Kana iropa rekubuda ropa rakawanda, kutonga nguva yekubuda ropa nekukurumidza vascular kunogona kuita mutsauko pakati pehupenyu nerufu rwemurwere. Mune ino chinyorwa, isu tichaudza iyo yekuItaly nyaya yekudzidza pamusoro pekushandiswa kwekutenderera uye intraosseous kupinda.

Iyo emergency emergency system 118 yeTrieste (Italy) yakafunga kugovera iyo EZ-IO® intraosseous access kifaa kune ese ALS ambulensi masevhisi enharaunda. Chinangwa ndechekushongedza ambulances kana kubuda ropa kwakanyanya uye kudzidzisa varapi vanoshanda munzvimbo yeprehospital mukutarisira hombe junctional uye lemb haemorrhages. Vakabatana ne "Stop the bleed" mushandirapamwe, wakasimudzirwa neAmerican College of Surgeon uye akaunzwa kuItaly neSocietà Italiana di Chirurgia d'Urgenza e del Trauma (Italian Society of Emergency Surgery and Trauma). Kushandiswa kwe a tourniquet uye kupinda muropa kunogona kureva shanduko yakakosha mukurapa kubuda ropa kwakaoma kudaro.

Vanyori: Andrea Clemente, Mauro Milos, Alberto Peratoner SSD 118 Trieste - Dhipatimendi reEmergency (attività integratedata di Emerenze, Urachitora Accettazione). Azienda Sanitaria Universitaria Giuliano Isontina

 

Intraosseous kupinda: Tourniquet uye rakakura kubuda ropa

Mwaka wega wega, kushungurudzika kune chekuita nehuwandu hwakakosha hwehuwandu hwekufa pasi rese. World Health Organisation yakafungidzira kuti muna 2012, vanhu vanosvika 5.1 miriyoni vakafa nekuda kwezviitiko zvinoshungurudza, zvakaita se9.2% yekufa pasi rese (huwandu hwevakafa hwakaratidzwa mumatare makumi masere nemasere pagumi zana negumi). Zvikamu makumi mashanu kubva muzana zvevakafa vaive pakati pemakore gumi nemashanu kusvika makumi mana nemasere, nekufa kwechirume zvakapetwa nekaviri chevakadzi (83).

MuItari, zviitiko zvekushungurudza zvine mhosva ye5% yehuwandu hwekufa kwegore (2). Izvo zvinoenderana nezve zviuru gumi nezvitanhatu zvekufa, izvo:

• tsaona dzemumugwagwa: zviuru zvinomwe nekufa
• tsaona dzemudzimba: kufa zviuru zvina
• tsaona pabasa: 1,300 nerufu
• zviito zvounyengeri / kana kuzvikuvadza: zviuru zvishanu zvekufa

Mazhinji anokonzerwa nekubvumirwa kuchipatara kweanopfuura mamirioni, akaenzana nechero gumi muzana yezvekuripirwa pagore (1).

Haemorrhagic kuvhundutsa ndiyo yechipiri inotungamira chikonzero cherufu mushure mekukuvadzwa kwemukati wemasisitimu system, zvisinei nechimiro zvekushungurudzika. Haemorrhage inoshanda 30-40% yevanorwara nezvedambudziko rekufa uye 33-56% inoitika mukubuda-mu-chipatara kurongedzwa (4).

Kuti ive inoshanda zvakanyanya sezvinobvira, kurapwa kwemhedzisiro kunofanirwa kupihwa nekukurumidza mushure mekukuvara kwaitika. Kubuda ropa kukuru kunogona kukurumidza kuendesa kune inonzi "kuvhunduka kwerufu" kana "lethal triad": hypothermia, coagulopathy uye metabolic acidosis.

