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Lithium reduces the intensity and duration of mood swings and full effect may require 6-24 months cheap alesse 0.18 mg on line birth control kills babies. Two manic episodes or one manic and two depressive episodes seem a reasonable guideline buy discount alesse 0.18 mg on line birth control effectiveness chart, although the length of time 3472 between episodes and the social consequences of attacks are equally important order alesse 0.18mg without prescription birth control cost. Family planning advice and a booklet outlining the basic facts of lithium therapy and its side and toxic effects are other important considerations discount alesse 0.18 mg without prescription birth control gif. Serum lithium levels are usually tested weekly for 3-4 weeks and 3-monthly thereafter, and thyroid and renal functioning are tested twice a year over the long term, or more often if indicated. Lithium should not be stopped in cases of relapse of bipolar or unipolar affective 3473 disorder. Withdrawal of lithium, especially sudden withdrawal, is associated with a high relapse rate, increased number of inpatient days, increased doses of antipsychotic drugs, and, according to some but not all researchers, a withdrawal syndrome. Some patients may simply become irritable and emotionally labile on abrupt withdrawal from lithium. Post ea (1992) contended that if effective lithium prophylaxis is stopped it may not work a second time although this argument is not convincing. Page ea (1987) investigated the fate of unipolar and bipolar affective disorder patients most of whom had taken lithium for at least 13 years. At follow-up 49% experienced a complete remission, 41% had a partial but significant response and 10% had no response to lithium. No specific individual or illness factor was found to correlate with a favourable outcome, and no correlation was discovered between the average serum lithium level and outcome. In a retrospective study of manic patients, Golney and Spence(1986) found a favourable response to be associated with bipolar status with a family history of depression or mania, unipolar status with endogenous illness, and with the absence of significant disturbance of personality. In the same study the response to lithium over 6 months in unipolar illness and over the first year in bipolar illness was strongly associated with long-term response. According to Prien and Gelenberg (1989), the average failure rate for lithium in preventive treatment studies was 33%, where a failure was defined as episodes needing admission or the addition of other drugs. Lithium therapy may reduce the frequency of repeated aggression or self-mutilation in the mentally handicapped, psychotics, or delinquent subjects. There are no special features in such cases that would help one to predict a useful response. Amiloride reduces lithium-induced polyuria without affecting lithium or potassium levels. Adding hydrochlorothiazide (50 mg/day) to amiloride increases the risk of toxicity. Other possible interventions include dose reduction, single daily dosing (trough assists renal recovery), and potassium supplements. Depending on individual circumstances the present author usually starts patients on an average dose of 800 mg lithium carbonate at night, further dose changes being dictated by clinical state and serum levels. Short-acting preparations may cause nausea, whereas delayed-release preparations may be more likely to induce diarrhoea. Hullin of Leeds has shown that lower levels are effective but high relapse rates occur below 0. Some factors increasing the likelihood of lithium intoxication Overdose High prescribed dose Renal disease Excess sweating Dehydration Hyponatraemia Vomiting 3477 Diarrhoea Tropical heat Sauna Infection Fever 3478 Trauma/surgery 3479 Diuretics Indomethacin 3480 Tetracyclines 3474 The patient should drink non-sweet fluids to compensate. Potassium-sparing and loop diuretics are relatively less likely to raise lithium levels. When treating a hypertensive patient who is taking lithium, consider a beta-blocker or clonidine, but avoid thiazide diuretics. Diclofenac, indomethacin, metronidazole, spectinomycin, ibuprofen and piroxicam have been reported to raise the plasma lithium concentration. Some factors that give a falsely low lithium concentration in tissues include >13 hours 3485 since last dose ingested , brain damage, and phenytoin. Lithium intoxication usually develops over days or more quickly in the case of overdose. Lithium should be stopped for a few days during an intercurrent illness or suspected toxicity. Lithium intoxication has to be a clinical diagnosis because it results from high intracellular lithium concentrations, which may not be reflected in serum levels. Intoxication may lead to full recovery, death, persistent renal symptoms, spasticity, cognitive impairment, or permanent cerebellar damage with loss of Purkinje cells. Management of intoxication includes early diagnosis and treatment of overdose (initially stomach washout and activated charcoal left in 3489 3490 stomach ). This is explained by the relatively slow equilibration between intracellular (incl. Because lithium is readily dialyzable (and not excreted by kidneys in dialysis patients - it is only removed at dialysis), it is therefore given (300-600 mg lithium) to patients – orally or into dialysate - on renal dialysis who need lithium for their affective disorder after their dialysis sessions. Serum levels are measured some 3-4 hours after dialysis because serum levels may rise following dialysis due to equilibration with the tissues. Contraindications to lithium therapy (vary with circumstances) Patient unreliability 3492 Early pregnancy Elective surgery Uncompensated renal disease 3493 Severe cardiac disease Diuretic therapy Lithium may cause acute tubular necrosis. Lithium should not be given to patients with 3495 myasthenia gravis , Addison’s disease or untreated hypothyroidism. Glomerular sclerosis, tubular atrophy, and interstitial fibrosis may occur in lithium treated patients and animals. However there is some evidence that the incidence is not particularly high 3496 when function is considered. Many authors have commented on the non-likelihood of death from lithium-induced nephropathy. Lithium can be used during maintenance haemodialysis where it has been given after dialysis in doses of 300-600 ms/day. Some increase in serum creatinine concentrations and a lowering of maximum concentration capacity in lithium-treated patients over time is neither uncommon nor worrying. Serum creatinine may be normal in the elderly despite impaired renal function because of reduced muscle mass. A recent myocardial infarction is a relative contraindication because of the risk of arrhythmias. Cyclosporine can increase lithium serum levels by decreasing its excretion, thus necessitating a lowering of the lithium dosage. After a few years on lithium some 3498 authors have found a 3-50% incidence of goitre (larger size on ultrasound in smokers) 3499 and 4-21% incidence of hypothyroidism. Pre-existing anti-thyroid antibodies or a family history of thyroid disease increase the chances of developing lithium-related hypothyroidism. Hypothyroidism and euthyroid goitre are managed with thyroxine 3500 supplementation and the continued administration of lithium. Whether uncommon cases of hyperthyroidism can be attributed to lithium is difficult to say. Rosser (1976) described the emergence of thyrotoxicosis after lithium was stopped and Byrne and Delaney (1993) reported a case where thyroid ophthalmopathy regressed after stopping lithium. The mechanism appears to be stimulation of granulocyte-stimulating factor and interleukin-6. It is suggested that lithium be withheld on chemotherapy days or during cranial (but not other) radiation in cancer patients. Side effects include polyuria, thirst, nausea (take after food), loose stools, metallic taste, 3502 3503 fine tremor, weight gain , Parkinsonism , fatigue, and delayed reaction time whilst 3504 driving.

