By C. Porgan. Rogers State University. 2018.
Enter- component in the management of both hypoxemic ing through the trachea buy 25mg anafranil fast delivery, inspired gas moves via respiratory failure and hypercapnic respiratory fail- bulk ﬂow down the pressure gradient through the ure purchase anafranil 75 mg amex, topics that are discussed in more detail in other conducting bronchi and bronchioles to the respira- chapters. The principle techniques for providing tory units, where gases move by diffusion within artiﬁcial ventilation have changed during the past alveoli and respiratory bronchioles, and then by century. Negative-pressure with the Drinker iron lung, followed by introduc- ventilators simulate the action of the respiratory tion of other negative-pressure devices. However, muscles by creating subatmospheric pressure sur- positive-pressure ventilation, which typically is rounding the chest, thus expanding the thoracic delivered through an artificial tracheal airway, cavity in a manner that is physiologically similar has achieved broad acceptance, whereas negative- to spontaneous breathing. Although the patient-ventilator interface ventilation system, however, yields less-efﬁcient for positive-pressure ventilation is most often an alveolar ventilation and gas distribution. It is is certainly inter-related, approaching the issues noteworthy that pleural pressure is often actually a separately can be useful to emphasize key elements. For mismatching with a large component of underven- example, plateau airway pressures of 30 cm H2O tilated or shunt-like alveoli contributes greatly to may be associated with a transpulmonary pressure hypoxemia and is often responsive to increases in of only 20 cm H2O in a patient who is obese and airway pressure through alveolar recruitment and who has a pleural pressure of 10 cm H2O. Ventilation is determined by breath characteristics, ventilator mode, and respiratory rate, including minimum mandatory breaths and additional patient breaths. There are three types of breaths as deﬁned by initiation and termination signals: ventilator-initiated mandatory breath, patient-initiated mandatory breath, and patient-initiated spontaneous breath. An important that are in-line pressure or ﬂow transducers that concept is that mandatory breaths are “guaranteed,” respond to the patient’s spontaneous efforts. Data both in terms of a minimum number of breaths each suggest that ﬂow-triggered sensors are more sen- minute, as well as delivery of a predetermined vol- sitive to the patient’s efforts than are the demand ume or a predetermined pressure and Ti. In contrast, sensors triggered by changes in pressure, unless spontaneous breaths are dependent on patient effort the pressure transducer is positioned at the distal for both breath initiation as well as breath duration. Depending on but Ti can be determined by the clinician (as in the sensitivity and responsiveness of the ventilator, a mandatory breath) or by the patient (as with respiratory muscular efforts may not be sensed a spontaneous breath). The breath (or -controlled) mandatory breaths, the breath is is terminated and exhalation permitted after the set initiated when a clinician-determined time interval Vt has been delivered. For example, if a frequency of modes, the Ti is also set, and exhalation begins after 10 breaths/min is set, a new breath will be initi- Ti is concluded. Among the conventional modes of ated to deliver the breath varies, increasing to a peak ventilation (Table 1), the frequency of mandatory pressure as the lung is inﬂated. In addition, inspiratory 10 breaths/min) is set; however, all additional efforts trigger the ventilator to supply additional breaths that the patient triggers are also manda- mandatory breaths. Because all breaths are mandatory determine whether an inspiratory effort triggers breaths, hyperventilation in this setting can be an assisted mandatory breath or a spontaneous detrimental because of the resulting high minute pressure-supported breath. Among