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Emergency Breathing System

Written By nursingstikes on Thursday, December 27, 2012 | 11:08 PM

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Emergency Breathing System
 

Epistaxis
Airway obstruction
Massive hemoptysis
Status asmatikus
Thoracic trauma



 
Epistaxis

Epistaxis or bleeding from the nasal cavity are common and most will stop spontaneously or by simple actions such as pressing the nose. Nevertheless there are hard cases that require immediate relief to not be fatal.

Various causes of epistaxis
A. Because local
1. Trauma: sneeze, nose picking, hit hard, irritating gas, foreign bodies.
2. Infection: rhinitis, sinusitis, specific granuloma.
3. Neoplasms: juvenilis nasopharynx angiofibroma.
4. Congenital: hereditary hemorrhagic teleangiectasia (Osler).
 

B. Because systemic
1. Cardiovascular: hypertension, Aartiriosklerosis.
2. Blood disorders; ITP, hemofili, leukemi.
3. Infection: typhoid, influenza, morbilli.
4. Changes in atmospheric pressure: Caisson disease.
5. Endocrine: menarche, pregnancy, menopause.

According to the source, epistaxis divided into:
1. Anterior epistaxis:
    Originating from plexus Kiesselbach or a. etmoidalis anterior. Especially in the encounter with the children, usually minor and easily overcome.
2. Posterior epistaxis:
    Coming from a. sfenopalatina and / or a. etmoidalis posterior. Often there is at an advanced age due to hypertension or arteriosclerosis. Usually severe and rarely stops spontaneously.

Management:
Having principles:
1. Stop the bleeding.
2. Prevent complications.
3. Prevent repeated by finding the cause.

1. Determine the origin of bleeding by putting a tampon in the wet with adrenaline 1 / 1000 and pontokain 2%, aided by a vacuum.
Wherever possible the patient in a sitting position.
 

When the bleeding was coming from the anterior:
2. Replace the tampon soaked in adrenaline 1 / 1000 and pontokain 2% for 5-10 minutes, and pressed toward the septum.
3. After the tampon is removed, bleeding from the caustic with AgNO3 solution of 20-30% or 2-6% trichloroacetic acid or with electrocautery.
4. If still bleeding, put tampons anterior consisting of cotton or gauze that was given boorzalf or bismuth iodine paraffin paste (BIPP).
Tampons are maintained for 1-2 days (when using boorzalf) or 3-4 days (when using BIPP).

When the bleeding was coming from the posterior:
5. Try to cope with the caustic and anterior tampon.
6. If failed, the posterior pairs of tampons (Bellocq );
How:
- Tampon is comprised of roll gauze that has two threads on one end and a thread at the other end.
- Enter the characters from the rubber into the anterior nares to look at orofarings and pull it out through the mouth.
- At the end of the catheter is attached to one of two existing threads on one end and the catheter withdrawn through the nose. In the same way that other threads released through the other nostril.
- Then the two threads that have come out through the nostrils was withdrawn, while the index finger of other hand to help push towards the nasopharynx, until proper shut koana.
- Lau both are tied to the other tampon which is located near the nasal cavity. Yarn from the other end out through the mouth and attached loosely in cheek, this thread is useful to draw out the tampon when will be released.
- If you need to be installed also the anterior tampon.
- Patients should be treated and tampons removed after 1-2 days. The following antibiotics.

When the bleeding has been settled despite the above measures, consider artery ligation surgery:
7. Ligation for bleeding anterior done a. esmoidalis anterior by making an incision from the medial part of    eyebrows downward along the bridge of the nose up to slightly below kantus internus; after the network is separated will look a. etmoidalis anterior.
8. Ligation for bleeding posterior done a. internal maxillary by making an incision in the crease gingivobukal as in Caldwell Luc operation; after entering the maxillary sinus posterior sinus wall removed so that it looks a. internal maxillary and its branches in fosapterigomaksilaris.

