Diversion is the safest way to save the patient’s life and is prefer- able to a primary closure of the perforation purchase lotensin 10 mg without prescription. These complications are avoidable because they are the result of a fawed technique discount 10mg lotensin mastercard. Breakdown of the wrap is due to dislocation of the sutures from the stomach and the esophagus buy lotensin 10 mg fast delivery. Tightness is due to nondivision of the short gastric vessels or noncalibration with a 60 Fr bougie. This can be done laparoscopically if the surgeon has special expertise, but it is safer to perform the operation using an open approach. One should also distinguish a slipped wrap caused by the sutures not involving the esophagus and allowing the stomach to “slip” behind the wrap from a wrap that was initially performed around the body of the stomach and not around the gastroesophageal junction; they present similarly on X-ray. This is usually defned on endoscopy as a distance of more than 4 cm between the gastroesophageal junction and the crura. A short esophagus is usually associated with a complication such as a stricture or Barrett’s esophagus. Technically it is possible to lower the gastro- esophageal junction by a careful dissection of the esophagus in the mediastinum. With a very short esophagus, the only possibility could be to approach it through a thora- cotomy and perform a lengthening procedure (such as a Collis–Belsey). While it may be possible to bring the “short” esophagus down, it is defnitely safer to perform an Nissen Fundoplication 83 a b c Fig. An elegant solution is the performance of a laparoscopic abdominal Collis gastroplasty. A 48 French bougie is inserted into the stomach and positioned along the lesser curvature, under laparoscopic control. A 21 or 25 size circular stapler is introduced through one of the left lateral ports, which is enlarged to accommodate a 33 mm port. The central rod of the stapler perforates frst the posterior and then the anterior gastric wall at a distance of about 4 cm from the angle of His, and the anvil is introduced into the abdominal cavity. The anvil is connected to the rod using specially designed laparo- scopic forceps. An endolinear cutter 60 is then introduced and the jaws placed in the gastric hole with the tip pointing at the angle of His. The staple lines are inspected and checked with methylene blue for potential leaks. The procedure is completed with the creation of a foppy Nissen fundoplication with the remaining fundus. After mobilizing the fun- dus, it is divided and resected using several frings of horitzontally placed cutters with blue loads. Then an articulating cutter, which has been calibrated with a 40 Fr Bougie, is placed vertically along the side of the esophagus and fred, creating a lengthened “neo- esophagus. Solid curved arrow indicates fundoplication Toupet The Toupet operation consists of a posterior partial wrap and is usually reserved for Posterior patients with poor esophageal motility on preoperative manometry, with a positive 24 Partial pH study indicating gastroesophageal refux disease. These patients beneft from a par- Fundoplication tial 270-degree wrap rather than a 360-degree wrap that puts the patient at risk of post- operative failure due to dysphagia. The original Toupet fundoplication was an extensive procedure with mobilization of the preaortic fascia behind the posterior fundus, allowing sliding of the fundus in the retroesophageal window. The right part of the posterior fundus was fxed to the right crura and the left part of the fundus was fxed to the left crura; then both aspects of the wrap were fxed to the ante- rior aspect of the esophagus, producing four lines of sutures of three sutures each, total- ing 12 sutures. Two more stitches incorporated the esophagus, resulting in a wrap fxed with 14 sutures. The problem with the technique is that it transforms a mobile wrap into a wrap fxed to the crura (Fig. It is well known that with belching or vomiting, or simple swallowing, the gastro- esophageal junction has vertical movements that put a wrap under tension. Moreover, the crura have closing and opening mechanisms on respiration that increases tension in the wrap with the risk of breakdown of the repair with time. An elegant solution is presented by the Fekete–Toupet modifed fundoplication (Fig. This consists of closure of the crura behind the esophagus and passage of the posterior fundus behind the esophagus, as with the Nissen fundoplication described Toupet Posterior Partial Fundoplication 85 Fig. However, instead of using a 360-degree wrap, a 180–270-degree wrap is used and sutured selectively to the esophagus, leaving one portion of the esophagus free from any wrap. The basic procedures are identical in all respects to the Nissen fundoplica- tion, with a takedown of short gastric vessels, but only six sutures are used to fx the wrap to the esophagus. Paraesophageal Patient positioning and port placement are the same as Nissen funduplication. The important step is to separate the hernia sac from the pleura and not pull the hernia contents inside the abdo- men, since they will be pulled back to the hernia sac right away. This starts on the right crura, extending superior- anteriorly toward the angle of the His. Then the hernia sac is dissected from the right crura extending toward the chest (Fig. One should be careful not to open the pleura, which will result in a pneumothorax. The anesthesia team should periodically check for breath sounds and peak inspiratory pressure to make sure there is no tension pneumo- thorax. If that is the case the insuffation should be stopped right away and a chest tube should be placed. Dotted line shows the line of excision; X the key of the resection of the hernia sac at the angle of His Paraesophageal Hernia 87 Fig. If the sac is completely resected there, the stomach will be more easily reduced from the chest. The dissection continues on the left crura until the two planes of dissection reach each other. Then the esophagus is dissected posteriorly from both the right and left crura and a penrose drain is placed around the esophagus. At this point all the contents of the her- nia sac should be reduced inside the abdominal cavity. Also if the closure is completely performed posterior to the esophagus, it may result in an angled esophagus. In most instances, we reinforce the closure with a piece of absorbable or biological mesh, cut in a U shape, that can be placed around the esophagus on the crura, and fxed in place with sutures or absorbable tacks. After this step, a Nissen or Toupet fundoplication is performed based on preopera- tive studies. Myotomy for On starting the esophageal myotomy it is essential to visualize the gastroesophageal Achalasia junction. This is achieved by division of the phrenoesophageal membrane, the dissection proceeding from right to left.
