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Confirm flutter valve patency • Free drainage of fluid from chest into bag • Get patient to cough and valve leaflets should part Figure 7 diabetes type 2 hyperglycemia order micronase now. Suture drain to skin securely (Source: Portex Ambulatory Chest Drain Set blood glucose 83 order micronase 5 mg on line, courtesy 7 diabetes related medications order micronase cheap. Paradoxical chest movement, hypoxia and respiratory distress characterize a patient in combination with unilateral (or occasionally bilateral) chest dull- with a flail chest. Management of High-flow oxygen (15 L/min) and sufficient analgesia for painless hypovolaemia takes priority. Where transfer times are short, rapid spontaneous breathing is often sufficient field treatment of this movement to a trauma centre with supplemental oxygen and care- condition. Large flail segments with resistant hypoxia may require fully titrated intravenous fluids en route is required. Other chest injuries Several other thoracic injuries may present in the prehospital phase Flail chest (Box 7. If suspected, continued resuscitative care should be pro- A flail chest is defined as the fracture of two or more adjacent ribs vided and the injury communicated to the receiving trauma team. A small flail segment may be difficult Life-threatening breathing problems: to identify because of local muscle spasm and splinting; however, medical large flail segments are usually obvious. The flail segment moves paradoxically inwards during inspiration and outwards during Acutebreathlessnessisacommonmedicalemergencyinbothadults expiration (Figure 7. Tidal volume is reduced and ventilation and children, and the differential diagnosis is broad (Box 7. Emerg Med Clin North Myocardial Blunt chest injury Supplemental Oxygen Am 2008: 869–279. End tidal carbon dioxide monitoring in prehospital fracture) and retrieval medicine: a review. Does prehospital ultrasound improve Cardiogenic shock treatment of the trauma patient? Eur J Emerg Med Simple pneu- Penetrating or blunt Supplemental Oxygen 2010;17:249–253. The Hypoxaemia Monitor for tension prehospital management of chest injuries: a consensus statement. Faculty Ipsilateral ↓ air entry Prophylactic thoracostomy of Prehospital Care, Royal College of Surgeons of Edinburgh. Prehospital pleural decompression and chest symptoms tube placement after blunt trauma: A systematic review. Haemorrhage Ischaemia Dehydration Valve Dysfunction Arrhythmia Introduction Sepsis The early identification and aggressive management of shock is an Cardiogenic important component in the resuscitation of the seriously ill or Poisoning Anaphylaxis e. Shock is defined as failure of the circulatory sys- tem leading to inadequate organ perfusion and tissue oxygenation. Inadequate perfusion may result from failure of the pump (the Neurogenic Shock heart), inadequate circulating blood volume (absolute or relative) or obstruction to the flow of blood through the circulatory system. In practice there is often considerable overlap, with dif- Distributive ferent types of shock co-existing in the same patient. Whatever the mechanism, inadequate perfusion leads to anaerobic metabolism, Figure 8. Hypovolaemic shock Hypovolaemia in trauma Hypovolaemic shock secondary to uncontrolled haemorrhage is by Hypovolaemic shock is shock resulting from inadequate circulating far the most common shock scenario seen in prehospital practice. Fluid may also be lost into body tissues or compartments these areas, the body’s compensatory mechanisms sacrifice the per- (socalled‘thirdspacing’),particularlyaftersignificanttissuetrauma fusion of less critical areas such as the skin and gastrointestinal tract.
