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Did they pass out and drown cheap 35 mg actonel with amex medicine in the civil war, die of the drugs and eventually slide under water purchase cheap actonel line medicine man pharmacy, or were they placed in the tub following an overdose in a futile attempt to revive them? Similar questions arise in regard to the individual with severe heart disease found in a bathtub under water purchase online tamoxifen. Did they die of a heart attack and then slip under the water or did they have an incapacitating heart attack, slip under the water and drown? The presence of pulmonary edema is of no help, as it might be present in drug overdoses, heart failure or drowning. If, while taking a bath, one’s feet are grasped and one is pulled underwater by them, there can be an involuntary inhalation of water as the water rushes into the nasopharynx. This, exacerbated by panic and being in a smooth-walled, wet, slippery con- tainer, could result in an inability to save oneself, with rapid loss of con- sciousness and death. Rarely, the authors have seen well-documented cases where an individual slipped in the bathtub, struck his head, and drowned. Scuba Divers Deaths occurring with use of scuba equipment can be caused by: Natural disease As a consequence of being underwater at increased pressure An environmental hazard As a result of defective equipment Death by Drowning 407 Too rapid an ascent to the surface can cause air embolism, pneumotho- rax, or interstitial emphysema. Equipment can be the cause of death if it is defective or if there is contamination of the contained air by a substance such as carbon monoxide. Severe rusting of the interior of the tank could result in a tank atmosphere depleted of oxygen due to formation of iron oxide. In any scuba death, the authors suggest examination of the equipment by a person knowl- edgeable in this field, analysis of the residual atmosphere in the tank, and consultation with someone in your area experienced in scuba diving. These deaths involve both low- voltage (<600 V) and high-voltage (>600–750 V) currents. They virtually always involve alternating currents, because direct current is used less. In addition, humans are four to six times as sensitive to alternating currents as to direct. Amperage, or the amount of current flow, is the most important factor in electrocution. Voltage is a measure of the electromotive force and ohms are the resistance to the conduction of electricity. High-voltage lines in suburban and urban areas are approximately 7500–8000 V line to ground with transcontinental high-tension lines 100,000 V or greater. For electrocution from low-voltage (110–120 V) household current, there must be direct contact with the electrical circuit, with death primarily caused by ventricular fibrillation. As the body approaches the high- voltage line, an electric current (arc) may jump from the line to the body. Death from high-voltage electrocution is usually caused by either the electro- thermal injury produced by the current, or respiratory arrest. Electrocution from these lines occurs when they break, fall to the ground and are touched, or when an intact or “live” line is touched by a tall metal object such as a ladder, pole, or crane with which a person is in contact. With 120 V, dry skin may have a resistance of 100,000 ohms; dry and calloused skin up to a million ohms; moist skin 1,000 ohms or less, and moist, thin skin as low as 409 410 Forensic Pathology Table 16.

Although it may be given with a bolus of 12 to 24 µg/kg over 10 minutes actonel 35mg with amex treatment of pneumonia, many clinicians directly initiate a continuous infusion at 0 order genuine actonel on line medicine technology. The potent vasodilating effects of levosimendan can cause significant hypotension purchase generic elavil on line, the risk of which may be reduced by 100 maintaining filling pressures. Levosimendan has an active, acetylated metabolite with a half-life longer than 80 hours, allowing it to have hemodynamic effects days after discontinuation of the infusion. Initial clinical studies demonstrated reduced arrhythmias and improved survival with levosimendan compared to placebo and dobutamine. Vasopressors These agents should be reserved for patients with marked hypotension in whom central organ hypoperfusion is evident. Vasopressors will redistribute cardiac output centrally at the expense of peripheral perfusion and increased afterload. Norepinephrine is a potent agonist of the beta and the1 alpha receptors but is a weaker agonist of beta receptors, resulting in marked vasoconstriction. Phenylephrine is a selective alpha receptor agonist with potent direct arterial vasoconstrictor effects. It should be given slowly because rapid administration may cause systemic vasoconstriction. Ischemia, hypokalemia, or hypomagnesemia may increase the likelihood of developing digitalis intoxication, even at the therapeutic doses. The theoretical advantage of ultrafiltration is the removal of isotonic fluid, resulting in greater 85 and more reliable salt removal, potentially without the neurohormonal activation seen with diuretics. Potential limitations of ultrafiltration include the need for large-bore venous access, systemic anticoagulation, and increased complexity of nursing care related to management of the device. Patients receiving ultrafiltration demonstrated a 119 greater reduction in body weight at 48 hours, but no improvements in dyspnea or renal function. Intriguingly, there was a reduction in postdischarge events at 90 days with ultrafiltration, although the number of events was small. In an observational study of 63 patients with persistent congestion refractory to hemodynamically guided intensive medical therapy, slow continuous ultrafiltration resulted in improved hemodynamics, yet was associated with high incidence of subsequent transition to renal replacement therapy and high in-hospital 120 mortality. There was no difference in renal function, but more patients assigned to ultrafiltration experienced adverse events. These hypothesis-generating data are intriguing, but they are limited by the unblinded study design and the potential confounding by postdischarge management. Larger, prospective, blinded trials are needed to evaluate this therapeutic approach further before adoption for clinical practice. A variety of potential explanations have been proposed, including lack of drug 123 efficacy, patient selection, timing of therapy, and endpoints.

