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The intraosseous space is a noncollapsible venous plexus and its cannulation takes 30-60 sec heart attack 36 discount zebeta 10mg amex. The recommended cannulation sites include the anterior tibia blood pressure medication at night cheap 5 mg zebeta with visa, distal femur blood pressure chart for age 50+ buy cheap zebeta 2.5mg on line, medial malleolus and anterior superior iliac spine pulse pressure medscape zebeta 5mg on line. The recommended dose for epinephrine for the unconscious, asystolic, pulseless cardiopulmonary arrest patient: initial dose 0. Amiodorone/5mg/kg/ may be considered in the treatment algorithms for supraventricular and ventricular arrhythmias. Vagal maneuvers have been added to the treatment protocol for supraventricular tachycardia for children who are hemodynamically stable and/or being prepared for cardioversion. Utilization of vagal maneuvers must not delay cardioversion or administration of adenosine for children with poor perfusion state. The most effective vagal stimulant in infants and children is the application of a bag with ice/ice water to the face. Ambulatory anesthesia for the pediatric patient About 70% of all pediatric surgical cases are done on ambulatory basis. Children are very good candidates for ambulatory surgery because majority of them are healthy, surgical procedures are simple and recovery period is short. Avoiding hospitalization for children is very beneficial minimal separation from parents, less risk of exposure to hospital infections. Patient selection criteria: the most important for selecting a child for ambulatory surgery are the physical status of the patient, and the type of surgical procedure. These factors should be also combined with how well facility is equipped and the ability to deal with complications. The child preferred to be in good health or any systemic disease must be optimized or under good control. For example, the premature infant is not a good candidate for ambulatory surgery because of immaturity of respiratory center, temperature control, and gag reflex. The age at which a former premature infant (ex-preemie) is no longer at increased risk for postoperative apnea is controversial and should be considered individually. When the pediatric patient looks toxic, has fever and you can not rule out lower respiratory infection and possible pneumonia elective cases should be postponed, surgeon informed; chest x-ray may be advisable and ambulatory treatment by primary pediatrician should be instituted. Asthma is common chronic disease of childhood, and many pediatric patients with asthma being scheduled for ambulatory surgery. Children with moderate asthma who do require daily medications to control their symptoms should be instructed to continue their medications until the morning of surgery. Sometimes glycopyrrolate (robinul) or small dose of steroids (for patients who are on steroid containing inhaler) may be beneficial in these patients, specifically when they have some respiratory infection symptoms. Information is sought concerning past or present risk factors like prematurity, chronic cardiac or pulmonary conditions and so forth. Many ambulatory centers have presurgical orientation programs when pediatric patients coming few days before surgery to facility and getting a tour with explanations. Inhalation induction is a popular choice for ambulatory surgery in children and sevoflurane is induction agent of choice. Sometimes after induction with sevoflurane anesthesia provider may switch to isoflurane for maintenance. Maintenance of anesthesia with sevoflurane too possible but risk of emergence delirium should be entertained. Combination of propofol with lidocaine is recommended to decrease pain on injection. Propofol infusion may be combined with inhalation agent and may prevent nausea and vomiting, specifically in strabismus surgery. Other antiemetic drugs may include: zofran, low dose of dexametasone, phenergan, compazine. Postoperative analgesia: preference for acetaminophen, total daily dose should not exceed 100 mg/kg. Potent narcotic analgesics: short acting should be preferred (fentanyl is drug of choice often). Regional analgesia like field block and other peripheral blocks provide excellent postoperative pain relief and early ambulation and extremely important in pediatric ambulatory surgery. Analgesia and sedation for children outside of the operating room Analgesia and sedation outside of the operating room also in offices and free standing medical facilities becoming more prevalent for pediatric patients and requires special approach and protocol. Some procedures are associated with loss of airway reflexes and are at increased risk of complications.
