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By L. Aldo. Coleman College.

Resuscitation 2000;46: followed by an attempt at cardioversion order topamax 100 mg line, either using drugs 185-93 cheap 200 mg topamax otc. If fibrillation has ● Kudenchuk PJ topamax 200mg generic, Cobb LA 100 mg topamax sale, Copass MK order topamax 100mg, Cummins RO, Doherty been present for more than 24 hours, heparin and warfarin AM, Farenbruch CE, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation should be started and elective cardioversion considered once (ARREST). This necessitates both an unobstructed bellows action by ● A respiratory minute volume of 6l/min air containing 21% oxygen, with a tidal volume of 500ml at 12 breaths/min the lungs to replace oxygen and eliminate carbon dioxide in ● An expired oxygen level of 16-17%, hence its use in expired the gas phase, and a continuous pulsatile action by the heart air resuscitation for effective delivery of the blood to the tissues. In the The “oxygen cascade” described by J B West 35 years ago presence of a normal haemoglobin level and arterial oxygen explains how oxygen is conducted down a series of tension saturation above 94%, this amounts to an oxygen availability gradients from the atmosphere to cellular mitochondria. These of 1000ml/min ● Average tissue oxygen extraction is only 25%, thereby “supply and demand” gradients increase when disease states or providing reserves for increased oxygen extraction during trauma interfere with the normal oxygen flux. Partial or total exercise, disease, or trauma where oxygen delivery is reduction of ventilation or blood flow are obvious examples impaired and form the fundamental basis for the ABC of resuscitation. Within the lung parenchyma at alveolar level, ventilation (V) and pulmonary artery perfusion (Q) are optimally matched to maintain an efficient V/Q ratio such that neither wasted ventilation (dead-space effect) nor wasted perfusion (shunt effect) occurs. Medical conditions and trauma—for example, aspiration, pneumonia, sepsis, haemorrhage, pneumothorax, pulmonary haematoma, and myocardial damage caused by infarction or injury—can severely impair pulmonary gas exchange and result in arterial desaturation. This causes hypoxaemia (low blood oxygen tension and reduced oxyhaemoglobin saturation). The resulting clinical cyanosis may pass unrecognised in poor ambient light conditions and in black patients. The use of pulse oximetry (SpO2) monitoring during resuscitation is recommended but requires pulsatile blood flow to function. A combination of arterial hypoxaemia and impaired arterial oxygen delivery (causing myocardial damage, acute blood loss, or severe anaemia) may render vital organs reversibly or irreversibly hypoxic. The brain will respond with loss of Pulse oximeter consciousness, risking (further) obstructed ventilation or unprotected pulmonary aspiration (or both). Impaired oxygen supply to the heart may affect contractility and induce rhythm disturbances if not already present. Renal and gut hypoxaemia do not usually present immediate problems but may contribute to “multiple organ dysfunction” at a later stage. The principles of airway management during cardiac arrest or after major trauma are the same as those during anaesthesia. Airway patency may be impaired by the loss of normal muscle tone or by obstruction. In the unconscious patient relaxation of the tongue, neck, and pharyngeal muscles causes soft tissue obstruction of the supraglottic airway. This may be The ABC philosophy in both cardiac and corrected by the techniques of head tilt with jaw lift or jaw trauma life support relies on a combination thrust. The use of head tilt will relieve obstruction in 80% of of actions to achieve airway patency, optimal patients but should not be used if a cervical spine injury is ventilation, and cardiac output, and to restore suspected. Chin lift or jaw thrust will further improve airway and maintain circulatory blood volume patency but will tend to oppose the lips. With practice, chin lift 25 ABC of Resuscitation and jaw thrust can be performed without causing cervical spine movement. In some patients, airway obstruction may be particularly noticeable during expiration, due to the flap-valve effect of the soft palate against the nasopharyngeal tissues, which occurs in snoring. Obstruction may also occur by contamination from material in the mouth, nasopharynx, oesophagus, or stomach—for example, food, vomit, blood, chewing gum, foreign bodies, broken teeth or dentures, blood, or weed during near-drowning. Laryngospasm (adductor spasm of the vocal cords) is one of the most primitive and potent animal reflexes. It results from stimuli to, or the presence of foreign material in, the oro- and laryngopharynx and may ironically occur after cardiac resuscitation as the brain stem reflexes are re-established. Recovery posture Patients with adequate spontaneous ventilation and circulation who cannot safeguard their own airway will be at risk of developing airway obstruction in the supine position. Turning Airway patency maintained by the head tilt/chin lift the patient into the recovery position allows the tongue to fall forward, with less risk of pharyngeal obstruction, and fluid in the mouth can then drain outwards instead of soiling the trachea and lungs. Spinal injury The casualty with suspected spinal injuries requires careful handling and should be managed supine, with the head and cervical spine maintained in the neutral anatomical position; constant attention is needed to ensure that the airway remains patent.

