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Postganglionic sympathetic axons to the head cheap 30mg nimotop visa muscle relaxer 75, heart purchase 30mg nimotop overnight delivery muscle relaxant 4212, and lungs originate in the cervical ganglion or upper thoracic paravertebral ganglia and make their way to the specific organs as identifiable, separate nerves (e. The pre- the cardiac nerves), as small-caliber individual nerves that ganglionic axons course through the spinal nerve and white ramus to the paravertebral ganglion. Synapse may group together, or as perivascular plexuses of axons with the postganglionic neuron may occur at the same spinal that accompany arteries. Postganglionic axons rejoin the The superior cervical ganglion supplies sympathetic ax- spinal nerve through the gray ramus to innervate structures in the ons that innervate the structures of the head. These axons limbs or proceed to organs, such as the lungs or heart, in discrete travel superiorly in the perivascular plexus along the carotid nerves. Structures innervated include the radial muscle of glion without synapsing in a paravertebral ganglion. Lesions that interrupt this pathway THE SYMPATHETIC NERVOUS SYSTEM produce easily detectable clinical signs (see Clinical Focus Preganglionic neurons of the sympathetic division origi- Box 6. The middle and inferior cervical ganglia innervate nate in the intermediolateral horn of the thoracic (T1 to organs of the chest, including the trachea, esophagus, T12) and upper lumbar (L1 to L3) spinal cord. Postsynaptic axons destined for the abdominal and pelvic Immediately after the ventral and dorsal roots merge to visceral organs arise from the prevertebral ganglia (see form the spinal nerve, the sympathetic axons leave the Fig. The three major prevertebral ganglia, also called spinal nerve via the white ramus and enter the paraverte- collateral ganglia, overlie the celiac, superior mesenteric, bral sympathetic ganglia (Fig. The paravertebral gan- and inferior mesenteric arteries at their origin from the aorta glia form an interconnected chain located on either side of and are named accordingly. These ganglia extend above and be- sympathetic innervation to the stomach, liver, pancreas, low the thoracic and lumbar spinal levels, where pregan- gallbladder, small intestine, spleen, and kidneys. Pregan- glionic fibers emerge, to provide postganglionic sympa- glionic axons originate in the T5 to T12 spinal levels. The deficits of function occur ipsilateral to the le- • Brainstem lesions, such as produced by strokes, which sion and include: interrupt the tracts that descend to the sympathetic neu- • Partial constriction of the pupil as a result of loss of sym- rons in the spinal cord pathetic pupillodilator action • Upper thoracic nerve root lesions, such as those pro- • Drooping of the eyelid, termed ptosis, as a result of loss of duced by excessive traction on the arm or from infiltra- sympathetic activation of Müller’s muscle of the eyelid tion of the nerve roots by cancer spreading from the lung • Dryness of the face as a result of the lack of sympathetic • Cervical paravertebral ganglia lesions from accidental or activation of the facial sweat glands. Johann Horner, a 19th century Swiss ophthal- traveling in the carotid periarterial plexus. Note the named paravertebral and solid lines, postganglionic axons by dashed lines. CHAPTER 6 The Autonomic Nervous System 113 superior mesenteric ganglion innervates the small and large Preganglionic sympathetic axons Adrenal intestines. The inferior mesenteric ganglion innervates the lower colon and rectum, urinary bladder, and reproductive organs. Chromaffin Adrenal cell medulla The Sympathetic Division Can Produce Local Vesicles or Widespread Responses The sympathetic division exerts a continuous influence on the organs it innervates. This continuous level of control is called sympathetic tone, and it is accomplished by a per- Vein sistent, low rate of discharge of the sympathetic nerves. When the situation dictates, the rate of firing to a particular organ can be increased or decreased, such as an increased firing rate of the sympathetic neurons supplying the iris to produce pupillary dilation in dim light or a decreased firing rate and pupillary constriction during drowsiness. The number of postganglionic axons emerging from the Blood capillary paravertebral ganglia is greater than the number of pregan- glionic neurons that originate in the spinal cord. Preganglionic sympathetic axons ter- preganglionic neurons by 100:1 or more. When stimulated, the chromaffin cells release epinephrine into the circulation. Divergence enables the sympa- and fatty acids, and blood cells which participate in the thetic division to produce widespread responses of many clotting and immune responses. The Fight-or-Flight Response Is a Result The Adrenal Medulla Is a Mediator of Widespread Sympathetic Activation of Sympathetic Function This response is the classic example of the sympathetic In addition to divergence, the sympathetic division has a nervous system’s ability to produce widespread activation hormonal mechanism to activate target tissues endowed of its effectors; it is activated when an organism’s survival is with adrenergic receptors, including those innervated by in jeopardy and the animal may have to fight or flee. The hormone is the catecholamine components of the response result from the direct effects of epinephrine, which is secreted with much lesser amounts sympathetic activation, while the secretion of epinephrine of norepinephrine by the adrenal medulla during general- by the adrenal medulla also contributes. Sympathetic stimulation of the heart and blood vessels The adrenal medulla, a neuroendocrine gland, forms the results in a rise in blood pressure because of increased car- inner core of the adrenal gland situated on top of each kid- diac output and increased total peripheral resistance.

