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The earliest manifestation of hyperkalemia is the development of peaked T waves high blood pressure medication and xanax 75mg triamterene, which become evident when the serum potassium level exceeds 6 blood pressure log sheet printable discount triamterene 75mg. This peaking of the T waves is a manifestation of the accelerated repolarization of the cardiac action potential produced by hyperkalemia. These changes indicate progressive inexcitability of cardiac muscle and are referable to hyperkalemia-induced inactivation of sodium permeability during the initial spike of the action potential. When the serum potassium level exceeds 8 to 10 mEq/L, the electrocardiogram may develop a sine wave pattern and cardiac standstill can occur. The correlation between serum potassium concentrations and electrocardiographic abnormalities is approximate at best; in a given patient, progression from peaked T waves to a sine wave pattern may occur rapidly, particularly if the serum potassium concentration rises rapidly. Therefore, the development of peaked T waves in conjunction with hyperkalemia should be viewed as a serious disorder; more advanced electrocardiographic manifestations of hyperkalemia should be treated as life-threatening medical emergencies. Administering 25 g of glucose, together with 10 units of regular insulin, is an effective way of reducing the serum potassium level rapidly. Using a 50% glucose solution may actually worsen the hyperkalemia transiently if given rapidly. Insulin promotes potassium entry into cells, and glucose is administered to prevent hypoglycemia. In insulin-dependent diabetic patients in whom sudden hyperglycemia has precipitated the hyperkalemia, insulin administration alone suffices to reduce the serum potassium concentration. Administering 40 to 150 mEq of sodium bicarbonate intravenously over a 30- to 60-minute interval also promotes potassium entry into cells, particularly if acidosis is also present. Potassium shifts from extracellular to intracellular fluids also may be enhanced by using aerosolized specific beta2 agonists; albuterol is a commonly used agent of this kind. Agents such as albuterol are most helpful in managing mild hyperkalemia in chronic disorders such as chronic renal failure and hyperkalemic periodic paralysis. This approach should be undertaken with constant electrocardiographic monitoring and should be used with extreme caution in patients who have received digitalis. In the latter circumstance, calcium administration may unmask digitalis intoxication, especially if other agents are used simultaneously to reduce the serum potassium level. Calcium salts should not be added to bottles of intravenous fluids containing bicarbonate, because water-insoluble calcium salts will form. The influence of calcium salts in minimizing the cardiotoxic effects of hyperkalemia may be understood by noting that depolarization of excitable tissues by elevating serum K+ concentrations inactivates sodium channels and that the extracellular sides of these sodium channels are electronegative. Divalent cations such as calcium provide a remarkably effective way of screening these electronegative sites. Thus, calcium salts raise the voltage gradient across sodium channels by screening electronegative surface charges of these channels on their extracellular fluid sides and consequently restoring the voltage-dependent excitability of these channels. Gastrointestinal potassium losses may be produced by the use of cation exchange resins in the sodium cycle, such as sodium polystyrene sulfonate (Kayexalate), or by agents that induce secretory diarrhea. Each gram of the resin contains approximately 1 mEq of sodium and exchanges for about 1 mEq of potassium. This stoichiometry is not precise, since the sodium form of the resin also exchanges for other cations in gastrointestinal secretions, including calcium. In chronic hyperkalemia, 20 g of Kayexalate may be given three or four times a day in a 70% solution of sorbitol. The sorbitol creates an osmotic diarrhea and enhances resin passage through the gastrointestinal tract. It must be stated that use of resin-cathartic therapy is relatively unpleasant for 558 the patient. Kayexalate may also be administered by enema, generally as 100 g of resin suspended in 200 g/mL of 20% sorbitol. The effect of single dose Kayexalate on fecal potassium output is minimal when compared to non-cation exchange agents that induce secretory diarrhea, however Kayexalate may be of benefit in management of hyperkalemia when given more chronically. The use of chronic Kayexalate therapy in patients with chronic renal failure carries with it the risk of sodium overload. Finally, acute hemodialysis or peritoneal dialysis provides another mechanism for potassium removal from the body. Study shows that standard-dose trimethoprim-sulfamethoxazole therapy consistently increases peak serum potassium concentrations. Nice article that discusses the reasons and mechanisms in management of hypokalemia. Data review showing that refractory K+ repletion is often associated with total body Mg2+ deficiency.

