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Cardiac rapture: · Myocardial infarction of the free wall may lead to eventual perforation of the heart pain treatment center memphis trusted maxalt 10mg. This complication who cancer pain treatment guidelines buy generic maxalt on-line, which results overwhelmingly cardiac tamponade fibromyalgia treatment guidelines american pain society order cheap maxalt line, is nearly always fatal pain management from shingles order maxalt 10mg on-line. Left ventricular aneurysm: · the infracted myocardium may evaginate and heal with fibrous connective tissue. Emergency management:Management of patients should start before they reach the hospital emergency room 1. Contraindication: · History of Cerebrovascular hemorrhage, marked hypertension, bleeding disorder. Direct percutanous transluminal coronary angioplasty: in best facilities in the developed countries this is the preferred method to restore perfusion of occluded coronary artery. When performed by experienced physicians the short and long term outcomes are much better than what can be archived through thrombolysis or fibrinolysis. Fibrous diet and Stool softeners like bisacodyl or Dioctyl sodium sulfosuccinate 200 mg /day are recommended. Intraaortic balloon pumping Percutanous transluminal angioplasty 283 Treatment of serous conduction disturbances; Heart failure: Internal Medicine Prognosis: depends on two factors the extent of coronary artery disease in terms of the number of vessels affected · · · · · Patents with uncorrected main left coronary artery disease have approximately a 20 % mortality in the first year Single vessel coronary artery has 2 % annual mortality. An ejection fraction of <40 % doubles the yearly mortality rate at each level of extent of coronary disease. Revascularization: significantly improves the short term and long term morbidity and, mortality when it is done at the right time by an expert hand. The extent of ventricular damage: left ventricular ejection fraction References: 1. Cardiac Arrhythmias Learning objectives: at the end of this lesson the student will be able to: 1. Refer patients with arrhythmias to appropriate centers Definition: Cardiac arrhythmias are changes in the regular beating of the heart. The heart may seem to skip a beat or beat irregularly or beat very fast or very slow. Other causes include: stress, caffeine, tobacco, alcohol, diet pills,"Khat", cough and cold medicines. In these cases, heart disease, not the arrhythmia, poses the greatest risk to the patient. In a very small number of people with serious symptoms, arrhythmias themselves are dangerous. Patients with arrhythmias often complain that they felt their heart beat very fast, experienced a fluttering in their chest, or noticed that their heart skipped a beat. Almost everyone has also felt dizzy, faint, or out of breathe or had chest pains at one time or another. They result from inadequate sinus impulse production or from blocked impulse propagation. They are not usually cause of concern unless the patient develops syncope or presyncope. Sick sinus syndrome: the sinus node does not fire its signals properly, so that the heart rate slows down. Sometimes the rate changes back and forth between a slow (bradycardia) and fast (tachycardia) rate 3. Often conduction is in a ration of 2: 1and it is prolonged enough to cause symptomatic bradycardia. The heart rate drops significantly to a range of 20- 40 beats/min and patients become symptomatic. Therapy: · Pharmacologic therapy: reserved only for acute situations to temporarily increase the ventricular rate. A series of early beats in the atria speed up the heart rate (the number of times a heart beats per minute).

For secondary prophylaxis against a subsequent attack- anticoagulants are inferior to antiplatelet drugs pain treatment wellness center purchase maxalt canada. For this purpose pain medication for dogs with kidney failure effective maxalt 10 mg, the effective options are warfarin/low dose heparin/low dose aspirin heel pain treatment stretches generic 10mg maxalt mastercard. Cerebrovascular disease Anticoagulants are of little value in cerebral thrombosis pain medication for dogs with hip problems purchase maxalt uk. They may be used in cerebral embolism, because showers of emboli are often recurrent and can be prevented by anticoagulants. A late start (after one week) anticoagulant therapy is advocated by many in case of large embolic stroke. Vascular surgery, prosthetic heart valves, retinal vessel thrombosis, extracorporeal circulation, haemodialysis Anticoagulants are indicated along with antiplatelet drugs for prevention of thromboembolism. Heparin flushes (200 U in 2 ml) every 4­8 hr are used to keep patent long-term intravascular cannulae/catheters. The coagulation factors get consumed for the formation of intravascular microclots and blood is incoagulable. Heparin paradoxically checks bleeding in such patients by preserving the clotting factors. They are therapeutic rather than prophylactic and work by activating the natural fibrinolytic system. Haemostatic plug of platelets formed at the site of injury to blood vessels is reinforced by fibrin deposition to form a thrombus. When excessive amounts of plasminogen are activated (by administered fibrinolytics), the 2 antiplasmin is exhausted and active plasmin persists in plasma. Plasmin is a rather nonspecific protease: degrades coagulation factors (including fibrinogen) and some other plasma proteins as well. Thus, activation of circulating plasminogen induces a lytic state whose major complication is haemorrhage. Even selective activation of thrombus bound plasmin can cause bleeding by dissolving physiological thrombi. Antistreptococcal antibodies due to past infections inactivate considerable fraction of the initial dose of Stk. Stk is antigenic-can cause hypersensitivity reactions; anaphylaxis occurs in 1­2% patients. It cannot be used second time due to neutralization by antibodies generated in response to the earlier dose. Urokinase It is