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GulmkerdSi tkivilis menejmenti saswrafo daxmarebis brigadis da sadispetCeros moqmedebis protokoli momzadebulia saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa sazogadoebis mier


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gulmkerdSi tkivilis menejmenti
saswrafo daxmarebis brigadis da sadispetCeros moqmedebis

protokoli




momzadebulia saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa sazogadoebis mier
2006w.

momzadebulia saqarTvelos kardiologTa kolejis da saqarTvelos kardiologTa asociaciis gaerTianebuli komitetis eqspertTa samuSao jgufis mier: zaza mgalobliSvili jo-enis saxelobis samedicino centri; rezo TaTaraZe msoflio jandacvis organizaciis programa “ CINDI’–s direqtori saqarTveloSi;

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;


mesame etapi - sadispetCero centri 2

organizacia 2

dispetCerebis moqmedeba gulmkerdSi tkivilis dros 3

sadispetCero centri – “swrafi moqmedeba” 3

meoTxe etapi – saswrafo daxmareba 3

saswrafo daxmarebis moqmedeba gulmkerdSi tkivilis mqone pacientTan pirveli kontaqtis dros: 3

boqimiuri markerebi 6



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:


  1. 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.

  2. prioritetuli gadawyvetilebis miReba (unda gadawydes brigadis da manqanis saxeoba simptomatikis da SemTxvevis tipis mixedviT).

  3. 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.

  4. 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 :


    1. 30 welze meti asaki

    2. diskomforti, romelic xasiaTiT hgavs adre gadatanil stenokardiul Setevas

    3. diskomforti, romelic moicavs orive mxars

    4. sinkope



meoTxe etapi – saswrafo daxmareba

saswrafo daxmarebis moqmedeba gulmkerdSi tkivilis mqone pacientTan pirveli kontaqtis dros:


  1. sasicocxlo funqciebis koreqcia

  2. simptomuri mkurnalobis dawyeba da mdgomareobis stabilizacia

  3. diagnostikis dawyeba

  4. 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

gaxangrZlivebuli da mimdinare tkivili gulmkerdSi,

SesaZloa asocirebuli: 1. dispnea

2. civi ofli

3. moWera

4 simZime

5.iradiacia mxrebSi, winamxxrebSi, epigastriumSi






sunTqva

gazrdili sunTqvis sixSire (>24/wT), mZime dispnea



cnobiereba



dabinduli




cirkulacia

guliscemis sixSire (<40/wT an >100/wT)
arteriuli wneva ( sistoluri<100mmHg an >200mmHg)
civi kidurebi
sauRle venis wnevis (JVP) gazrda



e.k.g

ST-segmentis elevacia an depresia, aradiagnostirebuli e.k.g. dakavSirebuli ariTmiasTan, gamtareblobis darRvevasTan, maRali xarisxis AV blokTan, parkuWovan taqikardiasTan




oqsigenacia arteriul sisxlSi-





< 90%

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

tkivilis xasiaTi

wva, Cxvleta, dawola, moWera, yru, mwvave

tkivilis lokalizacia

retrosternaluri an gulmkerdis erTmxares lokalizebuli, iradiaciiT orive winamxarSi an beWebSi

tkivilis xangrZlivoba

2-30 wT, wamebi, ramdenime saaTi

tkivilis maprovocirebeli mizezi

datvirTva, emociuri stresi,kveba, xvela

tkivilis kupireba

nitroglicerini, antacidi, ibuprofeni an sxva antianTebiTi arasteroiduli preparatebi

cxrili # 3




gulmkerdSi tkivilis klinikuri klasifikacia

tipiuri

1.retrosternaluri diskomforti, damaxasiaTebeli lokalizaciiT da xangrZlivobiT (cxr #4 )

2. provocirebuli datvirTviT an emociuri stresiT

3. kupirdeba nitrogliceriniT


atipiuri

gvxvdeba mxolod 2 - zemoT CamoTvlili kriteriumebidan

arakoronaruli

gvxdeba 1 an arcerTi - zemoT CamoTvlili kriteriumebidan

cxrili # 4





gulmkerdSi iSemiuri tkivilis daxasiaTeba

tkivilis xasiaTi

tipiur SemTxvevebSi moWera, simZime, zewola retrosternalurad, romelic SeiZleba iradirdes ybaSi, kiserSi, mxrebSi, winamxrebSi, zurgSi an epigastriumSi.

xSirad Tan axlavs diaforezi, gulisreva an qoSini



tkivilis xangrZlivoba

2-20 wuTi: stabiluri stenokardia

>30 wuTze: arastabiluri stenokardia an miokardiumis infarqti




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


  1. ganmeorebiTi e.k.g da klinikuri Sefaseba

  2. fermentebi (3sT-6sT) (troponini)

  3. 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:

    1. mwvave koronaruli sindromis menejmenti. (evropis gulis asociaciis samuSao jgufis rekomendaciebi 2000w

    2. miokardiumis mwvave infarqti (evr5opis gulis asociaciis da amerikis kardiologiuri kolejis erToblivi rekomendaciebi. 2000w)

    3. j.a. rosi. h.blekberni. r.f.jilumi. r.j.prineasi kardiovaskularuli gadarCenis meTodebi (2 gamocema).Jeneva.1982

    4. a.j.Saperi.d.j.kuki. m.vokeri.p.v.makferlini gulis iSemiuri daavadebis prevalireba saSualo asakis britanel mamakacebSi.( britaneTis gulis Jurnali. 1984w)







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