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Primary Raynaud phenomenon usually starts at a young age (teenage to blood pressure by age group order 0.25mg digoxin with visa 20s) and improves with aging blood pressure medication and weight gain purchase 0.25 mg digoxin fast delivery. These include diseases that damage blood vessels blood pressure medication names starting with a purchase digoxin online from canada, alter the nervous control of blood vessels or are associated with abnormal circulating factors high blood pressure medication and zyrtec 0.25mg digoxin. The most common diseases associated with Raynaud phenomenon are the rheumatic diseases, especially scleroderma, mixed connective tissue disease, systemic lupus erythematosus, Sjren syndrome, and dermatomyositis. Approximately 95 percent of those diagnosed with scleroderma have Raynaud phenomenon. These nerves sense the ambient temperature and relay this information to the central nervous system. The brain then sends a signal through the sympathetic nervous system to skin blood vessels to constrict if it is cold and dilate if it is warm. Sensory nerves in the skin also directly release small peptides that can alter blood flow. Studies suggest that in some there is a reduced release of vasodilators from sensory nerves. Raynaud phenomenon is a clinical diagnosis made by a history of cold sensitivity with the associated typical color changes (white, blue, red) of the skin. Patients with Raynaud phenomenon should have a complete history and physical examination to look for any underlying cause for the attacks. Enlarged, dilated or absent nailfold capillaries are noted among patients with scleroderma and other rheumatic diseases. Blood tests are performed if the history or physical examination suggests that secondary Raynaud phenomenon is present. For example, tests for the presence of autoantibodies may be done if an autoimmune disease like scleroderma or systemic lupus erythematosus is suspected. Warming the whole body with loose fitting clothing, stockings, vests, headwear, and gloves is a key strategy. Rapidly shifting from a warm to cold environment or cold damp breezes are very common aggravating factors. Conditioning treatment, temperature biofeedback and relaxation therapy are all non-drug therapies that are still controversial. These drugs include over the counter cold preparations containing sympathomimetics agents. Smoking can worsen attacks, because nicotine decreases blood flow to the fingers and toes. Use of estrogens or non-selective beta blockers is reported to be associated with Raynaud phenomenon, but this is still controversial. If the patient has primary Raynaud phenomenon the attacks are usually mild and do not cause tissue damage, then drug therapy is not needed. Non-drug therapy is very effective and recommended unless the attacks are intense, altering quality of life, and compromising the ability to perform daily activities. Oral prostaglandins are now available but more studies are needed to determine their benefit. Studies suggest that bosentan (an inhibitor of endothelin-1) can reduce the number of new digital ulcers in patients with scleroderma and recurrent digital ulcers but it does not reduce the severity of the Raynaud events. The goal of therapy is to reduce the severity of Raynaud’s events, to improve quality of life and prevent ischemic events. Martino, Messina, Italy 2Department of Neurosciences, Psichiatric and Anesthesiological Sciences, University of Messina, Italy 3Elie Metchnikoff Department, University of Messina, Messina, Italy 4Dipartimento Materno Infantile, Policlinico G. Although they are considered be was performed by combining the terms nign diseases as a whole, some rheumatic dis (haemophagocytic, haemophagocytosis, hemo eases may nevertheless be mortal, especially phagocytosis, hemophagocytic, erythrophagocy 2 those characterized by severe inflammation. If the bone marrow specimen is not conclusive, material may be obtained from other organs. The following findings may provide strong supportive evidence for the diagnosis: (1) spinal fluid pleocytosis (mononu clear cells) and/or elevated spinal fluid protein, (2) histological picture in the liver resembling chronic persistent hepati this (biopsy) 3. Kawasaki 109,253-year-old girl with incomplete Kawasaki disease; 1106-year-old boy; 17 25 disease 111retrospective study 7 cases; 11218-month-old child, respiratory failure, fatal; 113-1152 cases; 116,48,117autoimmune hemolytic anemia; 11832-month-old Japanese boy; 1192 cases; 12014-year-old boy; 121,1225-year-old girl, response to gamma-globulin therapy, ischemic colitis; 123infant of 7 weeks after clinical response to treatment, suddenly died from a myocardial infarction at 11 weeks. Other possible triggers/cofactors were non aspiration for evidence of macrophage hemophago Hodgkin’s lymphoma41, and antimalarial drugs65. Characteristics and long-term histiocytoses: searching for markers of disease outcome of 15 episodes of systemic lupus erythe activity. Reactive hemo cus pneumoniae Spr1875 protein fragments iden phagocytic syndrome in adult systemic disease: re tified using a phage displayed genomic library. Macrophage activation syndrome in [Hemophagocytic syndrome in a patient with sys duced by etanercept in a patient with systemic temic lupus erythematosus]. Sys mary herpes simplex virus 1 infection: report of a temic lupus erythematosus progressing to non first case. Hemo venile systemic lupus erythematosus: a multina phagocytic syndrome in systemic lupus erythe tional multicenter study of thirty-eight patients. Reactive hemophagocytic syndrome in adult mophagocytic syndrome and interstitial pneumo onset Still disease: clinical features and long-term nia with pneumomediastinum/recurrent pneu outcome: a case-control study of 8 patients. Ned Tijdschr Ge occurring in an adult liver transplant recipient neeskd 2010; 154: A2528. Rheuma the initial manifestation of systemic onset juve tology (Oxford) 2003; 42: 800-802. Macrophage activation syndrome after lefluno onset