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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Maintaining psychological well-being begins with crew selection buy sustiva overnight, and includes such factors as crew compatibility cheap 600mg sustiva with visa, crew-ground interaction buy sustiva toronto, crew autonomy, and family support (see Chapters 9 and 11. Problems in any of these areas can affect a mission every bit as severely as a pressure leak. Although considering countermeasures as potential hazards may seem counterintuitive, some (e. A balance must be struck between countermeasures, acceptable levels of health and fitness, and productive work, with the goal of optimizing 3 V 4 Ch 6 Principles of Diagnosis and Treatment in Space Flight Barratt productive work. In summary, the most effective specialists in space medicine will have an understanding of systems well beyond what is usually required of a clinician. Those specialists also must communicate well with others who are more directly concerned with each system (especially the life support systems), and should participate actively in all aspects of flight planning and monitoring. Medical Support Infrastructure As is true for any aspect of mission support, the end-to-end delivery of in-flight medical care involves a chain of coordinated links (Fig. The lead ground specialist, preferably a flight surgeon trained in aerospace medicine and familiar with both the crew and the payloads, communicates in turn with paramedical personnel, such as specialists in radiation, psychology, and hygiene, and with biomedical engineers when consultations regarding medical hardware are needed. The flight surgeon serves as a single point of contact for flight management regarding medical issues, and provides coordinated information to the flight crew. Each link in the medical chain must function well in order to provide effective support. Communication problems such as low bandwidth, low coverage due to satellite unavailability or contingency, or delays due to far distant operations will require that the onboard capability be increased accordingly in order to protect some specified level of medical capability. The time needed for one-way signal transmission between Earth and, say, a Mars mission or outpost is not negligible; such a signal takes 3 minutes to reach the minimum distance of 56,000,000 km, and 22 minutes to reach the maximum distance of 398,000,000 km. Privacy between the flight surgeon and each crewmember must be preserved if medical communications are to be candid. Finally, the ability to provide these private medical conferences should encompass the need for unscheduled as well as scheduled conferences. Diagnostic and Therapeutic Peculiarities in the Space Environment Many if not most of the techniques used in physical diagnosis in space are little different from their terrestrial counterparts. For the more common problems encountered in space flight, standard measures of diagnosis and treatment have sufficed reasonably well for the 35 years humans have been exploring near-Earth space. However, the deviations that exist are significant, and understanding them may make the difference between successful and unsuccessful medical support. The Patient Methods of diagnosing and treating illness or injury in space crews must acknowledge the simultaneous occurrence of the physiological response to microgravity. In a sense, space medicine involves supporting and healing extraterrestrial organisms—humans adapted to a totally new environment. Adaptation to microgravity should be considered a normal physiological response rather than an inherently pathologic process. With few exceptions (notably radiation exposure and bone loss [and subsequent risk of nephrolithiasis from calcium mobilization]), these 4 V 4 Ch 6 Principles of Diagnosis and Treatment in Space Flight Barratt changes are not limiting or hazardous, but become maladaptive only upon return to Earth. Nonetheless, the signs, symptoms, or presentation of various disease states clearly can be affected by the fluid shifts and changes in electrolyte balances and cardiopulmonary and hematological/immunological function characteristic of exposure to microgravity, and thus these disease states 9,10 could well present in atypical ways. All aspects of medical diagnosis, including physical examination, laboratory analysis, and medical imaging, must be redefined for the microgravity and partial-gravity environment. Although investigational steps have been taken in these areas, the normal complete medical examination for the weightless environment remains largely uncharacterized. However, some baseline medical evaluations have been conducted on some of the infrequent flights that have included physicians as crewmembers. In one scale