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Stage 4 of the Disaster You have now learned that communications were completely inadequate or had failed completely asthma x-ray image purchase 5 mg montelukast with visa. You have received word that signal fares were not seen asthma treatment in jalandhar purchase montelukast 4 mg, tele- graphs were never sent or completed in transmission asthma breakthrough order montelukast 4mg online, and several couriers were lost in the rush of water. In addition, other dams have failed or have been bombed by the military to reverse the water fow, communication lines are nonexistent, electricity has been lost over wide parts of the region, transportation lines have 68 ◾ Case Studies in Disaster Response and Emergency Management been completely severed, and you have over a million people who are isolated by foodwaters (Watkins, 2012; Navarro, 2008). After several days it has now been reported that over 200,000 are dead from the food, with several communities wiped from the face of the earth (Navarro, 2008; Watkins, 2012). You will need to get the million or so people out of the isolated area or get some type of transportation line open to them so that food and other supplies can be sent to them before famine occurs. The infrastructure will need to be fxed quickly so that supplies, people, and engineers can begin to repair the dams and evacuate anyone in need from the area. Another issue that will now have to be dealt with is collecting and stor- ing the corpses so that drinking water and other areas are not contaminated. Tis will require facilities that are undamaged to be designated as a repository so that bodies can be stored and eventually identifed. Until the communication infrastructure is operable, you will need to rely on couriers to send and receive any type of messages. Terefore, a priority should be placed on getting engineers working to restore the telecommunication lines and switching. Tis will also require getting the power restored since telecommunications is reliant on electricity in order to function. Until transportation infrastruc- ture such as roads and railroads is repaired, you will have to rely on aircraft or boats to deliver supplies and perform search and rescue operations. Medical resources will be needed not only to treat the wounded, but also to treat individuals for disease that could have come into contact with contaminated drinking water. Safe drinking water must be made available to all of the displaced persons, support personnel, and individuals that are cut of and isolated by foodwaters. Key Issues Raised from the Case Study Tis case study presents an emergency manager with a communications nightmare. The communication that exists is rudimentary, and the mode of communication (telegraphs) is limited to those communities that have access to such devices. China in 1975 would be considered a developing nation since the majority of the population in rural areas did not have access to telephones or any type of electronic communications that were available to residents in cities. The situation today in many developing countries is much the same, and emergency managers in this type of situation will need to develop redun- dant and robust strategies for communicating with their governmental agencies as well as the population that will be impacted. Conditions seen in this case study in the forms of communication mirror the communication gaps that existed in the Newfoundland hurricane in 1775. In addition, government ofcials appeared to Case Studies: Disasters from Natural Forces—Floods ◾ 69 be overconfdent in the dams that were constructed, which proved to be fatal since there were no apparent emergency management plans in place if a food were to occur. Emergency managers should always prepare for the worst-case scenario and be prepared to execute their plans to prevent or at least diminish the tragedy that can befall a community. Items of Note Eleven million residents were afected by the food, and the reconstruction of the Banqiao Dam was not completed until 1993 (Watkins, 2012; Mufson, 1997). Additionally, more residents were killed by epidemics and famine than by the food itself (Navarro, 2008). Chapter 5 Case Studies: Disasters from Natural Forces—Tornadoes Natchez Tornado, Mississippi, 1840 Stage 1 of the Disaster You are a county commissioner for a port city in the southern region of the United States. On May 7, you are inspecting a county road when you notice a big funnel-shaped cloud over the horizon (Tornado Project, 2007). Your frst plan of action should be to warn every- one in your area to take cover since a tornado is visible and coming in the direction of your community.
