109

- , - . , . , 3-5 mm . - , a , . :

() ,

: ( - ;

; .) ,

. , .

(. 82):

o tuber maxillae o foramina alveolaria o rami alveolares superiores posteriores

: o os zygomaticus o crista zygomaticoalveolaris o tuber maxillae

. 82. : tuber maxillae; foramina alveolaria; rami alveolares superiores posteriors

110

- .

. , crista zygomaticoalveolaris (. 83):

o (, ., 1960; Hofer, 1969) o (Fisher, G., 1955) o - (, .,

1962; , ., 1969) o (, ., 1953; , ., 1977) o (, ., 1957)

, , . , . ( plexus venosus prerygoideus ), :10 mm (Fisher, G., 1955);10-15 mm (, ., 1977); 20-25 mm (, ., 1969); 25 mm (, ., 1959; , ., 1962); 25-30 mm (Hofer, 1969). 1.5 ml 7-8 (, .) 10-12 (, .), , ramus alveolaris superior mdius (Seldin, 1948).

. 83. -

- ramus alveolaris superior mdius rami alveolares superiores posteriors (. 84). . , . 1-1.5 m, . . 1-2 , . 5-6 , 10-15 - , 15-20 - .

111

. 84. :

- . :

, . ( 1962) . , :

o , . (. 85). , , , . 2.0-2.5 cm.

o , . . (. 85), , , . 2.0-2.5 cm.

. 85.

. (1977) , ,

112

- , 2-3 m. (. 86).

. 86.

, . (1969) , . , , . .

(rami alveolares superiores anteriores), . , , , , , (rami palpebrales superiores,rami nasales externi, rami labiales superiores). (. 87)

o foramen infraorbitalis o fossa canina o rami alveolares superiores anteriores

. 87. : foramen infraorbitalis; fossa canina; rami alveolares superiores anteriores

113

: o margo infraorbitalis o foramen infraorbitalis o fossa canina

- ; :

, , . , . foramen infraorbitale margo infraorbitalis 5mm . margo infraorbitalis , - sutura zygomaticomaxillaris, 5mm . (foramen mentale).

( ).

, . (1962) A .

( ) ( 1.5-2 m) 0.5 ml . 7-10 mm, 0.5-1 ml (, C.; , M.; , .; , .). , . , (. 88). rami alveolares superiores anteriores, rami alveolares superiores media .

. 88.

-, . (1950) A ( ).

, , ,

114

- . (. 89) , . 2 m (Jorgensen, ., 1983).

. 89. -

, . (1980) , , . (, ., , ., , .) , . , , (. 90).

. 90.

- ; . :

. . , , (. 91). 0.5 m . .

115

( ) 7-10 mm . -, - -. ( ). - , - . , - . .

. 91.

. (. 92).

. 92.

n. incisivus n. palatuinus major n. incisivus

papilla incisiva (. 93). 0.25.-0.5 ml . . .

116

. 93. n. incisivus

n. palatinus major. , , , 1-1.5 m (. 94), - .

. 94. n. palatinus major -

, (. 95). , processus palatinus maxillae lamina horisontalis os palatinum. , - .

. 95. -

117

n. incisivus n. palatinus major (. 96).

. 96. E o n. incisivus n. palatinus major

. :

()

( ). , , . , , .

1884 .

William Stewart Halsted n. mandibularis - 13 4% . 7 28 . , . (. 97). (margo anterior rami mandibulae) , linea oblique. linea oblique crista temporalis fovea retromolaris. rista temporalis, , , - crus medial crus laterale. trigonum retromolare. , fovea retromolaris trigonum retromolare .

118

, , (foramen mandibulae), (lingula mandibulae). processus condylaris mandibulae (crista colli mandibulae). (sulcus colli mandibulae). , , . (Halsted-Braun ). processus condylaris mandibulae processus muscularis mandibulae, incisura mandibulae , torus mandibulae. n. mandibularis (n. alveolaris inferior, lingualis buccalis) - torus mandibulae, Gow-Gates (sulcus colli mandibulae).

. 97.

Halsted, W. S., Braun, G. (1884-1905)

- foramen mandibulae :

o trigonum retromolare o lingula mandibulae o ligamentum pterygomandibularae

: fovea

retromolaris ( linea oblique crista temporalis). , , 1 m plica pterygomandibularis (. 98).

. 98. Halsted-Braun

119

0.5 m 0.5 . n. lingualis. , , . 1-2 m, . , lingula mandiblae foramen mandibulae. . n. buccalis . foramen mandibulae (. 99).

. 99. Halsted-Braun

Gow-Gates, G.A.F. (1973). .. . :

o , m. pterygoideus lateralis o sulcus coli mandibulae

. - . (. 100). .

o ( ) o o

. 100. Gow-Gates

120

: , plica pterygomandibularis (. 101a). , , m. temporalis, . , ( ), . ( 25 mm) - . 1 mm, , 1.8 ml . 1-2 , (. 101b).

