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Petrolatum-based fine-mesh gauze is applied on the skin graft overlapping 3–4 cm and a cotton bolster embedded in normal saline and liquid paraffin is secured with the bolster stitches order 120mg arcoxia with visa. The bolster is then removed in 5 days (7 days for full-thickness grafts) unless purulent discharges are detected before the planned day of removal (Fig arcoxia 60 mg fast delivery. Other techniques that have been used for graft fixation include fibrin glue discount arcoxia 90 mg without prescription, resolvable staples generic arcoxia 60mg line, and tape buy 120 mg arcoxia with mastercard. Perfect positioning of graft site is essential for proper healing in a good functional position. The intervention of rehabilitation services is a key issue to The Small Burn 215 A B FIGURE14 Donor sites are extensive in minor and medium-sized burns, therefore wounds should be always covered with sheet autografts. Good preoperative planning should include postoperative posi- tioning and splinting. Grafts that extend over joints and other anatomical locations (hands, feet, and neck) need proper splinting. A comprehensive plan should be made before surgery, and preliminary splints should be tailored for postoperative positioning. Experts in physiotherapy and occupational therapy are invited to assist and intervene at the end of the operation. After a light protective dressing has been applied, the splints are then molded again to adapt to the anatomical configuration. After completion, they are hold in place with a second external dressing. Splints are revised during the first and consecutive dressing changes and tailored to the specific patient’s needs. Interim pressure garments should be applied as soon as possible when grafts are deemed to be stable (usually within 7 days). Dressings After excision, donor site harvest, hemostasis, and graft fixation are completed, the most crucial part of the operation still must occur. Proper application of protective dressings requires a mastery that can only be acquired through experi- ence and proper training. Burn dressings serve four main purposes: Graft protection Fluid and exudate absorption Creation of a microenvironment that promotes wound healing Patient comfort An ill-dressed burn graft may not serve any of these purposes and, conversely, may promote shearing forces and graft dislodgement. As with any other surgical discipline, it can not be overemphasised that the art of dressing is the final touch that completes the excellence of surgical technique. In general, patients are igno- rant regarding surgery and medicine, and they can not assess the excellence in technique as physicians measure it. They can only assess our mastery in terms of pain control, good outcome (i. A sloppy dressing means a sloppy surgeon and a sloppy surgical technique in the eyes of our patients. During the early postoperative period, the only way patients have to assess a successful operation is to watch the perfection of the dressing and the care that they receive. Dressings that do not match patients’ expectation will ruin their trust. Also, and more important, dressings that are not properly applied may ruin the operation. Therefore, the application of dressings should be unhurried, follow a precise plan and technique, and be thoroughly inspected to avoid postoperative problems before the patient awakens. For didactic purposes, burn dressings can be classified as to their two main anatomical locations: 1. Graft sites 218 Barret Donor site dressings should provide a microenvironment that promotes wound healing and reduces pain. For small donor sites that have surrounding normal skin, the best choice is the application of Opsite or Tegaderm, a polyurethane occlusive film. It can be secured in place with the application of benzoine to normal skin, which increases fixation of the film. The dressing is completed with a compressive bandage to protect the inner film and provide patient comfort.

