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Orthostatic Sodium Retention

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161. Diabetes Mellitus, Type 1 (Follow-up)

or parasympathetic chains and produce myriad manifestations. [ , ] Patients likely to seek care in the ED are those with diabetic gastroparesis and vomiting, severe diarrhea, bladder dysfunction and urinary retention, or symptomatic orthostatic hypotension. Treatment of gastroparesis is symptomatic, and symptoms tend to wax and wane. Patients with gastroparesis may benefit from metoclopramide or erythromycin. Before these therapies are started, the degree of dehydration and metabolic imbalance must be assessed (...) , and other serious causes of vomiting must be excluded. In severe cases, gastric pacing has been used. Patients with disabling orthostatic hypotension may be treated with salt tablets, support stockings, or fludrocortisone. Alleviating the functional abnormalities associated with the autonomic neuropathy is often difficult and frustrating for both doctor and patient. (See and .) Diabetic foot disease Patients with diabetes who present with wounds, infections, or ulcers of the foot should be treated

2014 eMedicine.com

162. Spinal Cord Trauma and Related Diseases (Follow-up)

hypotension after high lesions resolves, although orthostatic hypotension persists. For lesions above the lumbar/sacral centers for bladder control, the initial urinary retention is replaced by the development of an automatic spastic bladder. Lower lesions lead to permanent atonic bladder (lower motor neuron pattern). In humans, constipation persists and may contribute to delayed gastric emptying. Autonomic hyperreflexia in this phase is characterized by massive firing of sympathetic neurons after (...) extremity areflexia Anesthesia below the affected level Neurogenic shock (ie, hypotension without compensatory tachycardia) Loss of rectal and bladder sphincter tone Urinary and bowel retention leading to abdominal distention, ileus, and delayed gastric emptying Horner syndrome (ie, ipsilateral ptosis, miosis, anhydrosis): This is also present with higher lesions because of interruption of the descending sympathetic pathways originating from the hypothalamus. Lower cervical level injury spares

2014 eMedicine.com

163. Geriatric Rehabilitation (Follow-up)

physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP (...) ] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory, and processing speed, suggesting that a thorough cognitive

2014 eMedicine.com

164. Gynecologic Pain (Follow-up)

improvement in patients with IC who were treated with amitriptyline. [ ] Corticosteroids are not widely used because of adverse effects such as fluid retention and osteoporosis. However, a study reported improved pain control and overall satisfaction with oral prednisone in a cohort of women with severe refractory IC. [ ] Pentosan polysulfate sodium (PPS) (Elmiron) is claimed to restore the depletion in the glycosaminoglycan (GAG) layer. A double-blind placebo-controlled trial revealed subjective (...) a reproductive age woman presents with pelivic pain and a positive pregnancy test. An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients. Abdominal examination

2014 eMedicine.com

165. Cardiovascular Concerns in Spinal Cord Injury (Follow-up)

in the management of orthostatic hypotension Atropine: Drug of choice for bradycardia but rarely used in rehabilitation settings except during emergencies (phenylephrine and dopamine also can be considered) Alpha-adrenergic agonists: Improve the patient's hemodynamic status by increasing myocardial contractility and heart rate Corticosteroids: Cause sodium and fluid retention, resulting in improvements in symptomatic orthostatic hypotension Sympathomimetics: Augment coronary and cerebral blood flow (...) lead to increased blood pressure. Corticosteroids cause sodium and fluid retention to improve symptomatic orthostatic hypotension, and sympathomimetics augment coronary and cerebral blood flow. Anticholinergics are administered to improve conduction through the atrioventricular (AV) node; this is accomplished by a reduction of vagal tone by way of muscarinic receptor blockade. Previous References Partida E, Mironets E, Hou S, Tom VJ. Cardiovascular dysfunction following spinal cord injury. Neural

2014 eMedicine.com

167. Assistive Devices to Improve Independence (Follow-up)

mobility, orthostatic hypotension (systolic blood pressure [SBP] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory (...) , female sex, cognitive impairment, poor self-rated health, low BMD, osteoporosis, inactivity, sedative use, alcohol use, and orthostatic hypotension. Extrinsic risk factors include adverse effects of medications, polypharmacy, and environmental hazards. Psychotropics, neuroleptics, tricyclic antidepressants, benzodiazepines, analgesics, sedatives, skeletal muscle relaxants, cardiac drugs (diuretics, antiarrhythmics), vasodilators, and antihistamines may contribute to falls. Results of studies suggest