In view of the potential risk of strangulation buy generic lotensin 10 mg, it must be trauma purchase lotensin in india, infammation or ulcer cheap lotensin online, or an inappropriately timed operated as early as possible. It is is unretractable at birth (physiologic phimosis), but in helpful, but not really diagnostic of inguinal hernia. Inguinal hernia requires operative treatment as early By adolescent, only 1% have phimosis. Phimosis may be as possible in view of high incidence of obstruction and congenital or secondary to infammatory condition(s) of strangulation. Standard treatment for pathologic or true phimosis is and constipation (obstructed or strangulated hernia). Alternatively, betamethasone cream may be applied Hydrocele to the narrowed preputial skin twice daily for 4 weeks. After 2 weeks, the foreskin becomes soft and elastic and Te term, hydrocele, implies presence of peritoneal fuid is retracted gently and gradually in increments. Noncommunicating hydrocele is quite common in Paraphimosismeans that once the prepuce (phimotic) newborns and infants. It disappears spontaneously is retracted behind coronal sulcus, it cannot be reduced. Te scrotal swelling is nontender and well can be attained by application of lubricants under cover of transilluminated. Communicating hydrocele is characterized by rapid Hypospadias and Epispadias change in size in the subsequent months. Tere is a Te term, hypospadias, denotes abnormal placement of communication with the peritoneal cavity through the the external urethral meatus on the ventral aspect of the patent processus vaginalis. Tese cases need full evaluation for ambiguous Surgical intervention is indicated only when hydrocele sex and surgery. Te operation involves ligation and division of patent processus vaginalis Ambiguous Genitalia through a small inguinal incision. If It results from persistence of the patency of processus cryptorchidism is left as such, diminished spermatogenesis vaginal is accompanying the spermatic cord. In some cases, associated enlargement Infammation of epididymis (epididymitis) testes (orchitis) of the tongue may occur. In case of mumps, orchitis usually follows parotitis Spontaneous regression does not occur. A large unilocular cyst tender and swollen with red and edematous adjacent may respond to intralesional sclerotherapy in the form of skin. It is a smooth rounded midline neck swelling which is Acute Scrotum connected by a tract to the base of the tongue, representing the persistence of the thyroglossal tract postnatally. It Acute scrotal swelling may result from epididymo-orchitis, is likely to get repeatedly infected and burst. It should torsion of testis or its appendages, testicular trauma or be diferentiated from submental or pretracheal lymph idiopathic scrotal edema. It is of paramount importance nodes and ectopic thyroid gland, which, unlike the cyst, to diferentiate between testicular torsion and the other is always present at birth. Treatment is immediate of the body of the hyoid bone is a part and parcel of this surgical intervention, correcting the torsion and fxing the procedure otherwise recurrence as likely. Cystic Hygroma Brachial Sinus and Fistula (Lymphangioma) Branchial sinus is a discharging sinus at the anterior Tese are massive, nontender, unilocular or multicystic border of sternocleidomastoid (the junction of its middle tumors with semitransparent walls and thinning of the and lower thirds) and extends to external auditory canal overlying skin. Treatment is careful excision often at birth and occur in the head and neck region as the tract passes in between the external and internal (Figs 46. It is also called lymphangiomas, these tumors are capable of causing complications by their extension into the thorax and compression. Tere are no infammatory signs, z Neurogenic: Posterior fossa (cerebellar) or spinal cord tumor in but the child has torticollis due to muscle shortening. Abscess is a common pediatric surgery problem and signifes Treatment consists of stretching the afected muscle pus under pressure. Clinically, there is painful swelling with to the overcorrected position by gentle manipulation redness of overlying skin, fever and fuctuation on palpation. If response to conservative treatment Abscess can occur virtually in any body part. Examples are breast abscess, abdominal wall abscess, psoas abscess, liver continues to be discouraging by 6–12 months of age, abscess, etc. Treatment entails surgical drainage and appro- surgical lengthening and division of the sternal portion of priate antibiotics. As the most common organisms are Gram- the muscle or from mastoid process at its origin followed positive cocci (Staphylococcus and Streptococcus penicil- by exercise program should be carried out. Else, the infant lin group of drugs which also cover the penicillin-resistant may develop asymmetry of the skull and face, cervicodorsal strains, i. An intestinal mucosa-lined patch in the umbilicus presenting with discharge from umbilicus is: A. Phimosis at birth is usually physiologic, disappearing by 3 years of age in 90% cases 4. The best test for determining the level of defect in anorectal malformation is: A. B 830 Clinical Problem-solving Review 1 A newborn, immediately after birth, develops respiratory distress with cyanosis, chest retractions and gasping. There is nothing suggestive of an intestinal infection and there is no abdominal discomfort. The frst and foremost aim is to stabilize the cardiorespiratory system by decreasing the pulmonary arterial pressure. Laparotomy for reduction of viscera and repair of defect in thew diaphragm follows stabilization. Meckel’s diverticulum which results from persistence of embryologic vitellointestinal duct. Bleeding in this condition occurs due to a band going up to umbilicus or perforation secondary to ulceration from ectopic gastric mucosa. After the high index of suspicion, confrmation of diagnosis is by a barium meal study or yet better, a technectium-99m- labeled radionuclide scan. Treat- ment consists of conservative measures such as arch