?????????S??S

1
?????????S??S

• ???e??p? ??a??e??p?????
• ?p?µe??t??a ???a?ep?st?µ?a??? ??T ???

2

• 2004 St?? ?µe???? 2,4 e?at?µµ???a e???se?? se
  t????e?
• 75 ap? t? sp?t?
• 15 ap? t? ??s???µe??
• 2/3 pa?d?at????? p????sµ?? lt20 et??

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?a???e?s??

• ???e ??s?a d???t??? e??a? d???t????
• ??a?t?ta? ap? t? d?s? ?a? t? d????e?a t?? d?s??

10
Toxicokinetics

• ?p????f?s?
• ?ata??µ?
• ?p?ß???

11

• Poisoned person
• TREATMENT DIAGNOSIS
• Airway History
  
• Breathing Physical
  Examin
• Circulation Toxidrome
  Recogn
• DONT Diagnostic
  Tests
• Enhanced Elimination
• Focused Therapy
• Get Tox Help

12
?????s???µe?a??

• ?????e?ta? ?pe?a?????a?
• ?????e?ta? e?e???? ????a?a??
• DONT (Dextrose, Oxygen, Naloxone, Thiamine)
• ?e???d?a?ep??e?
• ??tta???a???? ??t??? e?d?f?eß???

13
??????? e??tas?

• ??t??? s?µe?a ?e?µ???as?a, ??, a?ap????,
  sf??e??.
• ?e????????? e??tas?.
• ???µa ????/????.
• ??????spasµ??/ß?????????a
• ??te????? ????.

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???µa

• ???µa, ?e?µ???as?a, ef?d??s? ? ???
  (s?µpa??µ?µ?t??? f??µa?a ? a?t??????e?????)
• ?sµ?
• s???d?? ???a??f?sf?????? est??e?, a?se????
• p???aµ??da??? ??a??d?a

15
?e????????? e??tas?

• ?e? ?p?????? est?a?? ?e????????? s?µe?a
• ??sta?µ?? fa???t???? ? fa?????????d???
• ???et?? ??sta?µ?? ß??ß? e??efa????? ste??????
• ?? a???p?st? ? ???µa?a G?as??ß??
• ?pt??? ?e???t?da, ?f?a?µ?p????a d???t???as? µe
  µe?a????
• Spasµ?? fa???t???? ??? d?ast???
  (ße???d?a?ep??e?)

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???e? ?f?a?µ??

• ??s? - COPS
• Cholinergics, clonidine
• Opiates, Organophosphates
• Phenothiazines, pilocarpine, pontine
  hemorrhage
• Sedatives hypnotics
• ??d??as? - SAW
• Sympathomimetics
• Anticholinergics
• Withdrawal

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• ???? ?p??e?d? de? ?????? µ?s??
• ?epe??d??? ?a? ??aµad???

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???ast???a??

• ??e?t????te?, s???a??, ????a, ??eat?????, a???a
  a?µat??, ?sµ?t???t?ta, ?sµ?t??? ??sµa, ??sµa
  a????t??
• Ge???? a?µat??/ ?????
• ??G
• ?p?peda fa?µ???? ( a?????a µe t?? ?p????a)
  ep?peda a?etaµ???fa???? se ap?pe??a a?t??t???a?
• ?/a ???a???, ?????a?

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Anion Gap (AG)

• Na Cl- HCO3-
• 8 -16mEq/L ? ?a? 6-14mEq/L
• ????s? AG se s??d?asµ? µe µetaß????? ????s?
  s?µa??e? e?te a???s? t?? e?d??e??? a????t??
  (?a?a?t??? ???) e?te a???s? t?? ??f???t??
  (sa????????)