these modes, an international breath (ie, an “assisted” mandatory breath), or initi- prospective surveillance study performed in 1998 ate a spontaneous breath. Further, as with any pressure-targeted in this mode as well, with the patient receiving three mode, deterioration in lung mechanics can result different breath types. Additionally, the termination of all Some Additional Commercially Available Modes breaths is determined by a reduction in inspiratory of Ventilation effort that is reﬂected in a decrease in ﬂow below a preset percentage of peak ﬂow. The amount of pressure can be adjusted sets the duration of inspiration (and thus the Vt to achieve comfortable breathing, with acceptable varies) by varying the Ti (time cycled) or by setting Vt and respiratory rate (frequency, or f ). There is a paucity sure devices have incorporated more sophisticated of outcomes studies that demonstrate improved alarm systems to circumvent this problem. Some of the recognized forms of patient— resent a small percentage of patients with acute ventilator asynchrony include ineffective trigger- respiratory failure at those centers, and blinding ing, double triggering, auto triggering, and ﬂow subjects and investigators to the intervention is asynchrony. Graphic display of ﬂow and pressure over time demonstrates two conventional breaths followed by an ineffective trigger in which patient inspiratory effort (arrows) does not trigger a breath. Double-triggering is along the bronchovascular bundles toward the identiﬁed by the presence of two positive pressure hila of the lung, rupturing into mediastinum, and breaths separated by a very brief expiratory phase then through the thoracic inlet to produce sub- (less than one half of the preceding Ti; Fig 3). Eventually, air ruptures the patient’s ventilatory demand is high, and the into the pleural space, producing a pneumotho- set ventilator time is too brief, leading to a decrease rax. It is important to recognize lesser forms of in airway pressure early in exhalation that triggers barotrauma, such as subcutaneous emphysema an immediate second positive pressure breath. Volutrauma The development of serious hyperinflation Atelectrauma can be subtle and can be recognized by wheezing Biotrauma Multiple organ dysfunction exhalation persisting up to the next positive pres- Ventilator-associated pneumonia sure breath, respiratory efforts (chest movement) Tracheomalacia without ventilator triggering, characteristic ﬁnd- Trauma and dysfunction of vocal cords Trauma to lip, teeth, oral cavity, nose, pharynx ings of ineffective trigger on ventilator graphics, Unplanned extubation hyperinﬂation on chest radiograph, or a decrease in Endotracheal tube malposition the Vt if the patient is receiving positive-pressure Bronchial intubation ventilation in a pressure-targeted mode. One can temporarily occlude the exhalation port by pressing a button on most modern ventilators, creating a no-ﬂow state that allows equilibration and hemodynamic compromise. Hyperinﬂation of the pressure in the ventilator tubing (where the can overdistend alveoli, increasing the likelihood pressure is sensed) with the pressure deep within of rupture as well as compressing the alveolar cap- the lung. This exhalation is decrease in intrathoracic pressure of sufficient often followed by rapid and dramatic improve- magnitude to be sensed by the ventilator. More definitive extreme, hypotension can progress to frank shock treatment includes bronchodilators, sedation to and even to cardiopulmonary arrest, typically reduce spontaneous respirations, and ventilator with pulseless electrical activity. Mechanisms adjustment to increase expiratory time (reduce include reduced venous return, plus a component respiratory rate, lower Vt, and perhaps increase of altered right and left heart chamber ﬁlling, and inspiratory flow rate). The magnitude of inspiratory deﬂation of alveoli produces damage and inﬂam- effort by the patient can be measured by the use mation, or so-called atelectrauma.
