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\fs18\cf0\par\pard\li400\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li400\ri0\sl-
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{Insuficiencia cardiaca en Urgencias}\b0 \par\pard\li0\ri0\sl-360\slmult0
\fs18\cf2\f0\charscalex100\b \i {Jos M Quintill}\b0 \i0 \par\pard\li0\ri0\sl-
306\slmult0 \fs16\cf2\f0\charscalex100 {Servicio de Pediatra. Seccin de
Urgencias. Hospital Sant Joan de Du.}\par\pard\li0\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {Universitat de
Barcelona.}\par\pard\sect\sectd\sbknone\cols2\colno1\colw3893\colsr-
0\colno2\colw3800\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-
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{GENERALIDADES}\b0 \par\pard\li466\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100
{La insuficiencia cardiaca (IC) es el estado fisio-}\par\pard\li186\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {patolgico en el cual el corazn es incapaz
de mante-}\par\pard\li186\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {ner una
circulacin adecuada para las necesidades}\par\pard\li186\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {metablicas del organismo, que en la infancia
tam-}\par\pard\li186\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {bin incluyen
el crecimiento y el desarrollo.}\par\pard\li466\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {Las distintas causas de insuficiencia cardiaca
en}\par\pard\li186\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {la edad
peditrica actan afectando alguno de los 4}\par\pard\li186\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {factores que determinan la fisiologa de la funcin
car-}\par\pard\li186\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100
{diaca:}\par\pard\li186\ri0\sl-213\slmult0 \*\tx466\fs16\cf2\f0\charscalex100
{1.}\tab \fs14\cf2\f0\charscalex100\b {Precarga:}\b0 { }\fs14\cf2\f0\charscalex100
{volumen al final de la distole que ser}\par\pard\li466\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {impulsado en la siguiente contraccin
cardiaca.}\par\pard\li466\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {En general
refleja el estado de volemia del pacien-}\par\pard\li466\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {te y afecta directamente a la funcin cardiaca
a}\par\pard\li466\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {travs de la ley
de Frank-Starling.}\par\pard\li186\ri0\sl-226\slmult0
\*\tx466\fs16\cf2\f0\charscalex100 {2.}\tab \fs16\cf2\f0\charscalex100\b
{Postcarga:}\b0 { }\fs14\cf2\f0\charscalex100 {es la fuerza que se opone a la
eyec-}\par\pard\li466\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {cin
ventricular.}\par\pard\li186\ri0\sl-226\slmult0 \*\tx466\fs16\cf2\f0\charscalex100
{3.}\tab \fs14\cf2\f0\charscalex100\b {Contractilidad:}\b0
{ }\fs12\cf2\f0\charscalex100 {la fuerza intrnseca con que
acta}\par\pard\li466\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {el corazn,
determinada por su ultraestructura.}\par\pard\li186\ri0\sl-226\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {4.}\tab \fs16\cf2\f0\charscalex100\b
{Frecuencia cardiaca:}\b0 { }\fs16\cf2\f0\charscalex100 {se relaciona
directamen-}\par\pard\li466\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {te con
el gasto cardiaco y tiene una importancia}\par\pard\li466\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {mayor cuanto ms pequeo sea el nio (en
los}\par\pard\li466\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {lactantes el
gasto cardiaco depende en gran medi-}\par\pard\li466\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {da de la frecuencia cardiaca).}\par\pard\li466\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {La Tabla I enumera las causas ms
importantes}\par\pard\li186\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {de
insuficiencia cardiaca en Pediatra.}\par\pard\li186\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li186\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b {ANAMNESIS
Y EXPLORACIN FSICA}\b0 \par\pard\li466\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {Se deben preguntar antecedentes de
cardiopata}\par\pard\li186\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {ya
conocida, enfermedades crnicas, medicaciones,}\par\pard\li186\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {problemas en periodo neonatal o de
lactancia.}\par\pard\li186\ri0\sl-226\slmult0 \*\tx466\fs16\cf2\f0\charscalex100
{\uc1\u8226X}\tab \fs14\cf2\f0\charscalex100\b {Sntomas generales}\b0
{ }\fs14\cf2\f0\charscalex100 {(valorar su presencia y el}\par\pard\li466\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {tiempo de
aparicin):}\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {-
Fatiga, cansancio con el juego, el deporte o}\par\pard\li640\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {incluso las actividades
cotidianas.}\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {-
Estancamiento ponderal o incluso prdida de}\par\pard\li640\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {peso.}\par\column\pard\li280\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li280\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li280\ri0\sl-
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{- Rechazo del alimento, dificultades en la ali-}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {mentacin.}\par\pard\li0\ri0\sl-213\slmult0
\*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8226X}\tab \fs16\cf2\f0\charscalex100\b
{Exploracin fsica completa,}\b0 { }\fs16\cf2\f0\charscalex100 {con especial
dete-}\par\pard\li280\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {nimiento
en:}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {- Estado general
y nivel de conciencia.}\par\pard\li280\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {- Perfusin perifrica, edemas.}\par\pard\li280\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {- Auscultacin
cardiopulmonar.}\par\pard\li280\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {-
Palpacin abdominal, presencia de hepatome-}\par\pard\li453\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {galia.}\par\pard\li280\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {- Toma de constantes: T, FC, FR,
TA.}\par\pard\li0\ri0\sl-213\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8226X}\tab \fs16\cf2\f0\charscalex100\b {Sntomas y signos sugestivos de
IC:}\b0 \par\pard\li280\ri0\sl-226\slmult0 \*\tx453\fs18\cf2\f0\charscalex100
{-}\tab \fs16\cf2\f0\charscalex100\i {Por fallo miocrdico:}\i0
\par\pard\li453\ri0\sl-213\slmult0 \fs18\cf2\f0\charscalex100 {. Mala perfusin
perifrica.}\par\pard\li453\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {.
Taquicardia basal (> 150 en el lactante y >}\par\pard\li626\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {100 en el nio mayor).}\par\pard\li453\ri0\sl-
226\slmult0 \fs18\cf2\f0\charscalex100 {. Ritmo de galope.}\par\pard\li453\ri0\sl-
213\slmult0 \fs18\cf2\f0\charscalex100 {. Sudoracin,
frialdad.}\par\pard\li453\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {. Pulsos
dbiles y rpidos.}\par\pard\li453\ri0\sl-213\slmult0 \fs18\cf2\f0\charscalex100 {.
Oliguria.}\par\pard\li453\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {. Falta de
medro en lactantes.}\par\pard\li280\ri0\sl-213\slmult0
\*\tx453\fs18\cf2\f0\charscalex100 {-}\tab \fs16\cf2\f0\charscalex100\i {Por edema
pulmonar:}\i0 \par\pard\li453\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {.
Disnea, ortopnea.}\par\pard\li453\ri0\sl-213\slmult0 \fs18\cf2\f0\charscalex100 {.
Taquipnea.}\par\pard\li453\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {.
Tos.}\par\pard\li453\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {. Sibilancias y
crepitantes (en fases iniciales}\par\pard\li626\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {slo hay taquipnea y sibilantes; los
crepi-}\par\pard\li626\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {tantes
implican un edema pulmonar impor-}\par\pard\li626\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {tante).}\par\pard\li453\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {. Cianosis.}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {. Infecciones respiratorias
frecuentes}\par\pard\li280\ri0\sl-213\slmult0 \*\tx453\fs18\cf2\f0\charscalex100
{-}\tab \fs16\cf2\f0\charscalex100\i {Por congestin venosa:}\i0
\par\pard\li453\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {.
Hepatomegalia.}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {.
