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M ateri at c hron iony prawel3' autors kim

CONCE'PlO DE SIS'TEMA '1INTE:GRAl DE: ATINCION

A LAS UR,GENC'IAS TRAUMATICAS,

etl. ~'l1~espscio lfej}gl':dfi·~ ['0' ,(j,f'fi,lli'ci'o" fNlE4 So,~'''CJ;rM~~'objei,f}f.o/bull en esse ca:r'O lX,Ji~';{;I! redueir ia ti,~ffn,[i.l;:dad(if.' J:OJi pr(j.t.·i(!JiQS~ralim{itieos y (;jwnhl0~"ar S,Mrf secueia».
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IE1. eoneepto (De S~SI\f.:~]fiI :~r~!ileg;~,[jJ1 haee referenda ,BL],iTh :~ra~e,gJ~ELc:~O~1,. ,CU;f}Ilfi:O :nHtWUl$ f~~lcimn:o], irle 8.quellas ,esl:rr1]C~ln:f!lS que 'p~l1ic:upru.l en la atemci,6n de los paclentes, ~ ...II ..iI1~, '...iI ,.~, "'..iI 'Le. ~ ',,{ ~ Itt'll l;J!e',u ~elnl'nI~I'!;{a, desae e I 111u:nne:i1Ilto00 ~ :t1Jl.e[ll~:~:tlCf1'CIO:Ill 'II 'pro, blenr18 nasta su :5ijJ!~:!lIC~,!JfII t.: ' " ~I· '-II· ~I h '~' ".!II Ie 1~,.1 I .~ :~!.l!(!i!/e'~1!10R1C I!JS:O JltiCerse' oe,.;;!:e!i1:'l:~V~ a. ~.~ iiI,'Cl~,,",'~!LIl~ :;;: {~I;UJI,C:4Ua!S:~, a, l~reV~!i1G~llil'l! y 'r,O\rm~d661L GCi\Uesra perspectlva poci!;eil;fJ,Qfi ;~clem~fi~ID!r ~'~gui~!fd;e.."!ie~ern:n,~ntt'o..'5 los e~~r1)lc!JUr~I.~
'_,.i

1 ~:;:k{i!s de

;3t~r.lci61'1i ;3, los :pacielfll'~es,'Illl'atI!lIMaJ:ico .. : S:isalerrw~ de Ireeepc:iolJ], de In, IDJh~~8 :'Y lLC~~:'!,!'i)ci.6nl reeurses, de :r!!Jf:i:rL~iCi6.t'i de 'prii'imeroN ,f!JS;ijiJJve!lilt,e~. _ R)~!CllJif:~S, ~si:s'~el1('~~le-ll,cl~-s:p~,~,.:ad,o'8, ~'I)I:ga'~' e'llel1l~R , :rul del
ILIlili :1l,u~u:~n'll~(~~

- Om'Ii.lL"'i!I[]irgllLlO~.iiru.cli,o,Tii!.t,.'; que: pusden ~11 necesarias paJrii:!l, ~,i!L ;1::;~$t~l1du (Bombcres, f'ohd". f:IfIO\lIe~lt:-i6il1 eiYi:~. CruZ Ri(}j~). _, Serv,Ddos de Urge:ndiilS HosiPi~ii1n;jM'i.o8. UIDI'nd~.de$ qlJ!,i['ijjrgka~. _, U ~ ndii1idesde c~rtkQs. '"",I I 'Ik ... ·'II·~ • _. nsiea 'Y IP!il!Ci[l!~O~;lCaL IC\"' • ~ - lJ fiUI!,;I.iiiI es I[ e :liie~malJil,~~~aCIii)n Los elementes ibacsicoi"l de pro~' (-'t1n {llilB ,iJ~~m~~. ,cQt.iliitll'[' ~II. :s,'~sl'e'milii sen:
I "

Y ~ro~QI;,~t.l;~1lJ.l) {fci'iv~lcioliL ~cgulii :gm'Yed~d-, (Ie - AC~Jer-d!l)S de '~l)IfL{:'io:nal'!llie~tto entre las O[,~,aI!Ji7.ach;:t!!i!e" - .Pro~'oC>D,];~ dE ,e.... ~~III.".cli}on de '~a di2:rri;:n]d~l_ ~ - ProloCQll~ d£ 3ClUv.nc:~6111 de :IDCIlIIC os ~l~alj;Uenrc,U~]I,(j;iS", ...
c,

_ A!::'rcd,~I':JI.c:~6:1I1 centres de

- Sistemas de regislm.
E!O,I'a~'uado~"f eomml de ·c~lid;,:u;ll.
r;1lfOCedi.lfnienr~ns ,il!-~i~$eril.Cli~Ies ,[1 rea.llDMJI" en I O! :~m:le PJ-e:lrul:;,pilll'l:~~rhll!_ Pro,gj[ltllY!.a." (Le :Wol1lilhtU;: ion. [1iI'te!i;me'i6~1,e~] I,OlSp:~~nn.es, Cffii[ustrofe. de
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reClUlfS(lI.S: de ItfJJOSIXl'!l1ie.

I~~,i[)ifgatmdzac:b6'11 (tiel

puesta tiene
IlIUlS

g~CifgnUlc:lli so'ti:!J'e la {~lIJee II s~'s.l'e!!:ri!a d~be de prr'e"~~lI'resi:l1tIipit!llt~~ii1d,:iL en Ci!uln'io al dhier.lO'~las ,~be~ 'jj[lilZUiil<fl~, lPianlcu.i1J preble'~l!;'.~IlSj'~:o pel;()i U)ua reeerri-

~J.,e' aJI;l1 derl!1,idl[d d.e :po'b~ac ~6.1il CO-JIb ll'~ifI!i:~lt~de$, de

mienrras ,que h~s be~sliuroll:es: ~O:!fl! bajja cilelil$~d;:.Uide pobh_.ci,.oi1J '!i :~fi~rsQS, rec!!Jinri~·)S ]iuwSi;i:1!, Ihl!JspiLI.~'~ referel~(::hJ iiLec"::$~.'~nl1l de !l:I.o~, COHOS hasta el Iirnspi[~1de referencia,
l!.'!illUl e'S:~f!ill!:.l.ura

pec!J!,Hw,
flll:lild.ru'iI1£\!iIU'L~dki~ S~,SI:eiIJ'l\lll, e~~:)iJ ho~piud :~~elP.or ~~e los pael

Conrm elernenro

clesnes trnt!Jm~li~,ran{l;. 10 que se die'be ,~~alble~er L~ acre~~it~d6ID! ~m ~lOS'iJ~la:D0!f de l~']; :pil.lr [!'i"ldes ,~r~, t:i1Hlill1iD ~~ su (':~pa.c~da(ll:pura, la :iiID~nlL'i6n del '~[;ii(jLllri:1~ ,gJF.m:'!.!'~_ :~~mJ ~~c:rocl,~.;['U;;:U6:1i1 ceutrcs de HLtV3 .:.I, 1J.l1I:iI~ 1-e::IiT.Ui\lj:ri:I~,iz;~ciorilcon ~]ua delf]liI:id.ollJ d.e: 1II11l res... pacio geogr.:i.'Fico di,1pend:n~~It.~ un CC['IJU!1f{(; de ~ni;irna, ilcmcl:itudo- OOli hll, ~.~~re~i,~£; t~LeiO:ifl,Y ~1!1, sec~or:~Zi!le,D6:n.,[j"ilJfeoe el eeneepto de "Oemrt,ros de l'rmJlTinl:l''''",
'hl·

M ateri at c hron iony prawem autors kim

E,LlM,ENfOS DE [lOS SISTeMAS DE ,AIENCION A LAS URG,E,NCIAS TlIAUMA:TICAS

..

La hr!!I':II~fllt~ci6111 tehe'[ol1io~, de milreacMiI~ re~~Mclild8 Ilfurn emergencias, del [~:pij) de '112 el,llmpeo '0 'sn I 1l01'il,eanulle:riicrn.no.. OOn$l,iu~,:yell, 1(lI~ pi]!1!!~s ~!l)b'J~ los CIIue se a:ll:i'emJLa l'OO~~:~3 cadaaa ,a.."'i,i8~,erilCli,at Lei fiJ,clhdacl de ,[OC'n."so at ;Jj~"sr'e.ma,~rrCI ryjjlJi(k~ e !wfli£K."I/in de l Ltl, cemra!f:lC~cMn la 1'I(Jrr.f(:~d~' {;,11;e1 ,Cent~'f} df! C OO~d.:1~aC',io,1~ J,~ .. v Q\,',~'il.>\C.\I'"i'()I,~lie' l>r~
~li'(-"'W..'!olJ' ql,~e"

de'
j,u'~

..ell clI'fa;!,J',f'Oi a So['ali.~lddn ~\~ \"(.4(11f.ls'(!'lIc.ral .l',n~(!· m

wdru

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.da t1~;ri." l::'J;p~Itt!j;Hl o,couicr3' {j /a ~t{l'V''(:'{kiJ .del (~'{'r~:d!fm'l'e"son los 1 ;[:.edtn ['t.!ij ,de :I·m ar!i:'tI ,gro~ aspectos chn-l,(! ef.~'ta t)1'.rmf!r~'1(;N;t (];'" /(1 (lsi;~~(.~',r,ja" gTtifie:a, en un 'dnko La lu:i:~i1;:ach)nde IU~ acceso ~ele'rr6!'~iiCil} ~~rik(l!,de 'il]f~rc~lei6[D ('ifnltro d'_e m.ardin£OC'lciIn redll!lc~da"co:~ la 'W"ii~IDIl!gJJ :1!"!1U~neraci61l.p~ra, lm allll~1 10 ter~iwr-ili() .riA!' tec,li;ui!jill-s es M ba.se ,k 'fud HI~,la aceesi b~li&.d, La ~ItiI~~;!l!£'L6:n e s,~sl/e'~n~s pU'iQrid de
zac.u6:uJ en la re8)pl!le~ta ~l!Iri(me una impnrtante mejora e'ffiI ~nEl, I iempos d;e ~:Ptl~U~1 y d i~llil'iaiJ!J1Iy£"1JiIvariabihdad glil la tcma la

~l1cias

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lma, ,gc~twn 'ra.c~ooal. &

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Illflstn d h,Q8piit~1 i~~tilj~ :SiE~m rud)iliil::~dos. ~i!rl'" ,1ll'1r:!1;r;.;in~Jfii;!"'I'~'j,'ll"'!" t·~, '. 111j"'IV"~~~ ,{it.',l ,Ii,~_.... I.... Ilil'ii~, ..... ~,~'" ""'r," ..... "_""~"""]I; ..... """J"J ,,~" '1;1i~""~:",~'ri':"" ,d t,,~lllh,I"" l.n}!;" '1'1;0-' ra, ill!i]~iZHlido !peI'8O'1~~]1 un a:ill:(!i'm:uv{~;1 tf'(!im11a~;::':r6!i!i' O~)!II [c!l!~~cidad P!l!J';a! con ,dI~ :rr~aJi~ zlIDr '~odtJ '~:ilpr~ 'Mii::IiI,ic:~~'s.[~,IJl~ p~.'K1i'10 hlilil:~O~liIlW'~e1U, ;[I~ nf!~.s 'ttb~Inpo' ~!Jl el hllgil.'l1'del ac,cirl(l:!tiii)(i:~ y '~~,:sel!luliI;dii., 1JI:~];I~~i;"~rt pensonal Cl!.'1!T1i [1~~:nl~:C;uC'i6m, Cirri, el :!~ij]I1Jl~410[ de l);iiOc~cni~:l.'~iefll)tmre~III~:z.O!f,!,OO'iiI tiempos ifIl14lc:i;, a, eertos en ~]: 1iI.1!,g,ui[' la '~~~lili. A:n,l00s de IIT[!O(le[[o~,. {~~Ie e\1l ]~!']Ia.dlji(] ~~.J!'.r• .I~,parecer COtli'mr.rueSi:fJs.." pili~d,(~n it{;:Si!i:liiil,l;F com· ( 'P:~~n:1en:t~r.i:il'i'I""~~ 'e~,:~lb!lif;'ic~.l] si (;il,l~dad.!osan~~~1!I~ hldlc;J,('iQ~~e$ :rlJ.lluoi61~, de Jas las en I~e~;b:~:ad'es de: ,c~td. i!;ilii10 ioo 'C~(;!iS }f f!~ ~lbi(:~'(;:~6n ~i!1 ~on~e.x)lli) [(h~irlr.i[lihiliinilll'o,. de en Ell tiCliflp!Jl' ~Ii] el 11J1~~UIi~~ ~odcllim:~.eesl~, en re~~d6" C-(lI~ I~$ dJU:~c~~t~esde e.\~ ' M~lcci6~ I~ ,,1C'~fu~nU!e! :nl~;nneif'O' y '~JljrJfj e J):FiOO(':tI~lifrl!iilt:n~il!Js, de' }1 d iru:ill:Uji'.J.ldr:}~L :En ,gelil.el':a'~;
tFif~fils'poiite
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M ateri at c hron iony prawem autors kim

:~O~ ~ie:rllites :IPO i;;'ill! esecna

00(11 trnlil:!lI'!>:,;Jl1l: 1i:.~~wrolliLOS.IPO:f acckl\g~~eJi e '~If:',:inCQ,oO:I1SI,:urne:~:J!T'! a."i; d

trauma pe:1l1i;'i;i:mmlit'e, :SUil:~ paeienre V,~ ~ ser l'r,fllSl:aij]adiiJi en '~e~,I,e6p&erurequ iere '!'!U];~lIlIl~lyOr. 'pmpunI,c:~61i1" ,~[i~rrye eon I delll1t:pos se :pro~,ol~~n. os, ,~o~emlVO~' L ellnlpleados en ,~~e~H;~bUiudl6l!J en las ~ie~, !l:UllIei IlIj~iill:~zarrll, helii,oopcem' pnm la ,e'!;o'aCIll,rli'c:~6:11'!a."iiC:~~m' ntre ILos e ~,:!3,fi!l1 miiliuiI!toS. :mieni:rr,:m,s que. ;e'1IIg,en!l1llli,sil el tiempo medie ,elil, el ~:IlI~airr'del, ~DCJd\gVl~ .. res oseila emre :8-~,6 ~lll'iru!1l~oo eusndc se l!1'~UiZ8el transpcne '~:eil11esl:re. tl de'lbaiE iSo'tJ,m la ,t'!~lili1~idHd, ~i~,Ib~'lruz;t'Lci6:1i1 'neoo:O;EI!c'D.l\p...'1itH It!:.'!' 'p:r{idlllt::~rfJ.e~1fIo~ ,~le lr,lliciitleue respuesta dli:r{!:ren~e ,cib:~{pemld~eadQe eada .'tis!(jemaJ. del I:i~f)de ,~esi,CiI:] y de: d :hl d~SIU[iidti :nl.~t~ cell'uro :ho$P~i;~h..tno el ~:fi:lii:i,IO~V{.1I.
1~,lblie

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ita lI1li:~izm;ion del 'hospital mnis cercano como 'PUlffil[il]! e ciLe!ri-v,aC:IO:riI, de los :pa, d .. c:i,<e:n]j~time ,e~,sCIiI'tildo dlB: tltoo;rual";e:1 ~'~~mpo, Irr.un:5p!.'li14t,e. :pcro iSolflllGti:e: ,11111plllc~e,n de ' .. ~e '. Ililli retraso en. :~~wi~~,ct6:1l d.e:ffi~:li~~,v:ll.cl,e' problem ill y ,~~ meaor fij'ivei~ ,~e'tl~!dlsSJU 'Lill tencia s3ni~31r:i.;;t.'prod!l!lciendo IlIIl peer resH~:~a;ttol n~3L ~'O:~' ~o lfir[Qt,Q, es 'rDtcoes@JriLo, a,credliJt~rel nivel de as li,stfJlda I,p~J',~ '11t~II.nIDJi, que tlenen los :hOSp~I'illJes hi zon [ji, :y de l~reesl~lbaecer normss de deru\'adon de :p~den!-e$, h!1i('~~ ~I~_~e que ~es :perunit. w ~ 1.1 os ifOCubilr la a~:usiJemlci;rn, derilril:~i:iy,[1IJ. 1a. rnortalidad d~ los r'ac'~eliljleS qrllH~ IfIBC:Uben ~.uE!Il" c:i.u.n en (;~i1Im~, ~lit;,if0thi~O'S {lie: tnUJilifl'll~, "eglhfi las espec~,fi,cUJL;~,{.1J1'CSde ,Aal'ij',il:"Ji',ic(m C(}#e~'(:" of Surg,ft()fj-:.!f" es menor I(Rl!.te cemros no ;i1e~~ed]l.tlliUO$. L~:sI;!lUfl~I.!c~1~O:~. seea ~ vcrii;d:u~iUl:imi.zundo :~~m.e:toooh),g;f~ de mortal idsd prevenible, ilruJ dsci:!oiIOIil, del ho:s.pd,c::aJ] ,die d\e-..s~·~n.o, cl.£DC hasarse 1BU1la _gr;a,vc.ilncil, del Iprut~i{,;I11~,i!L La, IUii:i:lliZ&ltion (!IE las ~tljl:~l!s de: .g[,s:vcr.hu:ll Pi!l:II,1'iII pat uenltc)i l[nlJU Uiliimt~:UCOO '(."{JITtI,,!] P,iuii];dle: scr lSS 0 em TS e su v~'D'::ii,{klJ'c[uuiliz.adift RTS, 'Y el TR[SS (que se a \i\ernlli, co;n 'fml!YiJr d~1~.d:~e n el c'~'I~l'~~'dopenmlJlen establecer e .5) La ,d€iCi~rAju ,deJ ~,osN~ ni:v,e~,e· Idle grav.ooaclJ p"lua cada ca~o. '~O'<~pil!.(:'iem!~e$COtil dete U'll:!ll d.e ,d'~s~~rul'J dfl. ~;l1Lin!ltd!l)s niv~~le:;l debel'll die ,~W' a!1:elflld.~dQ~,611 ell h.'O~!pi~a!~ refede pr,ocierue' pOlijtmilmn~M" rencla en li;,.'l[lD'lmposk:i.6n dE ;:.,~.qlll.eUO;S teos m8:mlOS g:rr:wves (JIlJJe o d.o debe basCln.e en, In [luerleifl ser iU~l!!ltidJo\ll, C'1a een ~91QS 1l'I!l)sp:~I;&~:lJJrjos '00t1 rnenor CiIJ.•• ~..!I._..J' .J'~. gro.~, ") .)• -tt.e ~ • t!2~~O~ Illaeid!MI ~sisteU'cia~. ~ 'Illti ~ioz,~,d6H ~,il$~!fr!!ao;;; de cI:a~:~fi;ca(:'~6:o de nes !Ck~p[q)[.r.e.n'.e IPOIl' grn,'!;o'edlurl, [parm li.denf~ou[,~car e~, ho~~i[~~i ,all qru.€: deben aeudir :~Oa :plIci,eii'iii:oCs ~lglJj:ve[gdJo ltlJ 'rocotl~~ntdiild,(Ine.s pree a ti.!blecid!'iJ$. lpl~!:e~, dificII,]IIUlidl~", Los :S;DslB:lJnatS: ,me d~m.."'i.ific3ci6n ':'U:lOIi2fDB:11I I[~C buj a :[I.e:nit~~b:u~ idlad ID~m 'id!eu'!tificar a 'io.!ii iD~N;iel'l,tes '!lTIi{t~ :gru,Yt:.;N; Y por 10 It~Uil[!l.) dlg'lbc ,I,'LC~P!:at,N£: ,~ie.ru.u ne~llbiUcl~~~ su '!;If'lo" Tm~hi6Jl debe ~~m~n'le ei!l (:1~r~~~:)I! el ~i:po ell le.sion~"i..; 'pOI"

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:2;3,

Iill. de IlJ,tros (!!l':~ltms. :U, ruHil,izul!ioiJriJ reg~ SI'[:W que :fefUej:9n :~~:9l1lefll,e'~6t1 de tos [1::»elemes I~JI'~Jlil1Tl:1itk((!s l)enW]I:e' e.s~a.bieiter r!jIUe'l,1'aS,~nejil]ras.en ~O'S medelos ,!!!,:;~i~~el1!il;:'l~-

ae

I~,., La ,!il.O'lJ"!illUlltu;ion de illlf(!!rWFti.t,c:ir6;n :Slobre I~~, ·c![_roC'~eri~~k~R na~nejo de 'Ios ~~~. y Idel'!i~.e$, ren'Dl:~!~' il::re~r rnocle~Q~, ~redlic[ij:v-os~ol~re':~i)Ij :pxi1:ba;bil~i~ad d\e :~nU.ecr1e. La. l'UlelndD:~il)gllia ,ciL~esms ,!1I.'r:ujl.iS\~~l)Ii:i'ili_Z;ll ...'CD!Il1I:(:~.e1l'is'1~_.caz.i, e!11 padelil:~.e" el hpo1l de :~e~ 1m d s]:ooe~ "J! las respuestas n~ioI6gic:as;. 'Y :apHc.rulrHfo nTlodelkMs ·dE re:gresl,6tn :lo,g;[si:ItH. 'e$t~ba,ece ~aJro cada 'Plu'::~£:Iii~e,en p:,'Ul:tucllI,hu:, hi. prob;ahi'~~d:ad ]iinlJler~f'!. ESI:t! '~:up!J' ,~le
,cilIi: cnnI~jrol dL::c~1I.Ud~ IPcntiil'iLIt idit;I1i~:uf~cmlr ~i:sItelllfm:s•. 0 ee~1itFJlm. cu,),ns reslld'Dud)OI§,es-

I;~ ~tlil deb'iljo de los :fJl'e..u~.itfld~~ ge~e[a~etL S~ en l!I n centllo es:pec{fi,co ~~I1i, f-aUeci;,d:o ~[c.ielll't\es en los q~e el fIilOA.te~o pred ecla U!~a,~~ja. I~rooolb[~~{fiarl m~e~e, se de
eglilJllProd~JC::i~l!)i!ltil·mlJ!.elile,,~no eso,pef(.d~$. Los ~~'s-~efIi!~'OO[! ilIDll!lerte:ii :IiIOe8pe:[ad~~.
le:;:!::ill:l(1I;f!1li'ie>Cieilirlo Ire!'H.II:~.;ado.Sl [po'br-.e.."'!.
s:u :~ CO!1l1~lr.I'(j1i1

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de Ios

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prloced~1il los dtli(}~ gen~f~.tes" La posfb.u~.idad.de !Col'Uall@mr 10$ resultsdes en I.Hl Si:51telllil3 e~ecHico ".I"" I.I~.ll~ ~ eesid !VI"'" ilo:;. .,....-o.,;~'·fi~;i-'!""if'U fua • ""'rI!"'I""lli";'"'~I\i'1I ... ~. U!JI_ ~IV. _!i'!1U __ 1_....". ~'!.l ...'!"'~;":.'",1'" ~I 'I~l' ~~. .;i~ ""' .... ~.'" ",_I h.. . .. ....h H. ~
ot!I_ '"'~ "-'!!

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l'IIi~aJli(IJ

J['eql!l!iel['~ 111]110:1.;eViJ~'I!I:ac~,on las :mejonl!l' o'lble'IlI~Jd_3!. de

Ln~ m~tOOij}iog~Hs eilnjp1;efLdH~ 'lfliChlyen l d.efi'u:i''Ic~ci{hl de mlller~'e$, :~re~e!liibles, po(!" .1J)~[!e:~e:il ex .. ertns, la :mO:I1'~~~~~dad de p :limsp:il;D!'h:lf'.ia. loom!~ulimda (:Oril. hi! e.~per'li,d8! extra~da. de :~1;iXlelos
p:rr.ed ~c~:uv'{'jt'l,; ]llll! niI{!!a"~a~.id~td. por
tmlJllll[Nl

'elUJ ~)r.»i' re;gi:'''ii·~[Qlil.p![Jibl~.•, ·

eienales 'Y ~a ~-llOI~!J)~ y el preeesc ,e~ d.iag~6:nico.,~e:;l~ific~s. idad L~ ·rD1ll1!.YO[UIlI! lill;i :~~Sublicacione .. conflrraan I~.1l;i;f!c3ciilll. de los O$l'iIitro5. die ·.r.rui)imi!t; p "'i;
si

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trnll;'ui'Ill'li

la 'filiiifiit:?li'lhhu] qiltC' 'pjje~c' ;Q:.S'~.~j[ ju:slti.f]!C'~.d~1 aT la m'ejQ'I'11 eli' iei p j!(;rm(J,ciO}~ .. Iu, m\~jom ,e.r~ servicios p~'i(!ho-spi.w(}.lari()s 0 ,e}~la cdbmiJ~u:ch.i~~· n las IOJ e tilNl'PIJO)jj ".e' ,'I'(,mslM~1;,e..
ruIlK :roditiOt:iol'il, •.

l~~ IOOfi'~o]~;cl:adJun,~c· Si:sAi~liI:1H5 p-llliitJ]~ i.tt ~!1.lC.l1Id On mI i(JJ-8, ~:"iIiCIG!IiI;~G!S trutimj]IIO~ cJolil :~~ ~rea-dI6nde hfiSp\~I:~'~e refe-fetlCi~!Ii. p~'~~ re~epci6fa. de los cases .gr,~ve~,_a.. ded ]~ 'h
Imo:sitm.oo,
Sill

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lEI campo' de IQS sistemas i[ll:e:_gl'8tes de 8l!e:6ld,u;n a i~£, ltl!giWli;{~EUS Y !!lSpcdfk~.mente S.U faeeia die:ootelltCuO:Iil llIi los. proeeses tnn.ll:tJlllt1iui(;loo ~ ~1i:(:U~IiI~ra f~~~e Ide-en de
h.l!i'ilis:it1:l!I.ie!'!i~je$. IM'O:"l!Ies~.a.~ de f~IUro': - S:~ste:m~~ registro d!e p:i.c:i;enit.es itF.11!11!1l11lli~k'ojj;·i) 11i'u'!;!~'1 de C{i!!1i,l~.~id;arl, q!J!.e~ :pefitl"!iit3!J.mI cua.n~:it1c3ir el puoltdemrll~ y evaluar ,ei :lul1dlil.lilum:h.,~DiI~o rle~ it,KIoi. ~:u!1;l-e:lItIl~rltS_ - Dise.a1;Qi ,!lite 11 0 ~dsIIB:1Il1aS; lp!:rura la mdil!Jcci.Qfli del i:ienl!:t,1!!l) h~s~~,a :;liNi'~le~C'ia. i(~m.0 . l [!it~v~, en hMS ;i[eu rnf~~es. imp:~emelil:tando tecraOhJJgl8s, Ide'loolul!lfIJic8dofl.~1l; y 1\;i$1'"
te-IfIi1~~ de '~l!f,~!I1tol(piO:V1er~idC).~,

~;iliJr.~fjlll:L');. plantean Se

M ateri at c hron iony prawem autors kim

hii~,egra:C~,Qn '00\!.1 el re~J~O ,de ~os !ii:u~~:,er:lla.s,la~,i~tt,eli,cialIB~. ipri~ifiI;a;F~t\ e~(p!2l(i~'I.h. y

bl'vef;l~'~g.".aC:i.6:n en las i!iireaE,';dE' pnJ(;~clin~,ieni~o5 iU!!l:u:n~liH:ial.n~s H,~'u.~ll:itz;.l'L'rr' la f3.~' en
,m,

~d~.
~ preBirQ~pihlJlaci~"
[C I'i\:: ia,

_, Desarrollo d!e nosmarlva

n ivel c!l)D1I]tilld[~riill

que

eleve

la c.~Hd.;:td, ,~lS~,Sde

A~m,enl,o de 'progmnfUls de famraaci6n en el 'pire' y postgrado,

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VALO~Ac~6NJNIC~AL 0 REVISION PR~MARIA 'y R.E5UCITA.CION

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N ada rn_tt~IQ!lJlelle~' "118. \rrenaiii!l se S:1];C[llf.',~s:wngr1e p;al-:'1ii.heI'l1Ul_grm:liI9 ... 'lti(ioq!!J~rillka, [:r-llmdnmeUilitlilil eenocer b. gh;l{:ern:~i'JI)., ,esllldIIO cill:mp:tC'~o de coaglll:~~d6:m1., .~OIlfletl1i3. g venosa 'Y 'pflrn cruzar y reservar s"lIilg~e. S:i Il1D se d~spO:mie de pulJSio)t ~111el'ufa, (~,lO ~1Je~efUlIl'dolilar corre!l;:!mJilel.!1~e en el pacie:mlle frJii) y rual 'pe:rfund~do), es (]oT'veI!1Iie[!f~e o'b!:ener !~J.li!b~.6n ,g,a~O:~Il,'ei~ria ,~'L1eri~~. co~dIFnll~£irln 1P'~lll(;eQje a perfuu-dh' UClfIlJ'1A se dD~ ~I?,~n]m! ~~s 'p:lJUI~N, ,cl.e~~~r~~ ,~I eatp.fiIJliJ!)u {t~Sh'Ock. Tan ]mpr~rta:IiiOO: e;'~ '~I1i. ~s '~f,M~· 11I1Ii<e]litl[;j' ,(l!D1I.ergico dG!1 .~lrof:.'k con ,t:rili~mtlll!O:~clcs~ iJ)1l)!i!)id~ Y ~1I,~. :UI(tlJtlllditaU~ J!] di[~r.i,· dm, ~;g~n:1 la s~lmrci6nh'lJ!m:C!dliruamlit::mJ del ,ptlcientuc •. ~mrlD '~~:~iM'i!iltli s-obi1C:inlflli'Siiumi ir~~~SHru~~ ,~,ljje pjj~::1 !l!tDiI(pC-'Ot09Jt I:;},Sliu:[l.ci,6fii de~, paCi,CfiilC he.-ntOdJilfi{Uiltilicmtr:'iealll~e estable, sobre tode en mdl'hls. mtdnno:s y en el, CiUtO [le lmlJl~lj}I'islj]l.@ crmneoonoer:~I:~oo,
grn'l1'e 'OO.~ bh?e:i1:e;.r:lfilij'oI:] en'{h;:liC::~arneiil!tSe f~f!'-!;tlliza C(i!Jl!J .I ~ m.(!!li!Jil:ori7.l;l,C:btin e~ec1looc[~u'-

diio,gJrolU1cael pade~~:e. d En. esta ,(t1.~ Ulilltti;lhi.r~;]lid:eJhie~el1ru}S !l:~e.~.~ar la segunda i,e.."{t6nque requiere t~,u'~a·
nI1iie:I1i~O 'uliljntedi:aJto!::}~el ~atpo:DllallIl:i,!!IIl~u' itmirnia.~o Ciiliil ~om!pmm~;OO' vit:ilil. Los s~~rLoB. elf[l!it·o..~ de :preiStlJUiti61ii ~nI: hIipoi:e:]lii!i~lcJn :rof[;jj.t:wia. ,:11! :~~~ oohUi!3!:;llII[g~~ UiqllllidmJ~ .RIUllTIi;1;liIlto de:l~~'presiton veuosa ceitll't1lJ1 (PVC)., t]~siil1l~ltad6rlJr tu'bol:b::;i6iTI, de :~O'S I[UIi'iD$ cardiaO O~ ,lll 18 nl]s-c[~ltad6:1il y ,d,isH~:~ncion, de los cOIm:lIp:~ejo~ u ,el.ecl]JO!l;8.Mi!JgJr,[ficos en el Iw'{i!!tulur, E~ !:~~~arml'te~~o,.es pU!~i!~lli'l,1'o, la pe:rtic~roioce-!l.lle~]~, se :pmede repe:;;i. es q!J!.e ~i'u:- si se 're'pmcllllloe el tarpon anfl itof;:l\!Jl iru 110';, ,deill cifte~er i[1~]~!j;~.\o, ;e~~ lell'! e."'l;pa-c!o pericanlli~iD. ~Itratami~lii~fi E d\e'fiil]~.'ujivo es ~~]i;mii[[~~co.

