Articles Posted in Medical

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When the skin is burned, the affected tissue will die depending on the severity of the injury. The dead tissue will naturally fall of as part of the healing process of the skin. However, in some cases where burns are severe (second and third degree burns), wound debridement is necessary. This dead tissue if not removed, will be a good medium for bacteria to grow and flourish, predisposing the wound for infection and other complications. Debridement is defined as the process of removing dead tissue and contaminated material from and around a wound to expose the healthy tissue.

There are four debridement methods which are : Surgical, Chemical, Mechanical and Autolytic debridement. The wound will be assessed to determine the best debridement method by examining the depth, extent and location of the wound; whether it lies close to other structures like bones, the risk of infection and antibiotic use, and the type of pain management that will be used during and after the procedure.

  • Surgical debridement:

This is done using scalpels, forceps, scissors and other instruments to cut dead tissue from the wound. It is the most effective method used if the wound is large, has deep tissue damage, and may be done if the wound debridement is urgent. The wound will be cleaned with saline and then the dead tissue will be cut, this method may need to be repeated more than once and sometimes skin grafts may need to be transplanted into the debrided site.

  • Mechanical debridement:

This is done by applying a saline moistened dressing over the wound and allowing it to dry and adhere to the dead tissue, when the dressing is removed the dead tissue will be pulled with it, this method is one of the oldest and can be very painful.

  • Chemical debridement:
    This is done by using enzymes and other compounds to dissolve dead tissue in the wound.
  • Autolytic debridement:

This method involves using dressings that retain wound fluids, allowing the body itself to naturally get rid of the dead tissue. This method is not used if the wound is infected or quick treatment is needed, it takes more time than the other methods and is a good method if the body cannot tolerate more forceful treatment.

Debridement is done under general or local anesthesia, pain medications may be given if there is pain.

It is important to take good care of the debrided burned area by keeping the wound and the dressing clean and dry. Contact the doctor if there are signs of infection (discharge from the wound, color change, swelling, redness, increasing pain, excessive bleeding, fever and chills).

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Dermabrasion is a surgical procedure involving the removal (sanding) of the damaged top layer of the skin using a specialized instrument called a dermabrader. This procedure is used for scars as well as other skin conditions such as wrinkles and tattoos.

Dermabrasion improves the appearance of the scar or other skin abnormality as a new layer of skin will replace the skin that has been treated. This procedure won’t entirely remove the scar or other abnormality but it will improve its appearance by softening the edges of the scar or other lesions.

The procedure can be done in a surgeon’s office or in an outpatient surgical facility. After the procedure the skin will be swollen, red and tender. Swelling gradually subsides within 2-3 weeks. You may feel some burning, itching, aching or discomfort for a while after the surgery. Pain medication, antibiotics and anti-swelling medications can be prescribed. Ointment and special dressing will help speed the healing process and your physician will give you instructions on how to care for the wound. Healing usually occurs within seven to ten days.

At first the new skin that is formed is pink in color but will gradually return to its normal appearance. The skin pinkness will largely fade within 2 to 3 months. The new skin should closely match the surrounding skin when full color returns. You can resume your normal activities within 2 weeks. Any activity that can cause injury to the area that has been treated should be avoided. You should also avoid sports for 4 to 6 weeks. Sun protection is also important to avoid pigment alteration. Avoid exposure to sunlight both direct and indirect for at least 6 months and use sunscreens on a regular basis when outdoors.

Skin color changes in the form of increased pigment (darker) or decreased pigment (lighter) after treatment is one of the complications of dermabrasion.

You should contact your doctor if:

  • The redness and swelling persists in the treated area as this could be a sign of a scar forming.
  • There is discharge or yellowish crusting as this may indicate an infection.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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In difficult circumstances, not only the person who has been exposed to a trauma, but the caregivers as well, need all the help and support they can get and will appreciate the presence of friends and family beside them at that critical time period. By being there even for a few minutes, this will bring comfort and support for that person and your help will not be forgotten as suffering a burn injury can be one of the most traumatic experience a person can go through both physically and psychological.

