This document discusses recent advances in cardiac trauma management. It begins by noting that cardiac injuries continue to cause significant mortality despite trauma care improvements. Most injuries are from violence, with penetrating wounds having a better outcome than gunshots. Rapid diagnosis and surgery can save patients otherwise lost. The treatment of cardiac trauma is described, from ancient times to modern developments like cardiopulmonary bypass enabling complex injury repair. Initial trauma management priorities and diagnostic tests are outlined. Treatment depends on injury mechanism and stability, and may involve pericardiocentesis, thoracotomy, or cardiorrhaphy surgery. Advances in cardiac surgery have allowed for more successful management of traumatic cardiac injuries.
Mediastinal injury includes cardiac, thoracic aorta, pulmonary vessels and SVC injury. Pelvic includes pelvic fracture. GI injury includes upper and lower GI injuries. Abdominal vascular includes abdominal aorta, IVC and other named vascular injury.
thoracic injury during trauma is one of most important life threaten that maybe occurred. so all of medical practitioner must learn and must do some primary survey
Mediastinal injury includes cardiac, thoracic aorta, pulmonary vessels and SVC injury. Pelvic includes pelvic fracture. GI injury includes upper and lower GI injuries. Abdominal vascular includes abdominal aorta, IVC and other named vascular injury.
thoracic injury during trauma is one of most important life threaten that maybe occurred. so all of medical practitioner must learn and must do some primary survey
chest trauma is one of the leading cause of death in poly trauma patients. ER doctor should be aware of how to suspect and how to deal with life threatening conditions resulting from chest trauma
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
chest trauma is one of the leading cause of death in poly trauma patients. ER doctor should be aware of how to suspect and how to deal with life threatening conditions resulting from chest trauma
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
3. ❑ Despite the improvement in trauma care, injuries
to the heart continue to be a source of significant
mortality.
❑ Most cardiac injuries are secondary to acts of
violence. Penetrating wounds from sharp objects is
associated in general with a better outcome than
those resulting from gunshot.
❑ A rapid diagnosis and surgical intervention can
salvage patients who would otherwise be lost.
4.
5. ❑The treatment of trauma to the heart has been written
about since 3000 BC and had an inauspicious beginning.
❑Until 19th century , commonly held believe that “all
penetrating cardiac trauma is fatal.”
❑Scenario changed in 20th century – successful treatment
of cardiac injuries began.
❑The first successful cardiac repair was performed by Dr.
Ludwig Rehn of Frankfurt on 9 September 1896
❑During World War II, it was recognized that cardiac
tamponade could be successfully managed by
pericardiocentesis.
6. ❑With the advent of CPB by GIBBON in 1953, repair of
more complex injuries became possible.
Initial Assessment and
general assessment
7. ✓ Initial treatment starts with standard Advanced Trauma
Life Care (ATLS) support protocols.
✓ The primary priority is
①Ensuring the patency of the airway
②Establishing adequate oxygenation and ventilation
③Assessment of circulatory system
8. ✓This may include tube thoracostomy for drainage of
hemothorax from the pleural space to allow
reexpansion of the lung.
✓Priority is given to establishing intravenous access
for the administration of crystalloid and/ or blood
products.
✓Sonographic confirmation for cardiac tamponade;
whether it is due to hemopericardium or due to RV
collapse during diastole.
9. ✓Treatment algorithm for cardiac trauma depends on
A. Mechanism of injury B. Hemodynamic status
According to nature of injury, it can be classified as
①Penetrating Cardiac Injury
10. ②Blunt Cardiac Injury
❖Most frequently occur with trauma to the anterior
chest. But, may occur with trauma to the upper
abdomen, chest, back and neck.
❖Majority of the injuries are anteriorly located and on
the right side of the heart.
Right Atrium 14%
15. Gunshot Chest
Iatrogenic injuries:
❖ Another form of penetrating cardiac injury and
increased in modern era.
❖ Occurs during various percutaneous interventional
and electrophysiological procedures. eg.
Pacemaker, ICD implantation, ASD occlusion
devices, coronary catheterisation, central line
placement etc.
16. ❖ Reported as high as 6% for radiofrequency ablation
procedures.
