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Assistant Professor, A. T. Still University Kirksville College of Osteopathic Medicine
Myalgias are the most common presenting symptom and often the only symptom in pediatric patients medicine cabinets purchase phenytoin 100mg with visa, so index of suspicion based on history and severity of myalgias needs to be high medicine quetiapine buy phenytoin 100 mg with visa. If an infectious cause was the trigger treatment as prevention generic phenytoin 100 mg free shipping, symptoms such as a sore throat or upper respiratory symptoms may be present medicine 3202 buy phenytoin 100mg on-line. In general, one should consider an underlying neuromuscular condition if the symptoms exceed the possible cause. Patients reporting myalgias and cramps within minutes of moderateto high-intensity activity, a phenomenon known as "out of wind," should be screened for glycogen storage diseases. Children seen in the outpatient setting should be sent to the emergency department for laboratory testing. Once the diagnosis is confirmed, if not apparent from history, more specific investigative studies to look for an underlying cause should be initiated. Urine and serum myoglobin can also be sent, but limitations and disadvantages of these studies are discussed later herein. If electrolyte abnormalities are present, an electrocardiogram should be obtained and cardiac monitoring with telemetry considered depending on severity. Myoglobinuria causes color change in the urine when levels exceed 250,000 mg/L (14,535 nmol/L), at which point more than 100 g of muscle tissue has been destroyed. For example, when an infectious etiology is suspected, testing directed at specific viruses or cultures for bacteria can be sent based on clinical presentation. In addition, if a medication or toxin is suspected, serum drug levels and/or a urine toxicology screen can be obtained. If history strongly suggests or diagnostic evaluation confirms a cause for rhabdomyolysis, no further evaluation is necessary. However, when an initial episode cannot be attributed to infection, exercise, medications, or toxins based on history, physical examination, or diagnostic studies, further evaluation is necessary to look into other causes. In addition, those with an initial episode and a personal history of myalgias or a family history of a myopathy should also undergo additional investigations. Last, those with more than 1 episode of rhabdomyolysis also deserve further diagnostic studies. In the acute setting, when an inborn error of metabolism is suspected, diagnostic testing should target the specific disorder suspected. For patients with concern for a glycogen storage disease, levels of liver enzymes, bilirubin, lactate dehydrogenase, and uric acid as well as fasting glucose, ammonia, lactate, and lipid panel can be performed as screening tests. A pediatric neurologist and a geneticist are often helpful in guiding this initial evaluation as well. Other tests can be helpful at arriving at a cause but are usually requested by a pediatric neurologist in the outpatient setting on follow-up. Muscle biopsy will show only nonspecific findings of muscle injury but will not assist in determining the underlying etiology until 6 weeks to 3 months after symptom resolution. There are no urine output goals for pediatric patients published, but given that the recommended urine output is approximately 3 to 4 times normal urine output for an adult, one could hypothesize for children a targeted urine output to be 3 to 4 times the normal urine output for pediatric patients, or approximately 3 to 4 mL/kg per hour. In general, more randomized controlled studies need to be performed comparing fluid rates, use of mannitol versus normal saline alone, and use of sodium bicarbonate versus normal saline alone. In addition, nephrotoxic medications such as nonsteroidal anti-inflammatory drugs should be avoided. In patients who develop disseminated intravascular coagulation, fresh frozen plasma can be given. Pediatric neurology and genetics consults should be considered when there is suspicion for an underlying myopathy based on history or physical examination findings, especially for patients with more than 1 episode of rhabdomyolysis. An initial evaluation can begin in the hospital, but often a diagnosis is not made until after discharge given that many of these tests take days to weeks to result. They should also follow up in the outpatient setting because many tests cannot be performed in the acute setting and/or may take weeks for a final result. For athletes, return to play is an important consideration, and there currently are no guidelines for when return to play is appropriate. When athletes do return to play, types of exercise that are known to cause rhabdomyolysis, such as eccentric exercise, should be avoided initially, with a gradual increase in activity.
Information regarding the chemical should be gathered while on scene including materials safety data sheet if available 6 85 medications that interact with grapefruit cheap generic phenytoin uk. Communicate all data regarding the chemical to the receiving facility Assessment 1 treatment upper respiratory infection buy phenytoin overnight. Concentration of the chemical the (higher the concentration treatment trichomoniasis order phenytoin 100mg with visa, the greater the risk of injury) c medications ending in zole best 100 mg phenytoin. Special attention to assessment of ocular or oropharyngeal exposure - evaluate for airway compromise secondary to spasm or direct injury associated with oropharyngeal burns 5. Some acid and alkali agents may manifest systemic effects Updated November 23, 2020 240 Treatment and Interventions 1. If dry chemical contamination, carefully brush off solid chemical prior to flushing the site as the irrigating solution may activate a chemical reaction 2. For eye exposure, administer continuous flushing of irrigation fluid to eye - Morgan lens may facilitate administration 6. Early airway intervention for airway compromise or spasm associated with oropharyngeal burns 7. Hydrofluoric acid readily penetrates intact skin and there may be underlying tissue injury. For all patients in whom a hydrofluoric acid exposure is confirmed or suspected: a. Vigorously irrigate all affected areas with water or normal saline for a minimum of 15 minutes b. If commercially manufactured calcium gluconate gel is not available, a topical calcium gluconate gel preparation can be made by combining 150 mL (5 ounces) of a sterile water-soluble gel. If calcium gluconate is not available, 10 mL of calcium chloride 10% solution in 150 mL in sterile water soluble gel. Apply generous amounts of the calcium gluconate gel to the exposed skin sites to neutralize the pain of the hydrofluoric acid a. Although generally low yield, there may be benefit to intravenous pain medication along with the topical calcium gluconate gel for pain control 6. If fingers are involved, apply the calcium gel to the hand, squirt