Aspirin (Salicylate), Iron Pill, Kple Ʋusɔgbɔdɔ ƒe Atikewo Zazã Gã¶

Le ƒomea ƒe atikedzraɖoƒe, nuɖaze, alo tɔgbui kple mama ƒe zãdokeli ɖesiaɖe kloe me la, aƒemetike kple kpeɖeŋutɔ ƒe hatsotso atɔ̃ nɔa anyi afisi atikekui 1 va ɖo 5 pɛ ko mimi (alo tsi teaspoon ɖeka) ate ŋu awu ɖevi si le zɔzɔm ("Atikekui Ðeka Wuwuwo"), eye afisi ame tsitsi ƒe atikekui si gbɔ eme hea lãmenugbagbeviwo ƒe dɔwɔwɔ kple dzitodzito me ʋu ƒe sisi kabakaba, si sesẽna beléle si kpena ɖe ame ŋu vɛ le mate ŋu atrɔ ɖe megbe atikekui tɔxɛwo manɔmee o:

1. Salicylates (Aspirin, Pepto-Bismol / Bismuth Subsalicylate, kple Methyl Salicylate / Oil of Wintergreen): Si ɖea mitochondrial oxidative phosphorylation ɖa, si nana towo me ɖiɖina (tinnitus), yaƒoƒo si nu metsina o, dzoxɔxɔ si gbɔ eme, ahɔhɔ̃mekawo ƒe glycopenia, kple aklã alo ahɔhɔ̃ me ʋu ƒe sisi si wua ame.
2. Elemental Iron Supplements (Adult Ferrous Sulfate tablets and Prenatal Vitamins): Siwo ɖi tsokolet M&M alo Skittles siwo wotsɔ akpɔnɔ ƒoe nyuie na ɖevi suewo, siwo gblẽa dɔgboa ƒe ʋuka me kple ʋu ƒe dodo hafi gena ɖe "gaƒoƒo 6 va ɖo 24 ƒe "latent quiescent phase"** si blea ame me eye hepatorenal kpata kplɔe ɖo kpododonu kple dzitodzito ƒe ʋuʋu.
3. Tricyclic Antidepressants (TCAs: Amitriptyline, Nortriptyline, Doxepin, Imipramine): Menye blanuiléle koe woŋlɔna na ame zi geɖe o ke boŋ le agbɔsɔsɔ sue aɖe me hã hena taɖuame nutsitsi, fibromyalgia, ahɔhɔ̃mekawo ƒe vevesese, alɔ̃madɔmadɔ, kple ɖevimenɔɣi ƒe abadzivɔ, siwo xea mɔ na dzitodzito me sodium ƒe mɔ siwo zɔna kabakaba be wòahe alɔ̃madɔmadɔ, alɔ̃madɔmadɔ, . kple wide-QRS ventricular arrhythmias le miniti 60 va ɖo 120 me.
4. Calcium Channel Blockers (CCBs: Amlodipine, Nifedipine, Verapamil, Diltiazem): Siwo wɔa L-ƒomevi calcium mɔ siwo le dzi kple ʋukawo me la lãmetutudɔ esime woxea mɔ na dɔgboa ƒe insulin ƒe dodo, si hea ʋuka keke kple dzitodzito ƒe dzidziɖedzi goglo si kpe ɖe suklidɔ si dze ƒã ŋu vɛ.
5. Beta-Blockers (BBs: Propranolol, Metoprolol, Atenolol, Carvedilol, Sotalol): Nusiwo hea dzitodzito me ʋu ƒe sisi sesẽ (dzi ƒe tsotso blewu), ʋusɔgbɔdɔ, ʋuka me ʋu ƒe sisi, kple suklidɔ ƒe ɖiɖi (tsɔ kpe ɖe sodium-mɔ̃ ƒe alɔ̃madɔmadɔ kple QRS ƒe kekeme kple propranolol, alo Torsades de Pointes kple sotalol ŋu).

Aɖiŋutinunya ƒe mɔfiamegbalẽ sia si me kɔ kpata la naa aɖiŋutinunya ƒe afɔɖeɖe siwo woawɔ enumake, aɖi ƒe dzidzenu siwo sɔ pɛpɛpɛ miligram ɖeka le kilogram ɖeka me, dɔdamɔnu ƒe ɖoɖo, kple ICU ƒe atikewɔmɔnu siwo ŋu kakaɖedzi le (IV Sodium Bicarbonate urinary alkalinization, Deferoxamine chelation, High-Dose Insulin Euglycemic Therapy [HIET], Intravenous Lipid Emulsion [Intralipid], kple Glucagon) wɔ ɖeka kple Amerikatɔwo ƒe Aɖinuwo Dzikpɔƒewo ƒe Habɔbɔ (AAPCC), Amerikatɔwo ƒe Atikewɔwɔ me Aɖiŋutinunyalawo ƒe Kɔledzi (ACMT), EXTRIP Dɔwɔha, kple Eŋlisiawo ƒe Dukɔa ƒe Aɖiwo Ŋuti Nyatakaka Dɔwɔƒe (NPIS).

Wɔ esia fifia¶

Ne ɖevi alo ame tsitsi aɖe mi aspirin, wintergreen oil, iron-tike, ʋu ƒe sisi ƒe atikekuiwo (beta-blockers alo calcium channel blockers), alo tricyclic antidepressants ƒe agbɔsɔsɔ si gbɔ eme:

