I-Aortic Dissection kanye ne-Rptured Abdominal Aortic Aneurysm (AAA) Triage¶

I-acute aorta dissection kanye ne-abdominal aortic aneurysm (AAA) ephukile yizimo eziphuthumayo zenhliziyo nemithambo yegazi ezikhathini eziningi kwezokwelapha, ezikwazi ukubangela ukopha okubulalayo kwangaphakathi noma ukwehluleka kwesitho phakathi nemizuzu. Ngenxa yokuthi i-aorta iwumthambo oyinhloko womfutho ophezulu othwala igazi eline-oksijini lisuka enhliziyweni liye ngqo ebuchosheni, ezingalweni, ezithweni nasezinyaweni, noma yikuphi ukudabuka odongeni lwayo lwangaphakathi (i-dissection) noma ukuqhuma engxenyeni ebuthaka (i-aneurysm ephukile) kudinga ukungenelela okuphuthumayo kokuhlinzwa okuphuthumayo. Usizo lokuqala lugxile ekuqapheleni ngokushesha izimpawu zefulegi elibomvu, ukubiza abezimo eziphuthumayo ngezexwayiso ezicacile zemithambo yegazi, ukugcina umuntu enganyakazi ukuze avimbele ukukhuphuka komfutho wegazi, nokugwema imithi efana ne-aspirin eyenza ukopha kube kubi kakhulu.

Yenza lokhu manje¶

1. Shayela inombolo yakho yasendaweni yezimo eziphuthumayo ngokushesha futhi umemezele "Isimo Esiphuthumayo Esiphuthumayo Esiphuthumayo" noma "I-Aortic Aortic Aneurysm Esolwayo." Shayela u-911 e-United States nase-Canada, 112 yonkana i-European Union, 999 e-United Kingdom, noma uhlole konke izinombolo eziphuthumayo. Tshela ngokucacile u-dispatcher uma isiguli sine-aortic aneurysm eyaziwayo, i-Marfan syndrome, i-bicuspid aortic valve, noma isifuba esidabula kungazelelwe, iqolo, noma isisu esibuhlungu ngokuquleka, ukuze bakwazi ukuthumela i-ambulensi yokusekela impilo ethuthukisiwe futhi baxwayise isibhedlela esinekhono lokuhlinzwa kwe-cardiothoracic noma i-vascular.
2. Mbeke emhlane umuntu emhlane (noma endaweni enethezekile yokulala kancane uma ephelelwa umoya) futhi uphoqelele ukuphumula komzimba okuphelele. Ungamvumeli lowo muntu ukuthi asukume, ahambe aye endlini yokugezela, noma aphumele ngaphandle aye ku-ambulensi. Noma yikuphi ukuzikhandla ngokomzimba, ukucindezela, noma ukuma kungazelelwe kubangela ukushaya kwenhliziyo nomfutho wegazi ophakeme (ukucindezeleka kwe-shear) okungabangela ukudabuka kwe-aorta equkethwe noma i-retroperitoneal hematoma ukuthi iqhume ngokuphelele esifubeni noma emgodini wesisu.
3. godla konke ukudla, amanzi, uketshezi, nemithi ephuzwayo, ikakhulukazi i-aspirin ne-nitroglycerin. Ungamgcini umuntu ngomlomo (NPO) ngoba uzodinga izinzwa eziphuthumayo eziphuthumayo ngokushesha lapho efika esibhedlela. Unganikezi i-aspirin, i-clopidogrel, noma izifutho ze-nitroglycerin ezingaphansi kolimi ngaphandle uma uyalwe ngokucacile udokotela okhiphe i-aortic pathology.
4. Gcina umuntu ezolile, ethule, futhi esesimweni esivamile kuyilapho ufiphalisa izibani ezikhanyayo futhi wehlisa ukwethuka ngokomzwelo. Ukwesaba nobuhlungu obukhulu kukhulula amagagasi amakhulu e-adrenaline (i-epinephrine ne-norepinephrine) egazini, okuqhubeza umfutho wegazi we-systolic kanye nokuqina kwe-aortic wall. Khuluma ngezwi elinensayo, eliqinisekisayo, khulula amabhande aqinile noma ukhololo, bese umboza umuntu ngengubo eyodwa yokulala ukuze ugweme ukuqhaqhazela ngaphandle kokuwashisa ngokweqile.
5. Hlola ukushaya kwenhliziyo ezihlakaleni zombili futhi uqaphele noma ikuphi ubuthakathaka obuhlangothini olulodwa, ukuba ndikindiki, noma umehluko womfutho wegazi. Uma unomfutho wegazi wasekhaya, kala umfutho wegazikuzo zombili izingalo ezingakwesokudla nesobunxele ngesikhathi ulinde abezimo eziphuthumayo, bese ubhala izinombolo. Yizwa kahle ukushaya kwe-radial ezihlakaleni zombili noma uhlole ukuthi umlenze owodwa uphaphathekile yini, ubanda, noma ukhubazekile, njengoba ukuhlukaniswa kwe-aorta kuvame ukuvimba amagatsha adla ingalo eyodwa, ubuchopho, noma imilenze.
6. Vula iminyango, qoqa amarekhodi ezokwelapha noma amakhadi ezinsiza afakiwe, futhi ulungiselele i-CPR esheshayo uma umuntu ewa. Cela obukele avule umnyango wangaphambili futhi avule indlela ye-ambulensi yohlaka. Uma lowo muntu engasabeli futhi eyeka ukuphefumula ngendlela evamile, qala ngokushesha CPR ngokucindezelwa kwesifuba ngo-100 kuya ku-120 beats ngomzuzu.

