Medical Concepts

 IV DRUG THERAPY- SELECTION OF EQUIPMENTS AND INSERTION OF CATHETER Equipment: Canula selection: Select cannula based on purpose and duration of use and age of patient. Consider risk of infection and extravasation. Cannula made from polyurethanes are associated with decreased risk of phlebitis. Steel needles have higher risk of extravasation and should be avoided where tissue necrosis is likely if extravasation occurs.       2. Skin Prep: Antiseptic solution, use an aqueous based alternative if there is a known allergy to alcohol.       3. Other Equipment: Intravenous solution as ordered, torniquet, giving set, IV stand/pole, infusion pump, transparent occlusive dressing, tape or similar to secure cannula, gloves, paper bag.       4. Additional Equipment which may be required: Syring (5mL), sterile sodium chloride 0.9%, local anesthetics (in children), 3-way tap or triflow, short extension tube. Selection Of the Catheter Site: Generally speaking, the vein section with the straightest a

 INTRAVENOUS THERAPY Definition: "Intravenous therapy or IV therapy is the giving of liquid substances into vein".  It can be intermittent or continuous; continuous administration called an Intravenous drip.  The word intravenous simply means "within vein" but is most commonly used to refer to IV therapy. Compared to other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions and lethal injections can only be given intravenously. The simplest form of intravenous access is a syringe with an attached hole in needle. The needle is inserted through the skin into a vein, and the contents of the syringe are injected through the needle into the bloodstream. This is easily done with an arm vein, especially one of the metacarpal veins. Usually, it is necessary to use a constricting band first to make the vein bulge; once needle is in place, it is common to dra

 DRUG-INDUCED HEPATOTOXICITY "Hepatotoxicity is the injury or liver damage caused by exposure to certain drugs, when taken in overdoses and sometimes when administered at therapeutic ranges, may injure the organ". Drug-induced hepatotoxicity is also referred to as the Drug-Induced Liver Injury (DILI). Physiological functions of liver: Formation and sensation of bile. Nutrient and vitamin metabolism (amino acid, lipid). Detoxification and inactivation of various substances (toxin drugs). Synthesis of plasma proteins (Albumin, clotting factors). Immune systems (Kupffer cells). Hepatotoxicity is most prevalent in older patients especially in those with pre-existing hepatic impairment. The few examples of drugs that cause hepatotoxicity are listed below: 1. ACE Inhibitors: Hepatic injury occurs occasionally with ACE-Inhibitors. Captopril and Enalapril are implicated in most reported cases, but others also have similar hepatotoxic potential. Most cases show cholestatic injury, b

 DRUG-INDUCED OCULOTOXICITY Occasionally, non-specific blurred vision occurs with almost all the drugs. The drugs listed below are associated with a specific pattern of drug-induced oculotoxicity when administered systemically: 1. Allopurinol: Despite the discovery of Allopurinol in cataractous lenses taken from patients on long term (>2 years) therapy, there is no clinical evidence for an increased risk of cataracts in allopurinol-treated patients. 2. Beta-Adrenergic Blocking Agents: A reduction in tear production occurs, which can produce a hot, dry, gritty sensation in the eyes. This is rapidly reversible with drug discontinuation. 3. Contraceptives, (Oral): A variety of retinal vascular disorders have been occurred due to oral contraceptives, but the association remains unproved. Some oral contraceptives users cannot tolerate contact lenses, possibly because of ocular edema or dryness. However, a prospective study failed to show any difference in lens tolerance between oral cont

  LIVER AND THE COMPLICATIONS ASSOCIATED WITH THE PROGRESSION OF DISEASE! Liver: The liver weighs up to 1.5kg in adults and is the 2nd largest organ in the body. Hepatocytes are the functioning unit of liver. Impairment of liver may lead to: Acute liver diseases Chronic liver diseases Liver cirrhosis Acute Liver Disease (ALD): ALD is a self-limiting episode of hepatocyte damage which in most cases spontaneously without clinical sequelae, but acute liver failure (ALF) may develop. This is a rare condition in which there is a rapid deterioration in liver function with associated encephalopathy and coagulopathy. ALF carries significant morbidity and mortality and may require emergency liver transplant. Chronic Liver Disease (CLD): CLD occurs when the longstanding cell damage causes permanent structural changes within the liver, with the loss of normal liver structure and functions. In many cases, this may lead to cirrhosis where fibrosis sears divide the liver cells into areas of regenera