Heart block: This maybe present in the acute stage generic 0.18 mg alesse with amex birth control kellymom, and maybe first degree purchase 0.18 mg alesse fast delivery birth control generic brands, second degree or complete effective 0.18mg alesse birth control pills vs iud. Recurrence of chest pain alesse 0.18 mg fast delivery birth control for women lenceria, either at rest or on mild exertion could be due to post infarction angina or re-infarction. Treatment is usually by increasing antianginal therapy – nitrates, beta blockers and calcium channel antagonists. Post infarction angina is an indication for early coronary angiography, to determine if re-occlusion has occurred, and to exclude other critically narrowed coronary artery branches. Acute myocardial ischaemia 141 Handbook of Critical Care Medicine Right ventricular infarction: Patients present in the acute stage with hypotension, congested neck veins, and clear lungs. Low blood pressure is due to reduced right ventricular contractility resulting in reduced left sided filling pressures. Careful administration of fluids will normalise the blood pressure; inotropes are sometimes needed. Papillary muscle rupture is a serious complication, presenting suddenly with pulmonary oedema and hypotension. Intra-aortic balloon pumping may be necessary; surgical repair is mandatory, without which the mortality is high. Cardiac tamIt is more common in the elderly, and in patients who did not receive thrombolyis. Pleuritic chest pain, pericardial friction rub, fever, leukocytosis, and sometimes pleural effusion or pulmonary infiltrates are seen. Treat with inotropes (dobutamine, Prognosis significantly worse than I adrenaline) and diuretics and nitrates. Definition: The rapid onset of symptoms and signs secondary to abnormal cardiac function. Acute heart failure is a dangerous and life threatening condition, which requires early recognition and aggressive treatment. The patient will be tachypnoeic, and will have bilateral fine crackles, and may have a wheeze. Management Monitoring – connect the patient to a continuous cardiac monitor and pulse oxymeter. Airway: clear secretions, open the airway (see section on airway management), if necessary use an oral airway. Breathing: dyspnoea and tachypnoea are the cardinal features of acute heart failure. Circulation: if the patient is hypotensive, fluid resuscitation and inotropes may be necessary, bearing in mind that fluid resuscitation may worsen pulmonary oedema. It is elevated in systolic and diastolic failure, but not in other causes of acute dyspnoea. Even if in doubt of the diagnosis, if the patient’s blood pressure is stable, diuretics will do little harm. Doses up to 400mg of frusemide maybe necessary in severe left ventricular failure. Frusemide can be given as a continuous infusion of 10-20 mg/hour, with dose reduction according to response. These are: Upper lobe diversion of blood Perihilar congestion Kerley B lines Pleural effusion Afterload reduction: If the blood pressure is high, it will increase the load on the heart and worsen heart failure. Sublingual and intravenous nitrates are used to lower systemic vascular resistance and improve heart failure. It acts by causing pulmonary venodilatation, and also by alleviating anxiety and calming the patient. It also improves cardiac output by reducing ventricular transmural pressure and thereby reducing afterload. Fluid therapy: It is important to ensure that circulating volume is adequate, as this will affect preload. Failure to optimise fluid volume will result in a further drop in blood pressure with diuretics. Correction of arrhythmias: Tachyarrhythmias compromise cardiac output and worsen heart failure. When the heart rate increases, diastole shortens more than systole, resulting in reduced ventricular filling time, and hence reduced preload. Atrial fibrillation, in addition, results in further reduction in ventricular filling because the atrial ‘kick’ is lost. Amiodarone is a useful agent to control tachyarrhythmias, but can drop the blood pressure. Temporary cardiac pacing maybe required to improve cardiac output in severe bradycardia. The different types of heart failure: Left ventricular vs right ventricular failure- isolated left ventricular failure is seen most commonly following acute ischaemia. Right ventricular failure can occur as a consequence of longstanding left heart failure, or can occur due Heart failure 147 Handbook of Critical Care Medicine to chronic lung disease (cor pulmonale) or primary pulmonary hypertension. In chronic congestive cardiac failure, features of both right and left heart failure are present. Systolic vs diastolic heart failure – in the majority of cases, heart failure is due to reduced contractility of the myocardium, due to ischaemic damage. This results in reduced left ventricular ejection fraction during systole, and is referred to as systolic heart failure. Often however, there is reduced relaxation of the heart during diastole, especially if left ventricular hypertrophy is present. As a result, left ventricular filling is impaired, resulting in congestive heart failure. Clinically, the patient presents with all the clinical features of heart failure, but on echocardiography his left ventricular ejection fraction is normal. Forward vs backward failure – this describes whether the predominant features are of forward flow (low cardiac output states resulting in hypotension and poor tissue perfusion) or backward congestion (resulting in pulmonary oedema and other congestive features). Low output vs high output failure – in most instances of heart failure, the cardiac output is low. In certain conditions however, there is low peripheral resistance and a hyperdynamic circulation. The cardiac output is high, although the increased output is inadequate to meet the requirements. Thyrotoxicosis, pregnancy, Beri-Beri, arteriovenous malformations, Paget’s disease are examples of high output failure. In septic shock, the cardiac output is normal or high, in a sense similar to high output failure. Heart failure 148 Handbook of Critical Care Medicine Treating the patient with resistant heart failure If the patient is in cardiogenic shock, cardiac inotropes such as dobutamine and adrenaline can be tried. However, these increase myocardial oxygen consumption, and if ischaemic heart disease is the cause, can make things worse. The balloon inflates during diastole to improve coronary and cerebral blood flow and deflates immediately prior to systole resulting in a reduction in afterload. It is not a long term treatment, and should be used only in situations where the underlying cause can be corrected, such as valve repair or coronary revascularisation. Once the patient is stable, consider the following issues: Was heart failure due to acute coronary syndrome? Was the heart failure a de novo occurrence, or was it on the background of chronic heart disease? Heart failure 149 Handbook of Critical Care Medicine x Beta blockers – improve long term survival. When anticoagulation is indicated, initially heparin or low molecular weight heparin is given, and long term anticoagulation is obtained with warfarin. Certain rhythm abnormalities such as ventricular fibrillation or ventricular tachycardia require emergency treatment.

