Ukwenzakala kwesifuba: imiba yeklinikhi, unyango, indlela yomoya kunye noncedo lokuphefumla
Umothuko ngoku sesinye sezona ngxaki zinzima zempilo yoluntu kwihlabathi liphela: kumazwe ahambele phambili kwezemveliso, yeyona nto iphambili yokufa kwabantu abangaphantsi kweminyaka engama-40 kunye nonobangela wesithathu wokufa emva kwesifo sentliziyo kunye nomhlaza.
Malunga nekota yeemeko, ukwenzakala kukhokelela ekukhubazekeni okufuna ukuba isigulane silale ebhedini kwaye sifumane unyango oluntsonkothileyo kunye nexesha lokubuyisela kwisimo sangaphambili.
Xa kujongwa ubudala bezi gulane ezininzi, umonzakalo unoxanduva – xa sithetha ngokwezoqoqosho – kukhubazeko olumandla kunye nokulahlekelwa yimveliso ngokubanzi ngaphezu nesifo sentliziyo nomhlaza ezidityanisiweyo.
Imiba yeklinikhi yokwenzakala kwesifuba
Imbali echanekileyo yendlela kunye neemeko zokwenzakala zibalulekile kuvavanyo lobungakanani bomonzakalo ogciniweyo.
Kubalulekile, umzekelo, ukuqokelela ulwazi malunga nendlela eyenzeke ngayo ingozi yemoto (ingaba amabhanti ezitulo zibotshiwe?, Ngaba ixhoba laliphoswe kwindawo yabahambi?, yayinjani imilinganiselo yesithuthi?, njalo njalo), umgangatho kunye nohlobo lwesixhobo esisetyenzisiweyo, ixesha eladlulayo ngaphambi kokuba uncedo lufike, enoba kwakukho nawuphi na umothuko ngelo xesha.
Intliziyo esele ikhona, izifo zemiphunga, zemithambo okanye zezintso, okanye ukusetyenziswa kakubi kweziyobisi okanye utywala, nako kunokuphembelela indlela umzimba osabela ngayo kumonzakalo.
Uvavanyo olukhawulezayo kodwa olunenkathalo kufuneka luqhutywe ukuvavanya i-patency yomoya, iipatheni zokuphefumla, uxinzelelo lwegazi, ubukho beempawu zesifuba se-flail okanye i-subcutaneous emphysema, i-symmetry kunye nezinye iimpawu ze-pulmonary auscultatory.
Indlela ekhawulezayo kunye neyocwangco yovavanyo lokuqala lwenkqubo ye-nervous, circulatory and breathing yinkqubo elula yokulinganisa inqaku lobunzima bemeko yekliniki yesigulane.
Eli nqaku lokwenzakala lithathela ingqalelo Isikali se-coma saseGlasgow, ubuninzi boxinzelelo lwe-arterial kunye nesantya sokuphefumula: iiparitha ezintathu zinikezwa amanqaku ukusuka kwi-zero ukuya kwezine, apho ezine zibonisa imeko engcono kunye ne-zero embi kakhulu.
Ekugqibeleni, amaxabiso amathathu adityaniswa kunye.
Makhe sithathe umzekelo wesigulana esine:
I-Glasgow coma isikali: 14;
uxinzelelo lwegazi: 80 mmHg;
izinga lokuphefumla = 35 ukuphefumla ngomzuzu.
Amanqaku okwenzakala = 10
Sikhumbuza umfundi ukuba isikali se-Glasgow coma yinkqubo yovavanyo lwe-neurological, efumana amanqaku ngokweyona mpendulo ibalaseleyo ye-ocular, yomlomo kunye ne-motor kwi-stimuli eyahlukeneyo.