1. Ƒo ka na 911 / 112 / 999 enumake ne ɖevi ɖesiaɖe ɖu dzomeŋɔli ƒe ami, ʋusɔgbɔdɔ ƒe atikekui, tricyclics, alo iron, alo ne dɔnɔ aɖe ƒe dzesiwo le eŋu: Zã míaƒe... xexlẽdzesi siwo wozãna kpata nyatakakadzraɖoƒe. Ne èdi ame tsitsi alo ɖevi si me dzesi aɖeke mele o si me wòhiã be nàbu miligram ɖeka ƒe kilogram ɖeka ƒe vovototodedeameme enumake la, ƒo ka na Aɖidzikpɔkpɔ (1-800-222-1222 le United States; NHS 111 / 999 le UK; 13 11 26 le Australia) esime nèle dzadzram ɖo be yeayi dɔwɔƒe si kpɔa nudzɔdzɔ kpatawo gbɔ.
2. Klɔ ɖevia ƒe nu me hena atikekui siwo womemi o eye nàƒo aŋetu ɖesiaɖe kple aŋekotoku ɖesiaɖe nu ƒu: Ne ɖevi si le zɔzɔm tsɔ atikekuiwo de nu me ko la, zã asibidɛ tutu tsɔ ɖe atikekui siwo me gblẽ o ɖesiaɖe ɖa le ŋgonu, xlẽ atikekui susɔe siwo le aŋetu la me, eye nàtsɔ nugoeawo tututu ava kɔdzi.
3. Mègana aɖuɖɔɖɔɖɔ le aƒeme GBEÐE o eye MÈGANA baking soda alo notsi GBEÐE Aɖidzikpɔkpɔ ƒe mɔfiame manɔmee o: Dɔnɔ si mi tricyclic antidepressants, propranolol, alo calcium channel blockers ƒe ʋuʋudedi wɔwɔ nye afɔku gã aɖe elabena kasia dɔnɔa ate ŋu abu alo axɔe le miniti 30 me, agbɔ ʋuʋudedi ɖe woƒe lãkusi me.
4. Se "Activated Charcoal Does NOT Bind Iron" ƒe sea gɔme: Togbɔ be kɔdzi activated charcoal blaa aspirin, tricyclic antidepressants, beta-blockers, kple calcium channel blockers (eye ele be woanae le gaƒoƒo 1 va ɖo 2 me, alo le agbɔsɔsɔ si wogbugbɔna me na enteric-coated aspirin), Activated charcoal MEbla elemental iron o. Iron tablets siwo me keklẽŋusẽ mele o siwo tsi dɔgboa me hiã kɔdzi Agbo Blibo Tsidede (WBI) kple polyethylene glycol electrolyte solution (GoLYTELY) kple Deferoxamine dodo ɖe ʋuka me.
5. Di Extended-Release ("XL", "XR", "SR", "CD", "LA") alo Enteric-Coated ("EC") ƒe nuŋɔŋlɔwo le aŋetu la dzi: extended-release verapamil, diltiazem, nifedipine, metoprolol, alo enteric-coated aspirin ƒe agbɔsɔsɔ si gbɔ eme ate ŋu akpɔ dzesi zero le 6 va ɖo 18 gbãtɔwo me gaƒoƒo hafi wòaɖe atike ƒe agbɔsɔsɔ si wua ame ɖe ʋukawo me zi ɖeka. Calcium channel blocker alo beta-blocker nono ɖesiaɖe si woɖena ɖe go ɣeyiɣi didi la bia woakpɔ dzitodzito dzi atraɖii le kɔdzi vaseɖe gaƒoƒo 24, ne dɔnɔa ƒe dzedzeme le nyuie keŋkeŋ le gaƒoƒo 4 lia me gɔ̃ hã.
6. Xlɔ̃ nu Dɔnɔdzikpɔlawo kple ER Ðɔktawo tso "Salicylate Intubation Trap" ŋu: Ne dɔnɔ si ŋu aspirin (salicylate) aɖi sesẽ le gbɔgbɔm kabakaba eye wòle gbɔgbɔm sesĩe (gbɔgbɔ 30 va ɖo 40 le miniti ɖeka me), be yaƒoƒo fũu akpa le wo lém ɖe agbe to carbon dioxide (\(\text{CO}_2\)) ƒoƒo me be woƒe ʋu ƒe pH nagaɖiɖi o. Ne wodo atike na dɔnɔa eye wòzu lãmetututɔ hena endotracheal intubation eye wotsɔe da ɖe yagbɔgbɔmɔ̃ si sɔ blewu dzi la, gbɔgbɔtsixetsixe ƒe ɖiɖiɖeme kpuie kpata nana ʋu \(\text{pH}\) ɖiɖina ŋutɔ, si wɔnɛ be salicylic acid si wɔ ɖeka la toa ʋu kple ahɔhɔ̃ ƒe mɔxenu la dzi tẽ eye wòhea dzi ƒe ʋuʋu enumake le aɖabaƒoƒo 2 va ɖo 5 me tso esime wodoe.

Emergency triage kple antidote flowchart na aƒeme atikekui siwo me afɔku le ŋutɔ¶

flowchart TD
    Start["Wosusu be Aƒeme Atikekuiwo Zazã Gã<br/>(Aspirin, Iron, Tricyclic Antidepressant, Beta-Blocker, alo Calcium Channel Blocker)"] --> Call["Ƒo ka na 911 / 112 / 999 alo Aɖidzikpɔkpɔ (1-800-222-1222)<br/>Kpɔ Aŋetu la ɖa be Ŋusẽ (mg) + Extended-Release (XR/XL/SR/EC) ƒe Nɔnɔme hã"]

    Call --> ClassCheck{"Atike ƒe hatsotso kae woɖu?"}

    ClassCheck -->|Salicylates: Aspirin, Enteric-Coated Aspirin,<br/>Pepto-Bismol, or Oil of Wintergreen| SalRule["SALICYLATE PROTOCOL (Tomeʋuʋu + Yaƒoƒo fũu akpa + Asrã)<br/>1. Multi-Dose Activated Charcoal (blaa aspirin concrements/bezoars)<br/>2. IV Sodium Bicarbonate (NaHCO3) be Ʋu ƒe pH nanɔ 7.45-7.55 & Aɖuɖɔ ƒe pH 7.5-8.0<br/>+ aggressive IV Potassium (K+ > 4.0) ale be ayiku nateŋu aɖe salicylate<br/>3 ɖa. ƑO ASA NA INUBATION ne anya wɔ; Ʋumenugbagbeviɣidɔ kpata ne >100 mg/dL alo ahɔhɔ̃meka/aklã ƒe dzesiwo"]

    ClassCheck -->|Elemental Iron: Adult Ferrous Sulfate/Gluconate/Fumarate<br/>or Prenatal Vitamins (Calculate Elemental Iron mg/kg)| IronRule["IRON PROTOCOL (Activated Charcoal MEXƆA Gayibɔ O)<br/>1. Ƒodo ƒe X-Ray (KUB) be woakpɔ gayibɔtike siwo me keklẽŋusẽ mele o le dɔgboa me<br/>2. Tsidede Dɔgbo Blibo (PEG-ELS / GoLYTELY) ne atikekui siwo me keklẽŋusẽ mele o le wo me<br/>3. Kpa Gaƒoƒo 4 va ɖo 6 ƒe Serum Iron Level + Ʋu me Gas/Lactate<br/>4. IV Deferoxamine Chelation ne Serum Iron > 500 mcg/dL, Ʋuʋudedi, alo Acidosis"]

