Joseph Y. Allen, MD, FAAP

• Assistant Professor of Pediatrics
• Baylor College of Medicine
• Texas Children? Hospital
• Houston, Texas

Withdraw needle stylet (blood should appear in the cannula) and advance cannula into artery as far as possible erectile dysfunction internal pump purchase 20 mg erectafil otc. Pass needle stylet (with bevel up) and cannula through artery at 30- to 40-degree angle to skin erectile dysfunction treatment at gnc 20mg erectafil visa. The inability to insert the cannula into the lumen usually indicates failure to puncture the artery centrally erectile dysfunction treatment with injection cheap erectafil online mastercard. This often results in laceration of the lateral wall of the artery with formation of a hematoma erectile dysfunction lawsuits purchase cheap erectafil online, which can be seen on transillumination fast facts erectile dysfunction buy erectafil 20mg free shipping. Transparent semipermeable dressing may be used in place of tape to allow continuous visualization of skin entry site long term erectile dysfunction treatment erectafil 20mg on line. Maintain patency by attaching T connector to extension tubing or arterial pressure line to run 0. Radial Artery Cutdown Cutdown technique may be required for the very small neonate, because trauma to the artery causes vasospasm, which makes percutaneous cannulation of a small vessel very difficult. Technique I: Cutdown at wrist the artery is initially exposed by cutdown, and a catheter is inserted under direct vision. A: Anatomic relations of posterior tibial artery, showing site of incision for cutdown. B: Cannulation of posterior tibial artery; cannula is attached to a transducer for continuous blood pressure monitoring. Percutaneous venous cannulation in neonates and infants: a method for catheter insertion without "cutdown. Infiltrate site of incision (point of maximum pulsation just proximal to proximal wrist crease) with 0. Deepen incision into subcutaneous tissue by blunt longitudinal dissection with curved mosquito hemostat. Advance cannula stylet into artery with bevel down, until cannula is clearly within vessel lumen. A: Puncture artery directly at angle of 10 to 15 degrees to skin, with needle bevel down. C: Withdraw needle stylet, allow for blood return, and advance cannula into artery. The incision can usually be kept small enough so that the hub of the cannula fills it and no closing suture is needed. Should not be a primary approach to radial artery (particularly if cannulation is achieved by cutdown) (1) Site is not easy to expose. The radial artery passes dorsally at the wrist and traverses the anatomic snuffbox, which is bounded medially by the extensor pollicis longus and extensor pollicis brevis muscles. The artery becomes superficial immediately after passing the extensor pollicis longus and before passing beneath the first dorsal interosseous muscle. The point for cannulation is located at the junction of a line drawn along the medial aspect of the extended thumb and another line drawn along the lateral aspect of the extended index finger. E: Introducing cannula into artery while gentle "back traction" is applied to suture. B: Point for cannulation of the radial artery is indicated by the junction of the dotted lines. A "second" radial artery for monitoring the perioperative pediatric cardiac patient. The former has the advantage that it offers the opportunity to extend the incision cephalad, should the posterior wall of the vein be perforated on the initial attempt at cannulation. However, it has the disadvantage that it may be made too far lateral or medial to the artery. The artery is usually found just anterior to the Achilles tendon and adjacent to the tibial nerve. Place mosquito hemostat behind artery, and loop 5-0 nylon suture loosely around it. Appropriate-sized syringe for sample (heparinized if sample is not processed on site) 6. Introduce 25-gauge needle through diaphragm and allow 3 to 4 drops of fluid/blood to drip onto gauze. Evidence of thrombosis or mechanical occlusion of the artery (2) Abduction of wrist (3) Flexion of wrist and distal phalanges of middle and index fingers (4) Opposition, abduction, and flexion of thumb (atrophy of thenar eminence) Technique 1. Blanching of hand, gangrene of fingertips, partial loss of digits (14,21,22,27) Topical nitroglycerine has been reported to restore perfusion in some cases. Healing areas of sloughed skin are seen at site of skin puncture on dorsum of foot and also on anterior aspect of lower leg. Thromboangiitis obliterans: methods of diagnosis of chronic occlusive arterial lesions distal to the wrist with illustrative cases. Incidence and duration of total occlusion of the radial artery in newborn infants after catheter removal. Wrist hyperextension leads to median nerve conduction block: implications for intra-arterial catheter placement. Alternative arterial catheterization site using the ulnar artery in critically ill pediatric patients. Percutaneous catheterisation of the radial artery in newborn babies using transillumination. Incidence of forearm and hand ischaemia related to radial artery cannulation in newborn infants. Resolution of peripheral artery catheter-induced ischemic injury following prolonged treatment with topical nitroglycerin ointment in a newborn: a case report. The use of topical nitroglycerin ointment to treat peripheral tissue ischemia secondary to arterial line complications in neonates. Peripheral portion of deep peroneal nerve- anesthesia of the lateral aspect of the dorsum of the hand, which results in no significant disability. False cortical thumbs (36) Burns from transilluminator (37) Hemorrhage (including accidental dislodgement of cannula) (32,34) Hypernatremia caused by heparinized saline infusion through cannula (6) Hypervolemia related to continuous flush device (38) Air embolism (39) Pseudoaneurysm (40) Acquired bone dysplasia (41) References 1. Percutaneous axillary artery catheterization in critically ill infants and children. Hypernatremia due to heparinized saline infusion through a radial artery catheter in a very low-birth-weight infant. Comparison of normal saline and heparin solutions for maintenance of arterial catheter patency. Light filtration during transillumination of the neonate: a method to reduce heat buildup in the skin. Acquired bone dysplasia