. 101. Gow-Gates

. 25 mm , , . , (< 2%) .

Akinosi, J.O. ( 1977) . , ,

o o rysta temporalis m. temporalis o o rocessus muscularis (coronoideus) mandibulae

o , , o

: , ( , ). . rysta temporalis m. Temporalis (. 102). (. 102b).

121

, . (. 102c) (). rysta temporalis. 30 mm, . . spatium pterygomandibulare n. alveolaris inferior, n. lingualis, n. buccalis . 4-6 2 1/2 5 (, ., , ., , ., 2002). n. facialis , , . 1.65% .

. 102. Akinosi: ) ; b) ; c)

: ; ; ; , : ; ; , .

o Levit, B. (1924)

- foramen mandibulae :

o plica pterygomandibularis o

:

122

plica pterygomandibularis, 1 m . , 2.5 m 1.5 . . n. alveolaris inferior. , a 0.5 . n. lingualis. n. buccalis , . 1929 . Levit - - (. 103), 1 m . .

. 103. Levit

B, . . (1940) ,

lingula mandibulae, , torus mandibulae. , ( processus condylaris processus coronoydeus mandibulae). . - torus mandibulae (. 104) :

o plica pterygomandibularis o o

: . plica pterygomandibularis, 0.5 m (. 104b), - 1.5 m . , 1.5 . . n. alveolaris inferior bucallis. n. lingualis. n . mandibularis. : 2 11 (), 5 7 (), 5 10 ( Berg), 10 15 (, ), 15 20 (). 30-40 .

123

. 104.

E . , . . . foramen mandibulae. incisura mandibulae, , . , Klein B., Sicher, H. (1915), , . (1962), , 22 mm, - 27 mm, - 13 mm, - 15 mm (. 105).

. 105.

Berscher--

(Mayer, 1916; Berscher, 1922). incisura mandibulae Berscher , . , . - incisura mandibulae :

o arcus zygomaticus

124

o tragus auricule o processus condylaris mandibulae

: , o , , (. 106). , . , , (. 106b).

. 106.

2 m , , (. 107), 2.0-2.5 m (Bercher). 15 ( n. alveolaris inferior). , . (1947) 3.0-3.5 m, m. pterygoideus lateralis. , ( n. alveolaris inferior n. lingualis). , . . (1929) 4.0-4.5 m foramen ovale (n. alveolaris inferior, n. lingualis n. buccalis). 4.5 m , m. pterygoideus lateralis, a. meningea media. .

. 107. --

125

Pehr Gadd (1913)

, a. facialis m. masseter. a. facialis , 30 mm. n. alveolaris inferior.

Klein, B., Sicher, H. (1915) foramen mandibulae 13 mm . . (. 108). 35-40 mm . n. mandibularis. . (1927) .

. 108. Klein-Sicher

Berg (1940) II, III, IV , (. 109). 1.5 m : 40 mm n. alveolaris inferior, 50 mm n. lingualis 60 mm n. buccalis.

. 109. Berg

126

Pekkert-Wustrow (1937)

processus mastoideus 1 m , 2 m. lingula mandibulae, . - n. facialis, .

(1956) . . , .

. -

. - , - . :

o ( 28 ) o / 28 - 12 ) o (1-7 .)

) (1-3 .) ) (4-7 .)

o (7-12 .) o (12-18 .)

, . 12- . E . , . , , . . . 7- - . :

o : > RR; ;

o o

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

127

, . :

, , , ( ).

, .

, , .

(). 0.1 mg/kg. 4-6 . 2 mg , 30-40 min . , 7-10 . 2-5 mg, 11-14 . - 4 mg, 15 . - 5 mg. , , . .

.

, , . . , , 3-7- , . . . , , .

- -

- - . 14-15- . (Donohue, D. et al. 1993; Jastak, J., 1995; , .. .,1997). , : , , . . , - , .

128

( , , ). foramen mandibulae . , . , , . (150), - 105-110. foramen mandibulae. 9 18 5 mm . 3 1/2-4 1 mm , 6-9 - 6 mm , 12 - 10 mm (, .., , . ., 1989). 3.3 mm 4.5 mm (Fischer, G., 1938). . - , . -, - . 15 mm, - . . , 10- (Maragakis, M., 1987). , (-, 1989):

o 5 . o 5 - 3-5 mm

, . (1975) : o ( 7 .) -

o 7 12 . - 2-3 mm o 12 . -

, - - . . , . , 6 12 . - , 12 . - . , , -, . . - , - . 1969 . - .