Edemas perifricos, ascitis, anasarca}\par\pard\li280\ri0\sl-226\slmult0
\fs12\cf2\f0\charscalex100 {De forma similar a la clasificacin de la New
York}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {Heart Association
para la valoracin del grado de insu-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {ficiencia cardiaca en adultos, existe una
clasificacin}\par\pard\li0\ri0\sl-213\slmult0 \fs12\cf2\f0\charscalex100
{especfica para nios, la clasificacin de Ross (Tabla
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\fs20\cf2\f0\charscalex100 {126}\par\column\pard\li0\ri0\sl-186\slmult0
\fs12\cf2\f0\charscalex100 {Protocolos diagnstico-teraputicos de Urgencias
Peditricas SEUP-
AEP}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn560\margrsxn133\col
s2\colno1\colw3720\colsr-0\colno2\colw4080\pard\li200\ri0\sl-213\slmult0
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240\slmult0 \fs12\cf3\f0\charscalex100\b {TABLA I. Causas de insuficiencia cardiaca
en}\b0 \par\pard\li1373\ri0\sl-200\slmult0 \fs18\cf3\f0\charscalex100\b
{pediatra.}\b0 \par\pard\li106\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li106\ri0\sl-
200\slmult0 \fs12\cf2\f0\charscalex100\b {Cardiopatas congnitas}\b0
\par\pard\li106\ri0\sl-266\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Sobrecarga de presin:}\par\pard\li280\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {- Obstruccin al tracto de salida del
VI}\par\pard\li440\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {(estenosis
artica, coartacin severa)}\par\pard\li280\ri0\sl-200\slmult0
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volumen:}\par\pard\li280\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {-
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Retorno venoso pulmonar anmalo}\par\pard\li280\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {- Insuficiencia valvular}\par\pard\li280\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {- Fstula arterio-
venosa}\par\pard\li106\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Otros defectos estructurales:}\par\pard\li280\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {- Arteria coronaria anmala}\par\pard\li106\ri0\sl-
213\slmult0 \fs18\cf2\f0\charscalex100 {\uc1\u8211X
Arritmias:}\par\pard\li280\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {- Bloqueo
cardiaco congnito}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {-
Otras arritmias congnitas}\par\pard\li106\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li106\ri0\sl-186\slmult0 \fs12\cf2\f0\charscalex100\b
{Cardiopatas adquiridas}\b0 \par\pard\li106\ri0\sl-266\slmult0
\fs18\cf2\f0\charscalex100 {\uc1\u8211X Miocarditis}\par\pard\li106\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Enfermedad de
Kawasaki}\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Colagenopatas}\par\pard\li106\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Fibroelastosis endocrdica}\par\pard\li106\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Miocardiopatas:}\par\pard\li280\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {- Anemia severa}\par\pard\li280\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {- Trastornos
nutricionales}\par\pard\li280\ri0\sl-200\slmult0 \fs18\cf2\f0\charscalex100 {-
SIDA}\par\pard\li106\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Enfermedades del pericardio}\par\pard\li106\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Cardiopata
reumtica}\par\pard\li106\ri0\sl-213\slmult0 \fs18\cf2\f0\charscalex100
{\uc1\u8211X Cor pulmonale}\par\pard\li106\ri0\sl-200\slmult0
\fs18\cf2\f0\charscalex100 {\uc1\u8211X Endocarditis}\par\pard\li106\ri0\sl-
213\slmult0 \fs18\cf2\f0\charscalex100 {\uc1\u8211X
Arritmias}\par\pard\li106\ri0\sl-200\slmult0 \fs18\cf2\f0\charscalex100
{\uc1\u8211X HTA}\par\pard\li106\ri0\sl-213\slmult0
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{Endocrino/metablico}\b0 \par\pard\li106\ri0\sl-266\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Alteraciones
electrolticas}\par\pard\li106\ri0\sl-200\slmult0 \fs18\cf2\f0\charscalex100
{\uc1\u8211X Hipoglucemia}\par\pard\li106\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {\uc1\u8211X Hipotiroidismo}\par\pard\li106\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Trastornos del calcio y el
magnesio}\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Errores congnitos del metabolismo}\par\pard\li106\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Enfermedades de
depsito}\par\pard\li106\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li106\ri0\sl-
200\slmult0 \fs18\cf2\f0\charscalex100\b {Otras}\b0 \par\pard\li106\ri0\sl-
266\slmult0 \fs18\cf2\f0\charscalex100 {\uc1\u8211X
Txicos}\par\column\pard\li200\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li200\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li200\ri0\sl-240\slmult0
\fs12\cf3\f0\charscalex100\b {TABLA II. Clasificacin de Ross del grado de}\b0
\par\pard\li960\ri0\sl-200\slmult0 \fs12\cf3\f0\charscalex100\b {insuficiencia
cardiaca.}\b0 \par\pard\li93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li93\ri0\sl-
200\slmult0 \fs18\cf2\f0\charscalex100\b {Clase I}\b0 \par\pard\li93\ri0\sl-
266\slmult0 \fs18\cf2\f0\charscalex100 {\uc1\u8211X
Asintomtico.}\par\pard\li93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li93\ri0\sl-
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266\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Lactante con taquipnea o
sudoracin leves}\par\pard\li266\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{durante las tomas.}\par\pard\li93\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Nio con disnea de ejercicio.}\par\pard\li93\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li93\ri0\sl-173\slmult0 \fs18\cf2\f0\charscalex100\b {Clase
III}\b0 \par\pard\li93\ri0\sl-253\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Lactante con taquipnea o sudoracin marcadas}\par\pard\li266\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {durante las tomas.}\par\pard\li93\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Duracin prolongada de las
tomas.}\par\pard\li266\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {Estancamiento
ponderal.}\par\pard\li93\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Nio con marcada disnea de ejercicio.}\par\pard\li93\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li93\ri0\sl-173\slmult0 \fs16\cf2\f0\charscalex100\b {Clase
IV}\b0 \par\pard\li93\ri0\sl-266\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Sntomas de reposo: taquipnea, sudoracin,}\par\pard\li266\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {retracciones.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-346\slmult0
\fs18\cf1\f0\charscalex100\b {EXPLORACIONES COMPLEMENTARIAS}\b0
\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b {Radiografa de
trax}\b0 \par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {Adems de
apoyar el diagnstico de IC puede ser}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {til para valorar el grado de empeoramiento si la
com-}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {paramos con otras
radiografas previas del paciente.}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {Tambin nos informa de la presencia de
sobreinfec-}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {ciones
respiratorias. Los datos importantes que siem-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {pre debemos valorar son:}\par\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100\b
{1. Silueta cardiaca}\b0 \par\pard\li280\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {La cardiomegalia es un hallazgo casi
constante.}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {Su ausencia
nos har dudar del diagnstico de IC.}\par\pard\li280\ri0\sl-320\slmult0
\fs18\cf2\f0\charscalex100\b {ndice cardiotorcico (ICT)= (D + I) / T}\b0
\par\pard\li280\ri0\sl-333\slmult0 \fs14\cf2\f0\charscalex100 {D = distancia mayor
desde la lnea media de la}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {columna hasta el borde cardiaco derecho; I =
distan-}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {cia mayor
desde la lnea media de la columna hasta}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {el borde cardiaco izquierdo; T = dimetro
torcico}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {transverso (a
nivel de diafragmas)}\par\pard\li280\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100\b {ICT normal:}\b0 \par\pard\li560\ri0\sl-213\slmult0
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}}}}\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\margtsxn453\margbsxn173\cols3\c
olno1\colw2720\colsr-0\colno2\colw4293\colsr-0\colno3\colw680\pard\li186\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100\b {2. Vascularizacin pulmonar}\b0
\par\column\pard\li0\ri0\sl-186\slmult0 \fs12\cf2\f0\charscalex100 {Insuficiencia
cardiaca en Urgencias}\par\pard\li1173\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li1173\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1173\ri0\sl-
226\slmult0 \*\tx1453\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab
\fs16\cf2\f0\charscalex100\i {Otros parmetros:}\i0 \par\column\pard\li0\ri0\sl-
186\slmult0 \fs20\cf2\f0\charscalex100
{127}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\co
ls2\colno1\colw3893\colsr-0\colno2\colw3800\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
{Patrn de congestin venocapilar (IC izquierda):}\par\pard\li466\ri0\sl-
226\slmult0 \fs14\cf2\f0\charscalex100 {redistribucin de la circulacin (lbulos
superio-}\par\pard\li466\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {res >
inferiores), tractos hiliofugales, lneas B de}\par\pard\li466\ri0\sl-
226\slmult0 \fs16\cf2\f0\charscalex100 {Kerley, edema intersticial-
alveolar.}\par\pard\li186\ri0\sl-213\slmult0 \*\tx466\fs16\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100 {Patrn de pltora pulmonar
(cortocircuito I-D):}\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100
{aumento de tamao de arterias pulmonares prin-}\par\pard\li466\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {cipales, imgenes redondas (arterias
cortadas de}\par\pard\li466\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {travs y
mayores que el bronquio satlite).}\par\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100
{Patrn de hipertensin pulmonar: arterias hilia-}\par\pard\li466\ri0\sl-
226\slmult0 \fs16\cf2\f0\charscalex100 {res dilatadas y perifricas
disminuidas.}\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-
226\slmult0 \fs18\cf2\f0\charscalex100\b {3. Parnquima pulmonar}\b0
\par\pard\li466\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {Enfisema lobar por
compresin bronquial por}\par\pard\li186\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {dilatacin vascular, edema intersticial-alveolar,
ate-}\par\pard\li186\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {lectasias,
condensaciones...}\par\pard\li186\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li186\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b
{ECG}\b0 \par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {No confirma
el diagnstico de insuficiencia car-}\par\pard\li186\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {diaca ni es til para cuantificar el grado de
descom-}\par\pard\li186\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {pensacin.
