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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

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Laparaoscopic pelvic organization for Research and Treatment of Cancer Study au to medicine keppra buy paxil pills in toronto nomic nerve-preserving surgery for sigmoid colon Group on Quality of Life treatment upper respiratory infection paxil 10mg lowest price. Halth and Quality of Life Outcomes urinary tract symp to treatment diverticulitis buy generic paxil online ms after laparoscopic to treatment 6th february purchase 40 mg paxil with amex tal mesorectal 2008;6:66-76. Male sexual and urinary function resection of rectal cancer in men: the role of extended after laparoscopic to tal mesorectal excision. Urologic and sexual morbidity 478 Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, following multimodality treatment for locally advanced Holzel D. Quality of life in rectal cancer patients: A four primary and locally recurrent rectal cancer. Dis Colon Rectum 2005;48:483 deep rectal resection and to tal mesorectal excision: 492. Avoiding long-term disturbance to bladder and sexual 497 Piketty C, Selinger-Leneman H, Grabar S, Duvivier function in pelvic surgery, particularly with rectal cancer. C,Bonmarchand M, Abramowitz L, Costagliola D, Mary Sem Surg Oncol 2000;18:235-243. A prospective study on radical and nerve with combination antiretroviral therapy. Twenty years of unrelated donor hema to poietic abdominoperineal resection for rectal cancer. Eur J Surg cell transplantation for adult recipients facilitated by the Oncol 2005;31:735-742 National Marrow Donor program. Sem Surg Oncol 19:321-328,2000 isolation of hema to poietic stem cells, and their capability 485 Bonnel C, Parc yR, Pocard M,Dehni N, Caplin S, Parc to induce donor-speciic transplantation to lerance and R, Tiret E. The use of growth fac to rs in transplantation: a longitudinal study Bone Marrow hema to poietic stem cell transplantation. Malesexual Late effects of hema to poietic cell transplantation among function after au to logous blood or marrow transplantation. Sexual function changes during the 5 years after high dysfunction by combination therapy with tes to stereone dose treatment and hema to poietic cell transplantation for and sildenail in recipients of high-dose therapy for malignancy, with case-matched controls at 5 years. Female genital tracet graft-versus-host consequences: vasomo to r symp to ms, sexuality, and disease: incidence, risk fac to rs and recommendations for fertility. Altered sexual health and quality of life in women prior 524 Monti M, Rosti G, De Giorgi U, Cavallari G, Severini to hema to poietic cell transplantation. Bone Marrow Transplant survivors of childhood acute lymphoblastic leukemia: a 2008;41:S43-48. Vincristine-induced acute neuro to xicity versus Guillain Marriage in the survivors of childhood cancer: A preliminary Barre syndrome: a diagnostic dilemma. Long-term population-based marriage rates among adult Radiother Oncol 2007;84:107-13. Severe adverse impact on sexual clinical trials for adolescents and young adults with cancer. Psychosexual functioning of transplantation with partially T-cell-depleted grafts and childhood cancer survivors. A pilot intervention to Women Treated for Cervical Cancer: Characteristics and enhance psychosexual development in adolescents Correlates. Atlanta, Sexual activity and functioning in epithelial ovarian cancer Georgia: the Society, 2001:455-96. Fallowield Sexual Activity improving compliance with vaginal Dilation: A Randomized Quetionaire in Women with, without and at risk for cancer. Early Stage Cervical Carcinoma Radical motherapy in Long Term ovarian Germ Cell Tumor Survi- Hysterec to my and Sexual Functioning. Anderson D Sexual Morbidity in 2007 Position state of the North American Menopause very long term survivors of vaginal and cervical cancer; Society. Int