Y. Bengerd. Jones College.
Comparison of single Cardiac advantages of normoxemic versus hyperoxemic dose versus multiple dose crystalloid cardioplegia in neo- management during cardiopulmonary bypass purchase toradol 10 mg with amex abdominal pain treatment guidelines. J Thorac nates: experimental study with neonatal rabbits from birth to Cardiovasc Surg 1995 discount 10mg toradol otc pain medication for dogs with hip dysplasia;110(4 Pt 2):1255–64. Organ preserva- cardioplegia on high energy phosphate kinetics during cir- tion solutions in heart transplantation – patterns of usage and culatory arrest with deep hypothermia in the newborn piglet related survival. Single-dose versus multidose car- dioplegia solutions using thermodilution cardiac output in dioplegia in neonatal hearts. Detrimental effects of crystalloid cardioplegia for repair of ventricular septal defects multidose hypothermic cardioplegia in the neonatal heart: in pediatric heart surgery: a randomized controlled trial. Ann versus multidose blood cardioplegia in arterial switch proce- Thorac Surg 2005;80:989–94. Ann temperature correlates with increased white cell activation Thorac Surg 2006;82:172–8. J Thorac sary adjunct to cardioplegic protection and cause of pulmo- Cardiovasc Surg 1992;103:219–29. Rapid cooling between calcium and magnesium in pediatric myocardial pro- contracture of the myocardium. Warm induc- induction of cardioplegia with glutamate-enriched blood in tion blood cardioplegia in the infant. J Thorac Cardiovasc coronary patients with cardiogenic shock who are dependent Surg 1990;100:896–901. Dexamethasone ervation in neonatal lambs: comparison of hypothermia with pretreatment provides antiinfammatory and myocardial pro- crystalloid and blood cardioplegia. Pediatric Cardiology, 6th comes associated with intraoperative steroid use in high-risk ed. The effect of tepid amino acid-enriched induction cardioplegia on the outcome of infants undergoing cardiac surgery. However, his frst patient, a The pathophysiology of congenital heart disease is limited to 15-month-old baby had died and the subsequent two chil- three main problems. There may be a volume load in which dren died leading Gibbon himself to abandon any further one or both ventricles must pump more than the usual amount open heart surgery. This is most commonly because of excessive pul- tiple deleterious effects that were particularly dangerous monary blood fow resulting from a septal defect. The priming volume for early circuits be a pressure load for one or both ventricles. This is usually was usually several liters, which necessitated exposure of an secondary to obstruction to outfow from the affected ventri- infant to what was effectively a massive blood transfusion of cle. The infammatory to reduced pulmonary blood fow but also may be because mediators, such as bradykinin and complement,2 that were of inadequate mixing between two parallel circulations as released in large quantities as part of the “systemic infam- in transposition of the great arteries. Early procedures were matory response” to bypass were particularly problematic designed to palliate but not cure these problems, thereby for the neonate and young infant who have a propensity to allowing the child to grow to an age and size at which “cura- greater vascular permeability and tissue edema than the tive” surgery was thought to carry a lesser risk. Robert SyStemic to Pulmonary arterial ShuntS Gross who had performed the frst repair of coarctation in the United States recommended deferring repair until at least 10 A systemic to pulmonary arterial shunt reduces cyanosis by years of age. Although this is a concep- Anesthesia for babies was in its infancy and intensive tually simple procedure, it nevertheless carries a number of care units appropriate for young babies did not exist in the important challenges for the surgeon. Diagnosis of heart disease was dependent on the inva- size of the shunt must be appropriate for the size of the child. Surgeons did not have microvascular of the child, what may be large enough for the child at the instrumentation or the knowledge of delicate surgical tech- time of the procedure may not be large enough in the future. For all these reasons, volume load on one or both ventricles so the child will have every attempt was made to manage the child medically and traded the problems of cyanosis for the secondary problems to defer surgery until the child was considered to be better associated with a volume load, most notably congestive heart able to withstand the stresses of surgery. Flow into the lungs could not be managed medically, a number of ingenious pal- during diastole lowers diastolic blood pressure and results in liative surgical procedures were developed. Blalock had discovered, perhaps without realizing it, that the size of the