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Ihab Roushdy Kamel, M.D., Ph.D.
- Clinical Director, MRI
- Professor of Radiology and Radiological Science
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0015667/ihab-kamel
Use with caution in diabetes medicine 6 year course buy lithium 150 mg amex, hypertension medicine keflex cheap 150 mg lithium overnight delivery, congestive heart failure symptoms 6 dpo purchase 300 mg lithium, known systemic fungal infection treatment refractory generic 300mg lithium amex, renal disease medications equivalent to asmanex inhaler lithium 300 mg with amex, idiopathic thrombocytopenia medicine organizer purchase 150 mg lithium amex, psychosis, seizure disorder, gastrointestinal disease, glaucoma, known sensitivity. Adverse Effects: Depression, euphoria, headache, restlessness, hypertension, bradycardia, nausea/vomiting, swelling, diarrhea, weakness, fluid retention, paresthesias. Use with caution in active infections, renal disease, penetrating spinal cord injury, hypertension, seizures, congestive heart failure. Glucagon may be helpful in instances where patients are taking beta-blocker medications. It may improve hypotension that persists despite treatment with epinephrine, producing both positive inotropic and chronotropic effects as well as bronchodilation. Explain why the allergic response and not the antigen is the greater threat in a hypersensitivity reaction. What is the principal chemical released by the body that produces many of the symptoms of anaphylaxis What is the suspected diagnosis of a patient reporting difficulty breathing and swelling of the lips who remembers a reaction to seafood several years ago Explain why electrical therapy is the preferred initial therapy over drug administration for cardiac arrest and some arrhythmias. Discuss medications used to treat symptomatic bradycardia: atropine sulfate, epinephrine, and dopamine. Discuss adenosine (Adenocard) and its role in the treatment of supraventricular tachycardia. Discuss the calcium channel blockers diltiazem (Cardizem) and verapamil (Isoptin). Explain the benefit of the beta blockers propranolol, metoprolol, and esmolol in the treatment of arrhythmias. Discuss the following ventricular antiarrhythmic agents: amiodarone (Cordarone), lidocaine (Xylocaine), procainamide (Pronestyl), and magnesium sulfate. Discuss the use of epinephrine in treating pulseless electrical activity and asystole. He reports to arrive to find a 72-year-old is you that he feels dizzy, and he denies any chest pain or shortness of breath. You take a pulse while your partner places the patient on the cardiac monitor/defibrillator. The pulse feels slow, and when the patient is on the monitor you note that his rhythm is a sinus bradycardia at a rate of 48 beats/min. Basic Electrophysiology the heart is a complex muscular organ composed of four smaller chambers that contract and relax in an organized pattern to pump blood around the body. Each chamber is made up of millions of cardiac muscle cells, and each cell is capable of contracting independently. For the heart to pump blood most efficiently, the muscle cells and the four chambers of the heart must work in a coordinated fashion. As each impulse moves through the heart, it signals each portion of the heart to contract in the required organized fashion. These electrical impulses coordinating cardiac contraction give the heart its rhythm. The aim of electrical therapy is to reset the heart and cause all the cardiac cells to pause and restart in an organized fashion. Many people will have a heart rate of less than 60 beats/min and be physiologically normal. For instance, a well-conditioned athlete such as a marathon runner will have a heart rate of less than 60 beats/min and be symptom free. Other patients may require a high resting heart rate to maintain an adequate cardiac output. Such patients may be accustomed to having a resting heart rate of 90 beats/min, and a decrease of their heart rate to 70 beats/min may be inappropriately slow for them and may produce symptoms. The decreased heart rate will decrease cardiac output and may produce symptoms of decreased mental status, syncope, hypotension, chest pain, congestive heart failure, dyspnea, seizures, or shock. The vagus nerve, when stimulated, causes slowing of the heart rate, much like applying the brakes when driving a vehicle. Therefore, a drug that inhibits the vagus nerve will increase the heart rate, as if you took your foot off the brake pedal in the vehicle. If treatment with atropine is unsuccessful, the electrical therapy for bradycardia is transcutaneous pacing. When confronted with a symptomatic patient with bradycardia, prepare for transcutaneous pacing. It usually takes time to apply a transcutaneous pacemaker, so drug therapy may be required while preparing the patient and equipment. Infusions of epinephrine (2 to 10 mcg/min) or dopamine (2 to 10 mcg/kg per minute) may be used while waiting to establish transcutaneous pacing or if pacing is ineffective. Both epinephrine and dopamine are beta-adrenergic drugs, meaning they bind and stimulate the beta1 receptors of the heart. These properties make these drugs chronotropic, which results in an increase in heart rate. Indications: Symptomatic bradycardia, nerve agent exposure, organophosphate poisoning. Adverse Effects: Decreased secretions resulting in dry mouth and hot skin temperature, intense facial flushing, blurred vision or dilation of the pupils with subsequent photophobia, tachycardia, restlessness. Indications: Bronchospasm, allergic and anaphylactic reactions, restoration of cardiac activity in cardiac arrest, persistent bradycardia where pacing is ineffective or unavailable. At high doses (>10 mcg/kg per minute), alpha- adrenergic agonism predominates, and increased peripheral vascular resistance and vasoconstriction result. Adverse Effects: Tachycardia, arrhythmias, skin and soft-tissue necrosis, severe hypertension from excessive vasoconstriction, angina, dyspnea, headache, nausea/vomiting. Correct any hypovolemia with volume fluid replacement before administering dopamine. Tachycardia (continued) Because the patient is feeling dizzy with a slow heart rate, you determine that the patient is experiencing symptomatic bradycardia. You feel a weak radial pulse while your partner measures a blood pressure of 92/74 mm Hg. Your partner repeats the blood pressure reading; it has increased to 122/81 mm Hg. Your patient isthough year-old woman with no medical problems except that she feels as her heart is racing. Carotid