    ClassCheck -->|Tricyclic Antidepressants (TCAs): Amitriptyline,<br/>Nortriptyline, Doxepin, Imipramine| TCARule["TRICYCLIC ANTIDEPRESSANT (TCA) PROTOCOL (Na+ Mɔxexe ƒe Mɔxexe Kabakaba)<br/>1. 12-Lead ECG enumake: Kpɔe ɖa be QRS > 100 ms alo Terminal R wave le aVR me > 3 mm<br/>2 hã. IV Sodium Bicarbonate Bolus (1-2 mEq/kg) vaseɖe esime QRS natsi < 100 ms & pH 7.50-7.55<br/>3. Benzodiazepines (MELE Phenytoin GBEÐE o) KO Da Alɔ̃madɔmadɔ; IV Lipid Emulsion nenye be mexɔa dzo o"]

    ClassCheck -->|Calcium Channel Blockers (CCBs: Verapamil, Diltiazem, Amlodipine)<br/>OR Beta-Blockers (BBs: Propranolol, Metoprolol, Sotalol)| CCBBBRule["CARDIOVASCULAR BLOCKADE PROTOCOL (Gaƒoƒo 24 ƒe ŋkuléle ɖe XR/SR Atikekuiwo ŋu)<br/>Kpɔ Ʋu me Suklidɔ: CCB ƒe agbɔsɔsɔme si gbɔ eme = HYPERGLYCEMIA vs BB ƒe agbɔsɔsɔme si gbɔ eme = HYPOGLYCEMIA<br/>1. IV Calcium Chloride/Gluconate + IV Glucagon (5-10 mg bolus, toa beta xɔla ŋu)<br/>2. Vasopressors (Norepinephrine / Epinephrine) na MAP > 65 mmHg<br/>3. Insulin ƒe Agbɔsɔsɔme Gã ƒe Euglycemic Dɔdamɔnu (HIET: Insulin + Dextrose si Wozãna Edziedzi Unit 1 va ɖo 10/kg/hr)<br/>4. VA-ECMO alo IV Lipid Emulsion (Intralipid) na dzitodzito ƒe ʋuʋu si mexɔa dzo o"]

Aƒeme Atikekui 5 Siwo Wòwuna Geɖe Siwo Wozãna Gbɔgbɔmenuwo Tsɔtsɔ Sɔ Kple Wo Nɔewo Bibi¶

Deep Dive 1: Salicylate (Aspirin & Wintergreen Ami) ƒe Aɖi¶

1. Salicylate Toxidrome (Esi nu sẽ kple esi nɔa anyi didi) ƒe dzesidede .¶

Salicylate ƒe aɖi dzɔna le ameha vovovo eve me: (a) Agbɔsɔsɔ si gbɔ eme kpata le ƒewuiviwo, sɔhɛ tsitsiwo, alo ɖevi siwo le zɔzɔm siwo mia aspirin, Excedrin, alo Oil of Wintergreen ƒe aŋetu ɖeka me, kple (b) aɖi si nɔa anyi didi ("atikewɔwɔ") salicylate ƒe aɖi le ame tsitsi siwo noa aspirin alo bismuth subsalicylate ƒe agbɔsɔsɔ gã gbesiagbe me (Pepto-Bismol) na ƒunukpeƒetetedɔ alo aɖuɖɔtoedɔ le ŋkeke alo kwasiɖa geɖe me esime woƒe ayiku ƒe dɔwɔwɔ dzi ɖena kpɔtɔna le mɔ si menya kpɔna dzea sii bɔbɔe o nu. Salicylism si nɔa anyi didi tsɔa ku sɔa gbɔ wu atike si wozãna wògbɔa eme kpata elabena zi geɖe la, wobua eŋu vodadatɔe be enye sepsis, aklãdɔ, suklidɔ ƒe ketoacidosis, alo ʋusɔgbɔdɔ/tagbɔdɔ.

• Tome ƒe Nuxlɔ̃ame Dzesi Gbãtɔ: Tomeʋuʋu (Tosese ƒe ɖiɖi alo Tosese si me womeɖea nu le o): Salicylates kpɔa ŋusẽ ɖe tomeʋuʋu ƒe lãmenugbagbeviwo kple spiral ganglion neurons dzi le mɔ si trɔna nu. Ne serum salicylate ƒe agbɔsɔsɔ wu 20 va ɖo 30 mg/dL la, dɔnɔwo kpɔa to me ɖiɖi sesĩe (to ƒe ɖiɖi) alo toa nyatoƒoe be gbewo ɖina sesĩe, si kpe ɖe eŋu kple ʋuʋudedi, ʋuʋudedi, kple ʋuʋudedi (fifia).
• Asibidɛ ƒe dzesi si nye Acid-Base si nye Signature:
• Gbã la, salicylate doa ŋusẽ medullary respiratory center le ahɔhɔ̃meka me tẽ, si wɔnɛ be dɔnɔa gbɔa ya sesĩe eye wògbɔa ya kabakaba (hyperpnea kple tachypnea), si ƒoa \(\text{CO}_2\) eye wònaa Primary Respiratory Alkalosis (ʋu ƒe pH dzina ɖe edzi kaba).
• Evelia, salicylate ɖea mitochondrial oxidative phosphorylation ɖa le lãmenugbagbevi ɖesiaɖe me le ŋutilãa me (abe dinitrophenol ene): lãmenugbagbeviwo ɖua oxygen dzikutɔe, wowɔa ŋutilã ƒe dzoxɔxɔ gã aɖe (hyperthermia) ɖe ATP teƒe, eye wòƒoa lactic acid, ketoacids, kple salicylic acid ŋutɔ nu ƒu, si wɔa ɖeka le ɣeyiɣi ɖeka me Acidosis si nye Anion-Gap Gãtɔ Gbãtɔ.

