File Name: fluid and electrolytes in surgical patient pestana .zip
If there are any important late-breaking developments-or any changes or corrections to the Kaplan test preparation materials in this book-we will post that information online at kaptest. PrefaceIn the year , when I was still in charge of the teaching of surgery to junior medical students at a medical school in Texas, I wrote a set of notes for them to use.
You are now reading an updated version of that little manual, which has benefited from the editorial input of Kaplan, and has been repeatedly updated. It might be appropriate to ask ourselves if there is still a role for a pocket-sized booklet, printed on paper.
I think there is. Besides the obvious practical issues-no batteries to recharge, virtually indestructible format-there is a conceptual need for this kind of text. True, we live in an electronic era. Almost the entire universe of knowledge is available at the push of a button. But whereas Siri can instantly tell you if rain is going to spoil your commute this morning, Siri never went to medical school-much less practiced surgery for a million years and had a prominent role in the design and implementation of both licensure exams and clerkship content.
I did those things. And in these pages, I will pass that knowledge on to you. Obviously in a very abbreviated fashion. This is not all you need to know about surgery, but rather a complement to what you learned from your faculty and residents, to fill the gaps for all the services and surgical specialties where you did not rotate. There is another issue I need to discuss with you.
Surgery is an art, more than a science. There are multiple ways to diagnose and treat patients. Regional variations. Institutional preferences. Evolving criteria. Students are bewildered when they read two different books and are given different advice. They want to know which is the correct answer for the exam. Will they have to choose between two versions of the truth?
No, they will not. A crucial feature of National Boards' exams is that each question can only offer one correct answer. All the other options have to be clearly incorrect, even when that does not seem to be the case.
Let's say you read a question, and you find two correct answers. Did the National Boards make a mistake? No, their quality control is awesome. Read that thing again, and you will realize that for that particular patient one of the two proposed management options is contraindicated. Let's use an example. Go read question 53 and you will see what I mean. As with all the other practice questions at the end of this book, the answer key will tell you where in the text itself you can find that information.
When you do, you will believe me. Fluid replacement in the severely burned patient is the most critical, life-saving component of the management of extensive thermal burns. Underneath a deep burn, a lot of fluid accumulates. This is essentially plasma that has been temporarily lost from the circulating space and trapped at the burn site. In extensive burns, this internal shift of fluids is enormous and, if untreated, leads to hypovolemic shock and death.
Thus, large infusions of intravenous fluids are required. Complicated formulas were devised to estimate how much fluid would be needed. The product was then multiplied by another number, empirically arrived at, ranging between 4 and 6, depending on the specific formula. That final calculation gave us milliliters of Ringer lactate that were meant to be infused most rapidly in the first 8 hours, tapering afterwards, and supplemented by a couple of liters of D5W every day and, if desired, by colloids on the second day.
The expectation was that no fluids would be needed by the third day, when the plasma trapped in the burn edema would be reabsorbed and a large diuresis would ensue. Furthermore, those detailed formulas too often failed to provide accurate numbers. As a result, they have been mostly abandoned in favor of a simpler approach in which fluid infusion is begun at an arbitrary, predetermined rate and then adjusted as needed.
Sugar is avoided in the Ringer lactate so as not to induce an osmotic diuresis from glycosuria, which would invalidate the meaning of the hourly urinary output. Estimation of fluid needs in burned babies differs from the adult in several measures. Babies have bigger heads and smaller legs; thus the "rule of 9s" for them assigns two 9s to the head, and both legs share a total of three 9s instead of four.
In determining what is third-degree, we should remember that in babies those areas look deep bright red rather than the leathery, dry, gray appearance in the adult.
Babies need proportionally more fluid than the adult. Other aspects of burn care include tetanus prophylaxis, cleaning of the burn areas, and use of topical agents. The standard topical agent is silver sulfadiazine. If deep penetration is desired thick eschar, cartilage , mafenide acetate is the choice do not use it everywhere else; it hurts and it can produce acidosis. Burns near the eyes are covered with triple antibiotic ointment silver sulfadiazine is irritating to the eyes.
