By I. Ben. Savannah State University. 2019.

Adverse life events especially if they are threatening in nature are known to precipitate anxiety order levothroid 200 mcg without a prescription. In addition buy discount levothroid on line, individuals may also develop late life vulnerability to anxiety when faced with challenges if they were previously exposed to early adverse experience such as parental loss buy levothroid 200mcg free shipping. In contrast to late life depression, phobic disorders in the elderly are not associated with the lack of confiding relationships; rather it is believed that in some cases the presence of close relationships may maintain phobic avoidance (Lindesay, 1996) because in a bid to protect and support the patient, families and other home based services invariably encourage the housebound approach and may thereby worsen the situation. Drug induced- A variety of drugs have been implicated in the onset of anxiety symptoms. They include: - Thyroxine - Antidepressants - Anticholinergics - Sympathomimetics 963 - Steroids - Alcohol - Caffeine In addition, withdrawal symptoms from psychotropic medications can also precipitate anxiety symptoms (Rodda ea, 2008). Co-morbidity with other psychiatric illness- - High levels of anxiety are often found in elderly patients in the early stages of dementia. Recent studies revealed that different genes showed evidence for association with specific types of anxiety disorders, such as panic disorder, social phobias or generalised anxiety disorder (Academy of Finland, 2008). Specific anxiety disorders and their clinical features Phobic disorder Phobia occurs commonly in the elderly with increasing frailty and prevalence ranges from 0. These disorders provoke clinically significant levels of distress and disability due to high levels of anxiety. They are usually heralded by a traumatic event usually of a physical nature and may have had a public manifestation. However, in spite of the complete resolution of the physical event, the psychological impairment persists. There are 3 main types of phobia: Agoraphobia- prevalence in the elderly is estimated to range from 1. These individuals may be rendered housebound because many are terrified by the thought of collapsing and being left helpless in public. It can occur with or without panic attacks but always causes anxiety symptoms during the situation. This fear may spiral out of control if there is no obvious escape route and embarrassment is perceived. Consequently the individual learns to avoid these situations and this avoidance in turn reinforces the fear. Fear can also occur merely in anticipation of the anxiety-provoking situation and symptoms are not better explained by another mental or physical disorder. Specific phobias- fear is experienced only in the presence of a particular object or situation. Onset is usually in childhood and prevalence in the elderly is estimated to range from 3. Anxiety is restricted to the presence of the specific phobic object or situation, all other diagnostic criteria are similar to those of social phobia. Panic disorder Panic attacks and panic disorder are rare and symptomatically less severe in the elderly, estimates of prevalence ranges from 0. However, the prominent physical symptoms of panic disorder may result in patients being referred instead to cardiologists, neurologists and gastroenterologists. In one study of cardiology patients with chest pain and no coronary disease, one third of those aged 65 and over met the criteria for panic disorder. Several attacks occur within a period of one month and symptoms are not better explained by another psychiatric or physical disorder. Panic attacks are often co-morbid with other psychiatric disorders, particularly depression, and it may be severe enough to mask depressive features. In addition the condition should not meet the criteria for other anxiety disorders, psychiatric or physical disorders. Onset in old age is rare, the majority starting before the age of 25 and usually running a chronic fluctuating course into old age especially if left untreated. Obsessional symptoms may appear at any age following head injury or cerebral tumour. The individual recognizes them as originating from his own mind but is unable to resist them despite repeated attempts at doing so. Compulsion is the irresistible urge to perform an act repeatedly despite the futility of that action. Insight is usually fully intact and the patients usually regard these symptoms as unreasonable and are distressed by them so much so that their functioning is impaired to a greater or lesser degree. Obsessions and or compulsions should last at least two weeks and not arise as a result of another mental disorder. The experience of the event is sometimes regarded as “near death” for the individual and might actually have involved the death of another person. Symptoms begin within six months of the event and should be present for more than a month, are severe enough to cause distress and impair functioning. Heightened emotional arousal in the form of exaggerated startle response, hypervigilance, emotional numbness, insomnia, irritability and poor concentration that were not there prior to the incident. Older persons who are frail have a greater tendency to feel threatened than their younger counterparts. Acute stress reaction This happens when symptoms of anxiety occur in response to extreme physical or psychological trauma. The risk of developing this disorder is increased if physical exhaustion or organic factors are also present as in the elderly. It is usually of brief duration, onset is within a few hours and it lasts only hours or days. Patient is initially ‘dazed’ with associated reduction in attention and consciousness, inability to comprehend stimuli and disorientation. This is followed by either withdrawal from the situation or agitation and severe distress, depression, anger and despair. The preceding event is a life changing one that is associated with significant subjective distress and emotional disturbance. The major difference is that the anxiety that follows lasts longer and emanates from difficulty in adjusting to the prevailing situation. Onset of symptoms is within one month of the event and duration is usually less than six months. Brief (< one month) or prolonged mild depressive reaction might accompany the anxiety symptoms. Symptoms may impair functioning but do not meet the criteria for another psychiatric diagnosis.

