vaxtang WumburiZe profesori Terapiis erovnuli centri; giorgi kaWarava jo-enis saxelobis samedicino centri; levan yuraSvili jo-enis saxelobis samedicino centri;
nata gonjilaSvili, jo-enis saxelobis samedicino centri; naTia axalaZe jo-enis saxelobis samedicino centri; giorgi papiaSvili jo-enis saxelobis samedicino centri; paata sulaberiZe akademikos mixeil winamZRvriSvilis saxelobis kardiologiis instituti;
ganmarteba: es moqmedebi gegma gankuTvnilia saswrafo daxmarebis brigadebisa da sadispeCeroebisaTvis. am ukanasknelTa samuSao sqema am etapze moicavs mxolod zogad principebs da momavalSi moiTxovs dazustebas da konkretuli protokolis SemuSavebas. rac Seexeba s.d.b-s moqmedebis gegmas igi exeba konkretulad gulmkerdSi tkivilis dros maT moqmedebas, romelic unda warmoadgendes zogadad saswrafo daxmarebis samuSao protokolebis nawils.
rogorc gulmkerdSi tkivilis gaidlainis srul teqstSia aRniSnuli “swrafi moqmedebis” gegma Sedgeba 5 etapisagan. sadispeCero erTveba me-3 etapidan xolo s.d.b me - 4 etapidan.
mesame etapi - sadispetCero centri
sadispetCero centri es aris organizaciuli struqtura, romlis dispetCerebs evalebaT swrafi gadawyvetilebebis miReba, movlenebis marTva da saswrafo daxmarebis xarisxis uzrunvelyofa.
organizacia
sadispetCero centri
SeiZleba iyos organizebuli, rogorc damoukidebeli struqtura, romelic ar iqneba dakavSirebuli sxva swrafi reagirebis struqturebTan, rogoric aris saxanZro da policia. Tumca, alternativis saxiT es struqturebi SeiZleba mWidro kavSirSi iyos erTmaneTTan. miuxedavad amisa, sadispetCero centri SeiZleba lokalizdebodes absoluturad damoukidebel teritoriaze, magram mWidro kavSiri hqondes sxva erTeulebTan, magaliTad saxanZrosTan, paramedikebTan da policiasTan. informacias SeiZleba iRebdes mxolod erTi sadispetCero servisi da Semdeg gadascemdes Sesabamis struqturebs. a.S.S-s gamocdilebiT gaerTianebul sadispeCeroSi Semosuli zarebis 85% aris sapolicio, 10% iTxovs saswrafo daxmarebas da 5% saxanZros.
dispetCerebi:
dispetCerebi unda gadiodnen specialur treiningebs, raTa pacientTan satelefono kontaqtis dros daicvan samedicino momsaxurebis maRali xarisxi. maTi gadawyvetilebebi zusti da swrafi unda iyos da ar iyos damokidebuli mxolod xist protokolze. kargad trenirebuli dispetCerebi valdebulni arian miscen saTanado rCevebi pacients satelefono kontaqtis dros, Tu dispetCeri ar aris saTanod momzadebuli umjobesia is daeyrdnos mxolod protokols. trenirebul dispetCerebs protokolis saSualebiT SeuZliaT daexmaron kardioreanimaciuli RonisZiebebis drosac ki satelefono kontaqtisas.
dispetCerebis moqmedeba gulmkerdSi tkivilis dros
informaciis miReba pacientebisagan da TviTmxilvelebisgan xSirad SezRudulia, rac qmnis araswori aRqmis an interpretaciis saSiSroebas. garkveul stress iwvevs aseve Semosuli zari, ramac SeiZleba daakargvinos drois samedicino Carevis organizatorebs.
dispetCerebis funqciebSi Sedis:
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Semosuli zaris dros kargad gamokiTxva da problemis garkveva. am fazaSi dispetCeri arkvevs, saWiroa daxmareba Tu ara. saswrafo daxmarebis brigada sasurvelia gaigzavnos simptomatikis garkvevis Semdeg. es procesi SeiZleba ar iyos srulfasovani Tu rekavs ara pacienti, aramed TviTmxilveli. siCqareSi, protokolis gamoyenebis dros xSirad uSveben uxeS Secdomas – SekiTxva dafiqsirebulia, pasuxi ki ignorirebuli.
