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Interestingly order viagra gold pills in toronto, others have suggested demographic factors with ultrasound estimates of fetal that death might occur if the fetal cell mass exceeds pla‑ size and/or fetal Doppler order viagra gold without a prescription, cervical length and/or mobility cental ability for tissue oxygenation purchase viagra gold 800mg without a prescription, and it has been of the pelvic floor [86–89]. There is currently no consen‑ proposed that maternal cardiac failure may contribute to sus on the factors that should be included in such a fetal death in this circumstance [77]. The heterogeneity of the Conclusion literature, using different charts and cut‐offs to define macrosomia, make it difficult to determine absolute Ultrasound is a diverse tool that has many applications in sensitivity of ultrasound and studies have reported the third trimester. Researchers have com‑ scan is not currently part of a routine antenatal screen‑ pared different algorithms for estimation of fetal weight ing strategy and there are limited data to support routine and prediction of macrosomia which have shown sig‑ population‐based screening. Predicting risk purely recognize that many contemporary obstetric issues are through ultrasound assessment using standard biomet‑ centred around the third trimester and ultrasound is ric parameters appears unlikely to be useful in defining likely to play a significant role in defining an individual’s a macrosomic cohort in routine practice [80]. There is risk and ensuring that appropriate strategies for main‑ also evidence that different algorithms should be applied taining pregnancy and expediting delivery are developed. Ultrasound is often best applied as one component of Risk assessment may be improved by acknowledging multivariate risk assessment and this is the subject of differing maternal characteristics and using a Bayesian much ongoing research, with applications as diverse as multivariate approach to screening [82]. It is not clear the prevention of stillbirth, shoulder dystocia or mater‑ whether screening should then be limited to high‐risk nal perineal trauma. Given the current medicolegal cohorts (perhaps defined through maternal characteris‑ environment, it is likely that these methods of risk tics and/or medical history), through a contingent process assessment will become an integral part of management based on findings of screening tests performed at an early of the third trimester as they will allow clinicians to have stage of pregnancy, or to the whole population [83]. Some of the trials in this meta‐analysis are relatively invasive placentation and appropriate management small and did not report all outcome measures. Further research is needed to deter- validated and strongly predictive screening test, it is dif‑ mine whether routine third‐trimester ultrasound ficult to advocate a process of routine screening and surveillance reduces the prevalence of stillbirth. A comparison preterm delivery in the Norwegian Mother and Child of vaginal ultrasound and digital examination in Cohort Study. Acta Obstet Gynecol Scand predicting preterm delivery in women with threatened 2008;87:1374–1377. Hypertension value of quantitative fibronectin testing in combination 2009;53:812–818. Ultrasound Significance of the ultrasound location of placental site Obstet Gynecol 2015;46:419–423. Is reductions with interventions in 39 countries with the third trimester repeat ultrasound scan for placental very high human development index. Lancet localisation needed if the placenta is low lying but clear 2013;381:223–234. Incidence of and risk progesterone reduces the rate of preterm birth in indicators for vasa praevia: a systematic review. Ultrasound Obstet Gynecol pregnancy and a short cervix: an updated meta‐analysis 2013;42:500–508. Predictive model for risk of Ultrasound assessment of cervical length in threatened cesarean section in pregnant women after induction preterm labor. Obstet Gynecol ultrasonography and magnetic resonance imaging in 2014;123:1185–1192. Prediction of complete uterine rupture by sonographic International standards for fetal growth based on evaluation of the lower uterine segment. Am J Obstet serial ultrasound measurements: the Fetal Growth Gynecol 2009;201:320. Gestational uterine segment thickness to predict uterine rupture age at delivery and special educational need: during a trial of labor in women with previous retrospective cohort study of 407,503 schoolchildren. Planned birth before 39 weeks and child of unexplained stillbirths using clinical practice development: a population‐based study. Update on the diagnosis and Effectiveness of detection of intrauterine growth classification of fetal growth restriction and proposal retardation by abdominal palpation as screening test of a stage‐based