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The lateral muscles of the abdominal wall comprise the external and internal oblique and the transverse muscles heart attack feat mike mccready money mark buy lanoxin 0.25mg overnight delivery. These correspond to the three layers of muscle of the chest wall— external wide pulse pressure icd 9 code buy discount lanoxin on-line, internal and innermost inter- costals arrhythmia when lying down discount lanoxin 0.25mg visa, and, like them, have their neurovascular bundles running between the second and third layer. They are clinically important in making up the rectus sheath and the inguinal canal, and also because they must be divided in making lateral abdominal incisions. Their attachments can be remembered when one bears in mind that they fill the space between the costal margin above, the iliac crest below, and the lumbar muscles covered by lumbar fascia behind. Medially, as already noted, they constitute the rectus sheath and thence blend into the linea alba from xiphoid to pubic crest. The obliquus externus abdominis (external oblique) arises from the outer surfaces of the lower eight ribs and fans out into the xiphoid, linea alba, the pubic crest, pubic tubercle and the anterior half of the iliac crest. From the pubic tubercle to the anterior superior iliac spine its lower border forms the aponeurotic inguinal ligament of Poupart. The obliquus internus abdominis (internal oblique) arises from the lumbar fascia, the anterior two-thirds of the iliac crest and the lateral two-thirds of the inguinal ligament. The transversus abdominis arises from the lowest six costal cartilages (interdigitating with the diaphragm), the lumbar fascia, the anterior two- thirds of the iliac crest and the lateral one-third of the inguinal ligament; it is inserted into the linea alba and the pubic crest. Note that the external oblique passes downwards and forwards, the internal oblique upwards and forwards and the transversus transversely. The fasciae and muscles of the abdominal wall 61 Note also that the external oblique has its posterior border free but the deeper two muscles both arise posteriorly from the lumbar fascia. The anatomy of abdominal incisions Incisions to expose the intraperitoneal structures represent a compromise on the part of the operator. On the one hand he requires maximum access; on the other hand he wishes to leave a scar which lies, if possible, in an unobtrusive crease, and which will have done minimal damage to the muscles of the abdominal wall and to their nerve supply. The nerve supply to the lateral abdominal muscles forms a richly com- municating network so that cuts across the lines of fibres of these muscles, with division of one or two nerves, produce no clinical ill-effects. The seg- mental nerve supply to the rectus, however, has little cross-communication and damage to these nerves must, if possible, be avoided. The copious anastomoses between the blood vessels supplying the abdominal muscles make damage to these by operative incisions of no practical importance. Superiorly, this is a rel- atively wide fibrous structure, but below the umbilicus it becomes almost hair-line and the surgeon may experience difficulty in finding the exact point of cleavage between the recti at this level. Being made of fibrous tissue only, it provides an almost bloodless line along which the abdomen can be opened rapidly and, if necessary, from Dan in the North to Beersheba in the South! This incision has the advantage that, on suturing the peritoneum, the rectus slips back into place to cover and protect the peritoneal scar. The adherence of the anterior sheath to the rectus muscle at its tendi- nous intersections means that the sheath must be dissected off the muscle at each of these sites, and at each of these a segmental vessel requires division. Having done this, the rectus is easily slid laterally from the posterior sheath from which it is quite free. The posterior sheath and the peritoneum form a tough membrane down to half-way between pubis and umbilicus, but it is much thinner and more fatty below this where, as we have seen, it loses its aponeurotic component and is made up of only transversalis fascia and peritoneum. The inferior epigastric vessels are seen passing under the arcuate line of Douglas in the posterior sheath and usually require division in a low paramedian incision. The rectus receives its nerve supply laterally and the muscle medial to the incision must, in consequence, be deprived of its innervation and undergo atrophy; it is an incision therefore best avoided. Subcostal incision The subcostal (Kocher) incision is used on the right side in biliary surgery and, on the left, in exposure of the spleen. The anterior rectus sheath is opened, the rectus cut and the posterior sheath with underlying adherent peritoneum incised. The small 8th inter- costal nerve branch to the rectus is sacrificed but the larger and more impor- tant 9th nerve, in the lateral part of the wound, is preserved.
