🚨🚨المريض دخل في صددممه!
صوت code plue code plue اشتغل
ايش نعمل🤔 ؟ كيف الفريق الطبي يلحق الوضع ؟ الضغط نازل ! مافي اوكسجين ! ، التركيز الان على حياة المريض واحنا هنا حنركز على السيطره على هذا الوضع الطارئ امشو معانا في ثريدز ال SHOCK 🚨🚨
صوت code plue code plue اشتغل
ايش نعمل🤔 ؟ كيف الفريق الطبي يلحق الوضع ؟ الضغط نازل ! مافي اوكسجين ! ، التركيز الان على حياة المريض واحنا هنا حنركز على السيطره على هذا الوضع الطارئ امشو معانا في ثريدز ال SHOCK 🚨🚨
🖇ان شاء الله اليوم حنغطي كل هذه الجوانب بخصوص ال SHOCK :
📍Definition - تعريف الحاله
📍pathophysiology - كيف صار المرض
📍Risk factor - عوامل الخطوه
📍 signs and symptoms : ايش يحس وايش نشوف عالمريض
📍Diagnosis - تشخيص الحاله
📍Treatment- العلاج و هدفنا لإستقرار المريض🛌
📍Definition - تعريف الحاله
📍pathophysiology - كيف صار المرض
📍Risk factor - عوامل الخطوه
📍 signs and symptoms : ايش يحس وايش نشوف عالمريض
📍Diagnosis - تشخيص الحاله
📍Treatment- العلاج و هدفنا لإستقرار المريض🛌
اولا:⚡تعريف الصدمة
-Defention of Shock
التعريف الأول :
1- Shock is an acute state of inadequate perfusion of critical organs that can lead to death if therapy is not optimal.
-Defention of Shock
التعريف الأول :
1- Shock is an acute state of inadequate perfusion of critical organs that can lead to death if therapy is not optimal.
التعريف الثاني:
systolic blood pressure (SBP) less than 90 mm Hg or reduction of at least 40 mm Hg from baseline with perfusion abnormalities despite adequate fluid resuscitation.
هبوط حاد في ضغط الدم بالتالي ضخ الدم برضو قل ممكن يؤدي الى الموت اذا لم يتعالج بالطريقة الصحيحة.
systolic blood pressure (SBP) less than 90 mm Hg or reduction of at least 40 mm Hg from baseline with perfusion abnormalities despite adequate fluid resuscitation.
هبوط حاد في ضغط الدم بالتالي ضخ الدم برضو قل ممكن يؤدي الى الموت اذا لم يتعالج بالطريقة الصحيحة.
ثانيا: ⚡ كيفية تكون المرض و ماهي اشهر اسبابة ⁉️
- Shock results in failure of the circulatory system to deliver sufficient oxygen (O2) to tissues despite normal or reduced O2 consumption.
نتيجة الهبوط الحاد ، الجهاز الدوري فشل في توصيل الاوكسجين الأنسجة او الخلايا .
#يتبع👇🏻
- Shock results in failure of the circulatory system to deliver sufficient oxygen (O2) to tissues despite normal or reduced O2 consumption.
نتيجة الهبوط الحاد ، الجهاز الدوري فشل في توصيل الاوكسجين الأنسجة او الخلايا .
#يتبع👇🏻
-Shock may be caused by intravascular volume deficit(hypovolemic shock), myocardial pump failure (cardiogenic shock), or peripheral vasodilation
(septic, anaphylactic, or neurogenic shock).
ممكن يكون بسبب نقص في حجم الدم او فشل عضلات القلب المسؤولة عن ضخ الدم.
#يتبع👇🏻
(septic, anaphylactic, or neurogenic shock).
ممكن يكون بسبب نقص في حجم الدم او فشل عضلات القلب المسؤولة عن ضخ الدم.
#يتبع👇🏻
-Hypovolemic shock is characterized by acute intravascular volume deficiency due to external losses or internal redistribution of extracellular water. It can be precipitated by hemorrhage; burns; trauma; surgery;
#يتبع👇🏻
#يتبع👇🏻
intestinal obstruction; and dehydration from considerable insensible fluid loss, overaggressive diuretic administration, and severe vomiting or diarrhea.
يتبع ⬇️
يتبع ⬇️
-Relative hypovolemia leading to hypovolemic shock occurs during significant vasodilation, which accompanies anaphylaxis, sepsis, and neurogenic shock.