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MUDILES

• Methanol
• Uremia
• Diabetic ketoacidosis
• Iron, inhalants, isoniazid, ibuprofen
• Lactic acidosis
• Ethylene glycol, ethanol ketoacidosis
• Salicylates, starvation ketoacidosis,
  sympathomimetics

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Osmolal Gap

• Osm 2Na BUN/2,8 Glu/18 (calculated)
• Osmometer (measured)
• ?easured and calculated
• ?G OsmM-OsmC
• Normal Gap 10 mOsm/Kg
• Methalol
• Ethanol
• Ethylene glycol
• Propylene glycol
• Isopropanol

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Osmolal Gap

• ?? a???t??? t?? e??tas?? de? ap???e?e? t?
  d???t???as? µe t?? p??a?afe??e?se? ??s?e?
• ? ?????? p?? pa????e ap? t? ???? t?? ??s?a?
• ?? t?µ?? baseline t?? OG t?? as?e???? ?a? ??
  t?µ?? ?at???? p?? p?????????
• ????t???as? µe f?s???????? OG s?µa??e? ? ?aµ???
  baseline t?? OG ? µetaß???sµ? t?? ?????? ??s?a?

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Ge???? ?????

• ? e??tas? t?? ????? se ???t??a de? ??e? ?fe???
• ?a ap?te??sµata sp???a t??p?p???sa? t??
  a?t?µet?p?s? t?? as?e???? ? ep???asa? t?? ??ßas?
• ??s? a?t?s?µ?t?? ??a?t? t?? µetaß???t?? t??
  ?????? ??s??? µe????? ap? a?t?? pa?aµ?????
  ?et???? ??a ?µ??e? ?a? de? s??d???ta? µe t??
  pa???sa ??????? ?at?stas?
• ???? ????? ? ??????t?ta t?? ?????, ?
  ??p?d?a??t?t?ta t?? ??s??? ?a? ? s????????s?
  ????? ??s???
• ?e?d?? ?et??? ?a? ?e?d?? a???t??? ap?te??sµata

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Ge???? ?????

• ?a µ?????????? a?t?s?µata p?? ???s?µ?p?????ta?
  ??a t?? a????e?s? ??s??? sta ???a a????e????
  ep?t?p??? ap? d??f??e? ?µ?de? fa?µ???? (?e?d??
  ?et???)
• ??t?st??f??, µp??e? ?a µ?? a????e?s??? ??e? t??
  ??s?e? p?? s???ata?????ta? st?? ?d?a ?µ?da
  fa?µ???? (?e?d?? a???t???)

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??t???????????? ??e????

• S?????? d?a?????s???ta? ?? ep?p????? ?p?? ?
  p?e?µ???a ap? e?s??f?s? ? ? a?????? e??efa????
  ß??ß?
• ??t?????????? ??e????
• ????t???as? µe s?d??? a?t???s??e?? ???
  ??a ta p?????ta s?d????
• Body packers (condomns, latex, cellophane)
  a/a ?????a? e??a? ? µ???d?? e??????
• ?at??????? ?????? ??a t?? a/a ?????a? se
  d???t???as? µe s?d???

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??e?t???a?d?????f?µa

• ?pa?a?t?t?
• ?a??tas? t?? d?ast?µat?? QRS a?ta????st?? t??
  d?a???? Na
• ?a??tas? t?? d?ast?µat?? QT a?ta????st?? t??
  d?a???? ?
• Te?ape?t??? ??????s? ?p??t???? d?a??µat?? ?
  ??????s? d?tta???a????? (t?????????
  a?t??ata???pt???)

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??af????? d?????s?

• ?p???a/ ?pe??ap??a
• ???efa???? epe?s?d?a (a??e?a??, t?a?µat???)
• ???µ??e?? ??S
• ?pe?tas??? e??efa??p??e?a
• ?etaß?????? e??efa??p??e?e?
• ??e?t????t???? d?ata?a???
• ?e?p??sµata ??S

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????t????se??

• Te?ape?t??? p??sp??as?

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Ge???? p???? a?t?µet?p?s??

• Ge???? µ?t?a
• ?e??s? ap????f?s??
• ????s? ap?ß????
• ??t?d?ta
• ???a µ?t?a

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Ge???? µ?t?a

• ??ap?e?st??? ?p?st?????
• ?????f????? ?p?st?????
• ??t?µet?p?s? spasµ??
• ???µ?s? ?e?µ???as?a?
• ??????s? ??e?t????t???? ?a? µetaß??????
  d?ata?a???
• Coma cocktail

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?e??s? ap????f?s??

