Kwimeko yokopha okukhulu, ukulawulwa kwegazi kwangethuba kunye nokufikelela ngokukhawuleza kwemithambo kunokwenza umahluko phakathi kobomi nokufa kwesigulana. Kule nqaku, siza kunika ingxelo yophando lwase-Italiyane ngokusetyenziswa kohambo kunye nofikeleleko lwangaphakathi.

Inkqubo yokhathalelo olungxamisekileyo i-118 yaseTrieste (e-Itali) igqibe kwelokuba inike i-EZ-IO® isixhobo sokufikelela ngaphakathi kuzo zonke iinkonzo ze-ALS zeendawo zezigulana. Injongo kukuxhobisa ii-ambulensi kwimeko yokopha kakhulu kunye nokuqeqesha oogqirha abasebenza kwi-prehospital setting kulawulo lwe-junctional enkulu kunye nokopha kwemilenze. Baye bajoyina iphulo elithi "Yeka ukopha", elikhuthazwa yiKholeji yaseMelika yoGqirha kwaye ingeniswe e-Italiya yi-Società Italiana di Chirurgia d'Urgenza e del Trauma (uMbutho wase-Italian woTyando oluNgxamisekileyo kunye noLothuko). Ukusetyenziswa kwe-a i-tourniquet kunye nokufikelela kwi-intraosseous kungathetha utshintsho olubalulekileyo ekunyangeni ukopha okuntsonkothileyo.

Ababhali: Andrea Clemente, Mauro Milos, Alberto Peratoner SSD 118 Trieste - iSebe likaNgxamiseko (attività integratedata di Emerenze, Urachit ed Accettazione). I-Azienda Sanitaria Universitaria Giuliano Isontina

 

Ukufikelela kwangaphakathi: Ukhenketho kunye nokopha okukhulu

Rhoqo ngonyaka, umothuko uxanduva lokufumana ipesenti ebalulekileyo yokufa kwabantu kwihlabathi liphela. Umbutho wezeMpilo welizwe uqikele ukuba ngonyaka ka-2012, abantu abazizigidi ezi-5.1 basweleka ngenxa yezehlo ezimbi, ezifana ne-9.2% yokufa kwabantu kwihlabathi (izinga lokufa liqinisekisiwe kumatyala ayi-83 kubantu abayi-100,000). Iipesenti ezingama-50 zokusweleka zaziphakathi kweminyaka eli-15 nama-44 ubudala, ngenqanaba lokubhubha kwamadoda kabini kunabafazi (1).

E-Itali, izigulo ezenzakalisayo zinoxanduva lwe-5% yokufa ngonyaka (2). Ihambelana nokufa kwabantu abayi-18,000, kubo:

• iingozi zendlela: ukusweleka abangama-7,000
• iingozi zasekhaya: Ukusweleka abangama-4,000
• iingozi emsebenzini: I-1,300 yokusweleka
• Izenzo zobunyulu / okanye ukuzenzakalisa: Ukusweleka kwabantu abangama-5,000

Uninzi lubangelwa kukungeniswa kwesibhedlele ngaphezulu kwesigidi, esilingana neepesenti ezili-1 zokwamkelwa konyaka (10).

Isothuso se-Haemorrhagic sesibini esikhokelela ekufeni emva kokulimala kwenkqubo ye-nerve yangaphakathi, ngaphandle komatshini umvandedwa. Haemorrhage inoxanduva lwe-30- 40% yokusweleka kwengozi kwaye i-33-56% yenzeka kwindawo yokuphuma kwesibhedlele (4).

Ukuze isebenze ngokusemandleni, unyango lwe-haemorrhage kufuneka lubonelelwe ngokukhawuleza emva komonakalo. Ukopha okukhulu kunokukhokelela ngokukhawuleza kwinto ebizwa ngokuba "trauma triad of die" okanye "lethal triad": hypothermia, coagulopathy kunye ne-metabolic acidosis.

Ukopha okukhulu kunciphisa ukuthuthwa kweoksijini kwaye kunokubangela i-hypothermia ngokutshintshana komdlalo we-coagulation. Kwimeko yokungabikho kweoksijini kunye nezakhamzimba ezihanjiswa ligazi (hypoperfusion), iiseli zitshintshela kwi-anaerobic metabolism, zibangela ukukhutshwa kwe-lactic acid, imizimba ye-ketone kunye nezinye izinto ze-acid ezihlisa i-pH yegazi ebangela i-metabolic acidosis. Ukonyuka kwe-acidity konakalisa izicubu emzimbeni kunye nezitho ezinokuthi zinciphise ukusebenza kwe-myocardial ngokuthomalalisa ukuhambisa ioksijini.

