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Total dose (concentration in ppm multiplied by time of exposure in minutes) determines the risk of pulmonary oedema cholesterol medication names uk cheap ezetimibe 10 mg otc. A cumulative dose of 50 ppm Ч min can result in delayed pulmonary oedema; a dose of 150 ppm Ч min will probably result in pulmonary oedema cholesterol lab values chart buy ezetimibe 10 mg otc, and a dose of 300 ppm Ч min is likely to cholesterol kinds cheap 10 mg ezetimibe visa be fatal. Exposure to 25 ppm is extremely dangerous and greater than 50 ppm may be rapidly fatal. Mode of Action Phosgene is hydrolysed in the body to hydrochloric acid which produces a systemic inflamatory response. It also stimulates the synthesis of lipoxygenase-derived leukotrienes causing pulmonary oedema. Further, phosgene increases pulmonary vascular permeability, leading to increased fluid accumulation in the interstitial and alveolar compartments. The ability of the lymphatics to clear the excess fluid is exceeded, resulting in gas diffusion abnormalities and pulmonary oedema. Clinical Features Phosgene gas has low water solubility and thus can be deeply inhaled into the lung before an individual is aware of significant exposure. Stage I: Coughing, choking, lacrimation, nausea, vomiting, headache, conjunctivitis, rhinitis, pharyngitis, bronchitis, and upper respiratory tract irritation may occur after exposure to concentrations exceeding 3 to 5 ppm. Exposures to 2 ppm may not cause eye irritation, but can result in significant, delayed respiratory effects. It is generally felt that if the victim survives 24 to 48 hours, the prognosis will be favourable. However, patients who survive exposure with pulmonary oedema may have persistent complaints of exertional dyspnoea and reduced exercise capacity and abnormal pulmonary function tests for months. Severe dermal burns or frostbite may develop following skin exposure to the liquefied material. Aminophylline 5 mg/kg loading dose followed by 1 mg/kg every 8 to 12 hours to maintain a serum level of 10 to 20 mcg/ml. Prepared for the first time in 1812, phosgene had a large scale presence in World War I as an asphyxiant war gas. The first chemical agent of warfare in modern times was chlorine, used by the German army at Ypres in 1915 against the Allies. Shortly thereafter, the Germans began mixing the chlorine with phosgene, or deployed phosgene alone as a weapon. Phosgene, together with arsenicals, blister agents, and mustard gas (also introduced during World War I) have been estimated to be responsible for approximately 1. By the time World War I concluded, mustard gas was the most widely used, but phosgene caused the most deaths. Chest X-ray may reveal incipient toxic pulmonary oedema much earlier than overt clinical manifestations. Monitor arterial blood gases and/or pulse oximetry, pulmonary function tests, and chest X-ray in patients with significant exposure. Steroid therapy: Steroids used soon after exposure may lessen the severity of pulmonary oedema. Betamethasone valerate, beclomethasone dipropionate, or dexamethasone sodium phosphate is generally recommended. The initial dose is five times that conventionally used in asthma, followed by about half the dose for 12 hours, and then standard asthma dosages for the subsequent 72 hours. Physical Appearance Pure carbon monoxide is an odourless, colourless, non-irritating gas, which is lighter than air. A carbon monoxide concentration of 5000 ppm in air is lethal to humans after five minutes of exposure. Mode of Action Carbon monoxide has an affinity for haemoglobin which is 230 to 270 times greater than that of oxygen. The net result of all this is the decreased ability of oxygen to be carried by the blood and released to tissues. In the brain this can cause further mitochondrial dysfunction, capillary leakage, leukocyte sequestration and apoptosis. This change primarily occurs during the recovery phase when lipid peroxidation occurs, which produces an overall reversible demyelination in the brain. In a study on rats, the delayed effects of neuropathology following carbon monoxide poisoning were studied.