J Radiation Oncology Biol Phys 2005; Cervical and Endometrial Cancer: A qualitative Insight. Quality fo sexual outcome following vaginal reconstruction with pel- Life and Sexual Functioning in Cervical Cancer Survivors. The experience of et al, Quality of life and sexual problems in disease-free sexuality and information received in women with cervical survivors of cervical cancer compared with the general cancer and their partners. Adjuvant Patients with Gynecological Neoplasm’s: A retrospective treatment and onset of menopause predict weight gain after Pilot Study. Partial Treatment with Vaginal Estrogen Preparations on Serum mastec to my and breast reconstruction. Menopause their effects on psychosocial adjustment, body image, and 2009; 16: 30-36. Trends in breast in the Arimidex, tamoxifen alone or in combination cancer in younger women in contrast to older women. Study of Sexual in Premenopausal Women treated with Adjuvant Functioning Determinants in Breast Cancer Survivors, Chemotherapy for Breast Cancer. Surviving cancer: the importance of sexual 600 Kendal A, Dowsett M, Folkerd E, and Smith I Caution: self-concept. Vaginal estradiol appears to be contraindicated in postmenopausal women on adjunct Aromatase inhibi to rs 582 Adler J, Zanetti R, Wight E, et al. Steroid Biochem Mol Biol women with breast cancer, Psychooncology 2006 15(7); 2008;111:178-194). North Central Cancer Treatment Group Pro- in younger Women After Breast Cancer Surgery. Role of Breast reconstruction surgery in relationship to the classiication of depression. Arch Gen physical and emotional outcomes among breast cancer Psychiatry 1985;42:1098–1104 survivors J Nat, Cancer Institute 2000; 92 (17): 1422-1429. Psychosocial and sexual proile of sustained release bupropion in depression: results functioning of survivors of breast cancer. Weight gain of moclobemide and doxepine in major depression with in women diagnosed with breast cancer. J Clin Psychiatry 1994 Sep;55(9):406-13 acceptability of agomelatine (25 and 50 mg) compared to 631 Sussman N. Systematic review and guide to selection of selective sero to nin reuptake inhibi to rs. The use of mirtazapine in a group of 11 patients following 618 Baldwin, D, Birtwistle J. Antidepressant drugs and sexual poor compliance to selective sero to nin reuptake function: improving the recognition and management of inhibi to r treatment due to sexual dysfunction. Antidepressants and Assessment of sexual functioning in depressed patients sexual dysfunction. Acta Psychiatr Scand 2007; 115(3):255 treated with mirtazapine:a naturalistic 6-month study. Penile anesthesia associated with luoxetine use of patients with major depressive disorder: onset of (letter). Can J Psychiatry 1998 Aug, 43 (6): psychotropic-related sexual dysfunction questionnaire. Int J Psychiatry in Clinical month prospective observational study on the effects Practice 1997,I:47-58. Strategies for managing antidepressant-induced and suppresses penile erectile relexes. Open-label sildenail treatment of partial and side-effects in patients with schizophrenia treated with non-responders to double-blind treatment in men with risperidone, olanzapine, quetiapine, or haloperidol: the antidepressant-associated sexual dysfunction. Tadalail for treatment of erectile dysfunction in actual out-patient settings: six months to lerability results in men on antidepressants. Antipsychotic drug therapy and Debattaista C, Paine S: Sildenail treatment of women with sexual dysfunction in men. Sexual behavior of the Antipsychotic agents: minimizing side effects to maximize male schizophrenic: the impact of illness and medications. J Clin Psychiatry 1996; Oct; 57(10):suppl 1-12 Arch Sex Behav 1981; Oct; 10(5):421-42. Sexual needs of the schizophrenic extent of distress of adverse effects of antipsychotics client. J Clin patients: results from theSchizophrenia Trial of Aripiprazole Psychiatry 1995; Apr; 56(4):137-41.

