PROTOCOLO DE ACTUACIÓN EXTRAHOSPITALARIA EN EL.docx

7/24/2019 PROTOCOLO DE ACTUACIN EXTRAHOSPITALARIA EN EL.docx

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PROTOCOLO DE ACTUACIN EXTRAHOSPITALARIA EN EL

PACIENTE POLITRAUMATIZADO

SISTEMA DE EMERGENCIAS SANITARIAS DE EXTREMADURA 061

MICHAEL ALEXANDER OMAA VELASCO

14141071

JUAN CARLOS GARCIA

HERRAMIENTAS DE DISEO DOCUMENTAL

UNIVERSIDAD DE SANTANDER

SAN JOSE DE CUCUTA

2016-A


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PROTOCOLO DE ACTUACIN EXTRAHOSPITALARIA EN EL

PACIENTE POLITRAUMATIZADO

SISTEMA DE EMERGENCIAS SANITARIAS DE EXTREMADURA 061

INDICE

Introduccin!

O"#$ti%o&!

E'id$(io)o*+,!

Protoco)o *$n$r,)!M,n$#o d$ ), %+, ,-r$,!

So'ort$ %$nti),torio!

S.oc/!

Tr,u(,ti&(o cr,n$o$nc$)ico!

Tr,u(,ti&(o torcico!

Tr,u(,ti&(o ,"do(in,)!

Tr,u(,ti&(o r,2ui($du),r!

Tr,u(,ti&(o d$ $3tr$(id,d$&!

Tr,u(,ti&(o& $n ), $(",r,4,d,!

Tr,u(,ti&(o& '$ditrico&!

A)*orit(o& d$ tr,t,(i$nto 5 "i")io*r,+,!

i")io*r,+,!


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INTRODUCCION

E) (,n$#o inici,) d$) ',ci$nt$ tr,u(,ti4,do 'r$&$nt, '$cu)i,rid,d$& 2u$ $3i*$n $)

di&$7o d$ '),n$& d$ ,ctu,cin $&'$c+ico&!

L, 'i$dr, ,n*u),r d$) tr,t,(i$nto inici,) d$) tr,u(,ti4,do ), con&titu5$n ),

id$ntiic,cin 'r$co4 d$) ',ci$nt$ *r,%$8 &u tr,t,(i$nto 'r$.o&'it,),rio corr$cto 5

$) tr,n&'ort$ r'ido ,) .o&'it,) ,d$cu,d,($nt$ dot,do 'or &u& 'orticu),r$&

d$(,nd,& ,&i&t$nci,)$&! E&t$ $no2u$ no 'u$d$ ))$%,r&$ , ), 'rctic, &in $)

$&t,")$ci(i$nto d$ &i&t$(,& ,&i&t$nci,)$& 5 'rotoco)o& d$ ,ctu,cin 2u$ ,ci)it$n

), conc$rt,cin d$ )o& $)$($nto& 2u$ int$*r,n $) $&2u$(, (u)tidi&ci')in,rio d$ntro

d$ un &i&t$(, ,&i&t$nci,) d$) 2u$ ',rtici',n u&u,rio&8 '$r&on,) &,nit,rio8 u$r4,&

d$ &$*urid,d8 '$r&on,) d$ ,'o5o8 unid,d$& d$ tr,n&'ort$ 5 un, (,)), d$

tr,n&(i&ion$&! Por $))o8 ), ($dicin, 'r$.o&'it,),ri, inc)u5$ ), INTEGRACINd$ntro d$ un &i&t$(, or(,do 'or un con#unto d$ $)$($nto& (u)tidi&ci')in,rio& 2u$

coordin,do&8 r$&'ond$n , un, d$(,nd, ,&i&t$nci,) '),nt$,d,8 d$ c,rct$r

indi%idu,) o co)$cti%,! Lo& $)$($nto& , int$*r,r &on $)$($nto& i#o& 5 (%i)$&8

.u(,no& 5 t-cnico&8 d$ inr,$&tructur, 5 d$ &o'ort$8 (-dico& 5 d$ ,'o5o8

.o&'it,),rio& 5 $3tr,.o&'it,),rio&8 t$rr$&tr$& 5 ,-r$o&8 $n),4,do& 'or un, (,)), d$

tr,n&(i&ion$& 2u$ )o& diri*$ 5 $n),4,!

Aun2u$ ), $3'$ri$nci, '$r&on,) $& un ,ctor i('ort,nt$8 ),& ,ctu,cion$& &,nit,ri,&

d$"$n o"$d$c$r , 'rotoco)o& $&tricto& 5 ), ,&i&t$nci, d$"$ $&t,r &i&t$(,ti4,d,

',r, )o*r,r ), (,5or $ic,ci, 'o&i")$!

En di%$r&o& $&tudio& &$ r$co*$n conc)u&ion$& (u5 'o&iti%,& d$ ), $ic,ci, d$ )o&

&i&t$(,& d$ $($r*$nci, 'r$.o&'it,),ri, $n ), ,t$ncin in &itu 5 $n ), ,t$ncin

inici,) .o&'it,),ri,8 &o"r$ ), r$duccin d$ ), (ort,)id,d 'or un tr,u(, *r,%$!

Co(o con&$cu$nci, d$ ), ,&i&t$nci, $3tr,.o&'it,),ri, , )o& ',ci$nt$& con tr,u(,

*r,%$8 ))$*,n , ur*$nci,& d$ )o& .o&'it,)$& ',ci$nt$& 2u$ ,nt$& (or+,n $n ),

$&c$n, d$) ,ccid$nt$ o dur,nt$ $) tr,&),do! E&t$ .$c.o &u'on$ un r$to ',r, )o&

c$ntro& .o&'it,),rio& 'or2u$ d,n )u*,r , 2u$ &$ ,ti$nd,n $n ),& r$,& d$

ur*$nci,& ',ci$nt$& (& *r,%$&8 con )$&ion$& (& &$%$r,& 5 (& di+ci)$& d$

tr,t,r! E& n$c$&,rio 2u$ ), or*,ni4,cin d$ ), ,&i&t$nci, ,) tr,u(, $n )o&


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.o&'it,)$& 5 )o& r$cur&o& d$&tin,do& , $))o corr,n ',r$#o& , ), nu$%, d$(,nd, 2u$

*$n$r, ), ,&i&t$nci, inici,) ,) 'o)itr,u(,ti4,do!

A '$&,r d$ ), *r,%$d,d d$ )o& ',ci$nt$&8 un t$rcio d$ $))o& 'u$d$ ,",ndon,r $)

.o&'it,)8 ,un2u$ ,)*uno& d$ $))o& con &$cu$),&! E&to& d,to& r$r$nd,n $n nu$&tro

($dio ), n$c$&id,d d$ di&'on$r d$ un, ,&i&t$nci, 'r$.o&'it,),ri, corr$ct, , )o&

',ci$nt$& con tr,u(, *r,%$!

Por todo )o $3'u$&to8 $& n$c$&,rio con$ccion,r un '),n 'rotoco)i4,do d$

,&i&t$nci, inici,) ,) 'o)itr,u(,ti4,do 5 ,ci)it,r $) ,cc$&o , un &i&t$(, d$

$($r*$nci, )o (& ,d,'t,do , nu$&tro ($dio!

O9ETI:OS

Un, ,&i&t$nci, 'r$.o&'it,),ri, $ic,4 $& ,2u$)), 2u$ 'u$d, d$&'),4,r $n 'oco&(inuto& ,) )u*,r d$) ,ccid$nt$ , $2ui'o& c,',c$& d$ ))$%,r , c,"o (-todo& d$

&o'ort$ %it,)8 d$ t,) (,n$r, 2u$ $) ,ccid$nt,do 'u$d, &$r r$,ni(,do 5 (,nt$nid,&

&u& con&t,nt$& %it,)$& dur,nt$ $) tr,&),do ,) .o&'it,)8 dond$ r$ci"ir $) tr,t,(i$nto

d$initi%o! P,r, $))o8 $& n$c$&,rio di&'on$r d$ co(unic,cion$&8 ($dio& d$

tr,n&'ort$ 5

'$r&on,) $ntr$n,do8 $n uncin d$ ),& n$c$&id,d$& 2u$ &$ d$ri%,n d$ ), oro*r,+,

5 c,r,ct$r+&tic,& d$(o*ric,& d$) r$,8 ti'o d$ ,ccid$nt$ 5 c),&iic,cin d$ )o&

.o&'it,)$& d$ r$$r$nci,!

Lo& o"#$ti%o& d$ $&t$ 'rotoco)o &on;

1 < Contro) 5 (,n$#o d$) $&c$n,rio d$) ,ccid$nt$!

=< E&t,")$c$r ),& 'riorid,d$& d$) (,n$#o d$) ',ci$nt$ 'o)itr,u(,ti4,do! E%,)u,r $)

$&t,do d$) ',ci$nt$ con 'r$ci&in 5 r,'id$4!

>< Inicio d$) (,n$#o 'ri(,rio 5 &$cund,rio n$c$&,rio& dur,nt$ ), 'ri($r, .or,

d$&'u-& d$ ocurrido un tr,u(,ti&(o 2u$ 'on$ $n '$)i*ro ), %id,!

?< R$&ucit,r 5 $&t,"i)i4,r ,) ',ci$nt$ r$&o)%i$ndo )o& 'ro")$(,& $n ord$n

'riorit,rio8 ,&+ co(o &u corr$cto tr,&),do ,) .o&'it,) d$ r$$r$nci,!

@< D$t$r(in,r &i )o& r$cur&o& d$) .o&'it,) d$ r$$r$nci, &on &uici$nt$& ',r,

r$&o)%$r $n or(, ,d$cu,d, )o& 'ro")$(,& d$) ',ci$nt$! Lo& c$ntro& .o&'it,),rio&


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d$"$n $&t,r c,t,)o*,do& d$ t,) or(, 2u$ )o& $2ui'o& &,nit,rio& cono4c,n con

$3,ctitud , dnd$ d$"$n tr,&),d,r , )o& ',ci$nt$& $n uncin d$ ),& c,r,ct$r+&tic,&

d$ ),& )$&ion$&!

6< Con&$*uir 2u$ ), $&c,), d$ co(, d$ G),&*o &$, uti)i4,d, t,nto $n -) ($dio

$3tr,.o&'it,),rio co(o $n $) .o&'it,),rio8 con $) in d$ r$ducir ,) (+ni(o $) ,ctor

'$r&on,) , ), .or, d$ $%,)u,r $) $&t,do n$uro)*ico d$ un ',ci$nt$ tr,u(,ti4,do!

Si ), c),&iic,cin $& in,d$cu,d,8 tod,& ),& d$ci&ion$& 'u$d$n %$r&$ ,$ct,d,&!

B< E),"or,cin d$ un P),n d$ Actu,cin $&'$c+ico ',r, $&to& ',ci$nt$& ',r, ),

Co(unid,d d$ E3tr$(,dur,8 t$ni$ndo $n cu$nt, &u oro*r,+, 5 d$(o*r,+,

co(')$#,&!

En $) r$, d$"$n $3i&tir di&tinto& C$ntro& Ho&'it,),rio& con )o& ($dio& &uici$nt$&

',r, un, ,t$ncin $&'$ci,)i4,d,8 ,&+ co(o di&tinto& C$ntro& d$ At$ncin Pri(,ri,con '$r&on,) or(,do 5 (,t$ri,) n$c$&,rio ',r, un, corr$ct, ,t$ncin ,) ',ci$nt$

'o)itr,u(,ti4,do! Lo& .o&'it,)$& d$ t$rc$r ni%$) d$"$n 'on$r todo& )o& r$cur&o& ,

di&'o&icin d$ ), ,&i&t$nci, ,) tr,u(,! Lo& $2ui'o& d$ $&'$ci,)i&t,& d$"$n d$

,ctu,r coordin,do& 5 )o& ($dio& di,*n&tico& di&'oni")$& d$"$n &$r ,cc$&i")$& $n

todo (o($nto!

