curs 2-conduita medicala
TRANSCRIPT
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Toxicologie clinica
curs nr. 2
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CONDUITA MEDICALA IN INTOXICATIILE ACUTE
1. STABILIZAREA:
EXAMINARE “SCREENING” PENTRUIDENTIFICAREA MASURILOR DE
PREVENIRE A AGRAVARII STARII
INTOXICATULUI
2. EVALUAREA COMPLETA A PACIENTULUI :
ISTORIC, EXAMEN FIZIC, TESTE DE
LABORATOR
Gaz c!"a#!$a%
GC
S&'c#!"'#( )'
"a*a + MS
Mc!ca-c(-a#!
I#'%a#a )' c(&-a'
Chromatogram Plot
File: c:\saturnws_old\data\prbio\insecticide\c. e.sms
Sample: C. E. perator: !ihai
Scan "ange: # $ %&'' Time "ange: '.'' $ ().)*.
+ate: #,(,'# ##:')
Sample -otes: rina salon CF / P01
#'' 2'' %'' 3'' ('' m,4
'5
2(5
('5
6(5
#''5
&%
*6
#2(
#6#
2#2
%22
Spect # #*.)(#min. Scan: ##%* Chan:# 7on:%'* us "7C:8P *6 9#((26(#''5; c. e.sms
#'
2'
%'
3'
minutes
'
#
2
%
!Counts
"7C all c. e. sms
metoat
!etamido
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/. MASURI DE SCADERE A ABSORBTIEI TOXICULUI :
DECONTAMINARE PIELE, OC0I
DECONTAMINARE INTERNA
VOMA, SPALATURA GASTRICA
CARBUNE ACTIVAT
PURGATIVE SALINE
. MASURI PENTRU CRESTEREA ELIMINARII TOXICULUI
!+7F7C0"E0 p1 P>0S!0T7C si "7-0"
+7"E?0 F"T0T0
1E!+70>7?01E!PE"F?7E
C0"8-E 0CT7@0T SE"70T
17PE"A780"7S!
EAS0-B@7-T"0-SF?7E
P>0S!0FE"E?0
5. ANTIDOT SPECIFIC : ≈ (5 din intoxicatii
NALOXON GLUCOZA 34 TIAMINA la toti intoxicatii cu deprimare S-C
6. TERAPIE DE SUSTINERE
8SE"@0T7E
E@0>0"E PS7170T"7C0
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STABILIZAREA INITIALA
08"+0"E0 S7 C"ECT0"E0
F-CT77>" @7T0>E
C07 0E"7E-E= "ESP7"0T70
C7"C>0T70
+EP"7!0"E S-C P"7- TA7CE
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STABILIZAREA INITIALA
PRIORITATEA IC07 0E"7E-E "ESP7"0T70
@E-T7>0T7E
A7BE-0"E
8ST"CT7E:
C-BEST70 !C0SE>"= SEC"ET77
+EP>0S0"E0 PSTE"70"0 0 >7!877
C"P7 ST"07-7
SIMPTOME: C70-?0= T017P-EE= +7SP-EE=
+70F"E?0= 0>TE"0"E0 ST0"77 !E-T0>E
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STABILIZAREA INITIALA
PRIORITATEA IISOC: CONSTIENTA ↓
TA ↓
VASOCONSTRICTIE PERIFERICA ACIDOZA METABOLICA
OLIGURIE
MECANISME:+ ↓CONTRACTILITATE, FORTA DE CONTRACTIE
$ 0IPOVOLEMIE
+ ↓PRESARCINA, ↑POSTSARCINA
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STABILIZAREA INITIALA
PRIORITATEA IIISTAREA SNC
PUPILE
COMA
PRIORITATEA IVDECONTAMINAREA
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PREVENIREA ABSORBTIEI TOXICULUI 1. DECONTAMINAREA EXTERNA
$ P7E>E: C0ST7CE= C"?7@E 0P0
7-SECT7C7+E 08-+E-T
$ C17: S>T7E S0>7-0 3$& l 2. DECONTAMINAREA INTERNA
2.1. DILUTIE: C0ST7CE= C"?7@E
%'' ml >0PTE= 0P0
CI: -ET"0>7?0"E0 C S>T77 0C7+E= "ESPECT7@
0>C0>7-E 9"E0CT7E EATE"!0;
PE-T" 0>TE T7P"7 +E TA7CE: D 08S"8T70
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PREVENIREA ABSORBTIEI TOXICULUI
2.2 E!E?0 $ S7"P +E 7PEC0 $ 0P!"F7-0
$ +ETE"BE-T >7C17+ %' !>
INDICATII, EFICIENTA: >0 !0A. 3$& "E +P0 7-BEST7E7-TA7C0T> T"E0?