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During the Second vidual one buy topamax 200 mg lowest price, and with his quiet smile and sly wink World War cheap topamax 200mg fast delivery, he was consultant in orthopedic he captivated both patients and pupils alike buy discount topamax 200mg online. He was also a man has ever portrayed the essential spirit of the member of the International Society of Orthope- doctor–patient relationship better discount 100 mg topamax otc. On social occa- dic Surgeons topamax 100 mg low cost, and an associate member of the sions, he loved to be surrounded by the younger French Academy of Orthopedic Surgery. Smith-Petersen died on June 16, 1953 in a Scandinavian manner, and provoking both at the age of 67, after a short illness. After the Second World War, he visited Great Britain in 1947, 1948 and 1952. On the foremost occasion, he was made an Honorary Fellow of the British Orthopedic Association, and also deliv- ered the fourth Moynihan Lecture at the Univer- sity of Leeds. He also took charge of the orthopedic staff conference and operated before a distinguished audience at the London Hospital. At a reception following this occasion, the gift of his characteristic ties will long be remembered by the recipients. It was during this friendly and amusing ceremony that the household dog laid her favorite bone at Dr. Smith-Petersen’s feet, this bone was none other than half the pelvis including the hip joint! After the termination of this visit to England, a Jensen silver bowl was presented to him by the staff of the London Hospital at a simple and moving little ceremony, which brought tears to the eyes of this great and senti- mental man. Smith-Petersen, accompanied by his wife, visited London to be given the Honorary Fellowship of the Royal Society of Medicine, and to attend the meeting of 311 Who’s Who in Orthopedics control. In World War II, he served in the United States Army from 1942 to 1946, first with the Twenty- fifth Evacuation Hospital and then as chief con- sultant in orthopedic surgery to the South Pacific area, the Tenth Army at Okinawa, and the Pacific. He was awarded the Legion of Merit, a Bronze Star, and five battle stars, and achieved the rank of colonel. On returning to civilian life, he became chief surgeon at Shriners Hospital for Crippled Chil- dren in Chicago; he retained that post until 1965, after which he remained a consultant until his death. He succeeded Beveridge Moore, about whom he often spoke and whom he greatly admired. Sofield truly enjoyed caring for the children at Shriners and was well known for his Harold Augustus SOFIELD technique of multiple osteotomies and intramedullary fixation (the shish-kebab opera- 1900–1987 tion) for osteogenesis imperfecta. His attitude of Harold Augustus Sofield was born in Jersey City, open-mindedness, relaxation, good humor, and New Jersey, on March 27, 1900. His favorite salu- northern New Jersey, where he attended a two- tation to his young patients, “Hi there, Skeezix,” room elementary school that held eight grades. This was coordinated in New York City and then Northwestern Univer- with Shriners and with West Suburban Hospital sity Medical School in Chicago. He interned at and was designated as the Hines–Shriners San Francisco City and County Hospital from program, of which Dr. Sofield was chief until 1928 to 1929, after which he returned to Chicago 1965. Sofield spent a good deal of time at Shriners institutions, which now compose the Sofield Hospital for Crippled Children in Chicago, where Orthopedic Association. He was on the contributed more than 40 papers to the medical staff at St. Luke’s Hospital, Chicago, from 1934 literature and wrote a chapter in Christopher’s to 1942, and at West Suburban Hospital, Oak Textbook of Surgery on the treatment of fractures. Sofield pioneered the operative fixation of Northwestern University Medical School, where fractures of the hip by performing the first nailing he attained the rank of professor. Harold Sofield received many honors and held His method of percutaneous nailing using multi- many offices (which are too numerous to list ple pins became widespread and well recognized. These was chairman of the Department of Orthopedic nails had a screwdriver-type point and were Surgery at West Suburban Hospital from 1930 to inserted percutaneously under fluoroscopic 1975, secretary of the American Board of Ortho- 312 Who’s Who in Orthopedics pedic Surgery for 8 years and president of that organization from 1955 to 1956, twice president of the Chicago Orthopedic Society, secretary of the American Orthopedic Association for the 1957 and 1958 meetings, president of the American Academy of Orthopedic Surgeons from 1959 to 1960, president of the Chicago Medical Society from 1964 to 1965 and trustee from 1971 to 1976, and a delegate to the Illinois State Medical Society and the American Medical Asso- ciation House of Delegates. In 1980, he received the Chicago Medical Society Public Service Award and in 1981, the Sheen Award, consisting of a plaque and $15,000, from the American Medical Association.

