iin ee ee ee ee ee] PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 1. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU DURERE TORACICA (Durares trac superes Funai vise stable 7) Sabina) (Tose €CGin maxim iOminite | Aminstrarea de Aspirin inca de SCA Monitorisare contin medias | obiectiv (sp02482-84%) | to ee (Geo wansoraci (pentru deci) [reuneee scent (aatemamen) Se gl i cen | de chirurgie | [Soret pene) OS ane | tamestionpeedit? | on (acidic et | (wots ent ccolectie pericardica La os sconce > ee ea) —_ yw ~ Yo (cnpeate | on, (Farmatrae (considera) Parcardocentez Interrre one {era ste seu? Conon entrar cu Tada ace pai pers Dereart te (cies. J a / (Conair ini) ) ~ Considenreintnceret la (( tvatarea scl NSTEMI/AL Aiea ) Ene ardce | | nepetb£cs dacs aurea perssta, —_) Recschoat y —_¥ Yo (aspiring (Aspirin sau inhibitor de) _(Externare/managementin ‘inibitori de P2V22 | recepton P2Y12 || ambulator. | Ir | | ane | | Betalocante pros Betalocante pros | | | Aniconulante sou inhibits Antesbgaante su niton | | secre | cece \| Internare J (Cinternare \ wn ‘cet ti fost aa in pret Tnbuncpres catty sec ean prepa de madd de gent prin aerotore i mplementre na propa de emre rt coors pun adn pres Une pp intermedi cnt hans pees tre uropean exis Pela ern bra Aarau Cost Feseral etn reorererat pn Agi Ehetond de Oar Cooper: Gover onde, ph Minster Finale Pubic Minor Sirs na mpemertt se Sve Cer ena Po Sere eStats Sere asters acu= a = = =a = a =a 3 a 3 a a a a a a a a a a a a a a a a a a a a 2 a 2 PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME 2. ALGORITM DE MANAGEMENT iN URGENTA AL PACIENTULUI CU STEMI Pacientcuistorie sugesty si ECG diagnostic pentru STEM! Oxigensuplimentar doar daciestenecesar Obiecti (943, 88-92% dac¥ BPOC) Monitrizare concious Aspirin 150-300mgperos(asemesteca) Analgeze (poi Anwoliticlanevoie Centra cu posbiltat de angloplaste (PCI) primara? Pciposibil in<120 minute dela sosiea paclentull in servicul deurgenta? Considerati administrares de Ticagrelor 180 mg/Ciopidogrel 300-600™me Administra Enoxaparins/Heperin’ * CConsiderayi adminisrarea de Ticagrelor 180 mg/Clopidogrel 300-600me ‘Administrapi Enoxapbring/ Heparind* (Preferabilin < 60 de minute) Fibrinolies media ** (verifcatabsentacontraindicatilor®**) (Preferabilin 30 minute dela sosireatn servicil deurgenta) Administra Clopidogrel 300-500mg Enoxaparind/Meparing® “Transfer imediat nte-un centr Pai Avetment es lgrin epresint orecomandre abr pact n rr dorm inact usec cin mp de sci ec coe in Acs mate ot eet naa proc dundee cat serio antler peal de mead de pent an cerotara mplomertare nu pgm Se omer’, rac oStream ine ot intermedi contrib een pervuUnunes Europeans ens. roel sade in br en cr te Co ‘el tern rn ae es evap eel om hid Fa 7k Feb sins St, ie nsemerest de vCal pens Pej Servl de Site) alae Se gee merenastutioe oaiii a ee ee ee ee ee | PROGRAMUL DE COOPERARE ELVETIANO-2OMAN ‘SWISS ROMANIAN COOPERATION PROGRAMME Dovel de anttrombotic cu PCI primar Heparina nefacjionata 70-100 U/kg bolus, dac8 nu se ve administa uterior sl inhibitor GPa 50-60 U/kg iv bolus cand vaf administat si un inhibitor GP a/b Enoxaparing 0.5 ma/kg iv bolus Bialirusing 10.75 mg/kg iw bolus urmat de 1.75 me/ka/h pans lah (O doza mai redusd de 0.25 mg/kg/h trebuie continuats 4-12 ore Cu terapia trombolticd Heparinanefractonats 60 U/kg iv bolus max. 4000 U urmat de pev continuu de 12 U/kg cu maxim 1000 Uh pentru 24-48 ore. APTT fnta este de 50-70 sec, sau 1.5 -2.X, monitorzat 3,612 s!26/h Ta paclenticuvarsta <75 ani: 30 mgiv bolus urmat la 15 min de 1 mg/k@ sc Enovaparin| Ja flecare 12h pana la externa. Primele 2 doze nu ar trebuis8 depiseascd 100 mg La pacieni cu varsta> 75 ani nu se acminisreaz3 bolus iv se Incepe prima dozds.c de 0,75 m/e, maxim 75 mg pentru primele 2 doze La pacienticu clearance de creatinini 30 m/min, inciferent de vartd dovele sunt administrate 0 singurd data la 24h Fondaparin 2.5 meg bolus, uemat de 2.5 mg scale Tratament inital streptokinaza 1,5 miigane Ulin 30-60 minute iv ‘lteplaza 115 mg iv bolus, 0.75 mg/kg in 30 de minute (pnd ls max 50 me) apoi 05 (eA) ma/kg In 60 de minute iv (pnd la 35.mg) Reteplaza 120 Us apol ned 10 Villa 30 de minute (eA) Tenecteplara| Bolus iv (TNA) '30 mg dact greutatea pacientlul este < 60 ke © 35mg doch este inte 60-70 kg = 40.mg dacd este intre 70-80 kg 145 mg dacd este intre 80-90 kg 50mg dact este > 90 kg CCONTRAINDICATI ABSOLUTE TROMBOLIZA Hemoragie digest n ultima lund Tulburare de coagulare cunoscuts -_Disectie de Aorts Accident vascular cerebral de tiologie nepreciatd sau hemoragle intracerebrald In antecedente = Accident vascular cerebral ischemicin ultimele 6 uni = Alectiun ale SNC, neoplasme sau malformatiariowentriculare ‘Trauma majorérecenti/interventichrurgical/traum craniana (in ultimile 3 s8ptémni) = __Punctianare in acu greu/necompresiile in ltimile 24 de ore (ex. puncte blopsie hepatics, punctielomibar) ‘CONTRAINDICATII RELATIVE TROMBOLIZA Terapie anticoagulant oralé Boala hepatic in stad avansat Endocardit infecioass Ucer peptic activ ‘cident ischemic tranaltoro ultimele 6 luni + _Sarcind in evolutie sau prima sptiman8 post-partum Hipertensiane arterial refractara [ TAS>180 3 / sau TAD>210 mmHg) 2 Resuscltare de lung’ durata sau trum postresusctare [racturi), “avcrament Aces ort erento ecomandore de br pacer urge ule deat ci ing ec ect ster stubinn cet, ce materials fot reset nel rc nbunseo ct se tegen pon devotes simpementares un pestom de fomar’ Imei artrauts Coetee pre Ununes Europea xs Fede Ein, reprints rn aura Cad Se Cer Cooperate Gove Rome, pit Nite ant Pubic nto an fod emer cir arr peer Pete 9 Servi Ge Sanat (CPS) atte eee 7 Sonate restless Se mes ae oc cnn in get tn iS thSe eee goon oe udddund dene euadeau PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME. 3. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUL CU SINDROM CORONARIAN ACUT NSTEMI ((urere traci avana aracteranginostipifatip CRaetiviate asic) )—> Gains) oor moaressewntet (hist suspic de dree treat de curb noncardiac? ‘ez algromal peta ‘Comport cu ECG mai vechi ww - tienen) = | Sreep092-951 tanec | Troponinal >1SN* ) » > (roponina | SLSN) =D ore (Grace > 140 ) ‘GRACE <140 { 8 Troponina | la 1h Durerea persistentS | ourerea cedeax8 dups | (bs) sau la 3h/6h (Tr) | ups ratamene veatament | -Repet ECs la fieare 2h | J [iosnostcierntia excss | suinardeduee——_) (Frese (roomie) | pon s8t0°) {rt moat resets cestane) | ) incrare _ . | Management mai (era adios (etre dese) | “Tratment sins Asin 2¥32 ¥ | Nroicerns Nitogcerns _ NYA ttn nora | Ancona | (Giemueleaie) (owmwria) [ Sistieare | | petaboant | Betblcarte (tressinambulator) (_dferentiale arcana \ ( szessinambulator, |_aferentiale } —— Consideratiimernares___) ulate * [SH LmitaSuperioar a Normalulu! _Avertament: Aces algoitmrepetet orecomandere de abardo pacientul i argent, dor inocweste udecota cet pus de specie ecru ca wm ‘cet atari ot eet ner roll Indu aa rao stale rspley demesend Sper pom devas impemertra ura progam de fomar’ oc o-vnit pot-un pct pais Ee pt Intrmedi contra Eee port Unluea Europeans et. rect sa drt nba Ber car ne Cn eer ein, repreertas pn ent Ean Se Beare Cooperate i Suvernl Roma, pn ante Pratl Pubic nto Sint Find rpementt elt Cet perv ait Sra o SnaateCSS esate e gemieaz a m z Z a a a 3 a a a a a a a a a a a a a 1 a 1 i 7 1 1 1 1 i 1 1 Scorul GRACE PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME 40-49 18 Creatinina (mg/dl) 50-59 36 0-0,39 2 60-69 55 0,4-0,79 5 70-79 73 0,8-1,19 8 280 91 12-159 di Lieu che) 16-1,99 14 <70 0 2-3,99 23 70-89 7 >4 31 110-149 23 Clasa! oO 150-199 36 Clasa I 21 Clasa Ill 43 Clasa IV 64 100-119 a7 120-139 37, Modificari de segment ST 140 - 159 26 Mortalitatea la 6 luni pentru categorille de risc conform scorului de risc GRACE Beton admisie ence eka Categoria de rise Scorul de risc GRACE Scazut Intermediar 109-140 Ridicat >140 > 3% Categoria de rise Scorul de risc GRACE Decesele la 6 luni dela externare Sc&zut <= 88 <3% Intermediar 89-118 38% Ridicat >118. > 8% http://gracescore.org/WebSite/WebVersion.aspx 2p ‘Avertiment et lari eset cand de abo o pace rer dna ast ict imp de pce ec cat tigen pin seats 6 poactlInburssres elt senor stoi preptaie de means 3b emer un gra de far, po ore ptan part Sn ae si pi) ‘terns Contributes prt Unlues Europea cea. lect erty bara haan ne Coa Fut Emenee rn Ara Che de Sonohare 9 Cooper Gae Romsns, pen Minster ser ace shee sn, tegen te Col parr Pas Sor eS (C5, naa de acecee ae ooo oon uuadag PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, ‘IISS-ROMANIAN COOPERATION PROGRAMME. 4, ALGORITMUL DE MANAGEMENT IN URGENTA ‘AL PACIENTULUI CU SUSPICIUNE DE SINCOPA { evawane | 8c + min examen nevroogie | sigue | | Lnonterzarecontau functiviale 4, Glicemie- Tata hipelicenia 2.Moniorsare lactic continu 5 Hemoleucoarams | Test sorcinalafemeien {3 Management adecvat a8C an _ EVIDENTIERE SELF Crteri de exclude: ) (eeepc Vay | este pete LURE ETOLOGE: ; ww ‘ean ) om | Estoncintet sponaneon | mw |b Sosa | ee 4 poalcanaianstscerearene tpce | Se / El-p onset abt aps esos! | 5. yin melas Ia. reveia/ een | | ramones nee ee (wonsncops >) —w — ——~ | Sraitepcate ¢ ‘olpe abs?) snap ar caus iris ) | conscccende | ay ~ Goudie’) Saunas Ceara) C vee) ‘.Mipovelemie = aint Seca oo on wy) ees (‘wcnasr? ) prise Paton) | ec aomat } seconds revo Zale srucuni card snrt)icmNs | - _ | sesh amiaoes, || 2S reps (ummamnenaycacwone | Somer 2 eeoadeuoopal recs mugen acer / | | 4 Sincopa asocaté cu trauma | ewogeniatend | 5: Ase protons actor pee en | ioe || Stsoneheedecohtnt oe owt seo | (camer ) 2.caroscans | 7 Precodat de papa, ure trac, spree (aa | 2 Staonal mene, | 8 Senne deine bac | ealonenete | cote + | Stans sooo nme | etc | vostro | Ao emer 8 ere seer i) | X —— vio pate seems 1 Tamponad crac 5. tote pulmonar ep | 6 Wieetentune puimonas | oa ann | tear t cies | (erate pentrs ((Pacent ete) 2 Sar deur cbr montarars ssinromate | | Sond rt tc | (Selita san tenaaii sania | — x hemor ded | _ _ 2Treuma | ((BUALUARE SiTRaTAMENT >) | Xn ae ps / [ seuison neconanoks | 4 Se rater ith a = wa ‘cet material 2 ot eet in cdr prolec Inbuntieo cat sero stale respi de medi de Urged pn deotares 7 inpemertares url pagan de fama”, pose onset pnt pats pata ai lt intel Cntr eee pert UnnesEropara ets Poet del mts Aeron Cos Fedor Ehain, repeat ph Agena Een de Deo Copeee Gover oi rn Meister arr Pookie instr isin leer er Cee perr Pat Serc de Snapecss ee eee enna PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, SWISS-ROMANIAN COOPERATION PROGRAMME 5. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU SUSPICIUNE DE DISECTIE DE AORTA Pacient cu suspiciune | de disectie de aorts a . ‘Acces, ECG, electro ureea, >) {cTetindhemoleucogramsgrupsanevin + (Anaigezieiv. yO Examindrl imagistice: ) 1L.CT torace x! abdomen cu substanta de contrast 2.Ecografie transesofagiana — la pacient instabil | 3.RMN 1 - Conamnre ease >) nu _ { Considerati examinari imagistice | Garments |_Ms Sere enpre (dlisectiet de aor \ disectie de aorta persist DA Y¥ ( Terapie betablocanté cu TAs )) (ints 120-100 mmHg J / ¥ Consideratinitroprusiat de | sodiu IV dacé valoarea tint | TAs nu poate fimentinuts | cu beta blocante* Se Transferati pacientul ntr-un | centru de chirurgie cardiovasculars V ale ghidulul european. Nitroprusiatul de sodiu nu este disponibil in Romania. Recomandiri alternative pentru administare iv. continua: nitroglicerin§, urapill wa ‘emt tri fn siti cal plunder cat ener peo pepo de meant ae gerd pnaesore plete na program deforma, pret cofarat pir gar putes Ceti Bh Feral ton represen wn aur Estand de Dente operas Suara asi, pr Mitr Panel PbiceshinserSina fd mplmrtt ects Con per Pati Sere de Sratate (C55 ncaa Se geneiii ee ee ee ee ee a ee i PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 6. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU SUSPICIUNE DE TEP (abl cine eon e rite) on | ow / Insabilhemodinamie tiac stu hipoTAR aur pra sblore (alert de maragenent in urgent a acetl) Insbl hedinaniecuswpidunede TEP) ‘igortom de managment in urge pace “Avartsment:Acstclgaritm reprsint®orecamandare de abord al pacientuli in urgent dar nu ilacuist udecata ini mpust de speci feta coe 3 ‘et mail fos rent ocr ris Jnduneive cals spate presales Ge mei de roe pen denoarn inplmentares una pragam se omer” post oft stn pan parte ti it Fes Eben, rpesrtar rn Aunt End Ge Dela Cooper Gutetnl oman pin Misr Fars Pie nears find pert ceca or peta oll eres Ge State (CPS) cla Agria a a a a a a a a a ei a a a a a a a 7 a a a i i 1 1 1 ! PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, ‘SWISS- ROMANIAN COOPERATION PROGRAMME ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI STABIL HEMODINAMIC CU SUSPICIUNE DE TEP rtrd apne — ‘Taetundemenbret fone Protea Pace susp ch de TEP sera el ‘blu cnc cer es) a peru ice cade au Rae Stl nenedaome OU aae lates ts Sati ne cae ne tt’ an antecedrte eT? 7 “eg Saag AE a ert Sunes ertopoes—_[ aoe Fitts tA ec, robotic opts Ste cree eased stu omens valuareprobabltate clinic pretest de TEP cor Wel sau Geneva) ‘Fartiaare ito; perlads postpartum jr (Qancas Probie Soca nlamatore intestinal niet (pncumoni, | cli pretest infect de tac urna iv) | ined pret ein ptt | te are “Chile laparoscope (x cletectonia) seins moblexela gst >i, moblicareinposhegexinds =) en Shipertersune aera, Diabet faharaObestate reattiy_ posit (Anai-Cr dsponbiimediat) sipermis ? meen lyse " se cota nncs ( 1) vista peste 49 de ani; - DRE ey a _ } Bere em | =) [amass ) 3} edemuniateral de membnu inferior rept | | Rewuitat | | parenteral 8 SecedalSe | os teri nde | 3 ctousatehemcas 4 =a r, + sciruti/intrmediars | | pretestridcata a L ( — Sustinere diagnostic TEP 4 vate Sane ok (eamnsasa > (fe consent ain Feat [amin ssienize *) pierre panne cs scoop senate || teoy amar ey | Consideratiinternarea | - a conte ter cnt ‘Remorse rapes genoa) [rr perinas q— Sonate commie emerage itacanan recent ( £0 ie). U | “inervenpi chirurgie (eurochiurgleale/ ocular recente ($102) Datere hemorage severe Relate: “Tumor/ metataze cerebral su vertebrae curl hemorle ( Procedu mtervent epidural sau vertebrae { examinavvconsutés | (esi sa “Intervenpiciurpeaesbdominale majors 8 oe; suplimentae ag] TWP sou) “Trgumatime mayor sau TEC med over | considerainterare | J Heraraggastoitstil gonto-uiare cent (s 1426) “—) “Tombectopens sever | < $0000/ mm romboctopene heparin induss Hipersersbate la hepaing Tubur de congue precatote Ha severs ncontoat (TAS > 200 mm ou TAD > 129 