Cee~ocnaeKo3apce (npeswem), 8-p K ~ T R 3axapueea (rnase~ pe~atmop), p p K p a w u p Xpuma (eofleq pe~amop), CTORH non00 (Tern.

pe~anop),E n e ~ a Koaapoea (opra~wsa~op), 8-p A ~ H M L ~ Pynapc~a (pena~~op), A-p P w ~ Hemoea a (peua~~op), A-p naeen A~renoe(penanop), p p Euun Bacunee (pe~atmop),&p Mapuo Ceusoe (penatmop). Mapm Kbweea (c~unoe penamop), Map~Ha n0n00a ( y p e f l ~ ~ ~ )

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Op4MHaTOp 318. KnHHHKa

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AOqeHT; K.M.H.

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H.C.lIICT.

O ~ar.$ap~.Bu~~opnn 6opucoea Munreaa H.C. I CT. O R-p Buxpa Pa~renoea 6o~eea H.C. I CT. O 4-p reopm naqoe Koqes CT.H.C. 11 CT. O 4-p reopm b ~ e C a~ o l ~ u p o e CT.H.C. 11 CT.; K.M.H. O p;p r e o p ~ E ~ r e rpnropos e H.C. I CT. 6 4-p r e o p MB~HOB ~ @ree CT.H.C. 11 CT.; K.M.H.

O 4-p E M MKoqee ~ Mwxalnos H.C. I CT. O 4-p Mealno Xpuc~oe Vo6a~oe H.C. I CT. @ 4-P M B ~ H TO~O~ M~PMHOBCKM OB CT.H.C. 11 CT.; K.M.H. O 4-P KOHCT~HTMH Kupunoe UOHKOB
OPflHHaTOp

O 4-p Jlbresap XPMCTOB 3axap~ee H.C. 11 CT. O 4-p M a p r a p ~ ~ reopmeea a HuKonosa CT.H.C. 11 CT.; K.M.H. O 4-p Maprapu~a CTORHOB~ reureaa-60~p2~~eea H.C. I CT.; K.M.H. 6 4-p Mapua~a ~ ~ M M M T ~ Kpaeea OW H.C. I Ci.

R-P M ~ ~ H MH HK O ~ MMHKOB ~~B H.C. I CT.; K.M.H. O R-p Mapun M l n x o e a Clw~u~poea CT.H.C. 11 CT.; R.M.H. O R-P Mapro X~UCTOB MapKos H.C. 111 CT. R-P Muna~ CTORHOB MH~~HOB CT.H.C. 11 CT.; K.M.H. O R-p Mun~o Jlro6onnupoe Pyces

HOB 11 CT.; K.M.H. O 4-p Ha~exqa Hln~onoea raepunosa H.C. 1 CT.; K.M.H. O R-p Haiifle~ Mea~oe Mupves CT.H.C. 11 CT.; K.M.H. OR P Hn~onaA KOHCT~HTMHOB A T ~ H ~ C O B CT.H.C. 11 CT.; K.M.H. O R-P HlnKonaA K O C T ~ ~ ~ M HMMHKOB OB
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o R-p MHHKO Kuplnnoe

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8 R-pOIHRH reopmee 6 p a ~ ~ o s 0 A-P OIHRH~

~ O P M XIWM~CKM ~ B CT.H.C. 11 CT.; K.M.H.

O 4-p n e ~ Mea~oea ~ a ne~reea CT.H.C. 11 CT.; K.M.H. O R-p Pocwqa I u ~ w T p o e a 6or~a~o~a H.C. I CT. O R-p Pocuua Ueemosa Muueea H.C. I CT. R-P CapKLlc P y I l e H M ~ K T Y ~ ~ H . CT.H.C. 11 CT.; K.M.H. O 1-p Cee~na Kupunoea Koc~oaa H.C. I CT. O R-p Cnac H ~ ~ o n Cnac~oe oe H.C. I CT. @ A-P C T ~ $ n ~eH Tp00 M H ~ ~ H O B CT.H.C. 11 CT.; K.M.H. 8 p;p Cmnu~a rpuropoea Krop~rueea-Mapu~oea CT.H.C. 11 CT.; K.M.H. O R-pT o ~ o p Me~ouuee Kycee sae.o~uene~ue O 1-p O ~ Hreopmesa M Mapm~oea CT.H.C. 11 CT.; K.M.H. R-P X~PHTOH B ~ ~ R M M HOBKOB M~OB
K.M.H.

O R-p nasen reopmee Mutues CT.H.C. 11 CT.; K.M.H. O 1-p n a a ~ a M B ~ H OT Bp~l n r ~ o s a CT.H.C. 11 CT.; K.M.H.

0 R-P XPMCTO MB~HOB MH%B H.C. I CT. O R-pXpucTo n a ~ o Xpuc~oe e

OpRblHaTOp

O A-p Ulepu M a K c Tawep CT.H.C. 11 CT.; K.M.H.

T p a s ~ a myepenu r ~ ~ Ha ~ a s a M Ha flOflHUTe KpahHMuU T~~BM~T YBpeflU U ~ ~Ha H rfle39Ha M U Ha XOpUflOTO MHOX~CTB~HM 4palcrypM Ha Kpah~lrllMTe YC~~OXH~HMR npM TpaBMU Ha KpahHMqMTe Aunyraqun Ha K P ~ ~ H M npM K 3flOnOflyKa rpbn~a TpasMa ~H~BMOTO~ U~ XeMOTOpaKC KC YC~OXH~HMR npu rpbp~a ~pae~a Cbpper~o-cbpoea TpaeMa T ~ ~ B Ha M CbpueTO H T ~ ~ B ~a M cbfloee~e M K o ~ ~ TpaBMa MH~
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132 141
145

Yponorur~o-re~u~an~a ~pae~a Tpa.9~ Ha ~6b6pe~a Tpae~u Ha IlMKOqHMfl MeXYp T ~ ~ B ~a My M pe~pa~a Tpae~u Ha CKpOTyMa U CbflbpXUMOTO Tpae~u ~a ~ O ~ ~ O BW U R~ H TpaBMaTM3bM npU ~ ~ ~ M ~ H H O C T Pa~u nmepa~ypa

148 150 151 153 153 155 155 158 160 163 164 164 165 165 166 166 166 168 172

PA3AEn-II. UlOK 06qa na~ore~esa ~a w o ~ a 0 6 n a~ ~0~ ~~ 3 ~ 0 f l 0 M peaKuUU ' i ~ U npM UOK Ila~orema ~a pa3nuq~u~e @PMU~a WOK npeqe~~ ~a aX M ~ O B O ~ ~ M M ~WOK HUR n~sepa~ypa

68 71 72 75 79

PA3AEn-Ill. TPABMATOnOM'lHH CnEUlHM CbCTORHMR 0 6 4 nPMHuMnU ~ Ha TpaBMaTOJlOMRTa 82 Vepen~o-MO ~~ H p~ a ~ ~ a 85 rpb6~aqH0-~03brHa TpaBMa 89 nuqeeo-renlocma ~ p a e ~ a 93 AC+HKCMR 93 Xe~oparu~ 95 Tpaeuu ~a K ~ ~ ~ H U L ( M T ~ 97 Bunoee T ~ ~ B M ~a U~ p a i r ~ c l w e 97 flUaIHOcTUKa npU TpaBMU Ha KpahHUqUTe 98 06wu MeTogu Ha cnetuHo neqetiue npn TpaeMu Ha K ~ ~ ~ H U ~ U T ~ 99 T~~BM~M~HU Ha PaMeHHUfi M R C U Ha r0pHUTe KpahHUuU 107 Tpae~am'i~u yqeu~ ~a pwca~a 118

PA3AEn-IV.OC06EHOCTM HA TPABMATA B AETCKA Bb3PACT 0 6 npUH~UnM ~ ~ Ha TpaBMaTOflOrMRTa B fleTCKa Bb3paCT 174 T~~BM~T YBpepU M~H Ha M Kpah~M4blle B pe~cma swpac~ 176 ~ ~ ~ K T Y HaPKOCTUTe U Ha rOPHUFi K ~ ~ ~ H M K 176 @palrrypMHa KOCTuTe Ha flOflHUR K ~ ~ ~ H M K 184 ny~cauuu 189 rpbp~a TpaeMa B peTcKa m p a m 190 TpaBMM Ha 6eflUfl npo6 191 T ~ ~ B Ha M CbpueTO M 193 llep+opaqu~ ~a xpa~onposopa 194 PynTypa Ha p ~ a + p a r ~ a ~ a 194 PyllTypa Ha ~~MM$HMR nPOTOK 195 M ~ o x e c ~ s +pa~-rypu e~u Ha pe6pa~a 195 Tpaa~u Ha rpbflHUR KOW 195 Cb'ieTaHM rPbflHM TPaBMH 196 CbcleTaHa TpaBMa Ha rPbRHUR KOW U KOpeMa 196 K o p e ~~ p a a eB ~R a e ~ c wspam ~a 196 3a~pu~ a p a e ~a ~a ~ o p e ~ c~ ~a e~~aa 197 3 a ~ p u KopeMHa ~a TpaeMa c yapena Ha IlapeHXUMHU OpraHU 197 3 a ~ p u KopeMHa ~a TpaeMa c yepee ~a~yxuopra~u 199 OTKpma KopeMHa TpasMa 200 Cbre~a~a o p e rpaerna m 201 Tpas~u Ha oTpnmenHaTa a c m a B~ e ~ tm xp aam 202

PA3AEJl-V.CbPAEqH0-CbAOBM CflEUlHM CbCTORHMR rpbfl~a 6on~a APMTMMM Hema6wn~a aHMHa neKTOpMC O m p u~$apm Ha MuoKappa YcnoXHeHMfl npM OCnp MH$~PKT Ha MMOKapfla Oc~pa flnceKaqufl Ha aopTaTa Ocrpa neeoKaMeptia U H C ~ $ M ~ H ~ H ~ M R OCTpa aOpTHa M H C ~ $ U ~ M ~ H ~ M ~ ~ K P M T H aopTHa ~H~ c~e~o3a OCTpa MMTpmHa M H C ~ $ M ~ M ~ H ~ M ~ ~ Cbpjqerl~a TaMnoHapa XU~~~TOH KPM3a M'-~H~ Ocnp nepMKapflHT klH$e~qM03eH eHfl0Kapfllrr Jl~~epaTypa
PA3flEJl-VI.6EJlOAP06HM CflEWHM CbCTORHMR Oc~pa p ~ x a ~ eH n~ ~R aO C T ~ ~ ~ H O C T 234 ~ H T ! ~ ~ ~ Ha~AaHHUTe T ~ ~ u OTu KPbBHO-ra30BMfl aHXlM3 236 6enoflpo6e~ OTOK 238 Pecn~pa~op RucTpec e~ CMHRPOM M CMHRPOM Ha ~ ~ o r o o p r~ ae ~ f~l a oc~anr~m 239 XPOHH'~H~ O~CTPYKMBH~ 6enoflpo6~a 60nec~ 241 ~ ~ O H X U ~ aCTMa J ~ H ~ 242 E K ~ T ~ ~ ~ ~IlpMrMHM ~ o H ~ J H U 245 6enoppo6~a xunep~e~3ufl 247 6enoppo6~o cbpue 248 6enoflpo6~a e ~ 6 0 n ~ ~ 249 C~OHT~ IlH H eBMOTOpaKC ~H 250 Ac~~u~~C ~M u H R o P O H M~ H 252 O q e ~ Ha ~a rpbAtiaTa pemeHocKonufl M rpa$ug B ycnoswma ~a c n e t u ~ m 253 nmepa-rypa 254

PA3AEJl-VIII.CflEUlHM CbCTORHMR HA MbXKATA nOnOBA CMCTEMA flpManM3bM 276 QMMO~ M~ napa$u~osa 276 OcTbp IlpOCTaTMT 276 OCTbp OPXMellHflHflMMUT 277 Topsuo ~a ~ e c ~ u c a 277 r a ~ r p e ~a ~ aC K P O T ~ M ~ 278

PA3AEJl-VII.CnEUlHM CbCTORHMR HA OTAEnMTEnHATACHCTEMA OCTpa 6b6pe'-l~a HeflOCTaTb'lHOCT PA3AEn-X.CTOMAUlH0-qPEBHM CflEUlHM Xena~ope~ane~ CMHRPOM CbCTORHMR n0~qbpXaHe Ha BOflHO-elleKTpOnUTHMfl6ana~~ KopeMHa 6on~a Hap~LUe~Mfl B O ~ M R H Ha ~ THaTpMeBUTe ~ QOHU ~ O K M U ~ U KOpeMHa ~ ~ H ~6on~a HapylueHMfl B 06MflHaTa Ha KWMeBUTe ~IOHM AM$y3Ha KOpeMHa 60nKa 6b6per~a KOnMKa OCTbp XMPYPrMCleH KOpeM Xe~a~ypufl pclar~ocT~ M ~a ~ $ e p e ~ qp ~~ aan r~o a3 a AHypMfl HaompxupyprM~eH KopeM OCTPH MH$~K~ Ha MOTflenMTenHaTa M cMcTeMa ~~PUTOHMT Ocnp n u e n o ~ e $ p ~ ~ 0cl-b~ XOneuMCTMT OCTbp U M C T M T O m p XonaHrMT 'iyx~~ Tena B ypeTepuTe Ocnp aneHpuqm

PA3AEJl-IX.AKYUIEP0-TMHEKOJlOrHqHMCflEUlHM CbCTOFlHMR ~MH~KO~O~M CllelllHU C ~ H M CbCTOflHMfl 280 ~ ~ H M T KPbBOTeCl ~ ~ H M e HMR 280 Tasoea 6on~a 281 TOP~UO Ha aflHeKCMTe 282 Pyn~ypa ~a oeapwan~a KMCT~ 284 285 YC~OXH~HMR cne~ a60p~ no xena~we K o M ~ ~ M K npM ~~u MHTpaVepMHHa M KOHTpaqenqMfl286 nep@pauMfl Ha MaTKaTa 286 Ocnp CannuHrMT M ~y60o~apuane~ a6cuec 287 A6cqecu ~a synea~a 288 EH~~oM~T flMCMeHOpefl, P M ~ ~ ~ , MMTeJlLLIMep4, ~eonna3~~ 288 ~~HMTW TpaBMa H~ 289 npernefl npu ~ a ~ a c w n e a ~ e 289 CIleluHM CbCTOflHMfl npM ~ ~ ~ M ~ H H O C T 291 ~ ~ ~ B ~ H M ~ ~T ~ O~CMI ~ HH ~ H O C T 291 C~OHT~ a60p~ H~H 291 KpbB0~e'ieHMfl BbB BTOPMfl M TpeTMfl TPMMeCTbP Ha 6peMeHHoClTa 293 XH~~PTO npefl H M3BMKaHa ~~ OT 6peMeHH0~TTa (npee~na~ncnfl-e~na~ncm) 294 AMHMOTM e~60nufl295 ~H~ XHRP~MHMOH 296 nponanc Ha nbnHaTa BpbB296 OCTPU~ ~ R O M U H 60nKM ~~H y 6peMeHHaTa M XeHa 297 Qe6pun~u CbCTORHMfl Y 6peMeHHaTa XeHa 297 Paxqa~e no c n e l u ~ o c ~ 298 Cne~u~ C~CTORHMR u B cneflpoflo~u~ nepuofl 299 Kpbeo~ere~ufl B cneflpo~oaufl nep~o~ 299 Cne~po~oa $~~PMJI~H nepno~ 300 flmepa~ypa 300

Ocnp naHKpeamT ~epH0~pChHa KOMa Oc~pa rpeeHa HenpoxopuMocT (uneyc) OCTPUCTOMaWHOYpeBHMKPbBOTeWHUR Ilospbqa~e MJ~~PRHUR Ha xpaHonpoBopa M cToMaxa O6pa3~a PMarHOCTMKa npM CneWHM CTOMBWHO'ipeBHM CbCTORHUR Jl~~epaTypa

PA3AEJl-XVI.@EfiPHnHMCnEUlHM CbCTORHMR OCHOBHU $e6p~n~ C~CTORHMR u 450 PA3AEJl-XVII.OC06EHOCTM HA CnEUlHMTE CbCTORHMR B aETCKA Bb3PACT Cbpper~o-puxa~en~a pecycquTaqm HapylueHuR Ha pMxaTenHaTa @YHK~MR Hapylue~ufl Ha cbpper~o-cbpoea~a @~HK~UR OCTPM~ H O ~ H O ~ ~ C T P Y K T M B ~JI H ~BPO-6en0pp06~~ M 3ahn~saB ~ peTcKa u ~ ~b3pac~ nneepan~u YcnoweHuR Ocrpu ~ b 3 n a n u ~ e XupyprurHu n~u ~ ~ ~ O ~ R B Ha ~ H U R KOPeMHMTe OpraHM B peTCKa Bb3paCT BbBepeHUe OCTbp XMPYPrM~eHKOpeM B ReTCKa Bb3paCT O m p aneHpuqMT npM peqa OT paHHaTa ~ b 3 p a ~ ~ (0-3) roRUtiH H o c o 6 e ~ o c B~ Kn#Ht+tHoTo ~ MY npoTuraHe Ocnp aneHAuquT npw peqa Ha ~ b 3 p a OT c~ 3 R0 15r0flMHM ~ ~ ~ L I T O H My TM HOBOpOfleHOTO O C ~nePMTOHUT P B AeTCKa Bb3paCT OCTbp naHKpeaTMTB peTCKa Bb3paCT OCT~P XOlle4MCTMT B ReTCKa Bb3paCT Ompo ab3nane~~e Ha Me~enosu~ pwsempMKyn BfleTCKa Bb3paCT qpeBHa HenpOXOflMMOcTB ReTCKa Bb3paCT Bpope~a rpesHa HenpoxopuMocT B ReTCKa Bb3paCT flpupo6u~a rpeaHa HenpoxopvMocT BReTCKaBb3paCT Cneponepame~a rpesHa Henpoxopmocr BAeTCKaBb3paCT MHB~MH~IJUR B fleTCKa Bb3paCT OCT~P XMPYprMqeH CKPOTyM B AeTCKa Bb3paCT OCTPM YPOllOrM'IHM CbCTORHMR B UeTCKa Bb3paCT O m p nueno~e$pu~ Ycnox~e~ $OPMM u Ha OCTPHR nueno~e$pu~ O m p l#lCTUT
~W~HO~~OCTUT

PA3AEJl-XI.EHAOKPMHHMCnEUlHM CbCTORHMR 3axape~ p~a6e~ 368 fl~a6e~ ~~ e~ aoaq~p03a 369 Xnnepoc~onap~a ~ e ~ e ~ oKrOeM~ ~ ~ a 371 X u n e p ~ a n q ~ e~pnsa ~~r~a 372 T#~~OTOKC KPM3a U'~H~ 373 M M K C ~ KPM3a ~~MH~ 374 Ap~co~oea KpM3a 375 PA3AEJl-XII.TPAHC@Y3UOHHMH XEMOCTA3HM CnEUIHM CbCTORHMR TP~HC@Y~MOHHH PeaKUHM M YCJlOXHeHMR Bpope~u ~oarynona~u~ n v c e ~ w ~ u p~ a~ ~a~ p a e a KoarynaqMR s~i~a A H T M K O ~ ~ TepanMR '~~~HTH~ @ U ~ ~ M H O ~ M T TepanUR M'~H~ nw~epa~ypa

378 385 394 397 399 402

PA3flEJl-XV.MH@EK~MO3HM CnEUlHM CbCTORHMR OCHOBH~ KOHqen~UR 3a M H $ ~ ~ M M T ~ 430 OCHOBHU KOHqenqMM 38 MMYHMTeTa 432 MH@~KL(M XenaTMT O~~H 435 O~Tbp6aKTepManeH MeHMHrMT 437 OCTPM Ty6epKyn03~~ YCnOXHeHMR 439 A H ~ ~ ~Mo H@ ~ ~H K ~U #M 440 06qa xapaicrepMcTvKa 440

OCTbp OPXMenMPHflMMMT OCO&HOCTM Ha 6 b 6 p e r ~ a ~ KOnUKa a npM peqa O C TPeTeHUMR ~ ~ Ha YpMHaTa Xunep~ep~u~l B peTcKa ~ b d p a c ~ Cen~uqe~un, cemmreti WOK B peTcKa ~b3pam Aemppa~au B~ peTcKa ~ ~b3pa~~ X~nepxuppa~aq~~ M ~ ~ ~ P RHR H xpaHonpoBopa MR M cToMaxa BReTCKa Bb3PaCT

Oco6e~m H a KpbeonpenusaHeTo npu HoeopopeHu U

~ e ~ a ~ o ~ p u ~ e c e r ~ a s b s p a c r Cnelu~a o6pa3~A a u a m o m K a B peTcKa Bb3pacr flmepa~ypa

528 529 530

PA3AEn-XVIII.TOKCMKOn0M~HM CnEUlHM CbCTOFlHMR Knacu$~~aq ~a uo ~ ~ ~ p OT~~BRHUFI m e

Ocrpu oTpaeflHufl C @o@opoopra~u~~u necru~u~u554 M ~ ~ ~ U K ~ M oCTPU ~ H T OTPaBflHHfl O~HU 555 OCTPU OTpaBflHUfl CbC CbtiOTBOpHu 6 a p 6 u ~ y p a ~ 555 u OCTPU OTpaBflHUfl C TPU4UWIMCIHU a~m~enpeca~~u 557 Ocrpu O T ~ ~ B R H UCR~e~ponen~u4u 558 OCTPU OTP~BRHURC T P ~ H K B U ~ U ~ ~ ~ U 559
OCTPM OTpaBflHUfl C HaPKOTUClHU aHUlreTU4U OCTPU OTpaBRHUfl C HeHaPKOTUqHU aHanreTM4U

532

560

E n u f l e ~ u o n o ~H f la OCTpUTe OTpaeRHUfl 532 TOKCOKUH~TUK~,TOKCO~MH~MMK~ U Me~a60nU3bM npU OCTPUTeOTPaBRHUfl 533 X u ~ u r ~uaniocm~a ~a ~a oc~pme o~paefl~ufl 534 OCHOBHM npuHuunu Ha n e q e w e Ha o c r p u T e o~pa~1fi~m535 n p o ~ u ~ nU e ~UTOBW ~ u OCTPU OTpaBflHufl 537 OCTPM OTpaBflHUfl C )KMBaK U XUBaClHU cbe~u~e~ufl OCTPM OTPaeRHUR C KaffMUfi M KaffMUeBU CbeAUHeHUfl

(awrunupem4u) 561 OCTPM OTpaBflHUfl C PUMU4MA 561 OCTPM OTpaBflHUfl C KaPRUOTOHU~U - ~UrHTanUCOBU rnt0~03u~u 562 OCTPU OTpaaRHufl C ~ H T M X U ~ ~ ~ T ~ H ~ U B U 563
OCTpU OTpaBflHUR C aHTHaPUTMMqHU neKapcTseHU

537 538

cpe~c~sa

564

OCTPM OTpaBRHUfl C XOnUHOilUTU4M 565 OCTpU OTPaBflHUfl C aHTUnaPKUHCOHOBM neKapcTBeHM cpe~c~sa 565 OCTPU OTpasRHHR C ~ H T M ~ ~ O T O ~neKapcTBeHu O~HM

Ocrpu OTpaeflHufl C $nyop M $nyop~u

CbeAuHeHuR OCTPM OTpaeRHUfl C XnOP U XnOpHU CbeAuHeHufl OCTPM OTpaBRHUR C @C@p U @C$O~HU Cbep,UHeHufl OCTPU o~paefl~u Cf em l no^ an~oxon Ocrpu O T ~ ~ W H UCR emn no^ an~oxon

538
539

cpe~crsa
O T p a B f l ~ U fC l aHUnUHOBU llPOU3BOfiHU OTpaBfl~e CbC CaJlU4UnaTU OCTPM OTpaBflHUfl n p U KOHTaKl C ~ U O ~ O M ~areHTU HU OT~~BRH OT Unqenu, R ocu U c~bpwenu OUPU OTpaBflHUfl OT 3MUU

539 540 541 Ocrpu O T ~ ~ B R H U CR emne~rnu~on 542 OCTPU OTpasfltiuR C neTpon U neTponHu npopywu543 Ocrpu oTpaBflHuR C eTunupaH (onoee~) 6 e ~ 3 u 544 ~ OCTPM OTpaBflHUR C TeTpawlOpMeTaH 544 OCTPU OTpaBflHUfl C flUXnOpeTaH 545 OCTPM OTpaBflHUfl C npona~6yra~ 546 Ocrpu OTpasflHuR C nylueviu r a m 8 ~~brnepofle~o~uc 547 OCTPU OTpaBflHUfl C b 6 ~ 548 @anom~~o 136140 o ~ p a m ~ e 548 VPUT~TUBHO b 6 ~ OTpaBRHe 0 549 M~CK~~UH 1O 36 B~ O OTpaBflHe 0 549 ~~HT~~MH m6110 OBO OTpaBflHe 550 HUTPOUAHO 1 3 6 ~OTpaBflHe 0 550 npo$unau~~ Ha aI ~ ~ H OTpaEIfiHuR M T ~ 551 OCTPM OTPaBRHUfl C XnOPOpTaHUqHM neCTU4UAU 551 OCTPU OTPaBflHUR C lleCM4UAU AUllUPUflUnU 552 Ocrpu OTpaefltiufl C necrMuuflu A U T U O K ~ ~ ~ ~ 553 M~TU OCTPM OTpaBflHUfl C IleCTU~MAU Kap6a~aTkI 553 554 Ocrpu OTpaBflHuR C n e m 4 u ~ nMpeTpouAu u

OCTPM OTpaBflHUfl nmepa~ypa

OT MOPCKU ApaKOH

566 567 568 569 569 569 570 570

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suco~o K ~ oqme. M C n e npaeuniio ~ m a w H e Ha MamaTa c A M ~ Y - ~ m ~u ~nopTaTuseH oH pecnupaTop uoxe Aa ce u s e b p w a ~ c u m p a ~ unu o ~o~~ponup o6fiuwM~e mo c recToTa OT l0 AO 14 min-'. IO~AULUMH~TO CM ~ C~ Kp~ R6m fla C! BHUMaM3a TO PHOTO HanRraHe (He no-suco~o OT 20 cm H,O), BUCOKOTO Hannratie Moxe na npeeuwu ~ o ~ yHa ca HuKHe He c a ~ B o6 e n u ~ A@, HO n B cToMaxa, I a npenu3BUKa Pe~MTauURUnU IlOBpbqaHe U CTOMaWHOTO cbppm.40 Aa 6 b ~ e BTnamaHo B 6 e n u ~ upo6. Tom e oco6e~o onacHo npu 6 0 n ~ u B Kola, npu KOUTO Moxe I a Hacnnu .~uxa~, He3a6enR3aHa peryprmauun U acnupa~ U R 3a . npefloTepaTRBaHe Ha Toaa ycnowieHue K ~ M MacKaTa ~ o x e ace nocTaeu eKcnupaTopetiBeHmn, c KOUTO UHcnupaTopHoTo HanRraHe Aa ce ~o3upa ~o 20 cm H,O. npu HanurneHa MexaHurHo npenmcTeue~o6nacrra Ha napUHKca UnU HeBb3MOMiOCT38 eHAOTpaXeaJlHa UHq6agun ce npeypueua cnewHa K O H U O ~ ~ ~ K U~ KOHUUR OTOMUR WIU MUKPOTPaXeOCTOMUR C IlOCTaBRHe Ha CneuUM H U ~ p b 3a 6U ~ HC~$~ Ha ~ KlrlCflOpofl. ~UR OToctioBHa WOCT, npeAu sa3npueMaHe Ha ~ o h o U Ra 6uno MemA 3a nompxaHe Ha npoxoAu~oma Ha AuxaTenHme m m q a e ocurypmHeTo Ha ToaneT Ha ~a3o$apu~~ca. TOM Moxe Aa 6 b ~ ocbqemeHo e MexaHUVHo C ~ y n @ p UnU ~ MapneHU TaMnOHU U UHCTpyMeHTantio c acnupauuoHHu noMnu U wupo~u, MeKu U aTpaeMaTUClHU $~~KCU~UJIHUKElTeTpU. flbn60KaTa aCnUpal $lR BbB $apu~~c npu a qacTuvHo 3ana3e~u pe$ne~cuMoxe na 6ble onaaia 3apapn npoaoiwpatie Ha noapbqaHe U nonapaHe Ha cToMawHo cbmpxu~o, ~ p b unu a vync,qn Tena B AuxaTenHme namqa. YecTo mm caMo Toanem Ha roptime AuxaTenHu m m q a e B cbcToFIHue Aa ocurypu TRxHaTa npoxoAuMocTn Aa oTnaye tiyx,qaTa OT cneuuanHme TexHu~ecKlil n p u l o ~ 3a u TOM.

MHO~O recro Meplwre 3a nompxatie Ha cso60n~o fl~XOAUMUAUXaTenHUmTU~aClpe3MaHYMHUUTeXHUqecw cpewea ca HeAocTanrHu. Toea ce onpenenn OT ecTemoTo Ha TpaewaTa unn 3a60n~sa~e~0, KoraTo 3a uasbpweane Ha ~eo6xoAn~me pecyc~maquo~ Mepo~u npURTUR e HI?O~XOAUMO PbueTe Ha neKapR a ! 6bflaT cBO~~~~ lllnbl H U3a , o ~ c J I ) ~ K ~Ha ~H eflUH ~ T nauUeHT o TPR~sa Aa ce B K ~ I O ~eiwn M OT peaHuMaTopu U cneuuanucTu OT ~pyi-u o6nam Ha MeAuuuHaTa; KoraTo e ~eo6xoflu~o cenapupaHe Ha UuxaTenHme nbmqa OT xpaHocMunaTenHuR TpaKT; npu 6 0 n ~ u B KoMa c RenpecnR Ha UuwatieTo unu Tpawu U yapenu B MexaHuKaTa Ha AuwmeTo n ra3006~e~a. Tesu C ~ ~ T O R H UHanaraT R ~ p a l enapeetie ~o

U nombpxaHe Ha BuxaTenHuTe nbmqa, KoeTo Moxe Aa 6 b ~ ocbu(ecTeeHo e cauo rpea eHnoTpaxeanHam ~ ~ y 6 a UHR. n 0 p a p Te3U ~ U pen APYM IlPUVUHUUHAUKauMUTe3a U H T ~ ~ ~ MoraT ~ U R Aa 6bAaT rpynupatiu B neT roneMu rpynu: 1 .l l o m p x a ~ npoxo~uumaHa~xaTentime e nbTuW. 2. Toane~u CaHauUR H ~ T ~ ~ X ~ O - ~ ~ ~ H X U flbPBO. UIHOT 3. Ha~aneHa o ~ c u r e ~ aU ~HapyureHuR un B raaoo6meHa. 4 .O B n ~ e a H Ha e TBXKU ibp'i0B~ CbCTORHUR C H&xoau~ocrr OT npunoxeHue Ha MycKynHu penaKcaHTu. 5. Heo6xoflu~oc~ OT U3KycTBeHa BeHTUnaqUR. EHp~TpaxeaJlHa~a U H T Y ~ ~ ~UMa M R KaKlO npenUMcTsa, TaKa U HegocTanuu. OCHOBHUT~ npeAuucTBaca cneAHme: Cmrype~ a o c ~ b ~o n RnxaTenHmTe nbmqa. l l p e ~ o TBpaTRBa C e O ~ C T P Y K ~ M RHa T ~AUXaTenHUTe nbTUqa OT e3UKa, KPbB, nUKBOP, CeKpeTU, CTOMalUHO CbAbPWlMO UnU ' i W U Tens. O C ~ ~ ( ~ C T B R KHa I H TpaHCtl ~ T O OpT M n U H ~ ~ ~ x o F ( u M O OT C TIlOCTaBFlHeHa ~ O ~ H U B nPUHYAUTenH0 U CTPaHUvHO IlOnO~eHUe, nOnOXeHUe no KOpeM, U3UCKBaT npU HaU'iHa O ~ C T P Y K ~ U R Ha AUXaTenHMTe nbTMqa napanua Ha Hepeyc peKypeHcunu eneM Ha rnoTuca, npu aHaTOMU'iHU O C O ~ ~ H O C T -UMUKPOlHaTUR, JlUnM Ha eKCnynCUR Ha MHOrO 3b6~, aHaTOMU'iHU pe$eKTU HaTBbPflOTO ~e6ue, TPaBMU HaTBbPAOTO~e6ue, 'ie~IOCTUTe,$palcryp# B 06nacna Ha npepiaTa repentia RMKa, HapatiRsaHuR Ha noAa Ha ycTHaTa WuHa U HapyweHu $apu~rean~u pe$neKcuun~~o~uo~pa3nur~oecTecTeo-qqbnxuTenH U curyp~o Bnapeetie Ha AuxaTentime naTuqa. n o BCRKO BpeMe n KoraTo e H ~ O ~ X O A U MMoxe O I a ce u3abpwu TOaJleT H ~ T ~ ~ X ~ O ~ ~ ~ flbpBO, H X IlaEMU U ~ J ~ aCnUpaH O T O uUR Ha ~ ~ ~ H X U ~ H AbPBO O T O Unu $ M ~ ~ O C K6O ~~ 0C ~x K0~cKonurruacnupauuR. Cmryp~on p e ~ n a 3 s a ~ OT e acnnpaqna B 6enma ~ p o 6 Oco6e~o . 3acTpaLueHu OT TOM ca nauueHTuTe c TeXKH 'iepenH0-MO3b'iHU TpaBMU, KOpeMHUTpaBMU U MneYCHU C~CTORHUR. Perypru~auu~~a unu noapbqaHeTo U acnupauuma Ha cToMawHo c b ~ b p x u C ~o ~ cuntio C Kuce10 pH e eAH0 OT HaU-T~XKUT~ 6enoflpo6~u YCnOwieHUR (cu~~p Ha o Mendelson) ~ c pa3BMTUe Ha 6eno~po6e~ eAeM U AuxaTenHa HeflocrraTb'iHocrr. TO npe~u3euma O C TO ~~ C ~ TPYK~U HapMXaTenHUTe R nbTUU@U OnaCHOCT OT xunoKcuR. B xofla Ha 6eno~po6~me HapyweHun npu acnupauug Ha Kuceno CToMawtioC ~ A ~ P W M O ce p a 3 ~ u ~ a pecnmpaTopeHAmcTpec CnHRpoM (ARDS). B~~MOWK 38 HKOHTpOnblpaHa OCT MeXaHHVHa BeHTHnaqua. K o ~ ~ p o n ~ p BeHTMnauuR a ~ a ~ a ce npunara Kamo npU H ~ ~ ~ X O ~ ~ UOT M OnepaTUBHa OCT UHTepBeHuUfl,TaKa U B c n e f i o n e p a ~ u enu ~ ~ CneATpaehnaTureH ~ nepuoA. CBO~OAHO onepaTmBHo none ~ b p x rnaeaTa y mnH mpnoTo. CBO~OAHU AuxaTenHu nbTuqa U W S M O ~ ~ K H O C T 3a U ~ K Y C T B a ~H e~ ~ ~ u n a npu uu~ H~O~XO~UMO OT C npunoT
'

18

. . , .

, ce , , - , - .

ce , , , , , , . - ce , ( ). , , .

- , . , , , , , , . , - ( ce 1 -2 ). , , - .

i v. Thiopental Metohexital Etomidal

Propofol Midazolam Ketamin Succinylholin

3.0-5.0 mg/kg 1.0-2.0 mg/kg 0.15-0.3 mg/kg

1.5-2.5mg/kg 0.1-0.2mg/kg 1.0-2.0 mg/kg 0.8-1.0 mg/kg

- MagiII, 6.5-9.5 mm (7.0-8.0 mm 8.0-9.0 mm ); Woodbridge , Carlens , high-volume - low pressure Lanz , Macintosh , , MagiII, , 5-10 c , , , , , - ce Ruben , . ce -

ce 5-10 Jackson", , , . ce , . , . . , , . ce . 1 , - . ce .

 19

ca , ce , , ce . ce - ce ( ) ce 2-3 , ce . ce . , ce 1-2 , , ce , . ce ce .

, . . ce ", . . . ce . ce , , . ce . ce 2-3 ce .

- ce , , , , , , , , , , , , , .

ce , ce .

- , , , . , - , ce ce . . ce , " , , ce .

ce , , ce ce - , ce . ce . ce -. ce high volume - low pressure . ce , , . 1 ce - , . , MagiII, ce . ce -

, ce . ce : 1. ce .

20

Cnequ+uu~uM ~ I I I o ~ u ~ L u I npoqegypu 8 cnewnama meguquncka nomoq

naquem c ~ p a w npu u KomnporueTwpaHeHa UwplcynaTopHaTa U AuxaTenHaTa @ y ~ q u u . 2. f l o ~ r o ~ e cu e ~TpaxeocToMHaTa e KaHma, onpefleneTe pa3uepa U wga U npoeepeTe 6ano~a. Ka~lona~a T~FI~E fla ! ~e roTo6a npenu paapea. 3. flpoeepe~e roToaHocTTa 3a acnnpauufi. 4. O u e ~ e ~ npaeuntio e 3~are~ue Ha ~cseTnHHaTa o U no3uumma. nawewwre aca3HaHue M ~ ~ M TcB~~ nT ~a60nKa npu x ~ n e p e ~ c ~ e ~ 3 n WHR. pa~ ilo-@pe a nowoxeTe Bwrnaatinua noA paMeHeTe Ha nauMewa, cne4 KaTo no'lucTwre noneTo.

Iloflro~oe~a. f l o r ~ c ~ KoxaTao~ e~e ~aHflU6yna~aflo KnlorMuMTe. Rann~paA~e CTpyKrypwre no cpeflHaTa nmHMFI, 38paOTKpMeTe XblOWC(HaTaKOCT, THPOWAHHR brbn, KPHKOHAHHR xpywRn M cynpacTepHanHaTa ~ ~ b 6 H a TuHa. Cnep Toaa c l ~ $ u n ~ p ~ p a KoxaTa A ~ e U nopKoxMeTo c 1% Lidocain no nlrHHma Mewy KPMKOU~HMFI xpywn U CynpacTepHanHaTa s ~ b 6 ~ a m ~ a . Paspes. Hanpaae~e Hanpeqe;l paapea no cpeflaTa Memy K P M K O M p H M RX P w n M c)TlpaCTep~EN~a~a Bjyrb6HaT M H a ($W. 1.l .),KaTO pa3peXeTe KOXaTa U IlOflKOXHaTa TbKaH fl0 nOBbPXHOCTHMFIn M C T Ha flbn60~a~a luUfiHa @a-

nHaTa mKa. npefl~me lorynapHn seHM nexaT naTepanHO, npeflHUTe K O M Y H M K a T M B H MBeHHOCTaBaTOTAOny. Te He TPR~B a ! ~ nona,qaT B nMHmTa Ha paape3a. Bncqepane~ oTAen. AKO M C T M Y ~ Ha T UMToBflflHaTa mesa e c ~ o 6 o p ~ nopBUxeH, o TO TOA Moxe fla ce oTeefle C PeTpaKTOpM Harope M n M HqOny. npM Bb3pacTHMTe norecTo m e s a ~ a e $n6po3~o npoMeHeHa M e n n m o cpacHana K ~ M npeTpaxeanHaTa $ a c q ~ ~ B. Tame cnpah

Cnequ@urnu ~ e m o g u k u u npoqegypu 8 cnewnama ~ e g u q u n c k a nomou(

21

ma~nwpah~e Hmyca OT nBeTe cTpaHH, npowlrlh~ero 1.2.) n no n n H a r m TO OTReneTe OT Tpaxema. BbBeAeTe TpaxeanHaTa KyKa non n b P B M R TpaxeaneH npacTeti n A~bnHe~e ~paxe~lra Harope M Hanpel. Cnen ToBa ~ ~ c m n ~ p a 1 ml ir~ Lidocain e BTpaxemaM HanpaaeTe paspesa Mewy BTOPMR M TpeTuR TpaxeanHM nPbCTeHH. He O T C T ~ ~ H R B npo30preTO ~ ~ ~ T ~ Ha XpyURna, T b i KaTO
($MT.
T O B a BOAM M H O r O recT0 A 0 TpaeMHM C T e H O 3 H B~OCneRC T B M I . nOc~ase~e ~paxeantia~a ~ a ~ l o ($~r. n a 1.3.).

pawn c~e~o3 nnn a nep$opaqn~Ha Tpaxema.

air-o6qo no~a3a~wma 3a TpaxeocroMnR dmn KOHMOTOMMRca O G C T P ~ H R Ha ropHwre UnxaTenHnmmqa, ~omo He Moxe A a 6 a ~ npeoRonRHa e rpes e~no~paxeanHa M H T y h ~ R M n M Bb3WOBOR. T O ~tlpo6neM, M BY C n O B n RTa H a CneWHocT. MOXe na B b 3 H W K H en D H 6017~14 CbC cneAHme 3a60nRkH~R: c w~n&wur~, HeKowponMpyeMMxeuopawn nnn Hacnencmetin~an@puaqwn H a AonHaTa r e n m m nnqeTo; ennrnoTwr, ~eonnas~n, ~ ~ C U ~ Ha Cn P M O C T p a H C T B O T 0H n HW O TRnO B b B QapkIHKCa; TpaBMU, $paKTyp~, naqepaqnn, C T ~ H O ~ M 6nna~epa, nHa napeaa Ha mactime spurn; no6po~arecrae~n ne-

Tpaxeoc~o~ KaHlona. ~a npaenn~nm ~ 3 6M 0 ~~ snon3ea~e Ha KaHwnaTa e n s ~ n l o r n ~ e n BMO ~ o 3a npefloTBpaTRBaHe Ha Y C n O M H e H M f T T aOT T p a X e O C T O M M R T a . HOBMTe TpaxeOcTOMHlr K a H O n M Ca C H ~ ~ A ~ CH 6ano~n M C HMCKO HanRraHe, KoeTo P R ~ K O C H M ppnKa ~ OT Manaqw M nocne-

3nu m u nanmonon Ha napnHKca m u Tpaxema. npoflbnmen~a n3~ycne~ eemmnaqmn. a HalrecToTo noKamne 3a T ~ ~ X ~ ~ C T O e M ocurypRBaHeUR TO Ha ~ o c ~ po b n Tpaxema 3a ocaqemReaHe Ha npommenHa H ~ K ~ C T B BewrlrlnaunR. ~ H ~ TFI ce Hanara npn flOKa3aHM $~6po6po~xoc~onc~w, TpaxeanHM epo3nbl UJlU YBpf3X)JaHURU lip# HeBb3MOXHOCT 3a nOWCTBaHe Ha ~ ~ ~ H x M M H Cel UT cpeTU ~ nw3 eHpOTpaxeanHaTa ~pb6a. noeere~o OT ~ e 3 ycnomewn n ca m p 3 a ~ C n xnpypmvHaTa MaHwnynaqnn: 1. Xe~oparmm. Te ce m m a T ~&Becle Ha Henpaen~On#MpaHeHaTnPOU~HHRH~CHnHHa3aCRraHeHa

Aocnn; n o - ~ a n recToTa ~a Ha KbpeeHe; nnnca Ha ycnoxHeHUR KaTO nHeBMOTOpaKC, ne3Mf-l Ha 6e3kl~eHHaTa apTePUR, ~paxeoea@arean~a $myna. K ~ H K O T M ~ O~ Me ~~ H 6~ pT neXM a~ ~ aHenMpeflCTseHo no4 K ~ U K O U ~ H M F xI p w n ($ur. 1.4). Tnponp~nm x p w n Moxe pa ce nwo6wnnanpa c Hepouuti#pauaTa pblta, AoKaTo ce Hanpaeu 1-2 cm paapes Mewy peaTa xpyqnna cbc clcannen. Bbeepe~e ppbxKaTa Ha cKannena B OTBOpa U r0 3aBbpTeTe n0A npaB bran, 3a Aa OTBOpUTe AnxaTenHnTe nbTnua. Iloc~aae~e KaHtona c eflm pasuep n o - ~ a nOT ~a npepnonaraeMuR M R 4u~cnpal~e. B cneurtin CKTyauUM Ta3U TeXHUKa e MHOrO 6bp3a W AOCTaTb'iHO CUrypHa. AKO HRMaTe KaHlOfla, MOXe pa n0CTaBUTe MaJlKa eHflo~paxeENHaTpb6a, klHTPaBeHO3eHKaTeTbpMnLlflpyr0 Tpb6~0 npncnoco6ne~ue sa apeMeHHo noname.

noflmtoruw-taTaBeHa. 2. B b 3 ~ u I e H ew6onm3a~.Toil e BcneAcTsne OT pa3paea~e Ha npemwretorynapw BeHn nnnHa noprcnto~urHwe. TOC~HOTO onpeflenRHe,Ha cpenHaTa nntinR npn metine. 3. n ~ e e ~ o ~ e f l m a c r n m~ nHeewotopaKc. ym 4. Tpaxeoe3ogarean~a @myna. 5. Acnnpaqn~l U acnmpaumoHeH nHeauoHmT. HalAo6pa~a npo$unamn~a e~ p a x e m o ~ n m ~a a ce nsabp~unpn npepBapwenHo n+n@npa~naqnewr.

pas~~noae~le~ocnyran~enpeporapam~oeaycno-KapllU~oM ~a nar

A H nnn ~ nyulecl~a ~~xa naqu~, MH$~KUMO~HM MR ~a ~ O P H M T pnxa~en~ HM nbTMIl@. npn fleua non 12 r. He ce npaeu KOHMOTOMMR.

Te C a CbWMTe, KaKTO M IlpU OCTaHWHTe $ O ~ M UHa Tpaxeantia M + ~ ~ M R . TP~AHO e, 06acle, pa ce peKoHcTpyupa cy6rno~nc~a creHo3a B aHaToMnrHaTa 3 o ~ a Ha KPUKOTMpoUflHaTa MeM6paHa. fl0 Ta3M IlPH'iUHa flauMeHTM C KaKewo M pa ca n p ~ 3 ~ aaanapu~rean~o yn yapewaHe Mnu cneA npoflbnmnTentiaeHloTpaxeantiaM H ~ ~ ~ e no-n06pe Aa 6bna~ TpaxeOCTOMklpaHM.

Cnen W e w m e T o B KnnHnclHaTa n p m n m npes T ~ X H HHa K~ H3lIbnHeHHe 1968r., ras~aelnm +m6poorrmse~ ~~OHXOCK HanpaO~ Bbnpocn npefln npoqeClypaTa: en peeontounR B noAxoAa K ~ M 60n~u C pa3nnv~n 1.60ne~yaa nn nayneHnT OT a m a ? pecnnpaTopHu npo6ne~n.Taan npouelypa e necHo 2. Lonepyaa nn nauneHnT OT cbpflewo-qoen 3amsmn~u~a cebp3a~a ; c no-uan~o ycnomeHuR; no~o~RB~HMFI? po6pe noHmMa OT nauemwre; ornewa no-ronma 3. Mua nn y p e l ~ q apbxKa? WCT OT ~paxeo-6po~xuan~o~o mpeo (oco6e~o ropHwe 4. M Mn M ~ nOTUCHaT MMYHMT~T? w o r n ) rpea Anpemtia eu3yann3aqnn; Moxe fla ce npo5. M M nn ~ anepru~? sews B cneluHoTo npueMHo oTAeneme Ha nernoTo Ha 6. Hanpase~n nu ca pewrretioeu CHMMKM H EKT? 6 0 n ~ n Purug~a~a ~. ~~~HXOCKO ocTaHa ~ ~ H R npeBnowTa7. npocne~e~n nn ca KpbeHwe ra30ee, ~po~60uwruHa npu ameHaTa xennomn3a (HW 200 m1124 h), o-rcrpaTe, ~ ~ O T ~ O M ~ M H O B OM TO IlapuMaJlHOTO T ~ ~ M ~ O ~ ~ ~ C T HRWe Ha W U Tens. ~ ~ ~ H X O C K O ~ @ HR HT ~P ~, OO~ITUC~H~ 80 epeue? 8. B3eMaJ-I nu e naqneHTbT B nocnepHo epeMe MeflmKaMeHT, KOATO YBpewa $ Y H W M Ha ~ TpoM60ulm~e ~ U aKo Aa - uxneAeaHo nn e epeMeTo Ha cacupea~e?

Cnequ+urnu Memoguku u npoqegypu B cnewnama ~ e g u q u n c k a nowoq

23

9. npmeuan nu e naquemT xpaHa npea nocnefliime 1. Cnefl ~ ~ ~ H X O C K O 6uoncu~ ~ C K ~ npU H ~ U H T Y ~ U ~ ~ 3-4 h? IlaqUeHTUUnU PYrUHHa~POHXOCKO~UR npU U H T @ I ~ ~ H Ha anapaTtiaBemunaquR,~anpaee~e pemre~oea CHUMK~ 3a 10. no~nucan nu e naquemT cbrnacue aa U ~ B ~ P U I BePfTTeH IlHeBMOTOpaKC. m e Ha npoqe~lypa~a? 2. AKOn a q u e ~ e n aemnupati, ~ ~opurupaiiTe napa11. H a a ~ a r e nu ~ ae n p e ~ e ~ u ~ a q u ~ ? MeTpmeHaanapaTHaTaBeHmnauMR. 12. MMa nU BeH03eH I%T? tie e U H T ~ G H ~ npomnxeTe ~H, noAKOnal&Wil%THe e uHTY~u~~H, $U~~OCK MOXe O ~ ~ ~ T 3. AKOn a q u e m ~ mnHmentioTo nonaeaHe Ha ~ucnopoa npea nocnenaaAa ce BbaeAe ~ a 3 a n unu ~ o opantio. B nocnepime roAuHu q m e 2 h. ce npennorma ~ a 3 a n ~ u r n ~ Ko~~uv~CTBOTO mn. Ha MeCTHUR aHeCTeTuK (M npennormatie e Lidocain)He ~pu6ea 4. npocnene~e suTanHuTe napaMeTpu npea eau 2 h, fla Hweuuraea 200-250 mg. npu BHe3anHa n o m Ha IoKaTo naqueHnT ce c~a6unuaupa. npoMeHu B CmaHueTo, MOP, XanlOquHaqnu, COMHO5. He noawn~eahe Ha ~ e u ~ T y 6 u p a naqueHTu ~u Ba newHocT unu x u n o ~ e ~ ~ au p~ ~ 6 na ea ce nonoaupa nunoC e XpaHfTT UnU RURT, ROKaTO He npeMMHe ~ ~ ~ C T B U Ha ~ T KaUHoBaUHIOKCUKa~UR. noKanHuR aHecTeTuK. npu6nu3u~en~o 1-2 h cnen npoqeAypaTa paapeweTe Ha nauvemana cu n u h ~ M e ~ K aofla. O AKOlla4UeHTbT Ha U3KYCTBeHa BeHTUna4UR (MB), @dpocxorm~ Moxe Aa 6bne abeefleti npea umy6aquo~AKOTO^ He KauR unu He ce naeu cac cnmKa, aba06~oseTe AueraTa MY. HaTa ~pb6a MU TpaxeocToMHaTa KaHma, rutno Iua~ e n p ~ p u 6 e a n no-ronum ae OT Nn 8 npu ebapac~~u 6on~u. ~OCT~~OHXOCKOI'I~H nepaoA. Bbnpocu cneA 6 p o ~ XOCKOnUR:

fluaniocm~~u Tbna rpbAHa TpasMa OWHK Ha ~ yepewmuma OT uHT)aaqu~ A~enelcraau Oc~po HnxanaqmwHomnaneHue Pemre~onwq~ cycneKquR a 3a r y ~ o p Ynopma ~alunuqa ~na@paman~~napanusu An$y3~0 napeHxHMHo3 a h n ~ s a ~ e Xeummc Me~acruq~a 6Onecr c Heu3eecreH rmpeureH @ K ~ C 6enoApo6e~ a6cqec n03nTU8HEl L(HTOllOMR C HOpManHa pl?HlTt?HoBa HaXOflKa napanuaa Ha Hepeyc p e w t i c Pewflueupaqa nHemoHuu Cernre~~ap~a 6po~xorpa@uu Hepe@upaq ce n@umpa~ B3uuaHe H a qmypu

Tepaneemr~u Enno~paxean~a uHT)aauu~ O6un~a ce~peuu~ n a~enem3a Clyqu ~ena Xe~omuanc npe~onepam~~a oueHKa H a pe3elcra6un~ocrra 6enonpo6e~ anmnape~ naeax npu npo~eu~o3a

