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Consider carrying on for longer especially when: » hypothermia and drowning » poisoning or medicine overdose or carbon monoxide poisoning 21 order generic precose pills diabetes medications reference chart. Resuscitation from cardiac arrest is less often successful in children and it is better to prevent cardiopulmonary arrest by recognising serious illness and managing it appropriately purchase 25 mg precose fast delivery diabetes symptoms hives. The effective treatment of cardiorespiratory arrest in children is the prevention of the arrest by early recognition and management of severe disease generic 50mg precose free shipping diabetes symptoms in men. Bradycardia in children is a pre-terminal event and needs to be treated with resuscitation. Circulation » Check for signs of life and presence of central pulse for 5–10 seconds. In younger children check brachial or femoral pulse, in older children use brachial or carotid pulse). During this procedure keep the neck and head stable in the neutral position to protect from cervical spine damage. Then » If 2 rescuers are present, carry out cycles of 15 chest compressions followed by 2 respirations. Consider stopping resuscitation attempts and pronouncing death if: » further resuscitation is clearly clinically inappropriate, e. If the child is still able to Transfer urgently to hospital for treatment and breathe accompanied with someone able to treat acute complete choking. If the child is able to talk Encourage the child to cough repeatedly while and breathe arranging transfer urgently with supervision. If the child is not breathing Urgent attempts should be made to dislodge the or is in a life-threatening foreign body. Back blows and chest/abdominal thrusts Infants: Place the baby along one of the rescuer’s arms in a head down position. If this is ineffective turn the baby over and lay it on the rescuer’s thigh in the head down position. In place of the chest thrust, abdominal thrusts are used (Heimlich manoeuvre) and may be used standing, sitting, kneeling or lying. For abdominal thrust in the standing, sitting or kneeling position the rescuer moves behind the child and passes his arms around the child’s body. One hand is formed into a fist and placed against the child’s abdomen above the umbilicus and below the xiphisternum. The other hand is placed over the fist and both hands are thrust sharply upwards into the abdomen towards the chest. In the lying (supine) position the rescuer kneels astride the victim and does the same manoeuvre except that the heel of one hand is used rather than a fist. If not relieved the cycle of back blows →abdominal thrusts →reassessment is repeated until the relief of obstruction or failure of resuscitation. Delirium is a sudden onset state of confusion in which there is impaired awareness and memory and disorientation. Delirium should not be mistaken for psychiatric disorders like schizophrenia or a manic phase of a bipolar disorder. These patients are mostly orientated for time, place and situation, can in a way make contact and co-operate within the evaluation and are of clear consciousness. The elderly are particularly prone to delirium caused by medication, infections, electrolyte and other metabolic disturbances. Main clinical features are: » acute onset (usually hours to days) » confusion » impaired awareness » disorientation Other symptoms may also be present: » restlessness and agitation » hallucinations » autonomic symptoms such as sweating, tachycardia and flushing » patients may be hypo-active, with reduced responsiveness to the environment » a fluctuating course and disturbances of the sleep-wake cycle are characteristic » aggressiveness » violent behaviour alone occurs in exceptional cases only 21. T – Trauma O – Oxygen deficit (including hypoxia, carbon monoxide poisoning) P – Psychiatric or physical conditions, e. Poisoning may occur by ingestion, inhalation or absorption through skin or mucus membranes. Frequently encountered poisons include: » analgesics » anti-epileptic agents » antidepressants and sedatives » pesticides » volatile hydrocarbons, e. Note: Healthcare workers and relatives should avoid having skin contact with the poison. Specific antidotes Hypoxia, especially in carbon monoxide poisoning: Oxygen Organophosphate and carbamate poisoning » Signs and symptoms of organophosphate poisoning include: diarrhoea weakness vomiting miosis/mydriasis bradycardia confusion muscle twitching convulsions coma hypersecretions (hypersalivation, sweating,lacrimation, rhinorrhoea) brochospasm and bronchorhoea, causing tightness in the chest, wheezing, cough and pulmonary oedema 21. Note: Send the following to hospital with the patient: » written information » a sample of the poison or the empty poison container 21. The definitions of sexual offences are within the Criminal Law (Sexual Offences and Related Matters) Amendment Act, No 32 of 2007. So called “cold cases” (> 72 hours after the incident) may be managed medically and given an appointment for medico-legal investigation. Medico-legal assessment of injuries » Complete appropriate required forms and registers. Adults Tenofovir, oral, 300 mg daily for 4 weeks and Emtricitabine, oral, 200 mg daily for 4 weeks or Lamivudine, oral, 150 mg 12 hourly for 4 weeks. If uncertain, phone Childline 0800055555 - Adults with: » Active bleeding » Multiple injuries » Abdominal pain » History of the use of a foreign object Note: Refer if there are inadequate resources with regard to: – counselling – medico-legal examination – laboratory for testing – medicine treatment 21. There is a higher risk when: » the injury is deep » involves a hollow needle » or when the source patient is more infectious, e. Other blood borne infections that can be transmitted