Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.

Neurointensivismo

24.306 Aufrufe

Veröffentlicht am

Aula de Neurointensivismo ministrada pela Residente Larissa Andrade R2 de Clínica médica da Escola Paulisra de Medicina.

http://clinicamedicaepm.wordpress.com/

  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier

Neurointensivismo

  1. 1. Neurointensivismo Larissa Guedes da Fonte Andrade (R2CM)
  2. 2. Neurointensivismo <ul><li>“ O objetivo primário no manejo de pacientes com dano cerebral na UTI é minimizar lesão secundária mantendo perfusão e oxigenação cerebral” </li></ul>
  3. 3. Neurointensivismo <ul><li>AVC </li></ul><ul><li>Hemorragia intraparenquimatosa </li></ul><ul><li>HSA </li></ul><ul><li>TCE </li></ul><ul><li>Sobreviventes de PCR </li></ul>
  4. 4. Modalidades de Monitorização <ul><li>PIC e PAM (PPC); </li></ul><ul><li>Bulbo Jugular; </li></ul><ul><li>Espectroscopia por infravermelho; </li></ul><ul><li>Oximetria tissular cerebral(PtiO 2 ); </li></ul><ul><li>Microdiálise cerebral ; </li></ul><ul><li>Doppler transcraniano; </li></ul><ul><li>Eletroencefalograma contínuo; </li></ul>
  5. 5. Autorregulação Cerebral 60mmHg 150mmHg 50mL/100g/min
  6. 6. Fisiologia Cerebral 25 mmHg 50 mmHg
  7. 7. Doutrina de Monro-Kellie 10% 10% 80%
  8. 8. PIC 150mL
  9. 9. Monitorização de PIC <ul><li>Transdutor ventricular; </li></ul><ul><li>Transdutor subdural ou epidural; </li></ul><ul><li>Transdutor intraparenquimatoso; </li></ul><ul><li>Curvas de PIC: Avalia complacência cerebral, autorregulação do FSC e capacidade de absorção do líquor. </li></ul>
  10. 10. Monitorização de PIC
  11. 11. Indicações de PIC <ul><li>Glasgow < 9 e TC alterada </li></ul><ul><li>Glasgow < 9, TC normal e 2 de: </li></ul><ul><ul><li>Idade>40anos; </li></ul></ul><ul><ul><li>PAS<90mmHg; </li></ul></ul><ul><ul><li>Postura patológica uni ou bilateral; </li></ul></ul><ul><ul><li>Perda de 2 ou + pontos glasgow; </li></ul></ul><ul><li>Considerar se: </li></ul><ul><ul><li>Glasgow > 8 e TC alterada; </li></ul></ul><ul><ul><li>Glasgow > 8 e exame neurológico comprometido(sedação, analgesia, bloqueio neuromuscular). </li></ul></ul>
  12. 13. Ondas A de Lundberg (aumentos de 40-80 mmHg por 5-10 min) Perda complacência Comprometimento da complacência descompensação dos mecanismos de controle da PIC
  13. 14. PPC e PIC <ul><li>Hipotensão </li></ul><ul><ul><li>Volume </li></ul></ul><ul><ul><li>DVA </li></ul></ul><ul><li>Hipertensão </li></ul><ul><ul><li>Tratar HIC </li></ul></ul><ul><ul><li>Tratar dor </li></ul></ul><ul><ul><li>Anti-hipertensivo </li></ul></ul>PPC = PAM - PIC PAM : 80-100mmHg PIC: 5-10 mmHg PPC:70-85 mmHg
  14. 15. Monitorização da Oxigenação cerebral <ul><li>Detectar e prevenir episódios secundários de isquemia. </li></ul><ul><li>Avaliar oferta de O 2 X consumo O 2 </li></ul><ul><li>Métodos: </li></ul><ul><ul><li>Saturação do bulbo jugular </li></ul></ul><ul><ul><li>Medida direta da tensão de O 2 </li></ul></ul><ul><ul><li>Espectroscopia </li></ul></ul><ul><ul><li>PET </li></ul></ul>
  15. 16. Bulbo Jugular Veia jugular interna dominante
  16. 17. Bulbo Jugular
  17. 18. Bulbo Jugular <ul><li>Indicações </li></ul><ul><ul><li>Trauma com glasgow < 9 </li></ul></ul><ul><ul><li>Tratamento de HSA </li></ul></ul><ul><ul><li>Procedimentos neurocirúrgicos </li></ul></ul><ul><li>Contra-indicações </li></ul><ul><ul><li>TRM cervical </li></ul></ul><ul><ul><li>Trauma local </li></ul></ul><ul><ul><li>Coagulopatia </li></ul></ul><ul><ul><li>Traqueostomia (maior infecção) </li></ul></ul>