The adrenal medulla pulse pressure 73 purchase zebeta amex, derived from the neural crest hypertension stage 1 jnc 7 order zebeta 10mg without a prescription, synthesizes epinephrine and norepinephrine (see figure on the following page) arteria basilaris purchase zebeta 2.5mg amex. Most of the blood that reaches the adrenal medulla has passed through the adrenal cortex and contains glucocorticoids that regulate the norepinephrine/epinephrine balance in the adrenal medulla through regulation of phenylethanolamine-Nmethyl-transferase hypertension vs hypotension order zebeta once a day. The fetal adrenal cortex functions to produce dehydroepiadrosterone, an androgen that is transported to the placenta where it serves as a precursor of estrogen. The gland is covered by a connective tissue capsule and divided into a cortex containing steroid-producing cells with prominent lipid droplets and a medulla containing chromaffin cells that secrete catecholamines and neuropeptides. Congenital virilizing adrenal hyperplasia results from the deficiency of an enzyme required for cortisol production. The thyroid gland is characterized by an extracellular hormone precursor (iodinated thyroglobulin) stored in its follicles. The follicular cells endocytose the storage product to form the thyroid hormones [triiodothyronine (T3) and thyroxine (T4)]. Scattered between the follicular cells are High-Yield Facts 33 "C" cells (parafollicular cells), which secrete calcitonin, a hormone that reduces blood calcium levels. Binding of antibodies to those molecules interferes with their uptake and function respectively. Infiltrating T cells and autoantibodies destroy the thyroid follicular cells resulting in hypothyroidism. The result is unregulated activation of the receptor and overproduction of thyroid hormones (hyperthyroidism). The pineal gland contains pinealocytes that secrete melatonin and is innervated by postganglionic sympathetic fibers. Endocrine cells of the pancreatic islets secrete primarily insulin and glucagon, hormones that regulate blood sugar by lowering and increasing gluocse respectively. Blood entering the islets bypasses the peripherally located glucagonsecreting cells to reach the more centrally-located insulin-producing beta cells. Blood leaving the beta cells contains insulin that influences glucagon secretion from the alpha cells. Blood leaving the islets travels to the surrounding exocrine pancreas and influences secretion from the acini. The beta cells are overworked and eventually lose their ability to secrete enough 34 Anatomy, Histology, and Cell Biology insulin in response to meals. Epithelial cells of the proximal tubule are specialized for absorption and ion transport. They remove most of the sodium and water from urine, as well as virtually all of the amino acids, proteins, and glucose. The cells of the distal tubule, under the influence of aldosterone, resorb sodium and acidify the urine. Transitional epithelium (allowing for stretch) is found lining the calyces, renal pelvis, ureters, and urinary bladder. Spermatogenesis involves the following lineage: spermatogonia (germ cells) (spermatocytogenesis) primary spermatocytes secondary spermatocytes (completion of meiosis) spermatids (spermiogenesis) mature sperm. Sertoli cells perform several functions: (1) maintenance of the blood-testis barrier, (2) phagocytosis, and (3) secretion of androgen-binding protein and inhibin, as well as Mьllerian inhibiting hormone in the fetus. The epididymis, like most of the male duct system, is lined by a pseudostratified epithelium characterized by modified microvilli (stereocilia). High-Yield Facts 35 the seminal vesicles produce fructose and other molecules that activate spermatozoa. The prostate is a fibromuscular organ that produces the enzymes responsible for the liquefaction of the ejaculate. Oocyte (germ cell) maturation involves several stages of follicular development (granulosa cells plus the oocyte): primordial follicle primary follicle secondary follicle mature, or Graafian, follicle. The theca interna synthesizes androgens, which are converted into estradiol by granulosa cells. After ovulation, these thecal cells form the theca lutein; the granulosa cells become the granulosa lutein, which produces progesterone (see figure below). During this phase, endometrial cells accumulate glycogen preliminary to the synthesis and secretion of glycoproteins. The vaginal epithelium is made up of stratified squamous cells and varies with maturity, phase of the menstrual cycle, pregnancy, and cancer (detected by vaginal Pap smear). During parturition, oxytocin secreted by the neurohypophysis stimulates the contraction of uterine smooth muscle.
