Metoclopramide

By O. Candela. Saint Francis College, Loretto, Pennsylvania. 2019.

Subcutane- Intravenous catheters (24 ga in medium to large ous fluids may pool in the ventral abdominal area birds) can be placed in the ulnar or medial metatar- causing hypoproteinemia generic 10 mg metoclopramide with visa, overhydration or poor ab- sal veins of some birds for continuous fluid admini- sorption buy 10mg metoclopramide otc. For placement in the ulnar vein, the cathe- taneous fluid administration should be decreased or ter is inserted using sterile technique, secured discontinued. Intraosseous cannulas the tongue depressor are then firmly incorporated in or use of the right jugular vein are the best access a wing wrap to stabilize the catheter. Dyspneic birds hematoma formation is probably greater using the and those with distended, fluid-filled crops should be ulnar vein than with the metatarsal vein. Many or metatarsal veins is difficult and frequently results birds will chew at the catheter, tape or extension set in hematoma formation. Isoflurane anesthesia is sometimes necessary for cannula place- ment in fractious birds. For placement in the ulna, the feathers from the distal carpus are removed and the area is aseptically prepared. Using sterile technique, the needle is in- troduced into the center of the distal end of the ulna parallel to the median plane of the bone (Figure 15. The needle is ad- vanced into the medullary cavity by applying pres- sure with a slight rotating motion. The needle should advance easily with little resistance once the cortex is penetrated. The mated to be ten percent dehydrated (reduced ulnar refill time, tacky mucous membranes, dull sunken eyes). Admini- Ineffective for shock stration of hypertonic or alkaline solutions can be painful and should be avoided. The advantages of Subcutaneous Fluids intraosseous cannulas include the ease of placement Primarily used for mild dehydration and maintenance, cannula stability, tolerance by Effective for providing maintenance fluids most birds and reduced patient restraint once the Given in axilla or lateral flank cannula is placed. Continuous fluid administration Divide dose among several sites by intraosseous cannula is less stressful than re- Intravenous or Intraosseous Fluids peated venipunctures. Rapidly expands circulatory volume Rapidly perfuses kidneys It has been shown in pigeons that 50% of the fluids Indicated in shock administered in the ulna enters the systemic circula- Indicated with severe dehydration tion within 30 seconds. Initial fluids should be administered slowly to check for subcutaneous swelling, which would indi- cate improper placement of the cannula. If the can- nula is properly placed, fluid can be visualized pass- ing through the ulnar vein. The cannula is secured in place by wrapping a piece of tape around the end and suturing the tape to the skin or by applying a sterile tissue adhesiveb at the point of insertion (Figure 15. A gauze pad with a small amount of antibact- erial ointment is placed around the cannula at the insertion site, and a figure-of-eight bandage is used to secure the wing. One to two loops of the extension tube should be incorporated into the bandage to de- crease tension on the cannula. Tibial cannulas are seated in the tibial crest and passed distally, similar to the technique used for obtaining a bone marrow aspirate. A light padded bandage or lateral splint is used to secure the can- nula in place (see Figure 39. Fluids are administered through the cannula using an infusion pump, buretrolc or Control-a-Flow regu- lator. In small mammals, fluids can be given at shock doses (90 ml/kg) at a pressurized flow rate of 2 l/hr. Excessively rapid infu- sion of the fluids may cause signs of discomfort or edema of the soft tissue in the area of the cannula. Fluid extravasation may occur if the infused volume is too large, or if several holes were made in the cortex while attempting to place the cannula. Intraosseous cannulas are most successful in birds if used during the first 24 to 48 hours for initial rehy- dration and shock therapy. Cannulas can remain in place for up to 72 hours without complications if placed aseptically and maintained with heparinized flushings every six hours. If fluid or drug administration will be restricted to a sponse when fluids are given through an in- single dose or a short period (eg, surgery), it is easier to place a traosseous cannula. No portion of the catheter is externally ex- itial treatment of birds that are weak, sick, debili- tated or in shock. Intrave- for long-term intravenous chemotherapy and total nous administration is recommended if septicemia is parenteral nutrition. Intravenous drugs can be given devices have been used in dogs and laboratory ani- 2,37 during the initial fluid bolus or through an indwell- mals. Intravenous drugs cess port include thrombosis, sepsis, local infection 2 should be given slowly to avoid circulatory shock.