), Co(unid,d d$ E3tr$(,dur,8 d$"ido , &u oro*r,+, co(')$#,8 &u *r,n $3t$n&in

5 &o"r$ todo8 ),& *r,nd$& di&t,nci,& $3i&t$nt$& , )o& .o&'it,)$& d$ ),& 4on,&8

r$2ui$r$ un,& con&id$r,cion$& $&'$c+ic,& d$ntro d$) Si&t$(, d$ E($r*$nci,&

Pr$.o&'it,),ri,&8 &i$ndo ), di&t,nci, un 'unto i('ort,nt$ , t$n$r $n cu$nt, 'or

dic.o (oti%o8 &$ ., con&id$r,do 2u$ cu,ndo ), di&t,nci, ,) 'unto d$ u"ic,cin d$)

$2ui'o (%i) d$ $($r*$nci,& ,) )u*,r d$) ,ccid$nt$ $& $3c$&i%,8 &$r n$c$&,rio

2u$ $) '$r&on,) &,nit,rio d$ )o& c$ntro& d$ ,t$ncin continu,d, (& 'r3i(o& &$,

$) 2u$ 'r$&t$ ), ,&i&t$nci, inici,) ,) )$&ion,do8 (i$ntr,& ))$*, ,) )u*,r $) $2ui'o

(%i)8 'udi$ndo $n $&t$ c,&o 5 &i ), *r,%$d,d d$) )$&ion,do ,&+ )o r$2ui$r$8

r$,)i4,r un, tr,n&$r$nci, d$&d$ $&$ 'unto , un, ,("u),nci, ($dic,)i4,d, ',r,

&u corr$ct, $&t,"i)i4,cin 5 tr,&),do ,) .o&'it,) d$ r$$r$nci,!

En r$&u($n8 &$ tr,t, d$ ))$%,r ,) ',ci$nt$ ,d$cu,do ,) .o&'it,) ,d$cu,do8 $n $)

ti$('o ,d$cu,do8 )o 2u$ $3i*$ un, &$)$ccin ,'ro'i,d, d$ )o& ',ci$nt$&8 ),


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di&'o&icin d$ ($dio& d$ tr,n&'ort$ "i$n $2ui',do& 5 un, c,t$*ori4,cin d$ )o&

.o&'it,)$& d$ r$$r$nci,!

ui&i-r,(o& d$&t,c,r )o %,)io&o 2u$ $& ',r, $) ',ci$nt$ 'o)itr,u(,ti4,do 2u$ $)

'ri($r '$r&on,) &,nit,rio 2u$ )o ,ti$nd$ )o .,*, corr$ct,($nt$8 ,un2u$ no

di&'on*, d$ todo& )o& ($dio& 2u$ d$&$,r+,(o&! Cu,ndo $&to& $2ui'o&8 c,&i

&i$('r$ d$ C$ntro& d$ At$ncin Pri(,ri,8 ',rtici',n $n ), $&'$r, d$ ),& UME o $n

), 'ri($r, ',rt$ d$) tr,&),do ',r, r$,)i4,r un, tr,n&$r$nci, , un, UME8 d$"$n

.,c$r)o d$ or(, 2u$ &$, $n $) ',ci$nt$ dond$ r$'$rcut, $) "$n$icio d$ &$r

,t$ndido corr$ct,($nt$ d$&d$ $) 'rinci'io!

EPIDEMIOLOGIA

E) conoci(i$nto d$ ), $'id$(io)o*+, $& d$ un, *r,n i('ort,nci, ',r, )o&'),nt$,(i$nto& t$r,'-utico&8 ,&+ co(o ',r, ), ,&i*n,cin d$ r$cur&o&

F'r$.o&'it,),rio&8 .o&'it,),rio& 5 d$ r$.,"i)it,cin

.,c$r un, corr$ct, '),niic,cin ,&i&t$nci,)!

E&t$ ti'o d$ ',to)o*+, con&titu5$ ), 'ri($r, c,u&, d$ (u$rt$ $n ), 'o"),cin

($nor d$ ?0 ,7o&8 con un, (,5or incid$nci, $n $d,d$& co('r$ndid,& $ntr$ )o&

1 5 ?? ,7o&8 5 ), &$*und, t$rc$r, $n cu,nto , (ort,)id,d *$n$r,) d$ ),

'o"),cin8 r$'r$&$nt,ndo )o& ,ccid$nt$& d$ trico $) B d$ tod,& ),& (u$rt$&8 'or

)o cu,) d$"$ &$r d$ un int$r-& 'riorit,rio!

R$$r$nt$ ,) tr,u(, &$%$ro8 )o& ,ccid$nt$& d$ trico &u'$r,n $) *ru$&o d$ nu$&tr,

$&t,d+&tic,! Por otro ),do8 un c,'+tu)o i('ort,nt$ )o or(,n )o& 'r$ci'it,do&8 5, 2u$

), *r,n $n$r*+, 2u$ &u'on$ $&t$ ti'o d$ tr,u(, 'ro%oc, )$&ion$& d$ *r,n

co(')$#id,d!

L, (ort,)id,d 'or tr,u(,ti&(o& *r,%$& ti$n$ tr$& 'ico& d$ incid$nci, $n r$),cin

con $) ti$('o;

1 < Pri($r 'ico o d$ (ort,)id,d in($di,t,; E& ,2u-)), 2u$ &$ 'roduc$ $n )o&

'ri($ro& (inuto&8 5 oc,&ion,d, *$n$r,)($nt$ 'or TCE &$%$ro8 )$&ion$&

($du),r$& 'or $nci(, d$ C?8 )$&ion$& c,rd+,c,& o )$&ion$& d$ )o& *r,nd$& %,&o&!

Su'on$ un 1@ d$ (ort,)id,d!


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=< S$*undo 'ico d$ (ort,)id,d FHORA DE ORO

'o&icin n$utr,8 5 )i('i$4, d$ c,%id,d "uc,)! Si $& n$c$&,rio ,&'ir,cin u&,r un,

&ond, r+*id,!

Co)oc,cin d$ cnu), oro,r+n*$,!

Tod,& ),& t-cnic,& &$ r$,)i4,rn con ri*uro&o contro) c$r%ic,)!

Ad(ini&tr,cin d$ o3+*$no , ,)to )u#o FJi 0= @08 10 )'(< con (,&c,ri)),!


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Contro) d$ ), r$&'ir,cin!

D$&%$&tir $) tr,3 ',r, co('ro",r (o%i(i$nto& torcico& 5 &i($tr+, d$) tr,3!

D$&c,rt,r ), 'r$&$nci, d$ )$&ion$& 'ot$nci,)($nt$ )$t,)$& Fn$u(otr,3 , t$n&in8

n$u(otr,3 ,"i$rto 5 tr,3 in$&t,")$

in($di,to con co)oc,cin d$ A""oc,t. n 1? o c,t-t$r d$ dr$n,#$ torcico $n =

$&',cio int$rco&t,) )+n$, ($dio c),%icu),r8 o $n @ $&',cio int$rco&t,) )+n$, ($dio

,3i),r!

Contro) circu),torio 5 d$ ),& .$(orr,*i,&!

Contro) in($di,to d$ ),& .$(orr,*i,& $3t$rn,& ($di,nt$ co('r$&in dir$ct,! No

,')ic,r torni2u$t$&!

Co('ro",cin d$ 'u)&o8 co)or 5 t$('$r,tur, d$ ), 'i$)8 r$))$no c,'i),r 5 t$n&in

,rt$ri,) F($di,nt$ ), d$t$ccin d$ 'u)&o c,rot+d$o F 60 (( H*< 5 r,di,) F 0 ((H* Monitori4,cin ECG8 TA 5 'u)&io3i($tr+,!

E3,($n n$uro)*ico!

:,)or,r ni%$) d$ conci$nci, FA:DN; A)$rt,8 %$r",)8 do)or8 no r$&'u$&t,

T,(,7o 5 r$&'u$&t, 'u'i),r!

E&c,), d$ G),&*o!

D$&nud,r ,) ',ci$nt$!

=< J,&$ d$ r$&ucit,cin!

! &ic,($nt$8 &$r $) tr,t,(i$nto d$) &.oc/8 2u$ &$ %$r (& ,d$),nt$!

! Si ',ci$nt$ incon&ci$nt$ F$n *$n$r,)8 GCS


9/80

! Si $3i&ti$&$n &itu,cion$& d$ ,&i&to)i, F',r,d, 'r$&$nci,d, $n $)

'o)itr,u(,ti4,do< R$conoci(i$nto &$cund,rio!

Q C,"$4, 5 c,r,! In&'$ccin d$ ), c,"$4,!

P,)',cin d$) crn$o!

Co('ro",cin d$ 'o&i")$& )$&ion$& ,ci,)$&!

Q Cu$))o!

In&'$ccin d$) cu$))o8 'r$&t,ndo $&'$ci,) ,t$ncin , ), 'o&icin tr,2u$,)!

:,)or,r $3i&t$nci, d$ ),c$r,cion$&8 .$(,to(,&8 $ni&$(, &u"cutn$o 5

c,r,ct$r+&tic,& d$) 'u)&o c,rot+d$o!

E3')or,r ), nuc, "u&c,ndo 4on,& d$ cr$'it,cin 5o do)or!

Q Tr,3!

In&'$ccin 5 ',)',cin!

Au&cu)t,cin d$ ,("o& .$(itr,3 F:-rtic$&; N$u(otr,3! ,&$&; H$(otr,3

S$ 'u$d$n cit,r ),& &i*ui$nt$& $ntid,d$& co(o ),& (& *r,%$&; H$(otr,38

.$(on$u(otr,38 n$u(otr,3 F(& *r,%$ &i , t$n&in o ,"i$rto


10/80

Cur, d$ .$rid,&8 in(o%i)i4,cin d$ r,ctur,&!

Co)oc,cin $n d$c"ito ),t$r,) ',r, $3')or,r ), $&',)d, F&i $& 'o&i")$

ojo! mantener siempre la traccin siguiendoel eje cabeza-cuello-tronco

E:ALUACIN INICIAL DE PERMEAILIDAD DE :A AEREA

L, c,u&, (& r$cu$nt$ d$ o"&truccin d$ ), %+, ,-r$, $n $) ',ci$nt$

'o)itr,u(,ti4,do $& ), c,+d, d$ ), ",&$ d$ ), )$n*u, .,ci, ,tr&8 2u$ &u$)$ ocurrir

$n tod,& ),& &itu,cion$& d$ incon&ci$nci,!

En otro& c,&o& $&t (oti%,d, 'or %(ito&8 &$cr$cion$&8 &,n*r$8 cu$r'o&

$3tr,7o&8 $'i*)oti&8 $d$(, ),r+n*$o8 $tc!

Co(o &i*no& d$ &o&'$c., d$ o"&truccin d$ ), %+, ,-r$,8 'r$&t,r$(o& $&'$ci,),t$ncin ,;

1 < Mo%i(i$nto& r$&'ir,torio& (+ni(o& o ,u&$nt$&!

=< A)t$r,cion$& $n ), co)or,cin d$ ), 'i$) Fru"$,ccinci,no&i&

>< Tr,",#o r$&'ir,torio ,u($nt,do!

?< R$&'ir,cin ruido&, o con tir,#$!

@< Diicu)t,d ',r, %$nti),r con "o)&, 5 (,&c,ri)), FA("

6< IOT diicu)to&,!

PROTECCIN DE LA COLUMNA CER:ICAL

In(o%i)i4,cin d$) cu$))o $n 'o&icin n$utr,!

Si &o&'$c., d$ )$&in c$r%ic,)8 in(o%i)i4,cin con co)),r+n c$r%ic,) r+*ido!

Situ,cion$& $n ),& 2u$ &o&'$c.,r un, )$&in c$r%ic,);

1 < P,ci$nt$& con )$&in &u'r,c),%icu),r $%id$nt$!

=< P,ci$nt$& i(')ic,do& $n tr,u(,& d$ ,)t, %$)ocid,d!

>< Accid$nt$& d$ (otocic)$t,!

?< Pr$ci'it,cion$&!

@< A.o*,do&!


11/80

JASE DE RESUCITACIN DEL POLITRAUMATIZADO

:,)or,r &i$('r$ 'r$&$nci,,u&$nci, d$ tr,u(, ,ci,) o )$&in c$r%ic,)!

L, %+, ,-r$, &$ )i"$r, ($di,nt$ ), (,nio"r, d$ $)$%,cin (,nu,) d$ ),

(,nd+"u),8 con cu$))o $n 'o&icin n$utr,!

Si ), %+, ,-r$, &$ $ncu$ntr, o"&truid, 'or un cu$r'o $3tr,7o8 &$ $$ctu,r ),

(,nio"r, d$ H$i()ic. ',r, con&$*uir ), $3'u)&in d$ dic.o cu$r'o $3tr,7o F$n

d$c"ito8 &i $& 'o&i")$

P,r, *,r,nti4,r ), '$r($,"i)id,d d$ ), %+, ,-r$, &u'$rior &$r n$c$&,ri, ),

uti)i4,cin d$ un tu"o oro,r+n*$o ti'o Gu$d$) o M,5o8 d$ n($ro ,d$cu,do ,)

t,(,7o d$) ',ci$nt$ FR$$r$nci,; E) tu"o d$"$ &$r ,2u$) cu5, )on*itud (& &$

,#u&t, , ), di&t,nci, d$&d$ $) )"u)o d$ ), or$#, .,&t, ), co(i&ur, "uc,) d$)

',ci$nt$

n,&otr,2u$,)8 d$'$ndi$ndo d$) ti'o d$ ',to)o*+, 2u$ 'r$&$nt$ $) ',ci$nt$!