APY~U O q e ~ ~a ~ aperuo~an~a se~runauuu Rnamomqe~ 6po~xoanseonape~ naeax nneepocltonu~

~~~HXOCKO He ~H ~pu6ea R na ce npoeema npm: tieonwreti ~ ~ ~ H X O C K O ~ U naquem CT; B K O M ~ T O ~ HC~CTORO m;H e w 3 M o ) m na ce ocurypu weKeama oKmreHaW, napquaniioHanRraHe Ha KHcnoponaB apTepuanHaTa ~ p a (Pa0,)~phea a C(a6 b ~ HW e 60 mm Hg no BpeMe Ha npoueClypaTa; HemMo)miocr na ce Kopurupa Koarynor-

pamaTa npm n u e m 3a 6uoncu~;~ e c ~ a 6 u n w u p a ~ cbpnevw ~ O ~ H n Ua ; y e m C H e n e m cunnrnoMaTuvHa a m a M x a p ve npH n a y e m cbc cra6un~a peTeHHa CO, Moxe Aa ce npoeene 6 p o ~ x o c ~ o n 6e3 u~ 0C06eH TO n p e k l e ~ q u m U a cenauumano BpeMe Ha n p o u e m a ~ p ~ i 6 na e ace npoeemaT BHuwaTenHo.

m,

24

Cnequ+ulmu memoguku

npouegypu B cneurnoma meguuuncka nomoq

Kora~o ce npaen OT OnmeH cneqnanncr,@16poc~oncKaTa ~ ~ O H X O C K O ~ M e RTBbpne 6eaonac~anpoueF\ypa. CWPTHOCTT~H~H~BHW ayCnOXHeHMXTa ~ B ~ ~ . ~ % ,1.8%. P~AKM neTanHw T ~ nHqnRercrn ca cebpaa~u c pecnnpaTopeH apecr nopan xeMopancrR, napnHro- unu 6po~xwnaab~ H capnereH apecT nopan ocnp MnoKappeH MHU n MP M T b M H C r l HaPyLLleHMR. KbcHUTe yCnOWeHUR, ~a6nwnamqn C e 24 h Cnen

npoqeAypaTa, ca: TeunepaTypa; samearantin peatqnn; napntiro- nnn 6poHx0~fla3bM; xnno~e~a Hu apmnn; ~ nHeeMoTopaKc; n@neun, ceapmn c a~ec~eanma n ~NHHR. npn HRKOM naqnem MoraT na ce n p e p n m eaeHTyanHme ycnomeHuR: npn amaTnqn MoraT na ce paaenmRnxaTenHnn capnerHocanoenycnometinn; naUHeHTH C nOTUCHaT HMyHUTeT Ca P U C K O B U 3a #H@K~wR; naqnem c xe~omw3uc-3ampeetie; naqnem c r a m rHa 06CTpyuuu~ H eti$p6po~xuan~n ne3mn - 3 a nneeluoHMR.

B ,De HumaniCorporis Fabrics", nmnma npe3 1555 r., Andreas Vesalius 3a npbe n b AaBa ~ no~po6~ cbo6qeme 0 3a . M O ~ ~ ~ H O wT w Om " e . T0i4 nuwe: .... T P R ~ Ra B ~ce o m p cTeona HaTpaxema, B ~ q m Ba o ce nocraan~pa6a OT TpmnKa, npe3 ~ o m q o e AyxaTe, TaKa r e 6ennm npo6 na ce penMru U MBOTHOTO Aa noeMe m. npn cnah Anwatie B cnyclame Ha MBO MBOTHO npo6b~ qe ce paaAye, q e M~~IMHHTopaKanHaTa qmHa n capqeTo q e cTaHe cun~o.Kora~o ~po6b mnro ~ BpeMe e 6nn ~ona6#pan, ~ H ~ H ~acbpqe~o ~ T O M apTepme narneyqa~bn~006pa3~0 n mowqo, HO KoraTo npOGb~ e OTHOBO p a w , capueTo cram w n ~ on . o ~ a a3 ~o npaw ~ o a M anpo6b~ ce p a w m nrcrepeann, AaweHneTo Ha capqeTo M apTepnme H e cnnpa...".Bnerarnneaqoe KaKVesalius~c6pe pa36npa.~o~ePHMT~" lpMH4MnM Ha CbMBRBaHeTO M KBK RCHO OnHCBa BeHTpHKynHaTa @ ~ 6 p ~ n a q u 3a n .CbXMeHUe, HeBMMOxtioma 3a a a r n w R K ~ M roBeKa 3 a 6 a ~npunoxeHne~1 TO Ha Ta3M T e X H W K a C 400 TOflUHM. CbBPeMeHHUTe pa36UpaHnR 3a KapflnO-nyJlMOHaJlHa pecyCqUTaw AaTUpaT OT 1966 r., KOraTO C a ~3pa60TeHU K O H C e H C Y C H MCTaHAapTM3a H ~ ~ H O T IlpowWaHe. O np~eTUT e B EBponeAcKa~a O ~ ~ H O Cn T CAU cTayapm ca flea: OCHOBHU Meponpumn 3a n o m p b m Ha MBoTa; Keann$nqnpa~n MeponpnmnR aa n o m p b m H aw m a .

HOW.

B m ~ a H 6 0 n ~ no r~ 6a c T m ~m a ue w m e~ m y p

HMno h n ~ n qa an o r e a &nta~cwem, ~ .yaa B yc~a m n ycTa

B HOC' WIH M~CKOBO & n u m e . 3a ~otrrpon HanuxaTenHnT e m w q a mpmaranHo ce npunara m H a 4ne~cx.wc u q p p n m e~an o n ~ arenlom. ~a EtIllITIOTUCbT,a H e emmT, em o a ~ a ~ a n p n r n ~ a 3 a ~a dm rop~u-re p ~ ~RmaTenHul m m q a npnh n m B 6 e w a ~ e n CbcTomine. ~o llpenapaTM OT TPYllOBe llOKa3Ba TO'IHHR MeXaHH3bMHa T E M 06CIQy($nr. 1.5.).

OCHOBHHMeponpHnm 3a noClqpma Ha m H s o T a
A&pe M~EI~CTHO e, r e e$n~actia~a mp~nenyn~o~anHa PeCyqUTwMFIC% OCHOBaBaHa M 3 K Y C T B e H O T OAOcTaaFlHe H~OK~M~~HM~~K~~BB~~~OTO ~pbeoo6paqe(CMCT~MHO) Hne B & e ~ ,pocraTbreH na cbxpa~n $ y ~ n w Ha e xua~eHO m n opra~n H B cbqo~o BpeMe Aa noaaonn 6bp30~0 Eb3CTaHOeRWHeHa(XIOHTaHHOTO ~pbB006paU@H~e. AMT~ KOMnOHeHTa Ha KapnMO-IlynMOHaJlHaTapeCyvaqclR (WmunaqnRM nep$yann) q e 6bmT paarnepaHnB ceeTnnHaTa Ha CbBpeMeHHUTe p~36UpaH~R. K o ~ ~ p Ha o nRHxarenHHre namqa H sewmnaqnfi

M a ~ e m e Ha ~X o H O H A H KOCT ~ noBnwra M M ~ M ~ C T Ba Hanpepe n w n o mOT ~ e r o w o6cTpymu~~a ~a ~O~M~MFI. fl0pa~lM npMKpenRHeT0 HaenMrn0TMMKbM XUOMpHaTa KoCT c nwrawew TOU Moxe na 6bne noWnmaT Hanpep rpe3 miyaneti npnUo~, KO~TO m M e m caMaTa KOCT Hartpen. 3afla ~ece cb3naaa~ BHCOKM HanRraHnRB nMxaTenHme mmqa, a c TOM M HamnmaHes e p o m m a OT npetcocouencln ompflHe tia xpatlonposopa, ce ~ a 6 n ~ Ha r a 6ae~a HpaTopHa $ass (1-1.5 S) npM n a y e m , KOMTO He M jupa~ no ~BpeMeHa pecycwauwma.n p c c npoeewaic OT AwMa ~ y u cnen r ~ BceKn 5 npmcKw#R Ha rpb~(tiwi KOW ce B ~ K W 3a,qbnmen~a nay=, 3a Ra ce oCMrypM BpeMe 3a 6e30nactia H e @ ~ a c ~ ~a e~unaq npcl w~ O T H o c M T e n H O HMCKM M H C n M p a T O P H M HMRTaHMR.

xpaHonpoeopa. C paqyrme Ha M p ~ ~ r e a 6ano~ n~u~ M pMcTanHaTa MaHweTa, nauMemTce s e m w p a npes OTEJCpme Ha e@arean~vn nyMeH. AKO ~ a ~pb6a 3 ~ nonWHe B Tpaxema, TO ~ e ~ r u n a 4 ~ce r nOcbqec-rBnea a npes ~ p y r u ~ nyMeH. Hmo eptio OT ~ e 3 u np~cnoco6ne He ~~ Moxe ~ fla 3annecTM ~myiaq~ma, acannocnym sa BpeMeHHoO C M ~ ~ ~ R ewe HapMxaTenHmem m q a npepnnocTaeRHeTo HaeHno~paXeanHa ~pb6a. AKO Te3M npll~nWo6Ile~MR MT e X H M K MM

Ilpmc~aue Ha rpnAHHn KOUI

A ~ C T ~ B R H ~Ha TO OKCW3HMpaHaKPbB no BpMe Ha KapAH~K ~ ~ ~ ~ T O C H O~B~H BO M OT CM ~$MK~CHO Ha C IlpT UTMCKaT~ He Ha ~ ~ ~ P H KOUI M . R npenopbrea~a~a recroTa e 80-100.

Eu~o~paxeanua ~1ny6aq~11

Tow e o 6 u r a i r ~ ~ MeTon m 3a noAqbpmaHe Ha puxa'renHme m q a . n o p poKa3atiaTa ~ ~ CM e $ # ~ a m mTOM , M e T O A e CTaHpapTeH M C e M3nOn3Ba OT BCMrKM (neKapM, cpeneH MenMuMHcxn nepcoHan, napa~en~un) B o6nama MYeO~~M~eHOOTM3MCKBaHM~a3aHHBa3HBHOCT. H a cneuHaTa MenMwHa, npn KapwaK apecr, B u3m~60nB npomnxeHMe Ha MHoro ~ ~ M H ceMcrmalue, r e HMVHM M 60IlHM~HlrlY C n O B M R . h T $ a l ( ~ TpR6Ba ~ ~ a fla ce KP~BOTOK~T n p npmcl ~ rcKaHeHa ~ ~ ~ A H KOUI M R e pe3yma~ OT npewowa OT BeHrunaqnR c pa3nMrHu np~cnoco6ne~vl~: npmcKatie Ha cbpueTo M e w rpbntiaTa K ~ C T MW ~ a r A~6y-~a c Knann m u np ~a 3 n i . 1pecnMpaTopn ~~~ c namn1HHRc~bn6. TO= 6eue Hapere~o.nnexa~M3'bM HaCbpperHaBHO HXlFIraHe, C H ~ ~ C ~ C KMCnOpofl ~HM eHM3TOVHMK WIM &HTa no~na". llocnenwq~~ MxnepwHnR e poeemxa 1 0 OTKPMBaHeTOHamepHaTMBeHMeXaHM3bM3a BWCTaHOeFleaHe Ha IcpbwToKa, a MMeHHo .rpbAHara nouna". .Knac~rec~me" npeAnonomeHnnOTHCCHO KP~BOTOnpM npmcKaHe Ha r p b p KOU ~ ~ no~a3~axa, ~ r e npn npmcxatie Ha mpqeTo Mewy creptya M r p a 6 ~ a r ~ n c'rbn6 ce npem3BMKw M3XBbpnRHeHaKpbBTaB C M C T e M H O T O M 6enoppo6~o~o ~pmo6pbqe~~e. ~~MHREB $yq~o~an~ xapaKTepumm me Ha em$arean~OWDT 3a npoMnHa B padupa~nma e ~a6nlo~e~ne HMR O ~ T ~ P ~ M eHfl T O O TpaXeaJl P HaTa -B ~pb6a I~~ TO,renpMM3KYCTBeHaBeHTWlaL(MRCn03mMBHOHanRTwe XOBOA W Cb~aMT3HaclUTellHO no-BMCOKMC U C T e M H OM MHTpaTOpaK ~ H HanRraHe, O oTKonKoTo npunpwrucKaHMn6e3 B e m a U M R M r e BCMrKH MIHWBPH, IlOBMWaW MHTpaTOpaKaJHMT e HaJlRrMMR, IlOBMWaBaT C M C T e M H O T O M 6e~0flpo6~0~ HanRraHe M noToK. Te3~ naHnn nmoxa moeatinn na ce npneue xnnoTeama, r e q q e H o T o nmratte M ~ O T O K npM KapnmnynMoHanHa pecycunTaumca BcneacTeMe ~ao6qo yeennqaeaHe Ha nlrrpaTopaKanHom HannraHe, KoeTo c I q a w eKCTpaT0paKaneHrpWMeHT Ha HallRraHeTO. ype3nByltaHanna exo~appuorpa$~~ npM nauuewn c KappMaK apecr e YcTaHOBeHO, Ye o 6 ~ 0 Il~ OBMWaMHe 0 Ha MHTpaTOpaKaJlHOTO HanRraHe, a He flMpKTHOT0 IlPMMCKaHe Ha CbPueTO, e IlpMclMHa 3a Bb3CTaHoBRMHe Ha KPbWTOKa. PM T O B a M3Cnenme e ycTaHoaeHo, r e MmpanHaTa Knana e matiana npea WOTO BpeMe omopetia, KoeTo atiaraw, r e nRmo
CbpueenacMBeHn~WflHMKHaRBMeHMeTOHaKPbBTaOT

min-l c ~ b n h r 3.3-5.2 ~ ~ a cm ( l m a ~ b c l ~ fla a cb3~qe nannaTopHo oce3aeu nync Ha CbHHaTa M n M@e~opan~a~ ap-rep~~). C ~ O T H O Wn ~p Hm M~ ~c ~ a ~ e - o m y c TP ~Fa I~ ~Be ~ fla e 50:50. Ma~ap na 6e po~a3a~o, r e O T K P U T M ~CbppereH M a mm r y p ~ w no-p&pa xeuonMtiaMMKa, npmaraHeTo

6enme npo6ose B aopTaTa, a He "no~na". Betrr~naqn~ cno3m~~ Hannrwe, o npwyxetia OT @ 4 K C % p Ia H e Ha KOpeMa C pa3nHrHM KOnaHH MllM Ha l%P#fTe

26

Cnequ+uunu mernoguku

npouegypu B cnewnarna

c wneTKu, ce npenoparaaOT pennqa amopw, HO ~ p y m MM onotiMpaT, qe TOM Moxe na olcaxe oVMqaTeneH e @ n

Bbpv K O p o H a P H O T O ~ ~ @ ~ ~ M o HHmraHe Ho M IlO T 0 3 M HaLfMHfla HeYlpaJlM3Mpae@lcra O T T ~ X H H K M T 38 ~ IlOBMUaBaHe Ha M H T p a T O p F l K W l H O T O HXlRraHe. Bbnpe~ eau ~ u~oro6poi~w e ~ c n e p n ~ e wM aorpan~~ HnreHo KonMrecTao WrwtiurHM ~ ~ a 3 a ~ e n nompxam~a, q M TeOpHRTa 3a OCHOBHaTapOnR Ha #HTpaTOpaKa~HOTO HannraHe, a He FjnpeKTHoTo npmwcKaHe Ha mpueTo K ~ T O M e X a H M 3 b M 3a BbXTaHOBRBNe Ha K p b B O T O K a , CbqeCTBYB~T AoKa3aTenmaa M 3a ponma Ha RnpeKnia'raKoMnpeCMR Ha CbpueTO, KarO O C H O B H a AeTepMMHaHTa 3a Bb3CTaHoenBaHe Ha yRapHw 0 6 e ~ P~C~HOTO . npmaraHe Ha cma ~bpxy ram OT rpbRHaTa meHa (Aone~ meptip) npenaaa uouew ( ~ o ~ n p e c cMna ~o~ M~ CKOPOCT) a ~bpxy nomexaUOTO Cbpue. T O ~M M O M e H T e ClleF(CTBMeH aK O M l T P e C M O H H a Ta Clma, KaTO M M n y n C b T e eKBMBaneHTeH H a IlpOMRHaTa B M O M e H T aH aB C M L f K HCTPYKTypH, KOMTO C e IlOBIlMRBaTOT T a 3 M KoMnpecwR. npmMcKaHeHameptiyMaMoMemTMoxe aa npe~cl3~m~a KoMnpecMn Mnn n 3 ~ e c ~ a a Ha ~cbpqero. e Ha Kounpeama HnM M ~ M ~ C T B ~ HHa ~TO CbpqeTO, K a T O BCRKO M H e P T H O ,H 0~ ~ @ P M M P CC! ~T ~m O,

PM

M~HO nOsnMRBaHe vecm MoraT Aa mpaT ~ a n o m tfa o $aran~me apmwn, ~ o m o M B M ~m T r p w m a ~ tfa e pecycqmaqm. tiqIyk3~epHbI ~ ~ M K ~ P ~ Te3m ~ M M . WraT fla G 3C M H Y C O B M MnM H O A a J l H H no lpOU3XOC(,M O G 3 T 'm C a ~~RM~BMKN OT Mmops cTeneH (mnI U II) m~ p m c r m aTpuoeewpnKynapeH (AV) 6no~. Cngmtme (m HOW+

ROMMHMP~H~TO

qe 3a~vc w ~ TOM K ~ K e npMnoxeHa as^ cma. npn KounpecMR c nocToRHHap n 6 o r ~ q ~e ace nonyvncbpAeLfHa K O M n p e c M R( K ~ ~ T K O T ~ ~ C AB H M ~ C o , Ka CKOPOCT), AOKaTO npn n o - n p o f l b n ~ ~ e nM en ~o - 6 a ~ e yRap ~ ~aonq y e ce nonPMM3Mc 'T a a H e HaCbpqeTO. Tba K a T O KP~TKOTP~~HMRT,

HM) 6pap1apm~~n M mn I BTopa c'rene~ AV6rm~HO ce mnxaT H a n p e ~ o 3 ~ pc aonMam. ~e M nomMRaaHe e ~ e 0 6 x o ~ caMo ~ ~ npn o m e m e , npc KMO 6 p a g n a p m n ~ e ~ mnpoeoReHa a OT cnagwe tfa AH, noRaa Ha n p ~ 3 ~ Ha aq p~ e ~ q ~ p Ha a~ ce apnew Mnu HanurueTo Ha eKTonM'iHa KaMepNa nenorwpH3awR. B C ~ KOT MTe3M npM3HauM T ~ R fla ~ CC! W npHeMa 3a Ha xeuoAwHauMrHo m~ enenpo$u3uono~w qywwe,c BepomHocT ga nporpecMpaB neTanHa apmw~. llqnmaranHoTo nereHMe e ~ ~ M K H O W H0.5 O mg Atropin i. v. U n p ~ ~ e o 6 x o ~ u ce ~o nosTapFl c~ npea 3-5min o6qa ~ p 3 2 a. c 2.5 g ? f . l AKO T O M e HeflOCTaTbrHO 3a IIWWHSW tfa

p b w o pycno, KoeTo ~ 3 m n aopTaTa ~a no spMe Ha KoMnP e C M O H H a T a HXlMClMeTO Ha K O M n p e C M R C IlOCTOR H H ~ ~ J ~ ~ O Y f l a ~ P H H M F H F T ~ 06eM , q e OCTaHe enHaKbB, IlpM yemnaaue Ha npmMcmnma, a cbpfle'i~nm~e6wr q e ce penwarn. RHec ce npueMa, qe recToTa 80-100rnin" npu Bb3CTaHOB b 3 P a C T H Me Hah-fl06paTa M BoflM nbllHOl@HHO

m.PM

tnpeonaran~a 1-24 pglmin6bHuetim y neGc~et4n.p. H q m e p ~ TaxMapmMMn. n T y ~ c 6mo%m e r~wmpRHOTO MbWeHe; WmeHe; AV-HOWH~ ; -T u p
TM@KaJlHa, IlpeflCbpAHaTaxMKapAWlul;~ C K W U U @ M entty" TaXMKaPRMM. ~ O W C ~ ~ T @PMM O He Ce OTHZWTT Kbll mewHaTa KapdMonomrHan w o u c flee m m : napoKCU3MXlHaTaHa,4KaMepHaTaXWapm C T XWlDle H 3 M R M nPeRCbPAHOT0 TpemeHe C 6bp3 KaWpH PUTbU, BoAeqRoKoMnpouempaHeH ax e ~K a p o m BepcuoTo M Verapamil ca cpe1cTBaTa Ha &cp r p new ~ HMeTO Ha T 0 3 M BMA B P M T M M M .Kapm~~epm 1 -m 3anorHe m 7 5 J U npw Heycnexnacen w m ~ p m 3 C O J, a mpaoHawHaTaAo3a Ha Verapamil e 5 mg i. v. U m e ~ e o G x o ~ ce 1 ~noeTapR ~o 10 mg cneu 1520 min. KaMepHn 6 p a ~ ~ a p m B uy ~~c . m m ~EUHOCT

B R B a H e Ha KpbBoTOKa.

n o ~ a c ~ o ~H qR e M a uRCHH ~ ( o ~ a 3 a ~ e n KOR m TexHwKa ~a

H a ~ a p ~ ~ o - n y n ~ pecycumaum o ~ a n ~ a nog6pasa KP~BOTOK~ M KoeTo e no-WO, HeeponowHaTanpomo3a npn naqMem c KapAMaK apem. Cpaa~men~a~a oqeHKa Ha xeMoAMHauMrHme napaMeTpnnpM xopa, ~ a ~ o we rnposeo

WaHa KOHBeHqMaJlHaMaHyaJlHaM H R K O MO T a J T r e p H a T M B H M Te TeXHMKM: ( B M C ~ K O H M ~ Y IlHeBMaWWa ~ ~ C H ~ ) ; MMleTKa C MnM 6 e 3 c M ~ y n a B ~ t ? ~ H T ~ M a n a q M R M M~061mM3a~MR H a KOPua He e oTKpma npMopmeT Ha H R K O ~ OT MeToAme. Tom AOKa3Ba, Lfe H e 3 a B M C M M O OT C ~ ~ ~ ~ # ~ $ Me C X a IH H M M 3 b M F,I m3na~aK q~ ~ B O T O BK gqetia ~ KnclHMrHa cwyaqm, pecyCwauMma e M O BpMeHHO nO/l,QbpM~O C b C T O R H M e , UoKaTo ce npnnoxaT ~ ~ a n n @ q ~ p aMeponpwrrwfl3a ~me nompxaHe H a WBOT~.

 2 7

, - , . 1.1. , ce , ce : ; ; ; - . . ce , .

- , ( ), . , , - , .

1.1.

. ce , . Adrenalin ce 5 min. Epinephrine ca - , .

28

, , . ce : = (W/sec) ce J () . ca - : ,

. ce 50 Ohm . ce () 50 J 50 Ohm - 50 J c 50 Ohm . ce , . . . , , . - , ce , (. 1.7).

. 1.7. (11 kg ), ce . ( ) , ce 200 J , - 200-300 J 300 J. , , ce , , ce . ce , ce . ce

 29

, .

ce Adrenalin. Adrenalin ce , , ce - . ce , Adrenalin ce - - , ce . Adrenalin , ce , . 0.5-1.0 mg 5-10 ml 1:10 000 . 5 min, , . ce 5-6 mg, ce , . , . Lidocain . , reentry" , ce . Lidocain 1 mg/kg, 360 J . , Lidocain ce 0.5 mg/kg 8 min 3 mg/kg. Lidocain, Adrenalin, Atropin ce - . , , , ce Natrii bicarbonat. ce . , ca . , ca , , 2. ce 2- ce

, 2 . 2 2 , . ce ce , - ce . ce , 1 mmol/kg. ca . Cabicarb, . -, 02- . 1.

, 10-20 min1. 30% ce - .

; Epinephrine Atropin. , , ? ce, , ce -, . ce . , ca . , , . . , ca . ce , - . ce , -

30

ce . , . (, ). ce -

. , , ce , ; , . - , .

,

- 4F 6F. 4F 5F ce ", ca . , ce . 6F ( , ) ca - , ce . ce . , 5 , ce . ce 20 ce . , . . 20 mV, ce , ce . ce . ca 0.5-1.0 mV. 1.0 mV, ce . , ce ce . - ce 3-4 .

. . , , ca . ce . ce , . ca - , ca . . . ce " () . " ce ( 35-45 , ce ). 10 . ce , ce 20 mV, ce ".

ca . 1.2.

-. ca . : ; ; .

 31

1.2.
I. : 1. , . 2. , . 3. : ) ;
) ( ).

4. . 5. . II. . III. : 1. . 2. . IV. : 1. . 2. . V. . VI. .

- . ce | . -, , .
24-50% (. 1.8. 1.9.).

. . - . - , ce . - ,

. 1.8.

. 1.9.

32

, . , ce , ce ( : , , ), ce ce , 0.5-1.0 I/min, 24%. (24-) . () (). ce . ce 2 - 55 mm Hg. ca : ce - , 2 60-80 mm Hg; ce 1 I/min .

(2 50 mm Hg, PaCO2 50 mm Hg ). 2 50-60 mm Hg. 85-90% l. , , - ( ') 2 . ( / , , / ), , . 2 , ce , ce .

, ce 24% . 30 min 2 50 mm Hg, ce ce . ce 30 min 2-3 h 2 ce 50 mm Hg ce

2 . ce 2 5-10 mm Hg . 2 ce , , . ce , , ce , . , ce (31 -2824%). ce , 2 , ( - , ). (2 50 mm Hg, 2) ce 2 60 mm Hg . ce 2, , ce -, , 2 ce . . - . ce . ce , , , no- ( . 10 min, 30min). ce 4-5 I/min, ce , ce . ca - , ce -. , . ce . : (2 60 mm Hg), , , ,

 33

. , / ( ce , ce ). - 1 mm Hg 50% , 2 . ce . ca : ce ; 2 . (rebreathing), , , , . , 20%. - , . - ce ,

. .

ca . ce - ( 80%) 12 h ce , . ce , 50% 48 h. (ARDS). , - ce , 2. ca - . , ce , , , ca , , 2 atm.

ce , . : , ce . 19- 20- ca , " . ce : - " (Iron Lung); (Cuirass Ventilator); Sauerbruch. ce , , , ce - . , ce . ca 1952 ., , , . - : ce . , ce . () , , . . , : . ce ce -

34

, , . ca ce . , ce . , , 1.3.

( ) . .

1.3.

50- Emerson H. . 1960 . - . : -, , , , : - (IRDS); (ARDS). : , . , Servo , ; ,

, .

. ( ) , , . , ce . / , . * . ( ). ca . , ca .

H a l d q o PEEP e nom3an npM T e r n p e $ p a ~ ~ e p ~ Ac~cmpa~a-~o~~po BeHTHnauHn. n ~ p a ~ a n p TO~ Ha YBenMraMuyl C eK M C n O P O A H M KOHueHTPZiuMH XMnOKCeT M n BeHTMnaqMR anapaTbT e rOTOB Aa OTOBOPM Ha M M ~ Toil . e HaRnone3eH npn nerettMeTo Ha 6enoppo6e~ BcRKoMHcnMpaTopHoycwncleHanau~ema,nonpMnMnca OTOK B pe3ymaT Ha noBMwen aneeno-~anwnnpe~ nepnne~aT ~ K O 3anor~a B ~ ~MX~T~~H qM mRnT~ B T O M ~ T M ~ npM HO a6wnme~ (ARDS) W ~ I noBMmeno x H a p o m m r H o Hannsa,q~e~ recToTa. a Hanpu~ep, npM ~CMCTH~~HO-~owrporaHe (~ap~(~orenen 6eno~po6e~ e~e~ npM ) , KOKO TORnMpaHa 'iecTOTa OT 10~ M W ~ ~ H M 3a F IMMHYTa PeCnMpaTOpbT q e npaew pMxaTenHn U M ~ M Ha 6 sel( npM nMnca Ha HMR PEEP penwasa PaO, (rpea Harm-iRwieHa MwrpanyMHcnMpaTopHnycMnMR. AKO naqMetiTbTTpMrepMpa anapaJlMOHmHMR UlbW M ll0flo6~fl~a~e Ha OTHOlUeHMeTO BeHTMTa, BrpaJl,eHMFiT,TaiMepU aBTOMaTML(H0 C e KOPMMPa M nau~dnep41y3~~1. Ma~ap r e PEEP AeicTsa rpea npepasn~ s r a ~ nocnepeaqoTo ea MHcnlnpaTopHo ycwwe. CnepeapepeneHMe Ha Mwrpaaneeonaptiwfl OTOK, Hma paHHM, qe Havanflea 6 e n o ~ p o 6 ~ a eKcTpasacKynapHa ~a TerHocT. Ha q o ~ MHcnMpaTopHo o ycMnMe we npepw3aw~a cnepeaqMR cnepsaqaTa cxeMa e noKamno s w e i r n ~ e Ha ~ oPEEP aCMCTMpaH 4MKbn, .TaiMepbTL' q e C e KOPMMPa OTHOBO ~bpxy 6enoppo6~a~a MexaHnKa M r a d ~ e n . CaM. M ~ ~ e p ~ m3 ea ma a b m e n ~ BeHnnnaunn a (IhrN). Bx. C x e ~ 1.2. a B w e i c m ~ Ha e PEEP sbpxy6eno~poTO~T H M n KOM~HHM CnOHTaHHaTa ~~ C KOHTpOnUpaHaTa 6 ~ a Mexanwa ~a M ra3006~e~. BenTMnaquR. C ~ O H T ~ H HAMwaHe O T O Ha nayetiTa ce B ~ c o ~ o r e c BeHTlnnaulnR ~ o ~ ~ a (HFV). npes 1955 r. Hacnaraasbpxy KomponnpatiuRTMn. H a n p ~ ~ enpM p , IMV EmersonJ. narewrosaanapa-r,nopaeaqB M ~ ~ M ~ ~ L L ( ~ C T P C recTOTa 6.mi1-1-' PeCnMpaTOpbT OCMrypflBa KOHTpOnMpaH ra3 Bbe B ~ ~ ~ ~ X O H O CnbTuqa H M T ~ Ha naunetiTa. Tosa M ~ O UMKbn Ha B C e K M 10 Sec. MeyrlyTe3MMeXaHMrHM, KOHTPO6peTeHMe nocTaaR HaranoToHa Hoea renepaqw anapam nMpaHM U M K J M l IlayMeHTbT MOXe fla flULua CnOHTaHHO, 3a ~ a ~ y c ~ BeHTwnauMfl ee~a , a saepno c TOEXI M Ha HOB K a T O PeCnMpaTOpbT CnyWl 3a M3TO'iHHK Ha 3aTOllneH, pex#M - BMcoKorecToTnaBenTMnauMfl.Ype3 caome muyenaxneti M o 6 o r a ~ e c~ KMcnopop B~MWEIH ra3. HM'iHM M eKCnepMMeHTaJlHM npoy'iMHMfl Sjostrand K. noIMV e noKa3ana npM naqMem, c n o c o 6 ~ pa ~~aabplucTaefl HaranoTo Ha MopepHaTa epa Ha HFV. K a ~ o BcflKa m none r a n OT pa60~a~a Ha pMwaHeTo. HOBa TeXHMKa HFV M M a M3BeCTHM OrpaHMCleHMR M HeAOCC M H X ~ O H H ~ IMV(SIMV). H ~ ~ H ~ SIMVeK O M ~ H H OT ~~R TaTbuM. Te ~pfl6ea Aa 6bpaT M3RCHeHM npeAM W M P O K O T O cnotrrantia M acwcmpaHa Bewrwnaym. Ha MwrepmM, onnpmoxetiue Ha MeTopa M HFV q e saeue csoeTo MRCTO B pepeneHM o~ onepaTopa, anapam cTaBa clyecTaMTeneti npopbnxwTennaTaM ~ K ~ C T BernMnaqMn. B ~ H ~ B nocnepHMK ~ M MHcnMpaTopHme ywnw Ha naqMewra M o ~ r o s a p Ha ~ Te HFlKOnKO rOnMHM B KJlMHHClHaTaIlpaKTMKaBCe no-WMpo~ e YCW~MR 3 ~ C MexaHMren, acwcmpati q m n . Mewy ~ e 3 ~KO HaBnM3aT AMXaTenHM Pe)l(MMM,OCHOBaTa Ha KOMTO e aCMCTMwHM 4 M W I M ~a~WeHbT AMWa WlOHTWHO C M : CBOR cnowrantioToAMuane Ha ~ O ~ H M F Ha I . cneAaaqaTa cxeMa co6c~sena recToTa M A ~ ~ G O C I M H HanpMMep, ~. npln SlMV ca n o ~ a 3 pMxaTentiMTe a~~ KPMBM Ha ~ e HOBM 3 ~ pewMM: 6.mimt anapaTbT e pe$pauepe~ K ~ AMwaneTo M Ha naqneb l ~ c n ~ p a ~ acwcTwpaHe op~o (IA); B e w r ~ n a c q~ noAqap~ wra 3a 10 sec. Cnep m3mrane~o Ha ~ e UeceT 3 ~ ceKyHpM anapam ce . c ~ H c M ~ M ~ M M ~n M3 ~r ~a ' ~ cnepeaqoTo ~a MHCnMpaTopHo ymMe Ha naqMetrra. Kora~o TO B ~ ~ H M K anaB~, panT nouaaa acMcTMpati uwbn C ~O~MTMBHO HanRraHe. Cne~ Toea naqMemT AMwa cnowranHo, p o m ~ o ~3~ere cnepeaqm p e $ p a ~ ~ e p nepnop. e ~ AKO nau~em H e~ Hanp a MHCnMpaTopti ~ ~ o ycMnHe npea ,C~HCMTMBHMR" nepMoA, PeWlMpaTOpbTaBTOMaTMrH0 BKlllo'iM Ha IMV M npaBM KOHContml d c h b t mole TponMpati qMKbn. SlMV H e npemara p a 3 n ~ npeAMMcTBa r~~ npep KOHBeH4MOHallHOTOIMV, H0 Ce C M R T a 38 ~~O-KOM@PT~H. Ha $MT. 1.l0 ca noKawM AMxaTentimre KPMBMHa onncanwe BemnaTopnnpemMuM. ~O~WTHBHO KpalH0 eKCnMpaTOpH0 Hannrane (PEEP). BPB EPAP PEEP npepcTaanReaM ~ K ~ C T B ~w HO a m e Ha ~O~MTHBHO (na,qa~~c@epno) nanflranecnen mnHonacMetioM ~ M W W He. ~ ~ o ~ ~ J I X M T ~ll03MTMBHO ~ H O T O HallRraHe npM CnOHTaHH0 )JMWaU.M na~MeHTH C e HaPMCIa CPAP. He3aeMc~~o OT MeToAa (PEEP M n M CPAP) nwrM aMHam ce ~a6nlopaea penweHMeHa ~ p a k o e ~ c n ~ p a 6enoppo6e~ ~ o p ~ w o 6 eM ~ mbWPM $ ~ H K ~ H O Hp ~e ~3 H~M ~R yan KanwmeT e~ (OPK), BcnepcTBwe oTeapRHe napnxa~ennme namqa M nepah~eqme po T03M M O M e H T aJlBeOnM.
3H

36

Cnequtpusnu ~ e m 0 g ~ k U LI npoqegypu B cneurwama meguyuncka nomoq

Cxeua 1.2.

PEEP

llOn06PRBA OKCMrEHA4MRTA
YPE3

BnOUlABA OKCMTEHAUMRTA

OPK -tCT'T

aL
VP 'T (P(A-a)O,.l) QslQt . l (vAIQ'b

QsIQt

("$/,.l)

xaHo HanRraHe (PressureSupport Ventilation);ney$aa~o no3mBHo HanRraHe B UnxaPenHme nbTnqa (BIBAP) M Oc~o6ox,qa~a~e Ha HallRraHeTO B AMXaTenHMTe nbTMU@ (APRV).

.Ors~ma~e" ce HapMqa npeKpaTRme Ha MeTopa Ha pecnnpaTopHo neretine, OT KoeTo naL(llemT e 6 m =BMCMM.

B p e ~ e3a ~o o m m e OT pecnnpaTopaHacTbnBacnep K~TO no~a3aHLIma 3a WHTW~~TOPHO I l ~ m p ~ cacra6nHe nn3npa~n nnncra6mn3npa~n n nopdpe~n. Tome M ~ K ~ I O rmentio w e t i MoMewro~ WOCTHHR npcqec Ha H ~ K ~ C T N Ha BemaUnfl. Jletapm e n 3 n p a ~ e npep ~ eAHa c e p ~ o 3 ~ a unnelma: OT ema crpaHa, OmnweTo ~pRGea ua ce npep npneMe KonKoTo ce Moxe no-cKopo, 3a Aa ce ~ 3 6 e n i a ~ ycnomeHnma OT npopnmentiaTa H ~ ~ ~ ~ UTpaxeocM F I , ToMnma M ~ y c ~ y r n i cna6oc~; a ~ a OT ppyra, npeweapeMeHtime o n m MoraT ua ce o m pewaeaqn ~ qpe3 ceome d p a ~ $M~MO~OM.IHM ~n M ncMxonomrHne @ ~ ml.l o ~ ~ l ~ o r a HOWTO HaTOBaPme, IlpeAH3BHKMOOT HeyCllRnOTOOTBHKm e , npmn nocneneaqme o n m Mtioro no-TPYAHH. Cnep KaTo naqnemT ce e cra6nnn3npan nnn nopo6pnn, 3a Aa pMllla CnOHTaHHO, C ~ O C O ~ H O C T My T~ fla UMWa CnOHTaHHO~ p ~ 6 ~C a e OqeHM. g a AKOIlaUHeHTbT C e BWIKI'iBa BbB BCM'iKM F(OllyO~UcaHll KpWePMM, OTBMKBaHeTO Moxe Aa aanor~e M nMa ronma BepomHocT TO pa e ycnewHo. MHC~~U~ cmna. ~TO Ilaunen~b~ ~ H ~ ~ p ~ 6 ua e a~ o x e ua cb3nwe oTpwl(aTenHoHanRraHe no-anco~o OT -20 cm H,O.n p o e e w a ~ e ~ o a ~ o TecT a n M~MCKB naqnetiTbT ~ pa HanpaBMMaKCMManeHM H C M P M Y MCpeWy 3aTBOpeHMUnXa-

Q n . 1.11.

TenHn naTnqa. Bn~anen KanaumTeT. Ilaqnemb~ ~ p ~ 6 Aa aa nua BMTaneti KanaL(meT noHe 10 mlkg TenecHa uaca. 3a eKcrpeMH0 IlbnHMTe XOpa T ~ R ~Aa MC e M3nOn3Ba MpeanHOTO

Cnequ+usnu ~ e m o g u k u u npoqegypu 8 cnewnama ~ e g u q u n c k a nomoq

37

TernO. OCB~H WeKBaTHaTa BeHTWlaTOpHa$~HK~MR, 3 w O BonmenHoTo npoaeWaHe Ha T O ~ M TecT M ~ M C K B naqn~ eHTbTflaeBCb3HaHHe,OPHeHTMpaH HAaCbTPY/JHCICIM. M H H ~ BeHTHna4HI II~~ H MaKCHManHa CflOHTaHHa seHTnna4m. n a q n e m ~pn6ea ~ Aa nMa B n o ~ oMMH~Ti H a semnnaqnn- 10 Vmin H Aa e cnoco6e~ pa R ypeon npu MaKCHMMHM CnOHTaHHbI YCUnMR. ~OPHMT T P ~H TeCTa He C a M OC a neCH0 M3ITbnHMMM,H 0 H TOrHO npepCKa3BaTCbCTORHMeTOHaflbIXaTeJlHaTaMeXaHnKa M ra3006ue~. Hal-0640 ce npmaraT flaa MeTofla: rmpenm e Tpac .T-napreu nnn ,onHT m npoean", KoraTo KapaMe naqneHTa Aa oqeHRea WnaTa CM pa60~a H a RnluaHe npnyeennraeaun ce MHTepeann Ha cnoHTaHHO AnwaHe. n a q n e ~ m e ce ~ a 6 n l o ~ a oT6nns0, aa~ KaTo

~ M ~ M O H H MeTop M ~

ce ocraeRT pa pnwaT yBna)KHeHM 3 a ~ o n n e ~~ b 3 p npea y~ T-napre; BTOPMRT MeTop e IMV ( w ~ ~ e p ~ m ~ ueHAoe~nia Toptia s e ~ m n a q ~n~ o)3,~ o n ~ a a naqwewnTe q Aa oqeHmaT caoma pa6o~a Ha BuwaHe nocTeneHHo. Ma~ap re M paaTa MeTopa ce nsnonsea~ MHoro recro, POpHec HRua p d p e KomponnpaHonpocnemnBHo MacnepaaHe 3a Toaa Koe OT TRX e aa npeAnornTaHe. Hai-0640 uoxe pa ce Kaxe, r e nbpenm e 3a npe,qnornTaHe npn naqneHTn, KOMTO ca 6unn 3a no-rcpamo speue Ha MB, a BTOPMRT npn no-npopbnmen~a. Teope~nr~w npepnMcTea e Ha IMV npep KOHBeHqMOHanHOTO OTBHKBaHe M, Lie TO^ MOXe pa Haioeapaan o c ~ e n e~ ~n ~o x a ~ e nMycKynaTypa, ~a~a a npnCbCTBMeTOHaBeHTlrlnaTOPaAaBa HRKaKBoIlCMXOnOMrHO IlpeAMMcTBoHa naqMeHTa. ~ o T ~ H ~ K U HepOCTaTbqM IHL~T~ Ha IMV ca ~ ~ M O X HypbnxacasaHe O Ha nmy6aqnma npn naqneHTme,KOMTOK O H B ~ H ~ M O H ~ ~ ~H oO rn ~n ~p Xa ~ 6~a OTBMKHaTll no-6bp30.

HO, K ~ T O ce 3anorHe c Tea#, BoAeqn~o ~ a XHeHMRMCeCMmeflOTe3UCBMCOKPHCK.

Pa3nnq~we ~(oc~bnn q e 6bnar pa3rne~a~n ~e~alnl - ~ a ycnon~o

K a ~ l o n ~ p a ~seHa e 6a3nnm~a (VB) H eeHa L ( e Qanln~a (VC) Tesn r0neMn B e H M Ha PbKaTa HM AaBaT AOCTbn 10 qempanHmeseHn,KaTocenpaanBeHenyHKqMfiHnnseHeceKqnR (@r. 1.12). VB nexn nc-mn6o~on no-~epuanHo H no-nec~o ce ~ o c ~ n r ropHaTa a ~ o npa3~a aetla, cneA nyHKTnpaHeTo n B nanTHaTa R M ~ VC . e pa3nonoxe~a no-na~epan~o n 3aanea oc~po npH noRsaTa CH uo tmaBnneKTopantiaTa$acqnfi, cneA ~ o a a npomnxaea B ~bn6ornHa n~ KnaenKynaTa, 3a aa ce npncbepnHm n~ BeHa aKcnnapnc (VA) nnn BeHa cy6mae.11~ (VS). O~HKHOB~HO nowcTBa c noCptopq (no acemw~a,HO He VC 3aebp~uea n a VA, HO Moxe Aa 3aebpuea unn Aa cTepnnHa ~emm~a). M ~ I I o ~ ce ~K KaTeTpn ~ T Ha pamnrHn HaManRea no MnHnmyM AnaMenpa CM, HenocpeAcTseHo $np~n, K~TO nan&~e~o e ~ b n m ~ a ~ ~a ae- H n ~~45 A Cnefl naKbTHaTaRMKa. VC M M a Wlan'll, 0C06eH0 KbM KpaR cm. npaemce BetienyHKqmH nomaTaHa K P ~ ~epngnqnB CM. K a ~ e n p b ~~ p~6e Aa a npeononee U novrn npaenrr bnn, npn ~okroVC ce BnneaB ~ VA. B n p o q e m Ha ~ ycnex npu KmlonnpaHeTo e 40 65% 3a VB n no 45% 3a VC. Be~me B n m w a RMK~ ce n36npa~ H noneTo ce

meguyuncka nomoq

neK0, KaTO ~ ~ B H O T MH$y3#paHe O no BpeMe Ha KaTeTPM3HpaHeTo npepoTepaTRBa Onopo'iaaHeTo ( K ~ ~ B O Tq O eK ~ T H~CM KaTenpa B npaaMnHa noco~a). AKO KaTeTbpbT cpeqHe cbnporMsnetiwe Hn# cKopoma Ha M H $ ~ ~ M HaMaRT~ nee, oTeegeTe pbKaTa n OTHOBO o n ~ ~ a L v pa e ro npmgeuxme. ~ ~ ~ B H ~ H eaaeyqatie O T O MoxeRaceynectiu n KaTo C e 06bpHe rllaMTa Ha ~ O ~ H U KbM R CTpaHa Ha IlYHKuMFITa, K O e T O KOMnpeCMpa L L ~ M ~ H M T BeHH ~ M He n03BOnRBa Ha KaTenpa ga eneae B TRX. C n e KaTO ~ KaTeTbPbT e Ha MRCTOTO CM H C e$MKc#~~ poGpe, TOW C e CbepHHRBa CbC CMCTeMa 3a M O H M T O P M H T . 10cTaTbl.leHe O ~ W K H O B.B ~OpeH H cTbn6" MaHOMeTbP. .ueH T ~ ~ ~ Hnonoxewe O T O " Ha KaTenpa~ o x gace e sepu$uqwpa M 'ipe3 noRmTa Ha neKn ocqnnaqwn B HHBOTO npn ycMneHlr puxaTentiwgeMxeHw. Mora~ pa ce noRaRT M no6bp3~ OCL(MIIaqHM,CbOTBeTCTBaU#l Ha CbPAe'iHaTa gefiHOCT. npaenn~a~a ~O~HUHR KORTO , e 2 cm ~ i f ~ qC H O T O IlpeRCbppMe, T ~ U ~no W Bb3MOXHOCT fla ce nOTBbpflM peHTreHononrHo. Y c n o x ~ e ~ u OT~nep~$ep~me ~a KaHDnMpaHMR M: XeMaTOMM, MH@?KL(MW H ~po~fh$ne6mn. Ka~lonmpa~e Ha seHa lorynapmc eKcTepHa (VJE) TRnexMoTbrbna HaponHaTarenlocr po x q cpegaTa Ha KntorHUaTa, mpeToce enmaebe se~acy6maem ($Mr. 1.l 3). AKO BetiaTaHeceenyqa H n M nannupa, TO ~e~p~16ea & C l e npMCTbnM KbM KaHlollMPWe. ~ o C T ~ B R H ~Ha T Onauuewa B nonoxeHMe ,TrendelenburgU M npmMcKaHeTo Ha eeHaTa ~4 KnrornqaTa O ~ M K H O B ~ Hn Oo 3 ~ o n TR ~~ pa a ce orbtie. K o x a ~ a ce norncTBa c noFytomq ~ ~ ~ T B O P , KaToce n o n s a a c ~ e p m n ~ a ~ e x ~ ~ ~ a . Vena jugularis intema

CbepMHRBaC M H $ ~ ~ M O CMCTeMa HH~ H n M CHCTeMa38 MOHMTopMpaHe. nocnep~a~a uoxe ga 6 b ~ e M n M O~HKHOB~H MaHOMeTbPC BOpeH m n 6 H n M eneKTPMWH TpaHCRtOCep. Yc~oXH~HMRT~ OT KaHlonHpaHeTO Ha VJE Ca CbqMTe KaKTO M npM KaHlonMpaHeTO Ha BCRKa flpyra nepM$epHa BeHa. Ka~mnmpa~e Ha seHa lorynapmc mHTepHa (VJI) TRneXM 3ifq JlaTepanHHR KpaK Ha CTepHOKneMflOMaC T O M p H M R MyCKyn M apTepMR KaPOTMC (@r. 1.l 3). ~ Y H K ~ M oHHaTa TorKa, npw neplcyraHeH gocnn go seHaTa, ce HaMupa B o6nama Ha cnlneaHeTo Ha peTe KpareTa Ha CTepHOKneUpOMaCTOMfiHMR MyCKyn Ha HMBOTO Ha K P M K O M R H M R XpyqRn. ~ ~ U M ~ H C eT IlO ~ CTaBR T B IlOnOXeHMe .TrendelenburgU, KoeTo onbea M pa31~1np~aa aeHaTa M HaManRBa aepomtiocrraOT ~ b 3 p y u ~ ~M a ~ O ~ rnaea~a M R . ce o6pbqa Ha npo~naononox~a~a cTpaHa. M o r a ~ Ra ce M3flOn3MT M pWTe CTpaHM, H 0 ARCHaTa M M a npepMMCTB0 c npaem CM xog go ropHaTa npas~a eeHa. llann~pa ce apTf?pMRKaPOTMC H C e AbpXM non npbCTMTe npe3 l@nOTO epeMe Ha KaHlonMpaHeTo.Bbeeyqace MrnaTa OT KoMnneK-ra3a KatilonMpatie nop brbn OT 30' m~KoxaTaM nocoKa m~MaMHnaTa. Cneg BaseyqatieTo Ha MrnaTa ce npoeeyqa nocToRHHa acnMpaqMR. B e ~ a ce ~a HaMupa Ha oKono 1-2 cm nop KoxaTa M cnep H ~ W H O T eepw$~qupa~e O npea wrnaTa ce ebaexqa ueTanHm Bogar, M n M Hanpaeo KaTeTbpbT, a K O KOMnneKTbTe 6e3 BOfla'i. M ~ T ~ ~ H BOAa' MR i T T P R ~ E ga ! ~ ce ebeeyqa c neKoTa. M a m a ce MrnaTa M no BOAa'ia C e BbBeHQa KaTeTbPbT. H a ~ p a KaTeTbpbT ~ Ce $MKCM M ~ nPMCbeAMHRBa ~ KbM M H $ Y ~ M O H CMCTeMa H~T~ M n M CMCTeMa 3a MOHHTOPMpaHe. KaHlonMpaHeT0Ha ABeTe IOrynapHM BeHH Ca BepORTHO H ~ ~ V ~ C M3nOn3BaHHTe T O AOCTbnU npM KaHlonMpaHe Ha UeHTpanHM BeHO3HM H3TO'iH M ~ MVJI . M M a no-BMCOK n p o q e ~ ~ y c n e a a enpu ~oc nocra~ BRHe Ha KaTeTpM. B egH0 npOCtleKTMBH0M3CneflBaHe 91% OT KaHlonupatiMmaHa VJI ca 6 w n ycneww, ~ C ~ cpegHo C 13%Y C ~ O X H ~ H M R(~anpeIHaT IlHeBMOTOpaKC,IlYHKuWR Ha apTepMR KapoTvc, HenpaaMnHa~ O S M ~ M aoT R) KaHlonMpa, HMma Ha VJE 76% ca 6wnn ycnetuHn, npM 24% ycnoxtleHMR.

A p y Ha6nlofla~aHM ~ ycnoxHeHnR ca: nHeeruv M n M XWflpOTOpaKC; Bb3AYUleH e ~ 6 0 n ~ 3 b M CbPflerHM ; apMTMMM,aKOKaTenpbTHaBfle3eBRRCHOTOcbp~eMpa3flpa~ H MMoKappa; M yepepa Ha flylcryc T O P ~ ~ H K Y(MMO C OTmm); yepexqaHe Ha Hepm ($pe~~Kyc H nneKcyc 6pax~anwc); ycyKaaHe; saebpsaa~eHa KaTenpa; T P O M ~ O ~ M ;

O n .1.13. Pa3nonnenre na v. v.subclavia, jighis extema et jognlarn intema

~ o H ~ C T O RCbu(eCTBmT ~ ~ M IIlaBHO ABe TeXHMKH 3a KaHonMpaHe Ha uetrrpantiwe eeHu; T. H. TextiMKa no Seldinger, nonaaaqaMeTaneti eopaq M TexHuKa, ~enanonaeaqa Tame. B nocnegHMTe ropMtiH npegnornTaHa e TeXHMKaTa no Seldinger. Bbe eeHaTa ce npoHMKaa c Katilona mpxy Hrna H n M caMo Hrna. npea KaHlonaTawnH HrnaTaceebaeyqa MeTaneti eopar M cnep KaTo TOW e Ha MRCTOTO m, no Hero ce BKapKi KaTeTbPbT. Cnep po6pa $MKC~~MR KaTeTbPbT C e

noKaneH UenynMT; Bep~e6panHa a p ~ e p ~ o e e ~ $MCT~o3~a na. Ka~lonmpa~e Ha seHa cy6~naemn (VS) TOWROCTbn M M a Hah-MHOTO YCJlOXHeHMR M He T P R ~ ea ga ce npegnpMeMa OT HeonMTHM onepa-ropn. VS ce ~~non~eaur~po~o~a~en~~e~anape~~ He M Moxe no-nec~o ga ce KaHlonMpa npM C~CTORHMRHa

Cnequ@uunumemo
MeAHanHaTa

TpeTa Ha

KnaBMKynaTa M n b P B O T O

pe6po

($Mr. 1.l 3). B e ~ a ce ~a npexebpnR npe3 pe6po~o M en#sa

B I-P~~HHR KOUI. ~ P KaHtonnpaHe H nauveHnT nexn no rpb6, C noF(noxeH, Haem H a pyno rapwa4 Meyqy nonaTKme M rnaBaTa, o 6 b p ~ a ~ Ha a npomBononoxHaTa cTpaHa. Mrna~a OT KoMnnema 3a KaHtonupaHe ce sbeeyqa B on#caHMR b n n go pocTwraHe Ha Kocrra H cnen TOM ce ,mnyp~a''nop HeR. Mrfla~a ce Hacorm K ~ M cynpacTepHanHaTa RMKa H ce npMneMxea c acnwpauug. Cneg seplr$uqHpaHe Ha BeHaTa no MrnaTa ce sbseyqa MeTanHMRT

PCRBaT Oil$! npM nOCTaBRHeT0. K O H T ~ M M H ~ ~ MCe R TYBe~ nclraea, aKo KaTenpbT npecToM noaere OT 5 AHM. O K O ~ O Hero ce 06pa3yea$u6pn~oe a a q # ~cnol e ~ M TO^ Moxe na
6bAe K O H T a M H H M P a H OT OTflMe'ieHM MeCTa.

E@!KTMBHOClla Ha nOKanHMTe ~HTH~UOTMCIHM MeWleMM M cllpeO0Be He e ymaHoeeHa. F~BHO e, 06aqe, r e TB~PROTO npngbpxaHe K ~ M acenTHrHa H mepMnHa TexHHKa HaManRea po
M M H M M Y M 'ieCTOTaTa Ha RTpOreHHaTa M H $ ~ K ~ M F I .

eouar, no KOATO cneg Toea ce sbeeyqa KaTenpbT. H~~-.~~cT yCnOXHeHMe oTo Ha T 0 3 M AOcTbn e nHeBM0T O P a K C b T (OKO~O 4%). C ( ~ C T O T ~ H Ta ~Y C n O X H e H M R T a PmT#ra no 31% H ocseH nHeeMoTopaKc amtorea: xeMoxn4poTopaKc; ~ p 0 ~ 6 0 3 HnM a e ~ 6 o n ~ 3 acencMc; u ~ ~ ; HenpaB M n H a n03HuMR. nal(MeHTHTt~e C TpaXeocTOMM M M a T BMCOK npoqem Ha 6 a ~ r e p ~ a K nO ~a ~ O H M ~ ~ KoeTo ~ M R , npepmaBnRBa O T H O C M T e n H aK O H T p a M H P M K a u H R 38 KaHtollMpaHe H a

vs.

llo~a3a~~11

O6qu~e ~pOTHBOnOKa3aHMR BKnloclMT MecTHa MH@HapywasaHe Ha opMemMpme OT g e $ o p ~ a u ~ ~ , TPM rnaBHM aHaCTOM03M: flbn60~MR~ apKyC IlanMapMC; apKyC nOp3aJlMC M I l O B b P X H O C T H M H T aPKyC IlanMapMC. TpaeMa, npenluecTeaqa xMpyprMrHa HHTepeeHqnq MnM nbreea Tepanw. O T H O C ~ T ~ ~~ ~H OM T M B O ~ O K ~ca: ~ ~ H M Rnbpewe gea ce 06pa3yea~OT AR, goKaTo TpeTurrT e npogbnxeHMe Ha apTepm ynHaplrc. CMCTeMeH CeIlCMC; KOarynOnaTMM; aHTMKOarynaHTH0 nereHwe. A o c n n b ~ npes eeHa IorynapMc He ~ p ~ 6 ga s ace &~KB~THO Ha CKOnaTepanHMR ~T~ K P b B O T O K Ce Onpe~ ~ n o n ~ e a n p ~ n a q u e ~ ~ ~ c ~ a p o ~ ~ g RenR ~~m no e MO~M@HL(IIP~HHR ~ 0 3 ~ ~ n ~TeCT a ~ Ha e Alen, ~ - KO~TO T P R ~ fla B~ ~ M ~ Ma MT, O ~ M npes aeHa cflmaew - npu nauMeHTM c Ce npOBefle IlpeAll BCeKM OnW 38 KaHtoJlMpaHe Ha AR. Moan$nunpa~nR~ T ~ C Ha T Alen, us non sea^ 3a onpepee ~ $ ~ vnw 3 e6yn~. ~ Heo6xop~~ocrra OT M H $ O ~ M ~ ~ M 3a R BeH03HMTe HanRHe Ha goMwHMpaqaTa apTepuR Ha pbKaTa, ce npoeexna no cneIHMR HarMH: C noeflMrHaTH paMo n npegpaMo Ha nnraHMRMHororecToHaAqenReaHqcTenemaHapMcKa nauMeHTa,onepaTopbT npMTwcKaM gseTe apTepMM. n a 4 ~ OT KaHtonMpaHe. eHTbT C B M B a M OTnyCKa HRKOnKO n b T M toMPYKa CM, KaTO M o H ~ ~ T o Ha ~H UeHTpanHOTO ~ ~ H ~ BeHO3HO HanRHaKpafl r0 ocTaBR OTBOpeH. O n e p a ~ ~ p OTnyCKa b~ YnHapraHe (CVP) HaTa apTepnu. m e ~ s a ~ ~ o Ha cn ynHapHaTa a apTepMR ce 3a uenTa ce ~ 3 n o n 3 s a MaHoMeTpM ~ C BoReH m n 6 onpegenfi no H ~ ~ ~ ~ ~ BnoRaReaHe H O T O Ha epMTeMa no nnw enempoHHn TpaHcntocepHM CMcTeMM. B cnyrame Ha WnaTa KUlMapHa IlOBbpXHOCT Ha PbKaTa, BKlllo~MTe~HO TeXKM 6 e n o p p o 6 ~ M ~ n M CbPfleCIHM 3a60nFI~a~Mfl CVP no n p b m e M naneua. K~~BOTOKIT B ~a3w apTepuR ce wore recTo He Moxe ga O T P ~ ~npasHnHo M HHBOTO H a c~masam6ase~ npnn o u s a ~e a p m e ~ a c n7-1 e ~5 S c n e ~ Boneunma M nopaffu Toea ce npegnorMTa nocTaeRHeTo OTnyCKaHeTO h. Cnen T O M T 0 3 M TecT MOXe Aa 6bne Ha nyJ'IMOHWleH KaTeTbp. nosTopeH H 3a AR. KOHT~O~ Ha HH ~ H~ @H ~K ~~ H R T ~
K~MR H
6aKTepMan~0~0 3aMbpCRBaHe Ha ueHTpallHbfTeWHO3 H M KaTeTpM BapMpa B U M P O K H VaHMuH OT 8.5 A0 88%. noeere~o uscne~ea~ ~l O n~ K ~ ~ Mr T e ,KaTeTpmece mm-

M ~ o r ap~epMM o M O ~ ~ 6bfla~ T R ~M3nOn3BaHM3a KaHtOnMpaHe. ApTepMFI pa~man~c(AR) e ~ a i - ~ a n o n s e aM ~a~ e MRCTO Ha ~360p, n A KaTo e necHopomnHa M c go6po KOnaTepallHO~pbB006paqe~Me. C n e f l ~ apTepklR a~ flopsanmc neAuc;aKcMnapHaTa, 6 p a ~ M a n ~ M a$ ~e a~ o p a n ~ a Ta apTepMM. T ~ K O ~ C ~ ~ B ~MO M ~ ~ ~ O ~ H CaMO O C T KaHtOM nMpaHeT0 Ha AR, MaKap r e HRKOH OT T e X H M K W T e M YCnOXHeHMRTa W a T M 38 APYrHTe aPTePMM. APT~PHR PaaHanHC e no-ManKMFIT K n O H Ha 6pax~anHaTa apTepuR M e ecTemeeHo npogbnxeHMeHa H ~ A H M R maon. Meyqy a p ~ e p m pa~uanwc n apTepMRyntlapMcM M a

40

Cnequcpusnu mernoguku u npoyegypu B cnewnarnar meguquncka nowow

Ta ce HeIoMnHnpaqaTapbm. no^ rpnBHeHme maan ce IlOCTaBfl Bb3rnaBHMCIKa H PbKaTa C e u~o6nnn3npa B eKCTeH3HR O K O n O6 0 ' ($MT.1.14). K o x a ~ a C e nOrMCTBa C n O p X 0 pa3TBOP. ~~ n p a ,~a6bpre" ~ ~ C nHKa Mrna C 0.5 m1 1% Lidocain. npe3 ~a6bpCIe~0 C e M H $ U M ~ M ~nOCyl ~ T exaqme nKaHn OT A w e upatin Ha ap-repnma. ~OHFIKOra TOM n ~ 4 n n ~ p n p Moxe a ~ e Ra HaManM nyncaqnme, HO TOM e C a M O BpeMeHHO. &$?KB~THOTO nepMapTepMUIH0 UH~)MM C~ MeCTeH M ~ aHeCTeTcl ~ H ~ KIlpeAOTBpaTRBaapTePMUIHMR Cna3bM, K O ~ T OBb3HMKBa npM nYHK4MFITa Ha

apTepnma c nrnaTa. 3a apTepnantio KaHlonnpaHe ce n3non3~a~ T. Hap. T ~ ~ ~ O H eKcTpaKaTenp O B (TOB e~ KaTenp BbpXy nrna). K ~ H D ~ M ~ MOXe ~ H #a ~C TeO M3BbpUlM no HawHa: vpe3 snM3aHe B apTepnma M np~nnb3eaHe Ha KaTenpaAMpeKTHo nnn n p e ~ ~ ~ a npe3 ~ a ap-reh~n pnma c MrnaTa M KaTenpa, pa ce n s p p n a ~ AaeTe neKo
AOKaTOCeyCTaHOBMnynCMpaqKPbBOTOKHpaCeBbBeAe

ToraBa KaTenpbT. l l p ~ Heycnex Moxe Aa ce noBTopn onclnT cneu 5 MMH~THO npnTMcKaHe Ha apTepmTa 3a IlpeflOTBpaTRBaHe Ha XeMaTOM.

llona3a~~~
MH~MK~~M 3a H apTepManH0 T~ KaHlonMpaHe Ca: np0AbnXMTenHO MOHtlTOPMpaHe Ha AH npM H ~ C T ~ ~ H na~ H M 4 M e H T M (no-TOYHO, KOraTO M3MepeHMTe C M ~ H W CTO~HO~T CTM Ca H e T O ' i H M npM M H O r O BMCOKO M n M MHOrO HHCKO ~an~ra~ remn e ) ; KP~BHM u a c n e ~ ~am. a~ KpbeHn ~ ~ , ra3oBe, XMMM~HM ~acnepea~ Mn xeMaTonomR ~ (oco6e~o npM saancln~ OT ~pecnnpaTopan a ~ ~ e w MHAyqMpaHa r~); xmoT~H~M (np~nara~e R Ha e a 3 0 p ~ n a ~ a ~ o p ~ ) .

HaA-~anonasa~~m KaTenp e TpMnyeHeH, OT MeK M neKae nonualrHMnxnopMA. ToA no3eon~ea ~s~epea~ H a HaIlRraHMRTa B MCHOTO IlPeflCbPAMe (RA) M 6eno~po6 ~ a qMPKyna4MR, ~a a BrpweHMRT TePMHCTOP M3MepBa CbPAeVHMflp e 6 'ipe3 ~ ~ TepMOAMJlyqMf?. TR~OT H a O BCMClKM KaTeTpM e MapKMpaHO npe3 10 C m OT BbpXa, 3a # YneCHM l

Hai-~~CT Y C M n O T X H ~eHMR npM KaHlonMpaHeTOHa apTePMM Ca: .laCTM'iHa MnM IlbnHa O~CTP~KL(HR C AMCTXlHa M C X e M M R ;~ M ~ O ~ M M a M C M ;B H O KpbBDTereHMe M JlOKanHa MH$~K~MR Cny'iaM~e . Ha O K J l y 3 M R Ha aPTePMMTe 3 a B M C R TB n o - r o n ~ cTeneH ~ a OT n o - ~ b n r o ~ speMe o Ha KaHlonwpaHe, oTKonKoTo OT npAbnxmenHocTTaHa npecToR Ha KaTenpa B TRX. C b q o ~ o Ce 0~6enR3Ba M no O T H O l U e H M e Ha ~e6enu~H aa ~KaTeTpme. a Y C n O X H e H M RB b 3 H M K B a T npM IlaUMeHTbl C H M C ~ K C ~ f~l e ~6 ~ (CO), ~ V ~~ H XM~OT~H~M aHTMKOarynaR, HTHO H n H aaaonpecop~o nerewe. cep~o3~1.1, MaKap M PeAKM YCnOXHeHMR, ca T ~ O M ~ O T M C O IH K n ~y 3 M RM n Me ~ 6 0 -

no-C~PMO~HM

npMTMCKaHe Ha HepByC MeflMaHyC B KaprlallHMR TyHen OT KpbEOTe'ieHMe M JlOKWIHa M H $ ~ K ~ M R Bbnpe~M . R B H OB M C O KMR IlpOqeHT YCnOMeHMR, M H O r O ManKO T ~ ~ A H Y B M P e # l O C T a B a T Cnefl apTepManH0 KaHlonMpaHe. B H H M ~ T ~ npeRnyHKqnoHHa oqewa, f l e ~ a i n ~ cn oa3~a~ H a enpaaMnaTanOBpeMeHanyH~MRTa,H3nOn3BaHeTOHaKaTeTpM C MallbKAMaMeTbp UA O ~ P M C Te ~ C T p M H C K MQIMXU B C M q K O IK O M ~ M H ~ ~ M R HaMaMA0 M M H M M Y MYCnOXHeHM-

Ka~e~p~aaq H ~ a AP m ace ~seapwea rpes KaHlonMpaHe Ha qetiTpanHa BeHa. Cnel KaHlonMpaHeTo Ha eeHaTa, npea KaHlonaTa ce Baeema MeTaneH war M npes Hero ce Bbeewa T. Hap. french introducer, T. e. pa3w~pmen. npo~cn~an ~~ p~ am i Ha IlynMOHanHMtl KaTeTbp Ce C b e A M H R B a C TpaHCAtoCepa K b M MOHHTOPHaTa C M C T e M a .~ M C T ~ H M R H Il T wKCMManHMRT o m p ce ~ npounBaT, a w o c r r a Ha 6ano~a ce npoeepgea rpes pa3AysaHe c 1-2 cc B .6anom~ ce ~ s n y c ~ Ma KaTeTbpbT ce Bbaema npea MHTpoAlocepa B ~ eeHaTa. B Cne~ pocTMraHe H a~ C H O T O npeACbpAwe 6anom~ ce pa3Apa M rpe3 6ae~o M BHnMaTenHo npMAwvtaaHe, nonnowoMaTO OT K P b B H M R TOK, KaTeTbPbT IlpeMMHaBanpe3 TPHKYCnmmHaTa Knana, WcHaTa KaMepa(RV) n o p m t r a ~Ha e ,rnaa~a~a" AP. C n e Toaa ~ ~ ononwa i B n o - ~ u c ~ a KJWH ne~ Ha AP, WeTo cnvpa. Toaa MRCTO Ce HapMra 6eno~po6e~ KanMnRpeH WIMH, a mMepaaHoToHanRraHe- nynmolcannnRpHo KnmHoemflHo HannraHe (PCWP). Kpneme Ha HanRraHMmaB RA, RV, PA m PCWP ca ~ a ~ n l o r m e xapan~o mepm M ca AocTanwM 3a sepw$~qnpatie Ha MecTononoxeHueTo Ha KaTeTbpa ($Mr. 1.l 5).

~ H ~ TMa~epMalTb~, ~ OT K

O ~e O HanpaBeHKaTeTbpbT, OMeK-

BacTereHne Ha epeueTo nofl e b 3 ~ e i I m e Ha ~o TenecHaTa TeMnepaTypa, TaKa r e sbpxb~ H a KaTenpa npM cnycH a T 6ano~ MOXe Ra MMQIMpano-HaTaTbK B MWKMTe KnO-

C~~J@B~ Ha H Il ~ YnMOHaJl TO HMR KaTeTbp C 6ano~ Ha ebpxa OT Swan & Ganz (1970) HanpaeM peeonloqnfl a AMamocTnKaTannereHMeTo ~aKPMTM~HO6on~me. nonycleHMTe X e M O f l M H a M M C l H H AaHHM OT KaTeTpM3aqMRTa Ha MR nynMoHanHc (AP) noasonnxa npMnaraHeTo Ha nomrHwe npwiqnnn Ha say~a B n3yaea~e~ Ha o

H O B eMB b B BKnMHeHa n03M4HR. AKO Ce n 0 R B R TK P M B MH HanRraHMR, HexapamepHM 3a nynMoHanHaTa apTepMR M IlpOMMBaHeTO Ha KaTeTbpa He KOpMMpa flMCn03M4MRTa, TO ~ p ~ 6 fla ea Ce M M C n M 3a IlepMaHeHTHa BKnMHeHa n03M4MR M KaTeTbPbT Ra Ce M3TernM 1-2 C m Ha3a M n M flOKaT0 ce noRem HanRraHMR M KPMBM, xapamepHM 3a AP. n p ~ HMK~KBMO~CTORT~~ H C~ TB O~~ T ~ KaTeTbpa B R ~ T ~ B b BB K n M HeHa l03MqMF1, T b A KaTO T O M Ue AoBeRe R0 6enoflpo6e~ HH$BPKT. P ~ ~ W H ~ Ha TO 6ano~a A0 nbnHUR My KallauUTeT, KOfaTO BbPxbT MY Ce HaMMpa B MalTbK K n O H Ha AP, MOXe

ganpe~~3~~~a~oc~anr~ocTpaHM~HoHanpex ~a~ o e e 1 ~0 e yapewatie ~a6 e n o ~ p o 6 ~ cbuoee, n~e ~ o n Ha napeHxMMa.

nomop~o~o p a 3 p ~H e a 6ano~a swam ce npam 6ae~o C no 0.2 CC, AOKaTO Ce IlpOMeHM K O H T Y P b T Ha

KpnBaTa.

42

Cnequ+uqnu ~ e m o g u ~ npoqegypu k ~ B cnewnama

nma AnpemHo n 3 ~ e p e a ~ Ha e HanRraHMma Ha ARCHOTO cbpqe, onpeflenme Ha CO M nHAHpenHo ~auepeane Ha

HanRraHMRTaHanRBOTOCbP4e. H ~ f l r a ~ MHa R ARCHOTO Cbpqe. ~ ~ ~ B O H ~ % U I H M3MepMHe Ha A F l C H O n P e A C b P p H O T O MA R C H O K a M e P H O T O CMCTOnHO M AMaCTOnHO HailRraHMR MOraT Aa Ce HanpaBRT OTKPMBMTe,nOnycleHM npM nOcTaBRHeTOHaKaTeTbpa.

no-rope 6e Ka3aHo, ve B nynMoKanMnRpHa eKnMHeHa ~ O ~ M ~ M np Re , ncaah~ KpbaoToKa ~ Mnpe~asai~ HanRran

HeTO Ha3W OT 6 e n o ~ p o 6 ~ u BeHM ~ e M KanMnRpM, M pa36~-

pa ce OT nRaoTo npeucbpAMe, PCWP HM Aasa MH+OPM~4MR 3a flBe Q y ~ f l a ~ e ~ ~ aAeTepMlnHaHTM Jl~lvr Ha KapAlnOnyJlMOHanHaTa @YHK~IMR. nbpB0, C T O ~ H O C T T Ha ~ TOBa

HanRraHe e
H # K oHe ~~ ~p

IlbpBMrHa AeTepMMHaHTa Ha 6enoflpo6~t.1~

~ 6 ~a aa ce ~snonaea TevHocT 3a pa3~y6ano~a, ~ b KaTO h M3pbpflMHeTO h OT 6ano~a T P a H C T B O M UlBeOnMTe. BTOPO, T08a HWlRraHe e TRCHO M O X B fla Ce OKa>lce HeBb3MOXH0,a M H ~ C ~ ~ O C O ~ H OH (a T T T ~ cebpaa~o c nRBoTo npeficbppwe M n p nmca ~ Ha 3a6on~TeclHocTme Aa ce CBMMT B O ~ H F(O npepaeaHe Ha MHoro BaHe Ha MwTpanHaTa Knana - c neaoKauepHoTo ~ p a A ~ o BMCOKM HanRraHMR ~a6enopp06~me cbp0Be M napeHXMM. RuacTonMrHo HanRraHe (LVEDP), KoeTo npeAcTaanma HbI~ora He ~ p ~ na 1 Ce 6 ~ npMABMXBa KaTeTbpbT C arcryan~o~o, nbnHeqo HanRraHe Ha nReoTo cbpqe. ~ e p a 3 ~6ano~. yr TPM~~~~~ KaTeTbp, HHMC RBrpWeH T T e P M M C T O P , AaM Hn~ora H e ~ p ~ 6 Aa e aCe BWM KaTeTbPbT C pa3pyr B b 3 M O X H O C T 38 M3MepBaHe Ha M M H V H M R CbPAeCleH o 6 e ~ 6ano~. no TePMOPMnYqWOHHMR nPMH4Mn, K O ~ T O Ce C b C T O M B CneB ~ ~ M3a3anctc ~ T o ~aPCWP~p~6eaflae MHHWM~~HO, A H O T O : aKO M 3 B e C T H O KOnM'ieCTBO TeclHOCT C no-HMCKa 3a Aa ce ceeqe no M M H M M c ~r p e m ~ b p x y CTeHaTa Ha TeMneparypa OT ~ a H a 3 KpbsTa ~ ce BbBeAe B UMpqnaqM6 e n o ~ p o 6 ~ apTepuR a ~ a n fla ce ~ 3 6 e r ~ PMCK~T e OT 6enoRTa, ce nonyvaea KpMea Ha oxnaxqaHeTo, n o 3 ~ o n ~ a a q a npo6e~ n~@apKT. paCeM3rMCnMCbOTHOWeHMeTOHaKpbBOTOKaBbpxyBpePe~~re~orpa@ H a wrpbpHMR ~ ~ a KOW He T P R ~ B Aa ~ MeTo, 3a KoeToce onpeAenR npouRHaTaHa TeMnepaTypaflOKa3Ba O T K n O H e H M R Ha BbPXa nOBe.le OT 3-5 C m OT Ta. 3 o ~ a ~ nonyveHa a, nog AclnyquoHHaTa KpMsa, Mome pa cpeRHaTa nmHm. ce u a ~ e c p npocTa ~ nnaHHMeTpm w n M c BrpWeH KOMnlOTbp B M O H M T O P H a T aC M C T e M a ($MT. 1.l 6). Ho~M~~ CTO~HOCTM ~ H H T Ha ~ HMRraHHRTa, CO M H R K O M ~ ~ O M ~ B O AnapaMeTpM HM ca noKa3aHM Ha ~a6n. .l .4.
BaHe H a

3aCT0h M ~ ~ O M M H M P ~ ~ $B~ npeMMHaBaHeT0 KTO~ HaTe'iHOCTll OT 6 e n o p p o 6 ~ ~ B e ~ H M e B MHTepCTM~MOHEUlHOTOnpOC-

Cnequ+urnu ~ e m o g u k u u npouegypu B cneurnama ~ e g u q u n c k a n o M o q m 43

Ta6nnqa 1.4. Hopmannn m i i n o m Ha HRROW napaMeTpn npn m e ~ p n 3 a q n Ha ~ MCHOTO cbpue

YC~OXH~HHI~
~ai-reao cpeqaHme ycnomeHnH ca: cnyKswe Ha

6ano~a; p w a Ha apTepMR rlynMOHaJlMC Mnll ppefla Ha cTeHaTa R; 3aebp3~a~e nnw ycyKsaHe Ha KaTenpa; 6eno~p 6 e w~$apa; ~ MH+~WMO~HM ycnomeHMR.

Topa~oqe~~e3a - ROCTaBRHe Ha ~pb6eH flpeH B nnespan~o~ npocTpaHmo o - qen ewKyaqw Ha: absayx Bb3CTaHOBRBaHeHa HOPMaJlHOTO OTPML@TenHO HXlRraHe B WbAHMfl KOUI; TWHOCTM (KP~B, eKCyflaT, ~ O ~ MaTeH M P~M). rpbfle~ApeH 3a nereHne Ha nneepaneH eMnMehn e ~anonaea~ OT 6tonay (1875). AHanM3lrpatI~bI ronm MaTepnan (orroraea, pocera), npnnoxeHneTo Ha rpbpeH ppeH npM rPbAHMTpaBMM flown0 fl0 CTaHOBMU@TO, 'ie PaHHaTa nbnHa eeaKyaqwA Ha ~ p b a n ~b34yx e Hai-po6pa~a npo$nnaaw~a 3a MH@K~IIMT~ Ha nneBpanHoTo npmpaHCTBO.

Texul~a Ha c r 3 n a n ~ e ~ ~ e
Topa~oqetneaa~a ce naabpluaac TpoaKap, c MHCTPYMeHT K o P H ~ ~ nOfl H~ 3aUMTa , Ha IlpbCT C e~OCT~B ~pb6eH R IpeH MnncneqMmeHTopaKmeHKaTeTbp. flpen0pb.lBa C e nOCTaBRHeT0 Ha TOpaKOqeHTe3HMR ApeH R a ce n~~bpurea B nemano nonoxewe Ha naqneHTa, nopa,qn cnenHwTe npwrnHM: 1. C e ~ ~ a n nonoxewe o~o e ~eyflo6~ Mo 60ne3~e~0, oco6e~o npn MHoxecTao $ p a m y p ~ p a pe6pa. ~~ Cun~a~a 6on~a Moxe fla Roeefle flo Konanc. 2. B cefltiano nonoxeHme nyHKqnma ~ p ~ pa 6 w ce M3BbPWM 3Ha.lHTenHO HHCKO, KOeTO KpMe OllaCHOCT OT yepena Ha: pna$par~a, repeH ~ p o 6cnes~a , M c-rouax. 3. ~ P nexaq M naqueHT cbqeasyaa onacHocT OT nyHKqMR Ha 6eno~po6~a setta, KoeTo Aoaewa ~o apTePMXIHa Bb3flylllHa e~60nMR. Topa~oqetme3a~a ce npam no q H a aKcunapHannHMR B 5" hnewyqype6pe~o npocTpaHcT8o.

[PM nHeBMOTOpaKC APeHbT BnM3a B WbflHMR KOUl $ p o ~ ~ a no n~ rurefl#otmaanKynapHaTa o nMHnR B ~ 2p B Mexflype6p~eM ce ~ t n a r a Harope K ~ M abpxa Ha nnespaTa. MRCTOTO Ha nOCTaBRHeT0~p~16ea fla e Ha pa3CTORHMe flea npbc~a OT pb6a Ha CTepHyMa, 3a fla C e ~36eme O~~CHOC Ta OT yspeRa Ha apTepw Topaqma HHTepHa. npM XeMOTOpaKC M IlHeBMOXeMOTOpaKC: 1. Knacnrec~a no3nq~ -~ flpeHbT ~ n ~ B 3 rap b f l ~ KOW no cpepHa aKclnnapHa n M H M R M B ~ewype6pe~o npcapaHcTBo, KaTo ce Hacorsa ~a3a,q M Harope. 2.flpeflnow~a~a ~ O ~ M ~ TorKaTa M R Ha nocTaBnHee cbqaTa KaTo npn KnaclrrecKaTa ~ O ~ M ~ M HO RIpeHbT , ce HaCO'iBa Ha34 M H ~ O n B yK O C T O ~ ~ M ~ $ P C ~M ~ H Y M C ,~ CH H KOeTO C e n0CTMra RpeHMpaHe Ha H ~ ~ ~ - H M TO'iC KaKHa ~T rpbflHaTa KfleTKa. T0pa~0c(eHTe3aTa He ~ p ~ 6 fla s aC e n0CTaBR no-HMCKO OT 6" ~ e w y p e G p ~nOp4# e, OnaCHOCT OT yspefla Ha flwa$parhna~a M KopeMtin opraw npM Hamrwe Ha TpaeMaTMrHa yapeAa ~ a f l ~ a $ p a r ~ fal~ pa xeMo~. TopaKc, Ha R&rpa$nM~erecTo He ce swwa nosAMrHaTaTa pwa$panna. OTflbnro BpeMe ce nsnonaea TopaKaneti KaTenp Ha Argiile. Toea ca CMnnKoHoaM flpeHamw, KoMnneK-roeaHHc MaHApeH, KOeTO 06ne~raaa nOCTaBRHeT0 MM. flpefllrlhn~~sa: Hanpaeeti e OT MaTepnan c flo6pa noHocnMocT, enacT M W H e M HMKOra He ~ona6npa.M ~ T ~ ~ H MaHflpeH MRT npe~na3~a nocnneatieTo Ha ~b3nyx B nneapanHaTa K)IXMHa npn nocTasRHe. ~ o K ~ XaHeCTe3MR I H ~ T ~BWlD'iE!Zl: MRCTOTO Ha HHqH3MRTa, IlOflKOXHMR nbT Ha ApeHa fl0 nep#OCTaHa pe6po~o M npnnexaqaTa nneapa Ha ropHMA pb6 Ha pe6po~o. nRBa~a PbKa mPXM BbPXa Ha ppeHa (CnOCTaBeHHR

44

C n e ~ + u v n umemoguku u npoqegypu B cneurnama megu~uncka nomou(

~ a ~ u pKe~~M MRCTOTO ) Ha nocTaBRHeTo MY, 3a Aa npeuoTBpaTM HeKOHTponllpyeMOTO6bp30 M ubn60~0 nocTaeRHe

Ha ClPeHa B rpaAHaTa KneTKa, KoeTo Moxe F(a AoBeRe U0 YBpefla Ha 6enw~ ~ p o4 !6 Ha aOp~aTa ( C X ~1.3). M~

keua 1.3. h n Ha ~ nomsnne (no Werner Glinz)

C n e MH~WBIIR ~ Ha KoxaTa, ApeHbT ~nu3a nepneHAnKYnRPHO Ha KOXaTa U0 IlOAKOmMeTO (A). B IlOAKOmMeTO RPeHbT BbPBH TaHretl4HMH0, 3a fla o @ ~ M # KaHm (B), CneA K O e T O TpoaKapbT OTHOBO C e IlOcTaBR B IlepneHAMKyI. I l ~ e e ~ o ~ o p a ~ c nFIpHa n03M4Hfl, K a T O pOcTMra r O P H M R pb6 Ha pe6po~o B 1. C ~ O H T ~ -H py ~n H q a Ha 6enonpo6~a 6yna. TOYKaTa Ha npoHMKBaHe B QIbRHaTa KneTKa. C n e TOW, ~ C 2. T p a a ~ a ~ n r e ~ : eAH0 no-CMnHO, KbCO ABMXeHMe C e npOHMKBa B rpbAHclrR a) $palcryptI Ha pe6pa C IlYHKuMR Ha 6en~R flpO6; KOUI (C). Cnefl IlpOHclKMHe C e kl3BaM4a MaHaPeHbT M 6) 4 p a ~ ~ y p Ha n pe6pa c KnanHo npo6owa~e Ha ycnopeAHo c Toea ce AoKapaa RpeHbT B rpbpHaTa KneTKa 6enn~ up06 - HanpertiaT nHeeMoTopaKc; (D). Kna~nnpa ce M c noMoqTa Ha MaHRpeHa ce npoeepnB) pynTypa Ha Tpaxen nnn ronRM 6 p o ~ x HanpemaT ea AbnxnHaTa Ha nocTaeRHeTo MY, cnea Koero ApeHbT ce IlHeBMOTOpaKC; BWIIO~M K ~ M nocroRHHa acnnpaunoHHa cucTeMa. Hopr) OTKPMTM paHn Ha r p b ~ KOUI, ~ n ~ npefln3sn~eaqn MWHO e HanRraHeTO Ha 6 b ~ e 25 C m H,O. Kora~o TOW KnaneH IlHeBMOTOpaKC. HanRraHe e HeAocTanwo ua paarb~e 6enn~ upo6, TO II. X e ~ o ~ o p a pe3yma~ ~c OT TpaeMa, npn ~ o h nMa o Moxe Aa ce noanwn no 45 nnn 60 cm H,O. npopnxawqa xeMoparnf! H ~ C300 ( mV3 h M ~ B w ~ H Ha~ rPbAHHR APeH 1. YepeAa Ha: napne'rantin cbnoee, nmepKocTanHn Hop~an~ nocTaeetinm o rpb4eH d p e ~ n p e w 3 ~ n ~ ~ a apTepnn,apTepnRTopaunKanmeptia. OTAenRHeTO Ha 100 m 1 eKCyAaT AHeBHO. Kora~o flpeHbT 2. Yspe~aHa 6eno~pob~n cbAoae, acownpaHn c AeHoHoqHo oTnenR He noaere OT Toea Konnrecrao, ~ o l 6eno~po6~n TpaBMM. Moxe Ra 6bne n 3 w e ~& . t e H b ce ~ KnaMnnpa 3a 12 h, 3. Ana$paman~n nnn cy6~na+paman~n Tpaennn CneA K O e T OC e H3BbpUIW Ro-KOHTPO~. 1/138ayqa~e~0 Ha Kpbeor pynTypnpana~na$pama nnn ~ p bOT e pymypnpaUpeHa ce H ~ B ~ P U J6bp30 W npn sKnloveHa (pa60~eu(a) nn KopeuHn opraHn, npeMnHana B nneapanHoTo npocacnnpaunoHHacncretda. r p b ~ ~KneTKa a ~ a ce x e p ~ e m n TWCTBO.

Cnequ+urnu memoguku u npovegypu B cneurnama ~ e g u y u n c k a nomow m 45 PO~HM yBpeAH H R M a TK n H H M V H a H3RBa. 4. Y B ~ ~ OT AM HenpaBMnHO IlOCTaBeH QlbfleH flpeH P M T b M H MCMyqeHMR IlpM K O H T a K T C b C CbpqeTO, e P 0 3 M M Ha ronew cbpoee, epoaclcl Ha Kynona Ha nneapaTa.

5. Hapywaw~e npoxonmoma ~ a p p e ~ a - ~ a a e ~
MOCT OT MaTepMana Ha ppeHa, nexatie ~ b p x y ApeHa, npMTUCKaHeHappeHaOTBb3maBHMqM. npea nocneAHMTe rogMHM B HMCM .H. ll. tlnporosuce ~ a e b p u nepiq-raHeti ~a TopaKaneH ApeHax c a~r~orpa$CKM KaTeTbp. ~ O C T ~ B R H ~ My TO Ce M3BbpluBa nod R& MnM ex or paw^^ KoHTpon. P e s y n ~ a ca ~~ MHoro ~ e @PM. npeR M M C T B a aTPaBMaTHC(H0CT M TO'iHa nOKa~lC13a~MR Ha ApeHa.

K o p e ~ ~ nyHKqnR a~a (nanapoqemeaa~a) e uetitia

gtIarHocTMrHa MatiHnynaqMn, itorno HepRplto enwa B cbobpaxe~~ Ke~ M KoMnneKca OT AManiocTMrHM ~3cneABaHMR. TR He e llOflXOmu(a 3a M3BbpluBaHe Ha M F I C T O -

~o~aanonony~ nospeMeHaTpaHcnopTa,acaMoe a~a~

YCnOBMRTa Ha n p O T M B O l u O K O B aM n M OnepaqMOHHa 3Ma H a c n e q ~ a n ~ 3 ~ p aaaege~ue. a~o~o EAHO OT ~ah-renewTe npe1MMcTsa e ~ e h ~ 6 ab ~ pa a~ ~O aC ,O~~H npM O cnyrau Ha Mac00 TpaBMaTM3bM. flanapoqe~Te3a,M3BbPLUeHa IlpeAM Ha'iMO Ha aHeCTe3MR, OTXBbpnR CbMHeHMeTO 3a M~Tpaa6flo~MHaJlHa IlPM'iMHa npM MHTpa- M CneflOnepa-

TMBHa XeMOflMHaMMrHa H ~ C T ~ ~ M ~ H O C T . K ~ Tupno, O p e 3 y n ~ a OT ~~ nanapoqe~~e3a~a ~e MoraT ga ce npMennaT KaTo MHoro ~06pu. i l p npocneAmaHe ~ Ha ronRMa cepw OT ~ ~ U M ~ H$ T ~~ M U I M B O nonoxMTenHara nanapoqe~~e3a e OT nopRpbKa Ha 3% a @anluweoO T ~ M qaTenHaTa 1.S%. @ a n u r ~ ~ HeraTMeHM o pe3yn~a ~~ a~ h-

recToceAbnxaTHanocTaeRHeHaKarenpaBnpenepMT O H e M l H O T O npOCTpaHCTB0, K a K T O M npM BbTpeKOpeMHM cpacTaatiMu OT npeAxoaqaqM onepauMm. H e r a ~ ~ peae~ s y n ~ Moxe a ~ Aa MMa, KoraTo nanapoqe~~eaa~a e HanpaseHa HenocpepprseHocneA TpaaMaTa, a KpbaoTereHMeTo

@M.1.17. 3mapewa ( ~ r y n l o q m n s mollnra. ) C eman p ~ ce so r p m a s a slaanttom xmntane na nynqmonnlm m, am a nnpllnara ~eo6xa~(nulw n m c r sa npeurnasawenpe3 ropeunara nena (no Wisner & Lawrence, 1993)

46 m Cnequ@urnu memoguku U npoqegypu B cneurnama meguquncka nomow

-

Our. 1.18. nepnmeaneu naaam qpe3 mopeua nnm "muman" rexn~ra. Cnw mapnne na 4acqruna n w o m a n nmnmna ce empmpa n nepnmweyvbTce noepyra. npaow ce m o p B nepmneyHa M ce nornon ~aremp non smyanen rompon (no Wisner 8 Lawrence, 1993)

XepMeTM3Mpa. B ~ M B Ce ~O T K O n O 1000 m1 ~ M ~ M O ~ ~ O M CepyM, CneA KOeTO 6 a H ~ a ~ OT aMH$Y~MFIT~ C e CBWR AeKnMBH0. npM MHTeH3MBHO 04BeTeH WpyM nanapOQeHTe3aTa ce npMeMa 3a nonoxmentia. n p 6ne~op030~0 ~ oqeeTReaHe MnTepnpeTaqMRTa noHRKora e TpyAHa. Toraaa KaTeTbpbT C eO C T a B R B KOpeMHaTa KYXMHa KaTO CMlHalleH ApeH Jlanapoqe~~e3a~a ce wa~bpur~a cnep ~ a ~ e ~ p ~ 3 ~ p a - 3a 24 h (open peritonea1lavage). 3a ynecHREaHe Ha M :~ B ~ ~ np We M 6 p o ~ ~ Ha a~e ~ e ~ a n a q u e ~ ~ a n o p n o ~ a n ~ a a ~ e c ~ e 3 MHTepnpeTaqnma ~ ~ n o ~ ~ e ~ Moxe e x ~ pace ~~~ ePMTPOqMTMTe B fTlm3. PM HallM'iHe Ha 100 000 el/mm3 OTBOpeHa M 3aTBOpeHa ( ~ ~ H K ~ M o H H ~ ) . nanapoqe~~esa~a ce npMeMa 3a nonoxmenHa. K o H ~ ~ H O ~ ~ o p eHa ~a oKono : 2-3 cm noA nbna no CpeflMHHaTpaqnn nop 50 000 erlrnm3 ce npMeMa 3a oTpMqaTenHa. Ta nMHMfl ce npaeM paapea 2-4 cm M ce AocTura 40 PM KOH4eHTpaqHFI MeWy Te3H ABe CTO~HOCTMMHTepnnepMToHeynna, KaTo 3 ~ b n x n ~ e n ce ~ npasv o qaTenHa xe~oc~asa. C n e oTsapmie ~ Ha nepMToHeyMa nop ~ ~ 3 y a - peTaqMmace ~ 3 ~ b p ~ 1 ~ a a a e ~ ~ o c n p e q e HaTa KapTMHa no OTHOWeHMe Ha KOpeMa. M a ~ e p ~ a 3a nb~ neH KOHTPOnB KOpeMHaTaKYXMHaC e nOCTaBR KaTeTbpM C e

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f i p e u e ~ ~ o c r He ra e ~ ~ O T M B O ~ O K ~ npM ~ ~ycnoH M ~ , BMe, Ve Ce M3BbplllBaB H M M a T e n H Ono O T B O p e H M F IM e T O AM ~4 nbna.

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~ T ~ ~ O ~ M Tpeaepe~ ce ~anonasa~ 3a nbpeMTe 18-24 h. Te ca HVHH 3a IlpeXMBRBaHe H a MO3bKa M $ Y H K ~ M O H M P ~Ha H~ 6b6pe$a3M: LUOKOBa (rpaHM.~Ha) M KbCHa (flow). no-K~CHO F. 4MTe. ~ O - H ~ T ~ ~ U eHeprMiHM H M T ~ HWMC e OCMrYPRBaT Moore (1952) pa3pen~1 flow-$asa~a Ha ~aTa60neH M aHarpe3 ~aTa60nkI3bM Ha 6 e n n q ~ M ~ rnMuepOflOBa e TPaHC6one~ eTan. $ O P M ~ ~ M HaMa3HMHMTe. FI ~ ~ ~ T ~ I ~ H U F V Cnep M ~ T e MHOrO 6bp3, AHeBHMTe 3ary611 Ca OT 300 p0 U l o ~ o e a ~ a ce xapamep~3~pa c ~ b a c ~ a ~ o e ~ ~Onepa~MFl aHe Ha 4 M P K Y n a T O P H M R0 6 e M ~TbKaHHaTa ~?P$Y~MR. Flow500 C J M Ce M3pa3RBaT C BMCOKa YPHHHa 3ary6a Ha a30T. n0ny.leHbITea M M H O K M C e n M H MCe M3nOn3BaTBClePHMRflp06 (ba3a~a 3anor~a cnep eaxTatioemaHe Ha nep$y3~ma M ce x a p a ~ ~ e p ~ c 3r ~ ep ~a epanns~p KaTa60nM3bM a~ M TonM no-ManKO B 6b6peqw~e 3a r n ~ ~ o ~ e o r e ~ BbnpeKM e3a. ~ 3 n o n 3 ~ a Ha ~e BbrnexMppaTMTe ~o M 6 e n n q ~ pecnvpa~e nonpoflylcum. TR e ~ai-po6penpoyreHa M Moxe Aa npOflbnXM AHki M MpMM4M B 3 a B M C M M O C T OT TeXeClla H a TOPHMRT KBOMeHT O C T a B aH M C b K , nOpaM TOBa O C H O B H H R T M 3 T O i ' H M K Ha eHepMR Ca M a 3 H M H M T e , KOMTO O C M l J ' P R B a T 3 a 6 0 n ~ ~ a ~npepwecTsaqoTo e~0, cbcTontiHe M MepMqMHCKaTa MHTepBeHuMFI. Ha~paR Ce AOCTMra A 0 aHa60nHa 80-85% OT HeR. $aaa, KOFITO npopbnxaea c e p u ~ M y Mecequ. ~ Me~a6on~Cy~ap~ e$em ~ m Ha paeTe e re~epan~3~ THMTe IlpOMeHM 06xaaqa~ e K C u e C M B H O T 0 M3pa3XOpBaHe ~aTa60n#3bM, 3ary6a H a 6emqw, TonnonpoflyKuwn M Ha eHeprm, BbrnexlrppaTHaTa HenoHocMuocT, 6ennr3ary6a Ha.TenecHa Maca. nocnep~a~a He ce cabpsea H M RMM a C T H M R ~aTa60nM3b~. C a M O C ~ H ~ ~ M A H 3ary6M. H T ~ %CT OT HeR Ce AbnXM Ha 3ary6a H a TenecHa Bopa. Mspasxo~ea~e Ha ecleprmn. rnapyea~e~o, MMO~CIn M 3 a U M R T aM B b 3 C T a H O B R B a H e T O Ca XapaWepHM 3a nOCT0Bbrnexmnpme~ Mela6011~3b~. X~neprnml~e~ nepaTHBHOT0C b C T O R H M e . rna&WHe~0M H M O ~ H ~ M ~ ~ ~ I I R - e 6ener 3a oTroaopa Ha cTpeca M woKa. ~ O B M W ~ H Ha M~ Ta Ca CBbp3aHM C IlOHMXeHM eHepreTMrHM M 3 M C K B a H M R , KpbBHaTa 3aXap HaCTbnBa M npM L U O K O B a T a , M IlpM flowpoKaTo penapaTMBHMTenpoqecn noeMwaeaT Hyw,qaTa OT $a3aTa. ~ ~ O M ~ H B b B M BbrneXMApaTHMFl T ~ Me~a60nM3bM eHeprMR. 0640,OnepMpaHMFlT IlaUMeHT M M a IlOBMWeHM npo~3~nc npepHMtio la~ OT p e i c ~ a ~ Ha e~ KaTexonaMMtiMo M 3 M C K B a H M f 4 , KOMTO BaPMpaT B 3 a B M C M M O C TOTTeXeCTTaHa Te, KOpTM3Ona,rnMKOreHa, MHCyflMHa,C O M a T O T P O n H M R XOP3a60nRBaHeT0 M p a 3 B M T M T e yCn0)KHeHMR. 3ppaBMTe M H MOH n coMaTocTaTwHa. Y c r a ~ o e e ~ e, o r e noeMweHaTa ~ M B M ~ cnep M ycnoxtieHa onepaung M M a TH e nosere OT KpbBHO3aXapHaKOH4eHTpauMRepe3ymaTHanOBMLUeHa 10% n O B M W e H M eH aO C H O B H M R eHepMeH pa3XOp, H 0 $e6rep~oppo6~ npoAyKunR a M yepepeHo nepn$ep~o ycaonpMnMTenT ro noevwaaa 3 i i a w ~ e n ~ o c 13% 3a Bcem BaHe, KOMTO Ca non eHPOKPMHeH KOHTPOn. M npU ABeTe rpmyC. T ~ x K M ~H $ T~ K ~~ M F nOBMLLlaBa I ~ H ~ P M ~M ~3 M HC M K $am ce ~a6nmpaea 3a6aee~a c ~ o p o Ha c ~yceomatie Ha B a H M R oqe noaere OT 15 po 50%. ~ ~ I O K O ~ H OHaToaapeaHe, TO r n m ~ o 3 yM pcbnpoTmneHMe ~~ E~epnnma Ce AOCTaBR OT TpM M 3 T O V H M K a : BbrneXMR Ha eK30reHHO BKaPaHMR M H C Y n M H . Bbnpe~M T 0 3 M T. Hap. palm, 6ennqm n MasHmHm pecnemMBHo 0.5,15 M 25% T ~ ~ B M ~ Tp M~ 'a ~6 ~e H rnIOKO3HaTa ~, KOHueHTpauMR, KOHCYOT TenecHaTa Maca Ha sppaa Mbm. TbB KaTo a c b q ~ o c ~ M a q M RM Y T M n M 3 a q M R OT nepM$epHMTe T b K a H M M npM ABeTe O P ~ ~ H M ~He M pa3nonara ~ T c ~ e pe3epeu, 3 ~ ~ ~ I O K O ~ H M T ~ $a3w ca no-rone~n, oTKonKoTo npM HophnanHM ycnoew.
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48 m Cnequ+urnu ~ e m o g u k u U npoqegypu B cneurnama

MHC~~MHO pe3MCTeHTHOCT B~T~ Ce flbnXM H a ~ ! ~ c T ~ u ~ T MR o n p WOK, ~ TpaeMa M cencMc ca hnamwre. noeuure~a H a KaTexonaMwMTe, ~ o p ~ ~ aM oflpyrM n a $atcropn. Yep~onunonM3a e ycTatioeeHa M B ABeTe $am. WoKoBaTa 4asa n o a u w e H a T a K O H ~ ~ H T ~ Ha ~K ~OW PT R M~O~ KaTexo, ~ P O ~ H H F BbrneXMppaTeH IT u e ~ a 6 o n u 3 cbq0 b~ Ce 3aCRra OT MHCYnMHOBaTa pe3HCTeHTHOCT. n p e 3 WOKOBaTa $a3a JlaMMHM, rnlOKaroH, COMaTOTpOneH XOPMOH, ACTH, noBMIlOBMlueHaTa KOHUeHTpaL(MR H a KaTeXOnaMMHM, KOPTM30n WeHaTa aKTMBHOCT H a CMMnaTMKOBaTa HepBHa CMCTeMa M M rlllOKarOH, H IlOHMmeHaTa KOH4eHTpaqMR H a MHCYnMH nOHMXeHaTa KOH4eHTpaqMR H a MHCYnMH Gnaronp~~~ BOART po 6 b p 3 a r n ~ ~ o r e ~ o M no ~T 3 pe an m e H a rnro~oaa, BaT nMllOnM3aTa. K O P T M ~ e O KPMTMreH ~~T XOPMOH B T03M OTrOEOp, Tbh KaTO HerOBOTO HWlM'iMe e H ~ O ~ X O ~ M3M 8O n a m a T M nnpyBaT OT r e p H n R pp06 n p e 3 flow4aaa~a KOHue~ T ~ r n t o ~ o ~ e o r e ~ e nepcMcTHpa 3a~a B a n p e w n o m ~ o p ~ a n - aKTMBMPaHeT0 H a pPYrMTe XOPMOHM. ~ O B H U ~ H HMTe CTO~HOCTM H a MHCynklHa. Toea BePORTHO npOM3TMra HTpauMR H a MaCTHM KMCenMHM M rJlMl&pOJl n p e 3 WOKOBaTa OTMHCYnWHOBaTape3MCTeHTHOCT. $a3a flocmra CBOR epbx npes nbpame 12 h. B y c n o e M m a H a Ba30KOHCTPMK4MR B MYCKynHaTa TbKaH M O X e fla H e 6enTbrle~ ~ a ~ a 6 o n ~Cnep sb~ onepaTMBHa . HwrepBeHqMR HOPMMHMRT 6ana~c Memy~~~T~YH ~M a~ Fa I 6 0 - HaCTbnM nOBMWeHMe H a nna3MeHMTe KOHl#?HTPa4MM H a nM3bM M a H a 6 0 n M 3 b ~ Ce HapyWaBa, B pe3ynTaT H a KOeTO ceo60p~me MaCTHU KMCenMHM. c B O 6 0 f l ~ M T eMaCTHM KMrnblqepon RT Ce M3nOn3BaT KaTO ce p a 3 s ~ e a oTpMqaTeneH a a o r e ~ 6ana~c. n o a u ~ u e ~ u e ~ o CenMHM M O C B O ~ O ~ ~ H M HaqnHHnRa3o~ec~bp3a~ocnoeMweHaeKcKpeqnnHa etiepw. B repHMR flp06 r n u q e p o n b T ce npeepbqa B r n o K o 3 a r p e 3 r n ~ ~ o ~ e o r e ~a e MamHMTe 3a, KMcenMHu ce ypen, cgpa, $oc$op, ~anwh, ~ameanh M KpeamHnH, nopaPMpaanm~at m e n r ~ MaTepMM. n M ~ O T O ~nH3M c n e p a a ~ ~ ~ OKCMpMPaT 'ipe3 @ O K C M ~ ~ ~ ~ M R . p o ~ a m ar~ e,aary6a~a H a 6 e f l n ce ~ pbnxn H a aary6a H a K n e n r t i a Maca, a cboTHoweHHeTo a 3 0 ~ l c ~ pM a a30~/ ~ a nnpepnonara ~ i 3 a r y 6 a H a MycKynHa Maca. A ~ a n ~ 3 b ~ OCHOBH~ qen T ~ H a napeHTepanHoTo xpaHeHe e fla H a~ ~ ~ T ~ ~ ~ bH pb Op T ~ aOH M # BKnlOclBaHeTO e H aPqMOMa0 6 e 3 n e . 1 ~n n a c T M r t i w e ~ O T ~ ~ ~ H O HC ao Tp Mr a ~ ~ m M pa a PKMpaHM aMMHOKHCenMHW BbB BMCl(epallHMTe TbKaHM M KOMneHCGlpa e H e p ~ h ~ MM f4 BOpHMR 6ana~c npcl WCTMrHa cKeneTtiaTa MycKynaTypa n o T s b p W a B a T , cle ce paarpaMnM nbntia HepoCTaTbrHocr H a o p a n ~ o ~ xpaHeHe. o Bere fla MyCKynHa TbKaH. Toea e TOrHO O ~ ~ ~ H T aH r nO ayBaHeH m a CbMHeHue OTHOCHO 3 ~ a c l e ~ H ~ aenapeHTepanHo~ o TO, n p KoeTo ~ BMcqepanHMTe 6ennqw ce anons sea^ npeTO xpaHeHe H a ~ O ~ H M npn T ~ ,KOMTO o p a n ~ o ~ npMehnaHe o AM MyCKynHMTe. C ~ ~ P H M MeTa60nM3bM RT H a 6 e n ~ b Ce u~ H a x p a H a e H ~ B ~ ~ M O WB OCBeToBHaTa . nMTepaTypa o6aOflpeAenR OT flOBMWeHMR K ~ nOHMXeHaTa T~ CM-~VenpOAbnmaBaTflMCKYCMMTe oIM~~ M, rnaBHOBbBBpb3KaCOTfleHTe3a MnM OT K O M ~ M H ~ ~ M HF aIfleeTe, T~ onpepennq ce OT nHM XpaHMTenHM BeqeCTBa M CbOTHOWeHMeTO nOMeX# T e m e c n a Ha 3 a 6 0 n ~ e a ~ e ~ Ko a.~ a 6 0 n M 3 b t p a ~ M6~een ~ b MM. UM ce ~snonaea~ rnaaHo 3 a rnMKoHeoreHe3aTa, w e T o nOBMWeHMe Ce OTw3RBa H a OCHOBHMR KOMnOHeHT H a eKcKpeqMRTa ypema. ~ ~ O T M E O ~ O K ~3a ~~ npoaematie HMR H a napeHTepanflo~a~ np oo u e H w e ~a6 e n ~ b . ~ 1 ~ a~ ra ~ h n ~ npea sb~ HO xpaHeHe H m a . Hanara ce o6are n o - B H M M ~ no^T~~ flow-$a3aTa ca flo6pe M3BeCTHM, 3a WOKOBaTa $a38 HRMa xop npM nop6opa H a cpencTeaTa n KonMrecTaaTa, KoraTo AoCTaTb'rHO flaHHM. Y C T ~ H O B ~ H (3 M IlOBMlueHM KOHqeHTce Kacae 3 a ~ O ~ c H TexKM M B O A H O - ~ ~ ~ K T P O ~ MpTa H 3M c~pauMM H a HRKOM aMMHOKMCenMHM: anaHHH, UHCTBHH, TapoficTBa, aHYPMR, H ~ $ P O T M ~ HCMHAPOMW, H HaPYWeHMR B y p n~ apoMaTHH ~ aMnHoKncennHH, KaTo ce crwTa, r e JlMflMflHaTa o ~ M R H ~ BpOAeHM , P ~ ~ C T ~ OB ~O C~ TM BR ~H ~ T nbPBMqHHRT OflpeflenRq $aKT0p He e IlOBMWeHOTOnepMXMnepr~MqepMpeMMfl,T P O M ~ O ~ M HaPYUleHMFI , B CbCMpWe$(?pH0 o c e 0 6 o ~ a e a ~a e HaMMeHOTO , YCBORBaHe OT 'iePHMR ~ 0 6 yBenMreHMm , ~ ~ P H O ~ P6 Oe ~n ~~H b ,r e KaTa~ 6 o n ~ 3M bO ~C B O ~ O ~ ~ B ~ HH a aMMHOKMCenMHM. ~ T O r H a HeflOCTaTbYHOCT M pp. M TaKa npOMeHMTe B 6eJlTb'4HMR ~ a T a 6 0 n M 3 b M B OTfOl l p nnatiMpaHeTo ~ HaTOT~HOTO napeHTepanHo xpaBOP H a woKa, TpaBMaTa M cencwa BtmloreaT ~ a T a 6 0 HeHe H a n p a m n K a ~ O ~ H ce M T pa ~3penH ~a ~ TPM rpynM: c n~3bH u a cKeneTHaTa MycKynaTypa c oTpMqaTeneti aso6a3an~k1,CpeaHH M BHCOKW RHeBHH HymCIH c b o 6 p a 3 ~ 0 TeH 6ana~c. Toea ce MHpyqwpa OT r n w y e a H e , HenopBMmC Temecna Ha 3 a 6 0 n ~ ~ a ~ e ~ o . HOCT MOT CyMapHMTe e$eKTM H a HeBPOeHpOKPMHHMROTTOHWM OT B o p a ce onpepenm OT 3 a r y 6 ~ ~ BOP. n e p c n c ~ ~ p a H ~ae TpaeMaTa, ~o oco6e~o H a cencnca, H a TWHOCTM, BnMReqM Ce OT MHOrO $~KToPH. HOpManOHeM3BeCTHMMeXaHM3MMBOpMpOnOTMCKaHeHa~annHM YCnOBMRflHeBHMTe KOnMW?CTBaBOpa, 3 a Bb3paCTHM Ca TauMOHHMTe MeXaHM3MM M YflbnmaBa BpeMeTO H a XMnep30 mllkg T. M.; 3a peqa 30-120 m k g T. M. M 120-150 m k g M ~ T ~ ~ O ~ U T HCbCTORHMe. OTO H a ~ p a~ ~~ ,~T~CIH HeflOCMRT T. M. 3 a HOBOPOpeHM. Tnr ~ n ~ B3 r ea~ e 3 a H ~a aMHoroopraHHaTa H e A o c T a n v EH~PM~H PH~BHH M T ~ W M RPM 6 a 3 a n YC~OBMR ~ ~ 3a HOCT (SMOF) M BOAM p0 C M ~ P T ,a K o He ce Kopumpa. Bb3PaCTHM (3 n p u 6 n ~ 3 ~ ~ e 30 n ~ k(3llkg o T.M., H 0 IlpM M ~ C TM ~~H T ~ ~ O J I L~ I ~~~ ~ MB . M3TOqHMK M R T H a eHep60nHMTe C M3pa3eH ~ a T a 6 0 n M 3 T be ~ HapaCTBaT p0 50-60

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Cnequ+uvnu memoguku

npouegypu B cncwnama meguquncka nomoq

49

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M. ~~KB~THO H H TT O p a B e H O 3 H O6 e n ~ b r ~ VaHeHe o MO-

[a Ce flOmbpM MM0 C aMMHOKMCen#HHM CMeCcl, VUWTO CbCTaB nO3BOnRBa OllTUMUlHa 6en~bCIHa C M H T e 3 a . AH~BHU KOflU' T ~ieCTBa aMMHOKUCenMHU,KOMTO Ce IlpetlOpbreaT, ca 0.7 gkg T. M. npu nosuweHucpefltln ~ y q Te n ca 1.5-2.0 g/kg T. M. 3 q b n m e n ~ n cbcTaem ~e Ha ToTan H O T 0 IlapeHTepaIlHOXpaHeHe Ca MaKpC- M MUKpOefleMeH T U , BOPHC- UM a C T H O P a 3 T B O P H M HB M T I M M H H ,K O U T O CbuO Ce A03UpaT ~ b 0 6 p a 3 ~ C0 WUTeH aB C e K U IlaqUeHT. u!n~a Ha napeHTepanHOT0 AaBaHe H a aMHHOKHCenHHl e HaManFlBaHeTOM n M KOMneHCUpaHeTOHa a30THMTe 3aQ6~ MU 3 p a B H R B a H e T OH a a30THHfl6ana~~. np#OqeHKa H a ~(I~KIUBHOCTT~ Ha aMUHOKHCenlHHHR IlOTOK MOXe Aa ce pa3'iu~a Ha ~ ~ O T H U 6ana~c R n n3nb'iaa~e~o Ha ypema, KOUTO Ca npocTU M HmelK)JHUnapaMeTpM M AaMT B b 3 M O XHOCT 3a ~(u$epe~uupa~e Ha ~ a ~ a 6 o n n 3 nba~a6o~ nU3bM. Ha a M M H O K # C e n U H M T e np# 6 0 1 7 ~ C~ 6b6per~a M 'iep~o~p06 HeppCTaTb' ~a iHOCT T P R ~ M fla Ce M 3 B b D U I B aM H O r O BHMMaTenHO.

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seqecraa B pamep M CboTwtueHue, KOUTO noKpuaaT ocHoeHme HWM U noenluetime nopqn 3a60nRBa~e~0 M 3 M C K B a H U f l . M ~ C T H M?MynCMM T~ OT TpeTO IlOKOneHMe, KOMTO cera ca Ha Hawe pa3nonoxe~ne ca n o v ~ nnweHu n OT C T p a H M i ' H U ~~~WCTBUFI, C KOeTO Ce Cb3flaBaT PeaJlHlll yCflOBHR3a M C T U H C K O KOMflneKCHO XpaHeHe. r 0 I l R ~ 6poL aBTOplr IlpeflOpb'iMT CneAHaTa flO3MpOBKa H a M a C T H U eMyncnn npn napeHTepanHo xpaHeHe: IlpenOpb'iaHO K O n U V e c T B O 1-2 g/kg T. M. R H e B H O , oKono 30% OT o 6 q o ~ o KonnrecTBo eHepruu; CKOpOCT Ha UH$Y~MFIT~0.1 gkg T. M. (B Ha'ianOTO M npn onpeAeneHn 3 a 6 0 n ~ a a ~ noBaaw). n~ 6bp3ufl~ HanpenbK B 06nama H a IlapeHTePanHOTO xpaHeHe B nocneptio BpeMe ocraeu Hecnpaeewnao 3a nocTa ropnHn Ha swe~ nnaH eHTepanHoTo saeewaHe H a XpaHH. MHOX~CTBOTO IlpeflaraHU A H e C eHTepMHU X p a H M T e n H M IlpenapaTM MOraT Aa 6bpa~ rpynMpaHM B TpM OCHOBHU rpynu:

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ToBa KaTo nponyw Ha n~~pa~a3an~a~anunonn3a ce B ~ D .lea rnnqeponbT, K O ~ T Ocbqo y'iacTBa B O ~ M R H ~ Ha T ~

BeqecTaaTa. Klainberger, R., 1984 pa3rpa~n'iaaa ToTanHOTO napewepanMO xpaHeHe F X ) OT KoMnneKcHo napeHTepanHoxpaHeHe (KnX), B cMncbn Ha nbntiouetiHO, KaTO B flOCneflHOT0TOW BKnloCIBa B C M i ' K UX p a H U T e n H U

flomnnuopanHoxpaHeHe; - 6ana~cllpa~a, onpe4eneHa no xpaHnTenHn aeqec~ e pueTa; a - XHMMCIHOOnpeAeneHa nneTa. Ao3npa~e~ H o a eHTepanHoTo xpaHeHe ~ p ~ 6 Ba ea 3ano'i~e nocTeneHHo, KaTo ce nsnonaea HapacTBaqa cxenna. nonpn~unn, KoraToemepanHoToxpaHeHeeBWMOmHo, T ~ R ~Aa M MY ce Aasa npeAno'inTaHne npeA napeHTepXlHOTO M n U H ~ ~ ~ - M ~ ~fla KO YCIaCTBa TO BC M e C e H O T O .

X e ~ o q u a n ~ s (XA) a ~ ae npoqec, npnK O ~ T O KpbeTaoT 60n~nfi npeMnHaeanpea eKcrpaKopnopaneHxeuonnannaa~op H ce spbqa npe'incretia O ~ ~ ~ T KH ~ M O naunema. Manw~e, p a 3 T B O P M M M'iaCTU'iKU Ce O T C T p a H R B a T O TKpbBTa 'ipe3 FIM$~BMR npea nonynponycmnsa ~ e ~ 6 p n a ce ~a M 3 X B b p n R T C flUaJlH3HUR pa3TBOP. E(IeKlMBH0ClTa h 31

HeH e$em, KOMTO H eBO~RT do pe3~n npoMeHu B xoueoc~a3a~ T a~ . K u B En ~e cp ~u ~ o ~ e a nfluanusa, ~ a ~ a nponbnxu-

TenHaTa a p ~ e p u o - B ~ H xe~@nn~pauu~ O~H~ M~ p .

K~HHH~HO npnnomeHne TO Ha cnewHaTa XP, e KaKTO cneAsa: 1.60nC ~ OCTpa ~ 6b6pewa H e f l O C T a T b C I H O C T(O6H). OTCTpaHRBaHe H aH U C K O M O le K Y n H HC~~CTIH~UM(C MOne2. O C T ~AeKoMneHcnpana O XPOHH'iHa 6b6pecl~a HeVnHa Maca flo 300 A a n ~ o ~e aMHoro ) ronRMa. T ~ K Uca B~ f l O C T a T b ' i H O C T (X6H), O ~ M K H O B ~ H BO pe3yMaTOTU H T e P K Y Bopa, enewponnTu, K ~ ~ W H M npopywn OT 6 e m ' i ~ a ~ a PeHTHH H H $ ~ K ~ M O ~ ~ HM ~ ~ O ~ R B ~ H U R . O ~ M RM H~ ~ pM . ~ o r flnann3a6nn~u o ca: a 3 o ~ (~one~yn~a 3. Y c n o m e ~ n npn ~ 6 0 1 7c ~ X6H ~ H a nporpaMHo, Macs 14), H ~ T P (24, M~ X n O p K M M ~ (39), K M ~ L I ~ (40), flnanna~o necleHne ( ~ a re fc~o B pe3yma~ OT pneTu'iHn ypeR (60), KpeaTMHMH (113), IlMKOCIHa KMCenUHa (168), rpeurltn, w e q u 40 xunepxnflpaTaqnn n xnnepltannernlo~osa (180). AKOxnnepxnflpaTaquma e rnaeHumKnnMUR) Hn'ieH npo6ne~, ce npoeewa lraonwpa~a yn~paann~pa4. OCT~H eK30reHHU H H T O K C L l K a 4 H M C ~~MEIJTM~~~UIIHU 4MR, KORTO n03BOnRBa OTCTpaHRBaHe Ha Te'iHOCTM n0 H O K C M . H F l K O n K O nHTpa Ha WC. 6bp3a~a KOpeKuUfl H a flUCeneKT5. Apyru npnrwn, npu KOMTO Moxe Aa HaMepu ponuTeuuR, aqnAo3a n a 3 o ~ e He ~n BnHaru ~ e XenaTennpnnoxeHne ca xunepypuKeMnFi, xnnepKanqueMnR, xnHa. Cll0pefl C b C T O f l H U e T OH a ~ O ~ H M FIlOHRKOra I, Ce npeflnoTepMuR (oco6e~o npu npoflbnxnTenHa xeuocop6qn~ c no'imaT AenypaqnoHm MeTofln C nodaae~, HO n o c ~ o ~ - aKTuaeH ~ b r n e ~ ) .

(ss),

napLlTeTa, PM YPeMMVHO 60n~M B M03b'iHMTe KlleTKH Ce HaTpyIlBaTT.Hap. .MflHOreHHM 0CM0nMU - OCMOTMVHO BKTMCbnoe nocnn n p c ~n e w a x e ~ o ~ ~ a n EKC~ s a . BHM BeqecTBa. PM MHTeH3MBHa W 6bp30 Ce M3nb'iBaT TpaKopnopanHaTa qHprcynaqMR npM W HanaraocbqecTH~TPM H ypeR ~ OT KpbBTa. nna3MaTa CTaBa XMnOTOHMrHa smaHe Ha cbpoa pocnn, ocMrypRaaq pe6m 200-300 mV CnPRMO M03b'iHMTe WleTKM, nOCnepBaHO OT HaBnM3aHe Ha min. T o l ce nocTMra ~ p e 3 neptq-rawo KaHlonMpaHe Ha BORaB MO3bVHaTaTbKaH. ~ M ~ ~ K B H ~ M ~ P CMHf M Yl P M OMnp0seHa @e~opanuc, seHa cy6tmae~nMnn seHa lorynapMc T M W C o6qu M HeBPOJl OMClHMCMMnTOMM: rWeHe, nOBpbMHTepHa. M ~ o r o nOflXOfl~MC a~ B O ~ H O ~ ~ M ~ KaTeHHMT~ qaHe, ncMxoMoTopna~a36ypa, rnaao6onme, mpqoee, 3aT P M( ~ ~ ~ M H Jly H MeH RT 3a B3MMaHe, flPYrMR - 38 BpbqaHe Ha ry6a Ha C ~ ~ H ~ H M XapaKTepHM ~TO, EEr npOMeHM no BpeMe ~pbBTa) npM epHOKpaTHa BeHenyHKUMR (@Mr.1.l 9). npM vlnM c ~ o p o cnep npMtmmw.aHe Ha f l ~ a n ~ s a Hanara ~ a . ce epHonyMeHeH KaTenp e HIO~XO~~MManapaT 3a "singlep~$epe~qnan p~anioaa ~a c ypeMMrHa e~qe$anona~# needleufluan~m,T. e, c Hanurue Ha KnaMnu3a nocnefloMIHMHMT, e~qe@anHT, M03bqeH KPbBOM3JlMB OT npOMeHM saTenHo TerneHe M BpbqaHe Ha KpbsTa. T ~ K Mca B~ B apTepHanHoTo HanRraHe M npnnaraHm no epenne Ha "Gambr0-AK1Ou.H ~ A O C T Ha ~ Tt?flMHMrHMR ~K KpbBeH nbT p~an~3 xenapuH. a Hanara ce cnMpaHe Ha f l ~ a n ~ s a ~ (single blood pathway) e HauaneHaTap ~ a n ~ e$e~-r~s~a OCMrypRBaHe Ha C B O ~ O ~ H FlM MXaTenHM nbTMqa, BeHTyaBHOCT nopWM HaManeH KP~BOTOKnpep p ~ a n ~ 3 a ~ M opa nH0 M H T @ ~ ~ CU M3KYCTBeHa R BeHTMIlaqMR. npMJlaraT C e peq~prcyna~~n ~a sere p n a n ~ s ~ p ~ ap ~b aB eap~epuan~aKMUMeB rnloKOHaT, HaTpMeB XflOpMfl, rllloKO3a, Manitol, Ta KpbBHa IIMHHR. HaJlM'iMeT0 Ha flMFUlM3HM anapaTM C cepaTlretw cpepcTaa M ppynl. n p o $ ~ n a m # ~ a Ha ~C aM H ~ ~ B O A H M KpbaHn noMnM ("Unimat", .SecuraY, .FreseniuspoMa, KORTO cbanaga M c 0 6 ~ a T a cTpaTemR Ha 2008-E", "Gambro-AK100" M pp.) o n m ~ ~ 3 KP~BOTO~pa~ nerewe npM cnewHo 60n~b1,a~nlorea: Ka. B b a ~ o x ~ eo CTaHflaPTHMRT eflHOnOMnOB pManM3eH 1. P ~ HpH ~a ~n ~ aT, a ,e. npepM n n a 3 ~ e ~ a yp ~e al ~ a anapaT pa ce wsnonsea, KaTocapoenmpocnn ce ocbqeKOHUeHTpa~MR M OcMOnapMTeTfla Ca CTaHanM MHOrO BMCOCTBM ~ p e 3 absematie Ha paa KaTenpa B e y a w n M pee KM. sew. Cnep p ~ a n ~ nyueHbT aa Ha KaTeTpwTe ce sanbnea c 2.3anowa ce c KpaTKa HaqanHa pnanwsa (2 h) npM xenapMHoe p a 3 ~ ~ 0 (paspepe~ p c$ M ~ M O ~ Op MaC 3~ ~ 0 Hp KpbeeH pe6MT 200 mumin. n o c ~ e n e ~ ce ~ yeenwiaea o B CbOTHOWeHMe 1:l), a Ha I lyHKqMOHHOTO MRCTO C e IlOCTaMHTeH3WTeTbT Ha neVeHMe. B T O ~ ~ e T 3~h, a BCRKa ~~c~ep~n~anpeepba~a. cnepeaqa no 4 h npm pe6m Ha KpbBoToKa 300 mllmin. ~ ~ o ~ ~ Ha ~ IlbpBaTa I ~X x nM HW 4T he~ pOnyCTMM0 ~ H C a M O npU n ! C e lH M e Ha ~ O ~ C H eK30reHHM M MHTOKCMKaqMM (EX. T ~ M ) . 3. l l p nbpaa ~ p ~ a n ~ He a ace npenopbraa yno~pe6a Ha ronm pnanwa-rop. noebpx~ocrra Ha ~ e ~ 6 p a MY ~a T ~ R ~pa Me cb06pa3e~a C pbcTa Ha 60n~MR.PM peqa ce ~3non3~ pa ~~ an~3ac ~ 0.6-0.8 o p ~ m2, a npM B ~ ~ ~ ~ C 1.O-1.2 m2. PM cnewHa p ~ a n ~ ~ sa al - n o p x o p u q ca ~ AMa n ~ 3 a ~c oypeeH p ~ ~ n ~ p Memy b ~ c 140 M 175 mllmin npn KpbBeH f l e 6 ~ 200 ~ llll/min. npM HaJlM'iMe CaMO Ha pMaIlM3aTOPM C no-rOnRM KnMPbHC, T P F ~ ~ M CbOTBeTHO pa C e HaMaJlM KpbBHHRT pe6n~. 4. HaTpMeBaTa KOHUeHTpaqMR B pHaJlM3HMR Pa3TBOP He ~ p ~ 6 pa e ae MHoro no-HMCK~ OT ~ a B 3 n n~ a a ~ a ~B a. @m.1.19. @ohonyucww m p sa cnemna elrerpampnopanna nenypaqrm. npoTMBeH cny'ia8 epHOBpeMeHH0 We C e M3Jlb'iBaT H ~ T P M llop,xoppq 3a nanmnnpawe na #ewopanwa, nmmrnrwa M YPeR. O C M O ~ ~ ~ M B KpbBTa T~T~ CnpRMO T T03M Ha nMKBOn Barpeluna nrrynapna eena pa 6bp30 HaManRBa M Ce CbVaBa Bb3MOXHOCT 3a RMCeKB M ~ M ~ P MCMHAPOM. ~M ~ P H BMCOKOCTeneHHa FeMMR M Oco6e~ocm Ha AH~JIH~HOTO neqeHme n p cnew~ XMnepHaTpMeMMR nbpB0 ~ p ~ 6 fla a aC e OTCTPaHM YpeRTa. H 0 6 0 n ~ #HHT~H~HBHOCTT~ . Ha XeMO,4MMM3aTa C e Onpeperm OT npopbnxMTenHocrra ir, ctcopocrra Ha K ~ ~ B H M R nposema ce M c HaTpneao caflbpxanne a p a 3 ~ ~ o p paeHo Ha n n a a ~ e ~ oC ~o n .e ~ Toea 6 a e ~ o M nocTeneHHo p e 6 #n ~ t~pMea6Mn~~eTa Ha ~ e ~ 6 p a ~na p ~naqMeHTM a ~. ~ p ~ 6 pa a ace Kopmpa XMnepHaTpMeuMma, KaTo cnea B ocTpa ypeMMR nbpame epHa, use W He ~ p ~ 6 pa sa ca p~an~3 ce a npunara p a 3 ~ ~ o Ha p Sol. glucosae 5% M MHOrO HHTeH3MBHM. 6bp3MTe npOMeHM npepM3BMKBaTA M 0.45% Natrii chloridum. ECT~CTB~HO ~ p ~ 6 pa aa ce BHMMIc6ana~c Memy KpbeTa, eKcTpa- U MHTpaqenynapHoTo Ba 3a XMnepXMflpaTayR. M ~ K C M MpOnyCTMMaTa ~~HO pa3npocrpaHcTao MssecTHn K ~ T O.disequilibrium syndrome" nMKa 3a HaTPMR Memy KpbBTa M pa3TBOpa npM 6 o nC ~ (CMH~POM Ha ~ e p a e ~ o e e c ~ e T~ oo l) ce . p b n m Ha 6bp3M npe~q~ann3 mnepHaTpMeMMR ~a e 3-4 mmolll. l l p ynoT~ IlpOMeHM B KAC, BOAHO-eneKTponMTHMR 6ana~c M OCMO-

T ~ X H HHa K ~3nanue~me ~

m-

Cnequ@wnu memoguku u nposegypu B cneurnama meguquncka nomow

51

noocMonapmeT n KoMneHcaropHonpMpemmaHe Ha eopa OT K P b B H O T O PYCnO K b MM H T e P C T H u M a J l H O T O IlPOCTPaHCT-

m. T O BBORM ~ ~o peAyuMR Ha I ~ ~ ~ B H oM 6e R ~apTepMan,

Ha xnnoToHuR, HapausatieBWHOTO mmpxaHe Ha uo3bKa, IlORBa Ha IcpaMnM M ~ M C ~ K B M ~ H ~ P H ~ M . n p e ~ q ~ a nxwnoHaTpnevnR ~3~a ce npnnaraRManM3eH pa3TBOP C no-~OnRMO CbpbPXaHMe Ha H ~ T P MKaTO ~, KOpeWMRTa T P F ~ ~ Ra B Ce ~ fl0CTMIl-EflOCTetleHH0. npe~qman~3~ cm ~o eh ~ o c T Ha n cepyMttuR ~anufi onPeRenRT BMfla Ha AMal'lM3HMR pa3TBOP ( K O H ~ # ? H T ~3a ~T~ XeMO~MaJlM3a-W). np# XMflO- MnM H O P M O K a lM e M M RCe npnnara K U - 3 ( p a 3 ~ ~ C 0p mMeBo CbppxatiHe 3 mm011 I). n p cepyMeH ~ ~ a nM ~e n w 5.5 M 7 mmoM ce ~anonaaa KXI-2 (cbpbpxaq 2 rnmoln KanMh). npn XMflepKaIIUeMHR HW7 Hah-floUXoRR~ e K U - 1 (~e3n pa3~~op ce nnpoua-

PM

T e n T Ha' ~

e ~ 6 p a ce ~a onpeRenR ~a c ~ o e @ m 4 m eHa ~~a ympa@mn~paqm~ (KU9. Toh npeAcTaenRaa KonMrecTBOTO T e C l H O C T B M M J l M n M T P M , KOeTO q e IlpeMWe npe3 Me~6pa~aTa 3a e A M H Vac npM C b O T B e T H O HanRraHe B MMnMueTpa xnmK (mWrnm Hg). KUf ce o ~ 6 e n ~ 3Bm TexHMrecKaTa xapamepMcTHKa Ha pmw3aTopMTe. KonKOTO no-BMCOKO e TMH (rpmgqne~n~ M e w y AeeTe npompa~msa), TonKosa n o - r o n ~ ~ qo ee M ~ B ~ M ~ H ~aH Ter~ T
HOCTM. npMMep: aK0 n O 3 M T M B H O T O HanRraHe B K P b B H O T O

aewaT y ~ a c ) .

npompaticmo e t50 mm Hg, a HeraTneHoTo HanRraHe B U M ~ ~ M ~ H OnpocTpaticTeo TO e -350 mm Hg, Toraea TMH (CGopb~ OT ABeTe npoc-rpa~cna) we 6bpe 400 mm Hg. PM yno~pe6a Ha pMEUlM3aTOp C KUf = 4, Toram YQ) We 6bpe 4x400 MnM 1600 mm. n p xunepxMflpaTMpatiM ~ 60nHM ce npepnorma-r~ ( ~ a n ~ 3c aKUf ~ o2 p6, ~T. e. (6 mlM mm Hg). OT'-~MT~H~TO Ha YQ) CTaBa: 1. no ~a6nnq1.1 Ha 3 a w a n p o ~ 3 a o ~ ~ ~ e n . 2. Ype3 npocnepxiatie cnmaHeTo Ha TenecHoTo Terno no BpeMe Ha YQ) c enempoHHa sea~a. 3. B r p V e BonyMeTpMWH ~ KOHTpon IlpMCbBpeMeHHkl-

6a~a M M IlpOMMBaHe C 2 1 @ ~ ~ M O ~ O M C Pa3TBOP ~ ~ H MnM yno~pe6a Ha CTePMIlM3MPaHM C raMa-nbCIM MnM napHa

CTPYR x e ~ o p ~ a n w 3 a ~ o p ~ . CTaHAaPTHaTa aqeTaTHa ablanH3a A M a lM 3 H M R T pa3TBOP CbRbpXa aueTaTHM OHM, KOMTO B ClePHHFl~p06 Ha na4MeHTa e flpeBpbqaT B6MKap60HaT. T 0 3 M HaClMH Ce KOPMMPa MeTa60nMTHaTaauMRO3a A ~ $ ~ T ~ T H pa3THRT B O PB O P MP O aPTePMLlllHa XMnOTOHMR npM H R K O U IlauMeHTM M nOBHWaBa CTpaHHCIHme R B n e H M R . 6~Kap60Ha~HaTa ~~anme sa MHoro noAxomqa n p ~ ~O ~ H c 06H. M TR nonecHo ce notiacg. AH e C T ~ ~ M ~ M HMoxe O Aa ce npoaewa 6e3npo6ne~~o ~ s a n ~ r Ha a ~TerticcTM. e Y Hac 3 a n o r ~ a flpoM3BOflCTBOTOHa pa3TBOpM3a 6M~ap60Ha~HapMaJlM3a, HO Bce oqe ca MMKO qewpoaeTe, pa3nonaraqn c nopxo-

PM

no

Tep~an~3~~anapaTn. npn TRX KUf uMa caMo OpuempoBbrHo 3 ~ a r e ~ ~ YQ) We 6 b ~ T eO ~ K O B K ~O ,n K O T O e IlporpaMMpaHa, HemBMC H M O OT Hero. npw c n e w ~ a ~ a ~ ~~e an ce ~npenopbrBa 3a OTcTpaHRBaHe Ha rOnRM0 KOJlMreCTBO T W H O C T M . Hah-~obpe e nocTeneHHoTon M ~ a e n ~ r npe3 a~e cnenmqme exeptieetiM R M W M 3 M .A K O I ~ M ~ C B ~ T O T aHa3apKa, O ~ M , ~ a 6 b 6 ~ a l.Mhnn HM BeHH, ce ~ 3 s n ~H r ea noeere ~ OT 2 1. ~ O W M R Tonepatic T K b M OTCT aHflBaHe Ha T e i ' H O C T M IlPM KOHBeHuMOHanHaTa c Y ~ o x ~a e ce mnxn ~a a q e ~ a ~ OHM ~ ~ B ~ pa3~~op no-BMCOK~T~ a, MY TeMnepaTypaMnM HenopxoRR-

e~3auep6npa anKano3aTa. Moxe na potleae po xmolcceMMR, CbPfleL(Ha aPMTMMR H R O P HneT8JleHM 3 X O A . 6MKap60H a T H O T O HMBO Ha flauMeHTa T P R ~ M pa Ce M O H M T O P H p a , KaTO e Bb3MOnOIOflpM H w a pa ce npeMMHe OT 6w~ap60-

HaTeH pa3TBOp C BMCOKO HaTpMeBO CbflbpXaHMe, TOraBa XeMOflMHaMMKaTa e cTa6MnHa. M30n~paHZI yn~pa@mn~paqm~ (.ympq~@y3~ Fe~", KBeHuMWHa@MIlTpauMR" ($Mr. 120). npM XMflepXMflpaTMPaHM 6 0 n ~ u M H m a OT OTCTpaHRBaHe Ha no-rOnRM0 K O n M c l e C T B OT e i ' H O C T M (HW 4 1) 3a IlpeAIlOrMTaHe e B HaraIlOTO fla Ce Cnpe AMaJlH3HMflT pa3TBOP. 3a 1-2 h Ce O T C T p a H R B a T2-3 1 T W H O C T M clpe3.~~a"yn~pa$Mn~pauM TRCe IlOHaCR no-~06pe, Tbh KaTO H e Ce IlpoMeHR C b O T H O -

52

Cnequ+urnu memoguku u npoqegypu B cnewnama ~eguquncka nomoq

lIJeHHeT0 Ha eneKTpOJlWTMTe B KpbBTa M H R M a aueTaT. eoAa OT MHTpauenynapHoTo K ~ M eKcTpauenynapHo npocCne~ TOM ce npoaexqa 2 h XP, (c nnn 6e3 Y@) 3a TpaHcTBo Moxe na yanecle M WMR. H a c n n ~ n a ~ xmepa OTcTpaHRMHe H a XenaHMR o 6 e T ~ei'HOCTM. KanneMnR ce orcTpaHRsa c kl3onupa~a~a ynlpa@nTpaqHR H R M a IlpeflMMCTBanpefl YQ) C 6MKap60~aT~a AMaKora~o x~nep~an~euwmae no-~MCKOB~~ OT ~~O~ HUR xMnepxuflpaTaunRTa, Toram nerleHneTo 3anoq~a c nwa. n p nauMeHTn ~ c 06H (x~nepxnflpa~au~fi, KanMeM M R H ypeMMFI), K O M ~ H H ~ ~ H M3OnMpaHa RT~, Y@ M 6 3 (M~~MWHM cepyMeH R ~ a n6apm ~ i ~ ~ 4 y aK ~~ pM AMMMa 3eH pa3TBOP C HMCKO K~MeBO CbflbpmHMe W-l), a yAarHa npM nMnca Ha cbepehnetw anapaw c B ~ ~ M O X H O cneA HeR ce npnnara nmnnpaHa ympa4~n~pauu~. CTM 3a ~ W K ~ P ~ O AMallMXt, H ~ T H ~~ 3 6 H 0 a HaTpMeBO ~ H U B 0 B pa3~mpa M BonyMeTpureH Kotrrpon H a yn~pa4~n~pa A J ~ T ~ ~ H ~nOAXOfl T M B npM ~ H XUnepXM/JpaTMpaHM M XMunR. IlePKMMeMMclHM IlauMeHTM 8 fla Ce flMMM3MpaT B IlpOAbJlXeHMe ~ a 4 - h, 5 H0 C HaMafleHKpbBeHfle6#~ 120mllmiIl, KaTO Ce O T C T p a H R TT e q H O C T H n0 1 h.

W.

YC~OW~HM npn R MaonupaHaTa yrrrpa4umpauu~ ca

apTepMUlHaTa X L I n O T O H M R M XMllepKaJlMeMMR. BbnpeKM O T H O C M T e n H O ~ O ~ P M RTOnepaHC T K b MO T C T p a H R B a H e Ha T~CIHOCTH, ~ KM O30nMpa~a~aY M H ~ O r OM H T e H 3 M B H a(HQ 2 1 Ha WC) e Bb3MOXHa XU~OTOHHR.~ ~ ~ M H H H a ~ M H ~ T O

06H). PellleHMeT03a U U MOMeHTbT Ha 3aflOCIBaHeTO h ce onpeAenRT OT uwinrHoTo cbcromne M na60pa~op~nT e M~C~~AB~H (c Me Fp Iy~~m H e M Ha ~ ypw, KpeaTMHuH, ~ a f l ~H f i~ , T P H KMCenMHHO-anKmHM5I ~, CTaTyC, PeHTreHHa 6 ~~ n ~ 0 EKT, 6 , KoarynorpaMa M ~pyrn). 3a p a 3 n ~ ~ OT a X6H, n p KORTO ~ 6 o n ~ m uo e ronma creneHca WarnMpaHH K ~ M ~~OT~MMR n Tp~06H ~ , ce sanorea X4 nereHwe npM KPeaTMHMH700 ITlmoId, ypeR 25-30 mmol/l, a IlOHRKOra M no-patio. Y p e ~ ~ w CM ~ Hm A~M ce p a 3 ~ n ~p ~ cnqarre ~ a Ha KPeaTMHMHOBMRKnMpbHC ~ a 5 - 1 ml/mifl. 0 T0h CC! flpoFlBRBa CbC 3al@a Ha afleTMT, WeHe, flOBpbqaHe, &QMHaMMR,

Jle~an~a uo3a ~ a e 100-150 ml, HO M 60 ml MoraT Ra ce OKMaT $ ~ T ~ J ~ U H Me . BMCoKO e$eKTMBeH MeTOP 3a fleTOKCMKa4MR. E T M J ~ ~ H ~ ~ M (MofleKyn~a K o I ~ ~ T ,Macs 62), OKCNlOBaTa KMCenMHa (126) M TeXHMTe MHTepMeAMepHM IlPOWM ca MHOrO ~ ~ a n n a a 6 E ~~ n~ ~H ~O . B ~ ~C M e ~H Raea Ha naqnewa eTaHon ( e ~ ~ n an~oxon) oe B HavanHa ~ o a 0.6 a glkg M nompxatqa ~ o a 70-140 a mglkgh. npunoxeHMm eTaHon ce KoHKypMpa C eTHneHrnMKona 3a anKoxonAexMAporeHa3aTa, c KoeTo tiannannsa npopy~qwma Ha oKcanoaa KMcenwHa. HRKOM npenopb'iBaT np~6aBRHe Ha eTaHOll KbM AMaIlW3HHR Pa3TBOPflOpa,4MHeXenaTentia p e w w Ha n n a a ~ e ~ MY o~ HHBO o no epeMe ~aXA.

PyflBaHe Ha )'pOXPOMHM IlMrMeHTM, KOMTO HOPMMHO C e $MRHa 3PMTenHMR HePB (CW3a@a Ha ~ P ~ H M ~FpeTO), ana area^ c y p ~ ~ a ~ ypemreti a), ~ b xnepMKappMT, , 3a6aw a ~ ~a e UHC. J l e ~ a n ~ a ~ a e ~3 o0 3~ a 100 0 rnl. C ~ b p r r a s e ~ a ~ o n u n c ~ a t q a r p e ~ ~ a n e p ~ c ~ m ~ ~ a HacTbnsa ~ ~ p . OT qepe6pan~~ rbproae M napmaa Ha pwwaHeTO. MeTaHoIlbT M MeTa60nMTWTe 1My Ca C B M C O K a A#allM~ponreonona3a~rn~ ~~~MJIHOC (T~ o n e ~ y ~ na ~c a 32.04). a e 16 ~o 22 m m ~O-~$~KT OT W HOpManHaTa BH~ 6b6pev~a eKCKpeqMR. HRM ~~ ~CO~~O KOHTpaMHAMKa4HH. THH HanpeAHanaTa Cnew~a U ce npunara n p ~a) : C~MH~H 3a M MHTOK~ saapacr, cbpAertiocaAoeaH ~ R ~ C T ~ T ~ ~ MH xe O~ CoT pamv C M K a u W R C MeTaHon; 6) noBMwetioHHBO B cepyMa ~q 100 HaTa AMaTe3a ce paarnewa~ noaere KaTo PMCKOBM $ a ~ -

Maca Ha canMqMnoeaTa WcenMHa e 138, Ha aqeTmcanM~MflOBaTa KMCenMHa (Aspirin) e 180. O T ~ ~ B R IlpOTM' H~TO ia c ~ e ~ a 6 o aqw~o3a n ~ ~ ~ MayBpewaHe Ha UHC. XP, ce IlpMnaraflpM KJlMHM'iHM flOKa3aHMR M n H CepyMHO HMBO H a 80 mgldl. OCbtqeCTBRBa AeflypaqMR M eAHOBpeMeHHa KopeKquR~aaqu~o3a~a. Xe~ofl~aJlIl3a IIpH eK30leHHH HHTOKCHKaqHH 6ap6nrypa~~ MoneKyn~a~a . Macs Ha 6ap6man e npnnoxe~me Ha xe~ogmann3a~a B ToKcmKonorn184, Ha 4e~o6ap6man -232. O T C T P ~ H R B ~ T CC~A rHaTa npaKTmKa. X e ~ o ~ n a n n 3 a e~ nereHclre a Ha n36op MK ~ ~ ~ o x ~ M o ~ I ~ ~ Y~MR . cepyMHo H M ~ ce$ npwnara npn IlpM eK30reHHM MHTOKCHKaqHH C BOF(HOPa3TBOPMMM,HMC~q 10 mg/dl. KOMOfleKyflHM BeqecTBa C HMcbK 0 6 e ~ Ha TbKaHHO pa3fln n ~ m iBnn3a . B m a e a Ha MeAwKaMewM 3a nerepeAeneHne, HaMMpaqMce B KpaeTa, ~ecebp3a~1.1 c nnaaH M e Ha a$enne~nncnxos~H RenpecMBHM C~CTORHMR MeHMTe 6emqn. Cfle~M$M~HM eK30TOKCHHM, npM KOMTO (nmee ~ a p 6 o ~a MoneKynHa ~ Maca 74 B cbcraea Ha ce Hanara npoeeyqatieHa cneluHaAnann3a ( l o p npeAn ~ npenapaTMTe Neurolepsin,Norrnothimin~np.). OIcrpa~flXnUn'iHMR a ~ a n ~ca 3 )eTMneHrnnKon (amcl$p~a) n MeTaea ce Mtioro ~ o 6 p e c TR ce npmara n p cepyeti ~ Hon ( ~ e ~ n n o an~oxon). a npnnara~e~o Ha 3a oTcrpaq mmolll, npn Koero caqecrayaa PMCK OT HRBaHe Ha cannwnaTn, 6 a p 6 ~ ~ y p an ~m # ,~ f i - c b m p ~ a - JIMTMA ~ a , 2.5-3.5 flpORBM Ha H~$~~TOKCM'IH~CT. npefl~pb'i~a~ C e IlpOnOHU(M flpeflapaTM 3aBMCUOTCePYMHOTO MM HUB0 M WIMHM'iHOmpaHa U ( ~ 12 qh) unn HRKonKo nopeAm U , nopqn TO CbCTORHHe. noBTopHoTo MY HapamaHe B c e p y a - rebound effect). Ennne~rnm~onar ce p a 3 m a B rlepHcllg ~ p o ~o 6 H~c~o~onen K~(nan~3a6nn~n yn~~ ca nmeeMm aqeTaT rnMKoannexw, rnMKonaT, rnwoKcanaT U o~canoea KMce109. nntia. V136poe~me ~e~a6on wm n n a ~ ~ o ~ o ~+KT. c n r e ~ c MoneKynHa Maca 66 M n m n e e m cyn$a~ PM a - n e ' i e ~ ~ Ha e eK30reHHM HHTOKCMKa4MM C e Yepewa~ wvim.i opraHn n cmcrewM. BKIMO~H ca M npeAnormaT xet.toAnann3aTopuc B M ~ ypeeH K WIM~~HC, 6b6pe'i~~IlOPalKeHMR, BWI. 06H. BKIHMKB~ eKCTpeMHa KoeTo rapampa n o - r o n flepMea6Mn~eT ~~ 3a TOKCMCIHMaqngoaa, K ~ T O pH MoxeAa a n w e no^ 7. L(epe6pan~me Te H O K ~ n . p o m m e n ~ o c Ha ~~ xeMoAmnn3aTa a e nonpoflBll(OT KpaMnHA0 K O M HaCTbnBaT ~) no BpeMe Ha ~ a f i ronma (5 h n nosere). npn T E ~ K O B neretine ~ caqempa BMCOKaTa KOH~eHTpaMR Ha OTwBaTa B KPbBTa. O K W ~ O~~~CH OT O XMI~O$O@~T~MHR ~T H N K i l l i 0 3 a , flpoM3TMrla~a THH KpncTann ce ~ ~ R B R B e~ ypnHaTa T 1-2 h cnen npnewa OT m a e a Ha n 3 n o n 3 ~ a ~ n ~ annae paneop. ~ Ha emeHrnmKon, a onmrypHma HacTbnBa cneA 1 2 4 h. p~anwsa, npomnxnTenHo a p ~ e p ~ o - s e ~ x 0e 3~ o a@ n ~ PagMR, IlepMTOHeanHaflMMM3a. flpM XeMOpaMqHH MH4MpeHTw ce npnnara 6 e 3 x e n a p ~ ~ Amnn3a o~a (EX. MeropM H axenap~~u3aq~~).

a.

54

CnequtfJurnu~ e m 0 g ~ k uU npoqegypu B cnewnama meguquncka nomoq

Mm~'xenap'Hn3aqnn
Ane~ca~ OCM'~~HKO ~p

6) B apTepManHaTa r a m 200 Ulml Heparin, B ~ BeHoB wars r a m 2 mdml Protarninurnsulfuricum:

mg Protarninurn sulfuricum. 3. Xenapm~maa~u~ cM ~ ~ ~ K H0 Heparin: 3 ~ a) ~wanw3a~opb~ ce n p o ~ ~c e500 a ml $ w a ~ o n o ~ r e Ma~ep~anme, OT KOWO ca Hanpaeetin f l n a n ~ a ~ ~ ~ e cepy, B KOATO M M a 1250 U Heparin; M~M~P~H ca MT, ~ o M ~ O ~ ~ H H npLl M . CbnpMKOCHOBeHMe Ha 6) naqMeHTbT ce x e n a p n ~ ~ s ~ cp 500 a U Heparin; KpbBTa C Te3M l r y y q M nOBbpXHOCTMC e aKTMBMPaT $aKT0B)Ha BceKH 30 min ce noAasaT no 100 m 1$ M ~ M O ~ O M pMTe Ha KpbaocacMpaatieTo.npoeeyqa~e~o Ha xeMonMareH cepyu, KaTo TMP ce ~arnacfiea ~ a ~r a e na , 6ana~c~nM3a 6 m 6 ~ n HeBb3MOXHO o 6e3 aHTMKOarynaHT, IlpeflOTBpa BnMBaHMfiTa C yfl~pa$Mn~paqMfi. npu YCnOXHeHMR Ce paTfiBauT P O M ~ ~ ~ H P ~ BH eKcTpaKOpflOp~HMTe ~TO nbTMnpeMMHaBa KbM KOHBeHqMOHaJHa XeMOflMaJlM3a. ua. Tow HarMH HaMnpa npMnoxetiMe npw naqmemM c M3non3saH WMPOKO B meToBHaTa npamuKa e Hepanepnlcapnwr, Kbpaetie OT TMT, qepe6poea~cynap~~ wqnrin. M ~ K ~ o M o MyKOfl ~ ~ O KflM ~3aXapMA, ~ ~ H 06pa3yea~OT F(eHTH,npeAMMCne~XMp)'?NTlclHM MHTePBeHqMM. 6a30$MnHM~eKneTKM Ha KpbBTa, TO^ e H ~ ~ ~ - M O ~ HH HCR T 4.6e3xenapm~oea xe~o~manm3a n HRKOMamepHa~ a u - W M cnemp ~ O K Ha ~eAcT6~e $manonornre~ aHT#KoTMBHM MeTopn - ~ H ~ M M H pO aarpwa~e Ha Heparin, KaTo arynatl-r. np# B ~ H O ~ H npMnoxeHMe O 3anorea Aa AeAcTsa ce anons sea $ ~ m MMnpeniMpati p c xenap~~a3a; HepaBeAtiarac nponbnmMTenHocT 6 h; n p u ~y c ~ y n ~ sanoro rill, T P ~ ~ HCBbp3aH O C MeM6paHa~a, KOATO OKa3Ba C a M O sa cneA 15-30 min M npo~bnxaea 6 h-MnpM n o f l ~ o ~ ~ o MecTeH e$en; Heparin-~Bbp36au(M hteM6pa~M. npnnoxetive - HaranoTo MY e cneA 40-60 min M 4eAcTea npn nerewe c Heparin ce H ~ ~ ~ I O ~ ~ E cnentiwe ZIT 8-12 h. CTP~HMC~HHT~ RBneHUfi ca: XMnOTOHMfi, 6 p a p ~ ~ a p - napaMeTpM: AMR, AMcnHefi, aneprmwn pealcqnw. 1. a P l T - a ~ r ~ ~ n napqnantio pa~o ~po~6onnam~~o Me~opme Ha aHKTMKOarylla~Mfi M : spe~e(32-51 sec). T p f i 6 ~ a e ~y a~ b n x e ~ 1.5-2.5 o nw. 1. C n c ~ e xenapm~m3aqm~: ~~a 2. Tpo~6u~oeo BpeMe (12-17 sec). Yflbnxaea~eflo a) HaranHa ~ o 3 a 5000 E Heparin + npomnxwrentia 1.5 nbTH. MH$y3Mfi 1000-1500 Uh; 3. B p e ~ Ha e CbcMpeaHe no Lee-White (300-600 sec). 6) flpoAbnX#TenHa XenapnHoBa W H $ ~ ~ 1000-1 H R 500 Aa 6 b ~ e non 20 min. MoflM$#qnpa~ MeTon: He ~pfi6ea KanKa KPbB C e nocTaBfi Ha 'iaCOBHMKOB0 CTbKllO, KaTO C Uh; B) caMo HaranHa xenap~~n3aqnfi 5000-7500 Uh; nohnoqTa Ha Mrna ce onpeAenfi nofieaTa Ha nbpaaTa $M~PMHOB~ HMWKa. r) MHTePMMTeHTHa:~ a ~ l ~ ~ a f l 0 3 a 2 5 0 0 - U 50 M0 npe3 0 4. C n e y ce ypwa-ra 3a nofiea Ha xennavpwfi. onpep,eneti# MHTepeanu no 1500-2500 U. n p npeflo3~pa~ece ~ npmara Protaminumsulfuricum, xenapm~m3aqm~: a 2. P e r m o ~ a n ~ KaTo 1000 U Hepann ce ~eyrpann3~pa-r c 1m 1 Protarnin. a) MHMqManHa posa 1000 U Heparin;

npn MHoro naquem C ocTpa aHypm, xnnepxnApaW C T O M HeOCbueCTBHMO. C T ~ H R ~ P T H M aqeTaT, RT TaqHfiTa e no-ronfiu npo6ne~ OT a3o~e~uma. Te nonyrac b ~ b p x an q n a n ~ s paJTsop, e~ qbn60raea mnoToHMfiBaT BbrfleXblApaTHM pa3TBOpU, eneKTpOnMTM,aMMHOKMCeTa H n ~ a n ~ s ~pfi6sa a ~ a Ra ce npeycTaHoeM. llepmo~eanuttu, MacTHM eMyncMM 3a napemepaniio xpaHeHe. MH$~nHaTa amannsaocMrypfiBanponbnxnTenHooTcTpaHfiaa3 ~ p ce a ~pbe, ~ 6nonpony~~n, ~HTM~UOTUUM, ~a3onpecopn He Ha TerHOCTM, H0 npM MHOrO ~ O ~ H C 06H M Tfi e npOTMM AP. 0 6 4 0 ~ 0 KOflMrecTBO TeClHOCTH Bb3JlH3a Ha 3-5 1 3a BOnOKa3aHa (H~J~M.IH~ OflepaTHBHaMHTePBeH~Mfi B KOpeAeHOHOuMe. B CbqOTO BpeMe, 6ae~o M HenpeKbCHaTOOT Ma CbC CpacTBaHMfi, M3raPRHHfl H TpaBMM B Ta3M 06nac~, o p r a ~ ~~ 3p ~d a e ace ~ orcTpaHfiea a eKeuBaneHTtioKonMAuxaTenHaHeAmanrHoCTnopaFlunpnTMcKaHeHagua'ieCTB0 T e C I H O C T M 38 nOmP)KaHeHa BWHMFl6anaHc M Aa $parMa~aOT flMaJlM3HMfi pa3TBOP, nOKmeH IlepMTOHMT, Ce MH$Y~MP~T HOB# pa3TBOPH. %TO TaKMBa flaqMeHTLl ca nepMTOHeEUlHOflfleBpaneHnpo6~e, aOpTeH r p a $ ~ M AP.). c qMpKynaTopHa cna6oc~ B pe3yn~ar OT cencMc, cbpnerl l p aHypMfi, ~ x~nepxn~pa~a Mq ~ ~fp l ~ y n a ~cnaop~a HO-cbpoea H e n m a n r t i m , BoAHoenemponwTeHpnc6a60CT MHoro ~OFV(OFIFI~M ca 6ez1anapa~~~~e, apTepnoeenarrc. Xe~oamanm3ara tie e H ~ ~ ~ - I I O ~ ~ X O nere6e~ ~~(MRT HO3HM MeTOgM3aOCIMCTBaHe. Pa3nM' iHMTe BMflOBeeKcTpaMeTOn. 3a KPaTKHfi nepMOF((2-4h) T P R ~ B na ~C e OTcTpaHM Kopnopantia 6 b 6 p e r ~ o 3 a ~ e m ~ a Tepanlnfi qa ca no~a3arOnfiMO KO~U~eCTBOTeCIHOCTH. Tome H@H~HO~OMCIHO, a HM Ha $MT.121. Te Ce 6 a 3 ~ p a Ha ~4 K O M ~ H H ~ ~ M M :

Cnequt#tuwiumemoguku U npoqegypu 8 cneurwarna meguruwcka nomoq W 55

Tpa~cnop~ Ha s e q e m a
1. flngy3m~ - nplrl xeuounanw3aTa ce ocbtqecTeflBa ~ ~ M $ YHa ~M HMcKouoneKynHM FI setqec~sanpes nonynponyCKnllBa Me~6paHa, pe3ynTaT OT KOH~eHTPa~MOHHMfl rpaAMeHT-pa3nMKaTaBKOHL(eHTpaqMMTe Hapa3TBOpeHMTe BetqeCTBa B KpbBTa M flHMH3HHR Pa3TBOP. Tarn C e OTCTPaHFlKiT HaTpyllaHbTTe B KpbBTa ypefl, KpeaTHHHH, K ~ J I u ~ , ~ a ~ M up. p M3snnra~e~o ~ i Ha TerHocTMnpmnepxunpaTMpaHM 60n~#) ce nocTwra c yrrrpa$wmpaq~fl, npH Komo flBMXetqaTa CMna e rpqMeHTbT B XMflPOCTaTH'iHOTO H M f l ratle. Yn~pa$wn~pauwfl~a Moxe fla ce npoeewa oTAenHo H H ~ ~ ~ B M C G OT I Mx O e ~ o ~ ~ a n (t130n~pa~a ~ s a ~ a ympa$ctn-

~paqnfl). 2. KOHBBKUHR- nplrl x e ~ @ n m p a q ~ n ce ~a ocbtqecTema KoiiBetqMR, T. e. npuAsnmHe Ha BoAa c nepuea~ M ~~ H ~HC T M npes ~ M BMCOKO nponycmwaaM ~ M ~ ~ (xe~ H E M@HIlTbp) B pe3ynTaT OT npeCOpHMR rp4MeHT ( x M ~ ~ ~ o TaTMrHo HanRraHe, noflo6~0 Ha TOM npM rnouepynHaTa $M~paqMfl).Cb3flqeHMfl~OTpMqaTeneH BOAeH 6ana~c C e KOMneHCMparpe3 HH$Y~HR Ha eKBMBaneHTH0 KOllMCleCTBO ~ ~ ~ K T ~ o ~ M T H o ~ M ~ Pa3TBOPM H c M ~ B ~ ~pbB006pbH H tqeHMeT0 Ha ~ O ~ H M F I . 3. K O M ~ H H ~ U H OT Rl H 2 Bxe~o~#a$~n~ -pa CAVHDF ($Mr. 1.21).

IuF SCUF HD CAVHD HE CAVH CWH HDF CAVHDF

= MHTepMbTTeHTHa yn~pa~MnTpa~Hfl = 6as~a npoflbnxmenHa y r r r p a $ ~ m p a q ~ ~ = MHTepMMTeHTHa XeMOpMMH3a = npopbnxtcMTenHaap~epno-se~o3~a xeMoflnancl3a = MHTepulrTemHa xe~o$nnTpaqn~ = npoAbnxMTenHa ap~epno-se~o3~a xeu@~nTpaqu~ = npofibnxmenHa B ~ H O - B ~ H O x~ eH ~~ o$~n~paqw~ = xeuofl~a$~nTpaq~fl = n p o p b n x ~ ~ ea np ~~ ae p ~ o - a e ~ x oe 3~ ua o~#a$~nrpaq~~

pqpq

IHD] pG-]

[iqpqpiq

pqpzq

bi - KPbBeH BXOfl bo- K P ~ B ~ ~H 3x0~ d, - AHmU3aTeH BXOA do- AMaJlU3aTeH M3XOR

U - ympa$clmpa~ S - aauec~eaqa T~~HOCT C - KOHWKlMBeHTpaHCnOpT D - ~ ~ H $ Y ~ HTpaHCnOPT oH~H

56

Cnequ@uunu mernoguku u npoqegypu B cneurnarna meguquncka n o w o q

I l p o ~ b l ~ ~ ~ l Ha ~e neqeHHe n~oc~

1. MHT~PMHT~HTHO ( ~ X ~ ~ H38 ~B noH HFl O KOnKO Yaca): MHTePMMTeHTHa ynTpa$MflTpa4Mfl- IUF, x~Mo$M~Tpaqm - HF, x e ~ o ~ w a n ~ -3 HD. a OT naqMeHTa ce ~asenqa npes KaTenp OT 2. ~ ~ O A ~ J ~ X W T (O~MKHOB~HO ~ ~ ~ H O 2-4 ~ ~ H O H O ~ M F I ) . Kpbe~a $ e ~ o p a n ~ apTepw. a~a n p e ~ ~ ~ npes a e a~ a n KanMnnb ~ ~ R O fl0CTbn B PeH x ~ ? M O $ M C~ nOfl P MaMMflHa ~ e ~ 6 p (a~~ Oa B~~XH 1. Ype3 KaHtonMpaHe Ha apTepm M BeHa $e~opan~c. 0.6 m') M C e Bpbqa O ~ ~ ~ T B ~pbBO06pa~eHMeT0 H O npe3 2. Ype3 KaHDnMpWe Ha ABeTe $eh!opan~M B e H MM n M $e~opan~a BeHa. ~ a A ~ ~ x e cMna q a e AH M noMneHaTa noglcntorMrHa M $ e ~ o p a n ~ BeHa. a $YHKUMFI Ha CbPL(eT0. P ~ ~ M C T ~ H THa HO $MnTbpa C ~ T ~e w m a , an e p ~ e a 6 ~ n ~ ~ e ronm. 1 - b ~A - o p npM ~ apTepnanHa XMnOTOHMFl e Bb3MOXHO aAeKBaTH0 ($Mr. 1.22) OClMCTBaHe Ha KPbBTa. n e r e ~ Ha ~ exunepxMppaTauMma, oTcTpaHmaHe Ha

M3nMUIHMTe eJleKTpoJlMTM, HMCKOMOneKynHM C)rfjCTaHuMM ()'pen, K ~ ~ ~ T M H M TOKCMYHM MH) IlpOflYKlMCbC CpeAHa MOJleKynHa Macs (~H~~OTOKCMHH M pp.). Me~opme,KOMTO pa3WMpFlBaT Bb3MOXHOCTMTe 38 JleqeHHe Ha ~ O ~ H CM 06H, KOraTO KOHBeHuMOHallHaTa XeMOAManM3a e TpyAHO npMnoxMMa, a nepwoHeanHaTa pManM3a -KowpaMtiAMqHpaHa, ca cneptime: 6 a ~ H npogbnm~en~ayn~pa#~mpaqm~ a (SCUF). O c ~ r y p ~yn~pa$nnTpaqn~ ea (2-6 V24 h), pop^ npM Mtioro HMCKO AH M cna6 KP~BOTOK(60 mllmin). MeToflbT e MHOrO nOmO@q npM XMllepXM~paTMpaHM 60nHM C 06H M HMCKO AH, npM KOMTO e H ~ O ~ X O ~ M M O npoaewatie Ha MH$~BMOHHO nereHHe M napewepanHo xpaHeHe.

llpoflbnm~en~ ap~epmo-se~o3~a a xe~o#wn~pa(CAVH). MeTopbT MHOrO ~ a f l o p 0 6 ~Il W pepMUIHMR. Pa3n~~e a~ Bo a 6 e ~ ynTpa$un~pa~, a KO~TO T ~ K e MHoro no-ronm npM yno~pe6a Ha C ~ ~ x Me R ~ o $ ~ n n Toea p . ce n o m r a pea BbseyqaHeTo Ha no-ronm, a a ~ e c ~ s a q o 6 e ~Manonsea . ce e n e ~ ~ p o n ~ ~ ~ o 6 a ~ n~a~~TcB~OpP MH$Y~M B KPbBHaTa ~ ~ H JlHHMFI, Bpbqaqa KpbBTa OT XeMO$~nnpa K ~ M ~O~HMR I l.o ~ t l ~ oe ra no-po6pe aauec~ea~ M Hp Ta 3 ~ ~ pace 0 p Bbaeyqa B ~ p a ~ o o 6 p a q e npes ~~e~ OTfleneH BeHO3eH KaTeTbp. M@y3Mpace M C e OTCTPaHRBa epHoepeMeHtioM HenpeKbcHaTo8-15 V24 h. Uen~a e rpea $MnTpal(MFi (KOHB~KTMB~H T~~HC~ gaO C e ~ OTCTPaHFI T) T nOBeYe 0TllW.iHM npOA)WM OT KpbBTa. M~TOA e~neYetiMe T no ~ 3 6 npM 0 ~ 60nHM c 0 6 H M
UHR

Cnequ+ulrnu memoguku u npoqegypu 8 cncurnama mcguquncka nomoq

57

UupKynaTopHa cna6oc~,npM KOMTO ~ ~ O T ~ M M eR OCHOT ~ eeH npo6ne~. Jlere~we~o npopbnxaea HRKonKopeHoHotl+ffl.

n o p BMWKMR ~ ~ CM nepMea6Mn~~eT aa cpeflttme MoneKynMa p ~ e p ~ o - e e ~ 0x 3e ~~ ao ~$ a ~ n ~ p Moxe aqn~ ycnelutio pa ce npMnara M npM HRKOM ~ K ~ O ~ ~ MHTOKCMK~H H M (M~TOA N? 2 ) ,Tbh KaTO o~cna6aa KOHBeKTMBHMRT TpaHC~ M M .n o ~ x o ~ l e ~ npu q a fleua, KoraTo He paanonaraue c nopT, a ~ e MoneKynM 3 ~ ~ M $ Y H P~ MO ~~ -~ T ~OT Bypema. HO pOCTaTb'rH0 M m b K xe~ocop6ep. MeT0pbT e llOpXO#44npM ~ O ~ H C OCTpa M aHYPMf4 M npoqbnxm~en~a B~HO-B~H xe~@mn~paqm~ O~H~ L(MpKynaTopHacna6oc~, KoraTo XMnepKanMeMnnTa M a30(CWH). Kora~o KPbBOTOKbT e HeWeKBaTeH Ha XenaHaTa TeMMRTa ca n o - ~ 3 p a 3 e OT ~XMnepxMppaTaqMRTa. ~ y n ~ p a $ ~ n ~ p Moxe aq~~ pa , ce B ~ B C I M KpbeHa nouna aa npupsuxsatie Ha KpbeTa. C~~~OBMFIT p o m n e se~a-se~a, llpopnx~~en B~~aH O - B ~ Hxe~oflmanm3a O~H~ T. e. He e HWHO HanRraHe, reHepMpaHoOT cbpqeTo. T a 3 ~ (CWHD). npu M H O ~ O H~CKO AH He Moxeua ce p a 3 . 1 ~~a ~a n o ~ n cb3paea a nonoxmen~o HanRraHe B KpbeHoTo nporonRua a p ~ e p ~ o - s e ~ 0 p3 a~ 3a n ~B ~HanRraHeTo. a Kpb~oCTpaHCTBO Ha $Mmbpa M Y C n O B M R 38 X ~ M @ M ~ T 3a ~~~M T OR K~T e HepocTanreH n e $ e ~ ~ w s ~ o cHa rra xeMopwanMnocTMraHe Ha oqe no-ronm e$ea Moxe pa ce emlow aaTa cnma. Caqem~yea onacHocT OT ~ p 0 ~ 6 0 3 ~ Ha pa~ BTopa (~erneqa) noMna OT cTpaHa Ha ppeHMpaHMR $ M ~ T - xeMoflnanM3aTopa. I l p ~ ~ a ~ ~ s a c ce nsmlorea y r a ~ KpaaHa paT. nOMfla, KORTO OCHryPRBa nPMflBMXBaHeT0 Ha KPbBTa Ha l l p o m n m ~ e n ap~epmo-se~o3~a ~a xe~o~manm3a 6 o n ~ m OT $ e ~ o p m a apTepMR ~a npea x e ~ o p ~ a n ~ 3 a (CAVHD). Manonsaa ce cbqum'$unnp, Kawo npu onMpa BM M ~ o p a n ~Mnn a ~ nopmlorMwaTa a BeHa. Oqe nocaHMTe no-rope MeTopM. T ~TO~I K ce npeepaqaB xeMoflMpo6pe (cBbp3aH0C Ilo-MUlbKPUCK) ea K O CbftOBMRTAOCTbn anM3aTOp, KaTO npe3 X~MO$H~TP~L(MOHHOTO MY npOCTpaC e OCbu(eCTBL4Vpe3 KaTeTPM3aqMR Ha ABeTe $ ~ M O ~ M H HCTBO C e IlyCKa pMUlM3aTeH pa3TBOp B IlpOTMBOTOK Ha BeHM. Kpbma. M3non3ea ce cTepMneH p a 3 ~ ~ 0 3a pnepmoHeanHa p ~ a n ~ 3Uen~a a . e noaMluaeaHe e $ e ~ ~ Ha a~ M $ ~ ~ H O H HMR TpaHCnOpT Ilpe.4 T03M Ha KOHBeKTMBHUR ( ~ M $ Y ~ MM R KOHBeKL(MR- BX. XeMo~MMM3a M IlepMTOHeaIlHa AMallMa n ~ 3 a ~TOM a . ca npepn Eicnwco ~ o a r ~ n a q ~ na o~ ~~ ~ ~i 38). n o T O ~ M HawHce nocTura noewaeaHe KonnqecTBoHeparin)M cafloeu ppex,qaHwi (~eocbqeoTO Ha OTCTPaHeHM MMKM MOneKynM (ypeR, K ~ ~ ~ T MM H H H )HMR (PMCKOT oco6e~o Ha K ~ M R n.9 , KaTo ce npMnara nepMToHeaneH

pa3~~0 (EX. p n e p ~ ~ o ~ e u~anma), a n ~ a npM K O ~ T O fl~$y3MOHHMRT rmHeHT e ~ a h - r o n~~ M ~~. ~ ~ M ~ pa3TBOP HHFIT c p e 6 ~ 15-30 s mumin unM 15-20 1124 h. n p ~~ a CKOPOCT 3 ~ ce nocTMra~ O V T M nbnHoowcTeaHe ~aypema. O T C T ~ ~ H saHeTo OT opra~nma Ha BeqecTsa cbc cpeatio MoneKynHO Terno npM CAVHD e no-uan~o, oTKonKoTo npM CAVH

Te M APylW, nPeflMMH0 HMcKOMOneKynHMBeqecTea, CE npM~ B U X B ~K T~ M pa3~~0pa rpe3 pw$yjnn n yrrrpa$wrrpaqm. G-rcpa~rrea~e~o MM OT o p r a ~ ~ s u crraea a rpea ppeHupaHe (M3~BbpllRHe) Ha AMaJlbQHaTaT e C H lO C T (our. 1.23). Am@ysmmae o 6 ~ Ha e ~ conn Mewy flea p a m p a , pavenew OT nonynponycmwaa ~ e ~ 6 p w ~ aH . HHRT OT TRX e Icpbma, n e p $ y n p a ~ KanunRpme Ha nepmoHeyMa. n p p m p a m p e BaaepeHnm B KopeMap ~ a n ~ 3nepua~. TOHemHaTa ~ e ~ 6 p CE a~ CbCTOM a OT KaIlMnflpeH eHpOTen, 6a3~nap~a MeMGpaHa, npUJleXacau(aCbepMHMTenHaT b K wM MemTenHn m e w Ha nepmotieynna. 3a p a 3 n ~ OT ~a xeuopmm3aTa, KORTO C roneMnHaTa Ha nopme CM OrpaHwaea n a m Ha MoneKynM HWOnpepeneH pamep, nepmmea-

~6Mfl~~eTbT ir ce npouew. Iloan~uam ce n p ocnp ~ nepmo(354,m ~ i(39). r Ananw~wrn pa3~~e 0 6ana~cupa~ p Taw, HMT, HaMWMBa npM $ ~ 6 p o 3 ~ p aAH$Y~MOHHMRT ~e. TpaHCr e na He ce M ~ B ~ M ~ Ye ~T o6xo~~ 3a ~opra~wma me enemn o p npea ~ ~ e ~ 6 p a ce ~ o6ycnaw a ~ a OT KmuewpauMoHHuR ponWM. Te ca no~6pww no CbCTaB M KOllMcleCTBO TaKa, r e rpqMew Mewy AmTa pa3~Bopa.Toh e H~A-BMCOK B tiaraAa ce nmwnie U n o m p x a om~MantisTo nna3~e~ HM 0B~ noTo, cne4 BnnBaHe B KopeuHaTaKyxcrtiaHa npeceHU M ~ ~ M - (~a6n. 1.5). BHF(HO e, ~ M $ ~ ~ M O H TpaHCfl HMF O~ pT . 3a HaT~ ~ T M H ~ M ~ ~ R B ~ C ~ ~ ~ B T O ~ M R C ~ ~ C ~ O p#A ~ ~ M mop F ~ M eM ~m ~ ~ ~ M3 B~H ar Rv B r e~n H e 3a ~ ~K H ~~ ~M R . ffiMpbHCbT npM nnC e M3'iUCnRBa Bb3O C H O B aHapa3nUKmuewpwMme. r p q u e m ~ ce nombpxa cape3 wcro CMeHRHe Ha flepHTOHeBlHUR p3TBOP. nn$y3upa~ 61~~30 KaTa B KOllMrecTBoTOOTcTpaHeHO Eeu(eCTE0C ApeHMpaHMR ~ a l - u a n m MoneKynM: e ypeR (~oneKyn~a uaca 60), pean ~ a n ~M 3 BeqecTBoTo a~ B KpbBTa. [ ~ P U 4-qaco~ npecroh B TMHHH (113), IlMKOVHa KMCenMHa (168), HaTpUh (23), XllOp KOpeMa Ha 2 1 AManM3eH Pa3TBOP, flMUlM3HMm PeeH a3OT

Ta6nnqa 1.5. hjppxaune na enemponm B nepmoneannnn pamop m n n a 3 ~ a ~ Ha a naqnema

(14) e 90% OT tlna3MeHOTO M y HHMBO. n~wo6cTpylaln~ ~ a ~ a ~ e n pn apcee nopbr~am parreopa ~ ace nap~~ a ~ ~ 200-500 UA.ToA ~ece a6cop6~pa OT 3a~ope~~aa~o3a~anp~60n~uc6b6pe ~~ e6 ~Heparin c~ f lp U T O e ) % a lO H M He M C K O TKbpBeHe. CTaTbClHOCTP ~ ~ T B o P ~ T c ~ ~ ~ P x ~ ~ H K e ~ ~H ~ ~ CbU#?CTByM T T ~ H ~P ~ M ~ ~ ~ C~CT~B (natcra~mn K~~ we~a~ C)n . e ahp6upatie~o ~ MMB ~leKora~o naqMeHTbT e HOPMC- WIM XMnOKanMeMMVeH, K ~ M pa3~~opa ce n p ~ 6 am ~~ e 10 mop^^ B KonMrecTso 24 mmolfl. ~a~oAa (Cnephnea6wn~~ ~ ~ C T OT MK~ PM ~ B)npea T ~ nonynpoKP~BOTOK~T B nepmoHeya e cpaementio nocTomieti nycmueara nepMToHeanHa ~ e ~ 6 p aP ~w ax. e q a cma e (70 A0 100 ml/min) M He C e MMRe CbU@CTBeHO OT npoMeHM OCMOTM~HMRT rpquew. 3a waen~ra~e Ha Bogs OT oprawB AH. IlA e npMnomMa n p nauMemM ~ c apTepuanHa xmo3Ma Ha ~ O ~ H HnpOM3BeN(QaHMTe R C(MWU3HM pa3TBOPM TOHMFI, H0 ~$~KTHBHOC~T~ no OTHOlueHMe flenypauURTa Ha CbflbPXaT OnpeAeneHO KOflMcleCTBOAeKCTpO3a ( D M ~ O M P I Manme MoneKynH e 3 ~ a r ~ ~ e nclcna6a n ~ o OT ~ a Ha 3 ~ Ha rnm~o3a~a). PM yro~pe6aHa cramapTeti ~ ~ ~ T B O P , xeMoAuanM3aTa. c b p p x a q 1.5% AeKcTpoa, ympa$~mpay~ma e 50-150 mVh M n U 1200-3600mV24 h, K O e T O HaIlbnHO AOCTaTb'iHO. np~x~nepx~ppa~ 6O ~p na ~ t~ inp~naraparr~opc4.25% c ~e AeKcTpo3a. C ~ ~ ~ , ~ J mnepocMonapmeT ,~HMRT B nepvrotieyMa OTHOWeHMeHa KpbBTaOCUrypFIBaoCMoTM'ieH rpMUem M ympa@mpaqm 300 500 mm. Msanere~a~a BoAa cbppxa p a 3 ~ s o p e ornagwin ~~ npomM, T.e. ocbqecrBUAOW nepmoHeanHa f l ~ a n ~ 3 a BRM ce M Aenypaqwi (~oea ReneHue e H ~ B ~ ~ TKH~ O TO O v a IlA. P ~ ~ T B O 3a PnepmoHeanHa ~T ~ ~ a n ce ~3a .TerneHe Ha pa3~aopmen~" nnM ~otiaetqm).B~HO~HMRT maema B nepmotieyhla M ce ApeHMpa npes BpeMeHeti flpeHEOK OT BMC~epaflHklFI IlePWTOWyhl03 OCblI@cTMBa OT .crmef KaTeTbp, nocTaeeH ~ ~ T ~ O B ~ ~ M rpe3 K ~ WKH O , IlOpTMHaTaCMCTeMa.C b ~ p ~ ~ a c e ~ e ~ C( T ~~ pO oK 3O a- U H R Ha KOpeMHaTaCTpaHa (C@~~~~M~MK~IIHO). ApeHambT M 3a) B AMMM3HW Pa3TBOP ce a6cop6upa U npe3 BeHa IlOpTe peu~$y3~rna Moxe Aa c r a a p b r ~ o M ~ C M MawMtiH 3a np, ce ~ a e e wAMP~KTHO a Br e p ~ u ~ ~ p C ob 6q . e c r ~ y w m ~ o x - ( n o n y a m o ~ a mM rn ~ M~ amouamrHH- .y~~nepM"). IlpopH~CT 3a xUneprnuKeMMR. n p A ~M ~ ~ ~ ~ ce TM yBenMrasaT W m T e n H m a Ha nereHueTo cpepHo e 2, 3 AeHoHoqMR. M H C y n M H O B M T e H)M#l. 403aTa Ha MHCyllMHa ce TOnepMpa 0 6 e m Ha ~ maewaHaTaTeyHmce OnpeAenFiOT pazuepa W cneq~$nr~me WH Ha nwwema. K ~ A MM ~ ~ M ~ H H R Ha nepvroHeanHaTaKyxcrtia. n p B~ ~ ~ P ~ C TTO^ HM e 2000 ml, paJrBop ce npn6aen Insulin: 4-5 U A npn AeKcTpo3a - 1.5% n p ~eqa-OT ~ 500 no 1000ml. ~ M UHKM H npopnxaea 60 WIM 7-10 un n p 4.25% AeKCTpO3a. min. Toh ~mlorea: BpeMe 3a ~nuBatie - 10 min, A M ~ ~ M B H O nopqnonac~oc~o~o6pa3ysa~e ~at$hpmoen ~ a n e epeue (npecrohB ~ o p e ~-30 a ) min, ~ p e ~ a m BpeMe o - 20

cnequ+urwu Memog~kU u npoqegypu 8 cnewwama meguquncko nomow

59

min. Bbeeyqa~e~o Ha no-ronm o 6 e noantuam ~ ~$MMBJlYMeH M CTpaHMVHM O T B O P M C qen IlpflOTBpaTRBaHe Ha Hocrra Ha IlA, HO BWHm ycnometiHR: h n m , yceqatinn 3anyureatie M n M npnnenwe Ha nepwroHeantiM E.HKM. Ha PMCKOM@PT, L(YBCTBO Ha paam~a~e. n o p q npmMcKa~ llpo~bnrmn~en~a a ~ 6 y n a ~ o llA. p~a AH~~M~H paMR He Ha uwa4pama~a HacTbnsaTaxnntieR M ~ o UMxaTenHa p ~ 3TBOp C e HaMMpa IlOCTORHHO B KOpeMa, K a T OC eC M e H R 3,4 HeflOCTaTb'iHOCT. RHeBHO Ype3 RpeHW M peMH@y3MFi(no TpaBMTa4Mfl, 6 HaWlOTO Ce 3anO'iW C no-MmbK o 6 e Ha ~ BneTMR 6e3 anapa~). p a 3 ~ ~ 3a 0 pWanTaqHR Ha naquenTa. Mnoro HenpMmHo e llponbnxnren~a UnKnHrHa ( . q ~ ~ n e p " - a c ~ c ~ ~ p Bb3HMKBaHeTO Ha U ~ e ~ ~ ~ n e f ~ KOraTO e ~ BbBeflea ~ ~ 3 b ~ , U~anw3a~a nn. aanorea Berep, KoraTo naqMemT ce HMRT pa3TBOp He MOXB pa 6bfle ppeHMpaH. Toea CTaBa now^ sanytuea~e,npenaatie Ha c ~ ~ n e ~ - ~ a M ~ n M enpa C)'lpMHTana~eHlbTCe M3KJltOqBaOT MFiUIMHaTa,K a T O My C e nonenmHeno oTmpwe MY H ~ ~ M ~ P M H O Hanenn. BM Yec-ro npecetipa3~~0p. T O ~p M a 3 ~ ~ ocTasa 0p B KopeMa C e HaJlara KaTeTbPbT ga 6bfle CMeHllBaH. M ~ ~ ~ H ~ H H C K HBbeewa FIT npea 4 e n ~ ~ R M ece nM~XB~P Berep ~ R npeRMmane, KoraTo nepcoHan, K O ~ T O npoBewa nA, ~ p ~ 6 fla ea e sanoa~a c~ qMKnepMawMtiaTaomosoce sKnnrea. BcMrmacnem Ha nereHMeTo. C b q e c ~ ~ B~BMOXHOy~a~ M ~ ~ e p ~ n nepnToHeanHa ~ e ~ m a nnanwsa(IPD). naCTM 3a XMnOBOneMMR M apTepMaJHa X M n O T O H M R IlOpWM UMeHTbT C e CBbp3Ba C MaWUHa 3a nd,O ~ U K H O B ~ H 3a O 10ronma y n ~ p a 4 ~ n ~ p 3a~oaa a q ~ ~ .~ p ~ 6 e ga a ce B O ~ M racoe nepMofl, no speMe Ha KOWTO P ~ ~ T B O P ce ~ BbBeyqa T TO'ieH 6ana~c Ha BnRT M UPeHMPaHpa3TBOP. CbqecTByW U UpetiMpa6bp30 (Ha BceKM30 rnin). Ceflnn~rtto ce npoeeOnacHocT OT mnoKanMeMMR U x ~ n o n p o ~ e # ~ e Ka~~~,nW y q a4 ~T ~ K M ~ Be ~ n y p aA~ ~ ~~ ~o . MO ~ CT H~ ~ .cfl B~ T Mew TO pa3TBOpbT He Cbflbp)t(a KNIM~, a IlepMTOHeyMbT e gy TAX, J l e r e ~ ~ ce e~ npoeewa o B qewpoee no nepwon p o n y c ~ 3a n~ 6~ e m q ~Heo6xouw~ . e na60paTopeHKOHeanHa guan~aa. HTpon M npw m a 3aMecTeaHe c nouxouflqo KonMrecTHa nepmoHeanHa flnann3a ca H;W114 OT 60n~wre C 00. B T ~ M C M~ XMf H lOTepMMR ~ C e na6n~flaea~, aK0 pa3Txpowrna 6b6pe'i~a HeflocTanwocT B qenw CBRI, a B ~ o p He b~ e npeflBapnTenHo 3aTonneH. n p anapaTHaTa ~ tjbnrap~fi 3a 1994 rog. T e ca oKono 20. nfl TeMnepaTypaTa Ha pa3nopa ce nombpxa Ha 37C. A p y Bb3MOMHM ~ MH4MfleHTMC a XMfleprnMKeMMfl npM UUa~~TMU (EX. M no-rope) M n M n p npoflbnxn-rentta ~ yno~pe6a 1. npI?flWp~enHM KOPeMHMOneP4MMCnepMTOHeanHM Ha pa3TBOp C BMCOKOflpo4eHTHOCbmpXaHMeHaueKCTpoCpacTeanMfl. 3a M nePMTOHMT (npM rpeUKM B aceflTM~aTa). 2. KO~~MHMV~M, meyc,a6m~~~an~~xe Ocsen n p nerenMe ~ Ha 6 0 n c~ 06H ~ ocTpaTa nepmo3. Hanpefl~ana ~~~M~HHO rOlleMM C T , ~OnHKMCT03HM HeanHa ~ ~ a n n Moxe s a Aa ce npnnara H B ToKcwKonorn6b6peq~. rHaTa npamlca. npes nepmoHeanHaTa M e ~ 6 p a ~ npea 4. M H ~ K ~ Ha M KoxaTa M Ha KopeMa,noKaneHnepcl-roHUT.

MMKa M OTrOBapR Ha 118 fl0 114OT Ta3M H ~ x ~ M o ~ ~ M ~ M Bce naK nu m a m cpegcm Ha ~ 3 6 npu 0 ~ M ~ K hew M (n0~M rpa4MnHM KpbBOHOCHMCbfloBe) M Bb3paCTHMna4Memn c n p o 6 n e ~ e cbpoe ~ ~ o c n nnpM , KOUTO xe~o~nanu3HOTO neretiwe e HenpMnomMo. X p o ~ n r nepmoHeantia ~a ~manmsa. TRce ocbqemBRBa rpe3 TPeH KaTeTbp, flocTaBeH OnepaTMBHO B IlepUTOHeanHaTa KyxuHa. T O W e c pa3n~'i~a m ~ a no-ronm ,

MycKynaTypaM enacTMrHocT HaKopeM~ E I T5.Orcna6e~a ~.

H M T e CTeHM. 6. EflpM XOpa, R P M KOMTO IlepMTOHeaJlHaTa IlOBbpX~ m cRBRW e ommenHo n o - ~ a n oTTenecHaTa ~a noebpxHCCT. npMT R X C ~ U ( ~ C T B ~ B ~ B ~ ~ M O 3a X H HO ~C M TX nepUT0I~H HeanetiK ~ M ~ ~ H nC pM o mH ~~ H ~ ~ ~ O C T ~ T ~ C I H O U M Ao6pn~e pe3ylTTaTM OT IlepMTOHeanHaTaflMallM3a 3aBMCRT OT IlpaBMnHMR nofl6op Ha ~ O ~ H M T ~ .

60

Cneyu+uqnu ~ e m 0 g ~ k u LI npoqegypu B cnewnamo ~egII~IJrtck0 noMou(

Ilnaa~a@epeaa~a (nna3~a3a~~ plasma ~ a , exchange) e MeTop, npn ~ o h o KpbeTa ce pa3pen~ Ha O C H O B H M T e h KOMnOHeHTM. T R HaMMpa IlpMJlOXeHMe npa ~a h n n s a ~n ~~ p ,~owro ~ ce Hanara n n a a ~ a ~ Ha a hn~nM n ~ pmeHa M ~ e h cbcTaeKa ~a Aa 6 b ~ e nopMeHeHa; Mnu KoraTo B neVe6HaTa npamwa ca H J ~ K H roneM MM M a C H neBKOqMTM, T P O M ~ O ~ M T H M PP.

1. OCTPM O T P a B R H M RC (~M~HIITMH, $~J~oMAMH a n y u ~ ~x~ ph o ,~XMHM~MH, , nponpationon. 2. Crush-CWH~~~OM, HeTpaBMaTMWa pa6~o~uonwm

KPMBaflpMO~BbpnRHeHaTpaHCflnaHTaHTa.

3. ABO-H~C~BM~CTMMO KpbBOnpenMBaHe, aBTOMMyHHM X e M O n M T M C H l M aHeMMM.

I. ~ ~ H T ~ O @B Cnel(MmH0 ~ X H ~ ~CT~O~CT (KaM6aBO Ha) 225 cm3 Mnu 375 cm3 ~ p b e ce qett~po$ympa~ npu 5000 s.mirrl. B aaenwMocT OT MacaTa CM pamuwuTe eneMeHTu Ha KpeTa ce yraRBaT Ha cnoeee, KaTo nnaauaTa ce oTlenR ~ai-o~rope.

Ilnaa~aNpeaa~a ce npmara oqe B: ~e$ponomma (MM~HHM M asTouMyHHu rno~epyno~e$pwrw), xeua-ronomma ( T ~ ~ M ~ O ~ M nypnypa, T O ~ ~ napanpoTenHeMnu, HMVH~ TP~HC$Y~MR Ha K P ~ B H M e n e ~ e ~Heeponomma ~~); (MM~C T e H W R rpaBMC, 6onem Ha P ~ ~ H o eH~OKPMHOnOMfl ), Ta (TMpeOTOKC#KO3a, MMKCeAeM, ManMrHeH ~K~o$TW~M), rampoeHTeponomma, 60nec~ Ha Crohn, VepHopp06Ha KoMa, xonec~am), pepuaTonomRTa(ncopuas~c, neu$nryc), OHKonorMma ( ~ a n ~ m T~MOPM). e~n

II. M e ~ 6 p a (nna3~a@mmpaqmt1) ~~a - KpbeTa npeMMHaea npea M ~ M ~ ~ ~ nnaauacenapa~op~ H H M (ueu6paH M T e ca OT nonMnponuneH M n w qenynoseH p ~ a q e ~ c a~) roneuMHa Ha nopnTe 10-200 nm, noa~on~saqn oTpenRHeTo Ha nnaa~a~a. Bnocne~mene N p ~ e ~ weneuemM re ce p e ~ ~ $ y 3 ~ - Konanc npu Hewetmarno O ~ ~ M H aO a ~ e c ~ Ha ~a paT meAHo c WeKaaTHo KonMremBo n n a ~ ~ o 3 a ~ e m ~ a q ~38necle~a~a nna~a; pa3~~0 -pxy~aHan6p~H, nanttoqeHHa ~pba,nnaaua, - BTpucaHe, $e6p~nwre~, a ~ a $ ~ n a peatqw ~ ~ w uB O ~ H O - e n e m p opanaopu. nu~~~ BnusaT ce 6en~bqHM aa~emaaqu paa~eopn; - mry6a Ha enemponm c p a a s ~ Ha ~~ xunoKanqMe eMMR, XMnOHaTPMeMMR, XMflOKanMeMMR; 1. K ~ c Knnaaua$epem~ H ~ oTAeneHaTa nnaauace -XMnePTOHMR,CTeHOKaPflMR,CbPpeClHaHeflOCTaTbCInpetcapeanpea HmonKo Me~6paHM c pa3nnre~ p~auenp HOCT, 6enoppo6e~ OTOK; Ha nopMTe no^ c$op~a~a Ha KacKma. TaKa n n a a ~ a ~ a - nep$opaq~~ Ha $ M ~ P M Ha T$~mbpa; ~ ~ ~ $ e p e ~ q ce ~ p aa ~~ oe ~a n~ (D~~K~ cnopep M M roneuu- K0ar)TIaqMOHHM HapyWeHMR. HaTa Ha MoneKynwre. Cnep nposenqqaHe Ha nna3ua$epeaa~a MoraT pa ce 2. Ilna3ua~p~o$nrrrpaq~~ - npn noHnxawtie Ha nomm xunonpoTeuHeMnR, X M ~ O ~ ~ ~ ~ M HnpoMeHM ~ M M R , TeunepaTypaTa ce o6paayaa~ npeqnnwraTn, KOMTO ce B KOarynaqMOHHMRC T ~ T ~ C - T ~ O M ~ O L ( ~ ~M TIl O pOMeHM ~~HMR $~mpnpa~, a WaHanaTa nna3ua cnep a a ~ o n n ~ ce ~ e B KOalJ'na~MOHHMTe$~WOPM, M3BnMVaHe Ha MeAMKaMeHspaqa OTHOBO B opra~ua~a. TM 3aepHO C nna3MaTa, M H $ ~ K ~ H YCnOXHeHMR. O~HM 3. M M ~ H O ~ C Onnaaua~a ~ ~ ~ Mce R neWy3~pa npea C b p o ~ ~AocTbn m M xenapn~~aaq~ma ca caqwre ~ e ~ 6 p a H Hoceqa a, atmrena M n M amMreHM. no T O ~ M Kamo n p ~ npoeenqqatie Ha xe~opuanuaa.OCHOBHMR HarMH OT o p r a ~ ~ a u ce a H ~ B ~ M amreHM, V~T aHTwrena, n n a 3 ~ 0 3 a ~ e c paa~~op, ~ ~ a q KO~TO ce npmara, e 100 ml UMK. 20% xy~aHaJl6yMMH B 400 ml PMHrep.

Cnequ#wrnu memoguku u npoqegypu B cneurnarna meguquncka nomoq

61

X~MOCO~~ VC) ~ He R MeTOfl T ~ 3a M3BbHTeneCHO ( $ ~ n ~ bpa3flen~q p, ~ p b s ~a ~a nna3uaM $op~ettu enenneOClMCTBaHe Ha KpbBTa OT TOKCHClHM C ~ ~ C T ~ H I # IKpbBTa M. HTM)M nna3~acop6ep( ~ ~ H R Kawo T , npM KXn). 3a Ha oTpoaeHMR ce cr3eewa npe3 epeMetieti cb~oe pocnn Kpamo BpeMe (1-1 112 h) ce flpeHMpaT 2-3 1 nnaaua. He e C nOMOqTa Ha KpbBHa nOMna, IlpeMMHaBa npe3 XeMOCO~eo6xofln~o n n a 3 ~ 0 3 a ~ e c ~ ~Ta ~ tie KaTo A, Qwn~p~pa~a p6ep M C e BpbU.@ IlpeClMCTeHa B K ~ ~ B o o ~ ~ ~ ~ ~~a H u ~ THe oce . uaxebpn~. nna3~a TRce nep$ysupa npea ~ap6oE$~KTMBHOCTT~ Ha MeTOfla 3 a B M C M OT: KOH4eHTPal#lRTa cop6epa n ce BpbLqa 06paT~0 B qMpKynaqnRTa. He ce Ha HOKcaTaB KPbBTa, ~ $ H H H if TKbM ~ Tcop6epa, ~ aKTMBHaHapyIllaM ~ ~ ~ T ~ C ~6ana~c H M R T B KpbBTa. MeToflb~He Ta nosbpxtiomM s ~ a ~ a c o p 6 ~ p aBeqecTBo, q o ~ o KP~BHMJI HauMparonmo npMnoxeHMe nopqM H ~ O ~ X O ~ M M O C I T ~ O T A ~ ~ M OT T . 3HaVeHMe ~ O C O ~ ~ H O C T BM TOKCOKMHeTMKaTa T~ nomomq anapaT 3a nnama$epe3a M no-BMCOK~T~ CM Ha cy6cratiq~wre.HF~KOM BeqecTBa w M a T ronm 0 6 e Ha ~ CTO~HOCT. O C B ~ TOBa H TO^ OTCTbnBa no ~$~KTMBHOCT Ha nKatitio pa3npeuene~~e. Aop~ in vitro Aa c a cop6~pye~aon~pa npmarawe ~o nnasue~ o 6 ~M e ~~ ap6oxe~oMM, Ha npatcrma e $ e m ~ OT XC e MclHMManeti, nopqM nep$y3~~.3ary6~a ce OCHOBHOTO npeflMMcTBo Ha nna3CBbp3BaHeTO MM C nna3MeHMTe 6 e m q M ~n M TbKaHMTe. MeHMFl06MeH-0TCTpaHRBaHe Ha MaKpOMOneKyJlM(TOKCHOc~oetiwre, a6cop6mpa~ maTepHanH ~ ca cMonMTe H M T e CBbP3aHM C 6en~bq~). 3a 4 h nna3~acop6qu~ npe3 U aKiM!MpaHMRT BbrlleH: ~ap6onep$ysopa npeMMHaBa 8-12 1 4Mn~p~pana nnaa~a. 1. ~ O H O O ~ M ~ AeTOKCbl H H ~ KaqHR. O C H O B ~ C e BHa ~ 3a c b q o ~ o BpeMe (240 min) npM KXn c R ~ ~ 200 M T mllmin $aKia, ye norbnHaTMTeToKcnvttM BeqeCTBa B opratiu3~a ce nep$y3~pa~ 48 1 ~pbe. C e AMC04MpaT Ha c n a 6 ~ KWCellMHM M OCHOBM. ~ ~ M ~ o x ~ H M - H a h - r o n ~ npunoxeHMe ~o e cneurtiaTa ToKcMKonorMR eT0 Ha XC C ~ O H O O ~ M ~ HC H M G O n I M 4enM OTCTpaHRBaHeTO HaMnpa x e u o c o p 6 q ~ ~ c .~OKPMT" ~a aumeti BbrneH ($MT. MM OT L(MplcynaqURTa. CHHT~TH'-IHKT~ CMOnH (~OHMTM) Ca 1.24). npll HeR FpaHynMTe Ca O ~ B M T H C ~Moc~BM~CTMM TBbpRM rpaHyllM C IlOnMMepHa CTp~lcrypa,CbflbPXaqU (qenynoa~a) ~ e ~ 6 p aTR ~a npeflnaasa . 4opue~~ ene~e AOHO~~HHH rpynM, cnoco6nn 3a o 6 ~ Ce UOHW, ~ HaMMpaqM MetiTn OT KoHTau C BbrneHa. M e ~ 6 p a ~ e ac ~~ ae 6 e n ~ ~ C e B KPbBTa. n0flpa3@n~T C e Ha K ~ T M ~ O H M T ~ HH , H~OHMTM OT 3-5 pm M nopM c paauep 450 pm, KoeTo n o 3 ~ o n ~ s a M ~O~H~M@ (cbflbpxaq~ ~ ~ M T M eflHOBpeMeHH0 M flBaTa npeMHHaeaHe Ha ToKcMvHMTe MoneKynM npea HeR M norBMfla rpynbl). 3aeflH0 C ~ O H M ~ M ~ TOKCMVHM ~ H H T ~ ~eTa60IlbqaHeTOMM OT BbrneHa. ~ P Te3M M cop6epu HaMNIRBaT n M T M OT KPbBTa C e ~0p6bIpaT M PeflMqa XM3HeHO H ~ O ~ X O CTPaHMVHMTeRBneHMR3aCMeTKaHaM3BeCTHOOrpaHMVaf l ~ h n M OH# (K*, CaU, Nat, Cl-M flp.). Toea M npaBM saHe cnempa Ha npMnoxeHMeTo MM. Ha ~a6n.1.6 ca HenoAxoflnqn3a KnntiMwiaTanpanwa. H a ~ ~ p a ~ n p n n o - nOCOVeHMM3BeCTHMTe cop6wpye~t.1 TOKCMVHM HOKCU, Oqex e w e npM npeclncTsaHe Ha BoflaTa 3a x e ~ o ~ u a n ~ 3 a . Hem cnopefl cTeneHTa Ha orwcTsaHeToMM B 5 KaTeropMM. 2. A ~ 6 e p n m XAA-4 e CMOna, KORTO OTCTpaHRBa Hah-fl06bp ?$emC e nOny.laM npM MHTOKCMKaqMMC ~ e h o ~ n s c r p nnno$wn~~ a~~, (M~CTHO~~~TB HOKCM O~MMM ) BeqeCTBa, BKnDVeHM B KaTerOPMMTe 1,2.3a Te3M OT 4 M KaTo eTxnopaution, rny-reTnMnfl, ~ e n p o G a ~MeTamaa~, 5 np#noxeHMeTo Ha KXn He e onpaeflatio. PMCK~T OT noH M flp.). npoaexp,aHeTo h ~ u x e b p n orlaKaaHlrR ~ TepaneaTweH 3. Kap6oxeuonep@ysn~ (KXn). Xe~ocopbq~rna c e$eKl. Bb3M0XHMCa YCnOXHeHMR, CBbP3aHMC OCbqeCTamBen BbrneH e ocHoseH MeTofl B neveHMeTo Ha Texm BReaHeTo Ha cbloeng Aocnn M npMnaraHMR xenapMH, eK30reHHH MHTOKCHKa4MM.BbrfleHbT M M a IllMPOK qcop6xeMopamM, MacweHn xeMaToMM, p y n ~ y p M~ nep$opaq~~ UMOHIH CneKlbp. O T C T ~ ~ H h0HM3MpaHM RM H H~AOHM~MHa cbflose, xeMo- M ntieeMoTopaKc M flp.), apTepMantia paw, n ~ n o $ M ~X nM ~~ ~Y @ ~ TOKCMVHM HM C~~CT~H~MM X M n O T O H M R (npM C O P ~ ~ MHa R Ba30aKTMBHM c ~ ~ C T ~ H ~ M CM: cpeflHa (300-5000)MoneKynHaMaca. Kora~o ce ~3noM H $ ~ K Ha ~M CbflOBMR M flOCl%nM A O p M flMPeKTH0 BbBewan3m .neno~pnf'BbrneH, xe~ocop6q~ma ea ~ a r ~ ~ e n ~ a He , Ha MMKPOOPraHM3MM B ~pbB006pa~eHMeT0, XMnOTepHO cbqecTByeaOnaaiocTOT nonqaHe Ha M ~ K VacTMqM M MHR ( B ~~ Bp b 3C ~npomnxnTenHaTa a eKcTpaKopnopanHa Ocee~ TOM B npoqeca Ha c o p 6 q ~ HacTbnm ~~a ana~~senHa rpaeMaTH3aqMR Ha ~ O ~ M ~ eneMeHTM H M T ~ c penyKu#R H~TPOM~O~H (PO TM 30%), JleBKOneHMR (fl0 10%), XeMOpaMClHH HH~HfleHTH H M H $ ~ K ~ M YCnOXHeHHR. O~HW llna3~acop6q~ e~ KOM~HHHPBH ~a MeTOfl Ha fleTOKCMKaUMR, qenR4 3ana3BaHe Ha KPbBHMTe KlleTKM OT KOHTarn C BbrneHa. H e 0 6 x o f l n ~ca ~ nna3~acenapa~op

HoeM racTnwn, anepmwM peaKquM K ~ M c~ep~n~3~p HHR C eTMneti OKCMA xe~ocop6ep. H e q e m a ~ ~ xenaa~a pHHM3a4HR BOflM ~ O ' T P O M ~ O ~Ha H ~ cop6epa ~ H ~ M/M~M KPbBHMTeJlMHMM. n0BMIlleH0~0 HanRraHe BTaKMMCny'-IaM B O R MflO pa3'-IfleHRBaHeHa KPbBHMTeIlMHMM M n M nep@opa-

~MRC~~e3an~aM06#n~a~pb~3a@a(fle
~an o ~ n e a 200-300 mllmin). K O ~ ~ KXn T Oce ~swpluea OT

62

Cnequ+us~umemoguku U npoqegypu B cnewnama meguyuncka nomoq

~

X ~ M O C O P ~ ~He MF M3WIDrBa IT~ W l a C M C l e C K M T e MeTOnM 3a AeTOKCMKauMR. TR Ce npeflLUeCT8a OT C T O M a W H M npoM M B K M ,O V M C T M T e n H a KJlM3Ma, P e a H M M a u M O H H M MeponpMRTMR, BmmrMTenHo OT anapaTHa BeHTMnauMR ( n p ~ HWfla), $opcMpaHaflMype3a (oco6e~o aKOTOKCMrHaTa HOKCa M M a 6b6pere~ WIHP~HC), aHTMAOTM, OpraHOnpOTeKTMBHa Tepanw. nMnca Ha e4eK-r OT npmoxeHoToMHTeHaM-

PM

KpbeHa nohnna, OCMT~PFIEI~M nocMeHHo 1113~ern~~e C nep4y3MpaHe M BpbqaHe H a KpbBTa. M36opb~ Ha xe~ocop6epa ce npaeM cnopefl ~ 0 ~ 6 4 O H H a T a nOBbpXHocT M TeXHMCleCKaTa My XapaKTepMCTMKa. H e o 6 x o ~e ~ Aa ~ oCe Cna3BaT yKa3aHMRTa B YnbTBaHeTO 3a npoMMsaHe M x e n a p ~ ~ ~ 3 a q ~l r P x ~ap60nep@y30pMH Te ,,Clarc" BbrneHbT e 0 6 8 C ~ XenaPMHCbflbPXaq ~ XMAPOren. n p e yno~pe6a ~ ~ ~ ocel c ~ e p ~ n ~ c 3 naptto ~ p a armKnaawpaHe. npw .Ericau M .Hernosorb" H e ce Hanara npeABapMTenHO npoMMBaHe C rntOK03eH pa3TBOP M T. H. HaC

BHonecleHMecenpaeMseHenyHwRMneplcyraHHaKaTeTPM3auHFI Ha rOnRM BeH03eH CbF\ ( B ~ H H T $~M o ~ ~ I ~ M c , rorynapuc nHTepHannMC ~ ~ W ~ ~ Bno MR M )~ T O ~a R~ Seldinger (EX. C b ~ o e nocnn npM cnewa x e ~ o n ~ a n ~ 3HaAa). nonxomuuc a ~ e o l ~ o n y KaTeTpM. ~ e ~ ~np# ~~ nMnca e Ha Tame ce npaaM BTOPM C ~ A O BAomn (3a apbqatie Ha OclMCTeHaTa KpbB). ~ Y H K T M P CB ~K)~MT~J'I 6eHa H ~ C fl~al'lkl3 ~ Mrna a M n M ce abeexqa BTOPM KaTenp B eAHa OT M36poeHMTe B e H M . npM HMMclMe C a M O Ha eflMH CbflOB Aocnn (c eponyueHeH ~ a ~ e n Mtioro p ) nomoyqa e X~MOCOP~~ CM anapaT R 3a "Single-NeedleU~#anu3a. AnapanT e cHa6fleH c yc~poAc~ao OT KnaMnM nnM paoA~a

~eon p ca c ~ e p n n ~ 3 ~ p ca eTMneH ~ w OKCMA. n p e yno~pe~ ~ 6a pa3TBOpbT T P R ~ Aa B ~ Ce O T C T p a H M , a ~0p6epbT Aa C e npoMMe c r n l o ~ o 3 e M~x e n a p n ~ ~ 3 ~ @ p~ as ~ lronomre~ Pa3TBOP. COP~L(MOHHMRT M y ClleKTbp e nOKa3aH Ha ~a6n. 1.6. E$~KTMBHOCTT~ Ha cop6epa HaMallRBa npM ~ a e n ~ s a H e ~ a a b 3 ~B yHero x ( ~ e n p a e ~ n ~ o c b r n e Ha ~~ Ka ~a ~~ Be HMTe nMHMM M rPeWKM B ~ ~ O M M B ~ H ~ TM O n M ) ~p0~603~pa
(H~~~KWT xH en Oa p ~ ~ ~ a u p a ~ e ) . 1/13noIl3Ba~ Ce KpbBHMTe n M H M M M KpbBHaTa IlOMna Ha anapaT aa xeMopnannaa. Cop6epb~ ce nocTaeR B ~ sepB T M K a H a n03MuUR. K ~ A M O n H M RM y ~ p a (BxoA~) h Ce Cbclne-

Cnequ$turnu M e m o g ~ k u~ npoqegypu B cneurnama ~ e g u q u n c k a noMow

63

Ta6nnqa 1.6. Ollncrsa~eHa w e j v ~ m r n n mmHw r p m ~ a p 6 m c e ~ o n Adsorba e ~ p Ha gnpnra~a Gambm

Substance Acetaldehyde Acetaminophen Acetic acid Adriamycin Alcohol Allobarbital Arnanita phalloides Arnitriptyline Ammonia Amobarbital Amphetamine Arnylobarbital Aprobarbital Barbial Barbiturates Benzene Benzodiazepine Bromide Bromisoval Butabarbital Butanol-l Butobarbital Camphor Carbamazepine Carbon tetrachloride Carbromal Chloralhydrate Chloramphenicol Chlordiazepoxide Chlorprornazine Chloroquin Codeine Colchicine Cyanide Cyclobarbital Category
3
1

Substance Dextropropoxyphene Daizepam Dapsone Dibenzepine Dichloralphenazone Diethylallylacetamide Diethylpentenamide Digitoxin Digoxin Dimethoate Diphenhydramide Diphenylhydantoin Diquat Doxepin Ethchlorvynol Ethyl alcohol Gluthetimide Hexobarbital lmipramine lsoniazid lsopropyl alcohol Levomepromazine Meprobarnate Methadone Methanol Methaqualone Metal ions Methsuximide Methyl alcohol Methylparathion Methylphenobarbital Methyprylon

Category

Substance Organophosphates Orphenadrine Oxazepam Paracetamol Paraldehyde Paraquat Parathion Penicilline Pentobarbital Phenantoin Phenformin Phenobarbital Phenytoin Primidone Propoxyphene Quinalbarbital Quinidine Quinine Salicylate Secobarbital Snake poison Tetrachloroethylene Tetrachlorornethane Thallium Theophylline Thiopental Thyroid Hormones Thyroxin (T4) Trichlorethanol Ttichloroethylene Trichloryl Triclofos Tricydic Antidepressants Triiodothyronine(T3)

Category 1 2 4 1 3 1 1 1 1 2 2 1 1 1 4 2 2 1 1 1 5 1 1 1 1 4 1 1 2 2 2 2 4 1

5 2 5 2 1 4 5 1 2 1 , 2

4 4 1 2 2 1 1 1 4 1 2 1
4 4

2 1 3 4 5 1 1 3 1
3

1 5 1 1
4 1 3

1 1 1 2 1 4

3 1 2 5 1 5 1 5 2 2 1

4
1 3 1 5 2

HRBaapTepManHaTaKpbeHanwHwR,n p e ~ e a p ~ ~ e n ~ o a a n b - BpeMe Ha KXn) M 2 1 x e n a p ~ ~ ~ 3 w (no pa 2500 ~ UA) Natrii ntietia c p a 3 ~ ~ 0~POMMBHURT p. p a 3 ~ ~ npeMnHasaoTflo0p chlorid 0.9% &c c ~ o p o 50-1 c ~ 00 mllmin. n p 3anovBaHe ~ ny Harope 3a M ~ ~ O H Ha B ~ cnyclaino H ~ nonwtianM ~ b 3 ~ y - Ha KXn B apTepMannaTa nMHm ce Bbeewa 2500 U L I H H MexypqeTa. npenopbveace apTepuanHaTanwHuRfla Heparin ( ~ a r a n n floaa). a H y m ~ l a OT ~ aHeparin e no-ron~MMa Bb3fl'jXOynOBMTen. ~ P O M M B K ~ Ce T npaBM ~ C 500 rnl Ma OT Ta3M npM XeMOAMaJlM3aTa, TbA KaTO BbrneHbT WSol, glucosae 5% (3a n p o $ ~ n a ~ ~na w xMnornMKeMMR ~a no copbpa racT OT Hero. n o ~ q b p x a q a ~ a oaM a HawHaT

64

Cneyut#wvnu memoguku u npoyegypu B cneurnama wcguquncka nomoq

Ha npMnoxetiMe ce n 3 6 ~ p nttpnenmanHo. a~ O~MKHOEI~HO Ha B C e K MWC C e IlpaBRT no 1000-1500 U Heparin flop KOHTPOn Ha BpeMeTO Ha CbCMpBaHe, KOeTO ~ p f l fla 6 ~ e MeWy 20 M 30 min.

Typa, capnertia u e k o c ~nync, , AH, pwwaHe. Ha aceKM 1 h: napaMeTpMre Ha xeMoKoaryna4ma. Aea claca npepM npeKpaTReaHeHa KXll, O ~ M K H O B ~ H O Heparin He ce npaeu, nopa,q~ nponotimpatinR MY e 4 e ~ l~l .p Hyx,qa ~ ce npam Protaminum sulfuricum cnep ~ s ~ n l o r s a ~1 eml(5 ~ o . 000 E) ce ~ e y r p a n ~ a ~ cp 5a ml Protaminum sulfuricum.

KO qaca - ~o ~ a n ~ a Ha a~ ~O e~HM OT RK O M ~ T O ~ H C~CTORO H M e MflH P O CHMXaWHe TOKCM'iHOTO HMBO B KPbBTa p0

A~TOKCMK~~MFIT~ Ha OpraHM3Ma flpO~bflXaBa HRKOn-

1. Bnoluaea~e Ha CbCTORHMeTO, BbflpeKU IlpOBeWaHOT0 U0 MOMeHTa a K T M B H O JleqeHMe. 6e3onac~~ rpaHMUM. KXll C e IlpeKbCBaIlpeWeBpeMeHHO flpM YCnOXHeHMR (H~A-WCTO XeMOPaM'iHM H H ~ M ~ ~ ~ H T M ) .2. llpono~mpa~a Koua. [PM ~p0~603MpaHe ~0p6epbT M nMHMMTe C e 3aMeHRT C 3. llornbqa~e M p e 3 o p 6 Ha ~ ~neTanHa ~ posa. H ~ M HOBM. l l p npopbnmenHa ~ yno~pe6a ( ~ 3-4 m h) Hacm ClMeHaOflaCHOBMCOKOHMB0HaOTpOBaTaBKpbBT~. nea HacMqatie M HaManRBaHe Ha e 4 e m ~ ~ ~ o cBb3~0na. 4. Temo flpOTM'iaqa HHTOKCMKa4MR C IlpOflBM Ha XHO e fl0pMRHaTa Ha cop6epaC HOB. nopa, 4gqno c e o 6 o ~ a XM~OTOHMR, antieR, XMnoTepMMR (Bp e 3 y n ~ a OT ~3 a c ~ r a ~ e BaHe Ha TOKCMHH OT TbKaHMTe C IlOBTOPHOflOBMWaBaHe Ha Ha CbOTBeTHMTe M03bVHM ~ ~ H T P O B ~ ) . nna3~e~0 MM ~ HMBO 0 M BnowamHe Ha CbcToRHMeTo ce 5. l l p ~ Ha e~ C~GCT~HUHM C ~ C 3a6a~e~ TOKCM~HOCT a HXlara flOBTOpHa KXn. A ~ ~ T ~ ~ H ~ PelueHMe TMBHO ( ~ ~ ~ O M napa~sa~). RMH, flpOmnmMTenHax e ~ o c o p C 6nep4y30pl ~~~ npwexaeaq ram6. Tema MHTOKCMKa4HR C BeqeCTBa, 3a KOUTO e ua e4emwa~a noebpx~oc~ M HMcKa HacMqaeMocT. VlanoM3BeCTH0,cle C e OTCTPaHRBaT no-6bp30C eKCTpaKOpnOpan3ea~t1~e OT H ~ Adsorba C C150 (sapeqa) M Adsorba C300 nHauenypaUMn,oTKonKoTononaTRHaeHuoreHHaTaenM(3a B ~ ~ ~ ~ C CbAbPXaT T H U ) CbOTBeTHO fl0 150 M 300 g MMHaUMfl. BbrfleH C IlOBbpXHOCT 150000m2M 300 000 m2.no AaHHM 7. YBpeWa~e Ha OpraHMTe 3a UeTOKCMKaUMRM eKCKHa n p o ~ 3 ~ o p ~ cop6epb~ ~ e n ~ ~He e ce Hacvqa npu yno~peum ( r e p e ~ upo6,6b6peu~). pe6a~a MY B npo1bnmetiMe Ha 17 h n p ~ epMH 6 o n e ~ KXn e npunoxuhira n p ~ MHoro cnyraw Ha T e r n MHTOKCMKMpaHC 6poM~ap6aMMp. H~ey~enMqMx~e IlPOpbflOflMMeflMKaMeHT03HM MHTOKCHKa4MMM n M TaKMBa C HeM3flXMTeflHOC~a Ha KXll Ha 8-10 h, K O e T O no~a3a no-fl06bp BeCTHa HOKM. H ~ J ~ O X M T e~ flocTaBFlHe ~ H O Ha MaKCMManWIMHMCleH, na60paTopeH M MKOHOMH'ieCKM @!KT. PM HO Tows eTMonorMwa u~amosa c KonwiecTBeHo M n M XUnOTOHHR C e IlpaBM06et.4~0 MeCTBaHe C BOnHO-ellemflOHeKaCleCTBeHO~OKa3BaHeHaOTpOBMTeBKPbBTa. PO~UTHH ~~~TBO T~ PA KaTo M , ~ a i - ~ l e TR c~ eo pexMppaTaK P M T H ~ H M T I CePyMHM KOH4eHTpaUMM 351HRKOM MeflM~ M O HB Hpe3yn~a~ ~ Ha N p c ~ p a ~ p~ypesa. a ~ a l l px ~~ n o KaMeHTM ca: Phenobarbital10 mgldl, Glutethimide -4 mg/ T e P M M R KPbBTa B M3BbHTeneCHOTO ~pb~006paqe~Me C e dl, Metaqualon - 4 mgldl, Theophylline - 30-40 mg/dl, 3a~on1-1~ ( c n e g ~ a n e ~ ~ e pHa ~o 37"C), c ~ acnaraTce ~ rpeAKOMTO HanaraTcneluHa KXn. C n e ~ u xe~op~ann3a ~a (ex. KM M n M ce alcnloqea xeuop~an~3a~op cnep cop6epa. AMT ~ MC ) e flpOBeWa flpM HMBO Ha CanMUMnaTM 80 mgldl, allU3HHRT pa3TBOP3aTOllnR KPbBTa flpeuM BPbqaHeTOh B ~MTMA 2.5-3.5 mmol/l, MeTaHon 100 mgldl. o p r a ~ ~ mM a .~ T O eM ~~ T B ~ C KaTo T ~ H xe~oflnanep#y3 Y 1 R M e oco6e~o flOne3eH IlpU KOM~UHHP~HM MHTOKCHKaU M M C pMallM3MPYeMM M C O P ~ H P Y ~ M TOKCMVHM M HOKCM. He CbqeCTByBaT a6~0flloTHM KOHTPaMH~MKa4HM38 Paaluwp~sa ce CnempbT 3a u e n y p a ~ p Ha ~~ HwcKoMonenpoeexqatie Ha KXll. TRHe ce npMnara n p KappMoreHeH ~ KYflRPHMc ~ ~ C T ~ H ~ OTCTpaHRBaHe MM, Ha BOua M efleKTp0WOK. OTHOCMT~~HM KOHTpaMHAMKaUtIM M TeMM TPOM~O nHTM. 4MTOneHMR,neBKO~MTOneHMR,KOarynOflaTMRMCbCTORHHMOHHTOPMP~T ce Ha aceKu 30 min: ~ e n e c ~ ~e a~ n e p a - R T a , n p o ~ ~ ~ o n o ~ a 3 a ~ u a a n pHaxenapMH. ~noxe~~e

Cnequ#urnu memoguku u npoqegypu 6 cneurnama ~ e g u q u n c k a nomoq m 65

Cnac Cnac~os
Cneur~o6 o n ~ w eM noCTpmanMTe V e C T O He Ca B CbCTORHMeflaflaaT TOVHM aHaMHeCTHVHHflaHHM, a$M3MK~HOTO ~acnefl~a npM ~e TRX cbwo Moxe fla 6bfle ~ H ~ V M TenHO 3aTpyflHeHO. TOMHM IlpMHyYqaBafla TbpCMM MeTOflM 3a 06etcrMBM3Mpa~e CbCTORHMeTO Ha laI#leHTMTe U 3a 6bp30 nOCTaBFlHe Ha TOVHaTa flMam03a. OTO r P O M H M R ~a6op MeTOflM Ha 06pa3HaTa flMalHOCTHKa H M e npenopb'iBaMe cneflHMTe npM ynoMeHaTMTecacTORHHR: Kopeua 1.4. Tepuorpa$m 1.4.1. O C T ~sb3nanwenHn M npoqecn 1.4.2. OCTPM CMyweHMR B KPbBWPOCRBaHeTO

2. M~TOAH c AonanHmenuo Kolrrpampaue

6e3 HHTepBeHqHR

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66

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KM~RKOB, 3 ~ pM3BbH6b6pe'i~~ . MeTOPH 3a OClMCTBaHe Ha KpbBTa, C., M e p ~ q ~ tMi a $MaKynTypa, 1984,135-143 Koanoe, B. nnaaua$epes H nnaa~ocop6qnfl B neretiuM YpOnOM'ieCKMX 60nbHblx, ~ O K T A .M C . , M,, 1989 MMnaHos, M. n ~ c e p ~ aC., q~ 1987 ~, H~HOB, A. K~MHMC~HO npMnoxeHwe Ha nnaa~a$epeaa~a, C., M ~ A M ~ MM $uaKynTypa, H~ 1987 Cne~u~ XMPYPMR, a C., MeflMqMHa M $~a~ymypa, 1993 Anesthesia, Churchill Livingstone, 1990 Braun U., H. Burchardi: Akute Notfnlle. G. Thime Verlag Stuttgart New York 1993 Critical Care, J. B. Lippincott, 1992 Critical Care, J.B. Lippincott, 1993 Davidson Ch. Anesthesia. Edinburgh, London, Melboum Glinz W. Ch. Trauma, Diagnose and Management Springer-Verlag, Berlin, Heidelberg, New York, 1981. Handbook of Critical Care, J. B.Lippincott, Philadelphia, 1994 Keller, A., G. Schutze, G. Offermann, M. Molzahn. Plasma exchange How does it work, Intem. J. Atif. Organs, 5, 1982,230-263 Kilian J., Ahnefeld F. W., Bergmann et al., Klinische Anasthesiologie und Intensivtherapie, Springer Verlag 1990. Larsen R. Ankthesie. Urban & Schwarzenberg Munchen,

Wen, Baltimore 1989. Latto I. P., M. Kosen. Difficulties in tracheal intubation, London, Philadelphia, Toronto, Mexico City, Rio de Janeiro, Sydney, Tokio, Honkong: Balliere Tindal, 1987. Lippincott, J. B. Handbook of Critical Care, Philadelphia, 1994. Lippincott, J. B. Techniques & Procedures in Critical Care, Philadelphia, 1991 Lippincott, J. B. Trauma Anesthesia and lntensive Care, Philadelphia, 1991 Lysaght, M. J., H. J. Gurland. Plasma separation and plasma fractionation, Karger, Munich, 1983 Manual of intensive care, Little Brown, 1991 MillerY.TraumaAnesthesiaand lntensive Care. Lippincott Philadelphia 1991. Peter K., L. Frey und al., Anbthesiologie, Verdinand Enke Verlag Stuttgard 1989 Peter K., L. Frey, J. Hobbhan: Anithesiologie, F. Enke Verlag Stuttgart, 1991 Saunders, W.B. The Management of Trauma, 1985. Sprender, U., H. Rasche, H. Franz. Membrane plasma separation. Complications and monitoring. Artif. Organs, 8,1984,3,360-363 Yearbook of lntensive Care and Emergency Medicine, Springer-Verlag

68

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76

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AlturaB. M. et al. Handboockof ShockandTrauma. Raven, New York 1989 Berne R. M., T. N. Rall, R. Rubio. Regulatory Function of Adenosine, Niyhoff, Boston -The Haque - Lancaster 1989 Beyer J., K. Messmer Organdurchblutung und Sauerstoffversorgung bei Sepsis. Verh. Dtsch. Ges. Inn. Med. 8.1985 Nirnmo W. S., Smith G. Anaesthesia, Volume 2, Blackwel

Scientific Publications, Oxford 1990 Parks D. A., G. B. Bulkley, D. N. Granger. Role of Oxygenderived Free Radicals., Surgery 94,415,1993. Pontoppidan H., B. Geffin, E. Lowenstein. Acute Respiratory Failure in Adult., Little Brown, Boston 1987 Tinker J., M. Rapin, Care of the Criticaly ill Patient., Springer Verlag, Berlin - Heidelberg - New York 1983 UngeheuerE., Katastrophenmedizin,Dtsch.Arzte Verlag, Koln 1991

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n M Ha CbllbTCTM~M YBpewaHMR B OTAenHMTe aHaTOMMrHM 06nac~u Ce AaM B C b O T B e T H M T e rnaBM.

I . Qpamypa Ha repena - enwwpaneti xeMaToM.

B ~ ~ B M C M M O COT T eTana Ha o ~ a 3 s a ~ Ha e cneuJHa M e p M u M H C K a IlOMOq RCHO Ce OVepTaBaT M npMOpMTeTMTe B nereHueTo. Te 3 a a ~ c m OT Texecna Ha TpasuaTa, XeMOflMHaMM.IHaTa C T ~ ~ M ~ H O Ha CT IlauMeHTa M Bb3MOXH O C l l a 3a ClleWHO M ~ ~ @ M H M T M B H X M OP y P M C I H O Jle'ieHMe. Uema e He c a ~ o M36Rr~a~e Ha CM~PTHMR MBXOA, HO M nPeAOTBpaTRBaHeT0Ha OcaKaTRBaqM n0CnepCTBMR. Hai0640 cneurHaTa peaHMMaqnR M X M P ~ P M ~ H O nereHne ca HaCOreHM H a nbpB0 M R C T OK b M nOmbpXaHeT0 H a UHC, cneAaaHo OT nombpxaHeToHa opraHnTe B rpbptm KOW, BKJl. AMXaTeflHMTe IlbTMUa, K O P e M H M T e OpraHM, K P ~ ~ H M 4MTe. B T O M OTHOWeHMe B nOCJleAHMTe rOflMHM IlOnyIlRpHOCT np~po6~ea KoHqenqMRTa 3a . ~ ~ ~ T H rac"; M R Toea ca

llp~op~~e Bn ~e m~el e ~3 ~ae~ ~~ oOT cm xe~0p~~aui.I 'iHaTa C T ~ ~ M ~ H O Ha C T na4MeHTa M HeBpOnOrHqHHR CTaTYC

M CneABaT onpepenetia xpotionoru~: M M O ~ M ~ M ~Ha ~ ~ MH~HHR M R ~b6HaK (~KO He e Hall-

paseHa npeueap~~en~o);

O K O ~80% O OT B C U q K MT p a B M MH e ca MMBOTO3aCTpawaaaqn. T e 3 ~ naqclletim nnoraT pa 6 b p a ~ TpaHcnopTMpaHM p0 ~ O ~ H M Y H O T3aBepeHMe, O KaTO O~MKHOWHO e ~ e o 6 xoflma caMo HRKaKae BMA M M O ~ M ~ M ~ ~ 06neK'ie~o ~UR, nonoxeHne Ha naqueHTa c M n M 6e3 nopaearre Ha KMcnopop, B pepKu cny'iall- 06ea6on~ea~e. Ocra~anwe 20% OT naqMetrruTe ca aacrpaure~~ OT
neTaneHM3XOpMnMTe)KKMPilHHMHKbCHUyCnO))(HeHMRM M 3 M C K B a T , Ha ilbpBO M R C T O , M3KJlK)'iHTenHO 6 ~ H npo$e~ 3 CMOHaneH TpaHCnOpT fl0 Cne~UaJlM3MpaHaTa60nHM~aa, KaReTo MoraT pa noryiaT ~ e 3 a 6 a e ~ ~~ o @ H H M T H B xnpyHO PMC~HOneqeHMe.

- n o m b p m i e Ha qMplcynaqnma( H H @ ~ ~ M O TepaHH~ nklfl); - nombpxatie Ha cbppevHaTa noMna (He3a6aBHa

n0mbpXaHeHa RMXaTenHMR nbT M A M W a H e T O (KPMKOTMPOTOMMR, T P a X e O T O M M R , MHT)&~MR, K M C ~ O P O ~ ) ;

~opa~oqe~~ ne pa HanperHaT ~ a nHeeMoTopaKc, nepwapp ~ o q e ~ ~n ea pa CbppevHa ~ ~a~no~aga); - KoHTpon Ha B~HWHOTOKbpBeHe ( a ~ o H e e ocbqecTseH npefleapu~en~o); - npeqewa 3a ~ e s a 6 a e ~ onepaqw a npM uacuseti

MHTpaKpaHMWeH X e M a T O M ; npeqetirta 3a ~ e 3 a 6 a e ~ rpbpHa a MnM KopeMHaonepatpm n p n ~a p e ~ xn ~e~ 3n ~~ Ba ~ e K3 ~ M~ HM; M M O ~ M ~ M ~ Ha ~ ~@palcrypMTe M R Ha K ~ ~ ~ ~ H M U M T

QBa Cnep OCbU@CTBRBaHeTO Ha T e 3 M IlPMOPMTeTM U n p nocTnrHaTa ~ xeMopMHaMuvHa c ~ a 6 n n ~ 3 ce a qnpe~~

MMHaBa B M ~ O ~ P O ~ H O@ TM O~MK~~H na60paT0pH0,06O, pa3HO M M H C T P Y M e H T a n H O M3CnepBaHe, T, e. OllMCaHMTe nPMOPMTeTHM neqe6HM M e P K M IlpeflUJeCTmT noflp06HaTa puamocTMKa.

llpnopn~e~u B onepaq~o~~ ~a ~ ~a(B n H aM pep):

~ X

- fleKOMIlpeCMR Ha MHTpaKpaHMaJleHXeMaTOM;

-peKoMnpecMR Ha nneepanHaTa KyxnHa npn xeMoTo-

PaKC M IlHeBMOTOpaKC;

KoHTpon Ha XeMopamma ( ~ ~ o p no a~ vecToTa a npMq M H a 3a CMbpTeH H3XOfl IlpeAH npMCTMraHeT0 B60nHMqaKotiTpon Ha MacuBHo KapseHe npn ~aaoaa @palcry~ a )Tom . e necHo OcbqeuBMMo, npM Mtioro OT cnyvawe pa; C BbHlLlHa XeMOpaMR, KaTO M3nOn3BaHMTe TeXHMKM We 6bfla~ pa3rnepa~n B CboTserHme rnam cnopep noKanM3aq~ma~a~pae npo6ne~am'i~ucarone~me ~a~a; mpeWHM K P b B O H 3 n M B M( X ~ M O T O ~ ~ K XC ~, M O ~ ~ ~ M T O nPM H~~M); TRX OCHOBHOTO neqeHWeno BpeMe Ha TpaHCnOpTa e #H@Y3 M O H H O T 0 , KaTO T P a H C n O P T H O T O BpeMe He 6wsa fla HWXOflepaTMBHO Ile'ieHMe M @ M K C ~ ~ M H R a@~~KTYP Ha M BbpnR 20 min; ~ M ~ ~ B cKeneT. M R

l l p &pa ~ K O O ~ ~ M H ~e ~w Uy Rx x p y p a n ~ oe ~pa3n~ VHM CneuuantiOCTM M ageKeaTtio npoaewatia peatiuMa~ M HRKOH R OT OnMcaHme onepaTnetiu HaMecM uoraTRace np0BewaT C M M Y n T a H H O , KaTO B b B BCM'iKH Cny-laM peK0MnpeCMRTa Ha rnaBHMR M O 3 b K e BOpeqMRT nPMOPMTeT.

p a 3 n M c l H M no M e X a H M 3 b M , TexecT M ~ 3 x 0 T ~~ . K ce elcnlorea~KaKTo K O H T Y 3 M M Ha MeKMTe clepellHM O~BMBKM, 3 q KOMTO M O X B pa CTOM ~epaanos~a~a M snocnepmaue ycnomeHa repenH0-MO3b'iHa TpaBMa (YMT), TaKa M TIXKM Y B p e p M Ha M03bKa M Ha HerOBMR CTBOn. O K ~ ~ B ~ ~ nbpBa M F InOMOq T ne~ap ~ p ~ 6pa aa ce opwe~~npa 6bp30 sa BMpa M cTeneHTa Ha ~ 0 3 b r ~ yapepa, a ~ a pa MMa npepaMn B ~ ~ M O X H O C T aa T~ K b C H MY C n O X H e H M R , pa O K m e QeKBaTHa I l O M O q H pa OCMrYPH q w qH6e3 PMCKOBe TpaHCnOpT.

T ~ ~ B MH a MrnaMTa T~

Yspepwe Ha repena ca:

npoTMraHe,

1. C r y n e a ~(~ @ ~p l awn) Ha repenHlnR noKpMa a) ~ M H ~ ~ e~MHM'iHH H M MM H O X e C T B e H M ; 6) oTnolrnbrHM 6e3 p a m e c ~ ~ H aa ~4pame~~wre; e B) O T n o M b r H M C p a 3 ~ e c ~ Ha ~a 4~ pe a r ~ e ~~ MMn~e

IlpeCMOHHM M A e n p e C M O H H M C r y n B a H M R . 2. Cclynsa~w H a repenHaTa oc~oea: a) Ha npepHa clepenHa RMKa; 6) Ha cpeptia clepenHa mKa;

B) Ha 3 q ~ clepentia a RMKa; r) Ha notlere OT epHa RMKa. 3. C u e c e (cclynea~w~ ~~ Ha repenHMR CBOA M OCHOB~).

Yepen~o-t.to3br~~ TpaaMM ce nonyaeaT ~ a C r e c ~ o Onrecrpen~me HapatiRsaHMnHa repena M Ha ~ 0 3 b ~ npM: ce pa3rnewa~ B oTpenHa rpyna. 1. ~ ~ T H O - T P ~ H C ~n O ~ O ~ M H 3 L M U e C T B M R -O~HKHOB~HO T e r n npM newexoAume. 2. n q a ~ e . M O S ~ ~cbTpeceHwe HO 3. Cnopqma~e. CaMO ~YHK~UOHU~HO-~MH~M M IlpeXOpHM 4. Hacm~e. HapylueHMR C K ~ ~ T K o TOTnqaHe ~ ~ ~ o Ha M 0 3 b ' i H M T e 5. Oniecrpen~~ HapaHReawm. ~YHK~MM. YBpepM~e Ha MeKMTe T b K a H M , Ha clepena M Ha M03bKa CMM~TOMM: IlpOMRHa (3aMa) Ha C b 3 H a H M e T 0 , aMHece nonyaeaT: ~ M R rnaeohn~e, , ceeToabpTex, cae~o60~l3b~, rqeHe. 1. O T npOHHKEa~ AMPeKTHO M H T p a K p a H M U l H O npC! AM03bqHa KOHTY3HR M B T . OCB~ ~ H ~HK~MOH~HO-~M HaPyllleHMR H~MHC MMa IHH H 2. O T npmMCKaHe. ~ o f i o n o m r ~yapepn n Ha MomrHaTa T b K a H - paalcbceaMexaHM3bM). 3. ClmHTe Ha yCKOpeHMeT0 (HellpR~ He, p a ~ a r ~ s a~ ~ ee ~,p o aepeM. a,

HenpRK M e X a H M 3 b M Ce nOny.laMT K O H T Y 3 M M Ha M O 3 b K a BbpXy HepaBHOCTMTe Ha clepella M OT MHeP4HRTa B OTflaJlecleHMOT MRCTOTO HaTpaBMaTa3 O H M T . Hap. COnfre COUP M e X a H M 3 b M . YBpepMTe Ha MO3bKaca I T b P B M V H M nPRK pe3ylTMTOT TpasMaTa- M BTOPMYHM- c n e p c r ~ ~ OT e ncxeMm, OTOK Hnn npMTMCKaHe Ha M03bKa.

no

no 06qoxnpypmre~ npnHqMn YMT ca o ~ ~ o p (OTe~n ~ p m )aKo , m a paHa Hamama. Te ca npoHnKBaqn,aKo e Hapyluetiaqenocna~a~ y p MaTep. a AKOHe e HapylueHa l#3nOClTaH a K O M T a , Te ca 3aTBopeHM ( ~ ~ K P w M ) . Cnopepc~enewa Ha ~ o a b r ~ppepa a ~ a (4yH~qwo~anHa MnM ~op$onorncl~a) YMT ca:

CUM~TOMM: 3ary6a Ha Cb3HaHHeT0, H e B p O l l O ~ ~ e H p e $ M u M T , mnr0~pahHM CY~~KTMBHM OllnaKBaHMR, a npM T e r n T e cnyran - peqepe6paun~ n n M peKopTMKauw. Mosbrl~o npHmcKaHe Ocee~ ropecnoMeHaTuTe, HamneaT M BTOPMVHM ~ 3 MeHeHMR OT RpMTMCKaHeTO Ha M O 3 b K a OT ellMpypalleH, cytipypane~ MnM nmpauepe6pane~ xennaTou. O a ~ a n ~ o 31 naqMeHTa e n p M T M C K a H e T 0 Ha M 0 3 b c l H M RC T B O n npM TeHTOpMUlHOMnMOK~MnMTMHOBKnMHR~He. CHM~TOMM: AaHHM 3a IlOBMUleHO MHTpaKpWMUlHO HanRraHe - npoMetin B C ~ ~ H ~ H M3acnnBaqo ~TO, ce rnam hnne, 6 p m n ~ a p p ~ ap-repllrantia ~1, xnnepToHnR, npcloee, HeeponorncleHp e a n w xeMmnape3a (nnem~), npoMeHM B U l M P H H a T a Ha 3eHM4We. MM~PM~TH'IH~T~, 6e3 PeaKUMR Ha CWTnHHa 3eHMqa, e KaceH CHMITOM!

K ~ K B~ Op h e Aa a ce Hanpaen, KoraTo ce npepnonara YMT? Hape~ c meorocnac~wupme ~ e i c r s w~s~apluea~, HH npn ~eo6xofln~oc'r, ~p~6ea ce pa36epeOT naqMeHTa MM OT oreempy n w nn 31iacln~en~o~e@op~upa~e H a
n~eo3HOTOC~~~,~eHOnUenpe~HOTO~ mama Ha noc'rpmannR, nonmannne n p y n a 3 e ~ Konati

YcTaHOBM #Man n M e nOCTpaJ@rlMRT l%pYOBe l4 OT KOR (onac~m U 3a W M A H ~ yape~a), n ~ n a ~ nn a ne OT KonaTa, CTpaHa Ha T R n O T O Ca 3anO'iHaJln. nO.lHHaJl n M e H R K O ~OT CnbTHHuHTe MY. AKOe naHW, T ~ R ~pa MC e pa36epe OT KaKBa BllCO'iMHa, AMPeKTHO H n M 3a Aa cnepnM c a z ~ ~ a ~ we eH ~~ oO , ~ X O ~ ~TO UM pa Oce He, Bbpv TBbppa OCHOBa nnn BbPv 3eMR HnH XpaCM. o T w a no KoMa cltana. H~CLUU~OKO pa3npoc~pa~e~a e Te3n ceeReHnR onpenenm T. Hap. .nmeKc Ha C ~ M H ~ H M ~ ' Glasgow KoMa cKanaTa. TR e npeIcTaBeHa Ha ~a6n. 3.1. npn &p Ha Towme nou 12TpR6Bapa ce peficTea6bp30, - BMMOXHOCT 3a nocepno3Ha TpasMa npn nauuew B CpaBHMTenHO ~ 0 6 p o CbCTORHIAe. a aKo Te ca nop8, HpHa e aKTnBHa peaHnMauw. naune H T C npOMeHM Ha Cb3HaHMeTOT P F I ~ B fla ~ 6b4e M3npaTeH Tp~6ea #a ce opnemupaMe pann e nuano sary6a Ha B3~pas~ 3aeeIetine o c B ~ ~ M O X H O C3a T cnewtia pMamocwiaHneTo n sa KonKo apenile. npn3ary6a ~ a c b a ~ a ~ n e ~ o HW5 rnin ce npneMano-cepno3~a ppepa. BWHOe Aa ce cTuKa M OnepaTnBHa HaMeca.

Ta6nuqa 3.1. O q e mno Glasgow

A~BHOCT O~BapflHe H a 0.1MTe C~OHT~HHO npu noentma~e npu 6on~a 6e3 OTrOBOp O~U~HTU~~H C~ a ~ a no ep ~~ ae ~ ~ a q ~ f l C HemeKBaTHM M3pa3M CH~C~~UM 3$8M ~~ 4H ~M 6e3 0Trosop Msrmn~uea KOM~HR~ no~anu3upa 6on~a Peampa npu h n ~ a Q)ne~cu~ npu 6on~a EKCT~H~HR B OTrOBOp H a 6onKa 6e3 OTrOBOp O~rooeop Oue~~a
4 3

2 1

~ O B O $YHKUHR ~ H ~

5
4

3 2 1

Aenra~en~a $~HK~HR

6
5 4 3 2 1

Kora~o ce onpeuenq C ~ ~ I H ~ H U ~ TT PO R, ~ B na ~ ce w a npeABmcTeneHTa Ha anKoxonHa MmoKcnKaunR,npneuaHeTO Ha C b H O T B O P H MH n M HaPKOTHqM. B TaKMBa Cny.la# Ha6nlofleH~eTo TpR6Ba Aa C e M3BbpWBa Ha no-ManKbl MHTepWM.

3. 3e~nuu-paaMep, epiaKem, peaKUnA Ha ceemn-

Ha.
4. CMM~TPM~HOCT Ha nnqeeaTa MycKynaTypa. 5. ~ B M X ~ H M -RCnOHTaHHM MnH nPOBOKMpaHM. 6. C~THBHOCT - peaKqMR Ha h n ~ c a @ n e ~ c nc ~, eKCTeH3HFI. 7. Pe$ne~cn - eAHaKBocr, nnnca, naTonoMrHn pe+neKcn. 8. K O H T Ha ~~a3oan~e ~ pesepBoapn. H~B~O~OM cTaTyC ~H~ C eR CneRM T B flclHaMMKa M no BpeMe Ha T ~ ~ H c I ~ o ~ T ~ ! Tbh K a T O 3a OKa3Ba~MR IlbPBaI l O M O q H e e Bb3MOM-D pa onpeflenn ToclHaTa pnamo3aHa epHa YMT, TO OT oco6eHa ~ O C e T I a ce onpeflenn Texecrra Ha TpaeMaTa Ha rnaBaTa. n e WT. ~ Ka~onetmpdaa ~ pace npneMaTTpaeMnHa rJlaBaTa6e3 3@ HaCb3HaHMeTOWIH CM: 40 5 mill, a TaKa C b q O bl TpaBMH 6e3 KnMHH.IHkl flaHHkl3a WBaHe Ha repena (sm no-pony), c Heatiarbrrentio r n h n n e , 6e3 HeBpOllOMcleHf@LIuMT. ~a~(uleHTLl C TaKUBa Ppefln MOraT

Mscnenea~e
1. ~ ~ ~ O X M P ~ P M ~ H O T ~ ~ Cce R6ene3n T Ha TpaeMa - o x q n ~ a ~ nouyrnw~, H M , PaHM. B H M M ~ T C ~ e~ Ornewa H O OKOCMeHaTa W3 Ha rnaeaTa, ornewaT ce HOC~T,ycTaTa, yurme 3a n3mra~e Ha KpbB, n M K B O PM n H Ha M03bWH AeTPMT (@pa~~ypa Ha repenHaTa oc~oea). T~PCRT ce nep~op614TaneH xeMaToM (or~na), KpbaotiacflnaHe3 q nnpuecyc Macronpeyc ($pamypa Ha VepenHaTa OCHOM). npn orneA Ha paHaTa ce T~PCRT $patmypn, KOCTHM + p a m e ~ ~KbpeeHe n, nnn M ~ T U qaHe Ha nMKaop no4 Kocrra. II. Heepono~.r~o To smlorm: 1. Hneo Ha Cb3HaHMeTO (EX. no-rope KOMa CKMM). 2. I ~ O ~ B ~ Ha Xowbrre HOC ~6bn~lrl. T

Aace xocnwran~3~pa~ 3a WTKO B OGLLIO~P~PM~HMorgeneHwR. AKO M M aycnoBuH3a~OGpo M HenpemcHaTo ~a6nmRetiMeB AouaurHa O ~ C T ~ H O TeB MoraT K ~ ,fla He ce xocnwrant13~pa~. W H C T ~ ~ Y T H ~ ce ~ T 6 n ~ 3 ~MM ~r fla e cneppr mHaHMeTo npea MwrepeanM OT 1-2 h (Mnpes ~ o q r aB ) ribpewre TPM AHM. naqueti~wre noMemT Ha xocnmanM3aqMR npM
npOMRHaHacb3HaHMeTOHnH3aCMnBaHeHaOnnaKBaHMma. I-IMTc~c CpeAHa TeXecT. Te C e IlpoflMBaTC IlpoMflHa M n M 3 a 4 a Ha C ~ ~ H ~ H M~a,q ~T5 O min, c neKocreneHHa npouma Ha C ~ ~ H ~ H Mnpw ~TO npernefla, cw: cycnemiu

flaHHu 3a $paicrypa Ha repena: $panypa n p ornep Ha paHaTa, 11epMop6clrraneH xehnaToM vnH KpbecmacnflaHe npoqecyc Mamoyqeyc, M ~ T M V ~Ha H~ nwKBop OT HOM M n M ylllMTe, C KnMHHrHM flaHHM 38 IlOBMUleHOMVaKpaHnanHo HanRraHe-cnnHo rnaWhn~e, noepbqatie,n a q ~ e m c Tamsa yapeAn ce npweMaT B oTfleneHm, MO ce WHMMaMTC HeBpTpaBMaTOnOMR -HeBpO-MpM,MqHMTOTfleneHwi M n M K~MHMKM B cTpaHaTa. T ~ ilMa M B ~ ~ M O X H3a ~T nz~~bpurea~e Ha KT Mnu a ~ m o r p a $ npv ~~ w a . TeXKH L(fdT.K O ~ ~ C e T YCTWOBRT: O TpafiHanpoMRHa~a Cb3HaHMeT0, nCHXOMOTOpH0H~C~OKO~TBO, HeBpOnOMVeH fle$MuMT, l%p'-lOBe, npOMeHH B WMPMHaTa Ha 3eHMqMTe, npOMeHM B 'ieCTOTaTa M PKbMa Ha flMLUaHeT0 - YMT Ca Texw. Toram ce Hanara 6bp3 cne~annsupati TpaHcnopT C Bb3MOXHOCT 3a PeaHMMaqMfl. nOCTpwaJlMTe B K O M a R0 Bb3MOXHOCT W TpaHCnOpTMpaT M @ M ~ ~ H M ~~HMCIHO 3aseAenMe, B KoeTo Moxe Aa ce olcaxe ~ e e p o - m p y p ~ r ~ a noMoq. naqMe~~M B KOMaC e IlpeHaCRT B CTP~HHC~HO CT~~H~HO

Ha~a6n. 3.2 e npeflmaaetiacxeua 3a noeefletiue npM CIMT. 1. nowpxatie Ha rMmuflMxaTenm m m q a H npoTeKU H R Ha UIU~~HHR pb6Ha~. 2. O c ~ r y p ~ B a Ha ~noGpo e fluwaHe. 3. n o m b p x a ~ e Ha ~ 0 6 p a qup~ynaqn~ c KoHTpon Ha KbpaetieTo. Xe~oc~asa, memaTa npeapwa, MaHyanHa KoMnpecm, 3 a q ~ n ~ Ha a ~m e p ~ cbfl ~ C ~Mnc-rpyMetiT. q 4. PM CbMHeHHe 38 IlOBMUleHO MHTpaKpaHHanHO HanRraHe: a) noepMraHe Ha rnaeaTa Ha 30",B Hey-rpanHo nonoxeHMe; 6) ~ 3 6 ~ r Ha ~a roneMM ~ e KonnrecTsa ~ o f l ~ o - c o n e e paneopw. 5. PM rbproBe- Phenobarbital 1-3 rngkg, Diazepam 10-20 rng.

llpn nmnaaHero B GO~HMCIHO 3aee~e~we npv 6 0 n e ~ cbc cpeflHa nn# Tema YMT, aKo He ca M ~ B ~ P U J ~ nereHM 6 ~ m Mepm e OT 1 fl0 5,TOBa T P R ~ B He3a6aB~0 ~ fla 6bfle Hanpaeetio. AKO M M a flaHHM 351nOBMUleH0 BbTPeL(ePenH0HmflraHe, m~ropenocoreHMTeMepm ~p86ea fla ce BKnloraT v: xMnepeewrMnauuR; KopTnKocTepoMflM- Dexarnethazonurn 0.1-1.0 rnglkg; Mannitol 18-20% 1.O gkg. f l a q u e ~ m c w : c b ~ ~ aa6bp30 e ~ n e p a ~ a n ~ a qm ce peYepeneH xennaTou, cnefl H ~ O ~ X O A M M O T~scneflea~e O (KT M n MK ~ ~ O M ~ ~ H ~ ~MH flOKa3BaHe MO~~ H$ ~X M~ RM ~C T eO HacoraaTsa cneurtia onepaqMfl. n p nnnca ~ Ha speue Mnlr anapaTypa ce npasM TpenaHaqMoHHo oTabpcTne n ce t?peMaxBaXeMaTOMbT. 3a cneurtia onepawa ca M naqnem c OTK~UTUcvyneatinnc Bflasatie Ha Kocrtime+patwemu ( H M ~ ~ ~ C H O U AenpecnoHHM c r y n e a ~ n nnn ~ ) Msna,qHanu B ennnemnreH cTaTyc cnen TpaeMaTa, K O ~ O He Moxe fla 6b4e OBJla,QflH Me~MKaMeHT03HO.

no A. Ducolombier C U3MeHeHMR

Ha6nlo~aaa~ Ce @ ~ H K L ( M O H ~ H O ~ M H ~ M U V HHapyWeM HMRcnpexopeHxapatuep. CMM~TOMM. 3a qacoee nnM po 1-2 ~ H npomtia M Ha

cemaHocna n napeaa Ha ~ p a i ~ ~ u m e . 2. KOHTY~HR Ha ~ P ~ ~ H ~ M03bK CIH#R Ha6nlo~aea Ce nbJlH0 MnM claCTMclH0 aHaTOMMqH0
~ P ~ ~ H ~ C I H O - M O ~T ~ P a VB H M M M Ce llOfly.laMT npM: 1. ~ ~ T H O - T ~ ~ H C ~ On P P O TM H3 M U l e C T B M R (Hafi-qeCTMCa YBpepMTe Ha W l l f i ~ M R vb6HaK). 2. n a a ~ OT e BMCOKO ~ a f i - q e c ~ o ' c ~ p m TopaKoa nyM6anHMRT oTpen. 3. ~ P M T M C K ~ HlP ~ O M 3 B O p C T B e H M 3JlOnOnyKM, CpyBaHHR B M H H H . 4. C~OPTHM MWBM qecTo ce p p e w a w ~ f i ~ rpb6HaK npM C K O K O B eB b B BOpa.

5. H a c ~ n ~ e . 6. Oniec'rpen~n HapaHRaattuR. YBpeflMTe Ha rpb6HaqHMR M03bK Ce AbnXaT Ha nbpB M c l H O HapaHRMHe OT TPaBMMPaqMR areHT, OT KOCTHH $pameM ~npmMCKaHe ~~ OT Clac'rH Ha pa3pp06e~o npewneHOB0 TRnO, OT K P b B O M 3 n M B , OT HaBnR3bn B rPb6Ha'iHMR Katian MewynpewneHoa ~ M C K Kora~o . HeaponomvHMm R ~ $ M ~ MHe T OTrOWpR Ha yOVHeHOT0 HMBO Ha rpb6HaVHa yepepa, Moxe pa ce npepnonoxM cbpoe npo~3xop Ha

npeKbCBtiHe H a ~ P ~ ~ H ~ C M03bK. IHMR CMMI'ITOMU. TpafiHanpo~flHa M n UJlMnCa H a C e T M B H O C T nop HMBOTO Ha yepeRaTa, Katcro H TexKa napesa M n M IlneMR C Ta3OBOpe3epBOapHM HaPYllleHMR PeTeHuMR. n0paM C n M H a n H M R WOK nbpBOHa'ianH0 napanM3aTa e BRna HaManeH MycKyneti TOHYC M nMnca Ha H ~ K O C T H O CyxoxMntiM pe$ne~ccl. 3. ~ ~ H T W C Ha K ~ rpb6Ha'i~blfl H ~ MOWK r p b 6 ~ a ' i ~ M03bK ~ m C e YBpewa K a K T O npM IlpWUCKaHe OT KOCTHH @ p a m e ~ OT ~K~~, ~ B O M ~ MnM ~ M OT Bqacm m Ha MewynpewneHoe~ M C KTaKa , M npn HapywetiM ~pbeocHa6p1BaHeM nMKBOpHa uMpKynauMR Ha rpb6HaqHMR M O 3bK. CMM~TOMM. KJlMHM'iHaTa KapTMHa C e IlOKpMBa C T a 3 M Ha K O H T y 3 M R T a , KaTO Ce YcTaHOBRMT PeHTreHOnOM'iHM, K O M ~ ~ ~ T ~ ~ - T OM M J l M O K B ~ O ~ p O @ n O K M V M H M paHHM, rOB0pew# 3a KoMnpecMR. B ~ e cnyvaM 3 ~ e H ~ O ~ X O 6bp3a ~ M M ~ onepaTueHa HaMeca.

yepepaTa.

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1. n p e p a 3 ~ ~ r a H a ~Mewynpewnetioeme e B~WKM. 2. Jly~caun~. 3. Qpatuyp~. 4. @ ~ ~ K T ~ CP nyKCqMM. M Vepea~~ Ha e rpb6HaqH~fl MOWK ce Aenm Ha:
1. Cb~peceHMe Ha rpb6HaqHMfl M03bK.
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90

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npM TpaHCnOpTMpaHeTO M y A0 ~ O ~ H H ~ H O3aBeReHMe TO M n M npM nmneaHeTo MY TaM. C M ~ W I D ~ ~Ha H cnyraM ~ MTe c 06~ypaqM0HHa ac$n~c~ TR nMoxe pa 6 b ~ npeAluee creaHa OT M H T ~ ~ ~ C ~ M ne Rw . ~a~ Ma H T ~ G ~ npenM ~ M R TpaR

'iepenHaTa tqmHa H H $ ~ K ~ M npea R setia awynapwc. l l p ~ npMTvcKaq ~ y ~ o xeMaTou p, MnM eu$weu Ha umma ce npwlanea BM M H T ~ ~ ~MnM ~ M
Ha acqeHpmpaqa B
CneWHa T P a X e O T O M M R .

XeOTOMMRTa O C M r y P R B a BpeMeHHO npOXO~MMOClla Ha AM-

xaTenHMre nbTnqa M ca3Aaea no-cno~oh~a O~CT~HOBK 3a HanpaBaTa h. kl~T'j6a4MR~a e I ~ o - K ~ ~M T a H M K - o nynaqnfi, HO npMTemKMTe M O C O ~ ~ H oO r ~ e c ~ pn~qealr en~~ TpaBMn He BnHam ce o~asea M no-nec~o ocaqecTBMMa Toea C e ~a6nlopam npM AMClOUMpaHM $ ~ ~ K T Y P Ha M 'ie-

nlOCTMTe, nPM'iMHRBaqM ~ ~ @ O P MM ~ H3MeCTBaHe ~MFI Ha r O P H M T e flMXaTenHH nbTMUa. kl~TY6aqMRTa Ce 3aTPyflHRBa M npMo 6 ~ n KbpBeHe, ~o npM HaTMVaHe Ha CeKpeTM M npM HClllM'iMe Ha ' i W M Tens. Kora~o H R M aB b 3 M O X H O C T 3a acnMpMpaHe M nor#cTBaHe Ha ycTHaTa M $apn~rean~a ~ M H MH, ~ B ~ ~ M O X H O ~a CT ce ~trry6npa M nunca~a a p e ~ e aa Hanpaea Ha TpaxeoToMMR, ce n p ~ 6 ~ m BM a KOHMKOTOM M R . Ka~lOna 3a K O H M K O T O M M R T P R ~ fla B ~M M a BCeKM eKMn 3a 0 ~ a 3 ~ H aa ~ enema e M~AM~MHC 110~04. K~ KOHMKOTOMMRT~ Ce nOCTMra 'ipe3 3 a 6 ~ s a ~ Ha eK O H M KoToMHaTa KaHmna Hanpaeo npea KoxaTa B ~ e M 6 p a ~ a KpMKOTMpeOMflea. C ~ ~ ~ C Tpa3llMqHM B ~ B ~KO THCTPyK4MM KaHlOllM, KOMTO Il0380nFIBaTBb3CTaHOBRBaHe Ha AMXaTenHaTa n p o X O A M M O C T3a 'iaCTM OT M M H Y T a T a . flpM HaCTbnMna ~C@MKCMR M Jl MnCa Ha K O H M O T O M H a KaHDna, KOraTO B C R K a CeKyHAa e UeHHa, B~ 3 8 b ~ 6 0 J l ~ M O'~ i~ Ca T~HOBK K O ~H ,H K O TOMMRTa MOXe Aa Ce HanpaBM M C nOflPbClHM CpeflCTW.

OMKCM ce~rnaaaTa ~ H a nocTpqannR n ce

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~e6m apTepMn M sew. Xapamep~o~o 3a KbpeeHeTo B nMqeeaTa o6nau e, Y e HapaHeHme cbAoee K ~ P B R T 06~n-

H 0BM O M e H T a Ha TpaBMaTa Ha M R C T O T O Ha nPOM3UleCTBHeTo. 0 6 ~ n npo$y3~o ~o KbpseHe Hacnnea M npM 4pam-yPM Ha CpeAHMR nM4eB eT%, npM KOMTO T b H K M T e KOCTHM @palMe~ OT ~C #T e H M T e Ha H O C H a T aM O K O n O H O C H M T eM M HM nOpR3BaTKaTO @UHMH O W ~ T60ra~o ~ K ~ ~ B o c H ~ ~ ~ ~ ~ Te M e K MT b K a H M Ha JlMUeTO. Ocobe~ocT Ha KbpBeHeTO B JlHqeBaTa o6nam e, 'ie HapaHeHMTe CbflOBe M M a TC W I O H HOCT 3a 6bp30 KOHTpaxMpaHe M OrpaHMClaBaHe Ha KbpBeHeTO. O ~ M ~ M HTPyflHO M IlO~aBa~ Ce M Ha OBnqRBaHe xeMopamM ce ~ a 6 n t o ~ a a Ma npM ~ 60n~n c HanpeAHann OHKOnOrMclHM 3 a 6 0 n ~ ~ flpM a ~e n P O ~3HR OT T Y M O P H H R nPOqec Ha cTeHaTa H a HRKOU KpbBoHoceH c b ~ B . nMqe6aTa o6nac.r xeMopaMma e oco6e~o onactia npw nocTpqanM C npOMeHeH0 cb3HaHMe.

Ha MRCTOTO Ha n p o w 3 u r e c ~ ~ ~ B~HWHOTO e~o KbpBeHe O TK P b B O H O C H MC b A O B e C e CflMpa C IlOMO~Ta H aM H C T P y Mewn 3a xeMocra3a, a npM WSMOXHOCT C nwrHpaHe Ha KbPBRqMR CbA. ~PO@YBHOTO KbpBeHe OT M B HOCHaTa K y X M H aHO K O n O H O C H M T e V M H H C e CnMpa C IlOMO~Ta Ha TaMnOHMa. npM o6nn~o KbpBeHe B M OT Y C T H a T aK Y X M H a e no~a3aM ~TaMnoHqaTa a U. 3a Aomna Ha ~ b 3 nTR y~ ce npaBM C a M O CneA M H T @ ~ ~ M R ,TpaXeOTOMHfl MnM K O H M K O T O M M R . ~ P ynOpHTO U KbpBeHe OT H O C H a T a WMHa, KOeTO He Moxe na ce ooenqee c npepHa ~ a 3 a n ~ ~a a ~ n o ~eq no~a3a~ npeMMHaBaHe o K ~ M 3 q ~ TaunoHwa. a K ~ npaseHeTo M Ha TaMnoHqa BnMqeBo-ventocTHaTa o6nac.r ~ p ~ 6 Ra ea ce npucnnea BHMMaTenHo M oTroeopHO. l l p ~ pa3~p06e~MTe n~qeawKYXMHM TaMnoHqaTa, meet!Kpbeocnwpaqo,m a n @op~~paqoflehc~arne. npaBM ce c Abnra, neKo oanaxtietia MapneHaneHTa, nopbce-

HallnaCTRBa C Abnbr M TbHbK a H a T O M M C l e HM H C T P y M e H T ,

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HMKBaHeTO Ha KaHlonaTa BXPaHOnPOBOfla 6~ KOMnpoMeTMpNlO U IlpOXOflMMOCTTaHa Bb3AyXa (BM~CTO BTpaXeFITa TOU ce Hacorm B xpa~onposo~a).

fleHH0 10nbnHOT0h yflnbTHFlBaHe. KpMT ~a HeflpeKbCHaTaMnoHMpaqa neHTa T P R ~ M Aa m p r ~ 1-1.5 cm M 3 B b H KyxMHaTa, O T K n O H e HB C T p a H M . T0h T ~ R fla ~Ce M eMwa M Aa e neceH3a xaaqaHe M n 3 ~ b p n ~ aTa~noHa~e. RaTa B n~qe~o-rentom~a~a o6naa ~pf16sa Aa 6 b ~ e non K O H T P O n B b B BCeKM M O M e H T M npM BCRKa Bb3HMKHaJla cnTyaqnn.

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CbflOBe, TaKa M OT M H O r O T O HeTOneMM, H 0C b C 3HarMTeneH

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CMH~HM~, c nM ~n u e c noTncHaTH pe$ne~c~, a oqe noApaMaTuqHo, KoraTo e c $ n ~ c n p a B~ O~ K ~ ~ ~ renlocm, M R M fla 06~ypwpa p M X a T e n H M R nbT, KaTO n P M i ' M H M ~C$MKCMR c peanHaTa B~BMOXHOCT3a $ a ~ a n e Kpai. ~ Manonsea~eTO Ha no-K~CH MapnM e p o n y c ~ n ~ caMo o aKo npepeapw TenHo ce ~ b p x H a~ ~ ~PHLUMRT H HqemHo epHa 3a ppyra. npu nMnca Ha roToaa pbnra MapneHa newa e 3a npennorMTaHe pa Ce M3nOn3Ba ~ H H T C nOPXO@qa l U M P M H aM pbnxMHa. npn cnyqamTe ~ a o b n n KbpeeHe ~o n p MHoxecTeeHM ~ $pawyp~ Mnu e p o 3 ~ Ha ~CTeHaTa Ha cbp OT pa3pac~~an Ce B CbCeflCTBO T y M O P TaMnOHWaTa Ce flbPWl H eH O M a n K O OT 6-8 A H M (TOM e M flpM'iMHaTa 3a H ~ O ~ X O ~ ~ I M O C T Ta OT nopbcBaHe Ha neHTaTa c h o ~ o @ oHa p~ npax).

Bb3MOXHOCTTa3a aCqeHflMpaHe H a MH$BK~MROT IlbPBMVH0 H H $ ~ K T M ~ ~ HY M C T TH ~ a , HNHa M O K O f l O H O C H MK y X M H M K ~ clepenHaTa M KyxwHanpea npeKbcHaTaTan p TpaeMaTa ~ qRnocT Ha IcepenHaTaoc~om. [PM nMnca Ha K a K B M T o M pa ca cpeuc~aa aa BpeMeHHa M M ~ M ~ M Ha ~ ~ renlocTHMTe ~ M R KOCTM Moxe Aa ce ~anonaea pbcwqa, KORTO ce nocTaaH B ycTaTa Ha nocTpqanMR noA ropHme 3 b 6 ~ M ~ M nop AonHaTa rentocr HalrnecTo n o p 6 p q M ~ce ~$~ MKCM~ HW ~ cBoAaHavepenanoonMcatiMRseqe HawH. TpaHCnOpTHaTa MM061rlnM3a~MR~ p ~ 6 a pa a Ce OT'iMTa OTM'iaHeTO HaTbKaHMTe. Pen03MqMR~a M $UKC~L(Mma Ha KocTHMTe $ p a r ~ uoxe e ~ ~Aa ~ AoeeAe AO HexenaH, 0 6 p a ~ e ~ $ e ~O ~ .~ e m n nKaHM, ~e KoraTo ce npmeC n0MOqTa H a BpeMeHHMTe CpeAcTBa 3a M~06MnM3aUMR, MOraT Aa IlPMTMCHaT AMXaTenHMR nbT M Aa npeAM3BMKaT CTeHOTMrHa ~C$MKCMR. Kora~o CbqeCTByBa TaKaBa onacHocT, cpepcrBaTa 3a BpeMeHHa M M O ~ M ~ M ~ ce ~ ~ B ~ P O R T H ~ OT CT p a T3~ B M T M e Ha M a C M B H a aCllMpa~MOHnocTaem xna6a~0, 6e3 pa npMTMcKaT, M n n He ce npmaHa ~C$MKCMRIlpM KbpBeHe B Y C T H a T a ,H O C H a T a MnM OKOnOraT. Kora~o ce Hanara HenpeMeHHoToMM M ~ I I O ~ ~ B ~ 3a H~ H O C H M T eK y X M H M , KOraTO He C eM 3 R B R B aB b H L U H OM M e A M ~ M H C K O T O n M ~ e H e r O ~ P C H H a C O ~ e H O ~ p M M 3 C n e f l B a H e T O pa ce cnpe KOCTHOTO KbpseHe M np., ce npaaw M TpaxeoToHa ~ O ~ H M R e , MHOrO rOnRMa M e C Bb3MOXeH $ ~ T X I ~ H MMR. M~KOT~K~H H a H P a M H R T B ~ a H M RH a MeCTOnPOH3UleCT~ p a iC . ~pe~e OM mC ~ c e a n R H e T oH a TaMnotiMaTa noBMeTo ce noKpMsaT cbc cyxa cTepMnHa npeapba~a. X~pyppaH0 HepRnKO B O F ( MA0 pe4MAMBMPaHe Ha KbPBeHeTO, C rMrHaTa MM 0 6 p a 6 0 ~ ~ ce a ~sebpluea npM nocnneaHeTo H~O~XOAMMOC OT Tn O B T O P H 0 TaMnOHMpaHe, AOnbflHMTen~a~ O ~ H M B ~RO ~ H H C I H O T O ~ KOnKOTO ~ B ~ ~ ~eH Bb3MOXHO M ~ H 0 TpaBMMpaHe M PeaJlHO YflbnXaBaHe H a CpOKa h. no-pa~o. AKOMoxe Aa ce npMcTbnMM K ~ c Mn e q ~ a n ~ 3 ~ p Ha 06pa60~Ka Ha K O C T H M T e JlMqeBM T p a B M M , BCMrKO Ce M~B~PLU B eAMH B ~ eTan, KaTo ~ a i - ~ a nce pe npaeM ~ ~e$uHMTMBHaTaX M P Y P M C l H a 06pa60~~a Ha KOCTHMTe CTPyKTyPM M ce aaebpluaa c ~ a Ha 3 MeKonKaHHnTe ~ Hapatiflea[PM TpasMnTe B nuqeea~a 06nam emeH eneMeHT Ha HHR. cnetuHaTa noMoqe MaHyanHaTap e n o 3 ~ M qspeMeHHa~~ Cxe~a~ H a af l e l c ~ s ~ Ha eO K ~ ~ B ~ nbpBa ~ M n Ro~oq Ta ( T ~ ~ H C ~ O P T ~~0611nM3a~MR H~) Ha $parMe~~UTe H a Ha nocTpqan B nnqeso-renm~a~a o6nac~ ~arne~ KocTMTe, ~ 3 r p w a nuqeBMR q ~ ARn Ha repena. TRM M a 3a

PM

CneCTM Ha ~ O ~ H M 60flKM~e R OT T p M e H e T O Memy K O C T H M T eI l O B b P X H O C T MH a $parMeHTUTe, fl0npMHaCR 3a CnMpaHeTO Ha KbpBeHeTO M B b 3 C T a H O B R B a HOpMaJlHUTe B~~MMOOTHOLU~H M MR e w n 3 r p q a q ~ nMqeaorenlo~e CTHaTa o6nacr CTpylcrypM. Tosa IlpeMilaxWM Bb3MOXHOCTTa 3a flpM'iMHRBaHe Ha flMCnOKa~MOHHa ~C$MKCMR.

uen fla

TaKa:

1. Ornep Ha nocTpqanuR po mlormclHaTa nuHun. 2. Y 6 e ~ a s a ~ Be IlpOXOflMMOCTTa Ha flMXaTenHMTe

IlbTMqa.

3. Orflep HaycTHaTa KyXMHa M IlO'iMCTBaHeTO h C Y B M T B MapnR M n M npnnwa n p b c ~ OT vlnyqu Tena, cnloHKa n KpbB. BCM~KM IlOflBMXHM npOTe3U Ce M 3 m a T .

Ha ropHaTa rentocr, a AontiorentocTHMTe $ p a m e ce ~~~ MM06MnM3Mpa~c nouoqTa Ha p a 3 n w . 1 ~ KO ~H C T P ~ K ~ M M n o f l 6 p q ~ ~npM q ~ .CbCleTaHMTe$ ~ ~ K T Y P Ha M KOCTMTe Ha CPeAHMR IlMqeB e T m ( ~ H M q B O T O Ha AbBKaTenHaTa PaBH M HH ~Ha ) flOnHHR nM4eB e T M (nonH H B O T O Ha AbBKaTeJlHaTa p a e ~ ~ ~ ~a ~ )o, 6 n n ~ a a q Moxe w ~ Aa ~ ace nocTnme M C a M O C nop6p~q~MK. ~oCT~B Ce R n0fl flOIlHOclentoCTHMTe $pame~ M~ ce~~ 3 ~ eHarope, r n ~ KaTo ce $ M K C M ~K ~~ M wanKaTa u n KeneTo ~ Ha nocrpqanMR MnM K ~ M ~HHTOB~ npeepbs~a Ha csopa Ha qepena. npn CbqeTaHHTe ropHoM flonttoclenlocTHn $panypn, npu ~ a ~ e r n Ha ~ ponHa~e~o Ta renlocr Harope ce yenMclaT M $pame~~me Ha ropHaTa renlocT K ~ M OcHoBaTa Ha clepena. C Toea ce Har.4anRBaM

4. O e n w e a ~ e Ha KbpeeHeTo ( a ~ o Mua ~ a ~ o e a ) . 5. V13cnep~a~e 3a eaeHTyanHn $pawyp~ Ha qenlocrHMTe KOCTH.

6. AKOIlOCTpQaJlMRT e B6 e x b 3 ~ a ~ M M n e MM M ap n O K a 3 a H M R 3a T O B a , Ce d p b q a no nblqe.

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l l o c o r e pep ~ ~B~ cxeuaTa ~ ~ a ~ e l ce c M~ ~ M~ ~ H~ B FIe 3 a B M C M M O C T OT AOMHHMpa~MR @ K T O ~BKJlMHMqHaTaKapTMHa IlpM B C e K MK O H K P e T e H cny'iah.

T ~ ~ H C ~ O ~ eT WM e~ HM ~O H M e H ~TT npM OOKa3BaHeTO H a cnewHaTa nouoq. K ~ Hero M ce npMc-rbnBa caMo cne4 KaTOCaOBn~RHMXMBOTOOnaCHMTeCbCTORHMeMeH3RCHeHO B KaKBO flOnOXeHMe, Kbpe M C KaKbB TpaHCnOpT q e Ce OCbqeCTBM.

H M 3 M a Ha TpaBMaTa. Cn0pep T O B a $palcrypkITe Ce penFlT Ha Hanperw ( n e p n e ~ p ~ ~ y n n y~ap), pe~ K ~ C M (ypap noR bbn), CnMpMOBMflHM ( ~ O T ~ ~ M O MeXaHM3bM H~H Ha TpaB~ a ~($WT. a ) 3.3). flpoume $palcrypu ca O ~ M K H O B ~ H M pey$par~e~ T~, PasflpoGe~~ ca ~~ ee s nnonyqew , npM noBep~ra~ Ha a HenpeKbwaTara cnewHa M ~ ~ M ~ M H C K THM ~ $pamyp~. Texm TpaaMM, KOMTO M M a T noee'ie OT pea $ p a m e~~a. IlOMOu3anO'iBa OT MRCTOTO Ha ilPOM3UleCTBMeTO M 3aBbpPaa~emea~e Ha ~ $palcrypa~a o ce onpeAenR OT nourea B c n e q ~ a n t 1 3 ~ p a ~ KnMHMKa. a~a np~ T p , a B a B M m e Ha noxeHMeTo Ha ~ M C T ~ ~ H $M pa H m e cnpmo ~~ npoKcunnanK ~ ~ ~ H M OPTOlleflMCIHaTa ~ L I T ~ T e P M M H O n O M R e 3qbnXMHMRB MrMTaJlHaTa P a B H M H a TO e flOp3aJlHO MnM BeHTpMTenHOyCJlOBMe 3a RCHaTa M HeflByCMMCneHaK O M y H M K a q M R H O , B b B $~oHTUIH BapyCHO ~ T ~MnM BallryCHO. O C B ~ H Mew)' eKMnMTe Ha IlpMeMHMTeOTReneHMR M CneqMaTOM p a 3 u e c ~ ~ aMoxe ~ e ~ Ra o e: p a ~ e c ~no ~ urMpwia a ~ e nMCTa KOHCynTaHT. (dislocatioadlatus); p a m e m ~ amcKbcmaHe ~e (dislocatio ad longitudinem); p a m e c ~ s a ~ nop e bmn (dislocatio ad axim); PoTaqMoHHo p a m e c ~~a (dislocatio ~e ad ce KaTo npetcbcBaHe qenocna Ha KOCT peripheriam). M n M Ha Xpyl4ln. Cnep~lnTe OCHOBHM T ~ ~ M M Hca M 3 w b 1 ) ~ lM Yec~o ~ ~ ~ M ~ C T e B TaKoBa, ~ H ~ T ve OMoxe pa ce onvTenHM 3a onlrcaHMeTo Ha $palcrypa~a: W e npaBMnH0 C a M O B CbWTaHMe H a H R K O M OT IlOCO'ieHHTe 3aKpMTa M n M OTKpMTa; -Towioonpepenme ~ a a a c e r ~ a ~ a ~ a ~ o c ~ ; TePMMHH. OCB~ T H e 3 M 3wllXVlTellHMO C H O B H MT e P M M H M e nonenocoKa Ha $palcryp~a~a n w M R (~oca, Hanpewa, 3H0 n03HaBaHeTO H Ha H R K O M RpyM, KOMTO pOnbnHWTenH0 cn~panoa~p~a); M O ~ M $ H ~ HH ~ yTowiRBaT ~T xapamepa Ha 4palcrypa~a: npocTa apamypa M n M pa3Rp06e~a TaKaaa; nbnHa M HenbnHa $pamypn (cbc 3 a c ~ r a ~ Ha epaTa M n w H a n M w e M cTeneH Ha p a 3 ~ e c ~ e a ~ e . C a M O Ha e p M H M R KOPT~KC); M3BbHCTaBHa M BbTpeCTaBHa O ~ M I X H MM ~T OueHKaTa O Ha $palcrypaTa ~ p ~ 6 fla ea $pamypu; a~yn3~o~~a$pa~~ypa-nony.ca~ace npM onbH 3anO'IHe C TOBa f l m M TR e OTKPHTa MnM 3aKpMTa. A0pM M U3TPbrBaHe nOp B ~ ~ ~ ~ ~ Ha T M B Y C M K y n ~ H M T CMnM; O T e 3 M ManKa Koxtia paHa B 6 1 7 ~ 3po 0~ $palcrypa~a ~ R npeapbua $pamypcl MuaTonpeAeneHM npegMneKqMoHHMMecTa; 061B OTKPMT~ (B ~ # O ~ O ~ M C M ~ M C H b n M HapyMaTa). R OTKPMTWT~ Tn ( M M ~ ~ K T U ~ ~ $pamyp~ HM) C ~ C ~ O H M O ~ Konanc; ~H $paKTyPM ca MCMHCKO CnelllHO C b C T O R H M e B TpaBMaTOnOnpM $palcryp#~e Ha TenaTa Ha npewneHMTe ~a6nlopasaMma ()I(MBOTOM n H ~ p a h ~ ~ ~ o 3 a ~ ~ pp aew p~ a )~ . aq~ Me B ~ M B ~CH K ~ O M n p e C M R (KOM~P~CMOHHM $palcrypM), Te ce macn$nq~par TaKa: ROKaTO npM $palcrypMTe Ha T ~ M E ~ ~ ~ H nnaT0 o T o B~MB~H~ I c-ieneti c paHa, no-uan~a OT 1 cm, nonycletia e c penpecm ( ~ e n p e c ~ o $pamyp~); ~~b naTonomwM OTBbTpe-HaBbH (T. HaP. OTKPMTM I ~ ~ H K T M$palcry@PM~HM $~~KT~PM $palcryp~aTa nMHMR M M H a B a npe3 KOCT C PM). ~Tpylcrypa; H ~ CpeqaT Ce npM RPOfleHM3a6017RBaII cTeneH -c paHa ~o 5 cm, 6e3 ronRMo a a ~ b p c ~ ~ a ~ ~e~ H O P M HMR Ha K O C T H a T a CMCTeMa, Bb3nanMTenHM ~ ~ ~ o ~ F I B ~ H M 683 ronmo p a 3 ~ a ~ ~ Ha aa Mew ~ e nKaHM. T Y M O P M , ~ O ~ ~ C MnM T M~ ~ $ M ~ M B T M O ~ M R H ~ M TT.~ H.; Ill cTeneH c O~WMPHM KOMM nauepaquM, ronmo c~pec+$palcryp~ (onpepen~~w B MnHanoTo KaTo .$palcry3aMbpCRBaHe U pa3MaVKBaHe Ha MeKM T b K a H M , 'ieCT0 C PM OT popa" clnu .Mapwoen $pamyp~") pbnxaT ce Ha paqpo6e~a KOCT. nOBTapRqaCe TpaBMa C HMCKa MHTeH3MBHOCT. Te 3aCRraT lllA c o6wup~o oronBaHe Ha Kocna. RpeflMMHOROJlHMTe Kpah~MqM npM CnOPTMCTM, TaHqbOPMH 1 1 1 6 c oroneaHe Ha KocTTa M OTnenRtie Ha nepMocTa. BOeHHM. lllB C HaJlMclHa ne3MFl Ha MaMCTpaneH Cbp. O~MC~HM Ha~ $pawpa~a TO ~ p ~ 6 pa e anpoClbnxM c TO'iHOTO OnpeflenRHe Ha aHaTOMMqHaTanOKaflM3aqMRHaMMeHoaaHMeTo H a Kocrra, n a ~ e p a n ~ 3 a M qnpw61-1~~~~a flyKcaqMMTe Ce ~e$MHblpaTKaTO nbnH0 T P ~ ~ H TpaBO ~MT~~HO pa3nonome~~e TO Ha $palcryp~a~a nMHm ropM e H O pa3MeCTBaHe Ha CbOTBeTCTBall#lCM apTMKynMpau(U Ha, cpepHa MnM IonHa 113 npM pbnmTe Tpb6eCTM KOCTM. n O B b p X H O C T M . %CTMVHOTO pa3MeCTBaHe Ce HapM'ia cy6~ ~ O C O Ha K ~ $T P~ ~KT~P nMHMR H ~ AaBa U a H H M 38 MeXanycaqMR. flyltcaqnn~e M cytiny~caqnn~e ce onMcBaT cno-

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OCO~~H npn O naqnewnc nonmpaeua. Toea e Kotiqenqnn, pasan~a npeanocneAHme10-15 roAnHn, K O ~ e O~ o ~ a s a -

npu npnCTnraHeTo Ha naqnema B 60n~nqa~a OTHOBO ce npeqeHqeaTAnxaTenHmena-rnqa,AutuaHeTo n uupynauma. n o c ~ a s e ~ m WUHW e nnn ~ p y m u ~ o 6 u n u 3 ~ p a ~ # MnpM#3nOn3BaHeHaBb3MOWOCTMTeHaCbBpeMeHHaTa a~ec~e3nonoru~ H pea~n~aq c~ na ~6 n n ~ a BbTpeurtia ~a cpeucTsa ce npoaepReaTOT cneunanwcT; He e ~eo6xopnnnn 6bHwHa@HKW.~R Ha 4palcrypme Moxe pa ce MBB~PMO TRXHOTO ~e3a6aBH0 CMeHRHe, a K OT e OTrOBaPRT Ha flBe urnaep~aracnepnpmopme~~merepen~o-~o3br~n ycnoana: PbaHO-KOPeMHH HHTePBeHqUH, npw ~ 3 6 p a H Cny' ~ iaM M a) noc~ase~n ca npaelm~o; , eAHOBpeMeHH0C TRX. 6) nponycKaT Ro-nbrUTe. OCHOBHH TeXHHKH Ha KpbBOCnHpaHe H HMO~HJIH3anorsa ce a m n x u ~ e n ~ npoTnaoTeTaHnrHa a npo3aqu11 @nnamn~a. npo~n~ora3ra~rpe~ npo$nna~~n~a o3~a ce 1. BpeueHHa XeMOCTa3a npaen no noKa3aHnR. Ro-rpa4nme ce npaamno no~aaaKpbBOCnllpa~e~0 Ha MRCTOTO Ha lPOM3UleCTBMeTOH B HMFI, HO HRKon OT TRX ca 3clqbnmentiu, Ha: UIHAHH cneur~o~o npneu~o o ~ ~ e n e ce ~n W e ~ B ~ ~no WHRKonKo M npeurneHn, ~a3, rpbneti KOW. Ha'iMHa: npn OTKPHTW@patqpn,~ o m ca o npaennHo wuHnpaa) Anpema Koh4npea.w ~bpxy paHaTa, ocbqecTseHa HM B fl060JlH~'iH~fl IlepHOA M He nOKa3BaT rOnRMa BbHWHa rpes c-repnn~a npeapwlta - MeroR, n o ~ x o m 3a q noTncxeMoparnR, cBanmeTo Ha n~o6nnnaaqnma e peltio pa ~a~e~a~e~o3~0~bp~e~ennnaaap~epn ce nsebpun eAaa B onepaunoHHaTa, noA o6qa aHecreOT neManKlrl WoBe AncTanHo OT naKaTR, pecnemHBHo 3~~,~enocpep~~~e~onpep~onepa4nma. KOnRHOTO; ~ P M30nHpaHM H 4patqp~ Ha K ~ ~ e AOnyCTM~IHH ~HT~ 6) pnpema MatiyanHa KosAnpecw sbpxy apTepnanMO BHUMaTenHOTO CBXlRHe Ha C I I M O ~ H ~ M ~ 3apa,4# ~~MRT~ n p e q e ~ ~ a ~ a ~ a u n p l c y n a q n ~ ~ a w n p o ~ e p ~ a ~ aHKe a a ~ MaMCTpanM a r e ~ a ~ npoKCnMX!HO OT HapaHRBaHeTO (+W. 3.4). 3 a ~ o n ~ m ~p ea i I ~ nTOM q n e a. fernoralis,3a ropHnTe KOMnapTMeHT-CMHflpoM. -a. axillaris n a. brachialis; npnIcpmTereHnRHa rnaaaTa Ilp~opln~ Ha e cneqman~3upa~a~a ~~ opToneAmrMoxe Aa ce onma npmncwte Ha a. carotis cornrnunis. R M ~ ~ K KOMnpeCl T H ~ TlR~MOXeRaceK O M ~ ~ H HHCTPYW ~ ~ C MeHTanHO3~nnBaHeHaKPbBOHOCHHRCbfl,aKOTOBaCe qMTe e OnepaTMBHOTO Bb3CTaHOBRBaHe Ha ne3MFITa Ha oTAwe. MaMCTpWleHapTepwWeHCbR; BCM'lKM AMaMOCTHVHM npoue~ypn, sKnlornTenHo ap~epworpa@nma, ~ p ~ 6 Isa ace M3BbPWaT B MaKCHManHO 6bp3 C P O K . Ha BTOpo MRCTO H A M XMpypMrlHaTa o6pa60TKa Ha OTKpMTHTe MeKOTbKaHHMHapaHRBaHMR M O T K P M T M T e @patqpn. C n e qaTeneH ~ n a w c MMHMM~M 10 1 cTepnnHun/ nnnamucemnwn paneopnce npeMaxsaTEtirKn r y w n Tena n ce e~cqn3npa~ peemann3npa~n~e TbKaHn. npn e~cqn3n~~acecnep~a~cne~~~~enpa~nna: - KOXaTa Ce neCTM MaKCMManHO, KaTO e AocTaTb'iHa C a M O MHnMMeTpoBa p b 6 4 0 eKC4M3HR; ~ -MycKynmecee~cu~3upa~ HawnpoKonAo3~paeo (no~a3a~en 3a ToBa e ceexoTo Kapaetie n KoHTpamunHOCT); - @acqnn~e ce pa3qen~a~ MaKcuManHo; - KOCTMTe Ce UwT, KaTO Ce IlpeMaxBaTM M 0 CUnHO 3aMbpCeHn M OWBMC(H0 nLlWeHH OT K ~ ~ B o c H ~ ~ ~ R B ~ H ~ AenepnocTnpaHn @patwemu; B) IlOcTaeRHe Ha TYpHMKeT. Tosa C e M3BbpWM Ha -HepBflTeMC~OMnMRTaHeCeeKC~M3MpaT. c a w e nnecra, ~ a m n o AnpemoTo nprncKaHe (HO He n 3 w n m e n ~ ce o wnMa MaTepnan3a M M K P O ~ H O ~ O - Ha UIHRT~). 3 a j p m e n ~ ce o perucrpupaT O C I H Mrac ~ M

MHWEl3OU'M~MHWUJE~~ neo~admhtl 'M)ltl M)~~YYI(uou M 0 'H~WOH* HadmUE)I '81WOY E H albwqdu M (01 -o~sladkuou MH~M~~E (L' $ - 'JM$) ~EH9qd.l H a M m-ounUox) B I E X L H U EH an~aUoiuge~ m w o w c q e !Elt&E~hdMh 8 tfMHahIh~3 mUHB :adh ledne~ungown a3 ~ e d e tlntiual u~ -EJMIU-OH~OUO E Ha l M ~ a ~ E ll 0 tlMht?M~ Uadou3 ~0~ - ~ ~ U aa d H uEU ahego olaon 'amdn3wn$o~ung~n ~~ouoleweedl1~nlrenhau3 !l~awJa3 1 0 oww mmdqee~ a ,: EU mUau:, ~ n ~ s d e a d Meo3uw u nH t ~ l e w a 3e e H ~ ntitlam elaeUEHatrehn?axq -duuhdnh M U M MHMm Eadh ~ ~ M ~ E E M UElE903UM M ~ O WJ M :malMh 'aeogsd uHmn amdlm -MHclfed!4 EH OI~H~?~HHHITI MdU UUM~HM~U aMHBOH30 10 EYMHIjEdY E H WHawaUa MHdbhdl3 al~HaUadeAaH .('H ' l HH ~ u ~ u ' J W~ EU~ 'LQ ~l ~ t l ) m3Uad3 MHhqd E H ~ H E ~ E E uB U E~ 'EBMLIEMOB~~Y ~U RH aHeBYlreWEH E E 'E1 -VOU Eadh H L M '(g 'JH$) (MHH0HhYEdl 'HHhHlEWBaHU 'MH -EYUOg E H OlaHeBEhYaU90 E E J E W O U 3 0laHEdMHMm b u d ) nHnm n~aUaacnodu o~h~dge 3@ MUM 'nnmdeadu 'ElEYUOg M E M 0 1 0E H ~HEBE~MHB~JO nnaw 3 MUMmrndqes~ a3 ~ ~ ~ H L M e ~~e ~ W~ a Mw a d e tMbMl~90~ RHHa~adg M 'Z 'JH$) EYMHIjEd!4E Ht l M W a X 3 M

m m

BE EMMHI?B~W EH oltnlhmaua M Uau eH olaHtleenou !a~ehadeA O H H E M U O H a W OHUalUH

-U~UO E H ~O H E e J H g E M t? aHEetllE~Uu0~ O H ~ U E I ~ O U -

' ( ' S '

!3uhu ~ada@dau 'no10

E H EY3hUl0 a3 1

e ~ u a W o d EH u olamtlgcn Uau~o 3 u!u OE ~wa3e ~ a ~ M 01 ~ E Y d 'OlaHtleel3OU h E HE ~ ~ H M

102

TpaB~amo~ozultnu cneurnu ocmonnun

oTc-rpatin Ha rnasaTa m $n~cnpa~n c ~ x e 3 n a neneHKa ~a npea VenoTo, ~ a b p $ ~a n 6 p # ~ RKH; ~u -~opaKo-ny~6aJleH rpb6~aK (@MT. 3.8 M 3.9)-$a6p~r H l l AbCKM 38 P ~ ~ H ~ M CMI O H ~H ~~H~~U IlO M APbvHM R, AbCKM C @ M K C M ~ HaTa3a, ~H~ VbPHMR KOUI, rnaBaTaM K P ~ ~ ~ H M ~ M Te; -~ a 3u~o6nnn3npa ce vpe3 nocTaeRHeTo Ha naqneHTa Ha TBbPAa IlO~OXKa, O ~ ~ ~ ~ K H OBbB B~H $IleK~#fl O B ~a306eupe~ n~KOneHHMTe ~e C T a B M (T. Hap. , , X ~ ~ ~ U I K O nonoxe~ne?; npn H ~ C T ~ ~ M T~~ HO MB $patnypn M C ronm KpbBOM3nMB C YCneX C e Y ~ O T ~ ~ BoeHHMTe ~ R B ~ TSIHTMUIOKOBM nHeBMaTHVHM IlaHTaJlOHH; - KJlloclUl@ ($W. 3.10) - TR Ce M M O ~ H ~ M ~HafiMP~ nectio M ~ @ H K ~ C H ~O p e npeepwlca 3 m n .oc~op~a", ~omo V e C T O e kl ~ ~ ~ @ H H H T H ~ B~ H0 ~6 T~ ~ l m n 3 a qTe3H ~ f l 3$pa~.ry8 P M ; - MnwHnua ($HT.3.1 1,3.12,3.13) - n~o6nnn3~pa ce ~$~KTMB B~ HAO ~ Y K ~M M (bne~clrl~ R B naKbTtiaTacTaBa KaTo KbM rPbflHl R I KOUI vpe: ce @n~cwpa a mpna nnn npeepba~a IH a Desault;

- n a ~ a cram ~~a - nopmn onac~ocrra OT w o e n H/ nnn Hepetinnesnn B ~ a 3 n o6nacr ce npennowa pnmnHa nnn n ~ e a ~ a ~ n~o6nrnsaqcl~ nv~a vpe3 H R K ~ K ~ BW B 41a6PnVHH W M H M ,~036OnR MOHMTOpcl ~ ~ ~ paHe Ha W O W HeBpOnOlW~H#R CTaTyC;

- npemtwtu~mqa UKWWI p n w a mm m m a n)l06WImC ~0 6 e H Ha naKbniaTam ; npn m n u o~onorpHwieHaTa c 1 . m Moxe ce omam JlaKbTm C ~ Q ~ ~ H H ;

-~M~~HIIP~CM(@W.~.~~)--~C~CT~T~-

qHa JleBKOnnaCTHa M M O ~ W I M ~ ~ ~ BM CbOTBeTHOTO FI 06ne~veHo nonoxewe; -~a306e~pe craaa ~ a ($Mr. 3.1 5) - eAHoTo paMo Ha W M H ~~ Tp ~f 1 6 s a ~~ Oa C T M ~ ~X OOT~ ~ M ~ O ~T ~O O R O ~ HnOnl M ROC Ha nonaTKaTa, a ppyroTo ce npocTMpa OT nepMHeyMa 40 xopnnoTo; - 6e~po - BpeMeHHaTa M M O ~ H ~ U ~ ~ ? ~CbuaTa, M R Kamo npu ~a306enpe~a~a cTaea; HanocneAaK c ycnex ce M3nOn3BaT $a6pnr~w TpaKUMOHHM UlMHM ($Mr. 3.16); - KOnRHO - 06x~aqa C e UenMRT AOneH K ~ ~ ~ H P OM K MHiEMHaJlHaTa bHKa C PMMAHa M n M IlHeBMaTMVHaWMHa; - no~6e~pn4a ($Mr. 3.1 7) - xqbnxmentio ce o6xeaqaT KonRHHaTa M r n e 3 e ~ ~ craBM; a~a - r n e 3 e ~ cTaaa ~ a ($MT. 3.1 8 n 3.19) - oceeH pMmnHa M n MIlHeBMaTHqHa,MOXefla C e M3nOn3MMeKaKOMnpeCMeHanpeepasKaMnMTaKaea,HanpaseHaoTneeKonnacTHM n e m ; npn ppeAM Ha AXM~~COBOTO cyxoxMnwe rnesetlHaTa UaBa ~ p ~ 6/Ja sa C e M M O ~ M J ~ MB~eKBMHM3bM; M ~ ~ - xoyno ($MT.3.20) - pMrtqHa MnM nHeaMaTMqHa H M O ~ M ~ M ~ ~ F 1 0 ~ M K O R n R H O T O HJlM MeKa H M O ~ H J ~ H ~ ~ ~ npn n o - n e TpaeMM. ~~

 107

- . ca: , . 0.5-3% . : 1. . 2. . ce . 1. . 2. Ro-.

1. - . 2. - . 1. . 2. . 3. . . .

0.5-1 % .
: 1. . 2. . .

ce . ce . ce , . 1. . 2. . . .

3. .
4. .

1. . 2. . 3. . 4. - . 5. . 6. . 7. . 8. . .

108

Bankart - Burrows.

1. , , , . 2. . .

-
ce , .

-
1. - . 2. - .

- - ce . .

: 1. . 2. . 3. . ce .

1. -. 2. . 3. " . 4. ca . 5. Ro- .

1. - - ". 2. . 3. Ro- - , - ce -. 1. . 2. . 2. . 4. .

1. . 2. .

Dezault, . 1. : ". 2. : : , , .

Dezault, (. 3.21.).

CHMllT~~altl~a
60nKa npM n0~0if M HeBb3MOXHOCT 38 a K T M B H M ABMxeHMR. n a u ~ e m npMAbpxa ~ cbc q p a a a ~ a CM pbKa K~~RHH MK r0~~~06lrlnM3Mpa.

Qwr. 3.21. no Primary Surgery, O x r o d , Med. Publ., 1987

Cneur~o 60n~ur~ nerewe o

1. MaHyWlHa penO3M4MR M H M O ~ H ~ M ~~flp!BpbUMR 3 ~ no a Dezault, R. Jones. 2. OflepaTMBH0 KpaBHa peflO3MqMR, MeTWlHa O n e OCMHT~ (BMHTOB~, ~~ K M ~ w H ~ ~ o Bnrn~) M M nnacTnKa Ha pa3KbCaHMTe Bpb3KM((I~C~MW~HII ~ ~ HM TM M Y C K Y n H MTpaHc~~o~M~MH).

Ycnom~e~~n
1. S o n e a ~ e ~ o npn a ~paif~ ~~ a A ~ K UMM$ R ~ ~ K C M FB I paMeHHaTa crasa. 2. HepenOHMpaHMTe nyKCalJMM - K03MeTMWH ne$etcr.

PM

Qnr. 3.23.

1 10

TpaB~amo~orultn cnewnu u actnonnun

1. Tnnnr~a g e @ p ~ a Ha q ~KnlorMqaTa ~ n p paa~ec~ 1. C ~ y n e a ~ Ha e KnlornqaTa. 2. Vlannrea~e Ha a ~ p o ~ n o - m a a ~ ~ y ncram. a p ~ a ~ a Teatie Ha 4 p a r ~ e ~ ~ w e . 2. KOCT~H npar M Kpenmauw Ha 4 p a r ~ e ~ ~ m e . 3. Crynea~e Ha cTaaHaTa noebpx~oc~ Ha nonawaTa. 3. llanna~op~a 6on~a. 4. Crynsa~u~l B ropHaTa TpeTa Ha paMeHHaTa KOCT. 4. nMarH03aTa ce noTebpWam p e ~ ~ r e ~ o r p a @ f l o 6 o n ~ n ~noseAeane o H neqeHne @C W TpaHcTOpaKalleH npo@Mn. MeKa n ~ o 6 n n n 3 a q Ha ~~ KpahHMKa B flpeBpb3Ka no Dezault, TpMannHa npna Inn MnTena.

Cnes~o ~OJIHWVHO nesewe

CTBaHe no MeTOAMTe Ha ~ypocrat, up er, Matt, Kocher, Stimson, c nocnelaaqa M M O ~ H ~ M ~ no ~ Dezault. ~ M R 2 . O n e p a ~ ~ ~ ~ o n e r e ~ Heycnex ~e-npn Ha MaHyanHaTa pen03MqMR C e M3BbpWBa KpbBHa peIl03M~LIR.
1. Yepexqa~e Ha Hepeyc aKcMnapMc. 2. TpaBMMpaHe Ha nneKcyc ~ P ~ X M M M C . 3. J l e a ~ Ha ~apTepnR aKcMnapMc. 4. Pyn~ypa Ha cyxomnMeTo Ha ~ y c ~ y n cynpacnnyc HaTyc. 5. Crynea~eHa roneMMR Ty6epKyn Ha paueHHaTa
KOCT.

MeKa M M O ~ H ~ M ~Ha ~ ~ KpahHMKa M R B npeBpb3Ka no Dezault, TpMbnnHa Kbpna #nu MMTena. 1.6e3~pba~o HaMecrmHe n u ~ o 6 u n ~ 3 a q Bu MeKa ~ flpeBpb3Ka T M n .0CM0pKau. 2. O n e p a ~ nereHMe ~ ~ ~ o no cneurHocT ce u3eapurea npn OTKPMTM 4 p a n y p ~ M npn npenceatie Ha apTepnR cy6Knae~n:p e n o 3 u q ~ H~ ~ M K C ~ ~ CU pR a 3 n ~ ocreor~~ crn~e3~ cpeRcTea. n

Lnaronp~m~ npn a nwnca Ha ycnoxtietiMR.

'leno~aH npHoplrreTH
OTH~MT~ rec-ro ~ H cpeqaqa O ce 4pamypa 6-8% OT CVyllBaHMRTa Ha KOCTMTI. PRAKO cpeqaqo ce crynmHe OT 0.5-1 % OT ecMrKM
C.lyflMHMR.

C~OHT~ 6o HnH ~a npM ~ O n M T 3a RBMXeHMe B ppefleHMR K P ~ ~ H M Kna4~eHl'bl . npblmpXa CbC 3ApaBaTa CM pbKa ~ p a k n n ~ro a n~o6nn~snpa.

6. C r y n m ~a ~~ cnwa ~ c~anynae.

5. Opamypa npea x ~ p y p m r ~ a UIMRK~. ~ a ( $ ~ r 3.24) .

1. Oupa h n ~ Bao6nacna ~a p a ~ o M ~n oo n a ~ ~ a ~ a . 2. O r p a ~ ~AaMxeHwR r e ~ ~ B paMeHHaTa cram.

n~amocnr~a
1. nody-r~~a c(mp~a~ Ha acaMaTa nonaTKa - cwnTOM Ha Shornoly.

2.6on~a npM AMuratte M nannaqw. 3. l l p nannaTopHo ~ wscne~ea~e -K 4. p ~ a r ~ o 3 ce a ~noTBbpXqaea a petrrre~orpa$c~~ Qac M np

Mem t1~06nn~3aqn~ Ha ~ p a h ~ B n npeapwlca ~a no Dezault, TpManntia Kbpna. 1. M e ~ M a M O ~ H ~ M Ha ~ ~ KpahHMKa ~ U R B npeBpb3Ka no Dezault. 2. l l p BbTpeCTaBHM ~ p a s ~ e c $pamyp~ ~ e ~ ~ - onepaTMBHO: KPbBHa penO3M4MR M MeTNlHa $ M K C ~ ~ Ha M$parFI MeHTMTe.

Y~TMPM CemetrrHa K ~ ~ C M ~ MHa Kp ~a~sM ~e Rc ~ e ~ 4pamyp~ no Nier (~AMH nnn noaere OT reTMpMTe roneMM cemema ca p a s m e c ~ e Ha ~~ 1 cm Mnlr atirynnpaHM Ha 45"). 1. peycemetrr~a AMcnoKaqMR: n 3 0 n ~ p a ~ pasmuo saHe Ha rnaeaTa (W HMBO aHaToMMrHa u l ~ h ~ a Ha ) , ocTa (Ha HMBO xMpypmrtia w h ~ a ) , ronetmn Ty6eplcynynn M M ~ K M Meplcynynn. R 2. T p ~ c e r ~ AMcnoKaqMR: e ~ ~ ~ a pasuec~e~a $pamypa Ha mpypmrtiaTa W M A K ~ c $pamypa Ha Ty6ep~yny Mah0p M MHTaKTeH ~ydeplcyny~ MMHyC; pa3MeCTeHa Qpamypa Ha xMpypmrHaTa tu~Ana c MHTatcreH Meplcyny~ ~aAop M $patcrypa Ha Ty6eplcyny~ MMH~C. 3. Y e ~ ~ p cernnetrrtia n AMcnoKaquR: cynmHe npes aHaTOMMqHaTa L U M ~ KM~ C'iYnBaHe M pa3MeCTBaHe Ha AmTa T y 6 e ~ l c y ~ a .

1, l l a ~ o n o m r noAenxtiocT ~a M KOCTHM KpenMTaqMM. 2. OTOK M Hapyuetia K O H $ M ~ ~ P ~ Ha ~ H paMeHHaTa R cTaBa. 3. HapyllleHMa K T M B H M ABMXBHMR. 4. CM~HO OrpaHMVeHM M 60ne3HeHM naCMBHM ABMXeHHR.

5. Ro-rpa$uma noTsapXqaea ~ ~ a m o a a ~ $ac a, M TpaHcTOpaKmeH npo$#n. Cnoped TonMKaTa Ha 4pamypa~a ~ M B (Manchini): ~ T 1. Opamypa Ha Kany-r y e p c l . 2. Opalcrypa Ha aHaTOMMqHaTa ulMhKa. 3. Opamypa Ha Meplcynynn ~ahop. 4. Opamypa npes roneMMn M M ~ K M q6eplcynp. R

1. Crynea~w~l Ha hlornqa~a. 2. JlyKcaq~~ Ha paMetiHaTa cram. Ha ~ K ~ O M M O - ~ n a a ~ ~ cTasa. ynap~a 3. Jly~caqn~ 4. CclyIlBaHMR HaCTaBHaTanOBbpXHOCT HanOnaTKaTa. 5. AMa4M3apHM cryneatiMn Ha paMeHHaTa KOCT.

Me~a M M O ~ M ~ M ~ Ha ~K ~ P M~ R~ H M BK npeBpb3Ka ~ no Dezault, TpMbrbntia mpna unln Mmena.

Cnelu~o 60flH~~ neveHHe O

1. MeKa M M O ~ M ~ M Ha ~ ~~ ~p MaRi i ~ B unpeepbsrta ~a no Dezault. 2. B M C R M~ ~ C no Caldwell. 3. flnpetcr~a ~KCT~H~M nocne~sa~a R, ~3a4HR.

nocTMraHe Ha swosonmen~a peno3~4 no ~6~e 3 ~ p b ~ e ~ Ha'iMH - KPbBHO HaMeCTBaHe M MeTallHa OpeOCMHTe3a (KH~WH~~ MrnM, O BnnaKa U M smwroae).

Bwr. 3.25.

6naronp~m~a B~~BMCMMOC OT T Tuna Ha CclynBaHeTo. PM WTBbPTU TMn CClYnBaHHR no Neer - aCenTM'iHa HeKpo3a.

npM nannauMR. 4. Ro-rpa@n~ 3a yrorHmHe Ha n ~ a r ~ o s a @ac ~a M npo$#n.

n ~ $ e p e ~ q u a n~~~ aa

r~osa

1. ny~caqnn Ha paueHHaTa cTaea. 2. C c l y n s a ~ B~ ropHa ~ TpeTa Ha paMeHHaTa KOCT. 3. C ~ ~ ~ ~ K OCVynBaHMR. H~M~HM 4, f l y c a q ~ Ha ~namTHa cTaBa.
~ O ~ O ~ H H noBeAeHHe ~ H O H neqerw

(nM06Mn~3a~MR Ha K P ~ ~ ~ H KM ~K T M R ~~ O T O C npeBpb3Ka T M n Desault M n U UMHMpaHe C Kpa~epoea LUMHa.

Cnelu~o ~O~HH~ neveHHe HO Knac~$~~aqn11

Cnopefl BMIa Ha @pamyp~a~a nMHMR: 1. fl0HM~y~MHallHa. 2. Hanper~a. 3. Koca. 4. C n ~ p a n ~ a . 5. Cemewr~a. 6. M H O ~ O $ ~ ~ ~ (@Mr. M~H 3.25) TH~.

1. M M O ~ M ~ B M U~ .WMH~" ~~M M nocneIeaqa R opTe3a. 2.M ~ H H ~ ~ ~ HaMeCTBaHe ~~TMBH UO MnCOM M M O ~ M ~ M -

3auMR - VbAHO-PbKaBeH MnC. 3. P n p e ~ ~~K~ Ca T~H~ MM nocneneaqa R rmcoBa MMO6nn~3aq~~. 4. npn HeewMoxtiocT3a awoaonmenHap e n o 3 ~ q ~ nereHMeTo e onepaTMaHo- Kpbetia p e n o 3 ~ q M n nneTanHa ~ ocTeocMHTe3a - c nnaKa unM MHTpaMeIynapHMcpeAcTea.
YCJ~OXH~?HHR

1. J l e m Ha HepByc pwnanuc. 2. fles#R Ha apTepnR 6paxnm~c d nnc. 3.3a6aee~o cpamaatie. 4. llcee~oap~po3a.

~ BeHa n 6paxua~

llpor~osa
f i n a r o n p ~ ~oceeH ~ ~ a , B cnyvame Ha ycnoxHeHng.

O~MKHOB~HO npM ~ H T O B M MC n O P T H MT p a B M M 1. flnpeue~ - npu nWaHe ebpxy n a ~ b M ~n M f l ypap no 3WHaTa M y nOBbpXHOCT. 2.klH#MpeKTeH- npM IlWaHe BbpV M3IlbHaT M OTBeA e H rOpeH K ~ ~ ~ H M K .

~ O ~ O ~ H Hnouefleuwe $HO H neseHHe

klM06MnM3a~MR Ha K ~ ~ ~ H M K ~ K ~ M T RC~ npe~pb3Ka OTO T M n Dezault M n ML U M H M p a H e C Kpa~epoea lUMHa M OTVMTaH e Ha qMpKynaToptiMR M HeBponorMreH cTaTyc npepw M cneA MM06Mnb13aqMfl~a.
1. MaHyanHa peno3~qm~ n npeepba~a no Blount. 2. M a ~ y a n ~ pa eno3~M q~ neplcyratitia ~ $MKC~UMR C KM~LUH~~OBM urn1 M rmcoea M M O ~ M ~ M ~ ~ ~ M R . 3. l l p Heycnex ~ Ha 6e3KpbBH0~0 neqetine ce npeAnpMeMa onepaTneHa MtiTepeeHqnR.

~UTOB M TPaHCfl OPTeH TpaBMaTM3bM.

1. A~peK-re~ ypap sbpxy namTHaTa cram. 2. klHpMpeKTeH- nWaHe BbPXY OTBepeH M eKCTeH3MpaH B naKbTfl ropeH K ~ ~ ~ H H K .

O r . 3.26.
nw)epe~qHanua flwar~osa

1. J ~ ~ K c ~ ~ Ha M naKbTtiaTa R cram. 2. opatcrypa Ha Monteggia.

Cnopep TonnKaTa Ha $pamypa~a: 1. @paKTypaHa AaTepNlHMR KOHpMn. 2. @paKTypaHa MepMNlHMflKOHAMn. 3. T P ~ H C K O H $patcrypM. ~~M~HM 4. ~ ~ H T ~ ~ K O H $patcrypM ~ V ~ H M (T M n M Y $patcrypM). Cnopep Riseborough M Radin. 1. Hepa3uecreHa @p-a Memy KanMTynyMa M TpoxneaTa. 2. P a a ~ e c ~ s a Memy ~ e KannTynyM M Tpoxnea 6e3 nopclepTatia P O T ~ ~ MBR ~ $~OHT~HMFI B nnaH. 3. P a a ~ e c ~ m c poTaToptia ~e pe$op~aqw~. 4. T ~ X KM OH O ~ O $ ~ ~ M~VynBaHe ~HTHO H a apTMKynapHaTa IlOBbpXHOCT C rOnRM0 pa3MeCTBaHe Ha K O H A M n M T e (ca~o Ha apTMKynapHaTa noebpx~oc~).

A~oepe~qwan ~~~a a r ~ o a a
1. Jly~caqu~ Ha naKaniaTa cram. 2. Qpamypa Ha Monteggia. 3. Qpamypa Ha oneKpanoHa. 4. P y n q a Ha ~ycKynyc 6~qenc6pax~n a~ ~ c r a n ~ a ~ a

My %CT. 5. Opamypa Ha rnaeMrKaTa Ha mremTa KM.

3. ~ ~ U M ~ npHAbpXa H T ~ T YBpeAeHMR KP~AHMK npM oKono 45O 4 n e ~ c ~ n . 4. Tpme WHOBHM KOCTHM IlPOMMHBHuMM, AmTa enMKoHRMna Ha xyMepyca U oneKpaHoHa He ca B caome HOPMWHM n03MqMM ( T P M ~ T ~ Ha ~ HNelaton). MK ~ M R 5. l l p e ~ ~ ~ w ~ uoxe u q aAa ~a e cocetia. 6. AKTMBHMT~ M naCMBHM ABMXBHMR C a HeBb3MOWM (npym~wpauo mnpo~ktene~we). 7. Hah-V~UO OneKpaHOHa e M3MeCTeH npOKCMMaJlH0 cnpmo enMKotiAunMTe. 8. Awar~oaa~a ce noTabpmam p e w r e ~ o r p a $ c -~ $ac M npo@n.
1. opamypa Ha Monteggia. 2. BbTpeCTaFiHM $pamyp~ Ha naKaTHaTacram.

1. MaHyaJlHa penO3MqMR M MnCOm M M O ~ C ~ ~ M ~ (3anrn~~e cKM~~H~ MrnM ~ OM B rnncom M MM06Mn~3aWR). 2. O n e p a ~ ~aKpbeHa ~ o peno3~qu~ n MeTanHam e ocMtrreaa (BMHTOB~, nna~n).

1. M H U M ~ ~ K npM T ~nqaHe H abpxy MsnaHaT ropeH

KP~~HMK.

2. Aupeme~,n p yAap ~ a naKbniaTa cram.

' l e c ~ o ~Hanpnopmm
Ha a~opoMRCTO no recroTa cneA nyKcaqMma Ha paMeHHaTa cram 20-30% OT BCM~KM nyKcaqMH.

npomo3a
6naronpnm~a npM nunca Ha ycnonweHMR.

Cllyneaue Ha Monteggia
npeflcraen~m crynmtie HanaKbTHaTaKOCT, npMRpyxetio OT ~ 3 ~ b n c l Ha ~ apWMantia-ra ~e rnam.

See~o~a H npnopwen
1-3% OT $palcrypwe Ha onop~o-C(~ura~en~~fl anapaT.

' l e m a U nprroprrrern
Cnopefl Bado, Boyd M Boals 60% OT $paKTypme Ha ynHaTa ca npMApyxeHM c nyltcaqnfi Ha rnaaaTa Ha navemTa KOCT ($HT.3.27).

Cnopefl Colton: 1. H e p a s ~ e c r e $palcryp~. ~~ 2. P a a ~ e c $pamypn: ~e~~ - aBYn3MOHHM; - KOCM M TpaHCBeP3aJHM; - pa3flpo6e~~; - $patcryp~-ny~caqnn.

n~ar~om~a
1. f l e w p ~ a q ~ Ha n mama. 2. C ~ O H T ~ MH nannaTopHa H~ 6onm. 3. H~B~~MOXHOCT 3a aKTMBHaeKCTeH3MR BnaKbTHaTa cram. 4. Hanpecl~a 6pawa M e q y $pame~m~e. 5. KOCTHM KpenniaqMM. 6. A ~ a r ~ o 3 a ce ~noTeapqaea a pewre~orpa$c -~ ~ $ac M n m n n .

KnacnQ~~aqu~l
Cnope~ Bado, Boyd M Boals: 1. n p e l ~ nyKcaqnR a Ha pqManHaTa rnam M $patcrypa Ha fl~a$n3a~a Ha ynHaTa c npema atirynaqw. 2 . 3 ~ ~ a ~ WHO-na~epan~anycaq~~ nln ~apawanHaTa rnaaa M $paKTypa Ha nua$usa~aHa ynHaTa cbc 3 ~ aHrynaqMR. ~ a Ta yn~a~a. p q ~ a n ~rnam a ~ aM $palcrypa H& I a y n ~ ~ ~a 4. flpefl~a RncnoKaqnn Ha pWwantiaTa rnaaa M $paKTypa Ha npOKCMMaJlHaTa TpeTa Ha pa,4MyCa M YnHaTa Ha eRH0 H U N .

l. Opawypa Ha Monteggia. e~~ Ha naKaTHaTa cram. 2. B b ~ p e m a $patcryp~ y lc a q m Ha naKaTHaTa cram. 3. J

1. r~ncoea ~~oGunn3aqw~ npM ~ e p a a ~ e c $pa~~e~u

TyP".

2. O n e p a ~ l neveHne ~ ~ ~ o npM pucnoqnpaHn cclynaa-

HMR - no Weber M eMwoaa o c r e o c ~ ~ ~ e 3 a .

n~anom~a
1. A e h p ~ a ~ qa ~' n ~a ~ b n t a cram ~ a M npegMMLuHMqaTa. 2. C ~ O H T ~ MH IlaJlnaTOpHa H~ 6on~a. 3. H ~ B ~ ~ M O X 38 HO aKTMBHa C T M IlaCMBHa eKCTeH3HR B namntaTa cram.

4. K~CTHM Kpenmawcln. 5. Onunm~e Ha pqgqnanHaTa rnam Ha HeTwnMrHo

MRCTO.

6. f l ~ a m o x i ~ ce a nwebpxqaea petrrre~orpa$c~~ $ac n npo$#n.

fln@epe~q~an nnano3a ~a
1. Bb~pemae~n $ p a w n Ha nanmaTa maw. 2. n y c a q Ha ~~ naKbTHaTa cram. 3. Opalcrypa Ha oneKpaHoHa. 4. @palcryp#Ha IlpoKCMManHaTpeTa Ha llpe&4MWHMqaTa.
~O~~JIHW nosenewne HII H neqeHHe

Tpw ~ T nM o - r o n ~ oTKonKoro ~a npw $palcrypa~a Ha Monteggia.

1. npeg~a nycaqm Ha ynHaptiaTa rnaea M $patqpa Ha p~a$nsa~a Ha pa#~ycac npeflHa aHrynauMR. 2.34~w an M 3 4 ~ 0 - n a ~ e p anyltcaqw n~a Ha ynHapHaTa rnaBa M $pamypa Ha ~ ~ a $ n s a Ha ~ pqnyca a cbc 3 4 ~ aHrynaqMR. a 3. CT~~HM.IH~ M n M npeflH0-CTpaHMrHa IlyKCaqMR Ha ynHapHaTarnaaa n $patmypa Ha u e ~ a $ ~ 3 Ha a ~p aq ~ y c a . 4. npep~a AMcnoKaum Ha ynHapHaTa rnaea M $pa~TypaHapncTanHaTaTpeTaHapqMycaMynHaTaHaeAHo
HMBO.

Muo6nnnxiq~~ B Kpa~epoea wma.

Cnelu~o~OJIHH~HO ne~e~~e
Onepame~o neqeme - p a H a peno3nqn~ M MeTanHa oc~eocw~~e3a (nna~a). npM neqa MaHyWlHa pWl03M4HR M MnCOBa M M O ~ M ~ M saquR.

YC~OXH~HHII
1. Ae$opMaqMR Ha rpMeHeHaTacTaaa U npepMnwHM1. Pepucno~aqw M n M cy6nycaq~ Ha ~ rnaaaTa Ha qaTa. PaC1MYM. 2. C n o m a ~ ~ M nannaTopHa a 6on~a. 2.llce~poap~po3a. 3. H ~ B ~ ~ M O X 38 HO npoHa4MR CT M CynMHaqMR. 3. Yspepa Ha m n 6 o ~ K n~ ~O H Ha p q ~ a Hepa. n ~ ~ ~ 4. H~B~~MOXHOCT 38 aKTMBHa M naCMBHa eKCTeH3MR B npono3a naKbTHaTa M rpMBHeHa CTaBM. 5. KOCTHM KpenMTaqMn. 6naror1pMm~a. 6. Onunm~e Ha ynHapHaTa rnaea Ha HeT~nMvtio MR-

Crynea~e Ha Galeani
npepcraen~ea cyeaHe Ha p#a$~aa~a Ha nbresaTa K~CT C H ~ K ~ ~ CHa I B ynHaTa ~ H ~ ($Mr. 3.28).

CTO.

7. f l ~ a r ~ o s a ce ~ noTBbpxqam a petrrre~orpaM -~ $ac M npo$~n.

1. Opatmypn Ha pMcTantiaTpeTa Ha npeRMnwHnqaTa. 2. B ~ T ~ ~ C $ Tp ~aB wH MM Ha rpMBHeHaTa CTaM. 3. Opamypa Ha pquyca Ha T M ~ M ~ H MRCTO. O

@m.3.28.

M~x~HH Ha~Bb3HHKBaHe ~M
1. f l n p e ~ ~ ypap e ~ ebpxy npepMcllwHnqaTa.

3. C r y n m ~ e Ha Galeazzi. 4. Crynaa~e Ha Monteggia.

1. MHpelcreH yuap mpxy npeflMMwHwqaTa. 2. ~ ~ H A M P ~ KT~ flpM H IlWaHe BbPv eKCTeH3UpaH KpafiHlrlK.

Knac~Q~~aqun
1. H ~ ~ w c ~ oQpalcryp~. ~ M ~ ~ H M 2. A n c n o q ~ p a 4pamyp~. ~~ Cfl0pe~ HMBOTO Ha QpalcrypaTa~ U W T : 1. ~ ~ O K C MTpeTa M ~ J Ha ~IlpenMMUHMqaTa. H ~ 2. .a. 3. ( a ~($MT. a 3.29).

Knact14~~aq~n
Cnope~ ~ e x a ~ n Ha a~ nonpamtie: a 1. E K C T ~ H ~ M TMfl OH (Colles). ~H 2. o n e ~ c ~ To M ~(Smith). ~ e~

Qr. 3.29.

Cn~monramwa
Kon~a M HapyweHa Q ~ H K ~ M R .

Juamom~a
1. fleQop~aqm Ha npegMllrwHMqaTa. 2. C ~ O H T ~ nH nannaTopHa H~ 6on~a.

naKbTHaTa M Q M lB H e H a C T a B M . 5. KOCTHM KpenmaqMu. 6. n ~ a n i o 3 a ce ~ anoTmpmqam pewre~orpaQc~n Qac M npoQnn.

mqnlbepe~q~anua aamoaa

nn4epe~qnan~a aanosa

1. Crynaa~e Ha Galleazzi. 2. Opa~~ypM Ha AMcTanHa TpeTa Ha npeAMMWHi.fqaTa. I. Opamypn HaeAHa OT KocTme~an p e ~ ~ n u r ~ ~ q a ~ a . 3. Bb~pecra6~i.f 4palcrypn Ha rpnweHaTa cram. 2. Opamypa Ha p q y c a Ha T H ~ M ~ HMRCTO. O

1 0 B T O ~ ceeToeHa ~ T ~ m i i ~nereHneTo a Ha yapepMTe Ha PbKaTa He 6enem m 6 e nnprpec. ~ Ka~o 0~6en~3Ba OrPOMHMTe 3aQ6M, A0 KOMTO BOpm YBpeflMTe Ha PbKaTa, MeflMqMHCKaTacnYlK6a ~aA M ~ ~ M K ~ a H P M C M R KBb3fla~T~ ra Ha C ~ e p n n 6b ~~ e n pa o p r a ~ ~ 3 mpenR ~ p a U e ~ ~ no bp XMPYPMR Ha PbKaTa. OTT O B a BpeMe HeqaTaC aC e M3MeHMflM3HaYMTenHO. BbB BCH'iKM CTpaHH no CBeTa CbqeCTByBaT 060co6e~u 3BeHa no XMPyPMR Ha PbKaTa KaKlO CneUIHM, TaKa M TaWBa, TpeTMpaWM KbCHM YBPeRM M KOHreHMTMHM M M $op~aq~~. M~oro El HawOHMHMTe M Me)l(9YHaPOflHMHaVHM APyXeCTBa no XMPYPMR Ha PbKaTa, KOMTO CflOMaraT 38 O ~ M R Ha H ~U H $ ~ P M ~ H~ O n M M T R M flOnpMHaCRT 3a & ~ M R nporpec B ~ a o6nac~. 3 ~ Cse~oe~a 4~ ea ~epaq no ~XM~ p y p Ha ~ pbKaTa ~ 6elue caspa,qe~a B 1966 r. ~ ~ P B M R T CBeTOBeH KOHrpeC no XMpypMR Ha PbKaTa C e CbCTOR B H o ~ e p npea ~a~ BHM 1988 r., npea lonM 1995r. B X ~ ~ ~ M H - ~ C T M R TCBeTOWH KOHrpeC no XMPYPrMR Ha PbKaTa. B 1986 r. y HaC e Cb3pweHO H ~ ~ M O H M A H ~O ~ ~ ~ C T no XMPYPMR Ha PbKaTa npeflCepaTenCTBOT0 HaCBeTOBHO M 3 B e C T H M R YCleH np@. ~ ~ B Z M IH ~ T ~ OT B 1987 . r. I p y xecrBoTo e rneti Ha C e e ~ o e ~ $ ae ~~ ae p a q u Ha ~ ppyxecTBaTa no X M P Y P r M R Ha PbKaTa. Peluaeaq npnHoc 3a nporpeca Ha XMpypMma Ha
XHMKI.

pbKaTaM3MTpaBbBewaHeTOHaMMKPOXMPYPMrHaTaTeOCHOBO~O~OXHM~M Ha XMPypMRTa Ha PbKaTa B

P a ~ ae ~~ as ~ n l o r m e m n~o w opratt. TRe OCHOBHO opbpMe Ha Tpypa, c KoeTo B npaKMKaTa ce peanna~pa n o w a c ~ r npowwpatro ~o OT rnaeHMR M O ~ ~ K . fllo60nb1~~0 e onpeAeneHMeToHa xyaomuKa PesaaHM 3a PbKaTa KaTO .~pafI~a qepe6pan~a I%HK~", noABclXeH KP~GHHK Ha M03bKa H TOBa Ha 6 b ~ e n Ye PbKaTa 3allOVBa AHCTMHO OT nyllnHTe M 3aBbpWBa B MO3bKa. Ka~o CeTMBeH OpraH Ha TaKTMnHOTO Bb3npMfTMe M MoTopeHopraH Haxecra, TR M M aM cneqn$ucc~o aHaToMMVHO YCTPO~ICTBO - KOHqeHTPMpaHeB OrpaHMWHa o6nac~ Ha MHOrO M pa3llH'iHM aHaTOMHCIHM eneMeHTM: HePBM (WTMBHH M MOTOPHM), capoae, cyxomnnR, cram, B ~ W K M , MyclcynM, KOCTM, C ~ ~ ~ M ~ nopKoma M C I H ~ TbKaH, KOM. l l p~ ~p y ~ o pefI~ocr ea pbKaTa e ~ e s a q n ~ M e cpae~a HMTenHO WCTO HapaHUMa. Exerofl~o Ha BCeKM1000 flyl u M 15 nOny'ia~T YEpepM Ha PbKaTa. B MHflyCTpMMHMTe C T P a H MO K O n O 113 OT BCMClKM TpYflOBM 3JlOnOnyKMElYBpeWaHMR Ha PbKaTa, KaTO npM1/3 OT IlOCTp~MHTe HaCTbnBa npo/JbnXkilenHaH ~ T ~ ~ A O C ~ O C O ~ HCbtTbTCTMHa OCT, C ~py~oaary6k1, Bb3nM3awM Ha 114 oT Tpy~o3aQ6HTe 0~6qe. Tom B O ~ po H OI-~OMHH MaTepManHM3ary61.1sampxaBaTaMApaMaTM~HMnOCneAM4MBnMrHHRMBCOqHMHMR XMWTHa nocTpwanMTe. B npoRnxeHne Ha MHoro ropMHMycunMma ca KoHqeHTpMpaHn~bpxyx~m~03acrpawa-

6bflrapMR ca F ~ H ~ Xoneeur, KM M B ~Ma~ee, H Ene~f al a ~ e sa. npea 1974 r. I o ~ r flonoa o M flaa~a T p ~ r ~ o nocraea sm ocHoeMTe Ha pennawaqMoHHaTa x ~ p y p m y Hac, ~ KaTo YCBORmT eKCnepMMeHTMH0 M BbBeWaT B KJl MHMKaTa MHKPOC~~OBMR weB. flpe3 1983 r. B 6a3a~a Ha .Il~poroe" e Cb3AmeHO nbpBOT0 CnelllHO 3BeHO no X M P Y P r M R Ha PbKaTa CbC 3aBewaq A-P T p ~ r ~ o s a .

OCHOBHURT MeXaHH3bM 3a Bb3HMKBaHe Ha YBpenMTe Ha PbKaTa ' 3 ~ M T O B M TM ~ nPOM3BOf lCTBeHM TpaBMM npM pa6o~a c pexeqn Mawmn. B nocnepHMTe neT ronMHM ~pa~~a~na~b~~apb~a~acey~ennr~~ THMTe, TaKa H npMAeqaTa, nOpmM HeKOHTpOnMpaHapa6oTa c p a 3 n ~MauMHu r ~ ~ 683 npepsapuTenHa noRroToeKa. OT ~ M T O B M T TpaBMM ~ 3HaYMTeneH flRn HMaT nOpe3HMTe paw, nonyrerln cnen yno~pe6a Ha anKoxon n e~cnno3~B H M T e M OlHeCTpenHMTe HapaHRBaHMR OT KpMMMHaJleH xapaeep.

eaqme yapepn. Yspe~n~e Ha pbKaTa, c ~ a n m nslcnloreHMR, 6 ~ x HernnmpaHu a n ocTaeeHn Ha rpnm-re Ha HeKsan~$~qup neKapM a ~ ~ ($Mr. 3.30).

KOCTHO-CT~BHH YBpeAH
Opa~~ypme M nyltcaqnnTe B o6nama H a pbKaTa ca M 3 B b H p e A H OC l e C T M . H~O~XOAHMO e BHMMaTenHO M flbnH0 MxneAmHe,sKnloreaqocboTeeTHMTenpoelcqnn RBrpa$MM, 3a Aa ce AnamocTMqnpaT Kamo KomHwTe yepeAn,
TaKa M CbllbTCTBalJ$lTe MM e K O T b K a H H M ne3MH. ne.leHMeT0 Ha K O C T H O C T a B H M T e YBpeflM H a PbKaTa Mome Aa ce naabpw~ Kauo B KBanM$MqMpaH0 neKapcKo 3 B e H O ( 0 6 4 TpaBMaTOnOMqHM ~ MO P T O n e A M C l H MW I M H M K M Mo r ~ e n e ~ u TaKa ~ ) , M B Cneqnan~a~pa~o n e ~ a p ca ~e oe ~ o (WIMHMKM M OTAeneHMR IlO X M P Y P M R Ha p b ~ a ~ a ) . 3a npegnovuTatie e necleHMeTo Aa ce npoeene cneuHO, HO e AonycTnMo M neqeme no oTnoxeHa cneuHocT.

I. O p a ~ ~ ~ ya p+~ ana~r~~e 3.31.

ManHa ~ ~ ~ e f i a n a ~ r ecram) an~a OT 15-20'; - npM Hec~a6MnHM $palcryp~ (KOCM Mc n ~ p a n o e ~ a ~ ~ ) ce ~3~bpurea s a ~ pp ~e~ no as n q ~ M~ neplcyratitia $MKC~U M R , npM HeyCneX - OTKPMTa penO3M4MR M $ M K C ~ ~ CM R KllpluHep~BM MrnM M n M BMHT. H a k r e c ~ a yape~a ~a ~ a c p e f l $ana~m ~ ~ ~ e ce npnrwHRW npln x ~ n e p e ~ c ~ e enMC, ~ s ux ~a p a ~ ~ e p ~ 3 ~ ce paqa c aeyn3~e~a$palcrypa OT BonaptiaTannorlta.AKO e MHoro Tewa, Moxe Aa npeflwse~~a Aopaantia pMcnoKaqMA. - aKo KOCTHMRT $ p a r ~ eWM ~ ~BonapHaTa craeHa nnowa tie e p a m e c ~ e nereHMero ~, e KoHcepeaTMBHo rpea M M O ~ M ~ M ~B~Aopaantia ~ M R Mncoea wMHa 3a 4 CeflMMuM; -npM pas~ec-re~a$palcrypace naabpluaapeno3~y~~ n0fl Ro-KOHTPO~ M IlePKYlaHHa$MKC~~MR C KHPWH~POBM wrnv npM yuepetta $ne~cnR B nMC; KoraTo s a ~ p n peno~a ~ H ~ He H R ce oTRwe, ce npeMuHaaa WM oTKpMTa penoslc~ MM RK ~ p u l ~ e p$MKC~L(MR, o~a KaTo ce ~anonasa yn~ape~ AOcTbn no HeyrpanHaTanMHMR.hnMTe C e M3BwaT CneA 3-4 CeaMML(M. 3. ~ P O K C M M ~ ~$W~HM. HM @pawpM~e Ha IlpOKCMrnanHMTe $ana~m ca TPYAHM 3a nereHHe nopwgqw HenocPeACTBeHMR MM KOHTaKT BOnapHOC $ ~ ~ K C O ~ CYXOXMHHT~ nMFl M AOp3aJlHO C eKCTeH30PHMRC)JXOXMneH anapaT. np# KOCTHOTO cpacTBaHe MoraT Aa 6bflaT O ~ X B ~ H ~MT~ M esn CTPylcryPM, KOeTO IlPH'iMHRBa 6~10KlrlpaHe Ha ABMXeHMRTa B npbcTa: - npn ~ e p a ~ e c ~ @palcryp~ ew nereHMeTo e rpe3 MnCOBa M M O ~ H ~ M ~ ~ 3 L 5 1 (H 4R CeAMMuM; - npM p a s ~ e c $pamyp~ ~ e ~ ~ ce Masbpluea MaHyanHa penO3MqMR M @ M K C ~ ~ W CR Kll~luHepOBM MrllM. ~ O C T ~ B C e R mncoaa ~ ~ o 6 n n ~ 3 a npM ~ p .$ne~cnR 1~ B M@C OT 90" n eKCTeH3MR Ha IlMC M IMC; - KOraTO 3aKpMTaTa pell03MuMR He Ce OTAwe (npM cnupanoeMAHu M KOCM $pamyp~),ce npeMMtiaea K ~ M OTKpMTa $MKCSIL(HR 0 KMPIJJH~~OBM MrnM. Kllplu~eposMTe MrnM ce ~ a a w Ha a 3,4 ~ cen~nua.l l p aapacrsatie ~ B ManpoTaqMR (snocne~lc-reue) ce Hanara KoperMpaqaocTIOTOMMR.

II. O p a m y p ~ Ha MeTaKapnanHme KOCTH

@MT.

3.33 M 3.34.

1. H e p a s ~ e c $palcrypn. ~ e ~ ~ Jlere~ue~ ce oM ~ B ~ ~ U J sa rpes rMncoaa M M O ~ M ~ M ~ npu ~ ~$ne~cun M R B M@COT 90" 3a IlpeAOTBpaTRBaHe Ha eBeHTyaJlHaTa POTaTOpHa fle$op~apm. 2. KOCM $pamyp~.nonyclasa ce npexnaseaHe Ha $parMeHTM~e,KOeTO npMrMHRBa CKaCRBaHe Ha KOClla. Penos~unma ce Msebpluea rpes TpaKunR Ha npbcTa M

IlepKYlaHHa$ M K C ~ ~ Ha M AMCTanHMFl R $parMeHT W M CbCeAHaTa MeTaKapnanHa KOCT. rwnco~a~a M M O ~ M ~ M ~ e~ 3a 3-5 CeF(MM4M. 3. KOCMT~ M CIlMpanOBHAHMTe$palcrypM, KaKTO M 3aCTapenMTe, H a f'ieCT0 M3MCKBaT OTKPMTa pen03MuMR M MeTanHa $n~cauw~. Manonseace gopaane~ plomn. Oc-reo-

C M H T ~ Moxe ~ ~ T fla ~ ce M ~ B ~ P W CM MtmpaMepynapHonocT~B~H Mrnw, M c ~ p a c r o c Mrnn a ~ ~M n M c noMoqTaHa nnaKa MB M H T O B e MMO~M~M~ C e ~IlOFlqbpXa ~ M F I T 3-5 ~ CeflMMqM. 4. H a f r e c ~ a Qpaimypa ~a Ha MeTaKapnanHMTeK O ~ M e T. Hap. . ~ O K C ~ O$patcrypa. ~ C K ~ "npnv~~~ ce le OT apMpe-

KTeH ypap ebpxy MeTaKapnanHaTa rnaBa, npM KoeTo ce nonyvaaa Hanpecltia MMnpecMoHtia$palcrypa Ha cbqaTa. I e $ o p u ~ ~e ecne~n$uve~: n~ pop3an~a mp6~qa M cmcmatte Ha MeTaKapnantiaTaKOCT. 3 a ~ p ~ peno3nq~n ~a~a ce oTpaea necHo, HO ~ p y p ce ~o 3;Wbpxa. MMO~HJ'IM~~UHma ce ocaqecrsma vpe3 Bonaptia M popsan~a mncoea W M H a npM20" UOP3XlHa $neKcMFI B PMBHeHaTa CTaBa M 60-90" $ n e ~ c B n MOC ~ 3a 3-5 cepu~qn. O~KPM penoanT~ UMR ce HanaranpH aacrapen~ $patcryp, n p pa3ppo6e~~ ~ $palcrypw M np# Heycnex OT KoHcepeaTMBHoTo nevetine. Oco6e~o Henpnmtio ycnoweHue e ManpoTaquma, KoeTO MBMCKB~ Kopempaqa OcreoToMMfl. Manonsea ce flop3aJleHflOCTbflM $ M K C ~ ~ KMPWH~POBM MR MrllM,MJ~M,F M .v 06pa3HM IlnaKM M BMHTOBe. 5. Opatcrypa Ha Bennett e ppyra xapameptia $patcrypa. TRe abTpecTaetia M 3acnra ocHoeaTa Ha I-eaMeTaKapnanHa KOU. M e ~ a ~ a p n a n KOCT ~ a ~ce a M ~ M ~ Cp T~ B ~ ~ a n HO M n p o ~ c n ~ a n nop ~o s~pelcreue~ Ha opbnmn a6py~TOP Ha naneqa. M ~ ~ K M $R pT ar~e ocTaea ~ ~ Ha MFICTO, 3abpXaH OT KOnaTepMHMR nMraMeHT. 3 a ~ pp ~e~ no a 3 ~ qM~neplcyranHa ~1 $ M K ~ ~ Mce R u3BbpWBavpe3 TPaKUMFI M KHPWH~POB~ $ M K C ~ Ha ~M MeTaR KapnanHaTa KOCT m~TpaneqoaqHaTa KOCT. Mrna~a He 6 ~ s pa a MMHaeanpea M ~ ~ K M $paruew, R a clpes $ ~ ~ c n p a HeTo Ha roneMwr $ p a m e ~ m~ ~ ~ p a n e q o ~ ~Kocrpa p~a~a 3abpm n o c r ~ r ~ ap ~e an ~o a 3 ~ ($MT. q ~ ~3.35 M 3.36). OTKPMT~ pell03H4MFIC e M3BbpWBa npe3 AOp30-naTepaneH p0cTt.n sbpxy MeTaKapnanHaTa KOCT Ha naneqa. n0fl HeflOCpeflCTBeH BM3yaJleH KOHTPOn C e M3BbpLUBapeflO3MqMFI M $MKM~HR C KHPWH~POB~ Mrna M n M BHHT. OCTeO C M H T e 3 H M R T MaTepMm C e M3BaK@ Cnefl 4 CeflMM4M,

MnCOWTa M M O ~ L ~ H ~C ~ e~ IlOmpXa MFI Owe 2 CepMMUM. Ill. @pamyp# Ha KapnanHwTe KOCTH ~30nMpaHMTe $palcrypM HaKapnanHMTeKOCTW C a MHOr0 no-VeCTM, OTKOJlKOTO C e flMarHOCTM4MpaT. Ha ReCeT $paimypw Ha pwwyca Ha mnMcltio MRCTO ce n w a epHa $patcrypa Ha KapnanHM KOCTM.

CHM~~M~THK~

PM Hanuwe ~ano~ann3upa~a ~ O ~ ~ ~ H ~ H OTOK O CMT , orpaHMclaaaHe Ha flBMxeHuma cnep nqaHe Ha ~ a n b ~ a ~ pbKa T P R ~ W pa ce wcnn 3a ~ a yepepa. 3 ~
1 I ~ a r u o m w a
KOCTM Ro-puaniocr~~a~a e Tpyptia M Te clecTo ce

n o p a n HenpaeMnHaTa reohneTpMrHa @ p ~ a Ha ~ e 3 nponyCKaT. Ro-06pa3b~ clecro ce ~ O ~ M T M cnep B M ~ HFl ~ KonKo ceflMML(M, KOraTO HaCTbnHKOCTHaTa pe30~6qMFI,3aTOBa BCFIKa a ~ a c l ~ ~ TpaeMa e n ~ a B o6nac-rra Ha rpMBHeHaTa cTaea M n p HeraTMseH ~ peHTreHoa o6pa3 ce M M O ~ M ~ M 3a~ M HRKOnKO CIpMM4M, CJlefl KOeTO Ro-rpa$MFITa C e nO0TapFI. IV. @paKl) 'p ' a Ha C K ~ @ O H ~ H KOCT ~T~ Hai-vecra~a $pamypa B KapnantiaTao6nacr.

O n .3.35. Oparrypa na Benet

O n .3.36. Manyanwa penmnqlw n Knpmeposa #nrcaq~ur

3a 10 AHM, cnel KoeTo Ro-rpa$uma ce noeTapR. AKO 6on~a~ nepcMmpa, a ~ ~ o 6 n n ~ s a ce q unpomnxam ~~a 3a oqe p e cepnnMqM M OTHOBO ce KotiTponMpa petrrreHoJlOrHCIHO. PM AMaMOCTM~MPaHa@palcrypaHa C K ~ $ O M ~ ~ H ~ T ~ KOCT ce nocTaeR qMplcynRpHa rnncoea M M O ~ M ~ H ~ ~ ~ M R , a a n o r a a q a ~ o p w OT ~o r n a a ~ r ~a ~~e ~~ ea ~ a p n a n ~ ~ ~ e KOCTM, BOnapHO no XOAa Ha AMCTaJlHaTa MaHHa nHKa, 06xsaqaqa ~trrep@ana~rean~a~a maaa Ha naneqa M naKeTHaTa cTaBa. r p ~ ~ ~ cTaea e ~ ce a ~ uuo6nn~a~pa a B HeyTpmHa n03MqMR M n M neKa ~ O P ~ M @ J ~ ~ K C M R .M M O ~ M ~ M 3aUMRTa B MnCOB PbKaB IlpoAbnXaBa 4-6 CeAMMUM, CneA 3a # HaCTbnM l 3Ha'iMTeJlHO pa3MeCTmHe B Ta3M CTaKoeTonaKeTHaTacTaaa ce ocso6o~qasa M M M O ~ M ~ M ~ M U M - Ba, ~ p ~ Aa 6 m C e YBpeAaT ABa OT TPMTe KOMnOHeHTa Ha RTanpo~bnxaeaaaoqe4-6 ceflMMUM. KOCTHOTO cpacTaaCTaBaTa: BonaptiaTa nnowa, KonaTepanHMTe nMraMeHTM HececnepMnepnouwvHo. M Lig. accessorium. nbnbr MnCOB PbKaB 3a 4-6 CeAMMqM. Aop3an~a~a nycaqvn npep~3am~m pa3~bcea~e Ha K ~ MnCOB c PbKaB 3a Oqe 4-6 CeAMMqM. BonapHaTa nnowa, AoKaTo Ligamentumaccessorium ocnepuofl~~tto peHTreHonoMwionpocneflReaHe. Tam sppae.

YC~O~H~HMR
n0p~M 0co6eHOCTMB K P ~ B O C H ~ ~ ~ ~ F Ha I BK ~O HC~ TT T~ O ( K ~ ~ B O C H ~ ~C ~ eR OCbqeCTBRBa B~H~TO npeM~eCTBeH0 OTKbM AMCTXlHaTa h 'iaCT), 113 OT lal(MeHTMTe C Ta3M

vl3cnen~a~e~o Ha maeHaTaH ~ C T ~ ~ M ~ H cram OCT no1 noKanHa a ~ e c r e 3 n no ~MeTona Ha .O6epd, KaTo npeAM TOW e ~acneflea~a ceTnBHocrraHaKoxaTa Ha npbcra. 3a ~o~aam HanMraMeHTapHa ~e ~ e c ~ a 6 w n ce ~o nasbpwsa c~ .c~pec"~ s c n e ~ e noA a~e Ro-KOHTPO~, T. Hap. .C~pecpeH~re~orpa@ufl". .C~pec"n3cnepm~e~o Ha ~ ~ ~ e p @ a n a ~ r e NIHMTe C T a B MC e M3BbpWBa B eKCTeH3HR, a ,,cT~~c" Rorpa@~ma Ha ~e~a~apno@ananrean~u~e cTaau B ~ $ne~B
CUR.

n p qacTuwa ~ nHraMeHTapHa yapefla ce nocTaeR Mncoea M M O ~ M ~ M ~3a ~ 2, ~ M 3 RceRMMqM npM @ n e ~ cB n~~ ~ M MC nvlc OT 30-350.

PM Te3M nyKMqMM e HMOXMTeJlHapen03MqMFI, n0CJleAmHa OT MnCOBa H M O ~ W J ~ M ~ ~ 3 ~a M3 R CeflMMqM. PM 3 a m e q m ~ e MeHqy nMraMeHTapHuR anapaT HacTbnea ~ p a i r nycaqw, ~a Komo He n o y e x u Ha MaHyanHa peno3uq~~. B ~ e cnyqau 3 ~ ce np#mnsa K ~ onepaw M BHO nevettwe.

O n . 3.37. Bsrpecraswa 4papalrrypa s npouctlllanwmmmfiananreanna crasa. O m p m peno3qlw n o n e o c m m c smwr

Ha OT ~ Y M ~ P M K ~ MycKynM, ~ H M T ~ BonapHaTa nnoqm, $neKCOPHOTO CyxomMnMe M noBbpxHocTHMR Hanpeqeti nMraMeHT OT nanMapHaTa $ a c q ~ ~ . Ta3M nyKcaqm e CT~~MIIH~. X u n e p e ~ c ~ e ~ s npe~ma
flM3BMKBaOTOKMTOqKOBMAHMKPbBOM3nMBM.

M a ~ y a n ~p a~ ea n o 3 ~ ce q~ oTRaea ~ no M ~ K ~ I O ~ ~ H fleWHMeT0 e OTKPMTa pen03MqMR M $ M K C ~ ~ CM Kupw~eR posaMrna~ y ~ e p e ~ a $ 3a2,3 n e ~ ceAMMqM c ~ ~ (@Mr. 3.38).

C ~ O ~ K H@ e p lv ~HH

l(o60nwa~onose~ewereH n e w w e
Mhno6nn~aaqn~ M TpaHcnopmpaHe ~o ~ O ~ H M V HaaO aene~~e.

I. Vepegw ~a e n e ~ c o p cyxomnna ~~~e non o ~ a n ~ 3$ anq e~ ~~ c o p ~ cyxoxMnHu v~e yape,qMca p a 3 ~ e n ~a e~ ~~ ~ T ~ O ($MT. H M 3.39). 3 o ~ II, a T. Hap. .HMCIMR so~a", e paanonome~a u e w y ~ ~ c ~ a ~n n ~ a n~ a ~ a

O n . 3.38. no Kaplan, 1954

4. H e e a a ~ o x ~ $an e ~ c B ~ nMC ~ M AVIC, ppepa M Ha fleere $ n e ~ c o p CyxomnnR. ~~

no~a3~a

Qnr. 3.39.30111na ~~elrcopnrn EylmanHn yspepn

1. K ~ M H pManiocTMKa M ~ H ~ 3a ycTaHoeRsatte Ha cyxomnHaTa ppena. 2. Toane~ Ha paHaTa M cTepMntia npeapba~a. 3. n p o $ v n a ~ ~ cpeqy ~ ~ aTeTaHyc. 4. Hacorsa~e K b M Cne4MXlM3MpaHO WpaBHO 3BeHO. 5. r~ncoaa noHreTa.

no BOnapHaTa nOBbpXHOcT Ha AMCTanHaTa wwrep$ana~rean~a cTaBa. B ~ a 3 3 o ~~ CyXownMflTa a ca pa3nonoxe~ B~ KOCTHO $M6p03eH KaHan, KbpeTo o$opMRHeTo Ha C ~ ~ C T B ~ He Mnpaenno. R
M n M H M R T a

J l e r e ~ ~ Ha e~ yapepwe o Ha $ n e ~ c o p CyxomnMR ~~~e 3 a B M C M OT nOKMM3aL(MRTa Ha YBpeAaTa, Bb3paClla H a naqMetiTa M flan^ e a a c e r ~ a ~ poMuHMpaqaTa a pbKa. B~~CT~HOBR Ha B$~ ~H ~~ KT CO O~H CyxOXMnMfl MT~ M 3 M C K B a C ~ ~ ~ M $ MXMPyPMqHM ~ H H Y M e H M R H 3 H a H M R , a no O T H O U l e H M eH aC y X O X M n H M F IUleB B,HMCIMR 30HaU M BnweeHe Ha MMKPOXMPYPMClHaTeXHMKa. H a h - ~ 0 6 pe3yllTaTM p~ OT C Y X O X M n H O T O Bb3CTaHOBRBaHe Ce nOny.laBaT, KOraTO TO e M3BbPUleHO no HeOTnOMHa CneUlHocT (p0 6 h OT ~Bpe~a~ Ca~) O . W ~ H OBb3CTaHOBRBaHe TO Ce M3BbpWBa c 410 M 610 weeeH MaTepnan M cbc cneqnanecl MHcTpyMetiTapnp 3a cyxoxMneH uee. Msnona~a ce MeTopbT Ha Bunnell, Kessler, Lange M pp. II. Yepean Ha ~ K C T ~ H ~ O P H cyxomnnn HT~
1. np#HeBWMOXHOCT3a eKCTeH3MR BNblc ( ~ M c B ~ Ha pncTanHaTa $ana~ra)ce Kacae aa T. Hap. ppepa .npbCT 'iyK'4eU M Ce flbnXM Ha M3TpblBaHe Ha eKCTeH30pHOTO cyxoxMnwe OT HttcepqMma MY aa ocHoeaTa Ha AMCTanHaTa $ana~ra. l l p Ro-rpa$w~ ~ Moxe Aa ce ycTaHoecl K O C T e H $parMeH~, M 3 M e C T e H IlpOKCMM~HO. 2. ~ P T.HHaP. , , ~ O T O H H ~ P ~ ~ ~ $ O ~ M H n ~ M ~H3BeCTHa MR, oqe KaTo KotiTpalcrypa~aWeinstein, yspepeHMm n p b u e B ~$ Bn e ~ c n B~ IlMC M x ~ n e p e ~ c ~ BAMC. e ~ 3 nne$op~a~ UMma ce p b n w Ha npeKbcBaHe Ha UeHTpanHaTaeKcTeHaopHa neHTa, npM KoeTo CTpaH#qtime neHTM $nemnpa~ IlMC M eKCTeH3MpaT AMC. 3. npM HeBb3MOXHOCT3a eKCTeH3MR B MoC C! KaMe

2. l l p KoHTpamypa ~ ~aWeinstein, T. e. npunpemcsaHeHa~eHTpanHaTaneHTaHaeKCTeH30PHOTOCyOMflHe Ha npbcTa ce na~bpuraanbpsclveH cyxoxHneH urea M @ U K C M ~ Ha ~ HIlMC ~ B eKcTeH3HR C nOMOua Ha Kupur~e-

M m B 300, nvlc H Avlc npH ~ K C T ~ H ~ M HF ~I neKa H @ne~cw~.

CUR,

p e a nrna. 3. npH CyXOXMnHMYBPeAH npKCMMallH0 OT MOC Ce u3~bpu~~acyxom urea n eno ~ MeToPaHa Bunnell, Kessler, Langl n ~ pP. b ~ a ce ~ anombpxa B rHncoea u~o6nnu3a4MR3a IlePHOA OT T P H CeAMHl$l npM KHTKI B flop3H@ne~-

1. np#npeoceatie ~a~ ~ r m a Hepeuce n ~ ~ nonyva~ e sa x ~ n e c ~ e no 3ynHapHaTa ~~ nnu pwuanHaTa nosbpxHOCT Ha IlpbCTa.

2. PM IlpeKbcBaHe Ha MepMNlHMR HePB e Hal'lMqe nMllCa Ha CeTMBHOcT B3OHaTa Ha HepByC MeAMaHyC, KaKTO
M M O M e H T a n H O OTnWaHe Ha M O T O P H a T a My @YHKIJMR: HapytuaBaHe Oll03M4MRTa M ~ ~ ~ ~ K I Ha J llMel@ M R T(@Mr. ~ 3.46).

3. IlpeKbCBaHeHa Y n H a p H M R HepBnMnCBa CeTMBH O C T B 30HaTa, MHepBMpaHa OT Hero. H e B b 3 ~ 0 X ~ ea a 6 p y ~M q wY_KL(MR ~~ Ha nPbCTMTe. H a ~ ~ b n B XapaKTea peH rpM@Ha 4-TMM 5-TMIlPbCTM. rpM@bTCe AbnXM Ha
puc6ana~c ~ewy @ne~cop~~e
M,

PM

In. rnedianus

n. radialis

Pb~a~ BonapHo a

wv-1~0nHepeaqMR e sanase~a npM p u c ~ a ne3m n ~ ~ Ha HepBa M fle~epBMpa~MTe ny~6pMKan~M MyCKynM, KOMTO He MoraT pa @rte~~wpa~ M($, nopun KoeTo nMC M AMC ca B b B@ ~ ~ K c M R a,M@C B eKCTeH3MR. YBpeAa H a PWMMHMR HepB, B 3 a B M C M M O C T OT HMBOTO Ha yapepaTa, Hacnnea pawnrHa oTnWHa c w n T O M a T M K a . YBPefla BRMCTMHaTa TpeTa Ha IlpepMMtuHMqaTa MOXe Aa Ce 3aCellie C a M On O B b P X H O C T H M R TK n O H Ha HepByC PWMaJlMC, K O ~ T O Ce HaMMpa B.aHaTOMMqHaTa TaGa~epa", pe3yn~an e~ x ~ n e c ~B e~ 3~ a~ m 3a . ~ np# BMCOKI, T O T M H a ne3MFI H a PWMWHMR HepB pbKaTa ,,BMCM~ M He e Bb3MOXHaeKCTeH3MR KaKTO B KMTKaTa, TaKa M B npbCTMTe. HMCKa ne3MR, Cnefl OTAenRHeTO Ha M O T O P H M R W r O HK b M eKCTeH30PHMTeCYXOXWlHFIHa KMTKaTa, eKCTeH3 ~ mB a wKaTa e sanase~a. n~ncea ~ K C T ~ H ~BM M@C R Ha npbcTMTe, a a6pyKIJMRTa Ha naneqa e HaManeHa.

5. Hacoraa~e K b M Cne4MMM3MpaHOXUPyPMqHO 388HO.

Cnelu~o ~ O ~ H W V neveuHe HO

PM

PM

PM

B~~CT~HOBRB H ~ aH HepBMTe ~ T O rp~6ea pa Ce M3BbPtuaa no HeoTnowa cnewHocT M BB B M ~ K c On e q ~ a n ~ 3 ~ paH0 XMPyPM'iHO 3BeH0, C B b 3 M O X H O C T M y M e H M R 31 M M K P O X M P Y P M C l H aT e X H M K a . nop nposopHa ~ H ~ C T ~ ~ BM 6e3KpbB~0 R , none M c noMoqTa Ha yaenwrewe M MMKpoxMpypmqeH MHCTPYMeHTapMyM ce naeapw~a ennHeepaneH, nepMHeepaneH MnM eHpoHeepaneH tuea. Msnonsea ce tueeeH MaTepMan OT nopFimKa Ha 1010 710. n p ~ H)oyqa Moxe pa ce npemtle M K ~ M mpBMwa HepsHa nnacTMKa, KaTo 3a TpaHCnnaHTaTCe M3nOn3BaHepByCCypMMC. P b ~ a ce ~a ~ ~ 0 6 n n ~B amnmea ~ p a w t i a 3a 25 AHM, cnep KoeTo ce aanor~a cneq~@~ @ r~ ~aa ~ o ~ eMp a

Kora~o nuncaTa Ha Koxa e s ~ a r m e n ~HO a ,e HanMqe AoCTaTbClHO MeKOTbKaHHa IlO~OXKa, PaHaTa MOXe Aa 6bpe nOKpMTa CbC ceo60pe~KOXeH npMCa,4bK, B3eT OT MMUIHM~~ M n T M ~OT 06nacnaHa npepHaTanaKeTHamtiKa. Bbpxoe~ aMnyraqHm Ha n p m e H a C n o ~ x o pca ~q pe6enme ~ KomHMTpaHcnnaHTaTM.noB~~XOE aMny-raqnM MT~ H a npbcrme ca H~A-rec~me HOPHOT0 MRCTO C e 3aTBapR nbpBMrH0. TpaBMM B o6nacrra Ha PbKaTa, KOMTO nOCTbnmT B CneLLIl l p BbpxoBa ~ a ~ n y - r mc a ~a ~~~a~ rmen~ sary6a a Ha H M T e XMPYPMrHM K ~ ~ H H M ~ 3a T H CblKaneHMe M H ~ ~ - ~ O W O nKaHn M oronme H a ram OT pwcTanHaTa $ana~ra paHaneKyeaHwTe. Ta Moxe pa 6 b ~ a e a ~ ~ o p no e ~epMH a OT cneptiwe HawHM: Cross finger ($Mr. 3.47); no MeTopa Ha Kutler ($Mr. 3.48); rpea TeHapHo n a d o ($Mr. 3.49); no MeToda Ha Kleinert ($Mr. 3.50); Mnn qpe3 noKanHo mpoeo-H~~BH OCT~OBHO na~60 no MeTofla Ha Moberg ($Mr. 3.51). M~flu~atpfme aa paannq~we BMpoee onepa4Mn ca no~a3H aa~ $MT. ~ 3.52.

careTaHu ppepu, nopa,qu cTpynmHeTo Ha MHoro BWM C T P Y K T Y P M B CbBCeM OrpaHMCleHM npOCTpaHCTBa. flpeKbcBaHe~0 HapMMTWlHMTeHepBM, HaynHapHMR M pqq~an~ Hepa u ~ recro ca cbveTatiM c npewceatie H a e~H0UMeHHMTeapTepMl4. flpM CbBpeMeHHOTO HMBO Ha XMpyprMRTa Ha PbKaTa TRXHOTO Bb3CTaHOBRBaHe e H e caMo xenaTenHo, HO B HRKOM cnyvaM M 3a,q~nxmen~o.

@m. 3.47. C mlinger

128

TpaB~arno~orurnu cnewnu cscrnonnun

Qwr. 3.48. V-o6pmno nau60 wa Kutler (no Millord)

Inr. 3.49. Tenaptto nau60

QM. 3.51. n m n o wso-nepsuo ocrposnonau6o na M o b c ~ (no ~ Millord)

TpaBmamo~ozusnu cnewnu cacmonnun

129

Cm6on~a KoxHa nnamKa

E + 3
A M ~ ~ ~ ~ ~ H yBpeRH O H H HHa paKaTa
A M ~ ~ ~ ~ ~ M FpeflM O H HH M aT PbKaTa ~ Ca Hah-~eXKklTe yepegu e ~ a 3 06nam. n l l p mnHM ~ aunyraqw amyrupa-

Te~ap~ nau60, o Cross finger

fla~60 H a Kutler, Kleinert, Moberg

npM HyH(qa Ce H3BbpluBaT PeaHMMaqMOHHM MeponpumMR, n p o @ u n a ~ ~ # ~ a c p e q y ~raaoaa e ~ a ~ aHayc, epo6~a C I H $ ~ K ~ MH R np@Mna~~MKa Cpel.l$J eBeHTyanH0 MH@~K~HO~ YCnOXHeHMe. HO HaTa~aCTeHanbnHOOTfleneHaOTnpOKCMMmHMROTflen 2. n0BefleHMe no OTHOlUeHMe Ha aMn)'TaqMOHHMRclyHa ~ p a h ~f ~ l p~ vacTMwiwTe ~a . aunyraqMMaMnyrMpaHaTa aMnyraqnM H M ce oTcTpaHRaa KoMnpecMW C TO C T a B an p M K p ! n e H a C TbKaHeH M O C TK b M K P ~ ~ H H K ~ , KaH: npM ~ M C T ~ ~ BHaTa npeapba~a M ce uaabpluea ToaneT H a paHeame H 0KP~BOCH~~F]RB~H h~ eTHanbnHO O npeKbCHaT0. Il O BbpXHOCTM. BMCOKM aMllva4MM He3a6aBH0 Ce OTCBbBeWaHeTO Ha MMKpOXMWpMclHa TeXHMKaCTaHa TpaHRBa TypHMKeTbT, M3BbPluBa Ce TOaneT Ha PaHeBaTa B b 3 M O X H O YClleUHOTO JleCleHMe M Ha T e 3 M YBpeflM. IlOBbpXHOCT U BpeMeHHa XeMOCTa3a. KbpsRqme CbflOBe Ce 3aqMnBaT C HeXHM X e M O C T a T M C I H MM H C T P Y M e H T M M Ce IlpaBMnMraTypaHa C a M M R Kpah Ha IlpeKbCHaTMRCbn, CneR 1. ~ P a M~ n y r a q ~ Ha uHMBO npbcTM, MeTaKapnanHa M KoeTocenwTaeRc~ep~n~anpeapbs~a. KapnanHa o6nam ce Hanara KoMnpecwBtia npespba~a Ha 3. n o e e f l e ~ ~ no eoTHolueHMe Ha aunyrnpaHaTaracT: aMnyTaqM0HHMR 'iyKaH, no B b 3 M O X H O C TC b C CTepMnHM ROCneflHaTa Ce IlOrlMCTBa OT r ~ f 3aMbpCRBaHe, i KaTO Ce MaTepMmM, C qen flpeflOTBpaTRBaHe H a KpbB03ar@a~a. OTCTPaHRBaT eBeHTyMHM ' i m M Tens. 0 6 a ~ s a Ce B Cyx A ~ n y r ~ p a ram ~a~ ce aO ~ B M B cTepMneH ~ KoMnpec M npu c ~ e p ~~ no e~~n pn ece c nocrae~ B s~paea nonwe~~ne~oe B b 3 M O X H O C T Ce nOCTaBR B y C n 0 B M R Ha X M n O T e p M M R . TOP~MCIK~ KORTO , ce saebpsea. B Apyra nonMeTnneHoea 2. npM BMCOKM aMtlva4MM Ha HMBO rpMBHeHa CTaBa, ~0p6MrKa Ce IlOCTaBRT ~y6ve~anen M T O @ # ~ CaMnyK~T~ flMCTanHa, CpenHa M IlpOKCMM~Ha TpeTa Ha npeflMMUJHMTMpaHaTa'iaCT Ce nOCTaBR B HeR. B T O ~ ~0p6MrKa ~ T ~ cbq0 qaTa ce Hanara VpHMKeT H ~ J I HMBOTO Ha FpepaTa, npH ce aaebpaea (@MT. 3.53). 3qbnXUTenHO 0~6enR3BaHeWCa Ha nOCTaBRHeT0 My 4. O p r a ~ ~ s a q u o Meponpnmwn: ~~n cneqnan~3~pa(M~KCMMMHO BpeMe Ha TypHMKeTa lh, 30 mill). no HOTO 3 ~ e ~ oyaefloMRsa ce no~ene$o~a. noc~pqanw~~c oTHoueHMe Ha aMny-rMpatiaTaram, noaefleHMeTo e Kawo wsnpaqa aqqbnxu~en~o c enMKpM3a, B KORTO e 0 ~ 6 e n ~ npM flMCTXlHMTe aMnyral(#M. 3aH WCbT Ha YBpenaTa, MexaHM3MbT H a TpaBMaTa, WCbT 3. ~ o c T ~ ~ ~ JCe ~ TpaHCnOpTMpa M R T no ~ah-6bp3Mf-l Ha nomaentie Ha aMny-rupaHaTa racT B ycnoaMu H a xmoHarMH fl0 H ~ U - ~ ~ H ~ Kneve6~0 OTO 3BeHO. T e p M M R , npoBenetiaTa ~ H T M ~ M O T M Cn IH p~o @ ~ n a wM ~~a peaHMMaqm. ~ O C T ~ ~ ~ Ce~TpaHCllOpTMpa M R T no Hah-6bp3MR HaClMHflOCne4ManM3MpaHOTOpennaHTaqHOHHO3BeHO.
IlOCTPaJIanMR:

PM

O ~ K T OBpeMe P ~ Te OT orpoMHo a~acle~ne aa ~ a x o ~ a HaneqeHueTo. flpM XM~OKCMRH a 6 h M Hah-fl06pe M3BbpweHaTa onepaqm e aannawe~a OT Heycnex. Cne~manmampa~ neKapcKa a no~ou Kora T ~ R ~ Ra W npMcibnMM mu p e n n a t i ~ a ~ n ~ ? A6conto~~a MHPMKauMR3a onepaumFi e Hanwue npn cneRHMTecnyqaM: 1. Auny-rauMR Ha naneu ($Mr. 3.54,3.55 M 3.56). 2.A~nyTaLpm Ha BCMYKMM ~ noBecleToynHapHw H npbc-

TH.

3. Aunyrau~~i Ha PbKaTa. A 6 c o n m ~ ~KOHTPaHHAHK84HH: m 1. Auny-rau~~ IlpoKCUM~HO OT naKeTa ( M ~ J ~ K MyUT~ CKynM Ha PbKaTa M IlPeflMMWHM~aTa $!46po3MpaT IlpeAM ceTMaHaTa M RaMraTenHa HepeHa pereHepaUm Ra HamnM). 2. C ~ P U O ~ 0614~ H M ~ ~ ~ O ~ R B ~~ Hn M aF6I e :apTepOCK~, neposa, 6eno~po6~n 3a60nn~n a RP. ~~~

3. T e m pa3flp06e~M ~ 4pamyp~Ha aMny-rupaHaTa ram. no npMHu#npennamaqume~ p ~ 6Aa ea ce M ~ ~ P U I B ~ B b B BMCOKO Cne4MaJlM3MPaHM I@HTPOBe npM 24 h rOTOBHOCT 3a cnewa onepaTMBHa f l e i ~ o c ~ . Cne~ qaTenHa npeqeHKa Ha MHAMKaqwme 3a BMMomapennawraqnfic e c @ p ~ ~ p pennamal(cl0Hei-i a emn. 6on~~~ ce 1noproTsR -r 3a npofibnxmentia ~ H ~ C T ~ OT ~ M nopRmKa Ha wem, oceM, AeaHmeceT M nosere raca. Bb3cra~oa~sa~ H e a~ npemcHaTMTe o CTP~KT~PM ce H3BbpUIBa B C n e p H M R PeA: 1. O C T ~ O C M H CT IlOMOVa ~ ~ ~ Ha K H ~ W H ~ ~ M O m M B,U
IlflaKH M B M H T O B e MnM BbHUleH @KC~TOP. 2. ~ ~ C T W O B RH B a eKCTeH30pHme ~H~ C y X O X M n M RM noHe HaedtiaaopsanHaseHa. 3. B ~ ~ C T ~ H OHa BR ~ ~ B~ ~K HC ~ O CyXOXbl ~ H M J T lM ~ R M Ha n O m O f l R ~ M T e3a aHaCTOMO3a apTepMaJlHM CbnOBe C noMOWa H a MMKPOXMPYPM'iHa T e X H M K a M Onepa4MOHeH M M K P O C K O n . 4. B ~ W ~ H O B RH B a AOrl ~H bnHMTenHM ~ B e H O 3 H M CbAO89, KaTO C b O T H O U l e H M e T O Ha BMCTaHOBeHMTe a P T e P M M K b MB b 3 C T a H O B e H M T eB e H M e eAH0 B M AB!. 5. ~ ~ ~ C T ~ H O BHa RB BC ~ M c H l K H ~ IlpeBCHaTM HepBM. 6. Koxa~a C e 3aTBapR C nbpBMrH0 OTCpO'ieH L U e B . one pupa^^^^ ce omaw HenpeKbcHaTocnenonepaTlnsHo Ha617Dfle~Me M npM Hyxqace npuc-rbnea ~eaa6aB H OK b MpeOnepa4MR ( ~ p 0 ~ 6 0 ~a 3 a~ P T ~ P M E M n U M~ BeHO~H 3eH Cb4 MnM H e n p o X O A M M O C THa CbAOBeTe n0Apyra IlpMrMHa - MHCY$M~MIHUHFI Ha C b n O B M R UeB, BeHO3Ha CTaa, aacTpauraaaqa npexMBRsaHeTo Ha pennaHTMpaHaTa

Our. 3.54.

nos

clam).

3a6enema: f l p HemnHme ~ aMny-rauMM noaeAeHMeTO H a p a 3 n ~ r ~ w eTanM ~ e ecbqo~o c, ~ ~ ~ n t oHa~oea, r e ~ ~

recneAToaneTaHapaHa-rancTepmHaTanpeepbs~ace nocTaaR nompxaqa mncoea wwa.

132

TpaBwamo~ozuwu cnewnu cbcmonnun

Ma M CaKpyMa M n M nyKcaqw Ha c a ~ p o - ~ n u a w a u~ am a. 111. flB0hH0 IlpeKbCBaHeHa Ta30BMR IlPbCTeH. 1. ABO~HO BepTMKanHa$palcrypa Ha IlpenHMR OTflen (X-o6paa~a Mamypa Ha n @ ~ M c MCUIMM). 2. fleoh~o BepTMKanHH$palcryp~ T#nMalgaigne($Mr. 3.57,3.58 M 3.59). 3. C ~ O W pa3pp06e~n M $patcryp~, KOMTO He MoraT pa 6bAa~ mac~$~q~pat IV. O p a n y p ~ ~a ~ a .
TpaBMaTMSHH PPeAH Ha Ta3a

Jlo~an~ Mp a ~ $ y 3 60n~a, ~a B U ~H ~nonoxeHweTo T Ha OpalcrypM~e Ha Ta3a Ca eAHM OT H ~ ~ - T ~ X YBpeAM KMT~ , M KpbBOHaCRnaHe B o6nacrra Ha Tarn, Ha o n o p ~ o - A B M ~ ~ T anapaT. ~ ~ H Mnpcl R 10-17% OT ~ 6 3 ~~ O ~ H M ROTOK HeeAHaKBMRT CTOeX Ha ABeTe C n M H M M CKbcRBaHeTO Ha yspeAm ce a a c ~ r a M~ ab~pe~a30~wre opratin, KoeTo owe e A M H OT K ~ ~ ~ H M U AOnaBRHeTO HT~, Ha KOCTHM KpenWaUUM noeereenoluaea npomo3aTa MM. C m p ~ ~ o c rn ra p ppe~ M$YHK~MOH~ H' J H ~ T ~ ~ M ~ H n A#B ~ K TP ~~ ~ H M K pMTe ~ a ~ a (De a a Palma) e K ~ 8-1 M 0%, KoeTo ru Hapewa ~ o r ~a a ~ a c o r BH a~ 3a yepena ~a ~a3a. Cflep repenH0-M03bVHMTeM rpbnH0-KOpeMHUTe TpaBMM. C o r n e ~ a ~ ~ a n l H ornepa B cbo6paxe~we Mpea M nannaTopHoTo~3cnepea~e ~a~asa, KaTo ce ~ a n o n3MT HRKOM O ~ ~ O M ~ B ~ C ~T PM H~ M~ O M HaTMCK M: BbPV fleeHaBrec~o CVYnWHMRTa Ha Ta3a B aKTMBHa Bb3Te C ~ M H M ~ a M Haabti 3 ~ ( ~ a 3 nopAaea b~ M ce p a 3 ~ e a p~ PaCT, Mewy 20-50 T O A M H M , KaTO MbXeTe C e 3aCRraT 4.2 6on~a B MRCTOTO Ha yspepa~a), npMTMcKaHe c pnatin Ha nbTM nOBe% OT XeHMTe. Ha TPaHCnOPTHHR TpaBMaTM3bM ABaTa rpe6e~a Ha ~bfl60.1Ha~a KOCT eUMH KbM Apyr (~a3bT ce n q a ~ a h - r o npoqeHT n ~ ~ OT ppepme Ha ~ a a a - 60ce n p u ~ ~-6on~a ra B MRCTOTOHa cqynea~e~o), npMTMcKa65%, cneu Hero ce HapewaT ~ ~ O M ~ B O A C T B ~ H M 64~0RT, He C loMpYK C M M $ H ~ Ha3q ~ T ~ (6on~aB MRCTOTO Ha BMFlT M Cl lOPTHMRT (Hah-qeCT~ aBYn3MOHHMTe $palcrypM). yepepa~a).B HRKOM cnyaM, npw Kbpsetie, ce Hanara Cnopep M ~ X ~ H Ha M ~ BM ~ ~~ H M K B Te~ce H ~ nonyram OT ~acne~(aa Ha ~pelcryMa e M BnarannweTo ( n p X~HM). ~ 1MpeKleHyflap, flpeflHO-qHa M n MCTpaHMVHa KOMpeCMR, 3a ~ K S ~ K T ~H ~~ amos Ba cb06pa~eHMeMpea Ronpn yAap, npvnqeti no ocTa Ha 6efipo~0,nqatie OT ~ s c n e ~ e aB ~p ea ~3 o n ~npoeKqMM, r~~ a npM H w a M KT. BMCOKO, BHe3anHO ~ ~ H O P M HCbKpaUeHMe O Ha IbnMTe MYCKYnMHa 6eflpo~o.npM TeXKUTe YBPefiM MeXaHM3MbT e Hah-Vec~o KOM~WHM~~H. C~U&~CTBYB~T MHOXeCTBO Klla~M$bl~a~MM Ha Ta3OBMTe yspeAM, 6 a 3 ~ p a w ce ~~a p a ~ n u r npMHqMnM. ~u E p ~ OT a H ~ B ~ A oOT ~ npaKTHrecKa H M T ~ rneuHa Tows e t m a c ~ $ ~ KaqMRTa Ha Key M Conwell. 1. O ~ ~ K T Ha ~M30nMpaHM PM Ta30BM KOCTM 683 IlpeKbCBaHeHaTil3OBMRflpbCTeH.

1. ABY~~~MOHHU:
- H ~ C ~ M H ~ M ~ H ~ K ~ ~ )MOP; H T ~ -HaCnMHaMflMaKaaHTe PMOP; Ha M e p OCMC HCUIMM. 2. V l s o n ~ p a $palcryp~ ~~ Ha nybMc M MCUIHM.

3. Opalcrypa ane ocwc nnw. 4. Opamypa OCMC calcpp. 5. Opamypa ocuc KOKUMMC. 11. np0CT0 (~RMHMVHO) IlpeKbcBaHe Ha Ta3OBMR IlpbCTeH. 1. Opa~rypa~a p s a ~ a ny6nc n MCUIMM (~AHOCT~~HHO). 2. D M C XHa MC ~M ~M $ M ~ ~ T ~ . 3. B e p ~ b ~ a napaapTuKynapHM n~v $palcryp# Ha umy-

Ha MRCTOTO Ha flpOM3UIeCTBMeTO ce 3anorea 6op6a C uoKa rpes attanreTMqcl M MH$Y~MOHH~ Tepanm, cepaTuBM. B H M M ~ T C ~e~nOBflMra H O ~OIIHMRT M C e IlOCTaBR Ha TBbpAa HoclrlnKa B nonoxeHueTo, B KoeTo nexM. no4 KOfleHeTe C e n0CTaBR HaBMTa Ha PyflO ApeXa - aK0 e no rpb6, aKo e no KopeM- noATasace nocTaw sb3rnae~~qa. To sanorea c Rd-nscne~ea~e, KoeTo onpenenn BHga HayBpepaTaM no-HaTaTbUHOTOOTHOUIeHMeKbM HeR.
caocHoeHMTeTwnaHaneremenpMTasoanTeyepenM.

Ko~cepea~ua~o nerewe, slcnloqsaqo no~ofi Ha ner-

ilpomo3a~a 3ae~u.1 OT paw0 npoeeReHoTo, e$emBHO n WeKBaTHo nereHMe Ha yepeAaTa, HO B MHoro ronm npO~eWOTC~aMTeTOBOAMAOTPyAHOBb3CTaHOBFIBaHe Ha pa60~ocnoco6~ocrra, ~ai-pa~ no o 6-MRMeceu, a ROCTa 'ieCT0 M 10 TpaA~a MHBMMflHOCT, M3MCKBaua HOBO
CouMmHoWanTMpaHeHanHfinenpa.

no Koirvee- OT 2-5% OT BCM'iKM JlYKCauMH; tl0 AaHHM Ha HMCM .Il~poroe"- 1.65% OT BcMclKn nylccaqncl. Hoffa q H H , npeAHM, T O P H M , ROnHM. B 3 a B M C M M O C T OT nonoxeHMeToHa 6eflpe~aTa rnaeace n o ~ p a 3 ~Ha en 1.3q~a: a) iliaca; 6) ischiadica; 2. n p e ~ ~ a : a) suprapubica; 6) infrapubica; B) luxatio scrotalis.

no, nerlewe rlpe3 ~ K C T ~ H ~ M nerleHue R, B xaMaK, eRHoMoMelrrHa peno3~wn no Conwell unn WatsonJones. Onepa~na~o~o nereHne elcnlorlea: KpbeHa penoawqnn M MeTanHa ocreoculrreaac swrroee, m m , C K ~ M M BbHWeH @~KC~TOP.

npn qHaTa nyKcauun (OT ReceT no ReweceT m m no-rlecro cpeqaHa OT n p e ~ ~ a~cKbcneaHe, a) $ne~cnn, aJlT#KuMfl M BbTpeWHa POTauMfl Ha C ( O n H M RK ~ ~ ~ H MOH K . x e Ra 6 b ~ e BncoKa (nn~a'i~a) Mnn HMcKa (nw~an~a). Bb3~ome a yepefla Ha n. ischiadicus. n p npeAHaTa ~ ny~cauwn (rop~a nnuawa, ropHa ny6nrl~annM o6qqa~op~a) - nonoxeHMeTo Ha RonHMn K ~ ~ ~ e HB U 3aencMMocT K OT ~ p a h ~ ~ aO ~~ aM ~ Ha M 6e~peR HaTarnaeaBbesbHwHapoTaunn H pa3nn'i~ac~ene~ Ha @ne~mn. B b 3 ~ o we a ppeAa Ha 6eflpeHMfl HeepoeacKynapeH won.

'lemon H npuopmm
Pefl03#~(~Rra T ~ R ~ flaW C e ln3BbpWU K O n K O T O MOXe no-6bp30 (10 12 h OT Tpae~a~a) B 60nHnqa no1 o6qa
~ H ~ C T ~ ~ U R .

na4~etI~bT C e TpaHClWpMpa BHMMaTenHOHa TBbpAa HmnKa B ~ ~ ( 0 3a 6 Hero ~ 0 nonoxetine B ~ ~ B W C H M OOT CT Tnna Ha nyKcaqnma (paann'i~acTeneH Ha @ n e ~ cn n~ a 6 ~ y ~ npn i . 1 npeAHaTa, ~ W H a H qetrrpantia nylccaqlm). 06qonpa~~~~yaa neKap q n mTpR6~aRa C'bCPRoTo'iM BHHMaHWeTO H YCMI lURTa CM BbpXy PaHHaTa PeaHMMa~ M R M np04lrmamn~a~a Ha TpaBMam'iHnR WOK - ~ a u 'iecraTa npnrnHa 3a Taan ppena e a r n o ~ o 6 n n ~ a Ka~a rac~poea. Jlere~ne~o e ~OJIHM'~HO, KaTo amlo'iea peno3nqn~ noA o6qa a ~ e c ~ e M 3n nocnenmqa ~ AnpeKTtia eKcTeH3HR. H ~ B ~ ~ M O ) K H C e O HaMeCTM CTT~ nyKCauURTa ~~~ rOBOp# 38 HHTepfl03HuHR Ha MeKHTbKaHH Mn# KOCTHH ~parMe~TM M B TOM cny'iai OnepaTnBHaTaMtrrepeeHqnfl e aa,qbnxnTenHa. ~ ~ O - M ~ B ~ CTextinw THM 3a HaMemBaHeca: Ha Alis npn 06~ypa~op nyKcaquR: ~a Ha m a ~ e n n ~ aHa e , XnnoKpa~ npn ~ a , q ~ m ny~caqun, e Ha Stirnson. rpetu~m, KOHTO T P R ~ B Aa ~ ce ~36~rei-n - onm 3a penoanqn~ Ha MRCTO 683 o6qa a~ecre3n~.

Cbmaen~Ba 7-13% OT m ' i ~ w crynaatinn. ~ O ~ W M H C IlauMeHTM Ca Ha Bb3paCT MewY 20-50 TOAMHM. C b o ~ ~ o w e ~m ne x~ eo l x e ~e n 10:l. 113OT cryneaHuma C a B AeTCKaTa Bb3paCT.
TBOTO

Knac~o~~aqmn
Winquist-Hansen.
~H~~HOCTHK~

Cnn~a cnotrraHHa n nannaTopHa 6 0 n e a ~ e ~ o Bc 06~ nacna Ha $pamypa~a, naTonomwianopenmoc~, CK~WBaHe, aHrynaqnn M p o ~ a ~ o p ~ a ~ e @ p Ha ~K ap qa wi ~ n ~ a , an4ya~a nopyTnHa Ha 6 e ~ p o ~ 0 rosopeua , 3a 06#nHa xeMopannR.

Ao6on~n~ noseReHHe o n neveHHe

Teau 4palcrypu ca o6efln~e~n B eAHa rpyna, aaqo~o IlpM TRX Ce 3aCRra npOKCllMaJlHaTa CnOHMO3Ha V a C T Ha 6enpe~a~a KOCT, n p e ~ n a e u ce ~~ OT an ~o ~ o 6 TpaaMaTne~ cleH MOMeHT M Ca flO~OXeHM Ha B ~ ! ~ C T B M ~Ha TO e A H M L4 C b q M ClmW, CBbp3aHM C MOqHma Ha MYCKYnHHTe KompanaqnuH npeHacRHeTo Ha Texecna. naqnetrrcll~e C e TpaHCflOpTblpaT Ha TBbpAa HOCMnKa no rpb6, npn neKa 4 n e ~ c Ha n ~~ a 3 0 6 e ~ p e ~ cram. a~a

fle'ie~ne~o e ~OJIHM'IHO. Opamypa~a (c ns~nlo'ie~ue Ha naronom'i~n~e) ce npepu3~nma OT a n c o ~ o e ~ e p m i ~ cnna M O ~ M K H O B ~ H eO cacTaaHavacT or ca'ieTaHa TpasMa. Kpbeo3ary6a~a B omnqeTo Ha apamypa~a e ronuua. B b 3 ~ 0 we a BacKynapHayapela Ha HneoTo Ha 4pamypaTa, npe~n3an~aaqa unw m p ~pbeonsnna, nnn ~ ~ 6 aa Ha a. fernoralis. Jlere~ne~o ~aii-'ietxoe onepaTneHo - nHTpaMeAynapHa oc~eocn~~e3a no Kunscher unn Russel-Taylor. PRAKO C e IIPM~RW R0 KOHCepBaTMBHOne'ieHMe, KOeTO BWIlorBa RHPKTHa eKCTeH3MR M flOCJleflBaU@ MflCOBa

HMO~H~~H~~~MR. rpew~m, KOHTO ~pf16ea aa ce m a 6 ~ r e a ~ onuT 3a pefl03tiqMRHa MRCTO, TpaHCflOpTMpaHe Ha H ~ H M O ~ H ~ ~ M

paH naqnetrr, HernnmpaHe Ha naTonomwio c'iyneatie, IlOp~M aHaMHeCTH'iHM AaHHH 3a neKa TpaBMa.

I. Opalrryp~ Ha 6eflpe~a~a rnasa

Knacn@nwaq~
Aupeme~ n wtiAnpemeH. Vl npn Rema MexaHnaMa e Heo6~0fl~Ma B U C O K O ~ H ~ ~TpaBMHpaqa M~H~ Wna. Pipkin (1957): l -an wn: Qpamypan q fovea capitis; 2-pu mn: $palcrypa ~ a , fovea q capitis;

BHO, KaTo ~aa-wxro ce us non am^ T ~ X H U K Ha ~ TScaglietti ~

nnM ocTeocMwe3a c A 0 auHToee. n p 6~ e3nepcne~~~~ Te c y 6 ~ a n ~ r a $pamypn n ~ ~ ce n p ~ 6 ~ m K a ~ nbpsnqtio M e~~onpo~e3npa~e.

n~ar~om~a
C~OHT~ nH nannaTopHa H~ 60ne3~e~o Bc o6nacrra ~ Ha yBpepeHaTa ~aao6eppe~a cTaBa; nbntfa HenopBMxHWTHa ~aso6eppe~a~a cTaea; ne@p~aqnma Ha ~pauHHKaeB3aBMCHMOCTOTBMAaHanyKcauVRTa.

fl~amo3a~a ce nocTaBR epMticTeeHo no Rodenea~. YM~CT eH ~o ~~ o r p a ~ $ n nm KT. a I

Knacmtjnwaq~~

M ~ x ~ H Ha H~ Bb3HHKBaHe ~M
Mtffl~peKTeH: npM nWaHe B I ~ ~ M ReKCTeH3MR , M eKcTpapoTaqMR Ha ~ p a o ~ unpcl ~ a .B ~ ~ P ~ C Tnaque~m HM qecTo e AocTanrHa MwHnManHa wna Ha TpaeuaTa.

Evans ($nr. 3.60). 1-BM TMn: -~epa3~ec~ -e C~ Tw ~~H~HM; - p a 3 ~ e c ~ epepyqMpaHn ~u, - C T ~ ~ M ~cHOU~ O ~ H ~ H Ha MepManHMR KOPTeKC; - p a m e c ~ e HepeRyllMpaHu ~~, - H~CT~~M~ 6e3 HU, On03H~MR Ha MeAHanHMR KOpTeKC; - pa3ppo6e~n - H ~ C T ~ ~ ~ I 6e3 ~HM on , o 3 u q Ha ~ ~Mepw mHMR KOPTeKC; 2-PM TMn:.- O ~ ~ ~ KOCM T H O -H ~ C T ~ ~ H ~ H M . Massie l-BM T m : C T ~ ~ H ~ HepasMecTeHM; HM 2-pu Tun: c ~ a 6 n p na ~3~ ~ec~e~w; 3-TH TWIT H ~ C T ~ ~ M pa3MeCTeHM. ~ H M

Knac~tjuwaqu~~ Pauwels - 3 Tma; Garden - 4 Tma. C~vmonnarn~a H AHanamKa

60nKa B HHrBHHanHaTa o6nac~,MpaAMMpall@KbM MeAMaJlHMR aClleKT Ha KOnRHOTO. 60ne3HeHW~ R P M nannaublfl, KaKTO H npM n a C M B H MMa K T M B H M ABMXeHMR B ~a306e~pe~ craea, a ~ a KaTo 6 0 n ~ a ~ ce a aacMnea npn $ne~c~Fi M BbTpewtia poTauuR. P ~ ~ M ~ C T $p ~a H rq M pT ~~ M M a T nO-Ll3pa3eHa KflMHMrHa CHMnTOMaTMKa. YBpefleHMRT KfIaoHlrl~ e BbB BbHWHa POTaqMR M a 6 p y ~ u ~ flpM ~. pa3~ec~e~ $pamypn me ce ~a6nlopam BM~MMO CK~CRMHe.

Cnelu~o 6 0 n ~ n nesettwe ~o
H e o n e p a ~ ~e~ AwpenHa o ~KCT~H~ 3a M 45-60 R AHM,

c nocnepmqo O T ~ ~ ~ M ~ H F I E E aa IH 6~Meceqa, npMnarauo ce no-recro npM Mnan naqneHTM; onepamaHo - .L"-

nnarca, Jichards classicM - nnarta, nwpotin Ha Ender np# BM~~CTHH naunem.

Knacn$w~aqwn
Seinsheimer ($Mr. 3.61). 1-BM TMn: HepaaMecTeHa M n w c p a 3 ~ e c ~ no-MW~a~e KO OT 2 MM. 2-pn T M ~ f: l ~ y $ p a m e ~ $pamypa. ~~a a) TpaHCBep3allHa; 6) cnMpanoawflHa, KaTo trochanter minor ocTaBa K ~ M ~ ~ O K C M M W H M $par~em; R B) cnMpanoaMflHa, K ~ T O trochanter minor ocTaea K ~ M flMCTaflHMR $palMeHT. 3-TM THn: ~ p ~ $ p a r $palcrypa. ~ e ~ ~ ~ a 4-TM TMn: TpOXaHTepHa $palcrypa H~A-MWKO B flea nnaHa, MsclcKBaqa flea nnaHa $HKC~L(HR nopaw KocaTa,
c~Mlll0MNllKa H AHalHOCTHKa

na~netn-b~ C TOW T M yspeAa ~ e B yepeneHo 06140 cbcToRtiMe. HapyWe~MnT YcKyneH 6ana~c n npemmpaqaTa T ~ ~ K U MHa R m. iliopsoas, rny-reantime MycKynM M BbHWHWe PTaTOpM BOflRT fl0 $ J ~ ~ K C M R , a 6 f l y u ~ M BbH~ WHa POTPL(HRHa YBpefleHMR K ~ ~ A H M KA .~CO~~ HeflOflOTH~ BMMOCT M CMnHa ~ O ~ ~ ~ H ~flpM H O BCRKO C T flBMXeHMe B cTaBaTa.

Cr.3.60.

C ~ ~ I U H~OJIHRHO O neqe~~le
He~flepaTMB~~-flMpeKTHa eKCTeH3MR C flOCIleflW~0 0~6peMe~RBEi~e. O ~ ~ ~ ~ TM .L'-llfla~a, B H O flMpoH Ha Russel Taylor, ~M~OH Ha M Ender n p mpacTHH ~ naunemw. rpem~n, KOHTO ~ p ~ 6 na ea ce n a 6 ~ r e a ~ n -p KM+ ~ KM OP~KTYPM B 06nacna Ha ~POKCMMWHOTO6enpo WHO-

T O R H M e T O Ha flaL(MeHTa M XOCflHTWM3aL(MR.

H ~ O ~ X O ~ ~ M M O OT (=T CfleWHa T~

M~cK~~Ho-C~XOXMHH WpeAH B IIpOKCHMiMHilTil

H CpeAHaTa VaCT Ha 6 e ~ p 0 ~ 0

~ H~ ~ ~arm O ~m ~~ a ~

napea c ~ e n eo ~6 p a ~ n yapena, ~a xapa~~ep~3~p

qa ce c 6on~a,penuclasaqa ce npM paMxeHMe M n M K O H T ~ ~ K ~ M3a6enR38aT R; ce neK cnaaau, OTOVHOCT M cna6a sary6a Ha @ ~ H K ~ M R . B~opa cTeneH (VamnV~o M ~ C K ~ ~paa~bcaa~e) HO x a p a ~ ~ e p ~ ce a ~c pnoKanHa a 6 o n e a ~ e ~ oyaenwaeac~, qa ce n p pBUxetiMe ~ unM KotrrpaKqMR, cpepeH cnaab~, OTOVHOCT, ~ K X H M O ~M M BnowaBaHe Ha MycKynHaTa I$YHK4 M R . Tpe~atxeneH (nan~o paa~bcea~e Ha ~ycKyna)nannmpa ce penpecnR Ha MRCTOTO Ha CKbcaaHeTo M ce OTKPMBaTTeXbKCna3bM, OTOVHOCT, eKXMM03HH 3ary6a Ha MyCKyJlHa @YHK~HFI. 3 a a ~ OT c~ CTenema Ha yepepaTa. ~ ~ P B M V H O T necleO w e stunlorea nocTaaRHe Ha nep npea nbpaMTe 24-48 h, nocnepsatio OT Tonnwia, KoMnpecMeHa enamwtia npesPb3Ka, 0~6peMeHflBaHe M ~ O K O aHaJlreTM~M, ~, IlpoTMEOBban an men^^ cpepmaa M MycKynHM penaKcamv. npn TpeTa meneti yapepa Ha MycKynyc Kewpuqenc ce npunara oneparMeHo neqetine.

BMHarn cnepBa pa ce MMcnMaa ~ a a ppepa. # npvl npepHaTa, 3a,q~a, MepwanHa M naTepanHa nylccaqm ce nannMpa IlpoMMHMPaqaTa flop MeKMTe TbKaHM TH~HFI B CbOTBeTHaTa nOC0Ka. n0pwM 'ieCTaTa CnOHTaHHa pell03M~HR peT ~ ~ ~ H OMT 6bp30 O H3CneflBaHe Ha HeBpoWCKyflapHMR cTaTyc e OT peurasaqo s ~ a ~ e ~ u e .

H a f remo pMpeKTHa TpaeMa, npmoxetia nepnetipMKYnRPHO Ha $poHTaJlHaTa M n M CaMTanHaTa PaBHMHa Ha CTaBaTa.

~ Y K C M P ~ H O T KOnRHO O C e HaMeCTBa He3a6a13~0 flop o6qa a ~ e c ~ e nyncaqnn~e a~~. Ha n e p ~ @ e p ~ mpoae me cnepea pa 6bpa~ npoBepeHMnpepM H cnep p e n o a ~ q ~ ~ ~ APT~PM~ YBpeAa H ~ TMOXe ~ pa Cbu(eCTByM ROpM npM ~an~r~e~anyncaq~~~cnyclame~a~eo~n Ha MHTMMaTa. VluoGnn~3aq~ma e B popsanHa wncoaa wMHa n p ~ 15-20@ n e ~ c ~ nocnepaatia n, OT qHpKynRpeH rnnc. npw ~eswbpxa~ Ha e peno3~qnma ce Hanara aaMrnRHe c K H ~ W H ~ UrnU. ~ O BnpM M MHTepflOHMpaHeHa MeKM TbKaHM M HeBb3MOXHocT 3a pefl03MuMR C e M3BbpUIBa KPbBHa peno3~q~~. ~P~WKM KO , HTOTPR~B Ce ~m36nrsa~-3a6ae~~e~~ TO ~a ~ O C T ~ B R H ~ ~a T fl~anioaa~a O aac~nea sepom~oma OT now ~ 3 x 0 Tonno~o ~. xopuno c nwnceaq nync He cnep~apace~~~epnpe~~pa~a~onp KonaTepanHoKpbB006paqeHMe. 87% oTyapepeHme ~ p a i HM~M MoraT pa 6bpm cnaceHn, aKo B ~ ~ C T ~ H O B R B ~ eH ~ T ~ a ~ b p po ~8 e h. ~ o

n w r a ~ e t r r a p yepepM ~ ~ ~ e ca ~ a i - r e c npes ~ u aTopaTa nycaqmma Ha KonRHoTo e pe3yma~ OT Tema TpaeM TpeTaTa peKqa, KaTo cboTHowetiMeTo ~ bxelxe ~ Ma. llonnn~ean~me apTepw M BeHa ca H ~ ~ - ~ ~ HnM pM ~M 21. M ~ H M C K ~ YBpeAM H U T ~CbCTaBnRBaT H a 60% OT Ta3M YBpepa. HMMVM~TO Ha IlyIlCAMcTWlHO He ~ p ~ 6pa sa BCMVKM MeKOTbKaHHMyBpe~MHaKOnRHOTO. ns~nlorea ppepa Ha apTepnRTa. npn 40% OT npepHme U 38% OT awHMTe nyKcaqMM w M a w o w yepepa. RPM 40% KII~CH@HK~~MR OT cnyawe C ~ C cbpoaa ppepa ce mnra po aunyraqna. Wemer Miller MycKynn~e, nMWeHM OT KpbEOcHa6~BaHe nO-)JL$lrO OT 2B epHa paetitwa: MepanHa Hema4 h, nOKa38aTM C X e M M V H MIlpOMeHM,CTaBaqMH ~ ~ ~ P ~ T M M M 1. Hema6nn~oc~n ~ M ~ H O CB T epHa paaHnHa; naTepanHa H~CT~~MIIHOCT B cnep 4 h. HepBMTe maeaT McxeMnwM cnep 30 rnin, c eAHa PaBHMHa; IlpeAHa H ~ C ~ ~ ~ M ~ B H epHa O C T PaBHMHa; He06paTM~M IlpOMeHH Cnep12 h. 3WaH~CT~~U~H BO epHa C T PaBHMHa. PM BMAMMa~ ~ $ O P M M ~ $y~K~M0Ile3a ~HFI Ha KOJlRHOTO, CbveTatia C ronma cma Ha TpaeMMpaqnR aretrr, 2. Porarop~a ~ e c ~ a 6 n n ~awepoMepManHa oc~: Hec-

HOCT;

3. K O M ~ M H MH ~~~C H TH ~~U~HO KO ~T MH ~ :M H M ~ PO~H~ TaTOpHa ~ e c ~ a 6 ~ B n MHOrO ~oc~ KwPaHTM; POTaTOPHa H~CT~~M~H+ O BapyC-BanryC CT H~~T~~M~HocT. Nicholas, 1973,Hughston, 1974,Kennedy, 1971,Trillat, 1971.

- u3cneAeaHe Ha o 6 e ~ a Ha AaMxeHMe, sanrycapec npn0" H 30' @ne~c#R M aapyc-c~pec n p 0" ~ M 30"+ne~cMR; -Tern Ha Lachman, npeAtio . r e ~ u e ~ x eWHO ", .ye~~ep)~ nMeoT e " , UIM$T Ten; -u~cnep~a~e~a~bc~o~~ue~o~a~ TecToeeTe Ha McMurry M Apley; -lracnep~a~e Ha CbmoRtiMeToHa naTenaTaM eKcTeH30PHMR MeXaHM3bMHa KOnRHOTO.
PM TBXKblTe nMraMeHTapHM YBpeflM CneABa fla C e M H C n M 3a CflOHTaHHO PenOHMp~a C e nyKCaqMR, KORTO

- HanMwe Mnln nwnca Ha xe~ap~posa;

M 3 M C K B a CnelLlHa XOCnMTanM3allMH. no~rosoe~a 3aTpaHcnopT: xenaTenHo e M M O ~ M ~ M ~ M paHeTo c ~ o p ~ LuMHa, n ~ cneAaa a ga ce ~ a n o m KoMnpecMBHa npespba~a, 3a I a ce ~ d e n i e HapacTeaHe Ha xewap~poaa~a.

cnelu~o 60nun~o nereune

np# mpaa cTeneH nnrannewapHayepega, (@acq~tcynapHo p a ~ m e a Ha ~e KonaTepanHmen c l r a ~ eH ~npn ~~)

KonaTepannwe nnraMem, KaTo npn H w a ce no1wnaaT c nnamnm no Boswosd nnn Hugston, a 3a naTepantinR KonaTepaneH nnraMem H ~ ~ ( Y K T O ce n3non3~a nnamnKacbccyxomMnneToHa m. biceps fernoris. rnncoea~a n~o6cmn3aqu~1 o 6 n ~ ~ o e e aa ~ o45 pHn. A~T~ocKo~e MHe3aMeHMM RT~ MeTOA 3a flUalHOcnlKa U nevetine Ha MewcKanHwTe ppefln. rpelulcur, KOHTO ~pR68a aa Ce H ~ ~ R T B B fla T He C0 3a~nto~le~ne H 3a Texecna Ha TpaeMaTa c a ~ o eb3 oc~oea Ha aHaMHe3aTa. al J He ce mncwpa.6ea npnvu~a: T. e. 6e3 ycTanoaeHa Anamoaa. 3a npeflnovuTaHee Aa ce tnnonaea opTe3a npeA pnrwHnR mnc.
B ~

MM~HO BbzTatioweatie Ha

Aupene~, utinnpemeH (npn a6~0pMeHa KotmpaKuuR Ha m. quadriceps fernoris) n K O M ~ M H U ~ ~ H .

Knac~@u~aqm~
I. O~cypa. 2. Henbn~a $pamypa. 3. f l b n ~ a $pauypa c 2 nnn noeelce opamem. 4. M ~ o r M p a m e $palcrypa. ~~~a
M. Hohl, 1967 ($nr. 3.63). 1. H ~ P ~ ~ M ~ @C ~ ~T KT ~MH )M M . 2. P a a ~ e c r e @ ~ np a w n : a) $pamypn c noKanHa AenpecnR; - @palcrypwc UeHTpantia Renpecm, - +palcryp~C pa3nene~a Aenpecuu; 6) +palcrypn c ToTanHa AenpecnR; B)QpauypuC $ ~ O H T ~ pamenme ~ H O Ha @pameme; r) M H O ~ $ ~ ~ M ~ H T H $palcryp#, M T M Y 06pa3~~. . A V ~nacn@~~ -a3uTnna n ~ M 3 noRrpynM.

~ O ~ ~ ~ H W npn O nannaung; C T OTOK, xe#ap~po3a, nannaqw Ha ~ ~ W MK@y~wnone3a T npn p a ~ e c ~ e ~ w e @pamypuHa naTenaTa n npw ToTanHwe pynrypn Ha cyxoxwnneTo Ha KeapvuencanC O ~ C T B ~ H O TcyxownMe O Culumo~am~a H Abl aniocmKa H a naTenaTa; OTOK, ~ O ~ ~ ~ H ~ H 0T~na68aHe H O C T HaclnnaTa npn ~ e p a a ~ e m e ~ $parcrypu we Ha narenaTaM qamnwinC~OHT~ MH nannaTopHa H~ ~ O ~ ~ ~ H ~ BH o6nacrra O C T T e PyIlrypM Ha eKCTeH30PHHR anapaT Ha KOnRHOTO. Ha PpeflaTa, OTOK M xeMapTpo3a Ha CTaaaTa, 60fle3tieHa M orpattuvetia n o ~ e n x ~ Ha o ccTasaTa. ~ Hema6nn~oc~, /JbnXaqa C e Ha HapyllleHaTaKOHrPYeHTHoCTHa CTaBHHTe noabpxtiocTw Mnn Ha npnApyxaaaua nuraMeHTapHa yepela (B 7-15% OT c n p a ~ ~ e O ) .~ o ~ v a ~ e Anamoaa n~a~a ce nocTaeR no peHmeHonomrHn 6ene31.1. H ~ ~ M ~ Ha M ~ MaCTHbl K M K M npM IlyHwblRTa e BmeH MHflMKaTOP 3a Yspe~a~ Ha a naTenaTa, HTO sbrpemaetia ppefla BbTpecTaeHa$pamypa. P e ~ m e ~ o n o mce r~ npneMa, o ve H3MCKBa O ~ H K H O B ~ HCnelllHO O OnepaTHBHO Bb3cTaHOBR~ e p a a ~ e m @patcrypa e~a e ~a3u, C AenpecnR no-uan~a OT BaHe. M ~ 6 n 6 n p a ~ C eK ~P o ~ Ha B MeKMTe TbKaH' GI3aTPYflHR5 mm. sa3HaclnTentioonepaTopaecneAeaqweF1nn. CTene~ Ha cnewocs. Te B K ~ I O C ~ B ~ THa~n6#anT~~M Jleve~ne~o Ha pa3ueme~me $patcrypn H Ha ~ o ~ a n - HOT0 nnaT0, eMklHeHuMR HHTePKOHAMnMKa, $palcrypM-nyKHme pyn~ypn Ha cyxomMnneTo Ha KmgpnyencaM CO&M u M M Ha K O n R H O T O M IlpOKCMManHaTaT M ~ M R MC e RBRBaT eeHoTo cyxomnne Ha naTenaTae caMo onepamaHo, KaTo BbTpeCTaBHM $palcrypM. BMMOXHU Ca flUCTWHM 4MPKYnpu @pamypweHa naTenaTa ce ~sebpusa ~ai-remo naTopHn HapyueHnR nopan ppena Ha a. poplitea. f l p ~ ocTeocnme3a no Weber, c e p m m nnn napueanna naTeyepeAa Ha naTepanHoTo nnaTo Ha ~n6uma MoraT na

6b,4a~ sacenla~n n. peroneus M a. tibialis anterior.

AoCon~~vuo nonedeuue U neveuue

K ~ ~ ~ Hce W wMHMpa K ~ T B~opaan~ tuMHa. a nocraem ce a ~ a n r e ~ ~ q ~ .

HaTa M M O ~ M ~ M ~ 683 ~ ~HaToBapBaHe M R UamT nonomeneti pe3yn~a~. Oc-ra~bq~a~a pMcnoKaqnR c noeeqe OT 5 mm~ao~a~a~a~a~o~ap~a~e~a~arm Ha 4 p a m e ~ ~ w ee cebpsaHa scltiaru c now p e 3 y n ~ a M~ e
H H A M K ~ ~ M R ~ ~ O ~ ~ ~ ~ T M B H O ~ ~ ~ ~ H

Cneuruo 60nu~vu0neveuue
Ka~o npaauno ~ o 6 p a ~ pe ano3nq~ n~ npomnmen-

PM ~ e p a ~ e c - r e ~~epaanpo6e~u u~e, $ p a w # ce np~nara neqe~ue C 6peac aa 45 AHM. ~ P BCUC~KM H 4pam-yP M Ha nPOKcMMmHaTa T M ~ H R W 6 e a Ra ce M M a nPeUBMp

Paspenm ce Ha KOCM, cnMpanoanntiM, tianperw, cerMeHTHM M pa3~p06eHM cClynBaHMR. no Weissmann: 1-BM TMn: MHHMMllanHOpa3MeCTeHU-Ha 115OT qMpKYh4$epe~quma M < OT 10" a ~ r y n a u ~ ~ ; 2-PM TMn: yepeHo p a m e c ~ s a ~ OT e 115-215 OT 4 ~ p q~$epe~q~ MfOT l ~10-30" a aHrynaqwR; 3-TMTun: 3 ~ a r m e n ~ po a3~ec~ea -~>eOT 112 OT qupKytd$epe~~(~~~a.

Ha $paKryp~~e Ha nofl6e@M4aTa ce ~aabpurea eAwClBeHO B ~ O ~ H M ~ 3aBefleHMe; HO ~ ~ ~ ~ B F IHaTpaHCnOpH ~ T O TupaHeToHanaulreHTa~oxe~agoee~e~opa3~~~ KOMnapTMeH CMHAPOM; nOCTaBRHeT0 Ha MnCOBa H M O ~ W n ~ 3 aM q HenpocnemsaHeTo ~ ~ B nocneAaaqMTe AHH B 6 o n ~ ~ Moxe q a ua AoBepe 40 c b ~ o ycnoxHeHMe. ~o
TO

PM ~ 3 o n ~ p a ~ $palcryp~ me Ha T M ~ U R p T~ a3~ec~~aHeTo PRAKO e ronmo M OTOK~T tie e TemK, CunHanoKanHa ~ O ~ ~ ~ H ~ OTOK, H O CCKbCFl T , BaHe M POTaqMR npM pa3MeCTeHme $palcryp~ Ha no~6eflp~qa~a. C~CTORHM~TO Ha MeKMTe TbKaHH np# CnMpanOBMAHMr n e 3 w apalrryp~ ~~ T e $palcryp~(rIpM.lMHeHM O ~ M K H O B ~ H OOT MHAMpeKTHa Kano npM B C M ~ K M $palcryp~, 3 a c ~ r a q cTaeHaTa ~ ~ p a s ~e ano-~o6po ) OT Toea npw HanperHMTe(npe~uae~nOBbpXHOCT Ha TeXecT-HOCeqM CTaBM, OCHOBHMRT npMHKaHU H ~ O - W ~ C T OT O AMpeKTeH ynap). q#n Ha neretikiero Ha r n e 3 e ~ ~ m $palcryp~ e e: B ~ ~ C T ~ H O C~M~~~~O $palcrypM B M ~B H AMCTanHa H T ~ TpeTa Ha TMBRBaHe Ha HOpMmHaTa BHITOMMR, KOeTO We npeflna3M OT 6~ma~ora~~a6afia~ycnox~e~~ n.o peroneus ~y~pefla~a pa3BMTMe Ha XPOHHVeH OCTeOaPTPMT. CTa6MnHo~na Ha nopww 06pa3yean~~ ce xeuaToM. r n e 3 e ~ ~ cTam a ~ a ce 06ycnae~ or qenocrra Ha H ~ O H ~ T npw $palcrypu B cpenHa 113 Ha n0~6eflpM~aTa HaAKoCTHa KOH$MT~~~L(MR M nMraMeHTHa CMCTeMa. TR e Haremo ce sac~ra n. tibialis posterior. nbnH0KOHrPYeHTHanpklBCMrKM l l 0 3 M ~ M M HaTayCa(hman, O ~ o ~ r a ~ e~ n~ ~aam ~o a ce aa nocTaeR eba ocHoea Ha 1976), OT nbnHa nnaHTapHa $ne~c## AO nanHa popaan~a R o - ~ a x o ~ ~A ap ~a y .M ~~ C ~ ~ A B ~ H ~M oR m, ce o umonseaT $ n e ~ c n f~l.p H ~O P M ~ ~ H O TAeMxeHue O B rneseHa ~ a n y c b ~ B mMHMKaTa, ca: neplcyraHHa $ e ~ o p a n ~ apTepMorpaa oKono naTepanHaTa CM ram. l l a ~ e p a n ~ ~ $MR, KT CKeHUpaHe, Ro-TOMOT~~$MRT~, C ~ M H T M ~ P ~ $ M ce R TpoTnpa ~ Maneon e T ~X~CT-~oc c-rpylcrypa, eqa npMnbpxaqa npuM~ e p ~ o r p a $ ~ ~ ~ a . 6n~3men~ 116 o OT Texecrra Ha TRnoTo (Elmendorff and na ce npaeM pa3nu~a Memy r n e 3 e ~ ~ Petes). Tp~6ea $palcrypM M $palcrypMTe Ha T M ~ M ~ H O TCTaBHO O nbfqe, T. Hap. nMnoHM $ p a ~ ~ y p 3ac~raqu ~, noBere OT 25% OT CTaBHaTa IlOBbpXHOCT.

Cnee~o ~OJIHINHO

neseHHe

PM ~ e p a a u e m e ~ $palcryp.~ ~ ~ e nereHMeTo e c mnC O W M~06MnM3a~Mfl 38 O K O n O 3 MeCe*,

HO Aa ce aanor~e HaToBapsaHe cneA 1-R

KaTO e Bb3MOXhneceq. PM p a 3 ~ e c ~ ~ e~~ KP ~H ~T$palcryp~ e M ce n p ~ 6 ~ r a a flOAMpeKTHaeKCTeH3MRMrMnCOBKpaClOnMnM MaHyViHa p e n o 3 ~ Ha q ~anapaTa ~ Ha Bohler M mncoa Kparon. PM OTKPMTHTe $palcrypM H ~ L - ~ ~C c eT M3BbpWBa o M3BbHOlHMqHa$MKCB~MR. f l p HeoTAaeaqa ~ ce p e n o 3 u q ce ~ ~~aabpwaa KpbeHo HaMeCTBaHe M $ M K C ~ ~ CH nnaKa, R BMHTOBe M n M MHTpaMeK,nacUaU~apfl Aynaptia oTeocMtiTe3a no Kunscher wnu Russel Teylor. rpelu~m, KOHTO ~ p ~ 6 Aa ea ce n s 6 ~ r e a ~ - n e r e ~ ~ e - Lange-Hansen (1942) - reHeTurHa t m a c ~ $ ~ ~ a

Lange-Hansen (1942) RCHO onucBa M ~ X ~ H H Ha ~ M rne3e~~a yspeaa ~ a M nonyeHaTa BcneAcTsMe Ha Toea naTonomR. Toh npemara t m a c u $ ~ ~ a 6awpaqa q~~, ce Ha nOnOXeHMeT0 Ha XOflHnOTO B MOMeHTa Ha yBpefla M nocoKaTa Ha yapewaqa-ra cma. Ton on#cm Ace o c ~ o BHM, BoneqM cunM, f l e t i c ~ s a q sbpxy ~ rnese~a - cynutla~ M M R npoHaqwR. HaL-rec~o ce cpeqaT npH CnopTHuR M 6 ~ ~ TpaBMaTM3bM. 00

nouara 3a pa36~pa~e Ha ~ e x a ~ Ha ~m a e~3 a e~~m @pae A ~ @ p e ~ q n a nfl~ano3a ~a KTYPM H paea ~ K ~ ~ ~ H 3aMTRXHOTO F I HauecTeaHe. Toh ~3~~~ep~a~H~~neK pa a~ pT op x pa fe 1 paann~~aaa 6~a onncaa 5 TMna, cebp3anu c ~ e x a ~ n Ha a~ ppem, a KaTo rne3eHHoTo HammHe, rucraTa nycaqnn, cy6nycaqnn B C e K M epMH OT TRX M M a 4 IlOprpynM B 3aBMCMMOCT OT HanepOHManHMTeCyXO~nMRMppe~MTeHaMeTaTap3YTexecrra Ha yapepaTa. ca OT rMcTaTa @pamypa. Brunner-Weber (1982) W ~ ~ C M @ M ~ rM n~ e3 ~e T ~~me @pawn CnoPeA ~ ~ ~ o n ~ - n o x e @paKlypaTa ~ # e ~ o Ha ~,0 6 0 n u ~ v u noBeneune o . . n neveune @~6yna~a, nocoraah~n, r e KonKoTo no-BMCOKO TR ce Ha~POBM~OP MH M ~ ~ ~ H ~ M Ha~ YBpeReHMR ~ ~ M R K ~ ~ ~ H M mpa, TonKoea no-~eww ca yape~me ~a~~6wo-@a6ynap(mv~~pane), nocTasRHe Ha nep eapxy rnese~a, nospnraH M T e nMraMeHTM. TMn A - @paKlypa~a e non HMBOTO Ha He Ha BMCOKO Ha KpahHMKa, aHanreTMqU M TpaHCnOpTHpacwilpe3~03a~a MT M n B - Ha HMBOTO Ha cw~pe3~03a~a, M He A0 ~ah-6llM3~0~0 6on~n.1~0 3aBepeHMe. AKO HMa TOnRIlpM T M n C (@MT. 3.64 M 3.65) - H q CMHF(e3MO3aTa- naRMa u e @ p ~ a q npMrMHRaaqa ~ ~ , capoea HepocTanwocT TemKMRT TMn. TaKa Te Ha6nflra~Bapy WHOCTTa Ha n aac~pa~uaaaula KomaTa WnocT, xenaTenHo e pa ce naTepanHuR KoMnneKc. BCM~KM @palcryp~ Ha rnesena, M ~ B ~ P L UM M np0~~3op p~ ea n o 3 ~ qk ~c ~n .e p a a ~ e ~ Ha o O~XB~H~ MTOT M ABeTe Klla~M@M~aqL4#, MOraT pa 6bpaT nyncaqMme Ha n e p ~ @ e papTepnn ~ ~ ~ ee a q b n m ~ ~ e n ~ o c~a6cmnn M ~ecra6unn~.

Cu~rrro~anr~a
M~X~HH Ha~ TpaBMaTaRaM M~T Bb3MOXHOCT3aOnpeIenRHe crenema Ha cMnaTa Ha ppepa. K~HHM.IHM npw3HaqM - nOKanHa 60ne3HeHOCT, IlOAKOXeH XeMaTOM M OTOCIHOCT,aKo e OT epHaTa crpatia, npe~nonara CT~~MJIH~ yspepa, poKaTo, aKo noKanHnTe npw3naq~ ce pa3npoc~paHmaT n OT peTe crpann Ha rneae~a,Moxe pa ce cuma, qe ppepaTa e ~ec~a6clm~a. Flena~aKnuiinwa pe@op~aqw Ha rneaena roeopM 3a nec~a6nn~a yspepa, KaKTO H ~ ~ H O P M ~ H O RBHXeHMe TO Ha TaJlyCa B me3eHHaTa BMnKa.

Cnelll~o60nu~vu0neveune
~MBHO M onepanmno.

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nereHwe - npn BcnvKM Hec~a6MnHM 4palcryp~. npae~ ce KpbBHa pen03MqMR M MeTmHa OCTeOCMHTe3a. [p# nMMmaTa aHaToMnvtia p e n o a ~ M qn ~a ~ 6 ~ n oneocw~~eaa ~a onepnpamm ~ p a h ~~onx~ pa e 6ape ocTaaeH 6e3 mncoaa ~ ~ 0 6 1 m u a a Mq Aa ~ ce ~ aanorHe paw0 pemeHMe B rneae~~a c-raaa, ~ a HO HaToBapsaHeTo Aa naHe ~ C H O ~~BMC OT M BHpa Ha 4paKrypa~a n C T ~ ~ M ~ H OHa C one~ I oclrl~~eaa~a.

sepHara cneq yapeAaTa, npeAM paaamue~o Ha oToKa M 6 o n ~ a ~OTOK~T, a. KO~TO 06x~aqa tpnaTa cTaBa, ce npMrMHma OT yapemqatie Ha cTaeHaTa Kancyna, cneA KaTo npepHMmTano-@M6ynapeH nwrauem ce e cfican. 6 ~ n a TepanHMXeMaTOMM C e BM)IWaTB 60% OT CnyclaKTeC TBMKH AMCTOPSMM B nbpBnTe 48 h. noa~qwma Ha rneaeHa M xoynoTo - BMRHMO p a a n ~ v ~ Be creneHTa Ha M H B ~ P ~ M R M n M eeepa~~, cpaaHeHa cbc 3 ~ p a ~ rneaeti. ~ f i 6on~a npM nannaqw. M3cJIepBaHe Ha KO~RHOTO,KaTo npaemo, sa OTKpMBaHe Ha npMF(pyXaBaqMYBpepLl Ha KOnRHOTO M n M Ha npoKcMuanHaTaQn6yna. Heapoaac~ynap~~m craTyc Te MOraT Aa 6bpa~ PaHHM M KbCHH. P~HHM - npM ~ p ~ 6pa sa ce Macnensa vpea nannaqMR Ha n e p ~ Q e p ~ m e HeOnePaTHBHOTO JlecleHMe - YCnOXHeHMRTa Blvllo'iBaT CbAOBe, KaKTO M vYBCTBMTenHOCTTa. O ~ ~ H H C ~ HPABM~HMR ncxeMMR, c nocnepeaqaVolkrnan KowrpamypaHa nop6exeHMma B r n e a e ~ ~ craea. a~a H~cT~~M~H sa om cT a ,Ha RpnqaTa M xopMnoTo, p a a ~ e c ~ Ha ~a $pamypa~a, ~e cy6R0 n ~ a npM nannaqm npvr n o - ~ e x ~ m cnyvaw. e nyltcaqw. K ~ C H -HorpaHMveHclR Ha pauxetiMma B rne- @ ~ H K ~ M 6 AaeatqH npeAcTaea aa c ~ a 6 ~ n ~ o c r r setitiaTa cTam c h n e a ~ e ~ oocrreonopoaa, c~, 3 y p e ~ o ~ C~pec-~ecroae~e, yepepa, T P R ~ M Aa ce npoeemqaT noA noKanHa aHec~ T ~ @ MOCTeOaplp03a, R, n ~ e B ~ 0 a p ~ p 0 3 a , ~ p o ~ 6 0 @ ~ eHa 6# ~. Te3HR. CHM~TOM~T Ha B ) ~ I ~ ~ B ~ (Tpan' H ~ TiM oHKa) rOBOpM PM OnepaTMBHOTOJlereHMe - PaHHbITe YCnO)l(HeHMFIMOaa pynrypa Ha naTepanHMR Konarepaneti nwraueHT. raT Aa 6bpa~: MH@K~MR, HenoHocMMon OM MeTana, C nocnepeaqoKoMnpoMeTupaHeHa MMnnamaHTa. Kbc~nxpoHMrHa M H ~ ~ K U U@myna, R, ocTeoMMenm, ocreonopo3a, OcTeOapTpO3a, ~ Y Q ~ K O ~ TBP ~ O~MR OrPaHMCl , eHMR Ha Qpawypa ~a @ ~ 6 y n a Maneon, p~~~ aeyna~o~ 4pa~w ABMXeHMRTa B rne3eHa C ~ O ~ ~ ~ H ~ H nOCTORHHa O C T , Gonem y p HaTM6ManHMR ~ Maneon,4pawypa~a ~aMaisonneuve, ~H~HOC npM T HaToeapsaHe, nepcMcTMpaqOTOK.

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ilportloaa~a aaeMcM ~ah-seve OT BMAa Ha QpaKrypaTa, OT Bwua Ha neveHMeTo H OT nocnepeaqMTe p e x a 6 ~ n ~ T ~ ~ M M $uauo~epann~. R CTa6MnHMTe Qpamyp~ ca c nonpomoaa OT H ~ C T ~ ~ M ~ H M T ~ . HaTa KOCT, B ~ ~ M O X H O38 CT r p e l ~ lC ~o ac ~ ~ 6 m a n eKCTepe~ HYM, yBpemqaHe Ha CyxomnnRTaHa M. T M ~ M ~ aHTepM~ M C

rne3e~~mep~crop npeAcTaenRBaT au~ norm 10%OT CJlyclaM, nOCeu(aMqM CneWHMR K ~ ~ M H ~ HahT. clecro ce nonyvaeaT npM cnopTtiM ppeRM. iloeeve~o p ~ C T O P B M M(80-90%)BKnlOClBaTnaTepaJlHMTenMraMeHTMnop a n TOM, ve KocTtiaTa C T ~ ~ H ~ H OeC n To-ron~~ OT a naTepaJlH0 OTKOJlKOTO OT MepManHO, nOpwM KOeTO MHs e p a ~B ~ rneaetia ~a e no-vena OT e e e p s ~ ~ ~ a .
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AKO M M a wKaKBo K O ~ ~ ~ Z I aa HM CTenema ~ Ha ~MCTOP~MFI, ~aA-no6pe e rneaetib~ na ce M M O ~ M ~ M B mncoB ~ M ~ ~ 6o~yu aa 30-45 AHM, C rneaeti B fiops~$ne~cw~, i l p no~ TexKme ~MCTOPBMMo ~ t i p e ~ e ~ m 3aa napeMTe ~ e 48-72 h. XHP~PM~HOTO Bb3CTaHOBRBaHe Ha YBPepeHMTe Bpb3KM e noKamHo np# Ill-~a neneH AMCTOP~MR. BCH~KM r n e a e ppepn, ~ ~ ~ oco6e~o ~ e sC~ nepcMcTu, paqa h n ~ aMoraT , pa ce ycnoxHm C p e @ n e ~ ~ o CMMp~a IlaTHKOBa~MCTPO$HFI. XpoHM'iHa H ~ C T ~ ~ U J ~ H O aTp@MR CT, HaZudeck npM r e ~ e p a n ~ a ~ pO aT~ O~ nM ~ ,KoeTo e q e AoeeBe 40 ocTeonoposa. flo6pa npM npaeMnHo neretiue. H e r n n m p a ~ e ~ Ha o ppeAaTa Moxe na noseae po nepcwcTMpaqa 60nea~eHOCT, H ~ C T ~ ~ H ~ H Ha O CTaBaTa CT M OTO'iHOCT.

B 3aBMCMMOcT OT KnMHM'iHblTe nPM3HaL(HCe pa3nM'iasaT 3 cTenetiH Ha ~ M C T O P ~ H R l. ~ neneti, a parrRraHe nnM clamrHo cKbcaaHe Ha 1 nwrauem; Il-pa cTeneH- oTcna6ea~e Ha eAMH nMraMeHT (O~MKHOB~HO npeRHMR T ~ ~ o @ M 6ynape~) M 3acRraHe Ha BTOPMR; I l l - ~ CTeneH a - npencTaBnma nbnHo CKbcBaHe Ha ABa nMraMema M noeere.

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XO~~M~ C e O CbCTOM T O OT 26 K O C T M , KOMTO H3llbnHRBaT eAHa uRnOcTHa @YHK~MFI. AH~TOMMYHO X O A M n O T O BKntO'iBaTap3MHMTeKOCTH, MeTaTap3WlHMTe M $WlaHIWe. MOx e na ce pa3flen~Ha 3 aHaToMMrHM r a m - npefltio, cpepHo M a w ~ xoAnno. o C p e ~ ~ xoflnno o ~ o e oTReneHo OT B~HOTO rpea maeaTa Ha Shopart, a cpeAHoTooT npeAHoTO xoAMno rpea cTaeaTa Ha Lisfranc. C n e MeKonKatiHn~ Te ppenw $ p a m y p ~ ~ M enyltcaunclTe Ha xoflMnoTo ca BTOpaTa no 'ieCTOTa yBpeA& OT BCM'iKM KOCTM Ha XOAMnOTO H ~ ~ ~ Y ~C C e YBpeWa T O TanycbT M KMKaHeyCbT. ,

Ka C IlepOHeWeH TeHAMHMT. opalcrypa Ha OCTPMrOHYM ~apm (cpeqa ce OT 5-774$pamypa Ha npouecyc nocTep ~ oT p ~ M flnc~opsnn , Ha rnese~a).

H e p a s ~ e c ~@ e ~p~a~qep-~M H O ~ O BMCOK n p o q e ~ no6pa nponioaa. npn BTOPM T M C ~ ~ C c y f i n y ~ c a 4Ha ~~ cy6~anap~a cTaea ~a -1 0 20% MMaT asaKynapHa HeKpo3a. PM TpeTM THn C nyKCauMR HaTRnOTOHaTMyCa-nOLlJa npomoaa - cbc 100% aeacKynapHa ~ e ~ p o a a .

It. 0paK-y~ H a KanKaHeyca

K a n ~ a ~ e ye c~ b~ a l - r o n ~KOCT ~ a Ha ~a XOAM~OTO, npeHacRqa Texecrra Ha TRnoTo W ~ ~ M F I T 3a ~ .Hen ce 3MaBFl M AXH~~COBOTO CyXOMHnMe. T0fi 0 O P M R 3wHaTa rac~ ~a H~,QII~~MR CBOA ~a XOUM~OTO. pamyp~pa ce no-reuo OT BcRKa Apyra ~ a p a a n ~ KOCT a M npeRcTaBnma 1 2 % OT BCMrKM $ ~ ~ K T M~ 60% PM OT BCM'iKM $paKTypM B ~ a 06nam. a ~ h a 4 apTMKynMpaqM $aceu~v.

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H ~ ~ R R Ha B ~ Tanyca, H ~

Hai-UIMpoK0p a 3 n p o c ~ p a ~ e K ~a n~ aac ~ $ ~ ~ ea Tau~ e p m a c MeTopa Ha nereme. Cnope~ Essex-Lopresti ce pa3nMclaKiT ABa OCHOBHM Tuna $ P ~ K T ~B~ 3aBMCMMOCT M, OT pa3nOnOXeHMeTO Ha BTOPMqHaTa $ p a w H a nMHMR. I-BMTM~-~~WK M 11-PM OBM TMn, ~~ no-reCT0 ~ H CpeU@HMRT - CTaBHO-flenpeCMBHM $P~KTYPM.

3~ Ha Essex-Lopresti.TRnpeuCTaBnRBa na~onoro-a~a~ MurHa xapamepMcTMKa Ha 4paKTypa~a M Mua AMpemHa

CTeH MeXaHM3MbT H a TpaBMaTa. B IlOBecleTO OT CJly'iaHTe TO^ HacovBa neKapR K ~ TaKa M HaperettMTe .CKPMTM crynB~HMR', KOMTO 'ieCTO OCTaBaT HeflMaMOCTH4MPaHM. T ~ K M BacaClrynBaHMRTaHaneTHHTeKOCTM,KOCTMTeHaTa3aM QIb6Ha'i~Mfl clan6 IlpM BMCO.IMHHaTpaBMa, a IlpM IlOCTpaflallllTe ~ B T O M O ~ M I ~BOna'iM HH @paKT)'pM~e H a Ta30BMTe ( e w e H nev KOCTM, C'iynBaHMrna B o6nacna H a r n e 3 e ~ ~ cTaea, a ~ a , . a . Ha npeluneHHme Tena B lu~hnaM ~ nouctlaa M e ~IlpeBpb3nd. a J ~au. I~ ~ s ~ ~ ~a r m p p e e ~pah~ e ~ ~@pamypn~e ~ Ta o 6 n a c ~ ~ . HMK. M H O X ~ C T B ~ H M@paKT)'pM T~ H a K p a k M q M ~ Ce e XapaKneveHle TePM3MpaT CbC CnepHMTe OCO~~HOCTM: A-. f l p~ ~e p a s ~ e.--....-(;~eI n~ v l ~ J ~ ~ K T ~ ~ M - M ~ Cm60 O B ~ ~ T ~ I U 1. Cfleq@M'ieH XOA H a Pa3BMTMe H a ne'ie6HMR IlpOqeC T e M O 0640 CbCTORHMe H a I l O C T p ~ ~ W T (fl0rl-r~ e, BMH~M) RHM, 6 8 3 H a T O M p M H e . CbllbTCTM~ TpaBMaTMreH WOK, 06MnHM KPbBOTeCleHMR H M H A H K ~ ~ 3a MM XMP~PM~HO necletilrle HapylueHMe H a C Bb3llaJ'lMTenHM I H M YC~OXH~HMR). uenocrra H a c f i a n a p ~ a ~ a cTaea, ronwa ~ e @ p ~ a q n ~ , PaHHM ~ M ~ ~ ~ M M 2. T B b p ~ 'ieCTOAOflyCKaHH e rpeluKM B AMaMOCTMvHMR n o w nbnna3ary6a nabmna H a Bohler. n p a e ce ~ KpbaHa M~ O C O ~ ~ HnpM O OKa3MHeTO H a p e n o 3 ~ ~ ~ ~ n ~ e ~ a n ~ a o c ~ e o c ~ ~ e 3 a ~ nM ~Bpne'ie6HMR e n o 3 ~ np04eCM u~~no ITbpMTa MeAM4MHCKa IlOMOu H a MRCTOTO H a 3nOflOnyKaTa R o - ~ K PM ~H a~6poUIMpaHe C KMpluHepo~M MrnM. 0 6 e 3 6 0 n ~ ~ a ~peaHMMaqMR, e, M M O ~ M ~ M ~ M~ Tpanc~ M R nOpT H a nOCTpa,4anMTe. 3. Heo~qm~ane ~ n o c T H o T BnMmiMe o H a nonmpamaT a ~bpxy o p r a ~ ~ M 3 3 ~ aa 6ae~ne H a npoTuBowoKoeaTa Tepanw. Kora~o n o c T p a a n w T e ca n o n y w n M 2, 3 M noeere 4. ~ ~ T P Y ~ H ~npw H Honpeflenme R MeTopuTe H a neveCvynBaHMR B pa3nMclHM30HM ( c ~ ~ M ~ H TH M a )K ~ ~ ~ H M ~ M T ~ , KOM @pamyp~ HMe Aa ce neKyeaT HeonepaTMBHo M KOM TpaBMMTe Ce OIlpeflenRT KaTO MHOXeCTBeHM @paKT)'pM; OflepaTMBHO, KOra fla 6 b ~ npOBefleH0 e OnepaTMBHOTO nen o ~ a n ~ 3B ~ CemetiTMTe p a ~ ~ H a eAMH K P ~ ~ H H ca K MOHOveHMe M OT KOR @pamypa Aa ce 3 a n o v ~ e . MenurHM, a KoraTo ca B enHonMeHnu c e m e H T n na pas~o5 . 3 ~ a r ~ ~ no-rec~n e n ~ o K~CHM ycnoxa+etiMR 3a6aMMeHHM K P ~ ~ H H CHMeTPM'iHM ~ W C'iYllBaHMR. BeHa KOHCOnMAa4MR, flCeBAOapTp03L4, Bb3flaJ'lMTenHWj CbMnoro 'iecTo B npamMKaTa M H o x e c T a e H m e @palcryROBM M HeBponOIWYHM YCnOXHeHMR. PM H a KpahHlrl4WTe W CbflpoBOAeHM C TpaBMM B A p y M Taw XapaKTepMCTMKa H a MHOXeCTBeHMTe C'iyllBaHHR 06nacrn H a TflnOTO (rJlaM, I-bpAM, K O ~ ~ MKOeTO ), O@PMR 3 ~ b n x a e~ ao 6 pA ea ce n o 3 ~ a e M a snaem ~ neh~oc~n~ KOMflneKCa Cb'ieTaHa TpaBMa. Mnn no-TO'iHO Ka3aH0, CbH a MeAM4MHCKaTa flOMOq H a pa3nM'iHM HMBa IlpM ne'ieHMWTaHaTa TpaBMa e KOMflneKC OT MHOXeCTBO MeKOTbKaHeTO.OpraHM3auMR~a MI l p O B e m a H e T O H a IlbpBaTa n o M O 4 HM M KOCTHM yBpeAM, n o ~ a n ~ 3 B~p p a3 a n~~ ~ ' i0~6~ n a c ~ ~ H a fl060flHM'ieH eTan e peluaeaq @ a ~ ~aa op ~sxona npM Ha TRnOTO. ne'ieHHeTO H a MHOXeCTBeHMTe C'iYnBaHMR. Kora~o flPMrMHM 3 1 CbcleTaHaTa TpaBMa M H e CaMO MeXaHM'iHM, H 0 MnPYM (XMMMCIHM,T ~ ~ M M C I H PQMa4MOHM, HH), rOBOpHM 3a K O M ~ M H M P TpaBMa. ~H~ O~aaeane~o Ha nbpeaTa M ~ A M ~ M H C AoneKapcKa K~ OCHOBH~ cbmasna qacT H a CbreTaHaTa TpaBua npe~IOM ~ pO R 6~ Mfla ce M3BbpUIM 3a KPaTKO BpeMe MB C T v r ACTaBnRBaT MHOXeCTBeHMTe C'iyflMHMR H a KpahHMqM~e xpotionomren pen (@Mr. 3.67). (@Mr. 3.66). C n e flpOB!W$@HeTO ~ H a ClleluHMTe MepKM 3 a Bb3CTaH a A - ' i e c ~ a npnvma 3 a uHoxeKecTseti#Te @pamyp~ Ha HOBRBaHe A ~ ~ H O CHT a flMlllaHeT0 ~ M CbPfle'iHMR PMTbM e K ~ ~ ~ H M U Ca HTeXKMTe T ~ IlbTHO-TpaHCflOpTHM 3nOnOnyKM, H ~ O ~ X O A H MAa O Ce H3BbPUIM WIMHMWa AMaRiOCTUKa H a MoraT Aa ~ P M ~ M H R 60n~a. T B 10% @pamyp~~e H a KanKaH e y c a ce n p M p p y x a M T OT @pamypnH a n y ~ 6 a n ~ MnM n 4epanKannn npewnenn. flpu pewrreHonom'iHoTo w3cnensane ~ a h - r o n anare~ue ~~o M u a b m n b T H a Bohler, HOPMa: 20-40".

cryn~a~k ca f lOTKPMTM M M H O ~ O @ ~ ~ ~ ~ T HO TH Bce M ~ gbn. XMHa OrpoMHaTa KHHeTMrHa cMna, KORTO ce n p e t i a c g 3a KpaTKo BpeMe ~ b p x y o n p e p e n e H a o6nam H a r o a e l u K o T o TRnO.

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KoeTo ce ~ a ~ v p a ! 6op6a C BbHUHOTO KpbBOTeqeHHe npH OTKpWrH $ p a ~ ~H y npm p ~ HapytueH MarHcTpaneH c b Ha ~ ~paiiHMqHTe. K ~ ~ B o T ~ V ~ HflpM M RO T T K ~ p M T MM H O X e C T B e H MCYnaaHMR, oco6e~o n p TpaBMam'iHo ~ npeKbcBaHe Ha MamCTpmeH C b A B3OHaTa Ha Kpah~MliM~e ca 'ieCTa IlpMWHa 3a C M b P T O H O C e H Kpah.
Aelicra~ma3a OBnwRMHe Ha BbHWHWeKPbBOTeVeHMR MMaT cpoqeH xapamep M ca awnmwren~~! Cbqecr~ym p~ a a n ~M re ~ T o A ~M 3a npeycratioeReaHe Ha BbHUlHMTe KPbBOTeVeHMR: 1. ~ ~ P M T M C K Ha ~ MaMCTpanHHR H~ C b A HW M R C T O T OHa YpeAaTa ecuapx, W e H Maplcy.l, MapneHa newa, KOnaH M up. B a x ~ e o Aa ce atiae, ve He 6 n ~ K a P ~ ~ Ha !M ~ T 6b~e npMcTerHaT ~ a 1 ph npea neTHMTe MeceqM n ~ a 30 p rnin npea amaTa. f l e p ~ o ~ e ~H ~~l O~~ o X O ~ ~ Aa M Mce O OTflyCKanpMCTRraHeTOCuenKpbBOOpOCRWHeTOHaAMCTanHo HauwpaqaTace qacT ~a~ p a h ~flpn ~~ npeAaaaHe a. Ha noapapannrr B c n e q ~ a n ~ a ~ MeAMqMHcKo pa~o aaaefleHMe Ha flpeBbp3aHMR K ~ ~ ~ H TP M FI K~ B Aa ~ Ce 3aKa'iM Ta6en~a,Ha KORTO Aa e o d e n ~ a a r~ a w M RaTaTa Ha nocTaaeHaTa npeepbalta. 2. O B l l w M ~ e Ha B b H L U H O T O KPbBOTeVeHHe 'ipe3 ~ o ~ n p e c ~ s ~ a ~ a ~ n o ~ - nH p~ eM eR pb ~a O~ H Ta Onem~a. Ha paHaTa ce nocTaeR MapneH IloweK (~a6op OT ~apnu) H Ce npeBbp3Ba CTemaTO C ~ H H T . 3. M ~ c ~ p y ~ e w xeuocra3a. an~a Y s p e A e ~ ~~pbeorn

3. I / ~ M O ~ M J ~ M ~ ~ ~ ( W MH OH Ha H(LUei~a) ~ Ha H. H O B ~ V ~ H KO. M3rpape~a e OT new anyMnHMeeM eneMewu. flpeflcTaBnFlM H O C M n K a C ~a6Op KOnaHM 3a H M O ~ H J ~ M ~ ~ ~Ha MFI TRnOTO H K ~ ~ ~ H M ~Taw L I TW ~M .H a neCHO npMfl06M~a BMA Ha w e k a ~@CTBO 3a n a ~ e r n Ha ~ ~nocTpapanw e OT ~ e c r o n p o ~ a w e c ~ l4s~b~peflt-m ~~e~o. e$em~a~ eanpM M~o6~mkI3a~MR Ha ~ ~ ~ ~ H ~ c C~I b H n6 M H Kpah~MuMTe R npU nonmpaeMa. ~.~H~BM~TU.IH rYMeHH M MaHUIeTM. Hanara~ Ce npe3 nocneAHnTe roAmM, 3 a q o ~ ca o new M nmTHo O ~ X B ~ ~ YBpefleHMR K ~ ~ ~ H 6bp30 M K . Ce M O H T M P a TB C M V K MM O A e n M (aa ropeH n AoneH K ~ ~ ~ H Ma KTaKa ) , cbqo ~ e 3npeAHa~ , 3HaVeHH 3a M M O ~ M ~ H ~ H ~a ~W HO R T O TRnO. Hah-BWOTO YCnOBMe, KOeTO T P R ~ B fla ~ Ce Cfla3M n pU ~M O ~ U ~ M ~ Ha ~$pamypme, ~ M R e HM06MnM3a~MRTa fla o6xeaqa n pseTe CbceflHn Ha $palcrypa~a claw. Toea flehCTBlre n p e M W KaKTO brnOBMTe,TaKa M P O T B U M O H H M Te A B H X e H M R Ha YBpeAeHMTe KOCTM. BW~H eneMew n p eearcyaqwma ~ Ha nonpapanme C M H O X e C T B e H M C'iynMHMR e C a H b l T a P H M R T TpaHCnOpT. 3 ~ a Ce, e V e BpeMeTOHe pa60~H BflOn3a ~aT ~ K M B ~~ O~HM, H~O~XO~ e~ 6bp3 M MW TpaHCflOpT, C B b 3 M O X H O C T M 3a npoBewaHeT0 Ha P e a H M M a u M O H H MA ~ ~ H o C Tn0 M BpeM e Ha IlbTyaaHeTO. Y H a C UJMPOKO e HaBnR3bn~ B T O M O ~ HMRT CaHMTapeH TpaHCllOpT. HaflOCneflb~ Ce M3nOn3BaT yfl06c~M~a, ~ o m npewaraT o c n e q n a n ~ a ~ p aeMoaa~~~e BeHa-CaHMTaPHMCaMOneTMHXenMKOflTepM,CKbCRBau(M BpeMeTo Ha eeaKyaqllrA c YacoBe. TpaHCnOpTHpaHeTO H a IlOCTpqanM C MHOXeCTeeHM $paKryp# Ha ~ p a h ~ ~ q em a6 ec o n l o ~ ~ 3o Wnxn-

PM

HoceH C ~ ce A 3axaaqa M ce npvqwnmc HanweH, 3amioTeflHO T e Aa 6bAa~ npMflpy>ltaMHM OT ~ B a l l H $ b l ~ M p a Ce XMpypMVeH M H C T P y M e H T . ~ e f l ~ q w ~ c ~ o n~ uo qe e,no ~n o p n c ~ ~ r aB ~ cneq~an~aue~o T ~ ~ H c ~ H~06MnH3aqHfl o ~ T H ~ HTpaHCnOpT Ha n e paHoTo aflpae~o aaeeAeHue Aa cneAM n n o m p x a $ ~ H K CTpanantlTe C MHOXeCTBeHH C'iynBaHHIl Ha KPB~HH4 ~ Ha ~ ~ a e h - m opraHM ~ ~ e H cnmeMn. UHT& M M O ~ M ~ M ~ ~ (UoM ~R ~T ~~ ~~BwxB ~a$paKTypM~H~To) Cnewno 6 0 n ~ ~ r n neseHHe o Te e A M TMna - TpaHCnOpTHa M OKOH'iaTenHa. Tpa~cnop THaTa UenH BpeveHHo 0 6 e 3 f l a ~ x ~ a Ha ~crynaaHwma e do flpn ycnoema Ha MtioxecTseHocT Ha $pawme npMmraHeToHa nocrpapanw~ c n e q ~ a n ~ a ~ p a ~ o ~ o 3 f l p a3HaWTeIlHO no-CMnHO e M3pa3eH 60nee~m C M H A p O MH BHO aaeedeme. Hah-remo nanonaea~me TpaHcnopTHH KpbB03a@a~a, IlpHVHHeHa OT $paKrypblTe 2500M M O ~ H ~ M ~ ~ ~ MW O W H H M HY MH a C Ca ($Mr. 3.68): 3000 ml). Tom 06ycnae~ cTenewa Ha TemecT Ha TpasMa-

(~m

na nMaTamnseHxapamep, a no opraHu3aqwflU cbAbpxatine Aa npepcTaenflsaTsnco~o cne~p1ann3npa~a no~oq! Jtere~ne~o Ha T O ~ H Komtirew nocTpaann no anp He C e OTnMVaBa OT T O M npn 60n~me C MOHoCTaTllVHH (epn~n'i~n) c y w n ~O .c o G e ~ m npn ~ ~ o x e c ~ s e ~ m - e $ p a w n e pa ce ~ 3 e peweHne: ~e KOR $pamypa pa ce n e w HeonepaTneHo M KOR onepamaHo, a ~ a C ~ ere KOR pa 6 b ~ e onepnpaHa no cneUHocT, KOR B nnaHoB ilOPRmK. H ~ o ~ ~ ~ ~ T nerewe ~ ~ B H ce oT cbcron o B MaHyanHa peno3nqu~ ( ~ a ~ e m s aHa ~e K) m e 683 nnn C noMouga Ha T ~ ~ ~ B U ~ HpemeHoB O H ~ H Kompon n nocTaeRHe Ha mncoaa u~o6nnn3aqn~ 3a C ~ K d , p a 3 e c ~ enAa Ha cryneHaTa KOCT. O n e p a m ~ ~neretine o ~ o ce cbcTon B .KP~BHO" (OTKPHTO)HaMecrBaHe Ha KmHwe w a r n e m n Q n ~ m p a ~ e ~ o MM C pa3llM'iHH no Bclp OCTWMHTe3HM CpeC(cTBa:MeTanHM nnpoHn, Bnmoee n nnaw. npea nocnepHoTo AeceTnneTne B ~ e p u q n ~ c npamm~a ~ a ~ a U H ~ ~ KHO~ B ~ R paann~ O X ~ VHM Mopenu W H U H ~$HKC~TOPH, rpe3 KOHTO $pamypn~e ycne~~ocec~a6wnwnpa~, KaTOCe H ~ ~ R M ~ ~ ~ R K K O H T ~ K ~ 1. Kpbeonsnue. ~ O P ~~ O M ~~TO KpbBOCHa6pflBaTO Ha $pamypa~a c n~&nnnanpaqnfi MeTan. He Ha KOCTMTe, $ p a ~ ~ y p ~'ieCT0 T e B O W A0 M a C M B H M Mzi~ntorwen~o aaxeH e BbnpocbT 3a OnepamBHaTa BbTPeWHM KPbBOM3nMBM, KOMTO MOraTAaIOBeAaTA0 UOK aKMBHOCT npbl IlOcTpaanHTe C MHOXeCTBeHln CVynBannn~ o po pneTaneH ~ ~ 3 x 0TOM ~ ; BM C nbnHa cnna npn HHR. TR ce onpepenn OT Aea ~ O B H $amopa: U TasoeuTe $pamypu, npn KOMTO He MoxeAa ce OcbqecTBM 1.06qo cmomne Ha nocTpaanuR - onpepem ce ~eKBaTHOKpbBOCnMpaHe,KaTOBHflKC)MCnyVa#WCTMra OT WI MHHC(HWTeIlapaMeTpHHaO C H O B H U T e OpraHH M CMCTeMM.

O K O n O HeR. Onepa~ne~o nereHue Ha $pamypn~e no cneurHm e Bb3MOXHO C a M O npM ~ O C T p ~ CbC ~M C T ~ ~ M ~ M ~ ~MHMC~H napaMeTpM: M AH - 100-110 mm Hg, nyncoaa recToTa - po 100ypapalmin, X ~ M O ~ ~ O - 80 ~ Hg/l, H cao6oAHa pnxaTenHa ~ e l ~ oqacosa c ~ , p w e 3 a - HW 30 rnl M npn 064 6en~bK - HW70 g/l. Ka~o npaenno no cnetuHocT onepaTnaHo ~ p ~ 6 pa sa

2. BMA Ha Walcrypa~a n cbcTome Ha Meme nKaHn

Bb3paCTHu qlpatcrypupa~a KOCT Paguyc U y n ~ a XYM~PY~ Tn6w U 4u6yna 6eR~o Tas KonureCT~o ~pbeosary6a (ml)
150 -250 250 500 1000 1500- 3000

npu peqa~a ~paec~aryGa~a OT $palcrypu O ~ U K H O B ~ H O e no-man~a U 3aeucu OT Bmpacrra Ha n a q ~ e ~ tKe~pea. time $pamypu AaeaT no 10% ~pbeoaaphaOT O ~ ~ U KPbBeH 0 6 e ~a , Ta3OBUTe OT 10-50%. 2. C b g o e ~ yepewaHmn. Jleaume Ha MamcTpanHu
apTepU~HUcbpOBeUnUHaWHO3HUMaMCTp~UCeCpeqaT npu onpeAeneHu $palcrypu U nycaquu U o~aaaau(~FIT rrbpea noMoq ~p~16ea pa 6bfle po6pe 3ano3~a~ c ~e3n

s ~ a Ha ~e y e n m a Ha Ulea~oen~e ~BUBKU - Moxe pa HaCTbnUCnOHTaHHOBWcTaHOBRBaHeHa$~HQuRT~, H0 TO e ua~nlormen~o 6ae~o n ~ecnt-yp~o); B) HeBpOTMe3UC - nbnH0 WaTOMU'iHO npeKbCMHe, U3UCKM~O XUPYPMClHO Bb3CTaHOBflBaHeHa BCRKa 4eHa. K n u ~ u r ~~ aa ~p a m~ ~ya cno~um Ha ~C~~WHO BWIIOCT rea sapha Ha noebpmmtia U A b n h ~ a ceTueHocT B CbOTBeTHaTa o6nac~,3aMa Ha aKTUBHU PBUXeHMFI U eaeHTyantiu xapaKTepHu Kompalcrypn. B cneAeauaTa ra6nuqa AaeaMe oralteatime HepeHu nesuu npu paanur~u xapaneptiu TpaeMu Ha ~ p a i ~ u q m e .
R

Bup TpaeMa H a~ p a i ~ u ~ a Ora~sa~a epa~a ne3u~

n a ~ b (~n~ ya ~ca~~~, Mepua~yc, ~~P,H~JIUC, cynpaKoHpunHa$pamypa) ynHapuc P~M~ nH y~ H c~ aw~ A~cunapuc yapeAu. Opalcrypu~e U nycayume Ha KonmiHaTa cTaea Kayna e ~ y ~ ~ a Q)pawpa~a c a ~ p y ~ a ca pe3yn~a~ OT Tema TpaaMa U recTo ce acoquupaT c Aqe~adynap~a $pamypa ppex,qaHeHa a. poplitea. Opamypme ~ape6pa~a ~ o r a ~ (c unu 6e3 swHa pa ce npuRpyxaeaT OT yapewatie Ha UHTepKocTanHa ~ a m 6 e ~ p nycawn) e~a Mmap,u~yc apTepun, cbc 3annaueaqxuBoTa ~pbeouanu~. rp~upanpep~a ~a306eppe~a ny~caqn Q)e~opanuc HeTo Ha apTepuanHme neauu cnopep s m o m a MM no Aua4usap~a 6eRpeHa 4pamypa Qu6ynapuc OTHomeHue Ha OnacHocTTa OT raHrpeHa Ha ~ p a i ~ e u ~ a K o n f l ~ nyrccaqufl ~a Tu6uanuc unu CnepHOTO: $dynapuc - nesun Ha a. fernoralis; mpamypa H a naTepantiuR - neau~i Ha a. poplitea; m6uane~ K O H A U n Q)n6ynapuc - cbreTaHa neau~ Ha a, tibialis anterior et posterior; - neaun Ha a. brachialis nponcuManHoOT a. profunda brahii; 4. K o ~ f l a p ~ n iCHHAPOM le~~ (cuH#)OM Ha KOCTHO-n e s n ~ Ha a. fernoralis superficialis; ~yc~yn~o-$acquan~me n o w Ha ~paii~nywe). Ko~nap- neau~ Ha a. iliaca; TMeHTCUHflPOMbT npepCTaNlRBa nOKaJlU3UpWa B Onpe- neaun Ha a. axillaris; Aenetia noxa (unn HRKonKo n o w ) ucxeMuR npn TpaeMn - ne3u~1 Ha a. brachialis p u c ~ a n ~ OT o a. profunda Ha KpakbILt~Te, AbnMu(a C e #nM Ha nOBHlueH0 TbKaHHO brachii. HanRraHe BcneAcTBue Ha $palcrypa unn d l u u p ~ 3a~puo K ~ ~ u H u KapTUHa ~ H ~ T npU ~ fle3UFI Ha MaMcTpMHa TO MeKonKatitio p a ~ a r ~ ~nnn a ~~a ene3un , Ha MarurnapTepuR sKnlorea h n ~ a6nefloc~ , Ha KoxaTa pucTanHo PaneH npoKCUMaJlH0 OT CbOTBeTHaTa nOM (TUn0Be 2 OT ppeAaTa, nunca Ha nepu$epe~ nync, napec~esuu U U 1 pecnemuaHo no Holden). Tow ycnoweHne moxe pa napanusu ~ u c ~ a nnpu ~ o Hanurue , Ha KonaTepanHo ~ p b ce npeebpHe B ocamTReau(o, aKo He ce Anammunpa aoo6paqe~ue ~ e 3 CuMmoMu u MoraT, 06are pa nunceaT B HaapeMe, nopmu ~ a m n e a ~ 3 a a~ 6p0eHci a l racoee mycnapawe racoee cneA TpaeMaTa. n p e q e ~ ~ ce a~ 3a~pypa KynHa M HepBHa tieqma. n b p ~ u m CHM~OM e HenponopHFIW U npu naquemu c nonmpawa B cmoRHue Ha KoMa yuo~an~ ronRMaTa o 6onm B mTBeTtiaTa o6nac~, popn unu UOK. B ycnoBuma Ha cnewHocT e wbnxmentio npu po6pe HaMecTeHa @P-a. Tasn 6onm e npnppyAonnepoeo~o nxneaaaHe. O ~ o ~ q a ~ eAuamocTuKa n~a~a xetia c napec~e3un n ce y w e a npn n a c n ~ e ~~ ac ~ e ~ 3 n cTaaa rpea n3abpmea~e~o Haap~epuorpa$ufl. TFIe noKaHa npmme Ha Kpaff~n~a. A n c ~ a n ~ nnync m Moxe Aa e 3aHa U K O ~ ~ T uMa O Hanurne Ha pncTaneH nync, HO MexaHannqe n ~a 3a6nypn n3cne~eaqu~. npu nannaqnn U=H U ~ Mn ~nolcanuwnma T HaTpaaMaTanpepnonaraTeaeHneAaaHaTaMycKynHanome ~ H HanpeniaTa. O 06emTyantia cqoea nesua. eHaTa Anamocrnm cram rpe3 n a ~ e p ~ Ha a~ ~e K~HHOTO 3. H ~ ~ B yepewaHHn. HH Te ce ~nacu@uunpa~ cnoHanflfaHe, K O e T O He 6nea Aa HaCycebpntI 30 mm Hg. pep cTenema Ha neauma Ha: Jlere~ne~o ce C~CTOH B paHHu H 06UInp~n $~C~MOTOM~H. a n ~ o OT KOWa) HesponpaKcnR ( $ y ~ ~ q u o ~ 3acRraHe 3a ropmtI WHHK KOLmap-mem-cumpomT Hacm 3~~~XeMaTOM,CO~aK~HOBb3cT~OB~BaHeC~O~ a H HaA-recTo HO nea npu pa3mecreme ~ K C T ~ H ~ H O HcynpaHH Ha $ytt~yuma - 6-8 ~eceya); KWWIHH Ha xyepyca c n e w i nnH cnaaM Ha 6) aKCOHOTMe3UC (~KCOH~JIHO IlpeKbcmHe npM 3anaa. brachialis, ~ c p a i ~ u pe3yma~ m npn ~atcbcHmo nererrne

e M ~ B ~ C T McxeMMrHa H~T~ Kompamypa Ha Volkmann. 3a AOnHMR K P ~ ~ H H KOMnaPTMeHT-MMpMbTHamnBa K HairecTo MnM n p n ~e 3 n ~ Ha a. femoralis HnM a. poplitea, wn# npM $palcryp~Ha AaeTe KOCM Ha n o ~ 6 e ~ p ~ c qa no~a ronma MeKonKaHHa TpaeMa. 5. Apyrn ycnoweHnR. Te HamneaT B no-K~CHMR nepmop - AHU M MeceuM cnep TpaeuaTa - M ~ ~ B H C R OT T WeKBaTHo npoeeAeHoTo cnewHo nereHMe: a) uacrHa edonm; 6) aeacKynapHa HeKpo3a (Ha 6eflpeHaTa rnaea, Ha rnaeMrKaTa Ha nbreeaTa KOCT, Ha nagMesMAHaTaKOCT Ha ' K M T K a T a , Ha T ~ Y c ~ ) ; B) pe$ne~ctia AMCT~O@MFI(60nemHa 3ype~, ~aysan-

75% OT B C M ~ K V aMnyraqMM ~ ca npM MbxeTe, noHexe np$e~M~HWHll-re M H ~ ~ ~ ~ c W O O n a C H H O ~ C T M ~ H ca U no-rone~ npM ~ TAX, OTKonKoTo npH xeHuTe. A u n y r a q ~ ~ nocnepMqa OT 3 a 6 0 n ~ e a ~ca m~ 1.5 nbTH no-vecrM npM MbxeTe. Hai-BMCOK~ recToTa Ha aMnyraqMme e B cpepHaTa M n o - e b 3 p a c ~ ~ rpyna, a ~ a B MnWaTa U cpeAHa ~ b 3 pacroaa rpyna Te ca cneucrene OT TpaeMa, KaTo 85% OT aMnyraqwTe ca npea ponHw K ~ ~ ~ H M K .

rw); r) cneqw$~r~cl ycnomeHw~, mnxaqMce Ha M M ~ ~ H n ~ 3 a q cnep ~ ~ TpaeMa ~ a Ha ~ p a i ~ ~xapamepHM q ~ ~ e , 3a ~ O - B ~ ~ ~ ~ C naqMeHm T H M T ca: ~ nHeaMoHw, pbn60~M T ~ M 6 o $ n e 6 ~6enoppo6~a ~~, ~ M ~ O ~ ypo~~$elcqm~, M R , paneBM MH@!K~MM (npM OTKPMTMTe @alcrypM M nOCTOnepaTMBHO), A e t q f i ~ ~ R a ~nB ~ M MycKynHa ,~ arpo$u~, crpec-yn~yCM, C b n P O B O A e H MC b C CTOMaUIHO-ClpeBHO KbpBeHe, nCMX0T M q H MC b C T O R H M R .

T ~ MABa K B cb06pMe~Me OqeHKaTa H ~ T ~ O $ M K Ha ~T KpaiHMKa, Y B ~ ~ R B ~ Ce ~CbqeCTByBa KM MnM He AMCTmHa aac~ynapw3aq~~ (~scne~eme Ha npbmu~e). 1. PO~OBM n P b C T M M Hall#WeHa KaIlMnRpeH@?HOM~H 6nar0flpMR~HM ycnoaw. 2. n p a 3 ~ M~ 6ne~ nynnM ~ M nMnca Ha KanMnRpeti $ ~ H O M ~H~ e 6 n a r o n ycnoem. p~~~~~ 3. AKO K P ~ ~ H M M ~ HCMHKaBM T ~ (~HBM~HM C )M H O r O 6bp3 KanMnRpeH $ ~ H O M ~H HmMrMe Ha C M H A P O M H a BeH03Ha K O M n p e C M R C BeHO3Ha CTa3a. 4. ~ 3 ~ n e ~ B a ~a H ~ee ~ r a ~ amMBtioCT e n ~ a H CeTMBHocT 3ayCTaHOBRBaHe Ha CYXO))(MnHM HH e P B H MyBpepM (BHMMaT e n H O aKMBH0 pa3ABMMBaHe BbpXa Ha IlpbCTMTe M KOHT a K T C MmKa MrnM'iKa MnM BbpXa H a XMMMKWK~). 5. Aa ce n p c $pamypa, ~ KoeTo Hanara n ~ O 6 ~ n ~ a q M R .
C ~ e n Ha e ~c n e l l ~ ~ o c ~

- Kacae ce 3a eKcTpeuHa cneuHocT, ocO6e~oaKo

n0p aMflyra~MR pas6~pa OTPR~B~H~ Ha TO KPal'lHMK npes uenocrra Ha Kocrra, a non Ae3aprvKynaquR - npea cTaeaTa. Pea~nyraqm ce oTHacA po cnyvall-re, KoraTo aunyraqwma ce Hanara Ha no-BMCOKO HMBO. AMnyrallMRTa e ~ a k ~ p e e OT ~ BCH~KM a ~ a XMP~PM~HM npouepypw M e 6mna M ~ B ~ P U I Boqe ~ H ~npM ApeeHnTe HapoAw. 3a ~ ~ ~ B M T M i ia ~ ~ T O a r ~ ~ mn e nMwa e ~$ ~ ~ H C K M RT BoeHeH xMpypr Ambroas Pare npea XVI B., KO~ITO cqam $yiilcq~o~an ryKaH e ~ M w3non3ea nuraTypaTa. A M I ~ ~ ~ ~ ~X M M P Y O P M H R H Ce~ nT o~o6p~ no-HaTanK, ~a Vpe3 BbBeH(QaHeT0 Ha TYPHMKeTa OT More1 npe3 XVll B. aMnyraquma e qRnocTHa; -~esa6aee TpaHcnopT ~ K ~ M qeHnp

xi CMn.

n o ~ r o ~ o 3a e ~TpaHcnopT a H e o 6 x o ~ e: ~~o

- pa Ce

OCbqeCTBM XeMOCTa3a H a npOKCMMaJlHMR

Kpai qpe3 KOMnpeCMBHa npeBpb3Kaca, M36RrBahKM eCMapX; - Aa ce s s e ~ e IMCT~HMR ~ p aMi Aa ce nocTaeM B M3cly@HIlnMK, H 0 fla Ce M36Rma AMpeKTeH KOHTaKl C nenetiv napreTa;

- H ~ O ~ X O A M npeBbP3O' M ieH MaTepMWI( C T ~ ~ M ~ K O HM H -

npec~ 20120 cm BAocTanrHo KonnrecTBo,~ M H T O 1011 B~ 0 cm), i0~MpaqM a H T M C e n T M i 'H H pa3TBOpM, TeH30MeTbP, KaTo nbpaotiavaneH ecMapx, K O ~ T O Aa ce ~ s n y c B ~KpaR e a 60 min. H a fr e c ~ a npMrMHa ~a 3a aMny-raqMFi ca n e p ~ $ e p ~ ~ - H fleve~ne B KonaTa 3a CMfl Te c b ~ o ~ e~ ~ ~ O ~ R B ~ aTepocKnepoz, H M R p ~ a 6M eT. ~ H. -3anoreacecpeamMaqMoHHM M ~ ~ O ~ ~ M R ~ TnMeRTe Ce OTHaCRT 38 Bb3paCTHM XOpa. B~opa Hah-VecTo W H M eH a XMnOBOneMHVHMfl UIOK; MHflMKauUFl e TpaBMaTa npU XOpa n0A 50 TOAMHM, KaTO - ~ p ~ 6 pa ea ce HanpaeM~ & p oM ~ K ~ ~ K TOnucaHMe HO IlpMOpMTeT Ce nwa Ha lPOM3BOACTBeH M TpaHCnOpTeH Ha yBpeyTe, npepM I a ce Hacow K ~ M cneqnanw3~pa~ TpaBMaTM3bM. ~ o - H ~ T BcbO6pMeHMe ~ T ~ K MpMT M3raPRHMRTa M M3MPb3BaHMRTa, M H $ ~ K ~ M R T T Y ~M ,O P M T e , HeBpOnOMrHM yBpeAM M KOHreHMTNHM a H O M W l M M .

nocTaau KoMnpecnetia npeapma, noep,nrai~ KP~~HHKa; w3non3ea~ ce KoMnpecu oKono paHnse, 3acTeniaTH c ~ U H T O B TaKaaa ~, KoMnpecneHa npeepba~a B ronRMa racT oTcnyvameeflocTanqHap,acnpeKpbmTevetineTo.

2. Tp~6sa fla ce Kynupa 6 e 3 c n o ~ o h c ~ ~ u Ha e~ nauno ewra rpe3 napewrepanHo npMnaraHe Ha TpaHKsMnawrw He ~ p ~ 6 p,a sa ce npMeMa H M ~ per O OS. 3. AKO KoMnpecMBtiaTa npeepwlca tie e p,ocTanrtia 3a cnMpaHe Ha KbpseHeTo e H ~ O ~ X O ~ , Up,a MO ce nocTaeM MaHuroH, K O ~ T Oq e ce H a y e non AH, cnefl KaTo ce noeAMme K P ~ ~ H M KAace ~ T . o~6enem qacbT H a nocraeR:
He10 Ha MaHUIOHa.

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xe Aa 6bfle

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yBpe~aTaHaBbTperpbnHMTeOpraHMnpU3aKpMTaTpaBMa

ce cMma 3a ~ a k o n a c ~la l .p 85% ~ naqMetiTMTe c rpbpHa TpasMa Morar pa 6bpaT neKyeaHM c npocrw, mBoTocnaCRBaqW TeXHMKH (MaHMnyna~HM), KOMTO He H3MCKBaT HaWlHa MHTepBeHqMR OT rpbAeH XMpypr (TO~~KOTOMMR

I.M 3 o n ~ p a ~KaTo a~n eneMem ~ Ha nonmpaehla (MHOxecTaeHa, cbqeraHa; K O ~ M H H P ~ H ~ , HaW-rec~o capper~a~ ~ap a a ~ cea n p o ~ s ~ K~ ~Ta O Tpae~uTe Ha capqeTo cac BucoKneTanweT.3 a r u ~ a ~ KoMnoHetn Ha MHoxecTBetia Tpaenna, 3acRraqa r p b p ~ KOW c npnppyxaBaqw ppepw Ha 6enw~e ppo6oee, Tpa6e3 pa pocmmaT 40 ~O~HIIICIHOa a ~ e p e ~ 6040% ~ e OT x e o 6 p o ~ x ~ Abpeo, ~ ~ o VbpHaTa ~o cTeHa M ~ ~ a $ p a r ~ ~apa~e~me.

rpnmpoB XPUCTO Mnqea

156 m T p a B ~ a m o n o z u ~ cneurnu ~u cbcmonnun

Ta. 11. B 3 a B M C M M O C T OT HWHqbIeTOH n M nMllCaTa Ha PaHa: 1. OTKPMT~ - flPH'iMHFIBaT C e H~Bv~CTO OT X I l q H O M oniecTpentio opbme. 2.3a~pma - H~L-remo np#r#Haca TpaHcnopTtiMm TpaBMaTM3bM M BMCOClMHHaTaTpaBMa, KOMnpeCMR Ha rpbBHaTa KneTKa. na~o~op@onorm macm@m~aqm~ r~a Ha ompmnTa cbpaertla Tpaenna I. ~ ~ O H M B K KYXHHHaTa B ~ ~ ~ CHCTeMa Ha CbPqeTO (qenocna Ha etipolcapfla e ~apylue~a) - c nnw 6e3 HMMrMe Ha r y q o mno. 1. T ~ ~ H ~ M T O - BXOAHO P H M M MXOAHO OTBepCTMe. 2. H ~ T ~ ~ H ~ MTC O a M O PH BXOAHO H OTBepCTMe. II. H e n p o ~ ~ ~ e B a Kyxcl q a HHaTa cMcTeMa Ha cbpqeTo ( q e n m a Ha eHAoKapBa e mnase~a): 1. C n e 3 ~ Ha ~ nepMKapB. 1 2. C nesm Ha MMoKapA - C M n w 683 3ac11ra~e Ha KOPoHaPHMTeCb~OBe. lla~o~op@onorm macm@m~aqm~ ~~~a Ha sa~pm~aTa cbpaewa TpaeMa I. PM 3aCRraHe Ha MMOKaPfl: 1. KOHTY~MF~. 2. Jlaqepaq~n. 3. Pyn~ypa. 4. A H ~ B ~-M M C T ~ M H M C K a ~M n M nbXUlMBa. 5. C e n ~ a n e ne$eu ~ (~a~epe~). II. l l p 3 ~a c ~ r a Ha ~ etmantim anapa~ ( p a s ~ b c a Ha a~~~ KnanHM nnaTHa, xopflan~n enaKHan nanMnapHM~ycKynn): 1. A O ~ T MHCY$M~M~H~MFI. H~ 2. MMTpMHa M H C ~ $ H ~ M ~ H ~ M R . 3. T p M K y ~ n M @ H la MHCY$H~M~H~MR. 111, PM 3aCRraHe Ha KOPOHaPHMTe CbflOBe: 1. Tpo~603a. 2. Jlaqepaq~~. 3. O ~ c ~ y n a . IV. n p 3~ ac~ra~ Ha e nepMKapfla: 1. X e ~ o p a r ~ ~ . 2. P e a n ~ s #snMe. e~ 3. Jlaqepaq~fl. 4. X e p ~ ~ p a Ha ~capqeTo. e 5. KoHCTPMKTMB~H IlepMKaPflHT ( K ~ T O O c T w MflM X w HH~HO ycno)i(~e~~e). V. K O M ~ H HOT ~~ ~M 36 R poe~m nesuw. e Jlo~anm3a~m~ 1. OTKPMTM HapaHRaaHun:nma KaMepa-OK. 45-50%, McHa KaMepa - OK. 30-35%, npeACbpflMfl M nepnKapA OK. 10-15%. 2.3a~pmn HapaHmaHnR: ~ a i i - r e m c a Kotny3nme Ha capqeTo, KOMTO no Ternem BapHpaT OT KOMOWO no KOHKBacaqMR Ha MMOKapfla. K O H T Y ~ M O 30HM H HCe ~~ noKMM3MpaT O ~ M K H O B ~ H Ono IlpeflHaTa IlOBbpXHOcT Ha nflsaTa n pRcHa Kauepa. 3aeuc~ OT BMAa Ha CbpAerHaTa Tpasua M HanwrueTo n Texecna Ha npMApyxaaau(nTe TpaeMaTMrHM nopaxeHMFI.

OCHOBHM CMHflpoMM: 1. O m p aHennmreHC H H ~ P O M - KapTlrtHaTaHaxeMopamreti UOK. T ~ X ~ C Ha TwoKa T ~ ce 06ycnaa~ OT MttTeH3MTeTa Ha XeMOparMRTa M HaJlMclMeTO Ha F(0nbnHMTenHM M 3 T O q H M U MHaKpbB03ary6a( X ~ M O T OXeMOnepMTOHe~~KC, Y M LIP.). 2. O ~ KOMnpeCHBeH P CHHflPOM - 6ene3me Ha cbpperHa TaMnoHqa OT MsnmaTa B nepwappa ~pae: UMaHOm, ~ a 6 b 6 ~ U aJ n M~ ~H M BeHM, BMCOKO uBH,Tax~KapBMA, XMnOTeH3MR. OTKOHKpeTHOTOCb'ieTaHMe Ha OnHCaHMTe CblHPwMM 3 a B M C M MHAMBMflyMHaTaKnMHMrHaCMMmOMaTMKa. Ompm~m Tpaennn C y c n e u sa ~~ cbpAertianeaua ca patime B sotiaTaHa m e ~ a n ~ (o~rope ~ a e - 2po nmo pe6po, o ~ ~ ( ony 8-MO nueo pe6p0, oTnmo - nRBa npeatia aKcMnapHa nHHwi, OT~CHO - pcHa MeRMoKnaeMKynapHa ~HHMFI) M ~e3i-1, pa3nonoxe~~ B enHracTpMyMa c x o Harope ~ M enmo. ~ ~ K P H T TpaBMH I Yec~o ce MacKMpaTOT TemKaTa npwApyxaeaqa rpaptia TpaeMa, oco6e~o npn HanurneTo Ha npeAeH nnM n m n p e ~ ~ o - c ~ prpbAeH a ~ ~ rKanaK. e ~ B o n a ~ ~ TpasMa a~a e sMtiarMno~o3pmen~aaa3a~p~~acbp~er~a~ Moxe fla C e YCTaHOBRT IlaTOnOM'iHH CbPfle'iHH UlyMOBe, HapylUeHMR B CbPfleClHMR pKll~M M WCTOTa. Marpaxqa ce eb3 o c ~ o m Ha 6bp3a~aa ~ a ~ ~ e 3 CTaTyC M IlaPaKnMHMrleHM MHCTpyMeHTaneHMHHMMW. ~~H~MOCTMC~H MePOnPMRTMR MT~ Ce M3BbpUBaT yCn0pe~ttocpeatinMaq~maMxMpypmrtioTonerettMeHanoCTpWaJlMR. napatmn~nr~n n MHcTpyMemanHMAHamomnvHn MeTOflM

1. R o - r p a $ ~ Ha ~~ ~ ~ A H KOLU H R - ycTaHoBRBa ce pa3luMpRBatie Ha capAerHaTa CRHW. 2. EKT- ST CeMeHTbTM T BbnHaT8nOKa3BaTMCXeMM'lHM M3MeHeHMR KaTO npM MMOKapAeH MH$~PKT, OTVMTaT ce P ~ M H M M ~POBOAHH HapytueHnn. 3. E x o K ~ ~ ~ ~ M o -~YCTaHOBRBa ~ ~ $ M F I HallM'iMeTO Ha nwna~nepwltappa. 4. EH~MMM - MXneABaTCe SGOT, SGPT, LDH, CPK n MB $pa~qnma B AntiaMMKa. flpn Ternme cbveTaHM TpaBMMCyBpenaHaatiarMTenHaMycKynHaMaca~esn ~H~MMM C a flOBMlueHM H~cI~~~M$Mwo. KnMHM.IH0 3HaWHMe 3a n~anio3a~a ~a c b p ~ e r ~ KOWHR a~a e noenuJeHneToHa MB $pawcqnma npes nbpeme 48-72 h OT TpaeuaTa. 5. t l e p l ~ ~ ~ a nyHKqnfi p ~ ~ a(no Marfan M n M Delom) ymatioenaa HanMrweTo Ha xeuonepwapA.

Tpa6~arnonozuvnu cnewnu cacrnonnun

157

3ana: npoAbmaea n e r e H M e T o H a LuoKa - UeHTpaneH M nepu$epe~ B ~ H O M~TOCIHMK, ~ ~ H O~~MH sa O ~ e c ~ a aMH~e, M a q w ~y , p e T p a n e H K a T e n p , RpetiMpatie H a rpbuHMR KOW, KOraTo e ~eo6xofl~u0, napaKnclHMreH MHHWMYM. 2. n e p ~ ~ a p ~ u~ ~H a K ~CHRpeHHpaHe FI H a nepMKapna
M n p o c n e m B a H e TeMna H a xeMopamRTa.
i

3. C n e W H a TOpaKOTOMMR B IlPOTMBOWOKOBa 3aJla C XeMOCTa3a npM flOcTpa/JXIM B TeXbK, TepMMHmeH WOK M WIMHMqHa CMbPT.

4. C f l e l u H a TOP~KOTOMMR B OIlepa4MOHHaTa C OKOH'iaTenHa X ~ M O C T ~ ~ ~ . 5. ABTOX~MOTP~HC$Y~HR.

Crew 3.1. Anmplrmu 3a panna oqenna n nmenne wa nponnrsaw cspneqwn napnnsrmn

- oceo60xqa~a~e Ha ropHwre UHxaTenHn nbTMtqa - OCMrypRBaHe Ha BeH03HM nbTMua (qeH~paJleJiU nep#$epeH)

(~opa~oqemes~)
-ypeTpaneH KaTeTbp - p e m r e H MeneMeHTapHn napa~nuHMrHuTecToBe

O U ~ HHa K CbcTOfiHMeTO ~

- o 6 e ~ s~ao ~ecrea~ rpes e MH@YBHH - nocTaeRHe npu ~ e o 6 x o ~ ~Ha ~o MHTepnpeapanHu cr ppeHoee

'no W. R. Chilwood and E. H. Auslin, 1988

158 Tpa6~arnonozurnu cnewnu cacrnonnun

Tpae~me Ha KpbBOHOCHMTe cbpOBe OT oco6e~o aHareHwe, 3aqo~o MoraT pa 6bpa~ OT eptia crpaHa m ~ o ToaannaweauM, a or ppyra pa poaepaT po Texm BTOPH'4HM yBpeAM Ha OpraHM M TbKaHM C noCnepBa~0 TpaR~0 misanMpMsMpaHe.Te cbcTaenRsaT0.9-4% OT B C M ~ K M TpaBMM. ' i e c ~ o ~ aHM ~ a3 ~ a r ~ ~ HapacrBa e n ~ o npn naqMeHTMTe c nonwTpaaMa 7-10%. O~ono 113 OT cbpoame TpaBMM Ca RTPOreHHM,pe3yllTaT OT pa3JlMrHM MHBa3MBHH KaPflUO~ O M ~ HUM penTreHonomrHwpMamocTHrHunpouepypu, a
no-pRpKOCaCnepCTBMeOTXMPYPMYHMMHTePBeHuMM.

pOMMHMHM, PeTpoIlepMTOHeMHM, CbnOBe B MMKMR Ta3. llo-recro ce aacRraT noabpxtiocmme cbuoee, Kamo apTepnn, TaKa M sew. B ~ a rpyna 3 ~c H ~ A - B M C O KremoTa ~ HaTpaBMaTM'lHMne3MMCa: 1. APT~PHR M BeHa $~Mo~NIuc. 2. A ~ T ~ ~ M BeHa M R 6paxuan~c K@lTW. 3. APT~PMR H BeHa r p q ~ a n M ~ynHapmc. c 4. APT~PMR n eeHa MnuaKa.

I. M30nMpa~M CbpOBMTpaBMU: apTepMUlHH- 35-45%; BeHO3HM- 5-10%; C epHOBPeMeHH0 3aCRraHe Ha aPTePHR M BeHa - 45-55%. II. Cbpoea TpaeMa KaTo eneMetm Ha nonqaaMa: 1. Cbpom lle3MR B CbCTaM Ha MHOXeCTBeHaTpaBMa - npM atiraxMpaHe Ha epHa aHaTolmnrHao6nam. 2. Cbpom neaw B cbcraeaHacbreTaHaTpaaMa- npM aHraxMpaHe Ha noeere OT enHa aHaTonnMrHa o6nam. 3. Cb~0Ba lle3MR B CbCTaM Ha K O M ~ H H M TpaBMa ~~H~ - npn yracTue Ha noaere OT epm TpasuaTMreH $ a ~ ~ o p . C b ~ o e a TpaeMa ~a u o x e Aa 6 b ~ oqe: e 1. OTKPMT~~ElnM'iMeHa PaHa. HaB-.~~CTH TpaBMaTM~ H npHrntiMTenu M -x n q ~ M o OrHecTpenHo opbme, m PM npeuMeTtr (mwro, nvpom, n a ~ a p ~ ~ a ) . 2 . 3 a ~ p ~ ~ a - 6HanMrMe e3 Ha paHa. HaA-recmTpaeMaTM'4HMIlpMClMHMTenM- nbTHO-TpaHCflOPTHMHHUMpeHTM, BMCO'iMHHa TpaBMa, KOMnpeCMR. M36poe~me TPaBMaTMqHM areHTM Ca IlbPBMCIHH. 3a BTPPM~HH ce npMeuaT $ p a m y p ~ p a K~ M~~ Ht $ p a m e ~ ~ ,
nPM~MHRBa~MpOnbnHMTenHaCbAOBaTpaBMa.

1 . 0 6 CMMllTOMM: ~ KJlMHM'iHaTa KapTMHa Ha XeMOpamqeH UIOK M Oclpa KpaeoManmaHaaHeMuR - xunoeoneMMR, TaXHKaPflMR, HHCKO UBH, 6nepa M M3nOTeHa KOXa, HapyueHne Ha mHaHMero, noHMxeHa racoea puypes. 11. ~ O K ~ ~ CMMnTOMM: H M 3aBMCRT OT llOKMM3a~MRTa M sMpa Ha cbpoeaTa TpaeMa. 1. A p ~ e p ~ a n ~ a YCT~HOBRB~T ce: 6on~a, ~ o x a B~ o6nacrra a p~man~o OT TpaeMaTa e 6nena n xnqHa, Hapyuraea ce CeTwBHoCTTa, npM no-nponbnw~en~a McxeMuR (5-6 h) HacTbnea KotrrpaKTypaHacTas~Te~3acema~a~aa~a~o Ha, nMnceaT nyncaum Ha apTepMnTe p ~ c r a n ~ HRMa o, nbnHeHe Ha noBbpxHocmlrlTe BeHH B 06nac~~a, nMnca Ha KanwnRpeH nync. a) OTKPMTa: MM8 PaHaM BbHLUHO KPbBOTe'leHMe, ~ H ~ T O
MHTeH3MTeT3aBMCMOTBMpaHapaHeBMRKaHm: - cMnHo C T P ~ H O KbpBeHe npw OTBopeH, npaa paHea#

xop;

OT cna6o po nclnceaqo KbpaeHe n p 3anyueH, ~ M~BMT paHeBM xop. OGpasyBa ce 6bp30 Hapamaaq, nyn-

Tpaa~a~ Moxe a pa npeKbcHe KP~BOH~CHMR TOK racTMVHO (C M ~ 6e3pe4ek-r M ~ a c b p o e a ~ a c ~Mnn e~a HamnHo ) (6e3 K0HTak-rMemy IlpoKCMManHMR M AMcTmeH ~ p a Ha h Cbpa), no OTHOUleHMe Ha CbpOWTa CTeHa ne3MRTa e npoHwKsaqa ( ~ o r a ~ npeMMHam o npes WnaTa c ~ e ~ M a) HenpoHMKaaqa ( ~ o r a He ~ o~ c ~ c cnoeae l m OT cTeHara ca 3acema~~). C ~ ~ O BTpaBMM MT~B O W A0 BbHUlHM M BbTpeUlHM XeMOpamM. BbTpeLU~kl~e B3 a B M C M M O C T OT nOKWIM3aL(MRTaCeflOflpa3pellRTHaMHTpaTbKaHHHMMHTpaKaBMTapHM.

Jlo~an~3aq~~ B ~ o n o r p a $ c ~ o - a ~ a ~ acnek-r o~nre cbnoeaTa ~ cncreMa ce C ~ C T O M OT: 1. ~ O B ~ ~ X H O ~pa3nOnOXeHM THO MaMcTpMHMKpbBOHOCHM CbflOBe - no L U M R T aM K ~ ~ ~ H U U M T ~ . 2. nbn60~0 pa3nOnOXeHM MaMCTpWHM KpbBOHOCHM CbpOBe - UHTpaKpaHManHM, MHTpaTOpaKanHM, umpaa6-

CMpaq XeMaTOM. npln TeXKM pa3KbCHO-KOHTy3HHPaHM M KOHKBaCaUMM KpasoTereHMe Moxe pa nclncea, nopqn p a 3 ~ b c ~ a M~ e npe~aaaa~e Ha apTepMma. 6) 3aKpma: nMncea paHa. 06pa3yea ce 6bp3o Hapac~ e a qnyncMpaq , xeuaTow. T~~BM~TH'~ MOMeHT HMRT IlpM 3aKPMTMTe aPTePMmHM TpaBMM~ C ~ ~ C T B IlO ~ COKa C OT MHTMMaTa KbM WBeHTMuMRTa Ha KPbBOHoCHMR Cbn. PM pa3KbCBaHMR Ha MHTMMaTa Ce paaatlaa m p a ~ p o ~ 6 o Ha a asacemaTara r a m OT cbna M JlMnCBa XeMaTOM ( C X ~3.2). M~ 2. B ~ H o ~ H ~ : 06qa~a M JlOKmHa WMmOMaTMKa flpM BeHO3HMR T ~ ~ B M ~ T p0 M ronma ~ ~ M cTeneH e HnemMrHa c ~ a w , onMcatia n p apTep#anHm. ~ HaA-remo ce ~a6nlopaea enHotlpeMetiHo3acRraHe Ha apTepnR M BeHa. Y C T ~ H O B BaT C e M HRKOM O C ~ ~ H O C T M : a) npM OTKpMTa BeHO3Ha ne3MR KpbBOTe'ieHMeTO He e c~pybo M nyncMpaqo, KpbeTa e n o - n ~ ~ a ; 6) IlpM 3aKpMTa BeH03Ha ne3MR XeMaTOMbT He e nyncupau. Pase~sa ce no-6ae~o; B) IlpM TpaBMaTMqHa ~ p o d o s a Ha BeHa C e pa3BMM
K ~ ~ T M H ~ T ~ H ~ B ~ H O ~ H ~ C T ~ ~ ~ : ~

Ha MeKMTe TbKaHM, KOXaTa TOnna, JlMBMpHa;

Anroplrrw

C l e w 3.2. panna ouenm m mem na u p o n m m esmmm miipnnalmrr (no W.R. C h M d and E.H. Auslin, 1988)

A~percr~ HapaHReaHe o
1. flwHM~Bau(a (OTKPMT~) TpaBMa a) n o p e 3 ~np060flHM ~, M omecTpentiM paw
Ta;

I.A H ~ M H ~ ~ ~ - M H @ 3a o MeXaHM3Ma ~ M ~ ~ wHaTpaBMatie emam Moxe Aa ce 06epe. 11. CTaTyc - 064: TbPCM Ce HWM'iMeTO Ha TpaBMaTM-

6) RTpOreHHMne3HH (aHrM~rpa@Mfl, CbpAe'iHM KaT e T P M , OnepaUMM, MHTpaapTepManHM M H X ~ K ~ M M ) 2. H e n w ~ M ~ B a u (3a~pM~a) a TpaBMa a) KOHTY3MR ( T P O M ~ O ~ ~ ) 6) KOMnpeCMR ( X ~ M ~ T O M @palcrypu) , B) K O H C T p H K 4 M R( C T ~ M ~ npeBpb3~M) TM

% H UlOK; IlOKWeH: TpaBMaTMVHaTanaTOnOMR Ce yCTaH0sma no cMcTehnM. T b p c ~ ce cb4oBa nesw. 111. ~ ~ H C T ~ ~ M3CneflBaHMfl: ~ H T ~ ~ H M 1. nonnepoea co~orpa@u~ aa n 8 c n e ~ ~ Ha a~ ce b~oame nyncaum M wmoBe. 2. bl3MepBaHe M YCTaHOBRBaHe Ha pa3JlMKM B HWRraHMma B C M M e T P H V H M 06naCTM.

11

~ ~ H R M P ~ K THapaHRBaHe HO

1. P a s ~ b c a a ~ OT e npepaa~~ratie 2. Aeqenepauu~ (rpbfl~a aop~a)

3.Ap~epM0Cna3bM
111 K ~ C HYCnOXHeHHFI M
1. Ompa Tp0d03a 2. M H @ ~ ~ M R 3. nepM$epeH OTOK, TyPHWKBTeH CMHflPOM 4. Jlaxn~sa a~esp~3ua 5. A P T ~ ~ M M aHeBpM3Ma H~ 6. A ~ T C ? ~ M O - B ~@ HM OC ~T HY~~ ~

3. AHMOT~~$MR npM HeRCHM CnVaM CbC 3aKpMTa apTepManHa TpaeMa: a) npeRonepaTveHa; 6) MHTpaonepaTMaHa. 4. Y C T ~ H O B R B Ha ~XeMOpaMR H~ B Pa3nM'iHMTe K y X M H M BX. CbOTBeTHWe pa3flenM. ~M~MOCTM'~HOTO YTOLiHFlBaHe Ce M3BbpWBa yCnOpeAH0 M C b B M e C T H O C Jle'ie6HMR IlpOTOKOn. AHaMHe3aTa M CTaTyCbT M3ClepnBaT Bb3MOXHOCTMTe Ha A O X O C n M T a n H H R nepMOfl. O C T ~ H M MA T M ~ a M O C T M i 'H M M e T o R M ce npMnaraT B 60nHM'iHa O ~ C T ~ H O B K ~ .

1. C n a c ~ s a ~ XM e B O T ~Ha nocTpqanMR - x e ~ o m a 3 a
M 6op6a c WoKa.

2. CbxpaHRBaHe Ha MCXeMM'iHaTa 30Ha flMCTmH0 O T cbAOBaTane3MR-Bb3cTaHOBRBaHeHaKpbBOTOKaBOnTMr) npMB ~ H O ~ H M T ~ T ~ ca ~ aanaaetiu BMM nyncauvmeHa M W H M CpOKOBe (A0 6 h). epH0MMeHHaTa apTepMR. Te MOraT Aa 6b~aT O T C ~ ~ ~ ~ H M 3. B p e ~ e ~ ~ a x e u o c r(a a 3~ ae o~ b a ~ o m a B) MRCTOTO : n o p a l npmMcKaHe OTB~H; Ha yepewaHeTo w n M B MACTO no ~ 3 6 0 ~ : g) npM OTKPMTM TpaBMH Ha WM~HMT~ B e H HM M a OnaCa) A~rmantia KoMnpecMR; HOCT OT pa3BMTMe Ha Bb3AyWHa ~ M ~ O ~ M F I ; 6) KounpecMetia npeepb3~a; e) oKono 50% OT nauMeHTme c HapaHRBaHe Ha ronnB) 3a4~naa~ Ha eK ~ P B R ~ M cR b B ~patiaTa; Ma BeHa H e ROCTMraT X M B M A0 60nHM4a~a. fle~allMTeTbT r) HanRraHe Ha Esmarch; npu nomnMnMTe e 40-60%; R) nMraTypa Ha cbna; X) M30llMpaHOTO HapaHRBaHe Ha rOneMMTe MIMCTe) nmaeme Ha BpeueHeHM ~ K ~ C T DHT B ~ H (OT c b u o ~ pantin eeHM e PRAKO nopqu p a 3 n o n o x e ~ ~ MM e ~B o XMpypr 3a T ~ ~ H C I ~ O ~ T M ~ ~ H ~ ) . 6 0 r ~ Ha ~ a TenecHme WMHM. 4. Haqano Ha 6op6a~a c~paawa~~'i~w~l/xe~opa K ~ M H M V KapTnHa H ~ T ~ Ha cbAoeaTa TpasMa cramamU l O K aKO e HaJlMqe TaKbB: IlM'iHa M 3aMbrneHanpM 60ntib1C TeXKM CbWTaHH T P a B M H a) OCllrypFlBa Ce ~ 0 6 b p BeHO3eH M 3 T O C I H M Y ' MT ~ ~ B M ~ T M ' ~ ~ H / X ~ M WOK. O~~MC~~H 6) 3ano'iaa ce MH@~BMR Ha BOAHO-cone~v I / ~ H T ~ ~ K ~ B M T Cbfl ~ ~O H BM MT lle3MM ~ IX IlpORBRBaT CbO5. klM06~mM3auMR. T B e T H O C: 6. 6bp3 TPaHCnOPT fl0 Cne~MallM3MpaHC ) 1. M H T ~ ~ T O ~ ~ K XeMOTOpaKC, WHM XeMOMeflMaCTM-

mn-

HYM.

saeeUetiMe.

TOM.

1. flpofinxa~ane'ie~~e~o HaTpaBMam'iHMR WOKAO

C KOHKOMMTaHTHaTaTPaBMaTH'iHa YBpeAa Ha I p y M

OBn~RBaHeTO My.

2. O ~ o ~ r a ~ xe~oc~a3a: en~a a) ~ a u n o ~ qn a p f~ l ~ @ y 3x ~e a~ o p a r ~ ~ . 6) nMraTypa - p a 3 r ~ ce ~a Ha KonaTepanHoTo ~pbeo06pbqe~~e. B) C~F(OBwes C M n u 683 "path", a ~ a c ~ o ~ KpaA o 3 aB ~ p acnep i p e 3 e ~ Ha q~ n~ o p a 3 e ~ pacTbK. n~

r) peKoHCTpyKUMRHa K~~BOHOCHMR cbp -C~AOBO npo~ e s ~ p an ~p e rone~n :~ fle@etcr~: aaronpo~e3~pa -~ ~e3 nonsea ce C O ~ C T B ~MaTepuan, H ~ah-reno aeToeeHa racm OT ~ e C O ~@ a H ~~ama; anonpo~e3~pa -~ Ce ~ROBM
npo~e3 OT ~M ~ K ~ C T MaTepMR. B ~ H ~

npe~na3~~~~ona~. K o p e ~ ~~ ap ~a a a Moxe ~ a pa npoTere 6e3 nocnepm2.Bpe~w Ha IlapeHXMMHHTeOpraHM (MHOTO no-PFIAKO), BMR, HO npwexacaea M UIMPOK p ~ a n a s o OT ~ycnoxHeHMR npM'iMHeHM OT flMarOHanHMfl PeMbK. OTnOBbPXHOCTHaTapa3KbCHO-KOHTY3HapaHaflOTpaBMa111. L(epBMKMHM M BMCOKMTOpaKanHM CnMHaJlHMne3MM TM'itiaTa pynTypa Ha KopeuHaTa aopTa. B ~ a rnasa 3 ~ We (flehc~a~e H a fluaroHanHuR peub~). ce ~a6neme Ha noMrecKaTanocneflo6aTenHocTOTnecleIV. Opalcryp~no KOCTHMR cKeneT Ha I - P ~ ~ H H R KOW ~ H M M T fl ~ MarHOCTM4HMTe flehCTBMR n p M BCeKM eAMH OT (p~aro~an peub~). e~ TpMTe eTana: MRCTO Ha C ~ ~ H T M ~ MT TpaHCnOpT O 10 6 0 n ~ n UaTa, npMeMHOT0 OTfleneHMe M XMpypMRTa. B KnMHMCleH ffiactIQH~aqH~ aCneKT M npM a6floMMHaJl~a~a TpaBMa, KaKTO npU OCTPMR 1. 3aKpMTa KOpeMHa TpaBMa HRMa HapyWaBaHe Ha XMPyPMCleH KOpeM, O C H O B H M T eC M M n T O M O K O M n ~ e K C M Ca: KoxaTa. t l p ~ r ~ ~ OT e flehme~e~o ~a H a n n npepMeT, n e P M T O H M 3 b M M / H ~ MMHTpanepMTOHeaJlHa XeMOpaMR C B sbpxoea H ~ R B ~ - x e ~ o p LUOK. a r ~B re np ~ a ~ ~ w ~ a ~ a o b a r e ,nmaH!OT BMCOKO, npM CnOPTHM CbCT!3aHMR, npM npM IlOBeVe OT 80% OT nOCTpmaJlMTe a6floMMHaJl~a~a MHflyCTpMaJHMyCnOBMRenOBULueHaBepORTHOC~aflaCa fleic~san pea ~ M noeere TpaeMMpaulM areHTa epHoepeTpaeMa e eneueHT OT nonwpasMaTa ( c b ' i e ~ a ~ H n a M KOMMeHHO TpaBMaTa e KOM~IIHMP~H~. 6~~npa~ 3a~oea a ) . anroplrruMTe Ha XMpypmrHo noeepe1. 6e3 yepena Ha opram OG~KMBHO ca HanMue H M e u(e OTClMTaT Ha ITbpBO M R C T OT 0 3 M @atcr.

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TeXKH K O M n p e C M M npM M H f l Y C T P M a n H M RTpaBMaTM3bM; ReIJenepaIJMOHHM MH O X M V H MM e X a H M 3 M Mn p M TPaHCnOPTHM. . Te n p O M 3 u J e C T B M R B TOBa O T H O W ~ H M T~ MflM'ie~ npMMep e ~ a a e c ~ BonaHHa ~ a ~ a TpaeMa cbc a a c ~ r a ~ Ha e IIpflM, KOpeM, AOneH K P ~ ~ H M MK 'iepenHO-M03b'iHM YBpep#. n p e f l n a 3 ~ ~ KonaHu ~e He peAyqMpaxa 'iemora-ra Ha a6poMbl~aJl~aTa TpaBMa, H 0 CnOpep HRKOnKO O ~ W M P H M npoyrsaHMa B CAUl e HahnanRna ~ H ~ C I M M O cpeRHo , C OKOnO 60% (35-85%), 'ieCTOTaTa Ha TeXKMTe OPraHHM yepep# (no A. W. Hanison, 1990). Ha 6a3a~a Ha OTHOCMTenHOTO ep~006pa3Me OT Cb'ieTaHMe H a yepeAMTe npu ~anonsaa~e Ha npepna3~me K O n a H H HaTe3M K O M ~ M H ~ ce ~M n 0 H C T a B M eTMKeT: The Seat belt syndrome .CMHAPOM~T Ha n p e f l n a 3 ~ ~~o~n a ~ " . O~OCO~ ca ~TPM HM rpyn~ cnopep ewpa Ha KonaHa: xopwSOHTaJleH, flMar0HMeH M KOM~IIHM~~H. 3a HaLUMTe yCn0BMR OT npatcrHrecKo 3 ~ a r e e ~TpeTvRT ~ e BMA. l l p Hero~ BaTa yno~pe6a npM IlTn Moxe fla ce oraltea: 1. KOHT~JMM Ha MeKMTeTbKaHMHa VbflHaTa HKOpeMHa CTeHa. 11. ~ ~ H T ~ ~ ~ ~ ~ ~ one3MM: M M H M H M 1. Ha KynTe opraHM M ~ e 3 e ~ ~ e p nF(bnxaqM y~a, ce

(nTn).

B) K ~ X (~HKO M ~ M ~e6eno ~~PBO ~ , b r Me~ X~Y ~ Mb'4HM nbTMula). 3. C u ~ o x e c ~ sppepa e ~ a ~aopra~cl: cbpose; napetiX M M H M ; KYXM; IlapeHXMMHM K y M M np. 11. OTKPMT~ e TpaeMaTa, KoraTo e HapywetiaKoxaTa. Hah-clec~0 TaKMBa PaHM Ce HaHaCFlTC: OmeCTpenHM OpbXHR, H O X O B e M OCTPM IlpeAMeTMOT 6 n ~ a MnM n P O M 3 B O P C TBOTO. Mnna onpepenew paanlr~ln Mewy OrHecTpenHMTe, H O X e B MMT. Hap. .fl~YfU'HapaHRBaHMR, HOTOBa e OTflenHa M OrpoMHa TeMa, HagxebpnRqa s a p l a r ~ ~ Ha eTO~M MaTepwan (sa no-noflpo6~~ ceepeHMR ex.: pbKosopcTsaTa no cnewHa XMPY~MR, BO~HHO-none~a x~pypm M~ M~TOCIHMqwe, noco'ieHu B 6w6nnorpa@~ma K ~~ M a rnaBa. 3 ~ OopMMHO IlaTOreHeTM'iHO OTKPMTaTa TpaBMa MOXe pa CC?

noppa3~en~~acnefl~~~erpyncl: 1. HenpoHMKBaulaB IlepUTOHeMHaTa KyXMHa.

2. I l p o ~ ~ ~ B a npe3 u l a nepMToHeyMa: a) .LL(~CT~MBO" HapaHRBaHe - C npOHMKBaHe, H0 6e3

HapaHRBaHe Ha KOpeMHH QpraHM. 6) C HapaHR6aHe Ha OpraHM; epMHM i H ' O MnM MHOXeCTBeHo HapaHmaHe; H a napeHxlrMHn dunn K ~ M opracln; B) C HapaHmaHe Ha cbfloae. Ha~eqenepaq~FiTacpeulyxop~30~~an~a~acacTaeKaHa Ill. K o p e ~ Tpaahna ~a B KoMnneKca Ha nonmpaeMaTa.

1. C b c l e ~ a H TpaBMa a e HWIMqe, KOraTO flOA f l t ? h ~ ~ B M ~HOBP~M~H CH T O M e M3Knlo'iMTenHO flOne3HO #a e T o H a eAMH T p a e u w p a q $amop ca HapaHeHH noaere OT ce s a n o M H m M 0 6 c ~ o ~ ~ e n c ~ oK soa no ~a anononyltaTa e A H a a H a T o M H r H a o6nac~ (~anp.:mam K o p e M MnM BMA H a npOM3lueCTBMeT0, CKOpOCTTa H a ABMXeHMe H a flpeBO3HOTOCp~~CTBO,flOCOKaTaOTKORTOCeeCTpenRnO K ~ ~ ~ HK HOK ~~M). flpM OrHeCTPellHO HapaHRBaHe H T. H. M H $ O P M ~ ~ M R T 2.3~areH ~a~ npMopMTeTMTe e B n e r e H u e T o HaTpaeMeHaTa 6onec~. f l pT ~e x K o paHeHMR ce ~ e h c ~ H eaa coreM o x e A a ce o K m e M H o r o u e H H a B c n e q ~ a n ~ 3 ~ p a ~ a a a e ~ e ~ l(~anp.: re s n o n o n y l c a , n p KORTO ~ e 3 a r ~ ~ epMH a n HO no c x e M a T 9 ABC. 3a~oea npc ~b r e T a H a T p a e M a c OT flbTyBaqMTe, O ~ M K H O B ~ HflPOTM'ia O C TeXKM Y B p e W a y r a c T M e H a rpbflHm=i KOW M K o p e M a M T. H., nbpeo (A) ce HMR M H a A p y M T e flbTyBau(M). T e 3 Bb3MOXHM ~ HapaHRBao c M r y p R s a cwrypeti Aocnn H a AMxaTenHaTa c M e c no 6e~ M~ R~ 0 T. 6 e.:, IlOrMCTBaT C e rOpHHTe AMXaTenHM I l b T M q a , HMR T P R ~ B ce ~ A flOflO3MpaT ~ M TbPCRT B Cne4MXlM3MpaHOIlOCpeACTBOM flneBpanHM T P ~ ~ H Ap M e H W M C e eMlcyMpaT TO a a s e ~ e ~ ~ e . n n e e p a n H M KoneKqMM, 3a Aa ce p a 3 ~ 6~e n a ~ ~~po6o~e K ~ K BHe O T P R ~ Aa B ~Ce t l p a B l l H a MRCTOTO H a ~ b 6 ~ Be. Cne~sa (B) noflnoMaraHe CnoHTaHHoTo MnM ocbtqecTM~TO? T s m a H e H a anapawo AMwaHe. Qea T o r a e a M o x e Aa ce 3 a K p ~ TpaBMa. ~ a He ~ p ~ 6 pa e aC e M3nMUHO MMCnM (C) 3 a a 6 f l o M M H a n ~ a HaMeCa. BMHarM IlpMOpMTeT B p e M e C HeF(OKa3MM 3HaW?HMeTO CM ~ P M ~ O M(Haflp.: M MMa3aCTpaUaMu(O XMBOTa BbHWHO KpbBOTereHMe. Bpe~ s ~ e p eO a~ ~M e K O ~H K a~K T o p~ e M a 3 a no-K~CHO cpaetieMeHHaTa XeMOCTa3a C e M3BbpWBa 3 a CeKyHflM. PRAKO npM Hue) M C MePOflPHRTMR, KOMTO C a nPMCbqM H a CII~~M$MVCbCleTaHMe C '-lepeflHO-M03b'iHa TpaBMa flOCneAHaTa MOHOTO aaeeAeHMe. Xe A a MMa nPMOPMTeTH0 nOnOXeHMe B CTPaTeMClHMR ~ ~ T ~ ~ $ H MO~ M T K O ~ ~0H 6O ~ n e f l ~ HHea 6 0 n e H B RBeH anrOpMTbM, H 0 B flOBe'ieT0 C n y r a M ( T ~ ~ K MO ~~paa6flotdMXMflOBOneMHCleH WOK, M3BbPUleHO H a MRCTOTO H a C ~ ~ W T M H ~ H K Ob p e e ~ e M ) o x e A a ce p a 6 0 CMHXPOHHO. ~~ eTo, H a r m n R s a W a H c o e e T e H a n o c ~ p q a Aa n ~oxmee. ~ 06oco6e~u B CTpaTeMreCKO OTHOWeHHe Ca CneflHMOTKPMT~ T p a B M a . npona6~pan~ BbTPeUHOCTM H e T e Cb'ieTaHMR: 6nea na ce penoHMpaT, ~ b K h a T o T a K a M o x e Aa ce KoHTaa) T O ~ I ~ TpaBMa; KO-~~~ ~O MM ~ ~ MMHMpa flepMTOHeyMbT. ~ ~ OH C T ~ T~ ~C e (A H aOC e H flOKpMRT C 6) CbreTaHMe M e w y a 6 f l o ~ M ~ a n HM a ypOTpaBMa; r M c T KoMnpec. B) Cb'ieTaHa a 6 f l o M M H a J l ~ aM rMHeK0nOMVHa TpaBMa. ~ ~ O H M KB BKOpeMa ~ ~ M M CTbp'iau(M HaBbH IlpeflMeTM cbqo H e 6 ~ m ~ace n#naT. E1mH a OnepaqMoHHaTa M a c a f l o 6 o n u ~ s ~noeeReuHe o H neveuHe MOraTfla 6 b f l a ~ o ~ c ~ p a H e -HeflOCpeflcTBeHO HM IlpeflM MnM B o ~ ~ ~ AOWIMHMCIHaTa ~MRT n O M O q (ne~ap CbC CfleWn p nanapoTonnMRTa. ~ Cauo T a K a M o x e Aa 6bAe c e o e e p e HO-MeflMqMHCKa K B ~ J ~ M $ M K ~ ~ n MeR K,a p , $ e f l ~ ~ e Mp np.) MeHHO OBna,4RHO HaCTbnMnO CneA eKCTpaKqMRTa KbpBeHe M3XOX&l a pt'i0ri OT TOBa KaKBO M O X e A a HaflpaBM M KaKBO MnM M3TMClaHe H a 'ipeBH0 CbAbpXMMO. HRMa IlpaBO fla M3BbpWBa flpM CbOTBeTHMTe YCnOBMR. ~ ~ M ~ ~ H O C T ~W p RK 6~ Ba T Aa ~ OTrOBOpM H a ClleAHMTe Uenu H a e $ e u w e ~ a ~AoKnwHMrHa a n o ~ o ca: q c f l e q M $ b l r H ~3 a a 6 f l 0 M M H a n H a ~ a TpaBMa BbnPOCM: 1. C ~ a 6 M n M 3 M p a H e H a BMTanHMTe $YHK~IIM: M M n~M C B O ~ O ~ ~ IlOflBMXHa HO TerHOCT (KbpBeHe OT A = Airways Bb3AyLLIHM flbTMqa; 3 4 b n X M T e n H O Ce napeHxMMeH oprati MnM ronm cbfl)? Mua n M yapefletiu oc~o60waea Bb3flYWHMTe ~ I l b T M q a , 3 a A a M O W H a noopra~M ~ ?Mn~ ~ cao6o~e ras? ~ M H T ~ ~ nu HM Mnneapanc ~ p ~ g q a n ~ ~ ~ a c e o ~ ~ r y p u ~ n ~ ~ ~ a ~ HHTe ~~K ~y n p aan~~ ~ ; n o~ n wa Mn 6 a a 3 r~ao ~ cw e H a 6 e n ~ ppo6oae? ~e B = Breathing AMwaHe; OTroeopb~ Ha~ e B~ 3~ P ~ OCM KOMTO , caMM no ce6e CM C = Circ~lation MaKpO- M MMKPO~MPlcynaqMRTa. ca ~ O K ~ ~ ~ 3a H M nanapoToMMR, F I ce T ~ P C M r p e 3M ~ ~ P O ~ H M C X ~ MflpOflbfllKaBa, ~ T ~ ~ ~ M C B O R B ~CM ~K IlOrTM M BCMrKM T e IlO-flOIly MeTOAM M IlpOTMra yCIlOpeF(H0 C MHTeH3MBHOTO ~YKBM OT naTHHM4aTa, H 0 3 a MRCTOTO H a C ~ ~ H T M ~CT aO nerewe H a wolta. B K O ~ T O ca no-ron~ua~a r a c T OT ~ O C T B W H M IlbpBMTe TPM. OT TRX 3aBHCM: OCMrYPRBaHe H a T ~ ~ H C ~ O ~ T ~ B ~ CbOTBeTHMTe ~ ~ H O C TrnaBM . Ce TpeTMpaT BbflpOCMTe 3 a BpeMeHHO UMHMpaHe H a KP~AHMUM, IlOBeMH$OPM~~HFI 3 8 Cny-IMnOTO C e TbPCMM OT ~ O ~ H M R OT , pewe n p M n o p o 3 p e ~ 3a ~ e~ M b a ~ p a B M M np. a B noeereA W M R I l b p B a n O M 0 q M flpMflPY))(MTenHTe. M ~ X ~ H M H a~ M TO c n y r a M B p e u e H H a T a x e ~ o c ~ a s np aM B b H w t i a x e M o p a TpaBMaTa e B W e H 3 a IlOBeAeHMeTO HM. C ~ M O Y e flpM rMR e KpaTKa. Cera Ce CMRTa, W e HallbnHO flOnyCTMM0 BCeKM OTAeneH flaL(MeHT Y B p e w a l q M T e CMnM A ~ ~ C T B ~ I l O C T p a M M R T flpM H ~ O ~ X O ~ ~ M M ~ O( C ce aT o 6 e 3 6 o n ~ nOHe, TOnKOBa HeflOflpeflMMO, TOnKOW M3HeHQBaq0, 'ie OnMTXe HOBMTe AMamOCTH'iHM MeTOBM (exorpa$Mfl, KAT, naHMRT XMPYPr, B ~ M M ~ IlPeflBMA ~ K M cb6paHM~e aHaMHeCTMrnapOqeHTe3a, n a f l a p O C ~ 0 f l M R )IlPaBRT HaflbflHO Bb3MOXHH AaHHM M 0nMpahKM Ce H a OllMTa CM, no-HaTaTbK C e H 0 nOCTaBRHeT0 H a flOKa3aHMR 3 8 OflepaqMR M 6 e 3 noMOp b ~ o a o fOT l ~ABe H e q a : CTPMKTHO cb6nloflaaa~e H a AHarU T a H a C@~KTHBHMR CMMnTOM 6on~a (P. Klaue, 1987; W. HOCTM.IHO-T~~~~~B anrOpMTbM T M C I H ~M RHHTyMqMRTa CM.

Kozuschek, H.B. Reith, 1993).

2. M 3 6 0 p H a n O f l X O f l R ~ 0CpeflCTBO 3a TpaHCflOpT M H a n o ~ x o ~ nere6~o ~ q o s a s e ~ e ~3 ~a en . or~a~o no ~ cxeo ~ a ABC ~ npomnxaM a M B n M H e h K a ~ ap , eaHM~06Mna MnM

xenMKonTepa.

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Yn~pasey~oe ~ne ~ o f l n ~ BnpyrMHHaTa '. npaewa ce npunara O ~ H K H O B ~ H cauo O real time exorpa$nR B PM OTKPMTaTa TpaBMa TPFI~W fla C e 0T6ene~M: - npona6Mpa~e~o Ha ~ ~ ~ o M M H M wcqepa HM e naToPeXMM B (rightness) - TR e 6bp30 OCbLL(eCTBMMa (npM noRroTaeH exorpa$~m),HanbnHo 6e3apep~a M ace noMOMOHMVeH C M M n T O M 3a IlpOHMKBaHe Ha HapaHRMHeTO; O Moxe C e BMAM - 0 T ~ e ~ R H e T O O T p a H a T a H a C b ~ b p ~ M O H a K ~ X K O p e - HmewHa, H 0 C Y ~ ~ K T H3aBMCMMa. MHHMMMHO KO~M'ieCTBOTWHOCT B KOpeMa. npaBM C eM MeHOpraH e ~aTOlHOMOHMreH C M M n T O M38 IlPOHMKBaHe Ha HapaHReaHeTo c opraHHa ne3n~.V1 B nBaTa CnyraFI ca p ~ $ e p e ~ q ~ a n ~ a p ~~ae r~ woy36 a~ c M n~ p ~ (M~ B c~H MT ) M ~ ~c MHanMrMe B Haexa, KaTo npM nocnepHHR He Moxe pa HanMqe ~ ~ C O ~ D T~H O HK ~ ~ ~ 3a HwMpoKa M R nanapoToMw ce pa3n~raea~ ~pbe, moi, VpeeHo C ~ U ~ P X M MM Op p y ~ M e~cnnopaqmn. IlaPTMKynMpaHMnpMMeCM KbM TeClHaTa $838. Ilannaqnn. Mora~ pa ce ycTaHoam M n o ~ a n ~ 3 ~ p appe6~o ~ B oTpenHMcnyraM Moxe pa ce npMnoxMcbreTaHMeTo cMMnTonilMTe Ha OXK - h n ~ a MycKynHa , PMM~HOCT po OT 0 6 ~ r a k ~ a B-mode ~ a real time exorpa$m c pbn6o~o R~$~H Blumberg c, M n M nepKyrOpHMRT My eKBMBmeHT, H 0 C a M O aK0 IlOCTpaMMRT e B Cb3HaHMe. B H M M ~ T ~ ~ H Doppler ~ T ~cKeHMpaHe - T. H. Duplex-exorpa$~~. Hanp.: 3a M3RCHRBaHe Ha M3TOqHMKa Ha epHa X ~ M O ~ M ~ M R . nannaqw HaMMpa M yroneuReaHeTo Ha repHMR pp06 M panaKa, noHmora M HeoraKeaHm T~MOPHMMacM (~anp.: AKOexorpa$MR~a no~asea cso60p~o nouaMxHa Tev XeMaTOM B O M ~ H T Y M ~ ) . HOCT M / M ~ OPM M po~asea cao60pe~ra3 B KopeMa, ce Ileplcycn~. tlponepea~~.~~o Moxe pace ~ P C R T rpaMMtiaea Ha nanapoToMm, T. e. Moxe pa ce npecltoru nanapoqemeaa~a. Exorpa$MR~a Moxe pa oTKpMe H orwH M U M T e Ha rep+?H pp06 M AMaK, H 0 B YCnOBMRTa Ha UHM ne3MM Ha napeHXMMHMTe OpraHM. Kora~o WIMHM'iHaCneUIHOCT O ~ H K H O B ~ HC O e npOBepRBa M M 0 3a CnTK. Ta KapTMHa paspeluasa, exorpa$c~onpocnepRsaHe MOAyc~yn~aqn uoxe ~ ~ aua HM nopcltaxe c OTC~CTBMx e pa ce npoeewa npea KpaTKn nHTepeanM - 1 h. e T O Ha nepMCTMTMKa 3a ne3MR Ha KOPeMHM OpraHM. KAT. M ~ o r BePORTHO o B 6 n ~ 3 6bpeqe ~0 q e ce HapeAwrn~an~o peKTanHo ~o nscne~ea~ Oe ~UKHOB~HO AM Hareno Ha MeTOpMKMTe. B ~ ~ M O X H O C Ha TM CnepBaT~ ce nponyclta, HO TO Moxe pa HM o 6 0 r a ~ c~ MHoro UeHHa MH$OPMB~CIR. OT~YCH~TMFIT, napeTHCleH PeKTyM MOXe Aa 4 O T O (3D) Fl OKOneHMeC AHMTMHa C ~ ~ T ~ ~ K ~Bb3MOM R ' M XHOCT 38 IlPOCTPaHCTBeHOBbpTeHe HaCbXPaHeHMRB U B R T e pe3ynTaT OT YBpeRa Ha ~ ~ ~ ~ H ~ C M03bK. I H M F KpbB I no ~bpxa~anpbc~aoa~arasane3~~~a~y~~op o6pa3 e ~ eca ~~ o p ryau~ npepcTaeMMM. ~, o B 6bnrapw~ Toaa MacnepeaHe aa cnewtiocna, KORTO npepcTaennsa KopeuHaTa no-BepORTHO Ha AMCTMHMTe OTpenM Ha pe6eno~o repB0. TpaBMa, e M nOMCTMVH0, M M K O H O M M C e lC K M MHOrO PFIpKO Mora~ ua ce onMnaT $par~e!i~v~e Ha HaTpolueHMTe~asoonpaepatio. BM K O C T M , lPOHMKBaU#l MUM He B nyMeHa Ha PeKTyMa. C M M ~ T OHa M~ ,$no~vpaqa~a T npoc~a~a" e n o w naTorM~saane~ MeToAn. n n a n a p o ~ e ~ ~ eTR 3 ae . 3mbnnOCTHOMOHM'ieH 38 KOMIlneKTHa TPaHCeKqMR Ha ~ e ~ 6 p a ~ 0 3 - XMTenHa npM HeKOHTaKTeH(no pa3nMrHM ~PMCIMHM) pman. O ~ n q a cauo aKo KnMHMrHo M exorpa$c~~ ma HaTa ypeTpa. paHHM 3a CnTK M n M R0 rpa$c~M e HEUlMUe ceo60pe~ ra3, ~OCT~BRH~ Ha TO HrC (~aso-rac~pan~a co~pa) e eneT. e. M n n a~ ~ C O ~ I O T H ~M OK~~~H 3a Mnanapo-rohnlrfi. FI HanoMeHT OT K O H ~ ~ ~ U M aa F I Tpcl T ~ Te KaTenpa, npMnaraHa B nW3: qeHTpMHO-BeHO3eH, YpeTpMeH M Ha30-raCTpacnepbK ce 3a6enmea y m o 38 ~ npepnorMTaHe Ha exorpaTH ~ ~ ~ H Bb3MOXHOCTM M T ~ 38 PMHaMMCl HO npOCllepRneH. Ilocnep~MR~ He 6 ~ pa m ce 3a6pae~ M npM ~ 3 o n ~ p a - $ M F IC BaHe. Ho He ~pR6Ba pa ce 3a6paa~, r e e $ e n ~ B ~ o c rh ra ~ a~ ~ ~ ~a ~ O M M H M H ~P T~ ~H ~C O e B OTKPMBa M ~ . KbpBeHe OT ropHrnTe oTpenM Ha rMT M ce nocmra peKoMnpecclR. e~ ~ B M C M M ~ exorpa$~c~a, OT ~ o h He o BMHarMe Ha pasnonoxewe. I a n a p o q e ~ ~ e 3e apMamocTMrHa ~a MaHunynan a 6 o p a ~ o p n Oqe ~ . c nocnneaHeTo Ha nocTpma~MR, pocnntia aa Bcew xMpypr M ce ~ O ~ M T M B MM npw ~ ~ n M R 3mbnXMTenHO C e npaBRT PYrMHHMTe M3CneflBaHMR HRKOnKO peCeTKM m 1KpbB, XllbrKa M n M 9peBHO CbpbPXMHa KpbBTa M YpMHaTa. 6KllD'iBaT C e CepyMHMTe H M B a Ha MO. 3a nocTpman B LUOK, c TemKa cbreTaHa TpaeMa, ypefl, KpeaTMHMH, saxap M enemponMTM. Onpepenm ce 6bp3M~aTa Ha nocTasme Ha noKa3aHMRTa aa onepaqm KpbBHaTa rpylla M Rh-$aKTopbT. ~ O A ~ O T B C e R flOCTaTbVH0 He e 6e3 a ~ a r e ~n~ p eMaCoBM . ~ snonony~ c~ MHoxecTeo KpbBCKPbCTOCaHOTMnM3MpaHe. 06pa3Hn n 3 c n e ~ ~ a0 ~6n3~0.~ ~ R0 O-W~C~~~EJ~H~. ' 3 a cacrasRnero na rasu m m 6 n a r o m p ~ Ha p-p B u l r r o p ~ Taceea. tktflM.~Me~o Ha cso6ope~ ras B nepmoHeantiaTa KyxMHa Or cbxpanenu8 TO uu@pu(OT anrnuAcw qu$pu = digits - nynu U npM 3aKpMTaTa M n M HenpOHMKBaU@TaOTKPMTa TpaBMa e euunuq~) o6pa3 Morar ua ce npeucraem no-ncno opranu no u360p - Hanp. 3a ~ ~ C O ~ K I T Hn O o ~ a a a 3a ~ ~nanapoToMnn. e OPM BwyanMceKyHuu cneu npufinmreane Ha uacneuaanero Mome ua ce uouaxe, r e usroraupa M Moxe pa n o ~ a n ~ 3 npoeimna ~pa npM omempenHUK na xeMonepuroneyMa e pynlypa na qepnun ~po6.

nlrpaHaMnMcbreTaHaTpaeMaw npvopMTeTMTe.

x e p ~ nanapqen~e3a~a ~u e ~ e s a u e ~M l lcr ~ r y p C eK~P M ~ HMHrOB MeTOp. flanapoc~onu~~a ( M ~~M ~ p e o c ~ oen 6bp3 ~ ~ pMar~a) HocTnreH, a B pep cnyvaw M TepaneaTnreH MeTop. PeBM3llR Ha PaHaTanpM O T K P M T M TpaBMM KaTO~HaMOcTMreH MeToA e a q b n x ~ ~ e noceeH ~ a , aKo He ce Hanara cepbxcnewia nanapoTouHR. ~ M ~ ~ H O C T M ~ H ~ ~ cMe ~ ~ M ~~ ~BO ~T ~O U KoraTo M JM M~ ~M , n npH ~ a h - q a ~ e n ornep e ~ Ha KopeMHMTe opraHM HRMa ~ ~ H 3a H yepepa M na T ~ K M Bn ~ . p cna3sane~o ~ na cyfjoppn HaqMRTa Ha ropHwTe MeTopw, npes nocnepnme ropMtiMTR cTaHa npMopMTeT M e no-rec~a npM npoHMKeaqaTaa6pouMnanHa Tpaaua - oKono 5%. P e a y n ~ OT a~ npaeMnno ~ npoaepenapwarHocTMKan p ~ a6poMMHan~aTa TpaBMa El: CnTK, Mti~paa6poMM~anHa xeMoparMRpo xeuopamren UIOK; ~ ~ P H T O H M nepwo~~M HMT; X ~ M O ~ M ~ M peTponepwToHeaneH R; xeMaToM.

3 a ~ p e f l a H a K ~ O p r a H M K O H C e p B a T M B H HaCTpOeHMTe O X M P Y P 3 M flPenOPbqBaT~MaMOCTMClHMRanrOpMTbM Ha3a-

KpMTaTa TpaBMa ($MT. 3.70). CT~TMCTWKMT~ 06are nOKa3BaT, Ye npM IlpOHMKBaUO Hapanmatie Ha KopeMa n e 3 n ~ Ha KopeMHme opranu M M a B ~q 90-95%. 3a~oaa n p npoHMKaauo ~ Hoxeao HapawBaHe e n o ~ a 3 a ~ nanapoToMMR. a T ~ K Tnpm ~ K s~ a ~ p n ~ TpaeMa a~a M36poen~~e B pa3pena .Cnelu~o 6 0 n ~ ~ nerer~o HM~ MeTOpM " B WaTa MM CbBKynHOCT C e OTHaCflT 3a a a ~ p ~ ~~ ~F a( ~ OM aM H ~ ~ ~~ pHaEa I~ KORTO a , B Mnoro cnyraMe
MCTMHCKOnpeflH3BMKaTenCTBO3a3HaHMRTaM38OnMTaHa

BopeqMR pMamocTMKaTa. Cnepeaqum anropwnnn roeoP M M M 38 ce6e CM. ABTOP~T TeKCTyanHO M C K a pa nORrepTae ue~tiocrra na nanapoqe~~ez~a~a B ~ BCMCIKM B HecvrypHM cnyvaM - C npOcToTaTa M p#arnocTMrHaTah ~ o q .

Illupo~a~a, n p KopnynetiTtilr ~ MH~MBM~ pasur~pena M B XHPYPM'IH~ TaKTMKa npM a6p0MMHan~aTa TpaBMa. HyxtiaTanocolta,cpepMHHananapoToMMflHRua anTepHaIlpernexqaA~~ nocTpqanm, x ~ p y p r a ~~ p ~ 6 pa aa pewM T M B a B CfleWHaTa KOpeMHa XHPYpMfl. npll HanH'iMe Ha - pa nanapoTohnnpanM (M~ora) #nM He. Toaa po ronRMa ~pbB a KopeMa ce n p c M ~~ T O ~ H M K M~ ce T cnMpa KbpseHeCTeneH 3aBMCH OT TpaBMaTa - OTKPMTa M n H 3aKpkITa. TO. He 6nea pa 3a6paewe M s b 3 ~ o x ~ o c r3a r a(ae~o)peT ~ K Tnpn ~ K oTKpnTaTa ~ TpasMa T P ~ H C ~ ~ Ha ~ acnHpMpatiaTa M R ~pbe. Cnep Toea ce npaw - n p 6onen ~ c orHecTpenHoHapatiRsaHeB KopeMtiaTa nbntla, qaTenna, n e p a n ~ ~pre ~ea w3~ Ha ~BcwrKMKopehno6nac~ H c ~ a 6 ~ xeuopMtiamKa n~a - R0-no~anM3MpaHe HM opratin. P e s ~ a ~ ce p abursa omentalis; npu ~ O K ~ ~ ~ ~anpoewvna, p e a n 3 Ha ~ ~paHaTa H panesw Kanan H npH C e . ~ ~ ~ O M U H M ~ Me3Ofl MP~e TpMTOHeMHO ~ pa3flOJlOXeHM npoHMKaatie - nanapoTouw; opraHM (pyopeny~, KO~OH). Cnep rn~o~ocnac~ea~.qa speMeHHa XeMOCTa3a C e M3BbplUBaT HyXHHTe KOpeKqHH B -n p6 ~o n e ~ B UIOK - 6bp3a ~ ~ B M ~ Ha M paHaTa R M CnenHMR IlpMOpMTeTeHpep: CbAOBe; napeHXMMHMOpraHM; JlanapOTOMHR. r0neMllCT~TMCTHKM r0~0pfTT (A.W. Hamson, K~XM opratiM. 1990; F. W. Blaisdail M D. D. Trunkey, 1993), r e HW90% OT npOCTpenRHMTe C a C ne3MM Ha KOpeMHMTe OpraHM, a C X~pypmrna~a TamMKa npu p a 3 n ~ r n opraHHM ~ ~ e ne1 1 3 r a ~ ~ a ~ noBepeHHe en~o ce noawwaea cMbpTtiocrra. MM He Moxe pa 6bpe o6em Ha TOM ~snoxenwe. YepepwTpeTMpa~eT0 Ha npOHMKBaqMTe HOXeBM HapaHFlBaTe El TOnKOBa pa3HOnMKM, r e TeXHMWCKMTe IlOXBaTM HMR (@Mr. 3.69) e epHa OT ~ a A - n p o ~ ~ ~ oop 6e na rc ~~ ~~~ ~MHOrO e nbTM El.MMflpOBM3aqMR Ha ~eMa ...".(Ha MHTepeCyIlpM ~ ~ ~ ~ O M M H TpaBMa. M H ~ T npM ~ flauMeHTM CbC c~a6#nsaulsre ce npenopbrsaM TpypoeeTe, M ~ ~ W B~ KHMroH M H a xeMopMHaMMKa M nMnca Ha naTortiouonnrnM6ene3~ n~ca.)

Cnew~o ~O~HHVH neqeHue O

Jlanapo~onnw~

Qnr. 3.69. A n r o p w npn urnrestre uapaunsanlw

a ~ a ~ ~M e KnuHureH 3a npernep

C~MH~H 3a M TpaaMa R Ha oTAenwenHaTa cHcTeua M M a npM: - HapaHRmHwRB o6nacna Ha Kpbcra, Ha ~ a a Mnu a Ha nepMHeyMa nnM npH acaKa Tema cbqeTaHa TpasMa (oco6 e ~ aK0 o IlOCTpmanHRTe B LUOK M n H K O M10 ~ )M3WIIOCIBaHeHallPOTHBHOTO; - PeTeHUMR Ha PHHaTa CneA TpaBMa; - xeMaTypwR MnH ypeTpopamR cnep TpaeMa; - Hanuwe Ha ypoxeMaTou B o6nacna Ha KpacTa HnM nepwHeyMa. BC~K n0CTpqaJl M T ~ R fla~ 6bpe M pa3nMTaH 3a MRCTOT0 Ha 60n~a~a, YpHHMpaIl nH e Cnep TpaBMaTa, U B R T Ha ypHHaTa; cnep T O B ~ p ~ 6 8 a f l a ~~ ae ~ apa pa ypMHupa. AKO HRMa OnnaKBaHMR H YPMHHPa 683 3aTPYpHeHMR 6 ~ c ~ p a ypntia M npM HeraTwseH$wan~ane~ cTaTyc no omoweHMe Ha oTAenwTentiaTa cHcTeMa ce nplrelma, r e HRlrna Tpaaua Ha 6b6peqt1, Mexyp M ypeTpa. Aa He ce 3a6pae~, qe npu HRKOH 6b6peqHM TpaBMM KbPBeHeTO MOXe fla C e n0RBM npM cnepaaqM MMKUMM, T. e. npM TpaeMa B o6nacna Ha KpbcTa ~OIIHURT T P F I ~ B pa ~C e ~a6nw~asa. Pas6npa Ce, OTClMTaTC eMO ~ ~ K T M B H M ~ T~~ H 3a H Hal M lMClMeHa OXJlY3BaHMR, XeMaTOMM, M H $ M ~ T B ~o6nacna ~ T M Ha nepMHeyMa, nepMTOHeaJlH0ppa3HeHe. KO~ITO H OT rOPHMTe C M M n T O M U Aa C e ycTaHOBL4, W b n X a M M3BbpWMHeTOHa AOnbnHMn p TexKo ~ 06140 cbcroRHne (~oua, UIOK)H n M KoraTo nocTpmanMRT He Moxe na ypminpa, 3 m b n m ~ e n ~ ce o ~a~e~p~a~pa.

Enronor~~l
HaA-V~UO 6 b 6 p e ~ ce b ~p p e w a npH TeWM TpaBMH

- TpaticnopTHH, TPY~OBH(cpyrea~e, np~mc~a~ 6e~ ) ,~ 0

BM,

CnOPTHM.

H ~ ~ ~ H R MHa H6b6pe~a ~ T o e pe3yn~a OT ~IlpHTMCKaHeTo K ~ n Mp e w n e ~ ~ AMP~KTHO ~e, 3 a c ~ r a OT ~e ~pae~mpaUMR areHT. n p e ~ ~ a p ~ ppeReHMTe ~ e n ~ o 6b6peq~ ce aacRraT no-rec'roM npM no-nem Tpasuu. n p o6paspan ~ ce ypoxeMaToM B caww 6b6pe~ (cy6~ancynap~o) M n M napapeHaIlH0,BnOCnepCTBMeCe pa3BMBaTCKJlePOTMrHMnp0U e C M M HaCTbnBaT B T O P M q H M T ~ ~ A HIlp M OMeHM B 6b6pe~a.

bae@~~aq~~
TP~BMM HaT 6b6pe~a ~ 6~sat: K O M O U H O(He ce BHwaT BaHe Ha napeHxnMa, 6e3 pa e tiapyuretia KancynaTa Ha 6b6pe~a), BbHwHa pynTypa ( ~ a p y t u e ~ ea M 6b6per~a~a ~ancyna), o~~bcea ~a ~6b6pe~a e OT C ~ ~ O B M nep~iqn. R

MaKPOCKOnCKM BbTpeLUHa PynTypa (pa3KbcT ~ ~ H H M ~ c ~ ~ ~ B ~ H M R ~ ~ ~ T o ~ H R B ~ H ~ H ~ ~ H H~P~LU~HMR), ~ ~ o ~ ~ T ~ .

C~~mo~am~a
OCHOBHH CMMnToMw ca: a ~ a ~ ~ 3a e3 TpasMa, a hn~a, xeMaTypw, onMmBau( ce napapetianetixeMaToM.

c $palcrypa Ha Taw. n p clnneH ~ ypap B AonHaTa racT Ha Kopeuacbu(oceppexqa npemnHenumnworeti Mexyp.

lla~ore~e3a
Yspeyqa~e~o e OT KocTHn $ p a m n e ~ Ha ~~ a a a nnM e ~ ~ ~ ~ ~ T ~ T O T ~ R ~ K O HaMHTpaMexypHoToHa~ O B M U ~ B ~ H ~

Cnep K ~ M H M ~ H Mnpernep R ce M ~ B ~ P U J BcnepHMTe ~T nRraHe npM npenbnHeH nuKoveH Mexyp. Paa~bcsane~o c n e u ~ a n ~ 3 ~M pa ~~ Cn ~ ~ ~ B ~ H M R : Moxe pa 6bne eltcxpa- M n M nmpanepMToHeanHo. - exorpa$m~ - T~PCRTce ~ ~ a 3napapeHaneH a, M~~MB, pe$em B CTpyimypaTa Ha napeHxmMa,KoarynyMB neretiCu~rrronnam~a reTo; OCHOBHM CMMnToMu: nMnca Ha ypwa npM ~ a ~ e ~ p ~ - yporpa$un - n p c ~ ce HanMrMe M n M nMnca Ha U M R , XeMaTyPMR, IlepMTOHeZUlHO ApasHeHe, ypOXeMaTOM oTpenmie, nsn~a ~a KOHTP~CT napape~an~o, orep~asa~e ~q cnu$~sa~ M a n w B d n a c n a Ha nepMHeyMa. Ha ypenpa. PM HWM'iMe Ha Bb3MOXHOCT M HeRCHM AaHHM OT fl~ar~om~a rOPHMTeM3CneflBaHMR MOMe fla C e IlpOBeflaTM peHOBa30npllr c b ~ ~ e n 3a u e~ p a e Ha ~a nMKWtinR Mexyp 6e3ycrpa$MR M KOMnlOThpHa aKCMWlHa TOMO~P~$MR. nOBH0 C e M3BbplUBa ~HCTOT~~$MR, KORTOCMryPHOIlOCTaBR 3 q a v a ~ Ha a HecneqManMcTae pa oueHH OT nperne Aa, exorpa$~ma M eKcKpeTopHaTa y p o r p a $ ~ pan^ ~ M M a cbutietiues a ~ p a e M ~pa a HacorMnaqMeHTa K ~ yponoruM ~ H O oTAeneHMe. np# nmca Ha paHHH 3a CTP~KTYPHM

MnMo~x~bpn~~~a~osa~a3a~exyp~an

~ o 6 o n ~ noeeAeHHe n ~ o H neveHHe
~O~HMR C e T TpaHCflOpTMpa ~ O ~ H M ~ sH ae Oe ~ e ~ ~ e .

A0 ClleqMaJ'lM3MpaHO

Cnew~o ~ O ~ H H ~neqeHwe HO PM lle3MR Ha nMKO'lHHR MevP - He3a6aBHa OnepaU M R , PeCn. HaCOclBaHe KbM ClleqHallMCT. 1/13BbpLUBa C e wee Ha uexypa, ocurypRsa ce ppetiax Ha ypuHaTa ( q ~ c TOCTOMMR) M ppetim Ha n a p a ~ e 3 ~ ~ a npocTpaHcTBo, n~o~o a npM MHTpanepMToHeanHa ppeAa - M Ha KopeMtiaTa KYXMHa. P ~ ~ H M M M~ ~H ~T MMR~ ~ K T ~ nereHMe. ~ M ~ H O

K O H C ~ ~ B ~ TM npM BHO neKocTeneHHM TpaBMM 6e3 pa3~~ ce n MHTpapetianeH M n w napapeHaneH xeMaToM. B~ntorea: ~OKO KpbBOCnMpal ~, J#l, ~ H T M ~ M O T M M ~M aKTHBH0 WlHHMVHO npOCneARBaHe (flMype3a, MHTeH3MTeT Ha
KbPBeHeT0,nOK~HaTaHaXO~KanOOTHOlLleHlneHanapapeHanHMR xeMaToM, K ~ ~ B H no~asa~enn), M Kamo M exorpa@CK0 npOCnemBaHe Ha CbCTORHMeTO Ha 6b6pe~a M

J l e m Ha ypeTpaTa ce nonyclaea npM TexKM TpaticnapapeHanHoTo npocTpaHcTBo. M TPyAOBM TpaBMM, KaKTO M npM ~IITOBM TaKMBa, Onepama~o-np~ HanMclMe~ a r o n ~ ~ a ~ b ~ M p~eM u r ~nOPTHM a ~ a r e fc ~ npn o a q e q o n m a ~ eHa " reTana ~bpxy ~~bp BbHWHa PynTypaM n M IlpM OTKbCBaHe Ha 6b6pe~a OT cbp0BMR nepMKyn M n M npw K O H K B ~ C ~ ~HaopraHa. MR M~~paone- npepueT. P a T M B H OC e M3BbplUBa: Bb3CTaHOBRBaHe Ha qenOClla Ha 6b6pe~a, OCUfypRBHe Ha ApeHEM Ha YpMHaTa ( H ~ $ ~ O C T O MMR), Apetiax Ha napapeHanHoTonpocTpaHcTBo. He$peKTOMMR C e M3BbpUaC a M O npM HanbnHOpa3pyWeH6b6pe~ w n Mn p~ ~p a e na ~a npepeap~~en~o a ~ a r w r e ny ~e op e ~ e ~ 6b6pe~. npn BcnclKnonepaqnn- peaHnMaqmM ~ H T M ~ ~ K T ~ ~ M anHo nerewe. K~HHM~H CM HM T~~ OMH Ha ypeTpantiaTa n e 3 ~ ca ~1 XapaKTepHM: ypeTpOpaMR, HeBb3MOXHOYpMHHpaHe M KaT ~ T P M ~ ~ ~o6pa3y~a~e MR, Ha nepMypeTpaneH ypoxeuaTOM.

CnOBHO fla C e M 3 B b P W H ype~pdrpa$MR, K O R T OC b C CMfYPHOCTnOCTaBRMIlH OTXBbptlRAMarHO3aTa.

n p HanMrMe ~ Ha ronm xeMaTou, oco6e~o HapacTBau M / M ~ WHeBb3MOXHOCT fla Ce

IlMnMpa T e C T U C b TM n H

TMM3aqMRMaKTMBHOXMPflMClHOnOBeAeHMeCpeBM3MR H aC K p O T y M a M Cb~bpXElHMeTO My. C~UJOTO Ce IlpaBMM IlpM OTKPMTM paHM H a cKpoTyMa Te nop,nexaT Ha cneuriia pee~3w.

O T K ~ ~yepexqaHMq T ~ T ~ ca penlta, p , ~ a r ~ o s a e~ a m a , a cbuo M noaep,eHHeTo - nbpenrHa xMpypmrHa 06pa60~~a. TR T P R ~ B pia ~ Ce M 3 B b p W M OT C l l e ~ M a n M C T .

A O ~ O ~ H M IlOMOU V H ~ Te~B OBllwRBaHe Ha KbpBeHeTO nMraTypa Ha K

~ P B R cbp,, ~ KnaunMpaHe, npOKCMManHaTaraCT OT WeHa.

npMcTRraHe Ha

A~ar~o3a e~nectla: a a~au~e3 3a a Tpaekla M npu ornep, n nannaucln ce ycTatioaRsa yeenweti M 60ne3HeH C K P O ~ 3arnweH , pene$ Ha KoxaTa, u e e m e OT ceeTno p,o ~ M H O C M Hn . p npernep,a ~ TPR~B p,a ~ ce npoeepM ~ a n w TecTMcbT ce nannnpa nnu He. AKO ce onwnsa - Ra ce ycTaHoeM MMa n M npoMeHM (60ne3HeH, yaenlcreH, p,e$opM M ~ ~ Hnpocnep~sa ). ce AwHauMKa-raHa xeMaToMa. CbcToRHMeTo Ha TecTMca Moxe Aa ce npoeepu M c exorpa$n~.

3 a ~ p n ~ TpaeMM n ~ e ca cbuo pep,KM M HacnneaT OT AMPeKTHO YBpeWaHe - K ~ T ~ c T 06xaaua~e ~ o $ ~ , OT TpaHCMMCMR, no6oci. AKOXeMaToMbT e ~ a n Mb He ~nporpecMpa
-KoHcepsaTuatio nerewe (nep,,no~oci, npucTerHaTanpeBpbsKa, KpbBOCnMpa~M, eBetiT. ~HTH~#OTHL(M). npll rOnRM xeMaToM onepaTHaHa ~ ~ B M ~ M R . M 3a nallmeti-ra, M aa neKapR e T. Hap. $palcrypa Ha rneiia Toaa e pynTypa Ha TyHMKa an6yr~-

A~~M~TM~HM -

Hea n Kopnopa ~ a a e p ~ o s npes a speMe Ha

TpasMa (PRSKO o t - b ~ a ~ e X) . ~

epeKqMR OT

M ~ T Oce M paaema ~T more 6bp30 M e ronm, nporpecMpa K ~ C MK ~ O T ~ M nepMHeyM, , H W C M M $ M ~ ~ rne~b~cep,e@pu~pa. T~, f l e r e ~ ~ BKJ-IIOe~o raa no~oci,neu, Kpbeocnlrpalqu, cTerHaTa npeepbs~a, ~ H T M ~ M O T M ~~M O. - R O ~ P M oco6e~o , K b C H M , p e 3 y n ~ AaBa a~~
OnePaTMBHOTOne'ieHMe C IlbPBM'lHO Bb3CTaHOBRBaHe Ha yapep,eHwTe CTP~KTYPM, BM. H ypeTpaTa, aKo e pasmcaHa, T. e. HacoqeaHe m~cneqmmcT.

cbo6ue~~ OT e ryW(AecTpaHHMH nevaT 3a

anapawo

M e A M K a M e H T O 3 H O IlOflflbpxaHe Ha XM3HeHMTe $)IHKL(HM

a h C~ .M03b' a iHa ~ M b p f s i l p ~ ~ b n X eHa ~M C e e U M M q M . L(en~a e XMBMRT nnop,B yrpo6a~a ci Aa AouMrtie p,ocTaTbqHa 3 P R n O C T M pa MMa W a H C )Ja Ouenee B M H K ~ ~ ~ T O P H H ycnoanfl. 3qara~a Ha ruHeKonora e uaKnDrmTenHo Tpyp,Ha, 3au0~0 TO^ ~ p ~ 6 na ea npeueHflBa He CaMO M H O ~ O O ~ ~ ~ eT0 Ha TpaBMMTe M Hah-pa3IlMclHM~e CpOKOBe Ha 6peMeHHocrra, HO TaKa cbqo M p,an~ ce Kacae sa T. Hap. "cepbxqeHeH nno~" u n 06pa~H0 ~ - cnyraci Ha HeXenaHa 6pe-

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Bar~ep E. A. X H P ~ ~noapewenclh MR rpy~1t.1.M,, Meflwuu~ a1981 . Toflo~oB,K., neBuqapoB cbI oM XMpyPmR, C., MefllrqMHa M @M3Kyn~ypa, 1990 Blaisdell, F.W., D. D.Trunkey.AbdominaItrauma.2nd ed.9 1993, G.Thieme, Stuttgart, New York, p. 422 Harrison, A. W. (Section editor). Blunt abdominal trauma (Section 5). - In: McMurtry, R. Y., B. A. McLellan (editors). Management of blunt trauma, 1990, Williams l ? Wilkins, Baltimore, etc. 235-296

n,

Heberer, G., R. J. A.M. van Dongen (ed.). Vascular Surgery, Springer-Verlag, Berlin, 1989 ~laue; P. ~tumpfes undpenetrierendes ~auchtrauma-ln: Beger, H. G., E. Kern (Hrsg.). Akutes Abdomen. G. Thieme, Stuttgart - New York, 1987, 129-138 Kozuschek, W., H. B. Reith (Hrsg.) Das Polflrauma, Karger, Basel, etc., 1993, p. 539 Robert, Y. MC. Murtry, Barry A. MC.Lillan. Menagment of Blunt Trauma, Williams & Wilkins, 1990, 186-206 Tumey, S.Z., A. Rodriguez, R. A. Cowle~. Management of Cardiothoracic Trauma, Williams & Wilkins, 1990

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nponio3a~a Ha e n w $ ~ 3 u o n ~ aM ~ eeeHTyanHnTe ~e 6bfleq~ PaCTeXHM CMYqeHMR (OT KOeTO 3 a B M C R T nPHOPM-

TeTMTe Ha cneluHoTo n e ~ e ~ uce e )onpeflenm ocHoeHo OT

2 $a~~opa: 1. C ~ e n e Ha ~~ flwpemtio a yepemqaHe Ha repuMHaTwB H M T e KneTKM Ha pacTexa no speue Ha TpaBMaTa. 2. C ~ e n e Ha ~~ yepemqaHe a Ha K ~ ~ B O C H ~ ~ ~ ~ R B ~ H ~ T O Ha e n u $ m p ~ u fKoMnneKc. l 3a~0Ba M~ I ~ M $ M OT ~ TMn M 1 Mo 2 nOKa3BaT ~M~ n0 HT~ npMHuHn ~ o 6 p a npomosa npM T U XKP~BOCH~~~~FIB~H~TO Ha enw$ma~a He ce Hapywaea. Tnnoee~e 3 M 4 ca TMnMV H M Bb~pecTaB~Ll $palcrypM C H ~ ~ Y W ellM$#3~0 ~ H O KpbBOcHa6flRBaHe M n o - ~ 3 p a 3 e ~ flnpemtio o yspenSqaHe Ha reP M M H a T M B H M T e WleTKM M CneflOBaTenHO npOrHO3aTa npM TRX c n e p ~ ~a a e npeflnaanclea, a n e r e ~ ~ enpoeefle~o ~o B OnTMMNlHM CPOKOBe.

II. M ~ Kn M e n a c T H w KOCTH, n o ~ p l r c r~ ~e6en

H 3flpaB IlepMOCT

no Ta3M IlPMCIMHa, OCBeH $pCIlcrypMTe, KOMTO Ce ~ a 6 nDRaaaT H npw B ~ ~ ~ ~ C T npM H M AeuaTa T ~ , ce ~a6nmflaea~ M CneflHMTe c ~ ~ ~ M $ M $ ~p HaG ~( lyp~:

rone~~ OcTeoreHemveH m noTeHquan M M a M HeramB H MC T P a H M MHflYqMPaH O T TpaBMaTa CBpbXpacTeX Ha pbnMTe T P ~ ~ ~ C K O T C T W M ,OCO~~H npM6eflpeHM O $palcryPM, c HacTbneaHe Ha HexenaHoyflbnxacaeatie Ha K ~ ~ A H M M cMy-retia noxofllta.

IV. r o n ~ xpywnHa ~a KoMnoHetma Ha KpaHqaTa

Te,

a)

HenbnHM $palcryp~ TMn .3ene~a npbv~a": nepw

KotiKaatiaTacTpaHa Ha aHrynaqMma ocTaaa sflpae, a $palcrypa~aHa KopTeKca e OTRM cTpaHaTa,

O C ~ OTRM T nOAnOXeHa Ha OnbH.

npM Te3M $ ~ ~ K T ~ HMKOra PH He HapMraT oKynTHM $palcryp~H a h - r e c ~ ~ n~ oe~ a n ~ HacnnBa CKbcmaHe. Te ce HaMecTsaT neciio. ca ~ a a o 6 e p p e ~ a maea, ~ a KonRHHaTa M naaTHaTa cTaeu, 6) # H $ ~ ~ K ~ $palcrypM, HM: npM K O M T O 3flpaBMRT nepMKbAeTo ce Ha61'1DflaBa~ oKynmM x o ~ g p a M nn M ~ ocTeoxo~ OCT ocTasa M B W ~ O HHTaKTeH, KaTo ce nonyqasa caMo ~ f l p a $palcrypn. n~~ B rpynaTa HaoKynTtiMTe $palcryp~ ce B ~ M B Ha ~ H cn ~o ~ m o 3 a ~ npM a ~eTa$MaHa no~anM3aqMR) IlpM'iMCnUBaT M POpOBHTe ~ ~ M $ M ~ M o ~ M ~ M . #nu $~cypa Ha KopTeKca ( n p p ~~ a $ v s ~ na o ~ a n ~ 3 aM q~~) Te3~ YBQepM npOTMVaT O ~ M K H O B ~ HC O KnMHMrHaTa
cy617epMoc~ane~ xennaTou.

MHO~O OT TOBa, KOeTO CTaHe KOCT npM Bb3paCTHMnpM BeyaTa e xpywn. O p a l c r y p ~ a ~ nMHm a Moxe fla npeKocma ~ 3 ~ xpywntia n o s o ~ aT .~KM $palcrypv B~ ce

.
~

KapTMHa Ha C T a B H O 3aCRraHe (KOHT~~MO, ~ ~ M c T o ~ ~ M 6e3 o), B) IlnaCTMClHM ~ ~ $ O P (deviatio): M~I& ~ M IM ~ $ M ~ ~ P H M peHTreHOnOM.IHa CMMnTOMaTMKa. O K ~ ~ T H M $p T a~ ~~ypM $palcryp~, KOMTO ce x a p a ~ ~ e p ~ 3 obeaHe ~pa~c Ha upnaTa ca recT C ~ T H M K Ha n y c a u ~ u ~ BeAeTcKaTa ~ b 3 p a c ~ . nop4e~nsa~e MM ~o Moxe pa poaefle no ocaKaTmaqM ~ b n r~ a p b 6 e c KOCT, ~ a 683 p a 3 ~ b c e a ~ Ha enepMocTa n 6e3 nocneRcTswR. nOKaflM3MpaH XeMaTOM.

176

Oco6enocmu na I

~ ~ ~ ~ M B U gemcka I ~ I U

Baspacm

MCaHMTe O C O ~ ~ H O C T Ha M peaKqMRTa Ha peTCKMfl 3bM KbM TpaBMaTa H3MCKBaT CnelllHaTa MeAHqMHloqpa6bpe oco6e~o n p e q ~ 3 BTa3M ~ a Bb3paCTOBa D ~ K T O,cnew~ocfl P ~ T e OT ronmo 3 ~ a ' i e ~ npM ~e ne'ieHHleTo Ha $patcryp~~e M nyKcaqnMTe B peTcKaTa Bb3paCT. Toea e ycTaHoaeHo oqe OT X ~ n o ~ 4 p a. a np. ~ H. e., KOAI ro n w e : . H ~ M ~ C T B ~ ~ Hp ~T ~O 6 pa a acraHe, aKo e DDJMU~(HO, Eeltiara, poKaTo ($pamypa~a)e oqe Tonna, M n M TOnKOBa 6bp30, KOnKOTO e Bb3MOW0, 3alL(OTOTOBa q e 6bpe 6bp30 M necHo 3a OnepaTopa M Mtioro no-uan~o 60ne3HeH0 3a naqMeHTa, aKo ce HBB~PUJM npepM pa HacTbnM 0 ~ ". ~ ~ "
S ,

O T ~ M V npomoaa. H~ KP~BHOTO HaMecreaHee HeHyxtio.

40

OT3ByWWHe Ha 6 0 n e a C ~M ~ H A P O MC e n0CTaBR MeKa M M O 6MnM3a4MR T M n .OCMOPK~".

YCIOXH~HHII

".
m .-. -

PR,~KQ, HO onacHo ycnoxHeHMe e KoMnpecwma Ha a. subclavia. f l ~ a m o c ~ u ~MY a ~M a~ M C K B cpaatimatie ~ Ha qseTa, TeMnepaTypaTa, KanMnRpHMR $ ~ H O M M~ nyncaqw H w e Ha aa. radiales Ha pBaTa ropHM K P ~ ~ H M K ~ .

II.@patnyp~ Ha cKanynaTa
J l o n a ~ ~e a KOCT, ~ a pa3nonoxe~a noA 3 ~ a ~ ~ no ~ e o6e~ MycKynHa Macs. OpalcrypM C e IlOny'iaBaT MHOrO PRflKO, O~IIKHOB~HO npM pupetcreti ypap c ronRMa KMHeTMCriia eHeprMR.

YRDI

Opal

MeXaHM3MbT Ha TpaBMaTa e M n M AMpeKTeH )'flap, M n M IlVaHe BbPXY IlPMBepeHOTO KbM TRnOTO paM0. Toaa C a eAHM OT H ~ ~ - ' ~ ~ c$palcrypM T M T ~ IlpM peqaTa.
SecToTaI H npsopmm

no1 ~e'ie OT nonoBMHaTaH a 10 roprIHM. HaA-'iec~a~a popc

. . a

B ebapana non

pa e cb40 ~ a 3 ~
ClleUIH0 ~ O J I H H ~ H O II~lleHHe
TO

nd N I I V C I M ~ ~ T ~ .

. . " . A

hacH@IKaqlr~

Cnopep ~ ~ H T ~ ~ H O 06pa3 B M R$palcryp~~e ce ~ n a c u $ ~ ra: 1palcrypMB aKpOMMallHMR ~ p a i ; lpatcrypki Ha p ~ a $ ~ s ( a~ ~aa fi-rec~~); lpaKTYpM B CTepHEUlHMR ~pah.

n p u~3 0 n ~ p a Qpatcryp~ ~ ~ ~ e Ha nonaTKaTa ne'ieHuece cbcron B MeKa M M O ~ ~ M ~ c ~ npeepba~a ~ M R Ha Desault 3a 3-4 cepMvqn.

Ill. Opalrryp~ Ha xyMepyca

Opatcryp~~e Ha y e p y c a MoraT Aa M M a T pa3n~'i~a no~an~3aq cnopep m ~ ~exa~uama Ha TpasMaTa c KopeHHo
pa3nUVHaWlMHMKaMne'ieHMe. O'iep~asa~ ce 3 RCHO p a 3 r p a ~ ~ cOHM: le~~

- $palcrypt4 Ha IlpOKCMMMHMR ~pafi;

dR K ~ ~ ~ H KbM M K TRnOTO M

- $patcryplc Ha p ~ a $ ~ s a ~ a ; - CyllpaKOHflMnHM$patcrypM. '

o saeepe~~e.
VllGYlnU

1. OpalrrypH Ha IIpOKCHMaflHHR XyMepyC

Peayma~ OT popoea TpaeMa Moxe pa e ~ ~ M $ M ~ M 3a OT THn I no Salter M Harris, KORTO npoTM'ia c KapTMHaTa

Te:

Oco6e~ocmu Ha mpa6mama 6 gemcka 6b3pacm

177

Bbe Bb3paClTa 1-15 TOAMHM Te3H $paKIJ'pM nOKa3BaT ABaRCHOOClePTaHMTHna: - ~~$paTyGeplcynap~n M~T~$H $~ pa HqM p u npn peq a ~ 12 o r.; -~ ~ M $ M ~ M OT T O M n ~II M npM ~ Reqa M HW 12 roAMHu.

SHB~ pea T eMna - KOCM M cnlcpanoeMgHw @palcryp#. T ~e KMunepaTMeHo npaeMno ~ s c n e ~ a a Ha ~e @YHK~o q w a t i a n. radialis, nopa,qw ~ e r o ~ o ~ o a ~ a ~ o ~ ~ noxeHMe B ~ a 06nac~; 3 ~ 3ac~ra~e Ha ~o TO~W HepB e cneqcl@nv~o ycnoxtiewe Ha ~ e $palcrypw. 3 ~
@MKCM~~ Ha H KpahHMKa ~ KbM TRnOTO.

M e x a ~ w Ha ~ bnonyvaaatie ~ eM n M p#peKTeH ypap, M n M na,qaHe ~bpxy OTBeAetiaTa pbKa. Tom ca cpaetiwenH 0 Cl eCTH $palcrypM. n o p q ronmaTa ~ Maca Ha m. deltoideus He ce nann#paT KpenwTaqwM. K O H B ~ H ~ H OpeHTreHoea H~~H~T AMar~ HOCTMKaeflOCTaTb~Ha3anOTBbp~amHe HaflMXHO3aTa.

rpb~Ho-pbKaBeH MnC (C M n M 6e3 P ~ ~ O ~ M L M ( n M MR runcoea U - W M H npM ~ no-rone~m~e peqa.

M ~ H Y pen03M~MR ~ H ~ MH M O ~ H J ~ M ~ ~ ( ~M M R~ C O ripeB~ Bpb3Ka no Desault npM M ~ T ~ $ M ~ $paKIJ'pM H M T ~A 0 12rOAMLUHa Bb3paCTM n H rPbAHOPbKaBeHMnC B IlOIlOXeHMeTO ,,CT~T~R Ha C B O ~ O( ~ ~~ KT C~ T "~~~~M CH IY ~K -~npM MR) WonecqeHTHnTe ~ ~ M $ M ~ M OT O T M n ~II. M~M A~petm~ cKeneTHa a ~KCT~H~ -M npM R TPYAHII, HecTa~M~H MM HO , ~ O $ ~ ~ ~ $palcrypM. M~HTHM Ma~yan~ pa eno3~q~ Mn neptyaHtia @MKC~L(IIR C Kirschnercn~qbt-np~ nonMTpaBMaM H ~ c T ~ ~ M$patay~ H M P M*

Cnopep M ~ X ~ H Ha M TpaaMaTa ~ M ~ ce Renm Ha 2 o c ~ o BHM THna ($HT. 4.2): - eKCTeH3HOHHM (98% OT cny'iall~e);

- $J~~KCMOHHH.
EKCT~H~MO C)QlpaKOHAHJlHa$palcrypaCe HH~T~ IlOny-lab p x y ~M a n M~ npepMMLuHMqaTa ~a c pa31-bHaT JlaKbT, npM K O e T O OneKpaHOHbT C e a6~m BbB f0SSa olecrani - ~ak-cna6a~a cTpylcrypHa ram Ha xyMepyca.
I M npM naF(aHe~

Cnope~ cTeneHTa Ha s a c ~ r a ~ Ha e nepMocTa ~ e $pamyp~ ce penm Ha: - C T ~ ~ M ~(@McypM H H M Hepa3MeCTeHM $paKtypM C HHTaKTeH ~ ~ ~ M o c T ) ; -OTHOCMT~~HOCT~~M~H (M c a ~ brnoeo o pa3~ec~~a sanase~ 3 ~ nepuoa); e ~ - H ~ c T ~ ~ M (TeXK0 ~ H M pa3MeCTeHM, HanbnHO pa3KbcaH nep~oa).

178

Oco6enocmu na mpaBmama B gemcka Bbspacm

p a 3 n ~ OT ~ anaKbTHaTa n y ~ c a q nM ~ .~ W I I O ~ WBT ~ ~ ~HO O e oqe n p fl060nHMrHa~a ~ noMo4Aa ce ycTaHoaM~ R O B M R cTaTyc ~aa a c e r ~ a K~ ~~ ~~ ~ lH Hareeaqa~a M K . ocrpa McxeMMR ce x a p a ~ ~ e p ~ c 3 6017~14 ~ p a B MycKynwTe pncranHo M M ~ B MRCTOTO ~ H ~a$pamypa~a, c 6nepoc~ M n M ~ u a ~ o~a 3a pbKaTa, O T C ~ F I ~ ~M Hn M o~cbcreaqnync Ha a. radialis, n a p e c ~ e snapan~3~. ~~, B a x ~ e, o &are, npepn KaKBoTo M Aa 6 ~ n o ~acneflsa~e, naKaTHaTa cram nbpso Aa ce
M M O ~ M ~ M ~ M ~ ~ .

n p e ~ p b a ~ a w n ~ e ~ c ~ e ~ 3 ~ p a npeepba~a ~e~ana~ no Blount. AKO HRMa nopo6pe~~e B paMKme Ha 112 h - c ~ a 6 ~ n a ~ p a Ha ~ eapatcrypa~a rpes nepKyTaHHa $ M K C ~ ~ (~ MK RO TaKaea He e 6ma ~ 3 ~ b p w ~ eo ~~a o r a sM an ) M nocTaeme Ha K P ~ ~ H M HaKflMpeKlHa ~ eKCTeH3MR. AKO tima n o f l o 6 p e ~ B CneAeaUMR ~~ 112 h, ce npeflnpneuaT: -n o f l p o 6 ~ flMXHOCTMqHM ~ M3CJleflBaHMR- aHMOrpa-

P ~ H T ~ ~ H O~acnenea~e B O T O n o ~ a 3 Tuna ~ a Ha $palcrypaTa cnopep onMcatime t m a c ~ $ ~ ~ a f ql~ pu~ cbuHeHMe . aacbfloa npo6ne~ ce ~anara Aonnepoeo ~ a c n e ~ a M an M ~e a~~orpa$cl~.

- onepaTMBHo neretiwe - ~ ~ B M ~ Ha M a.Rbrachialis M $~CL(MOTOMMM Ha npeflMMWHMUaTaM KMTKaTa. @ ~ C ~ M O T MMFlTa npM fleqaTa He 6wea fla C e M3BbPUJBa no-KbCHO OT 6-TMfl h OT MOMeHTa Ha TpaBMaTa.

B fl~cTanHaTa qacr Ha wepyca, B HenocpeflcTseHa 6nM30~T 1 0 $palcrypa~a npeMMHaaaT 3 - ~ e rnaeHM Hepaa Ha rOPHMR KpahHbl~ M a. brachialis, 3aTOBa M CyllpaKOHflMnHme Qpatcryp~ c a 6ora.r~ Ha ycnoxHeHnR. OT KohnnpeCMR Ha $ p a r ~ e w n M ~~ xeuaTou, npH s a ~ n e q e a ~Ha e C n e q ~ a n ~ s ~ p nevetiue a ~ o ~ oB ~ B M C M OT TMna Ha $paapTeplnma M n M npM HenpasMntio MaHMnynMpaHe uoxe fla mypaTa: ce nonyw TpaeH cnasb~ M n M~ p 0 ~ 6 0 3 Ha aa. brachialis c - cra6nne~ TMn: runcoea M M O ~ H ~ M 3a ~ ~3~ ce Mp Rm nOCneflBa4 KOMnapTMeHT CMHflPOM Ha IlpepMMLUHMUaTaM W; ~ M ~ KpaeH T O eTan e onMcaHaTa npea 1881 r. OT - OTHOCMTenHO C T E I ~ W ~TMn: ~ H MeKa M M O ~ H ~ M ~ C ~ ~ M pbKaTa, R Richard V O n Volkmann OCaKaTRBaU@ MCXeMM'iHa KOHTpanpeapbs~a no Blount 3a 3 CepMuuM; q p a . Yepepme Ha HepaMTe ca O ~ M K H O B ~ HnpexonHM. O -H ~ c T ~ ~ W TMn: I ~MaHyXlHa H pen03MUMR n0fl o6qa Hai-rec~o ce 3acRra n. medianus, cnepaaT n. ulnaris M n. a~ec~H e nepKyTaHHa 3~~ @MKC~~M CRKirschner cn#uM; radialis. npM HeyCneX - AMpeKlHa eKCTeH3MR M n M OnepaTMBHO nevewe. Ha onepaTMBHoneveHMe noMexaT M OTK~MTMTe cynpaKoHpMnHM $pamyp~. np0lIi03aTa Ha CynpaKOHflMnHMTe$ ~ ~ K Te~ no6pa PM ~ P CbMHeHMe M 38 Ha'ieBaua M C X e M M R M pa3BMTHe Ha npM npaeuntioneveHne 6e3 ycnomtteHMR; ~ ~ ~ B M T M Ha ~ T KOMnapTMeHT CMHAPM C e M3MCKBaT eKCTpeMH0 CneWHM cubitus varus e K ~ C H O KO~M~TMCIH YcnoxHeHMe. O uepm - nbnHo pa3qensa~eM oTsapRHe Ha MncoeaTa

OcoLenocmu na m p a B ~ a m a B gemcka Ba3pacm

179

IV. Opatrrypu B o6nama Ha natma-ra naea

.CbxUIeTe MnaMR XMpypr, C I M ~ T OnbPBM cny'iah B npaKTnKaTa e $pawypa oKono n a n ~ ~ r"e a ~ ~YMM, MspereHM npeAM 200 ropnHM OT a ~ r n ~ h c xMpypr w ~ sir Astley Cooper, c a aanMIH# M po pHec. Cnopep no~anusaquma CM $pamyp~~e B o6nama Ha JlaKbTR C e flenFlT Ha: - Cynpa- M TpaHCKOHflMnHM $palcrypM Ha XyMepyCa ( ~ a l - ~ ~ C KOMTO T M TBe'ie ~ , pasrnepax~e); - ToTanHa en~$n3nonn3a Ha pMcTanHaTa xyMepanHa enw$~3a (MHO~O pRqlta ppefla, nonyraea ce npeAMMHo npM P O A O B MT ~ ~ B M M ) ; - $palcrypM Ha PWMmHMR KOHAMJl Ha XyMepyCa (4-TO MRCTO); - Ha YnHapHMR enMK0H~Mn Ha xyMepyCa TO MRCTO no recro~a); - Ha rnaeaTa M u l ~ l ~ Ha a~ pq a ~ y c (2-po a MRCTO); -HaoneKpaHoHaHaynHaTa; - Ha processus coronoideus Ha ynHaTa.

M a C T H M Bb3rllaBHHVKH- C ~ ~ ~ ~ H $ IlO U nynyHHO V H O IlpOCBeTnRBaHe B ~ M C T ~ ~ H oTpen M R Ha xyMepyca Ha n p o $ ~ n ~ CHMMKM, K O ~ T O e MHpMKaTMBeH38 XeMapTpO3a - CneflCTB M eOT HRKaKBaBbTpeCTaBHa$palcrypa. H npMH ~ R - M ~ ~ K o TO CbMHeHue 3a naKbTHayepena mtor K ~ M peHTreHoBaTa AMamOCTMKa e CpaBHeHMeTOC R8-rpa$MRTa Ha 3IpaBMR JlaKbT; C b q O CTpec-rpa$MMTeM R ~ C K O ~Bfl M MHaMMKa. RT~

Pnn~ayepepa. nonyvaea ce npu ponoe~ TpaeMM M no A~amoc~e ~~ TpyflHa IlOpriqM OTC%CTBMeTOHa OCM$#K~~MOHHM Rppa B Ta3M Bb3paCT, a WMHM'iHaTa KapTMHa ~ a n o ~ o JlaKb6~~a THa nyKcaqMR; nereHneTo ce ocaqecTBRea B cneuuanu3MpaHa WIMHMKB.
M ~ K ~ I O ~po ~ H 2-ropnw~a M ~ ea3pacT.

e n ~ 4 ~ 3 a ppepa. p~a Cnopep cTeneHTa Ha 3anaaeaHeToHa BbTpecTaeHaTa x p w n t i a .ram OT naTepanHnR oTpen Ha condylushumeri n Bbmomoma 3a p a s ~ e c ~ a a ~ e , e $pawyp~ 3 ~ ce penm Ha:

h. 4.3. Cxwa na cporosen Ha nonsa w a ac@nuaqmnnwre

B a 6 n m Ha nabman crasa: 1 --anew (X 3 r., u 5 r.), 3 -yn~apu ennawnn (X 4 r., M 5 r.), 4 -oneltpanon (X 6 r., M 8 r.), 5 -rpoxnea (X 8 r.,

ROW
M 10 r.),

(X C8 N., w 1 r.), 2 -mass Ha m 6 -mill!eH e n r r o m (m 9 r., M l1 r.)

180 m Oco6enocmu na m p a 6 ~ a m a B gemcka Bwpacm

Ulnr. 4.4. Pemenonmno ~mlranonrsnnsrnm na nalarnm mes: a - n a m n b

~6 , bran na Baumann, B

- npa4lmenjwa$mnoennqmen srsn

- C T ~ ~ M ~($MC~PM H M M ~ e p a a ~ e$ cp~ ae ~~ ~y~ p~); - OTHOCMTeIlHO CT~~HJIHM( C ~ C3ana3e~a XPYuvflHa

na~~a);

r p a $ ~ ~M~cnopep a , no~mw3aqw~ Ha ~a xeMaToMa: naTePmHO npM Milch I M MepUmHO npM Milch 11.
fl060n~n~ n0 o

- H~CT~~MIIHM ( p a s ~ e m M e po~npa~u) ~~ ($Mr. 4.5)

Hec~a6lmHMTe Ce AeIlRT OT C B O R CTpaHa H a TMnOBe no

~ e ~ eneqeHHe ~~e

Milch:

kl~06MflM3a~Mfl Ha naKbTR B PMMAHa . . . UIMHa.

- TMn I = IV T M no ~ Salter & Hams;

- T M 11 ~ = 11 T
TM~O
M~ ~~ M $ M ~ M O I I M no ~ ~ salter & Hams. B no ~ Mkh T ~ Ce pUartiOCTuqMpaTOCBeH Ha Rij-

Cne~uuo ~O~HHVH neqeHue O

K~MHMVHOTO Jle'ieHMe 3 a B U C MOTTMna H~CTEI~MI~HOCT:

-C T ~ ~ M ~ $palcryp#: HM MnCOM U

M ~ H ~ ~ M ~ ~ ~

anr. 4.5. Cxewa na $panypars na m n r m m

m : a - 3ppasa m n n a nama (mnoc~rrenno m6mna); 6 - prseana x m n n a nama (neera6nnna)

OcoCe~ocmu Ha mpaBmama B gemcka Baqacm

18 1

- OTHOCMTenHO C T ~ ~ M ~ (fleplcyra~~a H M (PHKc~~MFI,

mnc);

Knacw4n~aqn~ - H ~ c T ~ ~ M (pen03MqMA ~ H M M llepl<yraHHa $ M K C ~ ~ # F I Mnlr onepaTHsHo neve~ne). OpaKTyPWTe Ha YnHapHMA eflMKOHAHJl IlpeACTaBnFIBaT aByn3HOHHM ~ I ~ H @ H ~ M o (~ ~ M~ ~o M $ w ~ M o IlOHe~M~M x e TaM e o 6 q o ~ o aanae~oMACTO Ha t $ n e ~ c o p ~ Ha ~e KMTKaTa H npmwe. Cnope~ cTeneHTa Ha p a 3 u e c ~ ~ a ~ ce Aenm Ha 4 THna no WatsonJones: T M n I - Hepa3MeCTeHM M n M C A0 2 MM pa3MeCTBaHe; Tun II - A M C T ~ H O pa3~ec~m noeere ~ e OT 2 MM; T M n 111- RMCTWHO pa3MeCTBaHe Ha HMBO Ha CTaBHaTa qenKa; Tnn I V - n ~ ~ a p q e p a Ha u~ enMKoHpMna ~ B cTaeaTa npM nycaum. K ~ M H M KapTnHa ~ H ~ Tce ~ ~ a ~ ~ $ e ccxapamepeti ~ ~ p a OBmeH OTOK HanaKbTFl OTKbM MeflManHO, I l O p ~ M M3BbHCTaBHOTO pa3flOnOXeHMe Ha YnHapHMR eflMKOHflMn. ABMxetilrlma MoraT Aa 6 b ~ sana3e~n a~ M He oco6e~o 6onesHeHH.
AMarH03a~a e TpypHa 3a HecneqManMcT n p nauMeti~ flOA 4-ropH~Ha Bb3paCT nOp4H OTCbCTBMeTO Ha OCM$MK~~MOHHO RRPO.
TM

4ecm~a
Hapema~ ce Ha 3-TO MACTO no YecToTa cpep n a w H M T e @paKTyPM M MHOrO C e lC T OC e CbfTbTCTBaT OT naKbTHa

l l e r e ~ ~~ eB~MoC M OT TMna Ha yepepaTa: T M n I - mflCOBa H M O ~ H ~ M ~ 3;14 ~ ~Cefl HM R M4M; T M n 11, 111 H IV - OnepaTMBHO ne'ieHMe C BbTpeWHa @ M K C ~ ~ MC F2 I Kirschner Mrncl. B penKM cnyl.laM Moxe fla ce nocTnme uawyantia p e n o 3 ~ qM~nepKyratitia ~i $MKC~~M

nonyasa~ ce npn B ~ ~ ~ ~ C H O - ~ K C T ~ H Mexa~MOH HapeyqaT Ha 2-po MACTO Meyqy naKbmwTe @paKTyPM,Cnep CyllpaKOHpMnHMTe. Opalcryp~~e Ha pQnanHaTa rnam n p AeuaTa ~ ca BCbLL(H0CTf!flH@~3~0nlr13~ OT CMITBeTHHTeTMnOBe no Salter & Hams H ca peAm.
H M ~ M ~ ce M

Opanypme Ha pqwanHaTa lunii~a ce ~nacwt$~qupaT cnopeR cTenetna Ha p a 3 ~ e c ~ m (.~~nea~e") ~e Ha pqnanHaTa rnaea: - A0 20 (30) TaAYca; - 30-60 rpm=; - n ~q 60 rpqyca. Oco6e~o flp06neMHM ca epanypme Ha pquanHaTa

urwi~a, onncaHM OT Jeffrey, n o r y e w rpe3 AeyeTaneH MeXaHM3bM Ha TpaBMaTa ($Mr. 4.7) npll CblTbTCTBaua naKaTHa nyltcaunn. O ~ p e n e Tnn ~ ca $ p a u y p ~ ~Ha e Patterson, npn KOMTO ce ~ ~ ~ M ~ C T B ~ A M C $parnew T~~HMR -~e~ana$~a Ha apanyca, ~a a rnasaTa MY ocTasa Ha MRCTOTO CH. Te cleCT0 C e KOM~UHH~ C ~~~a$M3apHa T $ p a w Ha ynHaTa U npeAcTasnReaT eKswaaneHTHa ppe4a Ha Monteggia.

CTBaHe:

-MMHMM~HO p a 3 ~ e c (10 ~ e20"): ~ ~ rMncoea MMOGWnw3aq~ 3a ~2 ~o 3 C ~ A M M ~ M ; - pa3MeCTeHM C 20"-60': MaHy8JlHa pell03MuHR, OCbqec~~e~a.1pea~pa~u~~,~apn3~pa~enp nMnuHwuaTa, nocneAeaHa OT rclncoea n ~ o 6 n n ~ 3 a q Bn ~ npoHaunR M $ n e ~ c wnon 90" B naKbTHaTa cTasa. n p ~ cMnHo p a 3 ~ e c ~ e $ ~p n~ ae w n Ha u r n h ~ a ~ Ha a pwnyca ce npMnarac ycnex neplcyTaHHaTapeno3wqu~ no ueToAa ~aA H ~ ~nnM ~o onepaTnBtio B neqewe c e b ~ p e u $MKC~ ~a ~ M (Kirschner R nrna).
llponoaa
npor~03a~a e go6pa n p ~ ~ ~ ~ M ~ C T B ~0 ~ H30" M RM npoTMBopevnea npn n o - ~ e x ~ m $pamyp~ e nopav oco6eHllR Tun K P ~ B O C H ~ ~ A R Ha B WManHaTa ~H~ maBa. ManK M T e Aeua TonepMpaT 406pe ocTanww brnM ~o 45". O c ~ a n rP ~~n ~M~CTB~H no Mul F M IpMHan o - r o n e OT ~~ 3 mm o6are HeAonycTnMn.

Ann.
~H~~HOCTUK~

Hepaa~ec~e~ $pamyp~ me Ha w n h ~ a ~ Ha apwwyca C e flMamOCTMuMpaT TpyAHO. Te clecT0 n03WMBMpaTCMMnToMa Ha p a ~ e c ~ e ~ luamn m e BtarnasHurKn, K O ~ TPRO 6eaua ce npcu qeneHacocleHo Ha n r n u n ~ m pewre~oe rpa$~n.

qnma, cepaxpacrex Ha pwnantiaTa rnaBa, cKbcReaHe Ha pwnyca, aeac~ynap~a ~e~po3a, paHoynHapHaCMHOCTO-

Oco6e~ocmu ~a m p a 6 ~ a m a B gemcka 6b3pacm m 183

M ~ x ~ HHa H Bb3HHKBaHe ~~M

nonyqaea~ ce no BapyceH nnM BanryceH M ~ X ~ H M O~ono50% OT TRX c a pa3uec~e~n nopqM MOUHOTO TerneHe Ha m. triceps brahii.
~ ~

Cneur~o6 0 n ~ n neseHHe ~o
npaelr ce rMncoea M M O ~ M ~ M 3a ~ ~3~ cepunq~ M R (Hep a ~ e c ~unn e ~onepaTMBtio ~ ) HannecTsaHe c BbTpewHa $MKC~~ (~ Ya IF n Ip e r ~ O aC ~T a~ O C M H T no ~~ Weber). ~

ycnexa Ha KoHcepeaTmHoTo neqetiwe OT ronmo a~aclew e e qecraTa cMma Ha runca M MopenHpaHeTo MY. A06bp M JleCeH 3a M3MepBaHe K P M T ~ P M 38 ~KaCl eCTBOTOHa rMnCOBMR PbKaB e T. HaP. . M nCOB M H ~ ~ K COTHOWeHMeTO ": M . Mewy LuMpwtiaTa Ha Mnca B n p o b ~ n ~ a peHTreHoaa ~a npoertqw-i M ~ a B 3 ~ $acoea~a~p~16eapa B ~ e o ~ o n 0.7; o npu no-rone~ CTO~HOCTM ~ uMa OnacHocT OT BTopuwa pHcnoKBUMR, a IlpM no-MaJKM- OT CMYqeHMR B UMpKynaqMRTa M pa3BMTUe Ha KOMnapTMeHT CMHflPOM. Qpalcryp~~e B~ M C T ~ ~ H orpen M R Ha npepMMurHMqaTa PeMOflenMpaT OTnMclHO M TyK Ca flOnyCTMMM OCTaTbclHM aHrynaqMw po 30" B popso-~onap~a nocorta. o p a n y p ~ ~ Ha p ~ a $ ~ 3 M a npoKcMni ~a lantiMR ~ p aHe i TonepwpaT oc-raTbqHM ~MCJlOKa~HM nOBecle OT 1p. ~~H~MKB 38 ~ OnepaTMBHO MU ne'leHMe: - OTBOPeHM $palcrypM; - naqMeHTH HW 13 roflMHM; - HeHaMeCTMMM$palcrypM Cnep He IlOBe'ie OT 20nMTa.

VI. Opatrrypa-nywcaq~~ Ha Monteggia

MexaHt13b~Ha Bb3HHKBaHe

nonyqaaa~ ce OT pwpeKTeHypap, nwaHe ~bpxy WaHTa (H~A-rec~o), nqaHe ebpxy npepMMwHMqaTa. BMHaru Cbu(eCTByBa POTa~MOHHa KOMnOHeHTa Ha Pa3MeCTBaHeTO, KORTO tie ~ p ~ 6 pa e ace 3a6pae~ npn p e n o 3 ~ q u ~ ~ a .

O ~ M C e 3a ~ H nbpBM ~ nbT npe3 1814 r. OT M3BeCTHHR MTWUaHCKMXMpypr M HoCM HerOBOTO MMe. ~ ~ ~ C M C ~ ~ C K I I R ~ai-rec 6apMati.r ~ e pua$~3ap~a $palcrypa Ha ynHaTa c npepHa nyKcaqMn Ha rnaeaTa Ha pajyyca ($Mr. 4.8).

Bado ~nacu$~qwpa yepepaTa Ha Monteggia cnopep nocortaTa Ha p a 3 ~ e c ~ ~ Ha a~ pqHantiaTa e~o nyKcaqm: Cnope~ no~an~3aquma CM ce pa3penm Ha TartHaa B T M n I - npepHa nyltcaqw c $panypa Ha ynHaTa (75% nportcuMannaTa.lam, p w a $ ~ a a p M~ p~ ~ c ~ aK n~ ~ M noc~; OT cnycla~~e). nepHMTe np#HwexaTM ~ ~ M $ M ~ M Ha O pwcTanHa~M~MT~ T M n II - 3 w ~ nyrtcaqm a c $ p a w Ha ynHaTa (15%). Ta PaffManHaenM$M3a, nOC(THBMHarM OT T M nIH n M 11. T M n Ill - naTepanHa nyKcaqMR c $palcrypa Ha ynHaTa CnopeR cTeneHTa Ha a a c ~ r a ~ ce e penm Ha nbnw (l0%). $palcryp~,HenanHM (~wn .aene~a npbrrtaq, nnacTnclHn T M n IV - npeptia nyKcaqMR c $palcrypa Ha pwuyca M p e $ o p ~ a qM ~~ H, $ ~ ~ K ~ U M . ynHaTa.

Knac~a~~aqcm

na npecnclacapitulum humeri BB 4.8).

BCH'I~I

npoe~G (@r.

184

Oco6e~ocmu n a mpa6mama B gemcka Bb3fJacm

C.4.8. Cxewa na 4panypa - nyrcauna na Monteggia. n o n m e n

pewnenonormeHcnnmon Ha Nigst n Baumann ( o m Ha paRnyca He npecwta rnaawma na pavettnara KM)

n e ~ y a ce a ~rpea neplcyrawa $ ~ ~ c a q M n M n~ onepaT M B H O ; r) $paK-rypa n enu$~3~onw3a Ha rnaaMrKaTa Ha IV M V MeTaKapnaJIHM KOCTM.

Ae@~~m~a~o~oB n~ er ee ~ ~u cebapam e~ a ~ Ba nom BcnrKMcnyraM ce C ~ C T O M B MaHyanHap e n o 3 ~ M qmnco~~ Ba ~~06MnM3aqMfl - PbKaB, no MeXaHM3bM, o 6 p a ~ e Ha ~ TO~M Ha nonyrasaHeToHayepegaTa. C p o ~a ~ ~~06~nu3aUHRTa- 6 ceAM#qM. Y ~ C T M peHTreHoBn T~ KoH-rponMrapaHT#paTnpunpocneflneaHeTotienponycKaHeHaBTopnrHa IMcnoKaqw. Tnn~rtio ycnome~we e 3acRraHeToHa n. interosseus posterior. Tow BMA $paK-ryp~ ce Ha6nlofla~aT ~aA-rec~ npM o Aeqa Mf?X,Q' 1 M 8 T O A M H M , KOMTO HRMaTM3rpmeHMHaBML(M Ha neluexoAq#:90% OT TRX ca p e 3 y n ~ a OT ~TpaHcnopTtiM 3nonony~~ Ha newexopqM, 6nbcHaTM OT ~ B T O M O ~ M ~ .

V11.Opalrrypa-ny~caq~fi Ha Galeani
C ~ ~ B H M PRflKa T ~ ~ YBpeN, H O OnMCaHa OT OTKPMBaTen~i1~1934r. Kacae ce 3a $pamypa Ha p m ~ y c a n nyKcaqm B AHcTanHaTa pmMoynHaptia maaa.

Tarn e KaTO ~ P O H R - Hajl-BMHHT~ nOCneACTBMR npM TpaeMa 3 a c ~ r a cbppxatqme ~ ce sbrpe opraw, a He caMaTa n p e ~ n a 3 ~ cTpyuypa. a B 87% OT TexKHTe T ~ ~ O B M $P~KT~PM C e Ha6nlofla~T~b~eTa~M yBpeAM npMCMbPTHOCT 8%. npn 30% OT ~ e naqMeHTn 3 ~ ce Hanara KpbeonpenMBaHe. Hai-WcTbITen0KNlHM CbreTaHM YBpeAM C a pa3KbCMHMR Ha roneMM KP~BOHOCHM cbAoBe (CPO 60% 3ary6a OT 0 6 e ~ Ha a q ~ p ~ y n ~ p aK uP a~ ~B M an )M ypeTpaTa M nwoVHMR Mexyp; H ~ A - r e c m oTAanereHu ~e CbreTatiMR ca repenH0-MO3bVHMTeTpaBMM (61%). B 34% OT Cny'iaMTe M M a APYM $paKTypM Ha QbnMT P ~ ~ ~ CKOCM. TM

VIII. Opanypn Ha K o m e Ha pKaTa

Knacug~raq~fi

BA ~ T C K Bb3paCT ~ T ~ C b q O Ce Cna3MT O ~ ~ O M ~ B ~ C T H M OT rneAHa TorKa Ha CneulHoTo nereHMe T ~ ~ O B M T Te npnHqmnn OT XMpypmma Ha pbKaTa. Qpamypn~eca $pamyp~ ce paqenm Ha:

Oco6e~ocmu ~a mpaBmama B gemcka Barpacm

185

rpyna 1 - HeyCJlOXHeHM ( H ~ O ~ M ~ $palcrypM ~ H M 683 sac~ra~ Ha e BbTpeUrtiM o p r a ~ ~ ) ; rpyna 2 - $palcrypu Ha ~ a a a c yapepa Ha BbTpewHn opraHM, MIMCKB~~M o n e p a ~ e~cnnopaqm; ~~~a recTo HaJlHrMe Ha T p a B M a T M C l e H LUOK, nOKa3aH 3a KpbBOnpenMBaHe; rpyna 3 - T ~ ~ O B $panyp~ H c neaw~ H a ronm K P ~ B O H O C e HCbp U M a C M B H a BbTpeWHa XeMOpaMFl ( O ~ H K H O B ~ H O ronRM K ~ O H Ha a. iliaca interna) M X M B O T O ~ ~ C T ~ ~ U J ~ B ~ ~ M C b C T O R H M R ,M 3 U C K B a q M KpbBOnpenMBaHeU 08 1MC M H O r O nOUa no OTHOWeHe npOrH03a 3a X M B O T a . OT TPaBMaTOnOM'4HarneRHa T O r K a Ta3OBMTe $paKT~PM ce penm Ha: a) epHHMrHM $ p a w n - m a 6 ~ n e TMn ~ (OS ilium 19%, OS pubis - 60%, OS ischii - 21%); 6) ~ B O ~$palcryp~ I H H c Hapyaeatie Ha qenocrra Ha T a 3 O B M F l npbCTeH (n0TeH~MallH0 H ~ c T ~ ~ MM~~H eM c~a6~nHM 4'pak-V~~):

- $parxypu npu n p e p ~ o - w KounpecMR ~a (~ah-reca

He

TO $paicryp~Ha paMeHaTa Ha OS pubis, OS ischii, p M C X M 3 aH aC M M $ M ~ ~ T KafTO ~, npM Bb3PaCTHMTe; $palcrypM npM C T p a H M V H aK O M n p e C M R ;

- BepTMKallHM $P~KT)'PM ( T M ~Malgaigne).

no-ManKMTe peqa Ce I l P M ' i M H R B a T OT O ~ H K H O B ~ H M nwaHm, poKaTo npM peqaTa HW 10 r o u M H M ce M ~ M C K Bb3~(ekTBMe H a rOnRMa nOCTOBa CMna MnM C M n e H pMpeKTeH ypap. KpbB03ary6aTa Moxe pa posepe po TpaauaTMr e H WOK. Y ~ C T O ce ~a6ntouaea~ mreTaHM T ~ ~ B M M npM T P a H C n O P T H M 3nOnOnyKM M naaHMR OT r0nRMa B M C O r M H a . HaA-rec~~ CbreTaHMR ~e ca c r e p e n ~ o - ~ o 3 bMnM r~a KO-

PM

pews Tpatlua. Cun~o pa3~eme~m Me pa3pp06e~me $palcrypw ca

~PMOPMT~TM Ha T ~npHeMHOT0 OTpeneHMe ( ~ ~ O T M B O WOKOBa 3 ~ aC ) a HaCO'ieHM KbM ne9eHMe Ha TpaBMaTMCIHMR U l O K M OBnWBaHeTO Ha XeMOpamRTa. ~PMOPMT~TM Ha T~ ~~~HHMTMBHO Jle TVeHMe O C a HaCOW H M Ha IlbpBO MRCTO K b M Cb'4eTaHMTe BMCuePaJlHU Re~ M Ma , cnep Toea M K ~ n M e r e ~ ~H e ~~Co~ M $pamypv M T ~ no MeXaHM3bM, 06pa~eH Ha nOny'iaBaHeT0 M M .

nOTeH4ManHOOnaCHM3ane3MRHaMarMcTpaneHCbpMnM Heroa K ~ O H c WMPOK nyueH, c nocnepeaqo p a 3 e u ~ ~ Ha e

OcTpa M C X I M M R .

II.Opalrryp~ Ha 6enpo~o
Cnopep n o ~ a n ~ 3 a CM q~ Te~ ce ~pa3pen~1~ a Ha TaKMsa B IlpOKCMManHMFl Kpah, ~(Ma$M3a~a M A M C T a n H H R Kpah. ToeaueneHMe He e MeXaHMqHO,ace HFUlaraOT Pa3flMVHMR TepaneeTMreHnop,xop M p a 3 n ~ r ~ w nocneucTBm, ~e KOMTO M M a T OTpenHMTe YBpeflkl.

1. (DpalrrypH Ha npOKCHMaJIHHIl6e~peH Kpai

P ~ ~ KH u 0 ,C
n0p-M HMR. rOnRMa K n M H M ' i H a 3 H a C I H M O C TY B P e p M , OnaCHOClla OT HaCTbnBaHeTO Ha K b C H M YCnOXHe-

- $palcrypu Ha 6eupeHaTa w ~ h ~ a ;

- TpaBMaTMrHM enM$M3~0nM3M;

Cnopep no~ann3aq~ma ce penm Ha:

0 4 r. nouc~o- paro one^ mnc c MaHyanHa peno3~~ M (R~ K O eH~O~XO~MM~); 4 12 r. -uwpefTHa cKenenia ~ K C T ~ H ~ 3a M4 Rcepwqu, nocnepBaHa OT no~c~o- paro one^ mnc 0640 3a 3

186

Oco6enocmu na mpaBmama B gemcka Baqacm

Meceua;

HW 12 r. M npw careTaHn TpaaMw pwpemtia eKcTeH 3 M RH n H KPbBHa pen03H~MR C H R K a K b B BMA BbTPeWHa

$n~caq~~.

nporwoaa

YC~OXH~HHR
Mome fla ce oraKea yAbnxaeaHe Ha K ~ ~ ~ H C1 Mp0 K4C m 3a OKOnO 5 TOAMHM.
aacema~n~

Knacuow~aq~~
Ka~o BbTpeCTaBHM a B y n 3 M O H H M YBpeAM Ce pa3flenRT
H a 3 Tlrna ($Mr. 4.9):

Tvn I: npeAHa clacTMrHa a e y n 3 ~ ~ ; Tnn II: nbnHa aeyn3n~ cbc 3ana3e~a XoHppanHa naHTa;
TMn

111:

HanbIlHO OTKbCHaTa e M M H e H 4 M R .

AWRT Ce Ha: M ~ T ~ $ H ~ M C $paKrypM IHH M enM$M3M0nM3~ Ha pwcTanHaTa 6eppe~a en~$~3a.

ne'ie~~e Ha ~o M~T~$M~H $paKryp~ MT~ Moxe Aa 3anorHe c pMpeKTHa ~ K C T ~ H ~ M F KaTo I , cneA oneyrlasaHeTo
Ha OTOKa Ce M3BbpWMMaHyaJlHapen03M4MR M IleplcyraHHa $n~cauMfl c

KJ~MH#'~HOTO n ! V e H M e

npM TMn 1 M 11 e KOHCepBaTMBHO

Kirshner cnMqM. ~ H ~ C T M ~ mncoB ~ M R Kpaqon3 a 4 5 ~ Tlnn ~ ~ Ill.nomexttnHa E ~ M $ M ~ M OOT ~M TMn ~M I MT 11~ no Salter & Harris Ce neKyeaT 'ipe3 ~ a ~ y a p ne~na o 3 ~M qn ~e ~p ~ y ~$ a~ ~~~ca a - onepaTMBHo nereHne c BbTpewtia $n~caqn~. E~~M$M~M Ha oIlPOKCMManHaTa ~M~M TM6Man~a enM@M4MR. Teslr OT TMn 111 M IV M 3 M C K B a T npe~M3HO OnepaTMBHO 3a ($MT. 4.10). C p e q a ~ ce BCMC~KM TMnoBe OT I AO IV no nerewe M eeeHTyanHo $ M K C ~ ~ M FCI Kirschner M r n M MnM Salter & Hams. ~ ~ O K C M M ~M6ManHa ~ H ~ T ~enM$M3a OCMBMHTOBI. I J p 'R B a 55%-60% OT PaCTeXaHa TM~IIRT~ M 3aTOBa npeuM~HOTO ne'ieHHe Ha ~ e yapepu 3 ~ M#a ronma CTO~HOCT.

- peno3~qn B~ mnepe~c~e~ Ha 3KonRHoTo n~ noA o614a

II ce n e y a T KoHcepeaTuBHo c p e n o 3 ~ q n M~ 111 M IV C a no~a3a~~3aonepa~~~~onere~ne. Aeynsnma Ha tuberositas tibiae e c n e q ~ $ n r e T ~ w n an@~3#onn3a; neKyeace rpes neplcyraHHa$u~caqmn ~o 15-rop~w~ mpacT, a a npM neronennme Aeua - qpe3
T#n I M eBeHTyanH0 IleplcyTaHHa$ M K C ~ ~ H R nOKaT0 , TMn onepaTMBHa $ H K C ~ ~ HC R BUM.

Oco6e~ocmu Ha m p a B ~ a m a B gemcka Bbrpacm

187

Tun l

. -,

., ... , :

Tun l

Tun 1 I

Tun 111

Tun lV

. -.
. -. , .

O n .4.10. C x e w na n ~ n o s n e enw~$mapnn RWII na npommannmTIImnna enw@wa

@ p a ~ ~ y Ha p nnpoKcnManHaTam6nan~a ~e~a@naa. qec-ro~oHanurue Ha nHTepnotiupaH nepnocl, a u

HRKOn flPyM, H e M 3 F I C H e H M ,$~KTOPM flOBeX#iT
fl0 IlOCTe-

neHHa m r y c ~fa l e $ o p ~ a ~flop^ u ~ npw norTu ~ e p a s ~ e c TeHM $palcryp~, 3aTOM e llHflll~UPaH0 OnepaTMBHO JleVeHHe.

2. dpalrryp~Ha ~ a $ ~ s m Haam6~ma H $~6yna~a

M~x~HH Ha ~Bb3HHKBaHe ~M

188

Oco6enocmu na mpaBmama B gemcka Baqacrn

ce 3ac~ra npepHaTa ~yc~yn~o-$acqnan~a noxa. AMpeKTHaTa nMnaqMR Ha MyCKynHclTe nOXM C b q O AaBa po6pa HH@PM~~MFI 3a CTeneHTa Ha HanpexeHweTo B TRX.

AO~OJIHH~HO noneflettwe m neveHue

OT~060n~~'iHaTa noMO4 C e bI3MCKM PMMflHa MMO~ M ~ M ~KORTO ~UM paR o6xaaqa , M xopwnoTo M pa pounra p0 npoKCUManHMR KpaA Ha 6eppo~o; C b q O M nbPBOHaWnHa oqeHKa Ha C ~ ~ O B M c-rai-yc. R

MeKOTbKaHHM HapaHRBaHMR K P ~ R H U K ~ C Te IlOCTaBR Ha pnpema ~ K C T ~ H ~ M ~~ R M . O T K P M T M$palcrypu, T~ KOMTO tie ca pepKn, ce npvnara BbHtutia @ M K C ~ ~ M cnep R napeMrHa XMPYPM'iHa 06pa60TKa Ha PaHMTe.

npornosa
nportioaa~a e po6pa, HO He ~ p ~ 6 pa s ace ponycKaT ocTaTbrHM brnoBM p e $ o p ~ a noeere q ~ ~ OT 10" B cam-ranHaTa paaHntia M noBere OT 5 ' B ~ $powan~a~a. B

Cneur~o~ O ~ H M ~neseHue HO
COB Kpa'iOn.

K~MHMVHOTO ne'ietiwe ce ~ C T O M B peno3nqn~ M rnnPM C M ~ H O pa3MeCTeHM$ ~ ~ K T C O~UICIIPHM ~PH

DTnn l Tnn II Tun Ill Tnn lV

Frost, Bosworth), 3a '~MRTO n p e q ~ 3 ~ pMarti a oCTMKa ce M 3 M C K B a KOMnloTbpHa TOMOT~~$MR.

Ao6on~n~ noeeaeHHe o Hn e ~ e ~ ~ e
Efl~a ~ a ~ n l o r ~ recra ~ e nTpaeua ~ o e enn$~3uon~3aTa Ha pMcranHaTaon6ynap~a enn$n3a, ~a~M$ecrMpaqa ce c noKaneH OTOK M 60n~a oKono $ ~ 6 y n a Maneon. p~~~ Taw yapepa 03ppae~aa M 6e3 M M O ~ M ~ M ~ ~ npM I + ~ po6pa R KOMyHHKa4MFI Mewy neKapR, POflMTenMTe M AeTeTO H~O~XO~M eM C~ OM O M~B~CTH 0~6peMeHflBaHe O p0 IlpeMMHaBaHe Ha ~ O ~ K M BbB T ~ .BCM'iKM 4PYrM Cny'iaM C e n0CTaBR rMnCOB 6 0 38 3 ~CeAMMqM. Enn$M3~onM3#~e Ha pvcranHaTa m6nan~a en~$~3a ca Ha 2-po MRCTO no 'iecToTa cnep ~ e Ha a pm-ranHaTa ~ en~4~3 Ha apwMyca. Cn0pep pa3nM'iHHTe M H A M P e K T H MMeXaHM3MHHa TpaBMaTa C e Ha6nloflamT M PX3JlM'iHM TMnOBe enM$M3apHM nea~n OT I M V.

A060flHM'iHaTa M M O ~ W I ~ M ~ ~ U MOxe M F I pa ce ocbqecTsMcpMMptiaulMtianpopM' i p e 3 0 n a ~ o ~ a ~ e ~ a r n e 3 BbB Bb3rllaBHMl@.

C~~~W ~OJIHHVHO H O Jle9eHMe

K n m ~ v ~ne'ie~ne o ~ o npM e n ~ $ ~ 3 u o n w OT~ Tun e ln 11 e KOHCepBaTMBHO - MaHymHa pen03MqMR M MnCOBa M M O ~ M ~ M ~ ~VlaKnlove~ne ~MR. npaeM BanrycHnm MexaH M ~ Ha ~ M TpaBuaTa npn e n n $ ~ 3 ~ o n ~ OT 3Twn a II, KbfleTo ce~anaraonepaq~~aae~~~pa~qn~~ B ~$ Bp a ~ ~ y p ~ nnocKocT a ~ a nepnocT. E ~ M $ H ~ H OOTTHn ~ M ~111 HMT IV, ~KaKTO M C ~ ~ ~ ~ H $ H C T e yapepM Ha Tillaux, nomexaT Ha onepaTMaHo nereHMe - , , X ~ ~ M ~ Tpen03H~MR M V H ~ " H$MKC~~ CM BMHTOW, R KOMTO He ~ p ~ pa 6 m npecMclaT $ ~ 3 a ~ a .

Auanocm~a
AM~MOCTM BK noBeveTo ~ T ~ cyiaM enecHaaa cneqmanucTa. B npexopHaTa loHotuecKa B ~ ~ P ce ~ C ~a6nlopaT saT cneqw$~r~n TMnoee r n e 3 e ~ ppepn ~ ~ (Ha Tillaux,

nponoaa
flponio3a~a ~ar n e 3 e ~ ~ w yepefln e a a e ~ ar c~ ~clrna ~a enn$n3ap~a~a neaw M ropnHme, KOMTO ocTamT no pm Ha pacrexa Ha BceKM KottKpeTeH na4~e1i-r.

Oco6e~ocmu Ha m p a B ~ a m a B gemcka Baspacm m 189

VI. dlpalrryp~Ha x o a ~ n o ~ o
@paKTypUTeHa TaJlyCa M M H O r O PeAKM, H 0 IlOTeHqMan~o onactiM 3a ~ ~ ~ B M T M H a ~ T aaacqnaptia O tieKpo3a IlOpaJpl C ~ ~ ~ M $ M ~ H O~pbBOGHa6~(flBa~e TO Ha T a 3 M KOCT. nere~ne~ ce o wsebpwea B cneu~an~3wpa~a KnuHHKa aHHa $CIKCI~MR M n M KPbBHa pell03MqMR. palcrypme Ha neTHaTa KOCT c a He TonKoaa pepm, HO O ~ M K H O B ~ H H O ec ap a 3 ~ e cM ~ tie e ~ npepcTaenRsaT ~ npo6ne~ B peTCKaTa Bb3paCT. O c ~ a ~ a n cKOCTM l ~ e Ha ~ap3yca ce $phmyp~pa~ no ~ a ~ n r o r npw e ~ pnpeKTHa ~e TpasMa.

ulnaris npn p e n o 3 ~ q ~n~ e~ re a~ . n e ce ~o C~CTOM B Matiyantia p e n o 3 ~ nop q ~ o614a ~ ~ H ~ C T ~ MM ~M MO R ~ M ~ M ~ 3a ~~M 3 cepM#qM.

nepT

II, J l y ~ c a qHa ~ ~~l a s o 6 e ~ p e ~ cTaea a~a

C p a e ~ ~ ~ pRgKa, en~o HO 3 a r e c ~ ~ s a q yepeua a nopaflM Y B e n M W H M e T OH a T e M M R nbTH0-TpaHCnOpTeHTpaB-

MaTM3bM. Taw nyKCaqMR e C rOnRMa K J M H M i 'H a 3Ha'iMMOCT ~ ~aeacKynapHa e @pa~~yp#Te H a MeTaTap3MHMTe KOCTM M $ N ~ ~ H T M T ~nopwgqn onacHocrra OT p a 3 e ~ Ha ~ e ~ p oH sa a6 e ~ p e ~ rnaaa. a~a npM peua~a ca O ~ M K H O B ~ H MHoxecTaeHn O M ce n e y a T no

o 6 1 4 ~npaema. ~e A a y n a ~ o ~ $paws ~ a ~ a Ha 6a3a~a H aV ~ e ~ a ~ a p a a ny~caq~w Ha ~ ~ea a o 6 e ~ p e cTaea ~a~a ce K n a c ~ $ ~ q ~ nHa KOCTCe npM.IMHRWOT BHe3anHa KOHTpaKuMR Ha I n . paT Ha 3 a (90% ~ OT ~ cnyqa~re), npepM (E%), RonHM fibularis brevis; B AeTcKaTa abspac~ nereHueTo e KoHcep(2%). Cnope~ naToaHaToMMRTa M C T ~ ~ M ~ H O C T KoeTo T~, B a T M B H O . M M a 3 ~ a r e 3a ~ ~ neretiMeTo, e ce K n a c ~ $ ~ u Ha: ~pa~ a) npocTM nyKcaqMM - c ~ a 6 ~ TMn; ne~ Jly~caquu 6) JlyKCaqMM C MHTepn03MyM - OTHOCMTenHO cTa6b11-1nopag~ ronRMaTa xpyuytntia KoMnoHeHTa Ha KpaMHH; qaTa Ha KOCTMTe M M3KJlDCIMTenHO 3flpaBMR BPb3KOB ariaB) $ p a K T y p ~ - n y ~ c aq H~ ~~C T ~ ~ M (c~ $pamypa H M Ha paT nyltcaqwse npM ReqaTaca ~ R ~ K O C Kbne~o T. abapacMnM n p O K C M M t 3 I l H H R 6eppe~ ~pah). T H M T e nonyqasaT nyltcaqm, peqaTa nonyraBaT e n ~ $ ~ 3 ~ -aqe~a6yny~a O~M~M 3a , up~0 $~13a~a e ~ M O M ~ X ~ H MH~R-cna6a~a ~HO
3o~a.

OTepHo ~3cnepea~e, npoeepetto B HMCM .Iluporoe" 3a 15 - r o p ~ ~ u nepMop, e~ ce ycratioema, qe 68% OT p e w K m en y ~ c ac q a~ ~~ esu Ha naKbTtiaTa cTaaa, 23% Ha naTenaTa M 9% - Ha ~ a a o 6 e ~ p e ~ cTaea. a ~ a 3a cbqnR

nepMopcaneKyaaHMcaMoepHanyKcaquRHapaMeHHaTa
CTaBa M PRAKO e P M H M C H l M nYKCa4MH Ha MeTaKapnC- M ~eTaTap30-$anaHreanHMTe CTaBM M IlPbCTMTe Ha PbKaTa M X0,JJHnOTO.

Maebpluea~e no cnewHocT MaHyanHap e n o a ~ nop u~~ o6ua ~ H ~ C T ~ ~ M R . no-H~T~T~W IleVeHMe H O T O3aBMCM OT TMna Ha JlyltCaUMRTa- KOHCePBaTMBHO npM C T ~ ~ M ~ TMnOBe H H T ~ M OnepaT M B H O RPM H ~ C T ~ ~ W I ~ H M T ~ .

Onac~oame upeaT OT ~ b 3 ~ o ~ ~ ~ 3 ao KoMnpecm crra Ha a. brachialis unH ~ t a ~ n e q e a Ha ~ en. ~ medianus o u n M n.

190

Oco6enocmu na mpaBwama B gemcka Barpacm

a) cnewHa penoanqu~ po 4-TMR rac OT TpaeMaTa; 6) npocTM JlyKM~MM 6e3 $palcrypn; B) Bb3paCT A0 6 T O A M H M ; r) pocTanrHo pbnro 0 6 p e ~ e ~ ~ Ha a aK ~ ~~ eR H M K ~ . Taao6eppe~n~e nyKM4MM, HaMeCTeHM Cnep 8-MHR vac, npM no-rone~u Aeqa M c HanMrHa $pam-ypa Ha npoKCMManHMR6eppeH Kpan UMaT nOWa npOlliO3a. n p e ~ M ~ I l 0 38 3~ TpaBMaTMCl 4~~ HaJlyKMuMfl Ha naTenaTa T P R ~ B pa ~ ce n p c npM ~ no-rone~n peqa, oco6e~o MoMMre-ra, c HRKaKBa cTeneH Ha genu valgum M cTaeHa XanTaBOCT.

~e'ieHMeT0 e KOHCepBaTMBHO- MnCOBa MM06MnM3a4 M R 3a 6 CepMU4M, a npM BbTpecTaBHa OCTeOXOH~pallHa $palcrypa - onepaTMBtio.

RI. Pmnatio dolorosa ( ~ m r n natrb~) e~

M ~ o r qecTaTpaaMa o B ~ ebapacna B 1-6roAMHM( ~ ce e ~a6nto~aea cnep TOB~). Mnyraea ce npM PRBKO ~ 3 ~ e r n u Ha ~e namw Ha peTeTo OT 6 n ~ 3 w ~ MY. e

MexaHH3bM Ha Bb3HHKBaHe Ill. IYKC~~HR Ha naTenaTa

Knac~o~waq~~~
l l a ~ o a ~ a ~ oce ~ Kacae ur~o aa cy6ny~caqna Ha ~ W M anHaTa rnaea c racTMrHo MHTepnoHMpaHe Ha lig. anulare radii.
~HMIIToM~TUK~
HMK.

Harano~o e oc~po. Ae~eq ~a o, q ~ uenw ropeH ~paR6nM3KMTe c b 0 6 q a ~ a 3a ~ .M3BmaHe Ha ~ ~ M O T O " .

Ao6on~mq~o noBefleHHe H neveHHe

J l y ~ c a q n Ha ~ ~naTenaTa a noHRKora Moxepace penoHMpa CnOHTaHHO: YMeCTHa e penO3M4MRTaHa MRCTOTO Ha MHuMDeHTa OT nepCOHana Ha ~ O ~ O ~ H M . I H MeAHuMHCKa ~T~ noMoq.

A~ar~om~a
n p npernepa ~ ce ycraHoeRBa nMnca Ha npoHocynnHauMR B npepMMLutiMuaaTa.

11060nHHqH0nOBefleHHe neqeHue
BC~K ~ M o x pa e tiavec~u ~ a ppepa 3 ~ rpea c y n ~ ~ a
..

B npMeMHoTo oTAeneHMe ~ p ~ 6pa ea ce cHeMe noppo6 ~ atiaMtiesa a M Aa ce HanpaeM p e ~ a i n ~ peHTreHoso o ~acne~ea~ smlorMTenHo e, aKcManHa rpa$n~,sa~qo~o nyKcaqMmaHanaTenaTarecTocecanpoeowaoTocTeo x o ~ ~ p a $pam-ypa. n~a

dolorosa, ro n ~ n ~ a recTo a a ~ cneA T O B ~ ; HO onpeReneHaTa ~ b ~ p a c ~ .

&MO

po

npor~oaa
,

nponiosa~a eo ~ n ~ r ~ a .

Knacu@waqm11

3. no TexecT - nelca, Tema. 4. HaJlMciMe M n M He Ha PaHa Ha MeKMTe TbKaHM OTKPMTI, 3aKpMTa. 5. L ( ~ n o Ha c ~ napueTanHaTa nneepa - HenpoHMKsaqa, npoHMKaaqa.

I. Iewa aawpcrra rpaAHa TpaeMa 1, no MeXaHM3bM Ha TpaBMaTa - TpaHCllOpTHa, &TOH a p a ~ ~ l e Ha a ~ rpbAHaTa e c-retia, npM KoeTo ce nonyBa, CnOpTHa, BOeHHa. n M OpaK2. no 6 p o ~ Ha sacema~meKyxnHn - ~ s o n ~ p a ~ a ClaBaT XeMaTOMM B MeKMTe TbKaHM M KOHTy3MR M Typa Ha pe6pa. (~pae~ Ha a rpbfl~wriKOW M opratime B Hero), cbreTaHa (np~ yepeyqatie Ha opraHM B noeere OT epHa K y x ~ ~ a ) , C~~rrro~am~a K O M ~ M H M ~(npM ~ H ~Bb3~(eficTBMe Ha pa3nMYHM TpaBMaTM'4HM ~ E H T H ) . C~OHT~ MH nannaTopHa H~ 6on~a.

Oco6ewocmu Ha mpallmama B gemcka Baspacm

191

II.Iena o m p m nenpouuneaqa rpaflua TpaeMa

PaHa Ha MeKMTe TbKaHM (nope3Ha, pa3KbCHO-KOHTy3~ ac)p a 3 n ~ r ~ pw a 3 ~ en pp ~a 3 n ~ r cTeneH ~a Ha KbpeeHe.

Han~qe C a TPM O C H O B H MC M H A P O M a TpaBMaTM'ieH M xeMoparweti WOK, AMxaTenHa HeAocTaTbrHocT M cbpAe'iHa HeAOCTaTbL(H0CT. n e ~ ee ~co6ne~a Koxa M BMAMMMnMraBMUM, ~ 3 n o ~ e HO, C ~ s p a a e ~ B pa3nnr~a a crene~ q ~ a ~ o Ha aa ycTHwTe M npbCTMTe H a K ~ E ~ ~ H M ~CM Y C TK ~ O p ,e H O AMWaHe, C lorynaPeH, MHTepKOCTMeH M enMracTpMeH T M p W .

P ~ H T ~ ~ H O ~ O MYCT~HOBRB~ CIHO. Ce 3aCeHVBaHe B 6enMR ~ p o npM 6 6eno~po6~a KOHT~~MR 3, a c e ~ ~ B anne~ e epanHaTa KyxMtta npM xeuoTopaKc MnM Konanc Ha 6 e n ~ p o nOpmM 6 npMTMCKaHeT0 My OT B b 3 w npM nHeBMOT0-

paKc.

Ill.Texna 3anpma rpaAHa TpaeMa

PM HeR HaCTbnBaTCneflHMTeYBPellSqaHMR HarpbflHaTa CTeHa M BbTperpbAHMTe OpraHM: 1. T ~ ~ B Ha M 6enn~ M ~po6: - KOHTYSMR Ha 6enMR ~ ~ 0 6 ;

~ s c n e ~ e aCnn~o ~ e . O T C ~ ~ AMtuane ~ ~ H O B cbOTBeTHaTa FbflHa n O n O B M H a , YCKOpeHa CbpAe'iHa Aehnoc~,MeK, necHo noTMcKau ce nync, apTepManHa X M n O T O H M R .

OM~MK~~HO

- pa3~bcea~e Ha 6 e n ~po6; ~~

- pynTypa Ha nepwapAa; - pymypa Ha cbpperHMR MycKyn cbc cbpnertia Taw noHa,qa; - PytlTypa Ha rOnRM KpbBOHOCeHCbfl.
3. flep$opaqn~ Ha xpaHonpomfla. 4. PynTypa Ha ~ ~ a $ p a m a ~ a . 5. PynTYpa Ha ~ M M $ H M Rnp0TOK. 6. MHOM~CTB~HM $ ~ ~ K T ~ Ha P Mpe6pa. 7.K o M ~ ~ ~ c Ha MR r P b A H M RK O W .

-pyn-rypaHaBb3ApOHOCeHnbT. 2. Tpaau~ H a CbpqeTO M K P b B O H O C H M T e CbAOBe: - KOHTY3MR Ha CbPqeTO;

Bewnnaq~~ c PEEP, crepoMAM, nombpxaHe Ha HO~ M ~ ~ H ~ ~ H K ~ T M ~ H ~ H ~ ~ R ~ ~ H ~ B P a H C T B O ,X M n O T e P M M R (TR H eC a M O HaMWFlBa H m M T e OT O , HO M npoAyKqMma Ha C02rpeaHaManeHMe Ha O ~ ~ M F Me~a60nM3b~), eKcTpaK0p~OpaJlHa OKCMreHa4MR.

H a frecro npoTMra acuMnToMHo.

192

Oco6enocmu H a mpaB~ama B gemcka Barpacm

cneA npetiaxa ce H ~ B ~ P L U onepaum, B~ npM KOUTO HeronRuoTo pa3mcaa~e ce wMe. f l p ~ ronRMa AecTpyKuMR 6eno~po6~a p e 3 e ~ qf ~ lp ~ronmo ~ . mpBeHe no BpeMe Ha onepaqMR 6enoppo6~uu~ xMnyc ce xeaqa cbc cbfloe~ Knannnn.

111. Pa3ltacea~eHa Tpaxema H ~ P O H X H T ~

Cpeqa ce MHoro P R ~ K On p I ~e q a H a i - ~ l e c ~ ce o HapaHRBaTrnaBHMTe~ P O H X M U TO B o6nacrra Ha 6 ~ $ y p ~ a UMFITa. P ~ ~ K ~ C B e~ TpaHCBep3al H ~ T O lHO M O ~ H K H O B ~ H O M ~ L ~ J I O Pyn~ypa . Ha rpbRHaTa qacT Ha TpaxeRTace nony-

KOM~~C Ha UrpbflHMFI R KOW B CaMTallHa nOCOKa IlpM M3nbnHeH C Bb34y~ 6 ~ ~n ~ M 3aTBOpeH 0 6 rnOTMC no BpeMe Ha MHC~MPMYM.B pe3yn~a~ Ha Toea nonoxMTenHoTo MHTpanynnnoHanHoHanRraHe npMrwHmapyn-rypa. Mexa~nq~ BeHTMnaqwR a (PEEP), a~~M6aKrep~anHM CpeACTBa, CTePOMPM, IKTMBHB $113~0~epaflMR. XHPYPMCIHO neqeHMe- p e 3 e ~ u n Ha ~ ~6a e n pp06 ~ ~ He ~ a e ~ ao6p~ pe3yn~a~1.1, n u KaTo yspewaHMma ca p a 3 n p o c ~ p a ~ e ~ ~ .

II. Pasltacsa~e Ha 6ent1~ ~po6

Abnx~ ce Ha $pamypa Ha pe6po M n M Ha noeuuetio
M H T ~ ~ ~ ~ O H X HallRraHe M ~ ~ H O flpM KOMnpeCMfl Ha rPbAHMR KOW. Bo~M A 0 XeMO- M flHeBMOTOpaKC, pa3MepMTe Ha KOMTO S~BMCRT OT Texecrra Ha 6enoflpo6~a~a new.

P ~ H T ~ ~ H O ~ OYCT~HOBRB~ MCIHO. C e flHeBM0TOpaKC 6 e n pp06 ~ ~He ~ce paarbsa cneA ppeHax, ronm MepMacTMHaneH e ~ $ w e u a~enema3a , Ha 6 e n ~ ~p ~ o6. ~ M ~ M K ~ ~ ~H ~ O o ,~ K OeM$M3eM M ~ H no UrMflTaM PbflHMR KOW, CUnHO O T C ~ ~ ~ BHWaHe ~ H O B CbOTBeTHaTa rpbflHa nonoBnHa. 6po~xoc~onw~. Ypea HeR ce onpeAenR MRCTOTO Ha Jle3MRTaHaBb3AYXOHOCHMR CbA.

P~HT~~Ho~~o YCT~HOBRB~ M'~Ho. C e HMBo Ha Te'iHOCT C sb3~yx ~ a Hero, p Konanc Ha 6 e n ~ ~p ~ o 6M , ~ M ~ C T Ha B ~ MeAMaCTMHyMaIlOBe'ie MUM no-MallKO B IlpOTUBOnOnOXHa nOCOKa. O M ~ M K ~XH ~O ne . p c o ~ o pTOH e ~ B npedHoropHMTe oTpenM Ha rpbAHnR KOW, cKbceH nepKyTopeHTOH B AonHaTa ram, c u n ~ o O T C ~ ~ ~ RMuraHe. ~ H O

H ~

roneMnTe KP~BOHOCHMcbAoBe ce nonyrasa sac~ohB 6aceh~a Ha ropHaTa npas~a eeHa M HaManmaHe Ha n p ~ TOKa Ha KPbB KbM CbPqeTO. T O BM3MCKBa ~ no BpeMe Ha TpaHcnopTaAa ce nocraem MrnM B noartoxueTo 3a HaMa-

nRBaHeHaBb3~YWHaTaKOneK~MRM~aCeM3BbplUMflneBpanHa ~ ~ H K ~ Vlrna~a M U . ce c~bpasa c ApeHax no Bulau, npM KOeTO 3aTBOpeHMflT IlHeBMOTOpaKC C e IlpeBpb~a B OTBOpeH, a IlOflBOAHMRf ApeHivK flpeflOTBpaTRBa nlonee-

HeTO Ha MeAMaCTMHyMa, flpeAM3BMKBaqO $ ~ H K ~ # ~ o H ~ HapyWeHMR.

Oco6enocmu Ha m p a s ~ a m a B gemcka Ba3pacm

193

T~~BM HaH capqe~o

TemM~e TpaBMM Ha CbpqeTO C a MHOrO PeAKM. flonyrasaT ce npn $pamypa Ha cTepHwa, MHoxecTeeHM@paKT~PM Ha pe6pa snmo, napacTepHanHM MHoxecTseHM $palcrypM, TpaBMaTMVHa ~@MKCMR, MeflMacTMHaneHXeMaTOM.

nereHue. npu n o - r o n e ~ pasuepln ~ Ha n e s ~ ~onepa~a 4MR.

CHMIITOM~MK~

BHCOKO UBH, aPTePManHa XMnOTOHHR, ~ a 6 b 6 ~ a n # WMLIHM BeHH,rnyxMc b p ~ eTO v~ HOB^, ~ napqoKcaneHnync.

II. Pymypa Ha nepuKapRa

Moxe Aa He C e flMalHOCM~Mpa. AKOM M a DHeBMOTOpaKc, ce nonyvaea M nHesMonepMKapb ~ P nW o-~O~RMO pa3ncea~eMua racTMrHa nnM ToTanHa nycaqm Ha cbpqeTo B nneepanHaTa KyXMHa, KoeTo BOPM PO KoMnpeCMRHaKO~OHaPHMTe~~OBeMTOP3HRHaCbPL(eTO.

IV. n p o ~ ~ ~ s HapaHmaHe aqo Ha capqem

npM HapaHRBaHe Ha CbPRerHMR MYCKYn M L U M P O K O nonyaea xeMoTopaKc. AKO HapaHReaHeTo Ha nepMKapRa He ~03BOnFlBaM3nM3aHe HaKPbBBnneBpWHaTaKyxMHa, ce nonyvasa xeMonepMKapn.

HapaHRBaHeHanepMKapna~b~nnespanHaTaKyXMHace

P~HT~C!HOJ~OM'~HO. YCT~HOBRB~ C e npOMRHa B n03MUMRTIHa CbP4eTO. H ~ ~ ~ M V Ha H nHeBMOnePHKaP/J ~TO npa~~~~amosa~a~c~a. EKT. M ~ M ~ C T Ha B CbpflevHaTa ~H~ oc.

P e ~ ~ r e ~ o n o mPasut~pe~a v~o. cbpuerHa cRHKa, xeTO,

' O T T ~ ~ . " ~ a nHanwvye ~o. ~a p a ~ B ao6nama Ha cbpqenpOHMKBa4a B IlneBpWHaTa KyMHa.

194

Oco6e~ocmu Ha m p a 8 ~ a m a B gemcka Baspacm

nereli~e Ha XeMOPaMClHMR WOK ( X ~ Y O T P ~ H C @ ~ ~ H F I , rnlo~o30-coneen ~ ~ ~ T B OnneBpaneH PM), ApeHax, nepnKapRMoqetiTe3a. Xupyp~r~ nereHne o -3 a w n ~ a ~ Ha eCbpAerHnR MYcqn.

V, Pymypa Ha ronm Kpaeoaocea cap,

1. Pymypa Ha aopTaTa
npn p a 3 ~ b c ~ Ha a ~acqeHlewHaTa e racT Ha aopTaTa xapatnepHo 3a KnntinrHaTa KapTuHa e cnMrrrouaTnKaTa Ha CbpflerHa TaMnoHqqa n B ~ H O sac~oh. ~ ~ H Tpaa~a~nv HaTapynTypaHaflecqetiReHTtiaTaracTtiaaopTaTaenorecTa. fion~a, CllCTOnlr'ieH UyM, KO~p~CMOHHMRB~eHMR: Ha nnaa noflKnrornrHa apTepnR, Ha Tpaxema - pucnHeR, Ha nesMR rnaBeH 6 p o ~ x - a ~ e n e ~ ~ aHa 3 aXpaHonpoBofla , ~~MC@~TMR.

B ~ ~ WnpnrnHn H M (3a~pn~ na npoHuKsaqa ~ p a s ~ a ) RflPOreHHMIlPMClMHM( ~ H ~ ~ O C K flWnaTal(#R, O ~ M R , COHflMpaHe, ryx,qn ~ena). Tpaa~wB uruhtia~aclan - xapatnepu3npa~ce c 6on~a, ~ ~ ~ n a n n npoqec, ~ e n e noAKoxeH ~ e~@~a Mee~ flHaCTMHMT. T ~ ~ BBM rpbAHaTa M VacT - MeflMaCTMHaneHeM@#3eM, MeflMaCTMHMT, nHOnHeBMOTOPaKC ( n p ~ HapaHRMHe Ha MeAMaCTclHanHaTann!Bpa), MefllraCTMHaneH a6cqec. T ~ ~ BB M KOpeMHaTa M WCT -B O A R T flO nePMTOHMT.

f i n ~ ~ a n H a ~ ~ ~ e M ~ R - ~ n n(rIapanneMfi), HanHa 6a6perHa. nep$Opal+lR: B rPbflHMR KOW ( ~ R X B~ M O T O ~ ~ BKC), xpaHonpoeofla ( x e ~ a ~ e ~ e s Ba 6)p , o~x (xe~on~oe).

Amanocm~a

- pa3WMpeH MeflMaCTMHyM; - Tpaxema n a ~ e c ~ ~ ea ~p ap c ~ o ; - flucnoKaquR Ha neem rnaeeH 6po~x;

-HenpaanneHaopTeH KOHT~P;

Peti~re~onomrtto. YCT~HOB ce: ~M

- XeMOTOPaKC BnRBO.
A o ~ T o ~ ~ ~flaea @M ~R aT i -~~ onti$opnnaqnR. r~a

2. Pymypa Ha ~pym ronennlr K ~ ~ B O H O C H cap,ose H

Tean pynTypu BOW flo TexKa xeMoparnR.

P e m r e ~ o n o ~ r Kpbrnu ~o. nonnqnKnnrHu ceHKu B nRBa rpbflHa IlOnOBllHa,Mnll HUB0HaTWHOCTC BbWYX H m

Oco6enocmu na mpaBmama B gemcka B s q a c m

195

Hero. K O ~ ~ ~ ~ T wacneflea~e H O T O Ha c r o ~ a w ~ o - ~ ~ ~ B H M R Tpam Aaaa H ~ ~ I - T O V H~ ~~ $ o p ~ a u n ~ . @ M ~ M K ~ ~n3cneflaa~e. HO Orcna6e~o flnwaHe B nRaa

rpbflHaflOnOBMHa,M3MeCTBaHeHaCbpflerHMTeTOHOBeB ~CH0,~peBHaflepMcTWTHKaBnRBanneBpanHaK~MHa.

Pymypa Ha ~ H M ~ H HnpoToK II np# )M aHallreTM4H, ~oK,M . 3 a ~ p TpaeMa ~ ~ a ce nonyraw npM x ~ n e p e ~ c ~ e ~ 3 ~ ~ eflMHMVHM ~ P ~ K T M npu MHoxecTBetiHapalcryp~ - nHeennaTnrHa c~a6nHarpbflHwe npewnetin.0nw-i~~ caeflMHnrtiM cnyaM Ha n ~ 3 a nnM q ~onepamBHo. ~ Crynea~e~ Ha o cTepHyMa ce npotiwsaqo HapaHReaHe. B nneepantiaTaKyxuHa ce HaneKyBa KoHcepeaTHaHo,npn p a 3 ~ e c ~ ~XMP~PMVHO. a~e TpyTlBa XMJlO3Ha TeCIHOCT, 6ora~a Ha ~ ~ ~ T ~ C IMMMa3HMH M ~ ~ ~ ~ ~ O K C W flMWHe H O T O CaMO no ce6e CM He e HHflMKaHM. 4 M R 38 MeXaHHCIHa BeHTHna4HR. T R e MHflUqMpaHa a M 0 KoraTo e HanMue AnxaTenHa HeAocTanrHocT nopqn KOHTy3MR Ha 6 e n # ~ pp06.
n~aruomwa
Ha. Pe~~re~onom 3r a ~c oe . ~r~B a rpbflHaTa ~e nonosnPM IlYHKUMR Ce eMKyMpa ~neKonofl06Ha TeVHOCT. @M~MK~~H nO p. ~ n n n eB ~ McHa ~ e rpbAHa nonoaMHa T C ~ ~ nuwatie. ~ ~ H O

I. Koanpec~n Ha r p b f l ~ ~ KOW n
nonyraea ce npw npmcKaHe uex,qy flee m p f l n noebpxHocTn, npu KoeTo ce noenwaaa HannraHeToB r o p HaTa npas~a setia, KbfleTo tiac-rbnea 3acToh c noa#weHo HanRraHe B repenHaTa W H a M pymypa Ha KpasoHocHn cafloae.
CHM~OMKIWK~
~~~T~XMW KpbBOM3nMBM HM no UIMRTa, JlM4eT0, KOHIOOTOrHOCT M nMBHf lHOCT Ha UlHFTIa M nMl$?TO, OTOrHOcT B OVHMTe AbHa, 3ary6a Ha Cb3HaHMe.

