Alexander R. Opotowsky, MD, MPH

• Boston Adult Congenital Heart Service
• Children? Hospital Boston
• Brigham and Women? Hospital
• Boston, Massachusetts

The aims of this activity are to establish the boundaries of the family unit arrhythmia with normal ekg discount isoptin 240 mg with mastercard, support parental hierarchy arteria zygomatica order isoptin discount, have fun while building Feelings charades family cohesion and build confict resolution skills through Parents direct a family game at the family table pulse pressure klabunde 40 mg isoptin amex, asking each turn-taking blood pressure cuff walgreens buy discount isoptin 120mg online. By the fourth week hypertension yahoo buy cheap isoptin 240mg line, parents are encouraged to Parents are asked to introduce their family by name; everyone adapt the game to family style hypertension 5 days postpartum buy discount isoptin line. The aims of this activity are the same as those of the fag design Kids play activity, except with the addition of building relationships with A team leads locally created, developmentally appropriate other families in the same life situation living in the same activities for separate small groups of children. The aims of this activity are to clarify the boundaries of the child subsystems, support the peer group development of A lottery is held each week and the winning family hosts the children and siblings attending the same school, have fun and following weeks meal, using the money from the lottery to buy actively build friendships and team trust. The Parents spend 15 minutes in pairs for intimate support, followed winning family is then applauded and each family member by 45 minutes in a mutual aid parent group, sharing their receives a prize. The winning family plans and cooks the next successes, listening to one another and sharing advice so as to weeks meal. Marriages become stronger, friendships emerge with trust and the aim of the lottery is to establish the boundaries of the reciprocity and social capital is built in the school setting. Closing circle All gather into a large circle for announcements, singing on Parent-child special play birthdays, etc. As a closing ritual, nonverbal movements are One parent sits with one child for 15 minutes, giving full passed around the circle; the group makes sounds of rain then attention to child-initiated play without judging, directing or uses movements to represent an emerging sun. Non-directive materials are the aims of the closing circle are to talk and listen in a large provided, parents are praised and interruptions are avoided. The aim of this activity is to clarify the boundaries of the parent Daily homework for parent(s): special play child dyadic subsystem within the family unit. This activity helps parents to apply newly learned thus building an intimate bond with the child. Lottery Discussion of substance abuse (week 5) Parents are asked to tell their children to trust them, convincing A team presentation is made to the group at large, after which the children that their family will win the lottery one week. This is the only session during family wins once over the course of the eight weeks. Parents who have been using drugs marginalized, low-income, immigrant, inner-city and often seek treatment during the same week. Graduation hats and music add to the celebration, stress and social isolation which is in the style of a high school graduation event. Materials for certifed programme trainers are suit externalizing behaviours as listed on the Child Behaviour able for college-educated persons with knowledge of family Checklist and small to medium improvements in systems and related research. The cost for 80 families is approximately $60 per listed on the Child Behaviour Checklist, except among family, or $5,000 in total. A certifed trainer comes to the Latino subgroup implementation site fve times over a four-month period. The cost Together programme were signifcantly more likely to of training for professionals is $800 each for three days of team engage in community volunteering and community training and three days of face-to-face supervision during leadership. Description of materials Training of trainers is conducted in the form of a fve-day compulsory seminar (following completion of team training) No materials required, as learning is experiential. A programme supervisor is assigned to each trainer intern to guide him or her through programme Programme team members require the following team training implementation. After graduation and a fnal day of training reviews, the trainer interviews programme graduates and provides training for the monthly booster sessions. Training of trainers minimum of four facilitators; 25-75 per cent of team members with supervision is offered to communities in order to promote must be local parents working in partnership with a drug abuse local sustainability over time. Eight hub teams can serve up to Parent leaders attend booster sessions over two years, after 80 families at one school. Over time, the proportion of parent which they work to improve their local community. However, programme integrity standards (which are non-negotiable) include the requirement that teams of local Lynn McDonald, PhD (Programme Developer) Professor of Social Work parents, young persons and professionals represent the culture Department of Mental Health and Social Work of the families at the local school, inter alia, in terms of University of Middlesex language, religion, immigrant status, ethnicity and income level. Archway Team members must be familiar with local issues of importance London to the families and are encouraged to adapt group activities to United Kingdom the local culture. The required two days of team training are followed by Madison Wisconsin supervised implementation. Implementation of the eight weekly United States of America multi-family group sessions is required for training to be E-mail: pdavenport@familiesandschools. A certifed trainer Telephone: +1 608 213 9557 attends three of the eight sessions to observe and supervise the Website: In Conduct Disorders in Childhood and Adolescence, Jonathan Hill and Barbara Boyd-Franklin, Nancy. Families and schools together: Therapy: Home-Based, School, and Community Interventions. New an experimental analysis of a parent-mediated, multi-family group York: Guilford, 2000. Families and schools together: an experimental study of multi-family support groups for children at Bronfenbrenner, Urie. Cambridge, Strengthening Interventions: Learning From Evidence-Based Massachusetts: Abt Associates, 2001. Impact of a family and Empowering Families: Principles and Guidelines for Practice. Science Programs, Offce of Juvenile Justice and Delinquency Prevention, Based Prevention Programs and Principles 2002: Effective November 1999. United States Department of Health and Human randomized controlled trial involving low-income, urban, Latino Services, Substance Abuse and Mental Health Services children. Community-based practices: integrating dissemination and adolescent problem behavior: implications for child and family theory with critical theories of power and justice. The programme focuses on strengthening Risk level family bonds and establishing clear standards of behaviour, Universal helping parents to manage their teenage childs behaviour more appropriately and, at the same time, to encourage the childs independence. In this way, the programme seeks to address Age of children specifc risk factors in the family and peer domains, including 12-17 years drug abuse by a parent or sibling, parental tolerance of drug abuse, poor and inconsistent family management practices, family confict, lack of family communication, involvement and bonding and association with delinquent and drug-abusing peers. Parents and their children Outcomes Sessions (number, length and interval) Parent outcomes In a waiting list control trial, results for parent participants 7 two-hour sessions for parents and children indicated that the group in treatment showed a statistically signifcant improvement in three areas: family discipline, family Languages non-tolerance of antisocial behaviour and level of family English bonding. In addition, risk factors such as poor family supervision and low parental commitment to school were shown to have Countries diminished in the treatment group following the trial. Overall, United States the evaluation indicated that the programme had the potential to infuence risk and protective factors in families (Pollard et al. Child outcomes Description of content An independent randomized control trial tested the programme in two formats: a self-administered intervention and an the programme is led by a facilitator and implemented over 7 intervention administered to parents and adolescents in weekly two-hour sessions held once a week. Both formats had a small to moderate effect in fexible and can be implemented by schools, health-care discouraging favourable attitudes towards drug abuse among