~ra.ves

El objeUv,(j e S ,tJ,'~~'~f'.~tJr'1' i!ifp.('~a:t.',itJni~(!'''~f().U}'gi('.{/: ~IJ'It f-(lll;l'l.'i,t,r,fl

tiea ~lr!fe'mfl. La
If'xpJmYKUh1 ICOI~S!.Gi'rjrl!~:c;Q'n,h?"J\i!t,e ,

Orl.'tiHul ~,(!.r'flP,e,~~-

(lq ,~dr' £:!;',t'(jl;j'~ti/It c.am'(j lte

G",,!~gOi.1P(,ECO)' _y &, 1-'e'il~"l'h~j:d~d p~II)Ual.~, J~ fICe; es m'~.morde 9 se P~'()Cf1ttrt !# ill i1-U~~MC.id\rl~ 'N'i?mNM:,i,{h~ jlnqcd:/l~jc~, !jeliliie,IIU~O la precauu;iorli de llliCi' J1 hi,p~[1V\e:flliIar, :mm:lrlillelil,ie.:lildo hi :Pa.c01: alrededor de 40 mrnHg. S~, eJ{'.:!j;'~·.e&e'~. slgnos de hl,pelfl:en:siinn a:rtl'eri;Lli,'i se anla~~,ra 1lI.li!:u.l~lol,. Ifk_,g de pe-SO. :9, p~;S~f en 10 !liii", S i se 1
obj;el:h/u.re-ftl
:!i:~gllliOiS de

e1iicHjomli~;Ui[O,. ~ll11lem:U8 (l~ :~o::l['il'~riGif:,- S('l: hl:pe!Ii,,",:eril'~i~a[',fi all :pildel:l re :nrililit:ltenie:~.do la .P'8,OO'~ alrededor d(:; 30 :1ii1im.~]g f'l,i'~r ,ea,':u[lul0 rr~'lml:(lti.frJU) " ,",~.1~,eooe',h~'efali,G'o'), rnte yn liCE gf.,~ve, se (lOJjsI)jJII~r,tt oJI 'ilieti[i(",~:iA :mIj,:lIibil,o.Sill~i,C'ihILiiidJl!J~1 :m~lsmiO heltilp-o, IL'm~ T AIL '1lI![,ge.:liI~e,. standn sin em.~:~:g,o :!}'I)I:e

:pcd~l;ad::iJSo realizacien

a :~a:[b£c~~I~,;ad~e ciilflil"gra l!IT~eli!i~:e ~~r lesienes heme-

:r-dgk:ms

C'rQU -COI1l1[;1!ro;Iil':Ii~,~1!)v:i~:f}lli.

M ateri at c hron iony prawem autors kim

&'3< ~m~~Qr~~!.1~,e 'i!!iI~'i:s.li!L"e:n ~.'l;Ie ,:;Iiril.te.

ib~[~(i,~,

IUlI,

he:mo~i'~~,tngiCa q~c '~S:lri!\ti:t" ~~, k~ h~.y ~odblt

'OD:!lI

TOlE. ,g;rr~'!{(l;con esi:a'C'~

~.lp!lJn:e de velamen,

'P['j!N;i'b':~e edem~ 'geoobra1 y ~~'m~I'!JHa!r~:t t¢~i'6D'i!i[1~r&e~~jfi(;iaL I£':mlb~r· :~ S~,~

'~;m!

el

de

IIlC

~!lglf;mv',mT un

go, ell I!l!!:i! pacieate 'C!i)~Tiel!

" ~ .~!'.'.

es :rrllJ'nda.IM.eilllti::.1 re·6 mo:n~81r ia ~le~:lllI'oO~fii,i!tfllnC!1!J., ultemiilJliI.(I!(lI :liH~nle.Ii1Ie:Ii' un ~ ~resm.'·111 arterial normal (ideal 1!I.!1i,1l '1'A.rlllled:U3de 90· ]O~ :rn.lnill~g), dado IqtUJe exisre 1IJn.D! 'p:wes:~6nJ de :peri~us:iolJ'ii ,oere'b.m~. cl,i~IiIl]lillll:ida,
e'm1 !;,f;U)CK,.
~

.An~~ LM'lt'l: ,abeyad6in. tie~ti2.stado de ronci~ldt~. se ,debe,I~ar en la: ezisitmG~, ~

()

hipQ.:rciQ:" 5hQc:k
,cral1!i!!O~

tf;aH~ll\(g_~im:t{ii

~JiLCef6lioo., E~diclfH6~df~

y un posible
(PIC)
C'O«l

,~U:Dl1ieITliOl :p~I~cl,6Jk:o de

]a

]D[lesiom

a,nt~~crmea]

cl resultado de ilUl ~gr~t!jfa!l1llierDt(l!de la isquemia cerebral (ver 'CSJpi'MJl0 de T~-aw1~'aiismo cJ'(UUt(J(N.rc~tauc(J),

w {Ie irun;,:ic{~(:i6n pot -"h l u.~U'gas d'-'-"--'set' ~DQ '_CL 0 ..L... -_i,W'I!;
siem,~)1I',-e ,de e_~ii~sr,(~n

I1

FHCmeO!:t:

ddbe de ref desvestido oon]p~e~8tmefli~e :rradUulIIi" la revisitm, separa

dtes~~dailoes i'~up.]!lt;al1te cld:'H"ir'h:i
ptaJ'¥i,

Cfi']fildf~f~~. Despt']~.sde

evitar 'loahillJ!fj1ern~~ia.

'Co:tl~:il!lU;fUi~6u se cQIOCaJ1l s~nd~$~

,~:;;~r~ca:piJf '~fa

Ila~~t

escepto si existiesen s.igrtLO$ de frr,:flctlTmde fos~ anterior de (:~~neo Ul~~ll!:!il:ormll !i!;lpeinr~l 'l1la$O:mlgi~, 0' ii;;1f-e~li.~ac'i.6!.1 rebnrp de de~ QTbv~IO~ i) I'Il~~}; en euyn case se CO~,.jJc3rill. la sonda :por V'f:a. o:rn~.,dado e::~:rii£s,go de :inmmdlucirh~ en h~ c:9vkhtdl, crune·a~~. La sondn crC$~ban.. :ITtlimJdamclu;at para >objeti.v~·herm.-U:urhl Y 'pil:va ca'~ilbfm'ell co:~m, QJr,l,lJ;lilrniemo rle:~shork (la ,cil:UIlI.ffi.'"318, horaria es uno de :100 mejercs pmlifictros). no ,'if' rolm:al'6 e'l los mn;)nes si existieee« siglu)s ,de i-o.tll£CJ ,t~reiraS (~11~re en meato. 'hemt9101'1il~eSCJJJlan,
-0

Ui~,,pacie1"lJ't
m~i~n
,[tit

,~lrauf"
~~Il'~

mpitbs cllmbi'os en, £:L~ e.stad'n, 'Ci[lI'I1 gr-a~ OO~l1l'~ ifYJrum~so uj:[.(J, POl' ,~ tim r:equine :J111'11,r.e.eIIJlaj,~CiV' o!m~.oonsWnre de· Sit esitOODveni!ei~torilJ" hi!'mij)~

lm~

penneal y

'lac~o

rectel con pr6.%url~ d:eSp:nnlfl-

druJ),de:jrutdn la reslizaclen de' 18 tecnnjea.en U1:!iJ nos del um~ogo. 1"'8m]ji,(:Jj {~:!jradi:e este ,per]ooil) es~:iij~ti(!li,ad~ reali7;aciug~ de !a

dil'lth'nioo Y'nifwol6gic'CI

de colrurnj'U~cervleel larerel, Ib:. ~6:r~xAP '/ Rx de pelvis. Algunos ausores ,o"£id)e~fii. qee ]:ilJ pund6fii. lavado pemoneal y h~:ECO ~'b{tomin~1 debe reallzarse
,R;(

una

(h'!l:!i~!Ii~,e re!c;j)~{l!dil11iemo rei

prinll~'I:'jC!- ~-Ili c ualqeler' casn hu fls,w.di('d l'mli.oIttSg:icos no d(!ben de retrasaria u.~md~a,ciQfldel PQ,.Cl'f.'I~l.i~',.

VALORACfI6N

SECUNDA,RIA

[la, [evl~iollJsceundaria 'DID debe :unlciar:s~hasra que 1~1tvisi6ii1. prim ada ~a.finaf :~ilAdo,se ha :~njdFido la ,restJJ",i~JtC',~6.1!1 ABC h,a sidQ 111!(J:l·'al,,~adQ. COm!:5,~5[e en 'vel
una :I1I11i1tf3111es,isll eval!llaci6n i

'filltooka corupleta Y un a expioJacion sis.temal:ic3 ''l deten id~ de pies ~ eabeea .. buseando s~gtlOS y le:s.i!l)!rH~::O; ooHC'lfeD4lis ..

M ateri at c hron iony pr

em autors kim

tt~J~~.Hictt.~ '~.e.[lt!'S{~'f,id:;:: ')1 ~1£'C~Hr le;.~im'il~~ qtl£ COtl~,~I~~rJJ ,kt [vidtl, :"J
... Ln :""~ q~..e '00 tt~;(i!iiilc (~'Ct:j.iinli:t ... ~~ clur@~(;'i~ "'lCCO~W'Cfr.

b~Qmw&~6!~ !\Q' :puede ()bl~iiSe ,de(11ntf:en~o h~,yque e ~J!rre~U1Ii1~t'ii! ~os: fim-n'Ulilli~es_ h:J;s s:;.olr,~ ~~A~'-L~lA/~e- l_~.nh, i ~,_ ,g/" .. = __~__ JI._.~_._ . .__ ~!JI t.h .. , 'rIO: ~Yl.!it~lF"'ilil L_ ,., it :rb"Cfl~ar los d~t,os fiJJn~~lfIt~le~ 00 la :h~ll5]Q~a, c]ir.d~~~.
'~@
_I. _I

s~

)\, - AU~rgi~8" M - ~dlic~:Ii;:;~,(lin br>IJ'u.ui:ll.Iut

p - P~oo~,O',gi;a~ euJernned~de8, 'p;~ev:i)~]~. 0 WJl= Li~ucio~eg. y (11~L~HOOa.lUli1e4;II;Q~\,

rrni(mW

tm!Tih!l,q~,. Rf'qitti,.~~~

[fa erl~':5

.} ,~o n~iru~j,tr1s, y. Sill, nlelC~lIU8I1JlO,

A - A.JI:]'Merrut'e;

dr'Cl!!;IIH;t!l1i_~c~a'S tre1iilci(]Jrl~d~sCUI!]:et

noci.del~)te

[~~~!!

"-'n~\'" nanz II], 'iUlu.m." ,D""\iJr,ood::J~,[!I. ""'i'I;;.[UU ""-''1I,I!J,l'''''''''''i'i ~!.c.", gLUUU.S "-"""~~]'l<''''''-'''' ,'_ IL'i'iiI"\fC """",.~~ ' ,.«, as, '~.,.:,~ .~ " ':.1, [;i'''':rn.I~." ~ stc.....,.',~- i'VI1i~~,:;,........-... us ,~,il.._k.-~.- "JIIIo..1!l ,Im""t'..,. 'liIaJilOO ,~~8 de '~~ :m.U~iill~dwe ](YS, nflkmil.o.s,pJ$ibl~ 1~~,orne8~e :~l~f!j ~I~ d q ri,(!(nillU;]~e:ru:vi:siulll per el ufJtd.i]~6r~o, Se :Pfdpiirf~(;tllid"d~rmmt~ tOOt>IJ :11iJJ J el eam (;,itll~o :P~litf~ clGrrGx;ttlf. 'fiftl(":I[~u:t~, , hlln~Jrr!l:1i.eru:os,3J :n~,c~~~ 0 m~~'![fJffi"" 6mJlt3;.';:'~ :mruJ.dibul~, y ca~.O'~H_N'o se Sl!IiJUrf'l1ifiin los .'fLtr';fJ,~l~mlmnOOIiiO:~ ~I!.I [~impiBz0J ~t ~2JJje" ,il :Y N'~)~ introdllll· ~;1r;!1:~. ~{'.S:@~ ~,i__, .~~~ .... ~~ ""I .·,i:.." ,fir, l~l~,lid·~ '~~, ir.;,~~~-.s: ~_=1h .,.~, Ij,,--~-~~ iTI'~I!'i;"':·It..-~n,i [~IJI "...i.flr-";" !F.-!l-~~_J ~.~~~-!U ,...... fii""~ Oi oc...ik.n ,il''''r\t/''''''-'''''-f'[ ~"" II!llj_~·!rt_r~1 ll~J ai1i'iadd61l! --..de iillrJocdol:teS. La, m~)f'iO'il.l! .. ·· la debel1 -- re.alJli.r.a:r ll: [~(iln:ihl(il'~lliIDIo--6'llrr'1,'1J e ,. 1.1.. \!II - '='-- .-~ \, --,rr--"-- = ... "... .. ... -''''"v .. _. -. . -. ._.
,,[!!JIg
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''l ~,'l;iiJlj i!~~~l

"'Ilptii[""""'c /'~'I'-,'JI'-1J["-~""" ,,",FdDlOOI,dC~U~.~ '!J.~';".Iv:~mU'U ·I'~':";V .. ·~~. ~,:,,~'h' ,.j.". _. ,:Ji~:[ Pu 1.oII ...1!I.1~1I.J,\iI~ 'lnerifl~ts,>hemat()fi[J.as, :ii'irfl..wm~i.a,fJl:f~rn~i.", '~~'bi,e 'pe~Ma d-; tJCR :pru' :ffit"lG'~llras, y
..:K;;
ii;l'f_ .....

~,'.r:o.Fi;" ·,·,""1 IlIIl1U "~'''if'M1I''"'''''';j;';'' v'r 'fi" •• ull~,~"","rn.t 'I' ~,-, ~iJl;:',F".",.! ....I"-".,,. J IiJIiIU

1.

,f.'

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[~llIr'!i_.~'-~~,

Ifll_lJw~I1I}~-'I..=.

,Sei [""xn'U~,l.ni, ,reti!F'•__ ~ __ II;ill o':'I;;'io'lrl~~rii'li1 o':'iin ;~'l.r'I""··ii1;t. , [(~"'\i:O, 'i-ji iF': el ~_~!",;:;Jlloi'io illin w¥ .. 'I'il}~ ~'~!J!.... _ • ~'.I~rr.=i~-I!.._~. _w .md[j;~:11~.ut!J_@....lMl_ ~
t!J •• Y~I\!J __ ~ !rIII!~~lIJII"'"

[.... .n.[~ ~~~:'l~1"' ' ' _, 1' 'KJV ,11IIJI~~.-Pll -~~;r.

nlliJfaodOn_ [IEIii, t':~~ ,~mte:rio.r 'lo~tI!~IiUHS O la p:r~liId;a, de ~i&.8, herna:~m~]as,11 de( fUifIDj~'Ij\~ ,acs;r (~(IiiitOla POSi.c~,6:Iii, :UriIJ lr'.iqu.(;i3J y una :~i>jbl~ ~11J,gU!r~ltaolOIi!I d.(;i '~~,g~'~ai~: S~ :p~lp;:;-~£ini pulses t:fimtlde;()J~,anwmdo C8JUdadd~J'PUbf)J S'~, ~im~lrl~,T~hie:~ los [CSCfinlVenJe:nl:e su ,i.1JusouiltllCi,{kfil ~[ii, ~;~,detc'Ocbiii'ide posiJbI.G...~ s-op]~\" Per (dtimo ~ '--o:-l-j~G,-:l~:I.:, -'-~'''';I ~...;;. :~"·I"'.t' -~-, poil iP.~m,ia rosa Sl!IJpffiie.."'1le-TIiM " '-~"-"" un ~n~,~:s.cmH Slbh:~lU1'1[1£O que C-t1lliFu.enZtli, en e,,'1ila, :iI':!i.l 'lila, 1"IJ'1i!" 'IWline :"on!71ie,:1Vi"l) .de '~T'Oa '~'uh'I"" at':e··~~·l'+~l! '~n~~n1''''''"'1'k~-::: ... n'I~I·''.~ ~" ;:Ii"i1I~'[~I"'" IP.."", :5... IJl.. __ . .., .. - """'L. ,!~".....,.~(I'",,", .1.11_..... ~.JII~ L""""'Jf~ .....tJ'IU"I''''Jf'''' ~_.~, :"'[ 'i.!,"-' ...-.::.L 1!Ii£'V\, • 'V .POT:' '11.1 ara pOS~.eri,f~r e palUpilliem.os ,clllidad~)1!'aIil1e1ljle :;mo.til:n~.o :re.."Fa.llite[o!l, clefo:t'1il'!!i~.~", ,(,;u<Wiul.docli0S, ~ :~nelt1,~oo[ If>IJ'pre."i(l(~ci~, [d6Iulf' Sl~, pl1dente 'e~l~,oon~·dente. 00 el '
1'1": .. (.,,-~-~,-~.-,,"
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..

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Y.· ..

..

~, .. . y",

'F~tIII'''iI!''I;' ,iI !IL'-I!'!I.+_~

M ateri at c hron iony prawem autors kim

:rr.ftdi{~,gr.fdla_ A~in~hm...ll palip~~mOS,ei, ~i:eL'J"g'):n; ,cle~~~i~o :rr~Jtes 0 e.sc!aJ)o:!~4,!, !lJ.i-, t vel del cuerpo, y las CUMf'ltL(ii]ia8! Il1du,ye.ncln :U&iS l1!"~,()~, ~1~m(x::JtJI,vi:(:iYI~. :p([Js~:c:r.io;ii1~'IC'i1d:e se refd:izl'HiI~' una iilillCl,;!:[I,ilifliSUIliHlfittai6:n , :m~Lt;,cljjjidadlliSa blll:SGfm~:o' :po:~i-

bles ,~re~s,,~eb~po,vel~lU~d6n_Una, hlu,pcrvcrMihll.f:Miil discreta '~I!I, tijJ1i} :h~~~lt6:u,~, no 1~,iI;!.~ ~~);Iil1!pnJ!lne~1i[Ul~~a ib~je!~n :f~Ind6n r.espinu;a~;:li Iyu,ije ser de'bidf~ a m;u~ltiJP~'~ .• ;(~j(iiJi'.'lij8,
~ffU]ijjil1aticfLiS tica
~'

{G-"{ji'li~lIl:s<i{m pulmonar,

br(lfiCn!ltS('Piu,~iJ.ti6li!, ,miteIf\c~u~~~s" be:m:u!lL

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d.'e [rrl;J'mll!f,~ dli.m!~~rr~,g;fiI.l~ti,Cli returu d~ tl)[]inu~ !8i~:C", y de. U:!iI~, vel me,g:!;l.dm; u ~Ie Jl!1;I!1f!1~tJi;, tie:[iiJC nbfSol:ililtiU, :pu[{J.\T~dad I,a d[ili~['iIJ i!..U:g~tiJi~~ se ... ibm ~J'I.~o.;:~~s,]on,~,:; ~enrn,('M:,r:.£~,(:~fl;';; :mdVt~~,~re~, a ii6:ilfIX, ,a1Dtli!lltr.1tnl 0 pelvis, que eernpren~,fj~:elf.l vida, Y en Sf.i,gmtdlo ~,I],,~a[r :~ (~i~\~~l)6slk(JJ'por 'lAC de ~~~5:leslones cerela e

bralea

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M ateri at c hron iony prawem autors kim

preeozmente (mil.xXlo,f:at;i.d ostei1J'8iil!1t,eS~.s ~obre 'hjUe:Sfi~,:~Hr.gtOS).~ralegada ,dli.liF:~liliir~ l~ 'v~j[iQ~' dia:s. N'o ~3y ''iI,i.U~:Qlv~!~.a:r a.dli]i:ilil~:l!ltr~U' ]8:5, meQ,i.e:i:flc:ioDieiSi cO[lliSixd\e:mdas, :urli@is lJiI:',gen~es: pfo:WH3.xi~s ,a!F!lIt:~tel:;I1ifiLica,~ 8itll~.bi(iJliera:p~8 si es :p(fj.ed.:m. ,l.!ln~]co'f[1:~c~~~es~ ~1i!;~18;e-si',COS". etc",
j

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d;e: '~n;llme.rosaiS complienciones asoeia,dl~~ y ~ '~N.]JilD~ en los di.f~ren;~ei!i. ca,p[I~JL'lJlos,de laobra, ,61,resurnea ~~ Itooo lo CX:pllie5lrli e:r:1 esl:e ,c~p(ill1Ll~.oqliJeQm rd'ej~:ndo en :~3 sigu:iernll;e t~'bll~ (T~1b:1f~ .:1). 2
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IDe~(IJ~IClr!le'-!ill!i!o~&ro): leli!~i6!r"', a - C~In:;~Jo~~on., ,. Cohibvii he~or~'Q91f:QIS'e>iltea'in:ctS,., • IEv!il~l)o:d61i!de~ ;shock. !Ii VnCII5, ",Ireiii O:5l0i5, '1 cUlJoH~ioo. • ftap.o;sidOn in ldCl~de I~'q!.iido~ "9 r~?). ~~!liiJ
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I)

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11

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Material chroniony pr 3 em autorskim

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lA.!MA 2. 1

WWRAC16N [NtoA.i 0 ~.MSnlNl PRtMArRIA Y RESurnli...aON {~pjnuoci6fl~

- t>:;fJ'DiSiGu6:h.
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dle:mnitOo,

lI,un;9,:se,-

rle dle sISGl!I!!'1lnci:;ts, ,cl:e: ruiC~JlJlfid6:liiI. e 1nd~ac:~oncs t::'IIi;]Jii}CJfI.cHS. Ge:raer.,ica'luefitte ,~l ,'mtM1 ejo se h!~:ida,',C-O',~,~e-c'l.icasnU1JU/fj'les '~'eUml'~ncaci&:l euerde d reni!l!~es ;a."J!;I!r~tCIOI'I!, " " .. "'1 'L'ri ldas de te . po~ ~;t!i'~~.Q:;jlj .' ~r.!lp.e m;iill[l~Oll;ilm.t~se,g_1IJI1 as tie tecmcas msteur~r.elilta~e.~ ~cal1!!I;I~,i'iI.."l: 'iO:ljijj][aJD"Tin:gB.t'lN; ~:nIIJtIilJful!b_ci.6rnl1it![iJinu:Ul!lemil r]uls!l;rurU~ns :~llliril!'nII!~~ '~Qm![JH.ul1C) s.61,oen 9quellios eases que 'lru!]l~Ul, 'fmc~!!i~dolss ~6c~±c~ ~un.slmllIleflliy tales e;xis~'~r..r~ :hl<1icad6:rr., Ide'~icrucas qUliJriill'gkru;, (il:ldootiIroidotO'~ut~)(T~'b1~J)3

TABlA. 3.]

1II"E:CN~ CAS. :D'I; IP!EIRMEABII'Ul"ACi

=

ON

DIE ILA, ViA

AE R E'A .
• ._. __ 1

TkrficiWi~ lM!lrjuJlCl~G!!;'_
>Ii -

EI i 1'IlII~I!li(lei\CKfli de ruerp.;os ,e.)I;I~oiJlnQ;s,.,

.~

~ Msrp,rm!!::lort.

.,'

.. Aperluml ,de In beee, .. 1i~Gei,(m ,jJ nt'e~iOf de 10 Il1fI!fJndl1bukm, . .. H~pelfle.x~elilsi6n de, lal c:gbeze tlimufcuj'o a las, OOl5()~5rffl ~pe~~~
IQ~

de

~5i~oo

I" ,ool!iJmfiO

~ar'ViOClII]_

_ Tkf!TC~$ iii!siFlUmefi1'cdeui.
.. Car'i"uulal oroFmii'lfliea. ... IrJI11U (l!d6n ,f;)ro3J~ql!Je~~" b .. M.(lsecnl~nlJl
,Iil,

Iminaoo.

CQ!iPb~tl)be"
COri ,g,gIYjidi.

_ f ecnic;(:lsquirW!r'giootS,.,
,~,Crioomlli"QidQ'fomfo
", CrioofiroidofDmTc_

'.' T(T(l-queotomia.

