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Shock Management
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
In the resuscitation room there is no justification for springing the pelvis to provide evidence of disruption; a check for symmetrical anatomical alignment and inspection of the groin and scrotum and external genitalia should be made. An absence of positive findings does not rule out the possibility of pelvic fractures and does not negate the need for a pelvic radiograph. Significant long-bone fractures, if not already identified, should become apparent during the ‘exposure’ component of patient assessment. Traction splinting of femoral fractures, in the absence of a pelvic fracture at the proximal point of purchase, decreases the space and volume for potential blood loss. The same rationale applies to the use of pelvic splints.10 Binding the ankles together and flexing the knees slightly will augment the pelvic binder in fracture reduction. Realignment also facilitates patient analgesia and subsequent patient handling. Retroperitoneal haemorrhage is invariably occult and may only become apparent once all other sites of bleeding have been excluded or controlled.
Acquired Bleeding Disorders Associated with Disease and Medications
Published in Harold R. Schumacher, William A. Rock, Sanford A. Stass, Handbook of Hematologic Pathology, 2019
William A. Rock, Sue D. Walker
A comprehensive approach to managing a bleeding patient should include (a) maintaining a hematocrit >30% with blood transfusions and or erythropoietin therapy; (b) dialysis before surgery or other high-risk invasive procedure, leaving all drains in after the next dialysis if possible, and dialysis as needed during bleeding episodes, with full recognition of the relationship of dialysis and heparin; (c) transfusion of cryoprecipitate and or DDAVP (0.3 µg/kg body weight in 50 mL normal saline over 30 min); (d) control of infections with antibiotics and vitamin K therapy with prolonged antibiotic use; and (e) long-term management of bleeding problems with estrogen if clinically indicated (89–93). In managing the chronic renal failure patient who is bleeding, there is often much frustration with continued bleeding when surgical hemostasis is achieved. Bleeding over several days does occur, and with a renal biopsy retroperitoneal hemorrhage is a significant complication. Unfortunately, despite therapy, the best that can be achieved is a slowing and eventual stopping of the bleeding. A sudden or miraculous cessation of all bleeding usually does not occur (Table 7).
Introduction to specialist investigations
Published in Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins, The Junior Doctor’s Guide to Cardiology, 2017
Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins
The most common complication that you need to be aware of is bleeding at the access site. This is more of a problem with femoral procedures, as the site is ‘hidden.’ Beware of the shocked patient. Retroperitoneal haemorrhage is a potentially life-threatening condition and must be recognised early. It is usually a consequence of high puncture of the posterior wall of the common femoral artery. Suspect it if there are signs of shock and pain during an ipsilateral straight leg raise post procedure. The diagnosis is best made by CT, and treatment involves emergency surgery.
Multi-modality management of hypertrophic cardiomyopathy
Published in Hospital Practice, 2023
Shiavax J. Rao, Shaikh B. Iqbal, Arjun S. Kanwal, Wilbert S. Aronow, Srihari S. Naidu
A recent systematic review and meta-analysis comparing ERASH and SM reported both groups having significant efficacy in changing the resting LVOT gradient, but the SM group had a larger reduction in interventricular septal thickness compared to ERASH. Both groups had similar improvement of NYHA class during follow-up. Notably, hospital stay and need for pacemaker implantation were less in the ERASH group [81]. Significant complications have been reported with retroperitoneal hemorrhage following sheath removal, paradoxical LVOT gradient increase resulting in pulmonary edema, and development of LBBB that progressed to complete heart block at 6-month follow-up [82]. This modest reduction may be limited due to RF delivered to subendocardium [83]. Due to the heterogeneity of techniques, there is no clear correlation between different guiding modalities (electroanatomic mapping, intracardiac echocardiography, transesophageal echocardiography) and complications [84].
How low can you go? Severe hyponatremia with a sodium of 94 mg/dL corrected with proactive strategy
Published in Journal of Community Hospital Internal Medicine Perspectives, 2020
Manan Shah, Viralkumar Amrutiya, Nikesh Patel, Sophia Kwon, Jeffrey Fein, Abraham Lo
An 83-year-old male with a history of Diabetes Mellitus Type 2, benign prostatic hyperplasia, and hypertension presented with nausea, vomiting, and multiple falls for several days. Patient reported drinking many glasses of water the day prior to admission and was also recently started on triamterene/hydrochlorothiazide for hypertension. Physical examination was benign. Laboratory data revealed serum sodium of 94 mg/dL; therefore, fluid restriction, concomitant 3% hypertonic saline and DDAVP were initiated in the intensive care unit as per Figure 1. Hypertonic saline was administered as 50 ccs/hr boluses with 2 mg of DDAVP every 6 hours for the first 96 hours until sodium was 113 mEq/L. Despite a hospital course complicated by retroperitoneal hemorrhage requiring transfusion and hypovolemic shock with a resultant acute tubular necrosis, the patient’s sodium slowly corrected to 136 mEq/L. The patient was eventually discharged without long-term neurologic or renal complications.
Ultrasound Guidance is Great, but not a Panacea
Published in Structural Heart, 2018
Some additional comments on the paper by Soud and colleagues: they state that bleeding complications often occur with “CFA (common femoral artery) access above the inguinal ligament”; generally speaking access above the inguinal ligament means that the needle is actually entering the external iliac artery (not the CFA). Retroperitoneal hemorrhage (RPH) is quoted as “being the most common femoral artery access complication with an incidence rate of 3%”; in fact, the most common is hematoma, with the rate varying by threshold for hematoma size. RPH occurs in significantly less than 1% (not 3%), including in the three references cited by the authors, but it is the most deadly. And although femoral artery pseudoaneurysms may occur in the high range the authors cite, this is only seen with routine post procedure ultrasound scanning, usually done as part of research protocols; most of these are small and resolve without intervention. Further, to the list of causes of pseudoaneurysm, the reader should consider low puncture, which has a greater chance of involving one of the femoral bifurcation vessels (superficial femoral or profunda femoris) resulting in a larger sheath to artery ratio and making vessel closure more difficult.