If you are visiting a patient who is still in the hospital, there are certain things to keep in mind including visiting hours, number of visitors allowed and infection control as burn centers have strict guidelines regarding infection control. Visitors may be required to wear a gown, mask, cap and gloves when visiting the patient. The nurse will give you instructions on the protective clothing to decrease the risk of infection.

Look for any signs outside the patient’s door that will tell you if you have to wear these protective garments when entering the patient’s room, it’s important to follow these instructions. You have to wash your hands prior to entering and after leaving the patient. Avoid visiting the patient if you have an active cold or an infection and inform the nurse about it if you do visit.

During the visit, offer a listening ear as it helps the patient to know that you are there to listen and this will make him/her feel at ease. When you speak, use the right approach, sometimes the best gift you can give a patient is an encouraging word rather than an advice. Don’t push patients to talk if they don’t want to as it is a traumatic experience for them remembering what they have gone through. Avoid showing pity, feeling sorry or blaming the patient for what happened as the purpose of you being there is to, encourage, support and guide that person to get through this hard time.

 

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Origin of hospital acquired infection:

Hospital acquired infection can be external (from outside the body) or internal (from the inside of the body).

External (Exogenous) infection: examples of external sources of infection may include

  1. Catheters such as the urine catheter (Foley Catheter)
  2. Instruments such as speculum, scissor, forceps.
  3. Hands if they are not properly sterilized.
  4. Blood product transfusion which can transmit Hepatitis B and HIV.
  5. IV lines like Central and Picc lines.
  6. Respiratory equipment such as ventilators.
  7. Airborne infection: such as Tuberculosis (TB).
  8. Linen that are contaminated.

Internal (Endogenous) infections: Internal sources of infection may include

  1. Skin: Certain bacteria live on the skin of many healthy individuals without causing any infection. However, these bacteria can cause skin infections if they enter the body through a break in the skin as in burns, open wounds and cuts. Staphylococcus aureus (Staph) is a bacteria that can be found living on the skin and in the nose of many healthy people without causing any infections. This bacteria can cause skin infections such as boils when the circumstances are appropriate.
  2. Oropharynx.
  3. Respiratory System.
  4. Gastrointestinal tract.
  • Pathogens that cause hospital acquired infections can be Bacteria, Fungi, Viruses and Protozoa.
  • Pathogens vary in their virulence (the ability of a microorganism to cause disease); the more virulent the organism is, the less the number needed to produce the disease.
  • The sicker the patient is, the higher the risk of contracting a hospital acquired infection.
  • The lower the patient’s immunity is, the higher the risk of getting a hospital acquired infection.
  • Certain circumstances may favor the growth and survival of the microorganism such as wet versus dry objects. Contamination is heavier in wet objects than dry objects.

Certain factors may affect the susceptibility of the patient to get nosocomial:

  1. The age of the patient: elderly and infants are more susceptible for infection.
  2. The presence of pre-existing diseases (co-morbidity): chronic diseases such as chronic kidney disease, chronic liver disease and diabetes can increase the patient’s risk for contracting a hospital acquired infection as all these diseases may interfere with the immunity of the patient making him/her more susceptible for infection.
  3. Low or compromised immune system: any condition that suppresses the immune system can increase the susceptibility of the patient for an infection.
  4. Malignancy, chemotherapy and radiotherapy: as all may suppress the immune system.
  5. Treatment with Antibiotics: this can cause the growth of antibiotic resistant micro-organisms that can cause hospital acquired infection.
  6. Procedures and surgeries: therapeutic and/or diagnostic procedures and surgeries may increase the susceptibility of the patient for a hospital acquired infection.