LH 1:D18,y'o:r ~H1ne d:e los :pa£iienll,es tUim:li!i'iuti,c'Os, ]'1~~ilI.ii~m'Ui, mLQdH1it:u[ Ia ;OSu]]'H '~1iIJ II.. !!lin.. , ,1:'1"'' ' "'11'1;""""'''~'r''''''''"'s: 11"' :;;: .. ...... ~u, 'II~,"I""..... I'"'., !\r."--JlI. 'd"""~'b."it".. "'.. ,lI"iii, ... ,.... ''iii' """"'rn,,"fl"'''''[ J-'" '"'f!i.I''0,.,,,.-....... Ii.;Il!UJlJl!tv ' lUg '~~~ ~iL,_~Ir'VJHIJL .t ~v ,'!..~IJI.i::.!f], _~ :~liI!a{;i6~.1en esra :pos:icihl:II1." Si, el pa,c:iemn,e es PO!fftad.Of de: Will,ICg]!SCQ. :pQ[',~re~lb;ar la!
'iJiV\~!! ,I~-Y_V~ ll!~_l.:.!lb~, !!P~:.lL IV!.']I 'jJ! ..... y·,ILU.V J
0

!\r.1·_

M ateri at c hron iony prawem autors kim

C''i,I':I:!Jh.~,aci611i ~

~J~

.....

i~.,:I.f(fjw,::::~. es '11I,'1.J!Cr!',l!!!:i.a'riLo : 're~~.ru!r easces

~.O~C9£COS

IIJI

otros

~:~emelIlI!M '(jj!1.lEl: pU-

diera ]~.Ie~:ttu'. :uetinlJciI~ La de

11l''a~~.e:lnteil!1c!ll~s>cieJl~e:O 'erTh ! :S;i!.i

debe reellzarse

de

fOJiilUt

:~"limediJH;a n e

'B~

el oOll~del1i~:e 'oon e''!.dcU,lent·e di[]cll!ll'~ad ~~$piJiiillliO\mtiiJl. LI§l ~6c[JJi,cade :red'rndlaJ del casee es .sel1dU~ 'p-e'~'O es neeessrio ,ooquli1iiir IID~l)i~ijdru:l en
IFC.iilUzm;:~.6:Iii. Hay !~;ili(,: :rut'!ifirnl~~r. que deiDe:lilio5
,;,tliili.. 'ip'itlIlftOS (

siempre ~~~ y,6:lItIlho·. til :p;BBsenc:i;ilI.

de ciilIMeni.do· g:\1i:1i:tr,~con 1:0. ro(r:llJr~l1l,gedebe hacemos prev!(1I]'i!l:' una a:S,]p4u.c:i6f!i1 iBli!J, e o ]a s~g:~ilelli~e :~lliSIJiiU~d.611 pacleme, rot~ndQ~ en hlQq;ue ~I I~,lPiI.)s~,ci6iJJ del 0 lateral. ,'lEn el pat:.ie"id.fl ira~~mdtie'Q'h.rft M,("lll.c'Cl:Ji (_Ir- !pft'trii.t!'clbil.'i:ul-('io.~~· .t~ ~fa a;d~-e~'d,gbe'n d L" m,odific·(J.'rse le.1~ los I~'~'S()S de de No 51! €ktJ€" ~ti~r€nen~ .f(J.fpr.d'lJ' de·lesl6.~~· ta, o/,mVUl ce~~~riC,(lr. el caso de &'015.de ·eo 11Il ('~hc~ h~w. ~U~ peeha iIll'fr.:!:m:rti absol'I)I~:iilil'!lle~.lI!!B Or:i(I:1u·,;r!tld.icada cl!;!i~iqllJl~!er IIJijJOIVW~ i·nO' se Mji.t1, ~CQfta:do zadora del ,cueHo. ~o:r ]0 taneo 12LS l:ec:n:uc8s :ifnJiJ~u9n:e~ y las u.... l'....~itm ~ ~ .-IUV_UJirUU!! ~ ,L ~ ........... ~ -----.: ._."""..... qjlll,£; se basan e.:Ll'I~,D!.r.i!l'IIgo5copiiLfi. ali eecta deben 'IIUOO lflearse, LmI fljaci6:mi de la cO~:lJIn:l:'lliia cervics], I:Llid,:1I!~'~Jbef]'~e .lTIiliillJllilllaI en

,an

tii

PO$lCIQI1J lI:let!rIJt~1111
• I]", ~

"I" ..;::, . V~.:~zaCh.rJ!Iclil:n:uca~. II

postenormen ~e COIii
•

...ifi..

~i I;.. '!JJ£!u;ierea.

I' ,1 :~Z~lr,..,,'e rorma 'IJIe If.'

lI!~$POOI~:~\1\OO de UIUl]IO>I ~.

"

IlI1me d' ~:8Jta. l

." de ~n,~ os ..JI" 1'~.p!J.S:Gl~:""'i[)S._ e i

IjJ

1][J,ovilizHI!::[oll1 i'iilPo c:o~.!,llI:~.mJe."'i. Fih:lrle!lfD3 IiIn, {.'It:Ii!ill8:i~l.!IiB'n ~a '~lli~.lIQ'"d]~.:laci6n {He Ci[lni!:pleta penln~.~:iemloigiros de l~:as'u~ 3011 .'!I f]!e:i'to~I'i;[Cl]s~.um~sdg 1O~II.II... Lu S

th:SlPooi:u'~v,m; lIilo. ,([j',g'bc 'n;u,t':C:rnJO~ ,Oo.:ll1I tiill ~!JJ, caJ.pt.I.c:u~m;d ,de infia'lt movi Hzar a. ~a horn. ·dle':Pf,~1iciillr a]guua de ]as, tlkl1l,icas,,, L~ seleeelon de: la ~ecl1lka. I] dispo-sjdvo para In fJtrnrlitruJbi:llb;ru.cidin de lit "':Uail aerea 'pueclJe co";S'~'iUJJ~'r' 1!m~ die :~ns d i:r.cull:Rde:s eat el ililil1~tjO. Ern. la ~dn~,e;rd. ~.]j[\Q,~ 1.;; iOl.a'Ci6~ la. ~cle._1:l!:ifk:~donde i,ia ~rese[ad~ de compromiso y la C3JUl~a.de ]~ cbstruecicn puede ·orfeli!:~lI1!:el :pm![folll,eIlL13,. Los paclemes 00'[0 a'lliernc:tOD1i. de 1~ coneieneia Ci] ~}(Ji£; que :h:l.'ndaj,a~i6['jj dlill bL ~ni]:SiCil.ahIJilll'll:1. o:rufad'liIge8J :'1 ~a :f~~:~';l!I. de meeaelsmos de 'P:tJ'0'1'ccc:u6In. :sOfii c~. Ulflld,OO problema pueden :m:!l!mJ~j3UG inicial'frn:l:llh: eon [·ecniiCtt£. munu:ldes, 'C~riI.i.du:s gr,O'hlring_c[!Ls. :moocaJrilblili, l~~rDIIiI.~a~y :po!:ite['iO!r.JI!:Jlel'!i~:e.; S~.,e'll IljfJce,.liiarf.~Q galf~nl~'vzar la :per.!illl~Ii!;e;~l~:~aJ la ~erDte!l!!hi:~~ ad, tie d ;con :ini:uiibUi;f;:lj,O:Ili trr,01i!f'aqueat Eril. ~)D(spacientes C{!iU com~rmIi!.i:N('l' (IIbSit['I)IIl;:~~'1;1'0 :pn~:u•. b:~emC:li1['c :~Hilii. '~.ecnl.ca.tS itillianllil~I~,~ no iliielinj sl!.a:fi!Cie!tIi:,~~ :pUltR ~..'];glt,i'lI.'r Ia :pttrill~:lba lisat clen y ~eng9.'~Il!e'recllInirse ,m,]a i·ottl1ioo,(jolt. y ~i e£~9.re:S!Jd~SJi·llrIJpracti,e.:;q.1bille .fiJ J~ 'I~crlk~s Iq,~jlf'i£i Ql~~'c~s.
Iln:::s-eijJC[~~ e£t!l}~ ~e

La cUlt~lliz_3,d6.l1I.,d,t'i: las Lttn:~cas ]tMirrn'lliul,(':s ]J\uJF.SJ d. 1'Ii'i:finej,o de· Ia (]lbs~l[llIcc:u611I. d,e It'I. 'd~ aerea en ern j:iQdenile tral!in:M~Jt~cO ~~efii~]a limha(l,~6mt.dJela neeesldad de miitl:~~lliz:B.J" IDo:~ f:lJ1Q"'i~iniemto·s:'~\e la CQ[lI!:mrn:a cervical en ~os cases die sespeeaa de le~i![1J~ de C;G]~ml]H~I! cervbcaL L~~ 1lr!!!:II~il'iobra5,mal!Jl!Lale~ die [lerl!ll'le~biUz;a'Ciof!l de la 'V(i!IJ a.,ere~. I)jl'lli,c~o-:1iel1ill-ea(:u:ij.~'n :!teiibre ~I COI1l!lf.oo1l1!.ioo :gene:~d!i) :por el ~,te5lll!)lliiilJZiilimieLr!to 'poiSteillW(L"' L~ leagua en el :[l~c:i;el]~:e ineonscieete, De ]a~ '~(ljiesm~·~·iom!'l· die qUiie llh~.iDIrJ'l)O;:; '~!Ii',f~ eorregir este r~roblej;nfi~ >I:l;pertrlilf.a, de ~)1iII ·Ib(!ic~ :~r!JJlb~.~.~{u::b6:[l •. :l)tu:er.unr ,dle :~H:m:liIHHbld:o. e hIJipereXJe1ils;itlilll de la eabeea, UiIJ~iCJiIl~ertll'e; e£IUt. uh~m9 nQ :p~ecl:e~e~lfrea~~.z;i;U:la.U. tecli!:ica. manual se [i:miJt~lni. Ia fU~c~,ci(l] : a Ide,:~~c!ilibeu
l

M ateri at c hron iony pri) ..em autors kim

------

:r,:iO'llid6n [}el.iu:rrlli~, ,c:o:n '1lI1Il~rn,:,tlllo, ,!'lD!Jml:p~fiml~a,(9,e; ,arpeuri,jJJIF.:::I!~E 1,21 'OO~I:I, Y trac' C:hifll S}ni~e;rn.'OO" de :~a,m~11Ldfuu]a, con '~~ otra. ' .a i~mo¥ilizac~&JiIde Ia OJ\~LWIill[Ili!leere!il ''!.I':~ca!~, IIN~[lJI,iZiillll'mi a[u.lii.dmei[lll:e: con un a.}"l!Idlrullltc 0 3e m
COIiII

,il'l~u!lTlilJ!de

:~illS

,cl:is\po:s:i~~:vos

diuseiiiadiDicS!

3,

tal e'£eclDI.

de ser eN:~j['~JOO&1 :¢ezas de:rmJt2lile&~ ~OO:i~Ii5,t.~:~8B lOs. de rom:r!l:a. pm~i'1lCLgre~~ eix::., :plIIooelill ser extruii'.difi~ m_muulllil:1e:rillte: 0 GOIll,I~,,fIrYu~;!;\

t» ,1J'l'im_~ri) IN" a;"",~F la, h(JI;(J y n,~i.r·[~'.!".. "[:0000 lo-s, e:.t~i!Ii1tllIil1!1ilS ,~i)iilll
~oca, s6'ltclo~'0 :~~,q,~ldo:~ deben
~n

tt ~cuool:w:n, e.ilil

,~_a,d,e:'pinms (,Fligu:rn 3.1

~!!ii~i(111

A~rt!"!ra :SYb!l!.!~~"

od'~ lb~c.a

a!!'te!lior i!i!e ra, mandibu

a.

t -.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-- _._.-._.-_._._._. ._._. .-.-.-.-.-.-.-.~ -

~ •
•

O~i.i~n

1i'I!4i

Iftl;!$\!ieitil!,

i J
1

~ INe@El_Sida~

d~ 'It!#i_n~iIaJ:;i~fiIa IPfEI$IOi1l 00$i'll1!.ia ..................................... ··Io.'·'li .,.

M ateri at c hron iony prawem autors kim

~I)e8!pU£S' ~iUI.l" qU'L}

iimpial-

gre" 9~rr'EiO:IiI.e;g,~ (J1e:],erun dlrenl'Ldm '00:1 OCiUl ([Q, al ~~defJi~e eil,l (Iloo~bito ~,HJte"']1ell bloque y nIIMlfic1tli.e:nciho,hi, a[i!t.leaci6~,de la 'Qo:~llbrlllllla.. l:'JJ M~~:Il1tc:i6:1iL,~1c: ,abeea y kl O:~'O:rfuri:~geeqeiere ,o;l!e ,eC[!!Ji'P3nrierruto ~lI!e- ~Ini'~:a ~ r ils.pi1a,!::iuml, de 3illl:GS l!"ol~.1l11nelne:5, iPOCQS seglWd\O\!l, ya t~aI'i,?e8 boqlll:i~,I~l'l' ~,pie;jl de Ide !i:',ae:i6:~,de d~flme'l'l'O !$lilll:lp:lilio.. ~_f.~ ~ooer extraer rest'o...~ a~:hlil,eali:ici,Ci~",En ]m; ©eIilJtOO!, p hO'Sp;Ui)9:~~rj,QSf! cuerea ,oon tU;ffi][[1J;d,(!!re~, po~e~~e$,'(!j,llle conectados a sendas d~ asS pi:~cbjl1i, rtgidi1JJ5, nll:d~~,:per~O',tmdasn $1iI, ex:ml'"emo.; para evitar sH ubstn],cc[or. :POf e RSIQS :!l6~ idoo. IOOlJlsi,sJU,eJil1~1il~ e:vacl;.I~cion ~l]iCn.. :ErtI, e~~ m.edJi(), p:rehfjspiltli~ilrio se CUe-~ltal 'OOTI e~l)J:upGs ~Um-e.:ni;ad.o,s por b:a[\e.nt:llIS ill nrUinrlll:tM~esque prestan ~:rn;!I.!y buenos
s.eiIi'V:~ C~OS,

(Jt(}f~tiri:ge"1.0$ IOotlte4;l~dQS: I~qrl!l'tcl.o8" 'i!6:n:~i:~'Q,sanser ,~lISp~rudJOS s~ [1;0 se ~isporne del ,eC!11!li,po adool!l~cl,n, y
k.ii

Su fu~ln,d61il conslste en ma[U~eneJr de$pla~acil;a la :~eJUgI!lJl die :~~ :parodJ ]po,sl:erlof d,e la far,llII.8e y por taLno e:~~~'.!'l iiru!L~(:a<da$ erJ: io..r pflclelJ'fC,'J coa o.l1.'c?nlt:,Mn' tie Ia !t·,W~,c,fe~~!d'a. lo~ ~a"Ci~l1!;t~so:nsil;:~,&nl~ su !l:!L'l1}(I[:ucidf.iJ 'Pro¥OCii, i:'l!iftiIilSeas" v,6.liUi~os:y IEI'!! c :;1UernciOIil}BS dE: ~JL:r.Tocillelil,.c:~iiI (:(uil~}m.ea,,~ ii?;!!:ta'i.iiI' c().~'ir:(lJndict!J(ls. La' coJ'iX"(J;dlm ,de las (;aliu.l{ij (woJa:dft,fj.'e'(j~lW "f,~pofle ,1rWIlfUi"aci6n de' ,'0. ,r:;O~' " • ~'- '",....",.."', ;-, ..,4 j:" !1,-,,'I'~" eu """ lil,~,ji7.i!IId"'::'(ij~_~,~ I ,~M1j!'II,Ml l":l'.!"~'l.ct~'~:por - ~ . qlllk': I1tJ' ......: iii"' .... ~.'U! -- - -- ..:...JS'llo! ",,'!JII.~~'.L'.~ ,II:~IJ!:~""~"""', · IOn .... .... ~_,~;"~~.:_:, __ :,~II,)! elfl '1Ili.'l !OII ,I~~'- - - - --- . -,. _ tc,. lLIe ,esu,u,u ., e eoJ,IJ.!~,1iLlilace\L'I,l',"C~_ I ~ ~ _.il.} _ ,.1 -I' :'_';:~, d .11'11" '.' 'i' 'Talb.la 1r:1ill:1li1~ 'DUn ~~~ee,IIIU

3.A.). La se~~-d6u del

l::lUtJl:e'.
1ne,J:
-' ,00

chuda, a u:~:~~ es :im~oFizur Sl!I, ooHc!it,vi,dadi '~]el1ie- lle, ~ su.n,cien!~e como :PI3J[;lj, onreq c
U!l!"U,l~ij{!! de
- "';.--', ,A . ..:11 ,a ~~, :n,Ul~e:ro ,llLueCIl.!3u.O ·11· seiecci " QUL., "':lC'ierildo se I~L_-'"' ~._.' _

ln base die:]~ lefl!gJUl~~oya!!1!do SiI;.lS aletas ,e:[ii, los :u[],cIshlo:i. P-~!f.!:li, adla:~ta;~se ~ las. di~ti,llIi1:as ,ciI.imlellJisi.ol1~ fDcia~~e:.lill~:~ds.i:elilcin- ~-_ ",. nameros. ~~

Tod'o ,vacicn~e q,!Jle. re",~cf. iU1D cirfli,Uk:c orafa~

;-'rt.ge:~, !tie rile suf~c.~e1l'~,~~'
• l' ,..II •• '!i!JiWr, ,~~ ,Cli'ltlCJ€i11:(:'j'ill CDmo

,QQhlddil1t :13 ,[tilet~ COn. :~os:~Ii!.C:~Sh1'Q8 buscandn :aqueUDJ 0

UL

pam no M;ea~~wrla;

C~IiI;lI-

ou.:ta, [lWliU;a,

:!1i.JlcaJ~Qe

el co!]dtllc¢o

~j]:iii:vo e:dtl;niIJO, (T.;,~Jb~21

3,.5).

...

lABLA 1.4

CO U)CACUlN DE '!LA CAN:ULA 'OROFA~,.NGIi:A

1_ S€iilfieCf,eiiI1Cllf el mmonQ ndecucdo de c-6r1iUJlo. 2. l,rr~Fo.dudr' 10 c:6n u la ron 10 C'Oi'iC:(ffiidod d i rig idlo Il1a:clill ~J P(]IC1d~]['.
:3;. lDe~fllg~r I~ pl,mJtI de 10 (onl!lle p.or ell poll.odar hQ~I'CI1'Clleenzar e~ pal:4Jdgr bku'!Go, n~a limrr 1,1 n g rFa d& ] 8~ y ~e_i:rnrilm IlQ i n~roouc,d I 0:11. 4. Compmoor ~iiJ po:sldon de lcs o!!3~O:5; ,d,e 10 CClfillU!O sebre los.lnelsivos,

M ateri at c hron iony prawem autors kim

4;7 ' ,

_
~ • •_ _ _

L.!.,atA '3.5_. aG

(til NUI!!.A5· ORO'F_AR~ NGE_45,

000 '00

Ne.on!!J~'O.
ILCllC~,@ Ie'. II!

o
1

IPree,sQQlor" IEs(olar'"

2 3
~,

Adol~$'C~Flihil_ MllJillo_
Mlu11lo 9 ronde,

el ~~u;o U~ '~1UiI)l) l!JYO' exrrerne d~;sl;m:i :&'(JiIlrelP"~liS(> ,a:scuerdas ''I,!'ocmJles,:''I el :P,im~ de C ~ N,imn'l se ~iocaHiCe :por fl.!l.e;lI':;I! die la ecmlsura buc~I" c.a/ulllr,nye ta' ,~'J(;ti1Ctl prlm{Jr~ di~;rJ ,lJ'ar-a togrt1Jl" pen'l~'I?Q,b.m,zaJ" ta '~,ia .a:e~(I. [fre~~'ea ~ eflLCwja, die este Mlooce-, iii: ~imief.llllOl exIUlSl'e:if!I, lJJlI'lm~ serie de ]lhllii:~iilciilInes, en Sill [-eiln~aciO!1! d~idas, :!il bI, necesldad de unas eiS~r.!l1ctll!rn',~S11Jfut'6mictiils Culil~""ii'¥m~S y a,:~a, 8 [Ji~'5<01rn,~ 'h~41 id~d, ,de'l realliiz;ador" EsHi indlcada en: _ ~'nwPQSli,bIJI~clad e C'O!'!!~e,glJj~r d au, ,~J:deeti!mJ:tJ 'I,;i~nti:~m:i6[lj.md~-e:n"3d,bJlen, p:~e~, ; . die' Url! traun:m, '~()!r~100" ,~~' SefJ..'CIi!lc _ _ - rnJ'lrm ]PuliI;~J1J8;dGn de la E8C~~ a de C{mlla, de OJas(giliYW 'in[er:iof U ~" _ 1'1i1~u~iIitI,ahs[J(J){[i~, faci3il,e,~ IQ eervicalea (pem:I;eu:tra!~'le:;; e no) CIDue co;~rllp:m:i1l1e~)oJ11 l e Pii!,.~1de alre a :~a, '[a,,aexEIJ. v
- P'ad.e<lil~e~ :;i!Jld ~~.{l!~ PQRil~it',iiI!liUlli:!lilt[:z~d{lis,

- Shock se~ro_
- P~Ci6J1lie8 cm:b1lJb~ti"!los:"

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D Yr~tU~ eJ nm~ej;o d~'1 ra«;ieru:e ~r~Itfi~4WOI ]iJj teC[lica de imt~'b~c~6n PlJlede ser ru~ce.~~.a.[flO ~OJ o.b~trt)l.cr~i61i1. dI~la 'Ilia. ,u~~aJ;.si'~oror necestdad de '~,P\~~C!l:D" :~I!]!lJyo \'e:Ultila~-!lJrio en eases de ~'UlS fic~eugd~ :U'e8pil~llOritt. ~ecfiLic~s de hiiPervent~bliY ,~i6Jjj,0 ,a:Ili[idpairtldill~e: a C'Qm,!I.lcill.c:~O:I1Ii;;!HS,~ C'Q1JiLCi, !l;.'::S. I!fll 'C(!I!SO de hils .qjl!lenl~(h;Jjra~. II?Qf
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M ateri at c h ron iony pra: IJJ em autors kim ,49'

I pZtC:I;eI~J~e~pOSJ!l;ILOI1 0;,': 'p~~tenle d I [pe11l0JlU, II que ri!',j.H·". I ." y_e. 'II" ce ]"!ilI i~:JJmu:~.c:i:6:!1; CiI,UUil:1.0 l p.acier!li'li:e .adilJ!lllO la hi~~I~eJi!~i6:n. en a de la ·c~l)C·zill!.y ell,e..... !;.71~~ (I"·· lns I"""'- ,'\'-...as es I"," iIil·l..::;,iAr'Ij1I ,·"'!;I"<[I' itlIe:-ir''f'll~~"""r. J""., 'IL!''''~.''.IIII·':''''~'~ "'"'1.1 "" ]1] na~~!·1·",IiII !JI ~ . ,uIlmJ H" i~,I[!'aI.....~ " ~ Ji II ,,'!o.;.,I! U ,,1!.!l1.1 ~,,~_~. ,I l",r~I"". • .... ~J';;"'I" ,\ilI.~, ~ t'L'Io cl _""_l!c ..... l'f~~ ~~iIi1lAI"'n:l. e 11"' i611i de Coi")o~[l!Il11illim.(ieFvk:l~~ se !I!e ilil:lfi1:endra. ;;:;n ]1~oi'i<"'k:~.rij'1i u'i!"" "" ""_~ 0""""lrf ...."..-.". d l!t\;.a;Jo_ "'_W __ .""'~ __ .~ •••• _ •••••. . . _. __ "'_ .JI._ .• :!I. __ W __ •• :m1.eum~a·1 COmi.una :f~ef8(jintl.'1. :irnn:1il.},'I,!'iilliz~um:t!lJ; Ia ca'be.z3, a.plh_'~arn.(fO! :ias tlUIIt.q8, a tl!I1'Ii'hns

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M ateri at c hron iony prawem autors kim

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MATER~;ALDE IINITUBAC~6N 'ORO'TIUQtJ EAL

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AdtJ~to.
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St~gm:l;(.ht" se re~}jl.i:ta la llfllJu'Omlruloch:)11i dell, tlilr'roQ ~16tico.

!I1Irolni~IUle~]l [i

tm'l,lcs, d:eil '(mUlcio

D~'l,'a,~~i't' Ij'(!J,(jio(}l.lj)wvc,(!di'ltrim~'i'() ;(.C'(iSNt et ,~"j(}~fJ ,(lv' ,:e11~'jrJ)j'i'tt1:C$6"l 'J por ]0 '~lli]Aiode br!J;l1lCO ~pir~.d{hilol' li'-ara, '~djudrl!;\S!tJe :~ies~;t], apnc~ 1~~i6:~ 8!Ubre ~ card~u_g:~ .. ~ 'cri, ~Q:~~~, ~;mrpid~Bnd)l) IB] ,(X~r:tt~~~d.o q~.~ :~i:qu:b~o d~1~(jif;l~n, ,:lJ'I¢~i;,:¢ la f~!il~~ ~t~ ~~ ~jJ_jc~:t!Illjl~ el :[~llnr:libl.'e de Ilj!(_I.i~;i;ob:rr,!J ~Se:I~:rc:it1;;',11 caso tl.e' '~tlt';~\i) ,ff-ctl~~!1' ,U'mn¥J: ,~(1 1 de , se {)J'{fJidH :h' ~~~ C()~:o'C(.' ,(1'1' f)(J'C,itmif;(J (;',1~' ,(1(J,'C,~b#o',~(lI;(N"a~'. N~~(:ro-tltlid6'1t~ /0 lJen,nit:e. 8~
I

liFfll,~ :i[ljIIlflOOu,e~~;(:}n ,d~la PI1H'I!lu, del ~1]jl}(l!'n~ibs, d~ 'Iuti,Cl!!.~dlU~, '\liOCU'~es se I»"@la ~H~. ;;;';\io;;,jl.", 1 .... ~I .. J.'V "01- ; '",'r"I"cJI"" '~'''-'I-Il ,_" Ihll._~h_"';1,\J !..II.... ~",,~t:il-~] ,il"-~ ;~li,r.ili"'-;'.I'·I-'QlifI.l'liI;'fl'.'"'ii',r,-;iiIil~ II~"-l ;f>.of"'fi' ''''U,r.:l'·~r~;'''ii',.I-;; 11',.,"" .·.lilil"~~"1'1"'1'1 1!1l._,i!W _I "'_~ I,. _ ",11.I11.'w,ILI,If~".II.... ",_,1& 'iofl! "-'Un..<:!__ ._ 1,1.." ~"ililoi' '::1...,..... U II..... in ~.L""" ,~- , ",i~-', ,.,-. "'-~- ,. ':;,: -- -.~'-'!'-Il"" ~.• . ,. - ~~.:,,,,~ L -"-Y'"",,!, ,.'Ii" ,iIL.-.U -- -~- :k,~-·,"'-~' 'II., '1"-1 _., -ellr•. ,Ulil~}C'(!illr scapes e ~b,;I'CO 10.0\1,1 vtillU, ,~c.Il~U,pre&[Il1U prJsnL .. ~, ('tl!n~~(p.i:thruc~&m'1iJI,~ .IiU

1~~Js.ic~;6n '~u'tWJ se dell.

:Ii\t:'ldhr;;a,

tUL>;cu]ll:anao p:rri:liuei~on el ''!,!'c~l!Ce p~:"-~rflnl~~~ e d~~~,

M ateri at c hron iony prawem autors kim

'i 'l,lI!qQ eUl, el i21il;lll)lti)e:~,O'1' :post.eriQ~,e;rd~se we;:d~1;;;;a>Il, 'IijO!ldJolJJ 1

cuidadosa
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paJJ1lJ

'ev,itM des:p:h)lt~_mjenm:03 (i! eJ;Jub!l(:J;ones aeei-

~i1! .qUi2'

'~@!i 'l: .'11crcnte~ ~ IJev~m, @r. ha~;p.i.i'a~

Ea cO'mpwbacion

tie la POSi.'dOfl del NiOO mMJaJ~"tlqlll!'dl

dc;~~" p,I'J't1Jlizado d .lJ.li{)C(!.'{iJ~ pm'mllll,~1

11.'.(m.'rlif~o~e l'il~,1}.(l;'W crf~'i.r:::o.l)~m

t~100ar()r~~~]~ ,ooJ.oc.adn ~C' ,~be ~5peCfm~:n c-J\ia'f~:U, m(]£a.