#يتبع👇🏻
#يتبع👇🏻
Compensatory vasoconstriction redistributes blood away from skin, skeletal muscles, kidneys, and gastrointestinal
(GI) tract toward vital organs (eg, heart and brain) in attempt to maintain oxygenation, nutrition, and organ function.
يتبع⬇️
(GI) tract toward vital organs (eg, heart and brain) in attempt to maintain oxygenation, nutrition, and organ function.
يتبع⬇️
♦️ Severe lactic acidosis often develops secondary to tissue ischemia and causes localized
vasodilation, which further exacerbates the impaired cardiovascular state.
vasodilation, which further exacerbates the impaired cardiovascular state.
ثالثا: ⚡عوامل الخطورة - Risk Factors ⁉️
رابعا: ⚡الاعرض التي تظهر على المريض - Clinical Presentation
(Sign&symptoms) 🔴
(Sign&symptoms) 🔴
خامسا:
Dignosis & Monitoring
Diagnosis assessment can be done by either:🔍
1- Invasive procedures (تتضمن فيها وسيلة الكشف اختراق الجلد) 💉
2- Noninvasive procedures (لا تتضمن فيها وسيلة الكشف اختراق الجلد )
3- Or, evaluation of medical history (التاريخ المرضي) 📝
#يتبع
Dignosis & Monitoring
Diagnosis assessment can be done by either:🔍
1- Invasive procedures (تتضمن فيها وسيلة الكشف اختراق الجلد) 💉
2- Noninvasive procedures (لا تتضمن فيها وسيلة الكشف اختراق الجلد )
3- Or, evaluation of medical history (التاريخ المرضي) 📝
#يتبع
4- Clinical presentation (الأعراض) 🔴
5- Laboratory findings (نتائج التحاليل) 🔬
5- Laboratory findings (نتائج التحاليل) 🔬
One of the main findings that can help in diagnosing:🔍
1. Hypotensionانخفاض ضغط الدم (SBP <90 mm Hg) 🔻
2. Depressed Cardiac Index انخفاض في مؤشرات القلب(CI <2.2 L/min/m2)🔻
يتبع⬇️
1. Hypotensionانخفاض ضغط الدم (SBP <90 mm Hg) 🔻
2. Depressed Cardiac Index انخفاض في مؤشرات القلب(CI <2.2 L/min/m2)🔻
يتبع⬇️
3. Tachycardia عدم انتظام دقات القلب (Heart Rate >100 beats/min)🔺
4. Low Urine Output انخفاض في كمية مخرجات البول(<20 mL/h) 🔻
#بتبع👇🏻
4. Low Urine Output انخفاض في كمية مخرجات البول(<20 mL/h) 🔻
#بتبع👇🏻
So…
Monitoring parameters include: (not all parameters are mentioned below)
1. Blood pressure (systolic/diastolic) 100–130/70–85 mm Hg ✔
2. Mean arterial pressure (MAP) 80–100 mm Hg ✔
3. Pulmonary artery pressure (PAP) 25/10 mm Hg ✔
Monitoring parameters include: (not all parameters are mentioned below)
1. Blood pressure (systolic/diastolic) 100–130/70–85 mm Hg ✔
2. Mean arterial pressure (MAP) 80–100 mm Hg ✔
3. Pulmonary artery pressure (PAP) 25/10 mm Hg ✔
Also remember that Renal Function Assessment (تقييم وظائف الكلى) through measuring Urine Output (كمية مخرجات البول), creatinine clearance based on isolated serum creatinine values is an inaccurate estimation
يتبع⬇️
يتبع⬇️
♦️also keep in mind that decreased renal perfusion and aldosterone release result in sodium retention and thus low urinary sodium (<30 mEq/L).
♦️pharmacology treatment
a)in a case of hypovolemic shock
inotropic agents and vasopressors are generally not indicated in initial treatment of hypovolemic shock if fluid therapy is adequate
إستجابة الجسم التعويضية تكون بزيادة ل CO و ال peripheral resistance للحفاظ على الضغط
a)in a case of hypovolemic shock
inotropic agents and vasopressors are generally not indicated in initial treatment of hypovolemic shock if fluid therapy is adequate
إستجابة الجسم التعويضية تكون بزيادة ل CO و ال peripheral resistance للحفاظ على الضغط
💊
use of vasopressors in lieu of fluids may exacerbate this resistance to the point that circulation is stopped .