Cerebral Infarction: Early buy cheap arcoxia 120mg line, increased (white) signal intensity on T2 weighted images buy arcoxia 60 mg free shipping, more pronounced at 24 hours to 7 days (Tl may show mildly decreased signal) Chronically (21 days or more) discount arcoxia 120mg overnight delivery, decreased Tl and T2 weighted signals Intracerebral Hemorrhage: Acute hemorrhage: decreased (black) signal or isointense on Tl and T2 weighted images Edema surrounding hemorrhage appears as decreased intensity on Tl weighted image; increased (white) signal on T2 images As hemorrhage ages arcoxia 90mg on line, it develops increased signal on Tl and T2 images Subarachnoid or Intraventricular Hemorrhage: Acutely trusted 120 mg arcoxia, low signal (black) on Tl and T2 images STROKE 19 MRI/MRA: Detects most aneurysms on the basal vessels; insufficient sensitivity to replace conven- tional angiography Lacunes: CT scan documents most supratentorial lacunar infarctions, and MRI successfully documents both supratentorial and infratentorial infarctions when lacunes are 0. Carotid Ultrasound: Real time B-mode imaging; direct doppler examination. Screening test for carotid stenosis; identification of ulcerative plaques less certain. Angiography: Conventional angiography, intravenous digital subtraction angiography (DSA), and intra-arterial digital subtraction angiography DSA studies: safer, may be performed as outpatient Evaluation of extracranial and intracranial circulation Valuable tool for diagnosis of aneurysms, vascular malformations, arterial dissec- tions, narrowed or occluded vessels, and angiitis Complications: occur in 2% to 12%; complications include aortic or carotid artery dis- section, embolic stroke, vascular spasm, and occlusion Morbidity associated with procedure: 2. Lumbar Puncture: Used to detect blood in CSF; primarily in subarachnoid hemorrhage when CT not avail- able or, occasionally, when CT is negative and there is high clinical suspicion 6. Transesophageal Echo: Transesophageal echocardiographic findings can be helpful for detecting potential cardiac sources of embolism in patients with clinical risks for cardioembolism or unexplained stroke. TREATMENT IMMEDIATE MANAGEMENT (Ferri, 1998; Rosen, 1992; Stewart, 1999) Respiratory support/ABCs of critical care Airway obstruction can occur with paralysis of throat, tongue, or mouth muscles and pooling of saliva. Stroke patients with recurrent seizures are at increased risk of airway obstruction. Aspiration of vomiting is a concern in hemorrhagic strokes (increased associ- ation of vomiting at onset). Breathing abnormalities (central) occasionally seen in patients with severe strokes Control of blood pressure (see following) 20 STROKE Indications for emergent CT scan – Because the clinical picture of hemorrhagic and ischemic stroke may overlap, CT scan without contrast is needed in most cases to definitively differentiate between the two – Determine if patient is a candidate for emergent thrombolytic therapy – Impaired level of consciousness/coma: If there is acute deterioration of level of con- sciousness, evaluate for hematoma/acute hydrocephalus; treatment: emergency surgery – Coagulopathy present (i. Many patients have HTN after ischemic or hemorrhagic strokes but few require emergency treatment. Elevations in blood pressure usually resolve without antihypertensive medica- tions during the first few days after stroke. The response of stroke patients to antihypertensive medications can be exaggerated. Current treatment recommendations are based on the type of stroke, ischemic vs. Hemorrhagic Strokes: Treatment of increased BP during hemorrhagic strokes is controversial. Usual recommenda- tion is to treat at lower levels of blood pressure than for ischemic strokes because of concerns of rebleeding and extension of bleeding. It should remain > 60 mm Hg to ensure cerebral blood flow Fever, hyperglycemia, hyponatremia, and seizures can worsen cerebral edema by increasing ICP Keep ICP <20 mmHg Management of ICP: Correction of factors exacerbating increased ICP – Hypercarbia – Hypoxia – Hyperthermia – Acidosis – Hypotension – Hypovolemia Positional – Avoid flat, supine position; elevate head of bed 30° – Avoid head and neck positions compressing jugular veins Medical Therapy – Intubation and hyperventilation: reduction of PaCO2 through hyperventilation is the most rapid means of lowering ICP. Keep ICP < 20 mmHg – Hyperventilation should be used with caution because it reduces