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Science, Technology and Medicine open access publisher.Publish, read and share novel research. Figure 1.Chest radiograph showed unilateral involvement of the lung with increased infiltrates and patchy consolidation with apical lung spared.
A 61-year-old diabetic man developed necrotizing fasciitis following blunt trauma to his right chest. Doing that will cause an invisible character to be written to the f1_notes field by frmnotesack.asp!! The reconstruction options included extensive split thickness skin graft (STSG), latissimus musculocutaneous transposition with STSG to the resulting back defect, transverse rectus abdominis musculocutaneous (TRAM) flap or free flap from a distal site.
A rare bacterial illness, scarlet fever causes a distinctive pink-red itchy rash that feels like sandpaper. Add some apple cider vinegar & 2 tsp of cayenne pepper in a glass of water and drink the mixture 2-3 times daily. Add comforting foods like soup, yogurt, liquid-type rice and cold treats (ice pops and ice-creams). Herbs like Oregon Grape, Usnea, Wild Indigo, Echinacea, Winter cherry, Yarrow, Seal and goldenseal are also good for scarlet fever rashes. Ask a Doctor Online Now!Itching skin during pregnancy may be due to a number of causes that were present prior to conception. However, itchy skin in pregnancy may be a result of some underlying condition or cause that has been exacerbated due to the pregnant state. Of these type of conditions, allergic conditions resulting in itchy skin are the most common.
The use of antihistamines to treat the itch are often of concern due to the debate surrounding the teratogenic properties of these drugs.
Ask a Doctor Online Now!Itching within the first trimester of pregnancy is common and is usually not a cause for concern if there is no visible skin rash or concomitant signs and symptoms.
There are certain causes of pruritus in pregnancy that may only occur or are more likely to occur in the pregnant state. Also known as polymorphic eruption of pregnancy (PEP) or previously as toxemic rash of pregnancy. More commonly affects a woman in her first pregnancy but may recur in subsequent pregnancies. Usually occurs in the areas where stretch marks (striae distensae) is most prominent – abdomen, thighs and buttocks. Previously known as herpes gestationis due to its appearance but it is not caused by the herpes virus. Tends to occur in the third trimester of pregnancy but may initially appear in the latter part of the second trimester. Progresses into large blisters (bullae) surrounded by rough, cracking skin (excoriated papules). Poses a varying degree of risk to the fetus and an early delivery may have to be considered. Occurs when bile (bile salts) enter the bloodstream due to the diminished flow of bile out of the liver. Please note that any information or feedback on this website is not intended to replace a consultation with a health care professional and will not constitute a medical diagnosis. The paramedic repeatedly pushed down hard on Beverleya€™s chest a€” and when 16 stone of muscle presses on 86-year-old ribs, inevitably the bones crack under the pressure. But I dona€™t advocate resuscitation on patients whose hearts, like Beverleya€™s, have stopped because it was the end of the dying process. If the heart stops, the a€?maximuma€™ treatment possible is CPR, followed by intensive care. We gave him antibiotics, oxygen and nebulisers to help improve his breathing but he continued to deteriorate.
Computed tomography scan of the lung showed multiple low-density regions with marked consolidation as well as some parapneumonic effusions.
IntroductionNormal lung function requires both adequate lung ventilation and adequate perfusion.
Repeated infection with regeneration will result in consolidation( hepatization) and may cause pulmonary artery occlusion. But now-a-days, this deadly disease is treatable thanks to modern medicine (antibiotics) and home remedies. To make garlic tea, add 2-3 teaspoons of crushed garlic powder in a cup of water and boil for 10 minutes. At other times, those conditions that appear after conception may have been developing or were bound to develop, irrespective of the pregnancy. Alternatively, pregnancy was the trigger for the onset of a condition which the woman was predisposed to but had not as yet presented due to the lack of precipitating factors.
The increasing estrogen levels are known to exacerbate allergy-related conditions and may be also be noticed by females using hormone contraceptives or even hormone replacement therapy (HRT).
