D. Lester. Trinity College of Florida.

However order xenical toronto, lack of consen- metronidazole are an effective combination in at least 98% sus suggests that better evidence is needed for peritonsillar of cases of peritonsillar abscess; (3) there is no convincing abscess management purchase xenical 120 mg, especially for recurrence rates and dif- evidence in favor of either aspiration or incision and drainage; ferent management strategies order xenical 60 mg. Potassium Hydroxide Smear for Wet Mount Obtain a sample of pharyngeal discharge using a cotton-tipped applicator. It is important to diagnose streptococcal Test results of 50% lymphocytes and at least pharyngitis so it can be treated promptly with antibiot- 10% atypical lymphocytes support a diagnosis of ics, avoiding serious sequelae, such as peritonsillar mononucleosis; a positive Monospot test result is abscesses, rheumatic fever, or glomerulonephritis. If it should be referred for further evaluation with com- is positive, the patient is treated without follow-up puted tomography. The test has a sensitivity of 75% to 85% and Nasal Smear a specifcity of 95% to 98%. The presence of eosinophils on a toms appear and remains positive for up to 1 year. When obtaining a culture, frst remove crusts Epiglottitis is caused by infection with H. The edematous epiglottis may be pulled across the posterior pharynx, and then swab the other into the larynx during inspiration and can completely tonsil. This titer does not A peritonsillar abscess, also called quinsy, is a collec- increase until 1 to 6 months postinfection, so it is of no tion of pus between the tonsil and the capsule of the diagnostic value. This condition occurs in children but is streptococci-associated infections, such as rheumatic more common in adults, especially in people with a fever, glomerulonephritis, and pericarditis. The patient’s presenting Chapter 32 • Sore Throat 387 concerns usually include a history of respiratory symp- Table 32-2 Groups at Risk for Group A toms, diffculty swallowing, otalgia, malaise, fever, and cervical lymphadenopathy. Children with retropharyngeal abscess are Tonsillar exudate None; treat on basis of risk usually under the age of 4 and need immediate referral. Scarlet fever None; treat Strep epidemic There usually is no tonsillar enlargement or pharyngeal Antibiotics already started exudate although infection with an adenovirus may produce exudate. About 10% of adults and positive, treat; if negative, 30% of children who seek care for sore throat symp- do not culture; do not toms, especially during winter months, have strepto- treat if culture negative coccal tonsillopharyngitis. The symptoms most likely to occur with streptococcal pharyngitis include a fever with a tem- complete blood count that shows greater than 50% lym- perature of 38. Splenomegaly occurs in about 50% of exudate, anterior cervical adenopathy, and a history of cases, and palatine petechiae are a less common symp- recent exposure. Examination shows an exudative pharyngitis with bilateral cervical lymphadenopathy. History typically Infammatory sore throat occurs in the presence of si- reveals a gradual onset, low-grade fever, mild sore nusitis or exposure to local irritants. The patient often throat, posterior cervical lymphadenopathy, weight reports postnasal drip and allergic symptoms (itchy, loss, and pronounced malaise and fatigue. Diagnosis watery eyes, runny nose) that may follow seasonal pat- can be confrmed with a positive Monospot test and a terns. On examination, the patient may have sinus 388 Chapter 32 • Sore Throat tenderness. The pharynx may be swollen or pale with Gram staining shows spirochetes and confrms the posterior drainage present. Aphthous Stomatitis Pharyngitis With Ulcers Aphthous stomatitis, or “canker sores,” appears as discrete Herpangina ulcers without preceding vesicles. The ulcers are located Herpangina is an infection caused by the coxsackievi- on the inner lip, tongue, and buccal mucosa. Headache, anorexia, and neck, abdomen, but immunological mechanisms play a major role. Within 2 days of onset, small, grayish, papulovesicular lesions appear on the Herpes Simplex Virus Type 1 soft palate and pharynx. Outbreaks is associated