 

Ukhenketho kunye nokufikelela ngaphakathi: amandla okusindisa ubomi

Ukusuka kwiingxabano e-Iraq nase-Afghanistan, sifunde ukuba ukusetyenziswa kwangoko kwe-tourniquet kunye neebhendi eziphakamileyo ze-heteratic zibalulekile kwiindlela zokusindisa ubomi. Indlela esebenzayo kakhulu yokuphendula, efundwe ngokunzulu yiKomiti yamajoni aseMelika kwiTactical Combat Casualty Care (C-TCCC). Ukuphunyezwa kwezikhokelo ze-TCCC kukhokelele ekunciphiseni okukhulu kwenani lokusweleka kwengqondo (5).

Ngenxa yamava anzulu aphuhliswe kwinqanaba lomkhosi, ezi ndlela zonyango ziqale ukusasazeka nakwindawo yokuhlala, ngaphezulu kwayo yonke loo nto, emva kohlaselo lobunqolobi olunje ngokwenzeka ngexesha leBoston Marathon ngo-2013 (6).

Izenzo ezikhawulezayo zokukhusela ubomi kulawulo lweehaemorrhages ngabaphenduli bokuqala, ababukeli babandakanyiwe, zinokuthetha indawo ebalulekileyo ekunciphiseni ukusweleka okunokuthintelwa (7). E-United States, esinye sezicwangciso ezibonise ukuba ziyasebenza ekunciphiseni ukusweleka okukhulu kwesifo sele kukuxhobisa abasebenzi bezempilo kunye nabaphenduli bokuqala (amapolisa kunye abacima umlilo) kunye nezixhobo zokulawula ukopha kunye noqeqesho (8).

Kwiinkonzo zonyango ezixakekileyo nezongxamiseko mihla le, bandage yoxinzelelo olusetyenziselwa isisu esikhulu esibuhlungu soloko kuhlala kunganele. Isebenza kuphela xa kwenziwa uvavanyo ngqo lwangaphakathi, olungasoloko luqinisekiswa kwimeko yokulimala kakhulu okanye iitaxi eziphuthumayo (5).

Kungenxa yoko imibutho emininzi engxamisekileyo isebenzisa ukhenketho. Inenjongo enye kuphela: thintela ukungcungcutheka kwegazi kunye nokuphalaza okukhulu kwelungu. Kungqinwe ngokwenzululwazi ukuba ukusetyenziswa kwayo ngokungathandabuzekiyo kuyisindisa ubomi. Izigulana ezifumana umntu othuswe ziimeko ezixhalabisayo zinezibalo ezingapheliyo zokuphila. Ukuqokelelwa kobungqina kwicandelo lezomkhosi kubonakalise ukuba abantu abonzakeleyo abafakelwe kuye ukhenketho ngaphambi kokuqala koxinzelelo lwe-hypovolemic banesantya sokusinda se-90%, xa kuthelekiswa ne-20% xa kwavakaliswa ukhenketho emva kweempawu zokuqala zokuothusa (9).

Ukusetyenziswa kwangoko kwe-tourniquet kunciphisa isidingo sokudibana kwakhona kwe-volemic kunye ne-crystalloids kwindawo engaphezulu kwesibhedlele (haemodilution, hypothermia) kunye ne-hemoderivatives kwindawo yesibhedlele (i-coagulopathies), ukuphepha ukubhebhethekisa ngakumbi izinto ezibandakanyeka kwi-lethal triad (10).

Ngexesha lempikiswano yaseVietnam, i-9% yokufa yabangelwa kukopha. Kwiimpikiswano zanamhlanje, incitshisiwe ibe yi-2% ngenxa yoqeqesho lokusetyenziswa kokhenketho kunye nokusasazeka ngokubanzi. Umgangatho wokusinda phakathi kwamajoni aphathwe ngohambo ngokuchasene noko kungasetyenziswanga kuko yi-87% vs.% (0). Uhlalutyo lwezifundo ezi-9 zamazwe aphesheya ziye zaxela i-6% yemilenze ebandakanyekayo.