mii) fndocardt,perenats 4 Averisment: cet lpi reoveanto recomondae de chard ol pacetu in argent, darn noite usecot cic impure speci ec ae 23 ce material om reset nc prec Inbuntre cal soso stoke 3 resis de mend de lige pon denstaresp mpemertares un paptom se omer prot fiat ptran pet sin pres Ee ph ‘nrc cout etre pets Unuren apes exons Poet = carl nba Ao cart ons Feder Een, repeat rn Aero Chen de Deolare Cooper Goer Ron, pn Minster Fesrear aie Minor Sis nampa ete Cer pent Pal Se erate (CPS), Inala Se gee astemesialtny Secugi PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI INSTABIL HEMODINAMIC CU SUSPICIUNE DE TEP Contrandcati sl watamentull anticoagulant: ( —) Absolute Suspcune de TEP pte ee Hermoragi acti (cerebral, gastro incest, gento-urnars) (blow cine factor de rs) emorgienraeraion rece |= 10 le} insted emodinamic Intervet churgele neurohurias / ocular) recente (store) Diatere hemoragice severe Tumor metastare cereale su vertbrale cu ec hemoragic Procedur inerventl epidural sau vercbrale _ v Intervet churgelesbcomiale majore = 48 ort; (feparn nange a ‘Traumatime majre sau TCC med / seer Ceara We ‘Hemorop gastontestinale /genito-rinare recente <8 — zie v oa Tomboctopenie ever (<$0.00/ mnt rombodtopeie wo — heparindindusd {Antec dsponibilimedat? ‘hpersensibitat a heparin Tulburii de coagulre = preoxstene STA seers recontroat(TAS> 200 moni sau TD > 20mm) Endocardt ericardits Fcoczrlogate | fst semne de nctrare de VO? Ecogaie cu compresie a membrelerinferoare: {xi seme de TP proimals? _ nw on ns ) (Cesena } Contrainte tratementulul trombelte: Absolute saceiden vascular cerebral hemovagicsau accident yy ‘ascular cerebral de oc tp nferent de momenta producers acestuia, acide vacua cherie ‘ produ in ultimele nt ‘len ale sstemul neros central sau neoplasm ‘traumateme majors recente/ interven hitugele/ = = lesion ale caput nutinale 3 3primdn shemorap gastrointestinal incurs ultmel unl — ‘sc hemorgi eunoscut (-_Terapie rombattes Interare ) | secautbate cure de Relate { tatenets contains) ‘ecient chemi tranatorin ultimele un = . insabiltate emodinamics_) atament cu anticoagulant orale rena sala mal pun de 1 sptimdnd de lanastere *locde puncte necomresi “revustare treumtes ‘hipertensunerefroctar (TAS 2280 mmig) ‘hepatopisevers,endocardite nfeciots ‘ulcer peptic aut Avermen: cs iar presi resomandar de shor penta arent der uli ject cing de spel fcr cot 3/3 est mater fost elit nel pre neue ot serio spate rele emesis de Cr pe oa sports al ron ear pro ntar ptEet t aeS Fer Een representa rin er Even de Devote Cooerare uel Ronde, rn ner Faro bie ne Ssh nd panama clr Caren pert Poel Servs de Seas (C5, neal ce AgerePROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 7. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU DISPNEE (—woumert >) Esa) —— —, omesgeante OS (esau po Te) vy ee { “nat zene singe sete nem UN maven?) a met | tee et. | wa ‘ce matali nce plea mbundcs cl serra pesos de mein de peril pan devote» mptmentarce wa pragram defers’ poet cara pean rar dn pres Cee ip imecme cnt Chefene pote Unhee aapean nish Pcl rth bea ears ne Co Feser een repeat in Agri tvtand de Denote Coopers Govern ami, pen Meer nse Penne es firs pemantst Se te Crt ont POWs Sere Sate (CSS, aot Se ENCSes ee SS 82 oH ee ood od od PROGRAMUL DE COORERAEELVETANO-ROMAN )MANIAN COOPERATION PROGRAMME 8. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU ASTM BRONSIC EXACERBAT Inoue invader aac << | seni t tot sons) ‘tre aurea) Ineo | (Gipeninamer petit) (eee, os ) A085 me pint) oe | Stn este SotiSiinve aa Fn vd Sanaa Feaerl tan rprertt pon Aeon E re cern pee Pii Serle Sent (CS) eatte eerie Paes Mester insti Rind ener ‘eet matri»fteet ocd pric Intute a senor SpOleT reset de medi de ert gon detotea semertare ul pam Se fama, pre cotarst pntvan part an pats Chel pt ‘seemed! contin thefene ports Unies Europeans et Pret drt nbs Arcane CesPROGRAMUL DE COOPERARE ELVETIANO.ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME Clasificarea exacerbérilor acute de astm la adulti dupa nivelul de severitate: ~ Variabilitate larg’ a PEF Exacerbajri tranzitori ~__Atacuri severe, neprevazute, apSrute pe un fond de astm bine controlat Exacerbare moderati. —[- _Accentuarea simptomelor ~ PEF > 50-75 % optim sau previzionat =__Far3 manifest8ri clinice ale exacerbérii severe Exacerbare sever’ = PEF intre 33 - 50% - Manifestéri clinice ale exacerbarii severe: ~ PEF <50% - FR> 25 respiratii/min = Sp, 292% - Puls 2 110 batai/min - Incapacitatea de a termina propozitit dintr-o respiratie fies Exacerbare ce pune Se eical PEF < 33 % PaCO, “normal” sau crescut SpO, < 92% (Paco, > 35 mmHg) Silentiu respirator, cianozé, efort Hipoxemie severa (Pa02 < 60 respirator slab mmHg) Aritmii, hipotensiune pH sczut sau H+ crescut Epuizare, alterare neurologicd Avertment Aces aigritm repent recomandare de obord 0 pacintu In urgent anu inlocuist judecata cnc impust de speci era coe 2 ‘cot tava fos reat ocd roecuhs inburdpen cl sei ptr pepo le made de lrgert pon denaors si npementar nu program de fae rect conan in gran partes See! pit Icon! conto heen pre Uns European ears Pro ea ert bara Aarau eae on Fesorl vetan representa Can de ebchre 5 Coopers Gavel am, ph Minar Slr Pubes Mosca sss nd impemertt ee Central pen Pa Seva Ge Sart PS) naa de ate angsty ieSees eee eos oo eeu dando PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 9. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU BPOC EXACERBAT (ew \ | antay seven emcrbine | eure soar, (mak wmeinc))_O* ie 087 { Tener eae eee = etoteapi em | ((sepoam enema?) ny Seach ere — Pm SOE) mena . +) {ieee pat acon ams nated (Gielen Avtar eto ecoondr orden ara doubts ining ec fcr in ‘est material forest ner rie Jnduntiea came seo spot respect de mei Se igen aon denies mpementars urs progam Se omar" pact oSrartptan pnt pats hi pl inermec cnt chee pres UnlanesCuropesna ts. rol ra Gut mba Acre ve Cons Fer Even, rena rn Agana Ean de Sencar Cooper Gurl Fomane, pn Mino Fare Pb moitenuiests nd emer ecient pea Pll Servis de baa (CPS ncaa se AgereClasificarea sever PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME exacerbarli BPOC Nivel de severitate al exacerbarii BPOC Gradul necesar de interventie medical de urgent Cu tratament la domiciliu Nivel | Nivel I Care necesita spitalizare em Care necesita internare de urgent pe TI pentru insuficienta respiratorie Clasificarea GOLD in raport cu gradul de limitare a fluxului de aer bazat pe FEV1 dupa administrarea de medicatie bronhodilatatoare: Clasa GOLD Gradul obstructiei Spirometrie GOLD! Usoara FEV,2 80% pred GOLD Moderat 50% < FEV, < 80% pred GOLD II Sever’ 30% < FEV, < 50% pred GOLDIV Foarte severd FEV, < 30% pred FACTORI de luat in considerare la externare/internare: Factor Tratament la dor Capabil si se ingriieasc& la DA domiciliu Gradul de dispnee MODERATA SEVERA Starea general BUNA INFLUENTATA/ACTERATA Nivelul activititilor desfagurate BUN INFLUENTAT/LA PAT Prezenta cianozei NU DA ‘Agravarea edemelor periferice NU DA Nivelul de constient& NORMAL AFECTAT Dependent de 0, la domiciiu NU DA LOCUIESTE Statusul social BUN SINGUR/NECOMPLANT Sindrom confuziv acut NU DA Ritm rapid de instalare al NU DA simptomelor Comorbiititi semnificative (in special afectiuni cardiace,DZ NU DA insulinodependent) $20, < 90% NU DA Modificiri radiologice ABSENTE PREZENTE Nivelul pH arterial 27,35 <7,35 Nivelul PaO, arterial 2 55mmHe. <55mmHe anasenu shun eae. 22 Avertment: het ort ers 9 recomondae de bord ace n urge Sr uci eatin ins peti ecco ‘ease material» foe resto eae plea intunatoen cla seri san pests de mend de Urgent aon derwtoras imolomerttea na program de formas ret cotiarst itn get Item contrat Ehepone pets nuns uropenn enh Molo der m bra ena Con ‘earl Ehet, repeat in Agneta de Oeste 9 Clopeare Sure oman, pn Minter nfl Puce ens fred plete arr entra Pat Sr eartat (PS), eae gee pares CenSuS SE UUUMOUNEEE EEE ddneunduduuuduud PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 10. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU CEFALEE ces codec te | rite cate semen eer [ees me | ((‘sonesep compart cu epsendee cea rer ( eetmen ine arrma | 2 St ste conse | | eter cow op fs chet epi eriktae de anit cafe sine de meng (czme [ESE Citron oiiecenersamaesxmnog) | (mbar) Sere dearest | (ec weirs) { feetassea) | Sevoma (aise ((@amen uri nals ( Ste commat J “yaar —) carcasses —{ ( ortoos Comite cade sipcune de: ) ars mba | inva cepses) «ge / eacote hema SS seondornamse cos noes) a ne ato a(n ) wreiceaamas” ) _Avertiament Aces igor rere o recomandore de abord ol pacientuln argent dar nu ilocuiste deat clic imu de specu feral cor wa ea mater fot eset nc pris nbd ARN servo seg ¥ prea de med de ‘roe an denon mpementares url rogram fra” proe corr ptan grt dn prea Eel oe Dubie Ninel Sn Rnd plement ete Col err alt Ser de Sot 659), cali eeewuuuuwu PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 11. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU STATUS MENTAL ALTERAT NONTRAUMATIC (SMA) seni le ema arrye) Montara htle vite TF FTE treet Sp: | iste se (Goan) (TEE wa ‘eet atrial fos eben cad proestfnbundpes cl sericirsptae pesto de mend de edn ders implore on rgram defo, oct cara prt part en pres Ee pn termed! conmbut Evetene pons Unies Eopeana etna Poet ert nba Aoruasr re ons ‘tral etan rpreceras pin Ager Een Ge entre Capea Gover Romi pi Misr! Prange ney mnstenSnd find parts eS Cen er Po So de Sia C5, ncaa d aeroSERB PERE EHHHEeeddeuuuuuduudg PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME 12. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULU! CARE PREZINTA O PRIMA CRIZA CONVULSIVA $I CARE A REVENIT LA STATUSUL NEUGOLOGIC INITIAL (fard febr3, cefalee sau trauma, cu semne vitale si examen neurologic normal dupa perioada post-ictal8) (_ Prima eriza convulsiva } = *Evaluati: medicatie curent3 | eerteona | trauma recentd, posibilitatea ‘Anamneza? unui supra-dozaj medicamentos, a posibilitatea expunerii la CO, ye aleoolism, antecedente de AVC, Electrolii, ECG malignitate, diatez’ hemoragicd siimunodepresie. Tratati tulburarea metabolicd sau disritmia gi internati pacientul ‘ntr-un serviciu adecvat ie aa) Tomografie computerizata ‘Anomalii structurale? al — ( Observati pacientul 4-6 ore | ( ——_* 4 (considera terea adrian . — | medicatiei anticonvulsivante j«———{__Convulsii recurente? (__ mectcati rer ((Pacientl este tn cortinuare cu status mental (e bazé nemodificat si cu serme vitale | normale? "Poate fextemet in siguranta?™ NU Consuitatie/Internare| intr-un serviciu adecvat Evaluare in ambulatoriul de specialitate Re-evaluati reconsiderati diagnosticul diferential al crizel convulsive “Avertsmant:Acestolaitm eprzintd 0 recomandre de bord al pacentuli in urgent dra inoeeste jusecota clined impusd de specific fect coz wa ‘cst materi fos rent nel procul Jnbuntire calesror stale prespacey de mend Urged pm aesoora mpementares una pagram se omer” pele oan prte-un port on pata Ei Pn su Ehehan reper pn Age Cea de Denote Cooperate Gavernl arly prin Mintel rte Pte nse sn nd emer cai en pt ol Ser s Sraate (C5, neal e geesea ee ee aed adu adda ua a PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘WISS-ROMANIAN COOPERATION PROGRAMME 13, ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU ACCIDENT VASCULAR CEREBRAL ISCHEMIC Deficit neurologic focal la momentulevaluri Glicemia < 50 mg/d Glicemia imediat Glicemia 250 and =< 400 Glicemie >400 mg/l Tata hipergicer Tratat hiperglcemia acd debutulsimptomelor <4 5 ore, apeat neurologul slefectuati HUG, coagulare, grup sanguin Evalati cauzele hipogliceriet Urgent CT cranian fra contrast Urgent angiaCT cranlan (dacd este posibil) Hemoragie la examenul CT? NU. Defiitul focal remis? ‘Dacé TA>180/120 contrlul HTA* Paciental nu este candidat pentru trombolizs Iniernare pentru evaluare sitratament Paciental nu este candidat pentru trombolizs DA ‘riterl de excludere @ ‘ombolizel pentru intervalul de 30-4. ore dela debut” Este pacientul candidat pentru trombolias? Nw + Completatformularul pentru criteri de incudere/excludere + Completay formularul de cansmtmant al pacientulul Debutalsmptomelor> 30 ore? “Administra TPA scontrolay! TA conform protocolulut Nu Internal paclental nro unitate adecvata statusull clive al paclentlu (arse paces Unitate pentryurgente neurovasculare sau terapie intensiv8 disponibile local? Ineo unitate adecvats * criter de excludere pentru interval 3-45 ore de lo debut: Vista > 80 an} Istore de AVC si ciabet Utiizarea oredr anticoagulant Miss >25 (CT eu hipodensitate >1/3 din emisfera cerebralé _Avertamen: Aces igor reprtint o recomondare de obord a pacientl in wgent, dor iow vdecta nic mpuad de species fcr cat we Tnternare in unitatea adeovata statusululpacientului ‘Aetmotril a fost ain in al pro nnd a err stale pepo de medi de tigen aon dentro mpemertare nu program defor roel cna Patan gat part Eel pin ‘ere conn heen prs Ununes Europeans in Prada etn bara eaaubenes ne Cos Foie Ehetan, reper rn geri Cen de esos fCaoperre 9 Gave Romses pen Mint nat « Die shart hy ine implants eS Cot prt ol Ser State (C35, ncaa de geneBEEP E EHP HUH UR ee eee PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, SWISS-ROMANIAN COOPERATION PROGRAMME In 20ND TRATAMENT — ‘Analt pentru tof pacenicu AVE bx neuralgs complet: ‘Management gener 2 2 Eco; 590, —y HLS 2. penta pacientus caplet a 30; hema 3. adm. oO, (5m 3 SPO? «95% | Bleweete: dou ni intravenoase una ev NaCl 9% 5 gnome xaminare pacien | cela va ut pent adminitrarea icemie; ‘Anamness ‘vomboitiull, 3 probe hepatce GOT GPT; 2. Excinc general ERG in 12 aera 10a neurologic minor NSSCS 2Simptomele remit spontan 3 Dewars fort in som su nepreciat “tye atu AVCinultmele3 un SMA in otmele 3 on G emorase gest sau uriar in levee 3 apt 4.lear gastrointestinal confirma in ele 3 on Sinerventi eneurgsale major in limele 3 a Sinerventi neurchruracle nel 3 un {0.neartrale noc necomprese nivel 7 le $store de emoragi cerebral [ETA peste 180/120 mig {avtoumatsne acute a exainare au singer statement ascoogulnt cu INR>17 1S Heparins adm nice dh 36-eerie sub Somes rrHematocre 25% i. emboete <100.000/mm" £.Connlcu sa fr cei neurite ultimele Gn Dasari, aster alptare 2.Ditere hemeragiecuneseute 22D nerogce severe (cor BARTEL Su 6) 2Rndocreit bacteriand sell, parca +09 megs Simen 30 aa iv-bolis 20% ‘rest dotl SE 1h peering lets intro s evauare nevilog: mp de ih J Auertament: es prin eset comondoe 8 bord pacer irre! corr Sheen errs Une 5 coagulograms 4 sabres moment trombotcull ack se consider sou se art debut antipeaa ci va neces ba 5. Dg Serena ‘cited excuaere >) ((trasamenrut HTa In cazutPACIENTULUI CARE TNDEPUNESTE CATERILE DE RONBOW "AS = 185.230 mmbaTA © 105-120 mig + ABETALOL* {© 10mgin 2s poste epet la 10-20 min © dora maxi80%m@ © Sm Se, se poate crete cu 2,5 mea S5min © dora medi 1Sma/ (ota mcie de tretinte 3 mg/h 1 10rmgivd (1-2 sin rapetat a newoie a -10 min pd la mani SO mE © lanevoieseadminsvenn continu, penta TA sot de 260, sng 100 mg Uap ee civead cu NaC 0.9% pa a 0 ml (2g) 1. dora mele de inretinee 8 mg/h fn func de TA sto] SLABETALOL" (© 10mgin 2min se poate epet la 20-20 min © dorama Is0%ng “eNICAROIINA 1 Sma/h ad. cont se post crestecu25imglaS.15min © dove ax 35 mg/m 2 dom deinvetere3 mg/h - URAPION, 1 JOmsivs 12min repattla neve la 5-10 min pi a mann SOE © fhneoie easiness continu, pentru TA sts de 160 mn 100mg Urap se clluead cu NaCl 0.9% parla 50 mi [mg/ml dana ‘mesie de tretiere 3 gh in feted TA sites] “|NITROPRUSIAT DE Na *- 05-10 /hg/in (20-600 ug/g) + aac este sponit ee arene {EU be ecomandsadminsraesin sop preventv a mesial ‘ANTICONVULSVANTE 2. NU serecomandh adminstraes de GLUCOZA ct pat cu ipa 5. NUseadminstrests ASPRINA sav HEPARINA pale elgbl pnt tronboak 4. Febase tateand oy ANTIPRETICE: PARACETAMOL 5 Dace num potensiune arterial, fudele bul adm ex proder MTA NU se tratets cu nogiceng ulin ares dunce dena cd put de specced cat ‘cst matron ned procl Indu cal seco spate prepa de mes de gent pon dee npementars ur psgam Se omar roe! oft pntun got in ate ei pl Feder Beton repeerta rn era Ee Ge Denoar Cooper Guetrl Romani, pin Mince Farsot Pubes Sins find mpamerat deca Cena pert Po 9 Se esante (55), meat de Agere 2APROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 14, ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU TRAUMATISM CRANIO-CEREBRAL ( Pacienteutraumatem cranioceretral_) Nu (Furctivitle tabiPABCDE (samme) . vomaguereren) > Saba Management dure (fewest ains) (Teeminori6es> 13) “ Ceca pf tec ever 0 \Lss38 1c moter oon ( ee cu seve pt) iad non de eat) | —Y_. Aeon peor Paden) | secur | indetneste | Arter conn | stent pets ee {cron | Nomorteni (omer const | | Nomorentge | 7 . 