海水淹溺院前急救体会

淹溺是意外伤害死亡的主要原因之一。据WHO资料,2000年全球发生淹溺估计有449 000例,其发生率约为7.4/100 000。海水淹溺后易致海水淹溺性肺水肿（PE-SWD）,若未及时发现救治,死亡率较高。     

海水淹溺患者的院前急救

海水浴疗法是夏季海滨疗养院组织疗养员实施的重要疗养方法之一,组织海水浴的同时,医护人员肩负着避免淹溺意外事故的发生,保证疗养员生命安全的重任,因此疗养院医护人员对海水淹溺患者现场急救技术的熟练掌握至关重要。溺水后尽早开始基础生命支持,恢复有效呼吸、循环是成功复苏、降低死亡率和严重神经系统后遗症最有效的方法。     

海水淹溺性急性肺损伤兔几种细胞因子的动态变化

目的 探讨TNF-α、IL-1β、IL-6 、IL-8、IL-10等细胞因子在海水淹溺性ALI中的作用.方法 36只新西兰兔随机分成六组:0(对照组),灌注1、3、6、12、24 h组,每组6只动物.灌注组经气管插管灌注2 mL/kg海水.不同时间点观察各组动物血气分析的变化.计算肺湿干质量比(W/D)、肺通透指数(LPI).以ELISA法检测肺组织和血清中TNF-α、IL-1β、IL-6 、IL-8、IL-10表达水平,同时进行病理学检查,并计算肺病理评分.结果 灌注海水后氧合指数迅速低至300以下,持续时间长达6 h.W/D值于S3h达高峰,肺通透指数以S6h组数值最高.各时间点肺组织和血清中TNF-α、IL-1β、IL-8、IL-10均显著高于对照组(P<0.05或P<0.01).TNF-α、IL-1β、IL-10高峰在6 h,IL-8高峰在12 h.血清IL-6于1 h后持续在最高水平,肺组织IL-6浓度仅在6 h时升高(P<0.05).肺大体标本于灌注后3 h瘀血水肿最严重,体积最大.显微镜下炎症细胞浸润于6～12 h最突出,肺泡间隔宽度随时间延长而加重.肺病理评分1 h时已显著高于对照组(P<0.01),6 h达最高.LPI,肺组织和血清TNF-α、IL-1β、IL-8、IL-10及血清IL-6表达与肺损伤程度呈正相关(P<0.05或P<0.01),TNF-α与IL-1β、IL-10以及血清IL-6亦密切相关.结论 TNF-α、IL-1β、IL-6、IL-8、IL-10等细胞因子以协同或拮抗的方式参与了海水淹溺性ALI的病理过程,全身性炎症反应和抗炎反应的失衡在海水淹溺性ALI发生发展中可能起重要作用.     

中性粒细胞活化在海水淹溺致肺损伤中的作用

目的 探讨中性粒细胞活化在海水淹溺致肺损伤中的作用.方法 36只新西兰兔随机分成6组:0(对照)、1、3、6、12、24 h组,每组6只动物.海水组经气管插管灌注2 mL/kg海水.观察不同时间点血气分析和支气管肺泡灌洗液(BALF)中性粒细胞计数及百分比的变化,计算肺通透指数(LPI);以生化法检测髓过氧化物酶(MPO)、丙二醛(MDA)含量,以酶联免疫吸附法(ELISA)分析中性粒细胞弹性蛋白酶(NE)活性,同时进行病理学检查,并计算肺病理评分(LPS).结果灌注海水后氧合指数迅速低至300 mm Hg 以下,持续时间长达6 h(P<0.01).肺大体标本以灌注后3 h瘀血水肿最严重,体积最大.显微镜下炎症细胞浸润以6~12 h最突出,肺泡间隔宽度随时间延长而加重.各时间点BALF中性粒细胞计数及百分比,肺组织NE、MPO、MDA含量,LPI及LPS均显著高于对照组(P<0.05或P<0.01),多于3~12 h达高峰.各指标间均有显著相关性(P<0.05或P<0.01).结论 中性粒细胞是SWD-ALI早期主要的炎症效应细胞,氧化应激反应与NE释放协同参与了肺组织损伤.中性粒细胞募集和活化在SWD-ALI发生发展中起重要作用.     

