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Prim and imaging (if there is any question about the diag- Care 11:161 buy 0.5mg dutasteride amex hair loss cure forum, 1984 cheap dutasteride 0.5mg overnight delivery hair loss 2. Observation includes evaluation of facial sym- Easterbrook M, Johnston RH, Howcroft MJ: Assessment of ocular foreign bodies. Palpation includes the Rhee DJ, Pyfer MF, Rhee DM: The Wills Eye Manual. This may be blood or cerebral spinal fluid Norwalk, CT, Appleton & Lange, 1999. The “ring test” is a method of detecting CSF Vinger PF: A practical guide for sports eye protection. This represents a severe facial fracture and requires immediate transport. X-rays may be help- 29 OTORHINOLARYNGOLOGY ful in determining the presence of a facial fracture; how- ever, computed tomography (CT) is the gold standard. Charles W Webb, DO Return to play guidance is based on the history and physical examination. Suspected fractures, airway obstruction or impending obstruction, bleeding, loss of consciousness, and changes in vision are con- INTRODUCTION traindications for return to play. They comprise 4–19% of all sports EAR INJURIES related injuries depending on age and gender. One- third of all dental injuries are sports related (Truman EAR LACERATION et al, 2002). In the pediatric age ranges, one-third of injuries are sports related (Luke and Micheli, 1999). With the addition of face- Treatment: Cartilage tear, repair with absorbable 5-O masks and mouth guards in football and hockey suture prior to closing the skin. Laceration should be (1950s and 1970s respectively), the number of severe irrigated and debrided prior to suturing. Baseball now accounts for the majority (40%) of all sports related facial injuries in the United States. AURICULAR HEMATOMA ASSESSMENT OF INJURIES ON THE SIDELINE “Wrestler’s Ear” or “Cauliflower Ear” is caused by Sideline management of the athlete with a facial injury bleeding between the skin (perchondrium) and the begins with the ABCs (airway, breathing, circulation). This occurs secondary to repetitive CHAPTER 29 OTORHINOLARYNGOLOGY 167 contusions to the pinna. This can evolve into a perma- TYMPANIC MEMBRANE RUPTURE nent cosmetic deformity with chronic hematomas, secondary to an increased pressure and eventual This usually occurs secondary to a diving, water necrosis of the pinna and cartilage. Compression prevents infection develops or the injury occurred in water hematoma from reforming and should be left in place sports. The athlete should not return to play 25% of the TM is involved to rule out nerve injury until after the removal of the compression device, (Blanda and Gallo, 2003). This allows the athlete to return to play quickly (same day with head gear); however, this NASAL FRACTURES treatment method usually leads to a permanent cauli- flower ear. Both the athlete and the parents should be Most common sports-related facial fracture as well as informed of the risk and the permanence of this defect the most common facial structure injured. Side blows usually result in simple fractures with deviation to the opposite side. OTITIS EXTERNA Signs and symptoms: Acute pain, tearing, epistaxis, facial swelling, and ecchymosis. Swelling makes Examination: Erythematous and edematous auditory adequate assessment of nasal deformity difficult. If canal with a normal or mildly erythematous tympanic unable to reduce an otorhinolaryngology referral is membrane. Fungal infections typically have a white to required in 5–7 days for reduction. Athletes should not gray appearance with spots that resemble cheese, and return to play the same day unless there are absolutely pseudomonal infections will usually have a sweet no other associated injuries and the nose can be pro- odor. Return to play is typically not advised for at least Treatment: Irrigating the canal allows the medication the first week postreduction. Cortisporin otic suspension (solu- are recommended for the first 4 weeks postinjury. If the canal is swollen, a cotton wick may be used to SEPTAL HEMATOMA help deliver the antibiotic.
