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Precautons Hepatc impairment (Appendix 7a); renal impairment; cardiac disease (see also Contraindicatons); skin reactons (see Adverse efects); history of blood disorders (blood counts before and during treatment); glaucoma; lactaton (Appendix 7b); avoid sudden withdrawal; interactons (Appendix 6b buy cheap cordarone 200mg line, 6c buy cheap cordarone 100 mg on line, 6d); pregnancy (Appendix 7c) discount 100mg cordarone otc. Patents or their caretakers should be told how to recognize signs of blood, liver or skin disorders and advised to seek immediate medical atenton if symptoms such as fever, sore throat, rash, mouth ulcers, bruising or bleeding develop. Leukopenia which is severe, progressive and associated with clinical symptoms requires withdrawal (if necessary under cover of suitable alternatve). May impair ability to perform skilled tasks, for example operatng machinery, driving; see also notes above. Adverse Efects Sedaton, dizziness, hyperactvity, behavioural problem, irritability, drooling, weight gain, sleep disturbance, blurring, diplopia. Contraindicatons Hypersensitvity to benzodiazepines, acute pulmonary insufciency, acute narrow angle glaucoma. Precautons Neonates, chronic pulmonary insufciency, hepatc and renal dysfuncton, porphyria, elderly, pregnancy (Appendix 7c), lactaton (Appendix 7b), interactons (Appendix 6a, 6c); avoid sudden withdrawal. Contraindicatons Respiratory depression; acute pulmonary insufciency; sleep apnoea; severe hepatc impairment; myasthenia gravis; avoid injectons containing benzyl alcohol in neonates, narrow angle glaucoma; hypersensitvity to benzodiazepine. Precautons Respiratory disease, muscle weakness, history of alcohol or drug abuse, marked personality disorder; pregnancy (Appendix 7c); lactaton (Appendix 7b); reduce dose in elderly or debilitated patents and in hepatc impairment (avoid if severe, Appendix 7a), renal impairment; avoid prolonged use and abrupt withdrawal; when given intravenously, facilites for reversing respiratory depression with mechanical ventlaton must be at hand (see below); porphyria; interactons (Appendix 6a, 6c); blood count test on prolonged treatment. Intravenous infusion of diazepam is potentally hazardous (especially if prolonged) calling for close and constant observaton and best carried out in a speciality centre with intensive care facilites. May impair ability to perform skilled tasks, for example operatng machinery, driving; see also notes above. Adverse Efects Drowsiness and lightheadedness the next day; confusion and ataxia (especially in the elderly); amnesia; dependence; paradoxical increase in aggression; muscle weakness; occasionally headache, vertgo, salivaton changes, gastrointestnal disturbances, skin reactons, visual disturbances, dysarthria, tremors, incontnence, urinary retenton; blood disorders and jaundice; hypotension and apnoea, pain and thrombophlebits (with injecton); increased appette; weight gain. Precautons Uremia, hypoalbuminemia, interactons (Appendix 6b, 6c); pregnancy (Appendix 7c). Adverse Efects Cardiovascular collapse and/or central nervous system depression, nystagmus, dizziness, pruritus, paresthesia, headache, somnolence, ataxia, hypotension. Gabapentn Pregnancy Category-C Schedule H Indicatons Add-on drug in resistant partal seizures with or without secondary generalizaton, rolandic epilepsy- preferred for safety reason, frst line in epilepsy patents with hepatc disease. Dose Oral Initally 10 mg/kg/day, increase 10 mg/kg/day to maintenance dose 30-100 mg/kg/day, in three divided doses. Contraindicatons Pregnancy (Appendix 7c) Adverse Efects Somnolence, dizziness, fatgue, nystagmus, behavioral changes (<10%)-aggression, hyperexcitability, tantrum, euphoria, weight gain. Lamotrigine Pregnancy Category-C Schedule H Indicatons Partal seizures and secondary generalised tonic-clonic seizures. Dose Oral Adult and Child over 12 years- 25 mg once daily for 2 weeks followed by 50 mg once daily for 2 weeks, increase by 50 to 100 mg every 1 to 2 weeks to maintenance dose of 100 to 200 mg daily. Child- Monotherapy- Inital dose 2 mg/kg/day for 2 weeks then 5 mg/kg/day for 2 weeks. Contraindicatons Child less than 12 years; hypersensitvity; severe