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Since there is no effective cure for lymphedema, the treatment strategies are designed to control the problem and allow normal activity and function Most patients can be treated with some of the following measures: (1) The flow of lymph out of the extremity, with a consequent decrease in the degree of stasis, can be aided through intermittent elevation of the extremity, especially during the sleeping hours (foot of bed elevated 15 20 degrees, achieved by placing pillows beneath the mattress); the constant use of graduated elastic compression stockings; and massage toward the trunk either by hand or by means of pneumatic sequential pressure devices designed to milk edema out of an extremity (2) Secondary cellulitis in the extremity should be avoided by means of good hygiene and treatment of any trichophytosis of the toes Once an infection starts, it should be treated by adequate periods of rest, elevation, and antibiotic therapy that covers Staphylococcus and Streptococcus organisms Infection can be a serious and recurring problem and is often difficult to control Intermittent prophylactic antibiotics may occasionally be necessary; dicloxacillin is a good choice (3) Intermittent courses of diuretic therapy, especially in those with premenstrual or seasonal exacerbations, can be helpful (4) Amputation is used only for the rare complication of lymphangiosarcoma in the extremity



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Drainage of pus from an infected wound should be carried out, generally after the above measures have been instituted and only when it is clear that there in an abscess associated with the site of initial infection There is no value in incising areas of cellulitis if there is no abscess to be drained

With proper therapy particularly an antibiotic effective against the invading bacteria, control of the infection can usually be achieved in a few days Delayed or inadequate therapy can still lead to overwhelming infection with septicemia

Painless persistent edema of one or both lower extremities, primarily in young women Pitting edema, which rarely becomes brawny and non-pitting Ulceration, varicosities, and stasis pigmentation do not occur There may be episodes of lymphangitis and cellulitis





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With aggressive treatment, including pneumatic compression devices, good relief of symptoms can be achieved The long-term outlook is dictated by the associated conditions and avoidance of recurrent cellulitis

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Tiwari A et al Differential diagnosis, investigation, and current treatment of lower limb lymphedema Arch Surg 2003 Feb; 138(2):152 61 [PMID: 12578410]

The underlying mechanism in lymphedema is impairment of the lymph flow from an extremity When lymphedema

The quality of service (QoS) standards that you saw in 12, Advanced Networking Devices, only cover the amount of bandwidth to use, not which port to use MPLS is a router feature that labels certain data to use a desired connection It works with any type of packet switching (even Ethernet) to force certain types of data to use a certain path This path in essence is a VPN just like the VPNs we saw in 12 (but not encrypted) When you use MPLS, you usually say MPLS VPN because it creates a virtualized private tunnel through the cloud of the Internet

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Hypovolemic shock Loss of blood (hemorrhagic shock) External hemorrhage Trauma Gastrointestinal tract bleeding Internal hemorrhage Hematoma Hemothorax or hemoperitoneum Loss of plasma Burns Exfoliative dermatitis Loss of fluid and electrolytes External Vomiting Diarrhea Excessive sweating Hyperosmolar states (diabetic ketoacidosis, hyperosmolar nonketotic coma) Internal ( third spacing ) Pancreatitis Ascites Bowel obstruction Cardiogenic shock Dysrhythmia Tachyarrhythmia Bradyarrhythmia Pump failure (secondary to myocardial infarction or other cardiomyopathy) Acute valvular dysfunction (especially regurgitant lesions) Rupture of ventricular septum or free ventricular wall Obstructive shock Tension pneumothorax Pericardial disease (tamponade, constriction) Disease of pulmonary vasculature (massive pulmonary emboli, pulmonary hypertension) Cardiac tumor (atrial myxoma) Left atrial mural thrombus Obstructive valvular disease (aortic or mitral stenosis) Distributive shock Septic shock Anaphylactic shock Neurogenic shock Vasodilator drugs Acute adrenal insufficiency Reproduced, with permission, from Stone CK, Humphries RL (editors) Current Emergency Diagnosis & Treatment, 5th ed p 193 McGraw-Hill, 2004

Hypotension, tachycardia, oliguria, altered mental status Peripheral hypoperfusion and impaired oxygen delivery

Shock occurs when the rate of arterial blood flow is inadequate to meet tissue metabolic needs This results in regional hypoxia and subsequent lactic acidosis from anaerobic metabolism in peripheral tissues as well as eventual end-organ damage and failure

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Classification (Table 12 1)

Hypovolemic shock results from decreased intravascular volume secondary to loss of blood or fluids and electrolytes The etiology may be suggested by the clinical setting (eg, trauma) or by signs and symptoms of blood loss (eg, gastrointestinal bleeding) or dehydration (eg, vomiting or diarrhea) Compensatory vasoconstriction may transiently maintain the blood pressure but unreplaced losses of over 15% of the intravascular volume can result in hypotension and progressive tissue hypoxia

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