Viagra Plus

By I. Karmok. Tulane University. 2019.

Stent implantation requires aspirin therapy and an adenosine receptor antagonist (i purchase 400mg viagra plus mastercard. Balloon-expandable stents have greater radial strength and are less likely to move on deployment purchase viagra plus 400 mg amex, which is important for ostial placement order viagra plus with visa. Such stents can be crushed by external compression and are therefore avoided outside the torso. They are sometimes used to treat tibial disease, but only for critical limb ischemia, for which long-term patency may be less of an issue once tissue healing has occurred. Nitinol stents reexpand on compression and are therefore used outside the torso, where external compression is more likely to occur. They may also be used in tortuous arteries, where they probably conform better than balloon-expandable stents. More recent self-expanding stent designs are more durable and less likely to fracture. Nitinol stents cannot be overdilated if the stent is undersized for the artery, which may lead to stent malapposition or even embolization. Drug-Eluting Peripheral Stents Earlier attempts at coating peripheral self-expanding stents were initially associated with less restenosis in the short term but were unsuccessful in longer follow-up, partly because of inferior stent platforms 17-19 20 21 prone to fracture. More durable stent designs and drug elution with everolimus or paclitaxel offer lower rates of restenosis. In one series, covered stents that cross the knee joint were associated with higher rates of occlusion and major 26 amputation than those deployed above the knee (34% versus 10%). Disadvantages of covered stents 21 include unintentional occlusion of important branch vessels, concerns about the risk for late stent thrombosis, and whether restenosis was merely delayed rather than prevented. A, Perforation after directional atherectomy shown enlarged in the lower right box (arrow). Drug-Coated Balloons Balloons coated with antirestenosis agents (drug-eluting balloons) represent an exciting development. This technology uses a non–stent-related method to deliver drugs such as paclitaxel into the arterial wall after conventional angioplasty treatments. Compared with plain balloon angioplasty, drug-coated balloons 27-30 have less restenosis and repeat revascularization in the femoral-popliteal arteries. Drug-coated balloons also offer a lower risk of restenosis compared with plain balloon angioplasty for treating in- 31 stent restenosis lesions. Late follow-up of two randomized trials at 2 and 5 years shows a sustained benefit on patency and repeat revascularization with drug-coated versus plain balloon angioplasty in 30,32 femoral-popliteal arteries, without safety concerns of aneurysm or late stenoses. Compared to plain balloon angioplasty, one randomized trial showed a lower risk for repeat 33 revascularization but no effect on major amputation or mortality. Differences in drug-coating techniques and eluting agents could explain the lackluster results of drug-coated balloons below the knee, 18 and the question of their value requires further evaluation. Thrombolysis and Thrombectomy Catheter-directed thrombolysis is an important adjunctive therapy for arterial thrombosis, stent thrombosis, and occlusive thrombotic venous disease. Thrombolysis may be indicated for acute thrombosis with a threatened but viable extremity, but an immediately threatened limb (e. It serves as an adjunctive treatment of semiacute manifestations such as peripheral stent thrombosis. Long-term results tend to be better when thrombolysis reveals an anatomic stenosis that probably precipitated the thrombosis and is treatable, for example, by repeated angioplasty. Catheter-directed thrombolysis is more effective than intravenous thrombolysis only if an infusion catheter (with multiple infusion holes) is inserted into the thrombosed vessel. Typically, the infusion continues for 12 to 24 hours, because treatment over 48 hours is associated with depletion of circulating fibrinogen and a higher risk for major 36 bleeding. Catheter-based thrombolysis with or without angioplasty or stenting also reduces the 35,37 incidence of post-thrombotic syndrome in patients with proximal (iliac) deep venous thrombosis, and 38,39 it is used as adjunctive therapy for massive pulmonary emboli (see Chapter 84). Absolute contraindications to 38 thrombolysis include (1) a cerebrovascular event less than 2 months previously, (2) active bleeding, (3) gastrointestinal bleeding less than 10 days previously, and (4) neurosurgery (intracranial or spinal surgery) or trauma less than 3 months previously. Relative contraindications include (1) cardiopulmonary resuscitation less than 10 days previously, (2) nonvascular surgery or trauma less than 10 days previously, (3) uncontrolled hypertension (sustained systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg), (4) puncture of a noncompressible vessel, (5) intracranial tumor, and (6) recent eye surgery. Catheter aspiration thrombectomy uses