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전체자료 49개

Acute drug intoxication

Drug intoxication General management of Poisoned PatientsHow do hazardous substances enter the body? The setting of the poison exposure may be occupational, environmental, recreational, or medicinalEpidemiology 0.5~2% of ER visits Common in young age, Female Poisoning leading methods of suicidal attempts Deaths from pesticide herbicide poisoning: 1,700/ yr (1998, Korea)Epidemiology More than 2 million toxic exposures reported in 2000 in USA Over half were children 6 yr The annual incidence of poisoning is increasing, with a 4.6 percent increase in cases noted between 2000 and 2001 In 2008, almost 2.5 million toxic exposures were reported to poison control centers in the U.S., with 1315 deaths related to the toxin or drug, with 58% involving children 12 years of age.In Emergency Room…. History Physical Exam TreatmentHistory It is often difficult to obtain a reliable and accurate history from overdose patients Poisoned patients with altered mental status Ask about The agent or drug, amou excessive lacrimation Lung heart bronchorrhea or wheezing, heart for its rhythm, rate, and regularity. Abdomen Bowel sounds, enlarged bladder, and abdominal tenderness or rigidity. Extremities muscle tone and note any tremor or fasciculation If the patient's condition allows, a more intensive neurologic assessment of cognition, cranial nerves, tendon reflexes, muscle strength, coordination, and gait is useful.Toxidromes Toxin + Syndrome = Toxidrome Toxidromes are collections of physical findings that occur with specific classes of substances In clinical practice, the identification of a specific toxidrome is helpful in establishing potential toxic agents when the history is not well defined. Odors and skin findings may also provide useful clues.Toxidromes SLUDGE Salivation Lacrimization Urination Diarrhea Gastric cramping EmesisAntidote Poison N- acetylcysteine Acetaminophen Calcium gluconate Calcium chloride Calcium channel blocker Amyl nitrate Sodium nitrate Thisulfate Cyanide poisoients Coma cocktail Oxygen 2mg Naloxone IV 50ml of D50W for adults and 1g/kg glucose for children 100mg thiamineTreatments Antidote Reduce absorption of the toxin Enhance eliminationReduce absorption Activated Charcoal Gastric lavage Emesis Cathartics Whole bowel irrigationActivated charcoal The agent most often used to decontaminate the GI tract after toxic ingestion Activated charcoal works by adsorbing substances in the gut lumen Most organic and some inorganic substances are adsorbed by activated charcoal Activated charcoal is typically given in a slurry of water or juice by mouth or through a nasogastric tube Recommended dosing is a 1g/kgActivated charcoal Drug and toxins poorly adsorbed by activated charcoal Alkali and Acid Ethanol and other alcohol Ethylene glycol Fluoride Iron Lithium Potassium Mineral acid CyanideActivated charcoal Contraindications Absent gut motility or perforation Caustic ingestion Loss of protective airway reflex Complications Aspiration pneumonitis Constiairway integrity Ingestion of sustained-release or enteric-coated tablet Ingestion of caustics Complications Respiratory depression Increase vagal tone Aspiration Esophageal trauma Airway traumaEmesis Work both peripherally on the stomach and centrally on the chemotactic trigger zone to induce vomiting The typical dose is 15 mL for children 1 to 12 years of age and 30 mL for adults Effective only within 30-60minutes Most patients reach the hospital beyond the time frame when the agent would still be in the stomach, because the toxin either has been absorbed or has passed through the pylorusCathartics 70% sorbitol (1 gram/kg) or a 10% solution of magnesium citrate (250 mL for adults and 4 mL/kg for children) Cathartics decrease the transit time for the passage of the activated charcoal (and presumably the adsorbed toxin) through the GI tract Generally not found beneficialCathartics Contraindication Ileus Intestinal obstruction Adverse effect Severe fluid loss Hypernatremia, hypermagnesstained release formulation Agents with potential for bezoar formation Iron and other heavy metal Lithim Contraindications Ileus Intestinal obstruction Complications bloating, cramping, and rectal irritation from frequent bowel movements.Enhance elimination Urinary Alkalinization Urinary Acidification Hemodialysis/ HemoperfusionUrinary Alkalinization Manipulation of urinary pH toward alkaline is done to enhance the clearance of specific toxins NaHCO3 becomes concentrated in the urine, which results in significant elevation of urinary pH When the urinary pH is significantly raised, toxins that are weak acids dissolved in the urine are converted from their nonionized form to their ionized form Chlorophenoxy herbicides, Phenobarbital , SalicylatesUrinary Acidification Acidification of urine can somewhat enhance elimination of weak bases, such as amphetamines, phencyclidine, and some other drugsHemodialysis/ Hemoperfusion Hemodialysis Removed by diffusion across semipermeable membrane Toxinhow}