sup- Phocomelia is a reduction deformity (congenital port, shoe modifcation and exercise. If this treatment fails, amputation) in which there is gross reduction in the orthopedic intervention in the form of removal of calcaneus proximal part of the extremity so that distal part seems to or, after age 10 years, arthrodesis. Treatment in most cases T e hand is deviated laterally because of partial or total revolves around amputation and orthotic rehabilitation. Orthopedic treat- In this condition, the thumb cannot be straightened since ment in the form of corrective manipulation with adhesive it is locked in fexion because of a nodular swelling of the tapes, splints or casts and wedging is helpful, provided it is long fexor tendon at the base of the thumb. Clinically, fatfoot is recognized when the An extra fnger/toe, usually close to the metacarpophalan- arch touches the ground on weight bearing or is close to geal joint of the little fnger/5th toe or the thumb, may occur the ground. Until age 2–3 years, foot normally appears fat as an isolated trait or as a component of such syndromes because of absence of the medial longitudinal arch. It may be hypermobility, rigidity with tarsal anomalies) or acquired rudimentary or articulated. Orthopedic intervention is in (fracture of talus or calcaneus, tear of plantar ligaments, the form of ligation or excision at birth or amputation at about 1 year of age.
Intraoperative bleeding from the vaginal dissection can usually be controlled with direct pressure on the paraurethral and retropubic areas and then followed by vaginal packing purchase lotensin 10mg without a prescription. Greatly increased bleeding that results in a retropubic hematoma usually arises from a blinded venous injury during needle passage purchase 10 mg lotensin fast delivery, and up to 2 buy lotensin 10 mg online. Vascular injuries involving large arteries such as the external iliac, femoral, obturator, epigastric, and inferior vesical have been reported and have been responsible for at least one mortality . Accordingly, arterial injuries must be managed immediately by laparotomy or angioembolization. Patients with a history of abdominal or pelvic surgery are at a greater risk for bowel injury because of adhesions in the retropubic space and pubic symphysis. Several reasons may account for this finding including atrophic, scarred, or compromised vaginal mucosa. Potential risk factors for extrusion related to surgery include inadequate closure of vaginal tissue, infection, mesh rejection, and unrecognized vaginal injury during needle passage. Patients with vaginal extrusion may present with vaginal discharge, vaginal pain, dyspareunia, or sling palpable. Most cases occur in the first few months after surgery but they can also occur later. In the case of small vaginal extrusion, spontaneous healing can be expected in 6–12 weeks . Bladder Erosion Bladder erosion occurs 4–11 months after surgery and can lead to recurrent urinary tract infections, overactive bladder symptoms, pelvic pain, and hematuria [14,21]. A resection of the sling combining an abdominal and a vaginal approach is generally performed [14,24] (Figure 80. Prevention of this complication may be done with a good training to the technique, checking during cystoscopy that the ancillary has not been inserted inside the detrusor muscle (moving it, the detrusor must not move with). In case of any doubt, the surgery must be repeated after removal of the ancillary and/or mesh. They may be caused by a poor surgical technique that could damage the integrity of the urethral tissue, excessive tension placed on the sling or local infection. Poorly estrogenized tissue, previous vaginal surgery, or a history of pelvic radiation may also contribute. Postoperative symptoms of erosion include overactive bladder symptoms, urethral or pelvic pain, recurrent urinary tract infections, urinary retention, and hematuria. Management of these symptoms includes complete excision of the eroded part of the synthetic sling and urethroplasty. De Novo Urgency The onset of de novo urgency and its possible treatment is one of the most clinically relevant and largely debatable postoperative complications of midsuburethral slings. This phenomenon is thought to result from a combination of mild obstruction and urethral irritation caused by the sling. Bladder irritability caused by undiagnosed pelvic hematoma has been proposed as well. After excluding reversible causes such as extrusion and obstruction, anticholinergic medications are the mainstay of current therapeutic interventions. In the case of urgency refractory to medical therapy and in the absence of any clinically significant obstruction, alternative therapy such as sacral neuromodulation and botulinum toxin A injections may be considered. Consequently, patients can complain of a slow or intermittent urine stream with a significant post-voiding residual volume and recurrent lower urinary tract infections. There are no significant differences in postoperative urinary retention between retropubic and transobturator approaches . Moreover, urinary tract infections in case of chronic obstruction can increase from 8% during the first year after surgery to 44% during the fifth year . In a patient with immediate postoperative retention or incomplete bladder emptying, indwelling or intermittent self-catheterization should be tried because resolution is commonly spontaneous . If improvement is not seen within 4 weeks, early sling lysis should be considered. Urinary Tract Infections Urinary tract infection is less commonly reported than some other postoperative complications. Moreover, the definition of urinary tract infections and how it is diagnosed is often not clear. In the case of recurrent urinary tract infections, voiding dysfunction and urethral or bladder erosions should be investigated. A randomized controlled study revealed that 16% of women in the transobturator (inside-out) arm had groin pain compared to 1. Injuries to nerves such as the obturator have been reported but are rare (less than 1%) [26,31,32]. In the case of persistent pain, some authors recommended resection of the sling . Dyspareunia Postoperative dyspareunia has not routinely been prospective reported. The authors attributed this finding to posterior migration of the tape, which could be palpated close to the anterior vaginal fornix. In Novara’s meta- analysis, midsuburethral slings were followed by significantly higher cure rates than Burch