catheters with a rapid-exchange port to direct the catheter to the thrombus and a large aspiration port to aspirate the catheter with a large syringe. These catheters can aspirate smaller thrombi but are generally inadequate for a large burden of thrombus (e. Mechanical thrombectomy uses a variety of devices that may include thrombolytic agents to help break 39 up thrombus before suction by an aspiration catheter or catheters using the Venturi effect. Although mechanical thrombectomy is a more rapid treatment than catheter-directed thrombolysis, embolization can occlude the distal arterial bed and lead to infarction and tissue loss, although combination with an embolic protection device might theoretically reduce this risk. Atherectomy and Other Treatments Atherectomy devices, although conceptually attractive, have not proved better than angioplasty in direct 17,18 comparisons in most arterial beds. Atherectomy is one of several niche tools and serves best in heavily calcified arteries to improve balloon and stent expansion or in regions where vessels encounter repetitive flexion or torsion, such as over joints, and where stents are avoided (because of kinking and increased fracture). In these settings, atherectomy may improve the distensibility of an artery to permit adequate expansion by balloon angioplasty without flow-limiting dissection. Drug-eluting balloons have renewed interest in this technology because they may reduce the contribution of excessive intimal hyperplasia to restenosis. Coronary rotational atherectomy devices (Rotablator) are generally too small for the larger peripheral arteries, and it is uncertain how a large amount of plaque ablated from a long peripheral lesion would affect the downstream microcirculation (Fig. Cryoplasty involves the use of proprietary balloon and inflation technology to inflate the balloon with nitrous oxide, which chills on expansion to −10°C (Fig. One pilot study suggested lower rates of 41 restenosis in the femoral arteries when used with nitinol stents compared to balloon angioplasty, but longer-term outcomes are uncertain and larger studies are needed. D, Final angiogram with some residual narrowing because of recoil adjacent to a heavily calcified segment of the popliteal artery (arrow). Planning an Intervention Vascular Im aging 4,5,10,18 Vascular imaging is the first stage of planning an endovascular intervention (Fig. Traditionally, invasive angiography served to determine the extent and severity of obstructive disease. Conventional angiography can use lower frame rates than needed for coronary angiography because most peripheral arteries are relatively static. Noninvasive imaging is used to plan the vascular access and the tools probably required for the 10,18,42 procedure. However, time-of-flight techniques may overestimate the severity of disease in regions of disturbed flow near obstructive or nonobstructive plaque. Duplex ultrasound is very useful for imaging arteries in the limbs and the cervical arteries and veins. Vascular Access 10 Vascular access can use either antegrade or retrograde approaches (Fig. A catheter enters the access side over the bifurcation of the aorta and into the target iliac arteries through a support wire. A sheath is directed up and over the aortic bifurcation and pointed into the target iliac artery (Fig.

discount 400mg viagra plus

Whether bradycardia has a role in epileptic patients who experience sudden death is not clear discount 400 mg viagra plus fast delivery. Patients can have concomitant epilepsy and heart disease buy viagra plus mastercard, leading to 46 ventricular arrhythmias and cardiac arrest buy generic viagra plus pills. These include male sex, onset of epilepsy at a young age, a long duration of epilepsy, high seizure frequency especially of generalized tonic-clonic 45 seizures, and the need for polytherapy to control seizures. Treatment and Prognosis A primary arrhythmia disorder needs to be considered in the differential diagnosis of epilepsy. Patients with poorly controlled epilepsy should be aggressively evaluated and treated at tertiary epilepsy centers. Nighttime supervision of the epileptic patient and supine sleeping positions should be considered. Acute Cerebrovascular Disease Cardiovascular M anifestations Acute cerebrovascular diseases, including subarachnoid hemorrhage, other stroke syndromes, and head 47,48 injury, can be associated with severe cardiac manifestations (see also Chapter 65). The mechanism by which cardiac abnormalities occur with brain injury is related to autonomic nervous system dysfunction, with both increased sympathetic and parasympathetic output (see also Chapter 99). Excessive myocardial catecholamine release is primarily responsible for the observed cardiac pathology. Hypothalamic stimulation can reproduce the electrocardiographic changes observed in acute cerebrovascular disease. Electrocardiographic changes associated with hypothalamic stimulation or blood in the subarachnoid space can be diminished with spinal cord transection, stellate ganglion