Kuvulala pakali pano ndi chimodzi mwazovuta kwambiri za thanzi la anthu padziko lonse lapansi: m'mayiko otukuka, ndizomwe zimayambitsa imfa za anthu ochepera zaka 40 komanso chifukwa chachitatu cha imfa pambuyo pa matenda a mtima ndi khansa.

Pafupifupi kotala la milandu, kuvulala kumabweretsa kulumala komwe kumafuna kuti wodwalayo akhale chigonere ndikulandira chithandizo chovuta komanso nthawi yokonzanso.

Poganizira za ukalamba wa odwala ambiriwa, kupwetekedwa mtima kumakhala ndi udindo - kunena zachuma - chifukwa cha kulemala kwakukulu ndi kutayika kwa zokolola zonse kuposa ngakhale matenda a mtima ndi khansa zomwe zimagwirizanitsidwa pamodzi.

Zachipatala za kuvulala pachifuwa

Mbiri yolondola ya momwe chiwonongekocho chinachitikira komanso zochitika zake ndizofunika kwambiri kuti tiwone kukula kwa chovulalacho.

Ndikofunikira, mwachitsanzo, kusonkhanitsa zambiri za momwe ngozi yagalimoto yachitikira (kodi malamba achitetezo adamanga?, Kodi wovulalayo adaponyedwa kuchokera mchipinda chokwera?, miyeso yagalimotoyo inali yotani?, ndi zina zotero), mtundu ndi mtundu wa chida chomwe chinagwiritsidwa ntchito, nthawi yomwe inadutsa chithandizo chisanadze, kaya panali kugwedezeka kulikonse pa nthawiyo.

Matenda amtima omwe analipo kale, a m'mapapo, a mitsempha kapena aimpso, kapena kumwa mankhwala osokoneza bongo kapena mowa, amathanso kukhudza momwe thupi limakhudzira zoopsa.

Kufufuza mwachangu koma mosamala kuyenera kuchitidwa kuti muwone momwe mpweya umakhalira, kupuma, kuthamanga kwa magazi, kupezeka kwa zizindikiro za chifuwa cha flail kapena subcutaneous emphysema, symmetry ndi zina zomwe zapezeka m'mapapo mwanga.

Njira yofulumira komanso yokhazikika pakuwunika koyambirira kwa machitidwe amanjenje, ozungulira komanso kupuma ndi njira yosavuta yowerengera kuchuluka kwa zovuta zachipatala cha wodwalayo.

Izi ziwerengero za trauma zimaganizira za Glasgow coma scale, kuthamanga kwambiri kwa mitsempha ndi kupuma kwa mpweya: magawo atatuwa amapatsidwa ziro kuchokera ku ziro mpaka zinayi, pamene zinayi zimasonyeza mkhalidwe wabwino kwambiri ndi ziro woipitsitsa.

Pomaliza, zikhalidwe zitatuzo zikuphatikizidwa pamodzi.

Tiyeni titenge chitsanzo cha wodwala yemwe ali ndi:

Glasgow coma scale: 14;

kuthamanga kwa magazi: 80 mmHg;

kupuma = 35 kupuma pamphindi.

Zotsatira za Trauma = 10

Timakumbutsa owerenga kuti sikelo ya Glasgow coma ndi njira yowunikira minyewa, yomwe imapeza bwino molingana ndi mayankho abwino kwambiri apamaso, pakamwa komanso pamagalimoto kuzinthu zosiyanasiyana.

Pakafukufuku wa odwala 2166, 'kuvulala kwapang'onopang'ono' kunawonetsedwa kuti kumasankha odwala omwe angapulumuke kuchokera kwa omwe adavulala kwambiri (mwachitsanzo, kuchuluka kwa 12 ndi 6 kumalumikizidwa ndi 99.5% ndi 63% kupulumuka, motsatana), kulola zambiri. zomveka kuyendera ku malo osiyanasiyana owopsa.

Kutengera kuwunika koyambirira kumeneku, njira yotsatsira matenda ndi chithandizo chamankhwala imasankhidwa.

Mayesero ambiri a zida ndi ma labotale amagwiritsidwa ntchito mobwerezabwereza kuti afotokoze bwino momwe akuvulala kwa thoracic komwe kumanenedwa. X-ray ya anteroposterior (AP) ndiyofunikira nthawi zonse kuti muwunikenso wodwalayo komanso ngati chitsogozo cha chithandizo chadzidzidzi.

Kuwerengera kwathunthu kwa magazi (CBC), kuyesa kwa electrolyte, kusanthula kwa gasi wamagazi (ABG) ndi electrocardiogram (ECG) kumachitika pakulandila kenako mosalekeza.

Kufufuza kozama kwambiri monga CT, kujambula kwa maginito (MRI) ndi angiography kumathandiza kufotokozera bwino kukula ndi kuopsa kwa kuvulala.