,~ID.sic1l0l'il,

miln,~~o_ ~ ]Iln~ich}u ,aIllomaila, suela ser [pm h'llI,l!Ibadoll1i, seleetlL

va del bronqaio :pr.inci~al cle:D'ift~,;lIOj

rMame:Faoc.: el izquier-

dOl. 'Y la IlilaR r-re()1!len~e: ~r.t~iprn1:~d6i:!J el UI!.lbo es en d es.6(r~go" d la, aeeeslded de no ~e~er ff,a~!\lo~ :~n~i~~:'Vo!'l la verlrleselon de hlJconecta poslonn ~i'(;iJ~e[ 'M;Jioo, h~ h~(;no d que :~os :~;rooL;ld:~[]J1:te~w,~ Sie ~IUi:;ollJJ~btrl 'm(iUi,:~Qe~-.~~ que l I'Ii1IH,;rOfil:Sdifi,t:u~,hid~ SCi 'p;ul~lTIi;n1lii ~;1fmIli :hlllllllbiic:iltlncs iJjifir(':i'~~s c:n ~1li.:.a,nfIDi:!l hostiles

Gun,pacientes

>S.~ Hpni2i~0

t::ifiUitiioon:i:vifiS. E[ :pt'!:1Cctlli~lil'~Cril~~O d;}:&~loo y obh~adiJ)

es :~:l

Hi];rou~:~a.eicln ~CIl1.g-ndBJ 'LlffilmIinOO~,v6:f:hocs :PtiJIJf[tQj]mr~s., la :[~~~I:i:'i Vi~UiIt~lad6riJ en cl~ ,e~ izqlj'~eMO ('OIl entrncl;&"de gms en el de\L~~lui! nes :~udia10 :klliitllbad6ilJ selectiva ,d;e'l ibrollqlIDio deuedlo, tU;Jlug~W!e siempre h~bu' 'q)ue de~C!ltJ"I~J:'la presencia de neufMOl:orax ,11l1l1 ~J Uli'e'~u' ,iiI,IlIllJeS rle lrell!lo:s:h;;~[tJ:li!D'r el t~lbo" ,IJ~ La apm,c;vO:IIl de d:~spmi~l:iV\O~, (Ii bien ,pOl" ~~~mka,seca, 0 a I'fW'iJe~:J. de abser'qJ~le., don ,de illilm~lJrr-oj;o~,son eapaees de d:e1!ec~-aJr ill presencia de c~lf'b6[b:nCio y dar lll[l~ ~
,~p"b:!la~~llrulfl :pelf.lll1!itido :liiea'~~.mITCi8jpml.onlel:rUrts. (~I ,gHS ,e:i'l:lP~rndo. y O'Iisfpo,d:elf' 1t,;".(Jj'iJf~mit:{i1t ",en. i]al{;:i6bi1 :unVCOI:;l[ e bi~UiIrlij) se ctlililsigue ];de[jil:G:[I~~rt'liiiilu, presien la prurcia[de CO2, ,~I fjjl1!i~ de la ~5;,pLrad6f1; :~n:)'~h,ml la ,!:W:e1ria~ 00-40 11fQ~Ii!fWg}. l.~ ~ 'Cfl!fl~!J,1Ii!.etrFa, :plalrnlJte,a [lJrob:~e:mOlJs cUaflltdo estemos ell! siitl!llaci,Ortes de :paraCiln cardia= ca y [pO'! 10 t:1l!l:1l1[l' e[ ,a:port:e de ,OO~3, los omJve.nhJSJIll."'i1ta IlIlIIJIY redueido, €in estas situaeicnes pucda d~llf :fmibuJs lilegiUi:vu;s. En ~io.Uilcs se :ffilnliJ descrho, :l!iit)ID,j'g tode en ~CliS' 'C~~Wit~j]letros qy tm'cc&~ seea, fon;SOO, poshivos e:sb~~(hJ' rube oxutra(~Wien~, n de el e ,e!!;6:f~JJ30pO'uIa presencia de gas c~rbOf.I!ico en eS<t6b11,]~go1'~b]{ll .3.9), [ (
respuesta
w..!!tA J,9

IJlROCEDIMIIENlIfO,5 PAlM LA. 'C:OMPRO BA'CION DIE LA poslc~6N DE'I" BO OROlRAQU EAL

ru

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AI!J$iC.u~I~i6il"1

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no mtl1lJ'lio

deel tu 00'.

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'Iln~,'P:;lru, as'lJ,iJ[,o;ra, tnl'\i'e.~ del tJl;ilbo Of:,(]I~:TlIp.ro(le(]Ji:m~:enri)!j, :s-~ndWh)q~e 'Pe.ni'tilli:~e ]d)criltlil]!C:!;j[r ]1:1, poo~,ei,6jji ,(jt~l,nlU~ r

'00 o;rotraque~L AI, a5~fur.a:r.sl S'!L! peslclon es corre01~1 se dlM~ene ~~~,S,~.lilifk:I!I:~'~ad:,Slru ,!!'UI e.Mre!~uose f;!ilitHUelli'Mri!!en e~Q'f~go,. :5:IJ!S jla1fiiede-s se ,oo'lap:;;:al'!! so'bJlie el
'~JUibn~
~10se

:Ho:.gra, ;;,ul;piw,all

gi;b"ii.

M ateri at c hron iony prawem autors kim

.53,

'f~~'j' 1~'fij(fc~\6jif tlr:bQ /)~7)1,1r~'(Jt~~~(d ?S 1J'fJf-'I!.S~j"'j:i;JI ()()J:O'/:al1" ,~l/~' S(Jlul(J,' ,'fJ'(J~'ffi'Jgii,fu >61'(11 ~ tPlca' lMl:J~ w"",iaT d tYJJu(J.'I,!ido ~~d~'f.lcP'lcr), [IilO h3Jbiu. ~ido:C'(i!~,{:!(.':ad~, iP~1oi:lalfli1e:ni'e" ~i

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La, 1~_fLIil!O'S(;O'pu~ di;[11;,.':01~ ~~'~di!l, La ilin,n~lrnach;}:n ~~fi'rnyllilll :iire~s :JiCf1l~'~)ie:n~8 q,iUe iP'fO'I; OC'aJ1JdescIl1rrgtlls silm(putlcltrs, C~'I!ug,rund~,ti.iqu:r(;LilfdiliS!~rurrij,l~m:uriLrs~ :h:upel:lte:nsii 6fi
I~

y e!l~vac:i~nl dte hi, p:r(·~i6i~,:iil'~ra£;r.ailtii~,~ n ~.~Ig,nnu$ ... e IC~OOS ~ltJPi:'e.ii6i'u 3tlbrre ~;a,~f~se de: In :rem.glJ.lfi f);~OVIOCii. ~,~],(Jij,C"dtt'(Jfi;~1!; b e:;~:lJ:'e(ljn~"JU11JI~' a lesl;o,S IC~']il~'bh)S, en:m!Uj.]jJ;l!i~o$. , h
1~~W'i""'·-"~I(~ ·"ii1I'''n ~ !l)~.. ~l", !;)! I.o!(I~_.IIIJI,,", _1_. ~]u~~[IL ifji'ikf'l, '!.]A;'

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ima:xYfl.a.mciita cuandn exL~~-e 'i\f;'3!lJmlmi:ismnm~~L!e:r!u:lef'3.I:iool loon 00 :Ua. [Jf~ ,~JUiIJlR:~f~nl Vit.'liOliJfiooom (Hill~I, i~mlt.o:rio, t(l;oohml. , Paea iCtJi ntro lar I.u,:iilJ.i.[ i il_ifl\ n de i3;..'5 tas t:Jrnfli1' :1i:cwlifli 1fI,a.'ii, &:"TI,v,ad!til de I, '1I'Irf!i(_:Xo"'tlhtlii~iii!p. ''if r~ r·-i)(~, ari~Jil~OO

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I~l$,'~ec:n;i;ca.$, de il]~lIibilci6J~ sin elil uso clre fllnna.t'i~}s' '~J11III':Ie.s~~11 ,dar:ame[J~~ Ias ''V'eJlItmJjas S'U luti~,iz~i6:nj' i!J]cl:u~o ;en :pa,~ de

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eioo~~s,~d:~M[i~oo" : All Jae:ill:ilnrt'":~[~Irre"nJli:l_aci,6~, la li~111i.ct~:~Ii:~~, ,~, :reh,j~,d6ul\e:i paclenre [~I],eden.red -- ~'·~~~lrp;" '~-·'~;:Ibf. i:-Jil··~-·'., eJm J)i,I,~~e,m:e8 _~o~,".·II·· ~,1Je .·'-'1 :-~I'I= '"I a ,[;.t;iiJL se .IULUIC_L~.cS I' eon 1:-' 1., .' -_.-.,:. :~l-·.(:[~ es [·1'···· elo~orros C~~)8 I I, e _, _e.8,I,QneS LID ~J~
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:~os

M ateri at c hron iony prawem autors kim

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TECNlICA I!)! ~ NTUBACHJN (,ON WNDUO': r.ON, RAPI DA

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'11.P'rl;io\!(i91ell!~ci;6n. :2. Premed leur '00111 ; ,_ IPanf:umlllio O,.'O·~ l!'fig _~ iv.'. J. rcuolli"~C!:r ·sBd!l:U• ._ S~oCinil~QIIi"ffWol mg, kg IV. 1,5,

,- Midazolmilil 0;05 m~_kg I'i/.

-4" Iniubaci'oifl,

- Sellk:k.
La r:elc~j"(tcid/,1J k I'Mj·.paC.r.e.~~'I."I?:t , ,~oshm.'(:!·.ln6,~· "~·ll:S1.."t!lj,r~,M:f!s la ,~'"€,~',urgl,r:'a(',r6.r~ por OJ ]iI .rai!'J~·oa ta hro!J(_Y)-aspinj'(;~:&~t.sobre liOdo :S:EhIJ ·~6cnk.a de ve..a:l~'ul,a.c~.6~ C"OIliI 1bO:lsl) 'Y rnl~®c~illil.a. ha slde adecuada l~ rnanlio'bra de Sel~ick, ~elner.illlldo ~i6'J1 sobre :[10 el cariul~gn ,c:r~,cQideSi,diUJra:n~e la. :~lUniliba'Ci6:!1I ~aJra 'OOMT"Q~,~r,e'Ilr.-e:n~]{i!, di:5i[filJi!'lJl!lj'ee~F te riesge y debe de re~I~~J'Se <Be '~~~iInilJJ. La wilj:,'!a'CUjl~~k f~l~jcmJtl!fml'lsculanJ'tf el·J.~'q ,€'I domh~io de' tas. '~tibJlidadesper, ra 'lAemUI(II' ,:par;:,ier-J'J.'c~'1I ,poJaiisJ.'£ JmNl,r;I,~~{j,/.r-il pr;der e.~W(j.blf.-c.er r~ni:1 roJl~ J }'[~ CJ~'liwiJrg.~,ea si la ,ilJcrlllmciol1, es h}'lpO!idbie. Esta '~-ecliI:k~ ,e~~a, CIlIIi1I:rnl[l;diilG~rl3i en ~ade:nt;Ek."'l: {l![JI C s~laJ de ~i'r.ca,!l:~I~d ~~ iru~l!JjbaciQm ~ru'lei~one$ Ii!) ImaJfurmacioraes so'bre :~~ ,en 'v:FElJ
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del, euadm de fe8p~le~H]J :~tllf],!.lJIil:l;~~:oril~~ de~eJit~ad:e:u~Ld(J! po:r l~U~~a;gres;b5:1il ,ge-' n{l(li'iiIll (~f~IIl!i!~ ~; .. lrl(Jt;k;seps;il'.;;;) ~) :~~)Cu'~aBiP i'lj;ll(:.:i6:~'I' e O:~ltl!li."i;i6:~,P'1!I'~!i!IIO'nar;!i!,e;I,]JlII(m:~ l,. ~ ~ iii! la, :ies~ione:ndoi:e:lrtl ]pJ'"(JlyrL"iCacii~, per los 'lfIi1ed;inclf~res, IdA! Ia in~~~umn('..:i6:n,~ nUilitil:e.ni;a ~.a l)f(fI1~~efd}:il~j~ktd.~scr~J[I,~r ])C!~;l~li~!e la fwJiidf-! [~ los ~!I.''iteoh):sde U~, e~,:~dfLd,J v y rieo e:UI ,o t 1~;!IIe !nO'~-eII:~'·uj. (;(!:dema .l)~'dm()j.r(.lr ~~Cic(J;V(;U,0'g.tf.1lic :posl;e;ri(J!litl~,e\lJI:ee '((~fmliz~con s !,!!in. [~:tUna:do ce'~~la!r" l~8OOfligool!l~!i!.c~iiI!S ~umiidw~le~ttiil!l~,80m ill~ dii~![li~i!Xc:i6Iii' \1CQ;diel [h.llflt(~n y :i~ ,(li198it~,(~dlf'ld P'1li~:~,lO'ifun~,como :u'Q:..~ )f •.!i1tfunliG dG: 1~l'Uill~ :~l:~,prJ,::<,{~mli:a, sGli;';iiJiilda,rhl f. la e};}clrU$~lo.H ,de ~dveQI.o~, :Il~]ooHs~!lieti!~;e ~]i;5l,nrlli!t1l!ie:t6ifl [l!e la ~rv.perl:1c~e ac~m. , p r,a el ittll:earc1i!.l!,n'b+o :~'.iili~SO ICL'),J:l 10 If~llje_ '~~f.iI!:e de la s•. :l;"l1i'e arra,viesa, lei_ ~Jldi1fU<"-~ \II U ~Xl\ri "'3,.~ ,I~"~ ~~ ~"~~~~~~~,~ ~.~- _~ ~ ~ ~ ~~~~~!}I~ ~ _. ~ zonas, nn ~:h:e3.~h'X_
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i:nH~,i:r:ado~, bi.hil!~~rn:le~" ,qjlU?,: han de. se:1t d:~8"~'illil~l!I!ild!()~ de:~~.e;~:la, ]Jil)d~1i!lol!;lal!~ 'il)ir-igen be::n:1iod,i:lil~'!il]llico {!il~ el .~!ib~1 de :~!OS'gases en SCU'Ils;re nrtCi.r,i:u~~ de "! ig~s se eneucntra desde el p:r,~!Ilc::u['~,,(ji descendlda, ~o.:~ pO~ peOl: I~:!l]l'!!bie![ pi)']" dCib~jy de ] es v !H:~p f(~S ij;()Jli:Ilif~ s f]ruJGiillfI. J,. ~.:S). ( E,'~S[JltA r'C!P;t'tesellil~a. :fr;o:m~i~] una snl'!,i'e de ilIilS:~fflid)e[j;(,;~Ju fC$pi.f..a,t{JiifiJ~ !tjjl!i£ exigc:!l' s;O'pi~iD"h;i IFeS!~,:u!l",[!ljimJr,uo [oj~mJ~, f'!,i't1;nt~:~a.c:i(]~ Hi!~C~!1J~C~ ~0!1J flO!! y ~;EP e,h.~.'Vi •.h.s} t clrbin~JiliC:<'; iPG: dod{~, iP[,(~']{!in~ncl)~J; 'uJil, {h:Jlb~ltlil,8!I:I1I:millt'e L:a] ~IiiJl~!!;la~li' Lo qlye i!;\e~illl,ere l el eemrel ,~i;e~. cf~feniliU} IG:1lJ ililiiUl,Unidad d(i Cukladas lli!i~~~:S~:VQ,s, b~jr~ la v~gi,lane hl de un '~qjni:pjJ,t:m;~:r'C~;lndo de FffilCdicu$ 'Y ,~,f~:iJ"i]]t~;.rD&_ A pesar ello, 11a.merS{,,;:Fvaii:1
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el 1'IiIlJ;Iil~A), de vi.sl'~~. ~~ cl ~~'1,; i)U,eF~ ~~ v~·~~ ~~ ",~~ illll'U;'ii)", lila. '~rilrni~J·"In .ia nr'Q'!j,lI(;)C ,U I U.·IIIl~ 1,.'., di;nf:F;'1 'V ~-l!i' ,1~,,1..4, f'" , ~ .. L'_.llt,', II, .. ,U,.. S~gJ!ilt1!!,':, ~iIJ!ll11.e:IIIW de:~t[a1bnjo I~,e: t!.ieSI~w[',mrl:'QiJ~~Q. :~a, :~ud~o,gr',!lrlf!;!!de '~:Ql~" se 0'0iE!'!!
l~

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M ateri at c hron iony prawem autors kim

--

TABu'"3.1j (RIU'RIOS PARA IEL[l:IlAGN05:I'ICO DEL

5D'ftA
1

l .. nte~edeflt~ iilOltn:sllF&fioo (ilralllmlll]~ ;c'ill1b!g1"!!l A may"Or~,~hocl,olil!Dc n$fu$r-6:n, ~epp

:si~. oij'f(:.
:2_ Srg ilQ.5, ,de, ili1$.iLI~cieficig li\espi ro1'Ouia ~:disWle'OI' toqu i pneOl, !l!lJPl~ntQ d~1 ilTubol~
e,Sp~fglori;i)].
(:QfiiI ~

i'PO~Qilln'ia !al 'g;i:lr.SQmlle.~rll'!l] mrefhat (~!Jeno se on

oorrige

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kl -'Qdlm~l!liisl1i",cnc'i61i1 O~ l~neku~16n O!Olri~. >, '2'00]1 til • de P

3. I!t~diog !"(:j1['f!O de' 'tiW'~l)i; ~Qn i FII~itF(:IrlQS bilof,eHllles. ~,ede:mall una veozde5(;dfmdo ~I edema ptI~mol'illm de oTigen CCllrdi'o:genioo", flQ~'medi)o de I!)~ ,dlcrki$ c~ni(Q$I ec~OO~iOS!i'Cli~(') y/,gl IT'i-eJd j'dlfl d~ IIfj FH'~,sj6i'1 cc:apina r p-wlmener ~<] ,e·

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~~

eenfluenefa

'I;{,a-riaN Cin::IUii'ililiihIIilC]iJS,: - A :pesar de IQ!il ~:'Hl!nOeS ~~crlloI6~ico.lolj :pelt:tl_arj]~oorr- dillJrouil1lrue'ilf~,pediiJdQ pro~,on[ ~ado ,elil '1IJ1I'IIs! S~:~JIJI~ld6ffi1, 21L11ti:fis;~():hl,g;vc:!L, eemo 1;0. ''jf,elrutH;ac~6n Iweciiir~'iiC!11;r.44presel]f~-a, Ililmillti, siltlll,achS:ifi llena de :~i~gos l:JIiU~ el iI~t!i!.dente. IE fe' [e~~:o~ :~,e-.... Q.S: dl~:or~lU;:~n.=Ia lil,1 .g IPres[i,6~~ ,~hrleO;~i:1!r; e:1ll hll,g~r de ]I,e~~t~:va. oo:n;,O CriJ la 'vellil~i"lut:i6I:1i~pimU;{~Dle~,se iJiiantiene ;e;!il v,[,1'lofes 'e.~evado~j lo que i,1;ni~Jta:[ju cm~$igiJIieillJl)es riesg,([i~ psra d p'!!J~lm);n ~!IJ~, (b~rotrollmil:<lL) y la d'~~.bei6:lfii, (d~;s'~u~:i1it1d6UD,d:el re~o;r:UOG veneso "'J e] :g~.~~ciIliid:ua~ .. ," '1;. ,i;;: ,,- : ~ 1110 [pftl.'<I!:lI! RfiI" I~'-~, -I :1I!liflB '!'JL-JiV': ... ..,.,_'" , i"', ....... ;lllll'" nenetra :::Ii. '~If,""'!}\es de lIn ll;:iDJ!,. l::rI~ '''' a t"' "'~IO!!"" l'" _ lL\'O.~
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ruJrtt~f~c:uaIJl.~ pe:ro:cellitlose 1,0S mecsnlsmos

de de]e\!ls~ fis:uoI6~;h;8JUUtracloliI.; ca-

8J6:n bacserianae

I traeto n;iSp~:Iil!i1~Or:~o :~fllfier,uo;ii. &;tii18 ,ciJ:'cl!llll~c~~_'~cia~, f-av'omec:el:"11 la :h:ufecciUlI1 ,)"!' 'DrJJl"rl,ie:rtt'e:n ,a ]l~~.!'~f',wtjOfi{a tldl.fJ/",iar:l'a a ~~ ~li(tnwUad6!f: m@c&,;'~.ic:aell! II_.]lil~, ...
UIiL~iiJliill:t::!l. peli:1itll@tnen;~e.

- No podemos o,:~'Vi,d,~tr el S'DRA ;es: '~a,rn,lalll~.tf,€'!ill<lld61i1, 1Ili.'I{,e~,pulmonac que t~ de un, :p;rr,oDcso ,~-e:I1I~ml~ :D"(:JUC:U!lllI1JtJ;~;o cOn ~_.~1 1'~~'fl~~noci,61i1 ilnra,"I!ascl!I,l~u'm:;Ii,I,ugrlia. POI' ello, ir;!! iJlaYQfi.a de 10'S paclentes 1];0 fNJIt;ce~lIiI,:po[ ~H i,1Ii sufleieae la, :u'es,:p',il!:'atoria,
CO"~

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po:r [~ a!fecl;;a'ci6:111 pmlg['~s:UYU, de: ,O'~:ros 6f.g8J1:l~S (renal,

u

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d]~~:shvo., cO~~JIII,:lt(:i6[il" ere )1, que coucl:I!_.I-Ce'~flJ de~f~ni:c:hla.aJI s:f~'l.dl"lm!e de e fracaso mlort~~.(ttgJr.,r~:,eo.

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l'G1~,lJJ:pelMicas ;5lC: ~hUIiI, ii:~g;~dAJ a ,t,;OiilJiba(iil:' estas d :Plillii:TiI,{[irtl'bit

(!Il)S c~il['(;lI,.IIrns~ancuas~,

m~dliaJli~:e Ye:ntHaci6!1i: ,!il!JiI:i:rr!C~,!;~;~ 'il'wel]~~J' :~8 e OOI]~lI.'ljJ;.oo Jar la reaeelen :~fij'n~Ul1la,!)o;l'ia, ,~nO'rrna~" actuandn ~oIbrosus m~dI13d,ore~ .. :m~nrt:e~era :rl!lnciol1l, l

M ateri at c hron iony pri&~ em autors kim

- £ajxwte ~'¥!~l)iJ¥t~'o~'iO', T~',~ldkj oomlln~j;e;nu:c, su t!bjeuVlo, {"i'.F~~ rmM:izfur ~[I, :f.G!spi[~'l.dQ(u' p3[f;:i lIlr~i~JI~e:r el :il:1r~:er-C~!1i~[bio gaseoso (es ~J'li,f'~1!~O d'd SDRA .s!l;rfii.~ dtedr. [1.10&gfLcSe:5 elf. S8JlIgffi: a[l[~rfl~~l)j ,~:e,.ntUI(); de 1:~I]~:flh~, ~lijJJj'liLl~~~~,. ilas '"l.e~lid'tlS geJ'taa~es , S~ljJ eJff:lib9f'g'OI, enl :!;O'S ~]ltitliilf~~ ~Jn,OS sG! ha :p.:r~~illI!::~do!JJ111 ~:n'l!po"" !:!;:ll!ne cminbio ~~l esta C5~lr,[lW .,gIi(~: [I;[~ t({.,~il~'~l piliJirlilifiUilU[ ,em, el :so,~:or,~t: n!'slJim!,wr~o y SDltA ~11l) s '~m[l;m,g.ellen, (e.s; decir, jrbiJ,illi[.o ,f~los a~,\i'~f}:~o.s e ~'IiIIJ;~,'M ~na,r I~@ ~lr,'il4le~~'~ injk~1'" d;~~,tos y !l)'bsitr1!,'~idoo. ~jS~~[11 mlf.'.os Sflliili!JS, que ~il:i\ii1 :~o.~ :nDMiml,~ (jjill~ tienen ]l~~ ~tlllil,.;;::i:6:I1" :l.lJIJiIlqlll,e de :ft)f,11IHl :preil;:~r]~). 1:1 h]~e!1i~A"Ji ~l~ Imru:unmle,'f cl rIiilJte.re(~iJflbi(~ ,~£~il)..~1 a iro(lla costa, ,ohli~ll ;!!j, iU!ri[l,i~lar pF'G!S~,(~ll€;,~ :~n~l!Inui:,i6uI elevadas J(~!2i ~~.e. e;sJti'mlit :'1 dfus~ie.mtde:lil, i1iJl'VteQI:Uos Slf[f~'()3(v'o~ hn

S.n~ l~~~.',nr,~~~~)t. 'pro¥l.J(.:~u~110 ~n ,~Uoo ijll:n~rem;c:~6:lil[il~d1a!:Ma~oJ'ia;, Cr!l!)'os [1j!ed:i~cl,oIT::.s ejercen su ~~~c~6ndlr~m;ums~bre ell ~rll]nn~ll\M,Y id, :rr>iJSl:fil, i!1€;] (}:rt'Mi~nno.t. Es ,~~d'r; , ' ,cl~ furn~;a, [p!~1ir1'tddji!l;~~. '~',fit:~eIMica qllc esjU~b:il~'I'il,i!jiS ]~~ iL'ij~:~~izfUmdo :PUnl. ciUrruJooii'IT el SDRA ,n'Ca1bu'ba s:iendo IU![!~. 'C~~'I!.I[ia, 'pet!Del;L1~ci6:Fi~,.Y ~,!¥~,afVmrlk':iflil!J' ,~£: ~,f'.:s;i6.rnI, de 'pu:~:rrU;!JJTmr y ,~lJU!J1II maSt tu,llliL~S:ffio:fl~:J!uJb~, Org;!lltllO Ie]~'I)_!Hf~ e8Jte [11~Jevn,fl~~e:1Ite :fll.1~~:Urrrjf1ide res :uJiifU,i'IJttlrt1IJto:mi1':!8, que ejel1l;:lbai!il su ~ocio[!l leil~l sobre fJIDl'Os, lli]~'i,rrel~fluj!um&.,8.st~i,:hllr:t6'~!!%l~S Stl].Sl'(~tll~:6, tie fI:FJ~icia~llue~~Jte eS';:l!III~.'o\S, itx:fJCr,Ui1~,(l:til~ll.~,~, {).iTII, 'poct'!!, en :~a,r;tC~1l,]~~lh!l~d iiw,
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efeero esm medisdfj, per la nwjmUi. ell! las :Ii'elac~m~esemiLeiJC]6J.Vperv fusioo. CIlYITI!~j;simo r[~dmoru:iI esm tot8menk:: aelasado. Ag,[!~!ijjuetodaVDiIi no

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de

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el E~np~C1!.O 1~"S'~aestmtegia ~(libJJ.-e la Ide

M ateri at c hron iony prawem autors kim

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1. RIII)i'd,(j J! J:g~"f)lj'~'t4{j" e ~~rndij;Cle t!!,~~!ij, 'rJ~fucfJ~reiCr~j~ef,~;S (::Ion de :~a, ~em,()dJ1:Jlt~m~;ca;, ,~il y IIDrh;[11];()lie(l1npo I~;u.~·u)el~lid:a!,req_11Ji~ir,ic,tldo ara ctlioflm:3[!,o 'Ulna,u!t".ra1l'.'cl'c.i(m (,'(),n'~~ti(mte" Lm;; p il'!lo,deDte.,~iIrIitirlrt1uiil@e<Q:fIJ (l!SltJaib ~,[Q:R.miemras 8£ redn oe iI'1i3!1!latl[If llf' .. . . :~-.., . "." [nm:l~,e~ltel:1), :1[lFUsi,(ln de t~q,u:idos. SOrt p~(;:i~nJt~iS, OOJfi ~~ngir,1i!;clo hm irados ell] ~:iiem,:poY ,ciltl!i:idud", ;C''{);niP~rd:klas {:or.ro:s..pwndil,£::rilll.e..."i.gradn ~.;}! [~,'l)IeI!m presen,f!Ij tan saagrado act'i'v(Ii 2,. ,Rt!'sp~,~eI;I'~ f(f~~r~'b~,e ,lfiti'O ,t~i(l.1tFit{)\j'i(j;." Puede ser debi.dtl, a ~i)Cl~'l causas: ~ EWI'lIJ,(ld/j:/,l h'J[ici(1J ,el·l'Jl\~e,a.So:n ~~:;I;c~el~tes [~ue ~~I~ 'PIIT'csett1[(ui'(l[ [!.iii] S!i,ijj@,Ta;~ .,:u"" ll, It lllli.II~.]",;r,I"'i'W1If~I'';-L'ifflJ'''r."'."~rn,cl.c. 1- ",,," "~"i"'IiI1--.••ci Om-ft" ·1-'''''I·.·,~• [ll.,.", "''''ro'' n'''''',~' [fli"'r 'III.. uue ••jl , ~,u ,U • . ""1. _ (.P.U! ,·11i'I;'"I'C~(il~ , 1111 ~11, .. ~ I, I .u r.} n~ h:!,l,'~' ~llic~ulll'!iI;d,ol!Jtl[~~:e~~,ic:h)1l1 [&p:t:iJtYI~jil" ii]] eulentecer [I[~ adlili1:unt.:;trad6n (fe
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- Ew.d'~'lcu_·.i&'i,~ hf[[(;.ial correeta ('6;j,11' ;''f'(lI~'!];J'{Jd(~ r.:otltb~/~Q, :Piilic~leli!:~~ 'eH [os ql!!,e hi! C:s;c'iiliniaC~,d:ii1 i:n:ic:uaJ~ cor,rudam~nte futl: [~e~o 'ijjue PF~~~'U!!l 'yltl smllg),udo 'CI!)J~th:ll!llO~ su;filie:udo un deterlero hQ:iliiO(:U~:I!I,th!ll~;oi1) al e:~d(:lil'lt'~oerelll a:poF1ie,d!e U~, [q:u,idQI:!] endoveueses. S'an pacientes c':h.lili'~n:W,C'liltt': 'qj! iltiifU:rgi,C'oQIf>.