COMPLICATIONS
Of bleeding:
- Anemia.
- Shock.
- From installation tampons:
- Sinusitis, otitis mrdis, septikemi.
- Hemotimpanum.
Molle-laceration palate.
Airway obstruction
Is an emergency that can be caused by various reasons, among others:
1. Airway edema: can be caused by infection (diphtheria), allergic reactions or due to instrumentation (endoktrakeal pipe installation, bronkopi) and blunt trauma.
2. Foreign objects.
3. Tumors: cysts larings, larings papilloma, laryngeal carcinoma; usual blockage occurs slowly.
4. Trauma larings area.
5. Muscle spasm larings: tetanus, emotional reaction.
6. Abductor muscle paralysis of the vocal cords (abductor paralysis): especially when bilateral.
7. Congenital Negligence: laryngeal web, causing fistula trakeoesofagus laringotrakeomalasia.

SYMPTOMS AND SIGNS
Can be divided into four stages (Jackson):
     I. Shortness of breath, stridor inspiration, retraction suprastrernal; general situation is still good.
     II. Symptoms of stage I + retraction epigastrium; patient became restless.
     III. Symptoms of stage II + retraction supra / infraklavikular, people are very nervous and sianotik.
     IV. Symptoms of stage III + intercostal retraction, people try very hard to breathe the air: long run going central respiratory paralysis, the sufferer becomes apatik and eventually died.


MANAGEMENT:
When caused by foreign objects (such as choking on food) try out immediately with the Heimlich maneuver:
A. patient in a sitting position / standing:
    1. .- helper sit / stand behind the patient.
         - wrap both hands around the patient.
         - make a fist with one hand, other hand gripping the fist with the thumb facing the abdomen and placed in the epigastrium.
        - do it firmly and quickly pushing towards the top.
        - this action can be repeated several times.   

   2. If not successful, try to hook a foreign object with a finger that was tied into the larings.
   3. When hard or foreign object is located in, patients in the bend and in a strong pat on the back of both the scapula.
 
B. patient in the supine position:
 
1 .- helper kneel on both knees in patients with left and right side of the patient's body
     - one palm placed on the epigastrium patients, the other palm on it
     - apply pressure with the heel of the hand with a strong and rapidly towards the top
     - this action can be repeated several times
2. If the patient vomited, twisting his body and clean his mouth.


If the above methods fail or when not caused by foreign objects, prepare immediately bronchoscopy or tracheotomies.
     Against persons with airway obstruction stage I and II be taken koservatif with oxygen, bronchodilators drugs (aminophylline, Bisolvon) and anti-edema (Papasee); and tight control over symptoms.
     Airway obstruction stage III and IV require intubation or tracheotomies immediate action.

Intubation
It is the act of laying pipes endokrakeal (usually has a cuff) or bronchoscope.

Difficult or not can be taken on larings edema, weight larings trauma, tumor n.rekurens closed glottis or bilateral paralysis. This method is relatively easy and quick to do, but:
- causes trauma that can arise larings scarring that makes it difficult extubation.
- not easy to set up more than 2 x 24 hours.
- often despite themselves so as to endanger patients.
- blocking peroral intake.

Tracheotomies
An act making the airway just by making a hole (stoma) in the trachea.
According to the urgency divided into:
- Emergency tracheostomy
Performed on an emergency, usually in areas glottis (high tracheostomy); should be replaced with low tracheotomies.
- Orderly tracheotomy
An action plan, carried out on ring III or below (tracheostomy below (low trakeostomy)

Technique:
- Premedication with atropine sulfate 1 mg i.m.
- Patient within hiperektensi position on the neck, if necessary neck propped up with pillows / bags of sand.
- After skin incision and antisepsis area of action, given local anesthesia (infiltration) with procaine 1% starting from the thyroid cartilage to the trachea previous supraster fossa region must be marked with endotracheal tube or bronchoscope.
- Incision is made from the bottom of the cartilage krikoid until suprasternal fossa, right in the horizontal, although cosmetic worse.
- Subcutaneous tissue is set aside, as far as possible do not cut the blood vessel, cut the muscle fascia in the midline.
- After the tracheal rings are visible, the thyroid isthmus is set aside (if necessary separated) to open fourth tracheal ring; bleeding treated.
- Can be injected a few drops of 5% cocaine through interkartilago I to prevent irritation of the installation cannula.
- Trachea should be opened in the midline below the third ring, then made a hole or flap in accordance with the cannula that will be installed.
- If any, foreign objects can be searched and removed through the stoma with the help of nasal speculum and forceps; if it is a foreign body was located distal to the stoma and can be retrieved, push to one of the bronchial airways to open for some and immediately send it to places that have facilities bronchoscopy.
- Post-actions do not need stitches, if necessary, can be made loose stitches at both ends insisisi.