developed for this purpose, numerical grades are assigned to various aspects of the physical examination to determine differences from terrestrial normal values; to 11 date, this scale has been used with 7 crewmembers (Fig. These preliminary observations must be strengthened by further periodic medical examinations during multiple short and long flights. Periodic examinations should accompany standard schedules of medical monitoring, and should include estimates of exercise performance, anthropometry, and hemodynamics (see Chapter 4, In-Flight Monitoring. These examinations will serve the dual purpose of providing a reliable overall picture of the adapted state and detecting potential pathology before it becomes clinically significant. These evaluations will build on the experience accrued during the 10 years of laboratory and hemodynamic monitoring regularly performed aboard the Russian space station Mir. With regard to therapeutic issues, new clinical norms probably will be established for many parameters in weightlessness, and must be considered as a new baseline from which the body deviates in injury or illness. Evaluation of lung function after a mild toxic inhalation, for example, must account for an apparent weightlessness 12 induced decrease in vital capacity of 10%, and cannot be compared directly to preflight baseline measurements. Prudence would seem to dictate that new clinical baseline values of selected physical and laboratory tests be obtained at the outset of a long flight, after the acute adaptation process is complete, so that these baselines can be used for comparison in event of illness or injury later in the mission. Another factor in the patients response to treatment includes the shifts in pharmacological response associated with 13 microgravity. Some medications do not seem to producer the same therapeutic response on orbit as on Earth. Certain aspects of the overall physiological response to microgravity may influence pharmacokinetics. Gastrointestinal motility, which correlates significantly with absorption of some medications, can be significantly affected, especially in the presence of space motion sickness. Most likely, bioavailability, rather than end-organ utilization, is most affected by normal adaptation to microgravity. As such, developing alternate methods of delivery for commonly used medications (e.

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La etiología en los distintos modelos se basa en la 332 Resumen predisposición genética order discount sustiva on-line, la inducción con antígenos específicos (la mayor parte en combinación con un coadyuvante) o la inoculación de prueba de agentes infecciosos sustiva 600 mg overnight delivery. Los modelos de enfermedades autoinmunitarias de inducción química son menos comunes cheap 600 mg sustiva overnight delivery. Ade más, los efectos autoinmunogénicos y alergénicos de los compuestos no se suelen identificar en los estudios de toxicidad normales, en parte porque se utilizan animales exogámicos y los parámetros per tinentes no se estudian. Además, los valores atípicos se suelen descartar de los experimentos, mientras que en realidad son éstos los que pueden indicar efectos inmunitarios inesperados e idiosincrá sicos. Se carece de una estrategia general para evaluar el potencial de autoinmunogenicidad de las sustancias químicas. Consiste en un modelo de prueba en animales sencillo y sólido que se puede utilizar para vincular reacciones directas de nódulos de linfocitos con la aplicación local de sustancias químicas potencialmente inmunoactivas. Sin embargo, estas valoraciones pueden predecir el potencial de sensibilización, pero no necesariamente el de auto inmunogenicidad de los agentes y no representan una vía sistémica de exposición. La carga para la salud y los costos elevados de las enferme dades autoinmunitarias resaltan su importancia con respecto a una evaluación del riesgo. En la evaluación del riesgo de autoinmunidad asociado con agentes químicos o físicos se deben considerar los datos epidemiológicos disponibles, la identificación del peligro y los datos de la relación dosis-respuesta derivados de estudios realizados en animales y personas, los datos relativos al mecanismo de acción y los factores de susceptibilidad. El proceso de evaluación del riesgo puede ayudar a calcular en último término el costo de las enferme dades autoinmunitarias asociadas con la exposición a agentes quími cos y físicos. En la actualidad, la evaluación del riesgo para agentes sospechosos de inducir o exacerbar la autoinmunidad o las enferme dades autoinmunitarias tropieza con la dificultad de la ausencia de información apropiada, en particular modelos animales validados. Debido a la carga de las enfermedades autoinmunitarias a nivel individual y colectivo, la