Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 1 of 8 PageID #:2021
`Case: 1:16-cv—00651 Document #: 47-5 Filed: 11/08/16 Page 1 of 8 PagelD #:2021
`
`EXHIBIT 5
`
`EXHIBIT 5
`
`

`

`Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 2 of 8 PageID #:2022
`
`The
`MERCK
`Manual
`
`Of Diagnosis and Therapy
`
`Robert S. Porter, MD, E:'ditor-i11-Chief
`Justin L. Kaplan, MD, Se11ior Assistant Editor
`
`N-HOM~ EDlTION
`
`Ric!1ard K. Albert, MD
`Marjorie A. Bowman, MD. MPA
`Glenn D. B1~mnstein . MD
`Sidney Col1en, MD
`Linda Emanuel, PhD
`Jan Fnwcett. MD
`Eugene P. Frenkel. MD
`Susnn L. Ucnclrix, DO
`Michael facewicz. MD
`
`Editorlnl Board
`Matthew E. Levison, MD
`James Jeffrey Malatack, MD
`Britm F. M<111clell, MD, PhD
`Gerald L. Mandell. MD
`Judith S. Palfrey, MD
`Albert A.. Rundio. Jr., PhD
`David A. Spain, MD
`Paul H. Tanser, MD
`Michael R. Wasserman. MD
`
`ce 10 the scientific community
`
`Published by
`MERCK SHARP & OOHME CORP., A SUBSIDIARY OF MERCK & CO., INC.
`Whitehouse Station, NJ
`2011
`
`

`

`Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 3 of 8 PageID #:2023
`
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`ISBK (10 digi1) 0.9119 10·19·0
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`Copyright© 2011 by Merck Sharp & Dohme Corp .. a subsidinry of Merck & Co. Inc.
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`Pii111~CI in 1he USA.
`
`Preface
`
`At lhe b~ginning of the 2nd decad·
`to health care practitioners is im1n
`announcing results of the latest st\
`only in u11ivcrsity libraries can be r
`demics. commercial orga11iza1ions.
`with n computer and an internet co
`
`What is the role of a genernl re fere
`entire body of medical knowledge:
`of knowledge available, finding i
`always been iniended as th~ tirsts11
`topic for the first time or for the f
`topic, readers wi II be well prepnre•
`information available elsewhere.
`
`As it has for over 110 years. Tile M
`organized by orgnn system or medi•
`orders, The Ma11J1a/ provides health
`cal explan111ions of "what to do" 10
`suspect a disease. the proper seque
`along with selected altemacivc:s. In
`etiology and patttophysiology to em;
`
`The Manual continues to enhance
`shells'" at llre beginning cf each dis<
`whenever possible. including a1 the
`
`In the interest of brevity, The Mere.
`ture. Nonetheless, readers can be 1
`peer reviewers are presenting the 1>
`evidence.
`
`Allhough the printed Merck Mamw
`it h'.1S returned to the pocket as co
`ndd111011. 77ie Merck MC11111al co111
`www.mcrckmanuats.com. Allhouel
`1~roduct cannot, 1he book still provi <
`ul_e satisfaction and ease of pen1~u
`w1 II change as techno logy adva11ces
`keep 'fhe Merck Ma11ual as useful u
`
`We thank the numerous contributor~
`and we hope you will find ii worth·
`for improvcmenls will be warmly \V
`
`

`

`Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 4 of 8 PageID #:2024
`
`Document 61 Filed OS/21/15
`
`rimary: Excision
`· ::;;-;: , ·
`nt primary: Palliation
`ic: Depends on tumor on· •· ... ·.' .. '· ·
`.
`gip-· ·
`'
`
`nt of benign primary tu «i. ~'~~ · :: :if3".
`c1s1on ~ollowed by seri;nll'is, > '-'-·-·
`Y o•er :> to 6 yr co monitor i~I).
`.
`umors are excised unless aJJ. ()r'iO.
`• .
`, dementia) contramdicat.eso~
`ery is usually curative .. (9~
`yr). Exceptions are rbabdom ll
`of "".hich regress sp~ntan ,,~
`~wre treatment, and peri=~
`hie~ may require urgenc pen .,
`Pauents Wlth fibroelastoma car- .
`valvular repair or repla~
`omyomas or fibrornas are-Dill&
`~ ~xc1s1on 1s usua!Jv ineffedi,~
`IS _ 1~ poor after the' first y.ear Ot
`at ::> yr.may be as low ss: IS%c
`t ~I malignant primary tnmois~
`txve (eg, radiation !herapy,i:&.
`man_a~ement of complicatiooi)
`._, <<
`nos1s 1s poor.
`t of. me1~ta.tic cardiac ~~~
`tumor ongrn. le may icclnct .
`motherapy or palliation. ::;: ;1
`·
`::·; ,.;0.•:.
