Deputy Director, West Virginia School of Osteopathic Medicine
Major blunt chest trauma can cause hemopericardium with or without obvious signs of injury medications for factor 8 coversyl 4 mg without prescription, from rupture of a cardiac chamber or medicine shoppe order 8mg coversyl mastercard, less commonly medicine 3202 buy genuine coversyl on line, damage to a coronary artery medicine in spanish cheap coversyl 4 mg without a prescription. Maintain a high index of suspicion for this condition in patients with risk factors, such as certain malignancies. The dissection may expand in a retrograde fashion by extending to the base of the aorta and into the pericardial sac. This is a very difficult diagnosis, and best visualized and comfirmed by bedside ultrasound. Risk factors for aortic dissection include hypertension, atherosclerosis, vasculitis. This complication is less common today than in the past (<1%)39 secondary to improved revascularization techniques, better therapeutic medications, and faster intervention times (shorter door-to-balloon times) for coronary ischemia. Radiation Pericardial effusions (secondary to radiation-induced pericarditis) can develop acutely during radiation therapy or may be delayed for years. Risk factors include the radiation dose, duration of exposure, and age of the patient. Chronic fluid accumulation allows the pericardium to stretch circumferentially and accommodate up to 2000 mL of fluid without any hemodynamic compromise. Thus, asymptomatic patients with moderate to large effusions may not need emergency pericardiocentesis, in contrast to patients with acute hemopericardium. Common causes of nonhemorrhagic effusions are discussed in the following sections. Any sign of hemodynamic compromise, however, warrants strong consideration of pericardiocentesis. Hypothyroidism Hypothyroid patients are at risk for pericardial effusions (up to 30%), but the fluid accumulates gradually, so tamponade develops in only a few patients. Medically managing the underlying hypothyroidism often reverses the effusion without the need for pericardiocentesis. Special Considerations in Pericardial Disease Pericardial tamponade is classically described as being secondary to circumferential effusion, which causes a generalized increase in pericardial pressure and compression of multiple cardiac chambers. Loculated effusions (caused by a local hematoma or an infectious process) or pericardial adhesions (from previous inflammation) can lead to tamponade by compressing one or more cardiac chambers and thus reducing both cardiac filling and cardiac output. These processes cause scarring, fibrosis, or calcification, and the pericardium eventually becomes a nonelastic and "constrictive" sac around the heart. Myocardial relaxation and cardiac filling are impaired, and diastolic dysfunction ensues. Without echocardiography, constrictive pericarditis can be difficult to distinguish from pericardial tamponade. It may be quite difficult to differentiate between effusiveconstrictive pericarditis and pericardial tamponade in stable patients because both are associated with effusions. Once a pericardial effusion is suspected (or diagnosed), the next step is to determine its size and hemodynamic significance and presence of underlying or associated diseases. History: Patient Profile and Symptoms the historical features of pericardial effusions are nonspecific and the diagnosis may easily be overlooked. Patients are likely to present with symptoms relating to the underlying disease rather than the pericardial effusion itself. If the history suggests pericardial effusion, the physical examination should focus on determining the underlying cause. Ironically, many pericardial effusions are not diagnosed from the history or findings on physical examination but are found incidentally during the evaluation for other diseases. In 1935, Beck characterized the physical manifestations of tamponade with two triads, one for chronic and one for acute tamponade. Almost 90% of patients have one or more of these "acute" signs,86 but only approximately 33% demonstrate the complete triad. It would be clinically desirable to identify patients in early tamponade, before hemodynamic collapse. They may be agitated, panic-stricken, confused, uncooperative, restless, cyanotic, diaphoretic, acutely dyspneic, or hemodynamically unstable. Such patients should undergo a brief and focused physical examination followed by a rapid hemodynamic assessment with bedside ultrasound because the time between initial evaluation and full arrest may be brief. Some of the findings on physical examination associated with tamponade are described later. Vital Sign Abnormalities There are three sequential stages that are typically described to reflect the natural history of acute tamponade (Table 16. Some patients are stable within a given stage for hours, whereas others proceed through all three stages and develop cardiac arrest within minutes. Nearly all patients with tamponade present with sinus tachycardia, although its specificity is low. Exceptions to the pairing of tachycardia with tamponade usually relate to the underlying cause of the effusion. Adding to the diagnostic complexity, not all patients in tamponade have a reduction in blood pressure. In fact, Brown and co-workers90 described several tamponade patients with elevated blood pressure. These patients were previously hypertensive and paradoxically had reduced systolic blood pressure following pericardiocentesis. It is observed in other conditions, such as hypotension associated with labored breathing (secondary to extreme reductions in intrathoracic pressure). The absence of distended neck veins may also result from severe venoconstriction secondary to intrinsic sympathetic discharge, vasopressor use, or severe hypovolemia. Bedside ultrasound is the fastest and most reliable diagnostic tool because it is noninvasive, does not emit radiation, and can be performed at the bedside without transporting unstable patients outside the Ed. As discussed previously, pericardial effusions are occasionally discovered incidentally during evaluation for other disorders.
