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By O. Marlo. LeTourneau University.

Unconditional positive regard and acceptance promote trust and increase client’s feelings of self-worth buy 60 pills speman with amex. Help client identify positive aspects of self and to develop plans for changing the characteristics he or she views as neg- ative buy speman 60 pills. Individuals with low self-esteem often have difficulty recognizing their positive attributes purchase 60 pills speman with amex. They may also lack problem-solving ability and require assistance to formulate a plan for implementing the desired changes. Encourage and support client in confronting the fear of failure by attending therapy activities and undertaking new tasks. Offer recognition of successful endeavors and positive reinforcement for attempts made. Enforce limit-setting in matter-of-fact manner, imposing previously established consequences for violations. Negative feedback can be ex- tremely threatening to a person with low self-esteem, pos- sibly aggravating the problem. Encourage independence in the performance of personal re- sponsibilities, as well as in decision-making related to own self-care. Help client increase level of self-awareness through criti- cal examination of feelings, attitudes, and behaviors. Help him or her to understand that it is perfectly acceptable for one’s attitudes and behaviors to differ from those of others as long as they do not become intrusive. As the client achieves self-awareness and self-acceptance, the need for judging the behavior of others will diminish. Client demonstrates ability to manage own self-care, make independent decisions, and use problem-solving skills. Client sets goals that are realistic and works to achieve those goals without evidence of fear of failure. Client will be able to interact with others on a one-to-one basis with no indication of discomfort. Client will voluntarily spend time with others in group ac- tivities demonstrating acceptable, age-appropriate behavior. Be honest; keep all promises; convey acceptance of person, separate from unac- ceptable behaviors (“It is not you, but your behavior, that is unacceptable. Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. Confront client and withdraw attention when interactions with others are manipulative or exploitative. Act as role model for client through appropriate interactions with him or her, other clients, and staff members. It is through these group interactions, with positive and negative feedback from his or her peers, that client will learn socially accept- able behavior. Client has formed and satisfactorily maintained one inter- personal relationship with another client. Client verbalizes reasons for inability to form close interper- sonal relationships with others in the past. Possible Etiologies (“related to”) Move from one environment to another [Losses involved with decision to move] Feelings of powerlessness Lack of adequate support system [Little or no preparation for the impending move] Impaired psychosocial health [status] Decreased [physical] health status Defining Characteristics (“evidenced by”) Anxiety Depression Loneliness Verbalizes unwillingness to move Sleep disturbance Increased physical symptoms Dependency Insecurity Withdrawal Anger; fear Goals/Objectives Short-term Goal Client will verbalize at least one positive aspect regarding re- location to new environment within (realistic time period). Encourage individual to discuss feelings (concerns, fears, anger) regarding relocation. Exploration of feelings with a trusted individual may help the individual perceive the situation more realistically and come to terms with the inevitable change. Ensure that the individual is involved in decision-making and problem-solving regarding the move. Taking responsibility for making choices regarding the relo- cation will increase feelings of control and decrease feelings of powerlessness. Anxiety associated with the opposed relocation may inter- fere with the individual’s ability to recognize anything posi- tive about it. Help the individual identify resources within the new com- munity from which assistance with various types of services may be obtained. Because of anxiety and depression, the in- dividual may not be able to identify these resources alone. Identify groups within the community that specialize in helping individuals adapt to relocation. Examples include Newcomers’ Club, Welcome Wagon International, senior citizens’ groups, and school and church organizations. These groups offer support from individuals who may have en- countered similar experiences. Adaptation may be enhanced by the reassurance, encouragement, and support of peers who exhibit positive adaptation to relocation stress. An individual who is experiencing com- plicated grieving over loss of previous residence may require therapy to achieve resolution of the problem. It may be that other unresolved issues are interfering with successful ad- aptation to the relocation. The individual no longer exhibits signs of anxiety, depres- sion, or somatic symptoms. The individual willingly participates in social and vocational activities within his or her new environment. Many of the behaviors have adverse or even destruc- tive consequences for the individuals affected, and seldom do these individuals know why they do what they do or why it is pleasurable. The individual is unable to resist an impulse, drive, or temptation to act in a way that is harmful to the person or others. The individual experiences an increasing sense of tension or arousal before committing the act and pleasure, gratification, or relief at the time of committing the act. Some clients report changes in sensorium, such as confusion during an episode or amnesia for events that occurred during an episode. Symptoms usu- ally appear suddenly without apparent provocation and ter- minate abruptly, lasting only minutes to a few hours, followed by feelings of genuine remorse and self-reproach about the behavior. Often the stolen items (for which the individual usually has enough money to pay) are given away, discarded, returned, or kept and hidden. The individual with kleptomania steals purely for the sake of stealing and for the sense of relief and gratification that follows an episode. The preoccupation with gambling, and the impulse to gamble, in- tensifies when the individual is under stress. Many pathological gamblers exhibit characteristics associated with narcissism and grandiosity and often have difficulties with intimacy, empathy, and trust. Motivation for the behavior is self- gratification, and even though some individuals with pyromania may take precautions to avoid apprehension, many are totally indifferent to the consequences of their behavior.

