Nthawi zina ndi bwino kudabwa ngati zinthu zomwe timamva, zomwe timawona komanso kumva zili monga momwe timaganizira. Dr Alan Garner amayang'ana mphamvu zanu mukalowa m'chifuwa ndikudabwa ngati zonse zili zolunjika monga momwe timaganizira?

Tiyeni tiyambire positiyi ponena kuti izi ndi za mabala pachifuwa. Ngati sizomwe mumaganiza ndiye nthawi yoyang'ana kwina.

Chimene ndikufuna kukambirana ndi matenda a matenda a pneumothorax m'munda. Chifukwa cha zokambiranazi ndikuti ndikukhulupirira kuti ndizovuta kwambiri. Pamene ndinkagwira ntchito ku UK zaka 6 zapitazo zinkawoneka kuti zovutazo zinkapezeka kawirikawiri ndipo chifukwa chomwe chinaperekedwa chinali phokoso pamene ankaphwanya pleura ndi forceps. Pamene wodwalayo anali ndi mpweya wabwino panthawiyo ndiye kuti phokoso liyenera kuti linali mpweya wothamanga kuchokera ku pleural space chifukwa mphamvu yawo ya intrathoracic inali yabwino panthawi yonse ya kupuma?

Kumbukirani momwe sitingadalire phokoso lomwe likukhudzidwa ndi kafukufuku wachipatala mu malo a prehospital chifukwa ndi osadalirika kwambiri? Chabwino ndimawuzidwa kuti uyu anali wolondola nthawi zonse. 'Nthawi zonse' ndi mawu aakulu mu mankhwala

Ndikudziwanso nthawi imodzi yomwe wodwala yemwe adawomberedwa ndi mfuti m'dera la epigastric kuchokera pachida chochepa kwambiri adalowa m'matumbo kenako ndi chala chapakati pa awiri. Ndemanga panthaŵiyo inali yakuti dokotala wa prehospital, yemwe mosakayikira adalowa mu zonsezo mwachikhulupiriro, adanena kuti pa nthawi ya thoracostomies anapeza pneumothorax kumbali imodzi ndi kupsinjika maganizo kumbali inayo.

Koma pojambula ndi opaleshoni, projectileyo inabwereranso mu kapamba ndipo palibe pafupi ndi hemithorax kapena diaphragm. Zowonadi kuvulala kokha komwe kumadziwika ku mbali iliyonse ya chifuwa kunali mabala a thoracostomy okha. Apanso wodwala wolowetsedwa kotero kuti intrathoracic pressure iyenera kuti inali yabwino? Ngati mapapo akumva pansi ndiye ayenera kukhala pneumothorax? Ndipo ngati panali phokoso pakuphwanya pleura kuyenera kuti kunali kovutirapo?

Mwachionekere munkhani yachiwiri zizindikiro zinali zosocheretsa ndiye chikuchitika ndi chani apa? Tiyeni tiyike pambali kwachiwiri zovuta za matenda oyambirira a pneumothorax ndikuyang'ana pa kumverera ndi chala ndi phokoso m'makutu. Kodi zikhoza kukhala kuti umboni wina umene takhala tikuukhulupirira umatiuza kuti tikulimbana ndi pneumothorax ukhoza kusokeretsa asing'anga odziwa bwino ntchito, ophunzitsidwa bwino?

Kulowerera

Mwina ndachitapo zochotsa pachifuwa zingapo kuposa zambiri. Mwa zina izi ndi chifukwa cha zaka zoposa 20 mu prehospital danga koma ine mwina anachita kwambiri pamene ndinali kaundula 25 chaka chapitacho. Ndinakhala miyezi isanu ndi umodzi ndikugwira ntchito kwa madokotala angapo opuma ndipo ndinayika madzi ambiri (makamaka chifukwa cha kuphulika koopsa) kwa odwala omwe analibe pneumothorax ndisanayambe. Zinali zachilendo kumva phokoso pamene pleura inaphwanyidwa pamene mpweya umalowa mkati.

Mwachiwonekere tiyenera kubwereranso ku physiology kuti tiwone chomwe chikuyendetsa kayendetsedwe ka mpweya kaya kulowa kapena kutuluka mu dzenje lomwe tapanga kuti tidziwe ngati phokoso lomwe tikumva ndi mpweya ukupita, kapena mpweya ukutuluka.

