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Impaired function of alveolar macrophages also allows bacteria to proliferate generic synthroid 75mcg mastercard. Further tissue damage results from recruitment and activation of neutrophils that produce extracellular proteases and oxygen radicals cheap 25 mcg synthroid amex. Pulmonary gas exchange is impaired by widespread ventilation perfusion mismatch and shunt. Bronchospasm and impaired hypoxic pulmonary vasocon- striction contribute to the mismatch of ventilation and perfusion. Shunt results from patchy areas of airway obstruction, atelectasis, alveolar flooding, and consol- FIGURE 1 Bronchiole cast. Small airways may be completely obstructed by casts formed from inspissated secretions, fibrin, sloughed mucosa, and, as in this image, inflammatory cell infiltrate. Work of breathing is greatly increased by decreased compliance and increased respiratory rate. Systemic Toxicity Carbon monoxide (CO) and cyanide (CN) are clinically the two most important toxic components of smoke. Along with asphyxiation, CO accounts for most fatalities at the fire scene. CO decreases oxygen-carrying capacity by displacing oxygen from its binding sites on hemoglobin. CO further decreases oxygen delivery by preventing release of oxygen from oxyhemoglobin (shift of the oxyhemoglobin dissociation curve to the left). At some point this decrease in oxygen delivery limits cellular metabolism, leading to hypoxic insult, anaerobic metabolism and metabolic acidosis. Signs of CO toxicity include head- ache, mental status changes, dyspnea, nausea, weakness, and tachycardia. These are all nonspecific signs and may be masked by other effects of the burn or inhalation injuries. Patients with CO toxicity have a normal PaO2 and oxygen saturation measured by routine pulse oximetry. The defini- tive diagnosis is measurement of carboxyhemoglobin levels by co-oximetry.

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In the hands of skilled practitioners buy synthroid 200 mcg cheap, ▬ braces for reduction cheap 50mcg synthroid visa, reduction with the Pavlik harness is a reliable method ▬ traction methods. Child with a Pavlik harness: The harness straps can be and holds the hips in over 90° flexion and an abduction of approx. Reduction with overhead trac- On the one hand, these findings were very prob- tion must be followed by immobilization, for which ably the result of inadequate compliance on the part we use the Fettweis spica cast (⊡ Fig. The Pavlik harness is relatively com- improves the chances of a successful closed reduction plicated and the numerous straps can be confusing for and reduces the risk of avascular necrosis of the femoral the parents. The main problem is that the harness Immobilization very easily becomes soiled by the child and cannot then The following can be used for immobilization: simply be wiped down like a plastic splint. Accordingly, plaster casts, one study has shown that plastic splints are much easier splints, to manage. Another study has also reported a relatively high necrosis rate of 33% after reduction with the Pavlik harness. Traction methods We make a basic distinction between two methods: ▬ longitudinal traction, ▬ overhead traction. Longitudinal traction: Longitudinal traction for reducing the hip is the first known therapeutic procedure and was described by Pravaz in 1847. A board placed beneath the feet is designed to avoid pres- sure on the malleoli. The traction weight is initially 1/7 of the infant’s weight, but can subsequently be increased to 1/4 or more. The pulleys are shifted later- else the foot of the bed can be elevated so that the weight ally to increase hip abduction of the body is shifted towards the head. Overhead traction: Overhead traction was introduced in 1955 by Craig, and remains a widely used method even today. This traction can also be employed for older children for whom a Pavlik harness is no longer appropri- ate.