Isihlahla sesinqumo sokunquma okuphuthumayo kanye nokuhlukanisa¶

Sebenzisa leli shidi lokugeleza lomtholampilo ukuze uhlukanise phakathi kwe-acute thoracic aortic dissection, i-aorta yesisu ephukile, kanye ne-myocardial infarction evamile noma umgogodla we-musculoskeletal back strain phakathi nemizuzu yokuqala yenkinga.

flowchart TD
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    RedFlags -->|"YEBO: Ifulegi elilodwa noma ngaphezulu elibomvu lemithambo"| SuspectAorta["SOLWA I-ACUTE AORTIC CATASTROPHE<br/>(I-Aortic Dissection noma i-AAA Ephukile)"]

    SuspectAorta --> CallEMS["Shayela ku-911 / 112 / 999 Ngokushesha:<br/>Memezela 'I-Aortic Dissection esolwayo noma i-AAA Ephukile'<br/>Cela ukuthuthwa ku-Vascular / Cardiothoracic Center"]

    CallEMS --> NoAspirin["IZIVIVINYO EZILIMILE:<br/>1. UNGANIKEZI i-Aspirin noma izinto ezinciphisa igazi<br/>2. UNGAKUniki ukudla noma amanzi (Gcina i-NPO ukuze uhlinzwe)<br/>3. UNGASIvumeli isiguli sime, sihambe, noma sizikhandle"]

    NoAspirin --> LocationCheck{"Buphi ubuhlungu obuyinhloko<br/>futhi ziyini izimpawu?"}

    LocationCheck -->|"Isifuba sangaphambili noma umhlane ongenhla phakathi kwamahlombe ehlombe<br/>Izingalo ezingalingani ezingalingani / izimpawu ze-BP noma unhlangothi"| DissectionCare["I-Thoracic Aortic Dissection (Uhlobo A / B) okusolwayo (Uhlobo A / B):<br/>- Hlala uzolile futhi unganyakazi (uhlale kancane noma uphansi)<br/>- Kala i-BP ezingalweni ZOMBILI nesobunxele uma i-cuff itholakala<br/>- Gada eduze ukuze uthole i-stroke, i-tamponade, noma ukonakala kwendlela yomoya"]

    LocationCheck -->|"Phakathi nesisu, iqolo eliphansi, noma ihlangothi/igroin<br/>Iphaphathekile, i-clammy, isiyezi, i-hypotensive, noma > 60 yrs ebhemayo"| AAACare["Okusolwa ukuthi I-Aortic Aortic Aneurysm (AAA) Yesisu Ephukile:<br/>- Lala ngomhlane; UNGACIndezeli ujule esiswini<br/>- Zigcine ufudumele ngengubo ukuze uvimbele i-hypothermia<br/>- Lungiselela ukushaqeka kwe-hypovolemic kanye nokudluliselwa kokuhlinzwa okusheshayo"]

    RedFlags -->|"CHA: Ukucindezela kancane kancane/ukucindezela ubuhlungu besifuba,<br/>ukushaya kwengalo okulinganayo, akukho ukudabuka"| CheckMI["Linganisela I-Acute Coronary Syndrome / I-Heart Attack:<br/>Bona Umhlahlandlela Wokuhlaselwa Kwenhliziyo we-EMS ejwayelekile kanye nephrothokholi ye-aspirin"]

Ukuqonda izimo eziphuthumayo ezimbili ezisongela ukuphila ze-aorta¶

Nakuba zombili izimo zihilela ukwehluleka kwesakhiwo komthambo omkhulu womzimba, ukuhlukaniswa kwe-aorta okunamandla kanye ne-abdominal aorta aneurysm ephukile (AAA) kwenzeka ngezinqubo ezihlukene zokukhanda, kuthinta amaphrofayili esiguli ngandlela-thile, futhi kudinga amasu ahlukile esibhedlela esiphuthumayo.

1. I-Acute Aortic Dissection: Izinyembezi zangaphakathi ezinomfutho ophezulu¶

Udonga lwe-aorta enempilo luqukethe izingqimba ezintathu ezincane ezincane: ulwelwesi oluncane lwangaphakathi (tunica intima), ungqimba oluphakathi olunwebekayo olunwebekayo oluphakathi (tunica media), kanye nejakhethi yangaphandle eqinile ye-fibrous (tunica adventitia). Ku-aorta dissection, kudabuke kungazelelwe olwembeni lwangaphakathi lwangaphakathi, ngokuvamile esifubeni (i-thoracic aorta) lapho igazi lishiya khona inhliziyo ngesivinini esikhulu.

