By P. Harek. Northern Arizona University.

Thyroid cancer detected during pregnancy can usually be observed until afer the pregnancy is complete buy lozol 2.5 mg amex arrhythmia unspecified icd 9. If needed lozol 2.5 mg online pulse pressure factors, thyroid surgery can be perfrmed safely in the second and third trimesters purchase lozol 1.5 mg on-line arrhythmia originating in the upper chambers of the heart. For thyroid nodules that are less than 1 cm, benign appearing, and no pres­ ence of positive clinical history of thyroid cancers, observation and repeat thyroid ultrasound in 6 months is appropriate. Diagnostic terminology and morphologic criteria fr cytologic diagnosis of thyroid lesions: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspi­ ration State of the Science Confrence. Clinical practice guidelines fr hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. She subsequently started having uterine contractions approximately every 4 minutes. She has had an uncomplicated prenatal course with good pre­ natal care since 8-week gestation. Her first pregnancy resulted in the full-term delivery of a 7-lb 8-oz, healthy boy. Her blood pressure is 110/70 mm Hg, her pulse is 90 beats/min, and her temperature is 98. The ftus has a cephalic presentation by Leopold maneuvers and an estimated fetal weight of 8 lb. Know the defnition of labor, including the three stages of labor, understand the defnitions and diferences in the categories of ftal heart tracings, and know the normal progression of labor in nulliparous and multiparous women. Understand the types of ftal monitoring that are routinely perfrmed during labor and how monitoring correlates with the physiologic processes occurring during labor. Be fmiliar with the abnormal progression of labor and some of the interven­ tions that can be made to address these problems. Considerations This woman arrives at the labor and delivery triage unit in need of evaluation fr the possibility that she is in labor and that she has ruptured her membranes (bro­ ken her bag of water). The accurate and appropriate diagnosis of labor is extremely important in obstetrical care. Incorrectly diagnosing a woman as being in labor may result in unnecessary interventions, whereas not diagnosing labor may result in complications or delivery occurring without access to appropriate personnel and fcilities. Furthermore, the diagnosis of rupture of membranes is critical fr sev­ eral reasons. First, especially at term, the spontaneous rupture of membranes may signify the impending onset of labor. Second, if the presenting part is not well applied in the pelvis, prolapse of the umbilical cord with resultant compression of the cord and disruption of the oxygen supply to the fetus may occur. The physician also must promptly make assessments of both maternal and fetal well-being. When available, prenatal records should be reviewed to evaluate fr any problems during this, or previous, pregnancies and to confrm the gestational age of the pregnancy. Fetal well-being is most commonly monitored using exter­ nal, electronic ftal-monitoring equipment, although other options are available. With this equipment, the baseline ftal heart rate, heart rate variability, accelera­ tions and decelerations, along with the presence and fequency of uterine contrac­ tions, may be evaluated. Determination of the presentation of the ftus (cephalic, breech, or shoulder [ie, transverse lie]) is also critical, as this may play a signifcant role in the determination of route of delivery (vaginal or cesarean). The frst stage oflabor is fom the onset oflabor untl the cervix is completely dilated. During the latent phase of labor, the contractions become stronger, longer lasting, and more coordinated. The active phase of labor, which usually starts at 3 to 4 cm of cervical dilation, is when the rate of cervical dilation is at its maximum. In active labor in a woman without an epidural, the minimum expected rates of cervical dila­ tion are 1. The second stage oflabor is fom complete cervical dilaton (10 cm) throug the delivery of the ftus. The combination of the frce of the uterine contractions and the pushing eforts of the mother results in the delivery of the baby. A normal second stage lasts less than 2 hours in a nulliparous patient and less than 1 hour in a parous patient. The third stage oflabor begns afer the delivery ofthe baby and ends with the delivery ofthe placenta and membranes. The third stage is typically short and is considered prolonged if it lasts longer than 30 minutes. The power of the contractions can be assessed subjectively by an examiner palpating the uterus during a contraction or objectively by placing an intrauterine pressure catheter, which directly measures pressure within the uterine