By T. Riordian.
Hypothyroidism is easily recognized when the clinical profle of a full-blown case is classical cheap ranitidine 300 mg overnight delivery gastritis diarrhea. Diagnosis must be confrmed depending on the individual merits of each case (Box 4 purchase ranitidine with a mastercard xanthomatous gastritis. Tere may be history of polyuria generic 300mg ranitidine gastritis or gerd, nocturnal enuresis, History and Physical Examination Body proportions: Tese are considered to be the most 71 accurate index of height. Upper segment/lower segment A good history and physical examination are important in ratio (short-limb short stature) is increased in hypo- evaluating a case of short stature (Table 4. Te ratio is decreased (short- Height: Accurate measurement of supine length less than trunk short stature) in spondyloepiphyseal dysplasia, 2 years and height at and beyond two years are important. It is calculated from at least two accurate Span: Measurement from midfnger tip to midfnger readings at a gap of 6 months (preferably one year). A tip in case of fully outstretched arms and hands is inc- velocity of less than 4 cm per year between 5 years of reased (more than height) in spondyloepiphyseal dys- age and adolescence is considered pathological. For plasia and Morquio’s syndrome and rickets involving younger children, it varies with age—15 cm for 0–6 vertebral column. Advanced z Genetic and chromosomal disorders (Down syndrome) z Sexual precocious puberty z Obesity z Hyperthyroidism z Adrenal hyperplasia. With the availability of assessment mentioned so far, the following guidelines determined as mean of father and mother’s heights are suggested: plus 13 in case of boys and minus 13 in case of girls as If height age falls within 2 years of the chronological age, described in Chapter 3 (Normal Growth). Te target range is obtained by plotting on the growth If height age is less than the chronological age and the chart where the two points 8 cm above and below the bone age is equal to height age, slow growth—in other target height at adult equivalent age, i. Tis words, constitutional delay is the likely cause of short represents the 3rd and the 97th centile for the said child. In this situation, the child attains his target Te 3rd and 97th centiles are constructed by tracing lines height subsequently. Such a child has short parents the contrary, if weight is nearly normal, but height is sig- and is likely to remain short. Growth hormone defciency and hypercorticism also consider constitutional growth retardation, hypothy- fgure in the diferential diagnosis. Sexual Maturity Rating (Pubertal Staging) Tis is done by Tanner’s method described in Chapter 7. Children with delayed puberty and Besides radiology and routine investigations, including meti- short stature should arouse suspicion of sex chromosomal culous stool examination on at least 3 successive days, it anomalies. In Turner syndrome, the child is likely to end should be ascertained if there is a need for intensive workup. In late specifc investigations are: maturers, both short stature and delayed puberty coexist. Karyotyping, especially in girls in order to exclude Tese late maturers eventually attain better heights com- Turner syndrome, pared to early maturers. Bone age assessed through radiological examination of z Growth (height) velocity less than 4 cm per year. In infancy, knee, wrist and hand, and in later years z Existence of characteristic features of an endocrinal cause or a elbow, wrist and hand are appropriate sites for bone age syndromal state. Idiopathic Zinc supplementation, growth Important comparative features of familial, constitu- hormone tional, growth hormone defciency and hypothyroid short Skeletal dysplasia Limb-lengthening surgery is possible stature are presented in Table 4. Occasionally, surgical excision may z Idiopathic short stature with low growth velocity. Fetal overgrowth Cost of therapy z Maternal diabetes Today’s genetically engineered growth hormone i. Administration and dosage Postnatal overgrowth z Age: It is mandatory to start such a therapy before 11 years of age z Familial for attaining the optimal height. Other anthropometric indices include: Skin-fold thickness Waist-hip ratio Weight for height. Around 50 million (20% in resource-limited world) children under 5 years of age are top of regular diet by children, lack of physical activity is the estimated to be overweight. Tis occurs as a result of excessive dietetic consumption, Physiological Obesity today’s most important nutritional problem in the Euro- pean countries (Box 4. But it is now beginning to hit the Tis occurs in early adolescence and is frequent among girls in particular. It is temporary and regresses after ado- upper strata of society in the developing world as well; that lescence. Manifestation in a child with exogenous obesity include: Obesity, excessive deposition of adipose tissue, results Fat deposition is generalized (Fig. But, as a matter of fact, they sufer from z Constitutional loneliness and profound psychological trauma. Manifestations