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Test Code : 250-512
Test title : Administration of Symantec Data Loss(R) Prevention 11.5
Vendor title : Symantec
: 161 actual Questions

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Administration of Symantec Data Loss(R) Prevention 11.5 exam

Wheezing in the Pediatric patient | 250-512 actual Questions and VCE drill Test

This CE activity is accepted by course of EMS World journal, a firm accredited by the carrying on with training Coordinating Board for Emergency clinical services (CECBEMS) for 1 CEU. To hold the CE inspect at various that accompanies this article, fade to www.rapidce.com to hold the check and automatically acquire your CE credit. Questions? email editor@EMSWorld.com.?

pursuits

  • Describe the pathophysiology of bronchiolitis and list signs and indicators
  • Describe the treatment of a affected person with bronchiolitis
  • Describe the pathophysiology of asthma and listing indications and signs
  • Describe the treatment of a affected person with asthma
  • Describe the similarities and transformations between the pathophysiology of bronchiolitis and bronchial asthma
  • focus on the epidemiological qualities of bronchiolitis and asthma
  •    A wheeze is a excessive-pitched, musical, continuous sound that originates from oscillations in narrowed airways. Wheezing is most regularly the outcome of bronchiolitis in toddlers and bronchial asthma in older infants. this article will argue the similarities and changes between these two childhood illnesses, along with management of the baby or child with wheezing.

    Bronchiolitis

    Epidemiology

       In children beneath 1 year of age, the respiratory syncytial virus (RSV) is estimated to breathe chargeable for up to 70% of cases in up to now appropriate toddlers.1 RSV is an endemic of the family unit Paramyxoviridae, which comprises many typical respiratory viruses, reminiscent of folks that trigger measles and mumps. The identify RSV derives from the proven fact that it A) is a deadly disease that motives respiratory tract infections, and B) combines with neighborhood viruses to figure a syncytia, or virus mass. The virus is so ubiquitous that practically All minute ones will beget had an RSV an infection by their 2d birthday. After first-time exposure to RSV, 25%-40% of toddlers and kids will demonstrate signals or signs of bronchiolitis, and 0.5%-2% will require hospitalization. Most infants hospitalized for RSV infection are under 6 months of age.2 Bronchiolitis because of RSV become the main understanding behind hospitalization among the ordinary inhabitants of minute ones within the united states between 1997-2000, accounting for an estimated 96,000 hospitalizations All the course through that point.3

       Mortality linked to bronchiolitis has lowered in previous a long time, despite the fact young minute ones can nonetheless die from bronchiolitis. those are usually the in impecunious health ones who then increase bronchiolitis.3,four The mortality cost is lower than 1%, with fewer than 500 deaths a year attributed to RSV in the u.s.. extended morbidity and mortality occurs in high-possibility patients,3,5,6 together with these younger than 6 weeks ancient, and people with a heritage of untimely birth, hypoxia, congenital heart disease, constant lung disease or immune deficiency.7,eight,9 Bronchiolitis is extra regular in adult males, toddlers residing in crowded situations, and infants who beget not been breast-fed.10,11,12

    Pathophysiology

       Bronchiolitis is predominantly a viral disease, with out a facts helping bacterial etiologies. besides RSV, other infectious brokers encompass parainfluenza, adenovirus, rhinovirus, mycoplasma and metapneumovirus. Viruses are spread from grownup to grownup by means of direct contact with nasal and oral secretions, airborne droplets produced with sneezing and coughing, and fomites. A fomite is any inanimate object, equivalent to a bedsheet or apparel, able to carrying and transferring an infectious agent.