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- ri)'a'~!>1 (j,(l() mast!,tCi" Paeicn te [c~,fLifa.m;el'l,te: oanlipromQitudJo. Prectsa :m3.8, 'vias, r ve;iilO as, soibrec'a:rga :~iipl.da,y 'C:O'flI.'U:~[ljl!UiL, mpo1';,ic:i6n i:nm!0cl:itllia. de ,~ml'lJg;re y clru,g;i~lil;ilrg(millJ. = .lJ'.ia,"g 'J'i1s,t,icO' iueonecso. ,P~'f,l!tl{!'pr1!.'Nt'J.u'(l,~' CI,~,1~J' rll)':.() d e :shock" 8:~e~l~1). inco-, 'Wee!iO el de ~j~]~Y'oletl1tia" pCiJidi,e:nu:JQ! :~[)ch~$o varse .(.~(lra, ~[,ffiJCi[un~.'elii:~D' .agf.,fL cl ,ft~:~~,· :n:liN!~'m.iiillQ. PtBeC~,S31'1! '~)()!niUl'r re8i6n Vet~lt]~a central p (PVC)., Dependiende ;(I!d N~siUJU~'I.do Ia s(lh[oc0Jr~~ ~lnJi~h,de 'ctl~dm)t~~,[;l; peTfl!!si[CfJil de s de ~!I:'ili:l;~I,o(icles;,"0 de [cf,i~.'~.a~~Qi,d,e.~ :sa'ng[~. :1lI,lUS, /1;; (l:N:tf(j,m"{_li'I,l{iji{l~}~,(!i\t:t(!' i;'iliJj,()iritli~t .. 11¥M~IJ'l~' ll)~.'1'~'ulir J"~'P0sic~~iJrJ '~~ P. l la de l,H~ll~·'~ a .l{_t.;,~ l,ie.c,e.t.id:.t;.J;e.~ reaie» dd pt.u:.. ,lml,'l? '1"an [pe:rjll)ldi~~:ur.l!l ,~ q~.edl;!im:Oi5,[OO11iOS perre7 bllandb una 8:utIJ.mci,QI'I! de tulpoo¥o:lcnfliiJa q,Uiill: aceflimtie los 'efbC'I1!8, ~il~deseiil.'b:l~:)ro, C',:iP'l!I~tQ$, Co:FJl:W e:r~",(~l!Ill~t:'per mlthila t:l1~.a st!ibr'~iiilfit]s~,t1ll! ,rj,e :~Lq,l1idH~ ,I.l! '~mlnpaeiente ~)Q\~' el $.'~!itlpleiw:cho die ~~'~ $'~f1rido I~.n~ tra[~!lil~'dhHil~~~, [c~.mllOOa,su $i,'uwaei6:~. hesea
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dlfereneia mItre ei~:pad.enle '~~l)Ie:laa,1:ddQ a!~ndido ~iQH :P1.'Q1"!!!:~fu.d y aquel [(!J,lue 10 ha S:rd-Irl' turdi~Mre 0 d~f'OliIDll :P<"'''Q' ~gre~i'\!'a::: ;()rm~J~liu~Hi:e es~'Ubleo.e., aJU.lfltqu.e :~,~ n se p~erl!e ser i!lifi~ ~Jtu~ tl ric de eum~'i, ,'[uc iP~Jm(,:!!ltl;t~'b:fJ~:iZ~lr Ullil iP~~d~IJ!~~' preciUi~l a ~ san ~m:l'd~.ad!ilJIJ;enlte tres UIilida.j;Jes de crislil'l)~iclJes ~o:r ["%td[~'~Hlidc~d, s:a[fi,glj'{~ (i:e :PCf~

d!id~ {~\!'h[en-!eJJi!Mle!:il1!inihhS~, es :ne~'ieS!,lJ_ri;a ~ii!d [-epo~ici6:L1de s~...Im~relImltdo ]~ ,erc (l)ida es '1iI:H:I,yur de un 30% },.,En dos Jl"dt~~,OOl'e;,"l: C:()!I'I! 1~;h):l:Ies'oO:I:n:par.abl~,y ,00:11 [I.~

M ateri at c h ron iony prp-.IJJ em autors kim

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~itismft '~rclld", ~,tbil:'ifLrl~, ~uQgJlIe,el '~!l.iees ,~lel~d~;d.Q f'Qm1i!a, :llO'I:aJbl,etili'tente d:~-, de de fe:uida, suele [)re;ci:S~J1' 3, {}.4 veccs, [rn~ l:i~l!Ih~.o~, ~wa,'es!~bi'I~il'~le; 'un ~ay()r I[I~ p t'Q~ dke de ~o:_o:\p]k~i().. nes l~lerXO:~; ql!le el ql!!~ es tr,a~nd\)de f'Qr:m!ll hllrnecilJiat1l y e~,~c!;i!. 1~J1f. (Itr.n,~rte. en el '(4Ici,o,tu:e esol~.d.';jel(1o.lil iUC~.S~, ~rc:t!!:s;i6~, de :~kt~idoo; ~.ob:roe l<Jdl) e,~ cafiiO~ ,d!e ,ai~~~~f'S; Qifi~)S ,f) e:~, (~i~Iii:~~s~~ub'h~s, (,"00 TOE gf~,¥~ (';'iJ1injpurtU1ii1J~ h!im~e:rt~sa:6n 0:tI~ d!.)(;:rfUIiI~~~, ~m' Gde:nllf~ eerebrsl, fi.!tede S-eli:' r~rn:u, [0ar:~iS~~! i!i'i'~i]ilo:n1tn~ te de n:ln~b(ill:UI,ii]lJ"I;i!l!ti.da~. Iuclaso en el paclente con ~nit 'i;"il'i,". ' 'I~_'! 1'1..... '[<> I~II'''-."1 "'.',: 4-' ,~!l1 _lL oj"" ,""'" ' ", '"," 111! "',wlil 1il!','ll",'~.·""I·" ',--'''',''. ~_."" n l'llil ~ -.... 1=·".. . vlLh..! ~_.~lIl~,'.!O!I~,I~JI]~'ic'_ [,1_~t"",~~..", ,~~I!c.I!]!I.I!,'. ~!lj!!W Lt'I;'J!!,I,-I;J'\~~~",IL~!lli""!;!' 'I'""~~",, t~n:iBl al ilJOi'liI'ittede ,e;~ •. - _ --~ ''!,i\o'hllin:te:n~~ de =';11_ Ifl~lll~d.n?''liue -n;;'i; - ".I! ... -'" _.... 1L •• ~~ l!;"_ --"'IP-'-" - - - nr:mcil[""', __ ." -- -" --~ -" (;.()f.it'es.polll.demt llliJu' O:~1r,~, :palifje '@ sus :perdidas I:eull;es. rmed'ein [esIAlIT," O][I!trriJbuyemrlo ,a un ,!il!~n:,~,~uil:d.eIil~O lkl!lII±d:G~,~~da, ie¥; '!~~ imlpo.rt~r!te. [OOr! Ii1Il~yQr de!~ioro, sobr-e de VN tode res~i;~~~nf;uo. kl que e8"~'@.ri~,[_~dic~d~ [lit~j~l;r:aJ~' si'~U!a¢j6;_"~U'-",]~ '~:r.'u\fj~,d~ POf IlJ , dtr1)~a~ V'.a~ofiol11rva.R; i~IIE;,ntwru:I1lo, di,~mi!l'n!l:i[" la !Ili.;lC-e."'tiiad d~ 'VOIIIlIi!~elill y de :li!leJinrar
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btc ~,6Fi,f~~.i!e.ratlo" (i)e C(~!Di(;G!iD:trad;(~iS,,~~ iF,' Itn~u£'II:I!S,!, s:~ £:X.i~l~ t[iJ:lrmbiJ!Ji~M:W y. c~:~,o· :UiIJ.;

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M ateri at c hron iony prawem autors kim

lEi aPQIFte de tl(J(~umen lH, neeesldad de; ~;po:rt~r QxJge[l;() a, :~os I)ejldos es hIJp\ll~()IJli-en ltlJwe inkra~, del par dm;u, ~H:sh;~~ del :p{iciern,'~e U1U'IrU18Iiurlo, La ,OOe~~~cl:~Q~ igen~~~~ntf' '[;rl!i'l;!:md,~nt"O 'L;Qn it]6.IU, .y el ,:IDpor~e' "!lOI'IlIHiLen tpQr.,a, IiI:UUlf!eiJile:r una volemla adede pttdida de ~/o~L~]t1~rlJ el"ii'''' euada SOl] ]ospn:!li:_lfe~ de '~a, 're~lIId:tucli,61ii, dJe[ piu::ie:lfi[e
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cu~~a1~,~~' p;r~Oi,i.t!l,'ri~ i' es

E~,mrport-ede vO]lIJ,mn~na :~ospaeiemes :~'~poIVOlelrrli,cos~1;a[lI'ea , ~m~seele de col]l~Uca;cj!lJ~e:!l (tl'haa 4.2) entre ~~'\cuales se~· CII;I)j~:I!1~~, ,el,lf:;vadol!1 de la p'res~,'i5n OC~~[I~d la n'!ve:~i,6n dG: 'In l;;li. 'Y '!!~socO'I1I8!tr.mQci61ii. COni la :!IpriliDiirn. rlG: lechos !C:a~ahi,re:s, en i'c:mtO~.o5 no yi£ales, y um~ dism~.FitllC.i6:[i dle;~aporte de i!lx~g;el:toa ,00"g~Uil~~ ',dta'~~$. I;::"BLA~.2

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M ateri at c hron iony prawem autors kim

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qJl!Jees •ma 'base pobre pl!ilUID! predeclr la, ,evol!J.I.don. i\dcrbl3..s ~el ~SS se C.lUCU:iH 'C'1!I8f.1)~ dJ~)'~Qd;a_~, lesiones h!itJl,sido (]iagmiQs~:k~dl~.s, L~ Se crii;~k~ '~aJlalb~tJ1 ilIlC~,p~cid~d, ~~m v~.1oo~J' ~UJ lesloaes uw~~-

La: es:c:a~a,iSS ~61o

tip~.C$en la misma regl,(Jrli ,~mjl:6nmi~t'Lj o()j]:Sl;d~[act';lf6~1l) ]e~' al IUI1Ji:1L si6n pur ~_[t:U. cO'~r.at :Deibido ~.~ c:Mo.. O:s~.e1t ,)i eels, 'prop~~~~-

ron en :~ 991 el Ne'l<1i' .f.SS (.N1;8S},~q.l!I~~.o:m~~n ,oons~rl~f[uiQnlas

(res :~es~.oJ1es:r1l:l~S graves, iltlcl,eiPe:ftlrlb~!I1l.'eniteil1re: Il.mJegiow, de r
~11@.~6r!nicai' y q)l!Ie e~~:;i ,palUil;;u;i:Iili!Umeni~e

Un cO'!1JCeptQ m1ad:~clo 'e!Sle ;!!!, s~ def:ulll£ wliliio :~mi ~ru,vedad I.e..."j;ion~il, 'qJl!le l[er~l)dl:a let~1 :pa1l'~ el 50'% die: les IpHciefirle~lI!!i~' 'I~si(;un~d.os. ~pe:Ub{l!e d~ hi, ,~dtirl~ s~,en·, do de l!!n ]5 S ,~, 40 para ]~~ edaees de 'I,:; !i), ,44, 311106, 29 P'3f.Jl ~.a~ edlades,de 45 a ,M't "I W ~lm 65 to 1'!I1.~i'l ,:;tiilQt;;:"

de:ilp'la~~~doilII~, ISS. ~'!!l~icede grn,Viooa~ es el LCtj():

PIJE'DI'CCION DE SUPERV V,E:NCIA EN TRA,U\MA

LD!:llimrod)!JI.cG~rltIJ de 1,05. sis iE!TIiI_L!llio nrganizades de ,[IDtelll(::uO:!1 1II:II,gelll;~:e 'p:I~liH).spmt alaria en :1Q)slill:iiifiWS, 8]100, !IH uru:u:iv.ado 'un ,c.wci~[ljl'e :~n!tiillrus, ill 11l!:iit.."C'sldnd. de repM ,ooger :uriL~om:md6rn preclsa de :~ns ,crumcc:ef.is[~.ca:s, de ius, pad~IlI:~esoi~~.'~[,m:iiiljjaatiu·' p do§. y 8:1!1 e¥'£iih.!Licid~,;, 1E~111\!l,da~os se h!l-_f;l~n:i~i:zarlLo:P;U'a,i~f.e'rju:i.l1.car '~lq,ueil~oo .. ' facl~tts,
HSoc~~cl:os eon [!UII :a~,pJ'm:too,tjb:~, ,1P~ra.d~'5i:lt!ffOU~rmocl:eJUo.~de m: y

I'..ll.~ i 1!.J!i!!!J;I1 'i ne :~wfl

1..=11>.."

p'red:roci6~,de :~ro-,

SUpt:N

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lvenc~iill"

M ateri at c hron iony prawem autors kim

de ca!Lcukt. de probabilldad ~]e sl!l;perV"l''ilef!LCli,8] en '~II;a'Unlla., a 'pe:salr de lI.l!I:!1, ]1~,lllliita!doli!E.:,,{; se CQIl1Isidera el t';:s[tJiUild~ur 'p:ar,:l (~li\Clhf(iW la ('.fJhcM:e1odd JJC(JU_)I}'J'h"!I~'J'O ,~~, '~:(i!~ ~CWJilI;e.~, identili!c;iu' L~ loJimeJ"i'es,t.~~pi~(ih~,(!s I)OJerlClai!O meI'J'$(JI!f~'i.~~bicse~~re el .30% ell Of!lnros generales y j, -5% en ( c-oni:iJimde i:rr,1!Iiillmaj Y errores ,de ]iTh~Hn::j)a~ "J OI;II:JiI,:ptliru[ ~iD~,resul-

EI :nni'~:odoCD

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et'1irobi~s

La esesla 0 modele '['[USS Sf: destIJrroU6 palr,[L evtIJl uilJr ~iii. :pro,_ 'Y c-o:mlJariJ1" ~m J"es:uJ~~ 'babi:~~rlad '~I!I!perV'ive;lllci;~ de (rn-:~) de los 'pad~!~!;e.~ pn1i~r~l\Jii~~~!.i- OO!!i.(~ los !i::~ifeif-enh:'.:ii:C~Ii1.... zados, ronsii]eJ~~1tdoP~~~let~[1Q)\l ~liiat,6:trrllkcs "J f~sk~:~6,gk'os y '~.Ql!Jiu.uurlo loomQ m[E:mmuj,a la 'bause dE irn:::nJtox MTOS (M(jjo'1' 'fro~IIJ!.~a ~~t"(l\I,~~e' O Sl,~~dy);:ul1!e.fIC:;JiI1l;'l, Eli! delinh]'!,;';j!j" es el empleo de !llOOe~,O!5,estadi!lll<icus de 'fC,g;ESi,Yrnl :U0ltil'Si ic~~]JUr'd, pror~h:::c~:r ~Jiti(jirt~l~ poor ~mnm~~. Esta M1i'O\$ la idnd ~£ 't::ii00£;'1iI 1'9(81 £:1i1 N o:rcemlIH~r.nC[i(Jj pm iniciativa (Ce ChampIon. ~,.Frey, 'Y ceordinado por e,~CO:lluit'e de 'Jral!!'nll~ del CoJ'e~:ilo Mleuicnl1l0' de CiIU1JJj~mtos"~~rn e\l,ilI'~W:ta!Ii' ~!aL e;\I\o:hldOB1l, y prr<tlJ1oohoo ([Ie;! traume, !IL)oesdel 98:2 ~J l 98.9' reco_g,b5 datos. de I;IIl:Ot':, ~,60JjOOpaeiemc i,rntlUji1lnujll;~tdos:unl£!iu::stlrlo:s ell! 139 :llu)$p:ui;a]c~ :nort'rutmrncanoiS {J'% del '~Q~~l hm:~;i~~le~ :I ill ~~OC~.), los ~fl~piHII~es, :lPropr1lH;irJIJI~!1i d~~Q~ d'e SIJI:Il, cite ,rJ.e :P;]t::i~['ijI:t'HSpohtli1~!J]m~,t~~iI)oo el :M1iOS les :pmpmc'uililila :uliI,fali1i1ladol1i de eual es '~1 8i1!l cu~'idlady ruSlJJllltmi~OSen la :atJe:uu:iun [Ill 'mi)',llLunfm, S:e '~'Ii,EIi~ahade crear una ;Ill!in]J~i~ base de datos de :pillcil':~]leS, truU1flla'u~lziftdos ,'.I cl:e de..ii~[fl'n)niJr y ''i,I'U~ i~~l!r][lUl5 :mJ!UiI'iIII.tI.:!!i, i de 'poobaJb~'i~d8dlde :iltlp!iFv]\tene,h1 'lDu:s~dI;:.tS en las e:sc~II.:I£, cl:C ,g~li~edlad. A.si, ~.(J~ 'PillC~,e.ii;U:e:s que rliiiOlf.'lnfili ,de: lesiones C,T.I IH~ que la p:rod:~cc.i6111, ra de SU~ e lJl)ef!;.riv>era£~~" :~.q~e'MQ~, $oblre!l,!'~vi~rii 0que euando la ,f1)feii:lkd!ou era de f9Ueci:riI1~fnto 1P!JJd~.'i'l!I:1~r 1d)e:m1t~:fic:ado~, para la ~~lfe'!l!~S:16n I[DClif' p<I)res", 1E8!;a revi,...ol1! pl!lod'e pe;!i'i nil1i[i:r ~rlelil;t:i!n[:,;1lI!1i '1iIl1Jl.eT~es, '~,e¥itaib1oe:l' {)o "pntenci nhlilellli~e evitilib~es"' 'Y er.mJies: de msn ej 0" ,'if' I'II1IQG'~v,m;Ii" eambies en liUls:si:!:![,t:"aillu:sde ,lfllt'Ii!Il(:,u6n. A*~nas. Los dltnos ,de los ~:egis~ros de tC1!!l!n]fI~omo el M'rOS :pl!Iedern,:lIer 'nll!JJ'y '6t~c les :11, kiog, IPlaml~:l1cadares y ~IIJtOl',b]ades sanirt:iJ.cli'iaJSi;aBI~ 108,.I~U;~I:a.ll!l.oSl,del M1"OS sl!l~iemill ia. !ilDtl!pom~nu;i~~ illlfifl ,~i:un :pruoo:z (.'Uirrodt~~si :se (jJi!i~ii!lru ,dGl ~O,git'dfILiIll:),rnrnn'Cci6.n s.lIJiS1~nd~1 de :UallI:.or:t~~idinrl; ejelllp.Lo., se sabe q ue ,el Tl~ de ml(J,'fil:lllos sin T{.J~ gru.:pm' \Ie (AJS ,<:-4) y ,e'l58% ([Ie 'rnilAerlo.~oonTCiIE ga1)j~e (AIS >3) .r~UecClit en ~,:i£,priJrtt{l[tlB : 2:~,'I1Lm~.,U[la redlUCcioJil del ,:nO% em las mueJi1es que oC!JJIrern a los :~ dins 0' :1!n~S,des0 de el acddenl:e l:entllia, ,ellliln'&lJiiQ e([eC~{iien ]~ :[n{)"~i~d que ~1~ilL red-IU.'Cciu[i (iJ.el 7.:5% ern las p~'il'1ilef~ 24 ho:u;u, Y esm apo:y~ la cencentracien de recursesen esas :hm~ms. S]IiI,e]rn'btlr~;Qo" e~"1:~.a, base de dla!~o~ M,mS :110 es poblacilOlil!i'~~, ]Jart~cipilC:i~!l es ~~, 'ij,!\O:hli'nlfl'ITIia ~lprurl,idpau 'h,(ii:spitaiJ.les, carn s"r:if/ COJiiI especial de~iejJci,t'hjl al Itr~J);iIltr'U~. OI~lim!l!llle~~ehan rro~o~iQl'!iado ,dat,nes 'hQ:;;:pi!:~le:il, de AIIJ:5itrJlU~, y Relno nlde, amnqllle este (j,ltm,mfllo:y utros pill:uses eon slstemas de !:rnUUiI;iJI,biilerle."litableddilJ~~ 'OO:!11VL) A.i~mMi:u,~ ~~l:1Lti ~:1I;i:'idlo ,S~, p:~U(pmi:iL base de ,(jlan;,u,s. la! (i','£(,ah:J '1w"lS!:J: c!]'liI1hh'll~~O~ vsleres d:e:i ,RTS ftl'Mj,l-,~ el ]SSl' la, edad d1,e;~TPiicie~lre 'Y el ti~~o de trn,lllIU[!J (ceru:,ooo 0< ;~e.i'iteu'al'!i~.e)" ru~ "~I c~I,(tUllQ' se 1!JI:i]~, lIJH!a'fN'f rn!!ii~m m~~lemui:icH con los v~lore$, del .RTS j.rRa'l, ISS 'Y la ed~d, del, :pilcieii'lil:e',.,~L 18 que se d~ ~1iL ~~'~O:Irde (ern' SI es ,1JI:1~o:r de ,~t); afilrn;,y die I s-i es nl!~YlO(lf' de 54,.
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M ateri at c h ron iony pr@9lJJemautors kim

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bO -+ b] (R.'IfS) + ~2, -+ IbJ (edadl e ._:2.·jQ ~2~:2_ (Los ·ooo:ll1c~.~liil\G:~ do ]Jic,glii\e'Siolil: bOt, IIJ :1. lib·!. 'lDa ~'Q1iIl tlas~~fiI'tllJs £c;gU!ti el looJirnd:o, 0 ·pelte;~1f:.L!t1f:.. ;e Y e~di~derivados del M OS).

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iiilUc'a. (aQd~:ncad@! d~ III ~~4 p!l.ll~1lus.): Fffit: f:re.t:lJ]e:lllic~:rJL reSlPllll:3f~'O'riL3i (cod:uf~cada. de: 0 a.

