By Q. Gunock. Minot State University.

She has had three vaginal deliveries and a total abdominal hysterectomy in the past purchase zudena discount, both of which are risk factors for developing P O P cheap zudena master card. Examination of the anterior compartment (bladder) is nor- mal in support discount 100 mg zudena free shipping, including Q -tip test. If the urethra were not well supported, the finding of urethral hypermobility might be present causing the urethral Q -tip to rotate through a large angle on Valsava. Almost inevitably, an ent erocele is present associat ed wit h vaginal vault prolapse. It is unlikely t hat con- servat ive measures, such as pelvic muscle st rengthening exercises, will alleviate this patient’s symptoms. Some studies suggest that a 10% decrease in weight may significantly decrease prolapse symptoms. T hus, this patient should be counseled regarding weight loss, which may alleviate symptoms, or at the least, reduce surgical risks and make the procedure technically easier to accomplish. T herefore, t he best t reat ment s include eit her pessary, which is a syn- thetic device used to act as a “hammock” to suspend the pelvic organs, or surgery. Fixation of the vagina is then achieved to a sturdy structure such as the sacrospinous ligament or t he uterosacral ligament s (vaginal approach), or abdomi- nal sacrocolpopexy (fixing the vaginal cuff to the sacrum using a synthetic mesh). T h e sympt oms var y an d can in clu d e a h eavi- ness or pressure sensat ion in the pelvis, a bulging mass (cent ral), difficulty voiding or incomplete bladder emptying, urinary incontinence (anterior), constipation or having to use one’s fingers to apply pressure on the vagina as a splint to achieve a bowel movement (post erior), sexual dysfunct ion or pain wit h int ercourse (see Figure 33– 1). The pelvic diaphragm, a muscular and ligamentous network, which attaches from the p u bic bon e t o the sacr u m t o the lat er al p elvic sid e walls act s t o su p p or the pelvic organs. The pelvic diaphragm consists of mult iple muscles such as the pubo- coccygeus, puborectalis, an d levatorani. T h e bladder sit s on the pelvic diaph r agm and defect s will lead to it s descent from the normal locat ion. Known risk factors for P O P in clu de mult iple vagin al bir t h s, agin g, prior pelvic sur ger y, h yst erect omy, con st ip at ion, ir r it able bowel syn d r om e, gen et ic p r ed isp osit ion, lack of est r ogen, and obesit y. Potent ial, but st ill debated, risk factors include episiotomy, high birt h weight infant s, ch ronic cough, exercise, h eavy lift ing, and lower educat ion. Physical examination can be revealing and indicate what type of defect is pres- ent. The examinat ion should be conduct ed wit h the pat ient in t he lit hot omy as well as st anding posit ions. W h en the pat ient bears down, it should be noted whet her t he bladder moves furt her downward. Addit ionally, a cot - ton applicator tip may be placed into the urethra and the angle of excursion of the Q-tip should be observed at rest and with Valsalva. Hypermobility includes a rest ing uret hral angle > 30° or a maximal angle st rain during Valsava > 30°. The rectum should likewise be examined both vaginally and with a rectal examination. If the patient has her uterus and cervix, then its position should be noted in relationship to the hymenal ring. Various systems are used to grade the degree of uterine prolapse; one such system is to delineate mild (above the hymen), moderate (at the hymen), complete (beyond the hymen). Sometimes the entire uterus is prolapsed out of the patient’s introitus, the so-called procidentia. Women who have had a hysterectomy previously are at risk for vaginal cuff prolapse du e t o failure t o fix the vagin a t o suppor t ing car din al or ut erosacral ligament s. A paravaginal defect is assessed by palpat ing the lat eral aspect s of the vagin a fo r it s su p p o r t an d m o b ilit y. In general, mild P O P defect s can be t reat ed wit h pelvic floor st rengt hening exercises and observat ion. More significant defect s may be t reat ed by pessary devices, which act as a hammock to support the pelvic structures. Different pessary devices are made for different types of defects (see Figure 33– 2, pessary). Fixation of the vaginal cuff to the sacrospinous liga- ment for instance is called a sacrospinous ligament fixation procedure. The use of vagin al m esh h as b een co n t r o ver sial r ecen t ly, an d it s u se is gen er ally r