In the 41 cases of manual strangulation studied by DiMaio extra super viagra 200mg otc erectile dysfunction gel, the incidence of fractures was 68 cheap extra super viagra 200 mg erectile dysfunction nyc. Of the 14 males order 200mg extra super viagra erectile dysfunction 37 years old, 10 had fractures of the hyoid, either alone (4 cases) or in combination with other structures (6); two had fractures limited to the thyroid cartilage; two to the cricoid cartilage. Bilateral fractures of superior horns of thyroid cartilage and fracture of cricoid cartilage. With unilateral fractures of the hyoid, fractures of the left side dominated 11 to 7. All the fractures of the thyroid cartilage involved the superior horns rather than the body of the thyroid. The latter fractures tend to be vertical and are usually caused by a blow to the thyroid cartilage. Because of its location high up in the neck, the hyoid bone is relatively safe from injury by direct blows unless the neck is arched. In direct blows to the neck, fractures of the hyoid are generally seen only in association with a fracture of the mandible. Whether the fractured ends of the hyoid bone are driven inward or outward is immaterial. The larynx, lying in front of the fourth through sixth cervical vertebrae, is protected in the midline only by skin and two layers of fascia. Thus, fractures of the body of the thyroid cartilage can be seen in blows to the neck. Lateral compression of the larynx, as might be expected in manual strangulation, causes fractures of the cornu (horns) of the thyroid. Fractures of the cricoid cartilage occur most frequently when the cartilage is compressed in an antero- posterior direction against the vertebral column. These fractures, which are usually vertical, might occur in the midline or laterally. In manual strangulation, there is usually trauma to both the external and internal aspects of the neck. Because of the way the neck is usually grasped, the tips of the four fingers with their associated fingernails dig into the neck. Asphyxia 267 Depending on the length, sharpness, and regularity of the nails, they can produce linear or semilinear abrasions, scratches, and scrapes (Figure 8. Therefore, nail marks are less common from the thumb, though a contusion may be present. In this method of attack, one sees small contusions and erythematous marks in association with nail marks on one side of the front of the neck caused by the fingers. An erythematous mark or contusion and, less commonly, a nail mark caused by the thumb, might be present on the opposite side of the neck. If two hands are used and the victim is attacked from the front, there are usually erythema- tous marks and contusions or nail marks on both sides of the front of the neck, usually posterior to the sternocleidomastoid muscles. A variation of a two-handed attack to the front of the neck involves using pressure applied by two thumbs on the central aspect of the neck. Here, the assailant presses both thumbs directly against or along the sides of the larynx and trachea. This results in erythematous markings or contusions of the anterior aspect of the neck. The area of hemorrhage can be either in a bilateral parasagittal plane or confluent across the midline. Fingernail marks, contusions, and erythematous marks caused by the fingers will be on the lateral aspects of the neck. If either one or two hands are used and the victim is attacked from the back, erythematous marks or contusions from the fingertips, as well as nail marks, are generally found on the front of the neck between the larynx and sternocleidomastoid. With one hand, the marks would be on only one side of the neck; with two hands, on both sides. A less common method of strangulation is an assault from the front using the palm of the hand to apply pressure to the neck without using the fingertips. The authors have seen this in a number of instances, all of which involved adults who were unconscious through acute alcohol intoxication, or young children. There was no evidence of trauma externally that could be related to either the fingertips or fingernails. In all but one instance, there was congestion of the face and petechiae of the conjunctivae and sclerae, as well as periorbital petechiae of the skin. No hemorrhage was noted internally and there was no injury to the internal structures of the neck. Nail marks can be classified into three types using the classification of Harm and Rajs: impression marks, claw marks, and scratch marks. Impres- sion marks are “regularly curved, comma-like, exclamation mark-like, dash- 268 Forensic Pathology like, or oval, triangular, rectangular epidermal injuries measuring 10–15 mm in length and up to a few millimeters in breadth. In the case of curved imprints, the concave surface does not necessarily correspond to the concave surface of the nail, but might just as easily be a mirror image. Claw marks are U-shaped injuries of both the epidermis and dermis, varying in length from 3–4 mm to a few cm. In claw marks, the fingernails dig into the skin at a tangential angle, cutting the epidermis and dermis tangentially and undermining it. Scratch marks are parallel linear abrasions or erythematous bands in the epidermis up to 1. While, in most manual strangulations, there is evidence of both external and internal injury to the neck, in some cases, there is no injury, either externally or internally. The first showed absolutely no evidence, either externally or internally; the second showed congestion of the face with fine petechiae of the conjunctivae and skin of the face, but no evidence of injury to the neck, either externally or internally; and the third victim had abrasions and scratches of the skin with extensive hemorrhage into the muscles of the neck. The modus operandi of the perpetrator was to meet a woman in a bar, buy her liquor until she was extremely intoxicated, and then go off with her and have sexual intercourse. At the time of strangu- lation, the women were unconscious through acute alcohol intoxication, so a very minimal amount of pressure was necessary. He would place his hand over their necks and push downward, compressing the vessels of the neck. In the last case, the individual regained consciousness and struggled, with the resultant injuries. The perpetrator admitted having killed a number of other women the same way over the past years in a number of states. It is suggested that, in all manual strangulations, a complete toxicological screen be performed. Harm and Rajs addressed this question in a study of 37 dead and 79 surviving victims of strangulation. Thus, sphincter incontinence, while more common in strangulation, is not an absolute finding. Asphyxia 269 In cases of strangulation, the presence of fractures of the larynx or hyoid indicate only that pressure or force has been applied to the neck. The authors have seen cases where someone has attempted to stran- gle an individual, causing fractures of the thyroid cartilage or hyoid, only to give up and stab or beat the victim to death. One must be sure that the fractures are antemortem, because it is not uncommon to fracture the larynx at the time of autopsy.