Bwererani ku Zowona

Kuthamanga kwa Transpulmonary ndiko kutsika kwamphamvu komwe kumayendetsa mpweya wabwino. Ndi kusiyana pakati pa kuthamanga kwa alveolar ndi Kuthamanga kwa intrapleural mu mapapo.

P_tp =P_alv - P_ip. Kumeneko P_tp ndi transpulmonary pressure, P_alv ndi alveolar pressure, ndi P_ip ndi intrapleural pressure.

(Ngati mungafune zochulukira pa izi Moyo wabwino kwambiri mu Fast Lane uli ndi kupsinjika kwa transpulmonary Pano.)

Komanso zikuwonekeratu kuti mutha kupeza chithunzithunzi cha google cha buku lakale la John West pa kupuma kwa thupi. Tengani kamphindi kuti mukasangalale Chithunzi 4-9 patsamba 59. 

Mutha kuwona kuchokera pagulu B (ndinatanthauza, pitani mukawone) kuti kuthamanga kwa m'mitsempha kumasiyana pakati pa -5 ndi -8 cmH.₂O pakatikati pa m'mapapo panthawi yopuma. Nthawi zonse imakhala yoipa ndipo izi zimachitika chifukwa cha kuchepa kwa mapapu komwe kumatsutsidwa ndi khoma la pachifuwa. Simayipa kwambiri kumadera omwe amadalira m'mapapo (kuchepetsa kukula kwa alveolar) komanso kupitilira apo (kuchuluka kwa alveolar).

Tiyeni Tiwonjezere Mpweya

Pamalo a pneumothorax yaing'ono mpweya mu pleural danga umapangitsa kuti kupanikizika kwa intrapleural kusakhale koipa ndipo kusiyana kwa kuthamanga kwa mpweya wabwino kumachepetsedwa. Ngati pneumothorax imatsegulidwa kwathunthu kumlengalenga monga ndi bala lotseguka la thoracostomy kuthamanga kwa intrapleural ndi kofanana ndi kuthamanga kwa mlengalenga, kutsekemera kwa mapapu kumapangitsa kugwa kwathunthu ndipo mpweya wabwino ndi chifuwa chachikulu sichingatheke - kuthamanga kwa mpweya wabwino kuyenera kugwiritsidwa ntchito.

Sikuti ndi vuto la pneumothorax lomwe limandidetsa nkhawa kwambiri. Ngati ali ndi hypoxic kapena hypotensive ndipo wodwalayo ali ndi pneumothorax chifuwa chiyenera kuchepetsedwa - palibe-brainer wathunthu. Funso ndilakuti chifukwa chiyani asing'anga abwino akuchepetsa zifuwa zabwinobwino ndikuganiza kuti panali pneumothorax kapena kupsinjika pomwe kunalibe? Kodi physiology imatifikitsa kumeneko?

Wodwala Mmodzi

Choyamba tiyeni tiganizire za wodwala yemwe sakhala ndi intubated ndi kupuma kwanthawi zonse komanso wopanda pneumothorax. Umu ndi momwe zinalili ndi odwala omwe anali ndi zotupa zowopsa zomwe ndimayika ngalande zaka zapitazo. Apa kuthamanga kwa alveolar sikuposa cmH₂O kapena ziwiri zabwino kapena zoipa. Kuthamanga kwa intrapleural komabe ndi -5 mpaka -8 cmH₂O. Chifukwa chake zilibe kanthu kuti mwaphwanya gawo la kupuma kwa pleura, kuthamanga kwapakati pakati pa pleural space ndi mlengalenga kumakhala koyipa ndipo mpweya umalowa mwachangu.

The gradient ndi yaikulu mu kudzoza pamene alveolar kuthamanga ndi zoipa (ndipo chifukwa chake kuthamanga kwathunthu kuli pafupi -8 cmH₂O) komanso kutsika koyipa pakatha nthawi yomwe ili ngati -5 cmH₂O. Komabe nthawi zonse zimakhala zoipa. Ziribe kanthu kuti ndi gawo liti la kupuma komwe mumaphwanya pleura, mpweya umalowa mu pleural space ndipo kupuma kwapapo kumayendetsa kugwa. Mukamva phokoso monga momwe ndimachitira nthawi zambiri, mpweya ukulowa mkati, bala la pachifuwa choyamwa. Ndi iatrogenic.

