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In renal losses, with diuretics and adrenal insufficiency: increased urine output and urine Na+ and decreased urine osmolality and specific gravity. In skin and gastrointestinal losses and with third spacing: decreased urine output and sodium and increased urine osmolality and specific gravity. If the infant is having seizures resulting from hyponatremia (usually sodium <120 mEq/dL), hypertonic saline solution (3% sodium chloride) should be given. The total body deficit of sodium (see section V,C,3) is calculated, and half of that is given over 12-24 h. The total maintenance fluids can be decreased by 20 mL/kg/day, and serum sodium levels should be monitored every 6-8 h. The maintenance sodium requirement for term infants is 2-4 mEq/ kg/day; it is higher in premature infants. Calculate the amount of sodium the patient is receiving, using the equations in Chapter 7. Use of supplemental sodium chloride or a formula with a higher sodium content may be necessary. Calculate the total sodium deficit using the following equation: the result will be the amount of sodium needed to correct the hyponatremia. Try to treat the underlying cause and increase the sodium administered to replace the losses. If a renal salt-wasting medication such as furosemide (Lasix) is being given, serum sodium levels will be low even though an adequate amount of sodium is being given in the diet. Most are also receiving oral feedings, so an oral sodium chloride supplement can be used. If a cuff was used, be certain that it was the correct width (ie, covering two thirds of the upper arm). If measurements were obtained from an indwelling arterial catheter, a "dampened" waveform suggests that there is air in the transducer or tubing or a clot in the system, and the readings thus may be inaccurate. Symptoms of shock include tachycardia, poor perfusion, cold extremities with a normal core temperature, lethargy, narrow pulse pressure, apnea and bradycardia, tachypnea, metabolic acidosis, and weak pulse. At the time of delivery, was there maternal bleeding (eg, abruptio placentae or placenta previa) or was clamping of the cord delayed Birth trauma (eg, liver injury, adrenal hemorrhage, intracranial hemorrhage, intraperitoneal hemorrhage). Endotoxemia occurs, with release of vasodilator substances and resulting hypotension. It usually involves gram-negative organisms such as Escherichia coli and Klebsiella spp but can also occur with gram-positive organisms such as in group B streptococcal and staphylococcal infections. Complete 21-hydroxylase deficiency and adrenal hemorrhage are the most notable endocrine disorders that can cause hypotension and shock. If there is a low serum sodium, high serum potassium, and hypotension, it is important to rule out adrenogenital syndrome. Hypotension in this group is rarely secondary to hypovolemia and more likely due to adrenocortical insufficiency, poor vascular tone, and immature catecholamine responses.

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According to various guidelines and fetal echo cardiography manuals, this view can be obtained in two ways, the so-called sweep and rotational tech niques [3]. According to the former technique, the transducer is swept slightly from the four-chamber view to insonate the very initial tract of the ascend ing aorta. The reason why we believe this technique is better than the other is because it aligns the transducer with the direc tion of the ascending aorta, allowing most of this ves sel to be visible on the screen. This view is obtained by rotating the transducer slightly toward the right fetal shoulder, in order to visualize the ascending aorta: this vessel arises from the left ventricle and points toward the right shoulder prior to curving into the aortic arch (Figure 5. This includes the following: (1) the pres emerges from the left ventricle, the mitral valve is closed, while ence of a vessel that connects with the morphologi the aortic semilunar valve is not visible since the cusps are fat tened along the aortic walls. As is evident, this view is almost at the level of monary trunk displayed on the long axis of the right the three-vessel view (see Figure 5. In this case, to reach the fnal diagnosis it is necessary to assess the right outfow (see Figure 5. Note the normal alignment of the interventricular septum with the anterior aortic wall (arrowhead). Abnormalities detectable on the left outfow tract view Crossover anomalies (Figures 5. If two parallel vessels are displayed on the long axis of the left ventricle, then an anomaly of crossover is pres Septal anomalies (Figures 5. On the other hand, if the stenosis is mod erate or moderately severe, the four-chamber view may be virtually normal. In this case, the anomaly is detected on the left outflow tract view, where the thickened semi lunar valve is seen and the stenosis diagnosed on color Doppler (Figure 5. The truncal valve, which view is significantly abnormal, and this leads to the diag derives from the abnormal fusion of the two semilunar nosis. Two different views may be used to assess the right out bifurcation); (2) the presence of a semilunar valve fow tract: the short and long axes of the right ventricle. On the contrary, to the direction of the aorta displayed on the adjacent the long axis, which depicts just the infundibular tract long axis of the left ventricle; and (4) the size of the ves and the main pulmonary artery with the semilunar sel is similar to that of (here, slightly larger than) the valve, can be obtained with virtually all fetal positions. This view is obtained from the long axis of the To obtain this view, from the four-chamber view, left ventricle, by curving the transducer toward the fetal the transducer should perform a rotation mirroring head. This includes the following: (1) the pres ence of a vessel that connects to the morphologi Checklist (same as for the long axis of the right ven cally right ventricle positioned on the right and that tricle).