- Indicaciones de I

1 < P,ci$nt$& $n &itu,cin d$ .i'o3i, 'ro)on*,d, o con ri$&*o d$ $)),!

=< P,ci$nt$& $n &itu,cin d$ .i'$rc,'ni, o con ri$&*o d$ $)), Fco("in,d, o no , ),

,nt$rior

>< P,ci$nt$& con )$&ion$& 'o&tr,u(tic,& $n $) r$,!

?< P,ci$nt$& con ,u($nto d$ ), PIC!

@< P,ci$nt$& con ,)t$r,cin int$n&, d$) ni%$) d$ conci$nci,!

- "entajas de la I#.

1 < A&$*ur, '$r($,"i)id,d d$ ), %+, ,-r$, &u'$rior!

=< P$r(it$ $) contro) $&tricto d$ ), %$nti),cin!

>< R$duc$ $) ri$&*o d$ "ronco,&'ir,cin!

?< Po&i"i)it, ), ,&'ir,cin d$ "ron2uio& ,)$#,do&!

@< Poc,& co(')ic,cion$& $n (,no& $3'$rt,&!

- $remisas para I

1 < Todo& )o& ',ci$nt$& ti$n$n ri$&*o d$ "ronco,&'ir,cin!


12/80

=< Todo& )o& ',ci$nt$& 'u$d$n t$n$r )$&ion$& tr,u(tic,& o ,)t$r,cion$&

(oro)*ic,&! Por t,nto8 $& n$c$&,rio t$n$r 'r$',r,d,& t-cnic,& ,)t$rn,ti%,& d$

contro) d$ ), %+, ,-r$,!

>< E& $&'$r,")$ ), ,ci)id,d ',r, $) %(ito con $&t,& (,nio"r,&!

- $reparacin para I#.

1 < Su(ini&tro d$ o3+*$no 5 di&'o&iti%o "o)&,(,&c,ri)),r$&$r%orio con$ct,do!

=< A&'ir,dor uncion,ndo 5 t$r(in,) r+*ido 5 )$3i")$ 'r$',r,do&!

>< P,ci$nt$ %$nti),do $ic,4($nt$ con "o)&,8 (,&c,ri)), 5 o3+*$no!

?< L,rin*o&co'io co('ro",do 5 )i&to!

@< Tu"o& $ndotr,2u$,)$& d$ di$r$nt$& t,(,7o& )u"ric,do&8 con ",)n co('ro",do

5 d$&in),do!

6< Ji,dor di&'oni")$8 5 &i &$ u&,8 )u"ric,do!B< Jr(,co& 2u$ 'u$d,n 'r$ci&,r&$ F&$d,cin 5 r$),#,cin< di&'oni")$&!

< A5ud,nt$& con in&truccion$& concr$t,& &o"r$ &u& uncion$&!

< Monitori4,cin FECG8 'u)&io3i($tr+, 5 TA< co('ro",d, 5 uncion,ndo!

10< P$r&on,) 'rot$*ido ,d$cu,d,($nt$!

- Complicaciones de la I

1 < Hi'o3i, 'ro)on*,d, 'or int$nto& inructuo&o& Fc,d, int$nto d$ intu",cin no

d$"$ &u'$r,r )o& >0 &in %$nti),r

=< Intu",cin $&o*ic,!

>< Intu",cin &$)$cti%, d$) "ron2uio 'rinci',) d$r$c.o!

?< Tr,u(, d$ di$nt$& o t$#ido& "),ndo&!

@< E'+&t,3i& $n c,&o& d$ intu",cin n,&otr,2u$,)!

Co(o ,)t$rn,ti%,& , ), t-cnic, d$ IOT8 cit,(o&;

1 < Cricotiroidoto(+,; Inci&in d$ ), ($("r,n, cricotiroid$, F, uno& = c( 'or

d$",#o d$) r$)i$%$ d$) c,rt+),*o tiroid$&< $ in&$rcin d$ un tu"o orotr,2u$,) o &$t

d$ cricotiroidoto(+, d$ ur*$nci,&!

Co(')ic,cion$&;

H$(orr,*i,!

Eni&$(, &u"cutn$o!

Tr,n&i3in d$ ), ),rin*$!


13/80

N$u(otr,3!

N$u(o($di,&tino!

%quipo necesario&

i&tur+!

Tu"o $ndotr,2u$,) corto d$ c,)i"r$ @ 68 o &$t d$ cricotiroidoto(+, d$

ur*$nci,&!

Pin4,& .$(o&ttic,& cur%,& ',r, di),t,r ), inci&in!

Ti#$r,& 2uirr*ic,&!

T-cnic,;

C,('o 2uirr*ico c$r%ic,) $&t-ri)!

Ini)tr,cin ,n$&t-&ic, d$ ), 4on,! E&t,"i)i4,cin d$ ), ),rin*$ con ), (,no no do(in,nt$ $ inci&in tr,n&%$r&,) ir($

d$ =? c(!

Di),t,cin d$ ), inci&in )u3,ndo )o& c,rt+),*o& con ),& 'in4,&!

Introduccin d$) tu"o $ndotr,2u$,) )u"ric,do F)u"ric,nt$ .idro&o)u")$


14/80

2u$ $) tu"o $ndotr,2u$,) 5 no r$2u$rir8 $n 'rinci'io8 r$),#,cin (u&cu),r ',r, &u

u&o!

SOPORTE :ENTILATORIO EN EL POLITRAUMATIZADO

L, in&uici$nci, r$&'ir,tori, $n $) 'o)itr,u(,ti4,do &$ $&t,")$c$ o "i$n 'or

($c,ni&(o& d$ o"&truccin d$ ), %+, ,-r$,8 o 'or ($c,ni&(o& 2u$ 'roduc$n un,

i('o&i"i)id,d ',r, (,nt$n$r uno& (o%i(i$nto& r$&'ir,torio& ,d$cu,do&! Entr$

$&t,& c,u&,&8 t$n$(o&;

O"&truccin d$ ), %+, ,-r$,!

A&'ir,cin!

N$u(otr,38 .$(otr,3 o ,("o&! Contu&in 'u)(on,r!

Tr,3 in$&t,")$!

H$rid, ,"i$rt, $n ), ',r$d!

L$&in cr,n$o$nc$)ic, o &$ccin ($du),r!

Co(o 'roc$di(i$nto& ',r, con&$*uir un, ,d$cu,d, %$nti),cin8 cit,(o&;

1 < R$&'ir,cin "oc, , "oc,; A'ro%$c., $) ,ir$ $&'ir,do d$) r$,ni(,dor Fcon un,

JiO= d$ 1 ,'ro3i(,d,($nt$< cu,ndo &$ $&t,")$c$ un, &itu,cin d$ ,'n$, 5

no &$ di&'on$ d$ (,t$ri,) ,d$cu,do ',r, d,r ,'o5o %$nti),torio! Un, %,ri,nt$ $&

$) u&o d$ (,&c,ri)),& ',r, r$,)i4,r ), in&u),cin Fr$&'ir,cin "oc,(,&c,ri)),

co("in,cin con un tu"o ti'o Gu$d$) u orotr,2u$,)!


15/80

L, ,d,'t,cin d$ ), (,&c,ri)), , )o& r$)i$%$& ,ci,)$& d$) ',ci$nt$ $& $) 'rinci',)

condicion,nt$ d$ ), $$cti%id,d d$ ), t-cnic,! En todo& )o& c,&o& &$ r$co(i$nd,

2u$ un, &$*und, '$r&on, $$ct, ), co('r$&in d$ ), ),rin*$ contr, ), co)u(n,

F(,nio"r, d$ S$))ic/< , in d$ di&(inuir )o& ri$&*o& d$ in&u),cin *&tric, 5

"ronco,&'ir,cin!

>< :$nti),cin con r$&'ir,dor ($cnico; Lo& %$nti),dor$& ($cnico& &$ 'u$d$n

c),&iic,r $n do& *ru'o&;

,< R$&'ir,dor$& d$ 'r$&in; In&u),n *,& .,&t, 2u$ $n ), %+, ,-r$, &$ ,)c,n4, un,

'r$&in d$t$r(in,d,!

"< R$&'ir,dor$& d$ %o)u($n; In&u),n un )u#o continuo 5, $&t,")$cido!

Lo& r$&'ir,dor$& d$ 'r$&in ti$n$n $) incon%$ni$nt$ d$ 2u$ &i ,',r$c$n o"&tcu)o&

$n $) )u#o ,-r$o $) %o)u($n d$ *,& in&u),do 'u$d$ &$r (+ni(o ,) ,)c,n4,r&$$n&$*uid, ), 'r$&in 'r$d$t$r(in,d,!

E3i&t$n di$r$nt$& (-todo& d$ %$nti),cin ($cnic,;

,< %$nti),cin contro),d,; L, r$cu$nci, r$&'ir,tori, $&t 'r$d$t$r(in,d, 5 $)

',ci$nt$ no 'u$d$ in)uir con (o%i(i$nto& $&'ontn$o& $n &u %$nti),cin! O")i*,

'or )o t,nto , &$d,r 5o r$),#,r 'ro)on*,d,($nt$ ,) ',ci$nt$!

"< %$nti),cin ,&i&tid,; Lo& cic)o& r$&'ir,torio& d$) %$nti),dor ($cnico &$

d$&$nc,d$n,n 'or )o& 'ro'io& $&u$r4o& %$nti),torio& d$) ',ci$nt$8 cu5o $&u$r4o

di&',ro 'u$d$ &$r 'r$$&t,")$cido! Si $) ',ci$nt$ $&t $n ,'n$, 2u$d,r &in

%$nti),r8 'or )o 2u$ &$ &u$)$ u&,r un, co("in,cin d$ %$nti),cin ,&i&tid,

contro),d,8 *,r,nti4,ndo un, r$cu$nci, r$&'ir,tori, (+ni(, ind$'$ndi$nt$ d$ )o&

$&u$r4o& d$) ',ci$nt$!

c< %$nti),cin o")i*,tori, int$r(it$nt$ FIM:


16/80

Incon%$ni$nt$& d$ ), r$&'ir,cin ($cnic,;

Co('ro(i&o .$(odin(ico 'or ($nor ))$n,do c,rd+,co!

,rotr,u(, 'u)(on,r!

Diicu)t,d d$ ,d,'t,cin 2u$ o")i*, , &$d,cin 'ro)on*,d,! R$2ui$r$ UCI 5 tr,2u$oto(+, &i $& 'ro)on*,d,!

Inco(unic, $ inco(od, ,) ',ci$nt$!

Co(')ic,cion$& d$ ), in(o%i)id,d 'ro)on*,d,!

In$ccin r$&'ir,tori,!

Ri$&*o d$ $&t$no&i& tr,2u$,)!


17/80

HEMORRAGIA

S$ d$in$ ), .$(orr,*i, co(o un, '-rdid, ,*ud, d$ ',rt$ d$) %o)u($n &,n*u+n$o!

E) %o)u($n tot,) d$ &,n*r$ ',r, un ,du)to $& d$ ,'ro3i(,d,($nt$ $) B d$) '$&o

cor'or,) F',r, B0 /*; @ )itro&


18/80

C),&iic,cin d$ ),& .$(orr,*i,&;

' ( Clase I.P-rdid, d$ .,&t, $) 1@ FB@000 cc

C)+nic,($nt$ ,'$n,& ,',r$c$n &+nto(,&8 &,)%o un, )$%$ t,2uic,rdi,! En ',ci$nt$&

'r$%i,($nt$ &,no& no n$c$&it, d$ r$'o&icin!

)( Clase II. P-rdid, d$) 1@>0 F001@00 cc

A',r$c$ t,2uic,rdi, (,5or d$ 100 )'(8 t,2ui'n$,8 c,+d, d$ ), ,(')itud d$) 'u)&o8

,)t$r,cin d$ ), TA con di&(inucin d$ ), di$r$nci, $ntr$ TAS 5 TAD8 ,n&i$d,d8

intr,n2ui)id,d 5 r$))$no c,'i),r ,n(,)o! Pu$d$ ,',r$c$r un, di&(inucin d$ ),

diur$&i& F=0>0 cc.or,

(u5 i('ort,nt$8 TAS (u5 ",#,8 ",#, 'r$&in d$ 'u)&o8 d$'r$&in d$) ni%$) d$

conci$nci, 5 diur$&i& (u5 di&(inuid,! L, 'i$) ,',r$c$ r+, 5 ')id, ), corr$ccin

d$ )o& d-icit& &i$('r$ &$r ($di,nt$ ), ,d(ini&tr,cin ur*$nt$ d$ &,n*r$ 5

corr$ccin 2uirr*ic, d$ ), c,u&, d$ &,n*r,do!