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In the event of accidental dental injury quality nimotop 30 mg spasms with stretching, an anesthesiologist should be frank and honest with the patient about what has happened 30 mg nimotop visa infantile spasms 6 months old. In actuality, dental injury is within the risks of anesthesia, but anesthesiologists often become defensive, arguing, “It’s not my fault, I didn’t do anything wrong. Frequently, dental claims are settled by reimbursing the patient for the cost of repairing the teeth to their pre-anesthesia state. To avoid inflated estimates, an evaluation by an independent dentist, who will not actually be doing the repairs, is often sought. Anesthesiologists are advised to first try working with patients directly to get these situa- tions resolved in a way that seems fair and equitable to everyone. Occasionally a dental claim does escalate, with the patient and anes- thesiologist generating legal bills many times greater than the cost of the actual dental repairs. Any physician who reimburses a patient directly is advised to obtain a liability release from that patient accept- ing that as payment in full (2). These are cases in which anesthesia errors directly cause serious patient injuries, including brain damage or death. In an era of sophisticated anesthetic techniques and monitoring, it is easy to forget that cases like these still can and do occur. Peer review of these claims has led to a series of risk management suggestions. MONITORING Since the widespread adoption of the pulse oximeter and end-tidal CO2 monitors, anesthesia has become much safer. However, serious injuries still result because of failures to use the monitors correctly. Inactivation of the pulse oximeter alarm accounts for a large propor- tion of anoxic injury cases that involve respiratory insufficiency that is noticed too late. Anoxic damage can occur within minutes of an unrecognized and untreated respiratory arrest, even in an operating room. Anesthesiologists should be very careful when silencing the auditory alarms on these monitors, especially if they are not positive they will remain directly in their line of sight. It is also important to remain vigilant with sedated patients having MAC or regional blocks, as the level of sedation can often deepen without warning. The sce- nario of an anesthesiologist who silenced a pulse oximeter alarm because of “false alarms” and then left the head of the bed or became otherwise distracted is seen in a very large proportion of these claims. ESOPHAGEAL INTUBATION Malpractice cases alleging esophageal intubation by the anesthesi- ologist still occur. Intubating the esophagus is not negligent, but the failure to promptly recognize the situation and replace the tube is. In many cases ultimately considered to involve unrecognized esophageal intubations, the anesthesiologists claimed they were sure the endotra- cheal tubes were correctly placed because they had watched them pass directly through the vocal cords. Alternatively, several argued that they had verified bilateral breath sounds over their patients’ chests. In this day and age, for operating room anesthesia, an end-tidal CO2 reading is the only acceptable method of proving correct endotrachial tube placement. Failure to immediately check and record an end-tidal CO2 reading in the presence of a functioning CO2 monitor would not likely be found to meet the standard of care. Chapter 10 / Anesthesiology 127 Anesthesiologists sometimes simply fail to consider the possibility of an esophageal intubation when encountering problems immediately after intubating a patient. It is not uncommon to have anesthesiologists claim that they were sure they were dealing with bronchospasm or prob- lems with the monitors before other physicians arrived to assist them, replacing the endotracheal tubes and correcting the problems. In a healthy preoxygenated patient, it may take up to 30 minutes before the blood pressure and heart rate become unstable in the event of an esoph- ageal intubation. If any patient develops instability in this time frame, esophageal intubation should at least be considered and ruled out. If the anesthesiologist is unsure whether the tube is correctly placed, then it should be removed and the patient ventilated by other means, such as a facemask or LMA.

