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When approaching the Although rare buy 160 mg super viagra with amex, lightning injury is one of the more hypothermic athlete effective 160mg super viagra, the FP must keep the following frequent injuries by a natural phenomenon with the points in mind: largest number of sports injuries occurring in water 1 best 160 mg super viagra. Treatment should routinely start with passive exter- sports and most injuries occurring during the months nal rewarming (i generic 160mg super viagra overnight delivery. Although to a warm environment, removing all wet clothing, it is by definition an electrical injury, it differs sig- and covering with dry blankets). Active external nificantly from high-voltage electrical injuries in rewarming and core rewarming should usually be both the pattern and severity of injuries as well as the CHAPTER 4 FIELD-SIDE EMERGENCIES 19 immediate treatment. Although the voltage of light- SUMMARY ning is extraordinarily high, it is usually an instanta- neous contact that tends to flash over the outside of a In conclusion, though most sports related injuries are victim’s body, often creating superficial burns, but minor, for the few urgent/emergent events the FP will sparing extensive damage to internal organs and encounter, planning is paramount. Lightning may injure a person by striking appropriate for the event and knowledge of life sup- either the person directly or something they are hold- port techniques is essential. A study of the topics pre- ing, or by splashing over from a nearby person or sented here should be helpful in preparing for object that has been struck. Although it can potentially affect any organ system, injuries to the cardiovascular and neurologic systems tend to be the most common, REFERENCES with the immediate cause of death most commonly being cardiopulmonary arrest (Jacobsen et al, 1997). Clin Sports Minor injuries include dysesthesias, minor burns, Med 16(4):739–753, 1997. The FP should keep the following points in mind Cantu RC: Second-impact syndrome. Clin Sports Med 1: 37–44, when approaching a victim of lightning injury: 1998. Victims do not “retain charge” and are not danger- Colorado Medical Society School and Sports Medicine ous to touch, so CPR should not be delayed for this Committee: Guidelines for the management of concussion in reason. Contrary to popular belief, lightning can and often Committee on Trauma: Advanced Trauma Life Support for does strike the same place twice, so personal safety Doctors: Student Course Manual. Hypotension in a lightning victim should prompt a Crump WJ: Managing adolescent sports head injuries: A case- search for occult hemorrhage or fractures as a based report. Spinal precautions are Cuculino GP, DiMarco CJ: Common ophthalmologic emergen- required. Pupils may become “fixed and dilated” because of Em Med Rep 23(13):163–178, 2002. Fowler R, Pepe PE: Prehospital care of the patient with major the nature of lightning injuries and this should not trauma. In lightning victims with cardiopulmonary arrest, Graber M: Minor head trauma in children and athletes. Emerg cardiac automaticity and contractions will often Med 14, 17, 18, 20, Oct. Phys time, while respiratory arrest from paralysis of the Sportsmed 29(3):45–62, 2001. Harmon KG: Assessment and management of concussion in Therefore, unless the victim is ventilated quickly sports. If promptly Kuhlman GS, McKeag DB: The “burner”: A common nerve injury resuscitated and supported, full recovery may in contact sports. The start and finish are common sites of med- Quality Standards Subcommittee: Practice parameter: The man- ical concern. The start area should be on a large level agement of concussion in sports (summary statement). The finish area should also be large Winbery SL, Lieberman PL: Anaphylaxis. Immunol Allergy Clin enough to prevent the athletes from bunching up and North Am 15(3):447–475, 1995. It should also have necessary facilities and resources to allow the athletes to properly cool down and recover after the event and easy access to medical treatment areas. Water temperature, sea conditions, road condi- tions, transition, acceleration and deceleration areas, and protective equipment must be carefully scrutinized. GOALS EPIDEMIOLOGY Mass participation events are those sporting events in which many people participate and are generally INJURY RATE spread out over several miles and variable terrain.

