Public Interest Law Initiative


By H. Urkrass. Lynn University.

Very rarely there may be bilateral tension •agradual rise in the inflation pressure buy torsemide 10 mg free shipping blood pressure ranges pediatrics, if the pneumothoraces order 10mg torsemide visa blood pressure 68 over 48. Severe hypotension Hypotension is a result of a reduction in either the Causes cardiac output or the peripheral resistance, alone Puncture of the pleura lining the surface of the or in combination (blood pressure = cardiac output lung (visceral pleura). Severe hypotension may 96 Management of perioperative emergencies and cardiac arrest Chapter 4 be defined as a systolic pressure 40% less than the usually the result of a combination of the above preoperative value. Reduced cardiac output Management Decreased venous return to the heart: • Hypovolaemia: blood loss, extracellular fluid Initially, time should not be spent trying to iden- loss (diarrhoea, vomiting). If hypotension renders • Mechanical obstruction impeding venous re- the patient unconscious, intubation will be needed turn: pulmonary embolus, tension pneumothorax, to protect the airway. Support ventila- • Intravenous and inhalational anaesthetic tion if inadequate or absent, using a facemask ini- agents. If a Anaesthetic drugs: bradycardia is present (heart rate <60/min), then •Adirect action on vascular smooth muscle in the consider atropine 0. At this point, treatment should be directed towards • The release of histamine, for example specific causes that may be suggested by the find- atracurium. Additional measures Sepsis: • Vasopressors: for example ephedrine to counter- •Toxins released can cause failure of the precapil- act vasodilatation. Dantrolene is Analysis of an arterial blood sample will orange in colour and supplied in vials containing demonstrate: 20mg (plus 3g mannitol); it requires 60mL water •aprofound metabolic acidosis (low pH and for reconstitution and is very slow to dissolve. Correction, using episode; the following techniques, may allow recovery •ensure that appropriate monitoring and without the need for further intervention. A sequence of actions is performed in which the airway, breathing and circulation are supported without the use of any equipment other than a simple protective shield interposed between the mouths of the rescuer and patient (e. At the same time, broken, loose or partial dentures should be re- moved, but well-fitting ones may be left in place (see later). Expired-air ventilation (rescue breathing or mouth-to-mouth ventilation) • There must be a clear path, with no leaks, be- Figure 4. The tips of the thumbs can • Keep the victim’s airway patent by performing a be used to open the mouth. Mouth-to-nose ventilation This technique is used where mouth-to-mouth ventilation is unsuccessful, for example if an ob- struction in the mouth cannot be relieved, or when the rescuer is a child. Circulation • The fingers of the lower hand are then used to Check for evidence of a circulation: perform a chin lift, and if necessary open the vic- •Look, listen and feel for normal breathing, tim’s mouth (Fig. To optimize compression and reduce rescuer (a) fatigue chest compressions are best performed with the rescuer leaning well forward over the patient, arms straight and hands, elbows and shoulders ex- tended in a straight line. This allows use of the res- cuer’s upper body weight to achieve compression, rather than the arm muscles, which will rapidly tire and reduce efficiency (Fig. Common errors Wrong hand position: • too high: the heart is not compressed; (b) • too low: the stomach is compressed and risk of Figure 4. Overenthusiastic effort: • Central arteries are more reliable than periph- • causes cardiac damage; eral ones as a pulse will be palpable even with a • fractures ribs which may damage underlying very low cardiac output. Failure to release between compressions: Chest compressions • prevents venous return and filling of the heart. This technique only results in a maximum cardiac When a collapsed person is not breathing and has output 30% of normal, and in order to achieve this no spontaneous circulation, they will require both the position of the hands is critical: rescue breathing and chest compressions; this is • The rescuer positions him/herself on one side of often referred to as cardiopulmonary resuscitation the victim. A ratio of 15 chest compressions to 2 breaths • The victim’s chest is exposed and the xiphister- should be used, irrespective of the number of per- num identified. If the heel of the other hand is placed adjacent to two or more healthcare professionals are present, them on the sternum (Fig. The 102 Management of perioperative emergencies and cardiac arrest Chapter 4 same ratio of 15:2 must still be used. The shoulder is pulled • Defibrillate if appropriate; do not delay for venti- towards the rescuer whilst at the same time the lations or chest compressions. The most important first step is to identify agement is summarized in the Universal Treatment the cardiac arrest rhythm, which can belong to one Algorithm (Fig. Defibrillation Defibrillation (and cardioversion) depolarizes a critical mass of the myocardium, allowing the nat- Figure 4. Defibrillators have a power source, either mains or battery, which charges a capacitor to a predetermined level.

