Words Unspoken...

Guys..I love all of you...It has been such a great experience knowing each and every one of you personally...I was seriously close to tears myself watching the video presentation this afternoon....I just cannot describe how grateful I am to be with all of you...

As a member of this group...I really marvel at the way everyone participates for practises...contributing one way or the other in making learning such a fun and great experience...We took turns to lead the learning sessions..That I felt was just absolutely brilliant...

When I first stepped foot into LS 8..i remembered that I felt inferior...not because of the depth of knowledge...but because..we practically did not really know one another prior to this..However..as the days went by..I felt more and more comfortable with all of you...my dear family members..Thanks for giving me the support I needed to survive this semester..Without all of you...the outlook of this sem would be utterly different..

This time..I really hope that we don't have to change PCL groups....I have developed this attachemnt with each and everyone of you in a special way...that only us...our Group H family would be able to comprehend..This whole post would be never ending if I were to continue...

Kudos to our group leader Huey Ting for the immense contribution in leading our group to scale greater heights...I totally believe that you somehow influenced us to buck up and changed the way we thought about studying...

From the bottom of my heart, I would like to say that I will forever love this group....I will never forget the memories we shared as one....we have really became so close till I didnt mind taking my pants off in front of all of you...XD..

Right now...I have a wish...

A wish to relive everything we experienced ....I feel like breaking down right now...
My dearest family....I love all of you....Lets please please please hang out as a group occasionally okay...I..........heres a picture of all of us...see how happy we look ...

My Family...I love you




Sincerely...
TJ...

Effect of folic acid on unborn babies

The strongest argument for pregnant women needing folic acid supplements comes from the tie between adequate folate intake and reduced risk of having a baby with neural tube defect, cardiovascular and urinary tract defects.

Neural tube defects are a category of congenital birth defects affecting the brain and spinal cord, the most common being spina bifida and anencephaly.

Neural tube defects can be severely disabling or even fatal for a developing baby. There is a large body of research showing that moms with adequate intake of folic acid before pregnancy have a 50% to 70% lower risk of having a baby with neural tube defects.

Folic acid remains an important nutrient for optimal cell division and growth, making the reasons to take it during pregnancy all the more obvious. In addition, there has been some evidence that folic acid might reduce the risk of other birth defects as well, and that moms with low folic acid might also have a higher risk of miscarriage, placental abruption, and preterm delivery.

however some reports claim that excess folic acid supplementation might be associated with a slightly increased risk of wheezing and other respiratory problems in the baby.

What Anencephaly Means:

In anencephaly, crucial parts of the baby's brain and skull fail to form. Without these brain areas, the baby can never gain consciousness or carry out the physical functions of life. Because the skull is also affected by the disorder, a baby with anencephaly is usually physically deformed and parts of the brain may be exposed. Babies affected by anencephaly frequently are stillborn or die at birth. Even if born alive, babies with anenecephaly always die within a few days of birth. There is no treatment that can change the prognosis.

reference: http://miscarriage.about.com/od/lifestylefactors/f/folic-acid-important.htm

Effects of spina bifida on sexual function and bladder/bowel control

Sex and Spina Bifida

Many people with spina bifida get married, have great sex lives and have a family of their own.

The major obstacles to a happy sex life are:

- lack of confidence and self esteem
- not meeting people
- no car
- not seeing ‘sex’ as being possible
- incontinence
- gaining independence from your parents.


-The nerve damage in spina bifida that affects urinary and bowel functions may also affect sexual functioning.

-Some people with spina bifida have no feeling in the lower parts of their bodies.

-Males may have normal sexual function, but this is commonly affected to some degree. Satisfactory erections are often possible, but there is no ejaculation. Other types of sexual dysfunction are also possible.

-Females are generally less affected in their sexual functioning - some might not be able to produce their own lubrication.

-In males and females, altered genital sensation can affect - but does not prevent - arousal patterns and sexual functions.

-Orthopaedic problems, for example with lower limbs, can affect the ability to use some, but not all, sexual positions.

-Most males and females with spina bifida are fertile. Many of the issues surrounding conception in spina bifida are due to mechanical and anatomical difficulties in conceiving rather than a lack of fertility. There is access to assisted reproductive techniques. Consult your clinic about these.

-Since people with spina bifida often have latex allergies, you and your partner may need an alternative form of contraception to condoms. See your doctor for advice about forms of contraception.

-Some women with spina bifida have to deliver through caesarean section.


Spina bifida and bowel/bladder control
Control over urination requires functional nerves in the lower spine (sacral spinal cord). These nerves sense bladder fullness and transmit this message to the brain. In an older child or adult who has normal urinary control, the brain is able to inhibit the bladder from contracting until it is socially acceptable.

-In many children with spina bifida the nerves to the bladder that control this reflex voiding are damaged. Only about 5 to 10% of children with spina bifida have normal urinary control and are able to toilet train and void spontaneously.

-This means that the majority of children with spina bifida are at risk for poor urinary control and incontinence as well as damage to the kidneys and bladder.

-Lack of bladder control present two immediate dangers - infection and back pressure on the kidneys, without proper management, can lead to renal problems.

-Urodynamic studies or cystometrograms are done in children with spina bifida to evaluate bladder function.

-These studies involve placing a catheter into the bladder and filling the bladder with water. While this is done, the pressure in the bladder is continuously monitored.
-Normally, when the bladder pressure reaches a certain level, urine begins to leak around the catheter.
-Some children with spina bifida, however, tolerate very high pressures in their bladder without any urine leakage, with the result that urine can reflux up the ureters and damage the kidneys. These children are often managed with intermittent catheterization, antibiotics for infection, and occasionally other medications and/or surgery.

VOTE FOR HUEY TING

HEY YOU!

If you didn't know, Huey Ting will be running for Treasurer for MUMedS.
SO PLEASE VOTE FOR HER! She needs your votes. Especially you Group H members!

Thank you for your interest in voting for the MUMedS committee of 2010!

Voting period will begin at 5.00 pm on the 20th of October 2009, and will end at 5.00 pm on the 23rd of October 2009. Both clinical and pre-clinical years will be voting online for both sides.

Voting will be done via www.ballotbin.com. All voters will be issued a secure, personalised email code so that they are only allowed to vote once. This email will be send out at 5.00 pm on the 20th of October.

The speeches and photos of nominees will be uploaded onto Blackboard for all members to see by 5.00 pm on the 20th of October.

URGENT: Please check your Monash email after 5.00 pm on the 20th of October for your secure, personalised email code for ballotbin.com. If you did not receive any such code, kindly write to mumeds@gmail.com requesting for one with your CORRECT Monash email. After we have looked through our member list, you will be resent a new code to vote with.

