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By W. Kaelin. Dawson College. 2018.

Dependent drainage of deep wounds must be employed << Place a Penrose drain (rubber tube) or wicking gauze into the wound>> generic 5 mg bystolic visa. Liberal fasciotomy of an extremity is often an additional precaution that allows for post operative swelling bystolic 2.5 mg for sale. Use when the 5 P are present distal to a limb injury – pain order bystolic 5 mg fast delivery, pallor, pulselessness, puffiness or paraesthesia - 172 - Survival and Austere Medicine: An Introduction m. Do not dress the wound with an occlusive dressing, but place a few strips of fine-mesh gauze between the walls of the wound, placed puffed gauze in the pocket formed and then dress the wound to protect, but not constrict. All wounds should be left open with the exception of wounds of the face, sucking chest wounds, head wounds, wound of the joints or synovial membranes, and wounds of the peritoneum o. Immobilisation and correct positioning of the injured part promotes healing, and these measures should be used even of no fracture is present. As we have said frequently here, if you attempt the things described here without the appropriate knowledge you will kill people. The standard technique of giving fluids to an unconscious, shocked, or dehydrated person is with intravenous fluids. This method will obviously not work if the cause of the problem is severe diarrhoea. A lubricated plastic tube with a blunt end (a large urinary catheter or nasogastric tube is ideal) should be passed through the anus into the rectum for about 9 inches. A longer length of tubing and a drip bag or funnel should be attached to the end and elevated. If 200 ml is tolerated it can be worth increasing the volume slightly or reducing the time to 3 1/2 or 3 hrs. A rectum full of faeces does not absorb water very well, so the amounts may need to be reduced, but given more frequently. Amputation was one of the most common surgical procedures of the last two centuries – life threatening infection from wounds and compound fractures were common, and in the absence of antibiotics amputation was the only option. Amputation in an austere situation needs to be viewed as something only performed to save a life. All attempts should be made to save the knee and elbow joints even if this means having a short stump. Extremities with severe involvement of the skin, muscle, and bone with anaesthetic terminus or irreparable nerve injury c. Under combat conditions the most acceptable form of amputation is the open circular technique 1. A circumferential incision is made through the skin and deep fascia at the lowest viable level. The muscle bundles are exposed and then divided circumferentially at the new level of the skin edge. Upward pressure is placed on the proximal muscle stump and the bone is transacted at a still higher level. The surgical wound will have the appearance of an inverted cone - 174 - Survival and Austere Medicine: An Introduction 4. Cold injuries are not indications for amputation – wait until the edges demarcate d. A layer of fine mesh gauze is placed over the wound and the recess is packed loosely with fluffed gauze. A stockinette is the applied over the stump securing the stockinette above the stump using adhesive. The stump is wrapped with ace wraps using compression decreasing proximally and 5-6lbs traction is applied. Superglue will effectively close wounds – with the same provisos as medical tissue adhesives (see chapter). However superglue is not sterile (likely to have little impact) and different brands have different preservatives which may be harmful to injured tissue. It is likely to be no problem for small wounds, but there is a potential for toxicity when large amounts are used. Hypothermia Note: precautions need to be taken where the person concerned has been in the extreme cold, either the snow or very cold water. Severe hypothermia causes a profound slowing in the body’s metabolism and as a consequence can mimic death. A dead person should be buried quickly in a reasonably deep grave to avoid predation by scavengers. Most religions have short rites for the burying of the dead but for the non-religious a favourite poem may be appropriate. This becomes important for legal reasons should things return to normal or in the case of an isolated expedition for the coroner on your return. Gastroenteritis is still a killer in the third world especially for young children (We include typhoid, cholera, Giardia, salmonella, "food poisoning" etc, under the general heading gastroenteritis). The most important preventive action you can take in preventing gastroenteritis is to wash your hands following defecation. Also hands should be washed before handling food, dealing with the sick or babies and infants. There has been much debate over what to offer to replace lost fluids and electrolytes. It must contain not only water, but also sodium (table salt), potassium (light salt), and some form of sugar. The sugar is vital for absorption to take place in the intestines; salts alone are poorly absorbed when the gut lining is damaged as it often is in gastroenteritis. The following is an easy formula for making an oral rehydration fluid: 1/4 Tsp Salt (Sodium Chloride) 1/4 Tsp Lite Salt (Potassium Chloride) 1/4 Tsp Baking Soda 2 1/2 Tbsp Sugar Combine ingredients and dissolve in 1000 mls (1liter) of boiled and cooled water.