(يعني لما يتم استخدام مثبطات الأوعية الدموية أو ( vasopressor ) بدلا من السوائل فهذا ممكن يفاقم المقاومة إلى درجة توقف الدورة الدموية )
use of vasopressors in lieu of fluids may exacerbate this resistance to the point that circulation is stopped .
(يعني لما يتم استخدام مثبطات الأوعية الدموية أو ( vasopressor ) بدلا من السوائل فهذا ممكن يفاقم المقاومة إلى درجة توقف الدورة الدموية )
vasoactive agents that dilate peripheral vasculature such as dobutamine are preferred if blood pressure is stable and high enough to tolerate the vasodilation.
(💊vasopressors are only used as a temporizing measure(
or last resort when other measures fail to maintain perfusion.
(💊vasopressors are only used as a temporizing measure(
or last resort when other measures fail to maintain perfusion.
♦️
initial hemodynamic therapy for septic shock is administration of IV fluid ( 30 ml/kg of crystalloid ). With the aim of using the least amount of fluid and lowest CVP
To achieve end organ perfusion. (الضغط الوريدي المركزي
initial hemodynamic therapy for septic shock is administration of IV fluid ( 30 ml/kg of crystalloid ). With the aim of using the least amount of fluid and lowest CVP
To achieve end organ perfusion. (الضغط الوريدي المركزي
Note that …. In case of
1) mechanically ventilated patients or 2) patients with abdominal distention or 3) preexisting ventricular dysfunction , the recommended goal of CVP =8 to 12 mm Hg or 15mmHg )
1) mechanically ventilated patients or 2) patients with abdominal distention or 3) preexisting ventricular dysfunction , the recommended goal of CVP =8 to 12 mm Hg or 15mmHg )
More than 30 ml/kg of crystalloid fluids may be needed to obtain goal MAP, reverse global hypoperfusion ( lactate clearance , SCVO2 more than or equal 70%) or achieve clinical indication of regional organ-specific perfusion ( eg urine production )
📊Therefore dynamic fluid response and clinical assessment should occur frequently after each fluid challenge
🔸Current recommendations are to measure serum lactate and administer 30 ml/kg of crystalloid for hypotension within 3 hours of presentation and obtain MAP > or equal 65 mmHg with vasopressors
reassess volume status and re-measure serum lactate if the initial lactate was elevated within 6 hours of presentation.
Although crystalloid and colloids are arguably considered equivalent for shock resuscitation , crystalloids are generally preferred over colloids ( because of ready availability and lower cost )
يتبع⬇️
يتبع⬇️
-unless patients are at risk for adverse events from redistribution of IV fluids to extravascular tissues or are fluid restricted .
🔸Dosage titration and monitoring of vasopressor and inotropic therapy should be guided by clinical response , the goal of early goal-directed therapy , and lactate clearance . vasopressor/inotrope therapy is continued until myocardial depression and vascular hyporesponsiveness
pressure ) of septic shock improve , usually measured in hours to days .discontinuation of therapy should be executed slowly with careful monitoring .💊
Receptor selectivities of vasopressor and inotropes in general act rapidly with short durations of action and are given as continuous infusions.
Potent vasoconstrictors such as norepinephrine and phenylephrine should be given through central veins because of possibility of extravasation and tissue damage with peripheral administration
Careful monitoring and calculation of infusion rates are advised because dosing adjustments are made frequently , and varying admixture concentrations are used in volume-restricted patients.
نتعرف على الادويه والجرعه المناسبه💊
———
Norepinephrine
( first line therapy for septic shock )
Properties✔
It has strong α1-agonist activity
Less potent β1-agonist effects
Weak vasodilatory effects of β2-receptor stimulation
———
Norepinephrine
( first line therapy for septic shock )
Properties✔
It has strong α1-agonist activity
Less potent β1-agonist effects
Weak vasodilatory effects of β2-receptor stimulation
Dose💊
Infusions are initiated at 0.05 to 0.1 mcg/kg/min and rapidly titrated to preset goals of MAP ( usually at least 65 mm Hg ) , improvement in peripheral perfusion
And/ or achievement of desired oxygen-transport variables while not compromising cardiac index.
Infusions are initiated at 0.05 to 0.1 mcg/kg/min and rapidly titrated to preset goals of MAP ( usually at least 65 mm Hg ) , improvement in peripheral perfusion
And/ or achievement of desired oxygen-transport variables while not compromising cardiac index.
