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By: William A. Weiss, MD, PhD

• Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

https://profiles.ucsf.edu/william.weiss

Extracting as latex allergy; much of the contaminating material as possible before it h) Learn to buy proventil 100 mcg otc asthma symptoms forum recognize the symptoms of latex allergy: penetrates the surface to buy 100mcg proventil with mastercard asthma definition images lower layers helps to proven proventil 100mcg asthma treatment beta agonist minimize this skin rash; hives; fushing; itching; nasal cheap proventil 100mcg mastercard asthma 2015 movie, eye, or sinus challenge. Cleaning and disinfecting the surface without symptoms; asthma; and (rarely) shock. Either single-use disposable gloves or utility gloves should be used when disinfecting. The wearing of gloves Diseases does not prevent contamination of hands or of surfaces Appendix D: Gloving touched with contaminated gloved hands. Hand hygiene Appendix J: Selecting an Appropriate Sanitizer or Disinfectant Appendix L: Cleaning Up Body Fluids and sanitizing of contaminated surfaces is required when gloves are used. Latex allergy in children: tions in both the individual wearing the latex glove and the Modalities and prevention. Hand-washing and a) Use non-latex gloves for activities that are not likely diapering equipment reduces disease among children in out-of to involve contact with infectious materials (food home child care centers. Center for b) Use appropriate barrier protection when handling Disease Control and Prevention. Creating a contact dermatitis); Chapter 3: Health Promotion 116 Caring for Our Children: National Health and Safety Performance Standards latex-safe school for latex-sensitive children. Bacterial spores are dormant bacteria that have formed a protective shell, Keeping objects and surfaces in a child care setting as enabling them to survive extreme conditions for years. The clean and free of pathogens as possible requires a combi spores reactivate after entry into a host (such as a person), nation of: where conditions are favorable for them to live and repro a) Frequent cleaning; and duce (6). It is important to use the least toxic cleaner, sanitizer used in close proximity to children, and adequate ventila and disinfectant for the particular job. Products must be used according to manu teachers from inhaling potentially toxic fumes. Sanitize safely and a ?frst step because the purpose of the bleach and water effectively: Bleach and alternatives in child care programs. Health solution is to sanitize (it is not designed to clean and is not and Safety Notes (July). Infectious diarrhoea in children: surface with water, should occur before spraying the surface Controlling transmission in the child care setting. Prevalence of Each term has a specifc purpose and there are many meth rotavirus on high-risk fomites in day-care facilities. These toys should be laundered before Bedding (sheets, pillows, blankets, sleeping bags) should be being used by another child. All toys can and the mats or cots are taken out of storage during nap spread disease when children put the toys in their mouths, time, and then placed back in storage. Providing bedding touch the toys after putting their hands in their mouths dur for each child and storing each set in individually labeled ing play or eating, or after toileting with inadequate hand bins, cubbies, or bags in a manner that separates the hygiene. Using a mechanical dishwasher is an acceptable personal articles of one individual from those of another are labor-saving approach for sanitizing plastic toys as long appropriate hygienic practices (1). Red book: 2009 report of the Committee on Infectious enough toys to rotate through cleaning makes this method Diseases, 153. Respiratory Tobacco use, alcohol, and illegal drugs should be prohibited effects of environmental tobacco smoke in a panel study of on the premises of the program (both indoor and outdoor asthmatic and symptomatic children. Am J Resp Crit Care Med environments) and in any vehicles used by the program at 161:802-6. Infants and young of environmental tobacco smoke exposure on the respiratory health children exposed to secondhand smoke are at risk of de of children 2 months through 5 years of age in the United States: veloping bronchitis, pneumonia, and middle ear infections Third national health and nutritional examination survey, 1988 to when they experience common respiratory infections (1-5). Beliefs about the health effects space does not eliminate or minimize exposure of nonsmok of ?thirdhand smoke and home smoking bans. Progress towards a fre-safe ticles clinging to smokers hair and clothing, cushions and cigarette. The