When you feel them getting in your way 60pills speman with mastercard, fight back and argue against them using the Self-Sabotage Diary presented in the next section order genuine speman online. Stopping self-sabotage Throughout this book order speman 60 pills with visa, we ask you to write out your thoughts, feelings, beliefs, and life events. That’s because writing is an invaluable tool for battling problematic emotions, sorting out issues, achieving important insight, and solving problems. In this section, we invite you to track and record your inevitable acts and thoughts of self-sabotage in a diary. None of her col- leagues are aware that she suffers from considerable anxiety and depression. She worries that others will discover that she doesn’t deserve her professional success. She realizes that, for the last decade, she has neglected friends and family in pursuit of success. Now, she feels lonely and despondent; success hasn’t brought her the happiness she expected, and her anxiety and depression have only increased. Molly sees a psychologist, and together they identify her self-sabotaging tendencies. She keeps a diary in which she records her acts of self-sabotage and responses to them. Part I: Analyzing Angst and Preparing a Plan 40 Worksheet 3-13 Molly’s Self-Sabotage Diary Day Self-Sabotage Response to Self-Sabotage Sunday It was raining today, so I Obviously, not a helpful thing to do. Everyone does the gym like my that sometimes, but I want to try and psychologist suggested. Monday I scraped my car on a I guess dumping on myself isn’t pole in the parking lot. I need to accept was so upset — it ruined my flaws and imperfections if I’m my day. Tuesday I was supposed to Wow, I guess that’s just another complete an exercise excuse. Thursday My assignment today When I try to do something difficult, I was to ask a friend out become so anxious I can’t think for coffee. I need to slow down, give it started thinking about some time, and relax — then go calling, I felt confused back at it. In the middle column of Worksheet 3-14, write down any thought or action from that day that you feel limits your efforts at overcoming your anxiety or depression. In the right-hand column, write down how helpful (if at all) you think the self- sabotage may have been as well as any arguments you can find against it. Maintain this diary for at least one week; keep it up much longer if you continue to see lots of self-sabotage. Criticizing yourself for the sabotage you notice yourself committing only leads to more sab- otage. Chapter 3: Overcoming Obstacles to Change 41 Worksheet 3-14 My Self-Sabotage Diary Day Self-Sabotage Response to Self-Sabotage Sunday Monday Tuesday Wednesday Thursday Friday Saturday You can download extra copies of this form at www. Rewriting your self-sabotaging scripts Our minds create stories — about ourselves, our lives, and our worlds. For example, you may have a long- running play in your mind that has you as its central character. Try creating a new story about you and your life that allows you to ultimately succeed. But remember, in addition to success, the new story needs to contain realistic struggle and difficulty. Part I: Analyzing Angst and Preparing a Plan 42 Worksheet 3-15 Molly’s Current Life-Script I might have money and a little prestige, but I deserve none of it. Although it takes her a while to start believing it, gradually she begins to see her life in a new light. Worksheet 3-16 Molly’s New Life-Script I have a good job, and I worked very hard to get it. Besides, I’m capable of learning new behaviors, and I’m working on my irritability. This will be a struggle for me, but I see myself cutting back a little on my work and making new friends. In Worksheet 3-17, write your current life-script, including how you see yourself today and in the future. Be sure to include your thoughts on hope, change, possibilities, as well as struggle. Worksheet 3-17 My Current Life-Script Worksheet 3-18 My New Life-Script Chapter 4 Minding Your Moods In This Chapter Listening to your body Figuring out your feelings Connecting events and feelings Tracking thoughts, events, and feelings ou can’t overcome anxiety and depression by running on autopilot. In this chapter, we provide instructions for