juvenile idiopathic arthritis]. Zhongguo mide treatment in an adult rheumatoid arthritis Dang Dai Er Ke Za Zhi 2007; 9: 610. Hemophagocytic syndrome tivation syndrome in children with systemic-on in a patient with rheumatoid arthritis. Etanercept-induced lupus accom associated macrophage activation syndrome in panied by hemophagocytic syndrome. Rapid and sustained remission of temic onset juvenile idiopathic arthritis with systemic juvenile idiopathic arthritis-associated macrophage activation syndrome misdiagnosed macrophage activation syndrome through treat as Kawasaki disease: case report and literature ment with anakinra and corticosteroids. A case of macrophage acti syndrome in an inadequately treated patient with vation syndrome successfully treated with systemic onset juvenile idiopathic arthritis. Pediatr pheresis for macrophage activation syndrome Infect Dis J 2003; 22: 663-666. Pediatr Blood lymphohistiocytosis in a patient with Kawasaki Cancer 2009; 53: 493-495. J Pediatr hemophagocytic syndrome in a patient with sys Hematol Oncol 2010; 32: 527-531. Pediatr Hematol Oncol 2010; complicated with systemic sclerosis: relationship 27: 244-249. Pediatr Infect ing as pancytopenia: case report and review of Dis J 2008; 27: 1116-1118. It provides metabolic support in the form of growth factors, hormones, and high energy lipids through blood vessels. These functions tend to be exclusive so that connective tissue that is mechanically robust ofers less metabolic and immune support. In contrast, connective tissue that provides metabolic and immune support tends to be weaker. Tendons resist tension and do not stretch making them ideal for linking muscle to bone. Collagen Elastin Glycosamino glycans There are several important molecules that allow connective tissue to generate diferent mechanical properties. In general, these molecules either resist tensile and stretching forces or compressing forces. Elastin also resist tension but behaves similar to rubber in that it can be stretched and will recoil after the force is removed. The dermis of skin contains a large amount of collagen fibers that are less organized and oriented in multiple directions. This allows skin to resist tension in diferent directions but sacrifices its overall mechanical strength. Organs, such as the small intestine, are structurally weaker than tendon because they require connective tissue to provide metabolic and immune support so the connective tissue must contain blood vessels, macrophages, lymphocytes. Most collagens, about 80-90% of total collagen, form fibers that provide the most mechanical strength.

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The autoimmune thyroid diseases blood pressure medication micardis digoxin 0.25 mg for sale, lupus blood pressure chart to keep track 0.25mg digoxin with amex, systemic sclerosis blood pressure chart 15 year old buy 0.25mg digoxin amex, and rheumatoid arthritis usually occur in late reproductive and early-postmenopausal years pulse pressure heart discount digoxin 0.25mg on line, while some other diseases. However, there is considerable variability in the extent of female predominance and no clear relation between degree of female predominance and type of disease or age at onset (Table 7). Animal models suggest that both genetic and environmental factors are important in co-morbidity, and of particular interest is the way in which environmental factors can modify genetic suscep tibility. Data pertaining to co-morbidity of autoimmune diseases in humans are surprisingly sparse. One study of the household showed that those living with subjects suffering from systemic lupus erythematosus were more likely to have related autoantibodies (DeHoratius et al. The study was not able to fully distinguish between a genetic and environmental relationship, but it raises many intriguing ques tions. Important issues with respect to interpreting these types of studies include the type of test used and definition of a “positive” result. In the recent population based sample in the United States, approximately 18% of people ages 12–80 who were not taking thyroid medications and did not report a history of thyroid disease or goitre had one or both of these antibodies. In the Pima Indians, a population with an extremely high incidence of rheumatoid arthritis, the prevalence of rheumatoid factor is higher in females than in males (Enzer et al. There are limited, and somewhat conflicting, data comparing prevalence of high-titre antinuclear antibodies by sex (Craig et al. None of these studies was able to provide data pertaining to ethnic differences in the prevalence of antinuclear antibodies. We do not currently have data pertaining to the predictive ability of antinuclear antibodies with respect to development of lupus. A complex relation is seen between dietary iodine and prevalence of antithyroid antibodies, with increased prevalence reported in relation to iodine deficiency and to excess intake. Smoking history has been associated with the prevalence of rheumatoid factor in several studies (Regius et al. These studies reported an increased prevalence of rheumatoid factor among smokers. With respect to thyroid antibodies, however, smoking was associated with a decreased prevalence of antithyroid peroxidase antibodies in a study of 759 women in the Netherlands (Strieder et al. Anti-glutamic acid decarbox ylase antibodies were also found at an increased prevalence among these workers (Langer et al. There are also other studies on pesticide immunotoxicity following exposure to the pesticide mancozeb (Colosio et al. Small studies examining pentachlorophenol (McConnachie & Zahalsky, 1991; Colosio et al. The 96 Mechanisms of Chemical-Associated Autoimmune Responses multifactorial nature of the process may explain why only relatively few patients develop adverse clinical responses. Mechanisms through which chemicals cause sensitization of the immune system are very diverse, but they can mostly be categorized according to the general strategy that is followed by the immune system (Janeway & Medzhitov, 2002; Hoebe et al. Once sensitized, T cells may activate various effector mechanisms that in turn may cause protective immunity or, depending on the antigen that is recognized and under certain circumstances, adverse. For instance, chemicals may interfere with antigen-specific stimulation (signal 1) by forming neoantigens (section 7. Based on these findings, the pharmacological interaction concept has been formulated (Pichler, 2002). From these findings, it can be inferred that drug-induced T cells can also react with autoantigens through cross-reactivity. As a consequence of tissue damage, however, antigens may be released in the system, and naive specific T cells may become activated. Foreign proteins as well as self-proteins contain dominant and cryptic epitopes (Sercarz et al. T cells that recognize dominant epitopes with too high an affinity or avidity have a high chance of being eliminated during the intrathymic selection process, whereas T cells that are specific to cryptic epitopes will usually not encounter their epitope in the thymus. Hence, these T cells will not be eliminated in the thymus and appear in the peripheral system. In addition, immune responses need to be quantitatively and qualitatively opti mal and eventually cease to be operational when the antigen vanishes. Twenty days later, immune alterations are again mostly at control levels, and the effects on the kidney (for instance, proteinuria) are clearly less than on day 10 (Aten et al. It appeared in this case that low-dose pretreatment prevented all clinical signs of autoimmunity in 60–80% of rats that were sub sequently treated with a high and usually pathogenic dose of D penicillamine. The present thought is that many drugs that cause sensitization undergo bioactivation by metabolizing enzymes (Uetrecht, 1990; Naisbitt et al. However, neutrophils are usually not in close proximity to where sensitization may occur. Women, especially those less than 40 years of age, were affected more severely than men; 61% of the victims and 66% of the deaths were women (Sanchez-Porro Valades et al. In addition, it resembles eosinophilia myalgia syndrome and diffuse fasciitis with eosinophilia. More than 70% of toxic oil syndrome patients presented with eosinophilia, regardless of age or sex. The toxin or toxins appear to be stable in oil, since consumption of toxic oil one year after the main epidemic led to development of the disease. Approx imately 60% of the patients progressed to the intermediate phase (2– 4 months), characterized by myalgias, eosinophilia, cachexia, liver disease, dermal infiltration/oedema, pulmonary hypertension, sicca syndrome, and hypertriglyceridaemia. While a number of treat ments were tested, none successfully controlled the disease, although corticosteroids and diphenylhydantoin did ameliorate some of the symptoms (Gomez de la Camara et al. The initial chemical analyses identified oleyl anilide as the primary contaminant and marker for case-associated oils, but the number of anilides and unidentified contaminants suggested that other compounds may also be involved (Posada de la Paz et al. Inconsistencies may reflect differences in the stage of the disease at the time of testing. The haptoglobin protein binds free haemoglobin during hepatic recyling of iron, acts as an antioxidant, has antibacterial activity, and is involved in the acute-phase immune response. Serum IgE levels were reduced and serum autoantibodies increased by all three experimental oils compared with levels in naive mice. Aniline, nitro benzene, p-aminophenol, N-acetyl-p-aminophenol, linoleic acid, linolenic acid, and triolein did not induce such a response. Only challenge with nitrosobenzene stimulated a secondary popliteal lymph node response following priming with either nitrosobenzene or linolenic anilide (Wulferink et al. Administration of toxic oil syndrome-related test chemicals by intra peritoneal injection resulted in the most severe symptoms and the highest mortality (30–50% for all anilide-treated groups); intra peritoneal delivery by osmotic pump induced disease symptoms, with survival of most of the animals until completion of the study. None of the mice that received linoleyl anilide by osmotic pump developed any symptoms. The only histopatho logical alteration was splenomegaly (Bell, 1996; Berking et al. Fifty to sixty per cent of the mice died within five days of severe cachexia, and another 20% within two weeks of exposure. T cells isolated from spleens of oleyl anilide-treated mice required the presence of antigen-presenting cells to initiate a proliferative response to oleyl anilide restimulation in vitro (Bell et al. Consistent with toxic oil syndrome symptoms in affected patients, the serological and gene expression changes in all three strains suggest a Th2-mediated mechanism with possible Th1 involvement in the acute phase and a humoral immune response with polyclonal B cell activation in the chronic phase (Bell, 1996; Berking et al. These findings suggest that developmental exposure to dioxins may accelerate the onset of genetic expression of autoimmune pre disposition. Some studies examined antinuclear or other auto antibodies in subjects exposed to pesticides in occupational settings. Another major problem in data interpretation is the uncertainty in the extrapolation of animal find ings to humans. One such example is the interpretation of enhanced antibody response to sheep red blood cells (Burns et al. In conclusion, the body of data available shows an equivocal association between pesticide exposure and autoimmunity. Victims developed a syndrome that has been called porphyria turcica, characterized by hepatic porphyria (Cam, 1958). Other clinical features were skin lesions in sun-exposed areas, caused by photochemical activation of accumulated porphyrins (Bickers, 1987), painless arthritis, enlarged liver, spleen, lymph nodes, and thyroid, and neurological symptoms (Gocmen et al. Histology of skin biopsies showed hyperkeratosis and infiltrations of lymphocytes and macrophages.

