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Each of them can be listed under the above two basic categories arteria y arteriola generic 5mg coumadin fast delivery, the hydrostatic pressure & the oncotic pressure blood pressure under 120 purchase coumadin overnight delivery. The capillary hydrostatic pressure (Pc) this pressure tends to force fluid outward from the intravascular space through the capillary membrane to the interstitium atrial fibrillation guidelines order 2 mg coumadin. The interstial fluid hydrostatic pressure (Pif) this pressure tends to force fluid from the interstitial space to the intravascular space blood pressure range chart purchase coumadin with visa. The plasma colloid osmotic (oncotic) pressure (p) this pressure tends to cause osmosis of fluid inward through the capillary membrane from the interstitium. The interstial fluid colloid osmotic (oncotic) pressure (if) this pressure tends to cause osmosis of fluid outward through the capillary membrane to the interstitium. The plasma oncotic pressure is decreased when the plasma proteins are decreased in various diseases such as: 1. Edema resulting from increased capillary hydrostatic pressure as in the following diseases: 1. Congestive heart failure Clinical classification of edema: One can also clinically classify edema into localized & generalized types. A) Localized 1) Deep venous thrombosis 2) Pulmonary edema 3) Brain edema 4) Lymphatic edema B) Generalized 1) Nephrotic syndrome 2) Liver cirrhosis 3) Malnutrition 4) Heart failure 5) Renal failure Next, we will elaborate on some of the above examples. May be generalized in encephalitis, hypertensive crisis, & trauma Narrowed sulci & distended gyri. Edema compression of medulla towards formen magnum compression of vital centers lead to - Hernation of the brain Patient dies b. Reduction of albumin due to excessive loss or reduced synthesis as is caused by: 1) Protein loosing glomerulopathies like nephrotic syndrome 2) Liver cirrhosis 3) Malnutrition 4) Protein-losing enteropathy b. Increased volume of blood secondary to sodium retention caused by congestive heart failure: 65. Some of these mediators (See the chapter on inflammation) cause increased vascular permeability which leads to loss of fluid & high molecular weight albumin and globulin into the interstitium. Inflammatory edema differs from non-inflammatory edema by the following features a) Inflammatory edema (exudate) Due to inflammation-induced increased permeability and leakage of plasma proteins. Therefore, obstruction of lymphatic channels due to various causes leads to the accumulation of the proteinaceous fluid normally drained by the lymphatic channels. In these conditions, the retained sodium & water result in increased capillary hydrostatic pressure which leads to the edema seen in these diseases. Hypermia and Congestion Definition: Both of them can be defined as a local increase in volume of blood in a particular tissue. Hypermia is an active process resulting from an increased inflow of blood into a tissue because of arteriolar vasodilation. Congestion is a passive process resulting from impaired outflow of blood from a tissue. Acute pulmonary congestion: Alveolar capillaries engorged with blood Septal edema 2. Chronic pulmonary congestion: Thickened & fibrotic septa Alveolar spaces contain hemosiderin-laden macrophages resulting in an appearance termed brown indurations. Hemosiderin laden macrophages In longstanding hepatic congestion, commonly associated with cardiac failure, there is a grossly evident hepatic fibrosis called cardiac cirrhosis 69 V. Haemorrhage Definition: Hemorrhage is extravasation of blood outside the blood vessel. Inadequate vitamin K leads to clotting factor deficiency because this vitamin is important in the synthesis of the clotting factors by the liver. Terminology: 1) Haemorrhage enclosed within a tissue or a cavity is knownas hematoma. Hemostasis and Blood Coagulation Hemostasis Definition: Hemostasis is the maintainence of the clot-free state of blood & the prevention of blood loss via the formation of hemostatic plug. Hemostasis depends on three general components: a) Vascular wall b) Platelets c) Coagulation pathways Whenever a vessel is ruptured or severed, hemostasis is achieved by several mechanisms: A. Vascular spasm Formation of platelet plug Formation blood clot as a result of blood coagulation Eventual growth of fibrous tissue in to the blood clot to close the hole in the vessel permanently.