SHOC EN EL PACIENTE POLITRAUMATIZADO

E) &.oc/ &$ 'u$d$ d$inir co(o un, ,)t$r,cin d$ ), circu),cin 2u$ oc,&ion, un,

r$,ccin 'round, 5 *$n$r,)i4,d, d$ ), '$ru&in ti&u),r8 'roduci$ndo un, )$&in

c$)u),r r$%$r&i")$ 2u$ &i &$ 'ro)on*,8 'u$d$ &$r irr$%$r&i")$! Por $))o8 $) o"#$ti%o

in,) d$) tr,t,(i$nto d$) &.oc/ &$r ,d$cu,r ), '$ru&in ti&u),r 5 no &)o ),

nor(,)i4,cin d$ ),& con&t,nt$& .$(odin(ic,&! Por )o *$n$r,)8 $) &.oc/ $n $)

',ci$nt$ 'o)itr,u(,ti4,do ,',r$c$ con un d-icit d$ %o)u($n circu),nt$ d$ ,)

($no& $) 1 @ =@!

En $) 'o)itr,u(,ti4,do 'u$d$ ,',r$c$r cu,)2ui$r ti'o d$ &.oc/ 'or $))o8 no&

'od$(o& $ncontr,r;


19/80

1 < SHOC CARDIOGVNICO; S$ d$"$ , un, int$n&, d$'r$&in d$ ), c,',cid,d

&i&t)ic, 5 di,&t)ic, d$) cor,4n8 "i$n 'or di&uncin (iocrdic, o 'or inc,',cid,d

d$) %$ntr+cu)o ',r, ))$n,r&$ $n di&to)$!

=< SHOC NEUROGVNICO; A',r$c$ co(o con&$cu$nci, d$) do)or E& un ti'o d$

&.oc/ di&tri"uti%o!

>< SHOC SVPTICO; A',r$c$ 'or un, int$n&, di&(inucin d$ ),& r$&i&t$nci,&

%,&cu),r$& '$ri-ric,&! S$ 'r$&$nt, $n ,&$& t,rd+,& d$ ), $%o)ucin d$)

'o)itr,u(,ti4,do8 'or )o 2u$ no d$"$ '$n&,r&$ $n -) $n ),& ,&$& t$('r,n,& d$)

tr,t,(i$nto! E& un ti'o d$ &.oc/ di&tri"uti%o!

?< SHOC HIPO:OLVMICO; E) (& r$cu$nt$ $n $) ',ci$nt$ 'o)itr,u(,ti4,do! Lo

,"ord,r$(o& con (& d$t$ni(i$nto!


20/80

SHOC HIPO:OLVMICO


21/80

E&t$ ti'o d$ &.oc/ &$ d$"$ , un, di&(inucin d$) %o)u($n intr,%,&cu),r con

r$),cin , ), c,',cid,d d$ )o& %,&o& $n $) ',ci$nt$ 'o)itr,u(,ti4,do ),

.$(orr,*i, %, , &$r ), c,u&,nt$ d$ ), di&(inucin d$) %o)u($n intr,%,&cu),r! P,r,

2u$ &$ d$&,rro))$ %, , &$r n$c$&,ri, un, '-rdid, d$ %o)u($n circu),nt$ d$ ,)

($no& $) 1@=@8 5 , ($nudo &$ ,co(',7, d$ un r$c)ut,(i$nto d$ )+2uido& d$)

$&',cio $3tr,%,&cu),r! L, r$&'u$&t, d$) or*,ni&(o , ), .i'o%o)$(i, d$'$nd$ d$ ),

cu,nt+, d$ ), '-rdid, 5 d$ ), %$)ocid,d d$ ), (i&(,8 ,&+ co(o d$ ), i('ort,nci, d$

),& )$&ion$& conco(it,nt$&! P,r, ',)i,r $&to& $$cto&8 &$ 'on$n $n (,rc., un,

&$ri$ d$ ($c,ni&(o& co('$n&,dor$& co(i$n4,n con un, 'ro*r$&i%,

%,&ocon&triccin d$ )o& t$rritorio& %,&cu),r$& cutn$o&8 %i&c$r,)$& 5 (u&cu),r$&8

(,nt$ni$ndo $) )u#o c$r$"r,)8 c,rd+,co 5 r$n,)!

E) 'ri($r &i*no $n ,',r$c$r $& ), t,2uic,rdi,8 ,co(',7,d, d$ un, r$duccin $n ),,(')itud d$) 'u)&o8 ori*in,ndo un ($c,ni&(o $ic,4 ',r, (,nt$n$r $) r$torno

%$no&o .,&t, un,& '-rdid,& d$) 101 @ d$ ), %o)$(i,! Si $) %o)u($n &,n*u+n$o

contin, d$&c$ndi$ndo8 &$ r$duc$ $) *,&to c,rd+,co8 di&(inu5$ (& ), ,(')itud

d$) 'u)&o8 c,$ ), TA 5 ",#,n ), '$ru&in c$r$"r,)8 c,rd+,c, 5 r$n,)! A ($did, 2u$

'ro*r$&, $&t, &itu,cin8 &$ d$&$nc,d$n, ), )i"$r,cin d$ c,t$co),(in,&8 2u$

'u$d$ co('$n&,r un, '-rdid, d$ .,&t, $) >0 d$ ), %o)$(i,8 5 &on ),&

r$&'on&,")$& d$ ), t,2uic,rdi,8 &$2u$d,d d$ "oc,8 t$(")or$&8 in2ui$tud8

di,or$&i&8 ',)id$48 ri,)d,d d$ 'i$)8 $tc8 todo& $))o& &i*no& t+'ico& d$) &.oc/! E)

(,nt$ni(i$nto d$ ), r$&'u$&t, 'r$&or, 'or c,t$co),(in,& conduc$ , un d$t$rioro

($t,")ico 2u$ 'u$d$ d$&$nc,d$n,r un $('$or,(i$nto 5o (u$rt$ d$) ',ci$nt$!

Si(u)tn$,($nt$ , ), r$&'u$&t, ,dr$n-r*ic,8 &$ 'roduc$ un, r$di&tri"ucin d$

)+2uido&8 ',&,ndo ',rt$ d$&d$ $) co(',rti($nto $3tr,c$)u),r ,) intr,%,&cu),r!

Lo& tr,u(,ti&(o& d$ ',rt$& "),nd,& 5 ),& r,ctur,& contri"u5$n , ), '-rdid, d$

%o)$(i, 'or;

E3i&tir '-rdid,& d$ &,n*r$ $n $) )u*,r d$) d,7o ti&u),r! L,& r,ctur,& d$ .u$&o&

),r*o& ti$n$n un, '-rdid, $n $) oco d$ B@0 () ),& d$ J-(ur 1@00 () F,& d$

'$)%i& =000 ()8 5 ), d$ un, co&ti)), 1@0 ()!

Ad$(& ,',r$c$ $d$(, d$ )o& t$#ido& $n r$),cin con ), (,*nitud d$)

tr,u(,ti&(o8 5 , $3'$n&,& d$) )+2uido $3tr,c$)u),r!


22/80

Lo& &i*no& ',r, ), %,)or,cin d$ ), $3i&t$nci, d$ &.oc/ &on;

T,2uic,rdi,!

T$n&in ,rt$ri,)!

Diur$&i&! Ni%$) d$ conci$nci,!

E3')or,cin d$ ), 'i$)!

In*ur*it,cin 5u*u),r!

Pr$&in d$) 'u)&o!

R$))$no c,'i),r!

Jr$cu$nci, r$&'ir,tori,!

MANE9O INICIAL DEL SHOC HIPO:OLEMICO

En )o& ',ci$nt$& 'o)itr,u(,ti4,do& $) tr,t,(i$nto inici,) &$r $) d$) &.oc/

.i'o%o)-(ico! Si$('r$ &$ co($n4,r d$ or(, $&trict, 'or un, %,)or,cin d$ ti'oAC8 5 ), 'ri($r, 'riorid,d d$) tr,t,(i$nto $& (,nt$n$r ), %+, ,-r$, '$r($,")$ 5

), ,d(ini&tr,cin d$ o3+*$no!

1 < Contro) d$ ), .$(orr,*i,; Lo& &,n*r,do& $3t$rno& d$"$n d$ contro),r&$ d$

or(, r'id, ($di,nt$ 'r$&in dir$ct, $n $) 'unto d$ &,n*r,do8 , ), %$4 2u$ &$

)o*r,r un ,cc$&o %$no&o ',r, inici,r ), r$'o&icin d$ %o)u($n!


23/80

=< Acc$&o& %$no&o&; D$"$n )o*r,r&$ d$ or(, r'id, &$ r$co(i$nd, $n $&to&

',ci$nt$& ), co)oc,cin d$ do& c,t-t$r$& corto& 5 *ru$&o& d$ c,)i"r$ 1? F),

%$)ocid,d d$ inu&in 'or $&to& c,t-t$r$& $& d$ 1=@ cc(in

',r, ), 'uncin $& ), o&, ,nt$cu"it,) Fdond$ $&$ $ncu$ntr,n ),& %$n,& c$)ic,8

",&+)ic,8 5 ($di,n, ,nt$cu"it,)

c,n,)i4,cin d$ %+,& c$ntr,)$& F&o"r$ todo &u"c),%i,8 5u*u),r int$rn, o intr,&$,

'or d$",#o d$ ), tu"$ro&id,d ,nt$ro&u'$rior d$ ), ti"i,

r,r,($nt$ &$ r$2ui$r$n ',r, ), r$'o&icin d$ )+2uido& $n ,&$& inici,)$&!

>< Tr,t,(i$nto inici,) con )u+do&; L,& &o)ucion$& $)$ctro)+tic,& i&otnic,& &on ),

id$,)$& ',r, ), r$'o&icin $n ),& ,&$& inici,)$& d$ $)),&8 d$ $)$ccin $& $) Rin*$r

),ct,to8 5 $n &$*undo )u*,r $) &u$ro &,)ino 08 Fri$&*o d$ ,cido&i&

.i'$rc)or-(ic,

Tr,& ), &o"r$c,r*,8 &$ %,)or,n )o& c,("io& $n )o& ',r($tro& .$(odin(ico&8 5

d$ ,cu$rdo , $))o&8 &$ contin, ), r$'o&icin d$ %o)u($n! P,r, c,)cu),r ), c,ntid,d

d$ )+2uido& , r$'on$r &$ uti)i4, ), r$*), d$) >31 8 d$ or(, 2u$ &$ r$'on$n >

',rt$& d$ &o)ucin $)$ctro)+tic, 'or c,d, ',rt$ d$ %o)u($n &,n*u+n$o '$rdido8

c,)cu),do ($di,nt$ )o& &i*no& 5 &+nto(,& 2u$ 'r$&$nt, $) $n$r(o! Co(o

r$co($nd,cin8 &$ 'u$d$ ,d(ini&tr,r un, &o"r$c,r*, inici,) d$ 1000 cc d$ Rin*$r

L,ct,to $n $) &.oc/ ti'o II8 5 d$ =000 cc $n $) &.oc/ ti'o III8 5 o"&$r%,r ),

r$&'u$&t,! En $n$r(o& con r,ctur,& d$ .u$&o& ),r*o&8 &$ 'u$d$ uti)i4,r co(o

'roi),3i& d$) $("o)i&(o *r,&o ), inu&in d$ =00 () d$ R.$oM,crod$3 &,)ino $n

1@=0 (inuto&! T,("i-n $& r$co($nd,")$ $) no ))$%,r ),& cir,& d$ TA .,&t, ),

nor(,)id,d8 &ino (,nt$n$r),& un 'oco 'or d$",#o F$n torno , 100 (( H* d$ TAS


24/80

5 $n )o& ni7o& (,5or$& d$ 1 ,7o&8 d$ 1 cc/*.or,! Si ),& diur$&i& &on

in$rior$&8 indic,n 2u$ ),& c,ntid,d$& d$ )+2uido& ,d(ini&tr,d,& &on

in&uici$nt$& 5 &$ d$"$ ,u($nt,r ), c,ntid,d 5o $) rit(o d$ inu&in8 ,&+ co(o

r$$%,)u,r ,) ',ci$nt$ ',r, d$t$ct,r 'o&i")$& nu$%,& c,u&,& d$ &.oc/!