`
`Cardiac Arrest 2255
`Max Horry Weil MO, PhD
`Cardiopulmonary Resusci1.ation 2256
`PosU'esuscitative Care 2263
`CPR in Infants and Children 2266
`
`Respiratory Arrest 2269
`Charles 0. Bortle, EdD, and Richard Levfion, MD
`Airway Eslablishment and Control 2270
`
`Respiratory Failure and Mechanicai Ventilation
`Brian K. Gehlbach, MD, and Jesse 8. Hall MD
`Overview of Mechanical Ventilation 2279
`Acute Hypoxemic Respiratory Failure 2284
`Vencilatory Failure 2288
`Other Types of Respiralory Failure 229 1
`Liberation From Mechanical Ventilation 2291
`
`2279
`
`Shock and Fluid Resuscitation
`Mox Horry Weil MO PhD
`Shock 2292
`Intravenous Fluid Resuscitation 2297
`
`2292
`
`Sepsis and Septic Shock 2299
`Max Harry Weil MC. PhD
`
`· U Approach to the
`Critically Ill Patient
`Critical care medicine spec'alizes in ca.ring
`for the most seriously ill patients. These pa-
`
`tients are be>! treated in an ICU staffed by ex(cid:173)
`perienced personnel. Some hospitals main(cid:173)
`tain separate units for sp<!eial populations (eg.
`cardiac, surgical, neurologic, pediatric, or neo(cid:173)
`natal patients). JCUs have a high outse:patient
`ratio to provide the necessary high intensity
`
`.. : . ·;::·
`
`2243
`
`

`

`Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 5 of 8 PageID #:2025
`
`'·"I
`
`2245
`
`Casi~i~4-~~:u°o4!J.r~@'ga•e 0~~%-ment·Ett--Rfedi)81Z:1d-~~ 13~~ID-#:-10-±~-A_P_Tf_.R_2_22_Approach to the Critically 1u Pa!ient
`
`or service, inc:luding treatment and monitoring
`of phys1ol?~1c pammacn._
`.
`.
`SUf>!.Xlltl\ecareforthe lCUp111enr tncludes
`prov1s1on of adequnte •.•utnllo11 (5ee I" 21)
`and e•:cvenuon of rnfect1on, stress ulce1~ and
`gi1~1n11s (seep. 131), n11d puhnooory embolism
`(sec .P· 1920).13e<:~tise 15 to 2J'.*>.of patients
`admmed 10 ICUs. d!e t!iere, phys.ic1nns should
`kn~w ho~ to minnn~ze .suffenne and help
`dymg pauents ma111tatn d1gn1ry (seep. 3480).
`
`PATIENT MONITORING
`AND lESTING
`Sonic monitoring is man.111 (ic, by di1ec1
`observation nnd physicul cXA111ination) uu<l
`interm ittent. wi1h the frequency tlcpendino
`on the patient's llb1css. This mcx1itoring usually
`includes measut'ClllCnt or vital Signs (ttOlper·
`ature, BP, pulse . and respira1io11 r>te), qua11-
`1ificatioo of all Ruid intnkc nnd output und
`often daily weight. HJ> may be rccor<led by an
`nulonuued sphygmomanomcter; a tmnscuta(cid:173)
`ncousscusor for pulseoximetry is u.o;ed as well.
`Ot.her roonitorlng is ongoing and continuous.
`prov111cd by complex devices !hfll n:quire SJIC·
`cial training and cxperi~nce to opemte. Most
`~uch devices gcncmte an alann if cc11Hin pl1ys-
`1olog1c poran1ctcrs ttre exceeded. Evc1y IC IJ
`should strictly follow protocols ror investi·
`gating alanns.
`
`Blood Tests
`Although frcqt1c111 hlood draws can dc(cid:173)
`s truy v~h•~. C<l\lsc pain. and lend 10 anemia,
`ICU l>allents typically have routine daily l>lood
`1csts to help detect problems early. Generally
`pa1ienl.1:: need a d~ily set of elcct.rolyles and~
`CBC. Potien\S with ttrrhythmias should also
`have Mg. phos\1hatc, and Ca levels 1111:ns11recl.
`P"tie111s rccciv ng Tl' N oeed weekly liver en(cid:173)
`zymes and congulation profiles. Other 1ost$
`(cg, blood cu lture fo1· fover. CBC after a
`bleeding episode) are done as needed.
`. Point--ofpcarc 1es1ing us~s minhuuri7.ed,
`lnghly nutolllntcd devices to do ccnain blood
`1csts at the pmicnt's bedside or unit (panku·
`lurly IClJ. et11ergcncy depa11111.nt, nod oper(cid:173)
`aring room). 0.1111monly available t~IS include
`blood d~nistries. glucose. AHGs, CBC. car(cid:173)
`di•c markers. ond congula1io11 restS. Many arc
`done in< 2 min nnd require < 0.5 ml. blood.
`
`Cardiac Monitoring
`Most critic.all cnre patiem1 have cardinc
`acti vity monitored by a 3·le11d sys1em; sig·
`nnls are usually sent to a cenll'tl monitoring
`
`station by Rsmull rndiou~n$11lillerworn~ .
`ble ln-1. POTENTIAL IND ICATIONS
`patient. Automored sy<1enu gcnerntc :'!·"i.: . ta
`FOR PlJLMONARY ARTERY
`f~abnonnol n llC$ and 1'!1yll1111i.anast~ .
`nonnal tracings for ~"bseciuenr revic °'ilb. ---·-· ---·----·-·
`CATHETERIIATION
`Some specialized cnrduic monito~
`.
`. , c;.:;iJac disorders
`advanced 1,amineters associated w'th 1f1<t ,,
`J.<Ote valvular 1·cgurglta11011
`nary ischemia, ahhough their clinic~~~ c.<di"~ tsmponade .
`is unclear. ~ pammeten; me Jude -"'<II ,
`()>Jllplicated bc:lrt failure
`uous ST-scgmcn1 monitoring and~~ con1~1tarcd Ml
`vu1:i•bilitr. Loss of normal beat-to-beat ".\': , · V•otncnlar •~ptal mil'.'':
`Ab1l11y signals a reduction in autoo ~. ,
`lkniodrnan•k 1ns1ubfhty
`ac1ivi•y and possibly ex>ronary ische .0111,., .