Uma igazi selibhodloza kulokhu kudabukelwa kwangaphakathi ngaphansi komfutho we-systolic, lihlukanisa (lihlukanisa) ungqimba lwemisipha oluphakathi, liqophe "lumen yamanga" (umzuzwana, umgudu wegazi ongavamile) phansi noma phezulu ngobude be-aorta. Njengoba leli siteshi esingamanga sinamabhaluni anegazi, libangela izingozi ezine ezisongela ukuphila ngokushesha: - Ukuqhekeka ku-pericardial sac (I-Cardiac Tamponade): Uma ukuhlukaniswa kuhamba kuhlehla kuya enhliziyweni kungene esakeni le-pericardial elizungeze umsipha wenhliziyo, igazi ligcwalisa isaka bese licindezela inhliziyo ize ingakwazi ukupompa, okubangela ukufa kungazelelwe. - I-acute aortic valve regurgitation: Ukudabuka kungaqaqa amapheshana e-aorta valve, kubangele igazi lithele lihlehle ku-ventricle yesokunxele futhi kugcwale amaphaphu ngoketshezi (flash pulmonary edema). - I-Coronary artery occlusion: I-flap ehlukanisayo ingagunda endaweni evulekile ye-coronary artery engakwesokudla noma kwesokunxele, kuqalise kanyekanye isifo senhliziyo. - Ukungasebenzi kahle komkhumbi wegatsha (I-Stroke, Paraplegia, Visceral Ischemia): Njengoba i-lumen yamanga izungeza phansi ku-aorta, i-flap yangaphakathi eqhumayo ingakwazi ukucisha imithambo ye-carotid ephakela ubuchopho (okubangele ngokushesha). unhlangothi), imithambo ye-subclavia ephakela izingalo (okubangela ukushayeka kwesandla esihlakaleni), imithambo yomgogodla ezondla umgogodla (okubangela ukukhubazeka okuzumayo kwemilenze yomibili), noma imithambo ye-mesenteric kanye nezinso ezondla amathumbu nezinso.

Odokotela bahlukanisa ukuhlukaniswa kwe-aorta besebenzisa I-Stanford Classification System, ebeka ukunakekelwa okusheshayo kokusinda: - I-Stanford Type A Dissection: Ihilela i-aorta ekhuphukayo (ingxenye yokuqala ephuma ngokuqondile enhliziyweni) kanye/noma i-aorta arch, kungakhathaliseki ukuthi ihambe ibanga elingakanani. Izihlinzeki zohlobo lwe-A ziyizimo eziphuthumayo zokuhlinzwa ezinenani lokufa elikhuphuka cishe ngamaphesenti angu-1 kuya ku-2 wehora ngalinye ukulungiswa kokuhlinzwa kubambezeleka phakathi namahora angu-48 okuqala. - I-Stanford Type B Dissection: Iqala ekwehleni i-thoracic aorta (ngale komthambo ongakwesokunxele we-subclavia odla ingalo yangakwesokunxele) futhi yehle iye phansi ngasesiswini. Ukuhlukaniswa kohlobo lwe-B kulawulwa ekuqaleni ngomfutho wegazi ongenela emthanjeni nokulawula izinga lokushaya kwenhliziyo ("ukwelapha okulwa nomfutho"), kanye nokulungiswa kwe-stent-graft ye-endovascular (TEVAR) uma izitho zibulawa yindlala yegazi noma udonga lusongela ukuqhuma.

2. I-Reptured Abdominal Aortic Aneurysm (AAA): Udonga oluqhumayo olubuthakathaka¶

I-aneurysm iwukunwebeka okuhlala njalo, okwenziwe kwasendaweni (ibhaluni) yazo zonke izendlalelo ezintathu zodonga lwe-arterial okubangelwa ukonakala okungapheli kwemicu yokunwebeka kanye ne-collagen. Nakuba i-aneurysm ingase yenzeke esifubeni (i-thoracic aortic aneurysm), ivame kakhulu ngaphansi kwesisu esingaphansi kwemithambo yezinso (infrarenal abdominal aortic aneurysm, noma AAA), lapho i-aorta evamile yabantu abadala ikala cishe amasentimitha angu-2.0 (0.8 amayintshi) ububanzi. Uma leyo ngxenye inweba ngaphezu kuka-3.0 amasentimitha (1.2 amayintshi), ichazwa njenge-aneurysm; uma seludlule ku-5.0 kuya ku-5.5 amasentimitha (2.0 kuya ku-2.2 amayintshi), ingozi yokuqhekeka kodonga ikhuphuka kakhulu.

Iningi lama-aneurysm e-aorta yesisu likhula buthule phakathi neminyaka ngaphandle kokubangela uphawu olulodwa kuze kube yilapho likhula ngokuzumayo noma lidabuka livuleke (i-AAA ephukile). Lapho i-AAA iqhuma, igazi liphuma ku-aorta libe kwesinye sezikhala ezimbili: - Ukuphuka Kwamahhala Kwe-Intraperitoneal: Udonga lwangaphambili lwe-aneurysm luqhuma ngqo emgodini wesisu ovulekile. Ukukhishwa okukhulu kwe-exsanguination kwenzeka phakathi nemizuzu, ngokuvamile kubangela ukuboshwa kwenhliziyo ngokushesha ngaphambi kokuba i-ambulensi ifike. - Kuqukethwe I-Retroperitoneal Rupture (Iwindi Le-Golden Triage): Eningini leziguli ezisinda isikhathi eside ngokwanele ukuze zifinyelele esibhedlela, i-aneurysm ikhala endaweni eqinile retroperitoneal ngemuva komgudu wesisu (eduze komgogodla kanye nemisipha ye-psoas). Izicubu ezizungezile kanye nomfutho wegazi okwehlayo kubamba okwesikhashana (ukuvala) ukuvuza imizuzu engama-30 kuya emahoreni ambalwa. Kodwa-ke, uma isiguli sizikhandla, sizihluza, noma sithola uketshezi oluningi olufakwa emthanjeni olunyusa umfutho wegazi waso uphakeme kakhulu, leli hlule le-retroperitoneal elintekenteke liyaphuma, liguqule ukuvuza okukhona okungasinda kube ukopha kwamahhala okubulalayo.