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Later in pregnancy arrhythmia chest pain generic 0.25mg digoxin with visa, important topics to heart attack labs quality digoxin 0.25mg discuss with patients during routine visits include childbirth education classes heart arrhythmia 4 year old buy digoxin american express, choosing a newborn care provider arteria in english discount digoxin, anticipating labor, preterm labor, options for intrapartum care, umbilical cord banking, breastfeeding, choice of a postpartum contraception method, and preparation for hospital discharge (see also “Second-Trimester and Third Trimester Patient Education” later in this chapter). Preconception and Antepartum Care 109 In group prenatal care, health care providers deliver prenatal health services and information to groups of patients during regularly scheduled shared vis its. The typical group visit includes 8–12 women and lasts longer than the traditional prenatal visit, usually 1–2 hours. The visit usually begins with physical assessments, including fundal height measures, fetal heart tones, mater nal–fetal well-being questions, and appropriate testing. The physical assessment is followed by an informational group discussion facilitated by an obstetrician–gynecologist, a certified nurse– midwife, or a family medicine practitioner. The group model is a promising innovation in prenatal care delivery, but additional research and evaluation of patient outcomes are needed. The first date of the last menstrual period, when known, should be recorded in the chart, as well as documentation regarding the reliability of this date. Once the dates are established by a last menstrual period with consistent ultrasound examina tion or an early ultrasonography alone, the final estimated delivery date should 110 Guidelines for Perinatal Care not be altered. Fetal Ultrasound Imaging Ultrasonography is the most commonly used fetal imaging tool and is an accurate method of determining gestational age, fetal number, viability, and placental location. Physicians who perform, evaluate, and interpret diagnostic obstetric ultrasound examinations should be licensed medical practitioners with an understanding of the indications for such imag ing studies, the expected content of a complete obstetric ultrasound examina tion, and a familiarity with the limitations of ultrasound imaging. In order to select the best time for a particular patient to receive her scan, health care providers must balance the types and accuracy of information to be gained at different gestational ages with the financial reality of limitations to the number of scans many insurance carriers will pay for. Each type of ultrasound examination should be performed only when indi cated and should be appropriately documented. A first-trimester ultrasound examination is an ultrasound examination performed before 13 weeks and 6 days of gestation. Second-trimester and third-trimester ultrasound examinations include the following three types: 1. Limited––A limited examination does not replace a standard examina tion and is performed when a specific question, such as fetal presenta tion or amniotic volume assessment, requires investigation. Patients with an abnormal fetal ultrasound examination result should be referred for evaluation and management of fetal anomalies to a health care provider who can accurately and thoroughly assess the fetus, communicate the findings to the patient and health care provider, and coordinate further man agement if needed. Fetal Magnetic Resonance Imaging If additional imaging modalities are required prenatally, magnetic resonance imaging may be chosen. Other laboratory tests that are routinely performed early in pregnancy are listed in Table 5-3 and Appendix A (College Antepartum Record). Antibody screen Any positive antibody test result requires obtaining a titer and further action by the health care provider. False-negative serologic tests results may occur in early primary infection, and infection after the first prenatal visit is possible. Urine screening Obtain baseline screening for urine protein content (dipstick) to assess renal status. Routine Laboratory Tests Early in Pregnancy (continued) Laboratory Test Potential Actions for Abnormal Results Chlamydia Women found to have chlamydial infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. Gonorrhea Pregnant women found to have gonococcal infection during (when indicated) the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. Uninfected pregnant women who remain at high risk for gonococcal infection also should be retested during the third trimester. Women who are at high risk of syphilis, live in areas of high syphilis morbidity, or are previously untested should be screened again early in the third trimester (at approx imately 28 weeks of gestation) and at delivery, as well as after exposure to an infected partner. Some states require all women to be screened at Preconception and Antepartum Care 115 delivery. Infants should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least one time during pregnancy and preferably again at delivery. Women aged 25 years or younger and those at increased