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Titlul proiectului: Dezvoltarea Competenelor n Transplant
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INTRODUCTION
The terms stupor, lethargy, and obtundation refer to states between alertness and coma.
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Alterations in alertness can be produced by focal lesions within the upper brainstem by directly
damaging the ARAS
Injury to the cerebral hemispheres can also produce coma, but in this case, the involvement is
necessarily bilateral and diffuse, or if unilateral, large enough to exert remote effects on the
contralateral hemisphere or brainstem.
Coma in toxic, metabolic, and infectious etiologies and hypothermia: impair oxygen or substrate
delivery, which in turn alters cerebral metabolism or interferes with neuronal excitability and/or
synaptic function.
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ETIOLOGIES AND
PATHOPHYSIOLOGY
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Hypoxic-ischemic brain injury most often results from insults such as cardiac arrest, vascular
catastrophe, poisoning (such as carbon monoxide intoxication or drug overdose), or head trauma
The induction of mild to moderate hypothermia (chill therapy) to a target temperature 32 to 34C in
the initial hours after cardiac arrest improves the neurologic outcome of resuscitated patients
Induced-hypothermia therapy impacts the prognostic utility of clinical examination findings and ancillary
testing
Validated protocols for assessing prognosis in the setting of therapeutic hypothermia are needed
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Pathophysiology
of increased ICP
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Intracranial pressure is normally 15 mmHg in adults, and pathologic intracranial hypertension (ICH) is present
at pressures 20 mmHg
Homeostatic mechanisms stabilize ICP, with occasional transient elevations associated with physiologic events,
including sneezing, coughing, or Valsalva maneuvers
ICP is normally lower in children than adults, and may be subatmospheric in newborns
CSF is produced by the choroid plexus and elsewhere in the central nervous system (CNS) at a rate of
approximately 20mL/h(500mL/day)
Problems with CSF regulation generally result from impaired outflow caused by ventricular obstruction or
venous congestion
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increased CBV
and hyperemia
hypoperfusion
and ischemia
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Closed head injury is one of the most frequent and best-studied indications for ICP monitoring
Indications for ICP monitoring in TBI (Traumatic brain injury) are a GCS score 8 and an abnormal
CT scan showing evidence of mass effect from lesions such as hematomas, contusions, or swelling
ICP monitoring in severe TBI patients with a normal CT scan may be indicated if two of the following
features are present: age >40 years; motor posturing; systolic BP <90 mmHg
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HISTORY
As an example, an initial hemiparesis suggests a structural lesion, likely with mass effect.
Transient visual symptoms, eg, diplopia or vertigo, suggest ischemia in the posterior circulation.
Did the patient have previous neurologic episodes that suggest transient ischemic attacks or
seizures?
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HISTORY
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GENERAL EXAMINATION
hypertensive encephalopathy,
hypovolemia,
cardiac failure,
certain drugs
Addison's disease.
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GENERAL EXAMINATION
infection;
heat stroke,
anticholinergic intoxication
Hypothermia could be
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Ventilatory pattern
Cheyne-Stokes respirations (a pattern of periodic waxing then waning hyperpnea, followed by brief
apnea) may occur with either impaired cardiac output or bicerebral dysfunction, and also in elderly
patients during sleep.
The shorter-cycle Cheyne-Stokes respiration linked to brainstem tegmental dysfunction may evolve
into irregular respirations with progression of downward herniation
Apneustic breathing (in which there is a prolonged inspiratory phase or end-inspiratory pause) is
rare and usually attributed to pontine tegmental lesions.
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NEUROLOGIC EXAMINATION
Level of consciousness
Motor responses
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Level of consciousness
Arousability is assessed by noise (eg, shouting in the ear) and somatosensory stimulation.
Pressing on the supraorbital nerve (medial aspect of the supraorbital ridge) or the angle of the jaw, or
squeezing the trapezius
Important responses include vocalization, eye opening, and limb movement
The GCS is useful as an index of the depth of impaired consciousness and for prognosis, but does
not aid in the diagnosis of coma.
The more recent FOUR score system has some advantages for intubated patients
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Motor examination
Flexion and extension movements usually represent reflex responses arising from subcortical
structures
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Decorticate posturing
upper-extremity adduction and flexion at the elbows, wrists, and fingers, together with
lower-extremity extension, which includes extension and adduction at the hip, extension at the knee, and
plantar flexion and inversion at the ankle
This occurs with dysfunction at the cerebral cortical level or below and may reflect a "release" of other
spinal pathways
Decerebrate posturing
Motor examination
upper-extremity extension, adduction, and pronation together with lower-extremity extension and
traditionally implies dysfunction below the red nucleus, allowing the vestibulospinal tract to predominate.