Es diagnstico en las arritmias. Valorar}\par\pard\li186\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {tambin ejes e hipertrofia de
cavidades.}\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-
226\slmult0 \fs18\cf1\f0\charscalex100\b {Laboratorio}\b0 \par\pard\li466\ri0\sl-
226\slmult0 \fs14\cf2\f0\charscalex100 {La necesidad de realizar analtica depende
del}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {grado de
afectacin clnica y de si se conoce o no la}\par\pard\li186\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {causa de la IC. En la descompensacin leve de
una}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {cardiopata
conocida probablemente tendr poca uti-}\par\pard\li186\ri0\sl-226\slmult0
\fs12\cf2\f0\charscalex100 {lidad, pero ser fundamental para la investigacin
etio-}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {lgica en el
debut de una miocardiopata de causa des-}\par\pard\li186\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {conocida.}\par\pard\li466\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {Los siguientes parmetros pueden ser tiles en
la}\par\pard\li186\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {valoracin de un
nio con IC:}\par\pard\li186\ri0\sl-213\slmult0 \*\tx466\fs16\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100\i {Hemograma:}\i0
{ }\fs14\cf2\f0\charscalex100 {para descartar anemia (puede
ser}\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {causa de IC),
poliglobulia (puede ser causa de IC}\par\pard\li466\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {o consecuencia de cardiopatas ciangenas)
y}\par\pard\li466\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {valorar signos de
infeccin intercurrente.}\par\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100\i
{Ionograma:}\i0 { }\fs16\cf2\f0\charscalex100 {descartar alteraciones causantes
de}\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {arritmias,
vigilar K, sobre todo en pacientes a los}\par\pard\li466\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {que administremos diurticos o
digital.}\par\pard\li186\ri0\sl-226\slmult0 \*\tx466\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100\i {Gasometra:}\i0
{ }\fs16\cf2\f0\charscalex100 {puede haber acidosis
metablica}\par\pard\li466\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {(bajo
gasto cardiaco), respiratoria o mixta. Valo-}\par\pard\li466\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {rar el grado de hipoxemia e
hipercapnia.}\par\pard\li186\ri0\sl-213\slmult0 \*\tx466\fs16\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100\i {Bioqumica:}\i0
{ }\fs14\cf2\f0\charscalex100 {glucemia, funcin heptica y
renal,}\par\pard\li466\ri0\sl-226\slmult0 \fs12\cf2\f0\charscalex100 {PCR
(infeccin intercurrente). CK, CK-MB y tro-}\par\pard\li466\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {ponina si se sospecha isquemia o
miocarditis.}\par\column\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100
{- Niveles de digoxina, en pacientes que reciben}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {dicho frmaco.}\par\pard\li280\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {- Todava en fase experimental, los niveles
de}\par\pard\li453\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {pptido
natriurtico (hormona secretada por el}\par\pard\li453\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {miocardio) se elevan en pacientes con IC.
Su}\par\pard\li453\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {magnitud se
correlaciona directamente con el}\par\pard\li453\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {grado de IC e inversamente con la fraccin
de}\par\pard\li453\ri0\sl-226\slmult0 \fs12\cf2\f0\charscalex100 {eyeccin. En un
futuro puede ser de ayuda para}\par\pard\li453\ri0\sl-213\slmult0
\fs12\cf2\f0\charscalex100 {la valoracin de la descompensacin de
pacien-}\par\pard\li453\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {tes
cardipatas.}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {En el
debut de una miocardiopata de causa des-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {conocida hay que determinar:}\par\pard\li0\ri0\sl-
213\slmult0 \*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab
\fs16\cf2\f0\charscalex100 {CK, CK-MB y troponina}\par\pard\li0\ri0\sl-
226\slmult0 \*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab
\fs16\cf2\f0\charscalex100\i {Microbiologa:}\i0 { }\fs16\cf2\f0\charscalex100
{serologas y/o estudios de PCR}\par\pard\li280\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {para adenovirus, Coxsackie, virus Echo,
influen-}\par\pard\li280\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {za, VRS,
parainfluenza, varicela, CMV, EBV,}\par\pard\li280\ri0\sl-213\slmult0
\fs12\cf2\f0\charscalex100 {HIV, parvovirus, enterovirus,}
{ }\fs14\cf2\f0\charscalex100\i {Mycoplasma, Borre-}\i0 \par\pard\li280\ri0\sl-
226\slmult0 \fs16\cf2\f0\charscalex100\i {lia.}\i0 { }\fs14\cf2\f0\charscalex100
{Se realizar tambin en aspirado traqueal en}\par\pard\li280\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {pacientes ventilados. Segn la procedencia
geo-}\par\pard\li280\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {grfica se
valorar tambin el estudio de enfer-}\par\pard\li280\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {medad de Chagas y dengue.}\par\pard\li0\ri0\sl-
226\slmult0 \*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab
\fs16\cf2\f0\charscalex100\i {Estudio metablico}\i0 \fs16\cf2\f0\charscalex100 {:
para descartar enfermedades}\par\pard\li280\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {mitocondriales y otros errores congnitos
del}\par\pard\li280\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100
{metabolismo.}\par\pard\li0\ri0\sl-213\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100\i {Estudio de enfermedades
autoinmunes}\i0 \fs16\cf2\f0\charscalex100 {, que inclu-}\par\pard\li280\ri0\sl-
226\slmult0 \fs12\cf2\f0\charscalex100 {ya Anti-Ro, Anti-La, ANA, anticuerpos
antimio-}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {sina, anti-
ANT, FR y VSG.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-
226\slmult0 \fs18\cf1\f0\charscalex100\b {Ecocardiografa + Doppler}\b0
\par\pard\li280\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {Es una prueba
fundamental, que proporciona una}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {valoracin anatmica y funcional (funcin
ventricu-}\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100
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\fs18\cf2\f0\charscalex100 {tos.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0
\fs18\cf1\f0\charscalex100\b {DIAGNSTICO ETIOLGICO}\b0 \par\pard\li280\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {En ausencia de estudios ms especficos
propios}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {del cardilogo
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\fs16\cf2\f0\charscalex100 {el diagnstico etiolgico inicial slo es posible a
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\fs16\cf2\f0\charscalex100 {ca y las pruebas complementarias susceptibles de
ser}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {realizadas en la
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\fs12\cf2\f0\charscalex100 {Puede ser muy til como punto de partida la
edad}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {del paciente
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olno1\colw1600\colsr-0\colno2\colw6200\pard\li0\ri0\sl-186\slmult0
\fs20\cf2\f0\charscalex100 {128}\par\column\pard\li0\ri0\sl-186\slmult0
\fs12\cf2\f0\charscalex100 {Protocolos diagnstico-teraputicos de Urgencias
Peditricas SEUP-
AEP}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn560\margrsxn133\col
s2\colno1\colw3720\colsr-0\colno2\colw4080\pard\li93\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li93\ri0\sl-
240\slmult0 \fs12\cf3\f0\charscalex100\b {TABLA III. Etiologa de la insuficiencia
cardiaca}\b0 \par\pard\li813\ri0\sl-200\slmult0 \fs12\cf3\f0\charscalex100\b {segn
su edad de aparicin}\b0 \par\pard\li106\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100\b {Recin
nacido}\b0 \par\pard\li106\ri0\sl-253\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Arritmias (bloqueo cardiaco completo,}\par\pard\li280\ri0\sl-
200\slmult0 \fs14\cf2\f0\charscalex100 {taquicardia
supraventricular)}\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Cardiopatas congnitas estructurales}\par\pard\li106\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Disfuncin miocrdica (asfixia,
sepsis,}\par\pard\li280\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{hipoglucemia, miocarditis.)}\par\pard\li106\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Malformacin