Diseases
Neutrophil predominance suggests bacterial infection diabetes type 2 undiagnosed buy discount micronase, acute interstitial pneumonia blood glucose borderline buy cheap micronase 2.5mg on line, By using the techniques of evidence-based and may also be found in patients with asbestosis medicine to guide their recommendations diabetes type 2 with erectile dysfunction generic micronase 5 mg online, or usual interstitial pneumonitis. Eosinophils are the American Thoracic Society and Infectious seen in patients with eosinophilic pneumonias, Diseases Society of America have recently reviewed these topics in great detail. The alveolar ics, the use of semiquantitative or quantitative macrophages are filled with pulmonary alveolar culture data, and the use of negative culture data proteinosis-positive material, and lamellar bodies to discontinue antibiotics in patients who have not can be seen with electron microscopy. Additionally, it is impor- that the use of bronchoscopy can often aid in the tant to note that multiple diagnoses often can be diagnosis of a radiographic occult neoplasm in a present simultaneously in these patients64 and that patient who presents with hemoptysis, a broncho- noninfectious conditions may have a similar pre- scopic diagnosis of malignancy is made in 5%. Bronchoscopy is an excellent method who present with hemoptysis and normal chest of evaluating these patients because the use of imaging if they are 40 years of age, are male, less-invasive techniques can miss the diagnosis in and have a 40 pack-year smoking history. Although the appropriate Helmers and Pisani30 suggest three broad cat- timing for bronchoscopy is controversial, there egories of immunocompromised patients: those is a greater likelihood of identifying the bleeding who are pharmacologically immunosuppressed, source when performed within the first 48 h of those with hematologic malignancy/malfunction, symptoms. Cryptococcus sp, Histoplasma sp, and Although many advanced techniques can be viruses such as cytomegalovirus are seen in patients performed with flexible bronchoscopy, the rigid with defects in cell-mediated immunity. By using a approximately 2 to 3 mm and, hence, the risk of definition of 500 mL/24 h, Hirshberg et al74 found airway perforation is less when compared with that 14% of 208 patients presenting with hemop- lasers. If rigid bronchoscopy is laser in the lower respiratory system and has been not available, the options include intubation with used for both benign and malignant disease. The main role of flexible bronchoscopy in the Despite this caveat, the safety record of laser patient with massive hemoptysis lies in helping to bronchoscopy is excellent, with an overall com- obtaining lung isolation by guiding the endotra- plication rate of 1%. The distinct advantage of cryother- tact method that uses ionized argon gas (plasma) to apy lies in the fact that the normal airway tissue is achieve tissue coagulation and hemostasis. As with laser therapy, the it only requires one bronchoscopy; however, the risks of electrocautery include airway perforation, catheter has to stay in place for 20 to 60 h, which airway fires, and damage to the bronchoscope. The main advantage of brachytherapy as compared with Photodynamic Therapy external-beam radiation is the fact that less normal tissue is exposed to the toxic effects of radiation. The greatest incidence of hemorrhage occurs Because the laser is not a heat source, airway fires during the treatment of tumors in the right and are not an issue. Similar to cryotherapy, maximal effects are delayed, and a repeat, “clean-out” bronchoscopy Montgomery is credited as initiating the wide- should be performed 24 to 48 h after drug activa- spread use of airway stents after his development tion. Newer drugs are being developed with the hope of increasing tumor selectivity and Airway stents are the only technology that can alle- reducing the duration of skin phototoxicity. They are com- has been shown to be curative for early-stage lung monly used in conjunction with the other modalities cancer of the airways and is an especially attrac- for patients with intrinsic or mixed disease. As with any procedure, it is crucial to understand the indica- Brachytherapy tions and contraindications of the procedure as well as be able to anticipate, prevent, and manage the Brachytherapy refers to endobronchial radia- associated complications. In a study108 of 112 subjects in whom asthma For malignant airway obstruction, the only appro- control was impaired, bronchial thermoplasty priate metal stents are covered models, which reduced the rate of mild exacerbations, and at minimize tumor in-growth. Some authors believe 12 months, there were significantly greater improve- that there is no indication for an uncovered metal ments in the bronchial-thermoplasty group than stent. In patient with tracheoesophageal fistula, easily identified, such as the carina, are marked, double stenting of the esophagus and airway is as is the target. The location of the guide in the electromagnetic field is accurate Bronchoscopic Lung Volume Reduction to 5 mm in the x, y, and z axes, as well as yaw, pitch, and roll. It is also less expensive and does electromagnetic field and rely on high-definition not require transport of a critically ill patient to virtual bronchoscopic road maps with ultrathin the operating room.