subclavian artery happened to be appropriate for supplying enough, but not too much, pulmonary blood fow. Furthermore, it had growth potential and could there- fore sustain the child for many years. However, in these early years which predated the development of vascular surgery and certainly predated microvascular surgery, the procedure was technically demanding for many surgeons, particularly working with small babies. Unless the anastomosis was con- structed perfectly, there was a high risk of shunt thrombosis. This led others to seek a technically simpler procedure with a higher probability of patency. Waterston Shunt The Waterston shunt is an anastomosis between the ascend- ing aorta and the right pulmonary artery. This oxygenator was used at St Vincent’s a left thoracotomy with a side-biting clamp applied to both Hospital, Melbourne, Australia in the mid-1970s. The Potts shunt has all the disadvantages of the Waterston shunt and in addition is very diffcult to take down. The modifed Blalock shunt was introduced by deLeval The Blalock–Taussig Shunt et al. Optimal Timing for Congenital Cardiac Surgery 221 between 3 and 6 mm in diameter is anastomosed to the left artery distortion. However, even a perfect Blalock shunt subclavian artery and the left pulmonary artery. The left sub- requires dissection of the right or left pulmonary artery, clavian artery is said to limit fow to an appropriate amount which is followed by adventitial scarring. Even if a stenosis and by using a larger graft the child is able to grow without cannot be seen it is very likely that the vessel wall compli- becoming excessively cyanosed. Modifcations of this shunt ance is decreased in the region of dissection and anastomo- are presently the most popular systemic to pulmonary artery sis. All of the palliative procedures result in some degree of shunt (see Chapter 25, Three-Stage Management of Single intrapericardial scarring which can obscure important car- Ventricle, for technical details). The high pressure and high fow in the Presence of Congenital Heart Disease pulmonary arteries will eventually lead after a year or two Because palliative procedures do not correct, but simply to irreversible damage to the pulmonary microcirculation, palliate congenital cardiac pathology, there will be ongoing that is, pulmonary vascular disease. For fed Blalock shunt, a band has the problem that it does not example, in the case of transposition physiology, not only is allow growth so that what may be an appropriate degree of there ongoing cyanosis, but in addition the most cyanosed band tightness for an infant will be too tight for the older blood is delivered to the coronary arteries and brain during child. Thus, the child will become increasingly cyanosed the period of critically important brain and heart develop- with growth. On the other hand, early monary artery that can lead to permanent distortion at the primary repair creates a physiologically normal circulation origins of the right and left pulmonary arteries and/or distor- which allows normal maturation of the individual. Infow occlusion with hypothermia was introduced ing of the parallel pulmonary and systemic circulations, the at the University of Minnesota in 1953,15 but suffered from the child will die from cyanosis. The procedure is performed through a of the advantages of early repair was provided by C Walton right thoracotomy. Incisions are made anterior and posterior to the low morbidity and mortality and excellent long-term results. With the advent of the Rashkind balloon septostomy nique fell into disrepute and attention was focused on open in 1966, it was rarely necessary to perform this procedure.
After a fre begins cheap toradol 10 mg without a prescription pain treatment medicine, it can go in any direction purchase toradol pills in toronto georgia pain treatment center, which could destroy vegetation or even consume large populated areas. The costs resulting from the damage of such fres can be tremendous to a community in terms of human sufering, dollars, natural resources, and wildlife. In this case study, there was no apparent plan of action to contend with the large-scale forest fre that swept through the area. Tere were very few resources that could be utilized or deployed to combat such a fre in the era when the disaster occurred. Unlike modern times, there were no aircraft, frefght- ing chemicals, or other infrastructure that could be used to bring in water or other resources quickly. Items of Note An estimated 1,670 people (Associated Press, 1988) were killed and an area equal in size to the state of Rhode Island was scorched (Greer, 1986). Big Blowup, Washington, Idaho, and Montana, 1910 Stage 1 of the Disaster You are the governor of a Northwestern state. On August 19, you are notifed that a forest fre has started and the