`,_.,essmcntofvolumcsiatus
`'"'• ~: . $b<l<k
`increased risk or death.
`": lltlt""1Ynomk tnonllnring
`, ·
`()111i•csurgcry
`.
`. .
`
`Pulmonary Arteiy Catheter Monlto ·
`
`Use of a pulntonaiy artery cuthcter °"· . · : f<JStoperauve care m cnucally Ill patt.ents
`!s becoming l?s~ common h1 ICU 1,4W~ · .. · s~'"l'.";;~:.:t'?i~~~r:.,~~c 111 patients
`
`1
`51
`, • t I
`I hts bnlloon-l1pped, now-darecrcd talhelii:"
`o
`in.1a1cd via ccnlral veins rhrouah the rigb.:.
`p;t11ton•"Y dlsordt1'S
`.
`.. eomplicatc:d puln1or.~ry emboh<nl
`of the heart into the puhnonll'y artery l\i
`cothcter tyiiic•lly contains sevcn11 por~t1* • :·, f'lolntonary hypcncnS100
`CftO monitor p1·es:surc QJ' ia1jecl OuidJ. s ·~
`~ r.
`. . --~. ------.-.... - ..
`PA_Csnlso include a sens-Or lo mcasurec.e:,.! i · •Par1icult1rly 1r 1uo1rup1c drugs ::uc 1ec1u1rcd.
`(mixed) veuou$ 0 2 su1u1,.1io11, Da1a trcln ~; •
`PA Cs arc <L~ed ma111ly to determine cerdi;c·
`' '.
`outpui and prelond. Prc:load is mOll IXJID.. • , ii\ll atrial or venn caval pressure. When !he
`mon ly estimated by the pulmonary aJ1«y • ' Cldielere.1te~ the pulmonary ancry, systobc
`occlusion pressure (see p. 2245). Ho.l\<el'tf '·~, ircs>"re does not chnnge, but diastolic prcs.(cid:173)
`prcl~ad may be more accurn1ely deteiiiti~'.). .. !He rises above right ve ntricular end·
`by .right venlncular end-diastolic vohi~···' ' 4111101ic press111 .. or cencrnl v•nous press\lro
`wl_uch •s measured usiug fast·1t.'Sponsc tbjf. ;•' (CV!'); ie, tl1e pulse pressure narrows. Fur(cid:173)
`>.r. · ' lltt movement or th~ catheter wedges the
`mmois _gated to he11rt rate.
`Despite lon&-'•••l<liug use, r ACs ba~ Iii(, : llllooll in a diSt•l pulmonacy artery. A chest
`Wc:u shown to reduce morbidity and nlO<ill•. 1' i.rty confinns proper placement.
`ity. Rather, Pl\C usu has been nssodatcdwib:·:~ ; ·111esystolic pres.,ure (norrn11I, 15 to 30 mm
`exccss mortaliry. ThisfmdingmRyhecxplsiJid ;·:. ~&)and <li•stolic pressu1·c (normal, 5 to
`by co~1plications of PAC u~e and misillld.\ ·j ~ l) mm Hg) on: recor<ktl with the catheter
`pretauon or !he dnra obr.1ined. Nevetthi!di;;: :.i.Jbln deflated. Tiie diastolic pressu1e COi'·
`•otne physicians believe PACs, wtiea com-i r itspOOds well to die occlusion pressure, al·
`b?ncd with 0~1c1· objective and clinical ~· ~ { b g)l dias1olic pressure cnn exceed occlusion
`01d rn the management of cerrnin critically m .; ',! ixcssurc when pulnionary vnsculnr resistance
`puucms. As will.1 many ph¥siolo,lc mearuit1· 1, !'elevated secondary to pri m~1y pulmonary
`1~n~s, a chungrng rrend 1s 1yp1eallX.!"°"· · ' ', ;sruc (eg, pulmonary ftbrosJS, pulmonary
`sigmf1ca11t lhM a srngle abnormal veluo.'· • i,penension).
`~ossible i nd ications for PA Cs are listed;.. : : • llllmonmy -.y ocdusion pressu1e (PAOP):
`. r tlilh the b•llOOtl ioftat~d, p1·essure at the lip
`hble 222- 1.