Measures taken by the healthcare staff to prevent and/or control nosocomial infection:

  • Proper hand washing and/or cleansing.
  • Wearing gloves, masks and gowns.
  • Aseptic technique and procedure practice.
  • Isolating patients with communicable diseases.
  • Proper disinfection and sterilization of reusable equipment.
  • Immunization patients at risk.
  • Proper disposal of waste product.
  • Prophylaxis
  • Educating patients and public about the causes, methods of transmission, treatment and prevention of infection

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Hospital acquired infection (HAI) is an infection that is acquired when the patient is admitted to a hospital or a health care facility for any reason other than that infection. The infection should not have been present or incubating prior to the patient’s being admitted to the hospital.

Sites of hospital acquired infections:

  • Burns and wounds: When a burn injury happens, the skin barrier will be broken and the body will become more vulnerable for all kinds of infections not only hospital acquired infections; this may as a result increase the risk of sepsis and septic shock.
  • Urinary tract: It is the most frequent hospital acquired infection site, foley catheterization accounts for more than 50% of hospital acquired urinary tract infection, that’s why the catheter must be removed as soon as there is no need for it to stay to decrease the risk of infection.
  • Blood stream: This is common in central line cathetarization where the hospital acquired infection may happen at the skin in the site of entry of the catheter or along the path of the catheter under the skin.
  • Respiratory tract: This type of hospital acquired infection is most common in critically ill patients, patients in the intensive care unit (ICU) and those on ventilators (ventilator associated pneumonia). These infections are associated with high infection associated complications and pneumonia.
  • Gastrointestinal tract (GIT): In children gastrointeritis is the most common hospital acquired infection which is mainly caused by a virus called Rotavirus. In developed countries a bacteria called Clostridium difficle is the major cause of hospital acquired gastrointeritis in adults.
  • Surgical site: The more complicated the procedure is, the higher the risk of having a hospital acquired infection.

Factors determining the risk of hospital acquired infections:

  • Duration of hospital stay: The longer the patient stays in the hospital, the higher the risk of exposure to hospital acquired pathogens and the greater the chance of being infected.
  • Age of the patient: Elderly and neonates are at higher risk of contracting a hospital acquired infection.
  • Immune status: The immune system plays a major role in fighting infections. Patients with low or suppressed immunity are at a higher risk for hospital acquired infections. Conditions that suppress the immune system may include malignancy, chemotherapy, radiotherapy, steroid drugs and malnutrition.
  • Procedures and interventions: Procedures such as Endoscopy and surgery increases the risk of infections.
  • Hospital and care personnel: Cleanliness of the hospital and health care workers hygiene plays an important role in the transmission and spread of hospital acquired infection.
  • General health of the patient: The general health of the patient has a role as the presence of co-morbidities increases the risk of contracting infections.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Treatment of severe burns is still one of the challenging issues for physicians and necessitates the collaboration of a multidisciplinary team due to the magnitude of the injury. Many patients with serious burns require ICU admission for their management in order to minimize morbidity and mortality. Despite the modern advances in the treatment of burns, still the mortality rate is high in patients with extensive burns with infection being a major cause of death. (Thompson, Herndon, Abston and Rutan, 1987) found that early excision of dead tissue (burn eschar) decrease the incidence of invasive burn infection and sepsis, improves the patient’s outcome and decreases the duration of hospital admission.

Burned patients are also at higher risk of developing infection and sepsis from catheters and central lines. A central line is a long, thin, soft plastic tube that is introduced through a small cut in the skin into a large vein to administer fluids, blood products, nutrients and medications over an extended period of time. It is often placed in patients who require care in the intensive care unit to provide nutrition, medication and fluids. Infection can be one of the complications associated with the use of a central venous line which can be caused by bacteria and/or fungi. Other complications may include bleeding, pain, blockage, kinking or shifting of the line, air embolism and lung collapse.

As the central venous line is introduced through an opening in the skin, bacteria can grow in this line making the patient more susceptible for blood born infection. Infections associated with a central venous line can be very serious as the bacteria causing these infections can multiply and spread quickly to the entire blood stream causing septicemia which can be fatal.