Certain antihistamines like chlorphenamine have a long safety record in pregnancy and can be used for palliating the itch although this should only be done after consulting a doctor or gynecologist. The latter may have been pre-existing and related to allergies earlier in life which may have also presented as as asthma or allergic rhinitis (allergic triad : eczema, asthma, hay fever). A tube was forced into Beverleya€™s throat to help her breathe and a needle stabbed into her bones for a shot of adrenaline. She revealed that she carries a Do Not Resuscitate card instructing paramedics not to keep her artificially alive should she be involved in an accident or fall seriously ill. The least, as in Beverleya€™s case, is a€?tender, loving carea€™, as we call it a€” not actually trying to save their life but ensuring the end of their life is not distressing.
On cut, there was foul smell and the lung was very fragile in some regions admixed with some fibrotic regions.
Adequate lung perfusion means normal blood flow can reach to the lung tissues providing nutrients and oxygen to the lung tissues and the waste can be removed.
AngniographyWhen normal blood flow to the infected lung had been disturbed, angiography is an adequate methods to evaluate the vascular structure and help differentiate from other diseases. If you don’t like tea, then inhale the vapour that comes out of the tea or use the water to gargle (4 times a day). In both these instances, pregnancy was not the cause or precipitating factor and these itchy skin conditions were non-specific.


Hormonal, immunological or unknown factors relating to pregnancy may serve as a trigger or aggravating factor for pre-existing or chronic skin diseases. Anxiety may play a role in this type of itching (psychogenic) as it is more frequently noted in first time mothers.
Finally, her heart was shocked back to life using a defibrillator a€” 1,500 volts of energy pulsating through her chest.a€?Shocka€™ says it all. This is not about the Liverpool Care Pathway, which is about how dying people should be looked after (stopping active and often painful interventions to prolong life, such as intravenous drugs, and instead making comfort the focus of care). For these patients, resuscitation wona€™t reverse the dying process though it can temporarily delay death a€” as it did in Beverleya€™s case a€” but it wona€™t stop it. Such interruption of blood flow further aggravates infection because the antibiotics may not reach to necrotic tissues. Perfusion of the lung may be disturbed in numerous settings, including infection, aspiration of foreign body, neoplasm[1], trauma and may be secondary to surgical complications, adverse effects of radiation therapy and chemotherapeutic agents.
On cut, there was foul smell and the lung was very fragile in some regions admixed with some fibrotic regions.8. Majumdar, Patients admitted to hospital with suspected pneumonia and normal chest radiographs: epidemiology, microbiology, and outcomes. Schirg, et al.Radiographics, 2002High-resolution CT and CT angiography of peripheral pulmonary vascular disorders. However if the itching is persisting, getting worse, affecting sleep or other activities, then it should be investigated. This is about the patient who has actually died because their heart has stopped, and whether it is appropriate to kickstart it back to life or not.
There are often a lot of patents who fit into a middle ground a€” ie, they dona€™t have the physiological reserve to survive CPR or intensive care treatment a€” here it would be appropriate to try to save their life with fluids, oxygen and antibiotics.
In most circumstances, the role of diagnosis has been replaced by CTA (computed-tomography angiography), which is a relatively less invasive approach. ECMOExtracorporeal membrane oxygenation is a strategy when lung fails to provide adequate level of oxygenation.[10] Whether a patient's condition is operable or can be treated medically, ECMO can maintain adequate oxygenation (V-V mode ) and circulation ( A-V mode ) when lung condition is potentially reversible. Within 2 days of the initial infection, patient experience itchy pinkish or reddish sandpaper like rashes starting from the neck & chest and finally all over the body. It is more akin to going ten rounds with the boxer Mike Tyson than the kiss of life you see on TV.But surely ita€™s worth it, you might think. Wea€™re not good talking about death, but without this conversation between doctors, patients and families, there will continue to be people like Beverley.
During this time, he had deteriorated and could hardly walk a€” but still liked seeing his grandchildren, even if he couldna€™t look after them.
Gangrenous change indicates tissues necrosis followed by decomposition of tissues into a slough. Currently, more and more evidences support the role of ECMO in non-cardiac circulatory failure. Other symptoms of the disease are high fever, headache, tongue covered with red spots, chills, infected tonsils and sore throat. Too often ita€™s because none of us a€” doctors or families a€” is willing to have the difficult conversation about what should happen.In the absence of anything in Beverleya€™s notes about the plan for the end of her life, I went to find her family. We all agreed that on this occasion we would try to make him better with antibiotics and oxygen, but that now he was too weak to go to intensive care if he deteriorated further.
