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By: Renee-Claude Mercier, PharmD, BCPS-AQ ID, PhC, FCCP Professor of Pharmacy and Medicine, University of New Mexico, College of Pharmacy, Albuquerque, New Mexico

Coagulation studies like prolonged clotting time and prothrombin time discount 80mg propranolol free shipping capillaries cells,18 hypofibrinogenemia generic propranolol 80 mg amex coronary heart anomalies. Urine examination may reveal hematuria cheap propranolol 40mg visa coronary heart 6 dude, proteinuria buy cheap zenegra online, hemoglobinuria and myoglobinuria order generic accutane on line. Management First Aid Most of the traditional and popular first aid measures do more harm than good. First aid methods with unequivocal benefit are reassurance, immobilization of the bitten part and tourniquet. A tourniquet should be used only in Krait bites and not in Cobra or Viper bites where it will increase local complications. The tourniquet should be one to four inches broad (preferably elastic crepe bandage) applied proximal to the Krait bite and loose enough to pass one finger below it and the distal pulses should be well felt. Rapid Assessment and Resuscitation Once in hospital, rapid assessment of airway, breathing and circulation should be done. Administration of oxygen, establishment of intravascular access and cardiopulmonary resuscitation started as needed. Some common situations needing urgent resuscitation are profound hypotension, shock, respiratory failure, hyperkalemic cardiac arrest, etc. Neostigmine: It is useful for neuromuscular junction blockade caused by neurotoxic snake bites. It is useful only for postsynaptic type of blockade (occurring with Cobra bites) and not for presynaptic block (Krait bites cause both pre and postsynaptic blockade). Local swelling involving more than half of the bitten limb (in absence of tourniquet) b. Neurotoxic signs: Ptosis, external ophthalmoplegia, flaccid paralysis, heavy eyes, bulbar paralysis, etc. Supporting laboratory evidence of systemic envenomation like early polymorphonuclear leukocytosis. It is always administered intravenously and not intramuscular or subcutaneous around bite. Sensitivity testing does not reliably predict early or late antivenom reactions and is not recommended. Adrenaline (Epinephrine) should always be kept ready for early anaphylactic reactions. Some studies have shown that subcutaneous adrenaline given just before antivenom infusion reduces the incidence of early antivenom reactions. Sometimes pretreatment with antihistaminics (both anti H1 and anti H2) and corticosteroids are also used in high risk cases. Best effects are observed when it is given within 4 hours of the bite6 but is useful in symptomatic patients even upto one week after the bite22 and in case of hemostatic abnormalities even upto two or more weeks. Mechanical ventilation: For respiratory paralysis in cases of neurotoxicity by Cobra and Krait, this form of therapy is life saving. Blood transfusion, blood components, volume expanders, peritoneal dialysis are needed depending on the clinical situation.

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Advantages and disadvantages The major advantage over con- • Rectal formulation – a 2 purchase genuine propranolol on-line zebra cardiovascular system. Tere is some suggestion that it is less Usual dosage Intravenous bolus (undiluted) 10–20 mg (adults) or efective than valproate generic 40mg propranolol amex capillaries functions, phenytoin or phenobarbital but there are 0 generic 40 mg propranolol mastercard cardiovascular system trivia. Rectal administration 10–30 mg adjustments need to be made in patients with renal failure (with (adults) or 0 red viagra 200 mg mastercard. The dose must be diluted in at least ous infusion in the refractory stage of status purchase 100 mg aurogra with visa, and is the only benzo- 100 mL of a compatible diluent and administered over at least diazepine that should be used in this manner because of its low risk 10 minutes as an intravenous infusion. A disadvantage is its tendency to develop Use in Acute seizures, premonitory and early stages of status epi- acute tolerance. In refractory status epilepticus in adults, drug accumulation, and also a lower risk of hypotension. In children the is thus usable only as initial therapy, and longer-term maintenance bolus dose is 0. Lorazepam is a stable compound that is not likely to precipitate in solution, and is Use in Stage of established status epilepticus. It has a stronger anticonvulsant action than other bar- Usual dosage Intravenous bolus of 0. Its safety at high doses has been established, and the drug can be continued as chronic therapy. The Midazolam disadvantages of the drug relate to prolonged use, where, because of the long elimination half-life, there is a risk of drug accumulation Use in Acute seizures, premonitory and early stages of status epi- and inevitable sedation, respiratory depression and hypotension. Usual preparation A 1-mL ampoule containing phenobarbital Advantages and disadvantages Midazolam is a water-soluble com- sodium 200 mg/mL in propylene glycol 90% and water for injection pound, the ring structure of which closes when in contact with serum 10%. Its side-efect pro- Phenytoin fle has been extensively studied as it has been used for many years in dental anaesthesia. Occasionally, severe cardiorespiratory depres- Use in Stages of established status epilepticus. Phenytoin is one of sion occurs afer intramuscular administration although this is rare. When seizures have been con- toin has been gained in adults, children and neonates, and phenytoin trolled for 12 hours, drug dosages should be slowly tapered over has proven efcacy in tonic–clonic and partial status. In children, 1–2 mg/kg bolus followed by infusion of prolonged action, with a relatively low risk of respiratory or cerebral 1–7 mg/kg/h. Its main disadvantage is the time necessary to infuse the drug and its delayed onset of action. Thiopental/pentobarbital The pharmacokinetics of phenytoin are problematic, with Michaelis– Menten kinetics at conventional dosages and wide variation between Use in Stage of refractory status epilepticus. Toxic side-efects include cardiac rhythm disturbances, metabolite pentobarbital, is, in most countries, the usual choice for and hypotension and cardiorespiratory depression.

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Signs and Symptoms: Pain and tenderness usually result from a perforation of the bowel generic 80mg propranolol amex capillaries vs arteries. Gastric Carcinoma 289 Description: Gastric (adenocarcinoma) carcinoma is one of the most common cancers in the world order 40mg propranolol with amex cardiovascular system and functions. Adenocarcinomas make up approximately 95% of all malignant cancers affecting the stomach buy propranolol now coronary artery risk development in young adults. Etiology: Dietary and environmental factors may influence the onset of the cancer order 75mg sildenafil mastercard. Nitrates order januvia 100 mg without prescription, pickled foods, salted fish and meat products, and smoked foods have been associated with gastric carcinoma. Epidemiology: Approximately 21,000 cases detected, with about 10,500 deaths annually. Treatment: Complete resection of the gastric tumor and involved lymph nodes is the only known possible curative treatment. Intussusception Description: Intussusception is a telescoping (invagination) of one portion of the bowel into another. Epidemiology: Approximately 95% of cases occur in young children, the remaining occur in adults. Signs and Symptoms: In infants, a triad of colicky abdominal pain, vomiting, and redcurrant jelly stools may be seen. Treatment: Hydrostatic barium enema is used to reduce the intussusception in most cases. The axial image shows a “target sign” in the right pelvis as a result of the intussusceptum telescoping into the intussusceptions. Ischemic Bowel Description: Ischemic bowel is a disease process which results in a reduced blood flow to the intestinal tract. Etiology: An insufficient blood flow through the mesenteric vessels is primarily caused by an abnormal fatty/lipid mass within the artery called an atheroma which occludes the vessel. Signs and Symptoms: the patient may present with abdominal pain, tenderness, and bloody diarrhea. Treatment: Surgery and interventional procedures such as stenting and balloon angioplasty may be possible methods for treatment. Prognosis: For transient ischemic attacks, these usually resolve within a few months without any further complications. There is a high mortality rate (90%) associated with occlusive infarct of the mesenteric vessels.