eser ved fo r large defect s wit h t h orough informed consent. Using a synt h et ic mat erial t o fix the vagin al cu ff t o the sacr al b o n e is called a sacr o co lp o p exy. R ecen t ly, the F D A h as issued warnings t hat synt het ic mesh es in t he vagina may lead t o erosion and ot h er complicat ion s. She states that she often needs to use her fingers to push her vagin a b ackwar d t o ach ieve a b owel m ovem en t. The surgeon is attempt- ing t o ensure t hat t he pat ient does not have subsequent vaginal vault pro- lapse. O ne st ep that is t aken is t o use sut ure t o fix the vaginal vault t o the uterosacral ligaments. W hich of t he following techniques may be used to furt her decrease the likelih ood of vaginal vault prolapse? This patient has symptoms consistent with pure stress urinary inconti- nence, typically due to the bladder falling out of its normal intra-abdominal position. Anot h er component of the urinary incont inence is loss of the vesico u r et h r al an gle an d h yp er m o b ile u r et h r a. T h e co m m o n d en o m in at o r is probably childbirth, leading to damage of the pelvic support. Because the support structure to the rectum is defective, the rectum is impinging int o t he vagina. W h en t he pat ient bears down t o have a bowel movement, the stool gathers in the pouch toward the vagina, instead of out the anal opening. When the patient splints against the rectum with her fin- ger s, sh e act s as t o alleviat e the d am aged mu scu lar “en d op elvic fascia,” an d simult aneous wit h Valsalva, t he st ool can be direct ed t oward t he anal open- ing. The surgical repair in t his inst ance is a posterior colporrhaphy consist ing of incision of the vaginal mucosa posteriorly, identification of the edges of the endopelvic fascia, and surgical repair of t hese edges t hat have separat ed. One important risk factor for subsequent vaginal vault prolapse is a very spacious and deep cul-de-sac. A surgical t ech nique of oblit erat ing t he cul- de-sac region is called culdoplasty. For instance, a circumferential sequence of purse-string sutures can be used to suture the cul-de-sac area closed. T his procedure reduces the opportunity for the small bowel to push into the vagi- nal vault and enterocele formation.

If administered to a patient who is already receiving opioids buy generic zudena 100 mg on line, naloxone will reverse analgesia order discount zudena on line, sedation order generic zudena canada, euphoria, and respiratory depression. If administered to an individual who is physically dependent on opioids, naloxone will precipitate an immediate withdrawal reaction. Pharmacokinetics Naloxone was traditionally restricted for use in the inpatient setting. Now with new legislation, naloxone is available for use by patients and families in the outpatient setting to help prevent opioid-related deaths from accidental overdose. Therapeutic Uses Reversal of Opioid Overdose Naloxone is the drug of choice for treating overdose with a pure opioid agonist. The drug reverses respiratory depression, coma, and other signs of opioid toxicity. However, the doses required may be higher than those needed to reverse poisoning by pure agonists. Dosage must be carefully titrated when treating toxicity in opioid addicts because the degree of physical dependence in these individuals is usually high and hence an excessive dose of naloxone can transport the patient from a state of poisoning to one of acute withdrawal. Accordingly, treatment should be initiated with a series of small doses rather than one large dose. Because the half-life of naloxone is shorter than that of most opioids, repeated dosing is required until the crisis has passed. If the patient received a dose of naloxone by a friend or family member for a suspected overdose, the patient should be transported by emergency providers to the nearest emergency department for further evaluation. Other Opioid Antagonists Methylnaltrexone Actions and Therapeutic Use Methylnaltrexone [Relistor] and naloxegol [Movantik] are selective mu opioid antagonists indicated for opioid-induced constipation in patients with chronic pain who are taking opioids continuously and who have not responded to standard laxative therapy. Accordingly, the drugs do not decrease analgesia and cannot precipitate opioid withdrawal. Pharmacokinetics Methylnaltrexone is rapidly absorbed after subQ injection, reaching peak plasma levels within 30 minutes. Naloxegol can be taken orally on a daily basis and