💊
Dose:0.01 to 2 mcg/kg/min improves hemodynamic parameters to " normal " value in most patients with septic shock .
Dose:0.01 to 2 mcg/kg/min improves hemodynamic parameters to " normal " value in most patients with septic shock .
2)Phenylephrine
Properties✔
It is a Pure α1-agonist , it is improves MAP by increasing cardiac index through enhanced venous return to the heart ( increase CVP and stroke index) and by acting as positive inotropes.
Properties✔
It is a Pure α1-agonist , it is improves MAP by increasing cardiac index through enhanced venous return to the heart ( increase CVP and stroke index) and by acting as positive inotropes.
Dose :💊
The dose 0.5 to 9 mcg/kg/min used alone or in combination with dobutamine or low doses of dopamine , improves blood pressure and myocardial performance in fluid-resuscitated septic patients.
The dose 0.5 to 9 mcg/kg/min used alone or in combination with dobutamine or low doses of dopamine , improves blood pressure and myocardial performance in fluid-resuscitated septic patients.
Side effects :🤦🏻♀👩🏻⚕
Tachydysrhythmias))
Infrequent particulary when it is used as a single agent or at higher doses because it does not have β1-adrenergic agonist activity.
Tachydysrhythmias))
Infrequent particulary when it is used as a single agent or at higher doses because it does not have β1-adrenergic agonist activity.
More information :👩🏻⚕👨🏻⚕
May be useful alternative in patients who can't tolerate tachycardia or tachydysarhythemia from dopamine or Norepinephrine and in patients who are refractory to dopamine or Norepinephrine
May be useful alternative in patients who can't tolerate tachycardia or tachydysarhythemia from dopamine or Norepinephrine and in patients who are refractory to dopamine or Norepinephrine
3)Epinephrine:
(it's an acceptable choice for hemodynamic support of septic shock
It's also considered second-line or adjunctive therapy to norepinephrine)
Properties :✔
Has combined α and β agonist effect
(it's an acceptable choice for hemodynamic support of septic shock
It's also considered second-line or adjunctive therapy to norepinephrine)
Properties :✔
Has combined α and β agonist effect
Dose :
Infusion rates of 0.04 to 1 mcg/kg/min alone increase hemodynamic and oxygen-transport variables to supranormal value without adverse effects in septic shock patients without coronary atery disease.
Large doses ( 0.5-3 mcg/kg/min ) often are required .
Infusion rates of 0.04 to 1 mcg/kg/min alone increase hemodynamic and oxygen-transport variables to supranormal value without adverse effects in septic shock patients without coronary atery disease.
Large doses ( 0.5-3 mcg/kg/min ) often are required .
Smaller dosage (0.10-.0.50 mcg/kg/min ) are effective when added to another vasopressors and inotropes
More information :👩🏻⚕👨🏻⚕
Younger patients appear to respond better to epinephrine ,possibly because of greater β-adrenergic reactivity.
More information :👩🏻⚕👨🏻⚕
Younger patients appear to respond better to epinephrine ,possibly because of greater β-adrenergic reactivity.
Based on current evidence ,epinephrine may be used as a second-line vasopressor as added on to norepinephrine in patients with septic shock refractory to fluid administration.
Although it effectively increases CO and Do2 , it has deleterious effects on the splanchnic circulation
Although it effectively increases CO and Do2 , it has deleterious effects on the splanchnic circulation
4)Dopamine
(it is generally not as effective as norepinephrine and epinephrine for achieving goal MAP IN PATIENTS with septic shock).
Dose :💊
The dose of 5 to 10mcg/kg/min increase cardiac index by improving contractility and heart rate primarily from its β1 effects.
(it is generally not as effective as norepinephrine and epinephrine for achieving goal MAP IN PATIENTS with septic shock).
Dose :💊
The dose of 5 to 10mcg/kg/min increase cardiac index by improving contractility and heart rate primarily from its β1 effects.
It increases MAP and SVR AS A RESULT of both increased CO , and at higher doses (>10 mcg/kg/min ) ,its α1 agonist effects.
At dosage exceeding 20 mcg/kg/min , further improvement in cardiac performance and regional hemodynamics is limited.
At dosage exceeding 20 mcg/kg/min , further improvement in cardiac performance and regional hemodynamics is limited.
More information :👩🏻⚕👨🏻⚕
Its clinical use frequently is hampered by tachycardia and tachydysrhythmias ,which may lead to myocardial ischemia.