wO

HKMBMTe,

M ~ o x e c n opatrryp~ e ~ ~ Ha pe6pa~a
B IeTcKaTa~ b s p aTe c~ ce cpeqaT MHoro PRAKO nopaPM ronmaTa enacTMrHocT Ha rpbflHaTa cTeHa. H a n ~ r ~ e TO MM rOBOPM3a TeMa TpaBMa M T P F ~ HaCO' ~B~ ieHO

fla C e n p c yepefla ~ Ha npyrvr oprmcl. TRce nonyraBa OT flnpemeti M MHflMpemeH yflap. P a a ~ e ce n ~Ha ~ Flea BMAa npeneH M naTepaneH.

11. flpo~Hl(~aqH Hapi

i l rpbRHHn K O W

B ReTcKaTa BwpacT ce cpeqaT B Y-12%. OCHOBH rpyna OT TRX ca OmeCTpenHme.

blle~atltl rpbnHH TpaBMH

TaxMnHeR, AMcnHeR, 6on~a Br p b ~ ~ w KOU, n AH, coneBH~HOCT npM nannaqw, nannque Ha noAKoxeHe ~ @ u a e ~

fl~aruom~a Cpeu(a~ ce B 34.2% OT ~ O ~ H U npM T ~ . TRX Ha nbpBO MRCTO CTOM q e p e n ~ o - ~ o a b q ~ a 66.6%, ~a cneAsatia OT OCHOBHO MRCTO 3 a e ~ p ae ~~ ~ r e ~ o r p a $ M~ exorpama KOpeMHaTa TpaBMa 14.9%, T p a B M MH aK ~ ~ ~ H M U MH T ~ @MRT~. Ta3a 12.8% M flpyM K O M ~ H H ~ ~ M 5.7%. M Tex~a~ qe ap e n ~ o - ~ o 3 bTpaeMa, r~a npu K O ~ O M M a Cnelu~o 6 0 n ~ n newawe ~o 3 a M a HaCb3HaHMe, 3Ha'iMTenHO 3aTpyAHRBa~MalHOCTMn e r e 6 ~ a TamMKa ~a ce onpeAenR OT ~ah-aac~pauaKaTa Ha rpbnHaTa TpaaMa, oco6e~o npM ~ K P M T M yBpexaaqn-re xMaoTa pa3c~pohc~ea. n p nmca ~ Ha e $ ~ ~ a c ~ #iHMR. cnoHTaHHo pMtuaHe ce npoeewa uexaHMclHa BeHTMnaUMR. [PM HallMClHe Ha HapacTBaqO KpbBOTe'ieHMe B nneCHMIITOM~THK~ BpaHaTa WMHa M nHeBMOTOpaKCe nOKa3aHa TOpaKOTOO T C ~ ~AntuaHe, ~ ~ H O nponnntia e neplcyTopHuR TOH, M m . XMP~~~ML(HOTO neqeHue 3anoc1~a c nanapoToMMR B cllsuec~~a~e H a cbpAerHn-re rpawqn. Cny-laMTe, KOraTO A O M M H H p a TC M M n T O M M T e Ha KOpeMHa A~aruocm~a xeMoparnn, a yapewaHwTa Ha rpbntiwe opraw ca TaKMBa, '-l! MOraT fla 6bAa~ n M K B M p M p a H M C IlJleBpanHa Pe~~re~orpa ~acnenea~e N~o Ha 6encl~ ~po6. n y ~ ~ q ~ ~ ~ n ~ p p e ~ ~ p a ~ e . Cneluuo 6 o n ~ n neveHHe ~o B HRKOM cnyqaM e H ~ O ~ X O A M M ~ O sebpwaa~ H e a onePaTHBHa M H T e p B e H q M R eAHOBpeMeHH0BrpbAHaTa M KOpeC b C l e T a H M yBpemaHMfl H a rPbflHHR KOW H 'iepeMHaTa WMHa npM HaJlM.IMe Ha C M M n T O M M 38 M a C M B H a n ~ o ~ o 3 bTpaeMa r ~ a ce mnoqea AeKounpecnBtia TpenaxeMoparMR B AeeTe OT TAX. H ~ ~ B Mcnyqame, R KoraTo cnMnToMclTe Ha KoMnpecm Ha

PM

~03b~ npeo6na,qaea~ a HW cwunsoume Ha yapewatie Ha OpraHMTe Ha rpbAHaTa K Y X M H a . npM XeMOllHeBMOTOpaKc nneepanHaTa KyxnHacenpeHllrpa npepBapnTenHo, KOeTO M3WIK)YBa p a 3 B M T M e T O Ha Hanpel-HaT nHeBMOT0paKc n nasa B~~MOXHKHOCT Aa ce cneAM npopbnxMTenHocTTaHaMHTpanneBpanHOTOKpbBOTe.leHMe.

nporuo3a
n e ~ a n ~ npn ~ erpbp,Ha n ~ TpaeMa npM peua ce Kone6ae ~ewy5-11%. HaR-qec~a npnclntiaHaneTaneH~ 3 x 0 1 e TeXKaTa VepenHOM03b.lHa TpaBMa M MHOXeCTBeHMTe
YBpemaHMR Ha WbAHaTa M KOpeMHa KPMHa.

K o ~ ~ MTpaBMa H ~ T npeAcTaBnRBa ~ BHe3anHO HaCTbnMn0 B b H W H OM e X a H M q H O ~b3fleficTBMe B b P X Y IlpeAHaTa KopeuHacTeHa M M H T ~ ~ p, e T p M eKcrpanepmoHeanHo pa3nonoxe~n~e KopeMHn opraHn n TbKaHn, KoeTo npeAM3 B M K B a@YHK~MOH~~ HnM HMO p r a H M C l H Mn a T O n O M C l H MM 3 MeHeHnR B TRX C MnM 683 HapyWaBaHe qenoma Ha
KOxaTa.

K o ~ ~ M TpaBMa H ~ TB ~ReTCKaTa Bb3paCT M M aC B O M T e OCO~~HOCTM Reqa~a . ~ p y o~RcHRE~T ~ ~ o ~ e x a ~ Ha ~ a TpaBMaTa M H ~ ~ H nbpBM H T ~ npoRBM. Te reHepanM3MpaT ~ O ~ K O B MycelJ@HMR. T~ ~ O - T ~ Y F (eH OpMeHTaqMRTa ~ 3a M H T e H 3 M B H O C T T a , nOKMM3a4MRTa M MPmMa4MRTa Ha nannaToptiaTa 6 0 n e 3 ~ e ~ o A ce ~. ~ c ~ cbp~ewio-cbpoaa a~a CMC T e M aM M ano-~06p K O ~M n e H C a T O p H MB b 3 M O X H O C T HK b M no-6ae~a~pbB03ary6a,HO 6bp30 n3nma B CPMB npM ompa MacMeHa ~pbeoaary6a. Bb3nannTen~Mm npoqec B

~ a

B H M M a H W T OHe C KOnM'ieCTBOTO, a C TPYnHaTa flMalHocTMKa, c n o x H m a H a ne'iewero W ~3xopa Ha 3a60nFlBa~eTO.

Knacn@m~aqm~
- napeHXMMHMTe OpraHM; - KYXMTe OpraHM.
OTKPMT~ KOpeMHa TpaBMa:

- KopeuHaTa cTeHa;

3a~pu~ KopeMHa a TpaeMa c ppepa Ha:

- HenpOHMKBaUJa - nPHMKBaqa C ppeaa Ha: napeHXMMHMTe OpraHM;

KyxnTe opraHw.

T ~ ~ B M ~ T MX V e M H a T M O M TH ~ Ha KOpeMHaTa CTeHa Ce neKyeaT HeonepaTwBHo. np~noxe~o nereHne ~o qen# pa Ha#an# BbTpeTbK a H H M F lK P b B O M 3 n U B C IlOCneAWqap e 3 0 p 6 ~ ~ 'ipe3 ~1, $M3MoTepaneaTM'iHM npoqeAypM. K ~ OnepaTMBHo M ne'iewe ce np~6~1ma npM nMnca Ha nonomTenHapMHaMhnMKavnlr B cnpan Ha abananweneti npoqec M O$OPMRH~Ha r ~ o i KOneKuMFl. Ha6nlo~aea~me BPeAKM Clly'iaM TpaBMaTM'iHM BeHTP W H M X e P H M M M ~epe30p6Mpa~ 0 ~ M @ ~ lM p a n X e M a T O M
nomexaTHannaHoeoonepaTMeHone'ieHMe.

~ ~ K P M TpaBMa T ~ Ha KOpeMHaTa CTeHa e BHe3anHO HaCTbnMnO BbHUlHO MeXaHU'iHO Bb3fleh~~BMe, KOeTO ripep M 3 B M K B aYBpeWaHe Ha aHaTOMM'iHMTe CnOeBe Ha KOpeMHaTa meHa, 6e3 HapyuaeaHe qenoma Ha KoxaTa. Y ~ C T O THa ~T 3aKpMTaTaTpaBMa ~ Ha KOpeMHaTaCTeHa B CTpylcrypaTa Ha KOpeMHaTa TpaBMa e 77%. O ~ B M Ha ~T yepeyqaHeTo Ha KopeMHaTameHa (OT AephnaTa po nepn~ o ~ e ysaaMcM ~ a ) OT cMnaTa Ha ypapa, OT HanpaeneHMeTo M OT B M p aH a TpaBMMpa~MR $aKTop. ~3J'lMBatl@~a Ce KpbB MM6~6flpa~paB~Mpa~U~e MO K O n H M T e T b K a H MH ~ o6pa3yM Ba OTPaHM'ieH X e M a T O M .

3 a ~ p KopeMHa ~ ~ a TpaaMa c ynpefla Ha n a p e ~ x w ~ ~ m i p r

3 a ~ p n ~ ppeun u ~ e Ha KopeMHM opraw ca ~al- exKMFlT BMA TpaBMa BCleTCKaTaBb3paCT,Tbh KaTO B b BB C M K i' M cnyran 3acTpauraeaT HenocpepcTBeHo mBoTa Ha peTeTO. B c~pyln-ypa~a Ha KopeMHaTa TpaeMa, recToTaTa H a ppeAn Ha KopeMHM opraHM npu aaKpma TpaeMa e 1.56%. Hah-rem~ B peTcKaTa BbapacT ca ppeAMTe Ha cnesKaTa 20-65.7% cnedeaHH OT ppepa Ha repHMR ppo6: 12-30% M Ha nawpeaca: 1.7-5.5%.

f f i n ~ n r ~ wC re M M ~ O M 3a U yBpeyqaHe Ha napeHxMMHM KopeMHlrl opraHM ca n p o m npenM m r K o Ha TpaeMaTcl'ieH M xeMoparu'ieH UIOK OT m p oHamnBaqaTaw p e ffiM~M'i~a C ~ M a M n T O M a T M K aCe nPflBFlBa C KpbBOM3KOpeMHa XeMOparHfl. H a c o w a q ~ KnUHH'iHM C M M m O M M nMa, OTOK M h n ~ ano~ann311pa~~ , B o6nacrra Ha ppew3a YBpeAa Ha IlaPeHXMMHM OpraHM C n O H T a H H M 60n~u B Ta, KaTO MHTeH3MTeTbT M Me B3 a B M C M M O C T OT 0 6 e ~ a Ha KopeMa, noepbqaHe, 6nepoc~ Ha KoxaTa M B M p H M H T e YBpeAaTa. He Ce Y C T a H O B F l B a T$ M ~ # K ~ K n ~ M H U C M l H MC H M nMraBMuM, OXJly3BaHe HXeMaTOMM Ha KOpeMHaTa CTeHa M pontiaTaTpeTa Ha P ~ A H M FKOUI, ~ 3 a e ~ aH ~a e npwyawenHo nonoxeHue Ha cTpaHaTa Ha yapeAaTa, 6ano~Mpa~ Ha KopeMa, nannaTopHa 6 o n e 3 ~ e ~ o no c~ q e n ~KopeM, ~l P e 3 M C T e H T H O C THa KOpeMHaTaCTeHa, nOnOXMTellHM CMMn T o M M 3a nepmoHeanHo RpaaHeHe, npmnmaHe B ~ B ~O~O~HMCIHO noBeAeHlrle TO aKnlo'iea WnocTeH nper$Jla~roBe~e Ha KOpeMa, KOeTO M 3 M e H RT p a H M q M T e CM npM neA Ha TpasMaTM'iHo yepeneiioTo AeTe M ~ 3 e ~ H aa~ e Hann'ine Ha cB060p~a nopanxtia Te'iHocT, BRna po nclncp e w e H M e 3 a x o c n ~ ~ a n ~ 3 a q n ~ M n n s a o ~ ~ a 3 0 ~ ~ eBaua ~ . nepUCTanTMKa. ~ ~ T O ~ O M O H C # M M '~ n T H O M U M 3a pAeqa C b C 3aKpMTa TpaBMa Ha KOpeMHaTa UeHa peWaHe Ha c n e ~ ~ aHa ~a repHllrR , 4po6 M Ha naHKpeaca ce naMcKBa ~ M H H C ~ H ~a6nlope~Me O 1 0 nbnHa yfieue~oc~, HRMI. C~eneHTa Ha M 3 F l B a Ha KnHHM'iHaTa C M M n T O M a T H K a 'ie HRMa3aCemaTMKOPeMHMOpraHM. f f i M ~ M ' i ~ 0 ~a6nlo~0 KOpeCnOH~Hpa Co6e~a H a PpeAaTa M ocTpaTa BbTpeKOpewe npM TesM ppepn Hua rnaeHo p ~ $ e p e ~ u ~ a n ~ o peMHa xeuopamg. HenocpepCTBe~o cneA TpaeMaTa ce AnamocTH'iHo 3 ~ a ' i e ~TO ~e M . ~ F I C H R B ~ ~ Ha H~ nbpBHC~T~ ~a6nloflaea HeorieTnneo n 3 ~ l e e ~ KnnHM' a iHa cuMnToMa'~HHnnH pa3~~~aq1.ice C M M ~ O M M 3 a y ~ p e ~ Ha a~ napee TUKa, nOpEi)$I no-MaJlKOTOKOJlU'ieCTBO KpbB B C B O ~ O ~ ~ H X M M H M HnM Ha K y X MK O p e M H M OpraHM. AKO T~KHW YBpeXKopeMHa KyXuHa, RpasHeqa no-cnah nepuToHeyMa. AaHMR H e MOraT C b CC H r Y P H O C T pa 6 b n a ~ M3Knlo'ieHH, n p n e a ~ o ~ o ~ e ~ ~ ~ o ~~o ac yns ep 3~ ea~ ~a a c~ n HanOxmenHO e npMnaraHeTo H a 1onbnHuTenHnO ~ ~ K T M ' WatiHaTa H nannaTopHa 6on~a, pe3uc~e~~~o Ha cr KOra B H U , HeMHBa3tlBHn MnM U H B a 3 M B H MM e T O p M 3a M3CneFjBaHe peMHaTa meHa n neplcyropHoTo npmnmatie ce ycraHoKaTo: exorpa@n, KovnloTbpHa aKcnanHa ~ o ~ o r p a $ n ~ , BRMT B nmoTo noflpe6pne M B n e w naTepaneH KaHan. pnamocTn'iHa nanapoqeHTe3a n nanapocKonnR. C~a6nnn~paH ~a eAH ~o B Hop~anHn p a ~ u q 3a u pa3n~-

Cm~mo~am H flmaruocmKa ~a

PM

198 a Oco6cnocmu na m p a 6 ~ a m a B gemcka Barpacm

cams cnabnn Ha nepll$ep~me cbpose M Ha ycKopRBaHeTO

rHme ~aapac~oeln rpynn ce m n x u Ha pe$nelcrop~n~

Ha nyflca b l HMara BHUMaTenHa IlpeOueHKa, ~ b K ha T O HeM3Klllo'iBa)'BpeflaHanafMHXMMHUOpraHU. C ~ o k o a u Te ~ a e p w p o u m n ex e ~ o r h ~ya c ,~ a ~ o 1 w0 ~ ~P nB U R rac cnep TpaaMaTa He daBaT B ~ ~ M O ~ fla O C ce T npeuetin cTenema Ha KpbmaMa, c no-ronma pnamocTHrtia c ~ o k oe cnpocnepRBaHeTo ~ MMB Mmepean. no-~acoreaq a K ~ BbTpeKopeMHa M xeMopamR e ~a6nmpaea~a~a neBKOUMT03a.

npn p y @ a s ~ppewaHHR n Ha c n e s ~ a cy6~an~a cynaptiumxeMaToM nouenentio HapacTBa M cnep naTeHTeHflepMO~OTHRKOnKOclaC~~OHHROnKOflHHnpeflM3BMKBa BbTpeKOwMHaXeMOpaMR. HHR ~

K n n ~ n r ~ cuumouaTnKa a~a 3a p p e w a H e Ha r e p 1 ~e 0no-OT' 6 ieTnMBO M3RBeHa, Tbh K a T O C KPbBTa B KopeMHaTa V H a nonqa H c b p p m ~ OT o yspeleHme nmpaxenaTanHn m r ~ mmqa, n ~paa~eq no-CM~HO o nepuTotieyMa. YcTams~~Ba ce cnomawa M nannaTopHa hne3~e~o B ~RCHOTO c~ no~pe6pne,~ ~ ~ H C T ~ H T H Ha OCT flu$epe~u~an~a flnamoaa ce npaaw c K O H T ~ ~ M Ha R KopeMHaTa cTeHa n nonomemu mMnToMH 3a nepuToKopeuHaTa cTeHa n yepefla Ha K ~ opraHm. M no-~pyfl~ ea HeanHoflpa3~e~ecnepicyropHonpmnRswe~~ecHMR flu$epenquanna~a fl~ar~oa ca perponepnToHeaneHx e naTepaneH KaHan. Cy6~ancynap~n~e xeMaToMw Ha repMaTonn. npn Hero6 0 n ~ a e ~n ao - c ~ n ~HO a ,683 HpwMauMR. HMR npo6 ce n o ~ a n n 3 ~ p no a pna$paman~a~a ~ noebpxHe C e YcTaHOBRBa pe3MCTeHTHOCTHa KOpeMHaTaCTeHa M HOCT n KIIUHM~HO ce nWBRsaT cac cna6a nannaTopHa C M M n T O M M Ha nepHTOHeWlH0 flpa3HeHe. npMTbnRBaHe~0 h n e 3 ~ e ~ oBFIRCHOTO cr M ~ nRBo M noppe6pne. npn mopnB ~ $na~roae~e B Ha KopeMa He M ~ M ~ H rpaHMu#Te R CM npn rHa pymypa Ha xeuaToMa ce pa3an~a KnnHnrHa CMM~TO3aBbpTaHe T R n O T O Ha AeTeTO (CMM~TOM Ha Joyce). MaTnKa Ha BaTpeKopeMHa xeuopamn. npn aaonnpa~a rep~oppo6~a ne3n~ n xeMaToMn ce w p u ~ p UeHTpaa net! xeMaTonn, rnmo esonloqnfle o @ p ~ HacbeflnHM~~e TenHO-TbKMeH~KWTPMKC,TpaBMaTU~Ha IlCeBNKMCTaM n M npunpo6na B m r ~ mmqa-xero6nnn~. n M3nn~b~ Ha KpbB npe3 ~3BbHrepH0flpo6H~e M b r H M mTUqa B CTOMaUlHO-'ipeBHMR TPaKT C e npoRBRBa KnMHM'iHO C KOnMKO06pa3~u 60nm B NCHOTO noppe6pue, MeneHa, no-p~fl~o xeMaTeuea, MexmnreHnaepnp~o6~ypaun~ HamrHMTe mTLlqa OT KpbBH# KOarynM, BTOPHClHaaHeMHR M x'enaTOMerNlMR. Hah-&mime MMllTOMnnpHTpaBMaTUrHOYBfMWaflere~ne~ Ha ogeua c yspepa Ha napeHxMMHHKopemHe Ha Cne3KaTaH 'iepHHR~(p06, y HOBOPOfleHH, HaCTbnMnM HM OpraHM IlpM 3aKpMTa KOpeMHa TpaBMa C e npOBewa intraparturn ca n o - r o n ~ ~ a ~ e n Maca ec~a npn pqaHeTo, npU eflHOBpeMeHHocT Ha flMalHOCTMKaTa M WeKBaTHO 6nepoc~ Ha KOHTa bl JlblraBHulrreH ~ ~ J ~ o H u P Ha ~ KOpeH ~ IlereHHe Ha TPaBMaTMqHO-XeMOPaMqHHF1UlOK C MHTeHMa. ~ M B uupKynaToptia H ~ M pmxaTenHa peaHnMaum c uen npu rpaeuamwo yepewaHe Ha nawpeaca MMc~a6nn~3~p Ha a~ sMTanHMTe e $ ~ H K ~Ha MM opra~nswa. HHrHaTacuMmonnamKa ce pa3anBa6 y p ~ OT o nonwHancln o ~ x o p ~ 3a q uHeonepaTmBHo n e r e w e yspeflM Ha naTe B KOpeMHaTa KyxklHanaHKpeaTMVHU$ ~ ~ M ~ H n0RBf.ITu. PeHxnMHM opraw ca peua, KOMTO noKpmaT cnefltime Ba Ce MHOrOKPaTHO nOBpbqaHe. n p O~~KTMBHOTO M3ClleKpMTepMM Ha np0rHOCTM'ieH IlpOTOKOn: XeMOflCIHaMMqHO p w e ce ycTaHoaFlea cwtia nannaTopHa 6 o n e 3 ~ e ~ o B c ~ C T ~ ~ H cnep ~ H M06eMH0 a a ~ e c ~ s Ha a~ He e noeere 0 ~ 4 0 % nRBaTa ennracrrpama nonoema, MycKynHa 3aqma Ha OT K P b B H M R 06e~ C KPMCTanOMfleH pa3TBOp (Ringer KopeMHaTa cTetia c nonomenHn cMMmoMn 3a nepmonaKTaT nnn 0.9% Natriurnchloratum), n o ~ y n n e ~ ~o np 6a e~ ~ Ha yspeflaTa rpea exorpa@~o unM KAT MxneAeaHe M HeanHo l p a 3 ~ e ~B e nepu$ep~a~a . ~pbe ce ycratioema Ha6flt0fleHMe B peatiuuaquoHHo oTAeneHne OT cneureH neBKowo3a C OneeRBaHe H yBennreHn c r o l ~ o c Ha ~ naeKun, BKnlorBaq xMpypr M peaHwaTop. O n e p a m ~ ~ o a~nna3a~a n Ha nnna3a~a.

np#3aKpnTaKOpeMHaTpaBMaC e Ha6nlopaBa~ 3HaWTenHM f l u $ e p e ~ ~ ~ a n ~ o - ~ TPY~~HOCTM, ~am~~ npona~ur~ Turaqu OT TOM, r e no-ronma racT OT KnMHnrHme CMMmOMM ca 06qM 3a TpaBMa Ha KOpeMHMTe OpraHM M C a M O Y a C T OT TRX C ~ ~ ~ $ M3a CYBPefl IHM a Ha KOpeMHM OpraHM. TOM BOA# R0 IlOBWUleHO H3MCKBaHe KbM MeTOflMTe 3a uscnepea~e npM a a ~ p n ~ a ~ o p e ~ ~ npnnaraHe a~pae~ Ha fl0nbnHbfTenHM O ~ ~ K T M B H HeMHBa3MBHM M MM H B a 3 M B H M MeTOflU KaTO: exorpa$MfI, KOMlloTbPHa aKCMXiHa TOMOFpa$cl~,RnamocTnrtia nanapouetiTe3a M nanapocKonwR. Pen~re~oeo~o ~acneflea~e npn yepefla Ha napeHxuMtiM opraHn AaBa caMo Koceennflannn: BMCOK cToex Ha pna$pamaTa c orpaHnreHa nouslrxHocT, BUCOKO paanonoxeH M e Ha ra30BMR MeXYP Ha CTOMaXa. ~ P M3nbf H B Ha noronmo KonnvecTso ~ p b e ce ~a6nlofla~a aace~lr~a B~ M~~KM ~R aM 3naTepanHMTe KaHanM.

Oco6enocmu no m p a B ~ a m a B gemcka Ba~pacm 199

nereHMe qen# nomMraHe Ha

pe$~~wwe xe~oc~aaa, ~a
CHMIITOM~MK~ H RHanlOGTHKa
HaA-xapaKTep~LI~e W I H H H V H MC M M n T O M M 38 YBpeX-

6wn~oc~a3a M nepmo~w3auu~ Ha yBpepeHme OpraHu. 3 ~ a r e ~ Ha ~ ec~ ne o3 ~ a ~ KaTo a opraH, H ~ O ~ X O A M3a M nOApaCTM~MR fleTCKl4 O p T a H M B b M ,K a K T OM p a 3 B M T M e T O

H a nocTcnneHeuoMMreH CMH~POM e MHAnKaunR 3a npwnOXeHMe Ha OpraHOCbXpaHRBa~H OllepaTHBHH MeTO-

AaHe Ha WM opraHu ca ~ e Ha 3 noKaneH ~ Inn ~ ~ $ y 3 nepuToHuT, npoRaeHn HenocpenmeeHo cnen TpaeMaTa AmKn. C n n e ~ e t m o ~ ~ em no a ~ a 3 a npu ~ a K O H K B ~ C ~ ~ Ha MFI npn npoHmKsaqnTe B nylueHa HapaHRBaHHu. YCT~HOcne3~a~ Ha yBpenM B o6nacrra Ha xunyca h. npn $ ~ c y p ~ BRBa Ce MHOrOKPaTHO flOBpbqaHe, ~ M O H M P ~Ha H~ KOpeM PYllTYPM ~aV ~ P H M R ~ ~ ca0 floKa3a~M 6 opraHoqa#R~H OnepaTMBHM M e T O A M K M . n ~ r a ~ y Ha p a.lepHoflp06~a~a apTepw e n o ~ a 3 a npu ~ a J ~ ~ ~yepexqaHwR O K M Ha napeHxMMa, cbnpoeoAeHllr c uaclreHoKpbeoTereHme. n p $pame~ HTaqw H KoHKeacaqm Ha opraHa ce npMnara aTunMrHa M a H a T O M M V H a pe3eKqMR. O ~ ~ ~ ~ T M B Jle'ieHMe HOTO Ha TpaBMaTHrHaTa x e ~ o 6 w BKllDrBa n ~ ~ TpM B M I a MeTOAMKM: OTsapme Ha xeMaToMa c nurarypa Ha K ~ P B R ~ H cbn R M eAHOBpeMeHH0 flpeHMpaHe Ha 0 6 4 Mlb'4eH ~ ~ IlpOTOK, nMraTypa Ha r e p ~ o f l p o 6 ~ a apTepMR ~a B cnyclai Ha AOKaMa, RWlllaTOpHa ~ O ~ ~ ~ H ~ H MyCKyJlHa O C T , P M M R H O C T Ha

PHOMpeHTreHOflOM~HOe~OCTOBepeHCMM~OM3ayBpe
WaHe Ha Kyx OpraH, H 0 OTCbcTevleTO My He e O C H O B a H M e

AaCeOTXBbpflMTa3MflMamO3a.

Pe~ponepu~o~ean~a~a pynTypa Ha AeaHaaeceToIlpbCTHHKaIlpoTMVa B Ha'ianOTO C no-AMCKpeTHaeMMflT0MaTHKa C IlOCTeneHHO pa3BMTMe Ha KnMHM'iHa KapTMHa Ha

peTponepuToHeaneH $ n e r ~ o ~ .
HHR CerMeHT ce p a 3 n p o c ~ p a ~ ~ no aa qRnaTa cTeHa Ha 'iepBOT0 M BOAM A 0M e X a H H C l H OC T e C H e H H e H $YHK~HOH~nHa YBpefla Ha nepMCTaJlTMKaTa.CneA ceo60fle~MHTePBaJl OT 1-1 7 BHM nOCTeneHH0Ce pa3BMBa K J l M H M ' i H a C M M n T O M a T M K a Ha B M C O K a 'ipeBHa H e n p o X O C I M M O C T . f l p M KOHTHPaCTHO M T ~PeHTreHOBO M3CneflBaHe KOHTpaCTHaTa MaTepMR cnupa Ha HMBOTOHa Ill lrlnu IV ram Ha AsatiWeceTonpbcT H M K a H OrepTaea onHcaHaTa OT Felson c( Levis 6ener Ha cnMpanHa npymtia, K O ~ T O e naTorHoMoHlrlreH3aficllamo3a~a.

sa~a~ h ne3m a rpe3 MHTpaonepaTHeHa a ~ r u o r p a $ n~ ~ rep~oppo6~a p e 3 e ~ u npu ~ ~ .yapena Ha naHKpeaca ce npMnaraT cyrypa c RpeHax, napqnantia p e 3 e ~ u M~ ~~ M naHKpeaTOF(y0fleHOeKTOMMR flpM YBpefla Ha rnaBaTa Ha naHKpeaca. Peae~uwfl~a Ha 213 OT naHKpeaca B peTcKaTa
Bb3paCT He B O A M A0 X O p M O H E U l H a M @ ? ~ M ~ HeflOCTaHTH~ T b q H O C T B ClleflOnepaTMBHMR nepMOfl. T ~ ~ B M ~ T H ncesnoKMcTu Ha naHKpeaca nomexaT Ha nnaHoeo one-

M~~paluypan~ xeMaTonn mn~ Ha ~ y o ~ e ~ o - i i e l o ~

PaTMBtionereHMe. B cneflonepaTMeHMR nepHoA ce npoaewa H H T ~ H ~ M B HO MH$YSMOHHO H ~ H T M ~ ~ K T ~ nereHue ~ u ~ ~ HnpM O KOHTpOnHaBCMClKMOCHOBHMnOKa3aTenM.

Henpo~rn~eaqn~e B nywetia Ha T~HKOTO repm HaP a H R B a H M R IlpOTMraT ~ ~ ~ C M M ~ T O M H O . O T K ~ C B ~ Ha ~ 'iepBOT0 TO OT Me3eHTepHYMa Ce npORB F l B aK J l M H H q H OC b CC U M n T O M H Ha BbTPeKOpeMHaXeMOpaM RMp a 3 B M T M e Ha IlePMTOHMT CneA nbpBOT0 p0 BTOPOTO

Hah-rec~n ~ a 6 n ~ ~ a cneAonepaTweHH sa~n ycnoxHeHMR Ca: MeXaHMrHa TbHKO'ipeBHa HenpoXOflMMOCT, HH-

~paa6flo~blHaJl~M a6cqec~,flOcTOnepaTMBeH nepMTOHMT MB T O P M q H a BbTpeKOpeMHaXeMOpaMR. Te HEUlaraTM3BbpLuaaHe Ha paws penanapoToMm.

BeHoHoqMe OT TpasMaTa.

YBpefla~a Ha PeTpOnepMTOHeEUlHaTaW C T ~ape6enoTO repeo npoTnra c K n M H M K a Ha T ~ ~ 4 On Be r ~ 0 M peTpo~ pam.

fln$epe~q~an flnamosa ~a Ha ppewatiuma H a Wxme opraHu ce npaw c TpaeMaTMrHn yapeyqaHuR Ha napeHxMMHuopraHn M c B C M ~ K M ~ a a n a n u ~ npoqecn en~~ B KopeMHaTa KyxuHa - o c ~ b p a n e ~ ~ n q Me~enoa w, AMaepTnKynm (Diverticulitis Meckeli), BbnpeKu a ~ a ~ ~ e 3a3 3aKpMTa KOpeMHa TpaBMa.

- HeflpOHMKBaqMBnyMeHa;
- IlPOHMKBawM BnykleHa;

H a fr e c ~ cpeUaHme o @PMM

Ha yepeAa ca:

JJ5on~nr~o noeeneHue ~o BtunKlrsa cmeMeH nperneA Ha rpaeMaTnrtioyapeAeHoToAeTe, yc-raHomBaHe Ha muHHwia CuMrnoMamKa 3a noKaneHunu ~ u $ y 3 e nepw~
TOHUT M TpaHcnopmpaHe K ~ M cneqwanwnpaHo AeTcKo X'GIP~PMC~HO OTAeneHue.

200

Oco6ewocmu na m p a B ~ a m a B gemcka Bwpacm

n e r e ~ ~ ce e~ npoaeyqa o npM cnaaeatte Ha cneAHwTe OCHOBHM flPMH~MnM: eflHOBPeMeHHOCT Ha AHaMOCTMKaTa M npoTMaoluoKoame MeponpMmnR, cneA nocnneaHeTo cBoeBpeMeHHo ~ ~ s b p l ~ l e Ha a~ ~e eo 6 x o f l ~ ~ AMarHocme TMVHM M e P O n P M R T M R , BWIDClMTenHO M AMalHOCTM'iHa nanapoue~~e3a, cnewHa nanapoToMm,o n e p a T H a H M KaCnOpeflMHTpaOnepaTMBHaTaHaORKa,CaHa~MRHaKOPeMHaTa KyXMHa, M H T e H 3 M B H a H H $ ~ ~ M O HMHa~~w6aKTe~ pManHaTepanm ~ c n e f l o n e p a ~ ~ ~ ~ ~ ~ n e p ~ f l p Pym-ypaHacToMaxa, ~ MrnpanepMToHeanHaTavacT Ha flyOneHyMa M MmKM PynTypM Ha T b H K O T O VePBO MeTOA Ha ~ 3 6 e0 CyrypaTa. ~ npM uMpKYnFIPHMPYnTyPM,O~MMPHM pe$eKT~ M n n 6nn3~0 pa3nonoxe~ epHaflo ~ Apyra pynTyPM Ha T b H K O T O' i e P B O C e H3BbpUBa Pe3eWMR C TIPMMHOTepnnMHanHa a ~ a c ~ o ~ o a a .pynTypa Ha fle6eno~o yepB0 Cmpa CM: M n M 6e3 AeKOMnpeCMBHa KOnOCTOMa. Onepaq~~l Ha ~ 3 6 npM 0 ~peTponepmoHeanHapynTypa Ha 4yoReHyMa e cy-rypa c AeKnMseH RpeHam M npencsaHe H a nacaxa npes RyoAeHyMacac cTouawHa pe3e~UMR n0 Billroth 11. ~ ~ P M K 3a ~ ~OnepaTMBHO M R JleVeHMe o6xofl~a a H a C T O M O 3 a npM T p a B M a T M V H M R MHTpaMypaneH xeMa7ot.d Ha ~ y o f l e ~ o - h e m ~ acerMeHT n ~ m ca cnyclawe H a BwcoKocTeneHHa rpesHa HenpoxonMuocT, HenoBnwsaqa ce OT npMnoxeHoTo KoHcepBaTMBHo neqeHHe (CTOMaluHa coHAa aa ~ e ~ o ~ n Mp napeHTepanHo e c ~ ~ xpaHeHe B npoAbnmeHMe Ha 10-12 Atin).

MeXaHM3bM Ha Bb3HMKeaHe P a H M T e Ha KOpeMHaTa cTeHa ce p a 3 p e n ~ Ha: ~ np060fl~M,n o p e 3 ~ P ~~ , ~K~CHM K O H T ~ ~ Ho Mr ,~ec~pen M~ HOCRT w xapatcrepa M 6 e n e 3 ~ Ha ~e C b O T B e T H M R BMA. H ~ ~ ~ H R B Ha ~H npeflHaTa M R T ~KOpeMHa ~ . Ce p83flenm Ha HenpOHHKBa~M CTeHa B KOpeMHaTa KyXMHa M IlPOHMKBaqM B KOpeMHaTa KyXMHa C MIlM 683 YBpeAM Ha K O p e M H M OpraHM.

no

PM

~ H W H ~ T ~ C M M ~ O M ~ HenpoHMKBaulMTe T M K ~ ~ ~ M HanpencTaeeHa OT n o ~ a n ~ 3 u p a 6on~a ~a B o6nacna Ha PaHaTa. ~ M H M V H ~C T M M ~n T O M a T M K a npM IlpOHMKBaqMTe H a P a H R B a H M RC YBpeAa Ha K O P e M H M OpraHM Ce BJlwee OT C M M n T O M a T M K a T a Ha BbTpeKOpeMHaXeMoparw nnM Ha noKaneH M A M $ Y ~ ~nepMToHmT. H A~amoaa~a npoHMKsaqo HapaHReaHe e HecbMHeHa npM nponanc OT KaHana Ha paHaTa Ha ronRuoTo Gyno, TbHKoVpeBHM bHKM, M3TH'iaHe Ha KPbB, Y p M H a , C l P e B H O M Mb'iHO CbAbPXblMO.

paHmatinR e

H a f vec-ro H ~ ~ ~ I O ~ ~ ~ B ~ H M ~ C ~HanaraqM O X H ~ H~ MF 3 I -, BbplueaHe Ha penanapoToMwR e nocTonepaTMaHMRT neP M T O H M T , mnxaq Ce Ha M H T ~ ~ ~ ~ ~ O M a6cqecn M H ~ ~MH M MHC~$M~M~H~ Ha M CYTyPM R M aHaCTOM03M. MHO~O PRAKa e npoRsaTa Ha .c~~flpotm H an p e f l n a s ~ ~ o~ na~ K "n . n~~rlHaTa M ~ R e B OT ~ 3-6 Meceua cnep, TpaeMaTa, npoRaeHa KaTo rpeeHa HenpoxoAnMocT BcneflcTsMe Bonaynyc Ha T~HKO vepm oKono oMeHTynn, npMsnereH KaTo 6 p n~ ~ ~ nocnpasMaTMreH xeMaToM Ha ~ e 3 e w e p n y ~ O~LUMPa. HaTape3eKuMRHaTbHKOTOVepmBOAMAOCMHflPOMaHa m T a VpesHa nHKa (Short-bowel-Syndrome), K O ~ T O Ce xapa~~ep~3 c~ HapyweHuR pa B M O ~ M ~ M TceKpeTop~T~, HaTa, A M r e C T M B H a T a M ~ ~ C O ~ ~ ~ M O H$~HK~HFI H ~ T E I Ha C T O MaluHO-'ipeBHMR TPaKT.

OT BCM'iKM BMAOBe TPaBMM Ha KOpeMa OTKPMTaTa KOpeMHa Tpaeva M ~ M C K B ~~a i - ~ a oprawa n ~ a M~v$epe~UManHa AMarHO3a, Tbh KaTO KlMHMVHMTe C M M n T O M MV ~ R T caoeTo a ~ a c l e ~ nopay ~e H ~ O ~ X O ~ M M O C IOT T ~ cneuttia onepaTMBHa ~ ~ B M ~ M R . C ~ ~ ~ MM3 ~Cn IeA ~ W H H M R M npU OTKPMTaTa KOpeMHa TpaBMa He C aH~O~XO~HM MH~ .TOA H ~ aT Byn~ep~rpa$MR
~eeno~a3a~np~~e~anop~~~b3~0
M M H a u M R Ha # H $ ~ K ~ M Ka F UIO , M HeCHVPHaTa MHTepnpeTauMRHape3ynTaTMTenOOTHOWeHMenPOHMKBa~MRMnM

HenpoHnKaaqxapaKTeptiaHapatiReaHeTo.

AO~O~HMCIHOTO noBeueHMe emtorea cucTeMeH nperneA Ha TpaeMaTM'itio yepeAeHoToClere, caHaunR Ha paHaTa c arnMcenTM'ieH ~ ~ ~ T B O MP ~ , B ~ P W Ha B ~ np Ho ~~ n 3 0 p ~ a xe~oc~a3 OT acunHo ~ P B R ~ caAoBe M , Ha paHaTa, nocTaBRHe H a CTepMnHa npeBpb3Ka M 112 CC TeTaHM'ieH a H T M T O KcnveH npeunnmaT (TAn) M TpaHcnopTMpaHe~o cneunannsnpa~o~ O ~ H M V H3aee~e~cle. O Ha T O ~ MeTan He ce

Oco6enocmu na mpaBmama B gemcka Ba3pacm

201

Cneluuo ~ O ~ H H ~nelleHHe HO
KsaT

OTKPMTK~~ HapaHRBaHMR H a KOpeMHaTa CTeHa M3MCnapenrtia x M p y p m r H a 06pa60~~a H a p a H a T a c qen

AMamOCTMKa H a BMAa H a HapaHRBaHeTO M MaKCMMaJlHO CHMXeHMe Bb3MOXHOCTTa 3 a 6 a I ' ~ e p M a J l ~ aKOHTaMMHa4MR. n e c l e ~ M e ~ H0a H e n p O H M K B a ~ M T eHapaHflBaHMR C e C~CTOM B X w p y p r n r H a 06pa60~~a ~a paHaTa. t l p ~ npowK B a q M T e HapaHfiBaHMR e 3kl@nXMTenHO M3BbpUlBaHeTO HacpeAMHHananapoToMwa 3 a p e a n 3 n ~ H a abrpeltopeuHHTe OpraHM. Jlere6~me cneponepaTMaHM MeponpMmMR, ~ n ~ 3 a U M B CbCTaBa H a KOMnneKCHaTa TepanMR, M HaCOVeHM K ~ m Me K B a T H o 3 a M e c r B a H e H a AexMlpaTaqMnTa, oenwa a H e H a nepMToHMTa, r p e e H a T a nape- M r p ~3x a~ ~ ~PBM~ H sapac~sa~e O H a paHaTa.