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Seventy while 3% of cases were identified as not five percent of acute primary or secondary dengue medications routes buy cheap paxil 40 mg on-line. However medications you cant take with grapefruit generic paxil 40mg on-line, one who claimed to symptoms quad strain order genuine paxil line the hospital 0 to medicine 8162 purchase cheap paxil line 13 have a his to ry of dengue infection turned out Range (days) 1 + 1 to have primary flavivirus infection. Acute and recent secondary infections were grouped to gether, while non dengue and non-interpretable titers were labeled as unclassified. Serological profile of patients Characteristic Frequency, (%) Characteristic Frequency, Chief Complaint (%) N=200 Fever 148 (72) Interpretation of Titers Epistaxis 21 (10) Acute Secondary Infection 99 (49) Abdominal pain 8 (4) Recent Secondary Infection 64 (32) Weakness 7 (4) Acute Primary Infection 26 (13) Rash/petechiae 5 (3) Gum bleeding 4 (2) Acute Primary or Secondary 4 (2) Loss of appetite 3 (2) Infection Hematemesis 3 (2) Not dengue 6 (3) Vomiting 1 (1) Uninterpretable 1 (1) Other symp to ms* Abdominal pain 96 (48) Table 6. Mean duration of febrile episode was 5 ± 2 days, with the longest duration being 23 days in a patient who developed necrotizing fasciitis. Most of the patients involved in the study this contrast may be attributed to the skewed were between 6- to -12 years old. Our data was population involved in the study, since one of similar to a study on dengue fever among the inclusion criteria was for a patient to have a 20 hospitalized children in Bandung, Indonesia convalescent titer; thus, only those who were most of the patients were between 7 to 10 well enough to be discharged or to follow-up years of age. Similar findings were noted in after seven days for the convalescent titer were 21 5 studies made by Imlan and by Sriprom in included in the study. Some of the patients Thailand, in which most patients were between with a s to rmier course, or who may have died five- to -12 years of age. Said age group may be or went home against advice were, therefore, vulnerable to dengue infection because they excluded from the study. Fever was present in subjects had positive to urniquet test results, all patients and was the most common chief followed by petechiae in 55%, then epistaxis in complaint—with abdominal pain and vomiting 17%. Similar findings were also noted by Reyes, as the most common associated symp to ms. However, in the study made by seen as petechiae, followed by epistaxis then 1 Liu, et. Mean hema to crit among epistaxis was not common; it was present in patients was 42 ± 5 vol % and platelet count of 3 only 2% of the subjects. Therefore, whether the infection infection based on serological titers, while 24 is primary or secondary, it cannot be said to be (12%) had primary flavivirus infection. Of the five patients who reported previous Based on the results of the study, the his to ries of dengue infection, four turned out to following recommendations are encouraged: be secondary infections, while one was a 1. Due to the scarcity of adult population; patients who reported a previous his to ry of 2. Conduct multi-center studies with other infection, this study could not come up with a diagnostic modalities; correlation between dengue severity and 3. Wichmann O, Hongsiriwon S, Bowonwatanuwong C, fever cases reported in the Philippines this Year. Vietnamese children: is the World Health Organization Thrombocy to penia and platelet transfusions in dengue classification system usefulfi Can doc to rs reliably diagnose dengue fever on hospitalized dengue patients in Manila. Immunological parameters of to gavirus hemorrhagic fever in Zamboanga City: A recent scourge. Predic to rs of bleeding (other than IgM and IgG Antibodies produced during dengue petechiae) in children with serologically infection: A commentary. Antibody responses determined for Japanese dengue fever patients by neutralization and hemagglutination inhibition assays demonstrate cross-reactivity between dengue and Japanese encephalitis viruses. Myanmar dengue outbreak associated with displacement of serotypes 2, 3, and 4 by dengue. Her right eye has been bothering her and her right ear seems sensitive to loud noises. Significant swelling over last three days now resolved revealing a “crooked nose”. Endo: adrenal suppression (q Avamys,Flonase,Veramyst dose, long-term therapy only),pgrowth (children). Therapeutic:anti-infiamma to ries(steroidal) Interactions Pharmacologic:corticosteroids Drug-Drug: Ri to navir and ke to conazolepmetabolism andqlevels of fiutica PregnancyCategoryC sone. Route/Dosage Indications Intranasal(Adults):Flonase–2spraysineachnostriloncedailyor1sprayineach Seasonal or perennial allergic rhinitis. Seasonal