observing the relationships among your feelings, your thoughts, and the happenings in your life. This information helps you become more aware of the physical components of depression and anxiety. Some people aren’t very good at identifying their feelings, so we help you by providing a list of feeling words. Finally, we show you how to become aware of how thoughts link up with feelings, events, and bodily sensations. Deciphering Body Signals Your heart may race or your hands may sweat when you feel anxious. Monitoring your bodily sensations gives you an early warning that a storm of emotional distress is brewing. Tyler begins to understand his body’s signals by monitoring phys- ical sensations on a daily basis. He jots down any time that he feels something uncomfortable in his body and includes information about what was going on at the time. Worksheet 4-1 Tyler’s Body Responses Tracking Sheet Body Response How did my body feel? Breathing/ I could tell my Tuesday evening while talking with Increased heart breathing was rapid my ex-wife. Headaches None this week Posture I noticed I’m walking I notice this mostly after lunch on around stooped Thursday and Friday. Other: Dizziness, Spacey and Saturday morning before paying sweating, lightness, light-headed bills. Worksheet 4-2 Tyler’s Reflections I noticed that my body seems to react to what’s going on in my life. These sensations aren’t very pleasant, and maybe the doc is right that I’m depressed. I realize that talking with my ex-wife and my boss both make me feel pretty weird and stressed. Now that I know all this, I really want to do something to get myself to a better place.

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People with bipolar disorder should exercise appropriate caution order 60 pills speman visa, including consideration of using a mood stabilizer while using inositol order 60pills speman amex. It is promising for bipolar disorder generic 60 pills speman mastercard, anxiety, obsession, compulsion, eating disorders, hostility, sadness, tension and fatigue. It is often sold as a dietary supplement in combination with other nutraceuticals. Inositol is present in a variety of foods, particularly beans, grains, nuts, and many fruits. Inositol is classified as a member of the vitamin B family, specifically vitamin B8. The depression study is the most robust, but the panic disorder results are also significant. The significance of this result is limited by the size of the study (27 subjects) and the four- 7 week duration. Attacks fell from ten to six on placebo and from ten to three and a half on inositol. Inositol outperformed placebo in three of the five controlled studies, but all sample sizes were small, and statistical significance was reached in only one study. The obsessive-compulsive study used a crossover design that makes it hard to evaluate, since there is a delay in the effects of inositol supplementation. The obsessive-compulsive disorder and eating disorder studies all used a crossover design that makes them hard to evaluate, since there is a delay in the effects of inositol supplementation. Eleven volunteers were given inositol or placebo in a double-blind, randomized, crossover design. Inositol was found to reduce depression, hostility, tension and fatigue compared with placebo over six hours. Side effects reported in the reviewed clinical trials, at doses of inositol ranging from 6 to 25 g per day, include mild increases in plasma glucose, flatus, nausea, sleepiness, insomnia, dizziness and headache. However, there have been case reports of inositol-induced mania in bipolar depressed patients. People with bipolar disorder should exercise appropriate caution, including consideration of a mood stabilizer while using inositol. There are no studies or cautions concerning use of inositol in breast-feeding women or in children, but Lake and Spiegel caution that inositol may cause uterine contractions, ruling out its use in pregnant women. Kava is generally safe for short-term use but can in rare cases cause catastrophic damage to the liver. Thus, its use is very controversial, and the sources are split four to three on whether it should ever be recommended. Alcohol, other sedatives, muscle relaxants, dopamine, haloperidol, acetaminophen, and