Zola discount 0.18 mg alesse mastercard birth control pills 853, a sociologist at Brandeis generic 0.18 mg alesse overnight delivery birth control not working, argues best 0.18 mg alesse birth control pills chart, “T h e list of daily activities to which health can be related is ever growing and with the current operating perspective of medicine seems infinitely expandable cheap alesse 0.18 mg amex birth control patch xulane reviews. And as indi­ viduals fail to meet society’s standards, their deviance is translated into illness. David Mechanic, another medical sociologist, characterizes the “medicalization” o f certain be­ haviors this way: The traditional approach. But even m ore astonishing is the degree to which society has become “medicalized” through drug use. Zola refers to a recent study showing that within a 24 to 36 hour period, from 50 to 80 percent of the adult population in the United States and the United Kingdom takes a prescribed or “medical” drug. But, as Zola argues, another reason why medicine has sought to expand its franchise lies in its recognition that many diseases are caused by behavior that lies beyond its reach. Zola points out that many physicians, for example, feel that a change in diet may be the most effective treat­ m ent for a num ber of cardiovascular disorders and perhaps some cancers. Physicians have had little control over the food preferences of their patients; but this may change. Zola alludes to an article in Time magazine that captures the mood, entitled “T o Save the Heart: Diet by Decree. Medicine should not necessarily be pilloried for seeking to “treat” m ore problems if it possesses the tools to help. Medicine may not be the best agent to treat hum an failings; there may be other and m ore effective approaches. T he expansion of medicine raises a dilemma: As medicine encroaches on m ore of hum an life, it further incapacitates its major ally—the patient—from assuming re­ sponsibility for health. Fragm enta­ tion, specialization, and a divergence between the goals of professionals and clients characterize all professional services today. But what is tragic is not what has happened to the revered professions, but what has happened to us as a result o f professional dominance. In times o f inordinate complex­ ity and stress we have been made a profoundly dependent people. O ur bodies are the cannon fodder of a National and Transnational Considerations 47 reductionist, mechanistic medicine. O ur emotional lives are buffeted by the fear that our behavior will subject us to the ministrations of mental health professionals. And our practi­ cal business and work worlds are increasingly governed by obfuscating legal terminology and practitioners. This has been true w hether medical services have been a respon­ sibility of central governm ent or assumed by local govern­ m ent with measures of private charity. T he twentieth century has seen the “nationalization” of health services in the W estern hem isphere. In some countries, such as Sweden and Great Britain, health services have been nationalized;30 in other countries, such as France, elements of the private sector rem ain. C urrent concerns with allocation of resources and increased mobility and inform ation have begun to internationalize our concepts of health. A lthough other nations have not m atched our gar­ gantuan appetite, it is nevertheless true that the more developed the nation, the m ore likely it is to consume a 48 Medicine: a. U nder such cir­ cumstances, the dem ands of less developed nations for more of the resource “pie” will become more strident. Resolving these dem ands without arm ed conflict will necessitate a reordering of priorities by all nations. Within a few years, it is likely that health services in the United States will absorb 9 percent of gross national prod­ uct; currently, they consume nearly 8 percent,32 a figure topped by some nations. However, it may not be unrealistic to achieve economies o f size through consolidation of elements of delivery systems am ong nations. Individual nations find it difficult to regulate effectively corporate bodies that transcend national boundaries. Thus, increases in transnational activity will inevitably lead to dem ands on the part of multinational corporations for transnational status (but not necessarily regulation). In fact, world organizations may be needed to control the continued developm ent of m ultina­ tional corporations. T he rise o f multinational corporations suggests the need for m ore sophisticated world health organizations, as well. Employees o f multinational corporations, because o f their high mobility, will in effect become m en and women without a country. Historically, health services have been paid for and received in the country o f domicile. T he erosion of domicile may result in the corporate em ployer assuming (or National and Transnational Considerations 49 being compelled to assume) the responsibility for the provi­ sion and financing of medical care services for its peripatetic employees. Finally, with m ore trade, m ore multinational corporate activity, m ore public and quasi-public transnational de­ velopment, and with accelerated dispersal of people throughout the world, the rapid “transmission” of disease agents from country to country is inevitable. U nder such circumstances, a world health organization will have to be established to facilitate international disease control. Health problems do transcend national boundaries, as do many other nagging problems such as air and water pollution, sanitation, and even edu­ cation. In the United States, medical care has reached a degree of sophistication vastly greater than in most other nations, and probably superior to any other country. But m arked disparities exist in the incidence of certain types of cancer am ong populations. For example: • Hepatic cancer is prevalent in Africa