A case-control study10 62 cases from 40 publications generic anafranil 25mg with visa, 7 of whom were showed that appetite suppressants (eg cheap anafranil 50mg with amex, amphet- entirely steroid naïve (eg, not receiving any form amines, fenﬂuramine, and dexfenﬂuramine) are of inhaled or oral steroids when symptoms devel- associated with an increased risk of primary pul- oped), suggesting that there may be a causal rela- tionship. Chest Reactions radiograph abnormalities include pleural effu- sions, atelectasis, diffuse interstitial inﬁltrates, and There are a variety of less common drug- alveolar inﬁltrates. Abciximab, a chimeric monoclo- patients receiving doses of 400 mg/d but can be nal antibody directed against platelet glycoprotein found in patients receiving low-dose therapy. Typically, the a profound impact on patient management, it is adenopathy regresses 1 to 2 weeks after drug with- important to establish a ﬁrm diagnosis as soon as drawal. This begins with an understanding of the is an unusual manifestation of an adverse effect of clinical syndromes caused by various agents com- corticosteroids. Although mediastinal widening in bined with the prudent use of noninvasive studies patients receiving corticosteroids may raise the and invasive procedures. Legionella, and acid-fast bacteria stain and cul- Other rare pulmonary adverse drug effects ture); and (3) immunologic studies to exclude col- reported in the literature include busulfan-induced lagen vascular disorders and vasculitis. Long-term salicylate step in the evaluation of patients with localized or ingestion can cause a pseudosepsis syndrome diffuse pulmonary disease of unclear etiology. Differential Diagnosis of Radiographic Abnormalities Approach to the Patient With Suspected Drug-Induced Lung Disease Diffuse Disease Localized Disease Infection Infection Diferential Diagnosis Malignancy Malignancy Lymphangitic metastasis Pulmonary emboli As mentioned previously, the diagnosis of Pulmonary edema Radiation pneumonitis Pulmonary ﬁbrosis Drug toxicity drug-induced lung disease is one of exclusion Radiation pneumonitis/ﬁbrosis because there are no pathognomonic criteria. Mercapto- mended in patients for whom the diagnosis purine, the active metabolite of azathioprine, is an remains unclear and the differential diagnosis antineoplastic agent. These cytotoxic agents, which are unique in had histologic changes that could be attributed to their ability to cross the blood-brain barrier, are a drug reaction. Bleomycin accumulates against v 6 blocked bleomycin-induced ﬁbrosis in the skin and lung, resulting in skin ulcerations in mice, even when administered after the develop- and pulmonary ﬁbrosis. A disease-speciﬁc gene expres- monary damage, which is the major dose-limiting sion-proﬁling study in which the authors used side effect, was ﬁrst recognized in 1972. Patients typically present with a induced pulmonary toxicity centers on withdrawing subacute onset of a nonproductive cough and the drug and limiting exposure to exogenous oxy- dyspnea within a few weeks to 6 months after gen, as noted previously. Physical examination are generally administered to all patients with ﬁndings may show tachypnea, bibasilar crackles, clinically significant toxicity and then slowly and hyperpigmented skin lesions. Patients with bleomycin- induced hypersensitivity-type disease may have Busulfan, an alkylating agent that is used in the similar symptoms but often with an associated management of chronic myeloproliferative disor- fever, malaise, and chest radiographic changes of ders, was the ﬁrst chemotherapeutic agent impli- chronic pneumonitis and ground glass-appearing cated in causing chronic pneumonitis/pulmonary parenchyma with little ﬁbrosis. In general, alkylating agents (eg, busulfan, and pathologic distinctions between ﬁbrosis and cyclophosphamide, chlorambucil, and melphalan) pneumonitis are not always clear. The inci- total dose is 300 U but 20% when the total dose dence of symptomatic busulfan-induced pulmo- is 500 U18; however, pulmonary toxicity can occur nary ﬁbrosis is approximately 