The oxygen supply at 50 psi is connected to a reducing valve that allows the pressure to be adjusted from 0 to 50 psi extra super viagra 200 mg amex impotence vs impotence. The side port of the endoscope is used as the Venturi injector site cheap 200mg extra super viagra with visa erectile dysfunction losartan, and the open end can be used for continuous viewing by the endoscopist cheap extra super viagra 200mg line erectile dysfunction and diabetes type 2. Bacher A, Lang T, Weber J, et al: Respiratory efficacy of subglottic low- frequency, subglottic combined-frequency, and supraglottic combined-frequency jet ventilation during microlaryngeal surgery. Donati F, Meistelman C, Benoit P: Vecuronium neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis. Jaquet Y, Monnier P, Van Melle G, et al: Complications of different ventilation strategies in endoscopic laryngeal surgery: a 10-year review. It is wise to convert this to a tracheostomy as soon as it is convenient to do so as this reduces the subsequent incidence of subglottic stenosis and cricoid chondritis. A tracheotomy is generally done in a controlled setting, either under general anesthesia in an intubated patient or under local anesthesia. Either a short transverse incision 1–2 cm inferior to the cricoid or a midline vertical incision beginning at the same location may be used. Strap muscles are retracted laterally, the thyroid isthmus is divided if necessary, and in adults an inferiorly based tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. In small children, it is better to make only a vertical midline incision to minimize the incidence of stenosis; left and right stay sutures are then placed to assist in reintubation in the event of accidental dislodgment of the tracheotomy tube. Trach ties supplement this securing of the tube unless these circumferential ties would interfere with venous drainage of a flap used in the head and neck reconstruction. When prolonged use of a tracheotomy is anticipated and it is unlikely that mechanical ventilation will be needed, there are specialized silicon tracheotomy tubes with minimal intraluminal plastic and may be associated with fewer intraluminal potential complications. Usual preoperative diagnosis: Indications for tracheostomy are numerous, but share the common theme of securing a safe airway either in anticipation of postop airway edema, inability to protect the airway from aspiration, or as an urgent need to obtain an upper airway in pending obstruction. The fastest way to obtain an airway in an outright emergency when intubation is not an option is a cricothyrostomy. Rarer indications are bilateral vocal cord paralysis or a history of recurrent allergy associated with larynogspasm. If the latter constitutes life- threatening emergency, tracheotomy/cricothyroidotomy may be the preferred approach. Aside from an occasional otherwise healthy patient in the 3rd category, all patients presenting for tracheostomy are usually debilitated, have associated cardiac or pulmonary disease, and frequently present with neurological and metabolic abnormalities. In the presence of significant airway compromise or anticipated very difficult intubation local anesthesia may be required. Mcguire G, El-Beheiry H, Brown D: Loss of the airway during tracheostomy: rescue oxygenation and re-establishment of the airway. It also can be caused by β-hemolytic streptococci, staphylococci, pneumococci, or unusual pathogens among immunocompromised individuals and drug/alcohol abusers. At one time, the typical patient was a previously healthy child 3–5 yr old; however, since the advent of the H-flu vaccine, epiglottitis is more common in adults (predominantly males). The most common presenting symptoms are sore throat, dysphagia/odynophagia, fever, respiratory difficulty, and drooling. Patients presenting with imminent or actual airway obstruction should be intubated immediately. Airway management for adult patients presenting with mild-to-moderate symptoms is controversial. Although routine prophylactic intubation of these patients may not be necessary, 18% subsequently develop complete airway obstruction; thus, close monitoring is mandatory if intubation is deferred. It is imperative to realize that total airway obstruction can occur suddenly and without warning. In the pediatric patient, it is critical that neither visualization of the epiglottis nor other maneuvers be attempted to confirm the Dx before anesthesia. Verbruggen K, Halewyck S, Deron P, Foulon I, Gordts F: Epiglottitis and related complications in adults. This is an acquired disorder, usually seen in the 6th to 9th decades of life and felt secondary to tonic spasm or achalasia of the cricopharyngeus muscle. Clinically, patients may experience dysphagia, globus, coughing, and regurgitation of undigested food. Endoscopy will reveal the presence of a pouch of variable size posterior to the cricopharyngeus muscle often filled with undigested debris. Cricopharyngeal achalasia may present in the absence of a well-formed diverticulum with much the same symptom complex. Treatment is usually aimed at division of the cricopharyngeus muscle and eradication of the pouch. The muscle is cut, the diverticulum resected, and the hypopharyngeal defect closed. Aspiration precautions should be observed at both induction (consider awake intubation in severely symptomatic patients) and reversal of anesthesia, as this is a common comorbidity in patients with Zenker’s diverticulum. Endoscopic: Selected patients may be candidates for endoscopic treatment of a Zenker’s diverticulum. This is better described as diverticulotomy rather than diverticulectomy because the redundant hypopharyngeal mucosa is not removed, and the cricopharyngeus muscle is not divided in its entirety. Rather, the common wall separating the