By Z. Jens. Texas A&M University, Corpus Christi.

Ideally order periactin no prescription, hospitals are the optimal setting to provide critical care for severely ill and injured patients 4 mg periactin overnight delivery. During major disasters buy periactin 4mg visa, hospitals should coordinate with community medical response systems to offload patients with minor injuries or illnesses so that hospital resources can be focused on the care of critically ill patients. Predisaster planning and training are essential for mitigating the adverse effects of an overwhelming disaster on hospitals and their communities. Carefully developed plans for surging critical care resources will facilitate continuation of usual hospital processes for the largest number of the patients. However, when surge procedures fail to meet the critical care demands of an overwhelming patient influx, processes to triage and alter the usual standards of critical care must be implemented. These planning concepts and guidelines can help guide critical care practitioners to care for their patients under the challenging conditions of a catastrophic disaster. The opinions and assertions contained herein are those of the authors and do not necessarily reflect the views or position of the Department of the Navy, Department of Defense, Department of Veterans Affairs, the United States Government, nor of the academic institutions with which the authors are affiliated. Medicare and Medicaid Programs: Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Fiscal Year 2016 Public Health and Social Services Emergency Fund—Justification of Estimates for Appropriations Committees. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care. Kudo D, Furukawa H, Nakagawa A, et al: Resources for business continuity in disaster-based hospitals in the great East Japan earthquake: survey of Miyagi Prefecture disaster base hospitals and the prefectural disaster medicine headquarters. Morton B, Tang L, Gale R, et al: Performance of influenza-specific triage tools in an H1N1-positive cohort: P/F ratio better predicts the need for mechanical ventilation and critical care admission. In these days of total warfare, the civilians, including women and children, are subject to attack at all times [1,2]. Critical care physicians must be familiar with these agents, their impact on patients, and the potential dangers these compounds can cause to health care workers. Although terrorists have traditionally focused their efforts on the use of conventional explosives, chemical agents have emerged as attractive weapons of terrorism for a variety of reasons: Raw materials for their production are readily available throughout the world. This chapter focuses on the recognition and management of patients exposed to common chemical agents of mass destruction. However, those that have been successfully weaponized are characterized by ease of production, ease of handling during weapon assembly, dispersion properties, and ability to cause injury and death at relatively low concentrations [4]. The next major use of chemical weapons took place more than 2 years later, on July 12, 1917, again near Ypres, when German forces attacked Allied troops with artillery shells containing sulfur mustard. Although many of the 20,000 casualties had debilitating injuries, less than 5% of the troops died as a result of the chemical attack. Persistent and nonvolatile, sulfur mustard caused a host of new problems for Allied forces, including a latency period before the effects appeared and the need for men, and their horses, to wear protective overgarments [5]. The Geneva Convention of 1925 banned the use of chemical warfare agents because of the physical and psychologic trauma they imposed on their victims. Gerhard Schrader, began research into the development of stronger insecticides, the first two of which were tabun and sarin. Later in the 1980s, reports implicated Iraq in the use of cyanide against the Kurdish population of northern Iraq [6]. The first took place on June 27, 1994, in Matsumoto and resulted in 600 persons exposed, 58 admitted to the hospital, and seven deaths [7]. The more famous and larger event took place the following year, on March 20, 1995, when they released sarin gas in the Tokyo subway system during rush hour. The subway system attack resulted in the deaths of 11 commuters and the medical evaluation of approximately 5,000 individuals [8]. Four days later Russian Special Forces fumigated the building with a derivative of the narcotic fentanyl. Although this method broke the siege, all but two of the 41 terrorists and 129 hostages died from opiate toxicity [9]. The most recent use of chemical weapons occurred in the early morning hours of August 21, 2013 in the Ein Tarma and Zamalka suburbs of Damascus, Syria. Social media reports and videos as well as satellite imagery demonstrated large numbers of sick adults and children with no visible trauma; medical personnel described the symptoms as most consistent with exposure to a nerve agent [10]. Three Damascus hospitals received over 3,000 casualties where the principle antidote atropine was in short supply and exposure to contaminated patients at one hospital resulted in 41 staff members, including 10 doctors, becoming contaminated [11]. However, hospital-based critical care physicians should understand basic concepts of these topics to better care for their patients and protect themselves and their facilities from potential harm. The most important tool for detecting the use of these agents is accurate and timely intelligence from military or law enforcement agencies. Unfortunately, hospitals are not usually in the information- sharing and decision-making circles with these groups. As a result, initial awareness of a chemical agent attack typically occurs with the first patient presenting to the emergency department. Hospitals and physicians can improve their preparedness for the management of chemical agent casualties by actively participating in disaster-planning activities at their respective communities. At the present time, all commercially available detection equipment uses point source technology; that is, proximity to the substance is required. The handheld Chemical Agent Monitor uses ion mobility spectrometry to detect mustard and nerve agents. Chemical agent detection papers, such as the M8 and M9 papers (Anachemia, Lachine, Quebec, Canada), can be used to detect mustard and nerve agents. The M256 Detection Kit (Anachemia, Lachine, Quebec, Canada) can detect mustard, nerve agents, phosgene, and cyanide. Standoff capability, that is, detecting agents from as far away as 5 km, has been developed to detect contaminated areas without being exposed [14]. Many of the readily available detection strategies cannot detect lower levels of chemical agent, thus being less useful to confirm successful decontamination or detect chemical agents remotely from the site of exposure. Most hospitals will not have capability to confirm exposure or nature of chemical agents used in a timely manner to influence patient care or protect their facilities.