management protocol. The Investigation and Management of the Small‐for‐ Customised antenatal growth charts. Value of changes in Doppler and biophysical parameters as of a single early third trimester fetal biometry for the severe fetal growth restriction worsens. Ultrasound prediction of birth weight deviations in a low risk Obstet Gynecol 2001;18:571–577. Than Award Lecture: Recognition of placental failure is Screening for fetal growth restriction with universal key to saving babies’ lives. Placenta 2015;36(Suppl 1): third trimester ultrasonography in nulliparous women S20–S28. Arch Gynecol Obstet formal fetal movement counting and risk of antepartum 2016;294:673–679. Customised versus Predicting poor perinatal outcome in women who population‐based growth charts as a screening tool present with decreased fetal movements. J Obstet for detecting small for gestational age infants in Gynaecol 2009;29:705–710. Clinical Practice Guideline for the 65 Oros D, ueras F, Cruz‐Martinez R, Meler E, Management of Women who Report Decreased Fetal Munmany M, Gratacos E. Umbilical and fetal middle cerebral in computerized fetal heart rate analysis antepartum. Fetal perception of reduced fetal movements: a prospective biophysical profile scoring: a prospective study in cohort study. Best Pract Res Clin Obstet Doppler ultrasound in predicting the perinatal Gynaecol 2017;38:12–23. Biophysical adverse pregnancy outcome: systematic review and profile for fetal assessment in high risk pregnancies. Doppler ultrasonography in 71 American College of Obstetricians and Gynecologists’ high‐risk pregnancies: systematic review with meta‐ Committee on Practice Bulletins—Obstetrics. Changes definition of macrosomia through an outcome‐based in fetal Doppler indices as a marker of failure to reach approach in low‐ and middle‐income countries: a growth potential at term. Stillbirth in gestation, increased intrapartum operative intervention diabetic pregnancies. Placental syndromes: getting to 64 Cruz‐Martinez R, Savchev S, Cruz‐Lemini M, Mendez the heart of the matter. Intrapartum clinical, sonographic, and perinatal outcome in small‐for‐gestational‐age fetuses. Ultrasonographic weight estimation in large for the value of ultrasound in the prediction of successful gestational age fetuses: a comparison of 17 sonographic induction of labor. Ultrasound 89 Garcia‐Simon R, ueras F, Savchev S, Fabre E, Obstet Gynecol 2013;41:398–405. Performance of the outcome after labor induction for late‐onset small‐for‐ ultrasound examination in the early and late third gestational‐age fetuses. Ultrasound Obstet Gynecol trimester for the prediction of birth weight deviations. Validation of Induction of labour at or near term for suspected fetal models that predict Cesarean section after induction macrosomia. Prior to this the fetus relies on placental trans­ able to cross the placenta and stimulate the fetal thyroid fer of maternal thyroid hormones. It has been estimated that (T3) increase with advancing gestation, from 14–16 weeks neonatal thyrotoxicosis occurs in 2–10% of babies born onwards [1,2].

Among patients with fungal endocarditis buy viagra gold 800 mg mastercard, the overall frequency of positive blood cultures is 54% [97] order viagra gold from india. Current commercially available routine manual and automated blood culture systems are usually able to recover yeasts within 5 to 7 days of incubation 800mg viagra gold for sale. Premortem microbiologic diagnosis may often be made by culture and special histologic stains of large arterial emboli or cardiac vegetations [66,97]. Noncultivatable or difficult to cultivate organisms may be detected by serologic or molecular studies. Timely inclusion of serologic studies, particularly in environments where Q fever, Brucella, and Bartonella sp. Several studies have demonstrated the utility of these methods in assessing patients with high pretest probability of endocarditis but who have negative blood cultures by standard methods. Limitations include potential for contamination and lack of an organism to test for antimicrobial susceptibility [67,100,101]. Sensitivity is affected by vegetation size, with 25% of vegetations less than 5 mm and 70% between 6 and 10 mm detected [108]. Obesity, chronic lung disease, and thoracic deformity may preclude obtaining the high-quality images needed to detect vegetations in as many as 30% of patients [108,109]. Diagnostic yield is also influenced by experience and skill of the person performing the procedure and the pretest probability of endocarditis. Relative contraindications include esophageal diseases, severe atlantoaxial joint disease, prior irradiation to the chest, and perforated viscus [113]. The prognostic implications of vegetations identified by echocardiographic studies remain controversial. Some recent studies have indicated an increased risk of embolization