The whole supracondylar area shows extensive intra-ar- ticular hemarthrosis after a fracture 160mg super viagra amex. Two thick fat pads Treatment are located at the front and back between the fibrous and Conservative synovial layers of the capsule cheap 160mg super viagra, resulting in a contrasting Type I: »fat pad sign« on the x-ray in the event of the intra-articu- Long-arm cast for 2–4 weeks discount super viagra 160 mg amex, depending on the age of lar accumulation of fluid generic 160mg super viagra free shipping. For initially non-displaced fractures, those Standard AP and lateral x-rays are arranged only if no at greatest risk of displacement are those in which obvious deformity is clinically apparent. In order to avoid at least one of the two condylar pillars is completely unnecessary manipulations, the x-ray is recorded in this fractured. In this case, a check x-ray, without cast, is case with the arm in the most comfortable position. Classification of supracon- dylar humeral fractures: Since the rotational deformity and the resulting instability repre- sent the central problem in these fractures, the only distinction required in such cases is between fractures without (a, b) and frac- tures with (c, d) rotational deformities a b c d 501 3 3. In the case of Without primary rotational deformities: If a toler- fixation from the ulnar side, a small incision should be able extension deformity is present according to the made to check that the nerve is not directly located at the patient‘s age (see Prognosis/Spontaneous correction entry site to rule out the possibility of any iatrogenic ulnar potential), a long-arm cast is fitted in the maximum neuropathy. The younger the patient, the more likely it is that cast, is recorded 4–5 days later to rule out any second- a constitutional anterior subluxation of the ulnar ary rotational deformity. Surgical Closed reduction Fractures that are difficult to stabilize, particularly those After closed reduction under anesthesia, the fracture is with substantial metaphyseal comminution and extensive stabilized, unless a type II fracture without a primary soft tissue damage, require alternative methods, e. The bony landmarks are often difficult to locate under Timing the swelling, but this is usually possible if the elbow is The taboo of the delayed management of type III fractures flexed. An anatomically reduced fracture should satisfy is increasingly being called into question. Neurovascular the following criteria: The radial epicondyle is located complications are not more likely to be observed as a dorsally in relation to the medial condyle. Since most compli- swelling, it should be possible to approximate it to within cations after supracondylar humeral fractures are iatro- approx. As regards the elbow axes, the extended unaffected arm should be used for guidance purposes since consider- Follow-up controls able individual differences exist. The reduction maneuver Once the function and elbow axes are the same on both starts with gentle traction in order to free the proximal sides, treatment can be considered as concluded. If this proves un- term monitoring is only justified if there is a bony defor- successful, the brachialis muscle must be massaged away mity in the sagittal plane, in order to verify spontaneous from the bone with »milking« movements in a proximal correction in younger patients or, in older patients, to to distal direction. We then eliminate the mediolat- discuss the possibility of a subsequent corrective os- eral translation while maintaining traction by holding teotomy, depending on the persistence of functional the condylar block between thumb and forefinger. Open reduction Open reduction is by no means simpler than the closed procedure. It is indicated only in the event of a vascular le- sion requiring revision and after a failed closed reduction, which applies in approx. The proximal fragment has penetrated the brachial muscle into the subcutaneous tissues. In relation to stability, note the correct position of the wires, which cross at a point proximal a b to the fracture Complications tive osteotomy should be discussed in older patients ▬ Movement restriction. Even in ideal cases it can often take over 6 months al, independent follow-up management are preferred. Premature If a movement restriction is capsular in origin, we physiotherapy usually proves to be useless or even perform a distraction arthrolysis: In this procedure a counterproductive. Translation deviations and in the frontal plane, particularly cubitus varus, do not deformities in the sagittal plane correct themselves correct themselves, regardless of age, as growth con- according to the age of the patient. The underlying cause is in- rotational deformities, they do not play a major role adequate elimination of the rotational defect and/or in functional respects as the shoulder is able to com- inadequate stabilization (⊡ Fig. Spontaneous correction, which can cosmetic appearance is still the commonest indication take more than a year, should be awaited in children for a corrective osteotomy, although sporting children under 6. In younger children, the medial apophysis lies within the capsule, whereas the fracture line in the more frequently affected older patients always runs outside the joint, which means that the radiological sign of an elbow hemarthrosis, i. A mere wid- ening of the growth plate is often only apparent with non- displaced fractures.

