Y. Georg. University of Texas Health Science Center at San Antonio.

Panic disorder Panic attacks and panic disorder are rare and symptomatically less severe in the elderly order tadapox 80 mg on line, estimates of prevalence ranges from 0 order tadapox 80mg on line. However, the prominent physical symptoms of panic disorder may result in patients being referred instead to cardiologists, neurologists and gastroenterologists. In one study of cardiology patients with chest pain and no coronary disease, one third of those aged 65 and over met the criteria for panic disorder. Several attacks occur within a period of one month and symptoms are not better explained by another psychiatric or physical disorder. Panic attacks are often co-morbid with other psychiatric disorders, particularly depression, and it may be severe enough to mask depressive features. In addition the condition should not meet the criteria for other anxiety disorders, psychiatric or physical disorders. Onset in old age is rare, the majority starting before the age of 25 and usually running a chronic fluctuating course into old age especially if left untreated. Obsessional symptoms may appear at any age following head injury or cerebral tumour. The individual recognizes them as originating from his own mind but is unable to resist them despite repeated attempts at doing so. Compulsion is the irresistible urge to perform an act repeatedly despite the futility of that action. Insight is usually fully intact and the patients usually regard these symptoms as unreasonable and are distressed by them so much so that their functioning is impaired to a greater or lesser degree. Obsessions and or compulsions should last at least two weeks and not arise as a result of another mental disorder. The experience of the event is sometimes regarded as “near death” for the individual and might actually have involved the death of another person. Symptoms begin within six months of the event and should be present for more than a month, are severe enough to cause distress and impair functioning. Heightened emotional arousal in the form of exaggerated startle response, hypervigilance, emotional numbness, insomnia, irritability and poor concentration that were not there prior to the incident. Older persons who are frail have a greater tendency to feel threatened than their younger counterparts.

Pulmonary Interstitial Emphysema • Neurological symptoms: The spinal cord is the most com- Mediastinal monly affected area and presents with symptoms akin to a spinal Arterial Gas Emphysema Pneumothorax Embolism (Tension) cord injury discount tadapox 80 mg line. Typically 80 mg tadapox, low back pain starts within minutes to hours, followed by a combination of paraesthesia, paresis, paral- Subcutaneous Emphysema ysis, faecal and urinary incontinence or retention. Any thoracic, abdominal or hip pain should be considered as originating from Figure 27. Headaches, visual field abnormalities, mental status alteration, and personality changes directly. Venous gas emboli are common after recreational dives, but are usually filtered out by the lungs. Environmental: Diving Emergencies 149 ◦ if unconscious administer intravenous crystalloids aiming for a Recompression therapy urine output of 1–2 mL/kg/hour The hyperbaric chamber is used to repressurize the patient to a • Evacuate to hyperbaric facility depth where the bubbles of nitrogen or air are made smaller and the ◦ take all the personal diving gear with the patient gas redissolves into the body tissues and fluids. High concentrations ◦ Ideally take the diving buddy as well, even if asymptomatic of oxygen can be administered during repressurization if required. Well-organized dives and diving clubs may supply their members with diving incident pro formas for completion following dive incidents. These documents capture data important for the Tips from the field treating hyperbaric team and should accompany the patient to the • Decompression sickness and arterial gas embolisation can occur chamber where possible. Type of incident and any other problems Decompression details Diver’s physical condition before, during, and after the dive First aid delivered. Early • Understand the relevant anatomical and physiological changes definitive airway management is recommended but a difficult air- in pregnancy way should be expected and planned for (expect a failed intubation • Know how to assess the pregnant patient in the prehospital in about 1 in 250, and a ‘can’t intubate – can’t ventilate’ scenario in phase about 1 in 500). The tidal volume increase occurs at the expense Be able to manage the pregnant patient in cardiac arrest of inspiratory and expiratory reserve volumes resulting in a • Know how to perform Neonatal Life support. As the gravid uterus enters the upper abdomen in the third Introduction trimester the lower ribs become splayed and relatively fixed, Caring for pregnant women can be daunting even for the most reducing the contribution of the intercostal muscles during forced experienced prehospital practitioner. There is also elevation of the diaphragm in late preg- ing of pregnancy related changes in anatomy and physiology and nancy due to pressure from the compressed abdominal contents a stepwise approach to care should enable prehospital teams to and as such it is recommended that thoracostomies are performed optimize outcomes for mothers and their babies. Anatomical and physiological changes Circulation in pregnancy The placental perfusion requirement increases with advancing ges- Airway tation and is reflected by a gradual increase in cardiac stroke Several anatomic changes occur during pregnancy that can impact volume and heart rate by 10–20 bpm. There is a pro- The engorgement and friability of the respiratory tract, mucosal gressive reduction in blood pressure in the first trimester, followed oedema and capillary engorgement of nasal and oropharyngeal by a steady increase in the third trimester to pre-pregnancy val- mucosa and laryngeal tissues increase the possibility of iatro- ues. Pregnancy-induced the pregnant patient at risk of postural hypotension during rapid weight gain and an increase in breast size may obstruct laryn- postural changes.