secondary to catheter-related complications in the neonate. Central venous lines may be placed by surgical cutdown when percutaneous access is not possible. Totally implantable vascular access devices (ports) are rarely used in neonates and are thus not included in this chapter. Regardless of the method employed to obtain secure and reliable venous access, the clinician should be familiar with the technique and anatomic considerations unique to the approach. Some form of analgesia and sedation is generally required, with general anesthesia being reserved for more complex access cases. The majority of venous access procedures in the critically ill neonate are performed at the bedside rather than in the operating room. Ongoing bacteremia or fungal infection (which may cause catheter colonization and infection) 4. Central venous catheters have significant risks of complications and must not be used when peripheral venous access is possible and adequate. Central venous catheterization must be performed by trained individuals who are familiar with the venous anatomy of the proposed catheter route. Hand hygiene (with soap and water or with alcohol based hand rub) should be performed before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing or dressing an intravascular catheter (2). Never leave a catheter in a position where it does not easily and repeatedly withdraw blood during the insertion procedure, to ensure that the tip is not lodged against a blood vessel or cardiac wall. If possible, the line should be inserted and cared for by specifically trained personnel. Central line teams and the use of insertion and maintenance checklists and bundles have been shown to decrease the frequency of catheter-related infections (3). Repetitive blood draws (catheters are not usually inserted primarily for this indication in neonates; only larger-lumen catheters may be used for blood draws without risk of clotting). Relative Contraindications There are no absolute contraindications, as the clinical situation dictates the need for venous access. The catheter should be placed in as large a vein as possible, ideally outside the heart, and parallel with the long axis of the vein such that the tip does not abut the vein or heart wall. However, one large retrospective audit of 2,186 catheters showed that catheters with their tips in the right atrium and not coiled were not associated with pericardial effusions (7). The tip of the radio-opaque catheter is usually seen on a routine chest radiograph. Two radiographic views (anteroposterior and lateral) help to confirm that the catheter is in a central vein. This is particularly important for catheters placed in a lower extremity, where the catheter may inadvertently be in an ascending lumbar vein and may appear to be in good position on an anteroposterior view (9). The use of radio-opaque contrast improves localization of the catheter tip, particularly when the catheter is difficult to see on a standard radiograph. With this technique, there is no need to inject the contrast material while the radiograph is being taken (10). Chest radiographs obtained for any reason should be scrutinized for appropriate catheter position. Routine weekly radiographs taken for this purpose do not appear to reduce the risk of complications (6). Advantages (1) Simpler to perform and relatively rapid procedure (2) Vessel is not ligated as in open cutdown methods (3) Decreased potential for wound infection/ dehiscence complications b. Disadvantages (1) Beyond the initial insertion into the peripheral vein, further passage of the catheter into its final position is essentially a blind technique, although there is increasing experience with ultrasound imaging (11). Catheters are usually silicone or polyurethane, with tissue in-growth cuffs that adhere to the subcutaneous tract, anchoring the catheter. Most catheters are single-lumen, but a few manufacturers make double-lumen catheters. Antecubital veins: Basilic and cephalic veins Saphenous veins Scalp veins: Temporal and posterior auricular veins Axillary vein External jugular vein Right-sided and basilic veins are preferred because of the shorter and more direct route to the central vein. The cephalic vein may be more difficult to thread to the central position because of narrowing of the vessel as it enters the deltopectoral groove and the acute angle at which it joins the subclavian vein. The axillary and external jugular veins are the last choices because they are close to arteries and nerves. Disadvantage: There is a potential for shearing or severing the catheter if it is retracted while the needle is in the vein. The introducer cannula or sheath is then retracted from the vein, split or "peeled" apart, and removed from the catheter. Disadvantage: the blunt needle attachment must be secured well, otherwise leakage can occur. Equipment All equipment used, except the mask, head cover, and tape measure, must be sterile. Although anesthesia is not required, nonpharmacologic comfort measures and pain medication should be provided as needed. When flashback of blood is noted, reduce angle and advance introducer sheath farther to ensure placement in the vein. Note that the catheter is stabilized by applying digital pressure to the vein distal to the introducer sheath. E: Remove the introducer sheath by splitting and peeling it away from the catheter. F: Aspirate catheter to check for blood return and flush with heparinized saline to ensure patency. A commercially available blunt needle adapter may be inserted and fixed in a similar manner. Measure approximate distance from the insertion site to the point where the catheter tip will be placed (Table 32. Perform hand hygiene as for a major procedure and wear sterile surgical gown and gloves. Trim catheter to appropriate size (trimming is based on unit policy and manufacturer recommendations). When a flashback is obtained, advance the needle about 5 to 6 mm at a lower angle to ensure that the whole bevel of the needle is within the vein. If a peel-away introducer with a needle is used, remove the needle at this time and advance the introducer sheath slightly. If the introducer (needle or sheath) is well within the vein, there will be continued blood flow through it. Using nontoothed iris forceps, gently grasp the catheter about 1 cm from its distal end and thread it care.

