Dilantin

By F. Abe. State University of New York College at Geneseo. 2018.

You will probably not cure the necessary purchase 100mg dilantin with amex, be removed electively at a endometriosis surgically buy 100 mg dilantin otc, no later time. Most bleeding can be chance of inadvertent injury to controlled with lesser procedures (D&C the bladder, bowel or ureters. Because the cervix remains in uterus and its blood supply followed by place, there is less chance of removal of the uterus. The most difficult long-term vaginal support part (and the part which leads to the problems since the supporting most complications) is removal of the structures (cardinal and lowest portion of the uterus and cervix. In an emergency setting, it is very The disadvantages to the supracervical acceptable to avoid those problems by hysterectomy are several, but relate more performing a "supracervical to the elective or semi-elective hysterectomy. If malignancy narrows, (above the level of the bladder is present in the uterus, an incomplete and ureters), a scalpel cuts across the procedure has been performed. Further, lower uterine segment, resulting in the if infection is present, some infected removal of the upper portion of the tissue may be left behind. The raw, cut edge of the cervix disadvantages seem persuasive, and the and lower uterine segment is sutured for advantages in speed, safety and hemostasis. This part of the uterus can, if 9 Surgical Emergencies in Obstetrics & Gynecology simplicity suggest supracervical These patients have moderate to heavy hysterectomy is preferable when needed. Prophylactic antibiotics cervix, you may grasp is gently with covering gram negative and anaerobic sponge forceps and ease it the rest of the bacteria is an excellent idea in the way out of the cervix. If pregnancy tissue is passed, If fever is present, broad-spectrum it is reclassified as either an incomplete antibiotics are wise, particularly if D&C or complete abortion. Rh negative women means the cervix has begun to dilate and should ideally receive Rhogam (Rh bleeding is so heavy that spontaneous immune globulin) within 3 days of a abortion must occur. Bedrest will usually slow the bleeding temporarily, but will not change the final Complete Abortion outcome of the pregnancy. A complete abortion is the passage of all Incomplete Abortion pregnancy tissue from inside the uterus. Typically, these patients complain of When some pregnancy tissue has been vaginal bleeding and cramping which passed, but more remains inside the leads to passage of tissue. The responsible bacteria are usually a mixed group of Bedrest for a day or two may be all that strep, coliforms and anaerobic is necessary to treat a complete abortion. Save in formalin any tissue which the Remember, though, that she has the patient has passed for pathology potential for becoming extremely ill very examination. If you can grab a portion of the placenta (assuming a part of it is or extruded through the cervix), you sometimes can tease the rest of the Cefoxitin 2. They typically involve a labor-type Third Trimester Delivery experience for the patient, with delivery Complications of a non-viable fetus. Cesarean Section After delivery of the fetus, be prepared to wait as long as several hours for the In the face of intractable hemorrhage in placenta (afterbirth) to separate and be an undelivered patient or totally delivered. While waiting, clamp and cut obstructed labor, emergency cesarean the umbilical cord and remove the fetus section will probably be life-saving. Manual Removal of the Placenta If the placenta remains inside longer than 6 hours, D&C is indicated to After delivery of the infant, the placenta remove it. Insert your hand through the Alternative diagnoses which can cause vagina into the uterus and grasp the similar symptoms include a corpus placenta. With This is generally caused by the uterus a threatened abortion, the pain is central failing to contract. After manually or suprapubic and the uterus itself may exploring the uterus to make sure no be tender. If she should suddenly rupture and go into Post Partum Hysterectomy shock, you can respond more quickly. Typically, this is a The vibration during a helicopter ride or supracervical hysterectomy (subtotal the jostling over rough roads in an hysterectomy) even in experienced ambulance or truck may provoke the hands because of the difficulty in easily actual rupture. A woman with an unruptured ectopic pregnancy may have the typical Ruptured Ectopic Pregnancy unilateral pain, vaginal bleeding, and adnexal mass described in textbooks. Women with a ruptured ectopic Alternatively, she may have minimal pregnancy will nearly always have pain, symptoms. If surgery is not an ultrasound scan to confirm the available option, stabilization and placement of the pregnancy. If abdominal surgery is not an available option, the outlook for a patient with a Ovarian Cyst ruptured ectopic pregnancy is not totally bleak. Aggressive fluid and blood These cysts are common and generally replacement, oxygen and complete cause no trouble. Each time a woman bedrest will result in about a 50/50 ovulates, she forms a small ovarian cyst chance of survival.