massage should never be attempted in older people who have a high likelihood of carotid stenosis because of plaque formation. The only vagal maneuver that should be performed in older patients is a Valsalva maneuver. Remember, synchronized cardioversion is indicated if your patient is unstable, such as having altered mental status, hypotension, or chest pain. This creates a short period of asystole or ventricular escape beats and is usually seen for a few seconds after adenosine has been given. Adenosine has an ultrashort half-life of 5 to 20 seconds and works only when the majority of the administered dose reaches the heart quickly. He has a long history of atrial fibrillation with a rapid ventricular rate and usually takes the beta blocker atenolol (Tenormin) for rate control, as well as warfarin (Coumadin) for anticoagulation. He has been noncompliant with his atenolol and started feeling as though his heart was racing this morning. They block the influx of calcium into cardiac cells and arterial smooth muscle cells. This slows conduction velocity of the cardiac action potential and prolongs the period of repolarization. In the preceding case, the administration of a calcium channel blocker will decrease the ventricular rate, but the rhythm will remain an atrial fibrillation. Some calcium channel blockers have more of an ability to result in arteriole dilation than do others. If you are administering a calcium channel blocker to treat a rapid heart rate like that in atrial fibrillation with a rapid ventricular rate, be mindful that the medication used to treat the heart rate may have the undesirable effect of dropping the blood pressure. Therefore, following administration for treatment of the heart rate, be sure to observe the patient closely and monitor the blood pressure frequently. The actions of calcium channel blockers provide many clinical applications in both the acute setting and for long-term therapy. Because of their arterial dilatory effects, calcium channel blockers are used to treat hypertension. Because they also block vasospasm, calcium channel blockers can be used to decrease anginal episodes and even decrease the incidence of migraine headaches. Various calcium channel blockers have different proportions of vasodilator, antihypertensive, and antiarrhythmic effects. Diltiazem (Cardizem) can be used for acute ventricular rate control and the management of hypertension. Advanced life support drug boxes that carry calcium channel blockers invariably use diltiazem. Verapamil (Isoptin) tends to produce more hypotension than diltiazem due to more prominent negative inotropic effects. Both of these medications can be given intravenously for urgent rate control in atrial fibrillation with rapid ventricular response; however, diltiazem is typically the preferred agent. Special Considerations: Do not administer to patients with heart failure or impaired ventricular function. Medical direction asks you to administer a beta blocker rather than a calcium channel blocker. As discussed in Chapters 1 and 6, beta blockers exert their pharmacologic effects on both beta1 and beta2 receptors. Beta1 receptors are located in the heart and act as the main mediator of rate and contractility. Beta blockers are negative inotropic drugs that decrease the force and velocity of myocardial contractility, thus lowering blood pressure and oxygen consumption. Beta2 blockers prevent vasoconstriction and contribute to lowering of blood pressure. Because of their ability to decrease both heart rate and myocardial contractility, beta blockers are useful in the treatment of dissecting aortic aneurysms. Special Considerations: Monitor blood pressure and heart rate closely during administration. The Vaughan-Williams classification of antiarrhythmic medications defines four classes based on primary mechanism of action: 1. These agents are further divided into subclasses according to their effect on the sodium channel. That is, it has some sodium-blocking effects, some beta-blocking effects, and some calcium-blocking effects in addition to predominant effects on the potassium channels. Because amiodarone exerts its effect in both atrial and ventricular tissue, the drug is capable of treating both atrial and ventricular arrhythmias. When a drug increases the duration of the action potential or the refractory period, what does that mean To explain this you need to imagine that you are standing on a bridge that passes over an interstate highway. What determines how many cars rush underneath your bridge in a matter of 1 minute The velocity of the cars and the distance between those cars are the principal elements that determine the number of cars that can pass underneath the bridge. The speed, or velocity, of the cars rushing down the highway can be likened to the action potential duration. The faster the action potential duration, the faster the action potential will move down the conduction system. Various medications and shifts of electrolytes can affect the duration of the action potential and, therefore, how rapidly that particular impulse moves down the system. If the cars are all traveling at 55 miles per hour (89 km/hr), the greater the space between the cars, at a given speed, the fewer cars can pass under the bridge. In the heart, each electrical action potential has a period known as the refractory period. The greater the refractory period, the fewer action potentials will travel down through the heart in 1 minute. It has been shown to decrease short-term mortality rates in patients with congestive heart failure. Amiodarone is recommended as the first-line antiarrhythmic medication for patients in cardiac arrest from ventricular arrhythmias; lidocaine is recommended as an alternative to amiodarone. Because it decreases nodal conductivity, it can be used for both atrial and ventricular arrhythmias. However, because it cannot be given rapidly and can take 20 to 40 minutes to work, most out-of-hospital providers do not use procainamide. Instead, it is polymorphic, with many different-shaped complexes that appear to rotate by 180 degrees over time, almost like it is twisting. Alcoholics typically have poor diets that cause several nutritional and electrolyte abnormalities that can result in arrhythmias. Therefore, magnesium should always be considered in alcoholics and malnourished patients. Although some of the medications used to treat all four rhythms are the same, there are variations. In cases in which you are treating an overdose of a beta blocker or calcium channel blocker, high doses up to 0.
