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It is most often due to refractory increased intra- cranial pressure subsequent to closed head injury or pulmonary complications purchase risperidone 3mg overnight delivery. With aggressive critical care buy risperidone 3 mg low cost, nonpulmonary sources of sepsis, renal failure, and multiple organ failure as a cause of death are declining. The management of the case presented at the beginning of this chapter is implicit in the discussion of trauma fundamentals that follows. Trauma Triage A cornerstone of trauma care is the timely identification and trans- port to a trauma center of those patients most likely to benefit from trauma care; this is the principle of triage. Trauma Fundamentals 551 French military concept, is at its simplest the sorting of patients based on need for treatment and an inventory of available resources to meet those needs. Trauma triage is founded upon the recognition that the nearest emer- gency room may not be the most appropriate destination. On a more complex level, triage involves the development of an algorithm that seeks to avoid undertriage (and possible adverse outcome) while minimizing overtriage (and overloading the system). Multiple prehospital scoring mechanisms have been suggested to assist in the triage decision. It has been hoped that some scoring tech- nique would facilitate identification of the 5% to 10% of trauma patients estimated to require the sophisticated trauma center. Current triage schema tend to assess the potential for life- or limb-threatening injury utilizing physiologic, anatomic, or mechanism of injury crite- ria. In general, physiologic criteria offer the greatest yield, while anatomic criteria are intermediate yield predictors and mechanism criteria are the lowest yield predictors. The best criteria of major trauma include prolonged prehospital time, pedestrians struck by vehi- cles moving at speeds greater than 20mph, associated death of another vehicular occupant, systolic blood pressure less than 90mmHg, respi- ratory rate less than 10 or greater than 29 breaths per minute, and Glasgow Coma Scale score of less than 13. The Trauma Survey The basic tenets of trauma resuscitation focus on addressing the man- agement decisions and treatment algorithms that are present for the patient who survives to reach the emergency department. Efforts during the initial or primary survey are directed at establishing a secure airway, using techniques of rapid sequence intubation if necessary, identifying that the patient has adequate breathing by ruling out or treating immediately life- threatening chest injuries (Table 31. Expeditious hemorrhage control, through operative and nonoperative means, has received increased emphasis over volume normalization through fluid admin- istration and blood pressure maintenance in the new iteration. Simply put, the best way to maintain or reestablish blood pressure is to stop the bleeding rather than to use pressors or large-volume administra- tion. This requires coordina- tion, communication, and treatment plans that are integrated and follow a logical sequence. The medical history obtained during the primary survey also focuses on the essential information. Immediately life threatening Airway occlusion Tension pneumothorax Sucking chest wound (open pneumothorax) Massive hemothorax Flail chest Cardiac tamponade Potentially or late life threatening Aortic injury Diaphragmatic tear Tracheobronchial injuries Pulmonary contusion Esophageal injury Blunt cardiac injury (“myocardial contusion”) Source: Used/Reproduced from American College of Sur- geons’ Committee on Trauma. Prehospital personnel should be questioned about vital signs en route and other details that could enhance under- standing of the patient’s physiologic state. A cornerstone of the primary survey concept is the dictum to treat life-threatening injuries as they are identified. This deviates from the traditional conceptual approach to the patient taught in medical school, wherein treatment is delayed until a thorough history is obtained, a physical examination performed, and all differential diagnoses are entertained. Management during the primary survey relies heavily on knowledge of the expected patterns of injury based on the mechanism of transfer of kinetic energy. X-rays should be ordered judiciously and should not delay resuscitative efforts or patient transfer to definitive care. Appropriate basic monitoring includes pulse oximetry and cardiac rhythm monitoring. Component Score Best eye opening Spontaneously 4 To verbal command 3 To pain 2 No response 1 Best verbal response Oriented and converses 5 Disoriented 4 Inappropriate words 3 Incomprehensible sounds 2 No response or sounds 1 Best motor response Obeys commands 6 Localizes pain 5 Flexion-withdrawal 4 Decorticate flexion 3 Decerebrate extension 2 No motor response 1 such as lethargy, stupor, or somnolence) into an objective scoring mech- anism. The score derives from assessment of the patient’s best motor, verbal, and eye opening responses (Table 31. This is extremely important, since it allows early detection of progression of neurologic deficit. Often, the trauma patient arrives in the emer- gency department intubated or therapeutically paralyzed. Alternatively, the verbal compo- nent of the score can be predicted from the motor and eye opening components using the following formula: Derived verbal score =-0. This especially is true when con- comitant head injury is present, and the head and neck axis should be considered as a single unit. Extending the alphabetical mnemonic to E, exposure, directs the examiner to remove all clothing and log roll the patient to fully evalu- ate for injuries. Trauma Fundamentals 555 The Secondary Survey The secondary survey naturally follows the primary survey, and it is here that a more thorough head-to-toe examination is performed. The secondary survey does not begin until the primary survey is com- pleted and resuscitation is well under way. Definitive hemorrhage control rather than normalization of volume status again is emphasized as the target of shock management. Blood loss may be estimated through assessment of blood pressure, heart rate, and skin color (Table 31. Hypovolemic hypotension requires 15% to 40% blood volume loss, but it may be a late sign in younger patients with good compensatory mechanisms.

