empyema necessitans
Greener Pasture: Fundamentals of Nursing
The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position. The nurse can elicit Trousseau's sign by occluding the brachial or radial artery. Hand and finger spasms that occur during occlusion indicate ...
Penetrating Neck Trauma
20 PENETRATING NECK TRAUMA
Clay Cothren M.D., Ernest E. Moore M.D.
1. Why are penetrating neck wounds unique?
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Although comprising only a small percentage of body surface area, the neck contains a heavy concentration of vital structures.
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Spinal Cord Injuries
19 SPINAL CORD INJURIES
J. Paul Elliott M.D., Sanjay Misra M.D.
1. What is the difference between a spinal injury and a spinal cord injury?
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Spinal injuries include damage to the bone, disc, or ligaments. These injuries sometimes result in spinal instability. They also may be associated with spinal cord injury, which is damage to the neural tissue, often with clinical deficit. It is crucial to determine whether there is (1) a spinal injury, (2) a spinal cord injury, and (3) spinal instability.
2. Describe the evaluation of a patient with a suspected spine injury.
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First, be sure that the patient is adequately immobilized and everyone knows to maintain spinal precautions. Second, inspect and palpate the spine for external trauma and step-off. Finally, do a complete neurologic examination including all four extremities. Assess strength, sensation (light touch/proprioception and pain/temperature), muscle tone, reflexes, and rectal tone. Carefully document your results.
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Traumatic Brain Injury
18 TRAUMATIC BRAIN INJURY
J. Paul Elliott M.D., Sanjay Misra M.D.
1. Is traumatic brain injury (TBI) a common problem?
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Yes. In the United States, 1 in 12 deaths is due to injury. One third of traumatic deaths are associated with TBI. Of deaths resulting from motor vehicle accidents, 60% are due to brain injury. Even more common is minor TBI, which accounts for 75% of admissions for head trauma.
Posttraumatic Hemorrhagic Shock
17 POSTTRAUMATIC HEMORRHAGIC SHOCK
John B. Moore M.D., Ernest E. Moore M.D.
1. Are hemorrhagic shock and hypovolemic shock the same?
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Yes.
2. What is hemorrhagic shock?
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Shock exists when the cardiovascular system is no longer able to meet the body’s metabolic and oxygen needs-inadequate tissue perfusion.
Hemorrhage is the most common cause of shock after injury. Depletion of the vascular volume results in decrease of the driving pressure returning blood to the heart, decrease of the end-diastolic ventricular volume, and decrease in stroke volume; all result in decrease in cardiac output.
InitialAssessment. Controversies
CONTROVERSIES
28. What is the role of the pneumatic antishock garment?
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The military antishock trouser (MAST) has fallen out of favor in most instances. The MAST suit is valuable for patients requiring long-distance transfer who have major bleeding from pelvic fractures. The MAST suit should be avoided in the presence of major thoracoabdominal trauma, especially if a diaphragmatic injury is suspected. The traction splints still are preferred for femur fracture transfer; they decrease bleeding and assist with pain control.
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Initial Assessment
16 INITIAL ASSESSMENT
Eric L. Sarin M.D., John B. Moore M.D.
1. What is the “golden hour”?
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The first hour after injury provides a unique opportunity to provide life-saving interventions. Because more than half of trauma deaths occur early due to bleeding or brain injury, rapid transport, appropriate triage, evaluation, resuscitation, and intervention can affect outcomes. The “golden hour” concept needs to be extended to several hours in the rural setting, but with the same structured approach. Trauma surgeons harbor the unique idea that an injured patient is their responsibility before they reach the hospital.
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Surgical Infectious Disease. Extra Credit Questions
EXTRA-CREDIT QUESTIONS
25. Should all patients undergoing elective laparotomy receive prophylactic antibiotic coverage?
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No. Doing so would contribute to driving up the cost of antibiotics and their complication rate and devaluing formerly good drugs by rendering them useless against common flora against which they were once highly potent. Operating room nurses have always classified the kind of operation by its status with respect to microbial exposure: clean, contaminated, or septic. These categories are approximation of the microbial risk exposure, and if additionally are superimposed categories of patient resistance (higher risk associated with aging, obesity or other malnutrition, concomitant drugs, or viral or mycobacterial or neoplastic disease immune compromise), these same strata are called class I, II, and III.