4 pone eval cpa ww 1 | dotdacb este postal | (Faden) a a _ wy | tepinege |g MY _(~Barnent readers) Y + chatteperre [| terun muccineplet i see deere — imines? a Pye { internare pe secide) ¢ | newochiraieehirurie) oa leat > rewrochurgu/Transfer (ch | estenecesir) (acientulindeplinege tate) NU —__) eee cere penteu | creranian ra a ove (‘weemare 52) | seta de top inant | | nercriurge_) *107 poate fnecesar3 in unele situa gla acest pacienti (ex: vérsituri agitatiepsihomotorie,convulsi etc) Avert Aest lar resent oresomandr de oor a pasetlsin gent darn Ineee atta inet mp de spc ec cat wa est motel» os reat ned role Inbuntes cl sector tang pepe de medind de trgen pen denon 7 mpementre na saya de omer’ rot cofnarat ian oe sn prea Eel pin lee carr Chere pert Ununes Europes xa. Stet ert aca ena Cont Ful Ehehan,epenra rn Aart Chen Se Cenohare Caspers Gaver andes p Miner ears Paes Mor Sinai, inmate ve Con ert Pai Se: e Sate (CSS ata de gee"sss see eee eee eee eeu duunduud PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME *Criterii pentru CT - Oricare din urmatoarele: Nivel de constientd alterat care nu se datoreaz8 clar unel intoxicati, statusului post crizé convulsiva sau unei tulburéri metabolice = Deficit neurologic focal - Tulburéri de coagulare (coagulopati, tratament anticoagulant) ~ Suspiciune de fractur8 craniand deschisd sau cu infundare ~ _Istoric de interventie neurochirurgicala in ultimele 6 luni + Cefalee progresiva Mai multe de dou episoade de voma = Semne de intoxicatie (droguri, alcool, etc.) = Convulsii postraumatice - Traum’ facialé sever’ - Politrauma ~ _ Istoric neclar al traumatismului actual Orice semn de fracturé de bazd de craniu (hemotimpan, hematoame bioculare “ochi de panda’, semnul Battle, otolicvoree, rinolicvoree) - _ Pierderea cunostinfei cu duraté peste 5 minute ~ Hematom extensiv subgaleal Amnezie retrograd8 a evenimentelor imediat anterioare producerii accidentului, cu durata peste 30 de minute **Deteriorare - Semne de deteriorare: - Deteriorarea semnificativl a nivelului de constient’, + Semne de herniere: anizocorie fara trauma ocular§, colaps cardio-vascular, tetraplegie Decorticare, decerebrare *** Criteri de internare — internati orice pacient cu CT negativ $i oricare din urmatoarele: Nivel de constient§ alterat care nu se datoreaza clar unei intoxicati, statusului post crizé convulsivl sau unei tulburdri metabolice ~ Deficit neurologic focal - Tulburéri de coagulare (coagulopati,tratament anticoagulant) = _Istoric de interventie neurochirurgicalé in ultimele 6 luni + = Cefalee progresiva \arsaturi persistente = Semne de intoxicatie (droguri, alcool, etc.) = Convulsii postraumatice - Traum’ faciald sever’ ~ Politrauma ~ [storie neclar al traumatismului actual ‘#64 Criteril de externare ~ puteti externa pacientul cu CT negativ dacé toate criterille de mai jos sunt indeplinite - Pacientul este din nou cu GCS 15, = Niciunul din factorii care impun internarea pacientului nu sunt prezenti (vezi crterii de internare}, + Exist suport adecvat pentru transferul sigur al pacientului in comunitate si pentru ingrjrile ulterioare (de exemplu, supraveghere competenté la domiciliu). sueresment est rit eat oeconandoe Se str pacentuin rg dor nance just ce inp sei et cat 2 ‘Ast material ot let nce inbuniea eat senor soles » peta te medi de tigen pon denotes mpemertars un propam de fama, poe soar pt at in aes os poh Faden Eben, representa prin Ager Cen de Devote Capea Giver ors, ph Mens Fare Pale ans Sint, Rnd mpamerat ere Cet err bat Sou ge Sate CS), mca de Sgn vanesanutsocM Secu(comin apne nas ** PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME 15. ALGORITM DE EVALUARE IN URGENTA AL PACIENTULUI ADULT CU TRAUMATISM VERTEBRAL CERVICAL (page Tanah =< est Tre ex Team ata panes, US ‘sh mean CEN DE ALES? ave nro), ae ules unn ahvenewate cares laehlet sonia reamed, sera vet, reer eeu nl ste ee chelsea even urge pers traumatism) | 1 a i 2 ESTA ONCARE FACTOR DERSCSCARUT? ESTE POSBLA ROTADAACTVA NEOUREROASAA ‘anu cv4s Aste $1087 aya cere Scns a Otero Sercomand ia 1 on (atop ene ay ea wench er wea | oy | eo nese) ‘us ova care of | races noel senrsasicinmed—| (Lo seecestenie") osu cto simvsneaminuasisnce | we Avetament: et lori esi orsoand de aarp nents dr nnn user cine Ings de specie ec eat ‘eat mater frt reat i cael poet nbondteo ct serlr sates erespaiest de medi de {ond gn denotore i plomataes unl rogram de fro, pre conan inn atm putea Chet pn ‘eres continue ine peer Uses eropeana etre Peet crt nbn Horan art Feral hein, presrtanp hgeaCetand ge Deter Coopeae Guerlain Mitel Fat teins Snipers eS Cot err Paty Src de Shatate CSS ata de gee wsrenut stoniii ee ee ee ee ee ee ee ee) PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME *Mecanism traumatic periculos - Cadere de la 2 1m /5 scari = Presiune axialé la nivelul capului (de ex. scufundarea la adancime) - Accident rutier la vitez’ >100 km/h, rostogolire, ejectare - Accident cu vehicule motorizate recreationale (ATV) - Biciclist lovit de masin& ** Accident rutier prin tamponare simpla din spate, EXCLUDE - _Deviat pe contrasens = Lovit de autobuz/camion mare ~ Rostogolire - Lovit de vehicul cu vitez’ mare *** Canadian C-spine Rules (CCSR) - _ Este prima alegere in selectia pacientilor adulti cu traumé, care necesita investigatii imagistice ale coloanei cervicale care intrunesc toate criteriile de includere si nu prezint8 niciun criteriu de excludere = Specificitatea este 42,5%, iar sensibilitate este 100% ~ _Validitate si eficient& in utilizarea sa in prespital (chiar si de paramedici) sin spital (chiar si de asistenti) - _ Criteriile de includere si excludere destul de restrictive (de exemplu nu poate fi utilizat la paciente gravide sau la pacienti cu boli vertebrale cunoscute) ****NEXUS criteria Criteriile de includere si excludere nu sunt atat de restricitve, asfel c3 NEXUS poate fi aplicat in selectia pacientilor care necesitd investigatilimagistice si la care nu pot fi aplicate criterille CCSR (de ex: gravide, pacienti cu boli vertebrale cunoscute sau chirurgie vertebrala) ~ Specificitatea este 12,9%, iar sensibilitatea 99% ( mai mic decat in cazul CCSR) Principala limitare este determinat de definirea imprecisa a celor cinci criterii, ceea ce determing itate in interpretarea si aplicarea in practic8 vari Arete: es lpr eprint cman short. petunia minded niin de special fer ct ae cst mail ot ei in aa poke nbd cat ercor salen pete de meds de tigen pen desta implements una roam de fare, poet coarae rian ra prea Chel ph ‘termed carro Svcs pervs Unies Eropeata ees Prec a dara h btn Aun ie Conta Fant Ehein, represent pera Cent de Dewoate Cooperore Gover om pr Minster Free Dts a ed no ole a rc ste aPROGRAMUL DE COOPERARE ELVETIANO-ROMAN, ‘SWISS-ROMANIAN COOPERATION PROGRAMME 16. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULU! CU HEMORAGIE MASIVA POSTTRAUMATICA 7 a TAs<90, Réspuns nesatisfactorlaresusctare volemics! ‘Suspiciune de hemoragie major8 activ (150 mlm “Declangeaza protocolul de hemoragie masiva | ee |. Aertarea echipelor de speciaitatet 1 Recattare probe biologice: grup sanguin, biachimie, hemoleucograma, PT, APPT, Controtul hemoragiot Resuscitare Ac calle Fibrinogen, Gaze arterale, Teg/ROTEM aeriene II, Comanda: Kit de hemoragie masiva B-respiratia | 1, Administreaza acid tranexamic C-clreulatia Daca pacientul este pe tratament anticoagulant luatin considerare antagonizarea acestuia® oo ; ar | Monitorizare continua ansamentconpresw | (“Aamintavare de preduse de snge Anlcare de grou peer Fxator pelvin | kit de nemoragie masiva | Siabitzara racirlor Consider produse do singe © negeti Laparotomie de urgent Consierat autoransuzi" | Temperatura 36 © ~ ~ Prevenirea acidozel | Prevenirea hipotermicl” pentru hemostaza a Chiurgicala Y | Hemastaza prin radiologie - —L_ — (ePrss J { intervenfionale ‘Singerare continua: ~ — a ‘Se repeta analizele relevante pentru coagulare: emoleucograms, PT,APTT, fodnogen, Ca ASTRUP, TEGIROTEM (dace sunt disponibile) | (Asa Tease oe oer ounT (( Baca rezutatele do laborator sunt disponible) disponibile Daca ‘Administra || Hope 79 Mass erroctars ‘Aministrare de produse de sango | Kit de hemaragie masiva I Trombocite < 60x 101° Masa trombocitara i snttepoa de Cropresip PT>1.5,APPT>1.5 PPO(15-20mlkgc) | ee pe ee aceel ea a Fibrinogen <1.5 gl" Crioprecipitat (2 unitat) Cat molt CGluconat de calciu i =a { Continuati cictul de monitorizare clinica and la oprirea hemoragie! Administrali produse de sange ghidate in functiede | rezultatele de laborator ya “urgent prin dezvotareo 31 implementarea und! program de formare” prow co-tnantat ptr un grant ain partes Ehetii ain ‘armed Combi! Eheene pete Ueunee rears eer. rela drut ba Arua in ae Fer dans epeertt in Aes e eta Coperre Gaver Ramis pi Winter Pratl Pate shiner hai in pleat er Cotl prt oti Send Saas CPS) ncaa de geePROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 1. Raspuns nesatisfacator la resuscitarea volemic&: ‘Administrarea de bolusuri de 500 ml de solutie cristaloidé cu mentinerea: = TAse 90 mmHg sau - puls radial absent sau alterarea stéri de constient§ fara semne evidente de TCC? 2. Echipele specializate: CT, transfuzia, garda de chirurgie, ortopedie, chirurgie vasculard, radiologie interventionalé, chirurgie plastic’ 3. Kit de transfuzie masivs. Conform ghidului European din 2016 se recomanda utilizarea kiturilor de hemoragie masivé cu continut standard de masé eritrocitaré/plasma/masi trombocitar& la un raport 1:1:1 Continutul kiturlor se stabileste de o comisie formata de medici de urgent, anestezisti, chirurgi si hematologi ‘Componenta chiturilor va fi stabilité prin protocol la nivelulfiecérui spital, respectand recomand&rile ghidului European de transfuzie masiva, 4, Administrare de acid tranexamic iin caz de < 3h de la debut 4g Vin 10 min 4g Vin Bh 5. Tratament cu anticoagulante orale: Warfarinice: vit K si PCC* i Xa: PCC* 25-50 U/kg : Idarucizumab, PCC* 25-50 U/kg, hemodializé sau factor Vill *Recomandarea ghidului European este de a administra PCC (complex protrombinic), in lipsa acestula adminstrati plasma proaspat congelats (PPC) 6. Autotransfuzia 250 ml de singe autotransfuz 7. Tensiunea arteriala sistolicd tint de 80-90 mm Hg este recomandaté in absenta traumatismului cranio-cerebral asociat. ‘Lunitate de masé eritrocitars 8, Prevenirea hipotermiel incdlzitor de fluide IV ‘incdlzirea externa a pacientului . Trombocite . in cazul asocierii unui traumatism cranian se recomanda mentinerea trombocitelor > 100.000/ mm3_ 2 Avetmen: cs lari presi recmanr short pant in ore uncut eat cnt nus dpe ec ca Acs mari fs reli nel ric Indu cals sptles preps de msde ‘igen pn ar inner rin eo po ora ean get pees pt Feder etn represent pin Aero Ein Ge Deolae Cooper Gurl Fonsi, pon Miner Fras ble tite srt ne mpemenat ecient pet Poll Sel ge Srdate (CS, nea Se Ee sanctum CA SoeurPROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME 17. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI ARS miner acces vero adest Temperatura > 3: preven hptemie \ Feast corsage po) [fanned alee ) earners an aa Cate pct a XSCTAank agua ace ‘Sour mode: meripalpriane® ont le | tees mend de eon | monic ann | (tends nt av tore de vant cee un {Tanessicite ropes cra cons etsas | | Eeieningundi eed a ) | ute proven ce eset) | Montreal, etry, tempeh ) | varsttan | = S| a, Vite evar > scra 3 Comorial precete - S| anutonan sora | (= cates suena sae stp ) | Sarat ga | 1 eesrenpuoinerte hore 6. arr cheferenl sou lear ee | 1 dete tetera spre aerate | ica, tt maton ental so peut | 1) Reeders hdl Forma and ence | ¢ Teatamentul durert |B. Asocierea cu trauma semnificativil | 5 emitter co ee aoc | Probabitatea de enn nhalatri? >, | “Imposbitatea de a controle dureres? J ‘Apart oalintoersi? Transfer . —___) nu la Wace en anes | Tratamentambulator cn | ) membre nferioare a —_ foi donals 2 | 2c, membrespefoare 7 1ie-repunea genital ; — _ I * eves racine ee |. -nemoteucograr ees a VolmuldeRingertacet || _pemaleveoaram | | erae ant abdomen Ainbx CTA x retake) | Zeaagulre | tddonls | ves | “taba erbo, eta) 1496 membre nerioare | sole || ope cor-pimin | | 2% membre superare \, cs 1% repnes geal Inprimle Bore uatoarele 6ore || cr caniutorace-somenfraums) _Averimant: cet olor reprint orecomandire de abard pace ie wrgent dor nu ileus deco ced impusd de specu fcr cot ut ‘en atrial fers in arpa nbunclen cond sec” sae 5 preset de mens de Se pn ana sparen na ron oa poe tar ah Pa Ea Feder Ehetin, penta pn Sgei thetnd se Dero Capers Gaver oni, pit Niner Fert Pubic nnn ne impoantst Ste Cart pert Pay Sercl oSarata (CS) matt de gre avsnu sou meniii ee eee ee ee ee ee ee | \euncrionat sexiricarw) ~ PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 18. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU DURERE LOMBOSACRATA ACUTA NON-TRAUMATICA tos set durere lomars Ta re we (btinerinormap store eveniment Ider ston de rie famine lini comets (dimes sereiai >) (@ onsosre orERENmA caer or pata gerne A ptogecae grrr focal ee “ biliopancreatice, nefroureterale, | (CA ei ater lombact = dure AS etadetelopbad duel — aorice/ vascular retopertoneas, | Detcondc cont agrorice stnconsats rls (~ounenenespecirica ~) aN Consider irvesigati smooerath rina oercr | (fadogsti ) pentruidentficare cuz specie | | __= pentru exciodere ate afetiuni | Bilouic pentru preciare cuze specie SS est fat henogana _ ; (— Wit cewrens >) (tenses watament >) (Comino cinemas JPA terse nt isponta | ecamandat e mee de ween) I Dae neg emt \ flare newoeniels carter) wy — (oscil dca? )——PA pt (ea nso “ }—2_p ) (caer earner nee?) ‘or wi (See name ba doe (Set nace spaue ("s-orive = ALARMA® ptr éuerea lombara iret a0 250 0) Durere> 6 éptimini Susie deinfetie spinal muy _,_ = Antecedente de cancer | Vint <18 sau 50 ai? ) ¥ iran = seta | Dorere> 6 sptimin? ‘apnea nce ; . Durere continud refractars | YP (i ricare ain intrebiie de mat sus neste“ 3 ; YY ARadiografi ) ude genta) [Resteaeiaersepere | CAs) (cat oan “cttadetwnntonoreme | -—puaigag >) | Sieyoecttn iotaaepees | (Sms ) 1” Averent: est grin presto raonondor db obra aces prt dru cue jet cn mp pee A est mtr renlit neal prlectusJnbunie ott servicio spe 9 pepe Se med trae rin dente mpemertares un program de frmare pret co ara pron rat npr el ih ‘termed Contra Cheene prs Unune Eoopeana ea, ret Gru tas here Cosi Feral hota, repent rin Agri then Se Deore Cooperate Gut Nomirt prin Minter inne Dice Mnsen Sty td npn i Cond pert oil Sens Se Sistas CPS net gee sousree stv GeetPROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS ROMANIAN COOPERATION PROGRAMME 19. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI CU DURERE ABDOMINALA ACUTA DDUREREA ASDOMINALA ACUTAIDAA) REZENTATA LA TRAL ) (OEBUTe48H,PANA LAS 2LE) -TRIAJ CONFORM PROTOCOLULUI NATIONAL . (=a) Samoa ve (cht) | Ine Ana SS oomm' atc cu enr> Teoma (oe A) {520 000/m stat eu CR > Som | Cetoaonjnm’ sate Pchomat_) ((aiponaisopa) (Crapbtrconuten) ES asa darsnn) So pF {(CTABOOMINO-PEWN + CONTRAST Nive 8) copa (consurr onRURGICAL (ve {(arasoscomi owGNOSTICR (wit) (TRATAMENT CONSERVATIV =) —_(aTrTUCINE CONSERVATIV TEMPORAN | DI=INTERNARECRUCACHRURGCALA) |_ITERMARECOMCAMEDCAA,) GU RERVALUNRELA 2 2 Auertsment het borin repeinto ecard de sored open er dor nine udcata eines ine e pce ect ot cst mati ost eet in cdr pleas inure cata sano eto prepa de meses de ‘roentgen censors mpementre na propa de ome ret cian prin ran pares Cel in imermect Contre Eee perry Une uopean vrs Pcl a auth its Araceae Cast Feder Eh, reper pin Aer Chet de Curae Cope Gaver Romin, pt Minter arlar Paes snr Sins, na implant Ste Crt prt oie! Sruc Snot [CPS neta gee"== BEEN MMMM PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME. DDUREREA ABDOMINALA ACUTA - CLASFICATA URGENT" - CU CARACTERE SPECIFCE LA EVALUAREA CUNICR ‘Management diagnosbcin urgent i (Vina) some) (rs pn) (etna) (rg \(ar >) (oreo >) (rr (“ween >) — (ane 50) pecnstsone | |e |e acc| | mms | | set | [ik artan || ec Seaowtah” | (Germesce) |S || MRED | saecntrcons| | amiemes | (tense) | apne | | wemmanucass | "=" (grant) |somese | | patent, | | Sa es | oe) cierto ea |e | nnn |g | [remiss | (Geto Semi |Sescem. | [Seeman | J | Semece | | nese | Spee] | Secor | wey) lime | — \seccr J | rata cont | S| amis | 7 a ean scincehvate) }\_ tag) c=] Caewerey_) (we : Ca) sesamin) | a EL) seinem) MNO | \ v ‘eeniuwew) — (3 secunde -Redoare de ceafa ‘Meningita bacterian’ Redoare de ceata Bombares fontanele! ‘Status mental aterat, Status epileptic Encefalita cu Herpes simplex Semne neurologice focale Convulsi focale Status mental alterat Pneumonia Tehipnee (frecvenga respiratorie >60 mtnut la varsta 0-6 lunt,>50 minut fa 622 lun 40 minut la >12 luni) Raluri crepitante Bitai ale aripioarelor nazale Retractiicostale Cianozs Saturatia oxigenulul <95%6 Infectia de tract urinar Varsaturh Inapetents Letargie Iritabiltate Durere sau sensibilitate abdominal’ Poliurie sau disurie Aririta septicd Tumefierea unui membru sau articulati Nefolosirea unei extremitsti Nusustine propria greutate ‘Boala Kawasaky Febra persistand peste 5 zile si cel putin 4 din urmatoarele ~ Conjunctivté bilateral = Modifica nivelul mucoas elor = Modifica lanivelul extremitatilor ~ Rash polimorf + Limfadenopatie cervical Auartgmant: est gr egress. ecomandae de bed pacer a urges dy uncut eat cnc msde sce ec ct Aes material fost reat nc rie Jnbandpes catty sec sae pesos de med de ‘roe pen cesar implore na program de fms et coarat iran gar rps Cel in incre Contra Chee pnts Ununen ropes evra Pez ea drat nbn Alene Cosi Fada Eatin, representa rin Agi Een Ge Devore Capers Gover onal ph Minster rar Pole ise rst sind implement See Cert ert Pt Ser erate (C5) mente gee 28SS EESU RHP NN RNa PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME ‘Anexa 2. Sistemul semaforulul pentru identificarea boli severe la copilul febril Verde - rise scézut Galben - rise intermediar Rogu ~ rise inalt Culoare (piele, buze, limbs) Culoare normalé Paloare relataté de apartinatori ~ Palid/marmarat/teros/Cianotie Activitate Raspunde normal la stimu social ‘Nu réspunde normal la stimull social = NurSspunde normal la stimuli social greutatea/nefolosirea unei extremitit Multumit/zambeste Nuzimbeste ~ Aspect de cop boinay Rimane treaz sau se treeste |- Se trezeste doar a stimulare ‘constataté de un cadru medical repede prelungta + Nuse trezeste sau dacd e teaz Plans normal puternic/ nu | Activitate scdzuta nurdmane tear linge ~ Plans slab, cutonaltate creseuts sau plans continu Respirator |- Respratie normala Bata alearipioarelor nazale = Geamat Tahipnee: frecvents respiratori |=. Tahipnee: feoventa espiatorie 250 resp/min a vista 6-12 uni; | 60 espiratifminut >40 resp/min{a varsta>12 luni |= Retacifeastale moderate sau Saturaia oxigenululs95%inaer | severe | Raluri crepitante ~ Saturetia oxgenului <80% in aer ambiental Circulate si |- Tegumente sicchinormali | Tahicardia = Turgorcutanat diminuat hidrotare Mucoase umede 160 batdimin fa vrsta <12 luni pest as >150 bati/min a vrsta 1-2 ani; 140 B3ti/min fa varsta2-5 ani = TRC 23 secunde Mucoase uscate Inapetents Durer sedeuts zl Altele ‘Niciunul din sermnele si ‘Varsta 3-6 luni temparatur’ 2 39°C | ~ ‘Witsta <3 luni eu temperatura simptomele galben sau rosu | Fabré peste 25 zile ae Frisoane + Rash care nu dispar la Tumefierea unui membrusaua | _itropresiune une! ariculai ~ Fontanela care bombears Membru care nu sustine * Rediare de ceafé + Status epilepticus + Semne neurologice focale ~_Conwulsilfocale Aversa: cs lpr presi recamanere dar a peta rps rune deat hn inp de sei fet at 38 ‘est material fost realiat n cal piel nbunstie tO sero spol » reply de mead de Urgent gen dear mpomentre un pga Se oar 3! ean represent prin Ager Eens de Detar Cooper Gurr Romine, en nr Fant Pub sen io fine mpamentat ecsreCetnd pert ate Srus ge Strate (C59), Wet 6 esePROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘WWISS- ROMANIAN COOPERATION PROGRAMME 21. ALGORITM DE EVALUARE IN URGENTA A COPILULUI CU TRAUMATISM VERTEBRAL CERVICAL y eng Comes -33 | ar) (sostmesuiaat su se saPRMTOONTARA usuwrncciane mvsneatunaaisnet | ” ance } 5 Hietatinsepece cemiatorcesbomen) apne Sine oon er est ‘reoiomnk anvens ete vora? cessing ; ew VG comet _Avetament: est orn ors oesand de bed pact In urgent dar nna eat ln inp se fa ot eet tr reat cdl rolecuh Inbar cat ei tae peptone madd de Urged pn derstora s moementt na program deforma", poe carn prin rah pares Shel pk UW itera Conta pene prs Ununee European er Poel a dat bce Acard on Feserl etn, rprestat pn Aerts Chen Se Oereare i Copeie Gaver amin, pn Nanton lr Dubie smn sna find penertat be ve Cot parr Pat Sr erat CS), mao Se eee vasesesut Sto eatSSBB EB RRR nnn PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS ROMANIAN COOPERATION PROGRAMME ‘A. Mecanism traumatic semnificativ - Pieton/biciclist lovit de masing - Pasager in autovehicul - accident rutier prin coliziune sau rsturnare = CAdere de la peste 3 metri = Lovit sau c&zut de pe cal - Proiectat de sau dintr-un autovehicul sau biciclet’ - Electrocutat - Inecat - Accident rutier in care cel putin o victima este in stare grav3 sau a fost necesara descarcerarea = Traumatism direct (arme de foc sau albe) sau indirect la nivel cervical - Politraumatism - _ Traumatism semnificativ la un nivel situat deasupra claviculelor (craniu, fat, mandibul’) B.Simptome si semne sugestive - Durere spontand si/sau sensibilitate la palparea apofizelor spinoase cervicale, posttraumatic - _ Limitarea miscérilor de flexie/extensie , lateralitate, rotatie datorit8 durerii - Semne clinice de traumatism vertebral toracic, lombar - Deficit neurologic acut, posttraumatic (parestezii si/sau slabiciune muscular8) - Torticolis acut ~ Hipotensiune si/sau bradicardie posttraumatic’ - Orice leziune care produce durere sau discomfort si distrage atentia pacientului (fracturi ) - Status mental alterat (alcool, droguri, traums) - _ Imposibilitatea de a stabili un istoric al boll, pacient gasit intr-o situatie care ar putea ridica suspiciunea de traumé, (a baza scarilor, sau pe strad&; f&r8 martori) sau pacient gasit in ap8, cu istoric sau probabili- tate de submersie (inec} . Factori favorizanti - Anomaliile de dezvoltare vertebralé si/sau laxitate ligamentar& = Sindrom Down - Artrit& reumatoids Sindrom Grisel (subluxatie non-traumaticd atlanto-axial’ determinati de inflamatia tesuturilor moi ca urmare a IACRS, abcese amigdaliene/retrofaringiene, interventii chirurgicale ORL - Mucopolizaharidoze (Sindrom Morquio- laxitate articulars) Sunt indeplinite TOATE conditiile urmatoare? - _ FSr& durere spontand sau la palparea coloanei cervicale - _ FSr3 durere sau limitarea misc&rilor de rotatie usoar8 a capului la stanga sila dreapta - Far durere sau r de flexie 5i extensie usoard a capului + Fard simptome/semne neurologice Avetaen: est egrets 0recmandr de oorbapocein rns dorminoaete ect cin inp i eta ‘eat tri fot alt nc pect Jnbundives cali serie spe preter de mend end pin dear tpemestore na pgm Be oor rt co Sat pron pet pata ee pn ‘tomadul CarrbutelSkeene pertrsUnoesEropeara ets Proc del bra Aearauuenrs te Con! Fer atm rennin tart Chen Se Derkare Cooperate Gaver Romi pin Mise Fate bios» hnsteucrty tind npn ear Con pert ls Sande Side CSS nels Se are asus eee‘PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 22. ALGORITM DE MANAGEMENT IN URGENTA AL COPILULUI CU CETOACIDOZA DIABETICA (STORE: ‘uni PARACINIG \ + Pout + Bvaluarea stride consienss | + Glicemie 2 200me/& + Poliisie + Permeabiitatea ci aeriene si |» Cetonemie >3mmoltsi/sau + Scere in greutte | respiratia(tahipnee respratie | cetonurie22+ + Durer abdominale kaussmaul) “+ Acidoz# metabolic: pH venos + Viritun + Tahicaraie, modifies ECS <730sbicarbonat< 15, + Alterarea stride consients_ | secundarehipo/ mei + Incazulcpiluicunoseuteu | hiperpotasemiei + onograma, ure, retina Diabet Zaharat Tip: varsitui, | © Evaluarea graduluige + taaatsere boli acute ascite, deshidratore [+ Hemoteucogram | | neadministrareainstinei | + inseria unui catetervenos pester | { (( CETOACIDOZA DIABETICA (CAD) | yo EVALUAREA SEVERIFAT CAD SLA DERCITULU OE UCHIDE (oc rarlaconiy >)" canstven’——~*C ex EDIE aD UjOARK | Shuspenteresib |=. Vistun || raebsemoectnice || lie tid mates perceptibil, || peshidratare 7-10% | de soc © Deshidratare < 5% | stipotensune arterald || * pltvenos<7.2, || 6 Hiperpnee |e pltvenos<7.3, stocscnsens) | etbomtaman | 1 Seeinese |” bert socutsre> 3mm | |) oD puvenose7a, || amol/ | Sbestidetare sion | Bicarbonat 10 + Tolereab hile ~ l ~ mmol/! eros “resuscrane >\(Sepetesdnsva (+ Haare rae cerere weirs | antuecae | | © nn rp eu cu ad sud de | 7 aeriene | cristatoid izotond actine ispro sou aspat)subeutanat | + Ongenetrapie || —_—Somitg admin ssvintamisculr 03 Ugur | [2 sctsarsoure || tena tors, max ord, de 01 Uke | cts nrond | 3Buur Omg | | «contin adminstrarea 20.1 U/kg din | AOnlkereeotare | since | 7 erbnord pnd ia reroharea cto dips cae bls roar Dora vereduce le 005UlKg acd | + Bagrosseafeemal | aehabac4S8- a0 teem sade ub 250 mal tex sep oOmiselte | yy ~ TTRATAMENT INITIAL Avertament Act alarm erento recanted be ol pace nents dar nea usta ine np de spec ecru eat Y ee + (EVOLUTIE NEFAVORABILA ) a — ee "ADMINISTRAREA DE LIGHIDE: Ser felologic 0.9% cantiatea = necesarullichidian zie" + % din deiit™*, ) administratintravenas cu rtm constant. ‘Odatd cu niieresinsulinei se adaugs KCI 7,49, 20 mln lecare acon 2 500 ml de ser Flog Tn car de | biperpotasemie,Kse adougd in solutia perfuzacd dups documentarea prezeneldiureze Ritmul de perfute nu trebue si depsseasch 2x tml corespunzétor necesaruul zinc delichide [NU SE ADMINISTREAZA BICARBONAT incerent de valose3 pH | ADMINISTRAREA DE INSULINK: se incepe dup 1-2 ore del ntierea administra lehidelor, 005-0. U/Kg/ora inulin rapid, in perfuae endovenoass continu Se intterupe administrarea insulinefolosit ca tratament de intretinere, se poate lua in considera continuareainsulinei LANTUS/LEVEMIR. Se poate administra pe acelas Cateter et lchidele, SOU insulin apid + 49.5 ml Ser fziologic= 1U/ml ya ‘ees material et ent cl pelea ntunsliren cal seis prae 5 pespbcet de median Se “rp evans een on be fm oe ar rn pa pate on Feu Eatin peer rn Aria thetand se Gurr Cooper Gaver ome, pn Minster Foreor Pb i anceral in Fd moment ve carr pen Pst Ser ear PS) alte awsren TY Sctiii eee eee eee ee ee ee ee ee PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME ( | © Glicemia—din orf in ord 4 Stas nesroogi- din orn ord + ECGmentorzare continud-unde Tina in hiperpotasemie,subdenivlare ST i aarieundelor inate, in | ipopotasemie + FCIAmenitorarecontinus [+ FR 550%-montozarecontinus [+ Temperatura 2 ore | + Electro, Astrup, ree, cetonemie (dacé este cisponiils)—a 2 ore. Pentru prelevareaprobelor de singe se jz sizeaad a dole eatetervenes perfec, mont pein membru leit