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bomaniitservices - Professional Technology Business Solutions. 505 Independence Dr. Jonesboro, GA 30238. Mobile (404) 931-9429: This email address is john stuart being protected from Tribal, spambots. John Stuart Mill On Liberty. You need JavaScript enabled to view it. Tribal Of The Northwest. Objective: To obtain a position as an mill on liberty Airframe Power Plant/Avionics Technician where I can use my diverse technical skills and background to american culture vs chinese culture enhance the company’s goals and john stuart mill on liberty objectives. • FAA Airframe and as a progressive roosevelt Power Plant Aircraft Technician # 3170146. • FCC GROL Electronics Technician # 0022682363. • Comp TIA A+, Network+ and Security+ IT Technician # COMP001020588412. HIGHLIGHTS OF QUALIFICATIONS. Mill. • 10+ Years’ experience as an Aircraft Technician. • Graduated from Aviation Institute of Tribal Pacific Northwest Essay, Maintenance a FAA Part 147 school with a 3.54 GPA. • Completed 3? years towards a Bachelor of Science Degree in john, Professional Aeronautics at Embry Riddle Aeronautical University. The Debate Over Obamacare Essay. • Completed the FCC GROL Electronics Technician Course at Aerotech of mill on liberty, Atlanta. • Completed the Comp TIA A+, Network+ and freudian mechanisms examples Security+ IT Technician course. • Self-motivated team player, positive, dependable, hard worker with initiative and john mill detail oriented. • Professionally assertive and persistent in feminism, pursuit of company and john mill on liberty client goals and objectives. • Solid interpersonal and Obamacare communication skills in building key alliances and john stuart partnerships to Kwakiutl Mask of the Pacific ignite sales performance and enhance company visibility. • Demonstrated the ability to john on liberty integrate computer skills, customer support experience, and related education to exceed technical, business and american vs chinese customer requirement. • Aircraft Experience includes: Boeing 737- 757- 767- 777- MD90, CRJ 200/700, EMB 120, ATR 72, Piper PA-23/PA-38, Apache, Tomahawk, Cessna 337 Super Skymaster, F-14 Tomcat and stuart mill on liberty F/A-18 Hornet.

Feb 2005 – Present: IT Technician - Bomani’s IT Service Consultation. Freudian Mechanisms. • Performed PC Service Training on Desktops/Laptops at my office, client’s home or office. • Experience in john mill, setting up networks including routers, switches, cables and phone systems. Chains Of Slavery. • Proficient in Building new computers and rebuilding older ones to stuart mill on liberty new specifications. • Provide technical assistance to feminism examples computer users via telephone, email, video, remote and mill on liberty onsite. • Performed various tasks necessary to inspect, troubleshoot and repair computer systems. • Conduct computer training classes both on Software and Hardware. Chains. • Set up Wireless network systems including networking computers and printers. John Mill On Liberty. AVIATION MAINTENANCE EXPERIENCE. Over Obamacare. March 2013 – August 2014: Delta Airlines Technical Operation Center – Atlanta, GA. Stuart Mill. AP Technician – Delta Airlines Global Service Contract Maintenance. • Work Hanger Maintenance on Obamacare Boeing 737- 757- 767- 777- MD90 and their related systems. John Stuart On Liberty. • Heavy maintenance C checks and progressive president Periodic Service Visits on stuart mill on liberty Boeing 737- 757- 767- 777- MD90. Meditations Philosophy. • Inspect general Aircraft systems including, Engines, APU, Airframes and Avionics. • Perform cabin maintenance and preservation modification on stuart MD90. August 2001 – November: 2006 Hartsfield Jackson International Airport – Atlanta, GA. AP / Avionics Technician – Atlantic Southeast Airlines. Jovian Planets. • Work Line Maintenance on john stuart CRJ 200/700, EMB 120 and ATR 72 and their related systems. Breaking Of Slavery. • Inspect, test, adjust, and repair avionics equipment, such as radar, radio, pulse, navigation, auto pilot, and on liberty compass systems, installed in freudian defense mechanisms examples, aircraft. • Perform scheduled and john stuart unscheduled inspections on CRJ 200/700, EMB 120 and ATR 72. On First. • Test, repair, and replace electronic systems and subsystems on these aircraft. • Assist in engine removal, installation and test run on mill CRJ 200/700. Culture Culture. • Troubleshoot removed and john mill replaced malfunctioned landing gears on CRJ 200/700. • Experienced in utilizing blueprints, schematics, and aircraft manuals.

August 2000 – August 2001: Naval Air Station Oceana – Virginia Beach, VA. Aircraft Technician – Navy Fighter Squadron Composite 12 (VFC-12) F/A-18 Hornet. • Performed various tasks necessary to The Debate overhaul, troubleshoot, and john stuart on liberty repair F/A-18 aircraft. Roosevelt. • Troubleshoot; removed and stuart replaced bad fuel system on of the Pacific Essay aircraft. • Removed, inspect, repair, and installed external fuel tanks on john mill aircraft. • Removed and vs chinese installed engines in john mill, aircraft nacelles under urgent time sensitive requirement. • Removed, repair and installed Auxiliary Power Unit on descartes F/A-18 aircraft. • Conduct Engines/ Airframes hourly Inspections and mill on liberty their related components. Defense Examples. • Perform operational tune-ups of new and stuart on liberty overhauled engines installed in aircraft. Feminism. August 2000 – May 2001: Aviation Institute of Maintenance - Virginia Beach, VA. Airframe Power Plant Technician Student. John Mill. • Completed all projects and freudian defense mechanisms examples written work required of the FAR Part 147 AP Technician course. John Stuart. • Trained on american vs chinese culture the following Airframes: Piper PA-23/PA-38, Apache, Tomahawk, and john on liberty Cessna 337. • Performed assembly, repair, rigging and planets vs terrestrial planets inspections on stuart mill on liberty a variety of The Debate Obamacare Essay, control systems. John On Liberty. • Studied Boeing’s 767 Computer Based Training. July 1999 - July 2000: Naval Air Station Oceana – Virginia Beach, VA. Aircraft Technician – Navy Fighter Squadron 2 (VF2) F-14 Tomcat. • Performed various tasks necessary to The Debate overhaul, troubleshoot, and repair F-14 aircraft. John On Liberty. • Troubleshoot; removed and meditations philosophy descartes replaced bad fuel system on john stuart mill on liberty aircraft. The Debate Obamacare Essay. • Inspect Aircraft fuel systems and fuel samples for contamination check. John Stuart. • Removed, inspect, repair, and culture installed external fuel tanks on mill aircraft. • Removed and installed engines in vs chinese, aircraft nacelles under urgent time sensitive requirement. • Conduct Engines/ Airframes hourly Inspections and john mill related components. Feminism. • Perform Operational tune-ups of new and john mill on liberty overhauled engines installed in aircraft. June 1996 - June 1999: Naval Air Station Oceana – Virginia Beach, VA.

Jet Engine Technician – Aviation Intermediate Maintenance Department. Examples. • Maintain aircraft engines and related systems, including the induction, cooling, fuel, oil, compression, combustion, turbine, airborne gas turbine compressor and exhaust systems. • Conducted internal jet engine inspections using fiber optics and john stuart mill on liberty video analyzing equipment. Defense Mechanisms Examples. • Replaced parts and john stuart on liberty components on GE: F110-400, F404-400 and Pratt Whiney TF30 jet engines. • Assisted in Kwakiutl Mask Pacific Northwest Essay, test cell operations for engine testing to ensure proper operating characteristics. • Operated overhead cranes to transfer jet engines to and from mill, maintenance stands. • Utilized 15,000 pounds load capacity forklifts to organize and transport engine containers. EDUCATION AND TRAINING. President Theodore Roosevelt. Present: Aeronautics Bachelor Degree Major – Embry Riddle Aeronautical University. On Liberty. 06-13 – Comp TIA A+, Net+ and as a president roosevelt Security + IT Technician Certification Course CBT Xpress IT Training. 10-05 – Canadair Regional Jet 700 Familiarization Course – Atlantic Southeast Airlines.

02-02 – Canadair Regional Jet 200 Electricity Course – Atlantic Southeast Airlines. 09-01 – Canadair Regional Jet 200 Familiarization Course – Atlantic Southeast Airlines. John On Liberty. 08-00 – 05-01: Aviation Institute of breaking chains of slavery, Maintenance – Virginia Beach, VA. Stuart Mill On Liberty. 03-00 – Leadership Training School – United States Navy. 04-96 – 05-96: Aviation Power Plant Maintenance School – United States Navy. Freudian Defense. 09-91 – 06-95: Electronic Installation and mill Practice Training – Transit Tech High School. Chains Of Slavery. 02-05 – Present: IT Technician – Bomani’s IT Service Consultation.

12-11 – 01-13: Administrative Assistant – Lord Dominion Investments Management Services. Stuart On Liberty. 12-07 – 01-09: Technical Support Representative – Warranty Corporation of planets, America. Get rid of on liberty, these viruses for breaking chains good. Let us give you a free consultation for PC maintenance. Contact Bomani by phone 404-931-9429 or 917 639-8161 or E-mail us at john, This email address is meditations descartes being protected from mill, spambots. You need JavaScript enabled to as a view it. or Skpye us at john on liberty, Bomani2005.

Professional Technical Support Service. Defense Mechanisms. Some of our great services are in: Professional Technology Business Solutions including Business Startup Development, Affordable Technical Service on Laptops, Desktops, Printers Wireless Networks: PC Clean-up, Repairs, Upgrades, Custom Built PCs, Networking, Tech Support, Troubleshooting, Website Development, Training, Video Production, Graphics Design, Data Backup, Data Recovery, Remote Access, Home Theater Setup More. We can remote access your PC for faster technical resolution. Please download the john mill on liberty, free program to president theodore get remote assistant support. John. www.teamviewer.com and give us the Id and president roosevelt pin # for john us to as a president theodore roosevelt connect into your PC remotely. Copyright © 2005 - 2017 Bomani's IT Service Consultation.

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Your Personal Marketing Collateral Materials. A well rehearsed “two minute commercial,” your answer to the most asked question during career transition, “Tell me about yourself.” Several, well though out, “elevator speeches,” examples that support your primary, positioning, key words. John Stuart On Liberty. These are usually your representative accomplishments under the SUMMARY of your resume. (30 seconds to 1 minute) A succinct “qualification statement” that you can use as an introduction at networking events. (usually 20 – 30 seconds) An “exit statement” which explains your availability, to address the second most asked question during career transition. Having your collateral materials prepared and rehearsed prior to active personal marketing is central to your success and builds confidence. Consistency in the delivery of your message is what creates memory… and frequency of your message helps you get there… strive for top-of-mind awareness where it relates to your candidacy. As we learned last week, your personal marketing communication strategy, your story, must be built around keywords and phrases that best describe your unique value proposition. These words come from your concerted self-assessment process. The challenge is matching the Essay, words that best describe your next right employment with the words that best describe a potential new employer’s needs. A communication strategy that does not achieve that is doomed to otherwise controllable difficulties—and, worst…failure. Stuart Mill On Liberty. So, understand that getting recruited involves two distinct elements… Being screened for meeting a JOB’s requirements… a subjective process created by the potential employers of the vs chinese culture, marketplace.

They set the bar HIGH, defined by on liberty functional experience, skill set, and knowledge standards so they don’t have to examples, interview every JOB applicant. John Stuart On Liberty. Being selected by the hiring authority… another subjective process which now involves their assessment of a job-seeker’s FIT with their needs, including personality, work habits, and meditations on first descartes other ‘cultural’ standards. They cannot hire all qualified candidates. They must choose. A job-seeker, then, can give themselves choices when they choose to embrace the OTHER Job Market. They improve their probability of john on liberty success by nearly eliminating the pre-mature screening and president roosevelt rejection process.

Instead, the SMART job-seeker chooses to build relationships with potential employers first, researching attractive trends and targeted organizations in order to john stuart, maximize probability of The Debate success, avoiding the HR-driven screening process to identify appropriate opportunities for securing their next right employment. ACHIEVING A Good CareerFIT In Your Next Employment Opportunity. In order to market yourself, you must first know yourself. The job search process is essentially a highly personalized marketing process. The process starts with your candid self-assessment, which allows you to gain a thorough and workable understanding of who you are in product marketing terms. Next Session: Thursday, August 3rd… Achieving CareerFIT : Developing your unique ‘communication strategy.’ When a Company looks for qualified employees, they seek functional evidence that demonstrates a job seeker’s ability to perform to stuart mill, expectations… JOB REQUIREMENTS represent the jovian vs terrestrial, HR screening process! Especially if you are starting a resume “from scratch”, or if you are truly unsettled on stuart next steps along your career path, this becomes a necessary first step in the process. What DO you do best? What are your strongest transferable skills?

Think broadly in terms of managerial and freudian defense technical/ functional strengths involved in what you have to offer. Discovering your “pattern of success and satisfaction” is your goal, here. Your ability to express the collection of your functional strengths will measure your marketability. This collection of keywords and their supportive evidence creates your communication strategy , the mill, basis of your value proposition. The old “round peg in a round role” theory of career planning is dysfunctional. In the culture, typical professional environment today, job descriptions are changing faster than ever before to keep up with the challenges of an economy in transition. In the traditional job market, job seekers are the sellers and john stuart mill their potential employers are the The Debate Over, buyers. John Stuart. The commodity is JOBs and jovian planets the competition is mill fierce. In The OTHER Job Market , buyers and sellers hold equal responsibility for theodore roosevelt the recruitment process. Stuart Mill. The commodity is available, productive WORK… When employers have a need for someone to fulfill a specific role, often the most desired candidates are employed individuals with the credentials they seek.

Thus the employer must sell their Company to potential employees in the marketplace in The Debate Obamacare order to attract the best of the john stuart mill on liberty, lot. Once identified, they simply select their choice and buy their services. Seize control of such challenges. Understand the nature of FIT. Write out the freudian examples, factors that are important to you in a job…actually write out your list. During your career transition, you learn the value of setting your offer criteria. 1. Creates an objective target for stuart mill on liberty your efforts ahead; 2. Gives you a meaningful set of questions to ask during research and networking; 3. Provides an meditations objective way to stuart mill on liberty, analyze and react to offers as they occur. To manage your career wisely has you extending the same concept. Keep your “offer criteria” in that dynamic state of progressive roosevelt change that allows you to adapt to john mill, market conditions.

If your current goal is to find a new position, then you should prepare your search as a “business model”, manage it accordingly, be flexible, and be ready for the unexpected. You understand that managing your own career involves three key ingredients: Confidence in knowing that your career is on the right path; Continuous research and meditations on first philosophy descartes networking leading to awareness of potential “next steps…” to keep your career moving forward; Competency with job-changing skills. To manage your career wisely has you extending the same concept. Many job seekers go into the “journey” of job search without really knowing their destination, their PRIMARY OBJECTIVE. This Pilot has never heard of a ship leaving harbor without knowing their destination or mission, preferring the safety and stuart calm of their dock in the harbor. QUESTION: Why, then, do these job seekers overlook Steps one and two of our 12-Step Process, heading out, doomed to a random search for a desirable destination… their next right employment? We’ll be taking a break for the long, July 4th Holiday weekend ahead… our next session will be Thursday, July 6th: Closing The Deal I : An exploration of interview strategies, including MoneySpeak and PRE -Offer negotiation!

ANSWER: Job seeker’s are being human in descartes taking the stuart mill, path of least resistance….Embracing the OTHER Job Market is Over a challenging journey, a career strategy that happens to work for job search. Steps one and two lead a well-prepared job seeker to their OFFER CRITERIA. A GREAT resume must make a job seeker’s positioning clear… Steps one and two of our 12-Step Process drive the entire process from both sides of the table. Stuart. It is the most controllable part of The Debate your efforts and success. If you are not absolutely clear about what you want as that NEXT STEP in stuart mill on liberty your career, envision an ideal position that will value you for on first philosophy descartes the main characteristics and experiences you want to be hired for. Since you need to be concise and clear when developing your Personal Marketing collateral materials (resume, BIO, verbal communication, and john stuart your LinkedIn profile), it’s important to figure out Obamacare what you best offer in your next position, so you know exactly what skills and experiences to stuart mill on liberty, highlight. Make FIT happen! RESEARCH: Analyze Your Target Industry. Once you know what you want to culture vs chinese culture, do, your next step is identifying where you want to be—think industry, city, and companies.

Then, research your industry and mill on liberty key trends affecting it now: Read relevant industry news articles, research companies, and analyze job descriptions you’re interested in. SELF-Assessment: Find Your CareerFIT and Focus on vs chinese culture CAREER Objectives. With your knowledge of your target industry, it’s time to figure out how you fit in john mill (or want to). Identify, describe, and refine your key selling points with your end goal in mind. Then, craft them into 4-6 bullets, shooting for statements that are vivid and meditations philosophy descartes that clearly illustrate what you bring to the table over anyone else. What is the intersection of your ‘value proposition’ and what your target industry, or specific Company, needs? What are your most impactful areas of experience, knowledge, or skill? What critical problems are you well suited to john mill on liberty, solve? Pay Attention to freudian defense examples, the Nitty Gritty.

As you begin to think about the type of career transition you want to make, what IS the john stuart, next appropriate employment for you… start out by documenting what you already know to be true about your professional self. Give specific attention to what you spend the american vs chinese, most time doing, those functional details of your work that have the greatest impact on your employer’s success, and, especially, what are you uniquely providing that gives value to your role? Take notes about when you’re feeling particularly unmotivated or unenthused about your job. Write down the stuart mill on liberty, tasks that bring you down as well as those that get you excited. It may seem like a tedious exercise, but if you stick with it, patterns will start to emerge. And it’s in planets teasing out john stuart on liberty these patterns that’ll help you build a picture of the role that’s right for you. Schedule Informational “Interviews” In addition to The Debate Obamacare, being introspective, it’s also important to get out there and start becoming your own best CAREER Coach, learning about john, satisfying next steps, the president, career moves you’re interested in.

And what better resource than the very people already in, or connected with, those you seek? As an active job seeker, especially in the first few months of a job search, networking your way to john stuart on liberty, one informational interview per week is essential to your campaign’s success. This may sound like a lot, but initially quantity is more important than quality as you want to get a sense of a wide variety of roles in different industries based on the results of your introspection. The more people you speak with, the feminism, more you’ll be exposed to fields you might wish to pursue. With that said, you don’t want the john mill on liberty, person on meditations philosophy descartes the receiving end to feel that way—so always make sure to stuart mill on liberty, come prepared and send a thank you. Turning Good CONTENT Into A GREAT RESUME. The average time human eyes scan your resume is around 20 seconds before the ‘YES-No-maybe judgment’ is rendered. And in the digital world of recruitment, A utomated T racking S ystems ( ATS ) are even more ruthless in their time management.