Kuphononongo lwezigulane ezingama-2166, 'inqaku lokwenzakala' elilungisiweyo libonakaliswe ukucalula izigulane eziya kusinda kwezo zonzakele kakhulu (umz. amanqaku e-12 kunye ne-6 adibene ne-99.5% kunye ne-63% yokusinda, ngokulandelanayo), evumela ukuba ngaphezulu. ingqiqo udidi kumaziko awohlukeneyo okwenzakala.
Ngokusekelwe kolu vavanyo lokuqala, i-protocol yokuxilonga kunye neyonyango elandelayo igqitywe.
Iimvavanyo ezininzi zezixhobo kunye nelabhoratri zisetyenziswa rhoqo ukuchaza ngcono ubunjani kunye nobungakanani bokulimala kwethoracic ingxelo. I-X-ray ye-anteroposterior (AP) isoloko iyimfuneko ukuze kuhlolwe ngakumbi isigulane kunye nesikhokelo sonyango olungxamisekileyo.
Ubalo lwegazi olupheleleyo (CBC), uvavanyo lwe-electrolyte, uhlalutyo lwegesi yegazi ye-arterial (ABG) kunye ne-electrocardiogram (ECG) zenziwa xa kwamkelwa kwaye emva koko.
Uphando oluntsonkothileyo olufana ne-CT, i-magnetic resonance imaging (MRI) kunye ne-angiyografi zinceda ukucacisa ubungakanani kunye nobuzaza bomonzakalo ngokuchanekileyo ngakumbi.
Unyango lokwenzakala kwesifuba
Malunga nama-80% abo bonke abantu ababhubhileyo okunxulumene nomonzakalo kwenzeka kwiiyure ezimbalwa zokuqala emva kwesiganeko.
Ukusinda kuxhomekeke ekusebenzeni ngokukhawuleza kweenkqubo zokuxhasa ubomi kunye nokuthutha kwiziko le-trauma.
Unyango olukhawulezileyo lwamaxhoba okwenzakala kwesifuba lubandakanya ukugcina ipatency yomoya, unyango lweoksijini ngeFiO ye-1.0 (umzekelo, ngemaski 'engaphefumliyo', i-ventilator 'yebhaloni' okanye ukuhanjiswa kweoksijini ehambahambayo izixhobo) umoya wokungenisa umoya, ukufakwa kwemigca ye-peripheral kunye ne-central intravenous (EV) yokulawulwa kwamanzi kunye negazi, ukusetyenziswa kwe-chest drain, kunye nokudluliselwa ngokukhawuleza kwigumbi lokusebenza (OR) kwi-thoracotomy engxamisekileyo.
Ukuqaliswa kwe-catheter ye-pulmonary artery catheter luncedo kunyango lwezigulane ezine-haemodynamically ezingazinzanga kunye / okanye ezifuna ukufakelwa kwamanzi amakhulu ukugcina ibhalansi ye-electrolyte.
Ukunyangwa kweentlungu nako kubalulekile.
Ukusetyenziswa kwe-analgesic elawulwa yisigulane (i-PCA) i-dispensers (umzekelo, i-systemic infusion okanye i-thoracic epidural) iphucula ukunyamezela intlungu, intsebenziswano yokuphefumla ngokunzulu, ukusebenza kwemiphunga kwaye yenza ukuba imfuno yoncedo lokuphefumula iyancipha rhoqo.
Uncedo lwendlela yomoya
Ukuvalwa kwendlela yomoya ngokuqhelekileyo kuthathwa njengoyena nobangela ubalulekileyo onokulungiseka wokusweleka kwizigulane zomonzakalo.
Le meko idla ngokubangelwa kukutyibilika kolwimi ngasemva kwi-oropharynx.
Umnqweno we ukugabha, igazi, amathe, amazinyo emboleko, kunye ne-edema emva kokulimala kwe-oropharyngeal zezinye izizathu zokuvala umoya.
Ukubeka intloko yesigulane kwindawo efanelekileyo kunye nokufaka i-oropharyngeal cannula inceda ukugcina i-airway patency kwaye ivumela i-100% i-oksijeni ukuba ihanjiswe nge-mask ye-balloon.
