Betoptic

Shiv Saidha, M.B.B.Ch.

• Associate Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0595017/shiv-saidha

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Creating note cards encourages you to separate large amounts of information into individual, concise thoughts that are easier to absorb and remember. To reduce your test-taking anxiety and help yourself concentrate to drated with water or fruit juice will help you feel great on test day. You are prepared to score high on the exam, so instead of worrying, focus on memory. Instead of cramming for the test the night before, try to fnd a relaxing activity such as reading a book the content and feel confdent about your chances for success. Regardless, make sure you fully comprehend each question before you you need ahead of time. Think Test-takers may not bring any personal belongings into the room in which they will test. This includes items such as purses and handbags, hats, backpacks, books, notes, study materials, calculators, watches of any kind, elec ing about the patient in a real-life scenario may make the test question seem more real and the correct answer tronic paging devices, recording or filming devices, radios, cellular phones, or food and beverages. To avoid each answer choice individually, looking for distracters or bias that might mask the correct answer. Is the question trying to determine if you can recognize the general symptoms of an questions. Though you may not think you need a break, it is a good idea to rest your mind and prepare for what is to come. Unscheduled break time is deducted from the hour allotted to complete a block of questions, so it is best not to take unscheduled breaks unless they are absolutely necessary. Do not include hobbies or lengthy details about jobs that have no relation to your feld or future duties. Before applying for professional jobs, assemble a file documenting your education and professional experiences. Many potential employers place re Gather and maintain the following documents in both paper and electronic format, if possible: sumes in a database. To fnd the right key words, read several job post feld ings and note the specifc language that employers use to describe a qualifed potential employee. In addition to job postings, mation you will include on your resume, and decide on a format that best showcases your specific job qualifica the site also features interview tips, a resume builder, and newsletters. The trained job counselors can help candidates locate and apply for jobs, create a resume, and brush up on interviewing techniques. Also keep in mind that initial interviews are not the time to ask about benefts, on-call rotations, or salary; these topics should only be approached by the interviewer, if at all. The more relaxed you are, the better you will be able to sell yourself to a potential 2. Staying relaxed also allows you to pay attention to what an interviewer is telling you about the job, so 3. While many job offers are delivered orally, either in person or over the phone, it is a good idea to get the details of the offer in writing as well. This not only protects you legally by spelling out the terms of the agreement, it also allows you to review the specific details several times before accepting or declining the offer. She has been suffering from diarrhea and (D) Bronchogenic carcinoma excessive flatulence after certain meals that include (E) Bronchiectasis foods like breads, pastas, cereals, etc. A young female patient is believed to be suffering also report that she has begun to show signs of from pharyngitis and is exhibiting a tender anterior weight loss and her abdomen is slightly distended. An 18-year-old man is suffering from mumps and what appears to be a urinary tract infection. An elderly male patient arrives in the emergency unilateral testicular swelling and a slight fever. Which (A) Prostatitis of the following symptoms would indicate right (B) Cystitis sided failure A 40-year-old male is suffering from an anorectal (E) Orthopnea abscess causing anal swelling, erythema, and dif ficulty with defecation. A 47-year-old non-smoking male patient who was treatments would be most appropriate in this case Which of the following individuals would be most complaining for the first time of sudden, severe rhythmia arrives in the emergency room. The a history of kidney problems and her laboratory exterior forearm exhibits thick, solid, firm plaques (A) A 35-year-old Italian man examination shows no signs of any type of ulcer findings indicate her serum potassium level is 6. She also has a few small lesions (B) A 41-year-old Chinese woman and she appears to be in good physical health. She mEq/L, her serum calcium level is 9 mg/dl, and and reports a strong desire to scratch the affected (C) A 24-year-old Greek man is known to be an honest and upstanding individual her phosphate serum level is 1 mg/dL. Lichenification indicates that she has been (D) A 53-year-old German man and she has a history of anxiety and depression. She has been treated (E) A 30-year-old Tunisian woman From which of the following somatoform disorders of her distress A 55-year-old female patient presents at the is the patient most likely