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The magnitude purchase actonel treatment 0 rapid linear progression, dynamic change order actonel 35mg on line medications epilepsy, and duration of the pressure difference between two cardiac chambers discount 20 gr benzac otc, or between the ventricles and their respective great arteries, dictate the duration, frequency, configuration, and intensity of murmurs. Intensity is graded on a scale of 1 to 6; a palpable thrill characterizes murmurs of grade 4 or higher intensity. Other important attributes that aid in identification include location, radiation, and response to bedside maneuvers, including quiet respiration. D, Ejection sound and crescendo- decrescendo murmur that extends to P in bicuspid pulmonic stenosis; 2 A ,2 aortic component of S ; 2 P ,2 pulmonic component of S. Note the holosystolic timing and plateau configuration of the murmur, both of which derive from the large ventricular-atrial pressure gradient throughout systole; v, v wave. Accurate characterization of the severity of aortic stenosis at the bedside depends on cardiac output, stiffness of the carotid arteries, and associated findings. An isolated grade 1 or 2 midsystolic murmur in the absence of symptoms or other signs of heart disease is a benign finding that does not warrant further evaluation, including echocardiography. A similar murmur may be heard transiently during an episode of acute myocardial ischemia. The stenosis also may be “silent,” as in patients with low cardiac output or large body habitus. Presystolic accentuation (an increase in the intensity of the murmur in late diastole following atrial contraction) occurs in patients in sinus rhythm. Left-sided events usually obscure findings in patients with rheumatic tricuspid stenosis. Less common causes of a mid-diastolic murmur include atrial myxoma, complete heart block, and acute rheumatic mitral valvulitis (Carey Coombs murmur). Continuous Murmurs The presence of a continuous murmur implies a pressure gradient between two chambers or vessels during both systole and diastole. Dynamic Auscultation Simple bedside maneuvers can help identify heart murmurs and characterize their significance (Table 10. Right-sided events, except for the pulmonic ejection sound, increase with inspiration and decrease with expiration; left-sided events behave oppositely (100% sensitivity, 88% specificity). Forward flow accelerates, causing an increase in the gradient and a louder murmur. After release of the Valsalva maneuver, right-sided murmurs tend to return to baseline intensity earlier than left-sided murmurs. Exercise: Murmurs caused by blood flow across normal or obstructed valves (as in pulmonic and mitral stenosis) become louder with both isotonic and isometric (handgrip) exercise. During the later tachycardia phase, murmurs of mitral stenosis and right-sided lesions also become louder. This intervention may help distinguish the murmur of the Austin Flint phenomenon from that of mitral stenosis.

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Brain swelling is due to an increase in intravascular cerebral blood volume second- ary to vasodilatation (congestive brain swelling) generic actonel 35 mg amex treatment lice, or an absolute increase in the water content of the brain tissue buy discount actonel 35 mg online treatment eczema, or a combination of the two discount 160 mg tricor amex. An increase in tissue water content, or cerebral edema, is often incorrectly considered synonymous with brain swelling. If continued long enough, brain swelling caused by an increase in the intravascular cerebral blood volume progresses to cerebral edema, presumably due to increased vascular permeability. The magnitude of the brain swelling does not necessarily correspond to the sever- ity of the injury. Massive cerebral (congestive) swelling can occur within 20 minutes following head trauma. The secondary swelling may, in fact, cause a more serious mass effect than the hematoma. With severe brain injury, diffuse brain swelling of a severe degree may occur immediately without the individual regaining consciousness. Brain swelling, however, might not occur immediately after an injury, but rather develop minutes to hours later. It is usually diffuse and more often associated with the less severe forms of brain injury. Typically, the patient receives a concussion, regains consciousness, only to become stuporous and lapse into coma minutes to hours later. Until recently, it was felt that children were more susceptible than adults to developing diffuse swelling, even after minor trauma. If brain swelling develops to a severe degree and continues over a suffi- cient time, there can be herniation of the brain or secondary brain stem hemorrhage. A rapidly expanding intracranial mass or severe brain swelling 178 Forensic Pathology Figure 6. Herniation may be either symmetrical, due to brain swelling, or asym- metrical, due to a mass in one side of the brain or subdural space, e. In the case of diffuse brain swelling, there is usually symmetrical herniation of the cerebellar tonsils without brain stem hemorrhage. The brain stem and cerebellar tonsils are forced into the foramen magnum, with resultant dysfunction or even infarc- tion of the brain stem. The individual becomes unconscious and develops respiratory difficulty that proceeds to arrest and death. In some individuals with pro- longed survival, the authors have seen the upper spinal cord encased in necrotic cerebellar tissues shed into the cerebrospinal fluid. In dealing with an asymmetrical herniation caused by a subdural hematoma, in addition to ipsilateral cerebellar tonsil herniation, one often has a secondary brain stem hemorrhage (a Duret hemorrhage) involving the midbrain and pons.