地塞米松对海水淹溺性肺损伤兔肺水肿吸收的影响

目的探讨地塞米松对海水淹溺性肺损伤兔的肺泡钠水转运系统及肺水肿的影响。方法新西兰兔随机分成对照组(CG)和地塞米松治疗组(BG)。CG兔(n=12)的气管内灌注4 ml/kg海水,DG兔(n=12)在CG的基础上静注1 mg/kg地塞米松。肺水肿用血管外肺水含量指数(EVLWI)监测。给药3 h收集肺组织标本,分别用RT-PCR和Western印迹检测肺组织中钠离子通道-α亚单位mRNA(α-ENaC mRNA)和钠钾泵-α1亚单位(NKA-α1)蛋白的丰度以及水解法检测NKA活性。结果DG的EVLWI显著的低于CG[(0．508±0．089)vs．(0．648±0．102),P＜0．05],而α-ENaC mRNA和NKA-α1蛋白的丰度均显著的高于相应的CG(P＜0．05,P＜0．05),NKA活性也显著的高于CG(P＜0．05)。结论地塞米松可增加肺泡钠水转运系统的表达或活性,并减轻海水灌注肺损伤兔的肺水肿。     

东莨菪碱治疗海水淹溺肺水肿15例

目的：探讨应用东莨碱治疗海水淹溺肺水肿的疗效。方法：对15例海水淹溺者接诊后立即去泡沫吸氧,建立静脉通道,静推东良菪碱0．3－0．9mg,每5－30min1次,视病情变化增减剂量或延长给药间隔,观察疗效。结果显效10例,有效5例。本组15例涨水淹溺肺水肿抢救成功13例。2例并发急性广泛前壁心肌梗塞室颤,抢救无效死亡。结论：东莨菪碱可以减轻肺水肿,使造成溺水者死亡的主要原因紧控制,取得满意的疗效。可作为抢救海水淹溺肺水肿的儿药。     

特布他林对海水淹溺型肺水肿兔肺水吸收的影响

目的 观察特布他林对海水淹溺型肺水肿(PE-SWD)兔肺水吸收的影响.方法 36只新西兰兔的PE-SWD机械通气模型,随机分成正常组(N组)、对照组(C组)和特布他林治疗组(T组).在不同时间点观察动脉血气分析,检测三组的血管外肺水含量指数(EVLWI)、伊文思兰漏出(ELI)指数,同时分别用RT-PCR和Western印迹检测肺组织中钠离子通道-α亚单位mR-NA(α-ENaC mRNA)和钠钾泵-α1亚单位(NKA-α1)蛋白的丰度,用水解法检测肺组织匀浆中Na -K -ATP酶(NKA)活性,并对肺组织进行病理学检查.结果 特布他林干预后PE-SWD兔血氧分压(PaO2)、二氧化碳分压(PaCO2)等均较对照组有明显改善(P<0.05).T组EVLWI显著低于C组(P<0.05),而α-ENaC mRNA和NKA-α1蛋白的丰度及NKA活性均显著的高于相应的C组(P<0.05),NKA活性也显著的高于C组(P<0.05).结论 特布他林可增加肺泡钠水转运系统的表达或活性来促进PE-SWD兔肺水的吸收,减轻肺水肿.     

低温海水淹溺大鼠额叶脑皮质与血浆神经肽Y及降压素的变化

目的 :观察低温海水淹溺过程中大鼠额叶皮质脑组织与血浆神经肽 Y (NPY)和降压素 (NT)以及NPY与 NT比值 (NPY/NT)的变化规律。方法 :将不同组的大鼠分别置于 19℃～ 2 1℃海水中自由游动。取30℃、2 5℃及 2 2℃组 (溺死组 )大鼠左心室血 1m l检测血气 (2 2℃组例外 ) ,2 ml用于检测 NPY及 NT放射免疫指标 ;最后取大鼠额叶皮质脑组织进行 NPY及 NT放射免疫指标检测。结果 :随着大鼠体温降低 ,脑组织NPY于 30℃组升达 (118.36± 14 .2 1) ng/L(P<0 .0 1) ,NT于 2 5℃组升达 (2 15 .77± 31.5 4 ) ng/L (P<0 .0 1) ,NPY/NT于 2 5℃组降至 0 .4 5± 0 .14 (P <0 .0 5 ) ;血浆 NPY及 NPY/NT逐步下降 ,2 2℃组分别达(2 93.6 7± 72 .84 ) ng/L (P <0 .0 1)及 2 .39± 0 .82 (P<0 .0 1) ,血浆 NT逐步升高 ,2 2℃组升高达 (132 .96±32 .5 9) ng/L (P<0 .0 1)。结论 :海水淹溺过程中的低体温、酸中毒和窒息是导致 NPY和 NT变化的重要原因 ;NPY和 NT失衡可能引起大脑皮质功能障碍。     