fade cl c atte fost pentru & tratament |= © Parametriicalculsti: | | 0 GAURA ANIONICA = Na — {CI +1CO,) VN = 12 £ 2 mmol/|. In CAD gaura anionicd este, in mod obisnuit, 20- 30 mmol/I, o gaurd anionicé > 35 mmol sugereaz’ acidoz8 lactica concomitenti | © NACORECTAT[még/t) = Na masurat + 0016 gleemiaplasmatcs mg/l 100 Incusultratamentul | Namrata crest lent ar Na crecat va sea, _OSMOLARITATEA EFECTIVA (TONICITATEA) = 2x Napasmatc + cei (mg/l) [PF TERAPIE ITENSIVA n CAD SEVERA, sou cu NSTABILITATE HEMODINAMICA sau RISC CRESCOT DE EDEM 4 eREBRAL | rerante wrenMeDiand in cao MEDIE |Z | 5 secre peoiaraie cu posit de monitrizare personal experimenta, in CAD USORRA | 2 | consuuroe secure pion eu ecperensnvatoment AO | INGULINA~adminsvarecontinod 005-01 U/ Rear ns rapids | flienibe sexecrRouT | + SER.0.9%in primele&6 ore uric tonictate mai mare de 0.45% + KC17S%, 20 mln fecare Nocona SCO | || canttatea de soa sdmiisrats webu sb asigute ocestereavalori No misuratin paral cuseBeeres flcemies. Hipopataerie ce nu se corecteata prin acminstrare parenteral de K ~se cae tml de | Edninistare a nelne | Risc de hipercloremie (raport Cl/Na > 0.79). Deficit de baze datorat hipercloremiei = Na ~ Cl-32 |_| GUiceite = 250-300 mg/al SAU GLICEMIA SCADE CU MAl MULT DE 100 mg/al/ord ] 41 Cetonemie s 3 mmo sou Goure Anionic normal (< 14 mol) + Lichie iw: er 0.9% glucozat 5% + 20 mi KCI 7.45% in lecare acon a 500 ml delichiéperfuzat | 5 exemple 2 250 mi ser fiiologi * 250 ml glucozd 20 %= ser 0.45% glucozat 10% le |i. 220 mlserfiologic + 40 mi NaClS.85%+ 250-mlglucord 20% =ser OK glucorat 10% | s + Inslina~se reduce tule .05U/kg/ord |B | 2. cetonemie> amma souGoure Anionic cresct8 > 14 mot) | z 1 Uchide nse 0.9% lucazat 10% + 20 KC] 75% in Mecare acon 2500" de eh perfurt ~ \E exemple = 250 ml ser fiziologic + 250 ml glucoz’ 20 % = ser 0.45% glucozat 10% | | 3 Ji, 240 ml ser fiiologic + 40 mi NaCl 5.85% + 250 ml glucozs 20% = ser 0.9% glucozat 10% | i + Insti continu curitm 0.1U/kg/os 2 _| use reduce cantitatea de glucozé din lichidul perfuzatndiferent de evoltia glicemici (se poatecreste, la | & | nevoi) Vaioarea pls defile bate pot infuenate de airs hiperloremies HIPOGUCEMIE —| 1 Gleemie< 200 mg/l | | ‘Se erase cancentraia de glucan dn chu perzat * acd persist cetora/gara anionic crescut8~s continu aeminstraes insulin! cu un lim de ce putin 0.05U/egors | 2. Glcemie 75mg + Bolus 2 i/tg de glcozs 10% Se reyte concentra deglcor nihil perfurat | acd persist cetoza/gauraanioncd crest ~rmul de aminstrare a insulin pate redus \ tempocarltimpde to) - - J Aversman: slain presto recomend daar pact vansrenuL Sw rae dr vino decal pus de spc ec cat ‘Jen material rele nel prc Inbunties altar spol» preter Se mead ae ‘rae pn devotes pementaro unt rogram Se fama’, pole sort pan par tn pares Eee eh incrmed contrast pers Uninea Eropeone er Prete Gru bts Adtran nein, epee pn Aan Cen e Denatare Capea Gara om ph Minster ror Pie Minster ios Rind plement eave Ceri perm ol Ser eS) alte Ags 28css. 2 Ra PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME ALGORITM DE EVALUARE $! TRATAMENT A COPILULU! CU CETOACIDOZA DIABETICA | Rorattate 25-28%, RISC CRESCUT copil < 2 ani, pH 7.1, hipacapnie dlscordant afd de acldoxs ‘+ Manito 20% 0.5-1 g/kg acministrat in 10-15 min, se poate repeta ups 30 min~2 oe in absentarispunsulu 32|° sw | BB | « wocta.rsav3% 25-5 mh adminsvatin10-8!min | FE | + restrcietchicans a 1/3 in ital inl | F 6 alicarea capt la 30° | & creranan err escluere tor cauze de degrade newcogs(hemorgtrombare + CLIN stare general bund, tolereaz ichiele per 0, So | + PARACUNIC™ pH> 7.3, iarbonat >15 mmal/etonemie <1 mmo/saunormalitares sul anonce 2 | + cetonurapoate si peste © | « nsvuna—aeminisrarea continu se opreste cups inieres isune sc, n seca de peal, interval de ‘imp depinde detpul de insulin. (*Mecesarichidionainic | Primele 10 kg = 100 rl/kg/a_ (secaleveassinfuncie de [Urmitoaele 10g = S0mV/ig/ i | srevtates misuratsin rs ecare kg peste 20 kg = 20k ral ‘momentul dagrostciri CAD) [Total hide neceare/24 de oe A im de adminstare —fesb/2e= wafer] (ahi administrate alos ena Fe a 1 Deft ichidion Se desisatore xaWal | é= mm |= 5 7% tn CAD wsoard sou 0 mmoserats ‘Def iho retool HeG-F= ar | © 7 10% tn cAD moderas [Rem de adminisrare =H 748 rs sees | [TRIM TOTAL DE ADMINISTRARE Bie vient \auenoeton ee w { 1°" DIAGNOSTICULEDEMULUI CEREBRAL CRITERI OEDAGNOSTIC CRITERI MALORE CRITERT NORE © ispuns motor sau verbal © congrenrsarerts | O varstur | __ morale dere © sesserea reeverte O cetaee | (© Posture decotzare sau coraace cu mai mult de | ° (eererre 2bstminut seSdere | © Letaresausomnoents cern se datoreatS © Taatasaes> sommig © Para de nevi carieni fin Saar | | special TV, Vi eee © virsta< ani © Pattern espator anormal somnulii © incontinent sicteriand (evaluate in funete de | var) | DIAGNOSTIC PORT =i CATTERIU DE DGNOSTIC au 2 CRITERT MAUORE sau I CRITERTU MAIR > 2 CRITERT NORE | vensbitate 92% lgnosifas psi 4) Diabetlinsipi est sem de hernere cerebral Avetument: ket oon resent o esac de bord pein rer aru uses ii npr ee ec cot 3/4 ‘cot mati fost rata n earl poet nbs ot sen spolen presale de meds de ud pn dear egloertareo un rogram de fama”, poe cofnanat pun gat partes Een ‘termed conto hepone pees UntuneeEoneana era Prete drut nbs Aer acute Con eer etn, rpesrat pn Agi and e Denote Capea Gaver Remi ie Mister uns Pace sine cna frees ec Cotnd prt ail Sees de Siac elated gee amsreaurshutice Seraii eee ee ee ee ee ee ee PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME. ANEXA 1 Fis DE MONITORIZARE PARACLINICA NUME si PRENUME INR. FISA: DATA: GREUTATE: i] ‘ORA T 7 7 LICHIDE mifora INSULINA U/ord Glicemie Cetonemie Na kK | cr Uree/Creatinind pH pCO; HCO; eB Na corectat ‘Osmolaritate efectiva _ Raportul Cl:Na ‘Gaura anionica | ‘Na CORECTAT = Na misurat + 0016 x [gicemia plasrmaticl mg/al~ 100) (OSMOLARITATEA EFECTIVA (TONICITATEA) = 2x Na plasmatic+gliceria (mg/dl)/18 GAURA ANIONICA = Na~ (Gi +HCO,) [MONITORIZAREA PARAMETRILOR VITALI SE FACE UTILIZAMD FISELE DE MONITORIZARE IN FUNCTIE DE VARSTA PACIENTILOR Avemen: cla presto recon e bol pact nurseries impuid sci ftcet ‘eet atrial 3 fot eet In al proc nbn cot err stale» prenpalcpt de eden de gerd gn drones pemertoca ums room de fara”, poe soars prt part pata Carl ph ‘een Contre! Chere porns Ununea Europeans er Prete dra nts Arad Cosi Feseral oti, repent pn hana Sand de Sects Cooperate Gover oi grin Minter anfeot bie tester int Rin leer ear Cert err Pa Srv Saat (CDSS neat de gee veer SAWN et 4PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 23. ALGORITM DE MANAGEMENT IN URGENTA AL PACIENTULUI PEDIATRIC (CU VARSTA DE PESTE 1 LUNA) CU STATUS EPILEPTIC haan on fn 25 ahr i at) oszo.n-03 mai ae a IPAM 03 mahgcp ingen ime Sigs San ean Tome peeson (ena. 05 mangers ner ins 20m mono 03min ae oxo 02 mete sos eels oe Seni roa SOU OPARNG 20 regio fuer pF ener meen 2 rei aint [ranean aps 19507) Carers HERAT) shel net reprezint orecomandere de ard ol pacentull in urgent dar nu inocwestejdecata clinic imp de speci! ec car ‘est materi fos aan cal proestdefbundpieo cal senior spate presproest de medind rend an dersare pigtenetareo un pragram ae formal cotati gar in putea Ein marmece! Conte! veo pee ntact Earpesna eres Proc drut mts Aarau ie Cara ‘Rien cepon, preset nn Rurta Ear de Dears f Coopers Gover amd, pri nt antler Dooce miter ots find pnertt te Certrl en Pal Srsl eS (PS), cate gee or arawnid~ aINN wR “x ann vz aiavouywan- ‘Ni ozSRNR PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, SWISS-ROMANIAN COOPERATION PROGRAMME - | . — ( wrevscevernanox — | 12] — —_ ~ | ® {Soba 6038 mehr, pl contin shan. 8 | Resta seer hence mn inci é | onal heurlpe eas clean ebb vont | _ petal nb p FEV eantit Lc S50 erie sn rete | aes ) > (( Fdcom 26 48. g (soot era tm c \ 2 | (Giensooineaisnn C : ww - ~13| _ — toanen | | _ —___. on (varie Pacoima =) indwavsiatauos | | | (Ceca comsor? Pel mato pnt 28 oe conutnensoge | | & = enn senoe reamesian | | ww /)|\z 2 | “Se reduce in continue PEV cantina LJ senatam cv whee S| Monier near terpentc a | (anes } Avertisment Aces aiortnrepreiB oracmrondare de odor al pacer in urgent rn inlocuist judecote ini puss Se pec fede cat 2p ‘eet mata» fos rent rc pric Jnbunirea ca serio pay rsp de mes gerd pen dtvoars sl ipemertre ns pgm Se mere pros! trast pon wt dn pate ei rn ‘terme contre heen press Europea ees. roe xa deat naa Peo cer ie Cra Fecerl hein, penn in Agari Chen de Denar Cooper Goel Ronan an Mil Frere is Pie mnt Sty finding etre Centr peta Plt Serle State (CPS ncaa de Aare sro acePROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 24, ALGORITM PENTRU TRANSPORT NEONATAL Evaluare ABCDE \ ) ReSPIRATORIE || ernck Onigenoterapie-daciestenecesar | Temperaturd | | | N=365C-37°C (CPAP —daci este necesar | | | | | T incubator = | Proteare respiatorie dat | Enawntsets | | dees resprtoie severs ase | “eianarSgeneraltatbcarenuse |S — | | | amelloreaz la administarea de O: -apnee | = bradicardie | «satus convulsvant CCorectarea dezechibrelor metabolice, efectuarea de masurispeciice necesare Inaintea transportulul Securizares sondelor r sicateterelorintravenoase (Mitre continua pedurats transport “in carol nowndsctollventiat | mecaiesmonitoizare gaze sanguine pe durta transport | {dacd este posibi Avertmant: het grt erent recandare ce rd pec get dc | 1. Atrezie esofagians cu/aréfistuld esogastric’ - montare sonda 2. Defecte congenitale de perete abdominal -mantare sond3, Is, Stabilzare ‘CARDIOVASCULARA ChE A aS =a py tga ee a ee vc toracice imediat oa , Se 2 i steacr nine 52S 2a 7s atari fst ad yi mii nl proetos inborn elitr spas peace Imei ce ger gin desres 7 mpemertares ura pram ae ommor”, prot cotati er i aes hei ted Cnt Chepene pore Unuins turopeaa eins Pret sa der ar eo ‘tr anal rcv han, repesta prin ean end Ge Gera Coopers uve Rami rae Pte ¢ Minste Sin, find emplermerta eve err pens Pt Se Seat alte ete netBURRS MM PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015 3. SUPORT VITAL AVANSAT Geman chematiechipa de resuscitate RCP 302 ‘Atagatidefibrlator/monitor Minimalizayintreruperle (one lal Cr (AEP, Asistola) (FV, TV far3 puls) 150 aoe Minimalizat Eo Intreruperile oc) Imediat relat RCP TERAPIAIMEDIATA Imediat reluat RCP pentiu 2 minute POSTRESUCITARE pentru 2 minute Minimalizayiinteruperie FA EEREME Mts Minimalizayjinteruperile ey Incuraul ace TRATATI CAUZELE REVERSIBLE 1 Asgut empresa lente poe "ramon su pumensrh 1 Mineaizaintenpelecompresorteracke porte Preumotorac naan Sasuuanaae Hpo-hpezaasemimetaboke Tangara crac, oe potemaiipener Tower 1 Uulestcapogeata eri * amaeoncin cot i sie coneaal 1 feces scar tates sa icon) * bank cope ‘hans aceain cre 35min * Compre enace mean pentfaitvesraneursbnent {oma aaron pa ea fc 1 hog coreneransieretcernaron pean PnPeeceroras ana ‘cst mata fost realeat 9 eda protec mbna cot serio sais pepe de meant de Ingen pm ders tpemertocs un ram de fare’, poe co-tara itn rat pares Eel pn iene contribs epee parr Unies Eeopesns ears ret erm bra Aarau cnrs inte Co Fer Een, reper gm hast vend de Sakae Cooperate Gera ors, ph Minter snr Pblce moe esi Remar ocr Cet per ait Son de Sant PS) nate 6 eeePROGRAMUL DE COOPERARE ELVETIANO-ROMAN, SWISS-ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015 4, RESUSCITAREA IN SPITAL bere ga aptly arr ee eerie irc} ma can Eon nue Cee Lita dei! Care aicilloraeriene eer a cog Era ca eo Predai pacientul Ck ere opi Can trope redeem ae sees AM SE ana Auertsment est grin egrets 9 recomandore Se abr pact in wget, ay noclese cea cn nus pee fete ‘eet materi fs eatin ul poet bunds eat err sptoler prepa de medi de {gn pin devote emplementae en gram ae fees, pole co-ara int-un gart npn Chel pon ‘armetl Conve Evetne pee Una freer err Peet ra cru nbn Aer cour one ‘rl ton rpresratp age cian de Denckae fCoparae Gaver Remi, pin Minter Palt Pace nse Sn, peat de te Col parr a Sat Stas, naa Je eee anasto SA retPROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015 5. ALGORITM DE MANAGEMENT AL PACIENTULUI CU TAHICARDIE @ Beem ‘Monee vars _Avertiament: Aces cori eprezintd 0 racomandove de abd ol pacentul in urgent dor navies judecta ccd imeusd de specu ficou coz sna ‘ee natal fos sy ulate ear proc Jnaunsiieca clip sews spl» penton de ‘resin rer po evar 3 glemetorea i prgram de frm, psc coor pion Lan Spates ett pon ira Cotnates Shape prt Unune Erepenra es. Molec det in tm eee ine Cosi edu Ehsan, repeat pn Aen ean ce Derr Coogee Gare ari, pn Mea rarer Puce nso, ia iplmeta G e Catv oll ens Se Sanat (PS), mele Agere ecPROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015, 6. ALGORITM DE MANAGEMENT AL PACIENTULUI CU BRADICARDIE EUROPEAN (@) Bescon counci. CSS Atroping 500 meg Rise de asistola? Asistolé recent Bloc AV Mobi Misurlintermediare ba Bloc AV complet cu in ‘complexe ORS lar + Atropna 500 meg vrepetat pind |.0dozé maxim& de 3 mg Pauz ventrculard > 3 5 “+ soprenaling Smee min ‘Adrendind 2-40 meg min IV + Mecicatie aterativs . Nu sau Pacing transcutanat 1 Sala tor unl expert Pregatiiv8 pentru pacing trensvenos Medicatia aterativs include Aminelina, Dopamins, Glucagon (ncazulsupradozalulu cubete-blocant sau blocante ale canalelr de Ca) Giicopyrolatul poate i uiizat ca altemativslaatroping _vereament: eet lpr reprint orecomendore de abo ol paceman rae dar nce adecta lnc inpusd de secu fac oe sna “et matri fo as 9 upt in al peta nba NO sro sales 5 pesaaens e Inedné de rg prin denotes» nplemertes und prgram ae forme rit co-frat pit wart 3 aes ‘rt pi trod Coir Chains pote Unaesfuopeea ete Prowl xs derdt nba Racha ine cont acral stan, penta rn sae hen de Gate Cooperate Gov ara, pn Mise Fonsi ove Mister Soh fed peer de ve Cv pen a9 Serve Stat PS), aa codgenieneetisSUNNY PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 25, ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015 7. SUPORT VITAL DE BAZA PEDIATRIC EUROPEAN @®) Resuscitation COUNCIL ed Nt See Pee Re Cur ry eer Cretan Pause ers Peo acta Pye ec Retainer Sg MBS Cis ees : " ma Avetment: es agri erent crandre obra cen Ug arn aot ln insu pec et cox ‘eas mater» fom vain muipleat ned proweua Inbundea cat sro spate plese de Imei de igen pm deiarea imglemenare un ergram ae omer ricco fara pian ar Spe © eis pen merci! Cott! hte prt Unune topes bss Pratl dat fae Acct ‘nr Corll eat etn, reper pon Ageia Eheind de Denote Cope Gemma ph Mose Fare Pubic Nester Sn fina imple de te Cnt per Po ers Stas [PS male ceigericcmetdae eee eee PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015 8. SUPORT VITAL AVANSAT PEDIATRIC EUROPEAN @) FESusciTaTION iL hema echipa de resuscate (0 rim Re nal das sunt sing) ACP (venti intial p01 152), ‘apatidefibiato/meontor ‘Minimalaaiintrerupee Rua Cores amen) Gaiety} cea \y EE nos Tecutne EEO "Seana unialzaiitreruperte PROPRIA Winimatzay respec InalsieasialSleacly consderat ad, amiodarone: near de TV fre pul tefactarela deine Incursul RcP. (CAUZE REVERSIBILE + Aiguratl compres traci efciente + Panifeainant de a treupe RCP tipo *amnitaogen Hipovolemia “Acces vascular (rravenessaunta0s0s) ipo iperpetasemiavmetabolice * Adminstatatenlins a acare 3-5 mn Hipotermi * Considera managementul vans al Trombors~coronar sau pulmonard dilaerene full capnegrata Paeumatoraxsufocant * Compresiteracce continue ups Tamponadacardncs ‘agurrea cor seene ToxcerDeveciibeterapece * Conca caaele reversible rar i re ts fh ep ear ne ie SN ge rae tahun ae eae Mout sgn, OM aa vement es lpr great ecomandare ter lpaetinwrget a unos dees ns impust soe ft ce Tes mtr fs ada ipa nal proietu TnBundtes elt ser soy pert de imesind ae ugenié pn dere ngementars un program deforma, pot cofears pian ear in partes @ ett pon rtemadulCotrutes Greene pet. UnunesEuopene exis Poet 2 drut bata Acorclureaty ‘ive Con Fans Sean petra pr get hers de Dental Cngeae Gaver min pn Nine arg use) Mister Sly i lent cite Corl per ac Sera G iat (PS), cla! detent neatBMS PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME. 