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Use with caution in patients with diabetes mellitus (hypoglycemic responses to insulin and oral hypoglycemic agents may be blunted) hypertension prevention purchase generic coumadin on-line. Onset: Immediate Indications: Atrial Fibrillation / Atrial Flutter Peak Effect: 20 minutes Duration: 5-8 hours Contraindications: Other beta-blocker use heart attack 14 year old purchase 2mg coumadin with visa. Caution in patients with sick sinus syndrome and diabetes (may potentiate hypoglycemia) blood pressure chart age 13 2mg coumadin visa. In seizures blood pressure medication enalapril side effects buy cheap coumadin 1 mg line, does not stop abnormal discharge focus but does stop spread of seizure activity though the motor cortex. Warnings: Use with caution with patients with altered mental status - respiratory depression may occur. Adverse Reactions: Lightheadedness, laryngospasm, bronchospasm, respiratory depression, respiratory arrest, motor impairment, ataxia, impairment of mental and psychomotor function, confusion, slurred speech, and amnesia. Can result in the sudden onset of opiate withdrawal (agitation, tachycardia, pulmonary edema, nausea, vomiting, and seizures(neonates)). Works on: morphine, meperidine (Demerol), heroin, paregoric, hydromorphone (Dilaudid), codeine, oxycodone (Percodan, Percocet), fentanyl, methadone, and synthetic agents (nalbuphine (Nubain ), pentazocine (Talwin), and butorphanol (Stadol)). Adverse Reactions: Tachycardia, hypertension, dysrhythmias, nausea, vomiting, and diaphoresis. Relaxes smooth muscle via dose-dependent dilation of arterial and venous beds to reduce both preload and afterload, and reduces myocardial oxygen demand. Lowers blood pressure, increases heart rate, and occasional may result in a paradoxical bradycardia. Warnings May cause hypotension, especially if given in conjunction with other vasodilators. Adverse Reactions Dose-related but may include headache, hypotension, nausea, vomiting, and dizziness. The action on alpha-receptors is stronger and results in peripheral vasoconstriction. This increases the blood pressure in hypotensive states such as cardiogenic shock and sepsis Onset: Immediate Peak Effect: < 1 minute Duration: 1-2 minutes Indications: Hypotension not related to hypovolemia. Administer through largest vein possible to reduce risk of tissue necrosis if it extravasates. Use caution in cases of cardiac ischemia as norepinephrine increases myocardial oxygen demand. May also cause bradycardia (usually because of increased peripheral vasoconstriction). Has no effect on dopamine receptors and therefore does not cause extrapyramidal symptoms. Rarely seen are angina chest pain, seizures, akathisia and acute dystonic reactions. Pharmacologic Action - Oxygen is present in room air at a concentration of approximately 21%. Providing supplemental oxygen elevates oxygen tension and increases oxygen content in the blood, thus improving tissue oxygenation, promoting aerobic metabolism, and reversing hypoxemia. Onset: Immediate Indications: Suspected hypoxemia of any etiology Peak Effect: < 1 minute Duration: < 2 minutes Contraindications: Non-hypoxic patients. Must be administered before the alkyl phosphate-cholinesterase bond becomes permanent (this is referred to as aging). Warnings: Rapid injection may cause laryngospasm, tachycardia, and muscle rigidity - intubation may be required. Excitement and manic behavior can occur immediately after recovery from unconsciousness.

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Immediate decontamination procedures will minimize the radiation exposure to all involved arrhythmia lasting hours generic coumadin 5mg on-line. Radiation Detection the most useful instrument following a radiation incident is a radiation survey meter commonly called a Geiger-Muller counter hypertension htn coumadin 5mg lowest price. This will readily detect sources of ionizing radiation including alpha prehypertension 131 order coumadin 1 mg with mastercard, beta wireless blood pressure monitor purchase coumadin now, or gamma energy released from radioactive elements. The Geiger counter can immediately detect contaminated sites and demonstrate the efficiency of decontamination. However, it cannot determine the total dose of radiation received by an individual. Personal dosimeters are used in medicine and in industry to quantify the accumulated radiation dose for those who frequently work near sources of radiation such as x-ray machines, medical radionuclides, and other radio active materials used in research and industry. Electronic dosimeters provide a real time determination of radiation exposure, whereas film based dosimeters require processing after removal from the patient. Radiation contamination is a unique form of chemical injury (radionuclides are unstable chemical elements which damage tissue by emitting alpha, beta or gamma ionizing radiation). For example, a release in a nuclear power plant or a spill while a medical worker is handling radioactive iodine suggests external contamination. Safety priorities: When encountering a patient with suspected radiation injury, the priorities include rapid removal from any presumed source of ongoing radiation exposure, decontamination including removal of possibly contaminated clothing and thorough irrigation of the contaminated skin with water. Copious irrigation of the exposed tissue with water or saline will remove most of the contaminants. Irrigation is continued until a survey with a radiation detector indicates minimal residual radiation, or at least a steady state condition. Consult your regional health care facility disaster plan for details of these protocols. At Chernobyl, when the patients were undressed, all the dosimeters remained attached to the contaminated clothing, received additional radiation exposure, and were useless in determining the radiation exposure of individual victims. Initially there is a sharp drop in the circulating leukocytes and platelets, followed by a drop in erythrocyte production. There is a prolonged depression of the bone marrow and death results from bleeding or septicemia. Prognosis the prognosis is determined by the total body radiation dose, the presence of any trauma or co-morbid medical conditions, and the availability of sophisticated medical treatment facilities. Radiation syndrome is often fatal unless managed with all the resources of a major medical research facility. Introduction Cold injury most commonly occurs after exposure to a cold environment without appropriate protection. Localized cold injuries (frostbite) can cause severe disabilities or require amputation, but systemic hypothermia can be rapidly fatal, so local cold injuries are treated only after reversal of any associated hypothermia. The physiological changes associated with cold injuries are distinct from heat injury and require a unique therapeutic approach. Military personnel, winter sports enthusiasts, older adults, and homeless persons are most at risk for these injuries. Incidence Primary hypothermia due to frigid environmental exposure or cold water immersion is most common during the winter months, accounting for approximately 500 deaths per year in the United States. Secondary hypothermia occurs when a medical illness, injury or drug ingestion lowers the set point for body temperature. For example, older adults with severe hypothyroidism, sepsis or uncontrolled diabetes may develop hypothermia, even indoors. The mechanisms for heat transfer include conduction, convection, radiation and evaporation. The patient experiences first a generalized cold sensation with uncontrollable shivering, followed by confusion, lethargy and impaired coordination of body movements. With a further decrease in core temperature, shivering stops and the patient becomes somnolent with depressed respirations and profound bradycardia. Even mild hypothermia induces diuresis and cold patients become rapidly hypovolemic.