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Plan the key steps and know the potential pitfalls in performing obstetrical procedures for adolescents d. Know the indications and contraindications for obstetrical procedures for adolescents 11. Know the anatomy and pathophysiology relevant to applying short arm and short leg casts b. Know the indications and contraindications for applying short arm and short leg casts c. Plan the key steps and know the potential pitfalls in applying short arm and short leg casts d. Recognize the complications associated with applying short arm and short leg casts 3. Know the indications and contraindications for management of hand and finger injuries b. Plan the key steps and know the potential pitfalls of managing hand and finger injuries c. Know the anatomy and pathophysiology relevant to management of hand and finger injuries d. Know the indications and contraindications for arthrocentesis and assessment of joint integrity b. Know the anatomy and pathophysiology relevant to arthrocentesis and assessment of joint integrity c. Recognize the complications associated with arthrocentesis and assessment of joint integrity d. Plan the key steps and know the potential pitfalls in performing arthrocentesis and assessment of joint integrity 5. Know the indications and contraindications for reduction of common joint dislocations and subluxations b. Know the anatomy and pathophysiology relevant to the reduction of common joint dislocations and subluxations c. Recognize the complications associated with reduction of common joint dislocations and subluxations d. Plan the key steps and know the potential pitfalls of reducing common joint dislocations and subluxations 6. Know the indications for management of fractures with neuro vascular compromise b. Know the anatomy and pathophysiology relevant to management of fractures with neurovascular compromise c.

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The Bleeding Time Test Principle the bleeding time is a measure of vascular and platelet integrity. Normal Values Children: < 8 minute Adults: < 6 minutes *Each laboratory should establish its own normal range which will depend on whether a lateral or longitudinal incision is made and precise determination of the end point. Apply firm pressure to the template while introducing the blade at a right angle on the upper portion of the template slot. Make a second (or third) incision parallel to the first and start separate stop watches. Under normal conditions the first full drop of blood appears in between 15 and 20 seconds. Whole Blood Coagulation Time Method of Lee and White Principle: Whole blood is delivered using carefully controlled venipuncture and collection process into standardized glass tubes. It is prolonged in defects of intrinsic and extrinsic coagulation and in the presence of certain pathological anticoagulants and heparin. Venous blood is withdrawn using normal precautions and a stop watch is started the moment blood appears in the syringe. Deliver 1ml of blood into each of four 10 x 1cm dry, chemically clean glass tubes which have previously been placed in a water bath maintained at 37oC. After 3 minutes have elapsed, keeping the tubes out of the water bath for as short time as possible, tilt them individually every 30 seconds. The clotting time of each tube is recorded separately and the coagulation time is reported as an average of the four tubes. Clot retraction is directly proportional to the number of platelets and inversely proportional to the hematocrit. Express this volume as a percentage of the original volume of whole blood placed in the tube. If clot retraction is normal, approximately half of the original total volume of serum should remain. Measurement of the Extrinsic System Prothrombin Time (One stage) Principle: the prothrombin is the time required for plasma to clot after tissue thromboplastin and an optimal amount of calcium chloride have been added. Add blood to 32g/l sodium citrate in a ratio of nine parts of blood to one part citrate.

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