diverticulum from the esophagus is reduced to prevent food and debris from collecting within the confines of the diverticulum. With the patient under general anesthesia and muscle relaxation, an esophagodiverticuloscope is placed transorally and advanced into the hypopharynx. Under local anesthesia with intravenous sedation, a skin incision is made at the level of the larynx and the thyroid cartilage exposed. Using a small saw, drill bit, or knife, a window is cut in the cartilage to the level of the inner perichondrium. Lateral pressure is then applied to the paralyzed side to gauge the amount of medialization necessary to improve phonation. Because the shape and size of the implant is created based on the location and degree of medialization needed to improve the voice, it is important for the patient to be awake and able to phonate during the procedure. Often the patient is kept in a state of deeper sedation in the beginning of the case and then is lightened as the case proceeds to allow the patient to be responsive and interactive with the surgeon. This can be a challenge for the anesthesiologist to strike a happy medium between patient comfort and coherence. After the desired degree of medialization is obtained, the implant is secured in place and the wound closed over a drain. Description: Arytenoid adduction is often performed in conjunction with thyroplasty. This involves placement of a suture around the muscular process of the arytenoid cartilage, which, when tightened, causes posteromedial rotation of the vocal process and adduction of the vocal fold. Usually the technique is employed when there is a persistent gap between the vocal folds posteriorly. Description: Injection laryngoplasty refers to medialization of a paralyzed vocal fold by means of injection, whether percutaneous or endoscopic. Its minimally invasive nature is its chief advantage over thyroplasty or arytenoid adduction. However, the longevity of the injected material as well as its side effect profile are major determinants as to whether or not this procedure should be considered.

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We have performed this procedure in patients undergo- variants of normal anatomy in congenital heart disease can ing complex congenital heart operations such as the Fontan complicate this straightforward treatment 200 mg extra super viagra with mastercard erectile dysfunction code red 7, however buy cheap extra super viagra 200 mg line erectile dysfunction doctors in brooklyn. This approach for tive techniques extra super viagra 200mg visa erectile dysfunction doctors los angeles, because the transcatheter approach to treating patients with congenital heart disease has not been fully evalu- atrioventricular nodal reentry tachycardia is so successful, but ated owing to significant anatomic variants, atrial wall thick- there are some indications for combined operative therapy. The incidence of For example, it may be used in patients with prior Mustard or complications from transcatheter techniques, such as pulmo- Senning procedures who are undergoing reoperation, in order nary vein stenosis, esophageal perforation or fistula formation, to avoid the retrograde catheter approach to the pulmonary and third-degree heart block, still must be considered, espe- venous atrium. Ventricular endocardial The arrhythmia can originate in the left or right ventricle and fibrosis resection and cryoablation of the areas between the is usually reentrant in nature. Surgical ablation is reserved for toward the tricuspid annulus (not shown), can be accom- patients who are refractory to medications and transvenous plished. We have performed surgical revision of residual ablative techniques, or those with ventricular tachycardia hemodynamic abnormalities in adults with tetralogy of Fallot who are undergoing repair of structural heart disease. Amiodarone is effective stimulation in the postoperative period is necessary to deter- in controlling these arrhythmias, but surgery is sometimes mine efficacy; defibrillator implantation is then performed if indicated for refractory cases if a localized area can be identi- sustained ventricular tachycardia remains inducible. Two such the right ventricular outflow tract or the septal surface of the patients had recurrent ventricular tachycardia associated left ventricle. Both forms can be effectively treated by cathe- with syncope in one and dizziness in the other. Catheter During the operation, large white plaque lesions were found, ablation under these circumstances is challenging. Successful surgical cryoablation of the well-circumscribed tachycardia focus was performed, using cardiopulmonary bypass and cardio- plegic arrest to protect the left anterior descending artery during the lesion placement. Some patients with postopera- tive tetralogy of Fallot or double-outlet right ventricle have late postoperative sustained ventricular tachycardia, espe- cially if large transannular patches were used in their initial reparative operation. These patients who undergo reoperations for pulmonary valve insertion, right ventricular outflow tract Fig. A high incidence of subsequent arrhyth- tic lesion, from the base of the right atrial appendage to the mia has been reported in a substantial number of patients who anterior tricuspid annulus (Fig. Patients with congenital heart disease have mul- the interatrial lesion that connects the fossa ovalis and the tiple anatomic variations that confound any lesion set. These posterior flap of the incised atrium across the crista termina- complex issues must be viewed with awareness that prophy- lis (as first seen in Figure 18. Bioethical principles of nonmalfeasance, beneficence, conclude the prophylactic lesion sets, the left atrium is patient autonomy, and justice are applicable. One