colposuspension, considering success rates evaluated according to any definition of continence. With regard to complication rates, bladder perforation was significantly more common after midsuburethral slings, whereas the risk of pelvic hematoma, urinary tract infections, storage lower urinary tract symptoms, voiding lower urinary tract symptoms, and reoperation were similar between the two surgical treatments. Indeed, the 10-year range of success rates of this surgery has been reported to be between 55% and 70% . However, the technique is invasive and followed by significant risks of de novo storage symptoms (3%–23%) and voiding dysfunction (up to 11% with 1. Although currently considered the gold standard for transvaginal sling procedures, recent studies have revealed some of these materials may encapsulate rather than integrate [37,38]. Although the pubovaginal sling group performed significantly better than the Burch colposuspension (66% vs. Randomized controlled trials comparing midsuburethral tapes and pubovaginal slings had similar efficacy in terms of both overall and subjective continence rate . With regard to complication, the risk of intraoperative bladder perforation were significantly lower in the pubovaginal sling group; pelvic hematoma was similar in the two procedures. However, midsuburethral tapes were followed by a significantly lower risk of storage symptoms and reoperation. Intraoperative Complications In case of bladder injury, localizing precisely the injuries by opening the bladder dome allows to repair and does not prevent from implanting the device if correctly repaired [40,42]. It is of trained center expert opinion that any injury at the level of the bladder neck or posterior urethral portion indicates not to implant the device. Any bladder injury far away from the bladder neck, either involuntary or voluntary done as an eye control of dissection, do not contraindicate implantation of the cuff. Vaginal injury is rare and leads to stop the procedure when it is located posteriorly to the bladder neck and/or urethra, in front of cuff placement.
The metacarpophalangeal joint line is described based on the following three reference points: ● Proximal end of the first metacarpal: The palpating palpated in which the lateral surface of the hamate is finger is placed in the snuffbox best buy for lotensin. The area in front of the hamate hollow is reposition and opposition of the thumb lotensin 10mg otc, the prominent marked as the third reference point (▶Fig purchase genuine lotensin. The eighth carpal bone, Directly after the base of the metacarpal bone, a def- the pisiform, can only be palpated from the palmar side. Dorsal Carpal Bones ● Proximal end of the fifth metacarpal: Palpation con- tinues in a proximal direction across the lateral part of The starting point for palpating the seven dorsal carpal the little finger and across the hypothenar. Its hollow distinguishes behind the fifth metacarpal, a small hollow can be it from the other carpal bones, making it easy to palpate. Lunate Triquetrum with pisiform (dorsal aspect Scaphoid not visible or palpable) Trapezium Hamate Trapezoid Capitate The lunate is located proximal to the capitate (▶Fig. After these carpal bones have been palpated, the tra- pezium is palpated radially via the trapezoid (▶Fig. To do this, both of the palpator’s index fingers are placed in this hol- low with the proximal index finger making contact with the scaphoid and the distal index finger making contact with the trapezium. While alternating between ulnar and radial deviation of the wrist, the finger gliding down the radial styloid process and, palpating deeply, feels the joint line between the scaphoid and the radius. The radial col- a b lateral carpal ligament is located here, but cannot be Capitate Lunate palpated. With the wrist in ulnar deviation, the joint line can be felt one fingerbreadth further distal between the sca- phoid and trapezium (▶Fig. The triquetrum is in front of or proximal to this bone with the pisiform located on the palmar aspect (▶Fig. The articular disk is located proxi- mal to the triquetrum, with the ulna next to this carpal bone. The proximal joint line of the wrist is located between the proximal carpal bones (triquetrum, lunate, and sca- phoid) and the ulna and radius. Between the proximal carpal bones on one side and the hamate, capitate, trape- Trapezoid Hamate zoid, and trapezium on the other side, the S-shaped joint line of the distal wrist can be palpated. It forms six osteofibrous canals and is The ability to palpate the carpal bones competently is a fused with the tendons and tendon sheaths running basic prerequisite for diagnosing and treating wrist prob- within it, as well as with the underlying bones and the lems. An additional mark is Dorsal Tendon Compartments placed 2cm proximal to the ulnar aspect of the trique- The central part of the extensor retinaculum arises from trum and the ulnar styloid process. Third dorsal tendon compartment Fifth dorsal First dorsal Fourth dorsal tendon tendon compartment tendon compartment compartment Fifth dorsal Fourth dorsal Second dorsal Sixth dorsal tendon tendon compartment tendon compartment tendon compartment compartment Sixth dorsal Second dorsal tendon compartment tendon compartment Third dorsal First dorsal tendon compartment tendon compartment ExtensorExtensor retinaculumretinaculum a b Fig. In the area of the first metacarpal, both tendons, along with the ten- First Dorsal Tendon Compartment don of the extensor pollicis longus muscle, form the ana- The index finger palpates along the radial aspect of the tomic snuffbox. Only part of the abductor pollicis brevis wrist to the radial styloid process on the flattened margin muscle is visible because the tendon of the abductor pol- of the radius. They form a smaller dons of the abductor pollicis longus and extensor polli- hollow, the small snuffbox. The abductor pollicis longus cis brevis muscles, it courses in a proximal direction muscle inserts at the base of the first metacarpal and the 87 2 Surface Anatomy of the Forearm, Wrist, and Hand Structures extensor pollicis brevis muscle inserts at the dorsal base the wrist must be performed for differential diagnosis. It is about 10mm wide and a tight watch strap or by handcuffs(“handcuff neuropa- extends proximally about 25 mm from the distal radial thy”159). In younger people, the V-shaped attachment of sor tendon compartment, the symptoms are triggered the extensor carpi radialis