• ?pe?a?????a (p?????s? eµ?t??)
• ???s? st?µ????
• ??e???? ????a?a?
• ???s? e?t????
• ?a?a?t???
• ?????s?
• ???a?s? ????? ??se?? (µ?t?, d??µa, s?µat????
  ?????t?te?)

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????s? ap?ß????

• ??e???? ????a?a?
• ????p???t??? (d?????s?- ?? ?????)
• ????s?
• ???s?µat??? ap?µ?????s?
• ?e??t??a??? p??s?
• ??µ?d????s?/??µ?d????s?
• ??asµafa??es?
• ??ta??a?t??? µet????s?
• ?pe?ßa???? ???????

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??t?d?ta
34
???a µ?t?a

• ????at???? ?p?st?????
• ???stas?a p??s?p????

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Coma cocktail

• ?e?t???? 50mg iv
• Te?aµ??? 100mg iv
• ?a?????? 0,2-0,4 mg iv ? 2-3min ?
• 1-2mg iv (total 10mg)

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??????s? eµ?t?? ?

• ???a??e?d? eµet??? ?a? ?efa????
• ????e?s? ?ast????? a?s??t???? ?p?d?????
  (pe??fe????) ?a? ??µe???p?d????? (?e?t????)
• S???p? ?pe?a?????a? (30 ml p.os) 2 p?t???a
  ?e??. ?p? ap?t???a? epa??????.
• ?µf???s? d??s?? se 20-30 min a???te?a ?a?
  d????e?a 20-30 min (µe epe?s?d?a)
• ????????S
• ?s?e??? se e??????s?
• ?????? 30-45 min ap? t? ???? ?????? ??s???

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??????s? eµ?t?? ??

• ???????????S
• ??ata?a??? s??e?d?s??
• ????? a?ta?a??ast??? eµ?t??
• ??µat?µes?
• ?a?d?a?? ??s?? ? ???
• ?at?p?s? ?d?????a???????, ????? ? a????e??
• 3? t??µ??? ???s??
• ?pa??? a?t?d?t??

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??????s? eµ?t?? ???

• ???????G???S
• ?a??st???s? ??????s?? e?e???? ????a?a
• ???????a ,pa??tas? eµ?t?? gt1h
• ???a???? ,?p????a
• ???et?? ,ef?d??s?
• Mallory-Weiss
• ??e?µ?µes????????, e?s??f?s?
• ??d???????? a?µ???a??a

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S?µe?a

• ? ???s? ?pe?a?????a? de? s???st?ta? p???? st? ???
• ?e? ße?t???e? t?? p?????s? t?? as?e???
• ?µp?d??e? t?? ???a??? ??????s? e?e???? ????a?a

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Gast????? p??se?? ?

• ????????S
• ???? ap? t?? st?µat??
• ?????? lt 2 ??e?
• ??ata?a?? s??e?d?s??

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Gast????? p??se?? ??

• ???????????S
• ?p??e?a a?ta?a??ast???? ae?a?????
• ???? d?aß??t???? ??s?a?
• ?d?????????a?e?
• ???d???? a?µ???a??a? ? d??t??s?? pept???? ???????

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S?µe?a

• ?? ?ast????? p??se?? de? e?de?????ta? ??a t??
  pe??ss?te?e? d???t????se??
• ???? se ???? ape???t???? ??a t? ??? p?s?t?t??
  µ?a? t?????? ??s?a? se ??????? d??st?µa µ????te??
  t?? µ?a? ??a? ap? t? ????

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??e???? ????a?a? ?

• ???s??f?t??? ep?f??e?a 900 m2 /gr 3150m2/gr
• ??????s? 1gr/kg se ?e?? ? se 70 s??ß?t??? p.os
  (101 ????a?a? t????? ??s?a) 25
• S???? t? µ??? µ?t?? ?ta? ? ?????? ???es?? de?
  ?pe?ßa??e? t?? 1-2 ??e?
• ?pa?????? a?? 4 ??e? µ????? ?f?se?? t??
  s?µpt?µ?t?? (25 gr a?? 2-4 ??e?)