Ordinary physical activity results in fatigue hypertension grades 75 mg triamterene, palpitations blood pressure medication enalapril side effects cheap triamterene 75mg with mastercard, dyspnea, or anginal pain. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind, or when under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions. Patient can perform to completion any activity requiring 5 metabolic equivalents but cannot and does not perform to completion activities requiring 7 metabolic equivalents. Patient can perform to completion any activity requiring 2 metabolic equivalents but cannot and does not perform to completion any activities requiring 5 metabolic equivalents. Patient cannot or does not perform to completion activities requiring 2 metabolic equivalents. They are comfortable blocks on the level and climbing more than one flight in normal at rest. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. From Goldman L, et al: Comparative reproducibility and validity of systems for assessing cardiovascular functional class: Advantages of a new specific activity scale. Osteogenesis imperfecta, which is associated with blue sclerae, is also associated with aortic dilatation and mitral valve prolapse. Retinal artery occlusion may be caused by an embolus from clot in the left atrium or left ventricle, a left atrial myxoma, or atherosclerotic debris from the great vessels. Hyperthyroidism may present with exophthalmos and typical stare, whereas myotonic dystrophy, which is associated with atrioventricular block and arrhythmia, is often associated with ptosis and an expressionless face. Jugular Veins the external jugular veins help in assessment of mean right atrial pressure, which normally varies between 5 and 10 cm H2 O; the height (in centimeters) of the central venous pressure is measured by adding 5 cm to the height of the observed jugular venous distension above the sternal angle of Louis. The normal jugular venous pulse, best seen in the internal jugular vein (and not seen in the external jugular vein unless insufficiency of the jugular venous valves is present), includes an a wave, caused by right atrial contraction; a c wave, reflecting carotid artery pulsation; an x-descent; a v wave, which corresponds to isovolumetric right ventricular contraction and is more marked in the presence of tricuspid insufficiency; and a y descent, which occurs as the tricuspid valve opens and ventricular filling begins. Abnormalities of the jugular venous pressure and pulse are useful in detecting conditions such as heart failure, pericardial disease, tricuspid valve disease, and pulmonary hypertension (Table 38-5). Carotid Pulse the carotid pulse should be examined in terms of its volume and contour. In aortic regurgitation or arteriovenous fistula, the pulse may have a bisferious quality. The carotid upstroke is delayed in patients with valvular aortic stenosis Figure 38-1 Normal jugular venous pulse. Positive hepatojugular reflux-suspect congestive heart failure, particularly left ventricular systolic dysfunction (echocardiography recommended). Cardiac Inspection and Palpation Inspection of the precordium may reveal the hyperinflation of obstructive lung disease or unilateral asymmetry of the left side of the chest because of right ventricular hypertrophy before puberty. Palpation may be performed with the patient either supine or in the left lateral decubitus position; the latter moves the left ventricular apex closer to the chest wall and increases the ability to palpate the point of maximal impulse and other phenomena. Low-frequency phenomena such as systolic heaves or lifts from the left ventricle (at the cardiac apex) or right ventricule (parasternal in the third or fourth intercostal space) are best felt with the heel of the palm. With the patient in the left lateral decubitus position, this technique may also allow palpation of an S3 gallop in cases of advanced heart failure and/or an S4 gallop in cases of poor left ventricular distensibility during diastole. The left ventricular apex is more diffuse and may sometimes be frankly dyskinetic in patients with advanced heart disease. The distal palm is best for feeling thrills, which are the tactile equivalent of cardiac murmurs. Higher-frequency events may be best felt with the fingertips; examples include the opening snap of mitral stenosis or the loud pulmonic second sound of pulmonary hypertension. The second heart sound is caused primarily by closure of the aortic valve, but closure of the pulmonic valve is also commonly audible. In normal individuals, the louder aortic closure sound occurs first, followed by pulmonic closure. With expiration the two sounds are virtually superimposed, whereas with inspiration the increased stroke volume of the right ventricle commonly leads to a discernible splitting of the second sound. This splitting may be fixed in patients with an atrial septal defect (see Chapter 57) or a right bundle branch block.