ERRORES W COMPLICACIONES EN LA REANIMACIN DEL SHOC

HIPO:OLVMICO

1 < H$(orr,*i, (,nt$nid,; E& ), c,u&, (& r$cu$nt$ d$ (,), r$&'u$&t, ,)

tr,t,(i$nto!

=< So"r$c,r*, d$ )u+do&; Si $) ',ci$nt$ &$ $ncu$ntr, (onitori4,do8 $&t$ ri$&*o $&

(+ni(o! L, ($#or or(, d$ %,)or,r &u 'r$&$nci, $& ), 'r$&$nci, d$ in*ur*it,cin

5u*u),r!>< R$&'u$&t, in,d$cu,d,; :,)or,r ), 'r$&$nci, d$ otr,& &itu,cion$&8 co(o

n$u(otr,38 '-rdid,& no %,)or,d,& d$ )u+do&8 di&t$n&in *&tric,8 t,'on,(i$nto

c,rd+,co8 di&uncin (iocrdic,8 $tc!

?< Ad(ini&tr,cin 'r$co4 d$ dro*,& %,&o,cti%,&; Nunc, uti)i4,r $n ),& ,&$&

inici,)$&!

@< E(')$o indi&cri(in,do d$ "ic,r"on,to!

6< Mo%i)i4,cin d$) ',ci$nt$ &in 'r$%i, $&t,"i)i4,cin!

B< E(')$o in,d$cu,do d$ &$d,nt$& 5 ,n,)*-&ico& 2u$ 'u$d$n $n(,&c,r,r ),

c)+nic, d$) ',ci$nt$!

< Po&icion$& incorr$ct,& dur,nt$ $) tr,&),do Fc,"$4, &i$('r$ .,ci, $) &$ntido d$

), (,rc.,


25/80

TRAUMATISMO CRANEOENCEJALICO


26/80

E) tr,u(,ti&(o cr,n$o$nc$)ico *r,%$ 'u$d$8 ,d$(& d$ 'on$r $n '$)i*ro ), %id,

d$) $n$r(o8 'roducir *r,%$& &$cu$),& +&ic,& $ int$)$cti%,&! E&t, 'o&i"i)id,d

,u($nt, &i &$ .,c$ un di,*n&tico 5 tr,t,(i$nto ,d$cu,do t,rd+o!

JISIOPATOLOGIA

L, )$&in c$r$"r,) tr,u(tic, $& din(ic, 5 $%o)uti%, $n ),& 'ri($r,& ? .or,&! A

), )$&in oc,) inici,)8 ,d$(& d$) d,7o 2u$ d$'$nd$ d$ &u $3t$n&in 5

)oc,)i4,cin8 &$ ,7,d$n otr,& )$&ion$& &$cund,ri,&8 co(o .$(,to(,&8

%,&o$&',&(o&8 i&2u$(i,& )oc,)$& 5 $d$(, c$r$"r,) $n *r,do %,ri,")$! E) $d$(,

c$r$"r,) 'u$d$ &$r citot3ico8 *$n$r,)($nt$ 'roducido 'or .i'o3i,8 con ",rr$r,

.$(,to$nc$)ic, +nt$*r, 5 d$ 'r$do(inio intr,c$)u),r8 o &$r %,&o*-nico8

$3tr,c$)u),r8 con ",rr$r, .$(,to$nc$)ic, rot,!

T,nto ),& )$&ion$& oc,)$&8 )o& .$(,to(,& intr, 5 $3tr,c$r$"r,)$&8 $) $d$(,c$r$"r,) 5 $) .i'$r,)u#o &,n*u+n$o c$r$"r,) ,u($nt,n $) %o)u($n intr,cr,n$,) 5

'or )o t,nto ), 'r$&in intr,cr,n$,)8 )o 2u$ $('$or, d$ or(, i('ort,nt$ ),

i&2u$(i, c$r$"r,)!

Hi'$rt$n&in intr,cr,n$,); E) crn$o $& un co(',rti($nto c$rr,do $n $) 2u$

$3i&t$n tr$& co('on$nt$&; P,r-n2ui(, c$r$"r,) F@

TCE )o& c,("io& d$ $&to& co('on$nt$& &$ 'roduc$n d$ or(, (u5 r'id,8 )o

2u$ con))$%, 2u$ '$2u$7o& ,u($nto& d$ %o)u($n 'rodu4c,n *r,nd$&

$)$%,cion$& d$ PIC! P,r, co('$n&,r ), $)$%,cin inici,) d$ ), PIC 'roducid,

'or un, .$(orr,*i,8 contu&in o LOE c$r$"r,)8 &$ 'roduc$ un, $)$%,cin inici,)

d$ ), r$,"&orcin d$ LCR &i , '$&,r d$ $))o contin, ), $)$%,cin d$ ), PIC &$

'roduc$ un, %,&ocon&triccin c,'i),r 5 %$no&, 2u$ r$'$rcut$ $n un (,5or

$d$(, 5 (& ,u($nto d$ ), PIC! L, c)+nic, d$ HTIC con&i&t$ $n 'ro*r$&i%o

d$t$rioro d$) ni%$) d$ conci$nci,8 "r,dic,rdi, $ HTA!

E%,)u,cin d$) t,(,7o 5 r$&'u$&t, 'u'i),r8 ,&+ co(o &u $%o)ucin!


27/80

Joc,)id,d n$uro)*ic,; D$ (odo &o($ro8 &$ 'u$d$n "u&c,r d-icit& (otor$&

F(o%i)i4,cin ,cti%, d$ ),& cu,tro $3tr$(id,d$&< 5 d-icit& &$n&iti%o&

F&$n&i"i)id,d di&cri(in,ti%,

E&c,), d$ co(, d$ G),&*o; R$&u)t, (u5 ti) ',r, ), %,)or,cin 'untu,) 5

$%o)uti%, d$) ni%$) d$ conci$nci, d$ un ',ci$nt$ con un TCE &i ), 'untu,cin

$& ($nor d$ &$ con&id$r, un TCE *r,%$!

TRATAMIENTO PREHOSPITALARIO DEL TCE

E) tr,t,(i$nto inici,) d$) TCE $n $) ($dio $3tr,.o&'it,),rio &$ ",&, $n (,nt$n$r

un, corr$ct, o3i*$n,cin8 %$nti),cin 5 .$(odin(ic, d$) ',ci$nt$ ',r, ,&$*ur,r

un, "u$n, '$ru&in c$r$"r,) 5 $%it,r ), $)$%,cin d$ ), PIC 'or $nci(, d$ un,&

cir,& 2u$ ,u($nt$n $) d,7o d$) t$#ido c$r$"r,)!


28/80

L,& ($did,& , to(,r &on di$r$nt$& &$*n $) $&t,do 5 ), c)+nic, d$) ',ci$nt$ ',r,

c),&iic,r)o& uti)i4,r$(o& ), $&c,), d$ G),&*o8 5 &$*n &u 'untu,cin8

di$r$nci,(o&;

1 < GCS $ntr$ 1@ 5 'unto&; En $&to& $n$r(o& to(,r$(o& ),& &i*ui$nt$&

($did,&;

M,nt$ni(i$nto d$ %+, ,-r$, '$r($,")$!

M,nt$ni(i$nto d$ un, corr$ct, %$nti),cin un, &itu,cin d$ .i'o%$nti),cin

'u$d$ ,c,rr$,r un ,u($nto d$ ), PIC!

Ad(ini&tr,cin d$ o3+*$no 'or (,&c,ri)), ,) @0 Ft,nto ), .i'o3$(i, co(o ),

.i'$rc,'ni, 'ro%oc,n %,&odi),t,cin c$r$"r,)

Otr,& c,u&,& d$ ,u($nto d$ ), PIC &on ), to& 5 ), in,d,'t,cin ,) r$&'ir,dor8

2u$ d$"$n &$r corr$*id,& )o ,nt$& 'o&i")$!

Corr$ct, o3i*$n,cin8 (,nt$ni$ndo un, S0= $n torno , !


29/80

M,nt$ni(i$nto d$ un, ,d$cu,d, 'r$&in d$ '$ru&in c$r$"r,)8 ',r, $%it,r $)

,u($nto d$ ), PIC o ), i&2u$(i, c$r$"r,)! S$ d$"$ (,nt$n$r un, TAM $n torno

, 100 (( H*!

Si $3i&t$ un, 'untu,cin GCS ",#,8 con &i*no& d$ HTIC Fd$t$rioro d$) ni%$) d$

conci$nci, .,&t, $) co(,8 (idri,&i& no r$,cti%, con ,ni&ocori,8 'to&i&

',)'$"r,)8 r$&'ir,cin d$ C.$5n$Sto/$& 5 &i*no& d$ d$cortic,cin o

d$&c$r$"r,cin< &$ d$"$ ,d(ini&tr,r M,nito)8 , un, do&i& d$ 1 */* d$ '$&o $n

=0 (inuto& F"o)o d$ =00 ()! Cuid,do con un, 'o&i")$ &o"r$c,r*, c,rd+,c, 5

con $) $$cto r$"ot$ d$ ,u($nto d$) $d$(, c$r$"r,) 'or ,rr,&tr$ d$ ,*u, ,)

$&',cio c$r$"r,)

E) u&o indi&cri(in,do d$ ), .i'$r%$nti),cin $n $&to& ',ci$nt$& no $&t

indic,do &)o &$ ,')ic,r cu,ndo $3i&t$n &i*no& d$ HTIC con $nc),%,(i$nto

c$r$"r,)8 'u$& $&t, &itu,cin condicion, un, i&2u$(i, (u5 i('ort,nt$ d$)

',r-n2ui(, c$r$"r,)!

No $&t indic,do $n $) ($dio $3tr,.o&'it,),rio ), ,d(ini&tr,cin d$

D$3,($t,&on,8 ,ntico(ici,)$& F&,)%o &i $) ',ci$nt$ 'r$&$nt, cri&i& co(ici,)$&@ d$ &u %o)u($n &,n*u+n$o

,nt$& d$ 'r$&$nt,r t,2uic,rdi,8 .i'ot$n&in 5 otro& &i*no& d$ .i'o%o)$(i,! E& ,&+

co(o $) $to 'u$d$ $&t,r $n &.oc/ 5 'ri%,do d$ '$ru&in %it,) (i$ntr,& 2u$ ),

condicin (,t$rn, 5 )o& &i*no& %it,)$& ,',r$c$n $&t,")$&! S$ contr,indic, ),

,d(ini&tr,cin d$ ,(in,& 'r$&or,& ',r, r$&t,ur,r ), 'r$&in ,rt$ri,) (,t$rn,8 5,

2u$ $&t,& &u&t,nci,& r$duc$n (& $) )u#o &,n*u+n$o ut$rino8 r$&u)t,ndo $n

.i'o3i, $t,)!

! E%,)u,cin &$cund,ri,;

L, r$%i&in &$cund,ri, d$"$ &$*uir $) (i&(o $&2u$(, 2u$ ',r, ),& ',ci$nt$& no

$(",r,4,d,&! E) $3,($n d$ ), ',ci$nt$ d$"$ inc)uir ), $%,)u,cin d$ ),


68/80

irrit,"i)id,d 5 $) do)ori(i$nto ut$rino&8 ,)tur, 5 &$n&i"i)id,d ,nor(,) d$) ondo

ut$rino8 ruido& c,rdi,co&8 5 (o%i(i$nto& $t,)$&! H,5 2u$ 'r$&t,r ,t$ncin

cuid,do&, , ), 'r$&$nci, d$ contr,ccion$& ut$rin,& 2u$ &u*i$r,n un tr,",#o d$

',rto 'r$(,turo o , contr,ccion$& t$tnic,& ,co(',7,d,& d$ &,n*r,do %,*in,)8

&u*iri$ndo ), &$',r,cin d$ un, '),c$nt, nor(,)($nt$ i('),nt,d, F,"ru'tio

(,nd,torio .o&'it,)i4,r , un, ',ci$nt$ $n 'r$&$nci, d$ &,n*r,do %,*in,)8

irrit,"i)id,d ut$rin,8 (o)$&ti, ,"do(in,)8 do)or o c)ico&8 $%id$nci, d$ .i'o%o)$(i,8

c,("io& o ,u&$nci, d$ ruido& c,rdi,co& $t,)$& o &,)id, d$ )+2uido ,(nitico! E)

$to 'u$d$ $&t,r $n ri$&*o , '$&,r d$ 2u$ $3i&t, un, (+ni(, )$&in $n ), (,dr$!