and Southeast Asia, Indonesia, Java, and Sumatra. In these countries, hepatic cancer accounts for as much as 80 percent of all cancers recorded. In comparison, in Southeast Asia and in parts of Africa the incidence of stomach cancer is infinitesimal. Little or no lung cancer has been reported in Korea, Ceylon, India, Burma, and Trinidad. Although some o f the differences may be due to lack o f prevention program s, infections are far m ore fre­ quent and m ore severe in passage from the tem perate zone, through the M editerranean, to the Tropics. Diseases such as smallpox and typhoid are found nearly everywhere; diseases such as trachom a, schistosomiasis, yellow fever, and plague are specific to geographic areas. Disparities in disease rates also exist am ong various coun­ tries within the same geographic zones. Poliomyelitis, for example, is m ore prevalent in the tem perate zone, but un­ explained variations in rates of the disease from country to country in that zone have been recorded. In 1949, the cases reported per 100,000 were 413 in Iceland, 37 in Sweden, 14 in England, 2 in Belgium, and 1. In general, the so-called “diseases of civilization” afflict persons in the more highly developed countries such as the United States, whereas the infectious diseases continue to decimate popula­ tions in less developed countries. But the impact of infec­ tious diseases was substantial in the United States some decades ago when the level of developm ent in this country was roughly comparable to that of nations now classified as National and Transnational Considerations 51 underdeveloped. A W orld Health Organization survey, con­ ducted to elicit expressions of m ajor health problems for the year 1963-64 and answered by 147 governm ents listing 46 problems, showed that the problems varied according to regions. Figure 2 depicts the regional profiles of health problems and, by implication, their relationship to develop­ mental stages. T he varieties of diseases and the variation in disease rates are argum ents for the m aintenance of domestic medical care systems. Countries must tailor the provision o f medical care services to the needs of their populations. We will fail to understand the variations in dis­ ease both within countries (since countries are at various developm ental stages) and am ong countries if a world health viewpoint is not encouraged. A lthough medical care services are m uch alike, differences exist between delivery system arrangem ents am ong various countries. T he differences are great between highly developed countries with sophisticated delivery systems and less developed countries with rudim en­ tary systems.

Insertion of a chest drain may ensure patency where transfer times If this occurs the dressing should be lifted to allow venting and are prolonged (Figure 7 buy 0.18 mg alesse visa birth control korea. Chest drain insertion in conscious if this manoeuvre fails decompression with a needle or incision patients requires infiltration of local anaesthetic prior to incision should be performed cheap alesse 0.18mg otc birth control for women zip up hoodies. Massive haemothorax Massive haemothorax is defined as a collection of more than Open pneumothorax 1500 ml of blood in the pleural cavity and occurs most commonly An open pneumothorax is an open chest wound that commu- as a result of a vascular injury within the lung parenchyma buy generic alesse 0.18mg online birth control pills 1st month, pul- nicates with the pleural cavity (Figure 7 alesse 0.18mg overnight delivery birth control pills oregon. Unexplained hypovolaemic shock Breathing Assessment and Management 33 Chest Drain Insertion Technique Portex® Ambulatory Chest Drain Set 1. Prepare equipment • Equipment as for simple thoracostomy • Chest drain - Adult: 28-32Fr Paed: (Age + 16)Fr • Drainage bag with flutter valve (primed) • Syringe for priming flutter valve • Suture 2. Insert chest drain into the incision using the finger as a guide +/- blunt introducer • Guide the tube anteriorly and apically • Ensure all drainage holes lie within the chest 4. Confirm flutter valve patency • Free drainage of fluid from chest into bag • Get patient to cough and valve leaflets should part Figure 7. Suture drain to skin securely (Source: Portex Ambulatory Chest Drain Set, courtesy 7. Paradoxical chest movement, hypoxia and respiratory distress characterize a patient in combination with unilateral (or occasionally bilateral) chest dull- with a flail chest. Management of High-flow oxygen (15 L/min) and sufficient analgesia for painless hypovolaemia takes priority. Where transfer times are short, rapid spontaneous breathing is often sufficient field treatment of this movement to a trauma centre with supplemental oxygen and care- condition. Large flail segments with resistant hypoxia may require fully titrated intravenous fluids en route is required. Other chest injuries Several other thoracic injuries may present in the prehospital phase Flail chest (Box 7. If suspected, continued resuscitative care should be pro- A flail chest is defined as the fracture of two or more adjacent ribs vided and the injury communicated to the receiving trauma team. A small flail segment may be difficult Life-threatening breathing problems: to identify because of local muscle spasm and splinting; however, medical large flail segments are usually obvious. The flail segment moves paradoxically inwards during inspiration and outwards during Acutebreathlessnessisacommonmedicalemergencyinbothadults expiration (Figure 7. Tidal volume is reduced and ventilation and children, and the differential diagnosis is broad (Box 7. Emerg Med Clin North Myocardial Blunt chest injury Supplemental Oxygen Am 2008: 869–279. End tidal carbon dioxide monitoring in prehospital fracture) and retrieval medicine: a review. Does prehospital ultrasound improve Cardiogenic shock treatment of the trauma