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Mcg/kg/day (max- mcg/day) (dose/day) Zn 250 < 3 mo 100 (5000) 3-5 mg 10-15 mg 100 > 3 mo Cu 20 20 (300) 0 generic super levitra 80 mg online. Molybdenum and selenium are usually present as contaminants in parenteral solutions discount super levitra 80 mg online. Goal is maintenance of optimal nutrition while progressing from parenteral to enteral nutritional support cheap super levitra 80mg with visa. Wean parenteral fluid gradually as enteral fluids are being advanced and tolerated super levitra 80 mg for sale; document enteral and parenteral intake via calorie count. Enteral feeds should be initiated in a slow continuous drip with age appropriate elemental formula. Check blood glucose 1 hour after initiation and 1 hour after each increase in dextrose concentration. After target dextrose, amino acid, and lipid concentrations have been reached, check all of the above weekly and after any change in prescription. Refeeding syndrome - Severely malnourished patients who are given adequate calories may develop critical hypophosphatemia and/or hypokalemia in the first few days. Every 3 months check: serum ferritin, free carnitine (in children with short gut or chronic diarrhea). Carnitine and cholestasis: Nutritional dilemmas for the parenterally nourished newborn. A m erican H eart A ssociation (A H A ) 3 A im s ofFirst A id • Preserve life • Prevent further injury • Protect the unconscious •• PrProm otom otee rrececovovereryy • Procure m edicalaid 4 Responsibilities ofthe First A id Provider • Ensure personalhealth and safety • M aintain a caring attitude • M aintain com posure •• M aiM aintntaiainn upup ttoo datdatee kknow lnow ledgeedge andand sskkiillllss. M edicalEm ergencies • A sthm a • Foreign Body A irw ay O bstruction-Choking • A naphylaxis • Fainting • D iabetes and Low Blood Sugar • Seizures • Shock 19 A sthm a A sthm a is an allergic reaction resulting in the narrow ing ofthe sm aller airw ays especially bronchioles. Follow the instructions printed onon tthehe pacpackkageage 3 H old the epinephrine pen w ith your fistw ithouttouching either end because the needle com es out the one end 4 Place the tip ofthe pen hard againstthe child’s thigh betw een the hip and knee. RecRecogniognittiionon •D izziness,lightheadedness,nausea •Pale,cold,clam m y skin •N um bness or tingling in extrem ities •Briefperiod ofunresponsiveness 34 Fainting:M anagem ent • Lay victim dow n prom ptly • Elevate legs above the heart levelifthere is no leg or back injury. Shock:Recognition Shock is a condition resulting from inadequate oxygen supply to the m ajor body organs Recognition •Tachycardia ••CoolCool,,ccllam m yam m y,,palpalee sskkiinn •Rapid pulse that m ay becom e w eak or slow •Rapid,shallow breathing •Thirst •D izziness,nausea,vom iting •A ltered responsiveness •W eakness,collapse 39 Shock:M anagem ent • Position the victim in a position ofcom fort,ideally lying dow n w ith the legs elevated slightly • Treatthe cause,ifpossible (e. A puncture is a w ound m ade by a pointed object (like a nail,knife,or sharp tooth). You w illneed 2 people to do this 7 Ifthe child responds and is vom iting,rollthe child onto his side Fracture A break or a crack in a bone is know n as a fracture. Types ofFracture • Closed (Sim ple)fracture: –– ccom plom pletetee brbreakeak,,cchihip,p,oror ccrracackk iinn aa bonebone iinn w hiw hicchh the skin is not broken) • O pen (Com pound)fracture – com plete break,crack,or chip in a bone in w hich the skin is broken. There is the risk ofinfection and severe bleeding w ith open fractures) http://health. Sym ptSym ptom som s ofofssprpraiainsns andand ssttrraiainsns iincncllude:ude: • Pain • Sw elling and inflam m ation • Loss ofm ovem ent in the affected body part 55 M anagem ent:Sprains and Strains R Rest I Ice -apply ice w rapped in a dam p tow elto the injured area for 15 to 20 m inutes every tw o to three hours during the day. D o not allow the ice to touch your sskkiinn didirrececttllyy becbecausausee iitt ccoulouldd ccausausee aa ccololdd burburn. C Com pression -com press or bandage the injured area to lim it any sw elling and m ovem ent that could dam age it further. It should be w rapped snugly around the affected area but it should not be too tight. E Elevation -keep the injured area raised and 56 supported on a pillow to help reduce the sw elling. Recognition:M inor B urns Burns are injuries that can be caused by contact w ith heat,electricity,or chem icals. M inor B urns •Scene safety •Take im m ediate action to stop the burning process ••CoolCooltthehe burburnn w iw itthh ccooloolor lor lukukew arew armm w atw aterer for 10 to 30 m inutes. Signs and Sym ptom s • U nconscious • Flushed,hot,and dry skin • M ay be hyperventilating • Rectal tem perature of105°F or m ore M anagem ent:H eat stroke • Call999 im m ediately • M ove the person to a cooler environm ent •• A lA ltterernatnatiivvelelyy,,m oim oissttenen tthehe sskkiinn w iw itthh llukukew arew armm w atw aterer and use a fan to blow coolair across the skin.