Mucosal changes associated with such agents include lamina propria oedema treatment 32 order cheap lithium on-line, haemorrhage medications 222 generic lithium 300mg without prescription, occasional neutrophils medications xerostomia generic lithium 300mg with amex, apoptotic activity medications john frew order lithium 150 mg with mastercard, and surface mucosal degenerative changes medicine advertisements order lithium online. Localised mucosal haemorrhage can also result from endoscope trauma during the procedure medicine omeprazole order lithium from india. However, none of these features overlaps significantly with those of microscopic colitis. Loughrey Differential Diagnosis of Collagenous Colitis If H&E assessment demonstrates a subepithelial collagen band, sufficient for consideration of a diagnosis of collagenous colitis, there are several differential diagnoses that require exclusion (Practice Points 20. Fibrin deposition or hyalinisation of the superficial lamina propria in this condition can resemble the collagen band of collagenous colitis. However, the hyaline material is not usually band-like and is typically more extensive within the lamina propria than in collagenous colitis. Finally, the clinical presentation is likely to be different, characterised by abdominal pain and bloody diarrhoea which are common in the acute setting and are rare in microscopic colitis. Radiation-related mucosal injury can closely mimic chronic ischaemic colitis and potentially collagenous colitis (see also Chapter 3). Crypt atrophy, crypt architectural distortion, vascular ectasia, stromal cell atypia, and lack of a band-like appearance to the hyalinisation can facilitate distinction from collagenous colitis. Furthermore, collagenous colitis tends to have more diffuse and superficial inflammation within the lamina propria. Systemic amyloidosis involving the lower gastrointestinal tract can potentially mimic the pale eosinophilic, paucicellular collagen deposition of collagenous colitis. Congo red histochemical staining for amyloid will confirm the diagnosis (see also Chapter 2). Fibromuscular expansion of the deeper lamina propria, thickening of the muscularis mucosae, and angulation of crypts indicate a diagnosis of mucosal prolapse, which lacks the inflammatory changes typical of collagenous colitis (see Chapter 26). There may be mucosal inflammation in association with diverticular disease, so-called diverticular colitis, and clinicopathological correlation may be required to exclude this diagnosis. Finally, a subepithelial collagen band may occur within a focal mucosal lesion, most commonly a hyperplastic polyp. However, a pathologist unaware of this association may inappropriately raise the possibility of a coincidental diagnosis of collagenous colitis, especially if the polyp is also inflamed. Loughrey Differential Diagnosis of Lymphocytic Colitis the differential diagnosis of lymphocytic colitis is much narrower than that of collagenous colitis (Practice Points 20. In the latter, crypt architecture is usually normal but neutrophils predominate in the inflammatory infiltrates, especially towards the superficial lamina propria and within surface epithelium. This makes distinction of lymphocytic colitis from acute transient infectious colitis typically straightforward. However, in the late or resolving phase of infectious colitis, neutrophils may be inconspicuous, mononuclear cells more prominent, and patchy surface lymphocytosis evident. In this setting, the features may be indistinguishable from lymphocytic colitis, and correlation with clinical course may be necessary. In one rare form of infectious colitis, known as Brainerd diarrhoea after the United States town in which the first outbreak was recorded, colonic intraepithelial lymphocytosis is a characteristic feature, although lymphocyte counts are less pronounced than in lymphocytic colitis. Colonic intraepithelial lymphocytosis may even occur in patients with constipation. Most well-sampled cases of collagenous colitis or lymphocytic colitis have clear-cut features of one diagnosis or the other, and true borderline cases are relatively rare. Furthermore, as clinical behaviour and treatment are essentially the same for both conditions, it is reasonable to label unclassifiable cases as microscopic colitis and to record the diagnostic uncertainty. Based on current evidence, it is best to consider collagenous colitis and lymphocytic colitis as two distinct but closely related conditions. However, the features of chronicity are usually mild and focal when they occur in collagenous colitis or lymphocytic colitis. With lesser degrees of collagen deposition, either in undersampled collagenous colitis or in lymphocytic colitis, the distribution of the associated inflammatory infiltrates can help distinguish Collagenous Colitis versus Lymphocytic Colitis It is important to remember that collagenous colitis and lymphocytic colitis are differential diagnoses of each other, distinguished mainly by the presence or absence of a collagen band. The only other useful discriminating feature is that intraepithelial lymphocytosis is often much more pronounced in lymphocytic colitis than in collagenous colitis. This differential diagnosis tends to be most difficult if sampling is limited, and indeed this issue confounds many of the studies proposing that collagenous colitis and lymphocytic colitis are different manifestations of the same disease. Distinction from lymphocytic colitis may be heavily reliant on the clinical and endoscopic pictures and on the presence or absence of diffuse surface intraepithelial lymphocytosis. Therefore, it is more likely that these reports of coexistence represent random association of two different disease processes. Therefore, if terminal ileal mucosa alone is biopsied, careful examination may demonstrate features suggesting an underlying diagnosis of microscopic colitis. More commonly, terminal ileal sampling accompanies colonic sampling and, if microscopic colitis is apparent in colonic biopsies, close inspection of the ileal mucosa may then reveal related changes. Ileal involvement may in turn indicate a greater likelihood of upper gastrointestinal tract involvement, notably within the stomach or duodenum (personal observation) and may merit subsequent upper gastrointestinal tract endoscopy and sampling. Prognosis and Treatment the natural history and treatment of collagenous colitis and lymphocytic colitis are very similar. Spontaneous remission of symptoms, principally chronic diarrhoea, will occur in some cases, but medical therapy with the aim of achieving remission is required in most. This may take the form of simple over-thecounter antidiarrhoeal agents such as loperamide, mebeverine, or bismuth subsalicylate. If symptomatic treatment is unsuccessful in controlling the disease, systemic therapy with oral budesonide may be necessary. There is no good evidence from randomised, placebocontrolled