PLEASE REMEMBER TO VOTE! WE OWE HUEY TING THAT MUCH FOR BEING OUR FEARLESS LEADER!

Complications of Spina Bifida

• Ranges from minor physical problems to severe physical & mental disabilities.
• Intelligence level is usually normal.
• Generally all nerves below the malformation are affected.

Severity is determined by

• Size & location of malformation
• Whether or not the skin covers it
• Whether or not spinal nerves protrude from it
• Which spinal nerves are involved

Complications

• Loss of sensation (esp. In lower limbs)
• Paralysis (esp. In lower limbs)
• Loss of normal bowel & bladder control
• Urinary tract infection
• Orthopedic problems (scoliosis, kyphosis, & clubfoot)
• Lipomeningocele
• Spinal cord tethering
• Chiari II malformation
• Hydrocephalus
• Meningitis
• Learning disabilities
• Latex allergies
• Gastrointestinal conditions
• Depression
• Obesity

Bladder complications

• Early catheterization to preserve kidney & bladder functions
• Further complicated by
  
  • Bladder stones
  • Bladder ruptures
  • Bladder tumors

Lipomeningocele

• Congenital lesion that is associated with spina biida
• Associated with abnormal fat accumulation that starts below the level of the skin & extends through the bony opening to the spinal cord
• Females are 50% more likely to develop lipomeningocele
• Damage is due to
  
  • Tethering of spinal cord
  • Compression due to progressive deposition of fat
• Signs & Symptoms
  
  • Obvious soft tissue swelling over the spine in the lumbosacral region in more than 90% cases
  • Lesion is covered by skin & painless
  • Weakness (symmetrical/assymetrical)
  • Bladder & bowel incontinence
  • Pain of variable quality may be significant in adolescence & adulthood (esp. Radiation)
  • Loss of back mobility
• Diagnosed with MRI
• Managed with surgery

Spinal cord tethering

• Literally low-lying spinal cord
• Spinal cord remains attached to the surrounding skin, causing abnormal growth
• Spinal cord becomes stretched & damaged
• Results in
  
  • Progressive neurological, urological, or orthopaedic problems
• Managed with surgery
• Preventive strategies disappointing

* Chiari I malformation

• Occurs when the lowest part of the cerebellum (cerebellar tonsils) descends a short distance into the cervical spine
• No involvement of the brain stem
  

Chiari II malformation (Arnold-Chiari malformation)

• Usually a rare condition
• Common in children with myelomeningocele
• Extension of both brainstem & cerebellar tissues into the foramen magnum
• Cerebellar vermis (tissues connecting both cerebellum hemispheres) may only be partially present
  
• Leading cause of death in the spina bifida population
• Results in
  
  • Spinal cord compression
• Signs & Symptoms
  
  • Difficulties with feeding, swallowing & breathing
  • Choking
  • Arm stiffness
• Complications
  
  • Blockage of cerebrospinal fluid – HYDROCEPHALUS
• Diagnosed with MRI
• Managed with surgery

* Chiari III malformation

• Occurs when the cerebellum & brainstem herniate through the foramen magnum & into the spinal cord
• Part of the brain's fourth ventricle may also be involved
• Rare instances of associated occipital encephalocele
  

* Chiari IV malformation

• Occurs when there is incomplete or underdeveloped cerebellum (cerebellar hypoplasia)
• Cerebellar tonsils are located further down the spinal canal
• Parts of cerebellum are missing
• Portions of skull & spinal cord may be visible
  

Hydrocephalus

• An abnormal buildup of cerebrospinal fluid in the brain
• Excessive buildup places damaging pressure on the brain
• Managed by ventriculoperitoneal shunt insertion to drain cerebrospinal fluid

Meningitis

• Infection of the meninges
• Potentially cause brain injury
• Potentially fatal

Learning disabilities

• Difficulty paying attention
• Problems with language & reading comprehension
• Trouble learning mathematics
• Perceptual motor problems (poor eye-hand coordination & ineffective motor skills)
• Hyperactivity/Impulsivity
• Poor memory
• Poor organization
• Problems in sequencing tasks
• Difficulty in decision making/problem solving

Effects of UMNs and LMNs Lesions

What is UMNs and LMNs?

What is upper motor neurons (UMN)?

Motor neurons that originate in the motor region of the cerebral cortex or the brain stem that carry motor information down to the final common pathway, that is, any motor neurons that are not directly responsible to for stimulating target muscle.

What is lower motor neurons (LMN)?

Motor neurons connecting the brainstem and spinal cord to muscle fibers, bringing nerve impulses from the UMNs out to the muscles. Terminates on an effector (muscle).

- Classified based on types of muscle fiber they innervate:

a. Alpha motor neurons (extrafusal muscle fibres –contraction)

b. Gamma motor neurons (intrafusal muscle fibres –proprioception)

OSCAR Answers

Yeah, yeah. Anyway, just going to put up the answers here, in case you wanted to review them. Not going to supply the pics tho, since a google search would be simple enough. & yes, I can't remember exactly what each question is about, but the answers should be a good resource regardless.

In a section through the spinal cord (grey matter), in the anterior horn...
There is the motor neuron (cell body)
Neuroglia – nutritive, supportive, mediate metabolite exchange, defence

In a section through the bone
Osteon (Haversian system) – functional unit of bone
Haversian canal - blood vessels, nerves, connective tissues
Volksman’s canal is at right angles.

With regard to the human embryo:
Rostal neuropore closes day 25, caudal neuropore day 27
Folic acid supplementation from 1 month till before end of 12th week
Test for alpha-feto protein to detect closure of neuropores.

In the dorsal aspect of the scapula:
The supraspinatus
Initiates first 15 degrees of abduction

In the developing limb bud:
There is the Apical Ectodermal Ridge.
Regulates limb bud outgrowth in proximo-distal direction; if disrupted, distal limb fails to form.
There is the Zone of Polarising Activity.
Regulates anterior-posterior patterning of limb; esp. sequential patterning of digits; if disrupted, extra or mirror image digits.

Regarding the Brachial Plexus:
Rami & Trunks: in neck;
Divisions, post to clavicles;
Cords, above & posterior to pectorialis minor;
Terminal branches, distal to pectorialis minor.
C5/C6 nerve roots –
Motor to deltoid & teres minor;
Sensory: skin over lower part of deltoid.