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Hypochromia and basophilic stippling are strongly suggestive of lead intoxication cholesterol levels diet and exercise 10 mg ezetimibe free shipping, but their absence does not rule out lead poisoning cholesterol medication withdrawal symptoms discount ezetimibe 10 mg fast delivery. In fact foods eat low cholesterol diet discount 10mg ezetimibe overnight delivery, the ability to reliably use zinc protoporphyrin levels as a screening tool to detect low blood levels is under serious question. For short exposure periods, it usually has a linear relationship to intake levels. Blood lead levels reflect recent exposure or exposure over a period of up to 3 to 5 weeks. Preferably, urine should be voided directly into polyethylene or polypropylene bottles which have been cleaned in the usual way, then washed in nitric acid and thoroughly rinsed with de-ionised distilled water. For children who are not toilet trained, plastic paediatric urine collectors can be used. In the laboratory, the urine volume should be carefully measured and stored at 20° C until the lead concentration is measured. Children with positive chelation test results should undergo a 5-day course of chelation. Bone ­ the x-ray fluorescence technique is brief and non-invasive and carries low-risk. It is based on the specific atomic property of lead to emit characteristic x-rays upon stimulation induced by external irradiation. The stimulated radiation is monitored externally by a solid state detector and can be expressed in terms of lead concentration in the bone. Because emitted radiation is considerably attenuated by the overlying tissue, the tibial shaft is chosen as the measurement site because of its thin overlying skin. Calibration of the system can be done from a cadaver leg, and subsequent atomic absorption analysis from the same site. Published regression equations that could be used to estimate mean skeletal lead concentration of the entire body and also to predict the lead concentration are available. Radiological examination of the abdomen may show radiopaque foreign material, if the material has been ingested during the preceding 24 to 36 hours. The significant finding in bone is the appearance of dense transverse bands or lead lines extending across the metaphyses of the long bones, and along margins of flat bones such as the iliac crest. The width of the lead line varies depending upon the amount of lead ingested and the length of time it has taken. Severe acute poisoning with encephalopathy: this is a medical emergency and the following measures must be undertaken immediately ­ a. Monitor cardiovascular function, renal function, and serum electrolytes carefully. For seizures: Treat seizures with intravenous diazepam (Adult: up to 10 mg slowly, repeat if necessary; Children: 0. Foley catheterisation: to monitor urinary specificic gravity, sediment, lead level. In addition to the above protocol, the following supportive measures must be instituted as applicable ­ Thiamine 10 to 50 mg/kg is said to improve neurological manifestations of lead poisoning. If intracranial pressure is high due to cerebral oedema, administer mannitol or steroids as required (vide supra). Chelation is done only if there is production of inorganic lead in the body from organic lead. And finally the sine qua non of treament of heavy metal poisoning: remove the patient from the source of exposure. In recent times, a new chelating agent called Succimer has been introduced in the management of lead poisoning in Western countries. If the result of screening test is 10­14 mcg/100 ml, perform diagnostic test for lead on venous blood within 3 months, and at least one followup test within 3 months. If the result of screening test is 15­19 mcg/100 ml, perform diagnostic test for lead on venous blood within 2 months, and at least one follow-up test within 2 months. If the result of screening test is 20­29 mcg/100 ml, perform diagnostic test for lead on venous blood within 1 month.

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Certain occupation may impart colour changes to cholesterol ratio statistics ezetimibe 10mg without prescription hairs for example copper smelters have greenish hair cholesterol range chart uk purchase 10 mg ezetimibe with visa, indigo and cobalt miners have bluish hairs cholesterol test normal results order ezetimibe 10mg free shipping. Revealing Latent Tattoo Marks Latent tattoo marks are faded marks and they can be visualized by: 1) Use of ultraviolet light. Definition: Fingerprints are impressions of pattern formed by the papillary or epidermal ridges of the fingertips. Principle: It is based on principle that the individual peculiarities of the patterns formed by the arrangement of the papillary or epidermal ridges on the fingertips are absolutely constant and persists throughout life from infancy to old age and that the patterns of no two hands resemble each other. The epidermal ridges are regularly spaced small down-growths of epidermal cells, which appear in finger and toe pads during the second and third months. They are known as primary epidermal ridges separated by corresponding dermal ridges. Loop: Ulnar loop-loop opens on ulnar side Radial loop-loop opens on radial side 2. Whorl: Concentric Spiral­clockwise Spiral ­ anticlockwise Double spiral Almond shape 3. Plain Method: · · In this method, inked fingers are brought in contact with unglazed paper and impressions are taken. Disadvantage of this method is that larger surface area is not obtained for comparison. Disadvantage is that it is somewhat difficult procedure and may blur the prints at places. Rolled Method: · In this method, the fingerprints are taken by rolling the fingers on paper from outward to inward direction without lifting fingers in such a way that an impression of whole tip is obtained. Plastic prints: these are the prints left over soft surface or articles such as soap, wax, clay, cheese etc. Latent prints: · these prints are either invisible or barely visible that were left at scene of crime. For the purpose of matching, pattern of ridge, ridge ending, missing ridge, counting of ridge, ridge breakage, fork formation, delta, island etc. The finger and fingertips of person is usually smeared by sebaceous secretion and sweat. Whenever a person touches any article or material, due to presence of sebaceous secretion, he leaves the impression of fingers over that article or material. Fingerprints at Scene of Crime Fingerprints encountered at a scene of crime are classified as: 1) Visible print 2) Plastic print 3) Latent print Fingerprints in Dead Bodies · Fingerprints are present over dermis and epidermis. If the skin is degloved as in advance decomposition, the skin should be removed, preserved in formalin and impressions can be taken from that degloved skin. Therefore, on basis of this primary classification, 1024 boxes are made and these boxes are called as pigeon holes. Presence of whorl pattern in finger Right thumb or right index finger Right middle or right ring finger Right little or left thumb Left index or left middle finger Left ring or left little finger Fingers with no whorl Score allotted 16 scores 8 scores 4 scores 2 scores 1 score No scores Mutilation or Alteration of Fingerprints · Criminals may at times, tries to hide the identity by destroying the fingerprints by applying burns or corrosive agents. Ridge alteration occurs in eczema, acanthosis nigricans, scleroderma, dry and atrophic skin. Permanent impairment of fingerprint pattern occurs in leprosy, electric injury, and radiation injury. Distance between ridges may change but pattern not change in rickets and acromegaly. In mummified bodies, the fingers are dry and shriveled and therefore prints are not possible. In such condition, the fingertips or skin is immersed in weak alkali solution to make them swell-up and then prints are taken. In primary classification, scores are allocated for presence of whorl pattern in different fingers of hand. At, both numerator and denominator, score 1 is added for convenience of calculation Example: suppose in a person, in all fingers he have whorl pattern, then the score will be as mentioned in Table 3. Thus by presence or absence of whorl Fallacy of using fingerprint50 If there is no reference available, even though fingerprints are available, they will have no use. These pores are opening of the ducts of sweat glands located in sub-epidermal region. These pores are permanent and unchanged during life of a person these pores vary in size, shape, position, extent and number over a given length of ridge in each person.