Some things to note:
- insisis which complicates the search too short trachea and facilitate the occurrence of subcutaneous emphysema.
- cannula as far as possible in accordance with melted diameter of the trachea:
   - if too small will be easy to move, giving rise to stimulation.
   - if too big will reduce tracheal wall, resulting in easy necrosis.
   - if too pentek, easy off and into the subcutaneous.
   - if too long end will shift the tracheal wall that stimulates granulation and stenosis.

Treatment of post tracheotomies:
- secretions are often cleaned with a vacuum, every 15 minutes.
- cannula in cleaned at least once a day;'m cannula out to 2-3 days.
- cloth pads cannula should be replaced when wet to avoid dermatitis.
- dekanulasi done gradually, at first closed 1/4bagian, if no complaint cap ½ parts, etc. ¾ and finally closed completely, only then cannula is removed.


Complications tracheotomies
:
- bleeding, especially from a truncated thyroid skin incision.
- the infection-prone perikondritis thyroid, pneumonia.
- granulation tissue
- tracheal stenosis or larings.
- fistulas trakeoesofagus.
- subcutaneous and mediastinal emphysema.
- pneumothorax.


MASSIVE HEMOPTYSIS
Cough is accompanied by bleeding more than 600 ml within 24 hours (Cook).
Classification of bleeding (Pursel):
+             : cough with bleeding-shaped stripes of blood in the sputum.
+ +          : a cough with bleeding 10-30 ml
+ + +       : a cough with bleeding 30-150 ml
+ + + +    : a cough with bleeding> 150 ml
Important to distinguish between haemoptysis with the aspiration of gastrointestinal bleeding (hematemesis), who coughed:
Haemoptysis, haematemesis clinical differences
Hemoptysis
- Colour pink
- No food scraps, foaming
- Reacting base
- History of lung disease / heart

Hematemesis
- Color black red
- Often mixed with food scraps
- Reacting acid
- History of gastrointestinal disease

Usually caused by pulmonary tuberculosis (TB) / (TBC), bronchiectasis, lung abscess or neoplasm which roughly can be predicted from the nature of the bleeding:
- If there is bleeding lines in sputum, usually due to acute bronchitis or pneumonia.
- If there is constant light bleeding is usually caused by endobronchial neoplasms
- If bleeding occurs in large numbers is usually caused by pulmonary infarction, cavities or bronchiectasis.
Patients may die because:
- Asfiksi airway obstruction caused by blood clots.
- Shock due to massive bleeding.

MANAGEMENT:

A. Conservative.
1. Rest lying with his head lower and tilted to the side of pain.
2. Clean the airway of blood clots; if necessary give oxygen intermittent.
3. Put the liquid infusion; if necessary to do blood transfusions.
4. Avoid loud cough by giving
    - Sedatives: - phenobarbital with a maximum dose of 250 mg / administration, im; or - diazepam 10-20 mg  iv / im.
    Antituif; - codeine 10-20 mg orally.
5. Coagulant drugs
   - Vitamin K 10 mg iv.
   - Adona AC - 17R 50-100 mg/3-4 hour iv.
6. Ice bag on your chest

Further action, if possible:
7. Determining the origin of bleeding with X-ray images and bronchoscopy
8. Determining the cause and treatment.

B. Surgery.

Surgery is considered an emergency when there is no indication as follows (Busroh)
1. Patient coughing up blood> 600 ml / 24 hours and in the observation does not stop
2. Patient coughing up blood between 250-600 ml / 24 hours with Hb <10 g % and coughing up blood mash continue.
3. Patient coughing up blood between 250-600 ml / 24 hours with Hb> 10 g %, but conservative treatment for 48 hours, do not stop coughing up blood.
Before the surgery done, as far as possible checked for lung function and make sure the origin of the bleeding, while the type of surgery ranged from segmentektomi, lobectomy and pneumonektomi with or without torakoplasti.

STATUS ASMATIKUS
INTRODUCTION
Status asmatikus is a severe asthma attack, took place within a few hours to several days, which is not member i improvement on the usual treatment.
Status asmatikus an emergency medic who can berakbat death, therefore:
- In the event of an attack, should be addressed Seara appropriate and preferred to overcome respiratory effort.
- The state should be prevented by taking into account factors that stimulate the emergence of an attack (dust, pollen, certain foods, respiratory infections, stress, emotion, etc.)