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A quantitative systematic account for this hourly volume restriction; in gen- review discount super viagra 160 mg visa. Many patients managed with clysis opioid analge- Does an acute pain service improve postoperative sia are opioid tolerant order super viagra 160 mg on-line, so double-check that the outcome? Gilfor order super viagra 160mg mastercard, MD The epidural space is continuous with the paraver- tebral space via the intervertebral foramina order super viagra 160mg line. Viscusi, MD Superiorly, the space is anatomically closed at the foramen magnum where the spinal dura attaches to the dura of the cranium. BACKGROUND AND HISTORY Caudally, the epidural space ends at the sacral hia- tus and is closed by the sacrococcygeal ligament. Hingson, Pages, Dogliotti, Tuohy, and Bromage, epidu- Posteriorly, the epidural space is entered by passing rals have become a standard modality for anesthesia. Brian Ready has been a driving between the vertebral spinous processes, piercing the force behind the establishment of epidural analgesia as two relatively soft supraspinous and interspinous lig- the modality of choice for postoperative pain control. Especially in the elderly, the ligamen- most widely used in the anesthesiologist’s arsenal. Because the dura and ligamentum flavum adhere to one another, the epidural space is a EPIDURAL MEDICATIONS “potential” space that surrounds the dural sac (see Figure 18–1 and Table 18–1): GENERAL COMMENTS REGARDING Anteriorly, it is bounded by the posterior longitudi- EPIDURAL MEDICATIONS nal ligament. Posteriorly, it is bounded by the ligamentum flavum All medications placed in the epidural space must be and the periosteum of the laminae. Usually exhibits marked negative pressure (especially if seated) Thoracic region Very narrow lateral epidural space Ligamentum flavum is thicker than in cervical DELIVERY METHODS region, but thinner than midlumbar T5 through T9 spinous processes are the most In the past, epidural medications were delivered as angulated, making midline approach difficult single-shot boluses, on an as-needed basis. This prac- Spinal cord is narrowest in the thoracic region Usually exhibits negative pressure (especially tice, however, inevitably leads to periods of inadequate when seated) analgesia and increased severity of unwanted side Lumbar region Widest epidural space effects resulting from high peak medication levels. Spinal cord ends at about L1–2 (in adults) Newer methods employ continuous and patient-con- Ligamentum flavum is the thickest Spinous processes have the least angulation trolled epidural analgesia (PCEA) infusions to allevi- Lumbar region has very prominent lateral ate the shortcomings of periodic bolus dosing. Standard concentrations and addi- ing a specified period (minutes, hour, or days). Typically, however, these pumps cannot accommo- Standardization of epidural analgesic medications for date the quantities of medication in the concentra- the institution may reduce costs and minimize waste tions usual for epidural analgesia. Peristaltic pumps: Deliver medications from a flex- Epidural catheters must be readily identifiable by ible reservoir via tubing that is squeezed between medical and nursing staff to prevent unintended rollers that create a positive displacement of a given injection or infusion of inappropriate agents. Peristaltic pumps colored flag-type labels near the injection port end of can accommodate larger volumes (50–1000 mL) the catheter work well for this purpose (see Figure than are possible with syringe pumps and are typi- 18–3). Elastomeric reservoir pumps: Force fluid from an elastomeric pressurized medication reservoir through a flow regulator. These devices are not well-suited for in-hospital epidural drug administra- tion because the flow rate is specific for the regula- tor installed in the pump mechanism and, therefore, is not adjustable. The lower rates are used for thoracic epidural infusions; the higher FIGURE 18–2 Typical epidural medication label. Lumbar catheter 10–18 mL/h Using ropivacaine instead of bupivacaine may reduce the motor block component while maintain- ing adequate sensory analgesia. LOCAL ANESTHETICS Motor block is less likely to be an issue with an epidural placed in the thoracic region. A thoracic Local anesthetics play the central role in epidural epidural catheter can provide adequate pain relief analgesia. Only a small fraction of local anesthetic diffuses into the sub- OPIOIDS arachnoid space. Nearly every available preservative-free anesthetic is typically not dependent on the drug’s opioid preparation has been used. The particular local Opioids may be used alone or, more commonly, as an anesthetic is chosen primarily because for its block adjunct to local anesthetic analgesia. Nausea: Treat with ondansetron, prochlorperazine, Commercially available bupivacaine is a racemic or low-dose naloxone. The R isomer is more Pruritus: Treat with an antihistamine, such as toxic than the S moiety. These effects can be managed by 40-µg boluses, until the desired effect is reached.