hepatc and renal impairment. Precautons Monitoring of liver and renal functon; abrupt withdrawal to be avoided; pregnancy (Appendix 7c) and lactaton; avoid in patents who need to undertake task requiring mental alertness; patents taking sodium valproate. Adverse Efects Skin eruptons; nausea; vomitng; headache; toxic epidermal necrosis; hepatotoxicity; leucopenia; thrombocytopenia; confusion; hallucinaton. Adverse Efects Most frequent somnolence, asthenia (dose dependent); headache, hair loss, vertgo, nausea, infecton; behavioral changes such as hostlity aggression, apathy, anxiety, depression, psychosis. Magnesium Sulphate Pregnancy Category-A Indicatons Preventon of recurrent seizures in eclampsia; preventon of seizures in pre-eclampsia; acute nephrits in children. Dose Intravenous injecton (concentraton of magnesium sulphate should not exceed 20%) Preventon of seizure occurrence in eclampsia: initally 4g over 5 to 15 min, followed by infusion 1g/hr for at least 24 h afer last seizure. Contraindicatons Not to be injected parenterally in patents with heart block or myocardial damage. Precautons Hepatc impairment (Appendix 7a); pregnancy (Appendix 7c); renal impairment; in severe hypomagnesaemia administer initally via controlled infusion device (preferably syringe pump); monitor blood pressure, respiratory rate, urinary output and for signs of overdosage (loss of patellar refexes, weakness, nausea, sensaton of warmth, fushing, drowsiness, double vision and slurred speech). Adverse Efects Generally associated with hypermagnesaemia, nausea, vomitng, thirst, fushing of skin, hypotension, arrhythmias, coma, respiratory depression, drowsiness and confusion, loss of tendon refexes, muscle weakness; colic and diarrhoea following oral administraton; hypothermia; stupor. Oxcarbamazepine Pregnancy Category-C Schedule H Indicatons Monotherapy or adjunctve therapy in the treatment of partal seizures, secondary generalzed seizure, substtuton for carbamazepine can be made abruptly with an oxcarbamazepine-to-carbamazepine rato of 300:200. Dose Inital dose: 8-10 mg/kg/day, increasing by 8-10 mg/kg/day as tolerated at 3-7 day interval. Phenobarbitone* Pregnancy Category-D Schedule H Indicatons Generalized tonic-clonic seizures; partal seizures; neonatal seizures; febrile convulsions; status epileptcus; sedatve, hypnotc, pre- anaesthetc. Dose Slow intravenous injecton Status epileptcus: (dilute injecton 1 in 10 with water for injectons), Adult- 10 mg/kg at a rate of not more than 100 mg/min (up to max. Precautons Elderly, debilitated, children (may cause behavioural changes); impaired renal functon or hepatc functon (Appendix 7a), respiratory depression (avoid if severe); pregnancy (see notes above; Appendix 7c); lactaton (Appendix 7b); avoid sudden withdrawal; interactons (Appendix 6a, 6b, 6c); habbit forming. Adverse Efects Sedaton, mental depression, agitaton, hallucinaton, syncope; ataxia, nystagmus; allergic skin reactons including rarely, exfoliatve dermatts, toxic epidermal necrolysis, Steven’s- Johnson syndrome (erythema multforme); paradoxical excitement, restlessness and confusion in the elderly; irritability and hyperactvity in children; megaloblastc anaemia (may be treated with folic acid); osteomalacia; status epileptcus (on treatment withdrawal); hypotension, bradycardia, shock; laryngospasm and apnoea (with intravenous injecton); cognitve impairment; aplastc anaemia; hepatc failure; connectve tssue disorder; hyperkinesias. Phenytoin* Pregnancy Category-D Schedule H Indicatons Generalized tonic-clonic seizures; partal seizures; status epileptcus. Child- Status epileptcus: 20 mg/kg at a rate not exceeding 1 mg/kg/min, maintenance dose 4-7 mg/kg/day in 2 divided doses, max dose 300 mg/day. Precautons Hepatc impairment (reduce dose; Appendix 7a); lactaton (Appendix 7b); diabetes mellitus; monitor blood counts; hypotension and heart failure (cauton with parenteral use); intravenous administraton-resuscitaton facilites must be available; injecton soluton alkaline (irritant to tssues); interactons (Appendix 6a, 6b, 6c); hypersensitvity; osteomalacia, it worsens myoclonus and absence seizures. Patents or their caretakers should be told how to recognize signs of blood or skin disorders and