winds are causing the fre to spread quickly through your state (Petersen, 2005). You are told by your staf that that there is not enough equipment available in the area where the fres are located to handle or contain the spread of the fre (Petersen, 2005). The frst step is to determine what resources the state has and what resources exist at local levels that can be used against a for- est fre. In many cases the Army Reserve or National Guard can be called in to fght forest fres. Additionally, the governor should begin to make plans to safeguard communities that are near the forest fre where a big loss of property and life could occur. Second, the governor should also take into account how to get these resources to the areas of need quickly by freeing up as many transportation routes as possible so that resources will have dedicated transportation corridors. The governor should keep in contact with all local ofcials who are in the vicinity of the fre as well as those ofcials that have resources that can be deployed to the frefghting zone. Stage 2 of the Disaster You are having difculty getting resources to the fre location because the roads are not adequate and the terrain is rocky (Petersen, 2005). Also, the fre has now spread to two more states in addition to yours, and the winds are causing the fres to spread rapidly due to dry grasses and timber (Petersen, 2005). As a governor, you now need to consider evacu- ation of areas that are in the path of the fre since you cannot get resources to certain areas quickly enough. You should develop a plan to fght the fres closest to population centers where you can get frefghting resources on the scene quickly. The governor now needs to fnd out what resources are in neighboring states as well as any resources available at the local and federal levels to battle against the spreading fre. The governor should contact the governors in the other two states where the fres are spreading as well as local and federal ofcials that can possibly provide resources to fght the fre. The local ofcials should be contacted about possible evacuation of their communities if the fres sweep toward these locations. Stage 3 of the Disaster You and the other two governors now have 10,000 people (by paying an hourly wage to volunteers) battling the blazes across the three states (Petersen, 2005). Army has now been thrown into the fray to battle the forest fres (Petersen, 2005). The key aspect of fghting the fre efectively is to make sure the resources get to where they are supposed to be positioned most efectively. Having 10,000 people fghting fres is only efective if the resources are being used efciently. The governor should review how all of the eforts are being coordinated and see how any improvements in transporta- tion can be made to make it faster to get resources where they need to be positioned. The governor should make every efort to ensure that local, state, and federal resources that are battling the fres are coordinated and in synch with one another’s eforts. Local leaders need to be Case Studies: Disasters from Natural Forces—Fires ◾ 35 reassured that resources will be forthcoming to provide their communities with temporary shelters, medical assistance, and food and water. One method that can increase the safety of frst responders is to gather more personnel and attempt to get state- of-the-art frefghting equipment to fght the fres as well as perform search and rescue operations. The governor should also attempt to improve logistics to the frst responders by ensuring that the frst responders have plenty of sup- plies for operations (e. Key Issues Raised by the Case Study The problems in this case study were the lack of infrastructure, poor coordination with diferent frefghting units, and a lack of resources to fght the fre efectively. A couple of preventative measures that may have assisted the frefghters in con- trolling the blaze would have been to thin out the trees in densely wooded areas as well as clear dead and dry debris from fallen trees so that if a fre did begin, it would have less fuel to burn. In addition, stockpiling frefghting resources and pre-positioning certain assets can also improve the chances of responding more quickly and efectively to a fre. Items of Note The fre burned 3 million acres of forest and killed at least 86 people (Petersen, 2005). Tis incident is possibly the largest forest fre in American history, if not world his- tory, and had no determined cause (Petersen, 2005). Hartford Circus Fire, Connecticut, 1944 Stage 1 of the Disaster You are the fre chief for a large metropolitan city on the east coast of the United States. The Ringling Brothers and Barnum & Bailey Circus has come to your city to do a series of performances. The circus has a traditional big top and 8,000 of your residents (the majority are women