or perennial nonallergic rhinitis nostril twice daily (not to exceed 2 sprays in each nostril/day); after severaldays, at (Flonaseonly). Patients 12 yr with seasonal Action allergic rhinitis may also use 2 sprays in each nostril once daily on an as-needed ba Potent, locally acting anti-infiamma to ry and immune modifier. Therapeutic Ef sis; Veramyst–2 sprays in each nostril once daily or 1 spray in each nostril twice fects:Decreaseinsymp to msofallergicandnonallergicrhinitis. Pharmacokinetics Intranasal (Children 4 yr): Flonase–1 spray in each nostril once daily (not to Absorption: 2%;actionisprimarilylocalfollowingnasaluse. Intranasal (Children 2–11 yrs): Veramyst–1 spray in each nostril daily; mayq Metabolism and Excretion: Rapidly and extensively metabolized by the liver; to 2 sprays if no response; once symp to ms controlled, attempt to pdose to 1 spray/ primarilyexcretedinfeces; 5%excretedinurine. Use Cautiously in: Activeuntreatedinfections;Diabetesorglaucoma;Underlying fi Moni to r growth rate in children receiving chronic therapy; use lowest possible immunosuppression (due to disease or concurrent therapy); Systemic corticoste dose. Pregnancy,lactation,orchildren 4yr(forFlonase)or 2yr(forVeramyst)(safety fi Lab Test Considerations: Periodic adrenal function tests may be ordered to notestablished;prolongedorhigh-dosetherapymaylead to complications). PotentialNursingDiagnoses Ineffectiveairwayclearance(Indications) Riskforinfection(SideEffects) Deficientknowledge,related to medicationregimen(Patient/FamilyTeaching) Implementation fi Do not confuse Flovent (fiuticasone oral inhalation) with Flonase (fiuti casonenasalspray). If patient is unable to breathe freely through nasal passages, instruct patient to blow nose gently in advance of medicationadministration. If not used for at least 7 days or if cap left off for more than 5 days, reprime unit. It is vitally important, given the rapidly changing nature of healthcare delivery in the ambulance service, that such changes are refiected in these guidelines. Some sections included in previous editions have been “Important new changes” removed, as they are now adequately covered in training manuals. Guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore individuals using these guidelines must ensure they have the appropriate knowledge and skills to enable appropriate interpretation. The committee does not guarantee, and accepts no legal liability of whatever nature arising from or connected to, the accuracy, reliability, currency or completeness of the content of these guidelines. Users of the guidelines must always be aware that such innovations or alterations after the date of publication may not be incorporated in the content. Modification of the guidelines may also occur when undertaking research sanctioned by a research ethics committee. Those not qualified to Paramedic level must practise only within their level of training and competence. Some sections have been removed as these are now adequately covered in training manuals, and other important areas of clinical practice have been included. Importantly, the paediatric section has been expanded recognising that the management of children is frequently different from that of adults. All drug pro to cols now have administration tables including: age, dose, concentration, and volume. In addition, standardised terminology relating to the administration of oxygen and fiuid has been included. Patient the following aspects have been added to the existing guideline, each of which confidentiality has become more prominent since the initial guideline was written: • Definition of ‘identifiable information’. Update Analysis Oc to ber 2006 Page 1 of 18 Update Analysis – Report of the Key Changes Pain Management Guidelines Pain management A new guideline for the assessment and management of pain in adults. Pain management A new guideline for the assessment and management of pain in children. The introduction of oral morphine sulphate solution further enhances pain management for patients and integrates care pathways between the ambulance service and other healthcare providers. The dosages and administration section has been standardised across all drug pro to cols, with the inclusion of administration tables. Drug introduction • Drug route section now merged in to the drug introduction section. Benzylpenicillin Change in the indications for administration to : (penicillin g) • ‘indicated by the presence of a non-blanching rash and signs/symp to ms suggestive of meningococcal septicaemia. En to nox • Labour pains have been added to the list of indications because en to nox is the appropriate analgesia for administration during transfer to further care. Hydrocortisone • Change in the indications for administration to include Addisonian Crisis.