with fever, headache, sore throat, and occur during the summer months. Characteristic clusters of yellow vesi- peaks in August, September, and October, although cles appear on the palate, pharynx, and gingiva. Recurrent lesions are characterized by common in children and in immunosuppressed prodromal symptoms of burning, tingling, or itching. Vincent Angina Candidiasis Vincent angina is caused by a fusospirochetal infec- Candidiasis is a yeast infection that produces white tion that results in necrotizing ulcerative gingivosto- plaques over the tongue and oral mucosa with ery- matitis. Without sec- fection occurs commonly in otherwise normal infants ondary infection, there usually is no fever. On exami- in the frst weeks of life; in immunocompromised nation, gray, necrotic ulcers without vesicles are people, including those with diabetes; and in people apparent on the gingivae and interdental papillae. It is distinct from coma, seizures, shock, vertigo, and other states of altered conscious- Key Questions ness. The causes of syncope can be diffcult to determine because patients generally are seen after the event Loss of Consciousness has occurred. Cardiogenic syncope has high associated morbidity and mortality, and the emphasis Prodromal Symptoms in diagnosis is to rule out the most serious causes Sweating, vertigo, nausea, and/or yawning are prodromal through a careful history and physical examination, symptoms that are associated with syncope; seizures may with a few laboratory and diagnostic tests to establish be associated with an aura or tongue biting. The authors of this guideline echocardiography, stress testing, Holter monitoring, or elec- undertook an extensive review of the literature to help clini- trophysiology study, alone or in combination (diagnostic cians maximize the diagnostic yield in the workup of syncope yield, 5% to 35%). Syncope in the elderly often results from polypharmacy of syncope: and abnormal physiological responses to daily events. Neurological testing is rarely helpful unless additional in whom heart disease is not suspected. Hospitalization may be indicated for patients at high risk those with exertional syncope who are at higher risk for for cardiac syncope or with acute neurological signs. Breath-holding spells commonly cause syncope in children and are usually precipitated by pain, anger, a History of Heart Disease/Congenital sudden startle, or frustration. Syncope occurs with rest Heart Problem or when supine during a seizure or arrhythmia. Syn- The presence of structural heart disease increases the cope that occurs without warning symptoms is highly risk of sudden death. Cardiac Event and Postevent Characteristics syncope may be either arrhythmic or mechanical in Rhythmic movements of extremities during the event origin. Cardiac outfow obstruction from aortic or usually indicate a seizure, although they can occur mitral stenosis or a prosthetic valve may cause syn- with syncope. Complete heart block, the result of interruption in returning to consciousness, and unconsciousness of atrioventricular conduction, is a leading cause of lasting longer than 5 minutes indicate seizure. Children who have had cardiac surgery to children with breath-holding spells have associated correct severe congenital heart disease are at risk for cyanosis, clonic jerks, opisthotonos, and bradycardia. Witness Palpitations The patient is unconscious when the syncopal event Supraventricular or ventricular tachycardia are associ- takes place, and therefore is a poor historian. Ventricular tachy- history is needed from both the patient and a witness to cardia with a heart rate of 200 beats per minute may be help in the diagnosis. Chaotic ventricular syncope episodes generally have an audience when the activity of ventricular fbrillation is always fatal unless event occurs and are able to describe details of the event it is reversed with electrical defbrillation (see Chapter that would not be known to an unconscious patient. Chest Pain or Shortness of Breath Key Questions Obstructive mechanical blockage may be caused by l Do you have a history of heart disease? Results showed that reversion is includes symptoms of chest pain, palpitations, dyspnea, between 19.