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Unfortu- nately topamax 200mg visa, very few studies have adequately examined the extent to which rehabilitation achieves these goals—and the relationship of achieving these goals to costs 100 mg topamax free shipping. In today’s climate of rising health care expenditures and emphasis on cost-containment best topamax 200 mg, it is incumbent on the rehabilitation community to demonstrate what works best and at what cost buy generic topamax 100 mg. He believes that scientific evidence about the benefits of rehabilitation is strong in selected areas generic topamax 100 mg mastercard, notably care following strokes. In most fields of health care, not just rehab, we have less evidence than we really need to make evidence-based decisions. They often feel—and their therapists concur—that they are more likely to maintain their gains if they are in a long-term rehabilitation program.... Once a patient has reached a plateau, once he is not making further progress, he is no longer eligible for services” (1995, 198). Marcia, in her mid thirties, has recently “been nursing a rotator cuff injury”—an injury in her shoulder joint caused by self-propelling her manual wheelchair. She wants an ultralightweight wheelchair, but it is more expensive than the standard heavier model, and her health insurer will not cover it. But you don’t know how it feels, so you end up buying something that may not work out for you. The insurance company won’t apply that $1,200 and let me pay cash for the extra. They’re protecting the disabled person because the wheelchair manufacturer is going to talk you into a more expensive, light- weight chair. Presumably to stymie unscrupulous vendors, Medicare precludes people from paying cost difference themselves, at least for now: “You must accept the chair they are willing to buy, or they will not cover you” (Karp 1998, 27). But the dealer won’t give you the chair until they get paid by the insurance company. It takes so long for them to get paid now that it creates a backup of chairs. They could have your chair in their shop, but since it’s not paid for, they won’t give it to you. From their perspective, such payment policies are, at best, “penny wise and pound foolish”—for example, cover- ing only heavier manual wheelchairs, which are more likely to cause upper-body injuries than lighter-weight models. Dealers seem entirely justified for not delivering a wheelchair until paid; less defensible is the delayed insurance payment. Karp finds that, “Although you may have to assert yourself to get the right wheelchair, it’s possible that approval from your insurance company will go smoothly” (1998, 25). Nevertheless, rifts frequently arise between pay- ment policies and practices and the needs of the people who require mobil- ity aids—a class of so-called durable medical equipment (DME). Insurers often impede requests for wheelchairs and other mobility aids from persons with chronic progressive debilities, by outright denials or re- peated demands for extensive justification or substitutions of less desirable equipment for preferred options. They might ultimately grant approval, but, as Samantha observed, people and their doctors must first “jump through hoops. Ron Einstein, a primary care physician, concurs: “It’s very hard to get good wheelchairs from health insurers. Unfortunately, a major impedi- ment exists in the form of the reimbursement criteria of public and private insurers. Tailored to the treatment of acute conditions, reim- bursement criteria emphasize curative medicine and rarely recog- nize the importance of maintaining health and improving function- ing. Thus most assistive technologies, which are tools of preventive care, do not qualify for reimbursement.... This shortsightedness is also reflected in the inadequate coverage that most insurers provide for long-term maintenance and replacement of the few assistive technologies they do fund. Medicare Part B covers only “medically necessary” DME, requiring 20 per- cent coinsurance from beneficiaries. Part A covers mobility aids furnished to qualifying homebound persons under an authorized treatment plan, with beneficiaries again paying 20 percent coinsurance. A rolling walker, for example, can cost $400, while good- quality standard manual wheelchairs typically cost $2,000, scooters are What Will Be Paid For? Medicare sets strict dollar ceilings for specific types of DME, generally far below the actual costs of good-quality mobility aids. Maureen’s Medicare carrier, for example, only allows $1,200 for manual wheelchairs, much lower than the price for a good-quality standard model, let alone an ultralightweight wheelchair.

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