organizations, civic organizations, social service organizations young persons. Parents and their teenage children attend the self-administered intervention reported a moderate decrease sessions together and are given a family workbook consisting in violent behaviour compared with control-group counterparts. The video No effects were found on drug abuse or delinquency among follows four ethnically diverse families as they struggle with those who participated in the interventions. The programme is structured around three major topics: the Lastly, a combined outcome measure of initiation of alcohol, importance of risk and protective factors, the power of tobacco or drug use and/or sexual activity found African communication and family management. American teenagers who participated in both the administered page 77 of 128 and the self-administered intervention signifcantly less likely Staff are required to have experience in working with families. The workshop leaders undergo 20 hours of training by the principal investigator and intervention coordinator in the specifc content of the programme and in the implementation of standardized intervention protocols. Group sessions are led by Description of materials two workshop leaders, typically one European American and one African American. Contact details the family workbook is suitable for persons with a reading For information on studies: ability equivalent to grade 8. For information on materials and implementation: Additional materials for programme participants: $55 per set Channing Bete Company (bulk discounts available. Parenting and adolescent problem References: behavior: equivalence across African Americans and European Americans (under review. Changes in and correlates of racial Care: effects on key outcomes at 24-month follow-up. The 1 independent randomized control trial programme, designed for parents and their children aged 3-8 1 randomized control trial years, is based on the theoretical assumption that non-compliance in children is a key factor contributing to the development of 16 quasi-experimental studies conduct problems and that faulty parent-child interactions also 12 pre and post-intervention evaluations play a signifcant part in the development and continuation of those problems. Risk level Parents attend sessions with their children and trainers teach the Selective, indicated parents the skills they need to increase compliance in their children. The intervention generally takes place in a therapeutic Age of children playroom and parents learn skills through instructions, models, 3-8 years role play and practice with their child. The parent must demonstrate profciency in one skill Target group before moving on to the next. Parents of children who are non-compliant or have other con the programme consists of two phases. A major goal is to break out of the coercive cycle by establishing a positive, Sessions (number, length and interval) mutually reinforcing relationship between parent and child. Parents also learn how to implement the parenting skills in situations outside the home (e. Countries Canada, United Kingdom and United States Outcomes Description of content Studies over the past 30 years indicate the following Sessions are typically conducted with individual families rather outcomes: than in groups (although the programme has been adapted for use in groups. Parent Training for the Noncompliant Parent outcomes Child: A Guide for Training Therapists. The use of a one-way radio device can be a useful supplement Staff in training sessions but is not necessary. If resources permit, the participation of a co-trainer can increase the trainers fexibility Cost of materials in demonstrating various skills to the parent and can serve as a useful in vivo training experience for new trainers. Trainers manual: $29 (paperback) (bulk discounts available; please contact publisher. The trainer should have a background in psychology or education and should be familiar with social learning principles and their McMahon, Robert J. Ideally, the trainer should have Noncompliant Child: Family-Based Treatment for Oppositional experience working with young children (3-8 years old) with Behavior, 2nd ed. In addition, Self-guided programme for parents trainees are required to read and study the trainers manual prior Forehand, Rex, and Nicholas Long. Child: the Clinically-Proven Five-Week Program for Parents of Two to Six-Year-Olds, revised and updated ed. McMahon, PhD Parent class curriculum Department of Psychology Long, Nicholas, and Rex Forehand. The role of Therapist manual and literature review maternal distress in a parent training program to modify child noncompliance. Parent behavioral training to modify child noncompliance: factors in McMahon, Robert J. In Adherence, Compliance, and Noncompliant Child: Family-Based Treatment for Oppositional Generalization in Behavioral Medicine, Richard B. Parent training for the Demonstration videotape noncompliant child: treatment outcome, generalization, and Forehand, Rex, and others. Paper presented at the therapy on the treatment outcome and generalization of a parent meeting of the Association for Advancement of Behavior Therapy, training program. Bibliotherapy as an management of their developmentally and language delayed adjunct to stimulant medication in the treatment of attention-defcit children. Modifcations of a parental with maritally distressed and non-distressed mothers: a multimethod training program for implementation beyond the clinical setting. Behavioral Counseling Quarterly, effects of parent training on behavior and attitude change. Parental satisfaction with parent behavioral training: an analysis of the relationship among multiple training to modify child noncompliance. An effectiveness of a standardized parent training program in altering examination of the social validity of a parent training program.

The report explores the effects of patents and licensing practices on basic genetic research arrhythmia electrolyte imbalance buy cheap isoptin 40 mg on line, genetic test development heart attack low isoptin 120mg, patient access to genetic tests blood pressure 45 year old male purchase genuine isoptin, and genetic testing quality and offers advice on how to address harms and potential future problems that the Committee identified blood pressure chart in urdu proven 240 mg isoptin. It is based on evidence gathered through a literature review and original case studies of genetic testing for 10 clinical conditions as well as consultations with experts and a consideration of public perspectives heart attack troublemaker purchase isoptin paypal. The Committee also found that patents have been used to narrow or clear the market of existing tests blood pressure chart morning cheap isoptin 120 mg overnight delivery, thereby limiting, rather than promoting availability of testing. The substantial number of existing patents on genes and methods of diagnosis also pose a threat to the development of multiplex testing, parallel sequencing, and whole-genome sequencing, the areas of genetic testing with the greatest potential future benefits. The six recommendations contained in this report identify steps that the Department of Health and Human Services could take to help address existing harms and to help eliminate potential barriers to development of promising new testing technologies. The statutory changes the Committee has proposed are narrowly tailored to directly address the identified problems without altering patent rights for therapeutics. We appreciate the opportunity to serve you and the Department and hope the report will help you and the Department in achieving equitable access to health care and stimulating progress in health care technology. Director Department of Commerce Office of Public Health Genomics Centers for Disease Control and Prevention Michael Amos, Ph. In addition, Brian Stanton was a technical expert from the government until he retired and then he continued on the Task Force as an ad hoc member. Robert Cook-Deegan and his team of researchers at the Center for Genome Ethics, Law & Policy at Duke University, who conducted the original case studies that informed the report and provided assistance to the Committee throughout the study. Cho, Associate Director of the Stanford Center for Biomedical Ethics; Mark McCamish, then-Chief Medical Officer of Perlegen Sciences; the Honorable Pauline Newman, Circuit Judge of the U. Court of Appeals for the Federal Circuit; Richard Gold, Associate Professor, McGill University Faculty of Law; Shobita Parthasarathy, Assistant Professor of Public Policy, Gerald R. Coyne Visiting Professor of International and Comparative Law, George Washington University School of Law; Bhaven Sampat, Assistant Professor in the Department of Health Policy and Management, School of International and Public Affairs at Columbia University; John Barton, Professor of Law, v Emeritus, Stanford Law School; and Christina Sampogna, Senior Project Leader for Patents and