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Gastroesophageal reflux Gastroesophageal reflux is common in infants up to 8 weeks of age because of 4 functional immaturity and abnormal tone of the lower oesophageal sphincter trusted super viagra 160 mg. The most common clinical symptom is non-bilious vomiting but other signs include failure to thrive and rectal bleeding in infants and young children buy super viagra 160mg low price, while 11 older children may present with heartburn and dysphagia order 160 mg super viagra visa. The barium meal examination is a relatively insensitive method of detecting oesophageal reflux because of the short period of time over which the patient is examined discount super viagra 160mg with amex. The 11 current diagnostic investigation of choice is 24-hour pH probe monitoring. Meckel’s diverticulum AMeckel’s diverticulum is a developmental abnormality resulting in a small pouch on the wall of the lower part of the ileum. However, inflammation of the diverticu- lum (diverticulitis) may cause painless rectal bleeding, intestinal obstruction and localised abdominal pain mimicking appendicitis6. Radiological diagnosis of Meckel’s diver- ticulum is difficult unless haemorrhage occurs. Inflammatory bowel disease Inflammatory bowel disease is a collective term for a range of inflammatory con- ditions including ulcerative colitis and Crohn’s disease (regional ileitis) (Fig. Diaphragmatic hernia Acquired: Herniation of an abdominal organ into the thoracic cavity. The most common type, hiatus hernia, involves the stomach passing through the oesophageal opening in the diaphragm. Congenital: The most common is the Bochdalek hernia, a postero-lateral defect more common on the left than the right. The anterior, Morgagni type defect is less common and usually smaller (Fig. Umbilical hernia Results from the incomplete closure of the fascia of the umbilical ring and is more common in premature and black infants6. An umbilical hernia usually presents during the neonatal period as a bulge at the navel13, and many resolve spontaneously, although strangulation of the hernia remains a risk with conservative management. Diagnosis is based on clinical examination and imaging is not required unless the clinical diagnosis is equivocal or the exact contents of the hernia need to be determined preoperatively. Inguinal hernia More common in males than females, the inguinal hernia is a prolapse of the bowel through the inguinal ring. The condition may be asymptomatic although compression of other organs may produce associated symptoms. Conservative management can lead to intestinal obstruction if the lesion becomes swollen and fixed (incarcerated) or if the blood supply is compromised (strangula- tion) causing pain and gangrene13. A sliding hernia can result in bowel wall irritation and functional obstruction13. Herniation of the liver through the diaphragm (right cardio- phrenic angle). Approximately 25% of all cases of inflammatory bowel disease first manifest during childhood and these form the most common chronic gastrointestinal ill- nesses in children and adolescents11. Radiographic appearances during gastrointestinal contrast examina- tions tend to be similar to those undertaken in adults. However, ultrasound has a greater role to play in the investigation of inflammatory bowel disease in chil- dren as the paediatric bowel wall may be technically easier to visualise than in adults11. Swallowed foreign body Most ingested foreign bodies will pass unimpeded through the gastrointestinal tract and plain film radiography is not routinely indicated unless the swallowed object is sharp or potentially poisonous (e. While objects passing through these sites are likely to have an uneventful transit through the rest of the gastrointestinal tract, long thin foreign bodies may lodge in the duodenal loop or terminal ileum10. If clinical concern exists for an infant an antero-posterior projection of the chest and upper abdomen should be performed with the patient in the supine position and the head turned laterally. The radiograph should be collimated to include the pharynx superiorly and the iliac crests inferiorly thereby excluding the gonads from the primary beam. For the older child, separate radiographic examinations of the chest (includ- ing the upper pharyngeal region) and abdomen may be requested. If a foreign body is identified in the neck or thorax then a lateral projection of this region should be undertaken to verify the object’s position within the pharynx or oesophagus and to exclude inhalation (Fig.

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