and children) have gone to see the show. The big top itself is canvas and has been waterproofed with a combination of parafn wax and gasoline (Willow Bend Press, 2007). You do not have the authority to ban canvas that has been waterproofed in this manner. You will need to construct an evacuation plan for the residents in case a fre occurs in the big top. In addition, you will need to plan and 36 ◾ Case Studies in Disaster Response and Emergency Management pre-position frefghting equipment in the vicinity of the circus so that you can respond quickly if a fre does occur. You also need to inform city ofcials about the danger of having such a structure for public events since the tent is highly fammable. The organizers of the circus should be made to comply with fre codes that require all exits to be marked and cleared of obstructions. As the fre chief, you will need to have frefghting vehicles and ambulances on standby in case an emergency does occur. In addition, medical supplies and fre extinguishers should be on hand and available at the circus. Stage 2 of the Disaster As the show begins, a fre has started on the canvas of the big top tent, which sends thousands running for their lives as the fre quickly engulfs the structure (Willow Bend Press, 2007). As the evacuation progresses, you realize that the crowd is evac- uating toward the fre (Brown, 2008). Furthermore, you notice that several of the exits are blocked by animals that are in cages (Willow Bend Press, 2007).
The other area of fed view of any perceived abnormalities of the vulva delayed information is the symptom of vaginal dry- and vagina generic 10mg toradol visa pain treatment clinic. Use of a camera provides pictures as a ness or discomfort with intercourse that too often baseline for comparison when the patient returns is broached for the frst time after completion of for follow-up after treatment order toradol in india pain treatment center albany ky. To address this issue, a reexami- tract anatomical changes, such as a urethral car- nation can be done. These caruncles can the twenty-frst century are not forthcoming about vary in size, and the degree of infammation ranges private matters¸ particularly their recent sexual his- from slight to extreme (Figures 12. These women should be immediately assured the question can be varied to help elicit the needed that the new growth is a result of estrogen lack information. Many of these women will complain she might share important medical information of pain and burning after urination. In every case, the physician’s willingness to listen is more important than any history-taking ritual. Any information obtained will specifcally target a physi- cal examination focus and direct the physician to obtain appropriate laboratory studies. In this diagnostic evaluation, it is also important to get a detailed medical history and current use of drugs by these patients. Women with a history of breast or endometrial cancer will not ordinarily be candidates for systemic or local estrogens. Some liver illnesses, such as cirrhosis from a chronic hepa- titis B or C infection, can preclude the use of oral estrogens as a treatment option. If local estrogens have been used, inqui- ries need to be made to see if the patient has had any adverse reactions to them. They can cause severe vaginal or vulvar burning after the application of an estrogen cream that contains propylene glycol as a preservative. In these situations, the vaginal estro- gen tablet that has no propylene glycol would seem to be an ideal choice, but menopausal women with reduced vaginal secretions can develop vaginal or vulvar irritation within a day or two of inserting the vaginal estrogen tablet from the gritty discharge of an incompletely dissolved tablet. The physical examination of the menopausal woman should be a cooperative effort of the doctor and patient. These problems occur more often in and touching it gently with a cotton-tipped applica- the winter months, with cold air outside and dry tor stick elicits a pain response. They take many area is prone to tear again with every attempt at forms (Figures 12. The diag- complaining of new growths in her private area was nosis can be made by a careful examination of the found to have a genital outbreak of condyloma acu- vulva with cotton-tipped applicators touching the minata (Figure 12. The diagnosis should be con- precancerous vulvar intraepithelial neoplasia 3 frmed by biopsy (Figure 12. The clinical diagnoses of vulvar multiplication, with resulting tissue infammation dystrophy, condyloma acuminatum, and precan- and patient symptomatology. One tion must be done in women with chronic vulvar patient complaining of perineal pain 1–3 days after changes, before any new long duration of therapy intercourse had a painful cluster of lesions, which is contemplated. This