blockade, vagolytics, and adrenergic blockers. Electrocardiographic abnormalities are observed in approximately 70% of patients with subarachnoid hemorrhage. The term neurogenic stunned myocardium is used to describe the reversible syndrome. The process can manifest with selective apical involvement, a takotsubo cardiomyopathy. Cardiac troponin elevation and echocardiographic evidence of left ventricular dysfunction are present in a significant proportion of patients with subarachnoid hemorrhage. Patients with a poorer neurologic status at admission are more likely to have an increased peak troponin level. The edema can have both a cardiogenic component, related to systemic hypertension and left ventricular dysfunction, and a neurogenic (pulmonary capillary leak) component. Life-threatening arrhythmias can occur in the setting of acute cerebrovascular disease. Ventricular tachycardia or fibrillation has been observed in patients with subarachnoid hemorrhage and head trauma. Stroke syndromes other than subarachnoid hemorrhage appear to be only rarely associated with serious ventricular tachycardias. Atrial arrhythmias, including atrial fibrillation and regular supraventricular tachycardia, have been observed. Atrial fibrillation is most common in patients presenting with acute thromboembolic stroke. Bradycardias, including sinoatrial block, sinus arrest, and atrioventricular block, occur in up to 10% of patients with subarachnoid hemorrhage. The patient subsequently was treated with a beta-adrenergic blocker without further ventricular tachycardia. Treatment and Prognosis Beta blockers appear to be effective in decreasing myocardial damage and in controlling both supraventricular and ventricular arrhythmias associated with subarachnoid hemorrhage and head trauma. Beta blockers increase the likelihood of bradycardia and cannot be used in patients with hypotension requiring vasopressors. Life-threatening arrhythmias occur primarily in the first day after a neurologic event. Careful monitoring of potassium levels, especially in patients with subarachnoid hemorrhage, is warranted. Refractory ventricular arrhythmias have been controlled effectively with stellate ganglion blockade. Electrocardiographic abnormalities reflect unfavorable intracranial factors but do not appear to portend a poor cardiovascular outcome. The magnitude of peak troponin elevation is predictive for adverse patient 47 outcomes, including severe disability at hospital discharge and death. Head injury (blunt trauma or gunshot wound) and cerebrovascular accidents are the leading causes of brain death in patients being considered as heart donors. These donors can manifest electrocardiographic abnormalities, hemodynamic instability, and myocardial dysfunction related primarily to adrenergic storm and not to intrinsic cardiac disease. Experimental studies on whether contractile performance recovers with transplantation are still controversial. Optimization of volume status and inotropic support with careful echocardiographic evaluation and possibly left-heart catheterization can allow the use of some donor hearts that would have otherwise been rejected. Future Perspectives Adult cardiologists and electrophysiologists are increasingly participating in the multidisciplinary management of patients with neurologic disorders that manifest cardiac issues. For many of these complex patients, management in tertiary centers is appropriate. Decisions on the use of pharmacotherapy and device therapy to manage cardiac manifestations will need to extrapolate indications from other patient groups because randomized controlled trial data will not be available for a majority of these rare diseases. Gene-based or molecular-targeted therapy is under current evaluation in many of the neurologic diseases and holds future promise. Distinct pathophysiological mechanisms of cardiomyopathy in hearts lacking dystrophin or the sarcoglycan complex. Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and pharmacological and psychosocial management. Predictive value of myocardial delayed enhancement in Duchenne muscular dystrophy. Regional circumferential strain is a biomarker for disease severity in duchenne muscular dystrophy heart disease: a cross-sectional study. Re-examination of the electrocardiogram in boys with Duchenne muscular dystrophy and correlation with its dilated cardiomyopathy. Myocardial fibrosis burden predicts left ventricular ejection fraction and is associated with age and steroid treatment duration in duchenne muscular dystrophy. All-cause mortality and cardiovascular outcomes with prophylactic steroid therapy in Duchenne muscular dystrophy. Eplerenone for early cardiomyopathy in Duchenne muscular dystrophy: a randomised, double-blind, placebo-controlled trial. Electrocardiographic abnormalities and risk of sudden death in myotonic dystrophy type 1. Increased mortality with left ventricular systolic dysfunction and heart failure in adults with myotonic dystrophy type 1. Myotonic dystrophy and the heart: a systematic review of evaluation and management.