Kubuda ropa kukuru kunoderedza oxygen uye kunogona kukonzeresa hypothermia nekuenderana kunochinja kweiyo coagulation Cascade. Mukushayikwa kweokisijeni uye zvinovaka muviri zvinowanzofambiswa neropa (hypoperfusion), masero anotendeukira kune anaerobic metabolism, ichikonzera kubudiswa kwe lactic acid, miviri ye ketone uye zvimwe zvikamu zveasic acid izvo zvinoderedza pH yeropa zvichikonzera metabolic acidosis. Kuwedzera acidity kunokuvadza tishu uye nhengo mumuviri uye kunogona kuderedza myocardial mashandiro nekuwedzera kukanganisa okisijeni kufambisa.

 

Tourniquet uye intraosseous kupinda: hupenyu hunoponesa hupenyu

Kubva pamhirizhonga muIraq neAfghanistan, tadzidza kuti iko kushandisa kweyekufamba kweanoshanyira mabhenji akakosha pakubata kwehupenyu. Nzira inoshanda kwazvo yekupindura, yakadzidzwa zvakanyanya neUS Army's Committee on Tactical Combat Casualty Care (C-TCCC). Kuitwa kwezvibodzwa zveTCCC zvakakonzera kudzikiswa kwakanyanya muhuwandu hwekufa kwehemorrheage kufa (5).

Nekuda kwechiitiko chakadzama chakavakirwa padanho remauto, nzira idzi dzekurapwa dzakatangawo kupararira munzvimbo yemagariro, pamusoro pezvose, zvichitevera kurwiswa kwehugandanga kwakadai seiko kwakaitika panguva yeBoston Marathon muna 2013 (6).

Zviito zvinokurumidza kuponesa hupenyu kuitira kudzora kweanoburwa nevatangi vekutanga vanopindura, vanosanganisirwa, zvinogona kureva chinhu chakakosha mukuderedzwa kwerufu runogona kudzivirirwa (7). MuUnited States, imwe yemazano yakaratidza kushanda kwayo mukuderedza kufa kwemweya kukuru kwave kwekushandisa vese vashandi vehutano uye vekutanga kupindura. firefighters) ine haemorrhage control machira uye kudzidziswa (8).

Mune yakajairwa uye yezuva nezuva emergency emergency services, iyo yekumanikidza bandage inoshandiswa muhombe yekurapa kazhinji haina kukwana. Izvo zvinoshanda chete kana kutungamirwa chaiko kwemaitiro kunoitwa, izvo zvisingagone kuvimbiswa muchiitiko chekukuvara kwakawanda kana maxi emergency (5).

Ndicho chikonzero masangano mazhinji ekukurumidzira anoshandisa tourniquet. Iyo ine chinangwa chimwe chete: kudzivirira hemorrhagic kuvhunduka uye kubuda kwakakura kubuda muchiuno. Izvo zvakave zvichitsanangurwa nesainzi kuti kushandiswa kwayo pasina mubvunzo kunoponesa hupenyu. Varwere vanosangana neanoshungurudza hypovolemic kuvhundutsika vane huwandu hwakanyanya hwepadhuosis ine mashoma ekupukunyuka. Unganidzo yakaunganidzwa munhandare yemauto yakaratidza kuti vanhu vakakuvara vakaiswa pamberi pavo hypovolemic kuvhiringidza vane 90% yakaenzaniswa, zvichienzaniswa ne20% pakashandiswa mucherechedzo mushure mechiratidzo chekutanga chekuvhunduka (9).

Kushandisa kwekutanga kwetemboni kunoderedza kukosha kwekudzidziswa kweiyo volemic pamwe nekrisryloids munzvimbo inowedzera-chipatara (haemodilution, hypothermia) uye hemoderivatives munzvimbo yechipatara (coagulopathies), kudzivirira kuwedzera kuwedzera zvinhu zvinosanganiswa neanouraya triad (10).

Munguva yekurwisana kweVietnam, 9% yekufa yakakonzerwa nekubuda ropa. Mumhirizhonga yanhasi, yakaderedzwa kusvika ku2% nekuda kwekudzidziswa pakushandiswa kwemutambo wekuratidzira uye kuwanikwa kwakapararira. Chiverengero chekupona pakati pemasoja akabatwa neyemutambo wevanoratidzwa vs. iwo mauri chisina kuiswa ndeye 87% vs. 0% (9). Kuongororwa kwe6 nyika dzepasirose ongororo dzakaratidza huwandu hwe19% yemakumbo akabatanidzwa.