in patients with vegetations greater than or equal to 10 mm in size, particularly in patients with mitral valve disease [122,123]. Still others have found that the predictive value of size for embolization depended on the organism and the mobility of the vegetation [122–124]. Most investigators agree that the presence of a vegetation alone is not an independent indication for valve replacement [122,123]. Although emboli may occur in as many as 16% of patients with Duke definite endocarditis who do not have vegetations on echocardiography [125], vegetations greater than or equal to 10 mm in size are associated with an increased risk of embolization [122,123,125]. Mitral location, causative organism, and the mobility of the vegetation also contribute to embolic risk, and echocardiography may be useful for stratifying patients to high-risk subgroups where early surgery should be considered [122–125]. The question becomes particularly acute for patients with intravascular foreign bodies, such as pacemakers, valves, and patches, and when the organism is S. The approach to this problem must take into account the propensity for the foreign body to become infected, the propensity of the organism to cause endocarditis, and the duration of bacteremia. Because sustained bacteremia characterizes infection of endovascular sites, the longer the bacteremia lasts, the greater the concern for an endothelial origin. In addition, even if the origin is distant and known, the longer the organisms circulate, the greater is the risk that they have settled out and seeded the intravascular foreign body secondarily. Infection usually occurs at the skin–catheter junction and thus is most likely to invade the circulation when the vessel is in close proximity to the skin wound. Enteric Gram-negative bacilli are among the most common blood culture isolates at most hospitals but are less common as a cause of endocarditis (see Table 78. Notable exceptions to this characterization of enteric Gram-negative bacilli are salmonellae, particularly S. Thus, patients with Gram-negative bacteremia in the setting of a prosthetic valve should receive antibiotic therapy adequate for possible endocarditis. The changing demographics of staphylococcal endocarditis have been discussed in detail in the “Etiology” section of this chapter. The absence of a primary focus appears to be a powerful predictor of endocarditis from community-acquired staphylococcal bacteremia [48,134]. Clearly, patients who have prolonged fever or bacteremia after catheter removal should receive the longer course of antibiotic therapy because of the high mortality from catheter-associated S. The more favorable outcome of injecting drug users is generally attributed to their younger age and absence of underlying systemic illness, as well as the location of their valve involvement (right-sided valvular disease). Enterococci have emerged as major causes of healthcare-associated infections and in so doing have become increasingly resistant to antimicrobial agents, most importantly the penicillins, aminoglycosides, and glycopeptides [17,144–146]. Mortality attributed to enterococcal bacteremia is high, ranging from 13% to 42%, and seems to correlate directly with the severity of underlying illness as well as with antimicrobial resistance [146,147]. Higher mortality rates are seen among patients infected with strains that have high-level aminoglycoside resistance and resistance to vancomycin [146–148]. Two case series of patients with enterococcal bacteremia examined the risk factors for development of endocarditis [144,145]. These studies refute previous reports that nosocomial bacteremia and polymicrobial infections with enterococci are rarely associated with endocarditis. Approximately 60% of the patients had nosocomial infections and polymicrobial bacteremia varied from 17% to 37%. Factors that were significantly associated with endocarditis included three or more positive blood cultures, the presence of a prosthetic valve, underlying valvular disease, and infection with E. Other patients at risk include those individuals with diabetes mellitus, renal dysfunction, heart failure, and oral anticoagulant use [149,153]. Studies that examined this outcome showed a lower risk of infection among patients given perioperative antimicrobial prophylaxis for the implantation procedure [149,154,155]. Infections of pacemakers can be divided into the following distinct syndromes: Generator pocket infections, which tend to occur within 2 months of surgery and are usually caused by S. Inflammation at the generator pocket may be absent or detectable only at surgery in patients with the latter two syndromes [150]. Local erythema, erosion over the generator site, or drainage characterizes pocket infections, whereas electrode infections and endocarditis present more typically with sepsis and