risk of chlamydia (eg, women who have a new sex partner or more than one sex partner) should be retested during the third trimester to prevent maternal postnatal com plications and chlamydial infection in the infant. Women found to have chlamydial infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester (see also “Chlamydial Infection” in Chapter 10). Women aged 25 years or younger are at highest risk of gonorrhea infection as are those of black, Hispanic, and American Indian or Alaska Native ethnicity. Uninfected pregnant women who remain at high risk of gonorrhea also should be retested during the third trimester (see also “Gonorrhea” in Chapter 10). In most women, glucose screening should be performed Preconception and Antepartum Care 117 at 24–28 weeks of gestation and can be done in the fasting state or fed state. A 50-g oral glucose challenge test is given followed in 1 hour by a plasma test for glucose level. Different screening thresholds (ranging from 130 mg/dL to 140 mg/dL) are utilized, and those meeting or exceeding this threshold undergo a 100-g, 3-hour diagnostic oral glucose tolerance test (see also “Gestational Diabetes Mellitus Diagnosis and Management” in Chapter 7). Testing is conducted by obtaining a single swab specimen (not by speculum examination) from the lower vagina (introitus) and rectum (through the anal sphincter), placing the swab in transport media, and using selective broth media. Antepartum Immunizations A routine assessment of each pregnant woman’s immunization status is recom mended, with appropriate immunization if indicated. There is no evidence of risk from vaccinating pregnant women with an inactivated virus or bacterial vaccines or toxoids, and these should be administered if indicated. However, live vaccines do pose a theoretic risk to the fetus and generally should be avoided during pregnancy. The benefits of vaccines outweigh any unproven potential concerns about traces of thimerosal preservative. The influenza vaccine should be recommended to all women who will be pregnant during the influenza season, regardless of their stage of pregnancy. Pregnant women with medical conditions that increase their risk of complica tions from influenza should be offered the vaccine before the influenza season. Administration of the injectable, inactivated influenza vaccine is considered safe at any stage of pregnancy. In contrast, the intranasal influenza vaccine contains a live attenuated virus and should not be used in pregnant women. In studies of meningococcal vaccination with the meningococcal polysaccharide vaccine during pregnancy, adverse effects have not been documented in either pregnant women or newborns. It is not known whether vaccine antigens or antibodies found in the quadrivalent vaccine are excreted in human milk. Both the varicella and the measles–mumps–rubella vaccine are contraindi cated during pregnancy. It is the responsibility of the health care provider to educate the patient and make her aware of available options. Videos, Internet resources, and interactive computer programs also may be developed for this purpose. The information about genetic screening should be provided in a nondirec tive manner. Referral to a geneticist, genetic counselor, or perinatologist may be necessitated by the complexities of determining risks, evaluating a family history of such abnormalities, interpreting laboratory test results, or providing counseling. Several methods have been established to obtain family medical histories, each with its own advantages and disadvantag es. A common tool used in general practice is the family history questionnaire or checklist. Any positive responses on the questionnaire should be followed up by the health care provider to obtain more detail, including the relationship of the affected family member(s) to the patient, exact diagnosis, age of onset, and severity of disease. Another family history assessment tool, commonly used by genetics professionals, is the pedigree. A pedigree ideally shows at least three generations using standard ized symbols, clearly marking individuals affected with a specific diagnosis to allow for easy identification. One way to screen for these disorders is to ask for family history and to determine the patient’s ethnic background. Certain disorders are more common in different ethnic groups, although it is essential to note that there are no disorders found uniquely in a certain ethnic or racial group and that many families may be interracial and not have an obvious predominant ethnicity. If carrier testing is to be done on the basis of ethnicity only, it is rea sonable to offer this to the preconception or pregnant woman first and then test the father only if the mother is positive. If testing is being con sidered on the basis of an affected relative, offer it to the family member of the affected individual first. Table 5-4 includes recommendations for genetic testing based solely on a patient’s ethnic identity. Abnormalities involving a major organ or structure, with a few notable exceptions, or the finding of two or more minor structural abnormalities in the same fetus indicate increased risk of fetal aneuploidy.