TA7CE +7?>@0TE 7- 17+"C0"8"7
CONTRAINDICATII: 7+"7= C70-= -7T"0T +E 0"B7-T= 0>C0>7-E= 0C7?7=17+"C0"8"7
0>TE"0"E0 C-ST7E-TE7
C-@>S77= 1E!"0B7E= 1E!0TE!E?0
TA7CE C EFECTE "0P7+E 90+T= 17-= ST"7C-7-0;
DOZA: %' ml
EFECT: #( %' min
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PREVENIREA ABSORBTIEI TOXICULUI
2.% SP0>0T"0 B0ST"7C0
INDICATII: C-T"07-+7C0T77>E E!E?E7
9C!0= C-@>S77= +EP"7!0"E "0P7+0;
T7!P !0A7! 3 & "E PST7-BEST7E
S>T7E S0>7-0 2'' 2(' ml= # min= +"E-0
CONTRAINDICATII: C"?7@E
1E!"0B7E
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PREVENIREA ABSORBTIEI TOXICULUI
2.3 C0"8-E 0CT7@0T 0"B!E-TE: EF7C7E-T0 "E>0T7@0 E!E?0= >0@0
EF7C7E-T0 C"ESCT0 7- P"7!0 "0
P0TE F7 P"7!0 PT7-E
INDICATII: FE-80"87T0>= TEF7>7-0= +7BA7-= -"T"7PT7>7-0=
0!7T"7PT7>7-0= !EP"80!0T= S0>7C7>0T7= -0+>>=C0"80!0?EP7-0= FE-7>8T0?-0= 8E-?+70?EP7-E=
FE-7T7-0
INEFICIENT: !ET0>E 9Fe= >i= 8o;= 0C7+ 8"7C= !0>0T7-= ++T=
C0"80!0T7= C70-"7= 0C7?7= 0>C0>7
ET0->= !ET0->= E>ECT">7T7= B>7C>7=
+7ST7>0TE +E PET">
DOZA: /5 6 155 $ 9 #' x +?0 +E TA7C;
"EPET0T= +?E SE"70TE
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CRESTEREA ELIMINARII DIGESTIVE
@7TE?0 E>7!7-0"E C"ESTE: PURGATIVE OSMOTICE
SORBITOL 754, 23' ml= >0TE-T0 #.% "E
CITRAT DE MAGNEZIU 2' %' g S>.#'5= >0TE-T0 3 "E
SULFAT DE MAGNEZIU S> #'5= #( 2' g= >0TE-T0 #6 "E
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CRESTEREA ELIMINARII TOXICULUI
#. !+7F7C0"E0 p1$ului P>0S!0T7C= "7-0"
2. +7"E?0 F"T0T0
%. 1E!+70>7?0
3. 1E!PE"F?70
(. C0"8-E 0CT7@0T "EPET0T
&. 17PE"A780"7S!
6. EAS0-B@7-T"0-SF?70
*. P>0S!0FE"E?0
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CRESTEREA ELIMINARII TOXICULUI
1. MODIFICAREA pH
* 0>C0>7-7?0"E0 p1 "7-0" 7,3 6 8 87C0"8-0T +E S+7 # 2 mEG,Hg
80"87T"7CE= S0>7C7>0T7
* 0C7+7F7E"E0 p1 "7-0" 3,3 + 9
C>""0 +E 0!-7 6(mg,Hg,23 ore
p.o.= i.I. 925;
0C7+ 0SC"87C
EF7C7E-T0 !+E"0T0: FE-C7C>7+7-0= 0!FET0!7-E= C17-7+7-0=ST"7C-7-0
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SNC
B0E
SANGE ALCALNIARE PLASMATICA
(BICARBONAT DE SODIU i.v.)
SNC
BHE
SANGE
FE-80"87T0> 7-7?0T -E7-7?0T
-E7-7?0T
7-7?0T-E7-7?0T
-E7-7?0T
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CRESTEREA ELIMINARII TOXICULUI
. DIUREZA FORTATA
* 7-C0"C0"E0 C F>7+E
* +7"ET7CE: F"SE!7+=!0-7T>
*
F>A "7-0" % ( ml,Hg,ora
INDICATII: 80"87T"7CE= 8"!"7= >i=
S0>7C7>0T7= 0!FET0!7-E
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CRESTEREA ELIMINARII TOXICULUI
!. HEMODIALIZA
* C-+7T77: $ B! J ('' +altoni $ 17+"S>87>7T0TE C"ESCT0
$ >EB0"E +E 0>8!7-E>E P>0S!0T7CE SC0?T0
$ @>! +E +7ST"78T7E !7C
* TA7CE +70>7?087>E:8"!"7= C>"0>17+"0T
ET0->= !ET0->= ET7>E-B>7C>=
0>C> 7?P"P7>7C= >i= 0C7+ S0>7C7>7C
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CRESTEREA ELIMINARII TOXICULUI
". HEMOPERFUZIA
"EST"7CT77 J
7-+7C0T77: $ SE+0T7@ 17P-T7CE -E80"87T"7CE
$ 80"87T"7CE +E SC"T0 +"0T0
$ C>"0!FE-7C>= FE-7T7-0
$ P0"0K0T= S0>7C7>0T7= ETC>"@7->
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CRESTEREA ELIMINARII TOXICULUI
3. CARBUNE ACTIVAT SERIAT
- "EC7"C>0T7E E-TE"1EP0T7C0 C>"0>17+"0T= FE-T70?7-E= C>C17C7-0= FE-7T7-0= +7B7TA7-0= S0>7C7>0T7= +7BA7-0= 0.+.