residue includes heavy metals, carcino smoking and alcohol drinking with residential fre injuries. Am J gens and radioactive materials that young children can get Epidemiol 135:26-34. Safe d) Rabbit; child care necessitates alert, unimpaired caregivers/teach e) Rodent. The use of alcoholic beverages in family child care homes Fish are permissible but must be inaccessible to children. Drugs, and Toxic Substances 119 Chapter 3: Health Promotion Caring for Our Children: National Health and Safety Performance Standards Only animals that do not pose a health or safety risk will be Special precautions may be needed to minimize the risk of allowed on the premises of the facility. The caregiver/teacher should instruct children on the hu When animals are taken out of their natural environment and mane and safe procedures to follow when in close proximity are in situations unusual to them, the stress that the animals to animals (for example, not to provoke or startle animals or experience may cause them to act aggressively or attempt touch them when they are near food). Appropriate re straint devices will allow the holder to react quickly, prevent All contact between animals and children should be super harm to children and/or the escape of the animal (9). Children should not be allowed to feed animals directly from Toxoplasmosis can cause problems with pregnancy, includ their hands. Animals teach children about how protects them from competition by other animals while be to be gentle and responsible, about life and death, and ing fed which would also provide protection for the children about unconditional love (9). Cleaning air flters more often if animals are in Children should be discouraged from ?kissing animals or childcare areas may be helpful in reducing animal dander. Some dogs complete training and are certifed as part of All children and caregivers/teachers who handle animals or ?dog-assisted therapy programs.

For staff can provide without compromising the health guidance and reproducible handouts about the manage and safety of other children discount proventil 100 mcg visa asthma symptoms upper back pain. Population-based study of the impact of childcare attendance on hospitalizations for acute respiratory frequent episodes of upper and lower respiratory tract infections proventil 100 mcg sale asthma treatment home. Infants and young children may have more upper respira Childhood upper respiratory tract infections: To what degree is tory infections when they frst enter out-of-home group incidence affected by daycare attendance? Infections Children under three years of age experience an average Facilities should employ the following procedures cheap proventil 100mcg mastercard asthma treatment experimental, in addi of fve to purchase proventil 100 mcg amex asthma symptoms for days ten respiratory tract infections each year, most of tion to those stated in Child and Staff Inclusion/Exclusion/ which are not severe and are caused by viruses that infect Dismissal, Standards 3. Routine hand hygiene and cough infections of the gastrointestinal tract (including diarrhea) or etiquette may reduce the incidence of most acute upper hepatitis A (1-3): respiratory tract infections among children in child care. Therefore, exclusion criteria based on symptomol should be removed from the facility by their parent/ guardian. Exclude diapered children if stool is not 311 Chapter 7: Infectious Diseases Caring for Our Children: National Health and Safety Performance Standards contained in the diaper, stool frequency exceeds two are not required from asymptomatic people for or more stools above normal for that child, blood or readmission to child care. Pending arrival of the increased frequency of diarrheal illness in children or parent/guardian, the child should not be permitted to staff in a child care facility. Caregivers/teachers with children younger than three years of age who wear diapers. The child should remain separated ers should observe children for signs of disease to permit from other children as described above until the early detection and implementation of control measures. Studies indicate that the risk of diarrhea generally may be allowed to return to child care is signifcantly higher for children in centers than for age once the diarrhea resolves, except for the case of matched children cared for at home or in small family child infections with Shigella, Shiga toxin-producing E. For Salmonella species other than serotype vaccine at twelve months of age (1,2) followed by a second Typhi, documentation of negative stool cultures Chapter 7: Infectious Diseases 312 Caring for Our Children: National Health and Safety Performance Standards dose six months later, rates of disease