has a slightly longer half-life (6 to 11 hours) than methylnaltrexone. Methylnaltrexone undergoes minimal metabolism and is excreted in the urine (50%) and feces (50%), primarily as unchanged drug. Adverse Effects, Precautions, and Drug Interactions Methylnaltrexone and naloxegol are generally well tolerated. The most common adverse effects are abdominal pain, flatulence, nausea, dizziness, and diarrhea. In the event of severe or persistent diarrhea, these drugs should be discontinued. Preparations, Dosage, and Administration Methylnaltrexone [Relistor] is available in solution (12 mg/0. Dosing is usually done once every 48 hours, and should not exceed once every 24 hours. In palliative care patients, dosage is based on weight as follows: 8 mg for patients from 38 kg to under 62 kg (84 lb to <136 lb); 12 mg for patients 62 to 114 kg (136 to 251 lb); and 0. In patients with severe renal impairment, defined as creatinine clearance below 30 mL/minute, dosage should be reduced by 50%. In opioid abuse, the goal is to prevent euphoria if the abuser should take an opioid. Because naltrexone can precipitate a withdrawal reaction in persons who are physically dependent on opioids, candidates for treatment must be rendered opioid free before naltrexone is started. Although naltrexone can block opioid-induced euphoria, the drug does not prevent craving for opioids. Therapy with naltrexone has been considerably less successful than with methadone, a drug that eliminates craving for opioids while blocking euphoria. Use of naltrexone for alcohol dependence and opioid addiction is discussed in Chapters 31 and 33, respectively. Accordingly, the drug is contraindicated for patients with acute hepatitis or liver failure. Warn patients about the possibility of liver injury and advise them to discontinue the drug if signs of hepatitis develop. Intramuscular administration can cause injection-site reactions, which are sometimes severe. Moderate reactions include pain, tenderness, induration, swelling, erythema, bruising, and pruritus. Severe reactions—cellulitis, hematoma, abscess, necrosis—can cause significant scarring and may require surgical intervention. For oral therapy, a typical dosing schedule consists of 100 mg on Monday and Wednesday and 150 mg on Friday. Tramadol [Ultram] relieves pain by mechanisms largely or completely unrelated to opioid receptors. This drug causes little or no respiratory depression, physical dependence, or abuse. Mechanism of Action Tramadol is an analog of codeine that relieves pain in part through weak agonist activity at mu opioid receptors. However, it seems to work primarily by blocking uptake of norepinephrine and serotonin, thereby activating monoaminergic spinal inhibition of pain. The drug is less effective than morphine and no more effective than codeine combined with aspirin or acetaminophen. Analgesia begins 1 hour after oral dosing, is maximum at 2 hours, and continues for 6 hours. Pharmacokinetics Tramadol is administered by mouth and reaches peak plasma levels in 2 hours. Adverse Effects Tramadol has been used by millions of patients, and serious adverse effects have been rare. The most common side effects are sedation, dizziness, headache, dry mouth, and constipation. Seizures have been reported in more than 280 patients and hence the drug should be avoided in patients with epilepsy and other neurologic disorders. By inhibiting uptake of norepinephrine, tramadol can precipitate a hypertensive crisis if combined with a monoamine oxidase inhibitor. By inhibiting uptake of serotonin, tramadol can cause serotonin syndrome in patients taking drugs that enhance serotonergic transmission. If these drugs must be combined with tramadol, the patient should be monitored carefully, especially during initial therapy and times of dosage escalation. There have been reports of abuse, dependence, withdrawal, and intentional overdose, presumably for subjective effects. Consequently, tramadol should not be given to patients with a history of drug abuse, and the recommended dosage should not be exceeded. To reduce risk, tramadol should not be prescribed for patients who are suicidal or addiction prone and should be used with caution in patients who are depressed, taking sedatives or antidepressants, or prone to excessive alcohol use. Preparations, Dosage, and Administration Tramadol is available alone and in combination with acetaminophen. The recommended adult dosage is 50 to 100 mg every 4 to 6 hours as needed, up to a maximum of 400 mg/day.