Symptoms and Signs

1. Patients in a state of severe shortness of breath accompanied by expiratory wheezing (wheezing); can be accompanied by a cough with thick sputum, difficult expelled.
On examination the patient was restless, breathe using the muscles of additional premises signs of central cyanosis, tachycardia, pulsus paradoksus and longitudinal phase accompanied ekspirium wheezing.
2. Examination of sputum and blood laboratirium eosinofili there, especially in allergic asthma.

MANAGEMENT

The principle of the laboratory are listed in Table 1.

Table 1. The principle of management of Status Asmatikus
1. Diagnisis asmatikus status
Important factors to consider:
a. Weighing attack
b. Drugs that have been given (drug and dosage)
       2. Bronchodilator drug administration
       3. Penilaan to repair attack
       4. Consideration of corticosteroids
       5. After the attack subsided;
a. Search of factors
b. Modifications further supporting treatment

1. Brokodilator
Not used bronchodilator drugs administered orally, but the medications used bronchodilators are inhaled or per enteral.
If you have previously been used sympathomimetic drug class, it should be given in per enteral aminophylline causes the different mechanism of action, and vice versa, if the drug group had previously used oral theophylline, the class of sympathomimetic drugs should be given by aerosol or parenterally. Drug-drug class of sympathomimetic bronchodilators selective form of adrenoceptor-B2 (orsiprenalin, salbutamol, terbutaline, isoetarin, fenoterol) has the properties is more effective and longer working lives and less side effects compared with non-selective form (adrenaline, ephedrine, isoprenalin .)
- The drugs in aerosol bronchodilators work faster and less systemic side effects. Good for use in children or in adults with severe shortness of breath. At first given two straws from a metered aerosol devise (Alupent R) (metered aerosols). If the improvement, can be repeated every 2 hours. If the assessment up to 10-15 minutes showed no improvement, give intravenous aminophylline.
- Sympathomimetic bronchodilator drugs side effects tachycardia. The use of parenterally in the elderly should be careful, be dangerous in hypertensive disease, cardiovascular and cerebrovascular. In adults tested with 0.3 ml of solution epineprin 1: 1000 in subcutan, whereas in children given a dose of 0.001 mg / kg subcutan (1 mg per ml) which can be repeated every 30 minutes for 2-3 times depending on needs.
- Provision of aminophylline intravenously with an initial dose of 5.6 mg / kg, in adults and children alike who injected slowly within 5-10 minutes. Furthermore, as a supporter dose is 0.9 mg / kg / hour infusion administered. Side effects that may arise is the blood pressure down, especially if the gift is not slowly.

TABLE 2. Bronchodilator medications

Adult Dose Name Dose How children
Adrenaline 0.1 to 0.5 mg 0.1 mg / kg SK
(1 mg / ml) 0.1 to 0.2 mg
(With dilution)
Isoprenalin
             (0.2 mg / ml) of 20-100 ug 0.1 ug / kg / min IV
(Slow)
Etilnoradrenalin 2 mg from 0.2 to 1 mg SK
            (2 mg / ml) 0.25 mg 5 ug / kg SK
             Terbutaline
            (0.5 mg / ml;
            0.1 mg / ml)
            Aminophylline 5.6 mg / kg IV as in adults
           (0.25 g / 10 ml) followed by
0.9 mg / kg / BW / hour

2. Corticosteroids

If giving bronchodilators drugs showed no improvement, followed by corticosteroids.
- 200 mg of hydrocortisone (Solu CortefR) or a dose of 3-4 mg / kg, given intravenously as a dose threshold and can be repeated every 2-4 hours parenteral to control acute attacks, premises followed by 30-60 mg of prednisone or with a dose of 1-2 mg / kg / day orally in divided doses, then the dose reduced gradually.
3. Giving oxygen can be through nasal kanule with O2 flow rate 2-4 liters / min and flowed through the water to member humidity
Expectorant drug such as gliserolguaiakolat can also be given.
To improve the state of dehydration, then the intake of fluids by mouth or infusion should be sufficient, in accordance with the principles of rehydration.
Antibiotics are given if there is infection.