Ukuqhathanisa okuphelele: I-Aortic Dissection vs. I-Rptured AAA vs. Heart Attack¶

Ngenxa yokuthi isifuba, iqolo, nobuhlungu besisu yizikhalazo ezivamile, abathumeli bezimo eziphuthumayo kanye nababukele bavame ukuhlukanisa ngokungalungile izinhlekelele ze-aorta njengokuhlasela kwenhliziyo, amatshe ezinso, noma i-sciatica. Buyekeza leli thebula lokuqhathanisa ukuze ubone izimpawu ezihlukanisayo:

Ukuqaphela izimpawu zefulegi elibomvu ngokuningiliziwe¶

Izimpawu ze-Classic kanye ne-atypical ze-Acute Aortic Dissection¶

Ngokusho kwe-International Registry of Acute Aortic Dissection (IRAD) kanye neziqondiso ze-ACC/AHA, ngaphezu kwamaphesenti angu-90 eziguli ezine-aortic dissection ebuhlungu zizwa ubuhlungu obungazelelwe, kodwa kuze kufike kumaphesenti angu-30 ekuqaleni axilongwa kahle. Buka lawa maqoqo omtholampilo:

1. Ubuhlungu "bokudabuka" noma "ukuklebhuka" obungazelelwe, obukhulu kakhulu ekuqaleni: Ngokungafani nesifo senhliziyo esakheka kancane emaminithini ambalwa, ubuhlungu be-aorta dissection bunzima kakhulu ngomzuzwana wokuqala njengoba ungqimba olungaphakathi luklebhuka. Iziguli zikuchaza njengokuzizwa "njengento edatshulwe phakathi kwesifuba sami" noma "njengokugwazwa phakathi kwamahlombe ehlombe."
2. Indlela yobuhlungu obufudukayo: Njengoba ukuhlinza kudabula i-aorta isuka esifubeni iye esiswini, ubuhlungu bungase buqale esifubeni noma emphinjeni, buhambe phakathi kwamahlombe emizuzwini eyi-10 kamuva, bese bushisa emhlane ongezansi noma ezinqulwini.
3. "Pain Plus One" (Ubuhlungu Besifuba/Emuva Buhlanganiswe Nezimpawu Zemizwa noma Zesitho): Noma nini lapho isifuba noma ubuhlungu beqolo kuba nokushoda kwemizwa noma isitho esibandayo, cabanga ukuhlukaniswa kwe-aorta kuqala:
4. Ubuhlungu besifuba/umhlane + Izimpawu zokushaywa unhlangothi: Ukunwebeka emithanjeni ye-carotid kubangela ubuthakathaka obungalindelekile ohlangothini olulodwa, ukuwohloka kobuso, noma ukulahlekelwa ukukhuluma. (Isexwayiso esibalulekile sasesibhedlela: Ukunikeza izidakamizwa ezivimba ihlule elifakwe emthanjeni njenge-tPA/tenecteplase esigulini sohlangothi olubangelwa ukuhlukaniswa kwe-aorta okufihliwe kohlobo A cishe kubulale emhlabeni wonke.)
5. Ubuhlungu besifuba/umgogodla + I-Paraplegia (Imilenze Ekhubazekile): Ukugunda kwemithambo yomgogodla (ikakhulukazi umthambo we-Adamkiewicz) kubangela ukukhubazeka okungazelelwe kanye nokuba ndikindiki kuyo yomibili imilenze.
6. Ubuhlungu besifuba/umhlane + I-Acute Limb Ischemia: Ukuvaleka komthambo we-subclavian noma we-iliac kushiya ingalo eyodwa noma umlenze owodwa ufile umhlophe, ubanda njengeqhwa, ungenawo ipulseless, futhi ubuhlungu.
7. I-Painless Syncope (Ukuquleka) kumaphesenti angu-5 kuya kwangu-10 ezimweni: Cishe isiguli esingu-1 kwezingu-10 esinesifo sokuhlinza siyaquleka sibe nobuhlungu obuncane besifuba obubikiwe noma abukho nhlobo, ngokuvamile ngenxa yokuthi igazi liye laputshuzela esikhwameni se-pericardial (i-tamonade yenhliziyo) noma linqamule kafushane ukugeleza kwegazi kwe-carotid.

Uthathu wakudala kanye "nomaskandi" be-Ruptured Abdominal Aortic Aneurysm (AAA)¶

Unxantathu wencwadi yakudala ye-AAA ephukile uhlanganisaubuhlungu besisu/umhlane/esifuleni ngokuzumayo, hypotension noma i-syncope, kanye nesisindo sesisu esidonsayo. Kodwa-ke, ucwaningo oluvela ku-UK National Institute for Health and Care Excellence (NICE) kanye ne-Society for Vascular Surgery (SVS) lubonisa ukuthi **zonke izici ezintathu zenzeka ndawonye ngaphansi kwamaphesenti angu-50 eziguli ze-AAA eziphukile **. Esikhundleni salokho, bheka okuthathu okujwayeleke kakhulu omaskandi basemtholampilo:

Ubani osengozini enkulu: izici zofuzo, ezokwelapha, kanye nendlela yokuphila¶

Ukwabelana ngomlando wesici sobungozi ne-911/112/999 dispatcher kanye nomhlengikazi wegumbi lezimo eziphuthumayo kungenye yezindlela ezisheshayo zokuqalisa i-ultrasound eseceleni kombhede noma i-CT angiogram.