sustained bacteremia. Infections that involve pacemaker wires and electrodes are almost never cured with antibiotics alone, and the entire system should be removed [103,149,156]. This usually can be accomplished in a one-stage procedure in which the old system is removed and the new system placed at a site remote from the infection (usually the contralateral side), followed by a course of antibiotics [149]. However, temporary pacing is not recommended and new device placement should be delayed until blood cultures have been negative for at least 72 hours in cases of bacteremia, and only if reevaluation of the indications determines that it is still required [103,149]. The optimal duration of antimicrobial therapy depends upon the extent of infection and whether bacteremia is present. Short-course therapy following extraction may be possible for infections confined to the pacer pocket in the absence of bacteremia, whereas much longer duration of treatment is essential in patients with bacteremia. Sometimes defective or infected electrodes become firmly enclosed by fibrous tissue and are adherent to the vessel endothelium, precluding easy extraction through the venous system. Removal of a retained wire using traction devices has been successful in some instances, but serious complications such as avulsion of the tricuspid valve and creation of atrioventricular fistulae have been reported [156]. A multicenter study reviewed the experience with laser sheath extraction in the United States where 1,684 patients (2,561 leads) were treated with a laser sheath [157]. Complete success, defined as removal of all lead material from the vasculature, was seen in 90% of the patients. The most predictive factor for failure to remove a lead by this procedure was lead implant duration of more than 10 years.

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However discount 800 mg viagra gold amex, some patients with severe thyrotoxicosis develop a decompensated clinical presentation called thyroid storm cheap viagra gold 800 mg online. It is characterized by hyperpyrexia 800mg viagra gold amex, tachycardia, and delirium [1] and generally occurs among patients with severe thyrotoxicosis, who then experience a physiological insult. The cause of this rapid decompensation is unknown, but it may be partly because of a sudden inhibition in thyroid hormone binding to plasma proteins, resulting in a rise in the already elevated free hormone pool [2]. Thyroid storm accounts for no more than 2% of hospital admissions for all forms and complications of thyrotoxicosis, and the diagnosis is often difficult to make because there is a fine line between severe thyrotoxicosis and thyroid storm. Because these agents are used to restore euthyroidism before surgery, thyroid storm is rarely seen in this context. Thyroid storm now occurs most commonly among patients with severe underlying thyrotoxicosis, frequently undiagnosed, who become ill for other reasons, such as infections, trauma, labor, diabetic ketoacidosis, or pulmonary and cardiovascular disorders. It can occur during or after nonthyroid surgery, and has been reported after external beam radiation to the neck [4], ingestion of sympathomimetic drugs (such as pseudoephedrine) in a thyrotoxic patient [5], and rarely with intentional or accidental overdoses [6,7]. Patients with thyroid storm are almost always febrile (temperature usually higher than 100°F) and have rapid sinus tachycardia and tachyarrhythmias (especially atrial fibrillation in elderly patients) out of proportion to the degree of fever that can frequently result in congestive heart failure. Hepatomegaly with abnormal liver enzymes and splenomegaly can be present; jaundice portends a poor prognosis. Most patients display the classic signs of thyrotoxic Graves’ disease, including ophthalmopathy, or toxic uninodular or multinodular goiter. However, in elderly patients, apathy, severe myopathy, profound weight loss, and congestive heart failure may be the predominant findings. As thyroid storm progresses, coma, hypotension, vascular collapse, and death may ensue unless active therapy is instituted. Serum T concentrations are usually similar, although it4 has been suggested that the serum-free T concentration is significantly4 higher in patients with thyroid storm [2], which might partially explain their more severe symptoms. On the other hand, the serum T3 concentrations are not higher and in fact may be less elevated or even normal in these patients when the precipitating cause is an intercurrent illness or surgery, because peripheral T production from T is markedly3 4 impaired in a wide variety of acute and chronic systemic illnesses. Liver function tests are frequently abnormal, especially in elderly patients with congestive heart failure. The differential diagnosis for a patient presenting with hyperpyrexia, delirium, and