continuous cryoablation lesion the P3 location of the posterior mitral valve annulus, and is shown connecting the tricuspid annulus at the commissure connection of the pulmonary vein confluence with the base of the septal and posterior leaflets with the inferior coronary of the left atrial appendage. Technical improvements have resulted in increased pulse generator lon- gevity and multisite pacing systems to avoid and treat the con- sequences of chronic right ventricular apical pacing that can lead to myocardial dysfunction. In addition, defibrillator ther- apy for primary and secondary prevention of sudden death has been applied more frequently to patients with repaired congen- ital heart disease and dilated cardiomyopathy. Epicardial pacemaker placement was the standard of care in young patients 20 years ago. The cardiac surgeon is usually called upon to place epicardial pacemakers in neo- nates, infants, and children who are too small for transve- nous techniques or who have special conditions that preclude transvenous access. The surgeon, along with the electrophysiologists, must choose whether to use transvenous or epicardial techniques. On the other hand, epicardial pacemakers have the potential for gen- erator migration, wound dehiscence, and a greater risk of lead fracture with activity. Most practitioners use epicardial systems in infants and small children undergoing surgery for structural heart disease, reserving the transition to transve- nous leads for a time when somatic growth allows a better chance of long-term success without complications. In some cases, however, bipolar atrial and ventricular leads are more easily placed through a median sternotomy and proper rectus sheath dissection. The linea alba Bipolar leads are now preferred to prevent far-field inter- is left intact posterior to the pulse generator and the ante- ference, but the exposure and principles remain the same. Finding an appropriate target site for the epicardial leads is This closure allows the surgeon the option of using both a challenge even to the experienced heart surgeon. In gen- rectus abdominis sheaths for a secure and tension-free eral, an epicardial location free from fat and prior injury or implantation in what otherwise would be a significant sur- fibrosis is preferred. Each site can be tested before implan- gical challenge if just one rectus sheath were used. The best site on the atrium is an area Using these epicardial and transvenous techniques, free of prior incisions and fibrosis. An actively contracting patients have been treated with the latest technological target area is likely to result in excellent sensing and pac- improvements, which include dual-chamber pacing, antit- ing thresholds. Submuscular implantation of the pulse generator, especially in infants and young children, is preferred to avoid wound complications and possible patient manipulation. The dis- section is started by a longitudinal incision to the umbili- cus to the linea alba. The subcutaneous tissue is undermined on the right and left rectus sheaths to expose the enclosed rectus abdominis muscle. A longitudinal incision is then made in the rectus sheath, thereby exposing the rectus abdominis muscles on both sides of the linea alba, all the time leaving the linea alba intact without entering the pro- peritoneal space. The space between the posterior rectus abdominis muscle and the posterior rectus sheath on both sides is developed with blunt and electrocautery dissec- tion. Once an adequate space is formed, the pulse genera- tor is temporarily placed to ensure that the pocket is of ample size. Arrhythmia surgery in patients with and without con- (Copyright © 2004 with permission from Elsevier. Hoboken: © 2007, with permission from Elsevier and the American Wiley-Blackwell; 2013. Maxwell Chamberlain of steroid-eluting epicardial versus transvenous pacing memorial paper for congenital heart surgery. Subaortic stenosis can be caused by fibrous rings, hypertrophied muscle, or abnor- Subaortic obstructive lesions are generally approached mal mitral valve attachments. Aortic valve lesions can be through the orifice of the aortic valve using aortobicaval car- caused by a small aortic annulus or fused leaflets. Supravalvar diopulmonary bypass, left ventricular venting, and a combi- aortic stenosis can be caused by a fibrous ring surrounding nation of antegrade and retrograde hypothermic cardioplegia. The aortic Care is taken to preserve the aortic leaflets during retraction arch can be malformed by a small ascending or transverse with careful fibromuscular ring resection, paying careful arch, coarctation of the aorta, or interruption of the aortic attention to the conduction system, and care is also taken to arch. These tenets are also true that often require multiple operations, anticoagulation, and for extensive resection of septal and circumferential obstruc- decongestive therapy. Each disease entity has associated tive muscle fibers for idiopathic hypertrophic subaortic ste- reparative operations. The most difficult parts of this operation are gauging the level of resection and removing the muscle fibers without leaving potential particulate matter, which can cause strokes. Specialized forceps and tissue hooks will allow the surgeon to identify muscle bundles, capture them, and use scalpel resection to create an appropriate resection while leaving a smooth surface without the potential for unwanted emboli. Liberal use of antegrade and retrograde cardioplegia will allow the surgeon the proper time for optimal exposure and effective resection. On separation from cardiopulmonary bypass, intraoperative pressure measurements and trans- esophageal echocardiography can be performed; their results may necessitate a return to cardiopulmonary bypass for fur- ther subaortic resection.