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??e???? ????a?a? ??

• ?p?p?????
• ??e?µ???a ap? e?s??f?s?
• ??s??????t?ta
• ???t??s?
• ???????a ?ta? ???s?µ?p??e?ta? µe s??ß?t???
• (?????? st?? epa?a?aµßa??µe?e? d?se??)

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???s? e?t???? ?

• ??te???? ??????s? µ?s? ?????ast????? s????a
  d?a??µat?? p???a????e?????????? (PEG-ES), ???t???
  ??d?te???, µ???? t? ?????? ap?ßa???µe??
  pe??e??µe?? ?a ??e? ?d?a eµf???s? µe t?
  ???????µe?? d????µa
• 1,5-2 L/h (e?????e?)
• 25-50 ml/Kg/h (pa?d??)
• ?sfa??? ??????s? sta pa?d??

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???s? e?t???? ??

• ????????S
• ??te???? epe?ded?µ??a f??µa?a pa?atetaµ????
  ape?e?????s??
• S?d????, ?a???t???
• ???????????S
• ?p?f?a?? ? d??t??s? e?t????
• ??µ???a??a pept????
• ??µ?d??aµ??? ast??e?a
• ?? ßat?? ae?a?????
• ???e?t???? ?µet??

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?a?a?t??? ?

• ??t???? ? ?e???? µa???s?? 150-250 ml
• Te???? ??t??? 150-250 ml
• S??ß?t??? 100-150 ml ( 2ml/kg)
• ?p?fe????ta? ta e?a????a (???d???? e?s??f?s??)
  ?a? ta ?at?????a
• Se ?ef?. a?ep???e?a ??? µa???s????a
• Se f?e?µ???de?? pa??se?? t?? e?t???? ap?f??? ????

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?a?a?t??? ??

• ???????????S
• ?p??s?a e?te????? ????
• ?p?f?a?? ? d??t??s? e?t????
• ???sfat? ep?µßas? e?t????
• ?p?tas? ap? ?p????a?µ?a
• ??e?t????t???? d?ata?a???
• ???? d?aß??t???? ??s???
• ?????a?? ???a

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Enhanced Elimination

• ? p??sp??e?a ap?µ?????s?? t?? t?????? ??s?a?
  ?ta? a?t? ??e? ?d? ap????f??e?
• ???p?p???s? t?? pH t?? ????? a??a??p???s? t??
  ?????
• ???s?µat???? t??p?? ap?µ?????s??

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??????s? ?

• St???? ? pa?a???? ????? ap? 0,5-2 ml/kg/h se 3-6
  ml/kg/h
• ?a???t??? 25-50 g/kg (??d?te?a ???a)
• F????seµ?d? 40 mg
• ?s???ß??? ??? 0,5-2g (????a ???a)
• ??tta???a???? 1-2 m Eq/kg (a??a???? ???a)
  ?p?f??? ?p??a??a?µ?a?

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??????s? ??

• ??d?te?? ? ???, ß??µ????a
• ????? ? fa???????d???, aµfetaµ??? st???????,
  ??????
• ???s??? st? µ??sfa????????a
• ???a???? ? sa????????, ßa?ß?t??????, t?????????
  a?t??ata???pt???

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??????? pa?????te?

• EDTA µ???ßd??, ßa??d??, ??dµ??, ??ß??t??,
  µa???s??, ???????,???????, se?????, ?a????,
  ???µ??
• ?esfe???aµ??? ??a S?d???
• ??µe??apt??? µ???ßd??, a?se????, ß?sµ?????,
  ???????, ?d????????, ?a????, ???s??
• D-pe??????aµ???a?se????, ??dµ??, ??ß??t??,
  µ???ßd??, ???????, s?d????, ?e?d???????, ?a????
• Succimera?se????, µ???ßd??

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??µ?d????s? ?