suffering She also reports sharp chest (B) Hypochondriasis (C) Hypercalcemia (B) Lichen simplex chronicus pain that worsens when she coughs. You suspect (C) Pain disorder (D) Hypocalcemia (C) Perioral dermatitis she may be suffering from a pleural effusion and (D) Malingering (E) Hyperphosphatemia (D) Nummular dermatitis diagnostic testing reveals that the patient has an (E) Conversion disorder (E) Seborrheic dermatitis 12. A 27-year-old female patient has been consistently infection within the pleural space. A 33-year-old male patient who is known to be a suffering for some time from a severe mucus 16. Which of the following is the predominant pre information, from which type of pleural effusion frequent runner arrives with severe pain in the area producing cough, weakness, sinus pain, diarrhea, senting feature of acute thrombocytopenia She has also been struggling (A) Development of petechiae on the skin and (A) Exudate in the middle of a low-stress run when he began with infertility issues. Her examination reveals mucus membranes (B) Transudate to feel the pain developing. There is no reported (B) Development of petechiae, purpura, and (C) Empyema the right posterior calf, 2 cm above the insertion bronchial damage. Which of the following diag hemorrhagic bullae on the skin and mucus (D) Hemothorax of the Achilles tendon. You are treating a 12-year-old male patient with nation reveals palpable kidneys that feel tender. Which of the following you most likely use as your primary means of emergency room complaining of severe arm pain. Of the following (B) Chronic tonsillitis (C) Ultrasonography to his arm ligaments or rotor cuff. A 43-year old woman arrives at the clinic presenting (B) Acromioclavicular separation (C) Rheumatoid arthritis 18. A 4-year-old male patient is brought to the clinic with irritative voiding symptoms and hematuria. You suspect he is suf and laboratory testing confirms a diagnosis of (E) Supracondylar humerus fracture 14. Which of the following treat (A) 12 months (C) Rotavirus (B) Fluoroquinolone ments should be administered first A 42-year-old female patient is suffering from (C) Bicuspid valve regurgitation rhosis arrives in the emergency room after he starts (E) Peripheral arterial disease an apparent infection that is causing a fever, (D) Pain radiating to left axilla vomiting blood. The patient also reports lighthead sore throat, and a general feeling of malaise. A 17-year-old male patient presents with a high edness, excessive thirst, and reduced urination. You examination reveals a tenacious gray membrane fever, persistent headache, vomiting, and a stiff 35. A 5-year-old male patient is brought to the clinic diagnose him with esophageal varices. They report that he appears to have the following would be the most likely form of is not affecting her ability to breath. Based on suffered a growth stunt, noting that his younger treatment for this condition You suspect he (A) Balloon tamponade is the first and most important form of treatment pathogens is most likely to be the cause of the may be suffering from growth hormone deficiency (B) Endoscopic injection therapy for this condition A 15-year-old male patient arrives with an apparent (E) Escherichia coli (C) Desmopressin infection in his left leg. Some parts of the skin have with abdominal pain, frequent and painful uri (E) Prednisone complaining of chronic dry eye and dry mouth. A 39-year-old female patient presents at the clinic bullae with clear, yellowish fluid. Which of the following with pelvic pain, excessively long menstrual following diagnoses is most likely to be correct An ultrasound (A) Erysipelas (A) Urine cytology (A) Lupus reveals the presence of uterine fibroids. A 13-year-old female patient presents at the clinic room complaining of chest discomfort. A 73-year-old female patient presents at the clinic (A) Pleuritic substernal radiating chest pain and following diagnoses is most likely to be correct You believe (B) Slowly progressive dyspnea, fatigue, and (B) Irritable bowel syndrome (A) Pterygium she may be suffering from a nutritional deficiency. A 64-year-old male patient with a history of (B) Biotin complaints cardiac problems presents at the clinic with fatigue, (C) Riboflavin (E) Tachycardia, tachypnea, narrow pulse 30. A 59-year-old male patient arrives at the clinic dyspnea, and decreased exercise intolerance. Physical exami believe he may be suffering from a valvular dis (E) Thiamin nation shows a herniation of the stomach through 26. He had no previous abdominal hip replacement is started on Coumadin therapy exclusively suggest an aortic, rather than mitral, surgeries. Based on these findings, from which and fitted with graduated compression stockings. Which of the following medi from abdominal cramping, bloody diarrhea, and a cyanotic and presents with shock, respiratory (A) Injected corticosteroids cations would you prescribe to specifically treat slight fever. You are treating a 78-year-old female patient for (C) Hypoplastic left heart syndrome (E) Benztropine (B) Irritable bowel syndrome thyroiditis and you need to determine the specific (D) Atrial septal defect (C) Celiac disease (celiac sprue) form of the disease she is suffering from.