       After inoculation, viral replication starts within the epithelial cells of the higher airway, then spreads to the mucosal surfaces of the lessen respiratory tract, together with the bronchioles. an infection of the epithelial cells outcomes in their destruction by course of middling mobilephone lysis, courtesy of the immune system, or by means of apoptosis, genetically preprogrammed cellphone dying. Necrotic cells slough off and unlock inflammatory mediators, leading to airway irritation and edema. furthermore, mucus production is extended. This combination of mobile debris, edema and extended mucus production effects in narrowing and obstruction of the bronchioles, multiplied resistance to air circulation, reduced ventilation and air trapping.

       apart from toddlers, there is additionally a risk of transmission to adults, exceptionally the immunocompromised or elderly. As such, All clinical practitioners should develop expend of adequate personal protective tackle to give protection to themselves and others.

    clinical exam

       typically, the patient with bronchiolitis is more youthful than three hundred and sixty five days and items All over the wintry weather months. The folks of a toddler with bronchiolitis will narrate a 1-5-day history of malaise, fever, irritability or impecunious feeding. A cough is normal, and clangorous respiratory, grunting, dyspnea and extended work of breathing may well breathe apparent; folks may additionally even narrate an audible wheeze. A guardian or caregiver could breathe capable of recall publicity to someone with a respiratory an infection within the previous week. it's censorious to determine if the affected person has a historical past of premature start, hypoxia, congenital coronary heart disease, persistent lung disease or immune deficiency, All of which can complicate the direction of disease. A caregiver may moreover additionally narrate periods of apnea, specially in babies younger than 6 weeks. it's essential to collect counsel about the patient's hydration repute, together with the presence of vomiting and/or diarrhea, urine output as decided by course of the variety of diapers in a 24-hour duration, and the quantity and frequency of fluid consumption and feedings. toddlers with tachypnea may moreover beget problem breast-feeding or taking a bottle.

       physical examination findings associated with bronchiolitis consist of fever, wheezing, tachycardia and tachypnea. indications of increased respiratory misery, together with accessory muscle use, nasal flaring, retractions, cyanosis and developing hypoxia, intimate austere ailment and airflow obstruction and require aggressive management. Pulse oximetry may soundless breathe performed on All patients with suspected bronchiolitis. it's inexpensive and gives quick and purpose facts regarding the diploma of hypoxia existing in a affected person.

       The aggregate of impecunious feeding and elevated insensible fluid loss secondary to tachypnea may cease up in dehydration and hypovolemic shock, additional complicating the respiratory compromise. As such, a cautious assessment of the fontanel, epidermis turgor and mucous membranes could breathe appropriate.

    bronchial asthma

    Epidemiology

       bronchial asthma is likely one of the few constant childhood ailments for which there had been increases in prevalence, morbidity and mortality in fresh decades. A CDC examine confirmed 34 million americans (eleven.5%), or one in 9 american citizens, beget been clinically determined with asthma All the course through their lifetime. present asthma prevalence is bigger amongst ladies (8.9%) than males (6.5%), and is bigger amongst toddlers a long time 17 years and younger (9.1%) than adults (7.three%).13 during the past 25 years, childhood bronchial asthma costs beget more than doubled.

       an ordinary annual 1.8 million emergency department visits for asthma beget been calculated for the three-yr length from 2001 unless 2003; 1.1 million visits were for adults and 696,900 visits were for infants. more visits were made via male babies (423,800) than female toddlers (273,one hundred). All over the identical three-year period, a regular annual four,210 deaths from asthma came about, with 200 of these deaths taking situation in people less than 18 years of age.14 There are Definite racial disparities amongst minute ones with this disorder. compared with white minute ones, black children beget a 60% bigger prevalence expense, a 260% greater ED visit expense, a 250% greater hospitalization expense and a 500% higher death expense as a result of bronchial asthma.15 in the united states, childhood asthma is probably the most typical explanation for childhood emergency department visits, hospitalizations and ignored faculty days (10.1 million faculty days lost a yr).

    Pathophysiology

       asthma is a inveterate inflammatory ailment of the airways characterized by using variable and habitual indicators arising from episodic and reversible airflow obstruction. This airflow obstruction is the result of a lot of pathological procedures, including bronchoconstriction, airway hyperresponsiveness, irritation and edema, and increased pulmonary secretions. bronchial asthma can breathe labeled as atopic (extrinsic) or non-atopic (intrinsic) in accordance with the factors of indicators. The term atopy refers to a genetic predisposition in opposition t the building of immediate hypersensitivity reactions to common environmental allergens. Atopic asthma is brought about via allergens enjoy pollen or animal dander. Non-atopic bronchial asthma, in distinction, isn't caused by an publicity to an allergen, but is always a response to an endemic or upper respiratory infection.