Regarding the gluteal region:
Injury to sciatic nerve
Motor: paralysis of hamstrings & all muscles of leg/foot, loss of movements in limb below knee with foot drop deformity.
Sensory: complete below knee except medial side of leg/medial malleolus to hallux to...
The sciatic nerve passes under the piriformis

In a cross-section through the limb:
Intermuscular septum made of deep fascia – necessary to separate muscles into different functional groups
Fasciotomy to correct compartment syndrome

With regard to the anterior (ventral) aspect of the wrist:
Injury to the median nerve
Loss of opposition of thumb with the little finger (opponens)
Skin over thenar eminence – palmar cutaneous of median nerve *unsure*

At the C8 spinal cord segment
There is the anterior ramus of spinal nerve
It contributes towards the brachial plexus

Vastus medialis of quadriceps femoris
Innervated by the femoral nerve
Extension of knee joint and prevents lateral displacement of the patella

Shoulder X-ray
Anterior dislocation is the most common injury
Adduction, external rotation & extension is the most common position of arm during injury

Of the spinal cord
Adult vertebra terminates at L1/L2 level
Lumbar puncture at subarachnoid space

The gluteal region
Adductors are gluteus medius & minimus, raising contralateral hip when standing on one leg, if this hip drops, there is a fault in part of the mechanism (muscular, nervous, or articular) – Trendelenburg test
Sciatic nerve injury – most commonly posterior dislocation of hip

In the femur
Fractured neck femur (subcapital, transcervical, basal cervical, intertrochanteric)
Femoral neck fractures, if above capsular attachment, the retinacular vessels are torn and supply to head is cut off causing avascular necrosis requiring head replacement.

Around the anatomical snuffbox
Tendons of extensor pollicis longus & brevis, along with adductor pollicis brevis
Proximal fragment of fractured scaphoid typically undergo avascular necrosis because arterial supply from the distal end (radial artery) as proximal end is covered by articular cartilage

In the knee joint
Anterior cruciate ligament
Anterior drawer’s test

In the popliteal fossa
Common peroneal nerve most commonly injured at neck of fibula as it winds down the neck
Injury produces foot drop & inversion of foot

To palpate femoral artery
Mid-inguinal point (1/2 way between ASIS & pubic symphysis)

X-ray of hip
Typical attitude/position of the limb in a fracture is intracapsular fracture/subcapital fracture, externally rotated & shortening. Gluteus medialis cause shortening. *possible error*
Profunda artery

Varicose veins in lower limb
Great saphenous vein
Perforating veins to drain from superficial to deep veins

At the wrist, the radial artery
The important tendon medial to it is the flexor carpi radialis

In the breast
The muscle directly posterior to the breast is the pectorialis major
Cooper’s ligaments are important for breast cancer
Pathologically, these may be contracted by fibrosis, causing retraction or pitting of the overlying skin. ONLY OCCURS IN METASTASIZED CANCERS.

Emphasis
Emphasize on root values.
Emphasis on nerve & vessel injury.
Emphasis of brachial & lumbar plexus.
Emphasis on specificity of answers.

Junaidah Has A Sore Foot

This week's look complicated... Oh well.

The Case:
Name: Junaidah
Gender: Female
Age: (Likely) 13 years old
Occupation: Student
Address: Sabak Bernam

History of Present Illness
What: A persistent, non-healing sore on foot
When: N/A
Where: Foot (which foot is unspecified)
Quality: Sore (unspecified)
Quantity: N/A
Aggravating factors: N/A
Alleviating factors: N/A
Associated symptoms: Starting to smell bad
Beliefs: (Likely) spina bifida

Medical & Surgical History
What: Lumbosacral myelomeningocoele
When: Upon delivery (childbirth)
Where: L5/S1 region
Cause: Spina bifida
Management: Neonatal surgery (unspecified)













Associated complications: Hydrocephalus days after operation
Management: Insertion of ventriculoperitoneal shunt 2 weeks later













Details of the Pregnancy & Birth
Overview: Born at full term
Complications: None
Prenatal Considerations: Folate & iron supplement 16 weeks into pregnancy

Social Considerations
Barriers to Access: Time, cost & distance factors
Quality of Life: Trouble in school (work & relationships)

Physical & Neurological Examinations
Normal:

• Hip flexion
• Knee extension

Abnormal:

• Knee flexion (weak) - Hamstrings, L5/S1
• Loss of peripheral sensation in soles of foot (tickling & pain induction) - S1

Possible hyperalgesia:

• Outer thighs (cried on injection) - (likely) L1/L2/L3

Think Tank
Folic acid is actually said to be protective against spina bifida - Was it just plain bad luck?

Resource list
Neural Tube Defects: 1, 2
Spina Bifida (General): 1, 2
Radiology: 1
Spina Bifida & Folic Acid: 1, 2, 3 (3rd is on Neural Tube Defects in general)
Myelomeningocoele: 1, 2, 3, 4
Ventriculoperitoneal Shunt: 1, 2, 3
Hydrocephalus: 1, 2
Extrapolated Statistics for Spina Bifida: 1
Neurology of Newborn (GoogleBooks): 1
Malaysian Children with Spina Bifida: Relationship Between Functional Outcome and Level of Lesion: 1

That's all I have. & I probably missed plenty, as usual. :3

Health care in Sarawak for rural people

Rural Health Centres

• Sarawak has 194 rural health clinics that function as "one-stop" family health centres
  
• provide an integrated service comprising
  
  • maternal & child care
    
  • general outpatient care
    
  • environmental sanitation
    
• All clinics have rest beds and birthing facilities to encourage safe delivery among rural mothers.
  
• Community clinics are smaller versions of health centres and serve between 1,500 - 3,000 people.
  
• Except for a few larger clinics with medical officers, all rural health facilities are managed by allied health personnel.
  

Mobile Health Services

• to serve people in less accessible areas.
  
• These teams either travel by road, river, on foot or by helicopter, depending on the accessibility of the areas they serve.
  
• In rural areas, Village Health Teams are based in rural health centres, while those serving peri-urban areas, are based at the Divisional or District Health Offices.
  

Flying Doctor Service

• introduced in 1973 to provide basic health services to people living in remote areas
  
• The service operates 3 helicopters that are rented under a contract with a private company
  
• The helicopters are based in Kuching, Sibu and Miri
  
• cover 175 locations throughout the State with a population of about 70,000
  
• comprises
  
  • a medical officer
    
  • a medical assistant
    
  • two community nurses
    
• Visit the locations once a month or once in two months.
  

Village Health Promoter Programme

As the mobile health teams can only visit remote villages once a month, Sarawak Health Department introduced a village health volunteer programme to provide basic health care to these communities on a more continual basis.

• Started in 1981
  
• two volunteers from each participating village are given three weeks' training on a fairly wide-range of health-related topics
  
• Upon returning to their respective villages, these volunteers
  
  • give first aid
    
  • do health promotion
    
  • make blood slides for detection of malaria parasites
    
  • make sputum slides for detection of tuberculosis
    
• The volunteers give regular feedback on their activities
  
• Regularly supervised by staff from the Sarawak Health Department
  

Issues

• Iban people's belief
  
  • Life and health are dependent upon the condition of the soul (samengat). Some illnesses are attributed to the wandering of one of an Iban's seven souls, and the shaman undertakes a magical flight to retrieve and return the patient's soul.
    