A Consumer Reports analysis of newly released data revealed that central line infections account for 15 percent of all hospital infections but are responsible for at least 30 percent of the 99000 annual hospital-infection-related deaths according to the best estimates available. Hospitals that are following simple hygienic steps have virtually eliminated those infections but many others are failing to act. Research shows that putting the catheter in the subclavian vein is best for infection control.

According to an article in the New England Journal of Medicine in December 2006, there was a 66 percent reduction in central-line associated blood stream infections after 67 hospitals in Michigan implemented a checklist developed by Peter Pronovost, M.D, Ph.D. Health and Human Services Secretary Kathleen Sebelius called on all hospitals across America to use the checklist to reduce central-line infections in ICUs by 75 percent over the next three years, this check list includes:

  • Washing hands before and after examining a patient or inserting, replacing, accessing, repairing and dressing the catheter (line).
  • Disinfecting the skin of the patient before inserting the catheter and during dressing changes.
  • Maintaining aseptic technique by wearing a mask, cap, sterile gown, and a steril gloves when inserting the line.
  • Avoiding placing the catheter in the groin because the groin area is hard to keep clean. A subclavian site is preferred.
  • Removing unnecessary catheters.

Not all hospitals follow this list. If a family member or a friend has to be hospitalized in intensive care, take this list with you and ask whether the intensive care unit uses it, says Dr. Pronovost in Consumer Reports. He also believes that public accountability powerfully motivates hospitals to get their infection rates under control.

Under new laws 27 states are disclosing infection rates or will have to while five years ago only four states did reported hospital infection rates.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Diabetes mellitus (DM) is a disease with an increasing incidence worldwide including the US. It is expected to reach 15/1000 in the United States by the year 2050. Most burns in patients with diabetes are due to contact with hot objects or scalds. Patients with diabetes especially if uncontrolled are usually associated with poorer prognosis with more complicated and longer hospital stay compared to healthy people and need special attention as they will form a large percent of burn center and hospital admission in the future.

Diabetes mellitus is a chronic disease that has many complications, among which is the effect of diabetes on the blood vessels leading to damage, narrowing and/or blockage of the blood vessels, leading to peripheral vascular disease (PVD) that results in the alteration of blood perfusion and subsequent reduction in the oxygen and nutritional delivery to the tissues which will affect wound healing.

Diabetes can also affect the nerves leading to nerve damage (diabetic peripheral neuropathy); nerves affected by the disease are usually responsible for temperature, pressure, texture and pain sensation. The nerves of the lower legs and feet when affected can lead to insensitivity to temperature and pain in the legs and feet and patients may experience numbness and tingling sensation in these areas.

Diabetic patients with neuropathy have an increased risk of burn injuries. These burns may happen from soaking the feet in hot water, heating pads, walking on hot surface, and contact with a warming device such as heaters. Because of the impaired sensation of the feet in these patients, they may sustain a burn injury without being aware of it. These patients have poor wound healing due to the effect of diabetes on the nerves and blood vessels and the increased risk of wound infection in diabetic patients.

Burns in diabetic patients even when they are minor may lead to ulceration of the wound, serious infection and even amputation of the limb. Therefore preventing and early recognition of burns in diabetic patients is very important.

Prevention:

  1. Maintain a proper glucose level.
  2. Test water temperature before going into the bath with a sensitive body part such as the elbow.
  3. Avoid using a contact warming device such as a heater.
  4. Inspect your feet and toes every day for infection, burns, bruises and ulcer.
  5. Avoid walking barefoot even inside the house.
  6. Avoid using heating pads.
  7. Don’t wear tight or loose shoes; wear a well fit shoe with a soft, thick socks.
  8. Contact your doctor if there is an infection, an ulcer or a burn which is not healing well.
  9. Make sure your feet are examined during each doctor’s visit.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Bedsores or bed ulcers are areas of ulcerated or damaged skin that happens when the skin and underlying tissue over a bony prominence is compressed between that bony prominence and an external surface for a prolonged period of time, the unrelieved pressure on the skin and underlying tissue will lead to compression of the blood supply to that area. As a result of the decreased blood supply and oxygen the skin begins to die forming an ulcer. Friction of the skin created by the body sliding over a bed sheet, etc contributes also to the skin injury and the formation of ulcer, too much moister such as sweat and urine may also contribute to the formation of an ulcer. Although pressure ulcers can happen anywhere in the body, the hips, heals and buttocks are common sites.