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Further assessment and treatment should continue en-route: fi family his to medications similar to xanax buy paxil 20 mg lowest price ry fi airway impairment fi social his to symptoms 6 days after embryo transfer buy discount paxil 30mg online ry symptoms diverticulitis buy generic paxil 10mg on-line. Medical Emergencies in Adults Oc to in treatment 1 buy 30mg paxil otc ber 2006 Page 3 of 5 Medical Emergencies in Adults – overview Head Ensure adequate O2 therapy and support. If this is a tension pneumothorax, pro to col for dosages and information) in Addisonian then the patient will have increasing respira to ry distress Crisis. If the level of consciousness deteriorates or respira to ry depression develops in cases where an overdose with Assess skin colour and temperature, and record. Correct A and B problems on scene and then Abdomen commence transport to Nearest Suitable Receiving Hospital. To speech 3 fi patients on long-term steroids or who have adrenal To pain 2 insuficiency may deteriorate rapidly because of steroid insuficiency. Mortality rises significantly in the over 50’s as they can have atypical Medical patients may present with significant presentations and are more prone to catastrophic dehydration resulting in reduced fiuid in both the events. Ambulance crews attend a variety of acute abdominal Rapid fluid replacement in to the vascular conditions. Early cannulation is desirable but should not delay on (refer to pain management guidelines). No one has conclusively proven that narcotics mask pain and Pain his to ry: 9 cause problems with subsequent surgical assessment. They also develop conditions such as diverticulitis rarely seen in younger patients. Patients may present atypically fi menstrual and sexual his to ry in females of child but pain is almost always present. En to nox is worth consideration but may not be as 1 Appendicitis is also frequently misdiagnosed and up effective in abdominal pain (refer to En to nox drug to one third of women of child bearing age with pro to col for administration and information). Refusal of Base Station fi Myocardial infarction is often misdiagnosed as Physicians to Authorise Narcotic Analgesia. Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care. Disasters: Keys to prompt Recognition Tenets of Clinical Policy: critical issues for the initial evaluation Therapy. Search strategy: 5 Turner J, Nicholl J, Webber L, Cox H, Dixon S, Yates Abdom$ / S to mach. A randomised controlled trial of pre-hospital intravenous fiuid replacement therapy in serious Pain. U Unresponsive Start correcting: Assess and note pupil size, equality and response to light. Eyes Opening: Spontaneously 4 Key Points – Decreased level of To speech 3 Consciousness To pain 2 fi Maintain patent airway. Dificulty breathing is one of the most common causes of emergency calls for ambulance assistance and is fi. Acidosis following salicylate overdose or ke to acidosis also causes physiological hyperventilation (treat specific cause Specific cardiovascular problems: as per relevant guideline). If problem from nail varnish then remove varnish or mount probe sideways on finger. Adult emergency visits for chronic A 10cm line with descriptive phrases cardiorespira to ry disease: does dyspnea matterfi Emergency Medicine Clinics of North the patient marks a America 1999;17(1):221-37. Discriminating corresponds with their perception of the causes of dyspnea through clinical examination. A comparison of the visual analogue scale and modified Borg scale for the measurement of dyspnoea during exercise. The experience of dyspnoea in late stage cancer: patients’ and nurses perpectives. An open, prospective comparison of beta 2 agonists given via nebuliser, Nebuhaler, or pressurised inhaler by ambulance crew as emergency treatment. Terbutaline vs albuterol for out-of hospital respira to ry distress: randomized, double-blind trial. Provide a Hospital Alert Message / Information call fi Is there any impairment of consciousnessfi These patients should not be left at home fi headache of severe, sudden (thunderclap) onset and require full hospital assessment. Meningococcal meningitis and Is a cause of severe one-sided headache, particularly meningococcal septicaemia are different illnesses and in elderly patients. Beware of altered clinical fi Any persistent headache or any headache presentations in partially treated infectious conditions. A distressed person may react very badly disorders may be provoked or maintained by or to rush and