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Which of the following is a function of (d) the eighth week (c) lower red blood cell count the placenta? Which of the following is the period of growth (d) faster heart rate (a) production of steroids and hormones from birth to the end of the fourth week? The first physical indication of puberty in (b) diffusion of nutrients and oxygen (a) the neonatal period females is generally (c) production of enzymes (b) the fetal period (a) alkaline vaginal secretions buy discount nimotop 30 mg online muscle relaxant easy on stomach. Developmental © The McGraw−Hill Anatomy purchase nimotop 30mg online muscle relaxant cyclobenzaprine high, Sixth Edition Development Anatomy, Postnatal Companies, 2001 Growth, and Inheritance Chapter 22 Developmental Anatomy, Postnatal Growth, and Inheritance 793 12. Twins that develop from two zygotes (c) perception of quickening by the 2. If a pregnant woman had a pack-a-day resulting from the fertilization of two ova mother. Match the genotype descriptions in the (h) formation of all major body organs 1960s to alleviate their morning sickness. Define the term infancy and discuss the development and resulted in tragically homozygous recessive Bb growth and developmental events deformed infants with flipperlike arms heterozygous bb characteristic of this period of life. Define the term childhood and discuss the development did such abnormalities 14. An allele that is not expressed in a growth and developmental events originate? What lessons were learned from heterozygous genotype is called characteristic of this period of life. Define anthropometry and give examples Can you think of some other reasons for a of anthropometric characteristics. Describe the implantation of the because it plagued many male members of that would lead one to believe that it was blastocyst into the uterine wall and the the royal families of Europe and Russia. Write a short paragraph about pregnancy that includes the terms ovum, blastocyst, consanguineous marriages—those germ layer give rise to? Explain why development is so critical implantation, embryo, fetus, gestation, and parturition. Why is it likely that a during the embryonic period and list the geneticist would endorse such restrictions? State the approximate time period (in weeks) for the following occurrences: (a) appearance of the arm and leg buds. Van De Graaff: Human Back Matter Appendix A: Answers to © The McGraw−Hill Anatomy, Sixth Edition Objective Questions with Companies, 2001 Explanations Appendix A Answers to Objective Questions with Explanations Chapter 1 9. His body into front (anterior) and back enlargement of a muscle fiber as a dissect. Using reference when describing availability of an adequate number Chapter 2 structures of the body. It we are classified as primates along the breakdown of inorganic connective tissues, muscular was not until the Renaissance that with monkeys and great apes. Basically, the nitrogen, and hydrogen compose from mesoderm, including learn about its structure and kidneys are filtering organs of the over 95% of the body and are often cartilage, bone, and other function. It is molecules and worn and damaged are characteristic of certain kinds Although the Hippocratic oath the anterior surface of the elbow. It was believed that too vertically through the body, but containing trapped particles is the mammary glands are classified as much phlegm, or not enough, there is no vertical plane moved in the bronchioles and compound acinar. Cartilage generally derives to printed material, and was abdomen is centrally located, mitosis immediately following its nutrients from surrounding fluids therefore important in ushering in medial to the right and left metaphase; it precedes the rather than from permeating blood the Renaissance. As compared to sphenoid bone is located located on the anterior side of the 1. When the thought to be important in the acromial extremity of the clavicle 6. Matching: 1(c), 2(d), 3(e), the body of the femur, where the leaves the patient crippled.