Poor maternal outcomes are highest in women with active nephritis or irreversible organ damage in kidneys erectile dysfunction diagnosis treatment generic erectafil 20mg mastercard, brain injections for erectile dysfunction forum order erectafil with a visa, or heart impotence of organic origin icd 9 discount erectafil 20 mg without a prescription. Recommendations are based on both retrospective and prospective studies o posttreatment clotting events and adverse e ects rom anticoagulation icd 9 code erectile dysfunction due diabetes order erectafil overnight. Plasma exchange or extensive plasmapheresis is usually li e-saving; most authorities recommend concomitant glucocorticoid therapy; there is no evidence that cytotoxic drugs are e ective erectile dysfunction effects on relationship discount erectafil 20mg with amex. Systemic treatment with retinoic acid is a use ul strategy in patients with inadequate improvement on topical glucocorticoids and antimalarials; adverse e ects are potentially severe (particularly etal abnormalities) erectile dysfunction and proton pump inhibitors buy cheap erectafil line, and there are stringent reporting requirements or its use in the United States. In therapyresistant lupus dermatitis there are reports o success with topical tacrolimus (caution must be exerted because o the possible increased risk or malignancies) or with systemic dapsone or thalidomide (the extreme danger o etal de ormities rom thalidomide requires permission rom and supervision by the supplier). Vaccination with attenuated live viruses is generally discouraged in patients who are immunosuppressed. Strategies to prevent osteoporosis should be initiated in most patients likely to require long-term glucocorticoid therapy and/or with other predisposing actors. Postmenopausal women can be protected rom steroid-induced osteoporosis with either bisphosphonates or denosumab. Control o hypertension and appropriate prevention strategies or atherosclerosis, including monitoring and treatment o dyslipidemias, management o hyperglycemia, and management o obesity, are recommended. In the United States, A rican Americans and Hispanic Americans with a mestizo heritage have a worse prognosis than whites, whereas A ricans in A rica and Hispanic Americans with a Puerto Rican origin do not. The relative importance o gene mixtures and environmental di erences accounting or ethnic di erences is not known. As many as 25% o patients may experience remissions, sometimes or a ew years, but these are rarely permanent. The leading causes o death in the rst decade o disease are systemic disease activity, renal ailure, and in ections; subsequently, thromboembolic events become increasingly requent causes o mortality. However in ections, oxidative stress, major physical stresses such as surgery, and discontinuation o anticoagulant treatment may induce the exacerbation o the disease. Clinical eatures associated with venous thrombosis are super cial and deep vein thrombosis, cerebral venous thrombosis, signs and symptoms o intracranial hypertension, retinal vein thrombosis, pulmonary emboli, pulmonary arterial hypertension, and Budd-Chiari syndrome. This clinical mani estation correlates with vascular lesions such as those in the central nervous system as well as aseptic bone necrosis. Arterial thrombosis is mani ested as migraines, cognitive dys unction, transient ischemic attacks, stroke, myocardial in arction, arterial thrombosis o upper and lower extremities, ischemic leg ulcers, digital gangrene, avascular necrosis o bone, retinal artery occlusion leading to painless transient vision loss, renal artery stenosis, and glomerular lesions, as well as in arcts o spleen, pancreas, and adrenals. Libman-Sacks endocarditis consists o very small vegetations, histologically characterized by organized platelet- brin microthrombi surrounded by growing broblasts and macrophages. Glomerular lesions are mani ested with hypertension, mildly elevated serum creatinine levels, proteinuria, and mild hematuria. Histologically, these lesions are characterized in an acute phase by thrombotic microangiopathy involving glomerular capillaries, and in a chronic phase with brous intima hyperplasia, brous and/or brocellular occlusions o arterioles, and ocal cortical atrophy (able 5-2). Di erential diagnosis is based on the exclusion o other inherited or acquired causes o thrombophilia, Coombspositive hemolytic anemia, and thrombocytopenia. The above drugs are administered by xed doses and do not require close monitoring; their sa ety during the rst trimester o pregnancy has not been clearly established. The presence o at least one clinical and one laboratory criterion ensures the diagnosis even in the presence o other causes o thrombophilia. It is the most common orm o chronic in ammatory arthritis and o en results in joint damage and physical disability. The relative importance o these di erent mechanisms has been highlighted by the observed bene ts o the new class o highly targeted biologic and small-molecule therapies. Much o this progress can be traced to the expanded therapeutic armamentarium and the adoption o early treatment intervention. The shi in treatment strategy dictates a new mind-set or primary care practitioners-namely, one that demands early re erral o patients with in ammatory arthritis to 89 a rheumatologist or prompt diagnosis and initiation o therapy. Patients o en complain o early morning joint sti ness lasting more than 1 h that eases with physical activity. The initial pattern o joint involvement may be monoarticular, oligoarticular (4 joints), or polyarticular (>5 joints), usually in a symmetric distribution. In ammation about the ulnar styloid and tenosynovitis o the extensor carpi ulnaris may cause subluxation o the distal ulna, resulting in a "piano-key movement" o the ulnar styloid. Although metatarsophalangeal (M P) joint involvement in the eet is an early eature o disease, chronic in ammation o the ankle and midtarsal regions usually comes later and may lead to pes planovalgus (" at eet"). Large joints, including the knees and shoulders, are o en a ected in established disease, although these joints may remain asymptomatic or many years a er onset. Atlantoaxial involvement o the cervical spine is clinically noteworthy because o its potential to cause compressive myelopathy and neurologic dys unction. Neurologic mani estations are rarely a presenting sign or symptom o atlantoaxial disease, but they may evolve over time with progressive instability o C1 on C2. The prevalence o atlantoaxial subluxation has been declining in recent years, and occurs now in less than 10% o patients. When palpated, the nodules are generally rm; nontender; and adherent to periosteum, tendons, or bursae; developing in areas o the skeleton subject to repeated trauma or irritation such as the orearm, sacral prominences, and Achilles tendon. Nodules are typically benign, although they can be associated with in ection, ulceration, and gangrene. The presence o elevated serum in ammatory markers appears to coner an increased risk o cardiovascular disease in this population. The in ammatory milieu o the joint probably spills over into the rest o the body and promotes generalized bone loss by activating osteoclasts. The cutaneous signs vary and include petechiae, purpura, digital in arcts, gangrene, livedo reticularis, and in severe cases large, pain ul lower extremity ulcerations. Vasculitic ulcers, which may be di cult to distinguish rom those caused by venous insu ciency, may be treated success ully with immunosuppressive agents (requiring cytotoxic treatment in severe cases) as well as skin gra ing. Sensorimotor polyneuropathies, such as mononeuritis multiplex, may occur in association with systemic rheumatoid vasculitis. Because low testosterone levels may lead to osteoporosis, men with hypoandrogenism should be considered or androgen replacement therapy. For example, the Native American Y akima, Pima, and Chippewa tribes o North America have reported prevalence rates in some studies o nearly 7%. And ourth, the risk loci mostly reside in genes encoding proteins involved in the regulation o the immune response. However, it has not been shown that smoking cessation, while having many health bene ts, improves