Usizo lokuqala lwesinyathelo ngesinyathelo kanye nokunakekelwa kwangaphambi kwesibhedlela ngenkathi kulindelwe i-EMS¶

Uma unakekela umuntu okusolakala ukuthi une-aorta dissection noma i-aorta aneurysm yesisu ephukile ngaphambi kokuba abezimo eziphuthumayo bafike, sonke isenzo siklanyelwe ukunciphisa ukucindezelwa kwe-aorta odongeni lokugunda kanye nokugcina ihlule eliqukethwe.

Isinyathelo 1: Ukuma kokuzinza kwe-hemodynamic¶

• I-Thoracic Aortic Dissection esolwayo (ubuhlungu besifuba/umgogodla ongenhla, ngokuvamile umfutho wegazi ophakeme): Basize balale phansi endaweni ebangela ubuhlungu obuncane nokuphefumula okulula, ngokuvamile ukulala (okuphansi emhlane) noma i-semi-Fowler's (ikhanda namahlombe asekelwe kancane nge-engeli engu-30-degree). Ungalokothi uphoqe isiguli esidonsa kanzima ukuphefumula ukuthi silale sicaba.
• Okusolwa ukuthi Kuqhume i-AAA noma izimpawu ze ukwethuka (aphaphatheka, amakhaza, anesiyezi, aquleke): Alalise ngokushelela emhlane. Ungayiphakamisi imilenze ngamandla uma kubangela ubuhlungu besisu, futhi ungalokothi uyivumele ukuthi ihlale iqonde noma ime, njengoba ukuhlala kudonsa igazi elisele ebuchosheni nasenhliziyweni.
• Uqulekile noma uphalaza: Zigoqe kancane ohlangothini lwazo uzifake kwisimo sokubuyisela emuva njengeyunithi eyodwa (isitayela se-log-roll, ngaphandle kokusonta umlenze) ukuze ukuhlanza kungangeni emaphashini.

Isinyathelo sesi-2: UNGADLALI kancane noma ucindezele ujule esiswini esishaya ngamandla¶

Uma ubona noma usola ukushaya kwenhliziyo phakathi nesisu somuntu, ungacindezeli ujule esiswini ukuze usihlole, futhi ungabavumeli abaseduze abanezisusa ezinhle ukuthi baphushe isisu. Ingcindezi ejulile eyenziwa ngesandla phezu kwe-aorta yesisu enezindonga ezincane, evuzayo ingaphazamisa ihlule le-retroperitoneal elintekenteke futhi kubangele ukugqashuka kwamahhala ngokushesha.

Isinyathelo sesi-3: Ungawenza kanjani izingalo ezimbili zegazi kanye nokuhlola ukushaya kwenhliziyo¶

Uma isiqapheli somfutho wegazi sasekhaya sedijithali siseduze futhi ukusisebenzisa ngeke kubambezeleke ukushayela abezimo eziphuthumayo noma kuphazamise isiguli: 1. Kala futhi ubhale phansi umfutho wegazi nokushaya kwenhliziyo ku-ingalo engenhla engenhla. 2. Ngokushesha hambisa i-cuff* engalweni engenhla kwesokunxele** bese ukala umfutho wegazi lapho. 3. Zisho ukuthini izinombolo: Kumuntu ophile kahle, umfutho wegazi we-systolic phakathi kwengalo yesokudla nesobunxele uyahluka ngaphansi kuka-\(10\text{ mmHg}\). Umehluko we-systolic womfutho wegazi omkhulu kuno-\(20\umbhalo{ mmHg}\) phakathi kwezingalo zesokudla nesobunxele (okubhangqwe nesifuba esibuhlungu noma ubuhlungu beqolo) ubonisa ukuthi i-aorta dissection flap ingase ivimbe omunye wemithambo engaphansi kwe-subclavia. Bika zombili izinombolo eziqondile kwabezimo eziphuthumayo ngokushesha nje lapho befika.

Isinyathelo sesi-4: Ukuzola ngokomzimba ("I-Verbal Beta-Blockade")¶

Emnyangweni wezimo eziphuthumayo esibhedlela, ukwelashwa kokuqala kwe-aorta dissection yi-beta-blockers (efana ne-esmolol noma i-labetalol) ukuze kwehlise izinga lokushaya kwenhliziyo libe ngaphansi kokungu-\(60\text{ beats per minute}\) kanye nomfutho wegazi we-systolic phakathi kuka-\(100\text{ kanye }no-}120\text{ mmHg}\), ukwehlisa ukushaya kwenhliziyo ngakunye noma ukushaya kwenhliziyo ngakunye. Ekhaya, ngaphambi kokuba kufike imithi ye-IV, uvalo nobuhlungu kuyisitha: - Sula izixuku ezithukile ziphume ekamelweni futhi uqeqeshe isiguli ukuthi siphefumule kancane, kancane, sikugweme ngokuqinile ukubamba umoya noma ukwehlisa (**gwema ukuqondisa kwe-Valsalva **, okucindezela i-aortic). - Gcina indawo ithule futhi ubaqinisekise ukuthi usizo lusekude nemizuzu.