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Disruption of the pupillary light reflex in comatose patients usually occurs because of:
Downward herniation of mesial temporal structures from an expanding supratentorial mass and/or
a lateral shift in the supratentorial compartment with stretching of the oculomotor nerve against
the clivus or
Primary brainstem lesions
In transtentorial herniation, after initial dilation and loss of light reactivity, pupils become somewhat
reduced in size (4 to 5 mm) and remain unreactive; they are called midposition and fixed
In severe sedative drug overdose or in hypothermia, the pupils are midposition and fixed; this
syndrome can mimic brain death.
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Eye movements
Large cerebral lesions produce a persistent conjugate deviation of the eyes toward the side of the
lesion (contralateral to limb paralysis if present)
Lateral and downward eye deviation (usually with pupillary involvement) suggests oculomotor
involvement of the nerve or midbrain nuclei, while medial deviation suggests sixth nerve palsy
In the comatose patient, bilateral conjugate roving eye movements that appear full indicate an intact
brainstem and further reflex testing is not required. This is also a relatively favorable prognostic sign
when seen early after hypoxic ischemic insult
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Vestibuloocular reflexes
In the oculocephalic maneuver (or doll's eyes), the head is abruptly rotated from one side to the other in the
horizontal plane
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When the oculocephalic reflex is present (positive doll's eyes), the eyes do not turn with the head, but in
the opposite direction, as if the patient is maintaining visual fixation on a single point in space
At least 50 mL of ice water is injected into the ear canal using a syringe with a small catheter attached. This stimulus has
the same effect on the horizontal semicircular canal as sustained turning of the head in the opposite direction, and
results in sustained deviation of both eyes toward the ear being stimulated
Five minutes should elapse before testing the other side
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Corneal reflex
The corneal reflex's afferent limb arises from small unmyelinated pain fibers in the cornea, the fifth
or trigeminal nerve and nucleus, and activates the dorsal parts of both facial nuclei in the pons
The reflex can be suppressed acutely contralateral to a large, acute cerebral lesion, and also with
intrinsic brainstem lesions
Loss of the corneal reflex is also an index of the depth of metabolic or toxic coma
Absent corneal reflexes 24 hours after cardiac arrest is usually, but not invariably, an indication of
poor prognosis
Corneal reflexes may also be reduced or absent at baseline in elderly or diabetic patients
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Herniation syndromes
Transtentorial herniation can occur with expanding mass lesions (eg, intracerebral, subdural, or
epidural hemorrhage, large ischemic stroke, abscess, tumor, obstructive hydrocephalus)
Horizontal shifts of midline structures greater than 8 mm are associated with some impairment of
consciousness; patients with shifts of >11 mm are usually comatose
Two variants are recognized: a central herniation and an uncal herniation syndrome
Other signs of increased intracranial pressure (ICP), papilledema, and Cushing's triad
(hypertension, bradycardia, irregular respiration) may be observed in this setting.
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Brainstem lesions
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Metabolic coma
Exceptions occur; in particular, hypo- and hyperglycemia are frequently associated with lateralized motor
findings
Fluctuations in the examination are common.
Pupils may appear abnormal but almost always are symmetric and constrict with light.
Suppression of VORs and corneal reflex occur with very deep metabolic coma
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Brain death
Locked-in syndrome
The locked-in syndrome is a consequence of a focal injury to the base of the pons, usually by embolic occlusion of the
basilar artery
Consciousness is preserved; however, the patient cannot move muscles in the limbs, trunk, or face, except that
voluntary blinking and vertical eye movements remain intact
May sometimes be mimicked by a severe upper spinal cord lesion, a motor neuropathy, myopathy, neuromuscular
junction disease, or extreme muscular rigidity
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Represent a subgroup of patients who suffer severe anoxic brain injury and progress to a state of wakefulness
without awareness
A vegetative state may represent a transition between coma and recovery or between coma and death
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If a patient remains comatose, the usual outcome is to recovery, PVS, or death within two weeks
On the basis of available clinical data, PVS is judged to be permanent after three months if induced
nontraumatically
For traumatic brain injury, a year in this state is generally required to be considered permanent
The distinction between PVS and the minimally conscious state can be difficult
In patients who continue in PVS, life expectancy is approximately two to five years, and most patients die from
infection of the lungs or urinary tract, multiorgan system failure, sudden death of unknown cause, respiratory
failure, or underlying disease.
