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He's agent for a big insurance company. The company's sent several representatives to discuss the matter. Ask the policeman where St. James Square is. He's quick in his movements. She has a very quick mind. Shake well before using. The politician stirred up the workers. When she heard it she got very excited. They ran through the inheritance. He's wearing himself out working so much. The edition went out of print quickly.

The provisions gave out in a short time.

I appreciate your kindness. I thanked him very much for his help. They're going to enlarge their store. This makes the situation worse. The patient got worse. We saw the military attache of the American Embassy. You have to add more details to the report. He wants a glass of cold water. We're having a rainy spell. You're right, that's as clear as crystal. Man overboard! Last night's storm washed out the road. You have butterfingers. Don't be a wet blanket. It's amazing how much he can stand. This is unbearable. Hang on tight! You have to take it.

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They met to decide peace terms. Let's settle accounts. He lifted the trunk to show off his strength. The sleeves of this coat have to be lengthened. Would you hand me the suitcase, please? The children are making a lot of noise. He's always short of money. They caught up with us quickly. I can't reach that can of tomatoes.

He reached the rank of general. From here I can't see it. The flowers will brighten up the table. I'm very glad to see you. Why are you so happy today? They're very cheerful people. What a bright-colored suit that is! He's a little tipsy. He showed great joy when he saw him. He was ill, but today he's all right. She needs a little cheering up. Encourage him to do it. Have you something to tell me? It seems rather expensive to me. Have you got some money? You must have a reason for telling me.

I don't know whether this'll be of any use to you. Somebody's knocking at the door. Has anybody come? I hope you'll come again some day. I want to ask you some questions. Do you want to ask me any questions?

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Do you need anything else? He visits us now and then. Some people have no patience. He was out of breath when he got here. Es una persona de muchos alientos. He's a very energetic person. We have to lighten the load. Hurry up, it's late. This food's not nourishing enough.

He enlisted in the Foreign Legion. We'd better get ready early because the train won't wait. There it is! He's up there waiting for you. Your friends are in there. Let's go that way. The village is beyond those trees. I saw 'em over there a while ago. Put it over there. His house is there on the right. She lives far from there. From there one could see perfectly. He says we should go that way.

It's a town of people. My dear child! Lo siento en el alma. I'm terribly sorry. Lo voy a consultar con la almohada. I'm going to sleep on it i. They rented a house. Rooms for rent. They were sitting around the table. It cost about thirty pesos. We have to make some changes in our plans. He showed signs of great emotion. There were disorders all over the country. His coming changed our lives completely. Don't get excited; it's nothing. What's that very tall building?

He talked to a high official of the Treasury Department. Prices are very high in this store. Don't talk so loud. He returned very late at night. They live in the upper story of that house. The house is on top of the hill. We've overlooked many important facts. We stopped along the way to have lunch. The soldiers halted at the entrance to the town. I don't feel well at such a high altitude. The lighting's poor in this part of the city. The street lamps don't give enough light. Can you light the way? He didn't raise his eyes from the book. They revolted against the government. He stole the money.

In the summer it dawns earlier than in the winter. That guy's very embittered. He makes life miserable for everyone around him. He couldn't stand the bitterness of the coffee. His misfortunes caused him great bitterness. They soon became friends. He made friends with John. He got acquainted there in a short time. We talked with the owner of the house. Don't tell the boss. He likes to talk of love. He's found a new love. Yes, darling. He has too much pride. He was peeved by what you said. I want an enlargement of this photograph.

They furnished the house very luxuriously. Do you think the road's wide enough for cars? This suit's too big for me. What's the width of the material? We took a long hike up to the summit. You're a great gadabout, my boy. It's too far to walk. The train began to move. Is that clock going? I've been chasing around all day.

He didn't win the prize, but he came close to it. The child's going on seven. Move on! Go on! The jockey fell right by the rail. The liveliness of the gathering surprised me. Don't be a jackass! Let's encourage the players. His arrival pepped up the party. I'm urging him to come with us. He was in good spirits. She cheered him up because he was depressed. It gets dark at five now. I'm anxious to meet her. The year before last we went to Europe. I told you that before. This street used to have another name. Let's eat before we go. They left before we arrived.

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Above all, don't forget to write me. He lent me 30 pesos. They advanced the date of the party. They arrived half an hour early. He got ahead of me.

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She likes to dress in an old-fashioned way. She does whatever comes into her mind. Lo hago porque se me antoja. I do it because I take a notion to. Happy New Year. I'm twenty years old. Put out the light. The lights went out. He was surprised by the sudden appearance of his friend. That's a separate question. Put this package aside. Don't get off while the vehicle's in motion. They were grieved by the illness of their aunt. We were worried because we weren't getting any news. He can hardly walk. Let me know as soon as he comes. He got very depressed after his failure.

They crushed all resistance. They flattened his nose. They flattened themselves against the wall. He's very studious. They put a coat of paint on the chair. How much do you bet? I bet I get there before you. Rest your foot on that step. No one supported his motion. I second the motion. He's leaning on a cane. I have great respect for him. Don't walk so fast; we'll get there on time. Please hurry; we're late already. Tighten this screw. This collar's too tight. He pressed down on the suitcase to close it. He gripped my hand.

