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H. Ooboshi et al.
shock. Transient loss of consciousness due to
vasovagal reex (transient bradycardia and
decrease in blood pressure due to pain stimulation against a background of anxiety and tension)
that occurs during dental treatment is frequent
but transient, and if it persists, other diseases
should be considered. Asphyxia causing hypoxia,
cardiac disease, and respiratory disease should
also be considered. Although rare, anaphylactic
shock and poisoning caused by anesthetics and
other drugs should be considered.
4.2 Delirium
Delirium is particularly common in the elderly,
in patients with dementia, and in patients with
severe physical complications. The risk factors
for delirium are known to be dementia, mild
cognitive impairment, history of delirium,
impairment of life function, visual impairment,
hearing impairment, severe physical illness,
depression, transient cerebral ischemia or
stroke, alcohol dependence, and the elderly
[12]. According to the diagnostic criteria of the
American Psychiatric Association [13], delirium (1) impairs attention and consciousness, (2)
tends to occur over a short period of time and
uctuates in severity over the course of a day,
(3) is associated with disorientation and other
cognitive decits, (4) does not occur in neurocognitive disorders or coma, (5) is not associated with other existing, established, or ongoing
neurocognitive disorders and does not occur in
the context of a marked decrease in arousal level
as in coma, and (6) is caused by physical illness
or substance intoxication.
The triggering factors are as follows [14]:
1. Environmental factors: hospitalization,
brightness, noise, and ICU admission
2. Physical factors: pain, dehydration, low nutrition, immobilization by intravenous infusion,
and drains or restraints
3. Sensory factors: loss of vision and hearing
4. Psychological factors: psychological stress
5. Anxiety, depression, and sleep-related factors: insomnia, disturbance of day-night
rhythm, and sleep-related disorders
Therefore, preventive interventions include
the following [15, 16]:
1. Cognitive function and disorientation: provide adequate lighting, clocks, and calendars, and facilitate visitation.
2. Dehydration and constipation:
Recommendations for moderate drinking
and appropriate uid replacement.
3. Hypoxia: Management of oxygen
saturation.
4. Limitation of movement: Recommendations
for walking and rehabilitation.
5. Infection: Treatment of infection and removal
of unnecessary catheter.
6. Multidrug combination therapy: Multidrug
combination therapy.
7. Pain: Do not overlook pain when communication is limited.
8. Low nutrition: Guidance on nutritional support. Dentures: Appropriate adjustment.
9. Sensory impairment: Provide assistance to
ensure that vision and hearing function
properly.
10. Sleep disorders: Minimize nighttime treatment and maintain quietness.
The administration of psychotropic drugs is
also considered as a symptomatic
pharmacotherapy.
5 Convulsion
MasayoFukuhara
A convulsion is a seizure in which a muscle contracts involuntarily, that is, independently of the
person’s will. It may occur in the whole body or
in some muscles.
In most cases, short convulsive attacks lasting a
few seconds to a few minutes occur. Along with
convulsions, abnormal body sensation, unresponsiveness (behavioral arrest), and disturbance of
consciousness may be observed. Vomiting and urinary and fecal incontinence may also occur with
loss of consciousness. Headache, general malaise,
clouding of consciousness, and weakness of the
extremities may also occur after the seizure.
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Table 4.6
conditions)
1. Central
2. Other
Causes of convulsions (diseases and
Epilepsy, cerebrovascular disease
nervous
system
disease
than
central
disease
(stroke)/encephalitis,
meningoencephalitis/trauma/brain tumor
Metabolic abnormalities: Electrolyte
abnormalities (Na, Ca) and blood
glucose abnormalities (hyperglycemia,
hypoglycemia)
Hypoxia
Hepatic failure: Hepatic encephalopathy
Renal failure: Uremia
Drug addiction
Febrile convulsion
There are various causes of convulsions.
Table4.6 shows the diseases and conditions that
can cause convulsions. The order is not necessarily the most common, but they are the ones that
need to be differentiated.
Repeated convulsions caused by repetitive
hyperexcitability of cortical neurons (epileptic
ring) are included in epilepsy. For more information on epilepsy, please refer to “Epilepsy” in
Chap. 16.
Convulsions may occur as an acute symptom of
stroke (cerebrovascular disease), and examination
of hemiplegia and other neurological symptoms is
necessary. Regarding blood glucose abnormalities, both hyperglycemia and hypoglycemia can
cause convulsions. If the patient has underlying
diabetes mellitus, it is important to check the blood
glucose control status. In addition, hypoglycemia
may occur in patients who are taking diabetes
medication (oral diabetes medication, insulin).
