By W. Lukjan. Spelman College.
Post-stroke anxiety disorders are often associated with depression generic dapoxetine 90 mg otc, previous psychiatric disorders and Anxiety disorders alcohol abuse order dapoxetine 90 mg with amex. Post-stroke anxiety disorders have received compara- tively less attention than post-stroke depression 60 mg dapoxetine visa. Post-traumatic stress depression ranges from 5 to 67% among all types of disorder is estimated to affect 10% to 31% of stroke patients discount dapoxetine 30 mg free shipping. Severe depression has a frequency stroke survivors and is associated with depression ranging from 9 to 26%, while in the acute phase and anxiety. Post-traumatic stress disorder after depression is present in 16–52% of the patients . A systematic review of 51 studies reported neuroticism or with a negative affect or appraisal of a mean prevalence of 33% (29–36%) . The symptomatology of post-stroke depression is dominated by depressed mood, closely followed by Post-stroke mania anhedonia. Loss of energy, decreased concentration and psychomotor retardation are also frequent, as Post-stroke mania is an infrequent complication of well as the somatic symptoms of decreased appetite stroke (1–2%) . Guilt and suicidal ideation are less disturbance in mood characterized by elevated, common. Clinical features of Concerning the features of stroke which increase post-stroke mania also include increased rate or the risk of post-stroke depression, all stroke types are amount of speech, talkativeness, language thought similarly prone to depression. The hemispheric side is and content disturbance, such as flights of ideas, also not relevant , although in some studies the racing thoughts, grandiose ideation and lack of frequency and severity of depression were higher after insight, hyperactivity and social disinhibition and left-sided lesions, in particular during the first months decreased need for sleep. Higher lesion volumes, cerebral atrophy, ity, confusion, delusions and hallucinations may be silent infarcts and white matter lesions are all associ- also present. To distinguish between true post-stroke ated with a higher risk of post-stroke depression. Acute of post-stroke mania to predisposing genetic (family/ depressive symptoms mainly have a biological deter- personal history of mood disorder) factors, subcortical minism, while post-stroke depression at 1–2 years has brain atrophy and damage to the right corticolimbic an additional psycho-social determinism. However, mania can also be detected in stroke patients Post-stroke depression has a prevalence of about without personal or familial predisposing factors, after 30%. Personality changes Persistent personality disturbances, defined as a Post-stroke depression change from the previous characteristic personality, Post-stroke depression is a prominent and persistent are one of the most annoying behavioral disturbances mood disturbance characterized by depressed mood found after stroke. For the caregiver these changes are or lack of interest or lack of pleasure (anhedonia) in hard to cope with and they are difficult to control all or almost all activities. There are several types of person- two subtypes: with depressive features and similar to a ality changes in stroke patients: aggressive, disinhi- major depressive episode. In the Figures related to the epidemiological features of apathetic type the predominant feature is marked post-stroke depression are highly variable, because apathy and indifference. Apathy is a disorder of they depend on the setting of the study, the time since motivation. In severe forms, there is lack of feeling, 190 stroke, the case mix and the criteria/method used to emotion, interest and concern, flat affect, indifference, diagnose depression. The prevalence of post-stroke no initiative or decisions and little spontaneous Chapter 12: Behavioral neurology of stroke speech or actions. Responses are either absent, Neglect is an inability to attend to, orient or delayed or slow. A key feature is the dissociation explore the hemispace contralateral to a brain between impaired self-activation and preserved lesion, usually of the right hemisphere. Amnesia can result from thrombosis or response to other people, and lack of complaining. Relatives are more worried than the choroidal artery and anterior cerebral and anter- ior communicating arteries. Stroke in anatomical locations that interrupt Prefrontal lobe deficits: the cingulate-subcortical thalamo-striate loop can executive deficits (showing difficulty decid- produce apathy. These include anterior thalamic, ing, leaving decisions to proxy and being medial thalamic, caudate, inferior capsular genu, stubborn or rigid), corresponding to the bilateral palidal, uni- or bilateral anterior cerebral dorsolateral prefrontal lobe artery and baso-frontal strokes. Visual agnosias are disorders of visual recogni- survivors detected apathy in 20–40% of the patients tion (for classification see Table 12. Apathy was associated with one of the clinical manifestations of posterior cognitive impairment (defects in attention, concen- cerebral