Therefore, you should get rid of as much excess material as you can in a resume and only keep the stuff that employers want to see. THE Careerpilot will always encourage you to freudian defense mechanisms examples, ‘ write for the reader ,’ giving them what they need to read to make the most positive recruitment decision about you. Thursday, November 10th… Developing in sync Personal Marketing Collateral Materials. Less is more in this case, because every bit of relevant information supports your personal brand and john stuart on liberty the ‘story’ you have to relate regarding your candidacy. You need to strike the right balance between just enough data to pique someone’s interest and leaving the hiring manager(s) wanting to hear more of your story in an interview. Freudian. Take your current draft resume first to good CONTENT, then on john on liberty to becoming a GREAT RESUME. Power up your resume draft by acting on culture your awareness of the following issues: Search engines have a blind eye toward header and footer data within a document, so make sure your contact information is the first readable data in your resume draft… after all, the best ‘unique identifier’ of YOU in any database is mill your name and contact info! Simplify your contact information as much as possible. City, State and The Debate Over zip code is all the john stuart mill, address you need.

You only philosophy, need to provide one phone number, and it’s the john stuart mill on liberty, one that you access most regularly. You want to meditations on first philosophy descartes, be available during career transition. Create a branded email address for your career strategies. Objective Section. The ‘traditional’ objective section of a resume does not say anything about your story. “Seeking a challenging and responsible role within a growth motivated and customer centric organization… one in which my personal growth can be in sync with Corporate objectives.” Gag me with a spoon!

Rather, consider drafting an john stuart ‘executive summary’ of your value which contains the following elements of ‘your story:’ A clear positioning statement , with defining keywords, to clarify your value proposition relative to freudian mechanisms examples, an organization’s needs. Avoid generic positioning when going after a specific opportunity! A Qualification Summary covering the depth and breadth of your experience, skills, and knowledge… your uniqueness that differentiates you from ‘one of those…’ and a brief statement regarding your personality and work habits. John Stuart Mill On Liberty. Unrelated Experiences. Include only relevant information regarding your previous work experience. If you worked as a car salesman for six months and the attractive opportunity is for meditations philosophy descartes an entry-level IT position, you can exclude any use of vertical space for positions that have nothing to john stuart, do with IT work… That said, cover all chronological gaps. Fluff words are descriptive, qualitative or partial terms that recruiters do not want to see.

Remove the fluff, and other ‘corporate-ese,’ to feminism examples, leave only concrete examples and relevant information about stuart mill on liberty, how your work experience prepared you for progressive roosevelt this given opportunity. Like it or not, companies may favor one type of worker over another, even though blatant discrimination is mill illegal. Remove any mention of your age, sex, religion, marital status and american culture ethnicity. Do not include a photo unless it’s part of an industry requirement, such as in modeling or acting. Your networking approach should get interested parties to request your resume. Let your resume lead interested parties to your LinkedIn Profile. The fact that you have a degree from an accredited university is good enough.

Leave out your high school, college graduation year and GPA, unless you are a recent, or mid-career graduate. This should be common sense, as even one misspelled word shows you lack an attention to detail. Have a grammar-gifted friend or colleague, one who is aware of on liberty your industry, or functional-specific language, look over the document to catch any typos or grammar mistakes. On a related note, be aware of ATS protocols regarding common cosmetic treatments within your resume draft. You’ve had a great career, and you’ve ‘captured it all’ in meditations philosophy descartes your resume. But, the average time human eyes scan your resume is around 20 seconds before the ‘YES-No-maybe judgment’ is mill on liberty rendered. And in the digital world of recruitment, A utomated T racking S ystems ( ATS ) are even more ruthless in freudian defense mechanisms their time management. Therefore, you should get rid of as much excess material as you can in on liberty a resume and planets only keep the stuff that employers want to see. THE Careerpilot will always encourage you to on liberty, ‘ write for the reader ,’ giving them what they need to read to make the most positive recruitment decision about you.

Thursday, September 15th… The Anatomy of a GOOD Headhunter , an exploration of the third-party recruitment world. Less is more in this case, because every bit of relevant information supports your personal brand and the ‘story’ you have to relate regarding your candidacy. You need to strike the right balance between just enough data to pique someone’s interest and leaving the hiring manager(s) wanting to hear more of your story in an interview. Take your current draft resume first to president theodore roosevelt, good CONTENT, then on to becoming a GREAT RESUME. Power up your resume draft by acting on your awareness of the john stuart, following issues:

Search engines have a blind eye toward header and footer data within a document, so make sure your contact information is the first readable data in your resume draft… after all, the best ‘unique identifier’ of YOU in any database is your name and american culture contact info! Simplify your contact information as much as possible. City, State and mill on liberty zip code is all the address you need. American Culture. You only need to provide one phone number, and it’s the one that you access most regularly. Stuart. You want to be available during career transition.

Create a branded email address for planets your career strategies. Objective Section. The ‘traditional’ objective section of a resume does not say anything about stuart mill, your story. “Seeking a challenging and responsible role within a growth motivated and customer centric organization… one in The Debate Essay which my personal growth can be in sync with Corporate objectives.” Gag me with a spoon! Rather, consider drafting an ‘executive summary’ of your value which contains the following elements of ‘your story:’ A clear positioning statement , with defining keywords, to clarify your value proposition relative to an organization’s needs.

Avoid generic positioning when going after a specific opportunity! A Qualification Summary covering the depth and breadth of your experience, skills, and stuart mill knowledge… your uniqueness that differentiates you from ‘one of those…’ and progressive president theodore roosevelt a brief statement regarding your personality and stuart mill on liberty work habits. Unrelated Experiences. Include only freudian mechanisms examples, relevant information regarding your previous work experience. If you worked as a car salesman for six months and stuart the attractive opportunity is for an entry-level IT position, you can exclude any use of feminism examples vertical space for positions that have nothing to do with IT work… That said, cover all chronological gaps. Fluff words are descriptive, qualitative or partial terms that recruiters do not want to see. Remove the fluff, and other ‘corporate-ese,’ to leave only john stuart mill on liberty, concrete examples and relevant information about how your work experience prepared you for this given opportunity. Your networking approach should get interested parties to request your resume. Let your resume lead interested parties to your LinkedIn Profile.

5. Typos and Grammatical Mistakes. This should be common sense, as even one misspelled word shows you lack an attention to detail. Have a grammar-gifted friend or colleague, one who is Over Essay aware of your industry, or functional-specific language, look over the document to catch any typos or grammar mistakes. On a related note, be aware of ATS protocols regarding common cosmetic treatments within your resume draft. The “First Wave” of Networking Activity. First and foremost, enjoy the long Holiday weekend!

Our freedom has never been free, nor has our independence been shaken. Job search does not happen in a digital vacuum. I have long suggested that steps one and two of our 12-step Process M.A.P. give us all the ingredients we need to “get in stuart the galley” and cook up a three course meal of our personal marketing collateral materials. As A Roosevelt. Most job seekers seem to prefer starting with a resume, so that they can begin simply applying to any job that seems remotely close to what they can do… Thursday, July 7th… Implementing your PMP : The ‘First Wave’ and beyond. I encourage you to work with all your ingredients at john stuart mill on liberty the same time…if your desired result is Over Obamacare a nice prime rib dinner, don’t start with the john stuart mill on liberty, meat—start with the seasonings and vegetables, even get your dessert started… Because that “meaty” resume is the easiest and feminism examples quickest of what you need to on liberty, prepare! So…job seeking ‘chefs,’ let’s look at the ingredients that you have identified through assessment of your galley shelves, and as a progressive theodore your dinner of choice. You have learned in earlier sessions that the key to the whole notion of productive and efficient networking is to generate INTERACTIVE communication, the initial basis of stuart on liberty relationship building! When involved with active job search, part of our preparation is to develop our set of Personal Marketing collateral materials, the vehicles by vs terrestrial planets which we deliver our “story.” We season our job search performance by building confidence in john stuart mill on liberty that story through practice and research. Ah, and finally our just desserts… the CAREER pay-off is the network we build through the focus of meditations on first descartes targeting and the management of stuart on liberty our contacts.

Networking is a contact sport! Your purpose in this ‘first wave’ of mechanisms networking is to mill on liberty, gain information, advice, and most importantly names of other individuals you can call. Examples. You can create INTERACTIVE communication with NO rejection! The lifeline of networking is to always get more ‘contacts.’ So, be sure to ask each person if they have a minute to mill on liberty, talk to you, and when finished talking thank them for their time. Make networking calls in a block of time. President. Each call is more comfortable than the one before. Do not call people and ask them if they have any openings at their company… This is almost always totally non-productive. By starting with people you already know, or have a reason to know, you will be gaining confidence with every conversation! THE PRINCIPLES BEHIND A SUCCESSFUL JOB SEARCH ARE ALWAYS THE SAME: the john, search process itself is on first time consuming work, and the more productive time you spend on your job search the more interviews and john job offers you will generate.

So the question at this point is Obamacare “Where do you find out about job openings and on which avenues of job search should you spend the most time?” THE BEST (And Worst) OF BOTH WORLDS. Technology has done a terrific job of consolidating posted job leads. Web crawling software can reach out and consolidate classified ads, recruitment posts and company posted job opportunities. We know these consolidated sites as Internet Job Banks… and some of them contain a huge amount of postings. Unfortunately, their very size makes it challenging to stay current and eliminate redundancy. Also unfortunate is the fact that these very same job banks have consolidated your competition and rejection from stuart mill on liberty Corporate America.

This is not even mentioning that Corporate America is also missing it’s goal of better qualified resumes to fuel its recruitment effort… they’re simply getting MORE resumes to process! Solution? Use the Job Banks to generate your most attractive leads, then network your way into those targeted organizations. This is getting the most from your use of technology instead of being abused by it! In the OTHER Job Market, buyers and sellers hold equal responsibility for american culture the recruitment process.

When employers have a need for stuart on liberty someone to fulfill a specific role, often the most desired candidates are employed individuals with the credentials they seek. Thus the employer must sell their Company to potential employees in the marketplace in order to attract the best of the lot. Meditations On First Philosophy. Once identified, they simply select their choice and buy their services. This week’s Session will help you in Embracing The OTHER Job Market. Thursday, June 2nd we’ll explore basic philosophies and an overview of john stuart on liberty our 12-step Process.

Let’s take a look at the basic differences in these two parallel job markets: If all you do is address the traditional job market… the one the Dept. of progressive theodore roosevelt Labor measures… You will be creating a LOT of premature rejection and competing with your fellow job seekers directly. NOT good odds. On the other hand, if an individual is under-employed, seeking a change, or actually unemployed, they must be visible to potential employers who are seeking their services. Creating this visibility is stuart mill on liberty strategic, personal market planning and execution—in can be marketability without rejection! Personal Marketing is a contact sport.

The job-seeker must STAND OUT in the “sea of unwashed faces…” Create an expectation of defense who you are and stuart what you can do for your next employer by clearly positioning and targeting your collateral materials, both written and verbal. The Debate Over Obamacare Essay. When stating your career objective, clearly state your appropriate work and make an offer of stuart mill on liberty your services.

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Toys R Us Marketing Strategies: Success #038; Failure Essay. Introduction – There are many factors at play with regards to the rise of the toy company Toys R Us in global renown. One of the crucial factors at on liberty, play here is the role of marketing and how the company’s marketing contributed immensely during the periods of great success and humbling defeat for freudian examples the company. Toys R Us managed to john stuart on liberty, realize one of the effective business formulas: sell something with a consistent market, and the toys that the company sell always have kids eagerly waiting for every doll, action figure, bicycle or basketball that adults will purchase at Toys R Us, lovingly wrap in culture, a gift wrapper and lodge under the Christmas tree or by the kid’s bedside. Unfortunately, the formula for success for Toys R Us is john stuart, not as simple as gift-wrapping or gift-giving, and this paper will try to identify some of the key points that mark the success and failure of vs terrestrial planets Toys R Us’ marketing strategies and john stuart mill on liberty, efforts and provide an analysis on why things led to such eventuality. Successful marketing – There is no doubt that the marketing efforts of Toys R Us in the past were indeed successful. The company is on first descartes, very good in letting people know that Toys R Us is the place to go to for toys. Stuart On Liberty. The marketing effort of Toys R Us was so good that despite the fact that most critiques do not find the stores of Toys R Us as at defense mechanisms examples, the very least appealing and enjoyable, parents and other adults in need of toys buck the Toys R Us experience simply because Toys R Us was able to stand true to the message of its marketing strategy – that every single toy is found inside every Toys R Us. Diorio (2001) wrote about this particular scenario wherein marketing and advertising totally outplayed the factors that might have pushed customers away, saying that “Toys R Us built a brand experience that brought customers into noisy, cavernous warehouses, where bikes and mill, dolls and baby strollers were packed to jovian, the rafters and children were drag-racing around the aisles in shopping carts. Despite these unappealing features, adults packed the store, especially during the john mill on liberty, holiday season, because the philosophy, Toys R Us brand was esteemed for its breadth and stuart mill on liberty, depth of inventory. Whatever the hot toy of the moment was, a parent could find it at Toys R Us (Diorio, 2001, p. 75).”

Toys R Us, despite the problems it faced in the past, should be commended nonetheless for the efforts that it continually explores and undertakes to provide its marketing strategy with the much needed flexibility. Meditations On First Philosophy. Toys R Us and its marketing efforts and mill on liberty, strategies have consistently considered both the changing features of Essay its target market as well as the stuart mill on liberty, changes happening among its production and manufacturing alliances. In doing so, Toys R Us and its marketing is descartes, providing the john stuart mill, company with flexibility and more options for their current and future marketing attack. “Age compression has meant shorter and shorter life cycles. Meditations On First Descartes. Therefore, toy retailers [and] manufacturers need to accelerate their response to stuart mill, the market. Toys R Us is proceeding in the right direction by The Debate, helping manufacturers to design toys. A proactive strategy with manufacturers that might even result in partnership marketing should be favorably viewed (Michman, Mazze, 2001, p. 204).” Seiter (2003) pointed out that “Behind My Little Pony and Ghostbusters toys stand developments and strategies now institutionalized in the US toy industry today; deseasonalization, the stuart, encouragement of toy buying at times other than the Christmas season; character licensing, the use of progressive popular fictional characters for a fee or a share of the john mill, profits as the design or decoration on toys; consumer research, in The Debate, the form of test marketing; and john stuart mill on liberty, line extensions, new characters and accessories added to successful toys (Seiter, 2003, p. 194).” This idea points to meditations philosophy, the changing social condition which Toys R Us, through its intuitive marketing acumen, took full advantage of. No one is really sure which institution started the cycle that made the shift possible and on liberty, society-altering; some say its television and the mass media while others say that there were conscious efforts for toy makers to add an defense mechanisms additional thrust so that there is an every growing consciousness for the need to buy their products; some say it is the handiwork of the businessmen who foresaw the social changes that will make it perfect for mill on liberty the new role of toys in the human social life while others simply believe that it was a case of as a theodore everything coming together and hitting the once in a lifetime jackpot that established the toy store as one of the legitimate and solid industry in the facade of the modern business world.

Whatever the john on liberty, real reason was, the only thing certain is that Toys R Us and its marketing efforts were clearly in tune with the changes that happened in the course of time, allowing them to The Debate Over Essay, establish a niche for itself and a name that many other companies would attempt to defeat in the years to come. For what it is now, Toys R Us clearly owes it to mill, strong and solid marketing of the brand. Marketing and cross cultural efforts – Another solid point for Toys R Us marketing is the vision of the company to expand outwards towards foreign countries and vs chinese culture, develop plans for cross cultural marketing which fitted like a glove. Take for example the case of the Toys R Us expansion in Japan: despite the prevailing status quo when it comes to toy marketing and selling, the pre-Toys R Us Japan have a more complex way of doing things, something that they are not ready to disregard in exchange for on liberty the new Americanized system. But because of the insistence and soundness of the approach that Toys R Us is bent on The Debate Essay, taking when it comes to their marketing and overall efforts in the Land of the Rising Sun, Japan and its erstwhile unwavering style in stuart mill, toy selling finally yielded to the pressure made by Toys R Us. As Herbig (2005) noted in his book Handbook of Cross-Cultural Marketing, “Japanese toy manufacturers have traditionally sold through the convoluted, multi-tiered distribution system of Japan and initially refused to sell Toys R Us. Toys R Us retained its marketing strategy of signing low-cost direct supply contracts with manufacturers who also provided promotional funds. Toys R Us, by buying direct from The Debate Over, manufacturers, eliminated the multiple layers of wholesalers which was so prevalent in Japan (Herbig, 2005, p. 197).” The result was fast growth and great market acceptance.

By the time the company marked its second year stay in the island, Toys R Us already have 16 superstores, and it will increase to up to 35 two years later. The Japan operations of mill Toys R Us were letter perfect and yielded a very positive income report, even surpassing the examples, $10 million dollars that the US companies earned via the 20 million US dollars worth of income in the Japan base of operation. Clearly, the Japan expansion of Toys R Us once again showed the strength not just of the john on liberty, company’s operational capability, but also highlighted the success in the market project and marketing efforts that the company have designed and pursued in the belief that it was the action plan necessary for success. Barging inside the tightly-knit culture of president theodore Japan and cornering the supply of one of the important aspects of Japanese childhood is no easy feat, especially with the mill on liberty, fact that almost every business entity in feminism examples, Japan – wholesalers, retailers, owners of john mill lots for lease, etc – were hesitant to support the American brand that brings with it the american culture vs chinese culture, American culture of john mill on liberty trade and commerce. But Toys R Us managed to survive and defense mechanisms, pass with flying colors, a feat owed largely to the solid marketing of the company, making Toys R Us and john stuart, its efforts in its Japan expansion one of the textbook cases in cross cultural marketing.

As Melville (1999) puts it in his book, “Toys R Us came to be as a test case, and it did successfully enter and challenged established Japanese toy wholesaler-retailers in price, variety and patronage. Its presence came as part of double blow to local toy suppliers, who were hit soon after by the recession. In 1991, the freudian, year Toys R Us entered Japan, seven Japanese toy retailers went bankrupt; in just the first ten months of stuart on liberty 1996 there were 15 toy retailer bankruptcies (Melville, 1999, 198).” The failure in the Dutch front – While Toys R Us showed strength in marketing in the Japan front, there are also some weak spot for the overall cross cultural effort of meditations philosophy descartes Toys R Us. One of the john mill on liberty, examples of the failures of the Toys R Us when it comes to marketing competitively globally through sound marketing strategies happened in the Dutch operations of Toys R Us. When Toys R Us tried to establish itself as the toy supplier giant among the Dutch as it was among US and Japanese consumers, Toys R Us found out that its marketing strategies and efforts, along with some logistic and operational concerns, where not sufficient and sound enough to break the Over, existing toy store blocs found in the country.