A sudden loss of a peripheral pulse discount 4 mg periactin otc, accompanied by limb pain purchase periactin pills in toronto, warrants immediate arteriography to identify and extract occluding emboli buy periactin 4mg mastercard. A normocytic, normochromic red cell morphology, low serum iron, and low iron binding capacity characterize this form of anemia. The erythrocyte sedimentation rate, a measure of chronic inflammation, is almost always elevated. With the exception of patients with hemoglobinopathies that falsely lower the rate of red blood cell sedimentation, the finding of a normal sedimentation rate virtually excludes the diagnosis of infective endocarditis. In nearly all cases, C-reactive protein, another inflammatory marker, is also elevated. A positive rheumatoid factor is detected in half of these patients, and elevated serum globulins are found in 20-30% of cases. Cryoglobulins, depressed complement levels, positive tests for immune complexes, and a false positive serology for syphilis are other nonspecific findings that may accompany infective endocarditis. Urinalysis is frequently abnormal, with proteinuria and hematuria being found in up to 50% of cases. These abnormalities are the consequence of embolic injury or deposition of immune complexes causing glomerulonephritis. The peripheral white blood cell count is normal, unless myocardial abscess or acute disease is present. Manifestations of chronic antigenemia mimic a connective tissue disorder: a) Elevated sedimentation rate and C-reactive protein b) Positive rheumatoid factor c) Elevated immunoglobulins, cryoglobulins, and immune complexes d) Decreased complement e) Hematuria and proteinuria 4. A chest radiograph may be abnormal: a) Circular, cannonball-like lesions in embolic right-sided endocarditis b) Pulmonary edema pattern secondary to left-sided congestive heart failure 5. Monitor the electrocardiogram closely; conduction defects can progress to complete heart block. In patients with right-sided disease, distinct round cannonball- like infiltrates may be detected; these represent pulmonary emboli. In cases of acute mitral regurgitation or decompensated left-sided failure because of aortic regurgitation, diffuse alveolar fluid may be detected, indicating pulmonary edema. The finding of a conduction defect raises concern that infection has spread to the conduction system; in some cases, this spread may progress to complete heart block. Findings consistent with myocardial infarct may be detected when emboli are released from vegetations in the coronary cusps into the coronary arteries. As compared with most tissue infections—such as pneumonia and pyelonephritis—that result in the intermittent release of large numbers of bacteria into the blood, infective endocarditis is associated with a constant low-level bacteremia (ure 7. The vegetation is like a time-release capsule, with bacteria being constantly released in small numbers into the bloodstream. It is this constant antigenic stimulus that accounts for the rheumatic complaints and multiple abnormal serum markers associated with infective endocarditis. Concentration of bacteria in the bloodstream over time in infective endocarditis versus bacteremia caused by other infections. To document the presence of a constant bacteremia, blood samples for culture should be drawn at least 15 minutes apart. In patients with suspected subacute infective endocarditis, three blood cultures are recommended over the first 24 hours. In these patients, antibiotics should be withheld until the blood cultures are confirmed to be positive because administration of even a single dose of antibiotics can lower the number of bacteria in the bloodstream to undetectable levels and prevent identification of the pathogen. However, if the patient is acutely ill, 2-3 samples for culture should be drawn over 45 minutes, with empiric therapy begun immediately thereafter. Because the number of bacteria in the blood is usually low (approximately 100/mL), a minimum of 10 mL of blood should be inoculated into each blood culture flask. Routinely, blood cultures are held in the microbiology laboratory for 7 days and are discarded if negative. If nutritionally deficient streptococci are2 suspected, specific nutrients need to be added to the blood culture medium. The sensitivity of blood cultures is excellent, yields being estimated to be 85-95% on the first blood culture and improving to 95-100% with a second blood culture. The third blood culture is drawn primarily to document the constancy of the bacteremia; it does not significantly improve overall sensitivity. The administration of antibiotics within 2 weeks of blood cultures lowers the sensitivity, and patients who have received