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Apply the most advanced principles of binocular vision and amblyopia (eg exo heart attack order discount zebeta on-line, physiology of binocular vision blood pressure medication cause erectile dysfunction buy zebeta cheap online, diplopia blood pressure medication lisinopril purchase discount zebeta line, confusion and suppression blood pressure reading chart buy zebeta mastercard, normal and abnormal retinal correspondence, classification and characteristics of amblyopia). Recognize and treat complex pediatric retinal diseases (eg, inherited retinopathies). Recognize and treat complex pediatric cataract and anterior segment abnormalities (including surgical implications, techniques, and complications). Recognize and treat complex pediatric eyelid disorders (eg, congenital deformities, lid lacerations, lid tumors). Recognize and treat (or refer for treatment) pediatric orbital diseases (eg, orbital tumors, orbital fractures, rhabdomyosarcoma, severe congenital orbital malformations). Describe screening strategies for childhood blindness at the community level and intervention. Perform more complex extraocular muscle surgery (eg, vertical and horizontal muscle surgery, including superior oblique procedures, transpositions, reoperations). Describe indications and contraindications for more complex strabismus surgery (eg, post scleral buckle and post cataract, thyroid related strabismus). Describe and perform preoperative assessment, intraoperative techniques, and describe postoperative complications for more complicated strabismus surgery (eg, reoperations, stretched scar, slipped muscle, lost muscle). Describe indications for and perform adjustable sutures in more complicated cases (eg, thyroid ophthalmopathy). Describe and manage more complex complications of strabismus surgery (eg, globe perforation, corneal dellen, inclusion cysts, endophthalmitis, overcorrection, undercorrection). Perform more complex strabismus procedures (eg, Faden sutures, posterior myopexy, Yokoyama muscle union, "Y" splitting). Describe basic principles of retinal anatomy and physiology (ie, basic retinal and choroidal anatomy, retinal and choroidal physiology), with emphasis on macular anatomy and physiology. Describe pathological anatomy, physiopathology, and clinical pictures of the most common vascular diseases:** a. Describe features of different types of retinal detachment (ie, rhegmatogenous, tractional, exudative). Describe typical features of retinitis pigmentosa, main macular dystrophies (eg, Stargardt, Best, cone dystrophy), and other hereditary pathologies. Describe basic principles of laser photocoagulation (eg, laser response to change in power, duration, and spot size) and photodynamic therapy for retinal treatment. Diagnose, evaluate, and treat (or refer) postoperative/posttraumatic endophthalmitis. Perform slit-lamp biomicroscopy with precorneal lenses, 3-mirror contact lenses, or other wide-field contact lenses. Describe the fundamentals of retinal electrophysiology and basic ophthalmic echography. Diagnose, evaluate, treat (or refer) the following retinal vascular diseases:** a. Describe the findings of major studies in vascular retinal diseases, including the following:** a. Describe the fundamentals of, evaluate, and treat (or refer) peripheral retinal diseases and vitreous pathologies (eg, vitreous hemorrhage, posterior vitreous detachment, retinal tears, giant retinal tears, lattice degeneration with atrophic holes). Describe the techniques for retinal detachment repair, including indications, mechanics, instruments, basic techniques, and surgical adjuvants, including heavy liquids, expandable gases, and silicone oil for the following: a. Diagnose, evaluate, treat, and classify open and closed globe trauma (eg, Birmingham Eye Trauma Terminology System). Describe, evaluate, and treat (or refer) postoperative/posttraumatic choroidal detachments and sympathetic ophthalmia. Describe, recognize, and evaluate hereditary pathologies, such as juvenile retinoschisis and choroidal dystrophies (eg, choroideremia, gyrate atrophy). Describe the indications/complications for and perform basic laser treatment for diabetic retinopathy (eg, panretinal photocoagulation, macular grid). Perform ophthalmoscopic examination with contact lenses, including panfunduscopic lenses. Diagnose the presence of pigment granules in the anterior vitreous (ie, Shafer sign) during a retinal detachment or retinal break. Interpret basic echographic patterns (eg, rhegmatogenous retinal detachment, tractional retinal detachment, posterior vitreous detachment, choroidal detachment, intraocular foreign body).
