By D. Sven. Saint Francis College, Loretto, Pennsylvania. 2019.

Dietary long-chain polyunsaturated fatty tomato to human health due to tomato carotenoids 80 mg tadapox otc, acids cheap tadapox 80mg without a prescription, such as arachidonic acid trusted tadapox 80mg, eicosapentaenoic acid mainly lycopene, b-carotene, and lutein [18]. People now take extra omega-3 fatty acids from and inhibiting tumor cell growth in animals [18]. Plant foods activity by neutralizing free radicals, which are regarded such as faxseed, soya oil, canola oil, Oliver oil, pump- as one of the major causes of aging and various cancers. M onoterpenes in citrus plenty of scientifc evidence shows that substitution of fruits, cherries, peppermint, and herbs have anticarci- dietary saturated fat by oleic acid and/or polyunsatu- nogenic actions, as well as cardioprotective effects in rated omega-3 fatty acids beneft cardiovascular health experimental models. The unique monoterpene derivatives or triglycerides also have benefts to human health thujaplicins from trees are widely used as antifungal [26]. Unlike long- or very-long-chain fatty acids, these medicine in clinic, cosmetic products, and wood preser- fatty acids passively diffuse into the portal system vation [19]. The most well-known sesquiterpenes such without requirements of modifcation and digestion. M etabolic syndromes, such Another important class of terpenoid phytosterols, such as abdominal obesity, dyslipidemia, hypertension and as stigmasterol, sitosterol, campesterol, are natural com- impaired fasting glucose, contribute to increased car- ponents of many plant foods. M edium-chain structures with cholesterols from meats, phytosterols fatty acids and medium-chain triglycerides suppress competitively inhibit human cholesterol absorption by fat deposition through enhanced thermogenesis and fat the gut [21, 22]. Coconut for cancer prevention and successful aging in both oil is composed of approximately 66% medium-chain women and men. Taking up the likely contributory factor to dramatic difference adequate essential amino acids are very important for between Asian women who have signifcantly lower health since they are building blocks of proteins, which levels of breast cancer and women in western countries carried functions of human body [1, 28]. Tryptophan is may be that Asian women take a vegetarian diet with used for synthesis of neurotransmitter serotonin and higher intake of legumes and other plant foods con- relief of depression; faxseeds have high tryptophan lev- taining a variety of lignans, dietary fbers, and isofa- els. Tyrosine is for dopamine, norepinephrine and adren- vonoid phytoestrogens, which act as nature’s sex aline synthesis for normal neurosystem activity and hormone modulators and provide estrogenic effects enhances positive mood. Isoleucine is necessary for the and an anti-estrogenic competitive effect [16, 17, 31]. Leucine has Epidemiological studies demonstrated that l-arginine, benefcial effects for skin, bone and tissue wound heal- chlorogenic acid, fermented milk, garlic, onion, tea, ing, and promotes growth hormone synthesis. Lysine soybean, ginger, hawthorn, and fsh oil have benefcial and valine are essential for muscle proteins, as well as effects on prevention, improvement, or treatment of the synthesis hormones and l-carathine which is essen- patient’s elevated blood pressure [32]. M ethionine is essential for all protein synthesis and helps in breakdown of fats and reduces muscle degeneration. Phenylalanine is benefcial for healthy nervous system and boosts Phytotherapy strategies using herbal drug combinations memory and learning. Phenylalanine may be useful with superior effcacy and lesser side effects in com- against depression and suppressing appetite. In addition, parison with single isolated constituents of plant extracts l-Arginine is a conditional essential amino acid for has been repeatedly assessed clinically as well as phar- infants and growing children, as well as for pregnant macologically [1]. Like other Chinese herbal medicines combined with various herbs containing dif- 6. Except for nutraceuticals such as glucosamine and secondary metabolites with similar structure with hor- chondroitin, many herbs have been tried for treatment mone estradiol and thus with ability to cause estrogenic of osteoarthritis and rheumatoid arthritis diseases [1, or/and antiestrogenic effects. Other degenerative diseases and immunosystem tained in our daily diets, such as soybean and cabbage, problems that could not be effectively treated by cur- nuts, and oilseeds, therefore also called “dietary estro- rent synthetic drugs become targets of herbs, nutraceu- gens. Allergic rhinitis is the most lated favonoids, and isofavones can act as antioxidants, frequently occurring immunological disorder. A tradi- estrogen agonists, and antagonists with multiple effects tional Chinese formulation Aller-7 comprising seven [30]. An optimal “estrogen balance” has implications herbal extracts was shown well tolerated and effcacious 6 Phytonutrient and Phytotherapy for Improving Health 53 in patients with allergic rhinitis without serious adverse The rapidly increasing number of such proof-of-con- effect [36]. Similarly, another formulation was also cept studies strongly support success of some phyto- studied in clinical trial and appears to offer symptom- nutrients and their phytotherapies on improvement