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Chapter 893 Grab Time

For this group of wounded, the most urgent thing at present is not to deal with their superficial trauma or broken and smashed limbs-yes, these are not the most important tasks.

In the eyes of emergency doctors, broken arms and legs are just a small problem.Although it is very painful, although it is uncomfortable, although it will bring almost endless torture to the patient in the future.

But that's not the most important thing right now.

"Urgently check blood potassium and urine protein, infuse 50 milliliters of isotonic saline per hour, and [-] milligrams of sodium bicarbonate per hour—the priority is to ensure that the patient's urine output exceeds [-] milliliters per hour." Zhou Jun quickly issued a treatment opinion, "It is necessary to ensure that the patient receives plenty of fluids and checks blood potassium every hour."

All of these patients were overstressed.And the specific oppression time is hard to estimate.So as a receiving doctor, Zhou Jun must be alert to the possibility of crush syndrome.

Once crush syndrome occurs, it is not a question of whether you will be disabled in the future, but a matter of life and death within a few minutes.

The patient who was pasted with black tape by Cao Yanhua before is now in such a state of life and death.After a wave of 8 minutes of full-force CPR, and as many as 8 times of electrical cardioversion combined with the use of 20ml of 5% calcium chloride solution, he barely recovered sinus rhythm.The blood gas report of the quick check confirmed the concerns of the doctors-the patient's blood potassium was as high as 9.46mmol/L.At the same time, his right arm and left leg had very obvious manifestations of compartment syndrome.The limbs were whitish and swollen, the fingers and toes curled up, and the arterial pulse could not be felt.

"His compartment syndrome...may have saved his life." For this situation, Dr. Cao Yanhua judged this way, "Crushing caused fractures and muscle death at the same time. Fractures caused tissue edema, causing bone and tendon Compartment syndrome, but this ischemia instead slows down the release of potassium into the bloodstream from dead cells in the right arm and left leg."

"Send it to the operating room after an hour. If the limb can be preserved, it will be preserved. If it cannot be preserved, it will be amputated directly." After rushing over, Zhou Jun glanced at the general report, and immediately made a decision, "Connect the dialysis machine first, and use all your strength. Potassium reduction."

Although compartment syndrome is a rare symptom in orthopedic treatment that needs to talk about "mortality", the risk to patients is even greater if surgery is performed immediately.The mainstay of treatment for compartment syndrome is complete incision of the fascia for decompression.After the fascia is cut to decompress, the blood flow in the injured area will improve immediately.This also means that a large number of blood released from dead muscle cells and accumulated in the occluded vein will rush quickly towards the heart.

Dead muscle cells release a lot of substances.But it's potassium and myoglobin that kill the most.A large amount of potassium will affect the relaxation and relaxation of muscles, causing the muscles to contract all the time, so that the heart muscle cannot complete the "stretch-contraction" pumping work.Myoglobin, in turn, clogs the kidney's filtration system, causing acute kidney injury and triggering a more severe electrolyte imbalance.

The dialysis machine is the most suitable means to deal with this symptom - the dialysis machine can filter out myoglobin and potassium in the blood, and quickly adjust the electrolyte level in the patient's body that has been completely out of balance.

But the dialysis machine needs time to work, and patients with compartment syndrome... the most lacking is time.

If the patient's blood potassium cannot be lowered to an acceptable level before the operation, the patient may directly experience fatal arrhythmia or even arrest during the operation.Compared with this risk, amputation has become an acceptable loss.

In such an emergency, it is impossible to contact the family members of patients and ask them to authorize relevant medical decisions.Fortunately, the higher-level department has pulled out the emergency response mechanism, and Zhou Jun doesn't even need to go to the hospital office to ask for the corresponding authorization—he can make a decision based on the situation on the spot, and as for the authorization and the like, he can just make up for it later.

"We can't save trouble and let it go." Although the patient's condition was serious, Zhou Jun still did not directly decide to perform amputation for him. "Treat it as much as you can, and if you can lower the blood potassium level, let's talk about it after lowering it."

Even if the amputation is aimed at cutting off the limbs to prevent the blood potassium level from continuing to rise, it will also cause the patient's blood potassium to rise-when cutting muscle tissue and connective tissue, when performing joint detachment, it will inevitably hurt the currently healthy body. organization.The patient's blood potassium level will still rise.

Other things can be ignored, but the blood potassium level must be lowered.

In order to lower the patient's blood potassium, doctors used many means.In addition to using calcium to antagonize the adverse effects of blood potassium on the myocardium, they also used a combination of short-acting insulin + glucose, using insulin to promote the process of converting glucose into glycogen, and bringing potassium ions into cells—that is, the so-called The means of "promoting potassium transfer into cells".

Since it is temporarily uncertain whether the patient has intestinal perforation after receiving heavy pressure, and the patient is unconscious and difficult to cooperate, the solution of using sodium exchange resin cannot be used.And in order to prevent the kidneys from being blocked by a large amount of myoglobin, the plan of using diuretics to excrete potassium was also temporarily suspended.

The only thing that could save his life was the dialysis machine.

"According to this blood potassium level, it will take at least two hours of dialysis to reduce it to a normal level." The nurse in charge of emergency dialysis roughly looked at the patient's blood potassium level, and said with a frown, "It takes a machine to be turned on to the maximum. Just over two hours."

"Then go to two stations." Zhou Jun grasped the time very tightly, "Two stations together, no matter what, his blood potassium should be lowered within an hour."

Short-acting insulin and dextrose lower potassium levels a bit, but only to a limited extent and not for long.Using calcium chloride to antagonize hyperkalemia levels also has certain risks - pushing too fast may also cause arrhythmia or cardiac arrest, after all, calcium is responsible for relaxing muscles during muscle work.The heart is an organ that needs to relax and then contract at any time. Although hypercalcemia and hyperkalemia have different effects on muscles, the final results are the same.

"If the two machines are on together, it will take less than an hour." The nurse installed the dialysis tube on the patient and said to Zhou Jun, "When the blood potassium is removed, we usually lower the blood potassium to a lower level to prevent withdrawal. The blood potassium rebounded rapidly after the machine was turned off. If the operation is urgent, you can consider not withdrawing the tube but turning off the machine—continuing hemodialysis during the operation.”

"Just do it like this." It is impossible for doctors to master every detail and skill in the medical process. In daily work, nurses are not only the executors of the treatment plan, but also undertake the responsibility of making suggestions for doctors and reviewing the doctor's treatment plan. Role.Zhou Jun immediately adopted this treatment plan, and prescribed a new treatment plan again—this time using antibiotics to prevent postoperative infection.

One hemodialysis machine after another was pushed into the emergency room. Among the sixteen injured, seven had blood potassium levels greater than 7mmol/L. If he hadn't known that they were patients with crush syndrome, Zhou Jun would have thought that the gang People are ready to commit mass suicide—the method of suicide is oral potassium chloride solution.And you have to drink two hundred milliliters in one go.

　There are double monthly tickets starting today, everyone who has a ticket, vote for it...

　　
　
(End of this chapter)