cavity. Its size, lie, presenta­ tion, and position within the birth canal all play a role in the progression of labor and rate of ftal descent. Finally, the shape and size of the Pelvis can result in delay or filure of descent of the ftus because of the relative disproportion between the ftal and pelvic sizes. The diagnosis of active labor is an indication fr admission to the birthing unit fr labor management and monitoring. The rupture of membranes can be confrmed by a carefl vaginal examination perfrmed with a sterile speculum and gloves. The visualization of fuid leaking fom the cervical os, either spontaneously or with the patient perfrming a Valsalva maneuver, and the presence of amniotic fuid pool­ ing in the posterior vaginal frnix are confrmatory. Using a sterile applicator to sample vaginal fluid and applying it to Nitrazine paper can make this determination. The presence of semen, blood, or bacterial vaginosis can cause elevated pH in vaginal secretions and a false-positive Nitrazine test. The visualization of ferning of vaginal fuid under microscopic magnifcation of an air-dried sample also suggests the pres­ ence of amniotic fuid. When the pregnant patient is admitted to the labor and delivery unit, ftal well­ being is assessed by either continuous or intermittent ftal heart rate monitoring. Continuous external fetal heart rate monitoring is the more commonly used pro­ cedure in the United States. Continuous monitoring can also be accomplished using an internal device (fetal scalp electrode), by attaching an electrode to the ftal scalp that directly measures and amplifes fetal cardiac electrical activity. With either of these two techniques, a continuous graphic recording of the fetal heart rate is recorded. Alternatively, inter­ mittent auscultation using a stethoscope or handheld Doppler can be perfrmed. In at-risk pregnancies, the monitor­ ing fequency is increased to at least every 15 minutes during the frst stage and to every 5 minutes in the second stage. Important considerations in interpreting ftal heart rate data are the baseline heart rate, vriability, and periodic heart rate changes.

Iron deficiency occurs in pregnancy as a result of the expanded blood vol- ume and active transport of iron to the fetus buy lozol 2.5mg amex blood pressure 700. Chronic disease generally leads to a normocytic anemia with elevated ferritin level (acute-phase reactant); although a microcytic anemia can also be seen purchase lozol master card whats prehypertension mean, a normocytic anemia is more common order 1.5 mg lozol free shipping arrhythmia upon exertion. Therefore, a negative fecal occult blood test in the presence of iron deficiency anemia should not discourage you fro m p u rsu in g a t h o ro u g h g a st ro in t e st in a l wo rku p. He became diaphoretic and began to experience chest pain, similar to that of his recent myocardial infarction. Co ro n a r y a n g io g ra p h y p e r fo rm e d prior to discharge revealed no significant coronary artery stenosis. His blood pressure is 124/92 mm Hg while lying down but drops to 95/70 mm Hg upon standing. He appears pale and uncomfort- able, and he is covered with a fine layer of sweat. His neck veins are flat, his chest is cle a r t o a u scu lt a t io n, a n d h is h e a rt rh yt h m is t a ch yca rd ic b u t re g u la r, wit h a so ft systolic murmur at the right sternal border and an S gallop. His a b d o m e n is so ft wit h a ct ive b o we l so u n d s a n d m ild epigastric tenderness, but there is no guarding or rebound tenderness, and no masses or organomegaly are appreciated. Rectal examination shows black, sticky stool, which is strongly positive for occult blood. H e is t ach ycar dic an d h as or t h ost at ic h yp o- tension, likely indicating significant hypovolemia as a result of blood loss. Rather than being a primary problem wit h his coronary art eries, such as t hrombosis or vasospasm, the cardiac ischemia is likely secondary to his acute blood loss and consequent tachycardia and loss of hemoglobin and its oxygen-carrying capacity. For a slowly developing, chronic anemia in pat ient s wit h good car diopu lmon ar y r eser ve, sympt om s m ay n ot be n ot ed u nt il the h em oglobin level falls ver y low, for example, t o 3 or 4 g/ dL. For pat ient s wit h serious underlying car diopulmonar y disease wh o depend on adequat e oxygen-carr ying capacit y, smaller declines in hemoglobin level can be devast at ing. Such is t he case wit h t he man in this clinical scenario, who is suffering a cardiac complication as a conse- quence of his anemia, in this case, unstable angina. Unstable angina is characterized by ischemic chest pain at rest, of new onset, or occurring at a lower level of activity. H e had been t reated wit h medical