Kuchekwa uku kungave kwakakonzerwa nehukuru hwekukuvara kwepakati uye husina kutsanangurwa sedambudziko repakati pakushandiswa kwemitambo (11). Muzvidzidzo zviviri zvikuru zvemauto, zvakaonekwa kuti huwandu hwematambudziko nekuda kwekushandiswa kwemitambo yakatorwa kubva pa0.2% (12) kusvika 1.7% (9). Zvimwe zvidzidzo zvakaratidza kusavapo kwekutenderera kwemakomboni akasara munzvimbo pakati pemazana matatu kusvika mana maawa (3).

Isu tinofanirwa kufunga nezve maawa matanhatu semuganho wakanyanya wekupukunyuka kwemakumbo (6). Mushandirapamwe wekuti "Stop the Bleed" wakasimudzirwa muUS neboka rinoshanda pakati pemasangano akasiyana siyana akaunganidzwa neDhipatimendi reHomeland Security ye "National Security Councill Staff" yeWhite House, nechinangwa chekuvaka hushingi pakati pehuwandu nekuwedzera. kuzivikanwa kwezviito zvakakosha zvekumisa kubuda ropa kunokanganisa kunokonzerwa nezviitiko zvetsaona zveupenyu hwezuva nezuva uye nezviitiko zvinoshata zvechisikirwo kana kwehugandanga.

"Dare reTrauma" reAmerican College of Surgeons uye Hartford Consensus ndomumwe wevanonyanya kukurudzira chirongwa ichi. Kubuda ropa kusingadzoreki kunoonekwa sekukonzera kufa kwekudzivirirwa nenjodzi, nepo yakakosha yekupindira panguva kwayo ndeyekushandiswa kwevakatarisa sevachangotanga kupindura kubata kubuda ropa kukuru kusvika pakusvika kwehunyanzvi hwekununura, mushure mekuziva kuti kupindira kuri kushanda mukati meiyo yekutanga5. -10 maminitsi.

Varapi ve118esteste system vakatora chikamu che “Stop the Bleed” kosi, yakaunzwa muItari neiyo Società Italiana di Chirurgia d'Urichita e del Trauma. Chinangwa ndechekuimisa maitiro pakushandiswa kwayo chaiko kwemutambo wemitambo, parizvino uripo pamatunhu ese ekuProvince mota dzinonunura.

 

Nezve tourniquet uye intraosseous kupinda

Mune yepamberi chipatara kurongedzwa, zvinowanzove zvakakosha kuve nekukurumidza kuona vascular, asi chinzvimbo chinowanzo dambudziko (16,17). Peripheral venous kupinda inoramba iri yakajairwa, asi kana mabasa akakosha akaiswa mukati, kudzoreredza kwacho kungave kwakaoma kana kunogona kutora nguva yakareba.

Zvinhu zvemunharaunda zvakaita sekusashanda mwenje, kushoma nzvimbo, kunetseka murwere kana zvekurapa zvinhu zvakadai seipheral vasoconstriction mukushamisika kana varwere vane hypothermic, varombo venous venous estate nekuda kwekukonzeresa kurapwa kana kufutisa kunogona kukanganisa kuwana peipheral venous.

Vakabatwa nekushungurudzika vane simba rakawedzerwa, kusungwa kwemwoyo kana sepsis inogona kuda kukurumidza kuwana kwemaseru.
Mune varwere vevana, kuwana vascular kupinda kunogona kuve kwakaoma tekinoroji (18). Chiyero chekubudirira mukumira paripheral venous yekuwana pakutanga kwekuchipatara ndeye 74% (19.20) uye yakaderedzwa kusvika pasi pe50% kana ikasungwa nemwoyo (20). Varwere mune hemorrhagic kuvhiringidza kunoda, paavhareji, maminetsi makumi maviri kuwana peripheral venous kupinda (20).