benzodiazepines. Taking kava with alcohol, other sedatives, or muscle relaxants can result in additive effects up to and including coma. Alcohol or acetaminophen (Tylenol), which may injure the liver, should never be used with kava. Kava may interfere with the effects of dopamine and drugs that are similar to dopamine and may worsen the neurological side effects of drugs that block dopamine, such as haloperidol (Haldol). Kava may also cause anesthesia to last longer and use should be carefully coordinated with the prescribing physician or anesthesiologist. Lake and Spiegel, Mischoulon and Rosenbaum, the Natural Standard, and Weil counsel that kava should be avoided in individuals with a history of liver disease or alcohol use, and in those who are taking concurrent medications with potential liver toxicity. Mischoulon and Rosenbaum conclude: “Kava should be prescribed and used with great caution. More research pinpointing risk factors could modify these recommendations, since liver toxicity appears to be extremely rare, and bad experience with other anxiolytics could prompt a trial of kava if the risk factors appear to be low, with proper medical supervision. Pregnancy, lactation or child use would appear not to impose a separate challenge. The risk of liver damage is substantial and may be irreversible, even though it appears to be rare. Kava, Piper methysticum, is native to the islands of the South Pacific and is a member of the pepper family. The root and rhizome (underground stem) of kava are used to prepare beverages, extracts, capsules, tablets, and topical solutions. Kava has been used to help people fall asleep and fight fatigue, as well as to treat asthma and urinary tract infections. Six sources confirm the beneficial uses of kava as a mild intoxicant and analgesic, but Brown et al. Kava was shown in “more than a dozen” passive placebo studies to be effective with good tolerability for treatment of “generalized anxiety, tension, agitation, agoraphobia, specific [other] phobias, generalized anxiety disorder, adjustment 3 disorder, and insomnia. Anxiety, insomnia and panic disorders would all be studied as promising practices if kava were not implicated in a few catastrophic cases of liver toxicity. Most of the studies are limited by small samples, short duration of treatment, and a lack of rigorous diagnostic criteria. Moreover, no published studies have yet tested kava’s efficacy for panic disorders. Taking kava with alcohol, other sedatives, or muscle relaxants can result in additive effects up to and including coma. Alcohol or acetaminophen (Tylenol), which may injure the liver, are strongly contraindicated for use with kava. Kava may interfere with the effects of dopamine and drugs that are similar to dopamine and may worsen the neurological side effects of drugs that block dopamine such as haloperidol (Haldol). Kava may also cause anesthesia to last longer and use should be carefully coordinated with the prescribing physician or anesthesiologist. Laboratory tests suggest a danger of bleeding, but this has not yet been found in human subjects. Still, Natural Standard cautions against using anticoagulants or antiplatelets with kava. Chronic use of kava up to 100 times the therapeutic dose results in an ichthyosiform eruption (yellowed skin) known as kava dermopathy, which is often accompanied by eye irritation. Less common side effects include restlessness, drowsiness, lack of energy, and tremor. In four cases, kava was associated with dyskinesias or worsening Parkinsonian symptoms. According to Mischoulon and Rosenbaum, the more serious toxic reactions have been associated with high doses (over 300 g. If any abnormalities are found, then kava should be discontinued immediately and liver enzymes should be retested in about two weeks, by which time they should return to normal. Less common side effects include restlessness, drowsiness, lack of energy, and tremor. In four cases, kava was associated with dyskinesias or worsening Parkinsonian symptoms. Mischoulon and Rosenbaum report that there is no consensus on the optimal daily dose, and lack of a standardized extract makes comparison impossible. Weil recommends 100 to 200 mg two or three times a day, as needed (300-600 mg per day).