Diseases
Microtia, meatal atresia and conductive deafness
LBWD syndrome
Systemic carnitine deficiency
Pulmonary sequestration
Hereditary angioedema
Spasmodic dysphonia
Decompression sickness
Urban Schosser Spohn syndrome
Hyposmia nasal hypoplasia hypogonadism
Usher syndrome, type 1C
This takes the tube out of the bronchus if it has been placed too deeply and changes the orientation of the bevel if the tube has been temporarily occluded with tracheal mucosa symptoms 9dpiui purchase generic coversyl canada. Air is easily aspirated if the tube was in the trachea medications kidney infection cheap coversyl 4mg amex, but repositioning it will make no difference if the tube was in the esophagus treatment pink eye purchase 8 mg coversyl otc. The syringe aspiration technique can be used before or after ventilation of the patient symptoms 4 days post ovulation order coversyl now. An early study with the Ellick evacuator bulb device reported that 82% of esophageal intubations were identified. Confusion may occur if the esophageal tube is tested more than once because subsequent inflations may be silent. With repeated assessments, false-positive refilling of the bulb may occur as a result of instillation of air during the first attempt. Delayed, though complete refilling of the bulb may occur with bronchial tube placement or placement in the more pliable pediatric airway. The bulb suction modification of the aspiration technique has not been studied as thoroughly as the syringe technique. A significant number of false positives occur with esophageal detection devices (the tube is correctly placed in the trachea, but the device suggests that it is in the esophagus). To date, there has been one reported case of unrecognized esophageal intubation undetected by the syringe aspiration technique. Eventually, all prehospital defibrillators will have advanced monitoring capability that includes capnography. A multicenter study of a colorimetric device demonstrated an overall sensitivity of 80% and a specificity of 96%. Colorimetric changes may be difficult to discern in situations with reduced lighting, and secretions can interfere with the change in color. Regardless of the monitoring device, patients should be ventilated for a minimum of six breaths before taking a reading. Adequate ventilation and oxygenation may be achieved in the supraglottic position, but there is still a risk for aspiration in the absence of a protected airway and the potential for further tube dislodgment. All studies are small, and sensitivity ranges from 96% to 100% for confirming tracheal placement, whereas specificity (detecting esophageal intubation) ranges from 88% to 100%. This method relies on the esophagus being located in the paratracheal position; if the esophagus is directly posterior to the trachea, then detecting esophageal intubation is very difficult. Sonographic sliding signs can also be used immediately after tracheal intubation is confirmed by waveform capnography to evaluate for main stem intubation prior to obtaining a chest radiograph. The detector device remained accurate when air was insufflated into the esophagus for 1 minute, thus simulating unrecognized esophageal placement. Clinical assessment alone yielded an alarming 30% rate of failure to identify esophageal intubation. Complications of Intubation Failure to achieve adequate ventilation and oxygenation is the most serious complication of tracheal intubation. The potential for hypoxia exists just before intubation as more conservative oxygenation methods are attempted and then fail, during difficult intubation when ventilation is halted for an attempt at intubation, and after intubation when esophageal intubation goes undetected. Because irreversible cerebral anoxia occurs within minutes, conservative airway management maneuvers Ultrasound Detection of Tracheal Tube Location Comparison of Detector Devices should be limited to 2 to 3 minutes; failure to achieve adequate oxygenation should lead to a quick decision to intubate. As a guide, limit intubation attempts to the amount of time that a single deep breath can be held by the patient. Longer attempts at intubation are permissible when guided by accurate data from an oxygen saturation monitor because oxygen saturation may remain in the normal range for much longer in patients who have been preoxygenated. The best assurance of tracheal placement is to see the tube pass through the vocal cords. If esophageal intubation is discovered, removal of the tube may be followed by emesis. Apply cricoid pressure during tube removal and maintain it until the intubation is successful. Alternatively, leave the first tube in the esophagus to serve as a temporary gastric-venting device and as a guide to intubation until tracheal intubation is achieved. Endobronchial intubation was clinically unrecognized without a chest film in 7% of prehospital intubations in one study. Pharyngeal stimulation can produce profound bradycardia or asystole, thereby confirming the need for an assistant to monitor cardiac rhythm throughout the intubation. Keep atropine available to reverse the vagal-induced bradycardia that may occur secondary to suctioning or laryngoscopy. Prolonged pharyngeal stimulation may also result in laryngospasm, bronchospasm, and apnea. Hypotension requiring intervention in the peri-intubation period occurs in approximately 1. Look for any avulsed teeth not found in the oral cavity on the postintubation chest film. Tracheal or bronchial injuries are rare, but serious and usually occur in infants and the elderly as a result of their decreased tissue elasticity. These concerns are essentially theoretical, with no credible data to prove or disprove a true effect. Many anesthesiologists prefer awake endoscopic intubation in this setting, but no data support one approach over another. The cervical collar should be removed for intubation, and cervical immobilization held manually by an assistant.