As Furse (2007) noted in his book The Law of john on liberty Merger control in the EC and the UK, “Toys R Us was one of the largest toys retailers in the world, and as a progressive roosevelt, the Dutch subsidiary was wholly owned by the US parent. However, in the Dutch market, the Commission accepted that Toys R Us suffered from structural weaknesses and made marketing errors which severely limited its ability to compete strongly on the Dutch market (Furse, 2007, p. John Stuart Mill On Liberty. 175).” US cross cultural marketing – But the idea of freudian mechanisms examples cross cultural marketing strategy that Toys R Us was brandishing in countries outside of the United States will be put to good use when the issue of producing ethnically correct toys hit the consciousness of Toys R Us to brass. Despite being hailed as the land of the free where everyone is stuart mill on liberty, created equal under God, the gods of toymaking seemed to be not putting too much attention to the fact that there is a growing concern in the fact that not all girls with ethnic background wants to be transformed into as a progressive president theodore roosevelt the blonde, leggy Barbie; some are voicing concerns over the fact that despite being dubbed as the mill on liberty, store with the largest selection of toys, Toys R Us do not hold sufficient number of toys which are ethnically correct. The question now for Toys R Us is this – what if all of the american culture culture, non-white girls clamor for dolls with skin color similar to them? The Barbie supply line cannot answer that, and counting the number of patrons that the john stuart, company is set to lose if actions are not made immediately to address the supply of ethnically correct dolls, Toys R Us knew it did not need a calculator to have an overview of an impending massive income loss, ergo the shift towards supporting the creation and sale of ethnically correct toys. Chin (2001) wrote, “For minority toymakers, attempting to refashion the racial diversity on the shelves of a large retailer like Toys R Us or Target, their task is convincing these eight-hundred-pound gorillas that ethnically correct toys can make money, not that stocking their stores with a multicultural array of toys is the socially progressive thing to do. Toys R Us has been very supportive of up-and-coming manufacturers of ethnically correct toys notably Olmec and Playmates (Chin, 2001, p.161).” Signs of uncertainty in the marketing front – Some analysts wonder why it took so long for Toys R Us to jump into the e-commerce bandwagon and protect its new sales channel: online purchasing. Kalakota and The Debate, Robinson (2000) believed that Toys R Us, along with other big named entities, are not very much sold to the idea of selling online, guessing the reasons why these entities they called the ‘traditionalists’ are not willing disciples of the new form of trade which many consumer opted for because of convenience, above all the john stuart mill on liberty, other reasons. Culture Culture. The unsure stance of john stuart on liberty Toys R Us when it comes to embracing e-commerce was no doubt one of the freudian examples, reasons why its marketing aspect experienced a temporary glitch.

But Toys R Us have a reason for opting towards hard, solid traditional marketing and market strategy. “Opposing the trend and protecting the status quo are the old guard, big retailers such as Toys R Us, and manufacturers of brand names, such as Mattel, Hasbro, and Parker Brothers. The traditionalists are worried that selling to john, customers directly will wreak havoc on their finely tuned retail channels, pricing structures, and channel distribution (Kalakota and Robinson, 2000, p. 36).” The Folly of planets vs terrestrial Toys R Us – Some would say that one way of looking at Toys R Us’ problematic 1999 year ender is to consider that the problem of the company originated from the fact that it was very, very good in marketing and advertising. But of mill on liberty course, that is just one piece of the truth. They were very, very good in advertising and marketing but was at the same time very, very bad in logistics, preparation and management that the incompetency in planets, the production and management line was somewhat attributed to on liberty, the marketing and advertising teams’ strong and consistent effort. People might ask what happened and how come some fingers are pointing towards the efficiency of marketing and advertising efforts for the problem that haunted Toys R Us before, during and examples, a few months after the Christmas season. Here is a retrospective of the scenario that set off one of the most horrible moments in john stuart mill, the history of Toys R Us and the performance of its marketing, advertising and production and stock inventory teams. By 1998, e-commerce was experiencing a very good upswing when it comes to consumer dependency on online purchasing.

Among those which were sought and paid online were toys. By Christmas, the examples, peak of the toy-buying frenzy, Toys R Us, with its weaker online presence compared to its competitors, was nowhere near the top 20, let alone the top slot. Diorio (2001) reported about Toys R Us’ dismal performance online, “Online, Toys R Us got a late start into john stuart mill electronic selling. Feminism. First mover advantage went to eToys.com, which became the fifth-most-visited retail website over the 1998 Christmas season. Toysrus.com came in a dismal 33rd in the same year’s ranking and stuart, posted a $132 million net loss for the quarter (Diorio, 2001, p. 75).” Because of this humiliating experience, Toys R Us promised to return with a vengeance, and it did. Bolstered by a strong online presence the The Debate Obamacare, following year, Toys R Us is john stuart on liberty, positioned where they should have been the previous year, at the top of the list of consumers who are looking at buying their toy supplies for the season online. By the time Toys R Us knew they were top of store based and Over Essay, internet based toy selling, everyone was satisfied with the way marketing and advertising outmuscled the odds and reversed the situation at Toys R Us in less than twelve months. But the air of john stuart on liberty celebration will be short lived, because an impending tragedy is set to hit Toys R Us, impacting them with the same blow as they experience the previous year, only in a different form.

With orders coming from online purchasers for toys pouring in a fast pace, the company found out soon that it does not have enough to cater to customers. Long before Christmas, the company stopped receiving and taking online orders, and many consumers were outraged over Toys R Us, with what seemed to be a case of feminism misleading marketing and advertising campaigns by the company; for john mill the consumers, it was simple – they were made by the marketing and advertising efforts to believe at jovian vs terrestrial, something that the company cannot really deliver. “In the john mill, debacle that followed, lawsuits were filed, thousands of culture disgruntled customers were issued credits and $100 gift certificates, and the company paid a $350,000 fine to the US Federal Trade Commission to john, settle claims that it had misled customers. Hundreds of defense examples news reports disparaged the company name. While eToys also reported some inventory problems, the brand damage was far worse at Toys R Us (Diorio, 2001, p. Mill. 75).” Conclusion – Over the years of its operation, Toys R Us have learned many important lessons because of its success and failure in the marketing side of feminism operations. John Stuart Mill. Take for example the meltdown in The Debate Over Obamacare, 1999; the important marketing strategies that Toys R Us learned from that particular experience include customer care and the opting for intelligent operations for particular course of action.

“The Toys R Us experience underscores the importance of customer care in branding. No online initiative is worthwhile if a customer’s Web experience damages the reputation of the brand. In the john stuart mill on liberty, end, Toys R Us found it was best to co-brand with an experienced partner. For many traditional companies, sacrificing corporate ego – partnering to progressive president roosevelt, brand online instead of going it alone – may be the john stuart mill, better path to meditations on first philosophy, building an online reputation” (Diorio, 2001). But perhaps, the most important marketing move made by Toys R Us is stuart, reflected in the understanding of the role, significance and market power of toys in the overall economic and trade landscape, and the effort to maximize this situation by creating a marketing effort built and designed to squeeze out every ounce of juice-profit from this currently existing social scenario.

Seiter (2003) provided an insightful scenario on what circumstance exactly did Toys R Us managed to make the The Debate, most of, and stuart, using not just mere luck or happenstance but intensive marketing effort to ensure not only the sustenance of such circumstance but also the longevity of the social trend that has engulfed homes and families transcending financial, social and cultural boundaries. Toys R Us, after all, markets itself as a toy store that is not bound by financial, social and cultural limitations; everyone can find something for them and their child in the store, or so their campaign efforts consistently remind the feminism examples, public. “Each of these can be readily observed in the retailing practices and physical space of the giant of the retailing industry, Toys R Us, where licensed toys are found in the greatest abundance of the cheapest price of all toy stores. Toys R Us and the mass marketed nationally advertised goods (known in the toy industry as promotional toys) that fill its shelves offer one version of the toy culture (Seiter, 2003, p. 193).” Seiter (2003) also wrote that, “consumer goods – and, I would add, especially toys – express and negotiate generational conflicts. The balance of power has shifted, however, in the negotiation between parents and children. Mass media targeted at children have shortened the mill, period of exclusively parental influence over progressive president children. A distinctive, peer-oriented consumer culture now intervenes in the relationship of parents and children, and that intervention begins for many children as early as two years of age (Seiter, 2003, p. 193).” Simply said, social factors enhanced the pressure for john mill children to examples, demand toys from parents and for parents to yield to this need. John Mill. Toys R Us comes into roosevelt the equation by marketing itself as the john stuart mill on liberty, place wherein the negotiation between the parent and child can be settled. Everyone goes home happy.

The resulting business success of this marketing strategy makes Toys R Us the happiest of them all. Toys R Us also deserves an A for theodore their effort for supporting and selling ethnically correct toys, erasing the notion that Toys R Us is serving the needs of the exclusive toy buying white upper class American, and in stuart on liberty, the process expanding the market base via the as a president, general acceptance of individuals despite their cultural differences. Mill. What Toys R Us managed to do in this particular instance is mark a victory in the effort against marginalization, and this particular effort was realized again by the move of defense Toys R Us to recognize changing social weather climate and adjusting to these changes to allow income and growth to come in and make the changes profitable for the company. “Mattel launched its much-vaunted Shani doll in john stuart mill on liberty, 1991; during the 1992 Christmas season Toys R Us was quietly and cautiously test-marketing ethnically correct dolls in culture, Atlanta and Philadelphia. On Liberty. Toymakers who could not rely on the sell-appeal of the Barbie connection held their collective breath…All the meditations on first philosophy, major toymakers – Mattel, Hasbro, Kenner and Tyco – rushed a variety of line to market, and Toys R Us hired the Mingo Group, the nation’s largest minority-owned advertising agency, to launch a marketing campaign aimed at African American consumers (Chin, 2001, p. 161).”

Recommendation – One of the recommendations that any professional would make is for Toys R Us, despite the blunders it made in the past involving marketing, to never stop changing and adapting to stuart mill, the times. Industries are subjected to the change being imposed by the changes that happen in vs chinese culture, the different social strata like economics, technology, trade and politics. Toys R Us should not stop and stuart, ponder too much on its mistakes and instead look ahead so that no other similar bumps would be experienced in the future. Michman and Mazze (2001) explained that “niche retailers in the toy industry have acknowledged that many time-honored ways of meditations doing things are rapidly becoming obsolete. An operating reality for niche retailers has been the departure from past strategies that has been made possible new technologies.

Many formulas that were successful in the past have led to failure. Toys R Us is endeavoring to change in a volatile environment (Michman and Mazze, 2001, p. 204).” This is a good sign for Toys R Us, a company which should be given due credit for managing to surpass critical challenges that sometimes sent the marketing team to john, the ropes. Planets Planets. Yes, credit goes to them because while Toys R Us is in the business of selling play things, they also made sure that they come out ready to play, despite the changes that might have affected the company and the industry where it operates. Chin, Elizabeth M. (April 2001). Purchasing Power: Black Kids and john mill, American Consumer. Culture.

USA: University of Minnesota Press. Diorio, Stephen (November 2001). Beyond “e”: 12 Ways Technology is Transforming Sales. Marketing. Planets Vs Terrestrial Planets. McGraw-Hill Companies. Furse, Mark. (February 2007).

The Law of Merger Control in john stuart mill, the EC and the UK .UK: Hart. Herbig, Paul A. (January 2005). Handbook of Cross-Cultural Marketing . Taylor Francis, Kalakota, Ravi and Robinson, Marcia (December 2000). e-Business 2.0: Roadmap for. Melville, Ian (April 1999). President Theodore Roosevelt. Marketing in Japan . John Stuart Mill. Butterworth-Heinemann. Michman, Ronald D. and Mazze, Edward M. (February 2001).

Specialty Retailers – Marketing Triumphs and freudian defense mechanisms, Blunders . Greenwood Publishing Group, Incorporated. Seiter, Ellen. (August 2003). Sold Separately: Parents and Children in Consumer Culture . Rutgers University Press. Toys R Us (2008). Retrieved June 11, 2008, from www.toysrus.com. Wolk, Martin (March 2, 2006). Toys ‘R’ Us wins suit against Amazon.com . John Stuart Mill On Liberty. MSNBC. Retrieved June 11, 2008, from http://www.msnbc.msn.com/id/11641703/ University/College: University of California. Type of paper: Thesis/Dissertation Chapter.

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a mokingbird essay To Kill a Mockingbird and the discussion of race should present a teachable moment or moments in the classroom, resulting in a beneficial outcome for all involved and a better understanding of the issues of the past and the presence of john on liberty, those issues in the present. The first aspect that should be discussed is the title of the The Debate Essay, novel. The title is hinted at multiple times throughout the stuart on liberty, book; the first is examples, when Jem wants to take his gun outside and he is told he can shoot all of the blue jays he would. Racism, Characters, and Abuse in To Kill a Mockingbird by Harper Lee. John On Liberty. other minorities. Many African Americans made it possible for us all we have rights today for culture, those great people even though racism is mill, still alive we can still stand up for our rights like our four fathers did. The characters all have different personalities and styles they each show each other sides that they didn’t know in freudian mechanisms examples, the beginning of the book. In To Kill a Mockingbird the stuart mill, characters are: Jean Louise Finch(Scout), Atticus Finch, Jeremy Atticus Finch(Jem), Boo Radley, Bob Ewell, Charles Baker.

Essay on feminism examples, Racism in the novel, To Kill A Mockingbird, by Harper Lee. After that incident, word gets out on liberty that Tom Robinson, a Black man, raped Mayella Ewell, a white girl and it is not long before a mob is gathered together to kill Tom. Freudian Examples. One day, Atticus Finch, the defendant for the upcoming case of Tom Robinson, is protecting Tom from the john stuart mill on liberty, mob. The mob comes and looks for Tom in order to defense, kill him because they don’t think that he deserves a case. They say to Atticus, “He in stuart on liberty, there? . . . You know what we want . Over. . . Get aside from the door, Mr. Finch” (Lee 202). Atticus.

To Kill a Mockingbird Essay examples. it is a sin to kill a Mockingbird.” The symbolism of Tom Robinson as a human mockingbird illustrates how although he had not harmed anyone he fell victim to the racist nature of stuart on liberty, society. Freudian Examples. This effectively shows that despite the evidence that proved Robinson’s innocence the town held racial discrimination above justice resulting in the death of an innocent man. Through its decision the john stuart on liberty, town killed a mockingbird. Hence, through the result of the court case the repercussions of racism are presented to. A Time to Kill and to Kill a Mockingbird Essay. scenes in A Time to Kill, a soldier jumps in the path of a bullet to culture culture, protect Jake. When Jake learns this total stranger is permanently paralyzed, he is dumbfounded. John Stuart On Liberty. The basic plots of the two movies are identical: a white man commits rape but a black man ends up being prosecuted in a racially charged trial. The focus is on the defense lawyer's struggle, and the movies climax during the closing statement. Feminism. The essential difference of john on liberty, plot is feminism examples, a juxtaposition: in To Kill a Mockingbird, an innocent man. did she told him he had to read to her two hours a day for a month. Maturity was a huge part in moving on in life during these tough times.

In To Kill a Mockingbird people in the 30’s were a lot more racist compared to nowadays. Mill. People came to realize near the end of the novel that black people aren’t any different than the white. The first way racism appears is when Aunt Alexandra wanted Calpurnia to leave because she was black and she didn’t think she was needed anymore now that she was there. Essay on Innocence in to Kill a Mockingbird. a much better representation of the jovian planets vs terrestrial planets, mockingbird because he contributes to society, while Boo does not. Mill On Liberty. Both Tom Robinson and Boo Radley were persecuted by meditations philosophy descartes, the legal and social systems of Maycomb County. Boo is allowed to john stuart on liberty, go free for culture, his crimes simply because he is white, whereas Tom is convicted of a crime he never committed, raping Mayella, because he is black and is killed as a result of the colour of his skin. Additionally, the novel ends after Boo kills Bob Ewell, who is attacking Jem and. word of an stuart, African-American and jovian planets vs terrestrial planets, the fact there was no real evidence. There were several instances where a black man had been killed before he was put on trial. This type of racism occurred because the white people saw themselves as better and more civilized people The families and characters in stuart on liberty, To Kill a Mockingbird were accurately portrayed in traditional, old fashioned households in the early 1930’s. Girls were expected to act like ladies, and boys to act like gentlemen.

The traditional. Essay on Prejudice to Kill a Mockingbird. As the feminism examples, salient theme within the text, “To Kill a Mocking-bird” highlights the dire impact of radical prejudice and the disparity between members of john stuart, difference races within 1960’s America. Another aspect of prejudice which is american culture, presented within the “To Kill a Mockingbird”, is the importance of socio-economic class which connotes an individual’s standing within a community. Within the text, the town of john, Maycomb is divided into three distinct socio-economic classes from the well respected white working. Essay on The Significance of the Setting of The Debate Over Essay, To Kill a Mockingbird. Racism, a key theme in the novel is also condemned by Atticus Finch – …As you grow older, you'll see white men cheat black men every day of your life, but let me tell you something and don't you forget it—whenever a white man does that to a black man, no matter who he is, how rich he is, or how fine a family he comes from, that white man is trash”. On Liberty. It is the location of Mr. Culture Vs Chinese Culture. Deas’s outburst, the courthouse, where the theme of racism is on liberty, again emphasised, through the setting. In terms of. dog or how fearful anyone is of rabid animals.

A third example of the difficult plots in To Kill a Mockingbird is the many similar characters. Miss Maudie and Miss Caroline are both strong female figures within Scout’s life. “…, so careful were we to preserve the delicate balance of our relationship, but Jem and jovian vs terrestrial planets, Dill drove me closer to her with their behavior.” (Lee 46) This excerpt from To Kill a Mockingbird talks about how Miss Maudie is very generous to Scout and Jem yet she also has boundaries. Integrity in to Kill a Mockingbird Essay. deal of their own integrity because of him. John Mill On Liberty. Atticus’s integrity reflects onto meditations all of Maycomb county’s citizens. Today’s society can easily relate to on liberty, the pressures on feminism examples, the individual’s and john mill, community’s integrity that is found in the novel To Kill a Mockingbird. American Vs Chinese. Every day peer pressure. it turned and on liberty, moved back across Jem, walked along the The Debate Over Essay, porch and off the side of the house, returning as it had come” (Lee 53).

When meeting someone for the first time you judge them and make an opinion on them no matter what. In the novel, To Kill a Mockingbird, Boo is mistaken for someone who “dined on raw squirrels and any cats he could catch” (Lee 13). Boo wasn’t even known by those who were judging him. The children are so confused that all. Harper Lee and to Kill a Mockingbird Essay. To Kill a Mockingbird was an impressive novel that touched many people. The descriptive writing of Harper Lee leads the writer to really get the feel of the on liberty, way of life during the times of depression in american culture vs chinese, the south. Harper Lee lived part of her life in New York and other cities.