in endogenous obesity depend on the Endogenous underlying condition (Figs 4. In Cushing z Genetic/chromosomal syndromes: Laurence-Moon-Biedl syn- syndrome, for example, obesity is typically central with drome, Turner syndrome, Prader-Willi syndrome involvement of upper trunk and face. Intelligence Normal Usually low Central:Upper trunk and face predominantly involved Height Either normal or Usually stunted as in Cushing syndrome. In order to label a child Bone age Either normal or Usually retarded fatty, the weight should be above 20% of average weight for advances age and body mass index above 95th percentile (30 kg/m2). Endocrinal Nothing apparent Acne, hirsutism, menstrual Height may be normal or little more than the average. Appetite-inhibiting/suppressant agents, though often recommended in adults, are best avoided in pediatric obe- sity. Whereas amphetamines should be avoided, orlistat, metformin, leptin, and octreotide may be considered in select pediatric cases. Orlistat, a gastric lipase inhibitor, is the frst anti- obesity agent approved for children. Leptin, which reduces the hypothalamic drive is indi- cated in leptin-defciency obesity. Curtailment of intake of snacks in between main meals and Restriction of television viewing to <2 hours daily. Te trafc-light plan for various foods are to cut down weight via acceptable means, including given in Table 4. Since the Type of Fruits, vegetables Lean meats, dairy, Fatty meats, stif skull vault does not allow the brain to grow, a kind of food starches, grains sugar, fried foods situation resembling raised intracranial tension may result. Quantity Unlimited Limited Infrequent or Underdeveloped sinuses are a common accompaniment. However, as a compensatory mechanism, excessive skull growth occurs parallel to the involved suture, resulting in a skull deformity varying with the afected suture. In addition to the primary craniosynostosis (resulting from abnormal development of skull per se), failure of brain growth, maturation and expansion may cause secondary craniosynostosis.
An overview of inficted head injury in nation or were a result of a medical procedure buy ranitidine without a prescription gastritis radiology. Injuries infants and young children buy cheap ranitidine 150mg on line gastritis diet 7 up coupon, with a review of β-amyloid precursor protein immunohistochemistry ranitidine 300 mg fast delivery gastritis healing process. Arch Pathol that lack signifcant hemorrhage may be postmortem Lab Med 2006;130:712–717. For interpretation challenges involving female genitals with Sci Int 2004;146:83–88. Te spectrum of normal appearance precursor protein staining of nonaccidental central ner- is represented in the below diagram, which includes the vous system injury in pediatric autopsies. Pediatric Forensic Pathology 199 Clitoris Urethra Vaginal Opening Complete Absence of Hymen Crescentric Fimbrated Capanculac Annular Trefrenestratos Sepate Libials Cribriform Microperforate Imperforate 200 Color Atlas of Forensic Medicine and Pathology Figures 5. Note the x-ray and the sunken lungs at the bottom of the water container indicate no breaths were taken. For example, postmortem bacterial gas produc- tion can enable lungs from a stillborn fetus to foat in water. While the utero-placental unit is usually a sterile environ- ment, bacteria may be introduced in cases of chorioamnionitis, for example. Note the marks and discoloration on the face as a result of endotracheal intubation and application of tape. It is important to document such fndings at autopsy, but they should not be misinterpreted to have been caused by smothering, for example. It is very important for clinicians to leave all interventions on or in the body so that their placement and effects can be accurately interpreted at autopsy. Diagnosis of exclusion means all other causes of death and unsafe conditions, including unsafe sleep practice, has been ruled out. Unsafe sleep practices include co-sleeping, sleeping on soft bedding, and sleeping in a prone position. The best way to evaluate and document organ system malfor- mations in fetuses and infants is with the en bloc evisceration method. When this was discovered, the organ procurement agency was contacted, who released the heart to the medical examiner’s office. The heart was found to have an anomalous origin of the left coronary artery from the right sinus of Valsalva, a rare yet documented cause of sudden death in adults and infants. The issue of organ procurement remains a controversial and, at times, problematic one for the forensic pathologist. For example, consistently reliable methods for evaluating the coronary ostia have not been established in many tissue procurement agencies. This a common mode of resuscitation in infants with extremely small, often collapsed blood vessels. Posterior rib fractures can arise from either therapeutic or abusive chest compressions. Clinical history and/or scene investiga- tion are vital to understanding the circumstances under which such injuries are sustained. Note the small bruise on the left