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Corneal Reflex and Gag Reflex: The corneal reflex is assessed by gently stroking the cornea with a soft wisp of cotton buy 10 mg forxiga with visa. The corneal reflex is mediated by the fifth and seventh cranial nerves generic 10mg forxiga visa, and intact corneal reflexes indi- cate integrity of the pons order 10 mg forxiga with mastercard. The gag reflex, in which gentle stimulation of the posterior oropharynx results in elevation of the soft palate, assesses the integrity of the lower brainstem (medulla). Motor Exam and Sensory Exam After the brainstem exam has been completed, a motor exam and a sensory exam should be performed. A thorough motor or sensory exam is difficult to perform in any patient with an altered level of con- sciousness. When a patient is not alert enough to cooperate with strength testing, the motor exam is limited to an assessment for asym- metry. This may be demonstrated by an asymmetric response to central pain stimulation or a difference in muscle tone between the left and right side. If there is asymmetry in the motor exam, this may be indica- tive of a hemispheric injury and may raise the suspicion for a mass lesion. Patients with altered levels of consciousness are unable to cooperate with sensory testing, and a sensory exam may not be reliable in intoxicated or comatose patients. Diagnostic Evaluation After the patient has been stabilized and an appropriate neurologic exam has been performed, the diagnostic evaluation may begin. Shepard Radiographic Evaluation X-Rays Skull x-rays rarely are used today in the evaluation of closed head injury. They occasionally are used in the evaluation of penetrating head trauma and can provide a rapid assessment of the degree of foreign- body penetration in nonmissile penetrating head injuries (e. The bone windows provide a survey of bony anatomy, and the tissue windows allow for a detailed survey of the brain and its contents. Check lateral ventricles for blood (especially in occipital horns), size (especially temporal horns), and mass effect 5. Look for intraparenchymal hematomas and contusions, especially frontal and temporal tips, inferior frontal lobes, and under any fractures (measure clot thickness in mm) 7. Check top cuts for effacement of sulci, often a subtle sign of mass effect Bone windows 1. Check five sets of sinuses (ethmoid, sphenoid, frontal, mastoid, maxillary) for fracture or opacification; the maxillary sinuses may only be partially seen on standard head cuts 2. First, the bone windows should be examined for fractures, beginning with the cranial vault itself, and then the skull base and the facial bones should be examined. Next, the tissue windows should be examined for the presence of any of the fol- lowing: extraaxial hematomas (e. Next, the brain should be surveyed for any evidence of pneumocephalus, hydrocephalus, cere- bral edema, midline shift, or compression of the subarachnoid cisterns at the base of the brain. Finally, the subdural windows should be exam- ined for any hemorrhage that may not be visualized easily on the tissue windows. Computed tomography scans may be used for classification as well as for diagnostic purposes. Skull Fractures: Skull fractures are classified as either nondisplaced (linear) fractures or comminuted fractures. A comminuted frac- ture may be displaced inward, which is defined as a depressed skull fracture. Intracranial Hemorrhages: Intracranial hemorrhages are divided into two broad categories: extraaxial hematomas and intraaxial hema- tomas (Table 32. Intraaxial hematomas Extraaxial hematomas Intracerebral hematoma Epidural hematoma Subarachnoid hemorrhage Subdural hematoma Cerebral contusion Extraaxial hematomas include epidural and subdural hematomas. They typically are biconvex in shape because their outer border follows the inner table of the skull, and their inner border is limited by locations where the dura is firmly adherent to the skull (Fig. Epidural hematomas usually are caused by injury to a dural-based artery, although 10% of epidurals may be venous in origin. Their outer edge is convex, while their inner border usually is irregularly concave (Fig. Subdural hematomas are not limited by the intracranial suture lines, and this is an important feature that aids in their differentiation from epidural hematomas. Subdural hematomas usually are venous in origin, although some are due to arterial bleeding. Cere- bral contusions are posttraumatic lesions in the brain that appear as irregular, heterogeneous regions in which hyperintense changes (blood) and low-density changes (edema) are intermixed (Fig. Shepard Intraventricular hemorrhages are regions of high intensity within the ventricular system. Subarachnoid hemorrhages that occur as a result of trauma typically are located over gyri on the convexity of the brain. These are thin layers of high-intensity signal located on the surface of the cortex.