trials for use of any other drugs to treat microscopic colitis. A budesonide dose of 9 mg per day for six to eight weeks typically effects a rapid response and induces clinical remission in the vast majority of patients. Approximately 50% demonstrate a reduction in subepithelial collagen deposition or in mononuclear inflammation within the lamina propria. This necessitates retreatment with budesonide, to induce clinical remission again, and attempted maintenance at a lower dose, typically 6 mg per day. Therefore, some patients will be unfit for investigation by colonoscopy and cannot have a biopsy diagnosis of microscopic colitis. Such patients with chronic non-bloody diarrhoea typically have a computed tomography scan of colon to exclude colorectal cancer and can then receive empirical treatment without the need for a histologically confirmed diagnosis of microscopic colitis. The Small Intestine in Microscopic Colitis Small intestinal mucosal inflammatory changes in association with microscopic colitis can take several forms. By the nature of their accessibility to endoscopy, there is more information about duodenal and terminal ileal involvement than about jejunal involvement. As discussed earlier, lymphocytic colitis and, to a lesser extent, collagenous colitis are associated with coeliac disease, leading to a recommendation to test all patients who have microscopic colitis for coeliac disease. As discussed, some cases of microscopic colitis appear to be caused or exacerbated by certain drug groups. If there is a clinical suspicion of a drug-related element, because of temporal association between drug initiation and onset of symptoms, the initial therapeutic approach should include cessation of the offending drug, switching to an alternative if necessary. The natural history of microscopic colitis is to wax and wane, with periods of remission and relapse. Rare refractory cases, unresponsive to budesonide, may require more aggressive immunosuppressive therapy with azathioprine, 6-mercaptopurine, methotrexate, or anti-tumour necrosis factor therapy. Incidence, prevalence, and temporal trends of microscopic colitis: a systematic review and meta-analysis. The epidemiology of microscopic colitis: a 10-year pathology-based nationwide Danish cohort study. Microscopic colitis: current status, present and future challenges: statements of the European Microscopic Colitis Group. Current and past cigarette smoking significantly increase risk for microscopic colitis. European consensus on the histopathology of inflammatory bowel 322 Chapter 20: Microscopic Colitis disease. Non-steroidal anti-inflammatory drugs as a possible cause of collagenous colitis: a case-control study. Collagenous colitis in setting of nonsteroidal antiinflammatory drugs and antibiotics. Proton pump inhibitor use is associated with an increased risk for microscopic colitis: a case-control study. Macroscopic findings in collagenous colitis: a multi-center, retrospective, observational cohort study. Microscopic colitis: a descriptive clinical cohort study of 795 patients with collagenous and lymphocytic colitis. Colonic ulcers accompanying collagenous colitis: implication of nonsteroidal anti-inflammatory drugs. Cat scratch colon is caused by barotrauma secondary to insufflation during colonoscopy. The differential diagnosis of colitis in endoscopic biopsy specimens: a review article. Lymphocytic colitis and collagenous colitis: a review of clinicopathologic features and immunologic abnormalities. Atypical forms of microscopic colitis: morphological features and review of the literature. Sequential histologic evaluations in collagenous colitis: Correlations with disease behavior and sampling strategy. Macroscopic findings, incidence and characteristics of microscopic colitis in a large cohort of patients from the United Kingdom. Microscopic colitis: clinical findings, topography and persistence of histopathological subgroups. The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea. American Gastroenterological Association Institute Guideline on the Medical Management of Microscopic Colitis. Paucicellular and asymptomatic lymphocytic colitis: expanding the clinicopathologic spectrum of lymphocytic colitis. Histology of microscopic colitis-review with a practical approach for pathologists. Colonic epithelial lymphocytosis without a thickened subepithelial collagen table: a clinicopathologic study of 40 cases supporting a heterogeneous entity. Collagenous colitis evolving into ulcerative colitis: a case report and review of the literature. Progression of ulcerative colitis to collagenous colitis: chance, evolution or association The terminal ileum is affected in patients with lymphocytic or collagenous colitis. Budesonide treatment for collagenous colitis: a randomized, double-blind, placebo-controlled, multicenter trial. Budesonide in collagenous colitis: a double-blind placebo-controlled trial with histologic follow-up. Budesonide treatment of collagenous colitis: a randomised, double blind, placebo controlled trial with morphometric analysis. Collagenous and lymphocytic colitis: systematic review and update of the literature. Budesonide is effective in treating lymphocytic colitis: a randomized double-blind placebo-controlled study. Long-term budesonide treatment of collagenous colitis: a randomised, double-blind, placebo-controlled trial. Treatment of refractory microscopic colitis with azathioprine and 6-mercaptopurine. Collagenous colitis: oral low-dose methotrexate for patients with difficult symptoms: long-term outcomes. Other roles of biopsy include assessment of histological activity, assessment of the distribution of microscopic disease, recognition of complications. Despite recent advances in endoscopic techniques, histology is currently the only reliable way to diagnose and assess dysplasia. There is considerable interest in the contribution of histology to the assessment of drug therapy in clinical trials. Individual histological features such as crypt abscesses, mucin depletion, basal plasmacytosis, and lamina propria eosinophils may help predict the effectiveness of drug therapy, but study findings are inconsistent. The term indeterminate colitis is not applicable to biopsy reporting (or endoscopic reporting). Other symptoms may include loose stools, reduced stool consistency, urgency, tenesmus, and crampy abdominal pain. Patient usually have symptoms for weeks or months before requesting a medical opinion, which is fortuitous for the histopathologist and for reliability of biopsy interpretation Table 21. Disease usually involves the rectum at presentation and may extend proximally into the colon for a variable distance, with a sharp cut-off between normal and abnormal. Symptoms at presentation are heterogeneous, and include diarrhoea, abdominal pain that may be crampy, and weight loss. Perianal disease includes fissures and fistulas, the latter occurring in 10% at presentation.