2. Nusita Aɖuɖɔtoe me Alkalinization (IV Sodium Bicarbonate) kple Potassium Xɔname Dɔ ("Ion Trapping") .¶

Salicylic acid nye acid si gbɔdzɔ (\(\text{pK}_a = 3.0\)). molekyul si me dzoxɔxɔ mele o (si me ion mele o) (\(\text{HA}\))** koe ate ŋu atso lãmenugbagbevi siwo me ami le ƒe lãkusiwo me age ɖe ahɔhɔ̃a me alo agbugbɔe axɔ ɖe ʋua me tso ayiku ƒe ʋukawo me, gake salicylate ion si me dzoxɔxɔ le (si me ion le) (\(\text{A}^-\)) ya xaxa ɖe lãmenugbagbeviwo godo:

• Nusitae ʋu ƒe pH si le ɖiɖim wua dɔnɔa: Ne dɔnɔa ƒe ʋu \(\text{pH}\) ɖiɖi tso 7.45 yi anyime va ɖo 7.20 (acidemia), dadasɔa trɔna vevie yia miame (\(\text{HA}\)), si wɔnɛ be salicylic acid si me dzo mele o la dona le ʋua me tẽ to ʋu kple ahɔhɔ̃ ƒe mɔxenu la me yia ahɔhɔ̃mekawo me, si hea ahɔhɔ̃ ƒe ʋuʋu, alɔ̃madɔmadɔ, alɔ̃madɔmadɔ, kple ku vɛ.
• Alesi IV Sodium Bicarbonate (\(\text{NaHCO}_3\)) léa salicylate ɖe ʋu kple aɖuɖɔ me:
• Atikewɔla siwo kpɔa nudzɔdzɔ kpatawo gbɔ naa bolus si nye 1 va ɖo 2 mEq/kg IV Sodium Bicarbonate, eye wodoa wo ɖa atraɖii (Ampule 3 [150 mEq] si nye 8.4% Sodium Bicarbonate si wotsaka le D5W Lita 1 me si wodo ɖe lãme na ame le beléle na tsi ƒe agbɔsɔsɔme ƒe teƒe 1.5 va ɖo 2).
• ʋuka me ʋu ƒe pH dzi ɖeɖe kpɔtɔ va ɖo 7.45 va ɖo 7.55 hea salicylate do goe le ahɔhɔ̃a me trɔna yia ʋukawo me.
• aɖuɖɔ ƒe pH dzi ɖeɖe kpɔtɔ va ɖo 7.5 va ɖo 8.0 naa salicylate si le ayiku ƒe ʋukawo me la wɔa ion ale be womate ŋu agbugbɔe axɔ o, edzia aspirin ƒe dodo ɖe ayiku me ɖe edzi zi gbɔ zi 10 va ɖo 20.
• Potassium (\(K^+\)) ƒe Se: Màte ŋu ate ŋu awɔ alkali na aɖuɖɔ ne dɔnɔa ƒe ʋu me potassium mesɔ gbɔ o (\(\text{K}^+ < 4.0\text{ mEq/L}\)). Ne serum potassium mesɔ gbɔ o la, ayiku ƒe didiƒe ʋĩ ƒe ʋukawo léna ɖe potassium ions (\(K^+\)) ŋu to hydrogen ions (\(H^+\)) tsɔtsɔ ƒu gbe ɖe aɖuɖɔa me (paradoxical aciduria), si wɔnɛ be aɖuɖɔa nɔa acid me eɖanye bicarbonate agbɔsɔsɔme ka kee nède eme o. Eyata ɖɔktawo tsɔa dziku tsɔa Potassium Chloride** **40 va ɖo 60 mEq/L dea tsi siwo wodona ɖe ʋu me la me be serum \(\text{K}^+\) nanɔ 4.0 kple 5.0 mEq/L dome.
• Ahɔhɔ̃ ƒe Dɔwuame Ɣaɣla ɖɔɖɔɖo ("CNS Neuroglycopenia"): Esi wònye be salicylates naa ahɔhɔ̃ me glycolysis kabakaba esime wògblẽa sukli ƒe tsɔtsɔ to ʋu kple ahɔhɔ̃ ƒe mɔxenu dzi ta la, dɔnɔ si ŋu salicylate ƒe aɖi le ate ŋu akpɔ ahɔhɔ̃ me sukli ƒe agbɔsɔsɔ si ɖiɖi ŋutɔ ne woƒe asibidɛ ƒe ʋumesukli xlẽ 90 alo 100 si sɔ keŋkeŋ gɔ̃ hã mg/dL ƒe xexlẽme. Dɔnɔ ɖesiaɖe si ŋu aɖi si nye salicylate le si tɔtɔ, eƒe tagbɔ gblẽ, kuviawɔwɔ, alo alɔ̃madɔmadɔ la xɔa IV Dextrose bolus (D50W alo D10W) enumake eɖanye asibidɛ ƒe ʋumesukli ka kee le wo ŋu o.

3. Ne Ele Be Woaɖe Ʋumenugbagbeviɣidɔ Kpata¶

Esi wònye be aspirin ƒe mama sue aɖe koe ta la, hemodialysis si wowɔna ɣeaɖewoɣi ɖea salicylate ɖa kabakaba le ʋua me esime wòle acidosis kple tsi ƒe agbɔsɔsɔ fũ ɖɔm ɖo. Le EXTRIP mɔfiamewo nu la, woɖee fia be woawɔ ʋumenugbagbeviɣidɔ kpata enumake na:

1. Susu ƒe nɔnɔme si trɔ (tɔtɔ, tagbɔdɔ, alɔ̃madɔmadɔ, alɔ̃madɔmadɔ, alo alɔ̃madɔmadɔ), ALOO
2. Acute Respiratory Distress Syndrome (ARDS) / Non-cardiogenic pulmonary edema si hiã oxygen kpeɖeŋutɔ, OR
3. Ayiku ƒe abixɔxɔ sesẽ alo esi nɔa anyi didi (si xea mɔ na aɖuɖɔtoe me alkalinization be wòagawɔ dɔ o), ALOO
4. Serum Salicylate ƒe agbɔsɔsɔ \(> 100\text{ mg/dL}\) (\(> 7.2\text{ mmol/L}\)) le agbɔsɔsɔ si gbɔ eme kpata (alo \(> 90\text{ mg/dL}\) si me ayiku ƒe dɔwɔwɔ gblẽ), alo \(> 60\text{ mg/dL}\) le salicylism si nɔa anyi didi me, alo agbɔsɔsɔ si le dzi yim togbɔ be wozãe zi geɖe hã dzoka xɔxɔ si wotsɔ wɔa dɔe kple IV bicarbonate.