  • Iban strive to maintain good life and health by adherence to customary laws, avoidance of taboos, and the presentation of offerings and animal sacrifices.
    

When they seek medication, they try the old ways through consultation with the old folk and the local healer, and you will be treated with folk medicine made from herbs and roots. Then, they try to sleep off the sickness.

For people who have serious illnesses like cancer and or difficult child birth, the likely scenario is that they lie down and rest, and wait to die.

Imagine people living in the headwaters of the great Baram or Rejang Rivers a few hundred KM away from any modern medical centres in Miri or Sibu. The nearest medical assistant is probably a minimal local clinic with a dresser or a nurse in charge, who can be reached by many hours of walking through the jungle and a boat ride in the treacherous water of the rapids.

For serious cases that require sophisticated and prolonged medical care, the rural patients will be in big trouble.

To get a helicopter to fly down the river to the big city is like hitting the jackpot in the Big Sweep draw. An alternative will be to travel many hours in a motor boat of some kind. Not many rural dwellers in upper Baram or Ulu Rejang have that kind of cash to pay for the fare.

In the event that the rural patient is finally brought to the urban hospital somehow, his or her trouble has just begun.

The patient may not have an identity card, which is quite common among remote rural dwellers. When they give birth in their jungle abode, who is going to report to a registration department many KM and many expensive Ringgits away.

The hospital might refuse to admit the patient without an IC, or refuse to grant him or her the kind of financial and other assistance that can be given to them by the social welfare department.

It has become a custom in Sarawak, for various relatives or family members to accompany the patient to the hospital, and there take turn to look after the patient 24/7, even on small matters like fetching a glass of drinking water or bringing the bed-pan.

But being from the remote mountainous region upriver, where are the relatives going to sleep and eat in the big city? By the roadside? We certainly cannot expect them to check into the Holiday Inn, can we?

Types of fracture

The Human Skeletal System

The skeletal system is made up of 206 bones and provides support, allows for movement, and protects the internal organs of the body.

What Is a Fracture?

Sometimes, too much pressure is applied to a bone that results in what is known as a fracture. Fractures are often classified as either open or closed.

What Is an Open Fracture?

An open fracture is a fracture where a piece of the broken bone pierces through the skin. This can be dangerous because the bone is exposed, increasing the risk of infection.

What Is a Closed Fracture?

A closed fracture is a fracture where the bone is broken, but does not come through the skin.

What Is a Compression Fracture?

A compression fracture is a closed fracture that occurs when two or more bones are forced against each other. It commonly occurs to bones of the spine and may be caused by falling into a standing or sitting position, or a result of advanced osteoporosis.

What Is an Avulsion Fracture?

An avulsion fracture is a closed fracture where a piece of bone is broken off by a sudden, forceful contraction of a muscle. This type of fracture is common in young athletes and can occur when muscles are not properly stretched before activity. This fracture can also be the result of an injury.

What Is an Impacted Fracture

An impacted fracture is similar to a compression fracture, yet it occurs within the same bone. It is a closed fracture that occurs when pressure is applied to both ends of the bone, causing it to split into two fragments that jam into each other. This type of fracture is common in falls and car accidents.


Video: http://video.about.com/orthopedics/Fractures-1.htm

complication of leg fracture

Possible complications of leg fracture:
-delayed union or non-union.
-malunion of bone that may predispose to arthritis.
-leg shortening.
-osteomyelitis.
-injury to deep peroneal nerve may lead to footdrop.
-popliteal artery injury in upper tibial fracture.
-reflex sympathetic dystrophy.
-compartment syndrome.
-Tetanus (possibly???) since a rusty spring pierces into James' leg.

Tetanus

Causative agent :Tetanus Toxin produced by Clostridium Tetani. (gram +ve, rod-shaped, produce endospores, usually found in soils, anaerobic type of metabolism.)

How does the tetanus toxin cause damage to the body?

The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates. This region is called the neuromuscular junction. The tetanus toxin amplifies the chemical signal from the nerve to the muscle, which causes the muscles to tighten up in a continuous ("tetanic" or "tonic") contraction or spasm. This results in either localized or generalized muscle spasms. The jaw is "locked" by muscle spasms, giving the name "lockjaw" (also called "trismus"). Muscles throughout the body are affected, including the vital muscles necessary for normal breathing. When the breathing muscles lose their power, breathing becomes difficult or impossible and death can occur without life-support measures. Even with breathing support, infections of the airways within the lungs can lead to death. Tetanus toxin can affect neonates to cause muscle spasms, inability to nurse, and seizures. This typically occurs within the first two weeks after birth and can be associated with poor sanitation methods in caring for the umbilical cord stump of the neonate.

How is tetanus treated and prevented?

Antibiotics and drainage are carried out in the hospital while the patient is monitored for any signs of compromised breathing muscles. Treatment is directed toward stopping toxin production, neutralizing its effects, and controlling muscle spasms. Sedation is often given for muscle spasm, which can lead to life-threatening breathing difficulty.

In more severe cases, breathing assistance with an artificial respirator machines may be needed.

The toxin already circulating in the body is neutralized with antitoxin drugs. The tetanus toxin causes no permanent damage to the nervous system after the patient recovers.

Active immunization ("tetanus shots") to prevent tetanus. (5 yrs once) Preventative measures to protect the skin from being penetrated by the tetanus bacteria are also important. For instance, precautions should be taken to avoid stepping on nails by wearing shoes. If a penetrating wound should occur, it should be thoroughly cleansed with soap and water and medical attention should be sought. Finally, passive immunization can be administered in selected cases (with specialized immunoglobulin).

Alteration of fracture healing in DIABETIC PATIENT

Normally, fracture healing proceeds with highly reproductive manner however, in severe pathological conditions such as DIABETES the progress of fracture healing can be substantially impaired.

FRACTURE HEALING

It has been described as a process of regeneration where the site of injury is replaced by bone, not scar tissue.

A cascade of events in corresponds to normal fracture healing which fulfills the three functions:-

a) Removal of debris

b) Re-establisment of the damage vascular supply

c) Restoration of the skeletal matrix

CAUSES OF IMPAIRED HEALING

absence of insulin

Insulin

Promotes marked stimulation of bone matrix and formation of cartilage.

When systemic levels of insulin are reduced, there is a late complication in nearly every body tissues, including bone.

Diabetic bone disease is characterized by OSTEOPENIA (a condition where bone mineral density is lower than normal).