Furthermore, when diabetes mellitus is complicated by infection, blood glucose may rise suddenly and hyperglycemia may occur. Hypoxia can
cause convulsions, and it is necessary to differentiate between the diseases that cause them.
The following is an explanation of febrile con-
vulsions. Febrile convulsions are the most common cause of childhood convulsions. Its
characteristics are shown in Table 4.7
. A tonicclonic seizure is a seizure in which the whole
body becomes stiff, the hands and feet stick out
strongly, and there is a repetition of a tonic phase
with ne convulsions and a clonic phase with
rhythmic movements.
Table 4.7
sions (especially simple febrile convulsions)
Concept Convulsive seizures occurring in
Susceptible
age
Duration Mostly 20min or less
Seizure Symmetric tonic-clonic seizure
Associated
with fever
Frequency Majority is less than four times a year
EEG Normal
Prognosis Simple type has a good prognosis
Concept and characteristics of febrile convul-
infancy associated with fever (usually
>38°C)
A clear cause of seizure, such as
central nervous system infection or
metabolic disease, should be excluded
6months to 6years
Often at the onset of fever
In addition, it should be remembered that anaphylactic shock and poisoning caused by anesthetics and other drugs occur rarely.
In case of convulsions, it is important to
check the vital signs and to secure the airway.
Consider the cause of the convulsions and
respond accordingly. If convulsions persist for a
long time or occur many times in a short time, it
is called “status epilepticus,” which is prone to
hypoxic conditions and requires immediate
treatment.
Physiological abnormalities of muscle tone,
such as cramp in the leg or temporary twitching
of the eyelids, are also called “cramps,” but these
do not require treatment in most cases.
6 Dizziness: Vertigo
HideoNiwa
There is a wide range of vertigo symptoms.
Some of the terms to describe vertigo represent
dizziness, presyncope, disequilibrium, and
light headedness. The diagnosis of vertigo can
be difcult because patients may not be able to
accurately describe their vertigo symptoms.
However, a detailed interview is important
because vertigo can be diagnosed to some
extent by interviewing the patient. In this section, we describe vertigo diseases that dentists
should pay attention to.
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6.1 Benign Paroxysmal Positional
Vertigo
Benign paroxysmal positional vertigo (BPPV) is
the most frequent form of peripheral vertigo and
is more common in patients over 50years of age
[17]. It is believed that oating otoliths in the
semicircular canal cause vertigo symptoms.
Vertigo occurs with head movement (turning
over, sitting upright). The onset is sudden and the
duration of vertigo is usually less than 1min. The
Dix-Hallpike maneuver shows characteristic
downwardly and torsionally beating nystagmus,
and the direction of nystagmus observed in the
supine position is opposite to that observed on
sitting upright. There are no cochlear symptoms
(hearing loss, tinnitus) associated with vertigo,
although nausea and vomiting may occur.
Treatment is mainly medication, but in the case
of otoliths suspended from the semicircular
canal, the Epley method is used to return the otolith to its original location. If nausea and vomiting are severe, anti-dizziness drugs and
antiemetics should be used. The patient may
recover autonomously and wait-and-see approach
may be taken.
characteristic nystagmus. Drug therapy consists
of anti-dizziness drugs and antiemetics.
Antianxiety drugs may also be used.
6.3 Meniere’s Disease
Meniere’s disease is characterized by repeated
symptoms of vertigo, hearing loss, and tinnitus.
Meniere’s disease occurs in a wide range of age
groups, from 20 to 60years old, and tends to be
more common in women. Meniere’s disease is
mainly thought to be endolymphatic hydrops,
which a clear uid can be found to increase in the
membranous labyrinth of the inner ear.
Treatments focused on sedation of vertigo and
improvement of hearing loss in the paroxysmal
phase. Osmotic diuretics, antivertigo drugs, and
anxiolytic drugs are used, and surgical treatment
such as injection of gentamicin into the middle
ear or endolymphatic sac decompression may be
performed in patients who do not respond to
pharmacotherapy. During the interictal period,
patients should improve their lifestyle to prevent
the onset of seizures. In Europe and the United
States, patients are advised to limit salt, water,
caffeine, and alcohol intake [19].
