By U. Pyran. Wake Forest University.

The size of the trial was too small to demonstrate a significant difference in renal failure depakote 500 mg with visa, and the incidence of tumor lysis was not reported [64] purchase 250mg depakote with amex. When rasburicase is used 250mg depakote visa, it is important to recognize that the enzyme can continue to degrade uric acid in blood samples at room temperature. Samples must be collected in prechilled heparinized tubes, transported on ice, and analyzed within 4 hours of collection. Institution of prophylaxis in patients identified as high risk (even those with solid tumors), which includes both rasburicase and consideration for early use of hemodialysis, is highly recommended [60]. Advances in oncologic emergencies, based on randomized, controlled trials or meta-analyses of such trials, are summarized in Table 95. Spinal cord Operable Surgery followed For operable [38 compression candidates: by radiation candidates decompressive therapy gave a whose life surgery superior expectancy is followed by functional more than radiation vs. Spinal cord Age Secondary data Age is an [39 compression stratification: analysis important decompressive demonstrates a variable in surgery strong predicting followed by relationship which patients radiation vs. Four hours after In patients who [64 syndrome allopurinol for the first dose, have evidence prophylaxis of patients of pretreatment tumor lysis in randomized to tumor lysis lymphoma rasburicase syndrome or patients compared to patients who (children) allopurinol are allergic to achieved an 86% allopurinol, vs. Trial demonstrated Rasburicase was [65 syndrome rasburicase + a significant approved by the allopurinol vs. Baba Y, Ohkubo K, Nakai H, et al: Focal enhanced areas of the liver on computed tomography in a patient with superior vena cava obstruction. Ben-Horin S, Bank I, Guetta V, et al: Large symptomatic pericardial effusion as the presentation of unrecognized cancer: a study in 173 consecutive patients undergoing pericardiocentesis. Markiewicz W, Borovik R, Ecker S: Cardiac tamponade in medical patients: treatment and prognosis in the echocardiographic era. Celik S, Lestuzzi C, Cervesato E, et al: Systemic chemotherapy in combination with pericardial window has better outcomes in malignant pericardial effusions. Dequanter D, Lothaire P, Berghmans T, et al: Severe pericardial effusion in patients with concurrent malignancy: a retrospective analysis of prognostic factors influencing survival. Dosios T, Theakos N, Angouras D, et al: Risk factors affecting the survival of patients with pericardial effusion submitted to subxiphoid pericardiostomy. Sorensen S, Helweg-Larsen S, Mouridsen H, et al: Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Maranzano E, Latini P, Beneventi S, et al: Radiotherapy without steroids in selected metastatic spinal cord compression patients. Maranzano E, Latini P: Effectiveness of radiation therapy without surgery in metastatic spinal cord compression: final results from a prospective trial. Major P, Lortholary A, Hon J, et al: Zoledronic acid is superior to pamidronate in the treatment of hypercalcemia of malignancy: a pooled analysis of two randomized, controlled clinical trials. Lassen U, Osterlind K, Hansen M, et al: Long-term survival in small- cell lung cancer: posttreatment characteristics in patients surviving 5 to 18+ years--an analysis of 1,714 consecutive patients. Thiebaut A, Thomas X, Belhabri A, et al: Impact of pre-induction therapy leukapheresis on treatment outcome in adult acute myelogenous leukemia presenting with hyperleukocytosis. Apheresis instruments are designed to separate whole blood into its component parts to selectively remove one component and return the remaining components to the patient. By processing one or more blood volumes, a significant amount of pathologic solutes or cells may be removed while the intravascular compartment remains relatively euvolemic. In an exchange procedure, replacement fluid or blood is given back to the patient to allow plasma or red cells to be removed. With any apheresis procedure, some type of anticoagulant is added to the circuit to ensure that blood flows freely. Centrifugation apheresis instruments use either a continuous or a discontinuous flow method to deliver blood to the separation device where blood cells and plasma are differentially sedimented according to their specific gravity. Continuous flow methods draw blood into the extracorporeal circuit, separate blood into components in the centrifugation chamber, divert the unwanted component into a collection bag, and return nonpathologic components to the patient without interruption. Discontinuous, or intermittent, flow methods accomplish the same steps but draw and process a discrete amount of blood into the extracorporeal circuit and then return the processed effluent before another discrete volume of blood is removed. Discontinuous procedures take a longer time than continuous procedures but require only single vein/catheter access [1]. The component to be collected is pumped from the device to a collection bag, and the remainder of the blood is returned, along with appropriate