의/약학| 2012.08.06| 32페이지| 3,000원| 조회(231)

약물중독, hemodialysis, Acute drug intoxicatio..

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NECK DISSECTION

NECK DISSECTIONCervical lymph node in level I-VLevel I Submental triangle (Ia) Anterior digastric Hyoid Mylohyoid Submandibular triangle (Ib) Anterior and posterior digastric Mandible .Level II Upper Jugular Nodes Anterior  Lateral border of sternohyoid, posterior digastric and stylohyoid Posterior  Posterior border of SCM Skull base Hyoid bone (clinical landmark) Carotid bifurcation (surgical landmark) Level IIa anterior to XI Level IIb posterior to XI Submuscular recess Oropharynx oral cavity and laryngeal metsLevel III Middle jugular nodes Anterior  Lateral border of sternohyoid Posterior  Posterior border of SCM Inferior border of level II Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark) Junction with IJVLevel IV Lower jugular nodes Anterior  Lateral border of sternohyoid Posterior  Posterior border of SCM Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark) Junction with IJV ClavicleLevel V Posterior triangle of neck Posterior border of SCM Clavicle Anterior border of trapezius Va  Spinal accessory nodes Vb  Transverse cervical artery nodes Radiologic landmark Inferior border of Cricoid Supraclavicular nodesLevel VI Anterior compartment Hyoid Suprasternal notch Medial border of carotid sheath Perithyroidal lymph nodes Paratracheal lymph nodes Precricoid (Delphian) lymph nodeStaging of Neck Nodes N X : Regional lymph nodes can not be assessed N 0 : No regional lymph node metastasis N 1 : Metastasis in a single ipsilateral lymph nodes, 3 cm or less in greatest dimension N 2 : N 2a : Metastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cmStaging of Neck Nodes N 2b : Metastasis in multiple ipsilateral lymph nodes, not more than 6 cm N 2c : Metastasis in bilateral or contralateral nodes not more than 6 cm in diameter N 3 : Metastasis in lymph nodes more than 6 cm in in greatest diameterClassification of Neck Dissections The RND is classified according to the Academy’s Committee for Head Neck Surgery Oncology into four major type : Radical Neck Dissection (RND) Modified Radical Neck Dissection (MRND) Selective Neck Dissection (SND) Extended Neck Dissection1. Radical Neck Dissection Removing all lymphatic tissues in regions I - V and include removal of SAN, SCM and IJV1. Radical Neck Dissection Indications Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN Large metastatic tumor mass or multiple matted in upper part of the neck Tumor should not be dissected to preserve Structures2. Modified Radical Neck Dissection Definition Excision of all lymph nodes removed with RND with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJV Advantage Reduce postsurgical shoulder pain and shoulder dysfunction Improve cosmetic outcome Reduce likelihood of bilateral IJV resection in contralateral neck involvement2. Modified Radical Neck Dissection Type Type I: Preservation of SAN Type II: Preservation of SAN and IJV Type III: Preservation of SAN, IJV, and SCM ( “Functional neck dissection”)2. Modified Radical Neck Dissection Indications MRND Type I: Clinically obvious lymph node metastases SAN not involved by tumor Intraoperative decision2. Modified Radical Neck Dissection Indications MRND Type II: Rarely planned Intra-operative decision for tumor found adherent to SCM but away from SAN IJV MRND Type III: For treatment of N 0 neck nodes Indicated for N 1 mobile nodes and not greater than 2.5 – 3.0 cm Depend on the biopsy Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels They are not found within the aponeurosis or glandular capsule of the submandibular3. Selective Neck Dissection Remove high risk lymph node groups based on tumor site Supraomohyoid Levels I-III Lateral Levels II-IV Posterolateral Levels II-V Postauricular nodes Suboccipital nodes Anterior Level VI RLN injury Hyperparathyroidism3. Selective Neck Dissection I ndication For treatment of N 0 neck nodes For N+ nodes when combined with radiotherapy Adjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spread Upgrade intra-operatively following positive frozen section4. Extended Neck Dissection Definition removal of one or more additional lymph node groups and/or non-lymphatic structures. Usually performed with N+ necks in MRND or RND when metastases invade structures usually preserved Examples Resection of the hypoglossal nerve resection or digastric muscle dissection of mediastinal nodes and central compartment for subglottic involvement removal of retropharyngeal lymph nodes for tumors originating in the pharyngeal wallsReference Charles W. Cummings et al., Cummings Otolaryngology: Head and Neck Surgery, 4 th edition, 2005.{nameOfApplication=Show}