Tourniquet uye intraosseous yekuwana: iyo inoshanda imwe nzira yekupinda venous yekupinda ndeye kupinda mukati memukati: inowanikwa nekukurumidza kupfuura yeperipheral vein kudzosa (50±9 s vs 70±30 s) (22). Muchipatara chemukati mevarwere veACR vane tsinga dzisingawanikwe, kupinda mukati kwakaratidza kubudirira kwepamusoro munguva shoma kupfuura. CVC kuiswa (85% vs 60%; 2 min vs 8 min) (23), uyezve nzira yacho haidi kukanganiswa kwechipfuva uye nekudaro inogona kuvandudza hupenyu hwemurwere (24).

European Resuscitation Council inokurudzirawo kupinda kwemukati senzira inoshanda mune imwe nyaya kana ikatadza kuwana mutsipa wechipfuva mumurwere mukuru (25) uye sesarudzo yekutanga murwere wepwere (26).
Kubva muna Kubvumbi 2019, iyo EZ-IO® Intraosseous Access System yakaitwa inoshanda pane ese ASUITS 118 Yepamberi Rescue Ambulances mushure mekudzidziswa kwevanamukoti uye kuparadzira maitiro ekushandisa, yaingove yega nzira yekuzvirapa yega yaive nemushonga.

Iko kusanganisa kweanodzora kune ma ambulensi ese kunoita kuti ive nekukurumidza kuvimbisa kupinda kwemassage, kuderedza nguva dzekurapwa uye kuwedzera humhando yemasevhisi kune vagari. Ongororo dzinoverengeka dzakaratidza kuti EZ-IO ® inoshanda intra-osseous nzira yekudzoreredza system: uwandu hwebudiriro hwese hwakanyanya (99.6% 27; 98.8% 28; 90% 29) pamwe nehuwandu hwebudiriro pakuedza kwekutanga ( 85.9% 27; 94% 28; 85% 23) uye inozivikanwa nekukurumidza kudzidza kudzidza Curve (29). Intraosseous kupinda kwakaenzana nekutsanangurwa kwehunyorwa hwepamberi maererano neachemacokinetics uye kliniki zvinobudirira (30) uye chikamu chekupindirana chakaderera kupfuura 1% (24).

Nezve intraosseous kupinda uye kushandiswa kwevanoona, kesi mushumo

Nyaya yacho:

6.35 pm: iyo 118 Trieste system yakagadziriswa neFVG Regional Emergency Medical Operation Kamuri kupindura kune inotambudza yero kodhi kumba.

6.44 pm: ambulensi yakasvika panzvimbo uye vashandi vaiperekedzwa nehama dzemurwere muimba yekugezera. Mukadzi ane makore makumi manomwe ekufuta, akagara pachimbuzi uye afenda (GCS 7 E 1 V2 M 4). Kufema kufema, kucheneruka, diaphoretic, kusinga nzwisisike carotid pulse, capillary refill time > 4 seconds. Ropa guru rinotsvedza patsoka dzemurwere; maronda etsinga aionekwa munhengo dzezasi uye tauro, rakanyikwawo muropa, rakanga rakaputirwa nemhuru yakarurama.

6.46 pm: red code. Mishonga yekuzvirapa yakakumbirwa uye vaifanira kufonera moto wekubatsirwa kuti ubatsire kutakura kwemurwere, vachifunga nezve huremu hwake nenzvimbo yakakwana. Iyo thaulo payakabviswa, mutsipa kubva pamubvuri wekuputika mutsipa wakaonekwa mu ulcuscruris, iri munzvimbo yekumeri kwemhuru.

Izvo zvaive zvisingagone kuvimbisa inoshanda yakananga kudzvinyirira uye kupa munhu anoshandira chinangwa ichi. Saka, ivo vakakurumidza kuisa iyo Combat Application Tourniquet (CAT), kumisa kubuda ropa. Mushure meizvozvo, hapana imwe hemorrhagic miromo yakaonekwa.