replacement fluid, to the patient. B: Circuitry and instrumentation for selective removal of pathogenic substance from the patient’s plasma. The patient’s anticoagulated blood is pumped to the separation device, and separated plasma is then delivered to the selective removal device. The purified plasma is then combined with the cellular portion of the patient’s blood and returned to the patient. The extracorporeal membrane consists of either a flat plate or a hollow fiber with a pore size that excludes cellular components from the filtrate. The plasma that is separated in the instrument is diverted for disposal or treatment, whereas the other blood components are returned to the patient [2]. Specialized columns and instruments have been developed over the years to treat separated plasma, with the goal of selectively removing pathogenic proteins or other solutes [2,3]. Two different columns are approved for patients with familial hypercholesterolemia who have failed combination drug therapy. For solutes that move freely between intravascular and extravascular compartments, complete reequilibration between the compartments occurs at approximately 48 hours after a plasma exchange. Circulating blood cells also traffic between sites of vascular margination and/or splenic sequestration and this, in turn, can affect the efficiency of a therapeutic cytapheresis procedure. The rate of intravascular regeneration of a pathologic solute or blood cell population after apheresis also depends on the rates of synthesis or production and decay or cell death. Plasma exchange typically removes large molecules at a rate that greatly exceeds their natural synthetic rate; thus, a simple one-compartment mathematical model is used to predict the depletion of soluble plasma substances. Assumptions of the model are that the plasma removed is replaced with a fluid devoid of the target substance, and that complete mixing of the replacement fluid with the remaining intravascular plasma volume occurs [6]. The reliability of the one-compartment model to predict removal of soluble substances may be limited by conditions that cause an expanded plasma volume, such as paraproteinemia, molecules with rapid synthetic rates, and situations where rebound IgG production occurs, such as in the setting of humoral solid organ rejection due to a preformed antibody [7]. The one-compartment model predicts that approximately 60% of the soluble substance will be removed from the plasma with a 1× plasma volume therapeutic exchange, and approximately 80% will be removed with a 1. Because roughly 50% of IgG distributes to the extravascular space, reequilibration between the intravascular and extravascular compartments occurs between sequential procedures, and 6 or 7 1× volume exchanges are needed to deplete whole body IgG to less than 10% of the pretreatment level. By comparison, IgM is predominantly intravascular, and, therefore, only 3 or 4 1× volume exchanges are needed to deplete whole body IgM to less than 10%. Factors that may hinder the prediction include a rapid rate of cell production, such as occurs with untreated acute leukemia; the propensity of the spleen to sequester abnormal circulating cells or platelets; and miscalculation of the plasma volume of the patient. Current apheresis instruments limit both the anticoagulant (citrate or heparin) dose and rate of blood return based on the patient’s total blood volume.

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Sudden apparent loss of consciousness discount depakote 500 mg otc, occasionally with seizures 250mg depakote with visa, may be the first signal of arrest and requires prompt reaction generic depakote 250 mg without prescription. After determining unresponsiveness, the pulse is assessed by a health care provider for no more than 10 seconds. Compressions should be performed at a rate of 100 per minute, compressing the chest 2 inches with each repetition and allowing the chest to recoil fully. Interruptions to compressions should only be allowed for essential interventions, such as intubation or defibrillation. Meticulous attention to establishing an airway and supplying adequate ventilation is essential to any further resuscitative effort. The team leader must carefully monitor the adequacy of ventilation, as well as direct the resuscitative effort. Because considerable cervical hyperextension occurs, this method should be avoided in patients with cervical injuries or suspected cervical injuries. The jaw-thrust maneuver provides the safest initial approach to opening the airway of a patient with a cervical spine injury; it usually allows excellent airway opening with a minimum of cervical extension. The angles of the mandible are grasped using both hands and lifting upward, thus tilting the head gently backward. Rescue Breathing If spontaneous breathing is absent, rescue breathing with an airway– mask–bag unit must be initiated (see Chapter 8). If equipment is immediately available and the rescuer is trained, intubation and ventilatory adjuncts should be used initially. Each breath should be delivered during 1 second, allowing the patient’s lungs to deflate between breaths. A rate of 