Indications: To induce neuromuscular blockade for the facilitation of endotracheal intubation treatment scabies buy discount lithium online. Carefully monitor and provide adequate sedation and analgesia for patients who are chemically paralyzed with vecuronium medications zoloft buy discount lithium 150 mg on-line. Has been known to increase gastric acid secretion May cause hypotension treatment of criminals effective 300 mg lithium, hypoglycemia; use with caution in persons with diabetes or cardiac disorders; avoid concurrent use with antidiabetics symptoms 5dpiui order lithium online from canada, antihypertensives medications borderline personality disorder cheap lithium master card, calcium channel blockers Generally recognized as safe when used in typical food preparations treatment herniated disc buy generic lithium on-line. Inhalation may cause dyspnea, congestion; when used as a "pepper spray" respiratory arrest and death has occurred Generally recognized as safe when used in foods; medicinal doses may not be safe when taken long-term; unclear if safe during pregnancy and lactation; has mild sedative effects, use caution when taking other medications with sedative Blessed thistle Anorexia, gastrointestinal discomfort, and dyspepsia Arthritis, diabetes, some skin disorders. These names often describe the chemical structure or properties of the drug molecule. Generic names are often long and difficult to remember and are registered with the U. Trade names are names created by the drug companies, often created to help providers remember the action or properties of the drug. The properties of medications include mechanism of action, absorption, distribution, metabolism, elimination, and toxicity. Typically, the higher the dosage, the higher the concentration of the medication at the site of action. The greater the amount of drug at the site of action, the greater the physiologic effect. Typically, as the dosage of a medication is increased, the physiologic effect manifested by the drug is increased. This effect continues with increasing doses of the medication up to a point at which increasing the medication no longer produces an increase in the desired physiologic effect. A patient having an asthmatic attack requires a medication that has nearly immediate delivery and action. Once swallowed, the oral medication needs to be absorbed and delivered to the site of action, which may take more than half an hour. Additionally, a patient having difficulty breathing may not be able to swallow an oral medication or any water to help swallow the pill. Medications absorbed through the gastrointestinal tract must first pass through the liver before being distributed throughout the body. While passing through the liver, the drug is often partially metabolized, reducing the amount of medication available for distribution to the body. Both active transport and carrier-mediated diffusion require a macromolecule to assist in transport. Both processes require specific binding of the drug molecule to the macromolecule, and both are capable of reaching a point of saturation. A half-life is the period of time required to eliminate half of an administered medication from the body. An agonist is a drug that produces the desired physiologic effect upon binding with a drug receptor. In contrast, an antagonist is a drug that either diminishes or eradicates the physiologic effect of the agonist. A drug interaction occurs when the actions of one drug modify or interfere with the actions of a second drug. The two types of drug interactions alter the plasma level of a medication or alter the effects of a medication. This results in an increase in blood pressure, heart rate, and cardiac contractility. Epinephrine is quite arrhythmogenic; that is, it is prone to causing cardiac arrhythmias. Stimulation of beta1 receptors increases the heart rate (chronotropism) and the force of cardiac contraction (inotropism). In a dose smaller than recommended, atropine causes a paradoxic slowing of the heart rate. The basic principle of Good Samaritan laws is to encourage others to assist an ill or injured person to the best of their ability without the fear of a lawsuit for potential mistakes they may make. To prove that a paramedic was negligent after a medication error, it must be proven that the paramedic breached his or her duty to the patient and the paramedic deviated from the standard of care. There must be actual harm to the patient, and the actions of the paramedic must be responsible for causing that harm. Standing orders and protocols are advance orders from a medical director and are to be followed in the event that certain medical conditions are determined by the paramedic. When protocols and standing orders are used, online medical direction is not necessary. They tend to be rigid and do not allow for unique patient conditions or situations. Shelf life is the period that a medication may be stored and remain suitable for administration to patients. Expired medications may not produce the intended beneficial effects when administered to patients. All refusals of care must be carefully documented to prevent the risk of a claim of abandonment or negligence. If a patient refuses a portion of treatment, such as the administration of a specific medication, the paramedic can still provide other treatment that the patient does consent to receive. A complete refusal occurs in situations in which the patient refuses all aspects of treatment. Minors are usually permitted by most state laws to be able to consent to treatment, but they usually are not considered legally competent to refuse treatment. Under advanced directives, the healthcare provider is allowed to treat the patient with palliative or comfort measures and restrict the use of resuscitative measures such as cardiopulmonary resuscitation, endotracheal intubation, and medication administration. In many cases, attaching the incident report to the patient care record is not wise because anything attached to it can become part of the medical record. Standing orders are instructions for treatment that are usually specific to a particular patient presentation and may or may not require consultation with medical control. As-needed orders can be obtained from medical control to treat a condition if it develops. The nine patient rights of drug administration are right patient, right drug and indication, right dose, right route, right time, right education, right to refuse, right response and evaluation, and right documentation. Enteral medications enter the bloodstream by absorption through the