cheek, which occurred several days earlier due to a fall. The resuscitative efforts were captured on a department store video camera in this child that became lifeless following a seizure. He was pulseless, apneic, and asystolic, and despite resuscitative efforts, he could not be revived. The mattress was separated from the wall by at least several inches, which allowed the infant to descend into the space and become compressed. There is also a faint area of dark discoloration on the left buttock (“Mongolian spot”). Subsequent scene investigation by the medical examiner’s office and police department revealed that the child had actually died from positional asphyxia, having slipped down and wedged between the crib’s mattress and frame. Autopsy dem- onstrated multiple mucous plugs within the medium-sized airways, along with other characteristic pathologic features of asthma. This 7-month-old female infant was verify the absence of injury, incisions into the subcutis of found unresponsive in a seat that had fallen to the foor the trunk and extremities are made at autopsy, especially from an adult bed, resulting in her chin being tightly in dark-skinned individuals in whom bruises cannot be apposed to her chest, satisfying the criteria for positional easily recognized on the body. The mother had allegedly left the infant and her 18-month-old brother unattended in an empty bathtub, and the mother postulated that the brother must have turned on the faucets when she was away. When attempting to reconstruct the scene, police dis- covered that the brother was unable to turn on the faucets by himself. Although the cause of death in this case was certi- fed as drowning and the manner homicide, the mother was released on probation. Mom reported fetal movement in the amniotic sac for a period of time following delivery. This individual had fallen in the past and accidently struck his face on a kitchen cabinet. It is important to realize that a homicidal smothering may occur without leaving marks on the body as well. If possible, it is always important to photograph infants as they are found, which allows for more accurate reconstruction of the terminal events (e. Vigorous resuscitation efforts, which include chest compressions, contribute to the formation of edema fuid, which is often blood-tinged due to rupture of small capillaries in the lungs. Oftentimes, the blood-tinged fuid is misinterpreted by scene investigation personnel as being suspicious of foul play. An intact upper frenulum with dried blood-tinged secretion around the left side of the Figure 5. The confuent burns/abrasions on his anterior chest refect application of defbrillator pad- dles during resuscitation. The blotchy red discoloration of the forehead and face (left side slightly greater than right side) might be inter- preted as livor mortis, but it is important to realize that vigorous resuscitative efforts may also alter the patterns of vascular congestion. The precise mechanism underlying the formation of petechiae remains elusive, but is believed to be related to the negative intrathoracic pressure created by terminal gasp- ing in infants. In this case, the petechiae, which appear as pinpoint hemorrhages, are particularly striking. Pertinent history included prematurity, maternal group B streptococcal infection, and a recent upper respiratory infection. The only signifcant fndings at autopsy were a moderately cellular mononuclear leptomeningeal exudate, consistent with a viral meningoencephalitis. This picture depicts prominent petechiae on the anterior epicardial surface of the heart. This picture shows sparse, inconspicuous petechiae on the visceral pleura and thymus, which were the only gross fndings at autopsy. Note the way that the hemorrhages conform to anatomic boundaries, similar to what is observed in aspiration of blood. Note also the confuent congestion within the posterior aspects of the lung, most likely a result of postmortem hypostasis, or settling of blood due to gravity.
Yes discount 300mg ranitidine with mastercard gastritis operation, hemihypertrophy is one the predisposing congenital conditions for Wilms’ tumor cheap 300mg ranitidine otc gastritis in english language. Other such conditions are Beckwith syndrome buy generic ranitidine on-line gastritis liver, aniridia, duplication of kidney or ureter, hypospadias, undescended testis, and ambiguous genitalia. Exposure Conventionally speaking, the term, immunity, refers to to a microbe second time provokes the adaptive immunity the defense mechanism that protects an individual against to recall previous express and react with a rapid rise in invasion by an infection. Innate immunity may be genetically passed on from Cellular Components one generation to another without depending on previous contact with a microbe. When it indicates a degree of T ymus and bursa of Fabricius (marrow in man) form resistance to all infections, it is termed nonspecifc. Spleen and lymph glands there is a resistance to a particular pathogen, it is called constitute the peripheral lymphoid tissues. Innate