SUPPURATIVE PNEUMONIA (ASPIRATION PNEUMONIA) AND PNEUMONIA IN IMMUNOCOMPROMOISED PATIENTS  SUPPURATIVE PNEUMONIA Definition: "Suppurative pneumonia is characterized by destruction of the lung parenchyma by inflammatory process and although microabscessation formation is characteristic histological feature, pulmonary abscess" is usually taken to refer lesion which is a large, localized collection of pus or a cavity lined by chronic inflammatory tissue from which pus has escaped by rupture into bronchus". Etiology: Inhalation of septic material during operations on the nose, mouth, throat under general anesthesia Bulbar Vocal cord palsy Esophageal reflux Alcoholism Infecting Organism: Bacterioder melaninogenicus Anaerobic/microaerophilic cocci B. fragilis S. aureus (most common) K.pneumoniae S.pneumonia. *Leimerres Syndrome is a rare cause of pulmonary abscesses. Usually, causative agent is F.secrophorum . Illness signs include sore throat, painful swollen neck, fever, ri

 HOSPITAL ACQUIRED PNEUMONIA Definition: "HAP refers to a new episode of pneumonia occurring at least 2 days after the administration to hospital. It is the most common Hospital Acquired Infection (HAI) and leading cause of HAI-associated death". Predisposing factors: Aspiration of nasopharyngeal secretion Bacteria introduced into the lower GIT. Bacteriaemia Old age Mode of Spread:  Droplet infection Infecting agent: Bacteria: S.pneumonia , S.aureus , H.influenza Virus: Adenovirus, Corona virus, Herpes Simplex Clinical Features: Purulent sputum New radiological infiltrates Temperature > 38 degree Celsius Leukocytosis Investigations: Chest Pain:  to confirm the diagnosis and exclude complication. Pulse Oximetry : to monitor response to oxygen therapy, if SaO2 < 93% features of sever pneumonia, identify ventilatory failure or acidosis. Cell count:  ESR, Neutrophil leukocytosis Microbiological studies:  for severe CAP and those that do not respond to initial therapy (Gr

 DRUG-INDUCED OTOTOXICITY What is drug Induced Ototoxicity? Drug-Induced ototoxicity can affect hearing (auditory or cochlear function0, balance (vestibular function) depending on the drug. Drugs of almost every class have been reported to produce tinnitus (sounds in ear), as have placebos. The following agents are associated with measurable changes in hearing or vestibular defect when administered systemically. 1. AMINOGLYCOSIDES: Aminoglycosides antibiotics can cause cochlear or vestibular toxicities. Cochlear toxicity: occurs as progressive hear loss, starting with highest tones and advancing to lower tones. Thus, considerable damage can occur before the patient recognizes it. S ymptoms of Vestibular damage : include;  Dizziness Vertigo Ataxia Both forms of ototoxicity are bilateral and potentially reversible, but permanent damage is common and can progress even after discontinuation of aminoglycosides. Clinically detectable ototoxicity in as many as 5% patients. Most aminoglycosid

 GASTROINTESTINAL DECONTAMINATION AFTER POISONING GI-decontamination can be achieved by the administration of: Activated Charcoal Gastric Lavage Ipecac-induced Emesis Whole-Bowel Irrigation Indication for GI-decontamination: Ingestion of a known toxic dose Ingestion of an unknown dose of a known toxic substance Ingestion of a substance of known toxicity * For all methods of GI-decontamination, the value of the procedure diminishes with time. Some investigators now question the usefulness of gastric lavage, or ipecac-induced emesis more than 1 hr after ingestion.* *In general, activated charcoal is the most useful agent for preventing absorption of ingested toxic substance. Other methods may be considered if the ingested substance is not adsorbed by activated charcoal or if circumstances do not permit its prompt  administration. * 1.Activated Charcoal: Activated charcoal is a non-specific absorbent that binds unabsorbed toxins within the GIT.  Activated charcoal is not effective for abs