The strongest correlation for a pulmonary injury is a history of being burned in an enclosed space coupled with the presence of facial burns or the history of patient incapacitation from drugs or alcohol purchase 10 mg forxiga overnight delivery. The serum carbon monoxide level may be used to tailor therapy forxiga 10 mg sale, but it may be unreliable if supplemental oxygen already has been administered cheap forxiga 10 mg free shipping. The concen- tration of carboxyhemoglobin is reduced by 50% for each 40-minute period of treatment with high-flow oxygen. Bronchoscopy has been advocated as a diagnostic tool, but it adds little to the accuracy of the history and the physical examination. Since signs and symptoms of inhalation injury may appear over an 18- to 36-hour period, patients at risk or patients suspected of being at risk should be admitted for a 24-hour period of observation. Steroid therapy is not beneficial and carries a risk of superimposed infection; bronchodilator therapy and aggressive chest physiotherapy are advantageous. Prophylactic antibiotics are not recommended due to the risk of selection pressure for the emergence of resistant organ- isms. The airway should be secured before edema necessitates a surgical airway; tracheostomy or cricothyroidotomy carries a higher morbidity and mortality rate. Treatment: The First 24 Hours The purpose of fluid resuscitation in the early postburn period is reex- pansion of plasma volume within the extracellular space. Delivery of sodium ion into the extracellular space results in reestablishment of 34. All agree, however, that restoration of plasma volume is essential in preventing renal failure and shock. As in the case presented at the beginning of the chapter, these lines may be placed through the burn wound if access sites are limited. This formula is a rough guide, however, and one fifth of patients need more and one fifth need less. In some formulas, colloids in the form of albumin or fresh frozen plasma are added in the second 24 hours or when the capillary leak has stopped. A diuretic phase begins on the third to fifth postburn day with mobilization of the resuscitation fluid. Emergency care of burns, either major or minor, requires adequate tetanus prophylaxis. The burn wound is anaerobic, and cases of clini- cal tetanus have been described even from superficial second-degree injuries. For those never immunized, both passive and active immunization using tetanus immune human globulin (Hyper- Tet) is suggested. Efforts are directed at maintaining body temperature and prevent- ing hypothermia. Iced saline is not used for initial debridement or wound coverage in the emergency department for that reason. Early in the management scheme, practitioners must determine if the patient requires hospital admission and whether resources for good burn care exist in their institution. Guidelines for admission have been developed by the American College of Surgeons and the American Burn Association (Table 34. Transfer to a specialized burn center is warranted if all components of the burn team are not available at the receiving institution. Treatment: After the Emergency Department The mainstay of burn treatment is good wound care, with attention to principles of infection control coupled with early wound closure and adequate nutritional support. All blisters should be debrided except for those on the palms and soles if they are intact. Mechanical debridement is necessary; merely submerging the burn patient in a whirlpool is not sufficient. Once the wound has been debrided, topical drug therapy controls bacterial colonization until spontaneous eschar separation and reepi- thelialization occur or until sharp debridement followed by surgical closure with skin grafts or flaps is completed. The advent of effective topical therapy significantly has reduced mortality from burn wound sepsis. The two major types of topical drug therapy currently in use are silver sulfadiazine (Silvadene, Flamazine) and mafenide acetate (Sulfamylon). It should be applied at least twice daily, removing old cream and cellular debris before each new application. It has only fair to poor eschar penetration, and it may not be effective in deeply burned or avascular areas. This prop- erty makes it more effective for prophylaxis rather than for therapy of burn wound infection. There are no significant metabolic side effects, but an infrequent hypersensitivity-type reaction may result in a tran- sient leukopenia. Silver sulfadiazine should be discontinued if the white blood cell count falls below 2000. Mafenide acetate is an alternative topical agent with excellent penetration into eschar. Its penetration properties make it a good choice for infected burns and burns in avascular areas, such as the ear.