6.2 Vestibular Neuritis
Vestibular neuritis is a disorder of peripheral vertigo in which vertigo symptoms occur suddenly,
most commonly in patients in their 30s–50s, with
no difference in gender. It is thought to be caused
by a viral infection of the vestibular nerve and
has been reported to occur after upper respiratory
tract infections [18]. The onset of rotatory vertigo
accompanied by sudden severe nausea and vomiting may last for several days. It is a disorder of
the vestibular system without cochlear symptoms. Vertigo gradually resolves from a few days
to a few weeks, but a feeling of light headedness
may persist for several months. In most cases, the
lateral semicircular canal is affected, and rotatory
nystagmus toward the healthy side and a tendency to fall to the affected side are observed.
The Dix-Hallpike maneuver does not show any
6.4 Central Vertigo
About a quarter of patients with cerebellar or
brainstem abnormalities complain of vertigo
symptoms [20]. Central vertigo includes cerebral
hemorrhage, cerebral infarction, and vestibular
system tumors, and dizziness and gait ataxia
appear more frequently than vertigo. Vertical
nystagmus appears in central vertigo, and downbeat nystagmus is associated with cerebellar and
brainstem disorders, while upbeat nystagmus is
associated with medullary lesions. However, it
should be noted that brainstem infarction in the
vertebrobasilar artery region and vestibular nerve
system tumors may cause nystagmus as well as
peripheral vertigo. Central tumors include
auditory nerve tumors, which are schwannomas
derived from the vestibular nerve. The tumor pro-
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gresses slowly, and symptoms such as tinnitus,
hearing loss, and facial nerve palsy appear as the
tumor grows. Surgical treatment should be taken
into consideration and when the tumor is small,
stereotactic radiotherapy (gamma knife) is used.
6.5 Cardiovascular SystemRelated Dizziness
Although cardiovascular system-related dizziness is infrequent, when oating sensation persists for several months, or intermittent or short
dizziness symptoms appear during physical
movement, abnormal blood pressure, orthostatic
hypotension, bradyarrhythmia, and cerebrovascular disease should be considered, and cardiovascular system examination is necessary [21].
Eventually if a patient complains of dizziness
or vertigo, it is important to consult a specialist
(otolaryngology or neurology) to improve the
patient’s QOL.
7 Higher Brain Dysfunction
[22, 23]
KazuhiroMuramatsu
The human brain has three main functions: (1)
motor functions to move limbs and face, (2) perceptual functions to sense sounds, smells, and
touch; and (3) higher brain functions to control
memory, cognition, emotion, and language. In
other words, damage to function (3) results in
higher brain dysfunction.
The brain is responsible for higher functions,
with the cerebrum and thalamus playing a particularly important role. Brain damage can be
partial (localized) or generalized (diffuse) and
occur in various regions. Depending on the location, extent, and severity of the damage, higher
brain dysfunction has qualitatively and quantitatively different aspects, including language,
action, recognition, and memory.
In the examination of higher brain functions,
patients are asked to perform various tasks, but
none of the tasks can be performed using only
one psychological process. If an MRI or CT scan
has already been taken, it is practical to use the
images to predict possible symptoms and to focus
on them during the examination. If the patient’s
level of consciousness or attention is impaired, he
or she may not be able to follow many of the
instructions given in the examination of higher
brain dysfunction, and the correct evaluation may
not be possible.
7.1 Aphasia
Aphasia is a loss of language ability due to brain
damage. The aspects of language that are
impaired in aphasia can be roughly divided into
four categories: speech, comprehension, calling,
and recitation.
The center of brain regions related to language is thought to be located mainly around
the Sylvian ssure in the left cerebral hemisphere (peri-Sylvian ssure language area). In
the majority of right-handed people, and in
more than 70% of left-handed people, the language area is located in the left hemisphere.
The posterior part of the inferior frontal gyrus
is called Broca’s area, and the posterior part of
the superior temporal gyrus is called Wernicke’s
area. Broca’s aphasia is characterized by slurred
speech (nonuent), word distortion (dysarthria), mild comprehension impairment, and
poor recitation. Wernicke’s aphasia is smooth
(uent) speech, no dysarthria, severe comprehension impairment, and poor recitation
(Fig.4.1).
The terms alexia and agraphia are used to refer
to conditions in which the ability to read and
write is an acquired impairment as a result of
brain injury.
7.2 Apraxia
There are three main types of apraxia: ideomotor
apraxia, ideational apraxia, and limb kinetic
apraxia.