       An exacerbation of bronchial asthma happens in two phases: early and late. during the early part, inhalation of an allergen or other irritant consequences in immediate bronchoconstriction. throughout the late phase, airway irritation, edema and hyperresponsiveness additional develop a contribution to airflow obstruction. it is expense taking a closer resolve these accessories of asthma.

    Bronchoconstriction

       In atopic asthma, allergen-brought on bronchoconstriction effects from the IgE-elegant unencumber of bronchoconstrictor mediators, akin to histamine from mast cells. This occurs when IgE antibodies establish an allergen and connect to them, forming an allergen-antibody complicated. This allergen-antibody complicated is then diagnosed by using and bound to a mast phone. The mast mobile degranulates and releases histamine, leading to immediate bronchoconstriction. additionally, other stimuli similar to pastime, chilly air, inhalation of irritants and even stress may cease up in acute bronchoconstriction. Bronchoconstriction is essentially the most instant, preponderant physiological adventure early in an bronchial asthma attack, and airflow obstruction can breathe reversed at this time with the administration of bronchodilators.

    Airway inflammation and Edema

       Cells of the immune device that unlock inflammatory mediators involve lymphocytes, mast cells, eosinophils, and neutrophils to a lesser degree. unencumber of those mediators, similar to histamine and cytokines, results in multiplied capillary permeability and edema. The airflow obstruction caused via airway edema can breathe worsened by course of mucus hypersecretion and the formation of mucus plugs. Airway inflammation and edema ensue later in an bronchial asthma exacerbation than does bronchoconstriction.

    Airway Hyperresponsiveness

       The time period airway hyperresponsiveness is used to clarify the exaggerated bronchoconstrictor response that happens in asthma and is linked to inflammation. The more inflammation it's latest, the better the hyperresponsiveness. a higher diploma of hyperresponsiveness correlates with an increase within the scientific severity of bronchial asthma. treatment that aims irritation can in the reduction of airway hyperresponsiveness and aid in bronchial asthma control.

    medical examination

       When evaluating the infant with bronchial asthma, the prehospital reliance company should soundless inquire as to the age of the affected person, the duration and severity of the adventure, simultaneous medicine use, and if there's a probability of a choking episode and singular physique aspiration. If there had been other attacks, the parents may soundless attempt to compare the latest ones with previous attacks. establish All treatment forms and doses. Any heritage of hardship napping or ingesting birthright through the assault suggests a reasonable to extreme exacerbation.

    general medical examination findings linked to asthma encompass tachypnea, tachycardia, wheezing and dehydrate cough. in addition to wheezing, crackles or rhonchi may well breathe auscultated over areas the situation mucus and inflammatory exudate beget accumulated within the airways. A reticent chest will moreover breathe an ominous register bronchial asthma, as it can moreover witness that ventilation is extremely diminished or nonexistent. another ominous symptom is head-bobbing or lethargy, indicating that the patient is fitting drained, hypoxic, or approaching respiratory failure. An oxygen saturation should breathe determined, as it can aid in identifying the diploma of affliction.sixteen birthright through the early levels of an exacerbation of bronchial asthma, hyperventilation effects in hypocapnia and a reduced conclusion-tidal carbon dioxide (ETCO2) studying. As bronchoconstriction and edema worsen airflow, alveolar air tide decreases and hypercapnia develops, resulting in a ascend in ETCO2. No unique bronchial asthma scoring desk has been universally adopted to determine the diploma of ailment or aid in determination-making concerning administration, however desk 1 can breathe used as a e-book.

       Measuring peak expiratory circulate cost (PEFR) is a straightforward and objective components of picking the severity of asthma in an adult, however arguably has constrained utility within the baby and child with asthma, who could breathe unable to celebrate commands integral for this trying out. in a unique inspect at, simply two-thirds of minute ones above age 5 were capable of complete PEFR trying out throughout an bronchial asthma exacerbation.17

    management of Wheezing

       After initial comparison of airway, respiratory and circulation, and the immediate remedy of lifestyles-threats identified birthright through the fundamental exam, the treatment of wheezing within the pediatric patient revolves round increasing air tide and oxygenation throughout the reversal of bronchoconstriction and airway edema.