Allergic Bronchopulmonary Fungal Disease Acute Bronchiolitis Allergic bronchopulmonary fungal disease There are many causes of acute bronchitis diabetic pump supplies order micronase with mastercard,9 syndrome affects asthmatic patients and patients with cystic fibrosis and results from an allergic most significantly infection and aspiration (may be reaction to fungi blood sugar monitor cvs generic micronase 2.5 mg free shipping. The most notorious fungi to cause this allergic phenom- pathology includes ulceration of mucosa diabetes joslin discount micronase 5 mg online, inflam- enon (allergic bronchopulmonary aspergillosis), mation, usually including neutrophils, and intra- multiple other fungi can cause the disease. Common exposures Chronic bronchiolitis10 is a nonspecific patho- include diacetyl (popcorn worker’s lung), sulfur logic term used to describe the presence of chronic mustard gas, and infection (eg, postadenoviral). Constrictive bronchiolitis may found in a variety of primary airway diseases and be preceded by acute and chronic bronchiolitis, but as a component of many classically “interstitial” histology is similar regardless of etiology. It is bacterial and viral infection; extrinsic allergic described as chronic inflammation with germinal alveolitis; nonspecific interstitial pneumonia (may centers around bronchioles. Pathology is the same regardless of clinical Diffuse panbronchiolitis is a form of bronchi- category: polypoid plugs of proliferating fibro- olitis associated with sinusitis. The nature plant recipients, silo filler’s disease and, occasion- of small-airway obstruction in chronic obstruc- ally, rheumatoid arthritis, there is evidence to tive pulmonary disease. Diagnosis and man- cause obstructive airways disease and can “prog- agement of allergic bronchopulmonary aspergillo- ress” to a lesion that is indistinguishable from the sis. Metaplastic bronchiolar epithelium may with specific histologic features, including Langerhans cell histiocytosis, hypersensitivity pneumonia, sarcoidosis, be very atypical and mimic carcinoma. Key words:granulomatous disease; infection; interstitial lung disease; neoplasia; transplant “Idiopathic” Interstitial Pneumonias Idiopathic interstitial pneumonias comprise a heterogeneous group of pneumonias with acute, Difuse Lung Disease eg, acute interstitial pneumonia, and more chronic presentations. The American Thoracic Society/ Difuse Alveolar Damage/Acute Interstitial European Respiratory Society endorses the clas- Pneumonia sification scheme shown in Table 1. There are two phases: acute and organizing (often overlapping caused by • Common in connective tissue disease, as a attempted repair at the same time there is manifestation of drug reaction and rarely ongoing injury). Alveolar septa are thickened by an inflamma- Cough 62 60 tory infiltrate that often includes mononuclear Fever 22 60 cells and occasional germinal centers. The most Weight loss 22 100 striking (and definitional) feature is the presence Adenopathy 95 of numerous lightly pigmented macrophages Autoimmune diseases, % Common Uncommon Sjögren syndrome 20 Yes within most of the distal air spaces. Transbronchial biopsy has become the On electron microscopy, Birbeck granules (pen- method of choice and can be expected to yield a tilaminar structure with a “tennis racket” mor- diagnosis in nearly 80% of patients, including 70% phology) appear. The likelihood of obtaining a radiographically: Langerhans cell histiocytosis diagnostic biopsy is related to the number of results from dilated bronchioles, paracicatricial specimens obtained, and the best results require a airspace enlargement (so-called scar emphy- minimum of 4 specimens in patients with stage 2 sema), and necrosis in the center of the lesions. Microscopic find- lymphangitic nonnecrotizing granulomatous ings include non-necrotizing granulomatous inflammation associated with broad foci of inflammation (although the granulomas often parenchymal necrosis and vasculitis. Differential Diagnosis of Diffuse Lung Disease With Small Granulomas* Hypersensitivity Pneumonitis Sarcoidosis Hot Tub Lung Interstitial pneumonia − − Chronic bronchiolitis − − − Granulomas Well formed − Single giant cells − − − Necrosis − Organizing pneumonia − − − Cultures − − Mycobacterium avium intracellulare * rare; occasional; prominent feature. Associations and Causes of Chronic Eosinophilic lung; (2) hemorrhage with or without capillari- Pneumonia Pathology tis (vasculitis involving capillaries recognized by presence of neutrophils in alveolar walls); Allergic bronchopulmonary fungal disease Simple pulmonary eosinophilia (3) bronchocentric; (4) organizing pneumonia- Systemic infection (parasites, fungi) like; and (5) eosinophilic pneumonia-like. Churg Strauss syndrome Positive p-antineutrophil cytoplasmic antibody Hodgkin lymphoma titers generally representing autoantibodies Inflammatory bowel disease directed against myeloperoxidase are less spe- Lung cancer cific but have been reported to be positive in *From Uchiyama H, Suda T, Nakamura Y, et al. Asbestos bodies are iron-encrusted fibers (one Classic pathology includes the following: type of ferruginous body, which is a more generic • Necrotizing granulomatous inflammation with term) that typically are beaded and dumbbell shaped geographic borders (appears more like paren- with a thin translucent core. There are no generally chymal necrosis than a true granuloma since accepted criteria defining how many asbestos bodies the foci usually lack significant numbers of epi- must be identified in any given case for a diagnosis thelioid histiocytes); of asbestosis, but the presence of even a single Centrally in foci of necrosis there is amor- asbestos body in a routine tissue section usually phous eosinophilic to basophilic debris with signifies “above-background” asbestos exposure. Pulmonary Complications of Asbestos Exposure* Palisading granulomas are tiny granulomas composed of a single layer of palisading epi- Pleural disease thelioid histiocytes that either radiate around Effusion a central point or surround a central eosino- Fibrosis philic structure resembling a collagen bun- Plaques dle.
