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Het aantal verkochte producten per maand wordt vermenigvuldigd met de prijs die voor het product vraagt. Als dienstverlener kun je het aantal uren invullen, wanneer je een vergoeding op uurbasis vraagt. De omzet moet je exclusief BTW opgeven. Phd Thesis! Je moet wel aangeven welk BTW tarief op jouw product of by kate chopin essays, dienst van toepassing is. (21%, 6% of latex, 0%). De belastingdienst geeft hier meer informatie over. Omzet wordt gemaakt op het moment dat de factuur naar de klant/opdrachtgever wordt gestuurd. Writer Editor! Dat wil in phd thesis, de meeste gevallen niet zeggen dat het geld direct wordt bijgeschreven op je rekening. The Awakening By Kate Chopin Essays! Betalen je klanten direct (contact of page latex, PIN) zoals in disabilities in india, de detailhandel, of cover page latex, moet je weken op je geld wachten. Deze periode noemen we de debiteurentermijn. An Experience My Life Essay! Onderaan de verkoopprognose moet je invullen wanneer welk deel van je klanten gaat betalen. Zorg ervoor dat je prognose kan worden onderbouwd met cijfers uit de branchegegevens, je concurrentieanalyse en marketingmix.

Houd rekening met seizoensinvloeden. Page Latex! Ga je direct in in india, je eerste maand omzet maken, of is phd thesis latex, er sprake van een aanloopperiode? Is het geplande aantal uren daadwerkelijk declarabel? Houd rekening met bijvoorbeeld reistijd, acquisitie, ziekte, administratie. Writer Editor! Is deze omzet haalbaar (reëel), gezien vanuit de geplande investeringen en personeelscapaciteit? Om geld te kunnen verdienen aan producten die je verkoopt, moet je die producten eerst zelf inkopen. Latex! Het verschil tussen wat je verkoopt en de prijs die je zelf hebt betaald om die producten in an experience that my life, te kopen is je brutowinst. Er bestaat dus een direct verband tussen inkoop en verkoop. Cover Page! De inkoopprijs van alle verkochte artikelen hoort tot de inkoopwaarde van de omzet. De formule om de inkoopwaarde van de omzet te bepalen is the awakening essays, als volgt: Beginvoorraad + Jaarinkopen Eindvoorraad. Alle producten die je al wel hebt ingekocht, maar nog niet hebt verkocht, heb je op voorraad en worden daarom niet tot de inkoopwaarde van de omzet gerekend.

Bedrijven die niet handelen in producten, maar hun kennis en tijd ‘verkopen’ aan de klant, hebben te maken met diensten. Diensten hebben meestal geen inkoopprijs (of slechts zeer gering). Phd Thesis Cover Page Latex! Bij diensten kun je stellen dat de brutowinst (bijna) gelijk is uc app other a g, aan de behaalde omzet. Er zijn meerdere factoren die de inkoopwaarde van de omzet kunnen bepalen. Latex! Denk bijvoorbeeld aan het inhuren van andere bedrijven (‘diensten van derden’). An Experience That Changed! Deze worden meestal ook rechtstreeks van de behaalde omzet afgehaald. Phd Thesis Latex! Andere voorbeelden zijn provisies die je betaald aan tussenpersonen of agenten, het huren van materiaal die je nodig hebt om een dienst te kunnen verlenen. Writer Editor! Dit zijn zogenaamde directe kosten.

Heeft een bedrijf te maken met een werkplaats, dan worden veel van de bewerkkosten of ‘maak’ kosten ook rechtstreeks verrekend met de behaalde omzet. Phd Thesis Cover Page! Eigenlijk alles met een rechtstreeks verband met de behaalde omzet! Om de inkoopprognose correct in te vullen, moet je invullen wanneer je daadwerkelijk voorraad moet gaan inkopen. The Awakening By Kate Essays! Afhankelijk van het product, de branche en de vraag zal de frequentie verschillen. Latex! Is het nodig dat je elke dag inkoopt (bijv. verse levensmiddelen), of kun slechts één keer per kwartaal je inkopen doen (bijv. Thesis On Learning! kleding)? Kun je inschatten hoe lang je product gemiddeld op voorraad ligt? En welke deel van je voorraad is cover latex, niet meer te verkopen na verloop van tijd (incourante voorraad)? In je exploitatiebegroting schat je in of je bedrijf rendabel is. Door de omzet en kosten in on learning disabilities in india, een overzicht te plaatsen, kun je in cover, een oogopslag zien of writer editor, je bedrijf winst of cover page latex, verlies maakt. An Experience That My Life Essay! In de exploitatiebegroting staan de bedragen exclusief BTW vermeld.

Uitgangspunt voor de exploitatiebegroting is phd thesis, de verkoopprognose (zie 3.3). How To Write A Reply! Door de inkoopwaarde van de omzet af te trekken wordt de brutowinst zichtbaar. De inkoopwaarde van de omzet wordt berekend aan de hand van de ingevulde inkoopprognose (zie 3.4). Door de brutowinst te verminderen met alle wederkerend bedrijfskosten, zoals huisvestings-, vervoers-, promotie- en personeelskosten, houd jij je netto bedrijfsresultaat over. Dit bepaalt of phd thesis latex, je bedrijfsactiviteit op zichzelf rendabel is. Thesis On Learning! Onder de bedrijfskosten vallen ook de afschrijvingen. Latex! Afschrijvingen zijn wel kosten, maar geen uitgaven. An Experience Changed! Afschrijvingen geven de je gelegenheid reserves op te bouwen om te kunnen (her)investeringen in de vaste activa van je bedrijf.

Je geeft het geld pas uit op het moment dat je moet gaan investeren. Je geeft je ook extra ruimte om je aflosverplichting te voldoen. Voordat jij je winst uit onderneming kan bepalen, moet je opgeven hoeveel vergoeding je aan de financiers, die je bedrijfsactiviteit mede mogelijk hebben gemaakt , jaarlijks moet betalen. Phd Thesis Cover Page Latex! Dit wordt ook wel rente genoemd. Als je winst hebt gemaakt, moet je daarover belasting betalen. Thesis Capone Does! Hoeveel dat is, hangt af van het winstbedrag en aftrekposten die je als zelfstandige mag opvoeren. Phd Thesis Cover Page! Voor deze aftrekposten gelden wel diverse voorwaarden. Write A Reply! Kijk daarom goed op de site van de belastingdienst.

De nettowinst is phd thesis, de basis voor uw inkomen uit een eenmanszaak of the awakening by kate, VOF. Cover! In een BV staat de ondernemer als bestuurder/directeur van de BV op de loonlijst en ontvangt een salaris. Coursework A G! Het salaris is phd thesis latex, een kostenpost voor de BV. How To Write A Reply! De omzet moet hoog genoeg zijn om ook het salaris van de directeur te betalen. We bieden je gratis een eenvoudige template voor exploitatiebegroting. Aannames moeten gebaseerd zijn op goed doordachte veronderstellingen Omzet op basis van marktonderzoek en niet op alleen basis van aantal x prijs Check de samenhang met het Marketingplan Omzet moet met gewenst personeelsbestand en kapitaal vervaardigd kunnen worden. Kun je elke maand alle rekeningen betalen? Door het maken van een liquiditeitsbegroting bepaal je of phd thesis cover latex, er iedere maand voldoende geld op je rekening staat. Inkomsten en uitgaven kunnen gedurende een jaar sterk wisselen.

Bijvoorbeeld door seizoensinvloeden, een vakantieperiode, belastingaanslag of door klanten die laat betalen. On Learning In India! Met een liquiditeitsbegroting maak je inzichtelijk op welk moment extra financiën nodig zijn. Vrijwel alle bedrijfskosten die zijn opgenomen in de exploitatiebegroting komen ook terug in phd thesis cover, de liquiditeitsbegroting. The Awakening Chopin Essays! Afschrijvingen vormen hierop de belangrijkste uitzondering. Phd Thesis Cover Page! De liquiditeitsbegroting toont hoe de kosten over that changed my life essay, het jaar worden verdeeld en aan in welke maand de kosten daadwerkelijk betaald moeten worden. Zeker in phd thesis cover page, een groeiende ondernemingen zullen met de omzet ook de kosten maandelijks variëren (en toenemen). Naast de bedrijfskosten, worden ook de (maandelijkse) privéopnamen, inclusief inkomstenbelasting, en aflossingen staan niet in how to a reply, de liquiditeitsbegroting opgenomen. Cover! Via onze site kun je nu eenvoudig een sjabloon liquiditeitsbegroting downloaden.

Op de exploitatiebegroting zijn alle bedragen exclusief BTW. The Awakening By Kate! In de liquiditeitsbegroting reken je de BTW ontvangsten en uitgaven mee. Uit de exploitatiebegroting kun je opmaken of je voldoende omzet genereert om de bedrijfs- en financieringskosten te dekken. Cover Page Latex! De cashflow berekent vervolgens of jij je privéopnamen wel uit de onderneming kan halen en of er daarnaast genoeg overblijft om leningen af te lossen, herinvesteringen te voldoen of by kate chopin, reserves op te bouwen. Grofweg is de cashflow gelijk aan de nettowinst plus afschrijvingen van een onderneming. Latex! De cashflow is the awakening, positief als er jaarlijks meer geld binnenkomt dan dat er uit gaat. Phd Thesis! De cashflow is thesis on learning disabilities in india, negatief als er per page, jaar meer geld wordt uitgegeven dan er binnenkomt. Een positieve cashflow wil niet direct zeggen dat je onderneming liquide is, dat er het hele jaar door voldoende geld op je rekening staat.

Dat moet blijken uit de liquiditeitsbegroting. Voordat je met je bedrijf begint, moet je weten hoeveel je maandelijks nodig om privé van rond te komen. Disabilities! Breng al je (huishoud)verplichtingen in kaart. Vermeld ook alle inkomsten die je huishouding ontvangt, zoals het loon (inclusief vakantie geld en dertiende maand) van jezelf en/of je partner, uitkeringen, pensioenen en eventueel kinderbijslag. Het verschil tussen de privéverplichtingen en -inkomsten bepaalt het bedrag dat je maandelijks uit je onderneming moet halen om van te leven. Houd je zakelijke betalingsverkeer gescheiden van je privé-inkomsten en -uitgaven door het openen van een aparte rekeningen. Een afschrijving is phd thesis, het in by kate essays, de boekhouding tot uitdrukking brengen van de waardedaling van een bedrijfsmiddel over phd thesis, een bepaalde periode.

Doordat je machines gebruikt zullen ze slijten. Ook zal de waarde van je gebouw of vrachtwagens in de loop van de jaren afnemen. Uc App Other Than! De waardevermindering van deze kapitaalgoederen wordt ook wel afschrijving of phd thesis latex, afschrijvingskosten genoemd. Er wordt steeds afschrijving toegepast om de slijtage door het gebruik tot uitdrukking te brengen. Deze afschrijving vormt een kostenpost in how to write, de Winst- en Verliesrekening en leidt dus tot een lager resultaat. Bekijk de mogelijkheden van Qredits. Ondernemingsplan template downloaden.

Als je een onderneming wilt beginnen, is phd thesis latex, het verstandig eerst een ondernemingsplan te maken. Writer Editor! Qredits wil je hier graag mee op weg helpen. E-learning Ondernemingsplan Schrijven. Deze e-learning laat jou nadenken over phd thesis, je onderneming. Changed My Life Essay! Je krijgt volop inspiratie en voorbeelden. Phd Thesis! Na afloop download je een kant en klaar plan. Vind je het moeilijk om je eigen ondernemingsplan op te stellen?

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5 Ways to Spruce Up Your Resume Right Now. Are you currently searching for employment, or want a new job? Don’t wait for the new year to come. You need to phd thesis, start your search now. Uc App! Begin by sprucing up your resume and giving it a revamp. There are many resume samples and resume templates you can find on the Internet to give yourself some inspiration and phd thesis cover page, a leg up.

However, you can also easily do it yourself by following these 5 steps. 1) Delete meaningless and silly words: Problem: Your resume is how to write, filled with words like “passionate,” “driven,” “results-oriented,” “team-player,” etc: It’s tempting to fill up your resume with “confidence inspiring” words, but doing so will only phd thesis page latex hurt your resume. Even if you have a significant amount of relevant experience, populating your resume with words like “passionate, “driven,” or “results-oriented” will only essays serve to dilute and pollute it. Why? Those words don’t mean anything without context. Generally speaking, people are using these words to put lipstick on a pig. Your resume should be direct and to the point. As with all good writing, it’s important to “show, not tell.” If your resume is simply “telling” the hiring manager that you’re passionate, driven, and results-oriented, that literally means nothing to them. Solution: Delete these words wherever you see them, and replace them with actual job duties and phd thesis page latex, accomplishments: Suggestion 1: Instead of telling the hiring manager that you’re “passionate,” give them an example of essay, a project that you spearheaded to increase company profits #8212; that kind of information relays your passion much more clearly.

Suggestion 2: Instead of telling the hiring manager that you’re “driven,” give an phd thesis cover page, example of how you went above and beyond the call of an experience that, duty complete a project or support another teammate. Problem: Your resume has no numbers specifying your achievements and the scope of your responsibilities: If you haven’t used numbers to describe your work experiences, you’re still doing too much “telling” and cover, not enough “showing.” Without numbers to help define the scope of your abilities and accomplishments, your resume will be vague, unclear, and boring. Even information like the size of the thesis statement establishment you worked in phd thesis cover page can provide the hiring manager with valuable insight into your previous work experience, and give your resume a little more character. Thesis Statement My Shirts! Solution: Wherever possible, specify your job description bullet points with numbers: Suggestion 1: If you helped increase company sales, write by how much. Suggestion 2: If you managed employees or trained new employees, write down how many. Suggestion 3: If you saved the company money, write down how you did it, and phd thesis cover page latex, how much you saved. Suggestion 4: Did you manage a budget? Write down how big it was. 3) Remove unrelated and old experience: Problem(s): It’s nearly 2015 – your experience from over chopin a decade ago may not be relevant, even if it’s in the same industry. Meanwhile, if you’re applying for a job that has no relation to page latex, your previous work experience, you’ve probably included totally irrelevant information.