atic relief and improvement of quality of life for some of health or even solve health problems. The eff- cacy and safety of the butterbur leaf extract Ze 339 were to be safe and effcacious in the treatment of 6. All these Loss, Facial Aging, and Cosmetic studies clearly suggest that multi-component tradi- Surgery tional herbals can offer a very effcacious and better therapeutic option to patients in many diseases. An increasing prevalence of overweight and obesity However, a lack of information on the phytochemistry has reached global proportions. Overweight and obe- and pharmacological section of phytochemicals, or the sity generate a major risk of chronic diseases such as synergistic effects of phytotherapies may threaten and type 2 diabetes, cardiovascular disease, hypertension, damage the customers and market [39]. Overweight and obesity are diet- Clinical trials and epidemiological studies are related health problems, their patients, however, may commonly used methods to investigate effects of not be simply and easily recovered by reducing diet phytonutrients and herbs on various health targets. Some synthetic drugs have been designs, proper controls, a long time period for feed- developed, yet their side effects and potential risks ing, observation and physiological measurements, are nor ignoble. W ith strong belief on the potential data collection, but also a large population of patients health benefts of phytonutrients people look for herbs willing to cooperatively participate in the study, as and phytonutrients that are effective in weight loss well as fnal systematic analysis. Actually, plants-based foods have because effects of phytonutrients are usually mar- low saturated fats and sugar, high levels of diet fbers, ginal, long-term, and individually differential. Also, and more balanced minerals and vitamins, and be other factors also can signifcantly affect the outcome eaten against many health-problems including weight of clinical trials and epidemiological studies, for and obesity [42]. M oreover, some phytonutrients instance, quality and quantity of herbs or phytonutri- from plant foods or medicinal plants have potent ents, absorption and metabolism of phytonutrient, effects on prevention and treatment of overweight and and drug–herbs or drug–phytonutrient interaction. For example, as one of the widely commer- which is a major risk factor for coronary heart disease cialized example of phytotherapeutics, Saw palmetto [43]. However, high- because of their rich amino acids, vitamins, antioxidants quality clinical trials and epidemiological studies on and other phytonutrients with antibacterial, antifungal, phytonutrients and physiotherapies provide most and anti-infammatory activity that are helpful for the close-to-realty and reliable evaluation of their bio- skin. Nowadays use of phytonutrients or herbs, effective logical effects on human health, and they are essen- cosmetics (many of them also contain phytonutrients), tial and highly needed to evaluate phytonutrients aesthetic plastic and cosmetic surgery, or combinations of and phytotherapies for continuous and healthy devel- them are widespread among people for various levels of opment of natural resources and healing system. Zhao certain herbs or phytonutrients have potent effects on symptoms and benign prostatic hyperplasia, bioactive reduction of weight, obesity, diabetes, facial aging and ingredients fatty acids and phytosterols), arnica M ontana rejuvenation, or other degenerative diseases, and nutri- (used as anti-infammatory and antibiotic regent, active tional defciencies, or improvement of overall health and ingredient: helenalin), St. However, there are also warns of nega- foratum, used for mild and moderate mood disorders or tive effects on uses of herbs and natural products, particu- depression, active ingredient hypericin), bromelain larly perioperative use of herbs and phytonutrient (pineapple stem, anti-infammatory, antibacterial, and supplements regarding aesthetic plastic, and cosmetic proteolytic activity), thunder god vine (Tripterygium surgery because these health problems on patients have a wilfordii, root extracts used to treat rheumatoid arthritis, signifcant impact on surgical outcome and complica- bioactive component: triptolide). Although phytonutrients have benefcial these herbs may have negative effects on surgical effects on some aesthetic plastic and cosmetic surgeries procedure or recovery, such as bleeding (ginger, gin- [47, 49], some raw herbs are more complex due to mul- seng, Ginkgo biloba, and garlic), immunosuppression tiple-components, limited information on their phy- (Echinacea), infammation (garlic, ginkgo), wound tochemical, medical/toxical, or clinical researches; healing (Echinacea and garlic), blood pressure and/or perioperative taking of these herbs by patients who are heart rate (Ephedra, garlic, ginseng, and goldenseal), undergoing surgery may have unexpected infuences on increase anesthesia effects (Kava, St. Valerian) and unexpected hormone-like effects (Saw M any plastic or cosmetic patients are taking herbal palmetto). However, just as biological activities of these medications or supplements, and a descriptive “top-10” herbs remain to be confrmed by more phytochemical, list of such herbs and preoperative recommendations clinical trials, and epidemiological studies, the potential was compiled for the plastic surgeon [50].