It is estimated that there are 10,000 to 25,000 adult patients in PVS in the United States, generating an
estimated annual cost of care of up to seven billion dollars.
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DIAGNOSIS
The goal of diagnostic testing in a patient in coma is to identify treatable conditions (infection,
metabolic abnormalities, seizures, intoxications/overdose, surgical lesions)
Early treatment in concert with the clinical evaluation
The presence of papilledema or focal neurologic deficits suggesting a structural etiology mandate
an urgent head computed tomography (CT) scan, particularly if the clinical presentation suggests
an acute stroke, expanding mass lesion, and/or herniation syndrome.
Fever suggesting bacterial meningitis or viral encephalitis mandates an urgent lumbar puncture.
Neuroimaging prior to lumbar puncture in a comatose patient is recommended
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DIAGNOSIS - Neuroimaging
subarachnoid hemorrhage (95 percent in early presentation), other intracranial hemorrhage (essentially
100 percent), acute hydrocephalus, tumors, marked cerebral edema, and large ischemic strokes
CT angiography particularly when brainstem stroke is suspected
MRI
herpes simplex encephalitis, early ischemic strokes (especially involving the brainstem), multiple small
hemorrhages or white matter tract disruption associated with traumatic diffuse axonal injury, anoxicischemic damage from cardiac arrest, and most disorders affecting the white matter
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Neuroimaging to exclude an intracranial mass lesion is required prior to lumbar puncture (LP) in
order to avoid precipitating transtentorial herniation
Coagulation test are needed
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DIAGNOSIS - Electroencephalography
In the comatose patient, EEG is used primarily to detect seizures or if the cause of coma remains
obscure after other testing
Diffusely disorganized, slowed background rhythms confirm an impression of toxic metabolic
encephalopathy, while strongly lateralized findings suggest structural disease
In some patients with coma, 8 to 12 Hz activity is seen; this resembles normal alpha rhythm, but
extends beyond the posterior cerebral regions and does not react to stimuli
This so-called "alpha coma" is associated with pontine lesions, and has also been described with hypoxic
ischemic encephalopathy following cardiac arrest, traumatic brain injury, and drug overdose
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ANCILLARY TESTING
SSEPs are the averaged electrical responses in the central nervous system to somatosensory
stimulation
SSEPs are the best validated and most reliable of the ancillary tests currently available for clinical
use.
Other evoked potentials (brainstem, auditory, visual, middle latency, and event-related) have not
been adequately evaluated
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ADVANCED NEUROMONITORING
Retrograde cannulation of the internal jugular vein that allows measurement of oxygen
saturation in the blood exiting the brain.
Normal jugular venous oxygen saturation (SjVO2) is about 60 percent.
SjVO2 <50 percent for 10 minutes is considered an "ischemic desaturation" and is associated
with impaired CPP and worsened outcome
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ADVANCED NEUROMONITORING
Intraparenchymal oxygen electrode placed in a manner similar to a fiberoptic ICP probe that
measures PbtO2 in the white matter.
Duration and depth of PbtO2 below 15 mmHg is associated with worsened outcome
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ADVANCED NEUROMONITORING
Cerebral microdialysis:
Intraparenchymal probe placed in a manner similar to a PbtO2 probe that allows measurement
of extracellular glucose, lactate, pyruvate, glutamate.
A lactate:pyruvate ratio >40 is suggestive of anaerobic metabolism, which is believed to
exacerbate secondary brain injury
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Prevention of hypoxia (PaO2 <60 mmHg) and hypotension (systolic BP <90 mmHg) are
priorities in the management of patients with severe TBI
Normal saline to maintain euvolemia (Grade 1B)
INITIAL MANAGEMENT
Patients with a GCS of 8 or less usually require endotracheal intubation to protect the airway
A set of arterial blood gases, along with the other blood and urine tests
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INITIAL MANAGEMENT
Treat hypotension (mean arterial BP of <70 mmHg) with volume expanders or vasopressors or
both.
With severe hypertension (mean arterial BP of >130 mmHg) repeated doses of intravenous
labetalol (5 to 20 mg boluses as needed) are often adequate for initial stabilization.