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However discount levothroid 50 mcg free shipping, if the energy flow becomes blocked generic levothroid 50 mcg on line, or promiscuously released purchase levothroid 200mcg with amex, acupuncture—the insertion o f needles at various acupunc­ ture points—can be utilized to reestablish equilibrium. T hrough the reestablishment of equilibrium, acupuncture apparently alters the body’s energy held. T he picture on the right shows the same hnger after an acupuncture needle had been inserted in the subject’s upper arm and left there for 5 minutes. It seems clear that the hum an body is surrounded by a “field,” but we do not fully ap­ preciate the significance of the heightening in the body’s energy field that results from acupuncture. T here is evi­ dence that acupuncture works, however, and we can assume that its efficacy might be related to its effect on the body’s energy field. T he purpose of this illustration, then, and o f the other illustrations in this section, is not to dem onstrate that al­ lopathic medicine is wrong, but rather that it is fallible. T he work o f Johnson and Moss with radiation photography sug­ gests that there is a “life” or “energy field” surrounding the hum an body. This fact alone, if convincingly established, will not repudiate allopathic theory. But it will be evidence that there is a newly discovered phenom enon—the energy field—which m ight serve as an indicator for use in diagnosis and healing. T here no longer is m uch doubt that it works —doubts are only expressed about how it works. This is ironic, since there is no generally accepted theory of anes­ thesia in allopathic practice. Andrew Weil, a physician and drug researcher, describes the anomaly: alth o u g h anesthesia has been a ro u n d fo r over a h u n d re d years a n d alth o u g h m illions o f persons have been p u t into th e state u n d e r close observation, no satisfactory theory o f g en eral anes­ thesia exists; doctors have no idea w hat these d ru g s do to th e brain that accounts for th e state. In part, it is attributable to the inflexibility of allopathic prac­ The Varieties of Medicine 65 tice, its intolerance of inconsistencies. This is not surprising since all paradigm s—and allopathy is a rigid paradigm —elicit extraordinary loyalty. In tests perform ed at the M enninger Clinic in Kansas, Chief Rolling T hunder, a Shoshone medicine man, was asked to “cure” a contusion on a subject’s leg. He placed his m outh over and around the bruise, sucked vigorously, then dashed to the opposite side of the room and vomited. T he bruise disappeared at roughly the same time that the scientists in the room rushed to retrieve the vomitus. T o the scientists, the “cure” could only have been effected if the dam aged tissue in the bruised leg had somehow been physically extracted. O f course, it was not removed in the sense in which the scientists could have understood it. To the subject and the Chief, the sucking and the vomiting were elements of dram a underpinning a belief system—a belief that a cure could be achieved. T he two groups perceived the episode differently, and the explanation for the cure may lie in this perceptual difference. A cupuncture practice is inconsistent with W estern medical theory in several ways. T o begin with, for an operation to be perform ed on any part of the anatomy, acupuncture needles may be placed in different parts o f the body for different patients. In one hospital the needles might be inserted into the forearm s, while in a second, the placement points might be the neck and the ankles. Accord­ ing to the allopathic theory of pain—the specificity theory —this makes no sense. U nder allopathic theory, specific points in the body receive and transm it signals to the brain. T he theory dictates that the person will experience pain precisely at the point o f the stimulus. The manipulation of acupuncture needles is designed to restore harm ony to the body. In both 1971 and 1972, the American Academy of Parapsychology and Medicine sponsored interdisciplinary symposiums respec­ tively entitled “The Varieties of Healing Experiences: Exploring Psychic Phenom ena and Healing,”52 and “T he Dimensions of Healing: A Symposium. Two of the m ore fascinating, but problematic, reports feature Arigo, a natural healer from Brazil, who is now dead; and bodily control m anifested by the Swami Rama, an Indian yogi who dem onstrated his yogic training program under carefully controlled laboratory conditions at the M enninger Founda­ tion clinics. Arigo, an uneducated natural healer, saw thousands of patients in the course of his