2014 eMedicine.com

168. Altitude-Related Disorders (Follow-up)

to displace the CSF. Conversely, those with lesser CSF to brain volume ratio have limited space for compensation of brain swelling and are prone to AMS. The role of fluid retention in the pathogenesis of AMS remains uncertain. Secretion of antidiuretic hormone and atrial natriuretic factor is altered in AMS and may contribute to vasogenic edema. More recently, hypoxia-induced alterations in oxidative stress and free radical metabolism have been implicated in the pathophysiology of AMS. [ ] Treatment (...) of the pathogenesis of HAPE is shown below. This image shows the pathophysiology of high-altitude pulmonary edema (HAPE) following ascent to high altitude. Factors leading to a low partial pressure of oxygen (PO2), such as exercise, sleep, or a low ventilatory response to hypoxia, increase the likelihood of developing HAPE. Alterations in the sympathetic nervous system are also believed to contribute to the development of HAPE. Recent evidence suggests that a defect in sodium transport across the alveolar

2014 eMedicine.com

169. Esophageal Varices (Follow-up)

can reduce arterial blood pressure and promote the activation of endogenous vasoactive systems that may lead to sodium and water retention. Although ISMN has been demonstrated to reduce HVPG markedly in acute administration, it provides significantly less reduction after long-term administration (due to probable development of patient tolerance). Combination therapy Although many authorities recommended a combination therapy of pharmacologic treatment and EVL as the first-line treatment (...) procedures, and liver transplantation. Decompressive shunts and devascularization procedures are mainly rescue therapies. Management of patients with liver cirrhosis and ascites but without variceal hemorrhage includes a low-sodium diet and diuretics. Nasogastric tube In patients with hemodynamically significant upper gastrointestinal (GI) tract bleeding, a nasogastric tube should remain in place for 24 hours to assist in identifying any rebleeding. Gastric lavage may be performed frequently through

2014 eMedicine.com

170. Toxicity, Neuroleptic Agents (Overview)

. With loxapine, seizures may be recurrent. Cardiac effects: Prolongation of the QT interval and QRS complex can result in arrhythmias. QT prolongation in antipsychotic use is caused by potassium channel blockade. Sodium blockade causes prolongation of the QRS complex. This effect is mainly seen with thioridazine and mesoridazine. Hypotension: Phenothiazines are potent alpha-adrenergic blockers that result in significant orthostatic hypotension, even in therapeutic doses for some patients. In overdose (...) is no-to-minimal risk; 1+ is low risk; 2+ is moderate risk; 3+ is high risk. Although all antipsychotic preparations share some toxic characteristics, the relative intensity of these effects varies greatly, depending on the individual drug and specific receptor affinity. Generally, all neuroleptic medications are capable of causing the following symptoms: Anticholinergic effects: Neuroleptic agent toxicity can result in tachycardia; hyperthermia; urinary retention; ileus; mydriasis; toxic psychosis; dry mucous

2014 eMedicine Emergency Medicine

171. Altitude-Related Disorders (Diagnosis)

to displace the CSF. Conversely, those with lesser CSF to brain volume ratio have limited space for compensation of brain swelling and are prone to AMS. The role of fluid retention in the pathogenesis of AMS remains uncertain. Secretion of antidiuretic hormone and atrial natriuretic factor is altered in AMS and may contribute to vasogenic edema. More recently, hypoxia-induced alterations in oxidative stress and free radical metabolism have been implicated in the pathophysiology of AMS. [ ] Treatment (...) of the pathogenesis of HAPE is shown below. This image shows the pathophysiology of high-altitude pulmonary edema (HAPE) following ascent to high altitude. Factors leading to a low partial pressure of oxygen (PO2), such as exercise, sleep, or a low ventilatory response to hypoxia, increase the likelihood of developing HAPE. Alterations in the sympathetic nervous system are also believed to contribute to the development of HAPE. Recent evidence suggests that a defect in sodium transport across the alveolar

2014 eMedicine.com

172. Cardiovascular Concerns in Spinal Cord Injury (Diagnosis)

in the management of orthostatic hypotension Atropine: Drug of choice for bradycardia but rarely used in rehabilitation settings except during emergencies (phenylephrine and dopamine also can be considered) Alpha-adrenergic agonists: Improve the patient's hemodynamic status by increasing myocardial contractility and heart rate Corticosteroids: Cause sodium and fluid retention, resulting in improvements in symptomatic orthostatic hypotension Sympathomimetics: Augment coronary and cerebral blood flow (...) lead to increased blood pressure. Corticosteroids cause sodium and fluid retention to improve symptomatic orthostatic hypotension, and sympathomimetics augment coronary and cerebral blood flow. Anticholinergics are administered to improve conduction through the atrioventricular (AV) node; this is accomplished by a reduction of vagal tone by way of muscarinic receptor blockade. Previous References Partida E, Mironets E, Hou S, Tom VJ. Cardiovascular dysfunction following spinal cord injury. Neural