Probably ketamine relaxes airway smooth muscle via an epithelial-independent mechanism order tadapox 80 mg online. Since the initial case reports appeared in the 1970’s generic tadapox 80 mg with amex, several additional case reports and investigations have demonstrated improved gas exchange order tadapox 80mg without a prescription, compliance, and overall lung function after infusion of ketamine in patients with status asthmaticus refractory to standard therapy. The effects of heliox are transitory and disappear when air is once again inhaled. Its temporary use, however, may lower respiratory resistive work long enough to forestall muscle fatigue and/or improve ineffective mechanical ventilation until bronchodilators and steroids can take effect. The mixture may improve the distribution of inhaled agents and lead to a faster rate of resolution of obstruction. Magnesium Sulphate12 Magnesium is an important cofactor in many enzymatic reactions and hypo- and hypermagnesemia can cause contraction and relaxation of smooth muscles, respectively. Only three citations appeared in all of the meta- analyses and four trials appeared in three of them. Various meta-analysis done concluded that there was insufficient evidence to support the routine use of magnesium in acute asthma. Antileukotriene Agents There are limited data on the effects of antileukotriene drugs in acute asthma. One abstract compared placebo with zafirlukast and found a small but significant difference in favor of the active agent. At present, these studies can be thought of only as preliminary and more data are required. Noninvasive facemask ventilation may offer short-term support for some subjects with hypercapnic respiratory failure who can cooperate with their care and are able to protect their airways. The goal of ventilatory support is to maintain adequate gas exchange until bronchodilators and corticosteroids relieve the airflow obstruction. This usually entails sedation, and possibly paralysis, as well as strategies to minimize dynamic hyperinflation. Ketamine may be necessary to supplement sedation with neuromuscular blockade with pancuronium, vecuronium, atracurium, or cisatracurium. All of the paralytics can be associated with myopathy, which is worsened by concomitant use of corticosteroids and aminoglycoside antibiotics. It rises directly with minute ventilation and can compromise cardiac output by reducing venous return. The institution of positive-pressure ventilation in an already hyperinflated thorax can markedly worsen hemodynamics and cause abrupt falls in blood pressure including cardiac collapse. Because the airways are heterogeneously narrowed, the less involved parts of the lungs may undergo regional overextension when exposed to high inflation pressures and rupture. For these reasons, ventilatory strategies that provide the longest possible expiratory time are desired so that dynamic lung inflation is minimized. This goal is accomplished by combining the smallest tidal volume with the slowest inspiratory rate and fastest inspiratory time to keep a static end-expiratory pressure (plateau pressure) of less than 30 cm H2O. Supportive Treatment Overall care of the child should also be given due consideration, with maintenance of good hydration status, control of temperature and strict maintenance of the fluid and electrolytes balance. Prognosis Despite concerns about increasing mortality, most patients survive acute episodes. Short acting bronchodilators along with inhaled anticholinergics and systemic steroids constitute the mainstay of therapy. Need for ventilatory support should be on an elective basis rather than letting the acute event reach life-threatening proportions. Measures should be taken during mechanical ventilation to avoid barotrauma and hemodynamic compromise. Asthma is characterized by reversible lower airway obstruction with air trapping due to inflammation, mucosal edema and bronchospasm. An acute attack of asthma is characterized clinically by progressively worsening of wheezing, shortness of breath, chest tightness. Emergency management includes simultaneous assessment and institution of therapy, assessing response and taking appropriate action in the face of deterioration. Short acting bronchodilators along with inhaled anticholinergics