By L. Ugo. Oklahoma State University.

They are active against for many gram-positive and gram-negative bacteria cheap 10 mg lioresal mastercard, including anaerobes buy 25mg lioresal with amex, rickettsiae cheap lioresal 10 mg amex, chlamydiae generic 25 mg lioresal otc, mycoplasmas discount 10 mg lioresal fast delivery, and are active against some protozoa. The main mechanisms of resistance to tetracycline is decreased intracellular accumulation due to either impaired influx or increased efflux by an active transport protein pump. Pharmacokinetics: Tetracyclines mainly differ in their absorption after oral administration and their elimination. A portion of an orally administered dose of tetracycline remains in the gut lumen, modifies intestinal flora, and is excreted in the feces. Absorption occurs mainly in the upper small intestine and is impaired by food (except doxycycline and minocycline); by divalent cations (Ca2+, Mg2+, Fe2+) or Al3+; by dairy products and antacids, which contain multivalent cations; and by alkaline pH. They are distributed widely to tissues and body fluids except for cerebrospinal fluid. Minocycline reaches very high concentrations in tears and saliva, which makes it useful for eradication of the meningococcal carrier state. Tetracyclines cross the placenta to reach the fetus and are also excreted in milk. Doxycycline, in contrast to other tetracyclines, is eliminated by nonrenal mechanisms. Clinical uses: A tetracycline is the drug of choice in infections with Mycoplasma pneumoniae, chlamydiae, rickettsiae, and some spirochetes. They are used in combination regimens to treat gastric and duodenal ulcer disease caused by Helicobacter pylori. They may be employed in various gram-positive and gram-negative bacterial infections, including Vibrio infections. A tetracycline in combination with an aminoglycoside is indicated for plague, tularemia, and brucellosis. Adverse reactions Gastrointestinal adverse effects: Nausea, vomiting, and diarrhea are the most common and these effects are attributable to direct local irritation of the intestinal tract. Tetracyclines suppress susceptible coliform organisms and causes overgrowth of Pseudomonas, Proteus, staphylococci, resistant coliforms, clostridia, and Candida. This can result in intestinal functional disturbances, anal pruritus, vaginal or oral candidiasis, or enterocolitis (associated with Clostridium difficile) with shock and death. It causes discoloration, and enamel dysplasia; they can also be deposited in bone, where it may cause deformity or growth inhibition. If the drug is given to children under 8 years of age for long periods, similar changes can result. They are hepato and nephrotoxic drug, the also induce sensitivity to sunlight (demeclocycine) and vestibular reactions (doxycycline, and minocycline). Erythromycin Erythromycin is poorly soluble in water but dissolves readily in organic solvents. Antimicrobial Activity: Erythromycin is effective against gram-positive organisms, especially pneumococci, streptococci, staphylococci, and corynebacteria. Mycoplasma, Legionella, Chlamydia trachomatis, Helicobacter, Listeria, Mycobacterium kansasii, and Mycobacterium scrofulaceum are also susceptible. Gram-negative organisms such as Neisseria species, Bordetella pertussis, Treponema pallidum, and Campylobacter species are susceptible. Pharmacokinetics: Erythromycin base is destroyed by stomach acid and must be administered with enteric coating. Clinical Uses: Erythromycin is the drug of choice in corynebacterial infections (diphtheria, corynebacterial sepsis, erythrasma); in respiratory, neonatal, ocular, or genital chlamydial infections; and in treatment of community-acquired pneumonia because its spectrum of activity includes the pneumococcus, Mycoplasma, and Legionella. Erythromycin is also useful as a penicillin substitute in penicillin-allergic individuals with infections caused by staphylococci, streptococci, or pneumococci. Adverse Reactions Gastrointestinal Effects: Anorexia, nausea, vomiting, and diarrhea. Liver Toxicity: Erythromycins, particularly the estolate, can produce acute cholestatic hepatitis (reversibile). It increases serum concentrations of oral digoxin by increasing its bioavailability. Clarithromycin and erythromycin are virtually identical with respect to antibacterial activity except that clarithromycin has high activity against H. Clarithromycin penetrates most tissues, with concentrations equal to or exceeding serum concentrations. The advantages of clarithromycin compared with erythromycin are lower frequency of gastrointestinal intolerance and less frequent dosing. Azithromycin The spectrum of activity and clinical uses of azithromycin is identical to those of clarithromycin.