The solar plexus purchase forxiga 10 mg without prescription, the most important of the vegetative nerve centers generic 10mg forxiga fast delivery, may be thus influenced from the stomach cheap 10mg forxiga with mastercard. The stimulant influence of Capsicum may, therefore, be extended through this, and be of marked advantage in states of great and sudden prostration with tendency to congestion. Given in water-brash, or where there is decomposition of the food, it is sometimes beneficial. So in topical disease - with free secretion and tendency to sepsis - its local application absorbs the one and checks the other. Why this checks it I can not tell; that it does it, I have the evidence of my own eyes. For several years I have employed the second decimal trituration as a remedy in passive hemorrhage, with most marked benefit. I employ it in threatened hemorrhage during typhoid fever, in menorrhagia, especially when chronic, in prolonged menstruation, the watery discharge that sometimes follows menstruation, hemorrhage from the kidneys, hemorrhage from the lungs, and in some cases of leucocythemia. A good indication for this remedy is a small pallid tongue, with lenticular spots, and with this it may be given in any form of disease. The dose of the first or second trituration will be one grain, repeated as often as necessary. In this form it is easily carried, and dispensed by adding the proper portion to water, so that the dose may be one teaspoonful. Carbolic Acid exerts a specific influence in those cases in which, with a broad moist tongue, there is a cadaverous odor of the breath. It makes little difference what the name of the disease is - whether bilious or typhoid fever, cynanche, pneumonia, diarrhœa, dysentery, disease of the urinary apparatus, or whether the disease is acute or chronic. In these cases it is used in small doses as - ℞ Solution of carbolic acid in glycerine, gtt. We employ it with marked advantage in cases of irritable stomach, and to check nausea and vomiting, when the symptoms above named present. As far as my experience goes, it cannot be used with advantage where the mouth is dry, or if the tongue is contracted, or enlongated and pointed. As a topical application, we employ carbolic acid when we need an antiseptic and a stimulant. Even here there must be the local symptoms, fullness and relaxation of tissues; whenever there is contraction, shrinking and dryness, it will prove harmful. These rules hold good, whether as a dressing for wounds, for erysipelas, for burns, for a chancre, for a gargle, a vaginal injection, or for the treatment of a gonorrhœa or gleet. As a local application in full strength we use this agent to destroy warts, and epidermal growths of this character. It is also a remedy in epithelial cancer, and in some cases it will exert a better influence than the stronger escharotics. The strength of the solution, in the treatment of cancers, will vary in different cases. In some the full strength of the solution in glycerine can be continually applied; in a few the full strength of the acid, rendered fluid by heat; but in others it will require dilution with glycerine. Use that strength that gives greatest ease, and leaves the parts in best condition. One of the principal objects is relief from pain, carbolic acid being a true anæsthetic in these cases, and the strength of the solution will be adapted to this use. It exerts, however, a special influence in colic, which renders it an important remedy. We have generally employed it in the form of the Compound Powder of Jalap and Senna, in doses of five or ten grains, frequently repeated until relief is obtained. An infusion of senna - or the tincture will answer the same purpose - for the relief of colic, whether the common wind colic or that known as bilious, I regard as one of our best remedies. Chestnut leaves exert a specific influence in some cases of whooping cough, so much so, that the relief is apparent in twenty-four hours. They have usually been employed in infusion, but the tincture will be found as good, and is more easily dispensed. In convulsive cough or paroxysmal cough, resembling whooping cough, it has also proven a successful remedy. It may also be tried in cases where there is unsteadiness in the gait, and a disposition to turn to one side. This remedy has been regarded as so valuable that it was monopolized by the government of Cashmere. A tincture is prepared from the root which is administered in doses of one drop; and is employed in giddiness, salivation, and as an antidote to poisonous bites and stings. In small doses the tincture of Catalpa relieves irritation of the bronchial tubes, and gives freedom to respiration. It has been used in asthma with marked success, and is also recommended in chronic bronchitis, and in some forms of functional heart disease.