gastrointestinal tract. A patient with an altered or depressed level of consciousness will not be able to take an oral medication safely. Oral medication must be transported through the gastrointestinal tract and then absorbed into the bloodstream, which delays transport and absorption. Thus a medication that is administered orally is not rapidly available for treatment of a potentially life-threatening condition. Immediately after using a needle or sharp, place it in an approved, puncture-resistant, leak-proof needle box. The Z-track technique allows delivery of medications deep into muscle tissue and prevents the medication from leaking into the surrounding soft tissue and skin. Medications that can be delivered by endotracheal tube include lidocaine, epinephrine, atropine, and naloxone. Consider an alternate method such as intraosseous if intravenous access cannot be established. When administering a medication by endotracheal tube, the paramedic needs to give 2 to 2. In addition to this increased dose, the medication should be diluted in 10 mL of normal saline. This exposes the medication to the large surface area of the lung and facilitates greater absorption. Extracellular fluid is composed of the fluid between the cells (the interstitial fluid) and the fluid inside the blood vessels. Colloid solutions use complex molecules such as proteins and complex sugars to provide osmotic pressure. Isotonic fluids contain sodium and other electrolyte concentrations that closely mimic the concentration of the extracellular fluid. Hyperkalemia may be caused by kidney failure, burns, crush injuries, diabetic ketoacidosis, and severe infections. Infiltration occurs when the tip of the catheter dislodges from the lumen of the vein and the fluid or medication is delivered to soft tissues around the vein. The way to prevent catheter shear is to never try to resheath an angiocatheter back over the needle while the needle is still inside the patient. The American Heart Association has identified the following risk factors for the development of acute myocardial ischemia: cigarette smoking, high blood pressure, high blood cholesterol, lack of exercise, obesity, and heart disease. Administration of nitroglycerin to a patient taking a medication for erectile dysfunction, such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra), can result in profound hypotension. Morphine helps relieve the pain from myocardial ischemia and causes vasodilation, which increases blood flow to the heart. Beta blockers decrease the heart rate, which decreases the amount of oxygen consumed by the heart. Also, blood flows through the heart during the diastolic portion of the cardiac cycle; therefore, slowing the heart rate increases the blood through the coronary arteries. Patients in pain may not be given narcotics because of concerns of respiratory depression and hypotension. Other concerns that prevent narcotic use include the masking of symptoms in patients with head injuries or acute abdominal pain. Morphine can produce hypotension by the release of histamine, which produces vasodilation and subsequently hypotension. Fentanyl administration does not release histamine and is less likely to cause hypotension after administration. Administration of narcotics to a patient with abdominal pain can mask the progression of an intra-abdominal disease process. The patient can subjectively feel better, but in reality the condition is worsening. Ketorolac (Toradol) is a powerful nonsteroidal anti-inflammatory analgesic that can be given parenterally. Nitrous oxide provides mild analgesia while allowing the patient to maintain and protect the airway. Benzodiazepines Antegrade amnesia is the inability to remember events from a point in time forward. Therefore, before an unpleasant procedure or situation, administer a benzodiazepine and the patient will be unable to recall the event. The symptoms of anaphylactic shock are shortness of breath, syncope, itching, swelling of the throat, and a sudden fall in blood pressure. An antigen provokes the body to produce an allergic response, which in turn stimulates cells within the body to release the chemicals histamine, serotonin, bradykinin, and slow-reacting substance of anaphylaxis. These chemicals, when released, cause vasodilation, increased capillary permeability, and smooth muscle spasm. Histamine is the chemical released by the body that is responsible for many of the symptoms associated with anaphylaxis. The most common cause of death in patients with anaphylaxis is airway obstruction. Allergy to shellfish is a common food allergy, and the patient reports a history of such reactions to seafood in the past. Epinephrine is the first-line drug therapy for patients having an anaphylactic reaction. Epinephrine causes the relaxation of bronchial smooth muscle and constriction of blood vessels. This rate of successful defibrillation drops by 7% to 10% for each minute defibrillation is delayed. Atropine is used to treat sinus bradycardia because it inhibits the effects of the vagus nerve. These agents are further divided into subclasses based on what effect they have on the sodium channel. Beta blockers exert their pharmacologic effects on both beta1 and beta2 receptors. The negative chronotropic effects of beta blockers result in a lower heart rate, automaticity, and conduction. Pulseless electrical activity is characterized by detectable electrical activity on the monitor but no mechanical cardiac activity as detected by the presence of a pulse or audible heart tones. Heart failure may be the result of ischemic heart disease, diabetes mellitus, hypertension, or disease of the heart valves. The onset of heart failure may be rather acute after a myocardial infarction or may take years to develop in conditions such as valvular heart disease, hypertension, or diabetes mellitus. Diuretics are commonly used in the treatment of congestive heart failure in patients with pulmonary edema. The decrease in the intravascular volume offloads the weakened and failing heart and reduces the congestion, or the backing up, of fluids in the lung. In the treatment of congestive heart failure, morphine is beneficial by causing venodilation, which reduces patient anxiety and lowers myocardial oxygen demand. Diastole is the portion of the cardiac cycle at which the heart is relaxed and blood is flowing through the coronary arteries. Systole is the portion of the cardiac cycle when the heart squeezes and ejects blood out of the ventricles. During systole, when the heart is contracting, blood cannot flow through the coronary arteries.