hurry. Take time to explain your actions to associated with consumption of alcohol and other both the patient and the relatives and always substances. The presentation may be a first contact endeavour to be honest about what you are going to with a patient who has a new disorder or a person with do and what is likely to happen. However, others explored, with particular reference to previous mental may need to be compelled to receive an assessment health service involvement, prescription medication, and treatment, possibly against their will, usually using the level of alcohol use and potential substance powers given by the Mental Health Act 1983 (England misuse. Many patients are upset, distressed, anxious, If possible, a physical examination with primary suspicious, disorientated or agitated when faced by observations should be undertaken and recorded. While considering their own other features are established from the nature of the safety, the approach taken by ambulance crews to consultation and by observation. When patients are willing Reasonable and proportionate steps can be taken to to accept the assistance offered, there is little dificulty. The who acquires the power to convey patients and to process should be thoroughly documented using the request the support of ambulance staff and / or the Ambulance Trust process. Also, some incapaci to us patients may not satisfy the Ambulance crews should make an assessment of their conditions for compulsory detention, assessment or personal risk when approaching upset, distressed, treatment. Ambulance risk is considered significant, the Police should be clinicians should seek the advice of a Doc to r and / or called to assist. Due note should be taken of capacity or its impairment Depression, panic disorder, phobias and obsessional in particular cases as a component of assessments of conditions fall in to this category. There may be mental state and the potential requirement for considerable distress, but the patient usually has application for compulsory powers. In this is a general term that describes a group of the vast majority of circumstances, at least one of the disorders in which the patient tends to be severely medical practitioners has, or is required to have, distressed and may not appear to be rational. Thus, delusions and to help induce sleep and also to hallucinations and impaired insight may appear to reduce anxiety. It and cardiac dysrhythmias are may present acutely with severe change in behaviour the most significant effects in or insidiously as a slow but progressive change over a poisoning. The legislation fi A his to ry and examination should also include an allows for patients’ compulsory admission to hospital. A Determined to repeat Place of Safety may be the local Police Station or a or ambivalent 1 hospital but this should be defined and agreed locally Total patient score and in advance. Taking and assessing a his to ry Pleuritic pain is associated with chest infection and pneumonia producing a stabbing, generally one-sided There are a number of specific fac to rs that may help in pain that is worse on breathing in. Most pain associated with indigestion is central, Is there a previous his to ry of coronary heart diseasefi Thrombolytic treatment is increasingly Many patients do not have ‘classical’ presentation as 1,2,5 provided by Paramedics in the pre-hospital setting. Journal of Clinical Nursing thrombolysis (within 3 hours of symp to m onset) in 2004;13(8):996-1007. It is an acute, life-threatening Suspect an anaphylactic reaction if, in addition to the response in patients previously sensitised to an above, the patient’s condition has deteriorated to allergen. In general, the longer it takes for anaphylactic include: symp to ms to develop, the less severe the overall fi airway compromise. Gastrointestinal oedema/ hypermotility can result from Facial oedema, laryngeal an anaphylactic event; patients present with colicky oedema and respira to ry dificulty abdominal pain, diarrhoea, nausea and vomiting. Bees may (refer to oxygen pro to col for administration and anaphylaxis leave a venom sac which should information) and adrenaline (refer to adrenaline be scraped off (not squeezed). Key Points – Anaphylaxis/allergic reactions Anaphylaxis: fi Anaphylaxis can occur despite a long his to ry of previously safe exposure to a potential trigger.

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Syndromes

  • Liver function tests
  • Drowsiness
  • Sleeping too much during the day
  • Avoid a lot of activity in hot weather.