generic 400 mg viagra plus amex

Discitis discount 400mg viagra plus overnight delivery, osteonecrosis effective 400mg viagra plus, and water inlet (green) and outlet (red) (From Ball [18] trusted viagra plus 400mg, with permission) the development of grade 1 anterolisthesis have been reported [23, 50]. With biacuplasty, this technically In one case, the catheter was placed in the vertebral foramen, frustrating task is no longer needed. Given the ease of perfor- a gross violation of standard of care, so that the cauda equina mance and the quality of evidence supporting biacuplasty, it was directly heated; in the second, the catheter was evidently is currently the preferred technology. The only complication reported with biacuplasty is the expected transient low back pain after needle insertion [54]. If the pain persists after conservative treatment, including therapy, exercise, oral and topical medications, and epidural injection therapy, treatment options are limited, and in the absence of other therapies, the condition is unlikely to Fig. Surgical procedures provide uncertain outcomes Isotherm lines form dumbbell shape around and between radiofre- and have signifcant risks and morbidity, including major quency probes to cover the posterior segment of the annulus fbrosus decrements in function. These approaches have the advantage of ease of performance, minimal trespass upon the patient’s physio- logic state, generally being performed as outpatient proce- There are no published cases of complications from disc- dures, and safety. Prospective clinical study on natural history of discogenic low back pain at 4 years of follow-up. Evidence-informed manage- effectiveness of biacuplasty in treating intradiscal disorders, ment of chronic low back pain with intradiscal electrothermal ther- particularly in patients who are younger and have single disc apy. Systematic review of randomized trials com- paring lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Fusion surgery for lumbar degenerative disc disease: still Key Points more questions than answers. Rejuvenation of nucleus pulposus cells using extracel- lular matrix deposited by synovium-derived stem cells. Percutaneous treatment of painful lumbar disc anterolisthesis, cauda equina syndrome, nerve irritation derangement with a navigable intradiscal thermal catheter: A pilot with catheter placement into the vertebral foramina, and study. Paper presented at: Proceedings of the 13th Annual Meeting breakage of the catheters have been reported. A randomized, placebo- controlled trial of intradiscal electrothermal therapy for the treat- ment of discogenic low back pain. A ran- References domized, double-blind, controlled trial: Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low 1. Comparison of intradiscal restor- dromes associated with lumbar spine degeneration. The use of radiofrequency heat lesions in the treatment apy in the treatment of chronic low back pain: experience with 93 of lumbar discogenic pain. Intradiscal electrothermal of discogenic pain: a prospective matched control trial. Intradiscal electrother- water-cooled bipolar electrode system in an in vivo porcine model. University of the West of England: sample size and power in clini- of discogenic low back pain. Cauda equina syndrome after intradiscal elec- opioids in interventional pain management. Complications of percutaneous techniques used expect: in search for the limits of the placebo and nocebo effect. Lumbar Percutaneous Mechanical Disc 17 Decompression Laxmaiah Manchikanti, Vijay Singh, Ramarao Pasupuleti, David S. Manual percutaneous lumbar Percutaneous lumbar discectomy is a minimally invasive surgical discectomy, microdiscectomy, and chemonucleolysis are not technique for treating contained herniated discs. Less radi- radiofrequency coblation or plasma discectomy known as cal procedures started to appear as early as 1939 [4]. In nucleoplasty; hydrodiscectomy; mechanical disc decompression 1959, Smith [5] coined the term “chemonucleolysis” to with a high rotation permanent device for nuclear extraction, describe the enzymatic dissolution of the nucleus pulposus as also known as Dekompressor®; and manual percutaneous lum- an alternative, less invasive means of decompressing a bulg- bar discectomy [1–18]. Hijikata [6] described manual percuta- over the last 20 years that all of these alternative procedures can neous lumbar discectomy in the 1970s. Discogenic Pain Herniated Nucleus Pulposus Nucleus pulposus Fissure in Phospholipase A Neovascularization of disc annulus fibrosus 2 Prostaglandins Nitric oxide Metalloproteinases Inflammatory cell infiltrate Sinuvertebral nerve (chemical signal for revascularization) Unidentified inflammatory Nociceptors in annulus fibrosus Dorsal root ganglion Nerve root–dura interface may Chemicals may reach nociceptors via be involved by inflammatory fissure to lower threshold for firing. Chemical factors and caused by mechanical forces superimposed compression both contribute on chemically activated nociceptors to lumbar pain Disc Rupture and Nuclear Herniation Rim Tears in lesion internal Herniated Nucleus annular nucleus Shortened pulposus lamellae pulposus disc space Peripheral tear of annulus fibrosus and cartilage end plate (rim lesion) initiates sequence of events that weaken and tear internal annular lamellae, allowing extrusion and herniation of nucleus pulposus Fig. Saunders-Elsevier; 2006; with permission) 17 Lumbar Percutaneous Mechanical Disc Decompression 311 – “Rupture” casts an image of tearing apart and there- • The base is defned as the width of the disc material at fore carries