Patients with this condition have blood sugar levels that are alarming treatment 4 pink eye cheap lithium online amex, but correcting the blood sugar levels too rapidly can be more harmful than no immediate treatment at all 9 treatment issues specific to prisons cheap lithium online american express. In times of stress medications causing gout order 300mg lithium otc, cortisol prepares the body by increasing the blood pressure medications in mexico order cheap lithium line, heart rate medicine 877 discount lithium 150mg online, and blood sugar level medications used to treat depression buy generic lithium canada. Patients with thyrotoxicosis commonly have tachycardia, tremor, diaphoresis, weight loss, and intolerance for warm rooms and environments. Specific hypertensive emergencies include hypertensive encephalopathy, hypertensive intracranial hemorrhage, pulmonary edema with hypertension, myocardial ischemia with hypertension, and preeclampsia and eclampsia (hypertension with proteinuria in pregnancy). When treating a patient with a hypertensive emergency, do not reduce the diastolic blood pressure by more than 10% to 15%. Contraindications to the use of nitroprusside include coronary ischemia or infarction, pregnancy, and conditions associated with elevated intracranial pressure. Labetalol decreases blood pressure by blocking beta-mediated contraction of vascular smooth muscle. Labetalol should not be used in patients who are hypertensive as a result of cocaine intoxication. A patient whose blood pressure is elevated as a result of cocaine intoxication will have an increase in blood pressure after the administration of labetalol. Nitroglycerin is the drug of choice for treating elevated blood pressure in a patient having a myocardial infarction. Administration of hydralazine will cause a drop in blood pressure but a reflexive increase in heart rate. Contraindications to the use of beta blockers include asthma, heart failure, pheochromocytoma, cocaine toxicity, and heart block. Administration of activated charcoal commonly induces vomiting; if aspirated into the lungs, the charcoal can induce a sometimes fatal pneumonitis. Do not give activated charcoal to someone who has overdosed on acetaminophen (Tylenol) because activated charcoal interferes with the absorption of medications that are administered at the hospital to treat the poisoning. Neither gastric lavage nor activated charcoal has a role in methamphetamine intoxication because the majority of the drug has been absorbed by the time the patient is seen by a prehospital provider. The most dangerous clinical manifestations of organophosphate poisoning are excessive respiratory secretions (bronchorrhea), bronchospasm, and respiratory insufficiency. Succinylcholine should not be used because it cannot be broken down, resulting in prolonged paralysis of the patient. Increasing the concentration of inspired oxygen increases the content of oxygen in the blood and subsequently the amount of oxygen delivered to the heart and peripheral tissues. Rebreather face masks, or partial rebreathing face masks, have a face mask and a reservoir bag. During inhalation, the patient inhales the oxygen in the reservoir, as well as some room air through the side ports. Nonrebreather face masks are similar to rebreather masks in appearance and function, with the exception of having one-way exhalation valves on the sides of the mask and on the reservoir bag. The valves on the sides of the mask prevent inhalation of room air during inhalation. The valve on the reservoir prevents any of the exhaled breath from entering the oxygen-rich reservoir. The class of drugs commonly used to treat bronchospasm are beta2specific agonists. These drugs cause dilation of bronchial smooth muscle by stimulating the beta2 receptor. The two methods of delivering medications directly to the bronchioles are the pneumatically powered nebulizer and metered-dose inhaler. The objective of delivering inhaled medications is to deliver the medications to the lung. Particles that are too large will not make it to their intended site of action, the lung. Particles that are too small will be inhaled and then exhaled without binding to their receptors inside the lung. The purpose of using the spacer is to slow the velocity of the medication particles so that they do not collide with the soft tissues of the oropharynx and the medication particles can reach their intended site in the lung. The principal goal in the management of the asthmatic patient is the reversal of the acute bronchospasm. Patients with a long-standing history of chronic obstructive pulmonary disease require a mild degree of hypoxia to continue breathing. This need for mild hypoxia to continue a respiratory drive is known as hypoxic respiratory drive. Status epilepticus is defined as continuous seizure activity for more than 30 minutes or a series of seizures without full recovery of consciousness between seizures. Acute-angle glaucoma is a contraindication to benzodiazepine administration because the drug relaxes the ciliary muscle of the pupil and can cause an acute increase in intraocular pressure. A prodrug is a medication administered in an inactive form and then converted to the active form after administration. The early clinical signs of shock in patients include delayed capillary refill, cold and clammy skin, and an increased respiratory rate. The five types of shock are hypovolemic, cardiogenic, neurogenic, septic, and anaphylactic shock. An initial therapy for the treatment of hypovolemic shock is to stop the bleeding. Control of hemorrhage from traumatic blood loss can be achieved by direct pressure or tourniquets. Patients who demonstrate improved perfusion, heart rate, or blood pressure with crystalloid infusion can be categorized as rapid responders, transient responders, or nonresponders. However, with ongoing manifestations of poor perfusion return, transient responders require blood transfusion and control of hemorrhage. Standard blood banking practices involve separating donated whole blood into components. Milrinone, a drug classified as a phosphodiesterase inhibitor, is a good drug to use in a patient in cardiogenic shock but not responding to an adrenergic agonist such as dobutamine. In septic shock, the patient has a source of infection that initiates a complex sequence of events in the body known as a systemic inflammatory response. Another effect of the produced toxins is that the blood vessels become "leaky," and the patient can become hypovolemic as he or she loses intravascular fluid to the extravascular space. Therefore, these patients have vasodilation such as that seen in neurogenic shock and decreased intravascular volume as seen in hypovolemic shock. Two types of trauma can occur to the brain: primary brain injury occurs directly to the brain from mechanical forces at the time of the initial insult. Hypotension and hypoxia result in a