disease activity. The synovial membrane, which covers most articular sur aces, tendon sheaths, and bursae, normally is a thin layer o connective tissue. In joints, it aces the bone and cartilage, bridging the opposing bony sur aces and inserting at periosteal regions close to the articular cartilage. It consists primarily o two cell types-type A synoviocytes (macrophage-derived) and type B synoviocytes (broblast-derived). The synovial broblasts are the most abundant and produce the structural components o joints, including collagen, bronectin, and laminin, as well as other extracellular constituents o the synovial matrix. The sublining layer consists o blood vessels and a sparse population o mononuclear cells within a loose network o connective tissue. Synovial uid, an ultra ltrate o blood, di uses through the subsynovial lining tissue across the synovial membrane and into the joint cavity. Hyaluronan is a glycosaminoglycan that contributes to the viscous nature o synovial uid, which along with lubricin, lubricates the sur ace o the articular cartilage. Chronic in ammation leads to synovial lining hyperplasia and the ormation o pannus, a thickened cellular membrane containing broblast-like synoviocytes and granulation-reactive brovascular tissue that invades the underlying cartilage and bone. The in ammatory in ltrate is made up o no less than six cell types: cells, B cells, plasma cells, dendritic cells, mast cells, and, to a lesser extent, granulocytes. Growth actors secreted by synovial broblasts and macrophages promote the ormation o new blood vessels in the synovial sublining that supply the increasing demands or oxygenation and nutrition required by the in ltrating leukocytes and expanding synovial tissue. The structural damage to the mineralized cartilage and subchondral bone is mediated by the osteoclast. These lesions typically localize where the synovial membrane inserts into the periosteal sur ace at the edges o bones close to the rim o articular cartilage and at the attachment sites o ligaments and tendon sheaths. It is associated with substantial thinning o the bony trabeculae along the metaphyses o bones, and likely results rom in ammation o the bone marrow cavity. T eir signal characteristics show they are water-rich with a low at content and are consistent with highly vascularized in ammatory tissue. The cortical bone layer that separates the bone marrow rom the invading pannus is relatively thin and susceptible to penetration by the in amed synovium. It is organized in our distinct regions (super cial, middle, deep, and calci ed cartilage zones)-chondrocytes constitute the unique cellular component in these layers. The cartilage matrix is characterized by a generalized loss o proteoglycan, most evident in the super cial zones adjacent to the synovial uid. Degradation o cartilage may also take place in the perichondrocytic zone and in regions adjacent to the subchondral bone. The pathogenic mechanisms o synovial in ammation are likely to result rom a complex interplay o genetic, environmental, and immunologic actors that produces dysregulation o the immune system and a breakdown in sel -tolerance. Precisely what triggers these initiating events and what genetic and environmental actors disrupt the immune system remains a mystery. However, a detailed molecular picture is emerging o the mechanisms underlying the chronic in ammatory response and the destruction o the articular cartilage and bone. People who smoke display higher citrullination o proteins in bronchoalveolar uid than those who do not smoke. Similarly, abnormal selection o the cell repertoire in the periphery might lead to a breakdown in cell tolerance. At least some antigen stimulation inside the joint seems likely, owing to the act that cells in the synovium express a cell-sur ace phenotype indicating prior antigen exposure and show evidence o clonal expansion. In these studies, the most glaring ndings have been the loss o telomeric sequences and a decrease in the thymic output o new cells. Although intriguing, it is not clear how generalized cell abnormalities might provoke a systemic disease dominated by synovitis. In the rheumatoid joint, by mechanisms o cell-cell contact and release o soluble mediators, activated cells stimulate macrophages and broblast-like synoviocytes to generate proin ammatory mediators and proteases that drive the synovial in ammatory response and destroy the cartilage and bone. The immune system has evolved mechanisms to counterbalance the potential harm ul immunemediated in ammatory responses provoked by in ectious agents and other triggers. Among these negative regulators are regulatory (reg) cells, which are produced in the thymus and induced in the periphery to suppress immune-mediated in ammation. Cytokines, chemokines, antibodies, and endogenous danger signals bind to receptors on the sur ace o immune cells and stimulate a cascade o intracellular signaling events that can ampli y the in ammatory response. Signaling molecules and their binding partners in these pathways are the target o small-molecule drugs designed to inter ere with signal transduction and block these rein orcing in ammatory loops. It upregulates adhesion molecules on endothelial cells, promoting the in ux o leukocytes into the synovial microenvironment; activates synovial broblasts; stimulates angiogenesis; promotes pain receptor sensitizing pathways; and drives osteoclastogenesis. These precursor cells undergo urther di erentiation into osteoclasts with the characteristic ruf ed membrane. Osteoclasts also secrete cathepsin K, which is a cysteine protease that degrades the bone matrix by cleaving collagen. Clinically, the analysis o synovial uid is most use ul or con rming an in ammatory arthritis (as opposed to osteoarthritis), while at the same time excluding in ection or a crystal-induced arthritis such as gout or pseudogout (Chap. The presence o radiographic joint erosions or subcutaneous nodules may in orm the diagnosis in the later stages o the disease. Plain x-ray is the most common imaging modality, but it is limited to visualization o the bony structures and in erences about the state o the articular cartilage based on the amount o narrowing o the joint space. Musculoskeletal ultrasound with power Doppler is increasingly used in rheumatology clinical practice or detecting synovitis and bone erosion. However, the vast majority o patients will exhibit a pattern o persistent and progressive disease activity that waxes and wanes in intensity over time. A minority o patients will show intermittent and recurrent explosive attacks o in ammatory arthritis interspersed with periods o disease quiescence. Early in the course o disease, the extent o joint in ammation is the primary determinant o disability, while in the later stages o disease, the amount o joint damage is the dominant contributing actor. Median li e expectancy is shortened by an average o 7 years or men and 3 years or women compared to control populations. Patients at higher risk or shortened survival are those with systemic extraarticular involvement, low unctional capacity, low socioeconomic status, low education, and chronic prednisone use. Practically speaking, however, this nding is di cult to appreciate on plain lms and, in particular, on the newer digitalized x-rays. It can also reliably detect synovitis, including increased joint vascularity indicative o in ammation. Joint in ammation is the main driver o joint damage and is the most important cause o unctional disability in the early stages o disease. These scales are increasingly used in clinical practice or tracking disease status and, in particular, or documenting treatment response. Second, a 1- to 2-week burst o glucocorticoids may be prescribed or the management o acute disease ares, with dose and duration guided by the severity o the exacerbation. Low-dose prednisone therapy has been shown in prospective studies to retard radiographic progression o joint disease; however, the bene ts o this approach must be care ully weighed against the risks. Best practices minimize chronic use o low-dose prednisone therapy owing to the risk o osteoporosis and other long-term complications; however, the use o chronic prednisone therapy is unavoidable in many cases.