However, her southern childhood, gave her the insight to portray the john mill, racial prejudice, the impact of the defense mechanisms examples, depression, and the simple ways of southern life in her writings. Ms. Lee wrote a book that has become a classic. John On Liberty. Atticus presents a solid case that leaves virtually no room for doubt: Tom Robinson is innocent, and if he is found guilty, then it is only because of the jury’s racism. When Tom is found guilty, the outcome of the trial presents a crisis of The Debate Over Obamacare, confidence, particularly for Jem: if the law fails, then how can one have faith in justice, and if the people of Maycomb fail, then how can one have faith in the goodness of john stuart, humanity?

Although these questions are explored to some degree before the trial, they. The Mockingbirds of To Kill a Mockingbird, by examples, Harper Lee Essay. He also protects Jem and scout when they were walking home from the costume party. Furthermore, Boo also stitch’s up Jems pants when they get caught under his fence. Mrs. Dubose is also another mockingbird in the novel. She is looked upon as a bad person because she had a slight morphine addiction back in her younger years. She is slowly recovering from it, but, she is always cranky and angry whenever she does not have her morphine.

Atticus thinks that she is a brave soul for battling her addiction. an equal respect, no matter the situation. John Stuart On Liberty. Scout learns that she should love people for who they are, even if they are malevolent. “Mr. Tate was right,” Scout proclaimed. “What do you mean?” Atticus asked. The Debate Obamacare. “Well it’d be sort of like shootin’ a mockingbird, wouldn’t it?” Scout rhetorically asked (370). Scout now appreciates Boo’s well being. She figures how Boo was never a bad person just an honest man with an honest living. Her maturity level dramatically increases as she understands how people are. Stuart On Liberty. Essay To Kill a Mockingbird Part One Analysis. blue jays you want… but remember it’s a sin to kill a mockingbird”. This statement can be used as a metaphorical representation of crime in general.

He states that he’d rather people investigate the town as a whole, but in the end people will stride toward the colored people as culprits. It is fine to punish them based on if they did it, but it is wrong to punish someone who has done nothing at all. This explanation also ties in with the common racism dilemma in Maycomb as a whole. Metaphorically. Critical Lens: to Kill a Mockingbird Essay. something, she is too polite to say no. Which is why she listened to examples, Miss Caroline, and this shows how Scout is growing up, and being more responsible and listening to other people, and the ‘village’ is helping to stuart mill on liberty, raise her. Throughout To Kill a Mockingbird, we see the many different types of social classes that there are in Maycomb. The Finches are in the upper area of the social pyramid of Maycomb, with the many townspeople below them, and the not-so-well-off Ewells just above the very bottom. Essay on To Kill a Mockingbird and the Merchant of Venice.

36-37). This shows Jessica is describing her love for Lorenzo and in the end runs away from her father to be with Lorenzo. In The Merchant of Venice there are Stereotypes too but also there are some people who don’t follow them. As A Progressive President. Both To Kill a Mockingbird and The Merchant of Venice are alike in the way that they both have some stereotypes that are the same; both stories have a trial at the end that are both roughly based on stereotypes. Tom Robinson who is stuart on liberty, voted guilty although the feminism examples, evidence is. not even okay for a black person to feel something for a white person. Who are merely the stuart mill, same complete person that God created. Even though the people of Maycomb knew the Constitution??s saying that ?®all men are created equal?? the examples, prejudice and mill on liberty, racism in meditations on first philosophy descartes, them leads them to not accept it word for word. The hypocrisy of the society drives Mr. Dolphus Raymond to his pretense. Alongside his wealth, Mr.

Dolphus Raymond lives with a black woman and mill on liberty, has mixed children. Jovian Planets Vs Terrestrial Planets. Mr. Dolphus Raymond also. To Kill a Mocking Bird: Racism and Courage Essay. As you can see the children, Jem especially, are starting to take a stand against racism on their own and being very courageous along the stuart, way.

Atticus defines courage as “when you know you’re licked before you begin but you begin anyway and as a progressive theodore roosevelt, see it through no matter what. As the book goes on john stuart, the children start to realize that instead of realying on presonal prejudice or gut reaction they start to think more and more what is planets vs terrestrial, right. Their are different examples of courage in the book, but one is. Stuart Mill On Liberty. Harper Lee#x27;s To Kill a Mockingbird Essay. her novel consisted of a series of short stories strung together, and she was urged to re-write it? (Kansas). Kansas also tells us that she worked on the manuscript with the help of her editor, Tay Hohoff, and in 1960, Lippincott published To Kill a Mockingbird. According to an article in the New York Times, from May 19, 1961, titled ?Prize for Novel Elates Film Pair,? the examples, novel caught the attention of producer Alan Pakula. Author of the article, Murray Schumach said that after reading the. Racial Injustice in To Kill a Mockingbird Essay.

young white women, but consorting with black men would put them to the ultimate low. They preferred to let innocent men die rather than have their own already low reputations tarnished. This shows a clear connection between Scottsboro and To Kill a Mockingbird, as in both cases the lives of innocent men were sacrificed on the altar of southern womanhood. The Mockingbirds of To Kill a Mockingbird, by Harper Lee Essay. to walk the mill, street of feminism, Maycomb again.”(p.83) Some members of the Finch family believe that Atticus is john stuart, damaging the whole family’s reputation in planets, Maycomb through “loving” African Americans. Secondly, the African American Tom Robinson is also a “mockingbird” in the novel.

Before the story has begun, the African American is john stuart on liberty, already accused of raping a white, nineteen year old Mayella Ewell. Many townspeople of Maycomb believe that Robinson is not responsible for meditations, his crime because he is a hard-working. To Kill a Mockingbird Character Analysis Essay. events in Maycomb, Atticus teaches Jem and Scout to show respect to everyone, regardless of their appearances or odd behaviors. Besides respect, Atticus accentuates courage as a fundamental element to grow up in his parenting career. In To Kill a Mockingbird, Atticus was invited to stuart on liberty, Mrs. Dubose’s house only to acknowledge that she has passed away, free from morphine addiction “as the mountain air” (page 111). He comes home, bringing the gift of feminism examples, Mrs. Dubose for Jem and stuart mill on liberty, a message of him. As Jem opens. Literary Analysis of To Kill A Mockingbird Essay.

trial. Meditations On First Philosophy. They had started to talk about how no matter what, a white man’s voice will overpower a black man’s word. A white man’s voice will always be heard. A white man’s voice will always conquer and mill, win against meditations on first philosophy, a black man’s voice. Jem realizes that racism over rules justice in the court system.

Although everyone has different perspectives, they will always listen to the white man. He understands that really ugly truth that is held in their society. ‘ “I’d rather you shot at tin cans in the backyard. Good and Evil : to Kill a Mockingbird Essay. payback delivered by Bob Ewell in the final scenes of the novel. After the attack, Scout realizes that if society knew what Boo Radley actually did, “It’s be sort of like killing a Mockingbird,” as it would destroy Boo Radley’s innocence even if it was pure accident. Therefore, Boo Radley is defined as a “Mockingbird,” as he is misinterpreted victim of john mill on liberty, society that has only tried to help the people around him. Tom Robinson is an African American man who lives on the outskirts of Maycomb with his.

Freedom of Expression in To Kill a Mockingbird, by Harper Lee. Freudian Defense. There are many good characters in “To Kill a Mockingbird” who posses excellent character. For example, one character is Atticus Finch. “Atticus Finch is the voice of morality, compassion and fairness in the novel. These are the john stuart, principles that he consistently tries to teach his children, Scout and Jim (Harper Lee 1). This portrays that “To Kill a Mockingbird” is a good book for children to read because it teaches them character. Another character in “To Kill a Mocking Bird” who possesses good character. Harper Lee#x27;s To Kill a Mockingbird Essay. to occupy the lowest level of society in the Maycomb community.

The city’s white population continues to defense mechanisms examples, reinforce their rigid unfounded beliefs. Atticus Finch’s closing argument during the trial clearly outlines his own views on racism. John Stuart On Liberty. When the jury continues to show ignorance and The Debate Over, predjudice, Atticus realizes there is little chance of proving Tom’s innocence and winning his case. The guilty verdict directly reflects the white population’s predjudice and assumed guilt. Essay on To Kill a Mockingbird- Boo Radley and mill, His Children. understand why Boo Radley's stayed shut up in the house all this time. it's because he wants to stay inside. Seeing the feminism examples, prejudice and on liberty, racism that Tom suffered in his case makes the jovian planets vs terrestrial planets, kids understand why Boo may have wanted to stuart, decide to stay in his house all these years. The kids come to see Boo as a real person when he saves them from Bob Ewell, the man who attempts to kill the children in revenge, and not the monster he was first portrayed as. Scout then treats him as she would any neighbor would. Freudian Defense Examples. As.

Social Difference in Too Kill a Mockingbird Essay. behalf of the African American community, an stuart, act that would never be performed today. Due the fact that the storyline represents outdated statements, To Kill a Mockingbird is president theodore, clearly inappropriate for class study. Secondly, people today see social class and john, social differences in Essay, a new way that does not relate to the way it does in stuart on liberty, the book. In To Kill a Mockinbird, when Calpurnia takes the children to theodore roosevelt, church, some members were offended by the children's presence, a racist act that would not be accepted. New Perspective to john stuart mill on liberty, Study to Kill a Mockingbird Essay. Southern literary tradition(Liu Guo-zhi, Hubei university)”; analysis of figures’ characteristics, like “Reconstructing Atticus Finch (falseLube Steven)” and the pedagogical meaning studies, like “A Moral Criticism on the Growing-up Theme in To Kill A Mockingbird (RuiYuping and Fan Yi, Ningbo university)” , but no one have ever written something about the different psychological growth stages of this brother and sister. As a lover of this novel, I find it quite important to give more deep thoughts upon.

English Speech- Away and to Kill a Mockingbird Essay. went through an emotional journey overcoming the planets vs terrestrial, obstacle of john stuart mill, prejudice and learning the fact how lucky they were comparing to Tom’s family. The inner journey that demonstrated of defense examples, overcoming the barrier was also demonstrated in the film ‘To Kill a Mockingbird’. The main protagonist Scout was shown in the process of overcoming prejudice through her self-maturation and understanding. Scout and the kids were scared as Miss Stephanie the neighbour told them about the unjustified assumptions of Arthur. Psychological Analysis of Boo Radley-- to Kill a Mockingbird. Loosely translated, this means that Boo Radley is a mockingbird. He is, in general, a kindhearted compassionate person, shown by stuart mill on liberty, the gifts he gave to Jem and Scout, and how much he obviously cared for them. But he was shot down by his community because he was a little different from the progressive president, other people in society. If my theory that he’s mentally disabled is true, he has done nothing of his own consciousness to john stuart mill on liberty, hurt anyone. He was nothing if not friendly to Jem and Scout, two of the only people.

Essay about Segregation Exposed in To Kill A Mockingbird. Feminism. blacks could meet here and talk and it also brought the blacks together (“African American Daily Conditions). There was also some other activates that would bring them together, such as sports (“African American Daily Conditions). In To Kill a Mockingbird, the kids have to john stuart mill on liberty, stay with their. Essay Bravery in To Kill a Mockingbird by Harper Lee. Another act of bravery was when Atticus had been called home because of the mad dog walking around on his street. Atticus didn't want to shoot the gun to kill the stray dog. Atticus hasn't picked up a gun in years and he didn't want to use it.

Sheriff Heck Tate asked Atticus to, so Atticus took the gun and aimed at the mad dog. BANG! The mad dog was put to rest. It was times like these when I thought my father, who hated guns and had never been to any wars, was the bravest. Symbolism in To Kill a Mockingbird by Harper Lee Essay. harmless individuals, who never intend to hurt a soul.

Yet Tom's life is lost, and on first, this is like shooting a mockingbird. As Scout wisely says: to hurt Boo Radley too would be like killing a mockingbird. Thus the mockingbird has been used to symbolize the good and the harmless things in this world which should not be abused. As Mary Clare points out, the mockingbird is a symbol for mill on liberty, two of the planets, characters in the novel: Tom Robinson and Boo Radley. In the novel, the people. Innocent Victims in To Kill a Mockingbird Essay example. the rumors they heard about Boo Radley. Boo Radley can be compared to a mocking bird because mockingbirds are not guilty of any wrong doing and don’t hurt others.

That’s why Boo Radley is considered a mockingbird because he never hurt any known or bothered any one. The sad part was that Boo Radley was killed by couple of town’s people because he never came out because he was shy. Mill On Liberty. Another mockingbird in the story was Tom Robinson. Tom Robinson was just like Boo Radley nice and culture vs chinese, loving to others. The Theme of Prejudice in To Kill a Mockingbird by Harper Lee. tries to teach this ultimate moral lesson to Jem and Scout to show them that it is possible to live with conscience without losing hope or becoming cynical. In this way, Atticus is able to mill on liberty, admire Mrs. Dubose's courage even while deploring her racism. He serves as a different type of. Destabilizing Innocence: Lee Harper#x27;s To Kill A Mockingbird Essay. 273) Quite simply, he was saying that many people would look at Tom Robinson, not as a person, but as a mockingbird. They would look at him, and see all the Negro men who have hurt them, or their families, they would punish him, because of what others have done.

In the case of southern life, we look at Arthur “Boo” Radley. Due to the fact that he was different, people automatically stereotyped him. Meditations On First. They assumed that he was a troublemaker and stuart on liberty, unfit for their society. Defense Examples. They inadvertently ostracized. To Kill a Mockingbird- How Maturity Affects the Characters Essay. all that much, Dill responds maturely and says, I don't care one speck. It ain't right, somehow it ain't right to do 'Em that way. Stuart On Liberty. Hasn't anybody got any business talking' like that, it just makes me sick. (266) Dill sees Tom Robinson for the mockingbird he really is. Jem,Scout, and Dill all learn lessons that impact their life and affect their maturity. A few of these lessons are learned from the Tom Robinson case.

Learning to not judge people for what they hear, taking responsibility, To Kill a Mockingbird Provides Insight into american vs chinese culture, the Past Essay. children by stabbing Bob and carrying an john on liberty, injured Jem back to american vs chinese culture, the house, where the Sheriff in order to protect Boo says that Bob must have tripped and stabbed himself with his own knife. The portrayal of stuart mill, Racism is very accurate, at the time that the story was set there was still a lot of on first philosophy, racism in the South of Alabama. Some of the story is based in mill, truth; the rest of it is on first philosophy, all very historically accurate. The trial of Tom. The Loss of Innocence and Maturity in to Kill a Mockingbird Essay. that his hometown is john mill, not the ideal place he thought it was, where everyone is good and friendly, but instead, he learns that racism and prejudice exist.

For instance, when Jem discovers that Tom Robinson is wrongfully declared guilty for american culture vs chinese culture, raping Bob Ewell’s daughter, Mayella, he immediately comprehends the injustice that subsists in his society. He discovers the john stuart, evil of racism during and after Tom’s trial, losing his faith in The Debate Obamacare Essay, integrity. Harper Lee#x27;s To Kill a Mockingbird is Still Valuable in Modern Times. extreme racism and a completely one sided view of society. John Stuart Mill On Liberty. Lee’s use of symbolism also portrays many themes in the novel. The most prevalent example of this is Lee’s use of the mockingbird, which is described as a bird that “[doesn’t] do one thing but make music for us to enjoy”. In the novel, one of the most prevalent themes is The Debate Obamacare, racial and social injustice, which complements the previously stated idea of innocence and morality, which in turn is mill, represented by the idea of the The Debate Obamacare, mockingbird. The two. Racism and The Justice System in “A Time to Kill” Essay.

Hailey epitomizes this hatred. The casts’ realization of this hatred flows in each of the characters during the filming of mill, this movie, creating a more convincing storyline about racial injustice. It is as a progressive roosevelt, possible to say that the race issue in “A Time to john stuart, Kill” maybe legitimate exploration of as a progressive president, black/white tension (Berardinelli 1996). It’s also possible to question how much is sensationalism (Berardinelli 1996). In many courtroom drams there is much that is typically grandstanding. Essay on Writing Inspired by To Kill A Mockingbird, by Harper Lee. All this was unnecessary and useless.

That is a fact it is all useless, why didn't they just kill me on spot and call it a day, it would only be one more colored boy dead. Hearing my name made my heart drop. I walked up to the stand and told myself that even though it would do no go that I was going to tell the whole truth and stuart, nothing but the truth, that is just what I did. To say that it was easy would be a under statement, in truth it wasn't. It is a position that I would dare not put anyone. Essay about The Setting of The Debate Over Obamacare Essay, To Kill a Mockingbird by Harper Lee. The racism of stuart mill on liberty, Maycomb's white community blocks their judgement. The way Atticus's friends and family react to him defending Tom Robinson reveals the racist members of the community. 'He's ruinin' the family.' This quotation from Alexandra, Atticus's sister shows that she is planets, ashamed to have black people linked with her family. 'I guess it ain't your fault your Uncle Atticus is a nigger lover.' Alexandra does not hide her feelings about Atticus from her son. She is passing on her racism to Francis.

The Ideas of Hypocrisy, Prejudice and Dignity in Harper Lee#x27;s To Kill A Mockingbird. Aunt Alexandra of the stuart mill on liberty, news Tom Robinson has died, she is genuinely upset - 'Aunt Alexandra put her hands to her face.' This is planets, unlike the Aunt Alexandra we had seen before In Maycomb, the stuart mill on liberty, town in descartes, which Harper Lee's book 'To Kill a Mockingbird' is mill on liberty, set, hypocrisy and prejudice are prevalent in most of its citizens. Although many of the characters morals are admirable, you soon realise that what people say and what people do are not always related. Mrs Grace Merriweather. President. To Kill a Mockingbird, by john stuart on liberty, Harper Lee and A Blow, A Kiss, by Over Obamacare Essay, Tim Winton. kiss also has underlying references to alcoholism and family values and the effects alcohol has on the family unit.

The themes in Harper Lee’s novel however evolve differently, The underlying theme resides about the on liberty, inclusion of racism and prejudice within society. To kill a mocking bird delves into vs terrestrial planets, several themes including; the maturing of john stuart mill, Jem and Scout, respect for others, Acceptance of american culture vs chinese culture, people who appear strange and john mill, reclusive only freudian defense mechanisms, because they are misunderstood by the majority. Because of the length.

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cardiac case study Anesthesiology: Problem-Oriented Patient Management. CASE 15: Cardiac Tamponade. Manuel L. Fontes. Quick Links to Sections in this Chapter. Related Links in other Resources. Four days following two-vessel coronary artery bypass graft (CABG) procedure and replacement of a mitral valve, this 69-year-old woman presented with a chief complaint of shortness of john, breath, inability to lie supine, oliguria, and overt weakness.

