Mark Little builds a framework for the clinical approach to patients with suspected poisoning or envenomation. Particularly useful in a country where everything is trying to kill you.
Fran Lockie is a Paediatric Emergency and Retrieval physician currently based in Adelaide. He is quickly becoming a leading expert in paediatric TBI and so was the perfect person to give this talk. The audio that goes with these slides is on Intensive Care Network (www.intensivecarenetwork.com). If you like these sorts of presentations, come to Cairns Bedside Critical care this September where we've got a great line up of speakers and we're doing it all again.
Frank Lockie, paediatric intensivist, discusses how kids are just little adults at Bedside Critical Care Conference 4 (Cairns, 2013)
The podcasts accompanying these slides will be uploaded onto www.intensivecarenetwork.com and libsyn.
Mark Little builds a framework for the clinical approach to patients with suspected poisoning or envenomation. Particularly useful in a country where everything is trying to kill you.
Fran Lockie is a Paediatric Emergency and Retrieval physician currently based in Adelaide. He is quickly becoming a leading expert in paediatric TBI and so was the perfect person to give this talk. The audio that goes with these slides is on Intensive Care Network (www.intensivecarenetwork.com). If you like these sorts of presentations, come to Cairns Bedside Critical care this September where we've got a great line up of speakers and we're doing it all again.
Frank Lockie, paediatric intensivist, discusses how kids are just little adults at Bedside Critical Care Conference 4 (Cairns, 2013)
The podcasts accompanying these slides will be uploaded onto www.intensivecarenetwork.com and libsyn.
Free handy references about Acute Coronary Syndromes Algorithm from the ACLS Certification Institute.
View all ACLS algorithms at http://www.aclscertification.com/
Case Studies (Clinical Pharmacy Assignment)
Case Studies
Case Study 1. Drug Related Problem
Case Study 2. Alcohol Toxicity
Case Study 3. Patient Counseling
Case Study 4. Peptic Ulcer
Case Study 5. Drug and the Newborn
Case Study 6. Night time Anxiety
Case Study 7. Clostridium Difficile
Case Study 8. Epilepsy and Pregnancy
Case Study 9. Parkinsonism
Case Study 10. Treatment May Be Worse Than Condition
Dr Ashling Lillis, National Director's Clinical Fellow Macmillan Support, final year trainee in Acute Oncology
Dr Clare Philliskirk, Trainee in Acute Medicine, West Midlands
Dr Sarbit Clare, Acute Medical Consultant, Sandwell and West Birmingham Hospitals
Simulation is one of the most important advances in healthcare education and skills training of our generation. We now have simulation mannequins that can blink, breath, or even give birth thus allowing us to practice scenarios and skills before we encounter them in real patients. However, these sim dummies are not real people and so it is all too easy to dehumanize the scenario. According to Dr Phil Hyde, Director of Children’s Major Trauma and Southampton Children’s Hospital, it is this lack of emotional attachment that makes pure sim inadequate for training health care professionals in the management of trauma – especially trauma in children.
In his talk from SMACC Chicago, Dr Phil Hyde illustrates why he and his colleagues have developed an educational program that takes sim to the next level. The key difference in this sim program is the incorporation of volunteer children to play the roles of injured paediatric patients. Another key aspect of this program are the incorporation of multidisciplinary teams including undergraduate students for all scenarios.
The benefits of such a program have been far reaching. For the health professionals involved, it humanizes the scenario and induces an emotional attachment to the training exercise which adds an essential component to the training. Furthermore, it teaches professionals from different fields (nursing, medicine, allied health etc) to work together in these scenarios as would normally occur in real life. For the children involved, it is a safe controlled environment where they can learn about the health professionals and the health system, they learn about primary prevention and they can provide feedback to staff from a different vantage point. The community benefits through the improved primary prevention which is the most important aspect of treating trauma, a “man made disease”.
This is a simple, yet powerful program that has so many benefits beyond the training of doctors and nurses to manage children involved in trauma. This is an intriguing, innovative talk that everyone can take something away from.
Southampton Children’s Hospital is part of the University Hospital Southampton NHS Foundation trust. It is one of the largest teaching trusts in the UK. All of the simulation programs developed by Dr Phil Hyde and his colleagues at Southampton are open access and available for all health professionals to incorporate into their practice.
Fran Lockie, a Paediatric Emergency and retrieval specialist, gives an update on paediatric resuscitation. This talk was given at the Bedside Critical Care Conference 2012 on Daydream Island.
Free handy references about Acute Coronary Syndromes Algorithm from the ACLS Certification Institute.