C! Monitori4,cin;

'( $aciente&

Si $& 'o&i")$8 un, %$4 t$r(in,do $) $3,($n +&ico8 ), ',ci$nt$ &$ d$"$ (onitori4,r$n 'o&icin d$ d$c"ito ),t$r,) i42ui$rdo! L, r$&'u$&t, d$ ), 'r$&in %$no&,

c$ntr,) , ), ,d(ini&tr,cin d$ un "o)o d$ )+2uido& intr,%$no&o& $& d$ *r,n %,)or $n

$) (,nt$ni(i$nto d$ ), .i'$r%o)$(i, r$),ti%, n$c$&,ri, $n $) $(",r,4o!

)( 2eto&

E) &uri(i$nto $t,) 'u$d$ t$n$r )u*,r $n cu,)2ui$r (o($nto8 &in 'r$%io ,%i&o8

,un2u$ ), r$cu$nci, c,rdi,c, $t,) &$ 'u$d$ d$t$r(in,r con cu,)2ui$r

$&t$to&co'io! E) ,u($nto in,d$cu,do d$ ), r$cu$nci, c,rd+,c, $t,) $n r$&'u$&t,

, )o& (o%i(i$nto& $t,)$& o "r,dic,rdi, $n r$&'u$&t, , ),& contr,ccion$& ut$rin,&

indic,n .i'o3i, $t,)!

D! At$ncin D$initi%,;

Ad$(& d$ ), *,(, d$ )$&ion$& $ncontr,d,& $n ), ',ci$nt$ no $(",r,4,d,8 $)

tr,u(, dur,nt$ ), *$&t,cin 'u$d$ 'roducir ru'tur, ut$rin,! L, ru'tur, tr,u(tic,

'u$d$ 'r$&$nt,r un cu,dro c)+nico (u5 %,ri,do 'u$d$ 'r$&$nt,r&$ con

.$(orr,*i, (,&i%, 5 &.oc/8 o &)o 'r$&$nt,r &i*no& 5 &+nto(,& r$),ti%,($nt$

(+ni(o&!

L, &$',r,cin '),c$nt,ri, d$ ), ',r$d ut$rin, F,"ru'tio '),c$nt,$< $& ), c,u&, (&

i('ort,nt$ d$ (u$rt$ $t,) d$&'u-& d$ un tr,u(, ,"do(in,) c$rr,do! E) tr,",#o d$

',rto 'r$(,turo 5 $) &,n*r,do %,*in,) $3t$rno 'u$d$n inici,r&$ con un,

&$',r,cin '),c$nt,ri, 2u$ co('ro($t, $) =@ d$ &u &u'$rici$! L,&


69/80

&$',r,cion$& '),c$nt,ri,& (,5or$& &$ ,&oci,n con ,u($nto d$) &uri(i$nto 5

(u$rt$ $t,)! Ad$(& d$) &,n*r,do $3t$rno8 otro& &+nto(,& 5 &i*no& 'u$d$n inc)uir

do)or ,"do(in,)8 do)or 5 contr,ctur, ut$rin,8 $3',n&in d$) ondo ut$rino8 &.oc/

(,t$rno!

Lo& %,&o& '-)%ico& *r,nd$& $ in*ur*it,do& 2u$ rod$,n ,) t$ro *r%ido 'u$d$n

contri"uir ,) &,n*r,do r$tro'$riton$,) (,&i%o8 d$&'u-& d$ un tr,u(, c$rr,do

,&oci,do , r,ctur,& '-)%ic,&! E) (,n$#o inici,) $&t diri*ido , ), r$&ucit,cin 5

$&t,"i)i4,cin d$ ), ',ci$nt$ $(",r,4,d,8 5, 2u$ $n $&$ (o($nto ), %id, d$) $to

d$'$nd$ d$ ), int$*rid,d (,t$rn,! L, (onitori4,cin $t,) d$"$ (,nt$n$r&$

d$&'u-& d$ 2u$ &$ ., r$&ucit,do 5 $&t,"i)i4,do , ), (,dr$! E&t indic,d, ),

int$rcon&u)t, con $) o"&t$tr,8 ',r, ,5ud,r $n ), ,t$ncin d$initi%, d$) $to!

TRAUMATISMOS EN LA EDAD PEDIATRICA

INTRODUCCIN

C,&i == (i))on$& d$ ni7o& &$ )$&ion,n c,d, ,7o $n )o& E&t,do& Unido&8 )o 2u$

&u'on$ c,&i uno d$ c,d, tr$& $n $d,d '$ditric,! L,& )$&ion$& &o"r$',&,n , tod,&

),& $n$r($d,d$& (,5or$& $n ,du)to& #%$n$& 5 ni7o&8 )o 2u$ ),& .,c$ $) t'ico

(,& &$rio d$ &,)ud $n $&t, 'o"),cin! Lo, ,ccid$nt$& con %$.+cu)o& , (otor8 5,

&$, co(o ocu',nt$8 '$,tn o cic)i&t,8'roduc$n ), (,5or+, d$ ),& (u$rt$& $n $&t$

*ru'o8 &$*uid,& 'or ,.o*,(i$nto&8 inc$ndio& d$ c,&,& 5 .o(icidio&! L,& c,+d,& 5

)o& ,ccid$nt$& oc,&ion,do& 'or %$.+cu)o& &on r$&'on&,")$& c,&i d$ un 0 d$

tod,& ),& )$&ion$& '$ditric,&8 ,un2u$ ,),r(,nt$($nt$ $) n($ro d$ )$&ion$&

'$n$tr,nt$& %, $n ,u($nto! L,& )$&ion$& d$ ()ti')$& r*,no& 5 &i&t$(,& &on ),

r$*), 5 no ), $3c$'cin! Por t,) r,4n8 d$"$ ,&u(ir&$ 2u$ $3i&t$n )$&ion$&

&i&t-(ic,& ()ti')$& .,&t, 2u$ no &$ d$(u$&tr$ )o contr,rio! Lo& ni7o& con

)$&ion$& $n ()ti')$& &i&t$(,& &$ d$t$rior,n r'id,($nt$ 5 &ur$n co(')ic,cion$&

*r,%$&! E& 'or $&to 2u$ )o& ',ci$nt$& d$"$n &$r tr,&),d,do& r'id,($nt$ , un,

unid,d con tod,& ),& ,ci)id,d$& ',r, (,n$#,r)o&! E) ord$n $n ), $%,)u,cin 5

tr,t,(i$nto d$) ni7o tr,u(,ti4,do $& i*u,) ,) d$) ,du)to!


70/80

Un ,&'$cto , con&id$r,r $& ), ,&i&t$nci, ,) ni7o (,)tr,t,do8 2u$ d$"$ d$

&o&'$c.,r&$ cu,ndo &$ ,&i&t$ , un ni7o 2u$ 'r$&$nt, )$&ion$& tr,u(tic,&

in$3')ic,")$&8 $n )u*,r$& inr$cu$nt$& F*$nit,)$&8 (,(,&!!!


71/80

En $) ni7o 2u$ r$&'ir, $&'ontn$,($nt$8 ), %+, ,-r$, d$"$ &$r ,&$*ur,d,

($di,nt$ ), (,nio"r, d$ $)$%,cin (,ndi"u),r! S$ d$"$ ,d(ini&tr,r o3+*$no

&u')$($nt,rio d$&'u-& d$ .,"$r $)i(in,do )o& cu$r'o& $3tr,7o& 5 &$cr$cion$& d$

), "oc, 5 oro,rin*$! Si $) ',ci$nt$ &$ $ncu$ntr, incon&ci$nt$8 'u$d$ &$r

n$c$&,rio ), uti)i4,cin d$ (-todo& ($cnico& ',r, (,nt$n$r ), %+, ,-r$,

'$r($,")$! Ant$& d$ int$nt,r $&t,")$c$r un, %+, ,-r$, ($cnic,8 $) ni7o d$"$ &$r

o3i*$n,do!

'. - C/nula orofar3ngea&

L, (,nio"r, d$ introducir ), cnu), ,) r$%-&8 .,ci-ndo), *ir,r 10 *r,do&8 no $&

r$co($nd,")$ $n $) ',ci$nt$ '$ditrico! S$ 'u$d$ oc,&ion,r )$&in d$ )o& di$nt$&

o d$ )o& t$#ido& "),ndo& d$ ), oro,rin*$! E& 'r$$ri")$ diri*ir &u,%$($nt$ ), cnu),

.,ci, ), oro,rin*$ uti)i4,ndo un d$'r$&or d$ )$n*u, ',r, d$'ri(ir $&t$ r*,no! Nod$"$ uti)i4,r&$ $n $) ni7o con&ci$nt$!

). - Intubacin orotraqueal&

L, intu",cin $ndotr,2u$,) $& ), (,nio"r, (& $$cti%, ',r, %$nti),r , un ni7o

con 'ro")$(,& d$ ), %+, ,-r$,! Con o"#$to d$ $%it,r $d$(, &u"*)tico 5

u)c$r,cin8 d$"$n uti)i4,r&$ tu"o& '$ditrico& $&'$ci,)$& &in (,n*uito .inc.,")$!

E) r$, (& '$2u$7, d$ ), %+, ,-r$, d$) ni7o &$ $ncu$ntr, , ni%$) d$) c,rt+),*o

cricoid$&8 $) cu,) or(, un ci$rr$ n,tur,) ,< tu"o orotr,2u$,) 'or )o t,nto8 )o& tu"o&

orotr,2u$,)$& con *)o"o8 no &on n$c$&,rio&! Un, (,nio"r, &$nci)), ',r,

&$)$ccion,r $) t,(,7o d$) tu"o orotr,2u$,) (& ,d$cu,do $& ), d$ uti)i4,r ), n,rin,

d$) ni7o co(o r$$r$nci, ,) di($tro d$) tu"o otro (-todo ti) $& $) d$ co*$r un

tu"o d$ di($tro co(',r,")$ ,) d$) d$do ($7i2u$ d$) ni7o!

L, intu",cin $ndotr,2u$,) ",#o %i&in dir$ct,8 con ,d$cu,d, in(o%i)i4,cin 5

'rot$ccin d$ ), co)u(n, c$r%ic,)8 'ro'orcion, $) (-todo (& i,")$ ',r, ,&$*ur,r

$) contro) inici,) d$ ), %+, ,-r$, &u'$rior! L, intu",cin n,&otr,2u$,) no d$"$

$$ctu,r&$ $n ni7o& F'u$d$ .,c$r&$ $n n$on,to&


72/80

.$(itr,38 , ni%$) d$ ), ,3i),8 ',r, c$rcior,r&$ d$ ), 'o&icin corr$ct, d$) tu"o! S$

d$"$n $&cuc.,r "u$no& &onido& r$&'ir,torio& $n ,("o& ),do& 5 d$"$n ,u&cu)t,r&$

con r$cu$nci, ',r, t$n$r ), c$rt$4, d$ 2u$ &i*u$ $n "u$n, 'o&icin 5 d$ 2u$ no

., 'roducido nin*un, )$&in 'u)(on,r co(o con&$cu$nci, d$ ), ,d(ini&tr,cin d$

un $3c$&o d$ %o)u($n d$ ,ir$! Cu,)2ui$r (o%i(i$nto d$ ), c,"$4, 'u$d$

d$&'),4,r $) tu"o $ndotr,2u$,)!

*. - Cricotiroidotom3a&

L, cricotiroidoto(+, 2uirr*ic, (u5 r,r, %$4 $&t indic,d, $n ), in,nci, o $n $)

ni7o '$2u$7o8 '$ro &i u$r, ,"&o)ut,($nt$ n$c$&,ri,8 d$"$ $$ctu,r), un ciru#,no!

Cu,ndo no $& 'o&i")$ o"t$n$r contro) d$ ), %+, ,-r$, &u'$rior ($di,nt$ (&c,r,

con "o)&, 5 %)%u),8 o ($di,nt$ ), intu",cin orotr,2u$,)8 $& 'r$$ri")$ uti)i4,r $)

(-todo d$ cricotiroidoto(+, con ,*u#,! T,nto $n $) ni7o co(o $n $) ,du)to8 ),in&u),cin d$ ,ir$ , 'r$&in , tr,%-& d$ un, ,*u#, introducid, $n ), ($("r,n,

cricotiroid$,8 $& un, ($did, t$('or,) &,ti&,ctori,8 '$ro no 'ro%$$ un, %$nti),cin

,d$cu,d, 5 'u$d$ 'roducir .i'$rc,'ni,!