management, including dual antiplatelet therapy with aspirin and clopidogrel. In this case, it is more likely that his angina is secondary to the acute drop in hemoglobin rather than new car diac disease. In this case of secondary angina, the anemia must be corrected, which requires an underst anding of t ransfusion medicine. Anemia is generally considered to be a hemoglobin level less than 12 g/ dL in women or less than 13 g/ dL in men. Although lower values often can be tolerated or underlying et iologies treated, blood transfu- sions have been bot h necessary and lifesaving at t imes. Indicat ions for use of each of t hese blood comp on ent s are d escr ibed below. Many believe that a hemoglobin level of 7 g/ dL is adequate in the absence of a clear ly d efin ed in cr eased n eed, su ch as car d iac isch em ia, for wh ich a h emat ocr it level of at least 30% may be desired. Transfusion carries a small but definite risk, including transmission of infec- tion, reactions, and consequences. Rarely, bacterial cont amination (eg, Ye r - sin ia en t er ocolit ica ) causes fevers, sepsis, and even death during or soon after trans- fu sion. Par asit es (eg, m alar ia) are scr een ed for by qu est ion in g a d on or ’s med ical an d travel history. W ith respect to immune mechanisms, it is possible that a recipient has preformed natural antibodies that lyse foreign donor erythrocytes, which can be associated wit h t he major A and/ or B or O blood t ypes or wit h ot her ant igens (eg, D, D uffy, Kidd). Because hemolysis can ensue, a “type and cross” is first performed, in which blood samples are tested for compatibility prior to transfusion. The most common cau se of this r eact ion act u ally is cler ical (ie, m islabelin g). Acute hemolytic reactions may present with hypotension, fever, chills, hemoglobinuria, an d flank pain. T h e transfusion must be halted immediately, and fluid and diuretics (or even dialysis) should be given to prot ect t he kidney from failure via immune-complex depos- it s. Less predictably, milder, delayed hemolytic reactions involving amnestic responses from the recipient can occur. Febrile n on h emolyt ic t ran sfu sion react ion s can occur an d may be h elped by ant i- pyretics. Reactions range from urticaria treated with diphenhydramine and trans- fu sion in t er r u p t ion t o an aph ylaxis, in wh ich case the t r an sfu sion mu st be st op p ed, and epinephrine and steroids are needed. Adjust ing the volume and rat e and using diuret ics will prevent this complicat ion. Multiple and frequent transfu- sions can cause iron overload and deposition (hemosiderosis), leading to cirrhosis, car diac pr oblem s (eg, ar r h yt h mia, h ear t failu r e), or d iabet es. It also can be used in patients who are banking a pre- surgical aut ologous t ransfusion to encourage quicker recovery of t heir hemoglobin levels prior t o surgery. Cell savers salvage some int raoperat ive blood losses, wh ich are then t ransfused back into the patient. Some patients may not wish to have foreign blood product s t ran sfused based on religious convict ions. In t h ese cases, we can increase t he baseline hemoglobin level by using eryt h ropoiet in and iron before planned surgery, minimize phlebotomy for laboratory testing, and use cell savers during surgery. When 3 a pat ient has a platelet count of less than 50,000/ mm and has significant bleed- ing, or when a pat ient is at risk for spont aneous bleeding wit h a level of less t han 3 10,000/ mm, plat elet s can be t r an sfused. Platelet transfusion is contraindicated in pat ient s wit h t h rombot ic t hrombocyt openic purpura ( T T P ), as it may worsen microvascular thrombosis and cause worsening neurologic symptoms or renal failure. H e is not ed t o be in hypovolemic shock wit h a blood pressure of 60/ 40 mm H g. Which of t he following is the most appropriate t ype of blood t o be transfused? W hich of the following labo- ratory tests would most likely confirm an acute transfusion reaction? This patient needs a blood transfusion immediately, as evidenced by his dangerously low blood pressure. Even t h ough the pat ient ’s wife is “absolut ely sure” about t he blood t ype, hist ory is not complet ely reliable, and in an emer- gen t sit u at ion su ch that u n cr oss-m at ch ed blood mu st be given, O -n egat ive blood (universal donor) usually is administered. This patient is su ffer in g fr o m acu t e h em o lyt ic t r a n sfu sio n r eact io n ch a r ac- terized by fever, evidence of hypotension and hemolysis. When life-threatening acute bleeding occurs in the face of coagulopathy due to warfarin (Coumadin) use, the treatment is fresh frozen plasma. Sometimes vit am in K ad m in ist r at ion can b e h elp fu l if the b leed in g is n ot sever e.

