急性有机磷农药中毒的急救护理

目的 探讨急性有机磷农药中毒的急救与护理措施,提高抢救成功率.方法 回顾性分析110例急性有机磷农药中毒的临床资料,对急救护理措施进行总结.结果 轻度、中度中毒均治愈,中度中毒患者死亡5例,抢救成功率95.5%.结论 彻底清除毒物,洗胃,正确使用阿托品和胆碱酯酶复能剂是抢救有机磷农药中毒成功的关键.     

创伤性休克的急救与护理研究

目的 探讨创伤性休克的急救与护理方法.方法 51例创伤性休克患者依据国际创伤急救复苏ABC原则,给予保持气道通畅,维持呼吸,进行液体复苏,采取紧急确定性手术等方法进行急救,并采取相应护理措施.结果 本组患者急救30min、1h后HR降低,SBP、DBP、MAP升高,尿量增加,急救1h后患者K+降低,Na+、Cl-升高,与急救前比较差异均有统计学意义(P<0.01).结论 建立有效循环,补充足够血容量,积极治疗原发病是抢救创伤性休克患者的关键.     

First Heal Thyself : Rescue of Dysfunctional Endothelial Progenitor Cells Restores Function to the Injured Kidney

This commentary discusses the role of endothelial progenitor cells in injured kidney.While the attention of the scientific community is focused on a panoply of possibilities for the use of progenitor and stem cells in promoting repair in a variety of tissues and organs, a study appears which suggests that these cells themselves may need to undergo repair before they can mount an effective healing and regenerative response. In this issue of the Journal, Yasuda and coworkers outline a convincing case for resident endothelial progenitor cell incompetence in the injured kidney as well as showing that this can be overcome by adoptive transfer of cells of the same type.¹The backdrop of this intriguing study was provided by the work of Challen et al² who followed others^3,4,5 in characterizing a “kidney side population” of cells, demonstrating that injection of these cells was able to reduce proteinuria in a mouse model of adriamycin-nephropathy. These data built on studies of murine hematopoietic stem cells, which demonstrate low fluorescence after staining with the dye Hoechst 33342, a characteristic which has been useful in the purification of these cells. When used in combination with other markers, such low-dye-expressing cells have been described as “side population” cells based on their ability to export intracellular dye rapidly.^5,6,7 Putative stem cells from a variety of tissues appear to conform to this phenotype.⁸In the study of Challen et al,² a resident population of cells of nonhematopoietic immunotype was identified, with a proximal tubular location and the ability to differentiate into multiple lineages. Introduction of such cells into mice with adriamycin-nephropathy improved glomerular filtration rates and decreased albuminuria but did not appear to integrate into renal tubules, leaving the mechanism for functional improvement unclear.The present study of Yasuda et al has taken this story forward in a new and potentially exciting direction. Using the adriamycin-nephropathy model, they hypothesized that impairment of endothelial progenitor cell (EPC) function is the basis for impaired regeneration and, if this were the case, rescue by exogenous endothelial precursor cells might be possible. They analyzed hematopoietic stem cells (HSCs) and EPCs derived from the kidneys of mice with adriamycin-nephropathy. (HSCs were CD150 and CD117 [c-kit] double-positive, and EPCs were CD34 and Flk-1 double-positive.)Both resident populations were sparse (<0.1% of total cell number) in control kidneys and did not change numerically after adriamycin-induced injury. These cells demonstrated decreased viability, increased senescence, and increased apoptosis, which were not attributable to loss of stromal cell–derived factor-1 production, a potential “niche” for such cells. In other words, they were dysfunctional cells.Adoptive transfer of normal EPCs resulted in improvement of glomerular filtration rate and reduction in proteinuria with a threefold decrease in mortality. This appeared to be associated with an improvement in the density of the microvasculature and a reduction of apoptosis, which were paralleled by reduced plasma levels of interleukin-1α and -β and Granulocyte Colony-Stimulating Factor (G-CSF) and an increase in vascular endothelial growth factor.A single injection of EPCs led to an approximately sevenfold increase in both HSCs and EPCs in the diseased kidneys, representing less than 2% of the injected cells. (The time course of the EPC increase in the kidney suggested that trafficking via the bone marrow may occur.)One route by which these adoptively-transferred cells were able to engage the resident cell population, and which was explored by Yasuda et al,¹ was tunneling nanotube formation between EPCs and mature endothelial cells. The formation of these microscopic tube-like structures extending between cells allows for the transfer of subcellular organelles. Transfer of fluorescent mitochondria was demonstrated from EPCs to adriamycin-injured HUVECs in vitro.Adoptive transfer of EPCs (which is achieved by systemic administration and does not require direct injection into the kidney) may serve as a useful tool, or even therapy, for mobilizing a healing response in diseased organs, but the route by which this may be achieved is not clear; what is intriguing is the possibility of a central role played by the microvasculature in the process.There is now convincing evidence in a number of experimental models of progressive kidney disease, that chronic hypoxia, which is associated with interstitial microvascular insufficiency and obliteration, is central to the progressive scarring process.