I just never say anything at all about my past that in any way would make a person ask what my past life was like symptoms type 1 diabetes generic betoptic 5 ml online. Women partners 10 medications generic betoptic 5 ml with amex, she said symptoms of flu buy betoptic 5ml on line, explained the general and indefnite character of her biographical remarks symptoms 0f pregnancy purchase betoptic 5ml line, which she delivered with a friendly manner medicine urinary tract infection discount betoptic amex, by a combination of her niceness and modesty medications emt can administer order betoptic 5 ml on-line. Instead, success in managing the present interaction consisted in having established or sustained a valuable and attractive char acter, of acting in a present situation that was consistent with the precedents and prospects that the presented character formulated, and for which present appearances were documentary evidences. For example, Agnes said that it was soon clear to her afer she started working for the insurance company that she would have to quit the job. The little innovations that she made in order to make the job more interesting gave only temporary relief. She wished very much to up-grade her skills and to establish a more impres sive job history. She was convinced that he would credit none of these reasons but would instead use the reasons she gave as evidences of defciencies in her attitude toward work. He had admonished her that for him, quitting for such reasons was not acceptable and that if she quit it would only refect again on her immaturity and irresponsibility. When she quit nevertheless she justifed it by saying that it was entirely out of her hands. A further set of passing occasions are particularly resistant to analysis as games. Tese occasions have the features of being continuous and developmental; of a retrospective-prospective signifcance of present appearances; of every present state of the action being identical in meaning with the-situation as-it-has-developed-thus-far; in which commonplace goals could neither be abandoned, postponed, or redefned; in which Agnescommitment to compliance with the natural, normal female was under chronic threat or open contradiction; and in which remedies were not only out of her hands but were beyond the control of those with whom she had to deal. All of these situations, both by her reports as well as by our observations, were stressful in the extreme. In this context she said that she did not recognize that the problem of remaining inconspicuous was any longer a problem for her. Her typical outft consisted of white corduroy pants and a shirt worn open at the neck which she arranged in the manner of a loose blouse. It turned out that the loose blouse as a management device was taught to her by her brother. Even with the developing breasts she had preferred to wear her blouse tightly tucked in. She changed only upon the disapproval of her brother who was a few years older than she and attended the same school, who was embarrassed by her appearance because of its feminine overtones and berated her for dressing like a girl. It was her brother, too, who complained that she carried her books like a girl and who demonstrated to her and insisted that she carry them like a boy. To obtain her comments on them required considerable efort with questionable results because of the prominence of her denials and idealizations. Agnes did not return to high school in September, 1957 which would have been her senior year. Instead, according to Agnesreport, her mother arranged with the vice principal of the high school for the services of a teacher furnished by the public school system who came each day to her house. Agnes was very evasive in saying what she and her mother had talked about in this respect and what kind of arrangement the two might have agreed or disagreed on about her schooling and tutor. Agnes professed to have no information on this agreement and claimed not to know what her mother thought about the arrangement, or what the mother had discussed specif cally with the vice principal. Agnes claimed further to be unable to recall how long each one of the tutorial sessions lasted or how long the home visits continued. Afer I came back I wanted to start going out and having a social life and mix in public and there I was, cooped up in the house with nothing to do. This she insisted on doing out of the sight of the nurses and interns whom she resented. A large penis sized plastic mold had to be removed in order to facilitate healing with the result that adhesions developed and the canal closed down over its entire length, including the opening. For almost a week afer her release from the hospital there was a combined urethral and fecal dripping with occasional loss of fecal control. The vagina had been anchored to the bladder and this together with its bearing on the lower intestine set up mixed signals so that as the bladder expanded under the fow of urine Agnes would experience the desire to defecate. The am putation of the testes upset the androgen-estrogen balance which precipitated unpredictable changes of moods. Arguments ensued with Bill who was quickly out of patience and threatened to leave her. Despite a campaign to discourage her mother from coming to Los Angeles, it became increasingly apparent to Agnes that the situation was beyond her control and that she could not hope to manage her convalescence by herself. The spasms were quieted; testosterone injections were started; the bladder infection was brought under control; the vaginal canal was reopened and a regime frst of manual manipulations of the canal and later of manipulations with the use of a plastic penis were started. The vagina was healing, only tenderness remained, and under Agnesconscientious use of the mold she had achieved a depth of fve inches and was able to insert a penis of an inch and a half in diameter. Quarrels with Bill had subsided and were replaced by an anticipatory waiting on the part of both Agnes and Bill for the time when the vagina would be ready for intercourse. If for Agnes all roads led to Rome, they did so by coming together at the boyfriend as a common junction