`' ·
`Pr~cedure: The PAC is Inserted througba· : 3. Ulbecathe1erreOcc1stheslaticbnckpresstll'e
`special catheter in lhe subcluvlnn or interoar · ~ ClfiheP11lmom1ry veins. ·n1c b•lloon must not
`j ugular ve111 wuh rhc halloon clellaied.011¢
`'· i4llllinini1111edfor>30sectop1"vc11t pulmo·
`1he catheter Lip reaches the superior.,.~· :, ·: ""Yinrarttion. Nomlally, PA0Papproximnle$
`cuva. partinl infllllion or the b•llOOtl' p!'i;r•ts ; ' ~fl atrial pressure, which in rum approxi(cid:173)
`blood flow to guide the catheter. The ~piot. :. · ••k:• left ventricular encl-<llastolic pressure
`of the cathcte1· rip is usually detcnnioed br, 5· '· .(l.VEOP). LVBDP reflects left ven<riculur
`pressure monitoring (see Tobie 222-2 for ii· ;·f. 1• 11\d-diustolic volume (1. VEOY). 111c L.VE\OV
`l1•C•rdiac and !!teat vessel prcssuru) o( \ , ) r<(JftSCnLI prelond, which is the nc1ual 1arget
`oe<:n•ionally by Ouo1'0$00py. Entry into!he. 2 . l'UOll!Clct. Many factors cau.'IC PAOP to 1e·
`nght v.emridc is indicated by u siidded t> ·; -. ~ l.VRDV inaccurately. 1llese f>et0!$ in·
`ci:ease m systolic pressure to about 30 l!llll Hg; . I .. dude milral stenos ii, high levels of positive
`d1as1olrc pre~sure remains unchanged fJOJI.: ~ .~ .. l).oxpiral(>ry pressure(> 10 cm H20J. und
`·.:i~ ·:-~
`
`chllllges in lei\ ventricular C001pliancc (eg, due
`to Ml, pericardia! effusion, or increased after(cid:173)
`load). Technical difficulties re.~nh from ex·
`ccssive bolloon inOation, im1>roper catheter
`position. alve-0lar prc.ssurc ex~cding 110Jmo(cid:173)
`ntlry venous pn:ssure, or severe pulmonary
`hr.pertension (which may make the balloon
`d1flicult to wedge).
`Elevated PAOP occurs in left-sided heart
`failure. Decreased PAOP occur& in hypo(cid:173)
`volemia or decreased preload.
`Mi•ed venous oxygenation: Mixed venous
`blood comprises blood from !he superior and
`inferior ,·cna cuva that has t»-Ssed through the
`right heart to lite pulmonary ancry. The blood
`may besamplcd from 1hcdh1a1 pon of the PAC.
`but some cruhetets have embedded fiberoptic
`sensors that di.rectly measwe Oz saturation.
`
`_____ ... _,,,,,._ ____ .
`
`Table 222-2. NORMAL PRESSURES IN
`THE HEART AND GREAT VESSELS
`
`AVERAGE
`(mm Hg)
`
`RANGE
`(mm Hg)
`
`lYPE OF PRESSURE
`
`ll1ght a11ium
`R1gl11 ventricle
`l'cak·systol ic
`End-diastolic
`Pulmonory anery
`Mean
`Poek·systolic
`cnd-di .. tolic
`Pulmonary
`111tery occ:Jusion
`Mc.an
`Left atrium
`Menn
`A wave
`V W-3 VC
`Left ventricle
`Pco.k··sys1olic
`End-<linstolic
`Urochial artery
`Me:ln
`Pcak-sys1olic
`t:nd-dinstolic
`
`3
`
`25
`4
`
`15
`2~
`9
`
`9
`
`8
`10
`13
`
`130
`9
`
`85
`130
`70
`
`0-8
`
`15-30
`~
`
`9-16
`lS.·30
`4-14
`
`2- 12
`
`2-12
`4-16
`9-12
`
`9(H40
`5- 12
`
`70-150
`90-1~0
`60-90
`
`Adapted froro Fowler NO: CartUoc f)Urgno-sis
`''"" Tremme111. e<I ), P!tiladct)i1ia, lB Uppincolt,
`1980,p. IL
`
`. .. --
`
`.. -.,, -
`
`

`

`Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 6 of 8 PageID #:2026
`
`2246 SECTION 16 Cnbcal U.e Med'°"'
`
`Case 1:14=cv-00487-GMS Document 6r Filea0872D15 p~
`hcan failure Cl<l'diom)·opathy, or ib~" CS!' 4od bonce dtcttuo ICP Howev<r, the
`Causes of low mixed venous ~ oontenl
`(Sm\02) Include anomia pulmorwy di.u.c,
`J>ulmu1uuy ptc.s•u.c).
`..anculo>tomy is also •he most lnva.1ve
`Pulmonary ancry ruptlll"O occua in .:o{l: -~hos the hlgl>esl infection rst•, and 11
`carboxybemoglobm, to-. c•rdiac output. and
`iocreued 1woeme1abolic .....i.. 'lll<-1•Uuuf
`
`uf PAC ••u.:11iuns. '011$ '.,.....lropbic ~ • ~a:ost difficult 10 plll<:C. Occt.sl<>m1lly. t~.e
`S..O, to (Sa02 - Smv01) deiermulQ lhe Id·
`ca ioo •~ }ft<H fdtal ar.d occursi~; ~cmybecolr.uocck11Jedduetose
`cquaey oi o 1 deliveq "llie .deal muo ls 4: I,
`·,cit blain edema.
`on wedging Ille catlleteratbcr uut.allyli'-.'
`whereas 2: I ts the onnunwn aocq>tal)le mllO
`mi a \uh.etjueat <?CCIUSIOn prt.uure'~- •.; ()dtertypts oftntnlaamal devicn include
`to mamlain 1etcbic metabolic needs
`n.us. ma:iy phyw..iai» prefer to~·~ , , ;;\ ~nchym!'1 muoitor •nd an erldunol
`Ul<lf!ltr ~'Y diastohc rre...suru fllbei·~ ., . Jto!t. Of th<se, the 1ni..pannchymal monucr
`cardiac output: Cardiac output (('0) 1s
`measured b~ inlerutlneat bolu> tnJe<:tion ot
`occlus1or pressures.
`~ . •
`Jlia<>!'e common!} u5ed. All ICP devices
`, .. :,;;.~-
`ice water«, w new Cllhetln. contml.M'xh warm
`.JtOllld u$Ually be chang<d or remc"eJ Qf\cr S
`.~~?~ , .. I> 7days because infcaio• i~ •risk.