patient? Eur J Emerg Med Simple pneu- Penetrating or blunt Supplemental Oxygen 2010;17:249–253. The Hypoxaemia Monitor for tension prehospital management of chest injuries: a consensus statement. Faculty Ipsilateral ↓ air entry Prophylactic thoracostomy of Prehospital Care, Royal College of Surgeons of Edinburgh. Prehospital pleural decompression and chest symptoms tube placement after blunt trauma: A systematic review. Haemorrhage Ischaemia Dehydration Valve Dysfunction Arrhythmia Introduction Sepsis The early identification and aggressive management of shock is an Cardiogenic important component in the resuscitation of the seriously ill or Poisoning Anaphylaxis e. Shock is defined as failure of the circulatory sys- tem leading to inadequate organ perfusion and tissue oxygenation. Inadequate perfusion may result from failure of the pump (the Neurogenic Shock heart), inadequate circulating blood volume (absolute or relative) or obstruction to the flow of blood through the circulatory system. In practice there is often considerable overlap, with dif- Distributive ferent types of shock co-existing in the same patient. Whatever the mechanism, inadequate perfusion leads to anaerobic metabolism, Figure 8. Hypovolaemic shock Hypovolaemia in trauma Hypovolaemic shock secondary to uncontrolled haemorrhage is by Hypovolaemic shock is shock resulting from inadequate circulating far the most common shock scenario seen in prehospital practice. Fluid may also be lost into body tissues or compartments these areas, the body’s compensatory mechanisms sacrifice the per- (socalled‘thirdspacing’),particularlyaftersignificanttissuetrauma fusion of less critical areas such as the skin and gastrointestinal tract. Anaerobic metabolism in these areas causes progressive systemic lactic acidosis and limit endogenous heat production promoting hypothermia. The circulating volume is insufficient to fill the dilated vascular space resulting in a state of relative hypovolaemia and systemic hypop- erfusion. Septic, anaphylactic and neurogenic shock are the most common subtypes of distributive shock. In anaphylactic shock vasodilatation results from the antigen-induced systemic release of histamine and vasoac- tive mediators from mast cells. Traumatic injury to tissue and subsequent poor perfusion acti- vatesanticoagulantandfibrinolyticpathwayswithinthecoagulation cascade. Common causes include cardiac tamponade, tension after injury will therefore be the most stable and effective clot and pneumothorax and massive pulmonary embolism. Cardiogenic shock is shock resulting from myocardial dysfunction in the presence of adequate left ventricular filling pressures. Myocar- Assessment of the circulation dial dysfunction may be the result of arrhythmia, myocardial infarction, ischaemia, contusion or underlying cardiomyopathy. Accurately assessing whether a patient is shocked is one of the most Without intervention myocardial dysfunction leads to a progres- difficult skills to acquire in prehospital emergency medicine. Lack sive reduction in cardiac output, reduced coronary perfusion and of monitoring, poor lighting, an austere environment, unknown worsening ischaemia (Figure 8. The initial circulation assessment process aims to identify signs of compensated and decompensated shock (Figure 8. Circulation Assessment and Management 37 Compensated shock notoriously inaccurate in low flow states and should be interpreted Hypovolaemic, cardiogenic and obstructive shock states are all in combination with the other clinical signs. Inanattempttomaintain The speed at which decompensation occurs will depend partly cardiac output the body increases the heart rate. Certain other factors can affect the response by the presence of pale, cold, clammy skin, prolonged capillary to shock (Box 8. A high index of suspicion is essential in these refill time and a reduced pulse pressure (palpable or measured). This has little effect on the actual oxygen content of the blood but does serve as an important marker Box 8. In these early stages cardiac output and blood pressure are maintained and the shock is considered Patient Group Caution compensated. It is important to recognize that although the systolic Elderly The elderly have less physiological reserve and will blood pressure is maintained, perfusion of the peripheral tissues is decompensate earlier impaired and continued lactate formation and progressive systemic Drugs Drugs such as Beta blockers will limit the ability for acidosis result. Pathological vasodilatation Pacemakers A pacemaker with a fixed rate will limit the ability may prevent compensatory vasoconstriction, resulting in flushed for the patient to mount a compensatory and warm peripheries in the early stages. Tachycardia may also be tachycardia and lead to earlier decompensation absent in neurogenic shock due to unopposed vagal tone. The Athlete The resting heart rate of an athlete may be in the By assessing the respiratory rate, feeling the pulse rate and region of 50bpm. This should be taken into strength, and by looking and feeling the patient’s peripheries, the account when assessing for relative tachycardia prehospital practitioner can rapidly assess for signs of compensated Pregnancy In pregnancy the normal physiological changes of shock (Box 8. Delayed capillary refill Penetrating A vagal response (relative bradycardia) stimulated Pale / cool / clammy peripheries Reduced pulse pressure trauma by intra-peritoneal blood may lead to Poor SpO2 trace. Decompensated shock A point will be reached at which the compensatory mechanisms Aids to identifying shock fail to compensate for the reduction in cardiac output or systemic A lack of plethysmography trace may reinforce suspicions of poor vascular resistance. At this point decompensation will occur and peripheral perfusion; however, hypothermia may have the same perfusion to the vital organs becomes compromised.