4 to 5%. Occasionally, more susceptible to bleomycin-induced pulmonary pleural effusions, nodular densities, or normal toxicity because of the fact that the kidneys primar- chest radiograph ﬁndings are noted. The extensive clinical indications occur within 10 days to 4 months after initiating for cyclophosphamide and its frequent use in con- therapy but can occur up to 1 month after therapy with methotrexate ceases. Chest radio- induces pulmonary toxicity in humans relatively graphs reveal diffuse interstitial inﬁltrates with infrequently,29 it clearly does so in animals. Other pathogenesis of pulmonary toxicity has not been radiographic abnormalities that are occasionally established but likely involves oxidant-mediated seen include nodular inﬁltrates, hilar/mediastinal mechanisms. Symptoms develop as soon as nary toxicity requires the following three major 2 weeks to as long as 13 years after the initiation criteria: (1) hypersensitivity pneumonitis by histo- of therapy, without any clear dose relationship. Most Risk factors for the development of methotrexate- patients are treated with corticosteroids based on induced pulmonary toxicity include the following: anecdotal reports of beneﬁt. Before the efficacy of Mitomycin steroid therapy was recognized, more than half of the patients required mechanical ventilation, and Mitomycin is an alkylating cytotoxic antibiotic the mortality rate was 33%. The presenting features drome include the release of vasoactive cytokines, as well as the radiographic and physiologic oxidants, and lipid mediators from inﬂammatory changes are similar to those seen with bleomycin- cells, as well as enhanced expression of leukocyte induced interstitial pneumonitis/ﬁbrosis. Although serial mon- patients in whom retinoic acid syndrome develops itoring of the Dlco to detect clinically occult dis- while they are receiving prednisolone have ease is unproven, it is generally recommended and responded to therapy with dexamethasone. A unique reaction of mitomycin is the induction of microangiopathic hemolytic anemia Other Chemotherapeutic Agents/Newer concurrently with noncardiogenic pulmonary Antineoplastic Drugs edema and renal failure. Other chemotherapeutic drugs are less com- The combination of mitomycin with vinca alka- monly associated with adverse pulmonary effects, loids (eg, vinblastine and vincristine) induces an which are seen more often than with the agents acute onset ( 3 h after receiving the vinca alkaloid) reviewed earlier. Chlorambucil, which is an alkylat- of bronchospasm that is associated with focal or dif- ing agent similar to cyclophosphamide, is used in fuse interstitial inﬁltrates seen on chest radiographs the treatment of lymphoproliferative disorders as and hypoxemia. Fludarabine, an tive biological response modifier that induces antimetabolite that is used in the management of 330 Drug-Induced Lung Diseases (Kamp) patients with chronic lymphoproliferative disor- the development of opportunistic pulmonary ders, can cause chronic pneumonitis/ﬁbrosis as infections. Paclitaxel induces hours after ingestion and may be associated with bronchospasm and a type 1 hypersensitivity reac- facial ﬂushing, rhinorrhea, angioedema, and con- tion in up to 30% of patients. These examination; (5) absence of ﬁnger clubbing or patients will often present with dyspnea, tachy- subcutaneous nodules; (6) the presence of blood pnea, altered mental status, and a chest radiograph eosinophilia, proteinuria, or liver dysfunction; (7) revealing diffuse alveolar inﬁltrates. In general, prompt resolu- diagnosis is suspected to enhance renal clearance tion occurs with drug withdrawal, and rarely, a and thereby reduce the serum salicylate level. Hemodialysis is reserved for patients with aspirin- Methotrexate: See the section “Chemotherapy- associated seizures, refractory acidosis, coma, or Associated Pulmonary Toxicity ” for a discussion. Out- Penicillamine: Penicillamine is an antiinﬂam- come is generally favorable in young patients with matory, antiﬁbrotic, and copper-chelating agent an acute salicylate overdose.