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Following cell depolarization yaz arrhythmia discount triamterene 75 mg mastercard, the potential gradually returns to resting potential blood pressure 40 over 30 purchase triamterene us. At the end of phase 3, the normal resting potential is re-established, and the excess of sodium and a deficit of potassium ions are rectified by a sodium pump. If the resting membrane potential is raised toward the level of the threshold potential, a relatively weak stimulus can evoke a response. Conversely, if the resting potential is lowered away from the threshold potential, a relatively stronger stimulus is required to produce a response. The refractory period of myocardial cells and tissue consists of the absolute refractory period, during which no stimulus of any intensity can evoke a response, and a relative (effective) refractory period, during which only a strong stimulus can evoke a response. The relative refractory period begins at about the time the membrane potential reaches the threshold potential and ends just before the end of phase 3; it is followed by a period of supernormal excitability, during which a relatively weak stimulus can evoke a response. The velocity at which electrical impulses spread through the heart depends on the intrinsic properties of different portions of the conduction system and myocardium, including size, shape, and orientation of muscle cells, and presence and type of connective tissue. Conduction of action potentials from cell to cell occurs over specialized intercellular channels or gap junctions. Capital letters (Q, R, S) refer to waves over 5 mm; lowercase letters (q, r, s) refer to waves under 5 mm. The U wave is the (usually positive) deflection following the T wave and preceding the subsequent P wave; it is thought to be due to repolarization of the intraventricular (Purkinje) conduction system and is often accentuated in left ventricular hypertrophy. In some circumstances, such as hypokalemia and hypomagnesemia, the U wave is thought to represent an oscillatory membrane potential, called an afterdepolarization. Negative U waves, best seen in leads V4-6, can be seen in acute myocardial ischemia (where they are insensitive but relatively specific markers of left anterior descending coronary artery disease), and left ventricular hypertrophy from any cause. If the ventricular rhythm interval is regular, this interval in seconds (or fractions of a second) divided into 60 (seconds) equals the heart rate per minute. The P waves are broad and notched, consistent with left atrial enlargement, a common accompaniment of left ventricular hypertrophy. Establishing the rate allows the atrial rhythm to be characterized as bradycardia (rate <60 per minute), normal (rate between 60 and 100 per minute), and tachycardia (rate >100 per minute). If atrial and ventricular rates are different from each other, their rates must be determined separately. Irregular rhythms should be further described as totally irregular ("irregularly" irregular as, for example, in atrial fibrillation) or regular with periods of irregularity ("regularly" irregular as, for example, in atrial bigeminy). Determine the P wave axis, duration, and morphology to provide information about the focus or origin of the atrial rhythm and whether the atria are being depolarized antegradely or retrogradely. If the atrial rhythm is sinus, the P wave morphology and duration can suggest the presence of atrial enlargement or hypertrophy. DeMaria Echocardiography is a non-invasive technique that evaluates cardiac anatomy and function with images and recordings produced by sound energy. Although introduced as a one-dimensional technique in the early 1970s, echocardiography has evolved into a two- and even three-dimensional imaging modality that is also capable of deriving hemodynamic data from measures of blood flow velocity using the Doppler principle. Cardiac ultrasonography is currently the primary modality employed to assess valvular, pericardial, and congenital heart diseases, as well as cardiac masses. Sound of a frequency above the audible range of 20,000 cycles/sec is termed ultrasound; it travels as a beam that obeys the laws of reflection and refraction. When directed into the thorax and aimed at the heart, a sound beam travels in a straight line until it encounters a boundary between structures with different acoustical impedance, such as between blood and tissue. At such surfaces, a portion of the energy is reflected or refracted, and the remaining attenuated signal is transmitted distally. In practice, the ultrasound signal is both produced and received by a single hand-held transducer that converts electrical to mechanical (sound) energy and vice versa. The central component of the transducer is a piezoelectric crystal whose ionic structure changes shape to produce sound waves when exposed to an electric current. This same crystal is deformed by the reflected sound wave to produce an electrical signal. Echocardiographic images and recordings are constructed in the form of a display of the distance between 192 individual cardiac structures and the transducer.