Once seizures are controlled for 24hr generic bystolic 2.5mg line, wean off thiopental by decreasing the dose by lmg/kg every 12hr order 5 mg bystolic with amex. The most common reaction bystolic 2.5 mg line, simple febrile reaction, is not life-threatening, but needs to be recognized early. Other reactions are more rare, but have a very high mortality rate (acute hemolysis and transfusion-related acute lung injury), and must be recognized and treated immediately. Ensure the patient really needs the transfusion and that the benefits outweigh the risks. Generally speaking, you can transfuse a unit of blood over 2hr (faster if it is a trauma patient or someone who is severely ill). If there is a transfer sheet from another facility, find out what antibiotic was given and how many doses • Exam o Obtain full set of vital signs, including saturation and temperature. If patient with fever on arrival and signs of sepsis, start antibiotics immediately. They require pumps for regular infusion and constant blood pressure monitoring (every five minutes). Treat aggressively with fluids and antibiotics, but if vital signs not improving or mentation stays low, call for transfer and further evaluation. Simple skin infections occasionally spread into deeper tissue layers and cause more serious local infection or systemic illness. If signs of systemic illness and pain out of proportion with exam findings, necrotizing fasciitis is likely. Recommendations • Simple cellulitis should be marked with a pen so patient or provider can monitor if redness extends beyond border despite antibiotics. They will often have vomiting, fast breathing, fruity breath, confusion, and vomiting. Medication is the key to treatment ■ Takingmediationasprescribedbutglycemiastillhigh • If on oral medications, start on insulin. These patient typically should be admitted overnight for glycemia monitoring to ensure correct insulin dose is started. Follow up in one week to check glycemia • If on insulin and taking appropriately, increase dose as needed. Can follow up in clinic in one week for glycemia check ■ Takingmedication,buthasnewsymptomsofinfection, fever, cough, etc. Must check renal function (Cr) and/or make sure patient is making urine (reason for Foley catheter) before giving entire fluid bolus. Therefore, must check potassium and supplement during insulin infusion • If K > 6 mEq/L, do not give potassium • If 4. Start with 2L bolus, but make sure patient urinating and check renal function before proceeding with remainder of fluid bolus. Give plenty of fluids in each case, monitor urine output, electrolytes, and do glycemia checks every 2hr while on insulin therapy. Even when lab potassium is near normal, patients are actually hypokalemic and need repletion. Transfer early- typically any patient who continues to have tachycardia, hypotension, tachypnea, or confusion after 24hr of aggressive treatment. There are three goals of treatment with different types of medications working for varying reasons. The goals of treatment are to 1) stabilize cardiac membrane, 2) cause an intercellular shift of K+, and 3) remove K+ from the body. Transfer to referral center for dialysis consideration any patient with hyperkalemia and renal failure. Recommendations • All patients with acute hypernatremia should be admitted to the hospital. Those equations are beyond the scope of these introductory guidelines and osmolalities are not often available. Recognize that correcting the sodium too fast will lead to severe brain damage and irreversible neurological deficits. Causes • Thermal • Chemicals • Radiation • Electrical Current Signs and symptoms • History o Important features include time since burn (hours, days? Note that rule of nines for a child with burn is slightly different (head is 18%, legs are 14% each) • Head: 9% • Front chest: 18% • Back: 18% • Arm: 9% each • Leg: 18% each o Depth of burn (see chart below) o Involvement of critical areas (face, hands, genitals, feet, major limbs) o Muscle compartment involvement (firm, painful) ■ Highestriskofcompartmentsyndromewithcircumferential burns and burns at calf/lower leg and forearm o Weight needed to calculate fluid resuscitation Depth of burn estimation Superficial Partial Partial Full st (1 Degree) Thickness Thickness Thickness rd (3 Degree) Superficial Deep Depth Epidermis Superficial Most All of dermis dermis dermis Appearance Red Pale/Dark White, White/dark pink, moist waxy/dry brown, dry/leathery Blisters No Small blisters No blisters None Cap refill Normal Sluggish Reduced None Sensation Normal/painful Normal/painful Reduced None Investigations • Labs: Isolated superficial burns do not need any investigations. Look for soot in the nose and mouth, mucosal lesions, swelling of the neck, wheezing, changes in voice, difficulty swallowing, drooling, circumferential burns to the neck or chest, tachypnea, or hypoxia. Regular dressing changes are necessary, but are extremely painful and require either conscious sedation with Ketamine (extensive burns) or opiate pain control (small burn area) o After initial presentation, remove any burned clothing and cover patient in clean sheet until burns can be dressed appropriately o Wash burn area thoroughly with sterile water or normal saline ■ If blister is intact, do not break open blister ■ If blister is open, de-roof blister and clean area of skin underneath o Cover clean burn area with light coat of honey (if antibiotic ointment unavailable) or Flamazine or other topical antibiotic ■ Donotcoverburnareawithdrydressing! A paper from 2008 estimated between 1300-2400 snake bites per year in Rwanda with between 43-328 deaths as a result. Mark the border of the edema/erythema and reassess both measurements every 30minutes. Follow the management guidelines closely- immobilize limb, elevate, do not place a tourniquet, but instead a "tight" compression dressing • Transfer to the closest facility that has antivenom if there is any signs of rapidly spreading wounds • Transfer to a referral center with surgical capabilities if there is concern for impending compartment syndrome, but fasciotomy should be done before transfer, if provider has training in the procedure, to save limb. Drowning Definition: A process resulting in a primary respiratory impairment from submersion/immersion in a liquid medium. Causes • Accidental submersion • Suicide attempt • Forced submersion Signs and symptoms • History o Ask about timing of event (how many hours ago did it occur? If saturation does not improve, transfer to referral center for intubation and positive pressure ventilation. If they remain asymptomatic, with a normal physical exam and saturation >95%, they can be discharged home. Identification of the specific substance(s) involved in a poisoning can frequently assist clinical management, but is not always possible in actual practice.

