Tavis tvinis mwvave dazianebis mqone pacientTa marTva ...

Tavis tvinis mwvave dazianebis mqone pacientTamarTva prehospitalur etapzez. metreveli, k. CixraZe, T. JorJoliani, T. kereseliZe, d. saraliZe, b. gurgeniZe, o.asaTiani, z. kirtava, n. raWveliSvili, k. papoSvili, m. Cekliakad. o. RuduSauris sax. erovnuli samedicino centri, Tbilisi, saqarTvelo;kavSiri `partniorebi janmrTelobisaTvis~, Tbilisi, saqarTvelo;`partniorebi saerTaSoriso ganviTarebisaTvis~(atlanta-Tbilisis partnioruli TanamSromlobis programa), Aatlanta, jorjia, aSSI. daavadebis definicia, sinonimebi, klasifikacia da terminologia:Tavis tvinis dazianeba warmoadgens gareSe meqanikuri Zalis mier gamowveul travmas,funqciis mudmivi an gardamavali moSliT. mocemuli rekomendaciebis mizania, Tavis tvinisarapenetrirebadi dazianebis aRqma da klinikuri marTva. Tavis tvinis msubuqi simZimistravmul dazianebas axasiaTebs mcire xniT cnobierebis dakargva da/an retrograduliamnezia da glazgos komis Skalis mixedviT, hospitalSi miyvanisas 14-15 qula fokalurinevrologiuri deficitis gareSe. cnobierebis dakargvis periodi Tavsi tvinis msubuqisimZimis travmuli dazianebisas zogadad 20 wuTze naklebia. Ddazaralebulebi, romelTacaReniSnebaT Tavis travma da glazgos komis Skalis mixedviT 13 an ufro dabali qula,arian iseTi nevrologiuri garTulebebis riskis qveS rogoricaa:a. intrakranialuri dazianeba S06 (ICD- 10) *• Seryeva;• Tavis tvinis travmuli SeSupeba;• Tavis tvinis difuzuri dazianeba;• Tavis tvinis fokaluri dazianeba;• epiduruli sisxlCaqceva (travmuli);• travmuli subduruli sisxlCaqceva;• travmuli subaraqnoidaluri sisxlCaqceva;• intrakranialuri dazianeba dauzustebeli.*avadmyofobaTa saerTaSoriso statistikuri klasifikacia da masTan dakavSirebulijanmrTelobis problemebi; meaTe gadaxedva (ICD_10); tomi I; nawili IV; janmrTelobisdacvis msoflio organizacia, Jeneva 1992

II. epidemiologiasaqarTvelos epidemiologiuri monacemebi ar aris cnobili.amerikis SeerTebul StatebSi yovelwliurad:registrirdeba 1.6 milioni pacienti Tavis travmuli dazianebiT, romelTagan 800 000 iRebsdaxmarebas gadaudebeli daxmarebis ganyofilebaSi da 270 000 Tavsdeba saavadmyofoSi.saSualod 52 000 adamiani kvdeba da 70 000 dan 90 000-mde adamiani iRebs janmrTelobismdgomareobis Seuqcevad moSlas.dadgenilia, rom dResdReobiT 5.3 milioni amerikeli cxovrobs Tavis tvinis travmuldazianebasTan dakavSirebuli unarSezRudviT.mamakacebSi aRniSnuli dazianeba gacilebiT ufro xSirad aRiniSneba.am saxis dazianebis yvelaze xSiri procenti gvxvdeba 15-24 wlamde. adamianebi 5 wlisqvemoT da 75 wlis zemoT arian aseve maRali riskis qveS.• aSS-Si yovelwliurad aRiniSneba daaxloebiT 2 milioni yvela saxis Tavis travmuli(Tavis qalis da saxis) dazianeba (175 – 200 SemTxveva yovel 100,000 mosaxleze).• yovelwliurad 1.5 milionze met amerikels aReniSneba Tavis tvinis travmuli dazianeba,romelic ar saWiroebs hospitalizacias. DaaaxloebiT igive raodenobas aReniSneba Tavistvinis travmuli dazianebis Sedegad cnobierebis dakargva, magram igi ar saWiroebsxangrZliv institucionalizacias (yovelwliurad 618 adamiani yovel 100,000 mosaxleze).• danarCen 300,000-s aReniSneba sakmaod Zlieri dazianebebi da saWiroeben hospitalizacias,aqedan 99,000 rCeba unarSezRuduli. sul 56,000 adamiani kvdeba yovelwliurad Tavistvinis travmuli dazianebiT.• aSS-Si Tavis tvinis travmuli dazianebiT gamowveuli sikvdiloba Seadgens mTlianisikvdilobis 34%-s.• dadgenilia, rom yovel 100,000 mozrdilze (15 weli da zeviT) 62.3 adamiani cxovrobsfunqciuri miSlilobiT, romelic gamowveulia Tavis tvinis travmuli dazianebiT.evropaevropis monacemebiT yovelwliurad 1 milioni adamiani mimarTavs saavadmyofoebs Tavistvinis travmuli dazianebiT.

