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Prevention Patients who have severe underlying heart diseases should not receive -adrenergic agonists as tocolytic therapy because of the risk of inducing pulmonary edema blood pressure keeps going down 1mg warfarin visa. Any patient at increased risk of pulmonary edema requires careful attention to fluid status arterial nosebleed purchase warfarin 2 mg without prescription. The presence of an intraamniotic infection mandates delivery in the great majority of cases arrhythmia dysrhythmia discount warfarin 5mg with mastercard, and patients with other infections must be monitored closely while undergoing therapy blood pressure medication that does not cause joint pain buy genuine warfarin on line. Patients with associated infection should be treated with appropriate antibiotics. Continuous fetal heart rate monitoring is essential until normal maternal pulmonary function is restored and hypoxemia corrected. In patients with slow resolution of pulmonary edema, structural abnormalities should be considered. A pulmonary artery catheter may be helpful in identifying the cause of pulmonary edema and guiding therapy. A normal echocardiogram often predicts rapid resolution, but in patients with abnormal findings, long-term treatment is usually needed. These patients should be instructed to report any asthmatic exacerbations, upper respiratory infections, increased cough, or other respiratory symptoms. Anemia, because it can adversely affect maternal oxygen transport, should be assessed and treated. Symptoms and Signs-Pregnant asthmatics present no differently than other patients with asthma. Patients with status asthmaticus complain of dyspnea, wheezing, cough, and failure of response to inhaled bronchodilator drugs. They may note inability to sleep because of dyspnea or cough, and they may report a frank upper airway infection. The time from onset of the attack should be noted because a prolonged duration may be predictive of poor response to treatment. Physical findings include wheezing, use of accessory muscles of respiration, a prolonged expiratory phase, tachypnea, tachycardia, and cyanosis. Patients presenting with acute severe asthma usually have a history of asthma; rarely, asthma will present initially during pregnancy. Laboratory Findings-Arterial blood gases should be interpreted in the light of changes seen in pregnancy. Severe hypoxemia in status asthmaticus is due to ventilation-perfusion mismatching resulting from bronchospasm and plugging of airways with mucus. As in nonpregnant asthmatics, spirometry is useful for assessing severity of asthma and following the response to therapy, especially because the peak expiratory flow rate does not change in pregnancy. Strong consideration should be given to obtaining a chest x-ray in those with unexplained fever, persistent bronchospasm, heavy sputum production, asymmetry on chest examination, severe hypoxemia, or suspicion of heart disease, pleural effusion, or pneumothorax. Status Asthmaticus in Pregnancy Asthma is the most common respiratory disease occurring in conjunction with pregnancy. In general, the influence of pregnancy on lung volumes, tidal volume, minute ventilation, and arterial blood gases has little effect on asthma. In most patients, the course of asthma during pregnancy is similar in subsequent pregnancies. This constancy of asthmatic outcome may be altered with newer methods of asthma control. Asthma can have adverse effects on pregnancy, especially when maternal hypoxemia affects oxygenation of the fetus. Premature labor and low birth weight are well-known complications of maternal asthma, and patients with hypoxemia owing to asthma are also at increased risk of fetal death. Thus the central theme in managing the pregnant asthmatic is prevention of maternal asthma exacerbation and hypoxemia. There is no known association of pregnancy with status asthmaticus (ie, asthma unresponsive to treatment and usually requiring hospitalization) or with severe asthma (ie, daily wheezing and need for medication). On the other hand, pregnant women with asthma may have worsening of asthma or may be reluctant to use prescribed asthma medications, thus increasing the risk of these complications.

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C5 C6 C7 C8 T1 motor function and pain and temperature perception (ie arrhythmia zoloft buy discount warfarin 5 mg on line, corticospinal and spinothalamic tracts) blood pressure jadakiss lyrics buy warfarin 1 mg amex, with preservation of proprioception and perception of vibration and light touch (dorsal columns) below the level of the lesion arrhythmia practice test buy cheap warfarin 2mg on-line. This is thought to result either from direct anterior trauma or from injury to the anterior spinal artery blood pressure over 200 in elderly discount warfarin 5mg mastercard, which supplies the anterior two-thirds of the spinal cord. The paired posterior spinal arteries supply the dorsal columns and the posterior onethird of the cord. Central cord syndrome-This is most commonly due to a hyperextension injury in an older patient with preexisting cervical spondylosis or stenosis. The motor and sensory deficits are greater in the upper extremities (more pronounced distally) than in the lower extremities. Hemorrhagic necrosis in the central portions (eg, gray matter) of the cervical cord results in upper extremity weakness. Since the lumbar leg and sacral tracts are peripheral in the cervical cord, they are relatively spared. The result is ipsilateral loss of motor and dorsal column function (ie, vibration, proprioception, and discriminatory touch) immediately below the level of injury associated with contralateral loss of pain and temperature sensation one or two Treatment Optimal treatment of spinal cord injuries must be initiated at the scene of the accident. The spinal cord is susceptible to reinjury after the primary insult, making prevention of secondary injury one of the most important aims of therapy. This includes immediate spinal immobilization with sandbags or a hard collar and rapid correction of hypoxia, hypotension, shock, or hypothermia, if present. After each weight increase, the lateral x-ray should be repeated to determine if realignment has been achieved. Application of a halo vest orthosis may be the proper choice for certain bony injuries of the cervical spine. Surgery-The principal goal in the management of cervical spine injuries is prevention of secondary neurologic injury and provision of an optimal environment for recovery. Securing a stable cervical spine (ie, bones, muscles, and ligaments) will prevent further neurologic injury and reduce the chance for persistent cervical pain resulting from instability. In general, bony lesions heal well if immobilized properly, whereas ligamentous injuries typically do not heal. The indications for operation are decompression of incompletely injured neural tissue and reduction and stabilization of malaligned or unstable cervical segments. Some of the basic features and treatment modalities for several common cervical injuries are outlined below. Atlanto-occipital dislocation-These injuries, which are seen most commonly in children owing to immature craniovertebral articulations, are often fatal. They involve extensive ligamentous disruption and can cause injury to the brain stem, cervical cord, nerve roots, or vertebral artery. Jefferson fracture of the atlas-This is a burst fracture of the ring of the atlas resulting from an axial force and is usually asymptomatic. If combined displacement of the left and right lateral masses on open mouth x-ray is more than 6. Axis fractures-A type 1 odontoid fracture involves only the tip of the odontoid and can be treated with hard cervical collar immobilization. Fractures through the odontoid base are classified as type 2 and have a high incidence of nonunion. Current treatment recommendations are for surgical fusion if the fracture is displaced more than 6 mm or halo vest immobilization for fractures displaced less than 6 mm. Anterior odontoid screw fixation or posterior atlantoaxial fixation may be performed. Type 3 odontoid fractures involve the base of the odontoid with extension into the vertebral body and require only halo vest immobilization for fusion. Hangman fractures are bilateral fractures of the C2 pedicles with anterior displacement of C2 onto C3. They are usually due to hyperextension injuries such as automobile accidents in which the head hits the windshield. Hangman fractures may be unstable and require traction initially if malalignment is present, followed by immobilization in a halo vest.