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prioritetuli gadawyvetilebis miReba (unda gadawydes brigadis da manqanis saxeoba simptomatikis da SemTxvevis tipis mixedviT).
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daxmarebis gagzavna/moqmedeba. es faza es aris adeqvaturi pasuxi miRebul informaciaze simptomatikis Sesaxeb. Tu SemTxveva miuTiTebs sicocxlisTvis saxifaTo mdgomareobaze, procesSi erTveba meore dispetCeri. misi funqciaa brigadis gagzavna da misTvis informaciis miwodeba, sanam pirveli dispetCeri iwers misamarTs da, saWiroebis SemTxvevaSi, iZleva aucilebel instruqciebs, magaliTad kardiopulmonaruli reanimaciis dros.
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instruqciebis da rCevebis micema, Tu es SesaZlebelia, magaliTad kardiopulmonaruli reanimaciis sworad CatarebisTvis.
sadispetCero centri – “swrafi moqmedeba”
1. simptomebis Sefaseba da prioritetis dadgena, magram ara diagnostireba.
2.. saswrafo daxmarebis brigadis gagzavna, roca saxezea Semdegi situacia – gulmkerdSi diskomforti (tkivili,simZime, dispnea), romelic grZeldeba 5 wT-ze met xans
faqtorebi romelic miuTiTebs swrafi moqmedebis aucileblobas :
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30 welze meti asaki
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diskomforti, romelic xasiaTiT hgavs adre gadatanil stenokardiul Setevas
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diskomforti, romelic moicavs orive mxars
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sinkope
meoTxe etapi – saswrafo daxmareba
saswrafo daxmarebis moqmedeba gulmkerdSi tkivilis mqone pacientTan pirveli kontaqtis dros:
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sasicocxlo funqciebis koreqcia
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simptomuri mkurnalobis dawyeba da mdgomareobis stabilizacia
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diagnostikis dawyeba
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mosalodneli garTulebebis prevencia
pirveli nabiji
aris gadawyvetilebis miReba, esaWiroeba Tu ara pacients e.w. ‘ swrafi moqmedeba”.(rac gulisxmobs hospitalizacias) es martivi gadasawyvetia #1 cxrilSi motanili monacemebis mixedviT:
cxrili # 1
simptomi
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gaxangrZlivebuli da mimdinare tkivili gulmkerdSi,
SesaZloa asocirebuli: 1. dispnea
2. civi ofli
3. moWera
4 simZime
5.iradiacia mxrebSi, winamxxrebSi, epigastriumSi
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sunTqva
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gazrdili sunTqvis sixSire (>24/wT), mZime dispnea
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cnobiereba
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dabinduli
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cirkulacia
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guliscemis sixSire (<40/wT an >100/wT)
arteriuli wneva ( sistoluri<100mmHg an >200mmHg)
civi kidurebi
sauRle venis wnevis (JVP) gazrda
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e.k.g
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ST-segmentis elevacia an depresia, aradiagnostirebuli e.k.g. dakavSirebuli ariTmiasTan, gamtareblobis darRvevasTan, maRali xarisxis AV blokTan, parkuWovan taqikardiasTan
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oqsigenacia arteriul sisxlSi-
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< 90%
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urgentuli moqmedebis saWiroeba izrdeba Tu pacients aqvs anamnezSi koronaruli arteriebis daavadeba an aTerosklerozis maRali riski. ZiriTadi/mTavari risk faqtorebia: moweva, ojaxuri
istoria, lipiduri speqtris gauareseba, maRali arteriuli wneva. am dros damatebiT risk faqtorebad ganixileba: mamrobiTi sqesi > 50 welze, mdedrobiTi sqesi > 60 welze, genetikuri datvirTva. pacientebs diabetiT da periferiuli arteriebis daavadebebiT aqvT miokardiumis infarqtis ganviTarebis igive riski rac daavadebulebs gulis koronaruli daavadebiT.