The runner sprinted on the last lap. There was such a crowd that nobody saw anything. He does everything very quickly. I don't approve of his conduct. Did you pass your math exam? The boss had to advance him some money. She made use of all the left-overs. Don't let him take advantage of you. Don't go too near the fire. You're aiming too low to hit the target. Jot it down in your notebook.

They drained their glasses. The situation worries me very much. Don't worry. Hurry up, child! Hurry up! I bought that scarf we looked at yesterday. I like this book better than that one. He isn't here. I'll wait for you in here. From now on we'll have to spend less money. Come this way. Wet firewood doesn't burn well. I was burned up by what he said. His arguments don't convince me.

I didn't like the plot of the movie. They armed the people. The machine has to be assembled. They made a big racket last night. The mules balked halfway there. He armed himself with a pistol. He built up a good business in a short time. He's always making a mess of things. He's always broke at the end of the month. Three pages have been torn out. We saw the car start. On a sudden impulse I returned to my home town. This car has a self-starter.

What a heel! He gets everything because he's a bootlicker. He was dragged along by the current. Be careful, your coat's dragging. They crawled out of the cave. Is everything arranged for the trip? I think they'll fix the radio this afternoon. Tidy up a bit and we'll go to the movies. How can I manage to finish on time? We did it according to your instructions. Do you want to rent your house? I want to rent a room. You'll be sorry for this. They live two flights up.

The bedrooms are upstairs. It's past the square. He looked him up and down. From above one could see the river. The car was going up. Let's go up. The hat was dirty around the top. He doesn't mind risking his life. If we don't take risks we'll never get anything done. Don't put the table so close to the wall.

Give me a hand! Don't throw things out the window. That rope has to be coiled. They were trampled by the crowd. That man ruined them completely. He was ruined by that business. Are you interested in art? Fine arts. He presents his arguments with great skill. Read the article on page two. They sell sporting goods. Let's roast the chestnuts. It's roasting in this room. The balloon went up slowly. He was promoted three times in one year. The bill amounted to pesos. He refused the food with disgust. Those things disgust me.

Don't come near me; you're filthy. He turns up his nose at everything. He fastened the horse's pack with a rope. I assure you everything will be ready on time. He maintains it's true. The baggage is insured. First make sure the information's correct. He took out accident insurance. That's the way it is. Recomendar el rgimen ampliado. El tipo de exposicin representa un riesgo aumentado de transmisin del HIV. Si la fuente, o en el caso de una fuente desconocida, el lugar donde ocurri la exposicin sugiere un posible riesgo de exposicin al HIV y el TE es 2 3, considerar el rgimen bsico.

Presentacin: c o m p. Buenos Aires, Argentina. Recomendaciones para la profilaxis pos-exposicin ppe ocupacional al VIH en trabajadores de la salud. Sociedad Argentina de Sida. Barlet, j. Guide to medical care ofpatients whit HIV Infection. Cap Baltimore: 2. The johns Hopkins Hospital Updated U. June 29, Abordaje y manejo de las mordeduras Valoracin general del paciente e n urgencias Evaluacin inicial y estabilizacin del paciente Evaluacin de heridas e n regiones especficas cuero cabelludo e n bebs y nios pequeos, mordeduras e n cuello Prestar a t e n c i n a la especie atacante: Animales venenosos y n o venenosos Evaluar l anecesidad deb r i n d a r t r a t a m i e n t o o antisueros especficos por ejemplo: suero antiofdico Evaluar el riesgo de zoonosis y necesidad de profilaxis especfica A t e n c i n q u i r r g i c a d e las h e r i d a s Evaluacin infectolgica de la m o r d e d u r a V a c u n a c i n antitetnica.

Las h e r i d a s profundas e ncuero cabelludo de nios pequeos n o deben explorarse introduciendo e l dedo o sondas. Requieren valoracin radiolgica y neur o quirrgica inmediata. Las serpientes venenosas argentinas estn representadas p o r :. Ver captulo de shock anafilctico. L o s agentes a e r o b i o s a i s l a d o s c o n m a y o r f r e c u e n c i a s o n : Pasteurella multocidaj dagmatis, Streptococcus sp, Moraxella Staphylococcus aureus, corrospj p e r o t a m b i n p u e d e n e n c o n t r a r s e Pasteurella sptica, Pasteurella canis, Pasteurella sp, Neisseria sp, Corynebacterium sp, Eikenella Fusobacterium dens, Capnocytophaga canimorsus, Bergeyella zoohelcum y b a c t e r i a s N O - I.

A t e n c i n a posibles reacciones anafilcticas Pasteurella aerogenesy Pasteurellapneumotropica, y se h a n d e s c r i p t o c o m p l i c a c i o -. P u e d e n ser secundarias a u n a crisis convulsiva. Rev Chil Infect ; Goldstein, Ej. Presutti, R. Early treatment and prophylaxis against infectious complications". PostgradMed ; Morgan, M. Clin ExpAllergy ; Medeiros I, Sacconato H. Cochrane Lihrary Volume 4, Estudios bacteriolgicos: frotis uretral, frotis vaginal y exploracin ginecolgica 3.