due to rotavirus and international travelers. Diarrhea To decrease diarrheal disease in child care due to all patho caused by Shigella, rotavirus and Giardia in day care centers; gens, staff and parents/guardians must be educated about prospective study. N Engl J Med bined with close monitoring of compliance, is associated 302:1222-27. Infections associated with tices can modify staff behavior as well as the occurrence of group child care. Update: disease to permit early detection and implementation of Prevention of hepatitis A after exposure to hepatitis A and in control measures. Facilities should consult the local health 313 Chapter 7: Infectious Diseases Caring for Our Children: National Health and Safety Performance Standards department to determine whether the increased frequency (1-7). Disease has occurred in outbreaks within centers and of diarrheal illness requires public health intervention. Hepatitis A vaccine is recommended for all children Caregivers/teachers should observe children for signs of beginning at twelve months of age. Prevention Prevention of hepatitis A after exposure to hepatitis A and in of hepatitis A through active or passive immunization. N Engl J Med among infants and toddlers in day care centers: Effects of active 302:1222-27. A major should involve frequent hand hygiene to prevent spread and purpose of surveillance is to allow early detection of disease evaluation by the primary care provider of children who have and prompt implementation of control measures. The length of time that child attending a facility is ill is important when considering a person is considered contagious due to a bacterial or viral a diagnosis of hepatitis A and other diseases transmitted conjunctivitis depends on the organism. Cases of these infections in house eye, nose, and oral secretions is the most common way that hold contacts may require questioning about illness in the organisms causing conjunctivitis are spread from person to child attending child care, testing the child for infection, person. Careful hand hygiene and sanitizing of surfaces and and possible use of hepatitis A vaccine or immune globulin objects exposed to infectious secretions are the best ways in contacts. Antibiotic eye drops and oral medica a child care attendee, staff member, or household contact tions may decrease the time that a person is considered should be communicated to public health authorities, to the to be contagious from a bacterial conjunctivitis. However, child care director, to all staff, and to all parents/guardians recovery time is not decreased with antibiotic treatment. Some children with conjunctivitis may have other symptoms including fever, nasal congestion, respira tory, and gastrointestinal tract symptoms. Consultation with a health care professional should be Infections sought in this situation. In requires; Managing infectious diseases in child care and schools: A quick c) the person with conjunctivitis has fever or a change reference guide. These dome shaped, sometimes conical in the mouth and/or a rash (usually on the palms and soles) lesions generally appear on fngers, hands, feet, and face. In addition to hand hygiene among young children in whom hand hygiene may be poor. Therefore meticulous hand hygiene following toilet use and Treatments of skin warts including liquid nitrogen and topi diaper changing activities should be practiced. Careful hand cal antiviral agents may result in earlier clearance of warts; hygiene and sanitization of surfaces and objects poten however, warts may reappear, requiring additional treat tially exposed to infectious secretions are the best ways ments. The presence of individuals with the appearance of skin warts is a common occurrence; im symptoms suggestive of enterovirus infections should be munocompromised people may have more lesions that may noted by caregivers/teachers and parents/guardians of the be present for an extended duration. The local health department evaluated; should be notifed if several children develop impetigo. The lesions may be should be notifed if a caregiver/teacher has a concern that found on the face, extremities, or other areas of the body. The bacteria generally enter the skin at an thy is an enlargement of a lymph node without infammation. Lesions bacteria and viruses, with fungi and parasites accounting for are considered to be infectious until treatment has been fewer infections. Lesions are less likely to with rapid onset and symptoms involving the lymph nodes be infectious once the crusting lesions have healed. Lymph nodes in other sites, includ should be kept covered and frequent hand hygiene should ing the groin and on one or both sides of the body may be be practiced to prevent spread.