Care~a~ T p~ a a~ Mn e ca c n e q ~ a ~ ~ r~ oa sono~r e~MHM~a,npMKORTOMMaKaCleCTBeHOHOBOnpOTMclaHeHa flaT0nOrMqHMR I l p o q e C B CpaBHeHMe C M30nMpaHMTe y p e AM. Te MH ~ ~ - T P Y P H3aAUarHOCTMKa M nOpa,Q4 HeOTVeTnMB 0 npOflBeHa KnMHM'iHa CMMnTOMaTMKa. n p M Cb'ieTaHM TpaBMM,CbllpOBOfleHM C WOK, r 0 n R M a KpbB03al@a, KapRHO-PeCIlMpaTOpHM HapylueHMR e BEWHO A M a M C T M q M p a HeTo H a ocHoeHaTa npMrMHa, eoAeqa M o n p e p e n g q a . TIXKOTO CbCTORHHe H a n O C T p ~ a I l O T AeTe. 0 H0 .BOAeqMRT' KnMHM'leH CMMnTOM ~a@ ~ H aa TeXKOTO CbCTORHMe H e BMHaM e OT'ieTnMBO IlpoRBeH M M3RBeH. C M M ~ T O MMTe HaTpaBMaTMreH WOK M KpbB03al@a M M ~ pa3nMYHO T flMaMOCTMCIH0 3HaCleHMe n p M M3OnMpaHMTe M Cb'ieTaHM

06w

YBpeWaHMR. n p M H3OnMpaHMTe CBMmTencTBaT 3 a Y B p e W a H e H a KOPeMHM OpraHM, TO n p M CbreTaHMTe TpaBMM I$RTCBOeTO 3Ha'ieHMe OpraHM, flOTOnKOBa, flOKOnKOT0

AOK~TO

TeXHMRTnPOM3XOfl3aBMCMHeOTyBpeWaHeHaKOPeMHM

a OT CbnbTCTBaqM ~

K C T ~ ~ ~ ~ ~ ~ OY M B pM e XH - ~ I

AaHMR B flPYMTe aHaTOMMClHMO ~ ~ ~ C T M TPaBMaTMqHO .

PM

yapewatie ~

a ~ a 3 a pc ae3 a ~ e n aa ~ p a a e 3 ~ ~M apn eT ~p~ oIlepMTOHeanHM XeMaTOMM CbC CMMnTOMaTMKa, 3aTPYflHRBbTpeKOpeMHM OpraHM. n p M ~ P ~ K T Y PH M a KOCTMTe H a

~aqanoc~aa~~e~o~a~or~a~~amoaaaay
K ~ ~ ~ H M U CbnpOBOAeHM MT~, C no-rOneMM BbTpeWHM Ki)bBOM3nMBM Ce pa3BMBaT CMMnTOMM H a XeMOpaM'ieH WOK C BTOPMClHaaHeMMR, HaCOYBaqM IlOrpeWHO KbM n p e A n O n a r a e M KPbBOM3nMB B KOpeMHaTa KyXMHa. T p a B M a ~ aH a r p b f l KOW ~~~ H y B p e w a H e T o H a 6 e n ~ ~p06oae ~e uoxe fla AOBeAe A 0 M p m M p a q M K b M KOpeMHaTa CTeHa 6 o n M ~ MyclcynHa PMMAHOCT H a n p e p t i a T a K o p e M H a c T e H a B ropHMR e T w , K o e T o Aa H a c o w n o r p e w H o K ~ y MB p e w a H e H a KOpeMHM OpraHM.

H ~ O T C ~ ~IlpORBeHaTa T ~ M B O KJlMHMrHa CMMlTFOMaTMKa H a YBpeWaHMFITa H a KOpeMHH OpraHM B YCJlOBMRTa H a C b W T a H a TpaBMa H3MCKBa MaKCMMaJlHO 0 6 e m s n 3 ~ p a ~ e
H a n p e p o n e p a T w e H a T a Awamo3a c n o u o q T a H a AonbnHMTenHMHeMHBa3MBHMMMHBa3MBHMMeTOflM38M3CneABaHe ( e x o r p a 4 ~ ~ KAT, 1, A H a m o c r M r t i a n a n a p o q e m e 3 a M nanapOC~0nMfl). n p M CbWTaHM Y B p e W a H M R , oco6e~on p M 3al@a H a Cb3HaHMe e 3 ~ b n X M T e n H O M3BbpllleaHeTO H a AMamocTMvHananapoqe~~e3a, 3 a ~ s ~ n l o r e MnM a~e ycraHOBRBaHe H a BbTpeKOpeMHM OPraHHM YBPeWaHMR.

J ~ ~ % H M ~ THoa Aeqa cbc c b r e T a H a T p a e M a e cbo6pa3eHOCbCCneAHMTeOCHOBHMnPMH~MnM. 1. Ha MRCTOTO H a MHqMAeHTa M no B p e M e H a TpaHCnOpTnpaHeTo: o ~ a 3 ~ nao M ~ o e q 3a o B n a y B a H e H a TpaeMaTHr(H0-XeMOpaM'iHHR WOK l l p e 3 BeHO3HM M H ~ Y ~ M HM a rnmK o 3 o c o n e s M p a 3 ~ ~ o p nnas~a n, nn n a 3 ~ 0 3 a ~ e c r u n e n ~ .

202 m Oco6ewocmu H a mpaharna B gemcka Baspacm

2.60p6a c ocTpaTaBMxaTenHaHefloCTaTbvHocTrpe3 OCMrypRBaHe IlpoXOflHMOcTHa rOPHMTe AMXaTenHM nbTMU@,M a C K O B O nOflaBaHe Ha KMCJlOpofl, no MHflMKaqMR M H T Y ~ ~ ~M HK RO M a H n H O AMWaHe, flneBpallHa n y H K U M RM

HM~~TO ~P a ~ ~ a m o c ~ ~ v ~ o - npa60~a e v e 6e~ ua l e~ $b a~ ~a

A e T C K O X L I P Y P M C I H M R eKMn, K O ~ T O OCMryPRBaCBOeBpeMeHHa cneutla KoHcynTaqMR C n p @ ~ n ~ p c an~ eq ~~ ~ae nwc~~ B flpOTMBOWOKOBa 3Ma Ce OCMrypRBaT BeHO3HMM3TOi'HM-

: M MacHBeH xeUM, BKIllOClMTenHO KaHlOnHpaHe Ha UeHTpaJlHM TaKMW M MOTOpaKC. eRHoapeMeHHo c 6op6a~a c woKa M ocTpaTa AMxaTenHa H e A O C T a T b V H O C T Ce M3BbpWBaT H ~ O ~ X O R H M H K T J l M ~H M i ' H M 3.1\cnwpaqmn I M H M a flOCTa. --- .. .....BRHe H aC T C J M a W H aC O H A a ,M M O U M n W 3 a ~ b l R Ha K P ~ ~ H M K ~ , M napaKnMHMvHwM ~ C ~ ~ A B ~ H BmmvuTenHo MR, H pewettoIlOCTaBRHe H a Ec~apxoe ~HHT (Esmarch) MnM KOMnpeCMa#TaKnsa. npln n o ~ a 3 a o ~q n e~ B~ ~ O T M B O W O K O aana B ~ ce BHa npespba~a npu ebHuHa xeMopanR, n p H ~~ O ~ X O A M - M3BbpWBa( H T @ ~ ~ M RC KOMaHAHOflMWaHe, TOpaKOueHTe3a, nanapoue~~e3a, AMarHocTnvHa f l y ~ 6 a n ~ ~a ~ H K ~ M R M O C T - XeMOCTa3a C H H C T P Y M e H T Ha CMflHO KbPBRq CbA. M3BbpWBaHe Ha XeMOCTa3a C H H C T P y M e H T M nPOBM30PHa Tpa~cnopTMpa 3bpWBa OT Cne!$lanHO 060M M O ~ H ~ M ~ H a ~W ~ M MR ~H npeWneHM # MKJI~~HM A0 K~ M O PynWHa ~ M H ~ A K ~ hC P ~ ~ H M M ~ ~ M O~HKH MM f l ~ KOMTO , flp0~em TeHTHO P e a H M M a 4 M O H H M T e MeHTa Ha ~~$MHMTMBHOTO IleW3HMe. KOHC~~T~TU Ce BPeWaBa HO BbnPOCbT 38 IlOCnepOBaMePOnPMRTMR OT nbpBMTe M M H Y r M Ha MHqMReHTa. P ~ ~ H M M a q M O H H M F I T eKMn Aa 3anOCIHe O B n a , & l B a H e Ha KllMHHrHaTenHOCTTa, BMAa M o 6 e ~ Ha a OnepaTMBHMTeMHTepBeHqMM. Ta CMbPT ( M H T Y ~ ~ ~ M KOMaHfl R, HO flMWaHe, MHAMpeKTeH 06e~bT Ha npe4-, MHTpa- n cneponepaTMBHaTapeaHMMaCbpAecleH M a C M , M e A M K a M e H T 0 3 H M CpeACTBa, ~ e $ ~ 6 p l r 4MRCeOnpeflen~OTKnMHHrHOTOCbCTORHMe,OnepaTMBn a u ~o~ q) e OT MRCTOTO Ha MHqHReHTa AO nocnnsaHeTo HaTa HaXOAKa M P Y T M H H H T eK n M H M C H l M M napaKJlMHM.IHM BI l P O T M B O W O K O B a 3Xla. n o ~ a 3 a ~ enpocneReHM n~, AMHaMuvHo.
acnwpaUMR npM HaI

AeLpTa C b C Cb'ieTaHM T p a B M M Ce IlpMeMaTB nPOMBOWOKOBa 3Ma, KaTO npM B M M O X H O C T 38 paMOBPb3Ka CMmanbT WOK CJleflBa fla Ce nO/JEQeno BpeMe Ha TpaHCnopTa n cboTseTHMTe eKunu Aa oraKsaT B nbnHa ro-roeHXT noc~pa,qano~o AeTe. neqa~a ce noeMaT OT AeTcKMR a ~ e c ~ e m o n o r - p e a ~ ~rnase~ ~a~op oTrosopHMK . M opra-

f l e ~ a n b l ~ enpM ' b ~CbveTaHMTpaBMM C YBpeAa Ha KOpeMHM OpraHM e OT 14-52%, KaTO BOAeqM nPMClMHM 38 ~e6nar 0 n P M R T H M RM 3 X O A

Ca m p e 6 e p 3 ~ 6 n e W ~ O K ~ ,~ M a C M B H a T a

~pbeo~a$a, TemnTe opraHHM yspeAn, cencnc, MHoroopraHHa HenocranvHoCT,Kano RMamocTwrti#M onepaw-

BHM nponyc~~.

T~~BM Ha H 6b6peq~~e
M

Ornen. B ~ H W HHapaHRsaHe, O a c M M e T p M R B ny~6anHaTa o6nac~.

C ~ ~ O HpH aO 3 n p e ~ e n e~~ no-rec~o e npea nponena xeMaToM ( a ~ n o~ a ~ a m a ) . npea nmoTo 3a p a 3 n ~ ~ OT acnyawTe n p B ~ ~ ~ ~ ~ C T H M llannawa. O~ono6b6pere~ Succussio renalis - nonowTenHo, AeqaTa pearMpaT,qopH xopa. HaFrecTo TpaeuMpatinTe opraH# npM AeqaTa ca HaneKonovyKBaHe. 6b6peq~~e. TOWce O ~ R C H F I B c~no-nec~o~o ~ p a ~ ~ n p a ~M e Tbpc~ ce xeMaTypm M aHeMMreti CMHAPOM. npn HaH a aHOpMWlHUTe 6b6peq~, fl0-C~~~ pO aT 3O e ~ Ha ~~ nyMe JlMvMeTO MM M C b M H e H M e 3aTpaBMa Ha 6b6peqw~e, peTeT0 6anHa~a MyCKynaTypa M 0 ~ 0 n 0 6 b 6 p e r ~ a M ~ a C aT H a Kance Hacorea K ~ M CboTBeTHoTo neve6~0 s a e e n e ~ ~K eq ,ecyna. TO e H ~ O ~ X O ~ M M ce OHanpaBw A~ exorpa$MR, eKCKpeT0pHa yporpa$n~ M aKo e H ~ O ~ X O A M M KAT O M pe~oea3orpa$~~

T O M .

Jwamomwa
A ~ a ~ ~ e npn 3a. peqaTa Heemam e peanHa ( n o p a ~ ropefloco.le~t~~e oco6e~oc~~).

Cnewuo ~OJIHRHO neqeuwe

KOHC~~B~TMBHO ne~leHMe - flpM6b6pe~~a K O H T y 3 M R# n p BbTpeuHa ~ pymypa: cTpor nocTeneH pemM (5-15
AHH), H H $ Y ~ M O H H ~ U X e M O C T a T M q H a TepaflMR, YpoaHTLfCe-

Oco6enocmu na mpadwama B gemcka Ba~pacm 203

muqn 3a npo$~namn~a Ha nocrrpaennaTnrtiuflnMenoHe$pm. Onepame~o neqeHHe - paHHo, cnewtio npu HapacTBaq XeMaTOM, BbHWHa M n M TOTanHa PynTypa M CbMHeHMe s a n e s n ~ ~ a c b ~ neAuKyn. oeu~

- aTMnnrHo npornclaq ( n o c ~ e n e ~ pasauaaq ~o ce, noeRno npoTuqaq, Aeqara ca Bb36yIeHb1,~ e c n o ~ o i$e~u, 6pwn~u,TaXUKaPAMqHM C HapyllleH enemponMTeH 6ana~c). E ~ c ~ p a n e p u ~ o ~pyn-rypa: e a n ~ a HapyweHue B ama Ha YpMHMpaHe, MaCMBHa XeMaTypHR (O~MKHOB~HO CbnpOBOAeHa c 4palcrypa Ha r a s o e ~ KOCTM); ~e 60n~a; oKonouexypeti xeMarou.

Tpaa~i!Ha ypeTepHTe bl3KnlorMTen~o PeAKkl, H 0 npM fleqa C KOHreHMTanHa x#flpHe$p03a e Bb3MOXHO nbnHOT0 OTKbCBaHe Ha yperepa.

3as~c11 OT no~ann3aqnma Ha TpaeMaTa n crenetma Ha yepeIaTa. Mtr~panepmo~ean~a pynTypa: HapywetiHe Ha ama Ha MHKqMRTa (nbXll~Ba 3wpbXKa Ha F M H ~ T ~ XeMaTy); P M R He MHOrO MaCMBHa; 60flKa - HenOCTOFlHeH CMMnTOM, npw Ieqa ~ w $ y 3 ~ h an ~ Ba KopeMa; I e $ a ~ c u nepnTotim

Oneparne~o, cnewHo (npw neann Ha npeAHa yperpa

- nbpaMreHwee, npunesnn ~aaa,q~a ype~pa-~ytienuaa~ HC R ~ cynpan@uc(e~ C ppeHsvK Ha ypnHaTa n IpeHax Ha napaypeTpaneHx e ~ a r o ~ ) .

204 a Oco6enocmu na m p a B ~ a m a B gemcka Baqacm

gency Medicine (3rd ed.). Williams & Wilkins, Balfimore, Muxaino~,A. Opa~~ypaTa Ha PaffMaJlHMR KOHPMn B AeTcKaTa sbspac~. A~cep~aqufl, C., 1985 1993 HOBKOB, X. T p a e ~ a ~ w nycaqug ~a Ha ~ a 3 0 6 e ~ p e ~ a ~ a Green N. E., M. F. Swiontkowski(eds). Skeletal Trauma in Children. W. B. Saunders Co., Philadelphia, 1994 CTaBa B ReTCKaTa Bb3paCT. a ~ ~ e p T a ~ M C., f l1994 , Novkov, H., I. Gyorev, V. Kaneva et al. The Multiinjured HOBKOB, X., M. rbopee. POAOBM @paKfyp~. Op~on. TpaBM., Child. USAlD Annals, Sofia, 1995 30, 175-180,1993 HOBKOB, X., E. Ta~oe,M. rbopea M cb~p. CHHRPOM Ha Ogden J. Skeletal Injury in the Child (2nd ed). W. B. aa~~ope ~y ~c~ ~~ yn e~ o - 4 a c q ~ npocTpaHcTsa an~n Daunders Co., Philadelphia, 1990 (KOM~~~T CMHPPOM). M~HTO~TO TpaBM., ~. 30, 44-52, Rang, M. Children's Fractures (2nd ed). J. B. Lippincott 1993 Co., Philadelphia, 1983 CbBpeMeHeH CMcTeMeH n 0 ~ KbM 0 ~ AeTCKaTa TpaBMa. Rockwood, C., K. Wilkins, R. King (eds). Fractures in HMCM.Il~poroe"~ a e ~ c ~6 a0~ na ~ ~ ~a qa @m,qen$~~, Children (3rd ed). J. B. Lippincott Co., Philadelphia, 1991 C., 1992 T~KOB, E., A. Mnxainoa, X. HOBKOB. TpaBMaTMqHM Salter, R., W. Harris. Injuries Involving the Epiphyseal rtycaqw ~ a ~ a 3 0 6 e p p e ~ a ~ BAeTcKaTa a c ~ a ~ a ~bapac~. Plate, J. Bone Joint Surg. (A), 45,587-622,1963 O~TO TpaBM., ~ . 29, 21 1-213,1992 Sauer H. (ed). Das Vedetzte Kind. Georg Thieme Verlag, Blount, W. Fractures in Children, Williams & Wilkins, BaltiStuttgart-New York, 1984 more, 1955 Trunkey, D. D., F. R. Lewis (eds). Current Therapy of Crawford, A. H., Wilkins K. E. (eds). Operative ManageTrauma, B. C. Decker, Philadelphia, 1991 ment of Children's Fractures. Orfhop. Clin. North Am., Weber, B., C. Brunner, F. Freuler (eds). Treatment of 21, N?2,1990 Fracturesin Childrenand Adolescents,Springer-Verlag, Fleischer, G. R., S. Ludwig. Textbook of Pediatric EmerBerlin, Heidelberg, New York, 1980

reopr~l Koqee

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Cneqn$nr~onerleHne Ha cynpasettTpuKynHnTe Ha Verapamil (Faliard, Isoptin) 5-10 mg i. v., B npoAbnxeH M e Ha 3 min. 3a MHoro ~06bp ce c w a e $ e m ~ OT i. v. apnTMnn npMnoxeHMe Ha Propranolol(5 mg, B npopbnmeHHe Ha 5 1. Cn~ycoea TaxuKapAnfl. [p# HopManeH cu~ycoe min). B cbo6paxe~mepea npMnoxeHMeToHa Propafenon MeXaHM3bM Ha Bb3HHKBaHe Ha MMnynca KaMepHaTa WCM n M Amiodaron i. v. B nocorceiirrre ~ 0 s HRKOM ~ . aaTopM ToTa HapacTsaOT 100-170min". HaA-rec~o ce npoaowpa cbo6qaea~, r e flop# i. v. npMnoxeHMe Ha Lidocain B po3a OT MH@K~M#, OT ~ O ~ K npM M HeBpO3a, , 01 MelMKaMeHTM. 1 mglkg B 25% BOAM no ycnex. l l p Heycnex ~ Ha nocoreHaAKOCnep OTCTpaHRBaHeTO Ha npM'iMHaTa TaXMKapflMRTa Ta Tepanw - KnacMrecKMm MeToA ( A ~ r ~ ~ a n ~ + a~ nepcMcTMpa, yemtto e npMnomeHMeTo Ha P-6no~ep Chinidin). (Proprandol),6aa~o i.v. ~poaapo 5 mg M ~ peros-3 M tabl. no 25 mg, KaTo ce omnTa e $ e m ~ Ha nbpeaTa noaa. np# K O ~ ~ ~ O M ~ T M ~ ~ XeMOAMHaMMKa H ~ M HeyCneX Ha MeAMKaMeHT03HOTO JlereHMe CpeACTBO Ha 2. Cln~ycoea Cpafln~ap~ufl (em.: npM npoeopHM Ha~ 3 6 CM 0 oc-raea ~ Kapqmeepcnma, KaTo ce aanorea 0611~~LU~HMR). KHOBeHO OT 100 W/Sec. 3. npeacbpa~o rnweHe. npepcraen~m HempA T ~ H ~TaXHKaPAHR J~H~ C 6 n 0 ~ npe~c~aBnRBa . yCPMHMpaHM, B M C O K O Y e C T O T H M(0~350-600min") $~6p~nepKopeHa npeflcbpAtia peAH0CT (130-250 min-l) c HannrMe HM cbKpaLL(eHMR Ha oTAenHM r a m Ha npepcbppwra, Ha M30eneKTpM'iHa n H H M R Ha EKr Mewy P-P BbnHM M KOUTO nOpaM HWMClHMR $ ~ H K ~ M o 6H no ~B ~ ~ AV-Bb3e~H na, tie B C M ~ K Mce npoeewaT WM KaMepMTe. $ ~ H K ~ u o AVdno~. H~~~~ KH ~M~PHM OTrOBOP R T MOXe /Ja n M HenpaaMneH M C p a 3 n ~ r ~ rlecroTa. a Ha cneurHo nereHMe noyexaT caMo napo~cn3~an- 6bpe npaelrneH M M~X~HM Ha~ Bb3HMKBaHe M ~ T He e )TO'iHeH, H0 ~ah-.lecTo H M T e M TO B M C O K O C e lC T O T H M no KaMepeH OTrOBOp (~OPMM: CepbnXM HaAMMTMMCOBaHHTOKCMK84MR. npn CPMB Ha qMpKynaqMma (LUOK): He3a6a~~a Kappuflere~ne:cnMpaHe Ha pmmanMca, BnMsaHe Ha Kaoeep3~ nbpso ~ cbc 100-150 Wlsec M npM Heycnex- 250n ~ 1Verapamil. , 350 Wlsec. Cneuu$url~onereHne Ha BeHTpnKynHnTe apmPM aana3e~aqnpKynaqMn cpepcrBo Ha ~ 3 6 e 0~ MHH Verapamil (Isoptin) B ~ o a a 0.075 mglkg, KoeTo npaew npM6nM3M~en~0 5-10 mg, 6aeno i. v. B OKono 60% ce 1. K a ~ e p eKcTpacncTonn. ~u npeflc~aen~ea~ npemnOCTMra Bb3CTaHOBRBaHe Ha C M H y C O B PMTbM. HalllMRT peepeMeHnMetcronMrHw CbKpaqeHMfiHa Kauepwe. HahonMT no~asaa, ve npM npepeapMTenHo p ~ r n ~ a n ~ 3 ~ p a WCTO ~ e Bb3HHKBaT npM: M C X e M M R Ha MMOKapAa M MMOKapHa naqMeHTa (Isolanid) 0.40-0.80 mg/l.v.) KoHeepcw WM @H MH$apKT, KOHreCTMBHa CbpAeClHa HepOCTaTb'iHOCT cuHycoa P M ~ HacTbnea M B np~6n~3men 80% ~ o OT cny(CH), KnanHM nopoqn, nponanc Ha MmpanHaTa Knana, ranTe. Verapamil e n p o ~ n e o n o ~ a s npH a ~Hanuwe Ha o6qa XM~~OKCUR, MHTOKCMKaqMH(~MMTaJ'IMc MAP.), enetcrWPW CHHAPOM! P O n M T H M HaPyllleHMR, eHAOKPMHHH ~ ~ ~ O ~ R B ~H0 HC M eR Knac~rec~wm narnH Ha n e r e ~ ~ 6bp30 e - p ~ r n ~ a n u - cpeqaT M npn npaKTMrecKM qpaeM nMqa. anpa~e (Isolanid0.80 mg unw Digoxin0.5mg i.v. chini id in Ha cnewo nereHMe nopnemal c a ~ eKcTpacumoo no 0.20 mg Ha l Mnn Ha 2 h po o6qa posa 2-2.4 mg He e nMTe, KOMTO Ca XeMOAMHaMMrHO 3HaClMMM, M Tf33M, Bb3HMsary6~n caoeTo a ~ a r e ~ M u e Moxe 6~ ~ah-ypare~. RPM KHWM B XOia Ha OCTpa MMOKapAHa M C X e M M R (EX.: OHM). neycnex Ha ropHme MepMKaMeHTM Mome Aa ce npnnoxaT 2. K a ~ e p ~ TaxuKapAnfl. a npepc~asnnsa TPM M n M Propafenon (Rythmonorm) 75 mg i.v. nnn Amiodaron nOBeVe KaMepHM CbKpaUJeHMR C VeCTOTa 120-250 min-'. (Cordaron) ~po3a5mg/kgi.v.,3ao~ono3min, ~ o e $ e m ~ O~MKHOB~HO Bb3HMKBa npM CbqMTe ~ ~ ~ O ~ R B ~nW0H M R He e CMrypeH (KOHB~~CMR B npM6nM3MTen~0 50%). qeHn npn KaMepHa eKcTpacvcTonMR. Tbh KaTo recro pe4. n p e ~ c a p ~ TpenTeHe. ~o npe~cra~n dbps~, ~~a reHepMpa B KaMepHo MbweHe M n M TpemeHe, n o y e m i P M T M M C H l H nPeflCbPflHM KOHTpaKL(MM(280-350 min"), KOMHa cnewno nereHMe: TO Cbq0 nOpaM $ ~ H K ~ M o H6 Nn ~o ~~ B HAV-~b3en He C e a) npM P ~ H a n a XeMOpMHaMMKa (LUOK, 6eno~po6e npoeexqaT ~ 3 w n 0 WM KaMepnTe. OT HeroBaTa creneH OTOK): ~e3a6aBHa KaPCIHOBeP3HFI C 200-300-400 W I S ~M C ~ ~ B M Crec'roTaTa M M pMTM#wiocTTaHa KaMepHaTa geinpn ycnex Lidocain B 6onyc 1 mgkg, nocnepaaHOT MH$YHOCT. n e c l e ~ ~ e cnepea ~ o npMHqnnnTe, M ~ ~ O X ~ npM HM ~ MB R ~ o 3 2-4 a mglmin B npopnxewe Ha 24 h. npe~cbP~H0 MbweHe. 6) npM aanaae~a xeMopMHaMnKa B c b o 6 p a x e ~ ~ MAe 5. n a p o ~ c u 3 ~ a n CynpaeeHTpnKynapHu ~n TaxneaT cnepHnTe MepnKaMeHTw:Lidocain 1 mgkg 6onyc i.v., Kapwn. Toaa e c6op~o notimue, KoeTo s~nlo~lea BCMC~KM nocnepaaH OT MH$YSMR B~oaa 2-4 mglmin, Procainamid TaXMKaPpMM, ' ~ H ~ T MeXaHM3bM O Ha Bb3HMKBaHe e H a 50 mglmin1 0 o6qa~oaa 1000 mg, nocnepea~ OT MH$Y~M cHona Ha Hiss. O~MKHOB~HO xeMoAMHaMwaTa e aanaae0 ~ 2 - mglmin, 4 Gilurytmal50mg/h i.v. 3a3 min, nocnepaati Ha M neveHMeTo ~ p ~ 6 pa e a3anov~e C HRKOM OT no-rope OT MH$Y~MR. OnMcaHnTe M ~ X ~ H M C ~~ HO MC O ~ (O H ~M ~a TValsalva, npMTunpn HeycnexHa n o c n e ~ o ~ a ~ e n ~ o ~ o 6 o i.v. n npw yc~o CKaHe Ha O C H lM T e fl6b1-1~14, MaCm Ha C M H y C K~POTMK~C).nOXeHMe Ha rOPHMTe MeAMKaMeHTM- KapAMOBep3MR, nonplr Heycnex- cpepcTBo3a ~ 3 6 ce 0 cMma ~ npnnometiMe cnepBaHa OT npoAbnmiTenHa MH$Y~MOHH~ Tepanm c

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~ O H R T M ~ T~ Oe c ~ a 6 M n aHrMHa ~ a neUOpUC (HAn) 06xaaqa: a) HOBOBb3HMKHanaTeHa aHMHa M n M 3aWcTRBaHe M ypbnmmHe Ha 6on~me npn c ~ a 6 u n ~ aHMHa; a 6) atinvia B n o ~ o npes i i nocneptiMRMeceqHnw nocnepnwe 48 h; B) aHMHa B ITbPBblTe 2 CepMMqM OT HaVanOTO Ha ~n@apma. EpHa n o - ~ o r Knacn@n~aqw~, ~a HO Ha cbqme npMHqunw, e npMnoxeHa OT Braunwald (1989).

n n a m o a ~ ce a nocTaaR po ronRMa cTeneHowe rpes a~a~~ea ( aaa~ re ac ~ ~ M n n M~no-npopbnx~~en~u, M n M ~ORBH~ ce MB n o ~ o C hT ~ H O K ~ P ~ nHpM~ c n ncbc ~ , snarcl~enHa MHTeH3MBHOCT M nPO~bJlXMTenHOCT, CM n M683 BereTaTMBHa C M M ~ T O M ~ T O M ~K ~~ K)M . B npM H O npMCTbna M O W pa ce ycTaHoam npexopHH T3- M n M T4-ranon nnM CMCTOB cTaqwotiapa nereHweTo ce npopbnxaaa no C ~ ~ M F I nHM uryMOBe Ha CbPflerHMFl BPbX. Ha'iMH: ~ O K O EK~-MOHMTOPMH~, ~, A0 06e36on~sa~e, KaTO EKr no speMe Ha npMcTbna e a q p n x ~ ~ e nB ~ 50a. 3~llMTenHO C e IlpeMHHaBaHa nOCTORHHa MH@Y~MFI Ha 60% OT CnyclaMTe C e YcTaHOBRBaT n = M M C X e M M V H M HuTponpenapaT(Perlinganit, Trinitrozan) rpea M H @ Y ~ O M ~ T ryoMeHu (penpecn~ M n M enesaum Ha S T - c m w u m B po3a 1-2 mgh, KaTo n p i ~ O K ~ ~ ~(nunca H M RHa e $ e ~ ~ BMCOKOnOJlOXMTenHM. M n M OTpMUaTenHM. OCTpQ&$XkUY- xMnepToHng) p o m a ce noeMwaea po 4-10 mgh. npopbMeTPM'iHM T-BbnHM], KOMTO 6bp30 IlpeMMHaBaTCnen ripenxMTenHocrra Ha H H $ ~ ~ M e OT RT 1-5 ~ ~HM. mcBaHe Ha npucnna. KanuMesMTeattTaroHncT#- Nifedipine (Adalat)-B poaa E H ~ M M M T~ ~O , BOD~UM 3a np~lcna ~ ~ o ~ a ~pe p ~p ~oa s a 3-4 nbm pHeeHo no 10-20 mg, Diltiazem B poaa 3 nbTM n m l , cron ca awarM n o p ~ a n ~ u . flnestio no 60-90 ma M V e r a 240 mg ~ m, cbwo MMaTMRcTo npunerenumo Ha HAn cornep Ha H~~M'IHMR ~aaocnaab~.

XopMMocTTa Ha racTMrHo m u Ha nbnHo s a n y u ~ e ~ a OT ~a aPTePMR M n M Cna3bM M C e HaManM KMcnopoAtiaTa KoHcyMaqMR Ha ~ b p q e ~ Bepyara o. cnep nocTaaRtie Ha AManio3aTa: nocrenen p e x m M qa~q TDancnoDT: 06ea60n~m~e - Nitroalvcerin cv6n~nrean~o 0~25-0.5'm~ "pea ---5 min M npM n e i n a e $ i c ~ Dh~@il H Fentanyl 1-1.5 ml i. v. wnn Morphin 10-20 m u ~~cn_poa~_epag-~g; npM nMnca Ha n p o ~ ~ ~ o n o ~a ~ ~ I ~ o Ha aHTHKOarYnaHTHOne' c I B ~ H ~ leHMeC Heparin750010 000 U i. v. M aHTMarperaHTM- Acetvsal375_mgpa. C qenpact?HaManMKMCnOpOpHaTaKOHCyMa4MRM npM nMnca Ha n p o ~ ~ a o n o ~ aP-6noKepMTe a a ~ ~ ~ ca BTOPM no BWJ-IOCT MeAMKaMeHTMnpM Jle'ieHMeTO Ha HAn. Tbh KaTO CbqeCTBym MHAHBMflyanHa yBCTBMTenHOcT, Jle'ieHMeTO rp~6aapace 3anoreaetinMaTenno, ~ a ~ o c e o ~ r m a e @ Ha n b p ~ o ~ a r a n ~ a ~ a p npunoxen~e~o oaa. Ha Propranog (Obsidan) i.v. e MHptqnpaHo oqe npM nocTaaEejaaarnosa~a,np~~apase~a~a~~~ap~~~ 1 m Imin po 0640 5 mgl5 min. OT M H O ~ O ~ P O ~ HPMT di~~3iijFr G s n p l m o z i i - y Hac ~afi-veno ce nanonaaa~ Pro~ranolol Bnoaa3 no 25 M ~ 40 M ma M Atenolol

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3. n p e ~ ~ o n a ~ e p aV n , eV ~ , :M n MV , 1, aVL. 4.06tu~pe npeAeH: ~ V, 40 V , I, aVL. 5. BHCOK npeAHonaTepaneHMnn BMcoKnaTepaneH: I M aVL. 6. A o n e ~ Mnu ~ ~ a @ p a n n a n 11, eIll, ~ :aVF unu Ill M aVF. 7. Aon~ona~epane~: Ill, aV, V , V , unu B I, aVL. 8 . 3 m e ~ noRaaHa : RSR-TM~ un# R:S B ~ B V n,o - r o n ~ ~ OT 1. 9.3ag~ona~epane~: Kamo npu 8 t Q-3b6eq aba V , unM I, aVL. TpeTMFFT OCHOBeH MOMeHT, BbPXy K O ~ T OC e rpmM ALlarHO3aTa Ha OHM, e nOBMWeHOT0 HMBO Ha eH3MMMTe: 1. K ~ ~ ~ T H H (KK) KM HHaU-Becle, H ~ ~ ~ Ha H ~ ~ H M H30eR H3MM MB, K O ~ T O e cneqM@M.leH3a MMOKapAHMTe KneTKM (KK-MB). Hopwa 3a KK po 80 UIL, 3a KK-MB OT 0-6% OT c ~ o i ~ o c rHa r aKK unw AO 26 UIL, B a6conm~a CTOWHOCT. noeutuaea ce 4-6 h cneA HaranoToHa u~@apma, IocTMra MaKCMMyM CneA 24 h M C e HOpManM3Mpa Cnep 3 A H M . 2. rnyra~a~-o~canaqe~a~-~pa~c@epa3a (CrOT). HopMa ~o 12 UIL. noentuam ce 8-12 h cnen ~ ~ @ a p m a , AOCTMra MaKCMMyM Cneq 18-36 h M C e HOpManM3MpaCneA 3-4 AHM. 3. Jlama~nex~ppore~a3a (JlpSc) M ~ai- ere H ~ ~ ~ H H R T M~O~H~ JIAX1, M M KO~TO cbqo ce cuma 3a c n e q ~ @ ~3a cle~ MMOKapAHMTe KneTKM. H o p ~ 3a a flax 10 240 Un 3a R0 140UA. ~ O B M W ~ H M ~ eT OO THOCMT~~H KbcHo-cnefl24O 48 h OT HaclaJlOTO Ha MH@aplcra, MaKCMMYMCneA 3-6 A H MM C e HOpMaJlM3Mpa Cnefl 1-2 CeAMML(M. Ka~o cneq~@~ ~ rH e~ ~M 3aM HamnMna MMoKagAtia ~ e ~ p o ce s anpMeua MB-KK, ni KaTo OcraHanMTe MoraT Aa ce noBMWaT M npw peanqa npym ~ ~ ~ O ~ R B ~ H M R . 4. O n p e f l e n ~ ~ e Ha ~~ o ~ o r n oB 6n~ n~ as a~ a u ~ ypua HaTa e 9yBCTBbITeneH 6ener 3a MMOKapAHa H!KpO3a, H0 sce oqe He e ~ o 6 u n tuupo~o pa3npoc~pa~e~~e.

flml

no 3-4 tabl. -360n~m~e: Morphine 10-20mg i.v., Fentanylt Droperidol 1-1.5 ml i.v.. Lvdol 75 ma i.v. 4. np~n0XeH~e HaAMpeKTeH aHTMK0al'ynaHT - H rin 7500-10 000 U i. v. u aHTMameraHT - A C Q ~ ~ ~ R 325 ma oer os (npu nunca Ha npo~ueono~a3a~u~). 5. ~ P Bb3MOXHOCT M o2 C Ha3aIleHKaTeTbp M n M MaCKa 4-6 Vmin. tip^ no-ronma~a clact OT 6 0 n ~ u ~ ee HanMqe XunoKceMuR, pe3yn~a~ OT HapytueHa ~ e ~ ~ u n a q ~ d n e p ~ M Ra , M noeere~o n a q u e ~ca ~u c ~ o n b n ~ u 6eno~po~en~~ ~ H 3a60nR~aHMR. M ~OBM~~~H O,-CbflbpXaHHe OTO Ha BAMW B a H M R Bb3AYX MOXe Aa npoTeKTMpa M C X e M M C H lM R MHOKapA. npu naqMeH-rM6e3 XunoKceMMR noAamHeTo Ha 0 , He IlOBMWaM HerOBOTO CbflbpXaHMe. B TaKMBa Cfly'ia#, popu u npM nunca Ha B ~ ~ M O X H O C 3a T ~3cnepea~e Ha ~ ~ ~ O B a~an1.13, M R ~ p ~ 6 fla ea ce npMeue 3a ~enecbdpaaHO, ney nauMeHTme c OMM, npea nbpBme 24-48 h na ce nOAaBa MHTePMMTeHTHO oz. 6.3a npo@~namu~a H nereHHe Ha PMT~MHM HapytueHMR: Lydocain 1 mgkg c ~ p N ~ o , n o c n e pOT a~ nocTwHtia MH~V~M 2R mglmin M n M 200 ma i. m. 7. M ~ B ~ C T e,H cle O KonKoTo no-patio ce 3 a n o r ~ e ~ M ~ O ~ M T M ~ ~ HnereHMe, OTO TonKoBa n o - r o n e ~ ca ~ LuaHcoseTe 3a ycnex, HO sacera BbnpocaT~ a n na u sanorm oqe B UOMa Ha ~ O ~ H MHRMa FI OKOHClaTenHO PetueHMe. 8. J l e r e ~ ~ Ha eycnowetiMRTa, aKo lnMa TaKuea. 9. ~ ! a o ~TDaHCnODT. lu

MOHMTOPeH KOHTPOn H CneAeHe Ha AH (Propranolol 1 mglmin AO 06qo 5 mg).

B ~ M O X H O C T 38

pn@epe~q~an nwamosa ~ a ~ a ~a OMM, oco6e~o KaTo C eM M a T IlPeABMA HeTMnM'iHMTe CnyclaM, e AOCTa WMpOKa M noHRKora TpyAHa. HaR-recro B cb06pme~neMAeaT cnenHnTe 3 a 6 0 n ~ e a ~nepwaplm, n~: AMceKaquR Ha aopTaTa, OCH, 6enoppo6~a ~ M ~ O ~ KonanctiM M R , C~CTORHMR, neeocTpaHeH nneepMT M nnesponHesMoHuR, CnoHTaHeH IlHeBMOTOpaKC BnRBO, nJleBpOAMHMR, OCTbp naHKpeaTMT, OCTbP XOneqMCTMT M n M Wlb'iHa KOnMKa, OCbP TaCTPMT, ~ 3 o c ~ p Mnl e ~r a nep@p#pana ~3m, e 3 o $ a ~ xMaTycHa ~, XIPHMR, MHTepKOCTanHa HeBpMMR BnRBO, C M H A P O M Ha Titze, CMHAPOM Ha Rumheld, HaraneH xepnec aoc~ep, 4. Ceanpa~e Ha 60nHMR (Diazepam, Lexotan). q e p e M K a n H a ~ ~ o p a ~ a n ~ a c n o ~ ~ n n o a p ~ p o 3 a ~ ~ p . 5. @ 1 6 p # ~ o n m r ~ TepanMu. a Kon~o~ no-pa~o o ce B ~ ~ C T ~ H OnpoxoAlvrMoma BM Ha aanytue~a~a KopoHapHa apTepMR, TOnKOW no-rOflRM e WaHCbT fla C e OrPaHHClH ~O~O~HM~H nereHMe OTO alcnlorm: rOneMWHaTa Ha HeKpo3aTa L4 Bb3CTaHOBFFT MCXeMMclHMTe 1. ~ O K O ~ . yracnqu. llpnnoxe~ne~o Ha @ M ~ P M H O ~ M T Me ~M C AoKa2. NitroglycerinC~~~MHMUIHOno 1tabl. npe35-10 min a a ~ N~KMBHOCT a 3a n0-~06paTa npomosa Ha OHM.

1, ~ O K M O HenpeKbcHaTO ~ E K ~ - M O H M T O PHeyM~~H cnometime n~@apmn He noMexaT ~aM H B ~ ~ M xeuoB~H AMHaMM'ieH KOHTPOn. T O We HHAM4MPaH npM HaJlMclMe Ha: recm, peqnflnanpaqn~ O ~ K Tema M; XnnoToHMFi 3 a ~ ~ @ e peHqMpaHe, an^ cram RyMa 3a xunoaoneMuFi unu 3a KUI; Tema CH; K ~ M H M ~ H Aati M HM 3a pynTypa Ha cenqwa, MmpanHa peryprmaqMR M n M cbpuerHa TaMnoHWa. 2. nM~BMflMpaHeHa ~ O ~ K O B CMMnTOMaTMKa, ~ T ~ a K O Bceoqe e HanMqe(Morphine, Droperidol+ Fentanyl, Lydol i. V. B nocoreHMTe no3~).

sa,qbnwTeneH MepMKaMem npn nevetiueTo Ha OMM. B HaranoTo ce aanor~a c npopbnxmentia i. v. M H $ ~ ~ M (np~ nmca Ha n p o ~ ~ B o n o ~ a rpe3 3 a ~H ~H ~$ ) Y~OM Ha ~T Nitroglycerin(Perlinganit, KaTo ce cnepM AH pa tie TOMe OCObeHOHliJlOXMTenHOnpM nepCMCTMpaqM~ O ~ K M ~pf16~ ep n0p a HenpeKbCHaT MOHMTOPeHKOHTPOnHa EKr XwnepTotiMfi H Hareaaqa ( M ~pM a m ~ aneeoeeHTpuKyn) (npocnep~sa~e Ha ST-eneaaq~~ M noma HaT. Hap. peneP$Y~HOHHM T~XM~PCITMHM), CleCT KOHTPOn Ha AH, n o Ha HeflOCTaTbClHOCT. ~ o - H ~ T C ~eTIlpOflbJlXaBa ~ K C per OS anePMVHa CMMnTOMaTHKa. ~ P W ~ O X ~ H M Ha ~ @M~PHHOTO npMnoxetiMe Ha Isodinit, Nitrolong, lsoket M pp. no 1 tabl. nMTML(MC B M C O K a ClleuM$MClHOCT CnPRMO @M~PMHI (fl-PA, 3-4 nbTH meBH0. Alteplase, APSAC, Emitase) ace oqe He e po6uno npuno9. D - ~ ~ o K ~npnnara~ PN. ce npM OVIM, s a q o ~ o Hannax e w e y Hac, rnaeHo nopaM BucoKaTa MM ue~a. nRBaT O,-KOHC~M~~MR Ha CbpqeTO, H ~ M ~ J ~ R KOHTpaB ~ ~ K M 6. A H T M K O ~ ~ ~ ~nereHHe ~HTHO C eT 3anOcl O Ba CbC 7500 K-rwnMTeTa, cbppeclHaTa recroTa M AH M Ha TexHMR a m U Heparin CTPV~HO,i . ~M.ce nponbnxaBa C 1000 U h MnM KaTeXOnaMMHOBM aHTHaPMTMMCleH e$eKT. V I ~ C ~ ~ ~ ~ M 7500 U16 h. B nDonbnxeHMe Ha 3-5 gy, He3aancmuo OT TOM a a n o ~ l ~ a n M ~e a$ H ~ P M H O ~ M TepanuR TM~H Mnu ~ He. CMRT Ce, ~ Cle T O M MOXe pa IlpeflOTBpaTM KOpOHapHaTa peTp0~603a, aKo e HacnnMna cnoHTaHHa ~ p o ~ h n ~ 3 a , M n M H O M T P O M Ha ~ RPYM ~ ~ KOwHaPHM aPTePMM. AHTHKoarynaHTtioTo neqeHue M M a w a r e w e M 3a npepoTspaTRBaHe Ha pbn60KbT~e BeH03HM TpoM603M H Ha 6enoppo6HMR.T~~M~O~M~O~M~~M. .(Obsidan) i.v. B ~ o a a lm a / m l n5 mq M ce Heroao~o npqAamasaHec Henpew atiTMKoarynatmn (Sintrom, Varfarin M L P I ). gHec ce npenopbrea caM_o:npw npopbnxam per OS 3-4 nbTM no 25 m9 Ha AeH. M ~ o r o ~ O ~ H C RaHHM M 38 XPOHMCl Ha BeH03Ha HHCY$M~#~H~MR; nop)tofl~q e M Atenolol B goaa 50-100 mg ptieatio. npM 6enoflpo6e~ T ~ O M ~ O ~ M ~ O npM ~ KaMepHa M ~ ~ M ; Mypa~ ~ O T H B O ~ ~ K ~ 6pa#I~apflMR, ~ ~ H U H : XMnOTOHMFI , CH, n ~ TP a IM AM@Y~HO A M ~ ~ T HM P now0 ~ H ~ cb~paBCM~KM CTeneHM Ha AV-6no~, X066, 6poHxMliJlHa a m a , qasau pa (npepnoc~ae~a 3a 0 6 p a 3 ~ ~ Ha e ~ 0 XAHK, TembK MHCYnMH03aBUCHMp ~ a 6 e ~ . ~pou6 K a n q u w a m a w w . nocnep~me npoyrea7. nnmarperatm. 3a ~ w m m e n w ~o e HMR ~ I O K ~ ~ B qe ~T tguyeBMTe , a~TarWNifedipine, cMma 3 a n o r ~ ~ ~ a Dilziazem) ~,a-e! Verapamil, pewHOnMTHClHOTO H aHTMKOarynaHTH0 neCleHMe. O C H O B ~ H M ~$aplcr~~e M roneuMHaTa Ha ~ ~ $ a p m Ni aJ .edipine popu 3a TOBa e nOKa3aHaTaP O n R Ha T P O M ~ O ~ M T H aTpera4MR ~T~ ywDaHHaTa.CMbDTHOCT. T e 3 ~ UaHHM Ca BMMflHM npM Bb3HMKMHeTO M 06pa3y~aHe~0 Ha 06~ypnpaqn~ M 3a BTopMwaTa n p o $ ~ n a ~ cnep ~ ~OMM. a OT TRXHOTO T ~ O M MnpoeepenwTe ~ HanocnepK w ~ p o ~ o ~ a ~ q3 a -6 ~ npMnoxeHue ~ M n n a non3a caMo npM ~ O ~ c H XunepTotiMR M M CneRMHMR, KOMTO nOKa3BaT, Cle PaHHaTaCMbPTHOCT, PaHYeCTMaHMH03HMnpMCTbnMMnpMBa30CnaCTM.IHaaHMHa HMTe H ~ $ ~ T NMH$apKT# ~ H M M M03bClHM MHCyJlTM C e HaMaTnn Prinzmetal. nRBaT CTaTHCTMCleCKM 3Ha'iMMO. Te3M M380AH BamaT M 38 BTopMrHaTa,p n r o ~ p a h ~ ~~ aO$M~I~KTMK~ lipC~~~OMM. YC~OHH~HWR npw o m p ~ ~ o a p tHa r r MwoKapAa noXeHMeT0 Ha Acetysal B K O M ~ U H ~ ~CM Dipiridamol R HRMa npepwMcTBo, nopwn KoeTo ce npenopbrm ~ a i - p a ~ ~ o sanorea~e Ha nerewe c Acetysal160-325 mg epMH nbT Ha AeH, B npomJlXeHMe Ha 1-2 TOIMHM. PM HenOHOCMMOCT Antistenmardin 3 m m no 2 tabl. pHeeHo. 8. H H T ~ ~ ~ T~ U~. ~ O ~ P M R TMM HM e$eKT R T npM nereHMI. PM~%MHM HaPYWeHMR eT0 H a b n X M Ha HaManRBaHeTO,KaKTOHa pep-, 11. ~ ~ O B O ~ HapyLUeHMR. H M TaKa M Ha CneAHaToBapBaHeTo Ha mpqe~o M c TOM, Ill. Oc~pa neeoKaMepHa HepocTanrHocT. HaManRBaHe M Ha 0 2 - ~ ~ ~Te ~npeMaXRaT ~ ~ a KOpOHa~ M ~ . IV. LUOK. e~ PHMR cna3b~ Hp a 3 w ~ p ~ ~ a ~ ~ o n a ~ e p a n n ~ e . T e x ~ n m e @ e ~K rapp~ore~ V. E ~ M C T ~ H O nep'bI~ap~MT. K~~F(~H e n0p06eH Ha OTKPMTHR HacKopO peneKcMpaq @mop (Nitric oxid), OTAenRH OT eHpOTenHMTe KneTKM. P~HHOTO VI. Cw~ppou Ha Dresler. npMnoxeHMe Ha HuTpaTn Moxe Aa orpatinrn roneMMHaTa VII. Pyn~ypa Ha MewyaMeptia nperpwa. Ha HeKPOTMrHaTa 30Ha. Te M ~ J l X H T e n e H MeRMKaVIII. Pyn~ypa M~M~~HKLIM Ha R nannnapeH MycKyn n Mew npnnereHweToHa OMM. B HaranoToce3anorsamc xoppe TeHpnHee.

CUR Ha ST-cet?deHT B 1 aVI, V1-6 O T B ~ ~ ~ H U R . ) 1. ~ M H HapyWeHHR U npu npepeti ~ ~ $ a 6 pnuo ~ e b OT ~ MH$P~XMCOB T M (C ~ PMTbMHUTe HapyUeHMRCa Hah-~ecTblTe YCJlOXHeHMR IlnnpoKM KaMepHM KOMllneKCMM CbPReClHa 'ieCT0Ta nOfl40 M TRXHOTO nereHne e ~ s n o x e B ~ vacrra o 3a apMTMMMTe. min.'. J l e q e ~ ~ e ~ wo s~yc~se KC. ~a Cneuuan~o 3a KaMepHme eKcTpacMcTonM~ p ~ 6 pa s ace Mwrpase~~puKynap~u~e HapyueHuR B xopa Ha OHM o~6enex~ re , ce Ha6fllopa~k3~ npM6r1~3MTenH0 B 95% (166, ce ~a6nlopaea~ 6o.nc ~OMM, ~ HO Ha neqetine noMexaT caMo ~ ~ O ~ M T M M - n66, JlnX6, n3X6 M KOM~MH~~MM) B npu6nn3men~o 23%. BbB Bpb3KaC TOBa Bb3HMKBaTpBa RTa, n o n u ~ o @ ~ # ~ rpynMpatiMTe e, no 2, 3 epHa cnep OCHOBHMsbnpoca: panw anouamT npomo3a~a U poKonKo ppyra M PaHMTe (R Bbp~yT-$eHoMeH). C~~~~ Ha Ct4360p TBO ca npepruecTseHuuM Ha A V d n o 3". ~ npomoaara Ha 6017e i. v. npMnoxeHMe Ha Lidocaine 1 mg/kg, nocnepeati OT H M T e C 0MM M MBH ce onpepem rnae~o OT HanuvueTo MH@~~M 2R mglmin. M n c c He Ha CH. C M ~ P T H ~Ha C6 T0 Tn ~~ u C OHM M LIBH, 6e3 CH, e 6-8%, nOKaT0 npM HanMqUe Ha CH -50%. n b p ~ ~ q 11. ~ P O B O ~ ~ HaPYUleHHR HH HaTa npMqUHa 3a CMbplla Ha Te3M 60n~M CH, a H e ~a~o$n3~onor Ha u~ npoaopHuTe ~a HapyweHMn MOenetcrpwitia H ~ C T ~ ~ M ~ mneH HOC AVdnoK T, M n M acMcTox e pa ce pas6epe no-pdpe, aKo ce M M a npeneup Kpbeon w . npu naquetiTwTec OMM M MBH cMbprra e 60-80% ce c~a6pnsa~e Ha ~ onpoeo4HaTa cncTeua. AV-~b3enbT, . . flbnxu ~a CH M ~ KUI. M CtionbT Ha His M napeaTa TpeTa Ha ~ I C H O T O6eppo ce noBecleT0 aBTOpM CMRTaT nORBaTa Ha MBH, oco6e~o K ~ ~ B O C H ~ ~ OT MB AV-ap~ep~fl, ~T K J I O H Ha qqHaTa pecqe6 ~ 6 n o ~ o e e3a ~e npeC(BeCTHUqM , Ha A M C T Z N H M R THn ~aAVHReHTHa apTepMR, KORTO B 90% M3JlU3a OT ARCHaTa KOpOH 0 CnOpeflppyrclTOBa He C e nOTBbpwa6a. BTa3M HapHa apTepuR M B 10% - OT nReaTa q#plcyu$ne~c~a. 6no~3", 0pb3Ka Bb3HHKBa CnOpeH BbnpoC A M M pa C e nOCTaBR ~ ~ O B O ~ HHaPYllleHHR M T ~ B Te3MCTPYKTYPMCape3ynTaT OT npo@~namre epeuetieH ~, KC M panu Toea no406pn~a RoneH HH$~PKT. Oma~ann~ 213 e OT ~RCHOTO M OT nRBoTo npOm03aTa Ha Te3M ~ O ~ H M C (.~ C T O T ~ T Ha ~ nORBa Ha AV6eppo C e ~pbBOCHa6flFl~aT OT nflBaTa UpepHapecueHpeH6no~ 39aaauc~OT acoquupaHoTo MBH HapyueHMe: 3a THa apTepMR. ~ ~ O B O ~ ~ HapyLUeHUR H M T ~ B Te3M CTPYWPM 0 6 6 cpepHo 23%, 3a 066+JlnX6 - 34%,3a A66+Jl3X6 ca p e 3 y n ~ a OT ~ npepeti ~ ~ @ aMpcenvua, a T. e. Ha 31% M Jl66 - 16%. 3~ar~~en~a~e~po3a. OT ronmo KJIHHM~HO3 ~ a c l e e ~ na ~e ce U ~ ~ H T U $ M AV-6no~l " . n o m 6 a ce B 6-16% OT cnyrame Ha paT ~ e 3 n nauneHTM c OMM n MBH, KOMTO q e ~ ~ ~ B U F OMM M TO rnaeHo npH poneti n ~ @ p u .He snoluasa nbneH AV-6no~. npomo3aTacl He H B M C K B ~ ~ ~ ~ ~ H M ~ . n a q u ec ~,,MamK ~ ~ PHCK": AV-6noK 2", T M n I (Wenckebach). Ha6nlopaea ce B 4A66 M n M 166, KOUTO ca 6 ~ n n Hanuue n p e y w~$ap10%, m q o rnaBHo npM poneH HH$~PKT, PRAKO nporpecnK-ra M AV-6n0~ 1", noneunce B xopa ~a~~$aptma; 4 6 6 Mnu pa K ~ A M V - ~ ~3" OM KHe snowam npomoaa~a. l l p cbppe~ n66, n0RBMnM C e B XOna Ha uH$apKTa C HOpMmeH PRrHa recToTa nop 50min-lAtropin 1 mg i. v. uHTepean; npenwecTBaU,amepHMpaq 6 n o c ~HopManeH AV6no~ 2", T M n II (MBbitz). Hac~bnea B 24% n TO Pfl-uHTepBan; M3OnMpaHM X ~ M M ~ ~ O K O B ~ . rnasHo npM npeQeH u~$aptm. C b p n e r ~ a ~ vecToTa a e naq~e~ c ,,BHCOK ~ m PRCK": oKono 40min" clecTo nporpecuDaK ~ AV-6no~ M 3" ccMnHo h T e p H ~ p a MBH, ~ # noRBMnHce B xoni KTa; enouaea npon+03a~a.'~~i-yp~o~onere~~e e~ a ~ y c ~ e e ~ a 6m@acu~~ynape~ 6no~ c tiecacentio KnoHre (Hanp.: Ta KaPflMOCTMMYfla4MR(KC). Q0 H ~ ~ ~ H O OCbqeCTBRBaHe TO I~J'IOKC~CC~C~ Knotire ~~HO ce onwsa ua ce nosMwMCbpperHaTa clecToTa rpe3 MH$~- Q66+Jl3X6); 6@ac nnloc A V - ~ ~ 1 O ".K ~ M R Ha lsoprenalin 0.5-2 pglmin. Moxe pa ce onma M l l o ~ a 3 a aa ~~a e ~a s p e u e ~ e KC: ~ e $ e m Ha ~ Atropin 1 mg i.v. 1. n b n e ~ AV-6no~ npu HanMrMe Ha MAC-CMHAPOM A V - ~ ~ 3". OK Hamnea B OKono 6% npM OMM H TO noH~~~BMCM OT Mn Oo ~ a n ~ 3 a q ~ Ha m~~@aprcra a (wnxuvecTo npu UoneH w~@aptcr (70%OT c n y a ~ ~ e npomoaa). T~~Ho). Ta M neqetiueTo ~ ~ B U C R O TT ~ O K ~ ~ M Ha ~ ~ ~~$aptcra. ~ M R T ~ 2. l l b n e AV-6no~ ~ npM npefieti n~$aptcr (3~nxmeCmpr~oma npM poneH n ~ $ a p u e n p ~ 6 n n 3 ~ ~ 20en~o 25%, poKaTo npu npefleH 70-80%, ~e3aaucu~o OT M ~ K ~ C - ~ H O ) . 3. n a n e A ~ Vdn0~ n p non ~ enTseHaTa KC. Tom n o ~ a s ~ra e, npomo3aTace onpepem He TonKoBa OT 6no~a, a OT roneMMHaTa Ha ~ e ~ p o s a ~ a . HO npH Hanwne Ha: a) XeMOaMHaMMVHM Hapyllltnnn, PM poneH MH$~PT 6 n o ~ e b OT ~ cynpaxncoe Tun (c 6) enelcrptweti H ~ C T ~ ~ M ( r~ eW m KaMepHH ~ T emTecHM KaMepHu KoMnneKcn n cbppewa recToTa H ~ C40 ( min.') Atropin 1 mg i.v. e e @ # ~ a c Ha e ~K . C n o ~ e x a ~ c a ~ o pacnmonu); cny.raMTe c: xeMoRnHaMwtHn HapyureHuR, eneKTpuqeH B) npeKapaH npeneti UH@~KT, Hnn wpa3e~a HewTaTbVHOCT Ha npAHaTa KOpoHapHa apTepnR (flenp3C~R H ~ C T ~ ~ MU ~ npeKapaH U T ~ T npeneHH H ~ ~ P KHeAocTarwT, Ha S T - c e w m B I, aVL, V1-6 omeqmnn. HOCT Ha npepHaTa KopoHapHaapTepnR (nspa3e~a Renpe-

2 16

Capgerno-cngoBu cneurnu cacmonnun

4. [PM HoBonoReMn ce A66 - e xopa Ha npepeti m~$apm (rec~o). 5. PM AV-6n0~ 1 MnM2O-npbi HMM'iMe ~a$aCLpKynapeH 6 n o ~ (rec~o). 6. PM A V - ~ ~ O K IM TIIM - npM ~ npepeti ~ ~ $ a p ln cTun r II, npw poneH (rec~o). 7. npn A66+nnX6 vnn 1 3 x 6 ( p e n a ~ n ~ ~ o ) . 8. PM anTepHMpa4 A66 C D66 (penaTMBH0). 9.npM~ P ~ M ~ ~ M T M MIlpM H RKJl MHMClHaCMMnTOMaTMKa (P~~AKO). 10. l l p Atropin ~ - ~ ~ ~ M C T cuHycoaa ~ H T H ~ 6pq~~apAMR M npM KJl MHM'iHa CMMnTOMaTMKa (PR~~KO). 11. PM CA-6n0~M npM KJlMHM'iHa CMMmOMaTMKa (P~~RKO).

B ~ H3a O IlpaKTMKaTae, 'te B 70% KnMHMClHMTeAaHHM CbBnaaT C XeMOAMHaMHqHMTe. ~ M H M ~ KapTMHa H ~ T Ha ~ ~ ~ C T O A H CH ~ npM T ~ OMM e onMcaHa B racna OCH.
~ P M H ~ M e pa ~ ~ ce T ynecHM pa60TaTa Ha nRsaTa KaMepa- rpes HauanReaHe Ha npep- H cnep HaToeapaaHeTO: l. O p ~ o n w n r ~ nonoxeHne. o 2. Kucnopopc MacKa, M ~ Hasaneti M KaTenp 4-8 Ilmin. 3. npM HeHanbnHO pa3npHaT 6eno~po6e~ OTOK Morphin 10 mg i. v. unM Droperidol + Fentanyl l-1.5 ml i. v. n0pwM OnaCHOCT OT IlOTMCKaHe Ha AMXaTenHMR UeHTbP, npM T ~ X 6enoppo6e~ ~ K OTOK T P R ~ pa B~ M M a rOT0BHOCT 3a
MHT)~~~MR.

Ill. Oc~pa neeowaMepHa neAocnTarnocT

n o ~ l e a Ha ~ aOCH saauc~ OT roneMvHaTaHa HeKpoaaTa M MCXeMHVHaTa 30Ha. AaMT C eA O p M npoL@HTM,npM H M M % e lT O Ha KOMTO TR C e nORBRM, H 0 TOBa He ip~6aapa C e a6con10~~3~pa, TbA KaTO npeF(XO~a~OT0 CbCTORHMe Ha MMoKappa M Toea Ha ApymTe opraHM ca OT ronnMo 3 ~ a r e TaKa, ~~e r e M . ~ a n ~ HeKpo3a a" nnoxe pa ce oKaxe $aTanHa. Hapyure~a~a neaoeeHrpMKynHa $ ~ H K ~ B HO F~I M po: HaMMeHYAapeH M MMHYTeH 0 6 e (YO ~ M CMO), HaMMeHa $~~KUM Ha F IH3TnaCKMHe C npORBM Ha OCH-Hanpe~; HapaCTBaHe Ha K ~ ~ ~ H O AHaCTOnHO T O HaRraHe M o 6 e M ~ PeTpOrpwHO 40 ~ ~ C T O BA MMKMR Kpbr C npORBM Ha CHHaaap. K ~ T Il O pH'iMHa 3a BWHMKBaHe Ha OCH npM OMM, ocaeti roneMnHaTa Ha ~ e ~ p o s a ~ a p ,~ 6 a pa a ce M M a T npepeMp pynTypaTaHa MexqyltaMepHaTanperpaa- lrnM nanmapeti MycKyn, Kamo M AMC$~HKC(MR Ha nocnepHMfl, lnnMxopAeTetipnHee. X~MO~MH~MM nvMeHM, '~HHT~ CbnpOBO~a~M OMM, MOraT fla 6bpaT KJla~M$MqklpaHM no MHBa3MBHH M n M KJlMHM'iHM AaHHM. X e ~ o p ~ ~ am ~a mcr#~ $a w~aq Ha ~Forester ~~ 1. H R M 6enoflpo6e~ ~ sac~gh M nepw$ep~a xnnonep$Y~MR nynMoKannnnpHo HanRraHe (IlKH) nog 18 mm Hg (2.40 kPa), CbpAeYeH MHpeKC (CM) H a 2.2. 2.6enoppo6e~sac~oA, 6e3 nepw$ep~a x~nonep$y3MR - nKH H w 18 mm Hg, CM H a 2.2. 3. nepn$ep~a x#nonep$yanfl, 6e3 6enoppo6e~ =cTOA - nKH nop 18 mm Hg, CM nop 2.2. 4.6enoppo6e~3acroA H nepn$ep~arnnonep$y3~~nKH HW 18 mm Hg, CM nop 2.2. K~MHM tm ~a Hc~~ $ ~ Ha ~a Kilip: q~~ 1.6e3 KnMHMllHM M PeHTreHOBM n p ~ 3 ~ 3a aq nBH. ~ 2. C ~ M H M ~ H nM p ~ 3 ~ 38 aq nBH ~ (T3-ranon, op~o-, pMcnHeR, ~ ~ C T O A H M xpMnoBe B 6enoppo6~meOCHOBM), 3ac~oA Ha pe~~re~orpa$nma. 3. l l a q ~ cen3pa3e~ ~ ~ ~ 6enoppo6e~ OTOK. 4. K a p p ~ o r e ~ WOK e ~(KUI).

4. AWYP~TMK Ha ~ 3 6 e 0Furanthril ~ (Lasix) B posa 4080 mg i. v., raA KaTo TOA M M a M pnpemeH, c b p o p a 3 ~ ~ p aaq e$em abpxy 6 e n o p p o 6 ~ cbpoae ~ ~ e (ab~pe aa 5 min). ~ 6naronpMRTeH e$em C TOM ce O ~ R C H R BHeroeurn npeAMAae ~ a m n ~ n a ~ ~ y p e 3 a . 5. H~sponpenapa~~ ca noKa3atiMnpM BcwrKMcnyvaw, npM KOMTO AH He e nop 100 ml Hg (13.33 kPa), n A KaTo Ha~annaaT, Kamo n p e k TaKa n cnepHaToeapaaHeTo. B Ha'ianOTO C ~ ~ ~ M H M H O , a B KJlMHMClHaO ~ C T ~ H O B i. KV. ~ # H $ ~ ~2-5 wR mglh. 6. ~ O ~ BMHaM T M e HallMqe M 6p0~~0~na3bM, nOpwM KoeTo e OT non% npMnoxeHMeToHa Novphylline 2 nbTM no 240 m@. v. H Urbason 40-100 mg i. v. 7. K~PAMOTM~HOTO nereHMe, MaKap M ocnopeaHo, BMHam e OT nonaa, oco6e~o npM HanMrne Ha TaxMapmMMR (Digoxin 0.25 mg, lsolanid 0.4 mg i. v.). 8. n p Heycnex ~ Ha ropHaTa TepannR ce n p ~ 6 ~ m ~o a Mmy6aqMfl M M3KyCTBeHa BeHTMnaUHfl nOp nOBMUeH0 Hannratie.

RI. Kap~wore~en luow

K~IIHMYHMT~ npomM M nereHMeTo Ha KUI ca paarnepaHn B paspena WOK:

V. En~cTe~owapAe~ nepHwapAm
~~MKHOB~ eH 6bp30npexopeH, O He snowaea nportio3aTaMHeHaJaraCnMpaHeHaaHTMKOarynaHTHOTOflerewe. 6 o n ~ a ~ npM a Hero ce Bnwe OT pMwaHeTo, rysa ce

xapamepHoTo nepMKappHo TpMeHe, HO TpR6~a pa ce p ~ $epe~qnpa OT cTeHoKappHaTa, aaqoTo nereHHeTo e paZ~~MCIHO. nocra~br~ eo npMnoxeHMeTo Ha aHanreTuqM M ~ecneqn$~ npo~~~oeb3nanmen~n r~~, cpepcTea (Analgin, Reopyrin) Mnn Urbason, aa Aa ce nonyw e $ e ~ ~ .

VI. CHHA~OM Ha Dresler

~~MKHOB~H C e O

Ha6nIOpaBa MeWy 14-21 AeH OT HaranoTo Ha ~ ~ $ a p m HO a , Moxe pa ce noRBM M npepw 7 peH (,pa~e~" Dresler) M po 2 ropnHM cnep ~ ~ $ a p m a

Cbpgesno-cagoBu cnewnu cacmonnun 2 17

(.nce~" Dresler). Vlspaa e Ha aeToMnnyHtia peaKqMR. K n ~ ~ nce r~ nponeflea o c nneepanHa M nepnKappHa h n ~ aanMReu(a , ce OT pMwaHeTo, cbnpoaopeHac $e6p~nMTeT. Y c ~ a ~ o a ~ce l a nnespanHo a n nepMKappHo TpMeHe, M~~MB BM nneepaTa M nepwappa (YCT~HOBRB~T ce ~ a f i recTo R&rpa$Mr~oMrpea ExoKT).@ M ~ M K ~ ~ MH pewreO HOnOMVHO Ce yCTaHOBRBa M IlHeBMOHMT, H0 He BMHBTM. EKr Moxe pa noKme npouetin, Kamo npw nepMKappwT, CY E ce ycltopma, a p ~ t $ e p e ~ q ~ a n 6poetie ~o~o HanealtoUMTMTe nOKa3Ba ~ O ~ H H O $ ~ ~ M'R . J l e r e ~ ~ e xaTo ~ o npM enMcTeHoKapptinR nepwap4MT M ~ H T M ~ M O T M L (He M Ce HaJlaraT.

PR3KO BnOWaBaHe CbCTORHMeTO Ha ~ O ~ H M CR nPORBH Ha 6enoppo6e~ OTOK unM KUI. Xapauep~o e ycTaHoeReaHeTO Ha HOBOnORBMn Ce rpy6 CMCTOneH Wynil C nYHKTYM MaKCMMyMHa nyHKTa Ha EOB M TpaHCBep3anHO pa3npCCTpaHeHMe. flerenve~o o ~ ~ a r ae n~ oa m npw o oc~pa~ I:KynHa HepocranwocT M MMa3a qen pa ce Haw H ~ M nmo-pece~ R WT 40 B ~ ~ M O ~ H O pa C ce T M~B~PLUM XMpypM'iHa KOPeKqMR. O ~ ~ ~ ~ T M BP M HC M Ke RMHOrO T BMCOK, H0 TOBa epMHCTBeHMflTHaWH fla Ce YabnMM MBOTa Ha ~OIIHMFI, n0Beqe ~ O ~ P O ~ H O C B clacna TM . O C T MMTpa~~ nHa perypm~aq~fi".

VII. Pymypa ~a ~ e w y l r a ~ e p ~ nperpa~a a~a

Clec~o~a e np~6n~3~~ 1% en M~ TO on p n ~pep~~, saa~rm~pau M ( cenTyMa ~ #~$apu~ n .p o ~ ~ ce ~ aca

VIII. Pymypa H RHC@~HK~HII ~a n a n w a p e ~ wcltyn H x o p ~ e j e ~ f l m ~ e

U(e 6bAaT paarnepa~n no-noppo6~o B racrra .Oc~pa MMTpantia p e r y p m ~ a q ~ ~ " .

~ Op A ~ c e ~ (paacno~ea~e) a q ~ ~ Ha aopTaTa ce pa36~pa pa3KbCBaHe Ha MHTMMaTa M HawlyBaHe Ha KpbB B MepMma ( c p e p ~ a ~ Oa ~BMBK KOFITO ~ ) , O ~ H K H O B ~ He OpereHepaTMBHo npoMeHeHa. AKOKP~BHMHT TOK ce H ~ C O naK ~M KbM MHTMMaTa M R pa3KbCa, OTHOBO Ce o6pasysa T. Hap. j e y q e e ~ an " ~acnnaa.ca~o~sne~yaa~e". Ho, Kamo craBa flO-'-teCTO, aK0 pa3Kbca s5qBeHTMqMFlTa, HaCTbnMi$aTaneH KPbBOM3nUBCnOKaJlM3aL(MR Ha MRCTOTO Ha pa3KbCBaHe.

nampa noA aplcyca. T M111. ~ IMceKaqMFfTa Bb3HMKBaUMCTMHO ( n 0 OT@~ nRHeTo Ha nRsaTa apTepnR cy6lcnaet.w) n ce paanpoc~paHRBa Hs5qOny. n p e ~ a r ce a M epHa no-onpoc~e~a, nopo6~a Ha ropHaTa, ~ n a c ~ $ ~ ~ a q n n : ~ ~ O K C M M TMn ~ ~A H= ~M , n I M 11. ~ M c r a n ~TMn a , B = TMn Ill.
~HM~M~TLIK~

Hair-.IecTo craea p w a 3a aTepocKnepoTnrHo npoueHeHa CTeHa B CbVeTaHMe C XMnePTOHMFI. OCHOBH~ npMWtia 3a ~ a c n n ~ a ~a ~~ eM ~o C ~ K e ~ HannrMeTo ~ M R Ha KMCTO3 ~ pereHepaqMR a Ha MepMRTa, p e 3 y n ~ a OT ~ peaem B 06pa3yea~e~o Ha KonareHa. H a f i - ~ ~ ncnyraM ~r~n sa~oea ca C M H ~ P O M ~ Ha T Marfan M C M H ~ P O M ~ Ha T Ehlers-Danlos. CH$M~MTHCIHMFIT MPTMT, 6MKy~1'7MpanHaTa aOpTHa Knana M 3aKPMTaTa rPbAHaTpaBMacaPeAKM npMclMHM3apMCeKa4MR. He e M3RCHeHa Bpb3KaTa Mew)' AMCeKaqMRTa M ~~~M~HHOC HO TB T~ 50% , OT cny.ranTe npM xeHw, TR Hacnnea npu 6pe~eHHM. B MoMema ~ a i - n p ~ e ~ n w es ~a a3n Ha De Bakey, 6a3~pa~ Ha a aHaTOMM.IHaTa nOKMM3aqMR: TMn I. P n c e ~ a q n aanorea ~~a Bacqe~peti~r ~a am ~a Ha aopTaTa, ~ a i - r e c ~ HenocpepcTseHo o ~s5q aopTHaTa Knana, 06xeaqa aplcyca M recTo npoflbnxacaea n Hqony. TMn II. 3anorea B a c q e ~ p e ~ aopTa, ~~a~ HO aHe npo-

H~~-TM~ML( CMM~TOM H M R T e CMnHaTa, pa3Kbc~u(a 60nKa 3s5q rpbutiaTa KOCT C n p s 5 q ~ a q K~ ~~ M mp6a. S o n ~ a ~ B mp6a ce ~a6nropaea B 94% npM pMCTanHaTaUMCeKallMR M aKo nvncea, p ~ a m o a a ~ ea nod CbMHeHMe. 6 o n ~ a ~ ec a ~bnH006pa3eH xapa~~e (v p 3 a ~ ~ x e a ,ce yclmea) M ce p a 3 n p o c ~ p a ~ HMony, ~ a a KaTo Moxe Ua 06xea~e 6b6pe.1eK
.
~ M renrocna.

K ~ M H Me KTBbpUe ~ T ~ pa3~006pa3Ha M 3aBMCM OT MRCTOTO M OT xopa Ha paxnoReaHeTo. Moxe pa npoTeee c KapTMHaTa Ha peqMpMBMpau(M CMHKOnM, M03bVeH MHCYnT, cbpuereH MH$~PKT, OCH, cbppertia TaMnoHqa, ocnp XMpypmreH KopeM M n M ocrpa apTepManHa HepocranrHOCT Ha pOflHMTe KpafIHMqM. @ I ~ M K ~ J ~ YCTaHOBRBa Ho nOBMUJeH0M n M nOHMXeH0 AH. B 50% wMa Hanwqe p a 3 n ~ B ~ nynca a M AH Ha cMMeTPMrHMTe K ~ ~ U H M ~ HOBO~ORBM~ M. Ce WYM Ha aOpTHa pevPMTaqMR, nePMKaPAHO TpMeHe, CMMnTOMM Ha OCH HnM

Ha nbpao MRCTO KynMpaHe Ha 60n~aTa(Morphin, e pa ce n o m p x a AA B Droperidol + Fentanyl), HO qen~a a no~aaea paswwpe~~e Ha paMKMTe Ha 100-120 rnrn Hg (13.3-1 6 kPa). npM HaJlM'iMe MaMnatiInnynna, aupI na Ia n tibPpeClHaTa CRHKa M f l l l M3JlMB Ha w o ~ - n e q e ~ ~ (BMX e~o T ~ M )np~ll . noBMweno AH, TO B nneBpanHaTa KYXMHa (O~CIKHOB~HO B~~RBO). ~ p ~ 6 6bpao e a pa ce noHu)KMM pa ce nombpxa B ropenoJlwnca~aHa EKr 6enes~ sa OMM, npM Hann'iHaTa coreHMTe r p a ~ ~Propranolol q~: 1 mg i. v. npea 5 rnin, 40 mecToKa rpbpHa 6on~a, roeopM c ronma C M ~ ~ P H ~aa CT nocTuraHe Ha e$em M n M po o6qa posa 5-10 mg. npln aopTHa AMCeKaqMR, H0 B 1-2% EKr nOKa3Ba TMnMqHH KoHTpavHpmKauMm 3a 8-6no~ep ce npMnara Chlofazolin 6enean 3a OHM ( ~ ~ o K c M MCl M MCeKaUMR H~ C KOMnpeCMR w n w Rauvazedin i. m. Ha KopoHapHMTe a p ~ e p u ~ w )Toraw ~ n $ e p e ~ q v a n ~ a ~ a pnamoaa e ~ p a u TpypHa. ~o HaA-c~ryp~me MeToAw 3a noTBbpxqaaaHe Ha RuarB cTaqnoHapa cpepmeo Ha na6op e Nitmprussid HO3aTa Ca EXO-KT, CKeHMpaHe M a~pT~rpa@IR. (Naniprus) B posa 2-8 pglkglmin. AKOCMMnTOMaTHKaTaHe M O X I fla Ce OBJlqee MeAMKaMeHT03HOM n M Ca HaJlMqe yCnOMleHMR (nporpec~pa~ OCH, xeMoTopaKc, cbppewaTaMnoHWa, npnTMcKatie Ha

Hak-o6qo~o onpeAeneHue Ha CH e H ~ ~ ~ ~ M O X H O C T - KsaT ynnopa H w y x . ~a~a capqe~o pa m r y p n q e ~ e a m ~ oo n ~ r e c m ~p o b 3a e IV mac: 6enesu ~a CH ca ~anwqe M n p no~oir. ~

Aopn ppepeHo cbpqeTo Abnro apeue e B cbcTonHMe pa oc~rypnHopManeH cbppereti A ~ ~ M T paxe , U npH yMepeH# @ M ~ M ' ~ ~ C K HaTOBapBaHMR, M Vpe3 BKnlO'iBaHe Ha T. Hap. KOMneHCaTOPHM MeXaHM3MM: TaXMKaPflMR; XMnepTW$MR Ha MMoKapBa; penM'ieHMe ~ap ~ a c ~ o nnbnHe~o~o He Ha KaMepme; yeenMqaaaHe Ha KpbeHnR o 6 e ~ qpe3 yaenn'iaeaHe Ha q 6 y n ~ a ~ pea6cop6qn~ a Ha H ~ T P H M~ Bopa; yeenM'ieHo npepaeatie Ha 0 , K ~ nKaHMTe. M Peayn~a~ OT CH - xeMopMHaMw'iHo HacnnsaT cneAHMTe IlpOMeHM: KnacmQ~~aq~n 1. tkitJaJR8aT YO, CM, CMO, $patqwma Ha n s ~ n a c ~ BaHe. 3a npaKTuclecKa oueHKa clenema Ha CH ce nsnona2. Ysen~vaaa~ce TeneflMacTonHnm~ ~ e n e c n c ~ o n sa ~aA-'iec~o ma( pKcKaTa KappHoRT 0 6 e ~ M HWRraHeTO Ha nRBaTa KaMepa, CpepHOTO nom'iHa acoqnaql HmRraHe l4 6 e n o p p o 6 ~ ~ HaJl ~e RraHMR Ha I mac: Bbnpeb '~HOs a h n ~ ~ ~ npepcbPpH0 e BCM'iKM HMM. 60nHMTe ca 6e3 OnnaKBaHnR B nOKO6l M npn 06nclah~nTe npn npeo6nqaaa~e Ha xeMopnHaun'iHme ~apyu~e $ M ~ M ' ~ ~HaTOBaPBaHMR. CKM HMR, now'ietiu BT. 1 CH ce ~nacu$~qupa KaTo xnnope6nII mac: B n o ~ o h 6on~me ca 6e3 onnaKaaHnR, HO THa (CH-HaIIpeA). 06u'iah~me$M~H'~~cKM H~TOB~PB~H lP H efl R H3BHKBaTYMCflpu npe06fl~a~aHe Ha Tean, nocoqeHu BT. 2 - KaTo Pa M w y x . 3amoh~a (CH - ~ a s q ) . Ill mac: M npn ~ a l - ~ a n t@ a im n q e m y m n WHH~ a cMcTonHa uepa.

TaTa Ha nReaTa KaMepa, rpe3 HmanRsaie Ha npep- M cnepHaTompmHeTo M noAo6pum~e Ha KoHrpammeTa: 1. ~ O ~ H M F C IT e IlOCTaBFl B O P T O n H O M C H l O nOn0XeHMe. 2.0, c MacKa nnn ~ a s a n e KaTenp ~ c fle6n~ 4-8 Ilmin. 3. Nitroglycerinec p e ~ ( c~a ~~ ~o3 6 (0 ~~ a~ann npep m M, n o - M ~ K CnenHaToBapBaHeTo O n pa3uup~ea KopoHaptime cbnose). 3anorm ce cbc c y 6 n ~ ~ r e a n npnnoxe~o K n n ~ n r ~ KapTnHa a ~ a Ha nesoKaMepHaTa CH ce onH M e Ha 0.5 mg npea 5-10 rnin, no 3-4 npMenna, KaTo ce penem rnaettoOT npoRaMTe, c ~ b p 3 a ~ cbc n CH - ~ a a qT., cnepn AH pa He c n q a nop 100 mm Hg (13.33 kPa). e. OT Bb3HMKHanHR 3acT0l B 6enme'~po60se.3 q y ~ b T e 4. Morphinum hydrochl. B ~ o s 10-20 a mg i, v., npnnoxapatmepeH CnMnToM. El HavanoToecaMonpnycMnne M n M xeH B HavanoTo e c npeKpaceH M 6bp3 e$eu (ycno~oma B nemano nonoxetine (op~on~eg) M ce cbnpoBoma OT Bb36y~leHnR AnxaTeneH uetinp M HaManRBa pa60ra~a Ha cyxa, upaa~eqa Kawnnua, n3pa3 Ha 6enodpo6e~ seHoAnxaTenHaTa ~ y c y n a ~ y p an ) . p TemK, ~ HanpeIHan 6e3eH M KanMnRpeH 3acT0h. Pe3ynTaT OT HaMaJleHMR CM0 no~po6e OTOK, ~ AOPM M Aa Hma npeAwecTsauo 6eno~ca npomme Ha o6qa oTna,qHanocT M Mycyntia c n a h c ~ , PO~HO 3a60nf1~a~e, IlPMnOXeHMeTOMy e 0naOH0,3a~OTO onnrypm, HMWPMR. npn $ H ~ M K ~ ~ n3cnepleaHe HOTO ce MOXe Aa nOTHCHe AMXaTenHMR UeHTbp M fla AOBeAe A 0 YCTaHOBRBaT ~ ~ C T O ~ ~H pM e 6 He3By.IHH ~n XpMn'ieTa B 6eanHOe, n O p a J $ l KOeTO ~pf16ea Aa M M a rOTOBHOCT 3a MHTYnoflpo6HMTe octioen, noeere B ~ C H O TaxnKapAuA, , ranon, 6aqn~ M 06flnwm~e. pa3WMpeHM nepKYlOpH0 CbPfleVHH TpaHMUM, mTepH#5. n p e p n o r n ~ a ~ p n y p e Furanthril ~ n ~ e (Lasix), npwnop a q nync. 8 0 nlKaTo npwexaaa H pMpetcreH EKr Moxe Aa noKaxe neaoKauepHa x n n e p ~ p o $ ~ ~ , xeti i.v. ~ ~ 0 3 a 4 0 - mg, BawnnaTueeHe$em sbpxy 6enonpo6~n~e cbnoee. n p ~ pM$y3Ha MCXeMMR, UMKaTPMKC OT npeKapaH kIH$apKT, nnnca Ha e$em: cnep 30 min no3aTa ce noe-rapn. Rbrpa$nma - yaennreHa cbppewa cmKa, Genop6. PM BCM'IKM cnyvan Ha KapAnoreHeti 6enoflpo6e~ 3ac~oi; OTOK (CH3KIlIOLleHHe Ha Bb3HMKHMMR B pe3ynTaT OT MMTExoKr - ~ U C $ ~ H K ~ Ha MR KaMepHaTa cTeHa, cbppeveti panHa c ~ e ~ o 3ce a ) npnnara i. v., 6 b p 3 0 f l e l ~ ~ B KappMa~ nopoK, $ p a w n ~ ~ a~ 3 t n a c ~ m ~ e . OTOHMK (Isolanid 0.4 mg, Digoxin 0.5 mg). 3a TMnMrHn n p o m Ha neBoKaMepHaTaCH, n3ncma7. T b i KaTO nOWI BMHarM e HaJlblue 6po~xocna3b~ q n cnewHo nevewe, ce cMmaT KappnanHaTaacTMa (npn npunoxeHneTo Ha Novphyllin 240 mg i. v. e OT nonaa. MHTepcTMuMalleH6eno~po6e~ OTOK) H 6eno~pG6~wm OTOK (npn aneeonape~).Tesn ~ ~ C T O R H M R HacnneaT n npn 8. ~ ~ M ~ O X ~ H Ha UKOPTMKOCTePOMAM ~ T O (Urbason40MwTpanHa C T ~ H O 6e3 ~ ~ ,pa e HanMue neeoeetiTpMKynHa 100mg i.v.) 3a HaManRBaHe nponycmcn#aoc.rra Ha KannnRHeAOCTaTb'iHOCT. PMTe e C HenOTBbppeH e$eKT. Te HMaT XapaKTepHa bl po6pe M3BeCTHa KIlHHMClHa BCHC~KH 6017~ C~ ocTpa neaoeeHTpMKynHa cna60c~ KaplMHa: CMneH HOweH nnU Cnep $ M ~ M V ~ Y C C M Kn M R 3a~ p f t pa 6~ 6bAaT HaCTaHeHM B PeaHMMauMOHHO OTpene~ y xo ; p ~ o - ~ n c - ~ a x nWYMHO, n ~ e ~ ;xbpxopeqo, vyaaqo ce HMe. OT P ~ ~ C T O R H UnwaHe; M~ Kawnnua c 06nn~a neeecTa M KbpBaMeKCneKTOpauMR. ~O~HIIFIT B Ha'iNlOTO e HeCnOKOeH, ab36y~e~,6nep, n 3 n o ~ e ncKa ~ , Aa s a e ~ e cepiano npopbnxacaeace c B ~ H O H ~H H ~~~ ~ vpe3 M R , ne@yop nonoxeHne,no-K~CHO C~~H~HH ce~3aMbrnma TO M TO^ ce Ha Perlinganit,Trinitrosan nnn lsoket B ~ o a 2-1 a 0 mg/h npn OTnyCKa. @I~HKXIHO, B 6enn~e Ap060Be C e YCTaHOBRBaT C T P M K T H O CnepeHe Ha AH M Ha nynMOKanll~RpHOT0 HEUIRwso6~nne OT pa3~o~ann6pe~n Emmuin xpnnoae n 6 p o ~ raHe M MOHHTOPeH KOHTPOn Ha EKr. npM H m a - IlOBTOpXOCna3bM, K O ~ T OO ~ H K H O B ~ HCbnbTCTBa O IlpORBMTe Ha HO npnnoxetine Ha ropenocoveHme MeplrlKaMetiTn. KapAllrantia a m a n OTOK. Cbppev~a~a aycymqnq &#KYM~CTHO e npv TemK 6enonpo6e~ OTOK 3 a n o r ~ a ~ e TO Ha ~ H T M ~ H O T M TepanMR. ~H~ npn nnnca Ha e$eu or npnnoxeHoTo nereHue M 3qbn60WBaHe Ha KnMHHVHaTaCMMnTOMaTMKaC e npn6~r M A0 M H T ~ ~ ~H~M3KyCTBeHa MFI BeHTMnaL(MRC nOBMWeHO HaJlRraHe.

np# Cb'ieTaHHe Ha IlpOMeHbITe OT T. 1 M T. 2, KaTO xnno~e6m~ na 3aCTolHa ( T O T ~ ~ H ~ ) . PM HallHqHeHa IlOBWWeHCMO, CH Ce KIla~M$#ubIpa KaToxMnepKnHeTnvHa(xnnep~npeow~(~sb~, aHeunn, Berry-beny, ap~epnoee~o3e~ W~HT).

Ocrpa~a aopTHa M H C ~ @ M ~ M ~ H no ~M ceoma R na~@n~MO~O~ MM XeMogMHaMMKa R ce pa3n~raaa OT x p o ~ w q ~ a ~ a M M B M C K B cnew~a ~ ~ ~ a n i oM a nereme, a KoeTo e qecTo M

XMBOTOCnaCRBaqO.

E~uonorcr5I
Hah-rec~u~e npwrMHM 3a HamnBaHe Ha ocTpa aopTHa M H C ~ @ M ~ M ~ H Ca: ~M 6amep~ane~ R eHgOKapflMT M Hak sere npMrMHeHnm OT c~a@~no~oKyc aypeyc M eHTepoKoKM, KOMTO B O ~ go T 6bp3a A ~ C T P ~ K ~ Ha M RKnanHMn anap q ~ paapywa~a o aop~~m ne n a ~M ~a ~ p M a 3 w ~ p ~aosa P T H H R IlpbCTeH; KaTO yCnOXHeHMe Cneg npOTe3MpaHe Ha aOpTHaTa Knana; 3aKpMTa PbgHaTpaBMa; MMKCeMaTO3Ha ~ e r e ~ e p ~a a u~~ n~ anaM ~c aw ~ g p o ~ ~a a Marfan. X ~ M O ~ M H ~ MHapyweHlnR M ~ H M T npw ~ ocrpaTa aopnia #HCY$M~H~ C M H n H ~O M C e Rpa3JlM'iaBaTOTTe3# npM X P O H M rHaTa. flpn nocneAHaTa,KoMneHcaTopHonRsaTa KaMepa e x~nep~po@~pana n AMnaTMpaHa,UoKaTonpM ocTpaTa TR nocpeqa HenoflroTeeHa yeenMreHMR o 6 e ~ ~pbe. K~TO pe3ynTaT OT TOBa npM XpOHM'iHaTa aOpTHa M H C ~ @ M ~ M ~ H ~ M ygapHum R 0 6 e ce ~ nombpxa norTn HopManeH, npM yeenMreH TeneAMacToneti o 6 e M ~ norm H O P M ~ ~ H HMRO raHe Ha nanHeHe, AoKaTo npM ocTpaTa Hacnnea 6bp30 noBMwetiMe Ha HanRraHeTo Ha nbnHeHe M peTporpaHo noeMweHMe Ha neeonpegcbpAHoTo n nynMoKanMnRptio HXlRraHe (6enoflpo6e~ 3ac~oA), KaTO eflHOBpeMeHH0 HaMMRBa M CM0 (XM~~OT~H~MFI). ~ a p a m e p ~ 3 ~ pc a6bp30 ce p a 3 m eH~CMM~TOM ~a M neB0BeHTpMKyn~a CH ( 0 ~ ~ 0 - ~ M C - T ~ 3aCT0hHM X W ~ HXPM~R, nOBe B 6enw~e ppo6oee, 40 6enogpo6e~ OTOK) M B CbqOTO BpeMe- C nWRBM Ha HaManeHCM0 ( X M ~ ~ O T g0 ~ UOK) H~MR npw ~ O ~ H M KOMTO , go MoMema ca 6 ~ B n cpaetimentlo ~

3aoeon~~en CbcroRHMe. ~o 3a xapamepHa HaxogKa ce ~ ~ ~ ~ a ~ ~ ~ ~ n ~ ~ ~ ~ n c e n n ~ ~ay aopTaTa. EKr (~ah-rec~o) He n o ~ a 3 ~ npoueHn, a xapameptiw 3a nesoKaMeptia x ~ n e p ~ p o HO $~ Moxe ~ , ga M M a genonRPM3aqMOHHM flpOMeHM B OTBewaHMRTa Cpeqy nRBaTa Kauepa. R o - M ~ c ~ ~ noua3~a F(B~H 6enoflpo6e~ ~ aacroh go 6enoflpo6e~ OTOK. HaBron~~ 3o ~ a r e 3a ~~ g~ ea r ~ o a M aM ~aaExoKr.

J l e ~ ae pF ~X~ ~ H ga n p e l t e ~ no ~K ~ M H M ~ ~ Ha ~p T- ~ TMH~ M AH KaM KOR X ~ M O ~ ~ M H ~ M vyna MC~ c Hn~ ~ ~OJIHMRT a M fla npMnOM4 HeOTnOXHM MepKM: 1. f l p ~ ~O ~ c H6enogpo6e~ M OTOK M AH 100mm Hg Nitroglycerin, c f l n ~ ~ r s a nM~ gMypeTMK o (Furanthril, 20-

40 mg i. v.). 21 flw 60nHMC X M ~ O T ~ H C M(AH F I nog 100mm Hg) M 6e3 6eno~po6e~ OTOK- BnmaHe Ha coneBM p a 3 ~ ~ B 0KonMp~ ~ ~ C T 200-300 BO mV30min npM cnegeHe ~aAH (~ah-flo6pe e Ra ce CneAM 4BH, H 0 B AoMawHa O ~ C T ~ H O B TOBa K~ e norm H ~ B ~ ~ M O X ~HP O nMnca H ) . Ha e@em - Dopamin, 515 pg/kg/min. 3. PM ~ O ~ H CM X M n O T O H M R M 6 e n o ~ p o 6 eOTOK ~ (CM~PTHOCT H ~ 90%) A - Doparnin, 5-15 pglkglrnin, MnM Dobutrex. IopaBa~e~ Ha o 0, c ge6ws 8-10 Ih rpe3 ~ a 3 a n e KaTenp M n M MacKa e 3 a b n r n ~ ~ e n ~ o .

Cneur~o ~OJIHHVHO newme

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r e ' c ~ b p ~ ~ oecH n~ a 50%. A n o ~ e r o e oo ~c ob q e c r s ~ w ~ TpR6Ba ga C e OBJlweRT XeMOflMHaMMClHMTe npo6ne~n, KOMTO CbOTBeTCTBaT Ha Te3M npM KLU. ~ N ~ oMHTPaH H ~ aOpTHa KOHTpanynCal(MR, KORTO nOBMlllaBa gMaCTOnHOTO HannraHe, e n p o ~ ~ ~ o n o ~ a a ~ a .

Paarnewa ce caMo TR, n h KaTo ~ e h ~ m npouBM e Emonor~~l npegcraenRaar cnewHM C~CTORHHR, qecTo 3acTpawaeaHah-vemo peBMaTHrHa, HO i p ~ 6 e fla a ce nMaT npe& XMBOTa. H O P M ~ ~ WanHannoul H ~ T ~ Ha aoPTaTae2.6BMA BpOAeHa 6 ~M n M TPM- KyCnMganHa mans M aTepocK3.6~171'. n ~ ~ c ~ e c ~ e ~ ~ e n o ~ 0 . 7 c m ~ r oneposa ~ o ~c~ ~3a~ ~ m ~ ~ n~ p apeeMamrHa KanuMeen oTnaraHMR. ~ emonoCT~HO~~. MR H ~ ~ Y ~ C eT 3acenia~a O M ~ n ~ p a n ~nana, ~a~f al o ~ a ~

npln ocTaHannTe Aae cTeHo3aTa e nson~pa~a caMo ~ b p x y aopTtiaTa Knana.

~ ~ ~ m o ~ m w a
nbnro BpeMe aopTHaTac ~ e ~ o ~ 3~ ao T u ' ~ ~ ~ ~ ~ c M M M H O , KaTO C b C T O R H M e T O Ce KOMneHCMpaOT IlOCTeneHHaTa x~nep~po$ Ha n~ nRBaTa KaMepa, K O ~ nombpxa O HOPuaneH YO M CMO, HO nocnefltiwm e .$MKCMP~H", T. e. n0VTM He HapaCTBa npM $ M 3 M ' i e c K M YqMnMR. @ M ~ W K ~ H O Ce YCTaHOBRBa TMllM'iHMRT rpy6 CMCTOneH Ufl Ha M3Tna-

ptia MnM npepcbppHa $ ~ 6 p ~ n a q ~ Ha6nlofla~a~ n. ce B oKono 25% OT 60n~we n npopnxMTenHocriaHa xMBoTa cnep TRxHaTa nonsae ~pM6nM3M~en~0 3 rop,wHM. Pewaeaq~ 3a fl~amoaa~a ca p b n r o ~ p a i ~ EKr a~a (Xon~ep-MOHM ~TOPMH~) T o - M e~qe$anorpa$wn~a. 3. ~ ~ O R B Ha M JleBOBeHTpMKynHa HeflOcTaTb'iHOCT. B HaranoTo - 3apyx npM ycwnme, no-WHO - KapflwanHa a C T M a M 6enoflpo6e~ OTOK. T O B e~ K b C H aC M M n T O M a T H K aM cnep ~ e i t ~ noma a ~ a npo&.nxMTenHocna Ha xtcMaoTa e 2 roflntiw.

A~@epe~quan~a ~uar~o3a
B ~ M $ ~ ~ ~ H ~ M ~ H o ~ # ~ ~ H oO cT H TO M W 'e ~ H M He o~pn6ea Aa ce MuaT npefleMg BCMC~KMqepe6pe M BacKynapHM IlpM'iMHM, KOMTO BOflRT p0 n o f l o 6 ~ C b ~ C T O F I H M F I . ,

3a KpMmwa aopTHa cTeHo3a ca xapaicreptiv:

1. ~ P O R B H Ha aHMHa ~ ~ K T O P M C - X M ~ ~ P T P O $ U P ~M ~MRT

pa60~e~~ Cpeqy ~ 1 - r nOBMWeH0 CbnpOTMBneHHe MHOKaPfl M 3 H C K B a IlOBMUleHa0 2 - ~ ~ ~ ~ T. ~ e. ~ HaJlMue a u ~ e npepR , ~ O C T ~ B safluc6ana~c, K ~ T ~ fl0pM M npM H O p M E U l H MKOpOHaPHM apTepMM. l l p o ~ b n x w e n ~ o c n Ha axMaoTa cnefl nonBaTa Ha aHrMH03HM npMCTbnMe npb16nM3M~ef7~0 5 rOflUHM. 2. ~ P O R B M Ha CMHKonn M r n a ~ 0 3 a ~ a i npH ~ ay ~c ew e M n M npomtia nonoxeHMeTo Ha TnnoTo. Hai-VecTo ce mnXaT Ha M03b'iHa M C X e M M R , ~ bKaTO i CM0 e .$MKCMp a ~ "HO , npMwHa MoraT fla 6bflaT 6bp30npexofl~a KaMe-

Kacae ce 3a oc~po HacTbnMna MMTpantia perypwa~ M (OMP), R pe3yn~a OT ~Btie3anHo pa3pywaea~e Ha HRKOR VacT OT tmanHMR anapaT, M n M OT noAqbpxauyTe ro
CTPYKTYPM.

Hail-'iec~~ nPMVMHM e 38 B ~ ~ H M K B ~ H Ha ~T OMP O Ca:

ocTpa

McxeMwn Ha MwoKapga,

aac~raqanannnaptiwe

~~TO$M~MO~OM Ha R OMP T ~ PRBKO ce paan~raea OT T a 3 M Ha XPOHM'iHaTa. B H ~ ~ ~ ~OH ~O ~M TH IlpeTOBapBaHe OO 3aeapea nmoTo npepcbpAMe HenoAroTsetto M ~ecnoco6HO 3a ~ ~ e 3 a ~ nn ~na a ~ a qnopap1 n ~ , KoeTo P ~ K O HapacTsa neaonpepcbppHoTo HanRraHe, I I ~ ~ ~ M ~ B M K B6e~~K noflpo6e~ sac~oi, KO~TO ce ~ a ~ ~ $ e c cbc T ~ 3wyx p a npM YCMnMe fl0 (DY~~PORHT~H 6enoflpo6e~OTOK.

MyCKynM M BOfleqa 10 TRXHaTa ~ ~ M @ Y H K ~ M OMM, R; 3 a C F 1 -

raq nanMnapeHMycKyn Mnu 06nacrra, B KORTO ce 3ana~n; C H M ~ T O M ~ Tce M onpepenn K ~ T ~ OT cTeneHTa Ha peryM H $ ~ K L ( U O ~eHflOKaPflMT ~H C $eHecTpa4MR Ha KJlanHMTe pmTaqMn H newKauepttaTa $ ~ H K ~ M R . PM F/MC$YHK~MFI n n a T H a , r e c T o n p e f l ~ 3 ~ m ~ ~ a q p y n ~ y p a ~ a x o p ~ eH ~a eIlanMnapeH ~p~MyCKyll M H C Y $ M ~ M ~ H ~ M F OI~ TH ~K H O B ~ H H O e Hee; PeBMaTM'ieH BanBynMT; MMKCefleMaTO3HaflereHepae TeXKa M Ce IlpOflBRBa C KnMHMKaTa Ha KapflMmHa aCTMa ~ M Ha R nnaTHaTa unv nombpxaqMR anapaT (~anp.: CMH(OPTO-, AMC-, T ~ X M ~ H ~ MRYMepeHa ) X M n O T e H 3 M R . PM flpOM Ha Marfan); 3aKpWa rpbflHa TpaBMa; ~ ~ M C @ / H K ~ H Ha R pynTypa Ha nanMnapeHMycKyn M n M xoppe TeHflMHee ~$yflMMTpanHa npo~eaa; p~13M ~a TexKa flMnaTaqMR Ha nnBaTa PORHTHO ce p a 3 ~ ~ 6enoflpo6e~ sa OTOK, CbnpoBofleH OT KaMepa, ebanlrraqa M Awnampaqaw MMTpantiMHnpbcTeH. KLU M B KpaTKo BpeMe Hacnnaa C M ~ P T .

222

Cwgesno-csgoBu cnewwu cacmonwun

Xapamep~a @wi~an~a ~axoplca e ycraHoeReaHe Ha HOBOnORBMn C e XOnOCMCTOneH Ulfl Ha CbPpe'iHMR BPbX. ToA Moxe pa nMncm npM ~ a p a a e ~ neeoKaMepHa a HepoCTaTbqHOCT. O~HKHOB~HO e HUlMqe CMHyCOBa TaXMKapE#IHCTBBHMRT UlaHC xi IlaqMeHTae KOnKOTO C e MOXe U M R , ROKaTO npM XpHMClHa MMTpanHa M H C ~ @ H ~ # ~ ~ H ~ M R Banpew wcoKaTa CM~PTHOCT, no-paw, ua ce npo~e3~p H a fWCT0 - IlpepCbpflHO MbWeHe. YCTaHoBRBa C e T4MwrpanHaKnana. Ao~oraBa M ~ ~ M K ~ M ~ H T O ~nereHMe HOTO ~ZUIOtl.B 6 e n ~ ppo6ose ~e C e KOHCTaTMPaT ~BCTOAHMX P M cecbcToM~npwnaraHe~aBa3opnna~a~op~cnpepM noee Mnv p a 3 n p ~ a KapTMHa ~a Ha 6enoppo6e~ OTOK. 4 H R BbPXY aPTePMaJlHHR TOHYC. KOMTO HaManRBaTCneUHaToBapeaHeToM neeOsempMKynHMRo 6 e M ~C ToBa M creneHTaHaperypmTaqMR. NitroprussidNatrii(Naniprus, 1 amp. = 30 mg) ce npMnara B MH~YBMFI B uo3a 2-4-8 pgkglmin, KaTo ce 3anor~a OT H ~ A - H M C K ~ T npM ~ , CTPMKTHO cnepeHe ~3pa3 ~aneaonpepcbpp~o O~~MH npeToeapwHe O B omeHa AH (ua He n q a nop 100 mm Hg - 13.33 kPa) u npw WaHe V1 Moxe F(ace nonen6 ~ 4 a 3 P-ebn~a ~a c W H ~ ~ K O - B~~MOXHOC naAT ere Ha nynMoKanunflpHoTo, KoeTo He ~ p ~ 6 pa a an q a nop 15 mm Hg (2 kPa). r o n ~ qacr ~ a OT naqMeH-rMTe c OMP ca c eKcrpeMHa X M ~ O T ~ H ~M M n M R U~OK - ToBa Hanara smloreatie M Ha M H $ ~ ~CM Dopamin R M n M Dobutrex B poxi 2-10 pgkglmin, Banpew r e B~IOKOHCT~MKTMBHMRTMM e@m Moxe pa a a c ~ n MMoKappHaTa ~ M C X e M M R H perypMTa4MRTa. flpM Bb3MO)KHOCT, no-~06pa f l o 6 0 n ~ n ~noeeAenHe o M neqenHe 8JlTepHaTMBa xi Te3M 60nHM e F(a C e npMnOW 6an0HHa MHTpaaopTHa KoHTpanyncaqMn. M e p u ~ a ~ e m o a Te~a~ BCM~KH ~ O ~C HOMP H nopexaT Ha cnewHa xocnnTaPaIlMR ~ p ~ 6 ua e aC e CMRTa 351 BpeMeHHa MRpKa, KORTO nM3allMR, H a fuo6pe B KaP~MOXMPYPM'iHaWIHHMKI, a K O UaBa Bb3MOXHOCT 38 M3BbpWBaHe Ha pa,4MKallHaXMpypMHqMgeHnT e HacTbnunB u o ~ a w O ~~a C T ~ H O B HO K ~ Toea , rMVHa KOpeKUMR. Ha npamMKa e PRUKO, T ~ KaTo U OMP e ycnoxaieHMe Ha npeuurecraaqoxi60nma~e M H a m n w npn sere xocnn TWlM3MpaHM ~ O ~ H M B .pOMaUlHa O ~ C T ~ H O BCMMnTOMaK~ TnKaTa Moxe ua HamnM npcl 6 0 n c ~n ~p o ~ e 3 ~ p a ~ a npomoaa OMM noRBaTa Ha OMP uo 24 h B 75% BOUM 1 0 MnTpanHa Knana M CMtiupoMa Ha Marfan M nereHweTo ce c ~ b pa~ po , BTopaTacephnnqa cwpniocrra uocmra 95%. C~CTOM B c y 6 n ~ ~ m a npMeuatie n~o Ha Nitroglycerin M AV-

C a p p e r ~ a~ a a ~ n o e~ cnewHo q a cacToRHne, KoeTo HaCTbnBa npM OcTpa KOMnpeCMR Ha CbpqeTO OT 6bp30 Ha6MpaHe HaTe'iHOCT B n e p ~ ~ a p f l T ~Oa P~ ~M aC I K uOBe)K~,
fla~O~OPR3KOnOBMUlaBaHeHaMHTPanePMKaPflHOTOHangratie, c nocnepaaqo p a 3 ~ m Ha ~ eWOKOBO CbcronHMeM neTaneti H~XOU,aKo He ce npeunpweue nepMKapptia nyH-

Ua, K ~ K T O M KbpBeHe npM T P O M ~ O ~ M T ~ MM M n M R YpeMHcleH nepnKapunT. Oqe no-~RUKO, cbpperHaTaMnoHqa Moxe #a Hacnnu npM nepMKappeH eKcypaT, moA Mnv ra3 (OT nHeBMOTOpaKC M n M ra3-npOAyllMpaqa MH@~KUMFI).

lla~ore~e3a

~ ~ ~ M K ~ ~ npOcTpaHCTBO ~ H O T O Ha '-lOBeUlKOTO Cbpl(e ~ o p ~ a cbpbpxa n ~ o MeWy 15-50 ml TewocT. MmpanePMKaPAHOTO HanRraHe e 0 M n M OTpML(aTenH0,HOpMaJlHO e H a l - r e c ~ a npMrMHa ~a xi ocTpa cbppewa TaMnoHanpk16n~3men~o paBH0 Ha MHTpanneBpUlHOTOHanRraHeM pa e MHTpanepMKappHaTa xeMopamR. TR Moxe pa e Qnytoywpa aaeu~oc Hero. Ha6~patle~o Ha TerHocT B pe3yn~a~o~:pyn~ypa~a~opo~ap~a~n~~ na ea po ~p ~~ a~ pa ga a~ ne peu~3eu~eapen~re~~e~a BPM~M M n M ~ Ha caMaTa aopTa; nep@paq~R Ha cbpqeTo R H O T O HatlRraHe. Cnoco6~oma Ha nepMKapflHOT0 npOCnpMCbpfleVHaKaTeTPM3a4MRClpe3TpaHCBeHO3eHKaTeTbp TpaHcTBO ua cb6~pa T~VHOCT 3aBMCM npeuMMHOOT CKOpOMnn enempou (oco6e~0,KoraTo naqMeHnT nonyaea Clla Ha Ha6MpaHe, a He TOnKOBa OT ~ ~ C O ~ ~ ~ T KOnMVeH O T O Heparin); pynTypa npw cbpuerHa KOHTYBMR; pynTypa Ha CTBO Ha TerHocTTa. Te'lHOCT 2 1 ( H ~no~ere) M Moxe ua ce npepcbppne. no-~RUKO cpeu(aHM npMvuHM xi Cbpuertia cb6epe 6e3 ua IIPM~MHM TaMnoHqa, aKo ce ~a6npa 6aeTaMnoHqa ca TyGepKyno3aunn ~ e o n n a s ~ Ha anepnltapHO, 3a40~0 nepMKapubT uMa BpeMe ua ce pa3~eme poc-

K4MR.

l l pc ~b p n e r ~ a ~ a ~ n o~a6nloflaBaT ~ ~ a c e M npoMeHM HaA-xapawepe~ 6ener e T O T ~ H M R T enewpHreH ameptiatlc. Ocee~ TOW, H M C ~ K BonTax Ha QRS KoMnneMHTpanepMKap~HOTOHanRraHe3aKPaTKOBpeMeROCTMra KCa, H 0 JlMnCaTa Ha T O M M3MeHeHMe B EKr He M3IVIWIBa B~~MOXHOCT 3a T~ nepMKappeH M ~ ~ n MeeeHTyanHa B Taw KPMTH~HHCTO~HOCTM; B ~ H O ~ H KP ~ ~TB tie ~ Moxe pa ce saptie K ~ ARCHOTO M npepcbppue M ppcHaTa KaMepa, UBH nOH4a. ST M T - M ~ M ~ H ~ OT H nePMKaPAMTeH MR T M n (M~c(M ce noBMwarn. Y s e n ~ r e ~ o MHTpanepMKapfl ~o Ho HanRraHe raHe Ha S T - c e m e ~ ~ Ba oTsemqaHMRTa cpeqy enwappIlpe'iM Ha YeKBaTHO pa3WMpeHMeM Ha CbOTBeTHO nbnHeHaTa nOBbpXHOCT Ha CbpueTO - 1, 11, 111, aVF M V,-V,; B He Ha cbpqeTo no BpeMe Ha AMacTona. AH~CTO~HOTOoTaemqaHnma cpeqy eHpoKaemapHaTa noebpm0c.r Ha KaMepHO HanRraHe e $YHKL(MR Ha MHTPanePMKaPRHOTO cbpqeTo (aVR, a notimora V,-V, MIM~M aVL), cemetim HallRraHe. Cbppe'iHMfl~ p e 6 MOXe ~ ~ B Ha'iXIOTO pa 6bpe ST e cHMxeH. npw xeMonepMKapg Mua n o - p ~ p ~ o 3p~ra nombpxati rpe3 OCTPO noBMwaeaHe Ha aMacTonHoTo He Ha ST-cerMeHTa,H0 CHMXeHMeTO M HeraTMBMpaHeTOHa HanRraHe. AKOMHTpanepMKapfltioTo HannraHe npopbnT-sbn~a~ ca a recTM. B npym cnyau npM xeMoparwR B x a m Aa ce yeenuraea, puacTonHoTo nbntiette cram nepwappa ce ~a6nlodaea~ ~ ~ e a a noRsMnu n ~ o ce BMCOKM, HeBb3MOXHO M CbPAeClHMRT A ~ ~ K MP L T I T M C I H O nqa. KOMOCTPM T - B ~ ~BH npeKopflManHnTe M oTsemqaHMn. O c ~ p a ~ a neHcaTopHa peaKuw Ha P R ~ K O notiuxeKeHMRyflapeti o 6 e ~ cbpperHa TaMnoHwa, pbnxaqa ce Ha cbppetl~a pynve TaXMKapflMRTa. M H T ~ ~ I ~ ~ ~ HMRraHe M K ~ ~M ~KaMeH O T O pa, Moxe pa npepw3~u~a e~e3an~ 6 ap ; ~ ~ ~ M aenep p ~ PHOTO pMacTonHo HanRraHe MoraT pa ce M ~ ~ ~ B H AecRT. IcrpoMeXaHM'iHa~MCOL(Ma~MR. HOnpepCbpAHOTO,K P ~ ~ H O TRMaCTOnHO O Ha 6enoppo6~aTa apTepMR, Ha MCHaTa KaMepa M nynMOKanMnRpHOT0 HanRraHece sK.tnMHneaTepHo B ppyro B paMtme Ha 5 mm C b p ~ e r ~ TaMnoHQa a~a ~ p ~ 6 Ra s a6bAe pa3rpa~wHg (0.666 kPa) ( ~ s m l o ' i e ~ npepcTaenRsaT ~e naqMeHTMreHa OT nepMKapptMR M ~ ~ M 6e3 B Tarunotiqa ( n ~ n c ~ Te, c npepwecTsaqa nesocTpaHHa cbpflewa cna6oc~, napagoKcaneHnync; He ce Ha6nlo~aBaT xapaicreptiMTe 3a npM KOMTO HanRratiMRTa B n e m e K~XMHM OcTaBaT nocbppewa TaMnoHwa xeMopnHalmnrHM n p o ~ e ~ n T)p . ~6BMCOKM OT Te3M B R ~ C H M T M~H ) . T ~ ~ ~ ~ ~ MHMRraK ~ ~ A H Osa TAa O ce M M a npepeMp M ocTpaTa pnctia a a c ~ o h ~ cbppea He MOXe ga C e IlOBMWM 3HaYMTenHO M npM nO-ManK0 rHa Hepocranrtiom, 3aqo~0 Moxe Aa n p e ~ ~ OCT3 ~ KOnMcleCTBO TWHOCT, a K O nePMKaPpbT e PMrMpeH IWPQM po paawMpeHMe Ha p a 3 ~ e p ~ Ha ~cbpueTo e npM rucTn 4~6po3a M n M TYMOPHa M H $ M M ~ ~ ~ M R . 6enoppo6~~ noneTa ( n p RO-M~CJ'I~~WH~); ~ HanMqe e noBMUleHO BeH03HO HUlflraHe M nOHMXeHO AH. Ko~recmaHaTacbppertia HeAocranrHocTMoxe pa npMrHHn Mtioro OCHOBHM IVIMHM~HM6enea~ Ha cap1e'iHaTa TaMnoHap ~ p napqoKcaneH ~o nync. Knlo'i K ~ M ~(uam03a~a Aasa Ra ca: exo~app~orpa$c~o~o wacnepea~e. 1. C n q a ~ e Ha AH. To nporpecMaHo ce notinxasa,
B EKr.

TaTbrHO. O ~ ~ ~ T6bp30~0 H O , Ha6MpaHe Ha TeVHOCT, A O P M 200 ml, Moxe Aa npMrMHw TaMnotiwa, ~ b KaTo h nepnKapmT He Moxe 6bp30 M Aoc-ranrtio pa ce pa3~eme n

AOKaTOCTaHeHeM3MePMMOMCePa3bpHeKapTMHaTaHa UOK C 6 e 3 n o ~ o i c ~ ~ o , 6 n cTypeHa e ~ a , M BnaxHa Koxa M

HaKpaFl - 6e3Cb3HaleJlHo CbCTORHMe. 2. ~oentuaea~e Ha UBH - noenwaeace Ha 15-20 cm H,O. Mspaa Ha nOBMuJeHOT0 UBH caHa6b6HanMTe W M ~ H M BeHM ('~~PHMFIT ~po6 O~MKHOB~HO He C e YBenM'iaBa npM cbpperHa ~ a ~ n o ~ q a ) . 3. Man~o, ,TMXO" cbpue; Cbppe'iHnTe ToHoBe ce rpaT oTpanereHH,rnyxu; a 6 c o n l o ~ ~ npmnnetiMe o~o ~sreaea, He ce nannMpa CbpperHMmyRap Han~ue e napqoKcaneH nync ( n o ~ ~ x a e Ha a ~CwmonHoTo e AH noaere OT 10 Kyc~aynoeum n p ~ 3 (n~cnn~a~ mm Hg npu BpMuraa~e). paTopHo yaenwaaatie Ha lorynapHoTo B ~ H O ~ HHannraO He) ce cpeqa n o - p ~ p ~ npM o cappewa TawnoHqa.

-Iflecle~lne~o ~a ocrpa~a c a p ~ e r~ a a ~ n o sa: n e p n ~ a p ~ ~Y ~H aK ~ M MR nombpxa~e ~aX rlKaTa. l l e p ~ ~ a p p ~~HKL(MFI ~ a ~ a e msoTocnacReaqa Matinnynaum, ~ o m o ~ah-reno ce ~ 3 ~ b p t no . u Marfan ~ IlyHKTMpa C e B bbna Memy MeYOBMflHMFI M3PaCTbK M n m T a pe6pe~a 1bra. AKOn a u ~ e e mMHoro ~ Bb36ypeH, ce npaeM npeMepMKauMRc Diazepam5 mg i.m. K O X ~ ce T~ ho~kipa M ce npaem MecTHa a ~ e c ~ e m c f2% i p a 3 ~ ~ Ha 0p Lidocain. Vlrna~a 3a ~ Y H K ~ M (R ~ b n x n8 ~ cm) a ce c ~ b p 3 ~ a C TpMnbTeH KpaH, KbM K O ~ T O 'ipe3 CTepMnHaTpdM.1Ka C e Hah-cMrypHo AMamo3aTa .CbpAerHa ~ a ~ n o ~ce q a " cKarea 30-50 ml cnpMHuoaKa. ~ O ~ H M R ce T nocTaaR B nocTaeR c e x o ~ a p ~ ~ o r p a $ ~scnepea~e. c~o C~a3n MeTonemano nonoxeHMe no rpb6 nop 45" M MrnaTa (rpea A M K a MOraT fla Ce BH3YXlM3MPaT 20 m 1TWHOCT, AOKaTO C MeTaHa U & n K la e CBbp3aHa C e~HOnOnloCH0 EK~~TB~ R0-~3cnepBaHe - He no-MWKO OT 200 ml. norpa$) ce ebeewa 6 a e ~ o Ha no-

CO'ieHOTO MRCTO IlOA bbn45"CflpRMO K O X a T a M no flOCOKa H a r o p e , K ~ WCHOTO M pauo. & $ M 6 p M n a ~ o p b T e aapege~ npepaapmenHo. f l e p ~ ~ a e pH pa~ 2-4 cm ~ b n 6 0 ' i M ~ a M n p M H e r o a o T o n p o 6 ~ e a ce ~ eyceqa n e K o c b n p o m e n e H M e . Kora~o H r n a T a e B nePHKaPflHOT0 IlPOCTPaHCTBO, TR C e ABMXM OT flMulaHeTO H a ~ O ~ H M H a ,KOraTO AOCTMlHe p0 enwapaa, EKr n o ~ a 3 c ~~ a n ~~ 3on ~ r H aa Tcemewa, ~ e KoeTo H a n a r a n e K o ~ 3 ~ e r H n a ~M ~ rna eT a H a a m . npn nonoxewe, 'ie MrnaTa e B c b p q e T o , ce B M x q a T RcHMTe h ilynCaqMM M Ce IlORBRBaT eKCTpaCMCTOllM. M ~ T O ' ~ B ~ H H~ aT O IlepMKapAHMR M3nMB C e npaBM flOA KOHTPOn H a UBH M AH. M~orp o q ~ ce o n p a e M ~ ~ H K ~ no MF Delorrn I (B o6nacrra ~a IV-V ~eyqype6pne M e y q y new n a p a c T e p H a n H a M M e n u oKnaeMKynapHa ~ M H M M ) .

flo~lqbpXa~e H~ a0 XeMOflMHaMMKaTa flpM OCTpa nePMKapAHa T a M f l O H q a C e IlpaBM C 6 b p 3 0 BnMBaHe H a Te'lH ~ T i. MV. ( K P ~ B ,n n a ~ aKonoMqHM , pa3~~opn, M v e H cepy). nbpao ce snMBaT 500 ml3a 10 min, cnel T O M CKOpoClTa H a BnMBaHHR C e HaManFlBa A0 100-500m1 B 3aBHCMMOCT OTXeMOAMHaMH'iHMFI e$eKT. 3a noflo6p~eaH e H a xeMoAuHaMuKaTa ce npmnara Doparnin 2.5-5 pglkgl min. n e p w a p A H a T a T a M n o H m a c l e r n o ce RBRsaT PWbMHM HaPyuleHMR H W K a M e p H M TaXMKaPflMM (fl0t3nMRBaT Ce OT AMrMTallHCOBM rfllOK03MflM M/#nM Propranolol), KaMepHM aPMTMMM (Lidocain, Chinidin, Propraflolol). HRKOM aHTMaPMTMM'iHM M ! ~ ~ M K ~ M ~T HP TM R ~ ~a B~ ce ~ 3 6 ~ r e Hanp.: Procainamid, n o p w M o n a c H o c T OT a p T e p M a n H a XMflOTOHMFI.

a an ono-

PM

X M f l e p ~ 0 ~ ~ ' i H KpM3a a ~ a e CfleulHO CbCTORHMe, IlpM KOeTO BHe3aflHO IlOBMUleHMTe AMaCTOnHO H M R r a H e H w 120-130 mm Hg M CMCTOnHO H q 250 mm Hg ~pR613afla 6bflaT n o t i M x e H m aao~ono 1 h ( x ~ n e p ~ e~qe$anoo ~ ~ ~ ~ Ila~klR) MnM 3 a H e no-Abnbr flepMOa OT 24 h ( a ~ q e n e p # pall@ M MaJlMrHeHa X M ~ ~ ~ P T O H M R 3 )8 , A a C e npeAOTBpaTRT O P ~ ~ H HyM apexqa~~n e s e ~ ~ y aC nM ~ ~a PT.

THHeHMTe CbAOBe, rOBOpMM 3 a aKUenepMpaU@ M M M m e H a XMnePTOHMR. P a 3 p e n e H M e ~ 0 C e OCHOBaBa H a HMM'lMeTO H a PeTMHMHH KPbBOM3nMBM MnM eKCYAaTM (a~qenep~pa qa) M OTOK H a n a n M n a T a ( ~ a n ~ m e ~ Ka ~) M . HM~ xapaH~T KTePMCTMKa M nPOL(eHTbT H a npeXMBReMOCT H a T e 3 M C MnM 6 e 3 e p e M H a IlanMnMTe C a TOflKOBa CXOAHM, 'ie HRMa ocHoaaHMe A a 6bfla~ p a 3 r n e w a nooTAenHo. ~ ~

Xmnep~o~n'i~a~a K P M B ~M o m e na y c n o m ~ K~KTO e c e ~ q ~ a n ~T aa~ Ka a ,M CMMmoMaTM'iHaTa apTepManHa X M n e p T o H w , HO M o m e na ce p a m e M y n a q M e H m HOPMOTOHMUM. f l p ~ nocnepHMTe npommpaq MoMetiT ca cTpeCOBM CbCTORHMR, OCTbP ~ O M ~ P Y ~ O H ~ $ P TOKCMK03a MT, Ha ~~~M~HHo MeRMKaMeHTO3Ha cTT~, PeaKUMR flpM yno~pe6a H a MOHOaMMHOOKCUpa3HM MHXM~MTOPM (Furazolidon,

Izokarboxazid, Nialamid, Pargilin, Fenelzin, Procarbazin),

B Cb'ieTaHMe C ~ ~ H T ~ M H O ~ ~ ~ ~ CMMflaTMKOMMMeTMCTB~~L(M C~HM aMMHH (Amphetarnin M HeroBM ~ ( e p ~ s M a ~ ~ nepwM ~ ) $~PHM CMMflaTMKOMMMeTMqM (Effedrine M HeroBM npOM3BORHM). f l p M XMflePTOHML(W nPM'iMHa 3 8 XMflePTOHM'iHaTa KPM3a MOraT C b q O A a 6 b A a CTpeCOBM ~ CbCTORHMR, BHe3aflHO CflMpaHe H a aHTMXMnepTeH3MBHOTO ne'ieHMe (~aflp.: Clonidin, Metyldopa, Propranolol M ~ p .Mnw ) eAHoepeMeHHOCflaBaHe HaaHTMXMflepTeH3MBHM M ~ P M K ~ M ~ H (~anp.: TM Reserpin, G u a n e t h i d i n e ) M MAO-HHXM~HTOPM. Cb'ie~a~Me T 0 H a MAO-MHXM~HTOPM C allKOXOn, TPM4MWIMVHM BHTMA e n p e c a H m , L-dopa, Meperidin M o m e P ~ K A O a noeMLuM AH M Aa AOBefle A 0 XMflepTOHM'iHa KPM3a. 3 q b p ~ a 4 0 C! ~0 AMaCTOflHO HaJlRraHe H w 130 mm Hg 'ieCT0 e CBbp3aHO C OCTpa CbflOBa YBpeAa. 6 b p 3 M ~ a ~ a lla~ore~e3a H a n o s M u l a a a t i e H a AH M o x e na 6 b A e OT no-cbqec~se~o 3Ha'ieHMe, OTKOnKOTO HMBOTO H a HerOBMTe ~ ~ C O ~ ~ D T H M BC~K nbT, M KOraTO AH PR3KO C e IlOBMulM M OCTaHe H 4 CTO~HOCTM 3a ~ ~ ~ A M ~ B M H aK oc B Tp ~a H y e~ p e A a H a cbfloKPMTM'iHOTO HMBO, pa3nMCIHM I l p O q e C M A O B e ~ a T 10CepMR BMTe CTeHH. Kora~o IlOBMLueHOTO AH OcTpO y B p e m a peOT n O K M H M M CMCTeMHH e$eKTM, KOMTO npeAM3BMKMT no-

X M ~ ~ ~ T O H M ' ~ HKPM3M M T ~ Ce H a TaKMBa, flpM KOMTO nOHMXaBaHeT0 H a AH T P R ~ A B a~CTaHe A 0 1 h M H a TaKMBa, n p M KOMTO MeflMKaMeHT03HOTO ne'ieHMe M O X e Aa CTaHe n o - ~ ~ B H HO 0 3,8 H e no-flbnbr IlepMOA OT 24 h. K ~ M n b p s a T a rpyna ce oTHacRT cneAHMTe c n e w H M XMflePTOHM'iHM CbCTORHMR: XMnePTOHMClHa eHUe$anoflaTMR OT p a 3 n ~ ~~ lPe O~ M ~ X O n~~paqepe6pan~a A; M cy6apaXHOMAanHa XeMOpaMR; MCXeMM'ieH M03b'ieH MHCYnT C xMnepTotiH'iHa ~pnaa; HRKOM cny-laM H a M a n M m e H a x m e PTOHHR; o c T p a a o p ~ ~ ~~ a c e ~ ao q c Tn p a~ neeoeetiTpMKyn; H a cna6oc.r; OCTpa KOpOHapHa HeF(0CTaTb'iHOCT; CneA KOpOHapeH 6ahnac; KPM3M n p M $ ~ O X ~ O M O ~ M T MnM O M flpM MeflMKaMeHTO3HO B ~ ~ M M o ~ ~ A c C TB MAO-MHXM~CITOP M~ c n e u o n e p a T u e H u x e M o p a m M ; OCTW e n m T a K c M c . K ~ M BTopaTa rpyna ce OTHacm: a l c q e n e p n p a q a M MWM~H~H~XM~~P Rebound T O ~ R ;XM~~~PTOHMFI, cnep B H ~ 3 a n ~ 0n p e K b c B a H e H a aHTMXMnepTeH3MBHOTO n e v e H M e ; n p naqMetiTM, ~ H a KOMTO ce H a n a r a c n e l u H a onepaTMBHa MHTepaeHUw; cneAonepaTwsHaxMnepToHMR;cneA 6b6pe'iHa TpaHCflnaHTaL(Mfl M C n e a O ~ W M P H MM3raPRHMFI H a TRnOTO.

Cbpgesn-goBu
OT J l O K a n H MMC U C T e M H H~ $ ~ K T H K O ,U T O flpeflM3BMKMTnoHaTaTbUrHO IlOBMUaBaHe H a AH M yBpeAa H a CbflOBeTe (~a6n. 5.3) pa3nmv~n, HO ~ H K H O B ~ H KoHKypHpaqH O ce npoqeca ce elcnloqaaT B na~ore~esa~a H a xunepToHnrHaTa e~ue$anona~wn. ~MHMRe T 4 y ~ ~ u u o ~ aflunaraum ne~

cnewwu cacmonnun W 225

AM

H a qepe6pan~we apTepMOnM, KORfO BOflW eKCueCMBeH uepe6pane~ KpbWH IlpMTOK, flpMVMHRBau( XMflepTOHMYHaTa e~qe$anonam~. R P ~ ~eR cTpymypeH T - oc~po yepewatie HacTeHaTaHaaprepulonclTe,n p e ~ ~ 3 a u m q o yaenuraeaHe H a ~ e i i ~ nponyclcn~~oc~. a~a K O ~ ~cpeflTO HOTO AH ce noenwM HW180 mm Hg (24 kPa), MaKcMMa-

M03bWHO T O K HCHMPOM Ha XklIlePTOHHqHae ~ q e $ ~ o f l a WR. C~ROBMT~ C T e H M , BO T r O B O PH aT O B a B K C q e C H B H O Hanm-aHe, ~aii-~epom~o AonpMHacm aa YpewaHeTo 'ipe3 flpOM3BewaHe H a TOKCUreH CyllepOKCMfleH aHM0HeH p8,4MKan OT Y C W I e H M R apaXi4lOHOB ~ e ~ a 6 0 n H 3 b ~ H O P M O T O H M q H .fl~06MBbT" HaCTbflBa IlpM C p e A H O AH o~ono 120 mm Hg (16 kPa), a n p xnnepToHnUn ~ - oKono

PM

180 mm Hg (24 kPa).

M~AMK~M~HT Nitroprussid Nitroglycerin Diazoxid (Hyperstat) Hydralazin (Apresolin) Enalapril (Vasotek i.V.) Nikardipine Phentolarnin (Regitin) Trirnetafan (Arfonad) Esrnolol (Breviblok) Propranolol Labetolol (Normodin, Trandat)

~03MpOBKa 0,2510 pgkglrnin, narno

UH@Y~UR

Harano Ha ~ekcrsne Muz~o8e~o 2-5 rnin 2-4 rnin

CT~~HM e~ qH e~ M~ u rage~e, no8pbqa~e, MYCHYAHU nornpen8a~ufl Taxu~apgufl,@hbw,sha6obohue, n08pbqaHe, M ~ ~ ~ X ~ M O ~ A O ~ U H rage~e, xunomoHuR, @nbw, rnaxunapgufl, 6on~u 8 zbpgurne Taxu~apgu~, @hbw,z~a0060~ue, no8pbqa~e, crneHoKapgHu H P U ~ U P R ~ KcnagaHe O Ha AH npu Bucono peHUH080 H U ~ Taxu~apgufl, sha806onue, @nbw, nonaeH @he6urn Taxunapgufl, @nbw flapesa ~a repea U n u ~ o r ~ ee ~x y p , oprnocrnarnu%~, CMY~~HU 8R spe~uerno, cyxorna 8 ycrnarna Xunorno~u~

5-100 pglrnin Harno i. v.

UH@Y~UR

50-100 rng i, v. mrno h y c unu 15-30 rnglrnin rpes

UH@~J~UR

10-20 rng i. v. 10-50rngi. m. 1,255 rng 5-10 rngh i, v. 5-15 rng i. v. 05-5 mglrnin ~ a m o i. v.
UH@Y~UR

10-20 rnin 20-30 rnin 15 rnin 10 rnin 1-2 rnin 1-5 rnin

500 pgkglrnin sa 4 rnin, cheg rno0a 150-300 yglkglrnin i.v.

1-2 rnin

1-10rng3 rngh

1-2 rnin 5-10 rnin

Crnpa~ur~ e@enrnu u ~a pbhonepurne no0pbqa~e, zopequ~a 0 zbpnomo, oprnocrnarnusbu, 8ue~e ~a c0flrn, zageHe

20-80 rng i.v. 60nyc Ha 6ce~u 10 rnin; 2 rnglmin i. v.

UH@~~UR

BewpuKynHa cna6m; ypeMuFi OT pa3nu'IeH npusxop (0C06eH0 C 6enoflpo6e~ OTOK); CbpOBOM03b'IeH UHqUpf?HT;M03bVeHTyMOP; ClePeflHO-MO3bVHaTpaBMa; eflUnenew; KonareHosu (oco6e~o nynyc c uepe6pane~ 8ac~y~ u T )~ ;H~~@J~ CBpb~O3aU u T M ; OTKa3BaHeOTHBPKOTU~U, ~M$~T~MUH xunepKanqueMufl; U; o a p a penpecufl c xunepeewunaquoHeH C U H ~ ~ M .

cneur~o 60n~nq~ neqeHne o

DO~O~HHVHO noBeAeHne H neqeHne

~O~O~HUVHO nevetiue TO 3a~uck OT T e x e m a Ha XUIlepTOHMVHaTa KPU3a U TPFI~BI Aa 3anOVHe CBOeBpeMeHHO C epuH OT u36poe~we no-pony MefluKaMewM. lloeepeHueTo aaaucu OT OCHOBHOTO 3a60nflBa~e, eeetrryanHu yCn0)KHeHUFI U pe3yiTaTa OT flpUnOXeHOT0 MepUKaMeH-

B ~a6nuqa 5.4 ca npepcTaeeHuH ~ A - ~ euanonseac~o Hwe MenuKaMewu npu neqeHueTo Ha XunepToHuvHwe KPUIU: B ~a6nuua 5.5 ca npepaaeetiu xuneproHuwu K P H ~ U C pasnu'~~a eTuonoruR U MeAuKaMewuTe, KOUTO ce npepnoqwaTnpuTflxHoToneqeHue:
npomo3a

llpu HeneKyaaHu 6onm cMbpTHoma e ronma U e pe3yiTaT OT M03bVHU, CbPfleVHU U 6b6pev~u YBpeWaHUR.

Xunep~o~ucl~a ~pusa XU~~~TOHU e '~ IH ue ~$anona~~~

Me~u~a~ Ha eu36op m Nitroprussid Diazoxid Trimetafan Nitroprussid Diazoxid Hydralazin Phentolamin Phenoxibenzamin Nitroprussid

Menu~a~em KOUTO , Tp~6Ba fla ce u36ursa~ unu ~a ce us non sea^ MHO~O BHuMaTenHo
ECU'IKU~RP~H~PM'IHM 6no~epu K~TO Propranolol, Metoprolol Metyldopa, Clonidin, Reserpin, Guanethidine

A~qenepupaqa (~anume~a) XMnepTOHUR XU~~~~TO KPM3a, H U V/JbnXaqa H~ C e Ha MefluKaMeHTosHo unuxpaHmenHo n p e ~ ~ s ~O uC~B a O~ ~O oW ~ B ~a ~H~ KaTexonaMuHu, ~3au~o~eAcreaqu c MAO-UHXU~UTOPU unu XunePTOHuLfHa Kpusa, p n x a q a ce Ha $~OX~OMO~MTOM XH~~~TOH KpMSa, U ' I HCsbpsaHa ~ C u~~paqepe6pan~a nu cy6apax~ou~an~a xeMoparuR Xunep~o~u.~~a ~pusa Uo q a nesoeempu~yn~a cnah Xunepm~ur~ ~pusa, a cebpaa~a c O6H u n X6H, ~ unu e ~ n a ~ n c u ~

BCU'IKM aRpeHepMVHU UHN~WOPU

Nitroprussid Trimetafan Furosemid unu Aadum etacrinicum Nitroprussid Trimetafan Nitroprussid Diazoxid Hydralazin Metyldopa

~~CUVK 8ApeHepM' M IHU UHXU~UTO~U

Diazoxid Hydralazin Trimetafan

Ocrpa RuceKupaqaa ~ e s p u s ~ Ha a aop~a~a

BCU'IKU ap,peHepruvHu UHXU~UTO~U Hydralazin Nitroprussid Diazoxid Nicardipine

nannnpa m ~ p OT e nepKylopmonpeuenetiaTa nma cbpnewa rpaHHqa, H n mm e Hece nannnpa. A6contoTHOTO nPmnneHuece pa3unp~m 3a cMeTKa Ha omocnTenHoTo. IOtynap~me WHM ca ~a6b6HanH n pa3urnpe~n, pe3yma~o~n~~mue~o~oppc~onpe~c~ Kncl~n~rna Ha n3nnan CM: cbpuevHa TaMnoHaa e HaA-vec~me n p w H n 3a o m p nepMmpumca: paarneua~a B .Cbp~ev~a ~a~no~qa". - snpyc~u n ~ @ ~ q nT. n ,Hap. .6e~#nie~n nepnlcapnnnpw mnanmeneti npoqec B nepltapna ~al-vecro mu(rp~fl, KOKCBKM, EXO-, WeHOBHPYCM L4 up.); CYE e ycxopetia m e Hanmqe neeKoqmmac oneeRmHe. - 6atcrepnan~w n~$elqnw: cTpemoltoKn, crawno~oPemre~onomv~o penwvame HacapRerHaTacRHKa ce KM, nHeBMOKOKM, MeHMHrOKOKM, Ty6ep~yn03a, nCblTaKO3a yc~a~os npm ~m n3nna ~q 250 ml. Hau-Hanpeu brbm~ m e wc b p u e w a C H H n ~una$pama~a cram OT m p up.; - Tpaennm: ~ a l r e m H a o6em Ha cneurHaTa n o ~ o e q Tbn, a n0-KbCHOB W i K H CbPneCIHH KOHTYPHl % M3lTlwaT aa~pma~ rpautia a TpaeMa; nep$opaunma Ha m a i a KaH cbpnevHaTa m ~ m uo6mm Wpma~a Ha .MeTnaU. flpn Mepa npn ~ a ~ e ~ p n s (M aq up.) n ~ca o6em Ha Kapunoxnpyoqe no-romw m3nne cbpuewaTa mHKa nonyam g o p pruma; maTa Ha . ~ o n WH m m m ~e w HeR H una$pama~a - m p n~$aptcrHa mnompua: enncreHoKapueHneOTHOBO cram ombp. pnlcapum n CMHAPOM Ha Dresler; EKr npomeHme ce m~ 3a xapatcrepm n ce ~ a 6 - ypevm n xe~ounann3e~ nepnKapueHa ~ ~ u p o ~ ; nlonamT npu HW80% OT cnyrame. B pe3yn~a~ Ha M e - DnceKupaqaa ~ e a p n a ~ Ha aaopTaTa; nuKapuHaTan e s B~ ocrpm~ ~ nepnou Hac-rbnm mnnrHaTa - HeM3RCHeHM. ~ H O ~ ~ T UCny' ~ H 4aH. M ~ KoKopumaenemw H ~ S T C ? B ~I,~ II,~ Ill, H aVL, T ~aVF n B neBme npeKopnmantim oTBewaHnR, a no-K~CHO HeraTnBmpaHeHa T- BantiaTa B pesyma~ Ha cydenmltapBHa HCXeMHR. ~ P ~ ~ I B CHHXeHHe H O T Ha O QRS KOMnB TnnnrHme cnyrau 60n~me npm g e 6 p n ~ C~CTORo ~aT ~ ~ H O C BT nepnltaHne nnucneu Heroce onnaKeaToTneK ~euomnr ~a~ a s ~ l y x neKwe e xapaKTepHo3a~a6npa~e M npeKapunanHah n ~ aKORTO , ~anouo6~ ncxeMnrHaTa m (no~ann3aqnt1,wpawaqn~),HO xapatcrepHoTo aa Hen e, ve ce snwe OT pHuaHeTo, ranTaHeTo, KaLunRHeTo U ~BWeHMeTO Ha T R n O T O (0T~na68a HnH H3W3Ba npn Ceu~ a n nonoxeHne o nnn npn HaaewaHe~anpeu). np#~ e 3 n 6 0 n~ ~p ~ ~ no6pe 6 m ua ce npeueHu uann ~ehcrscl~en~o aqyxb~ ce ubnm Ha xnnone~y3n~, pe3yn~a~ OT HaMaO m p u@apm Ha mnompua; nncetwpaqa a~eepnane~o~omn~e~e~acbpqe~o,~nuenapa~ ~ Ha a~ e ~ ~ ~ 6enonpo6~a ~oxMa aopTaTa; ~ p o ~ h e ~ 6 0nHTepKocnn~; Hocrra ( a a p q h ~n ~ a ~ a aa ), noeMaT uocraTbvHo~a3uyx. m t i a Heepanmn t3nnao; nesocTpaHHa nneeponHeeuoHMR; a 6 0 n ~ m Ha ~n XpaHonpoaoua ~ n MeunacTnHyMa.
@I~MK~J~Ho. Hah-clec~o ce yCTaHOBRm TMkIKapuMR,

no6on~nwo noaeneaweU nevetme

HeCMlTBeTcTsaqaHa TeMnepaTypaTa, aKo uMa TaKaea, m nevewero B o q n w nepmoa swnlovea: nocTeneH penoHnxeHne Ha AH. I l a ~ o n i o ~ o ~ c nn ve ~~m e onepnlca~ m m n npemaxeaw Ha 6 o n ~ a ~ vpea a o 6 n ~ ~ o an ep ~o nw P~HOTO Tpnetie c no~ann3aqn~ Bbe 11, Ill n IV ~ e w y p e 6 e.osb3nanmenHH H manrmvtin MeunKaMem: Analgin pMe, snmo OT crepHyMa c xapatcrepmnm, onncatia B ~ B 2-3 mm no 2 ml ~WBHO,i.m.; Aspirin 3-4 nbm RHestio no ecnvm y v e 6 ~ n ~Vlspaa n . e Ha c ~ ~ o $ u ~ ~ # H omarao~HI~ 500 mg p. 0.; Rheopyrin no 1 amp. uHeBHo, i. m.; Feloran H n R no enw M eHRoKapua. ~ O R B MY ~ T em ~ M o m a npn no 1amp. 2-3 mm AHeeHo i.m.; lndomethacin50-100 mg n~nceaq~m~anb~n3n~~~nepn~ap~a;~3v e3 e ~ o ~m yup. PWKO 3-4 mm m~RHewio ce Hanara npnnarmeTo Ha BnHarn e n p n a ~ a Ha ~ 03upae~aa~e. Tom Moxe ua e Morphin, Fentanylm up. KopTn~oc~epon~ure cbuo 6bp30 pe3yn~a~ OT ~a6npaw Ha ronRM nepnKapueHnann~, KOAnpeMaxmT 60nm~a vpea TexHmR npoTn~omnanmeneH TO MOXeA O p M Ba B n O ~ l l o 6 ~CbCTORHMe. 0~0 CbpflerlHMTe ewtcr (Urbason 40-80 mg i.v. 3a 2-3 ~ H H nocneumHo , OT T O H O B e OCTaBaT rnyxll, CbpflerlHHRT YAap o~cna6m bl ce nepopanm, npmnoxe~ne).

Cneluuo 6on~ullr~o neve~we

60n~nq~o neqeHne ~o ce onpelem OT ~ C ~ B H O T O 3a60nma~e n HmweTo mHe Ha cbpuewa TaMnoHaAa. npomnxaea ce nerleHneTo c nocoreHn-re no-rope

~ecneqn$nr~n npomaoea3nanwen~n cpencma, a awn6 n o ~ n c l ~~ ae ~a p a n ce n~ onpenen~ OT enna Ha npnrntimenn. n p cnMrnoMn ~ Ha cbpperHa TaMnoHqa xneoTocnacneaqa MattnnynaqnR e nepnKapnHaTa ~~HKLIMR.

Map~a~ Kpaeaa a
I

E m o n o r w n n imacnQn~aum
AHU M PbIKeTCHkl, KOklTO 3aCRraT e-pfla,

H M T~ ~o ~

x ~a e ce pa3npoc~patin OT aacema~a~a ~nana

npeflHMH0 Ha HaR-remo cpeqatium cnvrnoM npn ME e TeMnepaKnanHme mpymypn. Ponmam wpycn-re B emonornma TypaTa. M o ~ na e 6bne Hannqeo6qa oma,q~anoc~; o~6eHa W H @ K L ~ O I~ H H R e H m a p m B C oqe ~ He e y'rowena. nRaeaT ce Mnanmn, apvanrnn, rnaeo6onne. KnacnrecKnacnqecxo~o p w e n m e Ha ME o c r p ~ n nonocrpn m e KOXHM npOMetin (ne~exnn,60ne3HeHb1 Ocnepoen @PM#e Ha 6a3a~a Ha B H ~ ~ I ~ ~ H T H o~a CT HTH ~@ ~ ( ~ H ~ ~ H H R ewnn, xeMoparnn no no@npnqme u ~ p . ) HeenHarn ce ycraHoemaT npu $ n a n ~ a n ~ o nacnegeaHe. ~o npn HapKoMatin npncTpacTeHn K ~ M i.V. onnaTn, noReaTa Ha Kawnnm eHnoKapanT npenmaenRea HH@W OT enpynemeH qa c KpaeoxpaKn nneepan~a 60n~a e gocra nono3pmennpnrnHnTen ( S ~ ~ ~ ~ ~ ~ O aurens, COCC Strept. U S pneum., H0 3a HMMCl MeTOHa ME CbC CenTMClHU6eno~po6~n e~60Neisseria gonorthoeae, Strept. pyog., Haemoph.influer.) nnn. 3 m n x n ~ e n e ~BHnhnaTenHa a aycKymaqnR HacbpqeBbpv HOpMaJlHaKnana, K O ~ 6bp30 O I~PWWHRW H~~HOTO TO 3a HoeonoRennnce nnn c npoueHnne xapanep peryppa3pyuaea~e n Aoaewa ~o MHOX~CTB~HH MeTacTaTMMT~~MOHHM uqwoee. Ilpn 113 OT naqnewn~e wyMoee H e HH OrHUqa. CMbplla HaCTbnM3a IlO-MaJ'IKO OT 6 cenMUC e V a T . 3a KnUHWVHaTa KapTklHa Ha OCTpaTa MMTpWHa U. ~ o ~ ~ o c TeHnOKapAHT ~ L I ~ ce o 6 m m C H @ ~ K ~ # R MHCY$M~~HL(H B RX : .OCTpa MMTpaJlHaIHC~$M~H~H~HF eapxy n a T o n o m npoMeHeHa Knana (mi-recro Ha 6aC n n e ~ o ~ e r a ce n noTKpuBa ~ npn n o - ~ a n ~ OT ononoentia3aTa Ha PeBMaTMWH IlopoK), IlpHclHHeHaOT OTHOCMenHO Ta 60n~n. H a n o m e n e ~ e M npeuu3e~ Heaponomreti snpynemw ~ n ~ p o o p r a ~m Strept~c~axls w~ virridans CTaTyC, 3aUOTO KaKrO 6e CflOMeHaTO, HeMmKa OT nnn Staphyl. epidermidis. 3 a 6 0 m m e ~ o npomcla 6awo n a q u e m e (o~ono 17%) nonyclaeaT M O ~ ~ ~ e~60nun. HCI I. ~ .. a2 pronmn) n MeTamamwime m n w ca m l o v m e .. . nHo penm. T ~ K o M KnacnrecKo npefimmHe Ha ME cera ~~anroma ce cpeqa ~ R ~ K O~HKHOB~HO O. mqnem. c npo~e3npa~n AnarHm~a VIE ce nomaencnopea KnnHnwaTaKapcapnerHn Knann, HapKoMaHn H naqnem c nponanc Ha TnHa nfnnn Ha 6a3a~a Ha pe3ymame OT xeuoKymypme MmpanHa Knana nnn c Apyra Hepewamwa naTonornR npM OTCbCTBUe Ha TMnllrHa KnMHMKa. floKa30aHe~0Ha ca no-rema x e p m Ha emmpun-r, oTKonKoTo ~ e 3 u C eHnoKapnma H ~ W C K m3onnpatie~o B~ Ha M H $ ~ K T M P ~ ~ M peeMamclHn nopoqn. Tam K n a c n $ n m ce oc~oeaea MMKPOOpraHM3bM OT KpbBTa M n H OT e~6on, ManHH Bere~a a ~ a ~ o ~ n~a r nnao ~ e x a q a m ~ a H wpynewT P U M M ,M n H npM OTKpnMHe Ha M H ~ K T M ~ ~ BereTaqMH HM Hocrra Ha ~ H @ K ~ M O ~ npnvnHn-ren HWI n e OCHOB~ 3a npn xnpyprnwa nwepaeHunR nnn npn ay-roncnn VIE MoxeAa ce nono3npanpnnaqnewncbc cnr~n@n KMeH UlyM Ha CbPqeTO, KOraTO e HanUqe HI&RCH#MO $e6pnn~ocacToRHne OT noHe enHa ceAunqa, nnn npn H ~ @ ~ a \ ~ me w~r ~ r p ~ a p ~xino lvrr WeHapKOMaHM C $e6pnnwe~, A O p M kl IlpM OTCbCTBble Ha MWI (@y~remm). &ono 70% OT n a q w m e , ~ w ce o ury~oaa HaxoAKa. 3 a h n ~ ~ a Moxe ~ e ~ua o ce nonoswpa pa360n~I3aT OT ME, HMaT B aHHauHe3aTa IlpeCyllecTeaup npn Mnmn xopa c mHcynT n $e6pnnme~,a cbqo n npu cbpuerHo 3 a 6 o n ~ w e (m BpoAeH nnn pewamreH naqnem c npo~e3npa~n Knann U $e6pnnme~,npu KnacbpnereH n o w ) . llpe~ylonara ce, r e roes e npnrnHaTa nHa AW@YHKL(UFI H HOBOnORBMn C e IllyM. 3a notnpxHocTHm uet#tern no e w p m p w m KnanaTa, KMO cwuam BXWOXHOCT 3a 3acenmtie mh e w n , flnarHo3aTa MoxeAa ce nmasn Tow0 c a ~ c onoanOCO~~H Ha O uecTaTac uama T ~ ~ ~ ~ ~ ~ I H E IT ~H Bc Hc W TI MBHM xeMoKynTypn nnn c ~ ~ H M B Hqrnypn H OT edonn TOK. ETO 3aqo MKOM h e p m ce 3acenea~ H mnpeClean KnanHn BereTaqnn (npa xnpyprnrHa nwepaeHqnR nnn pn-renm, Hopnranrm m n H m Ba w n ay-roncu~).K O ~ ~xeuoKymypme TO ca npeueHeHn KaTo MW OT wytimeTa mmawelrra, npnvw nonomentin, ea3ttmm B ~ ~ M O X H O C T3a T ~ eHnoKapnm.

v .

T ~ @amopa M ~ p f 1 6pa ~a 6bpa~ paarnepaHn npn oqeHma-

Tawea nayMemw ca neKyaatiM c ~ H T M ~ H O T MnpeaM ~M ~ 3 e ~ Ha a XeMoKymypme. ~e Exo~appnorpa@u~~a ~ o x pa e p q e eereraquM, xapa3a ME. B noBeqe OT nonoBMHaTa n a q ~ e ~ ca~ u 6amepwe~wma e nbopbnmen~a a n n M~ p a ~ a ~ ~ ni o p ~ a meptiH , Hanuqe n e a ~KOUTO ~ , ~ p ~ na 6 6bpaT ~ a no-rone~ OT ~2 KaTo epHa MwpaBacKynapHa M H $ ~ ~ U KaKBaTo R , e eHpomm, 3a pa 6bpaT BM3yaJlU3UpaHM. KapnunT, KIIOHM K ~ M ca3paea~e Ha npopbnmentia 6amepMeMMH; 06paTH0 - npomnmrenHaTa 6 a m e p ~ e ~ u ~ ~ p ~ 6BMHaM e a na HaCO'iBa KIIMHMclHaTaMMCbnKbM Bb3MOB OTCbcTBWe Ha M U K ~ O ~ M O ~ O M C ~ HIlOTBbpweHHe O xHocrra 3a MHTpaBacxynapHa M H @ ~ K ~ M n R. pomnx~~enMoxe norpeluHo pa ce nocTaeM p ~ a m o a a ~ ME, a aaqo~o Ha 6 a m e p ~ e e ~ ~aau, n ~ npM KORTO euw M caq M M K ~ O cnepHwre3a60flR~aHMR MoraT pa Hanop06RT KnMHMwiaTa praHM3bMCe M3OnMpaOT KPbBTa B IlPO~nXeHUe nOHe Ha M y KapTUHa: 6enonpo6~a T~OM~O-~M OCTbp ~O~ CMCTeMR, 1 h, a TPaH3UTOPHa e Ta3U, npM KORTO rOPHMRT IlePMOp e MeH nynyC !pMTeMaTOpeC; T ~ I O M ~ ~ T I T I~ PH OM ~ ~OL(MTO~~ 30 rnin, lnnM no-uan~o. Maonnpa~e~o Ha pqeH MMKPOOPHMclHanypilypa; CbpnOBMpHO KJleTbclHM~ ~ ~ O ~ R B Cnen ~ H M R raHM3bM OT XeMOKyJTiypMTe epHOKPaTH0 ( a rOPHMTe necbppewa onepaqw, TeMnepaTypaTa Moxe pa 6bne pM0pM) 03HaclaBa KOHTaMMHa4MFI WIM TPaH3MTOPHa 6 a ~ CBbp3aHa C nOCTKappMOTOMeH C M H p P O MM n M I l b K pa C e TepneMw M He e AoKa3arencTm 3a ME. mnMM~ W O M ~ ~ ~ O B M ~ ~ C a He H Ha ~ M ME. HOCB~H ~ ~ K ~ BTOPMRT $ m o p e mnem@~al\~ma Ha ~mqxmpraToEl HRKOU IlaqMeHTM C LUyklOBa HaXOpKa Ha CbpqeTO HM3Ma. HRKOH 6 a m e p ~TaKllBa ~, KaTO CanMoHenM, 6pyqeMoraT pa nonyclaT $?6pMfl~Te~, m n x a q ce Ha Hmoe nH, M e H M H F O K O K HM ClpeBHM TaM-HeraTHBHM6aq~nu, ripeppyro 3a60nma~e, a tie Ha ME. B cnyclawe C HeraTmtiM ~ M B B M K BoTHocmentio ~T qemo npopbnmTenHa6anepvxeMoKynTypu npceHeTo r p ~ 6 pa ~a 6bpe HacocleHO K ~ M eMMR, H0 PMKO npMclMHRBaT ME./$YTM MMKPOOpraHM3MH, ~~ p npMcl y wiM ~ 3a @ e 6 p n ~ ~ e ~ a . KaTo 3ene~eeum~e CTperrroKow U ~ o a r y n a m - ~ e r a ~ w a ~

T M B H M T e CT~@MJ~O !BMOKOKMTe cleCTO nPMclMHRn e ~ c l~ ~o ,mo MOXB pa 6bpe B ~ npomnm~er T nnM pa He 6 b ~ e noKa3aTentia 3a ME. TpeTM @atcrope HanMrnero H n M nnncaTa Ha ppyro omuqe KaTo ~3pa3 Ha nponbnmviTenHaTa~ ~ K T ~ ~ M ~ M U F npn I. onpepeneHM U H ~ M K ~ ~ Moxe M M Ra ce npoaepe M K O M ~ V H ~OT ~T H P M R T e T@aKTopa ~ e OT CbqeCTBeHO x ~ p y p r u ~nereHMe. l~o s ~ a r e ~Hanpll~ep ~e. npM nponbnmenna nHeeMoKoKoAHTM~UOTU~MT~, KOUTOC~ ~3non36aT,TpR6Bapa6bpaT Ba 6 a ~ ~ e p n e BO ~T w C b C ~T B M e T O Ha IIHIBMOHMR, tlOA03peC 6amep~q~p e@eKT. e ~ M360pb~ Ha ~ H M ~ H O T M K M HeroHneTo 3a eHpoKappm e ronmo; npu HanMrueHa memo~araon~~~an~a~oaaceonpe~en~o~ HnA Moxe Aa ma, HO Moxe M Aa HnMa ewoKappMT. HMR M H K D O ~ ~ areHT H M OT TeCTa 3a 6ameo~uun~a , . . . aKTMBnpopbnmen~a K)HeraTMBHaC T ~ @ M ~ O K O K O B ~ HOCT Ha'ceplmnaHa ~ O ~ H M AHTH~HOTMK~T R. C e CMRTa 38 6a~~epue~u11, Bc a ~ ~ ~ p a e a c ~ y n a p e ~ ~ ae ~$ e~ ~~ ba pcKoraTo e~, M M a 6 a m e p ~ ~ amMeHoCT ~ p ~ a npn pae MHO~O r10p03p~ HpOKaPpHT;npUHanM.IMeHa 3peWaHe Ha CepyMa HQ 1:8 M n M KOraTO MUHMMmHaTa MtmpawcKynapeti KaTenp Moxe pa MMa, HO Moxe M pa u~x~6wpaqa KOHqeHTpa~tIR Ha ~ H T M ~ H O T H eKn0p ~ 0.1 HRMa eHpOKapAMT. OT na60paTopH~~e npOMeHH CYE e pglrnl (cnopep npym - 0.2 pgrnl). ycKopeHa, 6 e m - b e ~ HopManeH ~ M n M neKo PennqeH 3a n p ocnp ~ e ~ p o ~ a necle~~ero p n ~ ~ ~ p ~ 6pa sa sanoclcuema Ha y-rn06y1'1MHUTe. ~ O R B ~ Ha T ~uKpocKoncKa ~ He He no-KbCHO OT 1 h Cflen XOC~MTMM3ayMFITa, IOKaTO xeuaTypuR Moxe pa e M3pa3 Ha 6b6pecl~u M H K ~ ~ ~ M ~ O ~pMnOpOCTpMReH~OKap~MTHacl~JOTOHaneCleHMeTOM n M M . Han~qe e BMCOK TMTbP Ha PeBMaTOHpHUR $ ~ K T o ~ . x e pa ce a6aeu c eaeHTyanHo 2-4 ~ H po M nonyvaBaHe Xe~oqmypme ca ~ a i c n r y p ~ ~ e n a 6 0 p naHa ~ o p ~ ~pesyma~a OT xeMoKyrnypaTa, 6e3 Toea pa ce 0 ~ p a 3 tin. B 90% OT cnyclame nonomreneH pe3yn~a~ ce nony~e6naronp~RT~o Ha npomosa~a Ha 3a60nRBaHeTo. npor a m Owe B IlbPBHTe CleTMPH XeMOKynTypM M M H O r O PRpKO pbnXMTenHOCTTa Ha ~ H T M ~ M O T M ~ ~ HnecleHHe OTO e 4-6 Ceca H ~ O ~ X O ~ MIlOBecle MM OT 6 3a IlOTBbpWaBaHe Ha HO3aTa ME. Heo6xop~~o e BCRKO B3eTO KOnMVeCTBO KPbB pa ce oTrneWa npM aep06HM M aHaepo6HM ycnoeun. ~MT~ , H T H ~ H O T H ~ H Onecletive TO 3anorea, Kamo cnenea: MV@HMRTarew, K O ~ ce O ~ s o n ~ p axeMoKynTypMTe, or npw c r a @ ~ n u ~ o eHAoKapAMT ~oe c Cefalotin i.v. (6-12 9/24 ~p~6e pa a ce aanas~~ a i - ~ a n 1~ Meceu, o 3a pa ce h) Mnu Oxacillin i. v. (12 9/24 h) M Gentarnycin i.m. #nMi.v. npoaewa MHorotqpamo Tern 3a 6 a n e p ~ u u p ~ a (1 rngkg, HO He noeere OT 80 rng 3a 8 h) Mn# Naphcillin i.v. HOCT Hacepya Ha~ ~ H H O~ono R . 10-20%o~ nauneme 2 g 3a 4 h..np~ uaonnpa~ Streptococws viridans neqeHwC ME MOmT pa HMaT HemTMBHM XeMOKyJTiypM. %CT0 ero aanoqea c Penicillin G, 10-20 000 000 Ul24h i. v.

(HRKOM aBTopn ~o6aem H Streptomycin - 7.5 mgkg i.m., HO He noBeqe OT 500 mgll2 h; npn aneprnwn Ha nemunnwHnauMetiTnce npunaravankomycin(30mgkg/24 h i.v., YclI~lloll?~~~ H0 He nOBeYe OT 2 g 3a 24 h). np# ME IlpH'iHHeH OT Streptococcus foecalis, npenopbw ce K O M ~ M H ~ ~ OT UR Ycnowe~uma Ha ME MoraT na 6bAaT paqeneHu Ha Penicillin H Streptomycin nnu Penicillin H Tobramycin (3-5 Rse ocHoaHn rpynn: xeMoAnHaMnrtin (aamoi~a cbpfiermgkg 3a 24 h, paqeneHa Ha 8 h (u~~epean). ME npn Ha c n a h ) u ~ M ~ O ~ M V H 3a Mm . oiI~a~ CbpRertia a cnaHapKoMaHw, nanonamuln i.v. ~porm, Kauo u npn npo~eau6 0 (pe3yrrra~ ~ ~ OT Knaniia perypru~aun~) e 06#%iiI~aTa paHH KnanU C e npMclMHRBa W C T O OT rpaM-H~T~TMBHM OPnpwrntia 3a neTaneH MBXOA npn naqueHTn c ME. OT ra~n3~1.1. npenopbrea ce neqeHne c Gentamycin M eM60ll~~~KTe YCnOXHeHMR M03bCIHMTe ~ M ~ O ~ C aM CMrM Carbenicillin (500 mglkg124h). O K O ~ O ~ O ~ O B M H ~ T HM$MK~HTHO ~ O T T ~ ~nM o-~~C MT ca M no-rec~a n p n w ~aacmprra. a 60n~u pa3~ues aa ~c r o i ~ a cbpflevtia cna60c~. Hah-V~CTMRT npnlcuHmen Ha ME cnen KnanaHHonpoIlpomo3a Teanpatie e Staphilococcus epidermid. npenopbclea ce QHH OT H~A-T~)KKOnpoTnvaqme ME ca Tesn npnmnerehwe cvancomycin(2g/24 h) i.v., Rifampinperos(300 HeHM OT b 6 ~rb6~'iH~Te . MH$BK~MM aTaKysaT Hd-qeCTo mg112 h) M Gentamycin (1 mglkg/8 h i. v. B nbpame 7-10 npo~e3upa~n~nanu,a~a~acaqocbp~e.1~me AHW OT ~ - C ~ R M I ( C ~ ~ H HapKOMaHH L4 Ha Ila~lGIeHTM C nOTMCHaT MMyHUTeT. rb6~'iXmpyprmr~o nereHwe npm ME HnTe BereTauuu no KnannTe ca roneMn n ca C B ~ P ~ ~ CH M A ~ C O ~ ~ OHHIuKaunu: THM pe$pauep~aHa nevetiue PUCK OT roneMn cbfloen eu60nnn. npomo3a~a e nowa u B cbpAertia c n a h , cebpaa~a c mama ~MC$~HKL(UR; MHnoBeveTocnyranceHanaraonepaTnBHautiTepaeHqnn. OKaPAHM M n M IlepHBanByflapHM a6cuecu; He@eKTblB~a C noura npomoaa e M ME npn manHo npo~e3upa~e. Tepanw npn nepcncTupaqa6auepne~nfl #nu npn b6nO~ono 70% e cubpTHoma npu ME, pa3~un ce B nbpeme i'Ha H H $ ~ K ~ (M K~ RK T np# O HaTUBHa, TaKa H npM npoTe3M( p a ~ eHAoKape~ paHa mana); pequAMs Ha 3a60n~ea~e~o; H ~ C T ~ ~ W I H ~2 Meceua cneA manHoTo npo~e3npa~e , ) T I # a npM KbCHMR JleTMMTeT e O K O n O 45%. npo~esa.

m).

TOMOB, Jl., Mn. TOMOB. P ~ M H~H apywew ~a ~cbpfleqHaTa fleii~om,C., Mefl~~lccHa m +m3~ymypa,1990 TOMOB, Mn. H cb~p. K ~ M H H KapflwonomR. C~H~ Meflmqm~a m +w3~yn~ypa, 1992 Xernu~,P. Am$epe~wan~a flmamm ~a n ~ p e u r ~ w r e

6onec~w, Meflnqm~a m $ma~ymypa,1978 Braunwald, E. Heart Disease Fourth Edition, 1992 Luderitz, L.: Ventrikul3re Herzhythmusstorungen. Springer-Veriag Beriin - Heidelberg - New York. 1981

MW~H MH~~HOB Cnac Cnac~os

@a~~opm Hp ea 3 n ~ r ~ n ua ~~ eo @ 3 ~ o n o r u Mexar~~ HMBMM,BopeqMno pa3smue~o Ha AMxaTentia HeAocran~ H O C T ,KaTo npasuno ce careTaaaT noMexqy CM. Toea CTaBa BCe no-O'ieBMflHO C YCbBbpUIeHCTBaHeTOH a HaUIMTe P M a W O C T M V H MB b 3 M O ) K H O C T U . ~ O H R T M ~ TJMXaTenHa O Hefl~~TaTb'iHocT" 3a IlbpBM m e n p e f l n 0 ~ e ~ 0 0 T W i ~B tr 1854r., i ~ h HoMfloAHecHnua 06qonp~e~0, ~owo onpeneneHue Ha T O ~ U npouec. AMxaTenHa HeffOCTaTbClHOCTe CbCTOFIHMe, IlpM KOeTO ROCTaBKaTaHaKMCnOpOflflOTbKaHMTeMenMMMHMpaHeTO Ha BbrnepopeH~ B ~ O K M He Cce ocbqecrama no e @ m c e ~ HaqUH. Pasn~r~me aaTopM fle~aAnlraupa~ B MJB~CTH me~

Mtioro necHo Moxe W T M p M BbnpOCa:

E~uonoruma H a AuxaTenHaTa HeAocTanrHocT (AH) Aa 6bfle n 3 ~ c ~ rpe3 e ~ acne1HuTe

1. K o i OT KoMnoHemme Ha cucreMaTa e ~ a p y u e ~ ? 2. KoA e ~ ~ T @ M ~ M O ~ O ~ M ~ uH eM xR aT ~~3b Ha u HapyU r e H M R ra3006~e~?

3. X w n e p ~ a n ~ e#nM ~r~ HemnepKanHenrHa a (XM~OKCMVH~e ) AH?

4. Koe cneun$nr~o 3a60n~ea~e R enpefl~3~~~a

1. Ken KoMnotietnHacucTeMaTae ~ a p y u e 3~arme ~? A U C @ ~ H ~ M R , Ha K O ~ O n fla e OT Ko~notleHncrre (6enoflpo6e~ nnM ~3ebHGenoClpobe~) Moxe tea aoaeue m AMxaTenHa HeflocTanrHocT. H a p y u e ~ ~ m Ha aewrpanynMoHanHm oTnen ~ P ~ ~ M ~ B M noHuxeti K B ~ T ra3006~e~ Mexfly aTM@epaTa M flMCTNHUTe RMXaTenHHIlbTMwa M N W OnUTe. HapylueHMma Ha rlynMOHNHHR OTflen npeflM3BMKB a T HapylLleH ra3006tuleH MeXQyn M C T a J l H U T eR M X a T e n H M nbmqa H anwonme, M KanunRptlaTa K ~ B . 2. K d e ~~T@M~MO~OM~HIIFIT M ~ X ~ H H npenmw~~M, maqHapyueHnR r a 3 0 0 6 ~ e ~ Cl ? empuca octiowme MexanHaTa

PylueH d M e H npMC b C T O f l H M R Ha HaPylueHMRBeKCTpanyllMOHaJlHMFI OTflen. B flyllMOHNHMR OTAen MeXaHM3MbT, no ~ o k cram o BnowamHeTo Ha r a d ~ e ~ 3ae~cu a , OT T O M K O OT ~ K O M n O H e H T U T e e HapylueH. VIQ HwylueHMma

canpuruHa3aHapylueHuRBnonHmefluxaTenHMnbTnw.

& C H O n e B M R T UlbHT MnM ~ ~ M $ Y ~ U O H HHaPylueHWl MT~ Ca B O C H O B a T aH a HapylueHMR E I ~ M npM ~ HapyUJeHWl H H a aneeonc-~anun~p~a~a mHa. 3. X ~ n e p K a n ~ e ~HexunepKanHeMrHa r~a~n~ (mnmcur ~ ae)RH? npw XMneplcanHeMrHaTaAH PaCO, e noBMmeHO, a Pa0,- noHMxetio. An~ono-ap~epnan~~m rpmuelrr H M 3 M M , BmeqM fl0 HapyllleH EI3006MeH: aa KMcnopofla [P (A-a) 0 , l uoxe ha e, HO Moxe M na He e mnoaemmaqMR; HapylueHln ~ m m r ~ l ~ o ~ ~ o - n e @ ynoakwueti. X ~ n e p l c a n ~ e w rAH ~a~ ea pe3ymaTOT: m~ mno3OHHM O T H O U l e H M R (V/G)); WHO-nRB Mf.rrpallyllMOHaneH a e m a q m OT PMC@~WMFI HaeKCTpanynMoHmufl oTflen; m t r r ;HappeHa A M $ ~ ~ M R . WlM T e M M VIQ HapylueHMR, npM flblO$y~wMR Ha IlYllMOHaX ~ n o e e ~ ~ n a ue wMexawmbT, ra npe)$mmaq WnHm oTAen; mn (H~A-reno) OT K O M ~ Ha H meTe. ~

~ o p ~ a nnu n ~notiwxeHo, o PaO, e notiMxeHo, a P(A-a)O, e yaenMcreH. Tom m n AH ce nonyam B pe3yma~ OT: 6enoApoG~a UM@~HWHFI w n M yBenMreH ~ C H O - J W B W ~ WHO , He M BcneRCTBMeOT eKCTp~nMOHaJlHM npMVMHM.n B a ~ MeXaa ~naua, no KOUTO B ~ ~ H U ~ K Ba ~AH, 3 ce ~ RomneaT OT HapyB b 3 H M K B a , K O r a T O H R K O M O T a J l B e O ~ l r r e C ~ X M ~ O ~ W ~ M ~ aUeHMR B A H $ ~ ~ M R TKOMTO ~, Ce FIeRBaT KaTO ~ O I T d l B a $a~~Cfl,H0 HHKOra He JleXaT B OCHOBaTa Ha T03M BW aH. HM, cpaetietiu c nemymma (HUCKO VIQ), AoKaTo n p y ca ~ xunepsemnupatiw, cpaeHeHM c n e p $ y 3 ~ ~ (BMCOKO 1 ~ a VIQ). 3a60nrr~a~~ Hm ~a ~ ~ ~ O C ~ ~ O ~ H U T ~ m Fm ( M qa Xnpe~ T ~ nbpBoHaraJlH030HMTe C BMCOKOVIQ M O ~ ~ KOMneHCMpaT T R ~ AM~BMKEI~T Hapyuetim Ha ram06Me~a rpe3 VIQ Hapyuem i m e C HMCKO M He ce ~a6nlofla~a noeMureHo PaCO,, HMFI, Bb3HMKBaqMOT PeMOHaJlHMTe pa3nM'iMFI BbB BeHTUnanotilxetio PaCO, M s ~ a r ~ ~ noeMureH e n ~ o rpa,qneHT 3a UMFlTa, KOMTO IlbK Mpe3yMaTOT pa3nM~HOTO CbnpOTMBfleHwe Ha AMxaTenHMTe nbTuqa. H a C s ~ a w e n ~ p aa ~3 an ~ ~ KucnopoAa. Xunepmn~ema, n p e ~ ( n 3 ~OT ~K ~O a~ Ma ~ H H eKc~ ~ M ~ M ~ e w HexMneplcanHMrHaTaM xMnepltantiMrtiaTa AH e, r e VIQ HapWetiMma n p HexHnepKanHMwiaTa ca no-ne~o TpanyllMOHaJlHM, nyJlMOHanHMIlPMVUHU,Bb3HMKBanpM 3HaYUTenHM VIQ HapyUJeHMR, HaCflOXeHMabpXy HRKaKBOOrpau3pa3e~w. HMreHwe Ha noTom ra3. Tom ~ah-remo ce cpeqa npu 4. Koe c n e q t l $ ~ r ~ CbcTomMe o e npe~u3~uKaho AH? amua, X066 n p o p a Ha AnxaTenHaTa YmynaTypa. Cnepaqa~a ~a6nwqa~ 3 6 p o ~ no-rnaa~n~e 1~a npMruHw llm HewnepKantieMrHaTa( m n o ~ c u r ~AH, a ) PaCO, e (~a6n. 6.2).

XMIlepKZInHema, npeflM3BMKaHa~eKCTp~nMOHaJHMROTfin, Bb3HMKBa, KOraTO MMa nOHHMBaHe Ha nOTOKa ra3 M e w amoc$epa~a M nynuoHanHMnoqen. T a ~ PaCO, a e nOBMWeH0, PaC0,- nOHMXeH0, H0 P(A-a)O, e HOpMaJleH. Xunep~an~ema, n p e ~ ~ 3 ~ OT u~ 6e an ~oa~ p o 6 npnrmM, ~~

Xunep~an~eur~a EKC~~~~LJAMOH~AHU QenpecuuHa guxameAHuR yeHmbp Cu~gpou Ha nbp0ur~a a 6 e o ~ a p xunotle~mu~ayu~ ~a MUKC~~~M ~ ~ ~ o A F I ~ Ha ~ H ~P u ~ R ~ H ~ C M03bH IHUR A~uornpo$ur~a AamepaHa ctaepo3a llo~uo~ue~um flecu~u~upa cwepo3a ~a CUH~POM Guillain-Barre 60mlJA~3bM Muacme~u~ apa8uc M~JCK~JAH~ ~UC~PO@UR no~uuuosum Xun@oc@ame~u~ Ku$ocno~uo3a AHHUAO~U CnOHgUAUm ~~W, rpbge~ HanaH Topa~on~acmu~a Pecrnpu~mu0e~ n~e0pum 06cmpy~yu Ha ~ mpaxeflma Enu2~omum Age~oug~a U m o ~ 3 u ~ a xuneprnpo$u~ p~a
~~JAMOH~AHU

Hexunepnan~euwa EHC~~~~LJAMOHMHU HRM~

~LJAMOH~AHU

Acmua X066 KUC~O $u6posa ~H~ M H ~ ~ ~ c ~6 u e~ ~o g u p~ 06 ~ H~ U ~OAR~~HUFI

A c ~ M ~ X066 KUC~O @u6po3a ~H~ ARDS 6e~ogpo6~u cbgo8u 6onecmu kI~m!pCmllqUaAHU 6 e ~ o g p 0 6 ~~ ~~ ~

O A R ~ ~ H U R

WR3a UWeHo HMBOHa C O , I-IFCNI~~~HO or o p r a ~ w M ~a cemrMcnRaanocnelHoToypaeHeHue:

HcTaeHoTo~ 3 c n e ~ e 3a a~ oqeHm e Ha pwxaTenHweM MeTa60nw~we HapyueHm. flmxa~en~a~a HeAocTaTbrHmMOx e pa 6we onpepeneHa no HappeHuma Ha KrA (ap~epua n ~ HanpexetiMe o ~aCO, HWWwnnap-repnan~o tianpexeHapyweu~~l Ha ra3006nneua w e Ha 0 , non 50 mm Hg). n p a a ~ n ~ nwrepnpeTal a~a (MR Ha XH~OKC~MHR. OCHOBHW~ C~CTORHMR, npelnae~~ea KrA M3McKBan03HaBaHeTOHa: gaBHeHMeT0Ha Hendersonq~ XunoKceMMR ca: HMCKO Pi0, aneeonapHa xnnoeetiTnHasselbalch; ypawieHMeTo 3a allBeOnapHMR m; KOHqen a q w HapyueHo omoweHMe BemMnaqrn - nep$ya~a; n~~ma3aanseono-ap~epnan~m rpqqHewr3aKncnopola p e n w e n ~ c ~ o - urbwr; m e HapyweHaA M $ ~ ~ M RBCH~KM . [P(A-a)O,] MaClMcnReaHe Ha CbOTHoLueHUeTO AWPaCO, M Te T P H IlpMClHHH Ca KJlMHMClHO 3HaCIMMH3aXMnOKCeMMRTa. HeroeoTo npmaraHe 3a e3eMaHe Ha TepanemHM pewe xunepKanHHfI. ~a Tp# cacToRHnR Morar HMR; p ~ h p e ~ q v a AMamm n~a Ha pa3nnr~we a n ~ a n ~ ~ - Ap~ep~an l a AoeenaT ~o noeuweHo PaCO,: BgHweaHe Ha raa, K M C e J M lH H M HaPYlleHMR. cbmpxaq CO,; anaeonaptta xMnoaeHTMnaqm; i e m o H o p ~ a n ra3006MeH. e~ ~naeHa~a$ymyu HapmxaTeHapyWeHO OTHOWeHMe BeHTMnaqMR- ne@y3MR. K~MHMC nHaTa cMcTeMa e r a 3 0 0 6 ~ e ~ T b~ O. ~ npouec M Moxe ua HO ~ H ca caMo M nocnepHmeflee. h u e paa~ene Ha ~ flea oCHoaHu eTana: npeMMtiaeaHe Ha nOTOKa Bb3flYX OT aTMM@?paTaKbM TepMMHanHMTe Pecnwpa~opum anwanuo-mrcenwuuw HapyweuHR TenHM IlbTMqa M lM$y3MR Ha Ta30BeTe Memy TepMMHaJlHwe oTpenn Ha 6 e n pp06 ~ ~ M 6enoppo6na~a KanMnRptia Pecnupa~op~a aqunoaa. n p mpenvHaTa pecnnKpbB. paTopHa aq#loaa PaCO, e noeMweHo nopqn C(MC$~H P & , . HopMallHa~a CTO8~acr Ha PaO, W W M OT nOn04~11 ~ap m x a ~ e n ~cMcreMa. a~a n p H~O ~ M ~ ycnoeMn ~ H M tqe xenMeTo Ha nawewra, npn KORTO e meTa qmHaTa npo6a C e 0~6eneXa~ KOMneHCaTOpHM IlpOMeHH B HHBOTO Ha M m p a m a MY. b p ~ y n w e npelewaqM , HopManHaTa HCO,, aa Aa ce HaManM e $ e m ~ OT noeMweHoTo PaCO, CTO~HCCT Ha PaO,, ca: -e npaeononoxerne: PaO, = 104.2 -0.27 X m p a m a mpsnvHa pecnupaTopHaaqnpo3a e s a w 0 l a c e onpepe(~~HHM); - B nemano nonoxetiMe: PaO, = 103.5 -0.42 X m p a nHOT KonKo BpeMe PaCO, e noaillwetio. Toeace onpelen~ CTTa (TO~HHM). Vpe3 M3'iMCJlflBaHe Ha CbOTHOWeHMeTO AHIPaCO, AKO P(A-a)O,. 3a ~ o x npaemo e pa 6bpe nwrepnpmHRMaMe ~ ~ ~ ~ M U J H M C T O A HHa ~ CpH T MM PaCO2, TO IlpMeMapm0 Ha~anReatieTo Ha PaO, e H ~ ~ ~ X O A Mpa MO ce s ~ a e Me pH 3a 7.40 (H = 40 mEqiL), a PaCO, aa 40 mm Hg. pa3nnKaTa M e w aneeonaptimo (PaO,) M apTepManHoTo ce cltawu 40 OT nocneflHaTa PaCO, ce Mar#cnRea, K ~ T O HanpexeHue Ha mcnopofla. Aneeanap~o~o PaO, ce MWMH ~ M ~ ~ ~ H ~ C T Oa ~ H' HO C e CM3MepM, T, KaTOM3~MM 40 OT cnnm rpe3 onpocTeHoToypaBttetiHee: PaO, = PiO, - PaCOd nocnepHaTa MaMepeHa c ~ o b o cHa r H+.Bcfi~a npoMRHaB R, WeTo PiO, e napqManHoTo HannraHe B A M W ~ ~ H M R HMBOTO Ha HCO o~paanea HepeanHme 6y$ep~ (BOCTPMKMCnOpolH C% I l O n y r l a M H T 0 ~TMM@?~HOTO HarvlraHe ce Te CbCT0RHMR). dpM XPOHMCIHM HaPweHMR HaAKP, 6b6peynn~om no ~$pamyma Ha NMwmHnFi wcnopop (FiO,); R e qme nocTeneHHo ce crapam Aa KopMtvpaT HUBOTO Ha pecnMpaTopeHMmeKc. 0.8.P(A-a)O,ce BnweoTmpama HCO, B CbOTBeTHaTa IlOCOKa, 3a l a BbPHaT CTOAHOCTUT~ M n o n o x e ~ ~~a e~ ~o O~HM M ce R wawcnfieanoypeetieHHeTo: Ha H' H a w , H0 HMKOraA0 HOpMmHaTaCTOAHOCT. OcTpaP (A-a)O, = 2.5 + 0.21 X BWpaClla (TO~MHM) Ta pecnnpaTopHa aqnflo3a a ~ a v n nosllrureHo PaCO, OT flonymdm, ve ~ o p ~ a n PaO, ~o~ npllr o MnqMM 3 ~ l p a ~ n MMHYIMp0 HRKOJlKO lOKaTOXpoHMclHaTapeCnMpaT0xopa e 90-95 mm Hg, TO H O P M ~ H M P(A-a)O, ~ q e 6ble pHa aqMAo3a oa~a~laea noenureHo PaCO, OT HRKO~KO paeeH Ha5-10 mm Hg. Toan rpqMem e e a A - ~ w e n ~ ~ ~-H M .Kora~o HMaMe oc~ponoenwamtie Ha PaCO, npm RT nOKa3aTen3a ~ ~ ~ ~ J ~ R B ~ H M C FB I Tb~ W , M C HaPyLueHMe xponnwa WnepKanHen, TO Moxe l a ce orcpelHa Ha m3006~eHa. CTeneH Ha KOMneHCaqHR. CWTHOW~H~GI~TO AHhCO, 3a PaCO,. HopManHWTe r q CT~~HOCTM ca 37-40 mm Hg. OCTpa, X P O H M C H l a M M30CTPeHa XpHHClHa PeCIlHpaTOPHa Tem C T O ~ H ~ C Tce M onpepenm OT aneeonapHaTa eemnaa q w me K~KTO cnepea: 0.8; 0.3; ~q 0.3 - nofl 0.8.

HO~MW P~(A-a)02 H 3 a 6 0 ~ ~ 0 ~a a~ UHC u~ npego3upa~e Ha Meguuahnetirnu IlbpBuq~a xuno8e~mu~ayufl Mu~cege~ 3a60~~8a~ Ha u k?pb6HaqH~fl fl M03bH 3 a 6 0 ~ 6 a ~a ~u nepucpep~arna ~ ~ e p f l cucrnehna ~a Guillain-Barre Auuornp@uq~aAarnepanHa cwepo3a llocm noAuouueAurn M~oxecmSe~a cwepo3a Mu~C~~~ ZP H~ U~R UC
~ o ~ T ~ Y A u ~ ~ M

noBut.ue~P (A-a)02 6e~ogpo6~u 3a60~Ba~ufl X066 Acrnhna Kucmo3~a cpu6posa Mtirnepcmuqua~a @u6posa KO~UHU~ 3a ~hH wU 0 a ~ u fHa l zpbg~arna crneHa U 6e~ufl !JP06

3 a 6 0 ~ B a Ha ~ uzpbgtiarna ~ cmeHa Topanogucn~asufl A H H U A O ~CnOHgUAUm U~~~( 3a60~6a~u Ha f l guxamewarna ruycxynarnypa

~OAUOMUO~U~

M Y C H ~ guCfTlp@ufl AH~ O6crnpynqufl Ha zopHume guxarnewu nbrnuqa Enuz~ornurn YBpegu Ha AapuHuca Cmetio3a Ha rnpaxeflrna

HopMaAeH P (A-a)O, 3a60~Ba~u ~a f l 4HC XOPMOHU U MeguuaMeHmu 6pe~e~~ocrn Texna aHeMUR ncuxoze~~ xunep8e~rnlvlaqm a C~A yu~arnu U K~~~XOA~MUHU npo~cmepo~ npego3upa~e Ha aHaenrnuqu M ~ A U UHa ~~ rnupougeH H xopuo~

I~OBUW P~ (A-a)O, H rpa~-~ezarnu&ti cencuc E~gornouce~ufl Yep~ogpoG~a HegocrnarnbrlHocm M~rnepcmuqua~u ~ ~ A O ~ ~ O 6e~ogpo6e~ omo~ 6enogpo6~u ~M~OAU
~H~~MOHUR

~ H U ~ ~ ~ O A R ~ ~ H U

Acm~a

238

6e~ogpo6nu cnewwu cbcmonnun

CTpaHCTBO.

O 6 ~ ~ fTeClHOCTeH rr nOTOK Qf n p e 3 eHflOTen-

HaTa 6ap~epa M o x e fla ce npeRcTaeM rpea ypaeHeHMeTo H a Starling:

Qt = kA[(Pc-Pi)-(Cc-Ci)] = kA[(Pc-Ci)-(Pi-Cc)],
KbfleTO:

PC M Pi

M KallMnRpHoTO M MHTePCTMlJMaJlHOTO

XMflPOCTaTMCIHM HWlRraHMR;

CC M Ci

MHTeCTMuManHOTO KOnOMflOOHKOTMCIHM HanRraHMR; K nepMea6MnMTeTb1; A n n O q T a H a KanMnRpHHTe M ~ M ~ P ~ H

- KanMnRpHOTO M -

Cynrla~a OT reTMpMTe cMnM H a Starling e HaebH, n p e p M -

~BMKB~AKM eKcTpasacKynapHa $ w n ~ p a q H~ a TerHocTM~ Te. B H 0 p M a n H M R 6 ~ m #p06~ a 3 M eKCTpalM3MpanaTeClHOCT C e ca6~pa OT ~ M M $ H M T CbflOBe. ~ A~HOPMHO cb6Mpa~e Ha
TeCIHOCT B eKCTpaBa3anHUTe npOCTpaHCTBa M TbKaHMTe

we ce p

a 3 ~ cauo ~ ~ K aoraTo K a n a q M T e n T H a n HaTa m M n a e n p e x m p n e t t .

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noemwe~o KanmnnpHo xmapocTaTmwo HannraTOM e H ~ ~ V ~ C T M MeXaHM3bM FIT 3 8 Bb3HHKBaHe H a

OTOKa. OCHOBHMT~ nPMClMHMM:nRBOKaMepHa HeflOCTaTbClHOCT, CneA MMOKapfleH M H @ p K IT UnM CMCTeMHa XMnepTeH3MR, KaKTO M n p M MMTpanHa CTeHO3a M O~CTPYW(~MR Ha roneMMTe 6enoflpo6~~ BeHM. n p # BCMYKme Te3M CbCTOfl6en~mflp&~ee .cyx"opra~. H o p ~ a nTOO ~ o ampm efltio OT ~ a i - r o n e ~ m K oe n M c l e c T B a T e w o c T B o p r a ~ ~ 3 ~ a . HMR,KanMnRpHOTOXM~POCTaTMrHOHanRraHeCenOKa3Ba nopa,qM 6enoflpo6~a B ~ H O x~ Mn He p ~T e H c m . CB060flHMHT OT K p b B 6 ~ ~ np 0 T 6e X M 500 OT KOMTO 80% ca sofla. Heronmo KonMrecTBo Bofla ce n p o c M y K B a

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na~~peamum Y~~MUR
mac me^ e M 6 0 h ~ 3 b M 6ehogpo6~a HOHmY3UR

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BCM~KM Te3M CbCTORHMR B O W 10 flMP~KTHaMnM #HawW Cle T W M MeXaHM3bM PFlflKO e IIpMClMHa 3;16enoflp06eH p e a ~yepepa a ~aKanMnRpHnR e w o T e n M, ~ bKaTooTorHai OTOKC~M noce6eCM, TO~I ~ o x i e aB n o m m o K a , n p e ~ ~ 3 e u T a TeClHoCT Cb)$bpm TOTaileH npOTeMH B CTOGHOCT, 6 n ~ 3 ~ a KaH nOflpyr MeXaHM3bM. X M ~ O ~ ~ ~ T ~ M H ~ np MM M 'iePHOflFIT~ Ha~ a 3 B n cepya, M ~ X ~ H M ~ HM a TOW ~ T OTOK 6e H a p e r e H pobnaH e p c c r a n r H c c r HnM H ~ $ ~ O T M CMH~~POM ~ ~ H M xmep.CMwPOM H a KanWlFlPHOTO M3~M'iaHe'. ~ O H H ~ ~ KOnOH~WHKOTH'IHO H O HBnRraH8.

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H a ropHwre pnxaTenHM mmqa (decaa~e).
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OCHOBHMT~ eTMonomrHM ~ ~ K T O P M onpeAennqw , naT @ M ~ M O ~ O M C I H M T ~ npoMeHM npM ARDS, M:

1. ~ ~ ~ A Y KH T aM Me~a60nM3Ma H a apaXMpOHOBaTa KucenMHa. 2.6enM KPbBHM KtleTKM HTeXHKTe CTpaHMqHM npOAyK T M , m 6 e ~ KMCnOPOAHMTe 0 PWMKZUlM.

3. TPOM~O~MTM.

f l a ~ o n o r o a ~ a ~Mo ~C ~~~ ~~ rE~ E I~ HB M ~paHHaTa R e +a3a H a ARDS nOKa3BaT HaIlMVMeTO Ha M H T e p C T M q M Z U l e H eAeM; 4 o ~ a n ~ xehnoparw; a a~ene~~ Ma 6enoflpo6~a 3~ MHKpOCbROM K O H r e C T M R , npOrpeCMpa~H no-KbCHO B MHTpaanaeonapeii eAeM M xehnoparnu c TexKa KetirecTloR M aTeneKTa3a. H a 6 n ~ ~ a ce e aX~ M~MHHM MeM6paHM B anBeonuTe. Cnen 4-5 AHM HacnneaT ~ b s n a n ~ npMe~ e n ~ HM, KOMTO B K O M ~ M H ~ ~ M CR HaCnOeHaTa MH@~KL(MFI pa3LUMPRBaT 3 0 H M T eH a AeCTPmMR. B T 0 3 MM O M e H T HaCTbnBa enMTenHapereHepaqMR. P e r e ~ e p u p a q K ~n ~ e T e K M ca npe06nqaaaqo OT anaeonapeH THn 11, T. e., ~ e 3 KOMTO ~ , oTroaapm 3a npopylcuwRTaHa cbp4emawra. B T O ~ M cTa(Memy nbpsaTa M eTopaTa ceflu~ua) noaereTo 6onHM CARDS6bp30 ce Bb3CTaHOBRBaT, a CMbpTHOClla HaRBeW? Ce CBbp3Ba C p a 3 B M T M e T OH a SMOF. ~ ~ M K H O B ~ H 03F(paBRBaHeTOe ITbnHO, Tbh KaTO B C 8O q e H R M a YBpeXAaHe ( H ~ O ~ ~ ~ T M Ha Mr O O P )H M T eA M X a T e n H M nbTMqa.

AM^

Pecn~pmope~ AHcTpec CHHA~OM (ARDS)

M H u M A e H T KaTO WOK, TpaBMa, M a C M B H MT ~ ~ H c + ~ ~ A M MM ~, Y3eH I l e P M T O H W T , IlaHKPeaTMT, M a C M B H MM B T a P R H M R , eK30reHHM M H T O K C M K a q M M M flp. M ~ o r o 'ieCT0 6 e n o ~ p o 6 ~ o ~ o yspewaHe e MHAMpeKTtio.

AKOARDS nepcmcTmpa, ce Haenwa B KbcHaTa +aaa, xapa~~ep~3~p ce aq c anporpecupaqa + ~ 6 p o 6 n a c ~ nponw$epaqu~, 8ofleqa no MHTepcTMuMantiaM aneeonapHa 4~6po3a. 06qonp~e~ e,o r e +#6po3a~a e cebpsa~a c noeMweHa KoHqewpauHn Ha Konareti, HO HRKOM ~3cneAoeaTenM cbo6qasa~,r e KonareHHoTo cbAbpxatiMe e ~ o p u a n ~fo l. peoue~~ea TO h~ ~M ~ npo6neu, W. Zapol ycT a H O B R B a , r e KOHqeHTpauMRTa Ha KOnareH B 6eno~po6HMR napetixMM Ha nauMeHTM c nponoHmpaH ARDS e nOBMUleH. flpM'iMHM~e 38 I l O B M W e H M R KOnareH O C T a B a T HeHcHM. P e r e ~ e p ~ p a q aneeonapHa a~a KnerKa e M ~ K ~ I O rMTenH0 'iyBCTBMTenHaK b MB T O P M r H Oy B p e M , & i H e , He3aBMCMMO an^ TO ce Abnm Ha BTopMreti cencMc M n w K M C n O p O A H a T O K C M q H O C T .E ~ ~ K T P O H H O M M K ~ K O H3~~ CneflBaHMR nOKa3MT, r e T e 3 MK n e T K M CbflbPXaT rOnRM e ~ ~ o n n a m a m pemKynp, qe~ npeAnonaraqBMcoKacKop C T Ha 6en73VHa~a CMHTe3a. M ~ o r o e Bb3MOWO Te3M m e w Aa ca oTroeopHM 3a M ~ ~ M W H M KonareH, R KORTO 3aeAHO C Y B p e A e H O T O 06pa3pa~e H ac ~ P ~ ~ K T BOAM ~ H A0 T xapaKTepHMR T. Hap.: T B ~ P A 6 ~~ np o (stiff 6 lung).

ARDS e nporpecwpaqa nynMoHantia M H C ~ ~ M ~ M ~ H ~ M R KORTO , ce pamea racoee MnM AHM cneA HaranHwR

X M c T a M M H , CIPOTOHHH, ADP, ATP M ~P;WHKMHMH cbqo -rpe3e~3~~aq~~noo~cure~a3a~om~ M H ~ O e r O~ B~ W pM a. ~ e ~ o Ha npocTarnaHfluHn - ~ a h - r e c ~ ~ m ; flpoc~arna~p~~ npeflcTaenmT wre ~ah-ronm Mtrre- rpea e ~ a nMnoKcureHa3a ~ ~ a 1 0 oTAenRHeTo Ha peC I l O p ~ M MOqHMTe CM B a S O K O H C T P M K T O P H HC B O ~ T B (T*, PGF, ), c e o i t c ~ m ~ cn a fla ~ ~ ~ A M ~ B M arperaK B ~ T M O U H HB a 3 0 a K T M B H Mc @ ~ ~ H ~ HH M 3 B , e C T H M KaTO neBKOT~ MH R ~ T ~ M & ~ H (T$) T M H C ~ O C O ~ H O C MM T T fla ~ fl0BMWaP M e H M ; Ma Aa 6MeyMpaT ~ n m e ~xeMoTa- rpea apaw4oHoeaTaKwcenmHa, ~omo n pB ~~ ~ M M C - saT ~ a n t I n ~ p ~ ~ ~ n e p ~ e flehcre~e~o CM m C B ~ ~ ~ B NcnopoflHM HM p q q ~ ~ ocan~ Kcnc Ha ~ e y r p @ ~ n (n ~e ~e e ~ o ~ pPGE,, ~ e ~PGF,-). ~, HaMaRBaHeTO Ha 6enoflpo6~a~a XMllepTeH3MR M 6enoflpo~O6Oyqaea MoqeH xennoTaKcMreH arew. ~HMR ~ H M $ ~OTOK H M I ' I O ~ ~ O ~ ~ ~ H Ha U~T 6O enoflpo6~ ~ ~ B K O ~ J ~MFaFlT T M T ~IlbpBOcTeneHHapOnR3a pa3BMK O M ~ ~ ~ ~ npM R H BbBewaHe C Ha M H X M ~ M T O ~ U Ha CMHTe3aTM~TO Ha ~ ~ ~ T O $ M ~ M O ~ ~ flpOMeHH O ~ M ~ H npM M T ARDS. ~ Tosa Ta Ha npocrarnaHguHMTe, roeopM, r e Te urpam s m a oco6e~o Kacae c e n c ~ c - u ~ p y ~ n ARDS. pa~u~ 6enoflpa6ponR B pa3BMTMeTO Ha ARDS. ~ a ~ a n e ~ ~eon3pa3e~a c ~ a ~ npM a cencMc M e xapaKTepHa 3a e H f l O T O K C M H e M M R T a . flp# a K T M B M p a H e Ce oc~o6oyqaB a TM H O X e C T B O $~KToPM KaTO npOTea3M, flM3030MHM eH~ M M H ,K M C ~ O P O ~ ~ H pM qqu~an~ KOMTO , yepeyqaT 6 e n ~ ~ 1 ~ 0 6Y . cra~oae~ e,o r e cTenetrra Ha n e p ~ a 6 ~ n n ~ e ~ ~ o yepeyqaHe KopenMpa c KoHqetiTpaqwnTa Ha 6enoflpo6HMTe nM3030MHH eH3HMH. K o u n n e ~ e npeDcTasnRea ~n~ rpyna OT ~ H ~ M M H 6eM nnqm, rnmo qen e a a q ~ cpeuly ~ a ryxqwe eneMetrrH, oco6e~o 6amep1.1~.Kora~o oh ce alcrMBMpa OT cTpecoeM B HaranHaTa $a3a 6e3 aycKynaTopHa HaxopKa M c cMTyaunM KaTo WOK, TpaeMa, wrapme M n M cencwc, $paHopuantia petrrre~orpa$w~ Ha 6enw flpo6, nocTeneHHo meHm C5a, npMrMHRaaq arperaunFi Ha ~ e y - r m ~ n ~ ~ e , ~ORBRMT f l p e 6 ~ ce xpnnreTa ~ M HapacTBaHe Ha peHTreCe O C B ~ ~ O B b B ~ BbTpeCbfl ~ W OBOTO fl!JOCTpaHcTBO. H O ~ ~ ~ $ MM ~3 M He H e H TM ~ R flO T e M M AByCTpaHHM M H $ M ~ Anaeonap~w~e ~ a ~ p @ a~ mr p m aH ~a ~ ponR 3a TpaTM, $M~HKWIHM flaHHM 3a TeMK 6enoflpo6e~OTOK. p a 3 B M T M e T O Ha ARDS rpe3 ocao60yqa~a~e Ha M O U H H K n n ~ n r ~ KapTHHa a ~ a e HexapauepHa. A ~ H H M roeopm T~ X e M O T O K C M V H M $~KToPM. Te flpeflM3BMKBaT flbpBOHa.lan3a nporpec~e~o HenpeKbcHaToBnouraeatie Ha C~CTORHMHMR ~ b ~ n a n m e OTroEop. ne~ eT0. P o n ~ Ha ~ aKMcnopoutime p q q ~ ~ a no nc ,~o6o~e OT m neBKOL(HTMTe,e BYHMUOHBaHe Ha G a ~ ~ e p ~ @aroqM~re, TMpatiM OT ~ e y - r p @ ~ nTe3M ~ ~ eM . ~WIIO~MT~~ peamaHO H H areHTM MOraT fla 6bfla~ M H O r O fleCTPYKTHBHM, aKO Ce OCBO~O~~F BI T TbKaHMTe. Te flpoMeHflT M a c T H M R cllog Ha KnenrHaTa MeM6paHa rpea noeMureHo 06pa3yea~e Ha H O ,. , floe~ure~ 6enoflpo6~a a nMnMpHa nepoKcMAaqMR e ycTaHoeeHa n p oTpaeRHe ~ Ha roseK c napaKeaT (xep6~u 1 . 1 4 , KO~ITO B O ~ H flo Temo 6enoflpo6~0yepeyqatie p e 3 y n ~ OT a~ oceo60yqaea~eHa KMcnopoflHH pa,q~~anw).

OCso60~amHeT0 T R T p b M IlO eflUH OT Tpme Bb3MOMiM nbTR:

O C B O ~ O ~ ~ OT MH TP M OM~O~MTM K a T T O ~ fl!JOCTarnaHflMH#,

H 0 IlPOCTPaHCTBO, KaTO oc~06oyqam~ M a T p M K C a M 3aCMneaT efleua. Ha TRX ce flbnxu M yeenMreHaTan p o f l y u ~ ~ Ha T P O M ~ O K C ~ H K,O ~ ~ TflOBMUlaBa O HWRraHeTO B YBpefleHOTO KanMnRpHo nerno. AKTMBM~~H H a ~T KoMnneMeHTa O B O M I no a eraqna Ha T P O M ~ O ~ H T H T K O ~R ,T O Ce YBenMraBa flpM AR S. MMKpoeM60flM~e OT T P O M ~ O ~ H T H arperaTM H flpeflM3BMKBaTnoB M W e H M e Ha KaflMnRpHMFl n e p ~ e a 6 ~ n m Me flOflWpTaH0 ~

CHH~OM Ha MuorooprauuauefloeTaTbsHocT (SMOF)

Cnopefl onpefleneHHeTo Ha D. Fry (1992) SMOF npeBcTaenRm KoMynaTMsHa, nocneflaaqaopraHHa HenocraTbqHM flpM ~ O ~ H M npn , KOMTO Ce e pa30~n ARDS.

noaclureHne~ a 6 e n 0 f l p 0 6 ~ 0 ~ 0 ~ b HanRraHe. fl0~0 CbnoeaTa 06cTpyKqMR, IlpeflM3BMKaHa OT T ~ ~ M ~ o ~ arperaM T H ~ ~ M R tie , e pocTanrHa Aa floeeae no 6enoflpo6~a xmep TeHcMR n p ARDS. ~ Tom npeflnonara, r e $awop~~e,

B cpaeHeHllre c ARDS MHO~O no-MMKOca M ~ B ~ C T H n a ~ o $ ~ 3 ~ o n o rMexatinaMn, n r ~ ~ ~ e Bofleqn no p a 3 a ~ ~ ~ TO H a SMOF. OpraHHaTa HeflOCTaTbVHOCTflpM SMOF Ce nogema eflHoepeMeHHoMnM B onpegeneHanocneflomTenHOcT, n o f l c ~ a 3 s a h o6qa~a ~~ eTMonomR Ha p a 3 n ~ r ~ w

YBpeWaHMR Ha OpraHHMTe $ ~ H K ~ M M MO . P$~~OM~HMT (X066) ~ e 0 6 4 TepMMH, 0 6 e f l ~ ~ ~ p sa aq 3 n ~ C~CTORr ~ ~ H H R ,q M R T O o6qa VepTa e, 'ie npOTHraT C O ~ C T P ~ K Ha ~M xapatcrepmcTMKm Ha HanpeAHanw CMHBPOM ca onMcaHM B OrpaHMWH 6poh a)TOnCMOHHM npOyVBaHMR, H0 Te He C a noToKa ebqyx B 6enn~e ~po6ose. Hah-recro TOM e KOMnOKa3aTenHM 3a P a H H M R SMOF, HMTO MH$OPM~THBHM 38 6k1~a~pv-1 OT X P O H M W H O ~ C T ~ ~ K T M~POHXMT B~H M e~$M3e~. HeroBaTa eTMonorw. CbqeCTByBaT H R K O n K O apfybAeHTa, KOMTO nOAKpenRT x ~ n o ~ e 3 ar~ ea SMOF , e e y o nocnegcTBMe Ha reHepancl~ ~ T O $ M ~ M O ~ O M xapaKTepMcmKa VH~T~ Ha TOM 3a-

3 ~ p a ~ a ~ a a ~ ~ ~ ~ a u ~ ~ ~ a ~ e ~ ~ a ~ o 6p0 ~ ~ee ~O a bY a a eKCnMpaTOpHMR ne~~e~o . Bb3flyX, n~ ae ~ e ~ C~ TP K ~n M Ha R nOTOK 1. npM naqMeHTM CbC SMOF CMCTeMHO Ce YCTaHOBRnpeflM3BMKaHaOT3HaVMTenHOnOBMllleHOCbnpoTMBneHHe BaTWlaCMCleCKMTenpM3HauM HanOKanHOTOBb3naJleHMe. Ha MmKMTe 10 AMaMeTbp Bb3flyXOHOCHM IlbTWqa (no1 2 2. npepM~n03M~MR KbM SMOF M M a TB C M V K M ~ O ~ H M , mm). XPOHMVHMRT ~POHXMT BOUH AO 06MnHa ceKpeqm, a KOMTO M M a T ymnxetia M MacMeHa atcrMaaquR Ha KoMnnee ~ $ ~ 3 no e ~ nocTomHo b ~ yBenMretiMe Ha paa~epa Ha MeHTa. ~ ~ O H X M O ~ IlOpQM M T ~ , fleCTPYKTMBHM IlpOMeHM. npM T O B a 3. H e s u ~ a e r~ H ~ O ~ X O ~ ~ sKnmrsaHeTo MMO Ha 6a~reIlOrTM BMHaM Te3M nauMeHTM CaflMrOrOAMUIHM,C T P a C T H M PManHa MHBa3HR, Owe nOBeVe, r e npM T03M KOHTMHreHT nyuarn. 60n~w ~ ~ K T ~ ~ M ~ J ~cenc~c HMFIT ce p a 3 a ~ r~ea c ~ OT o HMCKO naToreHHH 6 a m e p ~KaTo ~ , Hanp. St. epidermidis.

A. Baue M D. Gothrie (1983) YCTaHOBRBaT CneAHwTe ~ o p $ o n o r npoMeHM ~ r ~ ~ npM SMOF: r e ~ e p a n ~ a MH~pa~

TepcTMulraneHeneM; KanMnRptiaTp0~603a M xeMoparMA; KaTo noewweHa npo4yKqMR Ha ceKpem M AMcnHefi, MaKap B6enw up06 - $ O K ~ HnHeBMOHMR, ~ nynMOHXlHaKOHreM nOne3HM, He C ac ~ ~ ~ ~ H $ M BbnpeKM ~ H M . 'ie YAbnXeHMRT CTMRM nneapanHaeKcyaaTMBHapeaKqMR;~e~posa~~~-eKcnMpMyhn M o ~ c n a 6 e ~ AMwaHe o ~ o npM aycKymaqMn HM $apq~pa~e B 6 b 6 p e q ~ ~reptiMR e, ~ p oM 6 c n e 3 ~ a ~a a, B HaBewaT Ha X066, a xMnepaepMpaHMTe 6enoflpo6~~ repeaTa- ynqepaqw M xeMopaMrHM oniwqa. B noBerenoneTa Ha peHTreHorpaMara uoraT na ~ ~ T B ~ P A nR o~ To3TOOT npOyVBaHMRTa, OTHaCRqMCe A0 SMOF, CenCMCbTCe PeHMRTa H#, HRMa no-.lyBCTBMTenHkl TecTOBe OT 6eno~ponpweMa KaTo octioaeti n p e ~ ~ 3 $atcrop. ~ ~ ~ ~ a q ~ H M $ T ~~ H K U M O H ~ ~ TeCTOBe HM M KrA. H ~ M ~ I ~ R B Ha ~H

CbOTHOLUeHMeTO:$ O ~ C M ~ eKCnMPaTOPeH ~H 0 6 e 3a ~ 1 Sec (@c),), KbM $ O P C M ~ ~ H M R BMTXleH KanaqMTeT (OBK) e XapatcrepMcmKa. 6@Tca n o n e 3 He ~ ~caMo K~MHM~ SMOF H O ce x a p a n e p ~ 3 ~ p ca~ b a n a n e ~ ~ e , cneuM$ur~a 3a nocTasRtie Ha p n a r ~ o ~ ~ HO a~ M 3a a , oqeiilta HaTexecrra re~epan~3~ eAeM, p a ~r e ~ e p a n ~ 3 w p a s~ aa 30g~na~aq~~ Ha O ~ C T P ~ K ~ H R XT ~~n . e p ~ a n ~ e wRH r ~B ap ~e a3 y n ~ a Ha ~ M nocnepaaua 3ary6a Ha $ ~ H K ~ M MHa T~ HRKOM opraHM. X066 B ~ ~ H M ~K R B ~ n K p O e OEO, ~ ~ Aa n 4 H e non l/. KrA Tp~6eaua ce 0~6enexb1, r e ARDS M SMOF B~PORTHO e M3Knlo'iMTenHO ueHeH np# OCTpa OH. TMnMVHaTa HaXOMvaT epHaKsa e ~ ~ o n a ~ o r e ~J e l3w a. n ~ ~ nepoKcuAa~a~a AKa npu X066 ca: noaMweHo PaCO, M a ~ a r ~ ~ noewen~o ~MR~ , a6nto~a~a ce qB a repHMR up06 cneA cencuc, ce W e H O PaO,, B KOM~WHIL(MR C nOBMUJeH0 P(A-a)02. noBM~ a 6 n n pM aB ~ 6 e n np6. ~ ~ ~ ~ O M ~ Ha H M K M T C n O ~p O A H M R LueHMTe aneeono-ap~ep~ane~ rpwMeHT M PaCO,o~pa3~TpaHCnOpT M KMCnOpOAHaTa KOHCyMaqMR npM ~ O ~ H C M BaT VIQ HapyLUeHMRTa. C T O ~ H O C T Ha M KrA T ~ n03BOnflBaT ARDS ca cBbp3aHMMMO C 6 e n o ~ p o 6 HapyweHMR, ~~~e onpeAenmeTo Ha ~ a e ~ o c r rHa a "Toea 3 a 6 0 n ~ a a ~T. e ,e. a BMHaM Ce YCTaHOBRBaT M IlpOMeHM B nepM$ep#R~a. OCTpa, M3OCTpeHaXpOHMrHa M XpHM'iHa. O C T ~ PeCnU~ T ~ BCMVKO T O M AaBa O C H O B a H M e Aa Ce HanpaBM M3BOAbT, 'ie paTopHa a u ~ ~ o HM 3a sagbnxasa cnewHo Aa ~ ~ q 6 ~ p ARDS M SMOF npepcTaanRBaTeAMHM c b q c l r ~ f l p oKaTo ~, naq~e~~a,xpo~~r~a~ape~n~pa~op~a ARDS e nbpBOT0 OpraHHO yE!pex,4aHe. Te ca KnMHH'ieH 3Ba, r e M H ~ ~ ~ ~ He M e F CrleLUHa, I T ~ a M30CTpeHMTeCbCTOH3pa3 Ha MHOXeCTBO Bb3tlWMTenHM peaKqMM, B K O H T O R H M R Ce MHTepnpeTMpaTno cepMhH#Te KrA M3CneflBaHMR. a K T M B H M T e nPOPyKTM Ha KOMnneMeHTHaTaCMCTeMa, rpa~ y n o q m ~npomarnaHAMHMTe, ~e, KMcnopoAHMTe pwnKan M M nH3030MHMTe eH3MMM HrPaRT BWHa POnR.

CHMI'ITOM~MK~

Ha cacTaaHa clam Ha TepanMma, KaTo nocnepHMm Mua AonbnHmeneH e$e~-rsa ~ O ~ O ~ ~ R E I H Ha ~ T qeHTpanHaTa O Be ca no-xapamep~w 3a acTMaTa, OTKO~KOTO 3a X066.3a pMxaTenHaKooppuHaqMR, ~ a p ~ a $ p a m KoHTpaicrMan~~~ p~amosa~ Ha a~ P O H X H ~ K T ~ ~ OCHOBHO M M T ~ noMara pemnMTeT M M M a AMYPeTM'ieH M MHOTpOneHe$eKlM. KOPTMKO reHorpahnaTa. CTepOMAMTe BC! Oqe OcTaBaT CnOpHM, H 0 nOBeVeT0 aBT0~ ocTpa ~ e AH MoraT Aa ~ 0 6 0 noseaeHHe ~ ~ ~ H neveHme ~ 0 H cneluHo ~ O ~ H H ~ H O p# M npenopbqmT. n a q ~ e m c HMaT ~OBMW~HO'HUBO Ha ~ H T M ~ ~ M Y P ~ T X M O C P M ~O ~H H( N X ) , neqeHHe IlOHMXeH 6b6pere~ KPbBOTOK U AeCHOKaMepHa HepOCTaTb'iHOCT, BCMClKMBOAeulMFjO nOBMtueH0HMBO Ha eKCTpaBanpas~n~o M~ HaapeMeHHo o neretine Ha X066 ce aopa, KORTO ce Bnme OT AMypeonpepem OT pa36Mpa~e~0 Ha n a ~ o $ ~ 3 ~ o n o m rMe~ m e cKynapHaTa 6enoppo6~a TUqMTe. B H M M ~ T ~ ~ MOHMTOPHHT HMRT Ha CePyMHMR KMMW XaHM3MM, IlPMCIMHMnMRMXaTenHaTa HeAOCTaTbqHOCT, a Te q e KoHTponMpa eeeHTyanHaTae ~ 3 a q e p 6 a Ha q ~anltano~ Ca: HaMMeHM I l O T O ~ M HanaraqM , OrPaHMCleHMR Ha BbmY3aTa M PMTbMHMTe HaPYUleHMR. ~ M M T ~ ~ M C O B MnpenaT~ WHMR ~ O T O K B 6enM~e ~po6ose; HenpaaMnHopaanpepenepaTM ce o~aaa, r e HmaT oco6e~ e4eicr npn nereHMeToHa m e Ha BeHTnnauuRTa, npepn3s~~mqo ~ee$emne~a BeKOP nynMotiane M AecHoKaMepHaTa HepocTaTbrHocT.AKO HTMnaqMR; nOBMWeHO CbnpoTUBneHMe Ha FlMXaTenHMTe 3 ~ mTMqa, yaenMraeaqo p a 6 0 ~ a ~ Ha aRMtuaHe; B ~ ~ ~ Y U J ~He H e HanMqe neeoKaMepHa HepocTanrHocr, ~ e MeAMe ace w36flraa~. n o p q apTepManHaTa ~ "~penn~ npepaqpatie, r"~ n p e ~ w 3 ~ ~ ~ ~ a q o n e c ~ a y KauetiTM ~ o p a ~ p ~ 6 Aa XunoKceMMR M pecnlrlpaTopHaTa aq~posa naqMeHTme c Ha AMxaTenHaTa uyclcynawa. KT ~~ HexenaHwTe M ~HM e$em~ Ha X066 ca n o - ~ ~ B ~ T B M I ~ P M 38 ~M OcTpa HM AeKoMneHcauMR npM X066. ,TM3 ~ nwr~ara" e~3auep6au npM ~ ~X066 B ~ ~ H M ~ Ka Bh ~- r e c ~ o ~ e npenapaw. naqMeHnT c nocnegeaqo seiiTMnaTopHo no4nmaraHe. Tom pelueHe T P R ~ Aa B ~ce ~ 3 e ~ ~b eWHOM 3 Ha nocroRHHanpeueHKaHaCbCTORHMeTOMY:

Bb3paCT, ~ O ~ H H O $ MB ~KPbBTa M F I TM~ XpaClKMTe H HWIHCIMeTOHaMHCnMpaTOpHWMeKCnMpaTOpHMCBMpKaqMXpMn0-

ACTM~T~ e 3a60n~sa~e, xapaicrep~3~paqoce c noscl1. h a nH a q p b x ~ a Ha CO ? WeHa 'iyacTBMTenHOCT Ha TpaXeFlTa M ~ P O H X M T KbM ~ pas2. C ~ O T H O U ~ ~ A HH U~ IP T~ O~ O flOKa3W ~ nH OCTPa, M3OCTpeHa XPOHMrHa M n M XwHHClHa PeCnMpaTOpHamKanoaa? 3. K ~ KeB cTenetiTa ~ Ha a q w p e ~ ~ m a ? 4. Moxe n M Aa nocTMrHe npueMnMao PaO, c HUCKM K O H ~ ~ H T ~ o,,~ 683 ~ M HenpMeMnmo M noe~ure~tre Ha PaCO,? 5. K ~ K M e TeHpeHqMma Ha npoMeHMTe Ha KTA? 6. M Mn M ~ n p ~ 3 ~ Ha aq yuopa ~ Ha RwxaTenHaTa ~ y c Bopeq~ emonomrHM $~KTOPM ca anepreHMTe. use KynaTypa ( ~ ~ ~ o K c E AMXaTenHM U ~ H M ABMX~HMFI)? rpym - e ~ m a n e p r e M~ eHAoanepreHm. ~ H~MH 7. M Mn M ~ npM3HaqUHaTeXKMHaPYWeHMRH ~ $ ~ H K ~ MOCHOBHM $~K~HO~ eK30anepreHM HMT~ Ca BOpeqM npM aTOIlM'iHMTe M T e Ha L(HC M CbpAerHO-CbnOBaTa CMCT~MM? $0pMM Ha ~ P O H X M ~ aCTMa, ~ H ~ T a~ MH$~K~MO mep~HMT n a q w e ~c ~ocTpa ~ ~ epecnMpaTopHa aq#po3a, HMCKO reHM MMaT sopeqo s ~ a ~ l n e p ~ ~ ~ ~ ~ e $ e ~ q ~ o s ~ o-an pH, HeZt,Q?KBaTHO P & , IlapaOKCaJlHM AMXaTenHM RBMwaTa $op~a. H a fW M ~ O K O p a 3 n p o c ~ p a ~ nuaT e~~e pacXeHMR, HapyllleHM$YHKL(MM Ha L(HC M CbPAeClHO-CbflOBaTMTenHMTe MepreHM, KaTO nORBaTa MM e C npepMMH0 Ta C M C T e M MC e H)9K#iflT OT BeHTMnaTOPHO n0pnOMaraHe. c e 3 o ~ xapaicrep. e~ qemo n p n ~~ $ e ~ q ~ 0 3 ~ o - a n e p m n a u # e ~c ~FleKoMneHcMpana ~~e X066 ~ p ~ 6 pa a anonyTa acma ce O T K ~ H aHTMHymeapHM, ~ T amMrnalcoMycKyraeaT AonbnHwTeneH KMcnopop. n o e ~ w a e a ~ e Ha ~B o~ M nHMMaHTMnapMeTanHMaHTMTena,KOeTOAaBaOCHOBaHMe UBaHOTO PaO, HaManRBaCbnpOTMBneHMeTOBAMXaTenHMB eTMonomma Ha acTMaTaAa ce ponycKaM eqoanepretiTe IlbTMqa (efl~aOT H ~ ~ - B ~ ) K H XaPaKTePMCTMKM MT~ Ha HO yvacTMe. X066) M YBenMClaBa anBeOIlapHOT0 PaO,, KaTO HaMWFlM 6 e n o ~ p o 6 ~apTepManHa a~a Ba30KOHCTPMK4MRM q e nono6 pp ~a 6 0 ~ a ~ Ha a pRcHaTa KaMepa. noeu~uaaa~e~o Ha PaO, q e ~ O R O 6b6pecl~n~ ~ ~ M KPbBOTOK, M03bVHaTa $YHBb3 OCHOBa Ha IlaTOreHeTMCleH npM3HaK Seadding K U M RM HaManM ~ H ~ ~ P O ~ Me~a60nM3b~ H M R M IIaicraTAenn acrnnaTa Ha: HaTa npoAylcqMR. 1. E K ~ o ~ (~TO~M.IH~) ~ H H ~ - PeaMHHM aHTMTena OT P-QP~H~~M'-!HHT~ arOHMCTM M Theophylline ca MrpynaTa Ha lgE.

WaHeTO O~UKHOB~HO e 3a6aae~o (10-14 I T b m B MMHYT~ b?3~#UlBaHeT0 e 3-4 n T H IlO-mnrO OT BAMLUBaHeTO. B AuxaTenHuR npoqec ce ~ ~ n l o c l Bcw' ea~ trm eKcnnpaTopHM MycKynu. T O ~ ~ K eC B nonoxeHne ~T Ha TpaeH nHcnnpup C XMflepCOHOpeH IleplcyrOpeH TOH, HnCbK CTOeX Ha # a l$ pamaTan PRBKO HaManeHaurn nuncBauapecnnpaTopHa IlOABMXHocT. A ~ C K ~ ~ ~ -T neK0 O~ OH T C O~ ~ ~ g0 ~ HH30O , cTpeHo se3n~ynap~o Anluatie, ymmeHo M ~ A M U I B ~ H M~ Ha6nloflaea~ ce Tpn $am Ha npoTnraHe Ha anepm'tHa C y # , CBMpKa~n, xbpKaulM M MbpKauM XPUHaTa peawm - nqwonom'ttia, naToxnMMrHa M ~ ~ T o $ M - nso6~nne n0BeAByCTpaHHO. Tea# CyxM, CBblpKaq#XpMnOBe (,cB#pesnonomrtia. E@emop~o~o 3ae~o Ha aneprnwaTa peat(aKo e ~ann~ M 3ac~ra6po~xnan~a~annra~nqa, R KpbaoHocHMTeC ~ A O - Heu)KopennpaT mcTenewa Ha 06c~pylaln~1, ~ Oe TO ~K .Jlnnca~a Ha .ceupe~e"y Be, 6poH~nCUlHaTa MyCKynaTypaMClly3HMTeMe3U. H ~ U - qe qeKaaTeti ~ b 3 ~ y w acTMaTnqn e 3acTpawmeneH n p n 3 ~ an ~h , KaTo npeflnoqe e cnacm'tHo catqaqaeatie Ha 6poHxManHaTa uyclcynara MLlHHMMeH Bb3FlyureHnOTOK, MMHaBau npe3 AMXana-rypa, xMnepceKpeqnn Ha cny3, ~a6b6ea~e Ha ~ P O H X M TenHmemTnqa,aTosaenpenaecTHnKHapecnwpaTopanHaTa nnramqa, pa3wnp~ea~e H noBMwetia npoHMuaeHMR apecT. Han~'tue~0 Ha nHcnnpaTopHo .cawpe~e"npeMoCT Ha KPbBOHOCHMTe CbflOBe. AnOnara MYK03eH OTOK Ha npOKCMMMHMTe AMXaTenHM Cbqemyea H HacneAcTBeHonpe~pa3nonxe~we K ~ M IlbTHuaU ~ 6po~xOCfla3b~, H KOMTO H I C B O pep ~ YBpemaT ~ ~ ~ H X MaCTMa. M H ~ MHCflMPaTOPHMFlU eKCnMpaT0peH IlOTOqM. C Bb3AyWHOTO saxeaqatie ( ~ p e n n ~una$pamme r) cTaeaT no-nnom. TOM B O I M 10 MeXaHH'tHMHaPylleHMR M CHMMeHaCMna Ha ffi#Hn'tHaTaKapTMHaHa 6A e MHOrO pa3~006pa3Ha M flkla$paIX4eHWe KOHTpaKqHM. BWIH)'~B~H~TO Ha flOflbnHUsaencw OT W p ~ a n ~ c~a,qw~ a Ha hnecrra, Kamo M OT rexlta 0 6 ~ ~ HMM.IMeT0 Ha YCn0)KHeHHRH llp#~p)OKa~~LI3a60nRBa- TenHaTa AnxaTentia MycKynaqpa 03~a'taea PyKqHR (@EO, non 1). npln TeMM aCTMaTMClHM IlpMCTbflbl HHR. B e1Hn cny'tan TR npoTura c T M ~ M V H Mn p ~ c n n n Ha 60n~nm Iopn He Moxe Aa roeopn M e C npoMeHn B eKCflMpaTOpeH3~nflepMOfl#Ha~nHawlllHMrHapeCb3HaHHeTOMC4eHTpanHaqHaHO3a. uncm, B ~ p y m - c nocTonwia, nepnopwio ycnneaqa ce l l p e p a 3 ~ ~ r a Ha ~e 6enwe ~ o ~po6oae U roneMnTeaMnpncnnHaAncnHeR, B TpeTn - npe&na,qaea n p ~ c n Ha n flnMTyAMHaMHTpaTOpaKanHOTOHanRraHeBOAFlTfl0aKqeKawnnqa. V p a H nyncyc amepHaHc. T03n $ ~ H O M'term ~ H ce H a q a n ~a a m a . Toea ca 60nHn c anepm'tHu M ~ 3 0 o ~ ~ p rnpn r~a n3~epea~ Ha eAH: no apeMe Ha nHcnMplnp MOTOPHU pu~mlrl Nnnn peqnAnsnpaquM H $ ~ K ~ Ha M ropW nqa. B HopMa TOM cna,qaHe e H e HWe AMXaTeIlHM nbTkIU@kl ~ ~ H x o - ~ ~ ~ CllC M Teo H ~cucTonHoTo ~ H ~ THanRraHe ~ noeere OT 10 mm Hg. CTO~HOCTH H;W15 mm Hg n p ~ Ma, np#~p)OKeH# C eKBHBalleHTn Ha 6po~xocna3bu, H0 aCTMaTklL(#CA CBbp3aHn C @EO, nOA0.9 1. @ C ? H O M ~ H ~ T 6e3 O@pMeH# npnmnn OT 3 4 p . ,nyncyc a m e p ~ a ~ c tie " e cneqn$n'te~ n Moxe Aa ce ACTM~THWH ~POHXHT. TO= e paHHa $ o p ~ a Ha 6A, cpeqa n npn nepnKapAHa TaMnotiwa, TexKa X066, K O ~ ce O npownea c npncnntia, HenpoAymnBtiaKawnMKap~llOMMOnaTHM UO C T p M XeMOpa~W. qa, npenwMHo HoqHa, B HRKOM cnyvan npuflpywetia OT npn acTMaTn'teH npnmn capAertiaTa ~ e h ~ o e cr neKa eKcnnpaTopHaAncnHeR n 3aabputeaqac oTpenmeYCKOpeHa, B T O P M R T flynMOHaneHTOH -aKqeHTyMpaH, AH TOHaeAHHMClHlrlCTbwlOBHAH#XPaqKM. neKo 40 pepeHo noanwetio. ACTM~TM~ npncnn. ~H Hah-~nnn't~a~a npoma Ha A C T M ~ T U ~ HCbCTORHHe. O Tom e TeXbK, Mb'tWeneH ~ ~ o aCTMa. HxM~I~H~T~ H npoflbnxmeneH npnmn OT w y x , ~ o h He o ce noennnpnmna~ Hacnnaa ~ah-'teuo npuaopn, HO Moxe m a OT npnnaraHoTo a,qemamo HecTeponAHo 6po~xoAa ce ~ O R B M H no BCRKO BpeMe Ha RetioHoqneTo,~ O H R K O A~~~~CTP~KTU Jle'teHHe. BHO ~ P M C T Tpae ~ ~ ~ OT TH R K O n K O ra MoxeAace npepoma OT p a ~ n n ' t ~ npomn: n cap6exn (4-6) 'tarn F(0HRKOnKOAeHOHOU(#R. Xapa~~ep~3Mpa C eC BH O C a M HOCOllTbTKaTa,3all)W.lBaHe Ha HoCa MD# PMHOpeR, TeXKa AMCflHeR, qMaHO3a H TaXMKapflMR, 0 6 ~ 1 M3nOTR~0 npnmnHo wxaHe, rnae&onne, neKa Kawnnua, ryec~ao BaHe, Hanpefleaqa p o p a M naToqeHne. B HaranoTo Ha BaTpetutio HanpexeHne n RP. ~ O ~ H M R ce T onnaKsa OT aycKymaqMRTa n o ~ a 3 ~ n306nnne a OT cyxn csnplcaqn M onpecnR B mpflme U nnnca Ha m3pyx. Toh e HanpemaT, XbpKaqM XpMflOBe, KOMTO flOCTeneHH0 HaMallFlBaT H C e HecnoKoeH, cRna B nernoTo, maea n o ~ e a nposopeqa, p~ a crura AO T. H. .TMX 6 m npn n o - ~ e m npnmnn n - 3aeMa npnHyAuTentio nonoxeHannqe e cueceH BemMnaTopeti~ e $ e ~Cbccna,qaHe .r Ha BEA no^ 80 Vmin ( ~ o p noA n HneceAHann HaeeAeti HanpeAconpeHMnamutiaoKon60 Vmin), Tema xnnoKcnR c xnnepKanHnR M pecnnpaTopHme npeAuem nnn onpetin Ha KoneHeTe. n ~ q e MY ~ oe ce 6ne~0, HanpemaTo, a npn no-~ema AncnHeR - ~ M ~ H O T M - Ha aqnpoaa, xmno- nnn mnepaoneMnR. Ha6nloflaea~ pe~nqanpo~~no~c~pa~a~a~ep~~a~a '~HO M ~OKPHTO cbc cTyAeHa no^. Hannqe ca Aonoennnn OT p a 3 c ~ o ~ cyxn, ~ n e canplcaqn n xbpKaqn xpwnoee, a AMrnaeo6onne, Hanpexetine m 6e3~bHne, TpeMop, a c Ha-

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I~ar~oc~~wa
Xapamep~merepTn Ha acTMaTa M noBHueHaTa ryacTBMTenH0CT Ha flMXaTenHMTe l l b T M l l @ M TRXHaTa AM$y3~a, 06pa~w~ 06CTpyq1~. a Cnun~oume, cebp3a~ c~ acTMaTa, KaTo Kalunuua, 3a~yx, rpbAHa onpecm U n p ~ 3 HaqMTe, KaTo ceMpKaqn, c y x ~ xpwnoee M ymnxeti eltcnnpnyu, He ca c n e q ~ $ w M He ~~ nouaraT 3a pnanioaa~a Ha nomexauaTa naTonomfl. E o 3 ~ ~ @ ~ n nuoxe m a fla e HanMue npM ocTpaTa O~CTPYKUMFI, HO e wwnKaTop 3a sa,~pnxw~ene~ anepmreti npoqec. pnamo3a~a Ha acTMaTa uoxe fla ce n m a e v npM ~acnep~a Ha ~6Q1T e no epMH lnnu flea OT cneRHme mmC~OBM 3a acTMaTa eneMeHTa: ~ ~ $ y 3 o ~6a p, am~a o6c~pyKUMR Ha pMxaTenHme WTnqa, n noeMueHa vyecTBmenHOCT Ha AHXaTenHMTe llbTMu(a. O q e ~ Ha ~a Texema HaaTaKaTa n nomwRaaHeToA OT nereHMeTo. C o h s e ~ a npeqeHKa ~a Ha naueHTa U oqeHKaTaHaneKapR3aWIMHHClHOTOCbCTOFlHHecaHe~OcTaTbrHO Cl YBCTBMTenHH npMocTpaaTaKa. BbB BCMClKM CnyClaM Te ~pfl6aa fla 6bfla~ nopKpeneHn OT n a 6 0 p a ~ o ~acnep~~ flBaHMR. TMnMClHMRT38 aCTMaTaKrA nOlca3BaHMCKM PaO,, PaCO, M IlOBMWeHOpH. 3a pa3llM~a 0 ~ x 0 6 PeTeHUMRTa 6 Ha CO, He e 3 ~ b n x m e n ~ Ma ce cpeqa npM MHoro TeXKHTe CbCTOflHHR. .Ce#pe~e"y naqneHM c finrorofluluHa amnnHe3a 3a

pHa HeAocTanrtim. P a 3 u ~ p e torynapHM ~ ~ ~ e sew M nepn$ep~me OTOUM He ca Ha,qex,qHu MapKepM B T ~ CnyCl ~ M aM. 3 a c ~ o b a cappewa ~a H e A m a n r H m Moxe pa ce pnarHoCTMllMPaVpe3 OTKPMBaHeTOHa N l W M , ~ ~ C T O ~ XpMnOHM EMnpu aycKynTaqMR Ha 6enme npoGose M yaenureHaTa cmKa Ha peHTreHorpaMaTa. 6enoflpo6~~m T ~ O M ~ O ~ M ~ PRfl OK~ O npep~3awM ~ ~ M K m . c B M ~ ~ HM, ~" aKO pPYM npM3HaUM He AOMMHMPaT, He snM3a B p w $ e p e ~ ~ u a n ~ p~amosa. a~a ACTM~ npep~sT~ BMKsa s ~ a c l l r ~ e n ~ en p$y3#0~ fle$em~ ~~ Ha 6enoppo6HMfl ~ ~ P ~ Y ~ M CKeHep O H ~ M 6e3 H T ~ O M ~ O ~ M ~ O 3Ha~ M ~ 'iMTenH0 ~ ~ T P Y A H R B MHTepnpeTaUMFl ~~~KM Ta My.

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Bx.: ~a6n. 6.6.

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Ho3ohozuwa eguHuqa X066 3acmofi~a cbpgerHa HegocmambrHocm 06cmpy~yufl Ha zopHurne guxarneAHu nbrnuqa EH~o~~oH~ X~ UC~~~ ~ \PH Y~ HL(UR Ompa6~~ Ce @OC 6ehogpo6e~ I?~~oM~o~M~OAU~~M A~a$u~a~cu~ Bguu8aHe Ha mOHCUrHU a & ! , flylU!H npus~aqu A~au~es sa arnlomloHonyueHe, mpyg~o n o 6 ~ u ~ B om a~e 6p0~~0g~hamam0p~ CbomBern~ama a ~ a ~ ~ Hapguouezru\ufl, em, sacmoir~u xpuno6e npu aycxyhmayufl Ha 6ehume gpo6oBe Cbom6emnarnaa ~ a ~ ~ e.c6upe~e" 3a, ce ry6a n o - u y u ~ o nag uunma U zoptiama racm Ha zpbgtiuR HOW AHaMHe3a, hOHru\U3UPaHO. ~ 6 ~ p e ~ e ~ . AttaMHe3a, ,,~6~peHe", bpo~xope~, nOHRHOza CUru\OpeR PR~H CpeqaH, O cbqecm8~6am ~UCKO~ @ U ~ K ~ O zpbgHa PU, 60hHa A ~ a ~ ~ sa es yxanoa~e, a npue~ ~a ne~apcm8a, ypmu~apu~ AHaMHe3a, He C e~ A U O Rm ~ 6po~xoguhamarnopu

~ A O @ O ~ H cnewnu U CbClllOnHUn

245

Ta6nnqa 6.7. Haii-qeno nanonasa~n rwilranneum npw ac-r~arnqennpncTbn

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MHO~O e 8 m o ga ce cnegu n ~ a 3 ~ e ~ oH rno U ~

Agpe~epaur~u cpegcmBa Gpinephrine 0,3 ml111000 pasmbp S. c. npes 20-30 rnin 0,5 ml pasmeop Tpeuop, cbpqe6ue~e, apurn~ufl, xuneprne~aufl

Aa ce u36~aBa npu no-Bb3pacm~u ca ~ a ~ ~ e s a 3a M6C Motqe~, HO He U cnequQure~ p-~u~ernu~

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Ko~~~uHOC~~~~OU~U Methylprednisolon Hydrocortison

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To m x e Mce paqqenn
HO.

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npe~bcea~e ~a e $ e p e ~ ~ u~nyncu ~u

MU~CT~HUR rpaBUC 6o~ynm3b~ M~~~UK~M~HTU Cu~flpo Eaton-Lambert ~ 06c~pylqu Ha ~ ropHme RuxaTenHu nbmqa (~HTpaTOpaKanHa) TpaxeanHU CTeHO3U Tpaxeo~anaquu TpaxeanHU TYMOpU B~HLU TpaXeNlHa H~ KOMnpeCUfl

KOK~C nHeBMotiMe,Xe~o@nyc ~ ~ $ n y en~ CTa@no~o~yc ~(e aypeyc. K o p ~ ~ ~ o c ~ e p o H~ Epinephrine ~ l l r r e m,cpnmenHo BnM3aT B TePaneaTMClHMR IlFOTOKOn Ha Te3M 3a60nRBaHMR. l l o ~ b p x a q neqeHme. o M e x a ~ n s Ha ~b eKcTpany~

nMoHanHaTaRMxaTenHa HeAoCTanrHoue anseonaptiaTa xunoeeHTunauMR, KORTO ce OBnaflBa C MexaHurHa BeHTMllauHR H MeKBaTHaXMMeHa Ha rOPHHTe AMXaTenHH rrb~wqa.

6eno~po6~ xa clnep~e~ MMaMe, 3 ~ ~ KoraTo CMcTonHoTO HannratieBapTepMR nynMoHanMc(PA) e ~4 35 mm Hg, RMacTonHoTo ~q 15 mm Hg, a cpeflHoTo HM 20 mm Hg.