    Oxygen

       All patients with wheezing may soundless breathe administered oxygen by the expend of an acceptable start tackle to hold a SpO2 above 90%. patients with adequate breathing (price and tidal extent common for age) can utilize a nasal cannula or nonrebreather masks, while patients with insufficient respiration (price and/or tidal quantity outdoor of norms for age) require BVM ventilation. reliance must breathe taken when offering BVM or mechanical ventilation, as air trapping can result in multiplied intrathoracic pressures and the possibility of lowered venous return. This could lead to decreased cardiac output and barotrauma, leading to pneumothorax. As such, enough (prolonged) expiratory time must breathe allowed for air to exit from the lungs. Permissive hypercapnia is a term used to clarify the increase in ETCO2 that happens when a methodology of minimizing tidal volumes and respiratory cost to breathe able to minimize top airway and intrathoracic pressures is utilized.

       Some EMS and demanding reliance transport features expend heliox within the treatment of extreme asthma. Heliox is a low-density blend (an eighty:20 ratio is usual) of helium and oxygen that results in much less-turbulent circulation through airways narrowed through bronchoconstriction and edema. In thought, the reduce in turbulent airflow should influence in decreased work of respiration, less respiratory muscle fatigue, and a lessen probability of respiratory failure. besides the fact that children, an analysis of clinical trials assessing the expend of heliox suggests that there is insufficient facts to befriend common use, and it is continually regarded best for minute ones with extreme exacerbation of bronchial asthma no longer responding to intimate remedy.18

       a relatively new figure of oxygen therapy used in cases of light wheezing in neonates and toddlers is heated, humidified, excessive-circulate nasal cannula (HFNC) remedy. HFNC allows for for the delivery of high gas flows (1-8 L/min in infants), with or with out an expanded oxygen concentration.19 HFNC provides some degree of continuous positive airway power (CPAP), although accurate rates are challenging to predict. Neonatal reviews demonstrate that the quantity of CPAP generated is dependent upon the inch delivered relative to the size of the affected person and on the leak across the nasal cannula.20,21,22

       continuous fine airway power, or extra particularly, nasal continuous positive airway pressure (NCPAP), has been shown to better scientific scores, lessen respiratory expense and better air tide in toddlers with bronchiolitis or asthma.23,24 enjoy PEFP, besides the fact that children, NCPAP is not typically well tolerated by course of infants and youngsters.25 toddlers and youngsters with more huge respiratory distress or with apnea require endotracheal intubation and mechanical ventilation to befriend oxygenation and ventilation. a trademark of respiratory failure and impending respiratory arrest is the stressed, agitated baby in respiratory distress who All at once turns into compliant. This may additionally point out that the affected person is drained and/or severely hypercapnic.

    Beta-2 Agonists

       short-performing beta-2 agonists (SABAs), similar to albuterol and levalbuterol, delivered with the aid of small-volume nebulizer, are the treatment of selection for babies with acute exacerbation of asthma. The proof aiding their expend in infants with wheezing secondary to bronchiolitis is less conclusive; despite the fact, there's sufficient medical overlap between bronchial asthma and bronchiolitis that both can not breathe unusual on physical examination findings by myself. therefore, for the paramedic working in the prehospital environment, management of the child or infant providing with wheezing of unknown etiology may soundless involve the expend of SABAs.

    Beta-agonists set off beta-2 receptors in the lungs, leading to leisure of bronchial light muscle, bronchodilation and better airflow.

       Epinephrine 1:a thousand and terbutaline, administered subcutaneously, can moreover breathe utilized in middling to austere exacerbations of asthma. due to its profound cardiovascular effects, epinephrine is frequently reserved for those newborn and infant sufferers in reasonable to extreme asthma; it isn't advised in those pediatric patients with comorbidities (e.g., congenital heart sickness) that may well breathe advanced with the aid of the extreme cardiac stimulation that accompanies its use.