The rapidity of onset is related to purchase proventil 100 mcg without prescription asthma symptoms no inhaler the severity of exposure (inhalation or ingestion) and may be dramatic with immediate effects that include early hypertension with subsequent hypotension buy generic proventil 100 mcg on line asthma action plan 0-5 years, sudden cardiovascular collapse or seizure/coma buy proventil 100 mcg visa bronchial asthma medical definition, and rapid death Exclusion Criteria No recommendations Patient Management Assessment 1 generic 100 mcg proventil otc asthmatic bronchitis statistics. Assess vital signs including temperature and pulse oximetry (which may not correlate with tissue oxygenation in cyanide/smoke exposure) 4. Identify the specific agent of exposure, time of ingestion/ inhalation, and quantity/timing of exposure 9. Obtain patient history including cardiovascular history and prescribed medication 10. Perform physical exam Treatment and Interventions There is no widely available, rapid, confirmatory cyanide blood test. Therefore, treatment decisions must be made on the basis of clinical history and signs and symptoms of cyanide intoxication. For the patient with an appropriate history and manifesting one or more significant cyanide exposure signs or symptoms, treat with: 1. Collect a pre-treatment blood sample in the appropriate tube for lactate and cyanide levels 3. Pediatric: Administer hydroxocobalamin 70 mg/kg (reconstitute concentration is 25 mg/mL) 4. If the patient ingests cyanide, it will react with the acids in the stomach generating hydrogen cyanide gas. Hydroxocobalamin is only agent safe for treatment of cyanide poisoning in pregnant patient Notes/Educational Pearls 257 Key Considerations 1. Pulse oximetry accurately reflects serum levels of oxygen but does not accurately reflect tissue oxygen levels therefore should not be relied upon in possible cyanide and/or carbon monoxide toxicity 2. After hydroxocobalamin has been administered, pulse oximetry levels are no longer accurate 3. Accurate exposure history o Time of ingestion/exposure o Route of exposure o Quantity of medication or toxin taken (safely collect all possible medications or agents) o Alcohol or other intoxicant taken. Hydroxocobalamin and sodium thiosulfate versus sodium nitrite and sodium thiosulfate in the treatment of acute cyanide toxicity in a swine (Sus scrofa) model. Smoke inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case. Revision Date September 8, 2017 259 Beta Blocker Poisoning/Overdose Aliases Anti-hypertensive Patient Care Goals 1. Early airway protection is required as patients may have rapid mental status deterioration 3. Assure adequate ventilation, oxygenation and correction of hypoperfusion Patient Presentation Beta blocker or beta adrenergic antagonist medication to reduce the effects of epinephrine/ adrenaline Inclusion Criteria 1. Labetalol hydrochloride (Trandate, Normodyne) Exclusion Criteria No recommendations Patient Management 260 Assessment 1. If risk of rapid decreasing mental status, do not administer oral agent without adequately protecting the airway 2. Check blood glucose level on all patients but especially on pediatric patients as beta blockers can cause hypoglycemia in pediatric population 3. Consider fluid challenge (20 mL/kg) for hypotension with associated bradycardia 5. Consider vasopressors after adequate fluid resuscitation (1-2 liters of crystalloid) for the hypotensive patient [see Shock guideline for pediatric vs. Consider transcutaneous pacing if refractory to initial pharmacologic interventions 8. Transcutaneous pacing may not always capture nor correct hypotension when capture is successful 2. Aspiration of activated charcoal can produce a patient where airway management is nearly impossible. Do not administer activated charcoal to any patients that may have a worsening mental status Notes/Educational Pearls Key Considerations 1. Pediatric patient may develop hypoglycemia from beta blocker overdose therefore it is important to perform glucose evaluation b. Glucagon has a side effect of increased vomiting at these doses and ondansetron prophylaxis should be considered 3. Atropine may have little or no effect (likely to be more helpful in mild overdoses) the hypotension and bradycardia may be mutually exclusive and the blood pressure may not respond to correction of bradycardia 4. Certain beta blockers, such as acebutolol and pindolol, may produce tachycardia and hypertension 3. Revision Date September 8, 2017 263 Bites and Envenomation Aliases Stings Patient Care Goals Bites, stings, and envenomations can come from a variety of insects, marine and terrestrial animals. Pain control which also includes limited external interventions to reduce pain Patient Presentation Inclusion Criteria 1. Bites, stings, and envenomations can come from a variety of marine and terrestrial animals and insects causing local or systemic effects 2. Patient physical with special consideration to area of envenomation especially crotalid bite Treatment and Interventions 1. Consider vasopressors after adequate fluid resuscitation for the hypotensive patient. For these envenomations, consider transport to hospital that has access to antivenom, if feasible b. As there is a significant variety and diversity of Jellyfish, it is important to be familiar with the species and the appropriate treatment for your local aquatic creatures ii.