Kwiimeko ezininzi zonxunguphalo, umgaqo womoya owenziweyo okhethwayo yi-endotracheal cannula yomgangatho ofanelekileyo, ene-sleeve, evumela umoya opholileyo womoya, iququzelele ukufunxa kwe-endotracheal kwaye inceda ukukhusela imiphunga ekunqweneleni kokuqukethwe kwesisu.
Ukuba i-fracture yomlomo wesibeleko ikrokrelwa, ukufakwa, phantsi kolawulo lwe-bronchoscopic, i-cannula ye-nasotracheal inconywa, kuba le nkqubo idinga ukwandiswa okuncinci kwentloko.
Iindlela zokubeka i-cannula ye-endotracheal zingabangela ukubanjwa kwentliziyo, ukunyanzeliswa kokungonelanga kwangaphambili kwe-oxygenation, i-intubation ye-bronchus engundoqo okanye i-esophagus, i-alkalosis yokuphefumula okwesibini ukuya kwi-ventilation ephezulu, kunye / okanye i-vasovagal reflex.
Ukubekwa esweni ngononophelo kokubekwa kwecannula ngokuchanekileyo kuyafuneka ukuze kuqinisekiswe ukuba yomibini imiphunga ingena umoya.
Enyanisweni, malunga ne-30% yezigulane ezithatha iindlela zokuvuselela, i-intubation ye-bronchus engundoqo iyenzeka.
I-X-ray yesifuba kunye ne-fibronchoscopy ivumela ukufumanisa ukuqokelelwa kwegazi, okufuneka kukhuthazwe.
I-bronchoscopy ye-fibreoptic, nokuba yoxilongo okanye yonyango, ihlala iluncedo kakhulu kwizigulana ezine-atelectasis eqhubekayo okanye ephindaphindiweyo.
Kwizigulane ezinemiphunga enzima ye-asymmetric okanye i-tracheobronchial ruptures, efuna umoya ozimeleyo we-lung, ukusetyenziswa kwe-double-lumen tracheal cannula kunokufuneka.
Ukuba i-endotracheal intubation okanye ukubekwa kwe-tracheostomy cannula kunzima okanye akunakwenzeka, i-cricothyrotomy inokwenziwa kude kube yi-tracheostomy.
Ngokungabikho kokunye ukufikelela okunokwenzeka, ukuqaliswa kwenaliti ye-12-gauge yindlela ye-cricothyroid inokuvumela, ngexesha elifutshane, i-percutaneous transtracheal ventilation kunye ne-oxygenation, ilindele ukubekwa kwe-tracheostomy cannula.
Ukhathalelo lokungenisa umoya
Izigulane eziza kujongwa kwi-apnea, ekungaphumeleli kokuphefumula okuzayo (izinga lokuphefumula elingaphezu kwe-35 / iminithi), okanye ekuphelelweni ngokupheleleyo kokuphefumula (i-PaO2 ngaphantsi kwe-60 mmHg, i-PaCO2 ngaphezu kwe-50 mmHg, kunye ne-pH engaphantsi kwe-7.20) idinga uncedo lokuphefumula.
Iiparameters zoncedo lwe-ventilatory kwisigulane esinokulimala kwe-thoracic yobunzima obungaziwa kufuneka kumiselwe ukubonelela ngenkxaso epheleleyo ngokuxhomekeke kwivolumu yoncedo-ukulawula umoya, kunye nomthamo we-10 ml / kg, umlinganiselo we-15 imijikelezo / ngomzuzu, izinga lokuhamba komoya ukuqinisekisa ukuphefumlelwa / ukuphuma (I: E) umlinganiselo we-1: 3, kunye ne-FiO2 ye-1.0.
Ezi parameters zinokutshintshwa emva kovavanyo olunzulu lweklinikhi kwaye xa iziphumo ze-ABG zifumaneka.
