general approach to the critically ill patient

... Approach to the Patient: Acute Febrile Illness A physician must have a consistent approach to acutely ill patients Even before the history is elicited and a physical ... Assessment of the patient' s general appearance and vital signs, skin and soft tissue examination, and the neurologic evaluation are of particular importance The patient may appear either anxious ... a febrile patient can be a harbinger of critical illness History Presenting symptoms are frequently nonspecific Detailed questions should be asked about the onset and duration of symptoms and...

Ngày tải lên: 07/07/2014, 04:20

... bacilli Surgical evaluation is 72 essential If a Ceftriaxone (2 penicilling q24h) or oxacillinsensitive strain is isolated, those agents are superior to vancomycin (penicillin, mU q4h; or oxacillin, ... discontinued Erythroder Group A Vancomycin If ma: toxic shock Streptococcus, (1 g q12h) plus penicillin- syndrome oxacillin- Staphylococcus a or 29, 130 toxigenic bacteria should be debrided; IV immunoglobuli ... A Penicillin (2 Urgent Streptococcus, mU q4h) plus surgical mixed evaluation 19, 130 is substituted for penicillin while culture data are pending Clostridial myonecrosis Clostridi Penicillin (2...

Ngày tải lên: 07/07/2014, 04:20

... patients succumb to sepsis at 58 times the rate of the general population; 50–70% of cases occur within the first years after splenectomy, with a mortality rate of up to 80%, but the increased risk ... encapsulated bacteria cause the majority of infections Adults, who are more likely to have antibody to these organisms, are at lower risk than children Streptococcus pneumoniae is the most common isolate, ... streptococci can present as intractable hypotension and multiorgan failure Treatment can usually be initiated empirically on the basis of the presentation (Table 265-3) Adjunctive therapy with either...

Ngày tải lên: 07/07/2014, 04:20

... of patients have skin findings Blanching macules develop initially on the wrists and ankles and then spread over the legs and trunk The lesions become hemorrhagic and are frequently petechial The ... petechial The rash spreads to palms and soles later in the course The centripetal spread is a classic feature of RMSF However, 10–15% of patients with RMSF never develop a rash The patient can be hypotensive ... Asia, and southern Europe Patients have fever, flu-like symptoms, and an inoculation eschar at the site of the tick bite A maculopapular rash develops within 1–7 days, involving the palms and...

Ngày tải lên: 07/07/2014, 04:20

... onset of malaise, chills, fever, and hypotension The patient develops bullous or hemorrhagic skin lesions, usually on the lower extremities, and 75% of patients have leg pain The mortality rate ... or mucosal portals of entry for the organism can be ascertained when a careful history is taken Colonization rather than overt infection of the vagina or a postoperative wound, for example, is ... streptococcal TSS Viral Hemorrhagic Fevers Viral hemorrhagic fevers (Chaps 189 and 190) are zoonotic illnesses caused by viruses that reside in either animal reservoirs or arthropod vectors These...

Ngày tải lên: 07/07/2014, 04:20

... and then progresses to ptosis, proptosis, ophthalmoplegia, and papilledema The mortality rate is as high as 30% Septic thrombosis of the superior sagittal sinus spreads from the ethmoid or maxillary ... instability Rapid recognition of the toxic patient with central neurologic signs is crucial to improvement of the dismal prognosis of these entities Subdural empyema arises from the paranasal sinus in ... cases Microaerophilic streptococci and staphylococci are the predominant etiologic organisms The patient is toxic, with fever, headache, and nuchal rigidity Of all patients, 75% have focal signs...

Ngày tải lên: 07/07/2014, 04:20

... Staphylococci are the most common etiologic agents This diagnosis must immediately be considered in patients with a history of antecedent back pain and new neurologic symptoms Almost 60% of patients have ... abuse; recent spinal trauma, surgery, or epidural anesthesia; and other comorbid conditions, such as HIV infection The thoracic or lumbar spine is the most common location; cervical spine infections ... entity should be urgently considered if patients who have recently traveled to areas endemic for malaria present with a febrile illness and lethargy or other neurologic signs Fulminant malaria...

Ngày tải lên: 07/07/2014, 04:20

... admission to intensive care units The most important task of the physician is to distinguish these patients from other infected febrile patients who will not progress to fulminant disease The alert ... illness, and lower respiratory tract symptoms Watery diarrhea may develop and may precede respiratory symptoms Dyspnea develops a median of days after the onset of symptoms and can progress to ... should be considered in patients with severe respiratory tract illness, particularly if they have been exposed to poultry To date, human -to- human transmission is rare Patients present with high...

Ngày tải lên: 07/07/2014, 04:20

... to the endothelium is increased, especially in septic patients, potentially leading to microcirculatory impairment and tissue hypoxia [13] Tolerance to anemia in healthy subjects and in the critically ... critically ill patient Tolerance to anemia is highly dependent on the volume status of the patient, physiological reserve, and the dynamics of the anemia (for example, chronic, such as the anemia ... potassium, release of proinflammatory cytokines) These stored RBCs also have an increased tendency to adhere to endothelium and could promote vasoconstriction; the stored RBCs act as a “sink” for...

Ngày tải lên: 20/06/2014, 23:20

... contact with the patient, if the operator touches, after patient contact, only the probe, the keyboard and the contact product, only these three elements will have to be wiped down after the examination ... from the rachis to the The pancreatic gland is then recognized anteala ilii rior to the splenic vein The head is anterior to the inferior vena cava The isthmus and the Bladder body are parallel to ... the Critically From the ultrasound perspective, the critically ill patient differs from other patients on two levels First, since most often comatose and immobilized in the supine position, the...