  • Rapid breathing
  • Avoid going out in dry, cold weather without putting on lip balm or lipstick
  • Eyes that are not aligned (dysconjugate gaze)
  • Problems sleeping
  • Transesophageal echocardiogram (TEE)
  • You have a fever or a cough that produces yellow-green phlegm

The intraosseous route may be to treatment tendonitis purchase genuine paxil online hospital as a priority required where venous access has failed on two fi in hypoglycaemia fiuid should be withheld unless occasions or no suitable vein is apparent within a life threatening shock is present when 10ml/kg reasonable timeframe symptoms before period purchase paxil line. The aim of management of any child with a cerebral insult is to symptoms neuropathy discount paxil 30mg amex minimise further insult by optimising their Fluid administration circumstances treatment viral pneumonia 10 mg paxil otc. Fluids should be: “Treat the treatable”; apart from the above, in pre hospital care this generally means management fi 0. Fluid Resuscitation in the nearest suitable receiving hospital without Pre-hospital trauma care: a consensus view. Capillary refill time in the field – it’s Remember that the patient his to ry may give you enough to make you blush! As for all trauma care, a systematic approach, While the law states that all children should be managing problems as they are encountered before restrained in vehicles,2,3 this is often not complied with moving on. There are, however, areas of difference in terms of ana to my, relative size and physiological response to In a small child, the size of the occiput may result in injury. A nasopharyngeal airway can also be used, but fi always look for evidence of children such as to ys or with adenoidal tissue there is the potential for bleeding. High concentration requires a careful approach, with an emphasis on 2 O should be administered routinely, whatever the explanation, reassurance and honesty. Paediatric Guidelines Oc to ber 2006 Page 1 of 5 Trauma Emergencies in Children – overviewTrauma Emergencies in Children – overview High fiow oxygen through a tightly fitting oxygen mask Assess for a haemothorax (refer to thoracic trauma with a reservoir is the ideal, although a compromise, guideline). Treatment should be based on res to ring ventilation, possibly by the chest wall in a child is very elastic and it is quite augmenting respira to ry effort with bag-valve-mask possible to have significant injury without there being ventilation using high fiow oxygen. Chest wall (refer to paediatric resuscitation charts for movement and the presence of any wounds should be normal values) if: sought. Areas to be listened to : Circulation Assessment fi above the nipples in the mid-clavicular line A normal mental state with good skin colour and fi in the mid-axilla under the armpits temperature are useful crude indica to rs of adequate fi at the rear of the chest, below the shoulder blades. In the first instance, assess for evidence of significant Table 1 – Normal Respira to ry Rate external haemorrhage and apply direct pressure to s to p any loss. Page 2 of 5 Oc to ber 2006 Paediatric Guidelines Trauma Emergencies in Children – overview Vascular access should be gained, where possible, Evaluate en-route to hospital, not prolonging the time on scene. Children are prone to rapid heat loss when exposed the widest possible cannula for identifiable veins for examination and immobilisation during trauma should be used. P Responds to painful stimulus U Unresponsive Secondary Survey this is a systematic and careful review of each part of If the child does not score A then the patient should be the injured child looking for less clinically critical considered time critical. Conscious level: Stepwise Disability Management fi assess the neurological status using the standard Confusion or agitation in the injured child may arise Glasgow Coma Scale (refer to Glasgow Coma directly from a head injury, but equally may be secondary Scale – Appendix 1) to hypoxia from airway impairment, impaired breathing or hypoperfusion due to blood loss and shock. Read the scene for mechanism of injury and manage in a manner similar to the adult trauma process. Agitation and/or confusion may presentation is important indicate primary brain injury, but could just as readily fi be due to inadequate ventilation and cerebral triage is dynamic. Item Score 2 the Mo to r Vehicles (Wearing of Seat Belts by Children in Rear Seats) Regulations 1989:1989 No. The Canadian C-Spine No response to pain 1 Rule for Radiography in Alert and Stable Trauma Patients. Signs include (but do not have to be particularly so in children who have been given present): penicillin as part of treatment for a (usually viral) infection and then developed a rash. Bees may Paediatric pens contain either 300mcg (approximating leave a venom sac which should Insect sting to the 250mcg dose below) or 125 mcg of adrenaline. Slow release drugs oxygen pro to col for administration and prolong absorption and information) via a non-re-breathing mask, using the exposure to the allergen. It may be considered in Main points include: exceptional circumstances after on line medical advice 1. This is particularly important in patents with asthma who may be predisposed to severe anaphylaxis. Warn carers that some children with even moderately severe attacks may suffer an early recurrence of symp to ms and some should be observed for 24 hours. Certain children are predisposed: fi severe slow onset reactions with unknown allergen fi severe asthmatic component or in severe asthmatics fi possible continuing absorption of the allergen fi previous his to ry of biphasic reactions. It will not, however, cause problems if the child Start correcting: who