  18. 19. Bulbo Jugular <ul><li>Vantagens </li></ul><ul><ul><li>Medidas freqüentes </li></ul></ul><ul><ul><li>Informações quanto a oxigenação </li></ul></ul><ul><ul><li>Fácil realização </li></ul></ul><ul><li>Desvantagens </li></ul><ul><ul><li>Invasivo </li></ul></ul><ul><ul><li>Oxigenação cerebral global </li></ul></ul><ul><ul><li>FSC  contaminação extracerebral </li></ul></ul>
  19. 20. Extração cerebral de O 2 ECO2 = SaO 2 – SjVO 2 ECO 2 = 24-42% SjVO 2 = 55-69%
  20. 21. HIC  ECO 2 reduzida Fluxo rápido (vasodilatação-hiperemia) FSC Hiperventilação( CO 2  VC) PIC ECO 2 SaO 2 = 95% SjvO 2 = 80% ECO 2 = 15%
  21. 22. Autorregulação Cerebral 60mmHg 150mmHg 50mL/100g/min
  22. 23. Hiperventilação <ul><li>Aumentar o volume minuto </li></ul><ul><ul><li>VM = FR X VC </li></ul></ul><ul><li>Manter uma pCO 2 30-35 mmHg </li></ul><ul><li>Não exceder 25 mmHg </li></ul>
  23. 24. HIC  ECO 2 aumentada Fluxo lento Isquemia Manitol Coma barbitúrico Hipotermia Corrigir hipovolemia PIC ECO 2 SaO 2 = 95% SjvO 2 = 40% ECO 2 = 55%
  24. 25. Autorregulação Cerebral 60mmHg 150mmHg 50mL/100g/min
  25. 26. Terapêutica da HIC <ul><li>Manitol 20% - 0,25-1g/Kg dose (bolus intermitentes) </li></ul><ul><ul><li>Manter normovolemia; </li></ul></ul><ul><ul><li>Osmp 310-320( IRA e hipovolemia); </li></ul></ul><ul><li>Coma barbitúrico </li></ul><ul><ul><li>10mg/Kg em 30min seguido de 5mg/Kg/h por 3 hs. Manutenção: 1-3mg/Kg/h </li></ul></ul><ul><li>Hipotermia </li></ul><ul><ul><li>35-35,5ºC </li></ul></ul>
  26. 27. Hipotermia <ul><li>6hs pós TCE </li></ul><ul><li>32-33ºC por 24h-48hs </li></ul><ul><li>Reaquecimento 12-18hs </li></ul><ul><li>Sedação e curarização </li></ul><ul><li>Distúrbios de coagulação, arritmias. K desviado para o IC </li></ul><ul><li>Reaquecimento leva a VD periférica queda PA </li></ul>
  27. 28. Espectroscopia por infra-vermelho
  28. 29. Oximetria tissular cerebral (PtiO 2 )
  29. 30. Oximetria tissular cerebral (PtiO 2 ) Oxigenação cerebral regional
  30. 31. Microdiálise Cerebral glicose, glutamato, lactato, piruvato, glicerol, colina Análises (10/60min) espectrofotometria cromatografia RL ou SF 0,9% Fluxo 0,1-2mcl/min
  31. 32. Microdiálise Cerebral
  32. 33. Metabolismo Cerebral <ul><li>Microdiálise cerebral </li></ul><ul><ul><li>Avalia os níveis de glicose, glutamato, lactato, piruvato, glicerol, colina etc. </li></ul></ul><ul><ul><li>HSA prediz melhor vasoespasmo que angiografia e USG doppler </li></ul></ul><ul><ul><li>Medidas de concentração de medicações </li></ul></ul><ul><ul><li>Ajuda na detecção de lesões secundárias no TCE; </li></ul></ul>
  33. 34. Midrodiálise Cerebral <ul><li>Metabólitos energia: glicose, lactato, piruvato, adenosina, xantina; </li></ul><ul><li>Neurotransmissores: glutamato, aspartato, GABA; </li></ul><ul><li>Marcadores de lesão tecidual e inflamação: glicerol, citocinas, K; </li></ul><ul><li>Substâncias exógenas: drogas administradas </li></ul>
  34. 35. Análises Hipóxia/Isquemia  dano celular Glicose Piruvato Lactato Glutamato Colina Glicerol Lactato/Piruvato normal: 0.03 > 0.08  isquemia
  35. 36. Doppler transcraniano