brain tissue PO2 (PbrO2); hypoxia may lead to ischemia of brain tissue, causing further damage in the CNS after stroke – Optimal PaCO2 ~ 25–30 mmHg – Hyperosmolar therapy with mannitol improves ischemic brain swelling (by diuresis and intravascular fluid shifts) – Furosemide/acetazolamide may also be used – High doses of barbiturates (e. Generally, IV heparin given for at least several days to increase PTT to 1. The most common cause is chronic atrial fibrillation Transient Ischemic Attacks: – Some studies suggest that a cluster of recent, frequent (“crescendo”) TIAs is an indication for anticoagulation therapy. Use of anticoagulants (heparin, Coumadin®) in TIA is empirical – May consider use of Coumadin® when antiplatelet drugs fail to reduce attacks Completed Stroke: – Anticoagulation not considered beneficial after major infarction and usually not of great value once stroke is fully developed – Empirically, some will utilize anticoagulation (initially with IV heparin) in setting of mild infarct to theoretically prevent further progression in same vascular territory Coumadin® may be continued for several weeks to 3 to 6 months – Anticoagulation generally not employed for lacunar infarction CORTICOSTEROIDS: No value in ischemic strokes Some studies suggest worsening in prognosis of stroke patients due to hyperglycemia CAROTID ENDARTERECTOMY (CEA) Symptomatic carotid stenosis CEA for symptomatic lesions with > 70% stenosis (70%–99%) is effective in reducing the inci- dence of ipsilateral hemisphere stroke. CEA is proven beneficial in: Symptomatic patients with one or more TIAs (or mild stroke) within the past 6 months and carotid stenosis ≥ 70% 24 STROKE 2. CEA is “Acceptable but not proven”: TIAs or mild and moderate strokes within the last 6 months and stenosis 50% to 69% Progressive stroke and stenosis ≥ 70% CEA for Asymptomatic Carotid Stenosis Indications—Controversial AHA guidelines (Moore, 1995) “Acceptable but not proven”: in stenosis > 75% by linear diameter (asymptomatic cases) Note: recent studies present opposing views on indications for surgery in asymptomatic carotid stenosis Asymptomatic Carotid Atherosclerosis Study (ACAS) (Executive Committee for the Asymptomatic Carotid Artherosclerosis Study, 1995) (Young et al. This 3 year study showed: In patients with asymptomatic carotid stenosis < 70%, risk of stroke is low, 2%. TREATMENT OF SUBARACHNOID HEMORRHAGE (see also Tx of ICP) Bed rest in a quiet, dark room with cardiac monitoring (cardiac arrhythmias are common) Control of headaches with acetaminophen and codeine Mannitol to reduce cerebral edema Control of blood pressure—have the patient avoid all forms of straining (give stool soft- eners and mild laxatives) Early surgery (with clipping of aneurysm) better; reduces risk of rebleeding; does not prevent vasospasm or cerebral ischemia Nimodipine (calcium channel blocker) shown to improve outcome after SAH (decreased vasospasms). Therapy should be initiated within 96 hours of the onset of hemorrhage TREATMENT OF INTRACRANIAL HEMORRHAGE Management of increased ICP and blood pressure (see previous) Large intracranial or cerebellar hematomas often require surgical intervention TREATMENT OF ARTERIOVENOUS MALFORMATION (AVM) (Hamilton and Septzler, 1994; Schaller, Scramm, and Haun, 1998) Treatment advised in both symptomatic and asymptomatic AVMs Surgical excision if size and location feasible (and depending on perioperative risk) Embolization Proton Beam Therapy (via stereotaxic procedure) Small asymptomatic AVMs: radiosurgery/microsurgical resection recommended STROKE 25 STROKE REHABILITATION INTRODUCTION The primary goal of stroke rehabilitation is functional enhancement by maximizing the inde- pendence, life style, and dignity of the patient. This approach implies rehabilitative efforts from a physical, behavioral, cognitive, social, vocational, adaptive, and re-educational point of view. The multidimensional nature of stroke and its consequences make coordinated and combined interdisciplinary team care the most appropriate strategy to treat the stroke patient. Recovery from impairments Hemiparesis and motor recovery have been the most studied of all stroke impairments. Up to 88% of acute stroke patients have hemiparesis The process of recovery from stroke usually follows a relatively predictable, stereo- typed series of events in patients with stroke-induced hemiplegia. These sequence of events have been systematically described by several clinical researchers.