Surgical Infectious Disease. Management Of Surgical Infections
MANAGEMENT OF SURGICAL INFECTIONS
21. What is the drug of choice for the treatment of an abscess?
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A knife. Surgically drain the abscess. Abscesses have no circulation of blood within them to deliver an antibiotic. The antibiotic, even if injected directly into the abscess, would be worthless because the abscess contains a soup of dead microorganisms and white blood cells (WBCs). Even if the organisms were barely alive, they would not be reproducing and incorporating the antibiotic. The drug most likely would not work at all at the pH and pKa conditions of the abscess environment.
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Surgical Infectious Disease. Prophylaxis
PROPHYLAXIS
17. Should systemic antibiotic prophylaxis be used in elective colon resection?
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Yes, beyond any statistical shadow of a doubt. At least two dozen clinical trials have been carried out using placebo controls against a variety of antibiotics, principally those active against at least the anaerobic-predominant flora, and nearly all have shown a reduction in infectious complications in the antibiotic group. Never again should this point need repeating, and no patient should be placed at risk when systemic antibiotic prophylaxis has been established as the standard of care. No new clinical trials against placebo in this group of patients with known risk can be performed ethically given the confirmed risk reduction.
Other risk groups (e.g., cesarean section after membrane rupture) besides patients undergoing colon resection have been standardized by trials in large patient populations and have shown similar risk reduction. The benefit of prophylaxis has been demonstrated. In other groups of patients that cannot be standardized because of unusual contamination factors or unique factors of host resistance impairment, guidelines for rational prophylaxis should follow similar principles.
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Surgical Infectious Disease. Antibiotics
ANTIBIOTICS
11. Are antibiotics the classic wonder drugs?
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Only because you wonder if they are going to work, if they are going to cause more harm than good, and if the next generation will be unaffordable or toxic.
Skepticism is healthy with regard to any procedure or agent in heath care but especially with regard to antibiotics, which are embraced almost universally as agents that both prevent and cure infections. The primacy of the host defense in this vital process and the potential interference by the very drugs given credit for infection control are overlooked. We must look critically at the limited role that antibiotics should play in health care and restrain their overuse, which generates even more harm than unnecessary expense.
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Surgical Infectious Disease
15 SURGICAL INFECTIOUS DISEASE
Glenn W. Geelhoed M.D., M.P.H., DTMH
1. Have modern antibiotic developments controlled many, if not most, of the problems of surgical infection?
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No. In seriously ill surgical patients in intensive care unit (ICU) settings, the problems of sepsis have increased and remain among the principal causes of death in ICU patients, especially those with multiple organ failure and impairments of host defense. Antibiotic treatment may change the biographical sketch of the flora associated with patients’ deaths but cannot overcome the multiple causes of failing host resistance to infection that accompany barrier breeches to microbial invasion and the inflammatory and immunologic responses to the “usual suspects.”
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Properties In Evaluation Of The Acute Abdomen. Surgical Treatment
SURGICAL TREATMENT
22. If the patient is sick (and not getting better), what should be done?
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After fluid resuscitation, the patient’s abdomen should be explored. An exploratory laparotomy has been touted as the logical conclusion of a complete physical examination.
Properties In Evaluation Of The Acute Abdomen. Lab Stadies
LABORATORY STUDIES
15. How is a complete blood count helpful?
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1. Hematocrit. If the hematocrit is high (> 45%), the patient is most likely dry or may have chronic obstructive pulmonary disease. If it is low (< 30%), the patient probably has a more chronic disease (associated with blood loss-always do a rectal and test the stool for blood).
2. White blood cell count. It takes hours for inflammation to release cytokines and elevate the white blood cell count. A normal white blood cell count is entirely consistent with significant abdominal trouble. Read more
Properties In Evaluation Of The Acute Abdomen. Physical Exam
PHYSICAL EXAMINATION
7. Are vital signs important?
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Yes. They are vital. If heart rate and blood pressure are on the wrong side of 100 (heart rate > 100 beats/min, systolic blood pressure < 100 mmHg), watch out! Tachypnea (respiratory rate >16) reflects either pain or systemic acidosis. Fever may develop late, particularly in the immunosuppressed patient who may be afebrile in the face of florid peritonitis.
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Properties In Evaluation Of The Acute Abdomen
14 PRIORITIES IN EVALUATION OF THE ACUTE ABDOMEN
Alden H. Harken M.D.
1. What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?
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1. To identify how sick the patient is
2. To determine whether the patient (a) needs to go directly to the operating room, (b) should be admitted for resuscitation or observation, or (c) can be sent safely home
Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