Family history should include others with bleeding prob- lems discount 100 mg zudena mastercard, such as excessive hemorrhage after surgery and women requiring hysterec- tomy after child birth discount 100 mg zudena with amex. After verifying that the patient is not pregnant purchase 100mg zudena visa, the next most important labo- ratory evaluation is the hemoglobin and hematocrit. The degree of anemia helps categorize the severity of bleeding and helps guide management (Figure 57–1). Women with hemoglobin greater than 12 g/dL are considered to have mild bleed- ing, and may be managed with iron supplements and careful follow-up alone. Women with hemoglobin less than 7 g/dL or less than 10 g/dL with significant orthostatic blood pressure changes are considered to have severe bleeding, and may need hospitalization and blood trans- fusion. Intravenous estrogen (Premarin) and high-dose oral contraceptives are used until the bleeding stops; further bleeding despite these measures may require dilation and curettage. Although these high doses of estrogen raise theoretical con- cerns about thrombotic events, none have been reported with the short-term use required in this condition. Iron supplementation should be continued for 2 months after the anemia is resolved. Upon further questioning you learn that she has had near- syncopal episodes the last few times she has tried to stand up. She denies fever, sexual activity, previous episodes of midcycle vaginal bleeding, and abdominal or genitourinary trauma. She has abdominal pain with rebound and guarding in the upper and lower left quadrants that radiates to the back. Her hemoglobin is 5 g/dL, her white count is 12,000/mm3, and her platelet count is 210,000/mm3. She had been seen 3 months ago when you noted a mild anemia of 13 g/dL, diagnosed her with abnormal uterine bleeding, and started her on iron supplements. Her hemoglobin in your clinic is 6 g/dL, her platelet count is normal, and her urine pregnancy test remains negative. You admit her to your local hospital and order a transfusion of packed red blood cells. In addition to stabilizing her circulatory system, which of the following is the most appropriate next step in the acute manage- ment of her condition? Her urine pregnancy test is negative, and an ultrasound of her right lower quadrant is negative for appendicitis. Which of the following is the appropriate outpatient management for her likely condition? Levofloxacin, 500 mg orally once a day, and doxycycline, 100 mg orally twice a day, both for 14 days E. The classic triad of abdominal pain, vaginal bleeding, and amenorrhea only occurs in about 50% of cases of ectopic pregnancy. Because ectopic pregnancy is the leading cause of pregnancy-related death in the first trimester, a physi- cian must consider the diagnosis for any woman of childbearing age with abdominal pain. Because this patient is hemodynamically unstable, admission and surgery are indicated; however, hemodynamically stable patients with an unrup- tured ectopic pregnancy and good follow-up may be managed expectantly or treated with methotrexate. Types 6 and 11 cause about 90% of all genital warts, but carry a low risk of malig- nancy. Immunization before sexual debut is ideal, but even women who are sexually active may benefit from the vaccine; because there is no commercially avail- able screening test to determine the serotypes to which a woman has been exposed, the vaccine may still provide some protection. Boys, too, receive this vaccination beginning at the age of 11 years in the effort to prevent warts and spread of the virus. Syncope has been reported in the adolescent population with all vaccines; current recommendations suggest observing adolescents for 15 minutes after immunization. Based on her anemia, this adolescent’s abnormal uterine bleeding is clas- sified as severe and warrants hospitalization. Stabilization of her circula- tory system is the first priority, and then steps must be taken to stop the bleeding. She has tried over-the-counter benzoyl peroxide for 2 months to no avail, and has stopped eating chocolate and French fries on her mother’s advice. Isotreti- noin (oral tretinoin) is reserved for severe, resistant nodulocystic acne. Considerations Acne vulgaris has the potential to be as damaging to the psyche as it can be to the skin. Managing acne successfully involves promoting patient understanding of the basics behind its development, creating thoughtful treatment regimens tailored to each patient, and periodically reassessing acne control in an effort to prevent pos- sible emotional and physical scarring. Pubertal hormonal surges lead to an increase in sebum production by sebaceous glands. Proliferation of the bacterium Propionibacterium acnes leads to distention of follicular walls, caus- ing obstruction of sebum flow. Follicles reach a maximum capacity and rupture, releasing their inflammatory contents. Inflammatory lesions are characterized by the presence of papules, pustules, nodules, or cysts. Physical examination of the patient with acne should include a thorough