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Very superficial incised wounds identical to hesitation marks occasionally can be seen in homicidal incised wounds of the neck purchase extra super viagra 200 mg free shipping impotence 101. This could be caused by either struggling of the individual prior to the infliction of the fatal wound or perhaps the perpetrator’s initial hesitancy to cut the victim’s throat best order extra super viagra erectile dysfunction uptodate. Most people have a vague knowledge of anatomy and do not know where to sever a major vessel order extra super viagra mastercard weak erectile dysfunction treatment. Some individuals cut their forearms vertically, rather than horizontally, due to an ignorance of Wounds Caused by Pointed and Sharp-Edged Weapons 215 Figure 7. When the patient cut his wrist again later in the week, he cut the radial artery correctly and bled to death. In self-inflicted incised wounds of the extremities, right-handed individ- uals usually cut the left wrist or forearm; left-handed individuals, the right wrist or forearm. These incised wounds are typically found on the flexor surface and radial aspect of the forearm (Figure 7. Thus, the presence of linear scars on the flexor surface in these areas suggests that an individual has attempted suicide in the past. Defense wounds are wounds of the extremities incurred when an indi- vidual attempts to ward off a pointed or sharp-edged weapon. They are most commonly found on the palms of the hands, due to attempts to grasp or ward off the knife; the back (extensor surface) of the forearms and upper arms and on the ulnar aspect of the forearms (Figures 7. In self-inflicted incised wounds using double-edged razor blades, the blade will often cut the fingers of the hand holding it. If individuals are using a knife and there is a lot of blood, there is a possibility that their hands could slip from the handle onto the blade, incurring an injury. Incised Wounds of the Neck Incised wounds of the neck can be accidental, homicidal, or suicidal. Acci- dental wounds are extremely rare, usually seen only when an individual goes through a sheet of glass or is struck in the neck by a flying fragment of glass or some other sharp-edged projectile. Thus, in one case, a 13-year-old male was struck by flying glass when a bottle containing dry ice exploded. Homicidal incised wounds of the neck present two different pictures, depending on whether they are produced from the back or the front. The head is pulled back, exposing the neck, and the knife is then drawn across it. Often, the victim is face down on the floor or ground at the time the wound is inflicted. The perpetrator usually starts the incision high up on the side of the neck 218 Forensic Pathology C D Figure 7. The knife is drawn across the neck, from left to right by a right-handed assailant and from right to left by a left- handed individual. The wound inflicted is first shallow, then deeper and then shallow again, terminating on the opposite side of the neck. The wound generally starts below the ear; runs downward and medially at an angle, then straight across the midline of the neck, and then upward, ending on the opposite side of the neck, lower than its point of initiation (Figure 7. Wounds Caused by Pointed and Sharp-Edged Weapons 221 Homicidal incised wounds of the neck inflicted from the front tend to be short and angled (Figure 7. A right-handed individual typically inflicts incised wounds on the left side of the victim’s neck, with the slashes running downward and medially at an oblique angle. Wounds across the front of the neck tend to be horizontal and short, extending a short distance to the right or left of the midline. Horizontally incised wounds inflicted from the front of the neck are the least common. The characteristics of the wounds produced by a frontal attack are obvious with an understanding of the etiology. Instead of the neck’s being cut with one long, continuous motion, these wounds are inflicted by “swipes” or slashes made while facing the individual. In self-inflicted wounds of the neck, the same general pattern holds as for a homicidal assault from the rear. The wound usually begins higher on the neck on the side opposite to where it terminates. Suicidal incised wounds of the neck are usually, but not always, accompanied by hesitation marks (Figure 7. In rare instances, a fatal self-inflicted incised wound of the neck may be accompanied by cadaveric spasm (instantaneous rigor mortis) with the knife or razor found firmly clenched in the victim’s hand — unequiv- ocal proof of suicide. Another person may have altered the scene, or, if the initial wound was not immediately incapacitating, the suicide victim was allowed time to conceal the weapon prior to death. Incised wounds of the neck may be extremely deep and extend completely