include hepatitis B, hepatitis C and syphilis and all source patients should be tested. Adverse effects occur in about half of cases and therapy is discontinued in about a third. Tenofovir is contra-indicated in renal disease or with concomitant use of nephrotoxic medicines e. Clinical features include: » tremor » confusion » sweating » delirium » tachycardia » coma » dizziness » convulsions » hunger » transient aphasia or speech disorders » headache » irritability » impaired concentration There may be few or no symptoms in the following situations: » chronically low blood sugar » patients with impaired autonomic nervous system response, e. Breastfeeding child administer breast milk Older children A formula feed of 5 mL/kg. Conscious patient, not able to feed without danger of aspiration Administer via nasogastric tube: Dextrose 10%, 5 mL/kg. Closed injuries and fractures of long bones may be serious and damage blood vessels. Note: In a fully immunised person, tetanus toxoid vaccine might produce an unpleasant reaction, e. Increased heart rate (> 160 beats/minute in infants, > 120 beats/minute in children). Decreased blood pressure and decreased urine output are late signs of shock and can be monitored. The other signs mentioned above are more sensitive in detecting shock, before irreversible. Types of shock Additional symptoms » Hypovolaemic shock Most common type of shock Weak thready pulse, cold Primary cause is loss of fluid and clammy skin. Intravenous fluid therapy is important in the treatment of all types of shock except for cardiogenic shock and septic shock after fluid challenge.
Raw Water Intake Hazard Control Direct surface water abstraction causing variability in water quality Change abstraction point to minimise variability in raw water cheap precose 25mg amex diabetes symptoms 9 days. Intake not secured against livestock access causing microbial contamination Install and maintain fencing in the vicinity of the intake purchase 25mg precose amex diabetes type 2 glucose range. Lake source intake point vulnerable to variation due to streams/ stratification/ Change abstraction point to minimise variability in raw water order precose 50mg amex diabetes joint pain. Raw Water Storage Hazard Control Susceptible to flooding / contamination Consider flood defences. Unauthorised access resulting in deliberate contamination Appropriate security and alarm system for site. Lockable covers on all Water Treatment Manual: Disinfection access points to water supply. Wildlife access to raw water tank causing contamination Erect fencing or cover to prevent wildlife access. Sludge build up in raw water tank causing contamination Regular inspection and maintenance programme. Leaking impounding reservoir causing ingress of contamination Regular inspection and maintenance programme. Raw Water Line Hazard Control Pipe corroded or not watertight causing intrusion of Surface Water Regular inspection and maintenance programme. Raw water serving consumers without disinfection or other treatment Ensure asset records are kept up to date and authorised connections refer to these records. Treatment plant operating above design capacity Ensure treatment plant is operating within acceptable limits. Plant data can be used to verify this By-passing of any stage of treatment Appropriate alarms to notify when individual processes are bypassed. Frequent and significant flow variations through the works Consider intermediate storage to smooth out flow variations. Verify with plant data Coagulation/Flocculation/Clarification Stage Hazard Control Chemicals delivered to incorrect storage vessel Ensure chemical deliveries are overseen by competent treatment works personnel. Floc carry over due to inappropriate/inadequate dosing regime Regular dose optimisation. Floc carry over due to overloading of the plant/ surge flows Operate process within design parameters. Floc carry over due to poor adjustment/maintenance/design of lamella plates Regular inspection and maintenance programme Floc carry over due to poor maintenance or flooding of settlement channels Regular inspection and maintenance programme. Consider covering settlement channels if flooding a serious risk Floc carry over due to variations in raw water characteristics Regular inspection and dose optimisation Floc carry over due to effects of weather condition Regular inspection and maintenance programme. Floc carry over due to inadequate cleaning of clarifiers Regular inspection and maintenance programme Water Treatment Manual: Disinfection Hazard Control Floc carryover due to poor settlement/ unstable sludge blanket Regular inspection. Floc carryover due to sludge float/ scraper not operating properly Regular inspection and maintenance programme Floc carryover due to sludge concentrators not operating properly Regular inspection and maintenance programme Floc carryover due to sludge bleeds not operating properly Regular inspection and maintenance programme Floc carryover due to insufficient sludge draw off Regular inspection and maintenance programme Chemicals used after expiration date – ineffective chemicals Ensure chemicals are stored appropriately and used within expiry date Inadequate storage areas for chemical stocks, risk of running out of treatment Ensure storage is adequate for required chemical stockpile. Consider moving dosing point Inadequate cleaning regime in mixing tank Regular inspection and maintenance programme Algal or plant growth in clarifiers causing poor water quality and clogged filters Regular inspection and maintenance programme Poor structural integrity of clarifiers causing contamination due to ingress Regular inspection and maintenance programme Sludge recycled to head of works Ensure sludge quality and quantity suitable for reuse. Inadequate particle removal due to blocked