10 to 12 breaths per minute is maintained for as long as necessary, with tidal volumes of approximately 600 mL. Delivering the breath during 1 second helps to prevent gastric insufflation compared with faster delivery. If the patient wears dentures, they are usually best left in place to assist in forming an adequate seal. If air cannot be passed into the patient’s lungs, another attempt at opening the airway should be made. If subsequent attempts at ventilation are still unsuccessful, the patient should be considered to have an obstructed airway and attempts should be made to dislodge a potential foreign body obstruction. Chest Compressions Artificial circulation depends on adequate chest compression through sternal depression. The safest manner of depressing the sternum is with the heel of the rescuer’s hand at the nipple line, with the fingers kept off the rib cage. It is usually most effective to cover the heel of one hand with the heel of the other, the heels being parallel to the long axis of the sternum. If the rescuer’s hands are placed either too high or too low on the sternum, or if the fingers are allowed to lie flat against the rib cage, broken ribs and organ laceration can result. Although it is important to allow the chest to recoil to its normal position after each compression, it is not advisable to lift the hands from the chest or change their position. The rescuer’s elbows should be kept locked and the arms straight, with the shoulders directly over the patient’s sternum. This position allows the rescuer’s upper body to provide a perpendicularly directed force for sternal depression. In large patients, a slightly greater depth of sternal compression may be needed to generate a palpable carotid or femoral pulse. At the end of each compression, pressure is released and the sternum is allowed to return to its normal position. Equal time should be allotted to compression and relaxation with smooth movements, avoiding jerking or bouncing the sternum. One rescuer, positioned at the patient’s side, performs sternal compressions, while the other, positioned at the patient’s head, maintains an open airway and performs ventilation. Lay people have not been routinely taught this method in the interest of improving retention of basic skills. When the rescuer performing compressions is tired, the two rescuers should switch responsibilities with the minimum possible delay. Awareness of these potential complications is important to the postresuscitative care of the arrest patient. Gastric distention and regurgitation are common complications of artificial ventilation without endotracheal intubation. These complications are more likely to occur when ventilation pressures exceed the opening pressure of the lower esophageal sphincter. Although an esophageal obturator airway may decrease the threat of distention and regurgitation during its use, the risk is increased at the time of its removal. To obviate this risk, the trachea should be intubated and protected with an inflated cuff before the esophageal cuff is deflated and the esophageal obturator removed. Complications of sternal compression and manual thrusts include rib and sternal fractures, costochondral separation, flail chest, pneumothorax, hemothorax, hemopericardium, subcutaneous emphysema, mediastinal emphysema, pulmonary contusions, bone marrow and fat embolism, and lacerations of the esophagus, stomach, inferior vena cava, liver, or spleen [46]. The more serious complications are unlikely to occur if proper hand position is maintained and exaggerated depth of sternal compression is avoided. Overzealous or repeated abdominal or chest thrusts for relief of airway obstruction are more likely to cause fractures or lacerations. Monitoring the Effectiveness of Basic Life Support the effectiveness of rescue effort is assessed regularly by the ventilating rescuer, who notes the chest motion and the escape of expired air. The adequacy of circulation is assessed by noting an adequate carotid pulse with sternal compressions. However, fixed and dilated pupils should not be accepted as evidence of irreversible or biologic death. In the sedated or ill patient, regurgitation of stomach contents into the pharynx is a frequent cause of respiratory arrest. Blood clots from head and facial injuries are another source of pharyngeal and upper airway obstruction. Even otherwise healthy people may have foreign body obstruction from poorly chewed food, large wads of gum, and so forth. The combination of attempting to swallow inadequately chewed food, drinking alcohol, and laughing is particularly conducive to pharyngeal obstruction. Children are also prone to airway obstruction by placing toys or objects such as marbles or beads in their mouths. Patients who experience partial obstruction with reasonable gas exchange should be encouraged to continue breathing efforts with attempts at coughing. A patient whose obstruction is so severe that air exchange is obviously markedly impaired (cyanosis with lapsing consciousness) should be treated as having complete obstruction. Patients who experience complete obstruction may still be conscious, but are unable to cough or vocalize.