Baroreceptor reflex: an autonomically mediated reflex response that influence the heart and blood vessels to oppose change in mean arterial blood pressure order 100 mg dilantin amex. Bundle of His: a tract of specialized cardiac cells that rapidly transmits an action potential down the interventricular septum of the heart 100mg dilantin with mastercard. Baroreceptor: receptor located within the circulatory system that monitors blood pressure. B- lymphocytes (B cells): white blood cells that produce antibodies against specific targets. Basophils: white blood cells that release histamine in allergic responses and heparin that removes fat particles from the blood. Body system: a collection of organs that perform related functions essential for survival of the whole body, e. Calmodulin: intracellular calcium-binding protein that upon activation is important in smooth muscle contraction. Cardiovascular control center: the integrating center located in the medullas of the brain stem that controls mean arterial blood pressure. Channels: Small water filled pathways through the plasma membrane providing highly selective passages for ions. Cholesterol: a type of fat molecule that serves as a pressure for steroid hormones and bile salts and is a sterilizing component of the plasma membrane. Cholinergic fibers: nerve fibers that release acetylcholime as their neuro-transmitter. Circulatory shock: when mean arterial blood pressure falls so low that adequate blood flow to the tissues can no longer be maintained. Congestive heart failure: the inability of the cardiac output to keep place with the body, needs for blood delivery with blood damming up in the veins behind the failing heart. Controlled variable: Some factors that can vary but controlled in a steady state Coronary artery disease: Atherosclerotic plaque formation and narrowing of the coronary artery that supply that heart muscle. Cytoplasm: the portion of the cell not occupied by the nucleus Cytosol: portion of the cell not occupied by organelles Cytotoxic T-cells: Cells that destroy host cells bearing antigens such as virus infected cells, cancer cells etc. Depolarization: a reduction of membrane action potential from resting membrane potential towards 0 mV. Effector organs: the muscles or granular tissue innervated by nerves that bring about the desired effect such as secretion or movement. Endoplasmic reticulum: Membrane network of fluid-filled tubules synthesizing proteins and lipids. Endothelium: the thin single celled layer of epithelial cells that lines the entire circulatory system. Eosinophils: white blood cells that are important in allergic response in combating parasitic infections. Erythropoiesis: Red cell production by the bone marrow Erythropoietin: the hormone released from the kidneys in response to hypoxia; stimulating Erythrocyte production. Excitable Tissue: Tissue capable of producing electrical signals when excited includes muscle and nerve. Feed forward mechanism: a response designed to prevent an anticipated change in a controlled variable. Fibrinogen: soluble plasma protein that is changed to thread like molecules that form the blood clot. First messenger: an extracellular chemical messenger that binds with the membrane receptor and activates an intracellular second messenger to achieve desired cellular response. Frank-Starling law of the heart: intrinsic control of the heart, such that increased venous return resulting in increased end-diastolic volume leads to an increased strength of contraction and increased stroke volume; that is, the heart normally pumps out all of the blood returned to it. Golgi complex: a cellular organelle that processes raw materials into finished product and sorts and directs for final destination. Granulocytes: Leukocytes that contain granules such as neutrophils, eosinophils and basophils. Helper T- cells: T- cells enhancing the activity of other immune response effector cells. Hyperpolarization: an increase in membrane potential from resting potential, becoming even more negative. Internal environment: The body extracellular fluid region having plasma and interstitial fluid. Left ventricle: the heart chamber that pumps blood in to the systematic circulation. Lysosome: Cell organelles having powerful hydrolytic enzymes that destroy unwanted material within the cell. Macrophage: large tissue bound phagocytic cells Mean arterial blood pressure: the pressure responsible for driving blood forward through the arteries in to the tissues throughout the cardiac cycle. Motor neurons: neurons that innervate skeletal muscles Motor unit: is motor nerve plus all of the muscle fibers innervated.