Both dietary triacylglycerols and cholesterol are packaged into chylomicrons; these enter the blood (left subclavian vein) via the lymph system buy discount anafranil 50mg online. They are metabolically very active; their stored triacylglycerol is constantly hydrolysed and re-synthesised purchase 25mg anafranil with mastercard. Free fatty acids may be absorbed directly by tissues, or bound to albumin for transport; human serum albumin possesses multiple fatty acid binding sites of various afﬁnities. Glycerol is returned via the blood to the liver (and kidneys), where it is converted to the glycolytic intermediate dihydroxyacetone phosphate (glycerol is an important source of glucose in gluco- neogenesis). These proteins are thought to facilitate the transfer of fatty acids between extra- and intracellular membranes. Studies in aP2-deﬁcient mice have shown that this lipid chaperone has a signiﬁcant role in several aspects of the metabolic syndrome, including type 2 diabetes and atherosclerosis. Chylomicron remnants, containing primarily cholesterol, apo-E and apo-B-48, are then taken up by the liver through interaction with the chylomicron remnant receptor (this recognition requires apo-E). Chylomicrons therefore function to: • deliver dietary triacylglycerols to adipose tissue and muscle • deliver dietary cholesterol to the liver. The endocytosed membrane vesicles (endosomes) fuse with lysosomes, in which the apoproteins are degraded and the cholesterol esters are hydrolysed to yield free cholesterol. The precise mechanism for these effects is unclear, but it may be mediated through the regulation of apo-B degradation. This process has the effect of lowering the level of intracellular cholesterol, since the cholesterol stored within cells as cholesteryl esters will be mobilised to replace the cholesterol removed from the plasma membrane. Lysosomal enzymes degrade the apoproteins and release free fatty acids and cholesterol. This can lead to excess circulating levels of cholesterol and cholesteryl esters when the dietary intake of fat and cholesterol is excessive. Excess cholesterol tends to be deposited in the skin and tendons and within the arteries, which can lead to atherosclerosis. Individuals suffering from diabetes mellitus, hypothyroidism or kidney disease often exhibit abnormal lipoprotein metabolism as a result of secondary effects of their disorders. The resultant hypercholesterolaemia leads to premature coronary artery disease and atherosclerotic plaque formation. Familial hypercholesterolaemia was the ﬁrst inherited disorder recognised as being a cause of myocardial infarction (heart attack). Caucasians and Japanese with the apo-E-ε4 isoform have between 10 and 30 times the risk of developing Alzheimer’s by 75 years of age. While the exact mechanism is unknown, evidence suggests an interaction with amyloid. Alzheimer’s disease is characterised by plaques consisting of the peptide beta-amyloid. However, the isoform apo-E-ε4 is much less effective, which might result in an increased vulnerability to Alzheimer’s in individuals with that gene variation. Drug therapy is considered as an option only if non-pharmacologic interventions (altered diet and exercise) have failed to lower plasma lipids. These are compounds that bind bile acids; the drop in hepatic reabsorption of bile acids releases a feedback inhibition, resulting in a greater amount of cholesterol being converted to bile acids to maintain a steady level in the circulation. Focus on: atherosclerosis ‘Arteriosclerosis’ is a general term describing any hardening or loss of elasticity of medium or large arteries, and refers to the formation of an atheromatous plaque. Lipoprotein-associated phospholipase A2 is an emerging cardiovascular risk marker. Monocytes enter the artery wall from the bloodstream, with platelets adhering to the area of insult. This membrane protein mediates leukocyte-endothelial cell adhesion and signal transduction, and may play a role in the development of atherosclerosis and rheumatoid arthritis. There is also smooth- muscle proliferation and migration from tunica media to intima, responding to cytokines secreted by damaged endothelial cells. They are thought to participate in the removal of many foreign substances and waste materials in the body. It is characterised by a remodelling of arteries involving the concomitant accumulation of fatty substances called plaques. As the plaques grow, artery wall thickening occurs without any narrowing of the artery lumen; stenosis, the narrowing of the artery opening, is a late event, which may or may not occur, and is likely the result of repeated plaque rupture and healing responses. Most commonly a plaque will rupture, forming a thrombus, which can rapidly slow or stop blood ﬂow, leading to death of the tissues fed by the artery: an infarction. There is some evidence that atherosclerosis may be caused by an infection of the vascular smooth-muscle cells. Chickens, for example, develop atherosclerosis when infected with the Marek’s disease herpesvirus. Herpesvirus infection of arterial smooth-muscle cells has been shown to cause cholesteryl ester accumulation, which is associated with atherosclerosis. Various anatomical, physiological and behavioural risk factors for atherosclerosis are known.