MEDICAL EMERGENCY- POISONING Management of the poisoned patient involves procedures designed to prevent the absorption, minimize the toxicity, and hasten the elimination to the suspected toxin. The prompt employment of appropriate emergency management procedures often can prevent unnecessary morbidity and mortality. A Regional Poison Center is a practitioner's best source of definitive treatment information and should be consulted in all poisonings, regardless of the apparent simplicity of the case. In all cases, every attempt should be made to accurately identify the toxin, estimate the quantity involved, and determine the time that has passed since the exposure. These data, plus patient-specific parameters such as age, weight, sex, and underlying medical condition or drug-use will assist the person and the Regional Poison Center in designing an appropriate therapeutic plan for the patient. POISONING BY TOPICAL EXPOSURES: Immediately irrigate affected areas with a copious amount

MANAGEMENT OF GASTRO-ESOPHAGEAL REFLUX DISEASE  "GERD refers to the endoscopically determined esophagitis or endoscopy-negative reflux disease" . "GERD is the term used to describe any symptomatic clinical condition or histopathological alteration resulting from episodes of reflux of acid, pepsin and occasionally, bile into the esophagus from the stomach". Patients with uninvestigated "reflux-like" symptoms should be managed as patients with uninvestigated dyspepsia. There is currently no evidence that H.pylori should be investigated in patients with GERD. Symptoms: Heartburn is the characteristic symptom of GERD. Acid regurgitation Dysphagia Belching Upper abdominal discomfort Bloating and postprandial fullness Chest pain Hoarseness Cough Complications include: Esophageal ulceration Formation of specialized columnar-lined esophagus at the gastro-esophageal junction known as Barretts Esophagus . Mechanism of Acid Reflux: The mechanism of acid reflux is mu

MANAGEMENT FOR H.PYLORI ERADICATION It is known that H.pylori infection is associated with over 90% of duodenal ulcers and 80% of Gastric Ulcers. Antibiotics alone or acid-suppressing agents alone, do not eradicate H.pylori . Both therapies act synergistically as growth of the organism occurs at elevated pH and antibiotics efficacy is enhanced during growth. Additionally, increasing intragastric pH may enhance antibiotic absorption. High eradication rates are achieved by a short course of Triple Therapy consisting of:            1 .PPI                                         2. Clarithromycin                         3. Amoxicillin/Metronidazole          in a twice recommended simultaneous regimen. First-Line Therapy :  European Guidelines recommended 1 week of therapy, whereas the US Guidelines recommend 10-14 days of therapy and achieve 7-9% better eradication rates.     OCA : Omeprazole(20mg), Clarithromycin (500mg) and Amoxicillin (1g)                                         

  COMPLICATIONS OF PEPTIC ULCER DISEASE Bleeding peptic ulcer Pyloric stenosis Zollinger-Ellison Disease Stress Ulcers Bleeding peptic ulcer: Peptic ulcer is the most common cause of non-variceal upper gastro-intestinal bleeding. Most patients with bleeding peptic ulcer are clinically stable and stop bleeding without any intervention, whereas other outcomes include re-bleeding and mortality. Endoscopy allows identification of the severity of disease. Endoscopic hemostatic therapy which is successful in reducing mortality. A number of pharmacological agents have been used for endoscopic injection therapy such as 1:10000 adrenaline (epinephrine), human thrombin and fibrin glue. Mechanical endoscopic treatment options include Thermocoagulation using a heater probe or endoscopic clipping. Combination therapies are superior to monotherapy and a combination of adrenaline 1:10000 with either thermal or mechanical treatment is recommended (SIGN,2008). Pyloric Stenosis: Malignancy is the most c

 PEPTIC ULCER Clinical Manifestations: Upper abdominal pain; occurring 1-3hour after meals and relieved by food or antacids in the classic symptom of peptic-ulcer disease. Anorexia Weight loss Nausea Vomiting Heartburn Hemorrhage Chronic-iron deficiency anemia Pyloric stenosis Perforations In the elderly, the presentation is more likely to be silent and gastro-intestinal bleeding may be the first clinical sign of disease. Patient Assessment: Presenting symptoms of dyspepsia require careful assessment to judge the risk of serious disease or to provide appropriate symptomatic treatment.      1.Reflux-like dyspepsia: Heartburn plus dyspepsia Acid regurgitation plus dyspepsia       2. Ulcer-like dyspepsia:  Localized epigastric  pain. Pain when hungry Pain relieved by  food. Pain relieved by antacids or acid-reducing  drugs. Pain that wakens the patient from sleep Pain with remission and relapse       3. Dysmotility-like Dyspepsia: Upper abdominal discomfort (pain not dominant) Early sati