work. His diagnostic skills were carefully m easured against diagnosis rendered for the same patients by allopathic physicians, and com pared well with them. Arigo generated his diagnosis without the use of sophisti­ cated technology, largely on the basis of visual scans of a patient. A lthough he utilized some m odern techniques such as drugs, and occasionally perform ed surgery, his repertoire also included surgical repair without the use of any equipm ent. U nder similarly controlled conditions, the Swami also dem onstrated his ability to stop his heart from beating. After he was “wired” for the dem onstration and told to proceed, the electrocardiograph records re­ flected an increase in heart rate from 70 beats per m inute to about 300 per minute. T he experim enters had expected the heart rate to stop altogether and thus thought that the ex­ perim ent had been a failure. A fter a final examination of the records, the investigators concluded that the Swami had stopped his heart for at least 17 seconds. The growing literature on biofeedback contains unmistakable implications for self-care. A lthough we have achieved an e x trao rd in ary am o u n t o f sophistication in d ru g an d surgical th erap y in w estern m edicine, this developm ent has been a bit unbalanced. W e have alm ost forgotten th at it is possible for th e “patien ts” themselves to learn directly to low er th eir blood p res­ sure, to slow o r speed th eir heart, to relax at will. Stoyva and Budzynski have been investigating the use o f biofeedback to “decondition” or “desensitize. If an individual can be trained to exercise control over some bodily functions, self- healing and self-restoration are possible. The evidence assembled thus far suggests that everyone can “learn” to exercise some degree of control. T he psychic surgeon appears to perform surgery without instrum ents and can, in certain instances, penetrate the body wall with his hands. T he film I have seen, to be com­ prehended, requires a m ajor widening of perceptual gates.

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Medical causes of shock will be dealt Bubble wrap (thermal bag) with in more detail in Chapter 22 on medical emergencies order levothroid canada. Orthopaedic scoop stretcher Tips from the field Battery pack • Patients who are tachycardic cheap 100mcg levothroid fast delivery, tachypnoeic purchase generic levothroid pills, with cold clammy skin Figure 8. It is rates essential that the patient is protected from the environment at all • The application of a pelvic binder and splinting of long bone times with exposure for critical interventions only. Various thermal fractures should be undertaken as part of the primary survey blankets and wraps are available (Figure 8. Acute coagulopathy of trauma: mechanism, identification and All shocked trauma patients should be triaged to a major trauma effect. Introduction emergency department and has therefore been extended into the In this chapter the indications for prehospital emergency anaes- prehospital phase of care. The importance of training, technical skill levels and equipment and the requirement for a robust clinical governance is no exception. The published evidence is difficult to interpret infrastructure will be highlighted. There are emphasis on training paramedics to perform intubation without wide variations in practice and complication rates. However, if poorly performed, it can result in Tracheal intubation is the standard of care for protection of the unnecessary morbidity and mortality. Clinical assessment in combination with physiological monitor- ing should be performed throughout the prehospital anaesthetic, The team approach including preparation, induction, maintenance and transfer. The assistant is usually a health-care professional who has been specifically trained for the role (e. Simple • Lacrimation airway manoeuvres and airway devices can be used to provide • Evidence of muscle activity and limb movements. The team is not just made up of an operator and assistant but also includes the senior clinical lead for the particular system and those Box 9. They are particularly impor- anaesthetised patient tant in maintaining clinical quality assurance and implementing standard operating procedures and protocols. In addition to performing the procedure, the ability to manage Measurements should be made at least every 3 minutes and the physiological effects of drugs administered, anticipation and appropriate alarm limits set on the monitoring equipment. Alarms management of the difficult or failed airway and the ongoing scene should be loud enough to be heard in the