Kwesinye isikhathi kuyafaneleka ukuzibuza ukuthi izinto esizizwayo, esizibonayo nesizizwayo zifana nalokhu ebesicabanga ukuthi beziyikho. UDkt Alan Garner ubheka izinzwa zakho uma ungena esifubeni futhi uyazibuza ukuthi ingabe konke kuqondile phambili njengoba sithanda ukucabanga?

Asiqale le post sisho phambilini ukuthi lokhu kumayelana namanxeba esifubeni. Uma kungesikho lokho obukucabanga sekuyisikhathi sokubheka kwenye indawo.

Engifuna ukukudingida wukuxilongwa komtholampilo kwe-tension pneumothorax ensimini. Isizathu sengxoxo ukuthi ngikholelwa ukuthi ixilongwa ngokweqile. Ngenkathi ngisebenza e-UK eminyakeni engu-6 edlule kwakubonakala sengathi ukungezwani bekutholakala njalo futhi isizathu esinikezwe kwakuwumsindo njengoba bephula i-pleura ngama-forceps. Njengoba isiguli sasinomfutho omuhle wokungenisa umoya ngaleso sikhathi ngakho-ke umsindo kufanele ukuthi wawuphuma emoyeni uphuma endaweni ye-pleural njengoba ukucindezela kwabo kwe-intrathoracic kwakukuhle kuwo wonke umjikelezo wokuphefumula kwesokudla?

Khumbula ukuthi singakwazi kanjani ukuthembela emisindweni ehilelekile ekuhlolweni komtholampilo endaweni ye-prehospital ngoba ayithembekile kakhulu? Hhayi-ke bengitshelwa ukuthi lo uhlezi eqinisile. 'Njalo' igama elikhulu kwezokwelapha

Ngiyazi futhi okungenani isimo esisodwa lapho isiguli esinenxeba elilodwa lokudutshulwa endaweni ye-pigastric esikhalini esinesivinini esiphansi saba ne-intuba kanye nethoracostomi yomunwe wamazwe omabili. Ukuphawula ngaleso sikhathi kwakuwukuthi udokotela wangaphambi kwesibhedlela, ngokungangabazeki wangena kukho konke ngokwethembeka, wathi ngesikhathi se-thoracostomies bathola i-pneumothorax ngakolunye uhlangothi kanye nokucindezeleka kolunye.

Kodwa-ke ekuthwebuleni nasekuhlinzeni i-projectile yabuyela ngqo kumanyikwe futhi akukho ndawo eduze kwe-hemithorax noma i-diaphragm. Ngempela kuphela ukulimala okukhonjwe kunoma iyiphi ingxenye yesifuba amanxeba ethoracostomy ngokwawo. Futhi isiguli esifakwe intuba ngakho-ke ingcindezi ye-intrathoracic kufanele ukuthi yayilungile? Uma iphaphu lizwakala liphansi, kufanele kube i-pneumothorax? Futhi uma kunomsindo wokwephulwa kwe-pleura kufanele ngabe bekunokushuba?

Kuyacaca esimeni sesibili izimpawu bezidukisa pho kwenzakalani la? Ake sibeke eceleni okwesibili izinselele zokuxilongwa kokuqala kwe-pneumothorax futhi sigxile ekuzizweleni ngomunwe nomsindo ezindlebeni. Kungenzeka yini ukuthi obunye ubufakazi esiye senziwa sakholelwa ukuthi busitshela ukuthi sibhekene ne-pneumothorax bungadukisa odokotela abanolwazi nabaqeqeshwe kahle?

I-Diving In

Mhlawumbe ngike ngakhipha amanzi esifuba ambalwa kuneminingi. Ngokwengxenye lokho kungenxa yeminyaka engaphezu kwe-20 endaweni ye-prehospital kodwa mhlawumbe ngenza ngisho nangaphezulu lapho ngingumbhalisi 25 ngonyaka odlule. Ngichithe izinyanga eziyisi-6 ngisebenzela odokotela abambalwa bokuphefumula futhi ngafaka imisele eminingi (ikakhulukazi ukukhishwa okuyingozi) ezigulini ezazingenayo i-pneumothorax ngaphambi kokuba ngiqale. Kwakuvamile ukuzwa umsindo njengoba i-pleura iphulwa njengoba umoya ungena ugijima. Kodwa lokhu kwakusezigulini ezifaka umoya ngokuzenzekelayo futhi lokho kwehlukile akunjalo?