- 5 mg/kg

30 kg = 150 mg 1 68 mg

150:68 = 2 ()

= 5 mg/kg X kg.ml = 5 30 = 150 = 3.7 ml = 2 % X 10 4 10 40

129

Sanders, B. , , :

2 . - 0.2 ml 3-4 . - 0.25 ml 5-6 . - 0.4 ml 7-9 . - 0.5 ml 10-14 . - 0.75 ml 14 . - 1.0 ml

, . (1988) 4-5- .

, :

- - -

-

, pH , ,

:

, . - . . - -. 10-15 , - 20-30 . (, ., 1975) (0.5-1%) 15-20 . (, , , , , / - . (. 110), , .:

. . .

, - .

- .

130

. 110.

( , , ) , , .

I. - ,

. , - . plexus venosus pterygoideus (. 111a), a.v. mandibularis, , , - a.a., v.v. infraorbitalis, angularis, facialis. , , , , (. 111b) . . - . . . ( ).

o 3-5 .

o 10-15 . .

o , .

131

. 10-12 .

o (, ) . - , , -, . 5-7 .

o .

. 111. : ) plexus venosus pterygoideus; b)

o ,

. o - ,

. , . .

. - . ( ). (. 112), - . , . .

. 112. : ) ; b)

132

n. facialis

, . , .

n. facialis , (, ) .

n. facialis , (. 113). ramus marginalis mandibulae .

. 113. n. facials

. rami zygomatici , , , . .

, , , . --. chorda tympani ( n. facialis n. trigeminus). n. auriculotemporalis , , ( n. Facialis).

o ( 1 1/2-2 ). , .

o

133

. , (Dibasolum tab. 0.02 g - 2x1; Nivalin tab. 0.005 g - ; Acidum glutaminicum tab. 0.5 g - 2x1) (, , ).

. - .

n. trigeminus n. trigeminus ( ) , . , , , . n. linqualis n. alveolaris inferior. . , (, .) (, ..). , , (Fisher, G.). , , , , . n. alveolaris inferior , . , , . . , .

o 2-3 . ( ).

o , , (Chlorazin tab. 0.025 g ) (Promedol tab. 0.025g ,2 x .), (Allergosan dr 0.025g , 2, 3 x 1; Tavegyl dr 0.001 g, 2 x 1). - . 1, 2, 12, .

o , (, , . 1). .

o . o .

. , - m. pterygoideus medialis.

134

, , , .

- - , - m. temporalis (, ..).

.

( ) ( ). , .

(, , .) (. 114).

o , (), .

o (, ) 3-4 , 5- , , .

o , . . - , , .

5-6 .

o o , o o

. 114. : ) ; b) -

,

( , , , , , , , , ).

135

(. 113) . , , . - . , , 5-8 . .

, . , , .

. . .

o , . 0.25-0.5% ( ) 5-6 .

o , 0.5% .

o . o ,

, . Haemodex 500 l, 0.9% NaCl 500-1000ml i.v/24 h.

o . o . o - (1 10-15

ml ). o , .

- . (. 115).

o , . o , .

, .

o :

136

, .

o , . o 5-6 m - 2 m

, . . . o ,

.

. 115.

. . . .

o . (. 205) .

o . .

o .

, .

. - , , , .

, (Kloh, R.).

137

, . ( ).

o . 48 , 5-7 .

o - , , , . (Diazepam) .

. - - (. 116).

. 116.

o o

. . .

, ,

. . , - (Rood, I.). canalis infraorbitalis . ( ). , .

o , . .

138

,

, ( , ). .

. , , .

o - , , . (, KJ).

o . o . o . o ,

.

II.

O (syncope)

. , . . ( ), - ( , ), , , , ( ), , . . . , - : , , ; , , , ; ; . - , , , , , , . , . - 20-40 s, - 30 s ( 5 min).

( , - ). . , 35-45/min, 80/40 60/30 mmHg.

139

. . . -, - ( 10). - . - - , , - - . .

10

- .

-

-

- - s..,i.m. - 2

a

- i.m.,i.v.

-

. : 1.

- , - (. 117). ( ), .

. 117.

2. - . - , , .

3. - . . , - .

140

4. - , , ( 5-7cm).

5. , . ( 55 ) i.v. i.m. (Atropini sulfas, amp.0.1% 1 ml - 0.4-0.6 ml ). 10 min.

( , , ). , 30 s, , - i.v. Coffein natrio-benzoicum (apm.10%1 ml), Effortil (amp. 10mg 1 ml, Vasoton (amp. 6% 1ml), Mephin (amp. 15mg 1 ml).

(COLLAPSUS) . , ( ). , . . , . ( ). . , . . , , . . 350 . . . . , e , . , , . . (, ) , . : 1. , - (. 117). ( ), .

2. - . - , , .

3. - . . , - .

! . - .

4. O , . i.v. 50-100 ml 40% Glucosa . , 1, 6,

141

(0.9% NaCl, Haemodex, Serum Glucosae). Mephin (1-2 amp. i.v.), Coffein natrio-benzoicum (1-2 amp. s.c.), Effortil (5-10 mg i.v.), Dopamin (50 mg 250ml i.v. - - 18 /min.).