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Frontal Lobe
Broca
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Fig. 4.1 Language area
Holistic Integration
(Thinking and Control)
Kinetic System
Higher Motor Functions
s area
′
Thinking
Emotion
Temporal lobe
Auditory Sense
Olfaction
Memory
Motor Speech
Center
Somatic Perception
Voluntary Movement
Olfaction
Central Sulcus
Higher-order
Recognition function
Sensory Language
Center
H. Ooboshi et al.
Parietal lobe
Sensory system (somatic sensation)
Information Decomposition
Wernicke′s area
Occipital lobe
Vision
Vision
Table 4.8 Tests of ideational apraxia
1. Wave goodbye
2. Come on in
3. Do the soldier’s salute
4. Imitate brushing your teeth as if you were holding a
toothbrush
5. Imitate combing your hair as if you were holding a
comb
6. Imitate locking the door
7. Imitate hitting a nail as if you were holding a
hammer
First of all, it is carried out by verbal command, and
when it is not done well, the examiner shows the act
and makes it imitate
7.2.1 Ideomotor Apraxia
It is an impairment of the ability to perform a
learned intentional action. It occurs in righthanded people with left hemispheric damage and
affects the left and right upper limbs. The actions
are impaired (Table4.8).
In the case of ideational apraxia, the patient is
unable to perform the serial manipulation of multiple objects in daily life. For example, a candle,
a candleholder, and a match are prepared, and a
person is instructed, “Please light the candle
using these items.”
7.2.2 Limb Kinetic Apraxia
It is a condition in which the performance of actions,
mainly with the hands and ngers, is incomplete,
coarse, or interrupted. Patients have difculties in
using chopsticks or fastening buttons.
7.2.3 Oral-Facial Apraxia
Intentional execution of movements using the
muscles of the lower face, tongue, larynx, and
pharynx is impaired. In severe cases, patients are
unable to open their mouths when asked to do so
but can open their mouth in natural situations
such as eating or in reexes such as yawning.
This symptom is caused by damage to the left
hemisphere.
7.2.4 Dressing Apraxia
It is a symptom of an inability to put on individual clothes or to put them on in the wrong way. It
occurs in right hemisphere injuries.
7.3 Agnosia
We know what an object is when we see it, and
we know who a person is when we see their face.
We can also hear sounds and spoken words and
understand their source and meaning. These easily and immediately recognizable abilities can be
impaired despite the fact that we can see and
hear.
7.3.1 Visual Agnosia
It is a cognitive impairment of visually presented
objects, and recognition through other senses
(e.g., touch) is well maintained. Although the
visual acuity and eld of vision are sufcient to
recognize the object, the patient is unable to rec-
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ognize the object. It is caused by damage to the
bilateral occipital lobes.
7.3.2 Prosopagnosia
You see a familiar face, and you do not know who
it is. On the other hand, you can recognize someone by listening to his or her voice. Not only can
they not say the name of a person they knew
before their illness, but they also cannot tell what
kind of person the person is, such as their
occupation.
7.3.3 Cortical Deafness
It is a condition of deafness caused mainly by
lesions of the bilateral temporal lobes. The patient
is said to be deaf and unresponsive to loud
sounds, whether pure tones, speech sounds, or
environmental sounds.
7.3.4 Tactile Agnosia
Inability to recognize objects by touch, despite
the absence of somatosensory disturbance. It
appears on the hand contralateral to the cerebral
hemispheric lesion (mainly in the parietal lobe).
7.4 Memory Disorder
The inability to remember new things and the difculty in recalling old experiences and knowledge are disorders of declarative memory. The
term “declaration” refers to the ability to consciously express memory information regardless
of its verbal nature. Procedural memory is a
memory that can be preserved in clinical amnesic
patients, and it can be preserved in movements,
actions, and behaviors.
8 General Malaise
ToshimiChiba
8.1 Concept
General malaise is a subjective symptom of
feeling tired or languid. It is synonymous with
easy fatigability and fatigue. Even healthy people feel general malaise due to physical or mental overwork, stress, lack of sleep, etc., and it is
called physiological overwork. However, pathological malaise is considered when the patient
does not recover even after rest or when the
workload is not so heavy as to make the patient
feel tired.
8.2 Pathophysiology
Physical fatigue is caused by hypotension,
chronic inammation, hormone secretion abnormalities, low nutrition, electrolyte abnormalities,
and drugs, while mental fatigue is caused by
depression and neurosis.