longus and brevis muscles at by the Finkelstein test. For this reason, the test for Tinel’s the second and third metacarpals is visible during small sign (tapping of the nerve) and pure ulnar deviation of extension movements. Stuttgart: Thieme; 2015) Radial artery Third dorsal Extensor pollicis Extensor carpi radialis Fig. Extensor carpi radialis brevis muscle Second dorsal tendon compartment Third Dorsal Tendon Compartment extensor indicis tendon, which takes an oblique trajec- tory distally and radially. The third dorsal tendon compartment is located on the The path of the finger extensor tendons through the ulnar aspect of Lister’s tubercle (▶Fig. It is about fourth tendon compartment is easy to see during small 25mm long, takes an arc-shaped trajectory around Lis- alternating finger extension movements (e. Lister’s tubercle acts as a deflection pulley for the located on the dorsum of the hand, ulnar to the tendon of extensor pollicis longus muscle and enables reposition. It is about 25mm long and 10mm For this reason, it is not possible to move any of the four wide, and begins its course 5mm proximal to the exten- fingers in isolation. In the distal part, the tendon sheath the index and little fingers is possible as the extensor adopts a fan-shaped path over the dorsum, ending in a indicis muscle allows the index finger to move and the recess. Medi- extensor digiti minimi muscle also allows the little finger ally it is about 49 mm wide and on the ulnar side about to move. Dorsal digital expansion Extensor retinaculum before each branch establishes contact with the ring and communis muscle should be inhibited by means of recip- little fingers, respectively. This is accomplished by asking the pa- tient to press the fingertips of all the fingers except the thumb on a surface, and then extend only the little finger. Fifth Dorsal Tendon Compartment This will make it easier to palpate the tendon of the The fifth dorsal tendon compartment is located directly extensor digiti minimi. It is the longest dorsal tendon compart- Sixth Dorsal Tendon Compartment ment and guides the tendon of the extensor digiti minimi muscle in the direction of its insertion onto the dorsal The sixth dorsal tendon compartment contains the exten- digital expansion of the little finger. The tendon can sor carpi ulnaris tendon and is located directly ulnar to easily be palpated across its entire course if the patient the ulnar head (▶Fig. To make sure the fifth dor- long and 6mm wide, and extends through a bony groove sal tendon compartment is not mistaken for the extensor between the ulnar head and the ulnar styloid process. It digitorum communis muscle, the extensor digitorum extends up to the base of the fifth metacarpal and has 90 2. Sixth dorsal Extensor tendon carpi ulnaris compartment additional insertions at the pisiform, hook of hamate, and Brachioradialis pisometacarpal ligament. Owing to the large range of Extensor carpi radialis longus motion of this tendon compartment, it rotates in a some- Extensor carpi what radial direction toward the ulnar head during supi- radialis brevis nation. It is easiest to palpate the sixth dorsal tendon compartment directly next to, and distal to, the ulnar head. Practical Tip Various types of tendinitis can be diagnosed by specifi- cally stretching the compartment in question. In the case of de Quervain’s tenosynovitis, the examiner places the thumb in maximum adduction and sharply deviates the wrist ulnarward (Finkelstein’s sign220). Proper extensor digiti minimi and Extensor carpi ulnaris extensor digitorum communis 2. The superficial dorsal muscles of the forearm, which include the brachioradialis, extensor carpi ulnaris longus area of the lateral epicondyle (▶Fig. Their muscle and brevis, extensor digitorum, extensor digiti minimi, bellies are visible up to the lower part of the forearm, and and extensor carpi ulnaris muscles, arise entirely in the become flatter from proximal to distal. The supinator 91 2 Surface Anatomy of the Forearm, Wrist, and Hand Structures Fig. Extensor carpi ulnaris muscle cannot be palpated at its origin because it is too Note deep; this makes it diﬃcult to assess hypertonicity of this muscle. The dorsal muscles, which are located deep and Using the ring finger palpation technique is a good way distal, include the abductor pollicis longus, extensor polli- to locate and assess the muscle tone of the superficial cis brevis and longus, and extensor indicis.
Pathological involvement of the atelectasis purchase lotensin 10mg otc, bronchopneumonia or bronchiectasis are respiratory tract from nasopharynx to bronchioles 10mg lotensin with mastercard, producing known to signifcantly prolong the convalescence buy discount lotensin 10mg on-line. Such factors as eating, sudden movements and change in z Frenular ulcer room temperature precipitate paroxysms. Clinical z Malnutrition as a result of frequent vomiting and disinclination It is easy to recognize a typical case, especially in the to eat. Te disease should be diferentiated from whoop produced as a result of pressure of enlarged para- Te most sensitive and specifc test for acute infection tracheal lymph nodes in tuberculosis and Hodgkin dis- is IgG directed toward pertussis toxin. It needs to be remembered that a pertussis-like syndrome may result from infection with Bordetella para- Complications pertussis, Bordetella bronchiseptica, Hemophilus hemolyti- Te incidence of complications in pertussis is high cus, adenoviruses and foreign body in the airway. Maintenance of Tere is, however, remarkably high absolute lymphocy- fuid and dietary intake is important. Te child tolerates the small feed better after Tis feature is quite suggestive of whooping cough. Erythromycin (preferably the estolate ester) is the antibiotic Chest X-ray may demonstrate perihilar infltration, of choice. If started after Te only defnite means of arriving at the diagnosis is the onset of paroxysmal phase, it still reduces communica- the positive nasopharyngeal culture on Bordet-Gengou bility and safeguards against superimposed bacterial infec- medium or Regan-Lowe medium. In place should be administered in a dose of 50 mg/kg/day in 3–4 of nasopharyngeal swab technique, the cough-plate divided doses for 2 weeks. Use of pertussis immunoglobulin in the frst 367 week of disease may considerably reduce the whoop but not cough and vomiting. Only whole cell vaccine for primary vaccination should be used unless there is a contraindication. Close