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Organisms capable of airborne transmission often produce outbreaks of infection when groups of susceptible people are exposed; examples include Legionella arrhythmia 200 bpm discount triamterene 75mg without a prescription, influenza pulse pressure lying down purchase triamterene mastercard, and anthrax. Droplets that exceed 10 mum in diameter are deposited by inertial impaction in the upper airways, a process that is promoted by the angulation of these structures. About 90% of particles 5 to 10 mum in diameter are deposited along the tracheobronchial tree, whereas particles 0. Smaller particles behave like gas molecules and are largely exhaled rather than retained. Droplet nuclei is the term applied to particles about 1 to 3 mum in diameter containing a single bacterium, the likely infecting unit for organisms transmitted by the airborne route. The first line of defense against bacteria deposited in the lungs is the mucociliary escalator, an integrated multifaceted system consisting of the ciliated cells lining the airways, the secretory cells (goblet cells and submucosal glands), and the secretions. However, the effectiveness of this activity depends on maintaining the depth and viscosity of secretions and coordination of ciliary activity. Processes that impair ciliary movement, cause excessive secretion of respiratory mucus, or change the viscosity of secretions may hinder the effectiveness of this transport system (Table 82-2). Bacteria that penetrate to the distal airways or alveoli are killed in situ by phagocytic cells. Nonspecific opsonization, which aids phagocytosis, may be provided by lung surfactant or fibronectin. Alveolar macrophages that reside in the lungs can ingest and kill enormous numbers of nonpathogenic bacteria, such as most of the normal oropharyngeal flora, without eliciting an inflammatory response. For bacteria that are more pathogenic, the situation is more complicated; some species promptly recruit neutrophils, and bacterial killing appears to depend much more upon the availability of neutrophils than on the presence of alveolar macrophages. Clearance of these organisms from the lung is enhanced by the presence of specific antibody. Immunoglobulin (Ig) G is the predominant immunoglobulin in the alveolus, comprising about 10 to 15% of the protein in alveolar fluid. If viable bacteria persist, an inflammatory response swiftly develops and is characterized by interstitial and alveolar edema as well as an influx of neutrophils. As neutrophils and bacteria accumulate, the milieu becomes acidic and hypoxic, and bacterial ingestion and killing are remarkably retarded. Spreading edema and inflammation at the periphery of the lesion continue until specific antibody appears (days 5 to 7) or effective antibiotic therapy is initiated. Community-acquired pneumonias are usually due to a single organism, an observation that appears to contradict the aspiration mechanism that necessarily includes multiple species. Organisms gain access to the systemic circulation early in the development of pneumonia. For example, pneumococci introduced into the lungs of dogs can be recovered from hilar lymph nodes within 15 minutes. Bacteremia and positive cultures of spleen and liver occur when the lung bacterial burden exceeds 104 bacteria per gram of lung tissue. Successful host defense against the systemic spread of infection requires a functioning reticuloendothelial system, opsonins, and adequate numbers of neutrophils. Patients who present with overwhelming sepsis due to pneumonia generally lack one or more of these defenses. Such patients complain of a brief prodromal upper respiratory illness followed by fever, a single shaking chill, pleuritic chest pain, and a cough productive of purulent or "rusty" sputum. Physical examination reveals signs of consolidation, which are readily confirmed by chest radiography. At the other extreme might be an elderly, confused patient who presents with only deterioration in mental function. The physician should explore the presence of risk factors, including chronic illnesses, recent acute illnesses, illness in family members, use of alcohol or other drugs, and possible exposures to infectious agents. A thorough physical examination, posteroanterior and lateral chest radiographs, and blood leukocyte count with differential cell count should be performed.

