By W. Koraz. Eckerd College.

The transfusion scheme must be adjusted ical situations generic 50 mg imitrex with amex, including giant hemangioma buy imitrex 25mg amex, metastatic according to the patient’s clinical and laboratory evolu- carcinoma purchase 25mg imitrex with amex, or the dead fetus syndrome. Liver failure is associated with a high risk of bleeding because of deficient synthesis of procoagulant factors and enhanced fibrinolysis. In addition, several posttranslational modification of glutamate residues to anatomic abnormalities secondary to underlying liver γ-carboxyglutamate, a critical step for the activity of vit- disease further promote the occurrence of hemorrhage amin K–dependent proteins for calcium binding and (Table 41-3). Dysfibrinogenemia is a relatively com- proper assembly to phospholipid membranes (Fig. The amount of vitamin K in the diet is often uation is mandatory for an optimal therapeutic strategy, limiting for the carboxylation reaction; thus, recycling of either to control ongoing bleeding or to prepare patients vitamin K is essential to maintain normal levels of vita- with liver disease for invasive procedures. Chronic liver diseases Esophageal varices such as primary biliary cirrhosis also deplete vitamin K Thrombocytopenia stores. Parenteral administration of vitamin K at a Decreased synthesis of coagulation inhibitors: protein C, total dose of 10 mg is sufficient to restore normal levels protein S, antithrombin of clotting factor within 8–10 h. Monitoring for clinical symptoms and clot- with venous or arterial thrombotic disease. However, ting times will determine if repeated doses are required bleeding has also been reported in lupus anticoagulant; it 8–12 h after the first infusion. Platelet concentrates are is attributable to the presence of antibodies to prothrom- indicated when platelet counts are <10,000–20,000/mm3 bin, which results in hypoprothrombinemia. To distinguish acquired inhibitors from lupus cipitate is indicated only when fibrinogen levels are anticoagulants, results of the dilute Russell’s viper venom <100 mg/mL; dosing is six bags for a 70-kg patient test and the hexagonal-phase phospholipids test will be daily. In addition, patient-associated parameters, century’s major contributions to human longevity and such as infection site, other drugs being taken, allergies, quality of life. Antibacterial agents are among the most and immune and excretory status, are critically impor- commonly prescribed drugs of any kind worldwide. However, provides specific data required for making informed their indiscriminate use drives up the cost of health care, choices of antibacterial agents. The rational use of antibacterial agents depends on an understanding of Antibacterial agents, like all antimicrobial drugs, are (1) the drugs’ mechanisms of action, spectrum of activity, directed against unique targets not present in mam- pharmacokinetics, pharmacodynamics, toxicities, and malian cells. The mechanisms static activity is adequate for the treatment of most of action of the antibacterial agents to be discussed in infections, bactericidal activity may be necessary for this section are summarized in Table 42-1 and are cure in patients with altered immune systems (e. Active efflux B Vancomycin Cell wall Interferes with addition of Alteration of target (substitution of new cell wall subunits terminal amino acid of (muramyl pentapeptides) peptidoglycan subunit) Bacitracin Cell wall Prevents addition of cell wall Not defined subunits by inhibiting recycling of membrane lipid carrier C Macrolides Protein synthesis Bind to 50S ribosomal 1. Active efflux Lincosamides Protein synthesis Bind to 50S ribosomal Alteration of target (ribosomal (clindamycin) subunit methylation) D Chloramphenicol Protein synthesis Binds to 50S ribosomal 1. Insensitivity of target F Aminoglycosides Protein synthesis Bind to 30S ribosomal 1. Alteration of target (ribosomal dalfopristin subunit methylation: dalfopristin) (Synercid) 2. The structure conferring cell wall Bacitracin, a cyclic peptide antibiotic, inhibits the con- rigidity and resistance to osmotic lysis in both gram- version to its active form of the lipid carrier that moves positive and gram-negative bacteria is peptidoglycan, a the water-soluble cytoplasmic peptidoglycan subunits large, covalently linked sacculus that surrounds the bac- through the cell membrane to the