to the vertebral column. Death from incised wounds of the neck may be due not only to exsan- guination, but to massive air embolus. An X-ray of the chest for the detection of air in the venous system and heart is recommended. The length of time it takes to die following an incised wound of the neck depends on whether the venous or arterial systems are severed and whether there is air embolism. Miscellaneous Pieces of glass have been used to cut wrists and throats and to slash people. The authors have seen a number of cases in which an intoxicated individual knocked out a pane of glass with a hand or fist. In the process, as the arm went through the glass, or when it was pulled back, a jagged projection of glass cut the arm, inflicting a deep wound and severing a major vessel, with resultant exsanguination (Figure 7. Psychotic individuals may use edged weapons to mutilate either them- selves or others. Non-psychotic individuals may mutilate as a warning, in revenge, or to collect souvenirs (usually ears). In bodies in which there is prolonged immersion in water, the water can leach out the blood in both stab and incised wounds, giving an almost postmortem appearance to these wounds, suggesting that they were inflicted after death rather than before (Figure 7. In both incised and stab wounds, one should always examine the clothing to see if there are defects corresponding to the wounds. This is to rule out an individual’s being stabbed or cut and then the body dressed. The presence of an incised wound of the skin, with an underlying comminuted fracture or deep groove in the bone, indicates that one is dealing with a chopping weapon (Figure 7. When the perpetrator pulls out a weapon that has embedded itself in the bone, he might give it a sharp twist, fracturing or breaking off the adjacent bone. In tangential wounds of the skull, chopping instruments may cut off disks of bone. He incurred wounds of the left arm, with severing of major vessels and exsanguination. Note incised-like nature of wounds with cutting of underlying bone While most chop wounds appear incised, when there is a combination of cutting and crushing, they can have both incised and lacerated characteristics. Chopping weapons cutting through bone can impart characteristic stri- ations on the bone unique to each type of weapon. Humphrey and Hutchin- son evaluated hacking trauma on bones produced by cleavers, machetes and axes.

Discriminators are individual algorithm components or “building blocks” that provide a partial or complete rhythm classification for a subset of rhythms generic extra super viagra 200mg overnight delivery erectile dysfunction treatment home. Rhythms are classified into three Rate Branches: ventricular rate greater than atrial rate (V > A) order generic extra super viagra pills erectile dysfunction nclex questions, ventricular rate equal to atrial rate (V = A) 200 mg extra super viagra visa erectile dysfunction facts and figures, and ventricular rate less than atrial rate (V < A). If V = A, the algorithm may also incorporate analysis of arrhythmia onset, which may be either chamber of onset or ventricular sudden onset to differentiate pathologic tachycardias form sinus tachycardia. In addition, it classifies appropriate therapy as avoidable if it could have been withheld without adverse clinical consequences. Strategic programming of sensing, detection, and therapy reduces inappropriate and avoidable 25 therapies and may reduce overall mortality. I A/B-R* Reduce total therapies For primary prevention adult patients, the slowest detection rate should be programmed to 185 to 200 beats/min. Signals that vary with the cardiac cycle (cyclic signals) indicate an intracardiac sources. Physiologic signals can be intracardiac (P, R, or T waves that cause one oversensed signal per cardiac cycle) or extracardiac (myopotentials). Cyclic oversensing of physiologic T waves and P waves or R-wave double-counting results in a pattern of 1 oversensed signal per true cardiac cycle that corresponds consistently to P waves, T waves, or a second component of R waves. The 60-Hz signal from line current appears with an 8-Hz modulation due to telemetry sampling at 128 Hz, just above the Nyquist limit. The approach to shocks delivered for oversensing is guided by the cause of oversensing. A patient with a single shock should be evaluated in person or by remote monitoring within 24 to 48 hours. In the absence of ongoing cardiac symptoms, a single appropriate shock (reviewed remotely) does not require further intervention. Because defibrillation success is probabilistic, occasionally shocks fail, but failure of two maximum- output shocks is rare if the safety margin is adequate. Many patient-related causes can be reversed, but system-related causes usually require operative intervention. Patient-Related Factors Metabolic (hyperkalemia) Ischemia Progression of heart failure Some antiarrhythmic drugs (e. Excluding leads with known high failure rates, the 30 overall incidence of clinical failure is about 1. Oversensing is the most common initial electrical 17,29 abnormality with either conductor fracture or insulation breach. Conductor fractures usually cause a 17 characteristics pattern of oversensing (Fig. Unlike conductor fractures, insulation breaches themselves do not generate abnormal signals. Several enhanced sensing features incorporate specific features of lead-related oversensing to alert patients and 20,29 physicians and, in some cases, withhold inappropriate shocks (see Fig. Pace-sense malfunctions can also present with pacing impedance changes, loss of capture, or abrupt decrease in R wave amplitude. Impedance and Impedance Trends in Diagnosis of Lead Failure Conductor fractures may cause abrupt increases in impedance; conversely, insulation breaches may cause abrupt decreases in impedance. Oversensing usually precedes impedance changes in pace-sense component failures, but impedance changes occur before or concurrently with oversensing in a minority of cases. When the cause of oversensing is in doubt, impedance abnormalities confirm the diagnosis of lead failure. To the left of the longest vertical line, data are displayed as vertical bars connecting weekly maximum and minimum impedance values. Conversely, a gradual impedance increase without oversensing usually occurs at the electrode-myocardial interface, caused at least in some cases by calcium deposition in the form of hydroxyapatite; lead replacement is not indicated unless pacing or sensing is compromised. Occasionally, silicone insulation breaches present with low or decreasing pacing impedance. Although this trend occurred in a normal lead, normal trends may occur with conductor fractures and insulation failures. C, Connection problem between the header and lead because of incomplete insertion of the pin. Highly variable impedances are seen beginning approximately 4 months after implantation, followed by approximately a 2- month return to baseline between early October and December 2007. D, Lead conductor fracture with a late, abrupt increase in impedance to highest reported value (>3000 Ω). Although the programmer displays impedance only up to a maximum value of 3000 Ω, impedance is measured up to 16,000 Ω. A late, abrupt increase in impedance to an open-circuit value is diagnostic of a conductor fracture. F, Gradual increase in impedance in a normally functioning lead, thought to be caused by changes at the electrode-myocardial interface. Fractures of high-voltage conductors can present as abrupt increases in shock impedance. Cinefluoroscopy in multiple views is more sensitive than chest radiography for identifying “inside-out” insulation breaches that cause cable conductors to protrude outside the outer insulation (externalized cables; eFig. Before revision, the lead connector pin was not advanced completely into the header (red arrow). The proximal connection between the ring electrode and the header was intermittent, which resulted in high impedance and oversensing causing pauses in the paced rhythm. All lead-failure diagnostics have false positives, and the diagnosis of lead failure must be confirmed before surgical 29 intervention to remove a failed lead. System revision involves either abandoning or extracting the failed lead and inserting a replacement lead. Usually, lead abandonment is associated with lower procedural risk and lead extraction with fewer long-term problems. The trade-offs depend on multiple factors related to the 17,29,31 patient, operator/institution, specific lead model, and patient preference. Implant-Related Complications Transvenous lead insertion may result in complications related to vascular access, lead placement, pocket 32 integrity, and infection. Overall, major complications occur in about 4% to 5% of new implants and 2% 33 to 3% of generator changes. Vascular Access Vascular access for transvenous leads can be complicated by pneumothorax and less often by hemothorax or injury to neurovascular structures. Rarely, failure to recognize inadvertent entry into the arterial system results in placement of a lead retrograde through the aorta into the left ventricle. There is also a risk of entry into the left atrium from the right atrium via a patent foramen ovale. An unexplained stroke should prompt echocardiographic examination to confirm that the atrial and ventricular leads are not in left-sided chambers. Upper extremity swelling on the side of the implant indicates thrombosis of the accessed vein. It usually resolves with elevation of the extremity and time, with or without anticoagulation. Lead Placement The most common complication is dislodgment of the lead, and this usually requires prompt revision.