This is required in order to assess resuscitation accurately prior to surgery and to provide appropriate resuscitation intraoperatively generic dutasteride 0.5mg without prescription hair loss xeloda. In fact buy dutasteride 0.5mg free shipping hair loss cure queentet, anesthesia for major burn surgery involves resuscitation from the initial injury and/or the effects of the burn wound excision. Preoperative evaluation must be performed within the context of the planned surgical procedure, which will depend on the distribution and depth of burn wounds, time after injury, presence of infection, and existence of suitable donor sites for grafts. An anesthetic plan requires understanding of both the patient’s physiological status and the surgeon’s plan. The patient’s physiological status is revealed by results of physical examination and review of the medical record. The medical record will provide information regarding previous medical history as well as a description of the injury and hospital course. When the burn wound has been previously excised, anesthetic records must be reviewed for information on how the patient tolerated previous operations. An understanding of the surgical plan requires close communication with the surgeons. Unlike many operations that follow a repeatable sequence (for example, appendectomy), no two burn wound excisions are the same. Each operation is guided by how much nonviable tissue is present and the condition of potential sites for split-thickness harvesting of skin for autografts. Often the surgical procedure depends on findings of close wound examination that can only be done in the operating room. The surgeons will nevertheless have some estimate of areas to be excised and donor sites to harvest. This information is necessary to estimate the amount of blood needed as well as what vascular catheters will be needed for replacement of volume and hemodynamic monitoring. Evaluation of Cutaneous Burns The skin has been described as the largest organ in the body. Thermal injury to the skin disrupts several vital protective and homeostatic functions (Table 3). Care of burn patients, either in the operating room or in the ICU must compensate for these functions until the wounds are healed. The skin helps to maintain fluid and electrolyte balance by serving as a barrier to evaporation of water. Heat loss through evaporation and impairment of vasomotor regulation in burned skin diminish effective temperature regulation. Burned Anesthesia 107 TABLE 3 Functions of Skin – Protective Barrier Immunological Fluid evaporation Thermal (insulation, sweat production, vasomotor thermoregulation) – Sensory – Metabolic (vitamin D synthesis and excretory function) – Social (self-image, social image) surfaces produce an exudate that is rich in protein. Loss of this protein along with diminished hepatic synthesis eventually reduces plasma protein concentration and contributes to accumulation of interstitial fluid (edema). Morbidity and mortality due to burn injuries depend in large part on how much and how deeply the skin is burned. The extent of burn injury is expressed as the percent of total body surface area burned (TBSA). This area is then classi- fied into the area burned superficially and the area burned through the full thick- ness of the skin. Partial-thickness burns will often heal but areas of full-thickness burn must be completely excised, sometimes down to fascia. Tangential excision is associated with more blood loss than occurs with excision down to fascia. Volume resuscitation of burn-injured patients is guided by estimates of percentage TBSA burned. A quick estimate of percentage TBSA burned can be made with the so-called rule of nines (Fig. More accurate estimates must take into account the changes in body proportion that occur with age (Fig. In the early period after injury, the adequacy of resuscitation can be evaluated by comparing the volume of fluid administered with what the patient’s predicted needs are based on common formulas.
Delay or underresuscitation discount dutasteride 0.5mg with visa hair loss treatment mens health, of course 0.5 mg dutasteride visa hair loss black women, can cause organ damage through ischemia. Overresuscitation can also cause problems such as 112 Woodson TABLE 6 Formulas for estimating adult fluid resuscitation needs Formula Crystalloid Colloid Crystalloid formulas Modified Brooke Lactated Ringer’s 2 mL/kg/% burn Parkland Lactated Ringer’s 2 mL/kg/% burn Colloid formulas Evans Normal saline 1 mL/kg/% burn 1 mL/kg/% burn Brooke Lactated Ringer’s 1. Pulmonary edema is unusual in burn patients unless intravascular filling pressure is increased above normal. Certain features of the burn injury can increase fluid requirements beyond what the protocols predict. Smoke inhalation injury has been found to increase fluid requirements up to 50% above what would be estimated from accompanying cutaneous burns alone. This effect is more important with less extensive burns and the difference is less distinct with burns greater than 50% total body surface TABLE 7 Formulas for Estimating Pediatric Fluid Resuscitation Needs Formula Volume Timing Composition Cincinnati 4 ml/kg/% burn 1st 8 h Lactated Ringer’s 50mEq NAHCO3 1500 ml/m2 burn 2nd 8 h Lactated Ringer’s 3rd 8 h Lactated Ringer’s 12. Extensive full-thickness burns also increase fluid requirements beyond the volumes estimated by formulas such as the Parkland formula. Formulas and protocols for burn resuscitation are only rough guides and fluids must still be titrated according to the patient’s response and physiological state. Resuscitation is an imprecise process: there is no single reliable end point to titrate to. Heart rate and mean arterial blood pressure along with a urine output of 0. However, numerous studies have shown that these indicators can be misleading. A state of what is termed compensated shock can persist for some time despite vital signs being within normal limits and an adequate urine output. Although these tradi- tional guides are important targets during early resuscitation, other signs and physiological variables should be included in the assessment to avoid unrecog- nized underresuscitation. Base deficit is readily available from the arterial blood gas analysis and provides a sensitive marker for global hypoperfusion. Base deficit has been shown to correlate closely with blood lactate and provide a useful indica- tor of inadequate tissue oxygen delivery. Base deficit does not provide a conven- ient end point to titrate fluid administration to, but it does give an overall indica- tion of the quality of the resuscitation. It must then be determined what needs to be changed in the resuscitation such as more volume, more oxygen-carrying capacity, or vasoactive infusions. Physical examination also can be very helpful in evaluating resuscitation effectiveness. Warm extremities with easily palpable pulses and adequate capil- lary refill are present when resuscitation efforts are effective. Cool extremities with poor pulses and slow capillary refill indicate inadequate tissue perfusion. If the patient survives the initial burn shock and is adequately resuscitated, a state of hyperdynamic circulation develops. The increase in metabolic demand is associated with pronounced wasting of lean body mass. From the second or third day postburn the cardiac output increases to meet increased metabolic demands and to compensate for decreased vascular resistance associated with the systemic inflammatory response (Fig. Patients unable to compensate with an adequate increase in cardiac output have a higher mortality rate. The hypermetabolic response to burns has profound effects on burn treat- ment. Inadequate nutritional support results in further stress and wasting, impaired wound healing, decreased immunity, and organ dysfunction. Interruption of nutri- tional support in the operative period along with stress of hypothermia and surgi- cal trauma exacerbate this condition. Airway and Pulmonary Function In the preoperative evaluation of burn patients, the airway and pulmonary function are major specific concerns. Burn injuries and resultant head and neck edema can 114 Woodson FIGURE 4 A hyperdynamic circulatory pattern develops during the first few days following extensive burn injuries. These changes may also compromise the patient’s sponta- neous ventilation and may make ventilation after induction of general anesthesia difficult or impossible.