It is disappointing that even for medications include teratogenicity buy tadapox 80mg without a prescription, toxicity or sionals should not shirk their responsibility sure to two medications and the second drug a medication such as lithium that has been in withdrawal symptoms in the newborn as well to advise on appropriate options order 80 mg tadapox with mastercard. Fully docu- may not have the effcacy of the original; and, use for over half a century, the sum total of the as the less certain risks of long-term devel- menting the nature and extent of any discus- fnally, continuing the current medication with world literature is not even 200 prospective opmental and cognitive problems in children sion is clearly important. Weighed When it comes to the decision about which Clearly, there are no easy answers, and again the situation is certainly better for medications against these risks, however, are the risks of medication to use, it is important to consider a full and individualized risk–beneft analysis used in psychiatry and additionally used in the untreated psychiatric disorders, including the drugs with the best evidence of reproduc- is important and should be meticulously doc- treatment of epilepsy, but there are potentially risk of a severe recurrence of illness. However, an individual woman’s umented in the patient record which should important differences in how medications are of studies implicate psychiatric disorder as history of response to various medications also state that the analysis had been accepted having important consequences on pregnancy, prescribed in other disorders, for example in 25 is clearly of vital importance. Rather, it is more lar history, additional factors that increase risk women with unipolar and/or bipolar disorder appropriate to deal in general principles that Inadvertent conception on medication include having experienced a previous episode who discontinue medication in order to con- should guide care. In a naturalistic study of 89 women with bipolar In an ideal world, all women with a history of and having a frst degree relative who has expe- severe mental illness would seek advice on a rienced an episode of postpartum psychosis18. In addition, should be asked about the above risk factors clearly carry a higher risk than others, sodium recurrence risk has been described in women the regularly estimated 50% of pregnancies and protocols should be put in place to ensure valproate being a prime example, each deci- with unipolar depression. Of 201 euthymic that are unplanned may even be higher in that women at potential risk receive a formal sion should involve consideration of a complex women with a history of major mental disor- women with severe mental illness. Therefore, patients with a Another major consideration is how to illness, pregnancy raises a number of diff- the importance of seeking help if contemplat- history of mental illness who might become cult issues. Severe recurrences are common in determine what level of information women ing pregnancy (or if unexpectedly becoming pregnant are well advised to supplement as a relationship to childbirth, and for women with want or are able to assimilate. Many fessionals need to be sensitive to differences of pregnancies are unplanned, all women with For women at risk, perhaps the most impor- medications used to keep women well are of between individual women and, wherever pos- childbearing potential merit thorough consid- tant aspect of management is to maintain known or potential teratogenicity, but stop- sible, individualize the information as well as eration of potential pregnancy when making close contact with their health care profession- ping medication may be associated with a very the manner in which it is delivered. The same data, nition that, due to its particular teratogenic other avoidable factors that may increase risk that these are issues that must be discussed delivered in a variety of manners, can confer and developmental effects, sodium valproate with all women with reproductive potential. Health care profes- Clearly, the earlier potential pregnancy is should not be used in women in their repro- example, and paying attention to sleep pat- sionals must be aware of their own biases and considered the better; many months or even ductive years if it can be avoided30.