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The pain is often worse with the first few diagnostic as well as therapeutic buy discount arcoxia 120mg line. Surgical release of steps in the morning or after rest discount arcoxia 90 mg without a prescription, also with jump- the medial plantar nerve may be indicated with failure ing or pushing off proven 120 mg arcoxia. Bone scan can help differ- entiate plantar fasciitis from calcanael stress frac- Tarsal tunnel syndrome is the most common compres- ture buy discount arcoxia 60 mg on-line. Primary treatment of plantar fasciitis is nonopera- entrapment neuropathy of the posterior tibial nerve in tive cheap 120mg arcoxia visa, conisisting of Achilles stretching and activity the tarsal tunnel or one of its terminal branches after modification. Cushioned be posttraumatic, as result of a space-occupying heel cups are often prescribed. Injection of corti- lesion, accessory muscle, or idiopathic (Schon, 1994). Repeated steroid boundaries are the medial surface of the talus, the injection may cause atrophy of the heel fat pad and medial surface of the os calcis, the sustentaculum tali, should be avoided. Ninety-five percent of patients with plantar fasci- canal consists of the flexor retinaculum as the roof and itis will have resolution of their symptoms within the abductor hallucis with its investing fascia. For the 5% of patients who fail Patients complain of burning, tingling, or numbness conservative treatment, surgical release of the on plantar aspect of foot and may have night pain, or plantar fascia may be considered. Radiographs are obtained to rule out extrinsic tear of the plantar fascia. Electrodiagnostic studies are help- acute pain or swelling of the plantar foot. A defect ful in differentiating from peripheral neuropathy or in the plantar fascia may be palpable, and loss of lumbosacral radiculopathy. Treatment varies with symptoms, ranging from aggravating activities, control of generalized edema, weightbearing as tolerated to nonweightbearing 393 CHAPTER 67 NERVE ENTRAPMENTS OF THE LOWER EXTREMITY MEDIAL CALCANEAL NERVE SAPHENOUS NERVE OBTURATOR NERVE 408 should be called tendonosis, referring to a degenera- The major pharmacologic effect of NSAIDs is to tive process, instead of tendonitis since inflammation inhibit the enzyme (COX), thus is not a major factor. The decreased monly used in these injuries to treat the chronic prostaglandins produce decreased inflammation and inflammation, judicious short-term use of NSAIDs to promote analgesia in the injured tissue. There are at control pain may still be warranted (Almekinders and least two forms of the COX enzyme, COX-1 and Temple, 1998). Most NSAIDs inhibit both COX-1 and Side effects of NSAIDs have a significant impact. Theoretically, this enhances the desired effects while The most common side effect is dyspepsia, occur- limiting the side effects. The (GI) ulceration, which occurs in 2–4% of effects include inhibiting articular cartilage synthesis patients taking the medicine for a year. They (including aspirin), concurrent corticosteroid use, are among the few agents known to be chemopreven- age over 50, and use of multiple or high-dose tive (Stanley and Weaver, 1998). Patients who are at capillary cell proliferation, often with discontinuity of risk for such an event should be treated with low-dose these cells. This suggests that chronic tendon injuries aspirin whether they are treated with COX-2-specific SECTION 5 PRINCIPLES OF REHABILITATION SIDE EFFECTS SAFETY LEGAL LEGAL EFFICACY EFFICACY SAFETY LEGAL EFFICACY Lateral tennis elbow Trigger finger DeQuervain’s tenosynovitis Trochanteric bursitis Carpal tunnel syndrome CHAPTER 72 FOOTWEAR AND ORTHOTICS WHAT TO LOOK FOR WHEN BUYING SHOES SPECIAL CONSIDERATIONS THE FIVE SHOE TYPES (Foot and Ankle, 2002) 447 455 SECTION 6 SPORTS-SPECIFIC CONSIDERATIONS 471 can develop through repetitive overload that leads to associated almost exclusively with the classical tech- tendinitis. The mechanism of injury is repetitive extreme can be torn or may be subluxed from the fibular extension of the MTP joint. The athlete will often report a pop in tive changes on inspection of the joint. Pain is exacerbated with Following the acute phase, a chronic clicking sensa- passive extension/flexion. Resisted eversion of the foot will Modifying nonskiing footwear to eliminate flexion with reproduce pain. Both tendons incorporating passive stretching and eccentric over- occupy the 1st dorsal wrist compartment and are gen- load exercise. Pain is precipitated with resisted thumb abduction or exten- Skier’s toe is a term frequently sion. The patient may demonstrate a positive used to describe pain in the 1st MTP joint. This makes children more likely to W eight training equipment can be found in sizes and gain heat from the environment in hot conditions and with weight increments appropriate for children. There is some evidence that Heat loss in children is even more apparent in water mouthguards can prevent head injuries as well.