    Anticholinergics

       Anticholinergics inhibit muscarinic cholinergic receptors in the airway, decreasing the intrinsic vagal tone latest and leading to bronchodilation. Ipratropium bromide (IB) is an anticholinergic intimate in the prehospital environment. The onset of motion of IB is long, and clinical advantages will moreover breathe delayed for as much as 60 minutes. regardless of the delayed onset of motion, studies beget shown that the expend of SABAs with IB is more advantageous in reversing bronchoconstriction than using SABAs by myself.26,27 It isn't individual to beget prehospital protocols that permit for administration of each medicinal drugs, which are placed birthright into a small-extent nebulizer and administered at the identical time as.

    Corticosteroids

       while corticosteroids are prevalent within the treatment of qualify to extreme bronchial asthma, their expend in bronchiolitis is limited. They don't appear to breathe considered a typical of reliance for the management of bronchiolitis (however they are used), and aren't advised to breathe used in up to now appropriate children with RSV.28 Corticosteroids are used to reduce the inflammation and edema linked to both acute exacerbation and constant bronchial asthma, and are most generally administered by the expend of IV within the prehospital atmosphere. enjoy anticholinergics, there's a delayed onset of motion (as much as a number of hours), so the advantages may additionally now not breathe clinically apparent within the prehospital atmosphere, however there's an competencies to early administration. An case of an intravenous corticosteroid often utilized by means of EMS is methylprednisolone (Solu-Medrol).

    Magnesium Sulfate

       there's enough proof to intimate that IV or inhaled magnesium sulfate may moreover capitalize each adults and children with austere bronchial asthma.29,30 Magnesium acts as a immaculate muscle relaxant and promotes bronchodilation, and the administration of magnesium has been proven to outcomes in diminished airway resistance and enhanced ventilation in adults. latest strategies posted in the country wide heart, Lung, and Blood Institute, countrywide Institutes of health's national asthma training and Prevention application professional Panel file three, guidelines for the analysis and management of bronchial asthma don't advocate a selected dose or route for magnesium within the newborn or pediatric inhabitants.

    table 1: asthma in the Pediatric affected person assessment device

      mildMODERATE excessiveFeeding standard much less terrible SaO2 on elbowroom air >/=ninety five% ninety%-ninety five% <ninety% degree of dyspnea Dyspnea only with endeavor Dyspnea interferes with or limits typical exercise Dyspnea at leisure, interferes with dialog Retractions None/minimalIntercostal Suprasternal accessory muscle use None huge excessiveWheezing None/minimal cease expiratory moderate, All the course through expiratory severe inspiratory and/or expiratory wheezing audible devoid of stethoscope Presence of lung sounds Full and equal breath sounds bilaterally lowered breath sounds, bilateral or localized numerous areas of reduced breath sounds intellectual prestigeAlert Alert/stressed restless/lethargic Inspiratory/expiratory ratio 1:1 1:2 Exceeds 1:2

    This continuing training activity is authorised by course of EMS World journal, an organization approved through the continuing training Coordinating Board for Emergency scientific functions (CECBEMS), for 1.5 CEUs. To win your credits, fade to www.rapidce.com, or to print and mail a replica, down load the test birthright here.