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Preservation of viscera and Other articles In suspected cases of poisoning average cholesterol daily cheap 10 mg ezetimibe with visa, viscera has to cholesterol in eggs white discount 10 mg ezetimibe otc be pre served cholesterol levels uk range 10 mg ezetimibe with amex. Refer chapter 33 for medicolegal aspects of poisoning and for preservation of viscera and other articles. Following are the usual type of laboratory support required Chest and abdominal Cavity · the chest and abdominal cavity should be examined for presence of any injury, disease, pathological lesion or collection of blood/fluid · the organs should be examined for presence of any injury, disease, and pathological lesion. The weight of organs, the size, shape, surface, consistency, cut surface, colour should be noted. Glucose, urea, creatinine, cholesterol, lipoprotein, catecholamine, magnesium, uric acid, proteins etc. Within a post mortem interval of 4 to 6 hours, there is a bodywise redistribution of endogenous flora and becomes more pronounced with lengthening of postmortem interval. If culture from organ is required, the organ area should be seared to dryness with aflat-facedsolderingironandpiecetaken. It con sists of cutting the tissue/organ with sterile scalpel and print cultures are made on the agar. Enzyme study · Enzyme and isozyme are utilized in postmortem state to elucidate cause of death. A case report of diagnosis of sickle cell disease was reported by molecular analysis of the globin gene. However, if red blood cells are required for analy sis such as for investigation of hemoglobinopathies or for the determination of glycated hemoglobin, another sample preferably drawn from peripheral vein should be collected. Examination of Chest and abdomen · Abdomenisopenfirsttonotethepositionofdiaphragm and then chest is opened. The technique is mentioned below:29 If fetus is less than 12 weeks of gestation or less than 25 gm weight, the fetus may be examined by free hand sectioning method. It consists of sectioning or cutting the trunk of fetus/embryo into slices of about 1 cm thickness. For fetus between 12 to 22 week (or less than 400 gm), a mininecropsy can be attempted and the organs are removed en bloc. Forensic Photography27 Photography is important in forensic practice because they can act as evidence and may be produced in the court. Photography varies from conventional photography to superimposition to ultraviolet and infrared photography. In addition to adult autopsy, following things required atten tion while conducting fetal autopsy · Note signs of maceration/mummification · Note the state of umbilicus and umbilical cord · Note the state of placenta, weight, disease, · Note the length, weight and morphological features of fetus · Note state of eyes, eyelids, eyelashes, papillary membrane · Note state of scalp hairs, body hairs (lanugo), nails · Note the colour of skin, wrinkling, presence of subcu taneous fat Negative autopsy An autopsy that fails to reveal a cause of death with gross, microscopic, toxicological and other laboratory investigation is referred as negative autopsy. Inadequate history Lapses in external or internal examination Inadequate sample collection Inadequate laboratory support. Obscure autopsy Inobscuretypeofautopsy,thefindingsdonotleadtodefi nite cause of death. There may be minimal, indefinite or obscurefindingsandcausesconfusiontomedicalexaminer. Dotted lines indicate plane of incision · Exhumation means to dig out corpse from the ground. It is a lawful process of retrieval of previously buried body for postmortem examination. Suspected foul play Examination of decomposed Bodies · · · · Autopsy should be done on same line as in other autopsies Record the injuries/ligature marks/fracture carefully Identify artefact produced by decomposition Note presence of any foreign body, mud, sand particles etc. Forensic Medicine authorization for Exhumation the exhumation is carried out only on receipt of written order from the Executive Magistrate or Judicial Magistrate. However, the period of exhumation is restricted in other countries for example it is about 10 years in France and 30 years in Germany. Examination of Mutilated Bodies Mutilation may be done: · By criminals to destroy identity/evidences · By criminals for convenient disposal of dead body · May be due to postmortem artefact. A Section Medicolegal Autopsy 127 · Hairs from head and pubic region should be collected · the body is shifted for postmortem examination. Available viscera should be preserved for chemical analysis along with teeth, nails and bone. The artefacts are physiologically unrelated to the natural state of the body or tissue, or the disease process, to which the body was subjected to before death. Therefore it is important to interpret these artefacts correctly otherwise misinterpretation may lead erroneous diagnosis.

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