advised to seek immediate medical atenton if symptoms such as sore throat, rash, mouth ulcers, bruising or bleeding develop. Leukopenia which is severe, progressive or associated with clinical symptoms requires withdrawal (if necessary under cover of suitable alternatve). May impair ability to perform skilled tasks, for example operatng machinery, driving; see notes above. Dose Oral Adult- 600 mg daily in two divided doses (preferably afer food) thereafer increase by 200 mg at 3 days interval clinical response tll desired. Contraindicatons Actve liver disease, family history of severe hepatc dysfuncton; pancreatts; porphyria; hypersensitvity. Precautons Monitor liver functon before and during frst 6 months of therapy (Appendix 7a), especially in patents at most risk (children under 3 years of age, those with metabolic disorders, degeneratve disorders, organic brain disease or severe seizure disorders associated with mental retardaton, or multple antepileptc therapy); ensure no undue potental for bleeding before startng and before major surgery or antcoagulant therapy; renal impairment; pregnancy {important see notes above, (neural tube screening)} (Appendix 7c); lactaton (see notes above; Appendix 7b); systemic lupus erythematosus; false-positve urine tests for ketones; avoid sudden withdrawal; interactons (Appendix 6a, 6c, 6d); hyperammonemia. Vigabatrin Pregnancy Category-C Indicatons Infantle spasms, refractory partal seizures with or without secondary generalizaton.

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It is recom- mended that parents are shown how to give approximately 75 ml/kg of oral rehydraton soluton with a spoon over a 4-h period and it is suggested that parents should be watched to see how they cope at the beginning of the treatment order cordarone 200 mg on-line. A larger amount of soluton can be given if the child contnues to have frequent stools purchase cordarone 100 mg free shipping. In case of vomitng generic 200mg cordarone amex, rehydraton must be discontnued for 10 min and then resumed at a slower rate (about one teaspoonful every 2 min). The child’s status must be re-assessed afer 4 h to decide on the most appropriate subsequent treatment. Oral rehydraton soluton should contnue to be ofered once dehydraton has been controlled, for as long as the child contnues to have diarrhoea. Plan C: Severe dehydraton: Hospitalizaton is necessary, but the most urgent priority is to start rehydraton. In hospital (or elsewhere), if the child can drink, oral rehydraton soluton must be given pending, and even during intravenous infusion (20 ml/kg every h by mouth before infusion, then 5 ml/kg every h by mouth during intravenous rehydraton). For intra- venous supplementaton, it is recommended that compound soluton of sodium lactate (see chapter 28. If the intravenous route is unavailable, a nasogastric tube is also suitable for administering oral rehydraton soluton, at a rate of 20 ml/kg every h. If the child vomits, the rate of administra- ton of the oral soluton should be reduced. Note: The soluton may be prepared either from prepackaged sugar/salt mixtures or from bulk substances and water. Solutons must be freshly prepared, preferably with recently boiled and cooled water. Accurate weighing and thorough mixing and dissoluton of ingredients in the correct volume of clean water is important. Adult- Fluid and electrolyte loss in acute diarrhoea; 200 to 400 ml soluton afer every loose moton. Adverse Efects Vomitng- may indicate too rapid administraton; hypernatraemia and hyperkalaemia may result from overdose in renal impairment or administraton of too concentrated a soluton. Antdotes and Substances Used in Poisoning These notes are only guidelines and it is strongly recom- mended that poisons informaton centres (Appendix 5) be consulted in cases where there is doubt about the degree of risk or about appropriate management. Patents who have taken poisons with delayed actons should also be admited, even if they appear well; delayed-acton poisons include acetylsalicylic acid, iron, lithium, paracetamol, paraquat, tricyclic antdepressants and warfarin. However, it is ofen impossible to establish with certainty the identty of the poison and the size of the dose but informaton