Emononrn H K

~ ~ C H ~ H K ~ ~ H I ~

npou3xofi~ Ha 6 e n o ~ p o 6 ~ a x~ uan e p ~ e ~ Moxe 3~~ ~a6 b ~ e1. : HanbnH0nacmeti ( n o p a noenweHo ~ nocmynMoHanHo KanMnRptio HanRraHe; 2. Hanbn~oamMseH (nopaw awMBtioTo yacTue Ha KanMnRpHmTe M npeKanHnRpHMTecbloae B noBMwarmeHa cbnpoTMBneHweTocpeqy no~o~a 3. ); P~~KTM ( ~B o~ ra H6enoapo6~a~a ~o cb~oea ~ p e x a p e a ~ p a ~ a x p o ~ ~ r ~ a ~ a n a c ~ ~ ~ a ~ oPetrrre~orpa~a~a ~ r e c ~ ~ ~ ~ le pnonea~a e3 npM nocTaaRHe Ha AMapa3BMTMeTO Ha aKTMBHa 6enoflpo6~a XMnepTeH3HR, HaCmoaa~ancexapa~~ep~3~pacbca~ar~~en~o noxetia sbpxy n a c ~ s ~ a ~ Tesu a ) . TPM C~CTORHMR MoraTAa Hwe Ha ~ C H O T O cbpue, rnastio 3a cMeTKa Ha apTepw 6 b ~p a a~3 n ~ r rpes e ~ ~~ s ~ e p e Ha a~ rpqMema e Memy nynMoHanMc, MHTepcTMuuaneti M n M aneeonapeH 6eno~PA ~pahH0 RMaCTOnHO HaJlflraHe M 6enoflpo6~o~o KnMHOp o 6 e ~eAeM. T e s ~ np~3~a ce y~a6no~aea KoraTo ~, BMAHO HanRraHe (PAED - PCWR). HallRraHMFlTa HaBMWaBaT 3HaVMTenHO HOpManHHTe - PA np#n a c u ~ ~ a x ~ n e psbnpew ~ e ~ w r~ e,PAED M PCWR ~a 45 mm Hg, PCWR HM 18 mm Hg. EKr e no-nOne3Ha npM OTKpHBaHe HXiMClMeTO Ha ca noauureHM, TpaweHnT Memy TRX m a e a HopManeti. C ~ ~ ~ ~PA H OCTaBa O T O B TpaHMuMTe M n M PRflKO HaBUWaBa Tema 6eno~po6~a X M ~ ~ ~ T ~ H cnelcTBMe ~ U R , OT nbpBMr35-40 mm Hg. npcl aimHBtiaTa x ~ n e p ~ noeMweHuTe e~3~~ HaTaKaBa, HaCneflCTBeHMCbPfleYHM 3a60nRBaHMR M MHTeHMRraHMR Ca CnepCTBMe OT Ba30KOHCTPMK4MFIW~MIU I aHapcmuHanHa $w6po3a ( O T K ~ O H R Ha B ~ocTa H ~ HWCHO, T O M M C H l a PeCTPMKuMR B 0 6 ~ 0 ~ HallpeVHO 0 CereHMe Ha AecHoKaueptia x ~ n e p ~ p o $ oTKonKoTo ~~), npu oTKpMBaHe 6enonpo6~o~o CbAOBO nern0. T a 3 ~ peCTpMK4MR MOXe Aa Ha 6enonpo6e~ e~60nM3b~ M X066. E X O - K ~ P ~ ~ M o 6bue B npeKanMnRpuTe M n M B KanMnRpMTe. r p a ~ e ~ ~ RTa b ~ O ~ M K H O B ~ H OnOTBbpH(4aBaAeCHOKaMepHOTO O ~ ~ M H O PAED - PCWR e a 6 ~ o p (paee~ ~ e ~ wnH HM 5 mm Hg), a npe~oeapaa~e. P a w o ~ s o ~ o na ~~ ar~ ~a orpa$ e~ BaxeH n PCWR e HopManeH. npu peaKTweHara x ~ n e p ~ ca e ~ 3 ~ MeToR ~ B OueHKaTa Ha Texecna Ha x ~ n e p ~ e ~ 36enou~~a
HanU~eeneMeHTMTeMHaaKTMBHaTaHnaCUBHaTaXHnep-

Hen, Kamo H OT AMcnHeR np# ycMnue. 3a p a 3 n ~ OT ~a TRX, naqMeHTwTeC amBHa x ~ n e p ~ e ~ ~3 a~ k~ re 1c , ce ~o onnaKBaT OT AMCnHefl npM YCMnMe (6e3 OpTOnHeR M HOqHa ~ w c n ~ ecnHKon ~ ) , npn ycMnMe H o6qa cna6o~~. Te3~ C M M n T O M M Ha 6 e n o ~ p o 6 ~ a XHnepTeH3HR ~a MOraT WCTO Ra 6bflaT 3amrneHH OT cMMmoMMTe Ha cbnbTcTeaqllrre ~ ~ ~ O ~ R B ~ XH ap MaR w.e p ~ 3a ~ 6enoflpo6~a~a mnepTeH-

TeH3MM. ~ P ~ F ~ H ~ PAED-PCWR HT~T e~~HOPM (paBeH ~ H lrnM ~ a , q 5 mm Hg), KaTo M smuHeHoTo HanRraHe e nOBMWeHO.

Ila~oreue3a
6enofipo6~0~0 ~pbB006pb~eHMe C e XapaKTepM3Mpa c ronm o 6 e ~ ~pbe,npoTMraqa npu HMCKO Hangratie. Han~qe e ~ a n cbnoeo ~ o cbnpoTMeneHue, HaManRBaqo oqe noeere npllr HaToaapaaHe. 6 e n o ~ p o 6 ~ w sew ~ e HRMaT KnanU, K R K O nOBMWaBaHeHaHXlRraHeTOBTRX npRK0 VBenH'laBa HallRraHeTO Ha 6 e n.o aDTeDMM. .. n ~ o 6 ~ .~ ~. e

Jn4epeuqnanua ~ ~ m o 3 a
Cnea nonyawte Ha c - r o b m e Ha PAED n PCWR n cnen onoeAenmie Ha rpqnetrra M e w TRX, no emone p~e~3mma ~ o x #a e ce ~ p ~a a nac#BHa, amBHa n p e a m w a (~a6n.

C~~rno~amwa
n a u ~ e ~ ~ lc l rnac~sna re mnep~e~3n~ I~HO ce OnnaKBaT OT opTonHeR n n a p o ~ c n 3 ~ a n HoqHa ~ a Awn-

nacue~a 6enoppo6~a xunep~e~3u~

neeo~a~ep ~~ ea poc~an.~~om 3a60nuea~ Ha ~MMTpMHaTa ~ Knana HacnepcTse~a c~e~o3 Ha a6 e n o p p o 6 ~ ~ BeHH ~e ~pup06u~ ~~ aC T P ~ K L ~ +ia I Rronehnlrre 6enoppo6~n BeHu K0p T P M a T p H y M 6enoppo6e~ e~60n~3b~ n b p s ~ r 6enoppo6~a ~a x~nep~e~3ufl Hapylue~u~ Ha B e H T M n a q M R T a Konare~o-capos~ 3a60nfl~aHHR tlop~an~ xa ~ n e p ~ e ~ 3 ~ ~

AKTuBH~ 6enoppo6~a xunep~e~3u~

Peamu~~ 6enoppo6~a a xnnep~e~3~~

HRKOU nawemu cbc 3a60nR~aHe ~a ~ ~ ~ p a ~nana n ~ a ~ a

6enoppo6~~ B e H O O K n y 3 M B H M3a60~fl~a~Hfl

AKTMBH~ 6enoflpo6~a T~ x n n e p ~ e ce ~3 p~ n~ x v rnaBHO Ha A B e IlPMVMHM: 6eno~po6e~ e~60nM3b M~ 6eno~po~ H ~M~ ~ O ~ R B ~ BOfleU&4 H M R A0 , B a 3 0 K O H C T p H K 4 M RHa 6eno~ ~ P ~ ~ H C b O R O TB O O nern0, aHaT0MMclHaTa My p e C T P H K i + l R M n M ~0~6MHal(Hfl Ha ABeTe. H ~ ~ - M o M~K J H l M H MClH ~ O 3Ha~HMM30KOHCTPMKIMBeHCTMMYneanBeOnapHaTaXMrlOKCMR. ~ e a m ~ ~ a ~ a 6 e n o ~ p o 6 ~ aB ~ n~ e pH ~np# eM ~ naqMeHTM C b C 3a60nfl~aHMR H a MMTpanHaTa KJlana, OCO6 e ~ npM o MMTpanHa CTeHO3a. s~ u~

Tom e CMHOHMM Ha c b p ~ ( e v ~ 3o a 6 0 n ~ m ~n ep , e~~3B M K a H o OT nomexaqa 6enoapo6~a naTonomR. B b n p e ~ ~ r e AecHoKaMepHaTaHeAocTaTbwtmT no-remoe cneAcTBue Ha nRaoKaMepHaTa, a m o e Aa ce UManiocTmqMpa Kora TR e cnepmene Ha 6enoppo6~a naTonomfl, aaqo~o:
KOP nynuoHane ce O T K ~ B M6 ~ 40% OT ay-roncMMTe; B noeevero cnyqan cbqecTsyaa c n e q ~ @ wM ~ycnelutia a TepanMfi W npomo3aTa Ha KOP nynMoHane e no-~o6pa OT ~a3n H a neeoKaMepHaTa HeAocTanvHocT.

H o ~ M ~ ~ H /$3CHOKaMepeH MRT CbpflereH ~e6m Ce Onpenenn o~cbqme MKTO~M, Kamo M Ha nRBaTa KaMepa: KoHTpaKTnnwreT;npenHaTompmHe;cnenHaToeapmHeM
CbpflerHa 'teCTOTa. ~ O W M HMKOra C a M O e A M H OT Te3U @aKTop# H ee B C b C T O R H M eAa AOBeAe 40 HenOCTaTbqHOCT.

ETHO~O~HR
Bx.: ~a6n.6.10. BCM~KM T e 3 M 3a60nflBaHMR B O m 10 MCHOKaMepHa HeAOCTaTbrHOCT no e A M H M Cbq MeXaHM3bM - v 3 npoBOKMpaHe H a 6eno~po6~a xnnep~e~3n~.

K~~MHM'~HMT~ IlPOFlBM Ha KOP IlynMOHane, K a K T OT e 3 M Ha 6enoflpo6~a~a X M ~ ~ ~ T ~ H cnaaT ~ M RK , ~ M A B e KaTeropm: TaKMm pe3yma.r OT mpenr~n 6 e n o ~ p o Hapyure6~~ H H R M TaKMm, pe3ymaT OT /$3CHOKaMepHa~~HC@YHK~MFI KOM~~HCU~~ KOp HO IlyIlMOHaJle TO Ce H3RBRBa K J l M H M i 'H O C a M OCT a X M K a p A M R M KapAMOMeranMR (flHnaTaqHfl M / M ~ M x~nep~po&w).

A~aruocm~a
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l l e r e ~ n e Ha ~ oKoMneHcMpatioToKOP nynMoHane,npM

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6enoplpo6~a TPOM~O~M~O B~ ~M ~F H~M n KB p .~O ~T K ~ ~ T B~H~TO Ha ' mn6o~ se~o3e TP ~O M ~M TpbreaHeTo MY no 6enoppo6~a~a UwpKynauMR, KbAeTo T O ~ M TPOM~ 3acnua C a lC T M C H l O MllM HanbnHO 6 n o w p a h ~ KpbBOTOKa ~ KbM HRKOM OT aPTePMMTe Ha 6 e n o ~ p o 6 ~ o aPTePMWHO ~o AbPBO.

me. T m n ~ e m a e TonKoBa xapaK-repHa, r e ~ e k a nwncanpasnUnamoaaTa~ a n eepoma. ~ o ~O-PF~~ cpe~KO q a ca~ X ~ M~ O~TM~M ~C a, n o ~ ~ aCMHKO~ a ~ e ,M 6eno~po6e KOMnOHeHT Ha B T O P M R CbpAeVeH TOH. ApTepManHM K P ~ B H M ra3088. HMCKOTO PaO,, npMppyXaBaUa Q ~ C ~ M Q ~ T MKan03a O ~ ~ H ~ e TMllMrlHaTa KaQTMHa

PaHHMTe ~ ~ ~ B ~ M H M M ~ J ~ M MHB ~W MT 'T M~ ~ TaTeneKTaM; M VbAHaTa 6onm Ca W T a Hah-reCTM 3M M n M p e n a ~ c ~ ~wa$pamnane~ pa~ Kynon ce cpeqaT npM CMM~TOMM,c e a p 3 a ~ c~ 6eno~po6~a ~po~6Oe~Gonnn. ~a Kalunnua~a M c-rDaxbT nDncbcTBaT B oKono 50% OT cnwa15-25% OT cnwawre.

AHC~H~RT~

B noeereTo cnpav 6enoflpo6~a~poM60eM60nMR B b 3 H M K B a Cnefl A ~ ~ ~ O B e K H 0 3 M H MT P O M 6 0 3 M Ha flOnHMTe KP~~HMT ~M a .~ rae npeflpa3nonarau~~e $amop# =fleeTe C b C T O R H M R Ca e A H a K B M M BKJlDrBaT: $palcrypM Ha Ta3a; ronew XMP~PMVHMM H T ~ P B ~ H ~ (0~0612~0 MM roneMnop~oneaMrHH onepaqm M n H n p o c ~ a ~ e m oMMoKapaeH ~~~); MH$aplcr; XO66; 3 a c ~ o b a CbpAeclHa HeflOCTaTbrHOCT; nnanvrHetiM npouecn; o 6 e 3 ~ ~ aTpaeMM c; M npoAbnxwTenHO 3anexaaa~e. @ M ~ M K ~ npernea ~ H W ~H e noTBapyqamIocToeepHo HamlrweTo vnM He omBbpnR cac CMrypHocr nuaniosa~a pbn60Ka BeHO3Ha ~ ~ 0 ~ 6 0R~tlnep~BMTe 3a. M3CneflBaHMR Ca CbuO H e T O V H M . Hai-~~O~P MeTOn M R T e Bb3XOARu(aTa R M H a M M V H a B~HoQ~~$MR.

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no 1000 Uh,npoAbnxMTentia MH$Y~MR, KaTo uoaa~a ce KOPMMPa no napqMaJlHOT0 T ~ O M ~ O ~ ~ ~ C T M H BpeMe. OBO T~OM~OJ~MTH.IHO neqeHme. To ce ~snona~a 3a HauanRBaHecMbpTHocrranpH naqmemc M ~ C M B6enoapo6~a H~

T~OM~O~?M dllmM ~ OOrpaHMVaBaHe ~MR Ha R O C T O R H H a T a3ary6a Ha 6enoupo6~0 cereHMe Ha cbnoBaTa Mpem. MexaHwr~o B~HOBHOnpelcaceaHe. n o ~ a 3 a ~ ~ ~

Jwoepeuq~an~a ~uar~oaa
An$epe~q~an~ AHamo3a a~a ce npaenc OMM, 6enoapo6e~ OTOK, cbpnertia TaMnoHWa, AMceKwpaua atieapv3~H aa aopTaTa, ocnp nepHToHm, o m p naHKpeamT, xMnoeonennMreH UOK M RP.

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BbnpeKMWeKBaTHOTOaHMKOaryflaHTHOnereHMe; C T P O M

R o ~ a s a e, ~o r e HMcKMTe ~ 1 0 Heparin 3~ (5000 U Ha 812 h, s.c.) HaMaJlRBaT npOueHTa Ha flbIl60KaTa WH03Ha ~podo3a v 6enonpo6~a~a T~OM~O~M~O KoraTo ~ M R ,ce a a n o r ~ npe4onepaTMeHo. a~ n p o $ # n a ~ ~HMCKM ~r~o 003~ Heparin ce ~ a a ~ a r a e H a aMHoro ~ naqMeHTM, KOMTO ca C BMCOK PMCK, H 0 npM C b C T O R H M R KaTO MMOKapAeHMH$apKT, 3acToiHa CbpAerHa HeflOCTaTbqHOCT,MHCyllT M pp. Te3H 1 0 3 ca ~ ~ ( o ~ a a~ ae ~e o$ e m ~ e ~ n .

flpe~lc~aen~sa eb3gyx B nneepanHaTa Kyutia. HanPeniaTMRT nHeeMoTopaKc npepmaenma eb31y-x B nneePmHaTaK p M H a nOA POCTaTbClHOnOnO)I(MTenHOHaJlRraHe ( O ~ H K H O B ~ H10-25 O cm H 0),s a a a o r p a ~pa3mea~e~o ~r~ Ha npOTMB0nOnO)KHMR 6Rn ~ ~ M 0Hap)'WM 6 B e H 0 3 H O T O ~pbqa~e.

npo6~e H a noeapxHocTHa cy6nne~panHa Gyna, paanonoxeHa O~MKHOEI~HO sbpxoeo. 6ynMTe naToreHeTMrHo ca CBbp3aHH C n p O M e H M B~ P O H X M T npM ~ , KOMTO Ce 06pasysa KnanaHeH M ~ X ~ H M B Awrantiwre ~ ~ M oTAenM Ha AwxaTenHHTe nbTMwa.

Emonorun

BTOPM~HMRT C n O H T a H e H nHeBMOTOpaKC Ce pa3BMBa npw HanMrMe Ha K ~ M H H ~ H ~Oa ~ u $ e c m p a 3~ a6 o0 n ~ e a ~ e ~a n o f l e x a ~ u ~y ea c ~ b q n ~a 6 e n ~ ~p~ o6.

noRewnM ce r p b ~ 6on~a ~ a M AMcnHeR. O M ~ M K ~ ~ npeHHR rneA ~aR-06tqoOTKpMBa: O T C ~ ~ ~AMUaHe; ~ H O CHHXeH

$ ~ ~ M M TM ~ nOBMUeH c pe30HaHC.

Hail-~~CT nbpBOHaVanHM MT~ C M M n T O M MC a BHe3anHO

HanpeniaT nHeewoTopaKc, npernepT oTKpMBa: TaXMnHeR, T a X M K a P A M R , H3MeCTBaHe Ha CbPAerHMTe TOHoee B npoTMaononomaTa crpatia, p a 3 ~ u ~ p ~ e Ha a~ UM~H B M e H M T M~ X H n O T e H 3 M R .P ~ H T ~ ~ H O ~ ~ M3CJle~@K IeaHe pam H ~ ~ - T O Y H ~ a 38 rone~k la

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Ha puxaTenHuTe nbTuqa 6yn03H~ ~ ~ ~ O J ~ R B ~ H M R X066 ACTM~ n~ee~a~ouene K U C T O$u6po3a ~H~ klp~ona~uq 6enoppo6~a ~a $u6po3a E O ~ M H O $rpaHyn0M U~~H Cap~ouposa AHaep06Ha IlHeBMOHUR CT~$U~OKO IlH K eBMOHUR OB~ r p a ~ - ~ e r a nHeeMoHuR ~u~~a AKT~~~HOMUKO~M Tfleprqnosa M~~o6a~~epuosa C~~KOM
~ ~ O H X O ~ KapuUHOM ~ H ~ H

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Tbna rpbma ~ p a a ~ a npo~u~sau(a rpbpHa TpasMa Fl~poreHHa TpaBMa 6apo~pae~a EsMarean~u pyn~ypu n~ee~onepu~o~ey~ C@~~HMCIHU a6cuecu Marfani syndrornurn

LIPF

MOTOpaKC, IlUnCa Ha RBHO H3TMClaHe Ha Bb3AYX ( ~ KHRMa O npobwna B peHTreHorpaMaTa 3a 24-48 h). A~~HM~ Ha ~IlneBpanHaTa H ~ T o KYXMHa e H ~ ~ ~ Y ~ uanonsea~um MeToA, qpe3 KOWTO ce nocTura WetmaTtio pa3bBaHe ~ a 6 e n~ u ~ 0~ 6 0 p, M npM aKTMBH0 H3TMWHeHa
Bb3flF.

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Cnew~o 6 0 n ~ n newwe ~o
dse ca rnaaHnTe qenn Ha neveHneTo: p a a m ~ a ~ Ha e 6enw ~ p o 6npeAoTspaTRsaHe ; Ha noaTopeH Konanc. kl3non3M~ Ce MeTOF(UTe: Ha6nlOfleH~e;IIYHKL(MR C nrna; nomaame Ha ApeH B nneepanHaTa KyxuHa; XMMMW H IlneBpOfle3UC; OTKpUTa TOpaKOTOMMR. ~POCTOTO Ha611~)fleH~e ce npunara npn ~ a n nHeeb ~

nnespope3uc. H~A-~~,~MK~ MeTOp ~HM 3a RCnMpaHe T Ha M3TU'iaHeTO Ha BbWyX e OTKPMTa TOpaKOTOMMR. P ~ M O HHa ~T M3THWHe ~ o x ~a e 6 b ~p ee 3 ~ ~ p 1 p Mnn a ~cyrypMpaH, nneepanHuTe nosbpxHocTu AHpemHo p a q p a 3 ~ aa e~ no ~ c ~ u r a Ha ~e nneepo~e3uc.

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252 m 6e~ogpo6nu cnewwu cacrnonnun

TO~I Moxe na aacuyre 6enonpo6~a nKaH M na Bb3HMKHe HH$~PKT. nneapan~a pealcqmn. HepRpK0 B ~ ~ H M K M B~ nneeT pan^^ peaKw Ha MRCTOTO Ha npem Toes nocTaeeH RPeH. E ~ n n e uf.l o c r a e ~ ~ e Ha ~ rpbneH o npeH Moxe na ce
~ M R TO ,

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6enogpo6nu cnewnu cbcmonnun W 253

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254

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5.3. Acnupaqno~~w npohneHv. 3. Y r o n e ~ mnycHM e ~ ~ ceHKn. 5.4. K O H T ~ ~ M M3MeHeHMR O ~ ~ H M Ha 6 e n n ~ p o 6 . 3.1.6enoflpo6~ax#nepaoneMuFI. 6. f l n b ~ ~ sa oc e ~ r e a ~ Ha e qRnaTa rpbpHa nonoema. 3.2. Bb3IlanMTe~~M M3MeHeHMFI. 6.1. ATepe~~a3a. 4. ~ ~ P O M ~BH 6M e n o f l p o 6 ~PMCWK. ~~1 6.2. Mac~een ~3nne. 4.1. f i e p e ~ p0 nunceaq - asac~ynapu3aqwfl M n M xunoeac~ynap~3a Ha q~ 3oHa ~ OT 6 e n n ~ gpo6, nneaMoTo7. Yrone~ena cpepuHHa c m a . paKc. 7.1. X w n e p ~ p o $ dunn ~ ~ RnnaTaquR Ha capueTo. 4.2. Ycnnen - xMnepmneMMR Ha cbfloao~opycno Ha 7.2. n e p ~ ~ a p ~ ~ M an ~~ eM nB . 6 e n ~upo6, ~ 1 cKnepo3a Ha 6 e n ~upo6, ~1 e ~ ~ n a n ~ r e n ~ ~ 7.3. M~~~MBCTMHMT. M3MeHeHHR, aHrEVKMPaqM MHTePCTMuMYMa. 7.4. A H ~ B ~Ha HaOpTaTa. ~ M ~ 5. ~ ~ ~ T H u C CeHKU. TM npvr TPYAHOCTH B a ~ a n ~ Ha 3 aR0-rpa$MFI e xenaTen5.1. Bb3nanM~enHM M~M~H~HMR. HO fla ce noTbpcM ~ m u $ ~ u ~ noMoq pa~a OT pen-rreHonor. 5.2. 6enonpo6e~ OTOK.

Ane~ca~flpoe, H., M. MM~~HOB, K~MHM M cneqManHa ~H~ TOKCUKO~OMFI, C., BO~HHO uwaTencTBo, 1992 Knpfl~oe,3. k l 3 8 b ~ 6 b 6 p e r MeTOfl ~ ~ H Ha O'iMCTBaHe Ha KpbBTa. C., Meflu~(M~a M $M3Kyll~ypa, 1984 Mywe~oa, B. ~ H $ ~ K ~KaTO MM nPMCl TH ~HM M YCnOXHeHMR Ha OCTpaTa 6b6per~a HeflOCTaTbCIHOCT. Ka~fl.AMC., CO$MFI, 1992 Henoa, A. K ~ M H H ~ npMnoxeHMe HO Ha nnaa~o@epe3a~a. Mefl~qHa M $M3KYn~ypa, 1987 n a ~ eE. ~O , C T ~ ~ ~ ~ ~ ~ ~ ~ H ~ H C., ~~ MeuMqHa ~OCT~ M $~aKyn~ypa, 1981 Atkins, R.G., N. Thomas, P. Parrell. Peritonea1 dialysis, Churchil Livingstone, Edinburgh, London, Melboum, New York, 1981, p. 400 Baue, A. Multiple organ failure, Livingston, N. Y. 1991 Brenner, M.D., J.M. Lazarous. Acute renal failure (Second edition), Churchill Livingstone, New York, Edinbourgh, London, Melboum, 1988 Cotton, C., E. Lowrie. Haemodialysis: physical principles and technical considerations: In: The kidney. Ed. by B. Brener, F. Rector, eds. Philadelphia: WB Saunders, 1981, p. 2425-2489 Dieberich, D.A. Acute renal failure. In: Current therapy in emergency medicine, Ed. by M.L. Callaham, B.C. Decker, JNC, Toronto, Philadelphia, 1987, p. 510-513 Fry D., Multiple system organ failure, Mosby Year Book,

Phyladelphia, l992 Garella, S., J. Lorch. Use of dialysis and haernoperfusion in drug overdose -an overview. In: Clinical use of drugs in patients with kidney and liver disease. Ed. by R. Anderson, R. Schrier. Philadelphia, Saunders, 1981, p. 296-309 Hoenich, N., D. Kerr. Dialysers. In: Replacement of renal function by dialysis, 2nd edition. Ed. by W. Drukker, F. Parsons, J. Maher, Den Haag: Nijhoff, 1983, p. 106-141 TLysaght, ~CIH OC T .Gurland. Plasma separation and plasM.J., H.J. ma fractionation. Karger, Munich, 1983 Nielsen, L., K. Nolph. Dialysis emergencies. In: Current therapy in emergency medicine. Ed. by M.L. Calaham, B.C. Decker, JNC, Toronto, Philadelphia, p. 531-535 Rippe, J, Intensive Care Medicine, Little Brown and Co., London, 1985 Rose B.D., R.M. Black. Manual of clinical problems in nephrology.Little, Brownand Company, Bostofloronto, 1990 Schelling J.R., L.L. Stuart. Hepatorenal syndrome. Seminars in nephrology, vol. 10, No. 6, 1990 Seyffart, G. Poison index. Dialysis and hemoperfusion in poisonings. FreseniousFoundation,Bad Homburg, 1977 Wendin, J., M. Smithies, M., Sheppard et al. Continuous high volume venous-venous haernofiltration in acute renal failure. Intensive Care Med., 1989, p. 358-363

PA3AEJ VII

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B w m e 06H npnrnm. Hal-WXHaTaqen e Tepannma e rHa OSH n pa BnouraT cacToRHneToclpea noeMwaeaHeHa HaTpMeBMR H B O R H H R R~$HL(MT. IlMKBllflLIpaHeHa 6b6pecl~a~a xMnoflep($y3nfInnn 06cTpyKqnH Ha nuKorHme mmqa, npeycTaHoeRaaHe ynoTpenpu pexnppaTupaHn h n ~ ce u npoeewa M H ~ ~ ~ M 6 a ~ Ha a H ~ $ ~ ~ T O K CMeAnKaMeHTM HCIHH 3a flpeflOTBpaTRHO~e'ieHMenOflKOHTPOnHaXeMOflMHaMHClHWTe nOKa3aBaHe neHaTanurHme 6b6per~M yBPe)KAaHHR. Heo6xoTenM - apTepManH0 W qeHTpMH0 BeHO3HO HWIRraHe, cbppewa recToTa. npnnara~ ce $ns~onomcle~ pas-reop p M M H ca A a H H M 351flMHaM#KaTaB C T O ~ H O C Ha T ~CepyM~ HMreypeR, KpeamtiuH nenelcrponmw;npneMaw 3ary6MTe c 5% Human Albumin, Ringer, n o - p ~ p ~ rn ol o ~ o 3 ~ pa3~n Ha TerHocTu 3a peHoHoqne; npoMeHme B TenecHoTo eopn n Haemodex. npn xeMopamn ce npaem xennoTpaHTerm n TeMnepaTypa; oqeHKa Ha capperHlrR, Ha Genoac$~~M AKO M .~ O ~ H H R ocTaHe T B OnnrypMR cnep nocTnraHe PO~HMRH Ha MKWIHO-KMCenHHeH CTaTyC Ha Ila~MeHTa. Ha xenaHm o 6 e ~ H ~op~annanpa no~a3a~enme, ~e ce np# CbMHeHMe 3a flpepeHanHa a30TeMMR (noBpbu(aHe, flp~nara ~PMMKOBU ~ p~ypeT#~ll. BtUllorBa~eT0 Ha T p a i ~ a pnapnn, $e6pnnme~-npepuremeaqn aHypnclHMR nepnMH$Y~MR C Dopamin (3-5 pgkglmin) uenn n o p o 6 p ~ ~ a op) ce npMcnneaK ~ o M 6 e ~ aa~emea~e. ~o Xena~en~ eo Ha 6b6perHaTa neMy3n~ M r n o ~ e p y n $nn~paum ~a KaTo pexnppaTaqwmapa ce npoeewa nop Kompon Ha AH n pa3w~pusa a$epetrr~me apTepuonw. UBH, capperHaTa recToTa M racoeaTa Anypea. AKO PM 6 o n ~ B nHOPMO-HnMXMnepXMflPaTauMclFI flMYPe3aonnrypnmanepcMmpa npu HOPMO- nnn xmnepxMppaTaTa ce cTnMynnpa c Furosemid OT 40 po 320 mg B 50 rnl qnR, ce npMnaraT ~ ~ H M K O BypeT#qn M (Furanthril). npn ~ ~ 3 ~ 0 l l O pa3TBOP. ~ ) ~ ' i eM ~ H $ ~ ~ MC R eT IlpaBM ~ i. V. B npoIlaJltlaTOpHHH flePKYTOPHM nWH# 3a yTOneMeH IlMKO'ieH pbnxeHne Ha 20-30 min. AKO He ce ~ O R B H y p ~ po ~ 1-2 a h, Mexyp ce nocTaaR ype-rpaneti KaTenp, n3cnepea~ ce Haf B ~ ~ ~ R T eH Bb3HHKHma O OpWMclHa 06H M ~LlYpeTHnpocTaTHaTameaa m WHeKcme. Yrone~e~w 6b6peu~ U qme ca w3nnur~n. npopnxaea~e Ha MH$~BMOHHOTO nexnppo~e$po3a npn peHanHa exorpa$n~ ca n o ~ a 3 a ~ e n ~ Cl ~eHHe HRMa fla Bb3CTaHOBM HOpManHaTa rnOMepynHa 3a MexaHurHa aHypMR, n p ~ ~o m o IIH$~BMOHHOTO nere$nn~paqn~, ni KaTo HapacTBa PORT ne@y3npa~~, HO He $wn~pnpaqnrnonnepynn. CbqemayBa onacHocT OT Hue Kpue 0nacHw-r OT xnnepxnppaTauuK npn nnnca Ha e$em OT npnnoxetioTo nereHne, BnoxnnepxMppaTaquR. uraeatie Ha CaCToRHMeTo M 3a@n60cla~a~e Ha 06H, cnep P e ~ a n 06H. ~ a Pa3~006pa3~me eTnonomrHn 4 a ~ KoHcynTaunR C ~e$ponor, ~ ~ H M Fce I Tnpeaewa B nereTOPM onpepenm H pa3nnr~n necle6~ MeTopn. ~ n p Hacla~ ~ H 3aeepe~necpnann3e~ O qemp. BCRKO 3a6a~fi~e KpMe nHn npomn Ha 06H npnnarwme po TOW MoMeHT MepMPMCK OT p a 3 ~ m Ha e rrmmTo3aCTpawaBaqn~CTOFIHMR KaMeHTM C flOTeHq#anHa H ~ $ ~ T O K C M ~ TPFI~BI H O Cfla T ypeMMrHa KOMa, MO3b'ieH OTOK, 6enoppo6e~ OTOK, peK0cnpa-r. npn a6conlo~~n noKa3aHnn w nnnca Ha ppyr nopMneHcnpaHa ~ e r a h n n ~ aqnpo3a, ~a pnceneKTponMTex o ~ npenapaT u nereHneTo c Hero Moxe pa npopbnrrm, MMR, Bb3HHKBaHe Ha pa3~006pa3~~1 PUTbMHM M nPOBOflHM HO C ymnxeH Mmepm n HaManeHa ~ O ~ M P O B cnopep K~ HapyureHnR.C b ~ e c ~ ~ PMCK y B anpnTpaHcnopra M ~ p y p ~ o - 6 b 6 p e r ~ KnnpbHc. ~~ ~pnnoxe~ne Ha ~o Calcium m npm 3anoreaHe Ha pnanns~o~o nereHne. Ao noc~bn~ ~ u cflp o eAM I~ aMHHOrJl ~ cM u K03MPHH ~ ~HTW~HOM OKa3~M ~ a ~ e ~ p n a n n ~ e ~ q e ~ n p n p n n o ~ a 3 a ~ ~ ~ c e p sa a ~npo$nnamnre~ a ~ ~ n c n o - e$em mpxy TRxtiaTa H~$POTOKC pop, KanMesM atnaroHHcru (Calcium gluconicum, Serum HOCT, KaTo 6 n o ~ ~ p 3a n a e ~ ~ MM ~ nnecra e 3a Ty6yn~n~e Glucosae 5% C Insulin),npaBU C e KOpeKunR~a MeTa60flMKlleTKM. np# eK30reHHM MWOKcMKauMM C TeTpaXnOpMeTHaTa al#lflO3a. n p e p ~ OcbqeCTBRBaHe Ha CbpOB fl0CTbn TaH, eTMneHrnwKon, MeTaHonce npncnnea K ~ peToKcMM 3a xeuopmnn3a ca H ~ ~ ~ X O ~onpepenme M M M Ha K p m a KaqMR M Aeflypaut4fl C f l O f l O ~ ~ ~38bH6b6peclH~ M MBTOrpyna M KoarymrpaMa. flM 3a OrMCTMHe Ha KpbBTa. TOKCMVHM~ e$eKT Ha MMOrno6u~a ~apxyTy6yn~me Kne-rKMe c no-rona~o s~are~ 3a Bb3HMKBaHeTO Ha 06H, O T K O n K O T O T Y ~ Y ~ o6c~pyH ~ T ~ K~MR C numetnHn qwnnHflpn. 3 a ~ o npcl ~ al MMO- n xeuor~O~MH~M BM pa R~ ~ a ~ a Q a 3 npoeema ace n n a a ~& eM ~~ H (nnas~a$epesa). n o c ~ p e ~ a 06H. n ~ a npn xnnepxHppaTnpaHn 6onnn .Bopeti yflapue npomBonoKa3aH. npnnara~ ce cna3~onnT W U M , aHaJlreTMqM, p~3nHClIiH yPOnOM'iHn MeTOAH 3a OTCTpaHReatie Ha npnrntiaTa. Y r o n e ~ e ~ n nworeti fi~ Mexyp M ~ yeenMcl U eHaTa npoc-rama m e s a HanaraT nocTaentie Ha ypeTpaneH KaTenp. npn OGCTPYK~MRHa ype-rpa Mnn .. K ~ M opratinwa 06H. YpeTbp flOHRKOra C e HWara 4HCTOCTOMa M n H H~$PoCTOn#ypeTUl(HTe HRMaT MRCTO B HaWnOTO Ha OnMmMRMa. llpu HeycnomeHn cnyvan ea3cTatioematieTo nacaTa n He TpR6Ba ~a ce npnnaraT npepu o 6 e u ~ o ~ 3aMecTo x a Ha ypnHaTa, cnep npeMaxeaHe nnu 3 a o 6 n ~ a n ~ Ha ~e m e . Te MoraTpa npeabpHaTonwrypnrHaTaB HeonnrypnO ~ C T ~ ~ K ce L ~nocnepea T ~ , OT oT1enme Ha o6wn~o KO-

Cneul~u cacmonnun Ha omgeAumeAnama cucmema

261

n n r e c m ypnHa (nopqn mnHnn Mexypnnncbqecmyaaq m e xqpoypenp n xunpo~e@po3a). Auypeaa~a nc ~ o l HOCMTe Ha a30THUTe Tena U ?HOpMaJlM3blpaT6bp30. BMHam cbqemysa onacHm OT acqeHpetiTtia ~POMH@K~UR KoeTo , Hanara ~nKpo6nonorur~o uz~cneflm~e H nereHnecypoamcenmqn. 2. AHYPH~HB $a31 n o 3anowaHe Ha Bnannaa npneMbT Ha Tertiom e CTpOrO OrpaHUVeH. A O ~ ~ Y C e CMaKCUMWl K~ HO (p. 0. M i. V.) KonurecTao paetto ~a pnype3a~a+ 500 ml. flpu $e6pnnnTeT ce 406aem no oqe 500 ml 3a eceKn rpapyc ~ a p HopwmHaTa TeMnepaTypa. Cpeqy ~ e ~ a 6 o n m a4u~a~a Aoaa U xnneplcanueunmace npnnaraT HaTpnea6n~ap60HaT, Calcium gluconicurn, rn10~03o-n~cynn~osn pa3~~oP M . ~ ~ H C T B ~flMtMM3HOTO H O neYeH#e MOXe fla nO&4bpBECT~HOBRB~H~ Ha 6a6peunx a x n m a B ~ a 3 @a3a n Te. To ocbqecTBRea Kopewng Ha ypeunfl, xnnepltanueMUR H aquho3a. Xe~0flU~n3a~aTpR6~afla 3anor~e paHo (np# HMBO Ha KpeaTMHHHa nOfl700 ~ o MypeR , nog 25 mmoIA) M ~ a n nno1 l 7 mmoM n ce npoeeyqa exeAHeaHo no Haenn3aHe B nonuypug. Kpmepnn3a cnetutiannannaa ca 6eno~lpo6~nm OTOK H cepyrneH ~ a n n~ l a7 pmmoVI. Xnnepxu~pa~aqnma ce o e n w m c noAxoppqa ympa$nn~paqun. no epeMe Ha xe~oflnann3a c Hen ce qenu exeAHeeHo WaeaHe Ha oTpuqaTeneHBofleH6ana~c OT 1500-2500rnl. T o l e ~ e o 6 x o 3a ~n sbaeyqatie ~ Ha pa3~WPM 3a napewepanHoxpaHeHe, MeAwKaMem,~ p a ~ c $ y 3ncl Ha KpbB H 6nonpo~ymn B yCn0BllRTa Ha aHyPMR. 3. n o n ~ y p ~Qaaa r~a C fl0~o6pRBaHe Ha CbCTORHneTOH ~ o ~ x o ~ ~ M M o COT TT~ MeAnKaMeHTo3HonereHneH ~ M ~ R Heo6xo~w~oe B ~ . no& mpxatie Ha ToreH W e H 6ana~c. 3ary6me c ypnHaTa ce
Bb3CTaHOBRBaTCeKBUBaneHTHOKOnH~eCTBOBOAHOeneK-

npenapaTa Eprex 50 ElkgTerno i. v. nnn S. c. npn UH@Kreon B ~a3n $aa, ce nposeyqa nereHne c nonxowqn, (6e3 ~ e $ p o ~ o ~ c u e@e~-r) a ~ ~ u 6 a ~ i e p n npenapaTn. an~n 4. B a 3 c ~ a ~ o e ~ Qaaa. ~en~a 60n~me ca Aucnaticepusupatin n ce n3cneAmTexeMeCWHO. ~ ~ U K H O B ~He HO C e Hanara MeAUKaMeHTO3HO neretiue. B 3aKnloreHue, 06H e H ~ O T C ~ ~ ~ np Be ~d Im ~ O ~~~ TencTBo 3a ~e$ponoame.Bbnpe~n HanpemKa B nowaHnmanTepaneamrHmeB~~MOXWOCTH CMbpmmanpea nocneflHwe IeceTunemR ce sqbpxa BncoKa- OT 50 1 0 70%. Tom ce m n x a Ha npoMeHn B npnrntime, B HapacTBaHeTo Hanocnpas~mrHaTa n nocTonepamaHaTa06H C ~Horo6pohHme HM yCnOXHeHMR. Bce ~ O - T ~ M YEpefle O HU naquewuce noffnara~ ~ a ~ n a n n a ~ o n e r (BK~KI~Me~ue
~UO~H ycnomeHn#, U K O ~ O ca

TponnTHn P ~ ~ T B O P H Hanara . ce n gomnHmenHo BbBexAaHe Ha ~annh noA @ p ~ a Ha Kalii chloridum (UH$~~UOHHO), Panangin(p. 0.). Aaea ce n a n ~ o u e n ~pa3~006pa~a a ~ xpaHa, a 6ora~a Ha HaTpuee xnopnA n BmaMuHu. 3a aHeMnma ce npunaraT menestin npenapaTn, @onneea npomnmmenHospeue. npn Hmon6b6per~me $~HWUH KucenuHa. npum u o n a i o c e ~noKa3aHn ~ y p HanereHMe c BpeMeHHO C H eC e Bb3CTaHOBRBaT M n M~0flo6pe~~e ~0 C ~ ~ K o M ~ H H ~'i0 H BetuKM T ~ H epuTponoemH (r-HUEPO) npexoA O M XpoHUVHa 6b6per~a HeAOCTaTbrHOCT.

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XHIlepHaTpHe~Hfl

Xmnep~o~mq AexuApaTaqm ~a O~nnraaa ce c HepocrMr Ha Bopa, MHorotcpaTHo npeBnwaeaq HaTpneeaTa =@a. n p Toea ~ cacTomiHe ce ~a6n10paeapexMRpaTaqMR H B peeTe npocrpaHcTBa.

Hah-rec~o cn~ppom ce ~ pa3sn~a cnefl 3ary6a Ha Bopa. T. Hap. . ~ e s ~ a r m e n sary6~ ~ ~ " (npes KoxaTa n 6enwe ~po6ose- pennretio noTeHe npu + e 6 p ~ n C~CTORHMR,cneA nsnaraHe Ha BMCOKM TeMnepaTypn, npu Emononn pecnnpaTopHMM H ~ K ~ M cMn e W ~ ~ ~ ~ P RHe H ce MR ~b ) 3c~a HoaRsaT, nopa,qn KoeTo n n a 3 ~ He~ ~ TP ~H ce ~ ~noe#ura~ Cpeuace npu ~ e p e ~ o - n c ~paxrpoirc~~a, xnr~~ cnen Ba. 3ary6me npe3 6b6peq~~e ca cnepcTelre noR8aTa Ha npMnoxetiMe Ha HFIKOM MepMKaMem (Chlorpropamid, p ~ a 6 (eq~ e ~ ~ p a nnM ne~ 6b6pere~) Mnn nopaBMCOKM A03H Cyclophosphamid), HeonnasMu ( K ~ ~ ~ M H O 6e3a~yce~ M flM OCMOM' iHa AMYPe3a (rIlIOK03a, MaHMTOn, Y ~ R Ipyra ). Ha ~ P O H X M6enoppo6~~ T~), MH$~K~ H n H MW O C T P M 3a60n~npH'iMHa3a pa3BMTMeTO HaXMflepTOHM'lHaXMflepXMflpaeatiw, nocTonepaTweHo. Moxe pa ce ~a6n10~aaa n npw TaqnR e 3ary6a~a Ha TerHocT npes r a m p o - n ~ e c ~ n ~ a XMflOTMPeOMAU3bM M n M ~a,q6b6~e'i~a HeflOCTan'iHOCT. HMR TPaK-r. HFIKOM XHflOTanaMHVHH pa3cTwhcT~a (XU~O ~ ~ ~ M O ~ ~ T M C ISlADH H M R T e Ll3KnIO'icl-re~HO PFI@K. flMflCMR MnM MMHepanKOpTMKOM~eH #3flMLUb~) BnM3 aB ~c b o 6 p m e ~ ~He e . e 6e3 waretine M npeMuHasaHeTO Ha BOpa B KneTKMTe npM IItprOBe, TeXKM $M~MCI !CKM T H ~ ~ca Hnpomme M Ha mnepmppaTaqwma. XapaHaTOMpBaHMR M pa6po~non~3a. K ~ ~ c M ' ~npMMep ~ c K M3a K-repHH6ene3n ca: H M C ~ K n n a m e ocMonanweT, ~ napasex v n e p ~ a ~ pc ~ pe eu xn ~n ~p a ~ ae uebspac~e~ ~~ n a q n ec ~~ Ha xMnotiaTpmennMR, BMCOK OcMonanMTeT Ha yputiaTa M MH$~K~ Ha MflM RKO'iHMTe flbTl/lqa, K O ~ T O e flpeyCTaHOBMn B M C O K a KOHqeHTpauMR Ha H ~ T P B MYPUHaTa. ~ npueMa Ha Te'iHocrn npes ycTaTa. Orpa~~rae ce a nplremT Ha Te'lHocTM per OS. noTexwwecny-lan eypartioAaceneKyaaTBcTawoHap. KopeKqMma Ha xwnoHaTpneMnmaH ~ ~ C npn K B~ ~o s n CMH~POM ocMonanmenT Ha npMnaraHaTa TerHocT Aa e no-BMCOK OT T O ~ H Ha ypnHaTa. O r n l r l ~ a n ~ o ne'iet-tkre ~o Hailara YPMHHMm OCMOnaIlMTeT fla 6bpe IlOHWKeH. TOM ce nocTnrac npMnaraHeTo~a~ ~ y p e ~ nnpe~norma qn. ce ~~MMKO pMypeTMK. B TO^ IlpeCIH Ha KOHqeHTpaL(HRTa Ha YpMHaTa, KaTO p p e w a pea6cop6q~maHa H ~ T P U M~ XllOp. n p XPOHMreH ~ SlADH C e M3flOfl38aT HHCKM p03M roen pWypeTnqM C HncKoconeaa RneTa nnn

Cyxa Koxa M ntiraeMqu, HaManeHrypmp, HncKo apTep a I l H 0 M BeH03HO HaJlRraHMR, TaXMKaPpHR. ~ ~ O R B H OT T CTpaHa Ha L(HC (~b36y~a, no-KbCHO COMHOneHTHOCT H K O Mca ~ )npepnsecl~a~~ OT ~ b ~ p e m e n ' i ~ e ax ~u a~ p a ~ MR. AKO ca B ca3~a~ne,60n~me ce onnamaT OT x m a .

~CTBOM noflxomqo nomneaiie c Bona npn MoHnTopMpaHe Ha n n a 3 ~ e ~ ~u a~puh Msnonaea~a~a . Np~yna 3a

0.5XT.M.X(

Na nnaslua

110

=H

~ O ~ X O ~ BORa ~ U (I) M ~

3a~ecm~e cTaea ~ o c 5% Sol. Glucosae i.v. cbc C K O p O c T He nOBe'ie OT 300 mlh. npM X H n O T O H M i 'H H na4Me H T U eyMeCTHO U3nOn3BaHeTO U HaM30TOHMVHUCOneBU pa3TBOpU. I$?HTpaneH 6e3e~yce ~~ u a 6~ ep ~ ~ 6 na ea

PM

ce nposefle noflroToaKacneKapcTsa, mhnynnpaquoceo60waEl~e~ Ha 0 60nHU C XUnOflUnCUR Ce OCTaBRT Ha $HKCMP~HBOfleH PeXUM.

m.

Xmnep~o~mlc~a xnnepxmnparaqun Xapa~~epuaupa ce c noaMweHa HaTpMesa KoHuewrpaum B nnashnaTa, o6ycnaa~wa MHTpauenynapHaTa BexunpaTauMR M eKcTpaqenynaptiaTaxunepxunpaTaqwn.
n p u ' i u ~ ~ca ~e ewepaneti npueM Ha conefia Bona (npu yflae~uq~) unu napeHTepanHo BbeewaHe Ha xclneP T O H U i ' H U C O n e B UP a 3 T B O P M .

npoRBRBa Ce C XaYqa, O T O u U , BKIlloVMTeIlHO M 6enoflp06eH OTOK, IlOBUWeHO B e H O 3 H O HaJlRraHe, H ~ C ~ O K O ~ C TBUe, A0 KOMI.

n p e ~ o ~ e aHoc p e ~Ha coneau p a 3 ~ ~ 0 p (nmonepau T U B H O U I~OCTT~~BM~TMC(HO ~ ~ ~ O ~ F I B ~IlPOTUVaUM HMR, C O T O q U (cb~fl?V Ha HeflOCTaTbVHOCT,'iepHonp06Ha uUpO3a c acqu~), 6b6pe'i~u 3a60nRBaHUR (~anp. rno~epyno~e$ PUTU, ~ e $ p o s e CUH~POM). ~

Jleqma ce npennMHo OCHOBHOTO 3a60nRElHe. Hanarace nomonnqflueTureH pemM, OrpaHu'iaBaq npweMa

Ha M BOfla. np# H ~ O ~ X O ~ U M O Ce CT CTMMyflUpa flMype-

sa~a c nopxoflRwa flMyperMrHa Tepanm. npu H y q a 60n~um Ce X O ~ ~ M T ~ J I M ~ M ~ ~ .

268

Cneurnu csemonnun na omgeAumennama cucmema

HapyluetIH~ B 06sgna~a Ha KanHeBHTe ~ ~ O H H

X~no~an~e
nonyvaeace npn nnaaue~a K non 3.5 mmoVI.
O H ~ ~ H T ~ Ha ~m ~ M~ R

Kan~m e~ah-BMHM BbTpeKneTbreH ~ KaTnoH. CpenHaTa MY KnenrHa KoHqewpaqMR e 125-140 mmol~l, a KOHL(eHTpa4MRTaB H3BbHKneTbCIHOTOIlPOCTpaHCTBOe 3.55.0 mmoV1. T a a ~ KoHqempaqMoHHa pa3nw~a ce nombpx a OT Na-K-ATP-no~na,paanonoxe~aB KneTbrHaTa MeM6paHa. & H O U ~ H M ~ T O MeWy BbTpeKneTb'iHMR M H3BbHKneTbClHMFlKmMh OnpepenR MBM~P~HHMFI flOTeHL(Mall

npHclMHM~e 38 pa3BMMeTO Ha XMnOKMMeMHR MOraT Aa ce 0 6 0 6 B ~cnegHw-re rpynw: 1. K n e n r ~ o npepa3npepen~~e ce ~a6nlo~aaa ~ai4recTo npM CbcronHMe Ha anKanoaa. n p e ~ a c ~ ~ Ha e~ BOflOponHMTeK a T M O H M BbH OT KlleTKaTae ~ ~ c T o T ~ Y pau(MR oTroBop, qenRq ~ o p ~ a n w 3 ~ Ha p aeKcTpaueny~e np~e;wm cxpaHaTa ~ a n npM ~ Hi O ~ M ~ ycnoaMR ~ H M ce napHoTo pH. Eneupo~eyrpanme~ ce nombpxac HasnMoTIenR rnaaHo c ypMtiaTa. Cbqecr~yaaM ceKpeTopeH aaHe Ha ~ a n B ~KneTmTe. h C~~uynaqwma Ha P,-qpe~oMeXaHM3bM, pa3nOnOXeHB MYK03HMTeKJleTKM~ane6eno~~$apm c oTnenRtie ) Ha TO repm, K O ~ T O perynMpaoT C~ anAocTepoH. n p ~ p e ~ m a - peqemopMTe cnen cTpec (~anp. KaTeXOnaMMHMMOXe na npM'iMHM O C T p O npepa3npeflenRHeTo Ha ~ a n ~OT i 4eltcrpa- &M MHTpaqenynapHoTo npocTpaHcTm ce nopnoMara OT Insulin M P 2 - w p e ~ e p m r ~ o He Ha KUIMR, OTrOBOPHO 3a nOBMWeHaTa CMbPTHOCT B nopo6~n cnyav. npn ~ ~ a 6 KeToaquno3a e ~ ~ a npMnaracTwMynMpaHe, KoeTo noewuraaa annetiocrra Ha Na-KHeTOHaMHCYnMHnpeflM3BMKBanpMpBMmaHeHaKanMRB ATP-no~na. Kne~~M~e.flecleHMe~0 Ha MeraIl06na~THa aHeMMR C QonH3a nompxaHeTo Ha paaHoeecMeTo Ha K ~ M ocnoR eaa KMcenwHa M Vitamin B, , Moxe na noeene ~o xmoltaBHO 3 ~ a r e M ~M ~ ae 6b6peq~a~a perynaqnrr. K ~ M R ce T nMeMMR r p e a y a e n ~ r e ~ a ~P ~O aA I ( K ~ M~a H K ~ ~ TM K ynaeuM $~n~p~ CB pOa~ O ~ Hnpea O rnoMepyna, pea6cop6~pa ce HeTO Ha K M M ~ OT TAX. n0'ITM HanbnHO (90%) B ~ ~ O K C H M ~ T@yn J~H MH npMMKaTa R 2. H H C ~ npweM K Ha K M M ~ ce ~a6nlonaaa PRRKO,W n Ha XeHne M C8 CeKpeTMpa OT KOpOBHTe cb6Mpa~en~M KaTo Ton e UM~OKOpa3npoc~pa~e~ B ~ BcMrKn B xpaHmeKaHm'IeTa. ~ ~ B M X ~ H MHa ~ TKaJl O Mu 3aBUCM OT npMeMa C nHM nponym. xpaHaTa, OT CKopocTTaHa HaTpueBaTapea6cop6aq~~, OT 3. X M ~ O K ~ ~ M BCnefl ~M cTBMe M R 3ar)16H OT TRnOTO MOCKOpOCTTaHa IlOTOKa B PMCTUIHMR Ty6yn MOT ocao6ox,qax e na 6ane n p e ~ ~ 3 e OT ~ M3BbH6b6pe' ~ a ~ a IHM (3ary6n OT BaHeTO Ha all~OCTepOH, npRK0 CBbp3aHO C nOBMWeHaTa raCTp0-MHTeCTMHanHMR TPaKT M npe3KOMTa npM$M3M'Ienna3MeHa KflMeW KOHqeHTpa~HR. A ~ ~ A o c TOTBa~~~H~T CKO HaToeapeaHe, ropeq n BnaxeH KnMMaT M cnen usraP R HaTPHeBMTe M KMMeBMTe KaHMHBnyMMHallHaTaMeM~RHMR) M6b6peq~ (A ~ M ~ ~ ~ T TepallMR M ' I H ~ Mnn noapbqa6pa~a ($Mr. 7.2). n o c n e ~ ~ a n yaenMreHne o~o Ha HaTpMeHe) npnvntin. M B neaTa c n y w HacTbnMnaTaAexMflpaTaBaTa KOHqeHTpaqMR BbTPeWleTbVHO CTMMynHpa Na-K~ Mn R p e ~ n 3 ceKpeuMma ~~m Ha anflocTepoti, KOLITO RMATP-no~naHa 6aaona~epan~a~a ~ e ~ 6 p a npexebp~a, PeKTHO ~bfleAcT~a 38 OTpenRHeTO Ha KallMR. ~ ~ ~ B M ' I H M R T nRhKM HaTPMR KbM nepMTY6ynHa~a TeClHOCT B 3aMRHa Ha M BTOPM' IHMRT XMnOanROCTePOHM3bMnpeflM3BMKBaT XMnOKU~~ HO ~B .M U ~ H no ~ T03M T ~ Ha' iMH KanMeM KOHqeHTpaKanMeMMR no c b q nbT. ~ ~X n n o ~ a m e a n e ~ ~caMa m a no ~ MB R KneTKaTa 6naronp~mc~aa ceKpeqMma Ha K ~ M B R ce6e CM Moxe Aa npenu3sn~a xunoKanneMMn, KaTo nocnyMeHa no e n e K i p o x u ~ ~ rpwMetiT. re~ neneanoTo Msrepneatie Ha K ~ M tie R Moxe ua 6ane KOPMMPIHO,aKO He C e Bb3cTaHOBMM MatHe3HRT.HRKOM 6a6pe'IHM ~ ~ ~ O ~ R B C Hap)4IJeHal@ynHa ~ H M R $)WK~HR (T@ynHa aqMno3a, CMHAPOMHa 6ap~ep) cbqo p o a e m a no ~ 3ary6a Ha KanMh.

Onpenen~ ce OT npohnetiwe B M ~ M ~ P ~ H HnoTeHuwMR an, K O ~ T O e ~OBHUI~H npn no~oh, T. e. a Aa ce ocaqecrBw KOHTpaK4MR e HFeH no-CbmeHApaaHblTen. 60nHM~e C nqaae~a MycKynHa cna60c~, nMnca Ha cyxomnm p e b new. ~ ~ O M ~ H B enempoKapnMorpaMaTa M T ~ no~aa~ ~ a r n ~ Ha a T~- ~ eb n ~ n a nomaTa ~a Ha U-nn~a.Xnno-

@)WK~HFI C Hap)4IJa~~e Ha K O H ~ ~ ~ ~ ~ M O
HOCTH nonMypuR npn HopManHa rnoMepynHa$nmpauwA.

Xnno~an~e~ npeppa3nonara~b~ ~ma apMTMHHrpeapenMreH ~ B T O M ~ T U ~ KaTo ~ M ,Moxe pa HamnM BHeaanHo cnMpaHe Ha cbpqeTo. H e o 6 x o ~e ~pa ~o ce nMmwpMpa npvrMtiaTa, Ioeena po xMnoKanMeMnR. flpn n e m e cnyvau ce npenopbrsa KOPeKqUR Ha pMeTMVHMR PeXMM. B IlpOTHBeH cllyvafi C e Hanara x o c n ~ ~ a n ~ 3 u p aa a~ MoHHTopMpaHe e Ha cepyMHMR K M U ~ ~ M 4eKBaTHO BeH03HO JleveHMe.

n~coeo neretiue cbqo BOW po XnnepKanueuMR. H a p y e ~ ceKpeqm a c ypnHaTa. flpn OnMroaHypMrHa 6b6per~a HepOCTaTbrHOCTXMnepKallMeMMR C e nOny.laBa epea cnep cna,qaHe Ha rnoMepynHaTa $ ~ n ~ p noA5 aq~~ rnllrnin. AKO06ave q 6 y n ~ ~ ca eMHTamHM, Te 3 a n a 3 ~ a C~OCO~HOCT CM T~ F(a CeKpeTUpaT M3flMWHUR KaJlMl. flpM xnnoanpoc~epo~~3b~, ~ a ref c ~ npep13aw~a~ o OT HaManeHa n n a 3 ~ e ~ peHwHoea a amwiom, M npM AMcTanHa q6yn~a aq~poaace ycTaHoaRBa cb40 nowraaHe Ha n n a 3 ~ e ~anuo. ~u~

Cnew~o ~ O J I H H ~ HneseHwe O

Bbaexqace BeHO3HOKaliichloridurn, KaTO KMMeBMRT np0TM'ia aCUMnTOMaTMrH0, pOKaT0 nna3MeHMRT Ka~ I $ M ~ H T npepBaPMTenH0 T P R ~ BAa ~ 6bpe M3VMCneH no nMl He HWBMWM 6.5-7.0 Illrn0lA. KI~HHMYH~T~ KapMHa $op~yna~a: OTHOBO C e OnpeflenFl OT IlpoMeHHB M ~ M ~ ~ ~ H IlO H TeHUMM R (4.4 mrnoVl - amyanHaTa n n a 3 ~ e ~ Ka O H ~ ~ H T ~ ~ ~ M R an. B T O ~ M cnyval ~ o e noHMxeH l Bn o ~ o Mle pocTanreH Ha K) X TenecHaTa Maca X 0.2 X 2 = KanMesMR pe$~qwr ~ea~ar~~ p en ae s~ ~ 3a ~ ~ ~ e ~ ~ nA M ~ B M HaKKOHTB ~ H (rnrnoM). p a ~ q Ha6nropaea~ ~~. ce cna60m, MycKynHM noTpeneau e n ~ Ha a neretiMeTo e ~ a n pa ~ m ~aeneae B nnaauaHMFI, n a p e c ~ e a~ ~O ~R. B R B ~ ce T noepbqatie, pMapm. flpoTa npepn pa e ynoeeH OT KneTKwre. B nepn$ep~a seHa MeHRcecbpperHMRTpmM,nocnenBaHoTKawepHaaeroIlpMnaraHMRT pa3TBOp He ~ p ~ 6 pa ea e C KOH4eHTpaqMR Ha MaTm M llO-!%CHO KaMepHOMbweHe. n p o ~ e ~ m B EKr e W ~ a nHW ~ 40 l rnmoIA, nilKaTo n p e p ~ a e u TpoM60$ne~~a XapaKTepM3MpaT C BMCOKM M OcTpM T-BbJlHM Ha T R C H a OCHO~ W T HA . o n y c ~ ~c ~~ ao~ pa o Ha c ~BbeewaHe ~ p ~ 6 p(a ea ce m, p a a ~ ~ QRS-~o~nne~c, pe~ PM~MHM pa~~polc~~ orpaHMrM po 20 rnrnollh, He noaere OT 200 mm01124 h IlOpWU OnaCHOCT OT OcTpa XMnOKMMeMMR U PMTbMHa c ~ b (10ml10% p ~ KCL = 20 rnrnol ~ a n ~ Aa l ) .ce M36Rr~ia llpw cbMHeHlrle 3a xuneplcanMeMvR npepM B C M ~ K O ce npMnaraHeTo Ha r n r o ~ o a o c a p b p ~ ~~ q~ ~T B O P npwnaM, 0rpaHM.laBa IlpMeMbT C XpaHaTa. B TeXKMTe CflYCfaM e raHeTo Ha KCL e epMHcTaeHo B ~ ~ M O ~ H OnevetiHe TO Ha B ~ ~ M O X H3anorsa~e O HaTepanwRTa c Calciigluconas i.v., an~anoaa~a npv ~ e cnyral. 3 ~ X p o ~ ~ r~ ~aa n~ e aaaryea HO e xenaTenHo GO~HMFIT ~esa6ae~ pa o 6bpe TpaHcnop6a, n p e p ~ 3 a u ~ a OT ~ pMypeTMrHo a nereHMe C T H ~ ~ H ~ H , TMPaH M XOCnMT~M3MpaH 3a IlpOBeWaHe Ha aeKBaTH0 Moxe pa 6ape npenoTspaTeHa c pasaHe Ha ~ a n ~ l - a ~ b nerettMe npM MoHwropMpaHe ~a a q ~ o 3 a H ~ KanMeMMma. a pxaqm p~ypemq~(Amylorid, Spironolacton).

Cnelu~o 60n~cls~o newme

X u n e p ~ a n ~ ce e~ a~ T~ aW ~~ no aTPM nbv: 1. AHT~~OHMCTM~HO flekTBMe BbpXy KneTbVHaTaMeM6pa~a. Kanq~m npaw nparoecln MeM6paHeH noTeiiqMan Ilceapox~nep~an~eum M M a npnTpaehnaTMwaxeuon o M ~ K enetmpoHeraTMseti, O KaTo no T O ~ MHawH ce nM3a no BpeMe Ha WMMaHeTO Ha KPbBHMTe npo6u, npM npoTMaonocTaaR ~a ~anweeo~o f l e l c T ~ ~n ep . ~ n a rce a~ 10 lrapaae~a nee~oqw~o3a MTPOM~O~MTO~~. rnl10%Calciigluconas aa ~ a ,3 qrnin M uoxe Aa ce noBTopw X~nep~anneuw~ nopa,qu yeenMveH o m p npueM aaHa sncn OT CnenHHTe $amop~: KonMremBoTo npHeT ~ a n ~ l , cnep 5 rnin npM nwnca Ha e$em. npoflbnxu~en~ocrra pelcrscle~o e 1 h. cnoco6~oma Ha racT OT n n a 3 ~ ~ ea ~ ~ n pa ~ ~Haeneae l B Ha ~ a nB ~ KneTKwre. l YM~CTHO e 2. npexabpn~~e Knemwre, KanMesaTa eKcKpeqMR c ypMHaTa M npepwemnpnnaraHeTo Ha Natriurn bicarbonicurn, KaTo ce o r a m eaqoTo Hnao Ha ~anwl.f l o ~ a r s a ~ e Ha ~o n n a a ~ e ~ ~ ~ e$em cnep 15 rnin c npopbnxMTenHocT 1-2h. Cbc c x o ~ ~ ~ a n uel ~ e s ~ a r n ~ npM e n nocTeneHtio ~o penMrasaHe Ha ~ e l c n w e n npMnaraHeTo Ha rnroltosa (25 g i. v.), KORTO npMeua.TasM a,qamaqnR ce cebpaea c e $ e m n e ~ o c ~ Ha ~a n p e p ~ 3 ~ u npM ~ea ~ e p ~ a 6 oe ce ~ o~ 60 q~ ~a a a ~ Ha e Insu6b6per~a~ ceKpeqwR a M BepoRTtio C H ~ B ~ M ~ ~ Ha H ~ T O ~ a nB KnemMTe. ~ l Moxe pa 6bpe Bbsepeti M Insulin (6-8 U lin. C rnro~o3a~a npepaanpepene~me Mewy KneTKme n u 3 ~ b ~ ~ n e n - aa 25 g rnro~oaa). 'iHaTa TeWOCT. 3a Her0 C ~ A ~ ~ M T H C B Y n M ~HT M KaTeXOna3. Vlanbvea~e Ha ~ a nM ~ ~ l Bo ~pH r a ~ m ~AMypeTMa. M M H M T e rpe3 P,-a,qpe~opeqen~opme. Oc~po HacnnMna4UTe Ca nOpXOARqM, H0 npM 6b6per~a HepOCTaTbCIHOCT Ta aq~posa cbqo n p e p ~ 3 e ~ ~ npeMecTBaHe sa Ha ~ a n ~ l . e$eKT~BHoclTaMM e OTpaHMreHa. K ~ T M O H O O ~ M ~ M~CMBHO KnenrHo p a s n q a ~ e npn p a 6 ~ o ~ ~ o ncnep ~3a, cMonM, npMnoxeHMper os nnM c ~ n ~ anoHRKora ~ a , paBaT Tpaeua M n M KnenreH pasna,q ( c n e ~ x~u~o~epan ~~3 n) - , po6p~ pe3yn~a~u (~anp. Kale~cana~). B TexKMTe cnyvaM TOqMTenHU$ M ~ H ' ~ HaTOBaPBaHMR ~cw MM a C M B H ORMMTace Hanara usnonaea~e~o Ha A M ~ ~ M ~MeTopM. HM

Toea e cnelueH CMHAPOM, C K O cpeqa B C ~ K M n p a ~ ~ n ~ y ne~ap. aaq

~ O HeMwiyeMo

ce

Emononrn
~PH'~MHM C a T pa3nMrHM, ~ H0 HaBqeCToT O M ca KOHKpeMeHTM, CbCMpeqM, ~ H O ~ H M M npMTMCKaHeOTBbH ~T~~MM, Ha ype~epa. P o n Mrpae ~ M cnaaa~ oKono npoeoKMpaqwR areHT.

PHR M OvepTaeaHeTo~aype~epa cw:cMrypHoCTH ~ K ~ I O C I 6b6per~a re~e3a ~a 60n~a~a. ETO 3aqo TOEH nxneneaHe Moxena ce ~anonasa npn TP~AHOCTH Bn ~ $ e p e ~ q ~ a ~a nwamoaa ~ e a 6b6peura~a y ~onln~ Ma HRKOM OT ~ ~ ~ O ~ R B Ha ~ H O C H T P R H R TXMPyPMqeH ~ KOpeM. Toea o6a'ce C e Hanara M3KJlIOqblTenHO PRAKO, B e A M H M C H l M CwaM.

nn@petIqHaIIIIa ~ n a r ~ o a a

K ~ M H He KTnnnrtia ~ T ~ -60n~a~ e cnntia a M aanorm a~eaan~o, H ~ A - Y ~ C TB OKpbcTa, KbAeTo e M n y ~ l c r y MaK~ CMMyM. Mpqq~pa no XOAa Ha YpeTepa, KbM MHrBMHXlHaTa IlHKa, CKpOm (na6n~). M MK~O ~ M K O O XapaKTep. ~ ~ ~ ~ ~ H n a q ~ ee ~ HecnoKoeti, ~b~ ABMXM ce B nernoTo, maea, KJlRKa, H0 nOn0XeHHeTO Ha TFlnOTO He yCnOKORM 60nKaTa. Moxe na M M a raqette, no-~RAKO noepbqaHe, nonyeatie Ha ltopenna. HepRnKo, HO He n w b n m e n t i o , nMa flM3YPMR. npw npernenace yc-ratiosfisa: nonomenHo c ~ c l n o PeHanMC npM MeK KOpeM, 3a6aae~ nynC. BWMOX~H C ! neK ~@$e6pMflM~eT. Jla60pa~op~u~e no~a3a~enw He c a peluaeaqM 3a flMatliO3aTa. Hah-V~CTO M M a ePHTPO~Q'PMR, nOHRKOra ne~anes~oqmoaa. PM npOTpaXMpaHO IlpoTHVaHe e Bb3MOWO 0640~0 C b C T O R H M e Aa 6ane YBpefleHO, oco6e~o CneA MHOrOKpaTHM MeflMKaL(MH- X M n O T O H M F I , AeXMnPaTaqMR, OnMrYPMR, rpesHa napea. flMaIH03aTa npn mnwtta KnMHMKa e necHa. no cneUrHocTMoraTAaceHanpaemcnepHMTeMxnepaaHrnR:

-0630pHarpa@1R HaoTnenmenHaTacMcTeMa: npcm ce cRHKaTa Ha 6b6pe~a (eeewyan~o y e e n ~ r e ~n aceHKH ) OT KoHKpeMeHTu B 6b6pe~a wnn no xoAa Ha ypeTepa;

- m r H a T a KonnKa ( A n $ e p e ~ q ~ a n ~ ~a ~~ aa nio3 ea nPC!AnMHO KnMHMqHa no MRCTOTO Ha 60n~ara,HehHaTa MpWMaqMfl, HeraTHBHOCYKyCMO PeHWIMCH nOnOMMTenH0 C ~ C M xena~w~a); O - OCTPMR aneHAMqm ( 6 0 n ~ a 3anorsa ~a nocTeneHHo, He e ~ o n ~ ~ o o 6 p ano~anna~pa a~a, ce B KopeMa c nyttKTyM MaKcMuy B MneoqeKanHaiao6nac~, H M ne$a~c ~ M nonoxMTeneH cnMnTohn Ha Blumberg, p a 3 n ~ MeayartcMna~a pHa M petcrantia TeMnepaTypa, neeltoqmoaa, ycKopeH nync); - nep$opaqn~~a Ha cTonnaLuHa ( u y o ~ e ~ a n naaa ~a) (60n~ae ~ BHesanHa, a HO B KopeMa, nMa nocToRtieHxapaKTep, o6qo~oC b C T O R H M e e TeXKO, fle$aHCbT e RCHO ~ a p a a eC~KYCMO ~, peHanuc e oTpMqaTentio. M Mc~ eob AeH raa B ~ o p e ~ a ) ; - ocTpnR naHKpeaTyr ( ~ ~ e s a 6on~a n ~ a B ennracrpuy a , onaceaqa KpbCTa, O ~ M ~ H noapbuaHe O ou(e B HaranoTo, a ~ a r w ~ e n ~ a n e ~ ~ o qTemo m o a a06qo , CbmontiMe, C~~~H$H na60paTopHM VHM n o ~ a a a ~( e~ n~ ~a c ~B ay 3pa~ HaTa, aMnna3a B cepy~a); - Mneyc (60nKMTe ca B KopeMa, HRMaT xapamepHa MpWMaqnfl, nMncaa ~ ( e $ e ~ a q Mu oTflenRtie ~ Ha ramee, nospbqaHwma nocTeneHHo ce a a c ~ n ~ a xapaKTepHM ~, PeHTreHOBM AaHHM 3a XMAPOaePHClHH HMB~); - OCTPMR WHeKcm (neneeonep~~o~m) (A~HHU 3a OCnp 064 BWnanMTeneH CMHnPOM, nOKanHM @HHM 3a abanane~~e c nannaTopHa6on~a M fle$a~c; MHeKonoMCIHHRT npernefl yroclHRsa n~amo3a~a). npn ram OT a a 6 0 n ~ ~ a ~ Ha ~ OCTPHR m a xwpypmreti Kopenn Moxe Aa ce Ha6nIOAaBa RwsypnR n epmpouwryP M R , IlPOBOKMpaHMOT Bb3nanMTenHM IlpO~eCM B MaKMR Ta3 ( ~ I ~ ~ H ~ H M~ ~K M CT M, T ) .

~ P M HHa ~nereHMeT0 M I ~ ~ Ha T 6b6per~a~ KOnMKa a e ~ b Kh~ T O 6b6pe~b n0 ~ ~ p e ~a ~ K eO ~ M K ~e ~O T C ~ ~ ~ R Aa ce nPMnoxaT eClHoBPeMeHHoaHanreTwMM CnaaMonM(M~ oTAenR M MHoro aa6a~e~o), TO M3BbplueHaTano cneluTMW. TaKa ce o ~ n a ~ 6 e0an ~ a M ~ce a npe~axsa H ~ ~ M ~ H HOCT eKcTpeTopHa yporpa$n~Moxe Aa e e A M H TecT 3a m cna3bM Ha ypeTepa. HanHqMeTo nnM nnncaTa Ha KonwKa. H ~ B ~ ~ M ~ H nB HOTO npemara~e K~TO e$em~e~ cnn e ~ ~ u ~~ Me O W H no6pa KoHueHTpaqMR OTAenRHe Ha KoHTpacTHaTa MaTe-

Cneulnu cacrnonnun H a omgeAurnennarna cucrnema

I

271

1. Calcii bromati 4% 10 ml Atropini sulf. no 0.001 g (amp. 1 ml0.05% M n M 0.1 %) Buscolysini 0.02 (1 amp. 1ml = 0.02). Analgini 50% 2 4 ml 2. Analgini 50% 4 ml Buscolysini 0.02-0.04 g Fentanyli 2 ml. 3. Lydol(1 amp. 5% 2 ml). Papaverini hydrochlorici 0.02-0.04 g nnM Atropini sulsulfunci 0.001 g. npunara~ ce oqe: Valoron, Lidocaine, Spasmalgon, No-spa M np. nortbn~ w ~ e n ce ~o npenopbrear Tonna rpeuKa Ha Kpwa, Tonna eatia, @ ~ s ~ o ~ e p a n ~ ~ . npM CbMHeHHe 38 OCTbP XMPwMCleH KOpeM OnMaTH HecenpaeRTAoyTorHReaHe~afi~amoaa~a. O~MKHOB 60nKa~a ~ H O HaMWlRBa 3Ha'iMTenHO A0 1015 min cnea MeAMKaquma. AKO OT nbpBoHavanHonpnnoxeHaTa MepMKaqnR KpM3aTa He ce y c n o ~ o ce ~ , npunara BTOpaK O M ~ H H ~ ~ M AKO R . H C HeR He C e flOcTHlHe XenaHMRT

B cTaqwoHapa ce amiorea cncreMa, npMnaraT ce noeTopHo n o - c ~ n ~ 06e360n~aaq~ u (Lydol, Valoron) M TaKa npamurecKw BMHarM ce n o m r a 06e360n~sa~e. A M ~ H ~ M R T 6b6per~a ~ ~ ~ ~ oKpM3a ~ M Aa T~ 6aue yCnOKOeHa B ~ BCMVKM B cnyraM B a ~ 6 y n a ~ o O p~ ~C aT ~ H O B cK.Haw~ q a ~ eC " roneMM A O ~ M M ronm 6poh MeguKaMeHTM, Moxe fla~OBe~e~OXM~OTOHMFl H KOnanC,flOOnMTyPMR. K~KBO Ra 6 b ~ e noeefletiMeTo cnep npeMMHaeaHe Ha hn~a~a? no OTHOUleHMe Ha ~ ~ M n a K T bHa l~ HOBa a KPM3a M n M oenappaaHe Ha no-cna6i.1 ~ O ~ K cM na :3~on~~ p.no., q~ 06wn~0 noeMaHe Ha TerHocTw. fl0 OTHOWeHMe Ha AMamOCTMCI HOTO M3RCHRBaHe Ha npmrnHaTa 3a ~ p n s a ~MMHMM~M a: (npn nbpsa K P M 06~~) sop~a rpa@nRHa oTAennTenHaTa cucTeMa, exorpa@#~ M npocneFylaaHe Ha ypMHaTa, sm. M Ha peawwma h (pH); npM OTKlOHeHHe OT HOpMaTaIlpMHRKOeOT rOpHMTeM3CneABaHMR - eKCKpeTOpHa )'POrpa@MR M KOHCYnT C ypOnOr.
C

BCRK xeMaTypcl ~ lR nozram npep nbpsnR nelcap, K ~ M Kororo naqnemT ce e o6ap~an 3a n o ~ o qAaa , OCHOBHH npo6neua. flbpBMRT U Hah-BarneHe T03H, 'ie XeMaTypMRTa M3MCKM 6bp30 ~acnepea~e 3a ~ ~ R C H R ~a B ~ ~He ~ i ~ napaoa ~ a npMwHa M p q ~ ~ a nereHMe nw Ha H O ~ O ~ O M C I H euw~T~ HMqa, 'iMFITO IlpORBa e KbpBeHeTO. ~ ~ ~ H O )'POnOl T O W.IHO ~3cnep~a e~sea p n x n ~ e n ~ He3aeMcMMo o OT cMnaTa, npopnmmenHocrra, nuncaTa~a~ ponnaKaaHnR, y ~ cnoHTaHHOTO IlpeMMHaBaHe Ha KbpBeHeTO, ~ O ~ ~ O oT 6O ~0 CbcTORHMe Ha ~ O ~ H M flMaIH03aTa R. XeMaTypMR e paBHO3HarHa Ha 3 a n o v ~ a ~ Ha e MxnepeaHw. ronma, ~ o p @a~an rp ~e au ~e ~pa a ce ~ ~ R C H x Re B ~ ~ a ~ y cp.necb~~~a ~HHKH', HacTnHKaH APYM n o ~ o 6 ~#ace n , wxnepea caMo KpbB M flMHa M npM HeraTMBeH pe3ymaT #l C e yCn0KOH ~O~HMRT np# . npaWHeT0 Ha KpbBOCnMpawM MHXeKuMMy naqMetiTa ce cb3aaea rpeluHo aneramewe, r e e npoaeClettonerewe U TO^ CHoTma CnoKoeH. O ~ r o ~ o p ~ o c pa rra 6 b ~ HacoreH e 3a n ~ c n e ~ e e a Ha ~ enapem neKap ( ~ e x y PeH, y.laCTbKOB, He3aBMCMMOOT ~neqManH~~lTa), OT KOrOTO e IlOTbpCeH CbBeT. BTOPMRT npo6neu, ~ o h o6qonpa~~uKyeaqwr o neKap j p R 6 ~ Ra 1 p e w , e 3a ~ e 3 ~ 6 c0xeuaTypMR, n ~ ~ npn KOMTO KbpBetieTo e s ~ a r w e n ~ Mo KaTo caMocTomeneH CMM~OM Hanara nereHne no cneluHocT, T. e. KoraTo

xeMaTypwma e npo$ya~a. Tp~6ea pa ce a~ae, r e KpbeTa nMa MHoro ronma oqeeTnTenHa C ~ ~ O C O ~ H MO M ~T ~ K KonMrecTso O Kpbe 04BeTRBaPMHaTaB CUnHO 'iePBeH0. ~ M OTH KPMTePMHTe3a npeqe~~a~anme~3~~e~a~a~bp~e CbCMPeuM. AKOM M a TaKMBa, Ce CMRTa, Ve XeMaTypHRTa e 3 ~ a r ~ ~ eCbc~peqme, n~a. OT CBOR c-rpatia, aKo ce HaTpynaT B Mexypa, MoraTga AoaepaT no T. Hap. xeMoTaunoHaAa - M3KntOlrMTenHO TeXKO CbCTORHMe, npM K O e T O MeXYPbT IlpeflbnHeHCbC CbCMPe4M, HanbHMTe 38 YPMHMpaHe Ca HenpeKbCHaTM M 60ne3HeHb1, H0 H ~ ~ @ ~ K T M BMH H ~oea Ha @ o ~Ha a a~armen~ ~pbmaary6a. a Onwnea ce 6one3~e rno6yc ~ B ~ ~ M K ~ ~ M C . ~

He BCRKO vepBeHo O ~ B ~ T R B Ha ~ypMHaTa H~ ce m n m ~ a x e ~ a ~ yT ppw ~ .6 s a ~ a n3~nmra~: ce X~MO~~O~HH~~ e ~ p o rH e~ ~ K~ ~ O ~~~ 6at-p~nH~ H H M BeqecTsa, npw~ec Ha Kpba OT reHmannTe Ha xeHaTa M OT ypeTpaTa npu ~ b x a M eBeHTyaHO 0640 3 a 6 o n ~ ~ a (~ ~H eT M K o ~ ~ ) ' ~ne~HTH rewe, KpbaHo a a h n ~ ~ a ~ npn e), KoeTo xeMaTypnma e eAMH OT CMMnTOMMTe. C ~ r y p po~asa~enc~eo ~o 3a HanMvMe Ha ~ p b B aypmaTaeycTaHOBRBaHeTOHaePMTPOuMM npM M M K P O C K O n C K O n3cnep~a~enn~~annr~e~o~a~bc~peuw.

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noHa,qa M n M H~RHOTO npeoponmaHe, npn B C R K ~ npoayaHa xeMaTypuR ~ p ~ 6 pa e ace npepnpMeMaT cnepHlrTe MePKH: Ha naqueHTa ce nmaan W ~ M O ~ ~aCpe6enw~ O TpnmTeH KaTenp (22-24 W)U ce sanorea npoMMeKa.AKO nMacbcMpeqM,Te ce acnlnpMparanweHo, KaTo npepeapw npeopon~ea~e~o Ha TaMnoHa,qaTa ce no3~aea no c~wxeaHeTo Ha onnaKmHMrrra, ~ a q e s e a ~ Ha e ~ro6yc o se3~~anwc MnMncaTaHacbcMpeqMaacnMpMpaHaTaTerHocT. ~ o C T O R H H ~ npOMMBKa T~ qenM Aa pa3peAM KPbBTa M j a R ,OTMM~"OT Mexypa M TaKa pa npepoTapaTH06pa3yeaHeTo Ha Koarynw. 3a npoklnalccc ce ~anonaea~ ~ a recro f 6a~m C $ M ~ M O ~ O cepy, MV~H B KonTo MoraTpace nocTaBRT KpbaocnMpaqM (PAMBA, EAK) Mnn Cbpocaueaqn

(Adrenalin). Ycnopep~o c n o ~ a n ce ~n ~p~ ~n ea r M aO ~ ~ U M T ~K, ~ K TO npM BMKO mpaeHe, Mepw - npocnepneatieHa KP~BHMTe noKa3aTenHM xeuopMtiaMMKaTa, KpbtrocnMpaqMnapeHTepanHo, npn H ~ O ~ X O ~ M M O peatinMaqMR. CT AKO TaMnoHa,qaTa He Moxe pa ce npeoponee - ~ e a a 6amo HaCO'iWHe O M H ~ ~ - ~ ~ M ~ ~OnOMClHOOTfleneK O T O HMe. np# npo@y3HMTe XeMaTypMM~pbB03alJ6a~a e 3HaCIMTenHa M aaToea ~ O ~ H M cnepea T ~ pa 6bpa~ xocn~~an~ paHM. Cnep npeoponfleatie Ha cneurHMR MoMetrr - aa,qbnXwenHoyponomqHoMacnepeaHe.

C n ~ p a ~ ~a e ~6b6peqHa~a o $ ~ H ~ Hpecn. R , o~pennHeTo Ha ypwa ce Hapnqa aHypMR. 3a pa H ~ C T BHYPMR, ~ ~ M TPR~B pa ~ ca p p e f l e ~ Mf ~l ~ a 6b6pe~a. ~a

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rpynM: 1. ~ ~ ~ P ~ ? H MHapyUleH Hu e HOpMaJlHMm 6b6peve~ KP~BOTOK(ronma ~pbeo3ary6a, LUOK, pemppaTaqMR M pp.) 2. P ~ H ~- H npMwHaTa M e B yapepa Ha rnonnepyna (HHTOKCMK~L(MM, O C T P M XeMOnM3M, H ~ @ ~ ~ ~ O M3a6on~CIH# B~HMR) r o p ~ mp e w rpynnaHypvn ca o6en Ha ~e@ponmma. 3. ~ O ~ T P ~ H -~ ~ ~ H O M K M Ha P ~6b6peqHaTa H ~ $~HK~ MB RpeaynTaT Ha 0 6 n u ~ e p a q Ha ~ypeTpMTe ~ no pa3n~qHH nPM' iMHM (Kan~yn03a, TyMOPM, RTPOreHHM H ~ M ~ C H ) . M~oro VeCTO naqMeHnT e C epMHCTBeH M n M enMHCTBeH0 @ ~ H K L ( M O H 6b6pe~. M~~~ K~HHMK e~ TMnM' T ~ iHa: VaqMeHTbT ~bo6qasa, r e He ypuHupa, a npu KaTeTpnsaunR nMKorHMRT Mexyp e .cyxn (pa He ce 6bpKa c peTeHqm Ha y p ~ ~ a ~ a ! ) .

~ P M ~ M H 3a MT aHypMRTa ~ Ca TPM

3 m n x ~ ~ ~es n c n~e ~ p e 3a a~ y~r o ~r l ~ ~ e a ~a ~e AM^moaa~a:o63op~arpa@w Ha oTpenMTentiaTa cMcTeMa (CRHK~ Ha 6b6pe~a, K O H K ~ ~ M ~~H HO TXM MM ) ,M ~ H M nOKa3aTenM, KpbBHa KapTMHa, XlKanHO-KMCenclHHO PaBHOBeCMe. E x o ~ - ~ ~ $AaBa MRT CBeneHMR ~ 3a eBeHTyXIHMR B M A H HMBO Ha npeqKaTa M CTeneHTa Ha AMnaTaqMRTa Ha KYXMHHaTa CMCTeMa Ha 6b6pe~a.

T e p a n e e ~ ~ r noeepeHMe ~o po x o c n ~ ~ a n ~ a a q YCnOKORBaHe Ha 6b6peq~a~a KOnMKa ( ~ K M O M a TaKaBa); cnopepcTeneHTa Ha pexMppaTaqMma- qemaTHn snusaHMFlHaBORHO-COneBMpa3TBOPMnpMOT~MTaHeCbCTORHM-

eT0 Ha Cbppe.1HO-CbpOWTa M 6enoppo6~a~a CMCTeMM; pMypemqu (B~ p Ha aenma~wn~a) ~ - FuranthrilB ronew p03H; KOpMrMpaHe Ha auMpO3aTa; H~H~@POTOKCMCIHM aHTM~MOTHUH.

a3a, O T U ~ ~ H onepaTMBHo ~H 6b6pe~ M~ a seqe f 3a CTpaHaTa Ha nocnepHaTa KonMKa, npepurecTsaqa atiypuma; Toea onpepem n o - ~ ~ ~ C ~ ~ K T &6pe~, MBHM T. R e. TOW, KO~TO e pa6o~~ npepn n aHypMRTa. [PM npernepa ce n p c nonoxMTentio ~ ~ ~ K Y C MpeHaO nMc, yeenMreH 6b6pe~, nannMpaqce ~ y ~ Bo Taaa, p cnepu OT OnepaqMU. BWHOC ! pa C e VO'iHM M 0 6 ~ 0 CbCTOFl ~ 0 HMe Ha 60nHMfi - XeMOpMHaMMKa, AeXMppaTaqMR, RaHHM 3a 6enoppo6e~ M n M M03bWH OTOK.

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Gatcrep~~, B M P Y C M , MMKOlllla3MM M PRPKO OT RPYM ~ b 3 6 ~ AMTenM, KO~ITO 3 a c ~ r a M nMenoKanMKcHaTa CMcTeMa, HO npeRMMH0 M H ~ ~ - C M ~ M H H T O e C T M 4 M Y M a M 6b6peclHMTeKaHan'ieTa.

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AH~MH~CTM'-~HO T~PCM IlpeflXOqa~O 3a60nRBaHe. e. B T O P M Y H O C T Ha H H $ ~ K ~ M R T ~ ~Q . ~ ~ x M T Ce ~M ~ 3K H- o nwsa c~a3a rpe3 exorpa$c~o ~3cnepea~e.
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l l e v e ~ ~ 3anoqea e ~ o c eMnMpM'itio non6pa~ ~lnnpo~ocnempeH ~ H T H ~ H O T M K cnen , ese~a ypwa 3a Gatcrep~o~~O~O~HH noBeReHwe VHO U neqeHcle noMrHo HacnepeaHe. Bnnea~uR Ha ~ H O - c o n e pa3~s~ BOPM. AKO D0 TpM n H M ~ H T M ~ ~ K T ~ ~ W M ne' HO ieHMe TO H e nere~me~ sanowa o c eMnnpMwo ~36paH ~ H T M ~ ~ K AOBepe R0 K n M H M V H Onono6pe~~e, ~ H T M ~ M O T MCe K~ CMeT TepManeH npenapaT. n p e ~ n ~ c ce e aKaTo enMHMrHa no3a H F I , ~b06pa3~ ~0 HTM~HOTMKO~~ HM~~~ TO ~ .B ~ M R B ~ H ~ KaTo T O KoHseHqMoHaneHwpc. I l p e a e a p ~ ~ ece w n M n ~~ o3 e Ha C e n T M r l H O T O C b C T O R H M e BHHarM T P R ~ B na ~ HaBeqa Ma ypoKynTypa. n0fl06peHMeT0 nacnnea 6bpao 3a 1-2 K ~ M MMcbnTa 3a paaa~eaq ce moeH n ~ e n o ~ e $ p (anon~ ~ H Mt. l p nepcucTMpaHe ~ Ha onnaKsaHMRTa ~ H T M ~ M O T M K ~ T C T ~ M ~ T ~ap6yHKyn, O ~ ~ , n~o~e$po3a). np~~a~oeacb~~ e cMeHR ce cb06pa3~0 amw6~o~~~orpa~a~a. HMe ce aanorea peaHMMaqHoHHa TepanclR, ~ H T M ~ ~ K T ~ ~ M - flpe~#HaBaHe H a OnnaKBaHHRTa He 3HaW BMHaM aJlHa K O M ~ M H ~ ~ M C BeHO3Ha R annMKa4MR H na4MeHTbT Ce nMKBMaMpaHeHa M H $ ~ K ~ #TOM RT~ ~. p ~ 6na sa ce A O K ~ npeeeyqa B c n e q u a n ~ 3 ~ p a oTpeneHMe. ~o Cbqo~o e noVpe3 H e K O n K O K P a T H M YPOKylll)'pM. BeaeHMeTo M npM BTopMwme OCTPM n~eno~e$pm~, HO A ~ a n o r ~er noeefleHueTo ~o M npM o c ~ b ype~pm p npM npu TRX ~ p ~ 6 8 na a ce npeononee oqe B HaclanoTo Ha Mbxa. nereHMeTo M c ~ a 3 a ~C a .n e M ~~~MCB~H OT ~ 60nHM~aTa TO

naqHeHTmexqbnxnTenHoce~~cna~cep~a~pa~.

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274

Cneurnu cacmonnun Ha omge~umeAsama cucmema

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onmm Mnn ~ W O T O TRno pa ce M ~ W M , aKo e B p ~ m a n -

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P~T~HI#IRT~ Ha &MHaTa IlpeflCTaBJlRBa HeBb3MOXHa IlaUMeHTa Aa ypMHMpa, BbnpeKM r e nMKOrHMm M e w e M3nbnHeH C YpMHa M HanbHHTe 3a M M K U M R Ca HenpeKbcHam H 6 o n e 3 ~ e ~ ~ . C~CTORHH~TO e ~ s ~ n l o r m e Temo n ~ o 3a n a ~ ~ e t rM ra npeoponRaaHeToHa 3 a p p b x ~ a ~ a p ~ 6 pa 0a maHe ~ e a a 6ae~o. Pe~e~u~ Ha m ypMHaTa a ~ p ~ 6 na a ace p a 3 r p a ~ ~ raea OT aHypMma.
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M3MCKBa OIIMT.

~PMVMHMT 3a ~ yPHHHa PeTeHUHfi Ca pBe rp)fTlM:MeXaHM'iHa npeclKa B OllOKa ( ~ o - ' ~ ~ cM THeBpOreHHM o) pa3CTpo8crea. K ~ MexaHnrHme M npvrMtim cna,qaT: TexKa $HMOS, KamHM M MM Tena B ypeTpaTa, CTpnKTypM Ha ypeTpaTa, TYMOPM Ha ypeTpaTa, 3a60n~eatiw~1 Ha npoCTaTaTa ( ~ ~ H oKBPUMHOM, M, OCTbP ~ ~ O C T ~ T CKJlepo3a M T ) , Ha MeXypHaTa ~MfiKa, T Y M O P M BTPMTOHyMaHa n M K O H i' M R Mew K~M HesporeHHme npMrnHn x t ypMHHa peTeHqMn cna,qa~ T p a e ~ a ~ ~ nes~n, r~me y o p m e M pereHepaTwaH M T e 3a60nR~aHMR Ha ~ ~ ~ H ~ M03bK, ~ H M KaKTO F I M 3860nRMHMR Ha UeHTpEUlHaTaHepBHa CMCTeMa.

fl~amoaa~a e nectta- no a ~ a ~ ~ e M 3onMneaqMm a~a ce yeenwreH nworeti uexyp B ponHaTa qacT Ha KopeMa, popw po HHBOTO Ha nbna(rno6yc ee3n~an~c). llann~pa ce KaTO mWbK, yMepeH0 IlnbTeH, 60ne3HeH npM HaTHCK mop. P e ~ e ~ q nHa ~ ypwaTa i~a Moxe Aa ce crpewM c ronm KopeMeti ~ y ~ oronma p, mcra nnM 6 p e ~ e Manca. ~ ~ a Ho CbWTaHMeTO OT XapaKTepHMTe aHaMHeCTMVHM OnnaKBaHMR H 06eKTMBHaTa HaxopKa norm tie 3 a ~ p y p ~ pMa~aa~ mosa~a.

AKO e~a~yaq~ Ha mypwHaTa a no ropHMR Harw He ce ocaqecTBM, ce npennpweMa cynpany6wr~a neprcyratitla nyHKuvR. TR Moxe pa ce M ~ B ~ P U I M C mnra Mrna M n H TpoaKap, HO 3a n p e p n o r ~ ~ e a~ a en o n s e a ~ e ~~ ao cneyan^^ (aa uen~a) ~a6op (~MCTO$MKC). ~ npw TRX, ocBeH IlYHKUHOHHaMrna, MM8 M ~ O ~ M ~ T M ~ ~ H O B ~ T P KORTO ~~HC npes HrnaTa ce Baeewa B Mexypa M ocbqemsrreaTpaeti ppeHax Ha ypuHaTa. Ca~a~ ~~ aH K U Hce R u3ebpwea no cpepHaTa n M H M R ~a,q C M M $ Mc ~noKanHa ~T~ ~ H ~ C T ~K ~o MxR a~ . ce a Uenm cw:cKannen n npea Hen, nepneHpHKynRpHoHa KopeMHaTa cTeHa, ce nyHKapa Mexypa. Y ~ M HM~~ T T M ~C nop ~ ~ HanAraHe. AKO ce ocTaeM noc-roRHeH cynpany6~re~ ppeHM,TP~~CIVK C e ~ 3alllMBa T~ 3a KOWTa. O~~CHOCT OT HapaHRBaHe Ha KOPeMHM OpraHM npM o$opnnen rno6yc B ~ ~ M K npamrecKn ~ ~ M C Hma. Cynpan y 6 ~ r ~~ a~ ~ a K ~e M npo~neono~asa~a F I npn npeKapaHM KopeutiM onepaqnM B ponHaTa racT Ha KopeMa, nopa,qgqn onactiocToTtiapaH~BaHetiarepeaTa.

He3aencn~o OT npMrMHaTa, eeaKyMpaHeTo Ha a m p xaHaTa ypwa ~pfl6ea Aa ce na~bpwlrcnewtio. Tom Moxe pa cTaHe no pea HarwHa: rpe3 ypeTpanHa KaTeTpM~ ~ U MM F n M I rpe3 cynpany6cllr~a neplcyrawa nywuufl. PM KaTeTpM3al(MRTaCe 3anO'iBa C MeK KaTeTbp 18-

qa K ~ M cneuvanwm xupypr Mnkr yponor. noeepe~~ cne1 e npeoponrrsatie Ha ocTpaTa yputitia 3qpbXKa: AKOIlaUMeHTbT e M M M M I l P e f l X O ~ ~ PeTeHUMM M M n M TeXKM m3yPMM- KaTeTbpbT C eO C T a B R IloCTORHeH40 M~RCHRB~ ~H a~ p~amoaa~a. BC~K naUMeHT H C peTeHUMR ~ p ~ 6 pa aa 6bpe HaCOqeH 3a yponoMrHM ~ a c n e p e c a orneA ~ ~ ~ Ha yrorHRsaHe Ha npMrwHaTaH eTMonomrtionereHue. %TO npM IlaUMeHTMC PeTeHUMR 683 npernefl (TYLUM p a ~ ece ) npepnMceaT XOPMOH~,n f i KaTo ce ponycKa, r e IlpMYMHaTa e npOCTaTeH WeHOM. Toea He ~ p ~ 6 pa s aC e npaBM, Tb8 KaTO npM HallMrMe Ha KIP4HHOM MbXKMTe XOPMOHM q e CTnMynMpaT pacTexa MY. Tp~6ea pa ce cnaa~a npwHqwnbT: nbpso p~amosa, cneA TOM nereHMe.

J l e c r e ~ ~ e ~ o ~ p ~ 6npoeege ~ a g a co~cneu~anumu e TO no ClleWHOCT, T b l KaTO BCRKO 3a6aBRHe IlOBnMRBa ~e6na~onpum~o mcHnTe pe3ymam. 3mava~a ~ag e x y p ~ n ne ~~ a e pga o 6 n e ~6 r0 ~n ~ a ~ a (06e360n~saqn)M ncclxuKaTa (O~~O~CIIOKORB~~LI), ga sanor~e nevetiue c Heparin (no 5 000 UI Ha Bcem 6 h) M ga o p r a ~ ~ 3 ~ ~ p3 a n p a q a ~ e Ha ~ o 6 0 n ~ n B~ cneq~an~3~pa~oo~gene~~e. C npManM3bM,H0 C n p ~ 6 a e CMMmOMM e~~ Ha nOKanHM M 064~ Bb3llanUTenHM npOMeHM npoTHra M OcTpOTO ~ b 3 n a n e Ha ~ ~Ke~ B ~ ~ H O ~ Tena H M( ~ Ta ~aep~n 6~ o) n . ~n~e

@ M M O ~ npegmaen~ea ~T~ ~ a n m v ~a ~e ~ a m ~ ( c r e c ~ e ~rnaenvKaTa ) Ha rnetta ce p a 3 ~ ~ s nporpecmeH a OTOK, o~eop Ha npeyqnynna, nopmMKoeTornasMncaaTaHavnetia npMgpymeH c ~ O ~ K M a ,np# n o - ~ a n p e g ~ a cnyvaH n~ M C He uoxe ga ce owpwe. TPO$M~HM CMyqetiMR (go r a ~ r p e ~ a AMa~03aTa ). e necHa o~~osa Moxe ~ a ga nocTaeM c n e i e ~ npo6ne~, - oroneti M oToreH rnatic n e w , 3~ K O ~ T Oce BMWa KOraTO: oTorHa KoxaTa Ha npenyuuynra. 1. Aoeeae ao pa3em~meHa 6 a n a ~ o n o c r m ~ . Bwnane~e Ha rnaeMrKaTa Ha rnetia M Ha BbTpeuHuR nMm Ha npenyqnynra cbc cb6npa~e Ha ceKpeT ( c ~ e r ~ a ) , 6 0 n ~napeHe ~, npM ypwiupatie.

peno~~pa Ha ~e rnaeMrKaTa: c gee pbue' ce o6xaaqa YneHbT, KaTO IlatlqWTe IlpUTMCKaT rnaBM'iKaTa HQOny, a M BgBaTac n y m nocnew~ocT~pR6safla ce p a 3 w ~ p ~ npenyqwym ce TernM Harope c ocTaHanMTe npbcTu. AKO nOHe VaCTM'IHO OTBOPbTHanpellyl(MyMa. Toeamam, K a T O ToBa H e ce oTgwe, ce ~ 3 ~ b p w e dorsumsisio, a T. e. nOCne~HMRTCeOnbHeHa3QKaMWHOeaTaHaVneHa,3a pa3cura~eHa npncTRraqMR npbcTeH no ropHaTa ga nponMrM MRCTOTO Ha oTeopa. T ~ cbc M coHfla M n Mc noebpmom Ha rneHa (aaga tie ce Hapatiuc a w m r n e ~ ) . flpb~~e C e~ ocao6o~aea b~ M penOHMpaHeT0 e 6e3 OCTbP MHCTPYMeHT (MYCKUTO) C e IlWHMKBa npe3 OTBOpa. npo6ne~.f l p ~ n a r ace noKanHa M H $ H ~ T ~ ~ ~ ToA ce pa3~ura M pa3urwp~~a. Ta~a ce gaea ono^ Ha a ~ e c ~ eCnen 3~~ MaHnnynaqMRTa . TpR613a ga ce cnegn 3a cb6pana~a ce cMema M n M ypnHa. mpe~qcbg, K O ~ Og , o pM ~~ a n b~~P, B npomnmTentio. H 2. C ~ e c ~ e ~Ha me oTeopa ~o cTeneH Ha nbnHa 06nm~epaqm~ m pa3emme Ha ypmHHa peTeHqmR. f l p ~ Ou(e no epeMe Ha a~ecrewma CW~ ce T npowma. OTHWMTenHOTeCeHHCHaM~eHaenaCTHClHOCTOTBOPHa AKOneKapm M M a npo6ne~u npM npeogonReaHe Ha npenyqnya, ~ o Moxe l ga ce n3~ernu KopoHarnattguc napa$~~o3a~a, rp~6ea ga Hacow BegHara ~ O ~ H M KR ~ M cneqvanucT. f l o c r a t l ~ ~ e Ha ~KoMnpecn o e HenpaeMnHo Ha netiHca M ga npMcreme KaTo B npbcTeH vnetia. B pe3yn~a~ Ha HamnnnwR3acroA B caMm npenyqMynr M e Te 3acMnBaT oToKa.

Ha ~e a~~~6amep~ Tepanwn a n ~ a (~o6pe e n a p ~ x n Mm e~ n a n m e n e npoqec. ~ n o ~ a i i ~ n - r e c ~ ~ r n o ~~ c la s ~ a i a e a KOM~HH~~ ycnoKomaHe MR), Ha 60nme ( a ~ a n r e ~ ca ~ O ~ K B nepuHeyMa M M ~a3a (CH~HM, no nync~paun), TOnnM MHM, $~3kI0TepanMR) MOCMrypRBaHeHaApeHalKHa HanbHM 3a ypMHMpaHe, TeXKa AM3ypMR P O PeTeHqMR Ha YpMHaTa. P ~ K T ~ J ~ H TyluMpaHe O T O e 60ne3HeH0, H0 B M 0 YpMHaTa ( K ~ T ~ T ~ M aK0 ~~ eH ~~M O ~R XO )A,H M O 60nHMRT . B yponomwo oTAeneHMe. 3a ~ n a r ~ o a a ~ B an.o - K ~ C H M CT T~ ~ M U e ~ b a u o x e ~ Hacorea 3a xocn~TanM3aqm

OCTPMRT OpxMennRnAnMMT e a b 3 n a n ~ ~ e n ~ o $e6pHnMTeT, oTnqHanocT, 6e3anemue. 3a60n~sa~e ~a rec~nca M ~ e M n n g q ~ ~HO a ,H ~ A - ~ ~ c U To n o ~ ~ ~ ooco6e~o ra, B ~avano~o ~ ,b 3 n a n e ~ u e Ha AmTa opraHa epHospeMeHHo. o6xeaua cauo enMAupMMa. Onnama~nma ca ~ O A O ~ H M HO npw nannaqMR ce HaMclrpa yaennreti M 60ne3HeH

KOMTO ~ ~ ~ H H K B ~ T H ~no ~B -b '3 ~X ~ O c m T uo I l b T (~Type~paTa, oco6e~onpM RTporeHHM HaMeCH KaTO KaTeTPM3aqMM, 6~)1~lpaHMfi M Bp.).

#06onuns~o noeeReuHe H neseuwe

3a60n~aa~e aanovaa ~o oc~po,HO He atie3anHo, c 60nw B TecTHca, K O ~ e O p e n ~ r ey~n, m ~ ~60ne3~e~. e~, K o x a ~ aHa CKpoTyMa e cac 3arnqeH pene$, Tonna, aarepae~a.B HanpeflHanme C T ~ M H Moxe Aa MMa $nyKTyaqMFI. O 6 q o ~ oCbCTORHUe e HapyWeHO -

n o c ~ e n ep~ e x m , noeflMraqa npeepba~aHa CKpoTyMa, $ ~ a u o ~ e p a (cbrpeeamqn n~~ ~o~npec M~ WMpOKOCneKTbpeH ~ H T M ~ H O T M K . AKO A0 TpeTMR AeH OCTPMTe Bb3llanMTellHM CMMnTOMM He HaManeRT ~HTM~HOTMK CMeHR. ~ T C ~n e ~ e H M e ~ 0 ~ p R IlpoAbnXM 6~~a A0 nbnHOT0 03flpaBRBaHe. PRRKOKaTO OCTbP opxnenwwMhnwr ~ o x~a e 3anorHe ~ o p ~ yHaTemca o p M n Mc n e q u $ ~ r e npoqec. ~ Hai-no6pe e 3 a 6 o n ~ ~ a Aa ~e ce neKyea B 60n~uqa.

Toparro Ha TecTlnca

Ha n p n ~ a n q MY. ~ ~n eo p a n ocTpaTa McxeuMR ce RBRW BMCOK C T O W Ha 3aCerHaTHR T e C T M C ( n 0 p ~ bCKaCeH I OT cllnHa60nKaM 6bp30 pa30M~lrle Ha HQKPOTMWH npOqeC (4ycylteaHeTo KOPBOH), cMnHa nannaTopHa 60n~a, yMepeHo 6 h). K a ~ o ce M M a npeABMA, r e OT TOM 3a60n~aa~e yroneMeH TecTMc, KaTo tie MoraT Aa ce o ~ r p a ~ n r a ~ n o 6 CTpaaT CbBCeM MnaMXOpa, OaTaJlH0CTTa0~3a6aBRHeT0 TecTncaTnenMnnAnMaT, KOPAOHLIT e 3tye6ene~. Pene$a~ Ha ~ ~ a m o a apecnemmio ~a, Ha nereHMeTo, e o r e e ~ n ~ a . Ha cKpoTanHaTa Koxa He e 3arnaeH - TR He e Tonna, ETO 3aq0, 3a60nRMHeT0 ~ p ~ 6 e C a e n03HaM ~a OT B C e K M HRMa $ny~~yaq#R. B no-KbCHMTe CTqMH Ce n p n 6 a ~ M~ neltap. Pb~otmue~ npnHqMn: np# m e w aKyreH C K ~ ~ T ~ M aa3nannTeneH npoqec, cMMmoMme ce B o 6 n ~ x a a a M~ Aa ce na~nmrwTOPBHO. He e rpewKa HacovBatie 3a noKpMsaT c opmenMAnflMMma. ~o~cy Mm onepaqw Ha AeTe c ocnp c ~ p o w H CM: c~~~e~~e3a~opa~o~w~~paonepa~~~onocne~~o~o~a He ce B o r n e . r p e m e Aa ce MMcnlcc 3a eeeHTyanHo, TOP~HO M Aa ce 3a6aen onepaqma.

Cwvmovm~ra
Xapamep~mecHMmoMn ca: BHe3anHa 6 o n ~ aB TecTHca, KOFITO e wnHa, nocTomHa. npaen BneraTneHne,

278

ce , ( ). ce . , - , . ce . : . , ce

. .

- - - , . . . . , ce .

, ( , , ). , ",
.

ca - , .

, , . - , . . Metronidazol. (- ). - , . .

ce ( ). , ", . . ( !) ce . , , . ,

280 -

ca , ce ce ce , , . ce . ca . - (), (PT). - : ; - : ; - ; - .

ce ( - ) . (+): ce (). . (-): : , , , ( , ). : , , . : , , . : . : , . : .

, ( ), , , , . 2. (, ) : , ( ), (, , ), , , (, , ), . : . : 3. (, ), , , , , . 1

1.

1. 2. 3. 4. , , , , . Rh. . .

I. .
. 1. : - ; - ; - (); - ; - (); - ; - . 2. - : - , , ; - , ; - ; - ; - , ;

1. , . 2. , -

3. , , , ce ce . - ( ); - .

- 281

ce !
1. ce () . 2. ce , ca . 3. ce . 2

, ce . . . : , , .

II. .
1. : - , ? - ; - (); - . 2. - : - ; - ( , , ) - , ; - . - ; - ce .

1. : , ; ; . 2. : ; . 3. : ; ; . 4. : ; ; 5. : ; ; ; . 6. : ; ; . 7. : ; ; ; - .

1. . 2. ( ). 3. . 4. - . 5. - .

1. , , , . 2. , Rh. 3. ce .

III. .
1. : - -/. ( , , ); - (, ); -(); -. 2. . ca - + , Ht, , Rh, ; -/ . - (, ); - (, ); - (, ). 3. , , .

1. - . 2. : - + , : - .

ce !
ce .

282 -

- : - (, ). ce - , , . - ; . , , 1. - -: - ; - , , ; - , . 2. - -: - ; - ; ; - ; - ; - ; - ; - , , , , ; - ; - ; - -, -, , ; - ; - .

. ce , ce , . : , , , . : , , ; , .

ce !
1. ce . 2. ce ( ), ce . - , , ce (7. 9.2)

() . ce , 6 , . ce , (, ).

, , - .

: 1. , . . 2. . ce . 3. : , , , ; , , . , , . ' : 1. , . 2. . 3. ,

.: . 9.1.

:
1. , , , , , , Rh, . 2. ( ). 3. - , , .

2. . 3. - : , , , . N. .:
1. .

 9.1.
. . .

. .

++

+ 75%

+/-

. .

+ 75%

++

6-8 .

+ 50%

. .

. .

IUD

. .

. . .

+ . .

+/-

(no Phillip, Ph., J. Goldstein, A. I. Rubin)

284 -

9.2

, , , , , , (
)

, , , ,
,

, , , ,

ce 4. (). ce , , , : 1. . 2. . 3. .

:
1. - . 2. - . 3. - .

ca , ce , , .

1. . 2. . . . 4. .

1. , . ca , . 2. ca : - - , ; - { ) - . : , , - . :

, - .

1. ce - ( -). 2. - - . - .

- 285

. : 1. - . 2. - - , . 3. - ce .

3. - . 4. , . : 1. , , . 2. . 3. . 4. . 5. .

, . 1. - . 2. - , , . 1. . 2. : . 3. - ( + ). , ce .

1. . 2. 3- (t,+ ). 3. - . 4. . 5. , , . 6. .

:
1. , t, , . 2. -. 3. - (, ). 4. .

1. . 2. ( , ). 3. . 4. . 5. . . 6. - , , , . 7. - . 8. 3- (V + ) - , , - .

ce (, , ) . ce , . : , , . : : 1. .

2. .

3. , . 4. . : 1. : , . 2. -

ce !
1. ce ( ce ). 2. ce . 3. ce , , ca .

286 -

"" . . ce IUD , ce . ce - .

ce !
1. . 2. , ce . 3. ce - , ce .

, , .

. - ce . ce, . , IUD , ca , . ce - .

: 1. , . 2. , . 3. . . 4. , . 5. , . 6. , t, . - . : 1. 2. . 3. - , , .

1. ce ( ). 2. - ( ). 3. , .

1. (, , ). 2. . 3. ().

: 1. . 2. . . , t, . 4. - .

1. , t, , , . 2. -. 3. , - . 4. t - - , ce . 5. .,

1. , - , , , . 2. - , ce . 3. - .

1. , , , . 2. : - ( ); , - - - + . 3. - .

- 287

, . ca N. Gonorrhoeae Chlamidia, , , , . - - (. - , Bacteroides, Enterobacteriacae). ce . ce , ce . : , , . , .

1. , , , , . 2. : , , , , . 3 - .

.: . 9.1.1

1. ce : . 2. -. 3. t - . 4. . 5. 2-3 , ce .

1. : - , - , per os. 2. : , . . Totapen (Ampicillin - 2 g/ .) Netromycin 6 mg/kg/ i. m. Flagyl 4 1 fl. i. v. ce : Vibramycin, Eritromycin. 10 , ce 3 . ce Augmentin: 4 g/i. v. 48 t, ce per os. 3. . 4. . 5. - ce . 6. ce . 7. , ca ( ). - . 8. 2-3 , ce .

: 1. ( ce ). 2. . 3. . 4. . 5. ; , . 6. . 7.- () ; . : 1. (, ) . 2. , ; - . 3. . . 4. , . : 1. - . 2. - ( ce ). 3. - , . :

ce !
1. ce , , -

288 -

- . 2. ce , - - , , ( - , ).

, (, ). - " 20 . ca: , , . , , . . . .

: ; ; .

ce - , .

, , , . - , .
. *

1. ce . . ce . 2. - 3. - . 4. - .

1. - , ; 2-3 . . 2. .

.; . 9.1. (). ce , . 1. - . 2, - ce -| ( ) .

, , ,
, , ce . .: , , , (. 9.1).

, , . ce, ce , ( ").

1. () - . , . 2. ( ) -

- 289

(, , , , , , .).

ce - () ( , ).

: 1. - - . - . 2. . 3. - , , , . .: . 9.1.

- , . ce . , . , ce . 1. ce ce . 2. ce . 3. - . 4. ce - , - . 5. -.

1. - Acetysal. 2. - . 3. .

, ce . 1. . 2. ce , . 3. : , , .

1. ce ; , . 2. - ce -- , . () . 3. .

, , . , , ce . , ce , . , . ce ce ce .

( , , , , . ), ( ) , . ce , ce ( , , ). , .

290 -

- : 1. , ; , , () ; . 2. . 3. . . . 4. . - . 5. - . 6. (). : : ; ; ; . 1. . . 2. , , , , . 3. . 4. (, , ) . 5. () . : 1. . 2. , . 3. , . . ce , , , , , , , , ce . , -, . 1. . 2. (, , . .). .

. 3. , ( , , , ). .. 4. . 5. . 6. (. Vibramycin, Erytromycin, - Trobicin). 7. (Norgestrel, Ethinylestradiol). 1. - . 2. . 3. . 4. , . 5. , . 6. .

1. , ce . 2. ce ( 3 ). ce 2 -. 1. . 2. , , , . 3. . ce .

ce !
1. ce ce . 2. ce ce , ce , . 3. ce ce 2 - . 4. ce . ce .

- 291

- . ce . ce , . , = . : - -, , , , , , . ce ce : : , ( - , , ). : , : - - , , - , . : - , . Rh; - ; - .

II.
: b - 24-48 ( 90% (+) (-), 5 . + + = ( ce ).

1. . 2. Methotrexate.

ce !
1. ( ca , "). 2. + . 3. . 4. ce - Rh- . 5. ce , , . 6. ce , , ca b- - 2 mUl\ml. b- - 1 h ( ).

1. (+): . 2. (-): , , , .

( 20 . ), - - ( 12 . ). 20% . , . ca ( , , - , ,

, (, ), - . -. ( ) .

292 -

, . - , , ) ( ).

3. , . 1. -, 48 , - : " . 2. . 3. .

1. . 2. .

: 1. , , b- . 2. , , , t. 3. (CA) : ce : ce : ; . 1. - , , . ce (, , ). 2. ( ). - . . , - . : ( ), . 1. ( , ) , , ca - . 2. , , ce ca . - ce . 3. ( , ) ce " ( ). ce - ( 6- ), ". : 1. ++ (, ).

, Rh , , . 1. . 2. , . . 3. . 4. ( ). 5. . . ce . : + , = ( ). ce . - , . . ce . ,, ". 1. ,,", +++ - 2. : - (); - , - 10 ; - - per os i.v. - : Totapen (Ampicillin, Gentamycin). (). 3. : - ++ - 8 : ; - - 8 : -

- 293

( ). 4. (): , , , , , - : (Klamoxyl 500 mg 2 caps 2 . 5 ). ce - -, Rh(-). ce , ce ce .

ce !
1. ce , = ( - ). 2. ce - . 3. ce . 4. ce , ce 8 . . 5. ce , .

2. , ( ), , , , . 3. . 4. , , . 5. +++, (). 6. . : 1., t, , . 2. (), , . 3. - , . 4. : , 5. : (- );

.

6. : , ce . : 1. ; . 2. . .

1. , . ce (, , , , , ). 2. - . 3. - . 1. , . Rh, , , t, Rh . 2. ce - - , . 3. ; ; . 4. , . . .

ce 4% .

1. ( ) () - 30%. 2. () - 20% . 3. ( ). 4. Vasa previa (Syndrome - Ben Kiser). 5. . 6. , , . 7. ( ). , ,

1. , . . 2. . 3. . 4. , --

: 1. (, , ).

294 -

, . 5. ce -, . 6. , Rh (-) Rh ca . 7. :) - , , () - ; - + : , ce ; ; . - : ; - : - . - : ; - : .

, , , .

: 1. , (, ). 2. . 3. - , , , , . 4. . 5. : , , . : 1. , ; . 2. , , , . 3. , . 4. . 5. , - . : - : 1. , . 2. . 3. , . 4. . 5. , , (Hellp ). 6. . . : = !

ce !
ce Rh Rh (-) .

, (- )
, ce , , . , . ce . ce . , ce . ( 140/90 mm Hg), - , .

, , ce . 1. - . 2. -. 3. Hellp-- ( ).

1. , , . 2. , . 3. ( , ). 4. . 5. , , , . - - .

- 295

6. - 7. - Diazepam, Valium, Nepressol, Trandate i. V. .

2. ce , ce .

1. , Aldomet (Methyldopa) 2-4 g/24 h . 2. / : (, , ) ( , ), . - ce , ce Nepressol ; - , ce ; - : . 3. - ce - . - ce ce . - Valium 50 mg 500 ce /12 h; Magnesii sulfas: i. v. 6 g/20% 15 min; 2g i. v/ h . ( , ) - Calcii gluconas 1 g i. v.; - ; ce ; ; - , , 110 mm Hg; - ce ; - ; : , ce . - - ; - : .

. - . ce . ce .

. ( 30 min) ce , ( ). , - ce , , , .

ce . , , .

1. . 2. . 3. . 4. - , . 5. .

ce . , , .

1. , . 2. , , , . 3. .

ce !
1. ce ( ).

296 -

, ce ( 2000 ml). , (, , , ). , ce . . . , . . (, ). . Rh. 1. . 2. , . 3. . . . 4. ( +++). 1. . . 2. . 3. . . : 1. +++. 2. . 3. . 4. ( ce ). 1. : , . 2. . - : , ; - : , , . .; - . 1. : ().

2. : Rh . . 1. : ce (b- . . 2. : ( ). ( -, , , US). ce (, ). ce ! 1. ce ce ( ). 2. ce , . . ce . : 1. . (). 2. , . . 3. ( ). : 1. ce . 2. . 3. . . : +: . . 1. ce . . . - - , ; - , ce

.

- 297

- - . ce ! 1. ( ). 2. ce ( ). 3. ce . , , . ce , . , , . : 1. (, ), . 2. (). 3. . 4. . 5. , . 6. , . 7. ( , , ). 8. . 9. (). : 1. : - . 2. . 3. , , . 4. (, , ). 5. , . 6. , . : 1. , , . 2. + .

. 1. (, ) .
2. .

3. . 4. , 5. . 6. . 7. . 8. . 9. ( ). 10. , . 11. . 12. . 1. , , , , . 2. - ( - , , ). 3. . 1. ce , - 37 . . ce . 2. . 3. : , , . 4. - . 5. - . 6. - . 7. . 8. - + . 9. -+. ! ce , ce , . ce , c . t , ce .

298 -

: 1. (, ). 2. ? . 3. ; , ? 4. - , --, . 5. . 6. , . 7. . 1. . 2. , . 3. ( , , ). 4. ( , ). : 1. . 2. - 38,5. 3. , . 4. . 5. . 1. : , , , , , . 2. , , . 1. , t, , Rh, , . .

2. , . , ( ca ), , . 4. ( ). 5. . 1. . 2. - . 3. - . 4. ( 4 , ). - Totapen (Ampicillin), Gentamycin ( ); - . 5. (. 9.3) 6. - . 7. . ce ! ce , , ( - ). . . . ( J. Belaisch Allan" et R: Taurelle) 37 . .

9... 37.., 1. (Ampicillin, Gentamycin) 2. (Paracetamol) 3. 4. - Urogestan 1. 2. ce (+) (-)

1. Ampicillin, Gentamycin, . 2. . - - ( ce )

- 299

: 1. . . . 2. ( ) . : 1. . 2. . . 3. . . . 4. . : 1. : , , , . 2. . 3. ( ce , ).

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1. , . 2. , , , . 3. . : , . , . - , . : + Oxitocin 5-10 UI i. v. + . : - ; - i. v.; - : . .

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300 -

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4. .

1. . 2. , . 3. ce ++. 1. -. : , +++, ; . - + Methergin (Methylergobrevin) 30 60 . 2. - : ; Sandopart 1/2 tab. 15 min ; - : ( ce ); - : ( , ); - , ce . 3. . , . 4. : - ; - : , : , . 5. . - : ; - : ; - : , , , , . 6. - , : - : : i. v. . ce ! ce : , .

5. - . 6. . 7. , , , . 8. : , ( ), . : 1. : t, , . 2. ( ++, ++) 3. . , , , , t 38,5. :

, ., , , , 1993 , ., , , , 1992 Goldstein, Ph. J., A. I. Rubin. Current Emergency Diagnosis and Treatment. Obstetric and Gynecologic Emergencies and Rape. Los Altos, California, 1983,328-346 Pierre Carli, Ives Lambert. Protocoles 91. Urgences plans & Schemas therapeutiques, Paris, 1991,152-183 Rath W., G. Grospietsch. Akute Notfalle; Pathophysiologie -Diagnostik-Erstbehandlung; Akute Bluntungen in der Gynakologie und Geburtshilfe, 1993; 413-459

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ne$a~c Ha KopevHaTaMycKynaTypa Clepe~ ppo6, cnes~a TYM~P P~KTWHO Tyure @ e v o p a n nyncaum ~~ (TO~HCIHM vec~a) BXO~ BpaTa H ~ (xep~w~) ~#M($Hu B M l l M (~ynpaKIlaBMKynap~L4 - paK Ha C T O M ~ ~ ) re~u~anuu l l p ~ ~ b n n no e ~$na~rose~e ~e L ~ ~ ~ BWYMOBe: HM HOpManHM, CMnHM, ~ Y P H MJl , MflCBa flepMcT~MKa Cbpue: a 6 c o n ~ a ~p ~m a m , cbppeqeH n o p o ~ 6 ~ ppo6: n nHeBMOHUR, U31MB, IlHeBMOTOpaKC YCTHMM JlMraBMqa: HeHOpManHaIlMrMeHTaqMR (6onec~ Ha Addison) PeutzJegher's CMH~POM) BeHqM: OTllaraHMR Ha O n O B O Koxa: nurvetiTauuR, neTexeanHuxeMopam, ~onare~osa Pea~qwi Ha nannnuTe (~a6ec popaanuc) O r ~ HanRraHe o (rnay~o~a) M~HMHM~~M C~o6one ra3 ~ nop p~a($pamna~a (BHMMaBai 3a npepuwtia nanapo~o~ud!) P e ~ ~ r e ~ m opa nu ce~M~KJ-ID~M , ~POCTP~HCTBOTO ~a Tpay6e - nep$opaum ~a CTOMaluHOrpeBHMRTpaKT; AA; c@$peH#'4eHa6cuec, CMHppOM Ha Xlrlna8gm-u (BWCHO, Hap c n e 3 ~ a ~ Ma pyope~y~a), PRAKO ram06pa3yeaqu nepMToHuTH EBeHTyanHo: flOBTOpeHMe CbC 3aBbpTaHe Ha TRnOTO B nRBO neXaUJ0 n0nOXeHMe ( ~ m q ce a no-po6pe e ~ p y x a ) EBeHTyanH0: nOBTOpeHMe Cnep 1 h CBO~O ra3 ~ cy6xena~an~0, ~H npeqeKanHo, peTponepuToHeanHo C~o6ope ra3 ~ B MlbqHMTe nbTMqa (flep$~pauMR);M M C n M 3a U3BbpWeHa xonepoxopyope~oa~ac~o~o3a ~POMRB H PeHTreHOCKOnMR ~ Ha CTOMaa, TbHKO M pe6eno qepElo (B~)KHo npM ~neyc!) KOHK~~M~HTU/BK~~~B~HW; fla~~peac )KJlbreH MeVp 6b6peqn YPMH~PHU IlbTMqa EXMHOKOKOBH KMCTM Xuppo~e$posa Xena~overanu~ Cnne~o~eranu~ ~ W ~ C H CeHKGl M ras noA p~a$panna~a, M ~ ~ MM B ,H $ M ~ T ~cbpperHa ~ ~ M R , KOH$U~P~L(MFI Ce06op~o flOABMXHa Te'iHOCT MllM OrpaHHCleHM T W H M KOneKuMM B a6po~eHa, xenaTocnneHoMerannfi, T ~ M O P M Ha repHuR pp06 U nawpeaca; 3me6ene~a cTeHa Ha MlbqHMR MeVP H a 4 mm, ~ B O ~ H KOHTyPMPaHa O CTeHa, TeClHOCT C ~ ~ X ~ ~ ~ unu oKono M ~ ~ H M R Mexyp, ~an~yno3a Ha vexypa M ~ M xnbrHnTe nbmqa, xnppo~e$po3a, ~an~ynosa u T. H. (Cbqo K ~ K T O npu nopro~oe~a aa e e e ~ ~ y a onepaqu~) n~a nKK c p n $ e p e ~ u ~ a n 6poe~e ~ o M CYE (nee~oqn~osa c oneeRBatie, y CKOpeHO CYE), KOarynOrpaMa, 8 0 ~ 0 r p a ~KpbBHa a, 3aXap, KpeaTHHMH, TpaHCaMUHEl3M, WKMHa @c$aTa3a, ypuHa/CrOT, C m , L(nK, np)c, MB $pa~uufl,a~unaaa, nunasa, KpbeHM ram88

Peti~re~ocxonln~ Ha KopeMa B npaao nonoxe~ue

lrtxnepea~e Ha rpbwuR KOUI Y3A ~a K O P ~ M ~

T M H

na6opa~op~~

Cxe~a 10.2. Knwu~run acnem n emonornn Ha 6onlca'ra npn oc'rbp xnpypmeu rcopenn

P ~ K T ~ JTyure, ~ H o XepHHaJlHU O T B O P U (~ecra) nync, AH, 4BH P W ~~a MA U W ~ H ~ T O @e6punme~ Vacoea nuypesa

I
V

Msonupa~a 6on~a Wibr~H a 6b6pecl~a KonuKa Fl3eeH CUHnpOM Xpo~ucle~ na~~pea~ll~ C n a c ~ ~KrOe ~M ~T (XYK)

+ 1" ( ~ p e c ~ a ) + pe@a~c
Ane~pULplT Xonequc~m CU~MOU~~MT ~neep~u~ynu~ C~~~MHMT nueno~e@pu~ Me~enoe puBepTuKyn An~oxone~ xenam C~ n e n r ~ a nexunpa~aqu~

+ Uepu~o~ea-

+ pe$a~c

+ MeTeopU3bM

C nOBHWeH0 4BH OT ~apnuore~ npou3xon e~

C xeMoparuR

U l o 6e3 ~ 6on~a nepmo~m y

Ocrbp n a ~ ~ p e a m npomnxaaaqa Kapnuar~a

H~B~HM~TOYH~

A~eapus~a Pyn~ypa Ha panaKa

(no J. Frexinos)

MM Ha Blumberg, Murphy, Ortner, Boas).

I. O m p anewmqtn
3an0Wa BHe3anHO C nocTOflHHa 6on~a B NCHaTa nnuarHa o6nacT; Moxe pa a n o w e H ecnnHa h n ~ Ba ennracTpnyMa nnu oKono mna, n cnep Hmonlto vaca ce no~anu3npa B ClffcHaTannnawa RMKa. 6 o n ~ a e ~ cbnpoa BOpeHa C rweHe M epHOKpaTH0 nOBpbqaHe (no-'iecTo), HaManetianeTnr n 3appbx~a Ha raaoee. Te~nepaTypa~a e 37-38C. Or nxnepswnma - TeMnepaTypHa pa3nn~a -1 T, nesKoqmo3a c oneematie, ycKopeHo CYE; Ro; exorpa$ m (f), TepuoMeTpnR n ~ e p ~ o r p a $ n ~ . YcTa~o~~ ce eyMepeHa a TaxwappnR. n p e p ~ a KO~a peMHa cTeHa e c OrpaHuveHa nop~nmocT npn pntuaHe. Bopeqw CMMmOMH M n0KmHaTa MyCKynHa P3McTeHTHOCT, CnMmoMme Ha Blumberg, Paqonc~w, 06pa3qo~, Rovsing,CWKOBCKM n pp. npn pa3npoc~pa~e~ne Ham o b HHR e~cypa~-pe$a~c HaKopeMHaTaMycKynaTypa,HO Bce naK C IlyHlcryMMaKCMMyM B WCHaTa HnMaclHa RMKa (f).

II. O m p xoneqwm
6 o n ~ a sanovea ~a a~ez~an (a ~o ~ a ~ ~x i e3 pnemrHa a rpetulta, mrHeKaMeHHa hnecr), no~ann3npa~a eB ~CHOTO noppe6pne M n w B enMracTpMyMa M npmwpa K ~ M ycHaTa nnetulta, nonaTKaTa nnn paMoTo. .Oc~pa,KHHx a n ~ ahnrca " cenpe~enc~ea 3a nep@pqn~ HaxnarHnrr Mexyp. OT nscnepea~nma - neaKoqmo3a c oneeReaHe, ycKopeHo CYE; exorpa$nma e c pocToeepHocT po 98.5%; Te~MOMeTPMR, ~epM0rpa$~~(80-95% pocToBepH0CT).

IV. flm~epm~yntn

I~OCTORHHM CLIM~OM ca ~ raF(eHe,Texecr, noepbqaHe, sane^. O~~KTHBHO B 2030% OT h n ~ m ce e 3a6en~3ea nwep no m e p m e n KoxaTa BcnepcmneToKcureH xenaTHT, XOnaHMT UnH ~ ~ T Y P ~ HaXrrbCIHWe ~ H R l l b ~ ~ qT a~ .MnepaTypaTa no npaenno e nosnweHa c BTpncaHe (3. nyncb~ e ycKopeH M cboTBeTcTea Ha TeunepaTypaTa. E ~ MK cyx, O ~ ~ O X ~ npn H . nannaqnrr ce ycTaHoema peQa~c B~CHOTO noppe6pne,mei l yaenmeH, HanperHaT, cnntio h n e 3 ~ m e~ v e H Mexyp (nonomen~cl CnMnTo-

V. Meweno0 AweepmKynwr
~ P M L ( M 38 H ~AMBePTMKynHTa MOXe pa 6bpe o6~ypaU M RH ~ $ ~ K ~ U n J M M ' ~H W H ~ena, T R C H ~ W M ~~ K~ ~. ~ R B

ce c xeM0pat-m (peuopam~)nnn qpeeHa HenpoxopnMOCT. ~MaIH03a~a e npeflMMH0 MHTpaOnepaTHBHa.

VI. Penonane~ Hnetn (6onec~Ha Krohn)

3ano'i~aaHe3anHo c h n ~ oKono n mna, ~ a Hero g MB McHaTaKopeMtianonoewia, c noBpbqaHe, TeunepaTypa - 38-3gaCC, TaXMKaPPMR. PM M3CneRBaHeTO C e YCTIHOBRea nonoxMTeneH cuMmoM Ha Blurnberg, Re$a~c.Moxe fla C e nP0RBM M C WlMHMKa Ha ClpeBHa HenPOXOPMMOCT ( ~ o n ~ ~ o o 6 ph a3 n~~ aBaKopeMa, cnvpaHe Ha oTRenRtie Ha ra3OBe M M3llpL3KHeHHR, XMAPOaepH'iHM C~HKH). Moxe Ra npTe'ie XpOHM'iHO C nepMOflMcIHHKOnMKOO6pa3HM 60nKM B KOpeMa, RMaPMR, XMnePTePMMR H neBKOU M T O ~H ~ .e p ~ ~ r BtMcHaTa o KopeMHa nonoewa ce onmBa ~na60n0flBktxeH MH$M~T~~T.

X. O m p ~ e a e ~ ~ e p n an ~e ~~ @ane~ C~~rrro~am~a
3ac~ra npepuMtio neTcKaTa M toHowecKaTa BbSpacT. npe~lllec~ M n ~ Ma IlpMRpyXaBaM H $ ~ K ~ Ha M rOPHMTe R AMXaTenHM nbTMqa. ~ O R O ~ H 60nm M 6bp30 Ca IlpeMMHaIlH B MHHanOTO. BHe3an~0 Ha'iMO C K O ~ M K O O ~ 60nKM ~ ~ ~ HBM KopeMa (BRRCHO), nonoxwTeneH cMMnToM Ha Blurnberg, TaXMKapAMR M $e6pMnH~e~. ~ ~ B K O ~ C H OTHOCMTenHa T O ~ ~ ~MM$O~M M n M T Jl O eBKOneHMR. ~~

A~arnocm~a
Bce naK ~ ~ a m o s e a IrtiTpaonepaTMBHa. ~a

XI. O m p racTptn

AH~MH~CTMC~HMT~ flaHHM3a HaWlOTO Ha flaTOnOMrHMR npOL(eC,Bb3paCT, Bb3HMKBaHe M pa3BMTMe Ha npMflpyxaeaqH ~ ~ ~ O ~ R B ycnoxHeHMR, ~ H M R , cny3, ~ p b M eAMapMClHM M3XOWaHMfl MT. H. ~ P llannal+M H ~ O ~ ~ ~ H ~ no H O C T

xoAa Ha YepeaTa Hnu I I H $ M ~ ~ ~Ha ~M cTeHaTa, R Ha OH^ Ha acTeHMreH xa6~-ryc, aHeMMCleH CMHR~OM M npk16ase~u K O ~ npoMeHH. M

XII. O n e r ~ Ha o ~cmruiaxa C ~ ~ m o ~ a m ~ a
X a p a ~ ~ ca ep 6bp30 ~ ~ HapamBaqMTe 60nw B enuracqxqma, Texecr, x w a , xbnqatie M noepbqatie. 6on~aTa ce ycvnea npM mnTaHe Ha eo1a M neKo HaManusa B npaeo nonoxetiMe.O6qo~o CbcToRHwe e Temo, 'iepTme Ha nHqeTo ca saocrpe~~; AH e HMCKO, nyncbT e cMnHo ycltopeti, TeMnepaTypaTa e BMcoKa, e 3 ~ e~ 06noxe~, b ~ OT YCTaTa C e OTflenR rHMnOCTeHAbX. K O P ~ M t ? neKO ~ T 6anoHHpaH, 60ne3HeH, n0HFlKOra C pe3MCTeHTHOCT M BFma IlepMCTaJlTMKa.

npRBflBa Ce C KmlHHKa Ha OCTbP aneHpMqMT B nRB0; 6on~a B nmaTa nonoBMtia Ha KopeMa, $e6pMnM~e~, AvaPMR, 3ane~ (C KP~B), ge$a~cB nRsaTa MnMawia mKa. O~~M ~R e$ Ta ~ e anapMa c 3a nwocTepKopaneH nepwoHMT.

3ano'iea ~ ~ e a a C n~ ~ cunHa C o 60n~a, KORTO ce cpmh n ~ a "6 . on~a~ ea noCToRHHo cHnHa, aano'i~aOT enMracTpMpa unM MCHOTO nonpe6p~eM 6bp3o ce p a 3 n p o c ~ p a ~ no mAecHuR naTepaneH KatianM no qenm Kopeu. T a ~ ce a p a 3 n p o c ~ p aM ~ MycKyntiaTa ~~a pwrnnHocT ( ~ e a a ~ cc ) , nonoxMTeneH cnMnToM Ha Blurnberg. Onpmnraea ce ~a. ~ o p e ~ - ~ b cc ~rnyxa a " , #nu nnnceaqarpesHa nepnmmlca, c ~ 3 ~ e 3 Ha ~ 'iepHoa~e APO~HOTOnpmnneHue neplcyroptio.
HRB~ c ,mHxanHa

Ha6nlopasa~ ce w o 6 q cMMmoMu: ~ Texecr, c y x m B ycraTa, xaxqa, pe@nemop~o noepbqaHe, KoeTo e MHOroKpaTHonpM nporpecwpatie Ha nepMToHma. Cbcro~~neTO H a6 0 n ~ e ~ Temo, ~ e nMqeTo e 6nep0, nolcpwro cbc cTyueHa nenltasa noT: AnwaHeTo e recro n noabpxtimHO. llyncb~ ce YCKOPRM, AH nporpecwBHo napa. l l ~ q e ~ o e ~3nnawe~0, crpapanreclto, a 6 0 n ~ ~ nm e m Ha rpb6 M n H HWRCHOCbCCBMTMKbMTRnOTOKOneHe. B KnMHM'iHaTa KapTMHa C e pa3nMraBaT: IlepMOp H a nep$opaqng (WOK), nepMop Ha MHMMO 6naronony~e M nepMOfl H a pa3BMT IlePMTOHMT. ~ o c ~ ~ ~ HC M HMqO R TH eC e pasn~rasa OT nep$opa~~se~ p#@y3e~ nepmoHHTC Bcma ppyra eTMonomR. BMHarM~ p ~ 6pa sa ce MncnM n 3a aTMnMrtiHnempa~ H MnoKpHTa : nep+opaqm; careTaHMe H a nep$opaUw M XeMOparMR; npM C p a C T B a H M R B KOpeMHaTa K Y X M H a(cJ~~A s a u ~ ~3 as a M T. H.); H a 3 ~ ~ cToMawHa a ~ a creHa C ~ ~ ~ P ~ M ceO uanclsa T O B 6ypca o ~ e ~ ~ Ma nmeneHn~c HO MoxeAa npeMMHenpea @ p a ~ e ~a ~a BHHC~OB. Pe~ponepMToHeanHln nep$opauun - Moxe fla nwncea ompo Ha'iaJlO, pbcK006pa3eHK O ~ ~ @ M ~~H H C M 6bp30 IlpOrpecwpatie Ha nepnToHnTa; ,H~MM" - nwncBa a ~ a ~ ~ 3a e3a HOU(Ha6on~a Ha rnQHO, C e 3 O H H O C T Ha 60n~aTa M T. H.

paqnn, nepMToHm Moxe pace pasacleM rpea npocMyltaaH eH a ~ H @ ~ K ~ OT M mmanmenHo R T ~ npoMeHeHaTacTeHa.

XVI. nep@opaqlmHa ~y6ep~ynoa~w 1 1 3 Ha ~~ rlepema

LO~HM caT c~ a ~ a ~ ~ 3a e3 TyGeplcynoaa a Ha 6 e n ~ ~ ~H n M 0 XpaHOCMMnaTeJl 6 HMRTpaKT. ~ ~ P M T O H M T e~HT~ O recTo orpaHMreH 6naroflape~we Ha MHoxecTBetiMTenpeABapMTenHMCpaCTBaHMR.

K ~ M H M Kapyiia ~H~T e~ Kamo npn nep$opaqwma.

flwaruocm~a
Bbspama, atiaMtie3aTa 3a oTnapHanocT, 6e3ane~~T M e , KOHCyMaTMBeH, aHeMM'4eH C M H A p o M (*), HaCO'iWT pnammnrHoToMncnetie. Momepa ce nannnpaTyMopHa @pmaqw B ennracrpnya.

XV. nep(topaqna Ha ~

H K qepao O npw Kopemeu W@

2-3C ~ ~ M M L ( OT M Ha'4an0~0 Ha3a60nR~atieT0 ce [OREReaT npepeecTHM4 H a nep$opaq~ma: npo$y3~a pHapnR, pemoparm, M ~ T ~ O P M cna6n ~ ~ M ,60n~m B KopeMa M epm ~a6en~a CMM~TOM a~ H a Blumberg. nep$opaq~mace np0RBFlBa CbC C M n H a PeXeqa 6on~a B ARCHaTa KOpeMHa nonoama, pe$a~c Ha MycKynaTypaTa,sma po nMnceaqa nepMcranTwKa, npMnnneHwe B ttucme r a m H a KopeMa, ne~~oq~~o3a~~e~~oxapa~~ep~a~anes~one~~~. ~ P Texm H cnyclan ~apnae~~epnn, OCWH npw n e w

~ # H # ' ~ HIlpoTMra o C T P M CbCTORHMR: CHHflPOM Ha M C X e M M R(.Ko~~M xa6a3, H ~ Mti@pKT Ha VepBOTO M HCXeM M e i' H eHTepOKOnMT. 1. Ypea~a~a M c x e M M R ce xapamepn3~pa c: patitia 60nKa Cnep HaXpaHBaHe; Y n O P M T ML I M a P M M ; IlpOrPeCMBHO enouraeatie; cucTonMreH t u y B enMracTpMynna. 2. HaA-recroM H @ ~ P K THa ~ TrepBoToce n p e p u 3 ~ ~ ~ OT: a~epoc~nep03a, peBMoKappMT M KnanHM nop04~, apMTMMR, T~OM~O$II~~MT Ha BeHa nOpTe, XMnepTOHM'iHa 60JleCT, MH@apKT H a MMOKappa, T Y M O P MB KOpeMHaTaKyXMHa. Onac~ocrra OT eM60nMR ce yBenMraBa C ~b~pacrra, c nporpecnpaHeTo Ha cbpper~o-6eno~po6~a~a HeAocTan r ~ o c ro ,n e p a q ~ Ha ~roneMMTecbpoee, capqeTo, 6 e n ~ ppo6, O~WMPHM M nPOAbnXMTenHMOnepallMM npMT y M O P M . Ocee~ eu60nm M ~ e c ~ ~ a ~ p 0 ~ 6 0 3 anpMrwia p p y i r a Moxe pa 6bpe ~Hn0nep$y3MfT~a Ha Me3eHTepManHMTe CbflOBe OT WOK M Tpaeti cna3b~ (qa~ena ~a ~ a ~ ~ 3a e~ sa ~0~ e~60nMrHa 6onec~). B crap^^ Ha ~ ~ $ a p m 6a 0n~a~ ea nocrouHHa, HW M H $ ~ ~ ~ ( M ~VepBO, ~HOT IlO O BbPHaTMTe MaTepMM M M a T MMnOCTeH AbX, WCTO 3apbXKa Ha ra3OBe M MSnPMHeHMR. B~ a n p a x ~ e ~ n Moxe m a pa ce n o m Kpbe KaTo . M ~ ~ M H eo xeneu.K O P ~ M e 6anoHMpaH, ~T 60ne3~e npM ~ nanna~ M RC , BRna nepMcTamMKa. 3. BC T ~ ~ M Ha Rn e p ~ ~ o ~ m a - m p a m aa ~,a ~ ~ e 3 a IlepMTOHeanHOTOppa3HeHe, TaXMKappMRTa (~PMTMMF M XMnOTOHMRTayneCHRBaT eK3~KTHaTa~MaMO3a.

3a Hma. Cnelu~a~a nanapocKonMR e c ~ ~ @ e p e ~ q ~ a n ~ o AMamocTHrtia qen. HaB-ron~~a pMamocTnrHa CTO~HOCT Mwa a~morpa@ma; npohneHM B KoarynorpaMaTa.

XX. IKmq~o-waaewwa6onea

KO~MK 3anO' ~T iBa ~ CbC CMnHa 6on~a BW C H O T O nOApe6p~e, KORTO Mpapupa K ~ M McHaTa nnema M paMo, c rapeHe M noapbqatie, HO nuncm nepmoHeanHo~paane3anor~a c ~on~~ooGpa cMnHa s~ah n ~ B a KopeMa, rapetie M noupbqatie (B navanoTo ~ ~ o ~ a w ~ o - ~ y o HO C npMMec Ha xnbrlca, no-K~CHOrpeetio c a f l b p x ~ ~ o ) , 3mpbXKa Ha ra3OBe M H3nPaXHeHMf4, IlOflyBaHe H a KOpeMa ( M ~ T ~ O P M ~ ~ PM a )e. ~ o ~ e p n noF(yeane o~o H a KopeMa c 60ne3~enoc~ no-rec~o ce cpeqa npu nnKorpeeHa Hef l p O X O A M M O C T ; MeTeOpM3MbT e IlO-pRmK C M M lT O M npM BMCOKaTbHKOrpeBHaMapTepMOBeHO3HaMe3eHTepManHa HenpoxopMMocT. n o p p ~ e Ha ~o ~ o p eB ~ea p ~ o6nac~ a e no-xapa~~ep 3a ~ o~e6enorpee~a HenpoxopwocT, HO @OPM~M T~ a C H M e T P M R T a Ha KOpeMa 3 a B M C R T OT J l O K F U I M 3aqnma Ha npenmcTeMeTo. He, TeMnepaTypa M n e e ~ o q ~ ~ o a a .

~e~an-

Amar~ocm~a
Mome I a ce nannwpaT pa3pyn rpeetiH ~PHMKM, vM O PM n M MHBaMHaT. IlePKyCMR Ce Y C T a H O B R B aTMMllaHnreH TOH, a npM aycKymaqm - mBa, Kyplcaqa rpeBHa nepncTanmKa, , n n ~ c ~ a ~ (.napa~e e" Ha K ~ ~ K M " ) . Pe~~renoeo ~acnepea~e ~o no~a3ea mppoaepwrH# H M B a , OTOK Ha K ~ P K P M H ~ O B LH MKTM ~ (JlMnca Ha ra3). CKOI~MRT~ C TeWH K O H T P a C T MnM M P M r O C K O f l M R T aY T O C I H R BaT H M B O T O Ha rIPenRTCTBMeT0.

6b6pe.1HaTa KonuKa ce x a p a ~ ~ e p n 3 ~ cac p a cMntia 60n~a B nyM6anHaTa 06nacr, K O ~ Mpwnpa O K ~ 6e~poM TO, T e C T M C a y MbXa, C C l e C T H n03MBH 38 ypMHMpaHe, 6a~10HMpaHe Ha KopeMa, 6e3 #e@a~c, nonomTeneHCMMllTOM Ha naCTepHaqKkl, ePHTP04MTYPMR.

PM

XIX. 3ameqewa xepHm CHMI~TOM~~MK~

B noeereTo c n y a # 3aKneqBaHeTo HacTbnea e~e3anHO, KaTO aHaMHeCTMrH0 BMHaM M M a TpaBMa MnM BHe3antio @ M ~ M ~ ~ C ycHnMe KO ( ~ a n p ~ BpMraHe ~ e p Ha TexecTM, KawnMqa, 3aneK, HaAyeaHe npn p e 4 e ~ a q n ~ T. H.), npoRBREI ce cac cnnna 6on~a, rapene (noapbqa~e), aappaxKa Ha ra3oee H M ~ ~ ~ ~ X H ~ Mpefl0Ha6MneH H M R , 60ne3~e~ npM IlallflaqW XepHHmeH TyMOP, TaXHKaPAHR. C ( ~ ~ B H O T O 3aKneU(BaHe, C M3WIK)CleHMe Ha IlPMCTeHHOTO, B O A H A0 pa3ewne~o Ha rpeeHa Henpoxofiwm. llpn 3aKneqeaH e Ha nMKoreH Mexyp (M npv nnwraqn ce X~PHMM) ce noReRea 60ne3HeH0 wanyc~a~e Ha ypntia.

3anorem eHe3anno c OCTPM, cMntiH 6 0 n B ~ropHaTa ~ vacT H a KopeMa. Bonsonyc 6onme ca ~ e c n o ~ o B ~ ~ b 3 6 y ~ e 6bp30 ~ u . ce nomnea nopyBaHe Ha KopeMa B ropHaTa MY yam, C Ha6enR3aHa MycKyntia ~ ~ ~ M C T ~ HOCT, OcTpa UnnaTaqMR H a cToMaxa OT BbeepeHaTa COW^ 6bp30 ce aCnMpMpa rOnRM0 KOJlMcleCTBOCTOMawHO c b m p m ~M o raao~e, a npu Bonaonyca coHRaTa He npoH H K B a BC T O M a X a .

PM

PM

~ P ~H ~HTT~HOBO ~T3 O c n e ~ ce ~ 3a6en~3ea a~e pa3wupeH C T O M a x ,CX O P M 3 0 H T W l H OH M B O Ha TeVHOCT, ~13060peH ra3 nHncBa. CKO~MR CT TeWH ~ K O H T p a C T e ~aTOlHOMOHM.IHa.

A~anocnr~a
Tp~6ea BMHaM pa ce cnasm cTporo npaacmoTo: npM BceKH cnyval Ha uneyc ua ce ~ 3 c n e n a a BmuoxwnTe ~ MecTa 3a xepHMR. P ~ H T ~ ~ H O B nO sc Tn O ep~a~ (x~ppoaee PM~HH HuBa M T. H.) noTBbpxgaBa ~ n a m o 3 a ~ a .

314 -

. : , , , - , , . , ca .

, ca , , , . .

XXIV.
, , , ( ).

XXVI.
, , , , . . , ca , . ce . ca . , , . ce .

ce - - , ,, , , , .

XXV.

, ce , . : ( ); (, .; , . 6. - , , . 7. - , , . 8. ( , .). 9. , ca . - ca . , , , , Proteus, Klebsiela . - .

ca (. 10.1.): 1. . 2. ," , , , . 3. . 4. " . 5.

316 -

( D. H. Wittmann). I. (1-2%) , , , ( ). (, ) . II. (= 98%) ca ce ( ) . 1. () - , , , ( ) , , (. ): - ; - ; - . 2. : - ; - ; - ; - . 3. : - ; - . 4. : ) : - () - : , , , , , .; - , . ) : - , , ; - , (90-100%). 5. : - ( ce 24 h); - ( ce 24 - 72 h); - ( ce 72 h). 6. : ; ; ; ; ; ; ; .

. . ( 10.3 10.4). ( ) , . ca : 1. ce . 2. , ce . 3. , . , ce . ce . 4. ce . ( ) ce , 5. - , . 80% ce . . () . , , , , , . . How , , , , .

 ce . ce . . -, . . ce . ( 10.4,10.5,10.6) ca , : ce . -

: 2 2, 1.0-1.4 2 . 5 mm 5-8 I, . , - . ce - . ce , - ( , , ), ( 2- ) ( - ).

 : 1. . , , , , , , . 2. . - : V-, , , , , . 3. . , , , , . 4. . , , , , , . ce , .

ca: , , (), , , + , . no- : - ce (, , ). , . . 7 ce . - . ce . - . , 2-6 .

320 -

. , -, , , , 3 ce . ce . - ce , . ce 12 ( Hageman). Shwartzman -Sanarelli . ce , , ce . ) , - ; ) , , , ; ) ce , , - ce . - , , ce . ce . ce , ce ce . ca . . ". ce , . , ce ( ). , , () . ce , . ( , , ) ce . "

. , , , , - ce . ce, ca - , , . ( ). - , (-) . (-) (+) ce . , .

. . . . . () ca: , , , , , , , (, , , , , , , ). ca: , (), , , (, , ), , , . , ca , ce . - ce ( 10.7) , ce , : 1. ( 24 h) - ca : , ( Blumberg), , . : 12O/min'; , , , . ce , , , , , . ca

( J. Frexinos) . 2. (24-72 h). ce . ( ) , , : , , , , 100/min1, , , , . - , . ca , , . 3. -( 72 h). ce - ce . . ce , , , - , , , , - , , . ce " . " , . ce .

ce , ( ), . - , - , , . ce , , , , , ,
.

- , , ", , . (.: ), . - -

- 323

, ce . - ce (Jn 111), ce . GA67 ce (24-48 h). , . - .

: ; ; . 1. - . -, ce - . , . , ce ce . 2. - , , . , . 3. - - . . , . ce . : 1. . 2. -

; . 3. , . - . - . - . ce : 1. (. . ), ce , ce , . 2. -, ce - ; 3. ce , ca . .

, , . 1. . ce , , . ce . ce - ce - . - ce - ( D. H. Wittmann). , - ce

324 -

. , -. ce . , (!). 2. . ce . . ce . - , . , . , ce . 3. . ce 10 l , , (). . , , , . -, , , - , ca . . , . ce , . . ce . 0.5-1 NaCI 0.9% Ringer . ce , ce ; ce 8-12 . -

. . . . ce , ce (-). - ce . : ce 4-6 -. (open packade). ce . ce . . . ce , , . ce . , - , ca . ce . . Taichman 1980 . , ce - . , , , . - . , ce - , , . . : - ; - ; - ;

- 325

- ; - ; - . ce : - ; - ; - ; - ; - , . 80-90% . ce . : 1. - 8-10 Ringer: ) , ; ) , . 2. 24 h : ) 8-10 Ringer; ) , . ce : - ; - , ; - 24 h , ; - , . 3. 24 h: ) , ; ) , ce . 4. : ) , ce ; ; ) .

, . -

, . ce - (PEEP). , - . ce (IMV), () . . . . third space , ( , -- - ). - . . ( , , ) ce , , Human serum albumin. ce Dopamin Dobutrex. Nitroglycerin - . ce , ( ), - . Lawrence Weil . - 1, 11.6. ce Dopamin , . ce , ce , . . ca - ,

326 -

. , , , ca . , - . - ca

, . Heparin. . IgG, - . - .

10.3.
PEEP IMV

30 ml/h < 16

Dopamin Dobutamin Nitroglicerin ( - ) Dopamin Osmofundin

. . "third space" - ( ) ,

- ?

? ?

Heparin

- 327

. , ." (R. Pichmayer). : ce , ( ),

, (), , , (-) (+) , ; ( ). - ( 10.8).

. , ce . , ; . (), ( ) . . , , , . " . ca ;

ce . : 1. , (, ), 2. , ", , . 3. (, ). 4. : , , , , ; . -

328 -

) , , . ce ; ) - ce, ; ) ce , ". - ca . , , , .

ce , (, , ). , , ce . (.: -- - 10.9 10.10) - - . 90% ce . - , . . ce , , . . , . , . . . ( ) . ce 50% . -- .

, ce , . ce , , , . ce , - . . ce , , . ce () (). ce ( ). - ( ). . , ( ). ca -Ortner). 20-30% ce , , , , . ce , : ) ; . ) , ; ) , ; ) ( Krebs). (, , , ), ce , ce (). , , , -, . . , , . .

ce , , .
( ), ,

, , -

- 329

10.9.

, , , . , , .. , -, , , . ca:

, , . ce .

, ce .

- 331

, , , (, , . .). 1. . 2. , 24-72 h, , , . ( 24-72 h ), ( "). 3. , ce ". ca , . - ca: . , . : 1. : , ; ; - ; 2. : 10 mm. ce ; ; ; " ; ( II III ). , . . "

") 0. . . : 1. , , , , . 2. , - , . : 1. 15 mm. 2. . 3. ce . 4. . 5. 15 mm. 6. . 7. - 15 mm. 8.- . ca: 1. . 2. 15 mm, 3. II-III . ce , , . . (+ ), , ce (+ ) . ce . ce (. . ce ) . - ce . ,

332 -

() . 1. - - , , ( ), ( ). 2. - , , , , . 3. -, , , . 4. - - , , . 5. . ce : 1. ( ). 3. . 3. .

, , . ( ) (), . ce . , ce . ce . ce . , . , , . . . ce .

. . I. (.: ), ce ( ) . II. - 1. . 2. ( ). 3. - (, , , , , , ). 4. . 5. () - . 6. (, , - ). 7. . 8. ( , , ). 9. ( ). 10. . III. . -

- ca ( 10.11). , . , , 39-40, , , Ortner Mussie. .

, , , , -

- 333

(-), .

, .

. .

, , (, .), - . 10.11. -

, - , (, ce ), , . - .: . ( J. Frexinos)

334 -

. . . Kretz ca . , , ca () -, - . . - , . ) . - . . , ce , - . ", ( , - , ). , - .

, , , . ca: 1. . Sahli " , 2. - , , . 3. , 4. ( ca , ). 5. (- ).

1. (). 2. (, , ). 3. ( , , , , , ).

, . (, , . , ). - , - - . , ce , , . , , , , , . . ( , ) ce , - . ce ,

, . ( Kocher); ( Kiimmel) ce ( ) . . - , , . , . 3/4 , , . 37-38, . , ce . , ,

- 335

. . , - ( McBurney, Lanz Kummell. ca: , Blumberg- - - , ce -, ce : -. Rovsing - . ce . . - . . - ce . . - . - - . - - - . - - . ce - - " . - - 2- 3- . Cope ce . , ce . 5 - 10% - ce (.: !!!), , , ( , ), . -

(, , ) . , ca : ce . ce , , , . ce , , ca . . ce ( ). . - 4-5 ca . - , . . - ce . - .

- , (, , , ). - . - . - , ; - ; , - , - , . () - . ce . , . 1. - , . ca - . ce . , . " (Baily).

336 -

2. , ce , . ce . ce " (= 50%) ce , = 20% ce . ( ) ce . ce , , , , , . ce , , . ce . ce 7-18 : (, ) , , , , . . ca . ce . - ; ; (, ). . ce Blumberg (). . ce , , , , , , , . , , (+ ).

3. . 4. , : , (), (). 5. ( ); (); - (, ) ce . ce , , , , ().

- , , , . . , ce , Blumberg, . (") . ce 800 ce . - . , , . , Blumberg . ce . - , , ( ). , ce , . ce ; - , , . - . - 4 mm, , , . - (-). - , , (), . . - ca -, , , , , ,

1. . 2. , ce , ca , Blumberg, Rovsing, -.

- 337

, - . , , ". Mayo-Robson . ce , , . ; (); Ro- 800 c ; , , . ce . , , , ce . ( Krohn) ce . , ce . ce . ce - , ce . ce , ce ". ce . , , , ce . . ce " ". . ... , , , , . , . , . , , , . -

. , . - . . , . , , () . ce , , (Ro-), (), , , , , .

- . ce , ce , . . ce , , , .

.
1. () ce . 2. ce . ) 12-24 h . ) 4-6 h ce , ce ( ). 3. - ce , , , . 4. (, ) ( - ) - , - . 5. " ( , .), ,

338 -

ce ce . 6. ce , - ce , ce ( ) . ce , , ; - ce , " (. .). 7. , , , - ( ) . 8. ce - ( ) , . . () . , , ce . ce . 9. : ) ( ); ) ; ) ; )

- , , . 10. ce . 11. ce - , ce . 12. - , .

1. - , , , , , . 2. - , (), , , , , ( ) . 3. - - , , - . 4. - - - , , , , , . 5. - , , , , . 6. - , , , . 7. - , , .

, - . - , , ce . 85-90% ca - . . ce , ca , , . . ce , : ) - ; ) - ;

- 339

) ; ) - . ce ".

, ce . . . : ) ( , ) ; ) . Blumberg (+); ) ; ) . . , , - . ca . ce , . ca , . ca , - . . , . ce : -. : ) - . ce , ce ; ) - ce - , - , , . ce , ce ; ) - ce . .

1. () - ce 1% 80-85% . . 2. (, ) - . 15-60%. 10-15% . ( 80% ce ). 3. - ce , ce . . ce , , . 1. - 10-14 , : . ) - ; ) - 7-8 . 2. - 14 , . . . . ce , , . - , . ce . , . ,

340 -

1. - ce . : . 2. : - ce ( - ), , , .

: . ce . - : , CRP, , , , , . ce . : ( 10.12). (no H.G.Beger, 1989)

10.12.

(< 50%)

( > 50%) -

- 341

- ce : 1. : - ; - ; - . 2. . 3. ; - ; - .

, ERCP , .). 3. . ce , ce ce .

ce . - -, , , , , , , . - , , , , , , , , .

- - . . - . .

- . ce - . : 1. - Ranson, Imrie . 2. - CRP, , -2-, - , . 3. - . , CRP, LDH .

. : 1. . 2. (, , -

, ( ), , . ce . 1. . ce , , . -10%. 2. ce - - . - 60%. 3. - . - 30%.

ce - , . , ce . - -. ce , , (, , ). , ce ce - . ce : - , -

342 -

, , / . ca: , , , . - , , . . ce , ce , ce . ce ce 30-70%. - . . ce - , . ce 1500 . . , , , , , ca . . ce - , .

. : I - (). ca , , , - . . ce . II - . -

, ce , , , , , , , . - , , . ce . . Ill - . ce , , , , , . V - . . . . . . , , , , . . ca , , , , . ce . ce , ca . . ce . . ce . ce 1 -2 . III IV 0. ce . . ca . . ca , . . ce , , - . - ce . . ce , - - - .

- 343

- . , , , . . ce , II, VII, IX X , . 20%. ce . ce ce . ce (Scopolamin, Faustan, Chloral Hydrate). ce Mannitol, .. . . - ce , ce : - , . Lactulose, ce . , ce , . ce 60-100 g/24 h. (Neomycin 4-8 /24 h) per os , . . ce per os. , , ce ( 20 mg/kg/24 h) , . ce 400800 mg/24 h. ce ,

- , , , , , , , , . . ce . . . , . ce , , (. Glutarsin .). , , (. AminosterU-N-Hepa). , ce . 4.19-6.28 kJ/24 h. ce Krebs ( ) ( ). ce , , , . ce - - . ce - -, . . ca - , , , , , , , . , . - 80% . ce , . ca , , .

344 -

()

. 10.13. ce - , - , . 4 : , , . ce , ( , ).

10.13.

(- , ), , , , , ; -- , , , . : , , , , , , .

(). , , ce , , .

, , , ce , ", " , , - .

: , , , -, , , , . Krohn, ; - , - , ( , ), .

: - , , , , , . ,?.-,-,4. - , , , . - , , , . - (, ), , (, ).

- 345

- , . - 5-6 I , ce . - , ce . 2-4 mm 20-30 mm . . 20 mm . . 5-9 /24 h. , ce . , , . 30 mm ce . 50 mm , . , - . ", , ce . - ce , , (. . ). , -, ce ". ( ) ce - . , ce -

.

, . no- . ce : 1. , - - ce . . (), ca . ( ) ce ^ , - - . ca - . 2. ( ). 3. , , ; ( - ). ce , . 4. .

ca: , , , , ( ), ( 10.14). - ce , (). - ce . ce . , , . ce , . ca . ca , ce -

90mm ,

346, -

10.14.

( J. Frexinos)

. ca , . , , , , . . ca . ce , . -

. . () - . - - , - - .

- 347

. , - . - . , . - , , ce . . - . ce , , , ". ce , , - , ( Vail). ce - -. ce , ce - . ce - Kiwul. - ce "- "- . ca . ce , . ce - - ce . - " ( -). ". ce . ( ). ce 500 ml ( -). ce Blumberg-. ce ( ), (), .

ce : " (), . 1. " 12-16 h. ce , , ce . ca . " . . 2. 12-36 h. () . ce . . ce , , ". , . ce . 3. ce 36 h . ca . , ce . ce . , . ce " ( ). , , , . , , ce .

ce ( ). , - ce , , , , . ca . : Kloiber, , , , . Kloiber ( 10.15): , - . ce ", ce . Kloiber ca , - .

348 -

10,15. -

(no C. Droste el al.)

, , ce ". ( ) , , ce . " ( ). - ( ) ( , . .). ce " . ( ) - . ce (), ce ce . ce ce . ce - ( , , ).

ce . ! 1. - , - . . 2. , -, - . 3. - - - . 4. - () . 5. ca -, - ca , - ce . 6. , . . . 7. ce " . 8. , ce , . 9. , ce

- 349

, , . 10. ce , . 11. - , . 1. 2. , , , , . 3. 4. , , ( ), , , , . 5. (), , , , , . 6. 7. ( , , ) 8. (, , ) 9. , ,

.:

. ce . . ce ( ) .

- - , - , ( ), . , . ce -

, . , , . (, ) . ce 4 h. ce 16-17. ce . , , . -, ce . - , , , , , , . ( ce ). ce , . - . - , (), (- ). - . ce , ce . . ce , ce . ce . ce . , , ,

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H40p~a~ Ha aTexecT Ha x e ~ f l ~ n ~ ~ a . 2. B ~ ~ MHa ~ nonypaanq T o 3a $atmop Vlll e OT 10-12 40pMa: 515%; Ha CY~X~M@WIHR: 1530%. h, KOeTO M3MCKBanpOBeWaHe Ha KOHTPOnHMH3CneflBaHMR flpn ~ e x ~ a 4 o p ~H a~ c~ e ~ I O A oqe ~ B ~ OTT ~, a h - p a ~ ~ a B TaKbB MHTepBm 01 BpeMe. IeTcKa ebspac~,MycKynHM xeMaTouM M x e ~ a p ~ p o 3 ~ . 3. T e p a n ~ ~ ce ~a KotiTponlrpa c onpegenme Ha K ~ ~ B o M ~ ~ MC a Bu TeXKM, T~ npoB0KMpaHM OT Hakne~M CTO~HOCTMT~ 38 napuMaJlH0 T ~ O M ~ O ~ J ~ ~ C T M H O BpeMe BO M rpaennu. n~ncea KopenaqMR~ewy clenema HarpaeuaTa HMBOTO H a $amop VIII. H Ta3M Ha KPbBOM3nMBa. %CTO KPbBOM3JlMBMTe C e 4. flpM BnMBaHe ~ a ~ o 6 nperMCTeH pe 6 ~ o n p o ~1(U y nonyraaaTcnomaHHo. X e ~ a p ~ p o 3acRraT a ~ ~ e npeflnMHo @amopVlll Ha kg TenecHo Terno noeMwasa HMBOTO Ha rOneMMTe c T a B M Ha K ~ ~ ~ H M U M %CTO T ~ . ROBTapFlUM Ce QamopVlll B qMplcynaqHmac oKono 2%. XeMapTpo3M N~flOTOTmHOaHKMnO3MpaHe HaCTaBUTe. 5. BMAbT, nOKanM3aL(MFlTa Ha KPbBOM3nMBa M PeTPOflePMTOHMallHH X e M a T O M MCa npMVMHa npeflCTORUaTa OnepaTMBHa MHTePBeHUMR H3MCKBaT 3a~enpa~~n~a~(~anio3a-o~~bpane~~~q w~. nocTuraHe H a onpeneneHo HMBO Ha @atmopVlll c qen Ha6nlonaea~ ce xennalypnn, rcltirnaoparwu, rapamnpaHe Ha @pa xennocra3a: e f l M C T a K C M C M ,K p b B O M 3 n M B MOT C T O M a W H O Y P e B H H RTPaKT. a) npM IlpOBewaHe Ha OnepaTMBHH MHTepBeHqMM, Y e p e n ~ o - ~ o 3 aK v~ ~n ~BOH~~ ce Mcpeqal BH no-~RRKO, HO cb06pa3~Bah~M Ce C M 3 X O Q H O T O HMBO Ha Vlll M ~akvemo 3a~bpluaa~ neranHo. BMAa Ha MHTepBeHqMFlTa,~ p ~ 6 e a : flpM OnepaTMBHM MHTepBeHqMM (M TO CneA nplllcnlo'i-npM neKMOnepaTMBHMMHTt?pBeHL(MMnpe~BapMTenH0 BaHeTo MM) ce ~ a 6 n l o ~ a Tern#, ~ a ~ npoAbnxMTentiM Aa Ce IlOACMrypM HMBO OT 35-40%, a CneA MHTePBeHqMRTa KpbBOTeveHMR OT O n e p a T H B H O T O none. floflo6~a KapTMHa Toga HMBO Aa ce nounbpxa B npoflbnxetive Ha 6-8 AHM; C e ~a6nlo~aea M npM 3 b 6 eKCTPaKUMM. ~ ~ B MOMeHTa Ha - n p ~ ~ e x ~ ~ o n e p a ~ ~ ~ nonc~ry ~ ~ e p MHTepBeHqMRTaKbpBeHeTO e H O P M W I H O ,H 0 CneA HRKOnKO PM M M H M M W H O HMBO OT 60-65% 3a $atcrop Vlll M TO Ce raca Hacnnea o 6 ~ n ~ KpbeoTereHHe. o flpuru~a3a nombpxa cneAonepaTnaHo B nponbnxewe Ha 10-14

A~CHOCT~~HHH

H ~ O ~ M ~ H OMnM T O nO.ITM HOpMNlHOTO KpbBOTereHMe npM CaMaTaMHTepBeHqMFle CbflOBMRTCna3bMM IlbPBOHaClaJlHO

H O P M X I H M R TT P O M ~ O ~ H 6T p~ oH ~ H~ Y H ~ M R .

npn cpe4Ha @ p ~ a KnnHuvHaTa

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AHM. npll eKCTpaKUMFl Ha 3b6 H M B O T O Ha Vlll T P R ~ Aa B ~ e oKono 40%. 6) npM TeXKM TpaBMM, T e M M XeMapTpO3M, MaCMBHM X e M a T O M M HMBOTO Ha $ ~ K T O Vlll ~ TPR~B fla ~ e 35-40%, a

eAHaKBa C Ta3H npM TeXKaTa @0pMa,H 0 IlpoBOKMpaUMRT TpasMaTMveH MoMew e a ~ a v ~ ~ no-c~ne~. en~o

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npoAanxmenHomaHaneveHueTo HmonKoAtiM; B) npM neKM T P a B M M , e~MClaKCMC,M W I K MX e M a T O M M , nOpe3HM PaHM, MHMBOpaMM e U O C T a T b ' i H O HMBOTO Ha 4amop Vlll Aa e oKono 15-20%; r)KPbBOM3nMBMBUHCM MHOrOTeMKMTpaBMM M3MCKBaT
nombpxaHe Ha BMcoKo HMBO OT 60%, KoeTo nponbnxaea flOM3qe3BaHe HaKpbBOM3nMBa;

A) KpbBOTeWHMR OT CTOMaluHO-qpeBHMR TpaKT M xeMaTypMu MBMCKWT HMBO OT 30-35% ~o n 3 v e 3 ~ a ~ Ha e

KpbBOTe.leHMeT0. BCM~KM ~ e CTOAHOCTH s ~ ca penaTuaHu M nereHMeTo B no~eve~ocnyrau~p~6 M~ M !a ~~ M(H aA H B H Axapanep, ~~~~H KaTo H ~ A - r e c ~ ce o AaeaT n o - r o n e ~A~O ~ M OT
H~O~XO~UMOTO.

soMHopeqecMaeHm ~ )3a60n~BaHe~o . cecpeqac recToTa 1:60 000. 60ne~yea~ npeAcTaenTennTe Ha M~MKKMFI non. Xe~nTece m s a T npeHocnTenKu. 3a60nR~aHeT0ce ubnxu HaM ~ H C KfH le$~un Ha ~$anop IX, HO ca onncaHM M p a s n ~$OPMM r ~ ~ Ha MoneKynetig e $ e ~ ~ .

6. f l p ~ n o x e ~ ~ e ~ o ~ a ~ ~ x e npM ~u Xu ~u M i@ .rn M.~ M U H e CTpOrO KOHTPaHH~H4MPaHO - BORRT A 0 MaCMBHM XeMaTOMM. Einonpo~y~ n~AosmpoeKa n Ha npoeemaHoTo neqeHne. Y Hac H ~ A - r o n ~ npMnoxeHue ~o HaMlrpaT KpMonpeqMnMTaTnTe.Toeaca6nonpopyicr~ C HMCKaCTeneH HanpevMcTaaHe. Pasn~raea~ce p a s n ~WPMM r ~ ~ cnopeA OT pyMHHMTe M ~ C ~ ~ A B ~ c Ha M~ Ro napunanHoToHaws Ha npoMsBoAmBo, HO H ~ A - ~ ~ C ce T OMsnonsBaT ~po~6onnam~ so pe m~ e cypbnxe~n CTO~HOCTM. A#ar~ o s a ce ~a nocrasn c onpepenme HHBOTO Ha t$anop IX.
C

A~Qepettqnan~a ~wanoaa ~HH). He3asucm~o OT Toea, r e c x e ~ a ~ ~ s ~ BOAH p a ~~o e~o X~MO$M~ AM MA 6onena Ha Bwne6pa~fl. onpocTReaHe Ha n e r e 6 ~ n noAxoA, ~ npenopbvsa ce cnenHaTa AoaMpoeKa aa AXr cnopeA T. J l ~ c ~ v ~ o e : enHCTaKCMC, MHMBOpaMM, nOflKOMHM H MaJlKM MyCKYnHM npe~lnmae~llr 3a nocTMraHeHa ornclManeHe$en ca: XeMaTOMM, MmKM nOpe3HM PaHM - AO3a OT 10 U/kg Aa ce aHae HneoTo Ha $amop IX npepn 3anoreaHe Ha epHOKpaTH0npMnOXeHM; XeMapTpO3M, f l b n 6 0 ~ MyCKYnHM ~ c y t j c r ~ ~ y ~ p a q a ~ a ~KoeroonpenenA e p a n ~ ~ ~ , cTeneHTaHa XeMaTOMM - pO3a OT 15-20 Ukg npe3 nbPBMR AeH, a B TeXeCT (alcryan~~fl F(~$M Ha ~ $am0p w IX); KnMHMrHaTa CneflBalqMTe AHM F(O3a OT 10 Ukg; MYCKynHH XeMaTOMM C CMMnTOMaTMKa M n M IlpM'iMHMTe, npeflM3BMKanM onactia 3a xmsoTa no~ant13aqw~po3a OT 25 U/kg npes KpbBOTereHMe,KOMTO M3MCKBaTOnpefleneHaWMpoBKa M nbpeMn peH, a B cnepeaquTe AHM po3a OT 10 Ukg; npomnxmentimtia nposewaHoTonereHMe;npMTexw CTOM~~HO-rp KpbeoManMrJn ee~n - Aoaa OT 15-20 U/kg TpaBMaTMqHH YBpewaHMFi M n M npM rOneMM OnepaTMBHM npes~ P B M F AI ~ Hcnep~oaaflooaao~ , 10U/kg flowsresea~e MHTepBeHqMMT ~ R ~ gaW C e IlOCTMIHeHMBO Ha IX B Ha KpbBOM3JlMBa; KpbBOM3nblBM B UHC - AO3a OT 25 U/kg 4MpKyna4MRTa HaA 50%; npM MaCMBHM XeMaTOMM, npes n a p a ~ peH, ~ l no-K~CHO po3a OT 15 Ukg ~o ~ 3 r e s e a ~ e KpbBOM3nMBM OT CTOMaWHO-'iPeBHMR TPaKT, XeMaTypM, Ha KpbBOM3nMBa; XeMaTypMM - 103a OT 20-25 Ulkg KpbBOM3nMBM B UHC, eKCTpaK4MM Ha 3b6~,He M H O r O eAHOKpaTH0 M 3 flHM KOPTMKOCTePOMflM; 3b6HM eKCTpaKroneMM M n w new onepaTMBHn nHTepaeHunM, npn no4 M M - AO3a OT 20-25 U/kg eAHOKpaTH0 M npMnOXeHMe Ha ronehnM paHeeM n o s a p m m HMBOTO Ha $amop IX a ~ H T H $ M ~ P M H O~M 3aTC M P O ~ KM OT 7 R H M ; OnepaTMBHH q ~ p ~ y n a q ~ ~ ~ a ~ p Fe 1 OT 6 a15-35%; a p a CnomaHtiMcrasHM ~ H T ~ ~ B ~ H ~ M M - R O ~ M ~~ ~~ ~~ B~ KH ~R TB ~ ~ CM ~ HAMBMN ~~HO. KpbBOM3nMBM, CnOHTaHHM MyCKYnHM KPbBOM3nMBM, flpes nocneptinTe rouMtin npMnoxeHwe HaMMpaT enMcTaKcMc, KoxHn M nMraenvHM K P ~ B O M ~ ~ M BneKH H, $a6p~r~ nP#3BeAeHM, o C IlOMOVaHa HOBM TeXHOnOrMM PaHeBll IlOBbpXHocTM, eKCTpaK4MR Ha BAMH 3b6 M 3 M C K B a T M BMcoKa CTeneH Ha npevwueatie, npenapaw, KOMTO HMBO Ha $ a ~ 0 p IX OT 10-15%. npnTexaeaT eMcoKa c n e q n $ ~ r ~ amllreHocT a Ha $amop Msnonasa ce 6 n o n p o p y m ~OIlK ($amopm Ha VIII. M ~ ~ q n a n Aosa ~ a ~npn a npMnoxeHneTo MM Moxe pa ~POTPOM~HHOBMFI K O M ~ ~ ~ KaTO K C ) Ce , cb6nlonaea ce u s r ~ c no n~ $op~yna: npaeHnoTo, r e BnneaHeTo Ha 1 U 4. lXkg TenecHo Terno mMqManHa ~ o s = a 2 no M no xenaHoTo noeMLueHne noewuaea HneoTo Ha $amop IX B q ~ p ~ y n a ~ u cm 1%. a B U (dl) no TernoTo B kg. C n e ~ o e a ~ e 3a n ~pa3nMKa o OT TepanMma npM x e ~ @ n n m M e MymunnnKaTop, K O ~ O ~ ~ B M COT M n n a s ~ e ~ A ~ KonMvecTmTo ~ Ha enmm 6 ~ o n p o ~ y ~pn6sa m Aa 6 b ~ e o 6 e Ha ~ naqwemaM npMnawemn c HW60 kgTerno=0.5; pea nbTu no-ronmo. KaTo ce s~ae,r e epeMeTo Ha or 30-60 kg = 0.7; nop 60 kg = 1.O. nonypasna 3a $atmop IX e 20-30 h, TO 6n~eatinma ce f l p n n o x e ~ ~ Ha e ~npenapaTa o DDAVP(1-AemMuHoM3BbpLUBaT Ha cllHTepBW OT 24 h. 8-D aprnHuH sa30npecn~)ce npenopbvea c a ~ o npM flpoeema~e Ha Kompontin n 3 c n e p ~ Ha a~ 24 ~h ~ 3a naqwemn c neKa @ p ~ a Ha x e ~ @ n n ~ ~ . onpenenme Ha HHBOTO Ha WKTO~ IX npM Tepannma e H ~ O ~ X O ~ ~3aqo~o ~ M O , OT TOBa ~ ~ B M CK Ma m pa 6bpe cnepaaqa~am3a n~ p 6 e a n nnpomnaea ~a ~epannma. n p nnnca ~ Ha @flK uoxe Aa ce npnnara npncm m ~ a 3 e nna3~a. ~a

qemp#paHMnpenapaT#3a 4amop IX.

15% OT cnyame.

Ha6nloflaea ce ronfluo pa3~006pa3MeB cwhnmoMaTMKaTa. TclnMrHn Ca flpOflbnXblTenHM, CMnHH KPbBOTereHMR OT neKM TpaBMaTMVHM yBpeW,4aHMR, npM Onepa@ ~ K T o P ~Ha T B~ne6paw IlpflCTaBnFlW MynTMMepeH n M eKCTpaKrnloKO~pOTeMH, K O ~ T O C T H M ~ ~ HqXe3Mfl ~ ~ T ~ ~ TMBHM M ~ HHTePBeHqMM, ~ ~ ~ T ~ OT PaHeBMIlOBbpXHOcTHM 4 M R Ha 3b6. Peukl~MB~paqM enMCTaKcMCM, XeMaTM)MH, M arperaqw B ~ ~ X ~ T ~ ~ M ~ O ~ ~ H H ~ B~ nn Oa B3~ ~~ a~ Xa H O C T . MeHOpaMM M KPbBOM3nMBM OT CTOMaLUHO-CIPeBHMR TPaKT. CBbp3BaHeTO My C ~ ~ K T O Vlll P HMa M H O $ U ~ M O ~ O M ~ H O XeMap~p03~ C e CpeuaT PflflKO. flbpBMTe nPORBM Ha a ~ a r e ~Kamo ~ e , B ymruKaaaHe BpeMeTo Ha nonypa3nq CMMnTOMMTe C e PerMCTpMpaTnpM 90% OT CnyaMTe OUe B VIII, TaKa M B TpaHCfl O pTMpaHeTO My fl0 MeCTa, Ha PaHHa fleTCKa Bb3paCT. B HanpeAHaJla Bb3paCT TeHfleHKbAeTO npOqeCbT Ha KpbBOCbCMpBaHe e aKTHBMpaH. U W R T P KbM XeMOpaMM HaMallRBa. Cume3b~ Ha 4amopa Ha B~ne6pa~fl ce ocbqemaflaa B A 6 c o n l o ~ ~KOHTpaHHflMKa~MR a e flaBaHeT0 Ha eHloTenHuTe KneTKM n MeraKapMoqmme. aqeTMncanMqHnosaKMcenMHa npM 6 0 n ~ n OT 6onema Ha Sonecrra Ha Bme6pa~fl ce m n m Ha KonMrecTeeH Blrneepa~~ KOeTO , MOXe fla flpOBOKMpa TeXKM KPbBOM3nUBM. ~#ne6pa npea ~ i 1926 r. Sonecrra~a B~ne6pawcecpeqa more no-rec~o OT xe~o+~nwfl A. T e ~ a @ ~p a~ e ac recToTa1:5000, alto ce eKnloraT M no-ne~w~e cnyvau, recToTaTa e 1:2500. OT 3a60n~ea~e~o cTpqaT npeflcraemenwe M HadeaTanona. Pa3nMWflTa B KOnM'ieCTBOTO M Ka'ieCTBOTO Ha aHOMaJlMMTe Ha 4aKT0pa Ha Bwne6pa~n, Ha HarMHa Ha yHacneflReaHe M Ha $ o p ~ a ~ Ha a KnMHMrHa H ~ R B c a~ ~ P M ~ M H3 M a pa3rpa~wclaea~e Ha 6 nonT-r#na: IT M n - KOnH'ieCTBeHO HaMaJleHO CbmPXaHHe Ha 4amopa HaBllme6paH~ n ~a4amopVIII K. Y~acneyea ce no aBT030MHO-AOMMHaHTeHTun. 60-70% O T ~ ~ H M U OTT ~ TOW mn. II A T M ~ Kaclemetin npoMeHH B MoneKynaTa Ha 4amopa Ha B~ne6paw,~spa3fleaqnce B nMnca Ha npw BCH~KM @PMM Ha 6onecrra Ha Bnne6pa~fl Moxe 4a ce nposene c y 6 c ~ ~ ~ y ~ Tepanm paqa c6~onpofly~ CbflbpXaqM 4aKf0p VIII. OT3Ha'ieHMe np# C Y ~ C T M T ~ M Tun. qaTa TepanMR e He cauo HMBOTO Ha $amop VIII, HO M II B T M ~ fle@eB ~ MoneKynaTa Ha 4amopa Ha noeHweHMeTo Ha HMBOTO Ha @amopaHa B~ne6pa~f B # n e 6 p a ~ cabpaati ~, c nlrnca cauo Ha roneuMTe B~MHO e C KaKBM ~ M O ~ ~ O ~ ~ CbflbPXaUM K T M , $aKTop V 1 1 1 , MynTMMepM B nnas~ara.Ha6nnnaea ce sacMneHa q e ce nposeAeTepanma. npu BMcoKoKarecTBetiw,~ o 6 p e nperucTeHM 4 a 6 p ~ r ~ no p o ~ 3 e e f l enpenapaTM ~~ HahW C T O CbflbpXaHMeTO Ha @aKfopaHa B ~ n e 6 p a ~ ef l B MnHwmtiM KonMrecTsa, IoKaTo npv cna6o nperMcTeHM npenapaw HeroeoTo KonMrecTao e AocTanrHo 3a npoeeWaHe Ha Tepanma. H a A - n o ~ x o ~ q ce nRBRB~T KpMonpeqHnMTaTMTe ( a a ~ p a a e M~n n o + u n ~ 3 ~ p a M ~ n M ) peuecnseH ~ m . ~HT#X~M@M~ rno6ynlr~ H H R T y HaC. II D Tnn - nunceaT H ~ A - r o n e ~ m MynTnMepu e B Aoa~poa~a ce ~a onpeAenR OT npaeunoTo 1 Ulkg nna3~a~a cbreTaHo , c ne4e~~ cTpyKTypa ~a Ha TenecHo Terno noBHwaea amMBHocTTa C oKono 1%. MynTMMepme. 12-23%e rpynaTaHa acMrKM h n OT m ~n ~ Tp~6eaflace Muanpeneufl, r e e p e ~ e ~anonypa3nq ~o II. Ha 4amopa Ha Bme6pa~fl e 12 h. Ill T H ~HMEOTO Ha +amopa Ha B~ne6pa~fl B nnaauaflpM OnepaTMBHM MHTepBeHuMM, TeXKM TpaBMaTMVHH an ~ p 0 ~ 6 0 w m e ~eK C T ~ ~ M nH oO ~ w x e nopqw ~o ~amnyBpeW,4aHMR M n M TeXKH KPbBOTe'+eHMRC e IlpenOpbrM HO Hapyuleti cnme3. HMBOTO Ha 4amop Vlll e cwntio flosa~a Ha AXr fla e 30-40 Ulkg npes Mmepean OT 12 h annMuHpaHM. Ilpe~(onepa~va~o ce qenM nocTuraHe Ha HMBO 3a 4amop Vlll M 3a $atmopa Ha B ~ n e 6 p a ~ -f lB

rpatiuuwe OT 50-100%. ~ ~ M ~ C T B ~ce H ~ uaebpluea T O HenocpepcTseHo npepw pa 3anor~eMHTepaeHqwTa. 3wbnw~en~ e onposeyqaHeTo Ha npenonepaTn6tio KotiTponHo ~3cneflea~e 3a HMBOTO Ha $auop VIII. Tow saxM M cnep npnKnnreaHe Ha nHTepsetiqMRTa. B Paarpa~~qaBa~e Ha pe$num Ha $atcrop II, V, VII n CJlepOnepaTMBHMRIlepMOflCeIlOMbpXaHMBO H a 50% 3a xeu@#nnfl A M B. fleptIofl5-10 AHW. K O H T ~ H ~H~ M CI Cf? ~ nPOBe)KC(aT ~~~B~HHFI epw n b Ha ~ 24 h. flpM RPYMWPMM HaXeMOPaMrHaH3RBap03HPOBKaTa B~ME~H Ha UR nnama M n M@n~ KOMTO , MoraT pa ce Moxe pa aap#pa OT 10-30 Ulkg. n p o s e ~ a ~ e Ha ~ o nposewaT epMH n b ~ Ha 24 h, a a q o ~ oapeueTo Ha KoHTponHM M ~ C ~ ~ ~ B ewbnxMTenHo. ~ H M F I nonypaanqq 3a $ a ~ ~ o Xp e 16-72 h. npw noproToeKa aa llp~noxe~ue Ha ~o $ o c $ o n ~ n ~npenapaw p~~ OnepaTMBHaMHTePBeHuMRIlOCTMraHeTOHaHMBO3a$aKT0p Fibraccel, npM 6onema Ha Bclne6pa~fl, oco6e~o KoraTo X 20-30% nopcnrypFiea po6pa xeuoc~a3an p ce nplrppyxaea c T P O M ~ O ~ M T O ~ ~ H Bce M R , noBecle ce MHTepBeHuMRM. aqan~3upa. A03~poe~a or 10-20 rnl, i.v. npMnoxeHn 3a ~ O ~ W ~ O 3a B @nK K ~ T npM ~ TeXKM KPbBOTe~eWR M n M ntrrepean 6 h, B npopbnxeHve Ha 1-3 ~ H H C . b~le~a C ~ a n p npoeewatle ~ HaonepaTmHanHTepeeHqme 15-20 U1 @c$onlrn~p npenapaw, ~~ c y 6 c r ~ y p a q a TepanMR ~a c kg IlbpBOHaWJlHO, a no-KbCHO n0 10 Ukg, HHTepBN24 h. $ a ~ ~ VIII o p eno-on~~uane ~a $ e m ce ~ nocrflra 3a nonpM neKM KpbBOTeVeHMR flO3aTa e 5 Ulkg, npe3 24 h. KPaTKO BpeMe. flpn & ~ H M OT I mn Ha GOnec~~a Ha B ~ n e 6 p w ce npvnara M Tepanw c DDAVP (1 f l e 3 a ~ ~ ~ 1-~PMHMHo-8 B ~ ~ O ~ P ~KC OM ~ TH O n )p, e f l ~ ~ 2-4 ~ ~m ~m n yeenMreHMe a Ha HMBOTO Ha $aicopa Ha B~ne6pa~p M Ha $ a ~ ~ VI o1 p 1, n o m u Y~acnefl~leace no ~ B T O ~ O M H O - ~ ~ ~ TMn. ~ CHRKOM MB~H sac~ne~o hny ~o oTpenRHe OT qoeoewoTenHwre pena. aeTopH cMmaT, r e yHacnepneaHeTocTaea no ~ B T O ~ O M H O fl03Mp0~KaTa e 0.4 pglkg MH$~~MOHHO B MHTepWl OT 12 h. AOMMHaHTeH TMn. OT 3a60JlflBaHe~0Ca 3aCerHaTM fleicrs~e~ Ha o npenapaTa ce usrepnw cneR 2-3 ~ H M . npepcTaaMTenMTe M Ha pBaTa nona. ~ ~ ~ O ~ R B ~ He n e r e ~ ~c e@nK ~o M n MTPOM~O~WTH KoHqeti H TpaTW e onwcatio 3a nbpeM nbT npes 1953 r. OT Rosenthal. Cpeqa H~~$~KTHBHo. C e MHOrOPFNKO. P ~ M C T P M ~ a ~0 H6 H 4O 0 KO~O~~~C

H a frecro ce ~ a 6 n n p a ~ a ~W ne ~~M u HacnoHTatiHu M IlOCTTpaBMaTMClHM KPbBOTeVeHMR. O ~ H C ~ Ca H# cneponepaTMaHo KpbaoTeveHw, npM KOMTO nMncBa Kopenaqw u e w y cTeneHTa Ha p e $ w q ~ M~ cTeneHTa Ha ~pbeoaary6a~a.X e u a p ~ p o s ~ ce ~ a 6 n r o p a s a M3KlloclMTenHOPRpKO.
M

C~MO YpbnXeHO IlapuManHO T ~ O M ~ O ~ ~ ~ C T M epeue, IpyMTe x e ~ o c ~ a 3 no~a3a~enu ~n ca B Hopua. AMaIH03aTa C e nOCTaBR C pMPeKTH0 OflpepenRHe HMBOTO Ha $amop XI. P a s r p a ~ ~ r a s ac ~n e ,p ~ A ~o ~ $ ~ Ha M4amop T XII.

ETHO~O~HII H na~ore~e3a

Y ~ a c n e f l ~ sce a no ~ E I T O ~ O M H O - ~ ~unu ~~CMB~H ROMMHaHTeH TMn. 3a60nRBaHeT0 C e ~a6nloflaaanpbl npeRcTamenmeM HaflBaTa nona. Cpetqace ~a~nlovmenH0 PflRKO, OnMCaHM Ca O K O n O 120 CnyVaR. X~T~PO~M~ aBT030MHO-fl O T H O , 0MMHaHTHO YHaCneflRC~~n~onnamwa eaHe. n e $ ~ q u n Ha ~n n a 3 ~ ~ ~ e 0 PMCKOB r e ~ @swop 3a 06pa3yBaHe~O Ha BeH03HM T p 0 ~ 6 0 3 M ~ eM60nMM. Xe~opamq~ MBRBM n n o m nMnceaT M f l e $ n q ~ n Ha ~ MMa flea TMna Ha TeHeTMqHM npOMeHM B nna3MM$ ~ K T XI1 O ~Hah-'iecTO Ce YCTaHOBRBa cny'ia9~0. HorenoaaTa MoneKyna: T M n I ( ~ ~ c n n a 3 ~ e ~ o r ece ~e C ~ ~ M ~ T O Me ~ CXORHa T M K ~Ha T~ Ta3M npM fle$M~blTHa omwaea c reHeTuveH ~e$etcr B atcr#eHH R ueHnp, HO $atcrop XI, l l p RaeHM ~ cnyvau ce ~a6nloflaea CKnoHtioCT KbM ~pou6o@ne6m~ M MMOKapfleH MH$apKT. O ~ M C ~ C a H M HMBOTO Ha lna3MMHOreHOBMR aHTMreH e HOpMZUlHO. Toea BOflM fl0 HaManRBaHe Ha $ ~ H K ~ M o H BKTLIBHOCT ~ H ~ T Ha ~ M M~Tpaqepe6panHM KpbBOM3nMBM. nnaa~~~ore~a. fl~ariiocmwa ~ ~ M 11 MT M~ M K OIM~ ~MH~ OTflMCllna3MMHOreHeMIIR, ~MR C ~ C ~ ~ T ~ H ~ C X M ~ O ~ ~ ~ ~ MHHBOTO M H O THa ~n Hn ~M a3 M~ F~ ~ OTPyTMtiHme TecToBe ce ~a6nlo~aea ypnxe~ue Ha reHa B nnas~a~ e a Hauanetio. npu Toea Moxe Aa 6b4e napuwanHoTo ~ p o ~ 6 o n n a c ~ apeMe. ~ ~ o e flMatH03a~a o ce aanaaeHa HopManHaTa MY $~HK~MFI, HO TR Moxe M fla e onpeAenR c wscneflea~e HMBOTO Ha $amop XII. HapyureHa.

~w~epe~qmantia fl~anoaa
P a s r p a ~ ~ r a e OT a ~fe le$~q~ Ha ~$atcrop a XI.

Bpofle~AL@H~WT Ha npeKantlKpetlH

Y ~ a c n e ~ ce e ano ~ B T O ~ O M H O - ~ ~ ~TMn. ~ C 3a60MB~H nRMHeT0 e M3Knlo~MTenHO PRflKO, Ha6nloflaBaH0 e M M 0 npM HRKO~KO$ a ~ n n n ~ 3a . nbpsM nbT (npes 1965 r.) e onMcatio OT Hathaway.

A~ar~ocnrwa Yflbnxe~o n a p q u a n ~ o ~ p o ~ 6 o n n a BpeMe c ~ ~ ~npM o~o

H O ~ M ~ CTO~HOCTM ~HM 3a OcTaHanme X ~ M O C T ~ ~ ~acnefl HM

BaHMR. T o v ~ a ~ a ~ ~ a mnocTaeR o a c e rpea KonMrecTsetio

onpeflenRHeHanpeKanMKpeMH.

HMBOTO Ha AT 111.

A~aruocm~a
Ype3 gMpemHo onpegenme H a HMBOTO Ha AT Ill lrnM H a HeroeaTa aKTMBHocT. f l p ~ cnapaHe Ha AT III-

amwstiocrra nog 70% OT HopMaTacbqecTayaa npegpaanonoxeHMe aa T ~ O M ~ O ~ M ~ O f l~pM~ aacerHaTM ~ ~ M . IlaUMeHTM Ce PeMCTpMpaT CTO~~HOCTM non 50%, B naeHM
O q e B cnegpogoBMR nepwog M M a cMMnToMM Ha xeMoparMrHa gMaTesa K ~ ~ B O M ~ ~OT M mnHaTa BM spba, enMCTaKCMC, MHrHBOpaMM, no-KbCHOXeMaPTP03M, KPbBOT e q e H M R OT PaHeBM nOBbpXHOcTM, IlOpapH nM3MpaHe Ha cbclrpeqw.

f l p Bpofleti ~ Ae$#qm~aAT Illce npenopraa npoeexAaHe Ha ~ ~ M I l a K T kClHHfl ~a MpeKTHM aHTMKOafYnaHTHOT

IJ~aruom~a
Tec~bT3a CTO~IHOCTM.

eymo60n~~osa nnsa

noltaaea

cnceHM

AMP~KTHOTO onpegenme Ha HHBOTO Ha c$

aHTMnna3MMH e H M C K O . YCT~HOBFIB~T Ce M flpOMeHM B HHBOTOHaaHTMreHaHaC(2aHTMnna3MMH.

rpynaTaHa KyMapMtime. l l p OCTPM ~ TPOM~O~ ce M npwnara K O M ~ H H M TepanMR ~ ~ H ~ OT K O H U e H T p a T M Ha AT 111 M Heparin. Q H ~ egu~nqa AT III Ha 1 kg ~ e n e c ~ o ~ enosfluraw rno am#6Hocrra MY B qMplcynaqLcma c 1.5 go 2%. ~ ~ M ~ O X ~ H HaKOHIpHTpaTM U ~ T O H ~ A111 T6e3 Heparin ce npMnara B g 0 3 ~ p o no ~ ~50 a Ulkg, MHTepean OT 48 h. npMJl0xeHMeT0Ha K O H q e H T P a T M~aAT 11 1, B CblreTaHMe cxenapwHoeaTepanMRcncfleaMHTepeanaHaannuKaqMR, 3aqOTO BpeMeTO Ha nOnypa3n~ 3a AT 111 npM H O p M a n H H YCnOBMR e OKOnO 70 h, H0 B K O M ~ M H ~ ~ M CF Heparin I Ce
C K b C R B a 3HaCIMTenHO. J l e r e ~ ~M e~o M C npoeeWaHe K ~ HarecTw,KonwrecTB e H M OnpeflenRHMR Ha HMBOTO Ha AT 111.

YH~c~!~ Ce R no B ~aBTO30MHO-g0MMHaHTeH TMn. ETHO~O~HII H nmoreue3a X e ~ e p o s ~ r o mpaa-r ~ n ~ e H ~ A - r e cOT ~o ~poM60-eM60nMr3a napen nbT Mamrnen, Tornas, Seegers (1960) HM ~ ~ ~ O ~ R B ~ H npM MF X O IM ,O 3 M r O T M T eA ~ $ M ~ M BOgM ~ T 40 neTaneH ~3x01. Paan~qaBa~ ce gae $OPMM Ha f l e $ ~ q ~ ~ : OnMCBaT IlpOTelH C nOfl HaMMeHOBaHMeTOAutoprothrornbin IIA. flpes 1976 r. Stenflo ~acnegaa Hoe, Bnlnfiew ce HaMMeH C M H T e 3 H a $~HK~MOH& HOpMmeH ~~HO AT 111; OT Vitamin K npoTeMti. H a p ~ r a ro npoTenH C. l l p o ~ C e~ HOpM&llHaKOHq!HTpa~Mfl H ~ A111, T HO~fle$eKTHa$y~Kl&l0e MaKntormentiom e t iperynaTop, KamoHacacMpeaHeTo HmHa atvM~Hm. 3a napa~ nb~3a60n~ea~ e onucatio e~o TaKa M Ha $M6pMH0nM3aTa. ~ n a u o n o m r ~amMBMpaHe o~o OT Egeberg (1965). To ce ~ a 6 n l o g a ~ MHoro a no-qeuo OT Ha npOTeMH C CTaBa C nOMOuTa H a T P O M ~ H HM x e u o $ ~ A, n~ c~ recToTa 1:2000 go 15000. T P O M ~ O M O ~ ~ ~T MP HO . M ~ O M O ~ ~llPOM3XO)I(Aa Y ~ H H ~ T OT AHTHTPOM~IIH 111 e H ~ ~ - B ~ X H M MHXM~HTOP RT Ha C b g O B M T e eHAOTenHM KneTKM. MRCTOTO H a aKTMBMpaHe Ha IlpOTellH C Ce OCbqeCTBFlBa B MMKPO4MPKy~a4MOHHIITe o6nac~~. PefYnaTop Ha aKTHBMpaHeT0 Ha npOTeMH C OT T ~ M ~ M KOMnneKC ~~MHO~M R B R R W AT 111. Onuca~ ca ~ cnpan Ha Texw ~ p o ~ 6 0 e ~ 6 0 n ~ r ~ ~ H - T ~ ~ M ~ O M O ~ ~ YH~c~~F Ce (F no ~aBTO30MHO-IOMMHaHTeH B~ TMn. Y C J l O X H e H M R npM fleqa ( B ~ ~ P ~Memy CT 13-15 ~ O ~ M H H ) . ABe @PMM Ha ~ ~ $ M L ( M T . flpn naqMeHTw Ha ~ b 3 p a c Memy ~ 20 H 30 roAHHM ce M ~ H U $ ~ C TC M TeXKH ~~ gbn6o~nBeH03HM T P O M ~ O ~ M , Tvn I- MCMHCKM fle$M4Mi Ha IlpOTeMHC,CbVeTaH C
6 e n o g p o 6 ~ ne~6onnb1, Me3eHTepManHM BeH03HM HMCKM CTO~HOCTM HaaKMBHOCllaM yB b BBPb3KaC HapyllleH TPOM~O~M CJleF(0nepaTMBHM , ~ ~ 0 ~ M 6 TpoM603M 0 3 ~ no C M H T e 3 . BpeMeH ~ ~ P ~ M ~ H H O PRAKOC~ CT. ~a6nlofla~~ap~epMWlHM Tun 11 @ Y H K ~ $ ~ O H ~ ~AH~O $~KTBH npOTeMH ~ ~ 0 ~ 6 0 3 ~ . (~one~yne~~le$em), c ~ a ~ m e ~ a 6 n o n oamuBHocT. mr~a flecleHMeT0 C OpmHH a H T M K O H q e n T W B H M CpeACTBa, %?CTOT~T Ha ~ fle@MI&4Ta Ha np0TeMH e 1:l 6 000.

394

T p a ~ c + y ~ u o n n u xemocrna~nu cneurnu cacrnonnun

3 a 6 0 n ~ s a ~ cTpWaT e~o npeflcraemenwre M HafleaTa nona.

C~~rnonnanr~a
no OTHOUeHUe Ha KnMHM'iHaTa CMMnTOMaTMKa HRMa p a 3 n ~~ ~a e wpee~e y ~ape@#~ Xm ~T ~~ .PO~M~OTHM 60n~w cTpWaT OT B e H O 3 H M ~ p o ~ 6 o e ~ 6H oa nfr ~e~ c .~ o Ce Ha6ntOflaBa~T~0~603~ Ha~bJl60W~eBeH~ HapOnHMTe K P ~ ~ H H(53%). ~ M M ~ o r oCa M nOBbpXHOCTHMTe T~OM~O@~~ (39%). ~ M T6 Me n o p p o 6 ~ e~ ~ 6 0 n lM rM ~a B 30% OT cnyrawe. PRRKO ca onucBaHM H ~ e a e ~ ~ e p w a n ~ l r B e H O 3 H M ~ ~ 0 ~ 6T0 ~3 XK ~TpaBMM, M . O n e p a T M B H MM H T B P BeHUMM, P W a H M R , ~ ~ ~ M ~ H H Ca OC IlpoBOKMpauMOMeHT T, 3a T ~ o M ~ O ~ M ~ O ~ M yCnOXHeHMR. ~ H U T ~ X e ~ o p a r w uepe6pan~~ r~~ MH@~~KTM cneAcTBue , OT qepe6pan~~ B e H O 3 H H ~pOM603M.KYM~PMHOBH HBKW3M, npM sanorea~e Ha aHTMKoarynama Tepanm ca KoMnnn KauMR nOpWMflM@y3HM TpoM603M BMHKP04HPKYlla4MRTa. X O M 0 3 M r O T H K T e 60n~w Ce Ha6ntOflaBaT TeXKM HeKv3M Ha KOXaTa, llypnypa @ ~ ~ M H H M ~ AMK. HC

WMM

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fl~artiocm~a
Onpeflen~~e~o Ha npoTeMH C Moxe fla ce nsabpurea
C $~HK~MoHC!J~HM M MMYHOnOMrHMM e T O n M . C nOMOqTa Ha

@~HK~HOH Ce ~ M3CnenBa ~ H # T ~ HerOBaTa a K T M B H O C T , C MMyHOnOrMVHMTe C e M3BbpluBa KOnMreCTBeHO onpeflenRHe. np# x e ~ e p o 3 ~ r o ~ HMBOTO w ~ e Ha n p O T e M HC e IlOp 50%, nOKaT0 npM XOM03MrOTMTe H M B O T O e non 1%.

nofl06Ha e Ha Ta3M npH fle@M4MT Ha IlpOTeMH C M AT 111. CK~OHHOCT KbM T P O M ~ O ~ M ~ O ~6enoflpo6~ M ~ ~ M ,

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npu X ~ T ~ ~ O ~ H ~ O nauHetiTM THM ce npunara pnrocporHa TepanMR c o p a n atiTMKoarynaHTM. ~~ Moxe fla ce npoeepe M x e n a p ~ ~ o e a ~ ec pnpo@~namur~a an~~ qen 3a ~36flrea~ Ha e PMCKa OT T P O M ~ O ~ M ~ O ~npelOneM~~M,

A H ~ ~ P ~ H AHamo3a UH~~H~
Bpofle~ f l e @ ~Ha u npoTeMH ~~ C M AT Ill.

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Cnopen cMnaTa Ha npoeoKaqMR ce ~a6n~flaea @yflp~ aHTHOnpoM.laHe HapMK, KOeTOCe OCbqeCTBflBa3aHRKOnKO MnM 3a H R K O n K OA H M ; XPOHH~HO, IlpOTpaXMpaHO npoTwraHe. X e ~ m a 3 ~ m npoMeHu e MoraT pa M M a T noKa. neH M n w r e ~ e p a n ~ 3 xapamep ~ p a ~ Ha p a ~ ~ m e .

Tponc+puonnu u xemocma~nucnerunu cacmonnun

395

Ta6nnqa 12.3. k u o m n npmrnHn n 3a60nnsa~nn, nposonnpaqn AMK

FaI o p r a WTO ~ ~ repeH 4@,6b6peqw, 6 ~ n H axeuma3~a~ cmcTeMa, a ce ~ ~ A C T B Katcro ~ T e ~ 3 o r e ~ - $ ~ H ~ MH UHC, cro~aur~o-rpeee~ F a n , K O ~m , e 3C ~BbTpewHa HaTa, TaKa M eHflOreHHaTa C M C T e M M Ha K P b B O C b C M P B a H e . K p a A ~ ~pe3yma~ rn e atcrlrawpaHeHa r1poTp0~6MHa. T ~ M - ceKpe4nR M ~ p . Ha6nloflm~me HapylueHHR nP%3 T 0 3 M CTaMa C a KO~ M H ~ M M BOflM RT~ npeBpbqaHe H a $ M ~ P M H O T ~B H b B4 ~ 6 M~MH~I&IFI OT HaPylueHMR BX e M O C T a 3 H M R IlOTeHqMMC KOHP M H M O H O M e p M C OTl@nWHeHa $ # 6 p ~ ~ o n e r n ~ A fln M 8; aKTM~Mpa$atcr~pWTe V M V111; 0 6 ~ 3K9 OM~J~~KCT~OM~ cyMaTMBeH HHXapaKTep, npO60KMpElqM OPraHHM MMKPOuMPKYnaTopHu npoueHM, KoeTo B O ~ M AO nonMopraHHa Hepocra~HTMTPOM~M 111 HM n O B M W a B aT ~ ~ M ~ O ~ M arperauMR. T H ~ T ~ T b i 'H O C T . na6opa~op~afl~amo3a: tea^ cxeMaTMrHonpeflcraaeHM npoMeHM HauMpaT ~3pa3 B IaHHme OT nahpa~op~me Ill. C ~ a n ~ Ha l lp e a m e H a xvlnep@er6per~on~3 MXneflElaHMR. 1. X n n @ d p n ~ o r e ~ e -~c~HalvlaneHn ~1 w r w cm~o Xapatcrepvsupa ce c Ha6nlofla~aHe KapmHaTa Ha HaAn O H M X e H M CTOAHOCTM 3a HMBOTO H a $M~PMHOT~H. Te)l(KM @PMW H a KPbBOTe'ieHMfl M C b C T O R H M eH a UOK. MUK2. n o ~ m u a ~ p a H a ~ TecroeeTe e 3a $ M ~ ~ M H M O H O M ~ ~ M p o ~ p o ~ 6 0 3 n p a ~ npoeompa e~o amBMpatie Ha n n a 3 ~ ~

3.C~bcRBaHe Ha CTO~HOCMT~ Ha napqMaJlH0 ~pCiMhnnacTMHO60BFt?Me B B Bpb3Ka C a K T M B M p a H e T 0H a $aKTop V M VlII. 4. ~ O H W ~ HH H M B ~ O T O Ha ~ K M I ~ O M ~ 111,HKHO ~ O Ce CBbp3m C T ~ ~ M ~ H H0 H M,C a K T M B H p a H M T e $~KTOPW11, IX, X, XI H XI1 M o6pa3y~a KoMnneKcM. PRBKOTO cnaaHe H a AT Ill H e Ce KOMneHCMp OT flOCTaTbClH0 6bp3 H O BC M H T e 3 Ha AT 111 B 'iepH#R flpo6 n e ~ 3 ~ n l o r ~ ~ we en H~ no ahpa~ope~

K O ~ O npefl~3~~ npoqec ~ea H a 41~6pn~on~3a. AKO tibpBOHarWIH0$M6pMH0flM3aTaMM~$M~MO~OMCIHO Bb3&3Am B M eC uen p e ~ a ~ a n ~ a Ha ~p HappeHaTa a~e MMK~UMPKYnww B 3acemaTme OT WoKa opratin, no-WHO ce ~ a 6 n o R a mr e ~ e p a n ~ a ~ M pa ~~ ~M a M H ~ Mc MHexenaHn R CT~~HM 'iHM ~ ~ ~ ~ C T ~B ~M ~R T. ~ O ~ M T M IlpOUecM C ~ H M3aeMaTfl T ~ OMMHMPaul0 M R C T OBX e M O C T a 3 H M F If l M & U l a H c , IlpORMBaqMCe C H ~ A - T ~ M M @PMM Ha xeuopamwa flMaTe3a. f l a h p a ~ o p p~amo3a. ~a Te3~ npoveHM HaMMpaT caoeno~a3a~en3anpo~e~a~e~aqene~acore~a~e p OTpaxeHMe a n ~ ~ . M B nahpa~op~me TO MxnepeaHw: m r m 5.T ~ M ~ O ~ M T ( X -finxaqa I ~ H H R ce Ha C M n H O M3pa3eMXneflBaHMR 3a $M~PMHAewaqMOHHM nPOflYI(MCe noHa T P O M ~ ~ M T arperauMR H~ n0fl fleACTBMeT0 H aT~~M~IIH. amnla~pa~ npMpeatcrcleHax~nep@#6pn~on~3a. Moflep~a~ 6. HapweHMR B allKanHo-KMCenMHHoTOpaBHoBeCMe. AMamocTuKa ce l r s ~ p w a a c onpeflenfitie Ha P, - AMMep. 7. nahpaT0pHMflaHHM 3a BHeMMR. TeCToBe 3a (XIpeflenRHe Ha $ M ~ P M H O ~ ~ flerp4aqMOHHM H npOflylcrM C b w Ce ll03MMBMpaT npM $~6pM~0re~0nM3a II.R~AHL Ha opraHHa HeAocTanvHocT Onpenen~l~e HMBOTOH ~ ~ M ~ P H H no O~ ~a~3H P ~R a ~KO cnapaHe MnM tibnHOT0 M YM 3 K O H C y M M p a H e . CMnH0ymXaBaHeHa H~e~onnne~caq Ha ag x e ~ o c ~ a 3 cHcTeMa ~a~a CTOAH~CTMT~3a napuManHo ~po~6onnacrw~oBo epeMe U ~ p o ~ h n n a c ~ speMe ~ ~ om so x a u ( o ce ~aM ~ K O H C ~ M M Ha BCMYKM @tcrop~ Ha CbCMpWHe. Moxe fla ce KoMneHcwpac HOB CMHT~BOT cTpaHa Ha repHwR S a p n m e n ~ a~ PyrMHHa a flwamrnia 6KnH)rBa OF A@. llocnefl~4me ca:nclnca Ha BcMrKM atc crop^ Kamo OT peAenRHeH ~ T ~ O M ~ 6pA, ~ H M HMBOTO R H~$M~PMHO~ eHflOreHHaTa,TaKaUOTeK30reHHaTaCMcTeMMHaKpbBOCbH M B o T O Ha AT 111, T e C T O B e 3a $ M ~ P M ~ ~ $ M ~ P H flewsHO~~H cnpeaHe, HenpeKbctiaTo mpaeane H a AT Ill c aKmeMpaHM~MOHHM npomm, napwantio ~ p o ~ 6 o n n a r n epehne, ~o~o Te @C~OPM B KOMnneKCHa@pMa, $ M ~ P M H O T ~ HCe ~ TnpeBspeMe 0 M T ~ M ~ M H O Bspeue. O Ko~~pon~ pbqa BB $M~PMH,npM KoeTo ce oTAenm $ ~ 6 p ~ ~ o n e r n ~ p #e r r ~ n a 3 ~ ~3cneflea~ ce u~ npoaeyqaT B nmepean 6-24 h, KoeTo e A M B. T p o u h ~ m ~ arperaqMR a~a n p o m a e a B oqe no~ J l W e n H npM O OCTPMTe @PMM Ha IlpOTMclaHe Ha AMK. M ~ R B $op~a. ~ H ~ YCT~HOMB~ ce n ~srepnea~e Ha $atcrop

n n w$dp~~onern A. fl

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XIII. Jlahpa~optia )q~amo3a. BCM~KM nmetiM B xennmam a c e KoHcraTMpaTC noMoq-raHa cnemmeMxneneaHuR:

YfinXeHO napqMaJlHOT0~pO~6OllflacTM~060 BpeMe; P R 3 K O HaMmeHO HHBO Ha AT 111; IlOHMXeHOH M B oH a$ M ~ P M H o ~ ~ H ~ nOKa3Ba C b C T O R H M eH a xcll~@M6pM~0re~eMMR; ~ & e a o 6 ) ? n i l Ce TeXKa @pMa Ha T ~ O M ~ I $ V O ~H ~ H B H O T M OR H a ; @(TOP Xlll e noHnxeHo; cneqn$wr~o~o onpeAenRHe H aT ~ M ~ H H ~ M ~ ~ M ~ M HK O O B M n n e K Ce n o 3 m ~ ~ o . ffiMHMrHaTa KapTMHa npe3 T 0 3 M C T W ~ e CBbp3aHa C HapyweHaMMKpowplcynaqMRB p a 3 n ~opraHn, r ~ ~ aceniaMOT WOW. X~nonep@y3uma WM H c x e M M R , MH@PKTMpaHe M H ~ K P O ~ H K. p a e ~ pe3yrrra~ e nonMopratiHaHeflocTaTbrHw. OT mweHo m o 3 ~ a r e w e e HapylueHaTa

H0 XOCllHTaJlM3MpaHe, KbAeTO C nOMOU(Ta Ha ClleuMMHM na6opa~op M~ ~~ C ~ ~ A B ~ce HM norabpxqasa R M n MoTxebpnR RMK. ~ ~ O ~ O ~ H M C I HnposewaHe OTO Ha cneu~$nr~a TepannR npM caMHeHMe aa AMK e HenpaaMnHo M uoxe ~a~ o e e ~o ~e

4. npo~eHHTe B elleKTPOllkllHMRM aIlKanHO-KMCenMHeH 6ana~c M~MCKB~ ~ Te o 6 x o p ~ u a KopewMR. ~a npea II c~a,quh ~ a o p r a~ ~e ~~ ao m a n r ~ o c ~ ~ ~ H~~UM Ha Rxeuocraa~a~a ccnlcTeMa ce uenw npetacsatie Ha naTonomrHme npoMeHM B X ~ M O C T ~ ~ H6ana~c MR W 3aMecT-

npes I CTWMA Ha mnep~oaryna6un~~e~ Bweu noKa3a~en e ~ ~ 6 Ha 0 AT ~ 111. 0 1. np# CTO~HOCMHa AT Ill 2 OT 70% ce npMnara xenapntiosa TepanMn B p03upo~~a 100-150 E Heparinkg Tenectio Terno, i.v. 3a 24 h. 3 ~ a r e ~ w e Ha ~TepanMma o c HMCKM mat4 Heparin e Aa ce n p e w e amMevpaHeTo Ha $a~~op II,~ IX, ~ X, e XI U XII, non sn#RHMeTo Ha AT Ill. O m ~ u a n amKoarynayoHHo ~o xenapwiom m g e h c m ~ e uoxe Aa ce rapamcnlpa c a ~ npu o CTO~HOCTM Ha AT 111 2 OT 70%. 2. PM CTO~~HOCTW Ha AT 111 -aKTMBHOCT < 70% ~pR6Ba Aa ce npoaeAe aauec~eawa TepanMR c AT Ill, 3a KoeTo cbqecTayeaTAea HarMHa: a) rpea npnnaraHe Ha AT 111 - KotiqempaTM, KOMTO IlpMTeXaBaTBMCOKO C ~ ~ ~ M $ M CTO~HOCTM C I H M Ha aKTMBHOCT, a caqeepeueHHo ce n 3 6 ~ r annameTo ~a Ha roneMn o6euw; 6) rpes BnMeaHe Ha npRcHo 3aupaae~a nnaaua, npM KOeTOcecy6c~mypaAT 111, @KTo~M Ha cbcMpBaHe,npoTeHH C H S, H0 M rOllRM 0 6 e ~CbppMHMeT0 . Ha AT 111 e 1 E B 1 rnl n p m o 3aupa3e~a nnaaua. np~noxe~ue Ha ~ Heparin o B ~ e cnyvaH 3 ~ ~ p ~ 6 qa ea 6bpe ~o6pe O~OCHOB~HO M 3aBMCM OT KnMHM' iHaTa CWMflTOMaTMKa. np# ~a6n10~aeme Ha KPbBOTeVeHMe C e npMnXa ca~o 3auemenHa TepanMFi c AT Ill ( ~ o ~ u e m p MI~M a~ n p R m 3annpa3eHa nnaaua). 3. PM ~ H H 3a H m e u m ce npenopbrea npMnaraHeTo Ha epwrpoucrTHa uaca M npRcHa nnaaua. B n ~ a a ~ e Ha ~o

TenHocT B Tepanlrlma: 1. npofinxaea npoeexqaHeToHa q6cnnypaqa ~ e panw c AT Ill, Kawo e oncnlcaHo no-rope, c napanenHo npMnaraHe Ha Heparin.C a ~ npu o H a 6 n I O ~ Ha ~~ Oe ~M~H KpbeoTereHHR He ce npunara Heparin. 2 . 3 a ~ e c ~ ~ TepanMu ~en~a no oTHotueHHe Ha @KTOPM T e HacbcMpBaHe,KoeToce n m r a rpea BnnBaHeHanpFlcHo ampase~a nnaaua Mnu KoHuempaT1-101 N p ~ a ~a ~@ aK l ($a~~opM Ha n p o T p o ~ 6 ~ ~ 0 KOMnneKC B~fl y H ~ C MIlbd' ) PSB. 3. Jlere~we~o Ha aHeuMma npoflbnxaea Ha C ~ ~ npMHqHn M c ropenocoreHme cpepcm. 4. ~ ~ M I ~ o x ~ H MHa ~ $II~PMHOT~H To - KOHUeeHTPaTHe ce npenopbrea. n p ~ r ~ ~ a ~ a 3 a ~ ve oB e~ aR eH , MF(T$M~ C e IlpeBpbqa BbB $M~PMHMOHOM~PII, KOHTO AOnbnHHTenHO C e BKnIOrBaTB IlpOUecaH ~ M M K P O T ~ M ~ ~ M~ 3aCWIBaT MPF~ Hap)UleHaTa MMKPOuHPKYnauWFIB 3aCeMaTMTe OT WOK OPram. Cmo npM ~ p a i HHCKW ~ o n a 6 o p a ~ o CTOAH~CTH p~~ 3a HMBOTO Ha $ H ~ P H H O e MHAML(WpaH0 ~~H HerOBOTO IlpMnOXeHMe. npea Ill c ~ a , q Ha ~ peamBHa i x~nep$~6p~~onu?a npoAbrvKaeaTepaneemrHaTacxehna, oTtiacRqace 3a II c~a,q~ B cauaTa nocne4oaaTenHocT. nplmXaHe~0 H~~HTM$M~PMH ~O ~U ~M ~A TH MC ~K MY HeH BbnpOC, K O ~ O npe3 IlOCJleAHMTe r O A M H M OTXBbpnM TRXHOTO npMnoxeHMe.~ P M ~ 3a M TOM H ~ e, r e x ~ n e m ~ 6 p tionM3aTa nua peannwH, $twonomve~ Knnpeticos xapaKTep, KOATO 4enM npeMaXBaHe Ha M M K ~ T P O M ~ O ~H M ~b~c~a~o~~~a~e~a~~p~yna~~ opraHM. B onpepeneHM cnyan M npw crpora MHAuKauclR uoxe Aa ce npMnaraT n n a a u ~ ~ a m a r o OT ~~ anpomHMHoe c~u mn (Trasylol, Contrycal) B p o a ~ p o OT ~ ~10 a 000 Eikg TenecHo Terno nbpeoHaranHo, cneA KWTO no 5000 Eikg TenecHo Ternoh, KoraTo Mua paHHM, ve mnep(1~6pn~on~3a~ ce I l O m p MOTTbKaHHMnJla3MMHOreHHMaKTMBaTOPM.T ~ K u B npeAnocraeKuca HanMqe, KoraToc a3acemaTMoprmM KaTo 6 ~ qo6, n opraHM Ha ypo-re~man~a~a cMcTeua, nnaueHTa, 3auOTO ~ 6 0 r a ~ HaTbKaHHM bI nlla3MMHOreHHUaKMBaTOPM.

A ~ ~ u ~ o a r y n Tepanun a~~~a Haunpa ~ a lunpo~o npmPaan~vaea~ ce flee r p y n OT ~ n e ~ a p c r ac ep ~e ~~ c ~c sa JlOXeHMe 3a npefl0TBpaTRBaHe Ha ~pou6006pa3yaa~e aHTMKOarynaHTH0 flehCTBWe: AMPeKTHO A ~ A ~ T B MM ~H -~ M n M npM np@MnaKTM~aHa T ~ O M ~ O ~ M ~ O ~ M YCnOX~ H M T ~ AMpeKTHO ~lehCTBauM aHTMK0arynaHTW. K ~ rpynaTa M Ha HeHMR. AMP~KTHO ~ e u c ~ ~ a u ccna,qa~ n l ~ e Heparin W x e n a p ~ ~ o

Hme cpeRcTaa. Heparin Hannwpa l ~ l ~ p npMnoxeHMe o~o B CnelLlHaTaMepMuMHa, M M e H H OnOpaM6bp30~0, flMpeKTHO

RehcTBMe. ~HflMpeKTHbl~e aHTMK0ar)'naHTM He Ce npMnaraT B cnewHaTa M ~ R M U M H Te ~ . HaMMpaT npnnoxeHue B eAnH no-lcbce~ eTan Ha nereHlrec qen rpou603~a npo$#namwa.

Am~oarynaw~ TepanHg a c Heparin

Heparin, KaTo C ~ ~ C T ~ H e ~O MT R~ , M npes T 1916 r., a KaTo TepaneemrHo cpeRcT8o e npnnoxeH 3a napBM WT npe3 1937 r. H~$~~K~WOHM Heparin P~HM Ce RnOny.laBaOT T C B M H C Ka rpeeHauy~o3a unMOT roBex,qM6 m~ ~ 0npeRcTaenH6 ,
B ~ ~ M ~ C O T M ~ K O ~ O ~ MB~ ~~ PM XM ~ c~ pM a3 An H~ Mr ~ a ~ b n w Ha. MOneKynH0~0 M y Tern0 e OT 5000-30 000 RaJlTOHa. Huc~o~oneKyn~ Heparin p ~ ~ m e c MoneKynHo Terno OT 3000-9000 RanToHa. npwnoxe~ s.c., HMcKoMoneKynRpHMRT Heparin HMa R B nbTu ~ no-pnro 6uonor~r~o Rehcselre B cpaBHeHlrle c H ~ $ ~ ~ K ~ M O H H Heparin. ~~HMR @apua~onomr~o~o pehc~ane Ha Heparin no OTHOwetiue Ha x e ~ o c ~ a 3 a Moxe ~a M H~~CX~M~TMC Aa I Hce O ~3pa3u~cne~ HacoKu: ~me 1. Heparin noTMcKa cbcupaaeuocrra, C B ~ P ~ B ~ ce ~ K M M ~KTHBMP~ ~H ~T K M M T P O M ~ H111, H KO~TO e$M~MO~O~M~~ MHXM~HTOP H a n n a 3 ~ e ~ cbcMpaaeMocr. a~a Heparin MHOrOKPaTH0 3 a c ~ n M ~a HXH~M~~~ RehcTeMe OTO Ha AT 111. AT 111 6 n o ~ ~ p a K a T M B M P a H M f 4 $aKTop X M no T 0 3 M Ha'iMH Ce 6no~~p Owe a B CaMOTO HaWJlO KaCKmHaTa CMCTeMa Ha
cbcMpeaHe.

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paHHm Heparin. 1. np~nara ce MHTepumupaulo, M H T ~ ~ B ~ H OH ~ aH BCeKM 6 h. O ~ ~ O KOnHW!CTBO TO Heparin3a 24 h e 20 00040 000 IE. 2. MH+YB#OHH~, M H T ~ ~ B ~ H Tepanw O ~ H ~ c noMoqTa Ha H H ~ ~ ~ O M KOFlTO ~ T , C e C'iMTa 3a Hah-~llTMMaJl~a, nOpa-

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KaTa 3a 24 h e 20 000-30 000 IE.

Heparin He ce npwnara i. m.

Jlabopa~ope~ Koqon
Msebpursace c onpelenme Ha T~OM~HHOBOTO BpeMe M Ha napqMaJlHOT0 T ~ O M ~ O ~ ~ ~ C T M BpeMe. HOBO

a xenapMHoeaTa TepaH 3a onTwMantio npoeex,qaHe H nMR ce cMma nocmraHeTo H a 2,3 ~ T ygbnxaaaHe M Ha

CTO~~HOCTH 38 T ~T ~ M ~ W H O B BpeMe O MllM YRbnXaBaHe Ha CTO~HOCTMT~ 38 IlaP~MaJlHO TPOM~O~~~CTMHO BpeMe BO 1.5-2 nbTM.

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2. Heparin - ~ H T M T P O M ~ M111 H PeflyuMpa

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C.,

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llpopbnx~~en npoaewatie ~o Ha xenapwioaa Tepanun (HRKO~KO ~eceua) eopu po oc~enopo3~. flp~noxe~lreT0 Ha MYCKYnHM HHXeK4MM no BpeMe Ha XenapMHOW TepanMR e KOHTPaMHflMqMPaHO.Cbll(e~TBy~a OnaCHOCT OT 06pa3yea~e Ha pbn60~M MyCKynHM XeMaTOMU, KOMTO noK~CHO a6~~epMpaT. B3aMM0pehCTBMeT0Ha HeparincaHTnarperawtinM n M ApyM aHTMKOaryllaHTHM CpepCTBa, IlOTeHqMpa HerOBOTO aHTHKoarynatnHo peknwe M noe#waBa ooncHocna OT KPb6OTeqeHUR.K O M ~ H H ~Ha ~M Heparin R T ~C aUeTMnCEUlMUMnOBa KHCenMHa npM'iMHa 3a TeMU XeMOpaMM OT CTOMalUHO-qpeBHMflTPaKT M He C e IlpMnara. fle~apc~aa KaTo atiTMxMcTaMnttoeM npenapam,~ M M Tanuc, HMKOTMH, ~ C K O P ~ W H KMcenMHa, OB~ ~ ~ H M U U ~ TeMH, TpaquKnMH, ~ m p o r n M O ~T eC ~~ ~~ ~H ~ ~B ~O ~ BTO T pehc-rO

Ba fla C e M3BbpWBa BHMMaTenHO, 3all(OTO cao60pe~, HeCBbp3aH C Heparin Pr~tarnifli SulfaS M M a aHTUKOarynaHTH0 pehcTBMe. Maeec~e~ e M T. Hap. Rebound $ ~ H O M ~ npM H, KO~TO HmonKo qaca cnep npMnoxeH#eTo Ha Protarnini sulfas s p b 3 ~ a ~ ae w Heparin-Protarnin y ce pa3nqa M ce ocao6owasa Protarnini sulfas, n p e p ~ 3 ~ ~ m KpbeoTeaq CleHMR. Kora~o HmapaHtin3a ronRMo npepo3mpa~e Ha xenapw~oaa~a~epe a no-po6pepa n~fl ~ece np~nara Protarnini sulfas, a pa ce ~ s q a ~ CnoHTaHHoTo a 0~3syraea~e Ha Heroeoro pefime~e, KoeTo n p i.v. ~ e 4-5 h.

J l e ~ a p m e ~(IOPMH w
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1. He$pa~q~o~wpa~wrn Heparince npo~3sewa ~ah1 ml.

OTflenHM $LIPMM nPOM3Be)l(FlaT pa3nM'iHM, no-KOHqeHTPMpaHMno CbpbpXaHMe Ha Heparin pa3TBOpU, KOMTO C a BbB $ ~ ~ K O NpMa HH~ M n M B CflPMH40BKH 38 eflHOKpaTH0 npunoxeHMe. Pasnpompa~e~n ca KanqHee M n w HaTpMee xenapw HaT, KOMTO ce npMnaraT npepmMHo s.c. 2. H n c ~ o ~ o n e ~ yHeparin n~pe~ -Fraxiparin, ErnbolexNM. llp~nara ce s.c., c n p o $ ~ n a m ~ .i~ e~ na npu nauuetiTM, C nOBMUleH P M C K OT T P O M ~ O ~ M ~ O ~yCnOHHeHHR M~HM B BM~. cneponepaTvlstiwflnepuop. l l p w n o x e ~ ~ MY e ~B ocnewtiaAHTM~OT: aHTMpoT Ha Heparin e Protarninisulfas. Toii e npenOpbrBa. RMPeKTHO enMMUHMpa ~ ~ ~ ~ C T B My. M fl03MpaHeT0 ~ T O ~ p ~ 6 - Ta MeLIU4MHa He C

T P O M ~ O ~ M ~e O npMrwHa ~U~M 3a ~neTaneH T ~ 3 x npu 0~ MM C ApyM MepMKaMeWM, C MHpMKwMRTa M KOHTpaMHAMKaMHoro nauvetrru. PasrparnC(a~e~0 Ha ~ p o Moxe ~ 6 pa Mua ~MRT~~~TRXH npmoxeHMe, OTO 3apace ~36emeo~puqa~ xumTocnacmalqo a ~ a q e ~K ~~e M . H M npMnoxeHve ~HO HaneH TepaneeTHreH e$em, a a p q e w cnyraM M PMCK 3a MHpaT cnepHme npoTeonmwHw C~~CT~H~MII: cTpemomm w T a Ha naqbfewa. He ~ p ~ 6pa ea ce xi6paa~, r e $M~PM Haxi, YpOKMHaxi, ~ ~ K O M ~ H H TbKaHeH M ~ ~ H nna3MMHOreHOB HOllclMqUTe He M ~HTUTPOM~OTH~HM CpepCTBa. 3a Ce aKTweaTop, ~ M ~ - ~ ~ ~ ~ M M H O ~ ~ H - C T ~ ~ ~ O K ~36eme M H ~ ~pe~poM603Mpa~e, ~ ~ K M B ~ T O ~ npMKnloreaHe Ha $M~PM cnep KOMflileKC (APSAC) M npoypoKMHaxi. BcMrmTe M ~ ~ P O ~ H H HonmMwaTaTepannR, 3a,qbnxmenHo e TR Ra ce ,3ac~bn~ n n a 3 ~ u ~ o r e amlileaTopM ~oe~ cacepn~npo~ea3w, c ~apaseMnu pa ce npomnmM c npMnaraHeTo Ha awwoarynama Ha C ~ ~ ~ M $cnpmo M C InH na ~3 ~ ~ ~ o r e ~ a . TepanMa -Heparin, no-K~CHO MHpMpemHMatnMKoaTynam. C T ~ ~ ~ T OM KAPSAC, M H ~ 3a ~ pa3Jl ~ TM ~ Ka OT ApyMTe $ # ~ ~ M H ca o W ~b l ~ Ha ~ OpraHM3Ma , C@~~H~MM C ~IH~~W TepanHm Hcac O crperrrowu~a3a ~HM~ aHTMreHnu caohcm, KoeTo Moxe pa poaepe po 06pa3y~aC ~ p e m o w ~ a xei npoTeMH ~a c MoneKynflpHo Terno OT He HaaHTmena.Toea e npwwHa xi Ha6nlopa~aHe HaTem 47 000 pamoHa, K O ~ He O npmexaea ~ H ~ M M H ~eicmwe. O aneprurHM peaKqMM npu TRXHOTO npwnoxewe. llp~noxellonyaea ce OT ~ymypa Ha P-xeuon~aupaul~ cTpenroKoKM HHeTO Ha $ M ~ P M H O ~ M TepanMR T H ~ HKpMe ~ OnaCHOCT OT OT Langcefield, rpyna C. npoB0KMpaHe Ha KpbB0Te'ieHW. E T O ~ ~ U O M311CKBaCTpOr TR C~pemow~a3a amsMpa ~a $u6pn~onmwa~ CMCa KnnHureH M n a b p a ~ o p KoHTpon. e~ E$emT OT nposewaTeMa MHpMPeKTHO, M n M aMMBMpaHeT0 IlpoTMqaflBy$a3060. HaTa $M~PMHO~HTMCIH~ TepanMRxiBMCM OT M3MMHMMR neB mpeaTa$am cTpemowHa3aTace mbp3aa c M ~ ~ M M H p ~ o apeMe p - OT uoMewa Ha 06pa3yaa~e~o Ha ~ p o ~po 6a reH M o6pa3yaaT. Hap. ~ ~ p e n ~ o m ~ a 3 a - n n a 3 aK~~ aanorea~e Ha Tepanma. l l p npwnaraHe ~ Ha cnonneHaTme TMMTO~. T O ~KoMnneKc M npmexasa cbeceu c n a h npoTe$M~PMHO~ TpR6BZi KTM pa ~C ecao6pa~ea~ Ce npopnxuonmr~opeiicT~ne. Bbaa~opa~a@xi (nop m p e A c r a ~ e ~ Tentiocna Ha TRXHOTO npunoxeHMe, c ~ 3 a ~ ~ o p e i i m a ~ e ~ oc ~ p e m o w ~ a 3 a - n n a 3 ~ ~ ~ o Ha am~sa~op) re~oall~ aanor~a

npMnaraHe Ha eAHOKpaTHa BMCoKa p03a OT 1.5 M M n M O H a IE crpemomtia3a,yflaptio,cnpoAbnxeiiMe: 30,60 M n M90 min. nmwra ce n o m nbnHo 3aatirmpaHe Ha nna3ucl~ore~ B al CMBaTOPHMR KOMnneKC, K O e T OB O R M p0 K ~ ~ T K O T ~ ~ nns~paqo ~ e i c r a ~6e3 e , Aa ce Ha6ntoAaBaT ycnoxtieim C T B M e M BbPXy HOpMallHMTe KOMflOHeHlM Ha XeMocTa3HaTa cMcTelma, KoeTo uoxe Ra a cepa3~B npommpaHe Ha (KpbB0~3flMBM). T O ~H H a C M l H Ha IlPMnOXeHMe C e flpenopb'iI S npu 6 0 n c ~n@apm ~ Ha MMoKappa. KpbBOM3flMBM. r o n e u ~ ~~a a~ npmm~a~apo3ac~pemom~a3ao6ya Cxe~a c ~cpai~ BMCOW o po3~ c~pemomtia3a: nbpeoCnaBR pa3nMreH @ M ~ P M H O ~ M T M ' ~ *KT. ~H BMCOKM A03M Harantio ce npMnaraT 250 000 IE cTpernomtia3a, cnep K m T O 1.5 M M n M O H a IUh C npofinXWTeflHCCT 6 h. UenM C e ~Tpem0KMHa3a WT ~ (06pa3pHeT0 0 Ha rOlleMM KOnM'ieCTB~ anweaTop, K ~ T a O t l r m p a n o m BcMrmn n n a 3 ~ ~ - mntio aHrmpaHe Ha n n a 3 ~ ~ ~ 0BraK-rMBaTopHm e~a KOM HOreH. H a ~ ~ p a q m cee MMKM, OCTaTbCI HMKOJlMi'eCTBa CBOnneKC. KOMMHK~~MM, KaTO KpbBOM3IlMBM, IlpM T03M Ha'iMH 60pe~ n n a 3 ~ ~ ~ca o RocTanrHM, re~ 3a Ra CM ~ m ~ o p e i c - Ha Tepanun He ce ~ a 6 n n p a ~Hai-clec~o a~. ce npmara npn IlepM@pHM BeHO3HM MflM EIPTePMmHM Tp0~603~. TBaTCaKTMBaTOPHMR KOMflneKCHTepaneeTM.IHMF1T pe3ynTaT e omMManeH, n o p q ~ mcoKaTa, n ~ 3 ~ p a q a am w m M Jlo~an~ npMnoxeHMe o -cram c nohnoqra Ha wtrrpaaPTepMmHa KaTeTPM3aWR. n p u c b p ~ e r ~~@aplcrceannnq~pa e~ MmpaKopoHaptio, 06pa3paT MmKM KOllM'iecTBa aK.MBaTOpeHKOMMeKC, QCyAapHo 20 000 IE cTpemowHa3a, nbpeoHawHo M ce TaBaT rOneMM KOllMClf?CTBaCK&R~H nna3MMHOreH. hcTeIlpofinXaBa C nOAqbpMcau(ap03MpoBKa OT 2000-4000 neHHoTece npeepbqaTBn n a s u ~~~~. ~ C T B M ~anna3u1.1~ T O min, npomnmenHocT OT 30-90 min. Ha e KOMflneKCHO M B CJly.laR e He M M 0 C O'iaKBaHMR, PM nepM@pHM ~ ~ 0 ~ H6eM60nMM 0 3 ~C e annMqMpa B n ~ 3 ~ pe$em, a q HO M C pa3rpaxqa~e Ha ~ p b m c ~ p e a u p ~ - MHTepBaJl:3-5 mill no 1000-2000lECTpenT0~MHa3a. np0nbTe $arxop~ V, Vlll H XIII, KoeTo ~ a ref c~o e npwrwa 3a n x w e n i i m a Ha TepanMma ~ B M C M OT roneMMHaTa M OT TeXKM HaPYUJeHMRB KPbBOCbCMPBaHeTO - XeMOpaMClHa MACTOTO Ha noKanwaL(MFi, HO 3a He noBere OT 3 h M B epHa AMaTe3a. no OTHOUeHMe Ha TpoM6a, npU B M C O K M T eA03M C e o6qa p03a OT 120 000 IE CTpemOKMHa3a. ~a6ntopa~a cna6a eKmreHHa, HO cwnHo Mmetia emoreHHa @ ~ 6 p ~ o n w B3 MMMR a T~OM K O e ~ T O , o6ycnaWI OnTMMa~ ~ H T ~ ~ M ~ e@KT. ~ M T npM M V HM ~c K HM T ~ ~ ~ O @M~PHHO~M~LI, Ma~bpur~a ce c nouoqra Ha cnepHme xe~ocra3~ono M~HM nahpa~op M~ ~C ~ ~ ~ ~ B ~-Hrpes M F IonpeAenRHe Ha T ~ M ~ H H O B O Tspeue. O Uen~ ce pa ce nocTMme p m po cleTHpM YfinMBaHe Ha M3XOpHaTa My CTO~HOCT.OnH a w Ha npHnomeHue pepem ce HMB~TOHa @M6pMH0reHa. AKOce ~ 3 n o n 3 ~ Mea CTpenToKMHa3aTaMOXe Aa C e npWllvlaraMHTpaBeHO3HO TOA~T Ha Klaus ce 0npeAeng-r w @ M ~ P M H O perpa,qau~o ~~H M MHTpaapTepManHo.npnnoxe~ve~o ce M B B ~ ~ U IM B~ H ~ Y ~ M -H M T e flpo~yKlL4 BK!lO'iMTeflHO; OnpeAenRHe Ha 1 -A H M OHHO, H~A-po6pe c nolmoqra Ha M H @ Y ~ O TFI Muoxe ~ T . Race M n M @M~PMH perpqawoHHM npo~ylcr~; onpepenwe HMBO npunara M ~ O ~ H T. Hap. O , AMpemHo .oGnpbc~Batie"Ha TO Ha n n a 3 ~ ~ ~ 0 r e ~ a . TpoM6a M n M eu6ona.