Levamisole plasma purchase 10mg metoclopramide, and the need for an accurate diagnostic test hydrochloride dosed at 30 mg/kg is routinely admin- is imminent discount 10mg metoclopramide with visa. Fenbendazole (15 mg/kg)17 and ivermectin A pigeon-like isolate of chlamydia has been diag- nosed in rheas and ostriches. They are frequently found in free-ranging ostriches where Ratites are susceptible to a number of parasitic infec- they induce no clinically detectable problems. Trematodes Philophthalmus gralli Cestodes Houttuynia struthionis Chapmania tauricollis, Houttuynia Davainea australis Davainea struthionis casuarii, Davainea infrequens Nematodes Baylisascaris procyonis, Codiostomum Ascaridia orthocerca, Deletrocephalus Baylisascaris sp. Fleas Ctenocephalides felis Louse flies Struthiobosca struthionis Lice Struthiolipeurus struthionis Struthiolipeurus andinus, S. The cause of apparent resis- Prevention of this cerebrospinal nematode may be tance in these older birds is unclear. It is possible possible by control of the vector, elimination of the that older birds were immune to the parasite or that environmental conditions conducive to transmission the neural tissues were less severely damaged. Several birds with mild neurologic signs were emu farms use anthelmintics in an attempt to arrest followed for a six-month period and never developed larval migration, but it is unclear if this preventative a microfilaremia. Although this parasite has not been re- ported in the ostrich, it should be considered a threat Grackles are the normal host for C. Following a migration been shown to cause neurologic signs in ratites (see of unknown duration, the larvae enter the brain and Chapter 36). When the microfilaria are ingested by Ostriches are subject to infestation by a variety of gnats, the life cycle of the nematode is completed. The ostrich louse, Struthiolipeurus struthionis, is commonly found on ostriches worldwide. Quill mites are responsive to monthly treatments with ivermectin at standard doses. Clinical signs are characterized by ocular or nasal discharge, and birds may be dyspneic and appear unkempt. Affected birds should be iso- lated immediately and flockmates should be care- fully observed. Adequate ventilation and reduced air- borne debris are necessary to prevent the spread of infections in the flock. Air sacculitis and pneumonia are most commonly caused by bacteria orAspergillus spp. Bilat- eral cataracts must be removed, and surgery has chewing lice feed on skin scale and feathers and by been successful. Infestation is easily diagnosed by Lacerations, abrasions or ulcerations to the eye may identification of the nits glued to the barbs along the cause epiphora or blepharospasms. Foreign bodies shaft of feathers, particularly under the wing (Figure may or may not be found. The ostrich louse fly, Struthiobosca struthionis, cases is usually clear and often is present in only one is a minor annoyance to African birds but may also bite eye. Standard ocular the feather shaft or along the external groove of the therapies used in other birds are effective in ratites shaft. Ticks from a variety of mammalian, avian and reptile hosts have been reported to infest ostriches. They Eye infections generally cause the production of a may cause blemishes on the skin that reduce its purulent discharge and will usually be bilateral commercial value. Cytology and cultures are necessary to tick species are potential vectors of livestock dis- determine the etiologic agent. The discovery of ticks on imported ostriches common with upper respiratory infections. A blocked released from private quarantine in 1989 caused the nasolacrimal duct is recognized clinically by United States Department of Agriculture to impose epiphora and swelling within the lower lid. The Egg The general principles of egg management for ratites are no different than those for other avian species. The maintenance of accurate records, in- ingestion of parsley was associated with a photosen- cluding the analysis of unhatched eggs, is an abso- sitization reaction in an ostrich (see Chapter 37). Adult lice small eggs lose excessive moisture during incubation and their eggs can be visualized along the shaft of the and produce small dehydrated chicks that rarely sur- feather (Figure 48. Feather picking can be caused by overcrowding, ex- The shell of an egg balances two opposing functions: cessive exposure to light at night and a lack of avail- the egg shell must allow the free exchange of oxygen, able food. Feather picking is common in adult os- carbon dioxide and water vapor, yet inhibit the pene- triches maintained in small, barren paddocks and tration of infectious agents. Thick shells and shells may be a reflection of malnutrition or environmental with low porosity inhibit gas and water vapor ex- stresses (Figure 48. Large deplumed areas of change, while thin, highly porous or defective shells skin are subject to sunburn. These birds will usually may lose excessive water vapor and readily allow respond to an enriched environment, especially bacterial penetration (Color 48. In one case, a large, reflective, chrome influenced by nutrition, disease and genetics, as well plate (mirror) was used to distract a male and pre- as by the conditions of the nest site and the egg vent him from feather picking a hen.