artery infarcts and occipito-temporal tration, working memory and reasoning) with deficits hemorrhages. Apathy was associated with Delirium often complicates acute stroke and is a right-sided lesions involving subcortical circuits, bad prognostic sign. Predictors are a vulnerable which comprised the ipsilateral frontal white matter, patient, the type of stroke and precipitating anterior capsule, basal ganglia and thalamus. Lesion: rostral brainstem and thal- Persistent personality changes (aggressive, disin- amic and partial occipital. Other reasons: hibited, paranoid, labile and apathetic) are frequent sensory deprivation or delirium or substance and for the caregiver one of the most annoying withdrawal. All stroke types are similarly prone to depression, but higher lesion volumes, cerebral atrophy, Chapter Summary silent infarcts and white matter lesions are asso- ciated with a higher risk. Persistent personality changes are most Aphasia occurs following middle cerebral artery annoying for caregivers of patients after stroke. Cardinal tests: (1) confrontation naming; (2) analysis of speech (fluent and nonfluent); (3) verbal auditory comprehension; (4) repetition of words, pseudo- words and sentences. Predictors of cognitive dysfunction after Study Group on Assessment of Unilateral Neglect subarachnoid hemorrhage. Posterior cerebral artery territory infarcts: clinical features, infarct topography, causes and outcome. Clinical, neuropsychological and electrophysiological findings in four anatomical 26. Aggressive behavior in patients with stroke: association with psychopathology and results of 45. Frequency of depression after stroke: a systematic review of observational studies. Stroke is the leading cause of physical not necessarily severe enough to induce dementia disability in adults: of one million inhabitants, 2400 when isolated). The term Even in stroke survivors who are independent, slight VaD cannot be used for all patients who have had cognitive or behavioral changes may have conse- a stroke and are demented, because many of them quences for familial and professional activities . Therefore, the This chapter will not cover: (i) cognitive impair- economic burden of dementia is important. The prevalence of stroke and of ably of vascular origin that occur in the absence of dementia is likely to increase in the coming years, clinical symptoms of stroke or transient ischemic because of the decline in mortality after stroke  attacks. Therefore, our review will focus only on and the aging of Western populations . Therefore, dementia that occurs – or was already present – in the burden of stroke-related dementia is also likely to patients who have had clinical symptoms of stroke. A study where stroke was not associated between stroke onset and cognitive assessment, and with an increased risk of dementia  was actually criteria used for the diagnosis of dementia [5, 12]. The incidence of dementia after stroke depends on whether the study excluded Stroke doubles the risk of dementia; the attribut- patients with pre-existing cognitive decline or demen- able risk is the highest within the first year after tia or not.
Pneumothorax Identiﬁcation Respiratory distress order 60 mg dapoxetine fast delivery, pleuritic chest pain on affected side generic dapoxetine 30 mg with visa. Can be ‘primary’ (for example in tall 30mg dapoxetine mastercard, thin males) or ‘secondary’: associated with pre-existing lung disease (which may also need treatment) generic 60mg dapoxetine. Examination may show decreased breath sounds on the affected side and hyperesonance to percussion. Differential/concurrent diagnosis Any cause or consequence of chest trauma, pulmonary embolism. The additional stress of Transport considerations helicopter/aeromed transfer in phobic patients must be weighed If travelling at signiﬁcant altitude in an unpressurized cabin an against time (and muscle) saved. Destination considerations Destination considerations Local resources and the availability of thrombolysis, percutaneous Hospital with appropriate services, e. Treatment Treatment A small pneumothorax will probably not need treatment prehospi- Oxygen if hypoxic or travelling by air, aspirin, nitrates and if tally. A large or tension pneumothorax should be decompressed as required parental analgesia (e. Use of beta-blockers, antiplatelet agents and heparin must be guided by local policy and practice – you must be familiar Cardiac emergencies with these. Classical central crushing chest pain radiating to the left arm Clinical tip: Beware the patient with dental pain or epigas- is neither sensitive nor speciﬁc for myocardial infarction. No tric/indigestion pain: always consider myocardial ischaemia high in feature of the history or examination is pathognomonic – the index your differential diagnoses. Acute pulmonary oedema A 12-lead electrocardiogram should be performed if it will alter Identiﬁcation your immediate management/choice of destination or you work in Respiratory distress, wheeze with ﬁne crackles at the lung bases with a region with a prehospital thrombolysis