Thiopental has no analgesic ac- pharyngeal and laryngeal reflexes are only slightly im- tivity and may be antanalgesic blood pressure chart heart foundation purchase lanoxin 0.25 mg visa. Antihypertensives or diuretics may aug- lucinations with delirium can occur during recovery (the ment the hypotensive effect arrhythmia questionnaire buy generic lanoxin 0.25mg on line. Thiopental reduces respiratory rate solely as an induction drug and followed by a conventional and tidal volume blood pressure top number order lanoxin 0.25mg online. Their incidence is reduced by giv- ing a benzodiazepine both as a premedication and after the procedure. Subanaesthetic doses of ketamine can be used to pro- Methohexitone is a barbiturate similar to thiopental but its vide analgesia for painful procedures of short duration such terminal t½ is considerably shorter. Since the introduction as the dressing of burns, radiotherapeutic procedures, mar- of propofol, its use is confined almost entirely to inducing row sampling and minor orthopaedic procedures. It causes pain on in- ingly popular for inducing anaesthesia in critically ill jection and excitatory muscle movements are common on patients. Even after a single dose of etomidate, ad- 5–10 mg/kg by deep intramuscular injection produces renocortical suppression can last for as long as 72 h and in surgicalanaesthesiawithin3–5 min,lastingforupto25 min. Despite all of these disadvantages it remains nous dose or 25% of the intramuscular dose are given to in common (although decreasing) use, particularly for prevent movement in response to surgical stimuli. Tonic emergency anaesthesia, because it causes less cardiovascu- and clonic movements resembling seizures occur in some lar depression and hypotension than thiopental or propo- patients but do not indicate a light plane of anaesthesia fol. Emergence reac- tions (above) are lessened by benzodiazepine premedica- Ketamine tion and by avoiding unnecessary disturbance of the patient during recovery. Anaesthesia persists for up to 15 min after intracranial pressure; eye injury and increased intraocular a single intravenous injection and is characterised by pressure; psychiatric disorders such as a schizophrenia profound analgesia. Ketamine is contraindicated in preg- contrast to most other anaesthetic drugs, ketamine usually nancy before term, as it has oxytocic activity. It is also con- causes a tachycardia and increases blood pressure and traindicated in patients with eclampsia or pre-eclampsia. It cardiac output, making it an increasingly popular choice may be used for assisted vaginal delivery by an experienced for inducing anaesthesia in shocked patients. Ketamine is better suited for use during caesar- ean section; it causes less fetal and neonatal depression 5N-methyl-D-aspartate. In the past, misguided cations and slow recovery) or by regional nerve blockade concerns about the effect of volatile anaesthetics on the (which may be difficult to do or contraindicated, e. Under these conditions some mothers were conscious blocking drugs enables surgery under light general anaes- and experienced pain while paralysed and therefore unable to move. Despite its extreme rarity nowadays,8 fear of thesia with analgesia; it also facilitates tracheal intubation, quick induction and quick recovery. However, mechanical awareness under anaesthesia is still a leading cause of anx- ventilation and technical skill are required. Neuromuscular blocking drugs first attracted scientific Mechanisms notice because of their use as arrow poisons by the natives When an impulse passes down a motor nerve to voluntary of South America, who used the most famous of all, curare, muscle it causes release of acetylcholine from the nerve for killing food animals6 as well as enemies. This activates receptors on Benjamin Brodie smeared ‘woorara paste’ on wounds of the membrane of the motor endplate, a specialised area guinea pigs and noted that death could be delayed by in- on the muscle fibre, opening ion channels for momentary flating the lungs through a tube introduced into the tra- passage of sodium, which depolarises the endplate and ini- chea. Natural substances that prevent Despite attempts to use curare for a variety of diseases in- the release of acetylcholine at nerve endings exist, e. Clos- cluding epilepsy, chorea and rabies, the lack of pure and ac- tridium botulinum toxin and some venoms. By competition with acetylcholine (atracurium, in medical practice until 1942, when these difficulties were cisatracurium, mivacurium, pancuronium, removed. These drugs are competitive Drugs acting at the myoneural junction produce com- antagonists of acetylcholine.
Blocking H2 re- Regarding the synthesis of norepinephrine blood pressure medication infertility 0.25mg lanoxin overnight delivery, tyrosine is ceptors does not ameliorate symptoms of hay fever or transported by a Na1-linked carrier into the axoplasm cause changes in wakefulness basic arrhythmias 7th edition discount 0.25mg lanoxin with mastercard. It can be dihydroxyphenylalanine (dopa) by tyrosine hydroxy- used to treat symptoms of hay fever but is not known lase pulse pressure and stroke volume 0.25 mg lanoxin amex. Dopa is then decarboxylated by the enzyme dopa decarboxylase (aromatic l-amino acid 102 The answer is A: Erectile dysfunction. Guanethidine decarboxylase) to form dopamine in the cytoplasm of blocks the release of stored norepinephrine as well as the presynaptic neuron. Peripheral effects: Anorexia, nausea, movement of ions that results in a hyperpolarization and vomiting occur because of stimulation of the che- of the postsynaptic membrane. Saliva and urine sient increase in the permeability of specifc ions, are a brownish color because of the melanin pigment such as potassium (K1) and chloride (Cl2) ions. These drugs should not be used in patients with 109 The best answer is C: Reduced rate of loss of cognitive Parkinson’s disease. Common adverse 106 The answer is A: Antagonizing the excitatory efect effects include nausea, diarrhea, vomiting, anorexia, of cholinergic neurons. Many of the symptoms of tremors, bradycardia, and muscle cramps, all of which parkinsonism refect an imbalance between the are predicted by the actions of the drugs to enhance excitatory cholinergic neurons and the greatly dimin- cholinergic neurotransmission. Therapy is aimed at restoring dopamine in the basal (B) Rivastigmine does not improve speech and lan- ganglia and antagonizing the excitatory effect of cho- guage function. This also impairs a person’s ability to learn properties of benzodiazepines, such as lorazepam, and form new memories. Clonazepam is occasionally (C) Hydroxyzine, an antihistamine, is effective as a used in the treatment of certain types of epilepsy, hypnotic, and it is sometimes used to deal with anxi- whereas diazepam and lorazepam are the drugs of choice ety, especially if emesis is a problem. Ethosuximide is the frst-line treat- this setting will not decrease risk of withdrawal and ment of absence seizures. It is physical dependence on benzodiazepines can develop not used in the treatment of absence seizures. Phenytoin has short elimination half-life, such as triazolam, induce many side effects, like hirsutism, nystagmus, gingi- more abrupt and severe withdrawal reactions than val hyperplasia, and megaloblastic anemia. When released, 121 The answer is D: Two weeks of therapy are required norepinephrine binds to a1-adrenergic receptors to for mood improvement. The most dopamine agonist used in the treatment of Parkinson’s important step in treating local anesthetic toxicity is disease. Benzodiazepines used for the treatment of bipolar disorder but not for can induce a temporary form of anterograde amnesia obsessive-compulsive disorder. Pyridostigmine is an acetylcholinesterase inhibitor, potentiating the 125 The answer is A: Duloxetine. Duloxetine is a sero- effects of acetylcholine released into the neuromuscu- tonin/norepinephrine reuptake inhibitor that can be lar junction. This excess acetylcholine can overcome used for depression accompanied by neuropathic the effects of antibodies blocking some of the recep- pain. This agent is not recommended for patients younger (B) Clomipramine is a tricyclic antidepressant that than the age of 18 years. Contraindications include can also be used for obsessive-compulsive disorder seizure disorders, anorexia, and bulimia.