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If further disclosure would have resulted in a decision that the patient would not undergo the procedure medication that causes erectile dysfunction purchase erectafil online, there has been malpractice because the health care team failed to disclose all material facts erectile dysfunction 18 erectafil 20 mg low cost. The treating physician would then be liable for all injuries resulting from the procedure (10) doctor for erectile dysfunction in hyderabad cheap erectafil 20 mg with visa. In some states erectile dysfunction drugs at walgreens cheap erectafil 20mg without a prescription, a physician or other health care provider may face a medical battery claim if he or she treats a patient without first getting informed consent or gets consent that does not adequately cover all aspects of the treatment (4) impotence lipitor generic erectafil 20 mg online. Except in an emergency no procedure other than the one(s) to which the parent or guardian has agreed may be performed erectile dysfunction quotes buy 20mg erectafil with mastercard. This includes Chapter 2 Informed Consent for Procedures 19 a modification to a procedure that is beyond the scope of the consent (11). Although damages may be more difficult to prove when the alleged battery was a successful procedure, courts may assess punitive damages (which may not be covered by malpractice insurance) and licensing boards may levy their own penalties (4). To prove such a claim, the plaintiff must generally show that the physician or designee failed to inform the patient, parent, or guardian of a material fact relating to the proposed treatment; that consent to the treatment was given without awareness of the material fact; that a reasonably prudent patient, parent, or guardian, in a similar circumstance, would have refused to consent to the treatment if informed of such material fact; and that injuries resulted from the treatment. Like a medical malpractice claim, a failure to secure informed consent claim may succeed even if the procedure was performed without negligence or there is insufficient evidence to support a battery claim (4,17). For specific informed consents, a written or oral disclosure (in many cases, both) is required. In the case of oral disclosure, the individual obtaining consent should summarize in the patient chart, in reasonable detail, the information provided. If consent is obtained by telephone, a witness should listen to the telephone conversation and co-sign the summary in the patient chart. Disclosures about proposed procedures should be presented in terms and in a language that the patient, parents, or guardians can fully understand. At minimum, the treating physician should ensure that the following are explained: 1. Disclosures should include information about the frequency and severity of the adverse potential consequences and the likelihood, duration, and degree of anticipated benefits from the treatment(s). There is a potential to overload the consentee with information; the patient, parent, or guardian does not need to hear every possible risk, especially if the problem is extremely unlikely to occur. However, the provider should consider the disclosure carefully when there is a low risk of a problem materializing but the consequences are death or severe morbidity. The physician-centered approach measures the disclosure against the accepted practice among other physicians; it asks what a reasonable physician would disclose. At trial, the court would expect testimony of medical experts to establish the standard disclosure for a given procedure (4,18). The physiciancentered approach is problematic because the standard disclosure may not actually include sufficient information. The Specific and General Informed Consent There are two kinds of informed consent: general and specific. A patient, parent, or guardian may give a general informed consent (sometimes called a "blanket consent") when the patient is admitted to the hospital and will require ongoing clinical intervention by a number of health care providers. The patient, parents, or guardians may be kept informed of the specifics of procedures during the hospital stay, but they may not be informed of every intervention. A general informed consent will cover routine medical care that a patient may receive while in the hospital, such as drawing blood or administering a nonexperimental medication. The hospital administration will define what constitutes routine care, depending on community and professional standards. The procedures considered routine may also vary depending on the hospital unit to which a patient is admitted. Examples of nonroutine procedures might be surgery for a congenital or acquired defect, renal dialysis, and extracorporeal membrane oxygenation. In such nonroutine cases, parents or guardians must receive sufficient information specific to the procedure to permit them to make a fully informed decision. In the case of general informed consent, the patient, parent, or guardian is likely to be asked to sign a written consent; these consents should be retained with the 20 Section I Preparation and Support patient-centered approach, on the other hand, will at times require considerable time and effort, often in circumstances where time may be limited. In addition, though the patientcentered approach is meant to be based on what the parties knew before the procedure and applied objectively, in practice it can be difficult to apply so rigidly. For these reasons, courts considering informed consent issues often end up with an approach that looks more like a hybrid of the physician-based and patient-based approaches: A physician should consider what other physicians in the field would disclose in the circumstances; what this patient, parent, or guardian would want to know about the options; and his or her competence with both medical terms and with the language in use (21). There is a lot to keep in mind-including the need to consider federal or state law, hospital rules, and professional association guidelines, along with the particular circumstances of the patient and/or family. If difficult issues arise, the physician should consider consulting with hospital legal counsel before proceeding. When the patient is a neonate and, therefore, cannot express autonomy, informed consent is more complicated than when the patient is a competent adult. Coercion, Manipulation, and Persuasion Consent that is not freely given is not consent. Obviously, manipulating the parents or guardians by deliberately providing incomplete or untrue information is unacceptable. Given that there is an information imbalance between the parties, it is especially important that the information the parents or guardians receive is accurate. However, there is no requirement that the physician be impartial and hide his or her opinion, as long as this opinion is based on medical evidence and professional experience, rather than religious or personal bias. It is appropriate for the physician to make a case for a particular intervention, and the parents or guardians will expect recommendations. Competency of Parents or Guardians and the State Consent is valid only if the consenting party is legally competent to give consent. However, if there are indications that the parents or guardians are not competent, the treating physician should not act on their proffered consent or refusal and should consult hospital legal counsel before proceeding. Some examples of circumstances in which one may question competency to consent include parents or guardians who abuse drugs or alcohol, who show signs of untreated mental illness, or