policy. Clinical tip: Check for signiﬁcant blood pressure differences in either arm that occurs with thoracic aortic dissection. Intravenous furosemide is probably not as effective as ﬁrst as they may not respond as well to adrenaline and steroids. Intubation may management easier – this information needs to be sought from be required depending on transfer time. Non-invasive ventilatory collateral history and presence of medical alert bracelets/cards. Oxylog 3000)butbewareofhighﬂowsrequired – carefuloxygencalculation Transport considerations isamust. Airway is likely to be difﬁcult to manage – allow the patient to position Arrhythmias themselves if possible. Destination considerations Clinical tip: Get a print off of the rhythm strip to analyse, as well Nearest hospital with emergency facilities and intensive care. Differential/concurrent diagnosis Treatment Beware of atrial ﬁbrillation with a coexisting bundle branch block. If airway obstructs be prepared to perform prompt surgical cricothyroido- Transport considerations tomy. Repeat commended – transcutaneous pacing may become necessary or doses as needed (0. Destination considerations Local resources and the availability of a dedicated coronary care Neurological emergencies unit will dictate destination. The ﬁtting patient Identiﬁcation Treatment Many seizure types and presentations exist. Self-limiting seizures Treatmentshouldbeadministeredaccordingtothelocaladaptation do not require emergency prehospital intervention. Use of speciﬁc cus (including tonic–clonic, tonic, clonic, myoclonic and absence treatments such as adenosine or amiodarone will depend on the seizures)andfocalstatusepilepticus(alsoknownaspartialseizures). Patients are at risk of traumatic injuries as a result of the cardioversion should only be attempted if you have the skill set for seizure. Severetonic–clonicseizurescanresultinposteriorshoulder safe sedation, in the presence of severe adverse signs and prolonged dislocation. Transport considerations • Skin: Oedema – typically facial and associated ﬂushing. Intravenous phenytoin may be adminis- tered during a prolonged transfer/on scene time (but not if seizures Treatment are associate with tricyclic overdose). Rapid sequence induc- appropriate with prolonged prehospital times and when the potas- tion with thiopentone should be considered for those who do not sium level can be measured. Clinical tip: Midazolam can be given via the buccal or intranasal Hypoglycaemia routes. Respiratory support may Identiﬁcation be needed following treatment with benzodiazepines. Be aware of purposeful insulin professionals and lay-people to identify potential cerebrovascu- overdose. Transport considerations In the case of agitated and confused patients correct this before Differential/concurrent diagnosis transporting them. Recovery position is appropriate for those that Arrhythmias, hypoglycaemia and other causes of seizures are com- can protect their own airway. Destination considerations Transport considerations A hospital with appropriate facilities. Treatment Oral glucose followed by complex carbohydrate if conscious and Destination considerations compliant. Block excision of the injection embolectomy within the locally deﬁned time window is crucial. Clinicaltip:Thoughtemptingtodischargeonscenethesepatients Treatment have a high relapse rate so are best transferred to hospital for The development of point of care testing which accurately distin- observation. Treatment currently consists of support- Poisoning ive management and rapid transfer. Identiﬁcation In the absence of a reliable and/or collaborative history, poison- ing may be a difﬁcult diagnosis. Consider in all patients with Metabolic emergencies altered levels of consciousness, unexplained arrhythmia or unusual High blood sugar including diabetic ketoacidosis clinical manifestations. Combinations of toxidromes can further and hyperosmolar states complicate identiﬁcation (Table 23. Identiﬁcation A high blood sugar on point of care testing accompanied by Differential/concurrent diagnosis autonomic symptoms: tachycardia, Kussmauls respiration, sweet Need to consider both alternative causes of the clinical presentation smelling/pear drop breath (ketones). Differential/concurrent diagnosis Transport considerations Attempt to ﬁnd and treat trigger, e. Destination considerations Transport considerations Rare poisonings and those requiring specialist intervention may Monitor for arrhythmias. Careful Opioid Opioid receptor Sedation, miosis, decreased communication and non-threatening body language are essential. Anticholinergic muscurinic acetylcholine Altered mental status, receptors sedation, hallucinations, Cases may include deliberate self harm or attempted suicide, with mydriasis, dry skin, dry associated trauma or overdose.