Varicella zoster and measles order generic lozol pills blood pressure medication one kidney, mumps and rubella vaccines are contraindicated in pregnancy order lozol 2.5mg line blood pressure understanding. C • Group B streptococcus is recognized as the most frequent cause of severe early onset (at less than 7 days of age) infection in newborn infants buy generic lozol line arteria lumbalis. The Sixth Report on the Confdential Enquiries into Maternal Deaths in the United Kingdom. Regular emptying by breastfeeding on the afected side will improve mastitis sooner. Breastfeeding jaundice is more of a mechanical problem and is due to insufcient intake of breast milk leading to accumulation of bilirubin in the body due to inadequate bowel movements in the newborn. On the other hand, breast milk jaundice is a biochemical problem and tends to run in families. It may be caused by factors in the breast milk that can block certain proteins in the liver that metabolize bilurubin. Tese babies may need phototherapy and formula feeds to get their bilurubin levels to normal range 2D: True – Breast abscess should be drained and treated frst. If this condition persists, lactiferous ducts can become infected and may lead to an abscess formation and sepsis. Terefore, one should not delay giving antibiotics in the presence of symptoms of pain, raised temperature or signs of mastitis (red, tender and swollen breasts). Although the primary source of this fever usually stems from the genital tract, a thorough evaluation of the febrile puerperal patient for other sites of infection is necessary before initiating antibiotic therapy. Puerperal pyrexia is commonly defned as a temperature elevation of 38°C on two occasions afer the frst 24 hours following delivery. Major risk factors for developing postpartum uterine infection include chorioamniotis and abdominal delivery. Other risk factors include prolonged rupture of membranes and multiple cervical examinations. Diagnosis and treatment Uterine tenderness, ofensive vaginal discharge and raised temperature (38°C or more) may all suggest a uterine infection. Early involvement of microbiologists is invaluable in severely ill patients and those who fail to respond to initial treatment. Metritis in the presence of retained products of conception warrants prompt evacuation. Intravenous antibiotics are continued until the patient has been apyrexial for at least 24 hours. Endometritis is higher among women who have had caesarean section compared to those who had a vaginal delivery. Perineal or episiotomy wound infection Women with this condition can present with fever, discharge from the perineal wound and perineal pain, an inability to pass urine due to severe pain. One should examine the perineum and take swabs for culture and sensitivity prior to treating with antibiotics. In the presence of a wound discharge, swabs for bacterial culture should be undertaken and antibiotics started. Contamination by catheterization, urinary retention and symptomatic bacteriuria all contribute to cystitis. An uncontaminated, catheterized specimen that shows pyuria and bacteriuria will help to make a diagnosis. Treatment with antibiotics should result in prompt resolution of the infection in most cases. Breast disorders Various minor breast conditions are common during the puerperium; these include sore nipples, milk stasis and mastitis. Infammatory changes are easily treated with frequent breast emptying; infectious conditions require antibiotics. Staphylococcus aureus and Staphylococcus epidermidis are the most common causative organisms. Breast abscess need to be ruled out in patients who do not respond to antibiotic treatment. The standard treatment is surgical incision, breaking down of loculi and drainage of pus under antibiotic cover. Ovarian vein thrombosis Ovarian vein thrombosis is a rare but potentially serious complication following childbirth. It is difcult to diagnosis and therefore a high index of suspicion is important to make a diagnosis. Tey usually present with fever and right lower quadrant abdominal pain and can therefore mimic appendicitis. Vulvovaginal and pelvic haematoma Vulvovaginal hematoma is an uncommon complication following delivery but can be associated with serious morbidity. Good surgical technique and hemostasis are important while repairing perineal tears and episiotomies. One must examine the perineum if there is a signifcant drop in blood pressure or signifcant drop in haemoglobin in a puerperal woman. The management includes corrections of hypovolemia, evacuation of the haematoma and secure haemostasis. The overall risk of obstetric anal sphincter injury is 1% of all vaginal deliveries. Childbirth is the most common cause of anal sphincter injury leading to faecal incontinence. It may occur following a rectal prolapse or in association with a neurological disorder. The prevalence of these symptoms in women who have undergone third- and fourth-degree tear repair ranges between 20–67%. The type of incontinence can be fatus (59%) or leakage of liquid and solid stool (11%) or solid stool (4%) or faecal urgency (26%). Mechanism of injury • Direct mechanical injury to anal sphincter (third- and fourth-degree perineal tears) • Neurological injury (nerve compression from fetal head or neuropathy of pudendal nerve following forceps delivery) • A combination of the above Aetiology of anal incontinence • Spontaneous vaginal delivery • Forceps delivery • Ventouse delivery • Midline episiotomy • Previous anal sphincter injury • Mediolateral episiotomy • Prolonged second stage of labour • Birth weight of fetus more than 4 kg • Epidural analgesia • Malpositions of the fetal head (e. Elective caesarean section is the only true primary prevention strategy for childbirth injuries to the pelvic foor. Once identifed, this should be repaired immediately by an appropriately trained person. Subsequently a follow up should be arranged at 6–12 months for women who had repair of third- and fourth-degree tear. Tertiary measures to improve quality of life Symptomatic women at postnatal follow up should be ofered endoanal ultrasonography and anorectal manometry and also should be referred to a colorectal surgeon for consideration of secondary repair of anal sphincter. Terefore, women should be assessed for symptoms and counselled appropriately regarding mode of delivery if they had a third- and fourth-degree tear following previous delivery. Obstetric anal sphincter injury: how to avoid, how to repair: A literature review. It should be administered into the bulkiest part of the thigh (vastus lateralis thigh muscle, which is located in the front upper outer segment of the thigh in infants).

Epidemiology • According to the World Health Organization an estimated 376 lozol 2.5mg discount blood pressure medication that starts with a,000 people drowned in 2002 purchase lozol 2.5 mg on-line hypertension diet plan. A small proportion of patients appear at post mortem to have no evidence of water in the lungs order 1.5 mg lozol fast delivery zopiclone arrhythmia, so-called ‘dry drowning’. Plausible mechanisms for this include breath holding, laryngeal spasm, and loss of consciousness, leading to death from other causes. Alternatively, only a small amount of water may have been aspirated, and this would have been absorbed into the circulation by the time of post mortem. As a treatment, mild hypothermia may be of some benefit, but if it occurs after near-drowning in warm water it is a poor prognostic sign. Freshwater vs salt water Salt water drowning tends to result in: • Hypernatraemia • Hypermagnesaemia • Pulmonary oedema (due to the osmotic gradient) • Less frequent microbiological contamination. Freshwater drowning is associated with: • Hyponatraemia • Haemolysis from fresh water aspiration • Pulmonary oedema—possible mechanisms include increased capillary permeability, neurogenic pulmonary oedema, and reduced surfactant • More frequent microbiological contamination. Management At scene • Extraction of the patient from the water should be considered carefully (where practically possible) to reduce the chance of further insult. Microbiology Bacterial and fungal infections are recognized complications and should be treated as guided by cultures. Aeromonas spp, Burkoholderia pseudomallei, and Chromobacterium violaceum are more common following fresh water near-drowning. In salt water near-drowning the overall incidence of sec- ondary infection is lower but more unusual organisms such as Francisella philomiragia are isolated more frequently. The type of microorganism retrieved from the lungs can be used as a test to determine whether the cause of death of a body found in water was drowning. Aspiration of gastric contents Gastric contents may be aspirated during coma, in the presence of neu- rological disorders, or during anaesthesia (particularly emergency and obstetric anaesthesia). Other risk factors include pain, alcohol ingestion, hiatus hernia, gastro-oesophageal reflux, prolonged vomiting, and head injury. The sequelae are related to the volume, the acidity, and the presence of microorganisms. Aspiration of gastric contents may result in: • Airway obstruction • Chemical pneumonitis • Bacterial infection. Other forms of aspiration Pulmonary damage from aspiration of other substances is relatively uncommon, as chemicals that are ingested tend to injure the upper airway and oesophagus rather than the lower respiratory tract. This led to the introduction of non-particulate antacids and non-ionic contrast media. These observations reinforce the need for preventative measures in rescue workers and also the need for long-term follow up of people with prolonged or severe exposure to dust and chemical inhalation. The terminology and classi- fication used to describe this body of disorders is potentially confusing. Recent guidelines and consensus statements from international societies have helped in this regard. The interstitial pneumonias are not always ‘idiopathic’ and can be a consequence of underlying connective tissue diseases or adverse drug reaction. Note, however, that eosinophilic pneumonia can