In addition buy lioresal 25 mg low price, a good understanding of pharmacology and toxicology and some knowledge of active elimination procedures and the use of antidotes are desirable generic lioresal 25 mg with visa. This chapter aims to provide some of the basic information required in the general approach of poisoned victims generic lioresal 25mg with amex. When acute poisoning is suspected buy 25 mg lioresal free shipping, the clinician needs to ask a number of questions in order to establish a diagnosis (history of present illness) buy 10 mg lioresal otc. In the case of an unconscious (comatose) victim, the circumstances in which the victim was found and whether any tablet, bottles or other containers (scene residues) were present can be important. If the victim is awake, he or she should be questioned about the presence of poisons in the home or workplace. Physical examination of the victim may indicate  The poison or class of poison involved. For example, the combination of pin-point pupils, hyper salivation, incontinence and respiratory depression suggests poisoning with a cholinesterase inhibitor such as an organophosphorus pesticide. However, the value of this approach is limited 21 Toxicology if a number of poisons with different actions have been absorbed. Moreover, many drugs have similar effects on the body, while some clinical features may be the result of secondary effects such as anoxia. Thus, if a victim is admitted with depressed respiration and pin-point pupils, this strongly suggests poisoning with an opioid. For example, coma can be caused by a cerebrovascular accident, uncontrolled diabetes infections as well as poisoning. The availability of the results of urgent biochemical and hematological tests is obviously important in these circumstances. Examples include: cardiorespiratory arrest (cyanide), hepatitis (paracetamol) and so on. B Generally Physical examination should include – Vital signs – Evaluation of specific parts of the body Investigations a) General laboratory tests  Hematological  Biochemical b) Toxicological studies c) Electrocardiogram d) X-ray findings 22 Toxicology Principles of management of poisoning The initial management of a patient with altered mental status follows the follow the same approach regardless of the poison involved. After this, one can begin in a more detailed evaluation to make a specific diagnosis. Therefore, in principle, during poisoning, one should treat the victim first followed by treating the poison itself. Supportive measures The first priority is to establish & maintain vital functions. Subsequently, most victims can be treated successfully using supportive care alone. Principles of toxin eliminations - If the poison has been inhaled, the victim should first be removed from the contaminated environment. However, repeated oral administration of activated charcoal appears to be effective in enhancing elimination of certain poisons. The results of either a qualitative or a quantitative toxicological analysis may be required before some treatments are commenced because they are not without risk to the victim. In general, specific therapy is only started when the nature and/or the amount of the poison(s) involved are known. Antidotes or protective agents are only available for a limited number of poisons. In summery there are four main methods of enhancing elimination of the poison from the systemic circulation: 1. Some antidotes &protective agents used to treat acute poisoning Antidote Indication • Acetylcysteine Paracetamol 24 Toxicology • Atropine Organophosphate • Deferoxamine Iron • Methylene blue Nitrates • Physiostigmine Atropine • Naloxone Opioids • Pyridoxine Isoniazid Exercise 1. Discuss about collection, transportation, storage, characteristics, physical examination &analytical tests of laboratory specimens. Describe about apparatus, reference compounds & reagents used in clinical toxicology laboratory 6. Introduction Clinical toxicology involves the detection and treatment of poisonings caused by a wide variety of substances, including household and industrial products, animal poisons and venoms, environmental agents, pharmaceuticals, and illegal drugs. The toxicology laboratory must provide appropriate testing in three general areas: Identification of agents responsible for acute or chronic poisoning; Detection of drugs of abuse; and therapeutic drug monitoring. Increasingly sophisticated analytic methods are available to accomplish these tasks, but it is imperative that they be used judiciously.

