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General indications of Referral to higher centers in a patient with chest injury:  Massive hemothorax or continued bleeding  Massive air leak  Perforation of the intrathoracic esophagus  Mediastinal widening associated with hemothorax lisinopril 17.5mg mastercard hypertension first line treatment. There was a big bruise on the Rt posterior chest & this hemithorax was prominent & hardly moves with respiration compared to the left side order genuine lisinopril on line arrhythmia lecture. No significant finding was detected in the other systems except simple bruises on the left lower limb. Site of insertion is 5thor 6th intercostal space along the mid axillary line if only pneumothorax 2nd intercostal space at midclavicular line 1. Clean the selected site with antiseptics & apply a sterile drape (preferably a fenestrated drape)  Infiltrate the skin, muscle &pleura at the chosen intercostal space with local anesthetics(1%lidocain) See the figures below (Fig 3:1-3:2). Make a small transverse incision just above the lower rib to avoid damage to neurovascular structures running along the lower border of the ribs. In children, it is better to make the incision in the middle of the intercostal space. Using a pair of large curved artery forceps, split the intercostal muscles, penetrates the pleura & enlarge the opening. To minimize subcutaneous emphysema, seal this opening with the index finger of the left hand while holding the tip of the chest tube with the same artery forceps &introduce it to the opening. Clamp the tube with an artery forceps &while the assistant keeps the tube in place, close the incision with interrupted sutures. With one of these stitches, anchor the tube & leave another untied suture adjacent to the tube for closing the wound when the tube is removed. Remove the clamp & connect the tube to the underwater-seal drainage system & mark the initial level of the fluid in the drainage bottle. Regular massage of the tube helps to dislodge any clots or dried secretions blocking the tube. Tumors (papilloma, ca) Trauma Neck trauma with severe injury to the thyroid or cricoid cartilages, hyoid bone or great vessels Severe facial fractures (midface, mandibular fractures) 2) To provide a long-term route for mechanical ventilation In cases of respiratory failure Severe head injury 3) To provide pulmonary toilet Impaired cough reflex due to chronic pain or weakness 4) Prophylaxis Elective maxillofacial surgeries Tracheostomy tubes  Present in different sizes expressed in numbers. In obese patients extra long tubes should be used as the distance b/n the trachea & the skin is large. Examination revealed: Severe respiratory distress with audible stridor Tachypnea &low grade fever Uninflammed tonsils & adenoids Severe inter & subcostal retraction with clear lung fields. Position-The patient must be in supine position with the neck extended using a pillow or a sand bag under his/her shoulders. Infilterate the area b/n the supra sternal notch & the thyroid cartilage along the midline with local anesthetics. Make a midline vertical incision b/n the lower end of cricoid cartilage & the superior margin of the suprasternal notch. A transverse incision few centimeters above the suprasternal notch can also be used.

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Symptomatic: Numbness and tingling order lisinopril 17.5 mg line blood pressure medication green capsule, hyperactive tendon reflexes buy lisinopril 17.5mg low cost arrhythmia lyrics, muscle and abdominal cramp, tetany with carpopedal spasm and convulsions. Symptoms can include fatigue, lassitude, weakness of varying degree, anorexia, nausea and vomiting. Other symptoms include severe headaches, pain in the back and extremities, thirst, polydypsia and polyuria. Alkalosis (accumulation of Base or loss of acid) Metabolic Alkalosis Causes • Loss of acid from the stomach by repeated vomiting or aspiration • Excessive ingestion of absorbable alkali • Hypokalemic alkalosis in patients with pyloric stenosis: potassium loss due to repeated vomiting. Clinical Features • Cheyne-stokes respiration with periods of apnea • Tetany sometime occurs. It can also be caused by hyperventilation due to severe pain, hyper pyrexia and high altitude. Treatment Can be corrected by breathing into a plastic bag, or insufflation of carbon dioxide. Acidosis (accumulation of acid or loss of base) Metabolic Acidosis Causes Increase in fixed acids due to: • Anaerobic tissue metabolism (shock, infection, tissue injury) • Retention of metabolites in renal insufficiency • Formation of ketone bodies in diabetes or starvation Loss of bases in: Chronic diarrhea, gastro colic or high intestinal fistula, excess intestinal aspiration Clinical Features Besides signs and symptoms of the primary etiology like shock and infection, rapid, deep, noisy breathing is found. Treatment Tissue hypoxia should be treated by reperfusion Sodium bicarbonate can be given where bases have been lost or where the degree of acidosis is so severe that myocardial function is compromised. Respiratory Acidosis Causes Impaired alveolar ventilation due to: Airway obstruction Thoracic and upper abdominal incisions, abdominal distention in ileus Pulmonary diseases (pneumonia, atelectasis especially post operative Inadequate ventilation of the