Digestive System: From Appetite Suppression to Constipation Age-related changes in the digestive system begin in the mouth and can affect virtually every aspect of the digestive system generic torsemide 10 mg overnight delivery hypertension young. A slice of pizza is a challenge discount torsemide 10mg line blood pressure levels high, not a treat, when you have lost teeth, your gums are diseased, and your salivary glands aren’t producing enough saliva. Swallowing can be difficult, and ingested food moves slowly through the alimentary canal because of reduced strength and tone of muscular tissue. Neurosensory feedback is also dampened, slowing the transmission of messages that stimulate the release of enzymes and hormones. Pathologies that affect the digestive organs—such as hiatal hernia, gastritis, and peptic ulcer disease—can occur at greater frequencies as you age. Conditions that affect the function of accessory organs—and their abilities to deliver pancreatic enzymes and bile to the small intestine—include jaundice, acute pancreatitis, cirrhosis, and gallstones. However, most digestive processes involve the interaction of several organs and occur gradually as food moves through the alimentary canal (Figure 23. Regulatory Mechanisms Neural and endocrine regulatory mechanisms work to maintain the optimal conditions in the lumen needed for digestion and absorption. These regulatory mechanisms, which stimulate digestive activity through mechanical and chemical activity, are controlled both extrinsically and intrinsically. Neural Controls The walls of the alimentary canal contain a variety of sensors that help regulate digestive functions. These include mechanoreceptors, chemoreceptors, and osmoreceptors, which are capable of detecting mechanical, chemical, and osmotic stimuli, respectively. For example, these receptors can sense when the presence of food has caused the stomach to expand, whether food particles have been sufficiently broken down, how much liquid is present, and the type of nutrients in the food (lipids, carbohydrates, and/or proteins). This may entail sending a message that activates the glands that secrete digestive juices into the lumen, or it may mean the stimulation of muscles within the alimentary canal, thereby activating peristalsis and segmentation that move food along the intestinal tract. The walls of the entire alimentary canal are embedded with nerve plexuses that interact with the central nervous system and other nerve plexuses—either within the same digestive organ or in different ones. Extrinsic nerve plexuses orchestrate long reflexes, which involve the central and autonomic nervous systems and work in response to stimuli from outside the digestive system. Short reflexes, on the other hand, are orchestrated by intrinsic nerve plexuses within the alimentary canal wall. Short reflexes regulate activities in one area of the digestive tract and may coordinate local peristaltic movements and stimulate digestive secretions. For example, the sight, smell, and taste of food initiate long reflexes that begin with a sensory neuron delivering a signal to the medulla oblongata. In contrast, food that distends the stomach initiates short reflexes that cause cells in the stomach wall to increase their secretion of digestive juices. The main digestive hormone of the stomach is gastrin, which is secreted in response to the presence of food. The Mouth The cheeks, tongue, and palate frame the mouth, which is also called the oral cavity (or buccal cavity). The labial frenulum is a midline fold of mucous membrane that attaches the inner surface of each lip to the gum. The next time you eat some food, notice how the buccinator muscles in your cheeks and the orbicularis oris muscle in your lips contract, helping you keep the food from falling out of your mouth. The pocket-like part of the mouth that is framed on the inside by the gums and teeth, and on the outside by the cheeks and lips is called the oral vestibule. Moving farther into the mouth, the opening between the oral cavity and throat (oropharynx) is called the fauces (like the kitchen "faucet"). The next time you have food in your mouth, notice how the arched shape of the roof of your mouth allows you to handle both digestion and respiration at the same time. The anterior region of the palate serves as a wall (or septum) between the oral and nasal cavities as well as a rigid shelf against which the tongue can push food. It is created by the maxillary and palatine bones of the skull and, given its bony structure, is known as the hard palate. If you run your tongue along the roof of your mouth, you’ll notice that the hard palate ends in the posterior oral cavity, and the tissue becomes fleshier. You can therefore manipulate, subconsciously, the soft palate—for instance, to yawn, swallow, or sing (see Figure 23.