Insulin can directly and indirectly action on BONE as it can:-

a) Directly increases collagen production by osteoblasts.

b) Promotes insulin-like growth factor 1 (IGF-1) which stimulates both collagen synthesis and cell proliferation in osteoblasts.

IGF-1 treatment has shown to correct osteopenia in diabetes.

Absence of insulin

Reduced calcification and ossificationà delayed cartilage formation

Fracture healing process in diabetes produce SMALLER and MECHANICALLY WEAKER callus.

metabolic alteration of calcium

Decreased systemic insulin levels à impaired duodenal calcium absorption.

This is supported by a study in humans,

Levels of calcium in the urine up to 13X than normal.

· Related to glomerular filtration, osmotic dieresis/ an insulin-dependent decrease.

Suggest that this can be offset by high calcium intake with an overall increase in food intake.

metabolic alteration of vitamin d

Vitamin D

Important for bone RESORPTION and bone FORMATION.

Synthesis of Vitamin D

Hydroxylated in liver (vitamin D3 à 25-hydroxyvitamin D3).

Metabolized in kidney to active metabolites (1,25 (OH)2 D3 and 24,25 (OH)2 D3).

alteration in vitamin d metabolism

Contributes to:-

· Osteomalacia- softening of bones due to defective bone mineralization (rickets in children)

· Osteoporosis

· Osteosclerosis- elevation in bone density; can caused by injuries that compress the bone

Because,

Vitamin D is involves with growth factors in bone formation and regulation of bone volume.

Tnf-a

During fracture healing, the levels of inflammatory molecules (TNF-a) is increased.

Diabetic animals have rapid loss of cartilage in the healing bones à increased no. of osteoclasts (regulated by TNF-a and a mediator called FOXO1).

Diabetes mediated increases in THF-a and FOXO1 may underlie the impaired healing of diabetic fractures.

James, Break A Leg. :)

Format shamelessly stolen & simplified from Tim. :)

The Introduction
Patient Name: James
Age: 57 years
Occupation: Farmer & tribal elder

History of Present Illness
What: Crushed leg with bone sticking out (likely compound & comminuted fractures)
Where: Left lower leg
When: Over 3 hours ago
How: Violent downward force on an extended leg resulting in a high-energy impact from the weight of a falling car
Quallity: N/A
Quantity: Brain-being-scratched-out levels :(
Alleviating Factors: N/A
Aggravating Factors: Being crushed by the weight of a car :(
Associated Symptoms: Pain & open wound hemorrhage (blood flow has been arrested)
Beliefs: Crushed by the weight of a car :(
Possible Damage: 1, 2, 3, 4

What: Bent knee (likely dislocation)
Where: Right knee
When: Over 3 hours ago
How: Violent backward force on a flexed knee resulting in a high energy impact from the weight of a falling sill panel
Quality: N/A
Quantity: Brain-being-scratched-out levels :(
Alleviating Factors: N/A
Aggravating Factors: Being crushed by the weight of a car :(
Associated Symptoms: Pain
Beliefs: Dislocated by the weight of a sill panel :(

Others: Puncture wound by rusty spring

Medical History
Diabetes

Medication
Diabetes; poor compliance

Smoking
Yes; low motivation to quit

Social History
Family: Wife died 5 years ago; lives together with 3 daughters
Occupation: A farmer most of his life, together with the rest of his community

Food For Thought
What structures are involved in the fracture?
What structures are involved in the dislocated knee?
Is there a risk of tetanus from the puncture wound by the rusty spring?
Is there a risk of infection at the bleeding site?
What are the complications arising from diabetes - amputation necessary?
What are the complications arising from smoking - additive to diabetes complications?
What are the first aid methods to deal with such a situation?
Are there any cultural barriers to be considered?
Are there any financial barriers to be considered?
Are there any geographical barriers to be considered?
Are there any other barriers to access to be considered?

Resources
Broken Leg: 1
Compound Fractures: 1, 2
KeShinn Bone Fractures: 1
Meniscal Tears: 1
Anterior Cruciate Ligament Injuries: 1
Posterior Cruciate Ligament Injuries: 1
Collateral Ligament Injuries: 1
Tetanus: 1, 2, 3
Diabetic Neuropathy: 1, 2, 3
Diabetes Medications: 1
Wound Care: 1
Fractures First Aid: 1

Extra:
To describe a fracture:
PLASTER OF PARIS:
Plane
Location
Articular cartilage involvement
Simple or comminuted
Type (eg Colles')
Extent
Reason
Open or closed
Foreign bodies
disPlacement
Angulation
Rotation
Impaction
Shortening

I probably missed plenty. :3

ACL and PCL pathophysiology

ACL Tears

-1) rotation of the knee while foot is planted followed by a force that drives the tibia anteriorly and the femor posteriorly, or (2) hyperextension

-Isolated ACL injury is uncommon Trauma to the PCL may provide a false positive for ACL injury

-Usually injury results from non-contact sport activity in which an athlete cuts or pivots quickly (ie. soccer)

- Predisposing factors to ACL injury may include: ACL size, joint laxity, muscular and athletic skill coordination, body motions, limb alignment, and menstrual cycle (increased laxity with estrogen and progesterone surges during the luteal phase)

-Females experience ACL sprains at higher rate than men



PCL Tears

-Pcl lig are stronger then Acl ligs

-Mode of injury is often due to posterior force to tibia

-Eg. Smashing your tibia into the dashboard during an accident

-Also a result of hyperextension



Other Fact that might not change your life but might help^_^

-The tensile strength streagth and the load it can bear of the PCL is greater than that of the ACL

-ACL is involved in 85% of anterior translation of the tibia

-PCL is fully involved in the posterior translation of the tibia

-Once injured the sub laxity of the ACL ligament make the joint more prone to injury

TREATMENT

Treatment

 

Immediately after injury

• Rest - The individual is advised to rest the knee from weight-bearing activities allowing the swelling to settle.
  
• Ice - Placing a cold compress or ice pack on the knee is helpful in controlling inflammation as well as helping to reduce pain.
  
• Compression - Utilizing an ace wrap for compression around the knee is beneficial to control the swelling.
  
• Elevation - Lying down with the leg elevated higher than the level of the chest is helpful in controlling and reducing swelling.
  

