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Oxford Handbook of Critical Care - part 10

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Một số bệnh nhân mang theo vật lý tiềm năng truyền nhiễm, lây nhiễm và cách ly nguồn requi lại, ví dụ như bệnh lao. Ức chế miễn dịch bệnh nhân, ví dụ: khi giảm bạch cầu trung fol lowing hóa trị, có nguy cơ bị mua lại nhiễm trùng. | See also Ventilatory support-indications p4 Endotracheal intubation p36 Defibrillation p52 Cardiac function tests p150 Basic resuscitation p270 Cardiac arrest p272 Fluid challenge p274 Tachyarrhythmias p316 Acute coronary syndrome 1 p320 Acute coronary syndrome 2 p322 Burns-fluid management p510 Burns-general management p512 Rhabdomyolysis p528 P.526 Near-drowning Following near-drowning the major complications are lung injury hypothermia and the effects of prolonged hypoxia. Although hypothermia bestows protective effects against organ damage rewarming carries particular hazards. Pathophysiology Prolonged immersion usually results in inhalation of fluid however 10-20 of patients develop intense laryngospasm leading to so-called dry drowning . Traditionally fresh water drowning was considered to lead to rapid absorption of water into the circulation with haemolysis hypo-osmolality and possible electrolyte disturbance whereas inhalation of hypertonic fluid from sea water drowning produced a marked flux of fluid into the alveoli. In practice there seems to be little distinction between fresh and sea water as both cause loss of surfactant and severe inflammatory disruption of the alveolar-capillary membrane leading to an ARDS-type picture. Initially haemodynamic instability is often minor. A similar picture often develops after dry drowning and subsequent endotracheal intubation. Acute hypothermia often accompanies near-drowning with loss of consciousness and haemodynamic alterations. Management 1. Oxygen FIO2 0.6-1 should be given either by face mask if the patient is spontaneously breathing or via mechanical ventilation. Comatose patients should be intubated. Early CPAP or PEEP may be useful. 2. Bronchospasm is often present and may require nebulised p2 agonists and either nebulised or SC epinephrine. 3. Fluid replacement should be d i rected by appropriate monitoring. Inotrope therapy may be necessary if hypoperfusion persists after adequate fluid resuscitation. .