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Principles of acupuncture In addition to the classic principles of Chinese medicine outlined above generic 60pills speman with mastercard, there is one key aspect of practice still to consider cheap speman 60 pills online. This is the theory of acupuncture points that are stimulated usually by the superficial insertion of 136 | Traditional medicine needles into the skin buy 60pills speman with mastercard. Other methods of stimulation include the application of pressure and the passing of a weak electrical current (see below). A further 1000 extra points and special use points may also be identi- fied on the hands, ears and scalp. It is not known how these points were discov- ered – probably it was by observation over hundreds if not thousands of years – nor is it known exactly how many points were first identified. Acupoints cannot be identified by their appearance and no consistent features of their anatomy have been found that distinguish them from other tissues. Practice of acupuncture There is archaeological evidence that shows that the earliest acupuncture needles date back to the Stone Age, when instruments called bian were thought to have been used in China. Needles were subsequently made of many different metals: gold, silver, copper, etc. Modern acupuncturists use solid sterile disposable needles of narrow bore, about 3 cm long (although longer needles may be used at different sites). As many as 15–20 needles may be inserted superficially at the appro- priate point(s). The practitioner then gently introduces the needles a little more deeply into the muscle, rotating them between finger and thumb. Qi and blood flow throughout the meridians and this is where manipulation of the needle is critical in properly moving this flow. The arrival of qi called deqi is signified by a dull ache or tingling sensation and slight inflammation. Some practitioners may use electrical stimulation, connecting the needles to a small piece of equipment powered by batteries. Needles are left in place for up to 20 min: the patient is invited to lie back and relax. Occasionally a needle may be left in place for several days, normally situated in the ear; these so-called indwelling needles should not be used in patients with heart valve disease or who are immunocompromised. Acupuncture point selection may vary at each treatment, depending on the patient’s response. Positive trials have been criticised because of inadequate blinding, and negative trials because the intervention was not administered by properly trained practitioners or control interventions may have had analgesic effects. The panel said that acupuncture was ‘probably’ also effective in the control of nausea in early pregnancy. The British Medical Association reached a similar conclusion in their report on acupuncture. Even if they can, there is evidence that acupuncture at non-classic points, the so-called trigger points, may have analgesic effects. When the needle was ‘inserted into the skin’ participants saw and felt the needle penetration. Both sham and genuine needles were held in place with a plastic ring and surgical tape so the procedure looked identical. After the run-in period, the acupuncturists followed identical protocols for administering real or continued sham acupuncture. Participants in the pill group were instructed to take one capsule each evening to minimise daytime drowsiness. The placebo capsule contained cornstarch, and the amitripty- line capsule contained cornstarch plus 25 mg amitriptyline. The primary outcome was self-reported intensity of pain in the most severely affected arm during the preceding week measured on a 10-point numerical rating scale ranging from no pain (1) to the most severe pain imaginable (10). The sham device had greater effects than the placebo pill on self-reported pain and severity of symptoms over the entire course of treatment, but not during the 2-week placebo run-in. It was concluded that placebo effects seem to depend on the behaviours embedded in medical rituals. Subsequently Traditional Chinese medicine | 139 they were asked to rate how much their clinical condition had improved or worsened over a specified period of time. Safety A study that investigated the incidence and severity of acupuncture reactions has been carried out in Japan. The most common systemic reactions were tiredness and drowsiness (11%), aggravation of symptoms (2. The authors concluded that there were some adverse reactions associated with acupuncture, but that they were generally transient and mild. It has been suggested that a fall in blood sugar could be involved46 and this might be a problem for patients with diabetes using insulin or oral hyperglycaemic drugs. Advice from a pharmacist on the rescheduling of administration would be appropriate. The adverse effects that may be attributed to acupuncture have also been catalogued. Infection during needling Hepatitis Re-using needles with inadequate sterilisation has been the source of hepa- titis in a number of patients, although the literature refers mainly, but not exclusively, to the 1980s and earlier. The report details a large outbreak of rapidly growing mycobacterial infection among patients who received acupuncture at a single clinic and concludes that physicians should suspect mycobacterial infections in patients with persistent cutaneous infections after acupuncture, and infection control education should be emphasised for acupuncture practitioners. It is no longer considered appropriate to use auto- claves to sterilise acupuncture needles due to the validation problems asso- ciated with bench-top autoclaves. Trauma A number of cases of damage due to acupuncture needling, including pneumothorax, cardiac tamponade and spinal cord damage, have been reviewed. Other adverse effects Other possible adverse reactions to acupuncture include cardiac arrhyth- mias,58 the triggering of asthma59 and the exacerbation of symptoms. Contraindications Acupuncture is contraindicated or must be used with extreme care in patients who: • are unwilling to be needled; they should not be pressurised to undergo treatment • have a tendency to bleed excessively • have a pacemaker; it might be affected by the electrical stimulation of acupuncture needles. Many dispute the existence of meridians or acupuncture points,69 preferring to link their practice to trigger points instead. They may remain sensitive for many years, causing pain that may be experienced some distance away from the trigger point. Interestingly, the trigger points and pain referral sites appear to be similar in all people and, furthermore, many of the trigger points are identical to acupuncture points. It is suggested that acupuncture works by stimulating the nervous system, leading to the release of opioid peptides (endorphins), compounds that are closely involved with the mechanisms by which the body controls its perception of pain. Thus, acupuncture is used in the treatment of intractable pain without the attendant traditional Chinese theory. This variant, which involves very brief needling lasting no more than a few seconds at trigger points, has been termed ‘minimal acupunc- ture’.