prehospital environment. Itshouldbeadequatelymaintainedandserviced not replace the need for clinical experience. The team of the characteristics of the prehospital environment, many believe must be familiar and have in depth knowledge of all equipment. The drugs prehospital environment makes it imperative that standard oper- used are usually selected for their haemodynamic stability, although ating procedures are in place, well rehearsed and understood by all it should be noted that there is no ideal drug – all have advantages team members. The patient should be placed draw and carefully label drugs so that they are ready for immediate in as controlled an environment as possible, ensuring adequate use. The ideal position to perform intubation is with the patient General principles supine (or slightly tilted head up) on an ambulance trolley at The general principles of prehospital anaesthesia are the same as thigh height allowing the operator to intubate easily while kneeling those for emergency in-hospital anaesthesia. To be attached to the patient as soon as is practical May need to be temporarily removed for extrication, etc. Oxygen Adequate supplies for on scene period and transfer (with redundancy) Simple airway Oropharyngeal and nasopharyngeal airways adjuncts Vascular access Intravenous and intraosseous equipment Drugs Limited selection to reduce drug errors. Intubating Laryngoscope with different sized blades, varied equipment sized endotracheal tubes, bougie Figure 9. Laryngeal Mask Pre-oxygenation is essential to prevent hypoxaemia during the devices Airway™) and surgical airway equipment procedure. This can be achieved using a non-rebreathing oxygen Lighting As appropriate facemaskwithreservoirattachedorabagandmask. Inapatientwith Procedural May be of benefit respiratory compromise gentle assisted ventilation may be required. Once manual in-line immobilization of the cervical spine is established, the cervical collar and head blocks can be removed until intubation is completed. Induction and intubation Induction should be straightforward but modified to the patient’s individual needs (e. The use of a yellow clinical waste bag and standard equipment lay-out will aid in the checking and location of equipment in emergencies (Figure 9. Monitoring should be applied to the patient as soon as practically possible and two points of circulatory access gained). Assistants should be fully briefed to ensure everyone knows their role and what is going to happen. Ideally four people are required: operator, operator’s assistant, provider of manual, in-line Figure 9. Once confirmed the endotracheal tube Induction should secured in place using ties, adhesive tape or tube holders. When secured the cervical collar and head • Change of operator blocks can be replaced. Althoughprehospitalairwaysareoftenconsidered journey, with redundancy, to ensure the patient receives opti- challenging well-rehearsed simple techniques produce good results. If intubation is unsuccessful at the first sion and reduce the chances of awareness. Monitor for tachycardia, hypertension, pupillary that can be optimized during this period. Aliquots of a hypnotic agent such as known as the ‘30-second drills’, as they should be addressed within midazolam and an analgesic, titrated to the patients’ physiolog- this time frame. Repeated intubation attempts should be avoided ical response are usually sufficient. Every system Transfer should have a written, and well-rehearsed, ‘failed intubation plan’. Maintenance of anaes- Thisshouldincludesupraglotticairwayrescuedevicesandprovision thesia, ongoing monitoring and continual assessment of the patient for performing a surgical airway. Supporting The breathing circuit should be connected and correct placement equipment (suction, intubating equipment, resuscitative fluids) of the tracheal tube should be confirmed as soon as possible using must be available and a contemporaneous record of vital signs and conventional methods (seeing the tube pass between the vocal interventions generated. Paediatrics • Optimize pre-oxygenation by utilizing airway adjuncts, airway Prehospital anaesthesia of small children is only rarely required. For toilet and titrated sedation if required most children the risks outweigh the benefits. Where actual airway • Consider the pre-oxygenation and induction of obese patients ina compromise cannot be overcome with simple airway manoeuvres head-up position (with cervical spine protection maintained) or in the risk to benefit ratio may change and drug-assisted intubation the sitting position may become appropriate.

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