The Heimlich valve does not require suction and can be used for outpatient therapy medicine 54 357 cheap coversyl online mastercard. With a one-bottle underwater seal system medicine used to stop contractions discount coversyl online, the intrapleural fluid or air exits under a small amount of water treatment ibs buy coversyl 4 mg without a prescription. The water above the tube acts as a seal because it is too heavy to be drawn back into the chest medicine qvar inhaler cheap 4 mg coversyl with amex. For drainage to occur, intrathoracic pressure must be greater than the water pressure at the distal end of the immersed tube. This pressure is determined by the height of the water above the exit port of the tubing. When the height is too great (the tube is too deep in the water), even coughing may not raise intrapleural pressure sufficiently to drain the chest. Place the collecting bottle below the patient, usually on the floor, to prevent inspiration from generating enough negative pressure to pull the contents of the collection bottle into the chest cavity. Use suction initially to treat patients with pneumothorax or hemothorax, but replace it with a water seal once drainage and expansion are satisfactory and no persistent air leaks are present. The suction device should have high suction flow (20 L/min) and be able to keep the suction constant. When negative pressure from the suction source exceeds the depth of the water in the chamber, air enters from the top of the third tube and causes continuous bubbling. The wall suction dial can be turned down until only occasional bubbling can be detected. The bottle combinations example is provided to illustrate the principles but is rarely used now. Many types of commercial, enclosed systems are available that essentially combine a twobottle method that can be connected to suction, but with the addition of an "air leak chamber". Bubbling in this chamber indicates the presence of an air leak, usually from the drainage system itself as a result of a loose tube connection. If bubbling is present, first check the drainage system, tube, and connectors for any problems or loose connections. If the leak continues, check whether all the holes of the chest tube are within the thorax. If the bubbling continues after these steps, a continued air leak may be due to a large hole in the lung parenchyma, which is usually seen only with expiration or with coughing. A continuous air leak or a leak during inspiration indicates a larger and possibly more significant lung injury. The drainage reservoir must remain below the level of the chest to prevent the fluid in the collection system from reentering the chest. Simple respirations do not generate enough negative intrathoracic pressure to pull the water in the reservoir up to the height of the chest if the reservoir is kept on the floor and the patient is either sitting or lying at standard chair or bed height. The length of the tubing should be long enough so that the reservoir can be kept below the level of the patient, but not long enough to cause it to form dependent loops of fluid or kinks. If these pressures become high enough (15 to 25 cm H2O), a tension pneumothorax may result. When the drainage system is functioning properly, the height of the fluid level in the drainage tube fluctuates with inspiration and expiration. Absence of respiratory fluctuation or a decrease in drainage may indicate that the system is blocked or that the lung is fully expanded. If the tube is blocked, the chest tube, collecting tubing, or both, can be changed or stripped to dislodge clots. Replacing the tube is a complicated process associated with risks, but the stripping procedure is controversial because of concern that the potentially high negative pressure from the procedure could damage lung tissue. The sudden increase in negative pressure may extract clots and fluid from a more proximal location. If the blockage is within the thorax, the tube can be cleared by forcing air or fluid back into the chest. The tube must be clamped distally and then compressed and stripped to force the contents proximally. Perform occlusive clamping of a chest tube only with close monitoring because a tension pneumothorax can result in rare cases. Patients with chest tubes in place are best transported with a Heimlich valve or water seal only, not with the tube clamped. B, Tie the knot securely and leave the suture ends long for wrapping around and tying the tube. Wrap the suture tightly at least twice around the tube, enough to indent the tube slightly, and tie securely. Another method to close the wound and secure the tube is with a horizontal mattress suture combined with a stay suture. B, the loose ends are also wrapped around the tube and tied loosely in a bow to identify the suture. This suture will be untied and used to close the skin incision after removal of the tube. First wrap the base of the tube at the skin incision with a petroleum-impregnated dressing.