point. For passing illustration, in the course of one of our conversations, at my request, Agnes recited in de tailed succession the events of a usual day, and considered for each the possibility of acting diferently than she had acted. Ten I asked Agnes to start with something that she felt was extremely worthwhile, to imagine something that could alter it for the worse and to tell me what would happen then, and afer that, and so on. I proposed earlier that the occasions of passing involved Agnes in the work of achieving the as cribed status of the natural normal female. Among all her accounts, those that implicate Bill are invariably the most resistant to game analysis. One of the most obstinate structural incongruities that results when game analysis is used consists of the historico-prospective character of the mutual biography that their intimate interactions assembled, and the difuse use to which this mutual bio graphy could be and was put by each. It is the difuse relevance of this biography that helped to make understandable how frantic Agnesfears were of the disclosure to Bill and how particularly resistant she was to tell me how the disclosure had occurred. Only toward the end of our conversations and then only upon the only occasion in which I insisted that she tell me, did she tell the story, and then it was delivered in the manner of defeat, and piecemeal. The mutual biography aided us, as well, in understanding how the possibility of disclosure became increasingly unavoidable for her, and how the disclosure increasingly assumed the proportions of a major agony. I shall confne my attention to two occasions, each of which was represented by a question that Bill had, which Agnes, while she stayed in the situation and precisely because there was no choice but to stay, found agonizingly difcult to answer. While Agnes permitted fondling and stroking she would not permit Bill to put his hand between her legs. Agnes met his frst demands for fondling and intercourse by claiming her virginity. She told him that she had a medical condition that prohibited intercourse; that the condition could not be repaired immediately; that she required an operation; that afer the operation they could have intercourse. She told him that she was not expert enough to furnish this information but would get it from her physician in Northwest City who was taking care of her. Fearful that Bill would leave her, Agnes returned to Northwest City where she asked the physician who had been taking care of her to write Bill a letter about her condition. He insisted that she tell him exactly what was wrong, and afer a severe quarrel follow ing frustrated intercourse made this a condition of any further courtship or marriage. She would insist that she was entitled to a private life and under no circumstances would she reveal how he had been convinced. He was frmly opposed to the decision to operate, stating that the operation was neither necessary nor ethical. It was his conviction that there had been anal intercourse, a conviction that he held because of the fabbiness of the anal sphincter. Yet along with this, Agnes had the additional aim of getting an operation done by competent hands at minimum or no cost, but to get this she had to engage in the research, not only because of the anatomical condition that Bill was preoccupied with, but which was only a small part of our research interests. Additional research interests were directed to the fact that she was raised until she was seventeen as a male. When she discussed it with Bill he either took the line or wanted her assurance that her psychological problems were due entirely to physical changes afer the operations, and that she was not that kind of a person i. Even afer the vagina had started to heal properly and the depression had lifed, she was still willing, and in fact desired, to continue the weekly conversations.

Three beeps at 1046 Hz for 100 ms duration each with a 150 ms silence between the first and second and the second and third medicine x protein powder order betoptic mastercard, followed by a 200 ms silence treatment pneumonia buy discount betoptic 5ml online. Priority 3 tones come in single and repeating types: for a single tone medications you cant take with grapefruit buy 5ml betoptic overnight delivery, the 3-beep sequence sounds only once treatment 4 anti-aging purchase betoptic 5ml visa. The alert tone shall consist of one set of two tones to precede voice prompts and to draw attention to the display medications related to the lymphatic system buy cheap betoptic 5ml on line. Visual Alarms Alarms are indicated visually by: the violated parameter flashes in inverse video with a message in the status region of the display medications used to treat bipolar disorder cheap betoptic 5 ml online. Alarm Silencing If a violated parameter alarms, the tone may be silenced for two minutes by pressing the Alarms button. A preemptive alarm silence is provided with selectable settings of 2, 5, 10, and 15 minutes. Energy Shunting If the paddles input is connected in parallel with a second defibrillator, energy delivery to the patient is reduced by less than 15 percent. Tall T-wave Rejection T-waves that are 1 mV high are not detected by the monitor when the R-wave size is 1 mV and input rate is 80 ppm. For all shock types, hemodynamic parameters (oxygen saturation and systolic and diastolic blood pressure) were at or near their pre-induction levels by 30 seconds after successful shocks. Sample sizes were too small to statistically determine the relationship between success rates of the waveforms tested. A total of 80 patients were enrolled in the study and were treated with one or more study shocks. This study showed that these biphasic shocks provide higher efficacy for cardioversion of atrial fibrillation, requiring fewer shocks, 65% less current and 65% less energy to cardiovert atrial fibrillation. Patients undergoing elective cardioversion with the biphasic protocol, as compared to those receiving the monophasic protocol, reported significantly less post-procedure pain. Objectives the primary objective of the study was to compare the cumulative efficacy of biphasic and