By U. Vigo. Kaplan University.
In all instances discount 2.5mg zyprexa mastercard, the aim is to achieve normal cervical curvature for the individual cheap zyprexa 2.5 mg fast delivery. For example 20mg zyprexa visa, extension should not be enforced on a patient with fixed cervical flexion attributable to ankylosing spondylitis cheap zyprexa 2.5mg with mastercard. One alternative is a vacuum splint (adult lower limb size) which can be wrapped around the child like a vacuum mattress (see below). However, an uncooperative or distressed child might have to be carried by a paramedic or parent in as neutral a position as possible, and be comforted en route. For transportation, the patient should be supine if conscious or intubated. In the unconscious patient whose (a) (b) airway cannot be protected, the lateral or head-down positions Figure 2. The flexion can be relieved by inserting padding under the neck on the spinal board, the semirigid collar must be the thoracic spine (b). Only the physically uncooperative or thrashing patient is exempt from full splintage of the head and neck as this patient may manipulate the cervical spine from below if the head and neck are fixed in position. In this circumstance, the patient should be fitted with a semirigid collar only and be encouraged to lie still. Such uncooperative behaviour should not be attributed automatically to alcohol, as hypoxia and shock may be responsible and must be treated. If no spinal board is used and the airway is unprotected, the modified lateral position (Figure 1. In the absence of life-threatening injury, patients with spinal injury should be transported smoothly by ambulance, for reasons of comfort as well as to avoid further trauma to the spinal cord. They should be taken to the nearest major emergency department but must be repeatedly assessed en route; in particular, vital functions must be monitored. In transit the head and neck must be maintained in the neutral position at all times. If an unintubated supine trauma patient starts to vomit, it is safer to tip the casualty head down and Figure 2. However, patients can be turned safely and rapidly by a single rescuer when strapped to a spinal board and that is one of the advantages of this device. Hard objects should be removed from patients’ pockets during transit, and anaesthetic areas should be protected to prevent pressure sores. The usual vasomotor responses to changes of temperature are impaired in tetraplegia and high paraplegia because the sympathetic system is paralysed. The patient is therefore poikilothermic, and hypothermia is a particular risk when these patients are transported during the winter months. A warm environment, blankets, and thermal reflector sheets help to maintain body temperature. If a helicopter is used, the possibility of immediate transfer to a regional spinal injuries unit with acute support facilities should be considered after discussion with that unit. Initial management at the receiving hospital Primary survey When the patient arrives at the nearest major emergency department, a detailed history must be obtained from ambulance staff, witnesses, and if possible the patient. Simultaneously, the patient is transferred to the trauma trolley and this must be expeditious but smooth. Alternatively a scoop stretcher can be Head injuries (coma of more than 6 hours’ duration, used for the transfer but this will take longer. In the absence of brain contusion or skull fracture) in 12% either device, the patient can be subjected to a coordinated Chest injuries (requiring active treatment, spinal lift but this requires training. The examination must be thorough because spinal trauma is frequently associated with multiple injuries. As always, the patient’s airway, breathing and circulation (“ABC”—in that order) are the first priorities in 6 Evacuation and initial management at hospital resuscitation from trauma. If not already secure, the cervical C=cervical Posterior spine is immobilised in the neutral position as the airway is T=thoracic columns assessed. Following attention to the ABC, a central nervous L=lumbar S=sacral system assessment is undertaken and any clothing is removed. The corticospinal S tract spinal injury itself can directly affect the airway (for example T L C by producing a retropharyngeal haematoma or tracheal deviation) as well as the respiratory and circulatory systems L T C (see chapter 4). S S L Spinothalamic Secondary survey T tract Once the immediately life-threatening injuries have been C addressed, the secondary (head to toe) survey that follows allows other serious injuries to be identified.
Postictal speech difficulties may help with lateralization of the seizure 2.5 mg zyprexa sale. Psy- chological factors in the child’s school discount zyprexa 20 mg on-line, family cheap zyprexa 7.5 mg with amex, or social life may lead to episodes that may appear to be seizures buy generic zyprexa 20mg on-line. Were there possible psychological factors that could have led to the event? Are there other things, medical or psychological, which could precipitate an alteration in aware- ness or a change in motor function? At the end of this very detailed and careful history, the event should be classi- fied as a definite seizure, a paroxysmal event that was not a seizure, or an event whose nature is uncertain. A careful history can usually and reliably differentiate an ‘‘epileptic’’ seizure (i. Seizures themselves come in two forms: febrile and nonfebrile, in various forms. Evaluation of First Seizures Febrile Seizures When a seizure has been diagnosed, the determination that it was a febrile seizure depends on the age of the child and the height and rapidity of rise of the fever. Feb- rile seizures occur in 2–5% of all children aged 6 months to 5 years of age. They are rarely followed by nonfebrile seizures (epilepsy) and virtually never require extensive evaluation or therapy. The seizure may be a subtle, brief stiffening, or may be focal or generalized tonic–clonic jerking. Several febrile seizures occurring on the same day, with fever, are considered a single febrile seizure and require the same evaluation and have the same prognosis. The recommendations of the American Academy of Pediatrics (AAP) are sum- marized in Table 1. Again, the diagnosis of a febrile seizure always needs a good his- tory. Assessment of its significance requires a good physical and neurological examination. Most children with a first febrile episode (or seizure) do not need to have blood work a CT scan, an MRI scan, or an EEG. In children under 18 months of age, the signs of meningitis may be subtle and when the child has had prior antibiotics, the physician should consider the pos- sibility of meningitis; otherwise, a lumbar puncture is unnecessary. Neither the AAP nor the author recommends continuous or intermittent anticonvulsant therapy after a febrile seizure. Table 1 Evaluation of a First Febrile Seizure Sometimes Usually Always History X Physical and neurological examination X Lumbar puncture >18 months 12–18 months <12 months EEG No Blood studies No Imaging No Counseling of parents X 58 Freeman The most important therapy for a child after a first febrile seizure is counseling the distraught parents. The author tells parents that the outcome for the child is good, although febrile seizures may recur. The child will not die, swallow the tongue, or injure himself, nor will he suffer brain damage as a result of the seizure. Parents typically have many questions about this diagnosis, and time is needed to answer them. However, this discussion is difficult in the busy emergency room at a time when the parents are very upset. Referring them to the author’s book about seizures (written for par- ents) is often very helpful. The AAP’s guidelines for the evaluation of febrile seizures are for neurologically healthy children between 6 months and 5 years of age who have had a single febrile seizure. The author recommends an identical evaluation for those children who have prior neurological impairment. Nonfebrile Seizures Nonfebrile seizures are also common in children and may be partial (simple or com- plex) or generalized—tonic, clonic, or both. The hallmark of nonfebrile seizures is an alteration of motor or sensory function or of awareness in a child who does not have a fever. However, fevers may trigger nonfebrile seizures by lowering the child’s seizure threshold. Since the physician is unlikely to treat a child after either a first febrile seizure or a nonfebrile seizure triggered by fever, the distinction between the two after a first episode is neither possible nor important.