contacts, especially neonates of mothers with pertussis, must receive erythromycin estolate for 2 weeks. Te muscle spasm and cramps, particularly about the contacts who have not been immunized earlier should location of inoculation, back and abdomen. Te earliest receive erythromycin for 2 weeks after the contact is manifestation in a newborn may be the refusal to take broken, until cough in the index case ceases, or until the feed which should arouse suspicion. In irritability, difculty in swallowing (even difculty in institutionalized epidemics, monovalent pertussis vaccine sucking) and, at times, convulsions soon follow. A typical tetanic spasm lasts for 5–10 seconds and Prognosis consists of agonizing pain, stifness of the body (Fig. Tere is high morbidity and mortality in the event As the disease progresses, a very simple stimulus also of complications. In advanced cases, spasms may good provided serious complications have not occurred. Long-term sequelae of pertussis in infancy include minor Cephalic tetanus, a rare variety of tetanus, is character- abnormalities of lung function and wheezing and other ized by paresis or paralysis of one or more of the cranial lower airway manifestations in adulthood. Tetanus is an acute bacterial disease, characterized by painful spasms and stifness of muscles as a result of a Diagnosis powerful neurotoxin. India stands In a large majority of cases, the clinical picture is sufciently di- declared neonatal and maternal tetanus-free in 2015. Moreover, it Etiopathogenesis is not feasible in areas where the disease is most endemic. Te causative organism, Clostridium tetani, is widely dis- tributed in the soil, dust and feces of animals and humans. Complications Transmission is usually through invasion of an injury Resulting from respiratory muscle spasm: Aspiration (howsoever minute) with the tetanus bacilli or contami- pneumonia, atelectasis, mediastinal emphysema and nated umbilical cord in the newborn (neonatal tetanus). Te bacilli, after entering the circulation, get attached to Resulting from tetanic seizures: Laceration of tongue, the motor endplate in muscles and motor nuclei in the buccal mucosa, etc. Resulting from poor intake:Malnutrition, dehydration Clinical Features and dyselectrolytemia. Te mini- Resulting from poor autonomic stability: Myocardi- mum recorded is 1 day and the maximal several months. Tree Treatment varieties of tetanus are usually recognized, namely localized, generalized and cephalic. Toward the fag end of Prophylaxis second week, ulceration of ileum results from shedding of Active immunization is outlined in Chapter 10 (Immuni- intestinal lymphoid tissue. Remember that active immunization of pregnant include enlargement of mesenteric lymph nodes, focal mother with tetanus toxoid is an efective and defnitive necrosis of liver, splenomegaly, myocarditis, muscle degen- preventive measure. At the same time, it is better to give 1 mL toxoid sub- of rising standards of sanitation and hygiene. Two more injections of toxoid should be other developing countries, typhoid, however, continues to given later at 1 month intervals. As for previously immunized subjects, a recall dose Te peak incidence of typhoid occurs in summer of toxoid sufces. Conduction of deliveries, both in and and rainy season when fy population shows enormous outside the hospital, under clean and aseptic conditions increase. Contrary to the popular belief and West-oriented and application of clean dressing during healing of cord teaching, typhoid is certainly common in infants and are also important. A recent survey in a slum-population of Delhi revealed an overall Prognosis incidence of 9. No doubt, the clinical up with cerebral palsy, paralysis, mental retardation, and picture in pediatric typhoid is remarkably diferent from behavioral problems as sequelae of apnea and anoxia what is often seen in the grown-ups. A survivor chronic carriers happen to be the major source of spread from tetanus needs active immunization since tetanus does of infection. Unlike adults, who show insidious onset with An acute bacterial infection, characterized by constitu- step-ladder rise in temperature, typhoid in children often tional symptoms like prolonged pyrexia, prostration and manifests suddenly. It does not cause Te manifestations are rapid rise of temperature, lifelong or even sufciently prolonged immunity. Te paradoxical relationship of low pulse rate and high pyrexia is not Etiopathogenesis common in children. Te disease is caused by Salmonella* typhi and Salmonella Some cloudiness of consciousness (this is what the paratyphi A, B and C** lead to a typhoid-like illness, the so- term, typhoid, denotes) is almost always present. Bradycardia, perhaps true of most other tropical and subtropical regions, an important sign in adults, is not a common fnding in especially where standards of sanitation and hygiene are pediatric patients. Transmission is by contaminated food, unboiled A rash (macular red rose spot) is said to appear about milk, vegetables or water. Housefy plays a signifcant role the ffth day on the front and the back of the trunk. In * Besides enteric fever, Salmonella may cause (1) septicemia, (2) enteritis/dysentery, (3) meningitis, (4) pneumonia/bronchitis, (5) osteomyelitis, (6) appendicitis and (7) peritonitis. Investigations 369 Eosinopenia or complete absence of eosinophils is a reliable fnding. Leukopenia with relative lymphocy- tosis, described as an important feature of typhoid, is most often absent. Tis is perhaps due to the fact that the patients generally report fairly late, particularly in developing countries.