The glandular buds grow into the surrounding connective tissue and branch to form the primordia of several alveoli and their associated ducts arrhythmia books discount zebeta online mastercard. The central cells of the alveoli break down hypertension updates purchase 2.5 mg zebeta fast delivery, forming an oily secretion-sebum-that is released into the hair follicle and passes to the surface of the skin blood pressure quizzes purchase zebeta in united states online, where it mixes with desquamated peridermal cells to form vernix caseosa hypertension patient education order zebeta overnight. Note that the sebaceous gland develops as an outgrowth from the side of the hair follicle. They develop as epidermal downgrowths (cellular buds) into the underlying mesenchyme (see. As the buds elongate, their ends coil to form the primordium of the secretory part of the gland. The epithelial attachment of the developing gland to the epidermis forms the primordium of the sweat duct. The peripheral cells of the secretory part of the gland differentiate into myoepithelial and secretory cells (see. The myoepithelial cells are thought to be specialized smooth muscle cells that assist in expelling sweat from the glands. Integration link: Sweat secretion -mechanism the distribution of the large apocrine sweat glands in humans is mostly confined to the axilla, pubic, and perineal regions and areolae of the nipples. They develop from downgrowths of the stratum germinativum of the epidermis that give rise to hair follicles. As a result, the ducts of these glands open, not onto the skin surface as do eccrine sweat glands, but into the upper part of hair follicles superficial to the openings of the sebaceous glands. The skin is characterized by dryness and fishskin-like scaling, which may involve the entire body surface. A harlequin fetus results from a rare keratinizing disorder that is inherited as an autosomal recessive trait. A collodion infant is covered by a thick, taut membrane that resembles collodion or parchment. This membrane cracks with the first respiratory efforts and begins to fall off in large sheets. Complete shedding may take several weeks, occasionally leaving normal-appearing skin. A newborn infant with this condition may first appear to be a collodion baby, but the scaling persists. Affected infants often suffer severely in hot weather because of their inability to sweat. Figure 19-4 Illustrations of the successive stages of the development of a sweat gland. A and B, the cellular buds of the glands develop at approximately 20 weeks as a solid growth of epidermal cells into the mesenchyme. D, the peripheral cells differentiate into secretory cells and contractile myoepithelial cells. B, A child with severe keratinization of the skin (ichthyosis) from the time of birth. Mario Joao Branco Ferreira, Servico de Dermatologia, Hospital de Desterro, Lisbon, Portugal. Joao Carlos Fernandes Rodrigues, Servico de Dermatologia, Hospital de Desterro, Lisbon, Portugal. Ectrodactyly-Ectodermal Dysplasia-Clefting Syndrome Ectrodactyly-ectodermal dysplasia-clefting syndrome is a congenital skin condition that is inherited as an autosomal dominant trait. It involves both ectodermal and mesodermal tissues, consisting of ectodermal dysplasia associated with hypopigmentation of skin and hair, scanty hair and eyebrows, absence of eyelashes, nail dystrophy, hypodontia and microdontia, ectrodactyly, and cleft lip and palate. Angiomas of Skin these vascular anomalies are developmental defects in which some transitory and/or surplus primitive blood or lymphatic vessels persist. Those composed of blood vessels may be mainly arterial, venous, or cavernous angiomas, but they are often of a mixed type. Angiomas composed of lymphatics are called cystic lymphangiomas or cystic hygromas (see Chapter 13).