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The goal of fluid resuscitation in thermally injured patients is to maintain vital organ function at the lowest physiologic cost blood pressure medication pills buy warfarin uk. A more physiologic restoration of intravascular volume and oxygen delivery would seem beneficial heart attack left or right order warfarin in india. Several approaches to reduction of edema formation and restoration of circulatory integrity are under investigation arteria3d mayan city pack buy cheap warfarin 2mg. Early intervention to block production of or to scavenge superoxide and oxygen free radicals has been shown to decrease edema formation hypertension 180120 generic warfarin 1mg on line. Administration of a soluble complement receptor that blocks the classic and alternative complement pathways has attenuated postburn edema formation in animals. Fluid resuscitation with deferoxamine has been shown to diminish the systemic effects of burn-induced oxidant injury, and an inositol phosphate derivative, 1,2,6-Dmyoinositol triphosphate, has been shown to decrease burn wound edema and resuscitation fluid requirements by an unknown mechanism. Vitamin C, which has been shown in various animal models to reduce burn wound edema and resuscitation volume, was administered to burn patients in a prospective, randomized, controlled manner. In part, injury is governed by particle size, which determines the anatomic region where injury will occur. Toxicities of noxious gases produced by combustion of synthetic and natural materials also contribute to the tissue injury of smoke inhalation but are at present impossible to quantify in patients following exposure. Most animal models used to study the effects of smoke inhalation fail to reproduce the clinical and histologic changes associated with inhalation injury in humans. Problems with smoke composition, carbon monoxide poisoning, and smoke delivery systems are common. In a recent study of smoke inhalation injury in nonhuman primates, high-frequency percussive ventilation was found to be superior to conventional volume ventilation and high-frequency oscillatory ventilation in decreasing barotrauma and the histopathologic severity of injury. Pharmacologic intervention to modulate the response to smoke inhalation may prove beneficial in decreasing pulmonary vascular changes and improving lung aeration. Recent studies in sheep have shown improved alveolar ventilation and diminished inflammatory response to smoke inhalation following postexposure treatment with pentoxifylline. The use of inhaled nitric oxide-which does not alter the normal inflammatory response-to ameliorate pulmonary artery hypertension following smoke inhalation is also being studied. Other treatments, including complement depletion and antioxidant therapy, are being investigated and may prove beneficial. Any attempt to modulate the host response to inhalation injury must proceed with caution to avoid impairing the normal mechanisms of cellular repair and immunologic defense. A nebulized cocktail of heparin and a mucolytic agent, N-acetylcystine, has been shown to reduce pulmonary failure and ameliorate airway cast formation in both an animal model and a case-controlled human study in 47 children. A blinded, randomized study or studies in adults have not been reported; however, decreases in reintubation rates and mortality rates for patients treated with this regimen were noted when compared with historical controls. In a small cohort of burn patients, sargramostim therapy increased granulocyte counts by 50%. Administration of sargramostim reduced granulocyte cytosolic oxidative function and myeloperoxidase activity to control levels without changing superoxide production. However, following cessation of treatment, superoxide activity was subsequently increased compared with untreated burn patients. A reduction in myeloperoxidase activity actually may be detrimental because bactericidal capability may be compromised. Increased superoxide production could potentiate endothelial cell damage leading to increased capillary permeability. The inability of immunomodulatory drugs to significantly alter the postburn changes in immune function simply may represent the inability of single agents to alter the complex cascade of pathophysiologic events occurring in extensively burned patients. The concept that the gut plays a central role in maintenance of a persistent catabolic state in severely injured patients has gained substantial popularity. Many animal studies support this hypothesis; however, the lack of clinically significant bacteremia and endotoxemia in humans makes the meaning of these findings unclear. Intestinal permeability is increased preceding and during episodes of sepsis in burn patients. Whether alterations in intestinal permeability result in infection or represent only an epiphenomenon remains to be proved. In a recent clinical study, the administration of prophylactic enteral polymyxin B to burn patients resulted in a decrease in endotoxemia; however, no correlation with illness severity score or outcome was observed.

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