yovelwliur SemTxvevaTa raodenoba aris 1 – 2 yovel 1000 mosaxleze, romelTaganumetesoba Semowmebisas aris sruliad naTel gonebaze da aReniSnebaT mxolod msubuqiformis Tavis tvinis travmuli dazianeba. sikvdiloba izolirebuli msubuqi formis Tavistvinis travmuli dazianebis SemTxvevaSi aris 1%-ze naklebi.III. etiopaTogenezi:etiologiuri mizezebis mixedviT gamoyofen Semdegi xasiaTis tramvebs:• satransporto travma;• sayofacxovrebo travma;• katastrofebi;• terorizmi;• sporti.paTogenezurad Tavis travmis dros Tavis tvinis dazianeba SeiZleba iyos pirveladi dameoradi. pirveladi dazianeba ganpirobebulia uSualod travmis mier, paTomorfologiuradgamoixateba nervuli boWkoebis difuzuri dazianebiT. xolo meoradi dazianeba viTardebaqalasSida garTulebebis Sedegad (magaliTad, qalasSida hematomebi, tvinis SeSupeba,infeqcia).klinikurad maRali riskis asakobrivi jgufebi Tavis tvinis travmuli dazianebisas arianZalian axalgazrdebi da Zalian moxucebi, maT visac utardebaT Terapiuli antikoagulaciaan aqvT raime saxis koagulopaTia an Talasemia, aReniSnebaT Tavis qalis kompleqsurimotexiloba da aqvT mravlobiTi dazianebebi.IV. klinikuri simptomatika da diagnozinebismier pacientze daxuruli travmiT, romelsac aReniSneba cnobierebis dakargvaSeiZleba vivaraudoT Tavis tvinis travmuli dazianeba.Tavis tvinis travmuli dazianebis sami kategoria arsebobs: (I) msubuqi _ glazgos komisSkaliT (gkS) 13-15 qula; (II) saSualo simZimis _ gkS-iT 9-12 qula; da (III) mZime – gkS-iT 9qulaze naklebi. msubuqi formis Tavis tvinis travmuli dazianebisaTvis damaxasiaTebeliamcire xniT cnobierebis dakargva, amnezia da tranzitoruli nevrologiuri deficiti.klinikuri prognozic am maxasiTeblebTan aris dakavSirebuli.travmuli pacientis Sefaseba

yvela saxis travmis dros, pacientis mkurnaloba iwyeba sasunTqi gzis da xerxemlis kisrisnawilis dacviT, sunTqvisa da cirkulacia-hemoragiis kontroliT.amis Semdeg iwyeba nevrologiuri Sefaseba. am dros yuradReba eqceva or komponents (a)cnobierebis donis gansazRvra gkS-is mixedviT da (b) pacientis gugebis zomis,simetriulobis da reaqciis Sefaseba. yoveli maTgani detalurad aris qvemoT ganxiluli.a. glazgos komis Skalaglazgos komis Skala aris Tavis tvinis dazianebis mniSvnelovani indikatori,gansakuTrebiT ki im SemTxvevaSi Tu vimeorebT am Sefasebas drois monakveTSi da avRniSnavTmdgomareobis gamosworebas Tu gauaresebas. umaRlesi qula aris 15, xolo yvelaze dabali3. ori maCveneblis daqveiTeba miuTiTebs mniSvnelovan dazianebaze. uneblie paTologiuripozac aris mniSvnelovani maCvenebeli (dekortikaciuli-fleqsoruli Tu decerebraciulieqstenzoruli).glazgos komis SkaliT Sefaseba unda moxdes rogorc sasunTqi gzis,ventilaciis da cirkulaciis pirveladi Sefasebisas, aseve unda gameordes yovelireanimaciuli Carevis an sedaciuri saSualebebis micemis Semdeg. glazgos komis SkaliTavadmyofi unda Seafasos saTanadod momzadebulma personalma da saTiTaod unda aRniSnossami damoukidebeli reaqcia:Tu pacienti imyofeba alkoholis an wamlis zemoqmedebis qveS, es unda aRiniSnospirveladi Semowmebisas, magram ar unda imoqmedos glazgos komis Skalis qulaze.danarTi # 1glazgos komis SkalakriteriumebiTvalebis gaxelaspontanuri (mizanmimarTuli)reaqcia xmazereaqcia tkivilzereaqcia ar aRiniSnebaqulebi4321verbaluri (metyvelebiTi) reaqciakiTxvebze iZleva swraf da swor pasuxebs (orientirebulia)pasuxobs abneulad (dezorientirebulia)pasuxobs araadeqvaturadwarmoTqvams gaurkvevel bgerebsver laparakobsmoZraobiTi reaqciaasrulebs miTiTebul moZraobebsSesabamisi reaqcia tkiviliT gaRizianebazetkiviliT gaRizianebaze amoZravebs kidurebstkivilze - kidurebis paTologiuri moxra (dekortikacia)tkivilze - kidurebis paTologiuri gaSla (decerebracia)moZraoba ar aRiniSneba54321654321