more implication of traumatic etiology the outer margin of the disc space origin, where disc than “herniation,” which conveys an image of dis- material displaced beyond the disc space is continu- placement rather than disruption. It is material forced from one domain to another intervertebral herniation (Schmorl’s node), a defect in through an aperture. Thus, appli- – A sequestered disc is characterized by extruded disc cation of the term “bulging” to a disc does not imply material that has no continuity with the disc of origin. This may result in a breach of the spinal create a change in the intradiscal pressure. With this method there is no heat damage to intradis- inferior to microendoscopic discectomy. The other three observational studies [12, 18, 79–81] – Based on the available reports with randomized controlled also showed positive results. The • Percutaneous disc decompression is reserved for those data was accurate only up to 6 months even though patients with back and/or leg pain of at least 3 months they provided at 2-year follow-up. The signifcant duration, and a contained herniated disc, who have failed improvement was shown in nucleoplasty group in 45 to respond to conservative therapeutic interventions, patients with similar results continued for 2 years. Even though posi- – Radiologic evidence of severe lateral recess stenosis, tive results have been shown, there are no randomized calcifed disc herniations, severe degenerative facet controlled trials. Anterior view Left lateral view Posterior view C1 Atlas (C1) C1 Atlas (C1) Atlas (C1) C2 C1 C2 Axis (C2) Axis (C2) C2 Axis (C2) C3 C3 Cervical Cervical C3 Cervical Vertebrae C4 C4 curvature vertebrae C4 C5 C5 C5 C6 C6 C6 C7 C7 C7 C7 C7 C7 T1 T1 T1 T1 T1 T1 T2 T2 T2 T3 T3 T3 T4 T4 T4 T5 T5 T5 T6 T6 T6 Thoracic T7 T7 vertebrae T7 Thoracic Thoracic curvature Vertebrae T8 T8 T8 Steepest T9 T9 T9 cephalad to caudal angle T10 T10 T10 in mild thoracic T11 T11 T11 region T12 T12 T12 T12 T12 T12 L1 L1 L1 L1 L1 L1 L2 L2 L2 Lumbar Lumbar vertebrae Vertebrae L3 L3 L3 Lumbar curvature L4 L4 L4 L5 L5 L5 L5 L5 L5 Sacrum (S1–5) Sacrum Sacrum (S1–5) (S1–5) Sacral Sacrum curvature Coccyx Coccyx Coccyx Fig. Saunders-Elsevier; 2006; with permission) 17 Lumbar Percutaneous Mechanical Disc Decompression 317 Anterior Superior articular process longitudinal ligament Transverse process Lamina Pedicle (cut) Posterior Body of Inferior articular process longitudinal L1 vertebra ligament Pedicle Intervertebral foramen Intervertebral discs Spinous process Interspinous ligament L2 spinal Supraspinous ligament nerve Superior articular processes; facet tropism (difference in facet axis) on right side Spinous process Lamina Transverse process Body of Inferior articular process L5 vertebra Ligamentum flavum L5 spinal nerve Iliolumbar ligament Iliac crest Auricular surface of sacrum Posterior (for articulation with ilium) superior iliac spine Sacrum Posterior Coccyx inferior iliac spine Left lateral view Posteriorsacroiliac ligaments Greater sciatic foramen Spine of ischium Lateral, Sacrospinous ligament Posterior sacro- Lesser sciatic foramen Ischial coccygeal tuberosity ligaments Sacrotuberous ligament Posterior view Fig. Spinal cord Pia mater Subarachnoid space Anterior internal vertebral venous plexus Arachnoid mater Dura mater Posterior longitudinal ligament Position of spinal ganglion Posterior ramus Extradural space Anterior ramus Extradural fat Vertebral body Transverse Intervertebral disc process Spinous process Fig. Saunders-Elsevier; 2006; with permission) – The lateral walls of the vertebral canal are formed by – The neuraxial compartment includes all structures the pedicles of the lumbar vertebrae. Cranial dura Elsevier; 2005; with permission) Occipital bone Medulla oblongata Spinal cord Epidural space Subarachnoid space T-1 Subarachnoid space Epidural space Epidural space T-7 Subarachnoid space Dura T-12 Nerve roots L-1 Termination of dural space L-2 Spinal canal Diameter Anteroposterior: 23 mm Internal Transverse: 18 mm filum terminale Filum terminale Size of lumbar epidural space 4-6 mm S-1 S-3 External filum terminale Sacral hiatus – The dural sac posteriorly is related to the roof of the ments in the spinal cord measuring 18 mm in the anterior, vertebral canal, the laminae, and the ligamentum posterior dimension at C4 to C6, with a transverse diam- flava. The lamellae are arranged adults, and the dural sac continues to the spinal cord to resist tensile and torsional forces (Fig. Better outcomes following percutane- – The right is usually slightly inferior, probably due to ous laser discectomies have been attributed to broad- the volume of the liver on this side. Automated Percutaneous Lumbar Discectomy – The cannula enters the skin and subcutaneous tissues and makes its way through thick muscle layers passing • Automated percutaneous lumbar discectomy has been through Kambin’s triangle inferior to the exiting nerve widely studied, including randomized trials. The whole process creates a greater with a pneumatically driven, suction-cutting probe in a upward inclination than the fourth. A Nucleotome probe or a large needle is used to allow placement of the will pass through a curved cannula. Nucleotome probe and creates a vacuum that draws – The dilator is removed and replaced by a trephine, the nucleus into a side port of the probe, where an which has a cutting tip. Nuclear material can be there is more pressure within the disc, the cutting rate seen moving through the tubing lines. Frequently as the disc material is lasered/cleared, additional Initial view down cannula—laser fber tip at 10 o’clock position.