There have been numerous reports These nutrients may be required as a specific energy of birds order 10 mg metoclopramide with amex, especially with health problems and de- source buy 10mg metoclopramide overnight delivery, as structural components or as factors and praved appetites, consuming copious quantities of cofactors in specific biochemical reactions or proc- grit and developing crop or gastrointestinal impac- esses (Table 3. Considering the small chance of benefit and the potential risk, ad libitum feeding of grit should be avoided. Energy The total amount of energy, or the gross energy con- Food Selection tained within the feed, is broken into several frag- ments as it is metabolized in the body. During the Psittacines, in particular, have individual prefer- process of digestion, potential energy sources are lost ences for foods based on previous experience (or through the feces, urine and urates. The remain- encourage them by providing what the bird is most ing energy (net energy value of the food) is available likely to readily eat. Any energy that remains these avid habits as an “addiction” to a certain food after satisfying the basic maintenance requirements (often sunflower seeds or peanuts) because the bird is available for production activities such as growth refuses to eat anything else by its own volition. This of body mass and feathers, deposition of fat, produc- type of limited feeding pattern can result in severe tion of eggs and for exercise. This is especially likely The bird derives energy from proteins, fats and car- if the poor eating habits are left unchecked for an bohydrates in the diet. It must be emphasized that efficient source of energy, because the body must these preferences are individualized, especially in deaminate the amino acid, excrete the nitrogen as the larger psittacines, with some individuals having uric acid and then use the remaining carbon skeleton very distinct preferences. After the losses have no color preferences whatsoever, while others through deamination and subsequent metabolic re- have distinct biases for certain colors (eg, red, yellow, actions, protein yields a net of 4. This is best accomplished by providing limited portions, or Carbohydrates are the most important energy source meals, to encourage consumption of everything of- for the body because they are the only energy form fered, as opposed to a virtual ad libitum feeding that the brain can use. Of the carbohydrate family, program where the bird can reach satiety by eating energy is derived from starches (digestible polysac- only one or two of its favorite ingredients. Providing charides), disaccharides (sucrose, maltose) and the a large variety of foods immediately pre- and post- simple sugars or monosaccharides (glucose, fructose, weaning is a very effective way to develop good eat- mannose, galactose). Lactose, the disaccharide con- ing habits that will tend to persist throughout life. This the diet, other dietary constituents and the intestinal fraction consists mainly of cellulose, which is essen- microflora. Generally, oleic and linoleic acids are the tially undigested because of the bird’s lack of the most efficiently absorbed by the bird. Also included are the hemicellu- because of the ease with which these fatty acids form loses and lignin, all of which are poorly digested. The hemicel- they will also enhance the absorption of other less lulose, psyllium, is an exception, as it acts to increase efficiently absorbed fatty acids when they are present absorption. The essential fatty acids are used as structural com- Dietary fat is not only an important source of energy ponents in the cell with particular importance in the but it is the primary storage form of energy in the cell membranes. Fat is also easily absorbed into Based on the general requirements for most other the body via the gastrointestinal tract, with its di- species, it can be safely predicted that the linoleic gestibility being dependent on the fatty acid compo- acid requirement for companion and aviary birds is sition. In seed-based diets, this would rarely fall short, but in a processed, low-fat diet there could be a marginal deficiency. Essential Fatty Acids Animals and birds have no requirement for fat per se, Amino Acids and Protein but they do have a requirement for the individual fatty acids that make up fat. Fatty acids are charac- Amino acids are the building blocks of the protein terized based on their length (ie, the number of carb- chain. A specific commonly referred to as saturated, unsaturated or protein is created by the shaping of the polypeptide polyunsaturated) and the location of the initial dou- chain into its unique three-dimensional structure ble bond. This compound cannot be syn- The protein chain can contain up to 22 different thesized in the body so it must be provided through amino acids. Arachidonic acid is sometimes considered to by the body, so they must be routinely provided by the be an essential fatty acid; however, it can be synthe- diet (essential amino acids). Three other amino acids Body fat composition will be somewhat influenced by (cystine, hydroxylysine and tyrosine) are formed dietary fatty acid content because of the absorption through modification of an essential amino acid and subsequent deposition of some intact fatty acids. Common vegetable oils are generally high in linoleic These are not considered essential per se, but they acid (eg, corn oil, soybean oil, peanut oil = 50%; may affect the total amount of the essential amino sunflower oil = 60%; safflower oil = 75%). Absorption of these fatty acids varies depending on The quality of a protein is determined by two primary the type, the form (free or as part of a triglyceride), factors. To be optimally utilized, the protein After a protein source is consumed, it is initially should have an amino acid profile similar to that of processed by the combination of pepsin and hydro- the animal’s body. If this occurs, each individual chloric acid secreted by the glandular stomach amino acid will be present in approximately the right (proventriculus). The resultant polypeptide chains proportion that the body needs with no major ex- are then further degraded by a series of enzymes cesses or deficiencies of any one amino acid. This from the pancreas (trypsin, chymotrypsin, car- profile is achieved only in a few foods, most notably boxypeptidases), aminopeptidases and finally dipep- in eggs and in milk.