Ezi ziphumo zisenokubangelwa bubukhulu bokulimala okuqala kwaye azange zichazwe njengezongxaki zesibini ekusebenziseni umnyhadala (11). Kwizifundo ezibini eziphambili kwezomkhosi, kwafunyaniswa ukuba inqanaba leengxaki ngenxa yokusetyenziswa kweqela labakhenkethi ukusuka ku-0.2% (12) ukuya kwi-1.7% (9). Olunye uphononongo lubonise ukungabikho kweengxaki zohambo ngokuqhubekayo phakathi kwe-3 ne-4 iiyure (13.14).

Kuya kufuneka siqwalasele iiyure ezi-6 njengowona mda uphakamileyo wokusinda kwimilenze (15). Iphulo elithi "Stop the Bleed" liphuhlisiwe e-US liqela elisebenzayo phakathi kweearhente ezahlukeneyo ezihlanganiswe liSebe lezoKhuseleko lwaseKhaya "labasebenzi bezokhuseleko kwezwe" kwiNdlu yeWhite House, ngenjongo yokwakha amandla ebantwini ukwazisa ngezenzo ezisisiseko zokuphelisa ukopha okubeka emngciphekweni okubangelwa zizigameko zengozi zobomi bemihla ngemihla kunye neziganeko ezimbi zentlobo yemvelo okanye yabanqolobi.

"IKomiti yeTrauma" yeekholeji zaseMelika zeSurgeons kunye neHartford Consensus ziphakathi kwabaxhasi beli phulo. Ukopha okungalawulwa kuthathwa njengoyena nobangela uphambili wokufa onokuthi uthintelwe kukhathazeka, ngelixa ilitye longenelelo ngexesha elifanelekileyo kukusetyenziswa kwababukeleyo njengabaphenduli bokuqala ukuphatha ukopha okukhulu kude kufike ukuhlangulwa kwengcali, emva kokufumanisa ukuba ungenelelo lusebenza ngaphakathi kwe-5 yokuqala. -Imizuzu engama-10.

Iingcali zenkqubo yeToyitoyi engu-118 yathatha inxaxheba kwisifundo esithi "Stop the Bleed", engeniswe e-Itali yi-Società Italiana di Chirurgia d'Urichita e del Trauma. Injongo kukulinganisa indlela yokuziphatha kwindlela efanelekileyo yokusebenzisa iindwendwe, ezikhoyo ngoku kuzo zonke izithuthi zokuhlangula zePhondo.

 

Malunga nokundwendwela kunye nokufikelela ngaphakathi

Kwilungiselelo lesibhedlele sangaphambi kwesibhedlele, kuhlala kubalulekile ukuqinisekisa ukufikelela ngokukhawuleza kwemithambo, kodwa ukubeka indawo kuhlala kunjalo ingxaki (16,17). Ukungena kwi-venous venous kuhlala kuyinto esemgangathweni, kodwa ukuba imisebenzi ebalulekileyo iyathotywa, ukubuyisa kwayo kunokuba nzima okanye kuthathe ixesha elide.

Izinto ezinjengokukhanya okungalunganga, indawo encinci, isigulana esinzima okanye izinto zeklinikhi ezinje nge-vasoconstriction yecandelo lokothuka okanye kwizigulana ezine-hypothermic, ii-venous estate venous ngenxa yonyango olungena ngaphakathi okanye ukutyeba kakhulu zinokwenza ukuba kube nzima ukufikelela kwi-venous venous venous.

Amaxhoba oxinzelelo lomfutho ngokwanda kwamandla, ukubanjwa kwentliziyo okanye i-sepsis inokufuna ukufikelela kwangoko kwe-vascular.
Kwizigulana zabantwana, ukufumana ukufikelela kumathambo kunokuba nzima kubuchwephesha (18). Iqondo lokuphumelela ekumiselweni kokungena kwe-venous perires kumzamo wokuqala ngaphandle kwesibhedlele yi-74% (19.20) kwaye iyancitshiswa ibe ngaphantsi kwe-50% kwimeko yokubanjwa kwentliziyo (20). Izigulana zothuko lwe-hemorrhagic zifuna, ngokomyinge, imizuzu engama-20 yokufumana ukufikelela kwe-venipheral venous (21).