It is also indicated in less urgent circumstances when medical therapy has failed treatment 20 coversyl 8mg with visa. In elderly patients symptoms at 6 weeks pregnant discount coversyl 4mg otc, in whom a prolonged rapid heartbeat can be anticipated to cause complications medicine misuse definition buy discount coversyl 4 mg on line. In the unusual case of sinus node reentrant tachycardia medicine vial caps coversyl 4 mg, rapid onset and offset may be the only clues. Ventricular rates in excess of those predicted for age strongly suggest an accessory pathway. Dysrhythmias caused by enhanced automaticity will not be terminated by uniformly depolarizing myocardial tissue because a homogeneous depolarization state already exists. Although cardioversion will not work in these cases, medications that suppress automaticity, including potassium and magnesium, may be useful. Digoxin is still generally withheld for 24 hours before cardioversion as a precaution against inadvertently elevated levels. Although many of these drugs are not used routinely, if they are needed, timing is likely to be critical. A significant and preventable complication of procedures involving sedation is hypoventilation leading to hypoxia. A pulse oximeter is generally recommended for patients undergoing conscious sedation. Synchronized monophasic or biphasic cardioversion is the appropriate first choice of treatment for unstable patients. Check to see that the machine is correctly identifying the R wave of the complexes (arrow). Sedative medications should be ready for use in labeled syringes, along with a prefilled saline syringe for flushing the catheter. If a patient has metabolic acidosis, compensatory hyperventilation after endotracheal intubation may be indicated before cardioversion. Sedation Cardioversion may be extremely painful or terrifying, and patients must be adequately sedated before its use. Administer the anesthetic agent or agents intravenously over a period of approximately 30 seconds and wait until the patient is unable to follow simple commands and loss of the eyelash reflex is noted. Administering the agent too quickly may result in hypotension; administering it too slowly may not allow blood levels to reach a therapeutic range if the agent has a rapid rate of metabolism. Cardioverter Use Selection of the synchronized or nonsynchronized mode is the next critical step. In the synchronized mode, the cardioverter searches for a large positive or negative deflection, which it interprets as the R or S wave. Once the cardioverter is set to synchronize, a brief delay will occur after the buttons are pushed for discharge as the machine searches for an R wave. If concern exists about whether the R wave is large enough to trigger the electrical discharge, the clinician can place the lubricated paddles together and press the discharge button. When the R- or S-wave deflection is too small to trigger firing, change the lead that the monitor is reading or move the arm leads closer to the chest. Electrode Position: Same as for Defibrillation Electrode paddles may be positioned just as they are for defibrillation. Any staff member acting as a ground for the electrical discharge can be seriously injured. The operator must announce "all clear" and give staff a chance to move away from the bed before discharging the paddles. Care must be taken to clean up spills of saline or water because they may create a conductive path to a staff person at the bedside. Energy Requirements the amount of energy required for cardioversion varies with the type of dysrhythmia, the degree of metabolic derangement, and the configuration and thickness of the chest wall. Obese patients may require a higher energy level for cardioversion, and the anteroposterior paddle position is sometimes more effective in these patients. If patients are shocked while in the expiratory phase of their respiratory cycle, energy requirements may also be lower. Cardioversion will be accomplished with 50 J in 90% of cases, and conversion should initially be attempted at this energy level. If the initial attempts at electrical cardioversion Methohexital 1 mg/kg Etomidate Propofol Thiopental Fentanyl 0. Midazolam is probably the most commonly used agent, with induction occurring approximately 2 minutes after a dose of approximately 0. Although induction with midazolam takes slightly longer than with the other medications, it has the advantage that a commercial antagonist, flumazenil, is available for reversal if necessary. Fentanyl can cause respiratory depression, but its action can be reversed with naloxone. Methohexital has the advantage of quick onset and a somewhat shorter duration of action than midazolam does, but it has a rare association with laryngospasm. All the drugs except etomidate and ketamine may cause a small drop in blood pressure, and infusion of propofol and etomidate is painful. If they do not, or if urgent conversion is needed because of a high ventricular rate, an electrical countershock should be administered in the synchronized mode at 50 J and doubled if necessary. Patients with ischemia or known coronary artery disease appear to be at much higher risk for significant post-shock bradycardia, with rate support pacing being required after 13 of 99 shocks in the aforementioned study. Therefore the proclivity for dysrhythmias is greater with high-dose cardioversion of an ischemic heart. Conclusion Cardioversion is a safe and effective method of quickly terminating reentrant tachycardia.
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