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By H. Makas. American Public University. 2018.

There may be neurological worsening hyperglycaemia which can alter the osmo- signs such as tremor buy accutane 30mg with mastercard acne 6 months after accutane, hyperreflexia or seizures accutane 30 mg with amex skin care solutions. Complications Prognosis Hypernatraemicencephalopathyandintracranialhaem- The mortality rate of severe hypernatraemia is as high as orrhage (may be cerebral, subdural or subarachnoid) 60% often due to coexistent disease, and there is a high may occur in severe cases. Hyponatraemia Investigations Definition r The diagnosis is confirmed by the finding of high Aserumsodium concentration <135 mmol/L. Serum glucose and urine sodium, potassium and osmolality should also be re- Incidence quested. If there is raised urine osmolality, this is a sign Occurs relatively commonly, with 1% of hospitalised pa- that the kidneys are responding normally to hyperna- tients affected. Hyponatraemia with Congestive cardiac failure, cirrhosis, r In psychogenic polydipsia, patients drink such large fluid overload nephrotic syndrome Renal failure volumes of water that the ability of the kidney to ex- Severe hypothyroidism crete it is exceeded. The brain is most sensi- Opiates, ecstasy tive to this and if hyponatraemia occurs rapidly oedema develops, leading to raised intracranial pressure, brain- stem herniation and death. If hyponatraemia develops it is acute or chronic and whether there is fluid depletion, more slowly, the cells can offset the change in osmolality euvolaemia or fluid overload. This reduces the degree r Acute hyponatraemia is usually due to vomiting and of water movement and there is less cerebral oedema. The severity depends on the ceases and the kidneys rapidly excrete the excess water degree of hyponatraemia and the rapidity at which (up to 10–20 L/day). In severe cases, the patient may have seizures water there needs to be the following: r or become comatose. It is important to take a careful Adequate filtrate reaching the thick ascending loop of drug history, including the use of any illicit drugs such Henle (where sodium is extracted to produce a dilute as heroin or ecstasy. This is impaired in renal failure and hypo- of fluid depletion or fluid overload (see page 2). Investigations r Adequate active reabsorption of sodium at the loop of To determine the cause of hyponatraemia the following Henle and distal convoluted tubule, this is impaired tests are needed: the plasma osmolality, urine osmolality by all diuretics. Almost all of the body’s potassium stores are intracellu- r Urine osmolality helps to differentiate the causes of lar, with a high concentration of potassium maintained hyponatraemia with a low plasma osmolality. If the urine ingcellularmembranepotentialandsmallchangesinthe is dilute, this suggests psychogenic polydipsia or ex- extracellular potassium level affect the normal function cessiveinappropriateintravenousdextroseordextros- ofcells,particularlyofmusclecells,e. Fluid reple- r Intake can be increased by a potassium-rich diet or by tion should lead to the production of dilute urine (low oral or intravenous supplements. Vom- In addition, thyroid function tests and cortisol should iting or diarrhoea can reduce total body potassium. AshortSyn- by the kidneys is controlled by aldosterone, which acts acthen test (see page 441) may also be indicated. Dis- Management turbances of the renin–angiotensin–aldosterone sys- In all cases, treating the underlying cause successfully tem can therefore cause alterations in the potassium will lead to a return to normal values. In severe renal failure, when 90% of the renal r Fluid depletion is treated with saline or colloid re- function is lost, the kidneys become unable to excrete placement. Anticonvulsants may be In most tissues, including the kidney, potassium and necessary to treat fits. Intravenous saline should concentration is high (acidotic conditions), the kidney be avoided and patients must adhere to a low-sodium excretes hydrogen ions in preference to potassium; in diet. In severe nephrotic syndrome with oedema, in- the tissues, hydrogen ions compete with potassium to travenous albumin may be required together with di- be taken up by the cells, so extracellular potassium con- uretics. As the acidosis is cor- rected, potassium is taken up by the cells and may cause Prognosis hypokalaemia. Conversely, in metabolic alkalosis potas- Acute severe symptomatic hyponatraemia has a mortal- sium is excreted in exchange for hydrogen ions, leading ityashighas50%. Chapter 1: Fluid and electrolyte balance 7 Insulin and activation of β2 receptors tend to drive may be a cardiac arrhythmia or sudden cardiac arrest. Investigations Hyperkalaemia U&Es, calcium, magnesium to look for evidence of renal Definition impairment and any associated abnormality in sodium, Aserumpotassiumlevelof>5. An arterial blood gas to look for aci- cardiac arrhythmias and sudden death without warning.