purchase viagra plus now

Lacerated wounds of the lung can also result in leakage of air into the pleural cavity purchase viagra plus american express, producing a pneumothorax buy viagra plus mastercard. When the pneumothorax is asso- ciated with intrapleural bleeding buy cheap viagra plus 400 mg line, it is called a pneumohemothorax. A tension pneumothorax can develop when the laceration penetrates deep into the lung and severs a large bronchus. On expiration, the lacerated edges of the bronchus act as a valve to prevent the air from passing out of the pleural cavity through the bronchus. With each inspiration, the volume and pressure of the trapped air increases until the air pressure is high enough to collapse 130 Forensic Pathology the lung and displace the mediastinum and heart to the opposite side. At autopsy, the pleural cavity contains a collapsed lung with air under pressure, a concave depressed diaphragm, and displacement of the heart and medi- astinum to the opposite side. When a lacerated wound of the lung involves a pulmonary vein and adjacent bronchus, air exiting the bronchus may enter the pulmonary vein and be conveyed to the left atrium and ventricle, with resultant cardiac and cerebral air embolus. If the blood in a pleural cavity is not removed, it will gradually break down, undergoing a series of color changes, red to brown, with the ultimate formation of a chocolate brown pigment deposit and turbid brown fluid. The lacerated lung, hemothorax, and diluting serous fluid are vulnerable to bacterial injection with production of pneumonia, lung abscesses, pleurisy, and empyema. A diagnostic needle biopsy of the pleura or lung or a diagnostic or therapeutic thoracentesis may terminate in sudden death during insertion of the needle into the pleural cavity with no anatomical cause of death at autopsy. Blunt Force Injuries of the Abdominal Viscera The abdominal organs are vulnerable to a variety of injuries from blunt trauma because the lax and compressible abdominal walls, composed of skin, fascia, and muscle, readily transmit the force applied to the abdominal viscera. If the victim anticipates the blow and tightens the abdominal muscles, this will disperse the force of impact and thereby reduce the probability of internal injuries. Thus, the boxer who has conditioned his abdominal muscles and is prepared to receive such blows will sustain no injury to his abdominal organs. The soft, compact, vascular liver and spleen may be lacerated or crushed; a distended hollow organ, such as the stomach or intestines, will burst due to the rapid increase in intraluminal pressure produced by the force of impact. The severity of trauma is relative to the size of the blunt object, the force of impact, the organ traumatized and its condition at the time of impact. It cannot be overemphasized that absence of external injury (contu- sions or abrasions) to the abdominal walls does not exclude injury, even massive injury, to one or more of the internal abdominal organs (Figure 5. The lack of external injuries is attributable to the lax and compressible abdominal walls and protection afforded by clothing. If a traumatized victim complains of abdominal pains, but lacks visible signs of injury to the abdo- men, the emergency room physician or surgeon may fail to clinically detect Blunt Trauma Injuries of the Trunk and Extremities 131 A B Figure 5. This is especially true of intoxicated victims and individuals on high doses of tranquilizer whose condition renders them insensible to pain and obscures the signs of peritoneal irritation. A 21-year-old male, involved in a motor vehicle accident, was admitted to a local hospital with pain in the left abdominal region. Vital signs were normal; physical examination was essentially negative, except for severe ten- derness in the periumbilical area. X-ray studies of the abdomen, in the flat and upright position, revealed no evidence of abnormality. Fifty centimeters from the duodenum, there was a 2 x 2-cm laceration of the proximal jejunum, with communication with the peritoneal cavity. The mesentery showed a 3 x 5-cm contusion and recent thrombi of the superior mesenteric veins. Trauma to the abdomen may be generalized, involving the abdomen as a whole, as exemplified by an individual run over by a vehicle, or localized, such as would occur if an individual was kicked in the