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015 9, SUPORT VITAL NOU-NASCUT EUROPEAN @®) REsusciTaTion COUNCIL CAS [Nerteron] ac terntscrdacinvoeste ‘imitans a) stein ene & ‘Spo, preductal de ajutor? 3| inn coal 2 amamimct tora | Cindi inepecmpreietocce coudonsteanteaic veal) | Y Avertan: cs larin repenit 0 recomandre de Obr4o paeln went rnc det cn soe scan sia 7 mater x Wau mat ml pod nbd a seri ote propre Imes ego pn demotaes 3 pment un pra Se frre pe oar pettan gar partes © eit pi irtrmede Contre: Gnepene prs Unune Saropears sre rcs dent nacre ine Cons eer! etn, epee pn aia hea de Dette Coopers Suetnl ome pen Minster Fears Pte tar Sap, Nid plement de ie Cet pnt hot enh de Sate (PS) eae eagepe mcause RRR eee PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULUI EUROPEAN DE RESUSCITARE 2015, ed Baie hres Diagnostic - cbutagi: * Debutulacutal boi «= Siuatiiameninfatoare de vat la nivel calor aeriene (A), respratie! (B) s/sau circulatie()' ' Modificaile caracterstice tegumentare 10. ANAFILAXIA * Strigati dupi ajutor « Intindetipacientul cu picloaree dicate (dacd functia respratorie permite aces ucry) a ( act echipamentul medical si calificarea permit: Asiguaticaleaaerian3— Monitorizare: xigen cudebit mare « Puls-oximetrie s Incerearecufluide!—w ECG * Clorfenamins* 1 Tensiunea arterials = Hidrocortizon* Percent ey Set ee se ana cs nae EES PA pati we tc cea ot ‘oni Fasc certs eae ess i iron 25a al ion aah open deenae Po sae aa -vertament et grim erent ecandoe de bord pace get darn eat cn input eo “cet materi fost ods 9 rupted poeta bude MO sro sts pesto mend ce wrgrt re eaatea st pemertare una pregame forme ct cofars pir eon én area ‘eis pin termed contr Cveine peers Ununes Europea etd ret erat In bat eaux tree Conta ace etn repecerat rs gen tert de Setar Coopers Gurl famine wn Mine Treat unis y sense! Son frd pert de Creer Pn ere de arate (59) cate eager cetaS eM RRP PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULU! CONSILIULUI EUROPEAN DE RESUSCITARE 2015 11. HIPERPOTASEMIA er Protjat cord eee Cree eerste trans Introduce icdepotamie i Intraceltar — See Luapin clea aati clea ain ‘alum reconium nia a organism Monitorats er nt mim ronan ronda dete wpe mele ii chin ee cst nh Tet rte twos ri nc pron nani a serio a # meee de ‘esc wen pn eon rte ripon Sa po cn prin Pa in ps @ Ente! nied! Conta: ene peer Ununea European ani ‘recon fede stn, repent pen Agra Crops de Outre Coopaae Gurl ane, pen Mine Fens Pusey tnt Sea hing meno eC pentru Pn Servs de ita (PS). meat feagena etePROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 25. ALGORITM DE RESUSCITARE CONFORM GHIDULUI CONSILIULU! EUROPEAN DE RESUSCITARE 2015 12. STOPUL CARDIAC POST-TRAUMATIC EUROPEAN @) RESUSCITATION ‘COUNCIL Cc a Stop cardiac! =z =z z = x Zz = = z= Zz : = . Pacient critic? a a ® a 5 . 8 . . 1 . ' 1 1 ' & t ' ' t “non-traumatice al ALS, so — a “4, Tratati amponada cardiacd Gebutul SCR nares tre pronnal? Boeri? sams —s uafmeateut NU Reluareacirulatelspontane?” 60mint<30°) DA See de vats? Doo pee rumvinnse I cies I Asistola. sau + INCERT Evaluati Sac i ane permeabile — jpreb es oer potasiul seric* ECS > ammo Consideratioprirea RCP Cao ntenucire Pees ate sag OH 28 ‘Avertament est orion erin orecomandarede bed lace n uge ar une deat cn ips dese ft co Tes natal om weds 9 ulipt nal prlectubndtiven cetyl sale prespoeet e ‘rsdn dean rn datore implements an pogam be omer”, rot cotnat pan gat i pas vein pin werd Contre Ehepene peru Ununes Europea ents Pract Gut ota Arcus Ine Con red hte, represrat pn heer Ehepar ce Dera Cooper Gurr Remdna, pon Mee Finn ube inte Stal P peerat cite Cron ae tro Sate (PS), eae Senger emesisUNMS ENE aa PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, SWISS.ROMANIAN COOPERATION PROGRAMME 26. RECOMANDARI DE BUNA PRACTICA PENTRU MANAGEMENTUL IN URGENTA AL PACIENTULUI CU HEMORAGIE DIGESTIVA SUPERIOARA Sumarul recomandarilor ghidului national: 1. 3. 5. 7 9. ‘Se recomanda ca pacientii cu suspiciune de HDS de cauza pepticd sa fie tratati cu itori IPP in asteptarea endoscopiei. (A) Pacientilor prezentati cu HDS, cu antecedente de ciroz8 hepatic’ se indic& area tratamentului antibiotic, de preferat anterior EDS. (A) a } Dupa tratamentul endoscopic al pacientilor cu HDS variceal, se recomand’ tratament vasoactiv (octreotid sau somatostatina in doz’ mare 3-5 zile). (A) i S mE Pacientii cu HDS cu sangerare activa si coagulopatie (INR >1,5 dar <3) ar trebui transfuzati cu PPC. Dac pacientul este stabil hemodinamic, nu este obligatorie corectarea coagulopatiel inaintea efectudrii EDS. La INR >3 se recomanda corectarea (INR<3) anterior EDS. (C) admi L EDS este prima linie de tratament in cazul pacientilor cu HDS. in cazul esecului tratamentului endoscopic, urmatoarea alegere terapeuticd este indicat a fi radiologia interventional (comparativ cu rezolvarea chirurgicala), acolo unde aceasta este disponibild. (C) TERLIPRESINA ar trebui admi 1 confirmarii EDS pacientilor cu suspiciune de HDS de cauza variceal semnificativa clinic.(A) Autorii sugereaza cd pentru pacientii cu suspiciune de HDS, evaluarea riscului, | prezentare, sd fie facut utilizand scorul Glasgow-Blatchford, iar ulterior evalu: endoscopice scorul Rockall. ’ rrombocitopenie sever’ (sub 50.000) ar trebui sé primeasca r3.(C) Paci -u HDS masa tromboci Pentru majoritatea pacientilor cu HDS masiva, fara comorbiditati semnificative, se recomanda administrarea materialelor sangvine transfuzabile cu scopul de a mentine Hb > 7g/dL. (B) Auertament eet orn grec ecards de abr poet rer dr neve atc inpus dpe eS aus ‘cst materi oat eet a idl proc bunches eat sence poke pple de median se Ingen ann denna mlamertece un program de fa rocco an pir an gta pres oh imemmedul cortrbutlEhefene ports UnnenEarpean ext Prost ra auth ns Aas cee Cons ‘ith mea arian cer Cn cama or see wecs se ee eee RRR RRR PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, 'SWISS-ROMANIAN COOPERATION PROGRAMME ‘Tratamentul cu IPP pre-endoscopic: - Ex: Omeprazol / Pantoprazol: 80mg bolus IV urmat de 8ma/h. Antibioterapia in UPU a pacientilor cu ciroza hepaticé prezentati pentru HDS: = Ex: Norfloxacin: 400 mg x 2/21 7 zile - Ex: Ciprofloxacin/Ceftriaxona: 19/21 in cirozdé avansate. Tratamentul vasoactiv dup tratamentul endoscopic al HDS de cauzé variceal’: = Somatostatina: 250 ug in bolus iv. urmatd de o perfuzie de 250 ug/ord, ‘nu mai putin de 24 de ore. - Octreotide: 50 ug in bolus iv. apoi in perfuzie 25-SOug/ord, 1-5 zile - Terlipresina: 2 mg IV la 4 ore 2-5 zile _ Terlipresina admi rat pacientilor cu suspiciune de HDS de cauza variceala anterior confirmarii endoscopice. ~ Terlipresina: 1-2 mg iv. repetaté la 4 $18 ore dupé tratamentul initial. Se intrerupe tratamentul dupé obtinerea hemostazei definitive sau dupa 5 zile, dacé nu existé o alta indicatie pentru utilizarea sa. a Cre enh) Elec Were aaa 6,5-7,9 2 89,9 3 Uree (mmoli/L) 10-25 al 225 6 1212,9 1 Hemoglobina (barbati) (mg/L) 10-11,9 3 ‘ <10 6 Hemoglobina (femei) (mg/L) 1018 4 <10 6 100-109 1 TA sistolica (mmbg) 90-99 2 <90 3 Puls (b/min) >100 1 Melena + 1 Alti market Sincopa + 2 Boal hepatica + 2 Insuficienta cardiacd + 2 Avetent: eet ri erst comandoe Se tard pacer in get Sr ule teats ips dpe fer co ‘est ati ot elt nc rec JInbundleo cl samo sptaen peptoice de meses de sre pn ceo sora i ron Some re ait pn pe et Fescr Seta, repel rh Aerts Ee’ de Oeroare Canperre Gave om, ph Minster Fnteat ble nr eh end vgemereat ore Cerra ert Poe Sa Ge Sarat PS), cate e gee 22MMMM EN EE PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME 27. RECOMANDARI DE BUNA PRACTICA PENTRU SEDAREA PROCEDURALA IN SERVICIUL DE URGENTA Sedarea procedurala si analgezia (SPA) sunt teria freevent | ventilate! soontane ineficente sau a paraiiei museulare drog- utiizate in servicile de urgent’ cu scopul de a reduce anvietatea, dscomfortul, dureres asociate unar proceduri diagnostice sau terapeutice si uneori de 2 asigura amnezia, Pentru realzarea SPA este necesari prezenja personalulul ‘medical pregatit in vederea adminisrdcii drogurilor sedative si/sau analgerice (cunoasterea farmacologiei medicamentelor respective, 2 modalititilor de administra, a efectelor adverse posible), monitori2iri sila nevoie asigurari managementului ca aeriene ia resuscitri Chiar dacd SPA este realizaté in mod obisnuit de medic specialist in anestezie pentru pacienti care sunt pregatti Tn vederea acesteia, ea este frecvent necesard in UPU/CPU sau prespital. C8 urmare medicii care Iuereazd in aceste servic trebvie si fle capabll si realzeze sedarea proceduralé 3/sau analgesia in aceste locuri,astfel int pacientis8 aibé benefil ‘maxime in condi de securtate, in Roménia medicii care Uurmeazi specialtate de medicind de urgenta beneficiar’ de Dregatire in acest scop in timp rezidentiatulu Recomandarle de bun practicé isi propun sé vind tn ajutorul acestora, si serveascd 8 0 linie directoare pentru ‘medicul de urgent, f8r8 i reprezinte ins singurdalternativa, aceastd tehnicd trebuind s8 fle adaptaté la condiile speciice pe care medicul le intdineste In practicd de 21 cu 2. Sedarea procedural si analgeria se referd la tehnica administrari sedativelor sau agentilor disociatvi cu sau fard analgezce, cu scopul de a induce alterarea starii de constiensé care si permits pacientulu tolerarea unor proceduri dureroase si/sau neplicute, prezervind in acelasi timp functia cardio respiratorie. ? Societatea Americané de Anestezie (ASA) defineste trei nivele de sedare si anestezia generals.” Sedarea minima (anniliza) este o stare drog-indusi in care pacientul rispunde normal la comenzile verbale, starea de Constientl find foarte apropiaté de cea de bazé. in ciuda faptului cd functa cognitiva si de coordonare poate fi afectats, functlle respiratorie si cardiovascular’ nu sunt afectate, °°" Sedarea moderata descrie 0 alterare a stiri de constient’ Ce condi trebule sé Indeptinenscs personal din UPU penta putes efectua sedare procedural? Nivel Recomandore Cn timpul sedan procedurale moderate si cele profunde, 0 persoand alfcatstreuies8 montorteze {in permanent pacientul.” Nivel Recomandare C: sedaea procedural in UPU trebuie supraveghents de un medic specist de orgenta sau alt specialist cv competents att protesionls cits legs’ de @ fects process © persoand aint ar treo desernati si se ocupe de rmonitorzarea paientuli pe toata data rocedur neal Sediriminime acesta poste assta medcul ce efectuearé procedura cu mis interventi de curt cura In cal sediri moderate este nevoie de dav persoane, un | medic care efecuea:d— procedura si 0 persoand {inedic/sstent eu rola doar de a monitoriza pacientl Medico! trebuie sé fie instrut in selectins) evaivaree pacientli, Tm special in evaluareo cal aerienetrebuie 58 Cunoascdcifertetehnic de sedare;trebuie sf fe ns in ‘esuscitre, management Bi aeiene sc experientin ALS; trebvie s3 _cunoascd farmacocietce. si fermacodinamica drogurir utizate, nclusiv antagonist speci trebue fe pregitt in flosea combinatd 0 droguilr. Perscana care fronllorsezd pactentul tebuie 28 se asigure cd functia respratore este adecvat, sermnele tale sunt tn limite | normale $\ trebvie sf antrenata in lS. In cal sess profunde, avind in vederea posblitatea ca 0 Interventie dura cil serene 38 Fle necesars este recomandat ‘cst motel a ot et aed protec Inbanstie ct frye an dence ements ut propo Se oma Pacey tne inst fra npnentst Sete Col err Pai Srl Svat (C39), esate de Ee | s8 fie implicate 3 persoane: medic si asistent pentru procedura sio persoand dedicaté monitorieéi Nivel Recomandare C: mediii care efectueaz’ consulturh in UPU trebuie si colaboreze cu personalul UPU in vederea efectuari procedurilr ce necesit sedare, 7. Ce echipamente gi materiale sunt necesare pentru a cefectua sedare procedurala in UPU? Nivel Recomandare C: oxigen, aspirator, agenti de reversie roguri, medicatie si echipamente ACLS trebuie si fie cisponibilecind se efectueaz3 sedare procedurala in UPU." 8. Este administrarea oxigenulul suplimentar necesar’ In timpul sedari procedurale? Echipamentele necesare administrarli de oxigen trebuie si fie imediat disponibile si oxigenul trebule administrat pacientilor care dezvolts hipoxemie." in cazul sedrii profunde oxigenul trebuie administrat tuturor paciemtlor cu exceptia celor care prezintd contrainicati Dacé se administreaz8 oxigen suplimentar este recomandat’ monitortarea continu a E1CO; In eazl in care acest cru nu poosiil ar fi de preferat mentinerea pacientului in aer atmosferc sau monitorizarea respiratiel de citre 0 persoand de dedicat 9. La pacienti (adult/copil) care necesité sedare pentru procedurd nedureroasi/dureroass in serviciul de Urgent se poate folos! ketamina? Nivel recomandare A: Ketamina poate fi utiliztl in siguranta pentru sedarea procedurala a pacientilor peciatrici in UPU."