Evaluar: A. M a n i p u l a c i o n e s articulares recientes punciones 3 Inmunodeficiencias 4. E n f e r m e d a d e s debilitantes: diabetes, cirrosis heptica, insuficiencia r e n a l c r n i c a , etc. E V con o sin amikacina. TABLA 3 4. E V m s nolonas. S i n foco infeccioso: Cefalosporinas de I A. Barcelona: Masson. Guide to antimicrobial therapy. EEUU, Smith J. Piercy E. Artritis infecciosa. En: Gerald L. Mandell, John E. Bennett, Raphael Dolin. Enfermedades infecciosas. Principios y prcticas. Buenos Aires: Panamericana, Perry, CR.

La duracin de la teraputica antibitica es por lo general de 14 das de tratamiento EV seguidos de por lo menos 14 das por va oral. Es u n e s t u d i o rpido, que p e r m i t e el diagnstico diferencial c o n otras patologas. Vmitos incoercibles Dolor refractario al tratamiento Rion nico o rion transplantado con obstruccin Infeccin del tracto urinario concomitante con obstruccin Crisis hipercalcmica Obstruccin de alto grado.

Fiebre Clculos mayores de 6 mm de dimetro Rion nico o rion transplantado sin obstruccin Enfermedad renal intrnseca Extravasacin urinaria Inmunodeprimido diabetes, HIV, cncer, tratamiento con esteroides, etc. Las drogas m s utilizadas s o n : Ketorolac 3 0 - 6 0 m g inicial intravenoso [ I V ]ointramuscular [ I M ] , l u e g o 15 m g c a d a 6 h s. E n ocasiones, aparecen sntomas asociados al a u m e n t o de la u r e m i a c o m o anorexia, fatiga, p r u r i t o , respiracin de K u s s m a u l , letarga, confusin, estupor, agitacin, asterixis, m i o c l o n u s , h i p e r r e f l e x i a , convulsiones, nuseas, vmitos e leo.

Cuando se detecta en la guardia un paciente con insuficiencia renal, deben plantearse tres interrogantes:. Bibliografa Kavoussf, Novick, Partin, Peters. Editorial Mdica Panamericana, Madrid Holst, P. Revista Argentina de Urologa ;69 3 N Engl J Med ; 7 Asplin, Coe, Favus. En: Harrison, Principios de Medicina Interna. Mxico, Me Graw Hill Interamericana. Manthey DE, J Teichman. Emerg Med Clin North Am ;19 3 Perfusin renal reducida por debajo de un nivel crtico que compromete la filtracin glomerular. Disminucin del volumen eficaz del lquido extracelular LEC : hemorragias, prdidas digestivas, etc.

Redistribucin del LEC: ascitis, sndrome nefrtico, pancreatitis Disminucin del gasto cardaco Vasodilatacin perifrica: sepsis Ureterales: litiasis, cogulos, tumores Vejiga: patologa prosttica, cncer de cuello de tero Uretra: estrechez Iguales causas que prerrenal pero ms intensas y prolongadas.

Depsito de cristales lisis tumoral ULeloma mltiple, hemoglobina, mioglobina Primarias, vasculitis, enfermedades del colgeno, etc. Intoxicaciones con una sustancia posible de eliminar por dilisis p. Infecciosas: pielonefritis aguda bacteriana, legionelosis, leptospirosis, Hanta virus, CMV, escarlatina, difteria, candidiasis Miscelneas: sarcoidosis, leucemia, linfoma, sndrome de Sjgren Grandes o pequeos vasos Trombosis vena renal y embolia arterial renal. Clames diagnsticas P r e r r e n a l : sed, h i p o t e n s i n ortosttica, mareos, taquicardia, d i s m i n u c i n de la p r e s i n venosa yugular, f r i a l d a d cutnea, sequedad de mucosas, signo del pliegue cutneo, antecedentes de prdida de lquidos e n f o r m a excesiva.

O r i g e n m i c r o v a s c u l a r : e n t r e l a s causas m i c r o a n g i o p t i c a s d e I R A p o demos m e n c i o n a r algndrome urmico-hemoltico S U H , la prpura trombtica trombocitopnica P T T , laQoagulacin intravascular disem i n a d a , la toxemia d e l embarazo eclampsia, H E L L P , la hipertensin acelerada, el l u p u s eritematoso sistmico, etc.

Hipertensin arterial. Edema perifrico, pulmonar, ascitis En forma aguda puede provocar edema cerebral y convulsiones. Evitar excesiva ingesta de agua; no administrar suero salino hipotnico o soluciones de glucosa Balance diario de lquidos peso diuresis. Lancet ; Hilton R. Sarano H, Mascheroni C, Gavosto j.