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Myocardial perfusion scintigraphy provides complementary data for assessing ischemic burden (see Chapter 44) pulse pressure pv loop cheap triamterene master card. Left ventricular function can be assessed by contrast ventriculography heart attack grill calories order triamterene overnight delivery, radionuclide ventriculography, or echocardiography. Chronic ischemic heart disease with transient supply/demand imbalance-thrombosis, spasm, physical stress 2. Disruption of mitral apparatus (1) Papillary muscle (2) Chordae tendineae (3) Leaflet c. Electrical Instability Related to Neurohumoral and Central Nervous System Influences A. In Braunwald E (ed): Heart Disease: A Textbook of Cardiovascular Medicine, 5th ed. The most important factor that determines the outcome of cardiac arrest is the time to defibrillation. As many as one third of deaths are attributable to heart failure or cardiogenic shock; 90% who will recover from coma with meaningful function do so by the third hospital day. Results are similarly persuasive in patients with heart failure who can tolerate beta-blockers. However, amiodarone does not appear to improve overall mortality, and approximately 5% of patients discontinue the drug because of pulmonary toxicity. It does not, however, confer benefit in patients with congestive heart failure due to ischemic cardiomyopathy. Because the likelihood of antiarrhythmic suppressibility is low and its long-term effectiveness poor (50% recurrence at 2 years), antiarrhythmic therapy is seldom considered a reliable means of secondary prevention. Pacemaker batteries, which are lithium iodide cells that typically have a life span of 7 to 8 years, now often weigh less than 30 g. Programmability of many different variables has become standard, as has the ability of the pacemaker to provide diagnostic and telemetric data. Pacemaker leads usually are bipolar, with the distal electrode serving as the cathode. Unipolar leads are less commonly used because of the potential for pacing chest wall muscles and for inhibition of pacing by skeletal muscle myopotentials. The leads are inserted into the heart either percutaneously through a subclavian vein or by cutdown into a cephalic vein. Atrial leads usually are positioned in the right atrial appendage, and ventricular leads are placed in the right ventricular apex. Fixation to the myocardium is achieved either passively with tines or actively with a screw mechanism. Newer electrode designs, such as porous carbon or steroid-eluting electrodes, have resulted in lower acute and chronic pacing thresholds. The mode of pacing is described in shorthand fashion by a three- to five-letter code. The first letter designates the chamber being paced (A for atrium, V for ventricle, D for dual-chamber); the second letter designates the chamber being sensed (A, V, D, or O for no sensing); the third letter designates whether the pacemaker functions in an inhibited (I) or tracking mode (T), in both modes (D), or asynchronously (O); and the fourth letter indicates whether the pacemaker is capable of rate-modulation independent of atrial activity. An additional fifth letter may be used to designate the capability for antitachycardia pacing (P), delivery of shocks (S), or both (D). B, At the onset of an episode of atrial fibrillation, there is tracking of the atrium that results in ventricular pacing at 140 beats per minute, which is the upper rate limit of the pacemaker. In general, pacemakers are implanted either to alleviate symptoms caused by bradycardia or to prevent severe symptoms in patients who are likely to develop symptomatic bradycardia. The most common bradycardia-induced symptoms are dizziness or lightheadedness, syncope or near-syncope, exercise intolerance, or symptoms of heart failure. Because these symptoms are non-specific, documentation of an association between symptoms and bradycardia should be obtained before pacemaker implantation. Third-degree atrioventricular block with pauses 3 seconds or with an escape rate <40 beats per minute in awake patients C.

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