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Efficacy of radiofrequency ablation for control of intraatrial reentrant tachycardia in patients with congenital heart disease asthma fever cheap 5 mg montelukast with visa. Location of acutely successful radiofrequency catheter ablation of intraatrial reentrant tachycardia in patients with congenital heart disease asthma definition journal cheap montelukast online american express. Moderate hypothermia in the management of resistant automatic tachycardias in children asthmatic bronchitis inhalers buy montelukast overnight delivery. Evaluation of a staged treatment protocol for postoperative rapid junctional ectopic tachycardia. Hypothermia for the treatment of postsurgically accelerated junctional ectopic tachycardia. Atrial pacing as an adjunct to the management of post-surgical His bundle tachycardia. Evaluation of a staged treatment protocol for rapid automatic junctional tachycardia after operation for congenital heart disease. Congenital junctional tachycardia and congenital complete atrioventricular block: a shared etiology? Junctional tachycardias: anatomic substrate and its significance in ablative procedures. Intravenous amiodarone for incessant tachyarrhythmias in children: a randomized, double-blind, antiarrhythmic drug trial. Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. Successful radiofrequency ablation of permanent junctional reciprocating tachycardia in an 18-month-old child. Successful radiofrequency energy ablation of automatic junctional tachycardia preserving normal atrioventricular nodal conduction. Transcatheter radiofrequency ablation for congenital junctional ectopic tachycardia in infancy. Successful transcatheter ablation of congenital junctional ectopic tachycardia in a ten-month-old infant using radiofrequency energy. Combined alpha-adrenergic blockade and radiofrequency ablation to treat junctional ectopic tachycardia successfully without atrioventricular block. Successful radiofrequency catheter ablation of congenital junctional ectopic tachycardia with preservation of atrioventricular conduction in a 9-month-old infant. Long-term results of catheter ablation of idiopathic right ventricular tachycardia. Idiopathic monomorphic ventricular tachycardia originating from the left aortic sinus cusp in children: endocardial mapping and radiofrequency catheter ablation. Ventricular tachycardia in nonpostoperative pediatric patients: role of radiofrequency catheter ablation. Non-contact mapping and ablation of tachycardia originating in the right ventricular outflow tract. Treatment of macroreentrant ventricular tachycardia with radiofrequency ablation of the right bundle branch. Fascicular and nonfascicular left ventricular tachycardias in the young: an international multicenter study.
It has been reported in association with ventricular septal defect asthmatic bronchitis heartburn order 10 mg montelukast with mastercard, tetralogy of Fallot (55 asthma from allergies montelukast 10mg with amex,56) asthma symptoms 3 dpo generic 4mg montelukast visa, and coarctation of the aorta (57). Patients may present with the usual symptoms of a vascular ring, including respiratory symptoms and dysphagia, or may be asymptomatic, with the diagnosis made incidentally (56,58). On barium esophagram, they demonstrate a right-sided indentation from the right aortic arch, and a posterior indentation from the diverticulum of Kommerell (proximal aberrant brachiocephalic artery) (55,58). Echocardiography demonstrates the transverse arch to the right of the trachea and the left brachiocephalic artery arising from the proximal descending aorta, best imaged from the suprasternal window (59). Note that this is one of the few instances where the first common carotid artery arising from the aortic arch is ipsilateral to the transverse arch. Isolated Branches of the Aortic Arch Anatomy and Embryology Left Aortic Arch with Isolated Right Subclavian Artery An isolated right subclavian artery is one that is disconnected from the aortic arch. Closure of the arterial duct would eliminate any prograde flow to the subclavian artery, in which case, the subclavian artery would be supplied by retrograde flow from the circle of Willis. An isolated right subclavian artery develops when there is regression of the right fourth arch (Fig. Unlike in the setting of an aberrant right subclavian artery from the descending aorta, the right dorsal aorta also regresses, leaving the seventh intersegmental artery (the subclavian artery) attached only to the right sixth arch. The right sixth arch does not regress and instead forms a right-sided arterial duct, the sole source of prograde flow into the subclavian artery. The seventh intersegmental artery retains its attachment to the vertebral artery, thereby allowing retrograde flow from the circle of Willis to the subclavian artery via the vertebral artery or from the contralateral vertebral artery via the basilar artery. Right Aortic Arch with Isolated Left Subclavian Artery Patients may have a right aortic arch with an isolated left subclavian artery, supplied by prograde flow through a left-sided arterial duct or retrograde flow through the left vertebral artery. The right aortic arch is formed through the usual process, with regression of the left distal P. The left sixth arch, which forms the left arterial duct, connects the isolated left seventh intersegmental artery (future left subclavian artery) to the pulmonary artery, enabling prograde flow from the pulmonary artery to the left subclavian artery via the arterial duct. The seventh intersegmental artery retains its attachment to the vertebral artery, thereby allowing retrograde flow from the circle of Willis to the subclavian artery via the vertebral artery. Rarely, the isolation may be incomplete, such that an atretic cord remains between the aortic arch and the isolated subclavian artery, with a diverticulum of Kommerell located posterior to the aorta. In this setting, a vascular ring is formed from the ascending aorta and pulmonary artery anteriorly, transverse arch on the right, diverticulum of Kommerell and the atretic portion between the aortic arch and the isolated subclavian artery posteriorly, and the arterial duct on the left (61,62). A: The right fourth aortic arch and the right distal dorsal aortic arch have regressed, such that the only way the right seventh intersegmental (future right subclavian artery) remains attached to the aorta is via the distal sixth aortic arch, the future right-sided arterial duct. B: The vertebral artery (lavender) allows for retrograde perfusion via the basilar artery and circle of Willis. C: Embryonic arch diagram showing ipsilateral loss of right fourth arch and dorsal aorta with persistence of ipsilateral sixth arch. Epidemiology and Etiology Data on isolated subclavian arteries are sparse and come mainly from case reports (1,16,62). Isolated subclavian arteries occur very rarely, with one report finding an incidence of isolated left subclavian arteries in <1% of patients with a right aortic arch (63). Cases of left aortic arch with isolated right subclavian artery have also been reported, but much less frequently (16,64,65). Associated Congenital Heart Disease Right aortic arch with isolated left subclavian artery is often associated with congenital heart disease, including ventricular septal defects and tetralogy of Fallot, more frequently in those presenting as a child (16,61).