evaluación del riesgo con respecto a este grupo de enfermedades adquiere una importancia especial. Therefore, close collaboration and a good communication Pa t H o G e n e s i s between laboratory and clinician is a sine qua non. Solid malignancy (ovarian carcinoma) In contrast, haemoglobinuria as a sign of intravascular Cold antibody aiHa (1:1000000) haemolysis is rare, but the patient must explicitly be Primary (idiopathic): frequently herald of occult lymphoma asked for that symptom. After warming up, the biphasic haemolysins (rare) cyanotic discolouring disappears quickly and in contrast to Idiopathic Secondary a Raynaud phenomenon, no reactive hyperaemia occurs. Frequently, column tests with gel-containing antihuman globulin reagent (fgure 1, middle. Direct antiglobulin test Polyspecifc direct antiglobulin test positive positive ↓ ↓ Test erythrocytes Test erythrocytes coated with Agglutination test erythrocytes (auto)antibodies Direct antiglobulin test Serum directed to human IgG or complement C3c/d Monospecifc direct antiglobulin test Patient erythrocytes coated with Agglutination patient positive autoantibodies erythrocytes ↓ Spontaneous agglutination Spontaneous agglutination of patient erythrocytes coated with IgM by means of the indirect antiglobulin test (iat, indirect Coombs test) circulating allo and autoantibodies present in patient serum are detected. Patient erythrocytes erythrocytes coated with igG are incubated with antiserum against are added to the reaction chamber and after a short incubation the human igG. Patient erythrocytes are incubated with a the erythrocytes pass the gel matrix forming a pellet at the bottom polyspecifc serum directed to human igG and complement (C3d. In that situation further laboratory diagnostics are also mandatory, to investigate the presence of either IgM or IgA. However they show an optimal binding at 37 °C and can lead to fulminant and fatal haemolysis. In Pretreated test erythrocytes, which are more sensitive for haemolysis addition, the optimal temperature for IgM binding and the than normal test erythrocytes are incubated with patient serum frst at 16 °C (a) and 37 °C (b) (control: C. A potentially clinically relevant cold antibody must be considered if agglutination occurs at 30 °C. If lysis occurs a auto-Abs concentration in the serum, bearing the risk of clinically relevant antibody which can potentially cause a false-negative result. If a specifcity of the polyreactive monoreactive serum eluted antibody can be identifed, this will be indicated in serum the diagnostic rapport (e. IgG C3d IgG/IgA C3c C3d IgM However, in many cases no specifcity can be identifed (non-specifc antibody. Literature suggests that alloantibodies can of the respective immunoglobulin or complement component on the be detected in 15 to 43% of patients suffering from patient erythrocytes. Mechanisms of red blood cell removal in increased risk to develop additional alloantibodies. With different absorption erythrocytes coated with igG autoantibodies are mainly removed via techniques (auto and alloabsorption) auto-Abs can be fc-gamma receptors on macrophages in the spleen. Complement deposition on erythrocytes in the absence of igG leads to red blood removed from patient serum in order to perform a proper cell removal in the liver via complement receptors on kupfer cells. However, these techniques in case of fulminant haemolysis, red blood cells are destructed in the are time-consuming, require abundant patient material circulation. The defnitions partial and complete response are adopted from the publication cited in the text. There is a signifcant risk for alloantibody formation upon transfusion treatment of Wa-aiHa in that situation. Moreover, ongoing haemolysis can be Transfusion exacerbated by transfusion, since auto-Abs also react the blood product must be compatible with respect to with transfused red blood cells. Anaemia should only be complement-activating alloantibodies present in patients corrected in case of clinical symptoms. In addition, the development of new there is no vital indication for a transfusion it is prudent or additional alloantibodies must be prevented. Therefore, to wait for the results of the immunohaematological a blood product as compatible as possible with the recipient tests and the ensuing transfusion advice based on this. The minimal requirement is that In a second approach the process of haemolysis must the selected product must be compatible to Rhesus and be stopped or at least be attenuated via an inhibition of Kell antigens. In case of severe haemolysis blood product autoantibody production and/or inhibition of premature selection may also consider the specifcity of auto-Abs. Figure 5 provides an overview on the different alloantibodies are more important than auto-Abs.