occur with a normal blood eosinophil count. This might be sufficient to diagnose bacterial pneumonia but is unreliable and is not sufficient for opportunistic infections or useful cytology. In ventilated patients the yield may be quite low; expect a return of approximately 20–30% of instilled fluid. Clinical features • Onset of breathlessness typically 1 year prior to presentation. This may represent around 10–20% of cases and this group is not reliably identifiable at presentation. Clinical features • Typically rapidly worsening breathlessness over a few days or weeks. Pathophysiology • Histologically organizing pneumonia is characterized by ‘plugs’ of organizing granulation tissue within alveolar ducts and airsacs, with a bronchocentric pattern. Sarcoidosis Sarcoidosis is a multisystem granulomatous disease of unknown aetiology. Although the disease affects the lungs in over 90% of patients, sarcoidosis very rarely presents with acute respiratory failure and only occasionally progresses to chronic respiratory failure. Clinical features Sarcoidosis has been described in virtually all organs, but the most common clinical manifestations are skin, pulmonary, and ocular sarcoidosis. Breathlessness, productive cough if secondary bronchiectasis has developed, and occasionally chronic respiratory failure. Rarely, stage 2 or 3 disease presents with acute respiratory failure and extensive radiographic disease. Diagnosis of sarcoidosis The clinical presentation is often highly suggestive of sarcoidosis, especially when presenting with Löfgren’s syndrome or with skin or eye manifesta- tions, but a definitive diagnosis requires histological confirmation from an accessible site of disease. Spontaneous remission is a feature of the natural history of pulmonary sarcoidosis and occurs in 60–80% of patients with stage 1 disease, 40–60% of patients with stage 2 disease, 10–20% of patients with stage 3 disease, and never in stage 4 disease. Progression or resolution of disease is usually evident in the first 2–3 years after presentation. Pulmonary sarcoidosis is usually responsive to corticosteroids at initial doses of 20–40mg daily. Primary pneumothorax may be managed with either observation, if small and minimal symptoms, or by fine needle aspiration of air in the first instance. Pleural disease Diagnosis In a mechanically ventilated patient diagnosis may be difficult. They may not produce an obvious lung edge and therefore the classically described radiological features may be absent. Pneumomediastinum, pneumopericardium, or surgical emphysema should raise suspicion of a coexisting pneumothorax. Ultrasound Ultrasound may be useful to exclude pneumothorax by visualizing the lung–chest wall interface. Aerated lung does not transmit ultrasound well and neither does a pneumothorax, therefore it requires an experienced operator and is less useful in the presence of surgical emphysema or pre- existing lung disease, especially bullous lung disease. This ‘lung sliding’ or ‘gliding’ indicates that the visceral and parietal pleura are apposed. In the supine patient the use of a linear array probe to check every intercostal space anteriorly is recommended. It does require patient transfer, and the risk/benefit ratio may be finely balanced. Management Not all pneumothoraces in spontaneously ventilating patients require drainage. The drain is then connected to an underwater seal bottle and should be left on free drainage. A bubbling drain should never be clamped since this may lead to tension pneumothorax. It may be considered if there is persistent bubbling after 48h, although it remains controversial.

Caution should also be exercised when treating older- adult patients best 1.5 mg lozol blood pressure 100 over 60, patients who smoke cigarettes buy lozol 1.5 mg fast delivery blood pressure 6040, and patients with H best buy lozol arrhythmia vs tachycardia. Aspirin should be withdrawn 1 week before elective surgery or the anticipated date of childbirth. Children/adolescents Because of the risk for Reye syndrome, aspirin should be avoided in children and adolescents. Drug Interactions Because of its widespread use, aspirin has been reported to interact with many other medications. Because aspirin suppresses platelet function and can decrease prothrombin production, aspirin can intensify the effects of warfarin, heparin, and other anticoagulants. Furthermore, because aspirin can initiate gastric bleeding, augmenting anticoagulant effects can increase the risk for gastric hemorrhage. Accordingly, the combination of aspirin with anticoagulants must be used with care—even when aspirin is taken in low doses to reduce the risk for thrombotic events. As a result, the risk for ulcers is greatly increased when these drugs are combined—as may happen when treating arthritis. In susceptible patients, combining aspirin with drugs in either class can increase the risk for acute renal failure. Accordingly, these drugs should not be used routinely to prevent vaccination- associated fever and pain. Signs and Symptoms Initially, aspirin overdose