Institute of Medi- pregnant patients regarding diet and nutri- Physicians must view pregnant patients (and ing of fruits discount alesse 0.18mg with amex birth control natural method, vegetables buy cheap alesse 0.18 mg birth control 7 7 7, meat discount alesse 0.18mg overnight delivery birth control pills not working, fsh generic 0.18mg alesse mastercard birth control mood swings, grains, fat, cine. This includes advising them to select high quality multivita- Iron, Manganese, Molybdenum, Nickel, Silicon, particularly true in the literature relating to nuclear households of one or two, the neces- min, mineral and micronutrient supplements Vanadium, and Zinc. Also, it is important cipal resource for the ‘Essential maternal/fetal daily-requirements-for-teenagers-and-active- ing one’s micronutrients in pregnancy through to remember that food choices often are based building blocks’ section of this chapter – and females diet requires planning, patience and know- on inherent tastes, that tastes are at least to are particularly grateful to Professor Wolfgang 10. World Association of Perinatal Medicine, the ledge about foods, in particular nutrient-dense some degree related to culture, and that cul- Holzgreve for his guidance. If one is not inher- roles of long-chain polyunsaturated fatty acids alone pregnant women: leafy vegetables such ently biased against supplementation, it is not 1. Dietary Reference Intakes: Macronutri- current knowledge and consensus recommen- as chard, collard greens, kale and mustard diffcult to envision circumstances whereby ents. Lan- assessment, prevention and control, a guide for pro- favin, Niacin, Vitamin B6, Folate, Vitamin B12, tial: required diteary intake and consequences cet 1991;338:131–7 gramme managers. Am J Clin Nutr versus lymphocyte subsets and markers of dis- Suppl):S101–11 2006;64:15–30 2000;71:179S–88S ease progression and infammatory response 81. J R increases (n-3) fatty acid status and alters Biol Trace Elem Res 1997;56:31–41 2004;134:3319–26 Soc Med 2008;101:282–9 selected risk factors for heart disease in veg- 69. A as to whether to continue or initiate a new comparison of therapeutic drug usage in preg- medication in an open, supportive and infor- nancy across Europe documented that 64% mative manner. Most conditions that require of women used at least one drug during their medication involve drug exposures at low lev- pregnancy3, while, in France, pregnant women els of relative and absolute risks. Whereas it potential impact of the condition and its vari- is plausible to collect data regarding the usage ous treatments on maternal and fetal health; of medications in the preconception period, establishing effective treatment for chronic it would not be wrong to imagine that such conditions before conception; and counsel- usage is higher than the rates that have been ing women to avoid the use of non-essential documented in pregnancy. Table 1 Preconceptional counseling on the use of describes simple strategies for prescribing medications is of importance, as the con- medication preconception and during preg- sumption of medications is on the rise, new nancy. In used to determine possible detrimental repro- contrast, the embryonic period (implantation Avoid multiple medications if possible and choose those that are ‘safe’ (anticonvulsants, antihyperten- ductive harm. Although such studies may be to 8th week of gestation) involves organogen- sives) and in the smallest dose possible helpful, especially if fndings indicate no addi- esis and encompasses the most critical time Determine what is the best method to monitor therapy (asthma: peak fow meters; hypertension: por- tional risk, their results do not reliably predict with respect to structural malformations. Whereas specifc harmful effects relate to the The healthiest mother is most likely to deliver the healthiest infant timing and duration of drug exposure during Focus on the underlying disorder, not on the drug alone, to explain any additional risk to the fetus (hy- this relatively brief but critical time of devel- pertension and fetal growth restriction, seizures and childhood seizures, systemic lupus and fetal growth Pharmacokinetics of drugs in pregnancy opment, information in humans is minimal or restriction) Only a few drugs are clearly linked with specifc birth defects (phenytoin, warfarin, alcohol, methotrexate, inconsistent regarding long-term effects, such The physiological changes during pregnancy as learning or behavior problems (functional diethystilbestrol, cis retinoic acid, valproic acid, carbamazepine) exert a marked impact on drug pharmacoki- teratogenesis) that may result from chronic Experience with frst trimester exposure for any drug is often too limited in humans to be considered netics and hence established therapeutic rang- prenatal exposure to given medications. As the placenta essen- contraindicated in pregnancy (category X) is possibility of fetal harm appears remote tially acts as a lipid barrier between the mater- listed in Table 3. B Animal studies do not indicate a risk to the fetus and there are no controlled human nal and fetal circulations and drugs cross it by studies, or animal studies do show an adverse effect on the fetus but well controlled passive diffusion, transfer of drugs to the fetus studies in pregnant women have failed to demonstrate a risk to the fetus is unavoidable. General anesthetics D Positive evidence of human fetal risk exists, but benefts in certain (for example, life-threaten- ing or serious diseases for which safer drugs cannot be used or are ineffective) may make use Intravenous anesthetics induce anesthesia of the drug acceptable despite its risks Human teratogenesis rapidly; common examples are thiopentone X Studies in animals or humans have demonstrated fetal abnormalities or there is evidence of and propofol, though the latter has not been fetal risk based on human experience, or both, and the risk clearly outweighs any possible Teratogenesis is defned as structural or func- used during the frst and second trimesters beneft tional dysgenesis of the fetal organs. Lack of understanding of the Commonly used inhalation anesthetics for products developed to treat conditions full and exact mechanisms of teratogenicity include halothane and nitric oxide. Halo- Safety information data specifc to pregnancy such as oxytocics and/ makes it diffcult to predict, on pharmacologi- thane can induce hepatotoxicity, and because or cervical ripening agents, human data on the cal grounds, that a given drug will produce of its property of relaxing the smooth uter- The safety and effcacy of drugs at a given dos- proper dosage and frequency of administration congenital malformations. Milk concentrations are Table 3 Examples of contraindicated drugs and their known adverse effects on the developing human genital defects, but other reasons, including roughly 40–60% of maternal serum levels. In an investigation infant was attributed to the mother’s sul- Drugs First-trimester fetal effects Second- and third-trimester of 1427 malformed newborns compared with fasalazine therapy (3g/day). Immunosuppressants Embryopathy Use of codeine during labor produces neona- Doxycycline Effect on bone growth Various abnormalities ranging from karyo- tal respiratory depression to the same degree I-131 Fetal thyroid development, typing abnormalities to multiple structural as other narcotic analgesics. It is also