on the type and tming of poisoning may be useful for symptomatc management. Cardiac conducton defects and arrhythmias ofen respond to correcton of underlying hypoxia, acidosis, or other biochemical abnormalites. Hypothermia which may develop in patents who have been unconscious for some hour is best treated by wrapping the patent in blankets to conserve body heat. Convulsions which are prolonged or recurrent may be controlled by intravenous diazepam. In some situatons removal of the poison from the stomach by gastric lavage may be appropriate (see below). Actvated charcoal can bind many poisons in the stomach and therefore prevent absorp- ton. Actve eliminaton techniques such as repeated adminis- traton of actvated charcoal can enhance the eliminaton of some drugs afer they have been absorbed (see below). Other techniques to enhance eliminaton of poisons afer their absorpton are only practcal in hospital and are only suitable for a small number of patents and only to a limited number of poisons. Gastric Lavage: The dangers of atemptng to empty the stomach have to be balanced against the toxicity of the ingested poison, as assessed by the quantty ingested, the inherent toxicity of the poison and the tme since ingeston. Gastric emptying is clearly unnecessary if the risk of toxicity is small or if the patent presents too late. Gastric lavage must not be atempted afer corrosive poisoning or for hydro- carbon products which could be dangerous if aspirated. There is no evidence that it prevents absorp- ton of the poison and it may increase the likelihood of aspira- ton. Preventon of Absorpton: Given by mouth actvated charcoal can bind many poisons in the gastrointestnal system, thereby reducing their absorp- ton. The sooner it is given, the more efectve it is, but it may be efectve for up to 1 hour afer ingeston of the poison. It may be efectve several hour afer poisoning with modifed- release preparatons or drugs with antcholinergic (antmus- carinic) propertes. It is relatvely safe and partcularly useful for preventon of absorpton of poisons which are toxic in small amounts, for example, antdepressants. Furthermore, repeated doses of actvated charcoal enhance the faecal eliminaton of some drugs (that undergo enterohepatc or enteroenteric recycling) several hours afer ingeston and afer they have been absorbed, for example phenobarbital, theophylline. Contraindicatons Poisoning by hydrocarbons with high potental for harm if aspirated; poisoning by corrosive substances-may prevent visualizaton of lesions caused by poison. Adverse Efects Black stools; vomitng, constpaton or diarrhoea; pneumonits-due to aspiraton. Calcium Disodium Edetate Pregnancy Category-B Indicatons Lead poisoning (acute and chronic) and lead encephalopathy. Dose Intravenous injecton Lead poisoning without encephalopathy: 1000 mg/m2/day as contnous infusion for 5 days. Lead encephalopathy: 1500 mg/m2/day by contnous intravenous infusion in 5% dextrose or 0. Lignocaine or procaine should be added to the injecton to minimize pain at the injecton site. Precautons Ensure adequate urine output, pre-existng mild renal disease; patents with lead encephalopathy and cerebral edema may experience a lethal increase in intracranial pressure following intravenous infusion, the intramuscular route is preferred for these patents. Adverse Efects Renal tubular toxicity which may lead to acute renal failure, fever, chills, lacrimaton, increased prothrombin tme, pain at intramuscular injecton site; hypotension; cardiac rhythm irregularites; thirst; headache; fatgue; malaise; urinary frequency; glycosuria; proteinuria; microscopic hematuria; histamine-like reactons. The only early features of poisoning, nausea and vomitng, usually setle within 24 h. Persistence beyond this tme, ofen with the onset of right subcostal pain and tenderness, usually indicates the development of liver damage which is maximal 3-4 days afer ingeston. In spite of a lack of signifcant early symptoms, patents who have taken an overdose of paracetamol should be transferred to hospital urgently. Administraton of actvated charcoal should be considered if paracetamol in excess of 150 mg/kg or 12g, whichever is smaller, is thought to have been ingested within the previous hour.