Algunas consideraciones sobre el tratamiento 1. Bibliografa Parodi R, M Garca. Rosario, Argentina: Corpus; ; Cohn A, R Brown. Clinical Practice". Sutton, JM. Teichman, J. N Engl J Med. Spenser j, Lindsell D, Mastorakou T. Seccin: Hemorragias durante el tratamiento anticoagulante. En: Battagliotti C, A Greca. Estos pacientes r e f i e r e n sntomas irritativos, a c o m p a a d o s de c h o r r o u r i n a r i o intermitente, hematuria, infecciones urinarias, d o l o r plvico.

A l t a c t o r e c t a l se puede palpar u n aprstata dolorosa, aumentada de tamao, de consis-. Causas Hiperplasia prosttica Estenosis u r e t r a l Litiasis vesical Uretritis Prostatitis Vejiga neurognica Hematuria L a m a y o r a d e estas p a t o l o g a s p r o d u c e n s n t o m a s s i m i l a r e s , q u e es i m p o r t a n t e diferenciar para poder realizar u ndiagnstico y u n p l a n teraputico correctos.

Disminucin de la fuerza y calibre del chorro urinario Aumento en la frecuencia miccional Retardo en el inicio de la miccin Urgencia miccional Sensacin de vaciado miccional incompleto tenesNicturia aumento de la frecuencia miccional mo nocturna Goteo pos miccional Disuria. L a o r i n a completa nos puede o r i e n t a r ante la presencia d e hemates p.

Holland-Frei Oncologic Emergencies. London B. Decker; ; Tammela T, Kontturi M, Lukkarinen 0. Scand J Urol Nephrol ;20 3 Nurs Times. Las infecciones urinarias IU son un motivo de guardia de consulta conozca frecuente en la atencin ms frecuentesj primaria. Clasificacin I. TABLA 3 9. L ab a c t e r i u r i a asintomtica debe tratarse y cualquier cuadro de I U requiere deu r o c u l t i v o para guiar el tratamiento.

Episodios previos de cistitis Actividad sexual reciente Retardo miccin pos coito Uso de espermicidas. A n t e u n a I U e n paciente sondado, debe permanencia. L a presencia de fiebre, dolor lumbar opuo percusin positiva i n d i c a n infeccin del p a r n q u i m a renal pielonefritis. D e b e pesquisarse y tratarse e n embarazadas, transplantados renales ye n.

Uretritis infecciosa: puede tener piura pero urocultivo negativo. Criterios de internacin 1. Signos de deshidratacin o d o l o r intenso 5. Tabla 3 9. Conducta inicial L a anamnesis y el examen fsico detallados d e f i n e n el t i p o de h u s p e d y la situacin clnica para comenzar a actuar. Varones de cualquier edad Mujeres con IU recurrente, signos de patologa urinaria concomitante hematuria, clico renal, infeccin por Proteus a repeticin, obstruccin al flujo urinario.

Bibliografa Fihn, SD. N Engl J Med ; 17 N Engl. Am FPhysician ;74 6 Greca, A. En: Greca A, C Battagliotti. Rosario-Argentina, Corpus, ; Las e n t i d a d e s m s f r e c u e n t e s causantes d e escroto a g u d o y q u e r e p r e sentan los diagnsticos diferenciales ms importantes son: Torsin del cordn espermtico T o r s i n del apndice testicular o e p i d i d i m a r i o Epididimitis Orquiepididimitis Hidrocele comunicante E d e m a escrotal idioptico Tumor.

Torsin de los apndices testiculares y epididimarios E l a p n d i c e testicular o hidtide de M o r g a g n i y el a p n d i c e del e p i d d i m o son propensos a latorsin e n laadolescencia edad de i n c i d e n c i a similar. Anlisis de sangre Ecografa testicular: puede revelar testculo y e p i d d i m o inflamados, a m e n u d o c o n la presencia de hidrocele.

Bibliografa Hawtrey, CE. A dinician's dilemma". Urol Clin North Am ; Marcozzi D, S. Emerg Med Clin North Am ; Kass EJ, B Lundak. PediatrClin North Am ; Horstman, WG. Exmenes complementarios I. Fedullo F, VF Tapson. Eur Heart J ; JAMA ; Brown, MD et al. Acad Emerg Med.

Parodi R, M Garca. Thorax ; TABLA Chlamydia pneumoniae, Staphylococcus aureusy b a c i l o s a e r b i c o s G r a m -. Neumona severa. Internacin en unidad de cuidados intensivos UT! Otras recomendaciones para c o m b a t i r laresistencia i n c l u y e n restringir el uso de cefalosporinas de 3 a. Agrega P. E n l a s i n f e c c i o n e s p o r Mycoplasma pneumoniae o Chlamydia pneumoniae el t r a t a m i e n t o debera extenderse p o r 3 semanas.

Journal ofChemotherapy ;14, Supl 4, Luna C, Calmaggi A, Caberlotto 0 y col. Grupo Argentino de estudio de la NAC. Gua prctica elaborada por un comit ntersociedades". Medicina BuenosAires ; En: Teraputica Clnica. Rosario, Argentina: Corpus, En: Harrison's Principies oflnternal. Tabla 4 3. Cuadro clnico Puede presentarse c o n sintomatologa variada, disnea, d o l o r torcico, fiebre. Depender dela cantidad delquido, lavelocidad de produccin y l a c a u s a s u b y a c e n t e.