In normal individuals asthma symptoms while pregnant buy montelukast once a day, the first phase of insulin secretion starts immediately after food intake and lasts for 10–15 min and is due to release of preformed insulin granules asthma symptoms panic attack cheap montelukast 10 mg with mastercard. This is followed by second phase of insulin secretion which lasts for 90–120 min and is due to biosynthesis of insulin asthma definition severity buy cheap montelukast 5mg on line. The first phase of insulin secre- tion is responsible for suppression of hepatic glucose output, while the second phase regulates the entry of glucose into insulin-dependent target sites including muscle and adipocytes. On the contrary, regular insulin has onset of action in 30–60 min, exerts its peak effect at 2–4 h and its action lasts for 6–8 h. The delayed onset of action of regular insulin mandates its administration at least 30 min prior to meal, and the delay in peak effect results in early postprandial hyperglycemia. In addition, the prolonged duration of action of regular insulin results in late postprandial hypoglycemia, leading to inter-prandial snacking. Further, regular insulin has marked intra- and interindividual variations in absorption (up to 20–50%), thereby resulting in increased risk of hypo- or hyper- glycemia, even with the same dose. Short-acting insulin analogues have an onset of action within 15 min and exert its peak effect at 1 h, and the action lasts for 3–4 h. Because of its rapid onset of action, it is convenient for the patient to administer insulin immediately before a meal, or sometimes immediately after a meal. This may be especially useful in children, elderly, and in patients with gastroparesis. The early peak effect results in better postprandial glycemic control, and short duration of action prevents the risk of late postprandial hypoglycemia. Despite these advantages of short-acting insulin analogues, the reduction in HbA1c is similar to that achieved with regular insulin. These are peakless insulins with duration of action of approximately 18–36 h, have less intra- and interindividual variability in absorption and decreased risk of nocturnal hypoglycemia. Parameter Detemir Glargine Degludec No of amino acid 50 53 50 Fatty acid chain Present No Present (myristic acid) (hexadecanedioic acid) pH Neutral Acidic Neutral Mechanism of prolonged Binding to Precipitation at Multihexamer chain duration of action albumin in neutral pH in formation in circulation subcutaneous tissue subcutaneous tissue Onset of action 1 h 1 h 1–1. Insulin detemir is weight neutral as compared to other insulins, and this effect is possibly mediated by a direct effect on satiety center. In addition, detemir is more hepato-selective in its action because of greater availability of albumin- bound detemir to liver as compared to peripheral tissues, thereby resulting in reduced lipogenesis. Majority of patients require twice daily injection of detemir as its duration of action varies from 6 to 23 h. Insulin degludec offers an advantage of flexibility in dose schedule and can be administered between 8 and 36 h. In addition, as it is a truly peakless insulin, it is associated with the lowest incidence of nocturnal hypoglycemia among the basal insulins. Administration of degludec results in very high plasma insulin levels, and degludec has been shown to be associated with higher incidence of cardiovascular events. Premixed insulin consists of short-acting and intermediate-acting insulin in a fixed ratio, in order to provide prandial and basal insulin together to minimize the number of injections, thereby making it convenient to the patient. Therefore, it is dif- ficult to achieve glycemic targets with the use of fixed-dose premixed insulin. The adverse consequences of intensive insulin therapy are increased risk of hypo- glycemia, peripheral edema, weight gain, initial worsening of retinopathy (includ- ing macular edema) and insulin neuritis. In addition, rapid reduction of blood glucose associated with initiation of intensive insulin therapy may result in change in refractory index of lens (hypermetropia), as a result of intraocular osmotic dis- equilibrium. The clinical implication of this observation is that patients with proliferative retinopathy should be effectively treated for eye disease, prior to institution of intensive glycemic control. Insulin lipodystrophy refers to localized hypertrophy or atrophy of adipose tis- sue at the injection site. Lipoatrophy was common with use of insulin derived from animal sources and is rare with the use of human insulin.
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