T"7C7C>7CE= 17+"C0"8"7 10>BE-0TE= ++T= 7?-70?7+0
&. 0IPEROXIBARISM: !-A7+ +E C0"8-= C70-"7
T#,2 C0"8A71E!B>87-0:
7- 0E" 0T!SFE"7C: 2(' min
>0 C-C.#''5 A7BE-: 36 min
17PE"A780"7S! $2=( atm : 22 min
6. EXSANGVINOTRANSFUZIA
8. PLASMAFEREZA
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Clasificarea antidoturilor in functie de
mecanismul de actiune
MECANISM EXEMPLE UTILIZARE CINICA
#.0ntagonism competitiIla niIelul "
0tropina 9". muscarinic;
-aloxona 9". opiacei;
-oradrenalina 9". al
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as carea an o ur or n unc e e
mecanismul de actiune
MECANISM EXEMPLE UTILIZARE CINICA
%. Chimic
c; "educerea
d; Electrostatic
0lbastru de metilen
Protamina
!ethemoglobinemie
1eparina
3. Fi4ic: dilutie 0pa 0lcaline= aci4i:ingestie
(. Fi4ico$chimic:adsorbtia Carbune actiIat Fenobarbital= etc.
&. -eutrali4are tip antigen$anticorpi
0ntiIenin Trat muscaturi de serpiIeninosi= scorpioni
6. "eactiIare en4imatica Pralidoxima=obidoxima
rgano
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TE"0P70 +E SST7-E"E
SUPRAVEG0ERE CLINICA MONITORIZAREA
DEPRIMAREA RESPIRATIEI, COMA 7-T80T70 PEEP 9P"ES7-E P?7T7@0 EAP7";
P-E!-70 +E 0SP7"0T7E 0-T787TE"0P7E
EDEM CEREBRAL PRESIUNEA INTRACRANIANAD;0IPOXIE, CO<
MASURI: 0IPERVENTILATIE
TERAPIE 0IPEROSMOLARA ;MANITOL 254 5.3 6 1$=>$=/5 "< CORTICOTERAPIE FUROSEMID ;INCARCARE CU FLUIDE<
CONVULSII
DIAZEPAM 3 + 15 "$ .?.
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TE"0P70 +E SST7-E"E
"EST0"0"E0 EC17>78">7 0C7+$
80?7C= E>ECT">7T7C S7 S!T7C
CIRCULATIA: C0TETE" @E-S !E-T7-E"E0 T0: C"7ST0>7?7=
S8ST7T7E-T7 P>0S!0= @0SP"ES0"E 1T0 : -7T"P"S70T '.( 2 Mg,Hg,min
+7"ET7CE
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TE"0P70 +E SST7-E"E
0IPOTERMIA
TA7C0 B"0@7T0TE !E+7E N O 0"7T!77 C0"+70CE $ >7+C07-0 "E7-C0>?7"E P0S7@0= 0CT7@0
0IPERTERMIA
0-T7C>7-E"B7CE
17PE"TE"!70 !0>7B-0 7!0= 0+"E-E"B7CE
MASURI: "0C7"E A7BE- "EEC17>78"0"E E>ECT">7T7C0= 0C7+$80?7C0 T"0T0!E-T> C-@>S77>"
SINDROMUL NEUROLEPTIC 0IPERTERMIC "E>0A0"E !SC>0"0 +7"ECT0 +0-T">E- -a # mg,Hg
8"!C"7PT7-0 2.( #' mg x%,?7
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TE"0P70 +E SST7-E"E
EVALUAREA PSI0IATRICA SUICIDUL EPISODIC
SINDROMUL DEPRESIV ENDOGEN
STRESS EMOTIONAL
ECONOMIC
FIZIC 6 BOLI INCURABILE
ALCOOLISM
TRATAMENT PSI0IATRIC