Hiring managers are looking for writer editor relevant resumes – period. As a rule of thumb, your resume should only cover be 1-2 pages long. Writer Editor! If you’re including experience that is over a decade old, it’s likely that your resume is phd thesis page, either really long, or you’ve been out of work and need some information to that changed essay, pad your resume with. If you’re trying to switch careers, writing a resume can be tricky. Many of the phd thesis cover page skills and abilities you have won’t be relevant for a different career track, and including unrelated job responsibilities will weaken your resume. You will need to get creative and that changed essay, find places where your knowledge, skills, and abilities overlap in a new career. Solution: Delete experiences older than a decade. If you are changing careers, delete your irrelevant experience, or modify it to emphasize the transferable skills. Suggestion 1: If you’ve been out of work, use a combination style resume to conceal your work experience gaps while relaying your relevant experience.

Suggestion 2: Read the hiring manager’s job description carefully, and phd thesis cover page latex, consider whether you current skill knowledge and skill set overlaps with their requirements. Present the how to best spin possible on cover page latex, your resume – even if you don’t have the skills yet, you may be easily trainable because you have foundational skills (such as software skills, customer service skills, management skills, etc.) 4) Make a new version of your resume for each job: Problem: You wrapped up writing your resume and think you’re finished. Actually, you’ve still got work to do. Your resume needs to be ultra-specific, and in india, ultra-targeted. Phd Thesis Cover Page! If the writer editor key to buying property is cover page latex, “location, location, location,” then the key to getting an uc app than a g, interview is “relevance, relevance, relevance.” Crafting your resume so that it adheres as closely as possible to the hiring manager’s expectations is the phd thesis cover key to getting their attention and landing an interview. Solution: Write multiple versions of your resume, each of writer editor, which targets a specific company. Suggestion 1: Find the cover hiring manager’s job description, and writer editor, sprinkle their keywords and phrasing into your resume. NOTE: This does not mean plagiarizing or copying what they’ve written – simply strategically employing important keywords to capture their attention. Suggestion 2: Draft your resume so that the skills and cover, abilities they are calling for are towards the top of your resume, where they’ll instantly be seen.

5) Add some color and a stylized font: Problem: Your black and white resume, with Times New Roman font, while acceptable, may not be putting your best foot forward. It’s not a problem per-se, but a black and white resume with standard font doesn’t really have a lot of “oomph.” You could increase your chances of writer editor, getting noticed by styling up your resume a little bit. But don’t go overboard! Solution: Using a different font and adding a splash of color to your black and white resume can be a good way of cover, making it “pop” out from your competition. Suggestion 1: Use a binary color scheme – black and another color is that essay, good enough. Use the cover color on your headings and keep your bullet points black. Suggestion 2: Keep it classy. Red, blue, and orange with comic sans won’t get you a job, unless you’re applying for a position at a clown college. Writer Editor! If you follow these suggestions, your resume will be ready for 2015. Don#8217;t hesitate to apply now #8212; get in before everyone else makes their new years resolutions!

Author: Mark Slack is a resume expert and cover, career adviser consulting for the smartest resume template creator, resumegenius.com. He is an by kate chopin essays, avid hiker and biker, and is fluent in Mandarin. You can follow him at phd thesis latex, @MarkWSlack. This post is written by a guest author. If you are interested our sponsored content options, check out the the Advertising Page - we look forward to hearing from writer editor you!

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como fazer um essay AFOGAMENTO - ACLS (Setembro de 2002) Dr David Szpilman. “Deus criou o mundo, a VIDA, e dela surgiu o ser humano, Os anjos foram enviados por Deus para nos guardar, O primeiro anjo a entrar no mar chamou-se GUARDA-VIDAS” (Szpilman 1999) A cada ano mais de 500.000 pessoas falecem em decorrncia de afogamento em todo mundo (1).

No Brasil o afogamento representa a 2a causa “mortis” na faixa etria de 5 a 14 anos. Phd Thesis Page? Anualmente 7.500 brasileiros morrem, aproximadamente 600 vtimas no so encontradas, um milho e trezentos mil so salvos em nossas guas, e 260.000 so hospitalizados, vtimas de afogamento (2,3). That Changed My Life Essay? Estes dados catastrficos impulsionaram um grande avano nesta rea nos ltimos 10 anos. Phd Thesis Cover Page? O acesso s informaes de sade permitiu importantes mudanas nos mtodos de preveno e na melhoria do estudo de afogados modificando radicalmente o conhecimento da fisiopatologia, das fases do processo de afogamento e principalmente da abordagem ao afogado proporcionando uma reduo de 18% na mortalidade por afogamento nos ltimos 20 anos(1979-1998) (2). O afogamento considerado como “Trauma” e contribui com uma parcela significativa na mortalidade Brasileira hoje em dia.

Quando avaliamos a mortalidade no contexto geral considerando todas as idades, o trauma se encontra em segundo lugar ficando atrs apenas das doenas do aparelho circulatrio com 249.639 (27,63%) mortes(3). Capone Does? O afogamento diferentemente de outras doenas ocorre inesperadamente na grande maioria das vezes, o que gera invariavelmente uma situao catica dentro do mbito familiar. Page Latex? O afogamento est em sua grande. maioria relacionado ao lazer familiar e geralmente testemunhado por ela, ou menos freqentemente se insere em seu contexto. Thesis On Learning Disabilities In India? Situaes de catstrofe familiar podem ser observadas quando famlias inteiras se afogam juntos, por desconhecimento, ou pela tentativa infrutfera de salvar uns aos outros. Phd Thesis Cover Latex? A perda de um ente querido de forma inesperada sempre um desastre emocional familiar, e ainda pior quando este ser jovem e com uma grande expectativa de vida ainda por vir. The Awakening By Kate Chopin? Citando a me de uma vtima de afogamento “um filho jamais deveria. morrer antes dos pais”. HISTRIA DO AFOGAMENTO (4) Senhor, Senhor! methought, que dor era se afogar!

Que rudo terrvel de guas em minhas orelhas! Que vises feias da morte dentro meus olhos! Methought eu vi mil naufrgios temerosos. Dez mil homens que pescam roeram em ti. King Richard III (William Shakespeare) Dentre as causas externas, o afogamento foi sem dvida um dos primeiros a causar preocupaes e chamar a ateno da humanidade, tendo vrias passagens bblicas onde se descrevem as primeiras tentativas de ressuscitao em afogados. Page? verdade que na poca a ocorrncia de homicdios, suicdios, acidentes de transportes e doena coronariana eram bem menores, prevalecendo a maior.

preocupao com os casos de afogamento. How To Write A Reply? A era Renascentista embora tenha significado o despertar de uma importante. atividade intelectual, se desenvolveu dentro de conceitos e crenas do cristianismo. Cover Latex? A cincia ortodoxa da poca considerava que ao morrer o esprito tinha de ser julgado, e esta “vontade de deus” no podia ser contrariada. Changed My Life? A possibilidade de tentar uma ressuscitao era considerada uma blasfmia. Phd Thesis Latex? Passamos ao sculo 18, onde a aceitao do conhecimento do corpo humano tornou-se mais aceita, e com ela a necessidade de desenvolvimento de mtodos cientficos que levassem ao conhecimento, em um perodo chamado “Iluminismo”. A Reply? Os. lderes intelectuais da poca proclamaram que o mundo podia ser mais bem entendido atravs da cincia e que os meios para chegar a verdade eram os mtodos cientficos. Os quatros principais componentes da ressuscitao (respirao, compresso-circulao, fenmeno eltrico e servios de emergncia) comearam a ser conhecidos e desenvolvidos. Phd Thesis Cover Page? Na poca, as mortes que ocorriam inesperadamente (morte sbita) eram as que mais provocavam ansiedade e desespero.

A causa mais freqente na poca era o afogamento. Write? O homem tentava restaurar o calor e a vida ao corpo frio e inerte, aplicando objetos quentes sobre o abdome ou chicoteando-o com urtiga ou outros instrumentos. Phd Thesis Page Latex? Nos perodos compreendidos entre, o sculo 18 e o sculo 20, diversos mtodos manuais de reanimao foram utilizados, alguns at how to write, como rituais. Phd Thesis Page? O ndio norte-americano enchia a bexiga de um animal com fumaa e depois passava a espreme-la no reto da vtima afogada. Chopin? Os mtodos de ressuscitao na sua maioria visavam insuflar ou desinsuflar os pulmes, manipulando o trax e/ou o abdome da vtima. Latex? A maioria, porm, sem conhecimento fisiolgico adequado, raramente resultava em sucesso. The Awakening By Kate Chopin Essays? Uma das primeiras citaes cientficas sobre a utilizao da respirao boca-a-boca na ressuscitao apareceu no ano de 1744. Phd Thesis Latex? Um cirurgio Escocs, William Tossach, utilizou a manobra para reanimar com sucesso uma vtima asfixiada por inalao por fumo. O pice do movimento de preocupao com a ressuscitao e o afogamento surgiu no sculo XVIII na Europa, mais especificamente na Holanda por sua liderana no setor naval na poca e as grande ocorrncias de naufrgios.

O primeiro esforo organizado na luta contra a morte sbita foi realizado em Agosto de 1767, na cidade de Amsterd, com a criao da primeira sociedade de ressuscitao “Maatschappij tot Redding van Drenkelingen” (Sociedade para Recuperar vtimas de afogamento - existente at thesis disabilities in india, os dias de hoje). Page? As sociedades de resgate de afogados se difundiram rapidamente por toda Europa, assim como nos EUA. An Experience That Changed Essay? Estas Sociedades tinham como objetivo principal encontrar o caminho para a ressuscitao com xito e comearam a difundir informaes sobre os cuidados na recuperao de vtimas de afogamento e outros tipos de asfixia. Cover Latex? Quatro anos depois de iniciado o trabalho da Sociedade em Amsterd, 150 vtimas de afogamento haviam sido salvas seguindo s recomendaes (“guidelines”) da poca: a)Aquecer a vtima (recomendado at the awakening by kate chopin, hoje) b)Remover roupas molhadas (recomendado at phd thesis latex, hoje) c)Drenar gua dos pulmes posicionando-se a vtima com a cabea mais baixa que os ps (parou-se de recomendar em 1993). d)Estimular a vtima com tcnicas tais como instilao de fumaa de tabaco via retal ou oral (parou-se de recomendar em 1890). e)Utilizar o mtodo de respirao boca-a-boca (recomendado at thesis in india, hoje) f)Sangrias (parou-se de recomendar h mais de 60 anos). No havia na poca um limite de tempo para a reanimao, considerando-se 6 horas um tempo razovel para o esforo de ressuscitar.

Com a inteno de retirar a gua, posicionava-se a vtima de afogamento com a cabea mais baixa que o tronco. Phd Thesis Cover? Na tentativa de melhorar esta manobra foi adicionada a presso do trax, de forma a aumentar a sada desta gua. My Life? Desta maneira nascia de forma espontnea e ao acaso a ventilao artificial indireta. Cover? Muitas vidas foram salvas desta forma. That Essay? Fazia-se o certo por razes erradas.

Em 1817, um mdico Ingls, professor de medicina, Marshall Hall (1790 a 1857) publica seu livro, intitulado “Handbook of cover latex National Science of write a reply Medicine for cover Theologist”, no qual a compresso cardaca e a respirao boca-a-boca eram preconizadas como mtodos de reanimao. Thesis In India? Foram feitas vrias consideraes como: perda de tempo no transporte da vtima; a tentativa de restaurar a temperatura sem fazer ventilao artificial era perigoso e ineficaz; a exposio da vtima ao ar fresco era um benefcio e o fato de a posio supina bloquear as vias areas com a queda da lngua sobre a faringe. Phd Thesis Cover? Surgiu ento a proposta de alternar a posio do corpo, abaixando-o e elevando-o alternadamente, 15 vezes por minuto, conseguindo-se volumes de ventilao (70 a 240 ml) que poderiam recuperar uma vtima. On Learning Disabilities In India? Pouco tempo depois, Henry Silvester sugeriu elevar os braos da vtima sobre sua cabea, de forma a expandir desta maneira a caixa torcica facilitando a entrada de ar aos pulmes, e em seguida o socorrista colocava as mos da vtima e as suas por sobre o peito do afogado de forma a comprimir o trax e exalar o ar. Benjamin Howard, um mdico de Nova York, criticou as manobras de Hall e Silvester e descreveu seu prprio mtodo, conhecido como mtodo direto. Page Latex? Colocava-se a vtima sobre uma elevao e enquanto um ajudante segurava a lngua, o ressuscitador realizava presso, iniciando no abdome superior at the awakening by kate, o trax em uma freqncia de 15 vezes por minuto. Phd Thesis Cover Page? Em 1884, Braatz sustenta a recomendao da compresso cardaca e respirao artificial como mtodo de tratamento da parada cardaca.

Em 1890, a “Royal Lifesaving United Kingdom” (Sociedade de Salvamento aqutico do Reino Unido – existente at essay, hoje e responsvel pelo salvamento aqutico na Inglaterra) formou um comit para avaliar as tcnicas existentes. Phd Thesis Page Latex? O presidente do comit, Edward Schafer, considerou todas as manobras ineficientes e criou uma nova manobra tcnica chamada de “Prono-presso”. Apesar de toda oposio que teve, a Cruz Vermelha Americana comeou a ensin-la em 1910 (20 anos aps). In India? O mtodo de Schafer tornou-se muito popular devido a sua simplicidade de aplicao, requerendo apenas uma pessoa. Latex? Consistia em realizar a expirao ativa e a inspirao passiva e ficou conhecido como mtodo indireto de ventilao artificial. Thesis? Existiam amplas variaes geogrficas na mecnica de seu mtodo de ventilao artificial. Phd Thesis Cover Page? O mtodo de Silvester teve maior difuso na Alemanha, Holanda e Rssia, enquanto o mtodo de Schafer se desenvolveu principalmente na Inglaterra, Frana e Blgica e os pases Americanos.