anesthetized patient Clinical Features Restlessness, hypertension and tachycardia may indicate inadequate ventilation with hypercapnia. Renal (slow) Diarrhea, As in respiratory acidosis Small-bowel fistula Metabolic Loss of fixed Vomiting Pulmonary (rapid) alkalosis acids Gastric suction Decrease rate and depth of Gain of base (pyloric obstruction) breathing bicarbonate Excessive bicarbonate Renal (slow) Potassium intake As in respiratory alkalosis depletion Diuretics 14 Review Questions 1. Know blood transfusion reactions and their preventions Definition Blood transfusion is the procedure of introducing the blood of a donor, or pre-donated blood by a recipient into the recipient’s bloodstream. Indications for blood transfusion the need for blood transfusion in patients with acute hemorrhage is based on • the volume lost • the rate of bleeding • the hemodynamic status of the patient; hematocrit may be normal if determined. It must be remembered that crystalloid infusions should be provided while the blood compound is obtained. Symptomatic patients exhibiting air hunger, dizziness, significant tachycardia or cardiac failure should, of course, be transfused. Component therapy is indicated when specific factor deficiencies are demonstrated. Compatibility tests If administrated blood is incompatible with the patients own blood, life threatening reactions may result. Group-A contains anti-B antibodies, Group-B contains anti-A antibodies, Group-O contains anti-A and anti B antibodies. In some instances when fully cross matched compatible blood is depleted or unavailable; type specific or O negative blood should be given. Irregular recipient antibodies cannot be detected and extra vascular hemolysis can also occur.

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Ante partum stillbirths have a number of causes purchase generic lisinopril on line pulse pressure over 80, including maternal infections – notably syphilis – and pregnancy complications purchase 17.5mg lisinopril fast delivery blood pressure medication that does not cause weight gain, but systematic global estimates for causes of ante partum stillbirths are not available. Newborns are affected by problems during pregnancy including preterm birth and restricted fetal growth, as well as other factors affecting the child’s development such as congenital infections and fetal alcohol syndrome. The purpose of this module is to introduce the participant to the evidence based approaches in the care of women during pregnancy to help decrease the existing high maternal and perinatal mortality & morbidity in our country. Module learning objectives: By the end of this module, the participants will be able to: 1. Recognize an emergency situation during pregnancy which requires immediate treatment and urgent referral to a higher level health facility. It also depends on the support available to help pregnant women reach services, particularly when complications occur. The care should be appropriate, cost-effective and based on individual needs of the mother. This approach was hard to implement effectively since many women had at least one risk factor, and not all developed complications; at the same time, some low risk women did develop complications, particularly during childbirth. This model has been further defined by what is done in each visit, and is often called focused antenatal care. The women selected to follow the basic component are considered not to require any further assessment or special care at the time of the first visit regardless of the gestational age at which they start the programme. The remaining women are given care corresponding to their detected condition or risk factor. The women who need special care will represent, on average, approximately 25% of all pregnant women initiating antenatal care. They cover the patient’s obstetric history, their current pregnancy and general medical conditions. In addition, she would have to undergo all activities that she missed owing to her late entry into the basic component that were not performed during her visit(s) to the higher level of care. The activities included in the basic component fall within three general areas: • Problem identification: Screening for health and socio-economic conditions likely to increase the possibility of specific adverse outcomes; • Care provision: Providing therapeutic interventions known to be beneficial; and • Health promotion: health education and educating pregnant women about planning for safe birth, emergencies during pregnancy and how to deal with them (birth planning & emergency preparedness). The activities distributed over the four visits are presented in the basic component checklist (Figure 3-3). Results of tests or treatments recommended should be recorded in the clinic’s medical records as is normally done. Rather, it is designed to serve as a reminder of the activities that have been and must be performed. Ideally, the first visit should occur in the first trimester, around, or preferably before, week 12 of pregnancy. As the basic component includes only four visits, sufficient time must be made during each visit for discussion of the pregnancy and related issues with the pregnant woman. For details of activities see learning guide 3-1 in the Participant’s handout, and the national management protocol on selected obstetrics topics.