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This is seldom There is renewed interest in combined therapy with important in practice cheap 60 pills speman free shipping. Celiprolol has hydralazine reduced afterload and the nitrate reduced pre- additional agonist activity at β2-receptors buy 60pills speman with amex. As mentioned above buy 60pills speman fast delivery, this improved survival in one ran- endothelium-derived nitric oxide, as well as being a highly domized controlled trial, but performed less well overall in a selective β1-adrenoceptor blocker. There is, however, a in African-Americans which confirmed the efficacy of rationale for their use in terms of antagonizing counter- hydralazine–nitrate treatment. It is now often used for patients regulatory sympathetic activation and several randomized of African origin. Hopefully, genetic testing will further improve controlled trials have demonstrated improved survival when the targeting of appropriate therapy (‘personalized medicine’) a β-adrenoceptor antagonist is added to other drugs, includ- in future. Bisoprolol and metoprolol are cardioselective β1 antagonists, whereas carvedilol is non-selective and has addi- For more information on the use of digoxin, refer to Chapter 32. Carvedilol may be more effec- William Withering described an extract of foxglove as a tive than bisoprolol in heart failure, but is less well tolerated ‘cure’ for ‘dropsy’ (congestive cardiac failure) in 1785. Heart failure • Intolerance Fatigue and cold extremities are common and patients in sinus rhythm who remain symptomatic despite dose related. Erectile dysfunction occurs, but is less optimal treatment with life-prolonging medications also ben- common than with thiazide diuretics. It • Airways obstruction β-adrenoceptor antagonists is usually given orally, but can be given i. Since the half-life is approximately 30–48 hours, pre-existing obstructive airways disease, especially repeated administration of a once-daily maintenance dose results asthma. The dose • Peripheral vascular disease and vasospasm β-adrenoceptor may be adjusted based on plasma concentration determinations antagonists worsen claudication in patients with once steady state has been reached (Chapter 8). Such determi- symptomatic atheromatous peripheral vascular disease nations are also useful if toxicity is suspected (e. This causes accumulation of intracellular Na and idiopathic cardiomyopathy are especially important. Clinical progress is assessed by measuring heart rate (at optimal filling; rapid atrial fibrillation is slowed by the apex): apical rates of 70–80 per minute can be achieved at digoxin). Unfortunately, since vagal activity is suppressed during Treatment of chronic heart failure exercise (when heart rate is controlled by sympathetic acti- • Dietary salt should be restricted. The proportion – hydralazine plus an organic nitrate in African- eliminated by these non-renal clearance mechanisms increases American patients. Blood for digoxin concentration determination should be • Other positive inotropes (e. The usual therapeutic range is 1–2ng/mL, although toxicity can occur at concentrations of Case history less than 1. A 62-year-old physician has developed symptoms of chronic congestive cardiac failure in the setting of treated essential Drug interactions hypertension. He had had an angioplasty to an isolated Digoxin has a steep dose–response curve and a narrow thera- atheromatous lesion in the left anterior descending coron- peutic range, and clinically important interactions are com- ary artery two years previously, since when he had not had angina. Pharmacokinetic interactions droflumethiazide for his hypertension and takes meclofena- with digoxin include combined pharmacokinetic effects involv- mate regularly to prevent recurrences of his gout. He ing displacement from tissue-binding sites and reduced renal disregarded his cardiologist’s advice to take aspirin because elimination (e. On