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J. Olivier, M.A.S., M.D.

Associate Professor, George Washington University Medical School

The concept was first devised and produced by Becton Dickinson under the trademark, Evacuated tube. Evacuated Tube Holder A cylindrical shaped holder that accepts an Evacuated tube on one end and a Evacuated tube needle on the other. The holder, tube and needle comprise the Evacuated tube System (see illustration), used to draw multiple tubes of blood with one venipuncture. This needle will puncture the stopper of a Evacuated tube tube allowing blood to enter the tube. Upon withdrawal of this needle from the tube, the rubber sheath covers the needle bevel, stopping the flow of blood. When a multi-sample needle is used the system will allow for the aspiration of any number of sample tubes with only one venipuncture. When the tube stopper is pierced by a Evacuated tube needle which has been properly positioned in a vein, the vacuum draws blood into the tube. A number of laboratory tests are performed on "fasting" blood specimens such as sugar (glucose) levels and tolerance tests such as glucose, lactose and dextrose. Fibrin the protein formed during normal blood clotting that is the essence of the clot. Fibrinogen the protein from which fibrin is formed/generated in normal blood clotting. Such passages may be created experimentally for the purpose of obtaining body secretions for study. Flash-back Relative to venipunctures, the appearance of a small amount of blood in the neck of a syringe or the tubing of a butterfly. G Gauge Needle diameter is measured by gauge; the larger the needle diameter, the smaller the gauge. Germicide An agent that kills pathogenic microorganisms Glucose the sugar measured in blood and urine specimens to determine the presence or absence of diabetes. Glucose is the end product of carbohydrate metabolism and is the chief source of energy for all living organisms. H Harvesting the collection and preservation of tissues or cells from a donor for the purpose of transplantation. Hematocrit the ratio of the total red blood cell volume to the total blood volume and expressed as a percentage. Hematoma A localized collection of blood within tissue due to leakage from the wall of a blood vessel, producing a bluish discoloration (ecchymosis)and pain. Hemoconcentration A decrease in the fluid content of the blood (plasma), resulting in an increase in concentration. Caused by a filtration of plasma into body tissues and often created by dehydration. A method often used for removing undesirable elements from the blood in kidney patients. Hemolysis the breaking of the red blood cells membrane releasing free hemoglobin into the circulating blood. In phlebotomy, this is usually the result of mechanical damage due to poor technique. Hemostasis the cessation of bleeding, either by vasoconstriction and coagulation or by surgical means. Heparin An anticoagulant that acts to inhibit a number of coagulation factors, especially factor Xa. Transmission is usually the result of poor hygiene and most often through the fecal-oral route. Most recently implicated in numerous outbreaks at restaurants where employee hygiene is suspect. The virus is shed in body fluids of chronic and acute patients as well as asymptomatic carriers. Transmission is primarily by blood transfusions, needlestick injuries by health care workers and sharing of needles by drug abusers.