❖ Prompt recognition of such injury are essential to
successful treatment.
Cardiac Fistulas:
❖ Uncommon yet dramatic complication from cardiac
trauma.
❖ Fistulous connection can occur between coronary
arteries, aorta and directly with the cardiac
chambers.
17. ❖ Presentation is variable from acutely after injury to
decades post injury.
❖ Patients often present with congestive heart failure
and surgical repair is usually required.
❖ Blunt cardiac injury (BCI) refers to injury sustained
due to blunt trauma to the heart.
❖ Are generally seen in the setting of high impact
trauma.
18. ❖ The manifestations of such range from clinically
silent, transient arrhythmias to deadly cardiac wall
rupture.
❖ In 2004 Schultz et al found myocardial contusion to
be the most commonly reported blunt cardiac injury
(60-100%).
❖ The distribution of injury amongst the different heart
chambers relates to the anterior positioning of the
right sided chambers in the chest.
❖ RV injury and RA injury are more common.
❖ Septal, coronary artery, and valve injuries occur
even more rarely
19. Right Atrium 8-65%
Right Ventricle 17-32%
Left Atrium 0-31%
Left Ventricle 8-15%
Source: AAST
◆Requires significant force to cause BCI (chest impact
> 15mph).
20. ◆Most frequently seen in motor vehicle crashes and
cases of pedestrians struck by motor vehicles.
◆Other mechanisms, such as falls, crush injuries,
assault, and sports related injuries with direct blows
to the chest also contribute.
◆Alternatively, severe abdominal compression can
lead to rapid increase in blood flow to the heart from
the inferior vena cava with chamber rupture due to a
sudden increase in intracardiac pressure.
21. ◆Commotio cordis: A rare type of BCI in which low
impact trauma causes sudden cardiac arrest, usually
22. occurs from being struck by a projectile during
sports. The cardiac arrest is theorized to occur from
the timing of the blow during a period of susceptibility
More comprehensively, BCI can be broken
down into different injury patterns:
I. Pericardial Injury
II. Valvular Injury
III. Coronary Artery Injury
IV.Cardiac Chamber Rupture
25. ❑ May range from complete hemodynamic stability to
acute cardiovascular collapse and frank
cardiopulmonary arrest.
❑ Clinical presentation depends on several factors
▪ Mechanism of wound
▪ Length of time elapsed prior to arrival in a trauma
center
▪ Extent of injury, i.e. if sufficiently large , causes
exsanguinating hemorrhage
26. ▪ Whether blood loss exceeds 40-50% of the
intravascular blood volume, resulting in cessation of
cardiac function
▪ Whether pericardial
tamponade is
present/absent
❑ Pericardial tamponade:
• Physiology of pericardial
tamponade is related to the
fibrous nature of
pericardium. • Sudden acute loss of intracardiac
27. blood volume lead to acute intrapericardial rise of
pressure and compression of the thin walled right
ventricle.
• Resulting decrease ability to fill and effectively
decreasing Cardiac Output and stroke volume.
• Increased myocardial wall tension causes increased
workload and thereby develop greater oxygen
demand.
• Failing to meet increased oxygen demand results in
hypoxia, oxygen debt and lactic acidosis.
28. ❑ Beck’s triad (with full blown pericardial
tamponade) consisting of
① Distended neck veins
② Muffled heart sound
③ Hypotension
❑ Kussmaul’s sign – paradoxical inspiratory
distension of neck veins upon expiration, which also
a classical sign of pericardial tamponade.
29. **Cardiac injuries can be extremely deceptive in their
clinical presentation, particularly thoracoabdominal
injuries which can be more lethal.
32. ✓ Cardiac enzymes
FAST:
Focussed assessment with sonography for trauma
With this technique it is possible to identify the
presence of intraperitoneal or pericardial free fluid.
In the context of traumatic injury, this fluid will
usually be due to bleeding.