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Scene size up: ŸŸ Sequence is not critical if all goals are accomplished ŸŸ Scene safety* and verbalized order 10 mg accutane skin care vietnam. Chest compressions: ŸŸ Finger position: Centered on lower half of sternum ŸŸ Exposes chest about 1 finger-width below the nipple line ŸŸ Initiates 30 chest compressions using ŸŸ Depth: About 1½ inches correct finger placement at the proper ŸŸ Number: 30 compressions rate and depth discount accutane 5 mg without a prescription acne bomber jacket, allowing for full chest ŸŸ Rate: 100–120 per minute (15–18 seconds) recoil* ŸŸ Full chest recoil: 26 of 30 compressions 4. Ventilations: ŸŸ Airway: Head-tilt/chin-lift to a neutral position ŸŸ Opens the airway* ŸŸ Ventilations (2): 1 second in duration ŸŸ Gives 2 ventilations using an infant ŸŸ Ventilations (2): Visible chest rise pocket mask* ŸŸ Ventilations (2): Delivers in 5–7 seconds 5. Shock advised: ŸŸ Clear: Ensures no one is touching the patient while ŸŸ Says “Clear”* shock being delivered ŸŸ Presses shock button to deliver shock* ŸŸ Delivers shock: Depresses shock button within 10 seconds 10. Spontaneous patient movement: ŸŸ Pulse check: Rescuer performing ventilations opens ŸŸ Checks for breathing and pulse the airway and checks for breathing and brachial pulse simultaneously for at least 5, but no more than 10 seconds Basic Life Support for Healthcare Providers Handbook 45 46 American Red Cross Section 3: Additional Topics Basic Life Support for Healthcare Providers Handbook 47 Key Skills When providing care to patients, rescuers need to be competent in the psychomotor skills, such as opening the airway and giving compressions and ventilations. In addition, rescuers need to integrate the key skills of critical thinking, problem solving, communication and team dynamics to achieve the best possible outcomes. Critical Thinking Critical thinking refers to thinking clearly and rationally to identify the connection between information and actions. When you use critical thinking, you are constantly identifying new information and situations, adapting to them logically to determine your best actions and anticipating patient reactions. Critical thinking is an essential skill in healthcare, and especially in basic life support situations. A simple example of critical thinking in action during a basic life support resuscitation may occur when a team leader is informed that it is becoming more difficult to ventilate a patient with the bag-valve-mask resuscitator. Using critical thinking, the team leader re-evaluates the situation to determine potential causes including overventilation, hyperventilation or poor airway positioning. Problem Solving Problem solving refers to the ability to find solutions to challenging or complex situations or issues that arise, using readily available resources. In situations requiring basic life support and resuscitation, problems or issues can arise at any point. These situations must be addressed with minimal interruption to patient care to ensure the best possible outcomes. Use whatever resources are at hand, including equipment, other team members or even bystanders if needed. You need to communicate with patients, their families and bystanders as well as colleagues. To effectively communicate with patients, families and bystanders, you need to: ŸŸ Build rapport. In doing so, you need to demonstrate credibility and trustworthiness, confidence and empathy. Communication with the patient and family Patients requiring resuscitation are unresponsive, making communication with the family that much more important. Remember, during emergencies, families are stressed and may not always hear what you are saying. Minimize their fears, as necessary, but avoid giving any misleading information or false hope. Communication with the family about a patient’s death Unfortunately, not all patients survive and you may be involved in communicating with the family about a patient’s death. In this situation: ŸŸ Provide the information honestly and with compassion, in a straightforward manner, including information about events that may follow. Basic Life Support for Healthcare Providers Handbook 49 Ÿ Anticipate a myriad of reactions by family members such as crying, sobbing, shouting, anger, screaming or physically lashing out. Communication with the team As a healthcare or public safety professional, you are often working as part of a team to provide care to patients. It can be difficult for any one person to be aware of all activity that is going on throughout treatment. Therefore, it is critical to effectively communicate with your fellow rescuers to provide effective care. When you are part of a team, it is critical that you communicate with members of your team. Everyone on the team needs to have a voice and be part of the process in order to be able to speak up if a problem arises. Crew resource management is an important team-based response approach to emergency care. The group members demonstrate respect for one another and use clear, closed-loop communication. Teamwork is crucial during resuscitation because the ultimate goal is saving a life, and effective team care requires a coordinated effort of the team leader and the team members.

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