Wodwala Wachiwiri

Sindikuganiza kuti aliyense angakhale ndi vuto ndi zinthu mpaka pano. Choncho tiyeni tipitirire kwa wodwala intubated yemwe alibe pneumothorax. Ndikuganiza pano kuti palibe kukana kwapanjira kwa wodwala wathu wovulalayo (zomwe sizikutanthauza kuti alibe matenda oletsa m'mapapo, anaphylaxis kumankhwala olowetsa omwe mudapereka kapena kutsekeka komwe kumakhala mu bronchus yayikulu. /ETT) chifukwa zimapangitsa kukambirana kukhala kosavuta kuganiza kuti kukana ndikochepa (kopanda phindu malinga ndi Daleks) ndipo kupanikizika komwe mukuwona pamagetsi anu olowera mpweya kumaperekedwa makamaka ku alveoli.

Kuyang'ana kuthamanga kwathu kwa transpulmonary equation, pokhapokha ngati kuthamanga kwa mpweya ndi chifukwa chake kupanikizika kwa alveolar ndikokwera kuposa 5 cmH.₂O ndiye gradient pa nthawi inu kutsegula pleura zikutanthauza mpweya kupita Lowani pleural cavity. (Ngati ali ndi kukana kwambiri panjira yapamsewu, izi zitha kuchitika ndi ziwopsezo zokwera kwambiri).

Ingokhalani ndi diso lachangu lanthawi ino lamphamvu ya voliyumu yoyenda panjinga yopanda PEEP (ndipo chikwama chodzipumira chokha chimapereka njira yofananira ngakhale yosinthika). Ndipo dala ndilibe PEEP mu tchatichi. PEEP sichingakhale chinthu choyamba chomwe timafikira kwa wodwala hypotensive trauma yomwe tangolowetsa kumene tikukhudzidwa ndi kuthekera kwa pneumothorax.

Ndi mapapu abwinobwino, kuthamanga kwapamwamba kwambiri apa kumakhala pafupifupi 20 cmH₂O. Ndi gawo lotani la kupuma kwathunthu ndi kuthamanga kwa mpweya (ndicho chifukwa chake kuthamanga kwa alveolar mwa odwala athu omwe ali ndi vuto lochepa la mpweya) ayenera kukhala pansi pa 5 cmH₂O? Ngati mpweya wanu wa prehospital uli ndi chiŵerengero cha 1: 2 I: E monga momwe ambiri amachitira, ndiye yankho ndilo lalikulu.

Mwanjira ina pokhapokha mutakhala ndi PEEP osachepera 5 cmH₂O ngakhale mu wodwala wanu intubated kuthamanga transpulmonary ndi zoipa kwa theka labwino la kupuma mkombero. Pafupifupi theka la kupuma, ngati mukumva phokoso pamene mukuswa pleura mukumva kuthamanga kwa mpweya. MU.

Kupumira kwa mapapu ndi chifukwa chomwe mumamva kuti mapapo akomoka panthawi yomwe mumakoka zikwama ndikulowetsa chala chanu pokhapokha ngati muli ndi PEEP.

Tsopano sindikunena kuti sipanakhalepo nthawi yomwe mpweya sunali kuthamangira mkati. Sindikuganiza zambiri za mawu oti "nthawizonse" muzamankhwala, mukukumbukira? Ndikungotanthauza kuti zomwe tikudziwa za physiology zingatsutse kuti pali gawo lolimba la nthawi yomwe kupanikizika kwa transpulmonary kumakhala koyipa mukaphwanya pleura, zomwe zikutanthauza kuti pangakhale gawo labwino la milandu yomwe zizindikiro "zina" zachipatala zimakhala zodalirika.

Kuti muwonetsetse izi ndi amayi a thoracotomies otseguka (mu cadaver) onani kanema iyi.

Mphepoyo imalowetsedwa, bala "lowolowa manja" la pleural decompression lapangidwa, ndipo pakatha nthawi iliyonse mapapo amagwera pansi pokhapokha ngati PEEP itayikidwa. Ndipo dziwani kuti kugwa kwatha pakutha kulikonse.