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Finally sustiva 600mg, consoles may need to be equipped with movable cases for storing documents order discount sustiva online, clipboards for making service notes order sustiva 600mg with visa, and places to put auxiliary and portable instruments. Methods of Evaluating the Ergonomics of Crew-Spacecraft Systems the high cost of eliminating problems made in the development of technology for human space flights, and the limited opportunities for modifying that technology while it is in use, make it absolutely essential to evaluate crew spacecraft systems as early as possible in the development process. The most complete evaluation of a system generally would be obtained through experimental studies of that systems prototype conducted by specially trained operators. Unfortunately, this approach largely precludes comparing alternative design versions or introducing changes, since by the time a prototype is created, usually the final decisions about its structure have already been made. For this reason, the specific methods used in ergonomic evaluation of human-machine systems depend on the stage of development of those systems. For example, during the early stages of system design, when the feasibility of various design configurations for work stations is being assessed, priority is given to computer modeling and use of scale models. At later stages, when information is available on equipment composition and dimensions, full-scale cabin mock-ups can be used. Mathematical Modeling At present, no universal mathematical model has been developed that can be used for a wide range of human machine systems. Specific models are developed for specific instances, and each model takes into account the features of a particular system, the reliability of initial data, the need for accuracy of results, and so on. In other words, the development of models requires profound knowledge of the essence of the process being modeled as well as mathematics and programming. In general, the process of mathematical modeling of such systems includes: • studying and formally describing the goals, objectives, characteristics, and conditions of system function; • analyzing the model using the selected mathematical approach and computer technology • obtaining results generated by the model; • evaluating the appropriateness of the model; • experimenting with the model; and • improving and updating the model on the basis of new data obtained. Details of how to construct models, and their properties and characteristics, are reviewed in References 1, 13–15, and 24–36. We will merely note here that mathematics derived from theories of information processing, reliability, queuing, operations research, and others can be used to solve problems of ergonomic design such as providing rationales for the structure of a human-machine system, allocating functions among its components, and developing rational algorithms of operator tasks. However, analytic evaluation methods are not without limitations, some of which include the small number of variables that can be analyzed, insufficient attention to dynamic interactions among systems components, and the stochastic nature of human characteristics. To paraphrase 26 Shannon, the term simulation can be defined as a process that includes constructing a model of an actual system and then designing experiments to study the behavior of the system or to evaluate various strategies for its functioning. A simulation model of a human-machine system must have the following properties: • encompass a functionally complete set of the tasks performed by the system; • account for the stochastic nature of the processes of its functioning; • reflect the group and individual characteristics of the human components of the system; • resemble the actual processes; • be sufficiently relatible so that decisions can be made on the basis of modeling results; and • be simple and convenient to use. Development of simulation models also requires selecting an appropriate means of analyzing and describing the processes and functional relationships of the system. At present, the most extensively used methods are discrete, continuous, and combined (discrete-continuous) simulation. In addition to models that simulate the behavior and activity of an individual operator, other models can be used to describe the interaction of the entire set of components of the system (personnel, equipment, communications, 36 etc. The structure of one possible model for evaluating and predicting the reliability of crew performance is outlined in 37 Fig. For this purpose, we define reliability as the probability of the flight program being accomplished with the necessary quality (accuracy, lack of error, timeliness) under specific living conditions. We contend that this definition encompasses the stochastic nature of system characteristics (through the