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This panel is considered to be “classical” medicine in terms of the approach to treatment order bystolic 5mg overnight delivery. On the right panel generic bystolic 2.5mg on line, we can see a schematic of molecular analysis of the tumour with possible fndings: an actionable mutation and consequently treatment with an already approved drug or with a new drug within the context of a clinical trial 2.5 mg bystolic sale. The fndings could also indicate a prognosis or could be of non-signifcant relevance. Category of Molecular Alteration Actionable in principle Situation 1: Treatment with already approved drug Situation 2: Treatment with a new drug within a clinical trial Prognostic Variants of uncertain significance Adapted from Garraway L et al. Researchers and clinicians once thought that all cancers that derived from the same site were biologically similar and they differed perhaps only in their pathohistological* grading. This grading is a score which classifes tumours from 1 to 3, where 1 is the least aggressive tumour and 3 is the most undifferentiated tumour. Other clinical differences were distinguished based on the presence of regional node metastases or distant metastases. For at least three decades, personalisation of oncology was based only on these parameters and on the patient’s physical condition, and even now these represent the fundamental elements for treatment decisions. Chemotherapy, surgery and radiation therapy were once the only treatment options for cancer. Although these treatments are still used, oncologists know that some patients respond better to certain drugs than to others and that a surgical approach is not always indicated. In recent years, researchers have studied thousands upon thousands of samples from all types of tumours. They have discovered that tumours derived from the same body site can differ in very important ways. The pathologist is able to distinguish different subtypes of cancer with the microscope. When a patient is diagnosed with a cancer, he/she will undergo a biopsy or a fne-needle aspiration. In some tumour types, debulking or removal of the primary tumour also allows sampling for tissue examination. This examination allows the pathologist to confrm a cancer diagnosis, but, through particular colorations of the tissue sample, the pathologist is also able to provide clinicians with a lot of additional information, such as the tumour’s histological characterisation, its hormone sensitivity, and its grade of differentiation*. For example, in the treatment of lung cancer the histology provides very useful tools to decide the best drug for the treatment of the patient. Clinical studies have shown that for a patient with lung adenocarcinoma* there might be more chance of a response if the drugs pemetrexed or bevacizumab are added to the chemotherapy, while for a patient with lung cancer of squamous* histology, it would be more benefcial to add gemcitabine or vinorelbine. For the treatment of oesophageal cancer it is mandatory to know if the tumour is squamous or not, because although deriving from the same organ, the treatment approach is completely different. This information is a useful tool in the frst step of the personalisation process. For example, lung cancer can be divided as a frst step into non-small cell lung cancer and small cell lung cancer, which are two completely different neoplasms*. Within the non-small cell lung cancer category, there are again several different tumour types. Lung and breast cancers are only two examples, because it is possible to recognise several entities within the same tumour type for many other cancers. Lung Cancer – Not One Disease: Histological (Tissue) and Molecular Subtypes of Lung Cancer. On the right side, a pie chart showing the percentage distribution of molecular subsets of lung adenocarcinoma. Personalisation Requires Humanisation of Medicine We don’t have the defnitive solution for all cancers yet, but it is very important for patients and patient organisations to understand a few issues. It will be very hard, for example, to start talking Medicine Task Force to patients about the evaluation of 255 genes that may be altered in a tumour that metastasises to the brain; we need to begin seeing through the eyes of our patients. So personalisation starts with an individual relationship on the part of the physician and the medical team who are taking care of the patient. Personalisation also depends on a multidisciplinary approach; we need a range of experts, because we need the medical oncologist, the surgeon and the expertise of the molecular pathologist, who should be part of the team in a more effective, integrated way than before. We don’t need the pathology report alone; we need to interact with all professionals, including nurses, who are dealing with the patient. This, to me, will create a lot of problems in terms of organisation of care and in terms of cost, but it is the only way to bring together knowledge on the biology and pathology of tumours for effective treatment in every single patient. We now understand that some genes contribute signifcantly to making us resistant to illness, while other genes may make us more susceptible to specifc diseases. In our chromosomes there are also instructions to make drugs work, or fail, or to produce side effects. Cancer occurs when the switches inside our genes that control cell growth do not work. For example, if a growth gene is supposed to be turned off, in cancer it is turned on. Knowing that oncogenes are the key, there can be no doubt that gene-based prevention and therapy will be crucial in winning the war on cancer. Now, things are changing and advances in technology and the results of the Human Genome Project* have enabled researchers to identify the molecular features of each single tumour. Researchers have found that there is a wide heterogeneity among apparently similar tumours. Each person has about 25 000 genes, which are stored in the nucleus, the vital centre of every cell.