Consequently buy dilantin 100 mg line, use is prohibited 77 at the extremes of age as well as in very ill or debili- Central Neuraxial Analgesia tated patients buy dilantin 100mg line. Opioids added to analgesics, a factor which is most relevant for those re- the (spinal) local anesthetic solution provide long- covering from bowel surgery. The duration of effect is directly proportional to the water-solubility of the com- pound, with hydrophilic compounds such as morphine providing the longest relief. Epidural analge- sia can be used to provide pain relief for days through the infusion of a solution containing local anesthetic, opioid or both. Intermittent or “bolus” doses lack titratabil- ity and are associated with a higher incidence of side effects such as respiratory depression. Continuous epidural infusions provide a steady level of analgesia while reducing the side-effects associated with bolus administration. It is believed to 78 lead to a decreased stress response to surgery, im- Peripheral Nerve Blocks proved post-operative pulmonary function and in high Almost any peripheral nerve that can be reached with a risk patients, decreased cardiac morbidity. The bra- management relies on proper patient selection, appro- chial plexus, intercostal and femoral nerves are exam- priate catheter placement (depending on the level of ples of nerves which are commonly blocked to provide the surgical site), adequate post-operative monitoring post-operative analgesia. A block may be used as the and specific training of personnel to identify and treat sole method of post-operative analgesia or it may be complications (including inadequate analgesia). A common use would brachial plexus) lend themselves to the insertion of be following (open) abdominal aortic aneurysm repair catheters for the continuous infusion of local anesthet- where the catheter might be left in for 48-72 hours. In the absence of catheter insertion, the major draw- casionally, the need for post-operative thrombosis pro- back of this method of post-operative analgesia is that phylaxis triggers the removal of the catheter as cathe- the duration of effect of a single block is limited, usu- ters should not be removed or left indwelling in the an- ally to less than 18 hours. A typical example of the use of a peripheral nerve block for post-operative pain would be the use of a femoral/sciatic nerve block for a patient undergoing total knee arthroplasty. You will develop an understanding of how anesthetic care is modified to accommodate these “special patients”. Malignant Hyperthermia terized by the onset of a hypermetabolic crisis in neuromuscular disorders, such as Duchenne Mus- response to certain triggers. The earliest sign The ryanodine receptor is located on the sarco- is tachycardia followed by evidence of increased plasmic reticulum. The remainder of pected that in the near future, the development of a ge- treatment is supportive and involves hyperventilation netic blood test will obviate the need for the invasive with 100% oxygen, fluid administration and active cool- muscle biopsy in the majority of patients. One should be prepared The anesthetic management of a patient known to be to treat hyperkalemia and cardiac dysrhythmias. Dantrolene prophy- surgical procedure should be terminated as quickly as laxis can be given preoperatively to high risk patients. Triggers are avoided by using a Patients should be monitored for recrudescence of the “trigger-free” anesthetic machine which is free of va- reaction as well as for complications such as myoglobin- pourizers, and has been flushed clear of residual vola- uria, renal failure and disseminated intravascular co- tile gases. The patient 82 can be discharged home if instructions regarding worri- some symptoms have been given and understood, and if the patient has reasonable access to the hospital from home, should problems arise. The best Physiologic Changes of Pregnancy means of avoiding this outcome is to avoid gen- Physiologic and anatomic changes develop across 1. Physiologic Changes of eral anesthesia (by using a regional technique) Pregnancy many organ systems during pregnancy and the and thus maintain intact laryngeal reflexes. Pretreatment of all par- changes are those that affect the respiratory and turients with a non-particulate antacid (30 cc so- circulatory systems. Finally, There is an increased risk of difficult or failed intu- a rapid sequence induction with cricoid pressure bation in the parturient. Laryngoscopy can be further With the apnea that occurs at induction of anesthe- impeded by the presence of large breasts. Gastric motility is decreased and “oxygen reserve” during apnea, has decreased by gastric secretions increase. This, combined with a 20% due to upward displacement of the dia- decrease in the integrity of the gastroesophageal phragm. In fact, airway complications (dif- Adequate ventilation must be maintained during ficult intubation, aspiration) are the most common anesthesia. The concomitant rightward shift in Labour Analgesia the oxyhemoglobin dissociation curve allows increased fetal trans- There are many methods of relieving the pain and stress of labour. This is significant for two rea- oxide), intravenous (opioids) or regional (epidural) are associated sons. Firstly, the normal signs of hypovolemia may not be seen un- with side effects and risks to both fetus and mother. This extends to include sacral segments (S2-4) during Due to the increasing uterine size, aortocaval compression (obstruc- the second stage. Thus, the principle of epidural analgesia is to ad- tion of the inferior vena cava and aorta) becomes relevant in the minister local anesthetics (with or without opioids) into the third trimester.