2014 eMedicine.com

174. Botulism (Diagnosis)

, dysphagia, and/or suppressed gag reflex Additional neurologic manifestations include symmetrical descending paralysis or weakness of motor and autonomic nerves Respiratory muscle weakness may be subtle or progressive, advancing rapidly to respiratory failure The autonomic nervous system is also involved in botulism, with manifestations that include the following: Paralytic ileus advancing to severe constipation Gastric dilatation Bladder distention advancing to urinary retention Orthostatic hypotension (...) no role in foodborne botulism Magnesium salts, citrate, and sulfate should not be administered, because magnesium can potentiate the toxin-induced neuromuscular blockade. Wound botulism requires the following: Incision and thorough debridement of the infected wound Antitoxin therapy High-dose intravenous penicillin therapy Prevention of nosocomial infections Measures to reduce the risk of nosocomial infections include the following: Close observation for hospital-acquired infections - Especially

2014 eMedicine.com

175. Assistive Devices to Improve Independence (Diagnosis)

mobility, orthostatic hypotension (systolic blood pressure [SBP] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory (...) , female sex, cognitive impairment, poor self-rated health, low BMD, osteoporosis, inactivity, sedative use, alcohol use, and orthostatic hypotension. Extrinsic risk factors include adverse effects of medications, polypharmacy, and environmental hazards. Psychotropics, neuroleptics, tricyclic antidepressants, benzodiazepines, analgesics, sedatives, skeletal muscle relaxants, cardiac drugs (diuretics, antiarrhythmics), vasodilators, and antihistamines may contribute to falls. Results of studies suggest

2014 eMedicine.com

176. Perioperative Management of the Geriatric Patient

; aortic aneurysm surgery; noncardiac thoracic surgery; and abnormal preoperative sodium, potassium, or glucose levels were found as independent, specific factors that preoperatively predicted postoperative delirium in elderly patients. Other independent precipitating factors are the use of physical restraints, malnutrition, respiratory insufficiency, dehydration, addition of more than 3 medications, and any iatrogenic event, such as nosocomial infection. Vulnerability factors are visual impairment (...) of symptoms. Patients may experience hypoxia from stiffening of chest wall muscles, transfer dysphagia, and worsened tremor (which can cause increased pain at the operative site). If possible, a weighted feeding tube can be used to administer the medication at appropriate times. Patients who take levodopa may develop orthostatic hypotension, nightmares, hallucinations, and, occasionally, delirium, all of which may worsen with the addition of surgery and anesthesia. Anticholinergic drugs

2014 eMedicine.com

177. Perioperative Management of the Female Patient

, date and method Sexual history – Preference (ie, heterosexual, bisexual, homosexual); orgasmic; if sexually active, dyspareunia; problems, concerns, questions – Difficulty becoming pregnant, evaluation or treatment for infertility Papanicolaou (Pap) smear – Last Pap test, abnormalities Infection – Vaginal discharge, previous vaginal infections, sexually transmitted diseases (STDs), Pelvic relaxation – Prolapse, vaginal splinting to defecate, urinary retention, Breast disease – Masses, discharge (...) count is close to 10,000/mm 3 . Platelet transfusion may be given to these patients before and during surgery to raise the count above 50,000/mm 3 . Electrolyte disturbances Vomiting, diarrhea, and the use of diuretics are the most common factors that result in electrolyte disturbances and intravascular volume depletion in gynecologic patients. Hemorrhage, starvation, and fluid restriction contribute to intravascular volume reduction. Patients with severe vomiting deplete their sodium and potassium

2014 eMedicine.com

178. Gynecologic Pain (Diagnosis)

improvement in patients with IC who were treated with amitriptyline. [ ] Corticosteroids are not widely used because of adverse effects such as fluid retention and osteoporosis. However, a study reported improved pain control and overall satisfaction with oral prednisone in a cohort of women with severe refractory IC. [ ] Pentosan polysulfate sodium (PPS) (Elmiron) is claimed to restore the depletion in the glycosaminoglycan (GAG) layer. A double-blind placebo-controlled trial revealed subjective (...) a reproductive age woman presents with pelivic pain and a positive pregnancy test. An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients. Abdominal examination

2014 eMedicine.com

179. Geriatric Rehabilitation (Diagnosis)

physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP (...) ] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory, and processing speed, suggesting that a thorough cognitive

2014 eMedicine.com

180. Nephrotic Syndrome (Overview)

defect in renal sodium handling. A primary increase in renal sodium reabsorption leads to net salt and water retention and subsequent hypertension. ANP might play a role is this mechanism; studies have shown an impaired response to ANP in nephrotic syndrome. This ANP resistance, in part, might be caused by overactive efferent sympathetic nervous activity, as well as enhanced tubular breakdown of cyclic guanosine monophosphate. Other mechanisms that contribute to a primary increase in renal sodium (...) of plasma water into the interstitial space. The resulting contraction in plasma volume (PV) leads to stimulation of the renin-angiotensin-aldosterone axis and antidiuretic hormone. The resultant retention of sodium and water by the renal tubules contributes to the extension and maintenance of edema. While the classical model of edema (also known as the "underfill hypothesis") seems logical, certain clinical and experimental observations do not completely support this traditional concept. First, the PV

2014 eMedicine Pediatrics

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