observation and description of lesion type(s) and distribution across the body (face, chest, back). Examples include tinea barbae pustules composed of dermatophytes under the beard of a rancher working with livestock and requiring an antifungal (griseofulvin); erythematous and papulopus- tular rosacea with undetermined etiology on the nose and cheeks of a teenager usually responding to a topical antibacterial (metronidazole); and allergic dermatitis with inflammatory papules on the chin of a toddler often controlled with an emol- lient or an occasional low-strength topical steroid (hydrocortisone). Acne treatment goals are elimination of lesions and diminishment of scarring (Table 58–1). Improvement may not be noticed for at least a month after therapy is initiated, with flare-ups possible during treatment. Patients should be discouraged from manipulating skin lesions because doing so will increase inflammation and promote scarring. The affected skin should be gently washed using antibacterial soap and rinsed well to prevent soap buildup on the skin surface. Scrubbing agents and harsh soaps should not be used, because they may stimulate more oil produc- tion and promote acne. Evidence-based guidelines for acne treatment, based on severity and lesion type, were issued by the American Acne and Rosacea Society and endorsed by the American Academy of Pediatrics in 2013. First-line management should begin with topical benzoyl peroxide or a comedo- lytic agent such as a retinoid (Retin-A). The combination of benzoyl peroxide in the morning and a comedolytic agent at night may be effective when either alone has failed. Benzoyl peroxide must be washed off prior to application of tretinoin or the retinoid will be rendered ineffective. It is available in over-the-counter preparations with variable uniformity, stability, and efficacy.

Additionally order zudena with amex, during the septal evaluation buy zudena 100 mg visa, the rotation and less deprojection cheap 100 mg zudena amex. The lobular arch is composed of the paired domal or apical arches The M-arch model further recognizes that these changes can deformity does not by itself render a poor surgical candidate. It is a fool’s game to col- mediate crura shortens the length of the infratip lobule and lapse under the pressure of patient distress and embark upon a increases the angle of the domal arch, thereby rounding the journey that has no reasonable course, the result of which will external soft tissue triangle. If the vertical division of the inter- be both an unhappy patient and an unhappy surgeon. The sur- mediate crus is performed near the angle or junction of the geon must sense that a sound rapport has been developed with medial crura and intermediate crura, a hanging infratip lobule the prospective patient—one that will weather potential turbu- can be reduced. The patient must also be physically and psy- or biconvex lobular arch can be narrowed. It is important to get an accurate sense of the technical and psycho- In the authors’ hands, the open approach provides the best logical challenges involved. The ideal rhinoplasty patient has a exposure for accurate tip structure diagnosis and surgical cor- clearly defined and realistic complaint of a long duration. Using scissors allows exact visual definition of the tip cartilages, even in revision cases—there is no guessing as to the position of the caudal mar- gins of the lower lateral cartilages as there may be in revision cases using the marginal incision. Once the nasal soft tissue has been adequately reflected and the underlying tip structures are visualized, diagnosis can be adequately performed. As stated previously, the length, tip pro- jection, and tip rotation have been previously assessed during the external physical exam. Now with the nasal tip fully exposed in its natural state, accurate diagnosis can be made as to the cause of these foundational abnormalities. Consideration should be given to the following tip assessments with the tip structures exposed: (1) medial crural length; (2) lateral crural length; (3) symmetry of the two paired medial and two paired lower lateral cartilages; (4) domal position and symmetry; (5) Fig. This previously placed tip grafts; (7) stability and strength of the tip technique allows complete exposure of the caudal septum for repair. Many variations and abnormalities may be encountered with proper diagnosis, including twisted and crooked tip complexes, caudal septum may be completely distorted or severely weak- asymmetric lower medial cartilages, asymmetric lower lateral ened and/or previously transected. In cases of curvature, scor- cartilages, biconvex or broadly curved lower lateral cartilages, ing can be successfully employed to straighten the curvature by asymmetric knuckling of cartilages at the domes, overresected scoring the cartilage along its concave side. Care is taken to cartilages, previously placed tip grafts, and weakened tip score superficially, avoiding complete transection and over- complexes. In cases of base deflection off the With tip assessment