Am Fam Physician ; Light, RW. Am j Med ; Parodi, R etal. Estudio de 55 casos". RevArg Med ; Supl. Porcel JM, M Vives. L o s traumatismos penetrantes de trax p r o d u c e n u n neumotorax al p e r m i t i r que el aire entre directamente en la cavidad p l e u r a l a travs de la pared del trax; si se penetra la pleura visceral, el aire puede escapar del rbol traqueobronquial. Tambin es u n hallazgo frecuente e n pacientes con traumatismos cerrados de trax.

E l dolor es agudo, localizado e n el hemitrax afectado y tpicamente pleurtico. Puede haber adems tos, hemoptisis y ortopnea, pero s o n raros. E l examen fsico revela taquicardia, taquipnea, expansin torcica asimtrica, h i p e r s o n o r i d a d y disminucin o abolicin del m u r m u l l o vesicular del lado afectado. E n los pacientes c o n E P O C , incluso n e u m o t o r a x grandes p u e d e n ser difciles de diagnosticar.

U n a frecuencia cardaca de ms de 1 4 0 latidos p o r m i n u t o , hipotensin, cianosis o la desviacin de la trquea sugieren la posibilidad de u n neumotorax a tensin. E n los casos de n e u m o t o r a x t r a u m t i c o s la conducta inicial consiste e n realizar u n a evaluacin clnica, control de los parmetros hemodinmicos y consulta urgente a ciruga torcica. C o m o tratamiento inicial puede ser til el aporte de oxgeno suplementario y analgesia endovenosa por ejemplo diclofenac 7 5 mg a travs de va perifrica para hidratacin parenteral.

E n el n e u m o t o r a x e s p o n t n e o depender la conducta inicial del tamao y del cuadro clnico:. C u a n d o el neumotorax es pequeo, unilateral y c o n pacientes asintomticos o c o n mnima sintomatologa la indicacin es reposo y observacin. Se debe realizar control radiogrfico e n 2 4 horas. E n algunos servicios de emergencia la conducta es p r i m e r o observar p o r 6 horas en sala de guardia y si no hay cambios se otorga el alta. L a indicacin es el drenaje, ya sea por aspiracin simple con catter o colocacin de u n tubo torcico de drenaje bajo agua.

E l tratamiento quirrgico est indicado cuando las tcnicas antedichas fracasan, c o n persistencia o repeticin del neumotorax. Este mecanismo permite el pasaje de aire durante la inspiracin y lo atrapa en la cavidad pleural en la espiracin. E l paciente tiene taquipnea, cianosis, taquicardia e hipotensin. E l movimiento del hemidiafragma homolateral est muy d i s m i n u i d o.

C u a n d o se considera el diagnstico de neumotorax a tensin, es c o n veniente la confirmacin p o r la radiografa de trax, si el tiempo lo permite. E l paciente debe r e c i b i r u n a concentracin alta de oxgeno y debe insertarse u n a aguja de gran calibre e n el segundo espacio intercostal anterior lnea medioclavicular del lado del neumotorax. Exmenes complementarios O b l i g a t o r i o : Radiografa de trax O p t a t i v o s : L a b o r a t o r i o general c o n gases e n sangre, T A C de trax E l neumotorax se diagnostica p o r la visualizacin de la separacin del borde externo de la p l e u r a visceral y del pulmn de la pleura parietal y de la pared del trax y la ausencia de trama p u l m o n a r e n ese espacio.

E n los neumotorax pequeos, donde algunas veces es difcil observar el borde pleural, puede verse ms fcilmente c o n u n a radiografa tomada al final de una espiracin mxima. E l neumotorax c o n u n a adherencia p l e u r a l tambin puede simular u n a bulla o ampolla p u l m o n a r. Puede ser necesaria e n estos casos u n a T A C para el diagnstico diferencial. T a m a o d e l n e u m o t o r a x : U n a forma rpida y prctica es la utilizacin de la divisin en neumotorax pequeos torcica.

E l aire que burbujea a travs del lquido confirma el diagnstico. Luego se debe preparar al paciente para la colocacin de tubo de drenaje bajo agua, p o r el cirujano torcico. Factores precipitantes Infecciones traqueobronquiales viral o bacteriana , neumona T E P , neumotorax. C o n t a m i n a n t e s ambientales Infarto de m i o c a r d i o , arritmias Exceso de medicacin sedante,fi-bloqueantes. Isquemia miocrdica Insuficiencia cardaca congestiva T r o m b o e m b o l i s m o de pulmn Broncoaspiracin r e c u r r e n t e. Bibliografa Jenkinson, SG. Clin Chest Med ; Peters J, E Sako.

Pulmonary Diseases and Disorders. Eur Respir ; Estudios complementarios Laboratorio general: hemograma, glucemia, funcin renal y electrlitos Estado cido base y gasometra arterial Radiografa de trax Electrocardiograma Pruebas de funcin p u l m o n a r pico flujo espiratorio, espirometra E x a m e n de esputo. Criterios de internacin Marcado i n c r e m e n t o de la disnea Fracaso al tratamiento mdico instituido mayor h i p o x e m i a o acidosis.