monophasic shocks of 200 J or less for cardioversion of atrial fibrillation. A triangular sequential design was used to test for a statistically significant difference between groups of patients treated with these two waveforms. Secondary objectives included 1) providing an estimation of the dose response relationship for the two waveforms which would allow clinicians to make well-informed selections of energy doses for cardioversion with biphasic shocks and 2) comparing the pain experienced by patients following treatment with monophasic and biphasic shocks. Results Seventy-two of the patients enrolled were in atrial fibrillation and 7 were in atrial flutter. On average, patients had been in atrial fibrillation for 88 days, were 66 years old, weighed 81 kg and had 72 ohms of transthoracic impedance. There were no significant differences between the groups of patients treated with monophasic and biphasic shocks, either in these baseline characteristics or in left atrial dimension, cardiac medications or diagnosis. The cumulative success rates for cardioversion of atrial fibrillation are presented in Table A-5 and Figure A-1. These data provide a reasonable estimate of the expected probability of cardioversion success for a single shock at any given energy level within the range studied. Energy and peak current delivered for all shocks at each energy setting are presented in Table A-6. The observed cumulative percentage of successes at 360 J was also higher for biphasic shocks than for monophasic shocks, but did not attain statistical significance. Patients treated with the biphasic protocol, as compared to those treated with the monophasic protocol, reported significantly less post-procedure pain just after (0. All patients with atrial flutter were cardioverted with the first shock (70 J), whether that shock was monophasic (n=4) or biphasic (n=3). Anterior-lateral electrode placement was used for treatment of most (96%) of the patients studied. Reports in the literature differ on whether anterior-posterior electrode placement provides better shock efficacy than anterior-lateral placement. If there is a benefit to anterior-posterior electrode placement, it may be possible to obtain modestly higher cardioversion success rates with both waveforms than those observed in this study. However, placement is not likely to affect the observed relationship between the efficacies of monophasic and biphasic waveforms. Conclusions the data demonstrate the Physio-Control biphasic waveform is clinically superior to the conventional monophasic damped sine waveform for cardioversion of atrial fibrillation. Specifically, compared to monophasic shocks, biphasic shocks cardioverted atrial fibrillation with less peak current, less energy, fewer shocks and less cumulative energy. Patients undergoing elective cardioversion with the biphasic protocol, as compared to those receiving the monophasic protocol, reported significantly less post procedure pain just after and 24 hours after the procedure. This may be due to fewer required shocks, less cumulative energy, less delivered peak current or other characteristics of this biphasic waveform. The study summarized here1 provides the best information available on which to base energy selections for cardioversion with this waveform. For cardioversion of atrial fibrillation, the results of this study provide specific guidance for three possible strategies in selection of shock energy levels. This can be expected to increase the success rate yet decrease the peak current of the first and subsequent shocks. Each of these strategies should provide effective cardioversion therapy while substantially reducing the amount of peak current to which the heart is exposed. For cardioversion of atrial arrhythmias other than atrial fibrillation, the data available to guide the selection of energy settings is very limited. It is likely that biphasic doses below 50 J will provide high success rates when treating atrial flutter and paroxysmal supraventricular tachycardia. However, until more clinical data becomes available, it may be advisable to use the same energy settings for biphasic shocks as are customarily used for monophasic shocks. Arrhythmias may persist for a variety of reasons unrelated to the type of waveform used for cardioversion. In persistent cases, clinicians continue to have the option to either increase shock intensity or switch to an alternate electrode placement. Seven patients who did not satisfy all protocol criteria were excluded from analysis. This study showed that these biphasic shocks have higher defibrillation efficacy, requiring fewer shocks, less threshold energy and less cumulative energy than monophasic damped sine shocks. A triangular sequential design was used to test for a difference between waveform groups. The secondary objective was to provide an estimation of the dose response relationship for the two waveforms that would allow physicians to make well-informed selections of energy doses for intra-operative defibrillation with biphasic shocks. A randomized trial comparing monophasic and biphasic waveform shocks for external cardioversion of atrial fibrillation. Two of the 91 patients included in this primary endpoint analysis could not be included in more comprehensive analyses due to protocol variances that occurred in the shock sequence after the 5 J shock. Thus, the cumulative success rates for intra-operative defibrillation in the remaining 89 patients are presented in Table A-7 and Figure A-2. These data provide a reasonable estimate of the expected probability of defibrillation success for a single shock at any given energy level within the range studied. Specifically, these biphasic shocks have higher defibrillation efficacy, while requiring fewer shocks, less threshold energy and less cumulative energy than monophasic damped sine shocks. There were no unsafe outcomes or adverse effects from the use of the biphasic waveform. Guidance for Selection of Shock Energy Biphasic waveform technology is a standard in cardiac defibrillators. The results of this study1 provide specific guidance for three possible strategies in developing a dosing regimen. In this study, biphasic