and systemic steroids are the mainstay of therapy. Ventilatory support should be considered on an elective basis rather that letting the acute event become a life-threatening episode. Continuous versus frequent intermittent nebulization of albuterol in acute asthma: A randomized, prospective study. A comparison of albuterol administered by metered-dose inhaler and spacer with albuterol by nebulizer in adults presenting to an urban emergency department with acute asthma. Randomized trial of intravenous salbutamol in early mangement of acute severe asthma in children, The Journal of Pediatrics, 1997;131(131):160-1. Kamabalapalli M, Nilchani S, Upadhyayula S, Safety of Intravenous Terbutaline in Acute Severe Asthma, A Retrospective study. A Case Presentation and Literature Review of Successful Ketamine Administration in a Patient with Refractory Status Asthmaticus. Helium–oxygen mixtures in intubated patients with status asthmaticus and respiratory acidosis. Mechanical ventilation: American College of Chest Physicians’ consensus conference. Pulmonary edema is often life-threatening, but effective therapy can rescue patients from its deleterious consequences. This article will discuss in brief the basic physiological principles that govern fluid filtration in the lungs, pathophysiology of pulmonary edema, diagnosis, treatment, and outcome of pulmonary edema and acute lung injury. The vascular compartment is separated from the interstitium by capillary endothelial cells. The interstitial compartment: The importance of this space lies in its interposition between the alveolar and vascular compartments. As fluid leaves the vascular compartment it collects in the interstitium before overflowing into the air spaces of the alveolar compartment. The alveolar compartment: This compartment is lined with type 1 and type 2 epithelial cells. Excess fluid present within the alveolar and interstitial compartments is drained via the lymphatic system. When the capacity for drainage of the lymphatics is surpassed, fluid accumulation occurs.

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However effective 80 mg tadapox, in another study that focused on patients ing pregnancy has not been established buy tadapox 80mg on-line, and pregnancy may reduce receiving high doses of oxcarbazepine 80 mg tadapox with amex, tolerability could be im- the serum levels of its active metabolite monohydroxycarbazepine. Occa- Why would oxcarbazepine be chosen as a frst drug for new-on- sional patients tolerate three daily doses better than two because set focal seizures over other drugs? Levetiracetam is widely used in this ence and better adherence than to pharmacokinetic advantages. Topiramate may be chosen if migraine Te manufacturer states that measurement of serum sodium levels prophylaxis is needed, but is more likely to produce cognitive ef- should be considered, particularly for susceptible patients (e. Lamotrigine is ofen chosen for women of childbearing age taking diuretics), or if symptoms possibly indicating hyponatrae- and is relatively free of cognitive side-efects, but establishing a mia develop, such as nausea, malaise, headache, lethargy, confusion therapeutic dose takes at least 6 weeks. Antiepileptic drug pharmacokinetics and interactions: zures, with or without secondary generalization, for both children impact on the treatment of epilepsy. Oxcarbazepine: pharmacokinetic interactions and tolerability with other drugs for focal epilepsy. Infuence of oxcarbazepine and methsuximide include a need to establish an efective dose quickly, to minimize on lamotrigine concentrations in epileptic patients with and without valproic acid comedication: results of a retrospective study. A double-blind, placebo-controlled inter- fects, and absence of a comorbid condition better addressed with a action study between oxcabazepine and carbamazepine, sodium valproate and diferent drug. Eslicarbazepine and the enhancement of slow strel metabolism by oxcarbazepine in healthy women. Oxcarbazepine: an update on its efcacy in the manage- droxy-carbazepine concentrations and adverse efects in patients with epilepsy on ment of epilepsy. Changes in the disposition of oxcarbaze- and their clinical significance: comparison with carbamazepine. Comparison of oxcarbazepine