immunity is also expressed in relation to response has two stages: species, race or individual. It should be considered primitive with no Phagocytic response consists of destroying the foreign memory. In the conduct of phagocytic response, additional Lymphocytic response is afected by either humoral or factors such as complement and opsonin may be required. If the invading agent is destroyed by phagocytosis, immune Humoral immunity is concerned with synthesis and response stops here only. However, if antigenic products release of antibodies (immunoglobulins) secreted by plas- are produced, the next step, i. Its which is the sheet-anchor of the immunologic system, functional cell is B lymphocyte, the bursa-dependent cell, must follow. T helper cells are essential for Complement refers to a series of factors in the normal their transformation into antigen recognition cells and pro- serum that are activated by antigen-antibody interac- duction of immunoglobulins. T suppressor cells suppress tion and subsequently mediate a number of biologically the activity and lessen formation of antibodies. It forms about 10% of human immune response is maintained within a tolerable level. Tere are 9 distinct components of com- On entry of an ofending agent (antigen), B cells plement system, one of them having 3 subunits (C´1g´, develop into plasma cells which secrete specifc antibodies C´1r´, C´1s´) thereby making a total of 11 proteins. Once the illness is over, level of of event in which complement components react in spe- circulating antibodies falls slowly over a period of several cifc sequence following activation of antigen-antibody weeks. In case the same illness returns, level of antibodies complexes and culminating in immune cytolysis is known against the antigen rises rapidly, thereby halting the as classical C´ pathway. Activation of C´3´ without prior invasion by the same antigen and acquisition of specifc participation of C´1´, C´4´ and C´2´ is called alternate immunity. Activities of the complement immunity against mechanisms by which the antibody was produced earlier. Functions C´1´ and C´4´, C´1´, C´4´, C´2´ and C´3´: Neutraliza- of the B cells include: tion of viruses Protection against Staphylococcus, Streptococcus, Hemo- C´4a´, C´3a´, C´5a´: Capillary dilatation phillus, Pneumococcus C´5a´: Chemotaxis of neutrophils, monocytes, eosino- Neutralization of viruses to prevent initial infection phils Action as a barrier along gastrointestinal and respira- C´3b´: Opsonization, enhancement of cell-mediated cyto- tory tracts toxicity stimulation of production of B cells lymphokines Active lysis of cells of autologus origin or engagement C´3b´, C´3d´: Increased induction of antibody formation in antigen-antibody complex disease C´3c´: Induction of granulocytosis Interference with T killer cells activity, or directly or C´5´: Opsonization of fungi indirectly blocking the reaction. In the thymus hormone, thymosin, is claimed to maintain their fetus, it is by far the only immunoglobulin present. Functions of T lymphocytes include: newborn receives it, by transport across the placenta, T helper function in sufcient amount depending on the gestational age, T suppressor function weight and efciency of placental function. Tere are further z Containment of fungal infections (candida) subclasses of IgG, say IgG1, IgG2, IgG3 and IgG4, based on diferences in heavy polypeptide chain (Fc). Te exact role of IgM in z Rejection of allograft (tumors) immune response is not yet clearly understood. Te major soluble factors include: z Transient hypogammaglobulinemia G Mitogenic factor which enhances lymphocyte multipli- z Panhypogammaglobulinemia (congenital agammaglobulinemia, cation Bruton disease) Permeability increasing factor z Dysgammaglobulinemia (common varied immunodefciency) Lymphocytotoxin Selective IgA defciency Selective secretory IgA defciency Migration inhibiting factor which favors phagocytosis Selective IgM defciency Transfer factor which transfers to the uncommitted IgG subgroup defciency. T cell (cellular) defects Cellular immune response ends up in destruction of the z Congenital thymic hypoplasia (DiGeorge syndrome) antigen. Tis may either be directly through the action of the z Nezelof syndrome sensitized lymphocytes or by activity of lymphocytotoxins. By immunodefciency is meant that one or more defense Neutrophil defects mechanisms are impaired or lacking. It may be primary z Qualitative when there is no obvious systemic disease to explain its oc- Chronic granulomatous disease Chediak-Higashi syndrome currence. In the secondary type, the cause is clearly outside Job syndrome the lymphoid system, e. Primary defciency is far less Cyclic neutropenia than the secondary defciency (Fig. Both sexes are afected, the incidence being z Ataxia telangiectasia, characterized by hereditary cerebellar higher in preterm infants. Te condition is associated ataxia and conjunctival telangiectasia together with frequent with frequent bacterial infections in which situation the sinopulmonary infections infant needs to be administered 