antibiotics often require multiple blood cultures spaced over days to weeks to identify the cause of the disease. When accompanied by Doppler-color flow analysis, echocardiography can assess valve function, myocardial contractility, and chamber volume—vital information for deciding on surgical intervention. Blood cultures document constant bacteremia with an endocarditis- associated pathogen: a) Blood cultures spaced at least 15 minutes apart, three over 24 hours for subacute bacterial endocarditis. Duke criteria are helpful in making the clinical diagnosis of infective endocarditis in the absence of pathologic tissue. Clinical criteria have been established that allow cases to be classified as definite and possible (Table 7. Using the modified Duke criteria, a finding of 2 major criteria, or 1 major criterion and 3 minor criteria, or 5 minor criteria classifies a case as definite infective endocarditis. A finding of 1 major and 1 minor criterion, or 3 minor criteria, classifies a case as possible infective endocarditis. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Complications In the modern antibiotic era, complications associated with infective endocarditis remain common, with approximately 60% of patients experiencing one complication; 25%, two; and 8%, three or more complications. Less commonly, vegetations become large enough to obstruct the outflow tract and cause stenosis. This complication is more common with aortic valve disease, and spread from the aortic valvular ring to the adjacent conduction system can lead to heart block. This complication should be suspected in the infective endocarditis patient with peripheral leukocytosis, persistent fever while on appropriate antibiotics, or an abnormal conduction time on electrocardiogram. Transesophageal echo detects most cases, and this test should be performed in all patients with aortic valve endocarditis. Small emboli are likely released in all cases of endocarditis, but they are symptomatic in only one-sixth to one-third of patients. Patients with large vegetations (exceeding 10 mm) and vegetations on the anterior leaflet of the mitral valve are at higher risk for systemic emboli.

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Extremely elevated blood glucose concentrations may be outside the range accurately measured by the bedside monitor and should be verified with a serum sample sent to the laboratory [39] buy cheap periactin 4 mg on line. In general buy 4 mg periactin, however generic periactin 4mg with visa, therapy should not be delayed by waiting for confirmatory results of laboratory glucose concentration in the proper clinical setting. Invasive indwelling intravascular sensors that measure blood glucose directly are also under development and have the potential for increased accuracy for critically ill patients [42]. Hyperglycemia Among the Critically Ill Predicts Adverse Outcomes It is intuitively plausible to assume that glucose concentration should always be in the normal range, and studies show that hyperglycemia among critically ill patients is associated with adverse outcomes. Even minimal hyperglycemia, plasma glucose concentration >110 mg per dL, has been shown to predict increased in-hospital mortality and the risk of congestive heart failure among patients with acute myocardial infarction [44]. Hyperglycemic patients also have an increased risk of wound infection as well as overall mortality following cardiac surgery [45,46]. Because uncontrolled hyperglycemia also provokes an osmotic diuresis, symptomatic hyponatremia can result. Hypokalemia predisposes to arrhythmia, and hypophosphatemia may interfere with platelet function and white cell motility. Uncontrolled glycemia appears to impair innate immunity (cytokine, pathogen recognition pathways, and phagocytic capacity), granulocyte function (chemotaxis, phagocytosis, and killing), and, possibly, lymphocyte function and adaptive immune function, including antibody formation [49–52]. What is the Evidence that Control of Blood Glucose Concentration Alters Clinical Outcomes for Intensive Care Unit Patients? Recognizing that hyperglycemia is a risk factor for adverse outcomes is not the same as saying that tight control of hyperglycemia for critically ill patients, with the attendant risk of hypoglycemia, is beneficial. Hyperglycemia, hypoglycemia, and increased glycemic variability are all independently associated with mortality of critically ill patients [54]. This study, together with the results of other single-institution reports and retrospective studies [46,56,57], generated widespread acceptance of the concept that intensive glycemic control is important for critically ill patients. The trial was stopped early because of