tachycardia includes severe infection, malignant hyperthermia [9], neuroleptic malignant syndrome, and acute mania with life-threatening catatonia. Thyroid storm can be distinguished from these disorders clinically by a history of thyroid disease, thyroid hormone, or iodine ingestion, and the presence on physical examination of a goiter or the stigmata of Graves’ disease, including ophthalmopathy, onycholysis, and pretibial myxedema. However, any of the disorders mentioned in the differential diagnosis can coexist with thyroid storm since they may precipitate decompensation for a patient with preexisting hyperthyroidism. Underlying Illness Nonthyroidal illness and surgery in previously undiagnosed or only partially treated patients with hyperthyroidism are the most common causes of thyroid storm. Cardiac arrhythmias and congestive heart failure require approximately twice the dose of digoxin needed in euthyroid patients or alternative management, and refractory arrhythmias should alert the physician to the presence of thyrotoxicosis. Patients may also have peripheral resistance to heparin and insulin, and higher doses may be required. It is evident that these patients must receive adequate antibiotic therapy; careful fluid, electrolyte, and vitamin supplementation; vigorous pulmonary therapy; and careful pre- and postoperative care. Supportive Care A cooling blanket can be used if the temperature rises above 101°F, but the shivering response that results from central cooling should be decreased by using drugs that block the central thermoregulatory centers, such as chlorpromazine or meperidine, 25 to 50 mg every 4 to 6 hours. Salicylates should be avoided because they displace thyroid hormones from serum-binding proteins and can increase the free hormone concentrations [10]. Dehydration is frequently present and should be treated with intravenous fluid while monitoring for congestive heart failure. Blockade of Peripheral Effects of Thyroid Hormone Many of the clinical manifestations of hyperthyroidism can be alleviated by the administration of drugs that deplete or block the peripheral action of the catecholamines. The widest experience has been achieved with propranolol, which also has the advantage of decreasing T to T conversion (see later). Because propranolol may be contraindicated for patients with congestive heart failure, it is frequently debated whether to use β- blockers for patients with severe thyrotoxicosis or thyroid storm. However, tachycardia and tachyarrhythmias are major contributing factors to the congestive failure in many of these patients, so β-blockers may be used cautiously along with digoxin and other cardiotropic drugs and diuretics. Rarely, hypotension and cardiac arrest occur after intravenous administration of β-blockers among patients with severe congestive failure and severe thyrotoxicosis [12]. For patients with asthma, the more selective β1-blocking drugs, such as metoprolol and atenolol, may be used. A short-acting β1-blocker, esmolol [13], and diltiazem can also be used to control the tachyarrhythmias associated with thyrotoxicosis [14]. Weeks are required to deplete the thyroid of stored hormone and observe clinical effects of these drugs. These drugs are not effective if thyroid storm is caused by excess ingestion of thyroid hormone (see the section Thyrotoxicosis Factitia) or painful or silent thyroiditis because they affect the synthesis of thyroid hormone and do not affect its release or peripheral activity. Blockade of Thyroid Hormone Release Iodide administration plays a major role in the treatment of thyroid storm because of its rapid inhibition of thyroid hormone release from the gland. Lugol’s solution or saturated solution of potassium iodide can be given orally or as a potassium iodide enema, 1 g in 60 mL of water, followed by 500 mg of potassium iodide in 20 mL of water every 6 hours, given rectally in a patient who is unable to receive oral medication. Iodide therapy results in dramatic improvement and should be maintained until the serum T and T concentrations are normal or near normal. In patients allergic to iodine, lithium has been used to inhibit thyroid hormone release and partially inhibit thyroid hormone synthesis [18]. Inhibition of Peripheral Generation of Triiodothyronine It is generally believed that the major bioactive hormone is T, that the3 major source of circulating T is derived from T, and that most, if not all,3 4 of the metabolic effects of T result from the intracellular generation of T4 3 from T. A variety of drugs impair the outer-ring monodeiodination of T4 4 to T, thus decreasing the peripheral generation of T. The corticosteroids, especially dexamethasone, are4 3 potent inhibitors when administered at high doses and also have an inhibitory effect on thyroid hormone hypersecretion. Their importance for treating thyroid