0. Clinical manifestations include repeated infections with Pneumococcus, staphylococcus and Hemophilus infuenza as also viruses, especially echotype 30, skin disorders like eczema and recurrent abscesses, malabsorption, Lam- blia giardia infestation, disaccharide intolerance and increased incidence of malignancy. Diagnosis is made by assaying the serum immunoglobulin IgM and IgA nearly absent and IgG invariably less than 200 mg/dL. Long-term complications include bronchiectasis, rheumatoid arthritis, malignancy, hemo- lytic anemia and infection with Pneumocystis carinii. Dysgammaglobulinemia (common varied immuno- defciency) refers to states of absence or defciency of one or more immunoglobulins. There was demonstrable defciency in T cell system with normal serum globulin is a remarkable association with autoimmune disease like levels. Te patient, how- Features (fne, thin hair, short-limbed dwarfsm with ever, has normal capacity to synthesize IgG and IgM antibod- characteristic roentgenographic features) of cartilage- ies. Overall is scaling erythroderma and total alopecia (absence of incidence varies between 1 in 400 and 1 in 1,000. Selective defciency of secretory IgA may occur in two Graft-vs-host disease after blood transfusion. Inselective IgM defciency, prominent clinical features include fulminant hematogenous spread of bacterial Congenital thymic hypoplasia or aplasia (DiGeorge infections, atopy and splenomegaly. Common associates syndrome) is characterized by embryonic combined def- are Whipple disease, regional enteritis and lymphoid ciency of thymus and parathyroids (both arise from third nodular hyperplasia. A vigorous antibiotic treatment as and fourth pharyngeal pouches) in association with con- soon as infection is suspected is indicated. Clinical symptoms suggestive of combined B and T cell Chronic mucocutaneous candidiasis. This 10-year-old boy that showed waxing and waning from early infancy, this 1-year-old had presented with chronic generalized lymphadenopathy (most marked in recurrent epistaxis and purpura, discharging ears and frequent intercur- the cervical and axillary regions where the nodes showed multiple dis- rent infections. Level of lgM was remarkably low though IgA prominence as also widening of the superior mediastinum (not due to and lgG levels were elevated. Emperically, antituberculous therapy was given Features of all above, except chronic mucocutaneous without any relief. Cellular and candidiasis and nodular lymphoid hyperplasia antibody responses were found to be normal.
There is also an association with cysts in other organs and intracranial berry aneurysms order 300mg ranitidine with visa gastritis diet in spanish. It is also important to know that acute obstructive urolithiasis with urosepsis can be rapidly fatal ranitidine 150mg on-line gastritis fish oil. Note the markedly enlarged prostate gland with areas of central nodularity compressing the prostatic urethra order ranitidine online now granulomatous gastritis symptoms. Note the trabeculations and thickening of the urinary bladder wall due to obstruction. This woman was known to be colo- nized by group A beta-hemolytic streptococcus (Streptococcus pyogenes). Approximately 8 hours following an uneventful delivery, she began to complain of back and pelvic pain. Within 4 hours she was in full-blown shock and was refractory to resuscitative measures. This picture depicts the gravid uterus and confuent brown-black discoloration of the left adnexa, which proved microscopically to show areas of necrosis with numerous clusters of bacterial cocci and scant neutrophilic infltrates. Postmortem cultures of multiple organs, including lungs, liver, spleen, uterus, and peritoneal fuid, all grew group A beta-hemolytic streptococcus beta- hemolytic streptococcus. This “toxic shock–like” death due to group A streptococcus has given rise to the term “fesh- eating bacteria. These areas of hemorrhage may be caused by minimal trauma, which may or may not indicate neglect or elder abuse, depending upon the circumstances. This may also be seen in association with therapy including intravascular catheters and blood drawing. When the latter situation is present, the manner ple: (1) these deaths ofen blur the boundaries dividing of death is most accurately designated accident. Many medicolegal and hospital death investigation; (2) many examples of legitimate therapeutic complications exist. Pulmonary gists and death investigators will, at some point during hemorrhage has been a recently reported complication their careers, be forced to handle these types of deaths. For example, if a 65-year-old man infarct (due to atherosclerotic heart disease)” and the who has stubbornly refused surgical intervention of a manner, “therapeutic complication. In such a case, foration of the colon during the procedure, the death the medical intervention or procedure played no part certifcate would read: “E. Admittedly, there are cases the death to “hallux valgus” would be as ridiculous as that fall within the murky zone between natural and it was erroneous. It