Material and Methods: This where the main aim is to get the patients to achieve independent was a 2 years prospective and 10 years retrospective study discount dapoxetine 60mg fast delivery. Poor overall aspects of qual- of 144 below knee amputees using various supports for mobilization ity of life following lower limb amputation is much secondary to were included in this study of which 63 were diabetics and 81 non restricted mobility safe 30 mg dapoxetine. On mance with a prosthesis is associated with its increased use fol- follow up they were observed for the type of support used for mobi- lowing rehabilitation discount dapoxetine 30 mg without a prescription. Results: Of 144 amputees dapoxetine 60mg on line, 92 patients initially used crutches would involve self donning and doffng, the amputees need to have for mobilization. This research aimed to study the association remained bed ridden before they died. Of 92 patients using crutches, between hand muscle strength and hand function with ability to 22 were in diabetic group and 70 in non diabetic group. Results: Mean hand grip strength in this group J Rehabil Med Suppl 55 Poster Abstracts 225 was 24. Increasing K- an underlying congenital limb defciency (right transverse defect at level was associated with increasing hand grip strength (p<0. Prosthesis use was found to be signifcantly associated age of 8 years, as he initially walked without any customised foot- with hand grip strength in multivariate analysis. Conclusion: Hand grip weakness present signifcantly in the lower Results: The ulcer had measured 2 cm × 2 cm ×1 cm. Hand function and demographic fac- patient on the effcacy of casting and the duration of non-weight tors had no signifcant association with ability to ambulate. Yasuy- Turkey oshi2 1University of Tsukuba Hospital, Department of Rehabilitation Introduction/Background: Pressure ulcer is defned as a localised 2 injury to the skin or underlying tissue, frequently occurring over Medicine, Tsukuba, Japan, Ibaraki Prefectural University of bony prominences. It remains a signifcant healthcare concern today Health Sciences, Department of Rehabilitation Medicine, Ami, Ja- pan, 3Ibaraki Prefectural University of Health Sciences, Depart- for the clinicians. The heel and the sacrum are the most common ment of Orthopaedic Surgery, Ami, Japan, 4Ibaraki Prefectural areas affected. Numerous papers have reported that heel wounds in particular are associated with poorer outcomes when compared with University of Health Sciences, Department of Physical Therapy, other parts of the foot. Herein, we present a case who had pressure Ami, Japan, 5Ibaraki Prefectural University of Health Sciences, ulcer on his heel and successfully treated with medical honey dress- Department of Occupational Therapy, Ami, Japan, 6Meiji Yasuda ing. Material and Methods: We summarize the case of a 33-year- Life Foundation of Health and Welfare, Physical Fitness Research old man who had sustained complete paraplegia at T11 level for Institute, Hachioji, Japan, 7Tsukuba International University, De- 2 months and pressure ulcer. Medical grade honey wound dressing was applied every other 9 pan, University of Tsukuba, Department of Orthopaedic Surgery, day. Conclusion: Various dressing materials have Introduction/Background: In adaptive sports, the risk of secondary been used for dressing the pressure ulcers. This study aimed to investigate ing is a cheap and practical material using in developing countries. Despite good clinical outcomes, the practice of applica- lower serum creatinine level (p=0. Material and Methods: A 38 year-old gentleman with is necessary for players to maintain a sporting life. Therefore, we additionally applied the pre-ischial shelf Further analyses and long-term follow-up are indicated to evaluate between the wheelchair seat and the cushion. A total 77 patients with spinal cord injury underwent in- terface pressure mapping during period were included in this study. The interface pressure was subsequently obtained with the pre-ischial shelf inserted under the seat cushion. With the pre-ischial shelf, the average 1University Science Malaysia, Department of Orthopaedic, Kota and peak pressure was signifcantly reduced to 44. The contact area was signifcantly Bharu, Malaysia, University of Malaya, Department of Internal 2 Medicine, Kuala Lumpur, Malaysia, 3University of Malaya, De- increased to 1,216. Conclusion: For spinal cord injury patient, pre-ischial shelves will help to reduce pressure partment of Rehabilitation Medicine, Kuala Lumpur, Malaysia during sitting. Our most signifcant fnding was that 1 45% of those clients reporting deterioration identifed mood prob- Universiti Malaysia Sabah, Faculty of Medicine & Health Sci- ences, Kota Kinabalu, Malaysia, 2University of Malaya Medical lems as a factor. This compared to reported mood problems in only 10% of the clients who were the same or improved after discharge. Exercise training remains the mainstay of intervention for now, however the appropriate training 784 duration still remains unclear. Each session began with 10 minutes stretching followed by 30 minutes of aerobic exercises with major upper and Introduction/Background: Current guideline based physical ac- lower limbs strengthening exercises and subsequent 10 minutes tivity prescription and exercise training for outpatient cardiac cool down period. The results Chang Gung University, School of