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By Y. Murak. Bradley University. 2018.

Understand the basic principles of management of poisoning Introduction The purpose of this chapter is to provide guidelines for evaluating the severity of an exposure to a potentially toxic substance discount lasix 40 mg line blood pressure ranges by age and gender, clues to the identity of the offending substance (its clinical effects on vital functions cheap 40 mg lasix with visa heart attack induced coma, its odor, and its effect on the skin), and, most importantly, how to manage the severely intoxicated victim initially. The trained analyst can play a useful role in the management of victims poisoned with drugs or other chemicals. However, optimal analytical performance is only possible when the clinical aspects of the diagnosis and treatment of such victims are understood. The analyst must therefore have a basic knowledge of emergency medicine and 20 Toxicology intensive care, and must be able to communicate with clinicians. In addition, a good understanding of pharmacology and toxicology and some knowledge of active elimination procedures and the use of antidotes are desirable. This chapter aims to provide some of the basic information required in the general approach of poisoned victims. When acute poisoning is suspected, the clinician needs to ask a number of questions in order to establish a diagnosis (history of present illness). In the case of an unconscious (comatose) victim, the circumstances in which the victim was found and whether any tablet, bottles or other containers (scene residues) were present can be important. If the victim is awake, he or she should be questioned about the presence of poisons in the home or workplace. Physical examination of the victim may indicate  The poison or class of poison involved. For example, the combination of pin-point pupils, hyper salivation, incontinence and respiratory depression suggests poisoning with a cholinesterase inhibitor such as an organophosphorus pesticide. However, the value of this approach is limited 21 Toxicology if a number of poisons with different actions have been absorbed. Moreover, many drugs have similar effects on the body, while some clinical features may be the result of secondary effects such as anoxia. Thus, if a victim is admitted with depressed respiration and pin-point pupils, this strongly suggests poisoning with an opioid. For example, coma can be caused by a cerebrovascular accident, uncontrolled diabetes infections as well as poisoning. The availability of the results of urgent biochemical and hematological tests is obviously important in these circumstances. Examples include: cardiorespiratory arrest (cyanide), hepatitis (paracetamol) and so on. B Generally Physical examination should include – Vital signs – Evaluation of specific parts of the body Investigations a) General laboratory tests  Hematological  Biochemical b) Toxicological studies c) Electrocardiogram d) X-ray findings 22 Toxicology Principles of management of poisoning The initial management of a patient with altered mental status follows the follow the same approach regardless of the poison involved. After this, one can begin in a more detailed evaluation to make a specific diagnosis. Therefore, in principle, during poisoning, one should treat the victim first followed by treating the poison itself. Supportive measures The first priority is to establish & maintain vital functions. Subsequently, most victims can be treated successfully using supportive care alone. Principles of toxin eliminations - If the poison has been inhaled, the victim should first be removed from the contaminated environment. However, repeated oral administration of activated charcoal appears to be effective in enhancing elimination of certain poisons. The results of either a qualitative or a quantitative toxicological analysis may be required before some treatments are commenced because they are not without risk to the victim. In general, specific therapy is only started when the nature and/or the amount of the poison(s) involved are known. Antidotes or protective agents are only available for a limited number of poisons. In summery there are four main methods of enhancing elimination of the poison from the systemic circulation: 1. Some antidotes &protective agents used to treat acute poisoning Antidote Indication • Acetylcysteine Paracetamol 24 Toxicology • Atropine Organophosphate • Deferoxamine Iron • Methylene blue Nitrates • Physiostigmine Atropine • Naloxone Opioids • Pyridoxine Isoniazid Exercise 1.