8.3 Dierentiated Diseases
1. Psychoneurotic diseases: neurosis, psychosomatic disorders, depression, and schizophrenia are considered as mental fatigue.
2. Infectious diseases: General malaise is often
observed in patients with slight fever due to
infectious diseases. In elderly patients, only
malaise may be present without noticing
slight fever. In addition, anorexia may lead to
low nutrition. Bacterial infections such as
endocarditis, tuberculosis, and abscesses, fungal infections, parasitic infections, and viral
infections such as AIDS are common causes.
3. Chronic inammatory diseases: General malaise may be observed in sarcoidosis and collagen diseases.
4. Neuromuscular diseases: General malaise
may be observed in myasthenia gravis, multiple sclerosis, etc.
5. Endocrine and metabolic diseases: Endocrine
diseases include Addison’s disease, hypothyroidism, and anterior hypopituitarism, which
cause hypotension. Diabetes mellitus is a
representative metabolic disease, and vitamin
B1 deciency also causes malaise mainly in
the lower limbs.
6. Drugs: Alcohol, narcotics, organic solvents,
heavy metals, and pesticides may cause general malaise.
7. Water-electrolyte imbalance: Hyponatremia
associated with vomiting and diarrhea, and
other symptoms such as hypopotassemia,
hyperpotassemia, hypocalcemia, hypercalce-
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mia, hypophosphatemia, and hypermagnesemia may cause general malaise.
8. Chronic diseases of each organ
(a) Hematologic diseases: Persistent malaise
may be observed in iron-deciency anemia. Pallor of the skin and mucous membranes may occur.
(b) Respiratory disease: Respiratory tract
infection may cause general malaise with
cough and sputum.
(c) Cardiac disease: Heart failure, valvular
heart disease, arrhythmia, etc. may cause
general malaise, accompanied by heart
murmur and hypertension.
(d) Gastrointestinal diseases: Anemia due to
peptic ulcer or chronic gastritis may cause
general malaise.
(e) Liver disease: General malaise and jaun-
dice may be observed due to liver
dysfunction.
(f) Renal disease: Edema and hypoprotein-
emia may be accompanied by general
malaise.
9. Malignancy: General malaise due to latent
malignancy may occur.
8.4 Diagnosis andExamination
On physical examination, fever is suspicious for
infection, yellowing of the ocular conjunctiva for
liver disease, edema for renal disease, eyelid conjunctiva for anemia, and protruding eyeballs and
the presence of a neck mass for thyroid disease.
In screening tests, positive urine protein indicates renal disease, and positive urine sugar indicates diabetes mellitus. In blood tests, decreased
hemoglobin (Hb) concentration is considered to
be anemia; abnormal of white blood counts
(WBC) or leukocyte fraction indicates leukemia.
In blood biochemistry tests, elevated CRP is suspected to be infectious disease, and elevated AST
(aspartate transaminase) and ALT (alanine transaminase) indicate liver disease. BUN (blood urea
nitrogen) and creatinine (Cr) are useful in screening for renal disease, serum Na, K, and Cl for
electrolyte abnormalities and T3, T4, and TSH
for thyroid disease. Chest radiography should be
performed when cardiac or pulmonary disease is
suspected, and electrocardiogram should be performed when cardiac disease is suspected.
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Endocrine/Renal/Blood/Other
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Symptoms
YoshiharuYajima, KeikoNaruse,
KimihiroMatsumoto, MasahiroIeko,
ToshimiChiba, YoshihiroMatsukawa,
NatsumiIkumi, andRyoichiTanaka
5
1 Dehydration
YoshiharuYajima
1.1 Introduction
Dehydration is caused by the loss of body uid
either external environment or internal biophysiological factors. Because the amount of body uid
volume depends on the balance between extracellular water and serum sodium concentration, dehydration is classied according to serum sodium
concentration. Severe dehydration can lead to lifethreatening conditions. Moreover, inappropriate
treatment can elicit serious complications.
Y. Yajima
Division of Internal Medicine, The Nippon Dental
University School of Life Dentistry at Tokyo,
Chiyoda-ku, Tokyo, Japan
K. Naruse
Department of Internal Medicine, School of
Dentistry, Aichi Gakuin University,
Nagoya, Aichi, Japan
K. Matsumoto
Department of Internal Medicine, Tokyo Dental
College, Ichikawa General Hospital,
Ichikawa, Chiba, Japan
M. Ieko
Department of Nursing, Faculty of Health and
Medical Sciences, Sapporo University of Health
Sciences, Sapporo, Hokkaido, Japan
1.2 Symptoms
Typical symptoms appeared in dehydration status, such as dry mouth, weakness, lightheadedness, indifference, anorexia, nausea and vomiting,
headache, dizziness, hypotension, convulsion
(seizure), somnolence, coma, etc.