A 12-lead electrocardiogram should be done
It is recommended to give 25 g of dextrose (as 50 mL of a 50 percent dextrose solution) while
waiting for the blood tests, if the cause of coma is unknown
Thiamine, 100 mg, should be given with or preceding the glucose in any patient who may be
malnourished (to treat or to prevent precipitating acute Wernicke's encephalopathy). FONDUL SOCIAL
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
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Titlul proiectului: Dezvoltarea Competenelor n Transplant
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Naloxone (0.4 to 2.0 mg IV) and flumazenil treatment should be used only in the setting of known or
strongly suspected drug overdose
Gastric lavage and activated charcoal are also often recommended for suspected toxic or drug
ingestions
If a herniation syndrome is evident clinically or appears imminent based on computed tomography
(CT) findings, urgent treatment is recommended.
INITIAL MANAGEMENT
If the patient has had a seizure, treatment with phenytoin (15-20 mg/kg phenytoin equivalent IV)
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
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Empiric antibiotic and antiviral therapy are recommended if bacterial meningitis (eg, ceftriaxone 2 g
IV every 12 hours and vancomycin 2 g/day IV in four divided doses) or viral encephalitis (acyclovir
10 mg/kg IV every eight hours) are among the suspected entities
Instrumente Structurale
2007-2013
Since hypothermia has neuroprotective effects in patients with cardiac arrest, only extreme
hypothermia (<33C) should be treated
Therapeutic hypothermia treatment should be limited to patients with elevated ICP refractory to
other therapies
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
POSDRU/186/3.2/S/155295
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
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Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
ICP treatment
Most guidelines and clinical protocols recommend that treatment for elevated ICP should be
initiated when ICP rises above 20 mmHg
Ventricular drainage is generally attempted first. CSF should be removed at a rate of approximately
1 to 2mL/minute,for two to three minutes at a time, with intervals of two to three minutes in
between until a satisfactory ICP has been achieved (ICP <20 mmHg) or until CSF is no longer
easily obtained
Slow removal can also be accomplished by passive gravitational drainage through the
ventriculostomy
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
Osmotic therapy
Hyperventilation
In refractory cases:
barbiturate coma,
induced hypothermia,
decompressive craniectomy
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
Osmotic therapy
Hypertonic saline is being used increasingly in this setting, (3 to 23.4%) and either as a bolus or infusion
Hyperventilation
control of ventilation helps prevent increases in intrathoracic pressure that may elevate central venous
pressures and impair cerebral venous drainage
hyperventilation-induced vasoconstriction may cause
increase extracellular lactate and glutamate levels that may contribute to secondary brain injury
guidelines recommend avoiding hyperventilation, especially in the acute phase (the first 24 to 48 hours)
following TBI
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
MANAGEMENT
POSDRU/186/3.2/S/155295
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
Coagulopathy should be corrected to maintain an INR < 1.4 and a platelet count >75,000/mm3
NOT using glucocorticoids for the management of patients with severe TBI (Grade 1A)
Short-term (one week) use of antiepileptic drugs (phenytoin,valproate) for the prevention of early
seizures (Grade 1B)
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
Epidural hematoma
larger than 30 mL
urgent surgical evacuation is recommended for patients with acute EDH and coma (GCS score 8) who
have pupillary abnormalities (anisocoria)
Subdural hematoma
Acute subdural hematomas (SDH) >10 mm in thickness or associated with midline shift >5 mm on CT
If the GCS score is 8 or if the GCS score has decreased by 2 points from the time of injury
The patient presents with asymmetric or fixed and dilated pupils,and/orintracranial pressure
measurements are consistently >20 mmHg
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
Intracerebral hemorrhage
if the GCS score is 6 to 8 in a patient with a frontal or temporal hemorrhage greater than 20
cm3with midline shift of at least 5 mmand/orcisternal compression on CT scan
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
Penetrating injury
Decompressive craniectomy
POSDRU/186/3.2/S/155295
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AP: 3 Creterea adaptabilitii lucrtorilori a ntreprinderilor,
DMI: 3.2 Formare i sprijin pentru ntreprinderi i angajai pentru promovarea adaptabilitii.
Titlul proiectului: Dezvoltarea Competenelor n Transplant
POSDRU/186/3.2/S/155295
Beneficiar: Academia de Stiinte Medicale
REFERENCES
1.
2.
3.
4.
POSDRU/186/3.2/S/155295
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