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B mask provides an oxygen concentration of 90% with the flow meter set at 7 liters/minute order lioresal 10 mg fast delivery. This kind of mask allows the patient to eat order lioresal 25mg online, Basic Nursing Art 127 drink and to expectorate discount 10mg lioresal fast delivery. Equipment - A cylinder of O2 with a reducing value and pressure tubing to be connected with the O2 cylinder generic 25 mg lioresal with amex. If the patient is unconscious order lioresal 25 mg line, a tray containing a galipot of saline or water, wooden applicator and receiver for soiled applicator is necessary in order to clean the nostrils Procedure 1. Connect the mask to tubing and open the fine adjustment to the required rate of flow. Stay with the patient till he is reassured if it is his first time to be on oxygen therapy. There are different kinds of catheters, a) A fine catheter b) A spectacle frame, which carries two, places of rubber tubing and is worn by the pt. Basic Nursing Art 128 c) Two soft rubber catheters connected by y shaped connection to the tube on O2 apparatus. Equipment - Oxygen cylinder with regulating valve and pressure tubing - Wolf’s bottle - Glass connection - Fine catheters, lubricant, plaster - Safety pin - Tray containing a. Turn on the fine adjustment to the required rate of flow the maximum liter flow being 6-7 litter /minute. Catheter is lubricated preferably with water and passed backward into pharynx till the tip of the catheter is opposite the uvula. Oxygen dries and irritates mucous membrane, therefore, should be passed through water (Humidified) before it is administered by catheter. Basic Nursing Art 129 The advantage of administration of oxygen by catheter is the freedom of movement that it gives to patients receiving oxygen. Close all appliances of the tent: place ice if the apparatus is without refrigeration device. Fill the tent with 12-15 liters of oxygen 40-60% concentration for the first half hour. After the first half hour regulate the flow of oxygen to 6-10 liters or as ordered by the doctor until the treatment is completed. Lighted matches, cigarettes, electric lights, nylon clothing, electric pads, bells mechanical toys should be forbidden. A rate of 2-liters/ minute is commonly used when oxygen is used in case of emergency minute is commonly used when oxygen is used in case of emergency instead of free air. Steam Inhalation Definition: It is the intake of steam alone or with medication through the nose or mouth Purpose 1. In order to produce a local effect on the upper respiratory passage during cold, sinusitis, laryngitis, bronchitis etc. To increase circulation in the lungs by increasing or decreasing the secretion of the bronchi. Either point in the graduate measure 90 cc of cold 0 water and 500 cc of boiled water to bring the temperate 82 c or half by half or pour half point (300cc) of boiling water into the inhaler than 5 co of Basic Nursing Art 132 tincture of benzene or any other drug ordered. Then add another 300 cc water making sure that the temperature of water in the inhaler comes to 0 82 C. Fix the mouthpiece firmly in the inhaler in direction opposite to the air inlet and cover the inhaler with blanket or towel. Prepare the patient usually in a sitting - up position making sure that he is well supported. Place the tray on the over- bed table or on his knees in such a way that he can bend over the inhaler easily. Tell the patient to breath in by putting his lip to the mouth piece which may be protected by a piece of gauze, and breath out by removing his lips for a moment from the mouth piece. The treatment can take from 5-10 minutes after which the patient should be kept warm and comfortable for some time. The patient should be covered up to the waist with a balance from a canopy, or the mouth of the jug may be covered with a towel to make the opening small enough for the patient to put his nose and mouth (not eyes) on it. Care of Equipment after use • Pour out the water from the inhaler (not onto a sink) • Wash the inhaler with hot water • Boil the mouth piece Basic Nursing Art 133 Emergency tray and Trolley List of Emergency Drugs. List of Emergency Equipment • O 2 -Tourniquet 2 • Morphine sulfate - O mask or nasal catheter • Aramine - plaster • Adrenalin( Epinephrin. Dressing of a Clean Wound Purpose • To keep wound clean • To prevent the wound from injury and contamination • To keep in position drugs applied locally • To keep edges of the wound together by immobilization • To apply pressure Equipment • Pick up forceps in a container • Sterile bowl or kidney dish • Sterile cotton balls • Sterile galipot • Sterile gauze • Three sterile forceps • Rubber sheet with its cover • Antiseptic solution as ordered • Adhesive tape or bandages 138 • Scissors • Ointment or other types of drugs as needed • Receiver • Spatula if needed • Benzene or ether. Technique Aseptic technique to prevent infection Procedure Explain procedure to the patient • Clean trolley or tray; assemble sterile equipment on one side and clean items on the other side.