Na Dinamarca, em 1932, o Coronel Holger Nielsen desenvolveu seu prprio mtodo que combinava as melhores partes das duas tcnicas. No Brasil, com seu grande litoral em praias e com o turismo desenvolvido na Cidade do Rio de Janeiro, o processo de desenvolvimento da ressuscitao acompanhou de forma semelhante o que ocorreu em todo mundo (Entra foto 6). Than A G? Todos os mtodos de ventilao indireta (Schafer, Holger-Nielsen, Marshall Hall, Howard, Silvester, e outros) foram idealizados com dois propsitos principais: a ventilao artificial e a retirada de gua do pulmo nos casos de afogamento. Phd Thesis Page Latex? Todos tiveram grande sucesso no princpio do sculo e certamente ressuscitaram muitas vtimas da morte. Uc App Other Than? Todos eles utilizavam o princpio contrrio a fisiologia do organismo, onde a inspirao era passiva e a expirao era ativa, desta forma o volume corrente produzido era geralmente inferior ao necessrio. Page? Estes mtodos so extremamente cansativos para o socorrista e difceis de serem mantidos alm de 5 minutos. An Experience Essay? Foram baseados na idia de retirar gua do pulmo do afogado, o que hoje em dia se mostra desnecessrio e at phd thesis, prejudicial. How To Write? Foram idealizados antes da noo da compresso cardaca, sendo possvel ainda sim sua realizao conjugada, porm com grandes dificuldades em casos de PCR. Page Latex? Nos casos de trauma cervical impossvel a sua realizao. My Life? Nos casos especficos de afogamento estes mtodos indiretos de ventilao no podem ser realizados dentro da gua, o que hoje em dia uma prioridade. A partir da metade do sculo 20, com a melhor compreenso da fisiologia aliada a pesquisa, os mtodos de ressuscitao foram aperfeioados.

Diversas conferncias sobre reanimao foram realizadas, entre elas a pioneira de 1948, realizada pela “National Academy of phd thesis cover page latex Science - National Research Council” (NAS-NRC), promoveram a divulgao e o debate amplo entre sociedades e autoridades mdicas, na tentativa da padronizao de condutas. Em 1949, Archer Gordon realizou trabalhos de investigao em estudantes anestesiados, curarizados e entubados. Coursework Other Than A G? Faz meno a respirao boca-a-boca, mas no a realiza. Cover Page? Conclui que, nenhum dos mtodos propostos at write a reply, o momento, nem mesmo suas combinaes, ofertam quantidade suficiente de ar (100/500 ml). Cover Page Latex? James Elam foi o primeiro investigador contemporneo que demonstrou que o ar expirado atravs do boca-a-boca era suficiente para manter uma adequada oxigenao. Uc App Coursework Other A G? Isto foi durante uma epidemia de Poliomielite em Minessota no ano de 1946. Phd Thesis Cover? Em viajem de automvel a Kansas para um congresso mdico, foi acompanhado por outro mdico que se interessou por sua experincia. Uc App Coursework Other? Este mdico dedicou sua vida a investigao da ressuscitao – Dr Peter Safar. Phd Thesis Page? Realizou experincias em voluntrios anestesiados que lhe permitiram chegar em 1957 a trs concluses principais sobre a respirao boca-a-boca: 1. Coursework A G? Simplesmente inclinando a cabea da vtima para trs se pode abrir as.

2. Cover Page Latex? A respirao boca-a-boca fornece uma excelente respirao artificial. 3. How To Write? Qualquer pessoa pode aplic-la facilmente e de forma efetiva. Cover Latex? O mtodo boca-a-boca foi adotado pelo exrcito dos EUA em 1957 e pela Associao Americana de Medicina (AMA) em 1958. In India? Nesta poca, o mdico Brasileiro Dr John Cook Lane, contribuiu efetivamente para a pesquisa e difuso destes mtodos em nosso pas. No ano de 1883 o Dr. Latex? Franz Koenig prope em seu livro, a compresso torcica como tcnica para ventilar um paciente de forma artificial. Embora na posio correta para a compresso cardaca, ele a descreve para outro fim. How To? Seu assistente, Dr. Phd Thesis Latex? Friederich Maass, durante a cirurgia de um jovem de 18 anos que havia tido uma parada cardaca durante a induo anestsica, inicia as manobras antes descritas, a princpio lentamente, simulando o ritmo ventilatrio. Uc App Coursework Other Than A G? Diante a falta de resposta aumenta a freqncia, chegando a 120 compresses por minuto, e observa que o pulso carotdeo se recupera, e em alguns minutos o paciente se encontra bem.

Em 1901, Kristian Igelsrud recuperou uma paciente com massagem cardaca interna ao final de uma anestesia, com recuperao em 1 minuto. Cover Page Latex? O primeiro caso Americano de massagem cardaca (como era denominado at thesis, poucos anos atrs) fechada ocorreu em 1904, quando o Dr George Crile ressuscitou uma mulher de 28 anos de idade cujo corao parou durante o ato cirrgico. Cover? No se tem conhecimento do porque as tcnicas de compresso cardaca no foram mais difundidas. How To? Talvez porque, a parada na respirao a princpio, parecia mais evidente e por esta razo deve ter sido mais investigada. Phd Thesis Cover Page Latex? Na realidade a tcnica de compresso torcica na circulao artificial foi simplesmente ignorada at the awakening essays, o incio dos anos 60 quando foi redescoberta. O redescobrimento parece ter sido acidental no laboratrio do Dr. Cover Page? William Kouwenhoven na universidade John Hopkins em Baltimore. A Reply? Junto com os Drs.

Guy Kinckerbocker e James Jude, descrevem a massagem cardaca aps uma srie de observaes. Phd Thesis Cover Page Latex? Publicam seus resultados sobre 20 casos de parada cardiorrespiratria intra-hospitalar no ano de 1960 na revista JAMA. Write? Entre os anos de 58 e 61, a respirao se combinou finalmente com a circulao artificial (compresso cardaca): Nascia a Ressuscitao Crdio-Pulmonar - RCP. Iniciasse assim uma nova poca onde a campanha anuncia “qualquer um, em qualquer lugar, pode iniciar a Ressuscitao Crdio-Pulmonar - RCP”. Phd Thesis Latex? Houve ento um perodo de demonstraes por todo mundo onde, Safar, Kinckerbocker, e Jude explicariam que “as duas tcnicas no deviam ser consideradas como unidades separadas e sim que ambas formavam parte de um mesmo ”procedimento salvador”. That Changed Essay? No ano de 1962, Gordon e Adams produzem um filme de treinamento de 27 minutos chamado “O pulso da vida”. Latex? Este filme foi utilizado em cursos de RCP por todo mundo e visto por milhes de estudantes. Capone Does? Para aumentar o aprendizado foi utilizada chave mnemnica para a ordem das manobras. Phd Thesis Latex? Estava criado o “ABC da Vida”. Thesis On Learning Disabilities? A – Abrir as vias areas (“Airways”), B – Boca-a-boca (“Breath”), e C – Circulao (“Circulation”) explicando a seqncia completa da RCP (o Dr Peter Safar faleceu em Julho de 2003). Por volta de 1960, Laerdal desenvolveu um manequim de treinamento em RCP.

O rosto da manequim foi inspirado no busto de mulher desconhecida que morreu afogada em 1930 no rio Sena. Phd Thesis Cover Page Latex? O nome da mulher nunca foi identificado, e a manequim recebeu o nome de “ANNE”, sendo mundialmente conhecida como “resusci-anne”. Write? No ano de 1966, as recomendaes so reconhecidas pela American Heart Association – AHA e Cruz Vermelha Americana, e finalmente publicada em definitivo, e de forma completa, na JAMA. A histria do afogamento no Brasil se iniciou na Cidade do Rio de Janeiro, na poca capital do Pas, privilegiada por belezas naturais incomparveis, com grande destaque as suas praias e favorecidas por clima de natureza tropical funcionaram como a principal fonte de lazer e atrao turstica, determinando um fluxo permanente e intenso de banhistas de todo o mundo durante o ano inteiro. Cover? Entretanto, as belezas de seu litoral na maioria das vezes escondem que suas praias, com ondas e correntezas fortes, podem tornar-se potencialmente perigosas com risco de afogamentos. Thesis Statement For Al? Estas caractersticas tornaram a cidade do Rio de Janeiro uma das regies com o maior ndice desta forma de acidente no pas. Page Latex? Sensvel a esta realidade, em 1914, o Comodoro Wilbert E. An Experience That Essay? Longfellow fundou na cidade do Rio de Janeiro, ento capital da Repblica, o Servio de Salvamento da Cruz Vermelha Americana. Cover Latex? Nesta poca, o objetivo era o de organizar e treinar Guarda-Vidas voluntrios, que atuariam em postos de salvamento, no apenas no Rio de Janeiro, mas por todo pas, supervisionando praias desguarnecidas. Uc App Coursework Other Than? Sentindo a ineficincia de tal estratgia, adotou uma campanha a nvel nacional, cujo slogan foi: “Toda Pessoa deve saber nadar e todo nadador deve saber salvar vidas”, na tentativa de despertar a populao para o problema da segurana nas praias de todo o Brasil. Phd Thesis Latex? “Each person should know how to disabilities, swim and phd thesis each swimmer should know how to uc app coursework other than, save lives.” O Corpo Martimo de Salvamento (CMS) teve suas razes no Servio de Salvamento da Cruz Vermelha, criado por Decreto do Prefeito Amaro Cavalcante, em 10 de maio de 1917, funcionando no Dispensrio da praia de Copacabana. Em 1939, o Dispensrio de Copacabana foi transformado no Posto de Salvamento Ismael de Gusmo, em homenagem ao seu organizador.

Naquele tempo foram construdas 18 torres fixas de salvamento ao longo da costa da Cidade do Rio de Janeiro. Phd Thesis Latex? Um total de 120 guarda-vidas trabalhavam nas praias com o auxlio de barcos motorizados, ambulncias, carros para transporte e uma equipe mdica equipada com o que havia de mais moderno em tecnologia de ressuscitao. A vtima resgatada era trazida estao principal “Ismael Gusmo” aonde a equipe mdica dava continuidade aos primeiros socorros realizado na praia. On Learning Disabilities In India? Nesta poca o banho era restrito a algumas reas da orla em frente s torres e a algumas horas do dia. Cover? Em Maro de 1961 este posto de Salvamento foi subordinado ao Departamento de Assistncia Hospitalar do S.A.A, passando em agosto deste mesmo ano responsabilidade do Departamento de Segurana Pblica.

O crescimento demogrfico explosivo, a intensa emigrao para a cidade do Rio de Janeiro e a melhoria das condies de vida da populao a partir dos anos cinqenta, provocaram um aumento do contato do homem com o mar, alertando as autoridades da poca para a necessidade da criao de um servio de salvamento e resgate especializado em acidentes aquticos. The Awakening? Criou-se, ento, em 1963, o Corpo Martimo de Salvamento - Salvamar, subordinado Secretaria de Segurana Pblica, que iniciou suas atividades com um grupo pequeno de amadores recrutado entre pessoas com afinidade e experincia para este tipo de socorro na praia. Em 1967, foi aprovado e criado dentro da estrutura da Secretaria de Segurana Pblica, o Centro de Instruo de Salvamento e Formao de Guarda-Vidas. Cover Page? Do total de 60 praias, apenas 27 eram guarnecidas pelo servio de salvamento utilizando 40 torres e 200 salva-vidas. Writer Editor? Neste ano foram realizados 4.032 resgates na orla com apenas 17 bitos. Em 1968, em razo da necessidade de um atendimento mdico mais rpido e eficiente, foram inaugurados os primeiros Centros de Recuperao de Afogados (CRAs), em nmero de 3, localizados estrategicamente na orla do Rio de Janeiro, nas praias de Ramos, Copacabana e Barra da Tijuca, com a finalidade de dar assistncia mdica de urgncia aos casos de afogamento.

Estes CRAs existentes at phd thesis cover latex, os dias de hoje possuem instalaes mdicas para atendimentos de emergncias e funcionam com uma equipe de Mdicos e Enfermeiros que se utilizam de ambulncias, barcos e helicpteros para o acesso aos locais dos acidentes. Thesis Statement Capone My Shirts? Com o passar dos anos foram se modernizando e se adaptando s novas necessidades e hoje representam locais de referncia em todo o Brasil para qualquer tipo de acidente aqutico. Em 1975, por determinao da Secretaria de Segurana Pblica, o Corpo Martimo de Salvamento ficou vinculado ao Departamento Geral de Defesa Civil, cujo Diretor seria automaticamente o Comandante do Corpo de Bombeiros. Phd Thesis Cover Latex? Em 1984, o Exmo. Statement For Al Capone Does? Sr.

Governador do Estado do Rio de Janeiro passou a competncia e atribuies do Corpo Martimo de Salvamento para o Corpo de Bombeiros do Rio de Janeiro (CBERJ). Page Latex? Em 16 de outubro de 1984, foi ativado o Grupamento Martimo – GMAR -, com uma base operacional em Botafogo e 3 Sub-grupamentos principais, mantendo em suas estruturas os CRAs anteriormente criados, de forma a estabelecer um atendimento integrado entre o resgate realizado nas praias e o atendimento mdico. Esta transio de gerncia do servio de salvamento foi um trabalho rduo e vagaroso, pois havia necessidade de treinar todo o pessoal militar nesta atividade altamente especializada, e o pessoal do extinto Corpo Martimo de Salvamento transferiu-se quase integralmente para outra Secretaria. Uc App Coursework Other A G? Alguns profissionais, entretanto, permaneceram no atual GMAR com a finalidade de treinar os militares para esta nova funo. Phd Thesis Latex? Os primeiros anos foram de muito sacrifcio para Instrutores e Alunos Guarda-Vidas e o nmero de salvamentos e bitos nas praias no sofreu alterao significativa.

Com o passar dos anos o nmero de salvamentos cresceu e o nmero de bitos reduziu nas praias do Rio de Janeiro, o que comprovou o acerto na deciso da mudana no sistema de Salvamento Aqutico no Rio de Janeiro e o alto grau de profissionalizao adquirido por seus homens. Com o enorme litoral brasileiro de 7.408 Km, natural que o fenmeno ocorrido no Rio de Janeiro se faria sentir mais cedo ou mais tarde em outras regies. An Experience My Life Essay? O servio de salvamento Aqutico adquiriu conhecimento e experincia com o passar dos anos, tornando-se um centro de formao de pessoal especializado em todos os nveis, no somente Guarda-Vidas e Instrutores, mas tambm na formao de pessoal mdico especializado, servindo de padro para todas as unidades da Federao e um exemplo para o mundo todo. PREVENO E ESTATSTICAS EM AFOGAMENTO. A preveno tem se mostrado o grande fator de reduo na mortalidade entre as causas externas e principalmente nos casos de afogamentos. Phd Thesis? As campanhas de preveno informam, por exemplo, que 85% dos afogamentos nas praias ocorrem nas correntes de retorno – local de aparente calmaria que funciona como o retorno da massa de gua proveniente das ondas para o mar aberto – indicando este local como perigoso para o banho. On Learning Disabilities? Embora o ato de prevenir possa aparentemente no transparecer a populao como “herico”, so eles o alicerce da efetiva reduo na morbi-mortalidade destes casos. Cover? Embora sejam grandes os esforos para melhorar o atendimento ao paciente afogado, com a preveno feita pelos guarda-vidas nas praias e piscinas e principalmente com campanhas de preveno atingindo crianas em fase escolar que obteremos o maior xito (5). Thesis For Al Capone Does? Nestes anos de trabalhos do Grupamento Martimo, a mortalidade de 0.3% dos resgates realizados nas praias do Rio de Janeiro se mostrou muito baixa (6), demonstrando que a preveno e a interveno precoce do guarda-vidas o caminho certo para reduzir o nmero de bitos neste tipo de acidente. Prevenir fundamental e prioritrio no caso de afogamento.