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E- Expose (undress) the patient fully for examination not to miss serious injuries cheap 80mg super levitra with amex. It includes the following aspects: A- Take History: The informant may be the injured patient generic super levitra 80 mg visa, relatives generic 80mg super levitra with amex, police or ambulance personnel purchase super levitra 80mg otc. The history should include: • Time of injury, • Mechanism of injury, • Amount of bleeding, • Loss of consciousness, • Any intervention performed or drugs given should be asked for. C- Make necessary investigations such as hematocrite, cross-match, urinalysis, X-ray, ultrasound, etc. However, never send a patient with unstable vital signs for investigation or referral before resuscitation. These include poor condition and design of roads, traffic mix (sharing of road by vehicles of different speeds and pedestrians), poor condition of the vehicles and poor traffic rule enforcement. The incidence of this serious problem can be reduced by improving the public awareness and the quality of training given to the drivers and strict enforcement of traffic rules. Moreover, improving the design and quality of the roads and regular checkup of vehicle fitness would help alleviate the problem. In many developing countries like Ethiopia, the magnitude of the problem is big due to high distribution of firearms among civilians who have little or no knowledge on safe handling and usage. It is made worse by the presence of large number of land mines, which are remnants of repeated wars and conflicts in these poor nations. Generally, missile injuries may be caused by bullets from pistols, rifles, machine guns or fragments from exploded grenades and mines. The degree of injury sustained depends on the amount of energy transferred from the missile to the patient as formulated below. The extensive tissue injury with the high degree of contamination creates a perfect medium for life threatening infection to occur. Missile injuries are classified into: I- Low- velocity missile injuries • Comprise missiles fired from hand guns (<400m/s) • Injury is limited to the path of the bullet. All patients with missile injuries should receive broad spectrum antibiotics and tetanus prophylaxis. It is mostly seen in developing countries where there is overcrowding, poor housing designs and wide spread usage of open fire for cooking. Types of burns, according to the mechanism, include: • Flame burn • Scalding • Chemical burn • Electrical burn, etc. The severity of a burn injury is a function of the burn depth (degree) and the extent or percentage of the body surface that is burned. Determining the percentage of burn surface is important to calculate the amount of fluid requirement while determination of burn depth is important for burn wound management. Classification of Burn according to depth (degree) 1- First degree burn: It involves the epidermis only and manifests with erythema. The extent or percentage of burn is determined by the “rule of nine” in which the body surface is divided into eleven parts each constituting 9% of the total (fig. In children, the size of the hand may be used to estimate the burn surface, which is approximately 1%. Endotracheal intubation or tracheotomy may be needed in patients with burns involving the air way. Half of the calculated volume is given in the first 8 hours and the remaining half over the next 16 hours from the time of burn. The choice depends on the degree, size and site of the burn, and availability of facilities and expertise. Emergency escharotomy and fasciotomy should be done for deep circumferential burns of limbs, neck or trunk. Prevention of Infection: Burn patients have impaired resistance against infection. Prophylactic antibiotics (penicillin) are given for severe burns but, routine administration has no value. Nutrition: Naso-gastric tube should be inserted after admission for patients with more than 25% burn and those who have nausea and vomiting. Burn patients are in catabolic state and tend to lose weight very fast, thus special attention to their diet is important.

