Txoj Kev Tseem Ceeb Los Ntawm Cardiac Arrest To Trauma Resuscitation

Taw qhia: Cov kev sib tw hauv vascular nkag mus rau cov neeg laus thaum muaj xwm txheej ceev
Hauv qhov chaw saib xyuas neeg laus thaum muaj xwm txheej ceev, tshwj xeeb tshaj yog nyob rau hauv cov xwm txheej tseem ceeb xws li mob plawv, mob hnyav, thiab kev poob siab, tsim kom muaj lub vascular nkag tau sai yog ib qho tseem ceeb ua ntej kom muaj kev vam meej. Txawm li cas los xij, nyob rau hauv cov xwm txheej ntawm lub cev tsis zoo no, kev nkag mus rau peripheral venous feem ntau ua nyuaj heev los yog tsis yooj yim sua vim lub nkoj tawg, cov ntshav ntim tsawg, thiab peripheral circulatory tsis ua haujlwm. Central venous catheterization yog txhim khu kev qha, tab sis nws yuav tsum tau muaj kev txawj ntse, muaj kev pheej hmoo ntawm cov teeb meem, thiab feem ntau yog siv tsis tau nyob rau hauv lub sij hawm ceev ceev ntawm kev kho mob xwm txheej ceev. Cov koob txhaj tshuaj intramedullary tau rov tshawb pom dua nyob rau hauv qhov kev sib tw kho mob no thiab tau rov-tsim nws txoj haujlwm tseem ceeb hauv kev saib xyuas neeg laus thaum muaj xwm txheej ceev.
Lub plawv nres: Lub sijhawm yog myocardium, thiab txoj hauv kev yog txoj sia.
Thaum lub sij hawm cardiopulmonary resuscitation rau lub plawv nres, txhua feeb ntawm kev ncua hauv defibrillation ua rau 7-10% txo qis ntawm kev ciaj sia. Thiab qhov ncua sij hawm ntawm kev kho tshuaj yog qhov sib npaug. Kev lig kev cai, cov neeg ua haujlwm kho mob feem ntau ncua kev tswj hwm cov tshuaj tseem ceeb (xws li epinephrine) thaum sim tsim kom muaj kev nkag mus rau hauv cov hlab ntsha. Cov txheej txheem niaj hnub no tau hais meej meej: Yog tias kev nkag mus rau cov hlab ntsha tsis tuaj yeem tsim tsis pub dhau 90 vib nas this, cov txheej txheem yuav tsum tau hloov tam sim ntawd mus rau qhov nkag mus rau hauv cov pob txha.
Qhov tshwj xeeb zoo ntawm kev siv IO hauv cov xwm txheej ntawm lub plawv nres muaj xws li:
1. Tsis cuam tshuam nrog cov txheej txheem resuscitation: Txoj kev IO tsim los ntawm lub taub hau humeral tsis cuam tshuam rau lub hauv siab compressions. Qhov no yog incomparable rau sab hauv jugular los yog subclavian leeg txoj kev.
2. Pharmacokinetic zoo: Cov tshuaj siv los ntawm cov pob txha pob txha kab noj hniav sai sai nkag mus rau hauv nruab nrab ntawm cov hlab ntsha. Cov kev tshawb fawb tau pom tias lub sijhawm kom ncav cuag qhov siab tshaj plaws thaum noj tshuaj epinephrine los ntawm IO tsis txawv ntawm qhov kev tswj hwm hauv nruab nrab venous, thiab cov ntshav concentration curves zoo ib yam.
3. Siab ua ntej- lub sijhawm ua tiav: Txawm tias nyob rau hauv cov neeg mob uas muaj lub plawv nres, thawj zaug - lub sijhawm ua tiav ntawm IO puncture tseem tshaj 90%, thaum qhov ua tiav ntawm peripheral venous puncture feem ntau qis dua 50%.
4. Kev sib raug zoo nrog ntau yam tshuaj: Txoj hauv kev IO tuaj yeem tswj hwm tag nrho cov tshuaj resuscitation, suav nrog epinephrine, amiodarone, lidocaine, sodium bicarbonate, thiab lwm yam, tsis muaj kev qhia txog kev siv tshuaj sib xyaw ua ke.