Cnope~ Spaethe ce ~a6ntopaea~: nem K ~ ~ B O M ~ MBB Henccpepm~o npep~ 3anorea~e Ha Tepanuma ce 3.5%; T e M KpbB0TeCleHMR B 0.3%; MePMClHM PeaUMM B npMnara 50-60 mg Prednisdon i. v., qen - ~ 3 6 ~ r e a Ha ~ e 2.3%; a ~ a @ ~ n a m LUOK ~rB e 0.1%; ~ noHMxeHMe Ha AH B CTPaHHClHMpeWqMM. 3.0%; noeMLueHMe Ha TeMnepaTypaTa B 1.l%. 3a pa ce C~ati~apTHa CXeMa: CneA eAHa MHMwXlHaflO3aOT 250 1436er~aTa~~ep~'iHM peaKqMw,npepBapmenHo, c n w l m a 000 IE, KOMTO ce M H @ ~ H A M B npopnxetiue ~~T Ha 2&30 min, mrHaqencenpMnaraTKopTMKocTepoMpMMMmuMmHaTa ce pam no~qapxaqa pos~poe~a OT 100 000 IVh. npuT O ~ M ~ o 3 Ha a cTpemoKMHa3aTa ce ~ ~ @ y H p ~~ ~p Ba Ho f l. p aHa~ Ha'iMti ~apo3~patie ce nomra ~ 3 ~ 1 e e ~ o n m ~ r ~ o p e h m ~e, @maK.Mre~ WOK TepanMma ce npemea He3a6aBH0 M ce eTo 3aqo ce npunara npM nereHcle Ha~p0~603a Ha roneMM npoaeyqa ne'ieHMe c KopTMKmepolrlF(M,qpetianMti M aHCbnOBe M n MT P O M ~ C rOneMM pa3MepM.M H $ Y ~ M O H TepaH~T~ T M X M C T a M M H O B M npenapaT#.npM KpbBOTe'ieHMFI C e npeK%C~ M F ce I npoeewa a npopbnxeiiMe Ha 3-5 ~ H M Ro-npopbn. ~a ne'ieHMeTo cbc cTpamoKMHa3a M ce npMnaraT ~ H T M @ M xwrenHo npoeeyqaHe Ha TepanMma KpMe onacHocT OT PMHO~MTM~ (PAMBA, M EACA M RP.).n p ronehilM ~ ~pbeo3aryHapacrsaHe Ha ammenaTa e KpbsTa. B e ~ ~ a rcnep a , npw6~ ce Hanara npMnaraHeTo Ha 3aMecrwrenHa Tepanw c JltO'iBaHe H ~ T ~ M ~ ~ M T M ' ~ H O T C O e~ BKllto'iBaMH@~~ C ~ ~ H M ~ , 6nonpopym. BMOHHO aHTnKoarynaHTHa Tepannn c Heparin. MHPMK~~MFI M KOHTPaMH#l KaL(WFI 3a IlpMnaraHe Ha Cxeua c npunoxeme Ha B M ~ ~ K pM o 3 c~pemom~a3a: ~ CTpeflTOKMHa3a (~a6n. 12.4).

Hasu~cr Ha flO3UpOBKa

f l e ~ a p m WPMM: e ~ ~ Streptase, Kabikinase, Awelysin. 1. C T ~ H A ~ cxenna: ~TH C~ n e npMnaraHe ~ Ha MtiuqnanHaA03a OT 100000 !E, KOHTO C eM H $ ~ H A M B IlpO~bJlXe~~T -va ~~KoH~A w~e Ha 20-30 min, ce npoflbnxaea c n o ~ ~ l b p x a q a ~ OT oa ce pansopH c $ M ~ M O ~ O M pa~mop. CI~H 40 000 flo 60 000 IEh. 2. C X ~CM: M C~ P A H O BUCOKM CTO~HOCM HaA03UPOBKa. flpnnara ce MHwqwanHaAo3a OT 250 000 IE, npoflbnmen~ 0 ~ ~ 2 0min, -30 an o p ~ b p ~ q a ~ a f le o60000-1 aa 20000 1 U Y ~ o K M H$ ~M ~~ ~ uo T~~ o M ' IlpMCbu ~ ~ H , Ha OpraHM3h. Ma, flMpeKTHopehc~eaq ~bpxy n n a 3 ~ ~ ~ 0anMBaTop. re~a 3. C X ~ M BMCOKM ~ C CTO~HOCM HaA03MPOBKa. M ~ ~ q u a CllHTe3llpa C e B 6b6peq~~e, H0 M M a AaHHM 38 CMHTe3 M B HaTaflo3a e or 600 000 IE M H $ ~ H ~ ~ B npopbnxeHMe M ~ ~ H M Ha eHflOTenHMTe KneTKM. no OTHOWeHMe Ha MOneKynHOTO 20-30 min. nompxaqara ~ o 3 a e 100 000-150 000 IEh. Terno ce cpeqaT Ace $OPMM - C BMCOKO MoneKynHoTerno 4. f l o ~ a n npMnoxeHwe: ~o n p a~ p ~ e p ~ o - s e ~U o~ 3~ eH ~T - 54 000 AanToHa M c HHCKO MoneKynHo Terno: 31 000 3a nombpxme Ha HeroeaTa npoxoflMMocT.AIInMqMpaT ce flanTOHa. ABeTe $OPMH aKTHBMPaT AMpeKTHO nna3MMHO25 000 IE, cnefl30 min, aKo ce iianara, Moxefla ce noBTopM retia B n n a 3 ~ nflehc~ene~o ~. Ha y p o ~ ~ ~ a 3asncM 3 a ~ aOT roneMHHaTa Ha npunoxeHaTa floaa. Cbuo Kano n p ~ OTHOBO CbqaTa A03a. CTpeflTOKMHa3aTa H YPOKHHa3aTa pa3Tpwa IlpoTeOnMTMCIHO He caMo $ ~ 6 p w ~ o r eHO ~ aM , ApyrMTe K P ~ B O C ~ C M P n p e ~ 3ano'imtie u Ha Tepanwma ce onpeflenm: T ~ M saqM $amop#, KoeTo Moxe Aa floeefle ~o xeMoparMrHa 6n~oso apeue, ~ p o ~ 6 o n n a m ~BpeMe, o e o napqManHo~po ana~e3a. 3a p a 3 n ~ OT ~ aC T ~ ~ ~ T O K U npMnoxetiMH ~ ~ ~ T ~ , ~ 6 o n n a c ~ ~ BpeMe ~ o a on T ~ M ~ ~ ~ ~ T H 6poi.Tepanu~~ M F I T eTo Ha y p o ~ ~ ~ He a 3Bofln a flo o6pa3ym~e Ha aHTMTena, ce KomponMpacnouowaHacnepiiMTen 3 c n e n s a ~'ipe3 ~~: KoeTo no3aon~m Ha noBTopHoToh nptmoxeHwe,~esa6aonpefienme Ha T ~ ~ M ~ M H O B O T BpeMe; O rpe3 onpeflenwe BHOMnMnpe3KaCMMHTepBanMOTBpeMe HMB~TOHa @6pntiore~; rpe3 OnpeAenRHe Ha $ ~ 6 p Aern~ pa4aqmoHHn npoAym; qpe30npefleng~e Hap e n ~ ~ n a 3 speue. Tepan~ma c ypowHa3a Moxepa ce npwnara7-1~ A H H . Ypow~a3a~a He e aHTureH, cneRomTenHo TFI Moxe na ce
@~~KOH OT M100000, 250 000, 750 000M1 500 000 C$CT~HL(MFI. npen~pbcl~ace CbDpMHHeTOHa$ J

THBHa $ M ~ P M H O ~ W aKTl HC lBHOCT IH~ BC a M M R TPM~. nonyaea~e~ Ha oBMcoKonperncTeH1-PA OT roeewKa MaTKa M KyJlTypa Ha MenaHOMHM KneTKM IlpepnOCTaBKa 3a kl3pa60~8aHeT0, C IlOMOqTa Ha reHHa ~ M O T ~ X H O ~ O M R Ha P C ? K O M ~ # H H ~ ~ H TbKaHeH lllla3MMHOreHOB BRIIBaT O P fi-PA. Toaa Bb3MO)I(HOCT 38 HerOBOTO KnMHMqHO Ha6nlo~(aaa~ ce neKn K ~ ~ B O U ~ ~ M TepanMma BM, He npMnOXeHMe, KaTO MOUHO TPOM~O~MTMCIHO CpeACTBO. TPR~B Aa ~ C e CnMpa; TeXKkl KpbBOTe.leHMR - TepanlrFlTa H a r c lHa ~ npmnoxennen AosMpoeKa: 1-PAMoxe Aa ce ~p~6a He3a6aBH0 a na ce npeKpaTn n pa ce npunoxaT npnnara MH$Y~MOHHO M n M nOKaiHO. 3a CTaHflapTHaA03M~HTM$H~PMHOJ~MTM~H. ~ P TeXKM H KpbB03aflM C e Hanara npoeeyqatieTo Ha 3aMecTnTenHa TepanclR c 6~onpo4y~- poeKa ce npenopbrea 1-PA, OT 0.25-0.75 mgkg TenecHo Terno aa 24 h, M H $ ~ H ~ ce M i. V. ~ npu ~ T cnyran c n~$aplcr TM. Ha MMOKapfla C e /Jam AO3a OT 70-150 mg B MHTePBall: 3-6 h, MH$Y~MOHHO. PM aPTePManHM ipoM603~ M n M ~poM603M H ~ A ~ ~ ~ BeHO3HM O K M Tcbfl0Bet-PA ~ MOXe fla C e Bx.: CTpellT0~kI~a3a. annwqMpanoKanHo,KaToce npenopbcleanoaa1.5-7.5 mg, Jlenapcrse~n~ O P M H ntrepean 30-180 min. n p o a e ~ a ~ $M~~MHOJIMTHVH~ a~a @~~KOH OT M 10000,25 000,50000,100000,2!50000, Tepannn Moxe pa ce careTae oqe OT caMoTo Harano c jnaHTHa TepanMR C Hepann. 500 000 n 600 000 IE ypowtia3a - cyxa c ~ ~ C T ~ H ~ M F aHTMKOar' I, npon3sefle~n OT p a 3 n n r ~ n $MPMM. Actosolv Jla6opampe~ Kompon (Behringwerke), Alphakinase (Alpha),Abbokinase (Abbott), npenopbrea ce onpenenntie HMBOTO Ha $ M ~ P M H O UrokinaseHS-Kabi(Kabi), Urokinase-HC medac (Medac). onpeAenRHe Ha $H~PMH nerpa~launo~~me npop,ywn, ~ 3 cnepaaHe Ha - A n ~ e p H onpeflenme Ha t-PA, KoeTo (tJ~6pn~onms~a TepanwIi Moxe Aa ce H ~ B ~ P U JBM cTporo c n e q ~ a n ~ 3 na6opa~pa~~ C TbKaHeH llJla3MHHOreHOB aKTHBaTOp T O P M M . Tb~a~n ~n nam 3 ~ n ~ o r e amnaaTop ~oe (1-PA)e cepclrHnpoTeaaac MoneKynHoTerno OT 68 000 Aan~o~a. Crimempa ce B eHAoTenHme KneTKn. Xapamep~o CBOA~TBO e c ~ ~ ~ M $ M ~~$MHMT~T H M R T C~PRMO $ ~ 6 p nnpn ~ . OTCbcTBMe Ha $n6pn~ 1-PA e now n n a 3 ~ n ~ o r e amn6aTop. ~oe Bwcone~apmeu~ ~OPMH KMRT ~ $ M H MHat-PA, T ~ T B M $ H ~ P H H O C B ~nna3MM~~~HHR @ n a ~ o0~20~050 ~n mg ~ctiiyse ~a$np~a~aThom HoreH M noenwaeaHe Ha 1-PA-n~pyuwpa~a~a nna3~n~oBehringwerke. reHoea amneauMR rpe3 $M~PHH BOW AO BHCOKO cenelcnoeTapRno ~ K BpeMe. O npoaenqa~a~a $cll6pu~onmr~a TepanMR Moxe Da a cereTae oqe OT c a ~ o ~ Harano o c atrrMKoarynarna Tepanm c Heparin. ,

A r p a ~ e ~B. ~o A., , H. H. C~arnnoea. re~o~pa~c$y3uo~Hble PeaKqMM M yCnOXHeHMR, M,, 1979 c ~ ~ ~ $ M M o B - ~ MB. MT #~ T~ ~H ~C B$ , Y~MOHH~X~ AH~CT~COB, A., AT. AH~TKOB, H. AO~~HHOBI. PeawnM M C., 1972 ycnoxHeHnR ngn KpbaonpenweaHe. C., 1963 Y~RHOM, M. A., E. A. ~ O T ~ K O H. B , H. CKaqMll~Ba. M~OMM Ao6peaa, A., E. Moppa~oea. K n w ~ n rx ~e a ~ a ~ o nC., o ~ ~ . MYHOnOMR H BOnPOCbl KnHHMKM M JleqeHMR reM0TpaHC1984 $Y~MOHH~IX ~C~OXH~H M. M ,~ 1979 . Ao6peea, A., H. ~ O ~ W H O B H. , Baclmee. T ~ ~ H @ ~ u o H H ~ Barthels, M., H.Poliwoda. Gerinnungsanalysen (Georg xeMaTonomR. C., 1988 Thieme Verlag) Stuttgart - New York, 1987. AoGpeea, A. Jlere~ne c Kpbe n K ~ ~ B H 6nonpenapa~n M C., Begemann, H., M. Begemann. Praktische HZlmatologie. MepMqM~a M $~aKymypa,1989 (GeorgThieme Verlag) Stuttgart - New York, 1989. Aoir~~oea H., , A. A~ac-racoe.V1~y~oxea~onomrr. C., Mollison, P. L., I.P., Engelfriet, M. Contreras. BloodTrans1977 fusion in Clinical Medicine, 1987 J~MCM~KOB,T. H a p y w e ~HaxeMocTa3aTa. n~ C., M e ~ n q ~ ~ aSpaethe, R., H.J. Kolde, Hglmostase - Physiologie, M $~sKynq!pa, 1987 Pathophysiologie, Therapie, Diagnostik. Baxter ~ ~ T ~ O B C 6. KM B.~Py~omflcreo , noo6qel L4 K ~ M H H ' ~ ~ C K O ~ ~ Deutschland GmbH, 1992.

C ~ ~ H ~ He MC~ b C T TO O R H M e , npM KOeTO C Y ~ ~ K TCM ~T flaw CMeTKa 3a T O M KaKBo CTaBa CM: C a M M R Her0 M C OKpbMBaqaTar0 Cpefla, a KOMaTa- Tom e T O r H O npOTMB O n O n O X H O T OC b C T O R H M e , KOraTO O C B e f l O M e H O C T T a3a Ce6e CM M 38 OKPbXaBall(MRC B R TO T C b C T B a ,A w e B y C n O B W ma Ha p e h c ~ Ha ~ ~B~HLUHM e flpa3~~~ (Plum en~ F., and

Posner J. 1986). Hai-eam~a~a npepnocTaaKa3a 6naronp~m~n~ Kpae HM 3 X O p OT K O M a T O 3 H O T OC b C T O R H M e e 6bp3a~a, ~$MK~c-

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3 H a U M . Me~a6onm H TOKCHlrHH ~ IlPHlrHHH MH~paUepe6panH~ nesmm. M~~paqepe6pan~me Heo n n a 3 ~xehnoparm, ~, ~~$apmc~# M a6cqec~ MoraT pa npeKOMMT~ OT~~U$Y~ MH~ ~ ,T ~ ~ O MnM ~ MT O TK H C M ~ i 'H a eTMp M 3 B M K a Tp a 3 B H T M e T O Ha K O M B . Uepe6panHMTe XeMOpaonoMA ca recra npMrMHa 3a noe~KeatiMfi H a cnelutiwe rMM ca ~ a i - r e c ~ a npMrMHa ~a 3a KoMaTa. TR P R ~ K Oce eKMnM M Ca p%Ta TpYpHM 351 flMarHOCTMKa. Ha KOMnIOTbP~a6n10paea npM O ~ M K H O B ~ H M xe~M@epHblMH@~PKTH U HaTa T O M O ~ ~ $ MHe R C e BMwaT 06eMHM ne3MM, KOMTO pa aKo e Hannqe, more recTo ce Kacae 3a nauMeHTH c nOKMM3MpaT M R C T O T O Ha ~ ~ M C @ ~ H K ~ MnM M Rpa T~ HM paBaT IlpMflP~aBa~M ~ ~ ~ O ~ F I B ~HH~ M ~A - ~, ~ C T O X M ~ O TnpM ~ H ~ M R eTMonomTa. ~ ~ M K H O B ~ ~H e~ ~T a~ 6onm MnM ~ ToKcMrHa a MMoKappeH ~ ~ $ a p MnM m ~MCPMTMMR. Koua ce npepuecTea OT racoee HnM ~ H Ha M nocTeneHHo B ~ H o ~~H p0 ~~T 60 ~3 ea reCT0 HepOOqeHRMHa npM06bp~BaHe M p e 3 o p ~ e ~ ~Ornepb~ a q ~ ~ .H e noltaaeanoKaY M H aa ~ KouaTa. TRMoxe pa BMHMKH~ npu 6amepnan~a neH # ~ $ M ~ M T , a HMBOTO H ~ ~ M C $ ~ H KC~eH OKa3Ba R HRKbpe HH$~K~MR pupemtia , O W ~ ~ ~Ha H cbpa R OT r y ~ o nnln p pa e Memy pBeTe xetJMc$epM M AOnHMFl C T B O n . TP~MOP ~ ~ ~ ~ M ~ ~ M K ~ H ~ O T X ~ ~ ~ ~ K O ~ ~ ~ ~ ~ ~ MM OH HOH CH ~~ C TT O R pa H M ~ . KO ~O C ~pf16m ~ HaeepaT cneuHMR neKap Ha CTBOJ~OBH ne3MH. T e s ne3MM, ~ BOAeqM 40 KOMaTO3pMaWO3aTaM ~ T ~ ~ O K ~O M M a . TflaqMeHT, H ~ IlpMen HeOTQaH 0 C b C T O R H M e , ca BbTPeUlHM Ha CTBOna MnM BbHUlHM, B H a ronuwa posa C e A a T M B H M npenaparu, Mome pa e c npmMcKaqu cTBona. apemama BeHmnaqMR, HO nporpecMBHo pa ce snouam, Tpo~603n Ha 6a3~napHaTa apTepHfl. Te ca recTa nOpZl@l IlpOrpeCMBHOTO IlOTMCKaHe Ha CTBOnOBaTa $YHKnpM'iMHa 3a KOMMTe. ~ ~ H K H O B ~IlaUHeHTMTe HO pa3BMBaT UMR. ETMOJ~OMRT~ Ha T e 3 MK O M M BWIIOCIBa: npeA03MpaHe TpaH3MTOPHMnpM3Hal(MMCMMnTOMM,HRKOflKOflHMnpepM H3nWaHeTO B KOMI. %CTM Ca pM3aPTPMR, /JM@~TMFI, pMnnOllMR, aTaKCMR M o6ua C ~ ~ ~ O C AKO T . MCXeMMRTa eHflOKaPpMTM; XMnOKCMR M eneKTpOnMTHM HapylueHMR. nepcMcrwpa K ~ M KoMa, TO MoraT pa ce nomm n MHNO OT Henommr Ha KHCnOpOA, C Y ~ C T ~ ~ HT Me~a60Ilbl H onMcatime npepn TOM n p u 3 ~ a qno~an~a~paqw ~, ne3~~- H H KO@BKTOPH. M03b'iHaTa X M I 1 O K C M R llpeAM3BMKBa KOTa Ha mBonoBo HMBO. Ma. 3 ~ b n x ~ ~ M eHe3a6a13~0 n ~ o ce o q e ~ ~ pvxaTenm ~ ~OHTHHHV XeMOParblH. ~ ~oHTMHHHT~ XeMOpaMM Ce time nbTnqa, pnuaHeTo, nynca, AH, a cnep Toea an~an M3RBRBaTBHe3anHOCKOMaT03HOCbCTORHHe,npMnaqMeH O K M C e n H H H M RC T a T y C M EKT. f l ~ n ~ Ha a~ KMCnOpfl3a a HTH C X M ~ ~ ~ T ~ H Awar~oaa~a ~ M R . He e TpypHa nopa,qM ~ o 3 bB ~ npoBnxeHue a Ha 1-2 rnin Mome pa poeepe po aHaMHe3aTa M TMilH'iHMTe HeBpnOMClHM npM3HaqM. HanpopbnmnTentia nnn pop^ nocToRHHa e ~ q e $ a n o n a rano~o Ha KoMaTa e ~ ~ e s a n K ~~o ~O , ~ H W H M R T Tern He M n M cTynop. n~ncara 3a HW 4 rnin B O ~ M po HeepoHHa npepM3BMKBa O'iHM A B M X e H M R , IlaqMeHTMTe Ca K B E I / & l M n c ~ b poco6e~o ~, B xMnoTanaMyca M qepe6enya. XwnornernrHM M C TO'IKOBMAHM 3e~nqn. nuKeMMma TpR6Ba 6bp30 pa 6bpe Kopnrupatia, 3a pa ce

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IlpeflOTBpaTRT OCHMTe IlOCne~CTBMRM n M CMbPTHMRT M3x o ~ HaWrecTo . TexKaTa xunorn#KeMMR, Bopeqa po KOMa, e B p e 3 y n ~ a Ha ~ npe~o3~pa H a ~e Insulin, cnyraWH0 M n M npepHaMepeHo. X u n o r n ~ ~ e ~ Mome ~ma pa npep~3 BMKa BPCIOBe M IlOKaneH HeBPOnOM'ieH ~ ~ $ M u M T ,K O ~ T O pa Ce IlORBRMMAaM3re3Ba. H ~ ~ ~ o c T H M~ ~ T% MT ~ M MOXe HH pa poeepe po KoMa n n M Hapyweti ncnxMreH cTaTyc npM naqHetiTMc HeAoxpaHmHe, Ha KOUTO e npnnaratiarn~o~

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pupewHMR CM e4ew ~ b p x y xe~~c$epa~a. E~c~paqepe6panHa~a MH$~K~HR MOXe fla npeflM3BMKa KoMa qpes 06pa3yea~e Ha c y 6 A ~ p ~ e eMnueM. H Taan WH$~K~H ce R cpeqa H~R-remo npM 6 a ~ ~ e p n C aMn H~ ~M ~ TM, HO Moxe pa ce cpeqHe M cnep TpaaMa, onepaqnn M n l n pynTypa H a qepe6pane~ a6cqec. HaRqeuo ce o ~ 6 e n ~ -

3BaT IlePCMCTMpauM M H $ ~ K ~ M MHa yi.llMTe MnM H O C aC a6cqec~~e. nocnepaaqo rnaeo6onne M noKanHn HesponomqHM npn3HaqM. Me~a6onmn TOKCHIIHH IlpHIIHHH M~~pa~epe6pa nesmm. n ~ m M ~ ~ p a q e p e 6 p aHen~~~e onnaw~, xehnoparm, MH$~PKTMM a6cqec~ MmaT pa npeKOMWT~ OT~~U$Y~ M H~~ T , ~ ~ O MnH ~ HTOKCM' T H ~ iHa eTMP M B B M K a Tp a 3 8 M T M e T O Ha KOMI. U e p e 6 p a n ~ ~ XeMOpa~e O n O M RC a VeCTa npM'iMHa 3a IlOBMKBaHMR Ha CneLIJHMTe rMM ca ~ a k q e c ~ a npMwHa ~a 3a KoMaTa. TR P R ~ K Oce eKMnM M CanOcTa TPYAHH 3a AMarHOCTMKa. Ha KOMlllOTbP~a6n~ae npM a O ~ M K H O B ~ H MX ~ M U C $ ~ ~ M HH H $ a p K T M M HaTa T O M O T ~ ~ $ MH Re C e B M m a T 06e~Hll ne3MM, KOMTO fla aKo e HanMqe, MHoro VecTo ce Kacae 3a naqHeHTn c nOKWM3MpaT M R C T O T OH a ~ ~ M C $ ~ H K ~ MMnM F I T na ~ HM AaBaT npnflpyxaeaqn3 a 6 0 n ~ e a ~H~~~~ 1 -, ~ ~ C T ~ X M ~ O nplr T ~ H ~ M eTMonorma. F I O ~ M K H O B~e H~ ~a T6 ~o n m MnM ~ ToKcMqHa a MMOKappeH MH$apKT M n M /JHCPMTMMR. KoMacenpepwecTeaoT'iacoBevlnMp~~tianocTenetiti B e ~ o a ~ a~ ra po~603 ea recTo HeRooqeHReaHa npM06bp~aa~ ne p e a o p ~ e ~ ~Ornem~ a q ~ ~ .He n o ~ a 3 nona~a Y M H a 3a KOMaTa. TRMOXe Aa B b 3 H M K H e npM 6a~~epMmHa neH ~ ~ ~ $ M L ( Ma T ,HMBOTO H ~ ~ ~ M C $ ~ H K Ce ~ OKa3Ba MR HflKbpe Memy pBeTe xe~Mc$epM M p O n H M R CTBOn. T p e ~ o p b T , M H $ ~ K ~ M R ,AMpMHa OW3MR Ha Cbfla OT T y M O P MnM fla e MMOKnOHYCbT ~ p ~ pa 1 HaBepaT 6 ~ C n e W H M R neKap H a pnar~osa~a ~ e ~ a 6 o KoMa. n~~ n~ aq a ~ enpMen ~ ~ , HeoqaH0 C b C T O R H M e , Ca BbTpeUHM Ha C T B O n a M n M BbHWHM, eHa ronma poaa CepaTMBHM npenapaT1, Moxe pa e c npmucKaqM cTeona. apemania BeHTMnaqw, HO nporpecMaHofla ce snowaaa, T p 0 ~ 6 0 3 m H a 6 a 3 ~ n a p ~ apTepwn. a~a Te M YecTa n O p Z I , L ( M npOrpeCMBHOT0 IlOTMCKaHe Ha CTBOnOMTa $YHKIlpM'iMHa 3a K O M M T e .~~HKHOB~ naqMeHTMTe HO pa3BMBaT qMR. E T M O ~ O MH R a T Te3H ~ KOMM BKlllO'iBa: npep03MpaHe Ha MepMKaMeHTn; xMnornnKeMMR; M ~ T F I ~ O ~ H aq~posa; TH~ T P a H 3 M T O P H M npM3HaqM M C M M O T O M M , HRKOnKO A H M IlpeflM M3nwaHeTO B K O M a . C(~CTM M A M 3 a P T P M R , flM@a~R, X M n e p O C M O n a p H MC b C T O R H M R ; 6a~~epManHM M e H M H r H T M ; pMnnonwR, aTaKcm M o6qa cna60c-r. AKO HcxeMMRTa BHflOKaPflMTM; X M n O K C H R H eneKTpOnHTHM HapyWeHMR. nepcMcTupa OM KoMa, TO MoraT na ce noRem U wore OT H~AoCTH H~ a Kmcnopoa, c y 6 c ~ p a ~ mn M ~ T ~ ~ O onMcaHme npepnTOM n p ~ ~ an q o~a , n ~ 3 ~ne3n~paq~ HH KO@BK~OPH. M03b'iHaTa XHnOKCMR npepM3BMKBa KOTaHaCTBOnOBOHMBO. Ma. 3 a p b n x ~ ~ e n M~ He3a6aBH0 o ce oqeHRBaT pMxaTen~OHTHHHM XeMoparmm. Ilotim~~me xeMopaMu ce Hwre nbTMqa, pnwaHeTo, nynca, AH, a cneu Toaa anltan#3RBRBaTBHe3anHOCKOMaT03HOCbCTORHMe,npM naqMeH O K M C e n M H H H RC T a T y C M EKT. ~ M I ~ Ha M K MT C f l~ OpO~ 3a HTM C x w n e p ~ e ~ aMar~03aTa 3~~. H e e TpypHa nopapu ~ o 3 bB ~ npopbnxetine a Ha 1-2 min uoxe pa poeepe po aHaMHe3aTa H T M n M C l H M T eH e B P O n O M ' i H M npM3HaqM. HanpomnxMTenHa w n v pop^ nocToRHHa e ~ q e @ a n o n a vano~oHa KouaTa e e ~ e 3 a n ~ 0 ~,a n o p w k ~TecT m He M n M cTynop. hncara aa HW 4 min BORM p0 HespoHHa npeflM3BMKBa O'iHM A B M X e H M R , IlaqMeHTMTe Ca KBCi&lMnCM~PT, OCO~~H BO xMnoTanaMyca M qepe6eny~a. X~nornerMrHM M C T O C I K O B M F ( H M ~ ~ H H ~ H . n M K e M M R T a ~ p ~ 6 6bp30 e a fla 6bfle KOpMMpaHa, 3a Aa Ce Uepe6pan~m .xeMoparMm. Te ca pepltw npMwHM 3a npep0TBpaTRT K b C H M T e nOCne~CTBMFi MnM C M b p T H M R T M3K O M a T 0 3 H M C~CTORHMFI,H 0 HeflOOl(eHRBaHeT0 M M M 3868xop. Hai-rlec~o TexKaTa xMnornMKeMMR, Bopeqa po KOBRtieTo Ha X M P ~ ~ M ~ H O neqeHMe TO BO~M po KoMa H CM~PT. Ma, e B p e 3 y n ~ a Ha ~ npe~o3~pa Ha ~e Insulin, cnyclai~o no~ecle~ OT o~ e 3 n ~ ~ U M ~ Hca TM C aHaMHe3a 3a xwnepleMnM npeptiaMepeHo. X l l r n o r n ~ ~ Moxe e~~~ pa ~npep~aa H 3 M R MnM aHMOMM. H a h - ~ ~ C TOnnaKBaHMFl MT~ M OT O K 4 M B M K a BPqOBe M nOKXleH HeBPOflOMWH fle$MI#T, K O ~ T O n M T a n H M 6on~1.1, rapeHe, noepbqatie, aepTMro M aaTpypfla Ce nORBRBa MAaM3cle3Ba.H ~ ? ~ O C T M ~ % T H MOXe ~TM~ HeHo xopeHe. npn ornepa naqMeHTme MoraT fla ca c pa poeefle po KoMa MnM Hapyweti ncwxMreH cTaTyc npM MncMnaTepanHa(Ha cTpaHaTa Ha nea~ma) aTaKcw, HHCnaqweHTM c HefloxpaHeaHe, Ha KOMTO e npMnaraHarnloltoTaraM~BTpeHqeHanape3aHanornepaKbMcTpaHaTaHa 38. ne3MRTa. Te MOraT fla ( 2BCb3HaHMe, H 0B C R K a npOMRHa OpraHHa AHC@YHK~HR. Ha B C e K H OPB ncMxMwMR cTaTyc e aampa~uaea~ M flo~aaea B~~MOXraH Moxe pa poeepe po KoMa.

Ha AeKoMneHcaqw. Uepe6pan~m m ~ g a p m mMora~ . ~aHanop06R0a~ qepe6pan~M~e XeMOparMM. C M M ~ T O M M T M ~M Ce pa3BMBaT B npoAbnxetiwe Ha MHoro BpeMe n ce W p x a T epHw M c b q ~ npes nocnepHMTe 1-3 ~ H M npepM ~ 3 n q a ~ e a~ K O M a . Hecb~oem aeCTpYKlHBHH ne3HH B CTBOIIa. M O ~ fla fl0BepaT A0 KOMa, H0 O ~ M K H @ B ~ H Ce O M 3 R B R B a T C n O C T O R H H 0 npOQleCMpauaKapTMHa Ha n0KmHaCTBOnOea ~ M C $ Y H K ~ M npepM R tiapywetiwe Ha C ~ ~ H ~ H M ~ HaR-qeTO. CTO npM'iMHa ca rpaHynouMTe, MeTacTaTMwMTe TYMOPM M

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mp'ioee. Ana6en~ M o x e fla

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floBefle po KoMa noHe no TPM M e x a t i M m a : xnnepocMonapHM C~CTOFIHMR; flMa6eTHa Keuoaq~posa Mnu f l M a 6 e T ~ an a m a T H a aqMplo3a. Hapywe~~m B~ a a ~ 6 b 6 p e rQYHK~HR, ~ a ~ a aoAeqM 1 0 xclno- MnM X M ~ ~ P @ ~ H K ~cbqo M R , MoraT pa p o a e n a T po KOMa, H 0 no-rleCTO B O Y T fl0 IlO-pa3nM'iHM CMMflTOMM. Xnnep- H X H ~ O T H ~ O H ~ HMoraT ~M~T fla Hapywa-r IlCMXM'iHMR CTaTyC. X H ~ ~ O T M P O M Hah-rleCT0 ~ M ~ M ~ TCe M3Rsma c xnnoTepM#R M XMnoaeHTMnaqMR. T o r ~ a fl#amo~a 3 a ce nocTaeR cnefl n p o a e w a H e H a TMPOMPHM @ ~ H K ~ M O H ~ H TecToBe, M HO 'iecTo nerleHMeTo C TPM~O~~TMPOHHH ~ p ~ 6 pa e a3aflO'iHe npeflM ~ ~ ~ O ~ ~ T OI l O ~T HB b Op w T eO HMe. X M ~ ~ P T H P O M ~ ~ah-rlec~o ~M~M~T ~ ~ ~ A M ~ B TpeM K B ~ MOP, pa3flpa3HMTenHOCT, M3flOTRBaHMR, TaXHKaPflMR, 6eua M AonbnHnTentioneretiMe. X M ~ ~ ~ C M O T M ' ~ H noppo6e~ OTOK H ~ ~ C T O A CbppeclHa H~ He~OCTaTbrlHOCT. Te CpeflCTBa q e CHMXaT HXlRraHeTO, KaTO HaCOrlaT BOAaEK~O~~?HH HHTOKCHKB~HH. H ~ W F IH Ta MeflUKaMeHT a OT MHTpaKpaHManHnR K ~ M BacKynapHMR oTflen. Manitol TMTe ( p a 3 p e U I e ~ M MnM He), TOKCMHMTe M OTPOBMTe, KOMTO (18-20%), n p M n o x e H 6onyc~0,B pcua 1.5-2.0 gkg, q e MOraT pa pOBeflaT A 0 KOMa, e OrpOMeH. M H T O K C M K ~ ~ M M T ~ CHMW HanRraHeTo 3a HRKonKo rlaca. C T ~ ~ O M HaMa~HT C MeflMKaMeHTM M TOKCMHM Ca MHOrO rleCTa IlPMrlMHa 3a n m a T HanRraHeTo c a M o npM HRKOM BMaoBe n e 3 ~ HO ~ , KOMaT03HM CbCTORHMfl. H n a o T o H a IlCMXMrlHa flenpeCMR BbnpeKM TOBa Ce IlpMnaraT IlO'iTM BMHarM. E @ M K ~ C M O X e /Ja e HHCKO ( J ~ ~ K 06bpKBaHe) O MnM BMCOKO (pbn6o~a 1oaa H e e y-rowetla, HO ronm 6poA amopn n p e M a r a T KOM~6 ) e 3 AMWaHe M OlTOBOp H a Kan0pMAHMfl TeCT. Cne16 mg DexamethasonAH~BHO, p a q e n e H H a H m o n K o npuWHMRT n e K a p BHHarn T P R ~ A Ba ~e H a q p e K 3a BnouraeaHe eMa. Cnefl 3 a n o r B a H e H a TOM nerleHMe e noKa3atia H a CbCTORHMeTO. B~PF~THOCTT~ OT noflo6p~aa~e B CbCTOKOMfllOTbPHa T O M O ~ ~ ~ @ AWe M R , a K 0 IlaUMeHTbT CKOpO e RHMeTO e BMHaM rOnRMa, OCBeH a K 0 HRMa YCnOXHeHMR, CKeHMpaH. K a r o XM~OKCHR. C n e w ~ a ~ na o~otq e nombpxaqa, HO 6enoflpo6~ M~ CbpAe'iHOCbflOBMFlT ~~ CTaTyC T P F ~ ~ M O X e fla Ce H m O X a T M ~ O C ~ ~ ~ ~ M @ M TOKCMKOnOMrlHM CIHM BHMMaTenHO fla Ce OUBHRT, a M ~ T ~ ~ O ~ M T Hfla MR Ce I IlpeOM ~ C ~ ~ ~ M H M R M M ~ T O A M H ~ ~ ~ ~ ~ ~ H M ~ . IJeHM.

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B # n n a # e e r n ~K ~P b r H a KPbB KbM TePMTOPMRTa H a CbOTBeTH a T a BbTpeUlHa CbHHa aPTePMR. no n p o T M r a H e p a 3 n ~ q a a a ~ TPM e WIMHMVHH @OPMM:

B ~ M @ ~ ~ ~ H ~ M ~ H o ~ M ~ ~ ~OTHOUleHMe ~ o c T H c I~ H p fo 16aa Aace M M ~ n T p e p 0~6~ e ~ npoqec, e~ npexo~~ pasc~poim

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a) ompa - a n o n n e ~ ~ ~ @ o p ~ e ~ a ; 6) n o A o c T p a ;
B) XPOHH'iHa
MnM IlCeB~OTYMOpHa.

o6eH ~ a c b p U e T 0 M pa3BMTMeTO H a M03bCIHa MCXeMHR.

B H ~ ~ ~ ~f lH b nO H 0T M3KJllo'iBaHe O H a e A H a OT BbTpelllHMTe CbHHM aPTePMM O ~ M K H O B ~ H eOHeCbBMeCTMMO C XMBOTa.

3. C M ~ f l p oH~a OlUly3HR H a B e p ~ e 6 p a n ~ M apTepMM ~e a) eAHocTpaHHoTo cTecHeHMe H a ~ e p ~ e 6 p a n ~ apa~a

TePMR WCTO flPOTMCla ~ ~ ~ C M M ~ T O MnH M HCO neKO CMyuleHMe H a PaBHOBeCMeTO ( M ~ J ~ K O M O ~~~ TV ~K HC ~ M RflOpapM ), p a 3 M e K M H e H a AOflHaTa MXlKOMO3b'lHa IlOBbpXHOCT, MnM C HeflbnHO IlpORBeHM E U l T e p H M p a ~ M CMHAPOMM H a HMCKMR cmon a ~ e a n r e M 3~ ~ ~ e p ~ a ~ eH ca ~ nMqeTo, e a ~ aTaK~ CMR M hop-6ep~ap-Xop~ep H a x o M o n a T e p a n H a T a cTpa-

H a M KoHTpanaTepanHa x e M n n a p e a c y r a c r v e T o H a Kayp m H a T a rpyfla VepeflHO-MO3b'iHM HepBM;

6) c b q a T a e KnMHnKaTa M npn v a c T w H a O

K ~ ~ ~ Ha M R

B T e x m e c n y v a H ce H a n a r a G O ~ H M ~ HnO eveHMe. M~orB oa X H O e Ce ~ O A O ~ P XeMOflMHaMMKaTa M M Aa Ce OTCTPaHRT IlPM'iMHMTe, BOfleqM p0 H a M m e H o 6 e ~ Ha q~p~ynnpaqa~a Kpbe, K a n o M ua ce n o ~ o 6 oKcMreHap~ qMRTa. 3 a p n ~ ~ e e nf l~ 0fo l 0 6 p R B a ~ e ~ 0H a peonomma M n p e~ KnloqeaHe H a s a 3 0 ~ n n a ~ a ~ Mo ~epe6poflp0~e p~
TMBa B Ha'imHMTe C T w M M AaBaT CpaBHMTeflHO 6 b p 3 M po6bp e@eKT, K O ~ T O q e c T o e BpeMeHeH.

6a3Mnap~a~ apTepMR, a BOKaTO nbnHOT0 M 3 M l o q B a H e H a KPbBOTOKa e HecbBMeCTMMO C M B O T a .

HeSpo~ozusnu cneutnu cacmonnun m 4 17

En~nenc~ma e nonneTuonorwrHo ~ ~ ~ o ~ I R L X xaI H ~ , WnaTa WcKynaTypa Ha TRnoTo M K p a h ~ ~ W~OHU~HO u~~e pamep~3upaqo ce c en~3opu'i~o BbstiMKsaqo oc~po cbKpaqeHue. Toraaa pMwaHeTo nponbnxaea F(ae Hem~ ~ ~ C T ~ ~ HaCC b T 3 H B a H O H e T O C MnU 683 HaJlM'iUe Ha ~MO)KHOU ~ H ~ H O Z ce I ~ 3qbn60'iaea. T~ O~MKHOB~HO ~ a b p ' i O B e , K O e T O f l O c T e f l e H H O B O ~ M ~ O ~ p O M R H a H a n M ~ H O - $asa npopbnxaea 1-2 min. Cnep npeMMHaeaHeTo Ha KnoHHrHaTa $a3a cneAm amHeTurHaTa $aaa, B KOFITO crra U cHMxeHMe Ha uwenema. ~OI'IHHRT e B mn60Ka K O M a .~M~C 3eHMrHM M T PeaKuMU, 3eHMIJHTeCa pa3WMpeHU, I l O T M C H a T H Ca CYXOWlllHMTe U HqKOCHMTe pe$fleKcM M BT03U IlePHOA HePRflKO Ce ~ a 6 PeflUua eK30reHHU$amopM KaTOTpaBMa, M H $ ~ ~ M M , JlloAaBa M3flyCKaHe no MaJlKa H w a , no-PRAKO no rOnRYBpeWalqM UHC, U H T O K C U K a u H M ,a H O K C M R Ha M03bKa n0 Ma. 3a M U H Y T U Cb3HaHUeTO Ha ~ O ~ H M e~ R b n 6 0 IlOMpa~0 BpeMe Ha B ~ T ~ ~ Y T P O ~ Hpaserne, OTO TaKa M cnep, p w a 'ieHO. ~ O R B R B C! ~ T nbpBMTe W W H M nMXaTenHMA B U X e H M R HeTo MoraT pa npMrnHm enMnenTMrHn CUH~POMH.M03bM 3a H R K O n K OM H H Y T MC b 3 H a H M e T O Ce flpORCHRBa, KaTO rHM T y M O p M M ~aJl@p~auMM, CKJlepo3a Ha M03b'iHMTe flpeMMHaBa npe3 COflOp, C O M H O n e H T H O C TA0 nbnHO ~ 3 6 CbflOBe, CbwO MOraT Ra M M a T KaTO W I M H M i H 'a M 3 R B a emlCTPRHe. JleflTHrHM flpMCTbflU. B CnY'iaUTe, KOraTO rOJleMMRTe~MnenTU'ieH IlpHn~K Cnopep p a 3 n ~ r aeTopM ~ ~ ~ e npM oKono 2-5% ce ~ a 6 Ce IlOCfleflM OT CePMR H O B M IlpMflqb~M,flpU KOeTO nlonaaa n HacnepcTseHocTM B Tame cnyrah ce rosopu 3a ~ ~ ~ H He M M R I B ~T B C ~ ~ H ~ c H~ Ma~~ , a ps ya ~ean ~ n e n ~ ~ reHyuHHa enmencun. cTaTyc. T o i Moxe na nponbnmnOT HRKonKo raca po epHo B pepnua cnyclaM H ~ ~ ~ B M C M OT MM O~ B ~ P W ~ H nopMT~ M noBere AeHoHoqMe. PO~HM W I M H M H i ' M M flaPaWIUHM'iHM M 3 C n e A L X I H U R HeBMHam Moxe na ce ycTaHoen ucTuHcKaTanpuruHa Ha 60necTTa .
E I ~ U J ~ ~ ~ T M ~cTaTyC H M R TCb3paMO f l a C H O C T 3a WlBOTa flOpqM Bb3MOXHaTa Te)KKa ~C$MKCMR, OCTPa CbpAe'iHa cna6oc.r M cMyqeHne B u ~ p ~ y n a u B~BMOXHO ~~~a. e M p a 3 B U T M e T O Ha 3ac~ohHa ~~OHXO~~H~BMO O H~ M M RK . HO HO ce ~a6nlopaea noBMuraeaHe TeMnepaTypaTa H a~ m o TO. E ~ ~ H ~ ~ ~ T MC C T a IT H y C MHanara R T CfleWHa XOCnUTMU3a4~~.

~ R enunenTu'ieH B ~ b p r . M ~ X ~ H M i~eM no ~n T~ p ~ 3 a 4MR -XUllep~OnRpM3~MR e ~HWIM'ieH KaTO flpU BCeKM HOB uumn x u n e p n o n ~ p ~ 3 a u u o ~ a~ bn a~p a a ~ u r ~ p~epu~ea TOPUFITaCUMyBnMC(aH0BMCTPYKTYPM.

rHa M

Cnewao 60nanao neseane CnYXOBM, 3PUTeflHU, O ~ O H R T ~ ~ M HM pp. XanlouMHa4MU, CneA KOeTO e TOHM'lHaTa $a%. ~ P H H e R Ce n O R B R B a 1 .npo~bnxaaa ce c annMqupaHeTo Ha aHTMKoHBynBHe3anHa 3aryba H a Cb3HaHHeT0, TOHM'ieH bp'i BeKCTeCMBHMTe CpepcTBa, CflOMeHaTU no-rope. H~OPIIT~ Ha ~ p a l ~ w q w AMxaTenHaTa ~e, MycKynaTypa M 2.~ P nMnM U Ha e@eKlOT MeAUKaMeHTM,U3nO~3LXIHH AbaKaTenHa MycKynaTypa. B ~ a a $amfluura~e~o n e cnpfipo MoMeHTa, ce smloreaThiopental BcMcTeMa.C n e ~as^ no. F ~ B Rce B uuaHo3a. ~ npopnm~en~ocrra e pa3nu'i~a HaranHa #oanpoe~a Moxe na ce npopbnxM uo 1 . 0g. - OT HRKOnKO CeKyHpM p0 MMHYTa M Ce IlOCnepM OT 3. I P nmca Ha M ~ e o G x o p e$emcnepea ~~n~~ KypapnKnoHurHaTa $a3a, PM KOFITO ce ~a6nlonaea D ~ ~ ~ R B T O 3 M D a H e Cflell H H T V ~ ~ U MB RV C n O B M R T a Ha D e a H H M a U M O H H O

Knac~rec~ enMnemHreH ~m np~nqb Hape'ieH ~, oqe ronm ( r e ~ e p a n ~ a ~enunenTMreH pa~) npwnqb~, Moxe pace ~ ~ ~ A M ~ B M ~~ K 6 ~ O yp T ~ooB m KORTO ~qe Mpae racT Ha M03brHaTa KOpa, oco6e~o OT OlHMqa BT. Hap. a K T M B H a ao~a, ~O~~MM enMnemMreH RT n p ~ n q ce b ~C~CTOUOT Ha'ianHa @a= (aypa), KOFITO Moxe pa 6bde MoToptia, ceTMBHa, eereTaTMaHa U pp. HRKOM 6on~u nony'iaBaT

E n ~ n e r r r ~ ' i ~ ~HanaranpoeeWaHeTo ~~c~a~yc HacneW e H KOMnneKC OT nere6~u MePOllPMRTHR. 1. O c ~ r y p m a ~ npoxopuMocrra e Ha B ~ ~ A ~ X O H O C H IlbTMqaM eBeHTyaJlHOT0 IlOCTaBRHeH a Gedel. A~flUpaqUR H aK p b B O H 3 n U B M T e BYCTHaTa KPUHa, flOnYeHH OT flpeXaflBaHMRTa. no Bb3MOWOCT flOCTaBflHe Ha M e K 06e~eH MaTepnan (~anp. ryMeHa ~pb6a) M e w y 3b6U~e C orneA b136Rr~a~e npexanBaHMma. 2. B ~ H O ~ aflnMuMpaHe HO Ha a H T M K O H B Y n C M B H H CpeBC-

TBa:

a) Diazepam OT l 0 po 30 mg unu Rivotril2 mg; 6) Phenobarbital200 mg - i.m.

o~pene~ne. 4.6op6a C M03bqHMR OTOK. 5. n o n y q e ~ ycnoxHetiMR ~~e OT enunemMwMncraTyc C ~ ~ ~ K ~ ~ ~ T O T O ~ ~ O ~ npn~qnnm-cbp~er~aC T ~ H O B ~ H M T ~ ~a cna6om c KappnaKa, ~ ~ O H X O ~ H ~ B M O HM cR ~T H~ TM~UOTML(H M np. Cnep n3nn3a~e~o OT enmenTweH maTyc cneAm fla

ce M~RCHRTnpMqMHnTe, poBenM po pa3rpbwa~e~o MY, KOpeK4MR Ha neCleHMeT0, KaTO C e HaCO'iM ~ O ~ H M RKbM T cneq~an~3~ nc~xo-~eeponomqe~ pa~ AMcnaticep. 3 ~ nxwentio e Aa ce Hacoclea K ~ M cneuttio KotiTpamHo KT ~acnepaa~e Ha ~ 0 3 b ~ puHaMMqtio a, npocneWBaHe Ha EEr HaXOpKaTa, AMHaMMqHOTO IlpOCneWMHeHa OclHMTe pbHa.

PA3AEJl XIV

420 Ocmpu neuxuvnu pa~cmpoircm8a

I l c ~ x ~ a T p ~ cneluttocr v ~ a ~ a npepcTaenRsa 10% OT npneTuTeBcneuHooTpeneHwe. 3a o ~ 6 e n ~ s e, ~a ve~OT e 06qo~0 Konnvemw ncwxuaTpmvtiH cneluHM cnyqan 37% npeucTa6nflmT onmm 3a c ~ M o ~ ~ M ~ ~ C 24% T B O ,CbCTOflHHR Ha KPH3a ( B M K ~ 3a H~ noMoq nop p a 3 n n v ~ $OPMH), ~ 18% M npepcTaseHuTenecHo M 20% lrpaaT 3 a p w ~ ~b36ype~n C~CTORHMR unM Hapyllletio noseueHue. noaeve~o OT onnTme sa M M O ~ ~ M ~ C T B ce O~ 3 ~ b p w BaTC MeflMKaMeHTMM 11% OT TRX no HaCMnCTBeHUMeTORM. PM nbPBMTe Cny%H CMbPTHoCrra HMCKa (2%), AOKaTO npM B T O P M T e CnyClaH TA HaCP(BbpnR80%. llcuxona~~me, enmenTMqnTe n ToKcnKoMatime HaPylllaMT YCTaHOBeHHR pe43a AamHe Ha nOM0~ B OTpeneiiuma 3a cnewtta nonnoq. Omeapn~qumpeane~c WCTO npM MepMqHHCKHR H naPaMeflMuHHCKMR,HenCMXMaTPMreH nepCOHan, ~pfl6Ba ua pOMMHHpa, a K O He MCKaMe ua ponycKaMe rpeluw - He MMO ~ e u n q n ~ r a n cbqo , TaKa M B ~ a i - e n e ~ e ~ xyMaHeH ~ape~ nnaH. a e n p n ~ u p a ~naqMem, ~m KO~TO MuBa B oTuenetiMe sa 6bp3a noMoq, tie e Tpypeti 3a ono3~am~e, KoraTo ce oTHacR 3a TexKa @ p ~ Ha a 6onecrra KaTo uenatixonvn. T~XHMRT M y M3pa3 B K O M ~ M H ~ ~ M CR QHHaMMR (~nM noPRflKOC Bb36yueH0~~) e KBa3MnaTOlHOMOHM'ieH: TO^ pa3Mulunma sa perpqaqnma CM, O ~ B H H R B ce ~ 3a 3nope~HMR, KOMTO He e CTOpMn, 'iyBCTm C e HeHylKeHM BMHOBeH, cbrnaceH e, ve aacnyxaea ~ a ~ a a allpn ~ ~crapeqa e. vpCTBOTO 3a 6 e u ~ o c M n ~ M eRpaTa Bbe $ a ~ a n ~ a Tenectia ~a o 6 b p ~ a ~ ce o c~a6ntoflaea ~ vecTo. Yuepe~a~a penpecclu ce xapamepn3~pa HaA-Berecbc sarpnxe~oc~ OT xunoxoWPMCleH TMn. Mpema 3a ca~oy6nlmm n p w m a norm anHaM n ~ p ~ 6 m p aOqt?HRBa ce rpMXJlMBO. B ~ ~ ~ T ~ M CMMITOBHMT~ MM ca T ~ ~ , ~ H ~ M O yMopReMocT, HHM: 3ary6a Ha aneTwr, 6e3cb~uenpepnMtio e ~ e 3 a n ~b6ymClaHMR. ~~ 3ary6a~a ~an~6~ MK fO lo H C T M ~ ~ ~M ~M %CTM R O~~~~KB~ @113~~eHHR. C K M T e CHMITOMM C a nOHRKOra llpe&n~aEaqbl, A O K a T O AenpecMRTa npeMuHe ~e3a6en~3a~a. B~~~Y~~ flenPeCMPaHHRT H H R T , MOXe no-TpynHO C(a 6bue On03HaT. npeBb36yuaTa B O U MU0 M3TOU(eHHe,K O e T O n o w e m Ha 6bp3a noMoq. Or npaKTMrHa rneflHa TOW T P R ~ Bpa ~ ce onuTa pa ce ysHae pan^ penpecma e MWOpHa M n M MMHOPHI. M~O~HOTO~~~~~CMBHOC~ eC OTnO-MaKOOT TORHM~ 2 CeflMMqM H C e XapaKlepM3Upa OT H R K O n K O CMMITOMM: HapyweHue ~ H H aHxepoHnR , (3a~pyp~e pnwa~e), ~o rpcrao 3a 6exunne, ~ B C T B O 3a BMHOBHOCT, ncMxoMoToPHO 3a6aBRHe HnH npeeb36ym~la~e, cunHo 6esno~oic~BO, HapylueHanaMeT M ~ o ~ q e ~ ~ p npewaaca~ofl~iaqn~,
CTBO.

M M H o ~ H$0pMa ~ T ~ e no-ManKO 6Ora~a,no-MWIKO cTpora n no-vec~a. KO~~ pT en Op e c ~ Marneyqa ~~a cabp3aHa c peKnaHLuupaHe(paapeoma~e), Toram ce roeopu 3a .c~Tyaqmo~~a". HRKOH xapamepMcTnm c aK B ~ ~ M ~ M O ~ O M cnme~HM: MaTHClHO npe~eBpeMeHH0p a 3 6 w a ~ e ,CnOHTaHeH pun^ Ha HacTpoetiMeTo (no-po6posevep~o apeue), ncuXOMOTO~HO 3a6aeu~e, npepnonaraqo euMH ~ m a n x o p ~ o Haneti CMH~POM. T O Be~eHUoreHHaTa cDopnna, npM KORTO aHTMUenpecMsuTe ca ~ a m t o v n ~ e n amMBHH. ~o M~aiHaKpaR ~ C l l X O T M ~ H O T O ~ O B e ~ e H M e , C b ~ p O B O ~ e H reHaTa uenpecw, cow MenaHxonnma ( ~ a ~ p a n r BM~sa HOBHOCT, ~YBCTBO sa BbTpewtio pa3nqa~e - CUH~POMHa Cottard, KORTO 614T P R ~ B ~ pa ~ ce O TpeTHpa rpea enempoUIOK.

Oqeu~sa~ Ha e pHcKa OT C ~ M O Y ~ H ~ ~ C

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M MMOTHH.

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~ p f l 6 pa ~ C 0~ ~ Y F ( ~ai-BMCOKO M nopo3pe~~e. Hac~poennauraT oKonHMTe xopa, ~ o m o He pa3no3~aea~ sere HHeTO CbqO ~ p f l 6 M pa 6bpe M 3 C n e p B a H O . Ha BbnpOca: nMrHocrra Ha ~ O ~ H H FlIl. o c n e p ~ m e~ poeepeH po KaTac.K~K ce ryw~sa~e?", mroeopme OT wna: J e n p ~ ~ ~ p a ~ ,~po@a BM ~ O ~ ~ ~ M O H H oTpenetiue OTO MnM nopap1eb36y~e~eqac~e~ c a . "anapMMpaqn , 6ene3~. EAMHo-rromp, Ha HOCT, 6e3cbHMe, arpeCMBHOcT M nMnCa Ha ~ona6opaq~n npbe nornep ~ O ~ M T M B ~ OT H ,Tuna jo6peU He MM Aa T o i cMyVaea noaere unH n o - M ~ KcO n o ~ o l ~ aTuoca~a 3a6nwaea npM nauuewM B M ~ K ~ I O ~ M T 6epcre~e. ~~HO @epa,~omo ce M B M C K BnonaraHe ~~~ Ha rp~m 3appyrme E~oquo~anW ~T oO ~R o HMe M O X e pa 6 b ~ e CMnHO sa6nynaqHewM. waeaqo: naqMeHTbT Moxe pa AeMoHcTpMpa m 3 ~ e p a ~ O ~ F ~ M O~ TO s ~ y u r Ha e~ pexypHnR ~e neKap e pa ~ 3 n ~OCT MnM O T K a q e H O C T . ToiI Moxe pa ce cMee ~ a cnyKu, p paTn TOW mn 60neH B epHa ncMxMaTpuclHa cpeAa. TOM KOMTO ro a $ e m ~ p a M~ ~ K ~ I O . I M T ~ ~ HHaWHbT, ~. no KOATO peuetine e B ocHoeaTa Ha ~ a i I - r o n ~ rpeurKa, ~ a ~ a KORTO M3Ka3M MMCnMTe CM M TRXHOTO CbAbPXaHMe, K O H C T M T y M Moxe pace ponycHe B oTpeneHueTo 3a cneuHa MeAuuMpa B m e H eneMew 3a AMamocTuqMpaHeTo: ncMxoTMquTe HCKa IlOMOq. B KpafiHa CMeTKa e T B b P A eB b 3 M O X H O nCMOflMCBaT X a n l o u M H a q M M- ~ ~ M K H O B ~ H O O A M M B H M (3ByK0xMaTpurHnTe cnMmoMMpa npepmaenAaaT epHa ~ a ~ H a ~ BM); npM HencuxoTMqMTe 6 p a p ~ n o ~ ~ em xapatcreptia a 3a cKpMTa OpraHwrHa a$e~unR,KORTO ~ M C K ~ pa M MMHe HeAenpecMma. M 3 6 ~ r ~ a q m M#cnM e ca 6e3cnop~o no-em3a6enR3aH0 B epHo ncnxMaTpMrtio oTpeneHMe. BWO e HH OTKOnKOTO n p M 3 H a T M T e VyBCTBa. ~ ~ K ~ He P ~ R p T~6ea~a pa Ce HanpaBM ~ a A - 6 n ~ 3 A M ~a a M O C T M K a , B TPyAHHTe Ce C T p a X Y B a fla nOCTaBR HRKOM AMpeKTHM B b n P O C H OT ycnoeug Ha cneurtiocr, c qen pa ce npepnMuaT KopeK-rHo TMna: .M~ann n~cre MAeR pa ce ca~oy6we~e?". O ~ ~ ~ T H On b p B M T e MepKM M pa Ce OpMeHTMpa ~ O ~ H M R K b T M WeKBaTO Ha TOM, KOeTO HRKOM MMCnRT, T O M HRMa Aa IlOATMKHe TeH CeKTOp. ~~cMxoM'IHMRT IlaqHeHTCe AbPm TaKa, KaTO naquetiTa Aa ro M ~ B ~ P U I M ,a ~ ~ ~ ~ T Hq O eT MY O nape r en w mBee BH OT peanHoma. Ha6n10~aea~ ce TPM ~ a l B ~ ~ M O ~ H Kpa HO roaopM. CT AKO epw penpwMMpaH naqwew B W H CMHAwMa: 06bpKBaHe, flenMp, A e M e H q U R . 06bp~H m a HaMepeHHe Aa ce c a ~ o y 6 ~ TO e , Toraea T p R 6 M Aa BaHero ce xapamepn3~pa c nunca Ha B~~MOMHOCT pa ce 6bpe nonwati: .3aqo He?", .K~KBO BM cn~pa?" - OTroBoMMCnM 6bp30 M C HOpMNlHa RCHOTa. ~ O ~ H M F e IT Ae3OpMepblTeHaT03M BbnpOCMOraT~aXebpn~CBeTnMHaBbpXy W M p a H , He M O K epa ce K0HqeHTpMpaU cna6o MnM ~ b o 6 q e T O M , KOeTO e PeanHO M m H O nPM T 0 3 MM H A M B M p . AKO He npoyMmaToea, KoeTo cTaeaoKono Hero. 0 6 b p ~ e a ~ e 60n~~ HMa m HaMepetiMe pa ce cauoyfjwe, Toram T P R ~ M e CbllpoBOpeHOOT HaManFlEiaHeHa MeHTanHaTa M $M3M~leAacenpeqempMcKa. CKaTa aKTMBHOCT. l l p~ ~a 3 o u q e ~ MoraTpa ~a ce Ha6nl0paBaTcnep~me flenmpb~ Moxe pa BKIIIO'IB~ HeraTlreHMTe eneMeww, eTann: onwcaHM no-rope,HOe ~ a l - ~ e c xapamepn3~pa~ le OT eAHa 1. Mpe~l3a ca~oy6~ic~m - TR e recTa, HO He T ~ R ~ M p e $ o p ~ a Ha q~ ecTecTseHaTa ~ B~~~PM~MCIMBO MC KoeTo T, pa anapMnpa. BOAM A 0 Xanlo4UHawM, CbHMqa, CTPaHHM a 6 c y p p ~ yCe~ 2. CpeflCTMTa - aK0 epHa M p e R CbqeCTBYBa, T ~ R ~ M qaHMfl, W C T O )OKaCRmu(M, KOeTO n O T 0 n R B a ~ O ~ H MBR npeq~3~ pa o ce ycTaHoem cpepmm-ra, KOMTO TR npepe A H 0 HanpeMaTO e M O q M O H a n H 0C b C T O R H M e . BMwa, KOeTO C a l mM p e R 3a H~I"IHOTO Y C T a H O B R B a H e . f l e ~ e ~ q m mnpepcTaenRm a 3ary6a Ha p a 3 c H ~ 3. A e i c ~ e ~ e epHa ~ o peuramqa cTbnKa e Hanpaee~al-aeqe pa3crpolm~e Ha acMrm MHTeneKTyantiu M noHa OT ca~o@~eqa, aKo ~ e i c ~ ~ e n aano'~~a~o. e~o Tom 3 H a B a T e n H M@yHKwM, KOmO nOTeHqManH03afla3eHM B Moxe pa npepcTaenRea aa~ynysa~e Ha opbxweTo, 3a06bpKaH0~0 C b C T O R H M e . TRMMnnMqMpa epH0 IlporpeCtIBnacqmtie C XarvieTa. Toraea PHCK~T e BHCOK. H 0H a M a n R B a H e Ha MeHTanHMFl KallaqMTeT, O ~ ~ ~ T H O Ha TO 4 . O n m ~ - a ~Mua o npeAMueHonm U aKo naqwemT o 6 b p K a H K H O C l T a H AenMpbT, K O U O nbK C a OT CBOR CTpaHa 06paTMMM H T p a H 3 b l T O P H H . npepa3rnenqanpo6ne~a, Toram BnM3a~e Bbe@a3a~a Ha Hai-BMCOK PMCK. AMH~~HR 3aMa T ~ , Ha IlaMeT, 3aTOpM03RBaHeT0, 5. ~ B ~ K O B XallloqMHaqMM M My nO~CKa3mT Ha'iMHa Ha IlOpapM ~ Y ~ ~ H O M T e H OT a n H OCbCTORHMe, BKJllo'iBa~OHOPc a ~ o y 6 ~ A cH ~epHa m cTpora MepMquHcKa a@ewwH MMHOTO pa36npa~e n n3non3m~e Ha romp, nnoxe pa peolcTse~oc~ ca eneMewme, Ha KOMTO TpR6Ba pa 6bne BMHOBHO 3a ~ ~ ~ P K ~ H O H 0 CM TK , T 0 IlpM p e M e H L ( M R T a , 06bp~e OCO~~H BHMMaHMe. O cncco6~ma 3a sa3npMeMaHe e He3acemaTa. flm@epe~qmpa~e ~a nbpenrlHnTeH BTOPH~HH ncmXOTH'IHH C~CTORHHR.Ha'Ian0~0 n eeonloqMma Ha ocrPwTe CHHflPOMH (BTOPH'IHH) OTnHClaBaT 'iyBCTBWenHOOCncmxo~nrle~ naqnem n opraHnwn Aennpn. AnTpWe I l C M X O T n q H M CbCTORHHR, HapeVeHM $ ~ H ~ M o H ~ M p e ~ q n a n ~anamocTmKa a~a Ha ocTpme ncuxoopraHnr(nnw m p e n r ~(~ cx ) e~a 14.1). 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422 a Ocmpu ncuxurnu pa~cmpoticm8a

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Ocmpu ncuxuvnu pa~cmpoiicm8a 423

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?HT#.C ~ ~ ~ C T B ~ M MHTeH3MTeTa B~H~TO H a nCMXMaTpMqHMT e C M w e H M R H e Ce A b n X a T H a CTefleHTa H a TMpeOTOKCMKO3aTa. M H K C ~ P ~CMMynMpa M~T nOHRKOra MaHMaKOAeflPeCMR, H 0 MCTMHCKMTe CMMmOMM H a AeflpeCMfl (MO~WIHM CleCTO $ ~ ~ ~ U I M BOn03HaBaHMR. M ~O~KM aary6a , H a caMoyeameHMeT0, ~ ~ B C T B 3O a caMoT- HOCT) 0640 WeTO JlMflCBaT. M ~ H T ~ J ~ HCuM C M ~ ~ ~ H Bb HB R Bb3llpHeMaHeTO. T e 3 CMYqeHMR ~ Tw~ e H M R Ca Ca H ~ U - 0 6BM3yaJlHM, ~0 BbflpeKM 'ie PRAKO Ce C p e q a T recm npM 6onema H a Addison. P a a ~ p a a ~ w ~ e n ~ o Mc OAMTMBHM CMweHMR. Ha MOMeHM CTaBa flyMa 3a @HOo6bp~a~ocna ca x a p a u e p t i M . MeH H a BM3yXlHa XMnepaKTMBHocT, KORTO BOAM HnIOJMM, ~ C M X M ~ T ~ M ~I lH PR MB TM ~flpM 6onema H a Cushing M H 0 IlOHRKOra H a 6 n l o f l a B a ~ e MCTMHCKM XaJlol#lHaqMOHeH IlOCneABaulMTe IlpepflMCaHMR H a KOPTMKOMAHMIlM H a ACTH $~?HoM~H. B u ~ ~ ~ I Xalllo4MHa~MM HMT~ M M3KJM'iMTenHO ca H e q a , 3 a KOMTO MHoro ce e nncano. n p 20% ~ OT XapaKTepHH 3 a OpraHMClHMTe nCMXOTMClHH CbCTORHMFI, 10cnyrawe H a X M ~ ~ ~ K O ~ T ceM 0~ ~6 Me~ nM ~ 3 ~CMXOTMVsa~ KaTO IlpM $ ~ H K ~ M o H ~ ~ HTaKMBa M T ~ , KaTO L U M ~ @ ~ ~ H H # T ~ , HM CMMflTOMM, AOKaTO 5-10% OT IlallMeHTMTe, I l p M e M a q M Ce C p e q a T OAMTMBHM XaJlloqMHqMM. KOPTMKOMAM HnM ACTH, MMaT CpaBHRMu(M flPORBM. Ta3M Tnnoee~e s ~ 3 y a nx ~a nn l o 4 ~ ~ a ca, q u~ ~a n p n ~ e$0p: . H ~ B ~ O T O K C H Y H O C ~H ' e e yHMBepCaJlH0 IlpMeMnMBa M TOflCMM (~BITHM I l e ~ H a ) ,300llCHM (MW~KH XHBOTHM), H3Kc b q e c T e y e a H e T o H a noAMonHa a $ e ~ q (cimepoaa ~ ~ Ha ~lo'-l~~~HOTM3 ~8 M CbCTORHMRTa ~HM HaXlKOXOneH AeflMnnaKMTe, nynyc e p m o u w o T e c , n p H c a x q a H e H a 6b6pe~), flpM KOMTO e H ~ O ~ X O ~ ~ neCleHMe MMO C rnMKOKOPTMKOMAM, MMTe. ~

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Ocmpu ncuxurnu pa~cmpocicmlla 425

Ha~pw pM$epeHuMaJlHaTa A M a M O C T M K a M e w y o6anape O C H O 6 a3aCMyUleHMR B nOBeAeHMeTO.6b6peq~a~a M pKaHocna M HRKOM C~CTORHMRHa A ~ M ~ H ~ OT MOHMPOHR .lepH0&106HaTa H e A O C T a T b C l H O C T BOPM no-CKOPO R0 06bpeH Tnn Moxe Aa 6bpe u m a 3aTpyutieHa. pKatiocT, oTKonKoTo 40 penMp. C n e p p o ~ w n ~ a ncMxo3a ~a H a ' i M H b T Ha HHCTXIMpaHe e M3KntOWTenHO BsurteH: Moxe Aa Gape p e 3 y n ~ a OT ~pa3nnr~n KoMnneKcHMp e k 06bpKaH0~lla Ce HHCTaJlMpa no O C T b P MnM C ~ ~ O C HaT~P TBMR: ~ O ~ K eKnaMncMR, M, xeMopam, M H ~ K ~ M M XOPMO, 'iMH M e O ~ M K H O B ~ H06paTMMa, O IOKaTO AeMeHqMRTa e HmHM ~ ~ ~ C T ~ O A He C T~ B o -~ M~J~K WHO o e, W3 6peMeHCKpMTa M MMKO 06paTMMa. Hocrra npeupasnonara K ~ M ncHxo3a (683 TR ua 6bue c n e q ~ $ ~ r ~HaKpaR a). no Bbnpoca 3a M ~ T ~ ~ O ~ M T H M T ~ a $ e ~ u HeKa ~ ~ , npMnoMHuM, r e n o e ~ p n cMMynMpa ~~a nOHRKOra UIM~@P~HMR. P~~~MTB H~ a6 H0 ~nT ~O ~TpypHO e M TF L P CnyclaMTe H a OTKa3BaHe OT aJlKOXOn M MenMKaMeHTM, npepocTaeetio HacneqManMcTncMxnanp. KOMTO ce Ha6nlouaBaT B oTpenetiMma aa c n e w ~ a nouoq, @ ~ P M ~ K O ~ O M V H O TnereHMe O BWIIO~W I pannam IMnonyra6a.r remo UenMpHa peKoMneHcaqMR. HaR-rec~o sa~opn, KaTo Chlorpromazin npM cnyrau Ha ab36y~ecpeqaHaTa $ o p ~ a e eTmwrtiaTa, HO npeKbceaHeTo ynoHOCT. 3anor6a ce c 50-75 mg Ha eceKM rac, no np#cnMaaTpe6aTa Ha 6eH30flMa3enMHb1, MeTaKNlOH,6 a p 6 ~ y p M a ~ ~ He. Cnep Toea nereHMeTo e OT 100-200 mg 4 nbTM Ha ueti ppyr~ ceuaTnqH Moxe pa Rape cbqaTa KapTMHa cac c p o ~ c Chlorpromazin. Largactil Moxe pa x~no~e~3 Ha MHCTMMpaHe, KOlnrO Ca pa3llMrHM M n ~ - ~ b n r ~ ~ p a ~ H M , e$etcr, 3a npepnormatie e recTo npoTHpeHUMn(Dominal)

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AHTMMYCK~PHHM~MT~, HaMMpaqMCe Ha (Iap~aqeBTM~HMR naap, ca a n ~ a n o u p canpoeopeHM ~ OT 6enapo~a (~T~o~M X M H O ,C u M a M M H , CKO~O~~MM M H n M ) IlpopYKlM Ha C M H T e 3 a (6eH3aTponMH). Te BOART 40 UenMPM, KOMTO M O raT Aa 6 b u a ~ KOHTPOnMPaHM9 3 MHXeKTMpaHe Ha 4 ~ 3 0 C T M r M M H (Antilirium).C M M ~ T M ~ ~ M H pHeC ~ T , UIMpoKO M3nOnaaa~ npM nerewe Ha rampo-pyope~an~a am, Moxe npM HRKOM ycnoBwn Aa uoeepe no perpecMeHa ncwxoaa BeAHara, U O M KaTO Ce Cnpe B 3 M M a H e T O Ha MepMKaMeHTa. Oawopcl~e, KOMTO BnMmT 3a ToBa PRAKO ycnoxttettwe, ca n p e a o 3 ~ p a ~ eBbapama ~0, Ha naquewme, CbcToRHMeTo Ha ~epe6pa11~0~0 MM p a 3 p p a 3 ~ e M ~6 ~b e6 p e r ~ a ~ Hepoa C T a T b V H O C T . K ~ ~ T 3a M CpaBHeHHe H ~ MOXe pa Ce CpeqHe [PM npOnpaH0nOn. ~ ~ H ~ ~ O C Ha T M T e 3 K M ~C b T C T ~ O R H H R MOXe Aa 6bpe Tpyptia, ~ a i - s e r e aKo naqMeHTme eaMMaT MeAMK a M e H T M T e B IlpO~bnxeHUe Ha H R K O n K OC e U M M u HM n M HmonKo Meceqa. ~~OKNIHMT~ aHeCTeTMUM- K O K a M H b T (KO~~T Ce OB 3 M ~ a )M ,n MKCMnOKaMHbT ('tpe3M H T p a B e H O 3 H OM H X e c e K M p a H e npM CMyUleHMR B pKbMa) MOMT fla AOBeAaT A0 RenMpM. no-M~K nO o 3 ~ a 6e3 ~ a cbuHeHMe e ncMxo3aTa OT npoKaMHaMMfl.

Xal'lloqMHOreHHM ~ M $ ~ T ~ M U H RPM M . OpraHMVHaTa06bpKaHOCT, x o c n m a n ~ 3 a u ~ e~ He06~0pMMa a awiam. B ~ H o TO e ga Ce O c T a B M CBeTnMHa B CTaRTa. M ~ K Cefl MaTMBHM A 0 3 M T P R ~ B Aa B 6bpaT OllMTBaHM, KaTO Chlorpromazin 25 mg i.m. Ha BceKw 4 h, KaTo ce yaenwaea poaaTa c 25 mg Ha BCeKM 4 h, AOKaTO Ce ~ 0 ~ ' A iO M C T a T b Y H O CeAMpaHe. B b 3 P a C T H M IlaqMeHTMMnM T a K M B a , KOMTO M M a T BaCl(ynapHo uepe6pan~~ npo6ne~n M npM KOMTO e y a xMnoTeH~HR 6~ ~ 0 r n pa a 6 b ~C eM n H O BpeflHa, ~ ~ T M ~ ~ @ KaTO HOH xanonepMAon (Haldol) Moxe pa 6bue uanonaaa~ ~aA O ~ M OT 0.5-1 mg 4 n b Ha ~pew ~

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aBTOnpeAflMcaHMe H a IlCMXO-aKTMBHMC ~ ~ C T B H ~ M KOMTO M, aac~ra ~e6naronpnmo ~ SppaaeTo, ncMxocoqManHoToM M K O H O M M W C K OC b C T O R H H e Ha MHAMBWI. ~ ~ P M B M K B ~ H onpepenn noaTapRqo ce ~anonsea~e Ha ppora, ~ o p e i 3 flOeAHOnpMHy~MTenHOnOBe~eHMe,KOeTOenpe~BCM~ APYrM3aHMMaHMfl Ha M H A M B M A I . ~ ~ C H X O ~ O M C3 ~ a B H U C ~M T~ MOCT ce x a p a ~ ~ e p ~ 3 OT ~pa3nw.c~~ pa cTeneHM Ha HaTpanrMBocT K ~ epHa M Mnn ~ p y m ppom. Onanrec~a~a 3ae~ C M M o C TeC b C T O R H M eH a $ M ~ M O ~ ~ O M C allTepal(MR IH~ np0AyKT Ha 3noyno~pe6a C pp0M M M 3 M C K B a TRXHaTa IlpoAbnxwrenHa yno~pe6a, 3a Aa ce ~ 3 6 e m cnMnTohnMTe a~ H a OTKa3BaHeTO. T o J ~ ~ ~ H T HCe oC IlpORBRBa T ~ ~ 'ipe3 HaManeHo pamtte Ha eptia nocToRHtiapo3appora. C b u e c ~ ~ sa KpbcTocaHa Tonepawtiom Memy p a 3 n n r ~ n ~ ppom e OT euHa M C b w Knaca. BT O K C M K O M a H M F l T a Ca

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CBO~O~ (MnM H~ Bb~H006pa3Ha) T~ TpeBOXHOCT e AOCTa H~KOM$OPTHO CbCTOFIHMe. TO C e npORBRBa W C T O C onnaKBaHHR ( ~ e n e c ~ KOMTO ~ ) , 3a n a q ~ e ca ~~ no-nec~w a 3a yllpaBJlRMHe, OTKOnKOTO MCTMHCKaTaOCHOBa Ha npo6C~CTORH Ha Hocrpa ~ rpeeora. Tpesora~a Moxe pa nennwe. PM MHoro OT cnyclawe Tpeaoxttocna e npeebce K O H ~ ~ H T B P~ MP~X~Y O ~ M ~K ~T OC06eHM M C ~ ~ I K T (CTpax MI~ pHaTa B TenecHM npoReH M Moxe TaKa pa 6bpe HavaneHa OT %@a Ha peTe, pa6o~a,tianp.) Mnn Moxe pa 6bpe e ~0361 npoqec, r e pa He 6bpe a 6 e n e x n ~ a OT WIMHM~Mcadop~a M ebn~ooGpas~a, cbc cbqme npogen, HO 6e3 ~a e .cbpperHaTa K P M ~ C " 'ipn p e q ~ 3 &etcr. e ~ TRce ~ R C H R noHmora B~ rpe3 $ ~ 3 ~ r e - cTa. n o r e c ~ a KoHaepcMFi CTBO Ha IlPeKOPflMaJlHa OnpeCMR, C TaXMKaPAMR H A O P M CKM YCeqaHMR C Jl MnOTMMMrlHM TeHF(eH4MM. B eKCTpeMHH 6on~n B nRBaTa PbKa. ~ O C I T M BCM'iKM $ M ~ M ' ~ ~ OllnaKBaC K H cmyaqw ~ O ~ H H R Moxe T Aa ~ s n m ryecTeo a Ha penepcoHMR ~0ra~fla6b~a~~MMynlrpaHM npM Te3M CbCTORHMR: npM ~ a n ~ s a qTpeeora~a u~. H ~ A - V ~ C Te O cebpaa~a cbc cMTyanapanna ce HahnMpaT OHM Ha ~ H ~ C T ~ M 0~cna6Hana ~ M R ~ M R KORTO , naqMemT He e c n o c d e ~ pa npeoponee. TR MyCKynaTypa, H 0 HeBpOnOMrHMRT KOpeH Ha CMMnTOMMTe MOXe pa 6bpe IlpoRBa Ha C K P M T M IlCMXMaTPHrHM MIlM necHo Moxe fla 6bpe nocTaeeH nop CbMHeHMe, nopapM OPraHM'iHM YBpeWaHMR (Hanp.: eAMH HeBpoTMK OT @ 6 ~ xapatmepa Ha TgxtiaTa Hexapatcreptia n o ~ a n ~ 3 a q ~ ~ VeH THn CTaBa M3KnD~MTenHO TpeBOXeH, aK0 He MOXe fla ynpaenma ceoma HaTpanclMBa ~lrcbn). Ep~a OT H ~ ~ - T P Y ~ HflM$epeH~Man~M MT~ AMarH03H e nbp~o ce yeepRaaMe, r e naqueHnT He cTpapa OT pa3no3~aea~e~o Ha r ~ c ~~peeora a ~ a M Ha6yptiaTa~peBoOpraHMclHo yapewatie. (Pas6upa ce He cram pyMa 3a xtiapenpecm. n e r e ~ w e B ~CnewHoTo o n p r i e ~ oTpene~o TOM pa ce Kaxe Ha nawewa, r e MY HRMa H H ~ OHe . 6~ea Hlne e epHo n cbqo. Tpeeora~a e recro nbpeaTan p o m Ha cbqo TaKa pa ce oManosaxaeaC M M ~ T O M ~a T pa , ce y6eA~ epMH enM30A Ha OcTpa UH~O$~~HMFI. QHa OT Hah-TMnMclnaqueHnT, 'ie Toea He e peantia onactiocr.) ~ O P M Da H M T e repw Ha U J M ~ O $ ~ ~ H M ~peaora ~ H ~ Te ~pecrpywypaCbqeCTBYM M H ~ ~ - M ~ ~ K CbMHeHMe, OTO ~p~6a pa aC e UMRTa. ~ O H A K epHO O ~ ~ MaHHaKMHO CbCTORHMR MOXe F(a npoqepMpa rpe3 hneTona Ha ~acnepea~e, 3a pa Moxe 6bpe 06bpKaH0 C iM ' CTa TpeBOXHOCT, H0 0 6 ~ B3eTO 0 T03M O~~KTMEJHMRT xapatcrep pa p a 3 y 6 e p ~ 6 o n ~ re ~ cTpapa ~1, Tun 6 0 n ~ # ca ey@pwclti#. OT MCTMHCKM OpraHMVHH YBpeWaHMR. ~~UM~HT KOMTO M, C a nO~OXeHM Ha nCMXMaTPMrH0 AHKCMO~MTH~MT~ npepM3BMKBaT MOMeHTanHO 06ne~HM, ~YTHPO$~HOHM) IlpepM3BMKBaTaKaTM3MR, KORTO MOXe pa C e 06bp~a C TpeBOXHOCT. Toea C ~ C T O R H H C e ~ XapatmePM3Hpa CbC CbuaTa B ~ ~ ~ Y ~ ~ CbC H O CbqMFIT C T , COMaTMVeH ~MCKOM$OPT M C ApyM XapaKTepHM nPRBM Ha TpeBOXHOClTa. ~ P M C ~ C T B M ~Ha T OeKcTpanMpaMMAaJlHM C M M n T O M M n03eon~ea pa ce oTnnraT. B noeereTocnyraM T p e e o w m a He H ~ M C K B nere~ HMe. na4MeHTb~ e ~Il0~06eH pa O~RCHM CaM TPY#lOCTMTe CM n aapara~aHa neKapR e pa HaKapa nauneHTa pa paa6epe, r e cnMnToMme tie ca Ha opraHHrHa oc~oea, a C a CBbp3aHU C HeroBMA MOMeHTeH KOH$~MKT.

Haw. H ~ ~ - R ~ pK aM 3e Tp ~ ~ $OPMM ~e~~ ca: ~ M H ~ ~ M F pa3pso~ea~e Ha nMrHocrra, ~ 3 6 ~ r H ~ 3aryba~a a ~ e Ha K ~ ~ ~ H M ABTOM~TH'~HOTO K . rIklCaHe, C O M H ~ M ~ Y ~ M Ca ~ W C T OT WflaTa KapTMHa. naqMeHTbT MMOPMPa CMMnTOMMTe, KOeTO My n0380nRBafla MMOpMpaM np06~1eMMTe CM. Ao6pe e pa C e ellMMMHHpaT OPraHMrHMTe CMWeHMFI, n0 npwiqnn TeMnopantia enmencnu, H emam T ~ e K~eo6xoP M M O MHeHMeTO Ha nCMXMaTbP. B b a 6 y ~ naUmeHT. e~ n p ~ e u t i oTneneHnR ~~e noa~aBaT po6pe M IlpMeMaT 6e3 OXOTa ~ N H IlaqMeHTM, M KOHTO o6bpK~aT$YHK~MOHMP~H~TO Ha CnelLlHaTa 3ma M C a aannaxa m nepcotiana H ppyrMTe ~ O ~ H M ~P . MHUM~ Ha ~ npepnmcea~e Ha MMHOPHMTpaHmMnaHm(6e~3op~a- ne'ieHwe alcnmrea ~ M ~ M V ~ C 0K 6O y ~ a e a Ha ~ enaqMeHTa, 3en~i-i~). n p u e ~ per a~ OS, ~ Te paeaT pea~qwfl20-40 min. KaTo MY ce npepnMuaT c e p a ~ ~ s BllHarM ~ ) . e 3a npenopbCnep 2 h e $ e m ~ ce pascelea. n p o p n ~ ~ e n yno~ a ~ a clBaHe pa ce HanpaaM pmTa n p e q ~ a ~ p# a$epe~q~an ~pe6a He ce npenopbrea. AKOTpeBOraTa e npoRBa Ha pMamocTvKa, c qen pa ce npepnMwaT ~ a l - n o p x o ~ q clcpma ncuxoa ( U J H ~ O $ ~ ~ MH ~M M HR ~HM~KO-penpec~~ ), RPM. ce w3non3sa~ M ~ X O ~ HTpaHmMnaHTM, M Hanpmep 50 rng M~HM~ nOKa3Ba K ~ T npM3HaqM Ha IlCMXOMOTOpHa6@xnopnpoua3~~ (Largactil) BepHaraMycKynHoM 200 rng per HOCT, TO^ e noropeclreH. BCRK~KBM pa3roeop~ C Hero ca OS, KaTo MoraT pa ce noeTapm Ha KM 4 h. Iml03Mfl, 3aqOTO M a 6 p a e ~ HanbnHO. Toea CbcTOflHMe B cnyraui, r e naqnemT He noHacfl $ I ~ H O T H ~ ~ M MH e o6n~~oae~ c~nposopetio o c npMnownmaTo Hacrpoe&em F sea n p o ~ a 3 n ~ (Prazine). a HHe M MeranoMwnR. J l e ' i e ~ ~ e ~ c Heeponermun, o Hanp.:

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cMcreua #nM Ha UHTOKCMK~~MM. Cpep TRX anKoxonHaTa pponepnpon (Dehydrobenzoperidol,Droleptan)nnM xanoxanloq~~o3a cbc ~ B ~ K O B XM ~~OL~IH~~ aM uM $e , ~au~~u nepMAon (Haldol). HaTa nc~xosa U peaKuMnTeHa LSD ca ~ a i - m a c ~ ~ l e c ~U3@peHUKbTC b q O MOXe Aa C e HaMHpa B 6 y i ~ o OCTPMT~ MaHHaKanHU CbCTORHHR MOTaT IlOHRKOra (HO CbCTORHMe. Heroell~e 6pb1qoneBeHMR ca HeCBbp3aHU M pa ce npepcTaem KaTo $opus Ha 6 @ ~ o noeepepenMpaHTHm.Xanloqu~aq~lrre uy ca ~ B ~ K O B M J .l e r e ~ ~ e ~ o PR~KO) Hwe. Xnnepamusu~en~, noropema M ~~EICTBOTO 38 Ben#ce cbcron B npepnucmHe Ha Heeponemmqn, Kamo npM weno~c~a3~a~nocneIHaTaAuamo3a. uaHMaKanHaTa~ p ~ aAKO a . Auamo3aTa e HecvlrypHaM aKo uua onacetim 3a BTOPM-H e$em OT ~ e MepMmueHTM, 3 ~ TO Toram T P R ~ BHuuaTenHo B~ Aa ce nHxemMpa ceAaTue c no-uanmcuna-K~TO npoTwneHpMn80 mg i.v. (Dominal). B nbpaMR eTan e ecrecTseHo Aa ce nouortie Ha n a y AJ~KOXO~MK~T MOX~ pa6bpe Bb36ypeHnOpwMeTUnMema pa KoHTponnpacmma arpecMeHocTno Tame Ha'iMH, r ~ HacMqaHe o H nopwH ompnqeatie Ha s a ~ p b m u ~ Ue r e pa ce onam - Kamo TO^, TaKa H OKonHHTe. ~ ~ ~ B H O eT no-PRAKO nOpwM nCMXO3a CbC 3ByKOBM XanloqMHaqMM, Aa ce pas6epe, r e naqMeHnT e oqe no-u3nnawe~, OTKOlrnu nopqMAenMpuyuTpeuetic. C~CTORHM~TO Ha~ ~ ~ C T B O nKOT0 06KpblKaBa~MTe r0 npep CUTYaqMR, KORTO TO^ He M arpeCMBHOcT e CBbp3aHO C npMeMaHeT0 Ha anKOXOfl M Mome ~306140 pa KoHTponwpa. BCRKO 3 a ~ b c ~ e ~BCRKO ue, ~ ~ M K H O B ~e H nocnepeaHo O OT nbntia ~ M H ~ ~ M llR a4 . ~yBbpTaHe3aCMn~TOBaOTCbCTBMeHaKOHTPOnMnOKaL(Ba eHTbT e TBbppe IlpUTeCHeH OT 4aKla, r e C e HaMMpa B rpaffyM Ha arpeCMBHOCT, T b i KaTO ~ O ~ H M R CM TAaBa CMe6 0 n ~ wM ~He a npoyMFlBaKaKBOe CTaHWlO. Hai-TpeBOxHoTKa, 'ie He uome pa MY ce nouome. Cnyvea ce Ra ce TO CmoFitiMe e uome 6u pennpuyuTpeuetic, mnpoeofleH noawa nouoq, 3a Aa ce ~ey-rpan~a~pa, 6e3 Aa 6 b ~ e C TpenepeHe, H3nOTRBaHe M BU3yNlHU XEUIl04HHaqUM. HapaHeH.Ta3U fleMOHCTpauMR Ha CMna O ~ M K H O B ~ H Oe 40Enunen~n~br ~ o x Aa e 6bpe floeepe~ B 6bp3a noMoq CTaTbrHa, 3a Aa MOXe ~ O ~ H M F I#a T KOHTpOnUpa CBOUTe nOpwU Bb36yfleH0 CbCTORHMe, K O e T O CbOTBeTCTBa Ha arpecnBHu MunyncM. AKOTO^ e IoeepeH o6y3fla~, neKaKpM3a OT TeMnOpMeHXapaKTep. ~~CTKPMTMVHOTO 6yir~~- P R T T P R ~ B C e ~pep#, ~ ~ pa3nMTBahKU r0, 'ie HRMa HaHOBO BO e no-~FNKO cpeqatio. l l e r e ~ u e e ~ KaTo o npu enunenAa ~3ry6n cauoKowpon. Tp~6sa Aa ce po6nmma~a ~o CUR. C T ~ P ' ~ ~ C K ~WCTBO OTO C e XapaKTepM3Mpa OT BacKyHero cueno, HO C ~ O K O ~ H O . naptia qepe6pan~a crcnepom U ppym craprecltn peMeHA~)~(YPHHRT neKap TpR6Ba na M M C n H KaKTO 38 CUTyP~ M M ne'ie~ue~o . ce MOM B npeRnmcaaHe Ha Coffein (100Hocrra Ha naqMeHTa, TaKa M 3acBoRTa. B p a ~ a Ha ~a mama 200 mg i.m.) M Ha npoTMneyMn (Dominal) 40-80 mg i.m,). aa p a 3 n ~ ~ s ~ a~ pe ~ 6~a ea ocTaHe nonyoTaopeHa, 3a pa ce B w a 3a6enem! Tp~6sa pa y e e u pa pasnuraaaHaMaJlcl 'iyETBOT0 3a 3aTBOPeHOCT,KOeTO MOXe pa M3nMMe HCTUHCKO GY~CTBOOT ~ C ~ B ~ O - ~ ~ ~ CBbp3aHO C T B OCT O , Ta ~ O ~ H H F I T . ppaa~eq eneuem - Hanp. oTKbcsaHe OT cernirc~eo~o J l e ~ a p~~p l ~ 6 pa a ae cMen M pewuTeneH. AKOnaquM n MOT nOnHl&lRTa e ~oCTaibClHO3ayCnOKORBaHeHa IlaUMe m T noryEICTBa O ~ ~ ~ T H O TO TO ToraBa , cnepBa arpecwa ewa. peaKqMR. Arpecllee~ W 6 y e naqwew. ~ CTam ~ l y 3a ~ MCTMa Hair-6bp3a~a cepauMR B ~ $apua~onomre~ B nnaH ce HcKa cneluHocT, KORTO EeKu pexypeti neKap ~ p ~ 6 ~ IlO anY'iaBa Vpe3 WIOPnPOMa3MH no MHTpaMyCKyneH nbT (Largactil 50-100 mg), KoeTo ~ p ~ 6 Aa s ace noeTapR Ha fla YMee Aa OBnWBa, 0.laKBahKM npMCTMraHeT0 Ha ncnxuanp. Amammuqupa~e~o e neckto, HO ce pa3aceKM 4 h. Hemena~ e 4 e Mome ~ ~ pa 6 b ~ cTpora e xclnoTenonara c TebpAe u a n ~ o speue, 3a pa ce MBRCHM CKPMHSMR, KOeTO H3MCKBa MOMeHTanHO n!Vl?HUe. AKOWIOpnTaTa npMrMrca 3a G@HOTO noaepeHue, ~ b i KaTo r wHTepP O M ~ ~ U He ~n T p o ~ ~ ~ o n o ~ uome a3a~ pa , ce u3non3ea~ seHunma ~ p ~ 6 e pa a 6bpe MouetrranHa. ppym C ~ ~ C T ~ H U(H G TO I U C ycnex) - napan~ex~p(8-10 ml i. Oll03HaBaHeT0Ha CbCTORHMeTO Ha ~FCTBO M O W fla m.) nnM nporuneHAnn (Domina180 mg i. m.). 6b~e nO-TpyflHO npM IlaqMeHT, K O ~ O HMKOra He C? 6 ~ n YCIIOXHIHHRn p H CbeTORHHIl H a B ~ ~ ~ ~ ~ H M arpecuseii mu HHKoro, HO K O ~ ~ Te O Ha npara pa w3ry6~ KoHTpon ~4 ce6e cn. Toir uarnewa HanperHaT M n m o ~ ~ P M K ~ U ~ ~ H na4MeHT. H F I T H ~ ~ - B ~ X He OAa TO C e RHHO ce pasxo~qa, He e C ~ O C O ~ Aa ~H ceptie Ha epHo Y C T a H O B M HRKaKbB KOHTaKlC 60nHMRMAa C eB O R R T nper0MRCTO. ~ O H R K O Kpequ ~ ~ M c p y l r 3annawaa xopaTa aopM. Cnepoea~en~o TPR~B Aa ~ ce ~ a c n y u r m Heroewe ~ HaoKono. T e s C~CTORHHR ~ ce pbnxaT~ah-remo Ha OcTpa ycnoem. J l e ~ a pe ~Tau, l ~ 3a Aa MY nouome, a He pa ro napaHonrHa W M ~ @ ~ ~ H H R . npecneAaa U abanclpa. n o n ~ 4 u f l 6n ~ a~p~6eanopa o6rpanauue~n MHTepnpeTnpa ~ O~MKHOB~HW @KM T~ M AM U ~ 3 o n ~ ~ pa ~ H M 3a R pa , uy nose on^ na noMMcnM U pa npncacTaMeToHaneKap KaTo3annaxa cpeqy c a u Hero. ~ ~ oTxBbpnn HauepeHumaMY, noAmKHaTnOT rna,q M x q a . Tot7 uome pa 6bne &em Ha cnyxoaw xanloqnHaUun, @ap~a~onormr~m ycnoxmeHmR. OTH~CR ce 3a xuKOWTOcau nmepnpempa KaTo 06s~~e~nf-i H n M 3annaxu. nOTeH30PHMR e@Kl Ha @HOTU~~UH. B cnyclah Ha OCTpa Apynne cnwpoun 3a paarnewa~e ca OT opraHnreH X M ~ O T ~ H ~naunemT MR ~ p ~ 6 Aa e a6bpe cnometi B nononpo~axopnce~bnxa~~aaacema~aqe~~pan~a ~epa ~a xeHne Trendelenburg, Mnn npocTo pa ~y ce noMHmaT

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b p w p a Ha H y H a T a CHCTeMa

nRBaHMR;Cpe~yMOTpaHCnnaHTaTMCpeaK~MMHaOTXBbM M ~ H Hc ~~ Tc ~r ee ~~as r p q e o ~~ ac n e 4 w $ c lc r~ ~~ pyprime. K a r e c T e e ~ n~ KonclrecTaeHn nponnem B MMYHHMR u y p Ha ~ opraHHo, meTarHo M MoneKynRpHo HMBO, KOMTO oTroeop 06ycnaa~~ a ~ a r e ~ MY ~ eB~ no a~ore~e3a Ha ~a Ce HaMMpaT non B n M R H M eH a pelynMpaqM MeXaHM3MM. more ~ ~ ~ O ~ R B ~ H Toea M F I onpeRenR . RMarttocTwrHaTa E A H OT ~ O C H O B H M T e KJleTKM, cnoc06~a C ~ ~ ~ ~ M $ M Cna IHO CTO~HOCTHa ~ a c n e f l m ~ e H ~ ao p a 3 n ~ r cTpaHM ~ ~ ~ eHa pa3no3~aea ~ M M R 3a o p r a ~ ~ m areHT a M na ocbqecToTrosopa Ha MuyHHaTa cucTeMa npM p a 3 n ~6r 0 ~n ~e c ~ ~ ~ B R B a pa3TpwaHeTO M OTcTpaHRBaHeTO My, e ~ M M @ O C~CTORHMRM npMnaraHeTo H a WeKsaTHo MMyHouoAynlrqnm. paqo nereHue.

O p r a Ha ~ ~unryHuara cucTeMa

&HT~~J~H OpraHM M T ~ Ha M M Y H H a T aC M C T e M a Ca TM~ y cn b KOCTHHRT ~ M O ~ ~a Kn , ep~$ep~~ ~M ~M e@HW BbsnM H AanaK ( ~ a n c y n ~ pM aM ~Y ~ K)O ~ H O acoqnMpa-

OCHOBHHn o u m f l
TepMlrHbT HMyHHTeT, C K O ~ T O flOCKOPO Ce 03HaraBawe Heea3npme~rusocrra K~M MH$~K~HO~H 3 M aT 6~ 0n~~aHMR, npe3 IlOCne~HHTe rOAMHM P a 3 U I M P M CBOMTe TpaHML(M. n 0 HMYHlTeT ~ Ce p a 3 6 ~ p a BCMrKM ~ M e X a H M 3 M M 3a aaq~~ H a ao p r a ~ ~ 3 cpeqy ~ a arem, HoceqM ryxqa reHeTwHa n ~ $ o p ~ a q # fM l -M K ~ O O ~ ~ ~ H M xpaH#, ~ M M ne,

Ha ~ M M @ O M A nKaH H~ (MAJIT)

-( ~ e ~ a n c y n ~ p a ~ ~

K n e m Ha uMyHHaTa CucTeMa

KapcTBa, IlOneHM, XMMMKMM M n M TeHeTMrHO IlpOMeHeHM CO~CTB~H KJleTKM. U ~ ' ~ M Y H M T ~ MOXe T ~ T fla 6 b ~ e BpOneH, ecTecTBeH M ~ ~ M A O ~ Cb3nWeH MT, KaTO pe3yJlTaT OT 3a60nR~aHe M n M CneA MMyHM3a4MR. (CD4). flpMfl06MT~RT M M Y H M T e T BKJlIO'iBa RBa O C H O B H M 2. T - K ~ ~ T K cynpecopM M (Ts suppres n o m c ~ a ~ MeHa KnenreH m xyMopaneH mMyHwTeT M n p y TPM ~ (CD8). $ ~ H O M ~ H TOnepaHTHOCT, ~ HMYHOnOrH'iHa naMeT M y6~84u (Tc cytotoxicity 4HTOTOKCManeprHR, KOMTO Ca CBbp3aHM C a H T M T R n 0 O ~ ~ ~ ~ Y MU H ~ T O 3. T-KJ~~TKM ~HOCT). KJleTbrHMR M M y H M T e T . OCHOBHOTO, KOeTO M 06eflMHR~a 4. T-K~~TKH, 06ycnae~uu 3 a 6 a e e TMn ~ ~ CBpbX.lyBC~ non nOHRTMeT0 MMYHWeT, e TRXHaTa C ~ ~ ~ ~ M $ M ~ HT. O e. CT, TBmenHoCT (TDTH delayed type hypersensitivity). TeCeMHflY4MpaTOTOnpeAeneHaHTMreH. 5. T - K ~ ~ TH K aM naMerra (Tm -memory naue~). C nOHRTMeT0 BHTMreH Ce 03HaWM BWKM areHT, T-~MM$O~MTMT~ yClaCTBaT B KlleTb'iHOMeAMHPaHMfl cnoco6e~ Aa Ce CBbpXe C KOMnOHeHTMTe Ha M M Y H H M R M M Y H H T e T . oTroeop. M M ~ H O ~ e~ wem H areHT, cnoc06e~ Aa MHRY~MOCHOBH~ @YHK~MR Ha B - J ~ H M @ o ~ M T M T ~ e llPOM3BOflpa MMyHeH O T T O B O P . BCM~KM H M y H O r e H M Ca aHTMreHM, H 0 C T B O T O M CeKpeTMpaHeTO Ha aHTMTena, nOpWM KOeTO 'X He B C H C K l M aHTHreHM 'X M M Y H O r e H M . TpM 'X O C H O B H M T e rnaBHMRT M3nbnHMTen Ha xyM0panHMR M M Y H M T e T . Cy6n0xapamepncTMKM Ha MlmyttoreHme: rynqepoaHocs, BM-

064 npeAUIecTBeHMK Ha KJleTKMTe Ha MMYHHaTaCMCTeMa e cTeonoeaTa KneTKa. TR npo~3nu3a OT KOCTHMR M O ~ ~~ K, a ~ nB ~ UMpKynaUnRTa, 3 a npehnwaaa npes o c ~ o BttMTe ~HM$OII~HM opraHM, npenpnma n ~ $ e p e ~ 4 ~ M CTaBa M M Y H O K O M n e T e H T H a .BT M M Y C a Ce TpaH~@pMMpa B T -~MM$O~MT a, B K O C T H M R M03bK - B B-~MM$o~MT. T-J~HM@O~HTHT~ CnOpefl $YHK~MMTI CM Ce 0 6 0 ~ 0 6 ~ B~T B OTAentiM cy6nonyna~~~: 1. T-KJ~~TKu - nOMOyHM4M (Th -helper - ~ O M O ~ H M K

O~HO-

COKO MOneKYnHO Tern0 M CnOXHa X M M L W H a CTPYKTYpa. MRCTOTO 38 C ~ ~ ~ M $ M VCBbP3BaHe HO C aHTMTflnOT0MnM peuenTopa Ha ~ M M $ O ~ M ce T HapMra ~ aHTureHHa AeTepMnHaHTa M n n enmTon. HaqanHaTa cpeua c aHTMreH B o p r a ~ ~ ce s~

nynaqMMTe Ha B - ~ M M $ O ~ MCa: TMT~ 1. n p e f f u r e c ~ e e~ ~a ~4 a~ ~ ~ ~ ~ ~ n o o 6 p a me3pay

TKH.

PM

2. PelynaT0pHM B-~MM$O~MTM 3. B - K ~ ~ THa KM nahoena.

3a weK# KnenreH mn cyUecTeyeaT c n e u n $ ~ . r ~ ~ amMreHu Ha fln$epe~q~a4n~~a. (CD - clusters of differentiation). O ~ M C ~ ca H78 H CD rpyn~.
Ma~pO@arWTe npeflCTaBnRBaTTpeTMRTMIl KJleTKM. Te H e Ca M M Y H O K O M n e T e H T H MK n e T K M HMrpaRT ponR Ha .CnO~ a r a ~ eK nn~ ew ~" B nMpHMR OTroBop. 3a p a 3 n ~ ~ OT a ~MM$O~MTM ~Ta ~~ p o $ a r u He ~e pa3no3~aea~ cneqn$wH 0 aHTHreHa. Te Ca $ar04MTMpa~M KneTKM, VMRTO $YKUMR e pa .nornbqaf' MMyHoreHa, pa ro npepa60~m M Ra r0 .Ilpep~~aBflf' Ha T-KIETKMT~ 3a MHflyllMpaHe Ha MMyHeH OTrOBOp.

Xyklopan~a ~ e c n e u ~ $ naaqma r ~ a ce ocbqecTeRea M OT T. H. O C T ~ O @ ~ ~ OnpoTewm BW C peamMeeti np0TeMH (CRP), L1 a H T M T P M n C M H , L2 M ~ K ~ o ~ I ~ o ~ ~ J $H~PHHO~~ 4 H e ,pynonna3~ H~ RP. ~

flpM HH$~KL(HUeHflOTOKCMHMTe CTMMynMpaT 0 ~ ~ 0 6 0 WamtieTo Ha HHTepneeKMH- 1 (IL-l) ( e ~ ~ o r nMpoe~e~ EH) M nHTeplleBKMH - 6 (IL-6), KOMTO OT C B O R CTpaHa

MOJI~~JIR KOMnOHeH~ ~HH Ha H w H a T a CHCTeMa

M~y~orno6ynn nnn ~ maHTHTena - BMcoKoMoneKynRpHM npOTeMHM, KOMTO Ce IlORBRBaT Cnefl Bb3pehcTBMe Ha aHTMreHa BbPV M M Y H H a T aC M C T e M a M Ca c n o c o 6 ~ Ra ~ ce c ~ b p 3 e C a~ ~~ ~ M $ M C C (H Hero. O P a 3 p e nce ~~ Ha 5 taaca:

IgG, lgA, IgM, IgD, IgE. AHTW~~HW Ha rnaBHHR KOMnneKC Ha TbKaHHaTa cbennecTulaocT(MHC)(majorhistocornpatibilitycomplex), npeflcTaeeHM y roeeKa KaTo reHM Ha HLA cMcTeMaTa (human leucocyte antigens). Pasnos~aea~e~o Ha aHTMreHa OT T-~MM$o~MTMT~ Ce M3BbPWBa C b B M e C T H OC MOneKynMTe Ha MHC.
~MTOKWHW

C T M M Y n M P a TC M H T e 3 aH a OCTPO@~~OBM IlpoTeMHM. CblqeCT~yBaT flBa nbTR Ha Bpb3Ka MeWy BpOpeHMR M I ~ P M ~ O ~ H T HH R M y H M T e T , KOMTO O C U r Y P R B a TO C H O B a T a Ha VMOpaJlHMR M KneTbrHMR M M Y H M T e T , PeCIleKTMBHO. AHTMTenaTa, KoMnneMeHlaT H n o n w ~ o p $ o ~ y w i e a p KneT~~~e KM npepnaaea~ OT eKcTpaqenynapHme O ~ ~ ~ H M p ~o M~ M a,TO T-M~TKMT~, 4 M T O K H H M T e , Ma~po$arMTe MNK-K~~TKH OT BbTpeKneTbClHM H H $ ~ K ~ H M . HaA-rec~ou a n o n a ~ i a ~ B~ npamKaTa ~e MeToflM 3a nacneflea~eHa ~ e c n e ~ ~ $ w 3aqwTa ~ a ~ Ha a opra~~su Ca: OqeHKa Ha $ ~ ~ O ~ # T ~ ~ H ~ T ~ Ha ~HeyTpo$MnMKTHBHO Te % $aro~(11~03a, $aroq~~ap rucno, ~o $ a r o ~ ~ ~ a KanaqnTeT, a 6 c o n l o ~ e $~ arou~~ap ne o~a3a~e nn oueiiKa Ha ~ W O X M M M ~aKTMBHOCT H~T~ Ha HeyTpo$MnMTe HMTpo6nayre~pa30noe TecT.

h q w e OTlOBOP ~
MMYHHMRT OTroBop ce O$O~MRKaTo p e 3 y n ~ a OT ~TO+
H O T 0M C n O X H OB ~ ~ M M O ~ ~ ~ H a ~KJleTKMTe C T B M Ha ~ M M Y H H a Ta C M C T e M a - T-~MM$OL(MTM, B-~MM$O~MTII, Ma~po$aIW. C x e ~ a ~M ~ ycnoeHo r ~ o npouecbT MoxeRace p a 3 ~ e Ha n~ TPM eTana:

- pa3TBOpMMM aKTMBHM BeqeCTBa, KOMTO

p a 3 n ~ 1 .KneTKM: r~~ MOHOK~HW - OT M O H O U M T M ,~ ~ M @ O K W H H - O T ~ M M @ ~ M T H , WHTepneBKHHH -4 M T O K M H M , YClaCTBaqM BMewYtaeTbVHMTeB3aMMoflehCTBMR. fl0-BaXHM ca M H T e p n e B K M H M T e (IL-1 IL-8), M H T e p$epoH raMa (IFN y), T y M O p HeKPOTM3Mpau $aKTop

ce ceKpeTMpaT OT

(TNF) M RP.
~ ~ C I ' I ~ ~M H ~~ X~ H HV HH ~ Ha M M 3H aqwa

I - amretitio npeflcTaBRHe, II - MewyWleTbrtio KoonepMpatie M 111 - wsnbn~mene~ eTan - oTcTpaHRaaHe Ha aHTwreHa ($MT. 15.1). B B~BMCMMOCT OT M ~ X ~ H H Ma~ flehc-re~e M ~ ce p a m -

raBaT: 1. KneTbrleH(KJleTbrlHO-MeflWblpaH) HMYHeH OTTOflMTe c ~ ~ C T ~ H KORTO ~MM Ce , OcbqeCTBRBa Vpe3 KOXaTa, BOP, K O ~ T Oce ocbqecreflea OT UMpKynMpaqMTe T ceKpeUMma Ha nMraeMqwTe,PecHMrecKmenMTen, cToMa~MM$OL(MTMC YC(aCTMeT0Ha ~~MM$oKMH#. UlHaTa KMCenMHa M MMKPO~HMR aHTarOHM3bM. AKOIlpoHM2. X y ~ o p a n e (~ a ~ m ~ n n o~eflwnpa~) mMyHeH KsaHeTo Ha 6 a ~ ~ e npopnxaea, p ~ ~ ~ e Te ce paapywaaa~ OTrOBOp, K O ~ T O Ce OCbueCTBRBa IlOCpepCTBOM CePyMHH OT T e V H W $~KToPM KaTO n M 3 0 3 M M M T e M qpe3 $ar04~~03a. aHTMTena, CeKpeTMpaHU OT B - K J ~ ~ T KB MXyMOpWiHaTa T~ @aroqm~o3a~a npepcTaenRBa nornbqaHe M paspyWaaaHe Ha npoHMKtianM q y m racmqw ~ ~ (~anp.:6 a ~ ~ e - cpena Ha o p r a ~ w 3 ~ a . PMM) OT $ a r o u ~ ~ ~ p K an qe~ w ~ enonw~o@o~ylvleapMMYHO~O~M~HHT! MeTOflM 3a OUeHKa Ha MeTb'iHMR H M Y H M T e T M: HM ~ e y - r p o $ ~ ( rnp ~a ~ y n o 4M ~~ ~a ~~ )po$ar~. KonMrecTseHoM C ~ ~ ~ M $ H onpenenme ~ H O Ha T- n CRCT~M Ha ~ KoMnneMeHTa T~ (C) e $ ~ n o r e ~ e ~ n r ~ o B - ~ H M $ O ~ MM T TexHme M T ~ cy6nonynaqn~ nocpeflcTBoM an-CT~PMRT MeXaHM3bM Ha H ~ C ~ ~ ~ ~ M $ 3aqMTa M C I H Ha ~ o p r a ~ ~ OT 3~ HH$~KUMM. a TR npMBnMra $ a r o ~ ~ ~ ~ p a qM ~ O H ~ O K e J l O H a n H MaHTMTena ( H M ~ H O $ ~ Y O P C ? C ~ ~ H T ~ M H ~TOA), K n e T K M K ~ ~M~ K T ~ P M ynecHuea MT~, nornbqaHeTon yeenMna3ep~a $noyqn~oue~pim (rpea a ~ a m l 3 a ~ o $noyun~op raea KanlrnRpHaTa nponycKnuBocT. npepcraennea MynMeTbp), e H 3 M M H O CBbp3aHa M M ~ H O C O ~ ~ ~ H TeXHMKa TH~ (ELISA) M ~ M M $ O ~ H T O T O K C M LTeCT; ~~H $YHK~MOHE~J~H~ a K T M B H O C T Ha J~MM$OQMTMT~ Ce OnPeflenR rpe3 ~ ~ ~ ~ T H o - T ~ ~ H c @ ~ M TeCT ~ ~M I# Vpe3 oH~ $n~yl(#~~Me~pllFI. M ~ T o ~ 3a ~M OUeHKa T ~ Ha XyMOpWlHMR MMYHMTeT Ca: OllpeflenRHeHMBOTO HaCePYMHMTeM M V H O ~ ~ O ~ qQe3 V~~M

OP~~HM M M ~aM ~e ~c T n e q ~ $ ~ q ~ a cpeqy 3aq~ ~~yax -

b. 15.1. m e nm a o p (am)(no Oa*apaa, remesa,1986)

MM~HOAM$~~MR OnpeAenRHe , $patq~'lrreHa KoMnneMeHTa (oco6e~o Clq, C3, C4), onpeAenRHe HUB* TO H a~ ~ p ~ y n ~ p a MM~HHH q w e KoMnneKcn, onpeuenwe H a aeToaHT'lrrenaTa, vpe3 ELlSA MeTofl. T ~ rnasHn M nMyHHn MexaHnsMa CTORT B mHoBaTa Kamo Ha HopManHnTe 3 a q m . 1@~HKL(MH ~ Ha opra~na~a, TaKa H Ha naTonomvHwe HapyeHMR. ~~PBHR HMYHBH T 381L(HTeH MeXBHH3bM, C K O ~ O OpraHM3MbT OTTOBaPR B Ha'iaJ'lOTO Ha 6amepwan~'lrre H H B~~Me M npepwwo , ~ e c n e u ~ @ w !sb~nane~ue, e~ xclnepTepMMn M $aroqwosa c enwMnHnpaHe H a MuKpoopraHH3 M M T e . BTOPHRT HMYHeH 38U(HTeH MeX8HH3bM Ce OCbUeCTBRW OT T- H B - n ~ ~ @ u ~ ~ ' lC rr Me H T ~Ha ~ atimena M CBbp3BaHe H a MH@~Mo~HHR areHT C TRX M n M AMP~KMH U M T O T O K C H i ' H U B ~ ~ W M O A ~ ~ C TCB yHM~OXaBaHe HR Ha

pmnantia

areHTa.

eHTepaJlHa @3a, PeMOHaI'leH ~ M M $ ~ ~ H # flbT pBt4VHa , reHepann3aqnfiHa snpyca, opratiHanoKann3aqnF1,BTopnET~oJIo~AR rHa re~epanu3aqn~1, narpax,qa~e Ha nuyHnTeTM OCBO~OxqaaaHe Ha opra~naua OT npnvnHnTenR. npn o p r a ~ ~ a Bnpycb~ Ha xenaTm A (HAV) e PHK ~upyc, weti Ha nOKWlM3a~HR C e YCTaHOBRBa HallllIrMeTO Ha A ~ C T ~ O $ # c ~ M ~ A C T B nnKopHmnpycn, O mac emepoenpycn. Xapa~flpOMeHM B XeflaTOuUTMTe, PeTMKynOe~epnanpa ce c BncoKa~epuopeaucrem~oc~ w ce P ~ ~ M H O - M H~KPO~HOTHCIHM x a w B KnenrHn qrrrypn. Bnpycb~ Ha xenam B (HBV) HAOTenbT PeaMpa C M H @ I I ~ T ~ ~ T H B H flp~nM$epa~~BH O MaMeHeHMR, IlpM KOUTO C e O'lepTaBaT CUHflpoMMTe: qMT0e PHK snpyc. npepcrraemen e Ha rpyna ~npycn, Hapereueae~x~~~oa~nanr ~ n x e n ~ ~ a ~ n p y ~ u , ~ e e n s o n n p a ~ ~ m e n r ~ u nnaa, ~ y me~c~pe~op~o6nnnape~, ypn. Yec~o npoqecn~e B XenaToqma a a ~ b p w ~ Ca HeKpom, ~ 3a ~npyca Ha xenam C ce npeAnonara, r e cbqecrayea ~ai-uan~ Bo Aee @pun, eAtiaTa OT KOKTO ce npeAaw KaTO TR e: @KEUlHa, 3OHWlHa, MaCHBHa. rnaaHo no napemepaneti m ~n , BTopaTa, ~ o m o nua c~MllTOMi3Til~a xapamepncmKaTa Ha ~npyca Ha xenam A. MHO~HHCTBOTO OT amopme npneuaT, Ire

I/IH$~~Mo~HHHT BHPyCeHXenaTHT e OCTpO IlapeHXbIM~ ~ 0flpeaH3BllKaHO 6, OT XenaToTponHn Bnpycn. B npamKaTace pamuIraBaTTpn @p MM Hahnecrra: u c r n ~ r m n ~ @ w m a xenam e~ A, TON, K O ~ ce O npenaea no KomameH n a ~xenam ; B, npeAasauce vpea HHoKynaqnRHa roeewlcawba; HUTO A-, HHTO B-xena~m,n a s e c ~ e (OT ~ c~opo)K ~ T OxenaTwr C, npn KOWO ca onncaHn H AeaTa ~ T Ha R 3apa3RBaHe.
H0 3a60n~ea~e Ha 'iePHHR

llmre~e3a

lla~ore~e3a Ha ~aa60n~ea~e cxeuaTMvHo ~o Moxe

Xenam~ A e ocrpa Komama MH@KUMR. Ilpe~aaHeTo Ha aapa3a~a e B M M O ~ Om rpe3 BoAa, rpea xpatia MmepnveHM CneAumepnIreHnepwonu Ha 3a60n~sa~e~ H AP., 3aMbPCeHH OT CeKpeTH Ha 60n~n.H~A-.~~cTo npoppouan~me RenetinR Ha npeflnmepMrHnfl nepnofl aa60n~aa~ nnqa B AeTcKa n B loHowecKa ~bapacr. no~aaea~ n a ~ e ~ eKOUTO ~n~ ca , xapameptin3a 3a60n~eaCMRT ce, ~ r e Toea e peayma~ OT nnncaTa Ha uMyHmeT. HMR Ha TaCTPO-MHTeCMHallHMRTpaKT. ~ O R Ha B ~ TeXeCT B P R ~ ~ce KO ~a6nlo~aea B Aeqa non eAHa roflnHa ( s p o ~ e ~ ropHaTa nonoantia Ha Kopeua, noapbqaHnR, Anapnn, a HM~HMT~T). Ceao~~m cbqo a e xapatcrepHa - npeAnucbqo TaKa M 3aneK. Texecrra B ARCHOTO no~pe6pne HO eceHHo paanpoc~pa~e~ue. H a fr o n ~ u e aonamma uoxe Aa ~ d n xapatcrep e Ha KonnKa. Cy6$e6pnn~n~e M OT aapaa~ea~e npea nbpame Ace, TPH ce~unqnOT BMCoKMTeTeMnepaTypH(2PRAKOCT. ~ O H R K ~ OO ~~ ~ HC M eT H H ~ ~ ~ ~ M O nepnod. H H ~ Ilpe6one~yeanu~e, R mnro speOnnaKBaT OT ~ O ~ B KCTaBMTe. M MaKap M PRflKO, YCTaHOBRM e MoraT fla ocTaHar 3apa3o~menn. Cbqerx~yea~ n BaT C eMO~~M~MM @ n M~c M K~ ~~ H~ ~ T # H O @ 06pna J~M~ BnpycoHocmenn, KOUTO HwKora He ca h n e m u . no KOXaTa. 3a CepyMHMR XenaTMT TaCTPO-MHTeCTMHanHM~ ~ ~ O ~ R B OT ~ xenmT H ~ TB O e cnopanrtio, HO ~ O H R Te OnnaKBaHMR Ca no-PeflKn, KaTO IlO-IreCTn PeBMaTOKora, cnen BaKcnHaqnn ce y c r w o m a ~ MCTHHCKM ennnenflHme onnaKsatiun. T a 3 ~ npeAntcrepn'lHa $asa e OT unw. 3 a h n ~ ~ a He ~e no~aaea ~ 0 C~BOHHOCT H e onactio HRKO~KO AHM AO 2, 3 ceflun~n ( K ~ TH~A-remo O e eAHa B ~ BcRKa B ~bapacr. TOcram rpea HapaHRmnRHa ~ o m - ce~unqa). Ta unn vpe3 n~$yann.O n a c ~ m e a~ a m npn o npenneaCnope~ AounHnnpaqme WIHHH~HMC H M ~ O M H npes HeTo Ha MnocTHa w e , TaKa n npn Aepneam OT Hen (nnasua, cepyu, $n6pnH0reH, T ~ M ~ H eplrrpoqma H, Mam). PM XUPYPMCIHKTe IrlHlePBeH4Hn C b q O e Bb3MOWO ucnenTnreH, ncewopeeMamreti,6 e a c n ~ n ~ o u e ~ . MHOKynUpaHeTO Ha BWpyCa. H0 TOBa C T m MHOrO PWKO, ~ O R M THa ~ MKlepa no cKnepMTe M IlOTbMHRBaHeTOHa nopwn no-~o6pa~a c~epnnnaaqn~, a npn onepaqun~ a h ypnHaTa oa~avaea npeMMHaaatieTo B cneneaqaTa $a3a recTo - qpea npenmaTa nnn rpea nnaaua, oneHa 3a60nRBaHe~0. C noRsaTa Ha ntcrepa Hacnnea n o ~ o p n p a ~ ~ ~ e c e 3 a p a a ~ e a ~ o ~ ~ n p y c o ~ m e n ~ ~6 e. pe~B ~0 e6 4 0 ~ 0 CbCTORHMe Ha 60JlH~fl. YptIHaTa craea Hanpaee~n~e y Hac npoyrea~m IIOK~~B~T,r e OT oue n o - n ~ ~ a an , anpme~nma no-cee~nn.Y e p ~ ~ xenaTnT A 60ne~yea~ w n xopa, a cneA 3 0 - r o ~ n ~ u ~ a ~ p o 6 e yroneueH npn onnneatie, Ha 1-3 npbcra no^ B ~ ~ D~~ CaT h-re00 OT xenam B. D I ~ ~ D ~ H ~ TC ~ rnaaKa I I ~ T noRbnxHm-vnneneHa ~ . nnhmnrrr

H~ ~ U K H O B ~ Ht?60n?3HeH. HO ~OPWH HaSlUVUeTO Ha XOnenpn HRKOU OTTe3H 60nH~ B Ha'iaJlOTOflOMUHMpaT npn3Hac~aaa 60n~me ce onnamr OT cbp6ex, OTU~UEEIT ce 4me OT crpatia Ha UHC KaTo AennpM nnM Knotinwo cneflu OT paa~ecea~e no KoxaTa. npn T e m e $OPMU ce TOHMVHU mproBe. ~a6noflaaa6 p q n ~ a p ~ XHnOTOHUR, n~, KaKTO M CbHnMno-peflm @pun ca xena~o-pe~an~n~rr cu~flpou, xe~n~, xenam. em. Y p ~ ae ~ca UBRT Ha Bnpa, a nRHaTa k e K ~ @ H U K ~ - n a ~ o ~ e $ ppequflMBnpaqum soaenetla. Cee~nu nsnpameHuR no HamnHo axonnwu. Mrne~amen Ha ~ umepa e pa3nn~e~, HO TOM He Aaea caeneHuR 3a Texema Ha 3 a 6 0 n ~ w ~ e ~ o . npeammeHmram nepnofl ~ a i - v e m ce o ~op~anuaupa TeMnepaTypaTa, HO ~ e ~ a 6 0 n m m $e ~HK~U Ha U rep~u npo6 ~ l ca3acemam, abrnexuflpama~ao6~~1~a~ae paac~poe~a, reptinm ~ p o 6 o6ep~~laa Ha rnuKoreH, Ha npam~aceyc~a~oe~eamnorn an npn ~ eo ~6 up ~e ,~e~~1BaHexuneprnuKeMHR. C no-ronu~o fluamocTurtio 3 ~ a r e Hue ca HapytueHuma Ha 6 e m r ~ a O ~~ aM R H Tow ~. ce B npeFyKnbrHuR c r q u i ce npaan c rpun, ~nanmu, p n x n Ha CMy-reHaTa, npoTemrneTuvHa $ ~ H K L ~ I F I Ha peBMaTM3bM, OCTbP eHTepOKOnUT, eHTepoBMpyCH0 3a60flpo6a. Bbe ~ p b 3 ~ Ca npoMeHme B 6embVHuR cbcrae nReaHe. (CM)THOLU~HH~TO a n 6 ~ k l ~ - r n oe 6nOfl1). y~~~ n~ p T~ ~MnpeaC T ~ U FHa I mmetinqaTa fllrl@pe~quan~a~a KM WPMU Ha xenam ce ycTaHoBflw HaManeHne Ha ypeamosa e c: M H $ ~ W U O MoHottyKneo3a, ~H~ mnTa TpecKa, RTa B KPbBTa H yBenUclaBaHe Ha KCaHTOnpoTeMHOBMTe UuToMeranHa 6onec~, cencuc, nen~ocn~po3a, nyec, MaBeqecTea. napwfl, nailu~a~no3a, na~6nuo3a, ~o~connaa~o3a. T~R llpopmen~ma Ha mameHuraeuR nepuofl e 6ea fla C eM M a T nPeflBMfl U V ~ P H O ~ ~ P O ~ H eH3MMOnaTMM UT~ pa3nnre~, cpeflHo Memqy 11-20 Atin. npn no-cepuo3~u Ha Giller, Dulbyn-Johnson, Rotor, 60necTTa Ha cnyclau 7-8 ceflMuqu. Moschkowitz,CbqOTaKa-TOKCUqHM XenaTMTH npM: Meflu3a60n~w~e npomra ~ o B neKa, cpema H Tema $0KaMeHTHM, npoMHLUneHM, XMMUVHM, b 6 OTPaBRHUR. ~ ~ He pua. npn neKaTa b p ~ HMFJOTO a Ha c e p y ~ 6nnupy6~~ ~n~ 6wea~a ce aa6pae~~, &HO npn ~ a a p a c r ~ u 6~ 0e n~n U e flo 85.5 mmVI, npn cpeflHaTa e flo 205.2 mmM, a npu TYMOPHUTe npo&Cll. TemTa c r o i ~ m m e ca no-suco~n. Xapamep~ ca ~ u3no-cbqec~ee~a e~n$epe~qnan~ pluar~o3a a ~ a c eKMeHeHuma B CepyMHme ~ p a ~ c a ~ n (CrflT, ~ a a u CrOT), cTpaxenaTanHaTaxonmam, KORTO HOCU p a a n u ~ ~ Haun nocneptime MoraT fla ce noKaraT flopn U flo 2000 E. MetioBaHuR KaTo nocTxenaTanHa, Mexatiuvtia, o6~ypaquXapamep~o 3a 3a60n~ea~e~o ca HopManHmeCTO~HOCTM oHHa U flp. TRe pe3yn~a~ OT MexaHuwoTo 3anyurBaHe Ha HanesKoumme unucna6o~o MMnoBuulasaHeC uapaae~a rOneMUTe U ~ B ~ H 'XribVHU I~P IlbTUqa HO OT~ TyMO~~ nu~$o~(mo3a. no~nulasa ce HnsoTo Ha anflonaaa~a, oppu, KotiKpeMeHTn, napa3n~u, cneflonepaTuBtiM pa6qu M Hm~H~ap6a~llmpaHc$Mpa3aTa, apMHa3aTa, rntOKO30flp. YCT~HOBRB~ C e pa3nbIKa B KnUHMrHaTa KapTMHa, a 6+c$a~flexuqmre~a3a~a, ~ o m ce o cnnmaT 3a opraHHo napaKnutiMrHwTe u 3 c n e p a ~ u ~ roeopequ , B nonaa Ha cne~n$nr~n. npn Tewn cnyclan HacTbnea pennvaeatie MexaHnrHaTao6~ypaqn~, ca: neeKoqnTo3a,BnpemHa xuHa CepyMHoTo xen~30. nep6nnupy6u~eun~1, noenluaeatie Ha anKanHaTa $@aC timanmaHe-ro Ha mmetinqma Hacnnsa non&~aaa, xonecTeponbT, nunonpoTeuHMTe n flp. pRmeTo Ha h n ~ m eHa , anema, Ha 0 6 ~ 0 c ~a0 uoy~cmne. OaflpaeR~a~e~o d a r e e 6as~o n Tpae Meceuu Hapefl, BKIMOXHO e Aa ~ o 6 u e mn~oo6paae~ xapaiuep. klblHbl'4Hbl @ O ~ M H HYCJlOXHIHHR. O C B ~ H O ~ M C ~ H U Te nO-rOfJe O ~ U K H O B ~ H$OPMH U B KnUHHCl HaTa npaKTUKa ce ycraHoeRw n ~ ~ ~ H % J T T ~ H $op~a. MVH~ T F I e norecra npn Mnqme h n ~ nHe3aancnMo , OT nHncaTa Ha m m e HUqa e Bb3MOXHO He CaMO X ~ ~ H U $ H ~ U PHa ~H 3860~?TO nREIHeT0, H0 A O P H yCJlOXHRBaHeT0 My C 4UW3a. Xona~ruonma~a W p ~ ce a o n u m KaTo KanMnRpon o p q u nnncaTa Ha eTnoTpontio nereme, TO e KOMxonatim. npn H e R ce paaenea mnHa axonwn c ynopm nneKcHo. A n e ~ a TpR6Ba ~a ~a 6 b ~ q e w q a reptim up06 cap6em, KaTo Vecro m~w npn lean 6 0 n ~ n ce uucnn 3a U eflHoBpeMeHHo fla e mnHoqeHHa. P e m ~ cneflsa b ~ fla MeXaHUClHa XWTeHYll.@. 6bfle nocreneH flopu U npu neKuTe cnyraM. h n u n ~ a ~W ~p a ~ Ha a a xenaTm ce paasnea6ap30 M~~~MK~M~H neYeHUe T O ~ HCe OnpoBewa TO C pa3TBOn nosewa no pa3amneTo Ha rep~oupo6~a KoMa, npu PM OT 510%: Sol. Glumsae unn Laevulasa, BuTaMutiu OT Tean 6 0 n ~ n ce paaeu~a ocrpa ~ e ~ p o Ha a areptinR flpo6. rpynaTa B, Vitamin C B ~ o 3 no a 20 ml. LUupo~o npunoxe-

OTHoueHwe K ~ M neqeHueTo. Cnope! Kirby R., Taylor R., and Civetta J. (1994) mwHwvHwre C U M ~ O M U ,B ~ ~ B M C U M O C OT TH ~ ~ Y ~ C cpeT O qaHwrenpulruHmenucepa3npe~enmno~aw~,npeAcTaeeti Ha (ra6n. 15.1). B racT OT 60n~wre, CTpqaqu OT enwueMuqeH MewHMT, MoraTAace H ~ ~ ~ I O R MacuBtiu ~ B ~ T ~ O R K O ~K KP H ~M BOusnw~u,pasnonoxe~uno pbqeTe M ropHaTa ram Ha Tpyila. M ~ ~ H u ~ H O C H ~ C T e~ pa3BUBa oco6e~o Onpo, c nocnepaqa 6ap3a 3ary6a Ha c a s ~ a ~ u e U~ Bo eau cnpaw ~pn6sa ~a npueMeM cpus Ha uMyHtiaTacucTeMa y naquetrra. Tor~a~a u ~ o fluamoaa ea e pesyma~ OT qaTenHo M M K ~ O ~ W O ~ O M Vbl3CneAElHe, HO npU K O e T OC e UBRCHRM

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Cxe~a 16.1. E m o n o w ~ a A n a n l o m l r a Ha @ e b p n n m(P)

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Cxe~a 16.2. ~mrmocnrr~a opnelrraqnn npn npommener 1be6pnnm

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pas6nparpes npaanmo ~a ~ e o f i ~ mAeqa e : no^ 2 ronnHH, C pemanHaTeMnepaTypano-snco~ao~ I 020no Oape~ x a (39C) h M nee~oqmo3a ~ a ,20 q 000 ca c 20% p n c 3a ~ HanclrHe Ha oKynTHa6amepue~u~. no-QCHO npaennoTo Ha ~ 0 0 h T r C ee npoMeHM no OTHOWeHHe M Ha AeuaTa H q 2~ ~ U M H nM ~ a n e ~ ~ o q m o 3npw a~a no-~an~anes~oqm . 3a nMa onacHocT OT npOnycKaHe Ha Mttoro ~ ~ K T ~ ~ H ~ Hbl fleqa. no CbBpeMeHHH flaHHH npn6nnsn~enno 10% OT IeqaTa M e w 3 Meceqa M 2 rountin, C n e ~ ~ o q m ~n a,q 15 000, TeMnepaTypa H a 39C H HanW'ieH H3TOCIHlrlK Ha LlH$eKqnR HMaT 6amepne~n~. Hapyure~a CeWBHocT, MeHHHM3bM HnH @ K W HHe~ BponornrHacnMmoMaTwKa ce ~a6nlo~jam npn M H $ ~ ~ M Ha UHC. C ~ p n ~ oxpunoae, p, peTpaiqnn, noAqbpxaHe Ha llnpore~me (TOKCHHU WIH KomnneKcme am re^-a~cpaeHmenHo nmoFiHHa ~ K C T ~ H ~ Ha M rnaeaTa R npn $neT~R~ OT O paa~oo6pa3e~ ) npon3xo~ npe~n3~n TeMm~ KWpaHa WMR recTn CMMflTOMH Ha O ~ C T P ~ K ~ M Ha R nepaTypa rpes cmMynnpaHe npomqnma Ha ennH nporopHnTe UwxaTenHnnbTuqa- ennrnoTnT, pe~po$lapw~reTenH OT (baroqu~me, HapereHeHuoreHeH nnporeH. Tow aneH a6cuec. ~ H C ~ H ! RqnaHcMa , nnM 6nenoc~, TaxnnHeR, npoTenti tiaennaa B qvpKynaqnma, wan~o~leilmea c paTaXMKaPPMR M XMIlOTeH3MR - OTpa3FlBaT CbpfleVHO-UHXa3nMrHn cne~~$lHrHtI Pe~eIlTOpHH HeBpoHH B IlpeAHMR TenHa HeAocTanrHOCT - nHeBMOHHR, nepMKapAHT, 6 a ~ xnnoTanaMycneo~lu~onp~q~~~HanpocTarnaH~uHn, TepnUleH eHflOKapflMT U CemWueMUR. X ~ M O ~ ~ 06M~ MoHoaMntin M up. Tean MeAnaTopu(Ha mail pea) nopaeaT P M B M Bb3HHKBaT npH 6aKTep~~eH M PHKe4M03eH CenCHC CMlHallM Vpe3 3llqHnR XHnOTaJ'laMyC KbM 8a30MOTOPHHR KaTO MeHMHrOKOWeMHR, neTHMCTaTpeCKa OT CKNIL~CTH ueHTbP, KOeTO BOAH C(O nepbI@pHa Ba30KOHCTpnKqnR, nnaHHHM H np. yeenMramHe Ha ~ e ~ a 6 o n n M a~a ~a ~ o n n o n p o ~ y ~M, qn~~a B ~ p a i l cveTKa, ~a no noKaraaHe Ha TenecHaTa TeMnepaTypa. ~ H C $ Y H KHa ~ #4HC R PRnKO BJlblReAMPeKlHO BbpXy XMnOTaJlaMHrHHTe CTp)MypH. K~HR np#UeqaTa:p n , HOC, rbpno, w n i l ~ nn#$~n n mnn, AnxaTenHa M nn~oro-nonoea cncreMa, r a c ~ p o - n ~ ~ e HmeHTpaU, CTaBH IC1 KOCTU. TbnaH'ieT0 MOXe fla nOKcuKe npm~aqn Ha ocnp O T ~ K , ~TO 3arepBnBaHe, n o w t i e , nnamomqnpa~mo Ha !&6pnnme~a moxe 6 w e HaManeHa n o ~ e n x ~ mreaeaHe m, Ha caeTnnHtinR pe$cnelutio, KoraTo e nouo noHocnM (240.5"C) dnnn npnuneKc, a npn nep$opaqn~ - H ~ T H C Ha ~ ~celcpeT. H ~ HOC~T PPeH OT CMMmOMH: 1. He0pon0M.1~~ - KOMa, KOHBynCMM, MeHlllHreallHO ycTaTa H npnoTo MoraT aa noKaxaT npnatiaqme Ha ewnanetine, coreqn n ~ $ e w n Ha ~ ropHHTe AnxaTenHn RpasHeHe. ITbTMqa, KaTO O ~ M K H O HaCTHHKa, ~~H~ CTPellTOKOKOB $a2. Kap~no-sac~ynap~n - Konanc, Taxmapflnn. PHHMT, nnn xepneceH rnHmmoMam. Llepan~an~nrn 3. nnxa~ennn - nonnnwn, RncnHeR. a,qeHm, K O ~ O e remo ycnoxHeHne Ha m~$le~qnme Ha 4. nexnapa~aLpt~. ropHme AnxaTenHH m n q a npn UeqaTa, Moxe Aa ce 5. Xe~oparm~l c BbTpewHamnn BaHLuHa Haw. sn3yannanpa npn ornea caMo c neKo noqnymtie B o6na6. KOXHM - nypnypa. n peTpaxnpaHe Bcnrm ~ e 3 n cnMmoMn, wonwpaw nnn ~06aee~n, crra Ha wnma, TaxnnHeR, c pa3wnpe~ne Ha Hoctime Kpnna. Canoc~aee~n c aycKymaTopHnOTKIIOHaJlaraT XOCllHTNlH3a~nR.06pa~H0, npH CMMIlT0MaTH.lHOTO TpeTnpaHe, ananio3a~a ~ p ~ Aa 6 6 ma ~ ~ e a M ~ f K O HeHllR MOXe aa ce npeflflOnOM nHeBMOHMR U ~paXe06p0~ x m Macneum~e~o . Ha KopeMa e n3~nlormen~o smo yrorHeHa. ~~arH0CT~rHa c m r y p Moxe ~ ~ ~aa ~ 6bue nocno~ann3npa~ nnn 064 ae$a~c H T. H.). BwnaneTnmaTa B cnewtin cnyan Ha nypnypa $ y n ~ n ~ a c ~ c (6on~a, Claforan- 25-50 mVkg Terno. M H @ K ~ O ~ OH ~O ~ C ~ O B ~ H H -Hne Ha cTaaaTa c orpaHnreHn ABnxeKeHnR npn @e6pnn~o AeTe Hacorm K ~ cemreH M apTpm. n o m n 3 n p a ~ ~ aocTe $e6pnn~nM O R H H R CB XOClllcrraJlH3lpaT BeAHara THa 60nKa M ~ w n a n e ~ n npeAnonaraT e ocTeoMnenm. (Cxe~a 16.1). npn nHeennoKoKaeaTa6 a m e p ~ e w noeeve~o OT Re@anocnrna wma cTaeaT a@6pnn~uB c p o ~ OT 3-4 WH C WIH 6e3 ~ ~ W I I O C I ~m ~~H aO e: m 6 a ~ ~ e p n a nolcpme. n~o flpw xem)myc mt@nye~qe 1. Cneaoea~enc~a a~am~e3a -non, mpacT, mn~anu H H ~ ~ C ~MeHWHVHC PHR yCnOMieHHR KaTO: nepCHcTH3 a 6 o n ~ w (n~$ewnos~n, u~ aneprmcl~n), npneM Ha Mepaqa k e p n e ~ nntieeuotinfi, ~, meHnHm n cencnc ce anKaMewM(Acetysal, a~~n6amepman~m npenapam, HeenonBRBaT w r e m o . ponen~nqn), Hawno Ha$e6pllm#Te~a, eeonloqnqTeMneXapa~~epmmm Ha n oKymiaTa 6aKTep~emmnce

OKyrn~a 6mep#emm~ -B Haranmo Ha 70-~e ro)pww KfIafiH M MH@K~+~oHuCTH OT 60nHl44a~a B~OCT~ nbPBM H nocorm-r BncoKaTa recToTa Ha 6amepne~m npn HOBOpoAeHn U MMKM Aeqa c TeMnepaTypa. n e w Ha w p a m M e w 6 Meceqa n 2 roan~w, c TeMneparypa39.4"C (nnn noeere) H CnesKoqwn ~a,q20000can~ann 6amepne~nfl B 28%. ~ O B ~ Y OT ~ T TRX O He Ca M H T O K C W K H p a H HH Y e C T O He nOKa3BaTRBeH H3TOCIHblK Ha UH$BKL(HR. H a f'4eC'MRTnpnVWHWen e CTpemOKOKyCIlHeBMOHMe- H a 85% OT nO3UTnBHme K~JITYPH, maHanme 15%ce pasnpeaenmMexAy x~Mo$HJ~Yc klH$JlYeHue M Hailcep~R MeHMHMTU~MC.

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K p b ~ HaTpUBKa ~a M~eJ70rpaMa Xe~o~yn~ypa f l y ~ 6 m ~QWK~UFI ~a

Nivaquin, A ~ ~ n 6 a ~ ~ e p u a n npenapam Glucantime, Pentostam AHTU~~KT~~UWHU npenapam

Tpec~a t yeenure~u ~UM$HH mnu Tpec~a t 06~~0

Lornidine Notesine ~~HKUU ~a R ~UM@H ~b3en Cyclines Cepo~uar~m~a Rovamycine Enw~e~uonoruv~a cpena, cep~~~amoc~ll~a Hasan~a nocReKa ~ ~ H K ~ ~a U ~R HM+~ m He n

Cu~rrrmamrm AIITU~~KT~~U~~HU npenapa~u C y n $ o ~ a ~ u Rifampicine ~u, Lomidine

TpecKa t UKTep TpeC~a t ~eepono~r~a CUMnTOMaMKa Tpec~a t eosu~o$unu~

K n u ~ u v cpena ~a Cuumo~amr~o T~~HC~MUH~~U fly~6an~ nyHKquR a

CUM~OM~TU~HO Apsobal AHTU~~KT~~U~~HU npenapam Biltncide Dehydroemetine, Biltricide Mintesol Xupyprur~o nere~ue Notesine Ciclines Erythromydne

6unxapquosa puc~o~a~osa Murpupana napea Tpuxu~osa EXUHOKOK (xuflampoaa) Q)unapuosa Ky-~pec~a 60nec~ ~a nemo~epa

Cepopuamoc~u~a

Myc~yn~ 6uoncu~ a P~HT~ Y3n, ~H, cepopuamocru~a Kpbe Ceponuamm~a

Tpec~a t n~ee~onam~

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MR HOBOpojqeHMTe H MmKMTe jqeqa e yMeCTHO, AOKaTO C e cHeMa a ~ a ~ ~ e ajqa eTeTo ~a, jqa cepn B cqma nnn B pbqeTe Ha pojqnTenR. 3 4 a e a ce ~ Bbnpocn m HarlanoTo n npomnxnTenHocna Ha @6p~nbiTeTa,6ncorlnHaTa Ha TeMnenpnrlu~n 3a $e6p~n~TeT, cebp3a~n HapyweHa cempaTypaTa ( a ~ o e ~ e p e ~ aUanonaeaHnTe ), neKapcTsa, BHOCT:6 a ~ ~ e p n a cencnc, n e ~ +e6pune~ rbpv, xnnornuKeCBbP3aHMTe C M : 3a60nfl~aHeT0 CHMnTOMM, HallMClMeTO Ha MMR BcnejqmBue HanouroxpaHeHe, noepbqaHeM jqnapnn, nojqo6~o 6onec~~ CbcTOFl o Hlre y POjqHWHUTe M n L 4n p W peMeHnHruT, e~ue+ann~, 3ane~, xnnoHaTpneMnrlHa pexnjqUaTa, C KOMTO e B KOHTaKf. OTHOCHO MkIHanUTe aa60n~eapaTaqnR, urnrenom,o~paan~e, ~enojqosupa~mpae~a ~a HUR rp~6aa jqa ce ~a6neme ~bpxy noBTapRqn ce TeMnernaeaTa, BKnwrlnTenHoShake baby syndrome, c KbpeeHe PaTypHM CbCTORHHR, nO-CneqnanH0BbPy 3a60llFI~aH~R H B UHC. TepanuR, KOUTO 6nxa Mornn pa KoMnpoMeTnpaT ~ o p ~ a n @ ~ ~ ~ H ~ H l% H pV ReTrlecT0, H0 O ~ ~ K H O B ~ j H qO6poO HUTe 3aqMTHM MeXaHM3MU - CbpllOBHjqHOWleTbrlHaaHeKavecTaeHo nenetiuenpu HosopoAeHu M M ~ K peqa M (OT 2 MMR, aCllfleHMFI, 3nOKa' ieCTBeHM ~ ~ ~ O ~ R M H MMYHOCYnUR, jqo 5%). rbprloee~e ca re~epanuanpa~n, TOHMVHO-WIOHHpecun. C n e j q ~ ce ~cTeneHHo npoMeHnTe y jqeTeTo, peat(~ H M Te . npojqbnxaeaT no-uan~o OT 10-1 5 min M ce nonBAqnu~e ~a jqpaa~n~enn, pecnnpaTopHnmcTaTyc, qeeTa Ha saT Ha sbpxa Ha TeunepaTypHaTa Kpusa. Hai-rlecT# ca nnqe~o, xpaHeHeTo, penraTenHaTa amnBHocT, n a p ~ o l c Memy 8-20 MeCeUa, HeTMnllrlHHCnejq 5-6 TOjqHHU. c a n ~ a paajqpaa~n~en~oc~ ~a n nnar Ha jqeTeTo HanpuMep, H a i f - 0 ~ 0 ~ 0 MoMeHT p e ~ B jqu+epe~quan~a~ajqnanio BbnpeKH OnUTMTe Ha POflMTeIlR jqa r0 yCnOKOL4, e CUMmOM aa e MeuHHrHraT, npnvuHRsaqTeMnepaTypa M nprloae. Ha MeHMHMT B PaHHaTajqeTCKa Bb3paCT. TbpW MeHMHM3bM, IlOBMUJeHa YyBCTBMTenHOCT KbM nnamoaa~a Moxe pa 6bpe necHa, KoraTo +e6pnnnjqpas~n~enn H HapyureHa ceTneHocT. B MnHanoTo npn TeTbT e npujqpyxeHOT: (Cxe~a 16.1) cnMmoMn, nonaaaaBCH~~K peqa H ce e Hanarana n y 6 a n ~ nyHKqnR. a Cnopejq q n 3 a 6 o n ~ ~ ~a a~ pea e opraH ~ (YHr, pnxa~ene~ anapaT, aaTopu OT Hopkins University, ~ a k p n c ~ o e m 3a e MeHMHnn~oro-nono~a CumeMa, Heeponomvtia, ruHeKonorurltia MT peqa ca ~eau: nojq 18 Meceqa, peqa, paa~nnn rbpr B H RP. CMCT~MM), 0 6 ~ ~W 6M , a BXOjqHa BpaTa, MKTeP. cnewoTo oTjqeneHne, peqa c @ K ~ H rbproee, M jqeqa, 4. Ko~cyn~aqun, cneqn+nq~nnacnejqea~un. noceTnnn neKap npea nocneptime 48 h, noeerleTo OT Anamosa~a e ~ p y p (~ Ca x e ~ 16.1 a ): ~ o r a +e6pnnn~o peqaTa HW12-18 Meceqa, paa~nnn KpanK re~epanuanTenT e naonnpaH nnn .ronU, nnncsaT cnMnToMn unu ca paH rbpv M BeCenbl,HeHHTOKCMKMPaHMCnep Hero, MOraT paa~onocor~n, aHaMHesaTa ~ p ~ 6 pa e ae .cnepoeaTencpa ce neKyMT 6e3 n y 6 a n ~ a IlyHK~UR. ~a", npceqa BTpncaHe, nano~nea~e, rnam6onne, ~ n a n OTHTHC Meffma-nnaHqeToce aarlepe~ea no cbqaTa M M , aHOpeKCMR, aCTeHMR, O T C ~ ~ ~ B ~ H H C~ ! . W C ~ MllU M ~ T O npnrlma, Kamo M nnqe~o npn TeMnepaTypa, aa~oaa TOM eaetiTyanHaTaacoqnaqnfi Ha ~eaw CMM~TOMM, C npom~n+~HOM~ cH a noce6e ~ cn tie e no~aaa~ene~. nomsa~en~a P a u l MOMeHTn( C ~ M M ~ CbcTORHUe, ~HO BMPYCHaMH$~K~IIR e 60nKaTa M HaXopKaTa OT npernepa. M T. H.), opnempa m nocoKaTa Ha n o - ~ a ~ a n u r ~ w r e M~HHHTOKOK~~MHR - B HaclMOT0 IleTeXUNIeH 06MxnepeaHnR. pm, a no-K~CHO - nypnypa. O ~ ~ U HM jqa Tce noMHn, ve ~ O M O Ha ~ PnHbITenHUTe T ~ bl3CflejqWWR: KpbBHa Memy 1.5 H 3-rojqnur~abapa am ~ o ~ a u n a p xnnepT~a~a Kapl'UHa: OpHeHTMpaqM M O M e H T M - neBK0HeyrponeHHR ~O$MFI(683 e ~ c y ~e aHOpMWl ~ ) Ha HaXOpKa. (6pyllenoa, Tn@cljq), neBKOqMTOa (6amepnan~a ~ ~ 4 0 Kpyn M enHrnomr - n peeTe MORHMR ce npoflmK~MFI), HOPMOqUT03aTa He M3KJlH)rlBa HHqO; aHeMHR (naM T C HHCllklpaTOpeHClpU~Op. n y p u a ~ )MoHoqnTapeH , cn~ppo (CMV, ~ MNI, xenam~), I~H~BMOHMA - n p o w a c Kaurnnw n xpnnoee. flpn Ro-rpa+nn ( n ~ e e ~ o ~ n Mmnnpa~e~o fi). Ha npurlntiwrenx no-~anm peqa Mome nnnceaTaycKymaTopwe xapaxewoKymypa, ~ p i ~ o 6 a ~ ~ e p n o n o ~ ~ ~ o nHaypnxnepea~e KTePHCTMKH (Riirpa$n~). HaTa, B3eMaHe Ha pa3flMrlHn6monorur~n TerlHOCTM, nWKO m p aneHAmqnT - w w e , nospbqaiie, 6 o mB aop, nneapanetinytiuaT, acqm n T. H.); napa3mono~rl~o HneoqeKamaTadnacr, ~ H (EX.: COXK). nacnep~a~e Ha nanpax~e~nma; nomoptia cepo-~namoH ~ ~ a r s l ~ a q n ~ - ~ ~ e ~ a n ~ ananrmpaula ~~a6orn mKa. ce uaca B KopeMa, eeelrryamlo m3npame~w1 m. m m & q m a w a x a ja n o m w e a p cnomra ~ HOBO mene. , nHemonocKonm.

Cemnve~ apTpm - aTonnme, 60n~a, OrpaHnreHa noAenmocr Ha maeaTa. Bapnqena - eesnKymcm c AnaMenp 2-3 mm sapxy aarepeetia m o e a (5-7.5 mm) - .cans ebpxy pome ~McT". Mop6nnn-opameeo-repee~~ a y o n a n y n m06e~ pne, c Kawnnqa, nanne6pane~ KOHIOHKMB~ H B paHtiHR C T ~ neTHa M ~ Ha Konnn~.Moxe Aa aMa CTPWOP. ABTOHMYHHH 6 0 n e ~ -C T ~MllH'lHO IlpoAbJlXHTeneH $~~~MIIMT~T MoraT Aa 6bAaT: I O W H ~ H M R TpeeMaTonAeH aPTPMT, CMCTeMHnRT nyTlyC H Eb3nXlblTenHklTe rpeBHM 3 a 6 0 n ~ e a ~nbpame n~. flee BOW PO apTpm M apTpanmn c BTopnrHaxnn@ywqno~an~a aqm$#fl Ha MycKynMTe. ~OCIleAHWTe IlpoTUYaTC O T l l ~ H a l l O C TO , T C ~ ~Ha ~ W Terno. B c n y m npM 6onecrra Ha Krohn unapnma He e x ~ , ~ p n ~ e HO n~ ea TwnnrHa , npn ynqepo3~n~ Konm. Knac~rec~nm DeeHnneH peannaTonneti apTpm npoTnra c npopnxmema sncoKa TeMnepaTypa(39-41"C) n o6qa nwoKcnKaqw, 6bp30npe~0AeH MaKynonanynoaeH o6pM0.3a110~Ei C apTpMMH b l MHallrHW, a He C HCTMHCKHR apTpnT. Moxe Aa ce nomn MnoKapAnT. A ~ a m w a ~ Ba C a M O T O HaVaJlO e TpyRHa, T b i KaTO CeponOMVHMTe Map

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HOBeHO C a yMepeH0 MHTOKCMKMpaHM,CbC C T a B H M~ O ~ M K M ~op6nnu$op~ o6pna e ~ nnn Erythema multifome. ilpe~o3npa~ Ha e neKapmeHH cpeAcTea H ~ C remo xnnepTepMMR cnepa npe~o3npa~e~o Ha Acetysal, aHTMXOnMHePMqM, P - ~ P ~ H ~ P 06~MTe M ~ MaHeCTeTMqM, , IWTWLI, LSD, M A O - ~ H X M ~ M TXeHOTMa3MB#Te, O~MT~, T P M U M KnnrHme aHTnuenpecatiTv. npM MHTOKCMKauHR C MAO-n~m6wrop~ Moxe Ra CC? pa3Bble eKCTpeMHa XUnepn#peKCMfl H HepBHO-MyCKynHa XHlleppeaKMBHOCT,KOMTOCaXMBOTO3aCTpaWaBaqM.Heluaace ~ n $ e p e ~ q # a n ~ a ~ n acm mm a p cTaaeH peeuao6xo~n~ eo 6bp30 $ H ~ ~ K WOxnSVl H O r,qaHe 6e~30flMa3MTH3bM. nntioan npenapaTn, Aenonnpnsnpaqn npenapaw (Pancoron). Cbo6qaeace sa w3aecre~ ycnex c Dantrolen. nperp~ea~ ne TonnnHeH ynap - nperpmaHeTo e cbnpoaopeHoOT cna6oc~ M MycKynHM KpaMnn, HO TeMne TOKCH~ LUOK ~ H- lPM'4MHRBaC e OTTOKCMH Ha Staphylococcusaureus. HaA-remo e npn Metimpywpaqn xeHu, paTypaTa ~ ~ H K H O B ~eH~m O 39C. nsnonaeaqn TaMnottn. npo~nra c encoKa TeMnepaTypa, npw TonnnHeHynap w M o w m a 3a noTeHee msreRnapnR, e p m e ~ a ~ o 3 dpne, e ~ neTapmrHo cacTontine, pnaHa. Te~nepaTypa~a recTo e HW 40"C, KoxaTa e neeKoqmorn, ~ p o ~ G O q m o n eysennreHn ~n~, CTOLIHOCM Tonna n cyxa, nonemm ce ~ m m p H~noArepTaHa n ~ Ha CTOT, CrnT, a6~0pMHa KoarynorpaMa. XUnOTeH3MR. n a q ~ e l i e ~CbHaPyllJeH ~ )'MCTBeHCTaTyC. OT na60paTopH~~e Ratitin ce yuattoem xeMoKoHqempaKonopa~c~ Tpeclca a - eTuonomrecKwm areHT e ~ H M R recTo xnnepHaTpneMnR, Kawo n pa6~o~nonn3a c M ~ PHK-empyc K OT peas Ha ap60a~pycn~e. Mma cTporo noewaeatie Ha CPK n M H O ~ ~ ~ H H ~ ~ H R . onpeueneHaennueMnonomrHasoHaB nnaHuHcKaTar a m 60nec~ Ha Kawasaki (~owo-nnraeme~ mwpo~ Ha K a ~ m a n 6pn~a~c K~ oa n y ~ 6 npenaaa ~~. ce rpes cac 3acRraHe Ha ~ ~ M $ Heb3ni M .IT ) ~ - TOM e aacKynm c KonopmcmR Kbpnex, K O ~ e OpeaepeoapHa enpyca M ce 3ana30a B npoRbnxeHne Ha rpn roAnHn. 3 a 6 0 n ~ e a ~ e ~ npOnOHMpaHOTeMnepaTypHOCbcTORHMe ~ w 4 0 " Cno=, r e OT 5 DHH. K ~ ~ H H M C ~e~OTKpnW C K H KOHIOHKTHBW, 683 ce xapa~~epn3npa c TeMnepaTypa, eTpncaHe, rnaso6onne, MblaJlrMR, neTapMR, aHOpeKCMR M KOPeMHM 6017~~ eKcyAaT, 3arepeeHw 6eneqn ce y m ~ n YannHoe , e3n~ H $ a p n ~ mB ~~ . arano~ o o x ~a e n ~ ~ a~ ~ ~ ~ H ~ H ~ O T O PRAKO ~ H O ce C nomea T ~a~yno-nanynose~ o6pne. Xapamep HO e AB~@~HOTO npoTnraHe c ~eymp6a TeMnepaTypHa Ha Matime n mnanaTa. no-WHO 3 a n o r ~ ga ce 6enn KoxaTa Ha npbcTnTe. Moxe Aa ce nomn repeeHoopaHKpMW. nbpBOHa.laJIHlme CMMmOMM M3re3BaT CneR 2-3 xee ~a~yno-nanyno3e~ o6pn0, LunA~a n n ~ $ m e ~ o n a ~ n AHM, ~ na4HeHTbT C e .lyacTsa OTHOCWenHO ~ o 6 p enpe3 (no5 cm). 3acnra~e~o HacapqeToce npoReReac nepnlcaCneflBaqKTe 1-2 A H M , CneA KOeTO CclMmOMaTMKaTa Ce p ~ TpueHe, ~ o ranoneH P M ~ M H KappnoMerannR npes Bb3Bpbua. B T O ~@3a ~ T O~UKHOB~HO ~ e no-TeMa OT ocTpnR nepnoft, a npes peKoHBanecqeHTHnn- ~ (Kopotiao napaaTa M npomnxaea 2-4 Atin. BWMOX~H e M TpeTn pHa aHeBpM3Ma. fla60pa~op~0 - neBKOqMTo3a, TPOM~O$e6pnne~ nepnoA, a BmaHoeFleaHeToe aa oKono Aee UMTo3a M Y C K O P e H O CYE. CeAMMqM. Ht30nna3~~ - MHOrO OT TRX, KaTO neBWMHR, ~ H M @ C p e ~ n a e a ~ o a o p crpeclca, ~a ceeep~o-a3ua~c~ Ma, ~eepo6nac~o~a, remo H M ~ npommwenHa T TewneKbpneXOBTM$ M K Y - T ~ ~ -c IlPM' KiM ~HRBaT C e OT PklKeqMU. paTypa, oTnmHanocT, aryfja Ha Terno. npn acRraHe Ha Knn~nrecm n TpnTe 3 a 6 0 n ~ e a ~ ce nxapamep~3~pat ~ c KoCTHHR M M b K H M I aHeMnR I IT P O M ~ ~ ~ H T O ~ ~ ~ H H R . eHe3anHa smcoKa TeMneparypa, r n a h n n e , oTnaHa-

nocT H MM&rlMR. MHKY~~~woHHMFIT IlepMOp e OT 5-7 ~ H Ma , aa K y - ~ p e c ~ a ~ OT a14-39 AHM. Ha MRCTOTO HayxanaatieTO ce paaensa ManKa ~aea,nopo6~a Ha nsrapme OT qnrapa. 3a K y - ~ p e c ~ a e~ xapameptia a pecnnpaT0pHaT-a naTonomg. Pa3anwce~a~yno-nanynoae~ 06pne,o6xwq a q popw maHme Ha pbqeTe H xoAnnaTa. @e6pmn~mpeaKqmm npm KpaeonpenmeaHmR pbnxaT ce recTo Ha awnneeKoqwrHn M awn~po~60qmHM a m e n a . Tec~yeaHe~0 3a TaKnea ammena He e PFMHHO. Oe6pwn~me T~~HC$~~MO~OM'IHH peaKI$4M PRpKOnpOrpeCMpaTKbMXHnOTeH3MRHpeCnMpaTOpeH~MCTpec. n o ~ s a MM ~ anpnX ~ M O T ~ ~ H H@ ~ ~~I ~ CcnnpaHeM K~ R TO i , l% KaTO ~ HRMa pOCTaTbClH0 KIlMHM'ieCKH 6ene3n 3a pa3rpa~nqa~a~e ~ao6n~~oee~a~a$e6 peaKqnR pnn~a OT

no-cepno3~a~a 6bp3a, ompa xe~onwa. 3no~aqecme~ xnnepTepmmn a -P ~ K O ycnoxiieHue npn ~ a p ~ o a (caHalotan w pp.) n MnopenaKcamn c eKCTpeMHa XMIlepnUpeKCMR (4243C) 3a H R K O n K O clam, KOFITO B 80.100% OT cnyvame aaebpwea neTanHo OT peKoMneHcaqnR Ha ~ p b 0 0 0 6 p b q e ~ ~3 ea ~6 0o . n~ea~e~o @MW~HO (~BTO~OMHO ~~OMMH~HTHO), npbl BPOpeH eH3M~~OBW OT~ HOBOPOpeHMTe TO A0 8 CefiMWqM M3MCKBaT ueH ne$em Ha MycKynHnTe mama. npn MycKynHa 611017napemepantia~ H ~ w ~ # o TepanwR, T # v H ~BoKaTo ce HeraCMR ce ycrattomea noetiureHacepyMHa~ p e a ~ n ~ $ o @ o ~ u TMBH3MpaT KPbBHMTe IlOCRBlUl H C e OTXBbpnM CePM03HO Haaa. Hanocnem~ce npnnara npenapanr Dantrolen, HO 3 a h n ~ e a ~Tow e . e npaeuno. Onpepene~n naqnetim c BbnpeKn ~ o e a npomo3a~a e noua. Ponmenme Ha ~ e 3 n MMHWManHaHHTOKCMKaqMRM n e JlahpaTopH~ ~ ~ OTKnOHeneqa (~~EITFI n cecrpn) ~pR6ea pa 6bflaT n ~ $ o p ~ n p 3a a~n H n R MoraT pa ce neKywT n y poMa - npn ~ ~ M O X H O C3a T pncKa OT onepawma, a AeqaTa na ce TecTyaaT n pecetiWeKeamonpocneppwHenwqnanHnycnoenR. C M ~ H ~ H ~ M ~ ~ T . M~om WIMH~~IICTM C M ~ T qe , $e6pun~n~e peqa U D~$epettqnan~a pnamo3acnopep enpa HaTeMnepano-cneqnanHoTesnc toHQ 39.5OC ce ryecTwT more noTypHaTa ~ p n w n npopbnmenHma Ha TeMnepaTypapdpe, aKo TeMnepaTypaTa ce c m n c aHTnnnpeTnqn. Ta: Oqe nosere amnnnpeTnrHaTaTepannR Moxe pa no3eoI. Bnp Ha TeMnepaTypHaTa Kpnea: nn Ha neKapR pa nsebpwnMHorono-~opeme~ npernenHa 1. Febris continua ($W. 16.1) - cpeqa ce npn KopepeTeT0H pa PeWMp a l l HMaH w a 0TnyM6anHa nyHKL(nR. MeHT@, neTHMCT m$, Cpyqenoaa, BUPYCHa IlHeBMOHUR M 06are aHTnnnpeTnqme MoraT M pa KonnnpoMeTnpaT yrovHmatieToHapeqac . o ~ y n ~ ~ a 6 a m e p n eni ~ nKaToTe ~", AP2. Febris intermittens. clnrnemqaT Mtioro po6pe cnep HeR. 3. Ferbis remittens ($nr. 16.1) - caqo c ptieetin 0640 aHTnnnpeTnrHaTa TepannR ~ p ~ 6Aa ea e dK O ~ ~ ~ ~HW H M l'C R, HO MnHnManHaTa TeMneparypa ce pa3e~a c na~@n3nonomr~a~a octioea Ha $e6pnnH0~0 RocTnra po HopManHara. C a r e ~ a ~ w e Ha ~o Tpme Tnna cacToRtine. Kora~o TeMneparypaTa ce m n x n Ha npoMeTeMnepaTypa xapamepnsnpa cemnrHara TeMnepaTypa. H e H M XHnOTal'laMM'4HH $YHK~HM KaTO IIIH$BKL(HHOT Mila 4. Febris recurrens ($nr. 16.2) - cpeqa ce cnep amreti-ammmo H ~annnimeT, o n m e pa ce Hanpaen yxaneaHe OT nmx, BonnHcKa TpecKa, moeti xonaHm, .~ep~oman cf aue~a~n~o ca $ce~~ ai-ronma eepoRnnennT H pp. 3a ManapnRTaca xapamepHn TeMnepaTyp TH~CT pa ce nopo6pn m c r o ~ l ~ n e ~ o naqnema. Ha AKO HnTe Tnnoee ~ e p q n a ~ Ma KwpTatia ($nr. 16.3). TeMnepaTypaTa ce n b n m ~annc6ana~c ~ e m npopyquy 5. Febris undulans - cpeqa ce npn M. XO~KMH, ~annPaHeTO M OTpaMHeTO Ha TOnnMHa ( n p TOnnMHeH ~ )'pap), meHn ~ ~ ~ O ~ R B ~ 6pyqenom. H H R , CneWHOTO OXllmaHe e a6~0nloTH0 H~O~XO~~ H#aHT#MO 6. E p ~ o p ~ e TeMneparypa e~a c 6bp30 noKareaHe n nnpeTnqme He 6nxa nonnorHann. no-PR~KO naqnemn C cnWaHe. H H $ ~ ! ~n~ xnnepnnpeKcnq FI ( ~ ~.l "C) 4 1 n3ncma~cnew7.6n$a3~a TeMnepaTypa- cpeqa ce npn KonopmcHO c m m e Ha TeMnepaTypaTaepHoepeMeHHo c amnnnKa TpecKa, ~op6nnn c eK3ameM Ha qeTmpmR peH OT PeTMqM H TOllnOOTHeMaHe. ~ ~ u H ~ HCbC T Mamon6bra~ ~ ~ o ~ R E z ($HT. ~ H ~ 16.7), T o nonnounenm ($nr. 16.4), neB a q HC e@ ~ P W H I L I t%p'iOBe C b q O ce H m M OT CneluHo mocnnpo3n ($W. 16.5), eppa wapKa ($nr. 16.9). nereHne, KaTo ce npenopbqea aqe~annn~@e~ (15 mgkg 11. llpomnxmen~om Ha TeMnepaTypaTa: T. Ha 4 h. 1. T e ~ n e p a m a 3a 2-3 n ~n m3nc~w ~a6n~)lle~ nn e ~ ~ O ~ H M VrDMXM H W C0 ~ CbCTOFIT O C H O B H OB 6 b ~ 3 0 ~

pomnHmenHo yrorHRBaHe. 2. Te~neparypa 3a 4-7 ~ H Mn , p c m ce pecnuparopHn cnnnmonnn; c eK3ameM - M O ~ ~ (Ha H ~4-5 M peHOT HaqanoTO Ha 3 a h n ~ w ~ ($MT. e ~ 016.7); cKapnaTMtia (1-3 p e ~c) xapamepeH 06pna ($W. 16.8) n T. H.; c n n ~ $ w e ~ -m qfiepKynom, aenn~oaa,cn$nnuc, n u ~ $ o r p a ~ y n o ~ a 3a, # H $ ~ K ~ M MOHOHyKl O~H~ leO3a; C KapAblanHlr CWMmOMM; c M M ~ ~ Mn Rpp. 3. Te~neparypa ~ a 14 g ptin - M H @ ~ ~ ~ H 3O a~ hH n~ MMHHR - CaJlMOHen03a (CraCTP0-MHTeCTMHanHMCMMmOMM, CllneHOMeraJlHR, JleBKOneHMR, 683 ~ O ~ M H O $ M no~M nomenHapeaKqnHHaBnpan, xeMoKymypa(@r. 16.1O), qfiepKynom, MoHoHyKneoaa, 6pyqenom, nenTocnnp 3a, TponnrecKn 60nec~n; KonareHo3n - nynyc epWeMaTOpeC(TMll~'-IHlrl LE-KJETKH B KPbBTa M M ~ H @ ~ pecqeHTeH ~ e ~ o p c )n, ~ p p Ha o~ Libman Sacks - npomva c ewoKappnT, ~ e $ p n apTpanmn, ~, neeKonetinR, recTo c n3nue B cepo3~we K~XHHH;nepnopnrtia6onecr.

nwreTa e npefln m r ~ KnuHnrHa; o $e6pwme~ r 40.5"C 3anorBaHe H a na~o$n3~onomr~a Tepanun eeeHTyanHo cneA npeqettlca c npnsHaqu H a HenottocnMocrdnnn nypnypa e n 3 ~ n t o r ~ TenHO CIleWHO M H $ ~ K ~ M C O b C ~ T O H R H O M e ; M3OnMpaH@e6U a ~ ~ ~ 6 a ~ ~ eTepanwn. pnan~a Onpe~en~H ~a eMmoKcnKaqnma ~o ce naaapluea no pUflHTe~~p~6Bafla BonU R0 xocnwranU3aqUn A 0 10A e H OT MHoronyHKToeTorKoe MeTon. Ha 6a3a~a H a a ~ a ~ ~ e 3 a ~esonmqnma. a H a UeTeTO C e OTCbWaT OT 0-2T O q K M , KOHTO OllpeAenAT B~m~a~m flo6atrena e: naTonomn, CKPMTO 83eMaHe H a neKapcTBa. HopMa unn oTKnoHeHne B: xpaHene, noeMaHe H a TewocTU, CbH M nrpa.T a ~ ~ a 6 0 p Mome b ~ ~(a6afle 0T O r M 3a H ~ A Amar~ocm~a Ha H ~ K ~ I I O V B ~ H ~ T npomlcnpaqw O: uoM H T O K C M K M P a H M T e U 8 3a H ~ G - ~ ~ H KH T OO K C M K M P a H M T e . M B H T M :~ 0 6 IlO ~Bfl 0 MFIBaHe; HeCbOTBeTCTBHeMew)' HaJlMl l p Aeua ~ c 5 U noeereTOCIM 6 6 3 3 n o ~ a n ~ 3 n HJIOCIHUK pa~ waTacuMmoMaTnKa M KnuHuvtimeuscne~ea~n~~; ncuxuH a M H $ ~ KU ~683 HR TOKCW~HM ~~ORB flpM M UaTenHOHXne rH# O T W I O H e H M F I . Aaatie HnMa cnyran H a ycratioeetta ~ ~ K T ~ ~ M ~ M U F I . V~~RCHRB~H~T nOn e r e ~ ~ ~a e ~$o e6p~n~o ~ ~e o B~ e Bwm~awme: peane~ $e6pnne~ e n n ~ oMa~epea~e ~. cnew~a~ Ka ~ M H U ~e K ~e n o c ~ n a c~ .qee~nnpae m". TO ~a ~ e ~ n e p a ~ y p Ba ~~ Pa MC~CTB ~a H ne~ap ~ no~asaa npaemna: unamomKaTa H a npnrwHaTa 3a 4e6pnanwpelccnn.
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M O H Wv ~MP~H~: EKT, cbppevwa vecroTa, p m ~ , nyncoe OKCMMeTbP, AH

na6opa~op~~: peKc~pocmK, KAC, enelcrponwu, BUN U pp.

c~bn6 ce ma6nnn3~pa~ npn ocnrypReaHe Ha 3a TOM eH~O~XOAM BTOPH M yvacTHnK, K O ~ T O Aa npnmpxa rnaeaB a H M R Bb3AYX KaTO C e ~o6nnmn 6y3a A0 H O C aM n M yCTaTa TaBCpeAHOnOnOXeHMeMAaU3BbplUBaneKaTpaKuMR B Ha AeTeTo; nOHMTynMHCUIHa nOCOKa #nu fla C e nOCTaBM LIlUhHa RKa. - ayclcyrrrnpa ce r p a ~ ~ n KOW m nnn Tpaxema. O C B O ~ O X ~ BHa ~ Afl H ~MOXe T O ga 6aje M3BbpWeHO IlOeflllrHOTCne~HMTe HaVMHM: Cneqmgns~nnneTopHm H npoqepypn 1. A o p x ~ ~ @~ na e ~ cHa n ~rnaeaTa M ~ K C T ~ H ~Ha MR spaTa (+MT.17.1). f l p Aeua ~ 1 0 3 rol. Aa He ce xmepelcc ~ e ~ ~3atqo~o p a , TRxHaTa TpaxeR He npwrexaea c m 6wn~a xpyqRnHa noAqpbxKa(@Mr. 17.2). flpn KapMaveTa xenaHoTo nonometine Ha rnaeaTa Moxe ua ce nomnme M vpe3 n o c r a e ~ ~ Ha e~ cmHaTa o Kapna nop oKqnnmanHaTa KOCT. npeMMHaeaHe Ha raaoeenpea roneMuTeAnxaTenHn nbTn2. EKCT~H~HR Ha BpaTa U noenuraHe Ha 6 p r ~ u w a ~ a u(a ce npnehna, ve e HanMqe 06CTpy~un~. BTO~M cnyvaii 3. OrcTpa~Rea~e Ha TR~o.ToB~ e oco6en cnyAeTeTo ce nocTaen B nonomeme, B KoeTo MoraT Aa ce vaA Ha Ba3CTaHOBRBaHe Ha npOXO~MMOCTla Ha 41. AKO oceo60&n A l l M Aa ce eeHTMnMpa. AKOC e noflosnpa TDaBMa - rnaBaTa M WU~HHFIT WaCTbK Ha I D ~ ~ H ~ ~ TRXHOTO H w ROTBaDRHe He CTMMVJl MDa nDORBa Ha CnOHTaHHO
TRX,

- npaecl ce onm Ra ce novyemea cTpyma Ha MBPMW-

Toea Moxe Aa ce npam n cac meTocKon;

all.

464 m Oco6enocmu Ha cneurnume cbcmonnun B gemcka Bb3paCm

h r . 17.1. jlopmnm 9nrrrm na m a nIe m m na muta

HaMnpaHa aeMma, nnn e npae npn KpaKaTa MY, aKo n e m AnluaHe ;rp~6ea na ce nposep gann AnxaTenHme m ~ n Ha HRKaKBannocKocr. JleKapm nocTaeR mama CM ebpxy u(a C a C ~ O ~ O ~ ~ OnMT H H . 3a OTCTpaHRBaHe Ha YT Ce H3BbPwea caMo aKo AeTeTo e B 6exb3HaHne nnw e B cba~a~ne, Kopeua Ha neTeTo, no cpenHaTa nnHnR H ~ A nbna, nop AOIIHMR pb6 Ha pe6pa~a, a UpyraTa My PbKa e Bbpv HO He Moxe Aa ro oTcrpaHn C ~ $ ~ K T H Katunuqa. BH~ n p KbPMaVeTa ~ BOneU@Ta. K O P ~ MC ~ C ! TIlPMTHCKa C 6bp3~ AB#)KeHMR HaebTpe n Harope. Cepnma npoflbnxaaa ~o 6-10 AeuxeAe~e~ ceonocraw Aa R ~ A M pbKaTa Ha neKapR, KaTo rnaeaTaMY e no-HMCKO OTTopaKca.A o n ~ a pbKa ~ a qpaso HMR, BCRKO eAHO OTflenHO M 3aBbpWeHO. Acnnpnpa~n ~ a ~ e p n ao nn ~~pn~m ce eOTcrpaHR~lapm rnaeara Ha KbpMarero, $n~cnpaAta AonHaTa renocr. Jle~apm nsnonaea 3a BonanHnTenHa onopa Ha B ~ rpea T acnnpaqng c KaTenp, BbeeneH pnpemo, npea MT nnn c noMoqTa Ha 6po~xoc~on. paKaTa - 6enpo~o CM. no np6a tia KbpMareTo, Mewy nonaTtarre, ce HaHacm4 nocnefloeaTenHn cnnttn ynapa c E ! B 60nH~'i~a O~CT~HOB npoX0AMMOCTTa K~ Ha MaHTaHaApyraTa palca. CneA Toea KbpMareToce 3wp npeoqeHRBa. npn nnamomqnpatie Ha naTonom, cebpx a KaTo caHflenr Mewy AeeTe paqe, o6pbqa ce no rpa6 aatia c npomnmTenHa H ~ B ~ ~ M O X H O C OT T cTpaHa Ha H AoKaTo paKaTa, KORTO npenn ~ o e a e 6nna oTrope, ro UeTeTo Ra m nowbpxa C B ~ ~ O ~ H TO: M, npnabpxa, c ApyraTa ce HaHacm 4 ynapa no r p b f l ~ ~ ~ - aKo ~o MoMetiTa npoxonnMma e nompxaHa KOW. rnaea~a nponbnxaeaaa 6bne no-HMCKO OT TRnoTo. MaHyanHO #n# C Bb3&%OBOA C e npeMclHaW KbM MHTYG~AKOKbpMareTo e eflpo nnn neKapm e ~ p e 6 e3a ~ ,onopa UnR; Moxe Aa ce n3non3~a n CWT. -aKo e wnyfinpa~o ce cnenu 3a MecrononoxermeTo npm no-rone~m Rqa U npoxoAnMoma Ha nHTy6aqno~~a~a Tpb6a. 1. PM neTe B c b 3 ~ a ~ u (cen~ano e nnu npaso) rpea II. M a ~ y c m e ~ BeHrmnaqmfi a MaHboeapa Ha Heimmlich - cepna; c$i~wa$paman~n, PM HWiM'iMe HaIlPOXOflHMHA n HCllOHTaHHOflnWaHe KOPeMHMnPHWCKaHlrlR,KOmO~pe3flOKacleaHeHaMmpace nonaaa 0 , . Toea ce naebpwea no ennH OT cnenHnTe TopaKanHoTo HanRraHe W a e a T na~ycree~a Kawnnqa, H a C I M H M : U3TllaCKMuaBb3pyx M rlecT0 C a M O T O YT HaBbH. n e ~ a p f l ~ 1. Clpe3 WcnoponHa MacKa - o6nwoee~a. Toea e e3 m UeTeTo, O ~ X B ~ H ~Kpma JI MY C pbqe. OMPWT Ha ~airec-ro ~anonaea~o~o cpeRcrso 3a no4aeaHe Ha 0 , BoUeqaTapbKacepasnonaranocpeAaTaHaKopeMaHa npw c n o m ~ nnwaHe, ~o m, ocnryp~ea ~enpenc~a3ye~ peTeTo, ~ a n HU ~ onana M AocTanrtio no-nony OT MewM HenOCTORHHa KOHqeHTpaYWR Ha nOAaMlHMR 0 , . BilAHMR Ibl3PaCTbK. O M P ~C K e 06xeaqa ~T C PPYraTa PbKa 2. Ype3 KUCnOpOAHaMaCKa C claCTll'iH0 O ~ ~ ~ BAMT H O l4 C e np#THCKa B KOpeMa C 6bp3n HaCOrleHM HaBbTpe WBaHe. TOM e K O M ~ # H ~ ~OT ( ~MaCKa R M ~ W ~ OKORTO H, ABMXeHMR. M~CIOBHC(HHFIT bI3paCTbK HIlM AOnHHRT pb6 Ha no3eon~ea noAaeaHeTo Ha no-enco~n KoHUeHTpaqun 0 , pe6pa~a He 6naa Aa ce AOKOCB~T,nopmn pncK OT 4 p a ~ OT 3060%. Typa nnn yapeAa Ha BbTpeweH oprati. Bceta TnacbK 3. Ype3 KncnoponHa Mama 6e3 &panto nnwatie. ~ p ~ 6 pa e ae oTpenHo n 3aebpure~o lenxetine. Cepnma TOM e C ~ % T ~ H U ~ ~ a cC w 6 m 0M ~Knana, 6e306pant0 npoflbnxaea ~o n3xebpn~~e Ha YT nnn no 10 onma. ennueaHe. Mora~ ua ce noAaeaT no 100% 0 , . 2. nplil AeTe B 6e3~b3HaH#e (nexaqo). Jle~apm ro 4. Ype3 Ha3anH~ K ~ H ~nM b l.a ~ e ~ b MM p bCB ~ cbo6pao6pbqa no rpb6. ToA e KneKHan npn KpaKaTa MY, aKo ce 3 ~ C ebapama ~ a Ha AeTeTo. P a a p e w a ~ e ~ Ha o nonaaa-

Oco6enocmu na cnewnume cacmonnun B gemcka Barpacm

HMR

465

cbo6pa3e~c ebapacrra ,3apa He npMrHHM npBeHe OT o2 B ~a3O@p#~rca HaMallRBaKOHueHTpaqMRTaM ) ' OT nnraeclqaTa Ha HOM, KORTO npM peqaTa e MHoro necHo 100% Ha 3040%. I ~ o H ce ~ no-po6pe c ~ OT no-ronennn pawhna. Moxe pa pa3~bca M QeHoMpHa TbKaH, KORTO ReW. caqo ce cpeqa recro B ~ a ~ 3 b~ ~p ancp~ o .~ ~ m n o ~ a 3 5. Clpe3 w c n o p o Kacm. ~ ~ ~ Te c a air-nopxomq~ 3a e yno~pe6a npw WeHonpHw BereTaqnMM KbpeeHeOT Hoca. HoeopopeHH n KbpMareTa. Mora~ Ra o~urypm 80-90% H~O~XO~JMMMRT pawep ce onpepem rpes ~ s v e p e a ~ Ha e caMo aKo noToKbT 0 , e c#neH. pa3CTORHMeTOOTHO3~PMT~~OTpa~MHa)'XOTO. 6. qpe3 KMCnOPO~HM nallaTKU. Te OCMrypflMT OT 2 1AKO Bb3pyXOBOpMTeM npeKaJIeH0 IbnM M A O K O C B a T 50% 0 , . napuHrca, uoraT pa n p e p ~ 3 noopbqaHe. ~~~a~ I l o c r a e ~Ha ~e opo#ap~~rean sbsflyxoeofl. e~ MsBMBKaTa M y ~ p ~ 6 pa B aC e cbo6pa3~sa CKOH$HT~~~~MRT~ M H T Y ~ ~ Pa3MepbT ~ Y I R . Ha H H ~ $ ~ L ( M O H H ~~pb6a T~ ce M OTrOBapR Ha CbOTBeTHaTa Bb3paCT. H ~ O ~ X O ~ M pasMMRT onpepenn no Wpnnyna~a(16 + sbspacr B rop.) 14 = MepceonpeflenRKaTocenocTaeMoTmpaH#HanMqeTo, BaTpeweH puannenp (mm), (~a6n.17.3). ~~PMH~OCKO~M TaKa r e 4ma~t-b~ MY pa e Ha HMBOTO Ha 3 b 6 ~ (pesu~~e), ~e Ta ce ~sebpur~a c naxuqm, oTroeapRqM Ha ~aapacna: aB~PX~T Ha bmna Ha ponHaTa renrocT. HoeopopeHH c TenecHo Terno ~o 1 kg - N o 0; OT Hoeopollocras~~ Ha e ~aao4ap~~rea sb3flyxoeofl. ne~ ~ e po ~ 3 rop. o N n 1 ; OT 4 po 8 r o ~. N o 2 . m B~HLUHMRT MY pnaMenp He ~ p ~ 6 fla e a6bpe no-ron~u, a

P;bnxu~a (cm) Bb3pa~~ HeaOHOCeHU H.P. ,4OHOCeHM 1-6~ e c . 6 ~ e c -. l roa. 1-3roa. 3-6r o ~ . 6-1 0 roa. Terno ( ~ g ) n 0 2.5 ~ 2.5-3.5 3.5-6.0 6.0-12.0 12.0-1 5.0 15.0-20.0 20.0-35.0 B b ~ pBMaM . opan~u ~ a 3 a n ~ ~

2.0-2.5 3.0-3.5 3.5-4.0 4.0-4.5 4.0-5.0 5.0-6.0 6.0-6.5

9-1 0 10-11 10-11 11-12 12-13 13-14 14-15

12 13 14 15 15 16 17

nonqa B TMT, p a w ro M Moxe pa poeeRe po peryprmaq M R M aCllMpqUR. TOM ce IlpepOTBpaTRBa C MaHbOBbpa Ha 3a6enem~a:B b ~ p e u r ~RMaMenp ~m Ha ~ a 3 a n ~ a ~ a Selik, HO cepbxnpmucKaHeTo nnoxe ga RoeeRe npu KbpMa~tiqfjauno~ @a ~ a e c 0.5mm n c - M ~ OT K opanHMR reTaTa 40 BropMrHa&TPY~(~MR Ha rAn. puaMenp. H a 2rop. eaTpewHwmpMaMenpHa ntiqfjaq~B 6 o n ~ ~O r~ ~Ca T ~ H O B npoxopmocrra K~ Ha An ce oHHaTa ~paGa ce ~ 3 v ~ c n no ~e Wpuyna~a: a 4.5 + ( B M ~ ~ C T npeoqeHRBa- aycKynaTopHo, petrrreHonomrHoM C uxneB ro~J4), a PnxuHaTaHa utiqfjauclo~~a~a ~@a ce MWM4BaHe H a KPbBHMTera30Be. f l o ~ b p X a ~ e T Ha 0/JMWaHeTO C cnfiaa no W p ~ y n a ~ 1 a0 : + ( B M ~ ~B CropR). T nOflaWHe Ha 0 , no e A M H OT Bb3MOXHUTe H a M i' H M eB n p peTe ~ c mnca Ha pwaHe MoraT Ra ce u3non3~a~ 3ae~cunnoc~ OT napamHHMvHMTe noKa3aTenM M BaeqaTa MaCKUTeC M 6e3 O ~ ~ ~ T H OM ~ e X M a H M W C H lM ~BeHTWl H ~ , aTOp HOKCa. M p(?CnMpaTOpM C HC?O~XOF(MMUT~ M 3 M C K B a H M R 3a AeTCKa Hapyure~un Ha CbpAeqHO-CbAOBaTa @YHK~HR mpacT. AKOH e ce pa3nonara c TexHurecta c p e p m , ce npepnplrelrnao6p~urea~e c M ~ M W He a w : Cnep ocurypRBaHeHa npoxopMMocrraHa pll M ~ b 3 c ~ a - n p KbpuareTa M Hoca M ycraTa MoraT pa 6bpa~ HoeRwie ~ar a 3 0 ~ a ~ a o 6 ce u~ npeqe~~ea ~a e@ma~cmo 6 m a ~ OT u ycTaTa Ha neKapR; Ta Ha ~pbB006pbqe~MeT0. -npM n o - r o n e ~ pew ~ H ~ HaReTeTo T ce cmcKa C p m npwra, a ycma Ha neKapR o 6 x w a nmTHo ycTaTa Ha ReTeTO. B e m a q ~ f r r a ~ p F 1 6 ~ q aOrpNMreHa 6b~e & I KonHreCTBOTO ra3, K O e T On O B a @ rl rPbRHMR KOUl M VeCTOTa - 3a 3a noCToRHHo cnepeHe Ha AH. KbpMareTa 20-24Bp~wJmin, 3a no-rone~n Reqa 16-20 AeTe C IlenenMBU B R THa KOXaTa M 4 M a H O T M C I H M nMTaBMBAMLUJmin. Kora~o p e ~ 6e3 e cnoHTaHHoAuwaHe ce o 6 p ~ u 4~ ~ai-sepomo ce Hyqqae OT nopnoMaraHe Ha quptcynaBa C MqMUlaH Bb3m, MaCKa M n M AM6Y, ram OT mpyxa UMRTa. T ~ H KrpbRHa ~ T ~c T H ! a B AeTCKaTa Bb3pXT RaBa

466

Oco6enocmu na cneurnurne caemonnun B gemtcka Baspacm

m e n a c e mnenm OT TRnoTo M ce w a r n cTepHymTnace Baptie B ~ o p ~ a nonoxewe. n~o P ~ M Ha ~npmcKwe T T P ~ M na e MHOrO MaBeH, 6e3 p3KM flBHXeHMFI. nwc no~a3ea, qe ynaptiMm 0 6 e ~ e WeKaaTeH. PM YCTaHOBeHO OTCbCTBMe Ha nepM$epeH nynC Ce l l p Aeqa ~ HaA 1 roAlvlHa C noMoqraHa mopn M ~ T n p M m Ha pbKaTa ,HauMpaaanorsa HenocpencTaeHa KnP. q a ce K ~ M KpaKaTaHaneTeTo, neltapm onpepenflAonHaTa ClleqM@H4~~ M ~ f l M I RM I llpOqewpH rpaHuqaHa pe6pe~a~a mra. Pb6b~ ce npocnewea c npwT no MRCTOTO Ha npecMraHeTo MY cbc c ~ e p ~ p a . C p e I. C a p ~ e r l ~ npmcKaHe o n p m ce nocTaeR Ha ~ a npecertia 3 ~ Tows. n o Hero ce ~~HAMK~~M ACMCTO~MR M. - YCTaHOBeHa C nMnCaTa Ha nep~$epe~ nync Ha ronmaTa apTepm, ~enep@ys~paq nonem noKameqaT. m a m a Ha cbqaTa pbKa ce nocTaeR TO~HO HWnpenMulHoTo pa3nonoxe~~e Ha pmTa npma, PMTbM- BeHTpMKYllaPHaTaXMKapflMR, BeHTpMKynapHM$16K~TO mnraTa A oc e ycnopentia Ha cTeptiya. n p m c ~ ce a ~ ~ ~ ~ M M - K ~ M T O O ~ H K H O~a B ~~ HO P ~ P CnMnCaTa ~ W M Ha c ewa p m Ha pn60qM~a 2.5-3.8 cm c recToTa 60-100. nync. min.', B ~ ~ B H ~ M M C OT C BNpac-rTa T M CmoweHMe ~PMTMCTeXHuKa Ha ~ 3 m n ~ e ~ 3a we o. m ~ a n ~ ~3wpwaao~o ~ ~ e l ~ ( 5:l. ~ w np am~ ~e c x a ~~pn6ea e ~ o fla e nnaaHo, a He He peTeTo ~ p h na w n e w no rpb6, Ha m b p MOCKOCT, ~ ~ BC ~ l e BbpHe B M3XOflHO nOn0npM KbpMareroce ~ 3 n o n s e a p b ~ a ~ a ~ a n e ~ a p ~ , ~ o mPR3KO. o n a rpbdHMmKOLU T P F ~ # xeHne cnen BCHKO npmcKwe, HO pbKaTa He T P R ~ B na ~ ce nopnMpa np6a. OTRelM OT rPb4HMR KOLLI. B ~ ~ M3a ~npMTMCKaHe To M OTVCnplvl KbpMareTa KaHe e epHatmo. AKOpeTeTo e eqpo wnv e HW 8 rod. ce Vep~ae MMcneHa ~ nMtiHR, cmp3eaw neeTe MaMunu. npMnal3 KnP, KaKTO npbl Bb3paCTHM. IloKameqa~ Ha BopeqaTa pbKa ce nocTaeR TorHo non II. Ocwrypnsa~e Ha e e ~ o 3 e naT ~ Ta3M JlMHMR, Ha MRCTOTO, KbneTO TR C e IliECM'ia CbC CTepHyTOM e Hafi-~pyflHaTa M 6aa~a WCT OT KnP B AeTCKa Ma. 3 o ~ a ~ Ha aKoMnpecMR e Ha 1 npba ~ ~ ~ C T O Rnop HM~ BwpacT. flpennorma~ ce qewrpanHM BeHu - B. WrynapMC Ta3M npeCeclHa TOVKa, TaM, KbfleTO C e HaMMpaT TpeM M uwreptia, B. torynapuc eKcTepHa, B. cfl~naan~, B. $e~opaYeTBbPTM nPbCT. 03 BHMMaM3a IlpWTHCKaHeHa MeqOBW nMc. nepu$ep~me sew, MaKapM n o - n e c ~ o f l o m nHece ~~, P H M R M ~ P ~ c T ~C K !~ P ~ ~ C I npHTMCKWe HOTO C e H3BbpWBa C 2 npednorwraT, nopqM ~ O - ~ ~ B H Onomneatie TO Ha MennKaM~M 3 npbcTa. Abfl60.1MHa~a MY e 1.5-2.5 cm, npM qecroTa MeHlMTe B ~eHTpaIlHOT0 KpbdpblqeHMe. kl3non3BZlT C e 100.min-l n cbomoueHMe n p m w c ~ a ~ e l ~ 4:l. ~~u B apm ~e Ha BCFIKO npmcKaHe HanRraHeToce npeKpaTm, 6e3 n p ~b3~0moc~ cbpperHaTa peh~ocr ga 6bpe nannMpaHaneCHO. Ao6bp n e p ~ @ p e nync ~ Ha a. 6pax~anuc n a. @~opa-

$HI.

17.3. THIN sa nylmmpaue na qenpannw sea. (1. Tosra Ha Jemigan sa 8. mronapnc mmpna. 2. T o w na Aubaniir 3a a. cy6ruaaa)

O r . 17.4. Tonor sa nynnpaue na nepu4epnn senn

Oco6enocmu na cneurnume cacmonnun B gemcka Batpaem

467

Kucnopop Adrenalin Natriurn bicarbonat Atropini sulfas Glucosa

100% 10 pglkglrnin 1-2 rnEqvkg 0.02 rngkg 0.5 - 1.O gkg

i.v. i.v. i.v. u n ~paxean~o ~ i.v.

HaTaM MMoKappHaTaxunoKcMR,npeAMpacaHacnnMnM H ~ O ~ ~ ~ TM3MeHeHMR. M M M Textiu~a Ha u s m n ~ e ~Haqan~a~a ~e. poaa e Bwam 100%, aaqoTo npefl pucKa OT neTaneH usxop ~ O T ~ H ~ M MHHTe OTpM~aTenHMCTpaHM'iHM e$eKTu Ha B M C O K M T e T ~ ~ H C ~ C T O R H U F ~ ~ ~ ~ ~ ~ T M R B ~ ~ H M ~ . KOHqeHTpa4MM Ha o2C e npetie6pen3a~. Adrenalin Natrium bicarbonat tie ce npunara MmpaTpaxeanHo, aaqo~o ApasHn pn, paspyuraaa c b @ a m a ~ ~ Ma Moxe pa 1. ilo~aaa~ufl. npu acwcTonwfl, e n e m p o - M ~ X ~ H M ~ H ~ flMCOuMauMR. npep~seu~a~acae~aa~ene~~a3a. Atropini sulfas T~XHM Ha K ~~ a n a n ~ e ~H na er . a n ~ a po3a ~ a e 10 pgkg i.v. B C R K cnepeaqa ~ po3a ce onpepenfl B saewcummcT OT t l o ~ a s m nL ~ .p q ~ ~ a p npnflpyxeHa ~~fl, OT xwnoTooTroBopa - BTopaTa poaa e 20 pgikg i.v., npw nmca Ha HMR, eKmpacHcTonM M n Hc#MrrroMamKaHa HeRocTanrHa oTroeop - TpeTa flea 40 pgkg i.v. n p nunca ~ Ha cbppeM03b'iHa M MMOKapAHa nefiy3Mfl. WO-cbfloao aa60nfiaa~eT O ~ Mnomofl e 6esonace~M TexHbIKa Ha u a n b n ~ e ~ u e H .aran~a~ ~ao a a e e$emclae~. 0.02 mgkg i.v. un# MwpaTpaxeantio. Moxe fla ce nova2. noKa3aHMfl. npM TeXKa XMnOTOHMfl, npOMRHa Ha PR Ha BceKM 5-10 min no MaKcmantia poaa 2 mg. MHHMnpaeunHuTe $u6punaq~~ B rpy6~, KOMTO no-nec~o ce MmHaTa pO3a e 0.1 mg. nopAaeaT Ha pe$u6punau~~. l l p o ~ ~ e o n o ~ aPUCK s a ~OT ~~ napqoKcantia . 6pq~T e x ~ u Ha ~ a~ a n b n ~ eH ~a~r a en . ~ a 40x1 ~ a ( n p CKO~ KaPaMfl, IlpeACbpflHaM BeHTpllrKynapHaTaXMapUTMHfl,MMp m1 rnlkgh e 1 yg/kg/rnin i.v. MH$~~MFI - 6 p g B 100 m1 OKapAHa MCXeMMfl. Ser. Glucosae 5% = 60 pg/ml. Glucosa [PM OTCbCTBMeHa BeH03eH~3~0'iti~~Adrenalifl MOXe T~XHM Ha K~ ~anbn~e~u He a.r a n ~ a ~ posa a e Aa ce annwqMpa n MHTpaTpaxeanHo B cbqaTa po3a M Un o - ~ o ~ q e ~ ~ p 0.5-1 gkg i.v. Moxe na ce ~anonaea~ KOHueHTpa4Mfl. HH pa3TBOPM. ~~OTMBOI~OK~~~ PM H MAeTeTO R. MHOrO nO-pqK0 C e ~ ~ O T M B O ~ O K ~ ~M ~H aw Mr Rt.~ r e ~ e~ npH e HompopecTlnra 1 0 ucxewR Ha MnoKapAa, HO ce Ha6ntOpaBaT cynHOTO, KbfleTO KOHl@HTPa4HRTaHe 6 ~ pa ~ HmBMlllaea a pa-M BeHTPMKYnaPHaTaXHKapflMfl,eKcTpaCMCTOnWMKa10%. MePHM $u6p~naq~w. 2. M~AHK~M~HTU OT B T O p M pep Adrenalin He ce cMeceac Natrium bicarbonat, saqoTo Lidocain C e MH~KTMBMP~! n o ~ a s aK ~a~ ~~ e. p $n6p~naqu~, ~n K O ~ He O ca recNatrium bicarbonat TM npn neqa, HO aKo ca Hannqe e cpeRmo Ha ~ 3 6 0 ~ . Textiu~a Ha Manantietiue.H a r a n ~ a posa ~ a 1mEqvkg T~XHU Ha K mamn~e~ue. ~ H a r a n ~ a poaa ~ a e 1mgkg i.v. l l p Aeqa ~ HW6 Meceqa ce npMnara ~epaapepe~, npM i.v. Moxe pa ce noeTopu qo 3 nbTM npes 5 min. Cnepea Aeqa nop 6 ueceqace paspexqa~o0.5 rnEqvIml, sapace MH$y3ufl B ~ o 3 a 20-50 pgkglmin. Moxe Ra ce npunara HauanM ocMoTMrHoTo HaToeapeaHe. nocnepeaqa~a poMHTpaTpaXeanHO. aa ce onpeAenfl ~ah-po6pe rpea KAC no $op~yna~a: Dopamin noKa3atiMfl. XM~OTOHMR M Hea@KMTHa 6b6per~a mEqv Natriurn biirbonat = (BE X Terno a kg X 0.4) 12, nefiyan~.

KbpeTo 0.4 e npocTpaHcTBoToHa npepasnpe~ene~ue Ha Natrium bicarbonat (40%) OT o 6 q o ~ o Tenectio Terno. npunara ce nonoaMHaTaOT nsvncne~o~o Konwremo, 3a AaHecenonyclnx~nepKopeKqn~uanmoaa. ~ ~ o T M B O ~ O K ~ ~P ~H HC UR K .O T X H ~ ~ ~ H ~ T mKaPU~ nosa, xunepocMonapmeT, BCF~KO epHo OT ~ e s C~CTORHMR u Moxe pa a a ~ a n npexmfleuocrra. ~ AKOBemMnaqnflTa He e WeKsaTtia, npMnaraHeTo Ha Natrium bicarbonat q e noeMwM P R ~ K O CO,, KO~ITO n p e ~ u ~ a6bp30 s a npes wrenwaTa ~ e d p a M ~sac~nea a BbTpewrenrHaTaa q n ~ o x ~ ~OTMCK~~ MUOKapfl KM HaTa$~HKL(MR. ~ P no-ManKM H fleqa

u e d n a ewllall a trvlhelwhabadew~ralenrb-owhaUdw ndu anwaUaaoU

'LIW9Edl MU)I(allO EJtrXE

ehnugel

suA& seol3~dssensel !~'~~KIOUOIEU E H ~ -aUds~ etnebkoxttaduEEeheHEO WM OlaUhMWH M elehaU ndu w u ~ H~WHOJE d l??atluek?13Uadu onUtrd OJOHW M M ~ -au~dgn$ alMHdi3~??)( ~#~hewdo$uew ~HhaUd93 n~aUode
a3 onUtrd-ou E H IIXU~U a3 130HhUE130~aH EHhakfd93 ElEHBM13aJHOW y , 0 6 e 1 3 ~ d w e.UOJ 1 oU ' d u 'nuwad-ou ~ ~ 1 2 3 un~amAd -??H ~~0~93-0Hhatfd93 alblHh~~d 13t?dq8 9~ E~3la9 u 'UMJOUOEOH eletnaUoe o~sedgos3 mwcuqUodu olawahau 'olalaU EH olan~t1013s~ EH aH -ednemung~13 M ~ ~ r n aw u~ dA wnna ~ trnHmau3 1 0 MH -aUaeodu 'eltrnmnduodaw mdeleou a3 tnnhn~/($ moUw -0HhaUdq3 e ~ a m h d e ndu ~ eneolrengo ~ H ~ H H U gO ~

'A

'1 6flw L unuosaqlatusxaa

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UOSEqn :a =OH B I E H W ~ E H 'aMHaHU9UBH EHEYHHXal .nom Hahnlua3 'no10 Hahssow 'oel3al3a o~wnUddeuedl3na 10 no10 HagodUouag 'trMHBEI?UOU '1?~0U ou M Ens1'HMHEEEWOU O U OflEy ' ~ ~ ~ h k ? l ~ h 3 A 3 a(anHax 3ad -OUM~U OIOHX~(~EE 1930d~98 ~adou3 am0 a3e

uWuodal~onnldo)l
fi~u 10.0 8 E O ~ E ~ ? ? H U E 'aMHaHUqUM ~??H ??H BYMHXal

oedsg M aa$a sdsg 3 a ~ w d s u a d 'U ~'! nun 'A '! 6y

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lunp!Jolq3
MUM

a3 ~ U E ~ ~ ~ E E O ~ M W ehaU ~WH nU dB w ~w Ha x , ' ~ H E E u ~ ~ ~ EEesuouEn M

trnwauoeouux n nnheledWnxaUn

d 'oenwauUadu ~ OJOHW

-3M EH!~~EYOMW M tr~W.lMd??~Xe~ '~~MHEEE)~ou~~M~

wonlfelaw '~n@lowod ' H M $ ~ O W ' H M ~ 'HM~UOY ~~X - nhnlonda~ HHhMlalHM3

pt-1 1m o we n u c A $ ~ ' 6~y w 1= y,~ a m 3 n l 9 'JaS lur 00 L

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~trnUd??nnUedg ??HWUOH nun m m A ~ n 3 'aeonoug 'nnwmd -~Mtfedg SEJnS ! U ! ~ O J ~E V H HHlHal3MEad 'BUHEEdeuOU u!leua~dosl .ua$a nnmuax eH a w J u l m u oU u!@y p T i S 1-Ea t ? ~ ~ l ? l E ~ l l 'a E MH8HUqUCn hE~ E HElblHXal

Oco6enocmu Ha cneuruume cacmonrrun B gemcka Barpacm

469

1 .O C B O ~ O W ~ Ha BAn. ~H~ 2. B e t r r ~ n a q cbc ~~ 100% 0 , .

3. B~HWHO cbppewo npMmcKaHe. 4. O c ~ r y p ~ e Ha a ~BeHo3eH e n b ~a , npM H ~ B ~ ~ M O X H O C ce T nonssa MHTpaTpaxeaneH. 5. Adrenalin B pwa 10 pgkg (1:10000)
6. Capuecle~ o'rroeop no 2-3 min:

Acuc~onu~

fl
ACHCTO~HR
1 .Adrenalin 20 pgkg ( 1:l0000) 2. Natrium bicarbonat 1 mEqvkg
1. Atropin 0.02mgkglmin 2.R o x i ~ a ce noeTapR Ha ece~rr 2 min 1. Adrenalin 40 pgkg (1:IO000)

470

OcoCenocmu na cneurnume crcmonnun B gemcka Barpacm

SPMMKAPjJMR 1. npeqema Ha cbpfler~o-cb~owre cuMmouu: cb3~a~ue, XunoroHufl, nepuQep~a nepQy3u~, eKcrpacucTonu, rpbuHa 6on~a. 2.Oceo60~aea~e Ha An. 3. Beti~unaqu~1 cbc 100% 0 , . 4. Cwflasa~e Ha setio3eH rmr, a npu HemMoxHocTce nonsea UwrparpaxeaneH. 5. Atropin 0.02 mglkglmin.

6. C b p ~ e r e orroeop: ~

6pa~1~~apfl~fl 1. Atropin 0.02 m@g/rnin 2. Aosara ce nowapfl Ha ece~u 5 min.

Hop~anaHa CV 1. n p e q e ~ ~ ~a aX ~ M O R M H ~ M U K ~ T ~ .

jJEQ)M6PMJlAuMR

. )

Acuc~onufl ~ n p o q e ~ a ~ a p e ~ ~ ~ ~ ~ ~ a ~ ~ f l U npu tianure~ fleQu6punarop I. fle@6punaqufl 2Wlseclkg 2. Jlunca ~a orromp 3. pe$m6punaqm 4WIsecikg 4. flunca ~a o~rosop:

ACUCTO~UR CHeU3BeCTHaflaBHOCT U 6e3 ~ a n u r fl+n6puna~op e~ l.Oceo60yqasa~ ce An 2. Be~~unaqufl CM: 100% 0 , 3. B~HLLK~O CbppeqHo npurucKaHe 4. Ocuryp~ea~e Ha B ~ H O nbr, ~ ~ H a npu H~~MOXHOC ce T nonsea uwrparpaxeane~ 5. Adrenalin nosa 10 pgkg (1:10000)

npoqe~upa ce, K~K-TOnpu acucTonuR

Oco6enocmu H a cneunume cbcmonnun B gemcka Bbnpacm

471

EflEKTPOMEXAHMCIHAflMCO~klAL(klFI 1. f l p e q e ~ ~ Ha a CbcTouHueTo: Hanuyeti, Kammo U fla e cbppereH pun^, OTcbmBaqa ocesaerda e @ m u ~ ~ qupKynaquu. a 2.Oceo60~a~a Ha ~e All. 3. BeHTunaqufl CbC 100% oz. 4. O C U ~ ~ ~ Ha RBeHO3eH B ~ H nbT. ~ 5. Adrenalin B ao3a 10 pg/kg (1:10000). 6. VI~TyGaquu C npeqewa Ha BeHwnaquuTa. 7. Natrium bicarbonat 1 mEqkg 8. Natrium chloratum 0.9% 10-20 mllkg

9.f l ~ f l c a Ha OTrOBOp:

v
~ P U

PM
Aqu~osa

XUK~KCUU

RPM

Pd!dfli ~ ~ i i ci6cii' ili ?cbp~eq~a ~no~ap,a?

PM
Buwa~e - pa3nur~o B AseTerpbflHunonoBuHu ?~H~BMOTO~~KC

bicarbonat

nepu~apfl~a acnupaquu

Tosa cnewHo CbcTouHue npegmaBnuBa O C O ~ ~ cnyvaii H Ha KnP B neTcKa BMP~CT, 3aqo~0 npu Aeqa nog 3 rofluHu BcuKa ~pbmaary6a ce 3auecma Ha nputiuuna .KanKa 3a ~ a n ~ a ' , OCO~~H npU O HO~pOfleHOTO, KbAeTO 06e~bT Ha 4UPKyflUpaUp KPbB npeflcTasnuBa 6575% OT TenecHoTo Terno. nnqn.,,, ------..--..- - r
A-

XEMOPAfMYEH W K

472

Oco6enocmu na cneurnume cacmonnun B gemcka Baspacm

Hah-~~C Ca T nOKaJl O M3MpaHMUByCTpaHHO. O C T p M T e M O ~ ~ H O ~ ~ C T P ~ ~ flne~p0-~~IIOU~O~HM CIMBHU ~ H O ~ H O ~ ~ C T P Y K T M B H npOMeHH MT~ B 6enwe flp0608e ~ ~ ~ O ~ F I B(Orpfl63) ~ H M R B UeTcKaTa BwpacT npeucTaBcnep acnMpaqmR Ha r w o TRno ce p a 3 e ~ a a ~~ a recro f 8 n R M T OrpaHMWHO ~ H O ~ ~ H O ~ ~ Bb3nWeHMe CTP~~ Ha CMB HO no6oee. 6 e n o p p o 6 ~ a ~ a ~KOeTO b~a~ B O ,p MU0 ~ 0 k ~0 c ~ o M H ~ H M UonHlnTe ~ n B nnespanHaTa KyxMHa.

f l p peqaTa ~ r t i o h ~ o u e c ~ p y m npoqec ~~~~~ uoxe 1-r~ ua

Ce pa3BMe: B HOPMaJleH 6

~ up06 n flop Bb3pekTBMeT0 Ha VaMHeraTMBHMM n M VaMn03MTMBHHMHKPOOprElHM3MM, flpM cenmKonMeMMn, Ha 6a3aTa Ha r w u Tena, npH HanMrMe Ha upyra 6eno~po6~a naTonorun ( s p o ~ e ~ aHoMannM, n e X M H O K O K O B MK M C T H ,T y k 4 O p M M up.).

Enronor~a
~ P M ' ~ M H U T Ha ~ ~orAn63 M MoraTfla6buaT: CTa$MJloKOK 32.4%, r p a ~ ~ e r a ~ n ~e ~~ ~u poopra~ (Proteus, na~n Pseudomonas, Klebsiella, E. coli M up.) - 27.6%, acoqMa4MFI Memy rpaMHefaTMBHHM TpaMll03MMBHM MMKPOOpraH M 3 M H - 29.6%. B 11.4% OT ~ O ~ H M H eT Ce ~ M3OnMpa MMKPO~~ IlP H MCIMHMTeIl.

Ha'iWIHM K n M H M r H MC M M n T O M M TeMnepaTypa, KaWnMqa. CMM~TO Ha M~ ~ ~ H MHTOKCblKa4MFI O ~ H ~ -BMCOKaTeMI nepaTypa c MHTepMMTupaq xapamep, o ~ n q q ~ a n o6ec~, aaneTMTwe, rqqetie, noepbqatie, 6a1o iH M p a H e Ha KopeMa, 6nepoc~e~ae ~BFIT Ha KoxaTa. CHM~TOMH Ha AnxaTenHa HeAocTmrHocT- TaxMntieR, UMcnHen, q ~ a ~ o 3n a3 , pa3e~ B~ p a 3 n ~ r cTeneH. ~a A ~ C K ~ ~ ~ Ce TY OCT ~aH H O B O R B a T~ ~ ~ H O K W I MBna~ ~ X H W XpHflOBe B M F C lT O T O Ha Bb3flWHTeJlHOTOOrHMqe. B KpbBHaTa KapTMHa Ce YcTaHOBRBaT aHeMMR, 3HaYM~ e n nea~oqwo3a, ~a M ~ M ~ C T Ha B ~$H op ~ ~yna~ Ha a6maTaKPbBHaKapTMHaHanFIB0,TOKCMrHM rpaHyflaqMM,yCKOpeHa CYE.

B KrA XMnOKCeMMR B pa3nM'iHa CTefleH. ~ H O ~ H O ~ ~ C T P Y ~ ~ T HIB lp HO M~ R eT C M0Xe ua 6bue O C T ~ P , nbTMqaTa3a np0HM~BaHe Ha klH$!~qMtITa cao6~raA CflpoTpmMpaWpa3BMTMeUX~HMVeH. Hme 3a mnanmeneti 6enoppo6e~ npoqec (gnxa~ene~, O C T ~pa3BMTMe O Bb3llMMTeJlHMRTIlpOUeC MMHaBaB xeMaToreHeH, ~ M M $ o ~ ~ H ~ H ) . o6 po a 3 a ~ uo ~ ~1-1 e 112 Mec. MHKPOO~T~HM B ~~ M~ M# T? ~ ~ ~ c T B ~ ~bpxy6eT~M~~KTH op a ~ ~ npo~pax~pa pa3e~me ~o 112-3 Meceqa. Jloupo6HaTa T ~ KOT ~epHa H CTpaHa Vpe3 T O K C M H H T I , KOMTO X ~ ~ H M C IP H~ O~ B H T H ~~ q3 qMeceqa. oTpennT M OT upyra cTpaHa rpea 6nonorur~o amMBtiH seqecrea, KOUTO n p o ~ ~ ~ o p e A c T Ha ea Knenrttwe ~ M Ha xyMOpUlHUTe $aKTopM Ha MMyHMTeTa. TOKCMHMT~, OTueflFlHHOT C a M M R IlPMCIUHUTBIlM flpomKTMTe Ha O ~ M R H M ~Y TB~O W P O T&Wo)(K MHTOKCUKa~MFI Ha OpraHM3MaMCMJlHOM3pa3eHTOKCMVeHCMH~~M.

Ilmorea~a

HaMMKaTa Ha 6enoppo6~a~a TbKaH 'ipe3 Cna3bM Ha IlepMUeCTPyKqMM, pa3MepMTe M M , Cb~PXMMOTO, C b C T O R H M e T O $epHMTe C b u O B M pa3KllOHeHUR M M H K ~ ~ T ~ O M B~ T F O I X , ~H Ha C b C e A H M F I 6enoppo6e~ napeHxMM. 6p0~~0rpa$MFI KOeTOBO~M~OHaTp~~HeHaHe~OOKMCneHMMTOKCMVHM M3BbpWBaCeflpMnpOTpaXM~~HOMXPOHMClHOflpOTM~a npopymw OT 06MFlHa~a Ha BeqecTBaTa Ha MaKpoopraHMHa 3a60nRBaHe~0 38 YTO'iHRBaHe C b C T O F l H M e T O Ha ~ P O H 3~a. X W a J l H O T O UbpBO. ~POHXOCKO~~MFI CflOMara 3a M3flCHflBaBcclrlcllTe3U BKOM~MH~~MFI BOW R0 T e r n H e HaunamoaaTaM CbqeepeMeHHo MMa n e r e 6 e ~ e$eKT. M O ~ @ ~ O M ~ HnpoMetin M B 6enoppo6~a~a n ~ a~ ~ 3 p,a 3 ~ - Oco6e~o qeHHa e n p HanwrMe ~ Ha rloyqo Tnno B pMxaTeneaqn ce B ~ e ~ p o H 3 pamqq, n HapyueHne Ha cretiwre Ha H U T e IlbTMua, flpM KOeTO flO3BOnRBaua6bpe OTCTpaHeHO. flepM$epHUTe ~ ~ ~ H X W KllOHOBe H H C 06pa3pa~e Ha a6cqecM H ~ b 3 u y u . K~XHHH. t~~ A6cuecme ce pa3nonara.r npepnnnHo cy6nne~pan~0, M ~ K ca M no p a 3 ~ e M p MHoro ~ npae~ ce c epopeHa ~ O ~ M K M C T O Munwaptia ~~, $ep6bp3o ce OTB~PFIT B nne8panHaTaKyXMHa. Me~aCTa~nr~u- ~yno3a, sponetia pna$paman~a XepHMg M up. Te a6cqecu Ha 6enn~e upo6oeece p a 3 ~ n no ~a XeMaTore~ H H e H M J ~ M M $ o ~ ~ H ~flbT H Ha IlpOHMKBaHe Ha H H $ ~ K ~ M OT R~~ M ~ B ~ H ~ ~ ~ O U OMMqe PO~HO (OTMT, O M $ ~ ~ M T O ,C T e O M M e AHT~~~#~? ~T ~M ~L H (X M O ,~ U T WTM~MOTMKOT~ M~M, (Oxacillin, Cefatrexyl M up., per OS). n U T , IlepMTOHMT, IHOeH flpOqeC Ha MeKMTe TbKaHH M pp.).

MKTo~u

J~@epeuq~anua AHaruocmwa

AO~O~HH noBeSuHe ~ H O neveuHe

Oco6enocmu n a cneurnume cacmonnun B gemcka Batpacm

473

nneepanti~ycnomeHMn
flere~~e e~ KounneKcHo o M alcntovea: L/IH$Y~MOHH~ TepaflHR - BllMBaHe H a rlllOKO30-ConeBM M 6 e n ~ b pa3TBOpM v~~ ( ~ M M H o K M c ~ I ~ M H M nna3Ma, , Human SelUm albumin), X ~ M O T P ~ H @ Y ~ M Ha RnpRCHa flbflHOqeHHa
KWB, B M T a M M H M .
A H T M ~ ~ K T ~ ~ neveme M ~ ~ H (onpenen~ O ce OT vyec-rB M T e n H O C T T aHa M 3 0 n M P a H M RMMKPO~~ nPM'iMHMTefl H K b M ~HTM~~KT~ cpeflCTBa). ~M~J~ OCHOB~H HM npMHqMfl npM On-

Bbs WHOM H a pa3~006pa3~a KnnHuvtia ~a M pewreH O B a KapTMHaIlneBp~HMTe Y C n O X H e H M R M O ~ ~ 6bfla~: T D ~ nneepaneH eMnueM ToTaneti, oTrpaHMveH; nMonHeauoTopaKc ToTaneti (~anpema~ c BeHTwn, HanpemaT c MeflMaCTMHaJleHeM$#3eM, HeHaIlpelHaT), OTrpaHMVeH HePMMAeH (roflRh4, ManbK), OTrpaHMWH PMMAeH (~OIIRM, ~anb~ n) ~; e a ~ o r o p a ~ c - ~ o (~anpema~, ~ a n e ~ HetianperH ~ T ) OTrpaHMreH , HepMMneH( ~ o ~ R M MM~K), , OTrpaHMcleH

peAenRHe Ha ~ H T M ~ H O T M C I H M KO T~ M~MH~~M eM OT'iMTaHe

PMMAeH ( ~ O ~ F I M ~, m b ~ ) .

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pHWM pecTpylcrMBHM @PMM C IlepMTOHMT. @M~MKMHOTO nscnepea~e p a e a 3 0 ~ 1 . i H~AH$Y~ nanna~op~a60ne3~eH~ HOCT B KopeMa, no-~pyp~o ce oTclcllTaT nonoxMTenHMTe 6ene3~ Ha nepMTOHeXIH0 flpa3HeHe W PMMflHOCTTa Ha npepHaTa KopeMtia cTetia. ~ O ~ R M pnamocTMcltio O waveHue npn ~ e peua 3 ~n p ~ ~ ( o 6 ~ pewanHoTo aa TyurMpaHe, K O M ~ H H M ~ ~ HCO~ M M ~ H ~IlaJlnauMR. M H ~

477

Ocnp aneHAwqHT npw Aeqa Ha ~ a s p a c OT 3 fl0 15 rOflllHH

OCTPMRT aneHAMuMT e H ~ ~ ~ Y ~ C T O Bb3naJlMTenHO TO K O P e M H O XMPyPMclHO 3a6on~ea~e. A a H H M Ha pa3nM'iHMaBTopM clecToTaTa ~a 3a60nRBaHeT0 e 60-75% B HRKOM eb3pac~oe~ rpynM (D.O.l/lca~oa,3. A. C ~ e n a ~ oA. e, Apo~oe, 1980). OC~~~HOCT BM IlpoTMclaHeTO T~ Ha OCTPMFl aneHAMI$lT B nepnopa HapwarHocTMclHoToyrocltimatie caswnBAeTCKaTa Bb3paCT Ce CBbp3BaTC H R K O M naTOnOrOaHaT0MenHM: KOHCYnTa4MR C peTCKM XMpypr, npM M3pa3eH MHclHM B a P M a H T M , KOMTO Ce OTpa3RBaT Ha KJlMHM'iHbTO M H T O K C M K a L ( M 0 H e H CMHAPOM MH$Y~MOHHOne'ieHMe, npM npoTMclaHe H a 3a60nRBaHeT0 B p a 3 n ~ c l ~ sb3pac~oe~ ~~e XMflepTepMMR aHTMnMpeTMuM ,npM M H O r O K P a T H M n0BpbCnoma~a e ~ 6 p ~ o r e ~ ecabpaaHa 3a, c $op~~pa 4aHMR TpahHa C T O M ~ W H O - ~C~ OO H~ ~6 ~ ~ AeTCKO . H ~ ~ ~ H rpynM. ~ HeTo~pa3nonome~~e~o~arpe~~~~~pa~s XMP~QM~HMR K ~ ~ M H BCMCIKM ~ T : peqa, npn KOMTO He Moxe KyxMHa 06ycnaw pa3llMclHM a H a T O M M i ' H M p a 3 H O B M A H O C T M cbc cmypHoCT pa 6bpe oTmbpnetia pMamo3aTa ocnp Ha MneoqeKantinRpaho~, ~~O~BMW~H qeKyhn MF~T no3~on~ aneHpMuMT, nomemaT Ha x o c n ~ ~ a n w 3 a MuamMBHo ~~ Ha aneHpMKca pa s a e ~ a pasn~r~ MecTononoxeHMe: o ~a6nlopeHMe no claCOBe OT K B ~ ~ M $ M ~ peTCK0-XMPYPM ~ ~ H M ~ K O T~~OBO ~epwoqe~an~o, , peTpoueKmHo, peTpoT M c l e H eKMn. naTepO~eKMH0 M cy6~enaTanH0. A~~H#~K eO cT ~ H O TC M Tentio no-pnbr M c no-WM~OK nyMeH. B ~ ~ ~ ~ C 0c06eTOB HOCTM ce Ha6n~paBaT M B mpoexa Ha cTetiaTa Ha anew pMKca. no-ronfi~ MHTepec npepcTaanRaa cTeneHTa H a pa3sm~e~ Ha o $onwKynme B ~ s p a c n ~ B a. pbs~a~ H a T O B K a e B 3 a B M C M M O C T OT C b C T O R H M e T O Ha AeTeTO, H 0 ~ M M $ HC ~M T C T ~e M a Ha MneO4eKaJlHMR b b n M alleHflMKCa PR~KO npesmuasa3-6 ~ . T alcnto'iaa: R M H $ ~ ~ M O H HnecleO C~ M M $ H C ~M T C T ~e M a Ha HRKOM K O p e M H M OpraHM M PeTpOHue, aHTMnMpeTMuM, npM w a KaPflMOTOHMuM, KOPTMnepMTOHeMHOT0 npOCTpaHCTB0 n03BOnRBa H ao C T P M T ! K O C T e P O M f l M , TpahHa CTOMaWHO-AyOpeHanHa COHna. npM sa3nanmen~ npoqecu ~ pace pa3npoc~pa~nea~ a e ~ ~ n e p M T O H M T B3 a B M C M M O C T OT CTWMR M y npM OnepaTMBHOTO neretiue cnep ~aabpwsatie ~a~ ~ ~ H ~ ~ K T O ce MnpncM R T ~ lrnM ppyra nocolta. Bbpxy npoTMclatieTo Ha OCTPMR anew ~HuMTnpM~euaTaOKa3BaBnMRHMeMCTeneHTaHapa3BMnnaa BM pwmantia caHauuR Ha KopeMHaTa Kyxutia C Tve Ha Omentum rnajos. OTHOCMT~~HO no-cna60~0 MY JlaBM, npM nOKa3aHUR, ~ H T M ~ H O T M IlepMTOHeanHa ~~H~ pa3BMTMe, oco6e~o BPaHHaTa AeTCKa Bb3paCT e IlPMClMHa nep$y3MR, npM M3KJlloclMTenHO T e M M @PMM C M3MeHe3a 6bp30 p a 3 n p o c ~ p a ~ e Ha ~~ ~e O~?CTHM npoqec R OT HHR B C I p e B H M T eBHKM (pMnaTauMfl) - ~ ~ K O C T O M MMHT@~ aneHpMKCa B C B O ~ O ~ ~ K O H P e ~M T H a ~K Y X M H a . 4HR H aT b H K M T e clePBa (He O C O ~ ~ H po6pe O n O H O C M M M npM

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AM Tena a nyeHa. B nocneptiwe ropMHn npeo6nqaea~ cTaHoeM4aTa 3a TPO$MCIHH npouew B cTeHaTa Ha opraHa, B W H M K H ~ ~ B M pe3yn~a Ha ~c b p o e o - p e $ n e ~ ~ o Hap~~ P Y W e H M RM a K T M B M 3 a U H F I Ha C O ~ C T B ~ H M~ HT KP ~ O~H $no~

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noavuraea HW 3YC, c p a s n ~ ~ Mewy a aKcMnapHaTa M pemanHa CTO~HOCTM HW 1%. E ~ H Ke~cyx, T o6noxe~, npw no-ronma r a m OT GO~HMTBcnnpa cnowaHHaTa Ae$e~aq~n n. p AeqaTa ~ c aTMnMrHo pa3nonoxe~~e Ha aneHpMKca ce ~a6nlofla~a M aTMnMrtio npoTMraHe. n p ~ MMKO ~ a 3 o ~ pa3nonoxe~we a cnotiTatiHaTa 6 o n ~ a ce no~an~3npa no-rec~o cynpanfluq~o, MMa ~0n~K006pa 3 e xapawep, ~ recTo ce npMRFyxaKaeao~ T ~ H ~ M ~ AMapMM M qHM M3XO)KFlaHHR. PM pa3BHT BTOPMYeH KOnMT Ca Bb3MO~ H K~PMBM H npHMecMB ~ 3 n p m e ~ uHa6nmpa~a ~ ~ a . ce recTo ypnHHpatie M 6 o n e 3 ~ e ~ oTpenRHe o Ha ypwiaTa. Pa3~006pa3Ha e WIMHMqHaTa KapTMHa M npM MeAMEUlHO pa3nonoxe~~enyrac~~e~a~e3e~~e qepao B ~ ~~nanMTentiMA B npoqec. Ha6nlo~aea ce ynop~TO noBpbqaHe, CMI1HM, K O ~ H K O O ~ ~ 60nKM ~ ~ HB MKOpeMa, nOHRK0ra IMaPMrHM M3XOYqaHMR, YCMneHa nepMCTanTM-

C ~ P M O ~ AMamOCTM' H H T ~ iHM 3aTPYflHeHMR, KOMTO nOCTaeROCTPMFFTaneH~MqUBfleTCKaTaBb3paCTBbBBPb3Ka C JlMnMTa Ha TMnMCl Ha WIHHMqHa KapTMHa M Bb3MOXHOCTTa 3a CbreTaHO IlpOTH'iaHe C HeXMPYPMrHM3a60nRBa~MR HmaraT H ~ O ~ X O ~ M M O COT TT KOMnneKCHa ~ OqeHKa Ha WIMHHqHcl-reCMMnTOMH H 3 ~ b n 6 0 r e WJl ~OCTeH npernefl Ha

AeqaTa, KOATO mmmqaa: 06140 cbcToRHHe, ~acnepea~e Ha rOPHM AHXaTenHM nbTMu(a M CbpflerlHO-cbpOBa CMCTeMa, Hacoretio n3cnepea~e ~a~opeu~a~a~yx~~a. ocaqecTen TOM ~acnepea~e A e ~ e cneAea ~o pa ce npeApa3nonox~, pa ce eneae B KoHTamc Hero. llannaq~ma Ha KOpeMHaTaCTeHa fla 6 b ~ nOBbpXHOCTHa, e qaF1Rl&l. h npaeMno ce cb6npa~ OT popMTenuTe, KOMTO O ~ H K H O B ~ H O naTopHaTa 6 0 n e 3 ~ e ~ o npM c ~AeqaTa c ocnp a n e ~ p ~ q HaCOqBaT BHHMaHMeTO KbM llpOCTyP,HM ~ ~ ~ O ~ R BM n ~ MH M R ~ ~ H K H O B ~oTroBapR HO Ha pa3nonoxe~ue~o Ha aneHpwKrpewKM B AneTaTa. Ca. PM fleCTpYKTMBHMTe @PMM C e AOnaBR MyCKynHa OCTPMRT anetipnqcl-r B peTcKaTa ebspac~ sanor~a c 3aqn~a Ha npeAHa KopeMtiacTeHa. Or 60neaw~e CMMnTo~eonpe~ene~a6B o~ n~ oa p e (T. ~a H. pe$nelcrop~a $aaa), ,MM 3a peTCKaTa Bb3paCT e OT 3Ha' ieHMe CaMO CMMnTOMbT KOFFTO e C YMepeH MHTeH3UTeT, IlOCTORHHa M C e 3aCUnMl Ha nepMToHeanHoTo p p a a ~ e ~KOATO e , ce nonyraea npw npMpeMxeHw, KalunMqaM n MCMRX. 6 o n ~ a ~e ~a npeMMHanoebpxHocTHanepKycnR Ha npepHa KopeMtia cxetia. npesa no BpeMe Ha C ~ HA . M$~~HM xapanep RT Ha cnowaHHanopbrea ce 6M~aHyaflHa nannaqng rpes p e w a n ~T o~ W M Ta 6 o n ~ Il a OCTeneHHOC e KOHUeHrDMDa BC ~ O H T ~ H H ~ ~ O ~ K ~ paHe. ~~M~MOCTMCIHMRT npoqec ce nopnoMara OT HRKOM . B ycHa MnMaqHa o6nac.r. n o e p b q a ~ e ~ eo recT cMMnToM IlpOMeHU B XeMaTOnOM.IHMTe nOKa3aTenM - 3Fi O C T P M R T Ha 3a60nRBaHe~o. B 80% OT AeqaTa ce ~a6nmpa~a oqe B aneHpMqnTnpM peqacaxapauepHn yMepeHaTaneeKoqnnapem DeH Ha s a 6 0 n ~ s a ~ e (pe$nenop~a ~o p e a ~ q ~ ~ ) . ~oaa - AO 15x109/1M oneeReaHe ~o 0.1 2. Tenec~a~ TeMnepaTypa a ce noeMuraea po cy6$e6p~n~a 3a Awammwqnpatie Ha 3 a 6 0 n ~ s a ~ e ce ~ npMnaraT o (373-38C). n p ycnoxtieHnTe ~ $OPMM TeMnepaTypaTace MHRKOM MHM3MBHHMHeMHBa3MBHMflMamOCTMYHHMeTO, a

no cneurnurne cacrnonnun B gemcko Barpocrn

479

T O F l H U e T O H a ~ O ~ HH HeTHaCO' ~ ieHa K b M KOpeKuMR Ha

fle$uqu~u~e U naTonomclHme sary6~ rpe3 MH$YSMM Ha BOnHO-ConeBM pa3TBOpM i. V. M B M T a M H H M , OBnmRBaHe Ha $e6pMflM~e~a. BT O ~ M eTan e paspeure~o npMnoxeHneTo MH a 06e360n~eaqu cpencTBa. n p o p n x ~ ~ e n ~ o Ha ma OCTPMRT aneHflMum Moxe fla npoTere B cbreTaHwe c npenonepaTHetiaTa nonroTosKa e 2-4 h. O ~ B MHa ~ XMT HeXUPyPMrHM M ~ O ~ F ~ M H H F O C ~T :P M KaTapM Ha rOPHM RHPyPMrHOTOJle'ieHHe Ce OnpeflenR OT CTeneHTaHa PasBMXaTenHM nbTUU@,VMn, IlHeBMOHMM, H H @ K ~ H O ~ H M eHTeOTCTeneHTa Ha POKO~UTM,cKapnaTMHa,M O P ~ H ~ M aapnuena, , x e ~ @ u n ~ ~ , TMe Ha Bb3naJlMTenHMRIlpOqeC M ~ah-Be'ie nepnToHeanHaTa peaKqMfl. n p HeAecTpylcmeHwTe ~ M orocTpa uanwmetia nee~oaa, ~ n a 6 eannacTMrtiw ~, C~CTORpatiHreHu$OPMM ce npenopbraa onepaTneeH flocnn no H M F I . ~ H ~ M O C T M V H M T3aTPyflHeHMfl ~ MOraT Aa C e PeWaT Davis MnM ROUX-BO~KOBM'~-~KOHOB. npM fleCTpyRMBHMycnewo, aKo ce s ~ a M e MMcnM 3a TOM cbreTaHo n p o w Te MM c F ( M $ Y ~ ~ nepmoHMT H cnepa Aa ce npMnara raHe. nanapoToMMR, 3a npeflnorlrTaHecpepwtia. l l p Henem~ C p e q a ~ cM e~ e x ~ p p r n~ r~w ~ O ~ R BKOMTO ~HM npoR,
T M W T C KapTMHa Ha O C T b P aneHflMuMT: I l H e B M O H M MM nneaponHesMotiMM, OCTPM BMPYCHM HH@K~MM, ennAeMMqeH x e n a ~ ~ ~ , ~ ~ a e ~ r e p w ~ , c ~ a p n a ~ PYKTUBHUT~$OPMM Ce M3BbpWBaTMnUVHaaneHfleKTOMMR,

c ~ ~ B M ~ 3a M FM I ~ K ~AHsepTwKyn. ~ o B AKOnpM ~ ~ B M ~ M ns He ce npenopbraa p e 3 e q ~ p a ~ MY, e~o ~ ~T aa~ ~ce p ycTaHoeM, ym c ~s~ntore~ Ha ue cnyvame, npM KOMTO M M a RaHHu 3a B npeAonepaTMBHm nepMop OCTPMRT aneHAuuw npu Bb3nWlMTeJlHHnpOMI3HH. ~ P fleCTpyKTMBeH M ZineHAMuMT C IeuaTa recTo ce Hanarafla ce o~flu$epe~u~pa OT peflMua noKaneH nepu-roHnT, npeRM u 3 ~ b p u l ~ a Ha ~ anetidernoe OCTPM K O p e M H MX M P y P M C I H M ~ ~ ~ O I ~ R KOHTO B ~ H npOTMMR, M M R T a Ce B3eMa MaTepMaJl 3a aepo6~o M aHaep06~0 YaTCKnMHMrHaKapTMHa,CXOflHaCMMHMqHaTaKapTMHa M M K ~ o ~ M o ~ o ~ M ' ~~ H3 o cne~ea cawpace ~e, aneHAuKynapH a aneHflMuUT. T ~ Ce K OTHaCRT OCTPMRT Me3eHTepHXIeH HaTa 06nac.r C aHTMCenTMClHM CpeACTBa M Ce M3BbpWBa ~MM$W~HMT nbpBUVeH, , KpMnTOreHeH IlePMTOHMT, OCTPO ~ ~ 3 n a n Ha e ~ Me~enoe ~ e lmepTMKyn, o m p X O ~ ~ ~ M C T M T , anetiflernoMMR. Peewawpa ce caMo 20-25 cm OT TepMMH W H M R MneyM 3a OTCTpaHRBaHe Ha $M~PMHOBM HaJlenH, O C T b P IlaHKpeaTMT, O C T b P IlbPBII'ieH OMIHTHT, 60nec~ Ha KOMTO MoraT na npMrMHwr paws ~ x e s ~ qpeatia o ~ ~ a Krohn, MexaHwrHaqpeeHaHenpoxofluMocT,rpeeHaMHsaHenpoxoAMMocT. l l p ~ c$op~~p nepManetiqMKynapeH a~ MHauMR, PeTpOnepMTOHeaJlHM M n M a C l H U a6cqecn M $nera6cuec, ~ e p a 3 r p m e K~ ~ M C B O ~ O ~ ~ KopeMtia H ~ T ~ KyxuHa, MOH#, HRKOM M H e K O J l O r M C l H M~ ~ ~ o ~ R B ~ H M R .

CneA eMKyauMR Ha MO~HMReKCYflaT M M M K P O ~ U O ~ O M ' ~ ~

neKapR, K O ~ T O ~

OCHOBHMRT M O M e H T B ~060n~M'iH0~0 nOBeReHMe Ha 60x,qaea~ ce rpeaHme G~MMK'M,KOMTO ca pami-raan~B n ~m 3 ap B ~ KoHTarn ~ C p,eTe, cycnerntio oTrpaHMraaaHe Ha a6cqeca.llpu oco6e~o TemM npoue3a o m p aneHnuqMT e1a ce M M c n M3a ~ ~ ~ O ~ ~ R E C I H n ~ Tp O .~ HM B cTeHaTa Ha TepMMHanHMn MneyM e n o ~ a 3 a r ~p ae s ~ a H a C O C l B a H e Ha B H U M a H M e T OK b MO C T b P aneHAM4MT e ~ e o 6 WHT@~~U npe3 R u e K O C T O M M R . A6cqec~a~a KyxMHaCe&EXOAMMO na ce npeycratiosu xpaHeHeTo M npMeMaHe Ha e r~ o$p~pa ApeHoee, ~ KOMTO ce ~saex,qa~ TerHoCTM peros, Ja ce aanor~e oenwReaHe ~ a $ e 6 p ~ n ~ - HMpa c ~ p b 6 M H a fleKnUBHO M R C T O ,M 3 B b HO n e p a T M B H U R pa3pe3. TeTa C $ M ~ H K ~ CpegCTBa J ~ H M ( B ~ W H M O ~ B M E ~ H M RMeflM). npu A M $ Y ~ ~aneHAMKynapeH H nepuToHMT ce eaaKynpa ~ H O ~ H M FeKCYflaT IT M Ce B3eMa MaTepMan3a MMKPO~HonomreH K O H T ~ M ~~ 3 .~ b p w ~ ce a TunM'itia aneH4eKToM M R .

PM BbBnMClaHeBbB Bb3rlaJlUTellHMRnpOl(eC Ha rOnR-

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6 ~ n Mti-rpaonepaTMeeH e~ naaax Ha KopeMHa-

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wme, ~ n a w w U, . ~i~a~~unmntl?a~~nepaxn~tlT a K l M K a M npOBeX(4aHe Ha K O M n n e K C H OM H T e H 3 M B H O nevewe B CneAonepaTnatiMR nepuop,.

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480

OcoCenocmu na cneurnume cacmonnun B gemcka Bbapacm

nanMTeneHnpouec, o6x~aqaq nepmoHeyua. Te ce cpeUaT PRpKO M Ce AbnXaT KaKTO Ha BPOAeHM aHOManHM M Ha CBbp3aHMTe C TRX yCJlOWeHm, TaKa M Ha PeAMua npMp0~MTM 3a60flRBaHMfl. E ~ ~ o n a ~ o r e ~ MM e 3e acxoptia ~a c ~ a npu 3 no-rone~ Mtrre peua, KaTo ce paannram caMo 3a nepMToHMTMTe, UbnxaqM ce Ha BpopeHw aHoManMM Ha xpaHocuMnaTenHaTa C M C T e M a M flpeflHaTa KOpeMHa CTeHa.

MMR. B cneponepamBHMR nep#oAce npoeewa MHT~HSHBHO MH@Y~MOHHO H am6amepnan~o nere~ve, HacoreHo K b M Bb3pefi~~BMe Ha aCOuMMpaHMTe aepo6~n M a~aepo6HM 6 a ~ ~ e p M ~H a@ n~ ~K~ ~ KaKBMTO M # , Ce CpeqaT B 74% OT
peuaTacaneHpnKynaptiM nepHToHm.