Kusobala ukuthi sidinga ukubuyela ku-physiology ukuze sibone ukuthi yini eqhuba ukuhamba komoya ukungena noma ukuphuma emgodini esiwenzile ukuze sinqume ukuthi umsindo esiwuzwayo wumoya ongena ngaphakathi, noma umoya ophumayo.

Buyela kuzinsisekelo

Umfutho we-Transpulmonary yi-gradient yengcindezi eshayela umoya ojwayelekile. Kungumehluko phakathi kwe ingcindezi ye-alveolar futhi ingcindezi ye-intrapleural ku amaphaphu.

P_tp =P_alv - P_ip. Lapho uP_tp ingcindezi ye-transpulmonary, P_alv ingcindezi ye-alveolar, kanye ne-P_ip ingcindezi ye-intrapleural.

(Uma ungathanda okwengeziwe kulokhu, i-Life enhle kakhulu ku-Fast Lane inengcindezi ye-transpulmonary lapha.)

Futhi kuvela ukuthi ungathola ukubuka kuqala kwe-google kwencwadi yokufunda yakudala kaJohn West yesayensi yokuphefumula. Thatha isikhashana uhambe futhi ujabulele Umfanekiso 4-9 ekhasini 59. 

Ungabona kuphaneli B (bengiqonde ukuthi, hamba uyobheka) ukuthi ingcindezi ye-intrapleural iyahluka phakathi kuka -5 kanye -8 cmH₂O ezingeni eliphakathi namaphaphu ngesikhathi sokuphefumula okuvamile. Ihlala inegethivu futhi lokho kungenxa yokuhlehla okunwebekayo kwephaphu okuphikiswa udonga lwesifuba. Alinayo i-negative kancane ezindaweni ezincike ephashini (yehlisa usayizi we-alveolar) futhi inegethivu ngaphezulu phezulu (okwandisa usayizi we-alveolar).

Masingeze Umoya

Esimweni se-pneumothorax encane umoya osesikhaleni se-pleural wenza umfutho we-intrapleural ungabi mubi futhi umehluko wengcindezi yokushayela yokukhipha umoya ngakho-ke uyancipha. Uma i-pneumothorax ivuleke ngokuphelele emoyeni njengokuthi ngenxeba elivulekile le-thoracostomy ingcindezi ye-intrapleural ilingana nokucindezela komkhathi, ukugoqa okunwebekayo kwephaphu kubangela ukuwa okuphelele kanye nokungena komoya ngokukhuliswa kwesifuba akunakwenzeka - ukucindezela okuhle kwendlela yomoya kufanele kufakwe.

Akusona isimo se-pneumothorax esingikhathaza kakhulu. Uma i-hypoxic noma i-hypotensive futhi isiguli sine-pneumothorax isifuba kufanele sincishiswe - i-no-brainer ephelele. Umbuzo uwukuthi kungani odokotela abahle benciphisa izifuba ezivamile futhi bacabange ukuthi kwakukhona i-pneumothorax noma ngisho nokungezwani lapho bekungekho? Ingabe i-physiology isiholela lapho?

Onesiguli

Okokuqala ake sicabangele isiguli esingafakwanga esinokuphefumula okuvamile futhi esingenayo i-pneumothorax. Lesi yisimo seziguli ezinemibhobho eyingozi engangiyifaka eminyakeni edlule. Lapha umfutho we-alveolar awulokothi ube ngaphezu kwe-cmH₂O noma okubili okuhle noma okunegethivu. Umfutho we-intrapleural nokho ungu-5 kuya ku-8 cmH₂O. Ngakho-ke akunandaba ukuthi yisiphi isigaba sokuphefumula ophula ngaso i-pleura, i-gradient yokucindezela phakathi kwendawo ye-pleural nomkhathi inegethivu nomoya uzongena ngamandla.

I-gradient inkulu ngokuphefumulelwa lapho umfutho we-alveolar unegethivu (ngakho-ke umfutho ophelele uzungeze -8 cmH₂O) futhi ibe negethivu encane ngesikhathi sokuphelelwa yisikhathi lapho icishe ibe -5 cmH₂O. Nokho ihlale inegethivu. Akukhathalekile ukuthi iyiphi ingxenye yomjikelezo wokuphefumula owephula i-pleura, umoya uzogeleza uye endaweni ye-pleural futhi ukunwebeka kwephaphu kuzoliqhubeza ukuba liwe. Uma uzwa umsindo njengoba ngangivame ukwenza, umoya ugijima, inxeba lesifuba lokumunca elivamile. I-iatrogenic eyodwa.