cell exterior. In gram-positive bacteria, peptidoglycan is the only layered structure external to the cell membrane and Glycopeptides is thick (20–80 nm); in gram-negative bacteria, there is Glycopeptides (vancomycin and teicoplanin) are high- an outer membrane external to a very thin (1-nm) pep- molecular-weight antibiotics that bind to the terminal tidoglycan layer. D-alanine–D-alanine component of the stem peptide Chemotherapeutic agents directed at any stage of while the subunits are external to the cell membrane the synthesis, export, assembly, or cross-linking of pep- but still linked to the lipid carrier. This binding sterically tidoglycan lead to inhibition of bacterial cell growth inhibits the addition of subunits to the peptidoglycan and, in most cases, to cell death. Peptidoglycan is ized by a four-membered β-lactam ring and prevent the formed by the addition of subunits (a sugar with its cross-linking reaction called transpeptidation. The energy for five attached amino acids) that are assembled in the attaching a peptide cross-bridge from the stem peptide of cytoplasm and transported through the cytoplasmic one peptidoglycan subunit to another is derived from the membrane to the cell surface. Subsequent cross-linking cleavage of a terminal D-alanine residue from the subunit is driven by cleavage of the terminal stem-peptide stem peptide. Virtually all the antibiotics that inhibit bacterial cell The β-lactam ring of the antibiotic forms an irreversible wall synthesis are bactericidal. That is, they eventually covalent acyl bond with the transpeptidase enzyme (prob- result in the cell’s death because of osmotic lysis. Most of the antibacterial agents that inhibit protein syn- thesis interact with the bacterial ribosome. The difference Macrolides, Ketolides, and Lincosamides between the composition of bacterial and mammalian Macrolide antibiotics (erythromycin, clarithromycin, and ribosomes gives these compounds their selectivity. Ketolide antibiotics, including Aminoglycosides telithromycin, replace the cladinose sugar on the Aminoglycosides (gentamicin, kanamycin, tobramycin, macrolactone ring with a ketone group. These drugs streptomycin, neomycin, and amikacin) are a group of bind specifically to the 50S portion of the bacterial structurally related compounds containing three linked ribosome and inhibit protein chain elongation. They exert a bactericidal effect by bind- Although structurally unrelated to the macrolides, lin- ing irreversibly to the 30S subunit of the bacterial ribo- cosamides (clindamycin and lincomycin) bind to a site on some and blocking initiation of protein synthesis. Thus, aminoglycoside activity is markedly Streptogramins reduced in an anaerobic environment. Spectinomycin,an Streptogramins [quinupristin (streptogramin B) and dal- aminocyclitol antibiotic, also acts on the 30S ribosomal fopristin (streptogramin A)], which are supplied as a subunit but has a different mechanism of action from combination in Synercid, are peptide macrolactones that also bind to the 50S ribosomal subunit and block pro- synthetase.

They are contraindicated during the nursing be- cause of their hipercoagulant effect and since they decrease the maternal milk quantity and quality generic imitrex 25mg without a prescription. It is recommended to begin use after the 28th postpartum day imitrex 50mg otc, although in patient of very diffi- cult control it is possible to apply medroxiprogesteron injection before hospital discharge buy 50mg imitrex overnight delivery, having scarce effect on the newborn. It is an effective and safe method in postpartum, and it does not present any adverse effect with the nursing, except when moving away the mother during the time of the procedure; in the immediate or mediate postpartum it is easier and surer a minilaparotomy, and later a laparoscopy. After the afterbirth: a critical review of postpartum health relative to method of delivery. A large percentage of births in the developing world occur at home without a skilled attendant present. Approximately 14 million women suffer postpartum hemorrha- ge every year worldwide. Without the presence of a skilled provider to recognize and treat the conditions leading to postpartum hemorrhage (uterine atony, uterine rupture, and/or genital lacerations) and to manage postpartum hemorrhage if it occurs, women rapidly experience shock and death, resulting in