In such cases buy 120 mg xenical visa, if production of the carbon monoxide ceases after the onset of irreversible coma xenical 120mg amex, the individual will gradually eliminate the carbon monoxide from the body cheap xenical 120mg online, even though irreversible injury has occurred. Thus, the authors have seen individuals who died from carboxy- hemoglobin poisoning register low or even negative carboxyhemoglobin lev- els at autopsy. An autopsy and complete toxicological analysis fail to 396 Forensic Pathology reveal a cause of death. If death does not occur immediately, the injury to these areas may increase over hours and days. Bilateral necrosis of the globus pallidus is the most characteristic lesion, though other affected areas include the cerebral cortex, hippocampus, cerebellum, and substantia nigra. The lesions in the globus pallidus, however, are nonspecific and can be seen in drug overdoses as well. In addition, there can be aphasia, apathy, disorientation, hallucinations, incontinence, slow movements, and muscu- lar rigidity. The median age of the individuals showing delayed deterioration was older than that of the hospitalized group as a whole. A lucid interval of 2–4 weeks commonly preceded the onset of the neurological sequelae. Three-quarters of the patients recovered within a year, though some showed persistent mild neurological injury. There were no clinical signs at the time of admission that would permit the physician to deduce which patients would incur the delayed neurological injury. The delayed neurological syndrome in carbon monoxide intoxication is associated with lesions of the cerebral white matter. It appears that a combination of hypotension and hypoxia is necessary to produce these lesions. Death by Drowning 15 Drowning can be defined as death caused by submersion in a liquid. It can occur in an ocean or, in the case of alcoholic stupor, epileptics, or infants, in water as shallow as 6 in. The original concept of drowning deaths was that they were asphyxial in nature, with water occluding the airways. Exper- iments in the late 1940s and early 1950s suggested that death was caused by electrolyte disturbances or cardiac arrhythmias produced by large volumes of water entering the circulation through the lungs. In freshwater drowning especially, large volumes of water can pass through the alveolar–capillary interface and enter the circulation. Even when large volumes of water are absorbed, there is no evidence that the increase in blood volume causes significant electrolyte irregularities or hemolysis, or that it is beyond the capacity of the heart or kidneys to com- pensate for the fluid overload. What is theorized to occur is that when a small amount of water enters the larynx or trachea, there is a sudden laryngeal spasm mediated as a vagal reflex. Thick mucous, foam, and froth may develop, producing an actual physical plug at this point. The authors have never seen the “physical plug” said to occur in the larynx and the “laryngospasm” cannot be demonstrated at autopsy, as death causes relaxation of the musculature. While the aforementioned explanation for dry drowning is interesting, it is a hypothesis and not proven. It is probable that dry drowning is just one end of a spectrum of changes seen in the lung produced by occlusion of the airways by water, with the other end the heavy, boggy lung containing a massive amount of edema fluid. This continues until a breaking point is reached, at which time the individuals have to take a breath. The breaking point is determined by a combination of high carbon dioxide levels and low oxygen concentra- tions. During this interval of submersed breathing, the patient may also vomit and aspirate some gastric contents. The involuntary gasping for air under water will continue for several minutes, until respiration ceases. The developing cerebral hypoxia will continue until it is irreversible and death occurs. The point at which cerebral anoxia becomes irreversible is dependent on both the age of the individual and the temperature of the water. Thus, cerebral hypoxia due to low blood P02, with development of unconsciousness, might occur before the breaking point is reached. In this case, the sequence would be: Voluntary holding of breath Unconsciousness Aspiration of water The type of water that is inhaled, fresh versus salt, probably has very little influence on whether the individual will survive. In fresh water, as previously noted, large volumes of water can pass through the alveolar Death by Drowning 401 capillary membranes. Fresh water alters or denatures pulmonary surfactant, while seawater dilutes or washes it away. Loss or inactivation of pulmonary sur- factant and alveolar collapse decrease lung compliance, resulting in pro- found ventilation perfusion mismatch with up to 75% of the blood perfusing non-ventilated areas. This refers to a submersion victim who arrives at an emergency facility and survives for 24 h. It is in the near drowning cases that physicians have been able to observe electrolyte changes. They have found that the electrolyte distur- bances and hemoglobinemia are mild, if present at all, and rarely have any clinical significance. The diving reflex refers to vasoconstriction in the vascular beds (except for the heart and brain), shunting of blood to the brain and heart and bradycardia, all triggered by immersion of the face in cold water. There is, however, some question as to whether the diving reflex exists in humans exactly as it does in animals. Many people feel that these children survive because of the rapid development of hypothermia. This is especially true in conjunc- tion with the swallowing and aspiration of large quantities of cold fluid. There is rapid cooling of the body caused by immersion in cold water and aspiration of cold water with absorption of this water into the circulation. Thus, while in warm water, a submersion time of 3–10 min is thought to represent the maximum time prior to irreversible neurological injury, in ice water, submersion times as long as 66 min have been reported with neurological recovery. The diagnosis is based on the circumstances of the death, plus a variety of nonspecific anatomical findings. Chemical tests put forth to make the diagnosis are nonspecific and essentially unreliable. A diagnosis of drown- ing cannot be made without a complete autopsy, especially a complete tox- icological screen, because this is a diagnosis of exclusion. If individuals are found in water and all other causes of death have been excluded, they are presumed to have drowned. It must be remembered, however, that people have fatal heart attacks and fall into water, and that victims of a fatal drug overdose are occasionally “dumped” into a body of water. Attachments of heavy weights to a body to keep it under water is consistent with both homicidal and suicidal drownings, as is disposal of the body of an individual who has died from some other cause than drowning. When a person drowns, the body sinks, assuming a position of head down, buttocks up, and extremities dangling downward.