Deep Dive 2: Iron Supplement ƒe agbɔsɔsɔme si gbɔ eme kple Dɔdaƒe ƒe Akpa 5¶

1. Akɔntabubu le Elemental Iron Dose ŋu le Dze Ƒomevi nu¶

Ne ɖɔktawo le ka ƒom na Poison Control alo va ɖo dɔwɔƒe si kpɔa nudzɔdzɔ kpatawo gbɔ le iron-tike nono vɔ megbe la, wobua aɖi si le eme ɖe ELEMENTAL IRON miligram ɖeka dzi le ŋutilã ƒe kpekpeme kilogram ɖeka me, ke menye iron salt tablet ƒe kpekpeme miligram bliboa dzi o:

2. Aɖi Siwo Le Gayibɔ Ŋu ƒe Dɔdaƒe ƒe Akpa 5 (Kpɔ nyuie Afɔɖeɖe 2 lia) .¶

1. Afɔɖeɖe 1: Dɔgbo ƒe Akpa si gblẽa nu le ame ŋu (Gaƒoƒo 0.5 va ɖo 6 le eɖuɖu vɔ megbe):
2. Direct corrosive necrosis of the stomach and duodenal mucosa hea ƒodo me vevesese kpata, sesẽ, ʋuʋudedi enuenu (zi geɖe la, ʋu dzĩ si le keklẽm alo "kɔfi-tu" dodo viviti nɔa eme), kple aɖuɖɔtoe si me ʋu alo tarry yibɔ le.
3. Se Vevietɔ si Wotsɔ Ðoa Amewo Dome: Ne ɖevi alo ame tsitsi aɖe xɔ aɖuɖɔtoe zero, aɖuɖɔtoetetedɔ, kple ƒodo me vevesese zero hena gaƒoƒo 6 blibo le esi wosusu be iron nono vɔ megbe la, woate ŋu agbe iron ƒe aɖi si ɖe dzesi le ɖoɖo nu la nyuie.
4. Afɔɖeɖe 2: Ameflunya si ɣla / si me ɖoɖoezizi le (Gaƒoƒo 6 va ɖo 24 le eɖuɖu vɔ megbe):
5. Aɖuɖɔɖɔɖɔ nu tsona eye ɖevia dzena abe ɖe wòfa tu alo le alɔ̃ dɔm ene, si wɔnɛ be ƒomewo (kple atikewɔla siwo si nuteƒekpɔkpɔ mele o) susuna be ɖevia le hayahayam. Le nyateƒe me la, wole iron si le ablɔɖe me xɔm tso dɔgboa me yi ʋukawo me, si wu transferrin ƒe kadodo ŋutete eye wòle tsi ƒom ɖe ʋuka me lãmenugbagbeviwo, dzitodzito me lãmenugbagbeviwo, kple aklã ƒe periportal (Zone 1) hepatocytes me.
6. Afɔɖeɖe 3: Systemic Shock kple Metabolic Acidosis ƒe Akpa (Gaƒoƒo 12 va ɖo 48 le Eɖuɖu vɔ megbe):
7. Lãmetsi ƒe dometsotso gã etɔ̃lia, ʋukawo ƒe kekeɖenudɔwɔwɔ tẽ, dzitodzito ƒe blanuiléle, kple gayibɔ-ʋuʋu ƒe tɔtrɔ le ferrous (\(\text{Fe}^{2+}\)) me wòzu ferric (\(\text{Fe}^{3+}\)) ions kple protons (\(H^+\)) ƒe dodo kple mitochondrial uncoupling hea hypovolemic/distributive/cardiogenic goglo vɛ dzidziƒoame, lactic acidosis si me anion ƒe dometsotso geɖe le vevie, ʋumenugbagbeviɣidɔ, kuviawɔwɔ, kple alɔ̃madɔmadɔ.
8. Afɔɖeɖe 4: Aklã me aɖi / Fulminant Liver Failure Phase (Ŋkeke 2 va ɖo 5 le eɖuɖu vɔ megbe):
9. Free radical lipid peroxidation le Aklã ƒe Anyigbamama 1 (periportal hepatocytes, aklãmenugbagbevi gbãtɔ siwo ʋu si me iron le si le ʋuka me ʋu si tso dɔgboa me ƒo) hea aklã ƒe kuku sesẽ, jaundice, transaminases ƒe dzidziɖedzi, suklidɔ ƒe ɖiɖi, kple ʋu ƒe dodo vɛ.
10. Afɔɖeɖe 5: Gastric Outlet Exstruction / Stricture Phase (Kwasiɖa 2 va ɖo 6 le eɖuɖu vɔ megbe):
11. Esi dzobibi goglo siwo gblẽa nu le dɔgboa me la le hayahayam to fibrosis kple abidede me la, dɔnɔwo ate ŋu axɔ pyloric stenosis / gastric outlet obstruction kwasiɖa aɖewo le agbetsitsi le atike si wozãna fũu akpa me vɔ megbe, eye woaɖee afia kple projectile non-bilious vomiting le nuɖuɖu vɔ megbe.

3. Kɔdzi ƒe Ðiƒoƒo (KUB X-Ray + Tsidede Dɔgbo Bliboe) kple Deferoxamine Chelation¶

• Ƒodo ƒe X-Ray (KUB): Ame tsitsiwo ƒe gayibɔti sesẽwo nyea radiopaque vevie (woklẽna ɣie nyuie le ƒodo ƒe X-ray gbadzaa dzi hafi wolɔna). Ne atikekui siwo me gblẽ o alo iron pharmacobezoar (atikekui siwo tsi ƒe ƒuƒoƒo) dze le X-ray la dzi la, ɖɔktawo dzea Agbo Blibo Tsidede (WBI) gɔme to Polyethylene Glycol Electrolyte Lavage Solution (PEG-ELS / GoLYTELY) sisi to nasogastric tube me le 500 mL/hr le ɖevi suewo me alo 1,500 to 2,000 mL/hr le ame tsitsiwo me vaseɖe esime tsi si dona le dɔgboa me la me kɔ abe kristalo ene eye X-ray si wogbugbɔ wɔ la, atikekui aɖeke megali o.
• Peak Serum Iron Level (Woɖenɛ le Gaƒoƒo 4 va ɖo 6 le eɖuɖu vɔ megbe):
• < 300 mcg/dL: Aɖi si sɔ / suetɔ kekeake.
• 300 to 500 mcg/dL: Aɖi si sɔ gbɔ (ehiã be woagbɔ agbe tsi si wodona to ʋuka me eye woalé ŋku ɖe eŋu nyuie).
• ** ** .> 500 mcg/dL**: Aɖi sesẽ si le ɖoɖo nu si hiã be woawɔ Deferoxamine Chelation si wodona ɖe ʋuka me enumake.
• IV Deferoxamine Protocol: Deferoxamine blaa ferric iron si le ablɔɖe me (\(\text{Fe}^{3+}\)) le ʋua me tsɔ wɔa ferrioxamine si me tsi le, si ayikuwo ɖena doa goe eye wòtrɔa dɔnɔa ƒe aɖuɖɔ wòzua amadede tɔxɛ "vin rosé" (pinkish-orange / salmon-red). Wodonɛ ɖe ʋuka me le 15 mg/kg/gaƒoƒo (wole ŋku lém ɖe ʋusɔgbɔdɔ si do ƒome kple ʋusɔgbɔdɔ alo aɖi si le aklã me ŋu nyuie ne wodoe wu gaƒoƒo 24).