Despite being from the one gene generic 10mg anafranil visa, exons may be spliced together in different ways so that different proteins may be manufactured in different tissues buy anafranil 75 mg. This means that organisms did not need to add many new genes over evolutionary time in order to become more complex. They translate extracellular signals into alterations in intracellular neuronal function by regulating the expression of other genes, the latter being referred to as late-response or target genes. These are named from 1-22 in terms of decreasing length; there is also a pair of sex chromosomes, X and Y, or X and X. A father cannot transmit an X-linked trait, be it dominant or recessive, to his son. A euploid cell contains an exact multiplication of the monoploid number of chromosomes, the normal euploid number in humans being 46, i. Non-disjunction occurs at or after the first zygotic division in mosaic Down’s syndrome. Humans, being diploid, normally have 2 copies of each 864 Introns were once seen as merely evolutionary vestiges. However, they can influence the pattern of gene slicing and an intron variant may point toward a functionally important variation in another part of the gene. Additionally, hormone levels and other extracellular factors exert influences on transcription. Transcription factors are required for the normal differentiation of cortical nerve cells. Mitosis is artificially divided into 872 interphase , prophase, metaphase, anaphase and telophase. It is also called reduction division, because the number of chromosomes in the cells produced by meiosis is halved. Put another way, each gamete receives either of a pair of homologous (matching) chromosomes. Four haploid gametes are present at the end of meiosis: in the case of the male germline these are retained as sperm, whereas in the female germline only one is retained as an ovum, the other three forming polar bodies. The process of meiosis consists of 2 steps, each with a prophase, metaphase, anaphase and telophase. Crossing over, the exchange of genetic material between chromatids of maternal and paternal homologous chromosomes, may occur when these chromosomes are paired during prophase of the first meiotic division. Half of all spontaneously aborted foetuses in the first trimester have major chromosomal abnormalities. A biological marker is a biological characteristic or abnormality that may be associated with an abnormal gene or a gene close to (linked) to that gene. Use of biological markers allows a more direct search for a ‘candidate’ (for the disorder) gene. Unfortunately, some markers are state rather than trait markers, the latter being more informative. He described the phenomenon of independent assortment: the pattern of inheritance for one trait was unaffected by the transmission of another trait. However, it has since been shown that when genes for two traits lie close to one another on a chromosome they do not obey Mendel’s independent assortment, i. For example, Mr A got a copy of chromosome 12 from his mother (another the other copy from his father) which is a mix of her 2 copies of that chromosome, one of which came from her mother (the other from her father), and so on back through the generations. If the recombination fragment, a measure of the recombination event, is close to zero, linkage (inheritance of 2 or more markers as a single unit because of their close proximity on the chromosome and not because of chance) is likely. In other words, the lod score is the log of the odds on linkage in genetic research: the logarithm of the odds ratio. The odds ratio equals the odds of the observed pattern of co-segregation between marker and disorder occurring if the marker and disorder are linked divided by the odds of the same co-segregation occurring if the marker and disorder are not linked. Pacitaxel, used to treat cancer, bind to microtubules and prevents movement or organelles. This action prevents formation of mitotic spindles and leads to death of the cell. The pseudoautosomal region of the sex chromosomes is a segment of sequence homology between the X and Y chromosomes in which meiotic cross-over (recombination) can occur. Depending on its exact location, a gene situated within this region could be inherited either in an autosomal or in a sex-linked manner. Normally, one X chromosome exists in an inactive, packaged state, formed during the late blastocyst stage: heterochromatic Barr body. Some parts of the ‘inactivated’ X chromosome remain active, the so-called pseudoautosomal regions. They can be caused by the environment during life and then be passed on to progeny. Such processes can change phenotypes and might explain why major psychiatric disorders do not follow the Laws on Mendel and they may explain how environmental factors translate into biology. Chromatin configuration can allow it to be activated (open; euchromatin - can be accessed by transcription factors) or inactivated (condensed; heterochromatin – cannot be accessed by transcription factors). Rett syndrome and even some of the major ‘function disorders’ such as schizophrenia.