Myelin breakdown into a linear train of myelin ovoids (debris) secondary to axonal degeneration generic lioresal 25 mg mastercard. All myelin sheaths distal to the point of transection of the axon have broken down simultaneously to form a series of globules of phagocytosed myelin debris within macrophages lioresal 10mg lowest price, known as myelin ovoids purchase lioresal 10 mg without prescription. In the ventral nerve roots cheap 10mg lioresal, loss of fibers mostly reflects loss of lower motor neurons in the ventral horn discount 10 mg lioresal amex, but peripherally motor nerves demonstrate a minor distal axonopathy that may antedate death of the nerve cell. This protein is expressed in several different inclusions of neurodegenerative diseases including neurofibrillary tangles and Lewy bodies. Ubiquitin is presumably linked to protein, but the composition of the inclusion has not been elucidated yet. Remaining large motor neuron and a proximal axonal swelling or "spheroid" (center) "Spheroids" or swollen axons occur in a wide variety of conditions, including certain toxic distal axonopathies. In lower motor neuron disease they occur in the proximal segment of the axon before the cell body is clearly affected. Polygonal fibers with nuclei at the margin and uniform, finely textured sarcoplasm (left). Myofibrils green; mitochondria and sarcotubular system as darker, slightly reddish, fine granules (left). Thickened perimysial septa between muscle fascicles Werdnig-Hoffman disease is a fatal hereditary, autosomal recessive, infantile spinal muscular atrophy. Muscle biopsy distinguishes this disease from infantile myopathies with hypotonia as a major symptom. A single motor neuron unaffected by the disease is thought to act through collateral reinnervation to eventually supply all fibers of a group. Because the nerve cell can determine fiber type, it can convert fibers of a group to produce fiber type grouping. In this patient, reinnervation has apparently kept pace with muscle denervation because few, if any, muscle fibers are atrophic. Why target fibers develop in muscle degeneration is not clear, but in experimental models they form when nerve regeneration and reinnervation of muscle fibers takes place. Top right: Sprouting axons of a surviving motor unit and reinnervation of muscle fibers with the formation of type grouping. Dark eosinophilia and hyaline textured fibers Necrotic fibers (top right) with breakdown of normal myofibrillar texture. Endomysial fibrosis (pale pink collagen) between muscle fibers Both necrosis and regeneration in a single muscle fiber (cell) is typically segmental, leaving intact portions of muscle fibers (not shown). Simultaneously, satellite cells become activated and proliferate as individual myoblastic cells. Subsequently, the myoblasts fuse with each other and with the surviving segments of muscle fiber to form a regenerating fiber with basophilic sarcoplasm. In normal muscle, the satellite cells remain dormant as reserve cells for muscle fiber regeneration. Loss of immunoreactive dystrophin in Duchenne dystrophy (2a, 2b) In Duchenne dystrophy, an X-linked recessive disorder, the gene that encodes for dystrophin (a large protein of about 410 kD) is defective. Inclusion body myositis is the most common myopathy in adults over the age of 50 years. Cytotoxic T cells invade muscle fibers (not shown), but the patients usually do not respond to immunosuppressive therapy. Hyperstaining fibers (right) Hereditary disorders of the electron transport chain are often attended by excessive numbers of mitochondria which, in muscle, appear as aggregates of finely granular material with a dark reddish color in the modified Gomori trichrome. Core lesions with loss of mitochondrial staining and a thin margin of increased staining (right) Central core disease is a rare congenital myopathy with an autosomal dominant pattern of inheritance. The central cores closely resemble target fibers, but no disorder of motor neurons or axons has been found. Patients with this disorder are at risk for malignant hyperthermia, a potentially fatal reaction to halothane and other anesthetic agents. Both disorders have been linked to mutations of the gene for the ryanodine receptor, a calcium-release channel of the sarcoplasmic reticulum. Orbital ecchymoses The hemorrhage from the fracture pools in the orbital soft tissues. A similar appearance could result from direct trauma to the orbits, but the absence of other evidence of facial trauma makes this unlikely. Localized accumulation of fresh blood, external to the dura mater A temporal location is most common for this lesion, which usually results from fracture of the squamous portion of the temporal bone with laceration of the middle meningeal artery, which passes along a groove in this bone.

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