A variety of toxicological tests are now available blood glucose units of measurement micronase 5mg generic, and metabolic disease in sheep buy 2.5mg micronase fast delivery, in the appropriate circumstances diabetes definition medical cheap micronase 2.5 mg, bedside screening assays for various bioterrorism agents. Diagnostic imaging Chest film An early portable chest X-ray is of paramount importance. It may also be helpful in pulmonary embolism—less for the presence of rare signs such as Hampton’s Hump and Westermark’s sign than for the absence of significant findings pointing to alternative diagnoses such as pulmonary edema and pneumonia. Cervical spine films The presence of cervical spine trauma may help explain the findings of shock, neurological deficits and ventilatory failure. Continued Pelvis This is an important film that may identify a source of hemor- 1 rhage and occult trauma. Lateral soft tissue neck This film may identify mechanical airway obstruction, a source of septic shock or foreign bodies. Abdominal films Although rarely helpful in resuscitation, a single abdominal film may show a pattern of calcification of the aorta in the case of a ruptured aortic aneurysm and the presence of radiopaque toxic ingestions such as iron, phenothiazines and enteric release tablets. Ultrasonography Bedside ultrasound is ideal for use in resuscitation because of its availability, repeatability and speed. Bedside echocardiography can be used to reveal the presence of various shock states by identifying cardiac tamponade, global hypokinesis or right ventricular outflow obstruction. In the future, it may be utilized by emergency physicians to evaluate valvular lesions and dyskinesis. It can also assist with the distinction between pulseless electrical activity and cardiac standstill (electromechanical dissociation). Abdominal ultrasound may quickly identify free-fluid (most importantly, hemorrhage) in the peritoneal cavity. Pelvic ultrasonography in the female patient with intraperitoneal hemorrhage may further delineate the source of shock. The absence of an intrauterine gestation in a pregnant female may represent ectopic pregnancy, whereas its presence may indicate a bleeding cyst, heterotopic ectopic pregnancy or occult trauma. Ultrasonography also has a role in assisting with emergency procedures, such as line placement and pericardiocentesis. It may identify the need for emergent surgical decom- pression, measures to lower intracranial pressure or the search for other causes of altered mental status, all which may change the course of a resuscitation. In the context of an individual resuscitation, some of these findings may be very important or even critical. Simply stated, the secondary survey is a complete, compulsive physical examina- tion. Once resuscitative measures are underway, every critically ill patient should have such an examination. The importance of the family of the critically ill patient should not be forgotten. In the case of patients with chronic, controlled disease, family members may be quite shaken by the sudden decompensation in their loved one’s condition. Early communication with family and friends serves several purposes: to obtain additional relevant history, to explain the current condition and resuscitative efforts that are taking place, to clarify any advance directives or previously expressed wishes of the patient, and to express the concern and support of the resuscitative team. Although controversy exists as to whether family members should be permit- ted to view resuscitative efforts, there is little doubt that interacting with family members in these situations is a skill that requires training, practice and flexibility. Other individuals that may become involved as indirect members of the resusci- tation team include religious or spiritual counselors, organ procurement specialists, law enforcement, forensic specialists, sexual assault and domestic violence person- nel. Ethical and Legal Aspects of Resuscitation Many ethical issues are magnified and intensified during a resuscitation.
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