Isinyathelo sesi-5: Ukuphatha ukuvikelwa kwe-thermal (Ukuvimbela i-Lethal Triad)¶

Esigulini esine-AAA ephukile esilahlekelwa igazi ngaphakathi, izinga lokushisa lomzimba lehla ngokushesha. I-Hypothermia (izinga lokushisa lomzimba lingaphansi kuka-\(35^\circ\text{C}\) noma \(95^\circ\text{F}\)) ikhubaza ama-enzyme namaplatelet okujiyisa kwegazi, okwenza ukopha kwangaphakathi kube kubi kakhulu. Mboza isiguli kusukela esilevini kuye ezinzwaneni ngezingubo zokulala ezomile noma amajazi, futhi ubeke ingubo ngaphansi kwaso uma silele endaweni ebandayo.

Ukuqonda imiqondo ye-ambulensi nesibhedlela: I-Permissive Hypotension and Impulse Control¶

Ukwazi ukuthi yini abezimo eziphuthumayo kanye nodokotela bezimo eziphuthumayo abazokwenza kusiza amalungu omndeni ukuthi akhulume ngokucacile ngesikhathi senkinga ye-aortic:

1. Kungani abezimo eziphuthumayo bezilolongela i-"Permissive Hypotension" ku-Rptured AAA¶

Ezimweni eziphuthumayo eziningi zezokwelapha ezibandakanya umfutho wegazi ophansi, abezimo eziphuthumayo bajova izikhwama ezinkulu zosawoti ofakwa emthanjeni ngokushesha ukuze umfutho wegazi ubuyele ku-\(120/80\text{ mmHg}\). Ekuphukeni kwe-aorta yesisu ephukile noma i-aorta dissection, okunikeza umthamo omkhulu woketshezi lwe-IV ukwenza umfutho wegazi ube ujwayelekile ngaphambi kokuba udokotela ohlinzayo ayibambe i-aorta kuyingozi. - Ukwenyusa umfutho wegazi we-systolic ube ngaphezu kuka-\(90\text{ ukuya }100\text{ mmHg}\) ngosawoti oxuba izinto zemvelo zokujiyisa, kupholise igazi, futhi kuphephetha ihlule lesikhashana ("okuphuma ihlule") okugcina isiguli siphila. - Ngakho-ke, imihlahlandlela yamazwe ngamazwe (i-NICE NG156 yase-United Kingdom, i-Society for Vascular Surgery e-United States, kanye ne-European Society for Vascular Surgery) iqondisa abezimo eziphuthumayo ukuba basebenzise i-permissive hypotension: inqobo nje uma isiguli siphapheme, sikhuluma, futhi sigcina umfutho wegazi we-systolic cishe \(70\text{kuya }90}\) inqatshelwe uketshezi inciphisa uketshezi* mmH egumbini lokuhlinza imithambo.

2. Kungani ukudlula esibhedlela ukuya esikhungweni se-Aortic kusindisa izimpilo¶

Akuzona zonke izibhedlela zasendaweni ezinodokotela ohlinza i-cardiothoracic (wohlobo A lwe-aortic dissection) noma udokotela ohlinza imithambo one-endovascular hybrid operating suite (ye-AAA ephukile) ocingweni amahora angu-24 ngosuku. Uma usho ngokucacile "I-Suspected Aortic Dissection" noma "I-Abdominal Aortic Aneurysm Eyaziwayo Nge-Sudden Pain and Syncope" phakathi nocingo lwakho oluphuthumayo lokuqala, izinhlelo ze-EMS zesifunda zingenza kusebenze indlela Direct-to-OR "Code Rapture" noma "Code Aorta", idlule emitholampilo emincane eqondile.

Umbhalo oqondile wokuxhumana we-911/112/999 kanye nokuhlolwa esibhedlela¶

Uma ukhuluma nomuntu ohambisa izimo eziphuthumayo noma umhlengikazi we-triage, sebenzisa lolu limi oluthile lomtholampilo:

• Ngokwe-Suspected Aortic Dissection:

  "Ngidinga i-ambulensi yezimo eziphuthumayo kokuthi [Ikheli Eliqondile]. Isiguli sineminyaka [Yobudala] ubudala [owesilisa/owesifazane] owaqala ukudabuka ngokushesha, u-10-out-10 [isifuba / umgogodla ongenhla] ubuhlungu [ngesikhathi] [Isikhathi]. [He/She] ubuye abe [nomehluko wegazi we-X mmHg phakathi kwe-syndrome yesokudla nesokunxele noma ubuthakathaka obungalindelekile / i-Marcus I-valve]. Sisola ukuthi kune-Acute Aortic Dissection ASIzange sikunikeze i-aspirin."