approximately 125. A few factors have made this definition somewhat arbitrary: • Visual estimation of blood loss is subjective and generally underestimated. Fortunately, due to physiological increases in plasma volume and red cell mass during preg- nancy, measured blood loss up to 1. In obste- trics the volume of blood loss can be difficult to assess as a result of concealed bleeding. The cause is due to abnormalities on one of four basic processes, or the ‘4 T’s’ mnemonic, which act individually or in combina- tion: Tone (poor uterine contraction after delivery), Tissue (retained products of concep- tion or blood clots), Trauma (to genital tract) or Thrombin (coagulation abnormalities)3. In developed countries, these lacerations occur more commonly with operative vaginal deliveries. In the developing world, they tend to happen when unskilled opera- tors perform unnecessary forceps deliveries and when unskilled attendants allow or persuade women to push before the cervix is fully dilated. Inherited disorders of coagula- tion, which might have been identified in developed countries with the onset of menar- che, often are not discovered until the woman develops severe postpartum hemorrhage in developing countries. Moreover, in many low-re- source settings, safe injection is not always possible due to the need for injection skills and training, lack of sterile equipment, and difficulty measuring the correct dose. The device comes individually in a sterile packet and is a prefilled, non-refillable, sterile, easy to use device with a fixed needle that can be «ac- tivated» for use after opening the sterile packet (figure 2). In situations where no oxytocin is available or birth attendants’ skills are limited, administering misoprostol soon after the birth of the baby reduces the occurrence of haemorrhage8. Education of women and birth attendants in the proper use of misoprostol is essential. The usual components of giving misoprostol include: • Administration of 600 micrograms (mg) misoprostol orally or sublingually after the birth of the baby. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. Immediate resuscitation measures include: • Establishment of a large-bore intravenous access. Compatible blood (supplied in the form of red cell concentrate) is the best fluid to replace blood loss and should be transfused as soon as available. If the uterus is poorly contracted, commence vigorous mas- sage and use therapeutic uterotonic agents. Emptying the bladder may facilitate uterine contraction and aid in ongoing assessment. Immediately resume bimanual massage and compression following exploration and evacuation of the uterus. Broad-spectrum antibio- tics are commonly advocated following manual removal, manual exploration, or instru- mentation of the uterus. Examination under anaesthesia should be performed, in particular looking for ex- tended tears in the cervix or high in the vaginal vault, as these may involve the uterus or lead to broad ligament or retroperitoneal haematomas. Traumatic haematomas are rare and may be related to lacerations or occur in isolation. Lower genital tract haematomas are usually managed by incision and drainage, although expectant management is acceptable if the lesion is not enlarging. However, clinical examination must be performed to exclude other causes of bleeding: retained products, lower genital tract lace- rations or haematomas, uetrine inversion or rupture, extragenital bleeding... If conservative measures fail to control haemorrhage, it is necessary to initiate sur- gical treatment. Oxytocin infusion (syntoci- non 40 units in 500 ml of 0,9% normal saline, infused at a rate of 125 ml/h) can be used to maintain uterine contraction. The rectal route may prove advantageous because it could lessen the gastrointestinal side effects, as it can be administered to patients who are vomiting or unable to take oral medications (e. Balloon tampo- nade using either a Foley catheter, a Sengstaken-Blakemore tube or a the Rusch urological hydrostatic balloon has been shown to effectively control postpartum bleeding and may be useful in several settings: uterine atony, retained placental tissue, and placenta accreta. A Foley catheter with a 30-mL balloon capacity is easy to acquire and may routinely be stocked on labor and delivery suites. Misoprostol – 400 to 600 micrograms given – Infrequent (diarrhea, nau- – Hypersensivity to drug.