a. gugebis Sefasebagugebis sawyisi da ganmeorebiTi Semowmeba gvexmareba im pacientebis gamovlenaSi, romelTacaReniSnebaT Tavis tvinis mZime dazianeba da mentaluri statusis cvlileba. prehospitaluretapze damxmare personalma unda icodes sinaTlis refleqsis da gugebs Soris 1 mm-ze anmeti sxvaobis Sefaseba. gugas, romelic aranair reaqcias ar iZleva sinaTleze ewodebaarareaqtiuli, fiqsirebuli guga da SeiZleba iyos unilateraluri an bilateraluri.unilateraluri dilatirebuli, neli an arareaqtiuli guga miuTiTebs iseT fokalurdazianebaze, rogoricaa epiduruli an subduruli hematoma, an mxedvelobis nerviskompresia. bilateralurad fiqsirebuli da dilatirebuli gugebi miuTiTebs TvinisSeSupebis an hemoragiis Sedegad intrakranialuri wnevis momatebaze. bilateraluradSeviwrovebuli gugebi SeiZleba gamowveuli iyos xidis doneze arsebuli dazianebebiT,metaboluri encefalopaTiiT an wamlebiT (opiatebi). aqedan gamomdinare, is dro rodesacpacientis guga gaxdeba arareaqtiuli an aRiniSneba 1mm-ze meti sxvaoba gugebs Soris undaaRiniSnos pacientis nevrologiur monacemebSi. SeniSvna: gugebis monacemebis prognozuliRirebuleba mcirdeba wamlebis gamoyenebis, hipoTermiis, orbitaluri travmis an hipoqsiisSemTxvevaSi. gugebis reaqcia unda aRiniSnos vitaluri funqciebis yoveli Semowmebisas(yovel 5 wT-Si), transportirebamde da transportirebis Semdeg, da yovelTvis rocaaRiniSneba pacientis zogadi mdgomareobis cvlileba.• glazgos komis SkaliT Sefaseba 15-ze naklebi quliT travmis Semdeg;• cnobierebis dakargva travmis Sedegad;• raime fokaluri nevrologiuri deficiti gamowveuli tramviT;• eWvi Tavis qalas dazianebaze an Tavis Semavali Wriloba;• travmis Semdgomi amnezia;• travmis Semdgomi Tavis tkivili;• travmis Semdgomi Rebineba;• travmis Semdgomi gulyra;• glazgos komis SkaliT (gkS) Sefaseba 3-8 bali (danarTi #1).VI. gamokvlevis sqemaa. pirveladi mkurnalobis prioritetebi.pirveladi Sefaseba- sasunTqi gza- sunTqva- cirkulacia da kisrisimobilizacia- mini-nevrologiuriSemowmebatravmuli pacientis daxmarebisas, prioritetadiTvleba sabaziso reanimaciuli Sesafasebeli dasamkurnalo protokolebis miyola. sasunTqi gzis,sunTqvis, cirkulaciis Sefaseba da kisris sayelosstabilizacia Tavis travmis mqone yvela pacientSi,sawyisi Sefasebis dros.stabilizaciis Semdeg, pacients SeiZleba davusvaTSekiTxva, raTa miviRoT verbaluri pasuxi angaaxilos Tvalebi. Tu spontanurad ar aRiniSneba Tvalebis gaxela, maSin gamoiyenebafrCxilis baliSebze dawola. Semdgom fasdeba motoruli pasuxi, gkS srulad da gugebisreaqcia.aucilebelia, rom saSualo simZimiT an mZime travmiT pacientitransportirebapirdapir gadayvanil iqnes umaRlesi donis travmis centrSi.sasurvelia transportireba moxdes maSinve da ar gadadoT raime arakritikulimaCveneblis gamo. Tu SesaZlebelia, sasurvelia pacientis kisris stabilizaciada transportireba mwoliare mdgomareobaSi.