A cada ano mais de 500.000 pessoas so vtimas fatais de afogamento em todo mundo, entretanto o seu nmero exato ainda desconhecido em razo de um grande nmero de casos no notificados por desaparecimento sem confirmao de bito (5,6). Cover Page Latex? Ironicamente, parece que nos EUA 90% de todos os casos de afogamento ocorrem a 10m de uma medida de segurana instalada (7). The Awakening By Kate? Estimativas indicam que 40-45% ocorrem durante a natao demonstrando desconhecimento do perigo iminente. Cover? Na prtica de esportes nuticos, os afogamentos so responsveis por 90% dos bitos (8). Write A Reply? Em 1998 a populao brasileira atingiu 161 milhes de habitantes, dos quais 7.183(4.44/105 habitantes) faleceram em virtude de afogamento (2).

As estatsticas mostram grande variabilidade entre os estados (entra grfico 1). Em nmeros absolutos observamos em ordem decrescente no ano de 1997, os cincos estados com os maiores nmeros absolutos de bitos: So Paulo (1.822), Minas Gerais (900), Bahia (507), Rio de janeiro (502) e o Rio Grande do Sul (447) correspondendo as maiores populaes. Page? Quando analisamos o nmero de bitos pela populao observamos os estados de Roraima (9.8), Acre (8.6), Mato Grosso do Sul (6.8), Amap (6.7), e Esprito Santo (6.7) como os de maior nmero de bitos relativo (por 100.000 habitantes) mostrando que estados no banhados pelo mar tem um maior risco de morte por afogamento. Disabilities? O Sudeste a regio de maior nmero de bitos relativo (5.0) e a menor a regio Nordeste (3.4). Cover Page? Na Avaliao de bitos por afogamento de 1996 para 1997 observamos uma reduo percentual no nmero de bitos relativo de 45.74% no estado do Amap, 35.2% em Sergipe, 22.6% no DF, 18.9% em SC, e 17,8% no Rio de Janeiro, enquanto outros estados aumentaram o seu nmero percentual: Paraba 251.8%, Tocantins 58.3%, Gois 45.7%, Mato Grosso do Sul 22.7% e o restante dos estados no tiveram alteraes significativas(2,3,5). How To? fato que grandes acidentes aquticos, como inundaes ou naufrgios em um estado podem elevar drasticamente estes nmeros de forma isolada no demonstrando um perfeito espelho da realidade. Phd Thesis Cover Latex? Nos EUA existem oito casos de afogamentos para cada caso fatal notificado (9). By Kate? Nas praias do Rio de Janeiro temos aproximadamente 290 resgates para cada caso fatal (0.34%), e um bito para cada 10 atendimentos no Centro de Recuperao de Afogados (10.6%) (10). Os afogamentos em gua doce so mais freqentes em crianas, principalmente em menores de 10 anos. Cover? Estima-se que existam mais de 4.500 casos de morte por ano s nos E.U.A (53% em piscinas)(9), onde 50.000 novas piscinas so construdas por ano, somando-se a 2.2 milhes de piscinas residenciais e 2.3 milhes no residenciais(11). Uc App? Nas reas quentes do EUA, Austrlia e frica do Sul, 70 a 90% dos bitos por afogamento ocorrem em piscinas de uso familiar (12). Phd Thesis Cover Page Latex? No Brasil, onde o nmero de piscinas domsticas infinitamente menor, o afogamento em gua doce ocorre mais em rios, lagos e represas perfazendo a metade dos casos fatais(13).

A faixa etria de maior ocorrncia de bitos no Brasil de 20 a 29 anos, sem distino entre os estados banhados ou no pelo mar. Capone My Shirts? O homem morre em mdia 5 vezes mais por afogamento que a mulher, no havendo distino quando menor do que 1 ano e sendo 8.7 vezes mais freqente na idade de 20 a 29 anos(2). Phd Thesis Page? Nos municpios do estado do Rio de Janeiro o maior nmero relativo de bitos se encontra em locais no banhados pelo mar (1). Nas praias do municpio do Rio de Janeiro, aproximadamente 86% dos casos situam-se na faixa etria entre 10 e 29 anos(idade mdia de 22 anos). The Awakening By Kate Chopin? Em mdia, 75% das vtimas so do sexo masculino sofrendo variaes conforme a idade, 83% so solteiros, 83.5% ingerem alimentos 3 horas antes do acidente, 46.6% acham que sabem nadar, e 71.4% moram fora da orla martima (6,14).

Como podemos deduzir, a maior parte dos afogados so pessoas jovens, saudveis e produtivas, com expectativa de vida de muitos anos, o que torna imperativo um atendimento imediato, adequado e eficaz, que deve ser prestado imediatamente aps ou mesmo quando possvel durante o acidente, ainda dentro da gua. grande a confuso da definio do termo afogamento na lngua inglesa. Phd Thesis? O uso do termo “near-drowning” traduzido como “quase-afogamento” ainda hoje erradamente utilizado e significam afogados que no falecem at on learning in india, 24 h aps o incidente e o termo “drowning” as vtimas que falecem em at cover page latex, 24 h. Changed My Life? Esta nomenclatura subestima o nmero total de bitos por afogamento nos pases da lngua Inglesa resultando em um grande erro no perfil epidemiolgico. Cover Page? Vrios autores demonstraram sua preocupao quanto a esta definio imprecisa em uso, mostrando que ela esta em desacordo com os parmetros prognsticos internacionais definidos em “Utstein-style”. Writer Editor? Em Agosto de 2000, com a edio dos novos “Guidelines” da “American Heart Association” aprovados pelo ILCOR (17), e com a realizao do Congresso Mundial de Afogamento em 2002 realizado na Holanda, o termo quase-afogamento caiu definitivamente em desuso.

Apresentamos abaixo a nova definio de afogamento. @ Afogamento (Drowning): aspirao de lquido no corporal por submerso ou imerso. @ Resgate: Pessoa resgatada da gua sem sinais de aspirao lquida. @ J Cadaver: morte por afogamento sem chances de iniciar ressuscitao, comprovada por tempo de submerso maior que 1 hora ou sinais evidentes de morte a mais de 1 hora : rigidez cadavrica, livores, ou decomposio corporal. CAUSAS de AFOGAMENTO (14). a - AFOGAMENTO PRIMRIO - o tipo mais comum, no apresentando em seu mecanismo nenhum fator incidental ou patolgico que possa ter desencadeado o acidente. b - AFOGAMENTO SECUNDRIO a denominao utilizada para o afogamento causado por patologia ou incidente associado que o precipita. Phd Thesis? Ocorre em 13% dos casos de afogamento, como exemplo; Uso de Drogas (36.2%) (quase sempre por lcool), crise convulsiva(18.1%), traumas(16.3%), doenas cardio-pulmonares (14.1%), mergulho livre ou autnomo(3.7%), e outros (homicdio, suicdio, lipotimias, cibras, hidrocusso) (11.6%). By Kate Essays? O uso do lcool considerado como o fator mais importante na causa de afogamento secundrio.

TIPOS DE ACIDENTES NA GUA E FASES DO AFOGAMENTO(9) Os trs diferentes tipos de acidentes na gua e as fases do. afogamento so sintetizadas na Figura 1(18). Phd Thesis Cover Page? A “Sndrome de imerso”(Immersion syndrome)(19) ou vulgarmente chamado de “choque trmico” uma sncope (provocada por uma arritmia do tipo bradi ou taquiarritmia) desencadeada pela sbita exposio a gua com uma temperatura 5C abaixo da corporal. The Awakening By Kate? Pode ocorrer portanto em temperaturas da gua to page, “quentes” quanto 31C freqentemente presente no litoral tropical ou em piscinas. How To? Quanto maior a diferena de temperatura, maior a possibilidade de sua ocorrncia. Page? A sncope promove a perda da conscincia e o afogamento secundrio. How To Write A Reply? Nenhuma explicao tal como estmulo vagal levando a sbita assitolia, fibrilao ventricular por grande descarga adrenrgica pelo frio ou exerccio, ou outras razes menos provveis foram comprovadas cientificamente como causa ou como sndrome comprovada (20,21). Phd Thesis Cover Page Latex? Estudos mostram que a ocorrncia deste acidente pode ser reduzida se antes de entrarmos na gua, molharmos a face e a cabea(22). FISIOPATOLOGIA DO AFOGAMENTO. Existem variaes fisiopatolgicas entre os afogamentos em gua do mar e gua doce.

Apesar de cada um ter especificamente suas caractersticas, as variaes so de pequena monta do ponto de vista teraputico. Changed My Life Essay? As observaes feitas por MODELL e cols.(23,24,25,26,27), demonstraram que as mais significativas alteraes fisiopatolgicas decorrem de hipoxemia e acidose metablica. O rgo alvo de maior comprometimento o pulmo. Page Latex? A aspirao de gua promove insuficincia respiratria e conseqente alterao na troca gasosa alvolo-capilar, e distrbios no equilbrio cido-bsico (12,27). Write? As alteraes fisiopatolgicas que ocorrem dependem da composio e da quantidade de lquido aspirado. Phd Thesis Cover Page? O mecanismo de alterao na ventilao aps aspirao de gua doce diferente daquele em gua do mar. In India? Estudos(14,33,34) demonstraram que os afogamentos em gua do mar no alteram a qualidade, somente comprometendo a quantidade do surfactante pulmonar, diferentemente dos afogamentos em gua doce onde ocorrem alteraes qualitativas e quantitativas produzindo maior grau de reas atelectasiadas(34). Phd Thesis Page Latex? A aspirao de ambos os tipos de gua promovem alveolite, edema pulmonar no cardiognico, e aumento do shunt intrapulmonar que levam hipoxemia (14,34,35).

Alguns autores descrevem uma maior gravidade na leso pulmonar em gua doce(14,33,36,37) outros estudos no apresentaram maior mortalidade do que os casos em gua do mar(10,38) ficando a questo ainda em aberto. On Learning Disabilities? A reversibilidade total das leses com a terapia apropriada o usual (9,21,39). Em animais de laboratrio, a aspirao de 2,2ml de gua/Kg/peso faz a PaO2 cair para aproximadamente 60 mmHg em 3 minutos(31,40). Page Latex? Em ces, a mesma quantidade provoca uma queda na PaO2 para aproximadamente 40 mmHg (26). The Awakening Chopin? Em seres humanos parece que aspiraes to phd thesis, pequenas quanto 1 a 3 ml/kg resultam em grande alterao na troca gasosa pulmonar e reduo de 10% a 40% na complacncia pulmonar (26,31,33,34). Write? FULLER(41)demonstrou que em 70% dos bitos h evidncias de aspirao de partculas de natureza diversa como areia(39), algas e lama, e em 24% h presena de restos de vmito.

Estudos realizados em ces afogados em gua doce, demonstraram que a fibrilao ventricular(FV) era secundria a distrbios no potssio srico(42,43). Cover Page Latex? Entretanto, isto raramente relatado em seres humanos, provavelmente porque estes raramente aspiram quantidade de gua suficiente para provocar distrbios eletrolticos to statement for al does, importantes(27). Phd Thesis Page Latex? A FV nos seres humanos esta relacionada a hipxia e acidose e no a hemodiluio, hemlise e hiperpotassemia(27), uma vez que 85% daqueles que falecem no aspiram mais de 22 ml/Kg/peso(40), e como o volume crtico para a FV provocada por hemlise parece ser de 44 ml/Kg/peso, provvel que ela ocorra em menos de 15% dos casos(28,40). An Experience My Life? As alteraes como a diminuio do dbito cardaco, a hipotenso arterial, o aumento da presso arterial pulmonar e o aumento da resistncia vascular pulmonar resultam da hipxia e da acidose(10,33). Cover Page Latex? Freqentemente observamos intensa vasoconstrico perifrica, devido hipoxemia, liberao de catecolaminas, hipotermia, reflexo de mergulho ou, provavelmente combinao destes fatores(44). Changed My Life Essay? Nos afogamentos por gua do mar, a perda lquida para o pulmo no contribui para a hipotenso arterial que secundria a depresso miocrdica provocada pela hipxia(10,33). Cover Latex? A taquicardia, o ritmo de galope e as extrassistolias so as alteraes cardacas mais freqentes, e so reversveis com a administrao de oxignio(10,44). As alteraes eletrolticas podem ser observadas nos afogamentos de seres humanos, embora clinicamente sejam pequenas(27,28). Write? Em trabalho recente com 187 aferies dentre 2304 casos (14), nenhum deles necessitou correo eletroltica inicial, confirmando os achados de outros trabalhos(27, 28, 29). Phd Thesis Cover Page? No existe portanto, diferenas entre gua doce ou mar quanto ao tratamento a ser empregado. Writer Editor? Afogamento em, gua salgada no causa hipovolemia, e em gua doce no causa hipervolemia, hemlise ou hipercalemia.

O hematcrito e a hemoglobina esto usualmente normais aps afogamento em seres humanos(24, 28). Cover Latex? A hemlise s aparece com aspiraes maiores de 11 ml/Kg/peso, o que raramente ocorre (30,31,32). Writer Editor? A Leucocitose esta presente em mais de 50% dos afogados, em geral com elevao das formas jovens, em decorrncia provvel do estress traumtico a que foi submetido, e no infeco (33,34). Cerca de 22% podem apresentar albuminria transitria, cilindrria ou ambos, o que provavelmente secundrio hipxia renal(35). Cover Page? A insuficincia renal aguda rara(28,36,37). Os afogamentos grau 3 a 6 cursam com hipxia importante embora somente no grau 6 ocorra leso potencialmente irreversvel do SNC (14,38)(ver classificao de afogados adiante). “Afogamento tipo seco provavelmente no existe” – Se a necrpsia no evidenciar gua no pulmo, a vtima provavelmente no estava viva quando entrou na gua“. Thesis? Nem todas as pessoas que se afogam aspiram gua em quantidade.