Use dopamine with caution in patients with elevated preload because it may worsen pulmonary edema.
Its clinical use frequently is hampered by tachycardia and tachydysrhythmias ,which may lead to myocardial ischemia.
Use dopamine with caution in patients with elevated preload because it may worsen pulmonary edema.
5) Dobutamine:
Inotrope with vasodilatory properties (an " indolator) . it's used to increase the cardiac index typically by 25%to 50% .
Dose :💊
Should be started at dosage ranging from 2.5 to 5 mcg/kg/min
Inotrope with vasodilatory properties (an " indolator) . it's used to increase the cardiac index typically by 25%to 50% .
Dose :💊
Should be started at dosage ranging from 2.5 to 5 mcg/kg/min
🔸Note … dosage greater than 5mcg/kg/min may provide limited beneficial effects on oxygen transport value and hemodynamics and may increase adverse effects.🔸
More information :👩🏻⚕👨🏻⚕
It given to patients who are intravascularly depleted
يتبع⬇️
More information :👩🏻⚕👨🏻⚕
It given to patients who are intravascularly depleted
يتبع⬇️
-dobutamine will result in hypotension and a reflexive tachycardia.
6)Vasopressin:
Dose:💊
Produces rapid and sustained improvements in hemodynamics parameters at dosage not exceeding 0.04units/min.
Doses above 0.04 units/min are associated with negative changes in CO and mesenteric mucosal perfusion .
Dose:💊
Produces rapid and sustained improvements in hemodynamics parameters at dosage not exceeding 0.04units/min.
Doses above 0.04 units/min are associated with negative changes in CO and mesenteric mucosal perfusion .
It should be used with extreme caution in septic shock patients with cardiac dysfunction.
Cardiac ischemia appears to be a rare occurrence when low doses are used , therefore use of higher doses in septic shock with cardiac dysfunction warrants extreme caution.
Cardiac ischemia appears to be a rare occurrence when low doses are used , therefore use of higher doses in septic shock with cardiac dysfunction warrants extreme caution.
In order to minimize adverse events and maximize beneficial effects ,use vasopressin as add-on therapy to catecholamine adrenergic agents rather than as first-line therapy or salvage therapy , and limit dosage to 0.03 to 0.04 units/min .
More information :👩🏻⚕👨🏻⚕
Vasopressin should be used when response to one or two adrenergic agents is inadequate or as a method for reducing the dosage of those therapies.
Increased arterial pressure should be evident within the first hour of vasopressin therapy
يتبع⬇️
Vasopressin should be used when response to one or two adrenergic agents is inadequate or as a method for reducing the dosage of those therapies.
Increased arterial pressure should be evident within the first hour of vasopressin therapy
يتبع⬇️
at which time the dose of adrenergic agent should be reduced while maintaining goal MAP.
Attempt to discontinue vasopressin when the dosage of adrenergic agents has been minimized ( dopamine ≤ 5 mcg/kg/min, norepinephrine≤ 0.1 mcg/kg/min , phenylephrine≤ 1mcg/kg/min ,epinephrine≤ 0.15 mcg/kg/min )
7)corticosteroid
Can be initiated in septic shock when adrenal insufficiency is suspected (eg ,patients receiving long-term therapy for other indications prior to the onset of shock),when vasopressor dosage are escalating or when weaning of vasopressor therapy proves futile
Can be initiated in septic shock when adrenal insufficiency is suspected (eg ,patients receiving long-term therapy for other indications prior to the onset of shock),when vasopressor dosage are escalating or when weaning of vasopressor therapy proves futile
♦️Adverse effects
Adverse effects are few because corticosteroid are administered
For a short time .usually 7 days.
Acutely , elevated BUN , white blood cell count ,glucose , and sodium may occur.
Adverse effects are few because corticosteroid are administered
For a short time .usually 7 days.
Acutely , elevated BUN , white blood cell count ,glucose , and sodium may occur.
💊treatment of septic shock with corticosteroid improves hemodynamics variables and lowers catecholamine vasopressor dosage with minimal to no adverse effect on patient safety.
More information👩🏻⚕👨🏻⚕
Assessment of adrenal function to guide therapy is not recommended .
More information👩🏻⚕👨🏻⚕
Assessment of adrenal function to guide therapy is not recommended .