an increased frequency of hypoglycemia together with lack of clinical benefit in the intensive insulin therapy cohort. The investigators reported that intensive glucose control increased mortality and the rate of hypoglycemia compared with the conventional target cohort. A number of trials have now highlighted the importance of avoiding hypoglycemia of the critically ill patient [61]. Among critically ill patients, an association exists between even mild or moderate hypoglycemia and mortality [62,63] (See also Chapter 138). It has been suggested that patients with diabetes may benefit from higher glucose target ranges than will those without diabetes [54,64]. The preponderance of available evidence suggests that intensive management of hyperglycemia to within the normal range for critically ill adults is not beneficial, although the precise ideal target is still controversial [65,66]. Glucose concentrations of less than 80 mg per dL should be stringently avoided because they pose the hazard of hypoglycemia and might contribute to mortality [55,62,63]. A less stringent target range may be preferred during the perioperative period and whenever staffing or training constraints prevent the implementation of more intensive therapy. Patients known to have type 1 diabetes are absolutely insulin dependent, and they must be treated with exogenous insulin at all times. Their absorption, metabolism, and excretion cannot be adequately predicted for the individual critically ill patient. Metformin should be discontinued because it can cause lactic acidosis in the setting of renal failure [69]. Our recommendations for the management of patients with ketoacidosis or hyperosmolar syndrome are given elsewhere (see Chapter 137). Insulin Therapy Although optimal glycemic targets are now agreed to, insulin infusion algorithms to achieve those targets need to be individualized by the responsible multidisciplinary teams. Every protocol will require development of guidelines for adjustment of the insulin infusion rate in response to both the absolute value and the rate of change in the glucose concentration. Glucose concentration should be checked hourly until it is consistently in the target range of 140 to 180 mg per dL, and every 2 to 4 hours thereafter. During the initial period, adjustments to the insulin infusion rate will depend on the patient’s sensitivity to insulin (see below) and the observed response to therapy, which cannot be exactly predicted. Tight glycemic control has been associated with a high incidence of hypoglycemia and an increased risk of death in patients not receiving parenteral nutrition [72]. Diluted insulin solutions prepared from continuous insulin infusions have a limited storage life because insulin adheres to the plastic infusion bag. There is no advantage to the use of rapid-acting semisynthetic insulin for this purpose, but it can be used when regular insulin is unavailable. A low rate of insulin infusion is often all that is needed to prevent ketoacidosis among patients with type 1 diabetes. An escalating insulin infusion requirement is a sensitive indicator of increasing insulin resistance and requires careful reevaluation of the patient’s overall metabolic status. Stressors that increase insulin resistance include sepsis, occult infections, heart disease, tissue ischemia, hypoxemia, and various medications. Insulin- mediated glucose disposal is impaired among stressed patients with hyperglycemia, and even extremely high insulin infusion rates cannot prevent hyperglycemia due to unmanageable carbohydrate loads. To control hyperglycemia among the critically ill, a choice must sometimes be made between increasing insulin infusion rates and reducing carbohydrate feeding. We recommend that insulin infusion rates not be increased beyond 20 units per hour (480 units per day) without first decreasing any exogenous carbohydrate loads, especially for patients who are obese. This suggestion is based on the fact that maximal insulin effects are achieved when only some of the available insulin receptors are occupied [73,74]. High concentrations of insulin, such as those achieved during continuous intravenous infusions at high rates, desensitize target tissues at both the receptor and postreceptor levels, paradoxically enhancing insulin resistance [75]. Factors that increase insulin sensitivity among critically ill patients include improvement of intercurrent illnesses, changes in medications, and reductions of enteral or parenteral feeding. Occasionally, hepatic failure, renal failure, or adrenal insufficiency leads to decreased insulin requirements. When plasma glucose concentration is lower than 140 mg per dL, a common response is to discontinue insulin completely.