used in phosphamide during the second trimester, the Tetracycline None known Staining of teeth familial Mediterranean fever, Behcet’s disease period of neuroblast multiplication, have not Thalidomide Limb reduction (gastrointestinal/ and amyloidosis. To lower the risk of Praziquantel is not a teratogen in animals, but up is required to exclude subtle cartilage and hemorrhagic disease of the newborn, vitamin there are few human data. The major abnor- treatment courses may often need to be pre- Except for eighth cranial nerve damage, no nytoin, carbamazepine and valproic acid, are malities produced by anticonvulsants are neu- scribed. Because of this potential toxicity, the reports of congenital defects caused by strep- considered safe for use during breastfeeding; ral tube, orofacial and congenital heart defects. The Collaborative however, observation for adverse effects such use of praziquantel during pregnancy should Neural tube defects are mainly caused by sodi- Perinatal Project6 monitored 50,282 mother- as drowsiness is recommended for women be reserved for those cases in which the para- um valproate (1–2%) and carbamazepine (0. In neither group was evidence found to sparse regarding the long-term effects of new- and postnatal growth restriction, motor or suggest a relationship to large categories of er antiepileptic drugs on cognition and behav- Antibacterials: betalactam drugs, mental defciency, short nose with broad nasal major or minor malformations or to individ- ior when used in pregnancy and lactation. Aminoglycoside antibiotics have drugs, antituberculosis drugs, mus, epicanthus, wide fontanelles, low-set or no detectable teratogenic risk for structural antifungal drugs and antiviral drugs abnormally formed ears, limb deformities, nail defects. This broad spectrum antibiotic crosses Primidone produces abnormalities similar to Chloramphenicol the placenta, chelates calcium and is deposited those produced by phenytoin. The risk for any single drug is about 6–7% Chloramphenicol should be avoided in late thic agent effective in the treatment of ascaria- The effects on bone are minimal, but discolor- (i. The syndrome usually starts 2–9 a risk of 15%, and for those taking a combina- rats, and is therefore not recommended for use ing of the permanent teeth is most likely when days after therapy is begun and causes vom- tion of valproate, carbamazepine and phenyto- during pregnancy. Its use in pregnancy 10 times the recommended dose of 400μg/ The observation of limb reduction defects at should be confned to life-threatening condi- day for normal pregnant woman. A recent study examining the effect of Nitrofurantoin er anticonvulsants, it is diffcult to ascertain albendazole during pregnancy is not recom- intrauterine exposure to quinolones suggested the teratogenic risk of these agents in isola- mended. Two study group infants Vancomycin is a bactericidal antibiotic with a had anomalies (tetralogy of Fallot and con- The adrenal cortex synthesizes two classes inhibits placental microsomal aromatase and fetal ototoxic effect. Based on these data, the coids and mineralocorticoids) having 21 car- in some pregnant women without complica- synthesis in bacterial cytoplasmic membranes. Except Antiprotozoal drugs: antiamebic in patients receiving replacement therapy for and antimalarial drugs Quinine adrenal insuffciency, glucocorticoids are nei- Trimethoprim inhibits the reduction of dihy- ther specifc nor curative, but rather are con- drofolate to tetrahydrofolate and readily Metronidazole sidered palliative because of their anti-infam- Newer agents have effectively replaced qui- crosses the placenta appearing in measurable nine to treat malaria. The use of trimeth- Most of the published evidence now suggests teratogenic risk can be documented, its use Prednisolone is the biologically active form oprim in pregnancy was associated with an that metronidazole does not present a signif- during pregnancy should be avoided. A study of 229,101 patients was increased with use during the second and has been reported, but the validity and the exposed to prednisolone, prednisone and third months after the last menstrual period clinical signifcance of this fnding is question- Antituberculous drugs methyl-prednisolone during the frst trimes- but not before or after this time. Metronidazole is contraindicated during ter failed to show any association between to avoid trimethoprim in the frst trimester 17 the frst trimester in patients with trichomo- Rifampicin these agents and congenital defects. The American prednisolone was used throughout the preg- administration, if prescribed, must always be No controlled studies have linked the use of nancy, cataracts in the newborn occurred in College of Obstetricians and Gynecologists accompanied with folic acid. All concluded that rifampicin was not are advised to wait at least 4 hours after a dose The use of metronidazole for trichomoniasis a proven teratogen and recommended use of before nursing their infants. Griseofulvin or vaginosis during the second and third tri- the drug with isoniazid and ethambutol if nec- Betamethasone use for therapy of pre- mesters is acceptable, as either a single 2-g oral 14 essary. The American Academy of Pediatrics term labor is associated with decreases in Griseofulvin is a systemic agent used to treat dose or a 7-day course of 750–1000mg/day in considers rifampicin to be compatible with respiratory distress syndrome, periventricular fungal infections of the skin, hair and nails. Griseofulvin other alternatives with established safety pro- precipitate myasthenic crisis in patients with use is contraindicated during pregnancy, and fles are available. In these cases, the patient Ethambutol myasthenia gravis, induce hyperglycemia and pregnancy should be avoided for 1 month after should be counseled about the potential risks rarely a hypertensive crisis. Men should not try to father chil- and informed consent obtained before initiat- No congenital defects are linked to ethambu- betamethasone have no effects on the fetus, dren within 6 months of treatment. Follow-up studies information on breastfeeding while taking aza- tinued at least 3 months prior to conception older children had well developed social com- have not shown any differences in cognitive thioprine is without consensus. Hydrocortisone and rheumatologists advise avoidance of azathio- written language and arithmetic, a picture its inactive precursor cortisone present small prine if possible, or counsel against breast- reminiscent of the non-verbal learning dis- ability syndrome28. In conclusion, drug therapy of 24,25 Based on relatively small numbers, the use of The use of nitroglycerin during pregnancy cardiovascular rhythm disorders should be Although extensive data support no cyclosporine during pregnancy apparently does does not appear to present a risk to the fetus. Because which cyclosporine is indicated makes these to be suffcient to jeopardize placental perfu- Digoxin benefts of corticosteroids far outweigh fetal pregnancies high risk and subject to numer- sion. Nitroglycerin appears to be a safe, effec- risks, these agents should not be withheld if ous potential problems, of which the most tive, rapid-onset, short-acting tocolytic agent. It can reach the fetus by transplacental suppressing cell-mediated hypersensitiv- These drugs exert their effects mainly on rap- passage and induce fetal hypothyroidism.