? Nivel recomandare C: ketamina poste fi folositd in sigurants pentru sedarea proceduralé a pacientilor adult in UP." 10. La pacienti(adult/copil) care necesita sedare pentru proceduré nedureroas3/dureroasa In servicul de urgent, se poate folosi propofol? [Nivel recomandare A: propofolul poate fi folosit in sigurants pentru sedarea procedural a pacientilor adults! pediatric in upu' 11, La pacienti(adult/copi) care necesita sedare pentru procedurS nedureroasi/dureroasa in servicul de urgent, se poate folosi combinatia ketamin’ si propofol? Nivel Recomandare B: © combinatle de ketaminé si propofol poate fl administrat Tn sigurantS pacientilor adult gi pediatrii pentru sedare procedurald in UPU.? 12, La pacientl(adult/copi) care necesita sedare pentru procedurd nedureroas8/dureroasé in serviciul de ‘urgent, se poate folol fentanyl s/sau midazolam? Nivel Recomandare B: combinatia fentanyl- midazolam este ficient pentru sedarea pcoceduralé in UPU" [Nivel Recomandare B: Agenti de sedare non disociatv trebule titra pand la efectul cine dorit pentru a ofer sigurantd ‘maxi’ proceduri.® 13, La pacienti (adult/copil) care necesita sedare pentru proceduré nedureroasi/dureroas3 Tn servichl de turgenta, se poate foosi etomidat? Nivel Recomandare C: etomidatul poate fi foloit in sigurants Pentru sedare procedurals 3 pacientilorgediatriciIm UPU.” [Nivel Recomandare 8: etomidatul poate fi folosit in sigurant pentru sedarea proceduralé a adultulul in UPU.? 2a roe dr uo deat cnc imps Se sec ec cat serio pte prepay de meses de proce cofarat pir rar partes See! pn=N MMMM Md PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, SWWIS-ROMANIAN COOPERATION PROGRAMME Tame aE Feb UPU orsauFOFTInF. | Loa procedur Diagnoste: — DE SEDARE-ANALGEZIE PROCEDURALA (SPA) - evawuage iniqiat oA om Vas TTT TTR Fe (Raw | wrORETS Grete eratevernene women: | 6 agatrreecice fen opariater Tea sees Dasa. 1 tare 0 sede ante ASA bose, care mu ari ta asa totems | Ra wr Scams] seem] | ater ree | ce oxy am caer eerie eaelr FICE senate? | OME Counancinee | was questen summery! |e om aden an penarusedare Docs NY OK © GAT: D normal Cscurt Dingust (© MEDIU (ASA 3, 4) oe |= SONDA ASPIRATIE GASTRICA: CD TINALT (ASA S) ier Le aaa ————s ———— meses 890, % Tat cl ao eee eatoa cs: Sealadurert= ...f0 | * Meh 2 | oe ite: niclunl —— ace re PROPOFOL mal ENT ral ROTO con [Dept sade insects FENTARE ld D erpctnats Cent WORF eam at 1 temgosoasm O heeruabe Div netreyonals OTA onions OasERVATT (ene; ncura Doel: Mie Deanna mares ile dein manlsck 1 ppd Guede! veriae mac tolon HOT Vette cain bol crtsoge mi Pacientul a fost urmarit pang la: 0 trezirea completa/ a starea initials, ora ‘Sao eT Ta etre Filton le (a ts arog a ct a Pact Sl bemeisareS#0:> On a amet Se pot dela sng sila tac ese) Groin inne nv abente Dicer mini assed Stored asda age de eve (de cl ‘tno deo pes aduaesponsla apm oman verbal sis Avera: Aces igri great ecard obra peo aren dor nine seat ln pd one Par oe sree eau. 3 est material» font ea in cad pret induces ca seer staal peatless de mein de trgent pn dtonace 3 ptomentarea a pram fra rit conan pean gat an pres Sr ih ives ont Eeene pets Unuren ropeans extn Prot a ent nba coda ce Con Foden Ein, repent ben Seal Cetard de Denote Cooperate Gurl Ronee, pn Minster Farot, Dice Maton Sei And emer ear Contr prt oli Ser de Sate (C2), atte arePROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS-AOMANIAN COOPERATION PROGRAMME 1. Godwin SA, CaroDA. Wolf SJ et al. American College of Emergency Physicians. ACEP clinical policy: procedural sedation and analgesia in emergency department. ANN EMER Med. 2005, 45:177-196. 2. Godwin SA, Burton JH, Gerardo CI et al. American College of Emergency Physicians. ACEP clinical policy: procedural sedation and analgesia in emergency department. ANN EMER Med. 2014, 63:247-258. 3. Continuum of depth of sedation: definition of general anaesthesia and levels of sedation/analgesia. |ASA, USA 2009 (http://bit.ly/11iGlax). 4, Guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in adults:2010. $ Afr J Anaesthesiol Analg 2010:16 (4)(Supplement 1):51-S4. 5. Safe Sedation Practice for Healthcare Procedures. Academy of Medical Royal Colleges. October 2013. 6. Sedation in Children and young people. Nice clinical guideline 112. December 2010. http://www. guidence.nice.org.uk/egl12. 7. Safe Sedation of Adults in the Emergency Department. Report and Recommendations by The Royal College of Anesthetists and The College of Emergency Medicine. November 2012. 8. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002, 94:1004-17. 8. Sedation and anesthesia in Gl endoscopy. Guideline. Gastrointestinal Endoscopy, 2008, volume 68 No.5: 815-826. 10. Guidelines on sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. Australian and New Zealand College of Anaesthetists (ANZCA). PSO9:2014. www.anzca.edu. au. 11. Clinical Policy: Critical Issues In The Sedation Of Pediatric Patients In The Emergency Department, Annals of Emergency Medicine. 2008;51(4):378-399, e1-e57. 12. R. Strayer / P. Andrus, Emergency Department Procedural Sedation and Analgesia Physician Checklist, emupdates.com 11.28.2013. 13. ESA Guideline on Pre-Operative Fasting. 14, Procedural sedation in adults, Robert L Frank, MD, FACEP, UPtoDate. 15,Protocoles MAPAR 2016. Editia 14, 2016 ISBN: 978-2-905356-45-1. 16. EB Medicine, EMPRACTICE, Martie 2010, Vol 2, nr. 3. Avertment: ces clot repreinté orecomendare de abord i pacientuourgent, dar nu neues deco ccd push de species fcr cae aie ‘est ati ot elt yc plein clay sec staan peptoce de medend de gerd pun dentate molonetrce vs prgram de fomere ret cotnrat pran rt n prea Se ih inte conn Chefene pons Une uopen ered Mosel del bra Aarau ees ng Cosi ser tan, reser nel tvtand de Ouro Coopers Serra fom, pn Minster srt Flee jose Sans rd penetra ert Po Sorc Sate RS} ate de geeiit eee ee ee ee PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, ‘ISS ROMANIAN COOPERATION PROGRAMME 28. RECOMANDARI DE BUNA PRACTICA PENTRU UTILIZAREA ANTIBIOTICELOR IN SERVICIUL DE URGENTA LA PACIENTI ADULT! Prezentul ghid propune céteva recomandéri privind folosirea antibioticelor (terapia antimicrobians) la pacientii adulti din UPU. Vor fi trecute in revist® doar acele afectiuni care neces o initiere @ terapiei cu antibiotice cét mai precoce de la sosirea in departamentul de urgents. in acest sens, {grupul de lucru recomanda urmatoarele afectiuni in care initierea antibioterapiei incd dela sosirea in UPU ar putea contribui in mod semnificativ Ia supravietuires/evolutia favorabilé a pacientilor CUPRINS GHIDUL DE ANTIBIOTERAPIE 1 ANTIBIOTERAPIA IN SOCUL SEPTIC SI SEPSISUL SEVER IN STRUCTURILE PENTRU PRIMIREA URGENTELOR 2 ASPECTE GENERALE 2 SELECT aNTIOTCULUL 2 AANTIIOTERAPIAEMPIRICAINSEPSISULLA COP 6 MENINGITA BACTERIANA z PRINCI GENERALE 7 MENINGITA, TRATAMENT EMPIRIC 7 MENINGTA, TRATAMENT SPECIFIC (AGENT ETIOLOGICIDENTIICAT) 8 CCONSIOERATH SUPLMENTARE 9 DDuRava TRATAMENTULU! 10 DDoZLEIN AZUL UNOR ANTIBIOTIC 51 CHMIOTERAPICEDESINTEZA FOLOSITEININFECTHALE SNC (CLUS -MENINGITA BACTERANA) 10 IMENINGITA BACTERIANKIWN PEDIATRIC n ANTIIOTERAPIAN CAZUL MENINGITI BACTERENE LA COMI (OUPK PERIOADA DE NOU-NASCUT) n ENDOCARDITA BACTERIANA (EB) 12 “TRATAMENTUL ENDOCARDITEI PE VALVE NATWVE EN.) 3 PrecrAat NTALE (NOTE) B ‘TRATAMENTULENOOCAROITEIPE VALVE PROSTETIE(E.V.P.) 15 ENOOCAROITA BACTERANKA COP 16 SEINE $SIMPTOME PREZENTELACOPI CU ENOOCARDIT BACTERANA 16 TESTE PARACUNICE MODIFEATEIN ENDOCARDITALA COP ” ETIOLOGIA ENOOCAROITE! INFECTOASELA COMI v7 ANMIBJOTERAPIALA COP CU ENDOCAROVTA BACTERIANA 18 PROFILAXA SAU NON-PROFLAXIA ENOOCARDITE!BACTERENE 18 1. Bou CARDIAC ASOCIATEENOOCARDITEIBACTERENE 18 I. ALTE pROCEDUR[NAFARA C#LOR TOMATOLOGiCE) $1 ROFIANA ENDOCARDITE! 19 BIBLIOGRAFIE 2 Avetnnt: stags prea recmandr dl obert.a paertlain rent donne seat clic ined se fest ssi sve ‘cet mtr fos eit nc procul Induntre cals soto prea de mead de {igen gon serotarea 7 mpementares un payam Se omar” pe conn pt pa pats Eee Pik Pabce p Mnsten nti nd mpemertat deca Cent pet Po Stl Sate (CSS), estate Se gis 13PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS.ROMANIAN COOPERATION PROGRAMME Antibioterapia in socul septic si sepsisul sever in structurile pentru primirea urgentelor Aspecte generale Regimurile terapeutice antimicrabiene (Antibioterapia). Se va initia tratamentul cu antibiotice pe cale iw. imediat dup obtinerea rezultatelor culturilor (inclusiv hemocultura) microbiene. Alegerea antibioticelor nu este simplé, ea trebuie s& tind cont de istoricul (antecedentele) pacientului, boli asociate, sindromul clinic (starea clinics), date despre germenii microbieni (Gram pozitv/negati, aerobi/anaerobi) si despre rezistenta microbiand in populatia general8 localé (aspectul rezistentei) (7, 52, 53}. © terapie antibioticd (antimicrobian8) intArziat8, inadecvatd sau gresit indicatd (de exemplu, administrarea de antibiotice la care germenii patogeni au fost rezistenti in vitro) este asociaté cu rezultate nesatisfacatoare [54-56] Tntr-un studiu prospectiv de tip cohorts, in care au fost inclusi 2124 pacienti, sa ardtat c& selectia gresiti @ antibioticului @ fost in proportie foarte mare (in mod surprinzétor), de 32% [57] Mortalitatea a fost mult mai mare la acesti pacienti, comparativ cu cei la care antibioterapia a fost indicat corect (34% fata de 18%). © analizé retrospectiva efectuatd asupra a 2731 de pacienti cu soc septic a demonstrat c& cel mai itiere a terapiei antibiotice potrivite [58] puternic predictor al mortalitati a fost timpul de Selectia antibioticului ‘Atunci cénd germenul patogen cauzal sau sursa infectiei nu sunt imediat identificate, recomandam adminsitrarea unui antibiotic (sau asociere de antibiotice) care s8 acopere un spectru larg de germeni microbieni (Gram pozitivi si Gram negativi). Nu sunt disponibile foarte multe ghiduri de initiere a terapiei antibiotice empirice in caz de soc septic si/sau sepsis sever. itd ar fi Dacé nu este vorba de o infectie cauzatl de Pseudomonas aeruginosa, o recomandare pot administrarea de Vancomicind plus unul din urmStoarele: 2}. Cefalosporine de generatia a 3-a sau a 4-a (Ceftriaxona, Cefotaxima sau Cefepima) sau bb) Asocieri de betalactamice cu inhibitori de beta-lactamaza (Piperaciliné-Tazobactam, Ticarcilin’- Clavulanat sau Ampicilind-Sulbactam) sau c). Carbapeneme (Imipenem sau Meropenem). Pe scurt, asocierile de mai sus pot fi \Vancomicina + Ceftriaxon3/Cefotaxima/Cefepima Avertsment es orion erento comondore de delat n urges day none uses nes input ee fe ‘cst mater fos rent ocr protect bunt or pace resptoess de mend de trom nn deve smpbmentaes un rSpam Se omar in pir rams partes Cet pn Inve! cnt hte prt Unuce Europea exes. roel a deat tua Bence Coal ‘acral cetan, mpesertar mn Ana Ehepnd ce Detar Cooper Guvrrl Romana pn Miter For Posie nse Ses find generat ere Contr pets Pl evs de Saat CPS) nae Ae 23SUNN HH gi PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘ISS ROMANIAN COOPERATION PROGRAMME Vancomicind + Imipenem/Meropenem Dac& agentul cauzal este posibil afi Pseudomonas aeruginosa, atunci folosim o combinatie dintre Vancomicing si doua din urmatoarele: 8). Cefalosporine antipseudomonale (Cefepima, Ceftazidima sau Cefoperazona) sau »). Carbapeneme antipseudomonale (Meropenem, imipenem) sau c). Asocieri de tipul betalactamice antipseudomonale-inhibitor de beta-lactamazé (Piperaciins- ‘Tazobactam, Ticarcilin’-Clavulanat} sau 4d), Fluorchinolone cu actiune bund pe Ps. aeruginosa (Ciprofloxacin8) sau €}. Aminoglicozide (Gentamicin8, Amikacind) sau 4. Monobactami (Aztreonam) Trebuie evitatd alegerea a doud antibiotice din aceeasi clasé (de exemplu 2 beta-lactamice) Subliniem importanta aspectului (pettern-ul) sensibiltstii la antibiotice @ germenilor din arealul ‘geografic local, atunci cand alegem o terapie antibiotic3 empiric, lnfectie cu Staphylococcus aureus, dact nu este trataté rapid, este acompaniata de o mortalitate crescuts (58). Se admite cS tulpnile de S. aureus meticilino-reistente (MRSA) sunt cauza sepsisulu ru numai la pacieni internat, csi la cei care nu au fost sptalizati recent [60,61], Muli din acest staflococi posed un facor de virulent (leucociina Panton-Valentine), care este responsabil de producerea unor infectii necrotizante severe [62]. Pentru aceste motive, recomandém ca pacientii care se prezinté cu sepsis de etiologie incerté si primeascé Vancomicin§ iv. (dozeleajustate relat a functa enalB) pin8 cind se poate exclude etilogia MRSA a sepsisulul Dupa primirea rezutatelor culturilor sia sensibiltati germeniior Ia antbiotice, recomandim ca terapia s8 fie una specifics, indreptats impotriva agentulul cauzal. Aste, chiar in conditile unei ameliorriclnice fat de inceperea terapiel empiice. De regula, infctile produse de germenii Gram negativ au fost controlate cu o combinatie de 2antibiotce din clase diferite. Cutoate acest, exists cateva studi clnice si meta-analize care au ardtat cB eficaitatea generali a terapiei combinate nu este superioard monoterapie, de exemplu cu cefalosporine de geratia 3-a sau carbapeneme (57,63- 67]. Mai mult, 0 meta-analiz’ a ardtat o incidents crescuté a reactior adverse in cazul unei duble acoperiri bacteriene (combinatie de 2 antibiotice) (66,67). Pentru aceste motive, recomandém folosirea unui singur antibiotic la care eficactates este dovedit iar toxicitatea este redus. Except, pacienti cu bacteriemie cu Pseudomonas cunoscutd sau suspectati ori avind neutropenie [7,65] Indiferent de regimul de antibioterapie selectat, pacientii trebuie observati indeaproape privind toxicitatea, rSspunsul la tratament si aparitia unor suprainfectii nosocomiale [68]. Durata tratamentulul va fi dictatd de rSspunsul clinical pacientului,tipul de agent patogen si sursa si gradul de infectie [7]. Dacd pacientul este neutropenic, tratamentul va dura pani ce neutropenia va fi rezolvat8, Dacd infectia poate fi exclusé, antibioterapia va fl intrerupt’ pentru a reduce la minim colonizarea sau infectia cu germeni rezistenti la medicamente sau suprainfectii cu alfi germeni patogeni (Candida). Averment est grim presi orecronre obra poet wn 4 nie det linus esol fete 3a ‘eet ater fost rent n cal pleas Inbunstira alt sro spol preted med de {aed prin sevoaraimpemertare no gap Se fama, o-raratpter pare ah pares Cel ih ‘termes corr eho prs Ununes Ciopena ear Pris = cra ints Ac ain Coa eer hetn representa in Aeris Chan de Deas Cope Gurrnd or rh Mn nna EO ric ia nner ec nari Pas be Se eee= SBS Seem ee ea PROGRAMUL DE COOPERARE ELVETIANO-ROMAN, SWISS-ROMANIAN COOPERATION PROGRAMME abel 1 - antibioticele (DC! si denumire comercial) folosite in sepsis ‘Antibiotic | Indica Doza adult Dora copii] Comentaril efotaxima | Sepsis fea | T2giu le facare ® | 50 malig tw | Galalonpornd de gen 3, Toate save (Ciaoran’) | gnecoiogice hi nu se vor depisi | lafiecaresh | pe germeni Gram-negatwi precum | neh Col, Proteus. 