Biotechnology, Organisation for Economic Co-operation and Development. The Committee also thanks all of the individuals and organizations that responded to the Committees request for public comments on an earlier draft of the report (see Appendix C for a list of public commenters. The Committee carefully considered each submitted comment; this input from the public greatly helped with the development of the report and recommendations. Consultants Kathi Hanna and Sara Maddox provided, respectively, writing and editing support and summaries of the public comments. Sarah Carr shepherded the project from beginning to end, overseeing the Committees study and managing the development of this report. The Effect of Patents and Licensing Practices on Clinical and Patient Access to Genetic Tests. The Potential Effect of Patents and Licensing Practices on Genetic Testing Innovations. The Potential Effect of Patents and Licensing Practices on the Development of Multiplex Tests. The Potential Effect of Patents and Licensing Practices on Clinical Whole-Genome Sequencing. Analysis of Potential Approaches to Addressing Problems in Test Development and Patient Access. The individual task force members possessed relevant expertise and diverse perspectives on the topic of gene patents and licensing. The task forces role was to guide the development of an in-depth study assessing whether gene patenting and licensing practices affect patient and clinical access to genetic tests, and if so, how. The study involved a review of the literature, original case studies, consultations with experts, including experts on gene patent policy in other countries, and the gathering of public perspectives. The task force presented a public consultation draft report to the full Committee for review in December 2008. The draft report summarized the Committees findings and conclusions from the case studies, literature review, and expert consultations and presented a range of policy options for public consideration. The revised draft report and proposed recommendations were extensively discussed by the Committee at its October 2009 meeting. The Committee made modifications to the recommendations and, with 14 voting members present, by an overall vote of 12 to one, with one abstention, approved the six recommendations. The Committee also called for further changes to be made to the report to incorporate a more extensive discussion of the public comments received during the public consultation process and at the October meeting. The Committee also wanted revisions that would clarify the basis for the Committees conclusions. During the revision period, three members wrote a statement of dissent, which appears at the end of this report. At its February 4-5, 2010, meeting, the Committee unanimously approved a motion to close the report and send it forward to the Secretary of Health and Human Services. At that time, the Committee decided to undertake a study of these issues to determine whether the weight of the evidence pointed to net benefits or net harms for patients. The expression also refers to claims to processes for the detection of specific nucleic acid sequences. Findings In examining the effect of patents on patient access to genetic tests, the Committee recognized that patient access to a high-quality test necessarily depends upon, first, basic genetic research that generates insights into the genetic basis of particular diseases and, second, efforts to translate those discoveries into clinically useful, widely available tests. Thus, in addition to looking at how patent enforcement has directly affected patient access to tests, the Committee examined how patents and licensing practices can affect basic genetic research and genetic test development. The Committee also considered the effect of patents on test quality given the Committees longstanding efforts to ensure that patients have access to those tests that are analytically and clinically valid. This section, thus, highlights relevant findings for these three issues: (1) the effect of patents and licensing practices on genetic research and genetic test development; (2) how patent enforcement has affected patient access to genetic tests; and (3) the effects of patents and licensing practices on the quality of genetic tests. Effect of Patents and Licenses on Genetic Research and Test Development the Committee found that the prospect of patent protection of a genetic research discovery does not play a significant role in motivating scientists to conduct genetic research. Scientists typically are driven instead by factors such as the desire to advance understanding, the hope of improving 4 patient care through new discoveries, and concerns for their own career advancement. Biotechnology, technology policy, and patentability: natural products and invention in the American system. Nevertheless, the Federal Government is likely the major funder of basic genetic 5 research. In addition, for that basic research that is funded privately, the investors may be motivated by the prospect of developing therapeutic applications as much, if not more so, than the potential for diagnostic applications. Therefore, the prospect of patenting therapeutic applications may be sufficient to motivate this private investment. Although the patent law requirement of disclosure and description of a claimed invention is meant to expand the public storehouse of knowledge and stimulate follow-on research, there is evidence to 6 suggest that patents on genes discourage follow-on research. Moreover, patents on genes are not needed to stimulate the disclosure of research discoveries. The norms of academic science encourage disclosure of research results, and scientists have strong incentives to publish and 7 present their discoveries. Finally, patents are not needed to encourage disclosure in industry because a new health care product or service will not be accepted by the clinical community unless there is disclosure and because products such as genetic diagnostic test kits can be easily reversed engineered. Similarly, lack of exclusive rights to testing for Huntington disease, a rare genetic disease, has not discouraged more than 50 academic and commercial laboratories from 9 developing and offering genetic testing for that disease. In contrast, when exclusive rights are successfully enforced, there is only one provider of a genetic test, such as in the case of genetic testing for breast cancer (a common disease) and spinocerebellar ataxia, a rare set of disorders. Rather, tests were quickly developed without patent protection by multiple laboratories and when patent rights were subsequently granted, they were used to narrow or clear the market of already-developed competition, thus limiting access. Commercializing the laboratory: faculty patenting and the open science environment. Impact of gene patents and licensing practices on access to genetic testing for cystic fibrosis. Reaping the Benefits of Genomic and Proteomic Research: Intellectual Property Rights, Innovation, and Public Health. Because a substantial number of patents claim gene molecules or methods of associating the gene with a phenotype, developing multiplex tests and parallel sequencing will depend on acquiring rights to multiple patents on genes and associations. Similarly, developing whole-genome sequencing likely depends on acquiring multiple rights to association patents and may require rights to patents on genes. Negotiating licenses to all relevant patents would be expensive, and, under current law, there is little to prevent the holder 10 of a needed patent from refusing to deal or from charging exorbitant rates. Even if all patent holders provide a reasonably priced license, the cumulative cost of multiple licenses could make products unmarketable. Laboratories utilizing multiplex tests are already choosing not to report medically significant results that pertain to patented genes for fear of liability. The prospect that patent holders will work together to solve these problems appears dim. Patent pools that aggregate patent rights and provide a single license to the bundled rights have been used in other areas to permit the development of technologies that infringe multiple patents. However, in the cases in which pools formed, no single patent holder could market a product without patent rights held by others. In contrast, the holder of patent rights to one critical gene or a few related critical genes can develop a test for those genes without the need for other patents on genes. As a result, questions remain concerning the likelihood that patent holders will voluntarily form a patent pool for the development of multiplex tests, parallel sequencing, and whole-genome sequencing. For the same reasons, doubts remain concerning the viability of a royalty-collection clearinghouse as a means of addressing the patent thicket in genetics. Effects of Patents and Licensing Practices on Patient Access to Existing Tests Where patents and licensing practices have created