Were the records clear and in sufficient detail to permit a satisfactory evaluation of the nature and extent of any previous mental disorders? Include if you agree or disagree with previous diagnosis or findings from the records you reviewed and why. Specifically mention if any of the following regulatory components are present or not: a. Continued use despite damage to physical health or impairment of social, personal, or occupational functioning;. Discuss rationale and interpretation of any additional testing that was performed; and include. Recommendations: Additional testing, follow-up testing, referral for medical evaluation. It should describe the circumstances surrounding the offense and any field sobriety tests that were performed; 2. It should include military court records, records of non-judicial punishment, and military substance abuse records. Substance use disorders, including abuse and dependence, not in satisfactory recovery make an airman unsafe to perform pilot duties. These evaluations are required to assess the disorder, quality of recovery, and potential other psychiatric conditions or neurocognitive deficits. Interpretation of a full battery of neuropsychological and psychological tests including but not limited to the "core test battery" (specified below). If pilot norms are not available for a particular test, then the normative comparison group. However, pilots found eligible for Special Issuance will be required to undergo periodic re-evaluations. If and when appropriate, you will receive an updated Special Issuance letter with updated Special Issuance requirements. Interval evaluations (every 3 months or as required by Authorization Letter) were unfavorable? Any evidence of noncompliance or concern the airman is not working a good recovery program. I have no other concerns about this airman and recommend re-certification for Special Issuance. Any evidence (such as a positive test) or concern the airman has not remained abstinent? Any evidence or concern the airman has not been compliant with the recovery program? If you do not agree with the supporting documents or if you have additional concerns not noted in the documentation, please discuss your observations or concerns. Demonstrate hearing of an average conversational voice in a quiet room, using both ears at 6 feet, with the back turned to the examiner or pass one of the audiometric tests below. A diagnosis or medical history of "substance dependence" is disqualifying unless there is established clinical evidence, satisfactory to the Federal Air Surgeon, of recovery, including sustained total abstinence from the substance(s) for not less than the preceding 2 years. The exam should be timed so that the medical certificate is valid at the time of solo flight. Heart, revised Coronary Heart Disease Disposition Table to include all classes considered. All previously listed cardiac condition categories are now considered for all classes. Medical Policy 440 Guide for Aviation Medical Examiners. Medical Policy 441 Guide for Aviation Medical Examiners 2020 09/30/2020 1. In Special Issuances, Atrial Fibrillation, revised content to match updated guidance. In Pharmaceuticals, Acceptable Combinations of Diabetes Medications, revised to add observation wait times and additional notes to combinations chart. Administrative Medical Policy 443 Guide for Aviation Medical Examiners 2. Medical Policy 444 Guide for Aviation Medical Examiners 2. Removed block for "Metabolic Syndrome, Glucose Intolerance, Impaired Glucose Tolerance, Impaired Fasting Glucose, Insulin Resistance, and Pre-Diabetes.

Usually, there are no clinical consequences until the levels rise to 6 mmol/L and above. Causes include acute renal failure, severe chronic renal failure, and use of potassium retaining drugs. Causes include inadequate dietary intake (rare), gastrointestinal fluid loss (vomiting, diarrhoea, fistulae, paralytic ileus), renal loss (diuretics, uncontrolled diabetes mellitus), systemic metabolic alkalosis, and dialysis. Urinary Fistula Abnormal communication between urinary system and skin or internal hollow viscus. Syr 200mg base/5ml (100ml) Cephalexin syrup 125mg/5ml (100ml) Ampicillin/Cloxacillin Neonatal drops 60mg/30mg (10ml) 6. Frusemide Tabs 40mg Hydrochlorothiazide Tabs 50mg Mannitol Inj 20% (500ml) Spironolactone Tabs 25mg 17. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright # 2007 by Oxford University Press, Inc. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. His pioneering studies into coma and its pathophysiology made the first edition of this book possible and have contributed to all of the subsequent editions, including this one. His insistence on excellence, although often hard to attain, has been an inspiration and a guide for our careers. The authors also dedicate this book to our wives, whose encouragement and support make our work not only possible but also pleasant. This page intentionally left blank Preface to the Fourth Edition Fred Plum came to the University of Washington in 1952 to head up the Division of Neurology (in the Department of Medicine) that consisted of one person, Fred. The University had no hospital but instead used the county hospital (King County Hospital), now called Harborview. The only emergency room in the entire county was at that hospital, and thus it received all of the comatose patients in the area. The only noninvasive imaging available was primitive ultrasound that could identify, sometimes, whether the pineal gland was in the midline. Thus, Fred and his residents (August Swanson, Jerome Posner, and Donald McNealy, in that order) searched for clinical ways to differentiate those lesions that required neurosurgical intervention from those that required medical treatment. The physician confronted with such a patient usually first images the brain and then if the image does not show a mass or destructive lesion, pursues a careful metabolic workup. In the 1950s the only pH meter in the hospital was in our experimental laboratory and many of the metabolic tests that we now consider routine were time consuming and not available in a timely fashion. Yet the clinical approach taught in the Diagnosis of Stupor and Coma remains the cornerstone of medical care for comatose patients in virtually every hospital, and the need for a modern updating of the text has been clear for some time. At the same time, there was substantial progress in theory on the neural basis of consciousness, and the senior author wanted to incorporate as much of that new material as possible into the new edition. A second obstacle to the early completion of a fourth edition was the retirement of the senior author, who also developed some difficulty with expressive language. It became apparent that the senior author was not going to be able to complete the new edition with the eloquence for which he had been known. Fred participated in the initial drafts of this edition, but not fully in the final product. Thus, the mistakes and wrongheaded opinions you might find in this edition are ours and not his. We as his students feel privileged to be able to continue and update his classic work. One of our most important goals was to retain the clear and authoritative voice of the senior author in the current revision.