The degrees of dexterity will dictate independence with respect to urinary tract management cheap lotensin 10mg visa. If a caregiver is willing to provide self-catheterization services discount lotensin, then he or she will need to have a similar skill set buy 10mg lotensin free shipping. Her understanding of the condition coupled with social, religious, personal, and economic beliefs and responsibilities should be considered as these may or may not lead to successful implementation of a given strategy. Despite adequate planning and informed consent, problems with a catheterization method can arise after implementation has been enacted. These problems need to be identified and addressed in a time- efficient manner to decrease potential adverse outcomes. Such issues include  the following: 689 Psychological issues: Implementation may require the assistance of a trained counselor or mental health expert to overcome fear, depression, and/or anger about the current situation. Teaching patients to use manual location of the urethral opening in relation to the vagina can be beneficial to prevent this problem. Under these circumstances, physical and occupational health services can help provide devices that may maintain or reestablish dexterity in otherwise difficult situations. These professionals are also experts with upper and lower limb aids to assist with adduction or abduction that may provide access to the urethral os. Also, these professionals may provide additional therapy that may be initiated to decrease other comorbidities that impede dexterity such as range of motion exercises for those individuals with arthritis. Technique of Clean Intermittent Self-Catheterization The first self-catheterization will set the tone for the woman to become confident and self-sufficient in self-care. The environment should be calm, prepared, and unrushed to assist her in achieving maximum benefit from the lesson. As an adult learner, it is best that she demonstrate the catheterization as opposed to watching the health-care provider do it . It is prudent to review with the patient the anatomy and physiology of the urinary tract system prior to introduction of the catheter to prevent any misconceptions of passage and potentially decrease anxiety. Written materials in the patient’s native language should be given if possible to further increase knowledge acquisition. Once the supplies are gathered, positioning the patient in a semireclining position with good lighting will aid her in seeing the urethral orifice with a mirror. Prior to attempting the initial catheterization, it is important to review her preexisting knowledge and goals and consider any limitations. These considerations will help to tailor the lesson to provide successful outcomes. Using a touchless system with an attached drainage bag may be beneficial in the early stages of learning. This technique decreases the concerns regarding spillage of urine out of the catheter and generally decreases anxiety and embarrassment. Once the bladder is drained, slowly advance the catheter approximately 5 cm further to fully drain the bladder, and then slowly remove the catheter. Indwelling Catheters A catheter may be placed that is retained with a fluid balloon. The catheter is placed through the urethral os into the bladder using sterile technique. The balloon is inflated with sterile water according to the manufacture’s guidelines. These fluids may crystallize in the balloon port, clogging it, and prevent balloon deflation and catheter removal. The bladder can be maintained in a decompressed state with the use of a drainage bag or may be intermittently drained with a plug. Limiting unnecessary indwelling catheter usage has been identified with varying degrees of evidence from the Infectious Disease Society of America . Placing and discontinuation of catheters should follow proper indications while considering the needs of the patient. The Centers for Disease Control and Prevention has outlined examples of appropriate indications for catheters including acute urinary retention or bladder outlet obstruction, accurate measurement of urine output in critically ill patients, and specific needs such as long-term diuretics, healing of open sacral and perineal wounds in incontinent patients and immobilized patients, and end-of-life care improvement . It is secured in this location using the same balloon mechanism as a urethral catheter. Approximately 1 month after initial placement, a well-healed epithelized tract is formed maintaining a patent opening for simplified office-based catheter changes. These tubes are indicated for patients who are unwilling or unable to manage urethral indwelling catheters or clean intermittent catheterization, for those individuals who have urethral disease precluding placement of a urethral catheter (e. Under anesthesia, a catheter is passed directly into the bladder via a stab incision through the abdomen 2–4 cm cephalad to the symphysis pubis. The catheter is exchanged in the office or in the patient’s residence every 4–6 weeks. A well-epithelized tract develops through the abdomen wall into the bladder allowing for simple catheter changes. When counseling a patient about the possibility of this catheterization type, acknowledgment and discussion about altered body image are essential. Many patients will find it difficult to accept a permanent foreign body protruding from their abdomen, identifying concerns of 691 “normal function loss,” changes in sexual practices, and leakage. Although such concerns are warranted, quality of life indicators may actually improve when patients have been converted from urethral to a suprapubic catheters especially in patients who are dependent on wheelchairs or who are sexually active  (see Figure 45. Infection is related to several potential mechanisms of entry of bacteria: insertion technique, cross-contamination with staff care, or retrograde flow from drainage bags. Upon insertion of the catheter, bacterial biofilms will begin to develop within 24 hours. These bacterial colonies are found on the device surface, and they will not necessarily result in an infection. Patients with catheters often have bacteriuria, which is the presence of bacteria in normally sterile urine. Bacteria will be present in the bladder within 2–10 days of insertion, but not necessarily result in an infection . After 30 days of an indwelling catheter, virtually all patients have bacteriuria due to colonization. This colonization of bacteria may not be eliminated with antibiotic use, and in the vast majority of cases, it is not necessary to do so. Bacteriuria or colonization is not equivalent to infection, the latter of which mandates treatment. An infection is an immunological activation in response to a foreign body such as a microorganism. Colonization is a symbiotic growth of bacteria in the body that does not result in activation of the body’s immune system. The catheter is changed and the urine is obtained from the bladder through the new tube.