He lives alone on a second-floor flat which may make it difficult for him to discount proventil 100mcg overnight delivery asthma treatment alternative treatments get out order proventil 100mcg with mastercard asthma heart rate. He has a petechial rash which could be related to generic 100mcg proventil with visa asthma 6 steps coagulation problems cheap proventil 100mcg on-line asthmatic bronchitis june, but the platelet count is normal. It would be important to examine the rash carefully to see if it is distributed around the hair follicles. A number of the features suggest a possible diagnosis of scurvy from vita min C deficiency. The rash, muscle and joint pains and tenderness, poor wound healing and microcytic anaemia are all features of scurvy. The classic feature of bleeding from the gums would not be present in an edentu lous patient. Plasma measurements of vitamin C are difficult because of the wide range in normal sub jects. In this patient, replacement with ascorbic acid orally cleared up the symptoms within 2 weeks. It would be important to look for other nutritional deficiencies in this situation and to make arrangements to ensure that the situation did not recur after his discharge from hospital. A used packet of paracetamol and dihydrocodeine is found in one of his pockets but no illicit drugs and no means of identification. Examination Tendon reflexes are present and equal except the ankle reflexes which are absent. Little history is available, but the tablets in his pocket might suggest that he has a problem with a painful condition. There are a number of possible causes for his unconsciousness including a cere brovascular problem, deliberate or accidental drug overdose, including alcohol poisoning, metabolic or endocrine disturbance or hypothermia. The slow respiratory rate could be compatible with an opiate excess suppressing ventilation. It would be appropriate to measure the paracetamol level in the blood and it would be worth giving the opiate antagonist naloxone if there remained a likelihood of overdose. Most cerebrovascular problems would be expected to produce some localizing neuro logical signs on careful examination even in an unconscious patient. He could have hyperosmolar non-ketotic coma detected by a high glucose and evidence of haemoconcentration. Indeed, in this case, repeat of the rectal temperature measurement with a low-reading thermometer showed a tem perature of 30. No paracetamol was detected in the blood and his alcohol level was low at 11 mg/100 mL. If this is not achieved by covering the patient with blankets, then warmed inspired oxygen, warm intravenous fluids, bladder or peritoneal lavage might be consid ered. Drugs and physical disturbance should be limited since the myocardium is often irri table and susceptible to arrhythmias. Her only other symptom is a gradual increase in frequency of bowel movements from once a day in her teens to two to three times daily. She says that the bowel movements can be difficult to flush away on occasions but this is not a consist ent problem. She thinks that her grandmother, who lived in Ireland, had some bowel problems but she died 3 years ago, aged 68. She is an infant school teacher and spends a lot of her spare time in keep-fit classes and routines at a local gym. Examination of her abdomen showed no abnormalities and there are no other significant abnormalities to find in any other system. The report of a dimorphic blood film means that there are both small and large cells. This suggests that the anaemia is caused by a combination of the folate deficiency indicated by the red cell folate and by iron deficiency. The Howell?Jolly bodies are dark blue regular inclusions in the red cells which are typically found in the blood of patients after splenectomy, or are associated with the splenic atrophy which is characteristic of coeliac disease. In coeliac disease, there is a sensitivity to dietary gluten, a water-insoluble protein found in many cereals. The proximal small bowel is the main site involved with loss of villi and an inflammatory infiltrate caus ing reduced absorption. Other diagnoses which might be considered are anorexia nervosa (her age and sex, commitment to exercise); she does not appear depressed (a common cause of weight loss and bowel dis turbance) and the laboratory findings clearly indicate physical disease. Diagnosis of coeliac disease can be confirmed by endoscopy at which a biopsy can be taken from the distal duodenum. The treatment is a gluten free diet with a repeat of the biopsy some months later to show improvement in the height of the villi in the small bowel. Another common cause of failure to recover the villus architec ture is poor compliance to the difficult dietary constraints. She has had three episodes of cough, fever and purulent sputum over the last 6 months. Recently she has had trouble with regurgitation and vomiting of recognizable food. She lived in the north-west coast of the United States for 4 years up until 10 years ago. She has always tended to be constipated and this has been a little worse recently. There are no abnormalities to find in the cardiovascular system, abdomen or other systems.

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