In the early period, all pain medication is given intravenously. After 2 or 3 weeks of wound care and general support, the burned areas that have not regenerated are grafted. Rehabilitation starts on day one. The concept of early excision and grafting is used whenever possible to save costs and minimize pain, suffering, and complications. It implies removal in the OR on day one of the burned areas, with immediate skin grafting.
On an exam question, you can expect the candidate for early excision and grafting to have a very limited burn. Bites and StingsTetanus prophylaxis and wound care are required for all bites.
Dog bites are considered provoked if the dog was petted while eating or otherwise teased. No rabies prophylaxis is required, other than observation of the dog for developing signs of rabies. Because bites to the face are very close to the brain, it might be prudent to start immunization and then discontinue it if observation of the dog is reassuring.
Unprovoked dog bites or bites from wild animals raise the issue of potential rabies. If the animal is available, it can be killed and the brain examined for signs of rabies. Otherwise, rabies prophylaxis is mandatory immunoglobulin plus vaccine. The most reliable signs of envenomation are severe local pain, swelling, and discoloration developing within 30 minutes of the bite. If present, draw blood for typing and crossmatch they cannot be done later if needed , coagulation studies, and liver and renal function.
Treatment is based on antivenin. Antivenin dosage relates to size of the envenomation, not size of the patient children get the same dosages as adults. Surgical excision of the bite site or fasciotomy are very rarely needed.
The only valid first aid is to splint the extremity during transportation. All the first aid measures that you learned at boy scouts are wrong. Do not make cruciate cuts, suck out venom, wrap with ice, or apply a tourniquet. Brightly colored coral snakes have a neurotoxin that needs to be promptly neutralized with specific antivenin.
Don't wait for signs of envenomation. True coral snakes are identified by the mnemonic "Red on yellow, kill a fellow," meaning that red rings and yellow rings touch each other. Harmless brightly colored imitators have black rings separating yellow and red. X-rays will not show anything for a couple of weeks. MRI gives prompt diagnosis. Treat with antibiotics. Genu varum bowlegs is normal up to the age of 3. No treatment is needed.
Persistent varus beyond age 3 is most commonly Blount disease a disturbance of the medial proximal tibial growth plate , for which surgery can be done. Genu valgus knock-knee is normal between ages 4 and 8. Osgood-Schlatter disease osteochondrosis of the tibial tubercle is seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps.
Physical exam shows localized pain right over the tibial tubercle, and there is no knee swelling. First responders use conservative management, as suggested by the mnemonic RICE: rest, ice, compression, and elevation.
If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Please consult the latest official manual style if you have any questions regarding the format accuracy. Proper management of fluid and electrolytes facilitates crucial homeostasis that allows cardiovascular perfusion, organ system function, and cellular mechanisms to respond to surgical illness. Knowledge of the compartmentalization of body fluids forms the basis for understanding pathologic shifts in these fluid spaces in disease states. Although difficult to quantify, a deficiency in the functional extracellular fluid compartment often requires resuscitation with isotonic fluids in surgical and trauma patients.
Christer H. Donald S. Liane S. Tong J. This book contains information obtained from authentic and highly regarded sources.
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Fluid and electrolyte management is paramount to the care of the surgical patient. Changes in both fluid volume and electrolyte composition occur preoperatively, intraoperatively, and postoperatively, as well as in response to trauma and sepsis. Now in its thoroughly revised, updated Fifth Edition, this handbook is the only volume on fluids and electrolytes that is geared specifically to surgical residents and surgeons. It explains, in practical terms, how to assess and manage problems of fluid-electrolyte and acid-base balance in surgical patients. They help your body to work, and they must be in balance with each other.
Always study with the most up-to-date prep! Look for Dr. Ranked 1 in his medical school class, Dr.
Link to Aquifer Cases. Basic Techniques of Wound Closure. Concepts of Scrubbing, Gowning and Gloving. Surgery: General - Preop Evaluation.
PDF | On Jun 1, , G. Bass published Carlos Pestana: Fluids and electrolytes in the surgical patient, 5th edn | Find, read and cite all the.Addison G. 29.05.2021 at 13:01
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Marino's The ICU Book: Print + Ebook with Updates (ICU Book (Marino) This item:Fluids and Electrolytes in the Surgical Patient by Carlos Pestana MD PhD.Laetitia L. 02.06.2021 at 21:00
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