Chithandizo cha kuvulala pachifuwa

Pafupifupi 80% ya imfa zonse zokhudzana ndi zoopsa zimachitika m'maola angapo oyambirira pambuyo pa chochitikacho.

Kupulumuka kumadalira kuyambika kwachangu kwa njira zothandizira moyo komanso zotengera ku malo ovulala.

Kuchiza msanga kwa anthu ovulala pachifuwa kumaphatikizapo kusunga mpweya wabwino, chithandizo cha okosijeni ndi FiO ya 1.0 (mwachitsanzo, ndi chigoba 'chosapumira', mpweya wa 'baluni' kapena kutumiza mpweya wothamanga kwambiri. zida) mpweya wabwino wa makina, kuika mizere yozungulira ndi yapakati (EV) yoyendetsera madzi ndi magazi, kugwiritsa ntchito kukhetsa pachifuwa, komanso mwina kusamukira ku chipinda chopangira opaleshoni (OR) kwa thoracotomy yadzidzidzi.

Kukhazikitsidwa kwa catheter ya m'mapapo ndi kothandiza pochiza odwala omwe ali ndi vuto la haemodynamics osakhazikika komanso/kapena amafunikira kulowetsedwa kwamadzimadzi ambiri kuti ma electrolyte azikhala bwino.

Chithandizo cha ululu ndi chofunikanso.

Kugwiritsiridwa ntchito kwa odwala-controlled analgesic (PCA) dispensers (monga kulowetsedwa kwadongosolo kapena thoracic epidural) kumathandizira kulolerana kwa ululu, mgwirizano wopuma kupuma, mapapu akugwira ntchito komanso kumapangitsa kuti kufunikira kwa chithandizo cha mpweya kusakhale kochepa.

Thandizo la ndege

Kutsekeka kwa ndege nthawi zambiri kumawonedwa ngati chinthu chofunikira kwambiri chomwe chimayambitsa imfa kwa odwala ovulala.

Matendawa nthawi zambiri amayamba chifukwa lilime limayenda cham'mbuyo kulowa mu oropharynx.

Kufufuza kwa kusanza, magazi, malovu, mano, ndi edema pambuyo pa kuvulala kwa oropharyngeal ndi zina zomwe zimayambitsa kutsekeka kwa mpweya.

Kuyika mutu wa wodwalayo pamalo abwino ndikuyika oropharyngeal cannula kumathandiza kuti patency ya airway ipitirire ndipo imalola kuti 100% oxygen iperekedwe ndi chigoba cha baluni.

Nthawi zambiri zadzidzidzi, njira yopangira mpweya yomwe mungasankhe ndi endotracheal cannula yoyenerera, yokhala ndi manja, yomwe imalola mpweya wabwino, imathandizira kuyamwa kwa endotracheal ndikuthandizira kuteteza mapapo kuti asakhudze zomwe zili m'mimba.

Ngati khomo lachiberekero likukayikiridwa, kuyika, pansi pa bronchoscopic control, cannula ya nasotracheal ikulimbikitsidwa, chifukwa njirayi imafuna kuwonjezereka kwa mutu.

Kuwongolera kwa kuyika kwa endotracheal cannula kungayambitse kumangidwa kwa mtima, kulumikizidwa ndi kusakwanira kwa mpweya wabwino, kulowetsedwa kwa bronchus yaikulu kapena kum'mero, kupuma kwa alkalosis yachiwiri kupita ku mpweya wabwino kwambiri, ndi / kapena vasovagal reflex.

Kuyang'anitsitsa kuyika kwa cannula moyenera ndikofunikira kuti mapapu onse alowemo.

Zowonadi, pafupifupi 30% ya odwala omwe akudutsa njira zotsitsimutsa, kulowetsedwa kwa bronchus yoyenera kumachitika.

X-ray pachifuwa ndi fibronchoscopy zimathandizira kuzindikira kuchuluka kwa magazi, komwe kumafunikira kufunidwa.

Fibreoptic bronchoscopy, kaya ndi matenda kapena achire, nthawi zambiri imakhala yothandiza kwambiri kwa odwala omwe ali ndi atelectasis yosalekeza kapena yobwerezabwereza.

Odwala kwambiri asymmetric mapapu contusions kapena tracheobronchial ruptures, amene amafuna palokha mpweya mpweya, ntchito iwiri lumen tracheal cannula kungakhale kofunikira.

Ngati endotracheal intubation kapena kuyika kwa tracheostomy cannula ndi kovuta kapena kosatheka, cricothyrotomy ikhoza kuchitidwa mpaka tracheostomy ikhoza kuchitidwa.

Ngati palibe njira zina zomwe zingatheke, kukhazikitsidwa kwa singano ya 12-gauge ndi njira ya cricothyroid ikhoza kulola, pakapita nthawi yochepa, mpweya wodutsa mpweya wabwino ndi oxygenation, poyembekezera kuyika kwa tracheostomy cannula.