arteriovenosa}\par\pard\li106\ri0\sl-200\slmult0 \fs18\cf2\f0\charscalex100
{\uc1\u8211X Anemia grave}\par\pard\li106\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li106\ri0\sl-186\slmult0 \fs18\cf2\f0\charscalex100\b
{Lactante}\b0 \par\pard\li106\ri0\sl-253\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Arritmias (taquicardia supraventricular...)}\par\pard\li106\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Cardiopatas congnitas
estructurales}\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Malformacin arteriovenosa}\par\pard\li106\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Origen anmalo de la coronaria
izquierda}\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Enfermedad de Kawasaki}\par\pard\li106\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Hipertensin arterial aguda
(sndrome}\par\pard\li280\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{hemoltico-urmico...)}\par\pard\li106\ri0\sl-200\slmult0
\fs18\cf2\f0\charscalex100 {\uc1\u8211X Sepsis}\par\pard\li106\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Otras (fibroelastosis
endocrdica, enfermedades}\par\pard\li280\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {de depsito...)}\par\pard\li106\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li106\ri0\sl-186\slmult0 \fs12\cf2\f0\charscalex100\b {Nio
adolescente}\b0 \par\pard\li106\ri0\sl-253\slmult0 \fs18\cf2\f0\charscalex100
{\uc1\u8211X Fiebre reumtica}\par\pard\li106\ri0\sl-200\slmult0
\fs18\cf2\f0\charscalex100 {\uc1\u8211X Miocarditis viral}\par\pard\li106\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Endocarditis
bacteriana}\par\pard\li106\ri0\sl-200\slmult0 \fs18\cf2\f0\charscalex100
{\uc1\u8211X Pericarditis}\par\pard\li106\ri0\sl-200\slmult0
\fs18\cf2\f0\charscalex100 {\uc1\u8211X Arritmias}\par\pard\li106\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Cardiopata congnita
estructural}\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Hipertensin aguda (glomerulonefritis...)}\par\pard\li106\ri0\sl-
200\slmult0 \fs18\cf2\f0\charscalex100 {\uc1\u8211X
Hipertiroidismo}\par\pard\li106\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Enfermedad pulmonar aguda o crnica}\par\pard\li106\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Enfermedades
neuromusculares}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-293\slmult0 \fs16\cf2\f0\charscalex100 {etiolgicos
(Tabla V). El ECG puede ser diagnsti-}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {co en arritmias, pericarditis o
miocarditis.}\par\pard\li293\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {En
pacientes que reciban digital, siempre hay que}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {buscar signos de toxicidad. La intoxicacin
digitli-}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {ca se
caracteriza por sntomas generales (anorexia,}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {nuseas, vmitos, diarrea, alteraciones visuales,
debi-}\par\pard\li0\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {lidad,
empeoramiento de la IC preexistente) y por alte-}\par\pard\li0\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {raciones del ritmo cardiaco, que pueden ser
muy gra-}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {ves. En
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\fs16\cf2\f0\charscalex100 {mia en un paciente digitalizado est relacionada
con}\par\column\pard\li93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li93\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li93\ri0\sl-253\slmult0 \fs12\cf3\f0\charscalex100\b
{TABLA IV. Edad de aparicin de la insuficiencia}\b0 \par\pard\li413\ri0\sl-
200\slmult0 \fs12\cf3\f0\charscalex100\b {cardiaca en las cardiopatas
congnitas}\b0 \par\pard\li1266\ri0\sl-200\slmult0 \fs12\cf3\f0\charscalex100\b
{estructurales}\b0 \par\pard\li93\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li93\ri0\sl-226\slmult0 \fs12\cf2\f0\charscalex100\b {Al
nacimiento}\b0 \par\pard\li93\ri0\sl-253\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Corazn izquierdo hipoplsico}\par\pard\li93\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Insuficiencia tricuspdea o pulmonar
severas}\par\pard\li93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li93\ri0\sl-
173\slmult0 \fs12\cf2\f0\charscalex100\b {Primera semana}\b0 \par\pard\li93\ri0\sl-
253\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Transposicin de los grandes
vasos}\par\pard\li93\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Ductus arterioso persistente (DAP)}\par\pard\li93\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Corazn izquierdo hipoplsico (con
anatoma}\par\pard\li266\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {muy
favorable)}\par\pard\li93\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Drenaje venoso pulmonar anmalo total}\par\pard\li93\ri0\sl-
200\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Estenosis artica o
pulmonar}\par\pard\li93\ri0\sl-373\slmult0 \fs16\cf2\f0\charscalex100\b {Primer
mes}\b0 \par\pard\li93\ri0\sl-266\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X
Coartacin de aorta}\par\pard\li93\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{\uc1\u8211X Estenosis artica}\par\pard\li93\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Shunts I-D amplios}\par\pard\li93\ri0\sl-
373\slmult0 \fs12\cf2\f0\charscalex100\b {Primeros 4 meses}\b0
\par\pard\li93\ri0\sl-253\slmult0 \fs16\cf2\f0\charscalex100 {\uc1\u8211X Shunts I-
D amplios (CIV amplia, DAP...)}\par\pard\li93\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {\uc1\u8211X Origen anmalo de coronaria
izquierda}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs16\cf2\f0\charscalex100 {el frmaco
hasta que se demuestre lo contrario. Hay}\par\pard\li0\ri0\sl-213\slmult0
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226\slmult0 \fs16\cf2\f0\charscalex100 {- Bloqueos de segundo o tercer
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olno1\colw7013\colsr-0\colno2\colw680\pard\li2720\ri0\sl-186\slmult0
\fs12\cf2\f0\charscalex100 {Insuficiencia cardiaca en
Urgencias}\par\pard\li1440\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1440\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li1440\ri0\sl-226\slmult0
\fs12\cf3\f0\charscalex100\b {TABLA V. Algunos datos que pueden orientar el
diagnstico etiolgico}\b0 \par\pard\li280\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li280\ri0\sl-186\slmult0 \*\tx3906\fs16\cf2\f0\charscalex100
{Historia previa de amigdalitis}\tab \fs16\cf2\f0\charscalex100 {Carditis
reumtica}\par\pard\li280\ri0\sl-200\slmult0 \fs18\cf2\f0\charscalex100
{Soplo}\par\pard\li280\ri0\sl-200\slmult0 \fs14\cf2\f0\charscalex100 {Presencia de
otros criterios de Jones}\par\pard\li280\ri0\sl-280\slmult0
\*\tx3906\fs14\cf2\f0\charscalex100 {Historia de infeccin respiratoria de vas
altas}\tab \fs16\cf2\f0\charscalex100 {Miocarditis}\par\pard\li280\ri0\sl-
200\slmult0 \*\tx3906\fs16\cf2\f0\charscalex100 {Alteraciones ECG}\tab
\fs16\cf2\f0\charscalex100 {Pericarditis}\par\pard\li280\ri0\sl-280\slmult0
\*\tx3906\fs18\cf2\f0\charscalex100 {Fiebre}\tab \fs16\cf2\f0\charscalex100
{Endocarditis}\par\pard\li3906\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{Sepsis}\par\pard\li280\ri0\sl-293\slmult0 \*\tx3906\fs16\cf2\f0\charscalex100
{Palpitaciones}\tab \fs16\cf2\f0\charscalex100
{Taquiarritmias}\par\pard\li280\ri0\sl-280\slmult0
\*\tx3906\fs16\cf2\f0\charscalex100 {Dolor torcico}\tab \fs16\cf2\f0\charscalex100
{Pericarditis}\par\pard\li280\ri0\sl-200\slmult0 \fs14\cf2\f0\charscalex100 {Tonos
apagados}\par\pard\li280\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {+/- roce
pericrdico}\par\column\pard\li0\ri0\sl-186\slmult0 \fs20\cf2\f0\charscalex100
{129}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\co
ls2\colno1\colw3893\colsr-0\colno2\colw3800\pard\li466\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li466\ri0\sl-
360\slmult0 \fs16\cf2\f0\charscalex100 {Unos niveles plasmticos superiores a 2
ng/ml}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {probablemente
se asocian con toxicidad si la clnica}\par\pard\li186\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {es compatible. Dicho aumento de los niveles de
digo-}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {xina puede ser
consecuencia de una dosificacin exce-}\par\pard\li186\ri0\sl-226\slmult0
\fs12\cf2\f0\charscalex100 {siva, pero tambin puede estar influenciado por la
insu-}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {ficiencia
renal, el hipotiroidismo y las interacciones}\par\pard\li186\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {con otros frmacos (ver captulo de palpitaciones
y}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {arritmias).