Aproximadamente menos de 2% dos bitos parecem ocorrer por asfixia secundria a laringoespasmo, portanto sem aspirao de lquido importante. Cover Latex? O termo “afogado seco” muito utilizado no passado foi recentemente extinto da nomenclatura, j que todos os afogados aspiram alguma quantidade de liquido (39). CLASSIFICAO DE AFOGAMENTO (14, 38) A classificao clnica de afogamento baseada em estudo retrospectivo de 41.279 casos de resgates na gua, registrados por guarda-vidas no perodo de 1972 a 1991. An Experience That? Deste total, 2.304 casos (5.5%) foram encaminhados ao CRA.

Os 38.975 casos restantes no necessitaram de atendimento mdico e foram liberados no local do acidente com o diagnstico apenas de resgate sem afogamento. Cover Latex? Dentre o total de 2304 casos avaliados, a classificao foi baseada em 1831 casos que apresentaram uma mortalidade de 10.6% (195 casos). My Shirts? Considerando a avaliao destes parmetros clnicos, e a demonstrao de sua diferente mortalidade, apresentamos no algoritmo 1 (14,40) um resumo prtico de seu uso que esta de acordo com o ltimo consenso de Suporte Avanado de Vida (ACLS) da “American Heart Association”(AHA) de 2000(17). A classificao de afogamento leva em considerao o grau de insuficincia respiratria que indiretamente esta relacionado a quantidade de lquido aspirado, determinando a gravidade do caso. Cover Page Latex? A parada respiratria no afogamento ocorre segundos at an experience that my life essay, minutos antes da parada cardaca (14,41). Cover Page? O quadro clnico do afogamento altamente dinmico, com piora ou mais freqentemente com melhora clnica, seguindo-se um perodo de estabilizao com uma fase de recuperao mais lenta. A Reply? A classificao do grau de afogamento deve ser feita no local do acidente. Latex? Embora nem sempre possvel, esta conduta demonstra a real gravidade e indica a teraputica apropriada e o prognstico mais preciso.

A presena de patologia pregressa ou associada(afogamento secundrio) representa um fator de complicao na hora de classificar o grau de afogamento e deve ser bem avaliada. A gasometria arterial no considerada na classificao, embora seja um exame complementar de extrema valia como veremos adiante(14,40). A hospitalizao deve ser indicada em todos os graus de afogamento de 2 a 6 (9, 14, 28) (ver algoritmo 1 – ACLS em afogamento) (14,17). Writer Editor? A tabela 3 mostra a mortalidade geral para cada grau de afogamento, a necessidade de hospitalizao e sua mortalidade pr e intra-hospitalar(14). Phd Thesis Cover? Como a classificao muito importante para profissionais que trabalham na cena do acidente como Tcnicos em Emergncias Mdicas (TEM), socorristas, guarda-vidas, guardies de piscina ou leigos que necessitem ou queiram aprender sobre primeiros socorros em afogamento apresentamos o algoritmo 2 em linguagem mais simples para o Suporte Bsico de Vida em afogamento (BLS)(40). Para os casos grau 6 ressuscitados com xito, recomendamos a utilizao das tabela 4 e figura 2 (41,42,43,44) para classificao prognstica. By Kate Chopin Essays? Em todos os casos de afogamento em que o lazer na gua precede o quadro de afogamento em algum tempo ocorre Hipotermia(14,40). Nos pacientes hospitalizados, 60 a 80% no apresentam complicaes,e 15% tem mais de 5(36,46,47). Sistema Nervoso Central(grau 6): Convulses(15%), Edema cerebral(30 a 44% -diagnstico clnico), e encefalopatia anxica(20%)(48,49). Aparelho respiratrio(grau 3 a 6): Broncopneumonia ou pneumonia (34% a 40% dos pacientes que fazem ventilao mecnica), edema pulmonar (28% - diagnstico clnico), pneumotrax e/ou pneumomediastino (10%), atelectasias lobares (20%), ARDS (5 %)(28, 50,51). Metablico(grau 2 a 6): Acidose metablica (31%), alteraes eletrolticas (K, Na)(23%)(14, 24).

Outras complicaes: Necrose tubular aguda (2%)(37), Hematria (4%)(52), Cardiomiopatia anxica (2%), hematmese e/ou melena (4%), Sindrome de secreo inapropriada de ADH (2%)(7), e Outras (7%)(7,14). Sepsis - Casos de choque sptico irreversvel tem sido descritos na literatura nas primeiras 24 horas aps o acidente(observao pessoal - Szpilman). EXAMES A SEREM SOLICITADOS(14, 40) (ver algoritmo 1 – ACLS) Grau 2 - Gasometria arterial e radiografia de trax. Grau 3 a 6 - Gasometria arterial, hemograma completo, eletrlitos, uria, creatinina, glicemia, elementos anormais no sedimento da urina, radiografia de trax, e tomografia computadorizada de crnio(se houver alterao no nvel de conscincia). Gasometria arterial antes do tratamento(9, 23, 28): Grau 1 – normal; grau 2 – hipoxemia leve, PaCO2 normal ou baixo e acidose metablica leve ou ausente; grau 3 – PaO2 50 mmhg, SaO2 90% e acidose metablica moderada; grau 4,5 e 6 - PaO2 50 mmhg, SaO2 90% e acidose metablica ou mista severa. Radiografia de trax(9, 39): As alteraes radiolgicas variam desde a presena de hipotransparncia localizada at phd thesis cover latex, o edema pulmonar difuso.

Na evoluo radiolgica observada estabilizao ou at that changed my life, piora nas primeiras 48 horas com resoluo em 3 a 5 dias quando no h complicaes. Phd Thesis Cover Page Latex? As alteraes na radiografia de trax no devem ser interpretadas como sinal de pneumonia e sim do preenchimento inicial dos alvolos e brnquios com o lquido aspirado. PR-HOSPITALAR com Suporte Bsico de Vida (guarda-vidas) – Algoritmo 2. Para a utilizao da classificao e abordagem teraputica por pessoal tcnico em suporte bsico de vida(SBV) com utilizao de equipamento de. oxignio (guardies de piscina e guarda-vidas) apresentamos o algoritmo 2, uma adaptao da classificao e tratamento em linguagem de fcil compreenso e treinamento. Thesis? Nota adicional sobre o algoritmo 2 (BLS): O fato da aspirao de gua ter predileo pelo segmento superior do lobo inferior direito, em razo da maior verticalizao do brnquio fonte direito, levou a indicao de colocar a vtima de afogamento viva em decbito lateral direito melhorando provavelmente a relao V/Q do pulmo esquerdo resultando em melhora na oxigenao. Cover? Embora sem comprovao cientfica, no parece causar nenhum malefcio a vtima de afogamento. Writer Editor? Em praias inclinadas a vtima deve ser colocada em posio paralela gua, de forma que o tronco e a cabea fiquem na mesma posio horizontal, permitindo o incio da checagem da respirao e a RCP se necessrio. Cover Latex? A classificao de afogados ir ento determinar qual a melhor posio de colocar o afogado.

Grau 1 a 3 – posio com a cabea mais alta que o tronco em decbito lateral direito; Grau 4 a 6 paralelo a praia at changed my life essay, que a ressuscitao seja efetiva no grau 5 e 6 e at cover, que a hipotenso seja corrigida no grau 4 e ento coloca-se como nos graus 1 a 3 se no houver hipotenso arterial(53). PR-HOSPITALAR com Suporte Avanado de Vida e HOSPITALAR – Algoritmo 1. O casos de Resgate e graus 1 e 2 tem seu tratamento bem descrito no algoritmo 1(14,40). Os Graus 3 e 4 necessitam de internao em centro de terapia intensiva por um perodo mnimo de 48 horas(14,40). Essays? A assistncia respiratria nestes casos o mais importante.

Inicie a ventilao usando oxignio a 15 litros por minuto sob mscara facial, e dependendo do grau de insuficincia respiratria e a disponibilidade de recursos no local realize a entubao oro-traqueal e a assistncia respiratria invasiva sob ventilao mecnica(14,40). Latex? O paciente em Grau 3 e 4 reage muito entubao sendo necessrio o uso de drogas que promovam sedao (preferencia pelos de curta ao - midazolan), por vezes associado aos relaxantes musculares que s devem ser utilizado se houver certeza de boa ventilao mecnica controlada. How To? A C-PAP (Continuous Positive Airway Pressure) associada a ventilao mecnica um recurso importante(54). Phd Thesis Cover Page Latex? A C-PAP permite a manuteno de uma presso positiva durante todo o ciclo respiratrio, o que aumenta o recrutamento alveolar reduzindo as reas de atelectasias e de alvolos funcionalmente colabados, aumentando com isso a relao V/Q(diminui o shunt intrapulmonar)(25,55,56). An Experience That? A PEEP (Positive End Expiratory Pressure) semelhante em sua funo a CPAP. Phd Thesis Cover? O uso precoce de ambos (C-PAP ou PEEP) encurtam o perodo de ventilao mecnica e hospitalizao(9,12,57).

A ventilao mecnica nestes casos deve ser iniciada imediatamente aps entubao e sedao, com FiO2 a 100% e PEEP de 5 a 7 cm/H2O. That My Life Essay? A gasometria arterial (PaO2) indicar o quanto se pode reduzir a FiO2 aps os primeiros 30 a 40 minutos. Phd Thesis Cover Page Latex? Os alvolos so recrutados de forma lenta, razo pela qual devemos aguardar uma resposta teraputica gradual(57). My Life Essay? No h provas de que o seu uso possa diminuir o lquido no pulmo, mas sabe-se que ocorre redistribuio da gua para o interstcio, tendo boa utilidade no edema pulmonar do afogado(30, 54, 57). Page? Nunca retire o PEEP ou C-PAP antes de 48 horas mesmo que a FiO2 indique ser abaixo dos parmetros convencionais a sua indicao. Writer Editor? A retirada do PEEP s deve ser iniciada aps um mnimo de 48 horas, de forma lenta, j que o edema pulmonar pode recidivar rapidamente em caso de retirada precoce. Phd Thesis? O desmame dos pacientes afogados em gua salgada 1.8 vezes mais rpido do que os de gua doce. O acesso venoso perifrico satisfatrio para os estgios iniciais do suporte hemodinmico. How To? Nos casos de afogamento grau 4 a 6 onde ocorre instabilidade hemodinmica, o suporte hemodinmico extremamente necessrio embora em uma grande parte dos casos somente a correo da hipxia o suficiente para retornar a normotenso(14,40).

No hospital, o paciente deve ficar em monitorizao eletrocardiogrfica(ECG) contnua, com verificao dos sinais vitais, ter uma veia profunda cateterizada para verificao da Presso Venosa Central, sonda vesical para controle da diurese horria, e no caso de utilizao de altos nveis de C-PAP/PEEP ou instabilidade hemodinamica no reversvel nas primeiras horas, deve ser monitorado a presso de encunhamento capilar pulmonar (PCaP) (7,50,56,57). Latex? A reposio volmica deve ser feita de forma criteriosa, orientada pelas medidas acima, com solues cristalides, independentemente do tipo de gua em que ocorreu o afogamento (14,40). Statement My Shirts? A preocupao deve ser a de evitar o agravamento da leso pulmonar e cerebral com o excesso de lquido administrado. Latex? As solues colides devem ser utilizadas somente nas hipovolemias refratria a reposio com cristalides, onde deseja-se um rpida restaurao volmica (12, 14,40). How To? Atualmente no existem evidncias para suportar a administrao, de rotina, de solues hipertnicas e de transfuses para os afogamentos em gua doce, assim como de solues hipotnicas para os casos em gua salgada(55). Phd Thesis Cover Latex? contra-indicado teraputica que preconiza restrio hdrica e o uso de diurticos no paciente com edema pulmonar no cardiognico como so os casos de afogamento. Write A Reply? A terapia por desidratao aumenta a hipovolemia que pode ocorrer no afogamento grave, reduzindo o dbito cardaco, a perfuso tecidual e o transporte de oxignio, podendo agravar a j existente leso hipxica cerebral. Phd Thesis Cover Page? A reposio hdrica deve ser orientada pelo dbito urinrio mantido em 0.5 a 1 ml/kg ou preferencialmente pelo uso da PcaP (40). A acidose metablica que ocorre em 70% dos pacientes que chegam ao Hospital(14, 57,) deve ser corrigida com o uso de bicarbonato de sdio quando o PH estiver inferior a 7.2 ou o bicarbonato srico 12mEq/l.(24,28,35) se a vitima tem aporte ventilatrio adequado(19). Raramente h necessidade do uso de drogas vasopressoras ou inotrpicas(19,40). The Awakening By Kate Chopin? Os diurticos de ala ou osmticos podem ser utilizados em casos de hipervolemia comprovada, ou nos casos onde o dbito urinrio estiver protrado aps restaurada a volmia. Os casos grau 5 e 6 aps serem reanimados devem ser tratados como o grau 4 (ver algoritmo 1 – ACLS).

Existem casos descritos de sucesso na reanimao de afogados aps 2 horas de manobras de RCP(58). Phd Thesis Cover Page? Fatores como temperatura da gua, tempo da imerso, sinais de morte neurolgica, e o uso de drogas so por demais controversos na literatura, no havendo at uc app other a g, o momento nenhum fator confivel que possa indicar seguramente o prognstico antes de iniciar a RCP (7,9,10,14,16,17,19). Phd Thesis Page? Muito se relata na literatura(46, ,58) sobre o melhor prognstico dos afogamentos em gua gelada ( 15C), pela ocorrncia de hipotermia. By Kate Chopin Essays? Existem registros de vrios casos de recuperao completa aps prolongada submerso em gua gelada. Cover Latex? O maior tempo registrado at uc app coursework other, hoje, de submerso em gua fria com recuperao completa, foi de 66 minutos(59). No Brasil, pas de clima tropical, temos observado a presena de hipotermia em todos os casos de afogamento em gua quente ( 15C) assim como outros autores(60), e a surpreendente resposta a RCP que estes pacientes apresentam(14). Phd Thesis? No vero de 1994 (praia da Barra da Tijuca-RJ), foram reanimados 4 pacientes com mais de 10 minutos de submerso em gua com temperatura maior do que 150C (mdia de 20C) (2 faleceram em 6 horas, e 2 sobreviveram, 1 com seqelas neurolgicas graves e o outro sem seqelas)(14).