Ngokuqhelekileyo, i-PEEP ye-5-15 cm ye-Hp iyimfuneko ekuphuculeni umthamo wemiphunga kunye ne-oxygenation.
Nangona kunjalo, ukusetyenziswa kwe-ventilation efanelekileyo yoxinzelelo kunye ne-PEEP kwizigulane ezineentlungu zesifuba zifuna ukuqaphela ngokugqithiseleyo, ngokumalunga nomngcipheko wokunyusa i-hypotension kunye ne-barotrauma.
Emva kokuba isigulane siphinde sakwazi ukuphefumla ngokuzenzekelayo ngokufanelekileyo, ngokukhawuleza, ukuvuthela umoya ohambelanayo (IMSV), kudityaniswe nenkxaso yoxinzelelo (PS), iququzelela ukulunyulwa kwi-ventilator.
Isinyathelo sokugqibela phambi kokutshatyalaliswa kukujonga umthamo wokuphefumula wesigulane kunye noxinzelelo oluqhubekayo (CPAP) kwi-5 cm H2O ukugcina i-oxygen eyaneleyo kunye nokuphucula i-lung mechanics.
Kwiimeko ezintsonkothileyo, iindlela ezininzi, ezintsonkothileyo zokungenisa umoya ezizezinye kunye neenkqubo zenkxaso zotshintshiselwano ngegesi zingasetyenziswa.
Kwiindlela ezibukhali ze-ARDS, ukusetyenziswa koxinzelelo-oxhomekeke kuxinzelelo, i-inverse-ratio ventilation inokuphucula ukungena komoya kunye ne-oxygen kwaye incede ukunciphisa uxinzelelo oluphezulu lomoya.
Izigulane ezinokulimala kakhulu kwemiphunga e-asymmetric efumana i-hypo-oxygenation ngexesha lokungena komoya oqhelekileyo, nangona i-PEEP kunye ne-100% yokuhanjiswa kwe-oksijini, banokuzuza kwi-ventilation ye-lung ezimeleyo usebenzisa i-double-lumen tracheal cannula.
Umoya ozimeleyo wemiphunga okanye umoya we-'jet' we-high-frequency ungahlangabezana neemfuno zezigulana ezine-bronchopleural fistula.
Kubantu abadala, i-extracorporeal membrane oxygenation (ECMO) ngokucacileyo ayisebenzi ngakumbi kunokungenisa komoya okuqhelekileyo.
I-ECMO ibonakala, kwelinye icala, ikhethwa kubantwana babantwana.
Nje ukuba ukusilela kwamalungu amaninzi okwesibini kumonzakalo kulungiswe, i-ECMO inokusebenza ngakumbi kubantu abadala.
Ezinye iindlela zokunceda ukuphefumla
Isigulane se-thoracic trauma sihlala sifuna iindlela ezongezelelweyo zonyango.
Ukufunyiswa kwendlela yomoya, ngomphunga oshushu okanye ongatshisiyo, kuqhele ukwenziwa ukulawula ukukhuselwa.
Ucoceko lwendlela yomoya lukwabalulekile kwizifundo ezifakwe ngaphakathi okanye ezo zinokugcina amafinyila.
I-physiotherapy yokuphefumula idla ngokuba luncedo ekuhlanganisweni kweemfihlo ezigcinwe kwiindlela zomoya kwaye zinokunceda ukwandisa kwakhona iindawo ze-atelectasis.
Ngokuqhelekileyo, i-bronchodilators ngendlela ye-aerosols isetyenziselwa ukunciphisa ukuxhathisa umoya, ukuququzelela ukwanda kwemiphunga kunye nokunciphisa umsebenzi wokuphefumla.
Ezi ndlela 'zobuchwephesha obuphantsi' bokhathalelo lokuphefumla zonke zibaluleke kakhulu kulawulo lwesigulane se-thoracic trauma.
Funda kwakhona:
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