5. , () -, .

6. , , ( 3) . , i.v. i.m. 0.4-0.6 ml Atropini sulfas. 10 min.

7. , - , :

A (airway open) - B (breathing) - C (circulation) - ( ) 1. .

: ( , ) (, ) Esmarch -

(. 118) 2. O

( ) , .

. 118.

, (). - ,

, . (. 119) . . , . . 5 s (12 ). ,

142

- 1 . 15-17% , . 1 12/min, 12 l/min, . . 150%

. 119. : ) ( );

) ( )

3. ( a.carotis a. femoralis) -

12/min. , (Isoprenalin amp. 0.5 mg 1 ml - s.c.,i.m.,i.v.). 1 ml 1:5000 (0.02 mg) 0.5 10 ml (0.01-0.2 mg).

, (. 118).

o , . , . o ,

.

o , 4-6 cm. , , (0.5 ). 60-80-100 , .

, , . , 1-2 , 12-15 . , , 1-2 , 5 .

: - - . , , . (, ), .

143

RR 60-70 mmHg . .

, .

1 min, - 5 s, 2-3 min. (, ). , (- 30 min).

8. .

A IgE , - 1% (Gall,H., Kaufmann, R., Calveram, C. M., 1996, Malanin, K., Kalimo, K., 2005).

. , . , , . (DeSwarte, R. D., 1980). . , , , , . .

1. () . , .

2. : Allergosan amp. 1% 2 ml (i.m., i.v.); Sandosten calcium amp. 10 ml.(i.v.); Dimedrolum tab. 0.05g; Tavegyl tab. 0.001 g.

3. (Urbason, Sopolcort ) .

. . . , , , , . . , , . , , . , (). . - . - (-), 10 cm .

144

- , , (38-390 ), , . . (, , ) :

1. () . , . 2. s.c., i.m i.v. 0.3 ml 1:1000 0.3 ml 5 min, .

3. : Allergosan amp. 1% 2 ml (i.m., i.v.); Sandosten calcium amp. 10 ml (i.v.); Dimedrolum tab. 0.05 g; Tavegyl tab. 0.001 g.

4. 1 . 5.

(Urbason, Sopolcort ), .

(, , , ):

i.v., i/m. 6

(edema Quincke) . . , , , . , , . . Quincke 1882 . , . , - , , , , , . (. 120) 10-14 . . . , , , . . , , - .

. 120.

145

. lymphangioma Merkelson-Rosenthal-Schuermann. , . - - , . -- , , , , . n. facialis , , . 10-14 , , , .

1. . 2. (0.1% 0.1-

0.5 ml) 3. (

, , ) i.v i.m. 0.3 ml 1:1000, (i.v. Sopolcort H, Methylprednisolon 20 ml 40% Glucosa).

4. ( ). 5. . 5.

.

( ) . - ( , , , ) . , , -. . - , . . , , , . 20 , - , , , . , , .

. 30 min . - . : ; , , , ; , , . , , , , , . , - . , , .

146

, , , . - , - . - 3- 10- (, . ., , . ., , . ., 1984). , ( 30-40 min.). . - . - , . (, ), - ( , ). , - . . (). : ( ) , , , . , . , . - .

, , , , ,

( ) ( ) ( ) ( )

. , , (, . ., , . ., 1976; Blanca M. et al., 1997). , , , 3% . 1. (. 116 ) .

2. - . 0.3-0.5 ml . (0.5 ml 10-50 ml 0.9% NaCl.) i.v. ( ) i.m., - . .

147

3. (RR, , ). . .

4. 2 ml 10% Coffein natrio-benzoicum .

5. (. 121) 0.9% NaCl.

. 121. e

, , ( ) i.v. - 0.5 ml 0.1% , 10-20 ml 40% Glucosa . i.v.-gutta ( 250 ml 5% Glucosa 2 ml 0.1% ). . , . Urbason (1-3 mg/kg) Sopolcort H (5-10mg/kg) - i.v. i.v. gutta 500 ml .

(-

)

, , , B-, 60/min, : 0.5 mg - 1 mg i.v. (max. 2 mg) 2-10 mkg/min 1-10 mg i.v. , .

6. Salbutamol - i.v. (5 mg 500 ml 5% glucosa), (5 gutta 5 ml 0.9% NaCl 15 min).

7. 1-2 ml Droperidol (2.5 mg). 8.

, - , .. ( ).

9. . - .

148

K

, . (, ) . . : ,

, . .

( ), (). .