Thoracic trauma

In general, any trauma to the thorax, either sharp or blunt, may:
In skin and soft tissue, injuries, bruising, subcutaneous emphysema
- on the bone: broken ribs, broken sternum, paradoxical breathing.
- the pleura: pneumothorax, hemotoraks, hemopneumotoraks, kilotoraks, serotoraks.
- in lung tissue: traumatic wet lung.
- in the mediastinum: pneumodemiastinum, roberakan esophagus, bronchus tear.
-at the heart : hemoperikardium bronchus .
-at the heart : hemoperikardium ,cardiac injury .
The principle of treatment of thoracic trauma are:
1. Overcoming the shock
2. Maintain airway
3. Restore / maintain airway negative pressure pleural space.
4. Pain relief.
- Stability of the chest wall
- Thoracotomy, if there are indications:
- - continuous bleeding 3-5 ml / kg / hour for 3-6 hours
- Pneumothorax is resolved in the normal way
- A torn esophagus
- Heart Injury

SUBCUTANEOUS EMPHYSEMA

It can be seen from the air krepitasi palpable under the skin, usually starting around the wound penetrating the chest wall or rib fractures. The air can come from outside, but generally from rips pleural.


Management


- Generally do not need to do anything because it will be absorbed by itself.
- Be wary of emphysema are:
• Not be accompanied by an open wound of the chest wall (eg in blunt trauma), because certainly there are also pneumothorax, emphysema when then quickly spread and the patient became short of breath with percussion hipersonor means there has been tension pneumothorax - soon stab in the area between the ribs II / III line midklavikular with a large needle to penetrate the chest cavity, while preparing waterseal drainage
• Starting from the neck area because it can indicate pneumomediastinum.


BROKEN BONE AND BREATHING PARADOXICAL RIBS

Broken ribs can be accompanied by pain and can pierce; pleura, causing pneumothorax. Paradoxical breathing occurs when there is motion in the opposite chest wall during breathing from a broken rib bones that surround a particular area. This situation is cause hypoxia because outside air can not reach the alveoli.


Management

- Pain is treated with local anesthetic intercostal nerve blogs concerned; needle inserted along the bottom edge of the ribs. Not recommended because of sedative suppress cough reflex and respiration.
- Simple rib fractures do not have to be taken, because of fixation to the detriment of the chest wall during respiratory movement
- But if there is paradoxical breathing, fixation should be done with the tape width, with an emphasis
- Attached patch from a healthy area of ​​the chest wall, encircling the wound down to healthy areas as well.

- Previous to put gauze over the wound in order to emphasis thick.
- Fixation performed during expiratory
- Pleaster installed-layered, as far as possible not aligned with a broken line.
Traction can also be performed for the same, namely the broken area with a wire tied to the objects do not move around the patient.




PNEUMOTHORAX AND HEMOTORAKS

Symptoms and signs

- Side of the affected do not participate in breathing, percussion hipersonor (in pneumothorax) or deaf (in hemotoraks) or there together (hemopneumotoraks); breath sounds disappeared.
- May be accompanied by subcutaneous emphysema and rib fractures.
- If the complaint shortness of breath behind the (pain) quickly become heavy suspicion of tension pneumotorax,
- Radiological lung shadows appear smaller, surrounded by a radiolucent area (pneumothorax), when there are local indicate radioopak hemotoraks.

Management

- When the radiologic pneumothorax only covers <15% of lung tissue and minimal complaints, just observations alone; if > 15% or widespread severe complaints must be puncture or drainage waterseal
- Determine whether intact or tear the visceral pleura
- When the chest wall intact (blunt trauma), pneumothorax must be caused by tearing of the visceral pleura careful of the possibility of tension pneumothorax
- When you open the chest wall (sharp trauma) patients were told to cough and when the visceral pleura will spray the air ripped out of the wound.
- Do not rush suturing the chest wall, because if it is turned inside the visceral pleura that action will change the open pneumotoraxs be closed / tension pneumothorax is more dangerous.
- If the visceral pleura intact enough to do the tap:

How to:

- Patients in a sitting position, tap on the contrary made in the posterior axillary line between the ribs as high as VII-VIII.
- Regional puncture is cleaned with antiseptic and then given a local anesthetic infiltration
- Use a needle puncture made with a large syringe ( No. 15-16 ), along the edge of the edge of the ribs, and the air / liquid sipped slowly so the lungs inflate could adjust in back.
- If the patient coughs, may be sucking too fast or lung puncture needle tip untouched; exploitation should be stopped for a moment and needles a little pulled.
- After completion puncture puncture area covered with sterile gauze.
- If the visceral pleura will measure the tear or bleeding, should be done waterseal drainage (WSD).