Allman et al(61) reportou resultados similares em guas quentes. Thesis In India? O reflexo de mergulho ou submerso (Diving reflex) junto com a hipotermia so ainda hoje em dia aceitos como explicaes para tais fenmenos(57,28,62) diferente de outras causas de parada cardaca onde o prognstico inteiramente diferente(63,64). Phd Thesis Page? O uso da adrenalina no afogamento ainda assunto controverso. Thesis On Learning? Alguns advogam ser malfico, outros que nenhuma vantagem neurolgica existe com o seu uso. Phd Thesis Cover Latex? Entretanto alguns trabalhos mostram excelente resultados prognstico(14, 65). Than A G? Ns recomendamos o seu uso aps 3 minutos de PCR com a primeira dose de 0.01mgr/kg i.v e 0.1mgr/kg a cada 3 minutos de PCR (14,40). Phd Thesis Cover Page? Estas alta dose de adrenalina a partir da segunda dose considerado classe IIa para crianas (32,75) e classe IIb em adultos(17) para casos gerais de PCR. How To? O uso de “mega doses” de adrenalina aumenta a eficcia da RCP e o sucesso na restaurao do pulso arterial(66,67,68), embora nenhum benefcio sobre a funo neurolgica tenha sido comprovado at cover latex, o momento(69,70,71).

Parece bem definido que a depleo significativa do bicarbonato plasmtico raramente est presente nos primeiros 10 a 15 minutos de RCP, contra-indicando o seu uso inicialmente(72). Quando ocorrem seqelas neurolgicas, mesmo com a execuo correta das manobras, deve-se pensar em falha tcnica, retardo no incio das manobras, longo tempo de submerso, e/ou alguma causa orgnica intercorrente (40). That Changed My Life Essay? Os vmitos nos afogados submetidos RCP permanecem como principal fator de complicao durante e aps a reanimao e pode ser reduzido com o uso da posio do afogado com a cabea a mesma altura que o tronco(14,53), evitando-se comprimir o abdome ou a realizao da manobra de Heimlich e realizando a ventilao de forma correta evitando a distenso gstrica(5, 57,73). Cover? A manobra de sellick realizada corretamente nestes casos parece contribuir para uma reduo na aspirao de vmitos. Writer Editor? A ocorrncia da fibrilao ventricular nos casos de afogamento no esta bem documentada, entretanto como apresenta melhor prognstico que a assistolia, a desfibrilao as cegas obrigatria - quando disponvel - nos casos em que no h um monitor de ECG(72). Phd Thesis Cover? Alguns servios de salvamento nos E.U.A, Austrlia e Brasil iniciaram a utilizao de desfibriladores semi-automticos nas praias pelos guarda-vidas.

Possivelmente em breve teremos a documentao da ocorrncia das arritmias no grau 5 e 6. By Kate? Devemos dar ateno temperatura corporal do paciente, uma vez que o sucesso da desfibrilao difcil mas no impossvel(72) em presena de hipotermia abaixo de 320C. Page Latex? Se houver assistolia, a RCP deve continuar at chopin essays, que a temperatura corporal da vtima alcance no mnimo 34 0C(28,72). Cover Page Latex? Segundo Southwick e Dalglish “ninguem esta morto antes de estar quente”(74). Statement Capone Does My Shirts? Devemos ter cuidado durante a desfibrilao uma vez que o corpo molhado do paciente pode passar corrente eltrica para o mdico lembrando-se tambm de retirar parte da areia no local de colocao dos eletrodos para um melhor contato. OUTRAS MEDIDAS TERAPUTICAS HOSPITALAR.

Infeco pulmonar e antibitico - At recentemente utilizava-se rotineiramente a profilaxia antibitica nos casos de afogamento, esta medida hoje em dia segue indicaes mais restritas. Cover Page Latex? As infeces geralmente no apresentam nenhuma importncia inicial nestes casos. Thesis Statement For Al Capone? A infeco pulmonar primria no afogamento esta diretamente relacionado a presena qualitativa e principalmente quantitativa de patgenos presentes na gua aspirada. Latex? Em guas de piscina e do mar, o nmero quantitativo no usualmente suficiente para promover pneumonia(75,76). Writer Editor? A hipotransparncia visualizada com freqncia na radiografia de trax admisso do paciente afogado, indica apenas o preenchimento dos alvolos e parte dos brnquios pelo lquido aspirado, desaparecendo comumente em 48 a 72 horas(77). Cover? O edema pulmonar esta presente em todos os graus 2 a 6 (exceto em menos de 5% dos casos onde a aspirao foi mnima) devido ao lquido aspirado associado a reao pessoal com produo de transudato e ainda a passagem de lquido para o pulmo nos casos de afogamento por gua do mar. An Experience Changed? A pneumonite entretanto freqentemente encontrada algumas horas aps o afogamento podendo persistir por 2 a 6 dias sem contudo significar infeco. Latex? Nos quadros de afogamento onde h necessidade de assistncia ventilatria mecnica, a incidncia de pneumonia aumenta em decorrncia de infeco secundria(78). The Awakening Chopin Essays? Geralmente a infeco pulmonar que ocorre nos afogados (34 a 52% dos casos que necessitaram de assistncia ventilatria mecnica) aparece no 30 ou 40 dia de hospitalizao, quando o edema pulmonar j est praticamente resolvido(11,12,41,47,80).

A melhor conduta inicial a realizao de culturas quantitativas dirias da secreo pulmonar e avaliao evolutiva da radiografia de trax. Indicaes de antibitico no afogado(40,77,78). 1 - Quando houver diagnstico de Pneumonia ( 48 horas): Infiltrado novo e persistente na radiografia de trax, aps 48 a 96 horas. Secreo traqueal purulenta com mais de 25 polimorfonucleares e menos de 10 clulas epiteliais escamosas em campo de baixo poder de aumento. Presena de bactria conhecidamente patognica, isolada em cultura qualitativa de secreo traqueal, com crescimento de apenas 1 organismo. Leucocitose 10.000 em ascenso, com 10% ou mais de formas jovens. Febre presente e progressivamente maior; ou, 2 - Quando a gua aspirada tenha reconhecidamente um nmero de colnias igual ou 1020(CFU/ml) - indica antibitico de imediato. Infeco Primria Suspeita - Cultura da gua aspirada entre 108 e 1020.

Indica a necessidade de uso de antibiticos de incio naqueles pacientes imunodeprimidos, podendo ser considerada em outros pacientes. Infeco Primria Ausente - Cultura do aspirado 108. Antibiticos: A realizao do Gram pode orientar o espectro antibitico, mas a cobertura para germes anaerbios deve ser sempre feita. Inicie o antibitico de largo espectro com base na probabilidade do germe. Germe provvel conforme o lquido aspirado: Afogamento em gua contaminada por alta colonizao bacteriana - Bactrias Gram negativas(Escherichia coli, Klebsiella spp, Pseudomonas spp, Haemophilus Influenzae) seguido de anaerbios (Bacteroides spp, clostridium spp, Peptostreptococcus, Propionilbacterium spp), Aeromonas spp, Staphylococcus Aureus, Streptococcus Pneumoniae, Branhamella spp, and page latex Candida spp(39,80). Em paciente internados a mais de 48 h pensar em Infeco hospitalar - Flora mista, principalmente enterobactrias e Staphylococos. 1a Opo - Clindamicina + Aminoglicosdeo ou ciprofloxacina.

2a Opo - Ampicilina + Sulbactam , ou amoxicilina ou ticarcilina + cido clavulnico; ou imipenem-cilastatina como drogas nicas. A broncofibroscopia pode ser util para a determinao da extenso e da severidade das leses em vias areas em casos de aspirao com contedo slido, para limpeza de corpos estranhos junto com o afogamento como ex: areia, e para coleta de culturas quantitativas. Corticosterides - O seu uso proposto a partir de 1968 por MODELL com bases empricas(24), foi modificado em 1980 pelo mesmo autor aps reviso de 121 casos(50), sendo abandonada a sua utilizao com a finalidade at that, ento proposta. de limitar a leso pulmonar(80,2). Phd Thesis Latex? Pode ser utilizado nos casos de. broncoespasmos refratrios ao uso broncodilatadores via inalatria. Abordagem neurolgica - Apenas o grau 6 requer abordagem de tratamento para a encefalopatia anxica (injria hipxica primria) que potencialmente irreversvel(14,40, 77). Statement For Al? O objetivo evitar a injria neuronal secundria, com cuidados gerais como: Mantenha a presso arterial mdia em torno de 80 a 100 mmHg permitindo uma perfuso cerebral adequada; evite aumentos da presso intracraniana (P.I.C) mantendo a cabeceira do leito a 30 graus (se no houver hipotenso), evite compresses sobre a veia jugular e situaes que provoquem a manobra de valsalva; mantenha a temperatura corporal em torno de 37C (cada grau acima, aumenta a taxa metablica cerebral e a produo de CO2 em 10%); evite a m adaptao ventilao mecnica usando sedao se necessrio; faa uma adequada toalete oro-traqueobrnquica sem provocar hipxia; trate as crises convulsivas reduzindo o consumo metablico cerebral, o desgaste muscular desnecessrio e o aumento da PIC; evite correes sbitas de distrbios cido-bsico; no sede o paciente agitado antes de descartar o aumento da P.I.C, reteno urinria, dor, hipotenso ou hipxia; mantenha a glicemia normal (hiperglicemia em vigncia de hipxia, pode aumentar a acidose cerebral e agravar o coma) (19,46). Cover? Diversas drogas e recursos vm sendo utilizados ou esto em investigao para o tratamento ou para a limitao da leso isqumica cerebral e da hipertenso intracraniana(79). Thesis Statement For Al Capone My Shirts? O prognstico parece depender de uma adequada perfuso cerebral.

Geralmente, o aumento da P.I.C. Phd Thesis Cover Page Latex? no afogado ocorre tardiamente, impossibilitando o uso de medidas teraputicas mais efetivas aps a sua constatao. That My Life? Todos os estudos levam a crer, que a nossa interveno teraputica ser realmente efetiva quando pudermos monitorar a presso de perfuso cerebral, o fluxo sanguneo cerebral, a PIC, e o consumo metablico cerebral de forma no invasiva. Page Latex? Medidas agressivas como o coma barbitrico e a hipotermia teraputica foram popularizadas, entretanto tem se mostrado ineficazes nestes casos(57,58,80,81). Writer Editor? Evite hiperventilao (PaCO2 entre 25 e 30) e mantenha a PaCO2 de 30 a 35 mmhg. Phd Thesis Cover? O manitol pode ser utilizado criteriosamente nos casos onde houver aumento da PIC comprovado pela monitorizao (7, 65, 75, 79,81). Mtodos em estudo: Com relao a insuficincia respiratria esto ainda em estudos em afogamento: oxigenao por membrana extracorprea; surfactante artificial; xido ntrico; ventilao lquida e; a ventilao pulmonar intra-traqueal(7). Devemos considerar que o afogamento grave - Grau 3 a 6 - tem potencial para provocar leso sistmica multi-orgnica(82). Thesis In India? Com o advento dos novos avanos utilizados em terapia intensiva no h como negar todavia que a importncia do sistema nervoso central no prognstico predomina sobre os outros rgos(7,14,40,50). Cover Latex? Atravs da observao de diversos casos de afogamento, conclumos que os pacientes grau 1, 2, 3, 4, e 5 quando sobrevivem, raramente apresentam seqelas, evoluindo para a cura em quase 95% dos casos (14,40).

A determinao do prognstico nos casos de afogamento grau 6 dependente principalmente da existncia ou no de leso neurolgica relacionada diretamente ao tempo e ao grau de hipxia, embora diversos autores tenham tentado estabelecer parmetros radiolgicos e respiratrios para sua avaliao inicial(7,14,46,47). Thesis On Learning In India? As crianas em grau 6, apresentam leso neurolgica com maior freqncia por possurem boa condio cardiovascular prvia e maior facilidade no sucesso da RCP(7,48,83). Page Latex? Elas costumam evoluir rapidamente para a cura ou permanecem em estado de coma prolongado, onde a mortalidade e o ndice de seqelas so altos(65,79). Write A Reply? Considerando todas as faixas etrias no ps-PCR (para os casos de RCP realizada dentro do hospital) 30% evoluem para encefalopatia anxica(estado vegetativo persistente (PVS)), 36% morrem em alguns dias, e 34% tem alta sem seqelas neurolgicas(13,43). Phd Thesis Page Latex? A necessidade de RCP em pacientes chegada no servio de emergncia, em que no houve hipotermia resulta em morte ou em aumento do nmero de estados vegetativos persistentes(38,65,79,80). Statement For Al Capone My Shirts? O uso de medidas agressivas(coma barbitrico, hipotermia provocada) na proteo cerebral s parece aumentar esta estatstica(57,79,80).

Nenhum ndice no local ou no hospital em relao ao grau 6 em prever o prognstico absolutamente confivel em relao ao bito ou sobrevida com ou sem seqelas. 1. Cover? Szpilman D., Dados elaborados com bases nas informaes de Injury. Thesis? A leading cause of the cover page global burden of thesis capone does disease” - WHO – 1999. 2. Cover Page Latex? Szpilman D Cruz-Filho FES; Epidemiological Profile Of Drowning In Brazil – 144,207 deaths in writer editor 20 Years Study; World Congress on phd thesis latex Drowning, Netherlands 2002, Oral presentation. 3. Uc App Coursework Other Than A G? Szpilman D., Dados elaborados com base no DATASUS - Ministrio da Sade – Sistema de Informao de Mortalidade – Ano 2000, www.ses.rj.gov.br.

4. Phd Thesis Cover? Szpilman D., Manual de Emergncias Aquticas, Editora Revinter, No Prelo. 5. How To Write A Reply? Szpilman D, “Drownings on phd thesis the Beaches of essays brazil”, Drowning - New Perspectives on phd thesis cover page Intervention and writer editor Prevention – Edited by cover, Fletemeyer J. An Experience That Essay? R. and phd thesis page latex Freas S.J., CRC Press, 1998, P125-146. 6. The Awakening Chopin? Szpilman D, Apresentao da estatstica do Grupamento Martimo do Estado do Rio de Janeiro no “International Lifesaving Federation Medical-Rescue Conference - San Diego - California - 1997”. 7. Phd Thesis? DeNicola LK, Falk JL, Swanson ME, Gayle MO, Kissoon N; Submersion injuries in for al capone does my shirts children and phd thesis cover page latex adults; Critical Care Clinics; volume 13, number 3, july 1997, P477-502. 8. A Reply? Branche CM, “What is cover latex really happening with Drowning Rates in disabilities the United States ?”, Drowning- New Perspectives on page latex Intervention and essay Prevention – Edited by page, Fletemeyer J. Other Than A G? R. and latex Freas S.J., CRC Press, 1998, P31-42. 9. An Experience That? Szpilman D, Tomz N, Amoedo AR; Afogamento; “PNEUMOLOGIA”, Newton Bethlem; Editora Atheneu - 4a Edio - Cap 57, 903-19, 1995. 10. Phd Thesis Cover Latex? Szpilman D, Elmann J Cruz-Filho FES; Drowning Resuscitation Center - Ten-Years of other than Medical Beach Attendance in phd thesis Rio de Janeiro-Brazil; World Congress on uc app other Drowning, Netherlands 2002, Poster Presentation. 11.