 

Choices of treatment

Non-surgical treatment

Non-surgical rehabilitation

• You and your doctor may choose nonsurgical rehabilitation if:
  
  • knee is stable during typical daily activities
    
  • knee cartilage hasn't been damaged
    
  • have no desire to participate in high-risk activities involving jumping, cutting and pivoting
    
  • You have a partial tear
    
  • Your knee isn't painful or unstable during normal activities
    
• doctor may recommend physical therapy, changing your activities and wearing a knee brace for possibly risky activities
  
• may also be appropriate for a child or an adolescent with a torn ACL
  
• If the child has no damage other than to the ACL and can avoid high-risk activities, the doctor may recommend postponing surgery until the child's bones have finished growing to avoid damaging the growth plate
  
• goal
  
  • strengthen the muscles around your knee to make up for the absence of an intact ACL
    
• Training focuses on the:
  
  • Hamstring muscles
    
  • Quadriceps muscle
    
  • Calf
    
  • Hip
    
  • Ankle
    
• early stage – work on re-establishing full range of motion in the knee
  
• Then progress to knee-, hip- and ankle-strengthening exercises combined with training to improve your stability and balance
  
• Finally, work on training specific to your sport or work activities, including exercises to help you prevent further injury, such as learning how to land properly from a jump
  
• Patients expected to return to normal their normal daily activities within a month
  

 

Knee brace

• doesn't take the place of the torn ACL
  
• can help stabilize your knee if you should choose nonoperative management while you take part in activities such as skiing, tennis or hiking over uneven ground
  
• usually custom fitted or tailored
  
• can be costly (may not be covered by your insurance provider)
  
• can continue to participate in many of their previous activities that don't involve jumping, cutting and pivoting
  
• may continue to experience instability in your knee during certain types of activities, even while wearing a brace
  
• If this happens, consider making additional changes in your activities or reconsider surgical reconstruction
  
• These repeated events could damage the cartilage and other parts of your knee
  

 

Surgical treatment

Reasons for surgery:

• The knee gives ways during typical daily activities (functional instability)
  
• Patients unable to participate in high risk activities that are important to them
  
• Damage to the meniscus
  

Goals:

• give patients the most stable knee possible so that they can resume their previous level of activity with a safe knee that minimizes the risk of future knee damage
  
• Though most people return to sports activities, some don't return to their previous level of high-intensity sports activity after reconstruction and rehabilitation.
  
• They limit their activities by choice or because of
  
  • Pain
    
  • Swelling
    
  • persistent looseness
    
  • age-related lifestyle changes.
    

 

ACL reconstruction

• replacing ACL with another tendon (graft) from your own body (autograft) or from a cadaver (allograft)
  
• typically come from patellar tendon and hamstring tendon
  

• Procedure
  
  • usually done with arthroscopic techniques
    
  • the graft will be taken from your chosen tendon. A hole is drilled at an angle through the tibia and into the femur, following the path of the injured ACL. The graft is then threaded through the holes, and the small pieces of bone at each end of the tendon are attached to the femur and the tibia, usually with screws, which are left in place permanently
    
• Both grafts are about equal in regard to the number of people who return to their previous level of activity.
  
• If your own tendons don't provide the best replacement for the injured ligament, your doctor may recommend an allograft.
  
• benefit
  
• recovery is usually easier, faster and less painful because you don't have to recover from the removal of the tendon used for the graft
  
• potential complications
  
  • Pain in the front of the knee after ACL reconstruction
    
    • particularly true in patellar tendon graft.
      
  • scar tissue may limit range of motion after surgery. Rarely, this may require a second surgery to correct.
    
  • instability of the knee following ACL reconstruction
    
    • may be related to stretching of the graft over time or re-injury
      
    • more common with allografts than with autografts
      
  • Occasional swelling of the knee can occur despite a successful ligament reconstruction
    
  • Infection
    

 

 

Rehabilitation after surgery

• The knee may be placed in a splint or brace for comfort and protection
  
• It typically takes six to nine months of physical therapy and strengthening exercises before you'll be able to return to your previous level of activity
  
• Some exercises require the use of weight machines, exercise bicycles or treadmills that you might do in a supervised clinic setting
  
• Occur in 3 phases (progression depend on the nature of particular injury and how well patients master the goals within each phases)
  
  • Phase 1
    
    • begins on the first day after surgery
      
    • takes about six to eight weeks
      
    • consists of
      
      • controlling the pain and swelling in the knee
        
      • regaining your range of motion
        
      • preserving muscle strength
        
    • work with a physical therapist a few times a week at first, then once every week or two as they progress
      
    • On days there is no therapy session, patients exercise at home for 30 to 60 minutes a day.
      
  • Phase 2
    
    • typically lasts from two to four months
      
    • focus on
      
      • controlling swelling
        
      • recovering full muscle strength
        
    • In addition to daily strengthening exercises, patients begin stability and balance training
      
    • see the physical therapist less often but continue with 30 to 60 minutes of exercises each day.
      
  • Phase 3
    
    • lasts several months after surgery
      
    • consists of a gradual return to full activity
      
    • requires full motion, normal muscle strength and the absence of swelling
      
    • they continue with stability, balance and strength training as well as training specific to your sport or work activities
      
    • may include exercises to help prevent further injury
      

It's important not to try to return to full activity too soon because your knee may become inflamed or re-injured. The graft needs to heal, and too much stress before it's completely healed may increase the risk of the graft failing.

Knee examination

A complete knee examination is always done for a knee complaint. Both of your knees will be checked, and the results for the injured knee will be compared to those of the healthy knee. Your doctor will also check that the nerves and blood vessels are intact.

Your doctor will:
-Inspect your knee visually for redness, swelling, deformity, or skin changes.
-Feel your knee (palpation) for warmth or coolness, swelling, tenderness, blood flow, and sensation.
-Test your knee's range of motion and listen for sounds. In a passive test, your doctor will move your leg and knee joint. In an active test, you will use your muscles to move your leg and knee joint. At the same time, your doctor will listen for popping, grinding, or clicking sounds.

Check your knee ligaments, which stabilize the knee. Tests include:
-The Valgus and Varus tests , which check the medial and lateral collateral ligaments. In these tests, while you lie on the examining table, your doctor places one hand on your knee joint and the other on your ankle and moves your leg side-to-side.
-The posterior drawer test , which checks the posterior cruciate ligament. In this test, you lie on the table with your knee bent at a 90-degree angle and your foot flat on the table. Your doctor will put his or her hands around your knee and push the top of your knee with the thumb.
-The Lachman test , which checks the anterior cruciate ligament (ACL). In this test, while you lie on the table, your doctor will slightly bend your knee and hold your thigh with one hand. With the other hand, he or she will hold the upper part of your calf and pull forward. The Lachman test diagnoses a complete ACL tear.
-A pivot shift test , which checks the ACL. In this test, the leg is extended and your doctor holds your calf with one hand while twisting the knee and pushing toward the body. It is often done just before a knee arthroscopy and after anesthesia has completely relaxed the muscles.
-A McMurray test may be done if your doctor suspects a problem with the menisci based on your medical history and the above examinations. In this test, while you lie on the table, your doctor holds your knee and the bottom of your foot. He or she then pushes your leg up (bending your knee) while turning the leg and pressing on the knee. If there is pain and the sound or feeling of a click, the menisci may be damaged.