Deep Dive 3: Tricyclic Antidepressant (TCA) ƒe agbɔsɔsɔ si gbɔ eme (Millisecond 100 ƒe QRS Se) .¶

Amitriptyline, nortriptyline, doxepin, imipramine, clomipramine, kple desipramine gakpɔtɔ le afisiafi na lãmekawo ƒe vevesese atraɖii, taɖuame nutsitsi, alɔ̃madɔmadɔ, kple ʋuʋudedi si nɔa tsatsam. Le atike si wozãna wògbɔa eme me la, dɔnɔ ate ŋu atso nuƒoƒo ɖekae le dɔnɔdzikpɔʋu me ayi generalized tonic-clonic seizures, coma, kple cardiac arrest le ɣeyiɣi si mede miniti 30 o.

1. 12-Lead ECG Nye Dɔwɔnu Gbãtɔ Si Wotsɔ Dia Dɔlélewo:
2. Esi wònye be TCA ƒe agbɔsɔsɔ le ʋu me xɔa ŋkeke geɖe hafi wogatrɔna tso nudokpɔƒewo ta la, atikewɔla siwo kpɔa nudzɔdzɔ kpatawo gbɔ kpɔa TCA ƒe aɖi gbɔ tẽ tso 12-lead ECG dzi:
   • Sinus tachycardia (tso anticholinergic muscarinic blockade me).
   • Nuwuƒe ƒe tɔtrɔ yi ɖusime milisekɔnd 40 le ŋgɔgbe yameʋu QRS axis: Wokpɔe enumake le ECG dzi abe nuwuƒe R ƒutsotsoe si dzena \(> 3\text{ mm}\) le lead aVR me (kple \(\text{R/S ratio} > 0.7\) le lead aVR me) kpe ɖe nuwuƒe S ƒutsotsoe si goglo le lead I kple aVL me ŋu.
   • QRS Ɣeyiɣi Didi Kekeɖenudɔwɔwɔ:
   • \(\text{QRS} < 100\text{ ms}\): Afɔku sue aɖe ko le alɔ̃madɔmadɔ alo ventricular arrhythmies me.
   • \(\text{QRS} \ge 100\text{ ms}\): Afɔku 33 le alafa me le alɔ̃madɔmadɔ si bɔ me (Efia be woadze IV Sodium Bicarbonate gɔme enumake).
   • \(\text{QRS} \ge 160\text{ ms}\): Afɔku 50 le alafa me le dzitodzito me ʋu ƒe sisi alo ʋuka ƒe ʋuʋu si ate ŋu ade ame ƒe agbe afɔku me.
3. Atike Si Wozãna Enumake: Sodium Bicarbonate (\(\text{NaHCO}_3\)) Boluses si wodona ɖe ʋuka me:
4. Ɣesiaɣi si QRS ƒe ɣeyiɣi didime ɖo alo wu milisekɔnd 100, alo ne dɔnɔa ƒe ʋusɔgbɔdɔ alo ventricular arrhythmia dze edzi la, ɖɔktawo naa 8.4% Sodium Bicarbonate (1 va ɖo 2 mEq/kg le bolus ɖeka me) ƒe IV tutu kabakaba le miniti 3 va ɖo 5 ɖesiaɖe me vaseɖe esime QRS la naɖiɖi va anyi wu 100 ms kple ʋu \(\text{pH}\) ɖoa 7.50 va ɖo 7.55.
5. Alesi wòwɔa dɔe: Lãmenugbagbeviwo godo ƒe sodium ions (\(\text{Na}^+\)) (si ɖua hoʋiʋli ƒe mɔxexe ɖe dzitodzito me sodium mɔ siwo zɔna kabakaba dzi) kple alkaline serum pH (si dzia protein ƒe kadodo ɖe edzi eye wòɖea TCA ƒe akpa si nye ionized si bla ɖe mɔ̃a ƒe xɔla ŋu dzi kpɔtɔna) siaa gbugbɔa dzi ƒe ʋuʋu si sɔ la ɖoa anyi le miniti ʋɛ aɖewo ko me.
6. Nu Vevi Siwo Tsi Tre Ðe TCA ƒe Agbɔsɔsɔ Gã Me:
7. MÈGANA Physostigmine GBEÐE na anticholinergic delirium le TCA ƒe agbɔsɔsɔ si gbɔ eme me (ehea bradycardic/asystolic cardiac arrest si wua ame vɛ).
8. MÈGANA Class IA (procainamide), Class IC (flecainide), alo Class III (amiodarone) antiarrhythmics GBEÐE (wogblẽa sodium channel blockade alo QT didi ɖe edzi; zã IV Sodium Bicarbonate gbã, kple IV Lidocaine [Class IB] alo 20% Intravenous Lipid Emulsion [Intralipid] ne refractory).
9. MÈGANA Phenytoin na alɔ̃madɔmadɔ siwo TCA hena vɛ GBEÐE o (phenytoin hã nye sodium-channel blocker; tsɔ IV Benzodiazepines [lorazepam, diazepam, alo midazolam] kpe ɖe IV Sodium Bicarbonate ŋu da TCA ƒe alɔ̃dɔdɔ vevie).