element of probability inherent in the concept of reliability) and the effects of space flight factors on those characteristics (through consideration of living conditions. If some crewmembers are free at a given moment, or if the selected task is given higher priority than others being performed, then the selected task is performed (block 2. If not, then performance of that task is postponed (or, if it is of low priority, precluded) and the flight program is adjusted accordingly (arrow to block 12. The identification of each task accepted for performance (type, requirements on operators, etc. Individual and group characteristics of operators are modeled in blocks 14 and 15, respectively, and their interaction is shown by arrows. The function of block 17 includes simulation of how these individual and group characteristics of operators are affected by combined exposure to such factors as flight duration, flight stages, and health status (simulated in block 21), as well as ambient factors (e. The effect of the last group of factors is shown by arrows from block 16 (the work environment) to block 12 (operational effects) and block 17 (psychogenic effects. In turn, the characteristics of the microsocial climate on board the spacecraft may affect the degree of completion of the flight program and the interactions with the ground control group (arrows from blocks 14 and 15 to blocks 12 and 20. If the functional capacities of the selected operator(s) correspond to the task requirements, the performance of the tasks is simulated, as indicated within the block outlined by a dotted line in the lower right of Fig. If they do not, after all possible selection variants are considered (blocks 9 and 4), then the message that the task cannot be performed at the given moment is sent to block 12. In block 6, the operations constituting each task (type of operations, equipment needed, organization of communications, etc. The model accounts for the presence of deviations from the nominal work-performance algorithm. The list and nature of these deviations are determined on the basis of preliminary analysis of data from actual flights, and occurrence of deviations is determined randomly in block 11/1. Deviations may lead to either changes in the accuracy or time characteristics of operations (arrow to block 7/1), or to the inability to perform them, which is determined in block 13. If the deviation leads to the impossibility of performing the task as a whole, then the appropriate command is sent from this block to block 12. If operations and tasks can be performed more than once, or are of low quality, they are simulated again (arrow from block 8/1 to block 7/1 or from block 10 to block 6, respectively. The success or failure of task performance with regard to individual and group characteristics of operators are indicated by the arrows from blocks 10 or 13, respectively, to block 17.

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Note clients emotional and behavioral responses resulting from Approaching death is most stressful when client and family increasing weakness and dependency buy cheap sustiva 200mg on-line, such as depression purchase 600 mg sustiva visa, coping responses are strained buy genuine sustiva on-line, resulting in increased frus withdrawal, hostility, hallucinations, and delusions. When family members know why client is behaving differently, it may help them understand, accept, and deal with unusual behaviors. Assist family and client to understand who owns the problem When these boundaries are defined, each individual can begin and who is responsible for resolution. Avoid placing blame to take care of own self and stop taking care of others in or guilt. Provides information on which to begin planning care and making informed decisions. Lack of information or unrealis tic perceptions can interfere with individuals responses to illness situation. Facilitate family conference; include all family members, as ap Knowledge can help the family prepare for eventualities and deal propriate. Collaborative Refer to appropriate resources for assistance, as indicated, May need additional assistance in resolving family issues, including family counseling, psychotherapy, community making peace, and maintaining personal well-being. Dying client faces momen tous losses of physical control and function, of indepen dence, of relationships, of possibilities, and ultimately of life itself. To family members and friends, the loss of a loved one causes great stress and temporarily impairs concentra tion, decision making, and work performance. Determine clients religious or spiritual orientation, current Provides insight as to where client currently is and what hopes involvement, and presence of conflicts in current for the future may be. Assess sense of self-concept, worth, and ability to enter into or Necessary to provide firm foundation for growth and guiding