Cov Txheej Txheem Kev Ua Haujlwm Kev Pom Zoo: Tom qab txheeb xyuas lub plawv nres thiab pib lub plawv nres, thawj pab neeg yog lub luag haujlwm rau kev muab cov kev ua haujlwm siab ntxiv -zoo hauv siab compressions thiab defibrillation thaum ntxov, thaum pab neeg thib ob yuav tsum sim ua kom muaj kev nkag mus rau hauv cov hlab ntsha. Yog tias thawj zaug peripheral venous sim ua tsis tau lossis xav tias yuav nyuaj (xws li rau cov neeg mob uas siv cov tshuaj txhaj tshuaj, cov neeg rog rog, lossis cov neeg muaj edema), yuav tsum tsis txhob rov ua dua; Hloov chaw, IO nkag mus yuav tsum tau hloov mus rau tam sim ntawd.
Trauma resuscitation: Tswj qhov raug mob, nthuav cov ntshav sai sai
Cov neeg mob uas raug mob hnyav feem ntau raug kev txom nyem los ntawm hypovolemic shock. Lub sijhawm no, cov hlab ntsha peripheral tau nruj heev, ua rau nws nyuaj heev los tsim kev nkag mus rau hauv cov hlab ntsha. Lub hauv paus ntsiab lus ntawm kev tiv thaiv kev puas tsuaj resuscitation (DCR) qhia txog kev ua kom lub cev muaj zog sai, nrawm thiab sib npaug, uas yog nyob ntawm kev nkag mus rau vascular txhim khu kev qha.
Hauv kev raug mob resuscitation, tus nqi ntawm txoj kev IO nyob hauv:
1. Tsis cuam tshuam los ntawm vascular mob: Txawm tias thaum lub systolic ntshav siab poob mus rau 40 mmHg, cov hlab ntsha ntawm cov pob txha kab noj hniav tseem qhib thiab txoj kev ua haujlwm tsis cuam tshuam.
2. Ntau qhov chaw xaiv: Xaiv qhov chaw puncture hloov pauv raws li qhov xwm txheej raug mob. Rau qhov qis qis qis, lub taub hau humeral tuaj yeem xaiv tau; rau kev raug mob sab sauv, qhov kawg ntawm tibia tuaj yeem xaiv tau; rau cov pob txha pob txha, qhov contralateral tibia lossis humerus tuaj yeem xaiv.
3. Kev muaj peev xwm nrawm nrawm: Lub tshuab IO niaj hnub no, ua ke nrog cov cuab yeej ua kom lub cev muaj zog, tuaj yeem ua tiav tus nqi ntws ntau dua 125 mL / min, ua tau raws li qhov xav tau ntawm kev nthuav dav nrawm. Los ntawm kev mob siab rau IO catheter (xws li 15G EZ-IO) thiab lub hnab ntim siab, tus nqi ntws tuaj yeem ncav cuag 250 mL / min, nce mus txog qib loj - txoj kab uas hla peripheral leeg.
4. Ntshav cov khoom infusion: Cov kev tshawb fawb tau pom tias infusing cov khoom siv ntshav xws li cov qe ntshav liab, ntshav, thiab platelets los ntawm txoj kev IO muaj kev nyab xeeb thiab siv tau zoo. Qee qib ntawm hemolysis tshwm sim thaum cov ntshav dhau los ntawm cov pob txha kab noj hniav, tab sis qhov kev kho mob tsuas yog txwv. Rau cov neeg mob raug mob uas xav tau loj - ntim ntshav, IO tuaj yeem siv los ua txoj hauv kev pib, thaum npaj txoj hauv kev hauv nruab nrab venous nyob rau tib lub sijhawm.
Kev txiav txim siab rau daim ntawv thov ntawm Cov Neeg Laus Tshwj Xeeb
Rau qee pawg neeg mob laus, tsim kom muaj kev nkag mus rau hauv cov hlab ntsha tuaj yeem yog qhov nyuaj tshwj xeeb. Nyob rau hauv xws li mob, qhov chaw nres nkoj implantable (IO) feem ntau yog qhov kev xaiv zoo tshaj plaws los yog thawj qhov kev xaiv.
- Cov neeg mob rog: Cov neeg mob rog rog hnyav (BMI> 40) feem ntau muaj cov leeg sib sib zog nqus thiab nkag tsis tau. Cov cim tseem ceeb ntawm cov pob txha yog qhov tsis cuam tshuam los ntawm kev rog, thiab qhov kev ua tiav ntawm kev sib tsoo tseem siab. Txawm li cas los xij, ib rab koob ntev (xws li 45mm EZ-IO koob) yuav tsum tau siv.