Adems, en la toxicidad digitlica no sola-}\par\pard\li186\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {mente influyen los niveles plasmticos del
frmaco,}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {sino que
hay algunos factores que aumentan la sensi-}\par\pard\li186\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {bilidad miocrdica, como son la isquemia cardiaca,
las}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {miocarditis, la
hipoxia, la alcalosis, las alteraciones}\par\pard\li186\ri0\sl-226\slmult0
\fs12\cf2\f0\charscalex100 {electrolticas (hipopotasemia, hipomagnesemia,
hiper-}\par\pard\li186\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {calcemia) y
el tratamiento con catecolaminas, betablo-}\par\pard\li186\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {queantes, amiodarona, quinidina o
verapamil.}\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-
226\slmult0 \fs18\cf1\f0\charscalex100\b {TRATAMIENTO}\b0 \par\pard\li186\ri0\sl-
213\slmult0 \fs12\cf1\f0\charscalex100\b {Estabilizacin inicial y medidas
generales}\b0 \par\pard\li466\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100
{Orientadas a asegurar:}\par\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100 {La
adecuada monitorizacin y control de estos}\par\pard\li466\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {pacientes.}\par\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100 {La
correccin de factores que pueden empeorar}\par\pard\li466\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {la situacin de IC.}\par\pard\li186\ri0\sl-
213\slmult0 \*\tx466\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab
\fs14\cf2\f0\charscalex100 {la minimizacin de estmulos y acciones que
pue-}\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {dan causar
irritabilidad y aumento de las deman-}\par\pard\li466\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {das metablicas.}\par\pard\li186\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li186\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b
{ABC}\b0 \par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {Asegurar
una correcta apertura de la va area y}\par\pard\li186\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {una ventilacin adecuada. En nios con signos de
ede-}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-360\slmult0 \fs16\cf2\f0\charscalex100
{ma pulmonar severo o de fallo respiratorio inminen-}\par\pard\li0\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {te suele ser necesaria la intubacin
endotraqueal pre-}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {via
a cualquier exploracin complementaria.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b
{Monitorizacin}\b0 \par\pard\li0\ri0\sl-213\slmult0
\*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
{FC, FR, T, TA, saturacin Hb.}\par\pard\li0\ri0\sl-226\slmult0
\*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
{Peso diario.}\par\pard\li0\ri0\sl-213\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100 {Diuresis y balance
hdrico.}\par\pard\li0\ri0\sl-226\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100 {En casos de gravedad es til la
monitorizacin de}\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100
{PVC y de presin de enclavamiento pulmonar}\par\pard\li280\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {(UCIP).}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b {Postura}\b0
\par\pard\li0\ri0\sl-213\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100 {Reposo
absoluto.}\par\pard\li0\ri0\sl-226\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100 {Antitrendelemburg 20-30 (disminuye
el retorno}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {venoso y
mejora la ventilacin)}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b
{Temperatura}\b0 \par\pard\li280\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100
{Mantener normotermia. La fiebre aumenta las}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {necesidades metablicas del organismo. La
hipoter-}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {mia aumenta
la desaturacin de oxgeno en sangre}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {perifrica.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b
{Sedacin}\b0 \par\pard\li280\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100
{Mantener al paciente en un ambiente tranquilo y}\par\pard\li0\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {sin estmulos que provoquen
irritabilidad.}\par\pard\li280\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {En
algunos casos puede ser necesaria la sedacin}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {farmacolgica:}\par\pard\li0\ri0\sl-226\slmult0
\*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
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\fs20\cf2\f0\charscalex100 {130}\par\column\pard\li0\ri0\sl-186\slmult0
\fs12\cf2\f0\charscalex100 {Protocolos diagnstico-teraputicos de Urgencias
Peditricas SEUP-AEP}\par\pard\li893\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-
226\slmult0 \fs14\cf3\f0\charscalex100\b {TABLA VI. Frmacos diurticos}\b0
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olno1\colw2013\colsr-0\colno2\colw2786\colsr-0\colno3\colw3000\pard\li106\ri0\sl-
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\fs18\cf2\f0\charscalex100\b {Frmaco}\b0 \par\pard\li106\ri0\sl-280\slmult0
\fs16\cf2\f0\charscalex100 {Hidroclorotiazida}\par\pard\li106\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {Espironolactona}\par\pard\li106\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {Manitol}\par\column\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-200\slmult0 \fs14\cf2\f0\charscalex100\b {Dosis
nio}\b0 \par\pard\li0\ri0\sl-280\slmult0 \fs16\cf2\f0\charscalex100 {2-4 mg/kg/da
en 2-3 dosis, va oral}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100
{2-3 mg/kg/da en 2-3 dosis, va oral}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {0,5-1 g/kg/dosis, va e.v.}\par\column\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-200\slmult0 \fs14\cf2\f0\charscalex100\b
{Dosis adulto}\b0 \par\pard\li0\ri0\sl-280\slmult0 \fs16\cf2\f0\charscalex100 {50-
100 mg/12 horas}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {25-100
mg/12
horas}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn560\margrsxn133\c
ols2\colno1\colw3720\colsr-0\colno2\colw4080\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-200\slmult0 \*\tx293\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100 {Midazolam: 0,2-0,3 mg/kg va
intranasal; 0,1}\par\pard\li293\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100
{mg/kg/h e.v. en infusin continua.}\par\pard\li0\ri0\sl-213\slmult0
\*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
{Levomepromacina: 1 mg/kg/dosis v.o.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b
{Oxigenoterapia}\b0 \par\pard\li0\ri0\sl-226\slmult0
\*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100
{FiO}\fs10\cf2\f0\charscalex100 {2}{ }\fs16\cf2\f0\charscalex100 {adecuada para
mantener una saturacin de}\par\pard\li293\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {Hb y una PaO}{\sub \fs10\cf2\f0\charscalex100
{2}}\fs16\cf2\f0\charscalex100 {adecuadas.}\par\pard\li0\ri0\sl-213\slmult0
\*\tx293\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100
{Cuidado en las cardiopatas con pltora pulmo-}\par\pard\li293\ri0\sl-
226\slmult0 \fs16\cf2\f0\charscalex100 {nar (el O}{\sub \fs8\cf2\f0\charscalex100
{2}}\fs14\cf2\f0\charscalex100 {es vasodilatador pulmonar y
aumenta}\par\pard\li293\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {la
sobrecarga de volumen de cavidades izquier-}\par\pard\li293\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {das).}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf1\f0\charscalex100\b {Cuidados
respiratorios}\b0 \par\pard\li0\ri0\sl-226\slmult0
\*\tx293\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100
{Aspiracin nasofarngea, fisioterapia respirato-}\par\pard\li293\ri0\sl-
213\slmult0 \fs18\cf2\f0\charscalex100 {ria.}\par\pard\li0\ri0\sl-226\slmult0
\*\tx293\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100
{Tratamiento antibitico de las sobreinfecciones}\par\pard\li293\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {respiratorias.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf1\f0\charscalex100\b {Lquidos y
electrolitos}\b0 \par\pard\li0\ri0\sl-226\slmult0
\*\tx293\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100
{Restriccin hdrica (entre 70-80% de las nece-}\par\pard\li293\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {sidades basales). En general slo en la
fase agu-}\par\pard\li293\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {da y
durante periodos cortos de tiempo, ya que}\par\pard\li293\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {puede dificultar el aporte calrico adecuado
en}\par\pard\li293\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {los
lactantes.}\par\pard\li0\ri0\sl-213\slmult0 \*\tx293\fs16\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100 {Corregir alteraciones
hidroelectrolticas (acido-}\par\pard\li293\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {sis, hipokaliemia...).}\par\pard\li0\ri0\sl-213\slmult0
\*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
{Corregir hipoglucemia.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b {TRATAMIENTO
FARMACOLGICO}\b0 \par\pard\li0\ri0\sl-226\slmult0 \fs18\cf1\f0\charscalex100\b
{GENERAL}\b0 \par\pard\li0\ri0\sl-213\slmult0 \fs16\cf1\f0\charscalex100\b
{Frmacos diurticos}\b0 \par\pard\li0\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100\b {Furosemida}\b0 \par\pard\li0\ri0\sl-213\slmult0
\*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100
{0,5-3 mg/kg/dosis cada 6-8-12 horas}{ }\fs18\cf2\f0\charscalex100\i {va
oral}\i0 \par\pard\li293\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {(adulto 20-
80 mg/dosis cada 8 horas).}\par\pard\li0\ri0\sl-213\slmult0
\*\tx293\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100
{0,5-1 mg/kg/dosis cada 6-8-12 horas}{ }\fs14\cf2\f0\charscalex100\i {va e.v.}\i0
{ }\fs16\cf2\f0\charscalex100 {(adul-}\par\pard\li293\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {to 20-40 mg/dosis cada 8
horas).}\par\pard\li293\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {Es el
diurtico de eleccin en el fallo cardiaco}\par\column\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {agudo (nivel de evidencia C). Puede producir
hipo-}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {potasemia,
hiponatremia y alcalosis hipoclormica.}\par\pard\li280\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {Otros frmacos diurticos, generalmente
poco}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {utilizados en
fase aguda, se resumen en la Tabla VI.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf1\f0\charscalex100\b {Frmacos
inotrpicos}\b0 \par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {En
el tratamiento de una insuficiencia cardiaca}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {grave generalmente es necesario el uso inicial
de}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {inotrpicos
potentes como catecolaminas en infusin}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {continua. Como tratamiento de continuacin o
para}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {el manejo de los
casos menos graves suele utilizarse}\par\pard\li0\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {la digital.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100\b {Digital}\b0
\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {Es el frmaco de
eleccin en la insuficiencia car-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {diaca en la infancia (nivel de evidencia B). En la
prc-}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {tica habitual su
indicacin pasa por la valoracin de}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {un cardilogo peditrico. No suele indicarse en
for-}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {mas asintomticas
de disfuncin de ventrculo izquier-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {do (nivel de evidencia C). Est contraindicada en
caso}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {de miocardiopata
hipertrfica, bloqueo cardiaco com-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {pleto o taponamiento cardiaco. La digital
aumenta}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {la fuerza
contrctil del corazn, mejora el vaciado}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {ventricular, reduce la presin de llenado y el
tamao}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {de las
cavidades cardiacas, aumenta el gasto cardia-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {co y disminuye la frecuencia
cardiaca.}\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {Las dosis
deben ser calculadas al menos por dos}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {personas distintas y de forma independiente,
dada}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {su potencial
toxicidad en niveles cercanos a los tera-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {puticos. Adems el error ms habitual es
administrar}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {una dosis
10 veces superior a la correcta. Puede pau-}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {tarse una dosis de carga (digitalizacin) y
posterior-}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {mente
continuar con las dosis de mantenimiento. En}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {los casos en los que la IC sea leve suele
comenzarse}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {directamente por la dosis oral de mantenimiento.