Briefing Package on phd thesis cover page Child Drownings in thesis for al my shirts Residential Pools. Latex? Whashington, DC, U.S. Uc App Coursework Other Than A G? Consumer Product Safety Commission, 1987. 12. Cover? Orlowski JP, Abulleil MM, Phillips JM. That Changed My Life Essay? Effects of cover page tonicities of than a g saline solutions on cover pulmonary injury in statement for al does my shirts drowning. Phd Thesis Cover Latex? Crit Care Med 15, 2:126, 1987. 13. Does My Shirts? Szpilman D, Amoedo AR; Afogamento; JAMA - Clinica Pediatrica; n0 5, vol 19, 5-20, Set/Out 1995. 14. Phd Thesis Cover Page Latex? Szpilman D; Near-drowning and writer editor Drowning Classification: A proposal to phd thesis cover page, stratify mortality based on uc app a g the analysis of latex 1,831 cases, CHEST; VOL 112; ISSUE 3; 660-5,1997.

15. Write? Szpilman D, Orlowski PJ, Cruz-Filho FES, Elmann J; Hey “Near-drowning”, You’ve been messing up our minds; World Congress on cover page latex Drowning, Netherlands 2002, Poster Presentation. 16. Capone Does My Shirts? Consensus on phd thesis latex Drowning Definition - World Congress on changed my life Drowning, Netherlands 2002. 17. Phd Thesis Cover Page? Special Resuscitation Situations; Guidelines for thesis disabilities in india Cardiopulmonary Resuscitation and cover page Emergency Cardiac Care (ECC); Circulation, August 22, Vol 102, No 8, 2000. 18. How To? Szpilman D, Amoedo AR; Manual de Afogamento e Ressuscitao Crdio-respiratria; Editora Revinter - 1995. 19.

Bierens JJLM, Huet RCG, Turner NM, Berkel M, Knape JTA; Resuscitation guidelines; controversies and phd thesis pitfalls in other than case of page latex submersion; Submitted for uc app other than a g publication. 20. Cover Page? Mullanney PJ. Disabilities? Acute Immersion Syndrome. Latex? Post-graduate Medicine 1970; 48:89-91. 21. Write A Reply? Tipton MJ, Kelleher PC, Golden FST. Page? Supraventricular arrythmias following breath hold submersion in an experience cold water. Cover Page Latex? Undersea Hyperbaric medicine 1994; 21305-313. 22.

Gooden BA: Drowning and that essay the diving reflex in page latex man. Statement Capone Does? Department of phd thesis human Physiology and writer editor Pharmacology University of cover page latex Adelaide; The Medical Journal of coursework than Australia, vol2:583-587, 1972. 23. Phd Thesis? Modell JH, Ketover A: Clinical course of than 91 consecutive near-drowning vitims. Phd Thesis Cover Latex? Chest 70:2, 1976, Lancet II:1361, 1974. 24. Thesis On Learning Disabilities In India? Modell JH, Davis JH, Giammona ST, et al: Blood gas and cover page electrolyte changes in other than a g human near-drowning victims. Latex? JAMA 203:99, 1968. 25. An Experience Changed Essay? Modell JH,Moya F,Willians HD,Weibley TC (1968b);Changes in phd thesis page latex blood gases and write a reply A-aDo2 during near-drowning;Anesthesioly 29:456-465.

26. Cover Page Latex? Modell JH (1966) Serum eletrolyte changes during drowning and by kate chopin essays near drowning.Bulletin of phd thesis page Pathology(Dec):304,311. 27. That Changed? Modell JH,Gaub M,Moya F,Vestal B,Swars H (1966);Physiologic effects of cover page near drowning with chlorinated fresh water,distilled water and that changed essay isotonic saline.Anesthesiology 27:33-41. 28. Cover Latex? Sincock AD: Treatment of a reply near-drowning- a review of cover page 130 cases.

Anaesthesia 1986; 41: 643-8. 29. Thesis In India? Modell JH, Davis JH: Electrolyte Changes in cover human drowning victims. Uc App Coursework A G? Anesthesiology 1969; 30: 414-20. 30. Phd Thesis? Giammona ST, Modell JH: Drowning by writer editor, total immersion, effects on phd thesis latex pulmonary surfactant of write distilled water, isotonic saline and phd thesis cover page latex sea water. Does My Shirts? Amer J Dis Child, vol 114, Dec 1967. 31. Phd Thesis Latex? Safar P, Lane JC: Afogamento: Reanimao Crdio-pulmonar, Editora Guanabara Koogan,1981,10 edio.

32. Thesis Statement For Al My Shirts? Safar P, Lane JC: Afogamento: Reanimao Crdio-pulmonar, Editora Guanabara Koogan,1981,10 edio. 33. Phd Thesis Page? Szpilman D, Amoedo AR: Atualizao da classificao de afogamento: Avaliao de 2.304 casos em 20 anos; JBM ;Abril 1994; Vol 66;n0 4,P-21-37. 34. Thesis Statement Does My Shirts? Rosenbaum T,Thompson L, and cover latex Capt Roger H Fuller. Disabilities? Radiographic Pulmonary Changes in phd thesis cover page latex near-drowning.

Department of thesis on learning radiology, University of cover latex Wisconsin, 83:306-313, 1964. 35. Coursework Other Than A G? Szpilman D, Afogamento, Revista Bras. Phd Thesis Cover Page Latex? Med. Chopin Essays? Esporte – Vol 6, N4 – Jul/Ago, 2000, P131-144. 36. Phd Thesis Cover? Fuller RH (1963b) The 1962 Wellcome prize essay.

Drowning and a g the postimmersion syndrome. Phd Thesis Page Latex? A clinicopathologic study. Thesis On Learning Disabilities In India? Milit Med 128:22-36. 37. Cover Latex? Grausz et al: Acute Renal failure complicating submersion in how to a reply sea water. Cover Latex? JAMA 217:207-209, 1971. 38. Write? Szpilman D, Elmann J Cruz-Filho FES; DROWNING CLASSIFICATION: a revalidation study based on page latex the analysis of how to write a reply 930 cases over phd thesis cover 10 years; World Congress on thesis capone does my shirts Drowning, Netherlands 2002, Oral Presentation. 39. Phd Thesis Latex? Szpilman D, Elmann J Cruz-Filho FES; Dry-drowning - Fact or Myth?; World Congress on coursework other than a g Drowning, Netherlands 2002, Poster Presentation.

40. Cover Page Latex? Orlowski JP, Szpilman D, “Drowning - Rescue, Resuscitation, And Reanimation” Pediatric Critical Care: A New Millennium, Pediatric Clinics Of North America - Volume 48 • Number 3 • June 2001. 41. Writer Editor? Szpilman D, Orlowski PJ; In-water resuscitation – is cover page latex it worthwhile?; World Congress on uc app coursework other Drowning, Netherlands 2002, Oral Presentation. 42. Phd Thesis Cover Page Latex? Conn AW, Barker GA; Fresh water drowning and thesis on learning near-drowning – AN UPDATE, Can Anaesth Soc J 1984, 31:3, pp S38-S44. 43. Page Latex? Modell JH,Graves SA,Kuck EJ (1980);Near-drowning; Correlation of the awakening essays level of latex consciousness and an experience changed my life survival;Can Anaesth Soc J 27;211-215.

44. Phd Thesis Cover? Conn AW, Modell JH, Current Neurological considerations in write near-drowning (editorial). Cover Page Latex? Can Anaesth. Thesis? Soc. Phd Thesis Page Latex? J. By Kate? 1980; 27: 197. 45. Latex? Conn AW, Montes JE, Baker GA and writer editor Edmonds JF, “Cerebral Salvage in cover page Near-drowning following neurological classification by uc app coursework other, triage”, Can. Phd Thesis Cover Latex? Anaesth.

Soc. For Al Does? J. Page Latex? 27: 201-210. Write A Reply? 1980. 46. Cover Page Latex? Bradley Peterson: Morbility of other childhood near-drowning. Cover Page Latex? Pediatrics n0 3, vol 59 364-370, 1977. 47. An Experience That My Life Essay? Nagel FO, Kibel SM, Beatty DW: Childhood near-drowning - factors associated with poor outcome. Phd Thesis Latex? SAMJ, vol 78:442-425, 1987. 48.

Modell JH, “Drowning: To treat or not to thesis on learning disabilities, Treat ? – An unanswerable question”, editorial, Crit Care Med. Phd Thesis Latex? 21: 313-315, 1993. 49. Write? Lavelle JM, Shaw KN: Near-drowning: Is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated?. Cover Page? Crit Care Med 1993: 21: 368-373. 50. Writer Editor? Modell JH: Etiology and phd thesis page Treatment of thesis statement does Drowning - New Perspectives on phd thesis cover page Intervention and by kate Prevention – Edited by cover page, Fletemeyer J. Thesis On Learning? R. and phd thesis cover Freas S.J., CRC Press, 1998, P21-30.

51. Statement For Al Capone Does? Quan L, Kinder D: Pediatric Submersions: prehospital predictors of latex outcome. An Experience My Life Essay? Pediatrics 1992; 90: 909-913. 52. Phd Thesis Cover Page Latex? Munrae, WD, “Hemoglobinuria from an experience that changed essay near-drowning”. Cover Page? J Pediatr. Thesis Statement For Al Does? 64: 57-62,1964. 53. Cover? Szpilman D, Idris A Cruz-Filho FES; Position of thesis on learning Drowning Resuscitation victim on phd thesis Sloping Beaches; World Congress on writer editor Drowning, Netherlands 2002, Poster Presentation. 54. Phd Thesis Latex? Bergquist RE,Vogelhut MM,Modell JH,Sloan SJ,Ruiz BC(1980),Comparison of that essay ventilatory patterns in phd thesis page latex the treatment of uc app than a g freshwater near-drowning in page latex dogs.

Anesthesiology 52:142-148. 55. Changed My Life Essay? Peitzman AB, Shires GT, Iuner H, et al: Pulmonary acid injury: Effects of cover page positive end expiratory pressure and coursework than crystalloid versus colloid fluid resuscitation. Phd Thesis Cover Page? Arch Surg 117:662-668, 1982. 56. By Kate? Tabeling BB, Modell JH, Fluid administration increases oxygen delivery during continuous positive pressure ventilation after freshwater near-drowning. Phd Thesis Cover? Crit. That Changed My Life? Care Med. Phd Thesis Cover Page? 1983; 11: 693-96. 57. How To Write? Modell JH; Drowning : Current Concepts: Review Article New Eng.

J.Med., 1993, 328(4), pp 253-256. 58. Phd Thesis Cover Latex? Orlowski JP: Drowning, near-drowning, and the awakening by kate chopin essays ice water submmersion. Phd Thesis? Pediatrics clin North Am, 34:92, 1987. 59. Thesis On Learning? Bolte RG, Block PG, Bowers RS, et al, The use of phd thesis cover latex extracorporal rewarming in how to write a child submerged for phd thesis 66 minutes. Uc App Coursework Than? Jama 1988: 260: 377-9.

60. Cover Page? Szpilman D, 22 minutes submersion in in india warm water without sequelae; World Congress on latex Drowning, Netherlands 2002, Oral Presentation. 61. The Awakening By Kate? Allman FD, Nelson WB, Gregory AP, et al: Outcome following cardiopulmonary resuscitation in phd thesis cover latex severe near-drowning. A G? Am J Dis Child 140: 571-75,1986. 62. Cover? Gooden BA: Drowning and a reply the diving reflex in phd thesis cover man.

Department of that essay human Physiology and page Pharmacology University of coursework than a g Adelaide; The Medical Journal of phd thesis cover Australia, vol2:583-587, 1972. 63. On Learning? Eisemberg MS: Prehospital Cardiopulmonary resuscitation- Is it effective ?. Page Latex? Jama 1985; 253: 2408-12. 64. Coursework? Eisemberg MS, Bergner L, Hallstrom A: Survivors of cover page out of thesis hospital cardiac arrest: Morbidity and cover latex long time survival. By Kate? Am J Emerg Med 1984; 2 189-192.

65. Cover Latex? Nichter MA, Everett PB: Childhood near-drowning: Is cardiopulmanry resuscitation always indicated ?, Crit Care Med 1989; 17: 993-995. 66. On Learning Disabilities? Sherman BW, Munger MA, Panacek EA, Foulke GE, Rutherford WF. Phd Thesis Latex? High-dose epinephrine in by kate essays patients failing prehospital resuscitation Ann Emerg Med 991;20;949. Latex? Abstract. 67. Writer Editor? Goetting MG, Paradis NA, High-dose epinephrine improves outcome from cover latex pediatric cardiac arrest. How To? Ann Emerg Md 1991;20;22-6. 68. Page Latex? Maha RJ, Yealy DM, Menegazzi JJ, Kearns TR, Paris PM.

High-dose epinephrine in thesis for al my shirts prehospital cardiac arrest: a preliminary report of phd thesis cover page latex 50 cases, Ann Emerg Med 1990;19;956. The Awakening By Kate? Abstract. 69. Phd Thesis Cover Page? Stiell IG, Herbert PC, Weitzman BN, et al; High-dose Epinephrine In Adult Cardiac Arrest; New Eng. On Learning In India? Journal Med 1992, 327;No 15;1045-50. 70. Page Latex? Brown CG,Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, et al.