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Late dissection at the repair site is rare buy extra super viagra with mastercard erectile dysfunction joliet, but false aneurysms cheap 200mg extra super viagra broccoli causes erectile dysfunction, usually at the suture line order extra super viagra amex erectile dysfunction drugs used, can occur. Long-term follow-up after surgical correction of coarctation of the aorta still reveals an increased incidence of premature cardiovascular disease and death, mainly resulting from prevalent associated risk factors (i. The respective roles of stent therapy and surgery over balloon dilation of aortic 67 coarctation are becoming better defined. These complications have been reduced with the now increasing if not exclusive use of 68 primary stenting in the adults with native coarctation as well as recoarctation. The significance of aneurysm formation is often unknown, and longer-term data are necessary. Prior hypertension resolves in up to 50% of patients but may recur later in life, especially if the 70 intervention is performed at an older age. In some of these patients, this may be essential hypertension, but a hemodynamic basis should be sought and blood pressure control should be attained. Systolic 70,71 hypertension is also common with exercise and is not a surrogate marker for recoarctation of the aorta. It may be related to residual arch hypoplasia or to increased renin and catecholamine activity from residual functional abnormalities of the precoarctation vessels. The criteria for and significance of exertional systolic hypertension are controversial, but its presence may predict the future development of 71 chronic hypertension. Late cerebrovascular events occur, notably in patients undergoing repair as adults and in those with residual hypertension. Endocarditis or endarteritis can occur at the coarctation site or on intracardiac lesions; if this occurs at the coarctation site, embolic manifestations are restricted to the legs. Patients with repaired aortic coarctation usually tolerate pregnancy well unless they have hemodynamically significant residual lesions, such as severe recoarctation or aortic stenosis from a bicuspid aortic valve. A greater propensity to develop hypertension during pregnancy has, however, been 72 reported. Particular attention should be directed toward residual hypertension; heart failure; intracardiac disease such as an associated bicuspid aortic valve, which can become stenotic or regurgitant later in life; or an ascending aortopathy sometimes seen in the presence of a bicuspid aortic valve. Hemoptysis from a leaking or ruptured aneurysm is a serious complication requiring immediate investigation and surgery. It has long been said that coarctation patients are prone to premature coronary artery disease, but a recent 66 study did not confirm this suspicion. There is substantial evidence of a generalized arteriopathy in 73 coarctation patients that is not addressed by relief of the obstruction. Aortic arch interruption is a rare lesion, but one where surgical success has resulted in an ever-growing number of older children, adolescents, and, now, adults with a history of surgical intervention. Of importance, it is associated with DiGeorge syndrome with microdeletion of chromosome 22. Interruptions distal to the left subclavian artery (type A) occur almost as frequently as interruptions distal to the left common carotid artery (type B). The right subclavian artery is of variable origin, frequently arising from the descending aortic segment distal to the interruption. Surgical resection of the posteriorly deviated outlet septum is dealt with at the time of primary repair in some centers, whereas others address it at a later date. Congenital Aortic Valve Stenosis Congenital aortic valve stenosis is a relatively common anomaly. As well, congenital abnormalities of the mitral valve and endocardial fibroelastosis are encountered more frequently in early presentations, but the clinical sequelae may persist into adulthood. Morphology The basic malformation consists of thickening of the valve tissue with various degrees of commissural fusion. The valve is most commonly bicuspid; in most cases, this is the result of fusion of two leaflets, rather than an actual absence of one of the leaflets. The fusion usually involves the two coronary sinuses, or the right and noncoronary sinus. In some patients (usually newborns), the stenotic aortic valve is unicuspid and dome shaped, with no attachment or just one lateral attachment to the aorta at the level of the orifice. In infants and young children with severe aortic stenosis, the aortic valve annulus may be relatively underdeveloped. Aortopathy is a common association and results in associated dilation of the ascending aorta and sinuses. Clinical Presentation For the adult cardiologist, a history of aortic valve stenosis in a newborn is relevant because it shows that this population invariably does not have isolated aortic valve pathology. It is common for them to have associated endocardial fibroelastosis, as well as abnormalities of their mitral valves. These patients as newborns often present in heart failure, are usually managed with balloon dilation at the time of presentation, and invariably have ongoing aortic valve issues in the form of residual stenosis and/or regurgitation. Many require reintervention in their younger years in the form of further balloon dilation or aortic valve replacement. These patients are surviving into their adolescent and young adult years, and will have more ongoing issues than those who present at a later date. In older children, adolescents, and adults, the diagnosis is usually made following the detection of a murmur. Symptomatic functional decline, presyncope, and syncope are rarely the first presenting features. Natural history studies performed several years ago demonstrated that a more rapid progression of aortic valve stenosis is more likely to happen within the first 2 years of life, following which the rate of progressive obstruction is more uniform. Clinical Findings In general most patients beyond the neonatal period are asymptomatic, having normal peripheral pulses if the stenosis is less severe, and low-volume, slow-rising pulses when it progresses. With severe stenosis there is a systolic thrill in the same area that can also be felt in the suprasternal notch and carotid arteries. Beyond the newborn period there is usually an ejection click at the apex that precedes the murmur. The second heart sound is usually normal in children, with reversed splitting seen only in older patients with severe stenosis. A systolic ejection murmur is heard along the left sternal border, with radiation into the right infraclavicular area. The overall heart size is normal unless left ventricular remodeling is severe or there is important associated valvar regurgitation. Dilation of the ascending aorta can be seen in those with an associated aortopathy. Two-dimensional echocardiography provides detailed information about the morphology of the valve, the left ventricular function, and the presence of associated left-sided lesions. Doppler echocardiography can be used to determine the severity of stenosis and the presence or absence of associated aortic regurgitation.