. sisxlis wnevis marTva. tvinis dazianebiT bacientebSi prehospitalur etapzemniSvnelovani momentia hipotenziis Tavidan acileba. pacientebi,Tavidan aicileT romelTac aReniSnebaT nevrologiuri dazianeba, gansakuTrebiThipotenzia i/vmgrZnobiareni arian hipotenziis mimarT: aseT SemTxvevebSisiTxeebis gadasxmis hipotenzia asocirebulia sikvdilobis da zogadad gamosavlissaSualebiTgauaresebis gaormagebasTan. travmis gaidlainebis mixedviT,rekomendirebulia 2 litri izotonuri siTxis, ZiriTadad Ringer’s lactate an fiziologiurixsnaris (hipertonuli xsnaric SeiZleba gamoviyenoT) swrafi infuzia.• arteriuli wnevis gansazRvra xdeba im SemTxvevaSi xelmisawvdomi meTodiT;teqnikurad hipotenzia aRiniSneba, rodesac sisxlis sistoluri wneva aris < 90 mm HgmozrdilebSi, bavSvebSi asakis Sesabamisi maCvenebliT. sawyis etapze cirkulaciisadeqvaturobis Sesafaseblad gamoiyeneba pulsis palpacia. Tu karotidul da femoralurarteriebze pulsi aRiniSneba, sistoluri wneva sul mcire 60 mm Hg-ia. Tu SevigrZnobTmxris arteriis pulsacias, sistoluri wneva sul mcire 80 mm Hg-ia. damatebiTi klinikurisisxlis moculobis Semcirebis indikatorebia: taqikardia, civi kidurebi, kapilaruliavsebis siswrafe 1 wm-ze meti da mentaluri statusis cvlileba.g. oqsigenaciis da ventilaciis marTva. hipoqsemia – Jangbadis saturacia (SaO2) 90%-zenaklebia, saswrafod unda iqnes namkurnalebi. Tu aris aparatura saturacia undaganisazRvros yvela pacientSi, romelsac aReniSneba Tavis tvinis mwvave dazianeba.miawodeT Jangbadipacientis respiratoruli statusis Sesafaseblad klinikuradunda ganisazRvros pacientis sunTqvis sixSire da tipi.cianozis arseboba an ararseboba da mentaluri statusis nebismieri saxis cvlileba.normalur ventilaciad iTvleba saSualod 10 amosunTqva wuTSi (20 bavSvebSi, 25axalSobilebSi); hiperventilacia – 20 amosunTqva wT-Si mozrdilebSi, 30 bavSvebSi da 35axlSobilebSi. pulsoqsimetris araswori maCveneblis mizezi SeiZleba iyosdishemoglobinemia, hipotenzia, anemia, kanis pigmentacia, manikuri da sxva.hipoqsemiis koreqcia unda moxdes JangbadiT. moerideT hiperventilacias. hiperventilaciamSesaZloa mogvces dadebiTi Sedegi mxolod iseT pacientebSi, romelTac aReniSnebaTcerebraluri herniacia – eqstenzoruli pozicia, gugebis asimetria, fiqsirebulidilatirebuli gugebi da swrafi nevrologiuri darRvevebi gkS-iT 9 qulaze naklebi.profilaqtikis mizniT hiperventilacia ar aris rekomendirebuli arcerTi pacientisaTvis.yvela travmian pacientSi, prehospitalur etapze damxmare personalma didi yuradReb aunda miaqcios sasunTqi gzis mdgomareobas. pacientebi, romelTac aReniSnebaT Tavis travmada cnobierebis cvlileba, arian sasunTqi gzis dazianebis maRali riskis qveS. daakvirdiTgulmkerdi moZraobs Tu ara simetriulad, mousmineT haeris moZraobas orive mxares dadaicaviT pacientis sasunTqi gza. ventilaciis da oqsigenaciis gamosasworebladprehospitalur etapze SesaZlebelia nikapis aweva an ybis win wamoweva, da Tu pacientiugonodaa, oraluri sasunTqi gzis Cadgma. imis niSnebi, rom pacienti Tavad ver icavs TavissasunTq gzas aris – orofarinqsSi sekretis akumulireba, Rebinebis refleqsis dafaringialuri stimulaciis ararseboba, umniSvnelo motoruli pasuxi, kisris hematomisarseboba, sunTqvis araregularuli tipi. saWiroebis SemTxvevaSi trenirebulmaprehospitalur etapze damxmare personalma an mimRebi