- Cov neeg siv tshuaj txhaj tshuaj: Ntev- cov neeg siv tshuaj txhaj tshuaj hauv lub sijhawm ntev nrog cov tawv nqaij tawv, thrombosed, thiab kab mob peripheral leeg tsis tuaj yeem siv txoj kev no. Txoj hauv kev ntawm cov pob txha kab noj hniav tsis cuam tshuam los ntawm cov xwm txheej no.
- Cov neeg mob kub hnyiab: Cov neeg mob uas muaj qhov kub hnyiab heev muaj qhov txwv qhov chaw thiab feem ntau raug kev txom nyem los ntawm qhov mob hnyav. Cov pob txha txoj hauj lwm yog qhov tsis tu ncua thiab yog ib qho kev xaiv txhim khu kev qha. Txawm li cas los xij, yuav tsum tau saib xyuas kom tsis txhob muaj kev sib tsoo los ntawm cov tawv nqaij kub hnyiab los tiv thaiv kev kis kab mob.
- Cov neeg laus: Osteoporosis tuaj yeem ua rau qhov nyuaj ntawm kev sib tsoo, tab sis lub zog tsav ntawm cov cuab yeej IO niaj hnub tuaj yeem hloov kho kom haum rau cov pob txha sib txawv. Cov pob txha ntawm cov neeg laus cov neeg mob yog nkig, thiab yuav tsum tau saib xyuas kom tsis txhob punctures tob heev, uas yuav ua rau nkag mus rau lub opposite cortical pob txha.
- Cov neeg mob Pathological edema: Cov neeg mob uas muaj lub plawv tsis ua hauj lwm hnyav lossis lub raum tsis ua haujlwm tau ua rau edema, thiab cov venous landmarks ploj mus. Cov pob txha txoj hauj lwm tsis cuam tshuam los ntawm edema, ua rau nws yog qhov kev xaiv zoo tshaj plaws.
Kev txiav txim siab tshwj xeeb rau cov tshuaj infusion
Txawm hais tias yuav luag tag nrho cov tshuaj resuscitation tuaj yeem siv los ntawm IO, muaj qee yam tshuaj uas yuav tsum tau ceev faj tshwj xeeb:
- Cov kev daws teeb meem Hypertonic: xws li hypertonic saline, mannitol, tuaj yeem ua rau mob pob txha kab noj hniav. Ua ntej- noj tshuaj nrog lidocaine (ntawm tib txoj kev IO) los yog qeeb infusion ntawm diluted tov tuaj yeem txiav txim siab.
- Cov tshuaj Vasopressor: epinephrine, norepinephrine, thiab lwm yam tuaj yeem muab tshuaj zoo los ntawm IO. Txawm li cas los xij, nws yuav tsum tau muab sau tseg tias nyob rau hauv qis qis qis, cov tshuaj yuav nyob twj ywm hauv cov pob txha kab noj hniav rau lub sijhawm luv luv, thiab thaum cov hlab ntsha rov pib dua, cov tshuaj ntau yuav nkag mus rau hauv cov hlab ntsha ib zaug, ua rau muaj ntshav siab sai. Nws raug nquahu kom pib nrog ib koob tshuaj me me thiab ua tib zoo saib xyuas.
- Tshuaj tua kab mob: txhua yam tshuaj tua kab mob siv tau tuaj yeem siv los ntawm IO. Muaj ib txoj kev xav txog kev pheej hmoo ntawm pob txha pob txha, tab sis qhov tshwm sim tiag tiag yog tsawg heev (<1%) and is related to the duration of the indwelling.
- Contrast agents: iodine contrast agents for CT scans can be administrative by IO, tab sis yuav tsum tau siv ib lub syringe pressurized thiab infusion npaum li cas qeeb dua li intravenous infusion. Cov kev tshawb fawb tau pom tias cov duab zoo tau txais.
Tiv thaiv thiab tswj cov teeb meem
Qhov tshwm sim ntawm cov neeg laus IO teeb meem yog kwv yees li 1-2%, thiab lawv feem ntau suav nrog:
- Infiltration ntawm qhov chaw puncture: Feem ntau qhov teeb meem, feem ntau yog vim lub koob lub taub hau tsis tau tag nrho nyob rau hauv cov pob txha kab noj hniav los yog cov puncture yog ua nyob rau hauv lub opposite pob txha cortex. Kev Kho Mob: Nres cov tshuaj, tshem tawm thiab hloov qhov chaw.