En}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {general la va oral
es ms segura y la e.v. se reserva}\par\pard\li0\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {para casos graves. Es una prctica til realizar un
ECG}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn560\margrsxn133\par
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51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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14005145140051451400514514005145140051451400514514005145140051451400514514005145140
05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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40051451400514514005145140051451400514514005145140051451400514514005145140051451400
51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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14005145140051451400514514005145140051451400514514005145140051451400514514005145140
05145140051451400514514005145140051451400514514005145140051451400514514005145140051
45140051451400514514005145140051451400514514005145140051451400514514005145140051451
40051451400514514005145140051451400514514005145140051451400514514005145140051451400
51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
14514005145140051451400514514005145140051451400514514005145140051451400514514005145
14005145140051451400514514005145140051451400514514005145140051451400514514005145140
05145140051451400514514005145140051451400514514005145140051451400514514005145140051
45140051451400514514005145140051451400514514005145140051451400514514005145140051451
40051451400514514005145140051451400514514005145140051451400514514005145140051451400
51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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14005145140051451400514514005145140051451400514514005145140051451400514514005145140
05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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40051451400514514005145140051451400514514005145140051451400514514005145140051451400
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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40051451400514514005145140051451400514514005145140051451400514514005145140051451400
51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
45140051451400514514005145140051451400514514005145140051451400514514005145140051451
40051451400514514005145140051451400514514005145140051451400514514005145140051451400
51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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40051451400514514005145140051451400514514005145140051451400514514005145140051451400
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00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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14005145140051451400514514005145140051451400514514005145140051451400514514005145140
05145140051451400514514005145140051451400514514005145140051451400514514005145140051
45140051451400514514005145140051451400514514005145140051451400514514005145140051451
40051451400514514005145140051451400514514005145140051451400514514005145140051451400
51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
14514005145140051451400514514005145140051451400514514005145140051451400514514005145
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
45140051451400514514005145140051451400514514005145140051451400514514005145140051451
40051451400514514005145140051451400514514005145140051451400514514005145140051451400
51451400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514514
00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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40051451400514514005145140051451400514514005145140051451400514514005145140051451400
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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40051451400514514005145140051451400514514005145140051451400514514005145140051451400
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00514514005145140051451400514514005145140051451400514514005145140051451400514514005
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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05145140051451400514514005145140051451400514514005145140051451400514514005145140051
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14514005145140051451400514514005145140051451400514514005145140051451400514514005145
1401FFD9}
}}}}\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\margtsxn453\margbsxn173\cols3\c
olno1\colw1960\colsr-0\colno2\colw5053\colsr-0\colno3\colw680\pard\li280\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li280\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li280\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li280\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li280\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li280\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li280\ri0\sl-
160\slmult0 \fs18\cf2\f0\charscalex100\b {Edad}\b0 \par\column\pard\li760\ri0\sl-
186\slmult0 \fs12\cf2\f0\charscalex100 {Insuficiencia cardiaca en
Urgencias}\par\pard\li493\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li493\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li493\ri0\sl-226\slmult0
\fs12\cf3\f0\charscalex100\b {TABLA VII. Rgimen de digitalizacin}\b0
\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-200\slmult0
\*\tx2680\*\tx3773\fs12\cf2\f0\charscalex100\b {Digitalizacin}\b0
\fs10\cf2\f0\charscalex100\b {1}\b0 { }\fs16\cf2\f0\charscalex100\b
{(g/kg/da)}\b0 \tab \fs12\cf2\f0\charscalex100\b {Mantenimiento}\b0
\fs10\cf2\f0\charscalex100\b {2}\b0 \tab \fs16\cf2\f0\charscalex100\b
{(g/kg/da)}\b0 \par\pard\li0\ri0\sl-186\slmult0
\*\tx1106\*\tx2680\*\tx3920\fs18\cf2\f0\charscalex100\b {Oral}\b0 \tab
\fs18\cf2\f0\charscalex100\b {EV}\b0 \tab \fs18\cf2\f0\charscalex100\b {Oral}\b0
\tab \fs18\cf2\f0\charscalex100\b {EV}\b0 \par\column\pard\li0\ri0\sl-
186\slmult0 \fs20\cf2\f0\charscalex100
{131}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\co
ls5\colno1\colw1960\colsr-0\colno2\colw1106\colsr-0\colno3\colw1573\colsr-
0\colno4\colw1240\colsr-0\colno5\colw1813\pard\li280\ri0\sl-253\slmult0
\fs16\cf2\f0\charscalex100 {Pretrmino}\par\pard\li280\ri0\sl-306\slmult0
\fs14\cf2\f0\charscalex100 {RNT y < 2 meses}\par\pard\li280\ri0\sl-306\slmult0
\fs16\cf2\f0\charscalex100 {2 meses-2 aos}\par\pard\li280\ri0\sl-306\slmult0
\fs16\cf2\f0\charscalex100 {> 2 aos}\par\column\pard\li0\ri0\sl-253\slmult0
\fs18\cf2\f0\charscalex100 {20}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {30}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {40}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {30}\par\column\pard\li0\ri0\sl-253\slmult0
\fs18\cf2\f0\charscalex100 {15}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {20-25}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {30}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {25}\par\column\pard\li0\ri0\sl-253\slmult0
\fs18\cf2\f0\charscalex100 {5}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {8-10}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {10}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {8-10}\par\column\pard\li0\ri0\sl-253\slmult0
\fs18\cf2\f0\charscalex100 {3-4}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {6-8}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {7-9}\par\pard\li0\ri0\sl-306\slmult0
\fs18\cf2\f0\charscalex100 {6-
8}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\cols3
\colno1\colw1960\colsr-0\colno2\colw2680\colsr-0\colno3\colw3053\pard\li280\ri0\sl-
306\slmult0 \fs16\cf2\f0\charscalex100 {Adolescente-
adulto}\par\column\pard\li0\ri0\sl-306\slmult0 \*\tx1106\fs16\cf2\f0\charscalex100
{1-1,5 mg/da}\tab \fs16\cf2\f0\charscalex100 {0,5-1
mg/da}\par\column\pard\li0\ri0\sl-306\slmult0 \*\tx1240\fs16\cf2\f0\charscalex100
{125-500 g/da}\tab \fs16\cf2\f0\charscalex100 {100-400
g/da}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\
pard\li280\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li280\ri0\sl-160\slmult0
\fs10\cf2\f0\charscalex100\i {1}\i0 \fs12\cf2\f0\charscalex100\i {Se divide en tres
dosis cada 8 horas: 1 (50%), 2 (25%) y 3 (25%).}\i0
{ }\fs10\cf2\f0\charscalex100\i {2}\i0 \fs12\cf2\f0\charscalex100\i {Se divide en 2
dosis iguales cada 12 horas.}\i0 \par\pard\li280\ri0\sl-186\slmult0
\fs12\cf2\f0\charscalex100\i {Niveles teraputicos: 0,7-2 ng/ml}\i0
\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\cols2\c
olno1\colw3893\colsr-0\colno2\colw3800\pard\li186\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-240\slmult0 \fs16\cf2\f0\charscalex100
{previamente al inicio del tratamiento con digital, para}\par\pard\li186\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {poder valorar posteriormente los cambios
producidos}\par\pard\li186\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {por el
frmaco y para comparar en caso de sospecha}\par\pard\li186\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {de toxicidad.}\par\pard\li466\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {El rgimen de digitalizacin se detalla en la
Tabla}\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf2\f0\charscalex100
{VII.}\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-
226\slmult0 \fs16\cf2\f0\charscalex100\b {Frmacos inotrpicos ms potentes}\b0
\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {Se utilizan para el
manejo de la descompensacin}\par\pard\li186\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {grave cuando hay una situacin de bajo gasto
impor-}\par\pard\li186\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {tante.