has inhaled a foreign body is treated for asthma. Respira to ry Examination fi check peak fiow if practical (take the best of three Refer to recognition of the seriously ill child for details readings); this is often impractical in children during of examination of the respira to ry system under an attack and should not be pursued if it causes “Breathing”. Paediatric Guidelines Oc to ber 2006 Page 1 of 2 Asthma in Children fi adminster salbutamol2 (refer to salbutamol Further Care pro to col for dosages and information) via an Remember the need to support the oxygen driven nebuliser, running at 6 – 8 litres per parents/guardians/carers of affected children. Special Cases In children under the age of one year, salbutamol should only be repeated if there has been a positive reponse to the first dose. Ensure safety of yourself the patient and the General principles of care are similar to those of adults scene. Inhalation of super-heated smoke, steam or gases in a It should be noted that the smaller airways in children fire, can induce significant major airway swelling and may make the management of the patient more problems in children. Early and rapidly developing airway swelling steam has been inhaled from a kettle; this has been may soon make intubation very dificult, so rapid known to cause fatal airway obstruction. Record the following information: If patient is non-time critical, perform a more thorough fi what happenedfi Those resulting from hot fat and other liquids Intravenous access in children may be dificult. The that remain on the skin will cause significantly deeper intraosseous route should be considered (remember and more serious burns. In any situation where smoke inhalation may have No creams or lotions should be applied to burns prior occurred, administer high concentration oxygen (O)2 to assessment by the hospital team. Be (refer to paediatric resuscitation charts for aware of the potential for hypothermia induced by normal values) if: continual irrigation of large areas of the body. It is rare to need more than 10 minutes irrigation except for – SpO2 is <90% on high concentration O2 chemicals that adhere to the skin, for example – respira to ry rate is three times phosphorus. Cling-film may be applied, followed by normal wet gauzes to produce cooling by evaporation. Vascular access will be necessary if: fi the child requires intravenous analgesia (see Analgesia (refer to management of pain in children) below) If the burn area is small, cooling and paracetamol fi the burn is more than one hour old and greater than (refer to paracetamol pro to col for dosages and 10% of the surface area. Page 2 of 3 Oc to ber 2006 Paediatric Guidelines Burns and Scalds in Children Significant burns or scalds may require En to nox (refer to En to nox pro to col for administration and information) if the child is able to co-operate, or oral morphine sulphate (refer to oral morphine sulphate pro to col for dosages and information). Burns to face, hands, perineum, must be taken directly to a specialist Burns Unit with paediatric expertise, if available. Hypoxia may be very simple which is why good A and B Most convulsions in children under the age of 5 years maintenance is important will be due to febrile convulsions. The other most common It is important not to label a patient as epileptic unless ambulance emergency there is a confirmed diagnosis. A nasopharyngeal airway is which the patient can be moved whilst still convulsing a useful adjunct in such patients should be considered and treatment may need to fi apply pulse oximetry and moni to r begin in situ. With small children it may be best to carry the child to the ambulance and continue fi check blood glucose level to exclude assessment and treatment en-route. Tepid sponging meningitis) is associated with increased patient distress and fi assess for mouth/ to ngue injury, incontinence. Any signs of potentially serious underlying illness require assessment in hospital. Chance remarks cause a this document draws on the experience of ambulance lasting impression and may cause offence. The Kennedy Report1 requires a multi-agency approach If possible, do not put children in body bags. The main objectives for ambulance clinicians when Allow the parents/carers to hold the infant if they so called to deal with the sudden unexpected death of an wish (unless there are obvious indications of trauma), infant are: as long as it does not interfere with clinical care. Alternatively associated with death or a valid advance directive ensure that they have other means of transport, and (refer to recognition of life extinct by ambulance that they know where to go. This is the opportunity, giving times and other details as normal but should be recognised and other forms of precisely as possible. Communication with other agencies Most local paediatricians or the medical direc to r of the ambulance service would be happy to discuss the After you have arrived at the house and confirmed that episode further if required. Many parents/carers have to ld the Foundation for the Study of Infant Deaths how important the actions and Find out about the multi-disciplinary case discussion, attitudes of ambulance clinicians were to them, and which should be convened by the paediatrician about most speak very highly of the way they and their infant eight weeks after the death, and attend it if possible. Your role is not only essential for immediate practical reasons, but also has a great infiuence on how the family deals with the death long Transferring the infant after the initial crisis is over. London: Royal College of Pathologists and the Royal College of Paediatrics and Child Health, 2004.

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