    References

    1. Henrickson KJ, Hoover S, Kehl KS, Hua W. countrywide sickness tribulation of respiratory viruses detected in minute ones through polymerase chain response. Pediatr Infect Dis J 23(Suppl):eleven, 2004.2. centers for ailment maneuver and Prevention. Respiratory Sycytial Virus an infection: an infection and Incidence. www.cdc.gov/rsv/about/infection.html. updated January 25, 2010.3. chief S, Kohlhase k. simultaneous trends in austere respiratory syncytial virus (RSV) among US infants, 1997 to 2000. J Pediatr 143(suppl):S127 -S132, 2003.four. Mullins JA, Lamonte AC, Bresee JS, Anderson LJ. huge variability in community respiratory syncytial virus season timing. Pediatr Infect Dis J 22:857-886, 2003.5. Thompson WW, Shay DK, Weintraub E, et al. Mortality linked to influenza and respiratory syncytial virus within the united states. JAMA 289(2):179-186, Jan eight 2003.6. corridor CB, Weinberg GA, Iwane MK, et al. The tribulation of respiratory syncytial virus an infection in young babies. N Engl J Med 360(6):588-598, Feb 5, 2009.7. Purcell okay, Fergie J. Driscoll toddlers's hospital respiratory syncytial virus database: risk components, remedy and sanatorium direction in 3308 infants and younger infants, 1991 to 2002. Pediatr Infect Dis J 23:418-423, 2004.8. Welliver RC. overview of epidemiology and clinical haphazard factors for austere respiratory syncytial virus (RSV) an infection. J Pediatr 143:S112-S117, 2003.9. Navas L, Wang E, de Carvalho V, et al. superior outcome of respiratory syncytial virus infections in a high-chance hospitalized inhabitants of Canadian toddlers. J Pediatr121:348-354, 1992.10. López-Alarcón M, Villalpando S, Fajardo A. Breastfeeding lowers the frequency and period of acute respiratory an infection and diarrhea in toddlers under six months of age. J Nutr 127(3):436 -443, 1997.eleven. Wright AL, Bauer M, Naylor A, et al. expanding breastfeeding fees to in the reduction of newborn sickness on the neighborhood stage. Pediatrics a hundred and one(5):837-844, 1998.12. facilities for disease manage and Prevention. Respiratory syncytial virus an infection (RSV).13. facilities for ailment maneuver and Prevention. 2007 national health Interview Survey Public expend facts File. www.cdc.gov.14. facilities for ailment maneuver and Prevention. countrywide Surveillance for bronchial asthma-u.s., 1980-2004. www.cdc.gov/mmwr/preview/mmwrhtml/ss5608a1.htm.15. Akinbami L. The situation of childhood bronchial asthma, united states, 1980-2005. Adv statistics 381:1, 2006.16. Geelhoed GC, Landau LI, Le Souef PN. contrast of SaO2 as a predictor of outcomes in 280 toddlers featuring with acute asthma. Ann Emerg Med 23:1236, 1994.17. Gorelick MH, Stevens MW, Schultz TR, Scribano PV. efficiency of a novel scientific rating, the Pediatric bronchial asthma Severity rating (pass), within the evaluation of acute bronchial asthma. Acad Emerg Med eleven:10, 200418. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Systematic stories 4:CD002884, 2006.19. de Klerk A. Humidified excessive-circulate nasal cannula: Is it the brand new and improved CPAP? Adv Neonatal reliance eight:ninety eight-106, 2008.20. Kubicka ZJ, Limauro J, Darnell RA. Heated humidified high-movement nasal cannula therapy: Yet yet another approach to carry continuous fine airway power? Pediatrics 121: eighty two-88, 2008.21. Lampland AL, Plumm B, Meyers PA, et al. Observational inspect at of humidified high-circulation nasal cannula in comparison with nasal constant nice airway force. J Pediatr 154:177-182, 2009.22. Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H. high-flow nasal cannulae in the administration of apnea of prematurity: A evaluation with common nasal constant wonderful airway power. Pediatrics 107:1081-1083, 2001.23. Thia LP, McKenzie SA, Blyth TP, et al. Randomised managed tribulation of nasal continuous wonderful airway power in bronchiolitis. Arch Dis newborn ninety three:637-638, 2008.24. Larrar S, Essouri S, Durand P, et al. results of nasal continuous high trait airway obligate air tide in children with austere acute bronchiolitis. Archives de Pediatrie 13:1397-1403, 2006.25. Yong SC, Chen SJ, Boo new york. Incidence of nasal trauma linked to nasal prong versus nasal masks All over constant efficacious airway obligate treatment in very low birthweight minute ones: A randomized control inspect at. Arch Dis infant Fetal Neonatal Ed 90:F480-F483, 2005.26. Schuh S, et al. Efficacy of time-honored nebulized ipratropium bromide brought to universal high-dose albuterol therapy in austere childhood asthma. J Pediatr, 1995.27. Qureshi F, Pestian J, Davis P, Zaritsky A. effect of nebulized ipratropium on the hospitalization costs of toddlers with asthma. N Engl J Med 339:1030, 1998.28. Watts KD, Goodman DM. Wheezing, Bronchiolitis, and Bronchitis. In: Kliegman: Nelson Textbook of Pediatrics, 18th ed., Saunders, 2007.29. Rowe BH, et al. Intravenous magnesium sulfate remedy for acute bronchial asthma within the emergency department: a scientific evaluate of the literature. Ann Emerg Med 36:181, 2000.30. Cheuk DK, Chau TC, Lee SL. A meta-evaluation on intravenous magnesium sulphate for treating acute bronchial asthma. Arch Dis newborn ninety:74, 2005.