`lhennodilutioo. Thci;anhac index divide.. the
`Noninvasive Cardiac Output
`CO by body surface area to correct !Or patient
`.
`Other m.'thods of determinmg CO 'II~ , .
`si1.e (see Table 222-3).
`tho>racic bioimpodancc and the eso~!f; ·._ . other Typu of Monitorins
`Other variables cu becalculate<l from CO.
`OuWi•• ""'"1tu1,01cbcu111.icV\;lupcdtQa;;j•.~ , SublingUal capuometry uses a sirmlar cor·
`They luclude systtmic ftlld pulmonary V&6CU·
`the compllc.nlon• of PA Cs. A!tbougb lb·.,. ',,tnuoo between efovated ; ublingual Pt-o,
`iar resistance and 11tht ventricular ~troke
`mc.thO<ls are potentially useful, nettl!Crik~ %, · .,9sys1e1mch~rfusion to monitor shock
`work (llVSW) and left ventricular stroke
`·: ~usiogu noninvasivesen~orplllt'~ under
`rehnble ns a PAC.
`•. ".
`work (LVSW).
`Thor~clc blolmpedance: These "
`• '. , i.otongue. This device it1e11$ier10 use titan gas
`Comptiattions and preautions: l'ACs may
`· :. iic 10110111elt)' and responds quick!) 10 perfu·
`u~e topttn.I electrodes on ~he anJc
`be difficult to insen. Cardiac arrhythmia.\ are
`~rd neck to fr!Casure cl~u·1col im
`j;QO changes with resuscitauon,
`the most coaunon complicauon. Pulmondr}'
`1e >p«lroooopy uses " 11vuln•11Slve
`1ho thorux. Th!• vu.Jue var10ti v.~lh ~
`infarc11011 secondary to ovenntlated or per(cid:173)
`changC:» in th~ic bltl<ld vul~1e and
`'
`. md (Nllt) sensor u<uolly ,1l•ced on
`manently wedged balloons, pulmonary artery
`ctn ~1uma1c CO. Tite ;y..1em ·~ liamt!
`~ "ddn above the taraei tissue to monilt><
`perforation. mtmcardiac pe1foration, valvulRr
`p1ov1des values qu.'cklY. (w1tbm 2 t~ ~
`~tocho11dnal cytochrome a,a rcdox st•t~•.
`injury, 1111d ondocarditis may occu1·. Rurely.
`>f. £~ti reRcct tissue perfusion NlR may help
`however, the lechmquc 1s very se~sltlV
`rhe catheter may cwl into a knOI within the
`· · · , 4apuise acute compartment syndrome• (eg,
`t~mtlon of 1~e el47trode con~ct
`right ventricle (especially in pallents with
`• , 'E. "tiawna) or isd\emia nfte1· free tissue tr11J1s
`t1cnt Th~'llC:lc bl0tn1~aoce" mc><o _
`1111 oco11"'.t.Jn11 d11nge> tn a glvenpatl~11i • •" 111d may be helpful in po$1opcra•ive mon
`
`Table 222-l. NORMAL VALUES FOR
`CARDIAC INDEX AND
`RELATED MEASUREMENTS
`
`MEASUREMENT
`0 2 upt>ke
`Ancriovtoous 02
`diftCRnce
`Cardioc iodex
`Stroke index
`Total syaemic
`resi3-la,.;c
`Toca! pubnon.ory
`resi~tan:e
`Pulmon&r) aneti(cid:173)
`ofar ~istance
`
`\JNITS SD
`14':1: 14 3 ml.Jr"'11m1
`4.t :t06dL
`
`3.S :t 0 1 U1nuvml
`46 :t 8.1 mLJbeaVml
`I !!'~nl·j' dynes
`205 51 d)""'""°'""".-~
`67 i 23 dyn.,.·sec-cm·~
`
`SD; SlaJtc!A.'d dt>iatiOIL
`Adnpced C.om Barrau-Boyes BO. Wood EH
`Ca.rd:~ ou~t 11wJ rela&ed Ule~ure•ncob .md
`p-cSSU11? values in 1he riatu hem ind '''udMed
`vcssels. togel.00· wi1h an an111ysia of the hcmo
`dynamic re•ponsc 10 Ille h1h•llltlon orhlgh
`o•ygco mbturc• ia healthy 1ubjc<1s. J"'"'"" fJf
`L<1lx11·aJ<Hy cmJ CUukul McdM.l11c 51 :72~ 1958.
`
`. 'Ollllg of lowcr-cxu-em11y vascular bypass
`m precisely measuring CO. 1
`
`, .~. NIRntonuonneofsmall-bowclpH may
`Eaophtla••I DoppfQr monitor (EDM)·
`devk~ i•••ofi6 mmca1he1ttthatia
`, · ',timcdtogaugetheadequacyofreStlScitation.
`;..U
`nuwpllaryngc:ally mto the esophagus
`sitioned behind the heart. A Dopplel: ""'
`1•
`"
`probe at 1 t> tip allow• (;(;Otinuous moiut01i;l
`o co aNI nmM! volu1ne. Unlike the cnv>SM.
`SCORING SYSTEMS
`-.