Arthrometric testing of the knee may also be done. In this test, your doctor will use an instrument to measure the looseness of your knee. This test is especially useful in people whose pain or physical size makes a physical exam difficult. An arthrometer has two sensor pads and a pressure handle that allows your doctor to put force on the knee. The instrument is strapped on to your lower leg so that the sensor pads are placed on the knee cap and the small bump just below it (tibial tubercle). Your doctor then measures pressure by pulling or pushing on the pressure handle.

Your exam may also include other tests to assess the degree of the injury and to identify damage to other parts of the knee.

Why It Is Done
A complete physical exam of the knee is always done for a knee complaint, whether the complaint is from a recent or sudden (acute) injury or from long-lasting or recurrent (chronic) symptoms.

Results
In general, in a normal knee exam:
The knee has its natural strength.
The knee is not tender when touched.
Both knees look and move the same way.
There are no signs of fluid in or around the knee joint.
The knee and leg move normally when the ligaments are examined.
There is no abnormal clicking, popping, or grinding when knee structures are moved or stressed.
The toes are pink and warm, and there is no numbness in the lower leg or foot.

If any of these findings are not true-for example, the knee is tender-you may have a knee injury. But the results of a knee exam vary depending on whether the exam is for a sudden injury to the knee or for long-term symptoms and also depending on how long it has been since the injury occurred. An abnormal finding does not always mean that your knee is injured. Your doctor will use the results of the exam, plus your medical history, to make a diagnosis.

What To Think About
These tests provide the best information if there is little or no knee swelling, you are able to relax, and your doctor is able to move your knee and leg freely. If this is not the case, it may be difficult to accurately check your knee.

If your knee is red, hot, or very swollen, a knee joint aspiration (arthrocentesis) may be done, which involves removing fluid from the knee joint. This is done to:
-Help relieve pain and pressure, which may make the physical exam easier and make you more comfortable.
-Check joint fluid for possible infection or inflammation.
-See if there is blood in the joint fluid, which may indicate a tear in a ligament or cartilage.
-See if there are drops of fat, which may indicate a broken bone.
-Local anesthetic may be injected after aspiration to reduce pain and make the exam easier.

If you are going to have arthroscopy, the knee may be examined in the operating room before the procedure, while you are under general or spinal anesthesia.


very useful link on knee exam:- (though i doubt any of you would actually click on it)
http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/knee.htm

Generalized Anxiety Disorder

Generalized Anxiety Disorder

Anxiety is a complex feeling of apprehension, fear, and worry often accompanied by pulmonary, cardiac, and other physical sensations. It is a common condition that can be a self-limited physiologic response to a stressor, or it can persist and result in debilitating emotions. When pathologic, it can exist as a primary disorder, or it can be associated with a medical illness or other primary psychiatric illnesses (eg, depression, psychosis).

Mental health disorders account for approximately 5.5% of emergency department (ED) visits and, among these mental health visits, 21% are due to anxiety. Because generalized anxiety disorder (GAD) and panic attacks present with a similar constellation of symptoms, a similar approach can be used for both.

The goal of the emergency physician (EP) is to differentiate whether the anxiety is due to an acute medical condition or is the primary diagnosis. This differentiation can be difficult since many anxiety symptoms are indistinguishable from common cardiopulmonary and neurological complaints. Unfortunately, a chaotic emergency department is not the best environment to take a detailed history of the symptoms or to comfort an anxious patient. In addition, because of the high volume of ED’s nationally, EPs are under great pressure to see patients faster. Anxiety, like other psychiatric diagnoses, requires more time to take a history and engage the patient about the underlying cause of the symptoms.

Pathophysiology

Heightened physiologic response and elevated catecholamine levels play an important role in the normal physiologic response of the body to stress and anxiety. Pathologic anxiety has been hypothesized to result from disturbances in the cerebral cortex, specifically the limbic system.

The neurotransmitters primarily associated with anxiety in these regions are norepinephrine, gamma-aminobutyric acid (GABA), and serotonin. The efficacy of benzodiazepines in treating anxiety has implicated GABA in the pathophysiology of anxiety disorders. Drugs that affect norepinephrine (eg, tricyclic antidepressants, monoamine oxidase inhibitors [MAOIs]) are also efficacious in the treatment of several anxiety disorders.

Clinical

History

• The initial assessment must include a complete history with a focus on the patient's social history and a discussion of possible recent stressors (eg, problems with employment, financial stress, recent family illness/death, spousal conflict/abuse, illicit drug use). In addition, a detailed dietary history is critical. Caffeine, nicotine, chocolate, over-the-counter "exercise" or weight loss pills, and other natural supplements are often implicated as causes of an acute anxiety attack. Patients often do not realize that these agents are stimulants and can cause pronounced palpitations and other signs of anxiety.
• The family is an excellent source of history for a patient with acute anxiety and may be able to provide information that the patient is reluctant to discuss or does not feel is relevant to the presentation.
• The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) classifies anxiety disorders as follows¹ :
• Global anxiety disorder (GAD) requires a clinical duration of at least 6 months. GAD occurs frequently with mood disorders (eg, major depression).
• Panic disorder with or without agoraphobia: Panic attacks are recurrent episodes of spontaneous, intense periods of anxiety, usually lasting less than 1 hour. Panic attacks accompany complications of agoraphobia within the first year. (Agoraphobia is a condition involving anxiety about being in places or situations where escape might be difficult.). Patients with panic attacks are often in significant distress and seek medical attention in the ED. A patient with a classic panic attack experiences at least 4 of the following symptoms: palpitations, diaphoresis, tremulousness, shortness of breath, chest pain, dizziness, nausea, abdominal discomfort, fear of injury or going crazy, derealization (perception of altered reality), and depersonalization (perception that one's body is surreal).
• Anxiety disorder due to a general medical condition is itself a unique diagnosis, but the emergency practitioner must thoroughly evaluate the known medical problem before making this diagnosis.
• Substance-induced anxiety disorder and anxiety disorder not otherwise specified are characterized by symptoms of anxiety that occur as a direct consequence of drug abuse, medications, or toxins.