a sole provider of a genetic test, patient access to those tests has suffered in a number of ways. First, patients are unable to obtain insurance-covered access to a sole providers test when the provider does not accept the patients insurance. For example, participants in a particular states Medicaid program cannot obtain covered access if the sole provider refuses to accept that particular Medicaid program. In this situation, patients have had to forgo testing because they cannot afford the test. Second, patients who desire second-opinion testing from an independent laboratory cannot obtain it when there is a sole provider. Effects of Patents and Licensing Practices on Test Quality the most robust method for assuring quality in laboratory testing is through the comparison of results obtained on samples shared between different labs. Moreover, the presence of multiple laboratories offering competing genetic testing for the same condition can also lead to improvements in the overall quality of testing through innovation in developing novel and more thorough techniques of testing. Neither sample sharing nor competition is possible when an exclusive-rights holder prevents others from providing testing. As a result, significant concerns about the quality of a genetic test arise when it is provided by a patent-protected sole provider. Recommendations Based on the above findings, a majority of the Committee made the following six 12 recommendations. The creation of an exemption from liability for infringement of patent claims on genes for anyone making, using, ordering, offering for sale, or selling a test developed under the patent for patient-care purposes. The creation of an exemption from patent infringement liability for those who use patent protected genes in the pursuit of research. The exemption is narrowly tailored to address identified problems without altering the enforceability of gene patents for therapeutic applications. The continued ability to exclude others from therapeutic uses of these gene molecules preserves the incentive such patents create for basic genetic research and any incentive they provide for the development of therapeutics. If enacted, the first recommended statutory change would enable multiple providers to offer tests that are currently available only from an exclusive-rights holder. Under these circumstances, a patient would have a better chance of finding at least one provider who accepts his or her health insurance. The change will also permit second-opinion testing and the sharing of samples to ensure the quality of testing. The Committee also urges the Secretary to use current authority to discourage the seeking, the granting, and the invoking of any patents on simple associations between a genotype and a phenotype. As with patent claims to genes, association patent claims threaten the availability of existing genetic tests and are a significant potential barrier to the development of testing innovations, such as microarrays and whole-genome sequencing. The Committee believes the changes described in Recommendation 1 offer the most direct way of promoting the development of high-quality genetic tests and patient access to them. Recommendations 2 and 3, below, propose changes that could be more easily implemented by the Secretary. The remaining recommendations call for changes that would have benefits regardless of whether the statutory changes are made. Recommendation 2: Promote Adherence to Norms Designed to Ensure Access Using relevant authorities and necessary resources, the Secretary should explore, identify, and implement mechanisms that will increase adherence to current guidelines that promote nonexclusive licensing of diagnostic genetic/genomic technologies. Since many of the problems identified in this report are associated with exclusive licensing, greater adherence to the guidelines would avert these problems in the future. Recommendation 3: Enhance Transparency in Licensing Using relevant authorities and necessary resources, the Secretary should explore, identify, and implement mechanisms that will make information about the type of license and the field of use 14 for which rights were granted readily available to the public. If this change were made, prospective test developers would be able to easily determine whether particular patent rights are available for licensing, a task that is difficult at present and represents a significant burden for test developers. The advisory body also could provide input on the implementation of any future policy changes, including the other recommendations in this report. This advisory body would be available to receive information about patient access to genetic tests from the public and medical communities to assess whether problems are continuing and, if so, to what extent. One way to achieve equitable access would be to ensure all payers include clinically useful genetic tests in their covered benefits. Accordingly, the Committee has published a series of comprehensive reports that recommend actions the Secretary can take to eliminate barriers to the development of reliable, effective tests and access to them. Reports that concern obstacles to the development of quality genetic tests include the Committees 2008 report on the oversight of genetic testing, in which the Committee recommended specific improvements in federal regulatory policies as part of an effort to create a favorable environment for developing and assuring the quality of new genetic technologies. Also in 2008, the Committee issued a report on the promise of pharmacogenomics, which underscored the role of federal policies in facilitating private sector development of new technologies in this rapidly growing field.

Collecting a catheter 20 understanding specimen of urine from the sampling port management principles 4 blood pressure 9555 order isoptin on line. Additional reading list 28 2 Advanced Infection Prevention and Control Training May 2018 version Handout 1 arrhythmia institute newtown buy isoptin 120mg. Inserting or applying an indwelling blood pressure 220 over 110 buy isoptin cheap, intermittent straight blood pressure number meanings purchase genuine isoptin on line, or condom catheter; immediately before putting on sterile gloves 2b arteria peronea order isoptin with amex. No Action Today No Cure Tomorrow All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document arrhythmia cardiac cheap 240 mg isoptin free shipping. However, the published material is being distributed without warranty of any kind, either expressed or implied. In no event shall the World Health Organization be liable for damages arising from its use. If needed, then catheter should be reviewed on a daily basis and removed as soon as clinically possible, preferably within 5 days. Urinary catheterisaton should be performed using sterile equipment and aseptc technique should always be maintained during inserton and afercare procedures. Hands must be properly washed before and afer procedure and during daily management. Catheters should not be changed routnely as this exposes the patent to increased risk of bladder and urethral trauma. Maintain a closed drainage system; open systems should be avoided if at all possible. Bladder irrigaton or washout and instllaton of antseptcs or antmicrobial agents does not pre vent catheter-associated urinary tract infecton and should not be used. The drainage bag should be empted at least once per nursing session into a clean receptacle used only on one patent. The risk of a cath eterised patent acquiring bacteriuria increases with the duraton of catheterisaton, the daily rate is 5% so that by 4 weeks almost 100% of patents are bacteriuric. One to four percent of patents with bacteriuria will ultmately develop clinically signifcant infecton,. Therefore, urinary catheters must only be inserted when there are clear medical indicatons ( See Table 18. In suitable patents, clean intermitent urinary catheterisaton or external condom catheters should be considered, as these have a lower risk of infecton. Urinary incontnence is not an indicaton for urinary catheterisaton; use napkins or absorbent pads instead. Indicatons for the use of indwelling urinary catheters Examples of appropriate uses of indwelling catheters Patent with acute and/or chronic urinary retenton or bladder outlet obstructon Maintain a contnuous outlow of urine for patents with voiding difcultes (as a result of neuro logical disorders that cause paralysis or loss of sensaton afectng urinaton) Need for accurate measurements of urinary output in critcally ill patents Perioperatve use for selected surgical procedures,. When a catheter is inserted, this fushing mechanism is circumvented and peri neal and urethral fora can pass up into the bladder in the fuid layer between the outside of the catheter and the urethral mucosa or in the urine in the catheter lumen. Because of this, bladder coloni saton is inevitable if catheters are lef in place for prolonged periods. In additon, bladder