The drug also is used for Teuscher E generic 50mg imitrex free shipping, Lindequist U purchase imitrex 50 mg fast delivery, Biogene Gifte - Biologie generic imitrex 25 mg on line, Chemie, constipation and as an emetic and to treat edema and kidney Pharmakologie, 2. Isoflavonoids: genistein, genistin Hansel R, Keller K, Rimpler H, Schneider G (Hrsg. The drug acts as a purifier, cathartic, diuretic, purgative and Lewin L, Gifte und Vergiftungen, 6. Unproven Uses: Formerly, the drug was used as a purgative Roth L, Daunderer M, Kormann K, Giftpflanzen, Pflanzengifte, and to remove bladder stones, as well as for digestive 4. Once an infusion has been taken, breathing deepens and pain in the lumbar and pelvic region is alleviated. Overdosage can lead to diarrhea and to symptoms Medicinal Parts: The entire plant has medicinal applications. The petal stems of the 4 lower petals are initially Mode of Administration: The drug is used internally as an straight, but in moments of tension, when for instance, they infusion. It Preparations: To prepare an infusion, use 1 teaspoonful of is brown, compressed at the sides, and contains 5 to 10 the ground drug per cup of water. The florescent green stems are smooth and produce fairly Bricout J, (1974) Phytochemistry 13:2819. Echinacea pallida herb consists of the fresh or dried in Food Drugs and Cosmetics, John Wiley & Sons Inc. Echinacea angustifolia herb and root consist of the fresh or Lewin L, Gifte und Vergiftungen, 6. Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde 1-3, Nachdruck, Georg Olms Verlag Hildesheim 1979. Not to be Confused With: The herbs and roots of Echinacea purpurea, Echinacea angustifolia and Echinacea pallida have Roth L, Daunderer M, Kormann K, Giftpflanzen, Pflanzengifte, different medicinal properties. The bracts are dodeca-2E,4E-8Z,10E/Z- tetraen acid isobutylamide in a number of rows. The bracts are leafy, rigid, thorny tipped, and longer than the conical erect disc florets. The Polyenes: trideca-l,ll-dien-3,5,7,9,-tetraine, trideca-1-en- reddish or occasionally white florets are conspicuous. The 3,5,7,9,11-pentaine, trideca-8,10,12-trien-2,4,6-triine, pon- M Hgual florets are usually sterile and 3 cm long. Water-soluble immunostimulating glycoproteins They are 7 to 20 cm long and have a rough surface. The herb exerts anti-inflammatory, 2,4,6-triine, pontica epoxide immunostimulating, bactericidal, and wound healing actions, Effective pyrrolizidine alkaloids: tussilagine, isotussilagine depending on the type of plant species. Confirmed by the Water-soluble immunstimulating polysaccharides (arabino- carbon clearance test and granulocyte tests, the ethanolic root rhamnogalactans) extracts significantly enhance phagocytosis (Bauer, 1988). The ethanolic extracts of both Echinacea plants also increase the total weight of the spleen (Bukovsky, Alkamides: including isomeric dodeca-2E,4E-8Z,10E/Z-tet- 1993). The component also induces a slight increase in T-cell proliferation (Burger, Flavonoids 1997; Luettig, 1989; Roesler, 1991). The length of the illness gen degradation was inhibited the greatest by echinacoside period was reduced significantly with the extract from 13 to and chicoriic acid, then cynarine and chlorogenic acid. The strongest effects on the collagen protection from free radical damage is through a clinical symptoms were achieved after 8-10 days (Brauning. The fluid extract, given 4 mL twice daily for 8 weeks, • Wounds and burns did not significantly decrease the incidence, duration or Echinacea purpurea herb is used internally as supportive severity of colds and respiratory infections compared to therapy for colds and chronic infections of the respirator) placebo (Grimm, 1999). It can also be applied locally to The efficacy and safety of Echinaforce® (Echinacea purpu- poorly healing superficial wounds. There were origin); increased susceptibility to infection due to temporar- 559 volunteers with a common cold included in the study. The radio and cytostatic therapy and in support of anti-infectious primary endpoint was the relative reduction of the complaint chemotherapy. All treatments were well • Fevers and colds tolerated with the frequency of adverse events not signifi- cantly higher than in the placebo group (Brinkeborn, 1999). Echinacea pallida root is used as a supportive therapy for influenza-like infections. The root extract dosages were 50 with headaches and stomach aches, measles, coughs and drops twice daily for 12 weeks from Monday to Friday. Fertility: High concentrations of Echinacea had adverse effects on oocytes in animal models (Ondrizek, 1999). Drug Interactions: The immune-stimulating effect of echina- Liquid — 120mg/5mL cea may interfere with drugs that have immunosuppressant Preparation: The root tea is prepared using 1/2 teaspoonful effects. Interaction may occur when using cyclosporine or of comminuted drug with boiling water.