Definicin E m p e o r a m i e n t o de los sntomas respiratorio de comienzo agudo, a c o m p a ado de u n a disminucin de la funcin p u l m o n a r. N o existe u n a definicin de exacerbacin ampliamente aceptada, la mayora de las definiciones p u blicadas m e n c i o n a n alguna combinacin de tres hallazgos clnicos:. Barnes, Pj. Eur Respir f. Chest ; 2 Suppl S-8S. American Thoracic Society". Eur Respir J ;8 8 Figueroa Casas, jC. Se prefiere las mscaras tipo V e n t u r i c o n conocidas.

Tambin cnulas nasales o mscaras faciales. E v i t a r 2 la retencin de monxido de carbono c o n F i O altas. P r o d u c e n rpida broncodilatacin. Va nebulizador o i n h a l a d o r c o n cmara espaciadora. D e reserva la va subcutnea. Pudindose aumentar la dosis si no se evidencia respuesta clnica. L a nebulizacin c o n t i n u a n o mostr beneficios. A c e l e r a n la recuperacin del flujo pico espiratorio y d i s m i n u y e n la severidad del cuadro. N o es necesario el examen directo y cultivo de esputo previo al i n i c i o del tratamiento.

Definicin Enfermedad inflamatoria crnica de la va area asociada con hiperreactividad bronquial, limitacin reversible al flujo areo y sntomas respiratorios. T o d o s los pacientes c o n asma tienen riesgo de presentar exacerbaciones caracterizadas por episodios recurrentes de sibilancias, disnea, opresin torcica y tos, caractersticamente en la noche o en las primeras horas de la maana.

Las exacerbaciones del asma s o n agudas, pero su comienzo puede ser rpido o presentarse e n forma gradual. La crisis asmtica es una emergencia inmediata. Hay poca evidencia c o n mucolticos N-Acetil-Cistena. L a kinesioterapia puede aumentar el broncoespasmo, p o r lo que n o se i n d i c a de r u t i n a. M e t i l x a n t i n a s Aminofilina y Teofilina : N o estn recomendadas para el manejo agudo.

Ventilacin mecnica:. Se i n d i c a cuando la h i p e r c a p n i a se asocia c o n depresin del sensorio, acidemia profunda o arritmias. Puede ser la convencional o a travs de u n a ventilacin n o invasiva c o n presin positiva. Factores desencadenantes Infecciones del tracto respiratorio generalmente virales Exposicin a alrgenos ambientales plenes, hongos, pelos de perros y gatos E j e r c i c i o fsico Frmacos aspirina, antiinflamatorios n o esteroideos, etc.

Reflujo gastr o esofgico C a m b i o s climticos, comidas, aditivos Menstruacin y embarazo. Estn indicados e n pacientes c o n Sat. L a s alteraciones ms frecuentemente observadas s o n h i p o x e m i a , h i p o c a p n i a c o n alcalosis respiratoria. Recuento de glbulos b l a n c o s : puede ser necesario en pacientes con fiebre o esputo purulento.

L a leucocitosis moderada es comn en exacerbaciones asmticas y e n pacientes tratados c o n corticoides. TABLA 4 6. Objetivos diagnsticos Evaluar la severidad de la exacerbacin Evaluar el estado general del paciente Identificar complicaciones Detectar actual o i n m i n e n t e insuficiencia respiratoria.

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Diagnsticos diferenciales Insuficiencia cardaca congestiva Exacerbacin de enfermedad p u l m o n a r obstructiva crnica E P O C Obstruccin de la va respiratoria superior Neumona T r o m b o e m b o l i s m o de pulmn T E P Disfuncin de las cuerdas vocales. Evaluacin A l e x a m e n fsico el hallazgo ms frecuente es la presencia de sibilancias en la auscultacin; s i n embargo algunas personas p u e d e n tener u n a auscultacin n o r m a l pero c o n significativa limitacin al flujo areo cuando se mide objetivamente.

E n la crisis asmtica severa, las sibilancias pueden estar ausentes. E n los pacientes e n este estado, otros signos clnicos reflej a n la gravedad, tales como cianosis, dificultad para hablar, taquicardia, hiperinsuflacin torcica, uso de msculos accesorios, tiraje intercostal, depresin del sensorio y sndrome confusional. E l P F E expresado como porcentaje del mejor valor previo del paciente es muy til clnicamente.

Oximetra de p u l s o : es necesaria para detectar hipoxemia. E l objetivo es m a n t e n e r u n a saturacin de oxgeno Sat. E n pacientes retenedores de monxido de carbono, especialmente aquellos c o n E P O C , el aporte de oxgeno a altas concentraciones puede. Salbutamol es el ms usado, tiene u n inicio de accin de 5 minutos y una duracin de accin de 6 horas. Las dosis e intervalos de dosificacin deben ser individualizados usando mediciones objetivas de la obstruccin de la va area. L a presencia de taquicardia con palpitaciones y temblores son indicativos de toxicidad.