Ngày tải lên: 09/08/2014, 15:20

... in the critically ill patient Hepatomegaly Although some operators can evaluate the weight of each lobe, the subjective feeling that the liver is enlarged is sufficient for others [1] In the critically ... if not, they are in shock or encephalopathic Pain is either absent or diffuse to the entire body Peripheral Peritoneal Effusion Peritoneal effusion is very frequent in the critically ill patient ... cholecystitis another cause explaining the symptoms We still should incite the physician to search for another find this policy valuable after 12 years of observacause to explain the present symptoms A...

Ngày tải lên: 09/08/2014, 15:20

... urinary pointing toward the rear and the bottom of the patient, probe The balloon and the end of the probe are visible one can see a regular round and medial structure, the in- The probe was obstructed ... imagine the head of a Thai dragon This is, in fact, a full bladder associated with peritoneal effusion in a young woman The bladder is the round shape at the top of the screen The eyes and the mouth ... mouth of the dragoon reflect the peritoneal effusion The nose is formed by the uterus and the large ligaments The teeth are generated by solid structures floating in the effusion - a hemoperitoneum...

Ngày tải lên: 09/08/2014, 15:20

... However, the studies dealing with the critically ill patient admitted in the ICU (in particular, the medical ICU) are rare In this patient, it is illusory to consider symptomatic and asymptomatic patients ... veins, which can be either Examination Technique: Recognizing the Vein As opposed to the ambulatory patient, the critically ill patient cannot be examined sitting, with the Fig 14.1 Common femoral ... the area of the vein, switch off the ultrasound 77 Fig 12.16 The operator's hand holding the probe exposes the vein in its long axis and remains strictly motionless over the thorax The operator's...

Ngày tải lên: 09/08/2014, 15:20

... 15.3 On the left figure, the probe explores the lateral zone up to bed level The bed prevents the probe from going further On the rightfigure ,the back of the patient has been sHghtly raised (the ... supine patient This zone will not be easy to approach Rotating the patient in the lateral decubitus will not be entirely satisfactory, since the effusion will subsequently move (Fig 15.6) The main ... saves time and lives If the patient does not tolerate the pneumothorax, it will not be necessary to wait for the return of the radiograph to treat In the trauma patient, when the pneumothorax has...

Ngày tải lên: 09/08/2014, 15:20

... transportation This is the major drawback in an emergency - The delay from the decision to perform a CT to the moment when the patient can benefit from therapeutic changes subsequent to the CT results ... Note that in this scan, the right of ery Often, the most central layers of the thrombothe image corresponds to the head of the patient sis are still mobile, and one can see them driven ... be transported to the CT room, or worse, to conventional angiography? Should that patient in shock be submitted to the risk of heparin therapy Let us recall that the location of the hemidiaor...

Ngày tải lên: 09/08/2014, 15:20

... acquiring an ultrasound dedicated to the transesophageal route blocks the way to general ultrasound and condemns the user to visualizing only the heart The reader will therefore not take offense if ... extend to the right All these techniques, when they provide an answer to the clinical question, should theoretically decrease the need for the transesophageal technique Above all, they respond to ... pen, the operator's hand lies firmly on the patient' s face, and the probe is gently applied toward the eyelid The progression of the probe ceases from the instant an image is obtained at the screen...

Ngày tải lên: 09/08/2014, 15:20

... proves to be an effective contact product (sterile gel can again be used) The operator holds the probe in one hand, the needle in the other, and proceeds to the tap Once the needle is in the target, ... difficult to detect it in the last third This situation comes up whether the needle is thin or thick, the gain is low or high, the patient is thin or overweight, whether the patient is on corticotherapy, ... critically ill patient admitted to the ER will be olemia (inferior vena cava caliper) were investigatquickly taken in charge by the intensivist Respira- ed and provided the answer to 90.6% of the tory...

Ngày tải lên: 09/08/2014, 15:20

... identified, and the patient will be grateful to us! Going farther, we could say that the free hand of the operator can also evaluate abdomen suppleness or, on the other hand, parietal contraction The Thoracic ... performed at the bedside is a clinical examination, in the etymological sense The other half will be achieved if one looks into the meaning of the word »stethoscope«, which comes from the Greek ... immediate use in the emergency setting Analysis of the hemodynamic status raises a number of issues The absence of a gold standard is not the least of these In the critically ill patient, blood...

Ngày tải lên: 09/08/2014, 15:20

... placement of the tracheal cannula It remains unclear whether this was related to the level of procedural experience in the individuals performing the procedures or due to other factors These observations ... coworkers, like other authors in the past, did not report findings in the patients who received surgical tracheostomy or were left intubated during the period while study patients were assigned to percutaneous ... manner will be able to gather further scientific evidence regarding the risks and benefits of different techniques for percutaneous dilatation tracheostomy In addition, such studies should try to...

Ngày tải lên: 12/08/2014, 20:20

... 428 Although the findings reported by Van den Berghe and coworkers are impressive, some concern arose regarding the applicability of these results to other types of patients Of the patients studied, ... hours, whereas the ICU stay extended up to 71 days, with a median of days Insulin was administered to only 9% of the patients during the 48-hour period of observation In addition, patients received ... insulin therapy in the critically ill: Insulin dose versus glycemic control Crit Care Med 2003, 31:359366 Finney SJ, Zekveld C, Elia A, Evans TW: Glucose control and mortality in critically ill patients...

Ngày tải lên: 12/08/2014, 20:20