• ?????????S ?????????????S ??S??S
• ?dat?d?a??t?
• ?? lt 500 d
• S??des? µe p??te??e? lt90
• ????? ?ata??µ?? lt 250 ml
• Clearance lt 100ml/min

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??µ?d????s? ?I

• ??de??e??
• ?????e????????? (t?µ?? p??sµat?? gt25 mg)
• ?e?a???? (t?µ?? gt25 mg)
• Amanita Phaloides
• ?a??a µ?ta??a
• Sa????????
• ?????

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??µ?d????s? ??I

• ?a?a?etaµ???
• ?µfetaµ??e? ,ßa?ß?t??????,µep??ßaµ?t?
• ??t?ß??t???
• Te?f??????
• ???
• ?
• ??????-????d???

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??µ?d????s? ???

• ?????e?ta? a??a???? 1ml/kg bolus, µe d?s?
  s??t???s?? 0,16 ml/kg/h
• ??? ????????????
• ??t??????e?????, a?t??staµ?????, a?ast??e?? ???,
  ße???d?a?ep??e?, da?t???t?da, ?p????a,
  pa?a?s??s?????a, t????????? a?t??ata???pt???,
  fa????e?a???e?.

57
??µ?d????s?

• ????aµfa???????, d?s?p??aµ?d?, ßa?ß?t??????,
  p???a??aµ?d?, ?e?f??????
• ?????????S ??S??S
• ?e???? ??
• ????? s??des? µe p??te??e?
• ??p?d?a??t??
• ?????? ????? ?ata??µ??

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??µ????a?s?

• S?µp???a da?t???t?da?-Fab, desfe???aµ????-s?d????
• ?????????S ??S??S
• ?e???? ??
• ??ade?a ?????f???a
• ?????? ßa?µ?? ?st???? d?sµe?s??

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??µ?d????s?

• ????????S
• Te?f??????, Paraquat (ap???te?)
• ?????????? a?t??ata???pt???, da?t???t?da,
  ßa?ß?t??????, d?fa?????da?t????, ????te??µ?d?,
  µe??t?e??t?, DDT.

60
????????

• ?p?te???? t?? e?t?p?s?a?? a?t?µet?p?s? t??
  d???t????se?? (glamorous aspect)
• Ost?s?, se ???? ????st?? ??s?a? t? µ??? a?t?d?t?
  p?? µp??e? ?a ???????e? e??a? ? ?a?????? (coma
  coctail)

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????????

• NAC
• ???a????
• ?a??????
• ?pe?ßa???? ????????e?ape?a
• F?s?st??µ???
• ?t??p???-??a??d???µ?
• Methylene Blue
• ??t????
• Deferoxamine
• ??t?s?µata
• ??tta???a???? ??t???
• ?sß?st??, ????a????, de?t????
• ?e???d?a?ep??e?
• ?s???a??d?
• ?e?a?µ?sfa????a?µ?a
• F?µep?????

• A?etaµ???fa???
• ?e?a????
• ?p??e?d?
• CO
• ??t??????e?????
• ???a??f?sf?????? est??e?
• ?e?a?µ?sfa????a?µ?a
• ??a??d?a
• S?d????
• ?a?t???t?da, ?????????
• ?????????? a?t??ata???pt???
• ??ta????st?? d?a???? asßest???
• F???µa?e????
• ????d???µ?
• Methylene blue
• ?e?a????, ???a????

62

• ????t???as? µe ??etaµ???fa???
• Se a???µ??a ep?peda t?? ??s?a? st? a?µa ? se
  ?pat??? a?ep???e?a
• ?????e? ta ep?peda ????ta?e????? d?a sa?
  ?p??at?stat? t?? ????ta?e?????
• ?p??e? ?a d??e? se ap?µa???sµ??? ??????? d??st?µa
  ap? t? ???? t?? ??s?a? e?? ?p???e? ?pat???
  a?ep???e?a a??µ? ?a? se f?s???????? ep?peda t??
  a?etaµ???fa???? st? a?µa
• Per os 140mg/Kg ?a? e? s??e?e?a 70 mg/Kg ??a 17
  d?se??
• IV