maintain loving relationships. Explore interpretation and relationship of spirituality, concept of Identifying the meaning of these issues may be helpful in life, and death and illness to clients spiritual centeredness. Comfort can be gained when family and friends share clients beliefs and support search for spiri tual knowledge. Explore ways that spirituality or religious practices, such Allows client to explore spiritual needs and decide what fits own as music, prayer, meditation, and rituals, have affected view, and provides support for dealing with current situation. Encourage client to be introspective in search for peace and Finding peace within will carry over to relationships with oth harmony. Establish environment that promotes free expression of feelings May help identify the real need of the day. Make time for nonjudgmental discussion of cultural and Spiritual or religious practices, customs, and rituals often play philosophical issues and questions about spiritual impact important roles, especially at a time of such significant of illness and/or impending death. Discuss difference between grief and guilt and help client to Identifies persons at risk for complicated grief and bereavement identify and deal with each, assuming responsibility for own and its associated depression and complications. May free the client to be more creative, loving, and into the experience of well-being. Determine how involved in physical care the family members Clarification of specific wishes can be helpful in reducing stress want to be. Collaborative Encourage participation in desired religious activities, prayer, May prove beneficial to both client and family members in meditation, or contact with minister, spiritual advisor, or reflecting on life and death issues. Validating ones beliefs in an external way can support and strengthen the inner self. Ascertain caregivers understanding and acceptance of clients If caregiver is not in total agreement with clients wishes, role wishes and advance directives. Helping a client and family find comfort is often more techniques, needed treatments, and appropriate complemen important than adhering to strict routines. However, family tary and alternative therapies, such as massage, herbs, aro caregivers need to feel confident with specific care activities matherapy, and relaxation techniques. Emphasize importance of self-nurturing, personal needs, and Taking time for self can help lessen risk of being overwhelmed social contacts. Identify and schedule alternative care resources, such as family, As clients condition worsens, primary caregiver will require friends, sitter, and respite services, as needed. Collaborative Refer to community resources to address specific needs, as May need additional assistance to facilitate clients wishes for indicated, such as insurance/financial services and end-of-life care and to support caregivers well-being. Following any disaster, those involved—victims, rescuers, ber of people involved and the wider the effect. Exacerbation of chronic condition, such as heart or amputations respiratory problems ii. Precipitation of emergent conditions such as premature organ damage, neurological impairment births, seizures, or mental health conditions iii. Disaster classifications and examples: may lead to suicidal thoughts and post-traumatic stress i. May be acute—beginning within 6 months and not lasting Chemical agents: Poisonous gases, liquids, or solids, including longer than 6 months; chronic—lasting longer than 6 months; nerve agents (sarin), biotoxins (ricine), choking or pulmonary or delayed—period of latency of 6 months or more. It is the behavioral event affecting a large population resulting in injury, death, health correlation to physical first aid with the goal being to and destruction of property that overwhelms local resources. Care Setting Related Concerns Wherever disaster occurs and includes triage areas, aid sta Burns: thermal, chemical, and electrical—acute and conva tions, clinics, hospital and emergency centers, and commu lescent phases, 638 nity shelters. Craniocerebral trauma—acute rehabilitative phase, page 197 Fractures, page 601 Pediatric considerations, page 872 Pneumonia, page 129 Psychosocial aspects of care, page 729 Sepsis/septicemia, page 665 858 Client Assessment Database Data depend on specific injuries incurred and presence of chronic conditions (refer to specific plans of care for appropriate data, such as burns, multiple trauma, cardiac and respiratory conditions, and so forth) and timing of presentation for care. Facial expression in keeping with level of anxiety—furrowed • Avoidance of circumstances or locations associated with incident brow, strained face, eyelid twitch • Sense of inner turmoil. Motor tension, shakiness, jitteriness, trembling, easily startled • Feeling stuck. Assists in providing safe medical and nursing care in anticipa tion of emergency need.