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Intraoperative use of low concentration bupivacaine or ropivacaine blunts the surgical stress and reduces the intraoperative opioid requirements buy xenical overnight. Carli F buy generic xenical 60mg line, Mayo N discount xenical 120mg on-line, Klubien K, et al: Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Carli F, Trudel J, Belliveau P: The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Nelson R, Edwards S, Tse B: Prophylactic nasogastric decompression after abdominal surgery. It must be distinguished from rectal mucosal prolapse, caused by elongation of the mucosal attachments to the underlying sphincter muscle, and internal intussusception, where the upper rectum folds into the lower rectum, but does not descend through the sphincter mechanism. Rectal mucosal prolapse is treated as part of the spectrum of hemorrhoidal disease, and mild-to-moderate intussusception does not benefit from surgery. The surgical approaches to procidentia are determined by patient age, concurrent medical disease, sphincter function, and prior operative history, including previous abdominal surgery and prior attempts at surgical repair. Surgical treatment of procidentia may be undertaken through an abdominal or a perineal approach. Abdominal repair of rectal prolapse can be performed in either an open or laparoscopic fashion. The abdominal approaches have a lower recurrence rate and because they do not diminish the capacity of the rectal reservoir and are generally preferable for maintaining fecal continence. Rectopexy is an abdominal approach in which the rectum is mobilized in the posterior plane from the sacral promontory to the levator muscles. The rectum is then pulled cephalad and sutured to the presacral fascia with multiple nonabsorbable sutures, or tacked to the presacral fascia using surgical tacks. Mesh may or may not be used to fix the rectum to the sacrum depending on the operative preference of the surgeon. They believe that removal of the redundant sigmoid further diminishes the chance of late recurrence and may alleviate constipation. A number of approaches have been described, the most popular being the Ripstein procedure. As in rectopexy, the rectum is mobilized along the presacral plane down to the level of the levators. A band of Marlex mesh is sewn to the presacral fascia at the sacral promontory, upward traction is placed on the rectum, and the mesh is sutured to the rectum. Transabdominal repair of rectal prolapse is the favored approach for younger patients with rectal prolapse or older paints with few medical comorbidities due to the significantly lower rate of recurrence of the prolapse. Not uncommonly, however, patients with rectal prolapse are significantly advanced in age or have significant medical comorbidities. The prolapsed rectum is withdrawn through the anal canal to its full extent, and a circumferential incision is made in the outer tube of the prolapsed bowel just proximal to the dentate line. Redundant bowel is mobilized from the distal end, up to the point that no additional bowel can be delivered into the operative field. The redundant bowel is transected, and a primary anastomosis is fashioned between the cut ends of the inner and outer bowel. Prior to anastomosis, the levator muscles are often approximated in the midline in an effort to aid continence. When the volume of prolapsed tissue is small or a previous abdominal approach makes blood supply to the rectum questionable, the Delorme procedure often is performed. During this procedure, the mucosa is stripped off the prolapsed rectum, and the prolapsed rectal muscle is foreshortened by plication until it resides above the sphincters. Perineal repair of rectal prolapse is most commonly done under a general anesthetic as the patient is typically positioned prone, the procedure can take 60–90 min; and in the case of a perineal rectosigmoidectomy, the peritoneal cavity is entered. However, in very high risk patients for whom intubation or general anesthesia is a concern, the procedure can be done under an epidural, or local with sedation. Lesions such as carcinoid tumor, endometrioma, and solitary rectal ulcer also may be locally excised. Transanal excision of benign lesions may be performed in the submucosal plane, whereas suspected malignancies are excised by removing the entire thickness of the rectal wall. Transanal excision usually is performed in the prone jackknife position, although the lithotomy position may be used when the lesion is located on the posterior rectal wall. On occasion, lesions may be prolapsed all the way through the anus and excised outside the