storm has been well documented; the survival rate for thyroid storm was improved when corticosteroids were added to the treatment regimen. Because relative adrenal insufficiency may be present in patients with thyroid storm, glucocorticoid therapy would also correct this possibility. Removal of Thyroid Hormone from the Circulation Direct removal of thyroid hormone from the circulation is occasionally required in patients who do not respond to conventional medical treatment. Cholestyramine, which binds T and3 T in the gut and decreases serum T and T concentrations by increasing4 3 4 the fecal excretion of these hormones [24], may also be useful, particularly if used early in a patient with an overdose. Thyrotoxicosis Factitia the inadvertent ingestion of excess amounts of thyroid hormone most commonly occurs in children, although adults may also ingest excess hormone for weight reduction or as a suicide attempt [6,7,25]. As previously mentioned, this form of thyrotoxicosis is not caused by endogenous production of thyroid hormone; therefore, drugs that inhibit the synthesis of T and T or those that block thyroid hormone release are4 3 not helpful. Therapy should focus on preventing the peripheral effects of excessive thyroid hormone with β-adrenergic blocking drugs and possibly corticosteroids. Specific therapy should be directed toward inhibiting the synthesis and release of T and T from the4 3 thyroid, blocking the peripheral conversion of T to T, relieving the4 3 catecholamine-mediated effects by β-adrenergic blockade, and treating the possibility of decreased adrenal reserve with corticosteroids.

It was associated with an unacceptably high incidence of postoperative hallucinations best purchase viagra gold, delirium viagra gold 800 mg without a prescription, and mania viagra gold 800 mg overnight delivery. More often, the base is dissolved in a liquid hydrocarbon and applied to the wrapper of a tobacco cigarette. Hypertension usually resolves within 4 hours, but a significant number of patients may remain hypertensive for more than 24 hours. The most common behavioral effects are violent and agitated behavior, which may predispose patients to traumatic injuries. The patients may exhibit bizarre behaviors such as driving less than 10 mph on the freeway, “playing bumper cars” on the freeway, sleeping on top of cars that are blocking traffic, lying down in a busy street, and wandering or acting wildly in public. Other musculoskeletal disturbances include oculogyric crisis, trismus, facial grimacing, circumoral muscle twitching, lip smacking or chewing movements, torticollis, tongue spasms, opisthotonos, and catalepsy. The major autonomic effects are profuse diaphoresis, copious oral or pulmonary secretions, and urinary retention. The patients may exhibit slurred, bizarre, or repetitive speech; ataxia; disorientation; confusion; poor judgment; inappropriate affect; amnesia of recent events; bizarre behavior; agitation; and violence. The duration of this syndrome often lasts for a few hours and rarely lasts more than 3 days, but has been reported to persist for 1 to 3 weeks. Characteristically, there is autistic and delusional thinking, commonly including global paranoia, delusions of superhuman strength and invulnerability, as well as delusions of persecution and grandiosity. Affect is generally blunted, with periods of suspiciousness often alternating with extreme anger or terror. These patients are ambivalent and their behavior is unpredictable even toward their friends and relatives. Hallucinations may be auditory or visual, or both, and may involve seeing brilliantly colored objects, but objects are not distorted and there are no kaleidoscopic effects. These patients may also be a danger to others because of their misperceptions, paranoia, and hostility, compounded by their confusion, tendency towards violence, and the unpredictability of behavior. This initial phase will gradually transition to a phase characterized by intermittent periods of gross paranoia, agitation, terror, and hyperactivity alternating with quiet paranoid watchfulness over the course of a week. The patients may explode in an unexpected flurry of violence when inappropriate demands are not immediately met. A third phase begins on an average of 10th day of hospitalization, and is characterized by rapid reintegration of premorbid personality, development of insight into the events leading to the hospitalization. The patients are typically mute, staring blankly, motionless, stiff, standing with extremities or head in bizarre positions, and unresponsive to noxious stimuli. Most catatonic syndromes usually do not persist for more than 24 hours (range 2 to 6 days), and most patients recover within 4 to 6 hours. The patients may emerge from catatonic syndrome with agitation or combativeness, delirium, lethargy, psychosis, bizarre