Physical

• While the physical examination of patients with anxiety is often normal, a great deal can be learned from observing the patient during the ED visit. The general demeanor, appropriateness, insight, hygiene, mood, cognitive capacity, and ability to engage the clinician in a discussion of the symptoms. However, a good physical examination allows the emergency physician to identify any potential life-threatening illnesses. The clinician should focus on the signs and symptoms of anxiety. Examination results may guide laboratory and imaging studies needed to evaluate cardiopulmonary causes of anxiety.
• As can be expected, comorbid diseases have their own characteristic examination findings.
• Mental status examination
• A mental status examination can be especially helpful in distinguishing functional from organic disorders. Differentiating among the numerous psychiatric illnesses is essential, as many share symptoms similar to those of anxiety disorders.
• The examination should focus on the following:
• Affect
• Behavioral observation
• Speech pattern
• Level of attention
• Language comprehension
• Memory, calculation, and judgment

Causes

• Comorbid diseases have been known to cause intrinsic anxiety. Many abused drugs (eg, alcohol, amphetamines, narcotics) raise anxiety levels.
• Panic attacks in patients who are susceptible to them can be precipitated by caffeine or iatrogenic agents, such as inhaled beta2-agonists.
• Many anxiety disorders demonstrate a familarl pattern. First-degree biological relatives of patients with panic disorders have up to a 7-fold increased probability, as compared to the general population, of presenting with the same illness.

Workup

Laboratory Studies

The history remains the best tool available to the emergency physician in the evaluation of anxiety. Laboratory tests are rarely needed to affirm the diagnosis.

However, if there is an abnormal physical examination finding, such a goiter or prominent nystagmus, or the clinician suspects a toxic ingestion, laboratory testing can help distinguish anxiety from drug-induced causes and organic illnesses (eg, systemic infection, toxin, electrolyte and endocrine disturbances).

Imaging Studies

• Imaging studies are not useful in diagnosing anxiety but may be needed to exclude other possibilities in the differential diagnosis.

Other Tests

• Electrocardiograms are useful for evaluating possible tachydysrhythmia and screening for adverse medication effects such as QT prolongation.

Treatment

Prehospital Care

Prehospital personnel may provide reassurance and symptomatic relief within the usual protocols of EMS. Early identification of symptoms can facilitate evaluation and therapy by the emergency physician.

Emergency Department Care

• Patients with significant discomfort from their anxiety can benefit from emergency anxiolytic treatment, primarily with a benzodiazepine. In addition to ED treatment, patients in an acute anxious state of such severity that they pose a danger to themselves and or to others should have a psychiatric consultation.
• In addition to anxiolytic treatment, the clinician should be vigilant in addressing any abnormal vital signs. Patients who present with initial elevated blood pressure should have it repeated when they are less anxious. Initial tachycardia that resolves with reassurance is common. However, persistent tachycardia should not only be attributed to anxiety and organic causes (eg, dysrhythmia, pulmonary embolism, thyrotoxicosis, toxin, withdrawal, dehydration) should be considered.
• While remaining vigilant for life-threatening illness, EPs should provide a reassuring encounter to those with anxiety. Place the patient in a calm quiet room where a formal evaluation can begin to identify the functional components of the patient's anxiety. Unfortunately, such a quiet place is scarce and the ED environment often compounds the patient’s stress. Overcrowding and long wait times may also contribute to anxiety.
• In the best of circumstances, a calm environment and social support from family, friends, and the emergency staff is ideal. For patients with more severe anxiety, a short course of a fast-acting anxiolytic agent is recommended. Chronic anxiety requires a comprehensive approach and the best pharmacotherapy varies for each individual and outpatient follow up with a psychiatrist is recommended. However, these patients can be discharged on a short course of benzodiazepines until they see a psychiatrist. Patients who express suicidal or homicidal thoughts should have an emergent psychiatric evaluation in the ED.

Consultations

• Psychiatrist
• Anxiety disorders are often chronic illnesses and require follow-up psychiatric intervention for successful treatment.
• Any patient with anxiety who presents with homicidal or suicidal ideation requires urgent psychiatric intervention in the ED.

Medication

Short-acting benzodiazepines are most useful in the ED.

Barbiturates are not recommended because of their high addictive potential, marked side effects, slow onset of action, and low therapeutic indices. Tricyclic antidepressants and MAOIs should not be prescribed in the acute setting. Beta-blockers do not reduce intrinsic anxiety, although they do reduce anatomic components (eg, tachycardia, diaphoresis).

Buspirone has a low abuse potential, and a short course can safely be prescribed in the ED. However, peak efficacy may take several weeks and, in patients with concomitant depression, buspirone alone is often not effective. However, because of its excellent safety profile and low risk for abuse, it may be a preferred choice for patients that are at risk for substance abuse.

Benzodiazepines

Benzodiazepines are agents of choice due to their short half-lives and high therapeutic indices. By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.

Lorazepam (Ativan)

Lipophilic inhibitory CNS agent that acts on GABA receptors as well as specific benzodiazepine receptors. CNS effects include sedation, anxiolysis, and striated muscle relaxation. Its IV administration has a rapid onset of action (3-5 min), and the half-life has been reported as 9-19 min.

Midazolam (Versed)

Similar to lorazepam but has shorter duration of action, approximately 1-4 h with a half-life of 2.5 h.

Serotonin receptor agonists

These agents stimulate 5-HT1-receptors, producing anxiolytic effects. Buspirone is a nonsedating antipsychotic drug unrelated to benzodiazepines, barbiturates, and other sedative-hypnotics. Has been found to be comparable with benzodiazepines in reducing symptoms of anxiety in double-blind placebo-controlled clinical trials and has fewer sedative or withdrawal adverse effects than benzodiazepines. Also has fewer cognitive and psychomotor adverse effects, which makes its use preferable in elderly patients. Major limitations include lack of antipanic activity and reduced anxiolytic effects in patients recently withdrawn from benzodiazepines. Also has a longer onset of action and, thus, is of fairly limited use as a sole agent in the treatment of acute anxiety in the ED.

Buspirone (BuSpar)

5-HT1A agonist affecting serotonergic neurotransmission in CNS. Has some dopaminergic activity as well. In addition, has demonstrated anxiolytic effect but can take up to 2-3 wk for full efficacy. Also has a low abuse potential and does not mitigate panic attacks. Not useful in benzodiazepine withdrawal but has a low adverse-effect profile.

Duloxetine (Cymbalta)

Potent inhibitor of neuronal serotonin and norepinephrine reuptake. Indicated for generalized anxiety disorder.

Follow-up

Further Inpatient Care

• All anxious patients with suicidal ideation, homicidal ideation, or acute psychosis require emergent psychiatric consultation.

Complications

• Some studies report the failure rate of diagnosing anxiety disorders at as high as 50%. This can result in overuse of health care resources and increased morbidity and mortality rates for anxiety disorders and comorbid medical conditions.

Miscellaneous

Medicolegal Pitfalls

• Anxiety states may be associated with increased prevalence of other physical illnesses.
• Avoid falsely attributing the somatic symptoms of anxiety to other medical conditions.
• Understand that anxiety can provoke or maintain other medical disorders. For example, the prevalence of hypertension has been found to be 13.6% in patients diagnosed with panic attacks compared to 4.4% in controls without panic attacks.