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Chest Trauma Approximately 60% of all multisystem trauma victims have some type of chest or thoracic trauma (Owens cholesterol in eggs and bacon purchase fenofibrate 160mg without a prescription, Chaudry cholesterol busting foods order 160mg fenofibrate amex, Eggerstedt & Smith cholesterol in eggs is dangerous order fenofibrate 160 mg visa, 2000) foods avoid cholesterol free diet 160mg fenofibrate with visa. Blunt chest trauma results from sudden compression or positive pressure inflicted to the chest wall. Motor vehicle crashes (trauma due to steering wheel, seat belt), falls, and bicycle crashes (trauma due to handlebars) are the most common causes of blunt chest trauma. The most common causes of penetrating chest trauma include gunshot wounds and stabbings. In addition, patients may not seek immediate medical attention, which may complicate the problem. The thorax is palpated for tenderness and crepitus; the position of the trachea is also assessed. The patient is completely undressed to avoid missing additional injuries that can complicate care. Many patients with injuries involving the chest have associated head and abdominal injuries that require attention. An airway is immediately established with oxygen support and, in some cases, intubation and ventilatory support. Re-establishing fluid volume and negative intrapleural pressure and draining intrapleural fluid and blood are essential. The potential for massive blood loss and exsanguination with blunt or penetrating chest injuries is high because of injury to the great blood vessels. Agitation and irrational and combative behavior are signs of decreased oxygen delivery to the cerebral cortex. Strategies to restore and maintain cardiopulmonary function include ensuring an adequate airway and ventilation, stabilizing and re-establishing chest wall integrity, occluding any opening into the chest (open pneumothorax), and draining or removing any air or fluid from the thorax to relieve pneumothorax, hemothorax, or cardiac tamponade. Many of these treatment efforts, along with the control of hemorrhage, are usually carried out simultaneously at the scene of the injury or in the emergency department. Depending on the success of efforts to control the hemorrhage in the emergency department, the patient may be taken immediately to the operating room. Principles of management are essentially those pertaining to care of the postoperative thoracic patient (see Chap. Secondary assessment would include simple pneumothorax, hemothorax, pulmonary contusion, traumatic aortic rupture, tracheobronchial disruption, esophageal perforation, traumatic diaphragmatic injury, and penetrating wounds to the mediastinum (Owens, Chaudry, Eggerstedt & Smith, 2000). Although listed as secondary, these injuries may be life-threatening as well depending upon the circumstances. The physical examination includes inspection of the airway, thorax, neck veins, and breathing difficulty. Specifics include assessing the rate and depth of breathing for abnormalities, such as stridor, cyanosis, nasal flaring, use of accessory muscles, drooling, and overt trauma to the face, mouth, or neck. The chest should be assessed for symmetric movement, symmetry of breath sounds, open chest wounds, entrance or exit wounds, impaled objects, tracheal shift, distended neck veins, subcutaneous emphysema, and paradoxical chest wall motion. In addition, the chest wall Sternal and Rib Fractures Sternal fractures are most common in motor vehicle crashes with a direct blow to the sternum via the steering wheel and are most common in women, patients over age 50, and those using shoulder restraints (Owens, Chaudry, Eggerstedt & Smith, 2000). Rib fractures are the most common type of chest trauma, occurring in more than 60% of patients admitted with blunt chest injury. Fractures of the first three ribs are rare but can result in a high mortality rate because they are associated with laceration of the subclavian artery or vein. Fractures of the lower ribs are associated with injury to the spleen and liver, which may be lacerated by fragmented sections of the rib. For the patient with rib fractures, clinical manifestations are similar: severe pain, point tenderness, Chapter 23 Management of Patients With Chest and Lower Respiratory Tract Disorders 559 and muscle spasm over the area of the fracture, which is aggravated by coughing, deep breathing, and movement. To reduce the pain, the patient splints the chest by breathing in a shallow manner and avoids sighs, deep breaths, coughing, and movement.