`PAC,thd!D)IJcloc:.notCJ1.....,~- -,._ ral
`•
`nrrhythrui1, or infection An libM msf ;!i_i1 • :• ""'c $COnllg SY•.term nave betn devel·
`ally tK ..,.. ... ~• ... tc ll""1 1 PAC in~ :toid11?&1llll'.eseventyol1llne.ss1ncnt1c•lly
`II pouents. These systems a-c moderately
`>\1th cui:hoc vahul"' lei.ions, scpti.J deli&:-
`a rlty1hm1es. or putmon~ry hyperte<>iltF .· ~te in pred1ct1n& 1nd1V1du1l surv1va
`However. Ule !:.OM may J05e its waW/8:l, ,~. theoe •y•te1os ..., •llOfe •llwboe lcr
`-.1th only a slight positionnl cbaa. geud
`-tan11&quahtydcareand rorconduami.
`dJcc dampened maccura!e read•nl~· ..a
`l ,'mrth studccs becouse ttccy aUo-. compu
`•
`· """-"""""' ;not 0UtCOO:C$ 8l":lOllJ. gJQUps or C'1hca:ly
`'~I .. ~~IS with si;n;lar 1Une!s severity.
`• _,
`lnt11crenlal Pressure Mon1tonng • , .4''4
`~/The ~common system is the 2l>d ""1SIOO
`11-Ile Acute Ph>•iolos1c Auenment and
`lntracnnial preuuie (ICP) moilltllf'llii&
`>"1ndaro for pailmts will se' ett dooed~ ,
`'IM>nic Helllth Evaluation II (APACHE IT)
`l11Jury. Thcsed.i,iceura llSCd toopti01i<G:it' " .-inlJ'Oduced in 198S. It generai.:s a poinr
`1 cl.>1..J pcrfo>iu11 P'"'""'c (11;<>UJ1 .rtcrial ¢:'-' .. ~"'"° ra.1ging from 0 to 71 based on 12 phys·
`""'c minus i111racramal prcsstN-e). Typi~ ~ 1'tiotic variables, age, and underlyhg health
`the cc1cbrnl pc1'fuslon prC$sure shoilld)ie .. ~T&ble 222-4) Tiie APACHE Ill syMcm
`:111 developed in 1991 Thlssystem iuoore
`'..i-tu>
`kept> (J() mm Hg
`.
`Severn I types of ICP moruiors are"'~ . · ):>mptex, has 17 ph)Moloi:lc variables, ftnd is
`The mmt useful ~ethod places a cath!I~ .. limewha1 less used. Tiierc are m•ny other
`through the skull mto a cerebral venu-: . _.'llttms, mcludmg the 2nd Simplified Aoutc
`(ventri<:ulo•lomy catheter) This devi4)$ -~ ~loloty Score (SAPS II) a'1d sevenil mor(cid:173)
`prdc1Tcd bocnuse l11c cnthcter c~a Jllsoiktill:'. ~~ty probability models.
`ti'~
`
`VASCULAR ACCESS
`A n11mbei of proct><!ures aJC used to gai1
`\llSCUlar aoccss
`
`Perlpher•I Vein tatheterbatton
`Mostpellcnis' ncc<hforlV flwd tnddrugs
`can be met with a ~n:ut11ncous penpheral
`•tnou~ ra·hctcr \ enous cutdo-.o ca• be
`t,;&:d wncn pen:uunrous catheter insttt1on is
`nnt 'eu1hlc. Typ1ct1l cutdown sites are the
`cephalic vein in the arm ind th~ ,,.phenou;
`•em 1.t the ankle.
`Comm0111.0<np~cations (cg, local infeaio1\
`vcnou. U>romboslA, thmmbophleb11Js, mter(cid:173)
`stlt!al flutd e~U'8Vllll8tion) can bt: reduced by
`~sine.a meticulous sterile techmque dtrring
`rnsertton and by rcplacmg or 1 eonoving the
`catheters wirhio 72 h.
`
`Central Venous Catheterlzatlon
`PoticnlS needing •ccu1e or loug-tcrm VII.';·
`culnr ncce'lll (eg, tu receive antibiotics, che(cid:173)
`motbcr•py, or TPN) are best treated with a
`central venous catheter (CVC). eves allow
`infusion of soluuons that •re (00 cooccntrl.led
`or itTitaunc for peripheral veins and allow
`mo1u10nngof ocntrol ,cnous pressure (CVP(cid:173)
`see p. 229'1)
`Procedure: CVC1111'C inserted using stcc;k
`1echn1q11e and 1 local aneuhctic (cg. 1%
`l!doc.iine). The suptrior vcnl cava is entered
`via pe11:u1aaeou.1 punoture of the subclavian
`or the mtcmol or external iugular Yein or by
`venous cutdown on the bas1:ic >etc. The in(cid:173)
`ferior vena cava moy be entered through the
`common femoral vein percutanoously or O)
`c.1klov..n on the sap~oou$ \cm. The choa
`of ~itc <l~j.l<nJs on open.tor preference llllC
`pa:icnt h•b !US Ind ambulat<a')' sta!JJS. How(cid:173)
`ever, femool VCOOt1J l4lhclCIS ha Ye a •hlh~y
`lti &her me of cnmpk.uo111 than those above
`the wain. Also, during canliac orres:, flwu
`and drug~ 1i•en through a femoral or s.aplte.
`n()U3 Ve•n CVC Often fail 10 ciicuJ.te above
`the diaphraam becau..e of the incrused in(cid:173)
`trathoracic pressure generated by CPR. ln
`this ea...e, a subclavian or internal jugular ap(cid:173)
`J>rOftCh may be prefom:d.