filters Run filters within design and operating limits. Assess by measurement of head loss, flow rate and turbidity Inadequate particle removal due to inadequate filter media depth Check appropriate media depth for design of filter. Water Treatment Manual: Disinfection Hazard Control Inadequate particle removal due to inadequate filter media type Check appropriate media type for design of filter. Regular inadequate cycle length, uneven scour, pump failure, loss of filter media) inspection of filters and maintenance of backwash equipment. Inadequate particle removal due to poor filter maintenance (cracks, boils etc) Regular inspection and maintenance programme. Rapid gravity filters put back into operation without slow start Use slow start, delayed start or run to waste on filter return to service. Slow sand filters put back into operation without ripening period causing Check appropriate ripening regime in place. Filtered Water – Cryptosporidium breakthrough Ensure turbidity monitors on each filter routinely reviewed. Assess with turbidity there is a risk of the presence of Cryptosporidium in the raw water measurements, provide appropriate alarms. Backwash water recycled to head of works causing increased turbidity Monitor turbidity and flow rate on recycle flow line. Water Treatment Manual: Disinfection Disinfection Hazard Control Disinfection system is not reliable Ensure robust disinfection system in place with appropriate monitors and alarms on key equipment. Chemicals used after expiration date – ineffective chemicals Ensure chemical storage is appropriately sized. Water Treatment Manual: Disinfection Other hazards associated with the treatment plant Hazard Control Loss of Power Supply Consider back up power supply e. Fire/Explosion - loss or restriction of treatment works Ensure risks are minimised through good health and safety procedures. Spill from unbunded chemical or oil storage tank causing contamination Regular inspection and maintenance programme. Chemical overdose due to poor process control Regular calibration, inspection and maintenance programme. Access to the plant - loss or restriction of access due to weather extremes or Install appropriate alarms to warn of impending access restrictions. Availability and continuity of supply of treatment chemicals Consider long term arrangement with suppliers. Risk of fluorine overdose in treated water Regular calibration, inspection and maintenance programme. Adverse weather conditions affecting treatment chemicals and/or processes Install appropriate alarms with failsafe mechanisms e. Insufficient disinfection in distribution network causing microbial contamination Provide secondary disinfection. Maintenance/ replacement of pipe work causing microbial contamination Procedure for disinfection of mains after repair or replacement. Backflow from industrial/ domestic premises or unregulated supply causing Install adequate backflow prevention devices. Leaking Reservoir causing ingress of contamination Regular inspection and maintenance programme. Unprotected access covers and/or vents causing contamination Lockable access covers, secure vents. Security/Vandalism to reservoir causing contamination Appropriate security and alarm system for site. Plant operator or relief caretaker not trained Ensure all operators fully trained in respect of their duties.
Failure to “shake well”: The failure to with its drug distribution system and a deficiency should “shake” a drug product that is labeled “shake be written cheap precose 25 mg on-line diabetes mellitus physiology. This will almost always lead to an Medication errors due to failure to follow under dose or over dose depending on the label instruction suspending abilities of the diluent’s and the elapsed time since the last “shake “ order precose canada blood sugar high after exercise. Also included under this category is the failure to 62 “roll” insulin suspensions buy precose 50mg online metabolic disease seizures. Insulin suspensions purpose can help further assure that the should not be shaken, they should be “rolled” proper medication is dispensed and creates in order to mix the insulin particles with the an extra safety check in the process of diluents without creating air bubbles. Crushing medications: Crushing tablets or Independent double-check systems can capsules that the label states “do not crush”. When this procedure is properly carried out, the likelihood that two individuals would make? Medications taken with food or antacids: the same error with the same medication for The administration of medications without food the same patient is quite low. Forcing functions and constraints they allow medication in order to prevent Gl irritation. Examples include software programs and whereas, some of the medication is with “forcing functions “ that require the entry administered in empty stomach or before of additional pertinent patient information taking food for better pharmacological & before the order is completed and the therapeutical action. Sublingual tablets which should not be and tasks can lessen human fallibility by swallowed: Swallowing a sublingual tablet limiting reliance on memory. If it is use of technologically and clinically sound swallowed, its absorption is greatly reduced. Use of inappropriate solvents : Some of the metric system except for therapies that use drugs (e. Use of Units should be spelled out rather than writing inappropriate solvent may reduce the efficacy “U”. For example systems from the archaic apothecary and Oxaliplatin must be reconstituted with 5% avoirdupois systems will help avoid dextrose only. Medication Error Reporting and Prevention and Institute for Safe Medication Practices emphasizes 4. Prescribers should include age, and when that illegibility of prescriptions and medication