It should be noted that the vast majority of patients will be on synthroid within 6 months to one year after therapy purchase alesse 0.18 mg without prescription birth control pills las vegas. Older patients alesse 0.18 mg lowest price birth control zero copay, multinodular goiter patients discount 0.18 mg alesse overnight delivery birth control pills lawsuit, younger patients alesse 0.18 mg mastercard birth control united healthcare, and autonomously functioning nodule patients all have increased rates of retreatment. A signed requisition must be approved by the nuclear medicine physician before isotope is ordered. All females in child bearing age (11-60 years old) scheduled for I-131 thyroid therapy: 1. Document pregnancy test results (or tubal ligation/hysterectomy/menopause) on the thyroid information sheet c. Check that the patient has not been on thyroid medication or had contrast studies for the past 6 weeks. Make the patient aware that I is eliminated by the saliva, sweat glands, and kidneys, and that his/her urine will be radioactive for a few days. Advise the patient to avoid close contact with small children for a few days, and to discontinue breastfeeding. Clear liquids only for 4 hours before and one hour after radioiodine administration. If the technologists is unable to answer any questions the patient may have, contact the radiologist to do so. A copy of the prescription should be available at the time the dose is administered, and 2. Some radioactive iodine is excreted in your urine, and a little is excreted in your saliva and perspiration, requiring some precautions to avoid spreading any significant radiation to by-standers. Most patients experience no side effects from this treatment, and only one in ten to one in twenty require a second treatment. After thyroid function becomes normal, nearly all patients will later go on to develop an underactive thyroid, requiring life-long thyroid hormone pills for replacement; your physician will check for this periodically. If any tenderness of the gland develops in the week after treatment, aspirin, ibuprofen or Tylenol will usually provide sufficient relief; if not, call your physician. Food and Fluids: It is preferable to not eat for four hours before and for one hour after radioiodine treatment to enhance absorption from your stomach. Following therapy, drink at least 2 quarts of liquids (8 glasses) per day for the first three days to hasten excretion of the radioiodine. Time and Distance: For two days, you should minimize the length of time in contact with others and try to maintain a prudent distance from them in order to reduce their exposure to your radioactivity. Sleep in a separate bed (at least 6 feet separation) for the first two (2) days after your treatment. Remain at least six (6) feet away from children and pregnant women for two (2) days. Do not nap with children or hold an infant or child for more than several minutes (<30 min/day) for 14 days.. Radioiodine is secreted into the breast milk and can damage the infant’s or child’s thyroid gland. Have the sole use of a bathroom; if not possible, wipe the seat of the toilet after each use. If you have plans to use commercial transportation over the next several weeks, you may need to present this note. If you have any questions or concerns after therapy, please contact Huntsville Hospital’s Radiologist and ask to speak with the Radiologist in Nuclear Medicine. Follow-up: It is important that you see your physician within the first 4-8 weeks after treatment and regularly thereafter in order to evaluate your response to your radioiodine therapy. The accumulation of Tl in a parathyroid adenoma is non-specific and is most likely related to the cellularity and/or vascularity of the lesion. The double-phase sestamibi study is based on the time dependence of localization within the thyroid and parathyroid tissue. An initial image represents the "thyroid phase" and is used mainly as an anatomical reference for the delayed image. Over time, there is decreased uptake in the thyroid gland and persistent uptake in parathyroid adenomas. Taillefer R, Boucher Y, Potvin C Lambert R: Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). Additional Information: The patient should be able to remain still for 30 minutes. Photopeak and window settings predetermined for Tc 140 keV, 15- 201 20%) and Tl (80 keV, 30%). Collect 20-minute Tl images at 60 seconds/image on the computer and four 5- minute images on the camera. Dynamic mode of data collection is used so that the data still may be salvaged even though patient movements may occur. Smooth all images (9-point smoothing) to reduce the effects of statistical variations. Examine the images carefully and select a region of thyroid that is comparable in 99m 201 the Tc and T1 images. Using a region of interest over this area, determine average count in this area for each image. Time interval between administration and scanning: 15 minutes and 2 hours Patient Preparation: Check that the patient is not pregnant or breast feeding. At 10-15 minutes post-injection, acquire digital images: view of neck and upper chest with head and neck extended. Calculation of parathyroid adenoma/normal thyroid tissue uptake ratio on both early and delayed images may sometimes be useful. Timing is important; the patient will undergo radioguided parathyroidectomy using a hand held probe, ideally 2. Time interval between injection and procedure: 10-15 minutes Patient Preparation: 1. Patient must be positioned for all views with head straight and a roll under the shoulders to extend the neck. Procedure may be performed regardless of medications after consultation with nuclear medicine physician. Interpretation: Activity on the subtraction images should represent pathological parathyroid tissue. Parathyroid imaging using simultaneous double-window 99m 123 acquisition of Tc-sestamibi and I. Rationale: The physiologic basis for this study is that intravenously administered macroaggregated albumin, which are larger than 10 microns in diameter, will be mechanically trapped in the pulmonary capillary bed. A normal perfusion lung scan effectively rules out the diagnosis of pulmonary embolus. If the lung scan is abnormal then the chest radiograph as well as another nuclear medicine study, the ventilation lung scan, may be used to evaluate the probability of pulmonary embolus versus that of parenchymal lung disease. The diagnostic considerations are that pulmonary embolus will cause an abnormal area of pulmonary perfusion with a relatively normal pulmonary ventilation. Pneumonia and chronic lung disease cause matching ventilation and perfusion abnormalities in the same pulmonary regions. An abnormal lung scan may confirm embolism, or in a difficult diagnostic setting, may direct the pulmonary angiographer to the location of the suspected embolus. Adult or child dose: 45-50 mCi in a minimum of 2 ml are injected into the nebulizer and an estimated 0. The ventilation scintigraphy should be performed before the perfusion scintigraphy. Use photopeak and window settings predetermined for Tc (140 keV and 15- 20% window) 3. Attach one end of plastic breathing tube to patient mouthpiece, and the other end to the manifold housing.

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