completed, attention should then be maxilla, a No. Many times, the length of the cartilage base must deformities of the caudal septum include curvature of the sep- be shortened to allow it to sit properly in the midline without tum and/or deflection of the septum and septal base off the midline anterior nasal spine. Other abnormalities may include a weakened or severely deformed caudal septal strut as a result of previous septorhinoplasty. Once diagnosis (and when done properly, confirmation of physical exam) is complete, attention should be turned first at correction of any caudal septal abnor- malities. We prefer to divide the soft tissue between the medial crura and domes to expose the caudal septum at the anterior septal angle. In cases of septal cartilage harvest or septoplasty, these procedures can be per- formed at this time. The strut is then secured in erally consists of either septal curvature, deflection of the base place. In cases of previously transected, severely deformed, or an overly weakened caudal septum, the caudal septum must be completely reconstructed and replaced or reinforced with a strong cartilage graft. This is best done with a straight portion of harvested septal cartilage combined with extended spreader grafts when necessary. Though removing the entire caudal sep- tum may seem daunting to the novice rhinoplasty surgeon, inadequate correction of a severe caudal septal deformity will inhibit adequate correction of the twisted tip and ultimately result in patient and surgeon dissatisfaction. This is done using a strong columellar strut to ensure that the base foundation is as straight as it can be. Analogous to building a house, if the foundation is crooked, the entire house will follow. In the case of the crooked tip, the foundation is likely already uneven and setting the new foundation will set up the rest of the procedure for success. Once the base is set, the upper half of the tip (top of the house) can be fine-tuned for symmetry. A second Keith needle is then placed just behind the first with a 4–0 Vicryl suture and the columella. The author’s technique for ensuring a straight base foundation follows: Construct an adequate columellar strut from the harvested cartilage (again, septum is best and rib base of the columella. A pocket needs to be dissected between the domes and retracted anteriorly straight up to provide optimal lower medial cartilages down to the anterior nasal spine. The nee- strut is then placed between the medial crura, with the base of dle is then passed through the opposite medial crura and mem- the graft resting on the spine. A second needle is then passed behind the col- through the membranous septum, through the right medial lat- umellar strut near the most caudal posterior aspect of the sep- eral cartilage, and into the columellar strut, low near the very tum from one side to the other; 4–0 Vicryl is used and the strut is secured in place. At this point, the surgeon assesses the straightness of the nasal base from the true basal view. If the columella is canting to one side or the other, or the columella is not straight, the sutures are removed and the process is repeated until the columella is completely straight up the midline. The key to this maneuver is focusing only on the nasal base at this point—pay no attention to the domes, as they may be uneven at this point. As long as the base has been corrected and straightened, the domes can be fine- tuned at a later step. In fact, when the cut cartilage edges are overlapped and stabilized, the M- arch is actually strengthened as compared with its native state. The arch is incised vertically and overlapped cartilage to analyze the lower two thirds of the columella and make sure that the construct is straight. Alternatively, 4–0 Vicryl sutures can be used to stabilize the cartilages through the ves- applied. This technique can be applied predictably to ally or bilaterally depending on the anatomic diagnosis at this achieve rotation, deprojection, and lobular refinement; to cor- point. Again, understanding the ideal tip structure will allow rect asymmetries; or to improve the nostril:columellar ratio any surgeon to assess and treat each of the problems associated. Alar Strut Grafting (Lateral Crural Grafting) Cephalic Trim Often, tip asymmetry is a direct result of the intrinsic asymmet- ric shape of the lower lateral cartilages. One cartilage may be The lateral crura are initially addressed to effect some degree of relatively convex, or biconvex, compared with the opposite car- lobule refinement. Horizontal resection of the cephalic margin of the lower lateral cartilage can achieve some reduction in supratip fullness and may allow for rotation by other means, though it does not in itself produce substantial rotation. Consid- erably more important than the cartilage resected is the amount and symmetry of cartilage retained, a principle that is readily noted using the open technique. Reduction of the crural arch to less than 8 to 10mm will serve only to heighten the risks of postoperative alar retraction and buckling.