Risk factors:

  • Persons at a high risk of developing pressure ulcers are those who are immobile due to an injury or an illness such as third  degree burns. Any injury or illness that leads to immobility or causes the patient to be bedridden for a long time will increase the risk of pressure ulcers.
  • Persons who have decreased or absence sensation due an injury or illness are also at risk.
  • Older persons have a higher risk because of their increased incidence of debilitating diseases and the thinning and fragility of their skin.

Clinical features:

Bedsores are classified into four stages depending on the severity

Stage 1: The skin is intact with pink or red coloration that doesn’t blanch with pressure; skin may be itchy, painful and may feel worm to the touch.

Stage 2: Partial thickness skin loss. There will be blistering or an open sore (ulcer), the area is red, painful and swollen, dead tissue may be present.

Stage 3: Full thickness skin loss, crater like ulcers are present that extends to the subcutaneous tissue.

Stage 4: Full thickness skin loss with the involvement of muscle, tendon, bone or joint.

Treatment:

  1. Treatment of bedsore starts by identifying and managing the underlying cause.
  2. Relieving pressure by changing position and using pressure relieving mattresses or cushion is important for healing.
  3. The treatment of a bedsore depends on the stage of the ulcer. When the skin is intact, removing the pressure will allow the pressure ulcer to heal.
  4. Pain medication may be used when the bedsore is painful.
  5. When the skin is broken, the protective barrier is no longer present leading to an increased risk of infection; antibiotics may be used when there are signs of infection.
  6. When dead tissue is present, it should be removed by debridement as dead tissue increases the risk of infection and interferes with healing.
  7. Cleansing the wound and dressing changes are important in decreasing infection.
  8. Special dressings can be used to promote healing of bedsores.
  9. Deep ulcers especially those beyond stage 2 may be difficult to treat and if they are deep, they may require surgical repair.
  10. Transplanting healthy skin to the affect area may be needed in some cases (Skin graft)
  11. Topical negative pressure therapy (suction) may be used in some cases.
  12. Your health care provider will decide what the best treatment options for you are and will assess the healing progress.
  13. Healing time varies from days to months and some may not heal especially when there is an associated illness.

Prevention:

  1. Frequent changes in the patient’s position, turning them every 2 hours in bed and every 30 to 60 minutes in a chair.
  2. Checking the skin every day for redness, bruises and blisters and documenting the findings.
  3. Keep the skin clean and avoiding dryness by using moisturizers.
  4. Adequate fluids, protein, vitamins and minerals should be encouraged and correction of malnutrition when present.
  5. Using foam cushions or pads or other supporting devices on the beds and chairs, ask your healthcare provider about the one that is suitable for you. Donut shaped cushions are not recommended as they may interfere with the flow of blood.

Complication:

  1. Septicemia which is spread of infection from an infected ulcer to the blood.
  2. Bone infection (osteomyelitis) from an infected ulcer.
  3. Limb amputation in severe cases.
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Compartment Syndrome:

A compartment is defined as a closed space of nerves, muscle tissue and blood vessels. This space is surrounded by fascia (thick layer of tissue) that doesn’t stretch. When the pressure inside the compartment increases from any cause and if the pressure increases substantially, this may lead to the compression of the nerves, blood vessels and muscles inside the compartment. The result may be impaired blood flow and reduced oxygenation that may result in muscle and nerve damage. Compartment syndrome most commonly involves the forearm and lower leg although it can occur in other places.