abdomen. Most homicides resulting from blunt force involve localized injuries to the abdo- men. Possibly only through a thorough investigation of the circumstances surrounding the victim’s death will one be able to determine whether the blunt force injury was of a homicidal or accidental nature. Since many individuals receive cardiopulmonary resuscitation nowadays, it is extremely important to differentiate iatrogenic injuries of the abdominal organs from those due primarily to trauma. Thus, with vigorous, slightly misplaced cardiopulmonary resuscitation, the authors have seen lacerations of the liver where it overlies the vertebral column. Several hundred milliliters of blood were present in the abdominal cavity in some cases, even though these injuries were, in a sense, postmortem. It is the largest of the solid abdominal organs and is the one most frequently injured by blunt trauma to the abdomen. Severe localized blunt trauma applied to the right upper quadrant will often lacerate only the liver, whereas generalized Blunt Trauma Injuries of the Trunk and Extremities 133 blunt trauma tends to injure not only the liver, but the other abdominal organs, though with less frequency. Fractures of the adjacent ribs may or may not be present, depending on the age of the individual and the calcification of the ribs. The liver is susceptible to trauma because of its large size, its anatomic position in the upper abdomen, its inability to give with trauma, and the solid nature of its tissue. A preexisting liver disease, such as fatty metamor- phosis or hepatitis, may make the liver more friable and thus easier to injure. In addition, fatty metamorphosis is often associated with impairment of the coagulability of blood. Injuries of the liver can be classified as transcapsular lacerations, in which both capsule and parenchyma are torn, and subcap- sular lacerations, in which the capsule is still intact and the injury is either beneath an intact capsule or intraparenchymal. The right lobe is injured five times as frequently as the left, with the lesions occurring more commonly on the convex surface. Any severe localized force applied directly to the front of the liver will drive the liver in a posterior direction, crushing it against the posterior vertebral column, and producing a transcapsular laceration at the junction between the right and left lobes, immediately beneath the site of external impact (Figure 5. A variation of this is the contrecoup laceration of the liver where the laceration occurs on the posterior surface of the right lobe, at the point where it rests against the vertebral column. The same localized force that can produce transcapsular lacerations, if violent enough and directed to the front of the liver, may compress the liver, not only in a backward direction, but also in a lateral direction, causing an internal (sub- capsular) laceration of the parenchyma. Blunt trauma applied directly to the front of the liver may strip the capsule from its parenchymal attachment at the point of impact, resulting in the development of a subcapsular hematoma. Either the hematoma will undergo complete organization and be replaced by a thick fibrous connective tissue capsule, or continuous subcapsular bleeding may create sufficient pres- sure to rupture with a resultant fatal intraperitoneal hemorrhage. If the force impacting the front of the liver is directed upward, it may lacerate the inferior (under) surface of the liver, whereas, if the force is directed downward and backward, there is deformation of the dome of the liver with lacerations of the superior surface. Multiple superficial capsular lacerations of the diaphragmatic or superior surface of the right lobe of the liver are common in motor vehicle accidents. If the force is directed straight at the liver, along its anterior margin, there can be lacerations of both the concave and convex surfaces. With severe crushing force applied over the front of the liver, such as might occur in a severe automobile accident or a brutal kick to the abdomen, there could be 134 Forensic Pathology complete amputation of the left lobe of the liver when it is crushed between the anterior abdominal wall and the vertebral column. In addition to injuries to the parenchyma of the liver itself, there may also be injuries to the portal vein, hepatic artery, and inferior vena cava.