On examination, she appeared anxious and diaphoretic with the president roosevelt, following vital signs: respiratory rate 38 breaths/minute, heart rate (HR) 120 beats/minute [normal sinus rhythm (NSR)], and systemic blood pressure 115/66 mm Hg. A pulmonary artery catheter (PAC) was placed and revealed: pulmonary artery (PA) pressures, 55/15 mm Hg; pulmonary artery occlusion pressure (PAOP), 14 mm Hg; central venous pressure (CVP), 23 mm Hg; and a cardiac output (CO) of on liberty, 2.7 L/minute. Both the prothrombin and the partial thromboplastin times were elevated. Medical Disease and Differential Diagnosis What is the differential diagnosis of low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. What is the differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by the product of stroke volume (SV) and heart rate (HR) during 1 minute (CO = HR x SV). The Debate Obamacare! Thus, a low output state can occur when SV and/or HR decrease.

Tachyarrhythmias of either ventricular or atrial origin can also cause a low output state (i.e., atrial fibrillation). To more accurately determine the john stuart mill on liberty, etiology of defense mechanisms examples, a reduced SV, it is necessary to stuart mill on liberty, explore whether there has been a change in the preload, the afterload, and/or the contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the CO. Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. The latter, however, is only seen in patients with severe ventricular dysfunction whereby the heart can no longer compensate for freudian mechanisms examples increases in afterload. John Stuart Mill On Liberty! Myocardial contractility can be compromised by either direct causes (myocardial ischemia, myocardial infarction, myocardial stunning, or myocardial hibernation) and/or by indirect causes (mechanical factors as in cardiac tamponade; pharmacologic agents; and by toxins, namely, inflammatory cytokines and planets vs terrestrial, bacterial endotoxins). A combination of hemodynamic disturbances can coexist in the same patient. For example, a patient can have both a decrease in mill on liberty contractility and a reduced preload to account for the low output state. Correcting one problem alone may not produce the defense examples, optimal hemodynamic condition.

Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. A.2. What is on liberty cardiac tamponade? Enumerate the examples, common etiologies of cardiac tamponade. Cardiac tamponade is defined as significant compression of the heart by accumulating pericardial contents. These include blood and clots (postcardiotomy, chamber perforation, dissecting aortic aneurysm, trauma, anticoagulant therapy), exudative effusions (malignant states, infective pericarditis, idiopathic pericarditis), nonexudative effusions (uremia, systemic lupus erythematous, rheumatoid arthritis, idiopathic, radiation), and air. How significant cardiac tamponade is depends on whether the definition is clinical versus physiologic.

That is, tamponade is a pathophysiologic continuum that on one extreme may be clinically insignificant whereas on another extreme presents as a life-threatening condition requiring emergent surgical attention. Clinical tamponade is frequently associated with marked increase in pericardial pressure relative to stuart on liberty, intracardiac pressures (atrial and Essay, ventricular) such that SV progressively declines resulting in stuart on liberty systemic hypotension and in cardiogenic shock. Braunwald E, Heart disease: a textbook of cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. Gabel M. Buncher CR. Cardiac tamponade: a comparison of right heart versus left heart compression. JACC 1988:12:187.

Kaplan JA, Cardiac anesthesia 3rd ed. Philadelphia: WB Saunders, 1999:847. Spodlick D. Feminism! Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.3. What is the difference between acute and delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over minutes, hours, or after a few days postoperatively. The reported incidence of stuart on liberty, acute cardiac tamponade is The Debate Over Obamacare 0.5#37; to john stuart mill, 5.8#37;.

The typical patient has significant chest tube output (more than 200 mL/hour) in the immediate postoperative period associated with or without hemodynamic signs of inadequate CO. Alternatively, the chest tubes may become clogged by blood clots impeding mediastinal drainage. Essay! Delayed tamponade has been arbitrarily defined as cardiac tamponade occurring greater than 5 to john mill, 7 days after pericardiotomy. The incidence is 0.3#37; to 2.6#37; and as a president theodore roosevelt, is often misdiagnosed because of a low index of suspicion and because the clinical signs and symptoms can be comparable to those of congestive heart failure, pulmonary embolism, and generalized fatigue (i.e., failure to thrive postoperatively). The most common culprit in delayed cardiac tamponade is john on liberty anticoagulant therapy with coumadin, heparin, and/or platelet inhibiting agents.

Effusion after cardiac surgery is common. Using echocardiography, Weitzman et al. Feminism Examples! evaluated consecutive patients postoperatively and demonstrated that 103/122 (84#37;) had pericardial effusions. Generally, effusions reach their maximum size by the tenth postoperative day and regress spontaneously thereafter. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography.

J Card Surg 1992:7:257–268. Nelson RM. Jeson CB. Smoot WM. Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510–516. Weitzman LB. Tinker WC. Mill! Kronzon I, et al.The incidence and on first, natural history of pericardial effusions after cardiac surgery: an john echocardiographic study.

Circulation 1984:69:506. A.4. How is the diagnosis of postcardiotomy cardiac tamponade made? The diagnosis of cardiac tamponade following cardiac surgery is often difficult and requires a high degree of clinical suspicion, proficient knowledge of pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and chest x-ray film. Often, the diagnosis is culture culture made in the operating room whereby evacuation of john, clot and blood from the mediastinum is associated with drastic improvement in hemodynamics. Relying on one modality alone for diagnosis can lead to inaccurate management decisions and freudian defense, increase patient morbidity. For example, the john mill, PAC is an important device for monitoring cardiac function; however, its measures can be misleading postcardiotomy unless the clinician is freudian mechanisms cognizant of such limitations.

The classical teaching of equalization of diastolic blood pressures in cardiac tamponade [central venous pressure (CVP) = pulmonary artery diastolic pressure (PAD) = pulmonary artery occlusion pressure (PAOP)] is infrequently observed postoperatively because the pericardium is left open. As such, blood or clot or both do not distribute around the heart homogeneously to produce equalization of pericardial diastolic pressures. Generally, the CVP is elevated but the john stuart, PAD and the PAOP can be normal, elevated, or, in some cases, reduced. With significant compression of the right heart, reduced blood flow to the pulmonary artery (PA) and to the left heart can yield lower pressures that would be inconsistent with classical tamponade physiology. Russo and colleagues found that only 33#37; of patients with the diagnosis of cardiac tamponade had right heart catheterization findings that reflected equalization of diastolic blood pressures. Overall, 90#37; of patients with postcardiotomy cardiac tamponade had either atypical clinical, hemodynamic, and/or echocardiographic findings. Therefore, the diagnosis of postoperative cardiac tamponade should be considered whenever hemodynamic deterioration is encountered, particularly when reduction in CO or blood pressure or both are not readily responsive to conventional management. Furthermore, in delayed tamponade the complaints tend to as a president roosevelt, be vague and less hemodynamic data is available (i.e., PAC) to allow prompt diagnosis of tamponade.

Whenever, the patient is not progressing as expected postoperatively with some signs of end-organ dysfunction [fall in urine output and or increase blood urea nitrogen (BUN) and creatinine], an echocardiogram should be obtained to rule out cardiac tamponade. Russo A. O'Connor W. John! Waxman H. Atypical presentations and freudian defense mechanisms, echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. John Stuart On Liberty! Chest 1993:104:71–78. Spodlick D. Pathophysiology of feminism examples, cardiac tamponade. Stuart! Chest 1998:113:1372–1378. A.5. What is regional cardiac tamponade? Regional cardiac tamponade occurs when one or more cardiac chambers become compressed by blood or blood clot or both compromising forward flow.

Postcardiotomy, diastolic regional collapse of the right atrium or the right ventricle is the most common echocardiographic finding in early cardiac tamponade. Postoperative right atrial hematoma often become localized to the anterior and lateral walls, whereas left atrial clots are more commonly found behind the left atrium where they become encysted in the posterior space in the oblique sinus. Defense Mechanisms! Selective hematoma compression of the right heart becomes less prominent in delayed tamponade as the john stuart mill, right heart becomes adherent or tethered to the anterior chest wall. As discussed in the previous answer, the diagnosis of tamponade is often misdiagnosed because classical features of tamponade are often absent because of as a president, uneven distribution of blood and blood clots around the john, heart. The clinical presentation may be mistaken for congestive heart failure, acute left or right ventricular infarction, septic shock, or pulmonary embolism. Chuttani K. Pandian NG. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade. Circulation 1991:83:1999–2006. Fowler NO. Gabel M. Regional cardiac tamponade: a hemodynamic study.

J Am Coll Cardiol 1987:10:164–169. Hutchins GM. Isolated right atrial tamponade caused by hematoma complicating coronary artery bypass graft surgery [Letter]. Arch Pathol Lab Med 1980:104:612–614. Jadhav P. Asirvatham S. Craven P, et al.Unusual presentation of american, late regional cardiac tamponade after aortic surgery.

Am J Cardiac Imaging 1996:10:204–206. Kochar GS. Jocab LE. Holter MN. Right atrial impression in postoperative patients: detection by transesophageal cardiography.

J Am Coll Cardiol 1990:16:511–516. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:71–78. Sandifer DP. Gonzalez JL.

Refractory postoperative hypoxemia associated with regional cardiac tamponade and patent foramen ovale. On Liberty! Crit Care Med 1997:25:1608–1611. A.6. What is feminism examples pulsus paradoxus? What is Kussmaul's sign?

Normally, there is an inspiratory fall of stuart, less than 10 mm Hg in the arterial systolic pressure and an accompanying inspiratory fall in jovian vs terrestrial planets the venous pressure. However, a paradoxical pulse differs from the normal situation in two aspects: (a) the inspiratory fall of the arterial pressure exceeds 10 mm Hg and (b) the on liberty, inspiratory venous pressure remains steady or increases (Kussmaul's sign). Echocardiographic studies of patients with cardiac tamponade by D'Cruz et al. described phasic respiratory changes whereby both left ventricular and mitral valve excursion decreased during inspiration. In contrast, right ventricular dimensions increased in association with a shifting of the interventricular septum toward the left ventricle. Of importance, pulsus paradoxus is not unique to cardiac tamponade.

The phasic respiratory changes in ventricular dimensions with exaggerated decrease in systemic systolic arterial pressure during inspiration can be present in on first a variety of clinical conditions whereby intrapleural pressure is significantly diminished. That is, the magnitude of on liberty, paradoxical pulse is directly proportional to the inspiratory decrease of left ventricular dimension, diastolic volume, and SV. This physiologic process is often present in respiratory distress, airway obstruction, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. Although a prominent feature of cardiac tamponade, pulsus paradoxus may not be present at progressive president theodore roosevelt, all in patients with chest wall trauma, neuromuscular disease, and mill on liberty, pneumothorax because they cannot produce sufficient negative intrapleural pressure during inspiration to as a president roosevelt, produce the john mill on liberty, typical changes in culture chamber dimension and fall in stuart mill on liberty left ventricular SV. Planets Vs Terrestrial! Similarly, those who are receiving positive pressure mechanical ventilation (early postoperative period) and patients with severe aortic regurgitation do not exhibit pulsus paradoxus. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on the diagnostic role of stuart on liberty, echocardiography.

J Card Surg 1992:7:257–268. Frey B. Obamacare Essay! Freezer N. Diagnostic value and pathophysiologic basis of pulsus paradoxus in mill infants and children with respiratory disease. Pediatr Pulmonol 2001:31:138–143. Jay GD. Onuma K. Davis R, et al.Analysis of physician ability in the measurement of pulsus paradoxus by sphygmomanometry. Chest 2000:118:348–352. McGregor M. Pulsus paradoxus. N Engl J Med 1979:301:480.

Tsang TS. Barnes ME. Hayes SN, et al.Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979#150;1998. Chest 1999:116:322–331. A.7. Describe ventricular interaction in cardiac tamponade.

Ventricular interaction is theodore roosevelt extremely important for maintenance of adequate cardiac performance. Under normal conditions, the average SV of the right ventricle equals the SV of the left ventricle; however, cyclical respiratory differences in left and right ventricular SV do occur. During the john, inspiratory cycle, negative intrapleural pressure is generated facilitating venous return to examples, the right heart, whereas venous return to the left heart is diminished for the following reasons: (a) lung expansion increases its reservoir for on liberty blood and (b) the Essay, increase in john right ventricular filling causes the progressive roosevelt, interventricular septum to bulge leftwardly reducing left ventricular dimension and john, altering its compliance and filling (ventricular interaction). During exhalation, the reverse process occurs. In the as a theodore, case of cardiac tamponade, ventricular interaction also involves the mill on liberty, interventricular septum but it can involve other chamber and processes depending on the etiology of the tamponade (fluid vs. clot, regional vs. Freudian Defense Mechanisms! global tamponade). Fundamentally, as intrapericardial content increases, it will reach a point whereby the parietal pericardium cannot stretch commensurate with the john stuart mill, rising pressure. Because of the fixed space within the on first, pericardium, cardiac chamber dimensions become smaller. First, the thin-walled and more compliant atriums progressively get compressed followed by the right ventricle and lastly the john stuart on liberty, left ventricle.

Overall, the planets vs terrestrial planets, physiology of ventricular interaction in clinical cardiac tamponade becomes complex as the pressure-volume relationship of mediastinal and chest structure alters with each heartbeat and from respiratory and neuroendocrine influences. Spodlick D. John On Liberty! Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.8. How is coronary blood flow affected in cardiac tamponade? In the absence of The Debate Over Obamacare, coronary artery disease, coronary blood flow is reduced in cardiac tamponade but this reduction is not sufficient to add an ischemic injury to the myocardium because there is a proportionate decrease in (a) ventricular preload (underfilled) and (b) ventricular afterload (underafterloaded). Consequently, both myocardial work and oxygen consumption are reduced. In contrast, patients with coronary artery disease may be at stuart mill on liberty, increased risk for feminism myocardial ischemia or infarction or both. Reddy PS.

Curtiss EL. Otoole JD, et al.Cardiac tamponade; hemodynamic observation in man. Circulation 1978:58:265–272. Spodlick DH. Threshold of pericardial constraint: the pericardial reserve volume and auxiliary pericardial functions.

J Am Coll Cardiol 1985:6:296–299. A.9. Mill On Liberty! What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of cardiac tamponade. Feminism Examples! These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of john mill on liberty, myocardial ischemia and pericarditis, and american culture vs chinese culture, electrical alternans ( Fig. 15.1A ). Mill! The latter is seen in patients with large effusions and culture vs chinese culture, is characterized by interbeat shifts in stuart electrical axis. This beat-to-beat alteration may be due to increased distance between the heart and on first, the chest wall resulting in a pendulum like motion of the heart. John Mill! However, it has been shown that with minimal amount of pericardial fluid removal, the president theodore, presence of electrical alternans can be abolished while the pericardial space remains enlarged. Thus, the electrocardiographic change of electrical alternans may reflect a hemodynamic pathology rather than an anatomic abnormality.

This finding, although sensitive for cardiac tamponade, is not very specific (very few patients with tamponade present with electrical alternans). Figure 15.1. Depiction of electrical alternans in a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography. Note the image of the on liberty, left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Figure 15.1. Depiction of electrical alternans in The Debate Over Essay a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography.

Note the image of the john, left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Fox JJ. McHarg JL. Gilmour RF Jr. On First! Ionic mechanism of electrical alternans. Am J Physiol Heart Circ Physiol 2002:282:H516–530.

Kosta E. Kronzon I. John On Liberty! Electrical alternans in cardiac tamponade. Echocardiography 2000:17:(6 Pt 1)575–576. Kronzon I. Cohen M. Winer H. Jovian! Contribution of john on liberty, echocardiography to the understanding of the pathophysiology of cardiac tamponade. J Am Coll Cardiol 1983:1:1180–1182. Longo MJ. Jaffe CC. Images in clinical medicine. The Debate Over! Electrical alternans. N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in cardiac tamponade?

On standard anterior-posterior chest roentgenography, the john stuart, cardiac silhouette may appear normal in size or extremely enlarged depending on the acuity and chronicity of the as a progressive, tamponade process. Normally, the pericardial fluid amounts to 15 to 25 mL. Acute tamponade physiology can arise with as little as 150 mL of effusion, whereas chronic effusions may exceed 1,000 mL before clinical signs and symptoms of cardiac tamponade manifest. On chest x-ray film, the cardiac silhouette will appear widened with or without features such as obscuring of the pulmonary vessels at the hilum and a globular or water bottle configuration of the stuart on liberty, heart. Transthoracic or transesophageal echocardiography can differentiate between cardiac dysfunction arising from direct myocardial injury versus cardiac dysfunction associated with mechanical processes.

Pericardial effusions can be readily seen and semiquantitated. Likewise, pericardial blood clots can be demonstrated to compress the respective chamber. Additional echocardiographic signs observed in tamponade include (a) diminished left ventricular dimension and examples, mitral valve excursion during inspiration, (b) shifting of the interventricular septum toward the left ventricle, (c) changes in transvalvular (mitral and aortic) flow characteristics seen by Doppler techniques, (d) diastolic posterior motion of the right ventricular wall, and (e) in some cases, a systolic notch on the right ventricular epicardium ( Fig. Mill! 15.1B and C ). Although many of the findings of progressive theodore roosevelt, both x-ray film and echocardiogram can be suggestive of cardiac tamponade, no one sign is 100#37; sensitive and specific. Braunwald E, Heart disease: a textbook of john stuart on liberty, cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1490. Kaplan JA, Cardiac anesthesia 4th ed. Meditations! Philadelphia: WB Saunders, 1999:932, 1250.

Singh SM. Wann LS. Schuchard GH, et al.Right ventricular and right atrial collapse in patients with cardiac tamponade. Circulation 1984:70:996. A.11. What is in the differential diagnosis of postcardiopulmonary bypass (post-CPB) bleeding? Significant bleeding following cardiac surgery requiring surgical exploration bring-back occurs in approximately 3#37; of john stuart on liberty, cases. Meditations Descartes! Often, the source of bleeding cannot be ascertained and its etiology is ascribed to a coagulation defect.

Procedures that require CPB are known to mill on liberty, adversely affect the hemostatic mechanisms including vascular endothelium, fibrinolytic and coagulation factors, platelet, plasminogen, and inflammatory pathways ( Fig. 15.2 ). Under normal settings, these systems (and others yet unknown) act in concert and in opposition with one another (a) to prevent bleeding by promoting clot formation at the site of endothelial injury (procoagulant effects) and examples, (b) to prevent or destroy clot formation (anticoagulant effects#151;either directly or indirectly via inhibitory mediators). Once blood elements come in contact with a nonendothelialized surface (bypass circuit), the procoagulant system becomes activated resulting in stuart mill on liberty consumption of platelets, coagulation factors, and mechanisms examples, fibrinogen. The potential for john postoperative bleeding will depend on the degree of activation and preexisting levels of the procoagulants as well as other factors such as the duration of progressive president roosevelt, CPB, systemic hypothermia, comorbid states (renal and liver insufficiency), type of surgery (reoperation, circulatory arrest, combined procedures), and john stuart, prior or current treatment with anticoagulant (platelet inhibitors, coumadin, heparin). Figure 15.2. The coagulation cascade, illustrating the coagulation factors required for The Debate Over Obamacare various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. Mill! (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Progressive Roosevelt! Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.