+. - "entilacin&

Lo& ni7o& d$"$n %$nti),r&$ , un 'ro($dio d$ =0 r$&'ir,cion$& 'or (inuto8

(i$ntr,& 2u$ )o& in,nt$& r$2ui$r$n ?0 r$&'ir,cion$& 'or (inuto! Un %o)u($n

corri$nt$ d$ B , 10 () 'or /i)o*r,(o $& ,d$cu,do ',r, in,nt$& 5 ni7o&! Aun2u$ ),

(,5or+, d$ ),& (&c,r,& con %)%u), 5 r$&$r%orio ',r, u&o $n ',ci$nt$&

'$ditrico& $&tn di&$7,d,& ',r, )i(it,r ), c,ntid,d d$ 'r$&in 2u$ &$ $#$r4,

(,nu,)($nt$ &o"r$ ), %+, ,-r$, d$) ni7o8 $) (-dico d$"$ r$cord,r ), n,tur,)$4,

r*i) d$) r"o) tr,2u$o"ron2ui,) 5 ,)%-o)o& in(,duro& con o"#$to d$ di&(inuir ),

)$&in 'ot$nci,) 5,tro*-nic, "ronco,)%$o),r!

4. - Catter de drenaje pleural&

Lo& tr,u(,ti&(o& 2u$ ro('$n $) cont,cto ')$ur,')$ur,8 5 'roduc$n .$(otr,38

n$u(otr,3 o .$(on$u(otr,3 , t$n&in8 &$ 'r$&$nt,n con i*u,) r$cu$nci, t,nto

$n ni7o& co(o $n ,du)to& 5 con ),& (i&(,& con&$cu$nci,& i&io)*ic,&! E&t,&

)$&ion$& &$ tr,t,n ($di,nt$ d$&co('r$&in ')$ur,) $n ($dio $3tr,.o&'it,),rio &i $)

cu,dro c)+nico )o r$2ui$r$8 con un, t-cnic, &i(i),r , ), d$&crit, ',r, $) ,du)to!


73/80

SHOC

1! Di,*n&tico;

En $) ni7o8 )o& tr,u(,ti&(o& &$ ,co(',7,n con r$cu$nci, d$ un, '-rdid,

i('ort,nt$ d$ &,n*r$! L, $3c$)$nt$ r$&$r%, i&io)*ic, d$) ni7o 'u$d$ oc,&ion,r

2u$ )o& &i*no& %it,)$& &$ $ncu$ntr$n t,n &o)o (od$r,d,($nt$ ,)t$r,do& $n

'r$&$nci, d$ $&t,do d$ &.oc/ &$%$ro! E&t$ $&t,dio t$('r,no d$ $&t,do d$ &.oc/

co('$n&,do $& $n*,7o&o 5 'u$d$ ocu)t,r un, r$duccin i('ort,nt$ $n $)

%o)u($n d$ &,n*r$ circu),nt$! L, t,2uic,rdi, 5 (,), '$ru&in cutn$, &on )o&

.,)),4*o& (& i('ort,nt$& ',r, r$conoc$r $&t$ 'ro")$(, 5 ',r, 'od$r in&tituir ),

r$&ucit,cin ,d$cu,d, con cri&t,)oid$&!

L, r$&'u$&t, inici,) , ), .i'o%o)$(i, $n $) ni7o8 $& ), t,2uic,rdi,! Si &$ %, ,

contro),r nic,($nt$ ), r$cu$nci, c,rdi,c,8 d$"$ t$n$r&$ $n cu$nt, 2u$ $&t$',r($tro 'u$d$ &$r (odiic,do 'or $) do)or8 t$n&in '&ico)*ic, 5 t$(or! L,

'r$&in &,n*u+n$, 5 )o& +ndic$& d$ '$ru&in or*nic, ,d$cu,d, $#; L, $3cr$cin

d$ orin, d$"$ (onitori4,r&$ con&t,nt$($nt$!

Lo& c,("io& $n $) &.oc/ .i'o%o)-(ico r,nco &on inconundi")$&8 &in $(",r*o8

'u$d$n &$r (u5 &uti)$& $n $) c.o2u$ inci'i$nt$ o $n $) 'roc$&o d$ $%o)ucin8 'or

)o cu,) &$ r$2ui$r$ un, o"&$r%,cin cuid,do&, d$) ni7o! L, ,&oci,cin d$

t,2uic,rdi,8 $3tr$(id,d$& r+,& 5 un, 'r$&in ,rt$ri,) &i&t)ic, ($nor d$ B0 (( H*8

&on c),ro& indicio& d$ &.oc/ $n $%o)ucin! L, 'r$&in ,rt$ri,) &i&t)ic, d$) ni7o

d$"$ &$r d$ 08 (& $) do")$ d$ &u $d,d $n ,7o&8 5 ), 'r$&in di,&t)ic, d$"$ &$r

do& t$rcio& d$ ), 'r$&in &i&t)ic,!

=! R$&ucit,cin con )+2uido&;

D$"ido , 2u$ &$ r$2ui$r$ un, di&(inucin d$ ,'ro3i(,d,($nt$ un =@ d$)

%o)u($n &,n*u+n$o ',r, 2u$ ),& (,ni$&t,cion$& c)+nic,& d$) &.oc/ &$ .,*,n

,',r$nt$&8 &$ con&id$r, ,d$cu,d, ), ,d(ini&tr,cin d$ un "o)o inici,) d$ )+2uido&

ti"io& d$ =0 ()*8 )o cu,) r$'r$&$nt, $) =@ d$) %o)u($n &,n*u+n$o d$) ni7o! E)

ni7o tr,u(,ti4,do d$"$ &$r cuid,do&,($nt$ (onitori4,do con o"#$to d$ $%,)u,r ),

'$ru&in ,d$cu,d, d$ )o& r*,no& 5 ), r$&'u$&t, ,) "o)o inici,) d$ )+2uido&! L,

$&t,"i)id,d .$(odin(ic, &$ indic, 'or;

1 ! Di&(inucin d$ ), r$cu$nci, c,rdi,c, F($nor d$ 1>0 ),tido&(inuto


74/80

=! Au($nto d$ ), 'r$&in d$) 'u)&o F(,5or d$ =0 (( H*

>! Di&(inucin d$) (ot$,do $n 'i$)!

?! Au($nto d$ F, t$('$r,tur, $n $3tr$(id,d$&!

@! M$#or+, $n $) $&t,do &$n&ori,)!

6! G,&to urin,rio d$ 1 ()*.or,!

B! Au($nto d$ ), 'r$&in &,n*u+n$, &i&t)ic, \0 (( H*!

E) $&2u$(, d$ r$&ucit,cin d$ )+2uido& 'u$d$ &$r un, *u+, ti) $n $) (,n$#o inici,)

d$) ni7o tr,u(,ti4,do!

>! :+,& d$ ,cc$&o intr,%$no&o;

E) &.oc/ .i'o%o)-(ico &$%$ro .,"itu,)($nt$ $& con&$cu$nci, d$ )$&ion$& d$

r*,no& 5 &i&t$(,& intr,torcico& o intr,,"do(in,)$&! Si $& 'o&i")$8 d$"$

$&t,")$c$r&$ inici,)($nt$ un, %+, d$ ,cc$&o intr,%$no&o '$rcutn$, F.u($r,)8$'icr,n$,)

$(or,) co(n $n ),ct,nt$& 5 ni7o&8 d$"ido , ), r$cu$nci, $)$%,d, d$ tro("o&i&

%$no&, 5 , ), '-rdid, d$ ), $3tr$(id,d 'or i&2u$(i,! Si no &$ )o*r, ), %+,

'$rcutn$, $n do& int$nto&8 &$ d$"$ con&id$r,r ), ,d(ini&tr,cin intr,o&$, $n

ni7o& ($nor$& d$ 6 ,7o&! L, 5u*u),r $3t$rn, 'u$d$ &$r '$rcutn$,!

L, o"t$ncin d$ un, %+, d$ ,cc$&o intr,%$no&o $n $) ni7o .i'o%o)-(ico ($nor d$

6 ,7o& $& un 'roc$di(i$nto di+ci) 5 co(')ic,do ,n $n ),& (,no& (& $3'$rt,&!

L, inu&in intr,&$, r$,)i4,d, ($di,nt$ c,7u),cin d$ ), (-du), &$, d$ un

.u$&o ),r*o $n un, $3tr$(id,d no )$&ion,d, 'ro'orcion, un ,cc$&o %$no&o d$

$($r*$nci, $n $) ni7o tr,u(,ti4,do cr+tico! L, %+, intr,&$, $& &$*ur,8 $ic,4 5

'u$d$ $&t,")$c$r&$ $n un ti$('o ($nor 2u$ un, %$nodi&$ccin &in $(",r*o8 ),

c,n,)i4,cin intr,&$, &$ d$"$ r$tir,r cu,ndo &$ .,5,n $&t,")$cido %$n,&

'$ri-ric,& ,d$cu,d,&! L,& indic,cion$& ',r, $&t$ 'roc$di(i$nto &on; Ni7o d$ 6

,7o& o ($nor d$ 68 $n 2ui$n$& ), %+, $ndo%$no&, $& i('o&i")$ d$"ido , un

co),'&o circu),torio 5o c,nu),cin %$no&, inructuo&, d$&'u-& d$ do& int$nto&!

L,& co(')ic,cion$& d$ $&t$ 'roc$di(i$nto inc)u5$n c$)u)iti& 5 (u5 r,r, %$4

o&t$o(i$)iti&! E) &itio d$ $)$ccin ',r, ), c,nu),cin intr,&$, $& ), ',rt$ ,nt$rior

d$ ), ti"i,8 'or d$",#o d$ ), cr$&t, ti"i,) ,nt$rior! En c,&o& d$ r,ctur, d$ ), ti"i,8 ),


75/80

c,nu),cin intr,&$, 'u$d$ &$r r$,)i4,d, $n $) t$rcio in$rior d$) -(ur! L,

c,nu),cin intr,&$, no d$"$ int$nt,r&$ $n &itio& di&t,)$& , un, r,ctur,!

S$ uti)i4, un &$t d$ %+, intr,&$,! S$ introduc$ $n $) .u$&o $n dir$ccin di&t,) , ),

ti"i, 5 &u'$rior $n $) -(ur con $) "i&$) diri*ido .,ci, ,rri", ',r, no )$&ion,r $)

$&',cio ,rticu),r 5 c,rt+),*o d$ cr$ci(i$nto! L, ,&'ir,cin d$ (-du), &$, ,&$*ur,

), 'o&icin ,d$cu,d, d$ ), ,*u#,! T,("i-n &$ %$riic, ), 'o&icin d$ ), ,*u#, ,) no

$3i&tir r$&i&t$nci, , ), ,d(ini&tr,cin d$ )+2uido& 5 &u $3tr,%,&,cin , )o& t$#ido&

"),ndo&! E) ti$('o circu),torio $ntr$ ), (-du), &$, 5 $) cor,4n $& .,"itu,)($nt$

($nor d$ =0 &$*undo&! Por $&t, %+, 'u$d$ r$&t,")$c$r&$ $) %o)u($n circu),torio

$n un ti$('o ,c$'t,")$!

?! T$r(orr$*u),cin;

E) ni7o d$"$ &$r d$&cu"i$rto dur,nt$ ), $3')or,cin inici,) 5 ), ,&$ d$r$,ni(,cin8 5 'o&t$rior($nt$ &$ d$"$n co)oc,r co"$rtor$& ',r, tr,t,r d$

(,nt$n$r ), t$('$r,tur, cor'or,) )o (& c$rc,n, , ), nor(,)id,d!

TRAUMATISMO TOR]CICO

E) tr,u(,ti&(o torcico c$rr,do $& r$cu$nt$ $n $) ni7o8 5 r$2ui$r$ d$ ), in($di,t,

corr$ccin d$ ), uncin r$&'ir,tori, ',r, $&t,")$c$r un, %$nti),cin ,d$cu,d,! L,

',r$d torcic, d$) ni7o $& (u5 $)&tic,8 tr,n&(it$ ), $n$r*+, d$) tr,u(,ti&(o , ),&

$&tructur,& intr,torcic,&8 r$cu$nt$($nt$ &in nin*un, $%id$nci, d$ )$&in d$ ),

',r$d torcic, $3t$rn,! Lo& 'ro")$(,& $&'$c+ico& oc,&ion,do& 'or )o&

tr,u(,ti&(o& d$ tr,3 $n $) ni7o8 no &on di$r$nt$& d$ )o& d$) ,du)to 5

.,"itu,)($nt$ 'u$d$n &$r tr,t,do& &in tor,coto(+,! E) (,n$#o t$r,'-utico $& $)

(i&(o!