examination, he has a regular pulse of 88 beats/minute, blood pressure of 160/98 Pharmacodynamic interactions are also important. In mmHg, a 4–5cm raised jugular venous pressure, mild pretib- particular, drugs that cause hypokalaemia (e. Routine biochemistry tests are β-agonists, glucocorticoids) predispose to digoxin toxicity by unremarkable except for a serum urate level of 0. These (a) Digitalization increase cardiac output and may bring some symptomatic (b) Intravenous furosemide benefit, but they worsen survival. New England Journal of Medicine 1998; 339: (e) Hold the bendroflumethiazide temporarily and start 387–95. Managing hyperkalemia caused by inhibitors of the Comment renin–angiotensin–aldosterone system. New England Journal of The aetiology of the heart failure in this case is uncertain. New England Journal of Medicine corrected, this could improve the blood pressure, dyslipi- 1999; 341: 577–85. Mechanisms of disease – aldosterone in congestive heart done immediately this is likely to precipitate an acute failure. Treatment with a fibrate would be useful for this pattern of dyslipi- daemia, but only after establishing that it was not alcohol- induced. If patho- • Second degree: There are two types, namely Mobitz I, in logical, treatment is directed at the underlying cause. This is common in athletes, in young The importance of first- and second-degree block is that healthy individuals especially if they are physically fit, and either may presage complete (third-degree) heart block. Severe cerebral underperfusion with if it causes or threatens haemodynamic compromise. Ventricular filling is consequently inad- to failure of conduction in one or other bundle and ‘aberrant’ equate and cardiac output falls. The method of treating atrial conduction with broad complexes because of the rate-dependent fibrillation is either to convert it to sinus rhythm, or to slow bundle-branch block. In an acutely ill patient, consider the possible immediate cause of the rhythm disturbance. The cardiogram usually shows a example from a distended bladder in a stuporose patient). Multifocal ectopics does not necessarily improve the prognosis – (ectopic beats of varying morphology, arising from more anti-dysrhythmic drugs can themselves cause than one focus) are likely to be pathological. Always think carefully before dysrhythmic drug to use in a particular patient remains largely prescribing one. If the patient is acutely ill on account of a cardiac some of the most clinically effective drugs used to treat certain dysrhythmia, the most appropriate treatment is almost dysrhythmias, some of which are listed in Table 32. Remember that several anti-dysrhythmic drugs can The European Resuscitation Council provides guidelines for themselves cause dysrhythmias and shorten life. Largely Diltiazem voltage-dependent Ca2 conductance superseded by adenosine for treating acute attacks. Digoxin (rapid atrial fibrillation) Shout for help Atropine (symptomatic sinus bradycardia) Adenosine (supraventricular tachycardia) Open airway Adrenaline (cardiac arrest) Calcium chloride (ventricular tachycardia caused by Not breathing normally? When a person is found to have collapsed, make a quick check to ensure that no live power lines are in the immediate vicin- Precordial thump if ity. Otherwise roll them on their back (on a firm surface if possible) and loosen the clothing around the throat. Tilt the head and lift the chin, and sweep an index finger 2 breaths through the mouth to clear any obstruction (e. If the patient is not breathing spontaneously, start mouth- Continue until breathing and pulse restored of emergency services arrive to-mouth (or, if available, mouth-to-mask) ventilation. Hypovolaemia Cardiac tamponade (Redrawn with permission from the Hypo/hyperkalaemia/other metabolic disturbance Toxins European Resuscitation Council Hypothermia Thrombosis (coronary or pulmonary) Guidelines, 2005.

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