generic 400mg viagra plus with visa

A positive identification with any of the immunoassay tests should never be reported unless it has been confirmed by another method of analysis purchase viagra plus american express. A positive immunoassay test cannot be confirmed with another immu- noassay test — even using different assay techniques generic viagra plus 400 mg overnight delivery. Toxicology Screens Generally purchase cheap viagra plus line, toxicological screens can be divided into four general groups. This involves analysis by gas chromatography 514 Forensic Pathology and will identify acetone, isopropyl alcohol, n-propyl alcohol, ethyl alcohol, and methyl alcohol. Blood for this test should be collected in a tube contain- ing sodium fluoride and potassium oxalate to prevent postmortem alcohol formation or loss. It detects tranquilizers, synthetic narcotics, local anesthetics, antihistamines, antidepressants, alkaloids, and other agents extractable from alkaline aqueous solution. Hundreds of drugs and metabolites can be detected by this procedure, depending on how it is structured. It must be realized that, in very acute heroin overdoses, the urine may test negative for morphine or monoacetyl-morphine. Less used is the screen for higher volatiles, a gas chromatographic method used to detect toluene, the most commonly abused inhalant; benzene; trichlo- rethane; and trichlorethylene. Blood from the test tube containing sodium fluoride and potassium oxalate should be used, because some of the active components of cannabis will otherwise deteriorate with time. We generally use an immunoassay screen on the urine for metabolites of delta-9-tetrahy- drocannabinol. Drugs not detected in the aforementioned screen include some whose blood therapeutic or abuse levels are extremely low. If these drugs are suspected or common in one’s population, an immunoassay screen can be performed on urine. Cyanide can be analyzed for by using a specific ion electrode or other chemical techniques. Alkaloid poisons, such as strych- nine and nicotine, are detected in the basic screen. It is the authors’ opinion that the more thorough the toxicologic approach, the better. Therefore, we make the following recommendations as to types of tests to be performed, depending on the type of case. Interpretive Toxicology: Drug Abuse and Drug Deaths 515 In all homicides, accidents, and suicides, the authors recommend the lower alcohol screen; the acidic and neutral screen; and the basic screen. In stranger-to-stranger homicides and those in which the use of narcotics is suspected, the narcotic screen is also recommended. In natural deaths, the authors recommend the alcohol, the acidic and neutral screen, and the basic screen. Some medical professionals think that this is unnecessary, especially in the elderly. Where the cause of death is undetermined at autopsy, the authors recommend the alcohol, acidic and neutral screen, basic screen, and narcotics screen. A cannabis screen is strongly recommended in all drivers of motor vehicles and work-related deaths. Deaths Deaths caused by ingestion, injection, snorting, or inhalation of drugs fall into four categories by manner: homicide, suicide, accident, and undetermined. For the most part, the accidental category is made up of deaths caused by drug abuse. In the nineteenth century, the “three curses of mankind” were said to be alcohol, morphine, and cocaine. Little has changed since then, except that a more potent opiate, heroin, has replaced morphine. It is responsible for tens of thousands of deaths each year both directly and indirectly. While deaths caused by an acute overdose of alcohol are uncommon, deaths caused by the chronic effects of alcohol are seen every day. Thus, between 25,000 and 30,000 people a year die of chronic liver disease caused by alcohol. Alcohol has also been linked to congenital anomalies and the development of malignant tumors. After alcohol and marijuana, the most commonly abused drugs are prob- ably heroin and cocaine. There are numerous other drugs of abuse: the synthetic narcotics, phencyclidine, amphetamine and methamphetamine, propoxyphene, inhalants, and so on. These drugs, however, come and go on the drug scene, but the “three curses” always remain. In the next section, we will discuss the three main drugs of abuse, a number of other drugs of abuse, and some drugs that cause deaths because their lethal potential is not appre- ciated or because they fall into the hands of a child. In fasting individuals, 20–25% of a dose of alcohol is absorbed from the stomach and 75–80% from the small intestine. Following ingestion of alcohol on an empty stomach, peak blood alcohol concentration occurs within one half to 2 h (average 0. The delay in reaching peak blood alcohol is directly proportional to the size of the meal and inversely proportional to the amount of time between food and alcohol consump- tion. The makeup of the meal appears to have very little influence at all on the rate of absorption. Because alcohol is soluble in water, it is present in the body tissue in direct relation to the amount of water content of the tissue or fluid. Speci- mens with high water content, such as blood or vitreous, will have high concentrations of alcohol compared with tissues such as the liver or brain. Forensic pathologists tend to deal in whole blood when performing alcohol determinations, while clinicians often use serum or plasma. It is often not realized that there may be a significant difference in the alcohol concentration of arterial blood and venous blood in the absorp- tive phase, with arterial blood up to 40% higher in alcohol concentration than venous blood. At autopsy, one should obtain the blood from either the femoral or subclavian vessels, with the former preferred. Alcohol disperses throughout the body in proportion to the water content of the tissue. Vitreous, with a high water content, has proportionally more alcohol than blood when at equilibrium. Because of its isolated location, the equilibration of vitreous alcohol with blood alcohol lags by 1–2 h. They will tell what the blood alcohol level Interpretive Toxicology: Drug Abuse and Drug Deaths 517 was 1–2 h prior to death after one compensates for the greater amount of water in the vitreous. In the absorptive phase of alcohol, vitreous alcohol levels are lower than in the blood.