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Except for a case of coronary thrombosis purchase cytoxan 50 mg medications not to crush, it is possible to defibrillate almost all fibrillating heart order cytoxan visa symptoms of strep throat. Sometimes the electric current becomes inadequate and in these cases complete defibrillation may not be possible generic cytoxan 50 mg line medicine for diarrhea. Cases of inadequate electric current include low voltage applied, defective electrodes and the manner in which electrodes are applied to the heart. These cases should be treated by mild hypothermia lowering the body temperature to 33° to 34°C. Careful monitoring of cardiac rhythm with an oscilloscope is essential as arrhythmias are not uncommon following restoration of cardiac arrest. In these cases intravenous administration of Lidocaine 1 mg per minute and procainamide is useful for suppressing cardiac arrhythmias. Renal damage is another complication of cardiac arrest due to less vascular flow to the kidneys. If renal activity is impaired, measures described under renal anuria should be instituted. Various other diseases such as pneumonia, hypotension, renal failure and cancer when previously exist in these patients, survival rate obviously will not be encouraging. On the other hand cardiac arrest in an otherwise healthy individual can be managed effectively as mentioned above. Precise cardiac surgery has been made possible by detail informations of the diseased heart through various special investigations. A few special views from different angles may indicate enlargement of a particular chamber of the heart e. This has been described in details under special investigation of various cardiac conditions later in this chapter. Certain amounts of functions of the cardiac chambers may also be assessed with this investigation. Conditions like coarctation of aorta, calcified valves may be detected through this investigation. With this technique important anatomical examination regarding size and shape of the different heart chambers, presence of a shunt or septal defects and function of different valves can be obtained. The aorta and the pulmonary artery and its branches are also visualised in detail. Selective angiocardiography is possible to delineate the anatomy of the coronary arteries in patients with angina. Atherosclerotic plaque in the artery, its correct size and extent and collateral circulation can be well assessed using Neopam 370 with a dose of 4 to 6 ml per selected coronary artery. In the 3rd period catheterisation techniques were modified and extended to allow the angiographer to treat cardiac disease as well as to diagnose it Access to the vena cava and right heart chambers can be attained either percutaneously or by surgical venotomy. Percutaneous right heart cannulation is usually done via the femoral vein, whereas venotomy is performed at the antecubital fossa. Right heart catheterisation can also be done from the internal or external jugular or subclavian veins. Cannulation of the left heart is performed percutaneously from the femoral artery or by surgical cut down on the brachial artery. Occasionally the left heart chambers are approached from the right atrium via the right femoral vein using a technique known as transseptal catheterisation. This procedure involves puncture of the interatrial septum with a special catheter. Most catheters are composed of Woven Dacron or nylon covered with a radio-opaque plastic coating. The normal haemodynamic values are — Right atrium — 0 to 8 mm Hg; Right ventricle — 5 to 30 mm Hg (systolic) and 0 to 8 mm Hg (diastolic). Pulmonary artery — 15 to 30 mm Hg (systolic); 5 to 15 mm Hg (diastolic); Pulmonary artery wedge — 1 to 12 mm Hg.
If the effusion is massive buy cheap cytoxan 50 mg online medicine school, the mediastinum is shifted to the opposite side causing compression to the opposite lung generic 50mg cytoxan medicine wheel colors. Severe cardiorespiratory embarrassment with cyanosis may also result in massive pleural effusion buy cheap cytoxan on-line medicine man gallery. Diagnostic thoracentesis is indicated in most patients with pleural effusion, unless the cause is already known. Thoracentesis is best done after careful localisation of the effusion by roentgenogram in frontal, lateral and oblique planes or by the use of fluoroscopic image intensifier. After thorough infiltration of the skin, intercostal muscles and the parietal pleural with a local anaesthetic agent, the needle of appropriate calibre and length is directed j ust above the superior border of the lower rib of the appropriate intercostal space. During aspiration low in the costophrenic angle, the needle tip should be directed upwards to avoid puncture of the diaphragm. Removal of all available fluid usually presents no difficulty unless sometimes after complete evacuation of a massive acute effusion, pain, discomfort and severe coughing may be initiated. Usually no more than 1500 ml should be aspirated in first attempt in a case of massive pleural effusion. Here I am giving a short list of the various causes of pleural effusion of surgical interest according to frequency :— 1. Of the above causes, subdiaphragmatic or intra-abdominal pathologies as the cause of pleural effusion deserve special