I-Tourniquet kunye nokufikelela kwi-intraosseous: enye indlela esebenzayo yokufikelela kwi-peripheral ye-venous ukufikelela kwi-intraosseous: ifunyenwe ngokukhawuleza kunokubuyisela i-peripheral vein (50±9 s vs 70±30 s) (22). Kwimeko ye-intra-hospital kwizigulane ze-ACR ezine-peripheral veins ezingafumanekiyo, ukufikelela kwi-intraosseous kubonise izinga eliphezulu lempumelelo ngexesha elingaphantsi. CVC ukubekwa (85% vs 60%; 2 min vs 8 min) (23), ngaphezu koko inkqubo ayifuni ukuphazamiseka kwesifuba kwaye ngenxa yoko inokuphucula ukusinda kwesigulane (24).

I-European Resuscitation Council ikwacebisa ukuba ukungena ngaphakathi kungenye indlela efanelekileyo yokufumana imeko ye-peripheral vein kwizigulana ezikhulu (25) kunye nokhetho lokuqala kwizigulana zabantwana (26).
Ukusukela ngo-Epreli ngo-2019, i-EZ-IO ® Intraosseous Access System yenziwa yaqhutywa kuyo yonke i-ASUITS 118 IiNdawo zokuGcina ukuHamba emva koqeqesho lwabongikazi kunye nokusasazwa kweenkqubo zokusebenza, ngaphambili yayiyinkqubo yeyeza lokuzinyanga.

Ukuphazamiseka kolawulo kuzo zonke ii-ambulensi kwenza ukuba kube lula ukuqiniseka ukufikelela kwamathambo, ukunciphisa amaxesha onyango kunye nokonyusa umgangatho weenkonzo kubemi. Izifundo ezininzi zibonakalise ukuba i-EZ-IO ® yinkqubo esebenzayo yokufumana ukufikelela kwi-intra-osseous: inqanaba lokuphumelela liphezulu kakhulu (99.6% 27; 98.8% 28; 90% 29) kunye nenqanaba lempumelelo kumzamo wokuqala ( 85.9% 27; 94% 28; 85% 23) kwaye iphawuleka ngephondo lokufunda elikhawulezayo (29). Ukufikelela ngaphakathi kuyafana nokufikelela kwi-venous parous ngokwe-pharmacokinetics kunye nokusebenza kweeklinikhi (30) kwaye izinga lokudibanisa lingaphantsi kwe-1% (24).

Malunga nokufikelela kwangaphakathi kunye nokusetyenziswa kokhenketho, ingxelo yetyala

Ingxelo yemeko:

Ngo-6.35: 118 emva kwemini: inkqubo yeTesteste engu-XNUMX yaqaliswa yiGumbi eliSebenzayo loNyango oluNgxamisekileyo lwe-FVG ukuphendula ikhowudi ephucukileyo yekhaya.

6.44 pm: i-ambulensi yafika kwindawo kwaye abasebenzi bahamba kunye nezihlobo zesigulana kwigumbi lokuhlambela. Ibhinqa elineminyaka engama-70 ubudala, lihleli kwindlu yangasese lingekho zingqondweni (I-GCS 7 E 1 V2 M 4). Ukuphefumla ukurhona, ukuphaphatheka, i-diaphoretic, i-carotid pulse engaqondakaliyo, ixesha lokuzalisa i-capillary> imizuzwana emi-4. Igazi elikhulu elityibilikayo ezinyaweni zesigulana; izilonda zemithambo zazibonakala kumalungu angaphantsi kunye netawuli, nayo eyayifakwe egazini, yayibhijelwe kwithole elifanelekileyo.

6.46 pm: ikhowudi ebomvu. Kwacelwa ucelomayeza kwaye kwafuneka bacele uncedo kumlilo ukuze bancede ukuthutha isigulana, kuthathelwa ingqalelo imeko yakhe enobunzima kunye nendawo enqongopheleyo. Xa isuswe itawuli, kwafunyanwa isisu esivela kwindawo yokuqhekeka kwemithambo-luvo kwi-ulcuscruris, esecaleni elingasemva kwethole.

Kwakungenakwenzeka ukuqinisekisa ukuhambelana ngqo okusebenzayo kunye nokunikezela umntu osebenza kule njongo. Ke, bafaka ngokukhawuleza i-Combat application Tourniquet (CAT), ukunqanda ukopha. Emva koko, akukho namnye umlomo we-hemorrhagic wafunyanwa.

Intloko yayilwandisiwe kwaye ihanjiswa nge-O2 nge-100% FiO2 ngokunyamalala kokuphefumla.
Ngenxa yesimo sokuthuthumela kunye nokukhuluphala, akunakwenzeka ukufumana ukufikelela kwe-venousher, ngoko ke, emva kokuzama kokuqala, ukufikelela ngaphakathi kubekwe kwigumbi elifanelekileyo lokuthambisa ngenkqubo ye-EZ-IO® ngenaliti engama-45mm.