Medicine, Taoyuan, Taiwan, of the multivariable analysis using a logistic regression are shown in 3Chang Gung Memorial Hospital, Department of Neurology, 4 table 3. Cognitive tasks, such as spatial memory, stroops, and calculation, have been commonly used during dual-walking tests but the relia- 788 bility have not be established. Material and Methods: Nine healthy individuals were participated with informed consent. During dual-walking and single walking tests, subjects walked on a instrumented gait mat with and without 1Sanno Rehab. Clinic, Rehabilitation Medicine, Ota-ku, Japan, added cognitive tasks, respectively. No priority instructions were 2Kyorin University Hospital, Rehabilitation Medicine, Mitaka City, given during dual-walking tests. Material port time) showed poor to moderate reliability during dual-walking and Methods: Case presentation: We present the case of a 71-year- tasks with spatial memory and stroop. He showed poor facial expression, severely dual task gait test with calculation are reliable measure with good stooped with spinal kyphosis, and could not walk without frequent reliability. Acknowledgements: This home-visit rehabilitation program for preventing falls started, and study was supported by the Ministry of Science and Technology his caregivers were instructed to support his home exercise. Asan Medical Center, Physical Medicine & Rehabilitation, Seoul, Republic of Korea 789 Introduction/Background: Dysphagia cause aspiration pneumonia, under-nutrition, or under-hydration. Saitoh1 Methods: Dysphagia patients with brain lesion that were hospitalized 1Fujita Health University, Department of Rehabilitation Medicine in the rehabilitation department were recruited. This system in- creases electrical stimulation with the increase in electromyography Introduction/Background: In swallowing, the bolus passed mainly signal of the target muscles. The surface electrodes were put on presence of asymmetric passage through the hypopharynx. The electrical stimulation was sequently we inserted a catheter through a nostril and placed in given only when the suprahyoid muscles activate during head rais- one piriformis sinus and infated the balloon, waiting for swal- ing. Results: We recruited twenty patients with neurogenic dysphagia and included eighteen for analysis. All of them showed 790 asymmetric passage in both semisolid and catheter evaluations. Watan- longer than fve months, thirteen out of fourteen, presented left 1 1 2 3 dominance even in fve left hemiplegic patients. Sonoda , 1 hand, ffteen among eighteen patients did not allow the catheter to Fujita Health University Nanakuri Sanatorium, Department of pass along non-dominant paths, while only three patients allowed Rehabilitation, Tsu, Japan, 2Fujita Memorial Nanakuri Institute- the catheter to pass bilaterally. Conclusion: A catheter swallow- Fujita Health University, Division of Rehabilitation, Tsu, Japan, ing test could be a simple and safe alternative to real food test. Introduction/Background: In compliance with the maximum al- lowed training hours of the hemiplegic patients set by Japanese medical insurance system, our study aimed at determining the ef- 792 fect of maximum hours of physical therapy training on walking improvement of the hemiplegic.
Noradrenaline is more effective buy dapoxetine 90 mg low cost, and is more effective in maintaining renal perfusion order dapoxetine 30mg overnight delivery, than dopamine buy dapoxetine 30mg fast delivery, and so is the preferred drug 30mg dapoxetine overnight delivery. If the patient has suspected or proven cardiac dysfunction, dobutamine should be added. If there is no response to dobutamine and noradrenaline, consider using adrenaline. Vasopressin is used in patients with refractory septic shock, and is useful as a noradrenaline sparing agent. However, it causes severe peripheral vasospasm and can result in peripheral gangrene. It was earlier believed that dopamine in low doses selectively improves renal blood flow. While this effect is seen in healthy volunteers, there is no evidence that this benefit exists in patients with septic shock. However, clinicians often vouch that dopamine seemed to improve renal perfusion – this is simply because dopamine increases the blood pressure and hence improves renal blood flow. Severe sepsis & septic shock 73 Handbook of Critical Care Medicine There is no logic in using multiple inotropes of similar effect, since in the doses that are used, the adrenergic receptors are usually saturated anyway. For example it does not make sense to combine dopamine and noradrenaline, since noradrenaline is more effective and has the same effect as dopamine. An arterial line must be inserted to monitor the blood pressure whenever possible. Doses must be given in either micrograms per kilogram body weight per minute or micrograms per minute. Note that there is no defined maximum dose, and the maximum dose of any inotrope is that dose beyond which further increasing the dose either does not help to improve the blood pressure, or beyond which side effects manifest. Clinicians sometimes use suboptimal