infecton can be caused by bacterial refux from contaminated urine in the drainage bag. Closed drainage systems reduce onset of infecton by limitng access of bacteria to the urine. Hands of personnel may also contaminate the urinary catheter system during inserton or management. Main sites through which bacteria may reach the bladder of a patent with an indwelling urethral catheter. This is because hospitalised patents be come colonised with resistant microorganisms, a process encouraged by an increased length of stay and expo sure to antbiotcs. In communites where indiscriminate antmicrobial use is common, mult-resistant Gram negatve bacteria (e. With additonal antbiotc exposure, infectons occur with multply drug resistant bacteria (e. Resistant microorganisms may also be acquired by transfer from other patents, most commonly via contaminated staf hands, but sometmes from environmental sources. Urine and urinary catheter systems should be carefully disposed of, botles and jugs cleaned and disinfected, and hands properly washed and de contaminated during inserton and management. If 2% lignocaine anaesthetc (single-use sterile) gel is used, then inject gel into urethra and hold it for 3-5 min before insertng catheter. Use sterile items /equipment (sterile catheter, sterile gloves, single-use sterile soluton etc. Use Urinary Catheter Pack (contains sterile items required for inserton of catheter in a Ascending Keep peri-urethral area clean and dry. Maintain unobstructed urine fow; ensure that the catheter and drainage bag tubing are free of kinks. If a sample of urine is required for bacteriological examinaton, it should be obtained from a sampling port using aseptc 3. Always wash or disinfect physically clean hands with an alcoholic hand rub before and afer opening tap. Staf training Healthcare personnel performing urinary catheterisaton should receive training on correct proce dures for inserton and maintenance of urinary catheters based on local writen protocols. Larger diameter catheters are more likely to cause unnecessary pressure on the urethral mu cosa, leading to trauma and ischaemic necrosis. Urological patents and some other patent groups may re quire larger sized catheters; these should only be used on the advice of specialists. Care bundle to prevent catheter-associated urinary tract infectons* Inserton Care Bundle Avoid unnecessary catheterisaton Chose catheters of appropriate size Use sterile items/equipment Insert catheter using strict aseptc non-touch technique Use closed drainage system Maintenance Care Bundle Review the need for the catheter on a daily basis and remove catheter promptly when no longer necessary Use aseptc technique for daily catheter care (e. If urine specimen required, take specimen aseptcally via the sampling port (see Fig. Note: the Care Bundle can be adapted or ex panded to cover more issues according to local needs. There is no evidence that they decrease symptomatc infectons and therefore they should not be used routnely. Catheter inserton Urinary catheterisaton should always be performed using sterile or high-level disinfected equipment and aseptc technique. To minimise trauma to the urethra and discomfort to the patent, a sterile lubricant or local anaesthetc gel should be used. Meatal cleansing Meatal cleansing should be performed regularly to ensure that the meatus is free from encrustatons. Cleansing with soap and water is sufcient; applicaton of antmicrobial ointment or disinfectant to the ure thral meatus is harmful and should be avoided. The catheter drainage bag must always be placed below the level of the bladder to promote good drainage. If a catheter stand is used, the drainage bag and drainage tap must not come in contact with the foor. During patent movement, the drainage tube should be temporar ily clamped to prevent back-fow of urine. Do not disconnect the drainage bag unnecessarily; maintain the closed drainage system. Emptying the drainage bag the drainage bag should be empted regularly via the drainage tap at the botom of the bag. If the bag does not have a tap, it must be replaced when 3/4 full using aseptc technique. Extreme care must be taken when emptying a drainage bag to prevent cross-infecton between pa tents. Hands must be washed or disinfected with an alcohol-based hand rub and non-sterile/clean disposable gloves should be worn when emptying the bag. Alcohol impregnated swabs should be used to decontaminate the outlet of the drainage tap (inside and outside. The urine container must be rinsed and disinfect ed (preferably in a washer disinfector) afer each use, dried, and stored inverted in a clean place before fur ther use. The use of these agents may damage the bladder mucosa or catheter and promote the development of resistant bacteria which are difcult to treat. Specimen collecton Samples of urine for bacteriological examinaton should be obtained from the sampling port using aseptc technique. The sampling port should be disinfected by wiping with a 70% isopropyl alcohol impreg nated swab. The sample may then be aspirated using a sterile needle and syringe and transferred into a sterile container. If the urinary catheter has no sampling port, then the sample can be obtained from the urinary catheter by wiping the tube with 70% isopropyl alcohol. Allow to dry and then aspirate the urine sample using a sterile small bore needle and syringe. Transfer into a sterile urine container and send it to the micro biology laboratory as soon as possible. In asymptomatc pa tents, routne bacteriological testng is of no clinical beneft and not recommended. Use of antmicrobial agents the routne administraton of systemic antbiotcs at the tme of catheter inserton/removal is not recommended. Condom catheters There may be a place for the use of condom catheters for short-term drainage in cooperatve male patents. Condom use for 24 hour periods should also be avoided and other methods, such as napkins or absorbent pads, used at night. The presence of multple microorganisms does not necessarily indicate contaminaton. Urine must be processed promptly, since even with good technique urine samples may contain small numbers of contaminants. These bacteria can multply at room temperature (especially in hot cli mates) and result in falsely high colony counts. If delay is expected, the specimen should be transported to the laboratory in an ice box and refrigerated on arrival. Alternatvely, boric acid (1% W/V or 1 g/10 ml of urine) should be added to the urine. In catheterised patents, a positve urine culture or dip-stck is not sufcient for diagnosis of infecton. In such patents, fever and leukocytosis or leu copenia are additonal diagnostc criteria. Diagnosis of symptomatc infecton can be difcult; you cannot rely on a positve culture result or dipstck as these are usually positve in most patents with a urinary catheter afer a few days of inserton. Renal angle tenderness in the absence of any other underlying pathology suggests pyelonephrits. In healthy non-catheterized people urine flow flushes out True False any invading bacteria 4. Reflux of contaminated urine from collecting bag is not an True False infection risk 6. Bacteria can only ascend into the urinary tract on the True False outside of the catheter. However, when a foreign body such as a urinary catheter is in place, local defences are bypassed and bacteria. Infections can be either endogenous (self-infection): typically via meatal, rectal or vaginal colonization or exogenous (cross-infection): via contaminated equipment and/or hands of health care personnel. Guide for Foley catheter use in hospitalized medical patients Appropriate indications 1. Acute urinary retention with bladder outlet obstruction due to non-infectious, nontraumatic diagnosis (e. Note: consider urology consultation for catheter type and/or placement for conditions, such as acute prostatitis and urethral trauma. Note: it is unclear whether a Foley catheter is appropriate for chronic urinary retention without bladder outlet obstruction (e. Severe pressure ulcers or similarly severe wounds of other types that cannot be kept clear of urinary incontinence despite wound care; other urinary management strategies (e. Daily measurement of urine volume that is required to provide treatment and cannot be assessed by other volume and urine collection strategies (e. Single 24-hour urine sample for diagnostic test that cannot be obtained by other urine collection strategies (e. To reduce acute, severe pain with movement when other urine management strategies are difficult (e. Improvement in comfort when urine collection by catheter addresses patient and family goals in a dying patient 16 Advanced Infection Prevention and Control Training May 2018 version 11. Clinical condition for which an intermittent straight catheter or external catheter would be appropriate but placement by experienced nurse or physician was difficult or for a patient for whom bladder emptying was inadequate with non indwelling strategies during this admission Inappropriate uses 1.