L a s dosis de corticoides va oral h a n mostrado ser tan efectivas y menos costosas que dosis equivalentes de corticoides intravenosos. E l uso de teofilina debe reservarse para pacientes que no responden a la teraputica inicial. A d r e n a l i n a : la administracin subcutnea o intramuscular puede estar indicada para el tratamiento de angioedema o anafilaxia. Sulfato de m a g n e s i o : la evidencia actual no recomienda su uso en forma r u t i n a r i a e n las exacerbaciones asmticas. Antibiticos: no se usan e n forma rutinaria. Se i n d i c a n si hay evidencia de u n a infeccin bacteriana.

Phipps P, CS Garrard. Thorax ; Me Fadden, ER jr. Updated British Thoracic Society". Revised edition November TABLA 4 7. R a d i o g r a f a de trax frente y perfil L a b o r a t o r i o : hemograma, recuento de plaquetas, gases en sangre arterial, funcin r e n a l y heptica, tiempo de p r o t r o m b i n a y K P T T , tiempo de sangra, grupo sanguneo y factor R h E l e c t r o c a r d i o g r a m a : e n caso de sospechar origen cardaco de la h e m o p tisis E x a m e n d i r e c t o y c u l t i v o d e e s p u t o para grmenes c o m u n e s , bacilos cido-alcohol resistentes y hongos C i t o l o g a de esputo ante sospecha de cncer B r o n c o f i b r o s c o p i a : localiza sitio de sangrado, detecta etiologa, permite tomar biopsias de lesiones sospechosas y adems b r i n d a opcin teraputica.

T A C t r a x d e a l t a r e s o l u c i n : puede aportar datos ante la sospecha de bronquiectasias o malformaciones arteriovenosas, como tambin detectar lesiones neoplsicas n o aparentes e n al radiografa. Cuadro clnico Puede presentarse c o n esputo hemoptoico hilos de sangre mezclado c o n secreciones respiratorias o b i e n c o n hemoptisis franca expectoracin de sangre p u r a.

Debe realizarse u n a exhaustiva historia clnica y examen fsico, para la aproximacin diagnstica interesan datos como edad, historia de tabaquismo, duracin de la hemoptisis, asociacin c o n sntomas de b r o n quitis aguda o exacerbacin de bronquitis crnica. Causas ms frecuentes: Bronquiectasias y b r o n q u i t i s crnica frecuentemente relacionada c o n sobreinfecciones Tuberculosis pulmonar Neoplasias sangrados n o muy abundantes hasta estadios avanzados T r o m b o e m b o l i s m o p u l m o n a r c o n infarto de pulmn Estenosis m i t r a l I n s u f i c i e n c i a cardaca.

Diagnsticos diferenciales E s importante diferenciar la sangre procedente de la va area subgltica de la proveniente del tracto digestivo o de la regin orofarngea. L a historia clnica ayuda e n esta diferenciacin. Criterios de internacin: Debe ser i n t e r n a d o e n U n i d a d de T e r a p i a Intensiva todo paciente c o n hemoptisis masiva que pueda provocar asfixia o c o n c o m p r o m i s o h e m o dinmico.

Antitusivos: codena 3 0 m g cada 6 horas va oral, c o n control gasomtrico p o r el riesgo de depresin respiratoria I O. Bibliografa Fracaso del tratamiento conservador ai 4 da con persistencia del sangrado Hemorragia unilateral lobar o segmentaria Reserva funcional para tolerar la intervencin propuesta toracotoma, lobectoma, neumonectoma Supervivencia estimada de la enfermedad de base superior a 6 meses o.

Origen del sangrado desconocido Reserva funcional pulmonar inadecuada Coagulopatas Cardiopatas Cncer en estadio terminal Hemorragia pulmonar difusa. Bronconeumol ; Conducta inicial C a s o de sangrado a u t o l i m i t a d o o c o n p e r s i s t e n c i a de m n i m a expectoracin h e m o p t o i c a : el paciente debe permanecer en guardia a la espera de los estudios complementarios y para cuantificar la hemoptisis durante 6 a 8 horas.

S i la hemoptisis no es cuantificable y n o hay sospecha de n e o plasia, se indicar al paciente consulta ambulatoria. C a s o de sangrado m o d e r a d o o grave: Tendr que ser valorado p o r i n ternista o neumonlogo para su posible hospitalizacin, y realizacin de broncofibroscopia. RoigCutillasj, Llrente Fernndez, F. J, etal.

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Guas Clnicas ; 2 Weinberger, SE. Definicin Tratamiento 1. Posicin de T r e n d e l e m b u r g , decbito lateral ipsilateral. E l paciente n o debe p e r m a n e c e r sentado, ya que esta postura facilita la aspiracin y dificulta el drenaje al exterior c o n riesgo de ocupacin b r o n q u i a l masiva y asfixia.

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V a l o r a r permeabilidad de la va area, teniendo disponible tubo e n d o traqueal, equipo para aspiracin y medicacin para realizar intubacin endotraqueal 4. C o l o c a r dos vas endovenosas perifricas va venosa central e n caso de inestabilidad hemodinmica o riesgo de sobrecarga de v o l u m e n , para medir P V C 5.