Syndromes

• MRI scan of the head
• Penicillin
• Kidney failure
• 12 to 15 months
• Adults: 15 to 41
• Check your blood pressure
• Some fractures of the bones of the knee
• Points to named body parts at 18 - 24 months

During testing the patient should be observed for respiration defined as abdominal or chest excursions. After 8 minutes have elapsed, arterial blood gases should be sampled and the ventilator reconnected. Alternatively, if respiratory movements are seen, the test is negative and retesting at a later time is indicated. Prior to initiating apnea testing the absence of brainstem reflexes should have already been established. Hypothermia must be excluded; if core temperatures obtained by rectal measurement are below 36. A systolic blood pressure of greater than 90 mm Hg should be maintained using dopamine infusion if required. If hypotension (systolic blood pressure less than 90 mm Hg) arises during the examination, blood samples should be promptly drawn and the ventilator immediately reconnected. As diabetes insipidus is a common complication of severe brain injuries, this should be recognized if present and managed. Accordingly, efforts should ensure euvolemia or positive fluid balance for at least 6 hours prior to testing. Confirmatory Laboratory Tests and Diagnosis When the clinical examination is unequivocal, no additional tests are required. This procedure also has the advantage, when positive, of establishing a structural cause of brain death. In cases where the original cause of cerebral injury is not known, the absence of blood flow provides the crucial information necessary to declare brain death with certainty. The second, and probably more common, occurrence is a progressive loss of blood flow that accompanies death of the brain. As the dead tissue becomes edematous, the local tissue pressure exceeds capillary perfusion pressure, resulting in stasis of blood flow, further edema, and further vascular stasis. If the respiratory and cardiovascular systems are kept functioning for many hours or days after brain circulation has ceased, the brain undergoes autolysis at body temperature, resulting in a soft and necrotic organ at autopsy referred to by pathologists as a ``respirator brain. Two types of abnormalities have been correlated with brain death: (1) an absence of diastolic or reverberating flow, indicating the loss of arterial contractive force, and (2) the appearance of small systolic peaks early in systole, indicative of high vascular resistance. The technique is limited by the requirement of skill in the operation of the equipment and has a potentially high error rate for missing blood flow because of incorrect placement of the transducer. Recent studies report a sensitivity of 77% and a specificity of 100% of diagnosing brain death if both the middle cerebral arteries and the basilar artery were insonated; sensitivity improved with increasing time of evaluation following initial clinical diagnosis. The test can be done at the bedside using a portable gamma camera after injection of isotope, which should be used within 30 minutes after its reconstitution. A static image of 500,000 counts obtained at several time points is recommended (taken immediately, 30 to 60 minutes after injection, and at 2 hours past injection time25). Cerebral metabolism in brain death measured by 18F-fluorodeoxyglucose-positron emission tomography demonstrating the unequivocal finding of an ``empty skull. Moreover, technical recording errors can simulate electrocerebral activity as well as electrocerebral inactivity and several ostensibly isoelectric tracings must be discarded because of faulty technique. After depressive drug poisoning, total loss of cerebral hemispheric function and electrocerebral silence have been observed for as long as 50 hours with full clinical recovery. Physicians have appropriately raised questions as to whether a few fragments of cerebral electrical activity mean anything when they arise from a body that has totally lost all capacity for the brain to regulate internal and external homeostasis. Death is a process in which different organs and parts of organs lose their living properties at widely varying rates. Death of the brain occurs when the organ irreversibly loses its capacity to maintain the vital integrative functions regulated by the vegetative and consciousness-mediating centers of the brainstem. Test of integrity of recording system by deliberate creation of electrode artifact by manipulation 4. No activity with a sensitivity increased to at least 2 mV/mm for 30 minutes with inclusion of appropriate calibrations 6. Recording with an electrocardiogram and other monitoring devices, such as a pair of electrodes on the dorsum of the right hand, to detect extracerebral responses 8. Given such evidence, when and how is one to decide in such cases that anesthesia has slipped into death and further cardiopulmonary support is futile?