Generalmente se utilizan en el entorno de cui-}\par\pard\li186\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {dados intensivos, por lo que su uso
detallado no se}\par\pard\li186\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100
{recoge en la presente gua.}\par\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100
{Dopamina.}\par\pard\li186\ri0\sl-226\slmult0 \*\tx466\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100 {Dobutamina.}\par\pard\li186\ri0\sl-
213\slmult0 \*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab
\fs16\cf2\f0\charscalex100 {Isoproterenol.}\par\pard\li186\ri0\sl-226\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
{Adrenalina.}\par\pard\li186\ri0\sl-213\slmult0 \*\tx466\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100 {Milrinona.}\par\pard\li186\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li186\ri0\sl-226\slmult0
\fs18\cf1\f0\charscalex100\b {Frmacos vasodilatadores}\b0 \par\pard\li466\ri0\sl-
226\slmult0 \fs14\cf2\f0\charscalex100 {Su mecanismo de accin es reducir la
postcarga y}\par\pard\li186\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {sirven
de complemento a los tratamientos anteriores.}\par\pard\li186\ri0\sl-226\slmult0
\*\tx466\fs16\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs14\cf2\f0\charscalex100
{Captopril: no est indicado como tratamiento ini-}\par\pard\li466\ri0\sl-
213\slmult0 \fs14\cf2\f0\charscalex100 {cial en la descompensacin aguda, pero s
es fre-}\par\pard\li466\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {cuente su
utilizacin como terapia crnica de la}\par\pard\li466\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {IC, sobre todo en la disfuncin ventricular de
gra-}\par\pard\li466\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {do moderado o
severo (nivel de evidencia B).}\par\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs16\cf2\f0\charscalex100
{Nitroprusiato.}\par\pard\li186\ri0\sl-226\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100
{Nitroglicerina.}\par\pard\li186\ri0\sl-213\slmult0
\*\tx466\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100
{Hidralazina.}\par\column\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-240\slmult0 \fs16\cf1\f0\charscalex100\b {Otros
frmacos}\b0 \par\pard\li0\ri0\sl-213\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100\b {Beta-bloqueantes:}\b0
{ }\fs16\cf2\f0\charscalex100 {generalmente no se utilizan}\par\pard\li280\ri0\sl-
226\slmult0 \fs14\cf2\f0\charscalex100 {en la descompensacin aguda. Su uso
crnico}\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {debe ser
evaluado individualmente por un cardi-}\par\pard\li280\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {logo peditrico. Existen ensayos con
carvedilol,}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {un
betabloqueante de tercera generacin.}\par\pard\li0\ri0\sl-226\slmult0
\*\tx280\fs18\cf2\f0\charscalex100 {\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100\b
{Nesiritide:}\b0 { }\fs16\cf2\f0\charscalex100 {es un nuevo frmaco para el
trata-}\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {miento de la
IC descompensada cuyo uso en}\par\pard\li280\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {pediatra todava no est suficientemente
evalua-}\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {do. Se trata
de un peptido natriurtico recombi-}\par\pard\li280\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {nante tipo B similar al endgeno, que aumenta
la}\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {diuresis y la
natriuresis y produce supresin del}\par\pard\li280\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {eje renina-angiotensina-aldosterona. Reduce
la}\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {precarga y la
postcarga sin producir taquicardia}\par\pard\li280\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {refleja. Su dosis es de 0,01 a 0,03 g/kg/min
en}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {infusin
continua.}\par\pard\li0\ri0\sl-226\slmult0 \*\tx280\fs18\cf2\f0\charscalex100
{\uc1\u8211X}\tab \fs18\cf2\f0\charscalex100\b {En fase experimental:}\b0
\par\pard\li280\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {- Antagonistas de
los receptores de la angiotensi-}\par\pard\li453\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100
{na: irbesartan, losartan, candesartan, valsartan.}\par\pard\li280\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {- Frmacos sensibilizadores al calcio:
levosi-}\par\pard\li453\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100
{mendan.}\par\pard\li280\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {-
Antagonistas de receptores de endotelina:}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {bosentan, darusentan, sitaxentan.}\par\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf1\f0\charscalex100\b
{OTROS TRATAMIENTOS}\b0 \par\pard\li280\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {En los casos en los que el tratamiento
farmaco-}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {lgico
resulta insuficiente pueden aplicarse tcnicas}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {de asistencia ventricular mecnica o de ECMO.
Se}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {aplican en Unidades
de Cuidados Intensivos y evi-}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {dentemente se escapan al objetivo de esta
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}}}}\pgwsxn8493\pghsxn11893\marglsxn560\margrsxn133\margtsxn453\margbsxn173\cols2\c
olno1\colw1600\colsr-0\colno2\colw6200\pard\li0\ri0\sl-186\slmult0
\fs20\cf2\f0\charscalex100 {132}\par\column\pard\li0\ri0\sl-186\slmult0
\fs12\cf2\f0\charscalex100 {Protocolos diagnstico-teraputicos de Urgencias
Peditricas SEUP-
AEP}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn560\margrsxn133\col
s2\colno1\colw4000\colsr-0\colno2\colw3800\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-226\slmult0
\fs18\cf1\f0\charscalex100\b {TRATAMIENTOS ESPECFICOS}\b0 \par\pard\li0\ri0\sl-
213\slmult0 \*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8226X}\tab
\fs18\cf2\f0\charscalex100\b {Arritmias:}\b0 { }\fs16\cf2\f0\charscalex100 {ver
pauta especfica.}\par\pard\li0\ri0\sl-226\slmult0
\*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8226X}\tab \fs16\cf2\f0\charscalex100\b
{Pericarditis:}\b0 \par\pard\li293\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {-
AAS 30-60 mg/kg/da (salicilemia 10-15 mg%).}\par\pard\li293\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {- Corticoides en evolucin
trpida.}\par\pard\li293\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {- Drenaje
pericrdico si hay tamponamiento.}\par\pard\li0\ri0\sl-226\slmult0
\*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8226X}\tab \fs18\cf2\f0\charscalex100\b
{Miocarditis:}\b0 \par\pard\li293\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {-
Inmunoglobulinas 2 g/kg dosis nica.}\par\pard\li293\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {- Control de las arritmias.}\par\pard\li293\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {- Inotrpicos
(dopamina/dobutamina).}\par\pard\li293\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {- IECA.}\par\pard\li0\ri0\sl-213\slmult0
\*\tx293\fs18\cf2\f0\charscalex100 {\uc1\u8226X}\tab \fs18\cf2\f0\charscalex100\b
{Enfermedad de Kawasaki:}\b0 \par\pard\li293\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {- AAS 80-100 mg/kg/da.}\par\pard\li293\ri0\sl-
213\slmult0 \fs16\cf2\f0\charscalex100 {- Inmunoglobulinas 2 g/kg dosis
nica.}\par\pard\li293\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100\b
{Cardiopatas congnitas:}\b0 \par\pard\li293\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {- Tratamiento general de IC.}\par\pard\li293\ri0\sl-
226\slmult0 \fs14\cf2\f0\charscalex100 {- Sospecha de cardiopata cianosante en los
pri-}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {meros das de
vida: PGE1 en infusin conti-}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {nua (carga de 0,1 mg/kg/min durante 30
min}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {y mantenimiento
de 0,03-0,05 mg/kg/min).}\par\pard\li293\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {- Tratamiento especfico de cada
cardiopata.}\par\pard\li0\ri0\sl-213\slmult0 \*\tx293\fs18\cf2\f0\charscalex100
{\uc1\u8226X}\tab \fs18\cf2\f0\charscalex100\b {HTA:}\b0
{ }\fs18\cf2\f0\charscalex100 {tratamiento farmacolgico de la
misma}\par\pard\li293\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {(ver pauta
especfica).}\par\pard\li0\ri0\sl-213\slmult0 \*\tx293\fs18\cf2\f0\charscalex100
{\uc1\u8226X}\tab \fs18\cf2\f0\charscalex100\b {Fiebre reumtica:}\b0
\par\pard\li293\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {-
Reposo.}\par\pard\li293\ri0\sl-213\slmult0 \fs18\cf2\f0\charscalex100 {-
AAS/corticoides.}\par\pard\li293\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {-
Penicilina.}\par\pard\li0\ri0\sl-213\slmult0 \*\tx293\fs18\cf2\f0\charscalex100
{\uc1\u8226X}\tab \fs16\cf2\f0\charscalex100\b {Intoxicacin digitlica:}\b0
\par\pard\li293\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {1.}
{ }\fs16\cf2\f0\charscalex100\i {Supresin}\i0 { }\fs16\cf2\f0\charscalex100 {de la
administracin del frmaco.}\par\pard\li293\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {2.}{ }\fs14\cf2\f0\charscalex100\i {Carbn activado}\i0
{ }\fs14\cf2\f0\charscalex100 {si se trata de una ingesta
acci-}\par\pard\li453\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100
{dental.}\par\pard\li293\ri0\sl-213\slmult0 \fs18\cf2\f0\charscalex100 {3.}
{ }\fs16\cf2\f0\charscalex100\i {Monitorizacin}\i0 { }\fs18\cf2\f0\charscalex100
{ECG continua.}\par\pard\li293\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {4.