^9,10 The possibility exists that homing of progenitor cells could be augmented by local hypoxia,⁹ but there is no current information to support or refute this. Evidence that adriamycin-nephropathy is associated with a decrease in glomerular and peritubular capillary density¹ indicates that, if left untreated, the kidneys will undergo scarring and loss of function. The restoration of microvasculature density with increased plasma vascular endothelial growth factor levels after adoptive transfer of EPC, in the study of Yasuda et al,¹ points to the potential reversibility of such kidney injury.The debate continues about whether or not a “renal stem cell” exists, and, if such a cell-type does exist, could it be used in a cellular therapeutic context? The literature remains conflicting on this issue.¹¹ The fact that the kidney has the ability to recover from acute injury does not imply the existence of such cells because differentiated resident cells could regenerate themselves. What seems quite certain, however, is that it is not possible to re-grow new nephrons in the adult kidney. So, any repair which does occur would have to be within the scaffolding of an existing nephron structure. Could a progenitor cell that gives rise to cells of different phenotypes achieve this feat by generating different phenotypes in different segments of the adult nephron? Although possible, this scenario is hard to imagine.At the end of the day, the architecture of the kidney makes it very different from other organs, such as the liver or the gastrointestinal tract, where cellular proliferation is the predominant repair mechanism. In contrast, each microscopic nephron is a home unto itself, and cellular regeneration and hypertrophy must occur within the confines of its existing walls.An intriguing possibility not discussed in the paper of Yasuda et al is that reversal of a variety of kidney diseases and progressive diseases of other organs may not require that stem cells be differentiated into phenotypes specific to the organ in order to achieve healing and regeneration, but that a strategy that results only in microvasculature restoration could serve as the common pathway to healing. Certainly in an acute setting, selective engraftment of a kidney-derived mesenchymal cell line has been shown to result in vasculogenesis and to promote functional recovery after acute ischemic injury of the kidney.¹²So, a new scenario suggests itself. It could be argued that the only prerequisite for renal regeneration after chronic injury is an adequate microvasculature supply and that it is the job of endothelial progenitor cells to look after this. When the kidney is injured, for instance by adriamycin, such cells malfunction and the microvasculature deteriorates in parallel with dysfunction of endothelial precursors. The ensuing local hypoxia leads to nephron loss and organ fibrosis. To reverse this process, all that may be needed is to re-establish normal EPC function or to re-supply normally functioning EPCs. Such normally-functioning progenitor cells could link up with resident endothelial cells to re-establish a functioning microvasculature. Improved perfusion and oxygenation would allow for the resident tubular and glomerular cells on the margins of injured areas to undergo hyperplasia and repair within the scaffolding of surviving nephrons. No tubular or glomerular cell differentiation from progenitor cells is needed for such repair, and no new nephrons need to be created. A restored microvasculature may be all that is required to initiate a fully differentiated tissue response to restore chronically-injured tissue. The kidney could then breathe again! The same paradigm could apply to the regeneration of other organs.     

某基层医院护士急救能力培训需求分析

目的 了解基层医院护理人员对急救能力的培训需求,为基层医院护理人员开展急救知识和技能培训方案提供依据。方法采用自行设计的调查问卷对某县级基层医院的141名护理人员对急救培训的内容和方式的需求进行调查。结果 6项急救能力需求中,认为“非常需要”比例占最大的项目为“解决问题”“配合协作”“发现问题”能力需求,其中“技术操作”“理论联系实际”“发现问题”3项“需要”比例大,分别为55.32%、51.06%、47.52%。护士期望的培训方式则以示范教学和短期培训（14.12%）、情景模拟（12.57%）、经验交流（10.83%）为主。不同学历之间的技术操作、不同科室之间的配合协作需要程度比较,差异均有统计学意义（P＜0.05）。专科学历护士对技术操作的需求程度高于本科学历护士,普通病房和急诊护士对配合协作能力的非常需要程度均高于ICU,差异具有统计学意义（P＜0.05）。结论 发现问题在急救能力需求中受到关注,基层护士需要发现疾病问题的能力,也是早期开展急救工作的关键。专科学历护士对技术操作的需求程度较高,普通病房和急诊护士对配合协作能力的需求程度较高,基层护士对急救能力培训方式期望程度依次为示范教学、短期培训、情景模拟、经验交流、案例分析、专题讲座、上级进修等。     