Musoro wacho waive wakakwirisa uye uchiisa O2 ne100% FiO2 nekutsakatika kwemweya wekufema.
Tichifunga iyo mamiriro ekuvhunduka uye kufutisa, zvaive zvisingagone kuwana peripheral venous kupinda, saka, mushure mekutanga kuedza, intraosseous kupinda yakaiswa mukamuri yekurudyi humeral kamuri ne EZ-IO® system ine sindiso ye45mm.

Kumiswa kwakakodzera kwekusvikira kwakasimbiswa: tsono kugadzikana, serous yeropa kusuwa uye kusheedzera kwekukanganisa iyo 10 ml SF push. Physiological Solution 500 ml infusion nebhegi kufuridzira yakatanga uye gumbo rakabatikana nemamella. Kana ECG yekutarisirwa yakaiswa, makumi maviri neshanu HR, PA uye SpO80 yaisaonekwa.

Kupfeka kwakasimba kwechiremba kunoiswa ipapo panobuda ropa. Yekukurumidza yekunongedza anomnestic yakaratidza kuti murwere airwara ne hyperthyroidism, arterial hypertension, dyslipidemia, OSAS muusiku wenyaya CPAP, atrial fibrillation muTaO. Iye akateverwawo nePurasitiki Kuvhiya uye Utachiona Zvirwere zvemazamu emakumbo maronda ane dermohypodermite naMRSA, P. Mirabilis naP. Aeruginosa uye mukurapa tapazole 5mg maawa masere, bisoprolol 8mg h 1.25, diltiazem 8mg maawa masere ega ega, coumadin zvinoenderana INR.

6.55 pm; iyo automedicator yakasvika panzvimbo. Murwere akaunzwa neGCS 9 (E 2, V 2, M 5), FC 80r, PA 75/40, SpO2 98% ine FiO2 100%. 1000mg EV tranexamic acid yakaiswa. Nerubatsiro rweFire Brigade, murwere akaunganidzwa aine cheya uyezve pane yakatambanudzwa.

Mune ambulensi, murwere akaunzwa neGCS 13 (E 3, V 4, M 6), PA 105/80, FC 80r uye SpO2 98% ine FiO2 100%. Iyo yekurudyi yemukati yekushongedza kwemukati yakawanikwa yakaparara panguva yekufambisa, saka imwezve kupinda mukati kwakakurumidza kuiswa muchigaro chekuruboshwe chekunyorova uye kulowerwa kwemvura kwakapfuurira.

Zvichipa kuvandudzwa kwemaitiro anokosha, analgesic therapy yakaitwa nefentanest 0.1mg uye yakazara 500ml yesaline uye 200ml yeringeracetate yakasimwa. Na7.25 pm amburenzi, nachiremba akabatidza bhodhi, yakasiiwa mukodhi tsvuku kuCattinara Emergency Room.

Kuvhiya, dhipatimendi rekuvandudza uye bhangi reropa rakanyeverwa. Ambulensi yakasvika muPS na7.30 pm
Chiyero chekutanga cheropa chakaratidza: hemoglobin 5 g / dL, masero matsvuku eropa 2.27 x 103µL, hematocrit 16.8%, nepo pakudzimba: INR 3.55, masekondi makumi mana neshanu, Ratio 42.3. Murwere akagamuchirwa kumishonga yekukurumidzira uye akavhenekwa hemotransfusions kwe3.74 zvikamu zve7 zveakakomberedzwa hematocrits uye mabhakitiriya kutenderera ane dalbavancin uye cefepime.

 

Tourniquet, yakakura kubuda ropa uye kupinda mukati: VERENGA IYO ZVINYENGA ZVESE

 

VERENGA ZVIMWE

Tourniquet: Misa kubuda ropa mushure mekurira pfuti

Kubvunzana neAURIEX - Tactical kurapwa yekubuda, kudzidziswa uye kuwanda kwekubuda ropa

Turino kana kuti kwete? Nyanzvi mbiri orthopedics dzinotaura pane iyo yakazara knee kutsiva

Tactical Field Care: Vatori vemagetsi vanofanira kuchengetedzwa sei kutarisana nemunda wehondo?

 

Tourniquet, yakakura kubuda ropa uye intraosseous kupinda BIBLIOGRAPHY

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