- Pob txha: Tsis tshua muaj, feem ntau tshwm sim rau cov tib neeg uas muaj pob txha pob txha hnyav lossis nrog cov txheej txheem puncture tsis raug. Kev Tiv Thaiv: Xaiv qhov chaw uas muaj cov pob txha zoo dua qub thiab tsis txhob punctures ntawm qhov chaw pob txha qub.
- Tendon sheath syndrome: Qhov mob hnyav tshaj plaws tab sis tsis tshua muaj tshwm sim, tshwm sim los ntawm qhov ntau ntawm cov kua dej nrawm nrawm mus rau hauv cov leeg nqaij. Kev Tiv Thaiv: Tsis txhob siv cov koob ntev dhau lawm, xyuas kom cov koob taub nyob rau hauv txoj hauj lwm kom raug, thiab saib xyuas qhov chaw puncture. Kev Kho Mob: Tshem cov koob tam sim ntawd, thiab yog tias tsim nyog, ua fasciotomy rau decompression.
- Kab mob: tshwm sim hauv<1% of cases and is related to the duration of indwelling. Prevention: Strict aseptic procedures, transfer to a venous access as soon as possible, and keep the indwelling for no more than 24 hours.
- Fat embolism: Txoj kev pheej hmoo, tab sis qhov tseeb tsis tshua muaj. Kev Tiv Thaiv: Tsis txhob tso dej ntau dhau los tiv thaiv kev kub ntxhov.
Qhov tseem ceeb ntawm kev cob qhia thiab simulation
Txawm hais tias IO puncture yog cov txheej txheem yooj yim, nws yuav tsum muaj kev cob qhia tsim nyog thiab kev txawj ntse ntxiv. Kev cob qhia simulation yog qhov tseem ceeb thiab yuav tsum tau ua siv cov cuab yeej IO tiag tiag thiab cov pob txha simulated (lossis cov pob txha tsiaj). Kev cob qhia tsom xam muaj xws li:
1. Kev txheeb xyuas qhov tseeb ntawm thaj chaw anatomical
2. Kev sib dhos kom raug thiab siv cov khoom siv
3. Mastery ntawm puncture kaum
4. Kev lees paub ntawm rab koob lub taub hau txoj hauj lwm (xav tias ploj lawm, ruaj khov koob tuav, du aspiration)
5. Kev sib txuas thiab fixation ntawm tubing
6. Kev txheeb xyuas thiab kho cov teeb meem
Cov kev tshawb fawb tau pom tias los ntawm kev simulation kev cob qhia, thawj zaug - lub sijhawm ua tiav ntawm IO puncture tuaj yeem nce los ntawm 60% rau cov neeg pib tshiab mus rau ntau dua 90% rau cov kws paub txog kev paub, thiab lub sijhawm ua haujlwm tuaj yeem luv los ntawm ob peb feeb mus rau 30-60 vib nas this.
Xaus: Kev hloov pauv ntawm Kev xav thaum muaj xwm txheej ceev
Kev siv dav dav ntawm kev nkag mus rau hauv intramedullary hauv kev saib xyuas neeg laus thaum muaj xwm txheej kub ntxhov sawv cev rau kev hloov pauv hauv kev xav hauv kev kho mob: los ntawm "sim nrhiav cov leeg" mus rau "kom muaj kev nkag tau zoo". Nws lees paub cov kev txwv ntawm cov txheej txheem ib txwm muaj nyob rau hauv cov xwm txheej physiological heev thiab muab kev ntseeg siab, nrawm, thiab yooj yim -rau- tus tswv lwm txoj kev. Nyob rau lub sijhawm tseem ceeb xws li mob plawv, mob hnyav, thiab ntau qhov kev raug mob, IO nkag mus feem ntau txhais tau tias muaj feem thib ob. Nrog rau kev txhim kho cov cuab yeej siv, kev tsim cov ntaub ntawv pov thawj, thiab kev tshaj tawm kev cob qhia, IO tau hloov zuj zus los ntawm "qhov chaw kawg" mus rau "kev xaiv thaum ntxov", dhau los ua ib qho txuj ci tseem ceeb hauv cov neeg laus niaj hnub kho mob xwm txheej ceev, tiag tiag embodying lub tswv yim xwm txheej ceev ntawm "tsim kom muaj kev nkag tau zoo ntawm lub sijhawm rau tus neeg mob zoo".