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Unilateral slowed capillary refill cheap arcoxia 90 mg without a prescription, loss of pulse buy arcoxia 120mg fast delivery, cool toes discount arcoxia 60 mg with amex, and dusky appearance can be easily recognized discount 90mg arcoxia mastercard. In most cases catheter-related vascular com- promise resolves quickly after removal of the catheter discount arcoxia 60mg on line. If not contraindicated, heparinization can prevent further thrombosis after a vascular injury. Airway Management Most patients with significant burns will receive continuous enteral feeding via a feeding tube placed in the duodenum. The hypermetabolic state following large burns requires aggressive nutritional support. It is impractical to fast these patients for 8 h periods prior to surgery. Gastric emptying is usually not impaired following burn injury unless sepsis develops later on. Enteral feeding can and should be continued up until the time of surgery. Aspiration of gastric contents from the nasogastric tube should be performed before induction of general anesthesia to reduce the risk of pulmonary aspiration during to intubation. In the ICU gastric emptying is moni- tored during enteral feeding by periodic measurement of gastric residual volume. An effect of sepsis is impairment of gastrointestinal motility as manifest by in- creasing volumes of fluid in the stomach. This should be noted during the preoper- ative evaluation and steps taken to avoid aspiration, such as reducing or stopping enteral feeding for a period preoperatively. When the head and neck are not involved in the burn injury and there is no risk of inhalation injury, airway management is by conventional guidelines (with the exception that succinylcholine may be contraindicated). Cutaneous burns to the head and neck or evidence of inhalation injury may require special considerations. Moderate to severe edema, or scar formation as wounds heal, may also make direct laryngoscopy difficult. When there is significant risk of inhalation injury, fiberoptic bronchoscopy (FOB) is indicated for evaluation of injury. During sub- sequent operations after initial excision FOB may be indicated as follow-up of the status of inhalation injury. For these reasons at our hospital nearly all acute burn patients are intubated fiberoptically. Intubation during spontaneous ventila- tion is the safest way to secure the airway when management is difficult. An additional advantage is that when this technique is used routinely under controlled conditions, it greatly in- creases the level of experience for all the involved personnel. As a result airway management in more urgent situations is facilitated and becomes more controlled. Fiberoptic intubation for adults can be accomplished in the awake state with topical local anesthetic and sedation. As described above, ketamine provides nearly ideal condi- tions for FOB or fiberoptic intubation. As mentioned in the section on pharmacology, succinylcholine is contrain- dicated after large burns. It is generally agreed that succinylcholine can be used safely for approximately 48 h after the initial injury. After that it becomes contro- versial because there is so little evidence during the time period up to 2 weeks postburn. It is best to avoid succinylcholine after the first 48 h following burns up to about 1 year after wounds have healed. Once the trachea has been intubated, the endotracheal tube must be secured. Tape will not adhere to burned skin and cloth ties may cross the surgical field. When patients are intubated nasally, many burn centers utilize some modification of a tie that includes the nasal septum (Fig.