Learner employs and maintains standards of aseptic and sterile technique (cleans 0 1 2 3 4 insertion site from inside outwards cheap imitrex 25 mg with mastercard, maintains sterility of needle and puncture site) 14 imitrex 50 mg low price. Learner identifies a vessel appropriate for venipuncture (non dominate arm if 0 1 2 3 4 possible discount imitrex 25mg without a prescription, palpates vessel, selects appropriate size vessel) 15. Learner inserts angiocath/butterfly needle appropriately (10-30 degree angle with 0 1 2 3 4 bevel up, advances sheath, removes stylet) 16. Learner is able to identify whether venipuncture attempt is successful or not 0 1 2 3 4 (flashback of blood) 17. Learner disposes of equipment in a safe manner, in appropriate container 0 1 2 3 4 18. Learner releases tourniquet before injection and in reasonable time frame 0 1 2 3 4 19. Learner connects syringe/tubing and secures catheter/butterfly appropriately 0 1 2 3 4 20. Early contrast media included bismuth in oil, iodized oil, organic iodides and strontium bromide. The very first contrast examination was attempted only one month after the discovery of x-rays in 1895. It was a mixture of cinnibar, vaseline, and gypsum injected into the vessels of a cadaver arm. However a successful contrast agent for use on living humans was not discovered for another 30 years. In 1923 it was discovered that sodium iodide (inorganic iodide) made an excellent contrast but the physiological effects were so dangerous that most patients died. Interaction of Contrast Media with X-rays The most commonly used radiopaque contrast media are Barium and Iodine. These are used because their atomic number and mass density are higher than the tissues being imaged. Their atomic numbers are 56 and 53 respectively, while human tissue has an average atomic number of 18. Iodine is the most widely used injectable agent as iodine absorbs x-ray photons and this limits the amount of photons that pass through the body and reach the image receptor. Structure of Iodinated Radiography Media Advancement in the finding of a suitable contrast occurred with the development of the water-soluble organic iodide compounds. These compounds are triiodinated compounds derived from the benzoic acid ring structure Iodine, the opacifying portion of the structure is nd th th rd th located at the 2 , 4 , & 6 , parts of the ring. The salts most commonly used for water-soluble organic iodides are sodium and meglamine. The generic name of a contrast medium is derived from the cation and anion, for example sodium diatrizoate (Sodium Hypaque). The toxicity of an ionic monomer is the result of the Osmolality and ionicity of the contrast agent. In the non-ionic agents, the cation was eliminated, as it was responsible for most of the osmotic effect of the agent. When dissolved in water a non-ionic compound forms a molecule not an ionizing solution. Its ion (Gd+) has 7 unpaired electrons and therefore shows paramagnetic properties. Ultrasound Contrast Agents Many substances may act as contrast in ultrasound and Doppler. The altered echo amplitude due to changes in absorption, reflection and/or refraction causes the contrast. Echo free fluids such as water or saline, distends body cavities to improve visualization of the luminal walls. The newer contrast media, designed for vascular work are intended to increase Doppler signals from blood or the echogenicity of tissue. They are based on either micorbubble solutions or solid particles suspended in solutions or emulsions. Depending upon bubble size and the mechanical properties of the bubble capsule, some microbubble contrast media may have resonance frequencies close to the transmitted ultrasound frequency. In an ultrasound field they will start to oscillate thus actively transmitting ultrasound. This contrast media (gas microbubbles) is taken up by the reticuloendolthelial cells of liver and spleen. When imaged by Doppler, the pressure waves caused by the bubble rupturing creates a coloured mosaic pattern in tissue. Tumors devoid of reticuloendolthelial tissue such as metastases stands out as dark, non coloured regions. The osmolality (concentration) and the chemical nature of these agents are believed to be the major factors responsible for the “side-effects” experienced with intravascular contrast administration. The osmolality of contrast media used today is two to three times greater than that of blood.