who are minors. The parents or guardians should not be disqualified from making medical decisions simply because they speak a foreign language. In addition, even when parents or guardians are able to make themselves understood, their understanding of the prevailing language may not be optimal. Thus, all efforts should be made to provide the information in the primary language of the parents or guardians, including locating a qualified medical interpreter or interpreting service (23). To do so, the parents or guardians must have the right to make decisions in the first place and must be legally and medically competent to decide to delegate their rights. In addition, the proxy taking over the decision making must be legally and medically competent to make the medical decisions. If the parents or guardians are absent and have made no delegation, state law may determine the proxy (usually there is a hierarchy of family members but an unrelated proxy, guardian ad litem, may be appointed). If the parents are married, consent of only one of the parents will be adequate in most states. However, if the parents are not married or there has been a legal separation or divorce, obtaining proper consent may be more complicated. Whether one parent or the other (or both) have the legal right to make medical decisions will depend on state law, as well as judicial orders or settlement agreements, if they exist. With help from hospital legal counsel, if necessary, the physician should determine whether the parent present can legally provide consent for the infant. These "intrusion[s] into and interference[s] with familial relationships between a parent and child can rise to the level of a substantive due process violation" (24). This is a very fact-dependent determination; when serious, irreparable consequences may result if a procedure is not performed, the court is likely to find that there has been no substantive due process violation. The risk in such a system is that physicians, with the weight of the state behind them, will take the right to make medical decisions away from parents and guardians, even when the parents and guardians have made an informed decision not to consent. The legal presumption is that the parents or guardians make health care decisions, and that is so even when the choice may be to stop treatment of a very ill child. In this circumstance, the treating physician, with the full knowledge and participation of the parents or guardians, may refer the case for consideration by an ethics committee and/or to another physician who is willing to follow the treatment plan requested by the parents or guardians. Informed consent, parental permission, and assent in pediatric practice [reaffirmed October 2006]. Homeostasis: Fundamental mechanism whereby living things regulate their internal environment within tolerable limits, thus keeping a dynamic equilibrium and maintaining a stable, constant condition. Normal body temperature: the core body temperature is maintained by the term infant within the range of 36. Cold stress: the infant senses heat loss as a stress and responds with increased heat production and peripheral vasoconstriction, with centralization of circulation, in an effort to maintain the core temperature (8). Clinically, it may be difficult to distinguish hyperthermia from fever (infectious origin); therefore, always consider both causes in any increase in temperature (9). Hypothermia may have severe consequences in newborn infants and may even lead to arrhythmias and death (10,11). Depletion of caloric reserves and hypoglycemia, causing a shift to anaerobic metabolism and lactic acid production (14,15). Decreased cardiac output, increased systemic vascular resistance, and decreased intestinal and cerebral blood flow (11) h. Controlled hypothermia may have a neuroprotective effect in term and near-term infants with moderate to severe hypoxic ischemic encephalopathy (22,23). Peripheral vasodilatation: the skin is hot, the extremities are red, and the face is flushed. Hyperactivity and irritability: the infant becomes restless and cries, then feeds poorly, with lethargy and hypotonia. If the increase in temperature is due to hypermetabolism (infection), paleness, vasoconstriction, cool extremities, and a core temperature higher than skin temperature may be noted. Infant (1) Large surface area relative to body mass (2) Relatively large head with highly vascular fontanelle (3) Skin maturation/thickness, epidermal barrier functionally mature at 32 to 34 weeks. Environment (3,4) (1) Physical contact with cold or warm objects (conduction) (2) Radiant heat loss or gain from proximity to hot or cold objects (radiation) (3) Wet or exposed body surfaces (evaporation) (4) Air currents in nursery or in incubator fan (convection) (5) Excessive or insufficient coverings or clothing c. Other factors (1) Metabolic demands of disease: Asphyxia, respiratory distress, sepsis (11) (2) Pharmacologic agents. Maintenance of thermal homeostasis is necessary at all times, but particular attention should be paid when the neonate is undergoing diagnostic or therapeutic procedures. Hats (2,10,26) (1) Stockinette caps are not effective in reducing heat loss in term infants in the delivery room; there is insufficient evidence in preterm infants. Extremely low-birthweight preterm newborn wrapped in occlusive polyethylene sheet during resuscitation. All aspects of homeostasis are maintained during a procedure by use of incubator portholes, swaddling, comfortable position, and sucrose/analgesia pacifier. Thermal resistor (thermistor): A probe placed on the anterior abdominal wall or interscapular area. Add an extra heat source (heat lamp) for unstable infants or stressful procedures. Interventions to prevent hypothermia at birth in preterm and/or low birthweight babies. Cardiovascular changes during mild therapeutic hypothermia and rewarming in infants with hypoxicischemic encephalopathy. Hemodynamics among neonates with hypoxic-ischemic encephalopathy during whole-body hypothermia and passive rewarming. Neonatal resuscitation: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Oxygen consumption and temperature control of premature infants in a double-wall incubator. The relation between environmental temperature and oxygen consumption in new-born baby. A prospective study of free bilirubin and other risk factors in the development of kernicterus in premature infants. Effects of the thermal environment on cold resistance and growth of small infants after the first week of life. Hypothermia and perinatal asphyxia: executive summary of the National Institute of Child Health and Human Development workshop. The effect of wool vs cotton head covering and length of stay with the mother following delivery on infant temperature. The bowel bag: a sterile, transportable method for warming infants with skin defects. This risk remains present for the first 2 to 4 weeks according to gestational age at birth. Gastroschisis/omphalocele: these abdominal wall defects increase the risk of heat loss, fluid imbalance, and visceral damage. The infant may be placed in a "bowel bag" from the torso down, or the entire abdomen may be wrapped in clean, clear plastic wrap. Avoid visceral ischemia by keeping intestines directly above the abdominal wall defect or keep the infant in right lateral decubitus position (29). Neural tube defects: Keep the infant in the prone position, cover the lesion with sterile gauze (soaked in warmed sterile saline), and then wrap the trunk circumferentially with a dry gauze. Finally, cover the dry gauze with plastic wrap to minimize insensible water losses and prevent hypothermia (30).