roca s.d.b. gamoZaxebulia pacientis mier, romelsac aqvs gulmkerdSi mwvave tkivili (tkivili an sxva diskomforti gulmkerdis areSi romelic xasiaTdeba uecari dasawyisiT, xanmokle mimdinareobiT 2-40wT. swrafi progresirebiT da saWiroebs urgentul Carevas), saukeTeso gadawyvetilebaa hospitalizacia. saswrafo daxmarebis brigadis taqtika, qronikuli tkivilisas gulmkerdSi, (romelsac mwvavesgan gansxvavebiT ar axasiaTebs uecari dasawyisi, swrafi progresireba, aris persistentuli da xSirad rezistentuli mkurnalobis mimarT), ar iZleva e.k.g dinamikas da #8 cxrilSi warmodgenil simptomatikas), emyareba koronaruli arteriebis daavadebis albaTobis Sefasebas (sqema #1), rac efuZneba pacientis tkivilis tipiurobas (cxr.#2, cxr #3,cxr.#4), sqess da asaks.
cxrili # 2
gulmkerdSi tkivilis klinikuri daxasiaTeba
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tkivilis xasiaTi
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wva, Cxvleta, dawola, moWera, yru, mwvave
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tkivilis lokalizacia
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retrosternaluri an gulmkerdis erTmxares lokalizebuli, iradiaciiT orive winamxarSi an beWebSi
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tkivilis xangrZlivoba
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2-30 wT, wamebi, ramdenime saaTi
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tkivilis maprovocirebeli mizezi
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datvirTva, emociuri stresi,kveba, xvela
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tkivilis kupireba
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nitroglicerini, antacidi, ibuprofeni an sxva antianTebiTi arasteroiduli preparatebi
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cxrili # 3
gulmkerdSi tkivilis klinikuri klasifikacia
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tipiuri
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1.retrosternaluri diskomforti, damaxasiaTebeli lokalizaciiT da xangrZlivobiT (cxr #4 )
2. provocirebuli datvirTviT an emociuri stresiT
3. kupirdeba nitrogliceriniT
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atipiuri
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gvxvdeba mxolod 2 - zemoT CamoTvlili kriteriumebidan
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arakoronaruli
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gvxdeba 1 an arcerTi - zemoT CamoTvlili kriteriumebidan
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cxrili # 4
gulmkerdSi iSemiuri tkivilis daxasiaTeba
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tkivilis xasiaTi
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tipiur SemTxvevebSi moWera, simZime, zewola retrosternalurad, romelic SeiZleba iradirdes ybaSi, kiserSi, mxrebSi, winamxrebSi, zurgSi an epigastriumSi.
xSirad Tan axlavs diaforezi, gulisreva an qoSini
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tkivilis xangrZlivoba
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2-20 wuTi: stabiluri stenokardia
>30 wuTze: arastabiluri stenokardia an miokardiumis infarqti
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sqema #1. koronaruli arteriebis daavadebis arsebobis albaToba da misi mixedviT saswrafo daxmarebis brigadis da ojaxis eqimis moqmedebis protokoli
tipiuri
atipiuri /SesaZlo koronaruli
arakoronaruli
asimptomuri
kaci > 40
qali > 60
kaci < 40 qali < 60
kaci
>30 qali>50
qali -40-50
qali< 40
kaci>40 qali>60
kaci<40 qali-50-60
qali<50
kaci > 40
qali > 60
kaci < 40 qali < 60
maRali
saSualo
Zalian dabali
dabali
hospitalizacia
ambulatoriuli monitoringi
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ganmeorebiTi e.k.g da klinikuri Sefaseba
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fermentebi (3sT-6sT) (troponini)
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datvirTvis stres-testi (8sT-12 sT-Si zalian dabali riskisas da 24-sT-Si dabali riskisas Tuki troponini negatiuria
eleqtrokardiografiuli gamokvleva
anamnezsa da fizikalur gasinjvasTan erTad igi aris yvelaze Zlieri iaraRi miokardiumis infarqtis dasadgenad, rac pacientis hospitalizaciis Cvenebaa. misi analizi prehospitalur etapze asocirebulia sikvdilianobis SemcirebasTan maTSi, visac aqvs gulmkerdSi mwvave tkivili. idealur SemTxvevaSi e.k.g. gadaRebuli da interpretirebuli unda iyos umokles droSi pacientTan kontaqtis Semdgom.