وآخر شي راح نتعرف على أفضل طريقة لمنع الصدمة القلبية هي إجراء تغييرات في نمط الحياة للحفاظ على صحة قلبك وضغط الدم قيد الفحص ومن التغيرات الي راح نتعرف عليها🔺
⬇⬇
⬇⬇
Don't smoke and avoid secondhand smoke
🔸بعد عدة سنوات من الإقلاع عن التدخين يكون خطر الإصابة بالسكتة الدماغية هو نفسه بالنسبة لغير المدخنين🔸
🔸بعد عدة سنوات من الإقلاع عن التدخين يكون خطر الإصابة بالسكتة الدماغية هو نفسه بالنسبة لغير المدخنين🔸
Eat less cholesterol and saturated fat
🔸الحد من الدهون المشبعة، يمكن أن تقلل من خطر الإصابة بأمراض القلب🔸
🔸الحد من الدهون المشبعة، يمكن أن تقلل من خطر الإصابة بأمراض القلب🔸
Maintain a healthy weight
🔸إن زيادة الوزن تساهم في عوامل الخطر الأخرى للنوبات القلبية وصدمات القلب، مثل ارتفاع ضغط الدم وأمراض القلب والأوعية الدموية ومرض السكري. إن خسارة 4.5 كيلوجرام يمكن أن يخفض ضغط الدم ويحسن مستويات الكوليسترول🔸
🔸إن زيادة الوزن تساهم في عوامل الخطر الأخرى للنوبات القلبية وصدمات القلب، مثل ارتفاع ضغط الدم وأمراض القلب والأوعية الدموية ومرض السكري. إن خسارة 4.5 كيلوجرام يمكن أن يخفض ضغط الدم ويحسن مستويات الكوليسترول🔸
Limit added sugar and alcohol
🔸سيساعدك على تجنب السعرات الحرارية التي تفتقر إلى العناصر الغذائية ويساعدك على الحفاظ على وزن صحي
🔸سيساعدك على تجنب السعرات الحرارية التي تفتقر إلى العناصر الغذائية ويساعدك على الحفاظ على وزن صحي
♦️وآخر نمط لابد منه ونأخذه ك روتين لنا وفي هذه الحاله ننصح به
Exercise regularly.
يمكن أن تؤدي التمارين إلى خفض ضغط الدم لديك، وتحسين مستويات الكوليسترول وتحسين الصحة العامة للأوعية الدموية والقلب. مارس تدريجيًا ما يصل إلى 30 دقيقة المشي أو الركض أو السباحة في معظم أيام الأسبوع
Exercise regularly.
يمكن أن تؤدي التمارين إلى خفض ضغط الدم لديك، وتحسين مستويات الكوليسترول وتحسين الصحة العامة للأوعية الدموية والقلب. مارس تدريجيًا ما يصل إلى 30 دقيقة المشي أو الركض أو السباحة في معظم أيام الأسبوع
🔸🔸To prevent susceptible hypovolemic shock, follow these steps:
• Keep the person comfortable and warm (to avoid hypothermia)
• Have the person lie flat with the feet lifted about 12 inches (30citemeters) to increase circulation.
يتبع⬇️
• Keep the person comfortable and warm (to avoid hypothermia)
• Have the person lie flat with the feet lifted about 12 inches (30citemeters) to increase circulation.
يتبع⬇️
• Don’t dive fluids by the mouth
• If person is having an allergic reaction, treat the allergic reaction if you can know how.
• If person is having an allergic reaction, treat the allergic reaction if you can know how.
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د.اسراء جابر @Esragabr
د.لمى سعد @LamaLabUtah
د.خالد محمد@iKhalid96x
د.غيداء عبدالله @Ghaiiiiiida
شكر خاص لفريق دار تجهيز المحتوى العلمي للنشر :
بقيادة : نوره @aishamylife_0
اعضاء الفريق :
رحاب الحربي @ra7ob19
ساره الشمراني
بإشراف على الثريد ونشره:
د.رنا كلاّب @rana_alshlagy
بقيادة : نوره @aishamylife_0
اعضاء الفريق :
رحاب الحربي @ra7ob19
ساره الشمراني
بإشراف على الثريد ونشره:
د.رنا كلاّب @rana_alshlagy
الاشراف على المحتوى العلمي وتخطيطه وكتابة محاور الموضوع :
بقيادة
@DrAntisaad د سعد
ونائبيه :
١- @morooj_3 د مروج
٢-@heroxide د خزنه سعد
بقيادة
@DrAntisaad د سعد
ونائبيه :
١- @morooj_3 د مروج
٢-@heroxide د خزنه سعد
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