Long-term use of alcohol is commonly associated with acute episodes of pancreatitis low cholesterol food indian purchase fenofibrate 160mg on line, but the patient usually has had undiagnosed chronic pancreatitis before the first episode of acute pancreatitis occurs cholesterol levels new zealand immigration 160mg fenofibrate sale. Other less common causes of pancreatitis include bacterial or viral infection cholesterol never sleeps purchase 160mg fenofibrate with visa, with pancreatitis a complication of mumps virus cholesterol medication new guidelines fenofibrate 160mg amex. Spasm and edema of the ampulla of Vater, resulting from duodenitis, can probably produce pancreatitis. Blunt abdominal trauma, peptic ulcer disease, ischemic vascular disease, hyperlipidemia, hypercalcemia, and the use of corticosteroids, thiazide diuretics, and oral contraceptives also have been associated with an increased incidence of pancreatitis. Acute pancreatitis may follow surgery on or near the pancreas or after instrumentation of the pancreatic duct. Acute idiopathic pancreatitis accounts for up to 20% of the cases of acute pancreatitis (Hale, Moseley & Warner, 2000). The mortality rate of patients with acute pancreatitis is high (10%) because of shock, anoxia, hypotension, or fluid and electrolyte imbalances. Attacks of acute pancreatitis may result in complete recovery, may recur without permanent damage, or may progress to chronic pancreatitis. The patient admitted to the hospital with a diagnosis of pancreatitis is acutely ill and needs expert nursing and medical care. Chapter 40 Assessment and Diagnostic Findings Assessment and Management of Patients With Biliary Disorders 1137 the diagnosis of acute pancreatitis is based on a history of abdominal pain, the presence of known risk factors, physical examination findings, and diagnostic findings. Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis. In 90% of the cases, serum amylase and lipase levels usually rise in excess of three times their normal upper limit within 24 hours (Tierney, McPhee & Papadakis, 2001). Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels. The white blood cell count is usually elevated; hypocalcemia is present in many patients and correlates well with the severity of pancreatitis. Transient hyperglycemia and glucosuria and elevated serum bilirubin levels occur in some patients with acute pancreatitis. X-ray studies of the abdomen and chest may be obtained to differentiate pancreatitis from other disorders that may cause similar symptoms and to detect pleural effusions. Ultrasound and contrast-enhanced computed tomography scans are used to identify an increase in the diameter of the pancreas and to detect pancreatic cysts, abscesses, or pseudocysts. Peritoneal fluid, obtained through paracentesis or peritoneal lavage, may contain increased levels of pancreatic enzymes. The stools of patients with pancreatic disease are often bulky, pale, and foul-smelling. Fat content of stools varies between 50% and 90% in pancreatic disease; normally, the fat content is 20%. Antibiotic agents may be prescribed if infection is present; insulin may be required if significant hyperglycemia occurs. Hypoxemia occurs in a significant number of patients with acute pancreatitis even with normal x-ray findings. Respiratory care may range from close monitoring of arterial blood gases to use of humidified oxygen to intubation and mechanical ventilation (see Chap. The patient who undergoes pancreatic surgery may have multiple drains in place postoperatively as well as a surgical incision that is left open for irrigation and repacking every 2 to 3 days to remove necrotic debris. Medical Management Management of the patient with acute pancreatitis is directed toward relieving symptoms and preventing or treating complications. All oral intake is withheld to inhibit pancreatic stimulation and secretion of pancreatic enzymes. Parenteral nutrition is usually an important part of therapy, particularly in debilitated patients, because of the extreme metabolic stress associated with acute pancreatitis (Dejong, Greve & Soeters, 2001). Nasogastric suction may be used to relieve nausea and vomiting, to decrease painful abdominal distention and paralytic ileus, and to remove hydrochloric acid so that it does not enter the duodenum and stimulate the pancreas.
Sodium may be lost by way of vomiting cholesterol test los angeles purchase fenofibrate 160 mg without prescription, diarrhea xanthelasma cholesterol levels order fenofibrate 160 mg visa, fistulas cholesterol recommendations generic 160mg fenofibrate, or sweating cholesterol in home grown eggs discount 160mg fenofibrate with visa, or it may be associated with the use of diuretics, particularly in combination with a low-salt diet. A deficiency of aldosterone, as occurs in adrenal insufficiency, also predisposes the patient to sodium deficiency. Water may be gained abnormally by the excessive parenteral administration of dextrose and water solutions, particularly during periods of stress. Neurologic changes, including altered mental status, are probably related to the cellular swelling and cerebral edema associated with hyponatremia. As the extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into the cells. In general, patients with an acute decrease in serum sodium levels have more severe symptoms and higher mortality rates than do those with more slowly developing hyponatremia. Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. When the serum sodium level drops below 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, and seizures, may occur. This phenomenon is sometimes manifested as "fingerprinting" when the finger is pressed over a bony prominence, such as the sternum. For patients who can eat and drink, sodium is easily replaced, because sodium is consumed abundantly in a normal diet. Serum sodium must not be increased by greater than 12 mEq/L in 24 hours, to avoid neurologic damage due to osmotic demyelination. This condition may occur when the serum sodium concentration is overcorrected (above 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia (Pirzanda & Imran, 2001). It may produce lesions in the pons that cause paraparesis, dysarthria, dysphagia, and coma. The usual daily sodium requirement in adults is approximately 100 mEq, provided there are no abnormal losses. With the addition of the diuretic furosemide (Lasix), urine is not concentrated and isotonic urine is excreted to effect a change in water balance. When neurologic symptoms are present, however, it may be necessary to administer small volumes of a hypertonic sodium solution, such as 3% or 5% sodium chloride. Incorrect use of these fluids is extremely dangerous because 1 L of 3% sodium chloride solution contains 513 mEq of sodium, and 1 L of 5% sodium chloride solution contains 855 mEq of sodium. If edema exists alone, sodium is restricted; if edema and hyponatremia occur together, both sodium and water are restricted. These fluids are administered slowly and in small volumes, and the patient is monitored closely for fluid overload. The purpose is to relieve acute manifestations of cerebral edema and to prevent neurologic complications rather than to correct the sodium concentration specifically. The nurse needs to identify patients at risk for hyponatremia so that they can be monitored. Early detection and treatment of this disorder are necessary to prevent serious consequences. For patients at risk, the nurse monitors fluid intake and output as well as daily body weights. The nurse must be particularly alert for central nervous system changes, such as lethargy, confusion, muscle twitching, and seizures. In Chapter 14 general, more severe neurologic signs are associated with very low sodium levels that have fallen rapidly because of fluid overloading. Serum sodium levels are monitored very closely in patients at risk for hyponatremia; when indicated, urinary sodium levels and specific gravity are also monitored. The elderly are at increased risk for hyponatremia because of changes in renal function and subsequent decreased ability to excrete excessive water loads. Administration of medications causing sodium loss or water retention is a predisposing factor. For example, broth made with one beef cube contains approximately 900 mg of sodium; 8 oz of tomato juice contains approximately 700 mg of sodium.