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Fiberoptic instruments provide a similar ability to examine these regions discount 200mg sustiva with visa, but with superior optics purchase sustiva 600mg on-line. The Ear Assess the external auricle for congenital deformities cheap 200mg sustiva visa, such as microtia, promin auris, or preauricular pits. The external auditory canal should be examined by otoscopy afer being thoroughly cleaned if it is blocked by cerumen. The canal should be assessed for swelling, redness (erythema), narrowing (stenosis), discharge (otorrhea), and masses. Changes in the appearance of the eardrum may indicate pathology in the 10 middle ear, mastoid, or eustachian tube. White patches, called tympano sclerosis, are ofen clearly visible and provide evidence of prior signifcant infection. An erythematous, bulging, opacifed tympanic membrane indi cates acute bacterial otitis media. Healed perforations are ofen more trans parent than the surrounding drum and may be mistaken for actual holes. Pneumatic otoscopy should be performed to observe the mobility of the tympanic membrane with gentle insufation of air. Eustachian tube func tion may be assessed by watching the eardrum as the patient executes a gentle Valsalva. Tuning forks can be used to grossly assess hearing and to diferentiate between conductive and sensorineural hearing loss. A tuning fork placed in the center of the skull (Weber test) will normally be perceived in the mid line. The sound will lateralize and be perceived as louder on the afected side in cases of conductive hearing loss. If a sensorineural loss exists, the sound will be perceived in the better or normal hearing ear. The tuning fork is then placed just outside the external auditory canal for the Rinne?s test of air conduction hearing. Placing the base of the tuning fork over the mastoid process allows bone conduction hearing to be assessed. In conduc tive hearing loss, the tuning fork is heard louder behind the ear (bone con duction is better than air conduction in conductive hearing losses. This is indicated in any patient with chronic hearing loss, or with acute loss that cannot be explained by canal occlusion or middle ear infection. Topical vasoconstriction with oxymetazoline permits a more thorough examination and allows for assessment of turbinate response to deconges tion. Nasal patency may be compromised by swollen boggy turbinates, septal deviation, nasal polyps, or masses/tumors. The remainder of the nasal cavity can be more carefully examined by performing fexible fberoptic or rigid nasal endoscopy. This allows a more thorough evalua tion of the nasal cavity and mucosa for abnormalities, including obstruc tion, lesions, infammation, and purulent sinus drainage. The sense of smell is rarely tested due to the difculty in objectively quantifying 11 responses. However, ammonia fumes can be useful for distinguishing true anosmics from malingerers because ammonia will stimulate trigeminal endings, and thus produce a response in the absence of any olfaction. The Mouth An adequate light and tongue depressor are necessary for examining the mouth. The tongue depressor should be used to systematically inspect all mucosal surfaces, including the gingivobuccal sulci, the gums and alveo lar ridge, the hard palate, sof palate, tonsils, posterior oropharynx, buccal mucosa, dorsal and ventral tongue, lateral tongue, and the foor of mouth. The parotid duct orifce (Stenson?s duct) can be seen on the buccal mucosa, opposite the upper second molar. The submandibular and sublingual glands empty into the foor of the mouth via Wharton?s ducts. Complete exami nation of the mouth includes bimanual palpation of the tongue and the foor of the mouth to detect possible tumors or salivary stones. The Pharynx The posterior wall of the oropharynx can be easily visualized via the mouth by depressing the tongue. Inspection of the nasopharynx, hypo pharynx, and larynx requires an indirect mirror exam or use of a fexible fberoptic rhinolaryngoscope. All mucosal surfaces are evaluated, to include the eustachian tube openings, adenoid, posterior aspect of the sof palate, tongue base, posterior and lateral pharyngeal walls, vallecula, epi glottis, arytenoid cartilages, vocal folds (false and true), and pyriform sinuses. Vocal fold mobility should be assessed by asking the patient to alternately phonate and snif deeply. The Neck The normal neck is supple, with the laryngotracheal apparatus easily pal pable in the midline. A complete examination should include external observation for symmetry and thorough palpation of all tissue for possible masses. The exact position, size, and character of any mass should be care fully noted, along with its relationship to other structures in the neck (thy roid, great vessels, airway, etc. Assessment of vocal cord function by fexible fberoptic laryngoscopy also provides information on the status of the vagus nerve. Deviation to one side indicates a weakness or paralysis of the nerve on that side.