• Nge-AAA Okusolwa Ukuthi Iqhume:

  "Ngidinga i-ambulensi yezimo eziphuthumayo [Ikheli Elinembile]. Isiguli sineminyaka [Yobudala] ubudala [owesilisa/owesifazane] esine [Abdominal Aortic Aneurysm eyaziwayo / umlando wokubhema nomfutho wegazi ophakeme] okuthe kungazelelwe kwaba nobuhlungu obunzima [besisu / eqolo / emhlane] futhi [uqulekile / uphaphathekile, ujuluka, futhi unesiyezi esinesiyezi]. I-Aneurysm. Sigcina [yena] elele phansi futhi enganyakazi."

Uhlu lokuhlola ukulungiselela ngesikhathi i-ambulensi isendleleni¶

• Isikhathi esiqondile sokuqala kobuhlungu esibhalwe phansi: Odokotela abahlinzayo kudingeka bazi umzuzu oqondile ubuhlungu obudabukisayo noma ukuquleka okwenzeka.
• Kokubili umfutho wegazi wezingalo urekhodiwe (uma kukalwa): Bhala phansi Ingalo Yesokudla i-BP kanye ne-Left Arm BP ephepheni.
• Ukuthwebula kwe-aorta kwangaphambilini noma amakhadi okuhlinza atholakala: Thatha noma isiphi isifinyezo sokukhishwa esibonisa usayizi we-aneurysm wangaphambilini (isb., "4.8 cm infrarenal AAA"), amakhadi okufakelwa kwe-stent-graft, noma amakhadi amavalvu enhliziyo.
• Uhlu oluphelele lwemithi enciphisa igazi ehlonziwe: Tshela abezimo eziphuthumayo ngokushesha uma isiguli sithatha warfarin, apixaban, rivaroxaban, dabigatran, edoxaban, clopidogrel, noma i-aspirin yansuku zonke, ukuze isibhedlela sikwazi ukulungisa ama-ejenti okubuyisela emuva izimo eziphuthumayo (njenge-4-factor prothrombin complex ngaphambi kokuhlinzwa, i-idaruciexab, i-alfactor ne-PCC, i-alfactor, i-alfactor, i-alfactor, i-PCC, i-alfactory, i-alfactor, i-alfactory, i-alfactory, i-alfactor, i-PCC, i-alfactory, i-alfactor, i-alfactor, i-PCC, i-alfactor, i-alfactor, i-PCC, i-alfactor, i-alfactor, i-alfactor, i-PC) ne-aspirin.
• Akukho okuqinisekisiwe ngomlomo: Tshela abezimo eziphuthumayo isikhathi sokudla kokugcina kwesiguli noma isiphuzo ukuze uhlele ngokuphephile izinzwa.

Ukuvimbela nokuhlola: Ukubamba ama-aneurysm ngaphambi kokuba aqhume¶

Ngenxa yokuthi i-aortic aneurysm engaguquki ingalungiswa ngokuzikhethela ngenani lokusinda elingamaphesenti angama-95 kuya kwangu-98, kuyilapho i-aneurysm ephukile inenani lokufa elingamaphesenti angu-70 kuya kwangu-80, ukuhlolwa kwe-ultrasound nokulawulwa komfutho wegazi kusindisa ukuphila:

1. Ukuhlolwa kwe-Abdominal Ultrasound yesikhathi esisodwa:
2. E-United States (USPSTF & SVS Guidelines): I-ultrasound yesisu yesikhathi esisodwa iyanconywa kubo bonke abesilisa abaneminyaka engu-65 kuya ku-75 abake babhema, futhi ngokukhethekile kwabesilisa nabesifazane abaneminyaka engu-65 kuya ku-75 nomlando womndeni wezinga lokuqala we-AAA.
3. E-United Kingdom (NHS AAA Screening Programme): Wonke amadoda amenywa ukuze ahlolwe i-ultrasound yamahhala phakathi nonyaka abaneminyaka engu-65*, futhi noma ubani oneminyaka engaphezu kuka-65 ongakahlolwa angazidlulisela yena.
4. Ukuhlolwa kweGenetic kanye ne-Echocardiographic for Thoracic Aneurysms:
5. Izihlobo ze-first-degree (abazali, izingane zakubo, nezingane) zanoma ubani ohlushwa i-acute thoracic aortic dissection noma one-bicuspid aortic valve kufanele bathole ukwelulekwa ngofuzo kanye nesisekelo i-echocardiography noma i-CT/MR angiography ukukala ububanzi bezimpande zabo ze-aorta.
6. Ukuvikelwa Kwendlela Yokuphila Kwansuku Zonke Kweziguli Ezaziwa Nge-Aneurysm:
7. Yeka ukubhema ngokuphelele (kwehlisa izinga lokunwetshwa kwe-aneurysm ngesigamu) futhi ugcine umfutho wegazi uphumule ngaphansi kuka-\(130/80\text{ mmHg}\).
8. Gwema i-Valsalva straining enkulu: Abantu abane-aorta aneurysms eyaziwayo kufanele bagweme ukuphakamisa isisindo esindayo se-isometric (lapho ubamba umoya wakho futhi ucindezele eduze komthamo omkhulu), okunganyusa umfutho wegazi we-intra-aortic ube ngaphezu kuka-\(300\text{ mmHg}\). Ukuvivinya umzimba okusesilinganisweni ngokuvamile kuyakhuthazwa; qinisekisa imikhawulo ethile yesisindo ngochwepheshe bemithambo.