Isimo esichanekileyo sokufikelela sasiqinisekisiwe: ukuzinza kwenaliti, isifiso segazi serous kunye nokulula kokutyhala i-10 ml SF push. Isisombululo sePhysical 500 infusion ngesingxobo sengxowa yaqalwa kwaye umlenze wangqinwa yimilitha. Xa ubeko lwe-ECG lubekwe, i-80 isigqi HR, PA kunye ne-SpO2 azange zibonwe.

Isinxibo sonyango esinomtsalane saye safakwa kwindawo yokopha. Ukuqokelela ngokukhawuleza kwe-anamnestic kubonise ukuba isigulana sasine-hyperthyroidism, uxinzelelo lwengqondo, idyslipidemia, i-OSAS kwi-CPAP yasebusuku, i-atraya fibrillation kwi-TAO. Ubuye walandelwa nguPlastic Surgery kunye nezifo ezosulelayo kwizilonda ezisezantsi ze-dermohypodermite ngu-MRSA, P. Mirabilis kunye no-P. Aeruginosa kunye nonyango lwe-tapazole iiyure eziyi-5mg, i-bisoprolol 8mg h 1.25, diltiazem 8mg qho kwiiyure eziyi-60, kwi-coumadin ngokwe INR.

6.55 pm; I-automedicator ifikile kwindawo. Isigulana esiboniswe nge-GCS 9 (E 2, V 2, M 5), FC 80r, PA 75/40, SpO2 98% ngeFO2 100%. I-1000mg EV tranexamic acid yenziwa. Ngoncedo lwe-Fire Brigade, isiguli safuduswa kunye isitulo kwaye nakwingqiniba.

Kwi-ambulensi, isiguli sasihanjiswa nge-GCS 13 (E 3, V 4, M 6), PA 105/80, FC 80r kunye neSpO2 98% ngeFO2 100%. Ukufikelela kwe-humalosseous ekunene kufunyenwe ukuba yahluthwa ngexesha lokudibanisa, ke olunye ufikelelo olungenayo lwabekwa kwangoko kwindawo efanelekileyo yokuphumla kwaye ufakelo lwamanzi luqhubeka.

Ukunikezelwa kokuphuculwa kweeparamitha ezibalulekileyo, unyango lwe-analgesic lwenziwa nge-fentanest 0.1mg kunye ne-500ml ye-saline epheleleyo kunye ne-200ml ye-ringeracetate ifakwe. Ngo-7.25 ebusuku i-ambulensi, nogqirha evuliwe ibhodi, ushiye kwikhowudi ebomvu ukuya eCattinara Igumbi loncedo olukhawulezayo.

Utyando, isebe lokuvuselela kunye nebhanki yegazi laziswa. I-ambulensi ifike kwi-PS ngo-7.30 ebusuku
Amanani okuqala okubalwa kwegazi abonakalise: i-hemoglobin 5 g / dL, iiseli ezibomvu zegazi 2.27 x 103µL, hematocrit 16.8%, ngelixa lokujija: INR 3.55, imizuzwana engama-42.3, iRatio 3.74. Isigulana samkelwa kwiyeza likaxakeka kwaye safumana i-hemotransfusions ngenani lama-7 ee-hematocrits ezixineneyo kunye nomjikelezo we-antibacteria nge-dalbavancin kunye ne-cefepime.

 

Ukhenketho, ukopha okukhulu kunye nokufikelela kwangaphakathi: FUNDA UVIWO LWE-ITALIAN

 

FUNDA KUNYE

Utyelelo: Misa ukopha emva kwenxeba lokudubula kwemipu

Udliwanondlebe kunye ne-AURIEX-Ukukhutshwa ngobuchule kwezonyango, uqeqesho kunye nokulawula ukopha okuninzi

Ngaba bakhenkethi okanye akunakundwendwela? Iingcali ezimbini zamathambo zithetha ngokutshintsha kwedolo lilonke

Inkathalo yeTactical Field: njani ama-paramedics aya kukhuselwa ukuba abhekane nenkundla yemfazwe?

 

Utyelelo, ukopha okukhulu kunye nokufikelela kwangaphakathi kwe-BIBLIOGRAPHY

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