doses, and care should be taken to ensure that adequate doses are given. Drug Dose Dopamine 0-20 micrograms/kg/min Dobutamine 0-20 micrograms/kg/min Adrenaline 0-2 micrograms/kg/min Noradrenaline 0-2 micrograms/kg/min Vasopressin 0-0. Corticosteroids If shock persists despite adequate fluid replacement and inoconstrictors, there may be a place for replacement doses of corticosteroids. Corticosteroids in large doses have immunosuppressant effects, and in the past it was thought that this effect might help modulate the effects of sepsis. However, clinical trials showed that large doses of steroids were of no benefit, and may in fact increase the risk of infections. It was postulated that certain patients with septic shock may have relative adrenal insufficiency, and this was the cause for the lack of effect of adrenergic agents in these patients. Subsequent trials showed that replacement doses of corticosteroids improve haemodynamics and improve survival. The recommended dose of hydrocortisone is 200mg per 24 hours, given either as a continuous infusion or in 4 divided doses. Antibiotic therapy Broad spectrum intravenous antibiotics should be commenced as soon as possible after obtaining two or more blood cultures and other cultures as necessary. Antibiotic therapy should be re-assessed every few days and modifications made based on clinical response, suspected sites of infection, regional antibiotic sensitivity patterns, and results of cultures. Intravenous insulin is preferred, aimed at maintaining the blood glucose below 150mg/dL. Once the patient is stable and taking orally, the infusion could be switched over to subcutaneous insulin given three times daily. There is some evidence that insulin may exert anti-inflammatory effects, and hence, be beneficial in sepsis. Renal replacement therapy Renal replacement therapy is necessary in patients with acute renal failure; this is discussed further in the section on acute renal failure. Either intermittent haemodialysis or continuous renal replacement therapy could be used, and are equivalent in benefit. The choice of dialysis modality is determined by the haemodynamics of the patient; haemodynamically unstable patients cannot tolerate intermittent haemodialysis, and continuous veno-venous haemofiltration is the preferred modality. Bicarbonate administration There is no place for administration of bicarbonate to counteract acidosis or to improve cardiac function in patients with a pH over 7. Possible benefit maybe seen if the pH is lower, however, there is no consensus on this. Intermittent boluses are preferred to continuous infusions, and daily interruption of sedation enables early weaning. Activated protein C Human recombinant activated protein C has been shown in a large multicentre trial to improve survival in patients with severe sepsis and a high risk of death. Severe sepsis & septic shock 76 Handbook of Critical Care Medicine Bleeding is the most important side effect. Correction of haemoglobin and blood product administration Blood transfusion is not recommended unless the haemoglobin drops to 7g/dL. A haemoglobin of over 10g/dL is required only in patients with ischaemic heart disease. Platelet transfusion is 3 required only if the platelet count drops below 5000/mm in the absence of 3 bleeding, and below 30000/mm with active bleeding. Stress ulcer prophylaxis Stress ulcer prophylaxis should generally be given; proton pump inhibitors are more effective than H2 receptor blockers. The above therapies are based on clinical evidence, and contribute to better outcome. Recommendations are based on the Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock 2008. Consideration for limitation of support In spite of the best of care, severe sepsis and septic shock has a high mortality. The patient becomes progressively worse, and generally resistant hypotension develops as a terminal event. Severe sepsis & septic shock 77 Handbook of Critical Care Medicine It is important to discuss severity of illness and possible adverse outcome with the patient’s family, and make sure that expectations are realistic. If recovery seems unlikely, decisions of limitation or withdrawal of support should be considered. Since severe sepsis can suddenly affect previously well patients, this is all the more difficult. Severe sepsis & septic shock 78 Handbook of Critical Care Medicine Evaluating respiratory disease & airway management This section discusses the structure of the respiratory system and how to evaluate respiratory disease, and also deals with how to manage the airway. The respiratory system is divided into two parts – the upper and lower respiratory tract. The respiratory centres are stimulated by hypoxia, hypercapnoea, acidosis, and through various receptors within the lungs. The history, examination and investigations help to identify the abnormality in the respiratory system, diagnose its cause, and fine tune management appropriate to the patient. History Ask for a history of previous lung disease: x Asthma: duration, severity, compliance with medications, severity of exacerbations, previous intubation.