an enzyme isolated from human urine; but commercially prepared from cultured human kidney cells. Urokinase is Indicated in patients in whom streptokinase has been given for an earlier episode, but is seldom used now. In general, venous thrombi are lysed more easily by fibrinolytics than arterial, and recent thrombi respond better. Streptokinase is inactive as such; combines with circulating plasminogen molecules to form an activator complex which then causes limited proteolysis of other plasminogen molecules to generate the active enzyme plasmin. The longer duration of action enables bolus dose administration (10 mg over 10 min repeated after 30 min). Time lag in starting the infusion is critical for reducing area of necrosis, preserving ventricular function and reducing mortality. Aspirin with or without heparin is generally started concurrently or soon after thrombolysis to prevent reocclusion. Alteplase has advantages over streptokinase, including higher thrombolytic efficacy. Its stronger lytic effect on physiological haemostatic plugs may compensate for the lesser systemic fibrinolytic state. Thrombolytics can decrease subsequent pain and swelling, but the main advantage is preservation of venous valves and may be a reduced risk of pulmonary embolism, though at the risk of haemorrhage. The lung function may be better preserved, but reduction in mortality is not established. Peripheral arterial occlusion Fibrinolytics recanalise ~40% limb artery occlusions, especially those treated within 72 hr. Regional intraarterial fibrinolytics have been used for limb arteries with greater success. Peripheral arterial thrombolysis is followed by shortterm heparin and long-term aspirin therapy.

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Though its pharmacokinetic profile and tЅ of 2­3 hr is similar to cimetidine lower back pain treatment videos order maxalt with paypal, a longer duration of action with greater 24 hr acid suppression is obtained clinically because of higher potency treatment pain between shoulder blades maxalt 10mg sale. Famotidine A thiazole ring containing H2 blocker which binds tightly to H2 receptors and exhibits longer duration of action despite an elimination tЅ of 2 pain treatment centers of america little rock discount 10mg maxalt visa. Some inverse agonistic action on H2 receptors (in the absence of histamine) has been demonstrated pain solutions treatment center atlanta purchase cheap maxalt online. Because of low affinity for cytochrome P450 and the low dose, drug metabolism modifying propensity is minimal. The oral bioavailability of famotidine is 40­50%, and it is excreted by the kidney, 70% in the unchanged form. Incidence of adverse effects is low: only headache, dizziness, bowel upset, rarely disorientation and rash have been reported. Roxatidine the pharmacodynamic, pharmacokinetic and side effect profile of roxatidine is similar to that of ranitidine, but it is twice as potent and longer acting. Duodenal ulcer H2 blockers produce rapid and marked pain relief (within 2­3 days); 60­85% ulcers heal at 4 weeks and 70­95% ulcers at 8 weeks, but they are seldom used now to heal existing ulcers. Suppression of nocturnal secretion by single high bed time dose is equally efficacious and physiologically more sound. Maintenance therapy with bed time dose reduces the relapse rate to 15­20% per year as long as given. Gastric ulcer Healing rates obtained in gastric ulcer are somewhat lower (50­75% at 8 weeks). Stress ulcers and gastritis Acutely stressful situations like hepatic coma, severe burns and trauma, prolonged surgery, prolonged intensive care, renal failure, asphyxia neonatorum, etc. Intravenous infusion of H2 blockers successfully prevents the gastric lesions and haemorrhage as well as promotes healing of erosions that have occurred. Zollinger-Ellison syndrome It is a gastric hypersecretory state due to a rare tumour secreting gastrin. Prophylaxis of aspiration pneumonia H2 blockers given preoperatively (preferably evening before also) reduce the risk of aspiration of acidic gastric contents during anaesthesia and surgery. Other uses H2 blockers have adjuvant beneficial action in certain cases of urticaria who do not adequately respond to an H1 antagonist alone. The only significant pharmacological action of omeprazole is dose dependent suppression of gastric acid secretion; without anticholinergic or H2 blocking action. After absorption into bloodstream and subsequent diffusion into the parietal cell, it gets concentrated in the acidic pH of the canaliculi because the charged forms generated there are unable to diffuse back. No dose modification is required in elderly or in patients with renal/hepatic impairment. Because of tight binding to its target enzyme-it can be detected in the gastric mucosa long after its disappearance from plasma. Faster healing has been demonstrated with 40 mg/day: some duodenal ulcers heal even at 2 weeks and the remaining (over 90%) at 4 weeks. Suppression of gastric acid has been found to facilitate clot formation reducing blood loss and rebleed. Stress ulcers: Intravenous pantoprazole/ rabeprazole is as effective prophylactic (if not more) for stress ulcers as i. Higher doses than for peptic ulcer or twice daily administration is generally needed. Zollinger-Ellison syndrome: Omeprazole is more effective than H2 blockers in controlling hyperacidity in Z-E syndrome. Inoperable cases have been treated for >6 years with sustained benefit and no adverse effects. Other gastric hypersecretory states like systemic mastocytosis, endocrine adenomas, etc. Nausea, loose stools, headache, abdominal pain, muscle and joint pain, dizziness are complained by 3­5%. Because of marked and long-lasting acid suppression, compensatory hypergastrinemia has been observed. This induces proliferation of parietal cells and gastric carcinoid tumours in rats, but not in humans. Lately, few reports of gynaecomastia and erectile dysfunction (possibly due to reduced testosterone level) on prolonged use of omeprazole have appeared.