63

• ????t???as? µe ?p??e?d?
• 0,2 4mg iv - Maximum d?s? 10mg
• ??? 5 ?ept?
• 2/3 t?? d?s?? p?? af?p??sa? t?? as?e?? se s??e??
  st??d?? ????s? e?d?f?eß??? a?? ??a
• 45 ?ept? d????e?a d??s??
• ? ?ef???? a?ep???e?a t? ????? ?µ?se?a? ????
  ?a?.
• ?p?t???a af?p??s?? ??? s?st? d?s?
• ???e? ??s?e?
• ?e?ad???

64

• ????t???as? µe ?e???d?a?ep??e?
• ?e? ?????e?ta? p???? st? Coma Coctail
• ???d???? ep???pt???? spasµ?? ?ta? ?p???e?
  p??d???es? ? ?st????? ep?????a?
• 0,2mg a????? d?s? se 30sec - epa???e????
• 0,2mg de?te?? d?s? ?a? e? s??e?e?a 0,5mg a??
  ??a ?ept? µ???? s???????? d?s?? 3mg.

65

• ????t???as? µe da?t???t?da
• ??t?s?µata p??ß?t?? ??a?t? t?? da?t???t?da?
• ???e f?a??d?? 40 mg e???dete???e? 0,6 mg
  da?t???t?da?
• Se ????st? p?s?t?ta 5-10 f?a??d?a bolus ?ta?
  ape??e?ta? ? ??? ? se 30 min ?ta? ? as?e??? e??a?
  sta?e???

66

• ????t???as? µe ???a??f?sf?????
• ?esµe?e? t??? µ??s?a???????? ?p?d??e?? ?e?e?
  µ????? ??e?, ad??e?, ??S
• ?e? ??e? d??s? st? ??S, st??? ????t???????
  ?p?d??e?? ?a? t? ?e???µ???? s??a??
• ?e?t???e? t? ß?????????a, t? ß?????spasµ?, t?
  µete???sµ?, t? ?a?t?a, t??? eµ?t??? ?a? t??
  ep???pt???? ???se??
• ?????e?ta? se s??d?asµ? µe t?? p?a??d???µ?

67

• ????t???as? µe ???a??f?sf?????
• ?esµe?e? t??? ????t??????? ?p?d??e??
• ?pa?e?e???p??e? t?? a?et????????este??s?
• ?e? d?? st??? µ??s?a???????? ?p?d??e??
• ?s? p?? ??????a ???????e? t?s? ?a??te?a
• 1-2gr iv ?a? e? s??e?e?a 0,5gr/h
• S?µf??a µe t?? WHO
• 30mg/Kg ??a t? d?s? ef?d??
• 8mg/Kg/h ??a t? s??e?? ????s?

68
??af???d?????s?

• ???p??????a??? ap???e?sµ?? ?
  
• ß?ad??a?d?a
• ?
• ?p?tas?
• ?
• ?p???a d???t???as?? µe t?????????
  
• a?t??ata???pt???

69
??af???d?????s?

• ??d??as?
• ?a????s? ? ???a?t?as?
• ?a?? GCS
• ??s? ?s?p??p????? a??????
• ?a????s? ? ???a??f?sf?????
• ?a?? GCS

70
??af???d?????s?

• ??d???se?? e? ??S
• ?p?tas?
• ?a???a?d?a ? ??????????
• ??d??as? Te?f??????
• ????de?µ?a

71
???a µ?t?a

• ????at???? e?t?µ?s? p??? t?? ???d? ap? t?
  ??s???µe??
• ???s?p??? ???/??T ??t?a ep?p?d?? C (µ?s?a
  p??s?p??, a?ap?e?st??? s?s?e?? µe f??t??) ?
  ep?p?d?? ? (st??? µe a?ap?e?st??? s?s?e??)
• ?? s?st?µa ae??sµ?? t?? ??T ?a µ?? ?ate????eta?
  p??? t? ????? s?st?µa ae??sµ?? t?? ??s???µe???