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As goal directed echocardiography is not designed to reliably detect this type of injury purchase depakote 500 mg without a prescription, the management team obtains immediate consultative echocardiography cheap 500mg depakote with amex, if there is clinical indication to do so 500mg depakote with visa. These are classified as multiple-path artifacts that are the result of reverberations between strongly reflective surfaces. When the ultrasound beam strikes an interface with large impedance mismatch between media, multiple reflections occur, especially if the interface is perpendicular to the direction of sound propagation. In the case of the ascending aorta, these commonly occur when the left atrium or right pulmonary artery are smaller in diameter than the ascending aorta. The source of the reverberation artifact is the interface between the posterior wall of the ascending aorta and the anterior wall of the left atrium or right pulmonary artery. Reverberations between this interface and the esophageal transducer may occur with the resultant linear reverberation artifact occurring in the aorta. The resulting linear artifacts do not correspond to anatomic structures, as they derive from reverberation between an interface and the ultrasonography transducer in esophageal position. These linear artifacts may be misidentified as intraluminal dissection flaps and lead to surgical intervention for a false positive result [110]. Multiply injured patients with thoracic injuries need to be comprehensively evaluated and their injuries prioritized and as a result, their successful care often requires a multidisciplinary approach. The treatment for thoracic injuries is evolving and requires a working knowledge of a number of both diagnostic and therapeutic modalities. As with almost all other traumatic injuries, the key to optimal treatment and outcomes is dependent upon having a high index of suspicion for the injury and to identify it early. The ability to competently manage all aspects of a critically injured patient is also important in effecting a successful overall outcome. Demetriades D, Murray J, Charalambides K, et al: Trauma fatalities time and location of hospital deaths. Plurad D, Green D, Demetriades D, et al: the increasing use of chest computed tomography for trauma: is it being overutilized? Wu N, Wu L, Qiu C, et al: A comparison of video-assisted thoracoscopic surgery with open thoractomy for the management of chest trauma: a systematic review and meta-analysis. Gage A, Rivera F, Wang J, et al: the effect of epidural placement in patients after blunt thoracic trauma. Simon B, Ebert J, Bokhari F, et al: Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. Kilic D, Findikcioglu A, Akin S, et al: Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location. Zhang Y, Tang X, Xie H, et al: Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion. Athanassiadi K, Gerazounis M, Moustardas M, et al: Sternal fractures: retrospective analysis of 100 cases. Kishikawa M, Yoshioka T, Shimazu T: Pulmonary contusion causes long-term respiratory dysfunction with decreased functional residual capacity. Juvekar N, Deshpande S, Nadkarni A, et al: Perioperative management of tracheobronchial injury following blunt trauma. Baumgartner F, Sheppard B, de Virgilio C, et al: Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Lindstaedt M, Germing A, Lawo T, et al: Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: results of a prospective study. Makhani M, Midani D, Goldberg A, et al: Pathogenesis and outcomes of traumatic injuries of the esophagus. Bautista A, Varela R, Villanueva A, et al: Effects of prednisolone and dexamethasone in children with alkali burns of the esophagus. Pacini D, Angeli E, Fattor R, et al: Traumatic rupture of the thoracic aorta: ten years of delayed management. Spiliotopoulos K, Kokotsakis J, Argiriou M, et al: Endovascular repair for blunt thoracic aortic injury: 11-year outcomes and postoperative surveillance experience. Piffaretti G, Benedetto F, Menegolo M: Outcomes of endovascular repair for blunt thoracic aortic injury. Lichtenstein D, Mezière G, Biderman P, et al: the “lung point”: an ultrasound sign specific to pneumothorax. Leblanc D, Bouvet C, Degiovanni F, et al: Early lung ultrasonography predicts the occurrence of acute respiratory distress syndrome in blunt trauma patients. Few areas of the human body are as difficult to assess following injury or to monitor subsequently as is the abdomen, particularly in the obtunded or intubated patient. Much of the morbidity and mortality due to abdominal injury results from delay in recognizing conditions that can be corrected once identified. Furthermore, the resuscitation for traumatic abdominal injuries is now known to have systemic physiologic effects. Trauma surgeons have traditionally separated injured patients into those injured by blunt mechanisms such as car crashes and falls and those injured by penetrating mechanisms, which are subdivided into gunshot wounds or stabbings. Blunt trauma patients are more frequently managed nonoperatively, whereas penetrating trauma, particularly gunshots wounds, more often require operative exploration. There will be a tendency for the intensivist to consider these patients identical to the elective general surgical patient who has undergone a comparable operation. Although there are certainly areas of commonality, there are critical differences that must be considered. The general surgical patient will usually have only a single acute problem unlike the trauma patient who may have sustained injuries to multiple body regions and possibly more than one organ in the abdomen. These differences often lead to management problems and complications that would not be expected of the general surgical patient. This approach has grown out of the recognition that many trauma laparotomies are nontherapeutic as opposed to negative. For example, a laparotomy for hemoperitoneum that identifies a small liver laceration and a minor tear in the mesentery is certainly not a “negative” laparotomy, but if both injuries have stopped bleeding spontaneously, it is difficult to argue that the surgery was therapeutic. Operations are painful; they expose the patient to complications rates in older series of up to 41% [2] and in more recent studies of 14% [3]. Complications include wound infections, pneumonia, urinary tract infections, deep venous thrombosis as well as ileus, bowel obstruction, and incisional hernias. Nonoperative management of abdominal solid organ injury is appropriate only for hemodynamically stable patients whose injuries are identified by imaging. The elderly, in particular, have an increase in mortality with blood pressures lower that 110 to 120 mm Hg [4]. Certainly, patients who require ongoing resuscitation with blood and blood products or pressors to maintain normotension are not considered stable. Other factors to consider include tachycardia or metabolic acidosis, and if present, would also preclude a state of physiologic stability. Patients with severe head injuries or ischemic heart disease are often considered to be at high operative risk, but a failure of nonoperative management also poses a high risk of mortality [5,6].

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