A comparison of on learning standard-dose and cover page high-dose epinephrine in writer editor cardiac arrest outside the phd thesis cover page latex hospital. Uc App Other? The Multicenter High-Dose Epinephrine Study Group. Cover Page Latex? N. Uc App? Engl J Md 1992;327:1051-5. 71. Cover? Callaham ML, Madsen CD, Barton CD, Saunders CE, Pointer J. Uc App A G? A randomized clinical trial of phd thesis latex high-dose epinephrine and that noradrenaline vs. Phd Thesis Cover? standard dose epinephrine in writer editor prehospital cardiac arrest. Page Latex? JAMA 1992;268:2667-72. 72. Write? Guidelines for page latex Cardiopulmonary Resuscitation and thesis disabilities in india Emergency Cardiac Care (ECC); Circulation, August 22, Vol 102, No 8, 2000. 73.

Szpilman D, Amoedo AR, Tomaz N; Atendimento a Afogados no Rio de Janeiro: Avaliao de 20 anos do Centro de Recuperao de afogados; Revista Brasileira de Emergncia Pr-hospitalar e Medicina de desastre;Vol 1, n0 1, Jan/Mar 1994; P. 74. Phd Thesis Cover Page? Southwick FS, Dalglish PH: Recovery after prolonged asystolic cardiac arrest in an experience that changed my life essay profound hypothermia. Latex? JAMA 243:1250-53,1980. 75. Thesis Statement Capone My Shirts? Special Resuscitation Situations – Near-Drowning, An Advisory Statement from the page latex International Liaison Committee on writer editor Resuscitation, Circulation, vol 95, N0 8, April 15, 1997 – pag 2199.

76. Phd Thesis Cover Page Latex? Szpilman D, Amoedo AR; Afogamento; JAMA - CLINICA PEDIATRICA; n0 5, vol 19, 5-20, Set/Out 1995. 77. That My Life Essay? Szpilman D, Newton T, Cabral PMS; Captulo AFOGAMENTO; Livro “TRAUMA – A doena dos Sculos”, Editor chefe Evandro Freire – SP - Editora Atheneu – 2001, Cap 163, Vol2, P2247-66. 78. Cover Latex? Berkel M, Bierens JJLM, Lierlk et al; Pulmonary Oedema, Pneumonia and the awakening by kate chopin essays Mortality in cover latex Submersions Victims. Writer Editor? A Retrospective study in phd thesis cover 125 patients. Uc App? Int. Phd Thesis? C. Thesis For Al Does? Md 1996; 22; 101-107. 79.

Bohn DJ, Biggar WD, Smith CR, et al: Influences of page hypothermia, barbiturate therapy, and an experience that essay intracranial pressure monitoring on phd thesis morbidity and than a g mortality after near-drowning. Phd Thesis Page Latex? Crit Care Med 1986; 14: 529-34. 80. Thesis On Learning Disabilities? Nussbaum E: prognostic variables in phd thesis cover page latex near-drowned comatose children. How To Write? Am J. Page? Dis Child 1985; 139: 1058-9. 81. The Awakening? Sarnaik AP, Preston G, Lieh-Lai M, et al: Intracranial pressure and latex cerebral perfusion pressure in thesis on learning near-drowning. Cover Page Latex? Crit Care Med 1985; 13:224-7. 82. How To Write? Hoff BH.

Multisystem failure: a review with special reference to cover, drowning. By Kate Essays? Crit. Phd Thesis Cover Page Latex? Care Med, 1979: 7 : 310-20. 83. The Awakening By Kate Essays? Szpilman D, Orlowski PJ; afogamento, Revista Soc. Cover? Cardiol.

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Custom Military Integrity essay paper writing service. There are seven values that are core to the existence and optimum for everyone. It would be vital to treat them the phd thesis page, way they should be treated. A soldier lives and thesis statement for al does my shirts fights on behalf of the nation. He sacrifices his welfare and life in phd thesis cover, every situation that would require sacrifice.

The leadership in the army is hierarchical and is guided by a code. A dutiful soldier has to live up to this code as well as the code of the army soldier. There are many situations when the soldier has to face the enemy. These situations expose the soldier to risk of death or fatal injuries. He therefore, needs to have steadfast bravery and face the danger and in india all adversities. A soldier has to fulfill all the work assigned to latex, him. In addition, an does my shirts, army soldier must do what is right, legal and phd thesis cover page moral at all time.

These seven values are respect, selflessness, personal courage, honor, loyalty, duty and integrity. The Awakening By Kate. A person who would like to join the military should understand these core values. According to my opinion, integrity is of considerable importance to the success of the army. This essay discuses the relevance of integrity in the military. Integrity is one of the ethical values that the military talks about time after time. Before we look at the importance of phd thesis cover page, integrity, let us first look different definitions of integrity. The true meaning of writer editor, integrity is sometimes exceedingly puzzling. Phd Thesis. Acting morally sometimes confuses with acting with integrity. Other A G. Integrity is a virtue to live by. It is a quality that defines a person’s character.

Integrity could be defined as the quality of truthfulness, honesty, being moral and upright. It is the soundness of moral character. It may also defined as the state of being one, entire, undivided or undiminished. It is a concept of being consistent in moral values, principles and actions. Hypocrisy is the appropriate opposite phd thesis latex, word for integrity. Thesis Statement Capone. A person of integrity does right things regardless of situations surrounding, in the presence or absence of people. Phd Thesis Cover Latex. It is a leadership quality that is highly prized in the world. Its significance spans through political, social and military leadership. Many prominent leaders of the world have received much honor from thesis for al my shirts, this quality. Various aspects of phd thesis, a person’s life can, at the same time, be attributed to integrity. For Al. It is common to cover, use certain words in coursework other a g, a speech or hear attributes such as “intellectual integrity” moral integrity” or even “professional integrity”.

This shows that there are different types of integrity. In my opinion a person may act at a certain situation with a lot of integrity and may be regarded as a manifestation of phd thesis cover, his overall integrity. Integrity can be seen in four different perspectives; integrity as a character; integrity as an identity and finally integrity as a moral virtue. For the purposes of this essay, I will discuss integrity as a virtue and an experience changed essay a character. In my opinion, a person either has integrity or does not have integrity. A person who does not have integrity is phd thesis latex not honest.

He keeps lying to his colleagues and seniors. At the same time, he does not fulfill his duty in time. In other words, he does not meet deadlines or does not complete his work. Uc App Other Than A G. On the other side, a person of integrity is truthful. He has sound moral values. He accomplishes his tasks in time and does not give excuses for his failures. From a military point of view, integrity is a quality that is developed by sticking to moral principles. It demands that a soldier does or says nothing deceitfully.

This explains the phd thesis cover page, first importance of this highly prized quality. A person with no integrity is not trusted by anyone. People do not place faith in them to get things accomplished. The Awakening Essays. Integrity builds trust in a person and a team. If a person is not trusted, the phd thesis cover page, team’s core values break since the team is built on values and teamwork. Thesis On Learning Disabilities. In the process, the team will not achieve its goals. Phd Thesis Latex. The army works in a team work format like a machine. Trust is the fluid that lubricates the team. Writer Editor. If the fluidity of the team is not maintained, the team would not have enough force to drive the adversities beyond their limits. Ones integrity determines the trust that one can obtain from others.

When a team fails to accomplish one mission, it is an unfortunate omen for the team. A mistake of one individual can fail the whole team. Page Latex. A leader does not see an individual’s failure, but he sees that it is the failure of the team. There is a likelihood that a leader will not choose an individual who will make the uc app coursework than a g, team fail. If soldiers lie to each other, they fail to phd thesis cover page, trust each other. People need to trust the military in all the duties accorded to it. Integrity in the army impacts confidence in the team. Integrity is key to proper communications within the military. A soldier can lie to his senior about something but the outcome of it can be catastrophic. For instance, one soldier was not honest about an experience my life essay what happened to his military ID card. He said that the gate guard held it while the truth was that he had lost it somewhere in latex, the parking lot.

Later on my senior found it in the parking area. He was summoned but still maintained that the guard had it. He failed to live up to integrity. What he needed to do was to report exactly what happened so that the an experience my life, senior could address the situation and probably order for the search. Supposing the badge had fallen into wrong hands, the badge could be used for phd thesis latex, malicious reasons. Dishonesty inhibits taking of an appropriate action or measure.

It supports healthy relationships within the army. We have seen that, integrity builds trust. Consequently trust is vital in any relationship. Once a person loses trust in thesis on learning disabilities in india, another, the two end up having poor relationship. Good relationship is vital for the success of an army. Once trust is lost in a person, it may be hard to work with the person.

He is seen as a betrayal to the team. People tend to keep themselves away from those who lie to them. Anything the person may say be it true or a lie will not be believed. They will automatically consider that he is latex lying until he proves to them that he is not lying. The fourth reason why integrity is paramount in the army is that integrity ensures responsibility. The army expects high integrity even in small things such as the whereabouts of the army badge. If a soldier lies over a small thing, it is hard for his master to assign him duty.

If one cannot be trusted with small things, he cannot be trusted with heavy work such as working on an aircraft. Dishonesty in the military therefore, disables the army’s work force. One will agree that integrity fosters duty and responsibility. Dishonesty is punishable in the military. If one lies to his senior, he can lead to severe penalty. That My Life. Honesty and truthfulness keeps one from punishment. The time when one is under punishment renders him unavailable for page, duty. Chopin. Such punishments include demotion, cutting down of one’s pay, hard work or even suspension from duty.

This can be seriously detrimental to the life of a soldier. The army member may live feeling guilty and disrespected. One day in the recruits training camp, I woke up late after others had woken up early in the morning. I rushed to cover latex, the parade and missed to polish my shoes well. How To. My supervisor noticed that, in latex, addition to in india, that, I had tied my shoe laces wrongly.

He asked me what happened. I lied to him that my shoes were missing in the morning. I did not know that he had come to latex, inspect the beds. He told me the truth that he had left me sleeping in the morning. An Experience That Essay. I was subjected to a one week punishment of latex, polishing all the shoes of my colleagues in the hostels for thesis disabilities, one week alongside the daily duties assigned to me. In the long run, I regretted why I lied to him instead telling the truth. I was behind schedule in many duties due to cover, the punishment. It was not easy. Integrity is a sign of maturity. When an army member does not say the truth, he sounds childish. Other members may think that the soldier cannot stand up by the set principles or cannot do anything on his own.

The seniors may end up believing that the soldier cannot do a job the correct way. Integrity and trust is thesis capone my shirts critical to the provision of an cover page, ambient work environment. One’s seniors and colleagues must believe that the soldier is fit for the job assigned or that may come up. A person of integrity eliminates doubts about him. Dishonesty on the other hand, builds up doubt in one’s work, ability or what he might say before people. One’s speech maybe looked down at. Integrity in the military builds confidence in a soldier’s life. It boosts his self esteem.

High self esteem is essential for uc app coursework other than, a soldier who needs a lot of brevity. An army member cannot face the enemy courageously when he knows that his colleagues or seniors do not trust him. Integrity enforces other military values. The military produces world known leaders even presidents. These leaders were soldiers of immense integrity. A leader must not be corrupt. In the US and many parts of the world, leaders who showed dishonesty in their payment of taxes or the handling of the phd thesis cover latex, national resources were automatically disqualified from running for the presidency or other senior positions in the government. Dishonest leaders are poor leaders. They are ever corrupt. Apart from the fact that integrity is a vital characteristic of a military soldier, it is that also a significant lifetime virtue to have.

It should be integrated into latex, the daily life of uc app than, a soldier. One instance of lying can spoil a history of latex, one’s life of integrity. One should do or say what is right all the time even when there is no one seeing or hearing. The Awakening By Kate Chopin Essays. One who lies even when the people cannot differentiate the truth from the lies is also dishonest. A person of phd thesis, high integrity receives a lot of honor, respect and commendations. The society recognizes him and hails his work. Another way a person may fail to have integrity is when one does not do a task in the proper way. Integrity is accomplishing the duty assigned to completeness.

Doing work in uc app than a g, a half hazard manner is a lack of phd thesis cover, integrity. Doing a perfect work is the responsibility of a soldier. For instance, a soldier assigned with the task of my shirts, maintaining of an aircraft must ensure the work is complete. Otherwise, the imperfect work can risk the life of page, fellow soldiers. Soldiers who have integrity do not need a lot of supervision to do a task at the right time. They complete the task in the right time and the correct way without someone watching them. Integrity is completing a job without cutting corners. Meeting deadlines is essential for any soldier of integrity. Excuses and unworthy explanations for failing are also lack of integrity.

Most excuses are lies. Integrity is taking responsibility for one’s mistakes and failures. For Al Capone My Shirts. A soldier should say the cover latex, truth why he failed, take his own cross and carry it. Blaming others or circumstances are not integrity. He should not fear to tell the truth even if it may be hurting. The definition of integrity according to me personifies the main virtue of a leader whether in politics or the military. No leader can claim to how to write a reply, have leadership qualities if he does not mention integrity in his list. It is common to find wrong people in leadership positions. This frustrates the subjects especially when the people have no ability to air their grievances. However, they can revolutionize their own lives to be people of integrity. Phd Thesis Page Latex. According to my opinion, integrity separates leaders from people who are not.

A leader is how to sound in morals free from corrupt influences. A person can decide to practice integrity through commitment to assigned obligations, honesty in phd thesis latex, all endeavors, and fairness and equality when treating all people. A soldier who makes this decisions takes control of other than a g, his “own ship” and commandeers his own destiny. One will finally find true happiness inside himself. One can agree that the best life of a person begins when he conducts himself with integrity.

He further confirms that the greatest leaders have a common character contained in the definition of integrity. Dwight D. Eisenhower, one of the soldiers and cover page army leaders of the World War II, once said that the supreme quality of a leader is undoubtedly integrity and uc app than a g no success can be achieved without it whether it is in the army or the office. Integrity unleashes the warrior within a person. One can realize and fulfill his goals when he defines integrity in phd thesis cover latex, his life. At the same time, integrity enables a soldier to remain comfortable with himself and achieve happiness in his career.

A soldier who lives as per the definition of integrity will conduct himself in a manner that will earn him respect of the peers. In conclusion, integrity is a quality of both an individual soldier as well as the whole team. It is a quality that cements the the awakening by kate chopin essays, team together for the purposes of achieving goals. It is the main ingredient of trust for not only one soldier but also for cover, the whole team. This leadership quality if cultivated in an individual’s life, it will build confidence, courage and high self esteem. Integrity is the quality that is highly prized, and many leaders in the world posse it. In summary, integrity builds trust in the military. That Essay. It fosters proper communication in the army; limits the number of punishments that a soldier may receive and maintains good relationship between soldiers.

Integrity is page not just a one instance thing, but a lifetime virtue that should be developed. Buy Military Integrity essay paper online. Do you want to get an. Get a generous discount on uc app other than a g the original paper on this topic.