Staphylococcus aureus is usually the causative organism in patients 2 months to 1 year old blood pressure hypotension purchase 10mg zebeta amex. Along with Bartonella henselae (cat-scratch disease) and nontuberculous mycobacteria hypertension 8 weeks pregnant buy zebeta without prescription, S heart attack unnoticed buy zebeta with a visa. These organisms can be the cause of cervical adenitis in older patients along with tuberculosis arteria 2013 purchase discount zebeta online, anaerobic bacteria, and toxoplasmosis. The timeframe is also an important factor to consider when determining the etiology of cervical adenitis. Acute bilateral disease is usually a response to acute pharyngitis, but can also occur with Epstein-Barr virus, cytomegalovirus, herpes simplex virus, roseola, and enteroviruses. Acute unilateral lymphadenitis commonly presents with an associated cellulitis and is typically caused by S. Symptoms Patients can present with unilateral or bilateral neck swelling, with or without any other symptoms. Malignancy is an important consideration in patients with no other signs of infection, recent weight loss or fevers, or those with isolated supraclavicular involvement. Noninfectious causes are much less common and include Kawasaki disease, sarcoidosis, sinus histiocytosis, histiocytic necrotizing lymphadenitis, and Kimura disease. N Evaluation Physical Exam Cervical lymphadenitis typically presents with acute unilaterally or bilaterally enlarged (3 cm) and tender lymph nodes in the jugulodigastric area. Atypical mycobacteria infection generally presents with an enlarged erythematous single mass, distinct from reactive adenopathy or fluctuant abscess. Pediatric Otolaryngology 567 Imaging Imaging is not necessary if cervical lymphadenitis is suspected based on history and physical exam findings. Cervical lymphadenitis will manifest as enlarged, enhancing nodes with low central attenuation if necrosis is present. Other laboratory studies, including Gram staining, acid-fast staining, and culture, can be done if aspiration is undertaken. Obtain the aspirate from the largest, most fluctuant node using a 23- or 20gauge needle. The etiology is discovered in 60 to 90% of patients who undergo needle aspiration. Excisional biopsy is indicated if the node is hard, fixed, fails to regress following aspiration or antibiotic use, enlarges, or is associated with fever or weight loss, or if the diagnosis is uncertain. Placing a portion of the specimen in a flow cytometry medium is important if lymphoma evaluation is required. N Treatment Options Medical Patients who have asymptomatic, small (3 cm), bilaterally enlarged cervical lymph nodes can be observed. Those with signs and symptoms typical of acute bacterial lymphadenitis (large, tender, erythematous unilateral node with no systemic symptoms) can be treated empirically for S. If cellulitis is present or if the patient is having severe symptoms, parenteral nafcillin, cefazolin, or clindamycin is appropriate. When lymphadenitis is secondary to dental infection, anaerobic infection should be suspected and clindamycin or penicillin plus metronidazole is effective. Azithromycin, trimethoprimsulfamethoxazole, or rifampin is effective early in the course of disease in preventing abscess formation if cat-scratch disease is suspected. Children 40 kg: 2545 mg/kg/day divided every 12 hours using either 200 mg/5 mL or 400 mg/5 mL suspension. Children 40 kg and adults 875 mg twice daily Clindamycin: Inhibits bacterial protein synthesis by binding to bacterial 50S ribosomal subunits G Children 16 years Oral: total dose of 825 mg/kg/day in 34 divided doses Parenteral: 1520 mg/kg/day G Adults Oral: 300 mg three times daily Parenteral: 1. Trimethoprim inhibits dihydrofolic acid reduction and sulfamethoxazole interferes with dihydrofolic acid. G Children 2 months Total dose trimethoprim 812 mg/kg/day in divided doses every 12 hours or 20 mg/kg/day in divided doses every 6 hours for serious infections G Children 40 kg or adults Oral: Trimethoprim 160 mg every 12 hours Parenteral: Trimethoprim 2 mg/kg every 6 hours Surgical Incision and drainage is useful if there is an abscess, especially due to S. Surgical excision or curettage is effective if nontuberculous mycobacterial infection is the cause. Removal of the largest node and necrotic nodes is sufficient because the remaining adenopathy will resolve spontaneously. N Complications Infection control is essential if a postoperative complication occurs.
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