  36. 37. Doppler transcraniano <ul><li>Vasoespasmo </li></ul><ul><li>Razão >3 </li></ul><ul><li>( resistência da ACM) </li></ul><ul><li>Hiperemia </li></ul><ul><li>Razão < 3 </li></ul><ul><li>( resistência da ACM) </li></ul>Razão de Lindegaard: Velocidade média de fluxo na ACM______ Velocidade média carótida interna extracraniana
  37. 38. EEG contínuo
  38. 39. EEG contínuo <ul><li>Detecção precoce de convulsão, diminuindo morbi-mortalidade (status) </li></ul><ul><li>Certas alterações predizem sobrevida; </li></ul><ul><li>Detecta doença neurológica focal em paciente sedado; </li></ul>
  39. 40. Manuseio do paciente neurológico <ul><li>Cabeceira 30º e cabeça posicionada em linha média </li></ul><ul><li>Evitar ataduras/fixadores do TOT </li></ul><ul><li>Controle da temperatura </li></ul><ul><li>Prevenção de úlcera de estresse </li></ul><ul><li>Prevenção de TEP </li></ul><ul><li>Fisioterapia respiratória </li></ul><ul><li>Hidratação (evitar soluções hipotônicas) </li></ul><ul><li>Sedação adequada </li></ul>
  40. 41. Ventilação Mecânica <ul><li>Hipoxemia: danos irreparáveis </li></ul><ul><li>(PaO 2 entre 80-100mmHg,PaO 2 >94%) </li></ul><ul><li>PEEP: RV do SNC  PIC  PPC </li></ul><ul><li>Manter PaCO 2 estável </li></ul>
  41. 42. Distúrbios do Na <ul><li>Hiponatremia ( Osmp) </li></ul><ul><ul><li>Edema cerebral e PIC </li></ul></ul><ul><ul><li>SSIADH </li></ul></ul><ul><ul><ul><li>Restrição hídrica, furosemida e NaCl 3% </li></ul></ul></ul><ul><ul><li>DCPS (hipovolemia) </li></ul></ul><ul><ul><ul><li>NaCl 0,9% e NaCl 3% </li></ul></ul></ul><ul><li>Hipernatremia </li></ul><ul><ul><li>DI ( Osmp e Osmu) </li></ul></ul><ul><ul><ul><li>DDAVP e reposição volêmica. </li></ul></ul></ul><ul><ul><ul><li>Após normovolemia NaCl 0,45% </li></ul></ul></ul>
  42. 43. CASO 1 <ul><li>Paciente vítima de TCE grave no 2º dia de internação com glasgow <8, com anisocoria, arreflexa de rápida instalação, em cuidados na UTI. Sob VM com TOT e SaO 2 86% e PIC de 35mmHg(cateter ventricular com sensor eletrônico) e SjvO 2 de 70%. Qual a conduta? </li></ul>
  43. 44. Condutas <ul><li>Cuidados gerais </li></ul><ul><li>PIC = 35mmHg </li></ul><ul><li>ECO 2 = SaO 2 - SvJO 2 </li></ul><ul><li>ECO 2 = 86-70  16% </li></ul><ul><li>Como tratar esta HIC? </li></ul>ECO 2 =24-42%
  44. 45. HIC  ECO 2 reduzida SaO 2 SjvO 2 Fluxo rápido (vasodilatação-hiperemia) FSC Hiperventilação( CO 2  VC) PIC ECO 2
  45. 46. Condutas <ul><li>Cateter ventricular  drenagem liquórica </li></ul><ul><li>Hiperventilação? </li></ul><ul><li>SaO 2 = 86%  corrigir hipoxemia pode corrigir a ECO 2 </li></ul>
  46. 47. CASO 2 <ul><li>Paciente com 25 anos vítima de acidente automobilístico apresenta TCE com fratura de ossos longos. Transferida para UTI em glasgow 7 e TC com apagamento das cisternas da base, redução volumétrica dos ventrículos laterais sem desvio de linha média. Monitorizada: PIC= 45mmHg, PAM = 70mmHg SaO 2 = 98% e SjVO 2 = 45%. Qual a conduta neste caso? </li></ul>
  47. 48. Condutas <ul><li>Cuidados gerais </li></ul><ul><li>PPC = PAM - PIC </li></ul><ul><li>PAM = 70mmHg PIC = 45mmHg </li></ul><ul><li>PPC = (70-45)  25mmHg </li></ul><ul><li>ECO 2 = SaO 2 - SvJO 2 </li></ul><ul><li>ECO 2 = 98-45  53% </li></ul><ul><li>Como tratar esta HIC ? </li></ul>ECO 2 =24-42%
  48. 49. HIC  ECO 2 aumentada SaO 2 SjvO 2 Fluxo lento Isquemia Manitol Coma barbitúrico Hipotermia Corrigir hipovolemia PIC ECO 2

×