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They coordinate numerous complex cell movements in transport of secretory vesicles from region to region of the cell purchase torsemide 20mg overnight delivery blood pressure goes up after eating, movements of cilia and flagella order 10 mg torsemide with amex heart attack demi lovato mp3, distribution of chromosomes during cell division, microfilaments are important to cellular contractile system and as mechanical stiffeners. The microfilaments are the smallest of the cytoskeleton composed of protein molecule actin having a globular shape similar to tubulin. It appears as ‘trilaminar’ layer structure having two dark layers separated by a light middle layer as a result of specific arrangement of the constituent molecules. All plasma membrane are made up of lipids and proteins plus small amount of carbohydrate. Phospholipids have a polar charged head having a negatively charged phosphate group 22 and two non-polar (electrically neutral) fatty acid tails. The polar end is hydrophilic (water loving) because it can interact with water molecule which is also polar, the non- polar end is hydrophobic (water fearing) and will not mix with water. Such two-sided molecule self assemble into a lipid bilayer, a double layer of lipid molecules when in contact with water. The hydrophobic tails bury themselves in the center away from the water, while the hydrophilic heads line up on both sides in contact with water. Cholesterol provides to the fluidity as well as the stability; cholesterol lies in between the phosphate molecules, preventing the fatty acid chain from packing together and crystallizing that could decrease fluidity of the membrane. On account of fluidity of the membrane it gives flexibility to the cell to change its shape; transport process are also dependent on the fluidity of the lipid bilayer. The membrane proteins are either attached to or inserted within the lipid bilayer; some extending through the entire membrane thickness; they have polar region at both ends joined by a non-polar central portion. Other proteins are on either the outside or inner surface, anchored by interactions with proteins that spans the membrane or by attachment to the lipid bilayer. On account of membrane fluidity many proteins float freely, although the mobility of protein that have special function in a particular area of the membrane is restricted - this gives ever changing mosaic pattern of the protein embedded in the lipid layer. Only the outer surface of the plasma membrane contains a small amount of carbohydrate. Short-chain carbohydrates are bound primarily to membrane proteins and to a lesser extent to lipids, forming glycoproteins and glycolipids. The plasma membrane is actually asymmetrical; the two surfaces are not the same; carbohydrate is only on the outer surface; different amount of different proteins are on the outer and inner surfaces and even the lipid structures of the outer and inner half is 23 not the same. The plasma membrane is highly complex, dynamic, regional differentiated structure. The lipid layer forms the primary barrier to diffusion, whereas proteins perform most of the specific membrane functions. Responsible for the fluidity of the membrane Membrane Proteins Membrane proteins are variety of different proteins within the plasma membrane; serve the following special functions: (see fig. Some form water-filled passage ways or channels, across the lipid bilayer; such channels allow ions to pass through without coming in direct contact with lipid interior. The channels are highly selective; they can selectively attract or repel particular ions. Other proteins serve as carrier molecule that transport specific molecule that cannot cross on their own. Many proteins on the outer surface serve as ‘receptor sites’ that recognize and bind with specific molecules in the cell environment. This binding triggers a series of membrane and intracellular events that alter the activity of the target cell. In this way hormones influence specific cell, even though every cell is exposed to the same chemical messenger via its widespread distribution by the blood 4. Another group of proteins act as membrane-bound enzymes that control specific chemical reactions on either side of the plasma membrane e. Some proteins are arranged as filaments network/meshwork on the inner side and are secured to certain internal protein elements of the cytoskeleton. These molecules protrude from the membrane surface that grip each other and grip the connective tissue fibers that interlace between cells. Some proteins, especially in conjunction with carbohydrate are important in the cell’s ability to recognize ‘self’ and in cell-to-cell interactions.