의/약학| 2011.05.28| 21페이지| 2,000원| 조회(230)

Neck node, RND, lymph node, neck dissection

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Blepharoptosis

BlepharoptosisBlepharoptosis( 안검하수 ) Definition Drooping of the upper lid due to deficient development or paralysis of the levator palpebrae muscle Compensatory Mechanism Overaction of frontalis Throwing back the headClassification 발생 시기에 따른 분류 Congenital Acquired 원인에 따른 분류 Aponeurotic Myogenic Neurogenic Mechanical TraumaticAponeurotic ptosis Levator aponeurosis 가 tarsal plate 로 부터 dehiscence 되어 발생 Good Levator function 높은 쌍꺼풀선 눈꺼풀의 두께가 얇음Myogenic ptosis Congenital Congenital ptosis Blepharophimosis syndrome Marcus-Gunn jaw winking ptosis Acquired CPEO (Chronic progressive external ophthalmoplegia) Muscular dystrophy Myasthenia gravisNeurogenic ptosis Third nerve paralysis Horner syndrome(ptosis , anhydrosis and miosis)Mechanical ptosisTraumatic ptosisEvaluation of ptosis Levator function: 수술방법의 결정 Good : 10mm or more Fair : 5-10mm Poor : 5mm or lessSurgical correction of ptosis Moderate or good levator function Resection of the levator m. Poor levator function Frontalis suspension (suspend the lid to frontalis m.)Levator resectionTechniques of Frontalis slingSling materials Autogenous fascia lata Banked fascia lata Supramid Extra  (4-0 nylon polyfilament ) Silicone Gore-Tex{nameOfApplication=Show}

의/약학| 2011.05.28| 13페이지| 1,500원| 조회(142)

안과, 안검하수, Ptosis, blepharoptosis

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VHL

Renal Cell Carcinoma (RCC)Occurs in 28% of individualsLeading cause of death in vHL vHL related RCC occurs at an earlier age than sporadic RCC, often multiple and bilateralCT scanning is more sensitive than U/STreatment - surgical (with preservation of renal tissue if possible)

의/약학| 2011.05.22| 12페이지| 1,000원| 조회(80)

VHL, hemangioblastoma, von Hippel-Lindau

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Hemangioblastoma

PrognosisThe outcome for hemangioblastoma is very good, if surgical extraction of the tumor can be achievedPersons with VHL syndrome have a bleaker prognosis than those who have sporadic tumors since those with VHL syndrome usually have more than one lesion

의/약학| 2011.05.22| 11페이지| 1,000원| 조회(98)

뇌종양, CNS tumor, VHL, hemangioblastoma

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