significant increase in mortality rate from traumatic brain injury. Therefore, the paramedic should strive to prevent or treat these conditions rapidly. The treatment of severe traumatic brain injury has two goals: to identify an intracranial injury that may require surgery rapidly and to prevent conditions that result in secondary brain injury (hypoxia and hypotension). Mannitol is an osmotic diuretic that decreases brain swelling by dehydrating the brain. Hypertonic saline must be administered slowly to avoid an increase in the rate of bleeding and an alteration of the ability to clot blood. Types of infusion sets include macrodrip infusion sets, microdrip infusion sets, blood tubing sets, volume-control chamber sets, vented and nonvented infusion sets, and multiple-drip infusion sets. Cerebral perfusion pressure is calculated from the mean arterial pressure and intracranial pressure. A goal for the cerebral perfusion pressure of 70 mm Hg is needed to ensure adequate cerebral perfusion. Therefore, increases in intracranial pressure and decreases in mean arterial pressure can result in an insufficient blood flow to the brain. Fluid replacement is essential in preventing hypovolemia in critically ill burn patients. Additionally, with large areas of burned skin, the body also loses large amounts of fluids from evaporation from the burns. Large amounts of crystalloid must be administered to replace the intravascular fluid loss that results from shifts to the interstitial space. This calculation is accurate for use in adult patients but is not adequate for calculating total body surface area of children because of the disproportion of their body surface area. Pregnant women have a delay in gastric emptying that results in a delay from the time a patient takes an oral medication to the time the drug is delivered to the intestine, where oral medications are absorbed. Pregnant women have higher minute ventilation than nonpregnant women, so inhaled medications result in more rapid systemic effects than in nonpregnant women. Teratogenic drugs are medications that result in a characteristic set of malformations in the fetus. Category X drugs are the most dangerous to use in pregnancy and should be avoided. The Pregnancy Safety Category system is limited in its usefulness because most research studies conducted to determine the safety of drugs have used animals. This system is being phased out as the Food and Drug Administration implements a more elaborate system to describe medication risks to fertility, pregnancy, and lactation. When the initial peak expiratory flow rate is less than 50% of predicted, corticosteroids should be administered after ipratropium bromide. Corticosteroids should also be considered when the peak expiratory flow rate does not improve by at least 10% after bronchodilator therapy or is less than 70% after 1 hour of therapy. Chronic hypertension occurs when the pregnant woman has a history of hypertension that precedes the pregnancy. The threshold for treatment that has been suggested is a diastolic blood pressure greater than 110 mm Hg or a systolic blood pressure in excess of 160 mm Hg. Diabetic ketoacidosis is a state of insulin deficiency that produces a condition of hyperglycemia, dehydration, and metabolic acidosis. Diabetic ketoacidosis in pregnancy can be fatal for the fetus, with fetal mortality rates approaching 50%. An adult has some variability of stroke volume; however, the stroke volume is held relatively stable in children. Complications of intraosseous infusions include osteomyelitis, cellulitis, infiltration of fluid, anterior compartment syndrome, tibial fractures, and fat embolus. Information on pediatric drug dosing is usually given based on age, weight, or body surface area. In most cases, drugs recommended for pediatric use usually propose a particular dose in milligrams per kilogram or pound. For many drugs, the recommended weight-based dose (or weight-normalized dose) is presented for children of different ages or weight groups. For many drugs, the weightnormalized dose increases as the weight of the child decreases. The percentage of total body water of an infant is approximately 80%, and this proportion decreases to approximately 60% by adulthood. Infants have a much smaller percentage of muscle mass than do adults, but they have much larger brains and livers in relation to their total body 13. Hypoxia Adenosine administration can cause transient atrioventricular block, which can appear to be asystole for the first 10 seconds. Too-aggressive fluid administration in a child with diabetic ketoacidosis can result in cerebral edema. Polypharmacy occurs when an individual patient is taking multiple medications for the treatment of several medical disorders. The danger of polypharmacy is the increased likelihood of an adverse effect or serious drug interaction. The causes of renal failure include trauma, pregnancy, hemorrhage, and complications of drug therapy. Hypertension and diabetes mellitus Medications that have the potential of becoming toxic in kidney disease include digoxin, antibiotics, antihypertensives, and antiarrhythmics. If I give these drugs and if/when this patient stops breathing, will I be able to intubate If I am unable to either intubate or ventilate this patient, do I have other options Does the patient have any medical problems or conditions for which these drugs and techniques are contraindicated Patients who should not be given succinylcholine are those with major burns, neuromuscular conditions, myopathic diseases, or hyperkalemia. Succinylcholine should be used with caution in patients with renal failure because these patients often have elevated potassium levels. Malignant hyperthermia is a genetic abnormality in which a patient has exaggerated, sustained muscle contractions in response to certain inhaled general anesthetics and succinylcholine. To avoid bradycardia after administration of succinylcholine, the paramedic should administer atropine to children younger than 8 years. Rocuronium has no negative effects on cardiovascular function and does not lower blood pressure or raise or lower heart rate. Etomidate has favorable properties for rapid sequence intubation sedation; it has a rapid onset (30 seconds), short duration of action (3 to 5 minutes), and minimal effects on the heart and blood vessels. A A3E3P3 ("A three, E three, P three") refusal guidelines a method of remembering and documenting the critical considerations when a patient refuses treatment. A3E3P3 stands for assess, advise, avoid; ensure, exploit, explain; persist, protocols, protect. It inactivates and prevents accumulation of the neurotransmitter acetylcholine released during nerve impulse transmission by hydrolyzing the substance to choline and acetate. The classification sometimes also includes myocardial infarction characterized by altered Q waves.
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