E) n$u(otr,3 , t$n&in o $) .$(on$u(otr,38 &on $) r$&u)t,do d$ tr,u(,ti&(o&

con *r,n tr,n&$r$nci, d$ $n$r*+, 5 .,"itu,)($nt$ no &on "i$n to)$r,do& 'or $)

ni7o8 d$"ido , ), (o%i)id,d d$ ),& $&tructur,& d$) ($di,&tino! E&t, (o%i)id,d .,c$

2u$ $) ni7o &$, $&'$ci,)($nt$ &u&c$'ti")$ , )o& 'ro")$(,& d$ tr,3 in$&t,")$! L,

$),&ticid,d d$ ), ',r$d torcic, ,u($nt, ), r$cu$nci, d$ ),& contu&ion$&

'u)(on,r$& 5 .$(orr,*i,& intr,'u)(on,r$& dir$ct,&8 .,"itu,)($nt$ &in r,ctur, d$

),& co&ti)),& corr$&'ondi$nt$&! Sin $(",r*o8 ), 'r$&$nci, d$ r,ctur,& d$ co&ti)),&


76/80

$n ni7o& indic, (,5or tr,n&$r$nci, d$ $n$r*+,8 )$&ion$& &$%$r,& , r*,no& 5 un

'$or 'ron&tico! Por )o t,nto8 )o& ni7o& con ()ti')$& r,ctur,& d$ co&ti)),&8 d$"$n

tr,&),d,r&$ , un, in&titucin c,',4 d$ 'ro%$$r un tr,t,(i$nto 'ti(o!

Lo& ni7o& &ur$n con ci$rt, r$cu$nci, )$&ion$& "ron2ui,)$& 5 ),c$r,cion$&ru'tur,

d$) di,r,*(, (& 2u$ $n $) ,du)to8 co(o con&$cu$nci, d$ tr,u(,ti&(o&

c$rr,do& o ,'),&t,(i$nto&! L, )$&in d$ )o& *r,nd$& %,&o& $& 'oco r$cu$nt$ $n

r$),cin con $) ,du)to! L,& )$&ion$& &i*niic,ti%,& r,r, %$4 &$ 'r$&$nt,n $n or(,

,i&),d, 5 r$cu$nt$($nt$ or(,n ',rt$ d$ )$&ion$& (u)ti&i&t-(ic,& (,5or$&!

En $) 'r$,do)$&c$nt$ ), )$&in '$n$tr,nt$ d$ tr,3 $& r,r,8 &in $(",r*o8 $& un

'ro")$(, $n ,u($nto co(o c,u&, d$ )$&in d$&'u-& d$ )o& 10 ,7o& d$ $d,d! E)

tr,u(, '$n$tr,nt$ d$ tr,3 &$ (,n$#, i*u,) 2u$ $n $) ,du)to!

TRAUMAT)SMO ADOMINAL

L, (,5or ',rt$ d$ ),& )$&ion$& ,"do(in,)$& '$ditric,& &on &$cund,ri,& ,

tr,u(,ti&(o& c$rr,do&8 'ri(,ri,($nt$ $n %$.+cu)o& d$ (otor 5 c,+d,&! L,&

.$rid,& '$n$tr,nt$& d$ ,"do($n8 ),& cu,)$& &on (& r$cu$nt$& $n ),

,do)$&c$nci,8 dict,n ), ',rtici',cin r'id, d$) ciru#,no! A) i*u,) 2u$ $n $) ,du)to8

$) ni7o con .i'ot$n&in 2u$ ti$n$ un tr,u(,ti&(o ,"do(in,) '$n$tr,nt$8 d$"$

.,c$r '$n&,r $n ), 'r$&$nci, d$ )$&in intr,,"do(in,) (,5or8 2u$ r$2ui$r$

tr,t,(i$nto 2uirr*ico!

E%,)u,cin

E& n,tur,) 2u$ $) ),ct,nt$ 5 $) ni7o '$2u$7o con&ci$nt$& &$ ,t$(oric$n (uc.o con

)o& $%$nto& 2u$ 'r$c$d$n , &u ,d(i&in ,) d$',rt,($nto d$ ur*$nci,&8 5 $&to

'u$d$ in)u$nci,r $) $3,($n d$) ,"do($n! Mi$ntr,& &$ )$ .,"), ,) ni7o con c,)(,8

&$ )$ int$rro*, &o"r$ $) do)or8 5 &$ $3,(in, &u,%$($nt$ $) tono d$ ), (u&cu),tur,

,"do(in,)! H,5 2u$ $%it,r ), ',)',cin 'round, ,) 'rinci'io d$ ), $3')or,cin $n $)

&itio d$ (3i(o do)or8 5, 2u$ $) ni7o &$ r$&i&tir , d$#,r&$ $3')or,r $) r$&to d$)

,"do($n! C,&i todo& )o& ),ct,nt$& 5 ni7o& '$2u$7o& 2u$ $&tn t$n&o& 5 ))or,ndo8

d$*)ut$n *r,nd$& c,ntid,d$& d$ ,ir$8 'or )o 2u$ ,nt$& d$ r$,)i4,r $%,)u,cion$&

'o&t$rior$&8 d$"$ d$&co('ri(ir&$ $) $&t(,*o ($di,nt$ ), in&$rcin d$ un,

&ond, n,&o*&tric,! Con r$cu$nci,8 ), di&t$n&in d$ ), ',r$d ,"do(in,)


77/80

di&(inu5$ $n cu,nto &$ $)i(in, ), di&t$n&in *&tric,! E) $3,($n d$) ,"do($n d$)

',ci$nt$ incon&ci$nt$ no %,r+, (uc.o con ), $d,d! L, introduccin d$ un, &ond,

n,&o*&tric, 5 urin,ri, ,ci)it,rn ), $%,)u,cin!

TRAUMATISMO CRANEOENCEJALICO

L, (,5or+, d$ )o& tr,u(,ti&(o& cr,n$o$nc$)ico& $n ), 'o"),cin '$ditric, &on

con&$cu$nci, d$ c.o2u$& d$ %$.+cu)o& d$ (otor8 ,ccid$nt$& d$ "icic)$t, 5 c,+d,&!

E& i('$r,ti%o $nt$nd$r ), int$r,ccin $ntr$ $) &i&t$(, n$r%io&o c$ntr,) 5 ),&

)$&ion$& $3tr,cr,n$,n,&! E) *r,do d$ &u'$r%i%$nci, $n $&to& c,&o& &$ r$),cion,

(& con ),& )$&ion$& ,&oci,d,& 2u$ con ), 'ro'i, )$&in cr,n$o$nc$)ic,! A) i*u,)

2u$ $n $) ,du)to8 ), .i'ot$n&in r,r, %$4 $& c,u&,d, 'or $) tr,u(,ti&(o

cr,n$o$nc$)ico8 'or )o 2u$ &i$('r$ d$"$ in%$&ti*,r&$ otr, )$&in ,&oci,d, 2u$ ),$&t- condicion,ndo!

A! E%,)u,cin;

L, r$&'u$&t, ,) tr,u(,ti&(o cr,n$o$nc$)ico 'u$d$ &$r di&tint, $n $) ,du)to 5 $n

$) ni7o! E&t, di$r$nci, 'u$d$ ,$ct,r ,) ni7o tr,u(,ti4,do! L,& 'rinci',)$&

di$r$nci,& &on;

1 ! An cu,ndo $n *$n$r,)8 )o& ni7o& &$ r$cu'$r,n ($#or 2u$ )o& ,du)to&8 )o&

($nor$& d$ tr$& ,7o& con )$&in cr,n$o$nc$)ic, &$%$r,8 ti$n$n '$or 'ron&tico

2u$ $) d$ )o& ni7o& (,5or$&! Lo& ni7o& &on (u5 &u&c$'ti")$& , )o& $$cto&

'roducido& 'or ), )$&in c$r$"r,) &$cund,ri, , .i'o3i,8 .i'ot$n&in con '$ru&in

c$r$"r,) di&(inuid,8 con%u)&ion$& o .i'$rt$r(i,! E& und,($nt,) r$&tituir $)

%o)u($n circu),nt$ $ i('$dir ), .i'o3i,!

=! An cu,ndo ocurr$ con 'oc, r$cu$nci,8 )o& ni7o& 'u$d$n &urir .i'ot$n&in

'or un, )$&in d$ crn$o8 con '-rdid, d$ &,n*r$ $n $) $&',cio &u"*,)$,) o

$'idur,)! E) %o)u($n &,n*u+n$o d$"$ &$r r$'u$&to ,d$cu,d,($nt$8 ,) i*u,) 2u$ &$

.,c$ con .$(orr,*i,& $n otr,& ',rt$& d$) cu$r'o!

>! E) ni7o '$2u$7o8 con un, ont,n$), ,"i$rt, 5 &utur,& (%i)$& to)$r, ($#or ),

$3',n&in d$ un, (,&, intr,cr,n$,n,! Otro& d,to& d$ (,&, intr,cr,n$,n, $n

$3',n&in 'u$d$n $&t,r $n(,&c,r,do& .,&t, 2u$ ocurr$ un, d$&co('r$&in

&"it,! Por )o t,nto8 un, ont,n$), ,"u)t,d,8 o un, di&t,&i& d$ &utur, cr,n$,n, $n


78/80

un ),ct,nt$ 2u$ no &$ $ncu$ntr, $n co(,8 d$"$n &$r tr,t,do& co(o un, )$&in

&$%$r,!

?! E) %(ito $& un &i*no r$cu$nt$ $n ),& )$&ion$& cr,n$o$nc$)ic,& $n )o& ni7o&

5 no &i*niic, n$c$&,ri,($nt$ .i'$rt$n&in intr,cr,n$,n,! Sin $(",r*o8 $) %(ito

'$r&i&t$nt$ o 2u$ $('$or,8 d$"$ 'r$ocu',rno& 5 r$2ui$r$ &$r %,)or,do ($di,nt$

to(o*r,+, co('ut$ri4,d,! L, d$&co('r$&in *&tric, $& $&$nci,) d$"ido ,) ri$&*o

d$ "ronco,&'ir,cin!

@! En )o& ni7o&8 $& r$cu$nt$ o"&$r%,r ), 'r$&$nci, d$ con%u)&ion$& d$&'u-& d$

un tr,u(,ti&(o8 .,"itu,)($nt$ &on d$ dur,cin )i(it,d,! Si ),& con%u)&ion$& &on

r$curr$nt$&8 n$c$&it,n &$r in%$&ti*,d,& ($di,nt$ to(o*r,+, co('ut$ri4,d,! L,

d$&co('r$&in *&tric, $& und,($nt,)!

6! L,& )$&ion$& d$ (,&, oc,) &on ($no& r$cu$nt$& $n $) ni7o 2u$ $n $) ,du)to!En c,("io8 $) ,u($nto d$ 'r$&in intr,cr,n$,n, &in (,&, d$"ido , $d$(,

c$r$"r,) $& (& r$cu$nt$! En )o& ni7o&8 $) '$r+odo d$ )ucid$4 'u$d$ &$r

'ro)on*,do8 5 $) inicio d$) d$t$rioro n$uro)*ico &$r t,rd+o co(o con&$cu$nci, d$

$))o! Aun2u$ $& n$c$&,ri, ), r$&titucin r'id, d$ %o)u($n circu),nt$8 d$"$

$%it,r&$ ), &o"r$.idr,t,cin8 ',rticu),r($nt$ con )+2uido& .i'otnico&!

B! L, $&c,), d$ co(, d$ G),&*o $& d$ uti)id,d cu,ndo &$ ,')ic, ,) ',ci$nt$

'$ditrico! Sin $(",r*o8 ), *r,du,cin %$r",) d$"$ &$r (odiic,d, ni7o& ($nor$&

d$ ? ,7o&8 d$ ), (,n$r, &i*ui$nt$;

P,),"r,& ,'ro'i,d,& o &onri&,8 &oci,")$! Ji#,cion$& 5 &$*ui(i$nto!!!!!!!!!@ 'unto&!

L)or, '$ro 'u$d$ &$r con&o),do!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!? 'unto&!

P$r&i&t$nt$($nt$ irrit,")$!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!> 'unto&!

In2ui$to8 ,*it,do!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!= 'unto&!

Nin*un,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1 'unto!


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W!M! J$%ri$r! S! 9o.,n$t! Editori,) M,&&on! 1 !

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M! P),n,&! Editori,) H,rtcourt r,c$! 1 B!

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80/80

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