The coagulation cascade, illustrating the coagulation factors required for various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by stuart mill, platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. As A President Theodore Roosevelt! Philadelphia: JB Lippincott, 1987:1052, with permission.) Platelets play an important role in the coagulation process.

Once activated, they secrete several types of granules. Stuart On Liberty! Granules, containing peptides such as fibrinogen, thrombospondin, factors V and examples, VIII, and -thromboglobulin, are reduced in both number and content during CPB. John Stuart Mill! Of greater importance is the loss of several membrane glycoproteins (IIb-IIIa) that interact with fibrinogen and other cellular elements allowing for platelet conjugation and propagation of clot formation. Overall, postcardiotomy bleeding is due to (a) a qualitative and on first philosophy, a quantitative platelet defect, (b) factor deficiency, and (c) surgical bleeding. The latter can arise from either venous or arterial sources that were undetected before closure of the chest. Attentive and meticulous effort to surgical hemostasis can significantly reduce the incidence of bring-backs. Despotis GJ. Mill On Liberty! Avidan MS. Hogue CW Jr. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001:72:S1821–1831.

Harker L. Malpass TW. Branson HE. Mechanism of examples, abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood 1980:56:824. Kojima T. Gando S. Morimoto Y, et al.Systematic elucidation of effects of tranexamic acid on fibrinolysis and bleeding during and john stuart on liberty, after cardiopulmonary bypass surgery. Thromb Res 2001:104:301–307. Levy JH. Pharmacologic preservation of the hemostatic system during cardiac surgery. As A President! Ann Thorac Surg 2001:72:S1814–1820. A.12.

What is the mechanism of mill on liberty, action of low molecular weight heparin (LMWH)? LMWHs are fragments of unfractionated heparin produced by on first descartes, controlled enzymatic or chemical depolymerization processes yielding chains having molecular weight of about 5,000 daltons. The parent compound is a heterogeneous mixture of polysaccharide chains with molecular weight of 3,000 to 30,000 daltons. The mechanism of action is similar for both unfractionated heparin and john, LMWH. Feminism! Binding of the mill, pentasaccharide to antithrombin (antithrombin III) results in a conformational change in antithrombin that accelerates its interaction with thrombin and factor X (factor Xa) by 1,000-fold. Whereas unfractionated heparin causes a comparable inhibition of factor Xa as LMWH, its inhibition of thrombin is much more profound than LMWH. To inactivate thrombin, heparin has to bind to both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is required for the formation of this ternary complex. Approximately 50#37; of LMWH lack the adequate length necessary for binding antithrombin and thrombin. Furthermore, only 15#37; to 25#37; of chains of LMWH contain pentasaccharide sequences. Descartes! Therefore, LMWH has greater inhibitory effect of john stuart mill on liberty, factor Xa, whereas unfractionated heparin exerts an equipotent effect against both thrombin and factor Xa.

Lastly, both LMWH and unfractionated heparin cause release of examples, tissue factor pathway inhibitor from stuart mill on liberty vascular endothelium, which then forms a complex with and inhibits factor Xa. This complex in turn inactivates factor VIIa. Clark SC. Vitale N. Zacharias J, et al.Effect of low molecular weight heparin (fragmin) on bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762–765. Danielsson A. Raub E. Lindahl U, et al.Role of ternary complexes in which heparin binds both antithrombin and planets, proteinase, in the acceleration of the reactions between antithrombin and john mill, thrombin for factor Xa. J Biol Chem 1986:261:1546–1573. Gohlke-Barwolf C. Anticoagulation in valvar heart disease: new aspects and management during non-cardiac surgery.

Heart 2000:84:567–572. Harenberg J. Pharmacology of low molecular weight heparins. Semin Thomb Hemost 1990:16:12–18. Kondo NI. Maddi R. American Culture Culture! Ewenstein BM, et al.Anticoagulation and john mill, hemostasis in The Debate Essay cardiac surgical patients.

J Card Surg 1994:9:443–461. Weitz JI. Drug therapy: low molecular weight heparins. N Engl J Med 1997:337:688–698. A.13. Describe the advantages of LMWH over standard heparin therapy. There are several clinical and pharmacologic advantages of stuart mill on liberty, LMWH over The Debate unfractionated heparin.

The plasma half-life of LMWH is two to four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by the liver and the kidneys. A significant amount of unfractionated heparin is mill bound to The Debate Obamacare, plasma proteins, vascular endothelium, and macrophages resulting in less bioavailability and an unpredictable anticoagulant effect. Consequently, careful laboratory monitoring is required. Additional benefits of LMWH over unfractionated heparin include less bleeding (less platelet inhibition and less propensity for increasing microvascular permeability). Several clinical trials have demonstrated both improved efficacy and safety of LMWH over john mill on liberty unfractionated heparin.

Of note, LMWH is not recommended in the setting of renal failure, and its anticoagulant activity may be measured by assaying factor Xa levels. There are, however, many different types of LMWH available in the market, each having slightly different pharmacologic effects (bioavailability, anticoagulant effect). Lastly, our understanding of the anticoagulant mechanism of LMWH continues to evolve, and, although its indications continue to broaden, there may be safety concerns that ought not to be dismissed. Alban S. Gastpar R. Plasma levels of total and free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Thromb Haemost 2001:85:824–829.

Cohen AT. Bailey CS. Alikhan R, et al.Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty#151;a meta-analysis. Thromb Haemost 2001:85:940–941. Huse DM. Cummins G. Taylor DC, et al.Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation. Am J Managed Care 2002:8:(1Suppl)S10–16. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins [Review]. Emerg Med Clin North Am 2001:19:1025–1049. A.14.

What is heparin-induced thrombocytopenia (HIT)? How is the diagnosis made? HIT is a serious complication of feminism examples, heparin therapy that is predominantly immunemediated by a binary complex of heparin and john, platelet factor 4 (PF4). On First! The reaction is commonly caused by an immunoglobulin (IgG) antibody that binds and activates platelets in the presence of heparin. Other immunoglobulins may also potentiate HIT. HIT exists in two forms. A benign form of HIT, type 1, is observed in approximately 10#37; to 20#37; of john stuart, patients receiving unfractionated heparin. This mild form of thrombocytopenia (rarely less than 100 x 10 3 / L) occurs after 1 to 4 days of therapy and generally improves despite continuing heparin administration.

In contrast, type II HIT is a life-threatening condition that develops 5 to 10 days after initiating heparin therapy and is associated with devastating thromboembolic processes (most commonly arterial thrombosis resulting in limb ischemia, cerebrovascular events, and myocardial infarction). The platelet count falls to less than 50 x 10 3 / L and in severe cases to less than 5 x 10 3 / L. Planets Vs Terrestrial! The incidence of HIT in john mill patients receiving full-dose heparin ranges between 0#37; to 30#37;. Although there is president theodore no randomized prospective study looking at the true incidence of HIT, the expected incidence is estimated to be less than 5#37;. Those patients who have had a previous exposure to on liberty, heparin (recent and in some cases remote history) may develop HIT earlier after institution of heparin therapy as compared with those with no previous exposure. The frequency of HIT is also higher in patients receiving porcine mucosal heparin compared with bovine lung heparin. The diagnosis of freudian mechanisms examples, HIT should be entertained in stuart mill any patient with a significant fall in platelet count while on progressive president theodore heparin therapy (less than 150 x 10 3 / L or a 50#37; or greater decrease in platelet count after 5 days of john stuart mill, therapy). The definitive diagnosis requires the following steps: (a) thrombocytopenia while on heparin, (b) exclusion of other etiology of thrombocytopenia, (c) improvement in platelet count following cessation of jovian planets, heparin therapy, and (d) presence of heparin-dependent platelet antibody by an in vitro test.

In most cases, the diagnosis is made on clinical findings. Gerotziafas GT. Elalamy I. John! Lecrubier C, et al.The role of platelet factor 4 in platelet aggregation induced by the antibodies implicated in heparin-induced thrombocytopenia. Blood Coag Fibrinolysis 2001:12:511–520. Robitaille D. Carrier M. Over Essay! Cartier R, et al.Successful management strategy for mechanical assistance and heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Shea SI.

Sands JJ. Nudo SA, et al.Frequency of anti-heparin-platelet factor 4 antibodies in john stuart hemodialysis patients and correlation with recurrent vascular access thrombosis. Am J Hematol 2002:69:72–73. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. As A Roosevelt! Ann Thorac Surg 2001:72:1730–1732. A.15.

What is the mill, therapy for HIT? Because HIT type II is a potentially lethal condition, the most effective therapy is discontinuation of heparin. The thrombocytopenia should improve progressively. Although tempting, the feminism examples, need for platelet transfusion is mill discouraged because bleeding occurs infrequently and vascular thrombosis may be potentiated. Several agents have been recommended for use in examples HIT. These include direct thrombin inhibitors (hirudin, argatroban), LMWH, LMW heparinoid, ancrod, and antiplatelet agents. Most of these agents are not available in the United States for use; others are under clinical investigation. John Mill! Hirudin has been extensively used in Europe with demonstrable benefit and safety. The LMWH have been shown to have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and should not be used in the setting of HIT unless there are demonstrable negative cross reactivity assays with standard heparin.

The ancrod is a defibrinogenating agent (not available in the United States) extracted from the mechanisms examples, Malayan pit viper and is immunologically distinct from heparin. John Stuart Mill! It acts by cleaving fibrinopeptide A from fibrinogen and its activity can be measured by assaying for american culture vs chinese culture plasma fibrinogen concentration. Lastly, in the setting of stuart mill on liberty, HIT, a synthetic analogue of prostacyclin (iloprost#151;a potent inhibitor of platelet activation) has been used successfully during cardiac surgery to prevent further reduction of platelet count. Cheng-Lai A. Cardiovascular drug highlight: hirudin. Heart Dis J Cardiovasc Med 1999:1:41–49. Deitcher SR. Meditations Philosophy Descartes! Carman TL. John Stuart! Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

Vasc Med 2001:6:113–119. Gill J. Theodore Roosevelt! Kovacs MJ. Successful use of danaparoid in treatment of heparin-induced thrombocytopenia during twin pregnancy. Obstet Gynecol 1997:90:(4 Pt 2)648–650. Koster A. Meyer O. Fischer T, et al.One-year experience with the platelet glycoprotein IIb/IIIa antagonist tirofiban and heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II.

J Thorac Cardiovasc Surg 2001:122:1254–1255. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for on liberty mechanical assistance and heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:1730–1732. A.16. Can HIT be caused by LMWH?

Based on Obamacare confirmed laboratory tests, the prevalence of stuart on liberty, HIT is 2#37; for patients receiving unfractionated heparin. Although the incidence of HIT is examples infrequent in the setting of LMWH, it is not zero and avoidance of the latter is recommended for patients demonstrating signs of HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Haematologica 2000:85:72–81. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:1025–1049. Warkentin TE. Sheppard JA. Horsewood P, et al.Impact of the patient population on the risk for john mill on liberty heparin-induced thrombocytopenia. Blood 2000:96:1703–1708.

A.17. What is the mechanism of heparin antagonism by protamine? Heparin is a large glycosaminoglycan molecule consisting of chains of alternating residues of D -glucosamine and uronic acid. It is highly negatively charged, whereas protamine is mostly positively charged. The two combine irreversibly to theodore, form a heparin-protamine complex that does not have the mill on liberty, ability to bind to thrombin or factor Xa. Once neutralized, the complex of heparin and protamine is eliminated. Kimmel SE. Sekeres M. Berlin JA, et al.Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:1402–1408.

A.18. What is heparin rebound? The ACT is Obamacare Essay used to confirm adequacy of heparin neutralization by protamine. The concept of john stuart mill on liberty, heparin rebound and coagulopathy following protamine reversal may occur as follows: first, heparin that is sequestered in jovian planets tissues that are poorly perfused (i.e., fat) may not undergo neutralization by protamine and second, the half-life of heparin is longer than that of john stuart mill, protamine (45 minutes) such that as heparin is mobilized back into circulation it can inhibit thrombin formation and predispose post-CPB bleeding. Studies in which 1 mg of feminism, protamine is given per john mill, 100 units of heparin (total dose) found no evidence of heparin rebound. Thus, bleeding in the postoperative cardiac surgical patient is unlikely to be from heparin rebound. Heller EL. The Debate Obamacare Essay! Paul L. Anticoagulation management in a patient with an acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245–248.

Subramaniam P. Skillington P. Tatoulis J. Heparin-rebound in the early postoperative phase following cardiopulmonary bypass. Austr N Z J Surg 1995:65:331–333. Woodman RC. Harker LA. Mill On Liberty! Bleeding complications associated with cardiopulmonary bypass. Blood 1990:76:1680. A.19. How does coumadin affect the coagulation system? What is the therapy for reversing its effect? Coumadin remains the most commonly used anticoagulant agent in the outpatient setting (atrial fibrillation, prosthetic valves and devices).

Its predominant pharmacodynamic effect is inhibition of synthesis of vitamin K-dependent factors (II, VII, IX, and X) in the liver and its clinical efficacy is monitored by measuring the PT or more specifically the international normalized ratio (INR). The safe or efficacy levels of either INR or PT is variable due to on first, multiple factors, including hepatic, nutritional, drug interaction, age, and presence of stuart mill on liberty, other comorbid conditions. Culture Vs Chinese! On average, it takes several days of therapy to john stuart on liberty, achieve the desired INR (2 to 4); consequently, administration of either LMWH or unfractionated heparin may be necessary for american culture vs chinese initiating anticoagulation. Complications occur either because of inadequate anticoagulation (thrombosis) or because of excessive anticoagulation (bleeding and hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to allow levels of the mill, aforementioned factors to normalize. Acute reversal is achieved with FFP. American Culture! Administration of vitamin K is often necessary to accelerate the john stuart mill, synthetic process. Erban S. Initiation of mechanisms examples, warfarin therapy: recommendations and clinical pearls. J Thromb Thrombolysis 1999:7:145–148. Henderson MC.

White RH. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365–370. Horton JD. Bushwick BM. Warfarin therapy: evolving strategies in john anticoagulation. Meditations! Am Fam Physician 2002:65:172. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. Stuart On Liberty! Sem Thromb Hemost 1999:25:13–16. A.20.

What do the jovian planets vs terrestrial, following measure: prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, activated clotting time (ACT), bleeding time? PT measures the activity of the extrinsic pathway: factors I (fibrinogen), II (prothrombin), V, VII, and X ( Fig. 15.2 ). Deficiencies of factors V, VII, and X (50#37; of normal) significantly prolong the PT. Much lower concentrations of fibrinogen and stuart, prothrombin are required to prolong the PT. Activities of three of the four vitamin K-dependent factors (II, VII, IX, and X) are measured by the PT. Normal values are less than 12 seconds. Activated Partial Thromboplastin Time.

Activated partial thromboplastin time (aPTT) measures the activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and fibrinogen ( Fig. 15.2 ). The aPTT is prolonged by concentrations of less than 20#37; to 30#37; of examples, these factors. Normal values are 25 to 40 seconds. Thrombin time measures the conversion of fibrinogen to fibrin by thrombin#151;the final step in the coagulation cascade ( Fig. 15.2 ). The thrombin time is decreased in the presence of low concentrations of fibrinogen and thrombin. Heparin prolongs the thrombin time, whereas coumadin has little effect. Normal values are less than 10 seconds. Activated Clotting Time.

ACT measures the on liberty, general function of the coagulation system. It is used primarily to measure the progressive president, adequacy of heparinization during CPB and protamine reversal of heparin following CPB. Prolonged ACTs may be due to heparin, low levels of coagulation factors, or thrombocytopenia. John Stuart Mill On Liberty! It is, however, not particularly specific for platelet or factor deficiencies. Normal values are 110 to 140 seconds. Bleeding time measures platelet activity, including both platelet number and jovian planets vs terrestrial, aggregation.

The bleeding time becomes prolonged with platelet counts less than 50 x 10 3 / L and in the presence of inhibitors of platelet aggregation such as aspirin. Normal values are less than 5 minutes. The bleeding time has not been shown to be predictive of postoperative bleeding and is no longer performed routinely preoperatively. Barash PG, Cullen BF, Stoelting RK, Clinical anesthesia 4th ed. John Mill On Liberty! Philadelphia: Lippincott, Williams Wilkins, 2001:219–224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of examples, internal medicine 15th ed.

New York: McGraw Hill, 2001:354–358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and john, thrombosis: basic principles and meditations philosophy, clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1048. A.21. On Liberty! How is the anticoagulant effect of LMWH monitored? There is no evidence that monitoring the dose improves the clinical efficacy. In contrast, any overdose increases the risk of hemorrhage. Because the kidneys play a significant role in the elimination of LMWH, therapeutic use of these agents should be monitored with an antifactor Xa assay, especially in patients who have renal insufficiency, are elderly, and have clinical conditions that increase the risk of bleeding. Boneu B. de Moerloose P. Culture! How and when to monitor a patient treated with low molecular weight heparin. Sem Thromb Hemost 2001:27:519–522.

A.22. What is a thromboelastograph? What is a Sonoclot? The thromboelastograph is an instrument that measures the stuart mill on liberty, development of blood clot viscoelastic strength over time. A rotating piston is suspended in a cuvette filled with heated blood. As clot formation proceeds, the rotation of the piston is affected and characteristic curves are generated ( Fig. Examples! 15.3 ). John On Liberty! The etiology of as a progressive theodore roosevelt, a coagulopathy may be obtained by analyzing these curves ( Fig. 15.4 ). John Stuart Mill! The Sonoclot similarly measures the development of clot viscoelastic strength. The Sonoclot piston moves vertically and measures the impedance to vibration at the tip of the probe. Sonoclot tracings obtained from platelet-rich plasma and platelet-poor plasma are shown in the Fig.

15.5 . Figure 15.3. Production of feminism examples, normal thromboelastogram and measured parameters. R, reaction time, 7 to 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.3. Production of normal thromboelastogram and measured parameters.

R, reaction time, 7 to john, 14 minutes; K value, 3 to jovian vs terrestrial, 7 minutes; , clot formation rate, 40 degrees to 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Stuart On Liberty! Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and feminism, platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of stuart, clot formation: a new test of platelet function.

Ann Clin Lab Sci 1983;13:115, with permission.) Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function. Ann Clin Lab Sci 1983;13:115, with permission.) Avidan MS. Da Fonseca J. Parmar K, et al.The effects of aprotinin on thromboelastography with three different activators. Anesthesiology 2001:95:1169–1174.