Before transporting generic sustiva 200mg line, immobilize the victim discount 600mg sustiva mastercard, in order to prevent further injury and reduce pain buy discount sustiva on-line. Intravenous solutions are administered by special protocols Hospital treatment the continuation of resuscitation measures initiated prehospitaly is required. Treatment and care of burned victims is very demanding and requires a multidisciplinary approach. It limits flexion by about 90% and limits extension, lateral bending and rotation by about 50%. It is an important adjunct to immobilization but must be used with manual stabilization or mechanical immobilization provided by a suitable spine-immobilization in field. The unique primary purpose of a cervical collar is to protect the cervical spine from compression. Prehospital methods of immobilization (using a vest, shortboard or a long backboard device) still allow some slight movement of the patient and the spine because these devices only fasten externally to the patient and the skin and muscle tissue move slightly on the skeletal frame even when the patient is extremely well immobilized. Most rescue situations involve some movement of the patient and spine when extricating, carrying and loading the patient. This type of movement also occurs when an ambulance accelerates and decelerates in normal driving conditions. An effective cervical collar sits on the chest, posterior thoracic spine and clavicle, and trapezius muscles, where the tissue movement is at a minimum. This still allows movement at C6, C7 and T1 but prevents compressions of these vertebrae. It is not supposed to be comfortable but must not be too tight to cause breathing difficulties or to raise intracranial pressure. If the head cannot be returned to a neutral in-line position (pain or resistance), the collar cannot be applied and neck immobilization should be provided by using improvised devices – rolled blankets, sheets, towels…. Must not inhibit a patient s ability to open the mouth or the care provider s ability to open the patient s mouth if vomiting occurs 4. It is versatile and can be used for rapid take downs of standing or sitting casualties as well as prone, supine or irregular casualties. Appropriate patients to be immobilized with a backboard may include those with: 93 Blunt trauma and altered level of consciousness; Spinal pain or tenderness; Neurologic complaint (e. The long backboard can induce pain, patient agitation, and respiratory compromise. Further, the backboard can decrease tissue perfusion at pressure points, leading to the development of pressure ulcers. Low grade ulcers can appear in as few as two hours and even healthy persons complain of pain after 30 minutes. Utilization of backboards for spinal immobilization during transport should be judicious, so that potential benefits outweigh risks. Patients with penetrating trauma to the head, neck or torso and no evidence of spinal injury should not be immobilized on a backboard. Two major adjustments in the previous methods are necessary when immobilizing a small child to a long board. The padding must extend form the lumbar area to the top of the shoulders, and to the right and left edges of the board. Blanket rolls can be placed between the childs sides and the sides of the board to prevent lateral movement. Pediatric immobilization devices take these differences into account, and are preferable. Patients should be removed from backboards as soon as practical in an emergency department. However, it is designed as a transfer device and should not be carried for any distance. They come in a range of sizes and widths and avoid the problems of local pressure areas as the force is evenly spread out along the whole body. However, if they puncture, the valve fails or the pump is lost, then they become of little value. They are becoming more and more popular with the ambulance service as the device of choice, especially for pregnant women and if transport lasts longer than 30 minutes. It is important that manual –in –line stabilisation is always performed before applying other devices. Comparison of the Ferno Scoop Stretcher with the long backboard for spinal immobilization. A numerical study to analyse the risk for pressure ulcer development on a spine board. Motion in the unstable 95 thoracolumbar spine when spine boarding a prone patient. Removing a patient from the spine board: is the lift and slide safer than the log roll? The 6 plus-person lift transfer technique compared with other methods of spine boarding. A cross-sectional survey of all Norwegian emergency medical services, Scand J Trauma Resusc Emerg Med. Revolutionary advances in enhancing patient comfort on patients transported on a backboard. Backboard time for patients receiving spinal immobilization by emergency medical services, Int J Emerg Med. These pathways are not intended to replace the clinical judgment of the individual physician.


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  • https://digitalcommons.wayne.edu/cgi/viewcontent.cgi?article=2737&context=oa_dissertations
  • https://pubs.acs.org/doi/10.1021/cr9001353

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