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Intensive Care Med 2002 200 mg nizoral for sale; 28:1208–1217 is “quality of evidence” and why is it important to clinicians? Boldt J: Clinical review: Hemodynamic monitoring in the intensive 2008 order nizoral 200 mg online; 336:995–998 care unit. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy randomized clinical trial. N Engl J Med 2001; 345:1368–1377 group: Early lactate-guided therapy in intensive care unit patients: A 14. Early Goal-Directed Therapy Collaborative Group of Zhejiang Prov- multicenter, open-label, randomized controlled trial. Am J Respir Crit ince: The effect of early goal-directed therapy on treatment of critical Care Med 2010; 182:752–761 patients with severe sepsis/septic shock: A multi-center, prospective, randomized, controlled study [in Chinese]. J Trauma 2009; 66:1539–46; guideline-based performance improvement program targeting severe discussion 1546 sepsis. Clin Microbiol Infect 2008; 14:391–393 with severe sepsis: A prospective observational study. Sendid B, Jouault T, Coudriau R, et al: Increased sensitivity of man- of the Modena-University Hospital: Effects on management and out- nanemia detection tests by joint detection of alpha- and beta-linked come of severe sepsis and septic shock patients admitted to the oligomannosides during experimental and human systemic candidia- intensive care unit after implementation of a sepsis program: A pilot sis. J Clin Microbiol Infect Dis 2001; 20:864–870 Jt Comm J Qual Patient Saf 2007; 33:559–568 68. Ferrer R, Artigas A, Suarez D, et al; Edusepsis Study Group: Effec- Converting guidelines into meaningful change in behavior and clinical tiveness of treatments for severe sepsis: A prospective, multicenter, outcome. Blot F, Schmidt E, Nitenberg G, et al: Earlier positivity of central- and mortality in septic shock patients: Results of a three-year follow- venous- versus peripheral-blood cultures is highly predictive of cathe- up quasi-experimental study. Ann Intern Med timing of antibiotic administration and mortality from septic shock in 1993; 119:270–272 patients treated with a quantitative resuscitation protocol. Guidelines for the management of adults with hospital-acquired, Med 2011; 39:2066–2071 ventilator-associated, and healthcare-associated pneumonia. J Crit Care 2004; tic shock protocol and care guideline for children initiated at triage. Leibovici L, Shraga I, Drucker M, et al: The beneft of appropriate using novel molecular technologies: Infection control and beyond. Clin Chem Lab Med 2008; 46:888–908 antimicrobial treatment of bloodstream infections on patient out- 61. Lancet 2010; ity of single daily dosing versus multiple daily dosing of aminoglyco- 375:224–230 sides. Ziemann M, Sedemund-Adib B, Reiland P, et al: Increased mortal- vival in the intensive care unit: A randomized trial. Crit Care Med ity in long-term intensive care patients with active cytomegalovirus 2011; 39:2048–2058 infection. N Engl J Med 2010; 363:87–89 with moxifoxacin and meropenem vs meropenem on sepsis-related 104. Kumar A, Safdar N, Kethireddy S, et al: A survival beneft of combina- in the management of sepsis. Intensive Care Med 2001; 27 Suppl tion antibiotic therapy for serious infections associated with sepsis 1:S49–S62 and septic shock is contingent only on the risk of death: A meta-ana- lytic/meta-regression study. Boyer A, Vargas F, Coste F, et al: Infuence of surgical treatment tim- with monotherapy in septic shock: A propensity-matched analysis. Bufalari A, Giustozzi G, Moggi L: Postoperative intraabdominal therapy is associated with improved outcome against sepsis due abscesses: Percutaneous versus surgical treatment. Centers for quinolone combination antibiotic therapy for bacteremia caused Disease Control and Prevention. Klastersky J: Management of fever in neutropenic patients with vention of intravascular catheter-related infections. Martin-Loeches I, Lisboa T, Rodriguez A, et al: Combination antibi- severe necrotizing pancreatitis. Am J Surg 1997; 173:71–75 otic therapy with macrolides improves survival in intubated patients 112. Intensive Care Med 2010; atitis Study Group: A step-up approach or open necrosectomy for 36:612–620 necrotizing pancreatitis. Crit Care cal Study Group: Combination antibiotic therapy lowers mortality Med 2011; 39:1800–1818 among severely ill patients with pneumococcal bacteremia. Liberati A, D’Amico R, Pifferi S, et al: Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive 94. Cochrane Collaboration 2010; 9:1–72 therapy reduce mortality in Gram-negative bacteraemia? Paul M, Silbiger I, Grozinsky S, et al: Beta lactam antibiotic mono- resistant bacteria in intensive care: A randomised controlled trial.