Deep Dive 4: Calcium Channel Blocker (CCB) kple Beta-Blocker (BB) ƒe agbɔsɔsɔme si gbɔ eme¶

1. Alesi Ʋumesukli Dea Vovototo CCB kple Beta-Blocker ƒe agbɔsɔsɔ si gbɔ eme dome Enumake¶

Ne dɔnɔ si mewɔa nu ɖe eŋu o va kple bradycardia si goglo (dzi ƒe tsotso 30 va ɖo 40 bpm) kple ʋusɔgbɔdɔ sesẽ (ʋu ƒe sisi 60/30 mmHg) la, abadzivɔ ƒe asibidɛ ƒe ʋumesukli ƒe dodokpɔ naa wokpɔa dzesi enumake:

• Calcium Channel Blocker (CCB) ƒe agbɔsɔsɔ fũ hea HYPERGLYCEMIA: Esi wònye be dɔgboa ƒe beta lãmenugbagbeviwo hiã L-ƒomevi calcium channel ƒe gege ɖe ʋua me ta la, CCB ƒe agbɔsɔsɔ fũu akpa nana insulinemia sesẽ kple suklidɔ si dzena (zi geɖe la, 200 va ɖo 450 mg/dL) le dɔnɔ siwo menye suklidɔ o gɔ̃ hã me. Le nyateƒe me la, suklidɔ ƒe agbɔsɔsɔ si sɔ gbɔ wu la do ƒome tẽ kple CCB ƒe agbɔsɔsɔ fũ ƒe sesẽ.
• Beta-Blocker (BB) ƒe agbɔsɔsɔ fũ hea HYPOGLYCEYCEMIA alo Normoglycemia: Beta-2 adrenergic blockade xea mɔ na aklã me glycogenolysis kple sukli si dona le dɔgboa me, si wɔnɛ be sukli si le ʋu me dzi ɖena kpɔtɔna (vevietɔ le ɖeviwo me).

2. Nusita Insulin ƒe Agbɔsɔsɔme Gã ƒe Euglycemic Therapy (HIET) Nye Dɔlékui Siwo Wozãna Ðe Dzitodzito me Ʋuʋudedi Ŋu¶

Le nɔnɔme siwo sɔ me la, dzitodzito ƒe lãmeka si le ɖiɖim la fiãa ami siwo me ami mele o koŋ hena mɔ̃memi. Le calcium channel blocker alo beta-blocker overdose sesẽ me la, dzitodzito si me nuteɖeamedzi le la dzea agbagba be yeatrɔ yeƒe amitsoƒe tso ami siwo me ami le dzi ayi glucose dzi, evɔ le ɣeyiɣi ma ke me la, dɔ wua insulin (tso dɔgboa ƒe L-ƒomevi calcium channel blockade me) kple lãmenugbagbeviwo me calcium:

• Alesi Insulin Euglycemic Therapy (HIET) si ƒe agbɔsɔsɔme sɔ gbɔ ɖea dzi si le kpo dom nu:
• Atikewɔla siwo kpɔa nudzɔdzɔ kpatawo gbɔ naa Regular Insulin IV bolus gã aɖe si nye Unit 1/kg (si nye suklidɔ ƒe ketoacidosis ƒe agbɔsɔsɔme si wozãna zi gbɔ zi 10), eye wodoa Regular Insulin** ƒe **1 va ɖo 10 Units/kg/gaƒoƒo/gaƒoƒo atraɖii, tsɔ kpena ɖe IV Dextrose si me wodea nuɖuɖui si me wodea nuɖuɖui ŋu (D10W alo D50W to titina line) be sukli nanɔ ʋu me abe alesi wòle ene (euglycemia: 100 to 200 mg/dL) kple potassium kpeɖeŋutɔ nana be serum \(\text{K}^+\) nalé ɖe te 2.8 to 3.5 mEq/L.
• Insulin si wozãna le agbɔsɔsɔ gã me wɔa dɔ abe inotrope nyui si ŋu ŋusẽ le ene: ezia sukli kple lactate dzi tẽ be woage ɖe dzitodzito me lãkusi siwo dɔ le wuwum me to PI3K/Akt ƒe dzesiwo dzi, egbugbɔa lãmenugbagbeviwo me calcium ƒe dɔwɔwɔ ɖoa anyi, eye wòdzia dzitodzito ƒe dodo kple ʋu ƒe sisi ɖe edzi le **aɖabaƒoƒo 30 va ɖo 45 me (si tae wòle be woadze HIET gɔme kaba kpe ɖe IV ŋu ɖo Calcium, IV Glucagon [5 va ɖo 10 mg bolus na beta-blockers], kple Norepinephrine/Epinephrine, tsɔ wu be woalala vaseɖe esime dɔnɔa ƒe dzidɔ xoxo).

Nya siwo wobiaa amewo enuenu¶

Vinye si xɔ ƒe 2 mi nye iron-tike siwo metsɔ do ŋgɔ na vidzidzi la dometɔ geɖe gaƒoƒo eve enye sia. Nukatae ɖɔkta si kpɔa dɔnɔdzikpɔƒe si kpɔa nudzɔdzɔ kpatawo gbɔ gblɔ be yewomate ŋu ana activated charcoal abe alesi wowɔna na aɖi bubuwo ene o?¶

Atike si wotsɔ wɔa dɔe wɔa dɔ to atike ƒe molecule gã siwo wotu ɖe carbon dzi la xɔxɔ ɖe eƒe nusuekpɔmɔ̃ me, gake elemental metal ions sue siwo me dzoxɔxɔ le (vevietɔ Iron, Lithium, Lead, Potassium, kple Sodium) meblana ɖe activated charcoal ŋu ​​kura o. Black activated charcoal nana ɖevi si mi iron tablets meɖea vi aɖeke o eye le nyateƒe me la, egblẽa nu le beléle ŋu to ŋkuléle ɖe nukpɔkpɔ siwo le dɔgboa me ŋu eye wònana womate ŋu ade vovototo dzoka xɔxɔ ƒe aɖuɖɔ si me afɔku mele o kple ʋu si dona le dɔgboa me si me afɔku le si gayibɔ hena vɛ dome o. Ke boŋ ɖɔktawo wɔa ƒodo me X-ray be woakpɔ gayibɔtike siwo me keklẽŋusẽ mele o, tsɔa Whole Bowel Irrigation (polyethylene glycol solution) klɔa wo to dɔgboa me, eye wodoa Deferoxamine chelation ɖe ʋuka me ne aɖi le ʋu me gaƒoƒo 4 va ɖo 6.