Tyre tread marks over the unclothed or not very thickly clothed areas on one surface of the body erectile dysfunction protocol hoax order erectafil 20mg overnight delivery, with grazelike abrasions on the opposite side erectile dysfunction natural shake order erectafil 20 mg with mastercard, i impotence caused by medication order cheapest erectafil and erectafil. The head may be crushed causing gross distortion and externalization of the brain or severe injuries may occur to the chest erectile dysfunction medicine from dabur buy erectafil in india, pelvis or abdomen shakeology erectile dysfunction order 20 mg erectafil. Avulsion injury occurs when the wheel moves over a fleshy part causing degloving of skin and subcutaneous tissue erectile dysfunction zenerx purchase generic erectafil on-line, by tearing it away from underlying tissues. Secondary Injuries these result from body parts striking the ground following the primary impact. They are more lethal than the primary injuries, especially to the head, chest and pelvis. When the pedestrian is thrown to the ground, he sustains abrasions (skidding brush burns are common), bruises or lacerations over the bony prominences, such as elbows, knees, etc. This is due to the moving head of the victim being suddenly stopped on impact (contre -coup injury)- diffuse damage to axons may be caused by the rotational or shearing forces acting upon the brain. Fractures of the spine, especially in the cervical and thoracic segments may lead to cord damage. Usually, it is very difficult to classify the injuries as primary impact, secondary impact or secondary injuries. Windshields, nowadays, are made of a thin outer and inner layer of glass with thick plastic core. The driver tends to receive a different pattern of injury as compared to either the front seat or rear seat passenger. The driver may receive a momentary warning of the impending collision and brace himself against the steering wheel. Fractures of the wrists and arms may thus occur, as well as fractures or dislocation of tibia, fibula and pelvis may occur from transmission of the force of impact from pressing on the brake and clutch pedals. If the driver is unaware, his knees will impact against the dashboard, his chest against the steering wheel, and his head against the windshield. An impact of the knees against the dashboard commonly causes fractures of the tibia, fibula, femur and pelvis. Severe impact against the windshield pillar may cause avulsion of the skin of the forehead, basilar skull fractures, closed head injury and fracture or dislocation of the atlanto-occipital junction. Steering wheel impact injury: the circular rim of the steering wheel may cause fractures of the jaws and facial bones, as well as imprint abrasions, minor bruises and contusions of the chest or bilateral rib fractures. Damaged steering wheel spokes may penetrate the chest and lacerate the heart and lungs. With severe thoracic compression, partial or complete transection of aorta may occur usually at the junction of the aortic arch with descending aorta- classical injury. Serious steering wheel injuries are less frequent, if the car is fitted with energy absorbing compressible steering wheel column. In pedestrian accidents, the common cause of death is head injuries and fracture dislocations of cervical spine, mainly at the atlanto-occipital joint. While the vehicle rapidly decelerates and stops, the occupants continue to move forward striking against the interior of the vehicle, unless they are restrained. If the head impacts against the windshield, the victim does not sustain severe cuts from the fragments of glass which used to happen when it A B. Without a seat belt, he is at risk of severe impaction of his head against the windshield with its consequences. The occupant may be ejected out of the vehicle through the windscreen, increasing the risks of secondary injuries or running over. Passengers of the rear seat often escape such injuries because of the absence of impact against the windshield and dashboard and of the cushioning effect of the front seat. However, they may be injured against internal fittings, like door handles or ejected through burst-open doors. A high velocity rear impact crash can deform and rupture the gas tank with ignition of the fuel. Side Impact Crash the vehicle strikes on the side of another vehicle or skids sideways into a fixed object. This is a common pattern in an intersection and is therefore a frequent occurrence in urban areas. Injuries are often severe, because the side of a car has a thin metal wall door and no other components to absorb the force of impact. Since the occupants of the vehicle move toward the side of impact, the persons sitting on that side run the greatest risk. Dicing injuries may occur which are superficial cuts of the skin caused by fragments of tempered glass (designed to shatter into small glass cubes on violent impact). They are linear, right angled or V-shaped laceration seen typically on the face, forehead and arm on the right side of the driver and left or right side of passengers. Cervical spine fracture, fractured ribs, contusions, lacerations and explosive tearing of the lungs on the side of the impact are common. External injuries tend to 253 be on the right side of the driver, the right arm and leg may be fractured. In the abdomen, a lateral impact on the right side commonly causes lacerations of the right lobe of the liver and right kidney. An impact on the left frequently lacerates the spleen, left kidney and left lobe of the liver. Roll-over Crash Although the automobile may suffer severe damage in a roll-over crash, the occupants receive surprisingly moderate impact, if the vehicle is not brought to a sudden stop and the impact is spread over a period of time. The crashing of different sides of the vehicle absorbs the forces of impact, if the passenger compartment remains intact, the belted occupants frequently survive the crash (anything that prevents ejection of occupants). Role of Seat Belts and Air Bags Numerous safety features such as safety belts, airbags, collapsible steering columns, softened interior dashboards and antilock brakes have contributed to the saving of lives. The air bag system has reduced the gravity and incidence of chest and facial trauma, especially in those individuals not using seat belts. These are intended to provide protection only in frontal crashes and to be used in conjunction with seat belts. Lap belts can produce tears of the mesentery, omentum and laceration of the bowel. Primary injuries may occur from impact by cars and trucks, but secondary injuries involving the head and chest are common from falling. A unique injury seen among bicyclists is