Four areas are examined
a. Perihepatic space (Morison’s pouch /
hepatorenal recess)
33. b. Perisplenic space
c. Pericardium
d. Pelvis
Extended FAST- examination of both lungs
Advantages of FAST:
➢ FAST is less invasive
➢ No exposure to radiation
34. ➢ It is cheaper, but achieves similar accuracy
➢ It makes emergency care faster and better Chest
X-ray:
35. Penetrating(knife) injury Pericardial tamponade
Chest X-ray is very important in diagonsing cardiac
injuries
Important CXR findings:
➢ Widened mediastinum
➢ Obliteration of aortic knob
➢ Deviation of the trachea
➢ Elevation of right mainstem bronchus
36. ➢ Deviation of nasogastric tube (if any)
➢ Widened paratracheal stripe
➢ Hemothorax
➢ Fractures of rib / Scapula
37.
38. Left CXR demonstrates bullet overlying cardiac
silhouette, Right Transesophageal echocardiogram
showing bullet in septum
42. CT scan showing hemopericardum
associated with left sided hemothorax
43.
44. Treatment of penetrating injury
Can be further subdivided according to patient’s
vital sign upon presentation to hospital
A. Management of stable patient(Systolic blood
pressure >90 mm of Hg)
A. Management of unstable patient(Systolic blood
pressure <90 mm of Hg)
49. Surgical intervention:
❖ Penetrating trauma to the chest in an unstable
patient is an indication for thoracotomy and possible
cardiorrhaphy.
❖ The ventricles are involved in 80% of penetrating
cardiac wounds.
❖ Once a cardiac wound is identified, hemostasis
should be obtained quickly with a finger or Foley
catheter while closure materials are prepared.
50. ❖ Surgical staples may be a faster and safer closure
method than the traditional approach using suture
with pledgets.
❖ Once the laceration is isolated, several methods
exist for temporary hemostasis
a) If the laceration is small enough, a finger may be
placed at the site of the laceration while suture is
prepared.
b) Lacerations to the atria can be controlled with
Satinsky vascular clamps.
51. c) Alternatively, if the laceration is large, a Foley
catheter may be placed through the wound and the
balloon inflated.
Pericardiocentesis:
Pericardiocentesis is the aspiration of fluid from the
pericardial space that surrounds the heart.
52. ❖ This procedure can be life
saving in patients with cardiac
tamponade, even when it
complicates acute type A aortic
dissection and when
cardiothoracic surgery is not
available.
❖ Pericardiocentesis needle insertion sites. The
subxiphoid and the left sternocostal margin are the
most commonly used sites (black dots)
53. Needle insertion: Insert the spinal needle through
the skin incision directed toward the left shoulder at
54. a 45-degree angle to the abdominal wall and 45
degrees off the midline sagittal plane
Thoracotomy:
❑ Incision is given in either the fourth
or fifth intercostal space. In men,
this location corresponds to the
area inferior to the nipple; in
women, the inframammary fold can
be used as a landmark.
55. ❑ The incision should begin just lateral to the sternum
on the left and continue to the midaxillary line.
❑ Confine the incision to the inferior border of the
intercostal space throughout its course. This
ensures wide exposure with the rib spreader
through a single intercostal space and decreases
the possibility of injuring the neurovascular bundle
56. ❑ After opening the
pleura, rib sprader is
inserted through the
inter costal space.
❑ Chest is opened widely
enough to allow easy
access.
❑ Identify the pericardium
and make a longitudinal opening in the pericardial
sac anterior to the phrenic nerve.
57. ❑ Avoid the phrenic nerve, which runs vertically along
the lateral border.
❑ If cardiac tamponade is present, a gush of blood
ensues after the initial opening is made.
Cardiorrhaphy:
❖ Once a laceration is found, simple use of a
monofilament suture (eg, 2-0 Prolene) can be used.
❖ Pledgets are used to prevent further injury to
already friable myocardium.
58. ❖ To begin cardiorrhaphy thread nylon suture through
the Teflon pledget, and place a horizontal mattress
suture across the laceration.
Locate the injury Suture threading
59.
60. Surgical repair of Right Ventricle
✓ Diagnosing and treating cardiac trauma patients
always remains a significant challenge.
✓ But, in recent times a shift in management from
conservative to surgical approach occurred with the
advances in cardiothoracic surgery and the
presence of trained surgeons – making successful
cardiac trauma management possible.