hnyiab feem ntau muaj cov metabolism hauv nrawm, uas yuav tsum tau nce hauv cov pa ua pa ib feeb kom ntseeg tau tias kev saib xyuas homeostasis.

cov cov khoom Kev siv yuav tsum muaj peev xwm xa tau lub ntim siab / feeb (txog 50 litres), thaum tswj kev siab siab siab siab siab (txog 100 cm H2O) thiab qhov kev tshoov siab / hnub kawg (I: E) ruaj khov, txawm tias cov ntshav siab xav tau. yuav nce.

Refractory hypoxemia tuaj yeem teb rau lub siab-dependent, thim rov qab qhov cua.

Kev tu lub ntsws kom txaus yog tsim nyog los ua kom cov pa tawm ntawm cov hnoos qeev.

Passive respiratory physiotherapy pab txhawb kev zais cia thiab tiv thaiv kev ua pa ntawm txoj hlab pas thiab atelectasis.

Tsis ntev los no daim tawv nqaij grafts tsis zam lub hauv siab percussion thiab vibration.

Kho fibrobronchoscopy yuav tsim nyog los thaiv cov hlab pa los ntawm kev tsub zuj zuj ntawm thickened zais cia.

Ua tib zoo saib xyuas cov kua dej sib npaug yog qhov tsim nyog kom txo qis kev pheej hmoo ntawm kev poob siab, lub raum tsis ua haujlwm, thiab pulmonary edema.

Kev kho tus neeg mob cov dej sib npaug, siv cov mis Parkland (4 ml ntawm cov tshuaj isotonic ib kg rau txhua feem pua ntawm cov tawv nqaij kub hnyiab, rau 24 teev) thiab tswj cov diuresis ntawm qhov tseem ceeb ntawm 30 thiab 50 ml / teev thiab hauv nruab nrab venous. siab ntawm 2 thiab 6 mmHg, pab khaws cia hemodynamic stability.

Hauv cov neeg mob aspiration raug mob, capillary permeability nce, thiab kev soj ntsuam pulmonary artery siab yog cov lus qhia tseem ceeb rau kev hloov cov kua dej, ntxiv rau kev tswj cov zis tso zis.

Nws yog ib qho tsim nyog los saib xyuas cov duab electrolyte thiab acid-base tshuav nyiaj li cas.

Lub xeev hypermetabolic ntawm tus neeg mob kub hnyiab yuav tsum tau ua tib zoo tsom xam ntawm cov khoom noj khoom haus tshuav, tsom kom tsis txhob muaj cov catabolism ntawm cov leeg nqaij.

Cov qauv kev kwv yees (xws li cov ntawm Harris-Benedict thiab Curreri) tau siv los kwv yees siv cov metabolism hauv cov neeg mob no.

Tam sim no, portable analyzers muaj nyob rau hauv kev lag luam uas tso cai rau serial indirect calorimetry ntsuas yuav tsum tau ua, uas tau pom tau hais tias muab kev kwv yees ntau tseeb ntawm kev noj haus.

Cov neeg mob uas muaj qhov kub hnyiab heev (ntau dua 50% ntawm daim tawv nqaij saum npoo) feem ntau yog cov khoom noj uas nws cov calorie ntau ntau yog 150% ntawm lawv qhov kev siv zog so, txhawm rau pab kho qhov txhab thiab tiv thaiv catabolism.

Nrog rau kev kho mob ntawm kev kub hnyiab, cov khoom noj khoom haus tau nce zuj zus mus rau 130% ntawm basal metabolic tus nqi.

Nyob rau hauv lub hauv siab circumferential kub hnyiab, cov caws pliav tuaj yeem txwv lub hauv siab phab ntsa

Lub escharotomy (kev phais tshem tawm ntawm daim tawv nqaij kub hnyiab) yog ua los ntawm kev ua ob sab incisions raws anterior axillary kab, pib los ntawm ob centimeters hauv qab lub clavicle mus txog rau lub cuaj-thib intercostal qhov chaw, thiab ob qho tib si transverse incisions stretched nruab nrab ntawm qhov kawg. thawj, los txhais ib square.

Qhov kev cuam tshuam no yuav tsum txhim kho elasticity ntawm lub hauv siab phab ntsa thiab tiv thaiv cov nyhuv compressive ntawm caws pliav cov ntaub so ntswg retraction.

Kev kho qhov kub hnyiab suav nrog kev tshem tawm ntawm daim tawv nqaij tsis tseem ceeb, kev siv tshuaj pleev ib ce nrog tshuaj tua kab mob, qhov txhab kaw nrog cov tawv nqaij hloov ib ntus, thiab grafting ntawm daim tawv nqaij los ntawm cov chaw noj qab haus huv lossis cov qauv mus rau qhov chaw hlawv. cloned.

Qhov no txo cov kua dej thiab kev pheej hmoo ntawm kev kis kab mob.

Cov kab mob feem ntau yog vim coagulase-positive Staphylococcus aureus thiab cov kab mob gram-tsis zoo, xws li Klebsiella, Enterobacter, Escherichia coli thiab Pseudomonas.

Cov txheej txheem kev sib cais kom txaus, kev ua kom lub zog ntawm ib puag ncig, kev pom ntawm huab cua, sawv cev rau lub hauv paus ntawm kev tiv thaiv kab mob.

Kev xaiv tshuaj tua kab mob yog ua raws li cov txiaj ntsig ntawm kev coj noj coj ua ntawm cov khoom siv los ntawm qhov txhab, nrog rau cov ntshav, zis, thiab cov hnoos qeev.

Cov tshuaj tua kab mob prophylactic yuav tsum tsis txhob muab rau cov neeg mob no, vim qhov yooj yim ntawm cov kab mob resistant tuaj yeem raug xaiv, lub luag haujlwm rau cov kab mob refractory rau kev kho.

Hauv cov neeg mob uas nyob twj ywm immobilized rau lub sijhawm ntev, heparin prophylaxis tuaj yeem pab txo qis kev pheej hmoo ntawm pulmonary embolisms, thiab tshwj xeeb yuav tsum tau them nyiaj tshwj xeeb los tiv thaiv kev txhim kho ntawm cov kab mob siab.