and zepine acetate and oxcarbazepine at steady state in healthy volunteers. A double-blind controlled clinical bazepine and 10,11-dihydro-10-hydroxycarbamazepine. Neurosci Lett 2005; 390: trial of oxcarbazepine versus phenytoin in children and adolescents with epilepsy. Oxcarbazepine (Trileptal) drug concentration rela- omized, placebo-controlled, monotherapy trial for partial seizures. Safety and efficacy of oxcarbazepine macokinetics of oxcarbazepine and its 10-hydroxy metabolite. Antiepileptic Drugs, 5th partial onset seizures: a multicenter, double-blind, clinical trial. Phenytoin, carbamazepine, sulthiame, lamotrigine, ing trial in refractory partial epilepsy. Oxcarbazepine-induced toxic epidermal necrolysis: a tory partial-onset seizures: a randomized controlled trial. Te regulation of serum sodium carbazepine monotherapy: a prospective study in adult and elderly patients with afer replacing carbamazepine with oxcarbazepine. Oxcarbazepine reduces seizure frequency in a high pro- in epilepsy patients taking carbamazepine or oxcarbazepine. Epilepsia 2006; 47: portion of patients with both newly diagnosed and refractory partial seizures in 510–515. A multicenter trial of oxcarbazepine oral sus- proate therapies on growth in children with epilepsy. Endocr Res 2012; 37: 163– pension in children newly diagnosed with partial seizures: a clinical and cognitive 171. Oxcarbazepine in children with nocturnal concentrations in children with epilepsy treated with oxcarbazepine monothera- frontal-lobe epilepsy. Te evaluation of thyroid functions, monotherapy in an unselected population of adult epileptics. Seizure 2005; 14: thyroid antibodies, and thyroid volumes in children with epilepsy during short- 72–74. Oxcarbazepine in painful diabetic neuropa- in children and adolescents with intellectual disability. Safety of the new antiepileptic drug oxcarbazepine during pregnan- double-blind randomized trial. A double-blind, randomized, place- partial seizures afer conversion to oxcarbazepine monotherapy. Epilepsy Behav bo-controlled trial of oxcarbazepine in the treatment of bipolar disorder in chil- 2006; 9: 457–463. Neuroprotective efects of anticonvulsants in rat hippocampal slice tions for oxcarbazepine. Cognitive efects of oxcarbazepine and and phenytoin withdrawal seizures during epilepsy monitoring. Epilepsy Res 2008; phenytoin monotherapy in newly diagnosed epilepsy: one year follow up. Adjunctive treatment of primary generalized tonic-clonic seizures in adults and children from 12 years of age with genetic O N (idiopathic) generalized epilepsy N Usual preparations 2, 4, 6, 8, 10, 12 mg tablets Usual dosage Initially 2 mg, increasing every 2 weeks or more in 2-mg steps. Usual maintenance 4–8 mg/day; maximum 12 mg/day N Dosing frequency Taken once daily at bedtime Signifcant drug Carbamazepine, oxcarbazepine and phenytoin have been shown to increase interactions perampanel clearance and to decrease serum perampanel concentrations by 50% or more. Carbamazepine reduced serum perampanel levels by two-thirds in a study in healthy volunteers. At a dose of 12 mg/day (but not a dose of 4 or 8 mg/day), perampanel decreased levonorgestrel exposure and therefore, the possibility of decreased efcacy of progestagen-containing oral contraceptives should be considered in women stabilized on 12 mg/day perampanel. Studies in hippocampal slices also demonstrated ilepsies have uncontrolled seizures [1]. To exclude neuroprotective com- es of perampanel that were efective in the seizure tests and those pounds that did not act on the receptor target, all candidates were causing motor impairment [5]. Te core structure 1,3,5-triaryl-H-pyridin-2-one was identifed using this strategy. Perampanel [2-(2-oxo-1-phenyl-5-pyridin-2-yl-1,2- Pharmacokinetics dihdyropyridin-3-yl) benzonitrate hydrate 4:3] was discovered by Perampanel shows linear pharmacokinetics over the clinically used optimization of the core structure, mainly focusing on increasing dosage range. Although perampanel has poor solubility in aqueous almost completely absorbed, with a low systemic clearance and a solution at neutral and alkaline pH, it has a pKa of 3. Peak serum concentrations occur about charged species dissolves readily at low pH, such as in gastric acid, 1 h afer dosing in a fasted state.