body. Generally, the dissection starts at the distal end of the lesion and proceeds proximally. When the specimen is removed, a few final sutures are needed to close the proximal-most incision. In this technique, the patient is placed on the operating table in a position that puts the lesion to be removed posterior. Because of this, the patient may be prone, supine in lithotomy, or in the right or left lateral decubitus position. The procedure is performed through a larger operating proctoscope that is secured to the operating table. The carbon dioxide will be absorbed through the mucosa of the colon and be exhaled. Laparoscopic like instruments are passed through the proctoscope, and the surgeon views the operation either through a stereo viewer attached to the proctoscope or on a video screen. Transsacral: The transsacral (Kraske) approach to rectal tumors offers wider exposure than the transanal approach, but is more painful and has a substantially greater likelihood of complications (wound infection, fecal fistula, incontinence). A transsacral approach may be advantageous when the lesion is located behind the rectum (retrorectal tumors) and when resection of the lower sacrum or coccyx is anticipated. An incision is made from the posterior commissure of the anus to the base of the sacrum. The sphincter muscles are spared, but the levator muscles are divided to expose the posterior wall of the rectum. It is also possible to remove the lower sacral segments through this approach, but increasing morbidity accrues as the sacral nerve roots are sacrificed. For a posterior-wall lesion, the posterior wall of the rectum is opened, and the lesion, along with a full-thickness disc of rectal wall, is excised. The transsacral approach may be combined with an abdominal approach (abdominal-transsacral resection) in some cases of low rectal cancer. Transsphincteric: The transsphincteric (York-Mason) approach to rectal lesions also gives wider exposure than does the transanal approach, but at the expense of a substantially greater risk of fecal incontinence. Transsphincteric excision is performed with the patient in the prone jackknife position. An incision is made at the posterior commissure of the anus and is extended along the lateral border of the coccyx and sacrum. The external sphincter, internal sphincter, and levator ani muscles are sequentially transected in the posterior midline.

The mesh of fibrin strands and platelet aggregates obstructs flow in the infarct-related artery purchase xenical amex. Pharmacologic reperfusion is a multipronged approach consisting of fibrinolytic agents that digest fibrin buy genuine xenical line, anticoagulants that prevent the formation of thrombin and inhibit the activity of formed thrombin 60 mg xenical overnight delivery, and antiplatelet therapy. Nevertheless, a meta-analysis of trials in the fibrinolytic era suggested that for every 1000 patients treated with heparin versus aspirin alone, five fewer deaths (P = 0. The most serious complication of anticoagulant therapy is bleeding (see Chapter 93), especially intracranial hemorrhage. In addition, both hirudin and bivalirudin cause higher rates of major bleeding than heparin when used with 74 fibrinolytic agents. Treatment with bivalirudin significantly 72 reduced mortality at 30 days and at 1 year, but increased the early risk for stent thrombosis. Overall, bivalirudin-based regimens lowered the risk of major bleeding (risk ratio, 0. Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials. A, Treatment with bivalirudin was associated with significantly lower rates of major bleeding and mortality at 30 days. C, Acute stent thrombosis during the first 24 hours was higher in patients treated with bivalirudin alone, but cardiovascular mortality was reduced in the bivalirudin group after 1 year of follow-up, thus providing strong evidence for this treatment strategy. The dashed vertical line indicates the comparison at day 2 (direct pharmacologic comparison), at which time a trend in favor of enoxaparin was seen. Individual outcomes of all-cause death, reinfarction, and major bleeding through 7 days are shown. In patients with a known history of heparin-induced thrombocytopenia, bivalirudin in conjunction with 1 streptokinase is a useful alternative to heparin. Antiplatelet Therapy Platelets play a major role in the response to disruption of coronary artery plaque, especially in the early phase of thrombus formation. Fibrinolysis can activate platelets, and platelet-rich thrombi resist fibrinolysis more than fibrin and erythrocyte-rich thrombi (eFig. In contrast to the observations of a time-dependent mortality effect of fibrinolytic therapy, the reduction in mortality with aspirin was similar in patients treated within 4 hours (25% reduction in mortality), between 5 and 12 hours (21% reduction), and between 13 and 24 hours (21% reduction). The reduction in mortality was as high as 53% in patients who received both aspirin and streptokinase within 6 hours of symptoms. Inhibitors of the P2Y12 adenosine diphosphate receptor help prevent the activation and aggregation of platelets. Thus it appears that clopidogrel did not increase the rate of complete opening of occluded infarct arteries when fibrinolysis was administered, but was effective in preventing reocclusion of an initially reperfused infarct artery. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Patients in the clopidogrel group had a lower rate of the composite endpoint of death, reinfarction, or stroke (9. However, subsequent large outcomes trials revealed no significant effect on 79 survival, and reductions in reinfarction were outweighed by the increases in bleeding. Prasugrel reduced definite or probable stent thrombosis by 42% compared with clopidogrel. If true aspirin allergy is present, other antiplatelet agents such as clopidogrel or ticlopidine can be substituted. The data available suggest that a loading dose of 300 mg of clopidogrel should be given to patients younger than 75 years who receive fibrinolytic therapy. Data are insufficient in elderly patients to recommend a loading dose in those 75 years or older who receive a fibrinolytic. Interpatient variability in the response to clopidogrel can occur (see Chapters 8, 60, and 93), and individuals with lesser degrees of 89 platelet inhibition have increased risk for death and ischemic complications. When using ticagrelor, the recommended maintenance dose of aspirin is 81 mg daily. General Measures The managing clinical staff should be sensitive to patient concerns about prognosis and future productivity. Thereafter, dietary intervention is an important component of an overall strategy for secondary prevention (see Chapters 45 and 49). The results of laboratory tests should be scrutinized for any derangements potentially contributing to arrhythmias, such as disturbances in acid-base balance or electrolytes. Delirium can be provoked by medications frequently used in the hospital, including antiarrhythmic drugs, H blockers, narcotics, and2 beta blockers. Use of potentially offending agents should be discontinued in patients with an abnormal mental status. The net effect is a reduction in myocardial oxygen consumption per minute and per beat. Data available in the pre-reperfusion era suggested favorable trends toward a reduction in mortality, reinfarction, and cardiac arrest. The rate of the composite endpoint of death, reinfarction, or cardiac arrest in the metoprolol group (9. To achieve these benefits safely, early administration of beta blockers to patients with relative contraindications should be avoided (Table 59. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Selection of Beta Blockers Favorable effects have been reported with metoprolol, atenolol, carvedilol, timolol, and alprenolol; these benefits probably occur with propranolol and with esmolol, an ultrashort-acting agent, as well. In this situation a trial of esmolol may help determine whether the patient can tolerate beta- adrenergic blockade. Because the hemodynamic effects of this drug (half-life of 9 minutes) disappear in less than 30 minutes, it offers an advantage over longer-acting agents when the risk for complications with a beta blocker is relatively high. Analysis of these unselective short-term trials indicates that approximately one third of the lives saved occurred within the first 1 to 2 days. Not unexpectedly, greater survival benefits of 42 to 76 lives saved per 1000 patients treated were obtained in the selective trials with a long duration of therapy. To replicate these benefits in clinical practice, however, physicians should select a specific agent and prescribe the drug according to the protocols used in the clinical 94 trials. Adverse reactions include hypotension, especially after the first dose, and intolerable cough; much less often, angioedema can occur. Serious hyperkalemia (serum potassium [K ] concentration, 6 mmol/L) occurred in 5. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. In such cases, nitrate-induced venodilation could impair cardiac output and reduce coronary blood flow, thus worsening rather than improving myocardial oxygenation. Clinically significant methemoglobinemia, although rare, can develop when unusually large doses of nitrates are administered.

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