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Many chemotherapeutic agents are employed in the treatment of cancers and generally they are used either as a single agent or in certain combinations bystolic 5mg on line. A combination of drugs with different actions can work together to kill more cancer cells discount 5mg bystolic mastercard. It can also reduce the chance that the cancer may become resistant to any single chemotherapeutic drug bystolic 5mg low price. The appearance or the lack of side effects does not tell us whether or not a treatment is working. If chemotherapy has an unselective effect, it is possible to tailor the treatment in many cases by using specifc biomarkers. Biomarkers help doctors know more about an individual person’s tumour, allowing them to take better decisions. Biomarkers may also be useful tools for monitoring the response to treatment and for detecting recurrences or progression. In order to personalise chemotherapy, doctors may use genetic biomarkers, which are either specifc genetic alterations expressed in tumour cells or protein alterations that are present in tumour tissue or revealed when blood tests are analysed. Therefore it is also possible that genetic somatic alterations may render people susceptible to treatments, in terms of toxicity and effcacy, in different ways. These alterations, which are also present in normal tissue, are generally called polymorphisms. Radiation therapy Radiation and radioactivity were discovered more than 100 years ago. Since then, advances in technology and a better understanding of its effects on the body have made radiation therapy an important part of cancer treatment. In fact, more than half of all people with cancer will receive radiation as at least one part of their cancer treatment. When radiation damages the genes of a cancer cell, the tumour cannot grow and divide any more. Radiation therapy kills cancer cells that are dividing, but it also affects the dividing cells of normal, healthy tissues. Each time radiation therapy is given, there needs to be a balance between destroying the cancer cells and minimising the damage to normal cells. It might take days or even weeks of treatment for cells to start dying, and the cells may continue dying for months after treatment ends. Tissues that grow quickly, such as skin, bone marrow and the lining of the intestines, are often affected right away. For this reason, radiation treatment can have side effects that might not be seen until long after the treatment has ended. Radiation is considered a local treatment because only cells in and around the cancer are affected. Radiation cannot cure cancer that has already spread to distant parts of the body, because most forms of radiation therapy do not reach all parts of the body. Radiation may be used by itself in these cases to make the cancer shrink or disappear completely. For other cancers, radiation may be used before surgery (as pre-operative therapy) to shrink the tumour, or after surgery to prevent the cancer from coming back (this is called adjuvant therapy). When radiation is used in combination with other forms of therapy, the treatment is planned by the surgeon, medical oncologist and radiation oncologist, all working together with the patient. Personalised treatment is fundamental for patients who need to be treated with radiation therapy. It is important that the radiation oncologist chooses the most appropriate technique for each patient. Then, the radiation oncologist must select the feld of radiation, which must be large enough to cure the cancer but avoiding acute and long-term toxicity to the healthy parts of the patient. For instance, a radiation oncologist irradiating the lung will preserve as much as possible of the heart, spinal cord and other parts of the lung, and if irradiating the rectum an oncologist will preserve the surrounding areas, the bladder and the remaining bowel. Defning the radiation dose is the fnal step in personalisation of the radiation treatment. Clinical studies have identifed the correct dose to be delivered in each individual situation. Targeted therapies Targeted therapy drugs work differently to standard chemotherapeutic drugs. They attack cancer cells and, in particular, the targets which are strategic points for cell survival, cell replication and metastases. In fact, these drugs tend to have different side effects to traditional chemotherapeutic drugs. Targeted therapies are used to treat many kinds of tumours: certain types of lung, pancreatic, head and neck, liver, colorectal, breast, melanoma and kidney cancers. There are many different targeted therapies in use and new forms are appearing all the time. Depending on the type of cancer and the way it spreads, targeted therapy can be used to cure the cancer, to slow the cancer’s growth, to kill cancer cells that may have spread to other parts of the body or to relieve symptoms caused by the cancer. Your doctor will talk to you about the goals of your therapy before you start the treatment. Although targeted therapy drugs do not affect the body in the same way as standard chemotherapy, they still cause side effects.