Imibuzo ejwayelekile ukubuzwa¶

Kungani ukuhlafuna i-aspirin kuyingozi phakathi ne-aorta dissection uma kunconywa ukuhlaselwa yinhliziyo?¶

Isifo senhliziyo sibangelwa ihlule legazi elivala umthambo wenhliziyo, ngakho ukuhlafuna i-aspirin kumisa lelo hlule ukuthi lingakhuli. Ngokuphambene, i-aorta dissection noma i-aneurysm ephukile iwukudabuka komshini odongeni lwe-aorta; ukunikeza i-aspirin kukhubaza ama-platelet, kuvimbela ukwakheka kwamahlule okuvikela, futhi kubangela ukopha okubulalayo esifubeni, esiswini, noma esikhwameni se-pericardial.

Ngingawubona kanjani umehluko phakathi kwe-aortic aneurysm yesisu ephukile kanye netshe lezinso kumuntu omdala omdala?¶

Kokubili kungabangela ubuhlungu obungalindelekile obuhlangothini olulodwa obukhazimula ku-groin ngoba igazi le-retroperitoneal licasula izinzwa ezifanayo kanye ne-ureter njengetshe. Kodwa-ke, noma yimuphi umuntu omdala oneminyaka engaphezu kwengu-55 (ikakhulukazi obhemayo noma onomfutho wegazi ophezulu) oba nobuhlungu betshe ezinso okokuqala ngqa ngesiyezi, isikhumba esiphaphathekile se-clammy, ukuquleka, noma umfutho wegazi ophansi kufanele aphathwe njenge-aortic aneurysm ephukile kuze kube yilapho i-ultrasound noma i-CT scan ikukhipha.

Usho ukuthini umehluko womfutho wegazi phakathi kwezingalo ezingakwesokunxele nezingakwesokudla ngesikhathi sobuhlungu besifuba?¶

Kumuntu omdala onempilo, umfutho wegazi we-systolic phakathi kwezingalo zesokudla nesobunxele uhluka ngaphansi kwamamilimitha ayi-10 e-mercury (mmHg). Uma umuntu onesifuba esibuhlungu ngokuzumayo noma ubuhlungu beqolo enomehluko we-systolic blood pressure omkhulu kuno-20 mmHg phakathi kwezingalo zakhe (noma ukushaya kwesandla okubuthakathaka ohlangothini olulodwa), i-acute dissection flap cishe ivimba umthambo ongaphansi ohlinzeka leyongalo.

Uma umuntu onobuhlungu obungalindelekile bomhlane noma besisu equleka abese evuka ezizwa engcono kakhulu phansi, ingabe isimo esiphuthumayo sesiphelile?¶

Cha, ukululama kwesikhashana ngemva kokuquleka kuwuphawu lwakudala lokuqhekeka kwe-retroperitoneal equkethwe i-aortic aneurysm yesisu noma i-thoracic dissection evuzayo. Lapho umfutho wegazi wehla ngesikhathi sokuquleka futhi isiguli silele sicaba, izicubu ze-retroperitoneal zivala okwesikhashana ukuvuza; uma besukuma noma bephuza ukubiza abezimo eziphuthumayo, lelo hlule elintekenteke livamise ukuqhuma ukopha okubulalayo kungakapheli imizuzu ukuya emahoreni.

Imithombo ihloliwe¶

• I-American College of Cardiology (ACC) kanye ne-American Heart Association (AHA, United States): 2022 ACC/AHA Isiqondiso Sokuxilonga Nokuphathwa Kwesifo Se-Aortic (Circulation / Journal of the American College of Cardiology).
• I-National Institute for Health and Care Excellence (NICE, United Kingdom): Abdominal Aortic Aneurysm: Diagnosis and Management (NICE Guideline NG156, okuhlanganisa ukudluliswa kwezimo eziphuthumayo kanye ne-permissive hypotension protocols).
• I-Society for Vascular Surgery (SVS, United States) kanye ne-European Society for Vascular Surgery (ESVS): Imihlahlandlela Yokuzilolonga Yomtholampilo Ekunakekelweni Kweziguli Ezine-Abdominal Aortic Aneurysm (Chaikof et al., Journal of Vascular Surgery; I-Wanhainen *I-Vascular Surgery, I-Endogenal ye-Vascular et al. 2024).
• I-European Society of Cardiology (ESC): Imihlahlandlela ye-ESC Yokuphathwa Kwezifo Ze-Peripheral Arterial and Aortic (ukubuyekezwa kuka-2024 kuma-acute thoracic aortic syndromes, Uhlobo lwe-Stanford A nohlobo lwe-B, nokuhlosiwe komfutho wegazi).
• I-International Registry of Acute Aortic Dissection (IRAD) & Marfan Foundation / John Ritter Foundation for Aortic Health (United States): Ritter Rules for Triage and Emergency Recognition of Thoracic Aortic Dissection.

Iziqondiso ezihlobene¶

• Ukuqashelwa kokuhlaselwa yinhliziyo kanye nosizo lokuqala olusheshayo
• Ukuqashelwa ukushaqeka kanye nokuphathwa kosizo lokuqala
• Ukuqashelwa kwesifo sohlangothi (FAST) kanye nempendulo ephuthumayo
• Ukuvuselelwa kweCardiopulmonary (CPR) kanye nomhlahlandlela we-AED
• I-Cauda equina syndrome kanye namafulegi abomvu wokucindezelwa kwentambo yomgogodla