In third degree burns the pressure increases due to fluid retention and edema (swelling) causing compression of muscles, nerves and blood vessels which will lead to ischemia (reduction in blood flow) and necrosis (death) of tissue if not managed quickly.

Clinical features include:

  1. Pain: it is usually severe pain and out of proportion with the injury. The pain doesn’t respond to pain medication and is increased by stretching the muscle group within the compartment.
  2. Alteration or decrease sensation of the skin.
  3. Paleness of the skin.
  4. Weakness and in later stages paralysis of the limb may occur if not treated.
  5. Capillary refill time (the rate at which blood refills empty capillaries) of the digits is prolonged.
  6. Congestion of the digits.

Compartment syndrome is considered a medical emergency that requires immediate surgical treatment. The surgical procedure is called a fasciotomy which is simply done by making a long incision in the fascia to release the pressure building inside.

Seizures

Seizures can happen following third degree burns specially in the first few days following the injury. Seizures may happen due to electrolyte imbalance, low oxygen level in the blood (hyp0xemia) or low level of oxygen in the tissues (hypoxia), infections leading to septicemia and septic shock, the toxic effect of certain medications administrated in burned patients or the accumulation of toxins in the body as a result of poor or malfunction of the kidneys.

Psychological complications:

Burn injuries can be devastating and can affect the patient both physically and emotionally. Children with severe burn injuries may suffer for psychological trauma for a long time such as post traumatic stress disorder (PTSD); they may also suffer bed wetting, nightmares and sleep disturbance. Anxiety, attacks of agitation, panic disorder and depression are also common. Patients may suffer personality issues such as low self esteem and disturbed self image as a result of the scarring and disfigurement caused by the burn injury; this often result in social withdrawn, feeling of worthlessness and loneliness. Psychological therapy play an important role in the healing of patients following burn injuries.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Third degree burns are burns that causes injury to all  layers of the skin (epidermis, dermis and subcutaneous tissue), it may also damage the muscles and bones. These burns are serious and may result in extensive scarring as well as other injuries and limitations. Third degree burns are vulnerable for  many complications, some of which are due to  the burn injury itself while others are due to the reaction of the body during treatment and healing process.

Complications may include:

Burn Infection:

The skin act as the main barrier against infection and when this is lost, the body becomes susceptible for infection by variable pathogens. Infection is one of the most common complications of burn injuries and the risk is more with third degree burns due to the depth of the burn and the wide area involved. When infection is severe, septicemia and septic shock may result due to the spread of infection to the blood stream which is a serious condition that may lead to multi-organ failure and death therefore, urgent treatment is needed.

Fluid loss and hypovolemia:

Hypovolemia is defined as a decrease in the volume of blood or fluids in the body. When the blood vessels are damaged as a result of a burn injury, their permeability to fluid increase leading to excessive fluid loss leading to a decrease in the blood volume of the patient. In addition, one of the functions of skin is to act as an insulation barrier to regulate the insensible fluid loss from the body, when this is lost in burn injury, the rate fluid loss and evaporation increases leading to hypovolemia. Hypovolemic shock and electrolyte imbalance may also happen due to excessive fluid loss, therefore fluid and electrolyte replacement are one of the main steps of burn management.

Deep vein thrombosis (DVT) and pulmonary embolism:

Patients who sustain third degree burns may need to stay bedridden for a long period of time. Lower limb muscle contraction during movement and walking act as a pump pushing the blood from the lower extremities back to the heart against gravity. Extended periods of bed rest increases the risk of developing blood clots as immobility can interfere with circulation of blood making it slower and causing the blood to collect in the veins forming blood clots. When these clots lodge in the veins of the limbs, it can cause DVT which is a serious condition that need to be treated as it may lead to pulmonary embolism and death if left untreated. It is important to start ambulating as soon as possible as the longer the patient is bedridden, the higher the risk of developing blood clots and DVT.  Using blood thinners and pneumatic compression devices (directed by the treating team) can reduce the risk of developing blood clots.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.