In these cases head blocks only are recommended in order that the neck remains clear for vascular observation generic anafranil 10 mg amex. Roll the casualty so that posterior wounds are not missed and remember to check the axilla and neck generic anafranil 75 mg without a prescription. Do not be falsely reassured by lack of wounds to the chest, as projectiles may still traverse the thoracic cavity from remote wound sites. Sucking chest wounds should be sealed off as soon as they are found using occlusive or valved dressings. Assess for and rapidly treat tension pneumothorax with needle decompression and/or ﬁnger thoracostomy if ventilated. Insertion of an intercostal drain may be indicated if transfer distance and time is prolonged or if the patient is spontaneously breathing. Management is supportive with supplementary oxygen, observation, judicious ﬂuid resuscitation and ventilatory support if there are signs of respiratory failure. Prophylactic bilateral thoracostomy should be considered due to the increased risk of barotrauma. Circulation management Circulatory volume should be preserved at all costs through the aggressive application of haemorrhage control techniques, splinting of fractures and minimal handling. Even simple wounds to the legs, particularlytheupperthigh,canprovefatalasuncontrolledbleeding occurs into the large volume of the thigh. Fluid resuscitation may be initiated during transfer Exposure and should be targeted to a central pulse or verbal response in It is vital that the patient is kept warm throughout the resuscitative penetrating torso trauma. Care should be taken to avoid volume process with appropriate use of blankets and vehicle heaters. Common sites for missed wounds include the back, have a high incidence of associated pelvic injury and the early buttocks, perineum, axilla and scalp. If broad spectrum prehospital application of a pelvic binder is recommended in these cases. Limbs amputated by blast or high calibre munitions may also prove challenging - subclavian central venous access and are rarely suitable for reimplantation. They should however be sternal intraosseous access are useful points of access in these bagged up and accompany the patient to preserve forensics. Tranexamic acid should be given to all patients at risk speciﬁcinterventionisrequiredforsuspectedblastbowelorblastear of ongoing signiﬁcant haemorrhage who are within 3 hours of in the prehospital environment other than standard resuscitation their injury. Disability Tips from the ﬁeld Head injury is common following blast injury and may be the result of primary (concussion), secondary (penetrating fragmentation) • Never enter a ballistic scene before police arrival or tertiary (blunt trauma) blast mechanisms. Gunshot wounds to • For the shocked patient with a ballisticairway injury, secure the the head carry a high mortality, especially through-and-through airway early because airway bleeding may worsen with wounds and those passing close to the brainstem. The level of consciousness after resuscitation is the most – deﬁbrillator pads stick better to clammy skin than electrode leads useful indicator of survival (Box 20. The team leaders come together at regular intervals to • Understand the concept of ‘reading the wreckage’ ensure the overall plan is progressing and that each part of the team • Know how to assess safety in casualty extrication scenarios is aware of the other’s constraints and progress. It is useful space in order to free the casualty to be able to describe standard parts of a vehicle and standard • Know how to safely extricate a patient from a damaged vehicle. The most common terms used in a rescue setting relate to the Introduction support structures that attach the roof. These are labelled, from Motor vehicle collisions are common and produce a signiﬁcant the front, as the A-post, B-post and, in theory, alphabetically as far burden of death and morbidity in a largely young adult popu- back as there are posts. Managing patients effectively during the rescue phase can and B) which are referred to (Figure 21. The whole rescue team should understand the processes involved and should be able to communicate with each other in a Casualty care team (and shared) tasks shared language. A structured approach to the management of motor vehicle Think about safety from the perspective of yourself, the scene collision casualties allows consistency and efﬁciency on scene. The medical team should be trained to work in this Although elements of collision scenes vary, many features are environment and be aware of the risks involved. The two • helmet functions are not necessarily provided exclusively by single services • eye protection ± face visor (e. The • dust mask if working inside a vehicle where glass (particularly the teams must work to a shared plan, and each has its key priorities. Consider too whether the vehicle is carrying any hazardous materials and react accordingly. Safety of the patient may include using a plastic shield (com- monly known as a ‘tear-drop’) when tools are being used in glass management or space creation. Think too about the risk of hypothermia using blankets, bubble-wrap, or chemical or electrical heating systems to keep the patient warm.
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