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Maximizing initial treatments Several studies have shown improved efficacy with higher doses of medication arrhythmia games cheap coumadin 1mg on-line, supporting the strategy of increasing the medication dose for patients who do not respond to an Copyright 2010 blood pressure higher in one arm generic coumadin 5 mg online, American Psychiatric Association blood pressure chart numbers discount coumadin 2mg with amex. These previous studies were either small in size or blood pressure chart printable cheap 1 mg coumadin with mastercard, in the vast majority of instances, were neither randomized nor blinded. Although results from these trials have been variable, up to 50% of patients have been found to respond. Data regarding the types of treatment-resistant patients who are most likely to benefit from particular changes in medication are limited. The findings of 16 placebo-controlled, randomized clinical trials of second-generation antipsychotic augmentation therapy for patients with major depression disorder (N=3,480) have recently been evaluated in a meta-analysis (448). Augmentation with a second-generation antipsychotic agent was significantly more effective than placebo in terms of rates of response and remission. Discontinuation rates for adverse effects were also higher in the active augmentation groups compared with placebo, suggesting that such effects need to be taken into consideration when choosing to augment antidepressant response with a second-generation antipsychotic agent. To date, few data from controlled studies address the longer term efficacy or side effects of combining antidepressants and antipsychotics. Case reports suggest that stimulant medications may be effective adjuncts to antidepressant medication therapy (205), although the results of larger scale clinical trials have not demonstrated efficacy (462, 463). Augmenting and combining treatments Traditionally, augmentation agents with the most evidence for efficacy have included lithium and thyroid hormone for partial responders to traditional antidepressant medications (1155). Both agents as adjuncts were associated with remission rates of around 30% on primary outcome measures. Patients who did not have remission with up to 12 weeks of citalopram therapy were as likely to benefit from adjunctive buspirone E. In a randomized double-blind trial that included 84 individu- Copyright 2010, American Psychiatric Association. A few studies have examined treatment with psychotherapeutic interventions administered in the continuation phase. One study found that among patients who responded to acute treatment with cognitive therapy, those who continued this treatment over 2 years had lower relapse rates than those who did not have continuation treatment (493). In a randomized controlled trial of cognitive group therapy as an adjunct to treatment as usual, Bockting et al. Cognitive group therapy was found to be effective in preventing relapse/ recurrence, and this protective effect increased in concert with the number of previous depressive episodes. Cognitive therapy patients, who were allowed no more than three booster sessions over that year, had a lower rate of relapse (31%) than those withdrawn from medication (76%). They also exhibited no greater likelihood of depressive relapse than patients who continued pharmacotherapy (47%), suggesting possible lasting benefits of cognitive therapy. The cumulative probability of recurrence through the first 12 months of the maintenance phase treatment was 23. There have been fewer investigations of the effectiveness of psychotherapy in the maintenance phase. Research on cognitive therapy has explored the concept of an enduring benefit by acquiring persistent skills that reduce the risk of depressive relapse after treatment has ended (68, 1110). Some results suggest that the combination of antidepressant medications plus psychotherapy may be additionally effective in preventing relapse over treatment with single modalities (314, 365, 506, 515, 516). However, in individuals older than age 70 years who received maintenance treatment with paroxetine and clinical management, interpersonal therapy and placebo, paroxetine and interpersonal therapy, or placebo and clinical management, the combination of paroxetine and interpersonal therapy offered no benefits over paroxetine and clinical management and each were superior to the other treatment conditions (729). However, there are still many unanswered questions about optimizing and individualizing treatment. To "personalize" care, and someday even prevent depression, we must understand factors that cause it. In the nearer term, science can focus on predictors of benefit and adverse effects of specific treatments. Potential causes of depression or moderators of treatment response may be found through genomics, proteomics, physiological markers, personality traits, personal experiences, co-occurring conditions, or clusters of specific depressive symptoms. Culture, race, and ethnicity merit study in shaping treatment selection and predicting response and side effects.

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