The two major treatment goals in septic shock are to identify and address the source of infec- tion (source control) discount zudena online american express, and to restore tissue perfusion as soon as possible to minimize remote organ hypoperfusion that can lead to organ dysfunction discount zudena uk. Time to antibiotic initiation has been well documented to influence outcomes associated with sepsis; therefore buy zudena in united states online, every effort should be made t o select and administ er t he appropriat e ant imicrobial treatments as soon as sepsis is recognized. The Su r vivin g Sepsis C a mpa ign is an international initiative to enhance the practice of sepsis management. If fluids alone are insufficient to achieve the blood pres- sure goals, a norepineph rine (Levophed) drip is recommended t o help ach ieve the target blood pressures once intravascular volume depletion has been corrected. If cont inu ed in cr eases in n or epin eph r in e in fu sion fail t o ach ieve t ar get blood pr es- sures, a cont inuous infusion of vasopressin at a const ant rat e of 0. The use of physi- ologic doses of corticosteroids can be considered for individuals with septic shock wh o do not ach ieve sufficient responses t o source cont rol, fluid administ rat ion, and vaso p r esso r s. Ca r d i o g e n i c Sh o c k : In t r i n s i c o r Ex t r i n s i c ( Me c h a n i c a l ) Intrinsic conditions causing cardiogenic shock are due to primary cardiac dysfunc- tion, and these include acute coronary syndrome, acute myocardial infarction, and heart failure. Conversely, a classic extrinsic cause of cardiogenic shock is ten- sion pneumot horax where t he mediast inal st ruct ures shift away from t he side of the pneumothorax causing kinking of the vena cava and affecting cardiac filling. Another example of an ext rinsic cause of cardiogenic shock is cardiac t amponade, in wh ich pericardial pressure compromises venous return t o t he right heart and hypotension. Ch est auscult at ion, chest x-rays, and echocardiography are maneuvers and modalities that can be helpful to identify patients with extrinsic causes of cardiac dysfunction. Mixe d Ca u s e s o f Sh o c k In some cases, hypotension and hemodynamic instability can be attributable to more than one cause. For example, an elderly man with a history of congestive heart failure wit h urinary t ract sepsis can h ave hypot ension due t o the combined effect s of cardiogenic and septic causes. For such an individual, echocardiography can be highly useful to determine cardiac function as well as intravascular volume status. The treatment of such a patient often requires prioritizing the more serious condi- tion or sometimes requires simultaneous treatment of both conditions. H is heart rate is 112 beats/ minute, respiratory rate is 24 breath/ minute, and temperature is 37. I n t r aven o u s fu r o sem id e ( Lasix) sh o u ld b e ad m in ist er ed t o im p r o ve h is urine output C. This patient likely is affected by anxiety and a mild anxiolytic should be provided with close observation D. T h e pat ient is not ed t o have low urine out put, wit h only 20 mL collected over 3 hours. H er blood pressure is 90/ 55 mm H g, heart rate is 110 beats/ minute, and temperature is 35. Which of the following will most likely help est ablish t he cause of her current condit ion? H er pulse rate is 118 beats/ minute, blood pressure is 110/ 70 mm H g, temperature is 39. Au s- 2 2 2 cultation of her lungs reveals rales and crackles in her left lung field. I n t r aven o u s t h r om b olyt ic t h er ap y sh o u ld b e given for h er p u lm o n ar y embolism C. C olloid r esu scit at io n is p r efer ab le over cr