A color Doppler signal that is seen superficial to the periosteum indicates misplacement of the needle with the risk of extravasation of adrenergic medication into the subcutaneous compartment buy 4 mg periactin otc. Cardiopulmonary resuscitation: statement by the Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences buy periactin 4 mg on-line, National Academy of Sciences—National Research Council periactin 4 mg overnight delivery. Guidelines for the determination of death: report of the medical consultants on the diagnosis of death to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Holmberg M, Holmberg S, Herlitz J: Effect of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Nielsen N, Wetterslev J, Cronberg T, et al: Targeted temperature management at 33°C versus 36°C after cardiac arrest. Nakahara S, Tomio J, Ichikawa M, et al: Association of bystander interventions with neurologically intact survival among patients with bystander-witnessed out-of-hospital cardiac arrest in Japan. Cabrini L, Beccaria P, Landoni G, et al: Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Konrad D, Jaderling G, Bell M, et al: Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Rumball C, Macdonald D, Barber P, et al: Endotracheal intubation and esophageal tracheal Combitube insertion by regular ambulance attendants: a comparative trial. De Backer D, Biston P, Devriendt J, et al: Comparison of dopamine and norepinephrine in the treatment of shock. Dorian P, Cass D, Schwartz B, et al: Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. MacMahon S, Collins R, Peto R, et al: Effects of prophylactic lidocaine in suspected acute myocardial infarction: an overview of results from the randomized controlled trials. The Hypothermia After Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. Salen P, Melniker L, Chooljian C, et al: Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Kantamineni P, Emani V, Saini A, et al: Cardiopulmonary resuscitation in the hospitalized patient: impact of system-based variables on outcomes in cardiac arrest. Blyth L, Atkinson P, Gadd K, et al: Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Tomruk O, Erdur B, Cetin G, et al: Assessment of cardiac ultrasonography in predicting outcome in adult cardiac arrest. Thanks to the pioneering work of Zoll and Lown in the late 1950s and early 1960s, the use of electric shock gained widespread acceptance. Cardioversion and defibrillation terminate these arrhythmias by simultaneously depolarizing all excitable tissue, disrupting the process of reentry. Arrhythmias may also be due to disorders of impulse formation (increased automaticity or triggered activity). The effect of shock on the fibrillating myocardium is complex and is dependent on multiple factors including energy, waveform, and myocardial refractory state [3]. In the case of hemodynamic instability due to tachyarrhythmia of nearly any type, the urgent use of shock is strongly indicated. One must be careful, however, not to shock sinus tachycardia, which is commonly present in patients who are hypotensive for noncardiac reasons, as doing so may provoke arrhythmias. Acute congestive heart failure and angina that are secondary to an acute tachyarrhythmia are also indications for urgent cardioversion; however, there is usually sufficient time to provide some anesthesia. In the absence of hemodynamic instability or significant symptoms, cardioversion is usually considered elective and the risks and benefits of the procedure must be carefully weighed. A minimum of eight cardioversions should be supervised before a physician is considered to be competent to perform the procedure independently. American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on invasive electrophysiology studies, catheter ablation, and cardioversion: a report of the American College of Cardiology/American Heart Association/American College of Physicians- American Society of Internal Medicine Task Force on Clinical Competence. Methods Patient Preparation In the case of unconsciousness due to tachyarrhythmia, shock must be performed emergently. In elective settings, patients should refrain from eating and drinking for several hours in order to decrease the risk of aspiration (6 hours for solids, 2 hours for clear liquids). Constant heart rhythm monitoring should be used throughout the procedure, and a 12- lead electrocardiogram should be obtained before and after the shock. Medications with rapid onset and short half-life are favored for achieving analgesia, sedation, and amnesia. The combination of a benzodiazepine, such as midazolam, and a narcotic, such as fentanyl, is a common choice in the absence of anesthesiology assistance. Propofol is often used when an anesthesiologist is present to assist with airway management and sedation. Existing hospital policies for monitoring during conscious sedation should be followed, including frequent assessment of blood pressure and pulse oximetry. Supplemental oxygen is delivered via nasal cannula, face mask, or, in the case of heavier sedation, an Ambu bag. Shock Waveforms Defibrillators that employ biphasic waveforms have largely replaced those utilizing monophasic waveforms. Advantages of biphasic waveforms are lower defibrillation thresholds, meaning shocks using biphasic waveforms require less energy to achieve defibrillation, and they are less likely to cause skin burns and myocardial damage [3]. Biphasic truncated exponential waveform and biphasic rectilinear waveform are both commercially available, with the former being more common. For instance, one study demonstrated the equivalent efficacy of a 120 to 200 J biphasic sequence with a 200 to 360 J monophasic sequence [9]. However, there is evidence that biphasic shocks result in less dermal injury, and no significant difference in myocardial damage [10]. Although an animal model suggested better maintenance of cardiac function after biphasic shocks, human data on myocardial function are not yet available [11]. Whichever modality is used, impedance can be minimized by avoiding positioning over breast tissue, by clipping body hair when it is excessive, by delivering the shock during expiration, and by firm pressure on the pads or paddles. The optimal anatomic placement of pads and paddles is not clear; however, the general principal holds that the heart must lie between the two electrodes [3].

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