51 Klebsiella. Actune variable Ps. Aeruginaso; Categoria de sorcin’: 8 (66 obcel sigur, benefit depasest ical) ‘eftaxona | Tfeehl ca germen!| Tals BATH (de | Sub WS Kg 50 | Cefalospornd de gen 3a cu spectre, (Rocephin’) | secretori de | 23x}; nuse vor | ma/keet, | indeoseb pe Gram negatv; efeactate F penilinas epi 4 feactionats in| mare pe germeni existent categoria de 2 done (a 12 | sorcind: 8 (de obice sigur, benef! | hy dlepasest rica) este 45 calaadut Tieareiind 7 ‘Wb aDig: Temallg | La Fel ca Ta | Periclind anipseudomonalé + mnbtow Clavulanat flay du de betalactamars; acoperre bund pe (imentin’ ‘Gram pontivi(exceptie MASA) st fr este 60 ka: 3.1 6 actune pe Gram-negatil s!anaerobi lwiaash Categoria de sori: 8 (de obicet spur benef depogeste rise) Piperacling Ta 3 BOTS giv. 6 | Sub Eni Wo | Pericling antpeeudamonall + inhib sobactam h este stablit | debeta‘actamars; Categoria de sarin (zosyn') 28 (de obice sigur, beneficul depdseste peste 6 tun | isu) 75 mal bv aon Tmipenem/Cll_| leat G etiologic | SOO malv-la6irne | Sub 3 Tunirnu | Carbapenem ew sciune pe majortatea statin multi, tm care | sevordepisia isi | estestabit | germenlor Gram-poutiv (exceptie (Mienam') | ate antbiotice nu MRSA), Grarn-negatly $i anaerobi; scopers un spectra Peste 3 luni | coregaria de sarcindC inv este stabi larg sou sunt esd 1015 me/ks| siguronto. in odminitare In vg ators tot eta6h | sarin) ‘Meropener Teiwheh “Sub STunk nu | CarBapenen ce acne mal mare pe {Meronem') cestestabit | Gram-negativ si mai mict pe Gram oct, comparativ ey imipenem Peste 3 tun: | categoria de arcing 8 (de obice sigur, 40 me/ke | beneficial depaseste sul) Ia Bh; ew se vor depisi 6 ela Glndamicina | Wiech cw anarobi | 00800 mgiv 8 | S10 malka | Categoria de sarc D (ra prentd (cieocn’) | are 0 oarecare | hy a ru se depas! | Lv. la 8; a nu | sigurantsinsorcind est cid a gravid) actiune pe tupini | 48 9/ se depisi 4 Mss ai erent Aet lari repent recomandar deo ol pacetin gent dor inetd cis neh de speci ec cot ween Sura Sect ‘ees material et eat nc poles tunes cl sence pain psp de edn de Urgent an dears mpementre na scp de emare ret cofnars pian gam an pares Cte ie ‘eer Ehapi,epreerta on Agra Chetan Se Gerctare Coopers Gaver orn, pn Minter finer Pobice sist ini sind molreit ve orl pen Poe Ser ear (PS) atte eee apaiii ee ee ee ee ee | PROGRAMUL DE COOPERARE ELVETIANO-ROMAN SWISS-ROMANIAN COOPERATION PROGRAMME Antibiotic | Indicatii Doza adult | Dozacopii | Comentarii (Flagyl) reguld. in asociatii | mg/ek iv. in decurs | adult, folosind | protozoare; Cotegoria de sarcind: B (de See | a dora de atac; nu Ciprofloxacina 400 mgiv.la12h | 10-15 me/kg | Fluorchinolon’ cu actiune variabili pe {Cipro") ivlai2h streptococi, stafilococi__—_meticilini Vancomicina | Endocardite, ‘30-45 ma/kg/aile &- | Nn (0-7 alle): | Categoria de sarcinas B (oral) 9 (Vancocin") meningite | (eu } 32h interval 15 me/kg | (injectabil; vez! semnificatia mal sus (MRSA), infect cu meskg la 8h ae cons arr : Categoriile de rise privind folosirea medicamentelor in graviditate. Clasificare preluata dupa recomandarile FDA (Food and Drug Administration} Normal8, studille controlate asupra femellor gravide nu au aratat un risc cembrionului/fetus; nu existé totusi tual foarte bine controlate la fernel | gravida. Sau, studiile pe animale au ardtat un anumit efect advers, dar care, tn studille controlate la ferneta gravida nu a fost demonstrat (nu exist& un rise Pentru fetus). Medicamentul poate fi administrat a gravide. Categoria A crescut de tulburdri/malformatit la fat. Medicamentul poate fi administrot a gravide. CategoriaS ‘Studille pe animale nu au demonstrat efecte ddunatoare asupra - Avetsmen: cli presi orecomandr obra porta n aren doris eat ns np i etc sansrcesiuiny acute eet tri fort rast incl pric nbn a gerd pn sersotorosmplenentarea un progam oe omar intmadul cnt Chefene perry Unues Europea esa. roel adult fa Arca ne Cons Fecer etn repreerat pn Aart Eeund ce Beare Cooper Guero pn ante Fare Pie shiner Ssh Md npr cect on pty Poll ers Sede (C9, wala de Asn 5/23ys PROGRAMUL DE COOPERARE ELVETIANO-ROMAN ‘SWISS ROMANIAN COOPERATION PROGRAMME ‘Categoria C ~ Studille pe animele au decelat un efect advers, insd nu existd studii controlate | la ferneile gravide. Sau, nu existd studil asupra animalelor s nici studi controlate asupra femeilor gravide. Medicamentul poate fi administrat numai cu precouti la gravide. Categoria ‘Studile corecte, bine documentate gi controlate sau studille observationale ‘supra femellor gravide au demonstrat un risc pentru fetus. Cu toate acestea, beneficiu terapeutic ar putea dep8si iscul potential. Medicomentul ar trebui evitat la gravide. | Categoria x ‘Studille corecte, bine documentate si controlate sau cele observationale la animale sau femeia gravid au demonstrat existenga tulburSrlor/malformatilor fetale, Folosirea acestor medicamente este contraindicata la femeta gravid sau care ar urma s8 devin8 gravid’, ‘Medicamentul este contraindicat (absolut interzis) la gravide, = a x a x 5 a s a a Antibioterapia empiricd in sepsisul la copii s Medicament Doze {me/kg/ai), | Doza maxima | Germenil vizati (cel mai frecvent a 1 a ' a a ' 1 ' ' ' 1 ' i 1 ' ' ' Intervalu dintre dore | sles “Amikacina 15235 (dvla gh) Te Bacil Gran negatv ulpnl de sptal “ampiclina Tors00 (swash) | 10e Germeni meapsulay obisnul amielina 150300 (dvia#eh) Germeniincapsulayiobipnal, anaerobr sulbactam ‘nfoterdnaB | 05-108 (a 12 aie) Infect fungicdinvaiva ‘Aateonam 720 diva 6A) eee BacillGram-negatiy, Culp de spiked Cefepime 100-150 (diviaS-i2n) | 68 Bacli Grannegati, tulpint de spa, staflocoei Cefotaxima 700200 (dvia6h) | 810g Germeniineapaulay obiana Ceaniima TOO1S0(dvissh) [45g ° | Bacll Gramnegativ Ceviaxona 30400 (dviai22ah) [2a Germenimneapsulat obisnuth Cefuroxime 100-150(aviaéh) | #68 German incapauliobipnu, staflocoa indamicina 60-100 (divia sh cry “Anaerobi,stafiococt Dowding Pa (a2an) 200™me Rickettsiae Gentamicina 575 (alvle Bh) 500 me Bacill Gram-negativ Tmipenem: 60-100 imipenem, (avis | 46g Bacil Grarvnegatii de spial, anaerour Gastatn (Tienamn) | &h) Levofloxacin S10ia24h 500 mg Bacili Gram-negativide spital,staflococi Tnerond 30 (diviash) 7200™m— Enterococi de sota,staflococi Meropenem eoldwiash) ae ‘acl Gramm-negativ de spl, anaeraby _Avertismont Aces igri repent ecomandore de obord a pacientua In urgent dar nv Iculte judecata chic impust de specie fcr caz 6/23 est material ot ent ocr ples intundies cle sami pater pple de men de tigen pon denotarea 7 moementre na peyram demon”, okt cna pian aren paren Pee pn Internat cot ire pee Untunes aroeans ett Poet crt mbes herent onal Fer atin represent pn ages ean ae Dene Cope Gaver omy prn ner Frail oe a bce sno sah, ing plement ety Cat err Patel Seruc de Saat, nealSSUN UUM PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'STSS-ROMANIAN COOPERATION PROGRAMME ‘Medicament Dore (rmg/ke/ai), | Doza maxim’ | Germeniivizati (cel mal Intervalul intre doze | ztlncd ‘Metranidazol 3idviaah) ag ‘Anaerobi - Oxaclina 750200(dvia#6n) | T0I2e “Stallocel Natalia 150 (aiviash) ite Staflacod Piperaclina 200300 (dvie#6h) | 18286 Pseudomonas Piperacling 240 piperaciina (diva 8 | 18 Peeudomonas, taflacod tazobactam » Tetradidina 250 (dvlsi2h) [12g icketsiae Ticaalina 700300 dvaeoH) | 1B2eH Pseudomonas TTobramicina 5-75 (aviash) Bo0me Bacil Gram negativi de spkal MET aT lavieiahy | 12e Saimonels, Shigella, Pneumocystis Vancomicina ‘0 divla 612A) ry Staflococ’ de sptal,enterocad, ppneumococireistent 1 Recomandbil dora concervailor pasate au montanes TORR Meningita bacteriand Principii generale (Odaté ce diagnosticul de meningitd bacteriand este clar, antibioterapia va fl intiatd et mal repede posibil, ideal in primele 30 minute. Nu trebuie asteptat rezultatele de la CT sau de la punctia lombar8. Dac8 punctia lombard poate fi ‘aménati se recomands efectuarea de hemoculturi si inceperea terapiei antibiotic, Tratamentul va fi ajustat apoi, in functie de agentul etiologic identificat side sensiblitatea acestuia la antibiotic. Dozele de antibiotice sunt mult mai mari in cazul infectilor SNC decat in cazul altor localiza Este indicat consuitul unui specialist in bol infectioase in cazul in care antibioticul de ales nu poate fi foiosit sau germenul cauzal este rezistent la tratamentul obisnult Meningita. Tratament empiric | Organismul gazda ‘Agentul patogen Antibiotic de ales ‘Alternativa (Alergie la - _ Penicilins) Imunocompatent” (sub | Pneumacoc, Vancomicing + Moxifioxacing? + 50 ani) Meningococ, Ceftriaxon’ Vancomicin’ influenzae Tmunocompetent Pneumocoe, Listeria, | Vancomicing + Monifloxacina” > (este 50 ani) Meningococ, H. Ceftriaxons + Vancomicing + Influenzae, Streptococ | Ampicilina TMP/SMZ" de grup B _ _Avertisment: ces olga repre o ecomondore de abardo pacentl in urgent, dar au inocuiet deco civic impus Se specif fete coe 7A “ca materi» fot elit nel ric neuter alti sero antler pepe de maid de trae an dots mpemertaree ur room de fara”, pc sotars pra gt nares Eee pn meme arr Shmtee pers UnuneaEuopeors ert Pret del h bra earns ne Coa Feet Ein, reper pr Aura Cena de Serckare 3 Cope Goverl oi, ans arr Debi sera Sant ond emer ne Catn per Pate Sewc dere), malt Hees nsrRuE shun eee.uM v Wr v wi un Qn sss a8 == 5 == se = mae PROGRAMUL DE COOPERARE ELVETIANO-ROMAN 'SWISS-ROMANIAN COOPERATION PROGRAMME. ‘Organismul gazda | Agentul patogen Antibiotic de ales ‘Alternativa (Alergie la I Penicilins) Tmunitate deprimata® | Pneumacoc Listeria, | Vancomicing + Vancomicing + negativi Meningococ,H. Influenzae, Gram Cefepima + Ampiciing | TMP/SMzZ + | Ciprofloxacin Dupa TCC penetrante | Pneumococ (dacd sau interventi existd scurgere de rreurochirugicale Lc), H. | nega Stafllococi, Gram- Influenzae, Vancomicing + Vancomicing + Cefepims Ciprofloxacin Sunt infectat Stafilocoe auriu, Stafilococi coagulazo- negativi Gram negativi Vancomicing + Vancomicing + Cefepims Ciprofloxacin [ Tegendi Se recomandl adrinsrarea de dexametazond;adSugarea dovarsetavonel se recomend lat packnbl ada suspectatde meningtd pneumococcc (majoitate paietior); dozele sunt de 0,15 mg/kglafecare 6h pe cae iv, timp de 2-4 le; prima dors se va administra cu 10-20 minute inalnte sau concomitent cu prima dox8 de antibiotic; administares ‘de antibiotice nu rebue 8 itraie adminstraea de dexametazond;dexametazona ny va administra acl la care deja ‘eau administra antiotie va continua cu dexametaron8 numa dai germeni dn LCR sunt eploeal Gram acl (Ciplococes pneumoniae) sauin culture din (CR sau singe cresetlpin de Streptococcus pneumoniae + se recamand consul alerglogein vederesefectui cure de desenibilzare la pricing TMP. SM2 = trimetoprim-slfametoratolraport de 1:5 (TMP: Sz}; “mutate deprimata (pacientimunocompromis nseamnd: transplan de organ soli, transplant de md in ultimul an, leucemi sub tatament say neutropeie: Meningita. Tratament specific (agent etiologic identificat) Este recomandat consultul de specialitate bolt infectioase (Bl) “Germenul cauzal ‘antibiotic de ales ‘Alternativ’ in car de alerge la Peniciné (consul alergologicin vederea testi eutanate a alergiel+/-desensibilizare pneumoniae (CM pentru PN € 0,06 meg/mi)s/sau Ceftiaxond (CMI < 0,5 meg/mi) Penicling sau eft ividkon’ Vancoricing sau Moxifloxacing sau Linesolid (caiz1meg/m)); Recomandat consultul Bi ‘S. pneumoniae (CMI pentru PN | Ceftriaxon& ‘Moxifloxacing sau Linesolid’ > 1 mcg/ml) si Ceftiaxona (CMI <1 meg/ml); Recomandat cconsultul BI ‘pneumoniae (CMi pentru PN | Ceftriaxond + Vancomicin’ + | Moxifloxacind sau Linesolid’ >O,1-1 meg/mi) siCeftiaxons | Rifampicin’ Avetont ee grin pra 9recomandore de bert urge, a cules ca cn pus de pec fcr savermsestncios Sweat ‘mt materi fos aia in lpia lund cat err stacey presto de medi de end pn aervaree piptenetaree ua program defrmoe”, po carat nm gar pues Eee! pr \narmecul Conbfe!Euefee pene Une Eurpeana ed Pratl a drt ybea eto court ante esr oton represent Age Evans de Denckae Capea Govern Romi, pon Viner Pat Pace sinsnd Snagit ete Com pert aie Sor e Sate (CS), naa de ge 3/23Whee wEeRUReeen ee ee ee PROGRAMUL DE COOPERARE ELVETIANO.ROMAN ‘SWISS-ROMANIAN COOPERATION PROGRAMME Germenulcauzal ‘ntlbotie de ales “Altemativa in cat de alegie a Peniciina (consul slergologic in vederea testriicutanate a alergiel +/-desensibiizare Tsteria ‘Ampielind +/- Gentamicing [meningitidis sensibiila PN | Penicling sau Ceftrixons” | Consult BI (CMI <0,1 mea/mi), | Fr Tnfluenzae (tulpini beta ‘Ampiclin’ sau Ceftriaxon’ Ciprofioxacina”™ - lactamazo-negative) He tniuenzae (eulpini beta- Ceferiaxond Ciprofloxacin’ lactamazo-pozttive) “PrMP sz Ps. aeruginosa Cefepima sau Meropenem Ciprofloxacin’ + Axtreonam (CM de oxacilind > 0,25) “Ampiclind + Gentamicin | E.coli, . Preumoniae Ceftriaxona ‘Aztreonam sau Ciprofioxacina sau TMP-SMZ Enterabacter sop. Meropenem TMP-SMz sau Ciprofloxacin’ | |S aureu masa Oxaciling Vancomicing ‘Saureu MRSA Vancomicing “Stoflococicoaularo-negativi | Oxaclling Vancomicing | (cai de oxacilins 1 meg/ml s< 0,5 mce/ml) “Antibiotic - Doza sicalea de administrare | Durata tratamentului PeniclinaG 18 mill U2 h pe cale iw, fie | 4 siptimani continu iv, fie fractionat in 6 + doze egate (a 4h) ‘mg/kg im. sau iv. la fiecare 8 | 2 *4PtEmani h (3 me/kg/2, fractionat in 3 | doze egale) Vancomicina 30 ma/kg/2a h, ractionate in 2 | 4 séptamani doze egale (la fiecare 12h); nu se vor depasi 2 g/ti ‘abel 1.3. Tratamentul standard In caz de endocardité produsa de enterococi’ “Antibiotic Doza sicalea de administrare | Durata tratamentulul Penicilina @ 18-30 mil UI/24 h pe cale Lv, | 46 sSptimani fie continu iv, fie fractionat in + 6 doze egale (la 4h) Gentamicin Ame/ke im. sau iv la flecare 8 | 46 s4atémani h (3 me/kg/i, fractionat in 3 doze egele) “Ampicilina 12 24h pe cle iv, fie | #6 sptimani continu iw, fie fractionat in 6 + doze egale (a 4h) Gentamicina mg/kg im, sau iva fecare 8 | 46 s8Ptéméni h (3 mafkg/, fracionat in 3 doze egale) Vancomicina™ 30 ma/kg/24 h, fractionate in 2 | 4-6 siptimani doze egale (la fiecare 12 h); nu + se vor depisi 2 g/2i Gentami 46 siptimani mg/kg im. sau iv. la fiecare 8 bh (3 me/kg/2i, fractionat in 3 doze egale) ‘Baree sun pera pain eu farce vera norma Avetment set ot erento resend de aor ol pce n aren darn eu adc cine mph pec cr at ‘Act mtr fos alia in

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