dawesebulebis eqimebma undaganaxorcielon orotraqealuri intubacia gansakuTrebiT ki im pacientebSi, romelTacaReniSnebaT Tavis Zlieri travma (gkS-iT 9 qulaze naklebi), pacientebSi, romlebic Tavadver icaven sasunTq gzas, da pacientebSi, romelTac aReniSnebaT hipoqsia, romelic arkoregirdeba Jangbadis miwodebiT. am situaciaSi unda ganvsazRvroT riski asocirebulidaucvel sasunTq gzasTan, intrakranialuri wnevis momatebasTan, qala-fuZismotexilobasTan an SesaZlo ezofagialur intubaciasTan. brma intubacia ar aris

ekomendirebuli da nazaluri intubacia akrZalulia. sedacia, analgezia,neiromuskularuli blokada unda Catardes Zalian frTxilad. da bolos, yvela saxismanipulaciisas, romelic tardeba sasunTq gzebze, unda ganxorcieldes xerxemlis kisrisnawilis imobilizacia.d. mkurnalobis sxva meTodebi. mentaluri statusis cvlilebis diferencialuri diagnoziZalian farToa. igi unda gatardes hipoTermias, infeqcias, gulyras, insults, quCiswamlebiT an alkoholiT intoqsikaciis, endokrinul daavadebebsa da eleqtroliturdisbalanss Soris. Tavis travmiT pacientebSi es mdgomareobebi unda ganvixiloT, rogorcpirveladi mdgomareoba an mainicirebeli faqtorebi, romelTac gamoiwvies travmisSemTxveva. amis gamo Secvlili mentaluri statusis mqone pacientebSi rekomendirebuliaglukozis donis gansazRvra. empiriulad deqstrozis gazomva ar aris rekomendirebuli. Tuaris dro da saSualeba, sasurvelia SemTxvevis adgilze ganisazRvros pacientis reaqciawamlebze, alergiuloba, nevrologiuri statusi. sxva mniSvnelovani informacia:transportis deformaciis tipi, zewolis farTi, pacientis asaki, SemTxvevis dro da a.S.SejamebaTavis tvinis travmuli dazianebiT pacientebis marTva unda daiwyos adgilzestabilizaciiT, transportirebiT iseT dawesebulebaSi, sadac mkurnaloben Tavis travmasda meoradad insultebs, rac xSirad mohyveba tvinis perfuziis daqveiTebas. amissamkurnalo gaidlainebis siaxle aris:1. sasicocxlo niSnebis, nevrologiuri statusis da zogadad pacientis sruladSefaseba yovel 5 wT-Si;2. saSualo simZimis an Zlieri travmiT pacientebis saswrafo transportireba!3. hipotenziis da hipoqsiis kontroli;4. xerxemlis cervikaluri nawilis stabilizacia transportirebis porcesSi damanam, sanam eqimis Semowmebis an radiologiuri daskvnis Semdeg ar dadasturdeba misimoxsnis SesaZlebloba.• Jangbadis saturaciis kontroli pulsoqsimetriT;• sisxlSi Jangbadis Semcvelobis gansazRvra xdeba pulsoqsimetris saSualebiT;• saturacia unda gaizomos xSirad, SesaZleblobisas unda xdebodes uwyvetimonitorireba• Sefaseba glazgos komis SkaliT (ix. danarTi, cxrili #1):• qulebis gansazRvra xdeba pacientTan kontaqtiT (mag: verbaluri miTiTebismicemiT, an im pacientebisaTvis, romlebic brZanebebs ver asruleben, mtkivneulistimulaciis, rogoric aris frCxilze dawola, ganxorcieleba)• isazRvreba pirveli Sefasebis Semdeg, rodesac sasunTqi gzebis gamavlobaaRdgenilia, ventilacia da sisxlis mimoqceva mowesrigebulia.• unda ganisazRvros manam, sanam iqneba gamoyenebuli sedatiuri an paralizurimoqmedebis medikamentebi, an maTi gamoyofis Semdeg.• glazgos komis Skala unda Seafasos gadaudebeli daxmarebis personalma,romelsac aqvs saWiro unar-Cvevebi.• Tvalis gugis kontroli asimetriaze, fiqsaciasa da dilataciaze:1. rogor unda gaisinjos gugebi:• asimetriulad iTveleba erTi an orive gugis gadaxra 1mm-ze metad;• guga, romelsac ar aqvs reaqcia sinaTleze iTvleba ugrZnob gugado unda dafiqsirdes Tvalbudis travmis arseboba;• unda dafiqsirdes gansxvaveba da xangrZlivoba marjvena da marcxena mxaresSemdegi parametrebiT:• unilateraluri an bilateraluri fiqsirebuli gugebi;

