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  • Endocarditis
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Following initial management purchase generic trandate from india blood pressure medication zapril, divers and pilots should be referred to tho- racic surgery for bilateral pleurodesis buy trandate cheap blood pressure limits. Tension pneumothorax Approximately 50% of mechanically ventilated patients with pneumot- horax develop a tension pneumothorax discount combivent 100 mcg on-line. The risk is increased by delay in diagnosis and it is potentially life-threatening. Note: These signs are non-specific but should raise the possibility of pneumothorax. Management of tension pneumothorax If tension pneumothorax is suspected clinically, do not wait for radiological confirmation. Whilst uncomfortable, it is usually not of significant clinical importance and will resolve as the pneumothorax resolves. Pleural effusion Pleural effusions are common in critically ill patients and the differential diagnosis is wide. Although clinical history and examination may point to the diagnosis, pleural aspiration and evaluation of the fluid is often required. Radiology, including ultrasound, may give important diagnostic information as well as aid investigation. Pleural effusions may be classified as transudates or exudates, defined by a pleural protein less then or greater than 30g/L, respectively. Light’s criteria The following suggest an exudate: • Pleural fluid protein:serum protein ratio >0. Protein • A transudate is defined by pleural protein <30g/L, an exudate has >30g/L. If the pleural protein is between 25 and 35g/L then Light’s criteria (see box) can be used to assist diagnosis. Glucose • Low pleural glucose (<3mmol/L) is commonly seen in pleural infection and rheumatoid arthritis. Haematocrit • Pleural haemotocrit may be used to distinguish between a blood- stained effusion, commonly seen in malignancy, and a haemothorax. Cytology • The most common malignancies causing effusions are lung, mesothelioma, breast, and lymphoma. However, a positive culture confirms the diagnosis and gives antibiotic sensitivities. Management In the critically ill patient initial management of the effusion may take pri- ority over the need for investigation of the cause, if not already known. In the majority of cases the management consists of addressing the under- lying cause. Bilateral effusions • Bilateral effusions in the critically ill patient are common. They are usually transudates due to cardiac failure or low protein states, although these can present as unilateral effusions. If required for acute symptom relief, a therapeutic pleural aspiration (500–1000mL) may be considered.

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The nurse must be diligent in assessing for and reporting any signs and symptoms of bleeding generic 100mg trandate visa blood pressure chart to keep track, including decreased level of consciousness cheap trandate 100mg amex blood pressure medication for pregnant, painful or swollen joints safe amitriptyline 50 mg, oozing gums, hematuria, or decrease in platelet or hemoglobin values. Benefits derive from reducing preload and afterload, promoting water loss, and favorably altering ventricular remodeling. Among the most severe are ventricular dysrhythmias, cardiogenic shock, and heart failure. Programmed ventricular stimulation with guided antidysrhythmic therapy may be lifesaving for some patients. Attempts to prevent dysrhythmias by giving antidysrhythmic drugs prophylactically have failed to reduce mortality. Worse yet, attempted prophylaxis of ventricular dysrhythmias with two drugs—encainide and flecainide—actually increased mortality. Similarly, when quinidine was employed to prevent supraventricular dysrhythmias, it too increased mortality. Therefore, because prophylaxis with antidysrhythmic drugs does not reduce mortality—and may in fact increase mortality—antidysrhythmic drugs should be withheld until a dysrhythmia actually occurs. Cardiogenic Shock Shock results from greatly reduced tissue perfusion secondary to impaired cardiac function. Patients at highest risk are those with large infarcts, a previous infarct, a low ejection fraction (less than 35%), diabetes, and advanced age. Unfortunately, although these drugs can improve hemodynamic status, they do not seem to reduce mortality. Drug therapy of heart failure is discussed in Chapter 40 Cardiac Rupture Weakening of the myocardium predisposes the heart wall to rupture. Early treatment with vasodilators and beta blockers may reduce the risk for wall rupture. However, they are still at risk for reinfarction (5%–15% incidence within the first year) and other complications (e. Outcome can be improved with risk factor reduction, exercise, and long-term therapy with drugs. Patients with high serum cholesterol should be given an appropriate dietary plan and treated with a high-dose statin. For patients with hypertension, blood pressure should be decreased to below 140/90 mm Hg. Although exercise is safe for most patients, there is concern about cardiac risk and impairment of infarct healing in patients whose infarct is large.


  • Breast milk production that is not related to childbirth (galactorrhea)
  • Heart rhythm problems (arrhythmias) from heart inflammation (myocarditis)
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