stripping of the skin from the leg due to limb being forced between the wheel spokes. Helmets reduce the risk of fatal head injury by 1/3rd and reduce the risk of facial injury by 2/3rd. Fractures of the lower extremities are common, occurring in approximately 40% of motorcyclists hospitalized for non-fatal injuries. Although, seat belts reduce mortality, they cause a specific pattern of internal injuries. Patients with seat belt marks on their body have been found to have a 4fold increase in thoracic trauma and an 8-fold increase in intra-abdominal trauma compared with those without seat belt marks. There are three forms of automobile belt restraints: Lap belts, shoulder (diagonal) belts and three-point belts (lap plus shoulder). The most popular and efficient seat belt is the 3-point belt which consists of both a diagonal and transverse strap set in inertia recoil housing. In a high speed impact of a motorcycle, there may be primary injuries due to the initial impact, followed by secondary injuries from striking the ground. Secondary injuries are mostly fractures of the skull, ribs and cervical spine, as well as contusions of the brain. Ring fracture around the foramen magnum may be seen in some cases by an impact of the crown of the head. Since some countries limit the damages to be recovered if the victim was not wearing a seat belt, any injuries consistent with seat belt injuries should be noted. History the history should include the condition of the eyes (corneal opacities), blindness, if the victim was suffering from any disease. Clothing the clothing should be described with special attention to tyre imprint marks, tears, amount of bleeding and foreign bodies, especially glass particles, metal, grease marks or oil stains and paint which may indicate the part of the vehicle that struck the victim and provide valuable evidence with respect to the suspected vehicle (hit and run cases). Similarly, hair, blood and other tissues can be transferred from the pedestrian to the vehicle. For this reason, autopsy surgeon should preserve hair and blood samples for comparison. Internal injuries: the distribution of fatal injuries is mostly related to the head and chest. Due to extraordinary resilience of the skin, serious internal injuries may be present without any evidence of corresponding external injury. Laboratory Specimens A blood sample (of the driver or pedestrian) should be analyzed for the presence and amount of alcohol (taken from peripheral vein and not from heart or viscera, if death occurred within 12-24 h of accident) and drugs, since the question of contributory negligence may subsequently arise. If sufficient blood is not obtainable, vitreous fluid from the eye can be analyzed for alcohol. Sometimes, it is necessary to know who was driving the vehicle for insurance purpose. Alcohol, Drugs and Trauma Alcohol and substance abuse are major associated factors in all forms of trauma. About 10% of the drivers with blood alcohol level higher than the legal limit account for nearly 1/3rd of non-fatal and half of fatal driver deaths. Injury to drunken pedestrians shows even greater association, as pedestrian accidents account for nearly 3/4th of adult traffic accidents. There is a strong association with alcohol, drug dependency and dangerous driving, violent and aggressive behavior. Drugs tested for should include alcohol, carbon monoxide, acid, basic and neutral drugs. In case of death, analysis of vitreous fluid is valuable as it reflects the alcohol and drug levels 12 h prior to death. Railway Injuries these are common in India and China because of a wide network and unprotected crossings. There is nothing specific about railway accidents, except the frequency of severe mutilation. The body may be severed into many pieces and soiled by axle grease and dirt from the wheels and track. When passengers fall off from the train, multiple injuries along with abrasions are seen due to contact with coarse gravel along the line ballast. Suiciders either jump in front of a moving train from a platform, bridge or other structure near to the track, or place their head across a rail causing transected neck, either partial or complete with black soiling at the crushed decapitation or amputation site. Furthermore, a careful search for unusual injuries (stabs, gunshots) and for vital reaction to the severe blunt force injuries should be made, as there many occasions when the victim of a homicide has been placed onto the rail track in an attempt to make it appear like an accident. These fragments have the potential to cause more devastating injury to tissues than bullets. The two main components of this wave are a blast wave (known as dynamic overpressure) with a positive and negative phase, and the blast wind (mass movement of air). Injuries are mainly due to the initial shock wave, but are aggravated by the subatmospheric phase. As the tympanic membrane ruptures at about 150 kN/m2, the effects on the human body of such an explosion can be devastating. Like sound waves, the blast pressure waves flow around an obstruction and affect anyone sheltering behind a wall or a trench. Also, any person standing in front of a wall or any surface facing an explosion is subjected to the added effect of a reflected pressure. This phenomenon results in injuries ranging from traumatic amputation to disruption. They are composed of propellants, such as black powder and pyrotechnics, such as fireworks and oil- or petroleum based explosives such as Molotov cocktails. Brain: It can cause concussion or mild traumatic brain injury without a direct blow to the head. There may be headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia or other constitutional symptoms. Secondary injuries are due people being injured by shrapnel and other objects propelled by the explosion. These injuries may affect any part of the body and sometimes result in penetrating trauma. Some explosives, such as nail bombs, are purposely designed to increase the likelihood of secondary injuries. Penetrating thoracic trauma, including lacerations of the heart and great vessels is a common cause of death. Tertiary injuries: these are the injuries resulting from blast wind that can throw victims against solid objects. Tertiary injuries may present as some combination of blunt and penetrating trauma, including bone fractures and coup contre-coup injuries. Quaternary (miscellaneous) injuries: Injuries not included in the first three categories. These include flash burns,* crush injuries, fall resulting from the explosion and respiratory injuries (toxic dust, gas) or radiation exposure. Primary: Primary injuries are caused by blast waves and characterized by the absence of external injuries.