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But it has this in its favor buy risperidone 2 mg mastercard, that it brings out all we know of medicine 4mg risperidone fast delivery, and enables us to classify our own knowledge and that of the books, so as to make them useful. When we study local remedies we find that they may be classified in a similar manner, some of them readily, others with difficulty. We have remedies that influence the respiratory organs, the digestive apparatus, the urinary apparatus, the excretory apparatus - skin, kidneys, bowels - the brain, etc. We find also that some remedies may be classified as they influence special tissues - mucous membranes, serous membranes, connective tissue, bones, etc. Let us call this the first study of remedies, a study that recalls and fixes that which we know, and that gathers from books the essential facts, or what seems to us essential facts of drug action. It is work, but I will guarantee that the physician comes out of it stronger in mind, and very much better able to prescribe for disease. There are some things which can only be learned by experiment, and I would urge every one to some effort in this direction. You have your own bodies, and though you may value them highly, it will do little harm to test some medicines upon your own person. There is nothing in medicine that I would not test on my own person, if I was engaged in studying its action. Very certainly if the physician has occasion to take medicine for any disease, he should carefully note its effects from hour to hour. Let us call this the second method of studying remedies, it is the Homœopathic method, though employed to some extent by all classes of physicians. It gives most excellent and reliable results, and we can not afford to dispense with it. The third method is by carefully studying the effects of remedies administered for disease. This study can only be made to advantage where notes are kept, when care is used in the diagnosis, and when single remedies, or remedies that act in the same way, are employed, It is true that we can carry something in our memories, and by repeated observations facts will become familiar, but it is not a good plan to trust the memory too far. There are two things we want to know - the expression of disease, and the action of remedies - and in so far as we can, we want to associate them together. We may keep a record of cases with but little writing, if we have a plan to commence with. One word will sometimes express the condition of disease, it will rarely require more than a line. Now when giving remedies we may note nearly as briefly the reason why we have selected the remedy. Pulse small, frequent - Aconite; pulse frequent, sharp - Rhus; veins full - Podophyllum; tissues full, œdematous - Apocynum; muscular pain - Macrotys; nervous, free from fever - Pulsatilla; periodicity - Quinine; dull, stupid, sleepy - Belladonna; pain of serous membranes - Bryonia; dusky coloration of surface or mucous membranes - Baptisia; mucous membranes deep red - Acids; mucous membranes pale - Alkalies; feeble heart - beef-tea; strong circulation, high temperature - boiled milk. I give examples as my memory recalls them, but I think that the majority can have a record in about as many words. We do not want to write a book for other persons, but to make such notes as will enable us to recall the entire history of the disease, with its expressions that have suggested the use of the remedies employed. The reader will see that the record of the effect of the medicine can be easily kept. A 0 will tell the story of no effect, and a group of half a dozen adjectives will note the more important influences that we wish to record. In making a study of our working materia medica, it is well to note the advantages of carrying remedies, and of extemporaneous prescription at the bedside. The advantages are threefold - to the physician, to the patient, and to the friends. To the physician in that he learns his remedies better, and prescribes with greater certainty. To the patient, that the remedies are given in less doses, are promptly administered, and are not admixed with unpleasant vehicles, and are of more certain value and action. I have no special love for retail druggists, and many unpleasant experiences have shown me that it is quite possible to procure the poorest drugs in the market from them, and that it is quite uncertain what you will get in any given case. Of course there are many exceptions, but this is applicable to the druggist in ordinary, who makes it a rule to buy cheap, and sell dear. I need not say that a contract between physician and druggist, by which the former receives a percentage on prescriptions, is a very small species of swindling, and unworthy the profession. Patients will soon recognize the advantage that comes from a well filled medicine case, and will pay their bills more promptly if they are not bled by the druggist. Talking about bleeding, I have seen, time and again, a poor family saddled with an expense of from thirty cents to a dollar and a half a day for weeks, and for drugs that were useless, or in quantities much larger than were necessary. Recently I counted on the mantel of a patient, seven four-ounce, two six-ounce, and three two-ounce bottles, with three boxes of powders, all of which had been procured in seven days for a child four months old. As regards the form in which medicines are dispensed, I greatly prefer fluids, as they are easily measured, miscible with water, which is the best vehicle, are readily absorbed by the stomach, and hence of quicker and more certain action. The physician carrying his medicine in fluid form will soon learn that the small dose is not only as good but better than the old doses, and that with the majority of drugs given for direct action, the standard gtt. Prescribed in water in this way, medicines are not unpleasant, and the child will take them without objection. In dispensing, we have them bring one or two glasses half full of water, and a teaspoon, and prepare the remedy before the patient.