If it is reasonably frm and bleeding is not severe order lotensin now, the provider should wait passively for signs of placental detachment order 10mg lotensin with amex, which can occur as early as 1 min cheapest generic lotensin uk, but usually within 5 min after birth. Signs of placental detachment include a small gush of blood, increased frmness of the fundus, lengthening of the cord, and rise of the uterus into the abdomen. The mother should be instructed to bear down gently while the cord is held taut but without traction. Once the placenta has been expelled into the vagina, the cord can be guided gently with a twisting motion to remove it completely. Uterine massage after placental delivery, in addition to the oxytocin release from nursing, will cause contraction of the uterus. The tone of the uterus should be reevaluated frequently until the plane lands and the mother and newborn are transported to the hospital. The mother should be placed in a knee-to-chest position or Trendelenburg position to relieve pressure on the prolapsed cord, followed by the insertion of a sterile gloved hand into the vagina to manually displace the presenting part off the cord. In this case, fight diversion should be discussed with the pilot and should be recommended if at all possible. Shoulder dystocia is a serious complication of the delivery process, in which the anterior shoulder is wedged behind the pubic symphysis. Any delay in delivery of the ante- rior shoulder should raise suspicion for shoulder dystocia. The McRoberts maneuver is the initial technique of choice because of its relative simplicity and effectiveness. In this maneuver, assistants sharply fex the mother’s hips up onto her chest into an extreme lithotomy position, fattening the sacrum and shifting the pubic symphysis back to free the anterior shoulder. If this maneuver is not successful, it can be combined with suprapubic (not fundal) pressure applied with the heel of the hand to increase the likelihood of success. If the shoulder dystocia persists, other maneuvers, such as delivering the posterior shoulder frst, episiotomy, or having the mother turn over on all fours, like she is about to crawl, may be attempted with the guidance of ground support. Breech presentations are some of the most feared and high-risk deliveries, because of their rates of maternal and perinatal morbidity. As the breech delivers, the umbilical cord becomes compressed, making delivery of the successively larger and less com- pressible parts even more time sensitive. The presenting parts should be allowed to deliver spontaneously with only the mother’s pushing up to the level of the umbili- cus. Premature traction increases the risk of head and arm entrapment, so it is best for the provider to maintain a “hands-off” approach until the umbilicus is exposed. At this point, the fetus will rotate spontaneously so that the sacrum is anterior in relation to the mother. Occasionally, the legs may need to be swept laterally to be freed completely, but again this should occur only after the umbilicus has been delivered. Next, the bony pelvis should be grasped with two hands using a warm, soaked towel. Steady, gentle, downward traction should be employed until the scap- ulae become visible. The fetus should then be rotated 90° to one side, exposing one of the axillae/shoulders anteriorly. To deliver the other arm, the fetus must be rotated manually 180° in the reverse direction. With the fetal body resting on the forearm of the provider, the index and middle fngers are placed over the maxilla to fex the head. The other hand grasps the fetal shoulders by straddling the neck, applying downward traction. Gentle suprapubic pressure should be applied by an assistant to keep the head in a fexed position (hyperextension of the neck can cause spinal cord damage). Once the suboccipital region is seen under the pubic symphysis, the body is then elevated toward the maternal abdomen to deliver the head, maintaining fexion at all times. To mini- mize bleeding, direct pressure should be applied with a gauze dressing or cloth. As previ- ously stated, the consistency of the uterus must be monitored frequently after birth. A soft, boggy uterus is initially managed with frm massage of the uterine fundus through the abdominal wall. Oxytocin (Pitocin) is the frst-line drug for postpartum hemorrhage secondary to uterine atony; however, it is typically not carried even in enhanced emergency medical kits. It 10 Obstetrics and Gynecology Considerations 103 should be suspected if the mother has severe pelvic pain with brisk bleeding and absence of a palpable uterus. The inverted uterus must be replaced manually as soon as possible, as hemorrhagic shock can ensue very quickly. Unfortunately, labor is not the only issue that pregnant women can have in the air. Women who are pregnant can get sick with many of the other ailments touched on in this book. The hypercoagulable state of pregnancy, stasis, and physiologic changes that occur during fight are a setup for deep-vein thrombosis in a pregnant woman. Pregnancy also increases the risk of cardiomyopathy and subsequent congestive heart failure. During fight, the patient can be assessed for diffculty with breathing by measuring the respiratory rate, heart rate, and blood pressure. A physical exami- nation should be completed, including visual inspection for accessory muscle use and auscultation of lung sounds to identify alternate diagnoses, such as wheezing in asthmatics or unilaterally decreased breath sounds representative of pneumothorax, which would require another management approach. The patient’s respiratory status, vital sign stability, and clinical appearance should be the key factors in deter- mining if fight diversion is warranted. Pregnant women in the late second to third trimester are at risk of preeclampsia or eclampsia. The symptoms of preeclampsia include swelling, malaise, nausea, vomiting, epigastric or right upper quadrant pain, headache, dizziness, and hyper- tension. Obstetric treatment of preeclampsia varies depending on multiple factors, including gestational age and severity of symptoms. Identifcation of these symp- toms and possible diagnosis should be communicated to the ground team and diver- sion should be considered. A provider confronted with a seizing pregnant passenger should frst control and open the airway, which can be facilitated by the jaw-thrust maneuver. Ideally, seizure is treated with magnesium, which probably will not be available in a fight emergency kit. Finally, recommending diversion of the aircraft should be strongly con- sidered so that the mother can be assessed adequately and the baby can be delivered emergently. The most important one is that an additional person is needed to displace the uterus off the inferior vena cava and aorta.