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Once again cheap cordarone 200 mg amex, leaving aside the complex motivational issues which limit generalization of laboratory studies to real life situations buy generic cordarone 200mg, we are left with the Heron findings that following isolation and confinement discount 200mg cordarone mastercard, beliefs around a topic such as psychical phenomena change significantly. This observation is also consistent with the hypothesis of a decline in internal perceptual norms and in ability to reason efficiently. It would seem likely that changing the emotional relationship between the authority and the subject would introduce another complex variable which cannot be assessed without data. The tendency to modification of belief in experimental circumstances is 1 Personal communication, 1958. It should be kept in mind that in the latter situation additional elements of uncertainty, stress, and coercion were brought to bear in inducing these changes (10, 42). Personality Findings The relationship of personality attributes to tolerance for isolation is one which has significant implications for issues as diverse as personnel selection and personality theory. That the study of response to this situation might be relevant to the study of personality was pointed out: by Hochberg et al. Whether any relationships exist between personality factors, the mode in7 which the Ganzfeld is perceived, and the course of color adaptation, is yet to be investigated. In addition to finding differences between suggestible and nonsuggestible subjects in tolerance for sensory deprivation, he observed a number of related personality attributes that seemed to differentiate the two groups. The suggestible subjects appeared to be more productive and more tolerant of regressive behavior, including delusions, hallucinations, and fantasies. The nonsuggesiible subjects, on the other hand, tended to be more threatened by disturbances in body schema, defensive about their intellectual control, and more aware of external factors which reinforce reality. They used a series of personality measures including the Minnesota Multiphasic Personality Inventory and the Edwards Personal Preference Schedule. For the Edwards test these authors reported a significant negative relationship between need Exhibitionism and length of stay in isolation, as well as near significant positive relationships between the latter variable and need Affiliation, need Succorance, and need Nurturance. They interpreted these findings to mean that subjects with greater tolerance for deprivation relate themselves more genuinely to people and seek more contact and emotional exchange with others. In a second experiment (47), with eleven subjects, under more severe conditions of isolation, these -69- investigators failed to confirm the original findings, observing instead a near significant positive relationship between need Autonomy and length of stay in deprivation. In studying ten subjects consisting of normal, neurotic, schizophrenic, and sociopathic individuals for response to one hour of isolation, B. The schizophrenic subjects showed no appreciable increase or decrease in their hallucinatory behavior and had a generally positive reaction to the situation, devoid of the anxiety typically exhibited by normal subjects. A more recent study of the response of schizophrenics to sensory deprivation was performed by Harris (35). Utilizing a procedure similar to that of the McGill group, he placed twelve subjects in isolation for periods up to two hours. These findings appear to be consistent with those of the two earlier studies cited previously. Working in a different theoretical context, Petrie, Collins, and Solomon (60) attempted to relate pain tolerance, cortical satiation, and perceptual deprivation. Using kinesthetic figural aftereffects, measures of pain threshold, and tolerance for isolation in the polio respirator, their findings tend to support the hypothesis that susceptibility to satiation is associated with tolerance for pain and intolerance for perceptual deprivation. Here satiation is seen as a key factor mediating the perceived intensity of stimulation; the higher the satiability the less intense are succeeding sensations. They emphasized psychoanalytic concepts, such as resistance to regression and modes of handling primary process material. Fourteen subjects were rated for the maturity with which they handled primary process as manifested in Rorschach test responses. Their verbal behavior during eight hours of isolation and -70- postisolation interview was then assessed by a scheme of content analysis which stressed modes of dealing with primary process material. In the first of these, subjects engaged in a variety of behaviors within the limits set by the situation and instructions. They talked freely, experienced pleasurable affect, little unpleasant affect, thought rationally, and engaged in daydreams, fantasy, and playful thinking without being threatened by the situation. In the second reaction pattern, there was unpleasant affect, anxiety-laden intrusions of the primary process, preoccupation with terminating the experiment, and impaired efficiency in rational or secondary process thinking. They found these two reaction patterns to be significantly correlated in the expected direction with the Rorschach measure of maturity of handling primary process materials. Those who on the Rorschach handled primary process in a mature and effective way were those who reacted in an adaptive way to isolation. Conversely, those who on the Rorschach handled primary process with poor control or avoided it reacted negatively to isolation. This finding is consistent with several others which point to the exaggeration of usual personality defenses under the stress of isolation (18, 56, 65). An overview of these data emphasizes the truism of marked individuality of response. Whether differences observed among various studies is a systematic function of varying experimental conditions is as yet unclear. The findings on suggestibility as a personality attribute and those on the relationship to satiation and pain thresholds remain conceptually unrelated to the other work. The Goldberger and Holt demonstration of relationships between preisolation personality attributes and the content of response to isolation is a carefully executed study which has a clear theoretical orientation and makes complex but reliable assessments of verbal and other behavior. Other studies have tended toward utilization of too simplified an index of response such as length of stay which fails to take into account complex behavior during the isolation situation. It may well be that personality variables and their interrelationships are insufficiently reflected in such a simple measure of tolerance for isolation. Thus specification of terms such as "schizoid" and "withdrawn" may have more meaning, permit replication of procedures, and evaluation of results. Although some of this difficulty in the present studies stems from their preliminary nature, there appears to be some insensitivity to the need for both conceptual and operational specification of measurement and assessment techniques. Progress with the problem of personnel selection and utilization for a variety of tasks, as well as theoretical clarification, awaits such refinement in research programs. Feeling States Changes in subjective feeling in response to reduced environmental input has been a common observation in these studies.

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