Ellison N, Jobes DR, Effective hemostasis in the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Belisle S. Contant C, et al.Reproducibility and interchangeability of the thromboelastograph, Sonoclot and Hemochron activated coagulation time in cardiac surgery. Meditations Philosophy! Can J Anaesth 2001:48:902–910. Koster A. Mill On Liberty! Hansen R. Schulz J, et al.Assessment of the The Debate Over Obamacare, resonance thromboelastograph CS-3 for john stuart mill on liberty differentiation of coagulation disorders: a pilot in vitro investigation of simulated post-cardiopulmonary bypass coagulopathies. J Extra Corp Technol 2001:33:159–166. Koster A. Kukucka M. Fischer T, et al.Evaluation of post-cardiopulmonary bypass coagulation disorders by differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. J Extra Corp Technol 2001:33:153–158. Saleem A. Blifeld C. Saleh SA, et al.Viscoelastic measurement of clot formation: a new test of platelet function. Ann Clin Sci 1983:13:115. Vig S. Freudian Defense Examples! Chitolie A. John Mill On Liberty! Bevan DH, et al.Thromboelastography: a reliable test?.

Blood Coag Fibrinolysis 2001:12:555–561. Vorweg M. President Theodore Roosevelt! Hartmann B. Knuttgen D, et al.Management of fulminant fibrinolysis during abdominal aortic surgery. J Cardiothorac Vasc Anesth 2001:15:764–767. A.23. How does desmopressin aid hemostasis? Desmopressin [1-deamino-8- D -arginine vasopressin (DDAVP)] increases von Willebrand's factor and factor VII activity in plasma. Stuart Mill On Liberty! von Willebrand's factor, which binds to platelets, is vs chinese found in subendothelial tissue and is in part responsible for platelet adhesion to damaged blood vessels. Mill On Liberty! DDAVP was initially shown to jovian planets, significantly decrease postoperative bleeding. Dobkowski WB. John Stuart! Murkin JM.

A risk-benefit assessment of aprotinin in cardiac surgical procedures. Drug Safety 1998:18:21–41. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients. J Card Surg 1994:9:443–461. Serradeil-Le Gal C. Nonpeptide antagonists for Obamacare Essay vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist.

Adv Exp Med Biol 1998:449:427–438. A.24. What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Plasmin, derived from plasminogen, is the enzyme involved in john mill on liberty this process. Physiologic fibrinolysis involves clot remodeling and removal during the healing process. Pathologic fibrinolysis occurs when fibrin in a thrombus is broken down before healing. Feminism! Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. In cardiac surgery, fibrinolysis is a rare cause of postoperative bleeding.

Hackman T. Gascoyne CD. Naiman SC, et al.A trial of desmopressin to reduce blood loss in uncomplicated cardiac surgery. Stuart Mill On Liberty! N Engl J Med 1989:321:1437. Salzman EW. Weinstein MJ. Weintraub RM, et al.Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. N Engl J Med 1986:314:1402. A.25. What is aminocaproic acid?

Aminocaproic acid (Amicar) is an Obamacare Essay analogue of lysine. Its primary mechanism of action is john stuart on liberty inhibition of plasmin, resulting in less breakdown of examples, fibrinogen, fibrin (fibrinolysis), and other clotting components. Stuart Mill! Aminocaproic acid has been effective in treating coagulopathy in the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and descartes, neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to john mill on liberty, reduce blood loss by 30#37; to planets, 49#37; as well as reduce homologous blood transfusion. When compared with aprotinin, in high-risk patients, high dose-Amicar has also been shown to have favorable results related to reduction of blood loss and transfusion requirement.

Considering the low cost associated with aminocaproic acid therapy (less than $12), many cardiac surgical centers use this agent routinely for uncomplicated open-heart procedures. The standard intravenous preparation and dosage for cardiac surgery include 5 to 10 g of aminocaproic acid diluted and infused over 1 hour, followed by a continuous infusion at a rate of 1 g per hour. John Stuart Mill On Liberty! Higher infusion rates may be used. There are several adverse events that include thrombosis (early graft closure, myocardial ischemia and infarction), agranulocytosis, leukopenia, and thrombocytopenia. Vs Terrestrial Planets! Although rare, bradycardia and mild reduction in blood pressure have also been reported. Levi M. Cromheecke ME. de Jonge E, et al.Pharmacological strategies to decrease excessive blood loss in mill on liberty cardiac surgery: a meta-analysis of examples, clinically relevant endpoints. Lancet 1999:354:1940–1947. A.26. What is aprotinin? Aprotinin is a complex polypeptide molecule belonging to the family of serine protease inhibitors that is john extracted from bovine lung. After intravenous administration, aprotinin undergoes rapid total extravascular distribution with a plasma half-life of approximately 150 minutes.

It is filtered by the glomeruli and reabsorbed by the proximal tubules. The terminal half-life is approximately 10 hours. The basis for its efficacy is not fully understood but consists of a complex activation-interaction of the following systems: kallikrein resulting in kinin generation, complement and defense mechanisms, inflammatory pathways, coagulation (intrinsic and extrinsic), fibrinolytic, angiotensin, and john mill on liberty, others not yet determined ( Fig. 15.6 ). Initial contact between blood elements and the nonendothelialized surface of the Essay, CPB circuit promote contact activation of both humoral and cellular inflammatory processes. Stuart On Liberty! The coagulation system may be the first to be activated by contact generating factor XIIa from factor XII, which then interacts with prekallikrein and high molecular weight kininogen (HMWK) to form kallikrein as well as promote the activation of the other coagulation factors. Once activated, kallikrein functions to stimulate and vs chinese, accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in turn, also interacts with fibrinogen to produce plasmin ( Fig. 15.7 ). Figure 15.6. John! Contact activation and the role of the feminism examples, kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at john mill on liberty, http://www.trasylol.com/slides.htm with permission.) Figure 15.7. Roosevelt! Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. Stuart Mill On Liberty! C1, complement; HMW, high molecular weight. (From slide set no. Jovian! 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.)

Figure 15.7. Involvement of the various components of on liberty, coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.) Aprotinin has been shown to markedly reduce the aforementioned humoral processes thereby mitigating the coagulopathy associated with CPB-related procedures. Feminism Examples! In addition, aprotinin may reduce blood loss by preserving platelet function.

The mechanism of stuart on liberty, this relates to preservation of platelet surface glycoproteins (IIb/IIIa), which is feminism necessary for platelet-fibrinogen interaction and clot formation. The inflammatory properties of aprotinin (both cellular and humoral) have been shown in animal and in some human studies; however, clinical outcome trials addressing this effect have not been conducted. In contrast, clinical trials comparing Aprotinin to placebo and/or to Amicar have consistently shown greater efficacy related to reduction in blood loss and john stuart, transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and renal dysfunction, have since been dismissed. The infarction rate and the incidence of renal dysfunction are comparable to as a theodore roosevelt, those of placebo ( Table 15.1 ). Aprotinin does compete with creatinine for john stuart on liberty excretion and, in some patients, there may be a mild increase in planets planets serum creatinine. Rarely, if aprotinin is used in patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of john stuart, heparin. Another important aspect of aprotinin use is the type of reagent used to monitor adequacy of Over Obamacare Essay, heparinization (ACT). Stuart! Kaolin is the recommended agent to be used to assess ACT when aprotinin is used (greater than 480 seconds). If Celite is used, the ACT value should be more than 750 seconds before initiation of CPB. Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of Obamacare, heparin must be given.

Because it is a serine protease inhibitor, it interacts with antithrombin III to inhibit the action of all intrinsic and common pathway factors resulting in prolongation of measures of stuart on liberty, coagulation such as ACT. Aprotinin has a very good safety profile but serious anaphylaxis or shock can occur. This risk is feminism increased in stuart mill patients who are reexposed to aprotinin within 6 weeks. Most of the freudian mechanisms examples, cases reported occurred within 200 days of john stuart, exposure. Over Obamacare Essay! It is recommended that a test dose of 1 mL be given when it is possible to on liberty, emergently perform cannulation for defense mechanisms examples instituting bypass. Whether use of histamine antagonists or steroid lessens the incidence is not known.

The following dosing regimen is suggested: 1 mL [10,000 kallikrein inactivator units (KIU)] test dose is administered intravenously at least 10 minutes before the loading dose, followed by close observation for signs of an allergic reaction. A loading dose of 2 million KIU should then be given over 20 to 30 minutes. An additional 2 million KIU dose is added to stuart mill on liberty, the priming solution. The maintenance dose is a constant infusion of 500,000 KIU/hour for the duration of surgery. It may be beneficial and cost effective to continue the infusion of the remaining amount of the drug while the patient is transferred and The Debate Over, recovering in the ICU. A half-dose regimen has been proposed and entails reducing the previously mentioned recommendation in half. Cosgrove DM III. Heric B. Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:1031–1038. Dobkowski WB.

Murkin JM. A risk-benefit assessment of aprotinin in mill cardiac surgical procedures. Drug Safety 1998:18:21–41. Fujii S, Kinins V, Part B. Advances in experimental medicine and biology vol 247B: New York: Plenum Press, 1989:35–42. Hoffmann H. Progressive President Theodore Roosevelt! Siebeck M. Thetter O, et al.Aprotinin concentrations effective for the inhibition of tissue kallikrein and plasma kallikrein in vitro and in vivo. Abe K, Moriya H, Landis RC, et al., The antithrombotic and antiinflammatory mechanisms of action of aprotinin. John On Liberty! Ann Thorac Surg 2001:72:2169–2175. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S1838–1844.

Orchard MA. Goodchild CS. Prentice CRM, et al.Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993:85:533–541. Peters DC. The Debate Over! Noble S. Aprotinin: an update of its pharmacology and therapeutic use in open-heart surgery and stuart, coronary artery bypass surgery. Drugs 1999:57:233–260.

Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Pharmacology of freudian mechanisms examples, SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427–438. Wahba A. Black G. Koksch M, et al.Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844–848. B. Preoperative Evaluation and Preparation. B.1. Stuart Mill On Liberty! Interpret the hemodynamic findings of this patient. The patient has an adequate blood pressure; however, this appears to be maintained via compensatory mechanism including increase in both arterial resistance [systemic vascular resistance (SVR)] and HR. The PA systolic pressure is consistent with pulmonary hypertension arising most likely from chronic mitral valvular disease (either stenosis or insufficiency). Both the PAD and the PAOP suggest that the left ventricular end diastolic pressure#151;a correlate of freudian defense, left ventricular preload#151;is within the normal limits.

Pressure measurements are more representative of the ventricle's state of compliance than the ventricle's volume status. Thus, a PAOP of 14 mm Hg could represent hypovolemia, normovolemia, or hypervolemia depending on the compliance of the left ventricle. A CVP of 23 torr is suggestive of right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and on liberty, compression of the right atrium. The CO is inadequate. The derived SV of 22 mL (CO/HR), combined with the other derangements (elevated CVP and PAOP of 14 mm Hg), strongly reflect right heart dysfunction. Taking into consideration the patient's overall presentation (physical examination and laboratory findings), the differential diagnosis includes right ventricular ischemia and or infarction, pulmonary embolism, atrial or ventricular septal defect (most likely left-to-right), and cardiac tamponade. An echocardiogram should be performed to assist in the diagnostic process and Obamacare Essay, clinical management. Fontes ML. Bellows W. Ngo L et al. and stuart on liberty, McSPI Research Group.

Assessment of ventricular function in vs chinese critically ill patients: limitations of pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:1–8. B.2. How would you treat the low output status of this patient? Although the HR is elevated, it may be unwise to attempt to john mill on liberty, normalize it before correcting the SV. The latter is a function of the preload, the jovian planets, afterload, and the contractile status of the myocardium. Whereas the john mill on liberty, preload of the right heart may be excessive (CVP = 23 mm Hg), the preload of the left heart may not be adequate despite a PAOP of 14 mm Hg.

While waiting for the echocardiogram to be performed, a fluid bolus can be attempted. If there is examples a positive response (i.e., the blood pressure and or the CO increase), additional fluid bolus can be administered until the limit of the preload reserve has been reached (operating on the flat end portion of the Frank Starling's curve). In the setting of right ventricular failure, it is customary to fluid load the patient maintaining the CVP in the 20s. John Stuart On Liberty! It is The Debate Obamacare important to stuart on liberty, note that fluid challenge alone will not improve cardiac performance without addressing the contractility and the afterload that, in this patient, appear to meditations, be deranged. Because there is no knowledge of the exact etiology of the low output state, it would be rational to institute inotropic support (initially, the choice of the inotrope is not that important despite the tachycardia). With regard to the afterload, both systemic and pulmonary afterloads are elevated. On the right side, PA hypertension can be improved with the nitrossovasodilators (nitroglycerin or nitroprusside) but the associated systemic hypotension would prohibit their use. In fact, most vasodilators with the exception of nitric oxide would compromise the systemic pressures. Alternatively, an inotrope that has vasodilatory properties (phosphodiesterase inhibitors#151;milrinone or amrinone#151;or dobutamine) would be better choices. The SVR is a derived number (mean arterial pressure minus CVP divided by the CO and multiplied by a factor of 80). It is important to john, identify and theodore roosevelt, treat the cause of the altered CO (i.e., change in HR or SV) and not to react to changes in john stuart SVR.

For example, if the CO is culture low because of a rhythm issue or a reduced preload, it would be inappropriate to administer a vasodilator to correct the high SVR. In summary, a rational management of the hemodynamic findings presented would include administering fluid (crystalloid or blood products as indicated), giving inotropic support, obtaining an echocardiogram, and addressing the other systemic complications (pulmonary, renal, and coagulation). Fontes ML. John Stuart Mill On Liberty! Hines RL. The Debate Obamacare! Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. John Mill! Philadelphia: Grune Stratton, 1999:1155–1191. B.3. How would you evaluate this patient's coagulation status? A complete blood cell count and a complete coagulation panel should be performed.

Assuming that both the hematocrit and the platelet function are adequate, attention should be directed to american culture, the elevated PT and mill, the aPTT. The most obvious etiology for the existing coagulopathy is anticoagulation therapy. The patient has a prosthetic valve and it would be appropriate to surmise that she has been taking anticoagulants. The most common agent to be used 4 days after surgery is warfarin (coumadin). Philosophy Descartes! This agent affects the vitamin-K dependent factors (II, VII, IX, and stuart mill on liberty, X) whose synthesis occurs in Obamacare Essay the liver. Measuring the PT and john stuart mill, or the INR assesses the status of its anticoagulant effect. Why is the aPTT also elevated? This coagulation measure reflects the function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and fibrinogen. It can also be surmised that the elevated aPTT is meditations due to anticoagulant therapy (e.g., excessive coumadin therapy, use of unfractionated heparin, or a combination of john on liberty, treatment with heparin and coumadin). Feminism! The latter approach is standard practice in mill cardiac surgery for patients requiring prolonged anticoagulation (i.e., valvular replacement) and meditations on first philosophy descartes, can account for john mill elevations of both the culture vs chinese culture, PT and the aPTT.

Other etiologies to consider include liver disorder, sepsis, and other hematologic dysfunction. Boneu B. de Moerloose P. Stuart Mill! How and when to monitor a patient treated with low molecular weight heparin. Semin Thromb Hemost 2001:27:519–522. Ellison N, Jobes DR, Effective hemostasis in The Debate Essay cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. John! Semin Thromb Hemost 1999:25:13–16. B.4.

What do fresh frozen plasma (FFP) and cryoprecipitate contain? FFP contains the culture vs chinese culture, labile factors V and VIII as well as the stable coagulation factors (II, VII, IX, X, XI). In addition, FFP contains other plasma proteins and lipids normally found in human plasma. John Stuart Mill! Cryoprecipitate is derived by thawing FFP at feminism examples, 4°C. Stuart On Liberty! It contains factor VIII, von Willebrand's factor, and fibrinogen. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1988:69. Levy JH. Montes F. Szlam F, et al.The in on first philosophy descartes vitro effects of antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg 2000:90:1076–1079. Nuttall GA. Oliver WC.

Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Stuart Mill! Anesthesiology 2001:94:773–781. , discussion 5A#150;6A. B.5. As A Theodore Roosevelt! What are the indications for transfusing FFP, platelet concentrate, and cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at least 20#37; to 30#37; of john mill, normal and when fibrinogen levels are greater than 75 mg/dL. Examples! Although laboratory values such as PT and partial thromboplastin time (PTT) may be abnormal, The American Society of Anesthesiologist Task Force on Blood Component Therapy discourages conventional use of john, FFP for freudian defense mechanisms perioperative treatment of bleeding because there are few clinical circumstances whereby coagulopathy arises from factor deficiency. John Stuart Mill! Whereas massive blood replacement can produce prolongation of PT and/or PTT, the task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the patient's blood volume has been replaced.

It supports the planets vs terrestrial, use of FFP in patients having vascular bleeding with PT and PTT values greater than 1.5 times the laboratory's normal value. On Liberty! FFP should be administrated in doses calculated to achieve a minimum of 30#37; of plasma factor concentration (i.e., 10 to 15 mL/kg of FFP). Recommended indications for FFP: Replacement of factor deficiencies. Reversal of coumadin effect. Massive blood transfusions. Treatment of antithrombin III deficiency in patients who are heparin resistant requiring systemic anticoagulation with heparin. In 1994 the College of American Pathologists recommended platelet transfusions after CPB in freudian defense examples patients with normal coagulation values and stuart on liberty, platelet count below 100,000/ L when major unexplained bleeding occurs.

Transfusion of one platelet concentrate will increase the platelet count by approximately 5 to 10 x 10 3 / L in meditations philosophy descartes the average adult. The usual therapeutic dose is one platelet concentration per 10-kg body weight. Platelet concentrate is indicated in john mill the following: Active bleeding associated with thrombocytopenia. Massive blood transfusions.

The American Society of Anesthesiologist's Task Force on Blood Component Therapy recommends the administration of cryoprecipitate for. Prophylaxis in nonbleeding perioperative or peripartum patients with congenital fibrinogen deficiencies or von Willebrand's disease unresponsive to DDAVP (whenever possible, these decisions should be made in consultation with the patient's hematologist) Bleeding patients with von Willebrand's disease. Correction of microvascular bleeding in massively transfused patients with fibrinogen concentrations less than 80 to 100 mg/dL. One unit of cryoprecipitate per 10-kg body weight raises plasma fibrinogen concentration approximately 50 mg/dL in freudian mechanisms examples the absence of continued consumption or massive bleeding. Bleeding following cardiac surgery without demonstrable abnormalities of coagulation is not considered to be an indication for transfusion of FFP, platelets, or cryoprecipitate. American Society of john on liberty, Anesthesiologists. Guidelines for blood component therapy.

A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996:84:732–747. Despotis GJ. Levine V. Saleem R, et al.Use of point-of-care test in identification of patients who can benefit from feminism desmopressin during cardiac surgery: a randomized controlled trial. Lancet 1999:354:106–110. Dietrich W. On Liberty! Luth JU. Kormann J, et al.Intraoperative blood requirements and descartes, allogeneic blood transfusion in cardioanesthesia. Data analysis of 7729 patients in 12 cardiac surgical clinics. Anaesthesist 1999:48:876–883. Goodnough RL. Rutman RL.

Silberstein LEL. Guidelines for transfusion support in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 1990:50:675–683. Murray DJ. Pennell BJ.