Nukatae afɔku le eme alea gbegbe be woado ya na dɔnɔ si ŋu aspirin (salicylate) ƒe aɖi sesẽ le ahatsɔe ade mɔ̃ si wotsɔ yaa yae me?¶

Dɔnɔ si ŋu aspirin ƒe aɖi sesẽ le la gbɔa ya zi gbɔ zi 30 va ɖo 45 le aɖabaƒoƒo ɖeka me kple gbɔgbɔ goglo siwo me gbɔgbɔtsixe tsia dzodzodzoe (yagbɔgbɔ fũu) be yeatsɔ aƒo ya si woyɔna be carbon dioxide eye wòana woƒe ʋu ƒe pH nanɔ alkaline vie (7.45 va ɖo 7.52), si nana salicylic acid nɔa ʋu me eye wòdona le ahɔhɔ̃a me. Ne ɖɔkta na atike siwo naa ame ƒe dzi dzea eme kple esiwo naa ame ƒe lãme gbãna be woatsɔ ade gbɔgbɔtsixe ƒe mɔ̃ me la, dɔnɔa dzudzɔa gbɔgbɔ sɛkɛnd 60 va ɖo 90, eye mɔ̃ si wozãna tsɔ yaa yae si wozãna ɖaa mate ŋu asɔ kple yaƒoƒo ƒe agbɔsɔsɔ gã si nye lita 25 va ɖo 35 le aɖabaƒoƒo ɖeka me si dɔnɔa nɔ dodom le eɖokui si o. Le aɖabaƒoƒo ʋɛ aɖewo ko me la, CO2 si lé ɖe te la nana ʋua ƒe pH ɖiɖina va ɖoa 7.20, si trɔa salicylate si me ion le wòzua salicylic acid si me dzoxɔxɔ mele o si ƒua du yia ahɔhɔ̃a kple dzia me tẽ, si wɔnɛ be dzia tsia zi ɖeka. Eyata aɖiŋutinunyalawo ƒoa asa na salicylate dɔnɔwo dodo ɣesiaɣi si wòanya wɔ eye wotsɔa ʋumenugbagbeviɣidɔ enumake ɖoa nɔƒe gbãtɔ.

Ne vidzĩ si le zɔzɔm la mi ʋu ƒe sisi ƒe atikekui ÐEKA ko (abe Verapamil SR alo Nifedipine XL ene) eye wòdze abe dzi le edzɔm 100% eye ŋusẽ le eŋu le gaƒoƒo eve megbe la, ɖe míate ŋu anɔ aƒemea?¶

Ao: ƒo ka na 911 eye nàyi kɔdzi enumake. Calcium channel blockers siwo woɖena ɖe go didi (SR, XL, XR, CD) kple beta-blockers le "Atikekui Ðeka Wuwu" siwo xɔ ŋkɔ wu le ɖeviwo ƒe dɔlélewo me la dome. Esi wònye be wowɔ atikekui la le polymer matrix si dona blewu alo osmotic pump shell me ta la, meɖea atike aɖeke kloe ɖe go le gaƒoƒo 2 va ɖo 6 gbãtɔawo me o, eyata ɖevia dzena abe ɖe wòsɔ keŋkeŋ ene. Emegbe le gaƒoƒo 8 va ɖo 18 megbe, zi geɖe le zã titina esime ɖevia le alɔ̃ dɔm la, atike la ɖoa aɖi ƒe agbɔsɔsɔ le ʋu me eye wòhea dzitodzito ƒe ʋuʋu kpata si wua ame kple dzi ƒe dɔmawɔmawɔ vɛ. Ðevi ɖesiaɖe si mi calcium channel blocker ɖeka si woɖena le lãme na ame ɣeyiɣi didi aɖe gɔ̃ hã la hiã be woalé ŋku ɖe dzitodzito ŋu le kɔdzi gaƒoƒo 24 blibo.

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Mɔfiame sia nye nyatakaka nana eye mexɔ ɖe dɔnyala bibiwo ƒe atikewɔwɔ alo Aɖidzikpɔkpɔ ƒe aɖaŋuɖoɖo teƒe o. Esi wònye be aƒeme atikewo zazã fũu akpa na ɖeviwo kple ame tsitsiwo ate ŋu ana ame naxɔ alɔ̃ kpata, yaƒoƒomɔ̃wo nabu, eye dzi natɔ te ta la, míele aɖaŋu ɖom vevie be nàwɔ ɖeviwo kple ame tsitsiwo ƒe kpekpeɖeŋunadɔ gbãtɔ kple CPR ƒe hehe si ŋu woda asi ɖo to Dukɔwo Dome Atitsoga Dzĩ Habɔbɔwo kple Ɣleti Dzĩ Habɔbɔwo ƒe Habɔbɔ (IFRC), miaƒe dukɔa ƒe Atitsoga Dzĩ Habɔbɔ, St John Ambulance, alo nutoa me hehenaƒe si ŋu woɖo kpee dzi.

Wolé ŋku ɖe dzɔtsoƒewo ŋu¶

• Amerikatɔwo ƒe Atikewɔwɔ ƒe Aɖiŋutinunya ƒe Kɔledzi (ACMT) & Amerikatɔwo ƒe Aɖidzikpɔƒewo ƒe Habɔbɔ (AAPCC): Mɔfiame Siwo Ku Ðe Salicylate, Iron, Tricyclic Antidepressant, Beta-Blocker, kple Calcium Channel Blocker Poisoning Ŋu.
• EXTRIP (Aɖi si Wozãna le Ŋutilã Me) Dɔwɔha: Kafukafu Siwo Wotu Ðe Kpeɖodziwo Dzi na Atikewɔwɔ le Ŋutilã Godo le Salicylate kple Tricyclic Antidepressant Poisoning (Annals of Emergency Medicine).
• Eŋutinunyalawo ƒe Nubabla ƒe Habɔbɔ le Calcium Channel Blocker Poisoning (Critical Care Medicine): Aɖaŋuɖoɖo siwo dzi woda asi ɖo le Calcium Channel Blocker Poisoning kple Insulin ƒe agbɔsɔsɔ gã ƒe Euglycemic Therapy (HIET) ƒe Dɔwɔnawo Dzi Kpɔkpɔ Ŋu.
• Dukɔa ƒe Aɖiwo Ŋuti Nyatakaka Dɔwɔƒe (NPIS, United Kingdom): TOXBASE Dɔnɔdzikpɔƒe ƒe Ðoɖowo na Salicylates, Ferrous Salts, Tricyclic Antidepressants, kple Dzitodzitowo ƒe Atikewo.

Mɔfiame siwo do ƒome kplii¶

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