behavior, or normal sensorium. The patients with euphoria may report a sense of “well being” or feeling “spaced out,” “freaked out,” or “tingling all over. The patients emerging from coma may exhibit delirium, catatonic syndrome, toxic psychosis, stupor, agitation, violence, bizarre behavior, or normal sensorium. Drug history should include type of product, method of use, time of exposure, circumstances surrounding intoxication, and description of effects witnessed by others or experienced by the patient. The physical examination should focus on vital signs, sensorium, behavior, and musculoskeletal, autonomic, and neurologic findings. Explosions in clandestine laboratories may have consequences of smoke or chemical inhalation, thermal or chemical burns, and blunt or penetrating trauma. Chest radiograph, electrocardiogram, arterial blood gas, computed tomography of the head, and lumbar puncture should be obtained as clinically indicated. Management the immediate management is to assess and treat acute threats to the airway, breathing, and circulation. Close monitoring of the patient in a quiet area with limited stimuli may reduce the need for physical restraint or sedation and provide a safe environment for the patient, attending staff, and other patients. These patients should receive supplemental oxygen, secure vascular access, and have their vital signs and cardiac rhythm continuously monitored. Mild sinus tachycardia or hypertension not associated with psychomotor agitation or evidence of end organ damage usually does not require pharmacologic treatment. Treatment of psychomotor agitation using benzodiazepine sedation often results in improvement or resolution of sinus tachycardia and hypertension. Persistent significant hypertension despite resolution of psychomotor agitation, or if there is evidence of end organ damage, should be treated with intravenous nitroprusside or nitroglycerin titrated to effect. The use of β-adrenergic antagonists to treat drugs of abuse-induced tachycardia or hypertension is not routinely recommended and may have deleterious effects (e. Persistent hypotension refractory to fluids necessitates a vasopressor such as norepinephrine or epinephrine. Pulmonary artery catheter hemodynamic monitoring may provide important data to guide pharmacologic intervention. Core temperature approaching or exceeding 104°F (40°C) is immediately life-threatening and warrants aggressive management. Completely undress the patient, begin continuous monitoring of the patient’s core temperature, and initiate active cooling measures. The initial management of a patient with altered mental status should include assessment and treatment of all readily reversible causes such as hypoxia, hypoglycemia, opioid toxicity, and thiamine deficiency. Imaging studies of the head should be performed for patients with persistent altered mental status, followed by lumbar puncture as clinically indicated. Antibiotic and antiviral medications should be administered as soon as the diagnosis of meningitis or encephalitis is entertained. The patient should be isolated in a secured bare seclusion room with frequent, but unobtrusive observation; seclusion safeguards staff and other patients, calms the patient through reduction of stimuli. The dose of benzodiazepine should be titrated to achieve moderate sedation to obviate physical restraints. Seizures refractory to sedative hypnotic drugs should be managed with nondepolarizing neuromuscular blockade and general anesthesia, along with continuous electroencephalogram monitoring. Management of rhabdomyolysis should include treatment of psychomotor agitation and generous intravenous crystalloid fluids to maintain urine output of at least 2 to 3 mL/kg/h to maximize glomerular filtration rate. Hemodialysis is not indicated for enhanced drug elimination but may be necessary in patients with acute renal failure. The patients with suicidal ideation or persistent psychosis should be referred to the psychiatric service. Hallucinogens are primarily composed of synthetic indolamines (derivatives of tryptamine), phenethylamines (derivatives of amphetamine, see Chapter 100), and botanical products. The psychedelic experience may precipitate homicidal acts, self-destructive behavior, accidental injuries, and acute or chronic psychosis. Physiologic effects vary from mild flushing to life-threatening alterations in vital signs, coma, seizures, and coagulopathy. Pharmacology Synthetic hallucinogens are sold as liquid, powder, tablets, capsules, microdots (dried drug residue) on printed paper, liquid-impregnated blotter paper, and as windowpanes (translucent 3 × 3 mm gelatin squares). The routes of administration are oral, intranasal, sublingual, conjunctival, smoking, or intravenous injection. Windowpanes are usually placed under the tongue or in the conjunctival sac, and may also be swallowed.