shocks of 5 J were successful in approximately half of the patients. Each of these strategies should provide effective defibrillation therapy while substantially reducing the amount of peak current to which the heart is exposed. Fibrillation may persist for a variety of reasons unrelated to the type of waveform used for defibrillation. In cases where fibrillation is persistent, physicians continue to have the option to either increase shock intensity or switch to a larger paddle size. Larger paddle size is known to decrease energy requirements for successful defibrillation. Message remains displayed while the monitor attempts to acquire data without interference. Service indicator illuminated (on device or Contact a qualified service technician. If problem continues, remove the defibrillator from use and j Place paddle surfaces together, and contact a qualified service technician. If User Test fails, contact qualified service technician and remove defibrillator from use. If variations in the transthoracic impedance signal exceed a maximum limit, the Shock Advisory System determines that patient motion of some kind is present. The operator is advised by a displayed message, a voice prompt, and an audible alert. After 10 seconds, if motion is still present, the motion alert stops and the analysis always proceeds to completion. This limits the delay in therapy in situations where it may not be possible to stop the motion. This artifact may occasionally cause the Shock Advisory System to reach an incorrect decision. To reduce the risk of inadvertently shocking a rescuer, the motion alert prompts the rescuer to move away from the patient. The skill and training level of the care providers should be taken into consideration when deciding whether or not to turn off the motion detection feature. Continue to press all three buttons until the inservice screen appears: Inservice Screen Exit the inservice mode by turning off the defibrillator power. Note: the Heart Rate alternates every 2 minutes between alarm and non-alarm states. Setup options should be changed only under the direction of a physician knowledgeable in cardiopulmonary resuscitation who is familiar with the literature in this area. Your hospital procedures should determine whether or not to change the options and should ensure that you receive training. For this reason, an additional factor of 10/3 is used in calculating the recommended separation distance for transmitters in these frequency ranges. Electromagnetic propagation is affected by absorption and reflection from structures, objects and people. The authors will continue to edit and revise the protocols to reflect the dynamic role of emergency medical services within the medical care community. Whenever possible, prior approval by direct verbal order from base station physician is preferred. Additionally, all variance from protocol should be documented and submitted for review by agency Medical Director in a timely fashion. An algorithm has certain limitations, and not every clinical scenario can be represented. Although the algorithm implies a specific sequence of actions, it may often be necessary to provide care out of sequence from that described in the algorithm if dictated by clinical needs. An algorithm provides decision-making support, but need not be rigidly adhered to and is no substitute for sound clinical judgment. In order to keep protocols as uncluttered as possible, and to limit inconsistencies, individual drug dosing has not been included in the algorithms. Drug dosages are included with the medications section of the protocols as a reference. If viewing protocol in an electronic version, it will be possible to link directly to a referenced protocol by clicking on the hyperlink, which is underlined. The patient is not entitled to confidentiality of information that does not pertain to the medical treatment, medical condition, or is unnecessary for diagnosis or treatment. The patient is not entitled to confidentiality with regard to evidence of a crime. Any disclosure of medical information should not be made unless necessary for the treatment, evaluation or diagnosis of the patient. Any disclosures made by any person, medical personnel, the patient, or law enforcement should be treated as limited disclosures and not authorizing further disclosures to any other person. Any discussions of prehospital care by and between the receiving hospital, the crewmembers in attendance, or at in-services or audits are done strictly for educational or performance improvement purposes. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient. A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, i. Understands the possible consequences of delaying treatment and/or refusing transport 3. Given the risks and options, the patient voluntarily refuses or accepts treatment and/or transport. Implied Consent: An unconscious adult is presumed to consent to treatment for life threatening injuries/illnesses.

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Syndromes

• Kidney disease, including glomerulonephritis, pyelonephritis, and acute tubular necrosis
• Very large wounds
• Difficulty lifting the head or legs when lying flat on the back
• Skin itching before the carbuncle develops
• Weight loss
• Pacemaker
• Increased social activity -- more visits in the home or going to an adult day care center for activities
• Long-term use of antibiotics
• For some patients with breast cancer or melanoma, to see if the cancer has spread (sentinel lymph node biopsy)