C o n t r o l de parmetros vitales presin arterial, frecuencia cardaca, temperatura, diuresis h o r a r i a 6. T r a t a m i e n t o del shock hipovolmico Se presenta i n s u f i c i e n c i a r e s p i r a t o r i a cuando el sistema respiratorio no puede oxigenar adecuadamente la sangre arterial hipoxemia, cuando no e l i m i n a el dixido de carbono C 0 h i p e r c a p n i a o cuando o c u r r e n 2. N o hay u n a d e f i n i c i n universal acerca de los niveles de presin de oxgeno P a 0 y de anhdrido carbnico P a C O e n sangre arterial 2 s.

E n la prctica, estos valores deben analizarse en el contexto de los antecedentes del paciente. C u a l q u i e r componente del sistema respiratorio puede fracasar causando insuficiencia respiratoria. Este ltimo incluye el flujo sanguneo a travs de regiones no ventiladas del pulmn, que es la causa p r e d o m i n a n t e de hipoxemia rebelde que se presenta en la prctica clnica. Adicionalmente se deben considerar la reduccin de la presin inspirada de oxgeno como ocurre e n las grandes alturas o en intoxicaciones con gases o h u m o y el baj o contenido de oxgeno e n sangre venosa mixta, que agrava la hipoxemia e n condiciones de bajo gasto cardaco.

L a asincrona tracoabdominaly la respiracin paradojal i n d i c a n u n a severa obstruccin de la va area o la claudicacin de la bomba respiratoria p o r fatiga diafragmtica. L o s p a c i e n t e s c o n e n f e r m e d a d e s n e u r o m u s c u l a r e s u obstructivas pueden referir disnea y presentar signos de dificultad respiratoria aunque los gases en sangre arterial sean normales.

E s necesario utilizar parmetros mecnicos para valorar el c o m p r o m i s o del sistema respiratorio. E l diagnstico definitivo de hipoxemia se realiza c o n la determinacin de P 0 e n sangre arterial P a 0. Puede 2 2. L a oximetra es til para monitorizar la evolucin y la respuesta al tratamiento. Para evaluar la profundidad de las anomalas en el intercambio gaseoso se utilizan los ndices de oxigenacin, que relacionan la fraccin de O en el gas inspirado F i 0 c o n la P a 0 obtenida.

E l ms utilizado es la 2 2. Cuadro clnico L a insuficiencia respiratoria aguda I R A puede presentarse e n pacientes c o n u n sistema respiratorio previamente sano o superponerse a anomalas preexistentes. Valoracin de l a ventilacin. L a h i p e r c a p n i a evidencia u n a ventilacin alveolar insuficiente. E l desarrollo de a c i d o s i s refleja, adems de la g r a vedad, la r a p i d e z e n la instalacin del proceso.

C u a n d o el aumento de la P a C O es lento, e n das o semanas, la retencin r e n a l de bicarbonato 2 amortigua su impacto sobre el p H. Tratamiento M e d i d a s generales I. M a n t e n i m i e n t o de u n a va area a b i e r t a y l i b r e de s e c r e c i o n e s Fisioterapia y tos asistida Drenaje postural Aspiracin naso-traqueal Eventualmente intubacin endotraqueal 2.

Hidratacin n o r m a l 3. Diagnstico E l diagnstico de insuficiencia respiratoria requiere la determinacin de gases e n sangre a r t e r i a l. L o s signos de hipoxemia cianosis, confusin, letargo, taquicardia o bradicardia son tardos e inespecficos. S o n signos de dificultad e n la ventilacin la presencia de. T r a t a m i e n t o de las causas desencadenantes y patologas asociadas.

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Nutricin: deber administrarse soporte n u t r i c i o n a l cuando la ingesta oral sea inadecuada. L a indicacin de V M debe ser i n d i v i d u a l i z a d a y considerar la reversibilidad del proceso que ha provocado I R A. Algunas variables fisiolgicas demostraron ser orientadoras a la h o r a de decidir el i n i c i o de V M. Debe probarse inicialmente ventilacin n o invasiva V N I en pacientes c o n E P O C , c o n patologas neuromusculares y e n sujetos i n m u n o d e primidos.

Mscaras faciales: es preferible utilizar mscaras con sistema V e n t u r i , que s u m i n i s t r a n u n a F i O s. Sistema de t u b o T : til cuando el paciente respira a travs de u n tubo endotraqueal o u n a cnula de traqueostoma. Ventilacin c o n presin positiva. U n aumento de la presin e n las vas areas puede mejorar la oxigenacin. Asegurarse el funcionamiento de la alarma de desconexin. O b t e n e r u n a muestra para gases en sangre arterial 2 O m i n despus de iniciada la V M.

Bibliografa Apeztegua Villarejo C, F. Terapia Intensiva, h- ed. BuenosAires: Mdica Panamericana, Cardonnet, L. Watson Editor: Routledge Fecha de lanzamiento: Watson con Libros Medicine And Justice: Medico-legal Practice In England And Wales, — Gratis In the past ten years medical and legal historians have clearly acknowledged the fertile links that have long existed between medicine and the law in Britain. Who Was? Extra Large 8.