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There 1s pauciiy ofdaw about safety of majority of drugs during pregnancy: largely because prospective drug trials in pregnant women arc fraught with ethical nerve pain treatment back generic maxalt 10mg without a prescription. The list is not exhaustive and manufacturers literature/ package inserts or other authoritative texts should be consulted unifour pain treatment center denver nc order 10mg maxalt with mastercard. Pnnc1plos of proscribing during prcgmmcy Where possible use nondrug therapy Prescribe drugs only when definitely needed pain management utilization maxalt 10mg sale. Avoid newer drugs pain treatment and management buy discount maxalt 10 mg online, unless safety is clearty established Over-the-counter drugs cannot be assvmed to be safe. Use the lowest effective dose Use drugs for the shortest penod necessary If possable. Cold-cough remedies Xylometazoline Oxymetazoline Budesonide Chlorpheniramine Promethazine Nasal drops 7. Antimalarial Isoniazid, Rifampicin, Ethambutol Diloxanide furoate, Paromomycin Chloroquine, Mefloquine, Proguanil Quinine (only in 1st trimester), Pyrimethamine + Sulfadoxine (only single dose) Piperazine Niclosamide Praziquantel Clotrimazole Nystatin Tolnaftate 12. Anthelmintic Albendazole (X), Mebendazole (X) Ivermectin, Pyrantel pamoate, Diethylcarbamazine (X) Amphotericin B (X), Fluconazole Itraconazole (X), Ketoconazole (X) Griseofulvin (X), Terbinafine 13. Estrogens (in oral contraceptives) and bromocriptine (D2 agonist) decrease milk production. Toxic effects on the infant are largely dependent on entry of the drug in milk in pharmacologically significant amounts. Maternal medication or breastfeeding should not be interfered in case of such drugs. However, currently available data are insufficient to make specific recommendations in the case of many drugs and the list given below is not exhaustive. Drugs whose amount in milk is too small to be harmful to the infant, or those found to be safe in ordinary doses Insulins Ipratropium Br. Vitamins (maintenance dose) Warfarin Acetazolamide Albendazole Antacids Antifungal drugs (topical) Aspirin (low dose) Baclofen Beclomethasone (Inhaled) Benzyl benzoate (topical) Bupivacaine Buprenorphine Cephalosporins Cloxacillin Codeine Cromoglycate sod. Fenfluramine Dexfenfluramine Terfenadine Astemizole Phenformin Rofecoxib Valdecoxib Rimonabant Rosiglitazone Nimesulide formulations for children below 12 years age Cisapride Phenylpropanolamine* Sibutramine and R-Sibutramine Gatifloxacin Tegaserod Human placental extract formulations, except for: i. Halogenated hydroxyquinolines in liquid oral antidiarrhoeals or any other dosage form for pediatric use. Corticosteroids with any other drug for internal use, except for metered dose inhalers and dry powder inhalers. Crude ergot with any drug except preparations containing ergotamine, caffeine, analgesics, antihistamines for treatment of migraine, headache. H2 receptor antagonists with Antacids (except those combinations approved by Drugs Controller, India). Salbutamol (or any other bronchodilator) with centrally acting Antitussive and/or an Antihistamine. Centrally acting Antitussives with Antihistamines having atropine like activity in expectorants. Centrally acting Antitussive and/or Antihistamine in preparations for cough associated with asthma. Estrogen and Progestin (other than oral contraceptives) containing per tablet estrogen more than 50 µg ethinylestradiol (or equivalent) and progestin more than 3 mg of norethisterone acetate (or equivalent), and all fixed dose combination injectable preparations containing synthetic estrogen and progesterone. Ethambutol with Isoniazid, except in the following daily doses: Isoniazid 200 mg + Ethambutol 600 mg or Isoniazid 300 mg + Ethambutol 800 mg. Pyrazinamide with other antitubercular drugs, except that which provide the following daily doses: Rifampicin 450 to 600 mg Isoniazid 300 to 400 mg Pyrazinamide 1000 to 1500 mg 23. Essential oils with Alcohol having percentage higher than 20% proof (except preparations given in the I. Antidiarrhoeals containing adsorbants like kalolin, pectin, attapulgite, activated charcoal etc. Antidiarrhoeals containing phthalylsulfathiazole, succinyl sulfathiazole, sulfaguanidine, neomycin, streptomycin, dihydrostreptomycin. Antidiarrhoeal formulations for pediatric use containing diphenoxylate, loperamide, atropine, hyoscyamine.