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First aid methods with unequivocal benefit are reassurance order 80mg tadapox with visa, immobilization of the bitten part and tourniquet generic 80 mg tadapox fast delivery. A tourniquet should be used only in Krait bites and not in Cobra or Viper bites where it will increase local complications generic tadapox 80 mg fast delivery. The tourniquet should be one to four inches broad (preferably elastic crepe bandage) applied proximal to the Krait bite and loose enough to pass one finger below it and the distal pulses should be well felt. Rapid Assessment and Resuscitation Once in hospital, rapid assessment of airway, breathing and circulation should be done. Administration of oxygen, establishment of intravascular access and cardiopulmonary resuscitation started as needed. Some common situations needing urgent resuscitation are profound hypotension, shock, respiratory failure, hyperkalemic cardiac arrest, etc. Neostigmine: It is useful for neuromuscular junction blockade caused by neurotoxic snake bites. It is useful only for postsynaptic type of blockade (occurring with Cobra bites) and not for presynaptic block (Krait bites cause both pre and postsynaptic blockade). Local swelling involving more than half of the bitten limb (in absence of tourniquet) b. Neurotoxic signs: Ptosis, external ophthalmoplegia, flaccid paralysis, heavy eyes, bulbar paralysis, etc. Supporting laboratory evidence of systemic envenomation like early polymorphonuclear leukocytosis. It is always administered intravenously and not intramuscular or subcutaneous around bite. Sensitivity testing does not reliably predict early or late antivenom reactions and is not recommended. Adrenaline (Epinephrine) should always be kept ready for early anaphylactic reactions. Some studies have shown that subcutaneous adrenaline given just before antivenom infusion reduces the incidence of early antivenom reactions. Sometimes pretreatment with antihistaminics (both anti H1 and anti H2) and corticosteroids are also used in high risk cases. Best effects are observed when it is given within 4 hours of the bite6 but is useful in symptomatic patients even upto one week after the bite22 and in case of hemostatic abnormalities even upto two or more weeks. Mechanical ventilation: For respiratory paralysis in cases of neurotoxicity by Cobra and Krait, this form of therapy is life saving. Blood transfusion, blood components, volume expanders, peritoneal dialysis are needed depending on the clinical situation. It is to be remembered that no amount of heparin, blood components, antifibrinolytics or coagulation factors can help till there is circulating venom in victims body. History of snake bite and fang marks are not must to diagnose snake envenomation (e. Cobra, Krait, Russell’s Viper and Saw scaled Viper account for majority of poisonous snake bites in India. In areas known for Krait bites when a perfectly normal person, sleeping on floor reports early morning with vomitings, abdominal pain and bulbar palsy, it should be diagnosed as Krait envenomation, unless proved otherwise. Don’t underestimate local complications of snake bites, it may lead to gangrene and amputation. Don’t ignore bite by small snakes, bite after eating prey or bite after several strikes–all such bites are capable of severe envenomation. Bacteriological studies of venom and mouth carriers of wild Malayan pit vipers in southern Thailand. Scorpion Sting Scorpion sting is a dramatic, life threatening medical emergency usually encountered in villages of tropical and subtropical countries. Bawaskar from Raigad in Maharashtra has contributed immensely in this field and has helped to reduce mortality. They are Mesobuthus tamulus (Indian red scorpion) and Palamneus Gravimanus (Indian black scorpion or Ingali). It is found in Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu, Gujarat and Pondicherry. They are commonly found in underground burrows, crevices in dwellings, under debris and logs of wood, banana, sugarcane and coconut plantations and paddy husks. A scorpion sting does not always mean envenomation because it can control it’s ejaculation of venom. Metabolic effects mediated by alpha receptors stimulation are suppression of insulin secretion, hyperglycemia, hyperkalemia, free fatty acid accumulation and elevation of free radicals (responsible for myocardial damage). Direct toxic effect on neurons: explaining seizures and encephalopathy in few cases. Skin and subcutaneous tissue: Toxin of Indian red scorpion has little or no effect on skin but the black scorpion causes severe skin manifestations. Other manifestations not commonly seen in India are pancreatitis, hepatic necrosis and intravascular hemolysis leading to acute renal failure. Autonomic storm: Cholinergic storm is initial and short lived while adrenergic storm is subsequent and more prolonged. In those patients who have severe local pain, no further systemic manifestations (like autonomic storm, pulmonary edema, etc. The local pain in such patients may reappear during recovery from systemic complications. Sometimes local edema, sweating, pinhead bleed, local fasciculations and spasm of surrounding muscle is seen. Presence of local pain in the beginning and appearance of local pain after treatment, which was absent in the beginning, both are good prognostic indicators. The former indicates nonpoisonous or nonbuthus sting and later indicates recovery from envenomation. Cholinergic storm: Patient initially shows signs and symptoms due to excess acetylcholine outpouring, i. Adrenergic storm – Inotropic phase: Patient manifest with tachycardia, hypertension, cold extremities and arrhythmias.

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