() . , (Altenburger, K., 1984; Neugut A .I. et al., 2001):

- - 7-14

, ()

( ) - , -

() -, ()

, , 2-3

- : Patch test ( ) - . , ( 700 ) 2.5-3cm . , , . Scratch test ( ) - . - , 700 2-4 cm , 0.1% . , 5 mm 3 mm, . . 20 min 24 h . ,

149

. : + , + , 2-3 mm ++ 5mm +++ 10 mm ++++ 10 mm , Prick test ( ) - 1 mm ( ), . , 2-4 cm. . - 20 min 24 h. . , . :

() 3 (Allergosan+Tavegyl Sandosten calcium+Tavegyl). , . ( , , , ) Prednisolon (3,4 x 10 mg ) - Wocar, C. et al., 1979, Waldhausen, E., 1998.

( ) 1amp. Sandosten calcium+ vit. C, (40 mg Urbason 100 mg Sopolcort H). .

o .

o (max. 1 ml 0.1%= 16-20 )

, 20-40 . , .

( 1-5 ), .

(), , , . 1. - Validol (0.06 g) Nitroglycerin (0.5 g). 2. , . 3. .

. : ( ,

, ) (, , )

150

() . . ( 2 ) :

- , ,

- , , , ,

, , ,

. , , . , . , , . , . , . .

- , , , . , . ( ), status asthmaticus, . , . , , , . (30-35/min) , 3-4 - . . (, ., ., 1994).

: , , 30 min 140/min , ,

. , . :

1. .

2. , ( 8-10 l/min 10-15 ).

3. (, , ) (, , ).

151

4. , (Adrenalinum amp. 0.1% 1 ml). , . . 20-30 min 0.5 mg, - 0.01mg/kg ( 0.3 ml), 5-10 min 20-60 min. .

5 g/kg, 500 g (0.5 mg) , - 0.01 mg/kg, 0.3 mg (Coop, P.E., 1995; Mathison, A. D., 1998). - , , , , , , ( , . ., 1994).

(, , , , , , ) Theophillinum (Novphillin) - amp. 0.48 g 2 ml i.m. 0.24 g 10 ml i.v. tabl. 100 mg . . .

(2 ), (, ., 1995; , ., ., 1996). , .

o Ventolin (Salbutamol) - tabl. 2 mg, 4 mg Clenbuterol - tabl. 0.02 mg

o Ventolin (Salbutamol) - 0.5% 2 ml (5 mg/ml) Fenoterol - 1% 20 ml

o Ventolin (Salbutamol) - 1 = 0.1 mg Fenoterol - 1 = 0.2 mg

, ., . (1996) :

2 : , 20-40 min 6.5 mg/kg 2 tabl.

1 h

() 2 - 2,3 7-10 g/kg - s.c.

3,4 ; 1 h 10-12 mg/kg 2 2 mg/kg 0.2-0.3 mg/kg/24 h

1 h

152

5. (ethylprednisolon /Urbason/, Celestone, Sopolcort H).

( ). ethylprednisolon 40 mg -100 mg 200 mg - 500 mg i.v, 1/3 , - . 4-6 h. ( ) - .

1.3% (. , 1995). . . (Atropini sulfas amp. 0.1% 1 ml Diazepam amp. 0.01g 2ml - i.m., i.v.).

. (, ) 130 mmHg 250 mmHg , , ( , ., 1991; , ., , ., 1996). . , , . - . Epstein, M. (1999) 600 000 , 1% 60 000 000 . . o , , . , , , , , , , -, . (Horky, K. ,1998). , , . : - - -

>200 mmHg >120 mmHg (Wenzel, et al., 1998)

- , ,

- , , ,

- , , , , , , - ( ) (, ),

, , . . , - i.v. . 160/90 mmHg,

153

30-60 min. () . 20-25% (Horky, K., 1998, Meiracner, A., Dees, A., 1999). , (Liuss, G., 1982, Damasceno, A. et al., 1998):

1. (. 122).

. 122.

2. . 20-30% ( 100-110 mmHg) . (Nifedipin-Retard tabl. 20 mg). 12 h.

Nifedipin retard - tabl 20 mg. , 10-20 min 3-5 h.

Nifedipin - caps. 10 mg, . (Damasceno, A., et al., 1998, Meiracner, A., Dees, A., 1999).

! Nifedipin (caps. 10 mg) .

Nifedipin retard 20 min Captopril - tabl. 12.5 mg 25 mg (6.5 mg, ). 25 mg - 50 mg 6-8 h. 15 min 4-6 h.

! .

: Isoket spray 0.5mg /0.5mg/

154

Clonidin tabl. 0.15mg per os, 1h. Chlofazolin/Clonidin/ amp. 0.1mg 1 ml - i.m. :

, ,,AV II-III . 3. .

. - , , , , .

.

. (angina pectoris ) . 3-6% 3-4% , 65- 25 43% (Coodley, E. 1990). , , . , (). . . . , , , , (), . , , . - () - IV V , (, , , , , , , processus mastoideus, , , , ). 9-18% (Tzukert, A., et al., 1981). . - , , . 2-3 min, 20 min. 1. - 450 - (. 123).