,4 PI!Ull!Q~)_ "lill~ coefli.cie[IJ~es, nfumelfic;os 0 9368:, O~'7316 ,)1 [Il 290i!t han s~do determinadns pot JrC~jlf~i61i1 'lo,gJstIC8, (lle I~. Ib~l~e,d,@ dJw~os MIDS). lE~l\G RTS fi,Ulf piLaGd:e 'V;t[,lur entre >0 'Y 7.8408.., 'EI ISS!:e c~kl!l~~s~matJldlrP.e'~cuad~do de lo~ '~:res:\I~!O'.w~~ ~llitQS del AlS.,1e-, (]laS l'IIii;o';li:do v.~lloreH~, lemlltrn :~ "I 7',S 'puni~os. Ej~~1I:p~;O.~ Piic:~C~iJ[e Y,~Umlii de 2:5 ;;fLnos {]iliC irlilgruSll. ~r.alS. :l3ai'frii:raeeidente d)e iri~:t-Xh 1i"'i@li£ rruDil. es de 9n 5., 11I:liiuTAS dB &:5 mmiHg ;Y IlIn:!JJ FR. dle JOhw:UI'lI. :P~senrt~. n ~8
j

~ili!lI]i~nl~ :k~!5~.{inBc~: :frnc~iUru~, h~, 3iL i!JJ '~i1 loo~1ilt3J~ il_(UI!i:h;:Ird!iltS, COIilI & li6f~_:_:\;' "1'00cc ~A[S de -4}.. ro:~1!.n~ de e4i;p~.~,mi con he\!;JitO~ri.'M}uae~ Ctl

a.e ~,,200 ee e4:l la

v~:"lel:'JII hemo-

La:Ir~·ro:IQrn:~~ (Am$. de 3}.. peq)l!JeA!!i!. 1:a~er~u;i6~]ei~ i mesenseele ~ArnS de 2)1, frJlctutii',1iJ 'ce:n"'....dJa dtg'l :~f3.medic del 'feml!l:rr' z~,l!Ii)effiol~Ams: ,de :H,. ,eros:iol'!es ~lUIpernda~e.~ en l IIlfI:'ib~ miUiQS y 0000 :iZ~.'ili~~tdo, (A18 ,de' :~). EI R'fS .il1~\ci(Jl~er[~ de .3 "" .3 +, :3 ;;;;;'9 (~obre 'U_1n ~nri_'_,<ha-lOde ]2). HI Rl'S/i'rlcd sglii;;'l.: ~9368 x :1 + o.~13i6x :1 +-'O;2~9[KR,I'< 3 ;;;;; ,,;S;g.~,; 5

.r~1 ~ss seiuj_o, de 4,." + ;3l

+'

3·=~ 34"

M ateri at c hron iony prawem autors kim

iE-s, Id.eCIT; e.s:te ipacienl:e 'Ioodrill, un :8,1% de pQ.'&ibm,d_ude~ die solm~~v:ilv:ir; xpresae do de otra w!aJlera" de ~,oolD$del'l!~:es, de esa edad :Y esas It':~£one:s sobreviven :il;Pro:
x i:urmdHilile[:1I!:e, 8,~,. En 'b@se ail cti~,ou~,o :~aPs se puede de;ter.:mi!il~f el riU:iiUe:ro de ml!!tl!ite41, ]lite~:]'e-, d~ ~~ada~, y 'Q~.'bi,e1.i1 de l"iil!Jpenl,ivem;il.:lS inesperadas de 1I.]I!U:l serie de 'p;jJjcie~-'lles, ,!OHtt~urm~tiz~JJf]{S,.Se: re;preni'll~~n ell U~1 ,gJr,nllco ~,os:allu.1~l1i dO'JJl~ ~@JI' e<IiIC~:~~ I~, lee d,~ :liUrtLi!!U, r.e\pre£elli~3, la, is~b!iiJr,~h 50 se g:utl!ian !lGjl!JeUos :pa,d£lTIIB 'qJllIe :sobrovi¥!.1mJ, que {S) 8, pesar de tener lI![l~ l~re~h;;cLQnde il11,QT~aJlidadP~ <)flj5(h~Y pur debajo aque( 1([:Jae:ffi11!,'~~~ce~ ~,:~es~r de ~e!1e[ lilIm prndJicci,(jn d.e !U.ll:pcrvi,~efiLd~ {Ps >0,.50). fF) {f',~,g;l!Ir.a 5,:1).

nos

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a. +----.------..Figura 5,.2., $; ,P!Jcjei!l!rE!$ que' sobreWlj:E'Il cuenc .. b pmdJOC:j&fj €'8 d:rf!' m!\J€'l1e fPs ,<D.50}; b pacienles ~1:Ie fu~Ji CI,fcm 00, 10 p"ecircdoo' .gs dig) ~~fVJ'!te,nda (ps >.0. 50),

r:

,Pu.e-:&tQ que lei TIUSS es II,m l1I1odi~o mai~miii~:uoQ~ ~tl:1s~ib:~~,idhld ~U (1j,roP@rc~,6u de sJt]pen:vh',ien;ttts con :pred~,e:c:u6:n de iilll~pel'v1vellcia) y 'espec~fid~

d)ad prodlieti.vaJs (propord6n de :r~necidos con 'IJr-ed~'C('~6:~. d)~ m,uerte) d!e;Jr)ei~de!T1 el :P!ll!lto de 'DO(f~e estab:toc:idlo e[lil:rr~0 y :~. d y el ilatjOOi" IJIIUbl;Q de eene se est:a'M0Ce mediante e~ II]SO 'r]£ cur¥,atl'lROC. Pobl:tl.c~,Ofi~con til] ease-mix de gJr,~v,eclad ~esiol1laill
.:II', - . ." ,-, .. 1l.JI1&~,~1iI:10~;11",'1 u~ ,ul:li

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O'R.'[:Ss.~ ASCOT~ leISS,. etc.) se oo:mpar.a ~noo:~~!il~'e f!!]e~id2IJs de dh~!i:lim~;naci,6i'iJ calibrnci,Of!j, e;,t1 'l!IrIi IPm~Q ,esilm~~~±co UG '~!Su'~t~cfifl'ilJ.'dej~,. y 'q U:m~de I~s d,esvent~jas del, m~io([J,o T.Rl:SS es su ib~jli seJ:l8:i~indad ~60%) para el '~rnM:JiTI!i!, lcernarl_o.; ~,oque 're:.nd~tl,en'il iiJlli'iI ,l.'Ii~loj]'U:~mero, e ~:liin.:Jem1es ine~~waffil, d ifl(J:U{'J~jlS: :pu~iemli~ que f.al1!eceil1,peser ~lte~[~Ei. B en. a'd!1lii~i6U"!~,jO). Esb."!!, se coo~ dbbidQ ,fl ,fl P que' ~-t1iibesthrrn!l!, TCE. ~.li)torna 61:1 c-llIl1ls,tclerm;i6n, muchas l\es:tooe.s gm'!.es ~Iil uml! :~oo, '~ui:sJJlTl~ re,g,~6ndel cuerpo y 1'Lfj, ,oolit~~'!iJ.ilil;;), ~'[H!liv:k~!!J~luileil1~ edl~d del p;:ac~,e[If~:e; :~@ ,adeali:l~, no di.ferel1Lc~ ~a~ h,eti~ par ~FI]13,'b\blil[lca,(UAB,) <Belas heridas 'pol ,~1l de' fuegn (HlAf). }f 00 [predice hien :I ~L 'l'Iilillii'~a~:id_arl .n, las ~aldfiS desde bilja, t~ill~lIJJ~. e

M ateri at c hron iony pr~r em autors kim

Otra, de ]~S limita;ciolil~, dclllRIIIS:S es (Iu:e se eentra Con ]lfi m,ofit~d:id\ad PJ1llf'"d, v.f~lo~ rar hi, .c3Jn~:ad [de ~,3J ~i8!ie:nc:ha ,a'~ tr"ul!fnti; :J" ~l~'b~lIl ~J~riud,i~oo n Cef;lj~ro~, dte ~rajY-, e m.:ll ~;iilitl!it2IJ, PU(;;~,;, UCS[)de l:a m.unaUd~d, como 'inclkadOf de CHlid~(t Adema5;" se el ~e cdtk~a, que es 'I)m~i8tt'e!i!la,cam' y [~,[!le COIilJS'!JU1ile nn'!!(:~lo l;ie.u~po" EI ,~wpo de. Der![leIJi,ades CQ!i!s'id~~ que la IPS (lRJSS ,P~!()b'il},ili:Jy ()f's'u"'!~i:v:~'J:).
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I '~'fi'~iiiJj~1i!:i) .. ,tti~~tn. ,c.~~e(i!e:[loeJ~~ ~TC~}r-re:;;;e!l!.I~~~ " len. I~in,!;!!, serie d~ c~un!o~.ert~Jtk,,!I!~, que 10 di'~ererit(;i~1ll e ].001;,!'~ilu!n]1lati:!i:~to:s. re:~ OU~lS ~~g~on~ del (i!ili!;[!ltli'~~lil!l)y d ' '~ ~)[}.i.IIjproxuumn ,e.mJ, I![]i Iri&loe:rel'il'Lea, Ia I8YO.~l1IiG~UO:III1' " ~" 'II" ~ "." "L ~. que liI.1o:m;~Dnzac~uU.n1' compuea-

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'Ullih

~m~n-

dan ifi..X1:D'';lIihosp:il;alar.~~l inmediara efecl:IlJad,m. per :permll~~~Il;:lLLaHfj,c:aifu, y 1P0000ter.~o:rr i~Ii1IiSI~.d:ol d)r;:: 'Do(iJ,o, TeE gJr.r!I:'V'C ~~ tinDsplt~~le:s. que d~IJQIil,g@11I de servicio de Nel>r~"Odn,~.~(a de IUI~l~dJa,rles e y d 'Mecil.ld:na, lril~'eri!s:~v.agpe~ia'~~.;;r;;~d:;l!~ u--:dJ~~~,~.iel'rto 'e$~:O~ e en el de nru:d e IJ! ~:eHS," ,Il'" Tode» las ,"r:f"dj,d(J:~" Irmlo diQ~'I~6.~rir::asomo tl?l'tl:phuiaL7. c qi'lin.kgi'tYJ..'il o ,~l'!I'), ,~if!,~~Ie'1I et TeE ,el ob}r.nivo tl(~ irt.rlJ-ediE pDr (!'fI jotlm; ias m~lj:os p'(:J:SU)~;e:Ji If;sqflf!mia 'Ll"r~,lvaique.' es la .['0'11'1la sa principal (Ie,Sdatf.o ~;t'r:(d)rf.tIsn'tmac!Jtio, ...

El TeE es evo~ldti.W e"n, ~.affilllJiM ,pa,nR: d.e h~

crum
ltr;(.uam.i~ruro ,~l et TeE es ewi~iu' l~, ~sq~~e!:nw ce-

fl objetirt'() ~.lti,mQ d.e!

l'l:'bml

F'I,SIOPATOLOGllA
h.r~ eel O!JI!froc~n '~[.fliHun~,e!f!~l) TeE res del
n~~iQ
'I;J~

cOUDocifb]'ve!1!'W ~~e ]~ fi8io-

lpmr~:o~ngia. eerebsal, :ml!ly ~,peda'hnelilte ,de la iC'urelUll~.d61:li. 'Y de ~i(]S dii:r-e:IJigli1iitM f:~ctores. '~~JI]i:ofmsio~rlgici!lN; como ptlJti1];~6,g.ro[j~q ue :pos-oo:n inn!l.ll(,;IIl'Cia, ~[jbrn ella.

y ~JlI!:s.'~Irri:g[iB. ql.ll{l: s:~[ve 'p~.n~'Pllio'cf::ge[;" ] ,encefa]o del paso de determ~:iiuld8S snstancias y d!e~ camble a
lIEs,una sep~Uril,l.c:I(h]1 i3l1lii:reel ,espacli.'i1l! ,ex,l:rnce:h:L~,@ir cerebral

de OM',~~!'i:, ~Jt~, '~n~'!'!il::lidaD:~",el.{te alones pefuc~~[~~p n a"'ltroci:~:o;s.;IUllJ!li[} oo:n unas 1;r}~'.imU!!i; j eurecteas entre las c!lalLII1!:l!s del en~m,e:I'io,!, y una lllem:lb(f;flIliJ,fl hasal GOm ilULfli C!Uii:'{1:IiII'~e: ,lite {':aiJtL~~I.e;5 [[[,I.fffil~-elildol'{i:~i,i:ilt:s. Ex:uste~:l gr.ID;[l (;:ttnt~d1oo, de :rrL]~.'wc(m)(!lruiils, pa ~'i11 el transporte acuvo de glucosa, 8[!l,l:noiiddos. etc. ESHii bartera puede ,:llil.'~e:rr:i!ll·se l:ra;tI~.liL~L'D.is.:na]o$,.ttlITI,lll:~n!$}d,opo:u' i
~J!ii'Y500'

de eeneenaactenes

IBeS de

~,i:)!ii:

nes

infecci oaes, M aterial chroniony pr ."]'em autorskim

;e'lllrni, e 'm:mmJ[,ener iUlril. tlltlljll.l 8anJg)lJ!(Iin:::~'j;Hrnecl!l;ad~'j;; ell, cnrerulQ lP~c l)IllJ('L red iJ;i!JI3.~i6n~l!e'~~~ ~'" i~lid~~~d!ie.iJtle del resto del O'!f);1;jUl ~'~nw ,~I._~ .. [ ~~ .~ ~ :liIlti~!lnO' ~~~_'i,;jJ" ~.~~ .. ~~.. _ .. ~ .. ill, _'i,;i ~.I,I!!;I'._.11Ii5~JI I,•. sie,mtlfioo que 1'[1 1111, ... ~ •.. ~, '1!'i~'C',~"" S~,YIlI ,ft1itt':lfI911 'iln~(Ufllse S~:M1e cnltlC 50 y ~.:sm[1f1ii1idi,g:" 181.:11.1jjj:~) :Stll~gij;ll~fit'it't cerebral O:tSiC') e!]!t(. {;$~:~lJ:u~.d,('J' fd['cd(Jd:Or ~l!e510 ~1~'IV:l1 !1m (II,:1,% del ®i~lSUO;cfu:,d~i~l,(:(~}",CO:IiiIT 00 8~!li!liend.Q 3.,3:5 m:1. OJ ~OJ. g(1!li!121)% die'l C~J~SI~mo '~:o!~J)~ l~;1FSiC i(~et'i~~e(LRl.e "30 { Si ~ '1rrl~i ,gin I .(~omliil':filY.1i,exi tli[ :tJ:SqjJ~Jeflfll)f~. ,~.eilJf~(!i 20 :m~. e pUi©Gl.e prrK![I;d[ UJ(]l fl per de s i[l;lfnNo y ;[rtcoo: de [0 ml ]l]~Jlb~'[!idA1! f.i!!hI~ev~ c les~-6;t] erebral iirfll:'e.''I,1'iurs;llb:tie. c La. tasa '!i1f'l;el~lOO;~k~l CQ!]JSU11il,o, O, (CMJR"IOJ se ebtleue n~JL1ll.'ttilpll;Cm'l;ld!o, ell. fln~1!e ~te JIOS~!~81u~mK" cei!'~'b~~ ~l!(lil"~,~d~ter-eHci.l aner]o-yug~J~~_'lt ~l\ero!1i~:el1lido de ()X,[S'el;lO (CMIHJi:;; fSC s: C"(.aMy)Ol), Su, 'vailio;rnOfm~'!l'1s de 6;3 m'l!tll N~)TIlilabne~~e e~ ise '~e limnFSC ;~decl!lacl)o ,~1J ]lo'Sn~q!!l~imie.~~~.lS :!rn~tal)i4iH!!;~)S d~I,el~c6fa~ol" el ]~.~_'lln(!l_do fU;ClI:1~:cm]iemom(!t(I'b6~'~~co. 11;i~, :n~~o ;&!lIn~}I;.I['rnI.I1;i~) ~h~Ii!de par d~'baj;() de su 'va~i(J~' Sit d m~U!3!r]:cl,{~ol::mI un IliImfl,lelfl~~) adn, se :p.-;p[lch.u:(;; !/jln d";;;3:uo(~p~:~'I!m.i~ni~n:une~31x~il, 'f d is:mo""f'~:l!I,~ jo Cill!l ;uiP'~Urii,(;'I6:~ de ]3'q'[lh~Ii~:i)folJ ~CM:R.Ol :> S liil[IWd~,).,:litIii,{1JiIili'[,~L'H s;ii :tIJ.!I]itte:li!t~~l flu'~JI!I~ e jo $~;nl fn!j;ifne:n~~;;Uil ~!OS,Ireql'liC.:lli:ifillh'::fUU]S rlil~,::i;iJ;b61:f:Cloo" o bien d:fJsi1f1:ilIflJiyeti:1 estos requfi'" '~~''''''','I~'!I1;i''''''' :s~,,_ '!oj., -'~'11 ,1"III:!I]~]'IIil"I~'1i''n;r_"""m~II'~..ji~'(I!I;~·[I''''''H''~~'f'''[1 .II ~~;)I!;~'" aos enc """,!,~,~ luo!."...., "'''''II~ !O!I ,.,~ " '~lll'lI'i"" 1,'!Jot;·,.; . .... I1oh·.,,~I~1oi'i<'" ~'o'C'it~ '1~111;~" ,llluJ~~ ,.... ""ti U .l;UIJi FU,.... !..... .Ju_. 01111 'I;!,;,wi.• ~....II~II}.., "',
Con
1...

Q_,J~,

S.iHII:~iC:i

(ion de

:1ll11,[Xii1[1I£l.:IIniu1'

ah.,«~il,lJJt~~:liielalt~:v~ ![II (.cMR0',2

La, ,tluilr}~,guL~t{::rl6:ifl~e: p'i~Jtd.e~liPm~]rliia~la;jili£liiiiB

-< 4 :lInl/clll). '~I!L ,~I50% d~ :~os~([L(::.i~r:it~:s i(:llm

TeE, ~:e'Culx:\r,~:lild;o\l!e ~)Qf itnui:nlo in~,e.di.o lcs 3,~4i,€Illns" ,~I

ru:ru ....'il;u::~~,d, I (1111(:0"" y RIal _ _ .. "...~: '"
I'Iil.-. ... ,..

'l

f~lCl'{~~ ~~,dlIL'uyi2(1TIi n 1&] ~PSC, :s;i:mtd~J!Bil[ e ! IllliaS~lml[M)fiUi!lj~yg:[I;!;l. :p~i6'H p!!!f"d;!.!!JI. ,O,;A 'rp':"'Lr'O") "'.'·I·"'I-~]d'" Iffc' ~\'~'I!_"', Y. ~, ~u. ;,..'!':;,fl, ,", t'.'~LIjtf C'I!I,,"m..,l... ~"TIiJ]'-~lt"'"]," "'~I·il.fl'" "'VI]~'ri'P'l! 21['1v !.:r!.~ '.,;· ",In!::>.,. '. 'Vj ,"1'1;.",. .:~., """'il'I ,,' ....II,IiJIL' ,...... 1 ,~, ~,. , <. . p,\;]C10'L ",..., fi'~"'!'~""''''"'i'11Ii 'V..,.,,..,......:l~~.;;I·:u..,i(f1 v ... ....~Ij! llvji, ..rll,-·:·I ~~:;<f'C·• V ~~I,._l'll 'vo(i;""'~'n: ,~~L_ l,Ii;J~ -If-I" v .. ~ !i!.!L. ,IJ,lc· .'-. Ii-_LI!i.'=11 lU"Ui., ~ ~illl· """111- 0'1'<'" ILl. ,I ,; ~~-~'. '! t~-.~-~~~ 1!.o!!=~!lU "-_.-ilI~ __ ~"-"_)f;lJi..:_·!.JS..lll '_' diiSJ!li!.]m!!;!:ci6nl fSC ,CIJ,I~Wildo ,cti:i!8!iHiI:lJnrye, l~ '~~jacj6l]~; d1.e m[ 3% del fSC, Uil-wxli.de] :Ml~~llI,llIelfllt£,; Ot cada 'unlmnHg..,:E:8, :illiiIFrocl!le;liii~ la ~b):~id,dm! [I:~,eaothridladl ~l CO~. P ~ r :ii\e(!U~diltJooe (:U8.illJtllo, sucede t':lil il.il.liis 24, :liIo;[;us.La ~N"siool 'parcial de O'.xig't'fflf)' t~UIll];-'[li~u, ~lrlfU.il.iye: flil.iilillii!Mj;a, ,;;~:'I fiSC 000 v,~'Uoro.s dEl! :UroJ l 1l~i2(mlmiffi8, ,cl!1;l 50 IlllimH~;; )' dil~~· PaO "Fl"~ ,_;",,',,'i"~ ,OJ~.~ ,Inl1:i,lIJ~..........""'.iJJirn!;;l.v ,,;('}~.':stl!pe:liluli~ .d~-' .1""1~, 'lfil~" '<.0:-'''' "'~ ~;l."'i ~,~:.c~ ....H " ,. c U,1111J)l~.I;1..1n !JI~II. s e ,,,"V,liJ]llinlllll,tl>"
i'li[-il~'-Iil''''11A,-;,. ,•. I~t.. 1 ._. !Jt~
oilI'\.o"
'v-

Diversos

~.!' <:!~7

e-

iiI,","

!I'!I_illJli.~

rj, -~

.".,~,

la, p:resi6!~
U~·

h1i~:t',f!rC;rmle.~1

(P~C}.CH)'O'

'¥,m]O:ii

se eensidera norpa-

:r ~.

L"'_.· presrvrl ~:f~~neQj. ~

1ifIi)~~1 {'~lJi~UmldilJ;~~3, i[1iCH" ,cl:t1ib~~o~l~

'n~{Jnlfll!l)jl)lloe millie

].5

~m!lll~IH[g,e~!:~~ ,oond:ucioI113~df~

'L:,n: rf5i1l'.mrrt:t-

de
~-.

r-ej~'!O

pot

1(~8tres e (]IU,l~mll:Ulirnenl~ns !illillrr11l.cr:.tl[[lie.~11I1:is:

il,?j

'(~Di-~r~«uMe:m'e

de 10
,

m~nllc!g" S(t
(,il~'IOO~'bl.1\i'e,:,;!UiI:S ~J1!:l)1'(1tf'¢5

cm~l£idern'!'l
r.~SWjle.s
.

drt 20 rmrtH:g

ueriiql!!.i~Ma oereb~IDJI, olumen Sfj;r.~1Jd·m,e(~ (~if{;'[.;t.~l~(,VSC) Y [1.1v qijlido ce~~1k'in~1\~IL]{deo (l'.oiCR.).Btl cendiciones l)ffUtOl6gicf~S. t~ estes ~O'~]part.UIJilelil;~:OS ,~1n(~dCe,u]1!JIJs :~~,anfilfldilS Jesiones ccuse :p~~lfIjU(l:Sde 'l1l:s:p~tdo (U)i~t [h~rni1iill!~:Qllil~~ ~XJu.',iii.Ct':~~1;1!ra~¢s in[~:!f.?l!~) en los It!FarLUi~,lilli.i:15l!i,1iIf~S.; ~1bs(:(:',;s(!iS; 1:l)Iu~o~$., quistes, ~1J '~ap~~I:o;I}(l>g£a no, !'~('!!~n:L~Jtk;[t

98,

M ateri at c hron iony prawem autors kim

de 10.-"" roI1lll~i!l.ll1:inil.enr~D~, oC'l,.IIi1I!!1dL)se sum ~ una LOE, 0 C LiaiD](£O se '~,fMJi oI:!Il~n.'lJf~s (:'~tt:IIJII1I~Jt~uil,cia:~j aunsenta la :p'1:'('" Al ser e] c~Ji!eQ '1,.111 esa tructura ~'lTIeNlensible", l aumemo de p:IDBsion va a, condicienar e ~to~, teceos i(te]!et~e :I100~,:: 'e:mr[p'Di'mc:r ~ug,~'1:[,a.Plil!!1:iC£; '0' se imensi fica, si ya existi ese por OU"dS, C;!JjIl!lS:ili~, na , u g$~tilerltlr:~f!J cerebral pur d~.::;ail.1~:riU'[iC d de] f!SC~ t':~.lJ 'wgund)u i6:D' htlgm:r cU:I!mido la ,P[C alcanza vslcres m uy ,:.di.O:s iii!:: pmduecn distorsiones en el 'p'.!u\~n:qlurlm.:lI. cerebral en 1I,JIn. 'prime!f ~!lJ:me;rnO' '~oca.les '0 ]ie,s!o:nilJie:!l, perc que siempre m!;:!Lb~jlUiL~ siguc ausi meotando :~HJ P[C. en I(JJrntl. 'fulemhrdQ(!l cerebral ~ tra.vas. dle~ '~err:to!"i:o (en.cajiii.'r!llieif!l~Q} com lel!l\~6nffIl'i~(Hdadel troneo cerebral. . Cl!mndo ~~illiiea]~:?i, de ~!l)S 'OOlutp;fljilinlenllo", cerebrates. tienen qu e d.ism irllu:ilr '1)1 ItO' los O~lI'!D~.pmf.lll. n.l~liIlelilelf estable ~,!hPIC.~ sin el1lii~.n!!rg,Q esta circunstancia s610 se da eusndo el ,C:~t;;i~]i[:n~lirJto ~5 pequcfio 0 11i1lL~,Yprnlongado en el ~ii,e!lr!lPQ. -l!]~08, trauE n~at~siil'l;O.s, C~tmb~O'Sson rnlUJY ,rriL'p:i:rnos; no pudiendo ,~unl1i:u~e cO'~pe!f!!sgr,dQ!ilies ios; efectivas, La CI!.U·V,llI, die p[-(~ es de upo expoiltlitci:ail., en la CIlI:l1IJI !lI~.lJ aurnento de vnlwu:nen lerlJ~(l!~ p']1ogresi vo, va prodnc teiildo Lm peqtieTIO :alLilnirtcuMo rl~la 'pre.."'ii~6n,has: ta qlll~ se 'p;r-ov,oca una d~!l~~r.lsaciQIl por 'lin mrlilpot~ante 'Y ~ii1JiSCO HilImeli1iU) de la :PJ,("" Los S'lgU10S cl'[ni~~~)s ~iperi:eLlt,.i'6n e~docr,illneal (~~EC) :SOI:l: d{;l di:srn:~r.ri!J.lc~.cindel [[]i:'!,I'e~dle coeciencia, 0 empeoramieare did Los sr.gruJ~di'i1!km rnismo si e:sti!l!b<a, :previaH1!e~]meafectado :por sus lesiones trau'UM NEe son: CllImrn.o aumenta algnno
mHI:i~~J~. pudiendo :Ue:gm;r:a~, estupor

,d'f'

y a~ roHli.JilI:;, b:[f'a.di.'c;m:!d~i1I!, e

h ~pe;I1:e[]d6nJ rterial a
Clui!!:r~clli)

- Dis1'llil1,ucirin progre~
sr4.4'1 ,dd 'liiive.l de
C'Clit1ci€n~

cemlenza a auruentar

13 PIC,

se produce unaumen-

derlvae ilon del mismo al es- Brar/i!rall'dra ~H· ._ . I' pad.o :sUOOlt,i:i[,(:II1;Qli,j],eo raqu ideo; para :pos~:e ~'iorJIlli!enr~e produclrjpertens~6rJI nt:nfU ~ se ~I mr:ueljl]'S'~[i{:cg6n. de' capilares "J '1€~1I1l1:~OliS, ue ~,jl bien evka q ini,(',uilJlmenf,e' que S~8H aumentande '~f~PJC~ a corto plaza pLn.Jm vocan 1!.~I1Ja, nueva siUli(~d~e bL misma d pillr la esiasis :sang_luO:l:1ea_ Con el fi.] de UillIOlJI1I,& '~:eI1e;u''1!I111!:lL [lIres~16nde l~er!fl!l~ir&!l1 cerebral {PfC) a~J~uad~,. se pt,'odjuce u~] ~JldlnlCrn.tij]! de ,~t~resion :U[[iteru~~1 ell cl caw, de pi&rrlidill! d,e: la ,m;I!II:,a;[re,gll,Jl~~i6n, cmnri~Jl!lye p Q.l1t::, i:o d£ la rea'b~ore~.6n LCR 'Y de
1)I!IlIi!L

cia

,iii, SU. vez a ,~UI,'W,etU!!Lr~8 P[C. , cOH1i.ieIfllZ:!I! a,

C UIliII'rJdo las C:Ufrf~5 de P~:C ~~~iCl;L'UIlZa[J'jJ 25 ~:(j~

i!Jp.~ec.ielil(]o g,.ign.os, de enoC·,aj:a[rlie~cir.o

TIHn]-l~,.
;ill

pr:iOCli!,rciSe lsq f

Ulel1fb1{IJ,

:PUirU'U[

de 40 l'iilmHg"

[Hern iaci:b:n ,cerebral

l ,', Sl'lbjaLl[ o ifN't::rl1(!'mis!e:n:rn_ Se PIJll.ed\e: rcdueir p cuando e~~~~1I1i 'rn,laJsa-s:loctl!l'U-· zadas ,eIDI. el .1.6bl[r.~O temporal, IE:Ihe,n~.ifl$e;r~o~:fool~do sufre un rle:Jp·lf~z.!lI_:t'nie~1i~jJ m~ cia e~ lado co~~n:d,~ten.l~O([' de'ba.J0' de la hQZ del cerebro, [tsu~.'~ru];!:I[!! ~, l}l]tllento m de 1~1squemia rugiomr"d, [IJIm cempresion de la ar1i:,eria cerebral mlllilerii.oT_ i

M ateri at c hron iony pr~1jJem autors kim

2:. R(),W~iOii.'o[u)ui}ji [0 c~i~u:rtlJ. C~;t'[mk[l,la [e~ll'!!~~:s,'i'!lid~;d fmn~~1 'J t~er(aJ]taa, la UU es :iiI~flJ m,(~d~ll, e~ld:il1!e d\esp:II[IJz;~ltJllih~[I!~:O un b~cia ,~'b~Ij'0101] comprresio!i!, run;~seri:C(l;~~~i~~,t'~L 0 La, dilJ~~Jc~ ~'nici~[s de ,es!~[lio:u:i' e 'l!lllJill!a.~mh'~ih.:;a~ m!;1p'irac~ 00 Cti1,Gyn~.;.Sto'ke~\., y 6n 8' L",,,IU,t'\I~ i'tfitCf"jiI"C!':9Udoe:11 ,cool'~iIlr~;a n:rrl)'flllrnb) COIfl.nilip:i~as liiib"dl1ii<S ~",' ',f,""''l"i~ciel1j~:e cse [en [coma ~L,!,\IJl_ .... ,.~ ,"","" u.... _,_ dLs06l'ic~s y ~aoc:i6n e;11 e~:~ell!sidl1!; OOilil [p~}S!t.er.b1}:U' rt'~!Jili~:m'-C:i6:((), ~s,telli:'o:[[o:s.a :':f :HltlNJeti,(:'0., .... ,

t~N:iJd;a.d.

l'1ncal C(~Hul;;Ii1!mLeii1i:e' (r.e:Ii1Q'lin~:if'f.CUli, .iel~£:ilJf~[~~h;~,\1:oji,., 'ia, !]1~8fa~~~[I,Es :m{{ifi~l'; reecnocible ~Jo:r$U,'pj,~nl4!~~i6'Jl tlll~ka, y p:rro,ge.s:u va., Se p:mdl,ll,ce !l;:~~[idl~' !httNl r les;b~me$e.\,~~]gi:vm) se loca!I:~zmr~n :~a,:~D~a, ~ :mB(Hll~0 en el '16blJi~,o I~~riiipot.a]", das'P:~~~!lInd'o' d 'I)InCU3, '1!e~.t!llPill[,~~1 tru.v-e..'t,;,,d,e:illtGilIltarn,(J\. ]jllk;:ilr~k'l.c:nl:e~It~ll t'tJil~rpre:sJ.~ilil SQ;J~ o bre 1'~'~)(nO[j! cerelbmll, 'p;t(~¥,oca,llIJilti ,~~fialGI;u[;~}Cifi rnu 'Iliif.(if.,fI;iflef~I" eon :iiuidr1;1l!sis, dcli; fo'j)()lumm:ch, '!i! a y ,ft'p:lr,~c:u III e .f~g;ilfr~ o (ul~,ie:Iil,~((I, h,~ focal ~cl!~1d, cOflj!:rala.jte:l1-a'~ de ~OCfu';;iIOrnJ:a:1:IiJ]~liIjte [el, c~t('ajfllilil~ie:[lI)O cO:lilln.ltKl!~e f,i)II!. SI!;e:1il lli~ '~lidriasb: [ooflJ~["!il;lal~ es ~~i) rail 'Y :~f~ :!1oc{.il,idacl, ~lLmJJu)lale:~nlJ. 'E'~,wmiiend~,de ~TIrerl~d~s ~F'~~lJtjca:s,~~~;u\'~L."i<; 0 ~ , ~11l1t.e a iil'lef0cl:ividrrd, ~('; ~':fL\,1l; J :il'lli~;ti.~;~'S:, In midriasis se hsee ,!i!iure~.c~:iv,!il". com respues__ ,HIt'p1.,1ia

e:~

~1iI ..~. f~:liIa~,I~'!'"'-I"'O~''''''~''I :'"1i!·'~""''I'~'i'~·~'c'It.f11i1 FIiilI"'.''''i~~>:>f:I''l~Ii1.)BI. w,~~t:!T~'t,.radl':rJi~ , a'I..~~GmrrnJd~J; ,~,If '11~~.II.~ [""~, ,,~ ............ ~ ~~ ...... ~" .IJ~~"IL V ,......,1':1"""",, l!t'....~ ~~.. ~... ,,",,~II -' . . IV _ .. , "" ~)"I.. _
;0)1,

!nel:)Jte ~ ~:!ila, S:iil~I)I:;.r;;::ii.1i1l1 de

n~icl'~'1i~'I;N;i:s, Ib~,b~im,!,~J tljl'F~a(~tjllv:a",

{:olfl:'m p[(Ih~iti~M'

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cia [me

mspllH~8it~~g :ifn;]:tm:fLL,-~.