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Choice B is a subject with hy- through an action at the presynaptic site of ACh re- poxia that resulted from inadequate ventilation; this lease or an action at the postsynaptic membrane buy nimotop 30mg on line muscle relaxant pills. Choice E shows values that the mechanism of suppression of the EPSPs is sup- pression of ACh release at the synapse order 30mg nimotop otc spasms mid back. Once triggered by the stimulus, the mm Hg decrease below normal in PCO2 (see Table action potential travels from muscle fiber to muscle 25. Choice C shows typical values for a chronic fiber as the ionic current travels across gap junctions. Nerve fibers ther lowered the plasma [HCO3 ] and reduced the severity of the alkalemia. Aspirin (salicylate) intoxication pro- the spread of the action potential and associated con- duces a mixed acid-base disturbance—respiratory alka- traction because tetrodotoxin blocked all neural func- losis (as a result of stimulation of the respiratory cen- tion. Interstitial cells of Cajal is not correct because the ter) and metabolic acidosis (as a result of inhibition of action potential traveled from cell to cell in the bulk of oxidative metabolism and accumulation of lactic and the smooth muscle. The respiratory alkalosis predom- rect because the action potential was triggered by a inates during the first several hours in adults; metabolic stimulus applied at one point, not slow waves originat- acidosis occurs at the same time and becomes over- ing along the segment of intestine. Rapid transit is not likely because the D shows the predominant respiratory alkalosis; the re- loss of inhibitory motor neurons results in delayed transit (i. Accelerated gastric duction in plasma [HCO3 ] is accounted for by the ac- cumulation of organic acids in the blood and is too emptying does not occur mainly because pseudoob- early to reflect significant renal compensation. Choice struction in the duodenum presents a high resistance to A represents metabolic acidosis with normal respira- inflow from the stomach. Choice B represents respiratory not correct because in the absence of inhibition, the acidosis as a result of alveolar hypoventilation or a mis- lower esophageal sphincter remains contracted and is a match between alveolar ventilation and pulmonary barrier to reflux. Diarrhea is unlikely because diarrhea APPENDIX A Answers to Review Questions 725 requires intestinal propulsion and this is compromised meal, mechanoreceptors signal the CNS. Inhibitory mo- limits of adaptive relaxation in the reservoir are tor neurons are necessary for the relaxation of sphinc- reached, signals from the stretch receptors in the reser- ters. Longitudinal muscle contracts and circular mus- forms of functional dyspepsia characterized by the cle is inhibited in the receiving segment. Choice B is not volumes and the CNS wrongly interprets the signals as correct because tone in the lower esophageal sphincter if the gastric reservoir were full. Choice choices would be expected to activate mechanosen- C is incorrect because the sphincter cannot be relaxed sory signaling of the state of fullness of the gastric after blockade of the inhibitory innervation by a local reservoir. Power propulsion is the pattern of the sphincter is higher than in the two compartments motility for defense of the intestinal tract. Choice E is incorrect because inhibitory the retrograde direction during emetic responses that neurons fire to relax the sphincter during a swallow. It occurs in the orthograde direction in absence of contractile activity. It is a significant behav- the lower small intestine and in the large intestine ior pattern, requiring a functional ENS. Each of the where it also functions to quickly eliminate threatening other neurally programmed patterns involves contrac- substances or organisms from the intestine. Gastric emptying of particles greater cosa and holds it in suspension in the lumen. This is than about 7 mm does not occur during the digestive followed by power propulsion, which rapidly clears state. The lag phase is the time required for the stom- the lumen of the material. This form of behavior is de- ach to grind large particles into smaller particles in this fensive but has the adverse effects of diarrhea and ab- size range. None of the other choices evokes con- from interdigestive to digestive states occurs immedi- scious sensations during daily occurrence. Observations on the transit of mark- incorrect because cephalic and gastric phases of acid ers after instillation in the human cecum show that the secretion reach maximum near the onset of the lag markers remain for the longest time in the transverse phase. Transit is significantly faster in the other parts the beginning of the emptying curve, not at the end. The plateau phase of the gastric ac- Weakness in the puborectalis muscle allows the tion potential and the associated trailing contraction anorectal angle to straighten and lose its barrier func- increase in direct relation to the amount of ACh re- tion to the passage of feces into the anorectum.

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