Critical care clinics
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Serious waterborne and wilderness infections are common and usually treatable if diagnosed early. The differential diagnosis for these infections requires a careful and thorough history and physical examination. ⋯ Pathogens causing serious infections include bacteria, fungi, viruses, and protozoa. Epidemiologic help can be obtained from local or state health departments as well as the Centers for Disease Control.
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Intensive care management of severely burned patients demands expertise in several areas. These include airway management, fluid resuscitation, support of the hypermetabolic response, infection control, and treatment of smoke inhalation injury. Surgical management of the burn wound, plastic reconstruction, and long-term rehabilitation are also essential aspects of modern burn care.
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Dissolution of the skeletal muscle, resulting in extravasation of the intracellular toxic metabolites into the circulatory system, and the accompanying manifestations, constitutes the clinical syndrome of rhabdomyolysis. The most frequent complication of this syndrome is acute renal failure, and its most life threatening side effects are hyperkalemia and metabolic acidosis. Intracellular release of free iron from hemeprotein and the oxidant stress is the principle mechanism by which the proximal tubular cytotoxicity is produced. The potential pathogenic mechanisms and the strategies to prevent rhabdomyolysis induced acute renal failure are discussed in this article.
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Electricity and lightning can cause injury in a variety of ways, some of which may remain hidden from the unsuspecting physician until it is too late. Prompt and, if necessary, prolonged resuscitation are of proven benefit. Particular attention must be paid to the patient who suffers high-voltage injury, and deep electrothermal burns on damage to vital organs should be excluded. Uncommonly late sequelae are seen, and such patients require appropriate care.
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Recognition of condition attributable to the environmental changes experienced by divers will facilitate appropriate treatment. The diagnosis of these conditions rarely requires sophisticated imaging or electrophysiologic testing. Divers who have suspected DCI, in addition to general supportive measures, should be administered fluids and oxygen and transported to a recompression chamber. For diving-related conditions, on-line consultation is available from the Divers Alert Network, Durham, NC (919-684-8111).