was her frst recognized followed by a thorough visual perusal and the use clinical outbreak, and it had been preceded by an of microscopic studies of vaginal secretions and asymptomatic primary infection. These fragile vascular structures are sometimes the source of an increased vaginal discharge. Women with a history of breast cancer who are tak- ing tamoxifen citrate have immature squamous cells present, with an increased number of white cells (Figure 12. Laboratory testing should be individualized to ft the diagnostic needs of each patient. During the suggested 3-year inter- vals between cytologic studies, precancerous cervi- cal changes can occur that will require colposcopy, biopsy, or conization procedures for these patients. Patients present with persis- tent vulvar burning and itching with an increase in their symptomatology every time they urinate. In women not taking estrogen systemically or These women are excellent candidates for local locally, the pH is usually alkaline. Then, the micro- estrogen therapy after a Candida infection is ruled scopic examination is performed. An estradiol cream ration often shows immature squamous cells and can be prescribed that patients apply to the infamed many white cells (Figure 12. Local adrenocor- cal examination, a variety of antiviral agents can ticoid creams or ointments are indicated if there is be immediately prescribed while waiting for the lab widespread infammation or lichen sclerosus is pres- report. The V-600 imaging system that enables the in the perineal area, which on biopsy are shown to observer to view tissue two cell layers under the sur- be condyloma acuminata (Figure 12. A variety face is a great aid in determining the extent of vulvar of ablative techniques or the use of locally applied infammation before and during steroid therapy. If a local yeast infection is confrmed, a In addition to the readiness to culture any infam- local nystatin cream can be ordered. If this causes matory lesions, the physicians must be prepared to a local contact dermatitis, oral fuconazole therapy biopsy any new suspicious growths on the vulva. After this treatment, local steroids can be a variety of treatment options are available to the prescribed. The usual course is close Postmenopausal women with infections of the observation over time with repeated biopsies to be vulva should be managed with specifc care directed sure there has been no progression of the lesions toward the pathogen identifed by laboratory stud- in this area. If any of these women complain of the sudden of the vulva is confrmed by biopsy (Figures 12. These gynecologic oncologist so that vulvar resection and may be clinically obvious lesions (Figure 12. These ing of a vaginal discharge or vaginal burning requires cases demonstrate the importance of obtaining a an accurate diagnosis for there can be a variety of Vulvovaginal Infections 134 etiologies for these symptoms. Symptoms due to the A large group of postmenopausal patients com- presence of an endometrial polyp (Figure 12. On examination, they have other, uncommon, benign causes of an increase in an alkaline vaginal pH, a negative whiff test, and on vaginal symptoms in these women. Rarely, a foreign microscopic examination, immature squamous cells, body is found, and when it is removed, the patient an increased number of white cells, and a diminu- becomes asymptomatic. If the cultures grow no Candida Vaginal infections in these menopausal women and no bacterial pathogens, a local form of estrogen should be based upon laboratory fndings. If the iso- this estrogen therapy improved the bacterial fora of late is Candida krusei or Candida glabrata, local these women, it was not as effective as a daily dose or oral azoles are not indicated, and a regimen with of oral nitrofurantoin in preventing urinary tract local boric acid is begun for a 2-week treatment infections in this population. The microscopic examination intravaginal estradiol cream given daily for 2 weeks of the saline preparation shows immature squa- is usually effective. If the patient has had a reaction mous cells and an infammatory response with an to the cream in the past or has a reaction with cur- increased number of white cells (Figure 12. Local estrogen, which should reverse this pro- who cannot or will not take estrogen, vaginal acid cess, is usually not indicated. The periodic use of gels can be employed, supplemented with the vaginal an acidic vaginal gel helps some patients, but relief use of vaginal boric acid once or twice a week. This always comes when the tamoxifen citrate therapy is maintains the normal acid state of the vagina for a terminated. The introduction of new, more effective time and does result in a diminution of the vaginal agents, such as exemestane, should reduce the over- symptoms in many of these women.