1.3 Physical Findings toBeConrmed
Basic vital signs informations such as body temperature, blood pressure, pulse rate, frequency of
respiration, and level of consciousness would be
conrmed as soon as possible. Also skin condi-
T. Chiba (*)
Division of Internal Medicine of Dentistry,
Department of Oral Medicine, Iwate Medical
University, Morioka, Iwate, Japan
e-mail: toschiba@iwate-med.ac.jp
Y. Matsukawa
Department of Internal Medicine, Tsurumi University
Dental Hospital, Yokohama, Kanagawa, Japan
N. Ikumi
Nihon University School of Medicine,
Itabashi-ku, Tokyo, Japan
R. Tanaka
Division of Dental Radiology, Department of
Reconstructive Oral and Maxillofacial Surgery, Iwate
Medical University School of Dentistry,
Yahaba, Iwate, Japan
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
T. Chiba, H. Yamada (eds.), Internal Medicine for Dental Treatments,
https://doi.org/10.1007/978-981-99-3296-2_5
53
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Y. Yajima et al.
tion or turgor and local moisture level in the
tongue, oral mucosa, and axilla, and enophthalmos can reect the severity of dehydration.
1.4 Causes
1.4.1 Poor Intake ofWater andSalt
Oral diseases, anorexia and malnutrition due to
gastrointestinal diseases, intake difculties due
to living and working environment, cranial nerve
diseases with oral intake difculties, some eating
disorders, and malabsorption due to gastrointestinal edema caused by hypoproteinemia.
1.4.2 Loss ofWater andSalt
1. Loss from urine: osmotic diuresis due to disease, salt-losing nephropathy, and diuretic use
2. Loss from the gastrointestinal tract: Leakage
into the interstitium due to vomiting, diarrhea,
intestinal obstruction, or peritonitis
3. Loss from the skin: Leakage into the interstitium due to sweating by exercise, work, high
temperature environment, or burns
1.5 Disease Classication
1.5.1 Hypertonic Dehydration
A state in which the serum Na concentration is
high. Both extracellular and intracellular uid are
decreased. Water is lost, and intracellular dehydration increases, resulting in a strong complaint
of thirst. It is seen in children and elderly patients
with high fever.
infrequent, it is seen in adrenal insufciency, saltlosing nephropathy, and inappropriate correction
of dehydration.
1.6 Dehydration inChildren
In childhood, the balance of the body is maintained with a high level of extracellular uid, but
the kidney concentrating ability is immature and
the body is small, so there is little extracellular
uid in reserve. Therefore, the loss of water and
salt can easily lead to dehydration. When dehydration is evident, it is important to consider the
possibility that the patient may already be
severely dehydrated. In addition, the patient may
not be able to report his or her symptoms appropriately; sufcient consideration is required.
1.7 Dehydration inElderly
Elderly patients are often receiving medications
for underlying diseases. For example, concomitant use of diuretics, laxatives, and some diabetic
agents may predispose them to dehydration due
to polyuria and diarrhea. The elderly have a relatively low extracellular uid volume and, as in
children, can easily become dehydrated due to
changes in physical condition. Dehydration and
heat stroke can easily occur in elderly patients
with reduced ability to adapt to the environment,
especially if they have poor appetite and difculty in uid and salt intake.
1.5.2 Isotonic Dehydration
A state in which the serum sodium concentration
is maintained. Extracellular uid is decreased,
but intracellular uid is maintained. It is seen in
large amounts of diarrhea, vomiting, and burns.
1.5.3 Hypotonic Dehydration
A state in which the serum sodium concentration
is low. The extracellular uid is decreased, but
the intracellular uid is maintained. Peripheral
circulatory insufciency is likely to occur
because salts are lost in larger amounts. Although
1.8 Heat Attach andDehydration
Heat attach is a general term for conditions
caused by impaired body adaptation to hot environments; dehydration in hot environments is
particularly referred to as heat attach. High temperature, high humidity, strong solar and radiant
heat, and light or no wind under high temperature
conditions all interfere with the body’s ability to
dissipate heat. Heat attach develops when the balance between heat production and dissipation in
the body is disturbed due to these environmental
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