is for cases like this that the concept therapeutic complication and between therapeutic com- of therapeutic complication merits consideration for a plication and accident. It is Once it is determined that the death was related important to recognize and remember that death certif- somehow to the procedure, the next question in the icates are not immutable documents that are “written in algorithm becomes: Was the death a result of a known stone”; rather, they can be amended should more accu- or predictable (albeit rare or unusual) complication of rate information regarding the circumstances of death a properly performed diagnostic procedure or appro- become available at a later time. When the former scenario exists, the an invaluable tool in the assessment of these types of 73 74 Color Atlas of Forensic Medicine and Pathology deaths, the practical applicability of the term to the death not include it on the death certifcate, then the manner certifcate has enjoyed less success. One other option is to list “therapeu- jurisdictions—Cuyahoga County, Ohio, and New York tic complication” in parentheses afer “natural,” but this City—include “therapeutic complication” as a choice in probably is not common practice. Terefore, nite future, forensic pathologists will be resigned to use when a death fts the criteria for therapeutic complica- the term as a conceptual tool in the evaluation of these tion as the manner, but the particular jurisdiction does most challenging deaths. Note the hemorrhagic discoloration around each eye (periorbital) and the plastic insert in the opened eye fol- lowing tissue removal. Medical record review and clinician interview revealed that these periorbital hemorrhages were not present at the time of admission. These are artifacts of transport, caused by a strap to secure the child’s head, as they were fown by helicopter from an outside hos- pital to a tertiary pediatric center. He was taken to the hospital in an uncon- scious state and remained so until his death. There was initial speculation that he was struck by another motor vehicle due to the “tire-like” patterns on his legs. Further investigation revealed these injuries were not present at the time of arrival to the Emergency Department. There was a pelvic fracture with blood seeping into the legs, extensive generalized edema, and disseminated intravascular coagulation. This pattern of ecchymosis was caused by the pressure boots in conjunction with the complications of the injuries. It is important for therapy to be left on the body and examined by the pathologist before removal. Also note the early putrefactive change consisting of green coloration of the lower abdomen. It is absolutely essential for the pathologist to examine the eyes before vitreous fuid is obtained. There was no trauma to his trunk except for the attempted resuscitation efforts by family and later by hospital personnel. He had hepatic parenchyma with lacerations and intact capsule and minimal sub Glisson’s capsular hemorrhages. The two lower images show a similar case of hepatic injury due to improperly placed hands while performing chest compres- sions. This is an artifact encountered frequently during resuscitative measures, often referred to in forensic text- books as the “Prinsloo and Gordon” artifact. Because of the rich esophageal venous plexus, this tends to be a very hemor- rhagic area following intubation and therefore may be confused with stigmata of manual strangulation. The epiglottis can be seen slightly behind the endotracheal tube, confrming an esophageal intubation. The close-up of this autopsy photograph depicts an esophageal intubation, with the endotracheal tube clearly within the esophageal lumen and the concentric tracheal rings visible slightly anterior to and (anatomically) to the right of the tube. Esophageal intubations during an elective procedure, on the other hand, would be very important and potentially causal or contributory to the death. Note the mis- placed endotracheal tube that crossed from the right side of her mouth to the left pharyngeal region where it perforated and penetrated the soft tissues of the neck, completely missing the airway. Note the perforations on the posterior surface of the trachea and the anterior aspect of the esophagus. During a bout of crying, the tracheostomy tube became dislodged, and after nurses attempted to reposition it, she rapidly developed subcutaneous emphysema, followed by bilateral tension pneumothoraces. Autopsy demonstrated marked subcutaneous emphysema, including periorbital swelling. The tube had been removed before the autopsy, precluding assessment of its placement. It is important that all tubes remain in the body for objective postmortem (autopsy) evalu- ation of their placement. This may make injury inter- onstrates a catheter placed into an injured blood vessel pretation more challenging. If at all possible, this should never be done because it makes injury interpretation much more difficult. Had it not been for this trauma, the infection that took his life would not have occurred.