mention. Cirrhosis of the liver and pancreatitis are also known to cause pleural effusion in certain percentage of cases. The method of formation of pleural effusion in these cases are still not clearly known. It may be that passage of fluid from the peritoneal cavity into the pleural cavity occurs through the lymphatics, whereas others hold the view that the passage of fluid occurs through recognised or unrecognised openings in the diaphragm. A collection of purulent fluid in the pleural space is called ‘empyema’ in wider sense. In fact all phases of pleural infection from an infected turbid effusion to a mature abscess containing thick pus are included in this term. The infective process usually extend to the pleura either directly or by the lymphatics, or by blood (haematogenous) spread or by rupture of necrotic pulmonary parenchyma. Lung infection may itself be secondary to bronchial obstruction either due to bronchogenic carcinoma or bronchiec tasis. A ruptured emphysematous bleb with spontaneous pneumothorax may also result in an empyema. So to narrate the sources of infection which may cause empyema are briefly as follows :— (a) Lung (pneumonia, lung abscess, bronchogenic carcinoma, bronchiectasis, tuberculosis). The most common organisms responsible for empyemas are the pneumococci, streptococci and staphylo coccus aureus. The last named organism is gradually moving to the top position so far as frequency of its existence and its virulence are concerned. Staphylococcal empyemas are often becoming antibiotic-resistant and causing real problem to the surgeons. A few gram-negative organisms are also causing empyema and these are Pseudomonas, Klebsiella pneumoniae, Esch. Previously two types of empyema were considered — syn-pneumonic and metapneumonic. The syn-pneuinonic empyema occurs secondary to streptococcal bronchopneumonia and the empyema occurs simultaneous with the bron chopneumonia. In case of empyema the actual pleural infection is preceded by the development of a serous effusion. The next stage is the starting of inflammatory changes in the pleura with exudation of fluid from the pleura. In the next stage fibrin is deposited on the surface of the pleura and the nature will try to encircle the septic area with a barrier of fibrous tissue.
Wegener’s granulomatosis Usually multiple thick-walled cavities with Cavitation eventually occurs in approximately half (Fig C 11-15) irregular inner linings (may eventually become of patients buy 50 mg cytoxan fast delivery symptoms weight loss. Large cavity lesions (arrows) fluid levels (arrows) of squamous cell carcinoma on a film in the left lung of an intravenous drug abuser with septic obtained after two cycles of chemotherapy buy cytoxan cheap medicine in the middle ages. Multiple cavitary nodules Fig C 11-15 throughout both lungs representing Nocardia septic emboli in Wegener’s granulomatosis discount cytoxan 50 mg fast delivery treatment 911. Traumatic lung cyst Single or several thin-walled cavities that may Typically occurs in a peripheral subpleural location contain air-fluid levels. Sarcoidosis Cystic lesions developing on a background of Very uncommon manifestation (should suggest diffuse reticulonodular pulmonary disease. Intralobar Thin- or thick-walled cystic mass that is often Almost invariably arises contiguous to the bronchopulmonary multilocular or multiple. Bronchogenic cyst Solitary thin-walled cystic mass that may Approximately 75% of bronchogenic cysts that are contain an air-fluid level. Congenital cystic Multiple air-containing cysts scattered ir- Expands the ipsilateral hemithorax (depresses the adenomatoid malformation regularly throughout a mass of soft-tissue hemidiaphragm and shifts the mediastinum to the (see Fig C 15-7) density. Large bullae in the right with air-fluid levels (arrows), predominantly involve the upper lung. Laryngeal papillomatosis is a common disease in (Fig C 11-19) children that infrequently seeds distally in the tracheobronchial tree to produce excavating lesions in the lung. Plombage Plastic (lucite) spheres appear radiographically Former therapy for pulmonary tuberculosis that (Fig C 11-20) as multiple perfectly round, cavity-like lucencies. The spheres are often not entirely watertight, so that a small amount of fluid may collect in each. On upright views, the resulting air- fluid levels can simulate cavitation and suggest the incorrect diagnosis of acute infection. Multiple small cysts super- Fig C 11-19 imposed on a diffuse, coarse, reticular pattern. The hilar nodes often calcify and are usually lymphadenopathy associated with ipsilateral parenchymal disease. In lymphangitic spread, there is (Fig C 12-3) generally a diffuse reticular or reticulonodular pattern. Lymphoma Primarily Hodgkin’s disease, which often produces asymmetric bilateral hilar adenopathy. The combination of a focal (open arrow), there is enlargement of anterior parenchymal lesion (arrows) and enlarged right hilar lymph mediastinal lymph nodes (closed arrows). Pulmonary embolism Result of vascular distention by bulk thrombus (not increased vascular resistance in the affected lung). Pulmonary artery coarctation Poststenotic dilatation of the affected pulmonary artery. Pulmonary arteriovenous Enlargement of hilar vessels is due to increased blood flow