yst alloid r esu scit at ion in patient s with septic shock C. In patients with septic shock, blood product resuscitation is preferred over crystalloid E. Distributive shock requires treatment with vasoconstrictive agents only wh ile h emorrh agic sh ock is t reat ed wit h blood component s and fluid repletion B. T h e t r an sfu sio n of b lo o d p r o d u ct s im p r oves h em o r r h agic sh o ck b u t is n o t indicat ed in dist ribut ive sh ock C. Both types of shock produce low urine output, but only hemorrhagic shock causes prerenal azot emia D. A 33-year-old man with gunshot wound to the abdomen with extensive amount of free fluid in t he abdomen on ult rasound D. A 38-year-old man who developed shortness of breath and hypotension aft er placement of a left subclavian vein cat het er. A 18-year-old man with splenic laceration and pelvic fracture following a motorcycle crash 3. The patient was taken to the operating room for an emergency exploratory laparotomy. O b ser ve the patient an d r ep eat the ser u m lact at e valu e in 4 h o u r s C. This is a young man who is hypotensive following an operation for st rangulat ed small bowel obst ruct ion. Given the scenario of hav- ing st rangulat ed small bowel obst ruct ion t hat required a bowel resect ion, it is likely that h e is hypovolemic secondar y t o the t h ird-space fluid losses associ- ated wit h his bowel obst ruct ion and his recent laparotomy. Furosemide is not indicated unless there is clear evidence that his intravascular volume is normal or elevated. Based on the information provided, there is strong concern for possible myocardial injury and cardiogenic shock. This patient h as p ost op er at ive r espir at or y d ist r ess, cou gh, fever, leu kocyt o- sis, and physical examinat ion findings suggest ive of left sided pneumonia. T h e u se of n or epin eph r in e is in dicat ed for the r esu scit at ion of sept ic sh ock patients if the patients do not respond favorably based on physiologic param- et ers and laborat ory paramet ers. Given t he dist ribut ive nature of sept ic shock, an alpha agonist such as norepinephrine is the pharmacologic agent of choice. Dobutamine is an inotropic agent that produces increased cardiac contractility and some peripheral vasodilat at ion to decrease t he afterload to the left heart. Dobut amine is an ideal pharmacologic support when there is intrinsic cardiac dysfunction leading to shock. Dobutamine use in the patient with septic shock will not likely improve t issue perfusion. The transfusion of blood products will help address the hypovolemia associ- ated with hemorrhagic shock; in addit ion, blood product s will improve t he oxy- gen carrying capacity in this setting. W ith distributive shock, the capacitance of the vascular system is increased, leading to a relatively hypovolemic state. Vol- ume repletion with crystalloids or colloids will help improve the vital signs and tissue perfusion. Some forms of distributive shock such as neurogenic shock will be associated with normal or low heart rate, but these findings are not present in all forms of distributive shock such as anaphylactic shock. The 30-year-old man with sepsis from perforated appendicitis will have increased cardiac output because he has increased heart rat e and normal int ra- vascu lar vo lu m e. T h e patient d escr ib ed in ch o ice “B” h as car d io gen ic sh o ck an d decreased contractility and reduced cardiac output. The patient described in “C” has hemorrhagic shock, and with decreased intravascular volume, the car- diac output is reduced. The patient described in “D” has tension pneumotho- rax that caused poor right heart filling and reduced cardiac output.