Prevalence order metoclopramide 10mg mastercard, goals and complications of heterosexual anal intercourse in a gynecologic population discount 10mg metoclopramide fast delivery. Hymenal findings in adolescent women, impact of tampon use and consensual sexual activity. Identification of sperm and non-sperm male cells in cervicovaginal smears using Fluoresecence In Situ Hybrid-isation— applications in alleged sexual assault cases. Identification of male epithelial cells in routine post-coital cervicovaginal smears using Fluoresecence In Situ Hybridisation—application in sexual assault and molestation. Postcoital detection of a male- specific semen protein: application to the investigation of rape. A comparison of the persistence of seminal constituents in the human vagina and cervix. Sperm survival and prostatic acid phosphatase activity in victims of sexual assault. The collection of data from findings in cases of sexual assault and the significance of spermatozoa on vaginal, anal and oral swabs. Variations in vaginal epithelial surface appearance determined by colposcopic inspection in healthy sexually active women. Toluidine blue in the detection of perineal lacerations in pediatric and adolescent sexual abuse victims. Adolescent sexual assault: documentation of acute injuries using photo-colposcopy. Findings in medical examinations of victims and offenders in cases of serious sexual offences—a survey. Linea vestibularis: a previously undescribed normal genital structure in female neonates. Sexual assault: clinical issues, Foley catheter balloon technique for visu- alizing the hymen in female adolescent sexual abuse victims. A simulated ‘acquired’ imperforate hymen following the genital trauma of sexual abuse. Variations in vaginal epithelial surface appearance determined by colposcopic inspection in healthy, sexually active women. Rape victims—assaults, injuries and treatment at a medical rape trauma service at Oslo Emergency Hospital. Experimental study of the reflex mechanism controlling the muscles of the pelvic floor. Discussion of spermatozoa in the anal canal and rectum and in the oral cavity of female rape victims. Ruptures multiples du sphincter interne après viol anal: une cause peu connue d’incontinence anale. Anal sphincter structure and function in homosexual males engaging in anoreceptive intercourse. Identification of polydimethylsiloxane lubricant traces from latex condoms in cases of sexual assault. Rape and sexually transmitted diseases: patterns of referral and incidence in a department of genitourinary medicine. Sexually transmitted diseases in sexually abused children: medical and legal implications. National guidelines on the man- agement of suspected sexually transmitted infections in children and young people. Post-exposure prophylaxis against human immunodeficiency virus infection after sexual assault. Injury Assessment 127 Chapter 4 Injury Assessment, Documentation, and Interpretation Jason Payne-James, Jack Crane, and Judith A. It has been suggested that the definition of physical injury in the forensic medical context should be “damage to any part of the body due to the deliber- ate or accidental application of mechanical or other traumatic agent” (2). This chapter specifically addresses the issues of physical assault and the assess- ment and documentation of wounds or injury. The purpose of assessment and documentation is to assist in establishing how a wound or injury is caused, which may often be at issue in courts or tribunals of law. These two skills should be within the remit of any doctor, although they are rarely done fully and appropriately. The interpretation of the causes of wounds and injuries is probably best undertaken by those with foren- sic expertise, because there may be many factors involved in such interpreta- tion. Because interpretation of wounds and injuries may be undertaken by review of documents, for example written descriptions, body chart mapping, or photo- graphs, it is imperative that the descriptions are comprehensible to all. For From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M. It is more appropriate for those who are documenting injuries to ensure that they have documented them in detail and unambiguously so that the courts can then make the decision regarding the most appropriate judicial interpretation of the injury or injuries described and their relevance to the case. In many cases, the initial examination and assessment may have been undertaken for purely therapeutic purposes, and the forensic significance of the injuries may not become apparent until several weeks or months later. Scrutiny of the doctor’s notes at a later stage, possibly in court, may reveal serious deficiencies, which not only bring discredit on the individual practi- tioner and the profession as a whole but also can seriously prejudice the legal proceedings.