       Scott R. Snyder, BS, NREMT-P, is the EMS education supervisor for the San Francisco Paramedic affiliation in San Francisco, CA, where he is amenable for the original and carrying on with schooling of EMTs and paramedics. Contact him at scottrsnyder@me.com.

    Michael Santiago, DO, EMT-P, is an attending physician within the ED and director of prehospital reliance at Rochester commonplace health hub in Rochester, new york. Contact him at ems@rochestergeneral.org.

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    Operations & Process Management: Principles & Practice for Strategic ImpactOperations & Process Management: Principles & Practice for Strategic Impact
    By Nigel Slack, Alistair Jones
    Publisher : Pearson (Feb 2018)
    ISBN10 : 129217613X
    ISBN13 : 9781292176130
    Our ISBN10 : 129217613X
    Our ISBN13 : 9781292176130
    Subject : Business & Economics
    Price : $75.00
    Computer Security: Principles and PracticeComputer Security: Principles and Practice
    By William Stallings, Lawrie Brown
    Publisher : Pearson (Aug 2017)
    ISBN10 : 0134794109
    ISBN13 : 9780134794105
    Our ISBN10 : 1292220619
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    Subject : Computer Science & Technology
    Price : $65.00
    Urban EconomicsUrban Economics
    By Arthur O’Sullivan
    Publisher : McGraw-Hill (Jan 2018)
    ISBN10 : 126046542X
    ISBN13 : 9781260465426
    Our ISBN10 : 1260084493
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    Subject : Business & Economics
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    Urban EconomicsUrban Economics
    By Arthur O’Sullivan
    Publisher : McGraw-Hill (Jan 2018)
    ISBN10 : 0078021782
    ISBN13 : 9780078021787
    Our ISBN10 : 1260084493
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    Subject : Business & Economics
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    Understanding BusinessUnderstanding Business
    By William G Nickels, James McHugh, Susan McHugh
    Publisher : McGraw-Hill (Feb 2018)
    ISBN10 : 126021110X
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    Our ISBN10 : 126009233X
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    Subject : Business & Economics
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    Understanding BusinessUnderstanding Business
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    Publisher : McGraw-Hill (May 2018)
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    Our ISBN10 : 126009233X
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    Subject : Business & Economics
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    Understanding BusinessUnderstanding Business
    By William Nickels, James McHugh, Susan McHugh
    Publisher : McGraw-Hill (Jan 2018)
    ISBN10 : 1260277143
    ISBN13 : 9781260277142
    Our ISBN10 : 126009233X
    Our ISBN13 : 9781260092332
    Subject : Business & Economics
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    Understanding BusinessUnderstanding Business
    By William Nickels, James McHugh, Susan McHugh
    Publisher : McGraw-Hill (Jan 2018)
    ISBN10 : 1259929434
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    Our ISBN10 : 126009233X
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    Subject : Business & Economics
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    Publisher : McGraw-Hill (Jan 2017)
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    Subject : Business & Economics, Communication & Media
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    By Peter Cardon
    Publisher : McGraw-Hill (Feb 2017)
    ISBN10 : 1260147150
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    Our ISBN10 : 1259921883
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    Subject : Business & Economics, Communication & Media
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