Isiguli Sesibili

Angicabangi ukuthi ukhona ongaba nenkinga ngezinto kuze kube manje. Ngakho-ke masiqhubekele esigulini esifakwe ngaphakathi esingenayo i-pneumothorax. Ngizothatha lapha ukuthi akukho ukumelana okuningi kwendlela yomoya esigulini sethu esihlukumezekile (okungasho ukuthi asinaso isifo se-obstructive pulmonary disease, i-anaphylaxis emithini yokungenisa umoya oyinikezile noma ihlule elihlezi ku-bronchus enkulu. /ETT) njengoba yenza ingxoxo ibe lula ukucabanga ukuthi ukumelana kuncane (kuyize ngokusho kwama-Daleks) futhi ingcindezi oyibona kugeji yakho yokungenisa umoya idluliselwa kakhulu ngqo ku-alveoli.

Uma sibheka i-equation yethu ye-transpulmonary pressure equation, ngaphandle uma umfutho womoya kanye nomfutho we-alveolar ungaphezu kuka-5 cmH.₂O ke i-gradient ngesikhathi uvula i-pleura isho ukuthi umoya uya faka umgodi we-pleural. (Uma benokumelana okukhulu nomgwaqo womoya lokhu kungenzeka ngomfutho womoya ophakeme kakhulu).

Vele ube nenhlamvu yeso esheshayo yalesi sikhathi seshadi lokucindezela levolumu evamile yokungenisa umoya ngamabhayisikili engenayo i-PEEP (futhi isikhwama esizikhukhumeza ngokwaso sizohlinzeka ngomkhondo ofanayo nakuba oguquguqukayo). Futhi ngamabomu anginayo i-PEEP kuleli shadi. I-PEEP cishe ayinakuba yinto yokuqala esiyifinyelela esigulini se-hypotensive trauma esisanda kuyifaka lapho sikhathazekile khona mayelana nokwenzeka kwe-pneumothorax.

Ngamaphaphu avamile umfutho ophakeme lapha cishe ungama-20 cmH₂O. Ingakanani ingxenye yomjikelezo wokuphefumula ophelele umfutho womoya (futhi yingakho nomfutho we-alveolar esigulini sethu esinokumelana okuphansi kwendlela yokuphefumula) okungenzeka ibe ngaphansi kuka-5 cmH₂O? Uma i-ventilator yakho encane ye-prehospital inesilinganiso esicishe sibe ngu-1:2 I:E njengoba iningi lenza, impendulo iningi layo.

Ngamanye amazwi ngaphandle uma une-PEEP okungenani engu-5 cmH₂O ngisho nasesigulini sakho esifakwe ngaphakathi ingcindezi ye-transpulmonary ayilungile engxenyeni enhle yomjikelezo wokuphefumula. Okungenani phakathi nengxenye yomjikelezo wokuphefumula, uma uzwa umsindo njengoba wephula i-pleura uzwa umoya ugijima IN.

Ukuhlehla okunwebekayo kwephaphu kuyisizathu sokuthi uzwe ukuthi iphaphu seliwile ngesikhathi ukhipha izindlawu bese ufaka umunwe wakho phakathi ngaphandle uma une-PEEP ethile odlala ngayo.

Manje angisho ukuthi akukaze kube khona isikhathi lapho umoya wawungasheshi ukungena. Angicabangi kakhulu ngegama elithi “njalo” kwezokwelapha, uyakhumbula? Ngiphakamisa nje ukuthi esikwaziyo nge-physiology kungaphikisa ukuthi okungenani kunengxenye eqinile yesikhathi lapho leyo ngcindezi ye-transpulmonary inegethivu lapho wephula i-pleura, okusho ukuthi kungenzeka kube nenani elihle lamacala lapho lezo zimpawu "ezithize" zomtholampilo ziba zithembekile kancane.

Ukuze ubonise lokhu nomama wazo zonke i-thoracotomies evulekile (ku-cadaver) hlola le vidiyo.

I-cadaver ifakwe ngaphakathi, kuye kwadaleka isilonda “esivulekile” sokuwohloka kwe-pleural, futhi ekuphelelweni kwesikhathi ngakunye iphaphu ligoqa phansi ngaphandle kwalapho kusetshenziswe i-PEEP. Futhi qaphela ukuthi ukugoqa kuqediwe ekuphelelweni kwesikhathi ngakunye.