Since rapid treatment of hypertensive urgency is not required arrhythmia untreated discount isoptin master card, some prefer to call it asymptomatic severe hypertension blood pressure chart 19 year old buy 120 mg isoptin amex. The term hypertensive crises can be further divided into hypertensive urgency and hypertensive emergency pulse pressure over 70 order isoptin 40 mg free shipping. Energy drinks containing taurine blood pressure quit smoking order isoptin in india, guarana root hypertension jnc 8 summary purchase generic isoptin on line, yerba mate arrhythmia cardiac isoptin 40mg on line, glucuronolactone, etc. All 11 treatment strategies should consider the patients comorbidities and risk of adverse events. Previously Treated Hypertension: trying one the following may be appropriate interventions (in no particular order) Restart/resume medications in non adherent patients Adjust & optimize hypertensive regimen! The choice of agent should include consideration for what is most appropriate long term. It is listed in the Beers criteria for potentially inappropriate medication use in older adults. Neither the authors nor Saskatoon Health Region nor any other party who has been involved in the preparation or publication of this work warrants or represents that the information contained herein is accurate or complete, and they are not responsible for any errors or omissions or for the result obtained from the use of such information. Readers are encouraged to confirm the information contained herein with other sources. This treatment option is still considered for certain indications in low risk populations (e. Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. Management and outcome of severely elevated blood pressure in primary care: a prospective observational study. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. Emergency Departments yearly (National Hospital Medical Care Survey), with benign to life-threatening causes, costing $6 billion. Acute aortic syndrome recibido el 27 de abril de 2012 aceptado el 12 de agosto de 2013. Diverse genetic disorders and acquired conditions have been related to the telefono: (562) 25742132 pathogenesis of this disease. A high degree of clinical suspicion and imaging studies are necessary for an accurate diagnosis. Prognosis is clearly related to underlying diagnosis and appropriate surgical repair, in the case of proximal involvement of the aorta. Involvement of distal segments of the aorta may require medical or endovascular therapy according to the presence of com plications. La mayor frecuencia se perfla entre las 08:00 y 09:00 h y durante los meses de invierno7. Con el paso de las horas, esta sangre (sumada al efecto de la presion arterial sistemica) es capaz de desencadenar una diseccion o ruptura aortica1-11 (Figura 1. Los trastornos, tanto adquiridos como geneti cos, comparten una via fnal comun que da lugar a la disrupcion de la intima. Todos los mecanismos que debilitan la capa media de la aorta, asociados a una mayor tension en la pared vascular, pueden inducir la dilatacion de esta y la formacion de un Figura 1. El factor de riesgo mas frecuente en la ulcera aterosclerotica penetrante; Hi, hematoma intramural. La sangre es capaz obesidad 11,1% de atravesar esta anomalia anatomica y separar la insuficiencia renal cronica 8,3% capa intima de la media o adventicia, creando un enfermedad de Marfan 8,3% lumen falso. La propagacion de la diseccion puede ser en sentido anterogrado o retrogrado (en rela cardiopatia coronaria 5,6% cion a la solucion de continuidad) y causar una ruptura aortica, insufciencia cardiaca o sindromes de mala perfusion17-19. La razon de esto es que entrega lumen verdadero, la relacion de la rama arterial informacion de la extension de la diseccion en con el fap intimal y del nivel de perfusion aporta vez del proceso fsiopatologico involucrado, in do por el lumen verdadero o falso. Sin embargo, la formacion que resulta indispensable para decidir isquemia visceral es mas frecuente cuando la disec el tipo de manejo29. Tambien se le describe en la region dorsal siguiendo hacia caudal hasta la region abdominal. Con tratamiento quirurgico la mortalidad a las 24 h Para establecer un diagnostico rapido y certero, disminuye a 10%, a los 7 dias a 13% y a los 30 dias es necesario mantener un alto indice de sospecha a 20%4. La sensibilidad, la especifcidad y Si bien la radiografia de torax, adecuadamente los valores predictivos estan por encima de 95%42. Sin embargo, se acepta que a menos de 80% cuando la diseccion afecta a la en el proceso diagnostico es esencial contar con aorta ascendente44. En contexto de urgencia, es una radiografia de torax porque no solo puede probablemente el examen que aporta mayor infor ofrecer signos compatibles y apoyar la necesidad macion y responde a la mayoria de los objetivos, de realizar otra prueba de imagen para confrmar evaluando ademas, las ramas viscerales de la aorta el diagnostico, sino que tambien permite identi abdominal43 (Figura 4. La gran limitacion es la difcul mmHg y un rango de frecuencia cardiaca entre tad para estudiar la porcion mas alta de la aorta 60 y 80 lpm47. El procedi der la endoprotesis distalmente mediante el uso miento consiste en resecar la aorta ascendente y de stents de metal de celdas abiertas, hasta que la el arco aortico (este ultimo solo si esta afectado) mal perfusion distal se corrija58. Tam no se necesitan maniobras de fenestracion aortica bien es necesaria la reparacion o reemplazo de la o revascularizacion con ramas, que actualmente valvula aortica, en los casos en que se presentan estan casi obsoletas59. Ademas del reemplazo tosa, la mortalidad disminuye a menos de 10% y valvular, dependiendo de la anatomia y el esta el riesgo de paraplejia a menos de 3%46. Promedios similares se han publicado en aorta descendente es la afectada, el tratamiento otros reportes y alrededor de 55% de los pacientes medico conservador es aceptado. Este examen permite detectar los cambios y a la hipertension intratable por un fenomeno de que se generan en la aorta, tanto precoces como pseudocoartacion dinamica o permanente16. En tardios, despues de una intervencion quirurgica ambos grupos el procedimiento endovascular pue o un tratamiento medico61, como un eventual de resolver en forma expedita y poco invasiva54,55 aumento del diametro aortico, signos de forma un problema que la cirugia abierta requeriria de cion aneurismatica y hemorragias en los sitios de extensos y cruentos procedimientos con una alta anastomosis o colocacion de stents. La intervencion Ademas del control imagenologico, se deben rev Med chile 2014; 142: 344-352 349 articulos de revision sindrome aortico agudo. Circadian variation of isometricos y las actividades que puedan provocar blood pressure. Presentation, complications, and natural history Conclusion of penetrating atherosclerotic ulcer disease. Vilacosta I, Aragoncillo P, Canadas V, San Roman J, po de enfermedades que involucra un elevado Ferreiros J, Rodriguez E. Acute aortic syndrome: a new riesgo vital, es deber del medico sospecharlo, al look at an old conundrum. Risk factors for aortic dissection: una evaluacion basica y un apoyo imagenologico a necropsy study of 161 cases. Stefanadis C, Karayannacos P, Boudoulas H, Stratos C, tecnologico, permite incorporar nuevas estrate Vlachopoulos C, Dotas I, et al. Medial necrosis and acute gias terapeuticas, como son los procedimientos alterations in aortic distensibility following removal of endovasculares, que resultan ser menos invasivos the vasa vasorum of canine ascending aorta. Von Kodolitsch Y, Aydin M, Koschyk D, Loose R, la enfermedad, lograra con el paso de los anos, Schalwat I, Karck M, et al. Suzuki T, Mehta R, Ince H, Nagai R, Sakomura Y, Weber ascending aorta: a case report and review of literature. Clinical profles and outcomes of acute type B Heart Lung Circ 2008; 17 (5): 380-2. Svensson L, Kouchoukos N, Miller D, Bavaria J, Coselli vite D, Evangelista A, et al. New insights into an treatment of descending thoracic aortic disease using old disease. Mehta R, Manfredini R, Hassan F, Sechten U, Bossone la Sociedad Espanola de Cardiologia en enfermedades E, Oh J, et al. Aortic dissection: prompt diagnosis and predict in-hospital complications and mortality in pa emergency treatment are critical. Januzzi J, Sabatine M, Eagle K, Evangelista A, Bruckman Diseccion aortica: estado actual. Trimarchi S, Nienaber C, Rampoldi V, Myrmel T, Suzuki Early anatomic changes in an in