The drainage cannula should be at the level of the renal veins medications zanaflex 5 ml betoptic sale, although some prefer to place it near the right atrium which has more recirculation treatment question buy line betoptic. The reinfusion lumen is a side hole which can be oriented toward the tricuspid valve and the drainage holes are placed as far away as practical from the reinfusion hole to minimize recirculation medicine 1800s purchase betoptic 5 ml. Placement requires imaging symptoms 9f diabetes discount betoptic 5 ml overnight delivery, usually fluoroscopy medications used to treat ptsd purchase betoptic overnight delivery, so cannulation is more difficult than 2-cannula access medicine 013 discount betoptic 5ml line. The advantage of single cannula access is that is easier to mobilize and ambulate the patient. Methods Cannulas can be placed via: 1) cut down, 2) percutaneously by a vessel puncture, guidewire placement, and serial dilation (Seldinger technique), 3) by a combination of cut down exposure and Seldinger cannulation, or 4) by direct cannulation of the right atrium and aorta via thoracotomy. Cut down exposure of the neck vessels is usually necessary in neonates and small children. Cannulation technique A bolus of heparin (typically 50-100 units per kilogram) is given just before cannula placement, even if the patient is coagulopathic and bleeding. Deep sedation/anesthesia with muscle relaxation is essential to prevent spontaneous breathing which can cause air embolus. The proximal vessel is occluded with a vascular clamp, the vessel opened, and the cannula placed. If the vessels are very small, if there is difficulty with cannulation, or if spasm occurs, fine stay sutures in the proximal edge of the vessel are very helpful. In the femoral artery a non-ligation technique can be used (see semi-Seldinger technique below) which may ensure sufficient flow past the cannula to ensure distal perfusion Percutaneous cannulation. The safest technique is to place small conventional intravascular catheters first. The position of these preliminary catheters is verified by blood sampling or measuring the blood pressure. After full sterile preparation a guidewire is passed into the small catheter and the small catheter is removed followed by serial dilators. With current equipment, two people are necessary to do percutaneous access: one to load of the dilators on the wire and pass the dilators, and one to occlude the vessel between dilators to avoid bleeding. When using the Seldinger technique with a large dilator and cannulas, it important to check the wire after each dilator. Correct placement can be confirmed by aspiration and then heparin is administered. The wound is then closed over the cannula, which is then treated like a standard percutaneous cannula. The advantages of this technique over a pure percutaneous approach are speed, accurate assessment of vessel size, and flexibility of approach. Management of the distal vessels: If the neck cutdown access is used, the vein and artery are ligated distally, relying on collateral circulation to and from the head. Some centers routinely place cephalad venous cannulae but this is an institutional preference and is not mandatory. If the access is via the femoral vessels the venous collateral is adequate but the femoral artery is often significantly occluded. If distal arterial flow to the leg is inadequate a separate perfusion line is placed in the distal superficial femoral artery by direct cutdown, or in the posterior tibial artery for retrograde perfusion. Adding or changing cannulas: If venous drainage is inadequate and limited by the blood flow resistance of the drainage cannula, the first step is to add another venous drainage cannula through a different vein. It may be possible to change the cannula to a larger size, but removing and replacing cannulas can be difficult. If a vascular access cannula is punctured, kinked, damaged, or clotted, the cannula must be changed. If the cannula was placed by direct cutdown, the incision is opened, the vessel exposed, and the cannula replaced, usually with the aid of stay sutures on the vessel. If the cannula was placed by percutaneous access, a Seldinger wire is placed through the cannula to facilitate cannula. This will typically be 50-80 cc/kg/minute when total gas exchange support is needed. The mixing of two blood flows with different oxygen content is described in detail in Chapter 4. If the patient is thrombocytopenic, in renal failure, or has circulating fibrin split products, a small amount of heparin may be required. When using anti-Xa to titrate heparin it is important to realize that factors other than heparin also affect blood clotting. There is a rare condition called heparin induced thrombotic thrombocytopenia, characterized by multiple white arterial thrombi and platelet count less than 10,000. In such a case, if there are no other explanations for thrombocytopenia, it is reasonable to use a different anticoagulant than heparin. This is routinely done in cardiac surgery where the effect of heparin must be maximal during operation, but minimal after coming off bypass. There is no reversal medication but the half life is a few hours so overdose is not long lasting. It may be a consequence of the primary disease, drugs, and other treatment, or caused by blood surface exposure. The usual practice is to transfuse platelets to keep the count greater than 80,000. Fibrinogen levels are measured daily and maintained within the normal range (250 to 300 mg/dl) by infusion of fresh frozen plasma or fibrinogen. The primary disease, or clots in the circuit, may cause fibrinolysis resulting in circulating fibrin split products. If fibrin split products are detected and/or if bleeding is excessive, fibrinolysis can be inhibited with anti-fibrinolytics (see bleeding). Extracorporeal circuits and devices are available with surface heparin coating or coating with other polymers intended to minimize blood surface interaction. These modified surfaces may decrease blood surface interaction somewhat, but systemic anticoagulation is still required when using the surface coatings currently on the market. If the pressure suddenly increases setting off the high pressure alarm, the cause is usually temporary occlusion of the infusion tubing or cannula. If this occurs stop the pump, then gradually return flow while determining the cause of the sudden increase in resistance 5b. If air is detected in the circuit stop the pump, clamp the lines near the patient, and put the patient on support settings. The most common cause is aspiration of air into the venous drainage line at the site of cannulation or through a connector or open stopcock. Another common cause is air bubbles in the intravenous infusion lines going into the patient. When air is entrained on the drainage side it is