boqimiuri markerebi
Teoriulad koronaruli arteriebis daavadebis mqone pacientebSi, SesaZloa bioqimiuri markerebis analizi saswrafo
daxmarebis brigadis mier , Tumca hospitalis teritoriulad axlo mdebareobis SemTxvevaSi amis sargebloba minimaluria.
mkurnaloba
mkurnaloba am etapze gulisxmobs tkivilis kupirebas, aspirinis, fibrinolizuri saSualebebis, nitratebis, heparinis da beta-blokerebis gamoyenebas.
ACS = mwvave koronaruli sindromi
AHA/ACC = amerikis gulis asociacia/amerikis kardiologiuri koleji
aPTT = aqtivirebuli Tromboplastinis dro
CCS = kanadis kardiologiuri asociacia
CK-MB = kreatinfosfokinaza MB izofermenti
cTnI = kardiotroponini I
cTnT = kardiotroponini T
CK-MB = kreatinfosfokinaza MB izofermenti
CT = kompiuteruli tomografia
ECG = e.k.g.
GP = glukoproteini
GPIIb/IIIa=glikoprotein
IIb/IIIa inhibitori
INR = saerTaSoriso normalizaciis Sefardeba
IV = intravenuri
LMWH = dabalmolekuluri wonis heparini
LOE = mtkicebulebis xarisxi
LV = marcxena parkuWi
MI = miokardiumis infarqti
MRI = magnito-rezonansuli gamosaxuleba
PCI = perkutaneuli koronaruli intervencia
PTCA = perkutaneuli transluminaruli koronaruli angioplastika
Rx= rentgenologiuri gamokvleva
STEMI = miokardiumis infarqti ST elevaciiT am jgufSi ganixileba pacientebi miokardiumis infarqtiT, romelTac e.k.g-ze aqvT persistentuli > (20-30wT) ST segmentis elevacia
UA/NSTEMI = arastabiluri stanokardia/ST-segmentis elevaciis gareSe mimdinare miokardiumis infarqti
s.d.b=aswrafo daxmarebis brigada
teqsti ZiriTadSi eyrdnoba evropis gulis asociaciis samuSao jgufis moxsenebis mokle variants. 2002
damatebaSi gamoyenebulia masalebi Semdegi literaturidan:
ACC/AHA praqtikuli gaidlaini UA/NSTEMI 2002
ACC/AHA gaidlainis sruli teqsti 2004w.
e. braunvaldi, zaips libbi, gulis daavadebebi, VI gamocema, 2001
brain p. grifini, erik j. topoli, kardivaskularuli medicinis saxelmZRvanelo, II gamocema 2004.
jef mani - gulis enzimebis gaidlaini, 2005
frensis kimi, li grini, “mwvave anu axal-dawyebuli gulmkerdSi tkivili”. “medicinis saukeTeso praqtika” 2001w. ukanaskneli modifikacia- 2002w.
aseve gamoyenebulia Semdegi literatura:
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mwvave koronaruli sindromis menejmenti. (evropis gulis asociaciis samuSao jgufis rekomendaciebi 2000w
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miokardiumis mwvave infarqti (evr5opis gulis asociaciis da amerikis kardiologiuri kolejis erToblivi rekomendaciebi. 2000w)
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j.a. rosi. h.blekberni. r.f.jilumi. r.j.prineasi kardiovaskularuli gadarCenis meTodebi (2 gamocema).Jeneva.1982
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a.j.Saperi.d.j.kuki. m.vokeri.p.v.makferlini gulis iSemiuri daavadebis prevalireba saSualo asakis britanel mamakacebSi.( britaneTis gulis Jurnali. 1984w)