Kusamalira mpweya wabwino

Odwala omwe amabwera kudzayang'ana pa kupuma kwa mpweya, pamene akulephera kupuma (kupuma kwapamwamba kuposa 35 / mphindi), kapena kulephera kupuma kwathunthu (PaO2 pansi pa 60 mmHg, PaCO2 pamwamba pa 50 mmHg, ndi pH pansi pa 7.20) amafunika thandizo la kupuma.

Magawo a chithandizo chothandizira mpweya kwa wodwala yemwe ali ndi kuvulala kwa thoracic koopsa kosadziwika bwino ayenera kukhazikitsidwa kuti apereke chithandizo chokwanira pogwiritsa ntchito mpweya wodalira mphamvu-wodalira mphamvu, ndi mafunde a 10 ml / kg, mlingo wa 15 m'mphindi / mphindi, kuchuluka kwa mpweya kuti muwonetsetse kudzoza / kutulutsa mpweya (I:E) chiŵerengero cha 1:3, ndi FiO2 ya 1.0.

Izi zitha kusinthidwa pambuyo pakuwunika bwino kwachipatala komanso zotsatira za ABG zikapezeka.

Nthawi zambiri, PEEP ya 5-15 cm Hp ndiyofunikira kuti muwonjezere kuchuluka kwa mapapo ndi oxygenation.

Komabe, kugwiritsa ntchito mpweya wabwino wa mpweya wabwino ndi PEEP kwa odwala omwe ali ndi vuto la chifuwa kumafuna kusamala kwambiri, pokhudzana ndi chiopsezo choyambitsa hypotension ndi barotrauma.

Wodwalayo akapezanso mphamvu yopuma mokhazikika bwino, yapakatikati, yolumikizira mpweya wokakamiza (IMSV), kuphatikiza ndi chithandizo champhamvu (PS), imathandizira kuyamwa kuchokera ku mpweya wabwino.

Njira yomaliza isanatuluke ndikuwunika momwe wodwalayo akupuma modzidzimutsa ndi kupanikizika kosalekeza (CPAP) pa 5 cm H2O kuti asunge mpweya wokwanira komanso kukonza makina am'mapapo.

Pazovuta, njira zambiri, zovuta zowonjezera mpweya ndi mpweya wothandizira zingagwiritsidwe ntchito.

Mumitundu yoopsa yaARDS, kugwiritsa ntchito mpweya wodalira mphamvu, wosiyana-siyana kungathandize kuti mpweya wabwino ukhale wabwino komanso mpweya wabwino komanso kuchepetsa kuthamanga kwa mpweya.

Odwala omwe amavulala kwambiri m'mapapo omwe amakhala ndi hypo-oxygenation panthawi ya mpweya wabwino, ngakhale kuti PEEP ndi 100% kutumiza mpweya wa okosijeni, akhoza kupindula ndi mpweya wodziyimira pawokha wamapapo pogwiritsa ntchito lumen ya tracheal cannula iwiri.

Mpweya wodziyimira pawokha wamapapo kapena mpweya wothamanga kwambiri wa 'jet' utha kukwaniritsa zosowa za odwala omwe ali ndi bronchopleural fistula.

Kwa akulu, extracorporeal membrane oxygenation (ECMO) mwachiwonekere sizothandiza kuposa mpweya wabwino wamakina.

ECMO ikuwoneka, kumbali ina, yabwino mwa ana.

Kamodzi kulephera kwa ziwalo zingapo pambuyo pa kuvulala kwasinthidwa, ECMO ingakhalenso yothandiza kwambiri kwa akulu.

Njira zina zothandizira kupuma

Wodwala matenda a thoracic nthawi zambiri amafuna chithandizo chamankhwala.

Kutentha kwa mpweya, ndi nthunzi wotenthedwa kapena wosatenthedwa, nthawi zambiri amachitidwa kuti athetse kutulutsa.

Ukhondo wapaulendo wapaulendo ndi wofunikiranso m'mitu yolumikizidwa kapena omwe ali ndi ntchofu.

Respiratory physiotherapy nthawi zambiri imakhala yothandiza pakulimbikitsa zobisika zomwe zimasungidwa mumlengalenga ndipo zimatha kuthandizira kukulitsanso madera a atelectasis.

Nthawi zambiri, ma bronchodilators mu mawonekedwe a aerosols amagwiritsidwa ntchito kuchepetsa kukana kwa mpweya, kuthandizira kukula kwa mapapu ndi kuchepetsa ntchito yopuma.

Mitundu iyi ya chithandizo cha kupuma kwa 'low-tech' ndi yofunika kwambiri pakuwongolera odwala omwe ali ndi vuto la thoracic.

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Medicina pa intaneti