additional calcium gel into a surgical glove, and then insert the affected hand into the glove 7. Take measures to prevent the patient from further contamination through decontamination 3. Do not attempt to neutralize an acid with an alkali or an alkali with an acid as an exothermic reaction will occur and cause serious thermal injury to the patient 5. Expeditious transport or transfer to a designated burn center should be considered for burns that involve a significant percentage of total body surface area or burns that involve the eyes, face, hands, feet or genitals Notes/Educational Pearls Key Considerations 1. Since the severity of topical chemical burns is largely dependent upon the type, concentration, and pH of the chemical involved as well as the body site and surface area involved, it is imperative to obtain as much information as possible while on scene about the chemical substance by which the patient was exposed. Contacting the reference agency to identify the chemical agent and assist in management. Decontamination is critical for both acid and alkali agents to reduce injury - removal of chemicals with a low pH (acids) is more easily accomplished than chemicals with a high pH (alkalis) because alkalis tend to penetrate and bind to deeper tissues 5. Some chemicals will also manifest local and systemic signs, symptoms, and bodily damage Pertinent Assessment Findings 1. Identify intoxicating agent Protect organs at risk for injury such as heart, brain, liver, kidney Determine if there is an antidote Treat the symptoms which may include severe tachycardia and hypertension, agitation, hallucinations, chest pain, seizure, and arrhythmia Patient Presentation Inclusion Criteria 1. Give fluids for poor perfusion; cool fluids for hyperthermia [see Shock and Hyperthermia/Heat Exposure guidelines] 3. Consider soft physicalmanagement devices especially if law enforcement has been involved in getting patient to cooperate [see Agitated or Violent Patient/Behavioral Emergency guideline] 6. Consider medications to reduce agitation and other significant sympathomimetic findings for the safety of the patients and providers. This may improve behavior and compliance [see Agitated or Violent Patient/Behavioral Emergency guideline] a. Do not use promethazine if haloperidol or droperidol are to be or have been given. If hyperthermia suspected, begin external cooling Patient Safety Considerations 1. Apply the least amount of physical management devices that are necessary to protect the patient and the providers [see Agitated or Violent Patient/Behavioral Emergency guideline] 2. Recognition and treatment of hyperthermia (including sedatives to decrease heat production from muscular activity) is essential as many deaths are attributable to hyperthermia 2.
Overland flow symptoms 5 days post embryo transfer purchase phenytoin overnight delivery, like rapid infiltration medications gerd buy genuine phenytoin line, is rarely used for onsite wastewater management medicine plies order phenytoin with amex. In wet climates or frozen soil conditions treatment zinc overdose cheap 100 mg phenytoin, an additional holding (storage) basin or larger dosing tank is required to prevent irrigation during periods when the wastewater would not be accepted by the soil for treatment and intended environmental incorporation. Regulations for buffer requirements from Texas, Virginia, and Pennsylvania are incorporated into table 1. Typically, the features listed below and their peripheral buffer zones are fenced to prevent exposure. Texas determines design rates based on evaporation, Virginia bases rates on soil texture, and Pennsylvania uses a combination of soil depth and slope. From a performance code approach, the application rate should be based on protecting the receiving surface/ground waters. It should be based on wastewater characteristics, critical constituent required concentrations (at a monitoring location Table 1. Buffer requirements to various features where a specific quality standard must be met), and the characteristics of the site. During the growing season, removal should be feasible by crop uptake and, to a lesser degree, ammonia volatilization. Therefore, the hydraulic and nitrogen loading rates for a specific site are the primary design parameter. Spray irrigation systems are designed to treat wastewater and evenly distribute the effluent on a vegetated lot for final treatment. The application rate is determined by two major factors: hydraulic loading and nutrient loading (usually nitrogen is the limiting factor). The application rate is designed to meet the capacity of the soil to accept the effluent hydraulically and subsequently allow it to drain through the soil. The treated wastewater is spread over the required application area through a sprinkler or drip irrigation system. Sprinklers are generally low-angle (7 to 13 degrees), large-drop-size nozzles designed to minimize aerosols. Application areas must be vegetated (with crops not intended for human consumption) and have slopes that preclude runoff to streams. The type of vegetation determines the nitrogen loading capacity of the site, but the hydraulic capacity depends on climate and soil characteristics. Spray irrigation of wastewater effluent must be timed to coincide with plant uptake and nutrient use. Temperature factors in some areas of the country may preclude the use of spray irrigation during certain times of the year. The wastewater may need to be stored in holding tanks during the coldest period of the year, because plant growth is limited and the nitrogen in effluent discharged during this time will be mineralized and unavailable for plant uptake. Others spray twice during the night or in the early morning to minimize inconvenience to the homeowner and to minimize the potential for human contact. The width of the required buffer zone depends on the slope of the site, the average wind direction and velocity, the type of vegetation, and the types of nearby land uses. Performance Studies that sample both the soil below the spray field and its runoff show that spray irrigation systems work as well as other methods of managing wastewater. Spray irrigation systems are designed for no degradation; therefore, hydraulic and nutrient loading rates are based on the type of vegetation used and the hydraulic properties of the soils. If the vegetation cannot assimilate the amount of nitrogen applied, for example, then nitrogen removal to reduce the nitrogen content of the effluent prior to spray irrigation may be required. The overall efficiency of a spray irrigation system in removing pollutants will be a function of the pollutant removal efficiencies of the entire treatment process and plant uptake. There have been few documented cases of health problems due to the spray irrigation, but use of proper buffer zones is crucial. One benefit of spray irrigation is savings on potable water because the wastewater is used for irrigation.
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