As pressure in the ventricles rises above two major arteries order dilantin 100mg with visa, blood pushes open the two semilunar1 valves and moves into the pulmonary trunk and aorta in the ventricular ejection phase generic dilantin 100mg mastercard. Following ventricular repolarization, the ventricles begin to relax (ventricular diastole), and pressure within the ventricles drops. When the pressure falls below that of the atria, blood moves from the atria into the ventricles, opening the atrioventricular valves and marking one complete heart cycle. Failure of the valves to operate properly produces turbulent blood flow within the heart; the resulting heart murmur can often be heard with a stethoscope. There are several feedback loops that contribute to maintaining homeostasis dependent upon activity levels, such as the atrial reflex, which is determined by venous return. Venous return is determined by activity of the skeletal muscles, blood volume, and changes in peripheral circulation. It originates about day 18 or 19 from the mesoderm and begins beating and pumping blood about day 21 or 22. It forms from the cardiogenic region near the head and is visible as a prominent heart bulge on the surface of the embryo. Originally, it consists of a pair of strands called cardiogenic cords that quickly form a hollow lumen and are referred to as endocardial tubes. These then fuse into a single heart tube and differentiate into the truncus arteriosus, bulbus cordis, primitive ventricle, primitive atrium, and sinus venosus, starting about day 22. The internal septa begin to form about day 28, separating the heart into the atria and ventricles, although the foramen ovale persists until shortly after birth. Although much of the heart has been “removed” from this gif loop so the chordae tendineae are not visible, why is their presence more critical for the atrioventricular valves (tricuspid and mitral) than the semilunar (aortic and pulmonary) valves? Why is it so important for the human heart to develop atrioventricular node contribute to cardiac function? When vessel functioning is reduced, blood-borne substances do not circulate effectively throughout the body. As a result, tissue injury occurs, metabolism is impaired, and the functions of every bodily system are threatened. An artery is a blood vessel that carries blood away from the heart, where it branches into ever-smaller vessels. Eventually, the smallest arteries, vessels called arterioles, further branch into tiny capillaries, where nutrients and wastes are exchanged, and then combine with other vessels that exit capillaries to form venules, small blood vessels that carry blood to a vein, a larger blood vessel that returns blood to the heart. Arteries and veins transport blood in two distinct circuits: the systemic circuit and the pulmonary circuit (Figure 20. The blood returned to the heart through systemic veins has less oxygen, since much of the oxygen carried by the arteries has been delivered to the cells. In contrast, in the pulmonary circuit, arteries carry blood low in oxygen exclusively to the lungs for gas exchange. Pulmonary veins then return freshly oxygenated blood from the lungs to the heart to be pumped back out into systemic circulation. The systemic circuit moves blood from the left side of the heart to the head and body and returns it to the right side of the heart to repeat the cycle. The arrows indicate the direction of blood flow, and the colors show the relative levels of oxygen concentration. Shared Structures Different types of blood vessels vary slightly in their structures, but they share the same general features. Arteries and arterioles have thicker walls than veins and venules because they are closer to the heart and receive blood that is surging at a far greater pressure (Figure 20. Arteries have smaller lumens than veins, a characteristic that helps to maintain the pressure of blood moving through the system. Together, their thicker walls and smaller diameters give arterial lumens a more rounded appearance in cross section than the lumens of veins. In other words, in comparison to arteries, venules and veins withstand a much lower pressure from the blood that flows through them. Their walls are considerably thinner and their lumens are correspondingly larger in diameter, allowing more blood to flow with less vessel resistance. In addition, many veins of the body, particularly those of the limbs, contain valves that assist the unidirectional flow of blood toward the heart. This is critical because blood flow becomes sluggish in the extremities, as a result of the lower pressure and the effects of gravity. The walls of arteries and veins are largely composed of living cells and their products (including collagenous and elastic fibers); the cells require nourishment and produce waste. Since blood passes through the larger vessels relatively quickly, there is limited opportunity for blood in the lumen of the vessel to provide nourishment to or remove waste from the vessel’s cells. Further, the walls of the larger vessels are too thick for nutrients to diffuse through to all of the cells. Larger arteries and veins contain small blood vessels within their walls known as the vasa vasorum—literally “vessels of the vessel”—to provide them with this critical exchange.