• unilateraluri an bilateraluri gafarToebuli gugebi;• fiqsirebuli da gafarToebuli gugebi;2. rodis unda gaisinjos gugebi?mas Semdeg, rodesac iqneba miRweuli pacientis stabiluri zogadimdgomareoba.VII. mkurnalobis sqema‣ sasunTqi gzebis gamavloba, ventilacia da oqsigenacia:• Jangbadis miwodeba• saWiro SemTxveveaSi sasunTqi gzebis gamavlobis uzrunvelyofa endotraqealuriintubaciiTTu SesaZlebelia,hipoqsemia (apnoe, cianozi an saturacia Sa02

‣ hospitalSi transportirebis gadawyvetilebaTavis tvinis mwvave travmuli dazianebis mqone pacientis pirdapiri transportirebasaWiroa umaRlesi donis travmis centrSi.Catardes sedacia, analgezia, neiromuskularuli blokada Tavis tvinis dazianebis mqone pacientTa optimaluritransportirebisaTvis. (ix. transportirebis gaidlaini) (danarTi #2)gaidlainis miRebis xerxi – adaptacia da Targmanigamoyenebuli literatura1. Peter Driscoll; david Skinner; Richard Earlam; ABC of Major Trauma. Third Edition. 20032. American College of Surgeones. ATLS for Doctors. Student Course Manual. 6th ed. Chicago19993. Sosin DM, Sniezek JE, Thurman DJ. Incidence of mild and moderate brain injury in the UnitedStates, 1991. Brain Injury, 1996; 10(1):47-54.4. Centers for Disease Control and Prevention. Traumatic brain injury--Colorado, Missouri,Oklahoma, and Utah, 1990-1993. MMWR, 1997; 46(1):8-11.5. Sosin DM, Sniezek JE, Waxweiler RJ. Trends in death associated with traumatic brain injury,1979 through 1992: success and failure. JAMA, 1995; 273:1778-1780.6. U.S. Department of Health and Human Services. Interagency Head Injury Task Force Report.Washington, DC: U.S. department of Health and Human Services, 1989.7. Guidelines for the Management of Severe Head Injury: Aitken Brain Trauma Foundation, NY1995.8. 7 Baxt WG, Moody P: The impact of advanced prehospital care on the mortality of severelybrain-injured patients. J Trauma 27:365-369, 1987.9. Clawson J: Telephone treatment protocols. J Emerg Med Serv:11:43-47, 1986.10. The Journal of Emergency Care, Rescue and Transportation: State and Province Survey 1997.Volume 26, Number 12, December 1997.11. Eichorn J: Prevention of intraoperative anesthesia and related severe injury through safetymonitoring. Anesthesiology:70:573-577, 1989.12. Klauber, M.R., et al. The Epidemiology of Head Injury: A Prospective Study of an EntireCommunity - San Diego County, California, 1978. Amer J of Epidemiology: 113, No. 5, 500-509,1981.13. AMA: Office of Quality Insurance & Health Care Organizationsa Attributes to GuidelineDevelopment of Practice Parameters. AMA; Chicago, IL, 1990.avtorTa jgufi:1. z. metreveli - katastrofisa da gadaudebeli medicinis samsaxuris ufrosi2. k. CixraZe – katastrofis medicinis centris xelmZRvaneli;3. T. JorJoliani - katastrofis medicinis centris eqimi;4. T. kereseliZe - katastrofis medicinis centris eqimi;5. d. saraliZe - katastrofis medicinis centris eqimi;6. b. gurgeniZe - katastrofis medicinis centris eqimi;7. o. asaTiani – informaciis marTvisa da uwyveti ganaTlebis samsaxuris ufrosi