How to:

- Position the patient and the region together with pleural puncture.
- After anesthesia, do the skin and subcutaneous incision.
- After that puncture through the incision wound trokar which was installed in the cannula pointing slightly upward through the muscle
- After reaching the pleural cavity trokar released and immediately insert a catheter / tube of rubber which is still clamped into the cannula.
- Cannulas released and the catheter / rubber pipe connected to the bottle
- Check that the clamp is opened and the pleural cavity relationship with the bottle remains smooth with respect to:
- The exit of the air / liquid.
- Undulation in the pipe bottle after the air / liquid do not come out again.
- Catheter / rubber pipe in the sewing on the skin around it covered with sterile gauze.
It is worth noting here that:
1. Catheter / rubber pipe must be covered from the possibility of entry of outside air
- Bottles should not be located higher than the mounting catheter in the chest wall, except in a state clamped.
Simplest bottle is a bottle I which can be made from infusion bottles, should be filled liquid antiseptic (sublimat or KMnO4 ) and stopper penetrated by two long pipes associated with the pleural cavity and the tip should always be located 3-5 cm below the surface of the liquid, this important to note when the pleural cavity flowing fluid (blood) which will raise the surface of the liquid in the bottle; being left short pipe connected with the outside air. Close the bottle need not airtight.
When I was with a bottle pressure of the pleural cavity can not be negative, such as pleural tear is too large, continuous exploitation jarus done (continuous suction), for it must be used bottle bottle series II or III.
Series III better, especially if the pleural cavity still produce liquid so that bleeding can be more precise Jumah measured and do not have any time to measure the depth of the second pipe
When the suction is stopped, the pipe leading to the suction device must be clamped.
3. When the pressure of the pleural cavity had been negative but fixed lungs do not expand, it means there is airway obstruction give Mukolitik, for example OBH 3 x 15-30 ml / day and recommend that patients often cough.

WET TRAUMATIC LUNG

Symptoms and Signs:

- Mainly occurs after blunt trauma.
- The patient complained of cough-cough, sometimes accompanied by blood, chest pain, shortness of breath; no fever
- On auscultation rhonchi sound evenly wet.
- It is important to distinguish from bronkopnemoni because clinical and radiologic picture similar

Management:

- Rest lying
- Release of the airway by:
- Encourage patients often cough.
- Pain is removed with intercostal nerve block anesthesia, sedatives are not recommended because suppress cough reflex.
- Sip mucus, if necessary, until the trachea; exploitation still be conducted even if the patient coughs because just when the lender will be pushed into the proximal
- When you need to do a tracheostomy.
- Drugs: Mukolitik and bronchodilators, for example:
- OBH 3 x 20 ml / day or
- Bisolvon 3 x 1-2 tablets / day

PNEUMOMEDISTINUM

Suspect pneumomedistinum when emerging subcutaneous emphysema that began in the area of ​​the neck, especially when accompanied by severe shortness of breath and shock. Radiological appear radiolucent shadow in the mediastinum and around the heart, or retrosternal on the lateral projection

Management:

- Mediastinotomi
- In accordance with a tracheostomy, and then proceed to the mediastinum in blunt with tracheal ring finger down and then performed a tracheostomy
- When accompanied by tears or brounkus esophagus and progressive pneumomediastinum will arise, in this case must be made Thoracotomy

TAMPONADE AND INJURED HEART

Accompanied by a rapidly deteriorating general condition accompanied by increased jugular venous pressure, cardiac deaf widespread, distant heart sounds and pulsus paradoksus sounded.
When the pericardium participate ripped, there will also hemotoraks.