`lfposslbll:, the patient's coogulauon status
`and pl•telel count should be nonnaliied be(cid:173)
`fore C\IC insertion. Percutaneous femoral
`linea must be inserted below the Inguinal lig(cid:173)
`ament. Otherwise, laaration of the cxtemnl
`ilinc vein 01· artery above the inguinal ligament
`may rei.ult in retroperitonc<ll hemolThage;clt(cid:173)
`ternal compt'eSsion of thetie vessels is nearly
`imj>O>~ible. The subclavlnn vein also is llOI
`
`

`

`Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 7 of 8 PageID #:2027
`
`--------
`.reactive protein (co11ti1111ed)
`continued)
`osteomyelitis and 371
`0111b1ued)
`protein-energy undernutrition and 16
`622-623
`1eference values for 3493
`to 623-624, 1746
`in rheL1matic fever 2863
`tor) 1746, 1749, 1750,
`creatine 3426, 3500
`53
`as dietary supplement 3426
`n of 1587
`urinary reference values for 3500
`1747, 1750, 1750, l 753
`creatinc kinase 301, 3494
`1 of 1587
`as cardiac enzyme 2104
`I) 496, 1747, l 754--1755
`as skeletal muscle enzyme 301
`of 1589
`reference values for 3494
`infection of .!420
`l747, 1750, 1753-1754 CrC<1tinine
`blood levels of 23 l 2, 24 I 3, 2438, 3494
`of 1587
`in hypertension 2068
`, 1747, 1755-1756
`injury to 2770
`urinary 3500
`creatinine cleurancc 2313
`of 1587, 1589
`4
`dialysis and 2446
`6
`drug dosage and 3091
`stibulocochlear) 429, 430, Creatorrhea 145
`(see also Hearing, loss of, Crede's method 2362
`Creeping eruption (cutaneous larva migrans)
`oma of 441-442
`710
`Cremasteric reflex 1593, 1617
`f 1589
`vims infection of 444-445 Creosote poisoning 3364
`Crepilus 285
`Crescentic glomerulonephritis 2393-2396,
`2394
`Cresol poisoning 3364
`CREST syndrome 310-31 l
`Cretinism, endemic 2888
`Creutzfeldt-Jakob disease 1729-1730
`blood transfusion and 1043
`CRH (see Corticotropin-releasing
`hormone)
`Cribriform plate, fracture of 3233
`Cricoid cartilage, pressure on 2275
`Cricopharyngeal incoordination 122
`Cricothyrotomy 2277, 2278
`Cri du cilat syndrome 3002
`Crigler-Najjar syndrome 2 l 8
`
`ngeal) 466, 496, 1589,
`-1757
`9, 1748
`, in seizures 1702
`1589, 1748
`!)497, 1589.1748
`3084
`601
`sis 1781
`tion 1757-1759, 1810
`lies 2970-2972, 2971
`dysplasia 2916
`767, 1815
`89
`
`ressive 1665
`sias 2916
`rstoses 2917
`
`alities of 2916,
`971
`84
`t 2083, 2084
`
`!Crimean-Congo hemorrhagic fever 1400,
`
`1429, 1431
`Critically ill patient
`approach to 2243-2255
`nlonitoring for 2244-2247, 2296, 2301
`scoring systems for 2247, 2248
`Crocodile bites 3319
`
`adenocarcinoma in 190
`nnorectal abscess in 18 l
`
`gingivn in 518
`
`ICrohn 's disease 169-172
`I extraintestinal manifestations of l 67
`1
`l I
`
`Index
`
`3577
`
`Crolm's disease (continued)
`hepatic innammation in 249
`primary sclerosing cholangitis and 278
`treatment of 167-169, 171-172
`ulcerative colitis vs 166
`uveitis and 609
`Cromoglycate 2529
`Cromolyn 1116, 1116
`in asthma 1879
`in mastocytosis 1125
`Cronkhite-Canada syndrome 132
`CROS hearing aid 437
`Cross-dressing 1571
`Croialidae polyvalent immune Fab
`antivenom 3318
`Crutamiton 712
`Croup 1410, 1844, 2732, 2879-2881
`epiglottitis vs 476
`pseudomembranous 2878
`spasmodic 2880
`Crow-Fukase syndrome 807
`Cruciate ligaments 3217
`injury to 3217
`Crutches 3457, 3459, 3460
`Crying 2735-2737, 2736-2737
`paroxysmal (see Colic)
`in stranger anxiety 27 50
`Cryoglobulinemia 982, 2399
`hepatitis C and 249, 256
`Cryoprecipitate I 039
`Cryopyrinopathies 3028
`Cryotherapy
`in actinic keratoses 674
`in prostate crmcer 2472
`in warts 717
`Cryptococcosis 1329-J 330
`HIV infection and 1446
`India ink stain for 1166
`Cryptogenic organizing pneumonia 1946,
`1948, 1950 1951, 1953
`Cryptorchidism 2476, 2892, 2894, 2987-2988
`Cryptosporidiosis 148, 150, 1338, 1339,
`1341, 1369-1370
`Crystalloicl solutions 2298
`Crystals
`calcium oxalate 352, 355
`calcium phosphate 352, 355
`calcium pyrophosphate <lihyclrate 351,
`352, 354_.355
`Charcot-Leyden 987
`monosodium urate 349--354, 352, 2441
`synovial fluid examination for 287, 349
`urinary 2309, 2309, 2310, 2703
`
`

`

`Case: 1:16-cv-00651 Document #: 47-5 Filed: 11/08/16 Page 8 of 8 PageID #:2028
`
`3640
`
`Index
`
`Infliximab 169, 172, 1087
`in rh.e11ma1oid archritis 339, 339
`tnnucnza JJ96. 1405-1408, 1925
`avian (bird nu) 1408-1409
`COPD and 1897
`drugs for 1407
`swine 1409-1410
`vaccine against 1171. fl 74-1175,
`1176-1177, 1408, 1929, 2718, 2720,
`2722. 3109
`in Kawusoki disease 2937
`in pediatric Hl V infection 2859
`Informed consent 3469
`lnfrnputcllur tendinitis 2913
`Infrnred henc therapy 3459, 3461
`Ingestion 76
`Ingrown toern1il 736
`lnhalationnl fever 1976
`lnhalacion challenge cest 1980
`Inheritance (s<!e Chronmsome[sJ; Genes)
`Inherited disorders (see Genetic disorders}
`Inheri ted disorders of metabolism 3009-3026
`lnhibin B 2339
`Injury (su afro Fracture; Trauma)
`birth 2769-2774
`hcnd 3218-3227,J2/9,J22/,3222,3225
`ovemse3296
`i.vinal oord 3227- 3231. 3228. 3230
`spleen 986
`lnocybf! poisoning 1614, 3337
`£NR (international nonnalized ratio) 227. 97 l.