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Status epilepticus is defined as a seizure that lasts 5-10 minutes or two seizures without full recovery between them order 200 mg nizoral amex. If a seizure lasts more than 30 minutes discount nizoral 200 mg without prescription, the body can no longer regulate homeostasis- blood pressure drops and acidosis builds, sometimes resulting in neuronal damage. Management: General goal is to stop the seizures as soon as possible to prevent permanent brain damage and aspiration. Once seizures are under control, patient should return to normal mental baseline between 1-8 hours. Once seizures are controlled for 24hr, wean off thiopental by decreasing the dose by lmg/kg every 12hr. The most common reaction, simple febrile reaction, is not life-threatening, but needs to be recognized early. Other reactions are more rare, but have a very high mortality rate (acute hemolysis and transfusion-related acute lung injury), and must be recognized and treated immediately. Ensure the patient really needs the transfusion and that the benefits outweigh the risks. Generally speaking, you can transfuse a unit of blood over 2hr (faster if it is a trauma patient or someone who is severely ill). If there is a transfer sheet from another facility, find out what antibiotic was given and how many doses • Exam o Obtain full set of vital signs, including saturation and temperature. If patient with fever on arrival and signs of sepsis, start antibiotics immediately. They require pumps for regular infusion and constant blood pressure monitoring (every five minutes). Treat aggressively with fluids and antibiotics, but if vital signs not improving or mentation stays low, call for transfer and further evaluation. Simple skin infections occasionally spread into deeper tissue layers and cause more serious local infection or systemic illness. If signs of systemic illness and pain out of proportion with exam findings, necrotizing fasciitis is likely. Recommendations • Simple cellulitis should be marked with a pen so patient or provider can monitor if redness extends beyond border despite antibiotics. They will often have vomiting, fast breathing, fruity breath, confusion, and vomiting. Medication is the key to treatment ■ Takingmediationasprescribedbutglycemiastillhigh • If on oral medications, start on insulin. These patient typically should be admitted overnight for glycemia monitoring to ensure correct insulin dose is started. Follow up in one week to check glycemia • If on insulin and taking appropriately, increase dose as needed. Can follow up in clinic in one week for glycemia check ■ Takingmedication,buthasnewsymptomsofinfection, fever, cough, etc. Must check renal function (Cr) and/or make sure patient is making urine (reason for Foley catheter) before giving entire fluid bolus. Therefore, must check potassium and supplement during insulin infusion • If K > 6 mEq/L, do not give potassium • If 4. Start with 2L bolus, but make sure patient urinating and check renal function before proceeding with remainder of fluid bolus. Give plenty of fluids in each case, monitor urine output, electrolytes, and do glycemia checks every 2hr while on insulin therapy. Even when lab potassium is near normal, patients are actually hypokalemic and need repletion. Transfer early- typically any patient who continues to have tachycardia, hypotension, tachypnea, or confusion after 24hr of aggressive treatment. There are three goals of treatment with different types of medications working for varying reasons. The goals of treatment are to 1) stabilize cardiac membrane, 2) cause an intercellular shift of K+, and 3) remove K+ from the body. Transfer to referral center for dialysis consideration any patient with hyperkalemia and renal failure. Recommendations • All patients with acute hypernatremia should be admitted to the hospital. Those equations are beyond the scope of these introductory guidelines and osmolalities are not often available. Recognize that correcting the sodium too fast will lead to severe brain damage and irreversible neurological deficits. Causes • Thermal • Chemicals • Radiation • Electrical Current Signs and symptoms • History o Important features include time since burn (hours, days? Note that rule of nines for a child with burn is slightly different (head is 18%, legs are 14% each) • Head: 9% • Front chest: 18% • Back: 18% • Arm: 9% each • Leg: 18% each o Depth of burn (see chart below) o Involvement of critical areas (face, hands, genitals, feet, major limbs) o Muscle compartment involvement (firm, painful) ■ Highestriskofcompartmentsyndromewithcircumferential burns and burns at calf/lower leg and forearm o Weight needed to calculate fluid resuscitation Depth of burn estimation Superficial Partial Partial Full st (1 Degree) Thickness Thickness Thickness rd (3 Degree) Superficial Deep Depth Epidermis Superficial Most All of dermis dermis dermis Appearance Red Pale/Dark White, White/dark pink, moist waxy/dry brown, dry/leathery Blisters No Small blisters No blisters None Cap refill Normal Sluggish Reduced None Sensation Normal/painful Normal/painful Reduced None Investigations • Labs: Isolated superficial burns do not need any investigations. Look for soot in the nose and mouth, mucosal lesions, swelling of the neck, wheezing, changes in voice, difficulty swallowing, drooling, circumferential burns to the neck or chest, tachypnea, or hypoxia. Regular dressing changes are necessary, but are extremely painful and require either conscious sedation with Ketamine (extensive burns) or opiate pain control (small burn area) o After initial presentation, remove any burned clothing and cover patient in clean sheet until burns can be dressed appropriately o Wash burn area thoroughly with sterile water or normal saline ■ If blister is intact, do not break open blister ■ If blister is open, de-roof blister and clean area of skin underneath o Cover clean burn area with light coat of honey (if antibiotic ointment unavailable) or Flamazine or other topical antibiotic ■ Donotcoverburnareawithdrydressing!