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On the other Packer M arrhythmia in children buy lanoxin 0.25mg with mastercard, O’Connor C M blood pressure 5332 buy lanoxin 0.25mg on-line, Ghali J K et al 1996 The effect of amlodipine hand arteria dorsalis nasi discount lanoxin 0.25mg otc, an occasional missed dose is of little consequence. New England Amlodipine differs from all other dihydropyridines listed Journal of Medicine 335:1107–1114). Mortality reduction here may result vascular smooth muscle cell growth, probably contributing from their being the only vasodilator that does not reflexly to the progressive amplification in hypertension once the activate the sympathetic system. A fall in aldosterone production may axis is required for this effect, not simply lowering the also contribute to the blood-pressure-lowering action of 11 blood pressure. Whether the long-term benefit of these drugs in protect against a decline in renal function and reduce hypertension exceeds that to be expected from blood pres- 10 macroproteinuria. The antihy- trandolopril, verapamil and the combination versus placebo with a pertensive effect increases progressively over weeks with 3. Whether combining the • Pregnancy represents an absolute contraindication two classes of drugs (‘dual block’) confers further protec- (see below). The effect of the tongue to life-threatening tracheal obstruction, is seen even in patients without overt signs of cardiac failure, when subcutaneous adrenaline/epinephrine should but who have low left ventricular ejection fractions (<40%) be given. Hyperkalaemia can result from use with thought to be crucial to the maintenance of glomerular potassium-sparing diuretics. Severe hypotension can occur on lisinopril, moexipril, perindopril, quinapril, ramipril and tran- dolapril. The clinical significance of these differ- Aliskiren is the only orally active non-peptide renin in- ences is disputed. Thedrughasashortt½ (2 h) but the metabolite is Other vasodilators much longer lived (t½ 10 h), permitting once-daily Several older drugs are powerfully vasodilating, but pre- dosing. Losartan is the former, it acts through its sulphate metabolite as an generally used in combination with hydrochlorothiazide. It is highly effective in severe hypertension, tive than atenolol plus hydrochlorothiazide in preventing but in common with all potent arterial vasodilators its stroke. Its effect is almost 14Yusuf S, Sleight P, Pogue J et al 2000 Effects of an angiotensin- immediate and lasts for 1–5 min. Therefore it must be converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. It dilates both directly relaxing arterioles, with negligible effect on veins; arterioles and veins, which would cause collapse were the the mechanism of vasorelaxation is unclear. There is a com- In most hypertensive emergencies (except for dissecting pensatory sympathetic discharge with tachycardia and aneurysm) hydralazine 5–20 mg i. This may cause a systemic lupus-like syndrome, more com- breaks down, liberating cyanide radicals capable of inhi- monly in white than in black races, and in those with the biting cytochrome oxidase (and thus cellular respiration). Fortunately, most of the cyanide remains bound within Three other vasodilators find a role outside hypertension: erythrocytes but a small fraction does diffuse out into Nicorandil is effective through two actions: it acts as a ni- the plasma and is converted to thiocyanate. It is subjects are also reputed to have the characteristic bitter administered orally and is an alternative to nitrates when almond smell of hydrogen cyanide. Clearly nitroprusside tolerance is a problem, or to the other classes when these infusion must be used with caution, and outside specialist are contraindicated by asthma or cardiac failure. Adverse ef- units it may be safer overall to choose another more fects to nicorandil are similar to those of nitrates, with familiar drug. It is the only antian- Sodium nitroprusside is used in hypertensive emergen- ginal drug for which at least one trial has demonstrated a cies, refractory heart failure and for controlled hypotension beneficial influence on outcome.