Malingana ngati thoracostomy ndi yaikulu yokwanira kulankhulana momasuka ndi mpweya (ndipo ngati mukudalira njira yotseguka ya "chala" m'malo moyika kukhetsa iyenera kukhala yaikulu kapena ikhoza kuyambiranso), mukayika chala mkati ikatha mapapu ake amakomoka pokhapokha ngati pali kuchuluka kwazinthu zogawanika za PEEP zotseguka mochititsa chidwi.

Idzagwetsedwa kaya inali kale musanapange bala kapena ngati izo zinachitika pamene mukufalitsa mphamvu ndi kupanga dzenje loyankhulirana. Nthawi pakati pa kupanga dzenje ndikupeza mphamvu ya mapapu mmwamba kapena mapapu pansi ndi chala ndi nthawi yokwanira kuti mapapo agwe pansi. Zikuwoneka ngati chizindikiro chachipatalachi mwina sichikuwuzani chilichonse chokhudza momwe masewerawa amachitira chilonda chisanapangidwe.

Kotero phokoso likhoza kukhala lachinyengo ndipo kumva mapapu akugwa zimangotanthauza kuti mapapu abwerera pamene pleura inatsegulidwa. Kodi mungatsimikize kuti ndi gawo liti la kupuma komwe wodwala analimo mutapanga dzenjelo? Pokhapokha mutakhala ndi 5 cmH₂O (ndipo mwinanso zambiri) PEEP pa nthawi yomwe mudaphwanya pleura kapena zizindikiro izi sizikutanthauza kalikonse.

Tsopano, chiyani?

Apanso, sindine kwenikweni kunena zinthu ngati "nthawizonse" kapena "sichoncho". Zomwe ndikupangira ndikuti pakhoza kukhala zotuwira zambiri kuzungulira zizindikiro zachipatalazi kuposa momwe zingawonekere poyamba.

Ndiye mungadziwe bwanji ngati anali ndi pneumothorax? Kwa ine pafupifupi nthawi zonse ndi ultrasound tsopano. Sindikudziwa kuti ndidakwanitsa bwanji zaka 15 mwazaka 20+ za chisamaliro chachipatala popanda wina. Nthawi zina ndithudi jambulani ndi equivocal ndipo muyenera kuyimba foni potengera zizindikiro mukuona ndi mmene wodwalayo koma ndikupeza kuti ndi infrequent kwambiri ndi wabwino mkulu pafupipafupi liniya kafukufuku.

Ndipo kupsinjika maganizo chizindikiro chake ndi matenda achilendo, makamaka kuthamanga kwa magazi. Ngati decompressing pachifuwa amakonza physiology ndiye anali ndi mavuto. Ngati sichoncho ndiye kuti anali ndi pneumothorax yosavuta - kapena alibe konse. Chifukwa phokoso limene munamva pamene mukuswa pleura likhoza kukhala mpweya wolowa kapena kutuluka m'nyumba, kumva phokoso sikukuthandizani. Kodi Elvis adakhalapo mnyumbamo?

Ndemanga:

Ndinali ndi Dr Blair Munford wanzeru kuwunikiranso mulu wa physiology apa kuti muwonetsetse kuti zikugwirizana.

Pambuyo kugwirizana kwa LITFL pang'ono pa transpulmonary pressure kachiwiri? Kenako pitani kumanja Pano.

Ndipo mbambande ya John West (chabwino tsamba lomwe latchulidwa) ndi Pano.

Chifaniziro chimenecho cha Nahni chokhala ndi makutu akulu chinayikidwa ku Creative Commons gawo la flickr lolemba Allan Henderson ndipo silinasinthidwe apa.

O, ndipo ngati simunamudziwe John West wodabwitsa, mnyamata wa Adelaide wopangidwa bwino, walemba nkhani yake yonse kuti mupite kukawonera. Chifukwa mukakhala muzaka zanu za 80 mwina mukhala mukuthandizira nawo maphunziro azachipatala monga choncho, sichoncho?

Werengani Ndiponso:

Tracheal Intubation: Liti, Motani Ndipo Chifukwa Chomwe Mungapangire Ndege Yoyeserera Kwa Wodwala

Kodi Transient Tachypnoea Ya Mwana Wakhanda, Kapena Neonatal Wet Lung Syndrome Ndi Chiyani?

Source:

Care Flight Collettive