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This lateral rotation motion is produced by the popliteus muscle of the This OpenStax book is available for free at http://cnx generic 80mg super levitra fast delivery. Located between the articulating surfaces of the femur and tibia are two articular discs super levitra 80mg online, the medial meniscus and lateral meniscus (see Figure 9 order super levitra 80mg otc. Each is a C-shaped fibrocartilage structure that is thin along its inside margin and thick along the outer margin cheap super levitra 80 mg with mastercard. While both menisci are free to move during knee motions, the medial meniscus shows less movement because it is anchored at its outer margin to the articular capsule and tibial collateral ligament. The menisci provide padding between the bones and help to fill the gap between the round femoral condyles and flattened tibial condyles. Some areas of each meniscus lack an arterial blood supply and thus these areas heal poorly if damaged. The knee joint has multiple ligaments that provide support, particularly in the extended position (see Figure 9. The fibular collateral ligament (lateral collateral ligament) is on the lateral side and spans from the lateral epicondyle of the femur to the head of the fibula. The tibial collateral ligament (medial collateral ligament) of the medial knee runs from the medial epicondyle of the femur to the medial tibia. As it crosses the knee, the tibial collateral ligament is firmly attached on its deep side to the articular capsule and to the medial meniscus, an important factor when considering knee injuries. In the fully extended knee position, both collateral ligaments are taut (tight), thus serving to stabilize and support the extended knee and preventing side-to-side or rotational motions between the femur and tibia. The articular capsule of the posterior knee is thickened by intrinsic ligaments that help to resist knee hyperextension. Inside the knee are two intracapsular ligaments, the anterior cruciate ligament and posterior cruciate ligament. These ligaments are anchored inferiorly to the tibia at the intercondylar eminence, the roughened area between the tibial condyles. The cruciate ligaments are named for whether they are attached anteriorly or posteriorly to this tibial region. The cruciate ligaments are named for the X-shape formed as they pass each other (cruciate means “cross”). In this position, the posterior cruciate ligament prevents the femur from sliding anteriorly off the top of the tibia. The anterior cruciate ligament becomes tight when the knee is extended, and thus resists hyperextension. The medial and lateral menisci provide padding and support between the femoral condyles and tibial condyles. The collateral ligaments on the sides of the knee become tight in the fully extended position to help stabilize the knee. The posterior cruciate ligament supports the knee when flexed and the anterior cruciate ligament becomes tight when the knee comes into full extension to resist hyperextension. Which ligament of the knee keeps the tibia from sliding too far forward in relation to the femur and which ligament keeps the tibia from sliding too far backward? Since this joint is primarily supported by muscles and ligaments, injuries to any of these structures will result in pain or knee instability. Injury to the posterior cruciate ligament occurs when the knee is flexed and the tibia is driven posteriorly, such as falling and landing on the tibial tuberosity or hitting the tibia on the dashboard when not wearing a seatbelt during an automobile accident. More commonly, injuries occur when forces are applied to the extended knee, particularly when the foot is planted and unable to move. Anterior cruciate ligament injuries can result with a forceful blow to the anterior knee, producing hyperextension, or when a runner makes a quick change of direction that produces both twisting and hyperextension of the knee. A worse combination of injuries can occur with a hit to the lateral side of the extended knee (Figure 9. A moderate blow to the lateral knee will cause the medial side of the joint to open, resulting in stretching or damage to the tibial collateral ligament. Because the medial meniscus is attached to the tibial collateral ligament, a stronger blow can tear the ligament and also damage the medial meniscus.