on the affected side. There is often evidence fistula of single or multiple parenchymal nodules with characteristic feeding arteries and draining veins. Normal variant Prominence of the left pulmonary artery occurs in adults younger than 30 (especially women). Also cyanotic admixture lesions (transposition of great vessels, persistent truncus arteriosus). Pulmonary arterial Bilateral enlargement of central pulmonary Primary or secondary to such conditions as wide- hypertension arteries with rapid tapering and small peripheral spread peripheral pulmonary emboli, Eisen- (Fig C 13-7) vessels. Also cardiac enlargement (especially menger’s syndrome (reversed left-to-right shunt), the right ventricle). Rare causes include metastases from trophoblastic neoplasms, immunologic disorders (Raynaud’s phenomenon, rheumatoid disease), schistosomiasis, multiple pulmonary artery stenoses or coarctations, and vasoconstrictive diseases. Fig C 13-3 Ossified metastases to hilar lymph nodes bilaterally from osteogenic sarcoma. Pulmonary venous Bilateral enlargement of central pulmonary Causes include left-sided heart failure and mitral hypertension veins associated with cardiomegaly and cephali- stenosis. Primary polycythemia Generalized bilateral increase in central and Increased blood volume produces prominence of peripheral pulmonary vascularity. Intravascular thrombosis may cause pulmonary infarctions that appear as focal consoli- dations or bands of fibrosis.
The daily output of potassium in the urine is closely related to the dietary intake purchase cheap cytoxan line 10 medications doctors wont take. This loss is highest during the first day following trauma buy discount cytoxan 50 mg treatment dynamics, but this duration depends directly with the degree of trauma and tissue damage cheap 50 mg cytoxan overnight delivery symptoms 89 nissan pickup pcv valve bad. The students must remember that in the immediate postoperative period there is excessive loss of potassium, but the sodium is conserved. If nasogastric aspiration is continued for a long time with fluid replacement by intravenous isotonic saline solution there is chance of potassium depletion. The patient lies in bed with the head drooping down on one shoulder and the jaw and cheeks hanging slack. Potassium depletion causes diminished motility of the intestinal musculature, which results in the accumulation of intestinal secretions. This in turn stimulates further secretion and more potassium is thereby lost into the lumen of the intestine. This causes ileus and abdominal distension which are common features of potassium deficiency in the postoperative period. It must be remembered that in sodium depletion also the blood pressure is reduced, but there is increase in the pulse rate and the peripheral veins are poorly filled. The electrocardiographic changes are particularly peculiar to potassium deficiency, but they do not seem to be closely related either to the severity of deficiency or to the serum potassium concentration. Potassium depleted patients are often very thirsty and may drink large quantity of fluid. Potassium chloride in the form of effervescent tablets may be given by mouth in the doses of 2 gm 6 hourly. Oral administration of potassium is always chosen first, to avoid the danger of increase of potassium concentration with intravenous administration of solutions of potassium salts. When the patient is comatose or nauseated and has difficulty in swallowing, intravenous administration is unavoidable. Infusion of as little as 1 gm of potassium chloride may lead to the recovery of consciousness. One must be careful to prevent increase of potassium concentration above 7 mEq/L in the extracellular fluid. One must ensure adequate flow of urine before administering potassium intravenously. When alkalosis is present, which is often an accompaniment of potassium deficiency in case of excessive vomiting and high small intestinal fistulas, potassium chloride should be administered. If the urinary volume is adequate, 2 gm of potassium chloride may be administered intravenously over a period of 4 hours. Alternatively potassium chloride may be administered dissolved in glucose solution — 20 ml of 10% solution of potassium chloride in 500 ml of 5% glucose solution. When there is associated acidosis, which is commonly seen in diarrhoea and low intestinal fistulas, the intravenous solution should contain sodium acetate in addition to potassium chloride. If given orally, potassium citrate should be administered by mouth in the dose of 2 gm every 6 hours. Intravenous administration of potassium salt is dangerous and should not be treated as a matter of routine. The quantity to be given and the rate of its administration should be carefully monitored. Hyperkalaemia is mainly iatrogenic and is due to excessive intravenous infusion of potassium salts. This is usually associated with (i) severe oliguria or anuria, and (ii) reduction in the volume of extracellular fluid may raise the potassium concentration. The gastrointestinal symptoms include nausea, vomiting, intermittent intestinal colic and diarrhoea. The cardiovascular signs are low heart rate with irregular beats, low blood pressure, poor peripheral circulation and cyanosed skin.
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