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There is no known cause generic 120 mg arcoxia, but possible causes include chemical or biologic weapons cheap arcoxia 120mg with mastercard, insecticides arcoxia 120mg without a prescription, Kuwaiti oil well fires buy 120 mg arcoxia fast delivery, para- sites order arcoxia 90mg with mastercard, pills protecting against nerve gas, and inocu- lations against petrochemical exposure. It is often a symptom of indi- gestion and occurs when acidic contents of the stomach move backward or regurgitate into the esophagus. It is a coagulation (blood-clotting) disorder and caused by an abnormality of plasma-clotting proteins necessary for blood coagulation. Disorders of hemostasis are caused by defects in platelet number or function or prob- lems in the formation of a blood clot, resulting in a bleeding or clotting disorder. Diseases, Pathologies, and Syndromes Defined 407 hip dysplasia: See congenital hip dysplasia. Hodgkin’s disease: A neoplastic disease of lymphoid tissue with the primary histologic finding of giant Reed-Sternberg cells in the lymph nodes. These cells are part of the tissue macrophage system and have twin nuclei and nucleoli that give it the appearance of “owl eyes. Huntington’s disease (HD): A progressive hereditary disease of the basal ganglia characterized by abnor- malities of movement, abnormal posture, postural reactions, trunk rotation, distribution of tone, extra- neous movements, personality disturbances, and progressive dementia. Often associated with chore- ic movement, which is brief, purposeless, involun- tary, and random. The disease slowly progresses, and death is usually due to an intercurrent infec- tion. Results from interference with normal circulation and with absorption of fluid, and especially, from destruction of the foramina of Magendie and Luschka. It is primarily caused by a hormone- secreting pituitary tumor, typically a benign adeno- ma. Other syndromes associated with hyperpitu- itarism include Cushing’s disease, amenorrhea (absence of the menstrual cycle), and hyperthy- roidism. Although the term allergy is widely used, the term hypersensitivity is more appropriate. Hypersensitivity designates an increased immune response to the presence of an antigen that results in tissue destruction. It is sometimes referred to as thyrotoxico- sis, a term used to describe the clinical manifesta- tions that occur when the body tissues are stimulat- ed by increased thyroid hormone. Excessive thyroid hormone creates a generalized elevation of body metabolism, the effects of which are manifested in almost every system. Diseases, Pathologies, and Syndromes Defined 409 hypochondriasis: A marked preoccupation with one’s health; exaggeration of normal sensations and minor complaints into a serious illness. The most significant clinical consequence is neuromuscular irritability producing tetany. It is a generalized condition in which all six of the pitu- itary’s vital hormones (adrenocorticotropic hor- mone, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, human growth factor, and prolactin) are inadequately pro- duced or absent. In primary hypothyroidism, the loss of thyroid tissue leads to a decreased production of thyroid hormone, and the thyroid gland responds by enlarging to compensate for the deficiency (see goiter). Secondary hypothyroidism is most com- monly the result of failure of the pituitary to syn- thesize adequate amounts of thyroid-stimulating hormone (TSH). It is sometimes referred to as alligator skin, fish skin, crocodile skin, or porcupine skin. When circulating immune com- plexes successfully deposit in tissue around small blood vessels, they activate the complement cas- cade and cause acute inflammation and local tissue injury. This results in vasculitis, which can affect skin, causing an allergic reaction; synovial joints, such as in rheumatoid arthritis; kidneys, causing nephritis; the pleura, causing pleuritis; and the pericardium, causing pericarditis. This invasion and multiplication of microorganisms produce signs and symptoms, as well as an immune response. Diseases, Pathologies, and Syndromes Defined 411 Systemic symptoms can include fever and chills, sweating, malaise, and nausea and vomiting. There may be changes in blood composition, such as an increased number of white blood cells (ie, leuko- cytes). The cortex supplied by the middle cerebral territory is most often affected (see middle cerebral artery syndrome). Occasionally, the origins of both the anterior (see anterior cerebral artery syn- drome) and middle cerebral arteries are occluded at the top of the carotid artery.

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