海水淹溺急性肺损伤大鼠肺组织水通道蛋白5表达变化的研究

目的 观测海水淹溺急性肺损伤(ALI)大鼠肺组织水通道蛋白5(AQP5)表达变化.方法 100只健康雄性Wistar大鼠随机分为两组,即海水淹溺组和对照组.海水淹溺组用气管吸入海水法建立模型,对照组除不吸入海水外,其他处理同海水淹溺组.分别于致伤后0.5、1、2、4及8 h时点,取大鼠颈动脉血做血气分析,观察动脉血氧分压(PaO2)的变化;光镜下观察肺组织病理变化情况;采用免疫组织化学法检测肺组织表达与分布;采用RT-PCR方法检测AQP5 mRNA表达.结果 成功复制了大鼠海水淹溺ALI模型:海水淹溺组在吸入海水后血PaO2明显下降,海水淹溺组各时点血PaO2显著低于对应时点对照组(P<0.01).光镜下可见海水淹溺组各时点肺组织有毛细血管充血、肺间质、肺泡水肿和灶性出血;对照组未见明显病理变化.免疫组化显示,海水淹溺组肺间质的毛细血管内皮AQP5的阳性表达,积分光密度值显著高于对照组的表达(P<0.05);海水淹溺组大鼠肺组织AQP5 mRNA表达也显著高于对照组(P<0.01).结论 海水淹溺ALI时肺组织AQP5蛋白及mRNA表达增加,AQP5在ALI/ARDS海水的转运中可能起着重要作用.     

Prehospital care: emergency medical services

Emergency medical services are becoming an increasingly important aspect of health care delivery. Prehospital care providers, termed paramedics, follow established protocols and work under a medical director in implementing treatment on the scene. Special problems include the physician on the scene, issues of consent and liability, and the treatment of terminally ill patients.     

Prehospital trauma care

The past two decades have been a period of increased concern over the improvement of prehospital emergency medical care. Training of basic and advanced EMTs to a level of professionalism that includes a distinct body of knowledge and the use of assessment and management skills is only one component of the prehospital system. Communications systems, transportation deployment plans, and improved links with hospitals have contributed to the refinement of emergency medical systems. The management of the trauma victim is an organized plan of controlling the airway, restoring breathing, and supporting ventilation, followed by a secondary survey of the less life-threatening problems. The role of EMTs or paramedics, therefore, is to assess, manage, extricate, and transport.     

Prehospital care of left ventricular assist device patients by emergency medical services

Abstract Left ventricular assist devices (LVADs) are frequently implanted as permanent (bridge to destination [BTD]) or temporary (bridge to transplantation [BTT]) cardiac support. When LVAD patients are discharged to home, they are very likely to require emergency medical services (EMS), but there is very little literature on out-of-hospital emergency care for patients with LVADs. We present two typical cases of LVAD patients for whom EMS was called. In the first case, the patient was in an ambulance two hours distant from our university hospital when a pulsatile system malfunctioned. In the second case, EMS was called to an unconscious LVAD patient. Emergency reference cards, training programs for emergency medical staff, and a 24-hour emergency hotline for the local VAD team are advisable. Key words: left ventricular assist device; emergency medical services; prehospital care.     

Prehospital emergency care.

Prehospital care is a diverse and complex entity. Recent studies have begun to emphasize the importance of all aspects of care in the community, leading through to critical analysis of the process of prehospital care provision. This paper examines the various aspects of prehospital care and discusses the various elements which need to be considered to provide effective care prior to patients being attended to at hospital.     

Prehospital care in Indonesia

Current system: Hospitals of varying standards are widespread but have no system of emergency ambulance or patient retrieval. Indonesia's only public emergency ambulance service, 118, is based in five of the biggest cities and is leading the way in paramedic training and prehospital care.

Challenges and developments: There are many challenges faced including the culture of acceptance, vast geographical areas, traffic, inadequate numbers of ambulances, and access to quality training resources. Recently there have been a number of encouraging developments including setting up of a disaster response brigade, better provision of ambulances, and development of paramedic training.

Conclusions: An integrated national regionalised hospital and prehospital system may seem fantastic but with the enthusiasm of those involved and perhaps some help from countries with access to training resources it may not be an unrealistic goal.

     

综合实验治疗海水淹溺肺水肿兔的肺形态结构变化观察

目的;观察综合治疗海水淹溺肺水肿（ＰＥ－ＳＷＤ）兔的肺形态结构变化并探讨作用机制。方法：用海水灌注的方法制作ＰＥ－ＳＷＤ模型,分别采用高频喷辞去爱气（ＨＦＪＶ）联合４种药物治疗,一氧化氮（ＮＯ）治疗和高压氧（ＨＢＯ）治疗,观察经３种综合实验治疗后兔肺形态结构变化,并用Ｃａ＾２＋超微结构方法观察兔肺细胞内Ｃａ６２＋变化。结果：３组治疗措施均能明显减轻肺水肿病变,且能明显缓解细胞内Ｃａ＾２＋超负荷状况