Cneponepar~e~trre ycnomeHMn, KOMTO ce Ha6nI0RaeaT cnep aneHReKToMnM B peTcKaTa ebapac~ca OT cTpaHa Ha npepHa KopeMHacTeHa ( c e p o ~~~@wmpam, ~, CynypauMM, ClaCTHrHM HnM IlbnHM~ ~ x H c ~ ~ H B ~KOpeMHM), HaTa KyxMHa ( c n e p o n e p a ~ ~ nep#ToHMT, ~e~ rpeaHa HeIlpOXOflMMOCT, ~pbB0~ecleIiMR) MnM CenTM'iHM YCnOXHeHHR OT cTpaHa Ha 6 e n pp06 ~ ~ M cbpuero. 3a npo@~namuKa Ha ycnoxtietiMRTae H ~ O ~ X O ~ U pa M ce O onepMpa aTpaB M a T M C l H OM Ce Cna3BaT C T P M K T H O nOKa3aHMflTa3a IlpMnafaHe H a ~afi-paukI0HaIl~a OflepaTHBHa TaKTHKa.

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H M B O T OH a flep@pauM~~~Mfl Y C l a C T b K OT q p e B H M R TpaKT. Hafi-Clem0 Te Ce IlPMClMHflBaT OT

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Oco6enocmu na cneurnume cacmonnun B gemcka B B J P ~ c ~ 483

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na cnewnume cacmonnun B gemcka Ba3pacm

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485

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3TO'iHHKa Ha Bb3llaJlUTeJlHURIlPqeC M B ~ W ~ ~ ~ C BbpT B M xy 6 a ~ ~ e p n a n ~npMruHmenu. me Jlerle6~um npoqec ce ocbqecTBRBa B T ~ eTana: M npenonepaTMBHanoAroToaKa, OnepaTMBHonerettMeunereHcleacneflonepaTnsHunnePHOA. flpeaonepanre~a nonroToeKa. 0 6 e m U ~ npomnXuTenHocna Ha npeuonepaTMBHaTa noAroToBKa ce onpeAenRT o~ m p a n a Ha AeTeTo, W~UHM~HUR C T ~ J MHa ~ pa3sn~~ Ha e nepMToHma, o 6 e ~ a Ha naTonomrtiMTe 3ary6~ U CTeneHTa Ha YBpe~aHe Ha O C H O B H M T e XH3HeHU $yi~qun. npomnmen~ocrra e 2-4 h M ce ocbqecTarrBa rpe3 BeH03HM M H @ ~ ~ MHa M BOAHO-COfleBMM rnMK030conesu pa3~~opu, nnama m nna3~03auec~u~en~. npu RmeHun Ha RuxaTenHa M t p ~ p ~ y n a ~ o HepocTaTbrp~a HOCT ca n o ~ a 3 a ~ KapAuoToHuqu, u KwcnopopoTepanw. KOPMMP~T C e IlpOMeHMTe B aJlKaJlHOWCenMHHOT0 WTonwe. Oenmea ce @6punme~b~. B TO~U nepuop e noKa3aHo npunoxeHue U Ha 0 6 e ~ 6 0 n ~ ~ a cpepmsa. qu PM RBneHMR Ha rpeeHa nape3a ce nocTaeR cToMaurHoqyofleHanHa coHna 3a npeAonepaTueHa eeaKyaquR Ha roKclrlwioTo c b ~ p x u u o OT ropHuTe oTAenu Ha xpwocvwnaTenHuR Tpan. Anepmr~megeqa ce TecTyeaT M loAroTBrrr C atiTwanepmrtiu cpeAcr8a. npeponepamsiaTa nWroToeKa ce clraeaplu~a ycnopeAHo c npocnemMeTOHaHRKOU~HOXHMUYHM nOKa3aTenHMnMC npMnara-

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486 m OcoCenocrnu na cneurnurne cacrnonnun B gernc

C O ~ C T B ~ HTbKaHM M H n M C IlOMOWa Ha aMnOKCeH, K O ~ O WalTfMpa pb60Be~e Ha KOpeMHaTa cTeHa Ha Pa3CTORHHe R0 2 C m eAMH OT npn Te3H flel(a BbpXyaMnOKCeHaC e WanTupaT Kowme pb60ae. B noAKoxueTo ce nHcrannpa Pep,o~ RpeHax. C a ~ B oefl#HnqHncryian nanapmoMMRTa He C e 3aTBapR ~~$UHMTMBHO. PM Te3U 60nHbl aMnoKcetibT npopacm c rpaHynaqnotiHa nKaH, abpxy ~omB o no-K~CHM cpoKoBe ce pa3pacma nmTHa $n6po3Ha IlOKpMBKa. Jleve~ae B CnenonepawBHaR nepaon. Jlere~ue~o Ha Beqa c nepnToHllrT B cneponepaTneHnR nepwod ce npoaexqa B peaHuMaquoHHo oTneneHne. npes T O ~ M IlepUOfl npOnbnMaBa H H T ~ H ~ # B H O T O I~~H$Y~UOHHO ne.reme, sanoq~a~o B npeuonepaTneHuR nepMon 3a KO~ ~ K U MHa R p,e$~qn~me M naTonoMrHme sary6n. CbUecTseti nRn OT neveHMeTo npe3 T O ~ Mnepwop, e amuEnronor~n 6a~~epManH0~0 neqeHwe, HacoreHo BM B ~ ~ A ~ L ~ C T B M ~ 0CTpMfl~ naHKpeaTMT e nOnMeTHOnOMrH03a60n~eaBbpXy aCOqUMpaHUTe aepo6~n( ~ ~ ~ R M TpaM-OTPMMHO He. Aonyc~a ce B ~ ~ ~ , ~ W C Ha TB pM a3 ~nT nO . 1eTHonomq~~ q a ~ e n ~M na ) ~ a e p 0 6amep~n. 6~~ HaA-y~a.r~a 3a AeTcHH $amop~, KOUTO 06ycnae~~ p a 3 n u q ~ ~op+onoruv~~e KaTa Bb3paCT C e OKa3m K O M ~ U H ~ ~ H M Re T~ w aMMHOHH npMeHn B mneaaTa. flyc~oe M ~ X ~ H M MoraT ~ ~ M Aa ~ ~ D K O (Gentamycin, BM~, Amicacin) + Cefalosporin (Ill-IV 6bflaT pa3nlr'iHM M ~ ~ C T O C ~ B M ~ C T H O ~ OPM' ~ ~ iM ~ HM: C T B no~one~ne) n Metronidazol(Flagyl), B caoTseTHn 3a Bcwa ~ ~ ~ O ~ F I B Ha ~ H)KITbVHMTe MR nbTMll&I M AyOfleHyMa C pas~ b 3 p a p,o3n. c ~ 3a KopeKUnR Ha npoueHme B KnenclHnu BnTwe Ha x ~ n e p ~ e M ~6 3~ n~ n ~ am pe u AyoAeHaneH ~ peMMYHHTeT Ca nOKa3aHM MMyHOMO~yJlMpa~bl M UMyHOCTM$~)'Kc; TpaBMaTUqHM )'BpeflM; HaBnM3aHe Ha M H $ ~ K ~ U HU areHTM; MeXaHMCl HO Bb3p,eiCTBMe qpe3 IlpMTHCKaHeOT H O B H M T e XM3HeHt4 $~HKI&IH ll0380nRBa # nOCTORHHa KOpeKquR Ha npoMeHuTe. Y p e a ~ a ~ nepucTanTnKa a ce noaanKoxon Mnn tienonxop,RqaxpaHa; nocTonepaTMsHwM p,p. nMma rpes npunaraHeTo Ha Nivalin, eneKTpocTMMynaB DeTCKaTa Bb3paCT OCTbP IlaHKpeaTMT C e CpeUa qMR. PRAKO. H ~ ~ Y ~ce CKacae T O aaTpaeMaTMrtiMyepedM (KOHYcnome~~n TY3MM, XeMaTOMM M n M 'iaCTn'iHM pynT)'pM) M n MCneF(0nepaTMBeH naHKpeaTMT. B ?AMHHClHMCnyVaM M M 0 npM ReqaTa Ycnox~e~wma, KOUTO ce HZI~~IIO~,~K~T npnAeqa, one3ahn~aa~e ce ~p oa ~ a u ~ cnep, a AMTM~HM rpelum M n M pnpaHM no noeontianepmoHMT,ca: npM Wlb'iHO-KaMeHHa 6onec~. a) ycnoxHeHuR OT cTpaHa Ha onepamBHaTa paHa@ n e m oHa ~ npeAHa KopeMHa cTeHa, cynypaqnn, nexmcKJ~~cH~HK~~HR q e ~ qm n~ c M ~ 683 M eencqepaqn~ Ha KopennHM opratin. Cbqec~eym penclqa ~ K n a c ~ @ ~ ~ apa3pa60~eHM qw~, 6) YCnOXHeHMR OT CTpaHa Ha KOpeMHaTa KyxblHa: Bb3 O C H O B a Ha ~ ~ ~ T O M O P $ ~ ~ Il ~ pOMeHM O M C IM H n M M TeXeT~ - nbpanrHo nporpecclpatieHa nepmoHllrTa - ~a6n10Clla Ha WlMHM'iHO nPOTMqaHe. Aaeace npu TaKTnrecKM rpeurltm,AonycHam npn neqeHuOCHOBHM na~o~op$onoru MPMM: .~~~ eTo Ha nepwToHuTa, ycTaHoeeH npw napenwaTa onepa1. Ocnp HHTepcTMquaneH naHKpeaTMT. UHfl; 2. OcTbp XeMOpaMqeH IlaHKpeaTMT. - OTnyCKaHe Ha 'ipeBHM C)TyPM H aHaCTOMO3M, Ha 3. OCTbp HeKpOTn'ieH IlaHKPeaTMT. aneHp,MKynapeH IryltaH, o6pa3y~a~e Ha MexqpHbwn 4. Oc~bp ra~rpe~on 3 moeti e ~ naHKpeaTuT. a6cuec~. QHO OT ~ah- emm me ycnoxaieHMRoTcTpatiaHa 5. K H C T O IlaHKpeaTlrlT. ~~H KopeMtiaTaKyxuHa e paHHaTa Mexatinwa qpeetia Henpo6. X ~ ~ H M naHKpeaTklT. C~~H XOflMMOCT. Bb3 ocHoaa Ha K~MHMC~HOTO npoTnqatie ce pa3nnqaB) ycnoxaieHw OT 064 xapamep - H~A-T~XKOTO saT TPM OCHOBHH $~PMM: neKa, cpeAHa M TexKa $op~a. ycnoweHue e cencumT c yepexqatinfi Ha OCHOBHMm 3 HeHM $ ~ H K ~ M M .

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Oco6enocmu na cneurnume cacmonnun B gemcka Batpacm

487

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OT rPb6~a'i~MR cnn6, no-BMCOKO

5. 'ipea~a HenpoxoAMMocT,flbnxaqa ce Ha Boneynyc M n M CTpaHrynaqUR Ha qpeBHa L H K a , IlPM'iMHeHa OT MeKenOB flMBepTMKyn M n M AOE ( K ~ ~ Y M C T M K ~ ) . 6. Morbus Hirschsprung- WMHH'~HU6enesn Ha H M C K a pe6enorpee~a HenpoxoflMMocT, xapamepHo KnuHwrHo npoTHraHe.

- CTOMaUHO M no-Man-

KO, no-HICK0 M H W R C H O OT T P ~ ~ H ~ C I H c'rbn6 WR & O 'g e HanHO. O C T C ~ H 'iaCT ~ ~ OT ~T KOpeMHaTa ~ KyXUHa e X O M O reHH0 3aCeH'ieHa ($Mr. 17.5). KOHTP~CTHO PeHTreHOBO M3CneflMHe, CM0 B H3KJllOCIMTeIlHM Cny-laM npM HeCbOT-

OTBepCTMe M PeKTyMa.

T ~ ~ H c-~B o CbBpeMeHeH ~ T TpaHCnOpTeH KyBb03 C

V M m M 3a M ~ ~ R W Ha: H ~ nOBpbqaHe, aCnMpaUMR, XMnOT B P M U R .

BeTCTBMe M e w y K n M H M i 'H a KapTMHa M HaTMBHO PeHTreHO-

so MxneAsaHe. E ~ f l o c ~ o n c -~KaTo o npeuonepaTHsHa

eHfl0CKOnMR.

I. Cynpananunap~~ @opu~ 1. A T ~ ~ H ~aM nMnopa R - pa3n~raea ce ~ rnaeHo no HaTmHaTa pemretiorpaua, nMnceaT ReeTe xMgpoaepMrHM H M B B . 2. Kappnoxanasu~ - xapamepbT Ha nospbqaHeTo e pa3nM.leH, H R M a HaPYllleHMR B OTflenRHeTO Ha M e K O H M y Ma. 3. B p o ~ e x#nep~po$ur~a ~a nnnopHa c ~ e ~ o 33 a~ a -

O n e p a ~ w ~ npe~(onepama~a ~o, noAroTosKa: 6-8 raca, KaTo B TereHMe Ha HeR ce oclrrypmaT: npoxojqwa ~ p a hC ~ T O aMaLUHa COHfla, #H$Y~HOHHOnecleHMe, ~ H T M ~ H OTMUM, K a P f l M O T O H H U M npM H w a . Onepa~MB~a TaKTMKa M MeTOflMKa B 3 a B M C U M O C T OT a H a T O M M q H W R BapMaHT. OCHOB~H OflepaTHBeH MeTOfl o6xofl~a a~ac~onno3a, 3a npeAnoqMTaHe Y-o6pas~a. npv M~M~~~HO~H~$O~M~-~~YO~ e K ~C ~ q M H3 O M F T IHa OM MeMMFI

Gpa~a~a, cy-rypa Ha flyoAeHanHara cTeHa - HanperHa.

Ilpbc~etioe~ae~ naHKpeac (pancreas annullare)

flo ~~ Be n~ ap l ~a aa~~ 'iMRTO ~ a nK M J l M RH ,MClHaCMMr ~ ~ e n ~ ~ n ~ - ~ ~ ~ a n ~ ~ l ~ a ~ a n o ~ p b q a ~ en ~poe c nap ~Be nR ef ~ IlTOMaTHKa e T a 3 M Ha nbnHa O ~ T Y ~ ~ ~ M flY0aeHanHa O H H ~ xapaKTepMcTMKa, xapanepw exo M peHTreHoea H ~ X O ~ K M . HenpoxoAMMocT OT ~ ~ @ p a n a n # n a xaparcrep, pe~ flere~wII. bl~$panan~nap~n @PMH eTo e OnepaTuBHo: o6xofl~aflyofle~o-flyofle~an~a unu 1. C T ~ HHa OAyOfleHyMa ~ ~ - KnMHMqHaTaCMMnTOMaa ~ a c ~ o ~ 3a o3 npeAnoruTaHe a Y-06TMKa e no-cnah ~ s p a s e ~ a npomma , ce B no-K~CHM flyone~o-Ceo~an~a paws nopa,qn no-flo6pu~e A A p e H a w M KarecTsa. cpoKoee cnen paxqaHeTo, peHTreHoeaTaHaxoAKa ce xapamep~3upaocseH c AseTe xMApoaepMrHH HMsa M c HZUIllrMe Ha OCKbflHO KOnH'iecTBO Bb3nYX no XOAa Ha AT~~~ HaHTbHKOTO R llepB0 T b H K O T O clepBO. AH~TOMM~ BapMaHTU: HU M ~ M ~ P ~ H KOPfl O ~O ~ HeH, H , nb2. CHHRPOM Ha Ladd - oc~po Hacnnuno aacunea~e neH TMn. npu nocneflHMR paTa cnmo 3 a ~ b p w a a q rpe~ Ha xapaKTepHaTa 3a AyoAeHanHaTa c ~ e ~ o 3 KnuHMrHa a B H U CeWeHTM C a HanbnHO OTfleneHM eflMH OT flpyr, KaTO C M M n T O M a T M K a , 6enes~ H a LUOK M IlePMTOHMT, M3XOwaHe 3qbnmMTentio M e w y TRX H M a fle$em Ha ~ e s e ~ ~ e Ha T b M H U IKMnKM K P b BM n M KbPBaBMMaTepMM, XapaKTepHa Ma. O C O ~ aHaT0MMWH ~H BapMaHT e aTpe3MRTa Ha T b H K O PeHTreHOBa HaXORKa. repeo npu T. H. CMHAPOM H a ~ 6 b n ~ Kopa o~a (Apple peel 3. A T ~ ~ ~ HauT b R H K O W P B O - no-KbCHa n O R B a H a syndrome), c b c r o ~ q ce B ~ BMcoKa B heto~an~a T P ~ ~ M IlOBpblqaHMRTa, MMaqM @eKyneH~e~ XapaKTep, AH$Y~HO nwnca Ha ocraHanaTa racT OT W e l o ~ y a M 3HarMTenHa 6ano~Mpa~e Ha KOpeMa, eC(HOKpaTH0OCKbflHO M 3 X O w K F l a racToT nneykla, saefl~o c npMnexaqw MM~ e 3 e ~ ~ e He Ha MeKoHMy wnH nmca Ha oT4enRHe Ha TaKba, MHOHaJlM'i~a~a Vat7 OT TepMMHWlHMR MneyM e C MHOrO K b C xecrBo xMApoaepMrHM HMBZI npu peHTreHoeoTo MscnenMeaeHTepMyu, 06ycnae~q HaaueaHeTo Ha repsoTo noA BaHe. $op~a~ Ha a o6en~a OT F I ~ ~ ~ KKopa. O B ~Pasn~raaa~ 4. M ~ K O HMneyC M~~ - KnMHMiH ' M 6ene3~ Ha H M C K a oqe: h e o ~ a n ( ~na o-~RAM KMneanHa ~) (no-rec~a) $op~a
TbHKO'ipeBHa HenpoXOflMMOCT, HaCTbnMqMO ~ M K H O B ~ H O HaTbHKO'ipeBHaaTpe3MR.

I e H cnefl pax,qaHeTo, xaparcrepHa Haxoplta npw (~H~HK~~H MO P e TH O T r e H O B O T O MXneflBaHMR.

cnefl3

Yec~o~a: 1:8000 Ha 10 000 p q a H # R , no-rec~o np#

M O M M C l e T a .

492

Oco6enocmu nu cnelunume cbcmonnun 6 gemcka Baspacm

Talnnqa 17.6. Bpope~a vpeaua HenpoxopnMocT M ~ X ~ H M ~ H ~ 06~ypaqMoHHa A T ~ ~H ~ a pYOpeHYMa. HR ~P~CT~HOB IlaHKpeaC. M ~ ~ ~ HA T ~ ~H ~ a nM HK R O WpBO. M ~ K O H M ImeyC. ~ M A T ~ ~Ha ~ pe6eno M R repB0.

CHH~POM H a MeKoHuanHa aanyluama. HRKOU @PMH H a 6onema Ha Hirschsprung. BHCOKM $McTY~~HM H 6+?3$MqJlHM M HMCKM ~ ~ @ H C T ~ ~ Tunoee H a aHopeKTanHu ~an@p~aquu. npuwc~a~ OT epynnHKaquM, n b n ~ a QMBePTMKYllM,TYMOPH. CTeH03a Ha pYOpeHyMa OT X U ~ ~ ~ $ M K C ~ ~ M O 6pupoae, nuraMeHT Ha Ladd, ManpoTaqufl, CMH~POM H a Wilkie, aHouanHo pasnonoxeHa eeHa nopTe, npuTMcKaHe O T B ~ H OT RHBePTMKYnM,T Y M O P H .
S .

C ~ e ~ oH sa a~ H K repBo, O ameaue~a npw ( 1 ~ 6 p o n n a c ~ ~ r ~ ~ Henbn~a nepm0Ht.m. C ~ e ~ o a H a ape6eno repeo. HRKOM $OPMM Ha 6onema Ha Hirschsprung. HWCKM $MCTY~HM THnOBe H a aHOpeKT3IHM MaJl$opMal$4M. Crpa~rynaq~~, eonaynyc, HoWnyc OT ductus ornphalomecen tericus pers. oKono MHTpanepmoHeanHuGpupoee, esamHaquR U b n ~ a ~~~apqepaquu ~a~ H K repeo O npea ductus ornphalornesentericus persist. M~~apuepaqu~ Ha ~ H K M O pe6eno repeo npM epopetia cfla6MHHa XePHMR.
HemnHa
~ M H ~ M M ~ H ~

CTpa~rynaquo~~a

'iac~ure~ soneynyc H a ~ H K repeo O npH o6u4 MeaeHTepMyM. ' i a c ~ u r e ~ Boneynyc H a nHKo qepeo npu racTpocxMaa. npM TeXKa HepOHOceHocT

nape~~r~a

FJM$Y~HO. K ~ c nORBa H ~ Ha IlOBpbLlJaHeHa $eKyneHTHo CbpbpXMMO. K ~ C HBnOUaBaHe O Ha 0 6 4 0 ~ 0 CbCTORHMe. Abflbn)~~ C e Ha HapylUeHMR B K ~ ~ B O C H ~ ~ # ~ Ha B~H~TO H a n ~ q ~Ha oc ~~ spaae~ paaw~pe~ no4Koma a B ~ H O ~ onpeueneH TbtiKorpeeeH yracTbK C ~ ~ $ a p u ~ Ha pa Me~e Mpexa Ha npepHaTa KopeMHa cTeHa. f l p ~ Hac-rbnnnM 3eHTepMMHMTeMYCbAOBelPa3BWHeHaHeKp3a,~nHa YCnOXHeHMR - neflopa4Hfl Ha 'ipeBHa BHKa - 6 a n o ~ ~ pesop6qn~ U n M T ~ ~ H C $ O P BbB M ~$ ~~ H 6R po3e KOPpOH, ~ paH KopeM, eneM Ha npeuHaTaKopeMtiaUeHa M BatituHnnMUeH OT nyM!H, 06ycnoee~~ OT ~ ~ ~ p a y r p Bb3HMKo6~0 Te reHMTanMH, Hanucltia MaKap M BRna nepwmmKa (ocoan^ maaruHauMM, cTpatirynauMM, Boneynyc Ha onpeAe~~HOCT). neHa rpeeHa rbHKa oKono OcTaTbuM Ha ductus ornphalomesentericuspersist nnv ~ p y m MHTpanepmoHef l n a r u o m ~ a an~n 6pnuoee, nocnepMua Ha ~ ~ ~ p a y ~ npeKapaH po6~0 A H ~ M H ~ C T AaHHM M~HM 3a XHAPaMHMOH, nOBpbuaHe acenTnreH nepmoHMT. c Ha $eKynem~oC ~ ~ P W M O 6anoHMpaHe , Ha KopeMa, C~~mo~ma JlMnCa Ha OTAenRHe Ha MeKOHMYM M n M OCKbAHO OTuenRHe. Q H ~ M K ~ ~HO eBeHTyanHo onwneatte Ha AllvlaTMpatiaTa BHCOK~ (fieIOHanHa) TbHKO'ipeBHa HenpoXOflMMOCT: HWaTpeTWHa rpeBHa bHKa. ExorpaN~o M3CneAMHe: noapbqatie - Mexqy 12-24 h, napmtiarantio AyoAeHan~ a n n r attexorewn ~ n OHM B KopeuHaTa KyXMHa. PewreHO, BnocneAcTBHe@ K y n e ~ ~ Jl~nca ~ o . n n OCK~AHO ~ epHon3cne~~a -~ ocHoeeH e MeToA Ha noc-rHaTanHaTa KPaTHO M n M PByKpaTHO OTAenRHe Ha MeKOHllyM. ~ X ~ O H M HOBO nonoxewe, o6xaapaHe Ha KopeMa n p e p m o B ropHw MY eTm. P~HHO AMamocTnKa- HaTnBtio B nsnpaee~o uawo BPAM M KopeM Hannrne Ha xnApoaepnrHH HMM HaCTbllBaLL(H AeXMnpaTa4MR M TeXW HapyUJeHMR BbB BOC pa3nMrHa nOKanM3aqMR M 6 p i . KOHT~~CTHOTO PeHTreAHO-eneKTpOnMTHOT0, 6emb'i~o~o M KMCenMHHO-MKmHOBO Mxnepeme c 6ap~eea cycneHcMR e KompnHAHqnHOTO paBHoBecMe c xapamepHa cnnnmoMaTHKa. P ~ H H O paHo (@Mr. 17.6), ($Mr. 17.7). BnOUaBaHeH ~ O ~ ~ O T O C ~ C T O R PRAKO HM~. B~~MoXHOCT~~ naJlnauMR Ha pa3UMp?HaTa HaaTpeTMclHa clpeBHa bHKa. H H C K(MneanHa) ~ TbHKOrpeBHa HenpoXOAMMOCT: HaPYlUeHHR BOTAenRHeTO Ha MeKOHMyMa-nllnCa M n M OCKbRHO oTAenRHe. noprep~mo 6aJloHMpaHe Ha KopeMa -

ETHOJIOMRH na~orene3a

Oco6enocmu no cnetunume cacmonnun B gemcka Ba~pocm

493

MOCT ~ H T M ~ H O M ~UIMPOKOClleKTbPHH M, BbB BMCOKM TepanemMrHn ~ 0 3 T ~ p.a ~ c n o p B ~~ y ~ b o C3 nouxopu4M TeMnepaTypa, a n w o c T , nonycentiano nonoxewe, eeeii~yan~o~~cnopopo~epanw~.

Onr. 17.5. H m n a pemenorpaua Ha noeopo~enoc rrrpe3nn na RyoReHylla. BWBT m fleere xwpoaepnrnn nnea - crovaluno n m e m a n n o

6 e n e 3 u H a HMCKa TbHKO'ipeBHa HenpOXOAMMOCT. flMU(M aHoManMM, x a p a t m e p H a peHTreHoea HaxopKa. CT~HOnCa H a OTAenRHe H a MeKOHMYM. 6anoHMpaHe H a 3 a H a AyogeHyMa 6enes~H a H e n b n t i a AyoAetianHa KopeMa. noapbula~e H a $ ~ K ~ ~ ~ H MaTepMM. T H M K~CHO H e n p o x o p w m c T c xapatcreptia p e t r r r e H o e a HaxoAKa. Me3aCRraHe H a 0640~0 CbCTORHMe. K O ~ ~ M H CTeHM MT~ Ca C KOHHYM H n e y c no-wc~a n o m M no-~oan~pa lnsnsa ~a IlOArepTaHO MeKOBaTa KOHCMCTeH4MR, MOraT A a Ce OnMH a KllMHMrHaTa CMMnTOMaTMKa, XapaKTepHH PeHTreHOBa naT pa3luMpeHMTe, M3nbnHeHM C yllnbTHeH MeKOHMyM TbHH W O p K a M reHeTHrHM M3CneflBaHMR. A T ~ ~ H ~ aupe6eno R KO'ipeBHM l%HKM. P ~ H Hpa3BUTMe O H a Bb3naJlMTenHM 6erepm KnMHuKa H a ~ ~ c ~ a p e 6 e n o r HenpoxoRHMocT pe~~a ~O&)O~HM YCn0)KHeHMR. XapaKTepH0 e no-MeKOTO KJlMHMc xapatcrepHa peHTreHoea HaxoAKa ae6enorpee~~ HH~ H O npoTMraHe H a 6~1e3MTe H a r p e B H a T a H e n p o x o n v Ba. C M H A ~ H ~aM MeKOHMMHa 3 a n y W X I K a KnMHH'iHH MOCT. 6ene3~ H a HucKa ~e6enorpee~a HenpoxoAnMocT, npeop o n R H a r p e 3 KJIM~M~.Sonem H a Hirschspnrng WIMHM~HM 6 e n e 3 ~ H a HMCKa pe6enorpe~~a HenpOXOpMMOCT C AH~MH~CTH.IHM flaHHM 3 8 @ a ~ M l l H a O~~~M~H~H xapatcrepHa pnHaMmKa, cneu~@ur~a peHTreHosa HaxopXapatmep~a~a no-wc~a M no-~oan~pa M~ ~aR H Ba ~ WIMKa, RatiHH OT p e m H a T a ~ M O ~ C MMR ~ s c n e ~ e a ~ Ha e ~ o HMVHaTa CMMnTOMaTHKa H a H a p y l u e H a r p e B H a npOXOflUXOnMHeCTepa3HaTa aKTMBHOCT. AH~petcraJlHM ~aJl@op~aMOCT. n 0 ~ a J l H a T a KOpeMHa HWOAKa Bb3MOXHa WlnaL(MM 6 e n e 3 ~ H a HMCKa pe6enorpe~~a HenpoXOflMMOCT C 4MR H a pMnaTUpaHMTe, U3nbnHeHM C MeKOHHyM VpeBHM n M n c a H a atiantio oTsepcrMe H a ~ o p ~ a MRCTO n ~ o M xapa~ H K MX .apatmep~a peHTreHoBa HaxopKa: M t i o x e c T e o xutmeptia peHTreHoea HaxopKa. APOaePM'iHM HMBa, KaTO B MlleOueKanHaTa 06nac~ Ce @ o ~ M R YraCTbK H a HeXOMOreHHO 3aCeHCIBaHe, HanOAO6~ea14 "nrentia n ~ ~u a n H".npoRpeHa OT Monuw ~pexa". n o n o x ~ ~ retieTMrHM e n ~ ~ M ~ C ~ ~ ~ B ~ Hnonoxtc~~en MFI. nMnOKapnMHOB n0TeH TeCT C BMCOKO CbflbPXaHMe H a HaTpMfi M XnOp B n0na H a HOBOpOfleHOTO.

AM$Y~HO

494 m Oco6enocmu no cneurnume cncmonnun B gemcka Banpacm

Culwmo~am~a

HUCK fle6enoclpe~~a ~ HenpoxoRMMocT.J l ~ n c a Ha OTAenRHe Ha MeKotiMyu. A#$Y~Ho, nporpecwBHo6 a n o ~ ~ p a He Ha KopeMa. KbcHa noma Ha noepbqaHe, cneA 24 h cnefl paxqaHeTo, c $ e ~ y n e xapawep. ~~e~ P~~BM Ha TM pasu~pe~ noAKoxHa a ee~os~ Mpem a no npe1HaTa KOJleve~ne~ eo npeAMMHo onepaTmHo. O n n n 3a ~ HeO B O~U(OTO CbCTORHMe M OnepaTlrlBHonecletcnece ~ C T O B Mn3~bpurea~e Ha ~ n ~ a ~PeMHa a CTeHa. K ~ C HBnOWaBaHe p a 3 s ~ Ha ~~ nem1paTaqMR e M HapyureHmB xoueocTa3aTa. c rac~porpa$w~ noA peiiTreHoe KotiTpon. f l p Heycnex ~ OT flByKpaTeH OnMT Ce IlpMCTbnBa KbM OnepaTMBHO Ile'ieHMe. n p o p b n x ~ ~ e nHa ~o npeflonepaTnsHaTa c~ noproTosKa: 812 h. O n e p a ~ v s ~ nevewe o~o e p e 3 e ~ Ha ~u yvacnK ~ OT 6 e n e s ~Ha HUCKa fle6enoclpe~~a HenPOXOflMMOCT. TepMMHaJlHMR MneyM M TbHKOclpeBHa aHaCTOM03a C 0 0 0 ~ XapaKTepHa PeHTreHOM HaXOflKa, XMflpoaepHrlHM HMBa MRHe Ha AePMBaqMOHHa HneOCTOMa nO MeTOflMTe Ha O T ~ H K OM - fle6enoclpeee~ xapawep, npw npMrocKonMRce Santulli, M n M 3a npeAnovMTaHe Ha Bishop-Coop. orepTaeaHMBoTo~aa~peswma.

OcoCenocmu Ha cneurnume cacmonnun B gemcka Baapacm

495

A T ~ ~ Ha ~ M HneyMa R n o - p a ~ noflea ~ a Ha nospbuaHHFITa,XMflpOaepM~HMHHBaCaMOOTnHKO.lpeBeHXapaKTep. M ~ K O H H ImeyC~ M n o 6 a e ~M a BOaJlMpaHa eBOJllOuMR Ha KnMHMwiaTa cMMrnoMaTMKa, xapaKTepHa peHTreHoea HaxoRKa, RaHHu 3a @ ~ M M ~ O HO ~P~M~HRB nonoxwTe~H~, flM@epeHuManHa~a pUalHO3a e M R e H T M i ' H a CT a 3 M Ha neti nwnoKapnMtioBTecT, nonoxu~en~w ~~H~TMY u3cneHM a ~ p e 3 Ha ~ ~ ~e ~6a eno~ repeo. o AeaHwR. CMHR~OM H a ~ e ~ o ~ ~ a n ~ a 3 a n y ~ #flew ~an~a-np~ T M q H aW I M H M q H aC H M n T O M a T W K a H PeHTreHOBa HaXOflKa, IlOJlO~MTeneH e@eKT OT M3BbPLUeHa O'iHCTMTenHa KJlH3Ma, JlMnCa Ha PeuMAMBHa M n e y C H O T OC b C T O R H M e , CMHflpOM Ha M ~ ~ K MnRB F I KonoH (Small left colon syndrome), WIMHMbonea Ha Hirschsprung ClHH 6ene3~ Ha HMCKa fle6eJl0clpeBHa HenpOXOflHMOCT C Kacae ce 3a nbnHa nMnca, ~ e f l o p a 3 ~ m M n M e H~~PR xapamepHa peHTreHoaa HaxogKa npM ~p~rorpa@w, 60nOCT Ha H ~ ~ B H O ~ ~ H ~ M eneMeHTM ~ H M T ~ B CTeHaTa Ha OnnecT Ha Hirschsprung, KnuHurHM 6ene3u ~afle6eno~lpeBpeReneH y a c n K OT fle6eno~orepeo, cbnpoeoneHM c Ha HenpOXOflHMOCT OT 06Typaublo~e~ TMn, IlpeOflOnRHa HapyueHm B M M ~ ~ M H M ~ ~ Ha ~ HepaHMTe M R T ~ BnaKHa B rpe3 HeonepaTclstiM cpepmsa M peuMRMeMpaqa OTHOBO fle6enorpeBHa~amerra. Hapywe~a e nponyn3~~ Ha ~a npM nmca Ha nocToRtitiM~ ~ M X3a Me ~ a ~ y ~ane6enoa q ~ ~ fle6en0rpeBH0~0 CbflbPmMMO M H ~ A H M F I KJlMHM'ieH eKBM'4peBHOTO CbflbPXMMO, BMCOKM 6 e 3 @ ~ c ~ y n ~ n Ha s a n e ~ ~ - f l e @ e ~ a qH w~ a~ pay. u e ~ (B ~H ~~~ R ce a ) wpa3~-

MM

a~0peman~uare~e3~~-nwnca~aa~an~oo~ ~e pn c~ e sar By o~ p aane~, ~~ ~ a npeKpaTReaHe~ac n o ~ ~ a ~ ~ a ~ a f l e ~ o p ~ a MRCTO, n ~ o xapaneptia peHTreHosa HaxoAKa npM KauMR H Bb3HMKBaHeHa nbnHa06~ypauM0HHafle6en0~pe~~sep~orpa@uma. aHa HenpoxoRMmocT,mnxaqace Ha 0 6 ~ y p a OT q~ o6pa~ 3 y B a H M R @ K ~ J ~M on MBCneflCTBMe~ @ ~ H K ~ M O H ~XaH~HHF
rnMoHepeH cerMeHT.

Yec~o~a: 15000 Ha l 0 000 pwaHwfl, npepHMHo npM

M O M C l e T a .

n e q e ~ ~e e onepaTMBtio. ~o l l p o ~ ( b n x ~ ~ e n~a ~o npecT AonepaTMaHaTa nogroTosKa- 8-10 h. TR~mtorm ~pah~a CTOMaluHO-flyOfleHNlHaCOHfla, M H @ Y ~ M O H H O ~ ~ CnpM ~~HM~, H m a - ~ H T M ~ M O T M ~ fMl .p e ~ n o r ~ onepaTmHa ~a~a MeTo-

flMKa- KOnO-KOnMrHaTepMMHO-TepMMHanHaaHacTOMO3a.

CHHA~OM Ha MeKOHHaJlHaTa 3aflylUaJlKa

f l p o ~ ce ~ c~ 6ene3~ ~ a ~an b n ~ 0 a6 ~ y p a u ~ o ~ ~ a f l e 6 e B~BMCM OT RbnxMHaTa M p a 3 n o n o x e ~ ~ e Ha ~ araHro norpeeHaHenpoxoRmocT,BcneflcTBueO@PMFIH~Ha nnbnbioHepHHR CerMeHT. Paanwaea~ ce: K ~ C (HMCKM) M -araHTHa MeKOHMMHa 3anylLlanKa, 06~yp~paqa HanbnHO flyrJlMOHePHMRT Y C l a C T b K 06xeaqa C a M O PelcryMa; PeKTOCMMeHa Ha flHcTanHme oTflenM Ha fle6eno~orepeo, HahMOMflHM (TH~~M!~HM) @PMM - araHrnMOHepHHFlT Y'iaCTbK recTo curMa. o6xeaqa npexoRa petqm-c~ma M n MpvcTanHaTaA nonoenHa; Abnm ( p e ~ ~@ u )o p ~ # aratirnMoHepHMm cemeti-r Emonorun ~ o c ~no ~@ne~cypa ra KonMnMeHanMc; C ~ ~ T O T ~a ~ rH aM ~flpex0flHM HapyUJeHMR B CbCTaM Ha M e K O H M Y M a , HerJlMOHePHMRTCerMeHT flOCTMrafl0@ne~cypa KOnM XenaTM3 P R n O C T Ha p e 6 e n o r p e ~ ~ m MePeKTMHM ~p0~ynCMBHH Ka; T O T ~ H M @PMM - qFInOTo ~e6eno repso e nMweHo or
M e X a H M 3 M M ,X U n O M a T H M e 3 e M M R .

H ~ ~ B H O ~ ~ H ~ eJleMeHTM. M ~ H M

Pasnuraea~ ce flee @OPMM: C O ~ C T M ~ ~ ~ MCMHAOH~H P O M (no-clec~a), C eHTep0KOnMTeH C M H f l P O M (no-~Rfl~a).

ffiMHM'iHa KapTMHa npM HOBOpOfleHOTO: JlMnCa M n M KbCHO C n O H T a H H O OTflenRHe Ha M e K O H M y M ,~ ~ M $ ~ ~ M O~H MH OO HMpaHe Ha KopeMa, noapbqatie c @ e ~ y n exapamep, ~ ~ e ~

496

Oco6enocmu wa cneurwume cacmonnun B gem

W H O BnOLUaBaHe B 0640~0 C b C T O R H M e ,K b C H OP a 3 B M T H e Ha pexMpparaqMH M cbnbTcTsauMTe R npoMeHM B xoMeo-

HOCT. Cnep nbpaotiaclaneH onm 3a HeonepaTmHo nereHMe rpes WIM~MM, npu nmca Ha e$em ce np~ci-bnea K ~ M

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Syndrome Ladd

CHMIITOM~K~

Oc~po HacTanMno 3acuneaHe Ha xapaicrepHaTa 3a UyOAeHaJlHaTacTeHO3a C M M n T O M a T M K a :M H O f O K P a T H M noBb3O C H O B aWIMHM~HaTaCHMmOMaTMKa, H a T M B H OPeHB p b W a H M R Ha )KJlb'iHO-flyOAeHaJlHOCbflbpXMMO, npeKpaTreHoeo M3cnenBaHe B ~anpaae~o nonoxeHne: t i a n M r T R B a H e Ha M3XOX#lHMFITa HnM M3XOWaHe H aO C K b A H O HM H n o ~ a n u 3 Haxvppoaepnrtime a~~~ H M B a ,cTeneH Ha Konwrecmo n 3 n p a x ~ e npMMeceHM ~n~ c KbpBaBM W ~ K M , rasoeo ~smnm~e ~ane6eno~o repao, eeeHryantioorep6bp30 BnOUlaBaHe B 0 6 4 0 ~ 0 C b C T O R H M e , p a 3 B M T M e H a TamHe Ha BoflBMpaHMRTbHKO'ipeBeH YaCTbK, npOMeHM B 6enescr Ha nepmoHmB n o - n c e ~ c ~ a p u i~ , ecno~oic~eue cTeHaTa Ha BoneMpaHaTa rpeeHa m K a : 3a,qe6en~m~e HH e M O T M B M p a Hfin,ar npn HOB( D ~ ~ U M ~~ HbM p ~ a r lK e~ ~Ta O o$op~n~ H a e noprepTaH nMraeMreH pene$. Exorpa$c~o eKBMBaneHT Ha CMJiHme KopelMHM 6 0 n ~ ~ . n3cnep~a~e: paHtiM 3a pa3nonoxe~me~o Ha aHexoreHHnTe 30HM. H e R C H aK n M H M Y H a KapiMHa K O H T P a C T H O peHTreHoeo n3cneneaHe nacax. Bb3 O C H O B a flMHaMHKaTa BK J l M H M C l H a T aC M M n T O M a T M Ka M nPOMRHaTa B PeHTreHOBaTa HaXOnKa: HaflMrMe Ha X O M O r e H H O 3aCeHCIBaHeBUeHTpmHaTa VacT Ha KOpeMHaTa KyXMHa, O C ~ ~ H r aHa o Konetqw ~~ B nep~$epm~~a i. BMco~a JleBKOqMTO3a C eKcTpeMH0 OneBRBaHe. H~THRHO peHTreHoeo n3cnepaa~e: npn HamnMna nep@opaum nHeaMonepwToHey.

Anamoenrwa

AHarUtICmKa

PM

~ O ~ O ~ H HnOBeAeHHe ~ H O H nelleHHe
3 q b n x ~ ~ MaHMnynaUuM e n ~ ~ B nepMoAa H a nnamoc m a . TpaAHa c r o ~ a w ~ o - p y o p e ~ a cotifia. n ~ a Peicran~o y w p a H e . MH$~~MOHHO nerewe. ~ ~ O T H ~ U ~ O K O MeBM

Cneluuo 60nunuo neseuwe

PM HyXJ@ KaPAMOTOHM4M. Cneluuo 60nunuo n e w w e

P O f l P M R T M R . HeKpO3a

Onepams~o, no cneurHocT. n p e ~ o n e p a ~ ~ l none~a~ r O T O B K a e KpaTKa- 2 4 h. Onepa~cllB~a MeTOflMKa: OTCTpaHReaHe Ha 6wpa M ~eeonenpa~e H a rpeetiaTa miKa, npM HeKpo3a pe3eKllMR C TepMUHO-TepMMHMHa aHaCTOM0-

3a.

Onepama~o, cnewHo. n p e ~ n e p a m e ~ a nonro'ro~a BKa e 3-6 h. O n e p a ~ ~ ~ HaMeca: tia pewnaMpaHe, npn

- pe3eKYMR M TepMMHO-TepMMHaJlHaaHaCTOM0-

3a.

Oco6e~a @p~a Ha cTpaHrynaunoHHaTa rpeBHa Henpoxopnrmx y HosopoFleHoToe eearwHaqHma Ha npmnexaqa-rarpeeHa rbtiKa c nmnepeaqaTa i MHKapuepa4MR npe3 nep3~c~t1paqAOE. P ~ ~ BCe MKJ B l M H ~ H ' i H a C M M moMaTnKa Ha ocTpa rpeaHa HenpoxonnMocT, nocnepsaHaOTTaKaBaHa~ePMTOHblT.

C~paurynaq~oueu nneyc
A b n m q ce Ha cTpaHrynaqw, Boneynyc, oKono ocraHa ROE, IlepMTOHeanHH6p~poee.

O c o 6 e ~ o c m un a cneurnume cacmonnun 6 gemcka Ba3pacm

.

501

cna6uuua xepua
Xapa~~ep~3lnpa Ce, r e IlpH aHaMHecMVHbl PaHHM 3a, peno~a6un~a C ~ ~ ~ M XepHmR, H H E ~ TR cram ~penoHa6#nHa M ce noRemaT xapalcrepHnTe &new Ha ocTpa rpeeHa HenpoXOflMMOCT.

~enpoxo~nnnoc~y ~oeopofle~o~oca: ~ma$par~ax ne ~p a HHR C MHKaP4epaqMflHa 'ipeBHH n H K M npe3 OTHOCUTenHO

Te3M Ha nporpeCMpau(a VpeBHa HenpOXO~UMOCT. To'~H~ AMamio3a ce nomaen rnaeHo 0 x 1o c ~ o m Ha xapamepHaTa HaXOAKa npM H a T M B H O T O PeHTreHOBOU3CneABaHe. OM$anouene - npn ~ a n pa3~epn ~ n ~aPewma B npepHaTa KopeMtia cTeHa n ronm 0~4anoqene~ caK, u 3 n b n ~ e c~ rpeaHu ~ H K Moxe M Aa Hacnnu MHKapqepaqnma UM, c noRm Ha 6ene3n Ha 6bp30 nporpecnpaqa ocTpa qpeaHa HenpoxoAnMm.f l y n n ~ ~ a q m n Ha ~~ eH K O T O 'lepeo nnn M H T ~ ~ ~ ~ ~ ~ oT Y M M O ~ P M ~H Y HOBOPOAeHOTO ~J'IHH MOraT qpe3 BoneupaHe Aa npn'inHRT cTpaHrynaquoHHa rpeaHa HenpOXOAnMOCT. M ~ ~ a p q e p a u Ha ~ F IllpeBHH l%HKH BbB spoae~u $e~ecTpaquu nnn~ p y m Pe$elcrn Ha MeaeHTepnyua unn B nepmoHeanHn~y~o6ose ca K ~ ~ ~ M C T M K ~ .

He~n~a~a.IpeEHaCTpaHryna~MOHHaHenpoXOflMMO

flere~ne~ npn o MoMnveTa e onepaTneHo no cnew- onm aa c n o t r r a ~ ~ a esn~~apqep cw a~ uB o ~cnyame, ~ KoraHOCT. llpn HoeoponeHn n KapMareTaOT ~ X K non U

ce noc-rnra rpes nocTaeRHe Ha AeTeTo c rnaeaTa ~qqony n c neKo n o r n q m e n eeeHTyaneH neK HaTncK ebpxy
MHKapqepMpaHaTaXePHRRBnOCOKaHaIrlHmMHMHHRKa-

an ce npaan onm aa penoHnpatieTo k. npn Heycnex onmT He ce nomapg. YKa3a~ne 3a Hamnnna PesnHKapqepallUR e MOMeHTEUlHOTO yCllOKORBaHe Ha F(eTeT0, nsqeamHeTo Ha @pwqnma, HepuPKo canpomgetio c xapamepeH uryu. CneA BcnKa ycnewHa PeanHKapqepa~ Ms Rq q a n m e n ~ a xocnmannaaqw~ B TereHne Ha 24 h n amatio ~ a 6 n l o ~ e OT ~n PeTm e xupypr. O n a c ~ o m npn CnOHTaHHaTaM n M MaHyMHa Pe3MHKapqepaqnR:TpaBMMpaHe Ha cTeHaTa Ha HHKapqepnpmaTarpeeHa r a ~ m nnn M~~OT kOc 06pa3y~a~e Ha xeMaToMn, npw PpamreH onm - nep$opaqn~ Ha rpeetiaTa cTeHa, penoHnpaHe "en bloc" c nHKapqepaqnoHHnH npbcTeH c nocneABaqn nep @paqufl n pa3eme Ha nepuroHm. A~CO~IOTHH npo~nBO~OK~~~ 3a H onur H R 3a HeonepamBHa~ e s n ~ ~ a p q e p a Knacn@nmqnrr ~ H R ca: paeHocT Ha HHKapqepaqnma noaere OT 6 h, 6ene3n Ha nneyc nnn nepmotim, n3xo~,qa~e Ha nsnpaxBm.: ~a6n. 17.7.

e us~ntocln~en~o pgnKa n Moxe pace p n x u Ha: qacTHqeH Boneynyc Ha ~ H K O T O vepBo n p n o 6 Meaemepnyv ~ unu racTpocxn3a. K n u ~ n r ~ KapTnHa a ~ a e Hexapameptia - Hannqe ca 6ene3n Ha HapyureHa rpeeHa npoxoAuMocT H ~ ~ ~ Y ~ OT C HeM3RCHeHO T O eCTeCTBO. OCHOB~H npeAcTaanTen Ha PntiaMnrHaTaqpeeHa HenpoxoPnMocT OT BpoAeH nponsxoA e napannrnvHaTa rpeeHa HenpoxoAnMocr, xapamepn3npaqace c 6ene3M Ha OcTpa 'ipeBHa HenpoXOPMMOCT 6e3 PeHTreHOBM RaHHH 38 HMUVUe Ha MeXaHH'iHa IlwqKa no XOAa Ha YpeaHnR rpalcr. TRce ~ a 6 n l o ~ a H~A-sere m npu ~oaopoReHMC Te)KKMHePOHOCeHOCTM He3pRnOCT. n 0 ~ q C a e Ha ~ neveHne c HeonepaTneHncpeAcma: emePHeeHn WIMBMU, cmuynaqnR Ha nepncTanTuKaTa c nepncTanToreHtin n @nauo~epanesmr~n npoqeAypn. C HmamHeTo Ha Terno M y3PRBaHeTO Ha HOBOPOAeHOTO6 e n e 3 ~ ~ Ha eHapyWeHaTa rpeeHa npoxoPnMocT npehnnHamT.

T P ~ A HCTOMaUl ~ HO-AyOPeHanHa COwa, #H~$Y~#OHHO neqettwe, no nHPnKaqnnM a m 6 n o m r ~ neqeHne. o OnepaTMBHaTa HaMeCa: XePHMOTOMnFIC pCI3CWaHeHa WHKapqe-

K ~ ~ T K O T P ~ 2-4 ~ H h~ H BKIllo'ilB: ~ o ~ K o ~ c ~ o K o R ~ B ~ ~ ~ , He3awcn~o OT MexaHnma

npm~o6m rexaunwa qpeeua HenpoxonHrocT

6a3HnKaaHe Ha m p a Ta rpeeHa HenpoxoAnuocT, p a 3 ~ e n ~ A ~e Ha ~BncoK o u H U ~ K T 06ycnae~ M ~ p a 3 s m e ~ Ha o wmHnwaTa KapmHa. npn BUCOKMR Tnn HaranoTo e oc~po, 6bp30 HamneaT BOPHO-eneKTponHTHMH XeMOflWHaMHrHMHapYtIJeHMR,POKaTo npn HnmR - pa3~mne~o e n&aa~o, npeaannpa ntiToKcuKaqnma, a Hapyetinma B xoMeocTa3aTa n xeMOPHHaMklKaTaC eH ~ ~ ~ I o P B Il ~ C-KbCHWe B ~ T eTanH.

502 w OcoCenocmu na cneuruume cacmonnun B gemcka Baapacm

(1-80 ~e~otloume) Moxe l a 6bue RweHa pemreHoKowpacnia MaTepnn per os nnM npe3 cToMawHa coHpa 3a YCTaHOBRMHe Ha npeIlf4TCTBUeTO. B nG-lcaCHme CTaQUM T03M MeTOn e npOTllrBOrlOKa3aH. ~ H ~ B M O K O ~ O C K O ~M WR Hamnsa npn sanywea~e Ha rpeetlw nyMeH M npenpnrorpa$nma D a m p d p a M H $ ~ P M ~ ~npn M R ~e6enormcsatie Ha rpesHnR n a m 6e3 3acRraHe Ha cbuoeoUHR. nscnepsa~e Moxe Ra HetlporeHHmeeneMemu Ha rpeeHaTa cTeHa. n p n r u ~ u ~ e peeHa O ~ T Y ~ ~ EXO~~~C~CKOTO nopnoMome nocTaanHeTo Ha ~namoaa~a. ca pa3nonoxe~n w p a - nnn e ~ c ~ p a - q w eM ~ ~~ op . anyMeHHa 06~ypaqnnC e npMclHHRBa OT: VIMCTHM HHBa3UM, pa3nur~n 6emapu, r y q n Tena, W o p n (uo6po~arec~sew u no-PWKO ~ ~ o K ~ ~ ~ cM T ~B X~ OW H ~u U )~ OT ,I npocBeTa Ha 'iepBOT0, $~KW~OMM, BpoReHW HeBporeHHklU 4PYEmonorn~ M aHOManMU Ha VPeBHHR Tpam, P R R K O Mb'4HU KaMbHM M up. E ~ c - r p a n y e ~ ~ o6Typauun a~a ce n p e f l u 3 ~ n ~ OT: ~a Hamnsa npH npC?KbceaHe Ha qpeBHaTa IlpoXORneKcTpanyueHtio pa3nonoxe~n ~o6po~arecme n~Man MOCT, K O M ~ H H H ~ ~ CH Ilp O UTHCKaHe Ha Me3eHTepManHOTO numeHu TyMopn, KUCTM, RynnnKaunM Ha rpeaHna Tpam, ~ p b m 6 p b q en ~ MttepsaunH. ~e npnrn~me ca BpoBeHu a~xe3nn u 6pnuoee(B~~I~HU U npn~o6mn), ~ ~ ? ~ C # M ~ T O M - nnn npnuo6nm: rpeaHn AynnnKaUnn, y o p n n KHCM, HO CbuemByBau M e ~ e n ClneepTnKyn o~ nnn ocTaTbqn OT s~~nanmen n~n np n ~ ( o 6 m cneu KopeMtin onepallnu Q~KT~ o~$anoewepn~yc C n up. 6pnpoee b l a X e 3 t l H A?. Hepo6pe H3FICHeHMCa MeXaHU3MUTe 3a 06pa3ysa~e Ha 'iPeBHH HOAynyCcl. K a ~ o HaisepomHn npnrntiu ce npneMaT BpopeHn rpesHn CT~HOSU, yaenureHn ~esetrrepnan~u n n ~ $ Bmnu ~ n M up. 06ycnae~ce OT Tnna rpeeHa o6Typaqnn ( m n ~ a , ~ e n b n ~u aBucornHaTa ) ~aa a n y l l ~ m ~ e0 ~6 o .~ 0 C~CTO~0 mine Ha peTeTo e c p a e ~ m e n ~ o 6 p M o ce snowaaa B nomcHnTe eTann. Cnupa $naTyne~qn~~a u ne$e~aqnma, HerIpeKbC~ame naTOnOM'iHclr HepBHM MMnynCM 01 no-K~CHO ce nomneaT raQeHen noepbqaHe. K o p e ~ ~ a ~ asacenra~u~ rpeeeti yamKnoseWaT no ~eepo-xy~opa 6on~a e nceH n p u 3 ~ a ~onn~ooGpa3~a ~, c HapacTsaq neH nbT R O TeMM HaPYllleHlllR Ha Ba30MOTOPHHTe PeaKUHTeH3UTeT. K o ~ ~ C M e 6ano~npa ~ T IlOCTeneHHO, HeRCHa UMM B ue3ewepuan~o~0, a no-mc~o u B qetiTpantioTo IlXInaTOpHa 60fle3HeHocT. ~ ~ ~ M c T ~ J T B T HaVanOTO MK~T~ ~pbeoo6pbqe~ne. Hamnsa Tema xunosoneMm, amne ycnneHa, BnocnepcTane ~arnam. n o ~ n ~ onpe3 r a KOenanpa ce rpeeHaTa ~n~po$nopa, a npes npoMeHetiaTa PeMHMTe CTeH#C e OVepTasaT nepMCTanTMpa~MTe rpeBHH rpeatia cTeHa B KP~BHOTO pycno H ~ ~ J T ewo~ E ~n TrnaeHo I%HKU. ~ P H M~ M H O ~ 6anoHnpaH O KOpeMn no-TbHKMKOpeMBHAOTOKCUHH, pa3BUM Ce eHf lOTOKCMHeMMR. HM crew Moxe Aa 6 b ~ nannnpa~a e @ o p ~ a ~ n nnpuru~a, C~nnmo~am~a Hnna 06~ypaqnma. P e ~ ~ r e ~ pnamo3a. oaa Han~rne Ha xuRpoaepnrHn 0640~0 cacTORHHe Ce BnOluaW IlpOrpeCllBHO B KparpeeHu Hnea ~ a MRCTOTO g Ha npenmcTBneTo n rasoae, TKU CPOKOBe (5-6 h). K O ~ M H 60nKa ~ T ~ e HMbI~eOT pa3nOnOXeHU flMCTXIH0. B Ha~anOTO Ha 3a60nR~aHeT0 HaVanOTO Ha 3a60JlRMHeT0, nbpBOHaraflH0e CUnHa, KO-

Ta6nnua 17.7.
lrHa

UuoHHa

06~ypaqu~ ~a n y ~ e ~a ~a ~ H K GI O pe6eno repm OT ~ena. n p m c ~ aO ~e T ~ OT H TYMOPU. cneAonepamBHa. h n ~ aApesue~a,

n u m , xnb'

nyMeHa e Ha ~ H K Innu O pe6eno repm OT I Hem3nHa qamrtio u 3 m n ~ a ~ ) Vamr~o npmcKaHe OT TYMOPH. w e : ~ U B H cnenl ~,

u Tena

,maquo~~a CTpa~rynauu~ ~a~ H K nnu O ~e6eno repao. Boneynyc. Ho~lynyc. M~~apllepaqn~ ~an~ HKO UnH l l b n ~ a pe6eno repao npn npnno6ma cna6UHHa XepHuR. Henbn~a yam re^ ~onsynyc ~a~
H K unn O ~e6eno repso

?XaHHrHaU ~ r Cneponepa~us~: ~ a c;nacTurHa

IrlOHHFl

gemcka Bs3pacrn m 503

n~~oo6pa3a ~a BnocneAcTBne , nocToRHHa, c HapacTsaq MHT~H~MT~ xemoKa. T, r q e ~U e noepbqaHe ca HaWJlH# C M M n T O M M , CbnbTCTBaqH p a 3 B M T H e T OH a 3a6on~BatieTo. C n ~ p $na~yne~qnma a M~ e $ e ~ a q ~ m KopeMb~ a. H e e 6ano~MpaH, IlOHRKOra e HmM4e aCMMeTpMFl M MyCKynHa salqu~a H a KopeutiaTa cTeHa, paHo ce noRBReaT CnMnToMl'l ~ a n e p m o ~ e a n ~ o f l p a 3npn ~e~ aycxymaum e.

nepMcTanTMKaTae HaranoTo~ a ~ a 6 o n ~ ee aycune~a, ~e~o c KypKaq xapamep, ycTaHoeRBa ce nnclcltatie, c HanpepBaHe Ha 3a60nRBaHeT0sarnbm. 6bp30 HamnBaT: MMHaMMR, T O K C M K O 3 a , T e M M BOflHO-eJleKTPOnMTHHHapylueHMR, noBpbqatiuma npuflo6n~a~ $eKynewe~ xapanep,

rpeeen y a m K . n e p u c ~ m ~ e a neKo ~ a ycmecla. Pew TTeHOllOMrHO 683 H 3 M e H e H M R .~ O B ~ H R CeB~~ o6pe OT c n a 3 ~ o n n ~ n Tepanm. r~a nape~lrr~a rpeana ~a tienpox o w ~ o ce c~ pawem Ha HRKonKo C T ~ M F I : l -BM m f l m W. 3qoeonmen~o 0640 C ~ C T O R H HCM)~, meTcTsaqo Ha cpoKa OT npOBegeHaTa onepaTHeHa MHTepMHqMR. ~ H H H C I H IlOBPbUaHMR, M fleTeTO nyCKa ra30Be. K o p e ~ P a B H O M e p H O ~ ~ ~ O H M MeK, P ~ H neK0 , 60ne3HeH npicl naJlnaqHR. A ~ c K ~ ~Ce Te H A M ~ H H ~ C ( H T MIlePHCTanTHqHH UlyMoBe. 2 - p H CTaflHW. BnoluaBa~e Ha 0 6 ~ 0 C ~b C 0T O R H M e , r e m noepbqatilrfl, Texecr B KopeMa U nocToRtiHa h n -

Ka, nnncea $ n a T y n e ~ q K ~~ o.p e ~ ce b ~6ano~npa PRBKO,

Auamocm~a
Pewre~oea AMamo3a. B HaranoTo ce Ha6nlo)laBa~ HeRCHMXM~waePM~HMnHKOCipeBH#HHBa,HepaBHOMep HO pa3npepene~ne ~arasoen KoneKquM B rpesHw Tpam. f l H H a M M C l H O T 0 Ha6nlofleHMe X. a. CeHKM Ce 3mpXaT O~MKHOB~H Ha O epHo n cbqo MRCTO. npn crpaHrynaqMR n no-rec~onpn nHKorpeeeH Bonaynyc ce ycTaHosRsaT U30nMpaHH H P a 3 R Y T MOT ra30Be M T W H O C T M 'ipt3BHl-l k H K n C nocT0RHHanOKanLl3aqMR, KapTHHa, 03HareHa KaTO $offee bean" (B~PHO OT ~a$e). B Hanpeptian cTqnA ce Y c T a H O B R B a H cB0hflHa T e i ' H O C T B KOpeMHaTa K Y X M H a .

PM

nannaTopHocMnHo 6 o n e 3 ~ e ~ . aycKynTaqnR P R ~ ~ K cna6lr nepncTanmrHn luynnoee. n p o ~ e ~ BxeMountiaMMcl KaTa TmKappMR npn ~ o p ~ a n AH, ~o noaMLuasa ce XeMOKpMlaT H a KpbBTa. 3-TH~ T a f l b l qTemo . 0640 C ~ C T O R H H AeTeTO ~, e OTllycHaTo, 6ne~0, ~ 3 n m cMnHa ~ a -a, M ~ O C T ~ ~repm HM Ha nblqeT0, HenpeKbCHaTM K O P e M H M ~ O ~ K MHOrOKPaTHM M, nOBpbqaHHR Ha $ ~ K ~ ~ ~ C H T O T M H a l u H oO CbflbpWMO, nMncm $naTyne~qw~ U pe$e~aq~n. K0pe~ cMnHo 6ano~wPaH, npe3 KOpeMHaTa cTeHa C e ~a6nloflaBa~ pa3flyTH rpeaHn ~ H K M . nannaqwi U nepKycnn Ha KopeMa 60ne3~eHoc~ M nnUCKaHe B KOpeMHaTa K Y X M H a . flepMcTamMKa He ce aycKynTnpa. Hannqe e TaxMnHeR,TaxmapflMR, CHHXeHHe H a AH, OnUrypMR, n O B M W e H M eH a XeMaTOKpma. Toan C T ~ M ce A R B m a KaTo cnencTsMe Ha HeosnaA R H HnM Bb3HMKBaq IlePHTOHMT. Pewre~oeaflnamo3a. MHOX~CTBO xnppoaepHrHn cemt#, pa3npepene~n paeHouepHo B Kopeua. n o ~ ~ ~ nMa ramen Koneqnn B pe6eno~o repao. H ~ ~ MHa v CBO~ODH T e ~' i H o C T B KOpeMHaTa KyxUHa.

PM

PM

IJHH~MH~ spesHa H ~ HenpoxomMocT

~ ~ H ~ M ~ W( M $y R~T q # o ~ a nnneyc e ~ ) KaTo npaelrno canposoyqa pefluqa x~pypmr~u 3a60n~BaH~R M uHTepsetiqwM Ha KopeMHaTa K y X M H a . Cnac~nr~a @ ~a p~a e Ma. cpaeHHTenHo pFiAKa, rnwcTHaTa M H B ~ ~ M eRH ~ A Y ~ C T ~ T ~ npclrwa 3a ~ e ~ c easpam. ~ a ~n aa p a n ~ ~ n r@ ~a p~ ~a ce a pa3BMBa B Ha'iVlOTO KaTO BMfl3aWWHa PeaKqMR BPaHHMR cneponepaTnaeH nepHop, KORTO BnOcnepcTBHe Moxe na npewtie B Texa rpeBHa napeaa n napanma, w3pa3~saq a ce c KnntinrHa cuMmoMaTnKa Ha Tema rpeeHa HenpOXOflMMOCT.

6aHaneH n n ~ $ e ~ q ~ o etrrepoKonm, 3e~ oc~bp anenflUlJMT, I l e P M T O H M T M , aC4MT npll C ~ ~ P H O A P O ~3 Ha H6 0 n ~ ~ a H U R HHe@p030He$p~TeH C M H P P O M ,~ ~ ~ O ~ R B H a ~XJlbH H R rHnR Mexyp ( ~ a ~ M apeflm p B AeTcKaTa swpac~), 6b6perH0-KaMeHHa 6onec~, 3a6on~~H aa ~HepBHaTa n~ CMCTe-

C~~mo~M a AHarHomrra m~a

Cnam~r~a @ ~p a~ a ce x a p a ~ ~ e p n 3 ~ cp~aT K O T paA~n npMcnnn OT cMnHM KopeMHM 60nw 683 onpeflene H a nOKallM3a~MR. ~ H H M C ~ IlOBPb~aHMR, HM HaJlHqe e $naTyneHqMfl, 6e3 fle$e~aqn~. K0peMbT H e e ~~J'IOHI~J~H, c Mew CTeHw, noHRKora Moxe pa ce nmnpa cnamveti

n p 0 M ~ Ce a B~ O ~ H M C 0I 6 Hc ~~ a ~ o npM w . flMHaMM~ H H Ra , B Harantime mqnn H H aO ~ ~ Y ~ ~ ~ H O H wteyc HHFI TO e ~ o m p e a m s ~ ~a3o-racrpan~a o: cowa, n ~ $ y 3 n o ~ t i TepannR, c n a 3 ~ o n m u q(Atropini ~ sulfur, Buscolysin, Spasmalgon), nepllcTamoreHHu (Nwalin, Prostigmin) B C b O T B e T H H 3a Bb3paClla n03L4, ra3OBa ~pb6a, CM@HHH K~HBMH. C ycnex ce npmara npo)pmwemaTa nepuw-

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CbrnaCHOyCTaHOBeHMTenpMH~MnM.

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XO~MMOCT e cnoma.

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Oco6enocmu n a cneurnume cbcmonnun 8 gemcka Baopacrn

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Or

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. . - .

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T O H H T M n e y Cn H e B M O K O n O C K O f l M U T a IlpeMMHaBaHeflOCpeAcTaeHo OT nuaniocrureti~nere6eti MeToA: n o - ~ a ~ a n w Ha u~cy+naqw Ha eb3nyx n noeMwaeaHe Ha HanRraHeTo B ~e6eno~ repso o c uen HeonepaTMBHa peRyKqnR Ha MtisarnHaTa. P ~ H T ~ ~ H 6enesn O B M 3a ycnelu~o~o h ocbqeCTBmatie c a mnHoTo M 6 e a n p e n ~ ~ c ~ s ManbneaHe e~o Ha KonoHa 6e3 p e m e ~ ~ Bn OvepTaHHma MY H npeMMtiamHe H a Bb3&'UlHHU K O H T p a C T B TbHKUTe VepBa. npM HeyCneUeH O n H T flHeBMOKOnOCKOllMUTa M O M e fla Ce IlOBTOpH owe 1, 2 ~ T BM MHTepBan 112-1 h, cnea npMnaraHe Ha cna3~on~~mqn. Heonepa~ua~a~a R~~MHB~TMH ce ~ OT~M Raaa B 70-80%OT cny'iame M cne4 HeR AeTeTo ce npneMa sa~pnmen~ B peTcKo o XMpypmrtio OTAeneHve 3a ~ a 6 -

Cnelutio onepamatio nereHcle ce Hanara npn HMMwe Ha ~ ~ O T U B O ~ O K ~ 3a ~ ~ Heoneparwrwa HMR penywl KyxMHa: O C T b P aileHAM4MT, Me3eHTepMa.lleH ~ M M $ ~ ~ H H T , nnM n p Heycnex ~ OT H~WHOTO npoBewaHe. npe~onepaAPYM @ o ~ M MHa OCTpa '4PeBHa H e f l P O X O A M M O C T ,H H $ ~ K ~ U T M B H a T a flO/JrOTOBKa e KpaTKo~paiHa (He nOBe'-le OT 2-3 h). O~HW etiTepoKonum, nenTnrHa ~313a un# ~banane~ne Ha TR ~rnto'isanocTaaRHe Ha ~aao-rac~pan~a coiioa, BeHoMe~enoa flMBepTMK'll, a6~0~MHaneti CMHflpoM flpM conea~o-~an~H oH e+ a~ ~ MC Rornen p a 3 a u n ~ ~ ce e UexMnpaTaHaSchOenlein-HenOch, CMHnPOM Ha PeutzJeghers. 4MR M MHTOKCMKaqMR, M3BbPWBaHe Ha He06XORMMMTe 3a
OPeMHaTa PaHuRq HanMrMe Ha WJOPHM0 6 ~ a 3 ~ B a 'H ~

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'pM Ha np0mB0n0Ka3aHMR:CP0K1 npeBMluasaq48 h OT h, tmMHMClHa KaPTMHa, Ha Pa3BMnce nePMToHW M n M nePUn ~ MCloKaasaHe
Ha HHBaMHaqMR

onepaqHma napamHwrHw M ~ C ~ ~ A B ~ HOneparnse~ MR. MeToA Ha ~ 3 6 0 e~ MaHyanHaTa AeaMtisarMtiaqMR no Hutchinson, a flpM HapylueHHe B b B BMTMMTeTa Ha MHBBMHMP~HOTO r e p ~ ce o ~anara r p e a ~p a e 3 e ~ qOnepa~m~~.

~o~onere~~eeno~a3a~onnp~~ne H a q M M H npM C H r Y f l H M RaHHM 3a MeXaHMVHa, nOmeMaU@

Ha XMPyQMVHOOTcTpaHRBaHe IlpM9MHa 3a Bb3HMKBaHeHa MHBaMHaqMma: rpeBHM nonMnH M WJOPM.

Tentio nonoxewe, s a ~ p y ~ AeMxeHMe ~ e ~ o no pap^ n p ~ HyRMTenHa ; W P ~ KH ~ aM KpaKa. R ~ORBRB ce ~ rqetie, noapbll&IHe, MeTeOPM3bM.C K W T ~ M e~ OTOcl T eH, C M3rnapeHM wn cnewHa onepaTMsHa MHTepBeHqMR. OCHOBHH 60nec~KOWH BHKM, 3a'iep~e~, BnocnencTBMe nMempeH. npw H Me n M H M q M Ca: T O P 3 M R Ha T e C T H C a , enHAHAHMa M IlpHnanannaquR3acemammTecTwc e cMnHo 6 0 n e 3 ~ eyrone~, TbqMTe MM, OCTPM T p a B M M Ha C K P O T y M aM T e C T M C a , OCTPM MeH, c BHCOK CTMX, X O P W ~ O H T ~ ~ pamonoxe~, HO c map OPXMM M O P X M e n H A H A M M H T M , OCTPO HaCTbnBaqO X U A p O KM O'iepTaHMR. qeCT0 e HallMqe C M M n T O M a T M i ' H O XMnpO~eH $y~~~yno-uene, wAMonaTnrHMefleMM MRP. H ~ B - ~ ~ec T o ne. l l p TopKsMpatie ~ H a npuRanuclTe HaTecTMcaM e n q w s a c e r ~ a KbpMarecKaTa ~a M n y f i e p ~ e ~ abspacr, ~ a ~ a KoeTo A M M a (aneti~uquc T e m c M e n ~ p ~ n0~ 64 ~0 ~ 0 C~CTORc) ce A b n w tia tie3aebplueHMR ~ e c q e ~ s Ha y cTecTuca ,xopHue e C ~ ~ B H M T ~ ~(06p0,60n~a~a ~HO MO T O K b T Ca M H O r O noM O H X I H M R PaCTeX, B b 3 M O ) K H O C T M T e38 Bb3HMKBaHe Ha cna6o ~ 3 p a 3 e n ~~ p ,nannaqw ~ Ha aacemaTvu TecTuc M e X a H M C l H H TpaBMH M Bb3lWlMTenHU 3a60nflBa~MR. 6on~a~ ea no-cna6a, a no noabpxtiocrra MY MoraT 0 6 ~

OCTPMUTXHPYPM'ieH C K P O T Y Me C M H A P O M , 06eflMHRBalq pa3nM'iHH 00 e T M O n O M R XMPyPMqHM 3a60nRBa~MR Ha crcpoqwa n opraHvTe, paanonoxe~~ B Hero, M ~ H C K B ~ -

HOBeHOflaCenaflnMpaTTOPKBMpaHMTe flPMAaTb4U. B n o m q Ha patiHaTa Awamo3a c ycnex ce ~snons~ exorpa$~~, ~3cneflaatie c nonnepoe Qnyopo~enp, C~MH-

~~rpac + 99Tc. n~ T~~BM~TH YBpeflH V H H H a CKPOTYMa H TeCTMCa HacTbnBaT npeF(uMHo Bbe Bbapama OT 12-15 rofl#HM, paapenm ce ~a3ar ~ M T Ma , B~ ~ B M C M M O C OT T

508

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clrnaTa M ~ e x a ~ u Ha a~ TpaeuaTnrHMR a M o M e H T nopaxeHMma ca OT neK xeuaToM B nopKomeTo no p a 3 ~ a c ~ a ~ e Ha TYHMKa a n 6 y r ~ ~ Ha e aTeCTMCa, A0 TeXKM KOHKBaCaL(MM Ha C b L L ( M R .OTKPHTMT~ TpaBMM 'ieCTO C a CbreTaHM C YBpeAM Ha nonoBlrlR wet+. Oc~po H a m n a a q o xnapo- H +y~n~ynoqene b l ~ r e ~ ~M a6 ne~~a p e xeptiw ~a (~eycnom~e M~ npwi~~~ ce la rnaaHo a OT ~ e m e b p w e 0 ~6 an w ~ e p a q ~ ~ ~oXHKH~ MHIBMHaneH H~), ~ ~ M M $ F I , ~ ~ HaJlepM'ieH MT, OTOK Ha IlpOqeCyC BaMHanMC IlePMTOHeM. B PaHHaTa AeTCKa cKpoWa, T~MOPMHa Tec-ruca, o m p aneHRMqw, oc: Bb3PaCTPOnRMrpaeMBpeMeHHaTaAHCn03M4MRBpa3BHVpeBHa HenpoXOflMMOCT. TMeTO Ha K P ~ B O C H ~ ~ ~ BHa ~ H MHIBMHO-CKPOTallHMR ~ T O palo~ M HapyweHue B npoqecme Ha TpaHcyRaqm M a6cop6q~ B~ cepoa~me npocrpaHcTBa Ha O ~ B M B K U T H ~ a T e C T M C a . OTK~M Ce BcI~YV~RHO, ~ IlORBflM Ce nOF(yrMHa BC b O T BemaTa nonosMHa Ha CKpoTyMa, neKo 60b3He~a. noayTuHaTae enacTurHa, n e ~ h o n e a ~ e ~KoxaTa a, Ha CKPOTY~ PT O Hp 3 U RH a TeCTMCa M enMflMflMMa3 a K b C H R B a H C ua e onbtiaTa, npospar~a. T ~ C T Me Cpa3nonoxe~ ~T O T B ~ M OTflOllY, nOAyTMHaTa He Ce PenOHMpa, f l O A K O X H M R T MHHaonepamBHaTaM H T ~ P B ~ H ~ BnoulaBa3~armen~o MR nl r ~ o a a OTHOCHO ~a 6bfleu(eT0 H aa a c e m a ~ TecTnc. ~~ rBMHaeH OTBOP e C B O ~ A ~ H . Y C Y K B a H e Ha KOpAOHa A 0 180' T e C T H C b T e )KM3HeH ' p e H O H O L 4 M R , a H a 180' O ~ M K H O B ~ H OH e K P O T M 3 M p aCl7 ~ - T M Rh OT Ha'4anOTO H a 3a60flRBaHeT0. Onepa~MBHb 3a p a 3 n ~ ~ OT asa~neqe~a ntimnHanHa ~a x e p H M R

nMnceaT 6on~a M 6ene3~ Ha rpeeHa HenpoxoRMuocT. Oc~pn BaanannTenwn3 a 6 0 n ~ ~ Ha a ~ CKpoTyMa n ~

H pa3nonoxe~n~ B eHero opraHn

AocTbneMHreMHaneH,corneAoTKpMwHeHacynpaaa
HaHa T O P 3 M R Ha TeCTMM. 06eMb~ H a M H T e P B e H q M f

K M ~ H ~ H O H a CTecTMl ~ ~ T O P 3 H R Ha IlPHflaTbqMTe H a TeCTMCa M enMAMnM a rpyna 3 ~ cnqaT sb3nanwen~w npoqec# Ha O n e p a T M B H M F I T AOCTbfl e CKpOTMeH. ~ P T H P a B M a T M Y KOXaTa M nO~KOXMeT0 Ha CKpoTYMa ( $ ~ ~ M o a6cuec, H, yepeulil Ha c l c p o y a M TecTMca onepaTneHara nHTepac ra~rpe~a), OCTPM H ~ C ~ ~ ~ U $ M C MI c H~ M~ ~ ~ M $ OPXMTM, M ~ H M UMR e ~ b 0 6 p a 3 ~ rOlleMMHaTa 0 H a HapaHRBaHeTO. enu4uflMMuTe M opxuenMAuF(uMwrn. f l o c n e ~ ~ n npenc~e HamnMno x ~ ~ p M o $y~~~yno-uene nyHK4MRTi TaBnRBaT MHTepeC B ~ M $ ~ ~ ~ H ~ M ~ H O - ~ M ~ ~ H O OTC T W H O oc~po HoUeHMe. Harano~o e OCTpO, peTeT0e BMCOKO $e6p~n~o, npo~ueono~a3a~a. ueqa ~o 1 roAMwHa ewpacl nunca Ha ~OK~~EIHMFI 3a cnewHa onepaTMatia M H T e p e c OnnaKBa ce OT cMnHM 6 0 1 7 ~ B~ 3acema~a~a nonoBuHa H a ~ M F I noBeAeHueTo e t ~ s r a ~ e a ~ eOCTPMT~ n ~ o . ~b3na C K P O T y M a , MMaqM n O V M C b q M R XapaKTep, KaKTO npM TenHU 3ahnRBaHMR Ha C K p O T y M a ,T e C T M C a M enMAMflM TOP~MR HaTecTuca. Hannue e o6are npegxomqaqo3a60ce neKyaaT KoHcepwTnaHo, npn nMnca Ha XMpyprw nRaaHe (napo~m, rpm, 0Kr)J-I M ~ p . )3ahnen~m . TecycnoxHeHMR. TMC ce yeenwaea no o 6 e nocTeneHHo, ~ noHRKoraAOCTM-

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0 c T p ~M ~e H ~ ~ K ~ Ha M nHKorooTAenmenHaTa M cmcTeM a B RercKaTa eb3pam ca recTo cpeqatin 3 a 6 o n ~ s a ~ n ~ . Te ce ~ ~ O R B R M OT ~HKHOB~HO B ~p O e ~H ea MnM Cnen RpYO ea3nanuTenHo 3a60n~sa~e (rpm, aHruHa, 6poHxonHeBM O H M R , OTMT M RP.). npe~ll0CTaB~M 3a B b 3 H M K B a H e T OM MC a He3penMRT M M Y H W e T Ha R e T C K H R OpraHH3bM M nOKanHM, npe~pa3nonaraq~$a~ OT ~cTpaHa o p ~ Ha nuKorooTAenMTenHaTa cncTeMa ( s p o ~ a e~ ~o ~~ a n HepR~l~o ~ ~ ) . ocTpme UH$~KUMMca npurMHa 3a RnaniocmqupaHeTo H a HRKOM OT M ~ J ~ $ O P M ~ T M yp0naTMM. BHMT~

Ompoab3nane~ne H a nnKorHwre mmqa, a a c ~ r

M 6b6per~n M ~ H T e p C T M q M y M . ~ P H ~ H H FCe I BO ~~MKHOB OT BMpyneHTHa r p a HeraTMBHa ~ $nopa (E. Coli, Prote~ Pseudornonasaerogenosa M ~p.). kl~$e~quma npoHMk IlO KpbBeH M ~ H M $ ~ nbT H OT APYrO Eb3naJlMTenHOO M M l B o p r a ~ ~ Inn 3~m a x o ~ ~ no qo ypMHoreHeH m~ OT B I

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Oco6enocmu na cneunume cbcmonnun B gemcka Baopacm

509

~OHMX~HMT 3auMTHM ~ CMnM Ha ReTeTO (HefloHOCeHOCT, HeROXpaHBaHe, PaXMT, ApyM M H $ ~ K ~ M MM ) 3a60n~BaHMR Ha eKCKpeTOpHaTa CblCTeMa (BpofleHM aHOMaMM,

blsabp~uea ce npv BcMrKM Aeqac ocnp n ~ e n o ~ e $ M 6ene3~ Ha M H T O K C M K a q H R M fleXMRPaTaqMR. B ~ O ~ H M V

O~CT~HOB Ce K ~Ha3HaYaBa M H $ Y ~ M O H H ~AeTOKCMVHa , M

~e$pon~~~asa).
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a ~ ~ ~ 6 a t c r e p TepanMR ~ a n ~ a c noeere OT e l w i ~ H T M ~ M O TMK, 38 ~pe&lOrlMTaHeC ~ ~ K T ~ P M O ~ M T H L . I H O ~ (For~~C turn, Cefalosporin, Amicacin) M BOAHO-conee~ ~~~TBOP

npM HaBpeMeHHOM ~eKBaTH03allO'iHaTOJlerleHUeTR e no6pa. B HRKOM cnyvaw 3 a 6 0 n ~ ~ a Moxe ~e~o Ra XPOHM$ML(H~ (XPOHMY~H ~ llMenoHe$pMT), 3aTOBa e H ~ O ~ X O ~ ~ M AMcnaHcepHoTo ~ a 6 n t o ~ Ha e~ AeqaTa ~ e B npopnxeHlre
H a HRKOnKO TOflHHM.

Ycnomn~ @ ~o p ~Ha n onpng n ~ e n b w e @ ~

HM, HanpertiaTM M 6 0 n e 3 ~ e ~ ~ .

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HaTa nocraBR eTMonomvHaTa ~wamoaa ~ a o n ~ p ce a M M K ~ ~ ~ H MnpMvMHMTen. FIT KpbBHaTaKapTMHaCe Xapatcre-

B ~ a n npoqeHT b ~ OT peqaTa OCTPMRT n ~ e n o ~ e $ Moxe Ra ce ycnoxw. Hair-remoce pa3e~aa H~KPOTMBMpau nanMnMT, a n o m e ~ a ~ o 3 ~e~ $ p l rK ~ ,~ ~ ~ Y H M a6cK ~ I qec H a 6b6pe~a, napa- M n M n e p ~ ~ e $ pn~o~e$po3a #~,
T e 3 M 3a60nRBa~MR Bb3rlNIMTenHMRT npOqeC M3nM3a OT rpaHMqMTe Ha nMKOrlHKTe nbTMua, KaTO MOXe Ra3aCeMe o ~ o n o 6 b 6 p e r ~ o npOCTpaHCTB0 ~o M ~ 0 6 ~ fleCTpylcea TmeH xapatcrep. 3 a 6 0 n ~ a a ~ e uoxe ~ o Ra nporpecmpa M fla Ce CTMlHe A0 CenCMC, eHAOTOKCMHOB WOK M OCTpa 6b6peq~a HeflOCTaTbCIHOCT.

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pnsnpacne~~oq~~o3a~one~~~a~e. Yn~pa3sy~oeo nscnep~a~e. 3agbnm~en~ ~prr6aa o fla ce npoeewa npw Ieua cocnp n ~ e n o ~ e 4To p~ Moxe ~. fia nOKaXe HMlnrlMeTO Ha BpOReHa aHOMMMR Ha nMKOrl0oTRenMTentiaTa cMcTeMa (ueraype~ep,x~ppo~e$po3a, n o n w ~ ~ c ~M o RP.) 3 a #nM Ha ~ e $ p o n w ~ ~ a sXapatcrepa~a. HMFlT YnTpa3BYKOB 06pa3 Ha 6b6peqme npn Aeqa C O C T b p nweno~e$p no~aaea ~~ we6ene~ 6b6perle~ napeHxMM,
HeRCHOpa3rpaHMcleHOTnepMpeHanHOTOnpoCrpaHcTBOCneflCTBMe OT KJleTbrlHMR OTOK. P ~ H T ~ ~ HMO P~MOM30TOnHM BM MXneflBaHMR. np0BewaT ce npM ~ O K ~ ~ ~ H M R .

Ha npeAeH nnaH u 3 n ~ 3 dqme a~ C M M ~ O M MPeqa~a . ca cw cenTMrlHa TerunepaTypa, c 6ene3~ H a MHToKcuKa~ M (@un~$opnne~ R nync, Taxmten, o n ~ r o - a ~ y p a~ 4~, ~oaa). 0 6 ~ 0n ~ M0 cbc-romMe ce BnotuaBa.

bl3BbpWBa Ce C ApyM M H @ ~ ~ M O ~ 3a60nRBaHMfl, HW IlpOTMVauM C U M C T M T H M OnnaKBaHHFI, KaTO rpMn, nHeBM0HMR, a,qHeKcMT M ~ pMacneflea~e~o . H a ypMHaTa, Kamo M Ha 6 b 6 p e r ~ a ~ $a ~ H K ~ MnoMara R 3a p a 3 r p a ~ ~ r a a a ~ e ~ o Ha ~CTPMR n~eno~e$pm OT nocovetime M H $ ~ K ~ M O ~ H M npoqecw.

3a no-ne~n~e cnyvan xocnuTanu3aqMma uoxe Aa 6b~e oTnoxeHa. Haa~avaea~e~o Ha wMpoKocnempeH ~HTM~HOTMK O ,~H~HOT IlOeMaHe O Ha TerlHOCTH M TOllnMTe npoqepypv B nyM6anHaTa o6nac~Moxe Aa ce oKme nomanrltio 3a 0~3eyvaea~e Ha cclunToume.

HapegC KOHCepBaTMBHaTaTepanMR( ~ ~ T o K c M ~ H HH ~ -, $~~MoHH a~ ~~ , ~ 6 a t c r e p ~B a noaereTo n ~ a ) cnyvaM e ~ e o 6 X O A M M O ll0 ClleWHOCT M XMPypMVHa HaMeCa.

510

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ce a m 6 u o ~ q H n ypoamcemqw cnopen amc16~orpaMaTa. Tonnure npoqenypnc y n p a n y 6 ~ r ~ MoraT o na ycnoKORT nOKanHHTe CHMnTOMM M AM3ypMRTa.

OCTPOTO WnaneHue Ha n#KorHHR Mexyp ce cpeqa c p a s ~ m e n ~ o n o - ~ RnpnpeqaTa,omonKoTonpv AKO ~b3PaCTHWe. ~~H$~KUMFITB MOXe Aa npOHMKHe no KpbBeH, xeMaToreHeH M H ~ A - q e c no ~ o acuetinemeH yp#HoreHeH nbT OT BbHUlHMTe reHMTXlHH ( B ~ ~ B O B ~ M 6ana~onocHMT, TMT H PP.). tlpenpaanonaraqn 4amopu. Toea ca npennMHo apoOcrpnm ~MCTMT MMa nonrepTaHacimoHtiomflapeqlAeHM aHOMXlMM HaROnHMTenMK0rHMnbTMqa ( C T ~ H Ha O~~ fl M BMpa M XPOHH@M~HP~, OCO~~H npM O HMMVMeTO Ha ripeypeTpaTa npn MoMMreTa, cKnepoxi Ha MexypHaTa urnir~a) npaanonaraq $amop 3a TOM ( c y 6 s e 3 ~ ~ a n 06crpy~~a M n M$ Y H K ~ M O H ~ H M T HaPYLUeHHfl ~ B ypHHHpaHeT0. ~ M RY ) .P M H ~ Ha T peqaTa, ~ npehnepyeann OT o c n p ~ M C TMT, ~ p h pace ~ a cnenn nepwonMrHo, a ~ ~ n 6 a ~ ~ e p Ca~mo~mwa B npopanxeHMe Ha HRKonKo Meceqa. 3a p a 3 n ~ OT ~ aOCTPMR n ~ e n o ~ e TYK @p Ha ~ npeneH ~ nnaH M3nM3aT nOKMHMTe CMMmOMH OT CTpaHa Ha IlMKO'iHMR Mexyp. AeLpTa ce onnaKeaT OT recro M 60ne3~eH0 ypMHwpaHe, 6 0 . n ~ HW ~ cn~$MxiTaM B n o - ~ ~ A cnyralr KM HHKOHTMHeH4MR. AKOB XOAa Ha 3a6011RBa~eTo TeMnepaOapo s a 3 n a n e ~ ~ Ha e BbTpewHHR n#CT Ha npenyqvTypaTa xinortie Aa ce n o a w a m n ce nomm 6enem Ha yMa H rnasMrKaTa Ha newca. ~ ~ C cpewaHo T O m6on~lmnHToKcMKaqvfi,~om03~ara~a re~epanw3npa~e HanpoHe npM MOMVeTaTa. O~MKHOB~HO Ce pa3BMBa IlOpWM Haqeca - qclcTonMenm- n l r e n o ~ e @ p ~ ~ . nMweTo Ha 4 ~ ~ 0 xCnep 1 . pax,qaHeTo Ha MoMqeTaTa BaTpewtiHm nMcr Ha npenytqgwa e 3anen~an racTncrHo 3a glans penis. llponyKq~ma Ha X J I ~ ~ M TB ~ ~ a 06nac~ 3 ~ l l p ornena ~ Ha reHmannme Moxe pa ce ycTaHoeM (~MetWa)M ypHHaTa cb3flaMT Cpena 3a ~ ~ K T ~ P M W Bb3flanMTeneH npol$?C (B~~BO~M O~HKHOB~HO H ~ ) . MMa pacTex. I l c - p ~ n ~ 3o a6on~m~e Moxe ~ 0 na n p e p w 3 ~ ~ nannaTopHa ~ O ~ ~ ~ H ~ B AonHme H O C T oTnenM Ha KopeMa. M n M qa 6bne n p e n ~ 3 s w ~ OT a ~ a o a 3 n ane~~ Ha e ypeTpaTa O6qo~o ~acnep,ea~e Ha ypMHaTa no~a38a xapaicrep- YpeTpMT. time n p ~ 3 ~ 3a a qy ~ p o ~ ~ $ e ~qn M~YMMH, ~i n a m OT neaKoqMTH M nc-pRnKo e p ~ ~ p o 6 ~a m i c.r e p ~ a n ~ a no~a cuaKa Ha ypcrHaTa n o ~ a 3 m M M K ~ O ~ H MnpHvwHwren R n Ilapeo~aran~ ce o noRaRaa cbp6ex B o6nama Ha HerOBaTa a~TM6aicrepM~Ha pe3HCTeHTHOCT. KpbBHaTa KapTnHa e HopuanHa HnM e c 6eneame Ha ~ b s n a n e ~ n e neHHca M napeHe npv ypMHupaHe. npn ornena npenyqmy ~ e b3aqepeeH ~ M B paan~r~ cTeneti a HanpemaT. B (nee~oqn~oxi, oneeReaHe, ycKopeHa yrair~a). tianpentianllrre cnyclaw qenMm neHMc oTMra, R B R B ~ ce Yn~pasey~oeo MxneneaHe.C Hero uoxe na ce HaMeTeunepaTypaTa ~ w , ce noauluaea. p m npMnpyxamqa OCTPMR q u m aHoManMR ~ (~eraype~e- mHmnHaneHn ~ ~ @ q e nopw~ 60nKaTa no apeMe Ha M M K ~ M R IeTeTo Moxe pa pn, x~epo~e$po3a n np.). cnpe Aa ypwtiwpa M na nonpH globus vesicalis. P~HT~~HKoHT~~CTHM, p~MOM30TOnHM M eHflOypOIl0mrHn ~ s c n e p s a ~ (K~tnk16pMpaHe ~a Ha ypeTpaTa, ~MCTOCKO~MR). Te ce npwnaraT npu noKa3aHMR,o6n~tmae~o cnep campaHe HaocTpnR ~ ~ ~ n a n ~ ~ e n e ~ n p o 4 e c .

Ma~yan~ Mn# o UHcTpyMemanHo oTneneaHe Ha npeW y M a OT rnaBnclKaTaHa metia. M a w m ~ ce a cb6panaTa Ce CMerMa M moA M JlOKMHO Ce HaMa3Ba C ~ H T M ~ H O T M rHa nama. n o c r a a ~ ce pMBaHonoe KoMnpec 3a HRKonKo %Ca. C n e CTHXWHeTO ~ Ha OCTPHR Bb3llMMTeJleHnp04eC BCeKMReH ~ p ~ 6 e Ce a npaBH ~ a TOaneT Ha reHMTMMMTe Ha MOMVeTO - 3a6enm~e Ha L(neH'ieT0, H3MMBaHeTO M YC xnwlta Bogs n spbqatie Ha npenyllwyua. B npomeeti

OcoLenocrnu wa cnewwume cacrnonuun B gemcka Barpacm

51 1

cny-iafi 3 a 6 0 n ~ e a ~ e Moxe ~ o pa peqwnwanpa.

He Ha ductuli serniniferi.

Cnenruo 60nuwuo neqeHne

Heo6xon~~ eo cavo B cny-iame c ycnomeHnR, KaTo peTeHqnR Ha ypmaTa, oc~bp U H C T ~n , ~ ~ $ w e ~ m .

H a frec~a~ar1pMrlMHa3a6b6pe.1~a K O ~ MB Kg ~e ~ c ~ a Ta Ba3pacT e ~ e $ p o n n ~ ~ a 3 Murpaquma a~a. Ha KotiKpeMew OT ~ ~ ~ P ~ C I H nerewe O T O no ypeTepa B O ~ M p0 rlacmqHO M n M IlbnHO 3anylLlBaHe Ha IlMKOrHMTe ITbTUWa, noBMulaBaHeHaXMnP0CTaTHrHOTOHmRraHeHaypMHaTaHa)J O ~ C T ~ Y K L ( MM ~T nORM ~~ Ha 60llKa. E F ( H O B ~ ~ M C~ TH OH MO C e npa3HM H IlapaCMMnaTMKOBHRT OTpen Ha PeHEIflHMfl

HepeeH nneltcyc, oTKaneTo no n.vagus MoraTna HacTbnRT OnnaKMHMR OT CTOMaUIHO-qPeBHMR TpaKT M KOpeMa (ra@He, nOBpbWaHe, ~ ~ ~ C T P O ~MeTeOPH3bM ~ C T B O , H n~.).

G H M ~ ~ T O M ~ THHflK Hal ~ HOCTHKa

&T~TO C e OnnaKaO T ~ O BCbOTBeTHaTa ~ K ~ CKpOTanHa nonoeclrla, KORTO e 3avep~e~a. l l p nannaqm ~ TemHCbT e Ha ~ o p ~ a MRCTO n ~ o H c#nHo 6 0 n e 3 ~ eMoxe ~ . na nMa H peawMaHo xvnpoqene. floeuwe~a~a TeMnepaTypa, acreH0a)JMHaMUFlTaM flpyMTe o6qw CMMllTOMM C a npenM3BMKaHH OT OCHOBHOTO 3a60nR~aHe, BHPyCHa H H @ ? K ~ naMR, poTMT.

f f i n ~ n v ~ KapTMHa a ~ a Ha 6 b 6 p e r ~ a ~ KOnMKa a B IeTCKaTa ~b3pacr e HeTwnHrHa. fleua~a ca ~ e c n o ~ oeb3b~, 6 y f l e ~He ~ ,Morarnacn HaMepmMR~TO,noBpbqaT. OnnaKMT ce OT p ~ @ y 3 6~ 0a n~a B KopeMa, ny~6anHMTe o6nacTH, HO ~ a f i ~ e m TR o e n o ~ a n w 3 ~ p oKono a ~ a nbna. B HRKOH Cn)VaM UpqMMpa MHrBHHXlHO B M CKPOlyMa H n Mn a 6 ~ ~ Te. Moxe fla UMaT 'ieCTO M 6 0 n e 3 ~ e ~ YpMHMpaHe, 0 C yceqaHe 3a HenbnHo ~snpasea~e Ha nuKorHMR cnen MMKUMR ( ~ 0 CwMnToM 3~ e xapatmepeH npn KahnbK B Ta30BMR H K)KCTaBe3HKZUlHMROTAen Ha ype~epa).

f l p ornena Ha peTeTo npaw BnevaTneHMe, r e TO e O C T P H R XMpyprttVeH KOpeM, KOraTO 4a)JM a6po~uHanHa~a o6llaCT M O ~ H K H O B ~ H e O CBWO M 1136~11~3 pBMXeHUR, 3aqOTO Te YCMnMT 60nKa~a. 3arepee~o~o rbpno, KawnMqaTa,xpeMaTa ca n p ~ 3 Ha ~a 06140 wnanuTenHo 3 a 6 o n ~ ~ ~ e . ~~O~OJIHHIH noneleune O W nereuMe flyncb~ npU TllmUqHaTa 6b6peq~a KOnMKa e 3a6ase~ floc-rene~p e x w . BMCOK n o e x Ha Temucme H ncM n M HOpManeH, (M~OTOHHR) 3a pa3nMKaOT O C T P H R XMPyFKantio pneaHonoa KoMnpec. 6 o n ~ o y c n o ~ o ~ ~ aMYeH q ~ KOpeM. (Buscolysin, Analgin, No-Spa). 3a n p o $ ~ n a m ~ Ha a6a~flp~ nannaqun HaxopKaTa tie BMHaru e xapatcreptia. TepnanHaTa MH$~KWRMoraT pa ce ~ a s ~ amr~ a HT ~H ~ M O fion~a~ ea ~ ~ $ y 3HO ~a Moxe , pa ce n o ~ a n ~ 3 B ~ anew pa T H ~ H .l l p ~ n a r a ce ~ HMepnKaMernH 3a noabfwasatie Ha pnKynapHaTa06nacr npw AecHocTpaHHwre KonMKa. 0 6 ~ MMyHHaTa 3aqma (Garna globulin, Tetracyclin, Tubocin, KHoBeHo nHncBaT 6ene3H~e Ha nepmoHeanHo n p a a ~ e ~ Irnunovenin). (CMM~TOM Ha Blurnberg, defance rnusculare). Succussio renalis e C M ~ H O nonoxwrentio. Cnelu~o 60n~wuo nneHne Q)e6p~nme~. He e xapalcrepeficnMmoM, HO Moxe pa Hmara ce M H O ~ PR~KO, caMo n p ycnometime cbqecTsyea ( n p n s ~ Ha a ~nexuppaTaqw H M H $ ~ K ~ M O cny-iaM, c 6ene3~Ha cynopaqnR Ha TecTnca w o6qa HHTOKCHKaqMFI.
H~C~OKO~H 3a O ,pa3nMKa OT

KaneH aneHAwqMT, eupymn MH$~WMM M T. H.). KpbBHa KapTMHa. npM TMnMclHaTa 6b6per~a KOnMKa TR e HopManHa, HO uoxe Aa ce ~a6nlo~asa peamMBtia
~ ~ B K O ~ M T O ~ ~ C O ~ ~ B R B ~ H ~ .

Oc~pa mnHa 3apffbx~a Ha ypHaaTa

OT flOnHlrre IIHKOqHH IlbTHUa (pe~eHqHfl)

C b c ~ o ~ ~xnae p,a ~ ~ e p ~ 3 ~ ce p acq eHe3anHo o Hacm IlMlla HeBb3MOXHOCT 3a ypMHHpaHe npM rlbneH C FMHa nMKoqeti Mexyp. 3a paaMlta OT B ~ ~ ~ ~ C T npM H AeqaTa M T ~ C e CpeUa no-PRAKO M ~ ~ M K H O B ~ HeOCMMmOM Ha flpyrO 3a60nma~e. n o nbntia 3 a ~ i p b x Ha ~ aypuHaTa B peTcKaTa Bb3paCT Ha6l-clecT0 flOBeX@T BPOAeHMTe 3a60JlFlBa~MR Ha nMKoclHMR Mexyp M ypeTpaTa (nonun Ha a q ~ a ypeT~a pa, x ~ n e p ~ p o Ha $colliculus ~~ serninalis, KMcTa Ha TpMroHyMa, YpeTepOqene M AP.), no-PRAKO HeBpOreHHMTe M ~ M @ ~ H K ~ pa3cTp0kTBa M O H ~ HBypMHMPWeTO. ~ ~ ~ ~ B eAM6b6peclHaTa KonMKa TpR6Ba pa ce p a 3 r p a ~ ~ q Ha a~a HM~HM CnyclaM cneA o c ~ o 6 0 ~ a a Ha a ~npenyqMyMa e npM IlbpBO MRCTO OT 3a60nRBaHMRTa, lPMclMHRBa4M OCTbP $M~03a,AeqaTa OT CTpaX OT 60n~aTa npM YpMHMpaHeTO xMpyprweH Kopeu. OTApyra c-rpatia, o 6 q ~ M ~H e $ ~ K ~ M M , MoraT Aa nonyclaT mnHa peTeHqw Ha ypMHaTa. aHrMHa, rpnn) MoraT Aa H ~ I I O ~ ~ O ~ R B KJ' ~IMHMC~HO T 6b6peclHaTa KOnMKP. P o ~ ~ ~ e cbo6qaea~, nll~e cle OT HmonKo claca AeTeTo He e ypMHMpan0 M30640 M n HC a M O Ha KarlKM. TOe 0 6 ~ ToII~M npoqeAypM (~barnae~wi~a, r p e l ~ a caMo ) Ha HoeeHo ~ e c n o ~ o knnaqe. o, H q C M M $ Mce ~~ nannHpa T~ n y ~ 6 a n ~ o6naa. a ~ a C n a s ~ o nM ~60n~oycno~o~aa~~q~ KaTo HanpemaTo T~MOPOBMAHO06pa3yBaHMe npenbntieqln (Analgin, Buscolysin, No-Spa, Cystenal, Alcosin, HMRT IlMKOcleHM e w - globus vesicalis. npM no-HeRCHMTe ~ enoeecle TeclSpasmalgon per OS unv supp). n o e ~ a Ha cny.la# e x o r p a $ ~ ~ noTsbpxqaBa ~a ~~amosa~a. HOCTM npes ycTaTa. Kora~o AeTeTo noepbqa M He Moxe Aa nue, Kamo M npM 6enem Ha AexMAparaquR, e H ~ O ~ X O xocnmanv~ M M ~ aaq~ma MY M 3anoq~a~e Ha M H $ ~ ~ M TepanlrlR. OHH~ TOB~ C eO T H a C R M 3a IlpOTpaXMpaHMTe HRKOnKO P H M KOnMKM, Kamo M npn HanMclueTo Ha npuApyxaeaq n ~ e n o ~ e 4 p ~ ~ .

Yn~pasey~oso w3cneAaaHe. X e n a ~ e n ~ o scwrKwflee qa CbC CbMHeHUe 38 6b6pecl~a KOnMKana C e M3cneRBaT C exorpa$. Yn~paaeyxoa~~l~ o6paa ~a 6b6pe~a npw KonMKa e TMnnreH. Mua AMnaTaqw Ha nMenoKanMKmaTa cwreMa M c~a3a Ha ypMHaTa. Pemre~oa M~ P ~ M O M ~ O T O ~~ Hs M c n e p aTe ~~ m~. 4 0 MOr8. T Aa nOTBbPnRT MJlM OTXBbPnRT flUXH03aTa, H0 C ua~ntocle~ Ha ~e 0630pHaTa r p a $ ~ ce~npoeexqaT cneA 0~3~yl.laea~e~aoc~p~~npoqec.

llponosa
TMnMclHaTa 6b6pecl~a KonbfKa e c ~ o 6 p a npomosa. B noaereTo cnyaM 6 0 n ~ a ce ~ aoanwBa 3a HnKonKo claca M KoHKpeMetinT6ma enMuMHMpati. npn norpelutia AMamoaa o6aqe ( ~ e c~ ocnp e aneHpMqwr, neKyBatio KaTo 3a 6b6pecl~a ~ o n ~nocneAcTBMHTa ~a) MoraTna 6b~aT 4a~anHM.

npn H ~ B ~ ~ M O X H OIC nT# TPYAHOCTM npM ~ a ~ e ~ p u a 4MRTa B 60nHMclHa ~ ~ C T B H O B IlO K A~o6qa aHecTe3MR ypMHaTa ce AepMBMpa nocpeAcTaow cbnpany6w~a ~ ~ H K ~ Ha IlMKOqHMR MeXyp C~MCT@MKC. PM Ta3M MaHMnynaqMR, aK0 MevPbT He e F(OCTaTbclH0~ o 6 p e M3nbnHeH, CbUeCTs p a onacHocT OT HapaHRBaHe Ha nepMTotieya M ~ y x Kopeuetioprati c ~ ~ ~ B M T M Ha~nepMToHm. T O Cnen eaaKyaqMRHa~MHaTaOTnMKOclHMRMexyp3aHRKOnKOAHMce

~aa~acla ypoaHmcenmclHo ~a nereHMe (5Nitrox, Nelidix, Ha M H ~ ~ K ~ M O ~ Biseptol, Giramid) 3a np@~namw~a YCnOXHeHMR.

Oco6enocmu na cneurnume cbcmonnun B gemcka Bbrpacm

513

ce nocTclra qpes ~ O C T ~ B R H ~ Ha TO ~ e $ p o c ~ on ~e ap . tya~HaTa ~ e $ p o c ~ o e~ HeonepaTHaeH a M~~KOMHB~~ MeMB T O R 38 AepMBaqMR Ha YpMHaTa OT KyXMHHaTa CMCTeMa Ha Xapatmep~a~pa ce c HanMweTo Ha BpogeHa nnM 6b6peq~~ BecneweH M n M HeoTnoxeH nopRubK. H a k npnflo6~~a npewa no xona Ha ypeTepa ( ~ a n ~ y n o x spai, r e c m e wHAuKaqnM 3a neptyawa ~ e $ p o c ~ o B Aerc~a new a ~ o u a n ~ Koero ~ ) , ~ ~ ~ A M ~ B M RnnaTaqwR KEZI Ha eKcKaTa Bb3paCT Ca BpOAeHMTe MaJl@p~aqMM Ha nMKO'400TKpeTOpHaTa CMCTeMa H 4 HMBOTO ~a O ~ C T P ~ K ~ M (MeraRT~ AenmenHaTa cMcTeMa, nponBRsaqM ce c AMnaTaqMR Ha ype-rep, x~npo~e$po3a), s a ~ p y ~ Ha ~ AenypaTMBHa~ ~ a ~ e rOPHMTe flMKO'iHM IlbTHQa M CTa3a Ha YpMHaTa, npM Hall#Ta $YHKL(MR Ha 6b6peqw~e, a npM nbnHa HeflpOXOflMMOCT ClMeTO Ha OTHOCHTenHM KOHTpaMHflMKaqMMB MOMeHTa 38 Ha ypMHaTa M RByCTpaHHO 3aCFlraHe- aHypMR M 6ene3u Ha OnepaTMBHO nereHGle ( H ~ ~ ~ O H O CHa ~H ReTeTO, O C T MH$~K06H. qM03HM YCnOXHeHMR - IlM0~e$po3a, YBpeReHO 0640 CbCTORHMe, 06H OT O~CTPYKTMB~H nPOU3XOflM AP.) no T03M Cu~rnonnam~a H nmaraocmKa HawH vpe3 nepKyaHHaTa ~ e Q p o c ~ OT o~ ea y a orpaHa 3 a 6 0 n ~ e a ~O e~ ~W oK H O B ~ H C e OflMarHOCTMqMpan0 noce nocTaeR ToclHaTa AMamoxi Ha u a n $ o p ~ a q ~ f(npol~a Bog Ha Apyro 3a60n~aa~e (nMeno~e$pn~, 6b6per~a KOBeXQaHe Ha PeHTreHKOHTPaCTHO M3CneABaHe Ha rOPHMTe nMKa M ~ p .Kora~o ) npoqeCbT e ABycTpaHeH (O~MKHOB~HO nMKOCfHMnbTMU(a npe3 nOCTaBeHMR gpeHi3K - npe3 ApenpM H O B O ~ O ~ ~nOB0nbT ~ H M T 3a ~ ) nOCTaBRHeT0 , Ha RMarHOHaxHa nporpqHa n~enoype~eporpa$~~), a, OT Apyra, sa~a e aHypMma - cnep pwaHeTo AeqaTa He oTAenm c n y w KaTo nbpBcl eTan OT neveHMeTo Ha aHouanwTa. ypmia, npM npaae~ nMKoreH Mexyp. ~ O ynTpa3ByKOB A KOHTPOn C e IlyHKlMpa nyM6an~0 6b6peqM~e MoraTAace nannMpaTyroneMeHM, Hanpenpea KoxaTa AnnaTwpaHaTa nvenoKanuKcHa cMcTeMa Ha mam. 6b6pe~a.~ ~ H K ~ M C eRM3BbpWEZI T ~ M n M CbC CneqMXIHM Exorpa$#R~a no~as~ AwnaTaqMR a Ha nMenoKanMKc~ a 6 o "Nephrofif p~ lrnM c ~ a 6 o p 3 a cynpany6clr~a nywHaTacMcTeua~c~a3aHaypMHaTa. L(MR Ha IlMKO'iHMfl MeXYP - Cystofix. B KvMHHaTa CMCTeMa

3anpax~a aa ypuaaTa OT ropame nwKoracr nanrqa (nvreno~an~~ cHcTenna c ~ a H ype~ep)

Mamlow~en~o a~ ~o are~n Ha exclnepTepnnMRTa npM AeqaTa ce onpeAenR OT ponma U Ha cMMnToM Ha 3a6on~saHe M OT recToTo fi npoRsneHMe B T ~ B ~ ~MB ~ ~ C rpyna T O B ~ (o~ono 25% OT neAMaTpMwMTe naqHeHTM ca $ e 6 p ~ n ~ ~ ) . O C B ~B H Cny.laMTe, KOraTO e llpHApy)KeH C bPCI M n M HqXBbpJlR41.lac, BMCOKMRT $e6p~nM~eT PRAKO npe#CTaenRsa PMCK XIAeTeTo, HO M ~ M C K M HenocpeAcTBeHo nerewe. (B noeeveTocnyraMr n a e ~ a ~ a r a e f l ~ a m o s a Ta M Tepanwma Ha 3a60n~sa~e~0, Boneqo 1 0 $e6p~n~T~T.)

1. M H $ ~ K ~ M O ~ H # a) UHC - OCTbP 6 a ~ ~ e p M a nMeHMHrMT; e~ BMPYCeH M~HuH~o~H~~$W~MT. 6) o w - nepMop6MTane~ qenynMT; op6mane~ qenynMT. B) rOPHM AMXaTenHM nbTMqa - IlpOCTyfla; $BPMH~HT TOH3MnMT; WMeH nMM$rlqe~kl~; nCeBfl0Kpyn; enMrfl0TMT; OCTbP CMHYMT; OTMT. r) ycTHa KyMHa - anBeonapeH a6cqec; xepnaHmHa; MHMBOCTOMaTMT; IlapOTMT.

514

Oco6enocmu Ha cneurnume cacmonnun B gemcka Barpacm

~ai-recro npM MeHMHM M TO H q l-roRMuHa ~ b a p a c ~ ) , PMT; alleHAM4MT. c ~ p ~ n o xapKaHe, p , TwpaX ( n p ~ O ~ ~ ~ P Y K U Ha M R rOPHHTe X) nn~oro-nonoea cucTeMa - M H $ ~ K ~ M G H a I nMKortiaAMxaTenHN nb~MIqa), pcntien, q ~ a ~ o sGne~om, a, TaxMnTa CMCTeMa; O C n p CannMHrMT. Hoe, TaXMKapflMfl,X M n O T O H M f l( n pC ~ M y W e H M R BKapAMope3) o n o p ~ o - g e ~ r a ~ e anapar n e ~ - cenTnreH apTpMT; CnMpaTOpHaTa $YHKL\MR IlHeBMOHMR, nePMKaPAMTj 6 a ~ O C T e O M M e n M T . TepManeH eHAOKapAMT, C ~ ~ T M U ~ M M FxeuoparMreH I), 06M) Koxa qenynuT; BMpyceH e ~ 3 a t r ~cKapnaTMHa; e~; PMB( 6 a ~ ~ e p ~MnM a n pMKeTqM03eH e ~ C ~ ~ C M CE ) .K ~ O ~ ~ H C W C T e M H M HH@K~MM, CBbP3aHH C M3pa3eH O~PMB. Te nMporeHM (npo,qym Ha MnM OT p a a n ~ Ha a MH($~K~HOK) C M C T e M H M~ ~ ~ O ~ R B ~ H IlbPBMCIHa M F I CeIlTMqeMWFI H M R n p ~ r ~ ~M ~ KoMnneKcbT ~ e n ) ~HTM~~H-~H~NR~O (rIlaBli0 M ~ H H H ~ O K O K ~ ~ M M OKymHa FI), ~ ~ K T ~ ~ M (rna~ M M R 3 pI3BMKBaT noltaqeatie Ha TenecHaTa TeMnepaTypa y e 3 B H O ~H~BMOKOKOB~ B M ) ;P Y C H MC M H A P O M M . MHqyqmpaHe Ha $ a r o q ~ K ~~ ~M ~ ~~e OM~BOACT Ha BO eHA02. reHeH nnporeH, KOATO n o c n n ~ a B4 ~ p ~ y n a 4 ~ ~ ~ a a) PeaKqMR Ha MeAMKaMeHTM M BaKCMHM; no-oco6e~w ca cnyrame Ha ($e6p~ncl~eT, KOMTO ca 6) canHunnoso oTpasRHe. cebp3a~ c~nproBe M ~ ca M ce npoRaMnM no spenne H a

npe-

BPY~M

'IKy1~o~a3acqauIaeaq~ IIPH'IHHH 31 @ebpyu\me.r

I. ~ ~ H ( $ ~ K ~ M o ~ H H a) UHC - o c n p 6 a ~ ~ e p n a MeHMHrMT; ne~ e~qe$anlrTM.

6) ropw AMxaTenHM nbmqa - ocrbp enMrnoTm; peTpo$ap~~rean a6cqec; e~ ~ $ T ~ P M (p R~ e no-~RUKO); c nceBROKpyn. B) 6 ~ gpo6 n

a~ec~e3~~1. rbproae~e, cbreTaHM c $ e 6 p ~ n ~ ~ MoraT e ~ , fla c: cMMnToM Ha x ~ ~ o ~ o 3 a c ~ p a u r a e M aH ua $ ~ K ~Ha # FI-IHC I Yec~o,o6are, M ~ ~ K O T peTe O nonyraea e A M H eRMticTset Tbpr, H ~ ~ - W CyTA O O M a CM M n H fiOKaTO r0 BOflRT npV neltapfl. Kora~o ro npernexp,aT, TO Marnexqa go6pe

- nHeBM0HMR ( M ~ C M B H ~ )MMnMapHa ; v-

6ep~ynoaa.
r)
Cbpqe

- MMOKaPAMT; 6 a ~ r e p ~ a n eHAOKapAMT; e~ raCTpOeHTe-

nioeti nepMKaplMT.
A)
raCTp0-MHTeCTMHaJleHTpaKT

Cnope~ peaMqa aeTopM o ~ o n o 3% OT nproaeTe npr fleqaTa Ce pbnXaT H ~ $ ~ ~ P M ~ M TeT~ ~M TB . 0flpe~enRHb ~ T KaTO o 6 ~ r a A -~ R B ~ R B a T Ce eF(HOKpaTH0 no BpeMe H 2 $ e 6 p ~ n ~ ebe ~ e abspacrra ~, M e w y 6 Meceqa M 5 roAMHb MH e~ p a m noeere OT 15 min, r e ~ e p a n ~ 3 ~ p ca aM ~ He w a
IlpMflpYXeHM C HeBpOnOMrHa HaXOflKa, MeHMHM3bM I

PMT; afleHflMqblT; nePHT0HHT (OT ApyrO ~ c T ~ U B O ) . e) o n o p ~ o - ~ e ~ r aanapaT~ e n e ~H ~ K P O T M ~ M MMOP~~

~ M (ras-e~e~). T X) C M C T e M H M - MeHMHrOKOKqeMMR; 6a~~epManeH~enCMC (upyr n p ~ r ~ ~ m e xeMoparMrHa n); TpecKa.

2. K o J ~ ~ ~ ~ H O oC ~ T b H PM PeBMaTM3bM. 3. APY~M

a) TMpeOTOKCUK03a. 6) TOnnMHeH yuap. B) a n o ~ a r e c ~ xmnepTephnMR. ~e~a r) oTpaaRHMR (Atropin, Acetysal, Arnphetamin, $ e ~ o T M a 3 M H O B M ~~POM~BO~~HM). p)s n o ~ a r e c ~ s o e6 ~p u a 3 y e a (~~~~~ BKo~ ~eepo6naM, C T O M M , ~~MM@MM). e) WeHonaTMM B rpb1HaTa KyxMHa C ronm p a 3 ~ e p M npMTMCKaHeHaTpaXeRTa.

IlpOMeHeH CeH30PMyM. ~ P O R B R B ~ Ce T OKOnO 12 h Cne) HarMOTO ~a$1e6pMflMTe~, H~BMluaMul38.5"C. npo6ne M ~ npM T peTe c Tatme b p r e an^ ce Hanara ny~6an~ ~YHKUMR, KOJTTO fla w l v l t o r ~ MeHMHmT. n p e n o p b r ~ a ct n p Reqa ~ noA 18 ueceqa, c n b p e ~ n p q , cabp3a~ c aucoi $ e 6 p ~ n ~ Ra ~e Ce ~ M3BbpUM , n y ~ 6 a n nyHKqMR. ~a Oe6punn~en~ no BpeMe Ha a ~ e c ~ Moxe e 3 ~ Aa ~ c u3pa3 Ha p a 3 ~ ~ ~ ce a ua a no~arec~se xwnepTepMm ~a KORTO ce oTKnloraa ~ a i - r e c OT ~ onpMnaraHeTo Ha xano, reHHM aHeCTeTMqM, &nOflRpH3Mpau\M MMOpenaKCaHTM H0 M OT PeAMqa APyM a H e C T e T M C c H M MeflMKaMeHTM M nCM, x@ap~a~a. TR e cwpsa~a c reHeTHwo 06ycnoae~c Hapyuretilre B KanqMewa O ~ M R H ~ ~M , RTO npoma ce OTK. narm OT npMnaraHeTo Ha M36p0e~MTeMepMKaMeHTM, Cabpsa~a e c BucoKneTanMTeT n c n e q ~ $ ~ r nereHMe ~o~o amtoclea Dantrolen B ~ o s 1 a mglkglmin; npo$~nam~w

X) AexMApaTayMR.

- 2.5 rngkg i. v. -

Cnea M3lvllo.l~a~e MH$~KL\MR UHC B C M V K MAeqa C $ ~ ~ P H ~ MH Q T ~ 38.5OC T M flop ABa MeCeqa M 3 M C K B a T MMHMMYM n a 6 o p a ~ o p M ~~~C ~ ~ A B ~ H nbntia MR KpbaHa KapTmHa, p e ~ ~ r e ~ o r p a Ha $w ~ ~ ~~ A H KOU, M Rypwa ( e a e ~ TymHO M 4epe6pocnH~an~a TWHOCT M K P ~ B38 ) 6a~~e an~o ~scnenea~e.

~ c o 6 e pmcltoea ~o rpyna n p ~ ~~ ~ B M T M Ha ~ $e6p~ T O nMTeTnpeAcTaanRBaTpeqaTa,r~~~o MeXaHM3~aq~~~ M M3 2 1 CnpaBRHe pop^ c I - I O - H ~ ~ H ~ ~ M T M ~H ~@ HM ?K~ ca MM HaMmeHM. B T a 3 M rpyfla flOflmaT: D --..- ---- - Urra......"..

....

Oco6enocmu n a cnewnume cacmomwn B gemcka Ba~pacrn

515

H a TeMnepaTypa flo 38C Moxe fla e e c c e p ~ o 3 ~ Ma H$~K4iR. flbpBMTe C M M n T O M M , TMllM'iHU 3a no-TOneMMTefleqa, H eC e ~a6nl0flaBaT B Ta3M Bb3paCTOBa rpyna (Hanp. MeH H H M ~ ~ flpM M ) . HOBOPOfleHUTe UMYHHaTa CMCTeMa He e HanbnHO pa3BMTa M KOMneHCaTOpHMTe Bb3MOXHOCTM C a orpaHvreHM. Aeua c HapylueHa @ Y H K ~ # R Ha AanaKa 1. Cbpn0BMflHa aHeMHR M ~efiHM~e BapMaHTM. 2. Bpofle~a acnnewfl. 3. X H P Y P M ~ EICi H~ lfleHHFI. Aeua cac SnoKarecTeeHln 3 a 6 0 n ~ s a ~l n l~ p .TRX ~ 3aUplTHMRT MeXaHM3bM Cpeuy HH$~KL(L/IMT~ e nOTMCHaT, KaKTO OT ~ ~ ~ O J ~ R B ~ H ~TaKa T O , M OT MMyHOCyllpeCMBHaTa TepanuR.

Amidophen 1% pa3~~0p, 0.5 rnllkg, Analgin, Acetyzal- lO15 mg/kg, Paracetamol, Chlorazin - 1 mg/kg. 2. flpo~ueoraproaaTepanMR - npM AeqaTa MHoro recTo xMnepTepMuma ce npMApyxamOT raproae, KOMTO ce KynMpaT c: Diazepam - 0.3 mgkg i. v., i. m., Lurninal3-5 mgkg, Thiopental - 2-3 mglkg i. v. 3. O M ~ M KoxnayqaHe ~ ~ H O - npM $Ie6pMnM~eT, o6ycJlOBeH OT flMC6ana~c B MeXaHM3MMTe Ha 3aTOnnRHeTO M oxnayqaHeTo ( ~ o n n ynap) ~ ~ ee~~eo6xofln~o cneurHo oxnwaHe, a He aHTMnupeTvK. Tom oxnayqatie ce ocbqenema qpe3 ~ ~ B U B K Ha U TR~OTO Ha AeTeTo c MOKPH KbpnM, IlOCTaBRHe H ~ T O P ~ H C I K M Cnefl B aKCMnMTe M MHIBMHWlHUTe I%HKU, WIU3Ma CbC CTyAeHM pa3TBOPH.

B 6 o n ~ u v 06cTa~oa~a ~a ~ora~~a6b noeTopetiM fla~ M IlOTPeTeHM MepOnpMRTMRTa, OCbqeCTBeHM Ha flo6on~~q 1. AHTM~M~~TMCIHO-TO ~pf16~afla BbpBMYCnOPeflHO C H0 HMBO. T ~ O K ~MKHOB~HO C e 3anOqBa H030nOM'iHO HaCOneCleHMeTO Ha ~ ~ T O $ M ~ M O ~ cy6CTpaT O~WVH Ha M 4e6p~R veHoTo nerewe. nMTeTa. 1. AHTM~UOTU~HO - fleTeT0 C U H $ ~ K ~PRfl MR KO e C Kora~o $e6pMn#TeT%T ce flbnXM Ha XMnOTMaMMVHMR TeunepaTypa, HaBMuraeaqa 41 .l "C, KORTO fla Hanara perynaqnoHeH qetinp (UH$~K~MFI, peaKqMfi ~ H T M ~ ~ H - a ~CneWHO nOHHXaBaHe KaKTO C FlHTMIlMPeTMK, TaKa M C r m n o , anoKarecTeeHn 0 6 p a 3 y a a ~ ~ onlnnT ~ ) , Aa ce no$IM~MK~J~Ho OXIlWaHe. npM flHarHOCTM4MpaHeTO Ha XMHMXM TenecHaTa TeMnepaTypa c amwnwpeTuK, n o w eo~o3ac~paura~aqa M H ~ ~ K ~ npMnaraHeTo MFI ~aam~6uo BMHarM e ycnelueH. TM~M ce 3anorsa HenocpeAcTseHocnefl ycTaHoaRsaHe Ha K~TO aHTHnMpeTM4M Hafi-'ie~T0 Ce M3nOn3BaT $e6pUnM~eTa.

HO~O~O~MR C~~CU MeHUHrMT, C, nHeBMOHHR, H H @ ~ K ~ H R H a MeKMTe TbKaHM Cencuc, MeHuHrMT, MH@. M e K M TbKaHM npepnonarae~a MH@ e ~ qc m H. influenzae

AHTM~MOTMK Ampicillin

Bb3pa~~ 1-4 CeflMMqM 4 CeflMMLp4 4-8 cephnnqu

003a/Fle~ 100-150 mqkg 150-300 mqkg fl0 300 rnglkg npU MeHUHrMT 100 rnqkg 100-200 mqkg 50-75 rngkg

nbTM/AeH 4
4 4

Cefarnandol &?f~roxirnum Chlorarnphemicol

2 3-4

4 3 4

Gentarnycin Cycne~u~rr ~a C~~CMC/M~HMH~MT npepnonarae~a

MH@~K~IIR CbC

< 6 CeflMuun

7.5 mqkg 100-200 rnqkg

Oxacillin

Streptococcus aureus

516

OcoCenocmu Ha cneurnume cacmonnun B gemcka Barpacm

Ta6nwqa 17.9. A m b m q n ynorpe6~eaan~ a i i - r e m npw no~ann3npaa nnI$e~qnn,cebp3an~ c I$e6pnnnrm

@OVC
~PM.~UHUT~~

A~~~MOTMK Arnpicillin Erythran Penicillin

fl03al~e~

nbTM/fleH 4
4

OTUTMC ~euua

Pneurnococcus H. influenzae Pneurnococcus

~H~BMOHUR

150-200 rngkg v p c ~a n e r e ~ ~ 10 eAHM 20-30 rnglkg 50 000 E (kg i.rn. nocneueaHoo~ 20 000 E/kg per 0s)

14 #IU

~~H@KL(MR ~a nuKowiaTa CucTeMa Uenynn~ 6a~~epuane~

@~PUH~MT

E. coli

Arnoxicillin

40 Q l k l

St. aureus Streptococcus A.

Cephalosporin Penicillin Benzycillin

100-200 rngkg 50 000 Ekg i.rn.

O e o 6 e ~ o c m uH a cnewnurne cacrnoRHuR 6 gemcka Baapacm

517

6owaBa~e Ha MepclaTopM OT newcoumw, T P O M ~ O ~ M TM M T b K S H H M KJleTKM. O c ~ 0 6 0 w a Ce ~a B ~ a 3 0 a K T M B H M BeweCTW M $UTOTOKCHVHM C ~ ~ C T ~ ~ KOWO T M , yepewaT MMKPuMpKynauMma. 3a KoMneHcaunR Ha TbKaHHaTa XM~OKCMR Ce IlOnyVaBaTX e M O f l M H a M M V H M IlpOMeHM, KOMTO Ce IlpORB R B a T B ABe @PMW:

~PM~MH 38 M pa3BMTkle Ha CenTM'ieH WOK B AeTCKaTa Bb3paCT: O C T P M raCTPOeHTepMTM; K O X H M MH$~K~HM nb, neH cencuc; aneHAnumM; nepmoHmn OT Apyr npo~sxop; ~ ~ O H X O ~ H ~ B M O H UM Me ;A M a C T M H M T M ; MO~~HM MeHMHrOeHq e $ a n ~ ~o nc ; ~bp xeMaToreHeH ocTeouMenMT. Hah-rec~n npwvuHmenw: rpau HeraTwaHM 6amepn~

P ~ H(~Mnep H ~ @ ~ H ~ M U @pMa Y H ~ ) C HaManeHO CbpOBO canpoTMBnetiMe, ~ 3 p a 3 e ~ apTepManHa a ~a3o~~n

(E. coli. Enterobacter, Klebsiella, Pseudornonasproteus); rpaM ~OBMTMBHM (St. aureus M epidermidis, l 3 xennonuTureH
CTpemOKOK; KaHflMAa; BMPyCM; PHKeTCMM.

~ H RnoBwtueH , cbppeVeH MMHyreH0 6 e M ~HaManeHa ~ O M neHa $ ~ H K L ~Ha ~R cbpueTo npn ~ o p u a n AH. ~ o 6enomo6H O T 0C b p O B O CbflpOTMBJleHMe Ce IlOBMWaBa 6bp30 flop, B n M R H M eH a HaTpynBEtHe Ha JleBKOuMTM M TPOM~OL(HTM B 6enoppo6~me KanvnRpM. T a 3 ~ $a3a e n o - ~ R A MK 6bp30 ~ npexoAHa npM AeuaTa. XMnO~HHaMMVHaTa @pMa CbPAerHMRT MMHFeH o 6 e Ha~anRea, ~ AH ce no~~xacaea c BMCOKOnepn$ep~o M

PM

6enoflpo6~0 c b ~ e CbnpoTnBneHue, o cbpfleclHa cna60c~, noenluetto UBH, Tema xnnoKceMm M M ~ T ~ ~ O aqu~ U T C e n ~ ~ rWOK ~ ~ce r onpeflenn n K ~ M rpynaTa Ha ~ U C T flo3a. pu6yrop~me ( B ~ ~ O ~ ~ H ~ TOKCMVHM T M C I HC U b C )T O R H M R , AbnxaqM ce Ha M H $ ~ K ~ M R T.o i e cnoxeH n a ~ o $ ~ 3 ~ o n o r n r e ~ IlpOueC, VMRTO O C H O B H aM 3 R B a e HeqeKBEtTHaTa nep$y3MRMOKCMXeHauMR HaTbKaHMTeMOpraHMTeBbBBPb3Ka c 6aKTepMan~aTa MHB~~M nR oTAeneHMTe TOKCMHM, C nporpecwpawo eH1oreHHo yapewatie Ha KnenvHMR 0 6 ~ e M pa3~~~ Ha we H ~ O ~ ~ ~ T npoqecm. M M M Jle~anmen~ a fleTCKaTa Bb3paCT no nMTepaTypHM flaHHM e Mewy 4070% BbB Bpb3Ka C HaMMeHMTe KOMneHCaTOpHMMeXaHM3 M M M npOMeHeHaTa BlnpyneHTHOCT Ha M M K P O O p r a H M 3 M M Te OT W M P O K O T O flPMnOXeHMe Ha ~ H T M ~ M O T M ~ M .

1. ~ H H -TaxMKapUMR, # TaXMnHefl, XMnepTepMMR, TOn n M KpaiHnq~, HOPMMHO MnM nOBMWeH0 AH, IlOBMWeH ~ cbppereti nHpeKc, HaManeHo UBH, cyxa Tonna Koxa, qeKeaTHa AMype3a (nonuypn~). 11. n o - ~ C H -T U~ X M K ~ P ~~~PM~F~I ~ ~~ MO K AMXaTen~ P ~ M R Ha Renpecm, xMnoTepMuR, 6ne~a Koxa, q ~ a ~ o 3Tpeca, Ka, cnqaHe Ha AH, HaManeHMe Ha CbppewiMR MHAeKc, I l O B M L U e H M e Ha L(BH, OllMrypMR 10 aHypMR, O ~ ~ P K ~ H O C
H ~ C ~ O K O ~C TO B M H M O ~ n e H ,T H O C T p0 KOMI, XeMOParMClHa pMaTe3a, nmep KaTo cnMnToM Ha r e p ~ o ~ ( p 0yepewa6~0

C~~TMCIHMRT LUOK HaCTbnBa IlpM 6 a u e p ~ a n ~ UHBaa ~ M ( R~ a i - r e u o rpa~-o~p~ua~e KoraTo n ~ a ) npwMHnTe, nMTe MnH TeXHMTe T O K C M H M IlOIl~HaT BK P b B H M R nOTOK. Oamop~ 3a pa3sme Ha cenTMveH WOK: Hanuwe Ha $ O K ~ ~ HOlHMqe, O HaMMeHa p e 3 M C T e H T H O C T Ha AeTCKMR opra~~aau, axoaHa BpaTa 3a npoHuKaatie.
blH~M6MpaHeT0 Ha $ Y H K ~ M RHa T ~T P O M ~ O ~ U T U KaTO T~ pe3yn~a OT ~ HapyweHwR Ha eHpoTenMyMa M amwsMpaHeTo Ha M H T ~ ~ H ~ $amopa HK AoeewaT ~o noeuwaeaHe HacbpoanRnep~ea6~nme~, HeAocranwiaTbKattHanep$~3Mfl, M H T e P C T M 4 M a n e HO T O KMn b l K CMH#WM. n0paffM oco6e~oc~me Ha AeTCKaTa Bb3paCT T e 3 M n a ~ ~ ~ 3 m n o npouecu m w i ~ npoTMraT @YA~~FIHTHO, re~epan~a~M p peuaTa a ~ o ~ a n q hntioro a ~ no-recro B TeXbK XMtlOAMHaMMreH C T ~ Ha M C ~e n T M V H M R WOK. H a ~ a n e ~ HMyHHa a ~ a 3 a w a npn HoaoponeHnn mpMareTa, npn cnneHemounpaHn peua e OT aHareHne 3a pa38mne~0 Ha CemnveH LUOK. n p e ~ n ~ a s a Ha ~e ettpo~o T O K C M H a npe3 peTHKyn0eH~OTenHaTa C M c T e M a AOBema

He, OCTpa AMXaTenHa HeflOCTaTb'iHOCT, n H e B M 0 H M M 10 MtiTepcTMuManeH OTOK, HaManeH 6enoppo6e~mMnnai a ~ c npoue~n~e . B X ~ M O C T ~ ~ M O ~ O ~n ~o V~ Ha M 3T a~ ~e ca: Hamnaatie Ha KoHcyMaTwBHa KoarynonaTwR, noBMW e H O reHepanM3MpWO KbpBeHe, IlOHUXeH $ M ~ P M H O T ~ H , ~ ~ o T ~ ~ M BpeMe ~ M H Mo TB ~ M ~~ O ~ M M .

Ill, n p o ~ Be na ~ h~ pa~op~n~ o~ ea 3 a ~ e n ~ : 1. B paHttaTa @3a-nee~oqrnoa, oneematie, x~noKC~MHR,pecnHpaToptia an~anoaa, ~ e ~ a 6 o a4n~on~~~ 3a, noBuweHa a p ~ e p n o - B ~ Hpamu~a, O ~ H ~ xmeprnhrteMMR, neKa ~ o a r y n a ~ o p ~ a a 6 ~ o p neKo ~e~ yBenMretiMe oc~, H a namame. 2. B KbcHaTa@3a -XM~OKCUR,pecnHpaTopHaaun1oa,~ e ~ a h n n naywoa, ia HaManeti 6eno~po6e~ mm,

CloamMBHpaHeHaKacKapaTaHacacnpeaHe,KanMKpeclHK M H H H O B a T aC M C T e M a , M3pbCWHeTO Ha ~ H ~ o ~ M HXBOM ,

xnnornnKeMnR, yeen~lce~a a p ~ e p n o - e e ~ o pamnlta 3~a Ha Kncnopona, KoarynonaTnR, namoaunpo3a. Heo6xopw~m n 3 c n e p a ~ np ~e : ~~re~orpa Ha @ 6e~n nwe pp~60ae;a n ~ a n ~ o - ~ n c e n ~n e~ ~e a~ h n wM 3~ bp ~b eHn raaow; EKT; enemponm, ypefi, KpeaTHtiMH, rnmo-

518

Ocolienocmu no cneurnume cacmonnun 6 gerncka Ba3pacrn

3a; vepH0flp06HM npo6M, K ~ J ' I ~ M @C$Op; ~, cbpfle'iHM eH3MMM - CPK; XeMaTOnOMfl: X ~ M O ~ ~ O ~ XeMaTOKPMT, HH, TPOM~O~MTM neBK04MTM , C ~M$epeH4ManHa KapTMHa; Xe~ o c ~ a s ~ o n o KoarynorpaMa; mn: ypMHa3axeuaTypm, npoTeMHyPMR, OCMOnapMTeT; MMKPO~MO~OMCIHM M3CneABaHMR 3a aepo6~a M a~aepo6~ $nopa, a KattAMAa M JP.; ~~yHoenempo@pe3a.

Ao6on~rrr~o noseReHHe H n e r e ~ ~ e
Heo6xopnua e cnewHa xocnmanM3aquflM KucnopopOne'4eHMenpM OCMryPeHMC B O ~ O ~ H rOPHM H H flOnHH AMXaTenHM nbTMqa C 060raTFiMHe Ha BflMUMHaTa ra3OBa cMec C ~ 3 Ca~onne M~ oBnaxHeH KMcnopop qpe3 MacKa HnMHa3aneH KaTeTbp.
Cll~luH0 ~ O ~ H H I I Hnl?9eHHe O

M~TyGaqm H M ~ K ~ C TB B~~ HH TM ~ ~ ~ UnpM M R cnenHMTe MHflMKaqMM: PaO, < 50 mm Hg M 0 , = 50%, PaCO, > 50 mm Hg, HaManeH BeH03eH KanaUMTeT M YBenMreHa ~ ~ H O P M H O pHxaTenHa VecToTa B ~ ~ B M C M M O C OT T awpama, 6pqwnHen, anHoMvHH naysu, TemKa HenoenMneaqace MeTa60nMTHa aqMpO3a, 6eno~po6e~ OTOK C pMCTpeC CUHppOM. OCM~~~ Ha RBeHO3eH B~H~ M3TOqHMK npeAMMH0 UeHTpaneH Ha seHa torynapwc eKcTepHa, uweptia, cyfi~naemn $e~opan~ 3a c6op6ac x ~ n o e o n e ~ n vpe3 n ~ a meKsaTHO 06eMH0 BMeCTBaHe, cb06pa3eH0 C AHeBHMTe H M M M eKCTpeMHMTe 3aMM. ~3n0n3BaHbl pa3TBOPM: Ringer lactat, Ser. glucosae-5%, Sol. glucosae- 1O%, Hemodex - 7 mllkg, nbnHoqeHHa ~ p b e 15-20 mVkg/t, nnas~a - 10 mlkglt, Human serum albumin, KonoMpHM pa3~aopt1, aMMH O K M C e n M H M (10-20 mVkg.) PMT~M M~ TeMllbT T Ha M H @ Y ~ H M T CneA ~ nbpB0HaVanHaTa 6onyc po3a 20 mVkgIt 3a 10 min ce perynMpaT OT MOHMTOPMHra Ha UBH ( H O ~-M 5-1 ~0 C m H,O). n o p ~ b p x a Ha ~ ecbpuerHaTa @~HKUHR- npe$epe~~HO MRCTO HMa Dopamin B ~ o 3 a 2-4-10 pkglkglmin, lsonproterenol-0.05-2 pkglkglmin, Dobutamin-orn~~aneH KappManeH e$em npu poaa - 7.5 pgkglmin, Ca Chlorid -5-7 mgkg npes qetfrpanHa seHa c anTepHaTMBa

Ca gluconat - l 0 mglkg. 3a KOpeKUMR Ha M ~ T ~ ~ O ~ M aUMA03a T H ~ T-~ Na bicarbonat- 1-2 MEqvkglt B nbpBMTe MMHYM 10 nonyvaBaHe Ha p e 3 y n ~ a ~ OT ~AK ~ eM cne4 Toea no $ o p ~ y n a ~ Tenectio Terno X BE X 0.3; nop 1 ropMHa -TernoTo X BE X 0.4. KOPTMKOCT~POM~M B M a C M B H M n03M e c ~ ~ ~ M $ M neveHve npM CenTMrHMn UJOK - npenapam: Methylprednisolon (Urbason - 2-10 mglkglt Ha 4 h, Dexamethason - 2-6, mgkglt, Solurnedrol- 30-50 mglkgl 1 , Solupertef - 50 mgkglt. AHTM~HOTM~M - CMHTeTM'iHM Penicillin no 260 mg/kg/t Ha 6 h, qe$anocnop~~u (Cephazolin, Ceftriaxonum, Cefuroxinum), a ~ ~ ~ o r n t o ~ o (Gentramycin, 3~pn Amikin, Tobramycin ~o 5 mglkglt), Metronidazol no 8 mglkglt TPM nbTM PHeBHO, npM HyX&l aHTMMMKOTMreH ~ H T # ~ # O T CIK Ancotyl no 150 mglkglt 3a 24 h Ha Aaa npneua, Diflucan3a Reua H~LI10 ronwn. noACIbPxaKaHe Ha 4 e ~ B a p~ype3a ~ ~ a 3a ~ ~ ~ M H T O Kauwn M n p o @ m a m ~ Ha ~6enonpo6e~ a e1eM - Furosemid - 1-2 mg/kg/t po e$em, ~anitoli-18% .0.5 - l glkglt 3a 24 h. C a ~ ~ p Ha a~ oniMqeTo e ~ M ~ H O M O ~ ~ MM ~ M ~~ H HTOM C ~ ~ C T M T ~ CpepCTBa M~~~M - Immunovenin ( l-3 mlkglt), Gammavenin (0.4-1.0 rnllkgl t, Decazis no 20 kg-50 mglkglt. BIIT~MMHM:C; 82; B6; B12; K3; E, a ~ a 6 0 npenapan~~
'

TM.

M o ~ m o p ~ p Ha a ~n eo ~ a 3 a ~ e n ~ ~ e 1. Ha UMxaTentiaTa $YHK~HR - puxaTenHa qecToTa, MMiiyreH pMxaTeneHo 6 e ~o , ~ c ~ x e ~ o r n o 6 n HacMqa~oso He Ha KpbBTa, npOCneflFlBaHe AMHaMbIKaTa Ha pMWaHeT0 vpe3 munnafia~ca M pe3~c~a~ca. 2. Ha xeuopvHaMwaTa - cbppewa vecToTa, EKT, AH, UBH, MMHYeH CbPAeVeH o6eu, eX0-KapAMO rpa$#n. 3. Ha p ~ y p e s a ~ -a ( A e ~ o ~ oM q vacoea) ~a - Hopua npM peTe - HW1 mllkgltlh. 4. Ha xe~oc~a3~onornrna - Ha 12 h KoarynorpaMa. 5. Ha MMKPO~HO~OMCIHCIIR CTaTyC B RMHaMMKa-XeMOKynTypa, a ~ ~ ~ 6 ~ o r p a ~ a .

OT TenecHoToTerno M nocTenetiHopocTMraT m~3-rop~wHa Bb3paCT C T O ~ H O C T M TnpM ~ Bb3paCTHM 60-65%.

2. P a s n ~ B ~pa3npepene~~e~o a HaTenecHMTeTerHoCTM - npM peUaTa no-ronn~a racT OT TevHocTMTe ca M3BbHWleTbVHO. 3. nopqep~a~a MttTeH3MBHocT Ha BO~HO-cone~ O~MRH npM ~ M ~ K peua. M n p KbpMareTaTa ~ ce 06MeHfl n o w 112,a npn B ~ ~ ~ ~ C T H M T117 ~ -OT A eKcTpaUenynapO HaTa TeClHoCT B AeHOHOqMe.

OcoCenocmu na cneurHume cacmonnun 6 gemcka 6b3pacm

519

BOAM AO HapyweticlR B ~ B BO A H O - e n e ~ ~ p o n O ~~~M t iR aH ~~ a 3ac~raq Katcro ~ 06e~a Ha TenecHM TevHocTH, TaKa M ocMonapMTeTa M KHcenMHtiocTTa Ha cpeflaTa. Hacnnaa xMnoeoneMm, xeMoKoHuetirpaum, enenponMTeH ~ M C 6ana~c, a l # l R 0 3 a . Hapywaea C e XeMOflMHaMMKaTa M TbKaHHaTa nep$y3MR. Cn0peA KOllMVeCTBOTO 3aMeHM TenecHM TevHocTM, j q e x ~ g p a ~ a q ce ~ ~ AenM ~ a Ha neKa, C p e A H O TeXKa M TeXKa. S

HO

1. Hepoc~ancle~ BHOC Ha TewioCTM - npm Henpawnopan~o#nu napeHTepanHo xpaHeHe M orpaHMreHo IlpMeMaHe Ha TeVHOCTM npM H R K O M 3a60nRBa~MR (AMx~-

TenHa HeflOCTaTbqHOCT,C T O M a T M T M , MHMBMTM, $ ~ P M H ~ M TM M RPYM C b C T O F I H M R ,C B b P 3 a H M C ~ O ~ K O BC M M H R P O M , HenoHocnwocT K ~ HRKOM M xpaw - noepbua~e). 2. f l o a ~ w e ~ 3ary6~: w a) nOBMWeHM3aIy6M OT raCTp0-MHTeCTMHNlHMflTpaKT nOBpblqaHe, flHaPMR, C I p e B H M $ M C T ~ ~ MMneOCTOMMM , M

B M ~Ha TflexMflpaTaqMma ce onpeAenA OT K O H ~ ~ H T PaqMRTa Ha H a T p M e B M OHM M OT OCMOnapMTeTa. H~T~M~BM (H RO T~ ~ 135-1 M O~H 50 mEqA) e rnaBeH OH Ha eKcTpaqenynapHoTo npocTpaHcTBo. V l ~ a sHaqeHme sa ~O~bpXaHeHaOCMOTMCIHOTOHMRraHeManKMHOKMCe nwHHoTopawoeeccle, UclMynMpapeaKqwe B MycKynHaTa M HePBHa TbKaH. 3a IlOmbpXaHeTO M y OCHOBHa POnR MPaRT 6b6peqn~e M KOpaTa Ha ~ ~ 6 b 6 p ( eM ~ a ~ocT p o ~ )3ary6a~a . Ha H ~ T P M OnpenenA ~ BMAa Ha 4exmppaTaUMRTa.

M~OTOHH'IHB CleXHflPaTa4HR BOAHMTe H COneBHTe 3 a r y 6 ca ~ Be f l ~ a ~ c sa ~ e nM eenemponmaTa ~ xoMeocTa3a He e HapylueHa. C ~ A ~ P X ~ HHa WH ~~ TTOP M BK ~ P b B H M R cepyM e 130-150 mEq/l. Cpelqa ce ~ah-clec~o np# racTpoLIP.; MneyC, IlepMTOHMT M pp. 6) nosMuJeHM eKcTpaqenynapHM 3ary6M $ e 6 p ~ n ~ - MHTeCTMHElllHM pa3c~pok~Ba, l~a npM capbxaary6a T ~ (1 T 0-12% 3a B C ~ K M1"C ~ 4 3 7 " C )o , 6 ~ nM ~~ o~ O T H B ~ H ~ , X n n e p ~ o ~ a rAexuApanuuR Ha BOAa M n M M3nMUJbK Ha O C M O T M C I H O a K T M B H Mp a 3 T B O P M noeMweHo nepcnMpaqMo M H C ~ H C M ~ M ~ M M~ Cp.; nopaFjM yeenMreHo noeMaHe MnM HeqeKsaTHa enMuMHaB) noBHweHHpeHanHM sary(j# nonMypwrHa$aaa Ha UMR. Han~qe e xMnepocMonapmeT, qecTo M xMneprnnKe6b6pe~~ H e a A O C T a T b C I H O C T , M H C Y $ M ~ M ~ H ~ MHa F I KOpaTa MMR, HaTpnRT e nosere OT 150 mEqA. Ha ~46b6peKa, flMa6e~~a nonMypMR M RP.;

r) AenOHMpaHe Ha T e C I H O C T M B TpeTO npOCTpaHCTB0 e nneapanHa Hnn KopeMHa KyxmHa; A) 3 a r y 6 ~ npv Tpaew, o n e p a q ~M ~, ~ ~ ~ ~ R H ppetiaM R , X M H AP.

Cpeqa Ce npM: IlOBMWeHO HaTpMeBO CbflbpXaHMe (npe~oaapm~e cbc conw, X M ~ ~ ~ ~ J I A O C T ~ ~ O CIMCTO HM~~ BORHM 3ary6u ( ~ H C M ~ M A ~ ~~Ha 6 e HaTpMeeM ~ ) , 3ary6~ no-

MMKM OT BORHMTe (~~CTPO-HHT~CTMHM M 6b6pev~ ~ ~ ~ o ~ R B ~ HcnnyqetiMe MR), B qetiTpanHoTo perynMpaHe (T~'MOPMH a UHC, M H $ ~ K ~ M H ) . A ~ a m o c ~ ~ q ~ Ha pa xMnepHaTpMeMuRTa ~e~o e cnew-

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520

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r) apTepMantio HanRraHe - noHMxaeaHeTo Ha AH e KbceH n p ~ 3 3a ~ xMnoeoneMwww a~ WOK M c noua npor~oaa npu ManKMTe Reua. B e x ~ p p a ~ a q ~~ p~~ 6e a fla a X a n o r o ~ n r l nexnnparaqnfi ~a - npM aary6a Haconlr 6b4e pManrocTMqMpaHa M Aa ce aanor~e nereHMe MHoro npeflM Ra ce noHMxu AH. Ilbpaa~a Aonoema npoMRHa B B noeeqe OT BoAa. n p T ~O ~ MBMA pex~dpa~aq~rr ~ahrecTo MHTpaqenynapHnm o 6 e e ~ 3anase~ 3a cMeTKa Ha AH e HaManueaHeTo Ha nyncoeoTo Hangratie ( o ~ e ~ s a Ha nynca). Toea uacnepaHe e Herowo M ce ~ 3 n o n 3 no~a eKcTpauenynapHaTaTewocT. Cbpper~o-C~ROBMT~ CHMnT0MM Ca H3pa3eHM M TeVHOCTHMTe ~ ~ ~ I $ MMOraT ~MT fla H ~ a n ~ HO o ,e qetieH n p ~ a B ~HaranoTo, a~ npepM Aa uhna ~ eAH. 6bfla~ npeyeenMreHM. P e a ~ u u ~ Ha ~LlHC a ce ~ s p a a ~ ~ a BMMOXHOCT 38 ~ m e p a a Ha B neTaprw M KoMa. n a q ~ e r n ~ c~ XunoHaTpMeMm e qec3a6enex~a: no Bb3MOXHOCT AH M nynCbT C e M3MepTO C a XMnOTePMMVHM. saT B nenianononoxeHne. B npaBow n M cepiianononoxeH M e AH Moxe #a cna,qtie c 15 mm xtcMsaK, a nyncbT ce Cpeua ce npM Aeua c Hea,qeKeaTtio HaTpMeeo aaMeCTBaHe ( K O ~ ~ KHa ~ fl M eXMPPaTa4MRTa FI CbC ceo60a~a BOyc~op~a ca 20 y~apalmincnefl 2-3 min. T e 3 ~ npoMenM #a), C HqHOpMeHM HaTpMeBM 3ary6M (~~cTP-MHT~CTM-Moxe Aa ce oTcleTaT KaTo xnnoeoneMm ( l u ~ p ~ Ha ~a HWIHMR 3ary6M npe3 COW# M CTOMM, X W ~ O $ ~ HHa K ~ M R MaHweTaTa e 2 1 3 OT O ~ M K O ~ Ha K ~nTp~ ep~uw~~qa~ Hq6b6peK~1, 6b6per~a H~RO~T~T~~ CH yBenMreHa OCT), 3. O u e ~ Ha ~a % Ha pexMApaTaq#n: cso60fl~a BOAa (BOAH~ MHTOKCMK~~MR), C H3KYCTBeHO noa) qpea ycTaHoamaHe p a 3 n ~ ~ B aTernoTo ~a Ha AeTeHmxeHMe Ha HaTpMeBoTo capbpxatiue npM xuneprnlrlteTO npepH a a 6 o n ~ a a ~ e M~ Bo MoMeHTa, oTqeTeHM Ha eAHa MMR (Ha BceKM 100 mgldl yeenMreHne Ha cepyMHaTa H Cbqa TernMnKa. O n p e p e n ~ ~ e Ha ~~ o e x ~ g p a ~e a rnlOK03a, CepyMHMRT H ~ T P M C e ~ IlOHMXaBaC 1.0 mEqll). wore TorHo (aary6a Ha 1 mg Tenectio Terno = Ha sary6a PM AeXMflPaTauMR 3aeflHOC HaTPMR Ce $RT M flpylltl Ha 1 ml T ~ ~ H OM C npM T ) oc~po 3a60n~aa~e WnaTa sary6a eneKTp0nMTMM IlPOTeMHM, MMaUJMOTHOUleHMe KbM BOAHOHa Terno ce AbnxM Ha a a r y 6 ~ ~ Ha eTevHom. 3a cbxaneeneKTpOnMTHMR 6ana~c. we, o6are, TernoTo HenocpepcTseHo npeAM aa60n~eaHeTO PRAKO e M3BeCTHO. ~POT~MHM HrpaFIT T ~ POnR B nOmbpXaHe Ha OCMOTMVHOTO CbCTORHMe Ha MHTpaBa3aJlHaTaTeVHOCT.3a PaHHa6) vpe3 uanonasa~e Ha KnwtinqtiMTe M B M T ~ ~ H GeneU Ta peTCKa Bb3paCT e XapaKTepHO $H~UO~~OMCIHO CHMXe3M M aHaMHeCTMVHMTeAaHHM. (Ta6n. 17.11) w e (50-60 g), nopqM KoeTo AeuaTa necHo n a n q a ~ B KO~MV~CTBOTO Ha B O A H M R~!@M~MT MOXeAa C e M3'iMCbCTORHMe Ha XMilOIlPOTeMHeMMR. cm, KaTo ce YMHOXM % Ha AexMApaTauuR (3%,5%, 10% n T. H.) no TernoTo Ha peTeTo. Hanpmep 3a peTe c C~~rnonnamwa TenecHo Terno 10 kg M AexMppaTaqm 10% 0 6 q ~ m A~$M 1.06140 cacToRHMe- npM npernepapeTeTo Moxe pa ~ M Ha T TeqHomM e 1000 ml Mnu 100 ml/kg/ T. T. 6b~e H~C~OKO~M HO pa3Apa3HMTenHO MUM OTnyCHaTO, Cnep onpepen~~e % HagexwApaTaqvRM ~ s r ~ c n e Bmo, anaTurHo. Jlwraeuq~~e u e 6bfla~ cyxu, ronuMaTa Ha eoAHme aary6~ ce sanorea neveHMe. Aeqa c neKa $0~~aHena MO C H lM T e R6bnKM - XJlbTHanU. KOXHURT TyppexMApaTaquR ( ~ 5%) o ~ah-qec~o nomexaT Ha opanHa rOp we e HaManeH, KOMTa - ~6pbrKaHaM YBMCHana. pexMApaTaqMR. A K O A ~ Tnoepbua, ~ T O ce 3anorea c M ~ K M Cna6o~o KanMnApHo HamnaaHe M cTyAetilrre K ~ ~ A H M ~ M KonMrecTBaSerum Glucosae (1-2 r a e w n b x ~ rnpea ~ ~ KaTo 6ener Ha nepu$ep~w~ cnawu ca M H A M K ~ ~ M R re , KPaTKM MHTepBanM OT BpeMe. K a ~ o Cnpe nOBpbqaHeT0, XM~OBOneMM~HHFl UlOK T e Bere HallMUe. KonurecTBaTa TerHomM ce yeenuvamT, KaTo ce cneAM 2. B M T ~ ~ 6ene3u: HM CbmoRHueToM TernoTo. He ~ p ~ 6~a sa ce paeaT mnepoca) TeMnepaTypaTa Moxe fla 6bpe noeMueHa B pe3ynMOnapHM TWHOCTM ( O P M ~ O BOpa, B ~ rah, MnRKO, ~ 6 b n ~ o TaT Ha OCHOBHOTO 3 a 6 o n ~ ~ a M n ~ M eHa B T O P O MRCTO Ha COK M pp.), 3auOTO MOraT fla M3BneKaT BOAa B TbHKOTO AexMRpaTaqMma. Xnno~ep~wma Moxe pa e cebp3aHa c i'!pBO M pa YCnOXHRT WlMHM'iHaTa KapTHHa C PMaPMR. XMnOHaTPMeMMR H n M TeXbK CenCUC. Cnep KaTo cnpaT naTonorurtime aary6~, pMeTaTa Moxe 6) cbpperHa clecroTa - npM Aeua c pexwppaTa'qMn40 nocTeneHHo Aa ce p a 3 ~ 1 u p n~ e. w cbc cpeptio TexKa M 10% TaXMKap~MRTaBMHarM e HMMqe KaTO npM3HaK Ha TeXKa AeXUApaTaqMR 6n ~p~168an0 fla ce X O C ~ M T ~ ~ ~ xMnoaoneMwTa. f l p naqwem ~ c $e6pMnM~e~ M xunoao~pace3anor~ecne~l~onere~ne. neMm CV we 6bpe n o - s ~ c o ~ OT aOqaKBaHaTa npu rMcTo $e6p~n C~CTORHMR ~~ (yeen~qe~ue OT 10 ypapalmin 3a B C e K M rpmyC HQ 3TC). CpepHa M TeXKa A e X M f p la T a I @ F ll B)AuuaHe - pMxaTenHaTaqecToTa n T W ~Ha T pnuta1. ABC Ha pecycqMTaqMma -ocMrypReaHe Ha cao6opHeTo MoraT na 6bpa~noKa3aTen aa KoMneHcaqMR Ha HHAMXaTenHMnbTMu(a, OCMrypRBaHeHa WeKBaTHaBeHTM~ e ~ a 6 o auupoaa, n ~ ~ ~~a o m canbTcTsa o TextcaTapexnnnaqMR, OqeHKa Ha XeMOflMHaMM'iHMTe nOKa3aTenM. BCMYPaTaqMfl. no Ta3M IlPMVMHaTaXMnHema M KYCM~Y~OBOTO KnnauMetiTunonyvaBaTKucnopop. pMwaHe ca recTo cpeqaHM C M M ~ O M M .
HO, ~ ~ Q O TpeaKquma O Ha UHC Ha xunepocMonapuTeTa BOAM A0 M03bqeH efleM, XeMOparMM M T ~ O M ~ O ~ KaTO M, V e C T O OCTaBaT T P ~ ~ HHeBPOnOrMrHM M YBpeWaHMR.

OcoCenocrnu

Ha

cneurnurne eacrnonnun B gemcka Barpacrn

521

n o ~ o 6 pn ~e ~Ba ~ ~ M O X Hn Op o m n x a w e Ha pexMnpaTa4MFITa no OpMeH nbT. PM T ~ X K MfleXMflPaTauMM, aK0 M M a M3BeCTHO noflo6pe~~e, H H @ ~ ~ M~ Kp T~ ~ 1 6 eC a e~ nOBTOpM a c 10-20 mllkg 3a 20 min. O~HKHOB~HO 30 mllkglt e RocTaHa eetia. OT mpeaTa KanKa ~ p b ce e ~3cne~a KpbaHaTa a 3aXap no 6 b p 3 ~MeTOA ~ 1 (CX ~ P T M ~~KCTPO@MKC). ~ K ~ n ' i ~ a ~ 0 3 a 3 a c ~ a G ~ n ~a ~3 A~X pM a~ A~ e~ T ~ U M B FTI T ~ ~~ 4asa n p H ~~ T ~ ~ B M ~ T naunetiT. M ~ M AKO ~ ~ cneA H MH~Y~MF 3. nbpB0Ha'iantiM~e04eHKM M C T ~ ~ H J ~ M ~ MOraT ~ ~ M R B CbCTOFI ~ e HMeTO, ~pfl6ea Ra 6bpa~M3BbPWeHM 683 na60pa~op~a MH@oPMF~~MFI,Ha T03M 06eu HFlMa n o ~ o 6 p e ~ e OCMrypM UeHTpaJleH BeHO3eH M3TO'iHMK M Aa C e ocHoeaeau(M ce ~ s ~ n t o r m e n Ha ~6bp30~0 o n3cne~ea~e fla C cnen# UBH. MOHMTOPMP~T ce cneAHMTe n o ~ a 3 a ~ e n ~ : Ha KpbBHaTa3aXap. 1. X ~ M O A M H ~ MCV, M~H AH, M :UBH, OUK, EKT. 2. f l ~ x a ~ eIn V~ , caTypaqMR ~: Ha KMcnopoAa M K ~ B H M ra3o~e. no-H~T~~W MeponpMmMH H M T ~ aaeucm OT napam3. KAC. HMrHMTe RaHHU, 3aTOBa He3a6aBH0 C e M3npau(a KpbB 3a 4. nwypeaa- racosa M aa 24 h. ~scnegaa~e Ha: 5. Y p ~ n a oTHocmenHo Terno, ocuonapMTeT, enetcra) eneKTponMTM (oco6e~o HaTpMD M nPOTeMHM; POnMTM. 6) xeMaTonoru'iHw n o ~ a 3 a ~ eX n~ ~M O ~ ~ O ~ xeuaMH, 6. X ~ M ~ T O ~ O MM ~MOXMMHCIHM ~HM nOKa3aTenM - XeTOKPMT; MO~~O~M XeuaToKpMT, H, eneKTponMTu, ypen, oc-rancleti B) KPbBHa !@?R, a30T, KPeaTHHMH; a30T, KpeaTMHMH, npoTeMHM. r) KpbBHa 3aXap; 7. X a u o c ~ a a n~ o~ a 3 a ~ e n ~ . R) WC; Jleve~me cneg nbpeoHaranHaTa c~a6nnn3aqnn e) ocuonapMTeT; 3a cbc-rasmie Ha ToreH TepaneaTM'ieH nnaH OT a~areX) CTO~IHOCTM Ha ~e~xeuornOGn~a ( ~ Ke O W~MHMVHO HMQca AaHHme OT flo~(p06~0 cHeTaTa a ~ a u ~ e 3 Ma u(aTenMH~~ML(M~~HO). HOT0 @ M ~ M K ~ ~ M3CneRMHe. HO M~cIMcJ~FIMT C e o6em~ M B ~ ~ C T ~ H O B RHa B~ CbROBMFl H ~ T Oo 6 e ~ B 1 M cKopoci-raHa en~eatiMma M ce onpepennB M ~ Ha T MHI$~~ 3ano'iea M H @ ~ ~ M O H H ~ cbc T ~ ~ Serum ~ ~ MGlugosae R 5% OHHme pa3TBOPM. T ~ P ~ ~ ~ ~ B T nnaH M~ TPFI~M HMR fla TBKlltO20 mVkg/tlt 3a 20 min M AMype3a. Cnep, ~ a 3 u MH@Y~MR 'iaa nonbneatie Ha fie@~qma, ocMrypRBaHe Ha ptieetime notinKora, n p no-ne~w ~ UexMApaTaqMM, CbcToRHMeTo ce Iexuflpa~aq~~ kf30~0HM'iHa XH~~~TOHM'~H~ XH~OTOHM~H~
,

2. OcllrypFIMHe Ha BeHO3eH M3TO'iHMK %CTO e TPY~HO npncnntio AexnRpaTMpaHMAeua. 3a nbpao~aranHa e o y a pecycqMTaqwR e RocTanrHa M uanKa nep~@ep-

H~T~M (mEoll) A 130-150 150 130

3ary6a H a sopa M eneKTponnTw (E) E= BOR~ E BOR~ E > BOfla

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Ta6neqa 17.11. Knnunrun 6ene3n n p pa3nnreu ~ % RexnnpaTaqnR

n e ~ 5% a Cyxa nvrra~vrqa Hauane~ ~yprop XflbTHana rOnflMa @0HTaHefla XflbTHaJlM O'iHU fl6bnKM Tax~n~e~ XM~OT~H~MR Ta~MKappllR Cb3HaHMe Yuepe~a 10% Tema 15%

+
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+
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+
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Ta6nnqa 17.12.
Yo

OT aona n enetrrponm cnopen % Ha RexMppaTaqHn

Ko~fle~ca~ Ha MB f lO R ~
50 mllkg 100 150

Ha H ~ T P M (mEq/l) ~
5 10 15

Ha KaJllld (mEqn)
3 6 9

n e ~ 5% a Cpep~a 10% T~xK 15% ~

M 3aMecTBaHe Ha TeKylqme 3ary6~. 1. &@MuMTbT MOXe fla Ce M3'iMCnH KaTO pa3nMKa B TernoTo, Hanp. ~ernonpe~n3aoonflsa~e~o 10.86 kg er no B M O M ~ H T ~ 9.77 kg

WM

A~@MUMT

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109 rnl 1043 m 1 376 m 1

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A~@MUU

1528 rnl flpM AeTe C M30TOHMrHaAeXM~PaTa~ M H @ Y ~ M M T6~ ~ ~ p ~ 6 s a Ua n oce snem cac c ~ o p o c ~ : ~ l e @ w f l ~ - 112 npe3 nbpBMTe 8 h - 112 npea c n e p a q w e 16 h np~uep: - IlbpBMTe 8 h F(~@MUMT 54.5 ml nombpxaqa M aary6~ 472.0 ml

1000.5 rnl (aa 16 h .62 ml/h)

n0~0flFIlq pa3TBOp npM M30TOHMCIHafleXMApaTal(MR e 5% Dextrose t 114 $M~MoJ~oMCI~H pa3TBOP + 2-3 mEq/kgl 24 h K ~ M W . Kan~0 ce anma caMo npM ~ b a c ~ a ~ o nMype3a. ee~a KO~M'~~CTBOTO K ~ JB IM M H~ @~~MOHHM pa3TBOP R Ra He HwBMlLlaBa 40 mE@. Bb3HklKBa OnaCHOCT OT PMTbMHM

Oco6enocmu no cneurnume cbcmonnun 6 gemcka 6b3pacm

523

Ta6n~qa 17.13. Peslo~e Ha n e s e 6 ~ ~ 1 npejlr~ome~ma e

Tun 06e~w Ae@~um ~I~OTOHH'~H~ AH~BHM H ~ X . # I TeKyqM 3ary6~ A~@MUMT AH~BHU HyW#l Te~yqu 3ary6u Ae@uu~~ XH~OTOHH~H~ AH~BHM H W H TeKyqM sary6n Paanpepene~ue 112 sa 8 h 112 3a cnep~aqu~e 16 h sa 24 h 3a 24 h sa 48 h 3a 48 h sa 48 h 112 sa8 h 112 3a cnepeaqme 16 h 3a 24 h sa 24 h P~~TBOPH

Ser. Glucosae 5% + KC1 3anoqea ce c Na chlorid nodepe~ Ha H ~ T P M pa3TBOP ~ 112 mEqnh 3a KOpeK4MR Ha HaTPMfl

XM~~~ HrHa ~TOH

XM~~OH~T~ KpM3a U~MU~ 2H mlkg ~

i. V. UHXeKqMR

3% Na chlorid

Ta6nmqa 17.14. noppo6e~ TepaneBTHveH nnac c orarBaHn MnHnvHn npoMeHn

@ass
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I $asa - po 112 h B ~ ~ C T ~ H O B R Ha B ~ H ~20 mlkg Ser, Glucosae 5% aa 20-30 sac~ynap~ufl o6e~ min, Moxe pa ce noBTopn c 10 mlkg

112 pe@MqMT ~bsc~a~on~~a~e~ae~c~pa~enynap~u~ 113 AHeBHH HymClM pe@m~m M KAC

111 @a3a- 9 - 25 h Bb3CTaHOBflBaHeHa EUO, MU0 M KAC

II $aaa - 112 po 9 h qamurHo

noenluaea~e Ha T.T.,c ~ a 6 ~ n ~ 3 ~ p Ha BHTanHMTe 6enesn, flOBUluaBaHe Ha pMype3aTa, qaCTMqH0 B ~ ~ C T ~ H O B R B Ha KAC C~aGwnnsclpa~e Ha TernoTo, ~ a ~ a n f l ~a ~a ~~ ~e OTHM IPO~~YKTH, T~ a ~ e ~ s puypesa, a ~ ~ a nopo6pflsa~e ~a eneKTpOnMTHOT0 CbCTORHMe n o ~ a w a Ha ~ eTernoTo, HopManHM ene~~pon~~u YCTO~~H IlOB BMILl O eHMe Ha TeneCHOTO Terno. l l n a 3 ~ e ~ m cbcTaeKM e ca HOPMEUlHM

112 fle@~qm 213 RHeeHu ~ y x @ l

IV $ass - 25 - 48 h n a n ~ a K O KAC M K ~ ~ M ~ Bm M aR ~yc

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emcka Bb3pacm

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n e r e ~ ~ce e~ paqena o Hapaa eTana: KopMrupatie Ha pe$i'qma, ~ 3 r u c n e Kano ~ npM H~OTOHMCIH~ pexMUpaTa~MR pa3npepene~o , a 48 h M BTOPM eTan BnmaHe Ha $M~MO~OTM Pa3TBOP W H He n06bp30 OT 112 mEqllih. B TO~M c n y a i n o m o w q p a 3 ~ ~ 3a 0 p3anorBaHe Ha nereHMeTo e $ n a ~ o n o r ~ r p~ a~ 3~ m~ 0 Cp po6ae~a IEIK ~ ~ M A . C ~ P ~ ~ HHM ~F TI PT Ce M ~M3CneABa BCeKM 4-6 h M C e KOpMrMpa KOHL(eHTpa4MfiTaHa HaTPMeBMRXJlOPMa BbB BnMBaHMTe pa3TBOpM. flp# C XMnOTOHHrHa fleXMflPaTaqMR HaTPMeBMRT fle$MuMT MOMe fla 6bfle 3aMeCTBaH no-6bp30. AKO e HanMue Tewa xMnotiaTpueMwn, ce BKapea i.v. 2 mllkg 3% Na chlorid. 3a 1 h Moxe pa ce anem 0640 10 mlkg 3% Na chlorid. TOM We yBenU.lM CePYMHMR H ~ T P H np ~ ~6n~3uTenHo 10 rnEq11. l l p o ~ eB ~ cbabpxaHneTo n Ha K' n Ca++ WOHH npn BexnApaTaqnn B AeTcKaTa eb3pac.r. Kanlnl ( ~ o p u3.5-5.6 a mEqll) - Mrpae ponn B npeepbqaHeTo Ha BbrnexvppaTme B etieprw M c w ~ ~ e 3 Ha a IlpOTeMHM OT aMMH0KMCenMHM. flp# XMnOKMMeMMR C e HapyluElBa MOTMnMTeTbT Ha CTOMaUHO-rpeBHMUTpaKT, ( ~ P O R B RC B eC ~aHOpeKCMfl ~H , noepbqatie, ~ e ~ e o p n 3 b w p enapea), e ~ a notiwtma ce CbROBMRT TOHYC M TOHyCbT Ha MMOKaPfla ( 6 p a ~ 1 ~ ~ a p p # ~ ,Emonor~n BPMTMMR, Ha EKr-WMp0Ka M HMCKaT BbnHa M CHMXaBaHe Pa3BMM C e npM HeBb3MOXHOCT Ha 6 b 6 p e u ~ ~ H ~ S T C ~ I M ~MyCKynHaXMl H T ~ ) , lOTOHMR.X H ~ O K ~ H ~ M M F ~ T ~ M ~ ~ M W eopa oTuenRT H ~ n T enenponm ~ nopqM opa n o w BMHaru e cebpaa~a c ue~a60nn~ KnenrHa ~a aqnM n M napewepanHonpeToeapaaHeM npM HRKOM 6onec 403a, npM KORTO flBHXeHMeT0 Ha Kt BbTpe B KneTKaTa e C~CTOFIHMFI (XPOHMCIHO 6b6per~0 a h n ~ ~ areptiop ~ e , 3a6aee~o.X ~ n o ~ a n ~ n~ pe m pa u3~~~ xcl e noKanMeMMR, a ~ H 60nec~n M c nopTanHa X M I I ~ ~ T ~ H ~ M RcbpperHa , c sa~oeanpM ciiMxaeatie Ha K+ ~ p ~ 6 e pa a ce ocvrypM 6 0 -~ no-PR~KO ~ npM peua). HOpMOBeHTMna~MR. X~nepxnppa~aunma cbqo Moxe pa 6bpe H~OTOH Ha, XMnOTOHMrHa H XMnePTOHM'iHa. Xnnep~anne~nm ea Hanuqe npu Temw TpaeMw M M3raPRHMFI, 06H, ~ q 6 b 6 p e r Hefl ~ aOCTaTb'iHOCT, MMCOH O M 60nec~, M a C M B H M pa3Ma'iKBaHMR Ha TbKaHM, XeMOTP~HC$Y~ Ha MKPbB, C I CbXpaHRBaHa IlOBeVe OT T P M RHM.

KpbBTa (noflno~araHaBnM3aHeTO Ha Kt B KneTKaTi OTAenRHeTO MY C YpMHaTa BMeCTO H');rnlOKO3a C Ins' (0.2 VE Ha 1 ml10% Sol. G ~ u c o s ~ ~ - C T HHaenM M~~ HeTo Ha K t e K ~ ~ T K M Calcium T ~ ) ; gluconicum (npo~ pehcTea Ha HexenaHHR e $ e ebpxy ~ ~ ~~o~appa) KanqnW ( ~ o p2.5 ~a rnEq11)-yracTsa B npoqecMTc BbrneXMflpaTHO-MaCTHOT0$0~@0penMpa~e, B CbC#pBa TO Ha KPbBTa, CTpyKTypHa OCHOBa Ha KOCTHMR CKer noenMRBa nponycmmoma Ha KnenrHaTa Me~6paH MrpaeponRnpMnpepasaHeToHaHepeHwTeMMnyncM Xnno~anqneunn~a K~MHMYHO ce M ~ R B R C BM ~ ~C H# KpaMnM, TeTaHMR, KOHBYnCMM, KOCTMTe Ca '4yIlnMBll Jlere~lre~o e c KanuMee rnmKoHaT M n w Kanquee X PMfl. Xnnep~anqne~nn (npv ~ a MtioxeCTeeHM$palcry KOCTHM TyMOPM, TyMOPM Ha napaTMpeOMflHHTe XJle3M: Cabpsa~a e cbc cKeneTtia 6on~a, oTnycHaTa cKec Ha MycKynaTypa, naTonomrtiw $pamypw.

C nereHMeTo ce qenu pa ce O C B O ~ A M opra~u3m U ~ ~ M L U Bonan H ~ T ~enenponMm rpesorpa~uraea

BHOCa, cTMMynMpaHe Ha M3nb'iBaHeTO. H a 3 ~ a . t a M u ~ y p e ~H n nereHne q~ Ha OCHOBHOTO a 6 0 n ~ e a ~ e . Mannlu~a~a Boas Moxe ua ce H ~ ~ M C ~ M : l, = t.t (kg)x0.6 t.t (kg)x0.6xNam,

Oco6enocmu H a cneurHume cbcmonnun 6 gemcka Bbrpacm

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525

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Bb3paCT (1-4 ~OAUHM), BCneACTBMe OT AeTCKOTO ~ I O ~ O ~ ~ M T C T K b B M O ~e6pemo CbXPaHRBaHM ~ H T O B M H n H npOMMWneHM X M M M K W M . Mexfly 0.4 po 8 Ha 1000 fleua, H ~ A - r e c ~ Bo se~e~en pafio~n M B nonynaqnM c HMCKO KynTypHo HMBO nony'iaeaT KOPO3MBHMyBpeflMOTpa3nM'iHaCTeneH.

pan M AP. ~ ~ ~ A H MBH PaHHaTa O fleTCKa

IIc ~ e n epa311pbc ~ IPKynRPHMpa3R3BRBaH M R Ha JlMraBMuaTa M C Y O M Y K 0 3 H M R M0fi C eAeM M @ M ~ P M H O B M OTllaTaHMR; 111 CTefleH C~UIHPHM 4MPKynRPHM Pa3R3BRBaHMFI M Y'iaCTbuM C HeKP03a Ha JlMTaBMqaTa, C#MYKO~HMFI HMYCK y n H M R cn0fi C nnbTH0 @M~PMHOBO IlOKPMTMe. OGMKHOB~HO B ocTpaTa 4aaa e TPYAHO na ce pagrpaH M C M I M3raPRHeTO OT 11 M 111 CTefleH, Tbh KaTO @ M ~ P M H O B ~ T

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~ a f i - C M ~@ HO a p ~ ~ rM ca xpaHonpoBofla, a no-~RAKO M

2. @ass Ha rpaHynaqMoHHoTo pa3pac~sa~e cne110R peH, KOraTO C flORBaTa Ha $ ~ 6 p o 6 n a c 3ano.lea ~~ OTUeKTopeH c n a 3 b ~ Ha rnbTKaTa M IeTeTo MHCTMHKTMBHOtie nRtieTo Ha KonareH M 3ano'i~a ~ O C T ~ ~ ~ H H C O T T ~ O C HRB~H nomnHe KOPOBMBHOTOBeqemBo, nopmeHMma MoraT Aa ce orpaHwaT caMo B opo-$ap~~rca. HRKOM n o - r o n e ~ ~ Ha nyhletia Ha xpaHonposoAa. 111 C T ~ MKbCeH ~ M n M UMKaTPMqMUeH (cJleA22-28 Ieqa, KOMTO n0fl06~0 Ha B ~ ~ ~ ~ C T nornbtqa~ H M T ~ roneMM f l e ~ ) , Haclan0 Ha $ M ~ ~ o~HOCK~~~O flpOl(eCM T M ' ~ HM MT KonMrecTaam~w~an cbc C Y M ~ M A H qen, ~ nony'iaeaT ~ 3 m Ha ~ pMrMntia e (pb6qoea) CTpMKTypa. PRHMR no qenm ropeHxpaHocMMnaTeneH TpaK-r. H e p ~ p ~ o nocTeneHtioo $ o p ~ ~ B cny'ia~,'ie ynl(ep0-HeKpOTM'iHMTe M3MeHeHMR He Ca ca cnyrame, KoraTo KOPOBMBHHT~ yBpeAM s a c ~ r a Koxa~ aaceman~ MycKynHMR cnofi (I1 cTeneH K O ~ ~ ~ e3o$aM B ~ H TaHanMqeTOMTRnOT0,ayCTHaTaKyXMHaMXpaHOnpOBOM O~UIMPHM qMPKyllRPHM C a MHTBKTHH. BCMC~KO TOBa r O B O P M38 H ~ O ~ X O ~ M M O MT) C~M Tn ~ IlpOueCbT He e 06xea~an o6nacm OT nyMeHa Ha xpationpoaona, Ha T O ~ MeTan OT patitia nMatwocTM'iHa e30$aro-rac~poc~on#~. npMKnIO'iea ~ ~ ~ A P ~ B M T npoqec ~ ~ H M H aR nMraswuaTa, npw H~~~BMC OT MBMna M O Ha XMMM'ieCKMR areHT M n M OT KOeTO O ~ M K H O B ~ H OH e Bb3HMKBaT C T P M K T y P M . aacenia~ opraH ~ ~ (opo-Qaputirc,xpaHonpoeop, c-rohnax, K O ~ O ~ U B HM M~T M~~ H ~ HHa MR cToMaxa (gastritis nnnop) n a ~ o ~ o p @ o n o npoMeHn r~r~~~ ne p TRX ~ ca wneHCO~~O acuta) S~V M M ~a T CbwO 3 CTeneHM: T M i 'H M . no Holinger JlOKaJlHHTe nOpWeHMR npM KOP3MBICTeneH-MpMTaTMBHO-epO3MBHM H3MeHeHMR HanMTaHMR e30$am~ ce cTeneHyeaT TaKa: BMqaTa; I cTeneH orpaHMreH lnnu A M @ Y ~ eAeM ~ H M xwepe-

K H C ~ ~ M HIlp M M' T iM ~ HRBaT IlOBbpXHOCTHa (KOarynau~o~tia) ~e~pos Manopan# Toea npeMMHaeaT 6bp30 B croMaxa, KbAeTo yepewaT npenwtio nmopo-a~~pan~ o6nac~, a~a a no-p~p~ noxpationpoaona. B HRKOM cnyraM nacamT Ha KOPOBMBHMR areHT npea rnbTKaTa e fl0-6bp3 M T a M HeBMHaM Ce Y C T a H O B R B a T M 3 M e H e H M F I Ha JlMraBMuaTa. AKO06a'ie B b 3 H M K H e pe$neCTOMaXa.

EH~OCKO~CKOTO CTeneHyBaHe HanOKaJlHMTe ll0pW.SHMR ~ p ~ 6 Aa ea ce cbnocTaeR c pMtiannMKaTa Ha ~ ~ ~ B M T eT0 Ha K O P 0 3 M B H M T eM 3 M e H e H M R ,0 6 0 6 q e ~ BC ~TWMM (no B~eam, bemlig M Kiihr): I crap~fi - paHeH unn aKyreH (OT 1-4 A ~ H ) pasnnqe~ , no MHTeH3HBHOCT OCTbP Bb3llanMTelleH IlpOqeC (oesophagitis corrosivaacuta) OT e p 0 3 ~ a ~ o - x e ~ o p a A0 yJlqep0-HeKpOTM'iHMM 3 M e H e H M R Ha MYK03aTaM C#MYKOaaTa, CbflpOBOfleHMC OTOK Ha JlMraBMqaTaM $M~PMHOBO OTnaraHe. 11 C T W M ~- nOCTaKyreH (3a M3MeHeHMRTa OT 11 M 111 crene~):

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526

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Te3M M 3 M e H e H M R Ce pa3nOnaraTO ~ M K H O B ~ H no O MallKaTa K P H B M H a , 34HaTa CTeHa Ha rOnRMaTa K P M B M H a H

a Ha Kopeua - npM cbuHeHHe 3a ntiesMonepmToHeynn. B nocTa~y-rHuRC T ~ wscnepa~e M ~ Ha xpaHonpoeopa c BOflHOpa3TBOpMM K O H T P a C T e HWHO npM CbMHeHMe 38 H ~ K P O T M V nep$opauu~. H~ B K~CHMR C T ; W Hapep M ~ c etino-

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H0 C pa3paCTeaHe Ha rpaHynauMMTe M HanpepaaHeTo Ha $w6po3~ocKJlepOTHrHMTe npOqeCM K b M KpaFl Ha 4 - ~ a M Ha'iMOTO Ha

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cTpLnKTypa. 3a ~ a uen 3 noBereTo ~ aBTopM n p ~ n a r a paH~ H0 6 y x ~ p a ~ Ha e XpaHOnpOBOfla, KOeTO Ce M3BbPUlBa pMPeKTH0 ( ~ H T ~ ~ P 4 ~ -H 94 o AeH ) CneA M3raPRHeTO. K ~ c

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KaTOCneflnbpBaTaeHflOCKOnMRWMHMpaMeTpaHCHa3mH0 XpaHOnpOBOpa C b CC O H n M N?N?18-24 CH, KOMTO He AOnyCKaT TpaeH Cna3bM M 6bp30~0 $H~PO~HO-CW~~POTM

Oco6enocmu Ha cnerunume cacmonnun .B gemcka Baspacm

527

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eTana Ha HanoxeuaTa racTpocToMa. OCHOB~H MeToA e peTporpqqHoTo 6 y x ~ p a no ~ eaoneq Kotieq npea racTpoCTOMaTa C nOMOuTaHa COHflM-flMnaTaTOpM, C I M ~ T O flMaMen p oTroBapA n p ~ 6 n ~ a ~ ~ Ha e nHopManHMTe uo paauepn Ha XpaHOnpOBOfla 3a CbOTBeTHaTa Bb3PaCT. T O ~MeTOA M sacTpaxoeaOT nep@paqnn Ha xpaHonposofla n noaaonflsa $opc~pauo~o AocTMraHe Ha MaKc~ManHuR paa~ep Ha

CTPMKT~PHM n M TaKma Ha ronmo npoTexeHMe ce npmcnnea K ~ M 3 a ~ e c ~ Ha ~a xpauon~e poaoAa c ~e6enorpeee~ TpaticnnatiTaT. Marap~ue~o Ha cTouaxa OT Ill cTeneH BOAM PO CTPMKTypa Ha nnnopa K ~ 24-30 M fleti, KoeTo Hanara ~asbp~ueaHeTo HanMnoponnacTMKano Mikuliecz. ~ ~ M T ~ X KO KM M ~Htinpatin yepeAM Ha xpaHonposoAa M cTouaxa ~onoeso$aronnacTMKaTa ce cbqeTaea c p e a e ~ q Ha ~ aHTpanHm ~ oT1en.

6yxa. n p PMMAHM ~

528

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B cepyua Ha HoeopoAeHme M peqa-ra~o 9 ~ e c e r ~ a KpbBHa rpyr,, B~~MoMHOCTMT~ 38 KpbBOnpenMBaHeH3BbHO~HWI~HO Bb3paCT Ce CbAbPXaT TpaHCflnaueHTapHO IlpeMMHanM nacvBHMaHTMTena. Te ca p e 3 y n ~ Ha a ~anoMMytiM3aqmHa M3nOn3BaHMTe YHMBepCanHM KpbBHM 6 ~ o n p e n a p a ~ (HMCKOTMT~PH~ ePMTP04MTHa MaM 0 M flna3Ma AB) MOraT M ~ A K CflpRMO ~ T ~ aHMreHM Ha ePMTPOuMTMTe Ha nllOAa, HacneneHM OT 6 a q a ~ a M nMncBauM y ~ a i ~ a ~ a Aa . CO pa3WMPRT, KaTO M360pbT Ha KPbB HnM ePMTPOuMTeH KOHqeHTpaT Ce cbo6pa3~eaO C B e H C KpbBHOrpyflOBaTa n p e ~ ~ ~ a eHa a aHTmenaTaoT ~e~o ~ a i ~ Ba nnoAa ~ acram IlpMHaffneMHOCT HaAeTeTO M C KpbBHaTarpynaHa MaiKaTa. npea nnaueHTaTa no BpeMe Ha 6 p e ~ e ~ ~ M o c ~ ~ a payqaHeTo. no T O ~ M H a r w nnomT nonyvaea atrrwena B Cny'iaMTe, KOraTO JlMnCBaT F(aHHM38 KPbBHOrPYflOBaTa OT ~ a i ~ aoc~ryp~leaqn ~a, nacMseHxyMopaneH MM~HM' IpMHa,qnextiocTHa u a l ~ a H ~ n M a H m a rmMoxwocT~a ce H~O~XOAM fl0 M OKOHraTenHOTO pa3BMTMe Ha C O ~ C T B ~ H ~acne~aa, KpbeHaTa rpyna Ha ~ a l ~ ce a npMeua ~ a 3a 0, MMYHOKOMneTeHTHaCMCTeMa. Ih (-) OTpMqaTeneH. npMT03M IlOAXOfl Bb3MOXHOCTMTe 38 1 3 6 0Ha ~ KpbseH 6~onpenapa~ cnopeA npeAnonaraeMMR nac~~~ aHTMTena m e ca MMKpoMoneKynRpHM OT K V IgG. Cnel p w a H e T o HMBOTO MM nocreneHHo HaManRBa M cneA oKono 100 AHM OT p w a H e T o , Te npaKrMreCKM 1 ~ ~ M ~ H R H Ha ~ T YHMBePCanHaTa O HMCKOTMTbPHa M3W3BaT. Oco6e~o remo cecpeqaw ca c BMcoKaceponomrHa ep~~poqm Maca ~ a rpyna 0 c eAHorpynosa ~ p b e M n wc a K T M B H O C T BWM-A M ~HTH-B aHTMTenaTa Y Aeua C K P b B H M KpbBOT rpyllao ( K O ~ ~ T O T O eM B~ M~HO~O~M~HOAO~~CTM rpyflM B M A, POAeHM OT MagKa C KpbBHOrpyflOBa ywnuraea cnyvame c MsnonasaHe Ha upnocrHa ~ p b a , flpMHaAneXHOCT 0. B Te3M CnyWU BnMBaHeTO Ha KOeTO MMa PeAMqa npeAMMCTBa. ~ ~ M ~ H R H Ha ~ T eflHOrpyllOBaKpbBMOXefiaflOBef&? A O T e H O C MX e M O n M T M r H M y ~ ~ s e p c a n ~ a ~ a n n a s ~ABcen~orpynoea ao~n~qe nnaa~a peaKqMM. n p e n e ~ n ~ ~P eM T P O ~ M Tca M C no-CM~ aHTMreH ~H p a 3 u r ~ p ~ lB m ~ ~ M O X H O C T M3a T ~ BnMBatie Ha n n a 3 ~ a OT A #nM B OT T O ~ M Ha UeTeTo, noHexe npowaxoyqa~ OT apRn n p m a Kpba, KoeTo e OT O C O ~ ~ H 3O ~aqe~u B ycnoema e Bb3paCTeH 'i0BeK M PeaMpaT C HaMMpaqMTe Ce B Ha CfleWHOCT. cepyMa Ha AeTeTo nacMaHM aHTMTena cbc cbqaTa Cb06pa3Fl~a~eT0 H~X~MOT~~HC@~~MOHHOT C~~~M@M~HOCT. n p HoeopofleHM ~ M KapMareTa ~o 9 ~ e c e r ~ ~b aa p a c c~
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Oco6enocmu n a cneurnume cacmonnun B gemcka Batpacm

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aHouanMw H a napeHxMMHnTe opraw, n p M x~nep~po$nvHaTa nHnopHa c ~ e ~ o M 3 T. a H.

530

Oco6enocmu no cneurnume cbcmonnun 8 gemcka Brrpacm

BaclnneeH. 6nonomr~o aKMBHM MaTePHaJlMB XMPYPMRTa. C., bte~MLpI~a M $~aKyn~ypa, 1986. npo~oe A. 0.Ompb~h annetinnum B peTcKom eoapame. M., Me~M4nHa, 1980. MEEIHv~B Me., A. KORHOB, Xp. X~MCTOB. OCTpM KOPeMHM XMPYPMrHM ~ ~ ~ O ~ R B B ~ AeTCKaTa H M F I Bb3paCT. C., MeAML(MHaM $MsKynTypa, 1984. Mea~ree, Me., A. Anomonoa, Xp. Xp~croe. npo~~ono B AeTcKaTa ~b3pam. C., MeflM4M~a U $~aKymypa, 1986 MBaH'ieB ME., CneWHM KOPeMHM XMPYPM'iHM 3i360nRBa- . HMR B peTcKaTa bapa am - rnasa OT Cnew~a xupyp~~, non peAaK4MRTa Ha A. ~ M H K M ~ Me. C BHR~KM. C., Mepw L(MHaM $~3KyIlTypa, 1993. M ~ ~ KK). OB Q., K). M. n o n p ~ aOnepa~clte~m . mpyprm c ~onorpa$~vec~oh a~a~o~u peTcKoro eQ eoapama. M., Meflu4u~a,1989. nyraree A. r. Xnpypmrec~m rampo3~~eponom~ AeTcKoro ~oapama.M., M~AMUHH~, 1982. CHM~OHOB E. C b e p e ~ e ~ n~ po n6 n e ~ Ha ~ nepMaTpwrna. C., MK .@~yc", 1994. C~pyoea A. M., B. M. ne~poea, B. C. Ilayltom. OCTpb~ii paan~~o nepmoHm. h M., Me#ILpIHa, 1987. TOWOECKM~ B. A n n e ~ f l y ~ ~ y f l e M., ~ eMefl#~(m~a, h. 1988.

X~MCTOB Xp., M. MBaH.leI3, A. KORHOB. Ocnp aneHAMqm M HerOBMTe YCnOXHeHMR B fleTCKaTa Bb3paCT. C., M ~ A M 4 ~ H $nsKyn~ypa, ~ a 1980. U~HKOB H., H. Bacunee. P e n a n a p o ~ oC., ~~ MepuqMHa ~. M $usKynTypa, 1987. Ashcraft, K. W., Holder T.M. Pediatric surgery. W. B. Saunders, 1933. ~ Barkin ~ Roger, PeterRosen, Emergencypediatrics. A Guide to Ambulatory care. Toronto, 1990. M. Bettex, N. Genton, M. Stockrnann. Kinder chirurgie. 2 Auflage Georg Thieme Verlug Stuttgatg, New York, 1982. Fleisaer Gany, Stephen Ludwig, Text Book of pediatric Emergency Medicine. Il-ed William and Wilkines, 1990. Glinz W., Chest Trauma. Springer, Verlag, Berlin, Heidelberg, 1981. Grande CHR, Text Bookof Trauma, Anesthesiaandcritical Care. Mosby St. Louis, 1993. MatherStephen, David Hughes. A. Handbookof paediatric Anaesthesia Oxford University Press, 1991. Slebst Stiven, Susan Torray. Pediatric Emergency Medicine for the House Officer, Ed William and Wilkines, 1988.

Mapraplrra reweea-bo~~neea Maprapm Hu~onosa Hail~e Mnpqee ~

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K ~ 2-3 M m 1 YpMHa ce ~06aMT HRKOnKO KanKM 5% WpeH p a 3 ~ ~ Ha o pcpe6bpe~ HmpaT. Ilonyvam ce c u ~ m OuBeTRBaHe, K O e T O npeMMHaBaB 'iepH0 U HaKpaR ~cpe6bPHO ornepano no cTeHuTe Ha enpyBeTKaTa. Abnw ce Ha pepyqMpaHeTo Ha ~pe6p0~0. Pea~unma ce npoeema npepM aanorlea~e Ha nereHne c Serum Glucosae n Vitamin C, KOMTO cbqo AamT peaqnma .cpe6bp~oorneAanoU. 5. Cannqmnam. K ~2 M m 1ypma ce n p d a w 1 ml10% W e H pamwp Ha @epnxnopn~. nonyvam ce qepeeHo oqeeTRBaHe. 6. XHHHHB IlpOMMBHH BOpl, PMHa M OCTaTbl#l OT

XpaHMTenHM IlpOpylcTMAaBaCMHbOOuBeTRBaHe. 8. M ~ A HConH. H K ~ 2-5 M m 1 YpMHa C e npn6ae~Ha KanKM aMOHRK. n o n y a m ce C M H ~ O OqBeTRBaHe. 9. E T H ~ ~ H ~ J ~ BH TeXHMVeCKM K o J ~ TeClHOCTH. K ~ 2-3 M ml OT ~ a c n e p e a ~ T a~ ~~ aH O C ce T npb16ae~~ 12m 1 10% pa3TBOp Ha HaTpMeBaOCHOBa M HRKOnKO KanKM 10% p a 3 ~ ~ 0 Ha pMeneH cyn@a~. Ilo~lea~a Ha C M H ~ O 04~e TmaHeey~a3a~~eaanp~cbc~elneHaemneHrnMKo 10. ( D O C @ O ~ O ~ ~ ~ CbepMHeHMR. HH~HH Ype3 onpeAenRHe HHBOTO Ha x o n ~ ~ e c ~ e p a aK3~a TMBHWT (XEA) B ce yMa Ha ~ O ~ H M Moxe R pa ce poKaxe O C T p O OTpaBRHe C OC. M3non3BaT C e 6bp3~ XapTMeHH TeCTOBe. Bbpxy npenMeTHoc n m o ce HaKanBa 0.02 ml cepp. O~rope ce nocTasn pealcrusHaTa x a p ~ ~ i i C ~ a~. H ce O IlpMTMCKaC nOKPMBH0 CTbWIO, pOKaTO C e HaMOKPM WnaTa xap~nh~a. Cnep 6 min ce orima no UseTHa cKana. npn CTO~HOCTH oKono Hyna ce Kacae 3a oTpasRtiMR C ~ O C OTVUT~ ce B JU/ml - HOpMallHa C T O ~ O C T O K O n O 3 JUIml. 11. Meranon H eTaHOn B YPMHa, KpbBeH CepP M MWMUlaH Bb3F(YX. K ~1 M cm3ypwa H n M cepyM ce npu6ae~ 1 cm3 10% pa3TBOP Ha KanMeB pMXPOMaT B 50% Pa3TBOP Ha CRPHa KucennHa. npo6a~a ce HarpRea Ha sopHa 6a~R.n p HanMwe Ha MeTaHonM n M eTaHon B MxneReaHaTa npo6a uBenT Ha peaKuMoHHaTacMeccTaBa aene~. P e a ~ u we ~ IlOnOXMTenHanpM CbepMHeHMR C peClyKl#lOHHM cBOhCTBa H 38 TOKCMKOnOMCl HOTOMXneF(BaHeM M a CTO~HOCT CaMO npM oTpnuaTeneH pe3yn~a~. .

AOK~~B~ MY Hmwno ~ T O M O X ~ace naeapurnc M M K ~ ~ O 12. M e ~ x e ~ o r n o 6 m ~ . 15. nCA ( ~ u e ~ u n ~a a~ nn3eprn~oea~a n~ ~ncenn~a Kpbe ce paspewa 1:l 00. Ilpn6ae~ ce KpncTanre OT K ~ npawnHKa M OT BeqecTaoTo 3a nacne~sa~e ce HaTpnee Mnn KarIclee qnaHnfl. U ~ O K O ~ W ~UBRT HMR ce T npn6aem 1-2 KanK#5% pa3TBOp Ha p - f l ~ ~ e T ~ n a ~ ~ IlpOMeHR BeRHara B P030BOL(ePBeH.AKOWOKOnQeHMRT ~ a a n ~ eB x eTaHoncflpHa u~ KMcennHa (95:s). n p ~ ~a n n UBRT ce ~ W ~ P X npo6a~a M, e o~pnqa~en~a. 'iMe Ha ncn npo6a~a C e OqBeTRBa B CMHbOBMOneTOBO. 13. K a p 6 o ~ c ~ x e ~ o r n o 6 m ~ . 16. MOP@HHOBH anKanoHaH (onul, MOP$MH, KoRenH K ~ 10 M ml ~ o ce~ n p a ~ 6 1-2 a~ ~ a~ nm ~ w e . PaamaM X~POMH) q a ce. nonyqasa ce naKoeo po30~ WT. ~ O ~ ~ ce B R 5T O6qa peaKqnR KanKM 20% HaTpnesaoc~osa. B e ~ ~ aGap30 r a ce pa3maK ~ npawMHKa M OT BeqemoTo ce npn6aam 1-2 Kanqa. ~ Q ~ P X ~ H Ha ~ T po30BMR O U B F I T HFlKOnKOCeKyHfllrlHnbl KM oqaeTRaaHee yltaaanoeere noTabpwaea HannrueTo Ha K ~ ~ ~ O K C M X ~ M O ~ - peamnB Ha Mapm. Bnone~om~o tine 3a Hannrne Ha MO@MHOBM an~anonpn. n o 6 ~ AKO ~ . PO~OBMRT ~ B R T npeMuHe B cnaMeHomanT, Peamm6 Ha M ~ ~ KKM ~ M 1 ml cRpHa KucennHa ce npo6a~a e oTpnuaTenHa. npn6as~ 1 m1 $O~MMMH. Pa3TBOpbT C e IlpMrOTBR flpeR# 14. Xawwlu (~apnxya~a). XaUJMlllbT M M a XapaKTepHa MMKPOCKOnCKa KapTbfHa. yno~pe6a.

OCHOBHMT~ npwHqnnn Ha nereHneTo Ha oCTpnTe OTPaBRHMR C e 06ycnae~~ OT CTwMMTe Ha TOKCOKMHeTnKaTa M TOKCOf lMHaMMKaTaM TRXHOTO 6bp30 IlPOTM'iaHe. K)PMRHrecKo a ~ b n x e ~ n Ha e BCRKO M~AHUMHCKOnnqe e na OKme flbpBa noMO4 Ha nOCTpQMMR IlO Bb3MOXHOCT oqe Ha MRCTOTO Ha nHquuewa. 1. n o npaswno ce sanowa c oqmcmaHeTo Ha BXOAHaTa BpaTa. C T O M ~ X C e ~OVUCTBa T 'ipe3 CTOMaWHa IlpOMMBKaC HRKOnKOnMTpapa3TBOpHaMeAbluHCKMBbrneH (3-4c. n. HanMnp ~ o ~ a KO~ITO ) , n o c ~ p ~nannaa.~a a n ~ ~ ~ ~KC". Toea Bofln A 0 ~$~KTHBHo eKCflnO3MBHO IlOBpbUHe. Cne~BaIlOrnbqaHe Ha CVlb4HHO OWCTHTenHO 10-30 g (cnopea ~wpacrra),p a 3 ~ ~ o p e B~ raua o xnWKa wua. npu Reqa 40 2 r. ce npnnara TereH napa$n~ 2-3 mkg. PM HeBb3MOXHOCT npOMHBKaTa na Ce OCbueCTBll no OllMCaHMR HI'IMH (npn M M K M AeUa, OTKa3,6e3Cb3~aTen~o Cbc-ronHMe, UIOK, Tema AeKouneHcaqnR, rbproee, anHO~), Cnefl CbOTBeTHaTa MeAIIKa4HR, PeCfl. bl~Ty6al#fR cbwTa ce naeapwea CM: OoMawHa coHAa no npn~qnna Ha CKareHMTe CbROBe. naqMe~TbTC e IlOcTaBR B n R B O CTpaHnrtio nonoxetine - rnaBaTa no-HHCKO OT TRIIOTO. A6conto~~n lpOTMBOllOKa3aHMR3a CTOMaUIHa IlpoMMBKa Ca KOPO3HBHH OTPaBRHlrlR CneA 40-~a mill, KpbBOll3nnB B xpaHochnnnaTenHuR n b n ~0c1-b~ XupyprnreH Kopenn. npn ~ e s cnyvan n ce npe~n3sn~sa noepbqaHerpe3 noRKowo MHxeKTmpaHeHa Apomorphin - 0.005-0.01 0 (npo~naonoKa3aH IlpW M m K M fleqa M MHTOKCMKa4MflC o ~ ~ H ~ T H ! ) . OCB~ CH IlpMeTOTO O'IMCTMTenHO 'iepBaTa C e flellypUpaT C O'iMCTMTenHa KnM3Ma (flpo~~B0fl0~a3a~a IlpM IcpeBeH KpbBOL43nMBM OCTbP XHPyPM'ieH K O ~ ~ M ! ) . [PM HHXaJlaTOPHa MHTOKCMKal&lf Ha flOCTp~Ulblfl Ce 0CbIr)'pRBa r # C T Bb3RyX, no Bb3MOXHOCT bl ~CJlOPOfl, KaTO ce 06nnw~a c pbreH pecnnpaTop. npn HenpeoAonnM c

MeAnKaMeHTMOTOK H n M CJla3bM Ha rnOTUCa- U H T ~ ~ ~ flpM HeBb3MOXHOCT - TpaXeOTOMMR. K O X ~C e TOclMCTBa ~ rpe3 OTCTpaHRBaHe Ha 3aMapCeHwe Rpexn n ns~anea~e, a npu H ~ B ~ ~ M O X H O CT ram'4HO H3MMBaHe C BOfla l4 CallyH H n M nOHe ~ 3 6 b p ~ B a C~ MeKa MaTepnR. O ' ~ MC T e~ IlpoMclBaTC$ M ~ M O ~ ~ O cepyM M V WIM ~ H TeWqa BoAa M ce noAcywaeaT. Hocb~ ce npoMnea c $n3nonornre~ cepyhn unn Bwa. npaa~ ce n cToMauHa npoMnsKa oco6e~o npn Aeqa. ~HKO~~HM MeXyp R T M BaMHaTa C e IlpoMUBaT C $6(3~0nornreH cepynn. npn yxansaHe nnn yboyqa~eOT WBOTHO n npn MHXeKTllpaHe Ha OWBa K ~ ~ ~ H HCe K ~~ T0 6 n n n ~ u p nocTaeR ce TypHnKeT no o 6 q n ~ e npaanna, npaen ce M H 4 M 3 M R H M3CMYKBaHe C IlOMflH'iKa M n H C YCTa (npn nmamHa ycwa nnraenqa), npaeu ce noKanHo nH)l(eKqwR c Adrenalin. 2. E ~ H M H H H Ha ~p ~eH 3~ 0p6~pa~a B~ KpbBTa a OTPOBa. M3Bbp~Ba C e fl0 Bb3MOXHOCT no-6bp30. Hal-necH0 OCbqeCTBMMa U C H~U-UIblp0~0 npMn0XeHblee @O~CMpaHaTaAnypea. npnnarace npn oTpoen, KOMTO ce n3nb'iBaT C ypMHaTa, U flp# nUflCa Ha flpoTtIBOflOKa3aHMR: 6b6per~a HeflOCTaTbqHOCTConuroaHypnR, TeMa CbPfle'iHa ~eKOMlleHCa~UR, 6eno~po6e~ H(H~TOKCM M03b~~H reH OTOK, BlGICOKOCTetleHHaaPTC!PHaJlHa XHflC!PTOH#R, XMIlOBOfleMM'ieH UIOK - nbPBO C e H3EbpWBa M H $ ~ ~ # O H peaHnMaqnR n pexqpaTaqnR. Ocuonwna HeyrpanHa @opcnpawaa m . M3nOfl3BaT C e (np~ no-TeXKn HHTOKCHK~~#~~~) 2 BeH03Hbl cans, eflnHmm - qempaneH. B eAHaTa BeHa ce BnnsaT nopeflHo ~ ~ I O K O ~ (5-20%) HH n enemponmn pazmopn H Manitol. llpe3 ApyraTa ce npHnaraT napanenno 6 e m b r ~ n

Pa3TBOPM B CbOTHOLUeHMe C rOPHMTe 1:4 (38 IlOMbPXaHe 3. Opra~onpo~elcrwe~o nerleHue ( ~ yapeyqaHwRa Ha OHKOTMClHOTO HMRraHe M npeflOTBpaTRBaHe pa3BMTHeTa, HaCTbnBaLL(#B 111-MR C T ~ M Ha ~TOKCOKMHeTMKaTa, TO Ha 0 ~ 0 4 ~ 0)6. 4 o 6 e Ha ~ BnHBaHMTe Pa3TBOPH CpeflHO PeCn. flpepOTBPaTRBaHeT0 MM). 3an0ClBa C e no Bb3MOX5-8 000 m1124 h, W H $ Y ~ MB ~HaCl ~ HanOTO M no-6bp30 p0 HOCT no-paH0. nocTMraHe Ha e$eu. PM peqa 06eMb~ e n o - ~ a n cnob~ ~ ~ ~ ~ ~ ~ O ~ ~ O neqeHne. T ~ K T ~ O M RB B O H Ha ~O Kwcnopep abspacrra. n o 10-rop~lu~a ~b3pac He ~ce npMnaraT pop H rlltOKO3a (OCHOBHM XpaHMTenHM C ~ ~ C T Ha ~ ~HeBT H MOH03aXaPMRHMPa3TBOPM H 4 10% (o~~cHoCT OT ReXMppo~a).n p ~ n a r a ~ Ha e aHTMxMnoKcatiTm (Pyramem), Centrofenoxin, Encefabol, B pa~a~w~). M T a M M H M OT rpyna B, Vitamin Ocnno~aq~a an~anwswpaqa t$opcwpa~a awypesa. C. CpeUJyTOKCMVHMR M03b'ieH OTOK- r~IOKOKOPTMKOM~M np~nara ce n p OT~OBU ~ c KMcena peaKqm - MeTaHon, .MHTpaBa3alleH flpeH& C 40% pa3TBOp Ha Sorbitol M n M canHqMnaTM, 6ap6w~ypa~n. n o c ~ ~ ce r ako~~3clpa~e~o Sol. Glucosae, 18% pa3TBOp Ha Manitol, 20% pa3TBOp Ha M M ,K O e T O HaManRBa IlPeMHHaMHeTO MM B KneTKMTe M Human albumin, nnaawa, Calcium gluconicum. 06paT~aTa MM p e 3 o p 6 q ~ B~6b6perHM~e Ty6yrIM. npM flyn~onpo~em~~wcpe SPOHXO~HTHL(M ~ c ~ e a . 6poTeXKM M H T O K C M K a 4 M M 04'3 B HaWJlOTO C e BnHBaT 500 m! HXOflHnaTaTOpM, KanqMeBM IlpenapaTM, rnlOKOKOPTMKOH8.4% p a 3 ~ ~ 0 Ha p Natrium bicarbonicum, n o - ~ a ~ ce an~ P M , UlHPOKOCneKTbPHM ~HTM~MOTM~M, KMCllOPOp. 4 0 6 a no ~~ $op~ynacnopep napaMeTpHTe Ha AKP (KAC). Kap~uonpo~elc~ cpeAcTsa. w~~n M a ~ p o e ~ e p Ppym~e pa3~aop ce ~npMnaraT no ropeonlrcaHHR Hawti. npenapaw (Atriphos, Phosphobion), B M T a M W H M OT rpyna o o p c ~ p a ~ p~ypesa a ~ a ce npoeeyqa nop nepuaHeHB, rJlDKOKOPTMKOMflH, npM H W a KaPAMOTOHHqM M aHTMaP M T M H C H l M CpeACTBa. THMR KoHTpon HacneptiwTeno~a3a~enlr: a) HeeponorurHoHa6n~peHMe, $ y ~ p y c ~ o nMm EETXena~onpo~e~~w cpencma. e~w MOHO~~X~ 38 M03bCleH OTOK; ~ ~ ~ T B O (ne~ynosa, P M rnto~oaa), opoToaa KMcenclHa H Ka6) $ M ~ M K ~ MH pO e~~re~orpa$ MscnepaaHe c~o Ha nMea opoTaT, B M T a M M H M OT rpyna B, Vitamin E, Vitamin K, 6 e n ~ ppo6oae ~e - 3a 6enoppo6e~ OTOK; aMMHOKMCeJlHHHM pa3TBOPM M IlpenapaTM, @OC@~M~M B)cbpRereH cTaTyc, EKr M napaMeTpw Ha xeMopMHa(Essentiale), rnroKoKopTuKoMpM, Silymarin (Carzil), Catergen, opan~o MuKaTa (AH, UBH) - 3 a p e ~ o ~ n e ~ c M n a wq XMnepxMppa~~ ~epesop6wpaq~ ce B H T M ~ M O T H ~(3a M TaqMFI; c~ep~nw3~p Ha a clepaa~a). ~e r) XeMaTonorMrHH n o ~ a ~ a ~X e~ nM ~ :O ~ ~ xeMoKO~HH, Het$ponpo~elcrw~~w cpeacTsa. KarIqMeBM npenaPaTMT; paw, Vitamin C, a~a60n~1.1 cpepcma (sa HauanmaHe Ha R) i o ~ o r p a ~ a ; ~a~a60n~ pecn. s~a 0,6 p a 3 y ~ a ~ e Ha ~~ oS O T H H ~ena), rnroK03HM H BOf lHOCOneBM pa3TBOpM (3a nOflflbpXaHe Ha 406e) a n ~ a n ~ o - K M C ~ n ~o M ~H aH sM a~en~; pa p~ypeaa). X) clacornpMypeaa (cnep ~ a ~ e ~ p ~ s w p a ~ e ) . 4. A H T # ~ o T H O ~ ~ PM '~~ HRKOM H M MHTOKCMKauMM ~. (C npll H w a C e npaBRT CbOTBeTHMTe KOPeKqHH, B W 1 . IlplllJlaraHe HaKaPAMOTOHMqW,flMypeTM4M. QOC, 0ncla.r~) sanorea BepHara. OpanHln aHTblflOTbl. @M3MClHM ( ~ ~ C O P ~ ~ M MO XMH M3~b~6b6pe MeTOaW q ~ ~ 3a enHMMHnpaHe Ha 01M M C H lM , ~ ~ ~ ~ C T B ~ 'iL pe3 L ( CHeyTpMM3MpaHe I Ha OTpOBaTa, poea~a. Xe~ofl~an~a xa e ,~ o n e p @ y s nepwoHeanHa ~~, np~nara ce ~ HenocpepcTaeHo npenn croMaluHaTa npopwanwa, nnama@epe3a. npunara~ ce npH Texm MHTOM M B K a npH HRKOM BMjJOBf! M H T O K C M K a q M M (KOPO~MBHM C KcMKaqvM, npM KOHTO $ o p c ~ p a ~ a pnype3a ~a He e AocTaaflKanOM~H, MeTXIM M pp.). AKTHBMP~HMRT BbrneH e Y H M ~ V He O@ u ~ a c M ~ n M aM M a ~ P O T H B O ~ O K ~ ~3a ~H npoBexMR AaHeTO h. bl3non3~aTce M 38 O' iHCTBaHe Ha eHpOTOKCMClHM BepCaJleH ($M~Mc~!H) aHTMflOT. nPOflYKTM, HElTpynBaUHC e B OpraHH3Ma npH TeXKM MHTOAHTWAOTW 3a napeHTepanHo npnnometiwe ( ~ y c ~ KcMKaqm c yspepeHaneToKcwHa$ ~ H K W Ha 6b6peu~~e nH0, BeH03H0, ~~o~~KoXHO). A~~CT no BCnefl ~T HMTe MeXaM Cl epHMR pp06. HH3MH: Vpe3 $ Y H K ~ M OaHTarOHM3bM H~~~H (~~OTMBO O ~ M ~ H KpbBOnpenMBaHe. HO M3noJl3Ba C e npM HeXHO Ha OTPOBaTa # ~ ~ c T B M KOMneTMTMBeH ~); (cbc~e3a~ Bb3MOXHOCT 38 npHnaraHe M n MH~~$~KTMB Ha HropeOCT n e ~MeXaHM3bM ) - M3MeCTBaHe Ha HOKCaTaOT CbOTBeTHMnocoveHwe MeTonv. n p a a ~ ce YacTMrHa M n M nbnHa eKcTe x#uclopeqenTop#nopqm no-ronm ~ $ M H MK T~ ~ TRX; T M C ~ H ~ B M H O T ~ ~CH npRCHa C$Y~ (24 MR ClacoBa) epH0rpyflOBa Clpea 06pa3y~a~e Ha HeTOKCMClHH KOMnneKCM C OTpOBaTa (xena~kl), KOHTO C e M3XBbpnRTCYPMHaTa; VPe3 ~ ~ O K M KpbB, HH$y3MpaHa npe3 @HnTbp BbB BeH03eH CbA. M3~0ClBa C e OT BeHa H n M aPTePHR. C ~ O T H O L U Mewy ~ H MBnRTa~ ~ M o T ~ ~ H c $ o ~ Ha M~ OTpOBaTa, ~MRT~ KOraTO T f i B O p M p0 06pa3yaa~eHa no-TOKCM'tHM OT HeR M ~ T ~ ~ O Cl ~pe3 ~M Ta M esaKyHpaHaTa ~ p b e 3:2. peaKTHBMpaHeHanOTMCHaTMOTHOKCaTaeH3HMHMCMCTenbpeo ce anMeaT 300-500 ml ~pbe, cnep KoeTo aanovBa M ~ T O C I B ~ H ( ~O TO ~ ~ C HOT O ~onanc). CT n p o c n e p ~ l ce ~a~ M M ; no HMyHeH nbT (npeflapa~kl, CbpbPXauM aHTMTena ~lpe3 p a ~ b c ~ Ha a~ ToKconpoTee IlapaMeTpMTe Ha XeMOflHHaMMKaTa M 6 e n o p p o 6 CTa~ ~ ~ ~ c p e w HFIKOM OTPOBM); M H O B H T e KOMnneKCM H M3XBbPnRHe Ha O C B O ~ O ~ OT~ H TyC ( O ~ ~ C H O OTC 0T~ 0 4 ~~)P . O T M B O ~ O K ~ ~ ~TeXKa HWF~: pOBa C YpMHaTa; Clpe3 BHOC Ha ~ ~ O K M ~ OT ~ HOKCaTa H M cbppertia peKoMneHcaqm, xenaTapmR.

e H 3 M M H M KOMnOHeHTM. (KOHKP~THO 38 aHTMflOTHOTOlle'ieHue - B c n e q ~ a n ~ a qac~). ~a

5. P e a ~ n ~ a u n nerleHme. o ~ ~ o p ~ x a ~ e peauman~a
qMR:CTMMynMpaHe HaAMXaTenHHR 4eHnpcMicoren, saHe ~a~ ~ c n o p oeH1oTpaxeanHa p; MH@~MR, 0 6 ~ ~ w a a He c pweH M n MaeToMaTMretipecnwpaTop; orMcTBaHe vpe3

6. C n ~ n ~ o u a m rnerleHne. l~o l l pH ~ W a ce npMnaraT ElHTHKOHByllCaHTM,CeAaTMBHM CpeRcTBa, aHZlJlenTMq#, atianreTwqH, aHTwnMpeTMqM, $ M ~ M K ~ H ox On q a u e . 7. #H~pa~op6#flHa ~ ~ O $ M ~ ~ KHa T Bb3MOXHMU K ~ Te ycnoxHeHnn. Toafle~Ha o w e , ycTaTa M KoxaTa; 06pbt~pHe HacTpaHw, n p t~ i m a - nocTypaneH Apeurn;

acnMpaqHR HaAMxaTenHuTenbTnuac KaTenp MnM 6po~xoUrMPOKOCneKTbPHM ~ H T H ~ M O T M ~ M npeAfla3HM ; CpeACTBa c~on; npM HWaTpaxeocToMa;x~nep6ap~a oKcMreHaqMR. npoTws pasemMe Ha A ~ K ~ G H T ~E Cn I~ e.~ ~ p o ~ a c Ha ax KapflkI~unpKyna~~pHa peaHnMaunn:6bp30AehcTI-P~AHMRKOIU M KopeMa ( n p o ~ B ~~ e ~ ~ I - T M Tycnoxue~ ~ H M saqM AHrMTanMcoeM npenapaw npnnoxeHM i. v.; KaTexoHMR M napesa Ha cToMaxa M qepaa~a). naMMtiH(Dopamin 10-50pglkglmin); X M ~ ~ ~ T ~ H ~ cpeM B H M 8. Pexa6mnm~aqnn. COM~TH ($ ~M H~~ w H ~ pexa6~) AcTsa, apeueHeH neirc~ehap. nwaqw: paws - p a 3 ~ e ~ x M ~Macrn a ~ e Ha ~ p a h ~ ~ #H$Y~AOHHI PeaHnMa~UR: M3BbpWBa Ce no 0 6 ~ ~ - B PeKOHBMeCqeHTHMR IlepMOfl- Bb3CTaHOBRBaHe Ha MyTe npaelnna c rntoKo3Hu M BO~HO-coneen ~~~TBO cnopeA PM CKynHaTa Clma, KOOPRMHa4MRTa Ha ABMXeHMRTa M pa6oCTOAHOCTHT~ Ha CbOTBeTHMTe IlapaMeTpbl. npM H W a ~ocnoco6~ocna. BnMBaHe Ha npRCHa KpbB.

PM HeBb3MOXHOCT 351 IlbnHO-

qe~~oxpa~e~e-nape~~epan~oxpa~e~ec~o~ XWHMTe o3axa $)IHK~MH. p~- ~ ~ ~

BUM, a M M H O K M C e J l M H H M Pa3TBOPM. 3 M .

ncMxM'iHa p e x a 6 n n ~ ~ aBb3CTaHOBRBaHe q~~: HaflCMB ~ P L U B M e ~ A M C4 M ~H O C K T M IlCMXOJlO-

X H B ~npeAcTaanRBa K~T TereH MeTan cbc c p e 6 p ~ c ~ U B R T , IleCHODa3TBODMM B OKHCnMTenHM K M C e n M H M .06~a-

~~H~~HUCTHK~

AH~MH~CTM RaHHH ~ H M 38 KOHTaKT C HOKCaTa. n p 0 ~ e -

n p nepopaneu ~ npweM 6er1TbrHaBona, cToMawHa IlpOMMBKa, O'iMCTMTenHO, aHTMAOT (Dimercaprol MnM

Unithiol). n p MHxanaTopeti ~ npMeu TaKTa C HOKCaTa, KMCnOpOfl.

- npeacsaHe Ha KOH-

AHTMAOTHO neqeHMe C Dimercaprol M n M Unithiol no cxeua, x e ~ o ~ ~ a n x ~e 3~ a o,n e p $ y 3M ~ nepwToHeantia ~

# l a J l M 3 a B ~a'id0~0 Ha M H T O K C M K a 4 M R T a M B T O P M C l H a XeMOnManM3a npM 06H, MH$Y~MR Ha BOAHO-ConeBM M MOH03aXaPMuHM pa3TBOPM, WeKBaTHM Ha C b C T O R H M e T O ,

~ H T M ~ M O T MM ~B MM T a M M H M . fle'ieHMe~0Ha HHXmaTOpHMTe

OTpaBRHMR B W I I O V M rnIOKOKOPTHKOM~H,6 p o ~ ~ 0 f l M n a T a ITM~M n 6op6a c 6eno~po6Topn, c:eKpeTonMu HMR OT1DK.

Te.

Maprapma rewesa-6on~esa

K~MMR M CbeAMHeHMRTa T M y IlPOHMKBaT B OpraHM3Ma npesAMxaTenHaTacMcTeuaKaToKmMMeeMnpaxMnapH, npea XpaHocMwnaTenHaTa c m e h n a , npea K o x a T a H nwaBMqMTe. TOKCMCIHOTO # $ ~ ~ T B L IC ~e A b n X M H a 6nompa~e
Ha ~H~MMH BepMrM, M y r a c T a a q M B MtrrpaqenynapHoTo UMWaHe. Kynnyn~pa B CIepHnR ~po6, n a H K p e a c a M ~pbeoHOCHMTe CbAOBe. r a 3 0 0 6 p a 3 ~ M ~ HOKCM e C a no-TOKCMCIHM OT n p a x o o 6 p a 3 ~ m e .

Maprapma reuresa-6onmuesa

TOKCHYHO ~eiim~e
@nyopb~ M CbeAMHeHMRTa M y IlPOHMKBaT BOpraHM3Ma npea 6enme npo6ose, xpaHocMMnaTenHaTa cMcTeMa, noPRAKO npes K o x a T a . TOKCMYHMRT MM e$ew ce nbnxn H a CBbp3BaHeTO H a KallL(HeBMR GOH, H a p y W a M H e T O H a Kanqveeo-+oc$op~a~a xo~eoc~aM 3a 0 6 p a 3 y M ~ e ~H 0a c m HO ~ p a a ~ e q $nyopoeoflopo~~a a~a KMcenMHa B crolmaxa. O C B ~T H O M 6 n o ~ M p a THRKOM eHBMMM, KaTO H a p y l l l a B a T

Cne~ MHxanaTopeH n p n e M ce ~ORBRMT W a s H e H e M 60nw 3 4 WbflHaTa KOCT, $e6pMnMTe~, a W y X , ~ ~ O H X O C na3bM, CyXM XpMnOBe. n p M TeXKMTe MHTOKCMKaqMM Ce pa3~~ 6enoflpo6e~ m OTOK, nocnenaati OT n y n ~ o $ # 6 p o 3 e npoqec ~ c H e n p e o R o n M M a XMnoKceMMn. n e p o p a n ~ ~ ~ e OTPaBRHMR IlpOTMWT C r W e H e , I l O B p b ~ a H e ,flMapMVHM ~ a x o w a ~KopeMHM ~n, ~O~KM nocneABaHM , OT x H n o B o n e MMR, M ~ T ~ ~ O aqMAO3a ~ H T HM ~ OflMrypMR. 6 XOAa H a T e X KMTe MHTOKCMKaqMM C e Y B p e w a T 6b6peqme M CIePHMflT

~ ~ 0 6 .

M ~ r e c T ~ e$ ~oap~ ~a a H a o~paa~~e.aano~~aac rmeHe, I l O B p b q a H e , ~ O ~ K M P b A H a T a KOCT M B KOpeMa, UMaHR. C n e TOM ~ ce noReRaaT x ~ n e p p e @ n e rbproee ~c~~, M TITIHMR. H ~ ~ I - T ~ x K M OTPaBRHMR T~ flPOTMVaT C yHeCeHOCT, 3 p W e n H M CMyU&?HMR, IlOTMCKaHe H a AMWaHeTO, PMTbMHM HapyWeHMR, 0CTpaCbpRe.IHO-CbF(0M cna6oc~. MHX W a T O p H a T a $ 0 p M a H a MHTOKCMKauMR C e flpeACTaBR C KaurnMqa, 6 o n ~ r p~ bAH 3 a T~ a KOCT, 3 ~c P ~ y ~ B~ MT HM a aCTMaTMCIeH ~POHXMT M ~POHXMO~MT.

a m

C I ~ ~ O C T ~ ~ H M ~ ~ ~ O ~ IM RH BX ~~H aM TO Rp , H MHTOKCMKIH UUM C a30THM OKMCH, a no OTHOWeHMe H a MHreCTMBHaTa @pus c x p a H w e n H o oTpaenHe.

3a KOHTaKT C HOKCaTa, IlOHMXeHMe H a K M 4 M eBOT0 HMBO B KPbBTa. EKT IlpoMeHM C PMTbMHM HapyllleHMR H y n b n x e H Q-T nepMoA.

A~HHH

MHXWaTOPHMTe OTPaBRHHR RpeKbcBaHe H a K o t r r a K T a c HoKcaTa, n o a a s a H e H a K u c n o p o g , o r p a H w a e a H e H a A s n x e H n A T a . l l p oTpaeRtinR ~ npes y c T a T a u o h n a W H a npOMMBKa, aHTMAoT CaNa, WTA 1 amp.

PM

ra3eHaTa O ~ C T ~ H O B OCMrypRBaHe K~, Ha ~ O K O TOaneT ~, Ha

l l p nepopaneH ~ npneM Calcium gluconicum per OS, C T O M a W H a IlpoMMBKa. npM MHXanaTOpeHflpMeM-flpeKpaTRWHe Ha K O H T a K T aC HOKMTI, KMCnOPOA, rnlOKOKOPTMK0n mqo Calcium gluconicum.

o w e M KoxaTa, HHxanauMM c Natrium bicarbonicum. l l p

nepopaneH npMeM

- cToMawHa npoMMBKa.

no~aea~ Ha e KMcnopofl, anapama BeHmnaqMrr npu H m a , rJlloKOKOPTMKOMflM, ~ H T W ~ H O T M6poHxo~Mna~a ~M, TOPM, CeKpeTOnHTM4H flpM flynMOTOKCMqeH CMHflpOM. Calcium gluconicum no 1 amp Ha B C ~ K M qac n p ~ qetilrleTo Ha OTpaBRHeToC 6ep~one~osa con ce npoeexqa TITBHMR, MH@Y~MOHHO IleqeHMe, I l P O T M B O L U O K O B M Ha H T M C $opcLlpaHa AMypeaa, rnlOKOKOPTHKOMflM,X ~ M O T ~ ~ H C a P M T M M i H ' M CpeACTBa; rnlOKOKOPTHKOMflM; ~ H T M ~ M O T H ~ H ; ~ M R KanqMeBM , npenapam, Vitamin C, x e ~ o f l ~ a n ~ a a . 6poH~0flUna~a~0pM M CeKpeTOnUTbIqM.

ne-

OCHOBHHRT MeXaHM3bM Ha YBPC!)((ClaHe Ce flbnXM Ha peaK4MmaHa xnopa c eonHaTa KoMnoHeHTa ttanwraeuquTe Ha flMXaTenHMTe nbTMUa M 06pa3paHeT0 Ha COnHa, XMflOxnOpHa M IlepwlOpHa KMCenMHM. Te flpa3HRT M p p e WaT nuraelyaTa Ha Hoca, Tpaxema M 6po~xme.np~l MHXaMpaHe Ha X J l O p BrOneMM KOHL(eHTpa4MM Ce flpa3HRT M MmKMTeAMXaTenHM flbTMqa C pa3BMTUeHa 6poHxUanHa O~CTPYK~MR.

H~CB~~~ $oa@p ~HM 6ma R TmnT U YepBeti. Toii e aKTlrlBeti eneMeHT H 3a ToKcHKonomRTa ~ a h - ~ O ~ 3R ~M a qeHMe M M a T : mnT M qepBeH @c+op, $ O C + O ~ O B O ~ ~ O ~ qnHKoa ~IOC@M~~, anyMMHnee @o@ug M f l e n ~ npenapa4~~ T H .

XbIlTMRT @C@P H 4 M H K O B H R T @C$MA IlOCTbnWT C n e nttxannpatie ~ Ha xnop ce pa3rpaqa~ ~ ~ M O T O K C M - npes xpaHocMMnaTenHaTacMcTeMa, a 'iepeetinm @c@p qeH CMHA~OM c npas~e~ Be Hoca, oqme, cyxa KawnMqa, M @C$opo~oflopo~b~ npea 6enu~e ~ p o 6 o ~OCHOBHM e. W, KpbBOXpa'ieHe, rqeHe M IlOBpbqaHe. M ~ o r BMCOo T O K C M i ' e H @~KTO e~ ~ ~ B o ~ KO~ oT O C~ e o6pao ~ K H T eK O H 4 e H T P a U M M Ha XJlOP MOraT fla flOBeflaT A0 6eno3y~a B cToMaXa cnefl B M M M O A ~ ~ C T B M ~ THa O conHaTa flpo6e~OTOK, rbproee n KoMa. npne~we nepopanHo K M C e n M H a M IlpMeTMTe m J l T $ o c @ ~ MllM 4 M H K O B @oc$M~ xnopHM C ~ ~ I ~ H ~ H M -R 6 e n ~ ~Sep~one~osa a, con (Kalium AehcT~a KaTo cMnHa npo~onnaa~e~a oTpoea, KORTO npechloratum) npnrlntiRaaTrwetie,noepbqaHeM wore PRRKbcW OKMCnMTenHOTO $~~$OpUflMpa~e. H~~-YR~B C a M KO A M a p M R . 6ep~one~oea~a con oceeti Toea BOAM1 0 o6paKJleTKMTe Ha C T O M a W H O V p e B H M R TpaKT, '4ePHHR ~ ~ 0 3 y ~ a ~ Ha e~ ~o e ~ x e ~ o rc nHamneaHe o 6 ~ ~ ~ax e ~ o n ~ 3 a , 6 b 6 p e q ~ ~ Me MuoKapna. a H e M M R , 6b6pe'i~ yepex,qaHMR ~ 1 0 06H.

540

Tokcukonozur~u cneurnu cacmonnun XHMTe eH3MMM. K ~ T p O a3c~pohBa M e ~ a 6 0 n M 3H ~ a KJleTKaTa, n p M r M H n s a T e w a M H T p a u e n y n a p H a XMnoKcMR C H ~ ~ Y L U $ ~ YB HK ~ ~H M~ RT H ~a B W M OpraHM -M03bK, V e p e H

BM M B n o t u a B a H e H a n p o r ~ o 3 a ~ M a .~ x a n ~ p a H ~ aenpax ~o OT VepBeH $ O C $ O ~ BOAM R0 TOKCMVeH ~ P O H X W T M~POHXMOnMT. n p M HHXMaTOpHM MHTOKCMKaqMM C $OC$OPOBOAO-

p01C e ~ a 6 n w ~ a raCTp0-MHTeCTMHNeH, aa~ IlynMOTOKCMVeH, ~ a p ~ n o - s a c ~ y n a Mp xe e~ na~o-pe~an CMHAPOM. e~

~ p oM 6RP. E ~ M M M H H P B~ 5% HenpOMeHeH n p e 3 6b6peU M T ~ ,K o x a T a M C AMtuaHeTo, a o c T a H a n a T a r a c T ce MeTa6 o n ~ 3 ~ p K@HM ac npOflylVM CO, M H, O. O K M C ~ ~ M T ~ ~ H O ~ e ~ a 6 o n ~ 3 ce ~ p wabpuea a ~ e B VepHMR 4p06 H a Asa e~ana:an~oxon~ex~~pore~a~a~anpe~p a q e T a n A e x v g , a a n p e x ~ m e x ~ ~ p o r e ~ ro a 3o a~a ~cn~ ~o CO,. no TON n b T ce ~ e r a 6 o n w 3 ~ 80% p a OT n o e T a r a aosa. O c ~ a ~ a 20% n~~ non e ~ e h c ~ H~ a K~ a Te ana ~s ao Ta M n p M yVaCTMeT0 H a H , O , C e OKMCnRBaT A0 K ~ ~ ~ H MeTaL I T ~

C MHTOKCMKaL(MW O T X e n a T W M H~$POTOKCMVHHHOKCM.

PM n e p o p a n H o oTpasRHe - ~ e s a 6 a e ~ cTonnawHa a
npoMvsKa

c Kaliurn hypermanganicurn M aoga (1.5 OOO),

OVMCTMTenHO. MHXMaTOpeH IlpMeM npeKbCBFlHe H a KOHTaKTaCHOKCaTaH flOAaBaHeHaKMCnOpOfl.

PM

A H T M ~ ~ o T H O ~ ~CV C~ U HM P ~~sulfuricurn U ~ ~ 1%no 15 rnl 3-4 nbTM peros, HH$YBMR ~a~ o # t o - c o n e e M~ uoHo3axapMflHH pa3TBOPM, r~IOKOKOPTMKOM~M, XenaTO- M uepe6ponPOTeKTMBHM CPeflCTBa, VaCTMVHO O ~ M ~ H HKpbBOnpeflMO s a H e M ~ap60~!~0ep$y3MM B nbpeMTe 6 h, BMTauMtioneVeHMe, ~ H T M ~ M O T M ~ H . HHXLUlaTOpHMTe MHTOKCMKaqMH rJltOKOKOPTMKOMflH, ~ H T M ~ C I O T WCeKpeTOnMTMuM ~M, M~ P O H xoAMnaTaTopM.

~O~HTH. ~ ~ O H H B Ko H p r~ a ~ ~ 3 B u TOKCMC(HM a AO~M MHapyuaB ~ ~ HOpMaJlHOTO K M $ Y H K ~ M O H M ~H~aH peF(Mua ~ eH3MMM, CiJlKOXOnbT AOBeN(4a fl0 HaTpyllBaHe H a KMCeflM llpO&fKTM B n K a H n T e ( r n a ~M ~n oe w a M o q e ~ wcenw~a) ~a H HacTbnsaHe H a T e x K a a q ~ ~ o 3 a O.c e e ~ T o s a ~ oH a i pytuaea M ~ T ~ ~ O I I MH ~aM BbrnexMApaTMTe ~ c p e 3 y n ~T a e~x K a XMnornMKeMMR. r o n e ~ K ~o~ nM e r e c T e a M o r a T Aa y e p e A m r e p H m npo6, nawpeaca, MHoKapna. M~B~CTH eO MH&luMPaHeTO Ha M ~ T ~ ~ o J ~ M ~ M eH3HMM n p M XPOHMVHa yno~pe6a H a aUlK0XOn C IlOCneABau a ~~BMCMMOCT.

PM

XMnepeMMR M OTOK H a M 0 3 b K a M M03b'iHMTe O~BMBKH, MpMTaTMBHM npoMeHM H a nuraawqaraH a xpaHocMMnaTen-

HMR TpaKT, BeH03eH 3 a C T 0 i B 6 e f l M ~ e gp060~e H RpYM BbTPeWHM OpraHM. n p M XPOHMClHa 3 n 0 y n 0 ~ p e 6 a - f l M ~ ~ ~ 0 $H'~HM npOMeHH BnapeHXMMHMTe OpraHH M rnaBHMR MOBbK,

~TPO$H'~HM nPOMeHM

no M J la r B M T $ ! la

H a CTOMaXa.

A~~KOXO KOHCYMaqMR ~ H ~ T ~ Ha ~~U&CTBOTO e B 3aBMCUMOCT OT n p 0 6 n e M M ~ e My. K P M ~ M C H M T CMTyauMM ~ Cb3aaa a T ycnoam 3 a ~ ~ C M ~ B ~ h,Ha~ nTp e O f l o 3 ~ p a ~ eH ~a o FlJlKOXOna f O l Be)t(@ f lO rPelLlKM n O p W M HeKPMTMVHOCT.

O@PMRT Ce 4 CMHAPOMa: OCHOBeH ( L ( ~ P ~ ~ P O T O K C M V ~ H ) ,raCTp0-MHTeCTMHaJleH, PeCnMpaTOPeH M CbpneVHOCbflOB. B 3aBMCMMOCT OT TRXHOTO CbRbPXaHMe B WIMHMVHaTa KapTMHa, KoeTo o n p e A e n R T e x e c r r a H a oTpaeRHeTo, OCTPMTe ~ K O X O n H M OTpaBRHMR H a 4 CTeneHM:

A. MOHOB pa3flenR

ETM~OBMRT UlKOXOn (e~a~0i-I) e ~ C ? ~ L ( B T~YHOCT, ~TH~ C xapauepHa MMPM~M M~ napnm B K ~ C ~ , o6pe ce c M e c e a c

I CTeneH, M3RBeHa C ey@pMR

M nCMXOMOTOpHa ~ b 3 6 ~

11 CTeReH, M3RBeHa C 6 e 3 ~ b 3 H a ~ e n CbCTORHMe ~0 npM aanaae~ p~ e $ n e ~ c~ ~o , 6po AMuratie M c a p ~ e c l ~ o - c a f l o s a ~~~GHocT; OCT~M OTPaBRHMR HaCTbnBaT n p M KOHCYMaqMR H a r0Ill c ~ e n -e c~ ~bn6o~ Ka O M ~HaManeHM , ~o nmncaaqu p e $ n e ~ c HenpaeMnHo ~, AMwaHe, u ~ a ~ o 3 a ; neMM KOnMVeCTBa CnMPTHM HanMTKM H I M VMCT CnMpT. ETHnoBMRTanKoxon n p o ~ ~ ~ ~ a ~ o p r a ~ ~ 3 ~ a n p e a x p a IV~ cT o en ce~ H~pbn60~a KoMa, a p e $ n e ~ co~ cT ~p,a pMxan a T e n H a T a cMcTeMa M PRRKO n a p e H T e p a n H o , npea K o x a T a T e n H a M CbPAeVHO-CbpOBa HeflOCTaTbVHOCT. MnM n p M MHXanaqMM. @ ~ K C M P ~C e B WleTKMTe C rOllRMO n o c n e ~ Ace ~ ~ cTeneHM ~e V e c T o ca c n e T a n e H ~ 3 x CbflbPXaHMe H a JlMnMAM- L(HC M VepHMR ppo6, I l O p m M nopwnBHeaantioanHoe~Konanc.
r o n R u a T a c M nMnoTponHocT. n p e ~ n ~ a e a n ecbiqo c ~ o npes JlMnOnpOTeMHOBMTe M ~ M ~ P ~ HH a MMTOXOHApHHTe, H MMKpO3OMMTe M llM3030MMTe, ~ B p e w ~ p a h $~ YM HK~MRT H~a Tena60paTop~klTe npOMeHM nOKa3BaT BMCOKa KOHueHTPaqMR H a M K O X O n a B KpbBTa, HaManeHMe H a BE M CTO~HOcTclTe H a pH, y a e n c l r a e a H e H a ageToHoalrTe Tena, xunor-

ne~an~ Rosa a (no A. MOHOB) 200-400 rnl 96" aa Bb3PaCTHM M 6-30 rnl 96" 3 a Aeua.
Bofla.

m;

HanpOHMKMHeCaflpM'iMHa'ieCTO3aTeXKMMHTOKCMKaUHM. Ha6ntofla~a Ce H ~ ~ B M C O KOHqeHTpa4MR K ~ H a MeTaHOn B 6b6peq~~e, 'iepHMfl ~ p o 6 raCTp0-MHTeCTMHWHMR , TPaKT M O C O ~ ~ H BMCOKa O KOHqeHTPauMR B HepByC OnTHKyC, BbTpeO'iHaTa Te'iHOCT, TbKaH. M03bKa, MyCKynMTe M MaCTHaTa

H~~POM Ce ~enMMMHMpa M ~ H B 2 4 % n p e 3 6b6pe4 ~M~ OT'iacTM e npea 6 e n ~ ppo6oee. ~e Me~a6on~awpa ce B 'iePHMFI ~ ~ C 0 Y'iaCTMeTO 6 H a WKOXOIlfleXMflpOreHa3a

A # $ e p e ~ q w a n ~ a~ ~~ aarttoa ~ ap

R p y M T e KOMaTO3HM CbCTORHMR (MOP$MHOB#, BM, B ~ ~ ~ ~ O K H C MH M03b'iHMR M) MHCynT.