Management:

 Shock-Overcome
- Perikardiosentesis
- Patient half-sitting position ( angled 35-40 o to vertical )
- Puncture needle is inserted in the left paraxifoid area toward the left shoulder
- This action is only temporary, must be followed by Thoracotomy
- Thoracotomy for repair rips or pericardium and heart wall


google translator of the article title from all countries in the world
Nood asemhalingstelsel, Sistemin emergjent Frymarrja, نظام الطوارئ التنفس, Արտակարգ Շնչառական համակարգի, Təcili Solunum Sistem, Sistem Pernapasan Darurat, Larrialdi Breathing Sistema, Noodgevallen Breathing System, Спешни дишане система, Надзвычайная дыхальная сістэма, Nouzové Dýchací systém, Emergency Vejrtrækning System, Avarii ,Hingamissüsteemi, اورژانس سیستم تنفس,
Sistema de Emerxencia Respiración, საგანგებო Breathing სისტემა, Emergency Breathing System, आपात श्वास प्रणाली,
חירום מערכת הנשימה
Córas Análaithe Éigeandála, Neyðarnúmer Öndun System, Di respirazione di emergenza del sistema, 緊急呼吸システム
, Emergency Breathing System, D'emergència del sistema de respiració, 긴급 호흡 시스템
, Ijans Respirasyon Sistèm, Hitna disanje sustav, Emergency System Respiratio, Avārijas Elpošanas sistēmas, Neatidėliotinos Kvėpavimo sistema, Sürgősségi Légzököri
, За итни случаи на системи за дишење, Sistema Nifs 'emerġenza, 紧急呼吸系统
, 緊急呼吸系統
, Sistem Pernapasan Kecemasan, Emergency Breathing System, Emergency paghinga System
, Emergency układ oddechowy, Sistema de Emergência Respiração, Système respiratoire d'urgence, Respiratia de urgenţă Sistem, Чрезвычайная дыхательная система, Хитна дисање систем, Nujna dihanje System, Núdzové Dýchací systém, De emergencia del sistema de respiración, Emergency hengitysjärjestelmien, Kinga ya dharura System, Akut andningssystemet, ระบบทางเดินหายใจฉุกเฉิน, Acil Solunum Sistemi
, Надзвичайна дихальна система
, ایمرجنسی کے سانس لینے کا نظام
, Hệ thống cấp cứu thở
, System Anadlu Argyfwng
, גוואַלד ברידינג סיסטעם
, Συστήματος Έκτακτης Ανάγκης Αναπνοή

verpleegsters, verpleging, infermieret, pleqsh, الممرضات، والتمريض, բուժքույրեր, բուժքույրական, tibb bacıları, Danışmanlık, perawat, keperawatan, erizainak, erizaintzako, verpleegkundigen, verpleegkundig, медицински сестри, медицински сестри, медсёстры, догляд за хворымі, zdravotních sester, ošetřovatelství, sygeplejersker, sygepleje, õed, hooldus-
, پرستاران، پرستاری
, enfermeiros, nurses, nursing, ექთნები, საექთნო,नर्सों नर्सिंग,,אחיות, סיעוד,altraí, altranais, hjúkrunarfræðinga, hjúkrunar-, infermieri, infermieri, 看護師は、看護, Krankenschwestern, Pflege, personal d'infermeria, infermeria, 간호사, 간호,, enfimyè, tete, medicinskih sestara, skrb, alit, nutrientibus, medmāsas, māsu, medicinos seserys, slaugos,, 護士,護理, 护士,护理,infermiera, infermiera, медицински сестри, нега, ápolók, az ápolási,, enfermeiros,, pielęgniarki, opieka, nurses, nursing, sykepleiere, sykepleie, jururawat, jururawat,, infirmières, infirmières, asistente medicale, asistenţă medicală
, медсестры, уход за больными, медицинске сестре, брига, medicinske sestre, zdravstvene nege,, sjuksköterskor, omvårdnad, manesi, uuguzi, sairaanhoitajat, hoitotyön, personal de enfermería, enfermería, zdravotných sestier, ošetrovateľstvo,, พยาบาล, พยาบาล
, hemşireler, hemşirelik, медсестри, догляд за хворими, نرسوں نرسنگ،, y tá, điều dưỡng,
, nyrsys, nyrsio, נורסעס, שוועסטערייַ, νοσηλευτές, νοσηλευτική


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4 komentar:

Catatan sang penulis said...

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mannu said...

Hat’s off. Well done, as we know that “hard work always pays off”, after a long struggle with sincere effort it’s done.

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mannu said...

I appreciate the concern which is been rose. The things need to be sorted out because it is about the individual but it can be with everyone.

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