Uma nje i-thoracostomy inkulu ngokwanele ukuxhumana nomoya ngokukhululekile (futhi uma uthembele endleleni evulekile "yeminwe" kunokuba ifake i-drain idinga ukuba ibe nkulu noma ingase iphinde icindezeleke), uma ubeka umunwe phakathi ngesikhathi sokuphelelwa yisikhathi iphaphu lizogoqeka ngaphandle uma kunenani elizwakalayo lezinto eziqhekekayo ze-PEEP ezivuleka ngokumangalisayo.

Izobhidlika noma ngabe bekuvele kungaphambi kokuthi wenze isilonda noma kwenzeka njengoba usakaza izindlawu futhi wenza imbobo yokuxhumana. Isikhathi esiphakathi kokwenza imbobo nokuthola lowo muzwa wephaphu phezulu noma wehle ngomunwe isikhathi esanele sokuba iphaphu liwe phansi. Kubonakala sengathi lolu phawu lomtholampilo alukutsheli lutho mayelana nesimo sokudlala ngaphambi kokwenziwa kwenxeba.

Ngakho imisindo ingakhohlisa futhi uzwe iphaphu eligoqekile kusho ukuthi iphaphu lihlehla njengoba kuvulwe i-pleura. Ungakwazi ngisho nokuqinisekisa ukuthi yisiphi isigaba somjikelezo wokuphefumula isiguli esasikuso ngenkathi wenza leyo mbobo? Ngaphandle uma okungenani ubuno-5 cmH₂O (futhi mhlawumbe nangaphezulu) I-PEEP ngesikhathi wephula i-pleura akukho kulezi zimpawu ezisho lutho.

Manje?

Futhi, angikho ekukhulumeni izinto ezinjengokuthi “njalo” noma “akasoze”. Engikuphakamisayo ukuthi kungase kube nokumpunga okuningi eduze kwalezi zimpawu zomtholampilo kunokuba kubonakale kunjalo kuqala.

Ngakho wazi kanjani ukuthi babene-pneumothorax? Kimina lokho cishe njalo nge-ultrasound manje. Angazi ukuthi ngakwazi kanjani ukunakekelwa kwe-prehospital engu-15 kuleyo minyaka engu-20+ ngaphandle kokukodwa. Ngezinye izikhathi vele ukuskena kuyalingana futhi udinga ukushaya ucingo ngokusekelwe ezimpawini ozibonayo kanye nesimo sesiguli kodwa ngithola ukuthi lokhu akuvamile kakhulu nge-probe enhle yomugqa wefrikhwensi ephezulu.

Futhi mayelana nokushuba kwesimo okugqamayo kuwukuphila okungavamile, ikakhulukazi umfutho wegazi. Uma i-decompressing esifubeni ilungisa i-physiology ngaleso sikhathi babe nokucindezeleka. Uma kungenjalo babene-pneumothorax elula - noma babengekho nhlobo. Ngenxa yokuthi umsindo owuzwile ngenkathi uphula i-pleura kungenzeka ukuthi wawungena noma uphuma esakhiweni, ukuzwa umsindo akusizi ngalutho. Ngabe u-Elvis wake waba sebhilidini nhlobo?

amanothi:

Ngibe noDkt Blair Munford okhaliphile ebuyekeze inqwaba yefiziyoloji lapha ukuze aqinisekise ukuthi iyahambisana.

Ngemva kwaleso sixhumanisi esiya ku-LITFL bit on transpulmonary pressure futhi? Bese uya kwesokudla lapha.

Futhi ubuciko bobuciko bukaJohn West (okungenani ikhasi elishiwo) yilo lapha.

Leso sithombe sikaNahni esinamadlebe amakhulu safakwa ku Creative Commons ingxenye ye-flickr ka-Allan Henderson futhi ayishintshiwe lapha.

O, futhi uma ubungamazi uJohn West omangalisayo ngempela, u-Adelaide umfana wenza kahle, urekhodile lonke uchungechunge lwezinkulumo zakhe ukuze uhambe uyolubuka. Ngoba uma ususeminyakeni yama-80s cishe uzofaka isandla emfundweni yezokwelapha kanjalo, akunjalo?

Funda Futhi:

I-Tracheal Intubation: Nini, Kanjani Futhi Kungani Ungayakha I-Airway Yokwenzela Isiguli

Iyini i-Transient Tachypnoea Yosana Olusanda kuzalwa, Noma I-Neonatal Wet Lung Syndrome?

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