1'tk,1.m(I".... !;l"W' .~,"r~""Lc",'''n"'.~ '''' ,'.!~, ""l' ..... '-i"... " .. I~.".h&~'" 'I'._ ·' ',I"._._'Jlp ·I'iOr~"'I""'"l """," i:l11'~-L'~ IUJ',f~,.~b .. ... !t'"~,,,, "".11, ,~""I ..."'~,. ... ' ••,"'"""'-. n, r~I;Jf,.; "1;,<.. """. 'C,'!l,,]I"'IIilI-.-'II,.~ 'IfI'.n'· ... '.'II,~~'~!.!J, "'~"JCiJ"i ~'·!';I, ial~'!1~ef~~e la fosa 1'l'08!t,®~1Io:I,',;, h.e!l~Ii1'h1.d6:~il.~~ las ,estnJlrnlll:r~~}; e!~1 :~a puede producirse ]!m,,",I];

c~~ ~rrib~. a, 't1[;;!a''''''~s di.;;1 l~nl!Or.ioj con ,i;.,"Oll'ilJpru:shl:n d(l:l, Irr'O:l:1o(:) Y :PJf(-;..s.e.:iiltfLe:iuifl, de !hidmCt1!f@!l:i~ o'fus1ttJlJ:ctUY,R; .(} haeia ;ajl1lf~(~, ~Ie:cl]]i~ftdo~e;tas .~[tIl,~gduijl[~s oerebelosa ~]'a,y(~~lt:'l~~gf~~j;e,f.{)l Ilil~gf!~) co-n~~f~c~nci6H del bt!['oo rc~I~lklc-oJ, ,

'lill;~I,

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C:0i!1i tr.r~~~n~{lfcr:S~fi:O CJ"ifI!·

'E:{l, I~,'f~J:-esi6m, mf]]:ullf!a, qwe .~u~;~rd:i~a ,~~,c~~dJa 1U!1ii~, ~tfticgi{ml !l;:eHi:lbr~tli.fie. obtleae rest~l!LIU.~D[]l~~ ]J;r~i6~, ]ni~r-l,l.cil';~'lJI:1e:H'1;H, ~,H!:pre.8i61i!, ,a'!r~~ti~iI. rifl~dria, (PfC ~ eAlM: - ,pille)" iE~,''Ialj.i(];T'ilnf:'n~:h'floilHf'~ I :1rn.ll~~1 sHICn~ !E'~ri 6(~[ liii~,iilLH:,g~':lHI~,qlll'(~ull..~UIfI,(liS f~~~(I[.e:Sla, rohf~:atl! 8ei
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M ateri at c hron iony prawem autors kim

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--Jt~ '-'-'-:!l • ..;j]"-,,, "-'''''~ ~ett'.t!lif"'lh~,~a,,_, ~._'<!~CU[-\.R.S.

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l:e-cnica~", ViI_flitm: a,

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[,uudli!lS .J.' S:~i]]!i'iI~,[f:;S Can, ~l!i:nd~:m~,[G:.~.to, ~ -0 lit" L1i!!S 'frac~iUr,as de! bOV-aliOI ce,f;I":'Jd~s y :!l:i:nl Illltifl~i:l~lk'j'~to

:MO

paeto, y tk~ Y:io~,[~~,{::UIll, mismo, H~i:y la del [q:llIt.:; prestar, m,t) 'oib;;s.. PDf [~fa lI~as~d f,filifill~e~lifUl alt-~[tci6n ,~,pt;..-~i~.] a, 'It., :id!eJiII~:~ficad6~de las lfne~s U ,~)(,,; fraetura q,IIJ:~crueen el 8,1!1f{',l[)- \!',a~C:lJ.d:a!f la tl!1lt.e!fi~,l1le~:lilr~· d~ ,~~ii. :m~d:ia, ~a, i.!i,~ ~~I$t,e una ~lliUi. pJ'l(.lb'ab~lid?l;cl, de ~~,e e;'1~~tde;lil~jeprcsente, 0 de:q : s~H,:rQller:~,:pitcl:[;l;~r!;er~:~e'l Ju~n~ jtm:n~,[e:pid !!I,nll, I!;m ~ La:N: rll",a~itl,il:T~!iii, li!t iba~ pllJ.edel11 II,ocaHzarse e~]:~a,fOSf~ a~ll;f;'rllil!)r, media (It 'POSI"" de te:rrio:fI':"Las des primeras pueden ser d)f:; di:fi',ei~ ~rl.eil1i~ f~.'caciQn ~!i! ]I~ rad~logf,!.lflil~ ~~.I~1l)l,e, d·ebid() a l:as ,e!MI\U~1U,!t:~~lg [6'8.e~ C!i:Hr!I,~cja1l1 y fjbig(l[rfl~~:i.i de :hl :l.I[~n)n,sl,ti(Ii1" [d,'01 ::l1llJ d~,~iIl!'1iI6:'ti,c~) .. ~ ~-~- veces ,dlll1~OO~~ ~~"~ (11Ue se nuedan L,~, L , L .•1I e- Iii mluch!;lS h~~~~'~~ '.~" ~ ~ !de~jlt~C"'ii,~~, .~ "'I ~ ~ ~ -"9'- ~ ~ ~~~ -~ ~ ~ ~-~ ~ ,,~, TAC" :~ :fra,G~I.!ia.~, -dB ~~,~ii,l aJ[d)~dur ~,~ lSO,-8[J'e-~'~~ln G~~p;~tm~i6H nivel de los .. t :por ;!.l" :rubo:~li.q ,o:mil~::l[[itj~, (!:~~lfIJ'I.:S;i6t1!,iPO'f :~~ prasenela [d£ :11:u:sorYaJgi~, y {~~I!lqll!!e :p.uecile tener [0([[0 or.i~Gn.) il) Iilaso.:iI~,Ci!iOr,m~ ~que se idc[llif~.'cj)l! :~m1is:l)I!rd~~III1elJ:,~:e. ' ,~I ceser [I,~ :nl:asD.rragi,a}", 'Y :~H ,ft:iPii.[ie:~6il1, d({ ~~lii. E.':'liIlQto:n.lu h :p:a:IIpe:'nt.~~I, (s~"grm del l1iu.[~och,e).Si, se o'ib:jel:i-va perdida de LCR PfJ.iiilJli'rlIIZ, h~y l,o£ pl'jhl.'jer~it-e.'f, DOn, que cle'lj,qwr 10 Imis f!'O. ~ble la caJb~oera, del ~;,;:~e!:1!~e p~I1JfafoliC[~!:~l'ns~k: [o.w. ~:nir~',~ 'voteC(i[' al {~i~iF.ro[de ~Ji:tl:g.tubl!, er~ctlllJl'IiId'~}unf~:e;I"~l!1ic:il6.1!1i : ,q:I)I:~-, riOT [0 '!t:nedilfl: con COlm,'uJ""
_I.

ph~JJil~e~l[ ~r{)h~ielitu_!sjeraTN5~:~:ko$,.ni dj(.SI~16~!u:tJcos, y(~ que I ,r.J'l!t,l1ifior r ~: sOl1;(k~, ~1.\{~Sjji~, .. • _..Ii~,l ~' 5Jue~,e~, ~i~~:i~g~drse facihu~nte de los Slll!L1DO'S 'vmilc~'~b.'J"e!ii' ]l~. l-ru~J'~Cill, de ~ie.f)€' ser c(;(oc;o:.. tlaJh:~a. lntema, Sun ]ncl:k~~H:vas el :1,tlI,gar q!!IJ~ sl)l:rri~o el ~~~,d ~~ '(U1, l:Mif 'Vrtl, QKal:, ~1J~,mc~,

,1~~'Cho. fr-acn~r:a:ik /):!lsO ~

Cuando eJljfs~e sosb

:ntrgk:a. sobre iift misma, S] 'rnifLi cisrra i2;iN;J.1Iorn,,~;iijl.liej]IJn:I(::;~_ll:e, UiCil, ;e:r!I, ~[I.fUllO de [~r~IOiS,~,:s,dJas," l,fts, de ~,f~ fosa mtoo:~ti S~ Ml\Sl:p~ch[,'I!r!I, ~IUJ~IHj,()! :~~d:iosrii§i(:-a~ll[e~~,e ~ obs-erv(f!! rIJI];ii-t f:rncn!!rn de 'In C$-'
cam;[1liBnr)[):~~l,1!'11~e t!i, _ ~.~~~~_ . ~ ~~_I" ~\L ~- "'C

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eP-lC'i':-~le-r~-:n ~,ilI~1 I" e p.re~t~1it U~ 'h,eIOCl;~~;Qm;a, b~, p6:[lsi~ ~l1i~;5to(i)cilles, otorrsgla ern, ~ y I] (~t,(];lh:::I!IIO:Ii'ru;:}_., NU IiIC3, ~~ ]lnm'rrt~HlI1:rd:ra1l! ~~$as, -0 ,J~:a, e 'bof-de d en el COitdiIJicllQ :a1~i:cl,itiI1,lO ni en fosas nasales, por ~]~ rues~lQ; de ~J~.feClc~,{i.n :!liO:brea[n~lc~idf- l~ OI)(,i£C('iP~la, ~;i e eOlfisidG:ii:',~~Ii{~~~" t, s saria, debe 8er ,eif''e(:ttl,]l~da po:~'el O'iOH,h:1;iJi~a.~'i:!il~\~lo~II)", Lf!I.'f fTtI'(;-t[ilnJ~.lj:r~ii-d'ilid,'tiJta!, sobre J'().(/t' Jd exisse (1;C(l;b,c~'.rgartti,e:n,f'')' (ht loe ,bljute's" r:(j{JU.i[l!f*,~~J,,~t{~i-~~eneJ6'!,~ .quinj'J"gic'{1J to mas _PT-eCt)'Z p(),!dMe; si'l!:m:l~"1?' a j.~_',k,f() .(J:e~ mn~I'Od~'lJr;jm~lo', Il!!!.f;!l, ~iep~r~Jj",!i!! d:I!I~1!!!'I1~~dJi"c ,am ev i'~,a.~' f~r)\af.k,ici~] ~ y biJ de un f~t~o elll'li'il~,enl!ol.,.ellliJ ~ O~Y!ill!n~~,6'~- 0 di:s;I,RDer,f,ld6:n de lacV I)i~~',eza, nor ~ -I"~ ~ ~ ,"'r~;bit'''I~ ~ ~ ~ ~~ ~ . '!I:~e~~I"--,El~. ~r ~ ~~~~ ~~~"~~-"'~ ~" ~~\II "C~" ~r-:~"gu:rr'as, \,,]1 'Y 6.:2). 6
1
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'Ii'!iier-'{Ic elI;li~ el '1i¥"ll;1lSC('l ff~ ~~ , ". !~"'L_..~.

11'_~'

M ateri at c hron iony P~~f em autors kim

1F.lgUfai 1i5,l. F.rCII;JIlfCI hWldimfe,r,Jro de c-.rcilnoo

Figura 6,2. f,ac.hJiro n1Jrtdimrenfo.

Cforleal.

~tj,:pO:Il1::JidJtcs, de la L.,. - -."'-,-".',!f:,''ro ""i. -- i' '_'~I .::lI·ueu,c,:;'i!Jlm.e[b~ac~,-. -.' ,1.' , 1,[Ip'e]1~1iI.sJ;IU',1iI nllJ~l1I,eiil.J;" c en Imayor 0 me"",~~..i rn,e{!!ly:f), Ai, " Illnr ulll1i'~fIIl~t:: tas $~gJUlieFltes horas .• inc! lIS@ d:laiil;.deSlpl!h~:!l del :acil;i'~,cl.efU:e,,I}udl:iendo ser de p;rernoll1ii ~io ~n:can.en e'~ afll1lib~,tQ de Ia les:i6n, !O d'u[i"uso. Se d~~'\;l'~nrgll,le:ndill." '~:1pos.:ifIir,undpales, (llg
I,O~:01'TCmi gmv(:'. es U:riilJ. de
'~r. ' ~-:;.

P,rn:serlit"siempre en

ius

'mHX]til'ltO$
I

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'eWlma: el vaso~n~cu, y ~Id:DOI:ti\i{i~o" 81 ""'a~og,6uic-oes de or.i~en l!r,~'umddcQ,e;xtmoolruL~r;.eon afectacj6~ de '~a~iWlTe-ra tu~m..:,\itoo:nQef:mca. y ]J~SO {lie prot:efril.::JjS; Y ~Jq]u:ud,{[is", :IE] d,m:OL'6~,ico, Indl!uddo pm '~l~]liOl'i.tfJJ~ de ,pred.on]'ttItIO~:~nmc-.eh.ll~aii es y 'OOn ~:[l.ttg~idil1{! e ta bsrrera ~];~mjlu]e.Ild

oef~1;~8" MElt rial chronlorv prawern aulorskim

'lrRA:!Ll MAHSMO C'RANiIDi!N'CEFAllCD.

(lONCI:I2-NCIA :II!.SCA1.A ViE OLAS{]OW

A.siri]jlable: a cotJlflfbnci6": eerebrsl, Ex~:ne ~-e~.id~tde cencieneia de (moo peees

.,11 1 rn •Ii!1'U~OO ee ..eurae

',.;:,

Ii:).H

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gum!!f-Ocai:id~d.~:rhe-nd(J' tarr!to ~alew~[or~d6J) o8reriQf,' como 'I~~, ro'eiba~de 'irn~,g<eua p ~ lfIIe,g;athnJ!!iL No ob~n;alllr~',. nn sa pnrlra, hiac~1J' !!jill dlii:l~IiI.6~dcJI! il!ll1TleHm.i~ d!<l;'DrmCIll8,~61!1 .. ,o, cere~'1Ira~ :~e~r!lhieJild\i) ~acieille iii: ,~I!I, um UclHo, ya, ~Iue e:ti.'~te ~.arg~ibi,~~dad, die ,i;'I]~~~, a.~ d
!r.1(::i:un dl~ DIi}ITt[~~,icat~ibliles [lit~Jtljrio:[tB:;.-"ii: ®cl,em Ill. 'D~rubr~:I;I, conU!l:Nii61i1, DG'rubrnl. h!3.1tl I·' [o:ma~ e~truC'e:'rr,];1:b;r.aI~s~pldul'lt8il). ,ij:U;: ..... 1£s ('D'm~eil'i!l?V-'ut' l'i8~',fQ1-t6~'tocl~ ptlderiflt? flirt! ( I.Ul;'fl1pnt!h!ti~(_uif)p~I"(li.d[1de Ctjut('ie,~lda. d,ej{l~u_{alt ingf'esado' en e~ ~r()\5'ptw.' dl~f(1tJ'1:2

24

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36 I~Orai\~

l!il:'!ii'~6:ti ~LrlJ~lto,I!tIiicia. con p05iliJ:l![l: C'G'liIlf,iI[ll:i'lC n1 ~.c fn::.'ltio:rr.~:g:uc{:!< Ulnad idil]!. Hsbi hn_dlnru::rua $ii.;'l IIOCltTiii:zill (h;;bujo de la zOri:frII OSC,t.'L (~l!I!! h;J sufrido el 'Inrrp:ac[o., .. ";
iI:UUtty.IIJf': 110 is-'Ol'i

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id

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r'I~~(:er'itbru' un

despl ~~.l~1'ill lelf1li!O,~

lesionarse ~~col isionsr

eeatra I SJ

pared

6se~ epuesta:

'puriJe-

to-'tcft'lfp0irlThl contralateral en 110 . ilm paetes ,~aterale". ill f[iQ(jj[<:II~. ill (mc~.piJl:i:I~ten '~O!!l :~n!i pactos poste:r,iores ,0 anterlores, As ienran en e u:dq!JJ.ieJ" IflblJioD1,!iliefildQ, S'U ex~~Ilis:i.6111. 'pro~;lII[11dld:arl JIULY ,,!!3!Fi,abl~., ~n relae ion CD]) la elle!l'g ITa, del :~n!lp'3£.W. y !T~m~u cl in~,~~·omo ~a gra.'lled~d \f~.'''n,e.1i1cendleionsdas pQF~1((bJcj]]izadiin .• la ]3 c , e::U,ern ~i dil )/ hI! ev,{)llJIc.i.6'ml. de. ~a. COf1II:llJsio:ll; que sl ee~ de fOll'l'bl~, eN:pansl va e n ~afl, O !'I,iglUie'!11'~i2;S homs 0 (H~!!l,. COD1lihc:1.IDmI.t1:'I1rl1cuadro de lillOC, lmll~n' :por-.el ~liI'l!lIlell1llin' de 1u c!!J[iflill:siI6(1j~ 'OtlmlO p(!if lH, >llL:Sociat:iollli dJ~ edema, U~gfUliido a 'P(ito!:il'I!IC:~1I' hem:i:!:Iici6.n t:cn;b,ml .Fig'hlnts 6.31 6.41, J' 6" 5).

F:i~~!r,~

6.3!. Co.nfw(On

ce.re-mi;J1

M aterl al c hron i any p,rawem au tors kim 10;3 ,

Figura Ii.!L muljrp.e$.

C6!ihJdDJl6!~

C£I~~bi~1et,

hefill[sJer.uoo ce111110 ,e~ tronce, eon retraecien ;mX'iJ\1'I~1 ..inid8!l, que :~ued_eb· seg'IJ~dil.de de.gelll'e:rm:e-iorti. ptD~~:li,iy,~ en IfL:l ::i.ig~je:rntes se]}lfk~~tS. lH ,,",:llin~ic~L ~iJ·j!l en yn e. Jt!llicW de eema, : se al!!IiI~~Je h!i!!YClue descartar otras ~.e.r.;:iO'fJe& 'P'!l6ch.u:]!(ij'OlCh!l(: ir~o::i~qlilf!I:li!'ia. :H'lEe '0 q.l!le h:.3iOrLdte trencn :1:"" hemi~£:~:un IC[iUDlliile:1111't'l·riaL nor eO[j~iste

t:ln. iIIr:1!~L :~sr.-!Jpcin;i"de i,!;l. :S!l!S!t:1l!l~ciJ~b~ane9,. U'Illo a 11lvel d U

Ma~erl::Jfchroruony prawern aulorskim

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:prus-e.ni,Wl.;h:in

liT~:UJ::l fre:!;;U~IJ]&C es 'PtJir.uC:~Oi)B,1lh-

frnoDlIra. de Ia caleta que c:ruzu, el SIJ,]JI'CO vascular de atom 311'1ed!lis, que ~~_a,rev~~~:ucll\, Idelllrl:('1n de 'la, 'tabla :ull~erml!;pOl' 'I~ dl!l.rnrmm:d!f:e, 'ta 'pgif somgm proC€:d61i1.te de 11:ru le:s:i:6:n itl,~ :~i'I! arteria ¥8J deiS[IJ€'gnooo Ia Las ~cieflte£i Cnn, ~ie.. dU[.!i!1!Ji1;ad~'forrliLint])ijS~ [LIn b~~i~'(!im~,'~'lJ)e.~I ~I~g__il$,a ~~, cier:I'c~..;r i..; 'J'iIm~~; !t~nl.!i.;mll~ .l)j~tl!!lP' ~o YO']I[IIT;(;{1'ITi,. P.tuOOllC'e' ,~fecl.o,lilUliSm:. ,H!!.IfllileIl"U.o d~ ~ PIC Y enea[fI, d~, ~eJ!J.ar ~.n. ~rv!l~ m jmmnaeoi:o riipid~]I I!1:n:13,m.~yod3i di11!as ncasicnas, La elinica cs l l(J dft li;tL-itie:z:, "!H~blc~J1loJ rm.ty v,ilmriable-., <d:e1;]e;ua~ieflido de hts 'l-e.-siones nsocisdas ,)r! de 13 iJ'i2'spub ~lntff~." I['~pidez Idle .I~~ ilIlSI:aUlr2i.d 03,1i; p:m;I!'~} se descr,uoo slempre 1!I:03. P:1ii!!!'ien:'~O::ti:;~.O[]Jtl!!!.l)f '~;Lp:icaJ.ClHnildo '~tII !iillllica. ~,(!is~6uQ es la fltl!lc:tu;n~ de "1....I ____~ ersnee fiiliii. a:['ectad61li ,;il:i;'i.e:ria[. i[U~e''himSlste ea ,lJbdi,(l(_~ i1-~i'(i,(ll;tie ir:l cO\l'It',i(~,j\t·ilfl. ~n~J)gr~,~Jlf WlUlI tie Sa miSH~a 1~'lU;t(N'ld'l dt! j'fx-aUd4d Ire~~I:(}I&,'ff,ic(tJ' ~"JC(:l,'.'i:i{)('"OH fl:tJi' ~f!f(1~'e'(J. para pO;SI:er.f('!n~~'(!"l~e, Ius p.rlfo.~ 'fi:Jimuos. ,,~,.e.sf,1UaI'Sle un tJ.et'e:rfam a fillJrda' tit. lt~··m~'l·i'~,1-u..'it~',f;[H,:'{lli(J(Kl, l ]i;j~g,mJ'Sde flEe)' em."{Jja~'f.lil:'J~'J'{}_ CU.slnd\m ~xi:S;m t,e:n OIJ"diS :~~miOnes m'l'll:mc:r-dln.eule;S; 1:~!IIil:n~~Uc~'pu:eile no '~K:Lsi:ilr solilldonu de centiIJlilfiitfi~rl entre la '~[J'did:u. {.te' cO'm;iC[l;ciu i:nkiuJ. e. Cil.lH,~Jqtlla,(:[J'f;u{:i.I~'i~Bady ~l d~oo.ii"iCiru '

poral ~o:r' roI:!Jr~, e ~ ~r~eria menfnsea medii) 0 c_le sus ]'rum~sl ~oiil'licidiendo eon da

r~,ido ~o;s.'lerto.r' " "'~gJlJim , ifi6)

l=m~bi:~l!Ja~mel~~:e' he'n~allimna de or~~en, ''!!enooo 'l~ro~I~.c'kJoor la rotura de es IJI~ p IM ~'v.ef]J~'" puente "1 ~lle, d~~ciI~' cerebro, d.e.'\.e:llnooC:!iJlI en los senos vennsns J.11I,el I:Ci~II.i'lilIiles. AIlilI1.qru€! sJilI !t':~,[n:~ca es ~,imlih:u~ ta del ~~€:rna~ij)TDlIaIepidural; su evolufu ,ei.o:n 'pilicdJeser tl'i:fi~;lenta e ins ~dh:H;~", :fad H~~d, de :poo~enta.chjug de lJfIJ hemaL~, I.O\i1:uitsldxlural es maynr >C'uandQl exisee lUU.!ii.,PJ~\da iiltOO:fi~ ce]:'eb~t iP!.iI·es a 1"i ·

MElt rial chrornorv pr6y.,orm aulorskim

l1Qi51

:!lllll!l!yO[ tE'lJli(tiOIil

de :~~13 '~naa: se ~!LilJii<N. ili!fij~~'mayOli oo~;iIl:ci.6j} y {h::~;p~aZ!1!!inh~"i:iHOde I," 50 Y :lTnij:!o;m~s". ·E:s,~.:a. o!Jn~i.c,i6il, se c!Jm.p:~e hii}bhllJ~~111efli~e el pac ~eflite :;I!r!('iano "I en e~, en ,aicoh6Ik:o C]'6~h:;o, ~Hlnn,iijndliJ'.~ ·UI~mI. I~,g[!]ii:II.c:!61i1 prfJ!bjjllhle,.. C
]~ei'ia.e fiih~1i'nd,~ )1
L!Lfli::!i.

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que &~f!"~

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d~ fi~hlIf ltlil1L ~[iJiDx~.caej61'ile'u U],a.elt, oo([1s:i@.erartd.o

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d~.s!llrt,'[it1. mtsl·omoo y

de la

m(l["c·h.a,

pu'!,)d~ ser ini-

ei :ahinBIi!:t~·8~I~rrp(j,n:ilbl&.~. ~.9J de litn h>e'~~1JSJ~O!t1HIJ !lIlbrln.naJL 3 s OC3S,~1lJ1lU3'~rn,{mm cl 'HiI,em ~U.onTII::J, ,1t!;i[!J)li~n i~;"" dUit~(} h!i.g~Iii·~ se fn.i{IO\r,ec~i(jo PI):!i" i,!!,iilill posible :au'o!fi,i.!L cerebral. a '1lI~.1·n.e~n~;t{l!!lla;sl!!.~;gurlo0' cWI1!:ico {aJ ,pact,]r (I.e TC1!:>l des Sena,!llla~.)- La e:xpre!'i,ivm.dtl.d el i'!rttc~311.'t@j~.e ser [pOC'{.'!l !IllO'UOf..il',~:p:titd:iendlo ser ·eS~Ii)Sp[Ll

cientes ·r..I:umll~u'.~ dfiim.~rttc:ill, de ~~i,('Oh6hc~1 ~.CilJi~,(F~gu'if~ (l! (]l",?) •

.E1Ii ncasienes •. ~iil:r(ji~:Ulf'a·1:n.m.IDItoir.icilI. de la 'ilrilcn.oc~rles dl~ h,[],galf:'i!~ la '~o'L'11ilac:l6~ de I] Il tl~Cjjmtilo de :lC.R en el espiic:uo tH)I·lbdlitru'~.1jlIref~relfi()~rn:'lenll:e de :~o~a.l'iz_ad6:11U nO!iln~t .81 :I~r1.1gre.'l;i·'!!o ~c~.~lu,l(!!de i(q.u~.cl.o :p!.l.~e deberse ,ia UI11mecan ~smoval....1!I·~ar_Sci nu regrt.\e"';·i.ImI ei!';,:poliI.l~l!le@lni!elllilie, p~ede :;:lei!"'m!ece:!'l,;a:ui~ lila evacl!!.a'C·io!l! qui-

n1r~k:~.