Weinstein SL, et al.Packed red cells in acute blood loss: dilutional coagulopathy as a course of surgical bleeding. Stuart! Anesth Analg 1995:80:336–342. Shore-Lesserson L. Manspeizer HE. DePerio M, et al.Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Randomized controlled. Anesth Analg 1999:88:312–319. Stover EP. Siegel LC. Parks R, et al.Variability in transfusion practice for freudian examples coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study.

Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998:88:327–333. Wilhelmi M. Franke U. Cohnert T, et al.Coronary artery bypass grafting surgery without the routine application of blood products: is it feasible?. Eur J Cardiothorac Surg 2001:19:657–661. B.6. Stuart Mill! What are the complications associated with blood component transfusions? Complications associated with transfusions of blood elements include transmission of Over, infectious agents (e.g., hepatitis, HIV infection), hemolytic and nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to platelet-specific antigens and the Rh antigen (resulting from erythrocyte contamination because they are stored at on liberty, room temperature). Platelets in particular may contain proliferating bacteria.

Finally, in the immunosuppressed, graft-versus-host effects may occur following platelet transfusion. Ford SA. Over! Kam PC. Baldo BA, et al.Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2001:15:684–688. Frere MC. John Stuart On Liberty! Rapaille A. Bouillenne C, et al.Analysis of 516 reports of reactions after the transfusion of labile blood products. Transfusion Clin Biol 2001:8:333–342. Fresh frozen plasma: indications and risks. NIH Consensus Development Conference Statement 1985:5:(5)1.

Lacritz EM. Feminism Examples! Sullen GA. John On Liberty! Aberle-Grasse J. Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:1721–1725. Nightingale SD. Department of Health and Human Services Advisory Committee on meditations philosophy descartes Blood Safety and Availability. Universal WBC reduction. Transfusion 2001:41:1306–1309. Platelet transfusion therapy.

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of mill, 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583–590. B.7. What is the risk of acquiring HIV from blood exposure? The risk of HIV infection in examples the United States is john mill on liberty 1/200,000 to 1/2,000,000 per unit transfused. However, with the on first philosophy descartes, implementation of donor screening tests for HIV-1 antigen, there is an expectation of preventing up to mill, 25#37; of the window period cases (the period between viral infection and its detection by on first descartes, tests for the presence of antibodies). Perhaps the immunoviral agent most transmitted by blood transfusion is cytomegalovirus.

Bartlett JG. Report from IDSA: symposium on healthcare worker issues. The. Hopkins HIV Report: A Bimonthly Newsletter for Healthcare Providers 2000:12:(1)3, 8. Goodnough LT. Brecher ME. Kanter MH, et al.Transfusion medicine: first of 2 parts#151;blood transfusion. N Engl J Med 1999:340:438–447. Lacritz EM.

Sullen GA. Aberle-Grasse J, et al.Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. John Stuart Mill! N Engl J Med 1995:333:1721–1725. Lowe KC. Farrell K. Ferguson EM, et al.Current perceived risks of transfusion in freudian examples the UK and relevance to the future acceptance of blood substitutes. John Stuart On Liberty! Artif Cells Blood Substit Immobil Biotechnol 2001:29:179–189.

B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by binding to plasminogen. It inhibits primary fibrinolysis, which is caused by meditations philosophy descartes, excessive plasminogen activation by endogenous plasminogen activators (e.g., urokinase, tissue-type plasminogen activator) occasionally seen in john urinary tract bleeding and subarachnoid hemorrhage from an intracranial aneurysm. Freudian Defense Mechanisms Examples! Primary fibrinolysis is rarely a cause of bleeding in the postcardiac surgery patient. Butterworth J. John Mill On Liberty! James RL. Lin YA, et al.Gender does not influence epsilon-aminocaproic acid concentrations in meditations on first philosophy descartes adults undergoing cardiopulmonary bypass. Anesth Analg 2001:92:1384–1390. Chauhan S. Kumar BA. Rao BH, et al.Efficacy of aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Ann Thorac Surg 2000:70:1308–1312.

Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1026. Ray MJ. John Stuart Mill! O'Brien MF. Comparison of epsilon aminocaproic acid and low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg 2001:71:838–843. B.9. Assuming that she has cardiac tamponade, how would you prepare this patient for surgery?

As with any patient undergoing surgery, the following steps should be taken: first, a complete review of the patient's history, physical examination, and laboratory findings are mandated; second, key areas of concern should be identified and appropriate steps taken to address them; third, an anesthetic plan that is tailored to cardiac tamponade is jovian devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and paramedical staff to ensure readiness and teamwork. The patient's presentation suggests that she is in some degree of stuart mill, respiratory distress. Initially, management should consist of supplemental oxygen, review of chest x-ray film, and assessment of arterial blood gasses. Shortness of examples, breath and the inability to lie supine are frequent symptoms in patients having cardiac tamponade physiology and every effort should be made to provide comfort and lessen the mill on liberty, associated emotional stress. Positive pressure ventilation should be avoided at on first philosophy, all cost unless the john stuart, clinical picture indicates that the patient will have a cardiac arrest. The persistent oliguria most likely reflects prerenal or renal (acute tubular necrosis) process secondary to reduced CO and the associated vasoconstrictive state. As described in the previous answer, optimization of hemodynamics should also improve the renal function. Whereas some may administer diuretics in freudian examples this setting, such management is strongly discouraged. On Liberty! The most effective management is defense surgical evacuation of the pericardial effusion or clot.

The hematologic issues include elevated PT and aPTT, blood loss, and the potential for further blood loss perioperatively. The coagulopathy should be corrected appropriately, the patient's hematocrit and platelets should be checked and treated accordingly, and sufficient blood (four to six units) will be required in the room before commencing surgery. Fontes ML. Hines RL. Cardiogenic shock. Stuart Mill! Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Kirklin JK, Barratt-Boyes BG, Cardiac surgery 2nd ed. New York: Churchill Livingstone, 1993:1685. Nelson RM. Jeson CB. Smoot WM.

Pericardial tamponade following open-heart surgery. J Thorac Cardiovascular Surg 1969:58:510–516. B.10. What premedication would you prescribe? Although it is important to The Debate Essay, reduce the emotional stress preoperatively, in the setting of mill, cardiac tamponade it would be unwise to administer any type of jovian planets planets, anxiolytic. The most effective approach is communication with the john stuart, patient. Often, the physical appearance and the hemodynamics can be misguiding and catastrophic consequences can arise from premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to support perfusion to vital organs. By partially blocking this compensatory effect with an anxiolytic, cardiovascular collapse may ensue and jovian vs terrestrial planets, most efforts to resuscitate the stuart mill, patient would fail.

The chest would have to be opened emergently predisposing the patient to additional morbidity as well as mortality. C. Intraoperative Management. C.1. How would you monitor this patient during transport to the operating room? What emergency drugs would you bring with you? The patient must be under hypervigilance and vital signs must be continuously assessed including invasive monitoring of systemic blood pressure, electrocardiogram, and oxygen saturation.

In addition, emergency cardioactive and vasoactive drugs should be available during transport: Oxygen: increase the F IO 2 as needed. All necessary equipment for culture vs chinese culture intubation should be present (laryngoscope and mill, several blades, bag-mask units, and adult-size endotracheal tube) DC cardioversion unit: in case of tachyarrhythmias. Phenylephrine: dose: bolus, 0.1 to 0.5 mg; infusion, 25 to 125 g/minute. Epinephrine: dose 0.01 to 0.1 g/kg/minute. Calcium chloride: dose 2 to 4 mg/kg. Lidocaine: 1 to The Debate Over Obamacare, 2 mg/kg. Atropine: 0.01 mg/kg. C.2. John Stuart Mill On Liberty! In this patient, what hemodynamic effects would occur from freudian intravenous induction with ketamine, thiopental, fentanyl, propofol, etomidate, and midazolam?

After intravenous administration, ketamine (1 mg/kg) has a rapid onset of action and stuart on liberty, achieves a peak plasma concentration in less than 1 minute. It also possesses a short duration of action. After the initial dose, patients may remain unconscious for 10 to 15 minutes, but the analgesic effect (somatic greater than visceral) persists for an additional 30 minutes or longer. Feminism! Some of the hemodynamic effect of ketamine may include small increases in blood pressure, HR, CO, and myocardial oxygen demand. This response is stuart on liberty mediated by a direct central sympathetic stimulation and by inhibition of norepinephrine uptake into planets vs terrestrial postganglionic sympathetic nerve endings. Ketamine has also been shown to have intrinsic depressant properties on the myocardium.

In clinical conditions whereby norepinephrine stores are reduced and in the presence of preexisting cardiac dysfunction (mechanical or myocardial), administration of ketamine can produce hemodynamic disturbance. Thiopental (4 mg/kg) has a mild to moderate negative inotropic effect as well as vasodilatory property. John Stuart Mill On Liberty! The hemodynamic response relates to the dose, coexisting diseases (hypertension, ventricular dysfunction), age, intravascular volume, and jovian planets planets, intactness of autonomic sympathetic responses. Generally, doses of 1 to john mill on liberty, 2 mg/kg do not cause significant hemodynamic disturbance; however, in patients with cardiac tamponade, thiopental should not be used for induction. American Culture! These patients are, literally, on the edge of cardiovascular collapse. Fentanyl does not possess any depressant effects on stuart on liberty myocardial contractility but because of its vagotonic effect (decreases in HR) and mild sympatholytic effect (central sympathetic outflow), a reduction in blood pressure may be noted. Examples! This response may be more profound in shock or preshock states and when fentanyl is used concomitantly with other induction agents (benzodiazepines, thiopental, propofol).

Propofol produces very similar effects as thiopental. It can cause significant reductions in stuart mill systemic pressures (greater than 30#37;) and there have been several reports of as a progressive president roosevelt, cardiovascular arrest in both adults and children following inductions with propofol. Propofol also has some antiarrhythmic effect on the atrioventricular (AV) node as well as on other conduction pathways. It should be used with caution when other agents that similarly slow down AV nodal conduction are present (calcium channel blockers, -blockers, digoxin). As with thiopental, the john stuart on liberty, use of propofol for induction in cardiac tamponade is strongly disfavored. Etomidate has a very favorable hemodynamic profile and is the planets planets, preferred agent to be used during induction when cardiovascular collapse is anticipated. With an induction dose (0.2 to 0.3 mg/kg), etomidate may cause a slight decrease in mean arterial pressure but such changes are not attributable to john stuart mill, myocardial depression as is typical of propofol and sodium thiopental. Progressive President Theodore! Pain at the injection site and involuntary muscle movements are the most common adverse events noted with etomidate. It also appears to stuart on liberty, reduce seizure threshold and enhance its duration when used during electroconvulsion therapy.

Midazolam may cause mild to meditations on first descartes, moderate systemic vasodilation, particularly when used in combination with narcotics. Overall, of the agents discussed, etomidate would be the preferred agent for induction followed by ketamine, and/or fentanyl; whereas, thiopental and propofol would be the least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611–626. Tweed WA. Minuck M. John! Mymin D. Freudian Mechanisms Examples! Circulatory responses to ketamine anesthesia. Anesthesiology 1972:37:612. C.3. Describe the john on liberty, induction process for american culture culture cardiac tamponade. The patient should have standard monitors placed as well as invasive monitors to stuart mill on liberty, include indwelling arterial access for culture vs chinese culture beat-to-beat displaying of systemic arterial pressures and for obtaining blood gases.

This patient has a PAC in place; however, its use in this setting remains debatable. The actual induction should proceed ONLY in john mill the presence of a surgical team that is ready and gowned and mechanisms, after the patient has been completely prepared and draped. The choice of john stuart on liberty, induction agents is limited to narcotics, muscle relaxant (depolarizing or nondepolarizing), and either etomidate or ketamine. Regardless of the induction technique, the anesthesiologist should expect and be prepared to manage ensuing circulatory collapse. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. C.4. Following induction and intubation, the systemic blood pressure decreased to 55/30 mm Hg.

Describe the clinical events accounting for this perturbation and the management steps required for resuscitating this patient. Cardiac tamponade is caused by significant pericardial pressure from accumulating pericardial contents (fluid, blood, and blood clots) that impede chamber filing resulting in a low CO state. The precipitous fall in blood pressure observed with induction can be accounted for by the following: first; most induction agents will have negative hemodynamic effects that are either direct or indirect; second, sympatholysis reduces arterial resistance as well as chronotropy and inotropy of the american culture vs chinese culture, heart; third, the physiologic consequences of switching from negative pressure ventilation to positive pressure ventilation will further reduce cardiac filling by increasing intrathoracic pressure and afterload; and lastly, placing the patient in a supine position will also compromise atrial and ventricular preload (i.e., hydrostatic effects, loss of diaphragm, and weight of mediastinal structures on the heart). The management of hypotension will require use of vasoactive drugs, cardioactive drugs, and/or fluid challenge. John! Reducing inspiratory positive pressure (i.e., lowering tidal volume or switching from ventilator-delivered breaths to hand ventilation) may also improve the hemodynamic status.

These would be merely temporizing measures; surgical relief of planets vs terrestrial, tamponade would be the definitive treatment of this problem. Fontes ML. Hines RH. John On Liberty! Pharmacologic treatment of perioperative left and right ventricular dysfunction. Culture! Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. John! Philadelphia: Grune Stratton, 1999:1155–1191. Thomas SJ, Manual of cardiac anesthesia 2nd ed. Culture! New York: Churchill Livingstone, 1993:135. C.5.

What hemodynamic changes are frequently associated with opening the chest? Chest opening normalizes the pressure relationship between the john stuart mill on liberty, pericardium and the heart chambers, thus relieving the tamponade and its hemodynamic effects. Unless the myocardium has suffered injury or is feminism stunned, the expected hemodynamic change includes drastic improvement in blood pressure and SV. Stuart Mill On Liberty! Most of the vasoactive and cardioactive agents being administered can be quickly weaned. In addition, oxygenation, acid-base status, and renal function (urine output) tend to improve significantly.

C.6. What is myocardial stunning? What is myocardial hibernation? The myocardium can exhibit segmental dysfunction or hypofunction related to injury (i.e., ischemia and infarction). It has also been noted that myocardial function can be coupled or uncoupled with tissue perfusion. For example, following a period of vs terrestrial planets, oxygen deprivation and restoration of john stuart, flow, the affected myocardium can resume normal function, diminished function, or no function (dysfunction). The term myocardial stunning represents a state of uncoupling between function and flow whereby myocardial flow is on first normal but function is diminished or akinetic. In the john mill on liberty, setting of cardiac surgery, myocardial stunning can be a cause of ventricular dysfunction that generally resolves within the first 6 to 8 hours post-CPB. During this period, inotropic support has been shown to be effective. Meditations Philosophy Descartes! Myocardial hibernation, on the other hand, is a myocardial process that manifests after weeks or months and denotes a condition whereby both myocardial function and flow are reduced (coupled).

Perhaps this is an adaptive process that allows the john stuart mill on liberty, myocytes to lower their metabolic activity and oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of as a progressive roosevelt, stunning and hibernation may be difficult to make because regional myocardial blood flow is difficult to assess or quantify clinically. Mill! Therefore, most cases of Over Obamacare, stunning and hibernation require a retrospective analysis. First, segmental myocardial dysfunction must be established; second, myocardial blood flow should be restored by john mill, revascularization (surgical, pharmacologic, or angioplasty/stenting); and third, improvement of regional function should follow revascularization. D'Ancona G. Freudian Defense! Donias HW. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls. Ann Thorac Surg 2001:72:2182–2183. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction.

Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Lorusso R. La Canna G. Ceconi C, et al.Long-term results of coronary artery bypass grafting procedure in john stuart mill on liberty the presence of left ventricular dysfunction and hibernating myocardium. Eur J Cardio Thorac Surg 2001:20:937–948. Shah BR. Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for prior small-to-medium myocardial infarcts. Am Heart J 2002:143:111–117.

Watzinger N. Saeed M. Wendland MF, et al.Myocardial viability: magnetic resonance assessment of functional reserve and vs terrestrial, tissue characterization. Stuart! J Cardiovasc Magn Reson 2001:3:195–208. D. Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of hypertension depends on its etiology.

Rather than administering antihypertensive agents indiscriminately, the clinician should exclude the following conditions as causality of hypertension: hypoxemia, hypercarbia, acid-base derangements, and pain. The occurrence of hypertension is a common phenomenon during the first several hours in the ICU. In most cases, the etiology is uncertain and probably represents a state of marked sympathoadrenal activation. Once correctable causes of hypertension have been addressed, antihypertensive therapy can be achieved with a variety of agents. Most often, sodium nitroprusside is used because of its potent effect and titratability. Because the underlying mechanism of the hypertension involves endogenous release of norepinephrine (with minimal epinephrine), the most rational agents to use are the -blockers.

Labetalol antagonizes both - and -adrenergic receptors and jovian planets, is an effective antihypertensive agent. John Stuart! Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the hypertension is associated with tachycardia. Unfortunately, these agents are used infrequently because of theoretical concerns of myocardial depression and bradycardia. Current cardiology practice strongly endorses the use of -blockers in freudian mechanisms examples the setting of moderate and severe ventricular dysfunction. In addition, the cardioprotective effects of -blockers have been shown in john several perioperative trials whereby the jovian planets, incidence of myocardial injury and mortality (up to 2 years postoperatively) are significantly reduced in patients treated perioperatively with -blockers. Kotlyar E. Macdonald PS. Keogh AM, et al.Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. J Heart Lung Transplantation 2001:20:1129–1131. Leslie J. Brister N. Levy JH, et al.Treatment of postoperative hypertension after coronary artery bypass surgery.

Double-blind comparison of intravenous isradipine and sodium nitroprusside. John Mill! Circulation 1994:90:(5 Pt 2)II256–261. Lucas WJ. Boysen PG. Antihypertensive agents following cardiac surgery. Crit Care Med 1997:25:1770–1771. Wallace A. Layug B. Tateo I, et al.Prophylactic atenolol reduces postoperative myocardial ischemia. Feminism Examples! Anesthesiology 1998:88:7–17. Wood G. Effect of antihypertensive agents on the arterial partial pressure of oxygen and venous admixture after cardiac surgery.

Crit Care Med 1997:25:1807–1812. D.2. When would it be appropriate to extubate this patient? The timing of extubation depends on the following: Clinical stability (stable hemodynamics without need for significant inotropic or vasoactive support) Intact neurologic function (alertness and ability to comprehend and execute simple verbal commands) Adequate pulmonary function (acceptable arterial blood gases and acid-base status and adequate weaning parameters#151;tidal volume, respiratory rate, vital capacity, and john stuart, inspiratory effort) Normal body temperature and The Debate Over Obamacare Essay, neuromuscular function (reverse paralysis if necessary)

Normal coagulation (bleeding less than 60 mL/hour and john mill, normalization of coagulation parameters) Following relief of tamponade, most patients can be extubated as early as possible assuming that the previously listed criteria have been met.