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Causes Causes Clinical signs/symptoms Meningitis - Very irritable - Stiff neck or bulging fontanelles - Petechial rash (meningococcal meningitis only) - Fever Cerebral malaria (only - Blood smear positive for malaria in children exposed to P 40 mg lasix mastercard blood pressure normal low pulse rate. Child having 3rd convulsion Lasting < 5mins in < 2 hours* Convulsion stops by 10 minutes? Coma Defnition: It is a state of extreme unresponsiveness generic 100mg lasix with visa prehypertension statistics, in which an individual exhibits no voluntary movements or behaviour and cannot be aroused to consciousness. Causes Causes Clinical signs/Symptoms Meningitis - Very irritable - Stiff neck or bulging fontanelles - Petechial rash (meningococcal meningitis only) - Fever Cerebral malaria - Blood smear positive for malaria parasites (only in children - Jaundice exposed to P. When seizures are recurrent, persistent or associated with a syndrome, then the child may be diagnosed with epilepsy. Combination therapy should be initiated by or in close consultation with a pediatric specialist or neurologist. Phenytoin and Phenobarbital may be used together but vital signs must be monitored closely and patient should be referred as soon as possible. Tis medication should be prescribed by or in close consultation with a neurologist. May increase dose weekly to maximum to 40 mg/kg/day in 2 divided doses with a maximum dose of 1. It is given as add-on therapy for many seizure types drug-resistant pediatric epileptic syndromes, such as Lennox-Gastaut Syndrome - Levetiracetam: Dosing not established for children <4 years. It is not recommended as mainte- nance therapy for children older than 2 years due to side efects such as sedation, behavioral disturbances, hyperkinesia and dependence, except in situations where there is poor adherence to other drugs. Children ages 2-4 years may metabolize the medication more quickly, as such for children <20 kg, consider initial dose of 16-20 mg/kg/day divided in 2 doses. If >8 years: initial dose is 125-250 mg/kg day at bedtime and may be increased weekly by 125-250mg/day to the usual dose of 750-1500 mg/day in 3-4 divided doses. Increase every 2 weeks by 1-3 mg/kg/day given in 2 divided doses and titrate to response. Post-pubertal female patients must be informed about neural tube defects and family planning methods should be encouraged. Tis is particularly true in partial seizures where there may be a focal neurological problem. If they occur, stop infusion, stabilize patient, then restart at 2/3 the initial rate. Recommendations - Once status epilepticus is resolved, consider maintenance therapy with an appropriate anti-epileptic drug depending on the etiology of seizure. If status epilepticus has resolved, further work-up by a neurologist may be indicated. Type I diabetes accounts for approximately 2/3 of the new diagnosis of diabetes in patients < 19 years old. It is a rare cause of hyperglycemia in the neonate and has an estimated incidence of 1/500,000 births. Te majority of afected infants are small for gestational age experiences weight loss, volume depletions, hyperglycemia and glucosuria with or without ketonuria and ketoacidosis. Signs and Symptoms - Polyuria: Tis occurs when the serum glucose concentration rises above 180 mg/dL exceeding the renal threshold for glucose and leads to increased urinary glucose excretion and a subsequent osmotic diuresis. Tis may be present as nocturia, bedwetting, or daytime incontinence in a previously toilet trained child, or heavy diapers. Diagnosis - Clinical: Te diagnosis should be suspected based on the signs and symptoms described above. Investigations - Blood sugar: Te diagnosis is made based on abnormalities of the blood glucose. Long Term complications • Vascular complications including both micro-angiopathy and macro-angioapthy: Ș Nephropathy Ș Retinopathy Ș Neuropathy Ș Cardiovascular disease Ș Hypertension • Dyslipidemia • Growth retardation or obesity depending on the insulin therapy. Te patient and family should be taught how to monitor blood glucose, record the test results, administer and adjust insulin doses based on blood glucose values and food intake.

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Eye Symptoms 103 buy discount lasix 40mg line arrhythmia types, 107 103 Two good quality trials assessed eye symptoms at 2 weeks (total N=891) buy generic lasix 100 mg blood pressure chart newborn. For eye symptoms at 2 weeks, the risk of bias was low based on the quality of the trials. Evidence was insufficient to support the use of one treatment over the other for this outcome. Comparative Adverse Effects of Treatments in Adults and Adolescents 12 Years of Age or Older Oral Selective Antihistamine Versus Oral Nonselective Antihistamine Key Points 81-83 All three trials that reported harms were 2-week trials. Evidence from three poor quality trials was insufficient to support the use of either oral selective or nonselective antihistamine to avoid sedation or headache. Synthesis and Evidence Assessment 81-83 All three trials (N=515) that reported efficacy outcomes also reported adverse events. Table 58 displays the risk differences and elements for the synthesis of evidence for this comparison. In two of these, risk differences favored selective 81 antihistamine to avoid moderate sedation (13 percent ) and unspecified severity sedation (28. Statistically nonsignificant differences also 81 83 favored selective antihistamine to avoid severe sedation and unspecified severity sedation. It is unclear whether effects were reported consistently based on differences in classification schemes across trials. Forty-one percent of patients were in a 83 trial that reported a statistically nonsignificant result. Evidence was insufficient to conclude that either comparator is favored to avoid sedation. The 81 risk of bias was considered high based on poor trial quality and insufficient adverse event 83 surveillance. Evidence was insufficient to conclude that either comparator is favored to avoid headache. Evidence was insufficient to support using either oral or nasal antihistamine to prevent common adverse events of sedation, headache, bitter aftertaste, and nosebleed. For bitter aftertaste, it is unclear whether future comparative trials would observe similar effects because all of the included trials used an older formulation of the currently available product. Synthesis and Evidence Assessment 84-87 All four trials that reported efficacy outcomes also reported adverse events (N=886). Table 59 displays the risk differences and elements for the synthesis of evidence for this comparison. Risk differences were not statistically significant, but favored oral antihistamine to avoid 84- sedation in both (0. Unspecified sedation was reported by four trials 87 with risk differences ranging from 1 percent in favor of oral antihistamine to 5 percent in favor of nasal antihistamine; none were statistically significant. Evidence was insufficient to conclude that either comparator is favored to avoid sedation. Evidence was insufficient to conclude that either comparator is favored to avoid headache. Thirty- 87 five percent of patients were in a trial that reported a statistically nonsignificant difference. Evidence was insufficient to conclude that either comparator is favored to avoid a bitter aftertaste. It is important to note that all trials reporting on this outcome used an older 151 Table 59. Risk differences were 0 percent in one and 1 87 percent (not statistically significant) favoring oral antihistamine in the other. Evidence was insufficient to conclude that either comparator is favored to avoid nosebleeds. Oral Selective Antihistamine Versus Intranasal Corticosteroid Key Points 95 90-93, 99 Of six trials that reported harms, one was 15 days in duration and five were 4 weeks in duration. Evidence from these trials was insufficient to support the use of either oral selective antihistamine or intranasal corticosteroid to avoid headache or nosebleed. Synthesis and Evidence Assessment 90-93, 95, 99 Six of 13 trials reporting efficacy outcomes also reported adverse events of interest (N=2038). Table 60 displays the risk differences and elements for the synthesis of evidence for this comparison.

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