usually as small bubbles, and usually is caught in the membrane lung or bubble trap before getting into the patient. This can occur if the membrane lung is higher than the patient and if the blood side pressure drops below the gas side pressure. Clotting in the circuit is detected by careful examination, using a flashlight to go over all the extracorporeal circuit. Every circuit will have some small clots at the site of connectors, infusion lines, or in areas of low flow in the pre-pump bladder or the membrane lung. These clots are in the range of 1 to 5 mm, do not require circuit changes, and are simply observed. Clots larger than 5 mm or enlarging clots on the infusion side of the circuit (post membrane lung) should be removed by removing that section of the circuit or by changing the entire circuit if there are many such clots. Platelet/fibrin thrombi appear as white areas on the circuit at connectors and stagnant sections. These are clots which have not accumulated red cells, usually because they are in areas of very high flow. As with dark clots, no intervention is necessary unless the white thrombi are greater than 5 mm or growing. The circuit should be designed to automatically switch to battery operation if the main source of electricity is lost. The battery will operate the circuit for 30-60 minutes while the cause of the problem is being identified. If the electrical circuit and the battery fails, the alarm will be a low flow alarm or alarms attached to the patient (saturation or blood pressure). Decannulation is a life-threatening emergency identified by major bleeding at the cannulation site, air in the drainage circuit (if the drainage cannula is coming out) and loss of volume and perfusion pressure if the infusion cannula is lost. Decannulation is prevented by securing the cannulas to the skin in at least two locations, and checking the position of the cannulas and cannula fixation at frequent intervals and adequately sedating the patient. If decannulation occurs, come off bypass immediately by clamping the lines close to the patient, control bleeding by direct pressure, and reinsert the cannula as soon as possible. Hemolysis is suspected if the urine has a pink tinge (which could be due to bladder bleeding, not hemolysis) and verified by plasma Hb measurement. Higher plasma hemoglobin can be caused by a condition primary to the patient, or by circuit components. The pump itself will not cause hemolysis unless inlet (suction) pressures are greater than minus 300 mmHg, which can happen if the pump suction exceeds the blood drainage. The pump can also cause hemolysis if there are clots in the pump chamber (which can occur in centrifugal pumps). This can occur if the blood return cannula has a very high resistance, or if there is a high level of occlusion in the post pump circuit. Hemolysis can also occur if a hemofilter or plasmapheresis device is attached to the circuit and run at high flows. Emergency drills addressing all these problems should be conducted by the team at regular intervals 5h. Clamp the lines near the patient, and clamp the lines above and below the component to be changed. With sterile technique, cut out the component and insert the new component, filling the tubing with saline and eliminating all bubbles. When changing or adding a membrane lung, the lung must be primed with crystalloid solution before attaching to the circuit. It may be necessary to travel to radiology, the operating room, or the cath lab as follows. Be sure that the battery is fully charged and the hand crank is available for the pump. Switch the circuit to battery power and portable oxygen before moving the patient from the bed. In addition to all the details listed above, the transport team must be totally self-contained for hospital to hospital transfer. This includes spare parts for all components, a variety of cannulas and sizes, operating instruments, and medications. The patient should be managed with inotropes, vasodilators, blood volume replacement etc. Because the pulse pressure is low the mean systemic arterial pressure will be somewhat lower than normal pressure (40 to 50 mmHg for a newborn, 50 to 70 mmHg for a child or adult). As these drugs are titrated down, resistance falls and systemic pressure falls proportionately. If the systemic perfusion pressure is inadequate (low urine output, poor perfusion) pressure can be increased by adding blood or low doses of pressor drugs. Systemic vasodilatation requiring pressor drugs is common in patients in septic shock. Although the mean arterial pressure may be low, systemic perfusion may be completely adequate. Assuming SaO2 is over 95% venous saturation greater than 70% indicates systemic oxygen delivery is adequate even though the pressure may be low. If systemic oxygen delivery is not adequate (venous saturation less than 70%) increase the pump flow until perfusion is adequate. If extra blood volume is required to gain extra flow, consider the relative advantages of blood and crystalloid solution. Cardiac failure may be due to pulmonary hypertension causing right ventricular strain or overload. Ventilator management: Patients are on high FiO2 and ventilator settings during cannulation. Each patient is different, but a general algorithm for ventilator management is: 2a. After 24-48 hours: (Stable hemodynamics off pressors, fluid balance underway, sepsis Rx underway) moderate to minimal sedation. If the patient has respiratory failure, the airway is managed by continuing endotracheal intubation at rest settings as above. Maintaining safe positive pressure can maintain existing lung inflation, and may improve lung function as lung recovery begins. Tracheostomy avoids the discomfort of intubation and decreases the risk of nosocomial pneumonia. However, tracheostomy has the risk of bleeding in anticoagulated patients, so the technique is important (see B10). This facilitates activity and ambulation and is often used for patients bridging to lung transplantation. At typical blood flow, the ratio of infusion blood to deoxygenated right atrial blood is usually around 3:1. If there is no native lung function, this will be the composition of gases in the arterial blood.