appropriate, weight of the patient on the orders has resulted in injuries to, or deaths of prescription or medication order. The following recommendations to help common errors in dosage result in pediatric minimize errors. The Institute for Safe Medication Practices patient can help dispensing health care suggests a number of error prevention tools professionals in their double check of the ranging from forcing functions to independent appropriate drug and dose. Strength should be expressed in metric amounts and 63 concentration should be specified. Ten-fold errors in drug strength and Error Reporting and Prevention Medication dosage have occurred with decimals due to Error Index. Prescribers should avoid use of abbreviations clinical pharmacology: J Clin Pharmacol, Jul including those for drug names (e. Reason J, Human Error, Cambridge, Mass : particularly dangerous because they have Cambridge University Press; 1990. Rothschild J, Computerized physician order entry in the critical care and general inpatient Conclusion setting : A narrative review; J Crit Care. Dec 2004;19(4) ;271-8 Pharmacists should ensure that “right” patient is receiving the “right” drug in a “right” 7. Guy J, Persaud J, Davies E, Harvey D, Drug medication safety and patient compliance. All health Errors : What role do nurses and pharmacists care professionals should have a common vision have in minmiaing the risk: J Child Health Care and that everyone works towards a common goal Dec 2003: 7(4):277-90 with the monitoring system. From the Medication Counseling : An Essential perspective of the pharmacy profession, we think Concept:; Chronicle Pharma Biz, April 2004, that we will do the justice by providing such Vol. She pulls two different pill boxes out of her bag and states that she is totally confused. Patient Case continued • Looking exhausted she explains that she is totally confused and has no idea what she is supposed to be taking. Upon examination of her inpatient record you see that she was to stop her diltiazem due to severe constipation and begin Metoprolol which she was discharged on. Polypharmacy Definition • Wide range of definitions • No consensus definition • Generally defined as “Administration of more medications than clinically indicated, representing unnecessary drug use. Pharmacokinetics continued • Protein binding changes – Malnutrition – Dentures – Food preparation differences – Dietary restrictions • Substance abuse affecting metabolism – Up to 10% of elderly use significant alcohol 1. Adverse Drug Events • Risk is 15% with two medications • Risk increases to 58% with 5 meds • Risk increases to 82% with ≥ 7 meds • Additional medications lead to greater incidence of drug interactions 1. Selected Beers Medications • Anticholinergics except amitriptyline • Antipsychotics • Benzos (especially long-acting) • Indomethacin and Ketorolac • Nitrofurantoin • Digoxin > 0. Conclusion • Pharmacist intervention had significant impact on polypharmacy prescribing • Decision support limited • Hard outcomes data limited • Longevity of interventions? It provides a valuable means to collect informa- tion, to connect with friends, business partners and the world at large, and to sell and buy goods. For many of us, the Internet has made professional and personal life easier, allowing previously onerous transactions to take place effort- lessly and in very little time. As a result, there have been important improvements in the quality of life of people in all countries and, in particular, for people in remote areas for whom it used to be difﬁcult to engage in timely communication and gain access to services. Child pornography, the promotion of violence and ﬁnancial fraud are probably the best-known forms of such abuse; most of us have read or heard about them. Among the numerous other ways in which the Internet can be exploited by unscrupulous criminals is drug trafﬁcking. Drug trafﬁckers use the Internet to establish and maintain their criminal networks and to sell illicit drugs or the chemical precursors used to manufacture such drugs. Less well known, but no less dangerous, is the misuse of the Internet by illegally operating Internet pharmacies to sell prescription medicines to the general public without the required prescription. Many of the pharma- ceuticals trafﬁcked in this way are either diverted from the licit market or counterfeit and, as such, constitute a danger to the health of individual consumers and the public at large. Moreover, the sale of controlled pharmaceuticals outside the legally established framework of bona ﬁde pharmacies constitutes a criminal offence. The online sale of such pharma- ceuticals by unscrupulous racketeers is no different from the trafﬁcking in illicit drugs, as it endangers lives just as much as street sales do. Preventive measures need to be taken to stop the further proliferation of illegally operating Internet pharmacies and to reduce their number. The Board hopes and expects that such cooperation will better protect the public against the illegal distri- bution of pharmaceuticals and, in particular, of controlled substances. The need for collaboration was the main reason why the Board developed the present guidelines, which have been elaborated with the support and contribution of national experts and relevant international organizations, Internet service providers, ﬁnancial services and pharmaceutical associations. The Board hopes that the guidelines will serve as a starting point for the kind of successful inter- national cooperation that will, in the long term, lead to a successful international agreement on the matter. Hamid Ghodse President International Narcotics Control Board iv Contents Page Foreword. Description of the problem The World Wide Web provides valuable services to a growing commu- nity of users.