持续质量改进在急救药品物品管理中的应用

目的 评价持续质量改进在急救药品物品管理中的应用效果。方法 将持续质量改进应用于急救药品物品管理中,定期检查急救药品物品质量,汇总问题,制定改进措施,比较应用前后的急救药品物品管理质量。结果 持续质量改进后急救药品物品布局图、标识指引正确符合率、急救车封条粘贴准确率、急救药品物品品种数量与目录符合率分别由76.92%、89.01%、97.80%,均提高至100.00%,急救药品物品完好率由97.74%提高至99.99%。实施前后比较,差异有统计学意义（P＜0.05）。结论 持续质量改进提升护理管理者的管理能力和水平,提高急救药品物品管理效果,促进护理质量的持续改进和提升。     

经皮穿刺气管切开术在神经外科重症患者急救中的运用与护理

目的探究采用经皮穿刺气管切开术在神经外科重症患者急救中的效果以及护理配合。方法选择行经皮穿刺气管切开术患者53例为观察组;选取同期内行开放性气管切开术的53例患者为对照组。两组均采用有效的护理干预,对比两组治疗效果。结果手术时间、术中出血量、切口长度以及伤口愈合时间均显著短于对照组,差异显著(P0.05);观察组术后并发症发生率低于对照组,差异显著(P0.05)。结论对于神经外科重症患者在急救中实施经皮穿刺气管切开术可有效改善治疗效果,缩短患者恢复时间,提高治疗安全性。在围术期间还需给予有效护理干预措施,以确保治疗顺利进行,提高患者抢救成功率。     

院前急救对中重度急性有机磷农药中毒患者的预后影响

目的 研究早期院前急救对中重度急性有机磷农药中毒(AOPP)患者预后相关因素的影响.方法 选择中重度AOPP患者120例,随机分为两组,120接入组(观察组)74例,自行入院组(对照组)46例.比较两组服毒至开始急救及洗胃的时间,分析两组的预后情况.结果 两组比较,观察组患者服毒至开始急救及洗胃的平均时间均低于对照组(P＜0.01);观察组患者的住院前死亡率及总死亡率均低于对照组(P＜0.01);两组住院后治愈率均达94%以上(P＞0.05),但观察组患者住院平均天数明显缩短(P＜0.01).结论 中重度AOPP患者院前死亡率较高,早期院前急救施措的应用能改善患者的预后,降低死亡率.     

Assessment of the Injured Ankle in the Athlete

OBJECTIVE: To present appropriate tools to assist in the assessment and evaluation of ankle injuries in athletes. DATA SOURCES: A MEDLINE search was performed for the years 1980-2001 using the terms ankle injuries and ankle sprains. DATA SYNTHESIS: Ankle sprains are the most common injuries sustained by athletes. In order to render appropriate treatment, a proper evaluation must be made. Assessment of ankle injuries includes obtaining a good history of the mechanism of injury, a thorough physical examination, and judicious use of radiographic evaluation and special tests. I will outline techniques for diagnosing the most common ankle injuries among athletes. CONCLUSIONS/RECOMMENDATIONS: In order to provide appropriate treatment, the examiner must differentiate among injuries to the lateral ankle-ligament complex, subtalar joint, deltoid ligament, and syndesmosis. It is important to realize that injury can occur to any or all of these structures simultaneously.     

Injured athletes and the risk of suicide

Research on the emotional responses of athletes to injury shows significant depression that may be profound and may last a month or more, paralleling the athlete's perceived recovery. Injured athletes cared for by athletic trainers are often between the ages of 15 to 24, the high-risk age group for suicide, which is currently a leading cause of death for young Americans. The purposes of this paper are to discuss postinjury depression, the incidence and risk factors of suicide, athletic injury as a psychosocial risk factor, the features common to suicide attempts in case studies of five injured athletes, and the motivation of athletes for sport participation. We also suggest ways in which athletic trainers can assess injured athletes for depression and risk of suicide. The five injured athletes who attempted suicide shared several common factors. All had experienced 1) considerable success before sustaining injury; 2) a serious injury requiring surgery; 3) a long, arduous rehabilitation with restriction from their preferred sport; 4) a lack of preinjury competence on return to sport; and 5) being replaced in their positions by teammates. Also, all were in the highrisk age group for suicide. As a primary care provider, the certified athletic trainer is in an ideal position to detect serious postinjury depression and to determine whether the injured athlete is at risk for suicide.