vitro model. Williams D, Lee D, Hamilton B, Marx M, Narasimham tomy and radiologic diagnosis of branch-vessel compro D, Kazanjian S, et al. Hiratzka L, Bakris G, Beckman J, Bersin R, Carr V, Casey Radiology 1997; 203: 37-44. Jagannath A, Sos T, Lockhart S, Saddekni S, Sniderman American Association for Thoracic Surgery, American K. Aortic dissection: a statistical analysis of the useful College of Radiology, American Stroke Association, ness of plain chest radiographic fndings. Am J Radiol Society of Cardiovascular Anesthesiologists, Society for 1986; 147: 1123-6. Selman R, Kursbaum A, Ubilla M, Turner E, Espinoza of Interventional Radiology, Society of Thoracic Sur C, Espinosa J, et al. Diseccion Aortic intramural haematoma: natural history and pre de aorta: evaluacion clinica, comparacion de las tecnicas dictive factors for complications. Nallamothu B, Mehta R, Saint S, Llovet A, Bossone E, Esp Cardiol 2007; 60: 428-39. Simple risk models to predict surgical senting with type B acute aortic dissection: insights from mortality in acute type A aortic dissection: the Interna the International Registry of Acute Aortic Dissection. Is surgery always mandatory for type A plete attachment after stent-graft placement in type B aortic dissection Santini F, Montalbano G, Casali G, Messina A, Iafrances Ther 2006; 13 (6): 738-46. Tra predictor of in-hospital death for patients with acute tamiento en la diseccion aortica toracica con protesis type A aortic dissection admitted for surgical treatment: endovascular. Characteristics and in-hospital outcomes of treatment of acute type a aortic dissection. Ann Thorac patients with cardiac tamponade complicating type Surg 2005; 80: 523-9. Sebastia C, Pallisa E, Quiroga S, Alvarez-Castells A, the treatment of acute aortic dissection. Complete cardiopulmonary arrest is induced to allow surgery on major blood vessels which cannot be bypassed intraoperatively and therefore upon which surgery would normally cause disruption to distal blood flow and profound haemorrhage in the surgical field. This represents profound suppression of cerebral metabolic activity and confers the neuroprotection of deep hypothermia. The use of hypothermic circulatory arrest is limited by the duration of the circulatory arrest that can safely be tolerated before significant neurological and multisystem side effects occur. In addition, some centres employ neurocognitive tests to detect more subtle changes post-operatively. Invasive arterial monitoring placement and its interpretation will be decided by the nature of surgery, the location for bypass cannulation and whether any perfusion adjuncts are to be used, and may require bilateral upper limb or a combination of right upper limb and lower limb cannulation. Often, two sites are used such as nasopharynx and oesophagus or nasopharynx and urinary bladder temperature. A pulmonary artery flotation catheter and bypass return line temperature are additional sources of information for temperature. Many centres pack the head in ice or use a head cooling device to prevent passive rewarming. If clinicians choose pharmacological neuro protective modalities they are administered before the circulatory arrest. Types of pharmacological neuro-protective agents will be further discusses later in the tutorial. The intravenous anaesthetic agents, if used, can be titrated, once the patient is below 28 degrees and additional paralytics can be re-dosed before the circulatory arrest. With differing study methodologies and wide variations in practice, a consensus on an optimal temperature is difficult to achieve. Glucose and haematocrit management 2 It is well established that hyperglycaemia is associated with adverse postoperative outcomes in cardiac surgery. Hyperglycaemia leads to intracellular acidosis as lactate is produced from glucose and promotes excitotoxicity. Deep hypothermia leads to increased blood viscosity, increased red cell rigidity, causes impaired microcirculation and potentially ischaemia. In addition, the oxyhaemoglobin dissociation curve is shifted to the left impairing oxygen delivery. Whilst there is limited evidence to suggest an optimal target, a haematocrit of 22% or Hb of 7. European centres most commonly administer thiopental compared to non-European centres (61. Corticosteroids were routinely used throughout all centres (approximately 70% of European Centres and 95% of non-European centres) and the most common agent was methylprednisolone. The greatest neuroprotective effects of thiopental are seen at high doses which tend to cause myocardial depression. In some units, general anaesthesia is maintained using volatile agents added through the circuit. Volatiles confer global cerebral protection, depress metabolic demand and reduce excitotoxicity by inhibiting glutamate release. Various other agents are used less frequently for example magnesium, mannitol and lidocaine. To correct for this, the temperature is manually input and the machine mathematically calculates the values for that temperature using the Rosethal correction (Change in pH = 0. There are two methods of interpreting blood gas analysis in the hypothermic patient: 1.

Ultrasonography of the internal jugular vein in patients with dyspnea without jugular venous distention on physical examina tion blood pressure medication make you cold buy isoptin master card. Changes in bronchial and pulmonary arterial blood flow with progressive tension pneumothorax heart attack jack look in my eyes isoptin 240mg amex. The clinical validity of normal compression ultrasonography in outpatients suspected of having deep venous thrombosis blood pressure 65 order 40 mg isoptin otc. Incidence of pericardial effusions in patients presenting to the emer gency department with unexplained dyspnea blood pressure chart doc isoptin 40 mg overnight delivery. Assessment of left ventricular function and hemody namics with transesophageal echocardiography blood pressure medication weight loss isoptin 40mg. Atypical presentations and echocardio graphic findings in patients with cardiac tamponade occurring early and late after cardiac surgery blood pressure chart different ages order isoptin no prescription. Correlation between clinical and Doppler echocardio graphic findings in patients with moderate and large pericardial effusions. Consecutive 1127 therapeutic echo cardiographically guided pericardiocenteses: clinical profile, practice patterns and outcomes spanning 21 years. Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejec tion fraction. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock. Diagnostic accuracy of identification of left ventricular function among emergency department patients with nontraumatic symptomatic undifferentiated hypotension. Outcome in cardiac arrest patients found to have cardiac standstill on bedside emergency department echocardiogram. Does the presence or absence of sono graphically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients Use of transthoracic Doppler echocardiog raphy combined with clinical and electrographic data to predict acute pulmo nary embolism. Quantitative two dimensional echocar diography in massive pulmonary embolism: emphasis on ventricular interde pendence and leftward septal displacement. Opinions regarding the diagnosis and management of venous thrombo embolic disease. Prospective evaluation of two dimen sional transthoracic echocardiography in emergency department patients with suspected pulmonary embolism. Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients. Short term clinical outcome of patients with acute pulmonary embolism, normal blood pressure and echocardiographic right ventricular dysfunction. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolus. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Sonospirometry: a new method for noninvasive measurement of mean right atrial pressure based on two dimensional echocar diographic measurements of the inferior vena cava during measured inspiration. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Emergency department paracentesis to determine intraperitoneal fluid identity discovered on bedside ultrasound of unstable patients. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospec tive comparison with chest radiography. Rapid detection of pneumothorax by ultraso nography in patients with multiple trauma. A prospective comparison of supine chest radiog raphy and bedside ultrasound for the diagnosis of traumatic pneumothorax. Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation. A novel use of ultrasound in pulse less electrical activity: the diagnosis of an acute abdominal aortic aneurysm rupture. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Emergency department ultrasound scan ning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Screening for abdominal aortic aneu rysm in asymptomatic at-risk patients using emergency ultrasound. Diagnostic potential of combined transthoracic echocardiography and x-ray computed tomography in suspected aortic dissection. Diagnosis of ascending aortic dissection using emergency department bedside echocardiogram. Dissection of the proximal thoracic aorta: a new ultra sonographic sign in the subxiphoid view. Improved diagnosis of vascular dissection by ultrasound B-flow: a comparison with color-coded Doppler and power Doppler sonography. Color Doppler ultrasound by emergency physicians for the diagnosis of acute deep venous thrombosis. Is color flow duplex a good diagnostic test for detection of isolated calf vein thrombosis in high risk patients Limited B-mode venous scanning versus complete color flow duplex venous scanning for detection of proximal deep venous thrombosis. Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities. Emergency department compression ultrasound to diagnose proximal deep vein thrombosis. Resident performed compression ultraso nography for the detection of proximal deep vein thrombosis: fast and accurate. Systematic review of emergency physician performed ultrasonography for lower-extremity deep vein thrombosis. Emergency clinician-performed compres sion ultrasonography for deep venous thrombosis of the lower extremity. Lower extremity Doppler for deep venous thrombosis: can emergency physicians be accurate and fast This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Assessment of hemodynamic status in a shock state remains a challenging issue in Emergency Medicine and Critical Care. As the use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and management of patients in shock. No longer a means to simply evaluate organ anatomy, ultrasound has expanded to become a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly consider integrating ultrasound into their resuscitation pathways. Incorporation of bedside ultrasound in patients with undi erentiated shock allows for rapid evaluation of reversible causes of shock and 2. He describes the chest pain as sharp these protocols combines many of the same core ultrasound and pleuritic, with associated back and upper abdominal elements, di ering mainly in the priority of the exam pain. On physical examination, his vital signs hypotension that will highlight how early integration of include a blood pressure of 82/60 mm Hg, heart rate 120 bedside ultrasound into clinical evaluation can assist in beats per minute, respiratory rate 24 breaths per minute, rapid and accurate diagnosis of shock. Lung exam reveals exam (Rapid Ultrasound in Shock), will be applied in both rales in both lung bases, but is otherwise unremarkable. She appears acutely ill with blood pressure of 74/58 mm Hg, heart rate 120 beats per minute, respiratory rate 30 breaths per minute, temperature 98 F, and pulse oximetry 94% on room air. In the rst case, hypotension in a patient with long standing hypertension indicates signi cant physiological compromise. While the most likely diagnosis is sepsis due to pneumonia, several clinical questions remain. Could this presentation be the result of a pulmonary embolus, aortic dissection, or myocardial infarction His cardiac status is unclear and his heart may not be able to handle a large volume infusion without resultant pulmonary edema. Could this patient be experiencing a massive pulmonary embolus given her history of cancer Fortunately, an ultrasound machine is available for use Figure 2: Types of pericardial e usions, subxiphoid cardiac view. On the paraster involves four classical views: parasternal long and short axis, nal long axis view, a careful evaluation of the uid in subxiphoid, and apical (Figure 1. Pericardial Clinicians caring for the patient in shock should begin uid will be seen anterior to the posterior pericardial with a goal-directed echocardiogram looking for three re ection and the descending aorta (Figure 3. In contrast, speci c ndings: pericardial e usion, left ventricular con pleural uid will be seen posterior to the posterior pericardial tractility, and right ventricular dilation. If a pericardial e usion is identi ed, the next step is to evaluate the heart for signs of tamponade. First, the ponade results when high pressure within the pericardium pericardial sac should be visualized to determine if the prevents the heart from fully expanding and lling during patient has a pericardial e usion, which may be the cause of the relaxation phase of the cardiac cycle. Small e usions may be seen as a thin stripe lower pressure in the right side of the heart, evaluation for inside the pericardial space, while larger e usions tend to cardiac tamponade speci cally focuses on the movement wrap circumferentially around the heart. Fresh uid or blood tends to and/or the right ventricular wall, to complete diastolic have a dark or anechoic appearance, whereas clotted blood compression of a chamber (Figure 5)[28, 29]. The examination focuses on evaluating motion of the left ventricular walls by a visual estimation of the volume change from diastole to systole [31]. A ventricle that has good contractility will have a large volume change between the two cycles (Figure 6. In contrast, a poorly contracting heart will have a small percentage change in the movement of the walls between diastole and systole (Figure 7. Based on these assessments, a patients contractility can be broadly categorized as being normal, mild-moderately decreased, or severely decreased. A fourth category, known as hyperdynamic, demonstrates small chambers and vigorous, hyperkinetic contractions that Figure 3: Pericardial e usion, parasternal long axis view. M-mode can be used to graphically depict the move ments of the left ventricular walls through the cardiac cycle. Placing the cursor across the left ventricle just beyond the tips of the mitral valve lea ets, the resultant M-mode tracing allows measurements of the chamber diameter in both systole and diastole. The M-mode tracing for a hyperdynamic heart shows the left ventricular walls almost touching during systole and a high fractional shortening (Figure 8. It should be emphasized that fractional shortening does not directly calculate the ejection fraction, rather fractional shortening correlates to overall left ventricular contractility. In comparison to the comprehensive and relatively time intensive volumetric assessments for measuring ejection fraction, fractional short ening is a semiquantitative method for determining systolic function that is fast and easy to perform and can provide critical data to guide resuscitation [33]. Motion of the anterior lea et of the mitral valve can also be used to assess contractility. In a normal contractile state, the anterior mitral lea et can be seen in the parasternal long-axis view touching or closely approaching the septal endocardium in early diastole. The degree of excursion of the mitral valve directly correlates with the contractile state Figure 5: Cardiac tamponade, subxiphoid view. If tam the M-mode cursor is placed over the tip of the anterior ponade is identi ed and the patient also displays unstable mitral lea et. As the mitral valve moves during diastole, hemodynamics, an emergent pericardiocentesis is indicated. Second, the left ventricle the initial and maximal opening of the valve to allow can be analyzed for global contractility. Immediately following is 4 Critical Care Research and Practice Figure 6: Good left ventricular contractility, parasternal long axis view. Looking at both the relative vessel size result in acute dilation of the right side of the heart. In this situation, the exam should be followed inferiorly as it passes through the liver, Critical Care Research and Practice 5 Figure 10: E-point septal separation with decreased contractility. In the size of the vessel in a pitfall known as the cylinder tangent traumatic conditions, the clinician must quickly determine e ect. For volume and ascites that may build up with failure of the heart, assessment, one should examine both the relative fullness kidneys, and/or liver.

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