Compromise of blood flow can be the primary cause and can be the result of other antecedent events. Computed tomographyComputed tomography (CT) can clearly define gangrenous lung disease into localized form and diffuse form. The exact timing and place of such treatment in lung infection management remains to be determined8.1. Yealy, et al.A prediction rule to identify low-risk patients with community-acquired pneumonia. Cases like that of Beverley, who I looked after following her a€?successfula€™ resuscitation, are the reason why.
I spoke to Beverleya€™s three daughters, all in their 50s, who were devastated by the resuscitation. Luckily, he improved and left hospital.But age was getting the better of him and though he enjoyed the next five months of his life, he started to deteriorate even more. Treatment and outcome were essentially related to its causes and depends on the timing of either medical or surgical intervention. With and without contrast enhancement can help identify the involved regions, preoperative evaluation for the extent of lung resection, and whether pulmonary vessels are occluded or not.
OutcomeOutcome depends mostly on the timing of detection of the gangrenous changes and prompt intervention, either medical or surgical.
Theya€™d wanted their mother to have passed away in the nursing home, with them holding her hand. Not able to get out of his bed and dependent on all care, he had to be moved into a nursing home.He developed another chest infection, but this time he and his family had made a plan with their GP, that if he deteriorated, they would relieve his symptoms but not send him to hospital for antibiotics. Gangrenous changes of lung on CT scan have features of multiple low-density areas, consolidations, air-trapping, loculated effusion and possibly hydropneumothorax due to broncho-pleural fistula.
Currently, there is still no reliable statistical results about the mortality rate and complication rate. Instead, theya€™d watched in shock and distress as an unknown paramedic forcibly compressed their mothera€™s chest, trying to keep her alive. Clinical featuresInflammatory changes can be locally confined in the lung tissues with lobar pneumonia, necrotizing pneumonitis, cystic changes and abscess occurring in any location where the tissues being destroyed. In some instances, auto-pneumonectomy may occur after severe infection in hemi-lung without resection.
But no plans had been made by the hospital, GP or nursing home about what would happen when nature took its course and she died.Nature did take its course and on the fifth day at the home, Beverley was found unconscious in her bed, her breathing laboured. Making plans had given him and his family an extra year of life, which he wanted, and a dignified death, when he wanted. Symptoms of local inflammatory diseases include chest pain, pleurisy, cough, dyspnea, purulent expectorants and reduced tolerance of physical activity. This condition is termed as " dry gangrene" and the involved lung becomes functionless and does not cause further systemic infection.
The nurses wanted to call the family so they could hold Beverleya€™s hand as she passed away.


But neither they nor the doctors had initiated the vital conversation about the a€?ceiling of treatmenta€™ a€” how much treatment it is appropriate for a patient to receive. Doctors need to have these difficult conversations with patients and their relatives a€” and patients and relatives need them with us.With Beverleya€™s family, we agreed to do everything appropriate, but no a€?heroicsa€™ such as continuing to ventilate her, which would delay, not prevent death.
But there had been no end-of-life plan arranged by her family, so nurses were obliged to call an ambulance.While paramedics assessed her, Beverleya€™s heart stopped a€” in other words, she died. Ita€™s an important conversation to have with anyone elderly, terminally ill, or who has a chronic condition such as end-stage heart failure where they might not surviveA  a deterioration ofA  that condition. The thought of having CPR and the possibility of being brain damaged (which happens in up to 75 per cent of cases) scared him and so he chose, in conjunction with me and his family, not to have it if his heart stopped. The focus of care would go from saving her life to maintaining dignity and stopping suffering.A  No active treatment, just very active care. Lung function testLung function test is not for definite diagnosis but for evaluation the possibility of lung resection and determine the extent of resection. In most conditions, prompt surgical intervention is mandatory if medical treatment failed to alleviate sepsis within days. But he wanted a fighting chanceA  so we agreed we would do everything possible to save his life a€” but not try to restart it if he did die.
We removed the breathing tube, moved her to a side room and when nature took its course (which it did 20 minutes later), we did not intervene. However, these symptoms may be subtle or non-specific and resembled to those symptoms seen in other common diseases.
When involvement of pulmonary gangrene extends more than one lobe, extent of lung resection need to be carefully evaluated. They were too good for their own good (and the patienta€™s good), and apologetically brought her to A&E.
Characteristic features included abundant and putrid sputum in the airway and hemoptysis caused by tissues decomposition. Thata€™s when, as the consultant in charge, I took over her care.As you might expect from someone in my job, I am passionate about keeping people alive, and I am a passionate advocate of resuscitation, but resuscitation on the correct type of patient a€” the one whose heart stops because of a sudden acute and reversible illness such as a heart attack, yet who could go on to have a life they would want to live. Long-term follow-up is mandatory because most patients with pulmonary infections, to the extent of necrosis and gangrene, have obvious predisposing factors and these factors must be monitored carefully in outpatient department. However, both perfusion and ventilation scan help a lot in evaluation of the extent of lung resection and estimated post-operative lung function. Lung function test alone can determine the patient's overall lung function but can not predict the function, perfusion and ventilation, of individual lobe and gives us more reliable reading than lung function test alone. Elevated white blood cells with shift-to-left usually indicates for systemic inflammation or infection. However, due to the limitation of resolution of nuclear scan, interpretation of the results should be careful and may discuss with the specialists.7.
ConclusionIn most circumstances, lung infection is a medical disease and rarely requires lung resection.
C-reactive protein, erythrocyte sedimentation rate and procalcitonin are also useful infection indicators. Medical treatmentMedical treatment is still the mainstay of treatment of gangrenous lung disease.
Sputum analysisObtaining adequate sputum for possible pathogens is essential to guide the use of antibiotics.
The goals of medical treatment is to control both local and systemic infection, preventing occurrence of SIRS and septic shock.
Prior to identifying the definite culprit pathogen, empiric antibiotics of broad-spectrum should be started as soon as possible.
Administration of broad-spectrum of antibiotics, proper fluid replacement therapy, steroid therapy, secure airway are useful strategies. Four common pathogens encountered in community-acquired pneumonia are Streptococcus pneumonia, Haemophilus influenzae, Staphylococcus aureus and Mycoplasma pneumoniae. When patient's response is poor despite of aggressive medical treatment, surgical evaluation ought to be considered. A positive gram stain for diplococci has near 100% sensitivity for pneumococcal infection but the specificity is poor (less than 5%).
According to the experience of our institute, after aggressive medical treatment for 48 hrs, surgical evaluation is to be expected to prevent bilateral involvement of necrotizing pneumonia and unavoidable lethal outcome. A multiplex PCR allows us to detect tuberculosis, Legionella spp, Mycoplasma pneumoniae and C.
Resection of the local infection can be either delayed or unnecessary depending on infection control. Surgical treatmentAdequate timing of surgical intervention isn't easy to determine because gangrenous changes of lung often accompany with pleural infection including empyema thoracis and chest wall infection. Resection of lung, division of pulmonary vessels and bronchus in an infected pleural space is risky for postoperative bleeding, prolonged air leaks due to bronchial rupture and persistent pleural infection. BronchoscopyBronchoscopy is a useful tool to help evaluate the condition of trachea and bronchus. A two-stage approach had been proposed a reasonable strategy.[9] With concomitant pleural space infection, tube thoracostomy to allow drainage of purulent pleural effusion or thoracoscopic deloculation and decortication to help cleaning of pleural space and prepare for subsequent lung resection.
Lobar torsion, most commonly encountered in right middle lobe following resection of right upper lobe, and subsequent lobar gangrene can be diagnosed under bronchoscopic findings of total obliteration of bronchial orifice.[6] Ischemic bronchial wall can also be demonstrated under bronchoscope. However, infection may be overwhelming in some situations and surgical intervention is emergent. With brushing, lavage with saline (BAL) and punch biopsy of suspected endobronchial lesion may also assist proper diagnosis prior to definitive treatment.6.
The most appropriate timing should be judged individually because such information in the literature is very limited. If tube thoracostomy failed to alleviate systemic infection, prompt surgical intervention should be started.
Chest radiographChest radiograph can demonstrate disease progression from a smaller pneumonia patch, lobar pneumonia, lung abscess, parapneumonic effusion and then to diffuse necrotic and gangrenous changes of the lung.
If bronchial or vascular structure is fragile and necrotic, pleural or muscle flap may be considered during operation.



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