`3496
`Insect
`in ear canal 456
`sti ngs by 3308· ·3309 (sec also Bites and
`sti ngs)
`Insecticides 647
`poisoning with 3340- 3341, 3363
`Insemination. intrauterine 2594
`Insomnia 1703-·1715, 1705, 1707
`drugs and 1705. 171 I
`in elderly 3103
`feta l 173 1
`physicnl d i~orders and 1487
`psychophysiologic 1711
`SSRls Md 1547
`InspinHory now rntc 228?.
`Insufficient sleep sync!rome I 71 1
`IMuln 1617
`Insulin (see o/.ro Diabete..~ mellitus)
`ollergic reaction to 875
`blood levels of 2, 3496
`in calcium chnnnel blocker poi.~oning 3327
`
`Insulin (co111i11ued)
`in chronic pancrentiris 146
`dawn phenomenon with 87S
`in diabetes mellitus 873, 874. 882
`in diabetic ketoacidosis 885
`growth factor effects on 759
`infection-related production of 1152
`in neonatal hyperglycemia 2796
`in nonketotic hyperosmolar syndrome 886
`in phcoch.romocytomo 802
`potassium levels and 83 1
`in pregnancy 2639, 2640
`preoperative 3447
`preparations of 873, 874
`regimens for type 1 diabetes mcllitus 875
`regimens for type 2 dinbetcs rncllitus 876
`resistance to 868, 871, 875, 1 J JO. 2082
`antirelro'lirals and 1453
`pregnancy and 2625
`in septic shock 2:102
`Somogyi phenomenon with 875
`for surgicnl procedures 882
`su11"e1>t1tiotL~ administration of 199
`for total parenteral nutrition 24
`lnsulinase 2625
`Insulin-like growth factor I (IGF-1 ) 759
`measurement of 760, 765. 769
`in children 767
`Insulin-like growlh factor binding prorein
`type 3 (!OFBP-3) 767
`lnsulinomn 198- 200. 199
`hypoglycemia and 888
`in MEN syndromcs9 10. 910
`Insulin resistance syndrome 64-65. 65
`Insulin lolt:ram;e test 765, 767
`lnsurnnce, medical 3157, 3473-3480
`Medicaid 3 ! 6.1-3162
`Medicare 3155- 3161
`private 3163, 3475
`TNT ACS (intracorneal rii1g segmenL~) 574
`lntcgrnsc inhibitors 1450, 1451
`in children 2857
`lntellectunl disability (mcntnl rcwdation)
`3044- 3048,3045,3047
`chrornosomnl abnormnlities nnd 3045
`diagnosl s of 3046, 3047
`in Down syndrome 3000
`in fetal alcohol syndrome 2799
`in fragile X syndrome 2998
`prevention of 3048
`I ntelligcnce quotienr (IQ) 3044
`Intensive care (see Critically ill parient)
`Intention tremor 1774. 1775
`
`fnten:ostal retractions I 826
`Intercourse, sexual (see Sexual activity)
`Interdisciplinary team 3115-3 l !6
`lnterfcron{s)
`in cancer 1060, 1067, I 072
`in chronic hepatitis 257, 258
`in hepatitis C 258
`in vi ral infectiou l395
`Interferon-a 1067
`in essential thrombocythemia 998
`in genital warts 1471
`hyperthyroidism and 78 1
`immune function of 1084
`thernpcutic use of 1088, 1090
`tremors and 1775
`in warts 718
`lnterfcron-a2b
`in mastocytosis 1125
`in polycy1hemie1 vcrn 1003
`Interferon-~
`immune function of 1084
`in multiple sclerosis 1782
`therapeutic use of 1088, I 090
`lnterferon-y
`in atopic dermatitis 665
`in eluonic granulomatous disease 110
`fever and 1152
`m1mune function of l 080, 1081, I 084
`receptor defects of I 093
`ther:ipemic use of 1088. 1090
`lntcrleukin(s)
`in cancer 1058, 1072
`immune function of !084
`Interleukin-I
`fever and 1152
`immune (unction of 1080
`lnterleukin-2 1088
`receptor for, protein-energy
`undernutritioo imd I 6
`lnterleukin-6 1152
`lnterleukin-ll 1088
`lnterleuk