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Department of Health and Human Services blood pressure chart nih buy digoxin once a day, Office of the Assistant Secretary of Preparedness and Response arrhythmia omega 3 fatty acids buy generic digoxin 0.25 mg online. Revision Date September 8 blood pressure medication cialis generic 0.25 mg digoxin with amex, 2017 19 Patient Refusals Aliases Against medical advice blood pressure index chart buy digoxin 0.25mg free shipping, refusal of treatment, refusal of transport Patient Care Goals/Patient Presentation (Overview) If an individual (or the parent or legal guardian of the individual) refuses secondary care and/or ambulance transport to a hospital after prehospital providers have been called to the scene, providers should determine the patient’s capacity to make decisions. However, state laws vary in the definition of competency and its impact upon authority. An individual who is alert, oriented, and has the ability to understand the circumstances surrounding his/her illness or impairment, as well as the possible risks associated with refusing treatment and/or transport, typically is considered to have decision-making capacity b. The individual’s judgment must also not be significantly impaired by illness, injury or drugs/alcohol intoxication. Obtain a complete set of vital signs and complete an initial assessment, paying particular attention to the individual’s neurologic and mental status 2. If patient has capacity, clearly explain to the individual and all responsible parties the possible risks and overall concerns with regards to refusing care 4. Complete the patient care report clearly documenting the initial assessment findings and the discussions with all involved individuals regarding the possible consequences of refusing additional prehospital care and/or transportation Notes/Educational Pearls Key Considerations 1. An adult or emancipated minor who has demonstrated possessing sufficient mental capacity for making decisions has the right to determine the course of his/her medical care, including the refusal of care. These individuals must be advised of the risks and consequences resulting from refusal of medical care 20 2. Mental illness, drugs, alcohol intoxication, or physical/mental impairment may significantly impair an individual’s decision-making capacity. The determination of decision-making capacity may be challenged by communication barriers or cultural differences 4. Special Considerations – Minors It is preferable for minors to have a parent or legal guardian who can provide consent for treatment on behalf of the child a. All states allow healthcare providers to provide emergency treatment when a parent is not available to provide consent. For minors, this doctrine means that the prehospital professional can presume consent and proceed with appropriate treatment and transport if the following four conditions are met: i. The child is suffering from an emergent condition that places his or her life or health in danger ii. The child’s legal guardian is unavailable or unable to provide consent for treatment or transport iii. The prehospital professional administers only treatment for emergency conditions that pose an immediate threat to the child v. A quotation of the patient’s actual words, stating they understand, is best • Reason for patient refusing care. Revision Date September 8, 2017 22 Cardiovascular Adult and Pediatric Syncope and Presyncope Aliases Loss of consciousness, passed out, fainted Patient Care Goals 1. Transfer for further evaluation Patient Presentation Syncope is heralded by both the loss of consciousness and the loss of postural tone and resolves spontaneously without medical interventions. It usually lasts for seconds to minutes and may be described by the patient as “nearly blacking out” or “nearly fainting” Inclusion Criteria 1. Prodromal symptoms of syncope Exclusion Criteria Conditions other than the above, including patients: 1. Patients with ongoing mental status changes or coma should be treated per the Altered Mental Status guideline Patient Management Assessment 1. History from others on scene, including seizures or shaking, presence of pulse/breathing (if noted), duration of the event, events that lead to the resolution of the event c. Should be directed at abnormalities discovered in the physical exam or on additional examination and may include management of cardiac dysrhythmias, cardiac ischemia/infarct, hemorrhage, shock, and the like a. Monitor for and treat arrhythmias (if present refer to appropriate guideline) Patient Safety Considerations: 1. Patients suffering syncope due to arrhythmia may suffer recurrent arrhythmia and should therefore be placed on a cardiac monitor 2. Geriatric patients suffering falls from standing may sustain significant injury and should be diligently screened for trauma – go to General Trauma Management guideline Notes/Educational Pearls Key Considerations 1. Consideration of potential causes, ongoing monitoring of vitals and cardiac rhythm as well as detailed exam and history are essential pieces of information to pass onto hospital providers. All patients suffering from syncope deserve hospital level evaluation, even if they appear normal with few complaints on scene 3. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. The emergency department approach to syncope: evidence-based guidelines and prediction rules. Transport to appropriate facility Patient Presentation Inclusion Criteria Chest pain or discomfort in other areas of the body. Atypical or unusual symptoms are more common in women, the elderly and diabetic patients. For these patients, defer the administration of aspirin and nitrates per the Pain Management guideline. Exclusion Criteria None recommended Patient Management Assessment, Treatment, and Interventions 1. Assess the patient’s cardiac rhythm treat pulseless rhythms, tachycardia, or symptomatic bradycardia [see Cardiovascular and Resuscitation guidelines] 3. Administer aspirin; chewable, non-enteric-coated aspirin preferred (162 to 325 mg) 6. The use of nitrates should be avoided in any patient who has used a phosphodiesterase inhibitor within the past 48 hours. Transport and destination decisions should be based on local resources and system of care Patient Safety Considerations 1. Pertinent Assessment Findings A complete medication list should be obtained from each patient. It is especially important for the treating physician to be informed if the patient is taking beta-blockers, calcium channel blockers, clonidine, digoxin, blood thinners (anticoagulants), and medications for the treatment of erectile dysfunction or pulmonary hypertension. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Revision Date September 8, 2017 29 Bradycardia Aliases Heart block, junctional rhythm Patient Care Goals 1. Toxin exposure (beta-blocker, calcium channel blocker, organophosphates, digoxin). See additional inclusion criteria, below, for pediatric patients Exclusion Criteria No recommendations Patient Management Assessment, Treatment, and Interventions 1. Check blood glucose and treat hypoglycemia per the Hypoglycemia and Hyperglycemia guidelines f. Transcutaneous Pacing If pacing is performed, consider sedation or pain control 2. Pediatric Management Treatment is only indicated for patients who are symptomatic (pale/cyanotic, diaphoretic, altered mental status, hypoxic) a. Initiate chest compressions for heart less than 60 and signs of poor perfusion (altered mental status, hypoxia, hypotension, weak pulse, delayed capillary refill, cyanosis) b. Manage airway and assist ventilations as necessary with minimally interrupted chest compressions using a compression to ventilation ratio 15:2 (30:2 if single provider is present) c. Consider the following additional therapies if bradycardia and symptoms or hemodynamic instability continue: i. Transcutaneous pacing If pacing is performed, consider sedation or pain control iv. Epinephrine may be used for bradycardia and poor perfusion unresponsive to ventilation and oxygenation. It is reasonable to administer atropine for bradycardia caused by increased vagal tone or cholinergic drug toxicity Patient Safety Considerations If pacing is performed, consider sedation or pain control Notes/Educational Pearls Key Considerations 1. Consider potential culprit medications including beta-blockers, calcium channel blockers, sodium channel blockers/anti-depressants, digoxin, and clonidine. If medication overdose is considered, refer to appropriate guideline in the Toxins and Environmental section 4. Bradycardia should be managed via the least invasive manner possible, escalating care as needed a. Third-degree heart block or the denervated heart (as in cardiac transplant) may not respond to atropine and in these cases, proceed quickly to chronotropic agents (such as epinephrine or dopamine), or transcutaneous pacing b. In cases of impending hemodynamic collapse, proceed directly to transcutaneous pacing 7.

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Recommended intervals for additional tests that are indicated after the first prenatal visit are detailed in the College Antepartum Record (see also Appendix A) heart attack zine archive order 0.25 mg digoxin overnight delivery. Routine Laboratory Tests Early in Pregnancy ^ Laboratory Test Potential Actions for Abnormal Results Blood type There is no abnormal result here blood pressure jumping around buy digoxin 0.25mg visa. D (Rh) type Patients who are Rh negative are at risk of developing isoimmu nization to prehypertension la gi digoxin 0.25 mg fast delivery D antigen blood pressure is low order digoxin with paypal. Weak rhesus-positive (formerly Du-positive) patients are not at risk of isoimmunization. Women who are of African descent, Asian, or Mediterranean should have a hemoglobin electrophoresis test performed to rule out thalassemia or sickle cell disease. Further testing may be warranted pending the results of these interventions and tests. Mantoux tuberculin skin Women with a positive or intermediate test result should be test or interferon evaluated with a chest X-ray and review of their pertinent gamma release assay history to determine the need for additional evaluation. Although this practice is recommended in the literature, more data are needed to determine the effectiveness of this strategy. Pregnant women at risk of hepatitis B infec tion also should be vaccinated (see also “Hepatitis B Virus” in Chapter 10). Any woman who gives birth to a stillborn fetus should be tested for syphilis (see also “Syphilis” in Chapter 10). Pregnant women found to have gonococcal infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. A positive or intermediate test result should be evaluated by obtaining three induced sputum cultures or with a chest X-ray. These patients also should receive anti-D immune globulin at a dose of 300 micrograms prophylactically at that time. This includes patients expected to have planned cesarean deliveries because onset of labor or rupture of membranes may occur before the recommended administra tion of prophylactic antibiotics. When deciding whether to immunize a pregnant woman with a vaccine not routinely recommended in pregnancy, the risk of exposure to disease as well as the benefits of vaccination 118 Guidelines for Perinatal Care for reducing the deleterious effects on the woman and the fetus must be balanced against unknown risks of the vaccine. All vaccines administered should be fully documented in the patient’s permanent medical record. Additional information on immunization during pregnancy can be found on the College’s Immunization for Women web site, available at. Other vaccines that are recommended in pregnancy, if indicated, include Tdap; hepatitis A; hepatitis B; and pneumococcal (recommended for pregnant patients with prior splenectomy or functional asplenia). However, no data are available on the safety of meningococcal conjugate vaccines during pregnancy. The manufacturer’s pregnancy registry should be contacted if pregnancy is detected during the vaccination schedule. Obstetric care providers must be knowledgeable about the choices available to patients in general and either provide that screening themselves or have established referral sources for doing so. Ideally, this information may be provided by trained support staff in the ambulatory practice setting. If the partner does not accompany a woman to her prenatal or preconception visit, a copy of the printed educational materials should be pro vided for her to give to her partner. Family