Of the free muscular flaps generic dutasteride 0.5 mg free shipping hair loss due to stress, the free flap of the anterior serratus muscle order dutasteride 0.5mg hair loss cure year, described simultaneously in 1982 by Buncke and by Takayanagi, provides great plasticity and a constant vascular pedicle of good size and length. When covered with a cutaneous graft, stable and long-lasting coverage is achieved. We use the last three muscular digitations for coverage of hand burn injuries that are not very extensive and that require coverage with high vascular density per gram of tissue supplied. They are especially indicated for coverage of high-voltage electrical burn wounds of the wrist, which may sometimes be corrected in associa- tion with nerve grafts in the same procedure (Fig. We emphasize the technical difficulties we often encounter when dissecting out the vascular pedicle from the bifurcation of the branch of the serratus and its entrance into the digitations we are going to transfer. A B FIGURE 6 Free radial flap for coverage of a hand with a full-thickness burn from contact with a hot solid. There are osseous lesions at the second metacarpal bone and affecting the palmar arch. Excellent functional results: stable and sensitive coverage 2 years after the accident following only one surgical procedure (A, B). A segment of the median nerve has been excised, and a sural nerve graft placed. To cover large burn injuries of the upper extremity, we use a free flap of the latissimus dorsi muscle covered by a cutaneous graft. Described by Maxwell in 1978, this flap is still in common use today due to its versatility, accessibility, and ability to provide filling and coverage for large injuries. The vascular system of the donor area is also from the subscapular–thoracodorsal artery (Fig. The free temporal fascia flap, first described by Smith in 1979, is based on the axis of the superficial temporal arteries and veins and allows coverage of burn injuries on the dorsal surface of the digits and hand. It provides well-vascu- larized coverage that is extremely thin and flexible and leaves a barely visible cosmetic defect on the scalp. The transferred temporal fascia, which easily allows a partial-thickness cutaneous graft, permits sliding of the deep structures of the digits and hand. A second surgical procedure is occasionally necessary to separate the syndactylized digits (Fig. OTHER PROCEDURES Placing the affected extremity in an elevated position, avoiding articular con- tractures with proper splinting, and limiting movement with proper therapy are crucial for the prevention of hand burn sequelae. In our opinion, it is essential The Hand 275 FIGURE 8 Free flap of the latissimus dorsi muscle for reconstruction of a large injury on the volar surface of the forearmfroma high-voltage electrical burn. Only a multidisciplinary group effort will be able to prevent the occurrence of sequelae and the need for secondary reconstruction of the hands of these patients. The ideal position for the burned hand depends on the location and depth of the burns. With dorsal and/or circumferential burns, the correct position is in the intrinsic plus (metacarpophalangeal [MCP] joints 50–70 degrees of flexion, interphalangeal [IP] joints in extension), with the thumb in opposition and ab- ducted. With deep burns of the palm of the hand, it is preferable to place the MCP and IP joints in extension, with the thumb and all the other digits in abduction. Prevention of hypertrophic scarring requires a correct initial diagnosis that makes possible coverage of the burned hands as soon as possible: within 2 or 3 weeks at the most. With deep burns on the hands, it is important to begin treatment as soon as possible with pressotherapy, especially if the healing process has been FIGURE9 Free flap of superficial temporal fascia based on the superficial temporal arteries and veins for coverage of a burn fromcontact with a hot solid on the dorsal surface of digits II, III, and IV of the hand. A second surgical procedure was necessary to correct the surgical syndactyly produced by the fascial flap and the graft. The functional results were better than those of the fifth digit, where the burn over the joint was grafted with a thick graft because the burn was more superficial than those of the other digits. In the acute phase, in addition to postural treatment and mobilization, elastic bandaging in strips or tubular forms may be used to decrease edema. They should be used for at least 6 months after the burn, and often for longer, until we observe flattening of the scars, which will progressively lose their bright red color and will become softer and more pliable. Mortality according to age´ ´ ´ and burned body surface in the Hospital Universitario Virgen del Rocıo. Mortality of the pediatric burn population treated at the Virgen del Rocıo University Hospital, Seville,´ Spain in the period 1968 1999. Sheridan RL, Baryza MJ, Pessina MA, O’Neill KM, Cipullo HM, Donelan MB, Ryan CM, Schulz JT, Schnitzer JJ, Tompkins RG. Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands.