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368 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

TABLE 14.10 Common medications prescribed with chest injury: pneumothorax

Type of drug Generic medication Route/actions Nursing considerations
Opioids Morphine IV. Sedative effect with respiratory depression,
Activates opioid receptors in the brain decreased cough reflex, bradycardia
and spinal cord. Histamine release may lead to flushing of face or
Depresses respiratory centre and hypotension, nausea and vomiting.
cough reflex. Reduces gastrointestinal motility.
Alters pain perception and CNS Reversed by naloxone.
modulation of painful stimuli.
Fentanyl Epidural and IV. Sedative effect with respiratory depression
A synthetic phenylpiperidine Can obscure the clinical course of patients with
derivative. head injury.
Pharmacological actions are similar to Slow IV injection reduces the risk of respiratory
those of morphine, but action is muscle rigidity.
more prompt and less prolonged, Use with caution in patients with renal and
and fentanyl appears to have less hepatic impairment, as action will be prolonged.
emetic activity. Respiratory depression can be reversed by
naloxone. Bradycardia can be reversed by
atropine.
Antibiotic Cephalosporin IV. Active against a wide range of gram-positive and
(1st generation) Bactericidal as a result of inhibition of gram-negative bacilli. Highly active against
for 24 hours bacterial cell wall synthesis. Staphylococcus aureus, including strains resistant
to penicillin.

addresses the risks and benefits of treatments for medical,
TABLE 14.11 Risk factors for venous surgical and oncology patients. Further, VTE guidelines
thromboembolism (VTE) 123 for patients with heparin-induced thrombocytopenia;
pregnancy and childbirth are outlined with a listing of
Primary hypercoaguable Secondary the publications to support the level of evidence for the
states (thrombophilia) hypercoagulable states clinical management guidelines.
Antithrombin III deficiency Immobility (including
Protein C deficiency long-haul aircraft travel) CLINICAL MANIFESTATIONS
Protein S deficiency Surgery Pulmonary artery obstruction causes release of vasoactive
Resistance to activated Trauma
protein C (inherited factor V Malignancy agents from accumulating platelets, with subsequent
Leiden mutation) Pregnancy and the puerperium raised pulmonary vascular resistance and acute pulmo-
Hyperhomocysteinaemia Obesity nary hypertension. The arterial obstruction causes severe
Lupus anticoagulant Smoking shunting and life-threatening hypoxaemia. Symptomatic
(antiphospholipid antibody) Oral contraceptive pill
Indwelling catheters in great patients present with dyspnoea (most common), pleu-
veins and the right heart ritic chest pain and haemoptysis. The physical signs of
Burns tachypnoea, fever, tachycardia and right ventricular dys-
Patients with limb paralysis function may also be present. If a massive PE has occurred,
(e.g. spinal injuries, stroke) the patient exhibits hypotension with pale, mottled skin
Heart failure
and peripheral and/or central cynanosis. 124
to higher incidence: immobilisation (due to long bone, ASSESSMENT AND DIAGNOSTICS
pelvic and spinal fractures) and closed head injury in Investigations to confirm VTE include compression
particular (see Table 14.11 for a list of risk factors). 123 ultrasonography for a suspected DVT, pathology test for
Most PE originate in the lower limbs, pelvic veins or elevated levels of D-dimer in plasma 125 and a ventilation-
inferior vena cava. Three predisposing risk factors for perfusion (V/Q) isotope scan, computed tomographic
thrombosis are venous stasis, vein wall injury and hyper- (CT) and pulmonary angiography (helical CT) scan
coagulability of blood. Clinical risk factors are immo- for PE. 122
bility, surgery, trauma, malignancy, pregnancy or
thrombophilia. PE may have no clinical consequence or
123
it may be catastrophic, causing sudden death, and is COLLABORATIVE PRACTICE
responsible for 10% of in-hospital deaths. 124 The morbid- Current and ongoing treatment modalities for PE are
ity and costs associated with VTE are also significant. An selected according to the patient’s individual circum-
evidence-based clinical practice guideline has been pub- stances. In general, options include medications and per-
lished to address this significant health issue 122 and cutaneously inserted vena caval filters. 126