produces a state of compensated respiratory alkalosis —the same state seen in mild salicylism. As poisoning progresses, respiratory excitation is replaced with respiratory depression. Acidosis, hyperthermia, sweating, and dehydration are prominent, and electrolyte imbalance is likely. Treatment Aspirin poisoning is an acute medical emergency that requires hospitalization. The immediate threats to life are respiratory depression, hyperthermia, dehydration, and acidosis. Intravenous fluids are given to correct dehydration; the composition of these fluids is determined by electrolyte and acid-base status. Alkalinization of the urine with bicarbonate accelerates excretion of aspirin and salicylate. If necessary, hemodialysis or peritoneal dialysis can be used to remove salicylates. Formulations Aspirin is available in multiple formulations, including plain and buffered tablets, enteric-coated preparations, and tablets used to produce a buffered solution. These different formulations reflect efforts to increase rates of absorption and decrease gastric irritation. For the most part, the clinical utility of the more complex formulations is no greater than that of plain aspirin tablets. Aspirin Tablets, Plain All brands are essentially the same with respect to analgesic efficacy, onset, and duration. Some less expensive tablets have greater particle size, which results in slower dissolution and prolonged contact with the gastric mucosa, which increases gastric irritation. When aspirin tablets decompose, they smell like vinegar (acetic acid) and should be discarded. Aspirin Tablets, Buffered The amount of buffer in buffered aspirin tablets is too small to produce significant elevation of gastric pH. An equivalent effect on pH can be achieved by taking plain aspirin tablets with food or a glass of water. Buffered aspirin tablets are no different from plain tablets with respect to analgesic effects and gastric distress. Buffered tablets may dissolve faster than plain tablets, resulting in somewhat faster onset. Buffered Aspirin Solution A buffered aspirin solution is produced by dissolving effervescent aspirin tablets [Alka-Seltzer] in a glass of water. This solution has considerable buffering capacity owing to its high content of sodium bicarbonate. Effects on gastric pH are sufficient to decrease the incidence of gastric irritation and bleeding. The sodium content of buffered aspirin solution can be detrimental to individuals on a sodium-restricted diet. Also, absorption of bicarbonate can elevate urinary pH, which will accelerate aspirin excretion. Because of this combination of benefits and drawbacks, the buffered aspirin solution is well suited for occasional use but is generally inappropriate for long-term therapy. Enteric-Coated Preparations Enteric-coated preparations dissolve in the intestine rather than the stomach, thereby reducing gastric irritation. Timed-Release Tablets Timed-release tablets offer no advantage over plain aspirin tablets. Because the half-life of salicylic acid is long to begin with, and because aspirin produces irreversible inhibition of cyclooxygenase, timed-release tablets cannot prolong effects. Rectal Suppositories Rectal suppositories have been employed for patients who cannot take aspirin orally. Absorption can be variable, resulting in plasma drug levels that are insufficient in some patients and excessive in others. Because of these undesirable properties, aspirin suppositories are not generally recommended. In addition, they all can cause gastric ulceration, bleeding, and renal impairment—although the intensity of these effects may be less with some agents. However, although the increase in risk with these drugs appears high, it pales in comparison with smoking, which increases cardiovascular risk by 200% to 300%. Other measures to reduce risk are discussed later under “American Heart Association Statement on Cyclooxygenase Inhibitors in Chronic Pain. However, for reasons that are not understood, individual patients may respond better to one agent than another. Ibuprofen Basic Pharmacology Ibuprofen [Advil, Motrin, Caldolor, others] is the prototype of the propionic acid derivatives. Like aspirin, ibuprofen inhibits cyclooxygenase and has antiinflammatory, analgesic, and antipyretic actions. In clinical trials, ibuprofen was highly effective at promoting closure of the ductus arteriosus in preterm infants, a condition for which indomethacin is the current treatment of choice. Ibuprofen is generally well tolerated, and the incidence of adverse effects is low. The drug produces less gastric bleeding than aspirin and less inhibition of platelet aggregation as well. Very rarely, ibuprofen has been associated with Stevens-Johnson syndrome, a severe hypersensitivity reaction that causes blistering of the skin and mucous membranes and can result in scarring, blindness, and even death. Nonacetylated Salicylates: Magnesium Salicylate, Sodium Salicylate, and Salsalate Similarities to Aspirin The nonacetylated salicylates are similar to aspirin (an acetylated salicylate) in most respects.