Tratar los}{ }\fs16\cf2\f0\charscalex100\i {factores predisponentes}\i0
{ }\fs16\cf2\f0\charscalex100 {anteriormen-}\par\pard\li453\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {te citados.}\par\pard\li293\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {5. El}{ }\fs16\cf2\f0\charscalex100\i {aporte de
potasio}\i0 { }\fs16\cf2\f0\charscalex100 {puede ser til, ms
espe-}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {cficamente
cuando sus niveles estn bajos. Si}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {el paciente presenta un bloqueo AV
causado}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {por la
digoxina no debemos administrar pota-}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {sio salvo para tratar una hipopotasemia
seve-}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {ra. Una
intoxicacin aguda por digoxina pue-}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {de provocar una hiperpotasemia, que se
tra-}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {tar con las
medidas habituales, excepto la}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {administracin de calcio, ya que puede
empe-}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {orar las
arritmias causadas por la digital. Ade-}\par\pard\li453\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {ms, esta situacin es una indicacin para
el}\par\pard\li453\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {uso de
anticuerpos antidigital.}\par\column\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {6.}{ }\fs16\cf2\f0\charscalex100\i {Tratamiento de las
arritmias}\i0 { }\fs16\cf2\f0\charscalex100 {causadas por
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segundo o tercer grado, hiper-}\par\pard\li346\ri0\sl-213\slmult0
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grave-}\par\pard\li346\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {dad de las
arritmias se puede administrar}\par\pard\li346\ri0\sl-213\slmult0
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}\fs16\cf2\f0\charscalex100 {o los}{ }\fs14\cf2\f0\charscalex100\i
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213\slmult0 \fs14\cf2\f0\charscalex100 {taquicardia ventricular es indicacin de}
{ }\fs16\cf2\f0\charscalex100\i {car-}\i0 \par\pard\li346\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100\i {dioversin.}\i0 \par\pard\li173\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {- El bloqueo de segundo o tercer grado
pue-}\par\pard\li346\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {de tratarse
inicialmente con}{ }\fs14\cf2\f0\charscalex100\i {atropina}\i0
{ }\fs16\cf2\f0\charscalex100 {(0,02}\par\pard\li346\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {mg/kg), aunque en muchas ocasiones
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{ }\fs18\cf2\f0\charscalex100 {tempo-}\par\pard\li346\ri0\sl-213\slmult0
\fs18\cf2\f0\charscalex100 {ral.}\par\pard\li0\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {7. Uso de}{ }\fs16\cf2\f0\charscalex100\i {anticuerpos
antidigital}\i0 { }\fs16\cf2\f0\charscalex100 {(fraccin
Fab).}\par\pard\li173\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {En general se
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\fs14\cf2\f0\charscalex100 {las intoxicaciones por ingestin accidental
de}\par\pard\li173\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {grandes dosis (>
4 mg 0,1 mg/kg en nios,}\par\pard\li173\ri0\sl-226\slmult0
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ventricular,}\par\pard\li173\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {bloqueo
cardiaco). Se administran por va e.v.}\par\pard\li173\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {en 30 minutos y es recomendable realizar,
si}\par\pard\li173\ri0\sl-213\slmult0 \fs12\cf2\f0\charscalex100 {la situacin
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\fs14\cf2\f0\charscalex100 {cutnea con 0,1 ml 15 minutos antes de
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\fs16\cf2\f0\charscalex100 {sensibilidad.}\par\pard\li173\ri0\sl-213\slmult0
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}}}}\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\margtsxn453\margbsxn440\cols2\c
olno1\colw7013\colsr-0\colno2\colw680\pard\li2720\ri0\sl-186\slmult0
\fs12\cf2\f0\charscalex100 {Insuficiencia cardiaca en
Urgencias}\par\column\pard\li0\ri0\sl-186\slmult0 \fs20\cf2\f0\charscalex100
{133}\par\pard\sect\sectd\sbknone\pgwsxn8493\pghsxn11893\marglsxn666\margrsxn133\co
ls2\colno1\colw3893\colsr-0\colno2\colw3800\pard\li800\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li800\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li800\ri0\sl-
226\slmult0 \fs16\cf2\f0\charscalex100 {zar debemos tener en cuenta la carga
corpo-}\par\pard\li800\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {ral total
(CCT) de la sustancia (no slo la}\par\pard\li800\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {concentracin plasmtica). Una vez
calcu-}\par\pard\li800\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {lada dicha
carga total en mg podemos saber}\par\pard\li800\ri0\sl-226\slmult0
\fs14\cf2\f0\charscalex100 {cuntos viales de anticuerpos Fab
necesita-}\par\pard\li800\ri0\sl-213\slmult0 \fs14\cf2\f0\charscalex100 {mos (ya
hemos dicho que cada uno neutra-}\par\pard\li800\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {liza 1 mg).}\par\pard\li640\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {- Si se trata de una intoxicacin aguda
acci-}\par\pard\li800\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {dental, la
carga total de digoxina correspon-}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {de al 80% de la dosis ingerida (sta es
su}\par\pard\li800\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {biodisponibilidad
oral) o a la totalidad de la}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {dosis inyectada. Si se desconoce la
dosis}\par\pard\li800\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {ingerida y ya
han pasado 6 horas post-inges-}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {ta pueden determinarse los niveles
plasm-}\par\pard\li800\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {ticos y
actuar como se describe en la into-}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {xicacin crnica. Si no es posible se
utiliza}\par\pard\li800\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {una dosis
emprica de 6 viales (puede admi-}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {nistrarse la mitad de las dosis y ver la
res-}\par\pard\li800\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {puesta antes de
administrar la otra mitad).}\par\pard\li640\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {- Si se trata de una intoxicacin crnica
nos}\par\pard\li800\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {basaremos en los
niveles plasmticos, cono-}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {ciendo que el volumen de distribucin de
la}\par\pard\li800\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {digoxina es
aproximadamente 5,6 L/kg. Para}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {calcularla, pues, aplicaremos la
siguiente}\par\pard\li800\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100
{frmula:}\par\pard\li800\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {CCT =
niveles plasmticos (ng/ml) x 5,6 x}\par\pard\li800\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {peso (kg)/1000}\par\pard\li800\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {En lugar de esta frmula podemos
utilizar}\par\pard\li800\ri0\sl-226\slmult0 \fs18\cf2\f0\charscalex100 {la Tabla
VII.}\par\pard\li800\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {Si desconocemos
los niveles plasmticos,}\par\pard\li800\ri0\sl-226\slmult0
\fs16\cf2\f0\charscalex100 {en nios < 20 kg se utiliza una dosis
emp-}\par\pard\li800\ri0\sl-213\slmult0 \fs16\cf2\f0\charscalex100 {rica de 40 mg
y en > 20 kg y adultos de 240}\par\pard\li800\ri0\sl-226\slmult0
\fs18\cf2\f0\charscalex100 {mg.}\par\pard\li466\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {8. Efectos no deseados de los anticuerpos
Fab:}\par\pard\li640\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {reacciones de
hipersensibilidad, empeoramien-}\par\pard\li640\ri0\sl-213\slmult0
\fs12\cf2\f0\charscalex100 {to de la insuficiencia cardiaca subyacente,
hipo-}\par\pard\li640\ri0\sl-226\slmult0 \fs12\cf2\f0\charscalex100 {potasemia
(puede suceder de forma rpida, por}\par\pard\li640\ri0\sl-213\slmult0
\fs14\cf2\f0\charscalex100 {lo que es conveniente determinar los niveles
de}\par\pard\li640\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {potasio cada hora
hasta que se estabilice). Los}\par\pard\li640\ri0\sl-213\slmult0
\fs12\cf2\f0\charscalex100 {anticuerpos tardan en eliminarse 3-4 das (5-
10}\par\pard\li640\ri0\sl-226\slmult0 \fs14\cf2\f0\charscalex100 {das en
insuficiencia renal), durante los cuales}\par\column\pard\li453\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li453\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li453\ri0\sl-226\slmult0 \fs16\cf2\f0\charscalex100 {pueden
interferir en algunas tcnicas de deter-}\par\pard\li453\ri0\sl-213\slmult0
\fs16\cf2\f0\charscalex100 {minacin de niveles plasmticos de
digital.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-226\slmult0
\fs18\cf1\f0\charscalex100\b {BIBLIOGRAFA}\b0 \par\pard\li0\ri0\sl-240\slmult0
\*\tx280\fs16\cf2\f0\charscalex100 {1.}\tab \fs14\cf2\f0\charscalex100 {Newburger
JW, Takahashi M, Beiser AS, Burns JC,}\par\pard\li280\ri0\sl-200\slmult0
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D, Chrisant MR, Edens E, Mahony L, Can-}\par\pard\li280\ri0\sl-186\slmult0
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SK,}\par\pard\li280\ri0\sl-186\slmult0 \fs10\cf2\f0\charscalex100 {Moffett BS,
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