~6e fla a~b06pa3M 6ap6~~ypo-

(44)n p e 3 @p~anflex~g do Mpae'ieHa

M Mne'iHa KMcenM-

Ha. ~ O ~ M ~ B O ~ ~ B flbT MC OKMCnRBa MM MpaB'ieHaTa KMCenMH a ~o CO,, KaTo c K o p o c r r a H a peaKqMRTa o n p e A e n R TOKCM'iHOCTTa H a MeTaHOna. O K M C ~ R Ce B 10 ~ nbTM no6 a e ~ OT o e T a H o n a M MMa no-~bnro s p e M e H a nonyenuMMHMpaHe. euHOBpeMeHeH n p M e M H a eTaHOn Ce noBM-

XPOHW'~HOTOOT~~BRH~ e MHTepeCHO C p a 3 ~ 0 0 6 p a 3 ~ M T e IlpORBM H a TOKCM'iHa ~ H ~ ~ $ W O ~ M~ HepBHO-nCM~TIIR XM'iHMTeCMYqeHMR-nepMOflMClHOHaCTbnBawMnCMX03M OT TMna H a RenMPMYM TPeMeHC,

PM

KOPC~KOB CMHflPOM M flp.

~

WaMCePyMHMRT nOnylKMBOT H a MeTaHOna f l O p 4 M MHOrOKPaTHO no-TOneMMR ~ $ M H M T ~ HTa

H ~ c T ~ IlOnMHeBpMTHM ~MT npOMeHH C pa3nM'iHa nOKWM3aUMR M Pe3MCTeHTHM H a Jle'ieHMe. A ~ K O X O ~ 3aBMCMH~T

MOCT

flCMXM'iHa M @M3M'ie~~a C T e X b K

CMHAPOM.

TOKCMVH R0 ~ 3T a BapMpa ~ B WMPOKH TpaHMqM - OT 10 fl0 100 rnl. n e ~ E l J l ~ a ~ a f l 0 3 a ~ e bM w~ of l M B M f l y E l J l ~ a - 0 ~ 3 0 ~~CTMH~HT~H fl0 100 rnl, C n e T a n H a KOH4eHTPauMR B K P ~ B T ~ - 0 F(O .5 1%. TOKCMCIHOTO fleic~euee p e 3 y n ~ a OT ~ KanmpaHeTo Ha AeaTa ~ e ~ a 6 o n $opuan~ex~p, ~~a M M p a e r e H a KMcenMHa. flea C a OCHOBHMTe MeXaHM3MM H a TOKCM'iHOTO ACT-

m K b M eTaHOna.

BMe: JlOKanHOMpMTaTMBeH, OTHOCMTenHO neK, H 0 MHOrO flp0flbnXMTeneH M UMTOTOKCM'ieH ( ~ ~ M C M ~ T ~ ~ O ~ M souey. H a ~ p y n ~ a ~ Ha eMpae'ieHaTa ~o K w c e n w a e npM-

CTOM~W IlpOMMBKa H~ ('ipe3 COHflMpaHe flpM KOMaTO3 H 0 CbCTOFIHMe; M O X e B Cb'ieTaHMe C M ~ T Y 6 a u l l f ln p M

flbn60~a KOM~). Oopcupa~a f l ~ y p e s aB o 6 e ~ 4 000-5 000 mu24 h,
K O M ~ U H MC ~W ~K H W ~H M pa3TBOpH 351 KOPeKqMR H a H a p y -

'iMHa 3 8 H a M M R B a H e H a 50% H a ~ H K ~ P ~ O H ~ Tp H eM 3 eR pB M nocneflaaqa ~ e ~ a h an q~ ~~ o ~ aM ~ a. pa aare~a~ KMa CenMHa nOTMCKa MMTOXOHAPMWHOTO uMlL!aHe C TbKaHHa XM~OKCMR, KORTO n b H ~ a p y w a B a MHTpaqenynapHoTo HAP/ H M H +CbOTHOWeHHe M CTHMynMpa a ~ a e p 0 6 ~ a rnMK0~a n ~ 3 cay e e n w a a a H e n p o A y K q w a H a nalcraTa. T O ~MeM XaHM3bM 3aCMnBa M ~ T ~ ~ O ~ H auMnO3a T H ~ T M~ e CbqO OTrOBOpeH 3 a ~ M K ~ P ~ O H ~ TAH~M @ RM ~ n Mp T M TeXKM MeTaHOnOBM OTpaBRHMR. M e ~ a 6 0 n M 3 H ~a b MeTMnOBMR ~ WKOXOn Cb3flaBa OCBeH TOBa eUMH OTHOCMTeneH R~$ML(HT H a

lueHMRTa H a KAC; UMxaTenHa p e a H H u a q w c Kvcnopofl

H a 3 X I e H KaTeTbp MnM M H T Y ~ ~ ~ M aHWenTM4M R; Caffein, C 0 r a Z 0 l M RP. nPM T e M M T e Cny'iaM; flMMM3a MnM O ~ M ~ H H O K p b B O f l p e n M M H e flpM K P ~ ~ H TeXKM O Cny'iaM; BMTaMMHU, ~ H T M ~ M o T MM ~UP. M CMMflTOMaTM'iHM C p e w T B a no nOKa3aHMR.

X P O H M ' ~ HallKOXOnHa ~T~ 3aBMCMMOCT M3MCKBa ne'ieHMe B c n e q ~ a n ~ 3 ~ ne'ie6~o p a ~ o saaefle~~ Me o6efl~~eHMTe YCMflMR H a TOKCMKOnOr, IlCMXMaTbp M 6 n ~ 1 3 Ha ~ ~ nauMeHTa.

~MPII~~OKCMH,K o e T o owe noeeqe 3 q b n 6 0 ' i a a a H a p y w a BaHeTO HaOKMCnMTenHO Bb3CTaHOBHTenHMTe npOqeCM.

Ha'iano M e w y 40-~a rnin M 72-PMh cnefl n p # e M a . B p e ~ e ~~ oe , o6xofl~ 3a ~~ oe~a6onwa~p Ha a~ MeTaHoe na, C e HapM'ia JlaTeHTeH IlepMOfl, C I l p O ~ b n X M T e n H O C T OT 12-24 h (6-30 h). T O ~flePMOfl M ~ ~ ~ C M M ~ T MnM O M C~
H ~ C ~ ~ ~ $ M OllllaKBaHMR. CIHM OCHOB~H ~ ~ ~ ~ ~ ~ o T o KCMHAPOM: c u W ? HrflaB060nMe,
CBeTOBbpTeX, aTaKCMR, HeMOTMBMpaHa ey$opMR, CMeHRU H Ce 6 b p 3 0 CbC CbHnMBOCT M CTeneHHO HapyWeHMe H a Cb3HaHMeTO fl0 KOMa; KOHBynCMH, 6 b p 3 0 f l p e ~ 0 ~ aHM30~a KOPMR M IlaTOnOM'iHM 3b'ieH OTOK. He, p e $ n e ~ c M , BpaTHa PHMAHOCT, MO-

flpepc~aan 6e3qeema ~~ Te'itiocT C BKYC M MMPMC, n o ~ o H6a eTMnOBMR ~~ XlKOXOn, ~ o m o ~ o 6 Ce p epa3TBapR B ~B Bo n a M eTep. Pemp6npace 6 b p 3 0 npea xpaHocMMnaTenHMFi TpaKT C MaKCMManHO HMBO B KPbBTa B 30-~a PO 90T a min cnefl n p I e M a . P I ~ x a n a ~ o p M~ ne ~ pK f ly ~ raHeH n b ~

no~an~onpn~a~ cnHflpoM: u s e ~ r a e H e , noepbqa60nB ~ KOpeMa. ~ n p M MHXElJlMpaHe H a MeTaHOnOBM napM - ~ p a a ~ e 3 ~ 4e r p b u H a T a KOCT, cyxa K a w n M q a ,

cbn30~e'ie~~e.

542

Tokcuko~otuvnu cnewwu cacmonwun

O ~ T ~ ~ M O T O K CHHnpOM. CHV~H M~RBR C e BB ~nbpBMTe WCOBe Ha OTpaBRHeTO M n M Ha 2-MR- 3-MR fleH B aaenc~voc~ OT KonMvecTBoTo peaop6npa~ MeTaHon M ce ~apaa~ B~ 3aTpyptietio a eMmaHe, .cHema 6yp~'po n b n ~ aary6a a ~aa p e ~ ~ eO ~~ o~ . K T M~~ Hp O p:v a aHaMaa, ne~apon~nceaqa a e ~ n rp ~e aa ~ u H~ ~~ C iB ~ T ~ cnaab~ MH~, Ha cbpoeeTe Ha peTwiaTa, orpaHMveHa a p ~ ~ e oc~pon~a Ta, crecHeHn nepMueTpM, CKOTOMM M ~TPO$MFI Ha a p ~ ~ e n HMR HepB. O' iHMTe YBPemaHMR OCTaBaT T P ~ ~ ~ npM HM 2550% OT npeXMBenMTe MHTOKCMKa4HRTa IlauMeHTM. f l m c ~ e ~ a 6 0 n mCHHAPOM: ~e~ EitIcoKocTeneHHa MeT ~ ~ O ~ M al(Mp03a, T H ~ PaHHa, AOCTMraLl@ A 0 HeCbBMeCTMMM C XMBOTa CTO~HOCTMHa pH M BE. A~HHM 38 pM3eneKTpOnMTeMMR B EKr P~HOTOKCHV~H CHHAPOM: He3HaVMTenHHna60pa~oP H M IlPOMeHM M n M 06H. Oa~yn~a~m Vep~O~p06eH se~ CHHA~OM: OcTpa vePHO~PO~ ~MCTPO$MF~. H~ K n n ~ ~ v KapTuHa ~ a ~ a uua 3 cTenetiM: neKa, cpepHoT e r n M TexKa. 3 a ~ p n x ~ ~ epaHHa n ~ a cro~autia , npoMMBKa c MepM~MHCKM BbrneH, nocnepwtia OT npneM Ha 6M~ap60HaTeH

~~$ya~ 3a m nocTHraHe a Ha eTaHonosa K O H ~ ~ H T P ~ UB HR KPbBTa 0.5-1%. 4. f l p y ~ nere6~n cpepcTBa. Acidum folicum 50 mg npes 4 h i.v. B p a a ~ ~ Ha o prnlo~o3a B npomnxeHne Ha 34R H M , KaTO KM~KToP Ha OKMCJleHMeTO Ha MpaBCleHaTa KMcenMHa po CO,. Piridoxin - 50 mg i. m. 3a 3-4 AHM. Natriumbicarbonicumno KAC. r n l o ~ o 3 0 n ~ c y n u m ~o ee -~ CM, Vitamin C, Vitamin B, K O K ~ P ~ O K C M Pyramem, ~~~~, x~nep6ap~a O K C M ~ ~ H ~ ~C MF bI~ . o p a a l u ~ p ~cpepcrBa ~aqu pe~po6yn6ap~o.

C n m e s ~ p OT a~ Wirtz npes 1856r., e ~ u n e ~ r n(Er) ~~o e Hacureti, peyaanemeH anKoxon (C,H,OH). 6 e a ~ e e ~ xnrpocKonMvtia TerHOcT, C ~ C cnwHnKaeonapnnB B K ~ C , BMWHeBO'iepBeH 4BRT, KOHCMCTeHuUR Ha CMPOn; T. Ha KMneHe 197.4", T. Ha a a ~ p w s a ~ 48"C, e HMUoxHaneTJlMBOCT.

paa~eop npeaycra~a (2-4n b x ~ Natrium v ~ ~ bicarnonicum B 200 ml ~opa) n C ~ ~ M H HovwcrMTenHo O - Magnesium TOKCH~HO ~ e i i m w e ~ ~ l f ~ r[PM i ~MaCMBHa ~ m . MHXanaUMR Ha anKOXOnHM napM J l e ~ a n ~ poaa a - 1-1.5 mllkg aa peua M po 100 ml 3a - ~ a a e ~ 06ra3eH0~0 a ~ ~ oMRCTO, ~ KMcnopoptia u ~ x a i a B ~ ~ ~ ~ C Iloc~bnBa T H M . npes ycTaTa n p ~ npea ~ KoxaTa. o 4 M R M MHXMa4MFIC pa3TBOpHa Natrium bicarbonicum.npM ; M xpoKoma a n n n ~ a q ~~ ToaneT i Ha KoxaTa rpea o 6 ~ n ~ o Ocrpa opantia M napeHTepanHaW p ~ anopocTpa HM'lHa OpMHa M AepManHa; MHXanaTOpHa- no M3KnloVeM ~ M M BC ~ Bopa H ~ M pameop Ha Natrium bicarbonicum. Hue. M e ~ a 6 o n ~ a ce ~ pnop a ~ e i c r ~ m Ha e~ anKoxonpexMo npore~aaa~a ( M ) npea rnwKonanpexMp, rnnKonoea n rnMOKCCiJlOBa KMCenMHa C KpaeH ~ e ~ a 6 o nCO, u r. T.Hap. fle~o~cuv IenypauMR ~a Ha xyMopanHaTa cpepa. . M M H O p naTU B O 4 M A0 OKCmOBa KMCenMHa M KUlqMeB 1. X e ~ o p ~ a n ~ em MeToA ~ a Ha ~ 3 6 M 0T ~ PR~B na ~ ce OKCanaT. AKOC eH a C M T MM n M 6normpa M,C ypMHaTa C e npoeene B nbpame vacoee pop^ M npM ~ e p a a ~ b p ~ a ~ a oTpenR ~ e p a s r p w e Er. ~ ToA nMa HapltoTHveti e$eu WlMHMClHa K ~ ~ T (MM~ M H OTHOl ~ ueHMeKaKTO KbM Hepa3rpa@HMR MeTaHOn, TaKa M KbM TOKCM' iHHTe M ~ T ~ ~ O ~ M T BbpXy H ) . UHC M HpMTaTMBeHBbpXy nMraBMuMTe. flHflM~a4MMTe M : KOHCYMauMR Ha MeTaHOn, KOHqeHTpa~ M Ha R MeTaHon B KpbsTa noBeve OT 0.2%, M ~ R B uepe~H I l p e p ~ u6 ~o ~ ~ oTpaame, 0 ~ 0 PR~KO onur 3a C~MOOT~POTOKCMV~ CMHAPOM, H HapyllleHMe Ha 3peHMeTO M BMCOpaewe. h a TPM C T ~ M F Ha I npornvatie. KocTeneHHa ~ e ~ a 6 o n w aqMpoa. ~a nbpen c~aamir- Havano oKono 3 0 - ~ a min cnen 2. A n ~ a n ~ $opcnpa~a a pnypea B o 6 e ~ 3.5-6 V24 h npneua, M ~ R B c ~p Ha a n ~ r no e ~TexecT qepe6pane~ CMHnpMcnepeHe HacboTseTHmeno~aaa~en~. p p o cnopep ~ KonMvecrsoTo Ha p a a r p w e ~ a ~ HOKM; a ra3. AHTM~OTHO neveHne: c n e u ~ $ ~awnpoT ~ l e ~ e emnpoMeHM nosum cnMpT nopapM HacMqaHe Ha M M ~b3cnnpa~e CTpO-MHTeCTMHaneH CMHppoM M na60paT0p~M (X~MOKOH~~H neBKOuMTO3a, T ~ ~ ~ M R KOMneHCMpaHa , auM06pa3yBaHeT0 Ha TOKCMqHMTe M ~ T ~ ~ O ~ M ~P TM M ~O . X~HCIIKa OM~HH~~ Ha MR qepe6eTo MY cnepBa fla 3anovHe oqe B nepMoAa Ha p o 6 o n ~ ~ v poaa). Ha6nlopaea ce p a a n ~ v ~ PanHMR M TaCTPO-MHTeCTMHMHMR CHHAPOM B CbCTaBa Ha 1 HOT0 neWHHe, KaTO He3aBMCMMO OT BXORHaTa BpaTa C e C T ~ Mn L .p npueM ~ Ha M ~ K p Mo a ~ Er, paHHa penypaunR paaa npes ycTaTa 40% anKoxon - 50-100-150 ml aa npM n o - r o n e ~ p ~o ~a e Mnu ~ npMeM Ha no-rone~n KonMveBb3paCTHM. flHTpaBeH03~0 C e MH@y3Mpa 5% pa3TBOP Ha RKOXOn, MHTOKCMKauMFl Ta anKoxon B 10% Sol. glucosae, Laewlose M n M $ p y ~ ~ o m , CTBa HOKCa B K O M ~ M H ~ ~CMaJl Moxe pa cnpe Ha TON C T ~ M ~ M I~ O ~ H U F pa I T oappaeee c npMroTBeHex tempore aa TepaneeTnveH@H p0 48-56-MR npopbnxuren~a uepe6pac~e~u~. r o n e ~ n p o noeTa 3 ~ HOh, Ha oTpeneH s e ~ o a e H~ ~T O ~ H M K npM , cpeptia KanKa Ha

Tot7 e ocHoaHa cacTaatia r a m Ha am$pn3a, a m a a nepeHMTenM M He3aMPb3BauM AHHIMMTM, CnMpaClHM T W HOCTM, B T K I T M H ~ B ~ T $~a , p ~ a u e ~ ~M~ nafilo~epnlr~a~a HaTa nPOMMUmeHOCTM.

K M 6bp30 pOBelK@Tp0 KOMa, KOMa C l%pCl M neTaneH M3XOA. BTOPH c~aflnii - peHaneH, p ~ c ~ e ~ a h n M uepeme~ 6pane~ CMH~POM.Ha $ o ~ a Ha e ~ 3 o r e ~ ~ ToKcMwia a~a eHqe$an~lla~MFIY P e M M R CbC CbOTBeTHaTa qepe6pan~a CMMnTOMaTMKa. H ~ P Y W ~ HHa MR KAC T~ Ca HaJlMqe Oqe B I C T ~ M H0 ~ , TYK ce 3Wbn60ClaBa~n o p m 6b6peCl~MTe YBpeWaHMR M M M a T KnMHM'iHa M3RBa. 6b6pe'iHMTe nOpaxeHm npoTwaT BpBe $ a 3 ~ -on~roa~ypw M~ nonmypna w a c MaeecTtia ~ ~ B M C M M O C MeWy T npopnxMTentiocrra Ha onwroaHypMwaTa $asa M B ~ ~ C T ~ H O B M T ~npoqe~HMT~ CM. PM TexKa creneH ce ~a6nlopaea~ M ReneHMR Ha ToKcMrHa xenaTo3a. fla60pa~0p~M npoMetin: onMroaHyPMR, WI~YMMHY~MFI, JleBKOuMTYPMR, ePMTP0qMTyPMFI M 4MJlMHflPM, OCTaTbClHOa30THa 3WpbmKa, XMnepKaJlMeMMR M $~K~~T~T nOBMWeHM M B H O TPaHCaMMHa3M, PaHHO HapyWeH M e Ha KOHueHTpaqMOHHMTen p o 6 ~ Ha 6b6pequ~e, TeXKM HapyWeHMR Ha KAC. Penapaq~o~ ctaanl. e~ nonnyp~cl~a $aaa ~ a Ha 6b6per~a HefiOCTaTbclHOCTe HaClalOTO HaT03M C T W MC~ , npofibnxMTermocT oKono pee ~ O ~ M H M Cnep . II Meceq Ha PenapaqMOHHMRCTWMM, npM HOpMWHapMype3a, 6on~1.1RT C e AeXOCnMTallM3Mpa C U m R qAMeTM'ieH PeXHM.

M3TOClHMK, Bb3MOXHO Hah-paHo3a TepaIleBTMCleH$OH 4856 h cnep npne~a. 3a ~ a c ~ q ~ aa ~u e c Ha~ O ~ X O ~ M 10 MM g ClMCT CnMPT Ha W C (MH$Y~MFI npM6r1~3MTenHo Ha 5000 ml/ 24 hH IT (H ~ O H T I ~ ~ ~ T B MH$Y~UP~T oP). CC! o6a~le 2 500 p0

nuar~ocnr~a
AHa~He3a 3a npMeM Ha OTpOBaTa, TeXKa auMp03a B 1 pettoHoqMe, HeKopecnoHpMpaqa c Texecrra Ha oTpaeRHeTO, TMnMClHa CT~CIM~HOCT Ha KllMHMClHaTa KapTMHa. OT na60pa~0pHM~e M3CneABaHMRC e ROKa3Ba HOKCaTa B 6110norMwme npopymM. 0'i~cTBaHe Ha OpraHM3Ma OT OTPOBaTa Ha HMBO BXOY'iaCTbK 'ipe3 CTOMaWHa npOMMBKa C MeAMuMHCKM sbrneti B ~ a i - p a CPOK ~e~ M Teveti napa@~ 50 po 100 ml cnep H ~ RcpeficTsasanpeoponRBaHe ; HaluoKoeoTocbcroRHMe M BKnIOClBaHe Ha nepOpalleHM n M BeHO3eH npMeM Ha awMpoT (e~a~on).
&?H

3 000 m1124 h 3a ~ 3 6 ~ 1 rYTeXHRBaHeTO ~a~e Ha qepe6panHMR CMHRPOM. ~ P H ~ ~ O X ~ H H Ha ~T aHTMAOTa O MOXe pa aanocltie per os cnep cTouawtiaTa npoMMBKa (5Ck100 ml 40% pa3TBOp epHOKpaTH0 M n M $panqaunnpaHO CbqaTa poga cnep paa qaca npM TpaHcnopTa Ha naqneHTa n HeBb3MOXHOCT 3a BeHO3Ha annM~a~MR). BTOPM aHTMAOT 3 a 6 n o ~ ~ pH a~ ae m - Pirasol a ~ o a 300mg a ~a 8 h peros, M ~ nnpaaonoe M npenapaT (Amidophen M n M Analgin) no 2 tabl. OT 0.30 mg Ha 6 h 3a Bb3paCTHM M cb06pa3eHa C ~bapacrra po3a 3a peqa. 2. A p p n e r e 6 cpepcTaa: ~~ a) paHHa RMypeTMwa cTMMynauMR3a npeoponmaHe "~onanca" Ha ~ e $ p o ~ -a 18% MaHMTOnOB pa3TBOP 250 m1 C Furanthril2-4 amp. Ha 12h. 6) Natriumbicarbonicum8.4% Bpoacnopep K A C a KopeKqMR Ha a~p1~03a~a; B) Calcium gluconicum 10% 10 m1 Ha 6-8 h 3a KOpeKqMR Ha XMnOKallUeMMRTa M peH0npoTeKqMR; r) Vitamin B , Ha 6 h no 1 amp. i. m.; p) opraHonpoTewueHM cpepmsa - 3a cTohnatutiaTanMraenqa (Almagel, Alumoxid M pp.), sa UHC HoorponHM npenapaw (Pyramem B poaa po 12 g npM K O M ~ T O ~ H C~CTORHMR M M p0 6 g npM CpepHO TeXKM $OPMM, Nootropil B CbUMTe po3n, Vitamin B,, B , B,, B neCle6HM 1 0 3 ~ .M ~ KpM o3~ CentrophenoxinnpMpenpecMBHMcbcToRHMFiM n MDiazepam npM Bb36ypHMnPORBM. ~ J ~ I O K O ~ MH neBynO3HM M pa3TBOPM, K O K ~ ~ ~ O K Atrifos. C M ~ ~ 3a ~ 'iePHMflpp06 , - rnK)KO3tiMM neeyno3~~ pa3~eop~, Essentiale, Vitamin B, Vitamin C rflIOKOKOPTMKOM~M B CpepHM p03M.

AenYpauMfi Ha KpbBTa - PaHHa X ~ M O C O P ~ ~ M M n F M I xe~opnan~3a. K b c ~ penypaUMR a - xe~opnan~3a 3a OVMcTeaHe Ha eHpoToKcmme. b p c n p a ~ a puypeaa ~a KaTo penypauMoHeHueTopBpaHHuRnepMopnpMneKMTecnyC a lMM n M ~0dMHMpaHa C eKCTpaKOpflOpanHOT0 OCl MCTBaHe R P M TeMKMTe. AHTM~OT Tepafl H ~M TR ~ (~TM~~H~J'IMKoJ~oB~ aHTMpOTHa BepMXHa K O M ~ H H ~ C ~ eHOCbqeCTBRBa R) n0 CnepHaTa cxeMa: 1. OCHOBHO cpepcTeo aa HacnqaHe Mnn 6no~MpaHe ~ a ueTaHon, : 5% pa3mp B 10%Sol. glucosae, Laevulose M n M Fructose. Moxe pa 6bpe npnroTseH eKc TeMnope clpea MHxemwpaHe Ha 25 ml96" cnMpT E 6aH~a wapeH p a 3 ~ ~ 0Cnepea p. pa 6bpe ~Knloqeti Ha oTpeneH B ~ H O ~

ne~ponbr M neTponHme npopytmw ca TewM MaCTHM BbmeBO~OpO~M, MaCnOBMAHMTeClHOCTM, KOMTO nPOHHKBaT B o p r a ~ ~ npea 3~a xpaHocMMnaTentiaTacMcTeMa, pMxaTenHaTa CncTeMa M KoxaTa. T O K C M C ~ poaa H ~ Ha T ~neTponae 100ml, Ha6ett3MHa20-40m!, a MaKCMMaJlHOpOnyCTMMaTa KOH~~HT~~U BM~F B ~b3pyxa I e 200 mVm3. TOKCMC~HO p e i c ~ Ha ~ neTpona ~e M neTpontiMTe npopym ce o6ycnaBR OT rOnFlMaTa MM MaCTHa Pa3TBOPMMOCT M B $ M H M T T I KbM 6ora~ Ha ~nMnMflM KlleTKM, PeCn. OpraHM (VIaBeH M03bK, ClepeH ~ ~ 0 6 , 6 b 6 p e cbpqe). u ~ , ~ C H nOABMXHM O TeClHOCTM, KOHTO npn 6naronpMR~HM ycnoeMn ce nnb3ra.r neKo no mawaTa nowpxtiom HapMxaTenHMTen m q a M MyepeWaT. Y B p e ~ a H e ~ Ha 0AMXaTeflHaTaCMCTeMae pe3ynTaT M OT OTflenmeTo Ha ronma Clam OT pe30p6MpaHaTa Ho~poaa npea 6enme ppo6oee.

q a ~ eB,

O c ~ p o~pae o M ~ ~a H c~

InaTopeHnbT: raffeHe,nospb? p o n o p o 6R ~B ~~ ~ H M R nc~xo,

npo$unaKTn~a M neqeHMe Ha 6enoppo6~n~e yepeqa HMR C: ~ P O H X O ~ M T C I ~ ~0KTehnM HH (~~H)KOKOPTMKOH~W, 6p0 HxonMTMUM - Bisolvon, Natrium bicarbonicum), KOMTO MO
raT pa Ce M3nOn3MT M MHXMaTOpHO. AHTM~MOTMK.CMMn TOMaTM'iHM CpeflCTBa: AMYPeTMK npM 6enoppo6e~ OTOH

M O T O p H a sb36ypa C KapTMHaTa Ha T. Hap. neTpOnH0 nMRHCTBO, p p a 3 ~ e ~ 3~ e rpbAHaTa KOCT, cyxa M ppas~ewa Kaunnqa,Tpaxem, ~POHXUT, ~POHXO~H~BMOHM ~P FI O , HXM-

Diazepam npM mpv.

OnMT. HHXaJlMpZlHe Ha BMCOKa KOHqeHTpa4MR - ~ c $ H OTpasRHMR C ennclpae 6e~3cl KCMR, XRnOTOHMR, 6enoppo6e~OTOK, K O M a C BP'iOBe. Oupo oTpaemie npM npMeM npe3 ycTaTa: raffetie,nospbqaHe, pHapwR, cMneH pbx Ha neTpon OT ycTaTa, rnaeo60nue M BMette Ha C B ~ Bb36ypa, , ,neTponHo ~MRHCTBO". B cnepeaqme ~ H M - .neTponHa ~ H ~ B M O H H R "neTponHa , xenaTonaTm c yuepeHa 6 o n ~ a B~CHOTO noppe6p~e M Y B ~ ~ X , ~ ~ HOT MeTMnMpaH FIT~ 6eH3MH Ca OT TeTpaeTM na60paT0pHM paHHM 38 HapyUeHMe Ha ~ ~ ~ H O F ( ~ O ~ H M T ~ nOBOTO M OpraHMClHMTe OnOBHM C b e A M H e H M R , KOMTO C( $~HKUMM. CbpbpxaT B ~ a r o p e n ~ MOTOPHM ~e ra3o~e. OT~~BFI HaCTbnBa npM pa60~a B 3aTBOpeHH IlOMeqeHMFI (~&~CT HM, ~KJlaffoBe), npM C(MCTeHe Ha TaHKOBe M Ha MeTanHl AH~MH~CTMC~HW R a H H M , CMneH pbX H a neTpOn, R 0 'iaCTM C eTMnMpaH 6 e H 3 ~ H ~~~-' Cnen -I~ MHXanaTOpel cTo po~asea~ Ha e6 e n o f l p o 6 ~ ~ yepeqaHuR, ~e na60pa~op~w KOHTaKT M nO-PRflKO npe3 KOXaTa. ~ M ~ O M ~ O ~ ~ ~ T B O ~ 3 c n e p a( a n~ o~ sm ~ u e CTO~IHOCTM ~~ Ha CepyMeH 6~nwpyClTB Ha TOKCM'iHMTe C b C T a B K M Ha eTMnMpaHMFl 613~3 ~ H H TpaHCaMMHa3H, , naKTaTfleXMApOreHa3a, neBKOqMT006ycnae~ neCHOT0 M M npOHHKBaHe M yBpeX,QaHe Ha Hep sa). H a ~ a n e pMxaTeneH ~ o6e~ npM nerponHa m e m o BHaTaTbKaH M ApyrM OpraHM H TbKaHM, 6 o r a HanMnMpHl ~~ HMR. C b C T a B K M C pa3c~poiBaHe Ha MeTa60nM3Ma B KJleTKHT( MM.

PM

Ocrpn

(onoee~)

M a s e q a ~ Ha e ~O~HM OTR 06ra3eHa~a cpepa, wcnopop c MacKa, i. v. annMUwpaHe Ha Novphyllin, Urbason, Calcium gluconicum. O w c ~ e a Ha ~ eycTaTa OT noebpttaTM MaTepMM, aKo e 6mo HanMqe noepbqaHe, M Toraea nopaKano npkl OCTPM MHXaJlaTOpHM OTpaBRHMR C neTp0n I aaHe Ha KMcnopop.AKOneTpontiwTnpopyne n p ~ e ~ n p e 3 IleTpOnHM nPOpyKTM. T ~ M K M a MRCTO aHTMAOTHO Jle'ieHM( yc~a~a-npep~3s~~ea~e~anoepaqa~ecnepnpe~eap~c CaNa,EDTA no OTHoUeHMe Ha onoeoTo. Tentio pasatie Ha TeveH napa$n~, cToMawHa npoMnaKa c p a 3 ~ ~ Ha 0 pMepwqHHcKM Bbrneti. K~cnopop c MacKa cnep

nO'iMCTBaHe Ha YCTaTa OT n0BbpHaTM MaTepMM, nPOTMBOrbpqoe~ cpepcma (Diazepam, Phenobarbital). npu TpaHcnopTwpaHe Ha ~ O ~ H M po R~ O ~ H M C I H sO aeepe~~ rnaaaTa e CenOCTaBR~O-HMCKOOTTFlnOTO,K~TOCeC~e~M3a~OBpb-

qa~e

pTa.

OCT~M OTPaBRHMR T~ HaCTbnBaT npM KOHTaKT C B H n M M ( MHTaKTHa Koxa, npes XpaHocMMnaTenHaTa M pMxaTenHa Ta CMCTeMa. T O K C M ' ~ A03a H ~ T ripe3 ~ YCTaTa e 30-50 m 1 neTanHaTa e 30-100 ml, a e 0.02 mglm3 ~ b 3 ~ n p ~ ~ e x nop.repTaHa a~a nMnoTponHocT M e KnacwiecK; XenaTOTpOnHa OTpOBa. TeTpa~ll~pMeTaHb~ 6bp30 Ce pe aop6clpaOT s x o n ~ a spaTa ~ a M ce p a 3 n p e ~ eHepaaHoue n~

nAK

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T w e uaTepnM.

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CKJlepMTe, 6on~a B 'iep~oRp06~a~a 06na0, OqBeTRBaHe H a YpMHaTa B ~%MHOK~@RBO (K~TO 6~pa). KonM'ieCT~0~0

TC- M P e H O n P O T e K T M B H O Jle'ieHMe, KOpMMpaq03aMeCTMTenHa M H ~ Y ~ M O Tepanw, HH~ noFlqbpxaHe Ha c ~ a 6 ~ n

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~HMR OTOK, i . ~ BnmaHMR . H a n p m a entiorpynoea ~pbe, npRcHo saupase~a nnas~a, $amop~ H a cbcupeaHe, Human albumin np# HapytueHMe Ha x e ~ o c ~ a s a ~ a .

eo1eqM B xenaTopeHanHaTa HenocTanrHocTca repHop~~~HMT~YBP~ a npM )KP MHXMaTOpeH ~HUR, M n M KOXeH nbT Ha npoHMKBaHe BOpeqM C a 6b6pe'i~M~e YBpeWaHMfl C paH0 HaCTbnMna 06H. B IlpoTM'iaHeTO Ha OCTPOTO OTpaB R H e C TeTpawlOpMeTaHCe @OPMFIT T P H CTWMR: 0 6 ~ 0 ~ 0 -

KCM'ieH, XenaTO-PeHaneH M Bb3CTaHOBMTeneH.

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TOKCM'iHM M ~ T ~ ~ (~MM O~ T ~M T ~ HMOHOXnOpOqeTHa O~, KMCenHHa, rnHKOnOBa M O K C a n O B aK M C ~ ~ M C HYClaCTMeTO ~) Ha MMKpO30ManHaTa OKCMAHpa~aC M C T e M a M L(MTOXPOM P450. Tescl TOKCM i ' H MM ~ T ~ ~ O ~ yBpeH(4aT M T M BbTpeKneTbi 'H M R Me~a60nM3bM Ha OpraHM, 6 0 r a ~ u Ha JlMnMflHM CbCTaBKM.

Te~atnfleCTPYKTMBHM npOMeHM no nMraBMqaTa Ha CTOMaLuHO-'ipeBHMR TpaKT, ~~MCTPO$HRH a BbTpeWHMTe OpraHM, M03b'ieH OTOK C KPbBOM3nMBM n0 MeHMHMTe.

qeHe, noepaqatie-puap~nc xeuopameti xapamep M O T n M B K MOT 'ipeBHa JlMraBMua, peXHppaTa4HOHHO-AM3enetmponmeMnreH c u ~ p p o MycKyntia ~, xnnoToHlrlR, catlnuBOCT, 6bp30 npeMnHaBaqa B KoMa c M n M 6e3 mprose, MTpa CbpflerHO-CbpOBa cna6oc~,eK30TOKCH'ieH UIOK. AKO Toea CbcroRHue ce npeoflonee, B cnefleaqme peHo-

- pnxaTenHa peaHnMauw; - ~ H $ ~ ~ UpeatinMaqw, O H H ~ ~bo6pa3e~a CM: 3ary6~-

Te Ha eopa M conw, aq~po3a~a, 1cpbeo3ary6a~a M pp. X e n aH ~PeHonpoTeKmBHo ~ neqeHwe: - MOH03aXaPMpHM pa3TBOPM, JleBYnO3HM pa3TBOPM, KOPMKOCTePOMflM, BMTIMMHM, eH3MMHM npenapaTM, @C~OPHU poHaTopM, Essentiale, Catergen, Carsil, Calcium gluconicum, opo~oea Kwcenwia M pp. X e ~ o c ~ a 3 o n p o ~ THpaqM CpepCTBa: MH4~3MpaHe Ha $~KTOPM Ha IlpoTpOM6 1 1 ~ 0KOMnneKC ~ ~ ~ 1 (OnK), $ H ~ P M H O Vitamin ~ ~ H , K, TpOM604M~Ha Maca, X ~ M O T ~ ~ H Ha @ n~ pm ~M a eAHorpynoaa R ~pba. HOOTPO~HM CpepCTBa: Pyramen, Orocetam, Vitapyracen. C H M M O M ~ ~nereHme: HO - npM KbpBeHe OT CTOMaWHOqpeBHMR TpaKT: PAMBA, Vitamin K, EACA, Decinon M pp.; - npn KOHB~IICMM - Diazepam, Phenobarbital-Natrii.

B Cb06pa~eHMeoCTPM OTpaBFlHMR C TeTpaXJlOpMeTaH, 4 a n o ~ p m64 ~ ~ eTMneHrnnKon unu flnnMpHRnnoeH nemqnfln, nemocnurpo3a M pp.
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[PM

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npoTM'iaHe -C BMCOK~~TUMT~T~T! AKOCMbPTTa HaCTbn M B mpeme racoee Ha oTpaeRHeTo, TR e p e 3 y n ~ a OT ~ OCTpa Cbppe'iHO-CbpOBa HeflOCTaTb'iHOCT, eK30TOKCMWH UIOK M HallM'ieH TaCTPO-HHTeCTMHaneHCHHflPOM, pOBenM po Texw p e x ~ n p a ~ a M up ~~ oz~ ~~ e~ nempon Hapyn~~~ weHMR M cb'ieTaHn c ~ e ~ a 6 o n m aq~aoaa. ~a B no-nce~ cpo~ cMbprra e p e 3 y n ~ a OT ~x e n a ~ o - p e ~ a yapexqan~~ HMR, PM npeOflOllRBaHeHa OTpaBRHeTO - X P O H M $ M ~ He Ha XenaTanHnTe M 6b6per~n YBpewaHMR.

Katmo npU O C T P M OTPaBRHMFl C TeTpaXnOpMeTaH. T ~ K aofleqoe peaHMMaqnoHHoTone'ieHMe 3a 6op6ac ~ K ~ O T O KCM'IHMR WOK, HapywetiaTaeop~o-enetmponma O~MRH~ M BMCOKOCTeneHHa M ! T ~ ~ ~ M auMflO3a. TH~ f l e ~ o ~ c m r ~ o - ~ e n y p aMeloam: q~o~~m - CTOMaWHa npOMMBKa C pa3TBOP Ha MeflMqMHCKM abrneH, KaTo npepn ocbqecreRBatieTo R ce paea TereH napa4n~ B KonMrecTeo 100-1 50 rnl; - orwrwenHa ~ n ~ suoxe ~ ac , pa3~~0 Ha pMepMqw& ? ~ ~ ? ~ ~ o T o K c HCHHAPOM v~H (eopeq): nomcKaHe HCKM BbrneH; Ha Cb3HaHMeTO10 KOMa (npM HRKOM 60nHbl C e ~a6nropaea - @pcnpaHa p~ype3a -3ana3e~a 6tbpewa ~ ~ H ~ M F I ;~Tynop), HapyUeHa KOOPflMHa4MR Ha RBMXeHMFITa, XOPM-eKCTpaKOpnOpanHaflenyPauMRMfle3MHTOKCMKaL(MRC 3OHTaJleH HMCTabM, TpeMOp Ha PbueTe, aTaKCMR, npeX0nepmotieanHapuannrn, xeMopMann3a, ~ap6oxe~onep$y- pHa aMaepo3a BcnepcTeMe yepewatie Ha UeHTpanHMR 3MR, nJla3MeHO ~ M ~ C H a lC ,T M H i' O O ~ M ~ H HKpbBOnpenMBaHe. O w n Ha 3PMTenHMR aHallM3aTOp ( ~ 0 3 b ~ H a KOP~). ~a P ~ ~ H H M ~ ~ HMeTOAH OHHH Ha JleqeHHe: Kap~HOqHpKyfla~OpeH CHHflPOM:TaXMKaPpMR,CHH- KappMOuMPKynaTOpHaPeaHMMaqUR; MeHMe Ha ST-cerMeH~a B EKT. npM TeXKM CnyraM -

KacaeC e 3aMHXaJlaTOpHa MHTOKCMKauMRnpMOTflenRHe Ha ras OT npenbntietiHc n p o n a ~ a y r a ~ ~ T H ~ now0 KM, YnnbTHeHH CbeflMHeHMR, ~epo6pe3aTBOpeHM BeHTMnM, HenpaeunHo mnanBaHe Ha r a 3 0 a ~ ~ ypepM. e ra3b~ ce HaMMpa Bbe eb3pyxa M npn ~ a n p a e ~ MticTanauMR, a aKo HRMa BeHTMIlauHR.

Tokcuko~ozurnu cnewnu cacmonnun 547

Ha Cb3HmMeTOp0 CTeneH collop. B ~ ~ M O W CaH W CbPpe'iHM P M T b M H M HaPyllleHHR. f l p ~ Te)KI(YITeM H T O K C M K a 4 M H 6e3Cb3HaH~eT0 pOCTblra p0 KOMa, lpomnWlBaU#l pHbl Hapep. fltlUIaHeT0 e HapyllleHO, HePMTMHVHO, IlOBbPXHOCTHO Mnll HaCTbnBa anH0e. YCT~HOBRB~T ce TaXklKappMR, rnyxn TOHOBe, PKfbMHH HaPyllleHUR,MH@PKI Ha MHOKaP flntjepeuq~anuamaruo3a pa nnn cuy-reHa penon~pn3aqn~ Ha EKT. flpn Macnatio 06ra3~sa~e 60n~nm ry6n WHaHne, HaCTbnBa OcTpa OT~~B cR BbrnepopeH H~ omc. napaJIW3aHa pUlUaHeT0M K P b d p b ~ e H ~ e T H 3a 0 HRKOnKo MMH~TM pupa. npn nHxanaL(nu Ha nyllleK c HncKo BbrneomcHo cbmpxattne Octioatin ca yapeWaHnma tta 6enwre ppo6oee: AMCnHeR, nOBbpXHOCTH0, HepMTMMqHO pUluaHe, Cneluuo ~ O ~ H H V H nereHHe O MbrwrenHa a 3a qnaHo3a. flpn ayclcyma4HFi C e K O H C T ~ 6po~xocna3b~, T ~ ~ ~ ~ BnaXHMH CyxM XpnnOPyramem, Manitol18% panmp, Sol. glucosae 20%, Be. Hannye e 6eno~po6e~ 3ac~oh, OTOK nnn OCTPO 6enoVitamin B,, B , C. flpn a~aapo3a ce npnnarax~nep6apHa Ha 6 0 n ~ ca n~ c qepeti UBFIT. OKCMreHa4MR, Dusodril, Dibazol. K ~ P ~ M o I ~ ~ ~ T ~ MK T M ppo6~o B H o cbpqe. Xpav~me fla60paTopHo C e YCTaHOBRBaT: XMflOKCeMMR, a4MflOKappuoToHnqHoneqeHne- Isolanid, Atrifos, Cocarboxylasa. 3a, xnneprnnKeMnR, rn~o~oqpnrr, ~ap6o~cnxe~orno6 HeMnR. Cmpna Hamnea npn Hnm Ha ~ap6o~cnxe~o no6n~a ~ a 60%. p

O~MKHOB~HO ce nocTaaR nectto, K ~ T O ce n3xonga OT no npaeuno 6naronpnm~a. O~CT~HOBK~ BTKORTO ~, e IlOCTpWan Ilal&WHTbT.TR Ce I l p o Q n n a m ~ as~nloqm ~a ocnrypmtie Ha TernwenopKpenRoTxMunrHmenpemreHoewren3cnepaa~n~. c~a~a~anpa~~oc~~araao~n~eypepn;npo~e~p~~a~e~a noMeqeHnma.

npono3a

flocrrpa~lannrrr ce n 3 ~ a m OT 06ra3e~a~a cpefla. KncnopopHantixanaqnn, B K J . I n no BpeMe HaTpaHcnopTa: npw Orpa~~~n HamnBaT ma npn HemHo ropeHe B noHapylueHo puLuaHe - n ~ ~ y 6 a qn w06pnluea~e. ~ Sol. MeUeHHR, OTOllnFlBaHH C BbrnHll(a, MaHTMM, caMOflenHM n a p ~ ~ o ~ o n n e ~ n ~ ~ n n r a 3 o ~ n n e ~ 1 ~ n , n p n ~ sglucosae n o n a ~ 10-20% a ~ e ~ a100-150 ml i.v., Urbason 60-80 mg i. v. M/M~ Novphyllin M 0.24 (np# 6poHxOcna3bM). ~ M Y ~ ~ T r a 3 0 ~ ~ 6 0 i n e nnn p n npn non3~a~ero Ha KoKcoe, poMeH npn 6enoppo6e~ OTOK. M n MCBeTWleHra3BnpoM~LUne~~Clla. Te B ~ ~ H M K M BnpM ~T racetie Ha noxapn, sapnmee n RP.

flpoaewa ce c KncnopoAHaM~xana~~f1,6poH~~a naeax M acnnpa4n~1, anapaTHo o6~nluea~e, ~~11ep6apHa flYWeKbT BbrnepOflH#RT OKHC IlPH'iMHflBaT XMIIOKoKcnreHaqnR, o 6 u e ~ ~ KpbmnpennBatie, o MepnKaMemn CMR Ha BCMqKM HMBa - B 6en~Te ppo60Be nOp~n3aTpyflcpeqy ~ o 3 b r U ~6enoppo6~n~ n~ OTOK, opraHonpoTemnHeHIOCTbn Ha Bb3pyXaOT 3anyuJBaHeTO Ha ~ P O H X U CbC T~ Cmtl, O T O K a Ha nLlraBM4aTa M ~ P O H X O K O H C T ~ ~ ~ K ~B M R T ~ ; BHM cpepcrrea, amn6no~nqn. KpaBTa nopmn o 6 p a 3 y ~ a ~ Ha e ~~ap6o~cnxe~orno6n~ o n HeBb3MoxtiOcT 3a npeHacRtie Ha mcnopopa; B nKaHwre flpn n e m e cnyclan e po6pa. TR e ~e6naronpnma IlOp~bl 6noK~paHe Ha 4UTOXPOMMTe H 4HTOXPOMOKCMAanpunHToKcnKaqnme,npoTeKnnc npomnmen~o6e3cbaa~a B KneTbrHaTa InxaTentia sepnra. sHaHne M C TexKn 6eno~po6~n yBpeyqaHnR. Cnep npeXMBRHO TeXKO BbrJleOKHCHOOTpaBRHe HRKOll OT 60nHL4Te pa3BMBaT HeBpo3a, IICMXOTMqHM CbCTORHHR, eHflOKPMHHM HapylueHnR, aHeMnu n pp. Tean C~CTORHMRce npueMaT KaTOKbCHM n~RBHHaBbrneOKlrlCHaTaHHTOKCMKa~HR.

rb6HMTeO T p a B R H M R ca XpaHMTenHU O T p a B R H M R OT He6amepnane~ npo~3xofi. Hamnea~ cnen KoHcyMaqmR m AnsopacTRqn r b 6 ~c ,a m p x a q mpa3~006pa3~n no XMMMreHCbcTasToKcMrtiHeeqecm. J l a ~ e w ~ nepMoR ~ m (speM e T O OT rb6HaTa K O H C Y M a l & l R A0 WpBMTe lUlHHH'+HM npM3~aqn Ha o ~ p a w ~ M e yapewaHnma, ) KOMTO HamnsaT OT ~ e TOKCH~HM 3 ~ Beqemaa, onpepenm Aae octioatin rpyn~ rb6~n OT~~BRHMR c: Abrrbr naTeHTeH nepbfop M c KpaTaKnaTetmeH nepnoA. OT r b 6 ~ m e oTpaeRtiMR c mmr (npomnmene~) naTemeti nep#op ~ a h - r o n a ~~o a r e 3a ~~ KnnHnvHaTa e T O K C M K O n O M RM M a @~O#~HOTO ~ H OTpaBRHe. O

na60paTopHM n p U 3 H a I # l :

XeMOKOHl@HTpal&lR, MeTa-

60nm~a aqn~o3a,A M ~ ~ ~ ~ K T ~ ~ ~ M xT ~~ ne Mp M 6F mI ~ , py~ M H ~ M M RnotiMxaeaHe , Ha cepyMHaTa xonMtiecTepa3a,

BMCOKM C e P Y M H M TpaHCaMMHa3#,eKCTpeMH0 BMCOKM C T O ~ HOCTM Ha ~ ~ K T ~ T A ~ X M A P O xMnonpoTeHHeMMR, ~ ~ H ~ ~ ~ T ~ , HMCKM C T O ~ H O C T Ha ~ ~ P O T ~ ~ M ~ H HBpeMe O B O A0 0, H M C K M CTO~HOCTMHa ~ $ M ~ P U H O ~ noBHtuasaHe ~H, Ha natcraTa M nMpyBaTa, Ha aMOHRKa, YpeFlTa M KpeaTMHMHa.

Ilpww~~leaceo~ rpyna~a~a$amw h~ e n(Amanita phalloides, Am. vema M Am. virosa), KOMTO no ~ T ~ H M rectm 6enean, MecToHaxoAnqa n C ~ ~ O H H O C ~anono6~1T saT RNneMTe n c p d p u BK~COBMKavecTaa nueqHa M noncKaneryp~a (AgaricusarvensisM Agaricus campester).
np# @ o J w lH M T e rb6n CBbp30aC flea BMAaTOKCMHM

V~H@~K~MO ra ~m ~H p o - e ~ ~ e p o ~ BWPYCHM o n ~ ~ , xenaTMTM, OCTPO OTpaBRHe C TeTpaXJlOpMeTaH.

- aMaHMTOTOKCHHH H(W~OTOKCMHH, KOMTO I l O p q M ~ 3 6 ~ paTenHaTa CM TOKW'IHOCT cnpmo repting ~ p 0 yapex6 AaT Herosirre cTpylcrypHn e4ntiMqw M 4 y q n u .

npe~n3an~eH aa ~noapbqatle. e C ~ o ~ a npouclew~a Ka C Bona M n M C BoAeH pa3TBOP Ha MeAML(HHCKMBbrneH. Adsorgan per OS. OclMCTMTenHa MM3Ma. ~ ~ O T ~ ~ B O W O K O B KoKT~~ BKllIOclBaHe ~M, Ha rnIOK03HM p a 3 T B O P M C BMCOKa

Aosa, Vitamin C AO 1 000 mg M Urbason 40-80 mg.

C T O M ~ U InpoMMBKa H~ H e 3 a B M C M M O OT BpeMeTO Ha IlOCTbnBaHeCnep fi6~aTa K O H C Y M B U M R .OC~MCTMT~J~H MM3Ma, MOXe C pa3TBOp Ha M e A M U M H C K H BbrneH ( M M OTHO~ L u e H M eK ~ e M ~ ~ e p o - x e n aKpbroepaT ~an~~~ Ha ~ ~ ~ O M A H Te 1 7 ~ 6T ~ O 1 K C ~ H ~Adsorgan ). per OS. h p c ~ p a puype~a 3a, K ~ ~ ~ O X ~ M O ~ ~ M ~C Il a C $T Y H i 'H ~O MO R~ M ~ H H KpbBollpeO

nMsaHe K a T o ~ e ~ o ~ a a ~ e ~ o ~ c ~ v ~ a ~ e n y p a q panHaTa cpeAa. Kap6oxe~onepf$ya~~~a ce npoeewa B nbpBMTe 12-24h CneA K n M H M i H 'O T O Ha'iaJlO Ha O T P a B R H e T O M Moxe pa ce noeTopM B cneAaaqMTe 24 h. C l a c r ~ v ~ o ~

o6we~~ KpbBonpenMaaHe o ce npaecl c efitiorpynoea ~ p b a e KonMvecTBo 1 200-2 500 ml HenocpeAcTseHocneA Kap6oxe~onep$y3~ma U Moxe Aa ce noeTopHB cnepeaqMTe 24 h. Ilna3~a4epe3a~a e MeToA Ha u360p npM 4 a n o ~ ~ ~ TO B ~ H OO T ~ ~ B F no IHO ~T H O L U e H M e o6pa3yBaHMTeT O K C O ~ poTeMHoeMKoMnneKcM B xyMopanHaTa cpepa. TRMoxe Aa ce MBB~PWM H cneA 24-36-MR h cneA Ha'lanoTo Ha oTpaaRHeTo. AHTM~OTPenicillini.v. ~posa24-48 MnH. U A O ~ A H M
CneA W I M H M V H O T O HaWJlO H aO T P a B R H e T O . C ~ CbLL(aTa C uenAzlocillin B p o x i 12-24g (24 h-TPM C)HM). M H @ ~ ~ M O H

TponwHn pansopn i.v. llpe~n3ern~~ace noepbqaHecnen peaHnMaunR. Kapfl~~qbIplcyna~~pHa peatinMaqnR3a h p K0 o n n r m o sa~onne~a Bola npea 6a C eK30TOKCM'iHMR UIOK. ~ ~ M ~ C T M T ~ ~ H O - K O P H M Aaeatie P ~ ~ ~ Ha 0 6 ~ 1 ~ ycTaTa (o~ono 500-1 000 ml) nnnce naeaAdsorgan 2-3 r. TepanHR no oTHoluetine $amopn Ha cacnpeane, sary6a n. npn Bb3MOXHOCT- CTOMaUIHa IlpOMHBKa C Pa3TBOP Ha Ha KpbB, XMllO~pOTeMHeMMR, HapylueHMR Ha al'lKal'lHOKMMeAnqnHcKn BbrneH. Bmlorea ce npoTnBoKonanceHKOKCenlrHHnR MeTa60nbI3bM. OpraHOnpoTe~q~R Ha clepHMR pp&, 6b6peqwe, M03bKa M CbPueTO. Xwnep6ap~a OKCU~ e hc n500 m 1Serum Glucosae, Effortil, Urbason, 60nHnRT reHoTepann~,xnnepoKcnAaHT~~besn~o~~~o ceHacorea~b~cTauuoHapHonereHne. 3~,~~~0~~ A O ~ MVitamin C ~o 2 g 3a 24 h, ~nomoea (n~noeea ~~cenn~ Carsil a ) , (Legalon), opoToaa KMcennHa (Orovit). CTOM~UIH~ IlpOMclBKaC BOfleHp3TBOp Ha MeAUL(MHCAHTM~HOTM~M 3 5 1nOTHCKaHe Ha 'ipeBHaTa aMOHnOreHe3a. KM BbrneH. CMMHHOorncTnTentio - Magnesium nnu CHMI~TOM~TM~HO Jle'ieHMe. i. Natriumsulfuricum, p a 3 ~ ~ o p B e150-200 ~n ml eoF(a. CHMIlpor~ma moMaTnrHoneretine, ~ O ~ K O ~ C ~ O KcpeAcm, O R B ~ ~ W~ CTPMHreHTHbl CpeACTBa, ~HTW~HOTMK, aHTMllHpeM4M. KOpnMpaHe Ha RexnlpaTaqnma n ~n3enemponwe~nma MH$~WOHH~ p e a ~ n ~ a qsmloreaqa n~, 3aMecTnTenHoKopuMpaqaTepannR: B~AHO-enemponmn MM O H O ~ xapnAHn pa3reopn B ~ a s n c n ~ OT o cBOUHO-enemponm ~ HnTe 3ary6n, c ~ o m o 60n~nm nomnea 3a neretine, rb6~nm npmameeHrac~po-ewepo~onw npeflcTaeKalum chloridumoco6e~o npn noflrepTatiAnapnreti CMHI l R M 11 A 0 21% OT BCllVKH BHAOBe n 6 OTPaBRHHR. ~ ~ ppou. l l p o ~ n m ~ o n a n~omehnm. c~n nompxaqa n~$yHa~~bnBa CneA KOHCYMauMfl Ha flHBOPaCTRqMTe n 6 ~ : B M O H H~epannfi ~ c n~$y3npa~e ~ap a 3 ~ ~ oB pKonnrecTBo u repeeHKa ( 6 ~ c n6a) ~ a - Russulaemetica, nbmnea ~ n e oKono 1 500-2 000 mu24 h. rtinqa - Lactarius torminosus, AmoncKa n 6 a ( o ~ p o a ~ a C n ~ n ~ o ~ a nerettne: ~ n r ~ o Almagel, Cimetidin nnn ~ a ~ a ~ ap Bolletus ~ a ) satanas, oTposHa CM- onostia Ranitidinnpn onnaKsaHnR OT 60nw B cToMaxa; ~ e a n ~ $ e n6a(o~poae po~@nnyc) ~ - Rhodophylussinnatus. Tean m a m Ha V ~ ~ B H H Tpam R npe3 ycTaTa (Chlorquinaldol), b 6 CbAbPXaT ~ CMO~YICTO~OCIO~HH T ~ ~ M o C T ~ ~ BeH~HM a,qmpnHremHn c p e ~ (Bismutannalbin, m Sulfaguanidin), qec-rea, Kamo H ~ n e r ~ o n 0 ~ COKCW 0 6 e ~ cnnHo roprnB M Chloramphenicol3anpo@nam~a~a~mn~n~en~ ApaaHeq slcyc. Pacra~ npes n p o n e ~ ~ o - n e ~ ceao~. nn~ eHa ~ H $ ~ KaHTnnnpeTnun ~MR npn TeMnepaqpa. C M O ~ M C T O ~ OTOKCH' ~ O ~iH H nM BeqeCTW, T~ K O K O npbl TepMnrHa KynnHapHa 06pa60~~a He ce paarpaxqa~, Kamo M~GK~~W n6uo HOB Ol'paBRHe O MM~~'~HO~O~~ COK, ~ H npefl M FM I 3BHKBaT T HpHTaTIIBHMH3n p n r n ~ ~ ce e a OT CneAHwe n6n: Amanita muscaria MeHeHMR no JlMraBMqaTa Ha CTOMaluHO-'IPeBHMR TPaK C (repae~a~ y x o ~ o p ~ npeAcsaanTen a), Ha ceue9c~ao xnnepeMnR M noBnlueHa cny3~ac e ~ p e u n H~ycnneHa Amanitaceae, p o Am. ~ Hooker, OT m6n npenmaawennHa nepncTanTnKa. ce~ehmm Tricholomataceae, p o Clitocyle ~ (roprnea MnJla~eme nepwoA: ~ KpaTbK (OT1 AO 3-4 h), P ~ K O pn3nns~a Clitocyle olearia, mrpoaa n 6 a TricholomaM~RB~ cbc H cro~alu~o-rpee ~~HCKOM@PT e~ B pardinum) M c e u e h m Cortinariaceae,p o lnocybe ~ (Banrn KOpeMa M 6 b p 3 0 n p e ~ ~ 0~ O~ ~~ KH). 3b6 - lnocybe patonillirdii).
,

exem em

C ~ o ~ a unpoMnBm, t~a Adsorgan per OS, Eqyw-eneK-

fla~emnm nepnofl e W T ~ K -OT 15 minflo 11-12 h.

HRKOW ~ O ~ H npna~aqme H m oTpaeRHe 3anoqeaT Owe IW BpeMe Ha r b 6 ~ a K ~ O a H c y M a l & l R . 06Ll nHO M3IWTRB a H e CM: cryneHa n nolcpmac noT Koxa, 6ne~a, HacTpbXHana. O6un~o CJllOHOOTflenRHe, Cbn30TeCleHWe, MU03a, 6 p a n ~ a p f l #6poHxo~na3bh4, ~, OTOK H a 6enn~ ~ ~ 0apTe6 , pnanHaxnnoToHnR,aplrr~n'I~aCbpfler~aflekm, KoMa, yMepeHw no nunceaqn racTpwremHanHn RsneHnR nOBpbqaHe, eflMHM'IHH flblapH'IHLl M3XO)IWaHHR.

np

PUOfl OT 1-3 h CneR b 6 ~ a ~ KOHCyMal a #lR. 6b~peLUHa HanpemiaTocT, ncuxoMoTopHa ~b36yfla, Mnppnam, ~axnKapAnR, 3 a r l e p a ~ ~ a Ha ~e KoxaTa Ha nuueTo, flennp c XMlOl(MHa~MM, T O H H i H 'O K n O H W C I H U BP'iOBe, KOMI. B HRKOM C n Y C l a U PeTeHuHR H a YpHHaTa. CK~OHHOCT OM KO-

nanc.

Auamoc
flaHHn 3a n 6 ~ K a O H C y M a u M R , MyCKaAH~I P U H O BChnuvum. IluilBHn C C ! P a H O Cnefl K O H C Y M a u M R T aHnH

no ~ p e ~

a.
BlH01

D@epel
C

oTpawHe c $oo$opoopra~n.~~n nec~nq#fln nnn OCTPM O T p a B R H H RCX O n H H O M H M e T M 4 H .

n o m c ~ aH ~a e~b36yfla~a c Diazepam, n p e f l n 3 ~ n ~ ~
He Ha noapbqaHe, cToMalutia npoMnBKa.

do60n~ns~o noaeAeuwe n neveune

npefln3an~~a ce noapbqaHecneuBatme ~a&HO CTOM~U IlpoMklBKa H~ C BOfleH pa3TBOp H a MeflHuUHCKonnrecTao eofla per OS. CTOMWH~ npouuaKa c paneop KW BbrneH C OMacneHa coHla. C a n n ~ ~ O'InanTentio. o Ha MeflnL(uHcmBbrneH. Atropin KaToaHTuAoT S. c. nnn i.v. , Pyrarnem. Y ~ e p e $opcupa~a ~o np#TeMn MYCKaplHOBHR B n e H H R . 3a~0nnRHe H ~ ~ O ~ H M R , Syntostigmin, Vitamin B AUype3a, CllMnTOMaTMClHO neCleHMe Ha I l C M X O M O T O P H a T a Ramtie Ha Tonnu TevHmn npes ycraTa, n~$y3upa~e Ha Bb36yAa, apTepnanHaTa XunoToHnR, npvoBeTe. npu KOBOBHO-ene~rponm~n pweopn. nanc A a ce atinMaBa c aHanemnuuTe ( ~ ce a nsnonssa~ Cneluuo 6 o n ~ n r ~ nerleune o Te3ll C n0HUXeH ll~p'I0B e@KT - Effortil). CTOM~LUH~ n P O M M B K a ,C a n U H H OO ' I M C T U T e n H O , HH$Y~ U O H peaHnMaqnR, H~ attTnRoniaTepannR -Atropin, y e HHTPOHAHO b 6 ~ OTpaBRHe 0 peH0@p~~paHafl~ype3a, CUMtlTOMaTHclHOne'ieHUe. 0611KHOBeHO Cnefl eAH0KpaTHa allnldKaunR H a Atropin MyCKaP U H O B U T e RBneHMR HaMaRBaT U J l H U3Ve3BaT. OT~~BRH HaCTbnBa ~ T O Cnefl K O H C y M a u M RH a RffnUBaTa H HeoTpoBHa m6a KonpuHKa (Coprinusantramentarius) npM eflHOBpeMeHHa UJlMn0-KbCHaK O H C y M a & R l Ha anKOXOn.

To~cnruo ueimne

TOKCM'IHOTO W~~CTBK OO , ~TO ~ b n~ H p Z~ I T ~ ~ K ecxo~H ~aoflucyn$upa~aU npoRaRaa Emonorun ceoeTo flefim~ue caMo npn Hanuwe Ha anltoxon. Sno~upace pa3rpaxqa~e~o H a MemuqHHti uflnpo4yk-r OT ~ e ~ a 6 0 ~ ~ P ~ B Ce R npH' H~ IcilHRBa T O OT AHBopaCTRqaTa m6a n u 3 n p a ~ e ~ o ~ a a n ~ o x o n a ucenonyra~a~a~ Arnanita panterina, npeAcTaanTen Ha c e ~ e i c ~ a o annexuRHu Tena. Amanitaceae, p01Arnanita Hooker (nawrep~a nnn neTtinC T a M~~oMo~K P ~~ ) .c BbPy T ~ IlO'iBH B UIUpKOnUCTHH, urnonncTHu n cweceHn ropn npea neTHme M eceHHu Cneq 10-20 min (npoflbnxu~en~oc~ Ha naTeHTHuR MeCeyM. no ~ O T ~ H M ' I ~ 6enean C K We C X O A H a Ha RmUBaTa U C flo6pu BKycoan Ka'IecTea 6ncep~a rb6a (Amanita nepnofl) OT anKoxonHaTa KoHcyaqnR ce nomma 3aqeprubescens). erraatie KoxaTa Ha nnqeTo U r p b f l ~ u KOLU, ~ AnulaHeTo ce yrecTRsa, noHRKora e cbc cnacmreti xapalcrep. T a x ~ ~ a
H a KonpnHKaTa,

OCHOBHOTO T O K C H I 'H O Wll&CTBO e M M K O a T P O n H H b T . b p 3 0 ce pemp6npa, flelc~aa mpxy M-xonn~opea~~uaHwe cncTeMn n npmo abpxy UHC. H~rn'~ea ce npea

PflMR, apTepHanHa X U n O T O H U R M n UX M n e P T O H M R , C W I O H HOCT OM Konanc.

66peuwe.

Knnumua Kapma
OT~~BRH ce ~npoRBFlea TO cnefl ~
M T ~ naTemeH K ne-

I l p e f l n a ~ ~ ~ce B anoepbqaHe 3a en#M#HnpaHe Ha npMeTMRanKOXOnHeBeHTyanHMOCTan~MOTKOHCyMMpaH H T e rb6~. C~~tJalllHa n p O M M B K a C BOpa MnM C BO#H pa3TBOP Ha MeflHuMHCKM BbrfleH. O C ~ M C T H T WIM3Ma. ~~H~

Sol. glucosae 10% M n w 20h i. v.

CTOM~W IlpoMMBKa H~ CM e f l M q M H C K MBbrneH, C a n M H H O oqwcTmenHo, oqncTMTenHaKnMaMa, pepe~a4opcnpa~a fl~ypeaa, ~ ~ D K O ~paamop~ HM i. V., Vitamin C, npoTMBoKonancHlr ~oweunn c rnK)KoKopTHKouflu,Effortil, Diazepam
3a noTwcKaHe H a HanpemtaTocna.

HarneflHMMaTevanHflaCe I~PM~~OMHRT OTHOBO 60TaHMreCKMTe O C O ~ ~ H O C T M Ha RmMBMTe flMBOpaCTRqM r b 6 ~ M 0~06eHoCTMTe Ha T e X H M T eO T W B H MA B O ~ H H ~ M . 3. i l p BCRKO ~ nsnw3aHe 3a r b 6 na ~ ce 6epa~ c a ~ OT o e A M H BMfl. 4. B c ~ Ke #~ 3 e ~ n n ce ~p npernewa ~a BHmaTenHoOT Cne~MailMCT;C b M H M T e n H M T e r b 6 Aa ~ He Ce M3nOn3BaT 3a

xpatia.

n p o @ ~ n a l r rHa ~~ Ia % ~ H MoTpaenHHg T~
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BMpyanHaTa'iyBCTBUTe~HOCT, P e m THa IlpoRBUTeHa C M M n T O M U T e3 a B U C H OT n b T RH a IlpoHMKBaHe Ha OTpoBaTa. OT~~BRH C~OOC T O npOTM'ia B 3 CTeneHU (no A. MOHOB): neKa, TemKa H MHoro TexKa U B 3 K~UHMVHU $OPMU B ~ ~ B M C M M O C OT T npeo6na~1aeaqme cunnmoMM. ilyn~o-racrpo-~~~ecrn~an~a: raJIeHe,noepbuatie, AUapMR, K O P e M H M ~ O ~ K CBeTOBbPTeX, M, rnaBO60nMe, nCMxoMoTopHa ~b36ypa, M U O ~yMepeHa ~, canMBauw n ~anoTmaHe, 6enoppo6e~ OTOK, ~ s p a s e B pa3nwv~a ~ cTeneti. flynwo-~o~syncne~a (~e~a ncMxoMoTopHa ): ~b36yIa, $ ~ 6 p ~ n noTpeneaHm, ep~~ PRAKO KOHBY~CMM Ha npwCTbnM, CbWTaHUC M3flOTRMHe, CanUMUMR, MU03a, 6enoppo6e~ OTOK, HapyuleHMR Ha Cb3HaHUeTO 40 COnOP M K O M B . napannmr~a #op~a (~paii~o e x ~ ac)a:n m ~ u u ~ , KoMa, M U O ~ 6enoppo6e~ ~, OTOK, 6 y n 6 a p ~ U~ ppyru napanU3M, W C T Oe K 3 0 T O K C M V e HW O K , BaPMaHT Ha IlapXIUTMCIHaTa @pMa e Cne~MHTOKCMKa~tlOHHWT napallMTU'-leH $~HOM~H napesu : MnH n a p a n ~ Ha s ~10-14-Rp,eH OT oTpaB R H e T O( P ~ H ~ TM H~ U )n M Ha 14-28-R#H ( K ~ C T ~M H~ ) . H a 6 n ~ ce ~ a pa3~006pa3~e ~ B KOM~MH~~M H a RT~ KnuHuwwTe $OPMH H ~ nocnepoBaTenHo M npeMHHasaHe or eRHa B cnefpaqacTeneH. Ha6no~asace U p e y ~ pHa u~ C M M m O M U T e Ha O T p a B R H e T O Ha 6-8-R #?H, BbnpeKU po6pe opra~w3wpa~o~onere~ue. n p # r # ~ anpoTpaxwpaHa pe30p64MR M n M 3a6aBeH0 ~ u o T ~ ~ H c @ ~ M u ~ ~ H ~ . Onuca~ e ur~3o$pe~onopo6e~ CUHAPOM cneA u3nu3aHe OT napaTMOHOBaK O M a C npOAbnXblTenHOCT 2-3 F ( H W U npoTpaxupaHa ~ppe6pacTeHM~1, KORTO u 3 ~ l e 3 ~ ~ aa i 6ae~o. Ha6nopaeace M ~ ~ ~ C M M ~ T O MM H n M O neK0 np0TUraHe Ha oTpasmeTo npu Hyneau C T O ~ ~ H ~ CHa T MXE. KOHHa pe30p64MR C IIaTeHTeHflePHOfl MOXe fla Ce O % K M TeXKO C b C T O F I H M e . C b M H e H M e 38 OTpaBFlHe C OOC ~O~HHR fla T Ce O C T a B M 1-2 A e H O H O q M R non neKapCKM K O H T P O n . fla60pa~opHM IlpoMeHM: IlOHMXeHMMnM HyneBMC T O ~ HOCTU Ha XE, HeKopecnoHpHpaupI qecTo c Texecrra Ha OTpaBRHeTO. ~ ~ B HOpMaJl H O M3UpaHe Ha $epMeHTa. B CepyMa MoraT pa ce AoKaxaT QOC, a B ypuHaTa napatiu~po$e~o Bn HRKOM cnyqaw. O c ~ a ~ a noKa3aTenu n~~e no~ a s e ~ecneqrn$wi~# a~ npoMeHM.

B R H H R OT WH)PHH C b e A M H e H M R M H H T P O 3 H M ra30Be; no O T H O W e H U eH a rbP'4OBUR C M H A P O M CW l O P U P a H M BbrneBOflOpO~M; npM K O M a T O S H O CbCTOtlHUe C M03b'ieH MH-

CynT.

C T O M ~ UIlpOMMBKa, H~ M e f l M U M H C K M BbrneH, CmMHHO orMcTwTenHo U TereH napa$w~150 ml npu npneM H a oTpoeaTa npea ycTaTa ( M H T ~ ~ ~ ~ MnpepM F I T ~Toea e s a p JlXUTenHa npM KOMBTO~HO C ~ C T O R H M ~Toane~ ). Ha KOXaTa c n~pu$epe canyw, ~~~~ pa3pe~e anKoxon ~ unu 5% HaTpMeB 6M~ap60Ha~ npM neplcyraHH0 npOHUKBaHe. ToaneT M nPOMMBKa Ha OCIMTe, OTcTpaHRBaHe Ha ~ O ~ H M OT R o 6 r a 3 e yracnK ~ ~ ~ U MHxanauMR C K M C ~ O P O ~ npM , MtixanaTOpeH npUeM. Moxe Aa Ce B K n I O ' i M nbpBa A03a aHTMPOT Atropin, X O ~ M H ~ C T ~ ~ ~ ~ O ~ ~ ~Kano K T UM M cnewtio T O ~ , CMMnToMaTMrtio neqeHue (~ynupa~e Ha rbpr, WOK M n M RMXaTenHa H~~~OCT~T~CIHOCT). 6bp3 M po6pe OpraHU3MpaH TpaHCnOpT Ha ~ O ~ H U R .

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~O~HHFC I TT e M O OTpaBRHe CneWHO T P R ~ B C(a ~ 6b~e HaCTaHeH Ha Tollno nern0. 1. A H T M ~ O TTepaIlUR H~ C ~ ~ Y U $ Ua H ~T ~ U A H O T e Atropinurn sulfuricum nplr TexKuTe i. npea 30 rnin A0 npeOflOllflBaHe Ha MyCKapMHOBMRT M n RBneHMR M n M po RsneHMR ~ a a ~ p o n ~ ~ ~ 3CneA w p aToea ~e. ce npunarai. m. no cxeua: Ha 4 h no 1 rng no a~ponw~u3wpa~e or ~ a fl03a; Ha 6 h no 1 mg p0 BbXTaHOBRBaHe Ha XEA.

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Xon~~ec~epa3opea~~u (PAM, ~a~o Toxogonin) p~~e cenpMnaraTcaMonpesnbpsuTepeHoHoqMaHaoTpaanHeTo (~~a6MnM3MpaHe Ha KounneKcaOOC-xonu~ec~epa aa cne4 TOM): PAM - no 500 rnl B 500 rnl Ser. glucosae K a n K O B OB e H O 3 H OA 0 2 000 m1124 h. Toxogonin 3 rnl/kg i. V. npu H m a npes 2 h. 2. nnxa~en~a peaHMMaunuc KMcnopop M WbnxuTenHa M H T ~ ~ ~ Unpcl M RKoMa, rbpq Mnunapeaa HapMxaTenHaTa MycKynaTypa.

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coqeimaa~ (Thiopental, ~ Methohexital, Tiamilal); c KpaT ~ K ebem (Nembutal, Sekobarbital, Hexobarbital); cpefl~oKbcoflei4c~Ba~M (Arnobarbital,Aprobarbital); c npomnm e n e H e b e ~(Barbital, r Phenobarbital, MetabarbitalMAP.). K~HHMC~HMRT e $ e~ ~ ~~B U C OT W a 6 c o p 6 q ~ MM, ~~a pasnpefleneHMeTOBTbKaHMTehKOnHCleCTB0TOHaaKTMBHMTe M~T~~O~a M npopbnxmenHocrra TM, H~A~~CTBM HeBM~TO Ham Kopenwpa cbc cKopocrra Ha enMMwiMpatieTo MM.

TOKCHVHO AB~CTBH~
~ P O H W K BnapeHTepanHo ~T Mnu npea ycraTa. Peaop6-

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BKJleTKMTe, 6 o r a Ha ~~ M a a H M H M ,6 ~~BMCMMOC OT T MaCTHaTa MM P~~TBOPMMOCT. Yn~paKbcofleic~~aqn~e ca cMnHo ~ M ~ O ~ ~ ~ T BMO ce~pa3npeflenR~6bp30 M M M B CMBOTO ~ 0 3 b 91-10 BeuecTBo. n o - ~ a n ~ ~o M ~ O ~ ~ ~ T B O~ M Phenobarbitaln ~ p aKyMyn~pa~ . nodae~o B ~ o 3 b ~Haia.

BHCOKaTa M M KOH&HTpaqHR B HeMaCTHa E K a H e HaMepeHa B repHMR ~ p 0 M 66b6peuwe. PhenobarbitalnpeMwnaBa 6bp30 npea nnaqenTaTa n aKyMynMpa oKononnopHaTa T e C l H O C T . MeTa60nt43MpaHeT0Ha 6ap6mypa~~~e ce M3BbpluM B tmeTKHTe Ha C l e p H M R ~ ~ 0a6 e1Ha , ram ce ennMMtiMpa HenpoMeHeHanpea 6b6peqme. 70-80%OT KonwveCTBoTo Ha 6 a p 6 ~ ~ y p C ano-ManKO ~ ~ ~ e OT 3 BbrneBOflOpoflHMaT0M a B cTpaHMrHaTa BepMra ce ennuMtiMpaT HenpoMenenM, a ~ e C3 noBeqe ~ OT 3 aToMa B 60-70% ce nHameMpaT B reptim ~ ~ 0n6 pe . napa~~ c~ KMcnoponeH e aToM Ha 4-TO MRCTO ~ e ~ a 6 o n ~ B 3M ~H pKa~~ ~~OM H M ax Te ~n a ~ o q ~a ~a, c S- TOM - B ~ p y m aeetia (nnas~a,MycKynM M np.). nopqw nnflylcqnR Ha xenaTnanHme ~ H ~ M M neKapcTBa M KaTo atrrMKoarynamn, Digoxin TPM~MWIMC~HM amuaenpecanm, KopTnKoCTepoMnM M lp. yaenMramT TOKCMC~HOTO MMAeacrsue. B TOKCMCIHHflow 6ap6~~ypa~we ce O ~ ~ c nrnas~o pa~ B KJleTKMTe Ha M03b'iHaTa KOpa, M e 3 e H q e @ I l o H a M cy6~anauyca, nomcKaT UHC U HopwpenepmwaTa ammHOCT. HapyJafBT~ ~ ~ C T B M Ha ~PeflOKC-eH3MMHaTa T O Bepnra B ~ B ~ H O T Ha O $ n a ~ o e ~ 3 ~ ~a~annawpa~ ~we; cclrrre3aTa ~ a 6 e n n B qCIePHMR ~ 1~06 YBpeWaT ; O K M C n R B a H e T O Ha rnloKo3aTa M nwp0rpoqenaTaKMcenvna. BCM~KO TOM e npMrMHa 3a Hapyluaaatie Ha C ~ ~ H ~ H M 3 ~q TO pb . x~me npoueCM IlpeMMHaBaT 3aKOHOMepHO OT KOpaTa KbM nOflKOpMeTO M IlpOflbnrOBaTMfl M03bK. npeflM fla npeAM3BMKaT K O M a T 0 3 H OC b C T O R H M e 06acle H R K O M 6ap6n~ypa~n MOraT Aa noTHcKaT ua6npa~en~o qeHTbpa Ha AnwaHeTo, KoeTo e VecTo npu.cMna aa CWPT Ha naqMetiTa 683 BetiTmaqMO H H a n0AqpbXKa. BHCOK~ 6ap6~~ypo A03a ~a n 0 T M C K a c b ~ o cKeneTHaTa MycKynaTypa, cbpAerHnR nnycKyn M T a C T P O M H T e C T M H a J H M RM O T M n H T e T(A0 Mneyc). B MMHMOTO ce cMmawe, rle 1mg% 6ap6llrrypaT B Kpbera npnvnmBa K O M a ,R H e CT a 3 M flO3MpoBKa Ce pa3luMpflBa. O C T P MO T P a B R H H RK J l M H M C I H M T ee@KTM 3 a B M C F I T O T

xofl.

Kap~~OI#Ip~ynalopeHcw~flpom. T ~ ~ M K ~ pa~AM ~ ~ H C I H O C T XMnoTotiMR, ~ ~ ~ H H ~ AO T e m K Konanc. Anc~eta6onwre CMHA~OM. ~ M e ~ a 6 o n aqM1o~~~a aa, x c l n e p n ~ p e OTTOKCMC~HO ~c~~ ~ p a a ~ na e ~epuopery~e naToptiMR qetinp. M ~ R B R ce B ~npn Ill M IV cTeneH. E n w ~ e p ~ a CMHAPOM. ne~ B 4-7% OT cnyranTe. HacTbnBa npM TeXKMTe $OPMM, CneA 2 4 - h ~C ~ 6yn03HM M HeKPOTMClHM npOMeHM no KOXaTa Ha epMTeMeH $OH Ha onpeueneHM MecTa. Aenwpose~ CHHAPOM. C n e nanusa~e ~ OT KoMaToaHOTOCbCTORHMe-TembKAenMPKaTOM3pa3HaTOKCMCIHa

e~uebanona~~~~.
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paHe H a CepyMa rpe3 pa3TBOp Ha HaTpMeB 6M~ap60Ha~ p O n p M H a C R 3a M a K C M M a J l H O 8 0 ~ ~ 3 M p Ha a ~6ap6mypa~a e M M3BnMWHeTO M y OT T b K a H M T e npM TeXKMTe CnyVaU C KOH4eHTpa4MR Ha H O K C a T a BKPbBTa H q 6 mg%. We

An~anW ~ ap c ~ p a ~ ~ a y p e cbc a a cpeaHo a n ~ a n ~ 3 ~ - pMaunma MMce ocbqecrensaB xenaToqMTa rpea xvnpo-

npMTeXal3aT eHTepoXenaTBneH KpbrOBpaT. ~ M O T ~ ~ H C $ O

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O~~OTOKC CHHflPOM H ~ ~ ~ (112 H

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~ ~ ~ H M B K OpraHM3Ma B ~ T no nepOpaJleH nbT. M M ~ T 6bp3a pe30p64MR B C T O M a U l H O V p e B H M R T P a K T M qpe3 ~pbBOO6pbllp~Me~0 uOCTHraT npe#4MHOV e p H M R up06 M M03bKa KaTO 6bp30 Ce $MKCMP~T K b M TFIX. E U H W ~CT Ce ~3nbrea npea ~ ~ C I H M Mexyp R KaTo nonaaT OTHOBO B

xMnepTepMMR.

Xonm~onmm~e~ CHH~POM: cyxoTaHaycTHmenwraC e p a T M B H O pefi~TBlle. %CTO IlpM'iMHRMT ocTpbl M H T O K C H BM~M~ , ~up~a TaxnKapnuR, 3a, $e6pnnme~, peTeHqnR Ha K a y M . Paqenmce Ha HflKonKo nourpynn. Ule paarnenaYpMHaTa, flenMp03Ha IlpoMRHaHa Cb3HaHMeTOC n C M X O M 0 Me no-BMMTe OT TRX. TOpHa ~b36yua, 3 P M T e n H MMC n Y X O B M XWlO4MH~MM. K a p f l L l O ~ O ~ c ~ ' 4CHHflpOM: eH TWMKapAMR, eKCTpaC M C T O n H aa p M T M M R , penOJlRpM3al.&lOHHH HaPyUJeHMR, XMCbflbpxaT T P M u M K n M V H O$~HOTM~~HHOB MW. O HRn O T O H M R , WOK. ~ P R K O T OK a P f l H O T O K C M V H O pC!iCTBMe Ha KOM OTTRX cbmpxaT M n~nepa3cl~oeo RUPO, 06ycnaa~qo TpHuMWIMVHMTeaHTM~enpeCaHTMCeueMOHCTpMpaCpa3p a 3 n ~B r npoTuvaHeTo ~ ~ M neVeHveTo. Ule paarneua~e C T ~ O ~ CB T~ B~ ~ ~ B o ~ u M CbPUe' C T iH T MR ~ ,P M T b M M PenOnRnbpao TRX: Torecan, Fluperin, Stelazin, Fluphenazin, p ~ 3 a q n ~r ~n aa . ~~ ~~o ~ C T P O ~ CB T aTpMoBeHTpMKynapBO Mageptil M up. HaTa npoeonMMocTe AV- 6 n o ~ I-ea M P R ~ K O Il-pacTeneH, pa3w~pe~ KoMnneKcM, n KaMepHa TaxMKappm, KannepHH eKcrpacMcTonM. P a 3 c ~ p o i c ~ m Ha ~p aM n M a ca Ha BTOPM nnaH: TaxMKapAMR, TepMMHanHa 6 p m # ~ a p pMfl ~M ~OBeH, TpMKynapeH PMT~M,npeucbpptia $ # 6 p u n a u ~ ~ a,c ~ c ~ o nw. Pax~pohmm~a B penonRpn3auMRTaca WnxnTen H M M nepCMCTMpaT H R K O n K OA H M : UenpeCMRM n UM H B e p C M R Ha T-Bbn~aTa 6e3 Bpb3Ka C Me~a60llMT~M pa3CTpohCTK3, MMOKaPflHa XMnOKCMR. ONPMRT ce 4 cTeneHM Ha oTpaeF1He: neKa UeneH Ko~~pamypn Ha o'ieuanraTenHHTe MycKynu C OTKJIO( O ~ ~ O T O K C M C I HnPRBM, M C b H n M B O C T , MMflPMa3a, YMepeHa HRBaHe Ha O'iHMTe R6bn~M, Ha W H ~ H MyCKynaTypa ~ T ~ TaXMKaPflMR 683 EKr ~ ~ o M ~ H CpepHO M); TeXKa ( 0 6 ~ 0 ~ 0 T O P T H K O n M C , MyCKynMTe Ha e3MKa OTKJIOHFlBaHe BCTpaK C M V H Hn P O R B M ,C b H n M B O C T , TaXMKaPFIMfl, CyxOTa BYCTaTa, M ,A M 3 a P T M R , ~ H C $ ~ M ReKCTeH30pMTe , Ha ~pah~MqMTe ~ ~ p p ~ aXnnoToHMR sa, C penon~p~3aq~ no p~ o~ ~ue ~ ~ ) ; H 3aTPypHeHH ABMXeHMR, PRUKO eKCTpaCMCTOnHa a P M T M M R TexKa cTeneH (penyu~pa~ O~~OTOKCMV C~ HH HU~M, KO(npM TeXKM MHTOKCMK~~MM). MaT03HO C b C T O R H H e 683 HapyWeHMe Ha pMWaHeT0, nOk 'iepTaH X O n M H O n M T M V e H M KaP~MOTOKCMVeH CMH~~~OM); KP~~H TeXKa O (KOM~K ,O H B y n C M M , WOK, P M T b M H M M npOB0U H M HapyWeHMR U0 a C M C T 0 n M . npM M3nM3aHe OT KOMaTaAenMpO3HM np0RBM).

Q l e ~ o ~ n a 3 ~ueeponeriu ~oen

no OTHOWeHMe Ha M3BbHTeneCHOTOO'iMCTBaHe MHeH M R T a Ca npOTUBOpe'iUBM. Cn0peu e U H Ma B T O p MX e M O p M a n ~ 3 ae ~~ a e e $ e m ~ nopapu e ~ a 6bp3a~a T ~ K ~ $ HM H K C~ ~uMR, H0 H ~ O ~ X O ~ 3a ~B M O U M H O ~P a 3 T B O P M M M T eMeTa60nMawopfl~ebpp-r, qecxeMonwanM3aTa~xeMoneHeylpan~a OcMoTM'itia $ o p c ~ p a ~ UMypeaa; a MycKynMoxe ua ce enMMnHMpaT 93-99% OT oTpoaaTa. HonnM~e~03~0np~naratie~aqeti~pan~nMMopena Macne~a~axe~op~an en#MMHwpa w3a 80% OT lmipraminB TM (Diazepam 5-10 mg n Vitamin B , 100 mg HeKonKoKpaKpbBTa npM HaVanHaKOH4eHTPa4MR 2 m@, a K ~ ~ ~ O X ~ M O THO - uo e$em). nep$y3~ma 93%. HaR-wnpo~o ~anona~ MeTou a ~ 3a UenypaqnR e @pc~pa~a~anwypeaa, npoaewaHa npomnxuTenHo speMe. npe3 1984 r. A. MOHOB MK O n e K T M BBbBewaT X O n M H O nmM'ieH aHTMpoTeH KoMnneKc: Physostigmin, Pyramem, Vitamin B , Diazeparn. n p o ~ n a o ~ o n a n ~0KTehnM; c~~ n eeettTyanHo 4peHannHoe pamsop u n M Effortil npn WOK. TexKMTe KapuMounpKynaToptinHapyweHMR MoraT ua ce nelcym-r c P-6no~epM B caVeTame c n p p aHTuapmMuVH M CpeuCTM. C M M ~ T O M ~ T M V TepaIlMR. H~

T M . A ~ ~ PQIY~MRT~

Ilpenapm uecbmpmaqH n~nepa3~uoeo ~npo

Chlorazin,Thioridazin, Promazin, Triflupromazin M up.

H e H nbT. o~a3BaTC M n e H H e B p O T O K C M C l e H e@KT Clpe3 6no~MpaHe Ha O K M C lW T e n H O T O @C@pMnMpaHe BHeapHa, pecn. yepeyqatie Ha ~ o 3 b ~ l Kopa ~a~ M peTMKynapHaa Ta $ o p m a q ~ ~ M . e ~ a h n w ~ ce pa npepnMHo ~ B MHKPOBOM M T e Ha XenaToqmTe. l l o n y v e ~ ~ ~ ee ~a60n ce mOTpenRT CpaBHHTellHO 6ae~o npe3 6b6peqr

IlOTMCKaHe Ha C b 3 H a H M e T O ; KP~TKOTP~~H KOHTpaKTyPU M Ha nMqeBaTa MyCKynaTypa C T P M 3 M y C , TOPTMKOnMC, AMC@MR, BpaTtia PMM~HOCT; BereTaTHBHa AmcToHmn ManoTfiBaHe, xnnepTepMuR. Kapflmoeac~ynape~ C I H A -

por: TaxMKappuR, yMepeHaapTepMantiaxnnepToHun.n p ~ MHoro TexKo OTpaBwe - napeaa Ha pMxaTentiMR uetinp.

lla~onoroa~a~o~ HaxoRKa nq~a

OTOK Ha M03bKa M MeHMHMTe.

n~arnornwa

no KflMHMrHaTa KapTMHa M XMMMC H lO T O M3CneRWe.

fl~@epeuq~anua ~~aruo3a
C eHqe$NlbIT, 60TynM3b~, M H T O K C M K a 4 M HC T b P C O lB M O T p o B M M $ ~ H O T H ~ ~ M(C HH nMnepa3MHOBO

n w ) .

IlaToa~aTonnnq~a HaxoRKa
fl?re~epaTMBHM IlpOMeHM B HIBPOHHTI, OTOK Ha M03bKa.

OCMOTMVH~ HeyTpanHa @ p c ~ p a ~ wypeaa; a Diazepam, Vitamin B, napeHTepanHoB yMepeHM ~ 0 3pMxaTe~ ;

nw@epe~q~anua ~~aruo3a C eHue$NlHT M APYM HHTOKCMKaqMM C HeBpoReIlpeC H B H H HOKCM.

~O~OJIHHSHO noseReHne H neveuwe

O ~ M C T MHa H~ BxopHaTa BpaTa no npaennaTa.

Cnew~o ~O~HHSH nereuHe O

HeyTpan~a ocMoTnrHa @pcupa~a pnypesa ( n p Te~ mm cnyvau xe~op~ann3a); Coffein HeKonKoKpaTHo ~o C?$~KT ( ~ H T M ~ O T O ~ O ~ pekTBMe); O~HO B M T a M M H M OT rpytla B; XMnepTeH3MBHM CpepCTBa.

THOKC~HT~HOBH HeBponermqH
Chlorprothyxen, Tiothyxen M pp. CTpOeX C a ~JIM~KMp0 $ ~ H O T M ~ ~ M H MYIlpaMHRT~. B a T HespopenpecMseH e $ e ~ ~ no-cna6o , n3pa3e~,6e3 eKcTpanMpaMnptia cmrnoMaTnKa.

no

YCJIOXH~HHI~
~~~HXO~~H~BMOHMR.

fleqeu~e
~OAO~H eO Ha T O B a npM $ ~ H O T M ~ ~ M H O B MMHTOKCMT~ KXiMM.

llpor~o3a
~~MKHOB~H 6naronpnma. O

6ynrpo@e~o~osn Hesponermqn
CbmpXa~ RAPOTO Ha ~ ~ T M P O $ I ? H Droperidol, OH~ Triperidol, Heloperidol M pp.

TOKCHSHO ~eicn~e
B o p r a ~ m nonWaT ~a npes ycTaTa. Y s p e ~ M a~ O ~ waTa Kopa, peTHKynapHaTa@ P M ~ ~ MM ReKcTpanMpaMnp~a~ac~c~e~arpesnpepn3~~~~a~e~a~ne~br~ax~no~CMR HP ~ ~ C T P O ~ Ha CT Me~a60nM3Ma. BO M e ~ a 6 o n ~ 3 n ce pa~
rnaBH0 B X M n a T O q M T M T e . (/13nbClBaTCe C YpMHaTa.

3ellMHOBMT p a H K B M n H 3 a T O P M M~ak'ieCTM. pa3rneflaM e @MO TRX. Ilpepxaewrenn: Rudotel, Rivotril, Lexotan,

u e

Radedorm, Diazepam, Lorazepam, Chlordiazepoxid, Oxazepam, Tazepam, Femazepam n up. C b m p x a ~ 6e~soflnaaenu~o~o RAP, alcnlor~tqo ceAeMaToMeHxeTepoqmn.

Cnewuo 6 o n ~ n r ~ neqeune o
OCMOTMVH~ Hey-rpanHa @opc~pa~a ~~ypes (canorOnRM o 6 e HH$Y~HOHHH ~ ~ ~ ~ T B O P~ H )P . TeXKM H Cny.laM x e ~ o n e M y #nM 3 ~ nnaa~a$epesa, ~ Centrophenoxin 1000 mg M nOBe'ie 3a AeHOHOtqMe i. V. ( ~ H T U ~ O T O ~ O ~ flek~BMe). npe3 IlOCneflHMTe r0qMHM KaTO aHTMAOT Ce npemara Anexate amp. 0.5 mg i.v, npw conop M Koua HeKOnKOKpaTHO nOpWM 6bp30 M3'iepnBaq Ce e $ e ~ @M~. 3 M C I H a M IlCMXMqHa pe~a6lmM~aqMR.

~ P ~ ~ ~ M ~ B H K B ~ T O T P no ~ BOpalleH R H U R MM H X e K q M O H e H nbT. C ~ HnwnoTponHM O BeqecTeacaM yapexqaT npeflnMHO ~ O ~ ~ T O HanHnMflu TO 6 ~ n seqemeo o Ha noAKopoawTe CTPYKT~PM H a UHC, peTMKynapHaTa @ o p ~ a u Ha ~n ~03brHMR CTBOn Hno-ManKO C M B O T O BeqeCTBO H a KOpaTa. OTCTpaHRBaT Ce nO'iTMC a M O qpe3 Me~a60nM3Mpa~e rnaBHO B MMKp030MMTe Ha XellaT04blTMTe B aKTMBHM M ~ T ~ ~ O ~ H T G I . Ype3 6b6peume ce M3nb'iMT 6ae~o H ManKO. Bcnr~o TOM yflbnxaaa TOKCM~HOTOMM ~ e h m ~6e~3op~a3e~e. nMHOBMTe X U M M O P e q e n T O p M (2 BMAa) Ca IlpbCHaTM M 3 qenMR M O ~ ~ 6 Ke . ~30~11a3en~ ynpaxHRsaT ~n~e noTMcKauo Aehc~ene rnaeHo 'ipe3 noTeHqMpaHe eetcra H a rauaauvnpoQnnam~a HoMacneHaTaKMcennHa M 6 n o ~ ~ p HRKOM a ~ e qpeHepmrBHMM~T~ npMnaraHe ~ H O Ha 6 e ~ 3 0 ~ ~ a 3 e n oco~~ H M (M X O ~ M H ~ P M ' ~ H M C T )P Y K T Y P M B UHC. 6e~o BeH03H0, IlOpWM BMCOKa ryBCTBMTenHOCT K b M TRX ~~MHRKOMMHAMBMPH.

Uepe6poflenpecmee~C H H ~ ~ ~ c OM noTwcKaHe Ha C b 3 H a H M e T O PO KOMI; ~ P ~ M ~ C M X M 3a6aBe~0 R, MMCneHe, 6pa~p1nanw~1, X M f l O M M M M R , nOHMXeH0 B H M M a H H e , XapaKTepHa PeTporpWHa XHlOMHe3MR A0 aMHe3HR; xMnope$neKCMR, HaMmeHan O B b p X H O C T H a M mn6o~a CTaBHO-MyCHap~o~ur~ aHanreTwqM we ca cneAHMTe neKapcmeKynHaKMHeCTeTM'iHaCeTMBHOCT. HM rpynH: onHaTw (Morphin,Pantopon); MOP~MHOBM npow H~B~OB~~~ CHHAPOM T ~ T H BoTpMuaTenHa ~H aM3 8 0 ~ (Heroin, 1 ~ ~ Dionin, Codein, Apomorphin); CMHTeTu'i$OTOHMR C npesanupaHe penpecMma Ha ctiMnamKyca: HM MO~$HHOBMflepMBaTu (Metadon, Lydol). tea^ MeAMKaMM03a, X M n O C a n M B a U M R ,. C M M ~ ~ ~ T M ~ C O B ~ X M ~ O T O H M R " , ~ ~ ~ M e H T M HaMMpaT npMnOXeHUe KaTO aHNlreTMqM (Blcn. M AMKaPRMR (npM TIXKH MHTOKCMK~~MM). cneffonepa~~~ C~ ~o ~) ~ ,M O ~ M T M Heap* L ~ I , M ncmxocenaM a J l ~ 0 ~ 0 3 b lCHHflpOM: le~ HaMWeHMe H a MyCKynT M B H M . HMR TOHYC M Clma, HapyllleHa KOOp~MHaqMR Ha ABMXeHMTOKCHSHO ~eimne RTa flMnnOIlMR, HMCTabM, A H 3 a P T P M R , TpeMOp Ha pbqeTe, CTaTMqHa H AMHaMM'iHa aTaKCMFI. n o c o r e ~ npenapaw ~~e ~ P O H M K B ~ T B O ~ ~npes ~HM

06~0~0K~H'l CHHflPOM eH YBpefleHO o6qo C b C T O F I H M e , aMHaMMR, neCHa Y M O P R e M O C T A0 6e3~MnMe. PeC~blpaTOpe~ CHHflPOM npM Te)KKM O T p a B R H M R : flenpeCMR Ha AMXaTenHMR UeHTbP, IlOBbPXHOCTHO flMUlaHe, HaMMRBaHe H aB M T a n H M R KanaqHTeT,nOHMXaMHeHa PO, B apTepManHaTa ~pae.

xpatiocMMnaTenHaTacMcTeMaM napeHTepanHo. C ~ b p 3 a a ce 6bp30 C ~ ~ J ' I T ~ L (M Hce T ~~ e ~ a 6 o n ~B arep^^^ ~pa~ np06 rpea rnmKypoHMpMHe, cyn@ypnpa~e, x~~ponw3~p Ma cyn$a~~ xo ~ ~ p o n ~ a ~TOKCMC(HMRT p a ~ e . MM e@ew e npeflM BCM'iKO B UHC - M03b'iHaTa KOpa, RflpaTa H a XMnOTanaMyca M qeHTbpa Ha AMuaHero, KaTo ce Hapyluasa nnuporpo3~le~a~a~~cenn~a.

F ~ ~ A H O C TH Ta ~e H 3 M M H M T e CMCTeMM B MMTOXOHAPMMTe Ha HepsHaTaKneTKa M ce 3a6ae~ oKMcneHueToHa r n m ~ o 3 a ~

K ~ H H HKapmua ~H~

Cp0~6e~~e$an OTpaBfl M ~ ;HMR OT flpyM HeBPflenpeC M B H MH O K C M .

OT~~BRH CT ~ e 3 T M O npenapaTM 3anOrBa C XMnOTOHMR H CoMHonewHocT, npeMlrHaeatqM B KoMa, npMlpyxeHa c M M OH ~6~ p q ~ n no ~ anHeR. e ~ Ta3M KapTMHa ce ~onbnea OT nOBMUleH T O H y C Ha IlMnOpa, C $ M H K T ~ ~ MHa T ~ aHyCa M n M K O V H M R MeXyp. CMHT~TU'~HMT~ MOP$MHOBH npeflapaTM

C e B ClePHHR ~ p o C 6 06pa3ysa~e Ha TOKCM'iHM ~eTa60nMTHM npoAyKTM. flupa30no~oa~~e npenapam M ~ e ~ a 6 o TwTe nu ce M3nbqm-r rpea ypMHaTa, recTo oqseTeHa qepeeHo OT 06pa3yea~a~a pyfiaao~oaa KMcenwHa. YspeWaT UHC - rnaBH0 M03bCIHaTa KOpa M HeBpOHMTe, KaTO npM'lMHRBaT M03bCleHOTOK M 6b6peqa~e -TY~~~oH~$

C OTPaBRHMFl OT f l p v IJ~P~~POTOKCMVHH H O K C M , 80AeUH A 0 KOMa. AHTWROT e Naloxon 1-3 amp. B S~BMCMMOCT OT C ~ C T O FlHMeTO.

1. AHTHAOTHO Allylnorrnorphinflo 4 amp. npes 15 min. H ~ B - ~ ~M3nOn3MHMRT cTo aHTMflOT e Naloxon.np# Bb3paCTHM n a q ~ ce e 3anorea ~ ~ ~ c 2 amp. M npM no-T~XKM oTpaaRHMR C 4 amp, flopa,qn n3~epnea~e Ha n e r e 6 ~ ~ ~ l e$ercr uoxe fla ce ano ox^ HeKonKoKpaTHa annMKauw. f l p noula ~ nep$y3~~l c y f i n ~ ~ r a a n npMnaraHe ~o~o e XMBOTOCllaCFlBa~O.flp# K P ~ ~ HTeXKMTe O MHTOKCMKauHH C e npenopbrm nepMaHeHTtia M H $ ~ ~Ha MR Naloxon B ~ o 3 a Tp~l6ea ~a ce M M a T npeflBMfl OTpaBRHMR C flpyrH IJepe100 ml/h OT enemponmetipa3mopc Naloxon4 mgA. To311 ~POTOKCMCIHM HOKCM; M03bVHM Bb3naneHMFI. HaClMH OCMrYPFlBa 400 PO. 2. O c ~ r y p ~ s a Ha ~e a,qeKsaTHa BeHTMnaqMfl - n p ~ anHOe M H T @ M H ~KOMaHAHO ~ H ~ flMUaHe. 3. C T O M ~ UnpoMweKa JH~ (stun. M npn napewepanHo OT~~BRH~). 4. O ' ~ M C T H TWlM3MM ~ ~ H M- HeKOnKOKPaTHO. 5. Y ~ e p e MH@Y~HR ~a Ha MAHO-conee~ M MoHo3axaCTOM~W npOMMBKa H~ M OCI MCTMTenHO. @0pcMpa~a P M A H M pa3TBOPM. AMype3a C BOAHO-ConeBM M MOH03aXaPMflHM Pa3TBOPM, 6. AHWI~~TMIJM. cbo6pa3e~a c enemponMTHMR M TevttocTHMR 6ana~c npM 7. E K C C ~ H ~ B M H O T ~ ~ npbl HC JlM $nCa Y~M Ha R aHTMflOTM. 6b6pe~1~M YBPeWaHMR AHTMKOHBY~CMBHM CpeflCTBa, racTponpoTercrlraHM (Almagel, Cimetidin).6op6a c u03brHMFl OTOK.

Xapamep~ ca ~ cneflHMTe CMH~~POMM: r a c ~ p o - n ~ ~ e c ~nrweHe, ~ a n e noepbqaHe, ~ xennaTeMe3a, Menex. Uepe6panew - ~e~weponoflo6~n npomn, mpvoae, KOMa. Xe~a~onor~ -lPRRKO r e ~ ce npomma c annacT#vHa aHeuMA M arpatiynoqwrox. P e ~ a ne npM ~ roneMMA O ~ M Ha ~ Y T ~ , ~ MCO xaparcreH PMCTHKaTa Ha MHTePCTMqManeH T Y ~ ~ ~ o H ~ -$ OTOIJM, ~MT OnMTI(PMR.

Maprapma rewesa-So~w~esa
fl~pa30no~oe npenapaw ~~e ca npou3wAHn Ha nMpaaono~a n 6yr~nn~pa30no~a. n o - u r ~ p o ce ~ oynoTpe6~EGIT npenapame: Analgin, Amidophen, Antipyrin, Butadion KaTO aHaJlreTMqM, aHTMnMpeTMqMM aHTMpeBMaTH'iHM CpeACTBa.
TOKCMCIHM fl03M

Rimicid (Rimifon) npeflcTaenma x ~ f i p a Ha 3 ~H~OHM~ KoTwomTa KMcenMHa. Msnonsaa ce 3a nereHMeHa$eplcynoaaTa.

O ~ p a e ~Hacnnea l~e npH npueMaHeTo uy per 0s. B nPMVMHRBa TeXKM yBpe)maHMR Ha UHC, rnaeHo Ha uo3bwa~a Kopa, no-p~lfl~o Ha A ~ e ~ u e $ a n o ~ flopw~ XMMMVHO6 n ~ 3 cTpoex b~ c Vitamin B, ro M ~ M ~ C T

562

T&cuko~orulmu cneurnu cbcrnonnun

sa M HHaKTMBMpa, KaTo pa3c~poAsa oKllrcnMTenHme npoueCM B H e B P O H a H npeflM3BMKBa XMnOKCMR. M~mr~a Ce C ypnHaTa. C~opo cnep nornbqaHeTo Ha oTpoeaTa ce p a 3 a ~ ~ a ropeH Ancnenmreti cnHApoM: rapeHe, ~ O ~ B K cToMaM xa, nospbqaHe. b p 3 0 HacTbnBaT M O ~ ~ C I H M pT p~ expawn, pecn. qepe6po~o~cnre~ cnHfipoM, KOATO e BOpeq: npM no-new MHToKcMKauuM ce ~a6n~paBaT ncMxoMoToptia~b36ypa, HanperttaTocT,rnaao6on~e, caeToebpTeX, TpeMOp Ha pbueTe, XOpM30HTWleH HHCTabM. no-T~MM cnyra# ce noRBRsaT e n ~ n e n ~ ~ $ o p mo~e~# HHCIHO-TOHMYHM BpqoBe p0 b p r o ~ c~a-ryc,npeoponnBaLL(M Ce M H O r O TPYRHO. ~ ~ M K H O B ~ H eO HMHue M K O M a oco6e~onpm peuaTa. ~ ~ H M U Mca T ~ pa3w~pe~ l l~p. ~ ~ a h - ~ e r oTpaemivR n~e cnepBa napan~aa Ha pMxaTenHMFlMCbP~eVHOCb~OBMR~eHTpOBeCpa3BmMeHaeK30T O K C M i 'e H UOK. B ~ ~ M O X eH MO YBpeWaHe Ha napeHXMMH m e opraHM po o $ o p ~ H ~a~ xena~o-pe~ane~ e CMH~POM C OCTpa .lep~oppo6HaM 6 b 6 p e r ~ aHepOCTaTbqHOCT. 6 KPbBTa Ce Y C T a H O B R B a nOBMWaBaHe Ha a30THMTe Tens, xMneprnlrKeMMR n yMepeHa n e a ~ o q ~ ~ o 3 a .

PM

~ M M T ~ ~ M C O B OTPaBRHMR M B HalLlaTa CTpaHa Ce npMrMHRBaT HBA-~BCTO OT cneAHHTe npenapam: Digitoxin, Acetyldigitoxin, Digitalin, Ceglunat, Cedilanid, Isolanid, Digoxin, Lanitop, Lanatilin M pp. OTP~BRHMR HamnBaT M npv npMeM Ha omapa OT Digitalis ( H ~ ~ P ~ C T H M HnM K ) npax OT nMcraTa MY.

~~HMTWUCOBMT rnMKO3M~M ~

(flr)pa3cTpohBaT CMnHO

AOHHOTO PaBHOBeCMe B WleTKMTe Ha CbPqeTO M APYMTe opraw, npMrMHRBaT eKcKpauenynapHa M cepywa xmePKaJlMeMMR M BbTpeKneTb~HO nOBMUeHMe H a HaTpMeBMTe, PeCn. KiMqMeBMTe ~ O H H Te . ppemaT KOHTpaKTMnMTeTa, ue~a60n~3u Ma C M H T e 3 a Ha MaKPOePMClHHTe $OC$~TM. ~ P M ~ W H F IB B a 3 ~ 0 K TO H C T P M K 4 M R ,nOTMCKaT 3apFtM@HeTO M npOBe~aHeT0 Ha Bb36~eHMeT0, nOBMLLlaBaTeKTOnMVHaTa B ~ ~ ~ ~ ~ M M O C T .

htlli~lllia KapTiIHa

O C T ~ flMrllTallMCOBa ~ T ~ M H T O K C M K a q M R(OB[n) Ce pa3aMsa B CPOK OT 20 min go 22 h OT npMeMa Ha npenapaTa. TR npo-nlra cbc cnepHMTe OCHOBHM CMH~POMM: r a c ~ p o - n ~ ~ e c ~ cnHApoM. n ~ a n e ~[nsnae~ c rapetie, IlOBpbqaHe, K O P e M H M 60nw, no-PRPKO RMaPMR. B CneflBaqMTe~ H ce M p a 3 ~ napeaa ~ ~ a Ha vepeaTa, MHoro P R ~ K O
Aer$epe~qeran~a nera11103a

C enclnencMR, oTpaBmie OT ppym nproev o~poelr (T~ML(MK~~M'-IH# aHTMflenpeCaHTU, XMHOnMHOBM IlpOM3BOflHM, Strychnin, nupa30no~~).

M CToMawHa napeaa. Kapfluo~nplcyna~ope~ CHHAPOM. ~ P O R B c ~b H~ ~ b u e 6 ~ e ~npecltaratie e, Ha cbpue-ro, 6on~a B cbppertiaTa o6nac~, 3qyX. YCT~HOBRB~T Ce rnyXM T O H O B e , apMTMMqHa cbpperHa peA~ou, 3a6aee~a MnM ycrtopetia. ApTepManH O T 0 HaJlRraHe e HOpMaflHO, B e H O 3 H O T O e nOHMXeH0. npM KappHoreHeH u o AH ~ cnapa, LpH ce nosfluam. EKT-

cHMxaBaHe Ha cemetiTa ST MnM c BMA Ha nponmaHe c XOpM30HTaJleH X04 M C X e M M W H TMfl. T - B ~ ~ H Ca MCHMT~ O C M O T MHemMHa ~H~ MnM cna60MltanM3Mpa~a $0XeHM, 6M$a3HM, HeraTHBHM. P # ~ % M H M M npBOAHM T~ HaPCMpaHa pMype3a; npM M a C M B H HM H T O K C M K a q M M- X e M O PyWeHMFi Ca pa3~006pa3HM MW C T O Ce CbWTaBaT BeAMH n e p $ y 3 ~n ~p . ~nara~ Ha eroneMM p03n Vitamin B , (amvEKT-3an~c. Maxopbr OT TRX r e c ~ e o ~ a ~ e p $~ ~a 6p ~~a n ~ O T ) 100-200mg 3-6 W T M BfleHOHO~MeTOi.V., aHTMKOH~ M R no-PR~KO , acMcTonMRTa. C b p p e r ~ a ~ cna60c~ a ce ByncaHTM (Diazepam, Phenobarbital); r e u o ce Hanara npomuaa c peKoMneHcauuR Ha cbpqeTo w n M BnoluaaaHe nephnaHeHTHa MH$YBMR Ha 6bp30peii~TBa1.1~ 6ap6mypa~ Ha HMHCIHaTa. (Thiopental) po e $ e ~ P ~~ . x a ~ e peaHMMauHR n~a M@MU e p e 6 p o ~ o ~ c ncnHApoM. re~ 60n~n~ ca eoTnycHapaHe M 0 6 p ~ l u e a ~ c pecnwpaTop; e npoTMBouoKoeonereTM, W M H a M W i ' H M , C b H n H B M HnM B ~ ~ ~ Y A C ~n H C M M X O ,M O T O P a ebs6ypa, B penMp M n M nc~xosa, p ~ pB ~ conop o MnM HHe C rnDKOKOPTMKOM~M (K~T~XO~~MM Ce H~ M3 T6 ~ ~raa~). H KOMa. ~ ~ U M ~ H TM M M a T T~ qBeTH0 BMmaHe B )KbnTO, 3ene~0, CMH~O MnM HeRcHo, 3 a ~ b r n e spe~ue, ~0 BMyqatie Ha KPbrOBe, . c H ~ ~ o w ~ $ ,C l e P H M neTHa, MMKPC- H M B K -

Cnew~o 60JH~st10 nesetiere

poncw.

Ha6nlopaea~ ce cbqo yepewaHnR Ha 6b6peqme, 'iepHHR pp06, ~ ~ O H X O ~ H ~ B M O H TM PR O , M~O~MTO T P ~ O -~ H M R ,

M~O~M~O~MM.

npu OnM ce ~a6nlopaaa~ 4 cTeneHn ( W ~ M M Ha ) npoTMraHe: nerta, c p e u ~ o - ~ e xTexKa ~ a , H CBpbxTexKa ($YFIPORHTH~ WPM~).

Chlophazolin(Clonidin, Catapressan, Haemiton,Catapress) e ~ ~ ~ p a 3 o n ~P oO m~ B W H ~e O epHo OT cpepmaTa 3a oenapeaHe Ha mnepToHmHaTa K P M ~ ~ Toh . e l~~po~opasnpoc~pa~e~y~ac. Chlophazolin u ~ x d n p a cmnamKycoe#fl e $ e ~ Ha ~
HMBO UHC. C~~namKycoan nMnyncM K ~ M nepn$ep#ma

Onl/1~ p ~ l 6 ua 6 aC e OTnM'iM 01OTpaBRHHflla C 'ieMePMKa, xno$ason~~, 6apuee~ M $nyopH# conlc; OT XpaHMTenH M T eM H T O K C M K a u M M M IlpMClMHeHMTe OT aTpOnMH M UpyM XOnMHOnMTMuM; B HRKOM Cny'iaM M OT OTpaBRHMfllaC XOnMHOMHMeTMuM.

H e nocnneaT. C b p p e ' i ~ ~ CbKpaqeHcl ~e rR ce pa3pewa~, HacTbneaH ~a30fluna~aum~. MMH~THMRI Cbpue'ieH 0 6 e w ~ n e p ~ $ e p ~ cbpoeo o ~ o CbnpoTmsnetiMece noHnxaeaT. ToBa B O U M p0 TeMO pa3~~pohcTBO Ha KpbB006pbqeHMe~0. To~cwr~n em 4 eo ~6 m q a AnxaTentiMH M B~BOMOTOPtinn u e ~ ~ bXno@amnn~b~ p. ce oTuenR c ypMHaTa B 60% n npes qepma 640%. O T p a e ~ ~ ~ HacTbneaT ma npbi y ~ u w neHo npueMaHe, npu npepo3npa~ew n M cnyclako npM Flew.

Cnep M3RCHRBaHe CbCTORHHeTO Ha CbPueTO KnMHMYHO M/M~M C EKT, 6ae~a, npes e e ~ o s e KaTenp ~ annnKaqnR Ha Atropin 0.5-1 rng nl~nw Lidocain 100 rng, cbqo i. v. CTOM~W npOMMBKa H~ C MeuMuMHCKM BbrneH. [PM HallHY M e Ha P M T b M H MM n M IlPOBOflHM HaPylleHMR IlpOMMBKaTa ce npasM cnep oenapwHeTo n mC ~ C CbqwTe cpepcTBa, IlpMnOXeHM MH$~~HOHHO. T ~ W napa$w~ H 80-100 rnl M llnameanee cyn$a~ 30 g per OS. Aeua~a nonpasaT c a ~ n oapa$~ 1-2 ~ rnlkg. ~ O ~ H ce M T TpaHcnopmpaT ~ caMo cneu oenqqfleaHe Ha PMTbMHMTe M IlPOBOflHMHapyWeHMR M n M npM 3HaqMTenHoTo MM ~ o p ~ ~ pno a BpeMe ~ e ! Ha TpaHcnopTa noclnrH a T M R T aHTMaPMTMM'ieH C?$~KT C e nOAqapXa C nMflOKaMHoaa HH$YBMR B uosa 1-4 rnglrnin l nnM c Atropin npm IlpoBOpHMTe HapyWeHMR.

Chlophazoline M3KflloYMTenHO aKTMBHa ~)rfjCTaH~klR YflBoeHala pHeBHa A03a e TOKCM'iHa 38 BMPaCTHM, npM ManKMTe peua 1-2tabl. O T p a ~ f l ~ npoTwqa e ~ o cbc cneutiMT e OCHOBHM CHHAPOMH: lJepe6pane~ CHHAPOM. M ~ R B CbC ~H CbHnHBOCT, OTnmHanocT, BcleHe Ha csm, 6 p m n n c ~ mnpn ~ . UeuaTa ce ~a6nlofla~a M no-T~MO noTncKaHe Ha cwHaHMeTo - conOp, KOMa. npM TRX C e YCTaHOBRBaT C b q O bPYOBe, UMWaHeTo ce pasc~pohm no mnHo cnupaHe - anttoe. 3 e ~ ~ Te c a crecHeHM, HepeampaqM unM c Myptia pealcuwn Ha CBeTnHHa. K~~AHO~HPKY~~ CHHAPOM. ~TO~~? YCT~HOBRB~ H C e ~PE~MK~PAM CbP#?qHaTa FI, $~~KB~ Cnma H~M U0R KPWMC~HM CTO~HOCTM - 40-25 ypapalrnin. nyncb~ ce paspewa, cTaea M e K M He ce onunaa. AH cbqo cna,qa po KpMmrHn CTO~HOCTH (4010-010). 6 HRKOM CJly'laM C e YCTaHOBRBa caMo Ha aycKymaum cMnHo 3~16aBeHaTa capAe'iHa pehHOCT. PaasnBa ce Temo WOKOBO cacTomiHe. O ~ ~ O T O K C H CHHApOM. 'I~H 06q0~0 C b C T O R H M e e Tewo yepepeHo, Hannue e a,qnHaMwR, u m r a q a po npompauun. K o ~ e T 6nepa ~ no mnTa, nMrasMunTe ca
CPM.

Ha EKr ce ~ C T ~ H O B R B ~ C M H ~ C O ~B P~ ~MK~PAM CMHYR, coaaapuTMm, B HRKOHCny'laH noBHu..aBaHeHa ST-cemeHTa HWn 3 0 e n e ~ ~ p ~n vn ~~ a~ n~a ~~ ,M ~ C T M eKcTpaT ~ ~ H M cncTonM, ~ R U K OHncKocTeneHeti AV 6no~.

Cb'ie~aBaHe~o Ha MM03a C ~ P ~ M K ~ HMCKO P~M AH, R, 6nepom, cyxu ~ M T ~ B M ~ nwnca M , Ha noepbqatte M M ~ ~ O T R

flp~ npMeM per OS naTenTHMm nepMoA pocTMra 3-4 h, a npM 6bp30 npnnoxeHne i. v. ToKcMrnMRT e$em ce npORBRBa Cnefl HRKOnKOMMHYTM. ~ I H T npOTMOK r a C ~ cnepHwTe C ocHoaHH C M H ~ ~ ~ M H : 1. C ~ o ~ a u r n npoMweKa a c MeflMqnHcm abrnen, cnep rac~po-HHT~CT cnHnpoM. ~ H ~ ~ ~60nnw~e H MuaT raKnMHwen npernep d ~ EKT. n n ~p 6~p q n ~ a p M pHHCKO ~~ flene, ryscTao 3a paanbaane Ha KopeMa, cna6a 6onna, AH ce npaaM Atropin 0.5-1 mg, npcc peqa B floss 3a ~O~MB 3a Mnoepbqane, noepbqatie. P R ~ K ce O na6n~pasb3pama i. m. u n i. ~v.; Effortil 1 amp. (0.01) i. rn., np# aaT pMapuR M n M 3aneK. peqaa cbo~ae~na~aflo3a. n o p q u BarycoeoToppa3nenwe Uepe6pane~cnHnpoM. MSRB~H C BMene Ha CBRT, npM npoMMeKaTa e nanwqe onactiom OT 3acMneane Ha WyM B YLUMTe, 3pMTenHM HapyLUeHMR, HemeKBaTHO nOBe6pqw~app~m na xMno~on#ma! petwe, pen~po3no cbcTomiMe. C ~ ~ H ~ H ceM napyuaBa ~TO 2. O ~ C T W T ~ Magnesium ~HO sulfuricum 30 g npw po conop M KoMa C M n M 683 nproae. B pMluaneTo ce B ~ ~ ~ ~ C npM THM peqa , - Teren napa$m 1-2 mVkg. nacnnea napan~sa M anttoe. 3.60nHMTe B 6e3cb3nanneC?MHTy6blpaT M o ~ ~ M L U B ~ T , noRemaT naya~, KapaHo~Hplcyna~opeH cnHnpoM. Xe~oflwnau~~ Cnep TOBa C e npoMMBaT M TpaHCnOpTMpaT. Ta ce napyuraea B ~ ~ B M C M M O C OT T po3a~a - OT neKo w n M 4. O c ~ l r y p ~ a a Ha ~seno3e~ e n an ~HH$~~HOHHO ne'ieyMepeno nonnxeH#e~aAH po p a 3 a ~ HaTemK ~ ~ e KappnHuenoapeuenaTpancnopTa oreHeH LUOK C HyneeM CTO~HOCTMHa AH M nynca. UBH e Cnelu~o ~OJIHHVHOnewHHe hnnoro BMCOKO. Cbppe'i~a~a peirnom Moxe pa 6bfle PMTMHrHa C A V - ~ ~ O M n M K Hah-recTo e 2pMTMMclHa IlOpaFlM npoaeqqa ce c @pcnpana pwypeaa. Atropin, Effortil, Vasoton, Isoprenalin, n e N y 3 c ~ Dopamin, ~ l r a ~ y c ~ e e ~ a PMTbMHMTe U nPOBOpHM HaPYlueHHR. Cbppe'itiMTe TOHOBe ca rnyxM w n M ce ryea e~6pMoKappM'i~a peinoc~. Hannqe eenmnaqMR, CTMMynaTopM Ha pMuraneTo, qepe6ponpo~ee pMCflHeR, qMaHO3a, MapMOpMpaHaKOMa. K~P~~HOTO KTMBHM, nPOTHBOrbP' iOBM CpenCTBa M pp. mm e $ e ~ Moxe pa 6bpe M ~ R B ~ caMo H c KaMepna cna60cr - npeAHwHo nma, flRcHa M n M o6qa. K~MHMCIH M ce r yc~anoa~ea e~ 6enoppo6en3ac~oU. npw m p a P~~BMT MHTOKCMKa~MM HT~ npOTM'iaT T ~ M O . ~ P O ~ H O - nap e ~ ~ CTHM naqHeHTM MOXe fla C e Pa3BMRT ~M~OIIMM. aaTa e ne6naronp~ma npn ~ C H 3ano'iwe O HaneLlenMEnetcrpo~apflworpa@~u ce peMcTpnpaT npoeopHw M eTo, npM Mnoro B ~ ~ ~ ~ C M np# T H peqaTa. M Bax~a~oa~aaPMTbMHH HapyWeHMR: A V d n o ~ OT BCMVKM CTeneHM, SAHeTo e npopbnmenno. 6no~, c~nycoe apecT. Oco6eno xapamepeH e MnTpaaeHTPMKynaPHMRT 6 n 0 ~ npM MHTOKCMKauMMTe C Tachrnalin, Lidocain, Chinidin, Ritmonorm. Ha6n~paea~ ce nqKaMePHH TaxwKappMH, KaMepna TaxMKappMn, eKcTpacvcTonMR, npeflcbpptio MbxqeHe n TpenTeHe, Kauepno TpenTetie, $~6pwnaq Ha ~ KaMepMTe, ~ acMcTonMR. Yc~anoaen~ ca M ppym yspexqatiufi: ToKcM'iHa ~ e $ OCTPMT~ OTpaBRHMR H ~ U - ' ~ ~ C M T OIlPM'iMHeHM OT CneponaTMn, xMnornMKeMMrHa KoMa, TPOM~O~MTO~~HII arflHMTe MeflHKaMeHTn: Chinidin, Tachmalin, Ajmalin, panynoquTo3a. Gilurytmal, Tachmalcor, Lidocain, Lincain, Lidocaton, K P ~ B H O ~ ~ ~aHaJl O BM M 3F MIAKP T nOKa3BaT npM WOKa Xylocain, Novocarnid, Disopyramid, Rytrnilen, Rytrnodan, X M n O K C e M M R H a4MpO3al cbo6pa3~0 TeXeCTTa Ha MHTOKPalpitin, Procainamid, Rytmonorm, Propafenon, Diphenin CMKaqMRTa. (Diphenylhydantein, Dilantin).

n0CTaBR C e no aHaMHeCTM'iHHTe AaHHM, KJlHHMClHMR npernep, EKT-naxop~a~a M XuMMrnHTe ~ a c n e p s a n ~ ~ .

6 0 n ~C ~; OTpaBRHMR OT X M H M H , aPTPOXMH, WMePMKa, Chlophazolin; C XMnOTepMM'iHM CbCTOFIHMR.

1. C T O M ~ W npOMMBKa H~ C MeRMqMHCKM BbflleH, nOCnepeaHaoTorHmMTenHonpMycnoalre,renMnceaTpnnMHM M n M npeoAHM HapyweHwR. TRce oTnara ~o o a n w -

~~IHH KapTblHa ~NH~

M M H T O K C M K B U M R npe3 BeHO3eH BaHeTO M M . ~ P Pa3BMTa KaTenp ( a 6 u ~ aM ~ )H $ ~ ~ M O H npunara HOC~ 5-10% Natriurn Lacticurn 100-200 rnl Mnu pas~eopa Ha Hartrnan (RingerLactat). ~ P ~M P ~ M K ~ PC e # BKapBa ~ R Atropin M / M ~ MH$YM ~MOHHO lsoprenalin (Dopamin). 2. n p HapyWeHO ~ fl#WaHe M n M KOMa ~ O ~ H M F IC Te n~Ty6npa MO~AMWc B mcnopoA. ~ 3. B ~ H W cbpdereH ~H Macam, u e $ ~ 6 p ~ n no a qno~~ Ka3aHMe. HRKOM atiTHapwTMMvHn neKapcTBa (Lidocain, Tachmalin M ~ p . ) ce ~e~a6anMsnpa~ 6bp30. ETO3auo xennoAwaMwKaTa ~ p ~ 6 Aa ea ce nombpxa c ecMrKu cMnM M cpepea. 4. T ~ ~ H cce ~npeAnpueMa o ~ T npM sHarmentio oenaARBaHe Ha MHTOKCMKaqMRTa,npMnOflaBaHe HaKHCflOpOpl M npM r OTOBHOCT 3a aeKMTHa HaMeCa fl0 tlbTR.

3arepe~sa~e Ha KoxaTaHa nMqeTo, cyxoTa e yc-raTa, Mnnpuasa, TaxclKapAnR, peTeHqMR Ha ypwiaTa, ncMxoMoTopHa eb36yfla, nennpostio nponneHeHo c b s ~ a ~ cbc ~e 3PMTenHM M C n Y X O B M XaJltOqMHaqMM, $e6pMnMTeT, CKJlOHHOCT K ~ Konanc, M raproae, napannsaHapwwaHeTo, KoMa. OCHOB~H CMHflPOM e XOnMHOnMTMCIHMRT.

fl~amocmna

A H ~ M H ~ ~ T AaHHM, M'~HW KJlMHM'iHa KapTMHaM ~ 0 ~ a 3 8 a He Ha Atropin e ypMHaTa.

n~$epe~q~a mamma n~a

C OCTpa ncMXO3a, BMpyCeH eHq!$aJlM~, M03bLleH MHCyilT, OTpaBRHMR, KOKlO IlPOTHWT C XOnMHOnMTH'ieH CMHAPOM (naHTepMHoB0r a 6 ~ OTpaBRHe, o OTPaBRHMR C T P M U M KJlMrHMaHTMAenpeCaHTM,aHTMnapKMHCOHOBMneKapCTBem cpeAcTea M ~ p . ) .

Cneur~o~OJ'IHHIIHO neqeHHe
llocrae~l ce epeMeHeH n e k u e i n p . npoeexqa ce AManM3a M n MO ~ M ~ H H Kpbeonpenusatie, O $opc~pa~ pa~ ypesa, opraHonpoTetcrnaHo nerewe, AwxaTenna peatiwMaqMR, aHTMaPHTMHClH0neCleHMe M AP.

~060JlHHqH0 noeeneH,ee%e H neqeHHe

0 6 ~ n npoMHaKa ~a c eons M n w $~swonomre~ cepyhn Ha orme, Hoca M paHeaaTa noebpxtiocr (sa HeR ce MsnoC BOAa n3MT CTepMnHM pa3~~0pM). CTOM~U Ilp H OMMBKa ~ Ha H nCM~ M n M pa3TBOP Ha MeflMqMHCKM BbrneH. ~ O T M C K ~ xoMoTopHaTa ~ b 3 6 y ~ c aDiazepam M n M Phenobarbital. oe~o~~aan npenapaw ~ o e ~ He ce ~snonaea~ nopan nere6~a~ TaxMKapAuR, a K O ~ canpoeoxqa O e$eria MM. I l o r ~ c T a a Ha ~ eymaTa OT noebpHaTuMaTepuu M O C M ~ ~ ~ eaHe Ha AnwaHeTo.

Cneur~o 6on~w~o neqeHle

Atropin m a WMPOKO npMnoxeHMe B belladona.
~B B CH~KM o6nac-

TM Ha Me~1uqM~a~a.TotI e a n ~ a n oKOATO ~ ~ , ce cqbpxa M B HRKOM pacTeHMR, ~ a l - M ~ B ~ C TOT HO KOMTO T O e Atropa

TOKCHVHO f l e i m m e

C ~ o ~ a l npoMMeKa, u~a (a~e o cbc cToMaluHa coHAa, cbqaTa ~ p ~ 6 Aa ea 6 b ~o e~ a c n e ~ a C ) .a n n ~ OrMcTHTe~o nHo, TereH napa$m~, ~ o a n Ha e~ nwaeMqnTe. oopcupa~a AblYpe3a. AHTMF(OTHO n!reHMe C X0nMHOMHMeTMCIH.I ripenapam -Syntostigmin (Prostigmin, Neostigmin).flwxa~enHa peaHMMaquR. Kynupa~e Ha raproeeTe M noTwcKaHe Ha nCMXOMOTOpHaTa ~ b 3 6 y ~CUM~TOM~T#'-IHO a. nereHMe.

npo~w~e Ba o p r a ~ ~ npea 3 ~ anuraeMqaTa Ha orwe, p a mu , r~po~oo~espe~n HocaM c r o ~ a l u ~ o - r p e e ~ n ~ r npes paHM M napeHTepaJlHO.6bp30ce peaopn6ac MaKCMMaJlHa KoHqewpaqwR B n n a 3 ~ a ~ cneA a 112-2 h. O~ono 50% ce cabp3aa c n n a 3 ~ e ~ m 6 e m w , npeMMHaea K ~ ~ B H O ~ U K Parkisan (Trihexyphenidylhydrochlondum)M M a qewBopHaTa 6apwepa n ce n m r e a npes 6b6peq~~e. TOKCMpaneH n n o c n a h n3pa3e~ nepw$epe~xonnHonwnreH rHOT0 pleilCT~Me Ha Atropin C e CBbp3m C KOMneT~BHOTO KT C IlOBnMFIMHe Ha BCMCIKW @PMM Ha naPKHHCOHM3M H x M ~ M ~Ha ~ H MymapnHoenR ~ e$em Ha aqeTnnxonnHa, Ma. 6nM3KM no Hero no q y w y p a M $ a p ~ a ~ o n o m r MeAMaTOp Ha XMMUOpe~enTOpWe Ha HepBHaTa CMCTeMa, ~ e l m u ca e npenapame Norakin, Akineton, Akinofil M ~ p T. e. npwremaa awnxonntiepmqeti e$eri.

KCM rpyna B nonoxewe 6, XMHOK~M~~MHOB npbcTeH c BnHnnoaa rpyna B nonoxetime 3. Y Hac ce npnnaraT cnepH#Te npenapam: Cortex Chinae, Extractum Chinae

gluidum, Extractum Chinae siccum, Tinctura Chinae compositum, Chininum hydrochloricurn, Chininum sulfuricum, Chininum taninum M RP.

UMM. rbp'io~e, HaPYllleHHR H aA H W a H e T O HXeMOflMHaMHKaTa, KOMI. Parkisan ce ~snonsw OT ToKcHKoMaHH, ~aG-Lcec~o Ha'iMHaeu\M, npeflMMH0 B paHHa loHOWeCKa Bb3paCT 3a

saonawomO
e H T M .

T OTpaanHHn ~ ~ npn TaKaw rpyna naqw

n~aruocnnwa
AH~MH~cTHL~HM naHHMxiK O H T a K T C aHMnaPKMHCOH0B M JleKapcTw, KnMHM'iHa K a p T M H aC X O n M H O n b l T M ' i e HC H H -

n A O K ~ ~ E IH ~a H Parkisan ~ B ypnHaTa.

nn@epeuqnan~a maruo3a
cbmpxaqw Atropin,

C ompa nwxom, oTpaemie c Atropin M neKapcrBa, c n a t i T e p m rb6~.

~060n~nu noeweune o n necleune

C T O M ~ UIlpoMMBKa H~ CB O R aH n Mpa3TBOP H a MeflHL(HH C W BbrneH. ~ O M C Ha K ~OMOTOpHaTa ~ H ~ ~b36yna C Diazepam. AHTMfloT Syntostigmin (Prostigmin).

Cneoruo 60n~wuo nneune

CTOM~W npounerca, H~ aKo He e ocaqemeHa. Cannwo o'i#cTwenHo. b p w p a ~ a Awypexi. AHTHAOTHO neLceHwe CM: Syntostigmin, npommrentio npwnaraHe H a Diazepam B ~ sclco~ll B noau 10-20-30 mg enHoKpaTHo nopaM T e m K nennp n noeTapntie ~a~ o m npn ~ a wiepn w e Ha e@ma h.

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Ha cnyxa.

Kap~moeactcynape~ CHHAPOM: npoRsRBa ce ycnoPeflHO C ~ ~ ~ ~ ~ ! J ~ T C 6nefloc~ oKcM Ha ' KOXaTa ~ H MM R nUranenypaqu~ Ha XyMopanHaTa cpefla cnewHo rpe3 B M q M T e , qua~03a H cryflew ~ p a i r ~ u qnpoMeHu n, B nynco@pc~pa~ fl~ypesa a 0640 4-6 1/24 h npM neK# n cpegHo BaTa V e C T O T aK b M TaXMKaPflHFl npM P M T M M i ' e H nync~o6pe TeXKM @PMM; O ~ M ~ H H KpbBOnpenMBaHe O IlbpBMTe2-3 h HananHeH lrnM M e K M pa3rpbqa~e Ha eKmToKcuveH UIOK np# TexKMre M X ~ M O T P ~ H @ ~ ~ npn M RKonanc; paHHaflMaC b CC p M B Ha LplplcynaqMRTa.HRKOU aBTOpM OnMCBaTTeXKM n ~ anpes a n b p e ~ vacoae. ~e A ~ x a ~ ep ne ~ a ~ v ~rpea a q P M T b M H HHaPyLlleHMR, E K ~ - ~ ~ O C M IlO ~ nUTOnHM HH eKCTpaMHT@~L(MR M aCHCTHpaH0 flMWaHe IlpM TeXKMTe @PMM, CMcronu no speMe Ha WOKOEOTO cbcroRHMe. Micoren M ~ Cordiamin M no 1 amp. npes 112 h HeKonKoKpaEKr-npoMe~M~e woraT fla ce B cnefltime THO nplr anHOe; ~pOTHB0KOna~CHM ~0KTeAnllC Effortil, HanpaBneHMR:IlpOMeHU B b B B ~ J ~ ~ ~ ~ ~ H( M T~ O XC HK T~ TP~~ ~ M R Noradrenalin M rn~KoKopTnKowflM. Vitamin C B ~ BMCOKM B U n U 6papU~apflMR); npMeHM B IlpOBOflUMOCTTa (Bb~penfl031.1, Vitamin A 100 000 U 3a npoTeKqMR Ha peTMHaTa, PeflCbPflHM eKCTpaCMCTOnH, AV-rIbneH UnM HeIlbneH6no~, Vitamin B,, Vitamin B,, no 500 Gamma. C n a s ~ o n ~ HapylLleHUeHa BbTpeKaMepHaTa IlpOEOflUMOCT,M 3 R B e H aC Nicotylamidno 2 amp. S. C., Papaverin0.02 g 2 nbTM no 1 nbneH M n M HenbneH 6eflpe~ 6no~). flpaeu BneraTneHMe amp. s. c. 3a npemtmpatie Ha O $ T ~ ~ M O T O K C M ~ H npoMT~ HallUqUeTO H a~ ~ M ~ O K H U S 3b6~U. I / ~ ~ M ~ H ~B H S-T w R T ~ MeHM; napa6yn6ap~o H O B O K a M H O B MM a T p O X M H O B M pa3TCemeHTa M CHmeHMe non ~ a o e n e ~ ~ pnuHw ~r~a C ~ a BOPM. XOpU30HTaneH MnM HMCXOflFlq BbPBeX B HaClXlHaTa WCT, cHuxeHa U p a 3 ~ 1 ~ p T-sbn~a. e~a EKr-npo~e~me MoraT fla 6bfla~ eRwHcraeHa npoma Ha M H T O K C U K ~ ~ U R T Peru~. CTPMpaT C e B HaVMHMTe 'iaCOBe M nOKa3MT 6bp3a flMHaMnKa, KaTo noHmcora npnm O ~ ~ ~ Tp H a3 Oe ~ ~ u cnen e H R K O n K O 9aCa MnM Ce 3WpXaT 1-2 fleHOHOQMR. AHM~HHOBMT~ npOM3BonHMCa F ( ! p M B a T M Ha napaaMMPasn~raaahne cnenHMTe KnMHnwu@ p ~ w HaxuHMHoH ~ H OH~a f .) T I o T ~ ~ ~ R IIlpenapaTH ~ ~ H M T OT ~ Ta3U rp)TIa B0 OTpaBRHe: ca PhenacetinM Paracetamol, c noAvepTaHaHanreTweH r a c ~ p $~ o~ p~ ~a (ne~a a c~ene~ rapeHe, ): noepbqaM no-MMKO aHTHnMpeTM'ieH ~ ( I ~ K T . He, OTnWHaIlOCT, MUflpMa3a,H 0C M ~ ~ ~ ~ ~ ~ ~ H O O ~ ~ O W T O RHMe. Kap~lnosactcynap~a eop~a (cpefl~oTema cTeBopra~n3~ npoHMKsaT a rnaeHo per OS, KaTo 25-50% n e ~ )0640 : PpefleHO C b C T O R H M e ,P H T b M H MH a P Y L L l e H M R , OT TAX Ce CBbp3MT C nna3MeHUTe npOTeMHM. E~MMHHHP HenpaauneH nync, woKoeo CbcToRHMe, HapytueHue Ha ce rpea ~ e ~ a 6 o n n a ~ p Ba repHHfi ~e ~ p o 6 (90%) M qpe3 $YHK~MRT H ~ a3 P M T e n H M R aHaJlM3aTOp (MMflpMa3a, HaMaypHaTa. OCHOBHMT~ ~e~a6onw M~ ~X ~~ nH M ~ ca M cyn4aH neHMe flo nmca Ha s p e ~ ~ eHa ) , cnyxoeug a ~ a n ~ 3 a ~ o p THa n rnloKypoHoeaKoHloraqHflc 0 6 p a 3 y ~ a ~ H a e cynQa~n (UYM B yWHTe H IlOHMXeHMe Ha cnya). bl rnlOKyp3HMflM. YBpeWc~la~ ' l e p H M R ~ ~ 06 6 b, 6peq~~

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M O ~ K a~Phenacetin , npnclHHnBaM M ~ T X ~ M O ~ ~ O ~ H H

B npoTnraHeToHa nmoKcnKaL(HmaC Paracetamolce ~a6ntofla~a CT~H~~HOCT. IC T ~ C I H (AO R 24 h) - rampo+HTemHarmw C I I I Y ~

~H CMeTKa ~ T O Ha Me~a60nM3klpaHeYBenMWBaHe Ha TpaHCaMMHasMTe M 6 m ~ p y 6 ~ ~ a . RHMB. E ~ M M M H U ~ 3a M r~~Ky~HOKOH Ill C T Q M ~ (3-4 p e ~ o ~ o t q~xenaTaneH. e) npo~s~lea TO B WPHMR p p 6 (rJlll~Mn~~~lora~(MR raqw) M npes 6b6peq~~e (ysenwraaaqoce npH an~anwce c noepbqatie, xe~a~euesa, mpeetie, mnTeHMUa, a~pa~ Ha eyp#HaTa M npM no-BMCOKO HMBO Ha K ~ ~ M B R CbHflMBOCT, O ~ ~ P K ~ H OM C KOMa. T PM OTpaBRHe C KneTKMTe Ha OpraHMTe CanMqMflaTMTe 6no~MpaT eH3MMM PhenacetinonnaKeaHunTasanorea~ oTcTpaHa Ha racTpoOT q ~ m n a Ha Krebs M cuyqaeaT BbrnexMppaTHaTa M HHTeCTHHanHMRTpaKT.K ~ ~ T BpeMe K O Cllep TOBa C e nORBRMacTHaTa O ~ M R H M ~ . e ~ a 6 o n ~a ~q~~a j~ ~oa s ea pesyn~a sa M ~ T X ~ M O ~ ~ O ~ MCMHR~OM HOB c qHaHo3a, pucnHeR, aHeOT KyMynMpaHeTO Ha CaJlMUMnOWTa KMCeflMHa M HaTpynMMR. Cnep 1-2 peHoHoqMuce ~a6nlopae.a peHaneHCMHABaHeTO Ha OPraHMrHH KMCeflMHM. YBpeX@I Ce npepMMH0 p o c~onclrypnn, a s o ~ po e O6H. ~ ~ ~ UHC - MO3b'iHaTa KOpa, KaTO npM no-HHCKMp03M npe06naaaa-r ab36yp~n~e npoqecM, a npM no-BMCOKM -penpeCMBHLlTe, CbnpOBOAeHM C TeMK fleXMflPaTa4MOHeH CMHpPM, HapytlleHMeHa B O ~ H O - e n e m p o n pasHosecMe ~~~o~o C TeXKa XMIWK~MeMHR M npOMeHM B KOarynauMRTa.
HM'iHO

CTOM~W IlpoMMBKa H~ M OC1MCTMTel lHO - Hakp06pe Natrium sulfuricum.

Cnopep Texema Ha mMHMrtime n p ~ s ~ ce aq ~a ~6 nlopaeaT 3 cTeneHn Ha canHqHnoeo oTpaeRHe. I c~enew-ne~a: rQeHe, noBpbqaHe, ~ O ~ B K enMraM CTPMYMI, CBeTOBbPTeX. II cTeneH - cpepHo TexKa: xe~a~euesa, pMapMR, rnaeo60n~e, n a p e c ~ e a ~ TaxMntieR, ~, TaxnKapaMR, u ~ p p ~ a sM a ,~ ~ O T R M B @e6pMn#TeT, ~ H ~ BopeqH po AexMApaTaqMg M aquposa. Ill cTeneH - Mtioro TexKa: penMP, nproae, 6enoppo6 e OTOK, ~ PMTbMHMHaPylUeHMR,KOMa. M O Xpace ~ pa3BMe M 06H. C ~ ~ M ~ M ~ OTPaBRHMR OBMT~ CleCTO IlpOTMClaTC yBenMreHaKanlrngpHanponycKnwaocT.

np# npMeM Ha no-rone~u p o s aHMnMttoBu ~ npenapaTM OTpaBRHeTO npOTMrla MHOr O TeXKO.

n0Be'ie OT 200 MepMKaMeHTM, KOMTO CbAbpXaT Acetysal (ecrrep Ha aqeTuncanMqMnoaaTa ~ ~ c e n ~ ce ~a), HapMraT canMqnnaTn. H a ~ l r p a urnpoKo ~ npMnoxeHMe B MepnqMtiaTa KaTo aHTMpeeMaTMrHn, aHanreTnrHw, aHTHnMpeTvrHn,TyGeplcynoc~a~wr~w M peayna~e~n cpepcrraa.
~~OHMKB B~ o Tp r a ~ ~ npea s ~ axpaHocMunaTentiaTa CMCTeMa. A ~ ~ ~ Y M MBH KpbBTa M T ~ CBbp3BaT 5040% OT CanMqnnaTme, a ocTaHanme ocTaaaT B ~ O H M B H P ~ HC~CTOO

~ ~ T ~ ~ H M3XOp M RHe T e PflpKOCT npM TeXKMTe OTPaBRHMR.

OCTPHOTpaBRHHR OT 3MHH
B
HaUaTa CTpaHa OTpaBRHMflTa C e npMrMHRMT OT

OTPOBHM BMMMOT rpynaTa B M ~ ~ ~(Viperidae) M A M c 4 npeAcTaslrTenM - nenenRtiKa (Vipera arnmydotes), O C T P O M ~ OT~OB CbAbPWa ~ T ~ CT~~PMHO~O BeqeCTBO , ~ O ~ HCO UyHecTa nenenRHKa (Vipera ursini), Y C O (Vipera ~I HeBPOTOKCMVeH '?@KT, e H 3 M M M ,X M C T a M H H H pp. npU~eberus), KaMeHapKa (Viperaaspis). O~poea~a ce 06pasyaa xaea M aHTMreHHM KarecTBa. Y ~ p e y q a q o ~ ~oe i l c ~ ~ n e B ) ~ n e 3paanonome~~ ~, Ha ropHaTa renlocT, n ce ~ 3 n ~ s 3a~O~BaKaTOMHTOKCMK~~HR,BXO~aHaKORTOCeOTWIIOnpea OTBOPM Ha KyreuKMTe 31611 npM yxaneaHeTo. w a anepmwa peaKuMR. 060co6~ea ce ToKcoanepmqHo C b C T O R H M e . AKO ~ O ~ H U R eT6wn npepBapMTenH0 MeprM3#paH,yCnOpeAHOCTOKCOanepMclHMRnpOl(eCCepa3BMO~poea~a cbnbpxa rnasHo ~ H ~ M M KaTo M $oc$on~naBa M MCTMHCKa MePlMqHa PeaKUMR. aa, ~ M M H O O K C M A nen~~pa3a, ~~~, x~anypo~~~ ~ae 3s a, ~o n a 3 ~aueTMnxonw. ; HacTbnw~ yepeyqaHMR Ha KoarynaUMRTa M BABeTe n O C O K M X e M O n H T M C I H M , XeMOpaMClHM M O ~ H K H O B ~ HWMnBaHe O ce nORBRBa IlapeUa 60TPOM~~TMCIH RBneHHR. H ~ ~ T H Ra T OTpOBaTa Ce YneCHRBa nKa, ~ p a a ~ e cbp6em ~ e , M OTOK, KOMTO npeMMHaeaT OT OT I#lTOnMTMCIHM npoueCM. Y B ~ ~ wCe ~6 Te n ~ b r M ~ ~ H F l K O n K O 'iaCa A0 1-2 AHM. $o@on~n~~ CTPYK-IYPM ~ w ~ e Ha wleTKme, HacnnBa mey>KnneaHe B o 6 n a c ~ ~ Ha a rnaeaTa M w m a , npM T b ' i H a AeCTPYKL(MR. O T ~ O B npMTeXaBa ~T~ M HeBpOTOKCMM H O X e C T B e H M y)KMnBaHMR MnM IlOnmaHe H a OTpoBaTa B reH e $ e ~ ~ . KpbaoHoceti c b ce ~ ~a6n10paea BnoluaaaHe Ha o 6 q o ~ o

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C b C T O R H M e , BMeHe Ha CBAT, PR3Ka OTnaHaJlOCT, rmeHe, PRAKO IlOBpbUaHe M AMIPMR. ~ O R B R B ~ Ce T O~PMBM,OTO4M H a WlenaL1HTe M Y C T H M T e , MHeKuMR Ha K O H I O H K T M B M T e . n p TemmTe ~ cnyraM ce ycTaHoaRaa eneM Ha mowCa, 6poHxocna3b~, AMCnHeR, W O K O B OC b C T O F I H M e . Cb3HaH M e T o ce Hapywaea, KaTo HacnneaT AenlrpM, conop, K O M a . Ha T 0 3 M $OH AMWaHeTO MOXe Aa Ce Y B p e R M AOnbnHHTenHO A0 anHOe.

J ~ ~ T ~ W H M RnepMoA T e OT 30 rnin 40 6 h. n p c l yxanea-

1. Vl3BwaHe Ha W M n O T O M 06pa60~~a H a ~PaHMVe KaTa C a M O H R K M BOAa (1:4), CnMpT M n Ma H T M X M C T a M M H O B M

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2.~ ~ M K O K O P T M K O C T ~ P O M ~ H npenapaTM M npM 0 6 4 RB~ neHMR M O~PHBM;B b B BMCOKM F(03MnpM WOK. 3. A ~ M X M C T ~ M M -H Alergozan, M Ahistamin 1 amp. i.
rn.,Calcium gluconicum 10% 10 ml c Vitamin C 6 a s ~ o i. v. 4. Adrenalin 0.5-1 mg S. c. npM Ternme cnyraw
(~36~m Ce a npM MHOrO B b 3 P a C T H M x0pa); A O n a M M H O B a MH$~SMR.

5.KMcnopo~~a MHXanaqMR, M H T Y ~ ~ ~ M 06~p1wea~e MR npM Hap)'WeHOAMUaHe M n M KOMaTO3HO CbCTORHMe. 6. PM OTOK B YCTHaTa KyxMHa M n U H a 1nOTMca M HenoBnmBaHe OT cpeAcTsaTa, npMnoxetiM uo T ~ K , ce snpbcKaa B rbpnoTo 1 ml Adrenalin.

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O~poaa~a Ha MO~CKMR UpaKoti nonwa a 'ioeeKa n p ~ y60waHe C n!pKLITe My. TR CbflbpXa HeBpOTOKCM'iHM Iloc-ras~ ce no xapamepHMTe patiuwM, ~ M M $ ~ ~ H M BeqeCTBa. 06ycnaa~U TOKCOaJlepM'iHMTe RBneHUR B Ta, oToKa, n ~ o 3 a ~ Ha a menawe. TR uoxe pa 6 b ~ e XOAaHaMHTOKCMKa4HFiTa. 3Ha'iMTenHO 3aTpyAHeHa.
ffiHHHqIia KapTMHa

npll CbMHeHMe 3a OTpaBRHe OT 3MRR C e flehCTBa, Kamo n p CMWHO ~ yxaneatte. 1. HanaraHe Ha cTemaTa npeepba~a HWMRCTOTO Ha yxaneaHeTo (T~PHMK~T) C OTnycKaHe npes 30 min. 2. YGowa~e c Mrna M n M cKannen Ha HRKonKo MecTa o~ono yxanatim y'iamlc M n a u e w a ~ e Ha KpbeTa. 3. I~POTMBOBMM~CKM c e p y - 1 amp.(100 AE) oKono yxanaHoTo MRCTO M 1 amp. i. m. 4. KOPTMKOCT~POMF(M BbB BHCOKM g03M npM WOK dMnM Adrenalin 1 mg S. C.; MH$Y~MFI C Dopamin npu HenoBnwRBaHe Ha WOKOBHTe CMMIITOMM.

Y ~ o ~ ~ce H npwflpyxaaa ~ T o OT c ~ n 6on~a, ~ a noc~oRHHO 3aCMflBaqa C e 40 HeTbpflMMOCT. ~ O R B R B C e ~ OTOK, o6xeaqaq M CbCeflHHTe TbKaHM. CKOPO CneA TOBa C e IlORBRBaT M O ~ ~ O T O K C M C I H RBneHMR M KaTO TeXeCT B l%PpMTe, s a ~ p y ~ ~ e ~ o p ~ CTyAeHM u r a ~T eP, ~ ~ K M rqeHe, , noapbqatte. Pase~ea ce WOKOBO CbcromiMe. llpu MHoro TexKM C ~ ~ ~ M C ~ ~ ~ C R ~ ~ M C ~ ~ H ~ H M ~ T O - ~ HapyweHuR Ha puuaHeTo.
flo60n~eq~ noseIeHue o H neqeHHe

1. A ~ a n r e 3a ~~ noTMcKaHe u~ Ha 6 0 n ~ a ~ -a Analgin, Morphin, Droperidol M Fentanyl i. m. 2. A H ~ c T ~ ? T6 M n' ~ oH ~~ aO aK O n O y60fletiMR YaCTbK. 3. ~ ~ H K O K O P T M K O M ~ M - Urbason, SopolCOrt M RP. BbB npoeewa ce c n ~ o 6 ~ n ~ Ha 3K a ~q~ ~ AH ~M ~ K~ a, s e e ~ BMCOKM A03M npM WOKOBO CbCTORHMe. npeepb3~~, Kounpecw. np~nara ce OTHOBO cepyM no MH4. AHTUXMCT~MMHM - Alergozan, Ahistamin MAP. no 1 AMKaL(MM,MH$Y~MOHHO M ~POTMBOWOKOBO Jle'ieHMe, aHTMamp. i. m. allepM'iHM c ~ ~ F ( c T B ~ . ~ o c TC ~ eB MR TeTaHMCleHaHaTOKCMH 5. ~ P KOMaTO3HO H CbCTORHMe M n M HapyWeHOflMWaHe (TAn), npOTMBoTeTaHM'ieH CepyM (CAT), ~ H T M ~ W O T W ~ M . ~ ~ q 4 i Mao6~nluaa~e q ~ ~ c Kwcnopop. Xnpyp~wio nerewe, aKo ce Hanara.

Cnew~o ~OJIHHVHO neveHHe

~ ~ O T M ' ~ ~ Ha H OTpaBRHeTO ~ T O O~MKHOB~HO e 6naronPMRTHO. PR~KO, n pK ~ ~CHO 3ano'iBatie Hane'ieHMeTo, npu yxanaaHe no rnaeara Mnn wMma M npw flew MBXOA~T

nere~ne~ cneA o xocnw~all~3a ce q npoaewa ~~ cbc cbqnTe cpepcTBa: ~ ~ 0 6 n n ~ s a Ha qw sa ~cer~~ ap ~a~ h~ HHK, ~ a 3 ne pe ~~ p ~ b 3np# ~ ~ .napesn Ha n e p ~ $ e p Hep~~ BM - H ~ B P O T ~ M ' ~Jle' H iO eHMe.

aneprww ~ ~ ~ O J ' I R B ~ H C., M RM~F(ML(MH~ . M$ ~ s ~ y n ~ y p Benresa, X., OCTPM O T ~ ~ B R H MC R XMHMH B p , e ~ c ~ a ~ a Bb3paCT. C., flMcepTal(MR, 1978 1977 MOHOB, A. ~ ~ M H M T ' ~~ H~ ~ ~ ~ ~ O C.,nBeHen, O ~ f 1995 l. reWeBa, M., OT~~BRHMR C XnOp M a30THM OKHCM. C., Hn~onoaa,M., OCTpM eTMneHrflMKOflOBM OTpaBRHMR H ~~MC~PT~ 1982 ~MR, aHTnAoTHo ne'ieHue. C., 1986, f l n c e p ~ a u ~ ~ M a p ~ ~ oA., a ,O T ~ ~ B R H c flumanncoBu UR npenapam. C., XyGe~oea, A., $)anoMflHa m 6 ~ a MHTOKCMKaL(MR. C., ~~HC~PT~ 1989 ~MR, fl~cep~aqw 1979 ~, MupqeBl OcTpu OTPaBRHMR C 6eH30flna3enM~0eM Matthew, J. Ellenhom, Donald G. Barceloux, Medical ToxnpenapaTn. C., fl~cep~aqcll~, 1977 icology Diagnosis and Treatment of Human Poisoning, MOHOB, A., Ulo~oen C~CTOAHMRnpn ocTpn TOKCM~HHM New York, Elsevier 1988

PA3RE.n XIX

Aopa T a ~ ~ e e a Ene~a rbopeea Enmcaeera Bbrne~oea Cnac Cnac~os

H~lronah AT~H~COB Orun~ X~~H~CKH Pocmqa M~lueea

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574

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i'Ha nOCOKa C qen Aa C e O T ~ ~ ~ M fl ~ MH xaTenHMTe R T ABMXeHHR Ha WbpHMR KOU. BCRKO 3 a 6 a ~ Ha ~~ HeKpeKTOMMRTa e po ~ a n p a q a ~ e Ha ~o nocTpqanMR B c n e q ~ a n ~ 3 ~ p saeepe~~e ~ o x pa e n ~ a @ a ~ anocnepuqM n~w 3a K P ~ ~ H ~anper~a~oc Ha i rnocTpapanMR a npaam 06e36on~~a~e- K a ~ p o p ~ 3 a n a q M e ~ ~ a . TO BaxeH @aKTop BnereHMeTo (Analgin,Lido1,Antialerzin). OTKPHTO nerleHne. n o ~ a 3 a ~ eo npn 6 0 1 7 B ~TemK ~ ~RJ~OCTHOTO n!i'eHMe Ha WOKa BWIIOCIBa M KOpeKqHR peKouneHcMpati WOK M ronmo wsrap~~e, KaK-ro M npM M3raPRHMR HanMqeH nepMHeyM. Ha p a 3 ~ ~ n ce a~ aqwpoaa, a atrrwarperatrrn (Heparin), BMTaMMHoTepanMR (Vitamin B M Vitamin C), npo@~nawn~a n a q ~ e t r r cnep ~ ~ enocl~mea~e ~ap a ~ m ce e nocTaam Ha CTpeC YnKyCM. AHTM~UOTHKOT~P~~HFI He Ce npklllara. B 3aTOIlneHMCTBM, B CTepMnHM clapllla@M, KOMTO Ct? CMeHRT no Bpeue Ha nereHMeTo ce Ha6ntopa~aT xeMopMtianepnopMrHo, M n M ~bpxy @ n y p ~nerna. u Mn'iHMTe H xet,-IaTonorMrHn-re noKa3aTenM- plrlwatie, q ~ ~ ~ K P H TnereHne. O Ilpeepb3~a~a qenM pa noeMe PKynaqm, IlpOMeHM B Cb3HaHMeT0, 6b6per~a @ ~ H K ~ M R ,paHeBMR eKcypaT, pa npepnasM paHaTa OT 6 a w e p ~ a n ~ K M C ~ ~ H O - a npaeHosecMe, ~ a n ~ o onacHocT OT xMnepHHoceMeHReaHe,panopnoMomeen~~en~aaq~~~aM @Y~MR (no-'iemo npM peqa). 2. n o ~ a n nerleHne. ~o B c n o ~ o h 60nHMrHa ~a 06craHoeKace npeoqeHHaa oqe sepmx nnoqTa Ha ~ s r a p ~ ~ e - HMR nepwop cnep ~ a r a p ~ ~B eb ~n op. e ~ re ~ He MoraT pa TO. no-TO~HOTO onpepen~~e Ha nnoqTacram no cxeMaTa 3ana3RT M3unO PaHeEiTa IlOBbpXHOCT OT 6aKTepManHa Ha C. Lund M Browder. Tp~6ea pa ce s~ae, r e poKaTo npM KOnOHM3a4MR, eXeflHeBHMTe npeBpb3KM M 6 a B ~ o r n~ 10 B~~P~CTH ManKa M T ~ rpewa B onpepenRHeTo nnowa Ha Ha~anmaHe Ha ~ a 3 u B~~MOXHOCT. Hah-nopxop~q~ KpeM~~~PFIH He ~e T onacHa, O TO npM peqa M oco6e~o 6e6e~a MoBe 3a qen~a ca cbgbpxaqMTe 1% cpe6bpeH c y n @ w ~ R O p M M M a K M HeTOClHOCTM MOraT pa 6bpaT @ ~ T X ~ H M . a3MH (Flamazin). AKTMBH~T~ MM CbCTaBKa M cpe6bpHMTe OHM, weTo p e h m ~ ce ~ ecbreTaea c TOM Ha ocao60peAbn6orln~a Ha H ~ T ~ P R H ~ T f lOp. ~ I CTeneH ce ycraHOBRB~ aarepe~ea~e Ha KoxaTa. !PM IIc ~ e n -06pa3ye~ HMR c y n w ~ a ~npn ~ p nlrnca . Ha Tawm KpeMoae c nopoeaHe Ha MexypM OT oTpenetiMn OT RepuaTa enwpepMnc n 6e~ KT e O.~%-MRT Pa3TBOP Ha cpe6bpe~ HMTpaT. npM 111 A - TO'iKOBMflHM KPbBOH3nMBM no 3arepBeHaTa MO~HM npenapaTM T~ (Povidonjodin, Braunovidon, pepMa. Jodasept) ca 3a npeAnorHTatie npM mnKMTe no nnoq P ~ H M03flpaBRBaT T~ CnOHTaHHO B o 6 u r a h ~ ~ 3a ~e H3raPRHMR (p0 15%). AKTMBH~T~ CbCTaBKa e 1O%-eH h0pbn60~MHaTa Ha w 3 r a p ~ ~ cpoKoee: e~o npn I cTeneH - 2-3 peH KoMnneKc c amMBHo 6 a w e p ~ q ~ pehme~e. p~o AHTMAHM, npM 11 CTeneH - 8-12 A H M , npM 111 - 18-22 PHM. ~ M O T M C I H M T ~KpeMOBe 3a nOKWIH0 IlpMnOXeHMe He C e npenopbrew. n p pbn60~0 ~ ~ a r a p OT ~~ Ille A creneH, Ha onpepeneHM @ Y H K ~ M O H ~ ~O HM ~ ~ ~ C Ha TT H R n O T O (KHTKB, rne3eH, CT~B IlpaBMJl ~ ) HOTO JlereHMe e O ~ ~ ~ ~ T M B H O TnpM O , 111 6 cTeneH e yHMqoxetia~ o x a B ~ ~a n aL p ~ea 6 e n ~ ~a anpn , B nbpeme racoee cnep M ~ ~ ~ P R H e ~B T ~~ OM O X H pa O IV ca s a c e m a ~ M~ c-rpymypme nop KoxaTa - MycKynM, C e pa3BMRT CneflHMTe YCnOXHeHMR: CbflOBe, KOCTM, CTBBM. ~ ~ W H HHa ~ Te3M T O M3raPRHMR e -OTOK Ha nMueTO M WMRTa - MOXepa nPHCiMHM CMbPT onepaTmHo. 'ipe3 ~C@HKCMR IlOYeCTO, OTKOnKOTO CaMOTO M3rapRHe; P~HHOTO nocTbnBaHe Ha nocTpqanHTe B cneqnanM- napMHmaneH cna3b~ - nonyraaa ce ~ah-remo OT 3MpaHMTe qeHTpOBe npaBM Bb3MOXHa PaHHaTa KpbBHa MH~ahblpaHe Ha TOKCM'iHM XeHTM; HeKpewoMMfl Kano npM ManKwTe, TaKa n npw roneMwre - napMHMWleH OTOK MnH O ~ C T P ~ K ~ M Ha R rOPHMTe MX~PFIHMR. H ~ ~ - ~ O ~ X O BpeMe ~ L L (3a O sano'iea~e TO Ha pMxaTentiu nbTMqa pep^^ B T O ~ M e~an) - pa3e~aa ce ~ ~ e onepaqm 3 ~ e OT 3 po 5 ~ H cnep M M~~~PRH~TO. Cnep RMpeKTHM MBraPRHMFI Ha rOPHM EMXaTenHM IlbTUqa, HeKpO- M $ ~ C ~ M O C TeO M3BbpUWT M ~ ~ npM gbn60~M a caqo TaKa M aKo nerettMeTo M TpaHcnopnT ce 3a6aaf1~ 111 6 M IV CTeneHM UMPKynRPHMM3rapRHMR HenOCpe~CTBec 4,6,8 h. HO cnep npneMaHe Ha ~ O ~ H M 3a R , pa ce npeKacHe KoMn3a nHTy6aq~~ nnn ~ p a x e c c r o ~ ~up~~ l 6pa ea ce MucnM pecwma sbpxy cbpoeeTe, HepsnTe M MycKynme B pbn60-

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~a A e i c ~ s w e ~ ~a o enelcrp~sec~ TOK a~

~a ~ ~ ~ C T B H ~a~enetmpersec~crn TO TOK

n p ~ r c l 3a ~a enempouroKa ca Kamo npeMMHaBaHeTo ~ a e n e m p ~ r e c ~ ~ ~ ~ o ~ n p e a ~ e ~ ~ p o e e ~ e ~ a c b p ~ e r ~1. aH~ enowraa~n eneqnrecwn H ~ ~ ~ P R H H I p ~ x a ~ e~ ne ~a i i ~B o~ c0~ 3bM ~p a a 3 c ~ p o i i ~ a ~a ~ eTRX~o PM TRX enempMrecKwT TOK tie npeuutiaBa npes H~T~~YHKUW TaKa F I , n pMpemHme yepepw Ha p a 3 n u r ~ ~ ~ e TflnoTo. cHcTeuM M opraHM.

Mexauna~ Ha sb3u~~saue

CHM~OM~T~K~ HepB~a cucrelua. M 3 p a 3 ~ ~ ce a c pa3nMrHa no men en ~o ~ p a r e ~ ~a o cC~~ ~ H ~ H M p0 ~n TbO n ~ a MY ~ a381368. n o ~ ~ ~ce o ~a6nlo~aea ra sb36ypa Ha nocTpqanme. YepeflMTe Ha nepw$ep~#~e Hepaw ca p e 3 y n ~ OT a~ pMpemHoTO MM 3 a c ~ r a ~ OT ee n e m p ~ r e TOK. c~~~

OTelleKTPMVeCKa MCKpa-npepM3BMKaHM OTHMCKOBOnTOB TOK, IlOpWH HeM3npaBHOCT Ha YpeAMTe Bfl0MaI.UHa 0 6 m a ~ o ~ ~ a ;

Or e o n ~ o e a p b r a - n p e ~ l n 3 c~ a~ o~ ~a u~ co ~~ o e o n ~
Cwsrnoaam~a
lloc~pwan~ OT ~e enempMrecKa McKpa ca noeere OnyUleHM H YIlnaweHM, a M3raPRHMRTa Ca OTpaHM%'HM W
I l O B b P X H O C T H M . Kora~o M 3 T a P R H e T O e IlpM'iMHeHO OT BOnTosa pbra, TO e c xapamepMcTMKaTa Ha nnaMbKoeo. Vec~o

Cap~ev~oca~loea cucrewa.O c a e y ~s p e n ~ B ~ MOe

3bVHMTe UeHTpOBe, IlOpWeHMRTa M O M T fla 6 b m M ~Cne-

RcTaMeOT pMpemHoTo 3acRraHe Ha npoBopHaTa CucTeMa,

I l p O f l B R m q O Ce B aPMTMMM, KaMepHM 4 ~ 6 p ~ n a q M~ aCMw CTOnMR. fluxarentia cmeua. A ~ w a ~ e ~ noebpxHocTHo, o ~ e e Q e m ~ ec ~nays~ o , Ha antioe, ~ P M ~ M H M MoraT T ~ pa 6bpaT M A M P e K T H M T e TeTaHMVHM K O H T P a K U M M Ha AMXaTenHaTa MycKynaTypa M ~eebannox~ocna 3a pMxaTentiM eKcK y P 3 M M BCnepCTBMe Ha 4 M P K y n R P H O M pbn60~0 M3rapRHe Ha T P b p H M R KOLU.

eCbreTaHOCMeXaHMVHaTPaBWnpMn~aHeOTBMCOK0 (c~bn6, BaroH M pp.).

2. KOHT~NTHM eneltrpnuecwn n 3 r a p ~ ~ n
EnelcrpMclecKMRT TOK flOflMp C IlpOBOflHMK. Toaa

npeMUHaBa npe3 TRnOTO npM

C a TMnMrHMTe eneKTPMreCKH

O~~enurentia cucreua.C ~ y q e ~ aba w ~~ ~ ~Ha KUMFITa Ha 6b6peqMTe ce pbnxaT HaA-~ere H a 3anywaa~e Ha

M 3 T a P R H M R . nn0q~a Ha M3raPRHeTO He TOnRMa, PFlAKO HWeMuraea 10-15%, HO nopmeHmTa B pbn60rMHa ca M H O r O TeXKM.

q 6 y n ~ OT ~e OTpenRqMn ce ~worno6n~ OT HeKpoTMrHwe MycKynM MnM Ha paae~na ce q 6 y n ~ a ~e~poaa. Yepep~~ ae ac~ra M~ ocTatianMTe opraHM M C H c T e M M .

M M ~ BXOpHO T MM 3 X O A H OO T B b P C T M e (~OHFIOT ~ A H O ) . HanopoG~sa~ ~paTep006pa3~M paHH C p b n 6 0 H ~e ~ K P O B M ,C M 3 T a P R H M R Ha M Y C K y n M , KOCTM M CTaBM. n0pWeHMfITa Ha B X O p H O T OO T B b P C T M e M noKOra IlOBere

576 m Cnerunu cacmonnun BcnegcmBue Bpegnu BatgeOcmBun na okonnama cpega

TeXKM, OTKOnKOTO Ha H3XOflHOTO. TMt7MclHa e napa,qoKcanHaTap a 3 n ~ Meyqy ~a Haxop-

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H e K P O T M q H M T eM Y C K y n M , B O P R T p0 6bp30 pa3BMTMe

3anor~a ce c snwsaHe Ha KpwcTanoMpHn pansopM (Ringer Lactat) p0 OTpenRHeTO Ha WeKBaTHO KOnMcleCTBO ~~e ypMHa. Oco6e~o roneMu KonlrrecTsa BnMsaHwR ca ~ e o 6 X O A M M M npM B M C O K O B O m O B M T eM 3 T a P R H M R . flpM T e 3 M naHa U M e H T M 0 6 e ~ Ha b~ B n M B a H M R T a e 40 pea nbTM no-TOnRM, OTKOnKOTO npM IlaUMeHTMCbCCbqHTe no nllOU&HOTepMMq H M M3raPRHMR. OCHOBHMRT ~pM~epMa 3a QeKBaTHOCT Ha MH$Y~MRT T~P R ~ B pa ~ 6bpe p~ype3a OKOnO 100 rnllh 3a Bb3paCTeH6one~ M OKOnO 1-2c~lkglh 3apeqa. AKOnMrLIeHTypMRTa nepcwcTupa HRKonKo claca, w3non3sa~e~o Ha Manitol sa pocmratie Ha p~ypesa 200-250 mVh 3a HRKonKO claCa, M n M 3a H~AHOTOM ~ ~ M C T P ReH3a,QbnXMTenHO. ~ flp~narace Natrtiurn bicahnat 3a K O ~ ~ K ~ ~a Ma Ry ~ p o 3 a Ta. AKO He ce nocTMme aWoeonMTeneti e@em OT TOM necletiwe, ~ p ~ 6 pa e ace o 6 c b p ~ p ~ a n ~ nerewe. a ~ o
nMR.
flap~en~ C 0PeaHMMaqMOHHMTe M e P O n P H R T M R Ce M3BbpUBa M HeOTnOXHa XMPypMclHa 06pa60~~a Ha nOKanHMTe nopaxeHuR. TRce ceeyqa po npeqetiKaHa nnoqTa

M pbn60clMHa~a Ha ~ 3 r a p ~ M ~06pa60~~a e ~ o Ha paHeBMTe nOBbpXHOCTMCaHTMCenTMrHMPa3TBOPMHOTF(enRHeTOHa C T p a H M C l H M 3aMbpCMTenM M CBJlecleH enMTen. flpM HallMclMe Ha 4 M P K y n R P H M M3raPRHHR Ha K ~ ~ A H M ~ M rPbIHMR T~, KOW M UIMRTICe M3BbpUBaT H e K P O T O M W MM @ ~ C ~ M O T O M W
H 3a ~ 3 6 ~ r e a Ha ~B e T O P M c l H M T eH e K P O 3 M OT C M y T e H O T O opocRsaHe, 3a ocMrypReaHe Ha ~ o p ~ a n puxaTenHM ~u e K C K y P 3 M M Ha rPbpHMR KOU U38 HaMaJlRBaHe Ha KOnaTePMHMTe OTOqM.

3anoraa ce c n 3 ~ n l o r ~ Ha a ~nocTpWanuR e OT eneKTpMclecKaTa BepMra, rpes O T M ~ ~ T B Ha ~npoeopHnKa H~ H n M M3KnH)CIBaHeHa TOKa. AKOIlOCTpWWMRT MMa CMyu(eHUe B XM3HeHMTe $ ~ H K ~ H TH P ,R ~ B fla ~ Ce npOBepM npOXOflMM O C T T a Ha AHXaTenHMTe nbTMu(a M npM H ~ O ~ X O ~ M M O pa CT ce 3 a n o r ~ eM B K ~ C T B ~ HpMwme O M CbppecleH Macax.
T ~ ~ H C ~ O ~ Ha TM 6o ~n ~B ~ H 6~ e ~3T cb O 3~a~en C ~ b C 0 T O R H M e M Ha TaKMBa C b C CbMHeHMe 3a Il-aHe

n o - H ~ T ~ ~ Wneclenve HOTO Ha enenpMrecKMTe ~ 3 r a PRHMR ce nsebpuea no o 6 q ~ npMHuMnM ~e Ha nnacrMclHoBb3CTaHOBMTenHaTaXMPYPMR.

OT BMCOKO

~ p ~ 6 pa e aCTaBa Cnep KaTO Ca B3eTM BCMclKM MePKM 38 HeflOllyCKaHe Ha AOnbnHMTenHM YBpeflM, oco6e~o npU CbMHeHMe 3a TpaBMa Ha ~ P ~ ~ H ~ C Ic~bn6. H I I R flpeBpb3~M
Ha M3raPRHeTO Ha M R C T O T O Ha MHL(MpeHTa He Ce npaBRT. noc~pwan~~l~ Moxe caMo pa 6bpe nocTaeeH B ~ M C T

XapaKTep~M 3a K O H T a K T H M T eM 3 r a P R H M R Ca BHe3anH M T e M 'ieCTM KPbBOM3IlMBM, nPMrMHeHM OT e P O 3 H R Ha

K P b B O H O C H M CbflOBe, OTnWHXI T P O M ~HIlM pa3BMna Ce

rapwa$ MnM ~

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noKpMeKa, saaeca.

HeKpO3aHaCbflOBaTaCTeHa. AOK~TO H M C K O B O n T O B M T eelleKTPMreCKM H3raPRHMR (C TOK p0 1000 V) npOTMqaT O ~ M K H O B ~ H O C a M O KaTO H3raPRH M R ,TO B H C O K O B O n T O B M T e(HW1000V) c l e C T O ca KOM~HHUpaw c enetapoKyqMo, a M HepRpKo ca cbreTaHM M c
nereHMeTo MM.

uexaHnrHaTpaaMa,KoeTo3aTpypHReapuarHocTMKaTa~

A ~ a m o c ~ ~ r ~ o - n e npo6ne~ r e 6 e ~ npM eneiupwecKMTe M3rapRHMR e CbreTaHaTa TpaBMa, KORTO yTeXHRBa npoTMraHeToHa 6onecna M BnowaBa npor~o3a~a. B~ e cnyraM ce Hanara ~ o n a 6 o p a c q~ ~p ~ a e ~ a ~ o nHeapooa~, X M W P 3 M M XMPfl3M. f l p e u e ~ ~ B Ce aBHMMaTenHO Bb3MOXH O C T T a 3a TpaHCnOpTMpaHe Ha I l O C T p ~ N I M R p0 CneqMan ~ 3 ~ p a nere6~o ~ o aaeepe~~e KbpeTo , pa npopbnxM

PeaHMMaqMOHHOTO H XMPyprMqHOTO Jle'ieHHe. AOPM M npM HanMweToHa cweTaHa TpaeMa naqueHnT c enelcrpweCKO ~ s r a p ~cnep ~ e ,c~a6un~3upa~e Ha xeMopnHaMMKaTa

M flMLUaHeT0, T P R ~pa B 6bpe ~ npMBeAeH B CneqMMM3Mpa-

Ha KnMHMKa M n M OTpeneHMe no n 3 r a p ~ ~ -e O~HKHOB~HO eTopoTo M n m TpeToTo peHoHoque cnep TpaaMaTa.

xMnoTepMlru. Te~nepa~ypa~a, ~ s ~ e pC e~~ ~~ aM H M H O , C~CTORH npM M~ KOeTO , M3MepeHaTa UeHTpXlHaTenecHa Teuneparypa e nop 35C. M H ~ M ~ ~ xMnoTepH T H ~ T ~ aKcMnapHo lrnM Ha TenecHaTa noebpxHocT, e TaKa HapeMMR ~ a i - q e c ~ eo csbp3a~a c npemofi B cpepa c HucKa qeHaTa TeunepaTypa Ha , O ~ B M B KHa ~T T~ ~O "TOU . e~~pa ntiaTa TenecHa TeMnepaTypa e ~ a 3Ha ~ octioeHMTe , opraTeMnepaTypa, 6e3 nbPBM'iH0 YBpeWaHe Ha M03bqHMTe HH -Cbpqe, 6 ~ ppo6, n MO3bK H BMCuepMHMOpraHM. TAC e qewpose, perynMpa4M TenecHaTa TeMnepaTypa. ~ s ~ e p rpes e a Tepuocottpa, nocTaeeHa B: xpaHonpoaopa C M ~ ~ T H e OT O 12-73%. C ~ ~ ~ (BPOnHaTa ~ ~ T B ~aPTePMR P T ) , nynMOHXlMC, PeKTyMa, Ha TMMnaHMqHaTa Me~6paHa. lla~o$m3monormr~1n npouecm.nporpec~e~o~ocn OCHOBHMT~ IlPMWIHM, BOpeU#l A0 pa3BMTMeTO Ha XMpaHe Ha TenectiaTa TehnnepaTypa B O ~ M 40 3a6aBRHe Ha noTepMm, ca: eH3MMHaTaaKTMBHOCT,M3pa3eHOpa3nMrHOBOT~enHMTe - ~anara~ Ha e cvp, npMppyxeH OT s m p M BMcoKa OpraHM M CMCTeMH. H ~ M X ~ R B ~ Ha HKMCnOpOpHaTa ~TO KOHB~WHOCT ( M O X pa ~ ce sacer~e Bcma ~ b 3 p a m o rpyna, ~a CyMaqMFi npeflM3BMKBa CMIMM$MK~HTHO 3a6ae~~ Ha eCKOH0 Hah-3a~~palueHM Ca HOBOpOAeHMTe M CTapMTe XOP~), POClla Ha C I ~ P H O ~ P O ~ HM!~a60nM3bM, MR MMaqO CbqeCTnouo noq6pa~o o6ne~no M ~C MM ~ H O M ~ T O U ~ Hca M~ pewaBeHo 3 ~ a r e 3a ~~ ue~a60n~3~pa Ha ~npMnoxeHMTe e~o saqM $a~~oplil. no-npopbnx~~en~o noTanRHe sba sopa c MepMKaMeHTu. C npoMRHaTa Ha TenecHaTa TeMnepaTypa TeunepaTypa nop 24C noHnxaBa ryecTBHTenHo TenecHacnnea M nponnwa B ~ ~ ~ T B O P M M O CHa T Tr ~a 3 o ~ e ~ Be HaTa TeMnepaTypa; KpbBTa. ~ ~ Q I ~ c M B H ~ T ~ ~ ~ ~ M $ ~ ~ H ~ B ~ ~ ~ (~ Ke o- TpaeMa, cbreTaHa c npopbnmwTenHo 06e3pelrxsanuua pa aanas~qeHTpanHaTa TenecHa ~ e ~ n e p a ~ y p He, ~ 3 r a p Ha ~ ~0e 6ur~p~ nnoq a OT TenecHaTa noabpxBOA# AO noBMwetia M ~ T ~ ~ O aq~posa. ~ M T H n ~ p cnqatie ~ HOCT; Ha TenecHaTa TeMnepaTypa, KpMsaTa Ha O K C M X ~ M O ~ ~ O - MepMKaMeHTH - MKOXOn (14-91% OT cny'iaMTe), HOBaTa flMCOL(Ma4MR C e M3MeCTBa HMRBO M HaMMRBa 6 a p 6 ~ ~ y p$ ae~ ~~ o,~ ~ a q #napanuTMrHM pn, areHTM; ocm60~aea~e Ha ~ KMcnopoAa o OT O K C M X ~ M O ~ ~ O ~ - npu npepsapmenHoyepepetiu xopa-~em~a cbppenporpec~~ p~ao3 ~ ~ ~ a q cea n ~n ae ~ a 6 o n ~ aq~po3a ~~a 'iH0-CbflOBa, 6b6peq~a M n M 'iep~opp06~a Hep0cTaTb.lvacTMqHo KoMneHcMpa T O ~ M npoqec. X w n e p a e ~ ~ n n a HOCT, TPYpHO neClMMH IlpoflbnXMTenHMM H $ ~ K ~ H M ; unH eKcTpeMHa KopeKqMR c Natrium bicarbonat, no BpeMe - eHROKPMHHM ~ H C $ Y H K~XMnOrnMKeMMFI UM , p~a6eHa PeCyCqMTaqMR, M O W OTHOBO Aa M3MeCTH KpMBaTa Ha THa ~ e ~ o a q ~ p oxMnepocuonapeH aa, CMHR~OM,xMnepTMO K C M X ~ M O ~ ~ O ~ M H OAMCO~Ma~MR B~T~ BnRBO. @ ~ H O M ~ H peOMAM3bM; .after drop" e npOrpeCUBH0 HaMMRBaHe Ha UeHTpMHaTa - CMFeHa qeHTpXlHOMO3b'iHa M QIb6Ha.lH0~03b~~a Tenectia TeMnepaTypa, cneA oTcTpaHusaHe Ha CTY~OBMR cTpec M n w no BpeMe ~a s a ~ o n n ~c ~n ee , sa3op~na~aq~ ~ $YHKUMM; - KOMHM 3a60JlRBaHMR - ePMTPO~ePMMR, nCOpMa3MC, nocnepeana noauwetia MycKynHa aKTMBHocT. T 0 3 $ ~~ H o MXlM03MC; MeH ce pbnxu Ha HaxnyBaHe Ha CTypeHa ~ p b OT e nep#$e- npM npopbnmmennw pwariioc-rMwHM ne.le6HM MHPMFlTa KbM TRnOTO, 6ora~a Ha CTpaHMCIHM M ~ T ~ ~ ~ ~ TepBeHqMM. npofllncrH.

C T ~ ~Ha ~ xunoTepnnuR: H M

- HOPMOTePMMR -n e ~X aM ~ O T ~ ~ M M R - yMepeHa xMnoTepMm - M3pa3eHa XMnOTepMMR

- pbn60~a XMnOTePMMR
Aa

- 36.6-37.5OC~; - 34.0-36.5%; - 28.0-33.5"C; - 17.0-27.5%; - 4.0-16.3'C.

M ~ o r OT o HXlM'iHHTe MBaqHMTePMOMeTPM He MOraT suep pea^ TenecHaTa TeMnepaTypa nop ~ a npM 3 neKa ~

C~ene~ Ha ~ HacnnunMTe a M ~ T ~ ~ O ~ MnpoMeHM THM abe BclrrKM opraHM M cumeMM e $YHK~MR Ha Temecna M npopbnxMTentioma Ha CTY~OBMRcTpec. Cbppe.1~0-cbpoeaTa cncTeMa pearupa nbpeotiavaniio c noaMwasaHe Ha CbpperHaTa qeCTOTa, Ha YflaPHMR 0 6 e M ~Ha CpepHOTO AH, pbnma4M ce Ha noeMweHoTo HMBO Ha q ~ p ~ y n ~ p KaTexonaulrtiM. n o e ~ w e ~ n ae ~p a~ $ e p ~ B~~OKOHCT a q M RB O p M A 0 IlOBMWeH UeHTpMeH KpbBeH o6eu - BUCOKO

578

Cneurnu cacmonnun BaegcmBue Bpegnu Ba~geircmBunno okonnama cpega

KOHCYMaL(MR,flOCneABaHaOTflOflbnHMTenHOCn~aHe H a UBH. C HanpepeaHeHa xMnoTepumTa, cbpperHaTa recTenecHaTa TeMnepaTypa. AMH~BMR Hacnnaa npu Tenet. TOTa M C b P R e i 'H M F I T YpapeH o 6 e ~ HaMMRBaT, flOKaT0 yceT omaaa CpeflHOTO AH OcTaBa HeflpoMeHeHO. B no-KbCeH C T ~ M ~ Ha TeMnepaTypa nop34"C, HO ~ O ~ K O B M R T 3ana3e~. npcl TeMnepaTypa nop 30CnocTpapanMTe ~ p y HacnnBa 3 ~ a w ~ e n HauanmaHe ~o Ha CbppertiMR ypaRHO pa3no3~asa~ 6nM3K~~e CM. peti o 6 e ~ Ha , capAerHaTa recToTa M Ha cpepHoTo AH. He e Ha6nlopaWH cnyrai Ha pbnbo~a KoMa, pbnxanpopnXM~enHo~0 MOHMTOPMpaHe Ha EKr llOKa3Ba np0q a ce caMo Ha xnnoTepMMR, n p Tenectia ~ TeunepaTypa QleCMBHO3a6aefl~e Ha C M H y C O B a T a reCTOTa, YAbflXeHM HQ 27C.TaKaBa Moxe pa HacnnM caMo npM 17% OT PR, QRS M QT-lr~~epBanM, MHBepCMR HaT-BbnHa,flpoQlec M B H a e n e ~ a Ha q~ QT ~ wwepwn, noma Ha BbnHaTa Ha cnyanTe c xMnoTepuuR noA 27C. nop 25C ~ s r e a a CyXOXMnOsborn MnM T. Hap. J - ~ b n ~npep~bpfl~bl a. $ ~ 6 p ~ n Ce a q ~ ~ 3eHM'iHHTe PeaKUMM Ha CBeTnMHa M ubn60KM~e ~a6nlopaea~ PFI~KO, npM TeMnepaTypn OT 34" po 25C. HM pe$ne~cu.nop 18C HanpaaeHaTa EEr e ~ 3 o e n e B ~ H T ~ M KQ~n ~ 6p ~~ ~nH aq Moral M~ ~ Aa Ce nORBRT npM pMrHa. TeunepaTypM nop 28C.E $ n ~ a c ~ o m Ha a npMnaraHMTe Mneyc, flaHKpeaTMT M repHoflpo6~a ~~MC$YHK~W Ce FI MepMKaueHTM no epeMe Ha KappMoqMpKynaTopHapecyccpeqa-r recTo npM XMnoTepMMR. Mneyc ce ~a6nmpasa M qMTaum e p ~ c ~ y r a 6 m6 ~p a .a p ~ ~ a eprecTo ~ ~ aTpo~~a npM TenecHaTeMnepaTypaHQ 30"C,HO BMHarw e HanMqe ~MHO~~~MCT~ Dopamin H T H ~ .M M a3 ~ a r ~ ~~ e$ n ~K ~ Ta MBnpM no-HHCKM TeMnepaTypM. HOCT, HO p o 3 ~ p o ~ MY ~a ~ ~p a h pa a ce npequ3~pa MH~HX M ~ O T ~ ~ M M R T ~ ~ nOTMCKa MP~KT OH CO B O ~ O ~ ~ B ~ BMflyanHO. ~ H C K ~ T ~ ~ H npMflOXeHMeT0 ~ ~ H O Ha LidocainM Ha MHcynMHa OT naHKpeaca M 6 n o ~ ~ p HeroaaTa a amBPropranolol. He ~ p ~ 1 6Aa e ace 3a6pae~,r e OxnapeHMTe HOCT B nep~$ep~ma, pe3yn~~paq Bo yMepeHo noeMtuanaqMeHTM~ ~ a ~ a ~ a r m e n ~ o p e ~ e$ewwae~ l y u w p aKpbeeH ~ BaHe Ha HMBOTO Ha KpbBHaTa 3aXap. X M ~ ~ O T ~ ~ M 3aCRMFIT o6e~ M HaManeHa C ~ O C O ~ H O C3a T ~e~ahnus~p Ha a ~ e ra 6enme M repeeHwTe K ~ ~ B H Tenqa, M T P O M ~ O ~ M T MM T npMnoXeHMTe MepMKaMeHTM. flOHRKbfle M KOaTyna4MOHHMTeI l p O ~ e C M~ . O K ~ flpM T O yMeP~HHM pecnMpaTopHln T~ npoMeHn ce x a p a ~ ~ e p n 3 ~ - PeHa XMnOTePMMfl Ha fleBK04MTMTe O C T a B a HOpMapal c noeMtueHa pMxaTenHa reuola, pbnxaqa ce Ha neH MnM neKo noBHuleH, TO npH TenecHareMnepaTypa nop qeHTpanHa cTwhnynaquR. l l p npogbnxMTenHo ~ oxnax,qa28C PFI~KOcnapa. HB M Ht ca noentuetiunopagqn HamHe HacnneapMxaTenHagenpecMRcHaManAeaHe Hapw nMnaTa ceKsecTpaqMu Ha Kpbma, pexvppaTaqMma, npMxaTenHaTa recToTa n o 6 e ~ .B b n p e ~ re ~ pMxaTenHMTe rwieHa OT T. Hap. .cold diuresisuM nomaTa Ha O T O ~ M AKO . F ( B M X e H M R MOraT Aa OCTaHaT MHTaKTHM M flpM TeneCHM xwnoTepnnMma nporpecMpa, ~ o ~ q e w p a Ha q ~ cepyM~ ~ a TeunepaTypM nop 25"C, ce ~a6nloflaaanoentuaaatie Ha HMR H ~ T P ce H ~noHuxaea, a Ha KanMR ce noBnwaaHaTOMM'iHOT0 M b P T B O flPOCTpaHCTB0, BOpeqO p0 HaMaaa.Toea ce mnmn H~A-sepom~o Ha noTMctiaTaTa~ H ~ M nmaHe Ha aneeonaptiaTa setiTMnaL\mn p sanaae~ ~ p~xaH a amMBtioCT Ha ~ a n ~ e e o - ~ a ~ pnonnna ~ e e aHa ~a KnenrTeneti o 6 e ~Yema . Haxoplta n p noc~papan~ ~ ca ~POHXMHaTa ~ e ~ 6 p aBbflpeKM ~ a . TOBa T O T a H a T a TefleCHa KOHTMTe M ~ P O H X O ~ ~ H ~ B M O H KOMTO M H , flOrIbnHMTenH0 YCnOXueHTpaUMFI Ha K ~ U IM M H~ TPM MOxe ~ ~ pa 6bpe 6 n ~ 3 0 p0 H R B a T ne~le6HMR flp0qeC. 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~~~cesa~~m~cyx~u~onn~o~eana~n~cnane~r~, Ycnope~~ co npomnxaaaqme pecycqMTaqMfl M MeaKo e B cb3nan~e, Moxe na nonyrn Tonnw noncnweHM pKn sa 3aTonnRHe ce nswpurm~ n H~O~XOAMMM noT~ HanMTKM. ~ C M ~ K nauMeHTM M C XMnOTePMMFI HnH CbMHeHMe HaTaTbUJHM ~MalHOCT#CIHH M na60pa~opHM np04!AypMl 3a TaKaBa ce x o c n ~ ~ a n ~ 3Mnoro ~pa~ recTo . e TPYRHO Aa BlcnlorBaqn p e ~ ~ r e ~ o r p a apTepManeH $n~, ~pba~oraao ce H B M ~ P H TenecnaTa TeMnepaTypaTa B ~o6onnurna 06aHMM3, h o ~ o r p a ~ a HB, , Ht, KpbBHa 3aXap, KPeaTMHHHM CTaHOBKa. n0pmM TOBa BHMMaTenHO M 6bp30 CHeTaTa ypefi B cepya, CPK, annwnasw, ocMonapMTeT M gp. aHaMHe3a M KJlMHM'iHa 0ueHKa AaBaT Bb3MOXHOCT 38 C ~ ~ ~ C T CnepHMTe B ~ M TMeTOAM 38 0 6 ~ 3aTOIl 0 nRHe ~e3a6aBH0 ~ 3 e ~ a Ha n epewewe OTHOCHO KpuTMrHocTTa -naCMBHO BbHUlHO3aTOllnRHe, aKTMBHOBbHUlHO3aTOnnRHacnyran. npn ~ 3 p a s e xMnoTepMm, ~a KoraTo nauMemT qeti~panno 3a~onn~~e. e B cTynop nnw Koua, ce Hanara He3a6aBHa M H T ~ ~ ~ ~ MHe, F I amBno . np# MeTopa Ha nacvsno B~HLUHO sa~onn~~ne ce M ~ M T a ~ ce a npepnasaa~fl~xa~en~me nbTnqaOT eeeHTyanna c ~ m n a q n e ~ ~fla b i e cyx, aaqmeH OT c ~ nys m ~p , aCnMpaqMFI. npM MyCKynHa PMMflHOCT M HeBb3MOXHOCT nOKPMT C TOllnM 3aBMBKM H n M CllaneH 'iyBan. no T03M aa U M ~ O K O oTsapFlHe Ha ycTaTa ce npenopbrea na30Ha'iMH C e HaMmRBa TOnnMHHaTa 3ary6a M C e n03BonRBa Tpaxeanna M H T ~ ~ ~ no6pe ~MF e no I . 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L ( ~ H T P W H BeHO3eH M ~ Kap ~ s ~ p Haa. a~e Mn# B. $e~opanwc, nos~on~eaqo oTAenRTeTbP ll03BOnRBa MOHMTOPMPaHeTOHa L(6H. nepM$epHMHe, aaTonnRne n spbqane Ha KpbsTa nocpeAcTBoM xeMoRT BeH03eH nbT MOXB Aa YBpepM AOnbnHMTenHO 3aMpb3pManMsHa MalunHa M n M oKcMreHaToptianouna. nanwe K P ~ ~ H M ~nM p .~ n a r a ce ~ pepeno XMnoTonMrnM n p n n a r a ~MeToA ~ ~ l ~Ha 3aTonnRtie ~pf16m Aa 6bpe K P M C T ~ ~ O M A HP M~ ~ T B O P M 3aTonneHM , 80 c ~ a i n Tewnepaa Typa. AKOXMnoTeHcMRTa nepcncTvpa n cried npoeeflenaHHflHBMpYaJlHOns6pan, KaTOC eM M a T npeABMA HallMClHOTO Ta IlbpBOHaVanHa MH$YSHOHH~ TepaflMR, C e BKJlDrBaT TeXHMWCKO 060py~BaHe, KapF(MOnynM0HaIlHMRTCTaTyC KaTexonawnM (Dopamin), BbnpeKcl r e PMCK~TOT KaMepHa nauMeHTa M npMApyxaBaqMTe ~ ~ ~ O ~ R B ~ H M F I . 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n~ ma pa qq an ~ o ~ ~ u t e ~ a ~ a ~ ~ c n o p o p ~ a ~ y m ~ l a u ~ enoTannHe ~ a 6 o nHa ~~ ~m - B nepeHo cTypena Bopa Mnn noKpuaaHeHa TRnoTo MY C nepeHM~ J I O K C ~ ~ TT ~ .O ~MeTop M poaa B O ~ po T noRBaTa Ha xMnepaeHTMnaquR n pecnMpae BMCOKO ~ $ ? K T M H0 B~ P M H C K ,b T OT KaPflM04MPKYnaTOPeH TOpHa WlKaA03a. KOnanC e MHOrO BMCOK. K O M ~ T O ~ IlaqHeHTH HHT~ ~ p ~ 6 e Aa 6b~aT H H ~ ~ ~ H ~ HB TOHflpeAH H ~ p a ~ c n o p3a ~ ana , ~HMIKOM~ HT AHaIHOCTHKa HK~ ce n p e ~ n a m AnxaTenHmTe ~ nbTmqa OT eeeHlyanHa ~ M ~ M O C T M ~ M ~ Ha ~ HXMnePTePMHCI ~TO HMR C M H p P O M acnmpaqn~. npepnonara TorHa aHaMHe3a M po6bp $ ~ a n ~ a n npere~ Cnew~o O H O ~ IJ JI~WHH~ nep, amloraaq wMepeaHeTo Ha TenecHaTa TeMnepaTypa. Ha B C e K M KOMaT03eH IlaQHeHTno BpeMe Ha TOnnMHHa Bcnyvawe, npln Kow&onncaHwe no-ropeMeTopMHa BbnHa ~ p ~ pa 6 ce ~ a HBM~PM TenecHaTa TeMnepaTypa. oxnwaHe He ~ o p m p0 ~ $ ~ K T McnapaHe B H O Ha TenecHa~ O R B Ha ~ HeKOOPf T ~ lMHMPaHMPBMXeHMR, cTynOp, KOnanC Ta TeMnepaTypa, ce npnnaraT nepnToHeaneH naaax c npM p a 6 o ~ e M qn M ~ aTneTM C BMCOKM HaTOBaPBaHMR,M3MoxnageHM enemponmHH pa3~eop~ po 2WC, xeMopMannc ~ e npMeMaHeTo a Ha ~ ~ a m o a TonnweH a~a ypap. OCHOB- 3a H n M cToMawHa npouMaKa cbc cTyReH cepyM. no speMe H M T e KpMTePMM BKJllOqBaT: qeHTpallHa TeneCHa TeMnepaHa o x n w a t i e MoHMTopupaHeTo Ha TenecHaTa TeunepaTypa H q 40C, C M n H O nOTMCHaT0 Cb3HaHMe, nOBMlLleH0 Typa e HallOWTenHO. HHBO Ha CPK, caoTseTHa a ~ a ~ ~ e 3 a . Jlere~ne~o Ha Hacnnnnwe ycnoxHeHm KaTo apwKnac~recw TonnwHeH ~~ ypap Hacnnea np# TeMneMMH, ~ e ~ a 6 o n w aq~po3a, ~a cappewa HepocTaTbrtiocT paTypH Ha oKonHaTa cpena HW32"C, KaTo pncKbT e no3 a e ~ eamtla a ~ p o na ~ n e r e 6 npoqec. ~ ~ ~ rbproeme MOrOnFlM B b C T O HaCeneHM rpmCKM PeeMOHH. B ~ ~ ~ ~ C T H RHMR M T ca ~ recT npo6ne~ oqe no epeMe Ha TpaHcnopTMpaXOpa (HW 65 ~ o ~ ~ H W HM H)~ , O$P~H6 M0 ~nW ~u T~ OT ~e ,napHero Ha nocTpWanme. AoGap e$eu ce n m n r a c npclnaKMHcoHoea 6onec~, napa- M KBagpMnnemqMTeca OCHOBraHero Ha Diazeparn i. v., B O ~ H C ~ ~R ~ O~ HM M ~ O B KM U HaTa pMcKoea rpyna. X v l n e p ~ e pM ~KoMa ~ ~ l ce ~a6nlopaPhenobarbital. n b p e o ~ a r a n ~ a M ~H a $~~UO TepanMR HH~ BaT npM Texw MH$~K~HII, ne3n~ Ha xwnoTanaMyca M aanorsa c enetcrponMTHM p a 3 ~ ~ o Mp aKo ~ HanMrHaTa eHR0KPMHHH3a60nRBa~MR K a T O MHCMnMfleHp#a6e~, $e0X M n O T e H C M R He 6 b ~ e IlpeOflOnRHa, C e BKnlo'iBaT KaTeXOXPOMOqMTOMa M pp. naMMHM, KaTO nO3MpOBKaTa MM T P R ~ B pa ~ 6bpe TOClHO

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582

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e K C u e C M B H 0K O lM % C T B O BOAa. Acnnpaq~ Ha ~ coneHa BoAa. A c n ~ p a q n ~ Ha ~ coa n e ~~ ao ~ .I J wM 3n K~ B3~ a~ ~a eu ~ ~ ~ a e a s a ern~a . .n a . .~ ~ M ~ B HOCT B anseonme. Toea ce nocneuea OT ; ~ n o e o n e M ~~ xeuoKotiqeHTpaqwA. Cbp$aKTam~ He ce yepexqa y p e KTHO, no-recro ce AocTura no 6eno~po6e~ eAeM, K O ~ T O e

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M ~ ~ Ha K MRCTOTO M H a HHqHfleHTa. C l l a ~ R B a ~ e . AKOyAasHuKbT e oqe B C M H ~ H M ~M , O ~ ace ~ T npMnoXaT CnaCMTenHM TeXHM'ieCKM CpepCTBa KaTO nOFlCM, XMneTKM, A ~ C K M ,neTBM M RP. Yecro 06aqe cnacRsaHeTo e BWMOXHO c a ~ C o npMnaraHe Ha IIPM~OMM O T K ~ M 13p6a.

Cnacu~en H e ~6 ~~ s a Aa AonycKa Ra 6bpe crpa6re~ OT AaBeu(MR Ce. Kora~o CMTYauMFITa H 3 M C K B a ,TPR~B fla ~ Ce M3nOn3BaT T P a H C n O P T H M nOMOuHM CpeACTBa. Clla~MTenRT ~ p ~ 1 6 Aa ea nnpa MHOrO ~o6pe, HOC~~~ YAaBHMKa, KM M

Cneurnu cacrnonnun BcnegcrnBue Bpegnu Ba3geircrnBun Ha okonnama cpega

583

pa snaee xaaTKnTe 3a ocso60wa~a~e. Cnep ~ 3 w a He OT BopaTa BeIHara ce npepnpMeMaT xuBoTocnacmaqln peaHmnnaqnoHHu uepKm, cnep KoeTo ypaBHMmT ce flOcTaBR tl0 rpb6 Bbpv TBbppa IlO~OXKa. naqMeHTbT C e IlOCTaBR 3a KPaTKO BpeMe B CTpaHMVHO nonoxetiwe, 3a a ! ~ a ~ eBopaTa r e OT ropHme pMxaTenHM nbmqa. T a s ~ wpKa He 6 ~ s a pa e npopbnxmentia. Oco6e~o B ~ H e Osefltiara pa ce aanor~e c oceo6o~asaHe Ha ropHuTepuxaTenHM nbTwqa, 06fluwea~e ,ycTa B YCT~ M n "M JCTa B HOC". PM Bb3MOXHOCT C e M3nOn3M uacKa M 6 a n o ~ 3a 0 6 p ~ u r ~ a Hah-po6pe ~e. e naq#eHTbT pa C e MHT@II(P~ C eHAOTpaXeaJlHaTpb6a C yIlnbTHMTenHa ( u a ~ w e 3a ~ acenapMpaHe Ha flMxaTenHMTe nbTnqa OT raCTp0-MHTeCTMHanHURTpaKT M flpeBaHTMpaHe Ha BTOPM-

e 0C06eHa @opnna Ha ARDS, recTo pecnMpaTopHa MHCY@ C I ~ H ~ H HaCTbnBa ~UR CneA IlpHeMaHe B ~ O ~ H M ' - ~ H O 3aTO BepeHMe.Ty B c b o 6 p a x e ~ HpeaT ~ e pewiMMc npMnaraHe

Ha PEEP npw ymnxeHo n c n ~ p a ~ o p ~ o l e ~ c n ~cbpa~ OTHOWeHMe. BTOPM~HOTO YpaBFlHe e IlpeRMMHO PeCnMpaTOpeH npo6nenn, npOTM'iau(0 C KapTMHaTa Ha 6enoapo6 e OTOK. ~ ~~TOI~ T I ~~ RR ~ fla W H CTaM ~T IlO O CTeileHHO C abtilutln, nepn@ep~o 3aTonnuqu cpeflcma, enMsaHe Ha ~~~TBO CP TenecHa M TennnepaTypa, o 6 p ~ u r cbc ~ ~sa~oe nneHa M oanaxHeHa KucnopopHa cnnec. Tepaneatu.~ MepKu. ~ ~ Yec~o n p yflaeFiHe ~ B cnaKa aoAa HacnneaT KahnepHM@u6pnnaq~~. Cnelu~o ce n3ebpuaa ene~~pofle@~6p~naqm Ha cbpqeTo. 6bp30 oc~ryPRBaHe Ha nepM@epeH M qeHTpWIi?HBeHO3eH nbT. K ~ T ~ pn3aqw~Ha ~ M K O ~ H MMevp F~ C noracoBo cnege~e ~a pwypesa~a. Ha BMHarM ~ p ~ 6 fla B aC e BWtO'iBa nPMTOK Ha ClMCT KMCnOKapflmoqmp~yna~op~a repanua. Kapfl~oc~w~yn pop. AKO IlaqUeHTbT MMaflOCTaTb'iHO CflOHTaHHOflMWaHe, paqlr MepuKaMeHTH:Adrenalin 0.001, Calcii gluconas 10%, 6~ ~ 0 r b#a n 6bpe T ~ ~ H C ~ O C ~M T a C H K O ~ B O ~M H n UHa3allHO 10 ml Isoprenalin. npu ~ e o 6 x o p ~ ~ nosTopeHue oc~ Ha co~po~ono~a~a~e~a~~cnopop. flOSMPOBKMTe, Cb'ieTaHO C eAHOBpeMeHHO npMn0XeHMe Ypae~~q npM ~~ W eM ~ K cnyiaM M ~ p ~ l fla 6 ~6bfla~ a Ha eKCTpaTOpaKaJleH Cbpae'ieH MaCM. TpaHCnOpTMpaHM 40 60flHM~H0 3aBepeHUe, KaAeTO fla C e K a ~ e x o n aDopamin ~~~~B : flonaMMHeprclrHa 6b6penpMnoxaT c n e q u @ ~ puarHocTwCrHu r~~ M TepaneeTMrHM rHa flos~poe~a 2.5-3.5pgkglmin. PeaHMMaqMOHHU MePOnPMRTMR. C ~ X M B M T ~ MePKU ~HWT~ 6 e n n . 1pa3~eop1.1: ~~ n p m o 3 a ~ p a a e nnaaua ~a Mnu ~pfi6ea C e nOClqbpXaT M no BpeMe Ha TpaHCflOpTa. HSA. E~~HOB~~ CT M O~ M fla HH C e O IlpeMHTMpa no-HaTaTbWHaBO~~H eneKTpOnMTHH M pa3TBOpM B flO3MpOBKa Ta 3ary6a Ha TOnflMHa. 30 mlkg124 h 3a B ~ ~ P ~ C TM HPO M 100 mVkgl24 h 3a fleqa. Llepe6ponpo~e~~~m: Tiopental5 mgkg, n p rbproee ~ p0 25-30 mglkg124 h ( M ~ T O X ~ K I/mM C M Henn6yran). T~~ Diazepam 10-15-20 fl0 30 mg @ ~ ~ K ~ M O H H P6onyc~o ~HO I~~~M~ npenpnenl H T M , paeeHe, TpR613a fla 6bpaT 3a 24 h. ~aGnt~paeB a orleneHMe ~u 3a M H T ~ H ~ M Tepanm BH~ ~aunpn xMnepToHHrtia peaKquuHa quplcynaqma, cbreManKO 24 h Cnep MHl+lfleHTa, He3aBMCMMOf l M M Ca pa3BMTaHa C M03bVHa CMMnTOMaTMKa - JIUTMCreH K O K T ~ ~ ~ . n M WIHHM'iHa CMMnTOMaTMKa M n M He. ~ ~ M ~ ~ H O C T M V H MM T ~ OCHOBH~ TepaneaTMrtia qen npu 6 0 n ~ B ~ KoMa ~e e ~ e p a n e e ~ ~~ r~ el p r ~oen p ce ~m ~ ~~ ~b ~p w a a ~ c nm ope ~f l- OCMrypRBaHeTO Ha WeKBaTeH KUCnOpOfleH TpaHCflOpT HM'iHaTa KapTMHa. Oco6e~o BHMMaTenHO ~ p ~ l 6 e fla aC e rpea nopxoppqa pecnMpaTopHaTepanMR M oana,qmatie flpel(eHM CbCTOFlHMeTO Ha M03bKa M yBPe)lWaHHRTa MY, Ha BOfleMMCrHMTe HapyWeHMFl. BOneMHrHOTO CbCTORHMe M na60paTopHMTe pe3ynTaTM. P e ~ ~ r e ~ o r Ha p a6@ en ~~ ~ppo6oae ~e esapnx~~en~a. PM peCflMpaTOpHMn p o 6 n e MHfl ~ ~ MKa~MMTe 38 HHTY6 a qM ~M3KYCTBeHa ~ BeHTHna4UR TPR~BI BHMMaTeflHO fla 6bpaTnpeI@HeHM.~ P H THap. . .BTOPMCIHOY~ KOeTO ~BRH~~,

Cnac Cnac~os

Octpa~a nblreea 6onec~ e 3 a 6 o n ~ ~ apaae~mqo ~e, B 3aammoc~ OT n o r b n ~ a ~ a n~ ca ~a ~a 0611br~He ce B p e 3 y n ~ a Ha ~ epHoKpamo, MacMeHo f l e u c ~ ~ Ha ~e ocTpaTa m r e m 6onec~ ce AenM Ha rempm cTeneHn: l o ~ ~ 3 n p rrbreHwR a q ~ B fl03~,npeeMwamqn ~ H ~ ~ H M O I - nem: ~ c 100-250 ~ a rad; II- cpeu~a: uo3a 250-400 flOflyCTUMHTe. rad; 111 - ~ e m ~103~1 a : 400-1 000 rad; IV - WHO ern:

584

Cnewnu cacmonnun BclregcmBue Bpegnu BsogeticmBun H a okonnama cpego

H aH e n P O X O f l M M O C T , Cbp~erHO*bflOBacna6oc~. CMbpTTa Hacnnea npes BTopaTa cep~nua OT 06nb~BaHeT0. T O K C ~ M @pMa M ~ H ~ npM 06nbvaa~e OT 5 000 p0 10 000 rad. Ha6nm~aea Ce TeXKa M H T O K C M K a 4 M R OT np0WKTMTe Ha T b K a H H M R pa3nW M a30TeMHR. CMbplTa HaCT M ~ M@ ~ H p~ ~H aa TocTpaTa ~ nbreea 6onecr K~MHHnnea npea nbpaaTa cepMuua cnep 0 6 n b r ~ a ~ e ~ o . ~ H ce O npepcTaaR B qeTwpM 4 a 3 ~ : L(epe6pan~a $opMa- n p 06nbrea~e ~ ~ q 10 q 000 rad. I $a3a npoppouantia: aaa~cu orpo3aTa ~ao6mreace npmo yapeqaHe Ha UHC c nocnepaaqo He. 3anorea OT M M H ~ T M po racoBe cnep e ~ c n o a u q ~ ~ ~ a Ha6nlopa~a . Tewo HapywaBaHe Ha pMwatieTo. Cwbpna Hamnaa OT Xapauep~anpace c aHopeKcw, rqqeHe, noapbuaHe, racose po 1-3 ~ H cnep M 06nbrea~e~o. pMapm, rpeBHM KpaMnM,canMsaqMn,pexMppaTaqMfi,yMo-

posa ~4 1 000 rad.

pa, ana~n~,o6wn~o M ~ ~ O T R B BTpucaHe, ~H~, rnaao6onne, X M n O T e H C M R . Ha6nlopaea O ~ M K H O B ~ H npM O p03M HQ 100 rad M BHHaM nOfl400 rad. A ~ a ~ ~ e 3a aa p~ wa~ a 4 ~ eKcnotiaqm o ~ ~ a e cbqecII$aaa -naTeHTtia:MBMCM o ~ p o 3 a ~Ia lp . opnxaBao~ TBeHa 3a AMaWO3aTa. O ~ ~ K T M B nOTBbpX(4eHMe HO MOW ~ H p0 M CepMMuH. MsreaBa o6qa~a cna6oc~, aneTnnT ce pa ce nonyw rpe3 ~ O ~ M M ~ T P M rR n. a ~ noTBbpqetiwe ~o Bb3CTaHOBRBa. ~ b 3 ~ 0 X H eR 0O R B R B a H e Ha HapyUeHMR B 3a H a n H w e T o Ha OcTpa nbreea 6onec~ ce nonyqaea OT KooppMHaunma, K O ) I ( H Mnpomv epMTeM, enMnaqwR ( K ~ M M3CneABaHeTO Ha KpbBHaTa KapTMHa C ~ u $ ~ ~ ~ H ~ M 12-16 p e ~ ) . Jlu~$one~# MoXe ~ ~ apa ce 3qqbn60ram 6poe~e, OT M3CnepBaHeTO Ha 6 p o Ha ~ T~O~O~(UTM MOT T~ nOCTeneHH0. HaManRBa~POFIT Ha T ~ M ~ ~ ~ M B T KOCTM T ~ . ~ a c n e p e a ~ Ha e ~enetcrponMTmTe. o Te ~ p ~ 6pa ea ce noeTaHMRM03bKM3Cle3BaTHeapenMTeKne-KM. PRT W C T O B IlbpBblTe 48 h cnep 06Jlb'iBaHe~o.A6conlo~~m Ill $asa ~ a ~ u $ e c ~ ~ Ha p6onema. a ~ e OTHOBO ce RT 6p0n H a ~HM$OL(MTKT~ e PaHeH MHpMKaTOP 38 nO3aTa noReRaaT popa, rnaso6onne, pMcntieR, BTpMcaHe. PasKora~o MMe no-ronmOT 1 500 mm3 emaT ce TPM OCHOBHMCMHppoMa: ~aa r p a ~ y n o q ~ ~ o M a a ~ a ~ao6nbclea~e. (B ~ e 48 3 h), ~ eKcnoHaqMnTa; H e e s ~ a c l ~ ua acnwaHeTo , ~ p o ~ 6 o q m o n e ~ Ha ~m Ha H, $ ~ K U M H xeMopamTa. ~~ HaMM nop 1 000 B mm33a nbpeMTe 24 h MnM noq 500 mm33a MaJlFIBa H ~ ~ ~ B K O ~ MA T0M nbnHOTO T~, UM M3re3BaHe nbpaMTe 48 h n o ~ a 3 TeHecrra ~a Ha O ~ ~ I ~ ~ B E I H ~ T O . npuTexKme cnyraM ~a6onec~~a. A H ~ M M F nocTeneHHo TT~ ce aa,qbn6orasa. no~lerrea~ ce xeuopamM no KoxaTa, nurasMqMTe,no racrpo-n~~ec~n~an~rn~patcr, recrocbcleTaw C XeMonToe, KbpseHe OT Hoca, rac~po-MHT~CTMH~~raCTpoeHTepUTM,O T p a B R H M R CTeXKM MeTMM, neBKeHUR Tpam, y p o - r e ~ n ~ a n ~ a ~ a c P ~m ~~ e~ Ba H ce . BT~ e xT KM M M R M H $ ~ K ~ M MBHMHM, I l H e B M O H M M ,n e P U T O H H T , CenCMC. noR B R B a T Ce HeKPOTHrHM R 3 B M n0 KOXaTa M nMraBH4MTe. K O X ~3ary6ea T ~ enacT~rHocna CM, noRBRBaT ce cbp6ex M parwn (no ~oma~a), KocaTanwa Ha ~urypu. Bba~om~a B napaaTa $ a s Ha 6onema 60nHMTe ce nocTaeRT e nORBaTa M Ha OrHMyHa HeBPOnOM'iHa CMMmOMaTMKa, nop neKapcKo Ha6nlopeHMe n npu tiloyqa ce npoeexqa M e H M H r M a n H M npM3Hal(M M T. H. C U M n T O M a T M V H O nt?reHMe. IV $asa ~ 3 x OT 0 6onema ~ BwaHoaRBatie Mnn C M b P T . ~ p u r u 3a ~u cMbprra HaAreCT0ca cencucbT, T e m M Bbe BTopaTa @aaa ce npoaeqa Tepanw, HacoreHa r e cMy4eHMR Ha enetcrponHTtiHR 6ana~c, AexnppaTaqwK ~ M npo$~na~~u Ha ~a CMHppoMme, ~a p a 3 ~ ~ ce ~ a B q Ta. TpeTaTa $a3a CTMMYnaTOPM Ha XeMOllOe3aTa, B M T a M M H M npn 6naronp~m~o pa3~mue Ha 6onena nocTeneHM T. H . H 0 WIUHMWHTe 6ene3~ Ce BaxTaHOBRBaT, K P b B H U T e noB ~ p e ~$a3a a ~ ce a npnnaraT~ o ~ n nO eT ~ ~H c TM~MOTH ~aaa~e cen~ ~o p ~ a n ~ s w Bp npopbnxeHue a~ Ha 4 1 0 8 4 M ,C T M M Y n a T O P MHa XeMOnOe3aTa, nna3Ma, ePMTP0qMTHa cepMlrqM. MaCa, $M6pMHoreH, T P O M ~ O ~ M T Mam, H ~ npRCHa 4UTPaTHa H~TM~M.IH# @ p ~ Ha n ocTpaTa mrem 6onec~ ca: KpbB, pMPeKTH0 KpbBOIlpenHBaHe, C U M n T O M a T M ' 4 H UCpeAClpeaHa @ p ~ a npM o 6 n b r ~ a ~ OT e 1 000 flo 5 000 cTsa 3a nombpxatie Ha AHLuaHeTo M cbpperHaTa penrad. BepHara cnep 0 6 n b r e a ~ e ~ 3anoraa o noapbyaHe, HOCT. C b 3 ~ a B a Ce ~ M Ce nOmbpXaT a H T M C e n T M C l H M yCn0flMaPMR, MMHIMMR. B P a M K M T eHa HRKOnKO flHM Ce n O R B R BUR 3a rnepaHe Ha ~ O ~ H U T ~ . BaT K p b B O M 3 J l M B UOT T a C T P O H H T e C T U H a n H H RTpaKT, rpeB-

PORT

PORT

Cneurnu cacmonnun Bc~egcmBue Bpegnu BaogeCcmBun na okonnama cpega

585

cine. Little Brown & Co., Boston, Toronto, London, Bwxpwea, 6.C. OXOM. M e ~ ~ q w1981,327 ~a, O ~ ~ A., O M. B C ~ ~ K M CM. OB 6y , 6 e ~ ~E o .~ ~ K T ~ o T I., ~ ~ B M ~1992,425430 . Me~wQwtia 1977 Masellis, M, et S.W.A. Gunn. The Management of Mass Bum CasualitiesandFire Disasters. Dordrecht, Kluwer %~B~HKO h., B, 6n. U]MHR~PCKM. Tep~nCltIlrl nOpMeHHfl H Academic Publishers, 1992,338 TRXHOTO neqetiwe. C., MeflMuwtia w $ws~yn~ypa, 1989 Muir, I.F.K., T.L. Barclay et J.A.D. Settle. Bums and their Baskett, P.J.F. Prehospital Phase. In: Grande, C.M. Texttreatment. London, Butterworths, 1987, 177 book of Trauma Anesthesia and Critical Care. Mosby Year Book, Inc., 1993,281-296 Nemes, C., M. Niemer, G. Noack. Datenbuch Anaesthesiologie. Gustav Fischer Verlag, Stuttgart, Bloch, Cecil. The Bums Handbook. Cape Town, Monica New York, 1979,240-243 Fairall Communications, 1987, 67 Boswick, John A. The Art and Science of Bum Care. O'Connor, N. Cold Injury. In: May, H.L. Emergency Medicine. Little Brown & Co., Boston, Toronto, London, Rockville, Maryland, Aspen Publication, 1987,395 1992,898-908 Bowe E.A., E.F. Klein jr: Near Drowning. In: Caplan L.M., S.M. Miller, H. Tumdorf: Trauma Anesthesia and InPavlin, E.G. Hypothermia in Traumatized Patients. In: tensive Care. Lippincott, Philadelphia, 1991. Grande, C.M. Textbook of Trauma Anesthesia and Braun U. Der Ertrunkungsunfall. In Burchardi H.: Akute CriticalCare. Mosby Year Book, Inc., 1993,1131-1140 Notfiille. Georg Thime Verlag Stuttgart - New York Seraj, M.A. Heat Stroke: The Management of Thermal 1993 Trauma. In: Grande, C.M. Textbokk of Trauma Anesthesia and Critical Care. Mosby Year Book, Inc., 1993, Brooks, D.K. Resuscitation. Care of the Critically Ill. Hypo1247-1256 thermia and Hypetthermia. Edward Amold Ltd., London, 1986,253-272 Settle, John A.D. Bums -The First 5 Days. Romford, Smith & Nephew Pharmaceuticals Ltd., 1986,28 Echinard, Ch. et J. Latarjet. Les Brulures. Paris, Masson, 1993,350 Seward, P.N., M. Robinson. Hypothermia. In: May, H.L. Emergency Medicine. Little Brown & Co., Boston, Elder, P.T. Accidental Hypothermia. In: Shoemaker, W.C. Toronto, London, 1992,431 4 3 7 et al. Textbook of Critical Care. W.B. Saunders Co., Skoog T. Electrical injuries- J. Trauma 1970 n 10 p. 816Philadelphia, London, Toronto, Montreal, Sydney, Tokyo, 1989,100-109 830 List W.F., P.M. Osswald, Komlikationen in der Vidal Garcia Torres, D. Quemaduras. Tratamiento de Urgencia. Madrid, Duphar Farmaceutica, 1993,254 Anathesie. Springer Verlag, Berlin, Heidelberg, New York, London, Paris, Tokyo, 1989 Yang Chinchun et al. Treatment of Burns. Berlin, Springer Lonzon, H. Heat Illness. In: May, H.L. Emergency MediVerlag, 1982,403

n.,

2
HIV - AIDS

4
Cryptococcus neoforrnans

5
Arnphotericin B PenG (HD)' Aminoglicosidee+ PRSR1+ Ceftazidime Augrnentin Fluconazoie

0-4 n e ~n, o c ~ ~ p a ~ n a n ~ a , S. pneurnoniae nomcnn~an~a pae~a, u3mqa~e ~a ~ M K B O P Enterobacteriaceae,Staph. aureus, Pseudornonas sp. Cnefl 4-MR R ~ H S. pneurnoniae

Cefotaxirne M ~ Ceftriaxone M nnn Chlorarnphenicol

Ylun

OTUTMC ~enna ~yra

Ho~opofle~n no4 3 ~ e c e q a

S. pneumoniae H. influenza0 Enterobacteriaceae group B strep. Staph. aureus S. pneurnoniae H. influenzae M. catanhalis Staph. aureus group A strep. Sterile Bacteroidessp. (B. rnelaninogenicus B. oralis) Peptostreptococcussp. Fusobacteriurn sp. S. pneurnoniae H. influenzae Staph. aureus K ~ K Tno-rope O + r p a (-) ~
~ ~ K T ~ P M U

Cefotaxirne M ~ (Arnpicillin M + ArninoglycosideQ)

Aeqa M B ~ ~ P ~ C T H H

Augmentin

TMPISMXl0 u n Cefuroxirne-axetil ~

Pecn~pa~op TP~KT e~ 6 ~ ~np o 6

A c n ~ p a q ~ nHesMoHnR o~~a

MH$BK~. acnnp. nHeBMOHMR, 6eno~po6e a6cqec, ~ e ~ n ~ e ~ a

Augrnentin unM Clindarnycin

PenG (HD)%nn Cefoxitin

Bb~pe6on~~r~a, cneflMHTecTuHanHa O~CTPYK~MR, yflasnHe Onopno-aemra~ene~ anapar Koxa L4~6etmpa~n paw, TpaBMM 6e3 cencwc Cbc cencMc M HeKpomsUpaul Qacqe~~

Augmentin + (ArninoglycosideQ)nnM (Clindarnycin + Arninglucoside) PRSP1nnM Augrnentin, npomeoTeTaHMVHa np@~na~m~a

(APPenZ+ AminoglycosideQ) Mnu (Metronidazole + Cefuroxime) Hosn MaKponnAMM Clindarnycin Glycopeptide (Vancornycin, Teicoplanin) + Arninoglycosideg

~O~HMHKPO~H~:

Staph. aureus group A strep. Anaerobic strep. Enterobacteriaceae C, perfringens, C. tetani K o ~ ~ a lccBoAa: r P. aeruginosa

2
Yxanea~e OT ~
O B ~ K

4
Augrnentin

5
PRSP1

npo@unam~a B n b p ~ ~ ~ eViridans strep. group A strep. 12 h or yxanea~e~o H ~ M Staph. aureus ~epanun ~a w s n ~ e ~ a Eikenella corrodens MH$~K~HR Bacteroides sp. Fusobacteriurn sp. Pasteurellarnultocida Staph. aureus Pasteurellarnultocida Viridans strep. Staph. aureus Staph. epidermidis Bacteroides sp. Fusobacteriurn sp. CDC group EF-4 Capnocytophagacanirnorsus Streptobacillusrnonilifonis noc~mepam~~o nompae~a~nr~o Staph. epidermidis (40%) Staph. aureus (20%) Enterobacteriaceae Pseudornonas sp. Staph. aureus Staph. aureus Enterobacteriaceae Pseudornonas sp. C. perfringens n ~pym histotoxic Clostridium sp. Enterobacteriaceae68% Enterococcus sp. 14% Bacteroides sp. 10% Clostridiurn SP. 7%

Yxanea~e OT K O T K ~ Yxanea~e OT ~ p e

Augrnentin, npomeo6nc~a npo+unam~a Augrnentin, npom~o6nwa npo@nnam~a

Doxycycline PRSP1Mnlr Doxycycline

Yxansa~e OT mbx BPWKH Cenmre~ a p ~ p ~ ~

Arnoxicillin ~ t (PRSP1n n Pceph16) AminoglycosideQ

Doxycycline (Vancomycin t ArninoglycosideQ)~ n FQ3 n

Cenmre~ 6ypan~ KOCTH OCT~OMM~~HT

noc~onepa~na~o nompas~amr~o Iloc~oneparm~~o Ilocnpae~a~clr~o

PRSP m n Pceph16 ~
( F P m n Pceph16) ~ t Arninoglycosidee, npomeo~e~a~ur~a npo$~nam~a

Vancornycin

Myc~yn~

ramea r a ~ r p e ~ a

3 a ~ b p c e TpaBMamrHa ~a pa~a

PenG (HD)B

Ciindarnycin H

~ Doxycycline M

Xnbq~a H )I(~~CIHH nbwqa

Xone~mcrm, Xona~mr 6 ~ n ~ a cenc~c pe~ o or 3anyluea~e ~a x n b r ~ ~ ~ eq a m r ~ aanywea~e KaMbK HnH TYMOP nbTHUa

Augrnentin, Piperacillin Arnpicillin t C Y ~ ~ ~ K

Cefazolin t Arninoglycoside
T ~ M

Cefazolin + 5-nitro-irnidazole7

2
3anywea~e ~a x n a r n u ~ e nbTUqa

3
nbnno sanyweane npu yap
M ~ ~ M~ H K P ~ ~ T M T

4
Yec~o~ (0 a- 15%) ~a MH@~KTM~~H~ Helicobacter pylori

5
He ce npenopawa Amoxicillin + Metronidazole Augmentin Cefoxitin Ampicillin Augmentin TMPISMX + Metronidazol

r a c ~ p o u ~ ~ m ~T aPn ~K eT n Ayo~enanna ~ s ~ a racrpu~ nepw~oneane~ abcqec

Peynn~ Type B antral

T~T~~uuK~uHLI Epnrpo~~qunu (Clindamycinunu 5-nitro-imidazole? + Aminoglycosidee [(Clindamycinnnu Cefoxitin) + AminoglycosideQ] + [5-nitro-imidazole7 (TMPISMX'O unfl FQ3)] Cefoxitin unu Cefotaxime unn Ceftriaxone Cefoxitin u n ~ IMP4unu (FQ3+ 5-nitro-imidazole? (TMPISMXIO + Vancomycin)
B~uan~oa~a

Enterobacteriaceae Bacteroidessp. Enterococcus sp. H R MBowel-nep$opaqu~ ~ Enterobacteriaceae Bacteroides sp. Enterococcus sp. S. pneumoniae group A strep. Enterobacteriaceae Staph. aureus Enterobacteriaceae Enterococcus sp. Bacteroides sp. P. aeruginosa Staph. epiderrnidis(45%) Staph. aureus (14%) Streptococcus sp. (12%) Enterobacteriaceae (14%) Candida sp. (2%)

nepn~o~eyu

~ueepm~ynn~

nepu~onn~

nbpeure~ 6a~~epuanen unu ne$pomre~ unu quporuren

Augmentin

BTO~U (Bowel-nep$op.) ~~H o6qa M H $ ~ K ~ unu U RB6M

Aminoglycoside3+ (Augmentin, 5-nitro-imidazole Clindamycin) [(Pceph16unu PcephP) + Vancomycin] B~uanu3a~a Amphotericin B + Flucytosine Augmentin t Aminoglycoside

~ P ~ A P Yc~ H npo~bnxu~en~a a~6ynarop~ nepu~oneanna a ~uanusa

B ~uanusa~a

qepe~ p o 6

Yep~o~po6en a6cqec

Enterobacteriaceae Streptococcus sp. Bacteroidessp. Staph. aureus Entamoeba histolityca Candida sp.

+ unn -

(Pceph16,PcephZ6)

Aminoglycoside9

1
O~flenn~en c~ na c~e~a

2
Ocrbp ~MCTMTnnu nnyp~apn3ypnre~ CMHAPOM

3
Le3 cencnc, yponornr~u npouepyp~ HnH B6U

4
Enterobacteriaceae (E. coli - ~ a i - r e c ~ o ) Staph. saprophyticus Enterococcus sp. Chlamydia sp., Ureaplasma urealyiicum, (Trichomonas vaginalis, Candida sp.

5
TMPISMXIO (p.0.)

6
Amoxicillin nnn Norfloxacin nnu Nitrofurantoin HOBU MaKponMfln

H~~OHOKOKOB ypeTpMT

Doxycycline

~POCT~MT

O m p (ce~c. amBtin M M ~ )

N. gonorrhoeae, C.trachomatis Enterobacteriaceae Enterococcus (80%) M n M P. aeruginosa (15%) N. gonorrhoeae C. trachomatis Enterobacteriaceae Enterobacteriaceae (E. coli - nal-rec~o) Enterobacteriaceae Enterobacteriaceae P. aeruginosa

BM.: O p x n e n n ~ n f l n ~ n ~

PPYM

XPOHM'~~H, HaJMqHa HH$. Ha y p n ~~ . pam Opx~ennfl~flu~~~

< 35 ronnHn

FQ3,Norfloxacin TMPISMX1" (Amoxicillin nnn F P ) Augmentin + Doxycycline Augmentin, Ampicillin cyn6 a u a ~TMPISMX , Noffloxacin nnn F P , OcephE,TMP/SMXIO, Augmentin Augmentin (Pceph16+ nnu - Aminoglycosideg) Piperacillin nnn F03 (APPen2+ Aminoglycosideg)nnn Ceftazidime PRSP1, Pceph l 6 Vancomycin

+ Doxycycline
F09

> 35 ronn~m

nneno~@pm

6e3 cencvrc n yponomr~n npouewpn Cencnc nnir PC < 38,5"C 3anywea~e, peenyltc, npouenypn
1

nepn~e$pane~ a6cqec

npnflpyxe~ cbc c~a$. 6amepne~nfl npnnpyxe~ c pyelonephrais

Staph. aureus Enterobacteriaceae Bacteroidessp. group B, strep. Gardnerella vaginalis Enterobacteriaceae Mycoplasma hominis

r e ~ n ~ a~ ne p~ au

Cenmre~ a6op.r - aMHuoHuT

Augmentin Doxycycline

[(Clindamycin+ AminoglycosideO)unn APPenz I n n Cefoxltin] + (Doxycycline nnn HOBM ~a~ponn~n)

2 EH~~OMHOM~TPMT Postparturn

4 Bacteroides sp. group A, B strep. Gardnerella vaginalis Enterobacteriaceae Mycoplasma hominis C. trachomatis
N. gonorrhoeae C. trachornatis Bacteroides sp. Enterobacteriaceae Streptococcus sp. Mycoplasma sp.

5
Augmentin, Doxycycline, 5-nitro-imidazole

6
[(Clindamycin t AminoglycosideQ) nnn APPenZwnn Cefoxitin] + (Doxycycline nnn ~oen ~a~ponn~n) Oceph6+ 5-nitro-imidazole7 t (Doxycycline nnm ~oen ~a~ponnnu)

Cannm~rm, neneeonepmotim, q6oosapnaneti a6cqec

Augrnentin + Doxycycline

1. PRSP - ~ ~ H M ~ M ~ M H ~ ~ ~ - ~ ~ nonycutiTeTMwu ~ M c T ~ H T H~ M ~H , M ~ U ~ Erithromycin MHM. Mnu Clindamycin MoraT pa 6 b p a ~ anTepHaTMsa npM no-ne~m MH$~K~MM. 2. APPen - aHTnncespoMoHacoeu neHuuunnHu. 3. FQ - $ ~ ~ O ~ O X M H O ~ ~ O H H . 4. IMP - Imipenem + Cilastatin. 5. Oceph - o p a n ~ u qe$anocnopu~u. Oceph' - nbpsa reHepaquR opanHn. Oceph2- sTopa retiepaqw opantln. 6. Pceph - napeHTepanHM qe@anocnop~~n. Pcephl - nbpsa reHepaqufl napeHTepanHu. Pceph2- BTopa reHepaqm napeHTepanHM. Pceph3- TpeTa retiepaqw napeHTepanHM. 7. HD - BMCOKM p03U neHM4MIlMH OT 12-24 MnH. EIfleH. 8. TMPlSMX - T P M M ~ T O ~ ~ ~ M ~ C ~ ~ ~ $ ~ M ~ T O K C ~ ~ O ~ . 9. H o w MaKponMpn - Clarithromycin, Roxithromycin.

AHTM~HOTMK
~~HH~H~HHH

fl03~poBKa 0.5-1 g p.0. Ha 8 h 0.25-0.5 g p.0. ~a 6 h HncKa ( O ~ H K H O~ B 0~ 3H 8 )~ 3-6 MnH. E / p e ~ i.m. cpep,~apoaa 6-12 M ~ H W . pe~ i.m. BncoKa poaa 12-24 MnH. E h e i.v. ~ 2-4 g i.v. ~a 6 h 5 g i.v. ~a 6 nnn 8 h 0.5 g p.0. Ha 6 h 0.5 g p.0. Ha 6 h 0.5 g p.0. ~a 6 h 1-2 g i.v, nnn i.m. ~a 6 h 0.375 g nnn0.625 g p.0. Ha 8 h 1.2 g i.v. Ha 8 h 0.25 g i.v. ~ n i.m. n ~a 8 h 1.5 g i.v. nnn i.m. ~a 6 h 0.5 g i.v. nnm i.m. ~a 6 h 2 g i.v. m n i.m. ~a 4 h 0.5-1 g i.v. nnn i.m. ~a 8 h 0.5 g i.v. nnn i.m. ~a 6 h 2 g i.v. m n i.m. ~a 4 h 0.5 g i.v. m m i.m. ~a 6 h 2 g i.v. llnn i.m. ~a 4 h 1 g i.v. nnn i.m. ~a 12-24 h 1-3 g i.v. nnn i.m. ~a 12 h 1 g i.v. nnm i.m. ~a 8 h 2 g i.v. nnn i.m. ~a 4 h 0.75 g - 1.5 g i.v. nnn i.m. ~a 8 h 1 g i.v. nnn i.m. ~a 8 nnn 12 h 2 g i.v. nnn i.m. ~a 4 h 1-2 g i.v. nnn i.m. ~a 8 nnn 12 h 1-2 g i.v. unn i.m. ~a 24 h 0.5 - 1 g i.v. ~a 6 h

AHTYI~HOTMK

fl03~po~~a 15 m g k g l ~ e a i.v. ~ o nnn i.m. Ha 8,12 nnM 24 h (xena~en~ co e p y ~ o HMBO: ~ o 15-30 mg/I) 3-5 mgikg/C1~ewo i.v. nnn i.m. Ha 8.12 nnn 24 h ( x e n a ~ e n ~ o cepyMno HMBO 4-10 mg/l); 4 mg Ha 12 h i.r. 15 mq/kg/p,~eB~o i.m. nnn i.v. ~a 8 nnn 12 h ( x e n a ~ e n ~ o CepyMHO HMBO 15-30 mg/l) 3-3.5 mg/kg/p,~e~~o i.v. nnn i.m. Ha 8.12 m m 24 h ( x e n a ~ e n ~ o CepyMHO HUB0 4-10 Ill@) 2 g i.m. 0.15 - 0.45 g p.0. Ha 6 h 0.15 - 0.9 g i.v. nnn i.m. Ha 8 h 0.5 g p.0. ~a 6-8 h 0.6 g i.v. nnn i.m. ~a 8 h 0.5 - 1 g p.0. na 6 h 1 4 g i.v. AHermo 0.25 - 0.5 g p.0. ~a 12 h 0.15gp.o. ~ a 1 h 2 0.5 - 1 g p.0. Ha 6 h

Amoxicillin Ampicillin Penicillin G Piperacillin Ticarcillin Cloxacillin Dicloxacillin Flucloxacillin Oxacillin Amoxicillin + clavulanat (Augmentin)

AMHHO~~HKO~HAH
Amikacin Gentamicin Kanamycin Tobramycin Spectinomycin
'M~K~o~H HR JlHHK03aHHRH H

Clindamycin Lincomycin Erithromycin Clarithromycin Roxithromycin Spiramycin

~~~O~OXWHO~OHH

lle$anocnopn~m
Cef azolin Cephalothin Cephaloridin Cephradin Cefamandol Cefonicid Cefotetan Cefoxitin Cefuroxime Cefotaxime Ceftazidime Ceftriaxone Imipenem + Cilastatin

Ciprofloxacin Ofloxacin Pefloxacin

rnn~onernmg~

0.5 - 0.75 g p.0. ~a 12 h 0.2 - 0.4 g i.v. ~a 12 h 0.2 - 0.4 g p.0. ~a 12 h 0.2 - 0.4 g i.v. ~a 12 h 0.4 - 0.8 g p.0. ~a 12 h 0.4 g i.v. ~a 12 h 0.8 - 1.6 g I" posa cnen TOM 0.4 - 0.8 g i.m. mnn i.v. Ha 24 h 1 g i.v. Ha 12 h; 125 mg p.0. 5-10 mg i.r. Ha 48-72 h

Teicoplanin Vancomycin

Aztreonam

Metronidazol

0.5 g ~a 8 h nnn 1 g ~a 12 h p.0. nnn i.v.