Ma erial chroniorv prawem autorsklrn

y ,eMtel1lsiOllli.;. :Ii'rnsden ser 'fiilim:l!lh~,liO\S: rnll]], extensos, 0 '~~'II~.i"jnmQsee-ucualquier J,U;gWf ~,et rnJo{i;hJio;, con~c:a~:~o suhcortieales en C~ML~~ qllier ~:u!i]Wij).gll~~ io:s 'basa~~.s,. ~mnco I cerebral ,0 cere be 10.. I a ,e;;pre;;;1 ~dw c·jfl1iu~ '!I C:II eShi en P!Jl1d6:11 de: :SU' LocPi~ i~~ci61f1, ,adelli1~i1: (lei ef'e.c[.[], m:"1.S2. (~ue. ~rodJL.tCli1:n :1108 ''''''IlI~r ;r;,·"'I..'n .............. .. ""'~liIli'.nImn,.,." '~~I[IC'C ''i.;' 1lif~"':LIi-.:ilp;....[IIirU~O JJ~ ~ "I~ ,1:lL lei· ~. t,"'-"!"a, !LJL ..... ~ '.. ~."'~"'J~,.:::r;.;,;,.......E'; ~ .'''''''r''["'_:~'''-I''l''''.,." I lJud3 U!J lJj!lJLII~llIlllI~
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M aterl al c hron i any

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posterlores

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en caso de dll:dffii se debe realizar s:oemrp,rti::una TAC. .'L~ 1Ae 9,.}' .eJe,c~~lti!' i.~~gr~lNl)', Ius 48 h'()r~'~:" Jii {Jo$;;eal u d(JlJ'j,I~',enl'il ,(:,(ld~' ., ,(1. /'() dia~~ s~: 'JlO 1~~~b.f,(Jse cilmbi·o.s ot:~'ld{J'S

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0

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:tdgd:f~, mo:ftIlcltU,1P

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<[II

Ll, reclI~i6n, .de 'Wl, CT'm debe '1Ii!c'!1~~ l,'Ctf(n~

;cteu~l! .tl! !lHll. cen~ 0)'lIl. :S'mrktG.(fu ,Netu''ocb14~i)[

~Qtl!ltlr~lI!.fna~:uca", - Cualquier e~t!lrn,o~n!l]mt1 del [!.dv.e[ de coacleaela ~I

t(;;;rruci6nl en

~d~

jJC"11r-'C'~ 'Je:rI!€; I!h]-'1"--'11 .. ":11e[1!e cona,jl 'baliUli,:IIl!.'f,ICO Y ell:) 'II d e' I~ ~ - ~ '. :Uy~tl[.!l- t el !~~ ,cc.!!.,J' . '1"," i oil; " ,~il, . • teccien de: PQ~~les !C:r.i:s.is. ill,'lbclilll~,ca:s,~no :s~.'e[l;clj[Ji rng~)Ddo b s un diag!llostilc(Ii eSef'ilC~8mpm:rtl, !litn.W 'p;ruIQ'I!!J'grnms,,,Los pO'i£'IfL(:;I'iil~$
evneadesV";:J'!I _ .' v..
'~, ~¥

la e:xph)f~16:n !le~n:li]16gic~.

,c!'IlI"" ~~Y' '~Ir '",.... '''-''''

.,,;i;"\il:i""~''''", ~lL~'~o~M~

ifrI .... r IF'~'

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~..!Jj~1

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el caao d~~EEU; li,el1!eD1!, 'l!Jd:~:u!clla!dl p~~!'\ la 10-

M ateri at c hron iony prawem autors kim

--_. -~.~ -

C3'~:~Z(lil::,16[] de

la :~esi6(L1,y como '1,1';aI ]l~'~!1l,6\S;'!:ioO'r EI d()1'11:J'/(n O;E"

Vi!Jj:>l(!!e:sp@~'U~:lQ~,. f:;reclUel:~te8

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SllJlh8JrlII!l::;mI!!Ji,:udca~.

p~r,aIi eteetar d

e~lI ~.a~hereosragias

T1RATA_MIENTO
lEf:ectu~d:a :~~''I,<'a~!oT,:ll(::i.6([1set,:uni:9aria, se cstablecen las tIIi'fell cffiulles 'prior.hB~deli ~~nto d~}l!Igr~68ti(:m:;\" Omic) te~~peu~:~ca;sC ('\!la~q~I~J[~[il~lin l '~alll~ml1i~,e qu'G ~OT:iga ~11J ]Jc~ :~~,gJ[-o YidruJ del :pacielii~e" blllrah) a nivel i(;J[.i(::~"lO" ~!bdQU:1j~l(l[ o la IDel'~'ko; te;ncl:r,:iij prefe['em~i~, lSo'lbru ,~IdJi:agIlil6~iico'Y '~II:',:lI!ulirl'li,e~mio, 'Ji1l(kI, Ires-JUn, :tangta~,tt de UI~;N, posi'tlEe te~i61l1 cerebral, U:rrm vez descartada lun;1Ii, ~e.shJ!i1! ~~~b.s~"&i'af,r~ ci~~~" de' :S:il!ii1g:Ji'~~~e que co~nfl{"ml)e '~e~1j'j; 'ViI'~ail,.,I.). bien efecniada interr

''!,l\eli!c:biJ;Jl'~,'Ulij:D1fi;!fgk:a sobre ella, Ia prinridad lIil6s~o~oo tratamienro del T,CE. y

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rerU:~1 en (':1, diag-

[it.'l~e }Jr,!OridGld .sobu d

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[IJ~li~~ la

i~ifiii flcaci,6lj, de

:~[jJ poslble lesi6n

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l1uib\i;e~ ~~S-I~O lWLl~ ~'ec:niC:!l ,ciI,ia.g!JlO:~~:ka a, :p,j;e Il:~eC~lm.~ [p:t:IIlitd6:n :ia,\fi.ido p€:ltiltO:DII~-' al (fLP), ~og;rr,a:r£'a;ere.], pDlS['Bnilr}ml'elJil[,e ~ rcu~,ixur.u[tlj na TAC eraneal. lUi Si ~,8! e:xp'lo:rn:ciolil, Itan"icicH 00 itIIj)rjOiltil~l:al hubiera requeride el I:mg~.J[dodel pacicnte al servicin de :Ru~:.O'ti:~fi;gDll&s1t~!ClO {:d.e.mpu'e~rr~esg;~do ,'!j' ~o ~~hle en ~Iil :POGi.ervleen si"odr.'t s~lvo causa de fuerza I]]J,yrOU :,. se pued:e realizar la rA.C CJlMe= al ,~R]miSlID{j1'~icl[1p!} que la wra£;o,ID.'bdoHil'~I];ID.~", sebre tndo (on la TAC helleeidal, que ~lrnclbcru[1I'Iie:n~~e sl!I,j)nGlc ])erdid~ de tie~ll)i,) ,ill'IJ1~(Udar rut) S:i bll"AC d~m{i~rt:mra,uaa liOE eonefecto rnasa {h>e!n-u!.to~lars: e;,~~idll;uraL~!.II,lbdl!Jo :rol 10 illilltr-.i1.p8!~e:rilqlJ'~I.li1ai)o>8o)tcs cbvin 'grille ~ preeisarfa ulilHiCV,:ilClLl~i;(j6:rra 'q1iJi:nh,g;vca illlrillCcl:iuillt de ~JL misma 'I).Qr ell ne[~iroc-i:riJ.!jf!!i~«i.Un;j,t ''i,!''e7.,efec~1I,JI:;tda, ]iiIi h'u;ew .... ,lIci6~; '0 ~ sl la, lAC' e'V~demd;i!lS:e ,!))tro!ll1, le~;iones !lll") ql!,l,ilr:(!]II'JJk~ (.oo:nl:us:u6'n, edema cerebral, heruorragla ~l!!.'baracri!oide~.COlilh:L:N;i61i1,-'Hile~JiI;t,ltto:litIl~~en, ,t)3:.iN;dDif,:i'~} ,el 'po:a£~eii'u:e i:lio:rmo requiere 'Vigu~;ji(jnci3.~niit1ll1i[·o:ml:z:a,;;:~,6n tnU;~L'tJnie~lIco, SILiSleslenes ,oerew~le:!l, ell y de urm unidad de Cl!I:idlm.doo e~[tioos, eS«:!Iecia[iz;;u;~!!!',odol e,U;n, ~,u[!r :perjl!l,idID' de contil

:~JiJj~r eaploraciones 19£,

nil'S. etc.)
rneH'~~-@ ]

d~}~11i68dc4U;, p:rior~taJi,as no

(:~d:~O~r'~lfia~, $~:mrp:~es; l!U1J)gl"~~

~ra!;aimief!1~(lI~ ¥itadoe~~ :!lIQ ~obre @'~ml*ii :aru~~", EI o'bje~:i\l1l)d'e:~'!'fi'';llt:ail1il ie~li!n es detectar rrecozurileliltel:iii, preaencia de ~!rn:sione;s :;;)ecull:lcil!a'~a;."". de apfil!ril!i;ion ,di:fe:rida.~ y eonservar ;d 'en,c~:rlil!lo en :~mJs rn.ejofCs condiclones, 'PU[.;,!(, liI'Ii1~] lIl~iII~]enlci6n~o ~'n~S, ~nV! po~i'L':i.:lle. C;Q~~~:!Iat,:ie~bd.o I:ler-~ic.i:li,,6-pt~ ~
![Ii

HOC Y la .is~lIIe~,M,ia, clll~~qllJli£1rel:io~,Qgi.:ll,., lBuicullJ9C~lil:e:~I!:" requi!l~"if!fa de, , ~,?,J'011"J'o.ri:zc~'t'MJ~ e h1. .'Pte" ~Jft. XCIi P'/JC" .y till ~a saWrtu;-j,6n Y~f.fIiiSar de OJi'(g,fmo d
fS,]i~Oi)"

de hi!'P[C ~l!IIe~e:1!lI,emp:~e~rnevaries ~;u:de:m~I.iS, sicrIi(io los mil:;; ~~lIIa~~ tret'l,; ~e:U1:-iOr ep:idlil.i[a'~1 li:'ill'~(:ruse:Uils-or :ill~;~r,ap'@reiliql!l inii8!iO,OO "i calif:~er .~nr tFar'!,i'enr~1fill;:[U'13j[. lo.s 'IiIlmi!i:e:mpl;3Ji~!iH~ ' :suiti los dos ~'itijjJ1io!5,.siendo mejor el c@I:e4'er '~11!,~ u .1'V,,",u~lilt:1L1~~_"I-'''''' P"'''''''' ""'\t.'"'~~~,,.,. .",1~,-"""'''''''lj'''''iP~Zi!lir la DIe· " 11;(l!!l,11i!"'~U1IlIite e:1:l mnmenms 'IlILllIiI:.:tI~." y,,",,<:> :B1i'II"""j"" !;II"" I,UI"-"U~lV~ ,1___ n I.-"'~ __ __ _ _ _. __ I~
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P,m,rm:~;j)~n'OnitooizadQf!!

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,cihlJthl. ~100 ,lfLyililb~ aJ ,aO'J:lt~).1)lar la fIC, Elproblema I!!S, b. ,cl,i:r.CtJIU~td.'(;111, Sl!I ,oO:ioc·.:i.it:kl(i]!il.i~ui1b(Do ( exisie 100~,Ill:lfiso i1]; ,dI£8;'!,r~;LIld6n ¥C:li1trii,cIll~J~II~ i~p.ar~it: uaa m;ruy!i)"1" :hl,C~cl!enda., de ~Q~nplk;[M::uode ncs: ,!i:~h~_a. o'bs:trucci6Gl. e :~ne':~l!Isoilll[eocio!-] (''i,\'el:\'~rh;;l!tl:u!:i~)_

tuales 1:0, ~,tra(:c~,6n de lC[t que segd;~ l~ 'CIIII!''!1~,pre""u~melilt'e e

M ateri at c hron iony prawem autors kim

11l~

de I@!SyO~fEe re~I:~~.oo~oc:mdo I;I!I1Ic~u:e~',eD'li la 'v<e:n~.ylllgl;l~;;;iII" , :int,e.ma. 11:'; iii. dllFe0c:10rrl a~ClmiJerilJle.; cnn el e:x.ill'e~:1iIo djis~a~. ~!o:nad('j; en en. '~:milbo,-de la Jll(a.~ gUl:~~ifi, Puede realizarse con !!.In'Gi!I!tel~r $~mpillS, romando ]1[jJu~SItt'~, :pe:ri,orjiL<an.e;IiIJI)13 ill l~iunl :~i:atilr(l: un cm:~ciicr d~ lilDr'd. api.ictIL COlli :lootllllr:Sl. Cillllli:iltlnl de :I~.~i:!lJrncidU1 en 'llIlil :LmIDI:or.. SieJrJ.;l!)fe se de'be ~o:mlJ)~..BJ'":~~ ~D!~1!.lfad6nYUg\~hu COil1. Ia. venosa nOJ.1l][d. La! ,~lcrl1~:~:Qr,U z~ad6:~ se CQI]]\P~e._mil;)i!1Ul !l;;QP1!, L~de la TA pol: ~l1le.jj;,~Jo ]fJJVasl'VQ t(P~E~t e::~c~i~c;LII~,o la PPC), :~a.IPfJ1;.':si;ii!1 vennsa eentral (PVC). el CO! ~~:pLracl.o la!satude 'J :U.~ic~6:Ii1I. OIl iPo:u· ·Pli~si.o](:inrileltr.u·~~.Eil. ,o!bjcti:vo ~ :m~Uniil~ner p.~:cen 'vDllores [pClm'lme(Ile: :~~ 'bmljD' de 20 :l1ljm~lg.1:3. PC mayor d,e 00 lilfU'IIlHg Y la P eU'~rr~, :Y' 7'.5 %. 5,' La FPC ~ p:rOCil.llrar.m. mantener siel'!Jl[p1"e e;o ''Ilannres ~U'perio~esa 60 '~u~dJg" ele'v[itJrildo I[HiI~.TA Ib~~jii.mem:umille la pe1tf[l:~i,{ilil de '~llqll,1lidillS; '0 droga~ ",~oaoc:ti"'a~·3~. '11 c:st~do de :1i1~,d[.l!J;~t"!ii;i,o[IJcs ,COtrol;;l,Q Y ~k!L :l'J.."'O!bruc~urgtl. :~!i'.qll]id[iJj upuslese IUIiI :mie..""iogo a de aluneUllW de la [iEC. Si LID!n>:PCfuese menor de ,6A) llllil'lH:g ~O,1il 'UHm TA adecuaI d~ 'y una P]C ,aJl[lll!. evidente .cyllle 'In~~~miS.,e!ll[Uierzos :ilran encammados a ·dli~mi~· es TiiUi[ ~A.lI, P1JC,. PUt;S IUlili.. :!L'Urtmei1ily :undit«.::~:[n~:ii'bm:lo 1~ TA wnillev:::wf1i. '!J.I~'1I m.ll~IitI.0.nlt:l; del de Vst ell :i1:[li~fOI exisra iJj~:];j]j;ijllllto.rreglll:~ad~fIliJ1.ltera£t::JL. : p:rovocood'o IUl.n~iJjm.t':ltlJltl :&~(:llul-' .. d~r.i.D de la HOC. La :p~:cy la S)~0:2 se ID:lmejan de :fiD[nn~ oo:njl)lnr~a.. ues :.Ul,lIiba:s: e!'lUi'l1·if!!tefJ,ri:ela.~ p cionadas .. - SyD ~,~n>l?'nOl'fJe' 55% ·COI,! JiMlI'o.·PlC lJ~e~l\r.!I" de 20 mm#jj. En L~n. primer Il'U)mne:llilJi:o ~]i!I!,~1 ue desc3lJri:lli1i qlit:: ell. :pad(i:lif~.~ e..~t.chiperventilaq :UiIo do, wooc!J.iitiibnd;o :~nfUmJl~ellil.e[el ()):;: ~~:~.cu;o;t (he 4(11 :mrrrfH~. Posi:e[iGrniliI.ellr~e :o.»e in'tell'uu"a. a;umeni~'t~Jf'el g~~~:o card~[tQ, biel1l con flr!.lid~~:er.[!j@liit!l,. ien COJ•. dregas V~O>b aetivas si la ~ilJ!'IIJ;DGCtlJrg~ :~[qu e~tlllviJE:..'iC: cO:nii:rnn·liIdliC3dt~ .. idruJ .- Sy.i(): j?~'e,.,rur d~ 55% ·t.'Vf.r lr.i1:.c.i pte maym- de. 261 mmU;,_~·. Se adUll~h~'isUIDira 11IlaJ1Ji~ol.",~~dosis de 0,25 gfiOCg de peso ..lEI:uml'n~.to~.puede adse :lni~1m·s;·mr.n'lr forma de repetida, siernpre ,~rigHi!I!liIdo balance h~drico del ~Jladen;te, Pii!.~ el :rr]~ eYi~~~r II.IIn~~e.p:~c!:..:i61i1'1 los iO'D1Ie~. ".l la osml!l;lar~d.ad oe~ll ~!l'r!gl.ied y ~ - S)~(}:ti-llrP. 55 )I 75% ~',o.!'~ ,~UU[.'PiC meeo« de 20 I}'m'll.cl'g·,. ,E~,la s~tlJlad.on ~dea], no P;1:'«~usilll;d~ niIDI:guituiJ medida espvGU~,e'a. o'lbre ,e5i:O>S. ~ pa:l~l mOril:imo:nzad61.1
j

s-o,
1

.o~;

:~'ffirIDIl et~1\OS ..

- .syOl
Sc

fj~Ur~ 55

y 75%

CO'J.~.~U'.r'"

P.lC mayo\!'" die'20 nunHg.

,l.'l.dliill'uli,i:strad munih]&~ d\e: ]I~~ mi~m)l!L Kootlitl.a Il:V.K'i se ha referidn ,r;rnt.e:rrnor.lne'!f!le. Con \I,!i!'~N"S: a1l:o$ de SyO! se puede .~OCj,~~ii 'lill!l:1r,disereta hire:ItVCtni'i£m.do.lliI. v.ig~:~ lando que' se nl~Jiltelil~[!'aquella en v:il~}o;res lito;r.ol1l~~les. = SyO':! 1H'~yOJ' df? 1'5'% ·COI,~ .Pte mi!mor de' 20 mmHM;.

No requiere UI!~tip(mO i:Il1~I.:91i:'iI['icln;~i[!!ug:re~i:'iI'iD. S'on :~oopacientes qllle _"!lllllelB:mJJ1J'06senUui" UIU'i buena ·evoll.ll.Id.lon • .- S}i.O-"mo.YOf de 75'% ·"01.' j,tJllKIl' .PIC mayor de 20 nm1'l·lg·,.
de: Gix.l:geno es dledbt~(k!,a. 1I,li1ii. 'f]Jf:af~{l! extense CIOOl bEl~(!IOOIT.lSI1Ull.lO efecm masa ,00:[1 h:Dpe:rte:~S\hi~. endocraneal, 0 ,[t un !hi.. Y :pera:nujir> 'V'erdaiL\e:[o ~~e ·cO'I~"'!IP'4JIrte 'baj~ extrac~16;jj ~l!eox(ge[to y ~LnAd~Ylil'~I]a t.:UOffil. ·~3.:p~C- EIllI e'~ :prhJi!.e:u· c~~o ~e Itfiltar,a C'OfJ! fI1Ullf!l.ato~. y en e.~ :se,gumido se de l,.ipe:r'heil1lnarn. ,~I pillc:~en:~e. rm!ufilu.::n~eUlldo ItaJ P.aCO~ en valeres CeIFCOJIll1l1.l:Ea. 32 :o:1i!ll1H.g" v~{r1~.ili.'n.dlt) e,1I ~!i)CJQ 'ifl'!!o.melllJ[() ·~o:s ''i,I'lIk'(IN;S de I~. :nltlJ.lllT.adon. ylllgu.lall:' de oxigcn{J\~ ;C:'v:ui;!mdlo que desclendan del 6:0%. S:u ~~ hi ~J)eNoe;mtilacw6:Ll no fuese sufiflki)/ i[~iUe disi.ill1l.giliir :&i :~~~ ~~.t::1ull:uD1tciCin ~ s

~~,.ra .

M ateri at c hron iony prawem autors kim

d;glll~e pmr,l!I!

manrener la P]C en valoees normales, se puede asoeiar '1iYa1f'Il:!.~l~lricos (ttn.OWeI1i~ilIJ]) bolos de 3, mgliK,g d.t ~UI,~ de forma l'Ct'Pci:id~l. ¥ I~i,k,[j;doI~. ~t"moen dlilili'i!litll cs,

Cusndn ~aM1lon~Jorizaci6n efecnle eon drenaje :~lr~r.a'\l'eI11~'r:kuhtr. '~mllas 'Ias se en

OC~'5<iOlilfk,,{

qn<e se f!re.~lE

I,IlI'!>ll

:P[C ,~It~ e i,!}CiQ'lTWtm~ :lj.'b:be, se podil1i, proeeder

~,ex-

lCR. jjJlil'UlIH!talllmell.liIE' pam d:ilsrn,~n l!I:urla • .Lt.'L h~Ii:'~P~,~ 'bu['Ib~i:~ii:'icil., cOInn.1ifll1fnen[(': conocida OO\il1iO C'OjjUl ,fmtb~)'l$tir.'o" Uli1i,CifL'~ nIU~Il1~:e e:rfl'pi~ea!e!l'! :~ooC~~ de:>le:;;pemdlns que p.Fe~eU1!ltaup,le eTe",~daJs, con gIl'U'se ve HEir 'Y rerfa£t~rJ~s a cu~~~q,!J.I:i de los l1lDet,oo~s descrhos hasta 811,0([',:[. Se ir1Ji,~ em cia con IJUlltl dosis de c(Jlrga de '~OImW«g en infusien ooll;m, '0 liie~Jf~:irla'en :2 0' J OOJ.~~. P;og~eil'iOi"melil~e se ~n;iJci:a, ,IIn4l!r,erh,L~i6111 tOe ~~!l'l\IJ!e:~¢a~, I 00 'mtligr-I(g erri, ;;(.JO Q : de m'll de del'l;tlfO&ia, al ,5% '~~!fil 24 :~O~~. dosis 'Par~~,lol'ii,,~i,g~ieu1les: dm,[.l~ se ~'~;ulh~e-La ee .se,gUin los fiJiv(:~,e:.') fQr:i'rtIII)(;g~,6g~,oolS i,iQpel!1~u~ {2.5'~L ,;5 IIli~ ~t'i~ mll.)" ~~sobre tode de porr' el e'h!l;;l:rre~ICellll'~IiJgr.,:n.1iml(EEG) d~Jlr;io.que tiene i[~iJje :ak~~UUiZut iJ.Ili1IlliVf;~ 4A (~~\"a:s·~IJ;IIp:we~~J6n 8: ~, ,~Ore;gl!l'ndi)"."i,)_ IEs~:<:I! ['e~~)el!lt~ca se 1nm:'IlI~'elildtra h;uJ~;~a,i:4 de horas despuds de Im)Jl1f1:t1~~z:.i,t1ise PIC. los dCt'!I)D~ b~li1Iilotr.C:~~ del ~i'o;pcm:tl'1 ~e: la eenrren en, Sill C:tlpm.c I~~~d, ara d1L'iWl~:nJijJ~:r consusao cerebrsl de OJ'''een tma 1tC... p cl. dlJodtlfIJ del :FSC "J.' eSlI;!;:(bU b:aciof!l die I~, ~nelnbraHa a~'~l!.u~Ul!do sebre los :~~d,k;:a~es I ib~ de 01, Go:m,o'efectes i:!il~~e~ea'hles pre:;::eH~1I!, UlI1a deprre~~.6[, dlel s~:!ltt,ef!lla c~rd~oci[iG'I),llaJ!ulrio, qJlIIe oMilgm. en !'ii mli1li!~tr-OM1'I. ccasi ones i!I~, ~8,0 die ill1l!l)~lIiop~~. y de la im.lJ1JlJIl'Lid~td ~ 00[11 [tree uentes infecciones ,a~iJc:u~1tda'So. n 1;a3 :UllIIE pw,cgnru;t;ione'l: IPrnfilii ndas eun [iupemJhll~pueden psesen tarse ,Ei tJ.t.i,jll".ocf.-r~jjlCrt(;l Jf!be C'..."I.ifnib:uQs:piL:iJPDh~.re5 Iq,Ut; 'ili1l(hi:lC.~lll1, f] error (':111 :I];) expICir,~u~:,~6:[~,., ser cOMu:hndo siempr.e CilJ!iIIlO 'Ilnr.;~lid!m.'li t'l[Jfrp'Ii!;:.':liIl~IfI,:t~l[i:as [IJ~~rtl, o !l::olfl,tto:l f~r :hJ ~IEC. de' fm-nla pr1!OOZ ~J~,~ podemos c:ilt;:!J:iJ'I~,Y.fili cumem,llltl~ ,e)litr:lB.cc~.'6:i1i hil~ertrlJi[eni~C dJe Wt10 TeE L.eA:. l' ~ ,cranie-ctOll!l1m£l, descoraprestva ~u.e,; tras 1!IT10~ aliilo."i. die a a'b~ni1.olilfl;,p~re!l;:e vO~,'I,o'era considerarse en a'l,g,LIInlltl,j: ocasiones.
traer

lJ[~8 cOllllplicill.C:~on ~~ible Oi) l]fjS ,fmC'iUftlS, ,l!Lbie~tt, ~ de base (De ernlleG. es bt 'rallenin;gitus. E-$ una eemplicae ~6:n ~lIlJ1y ,g~~'~e,peto '0011 inddle~d a mJ!'!lim:!!!, $,Use prescrjbe de forrna '5)recoz ~U[tUyuli)~era~ia" de mnl')Ho espeetro a 1[000 ~adel1![teqlJ!(' ,[pfe'SeW!!le d,~cha:il, lesioees, ilas crisis co~vtd$ivas ~o.!Il U!I1;:] cmnl')l nc~d6~ frecuente c Ui1I!fI!d!lJ e8lta :!!i:fec~~da, la cortesa cerebral, como es el C~~SOdie la~ coni~!I1:;;:~ml,e:s, di:s,~aDeifncioD1lesl, 0 helill(IJ!n'mm.,,<.j;

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'~o:i1!clo ii:ln~ di fi;m il'b:~d,mj[l~iL1;rIDia, il}'~1Po. f~n·~ac!i) all1i~km:1Jl:ki!~ij,_ I'll'll i~l!Iiib1ie!oo(!la8, oc~.~~;j)-' Ii,!J l!le$ .~ e('!llplea, el '~~~J.tanl'le:lfltol cilll: forma i PIi'Brotz; em! ~mi, padiBill'llE."l: ([Jue p:re_~1II1I1i111 las '~eS~JCi[J;~rcI-e:ll'idas; con el fUn: de g""',~i)IJj[ la O:IptlJ[icli de las cr~si~. 'm~ilmJli~lTil'i,eDild~' t 6n di.!i'~Mu~~e unns 15 di,i.lLS. los crisis vegel;~dvas: sedoraclon, hi[]ertem1.L~.hi~[]enelfl~:lou" '~aqu'bc!i!:~d ta~a, qt!!,il[]rr!ea e hipe;!ll:Q11I ra geliler~'i~ ~d~ (;ei!) o~~s~,oalesil;:Qmi ,o\[JIi~~6~ml,Q~,0 p;nel)l:lPCk'j;to~:o~ ' mlS:), ~e Pli1e.oo:lllil'llflen ~.(1~,pac:uCliIltCs eon 1c:s:~6;n {~C' tmlTillt'!o cerehral prim:tlriu.
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M ateri at c h ron iony P~iwem autors kim

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