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Wherever You Go 200mg nizoral for sale, There You Are: Mindfulness of thoughts and feelings may food through us buy 200mg nizoral overnight delivery, our patience Meditation in Everyday Life. New York: Oxford can learn to stay present with our feelings and let go of the University Press. Through narrative, practitioners beliefs, and hence our responses to situations, and can better understand the experiences of their patients as well • demonstrate how writing can help us slow down, focus, as their own journeys as physicians (Charon 2004). Case A journal of the grieving process A second-year resident began their cardiology rotation two Dr. She was distressed by the loss of two young patients, ful week with more than the usual number of admissions. She began to write intermittently in a journal, old architect to the coronary care unit with the diagnosis describing her thoughts and interpretations of these dif- of a second myocardial infarction. She purposefully wrote without much fore- well until shortly before his 49th birthday, when he began thought, letting the words fow, letting her feelings bubble to experience anginal pain. His recovery proceeded without com- plication, and he returned to work within approximately She described the rooms where Jason and Steven had died three months. This second heart attack, four years later, and was surprised at how vividly she remembered certain has caused the patient a great deal of anxiety, and he no details: Jason’s fsh tank, the morning light fltering through longer wants to adhere to any treatment regimens. The resident feels threatened and uncertain about how to proceed, given the patient’s apathy. During cardiology She recalled how she had bought a large bouquet of helium rounds with the staff cardiologist, various medical data balloons on her way home from work the day after Jason are reviewed and a vigorous debate ensues among team died. She was coming home to her two-year-old daughter, members regarding the appropriate thrombolytic therapy and to her son, who was Jason’s age. The resident realizes during the course of to her own children some emblem of joyfulness and hope, daily assessments and interactions with the patient that, as and something that pointed toward heaven. This process The following week, overtired but determined, the resident allowed her to refect on her responses and to consider her fnally breaks through. The resident ends up asking the personal reasons for feeling so overwhelmed at the time. She also began to speak with Introduction a more experienced colleague about how she was handling Medical practice has always been grounded in life’s intersubjec- things. It unfolds in a series of complex clinical encoun- to her, and that the act of writing them down, had given ters involving narratives—stories in which one human being her more insight, more acceptance of her emotions, and a listens and extends help to another. Physicians engaged Case resolution in clinical care are inevitably affected by the complexities of The patient hesitated but then, with relief, talked about his patient care: joy, suffering, courage, loss and love. He spoke of his anger practitioners, we learn to identify and interpret our emotional and resentment of being afficted with a life-threatening responses to patients and in doing so are able to “make sense illness so early in his productive years. He did not want of their life journeys and grant what is called for—and called people’s sympathy, nor did he want to be a burden to forth”—in facing ill and vulnerable patients (Charon 2006). By the time the resident was completing the car- diology rotation and was following the patient in cardiac On some level, physicians grieve along with their patients; they rehabilitation, the patient was noticeably better in terms are “aware of how disease changes everything, what it means, of mood and in his acceptance that lifestyle changes what it claims, how random is its unfairness and how much would be permanent. The resident learns The textbox gives an example of how keeping a journal can the therapeutic value of talking with a patient about his assist in this emotional process. Summary Writing in a journal can help us to bridge professional and Key references personal gaps. A model for empathy, close reading allows physicians to do what medical sociolo- refection, profession, and trust. New England Journal it affecting one’s own life and to fnd in that effect a certain of Medicine. By chronicling our experi- ences as physicians, we learn the value of telling and retelling, of gaining understanding, and of respecting and learning from the many authentic stories we share. Many people activity into one’s lifestyle, and do not appreciate that the multiple health benefts of regular • discuss the importance of modelling being physically ac- physical activity—enhanced cardio-respiratory and musculo- tive to colleagues, students and the medical community. It is not necessary to become an athlete to enjoy breathless than before when climbing stairs. The benefts of cally active throughout their teens, as an undergraduate sustained, moderate-intensity aerobic activity are protean and medical student, the resident realizes that over the and go well beyond improving cardiovascular health. Regular four years of the postgraduate program they have become physical activity can be a time for recreation—in the fullest increasingly sedentary. Thirty minutes spent walking, biking, jogging, swim- to spend time with their partner and young daughter seem ming or skating can permit an escape from pagers, telephones to have eliminated the cherished private time when they and the pressures of practice and provide an opportunity for would jog to and from the hospital as a student and frst- retreat and refection. The so-called “talk test” (exercising at Evidence of the health benefts of physical activity is long- an intensity that permits simple conversation with an exercis- standing, incontrovertible and ever-increasing. Regular par- ing partner or friend) is a remarkably accurate indicator of a ticipation in physical activity greatly decreases the likelihood level of activity that optimizes cardio-respiratory function and of chronic disease and premature mortality. How does the busy practitioner despite this knowledge, physicians appear to be no more active protect suffcient time for physical exercise? And, sadly, although medical integrate physical activity into one’s personal and professional students are typically active on a regular basis, it is too often the lifestyle?

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