. 123.

155

2. , , .

3. - . .

4. - . , () (Nitroglycerinum tab. 0.5 mg ) . , . 3 min 75% , 15% - 4-15 min. (Glasser, I., 1972). 45 min.

, . . . . - , , .

5. () 3 min, .

3 .

6. , (Sandler, N. A., Ziccardi, V., Ochs, M., 1995, Hupp, J.R., 2008). 325 mg Aspirin i.v. ( 30 ml/h). s.c., i.v.2 mg 3 min, ( Talamonal, amp. 1 ml - im. i.v).

7. - ( ). .

. . . ( ) tabl. Nitroglycerinum .

. (, , , ), ( , , , , , , WPW , , ). . , 160-220 , . :

() . , 20-40 . , . . , , , , . () , . .

156

. , , , . 120-220/min. . , ( 220-350/min) ( 350/min) .

. , . , :

o , , .

o ( ) - 15-30 s. . 60 . .

o ( -) 4-5 s, . .

o ( ) o

o -

.

- . , , .

. ( ), . , ( ). : (RR 160/110 ) ( 50 ) . (, . ., 1985) (status stenocardicus) - , , , - . , , V , - , , . ,

157

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

. 5-10% (status asthmaticus) 2-3% (status gastralgicus). , . . , , . . . , . . . :

1. .

2. - , , .

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Archer, W.H. (1975) , , , , , , (. 191).

. 191. Archer

, (. 192):

211

-

-

- ,

- , , .

. 192. Archer

, :

. - .

. , , . (. 193).

. 193.

. , (. 194).

212

. 194. ,

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, . , , . . .

.

- , , : ; ; ; ; .

20 . 30 . . (, ), , ( , ). ( ) (, ) . : , ( ).

:

, . .

,

213

. . - .

. . . .

, , .

o . . . (. 195).

. 195. : ) ; b) ; c)

, ; d)

( )

- . , , - . (. 196).

214

. 196.

9- , 11- . 11- , . 14 ., 50% 16 . 18 . 24- 9% . () 13-14 . - . , :

,

. , , . , . . . , (. 183). , , (. 197).

. 197. : ) ; b)

215

. , , , , 3% . . . 5-7 . 10% (Nordenram, A., 1883) :

o . .

o . , . . - 5- .

o . - 5- .

o - 12- . - (Seymour, R.A., Meechan, J.G., Blai, G.S., 1985). , -. , (1-2 ) (dexamethasone methylprednisolone). dexamethasone 4-12 g .. , 4-8 g . methylprednisolone - 125 g .. 40 g . (Bustedt, H., Nordenram, A., 1985). , -2 - Rofecoxib (Vioxx) Nimesulide (Aulin, Enetra), 12 5 .

o 1-5% (Loukota, R.A., 1991), .

o , .

o , 20-25% (Mitchell, L., 1984), . (50% ) . .

o - , - . 3% (Mason, D.A., 1990).

o

216

. , . , 2-3 , , . .

o . ( ).

- , . . , , . , .

.

.

.

(, , , ) .

. . ,

.

1.

, , , - . 110 . Lewis Grant , , 1930 . Rushton . 1935 . Orell Ellit .

, .

217

, , ( , , ). , - 17 51% (Williams, P. M., Epstein, J. B., 1991; Braun, S. et al., 2000). (ADA&AHA, Wilson, W. et al., 2008) . :

, (. ).

. ():

o , .

o , .

o ( ).

, . , , . , , :

o o o

:

( 13). , , , (. 1:200 000) ( - 3.3).

218

(Wilson, W., et al., 2008) 13

: 30-60

Amoxicillin 2 g 50 mg/kg

Ampicillin Cefazolin Ceftriaxone

2 g im. i.v 50 mg/kg im. i.v

1g im. i.v 50mg/kg im. i.v

Cefalexin*

Clindamycin

Azitromycin Claritromycin

2 g 50 mg/kg

600 mg 20 mg/kg

500 mg 15 mg/kg

Cefazolin Ceftriaxone**

Clindamycin

1 g im. i.v 50 mg/kg im. i.v

600 mg im. 20 mg/kg im. i.v i.v

* ** - ,

. . . :

. ,

, . , . .

. (. 1:200 000)

. ,

RR. ( )

.

.

219

( >140 mmHg; >90mmHg) , :

( ).

. RR . ,

( ), 0.04 mg .

, .

. ( )

. , - . , 12- . - . - ( ., 2009). , . , - - (Elliot, W.J., 2001). . ( >200 mmHg; >110 mmHg) () - . - .

, 110/60 mm/Hg , , , . .

: . (

). . (Effortil, Coffein natrio-

bensoicum, Mephin). ,

. .

(Angina pectoris) , ( ) . . , , . - 40 . .

220

: , , , . . , , , , , (Hupp, J.R., 2008):

() () ,

( 0.04 mg)

(. )

,

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

(Infarctus myocardii)

3-6 . (, ) - . , , :

, (, )

-

(. 1:200 000)

, , , () . .

221

. , 3 -6 . , 3 , . , , .

(,

, ), a . , , , , . , . , INR 2.0 3.0 (Friedlander, A.H., et al., 2009). Adams-Stock, - . . :

, , , .

50 / .

, .

1 .

( ) ,

. . . :

o (, , , .). , .

o . o .

2. (

)

222

- . , . . - . . , :

()

45 ( ) ( 1:200 000) ( )

. , , . , . . , . , , , . . (Coop, P.E., 1995):

o .

o . o . o ,

. o , :

N2O

o 2 .

o (). o . o . o . o , Na . o , . o .

o .

223

o , . o , . o

.

3. 3.1.

, . : ; - . 12 ; ; ( ).

, .

:

, .

.

.

. - :

o - . , .

o ; , , .

. ( ) .

3.2 . () ,

. , , - .

, . : , .

: , , ,

, ( , , , , , ).

.

224

( ), .

( ) , , .

.

3.3. (haemostasis) 5 (Gomez-Moreno, G., 2005): 1. () - , . (, , e), . , . , . 2. ( ) - . 2, , , : ; ; X (Stwart-Power) II (prothrombin). , von Wilebrand factor (VwF), .

> - Thr

> - serotonin thromboxan A2 FX,FII

vWilebrand Factor

. 3. (). . , , : ) - (II, VII, IX, X). .. ( ). . - (I, V, VIII, XI, XII, XIII). ( VIII). : . , -. .

o

225

VII (Proconvertin) . F VII F IX (Cristman factor - PTC) F X. X II (protrombin) . , , .

VII IX X II trombin

Fibrinogen; Fibrin o

. . (PKF), F XII (Hageman factor ) (Fletcher factor). , F XI (PTA - ). - F IX . F IX F X F VIII ( ) F X II () V ( ) . F V F VIII ( ). F V F VIII (Norris, ., 2003).

PKF F XII; Fletcher factor F XI Ca + F IX

X F VIII

F II F V

trombin fibrinogen fibrin

, : ) ( VIII) ) von Wilebrand, F VIII , , von Wilebrand (vWF) ) ( F IX) Christmans 4. (/ . , . , , thrombomodulin. , .

226

, , hypofibrinogeminia, ( I), afibrinogeminia. dysfibrinogeminia. F XII (Fibrin stabilizing factor) . 5. ( ) , . , fibrinolysis, e , , . : tPA- . . , -2, . , , tranexamic acid, . -2 .

Plasminogen

Plasmin Antilpasmin 2

Factor I - Fibrinogen Factor II - Prothrombin Factor III - Thromboplastin Factor IV - Calcium Factor V - Accelerator globulin Factor VI - Factor VII - Proconvertin,Co-thromboplastin Factor VIII - Antihaemophilen factor;vonWilebrand factor Factor IX - Plasma thromboplastin component (PTC; Christmans factor) Factor X - Stewart-Power fctor Factor XI- Plasma thromboplastin antecedent (PTA) Factor XII - Hageman factor Factor XIII - Fibrin stab. Factor Fitzgerald Factor - Fletcher Factor - :

1. 2. 3.

227

3.3.1.

( ). ( ) ( . ), .

von Wilebrand o

, , . . ( ). F VIII ( ) . F VIII , . F VIII . , F VIII, ( 14):

14 F VIII %

50-100% 25-50% ( )

5-25% ( ) ()

1-5% ( ) ;

; 0 (o ) () ;

,

. . , , . :

o o ( ) o > ()

VIII , F VIII. , () . , -

228

. : C . , . 10-15 ml/kg (7-10 U F VIII) 40-60 . 15-20% F VIII . F VIII Tranexamic acid (Djulbegovic, B., 1992 ). , , - .

Cryoprecipitate. ( 37 ) F VIII. F VIII . i.v. EACA - 0.1 mg/kg. - 0.1 mg/kg 6 7-10 Tranexamic acis - , i.v.- 4 x 1.0 g (30 mg/kg, 1 10 mg/kg 20 ml serum 20 ). 1.0 g 5 . 20 mg/kg (Kasper, 2000). - , 6 ; . , .

Franchini, et al. (2005) 1 F VIII IX , 30% . , 50% ! : 1.0 g Tranexamiuc acid 4 7 ; 4 ( 2 ) 7 10 l 5% Tranexamiuc acid; ; ; 50% ; - , 6 ; .

. . , , .. . . Filho, A.M.B., et al. (2006) Beriplast P (Aventis Berhring Gmb, Marburg, Germany), 2 : 1 Aprotinin, Fibrinogen F VIII; 2 CaCl trombin. , F VIII. , , . Aprotinin , . . , - AHG 7-10 , .

o von Wilebrand , , von Wilebrand factor (vWF). F VIII . :

o F VIII o

: 1 - vWF ( ), , FVIII

229

2 - vWF ( , FVIII , , FVIII . , FVIII vWF. () tranexamic acid . 20 mg/kg 8 , , (Protet at al., 2002).

o - Factor IX - (1/300 000). , -, . Factor IX, . - Factor IX. 2 . . F IX (60U/kg), 10 (Djulbegovic, B., 1994). Factor IX , .. - . - (II, VII, IX, X S). trtanexamic aciud .

o Factor XI - (1/1000 000),..

FXI ( < 20-30% ) . - (FFP). Factor XI 72 .

o . . . , . . . - . 2 .

o Factor XIII ( ) < 1.2% , . , . . . , . - 5-10% Factor XIII . Factor XIII 2 , .. , .

o 2 . , , ( , . - (Nakahara&Koyanen, 2003).

230

, , .

3.3.2. ( ) , . : Rendu-Osler, Ehlers-Danlos, von Willebrand ( ) , . 3.3.4. ( ) (/ . 140T/l , 440T/l . , Glanzmann, . - . - , , , , . . . . . 50 000/mm . 20 000/mm - 50 000/mm, , . , 50 000/mm, . 20 000/mm . , , . , . :

o , , , , , , .

o . o ,

, .

o 2 . o ,

. o . o 50T/l .

3.3.5. , :

231

- (Heparin Natrium, Heparin Calcium, Fraxiparin)

- (Syncumar, Sinthrom, Pelentan, Warfarin)

- . (XII, XI, X), V . ( ), . , (V, VIII, XIII). i.v. (Na heparinat) s.c. (Ca Heparinat) . . ( 2-6 2-3 ). 6 ( ) 24 ( ) . , , , . , , , . (Fraxiparin) . , . ( ) (Protamini sulfas amp. 1% 5 ml, 10ml; amp. forte 0.25g 5 ml). 10 min ( ) i.v. 1 ml, 5 ml . - . (II, VII, IX, X). (Pelentan), (Syncumar) (Sinthrom). Warfarin. INR. . 1 (Kanavit) - amp. 1% 1 ml. i.v. . ( 15). . (Campbell, J., et al, 2000; Glasse, S. P., 1997), (Patton, L.L., Ship, J.A., 1994; Robert, H. L., 1996), (Merha. P., et al., 2000) , .

, (Harish, J., 1995) ( 15).

, , , (). 2-3- , . INR 2.0 , . 2-3 . INR 2.0 3.0, ( ). INR 3.0, , 3.0.

232

INR 1.6-1.9, . . (Hupp, J.R ., 2008).

15

INR / 2.0-3.0 2.0-3.0 2.0-3.0 2.0-3.0 2.0-3.0 2.0-3.0 2.0-3.0 2.0-3.0 ( ) 2.5-3.5

. Johnson-Leong, Ch., Rada, R.E. (2002) s.c. enoxaparin 3 . (INR 1.1). . 3 . :

(INR) , (.

) ,

, ,

, , , , . , . ( ) , .

, , .

, , (Barrero, M.V., 2002):

, - 5 (91.7%) , 5 (7.9%) , (0.4%)

3.3.6. , Acidum acetylsalicylicum (Acetysal, Aspirin)

233

Dipyridamole (Antistenocardin) Clopidogrel (Plavix)

- ( ) ( , ), , , , ( 16).

().

, , e . . , , 3-7 ( 5 ) . , - 24 .

16

-,

Clopidogrel Aspirin - 12

Aspirin; Clopidogrel; Aspirin Dipyridamole

Clopidogrel ( Aspirin)

Clopidogrel 7 . , 5-7 . - , , 7 . 5 .

4. (Diabetes mellitus)

, . , . (WHO, 1980) : - I, - II ( ; ; ). (Slavkin, H.C., 1997) - . , . - II .

(IDF) 245 , 3,8 . . , . . , ( ).

234

, . . , . , . , , , . , . , . , . , .

:

o - . 10 mmol/l . .

o . o .

( ), - - 1-1.30 ( ). .

o . o .

. . . (1:50 000) .

o , , , , . o . o , (

). ( , ).

o . - . .

o . , , . , , , . .

, . , , , , , , , , , , , .

235

, , , , , , , , . : , , , , , . . . , , . , , . , .

:

.

, (

) ( ). ( ) , . - . .

, , , , , , , , , . , .

() . : , , , . - ( ). , , , . , , - . , . ( ) (). . ( ) (Hupp, J.R., 2008):

()

236

, , ,

, - 20 mg ( ) 2 , :

() , 60 mg ( )

( i.v. i.m. 60 mg )

40 mg prer os 20 mg, 6-

5.

, -