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In the case of an H5N1 pandemic buy cheap super levitra 80mg line, the frequency of resistance emergence during osel- tamivir treatment of H5N1 paediatric patients is uncertain buy super levitra 80mg cheap, but it is likely to be no less than that observed in children infected with currently circulating human influ- enza viruses (Hayden 2005) order 80 mg super levitra otc. Neuraminidase inhibitors are effective against the virus that caused the 1918 pan- demic (Tumpey 2002) generic 80mg super levitra. Indications for the Use of Neuraminidase Inhibitors ® ® Oseltamivir (Tamiflu ) and zanamivir (Relenza ) are currently licensed for the treatment of influenza A and B. They should be used only when symptoms have occurred within the previous 48 hours and should ideally be initiated within 12 hours of the start of illness. In addition, oseltamivir – but not zanamivir (with the exception of two countries) – is also licensed for prophylaxis when used within 48 hours of exposure to influ- enza and when influenza is circulating in the community; it is also licensed for use in exceptional circumstances (e. Oseltamivir and zanamivir seem to have similar efficacy, but they differ in their modes of delivery and tolerability. Zanamivir is delivered by inhalation and is well tolerated; however, children, especially those under 8 years old, are usually unable to use the delivery system appropriately and elderly people may have difficulties, too (Diggory 2001). Antiviral Drugs 173 M2 Ion Channel Inhibitors Amantadine and rimantadine are tricyclic symmetric adamantanamines. They are active only against influenza A virus (influenza B does not possess an M2 protein), have more side effects than neuraminidase inhibitors, and may select for readily transmissible drug-resistant viruses. M2 inhibitors block an ion channel formed by the M2 protein that spans the viral membrane (Hay 1985, Sugrue 1991) and is required for viral uncoating (for more details see the Drugs chapter). Both drugs are effective as treatment if started within 24 hours of illness onset, reducing fever and symptoms by 1–2 days (Wing- field 1969, Smorodintsev 1970, van Voris 1981). Daily prophylaxis during an influenza season reduces infection rates by 50–90 % (Dawkins 1968, Dolin 1982, Clover 1986). In one study, rimantadine was ineffective in pro- tecting household members from influenza A infection (Hayden 1989). In addition, amantadine has a wide range of toxicity which may be in part attributable to the anticholinergic effects of the drug. The same frequency of side effects was found when the drug was tested in young healthy volunteers over a four-week period. Among 44 individuals, side effects (dizziness, nervousness, and insomnia) were well tolerated by most subjects, but 6 volunteers discontinued amantadine because of marked complaints. When studied in 450 volunteers during an outbreak of influenza A, the prophylactic effects of rimantadine and amantadine were comparable. Influ- enza-like illness occurred in 14 % of the rimantadine group and in 9 % of the amantadine group (Dolin 1982). Withdrawal from the study because of central nervous system side effects was more frequent in the amantadine (13 %) than in the rimantadine group (6 %). The potential for drug interactions is greater for amantadine, especially when co- administered with central nervous system stimulants. Agents with anticholinergic properties may potentiate the anticholinergic-like side effects of amantadine. Point mutations in the M gene lead to amino acid changes in the transmembrane region of the M2 protein and may confer high-level resistance to amantadine. The genetic basis for resistance appears to be single amino acid substitutions at positions 26, 27, 30, 31 or 34 in the transmembrane portion of the M2 ion channel (Hay 1985). In an avian model, they were also genetically stable, showing no reversion to the wild- type after six passages in birds over a period of greater than 20 days (Bean 1989). Such strains may develop in up to one third of patients treated with amantadine or rimantadine; in immunocompromised individuals the percentage may even be higher (Englund 1998). Drug-resistant influenza A virus (H3N2) can be obtained from rimantadine-treated children and adults as early as 2 days after starting treat- ment (Hayden 1991). Some H5N1 strains which have been associated with human 174 Treatment and Prophylaxis disease in Southeast Asia are resistant against amantadine and rimantadine (Peiris 2004, Le 2005), while isolates from strains circulating in Indonesia and, more re- cently, in China, Mongolia, Russia, Turkey and Romania are amantadine sensitive (Hayden 2005). Some authors have suggested that the use of amantadine and rimantadine should be gen- erally discouraged (Jefferson 2006).

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