history plays a critical role in assessing risk of inherited medical conditions and single gene disorders. The health care provider may decide to complete a detailed pedigree or refer to a genetics professional for further evaluation. The pedigree may visibly assist in determining the size of the family and the mode of inheritance of a specific condition, and may facilitate identification of members at increased risk of developing the 120 Guidelines for Perinatal Care condition. The screening tool selected should be tailored to the practice set ting and patient population, taking into consideration patient education level and cultural competence. Whether the pedigree or questionnaire is used, it is important to review and update the family history periodically for new diagno ses within the family and throughout pregnancy as appropriate. Screening can be offered for the following: • Single-gene (mendelian inheritance) disorders––Disorders inherited as autosomal dominant or recessive disorders of single genes are typi cally referred to as mendelian inheritance disorders. Health care providers should be aware that many single-gene disorders are discovered each year and may be tracked using Internet databases, such as Online Mendelian Inheritance in Man ( Fetuses with aneuploidy may have major anatomic mal formations that often are discovered during an ultrasound examination that is performed for another indication. Women should be counseled regarding the differences between screening and invasive diagnostic testing. Regardless of which screening tests your patients are offered, information about the detection and false-positive rates, advantages, disadvantages, and limita tions, as well as the risks and benefits of diagnostic procedures, should be available to patients so that they can make informed decisions. Down syndrome screening in the first and/or second trimester: model predicted performance using meta-analysis parameters. There are many strategies available to screen for chromosomal abnor malities (Table 5-5). Ideally, patients seen early in pregnancy can be offered first-trimester aneuploidy screening or integrated or sequential aneuploidy screening that combines first-trimester and second-trimester testing. The options for women who are first seen during the second trimester are limited to quadruple (or “quad”) screening and ultrasound examination. When a first-trimester screening test is performed and followed by a separate second-trimester screening test, the results are interpreted inde pendently and there is a high Down syndrome detection rate (94–98%); however, the false-positive rates are additive, leading to many more unnecessary invasive procedures (11–17%). For this reason, women who have had first-trimester screening for aneuploidy should not undergo independent second-trimester serum screening in the same pregnancy. The results are reported only after both first-trimester and second-trimester screening tests are completed. The possibility that patients might fail to complete the second-trimester portion of the screening test after per forming the first-trimester component is another potential disadvantage because the patient would be left with no screening results. In the stepwise sequential screening women determined to be at high risk (Down syndrome risk above a pre determined cutoff) after the first-trimester screening are offered genetic counseling and the option of invasive diagnostic testing, and women below the cutoff are offered second-trimester screening. It generally is performed between 10 weeks and 12 weeks of gestation, either by a transabdominal or a transcervical approach. Complications include transient vaginal spotting or amniotic fluid leakage in approximately 1–2% of all cases and chorio amnionitis in less than 1 in 1,000 cases. Early amniocentesis performed from 11 weeks to 13 weeks of ges tation has been widely studied, and the technique is similar to tradi tional amniocentesis; however, performing early amniocentesis results in significantly higher rates of pregnancy loss and complications than performing traditional amniocentesis. For these reasons, early amnio centesis (at less than 14 weeks of gestation) should not be performed. Chorionic villus sampling should not be performed in women who are red cell antibody sensitized because it may worsen the antibody response. Psychosocial Risk Screening and Counseling Psychosocial issues are nonbiomedical factors that affect mental and physical well-being. Screening for psychosocial risk factors may help predict a woman’s attentiveness to personal health matters, her use of prenatal services, and the health status of her offspring. The reason for this is that past obstetric events and infant outcomes, medical considerations in a current pregnancy, beliefs about and experience with breastfeeding, and family circumstances (among other factors) influence the experience of labor, delivery, and early neonatal and postpartum adjustment. Additionally, some women experience social, economic, and personal difficulties in pregnancy. Given the sensitive nature of psychosocial assessment, every effort should be made to screen patients in private. Even then, patients may not be comfortable discussing problems with physicians until a trusting relationship has been formed. Screening should include assessment of patients’ desire for pregnancy, tobacco use, substance use, depression, safety, intimate partner violence, stress, barriers to care, unstable housing, communication barriers, and nutrition. Screening positive for a con dition often necessitates a referral to resources outside the practice for further evaluation or intervention. The health care professional should make every effort to avoid introducing personal bias. Physicians often may best fulfill their obligations to patients through referral to other professionals who have the appropriate skills and expertise to address these difficult issues. All pregnant women should be screened at their first prenatal visit about their past and present use of tobacco, alcohol, and other drugs, including the recreational use of prescription and over-the counter medications and herbal remedies. To reinforce and encourage continued abstinence, periodic health care provider follow-up is important.