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Now examine the disc for clarity of outline generic 20 mg torsemide amex prehypertension third trimester, color cheap 20 mg torsemide free shipping blood pressure medication nifedipine, elevating and condition of the vessels. To locate the macula, focus on the disc, then move the light approximately 2 disc diameters temporally. You may also have the patient look at the light of the ophthalmoscope, which will automatically place the macula in full view. The red-free filter facilitates viewing of the center of the macula, or the fovea. To examine the left eye, repeat the procedure outlined above except that you hold the ophthalmoscope in the left hand, stand at the patient’s left side and use your left eye. If the patient has a refractive error, try dialing up plus or minus lenses in the ophthalmoscope to bring the fundus into focus. It is difficult to see the fundus clearly so use a strong minus lens in the ophthalmoscope. Seat the baby on his mother’s lap, so that her hands restrain his arms and steady his head 2. Wrap the baby in a sheet or blanket, with his head on the examiners lap, and continue what you are going to do 3. In very difficult cases, it may be necessary to apply a drop of local anesthetic, and use a speculum to hold open the eyelids. Intra ocular pressure ƒ Should be measured in any patient with suspected glaucoma. Ahmed 5- Albert and Jakoboiec Principle and practice of ophthalmology 6- Up to date - (C) 2001 - www. At the end of the course the students are expected to have adequate knowledge about eyelid and lacrimal apparatus disease; the diagnosis and management of such diseases. Internal Hordeolum • a small abscess collection in the Meibomian glands • Caused by staphylococcus Symptoms pain, redness, swelling within eye lid Signs tender, inflamed mass within the eye lid. Treatment _ Hot compress _ Topical antibiotics _ If the above treatment fails, referral for. External Hordeolum /stye/ ¾ An acute staphylococcal infection of a lash follicle and its associated gland of zeis or moll. Chalazion - A chronic lipogranulomatous inflammatory lesion caused by blockage of meibomian gland orifices and stagnation of sebaceous secretion - Patient with acne roscea or seborrheic dermatitis are at increased risk of Chalazion formation which may be multiple or recurrent. Symptom ¾ Painless nodule within the eye lid Sign ƒ Non tender, firm, roundish mass within the eye lid. Molluscum contagiosum - Uncommon skin infection caused by a poxvirus - It is common in children and immunocompromized patient. Sign ¾ Single or multiple ¾ Pale, waxy ¾ Umblicated nodules ¾ If the nodule is located on the lid margin it may give rise to ipsilateral chronic follicular conjunctivitis and occasionally a superficial keratitis Treatment ¾ Expression ¾ Shaving and excision ¾ Destruction of the lesion by cauterization, cryotherapy E. Blepharitis ¾ a general term for inflammation of the eyelid ¾ Can be associated with conjunctivitis There are two main types of blepharitis 1. Entropion - Means the eyelids turn in wards then the eyelashes rub and damage the globe Treatment - Referral for surgical correction C. It can cause ambylopia if it is unilateral Treatment - Referral for surgical correction 31 3. Treatment - Hot compression - Systemic antibiotic -Incision and abscess drainage may be required Complication - Preseptal cellulitis - Orbital cellulitis Chronic dacryocystitis Symptoms - Tearing - Swelling over the medial aspect of the eye - Mucoid or purulent discharge with pressure on the lacrimal sac area. Preseptal cellulitis Definition: it is infection of the tissues anterior to the orbital septum Symptom - No visual reduction - Mild periorbital pain - Localized eyelid redness and swelling Sign - V/A is normal - Tender and hot eyelid - Ocular motility is normal Treatment - Ciprofloxacillin 500mg po bid for seven days. Orbital cellulitis An infection of orbital tissue posterior to the orbital septum. Symptom -Pain -Proptosis -Fever - Limited ocular movement -Visual reduction 33 Sign - V/A is reduced -Tender eye - Reduced to absent ocular motility Treatment It is an ophthalmic emergency that needs admission; intravenous antibiotics and close follow up. Ahmed 4 - Albert and Jacoboiec Principle And Practice Of Ophthalmology 5 - Up to date - (C) 2001 - www. They will also be alert on the differential diagnoses ranging from self liming to sight threatening cause of red eye. They will be given a clear description on how to approach patients with red eye and what to do at their level. At the end of the course, students are expected to differentiate self limiting condition from sight threatening conditions; and to act early.

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