View all ACLS algorithms at http://www.aclscertification.com/
Case Studies (Clinical Pharmacy Assignment)
Case Studies
Case Study 1. Drug Related Problem
Case Study 2. Alcohol Toxicity
Case Study 3. Patient Counseling
Case Study 4. Peptic Ulcer
Case Study 5. Drug and the Newborn
Case Study 6. Night time Anxiety
Case Study 7. Clostridium Difficile
Case Study 8. Epilepsy and Pregnancy
Case Study 9. Parkinsonism
Case Study 10. Treatment May Be Worse Than Condition
Dr Ashling Lillis, National Director's Clinical Fellow Macmillan Support, final year trainee in Acute Oncology
Dr Clare Philliskirk, Trainee in Acute Medicine, West Midlands
Dr Sarbit Clare, Acute Medical Consultant, Sandwell and West Birmingham Hospitals
Simulation is one of the most important advances in healthcare education and skills training of our generation. We now have simulation mannequins that can blink, breath, or even give birth thus allowing us to practice scenarios and skills before we encounter them in real patients. However, these sim dummies are not real people and so it is all too easy to dehumanize the scenario. According to Dr Phil Hyde, Director of Children’s Major Trauma and Southampton Children’s Hospital, it is this lack of emotional attachment that makes pure sim inadequate for training health care professionals in the management of trauma – especially trauma in children.
In his talk from SMACC Chicago, Dr Phil Hyde illustrates why he and his colleagues have developed an educational program that takes sim to the next level. The key difference in this sim program is the incorporation of volunteer children to play the roles of injured paediatric patients. Another key aspect of this program are the incorporation of multidisciplinary teams including undergraduate students for all scenarios.
The benefits of such a program have been far reaching. For the health professionals involved, it humanizes the scenario and induces an emotional attachment to the training exercise which adds an essential component to the training. Furthermore, it teaches professionals from different fields (nursing, medicine, allied health etc) to work together in these scenarios as would normally occur in real life. For the children involved, it is a safe controlled environment where they can learn about the health professionals and the health system, they learn about primary prevention and they can provide feedback to staff from a different vantage point. The community benefits through the improved primary prevention which is the most important aspect of treating trauma, a “man made disease”.
This is a simple, yet powerful program that has so many benefits beyond the training of doctors and nurses to manage children involved in trauma. This is an intriguing, innovative talk that everyone can take something away from.
Southampton Children’s Hospital is part of the University Hospital Southampton NHS Foundation trust. It is one of the largest teaching trusts in the UK. All of the simulation programs developed by Dr Phil Hyde and his colleagues at Southampton are open access and available for all health professionals to incorporate into their practice.
Fran Lockie, a Paediatric Emergency and retrieval specialist, gives an update on paediatric resuscitation. This talk was given at the Bedside Critical Care Conference 2012 on Daydream Island.
Shock is a common complication of severe febrile illness, and worldwide aggressive correction with intravenous bolus therapy is recommended as the initial treatment. Nevertheless, the evidence supporting this approach remains weak. The only controlled trial of fluid resuscitation, Fluid Expansion as Supportive Therapy (FEAST), involving 3141 African children with severe febrile illness, including large groups with sepsis and malaria, called into question aggressive fluid resuscitation, demonstrating excess mortality in both bolus arms (albumin and saline) compared to no-bolus control, relative risk of morality in bolus versus control was 1.45(1.13-1.86, p=0.003). Excess mortality was consistent across all subgroups, being greatest in those with the most severe forms of shock and acidosis. Remarkably, despite earlier shock reversal in those receiving fluid boluses the excess mortality in the FEAST trial was caused by subsequent cardiovascular collapse and was not secondary to fluid overload.
These observations are intriguing warranting an in-depth understanding of host responses including those of the myocardium to fluid resuscitation and at the microvasacular level since the two maybe synergistic. Current studies are underway in ovine models of sepsis (‘FEAST-in-Sheep’) in Professor John Fraser’s laboratory, Brisbane to understand the mechanism of harm, gain further insights in host responses to fluid management, and re-define the optimal fluid and supportive inotrope/vasopressor management of septic shock.
Four years have elapsed since the publication of FEAST, yet World Health Organization continues to recommend fluid boluses for children managed in resource-poor hospitals, where there is no access to intensive care. These are the precise settings where the FEAST trial was conducted in order to inform management guidelines. In Africa alone, where one in 10 febrile child admissions present with shock, we have estimated that the current guidelines, if fully implemented, will result in ~5,600 and 33,000 excess deaths each year per million hospital admissions treated for shock.
Liz Crowe delves into the deeper issues surrounding critical care and religion. She explores how religion influences patients and their families, why doctors can push against faith, and how the healthcare community can integrate an acceptance of faith into their care.
The Sim revolution. Jon Gatward on the future of simulation in critical care. Strategies for pulling it off, no matter your resources. See smacc.net.au and intensivecarenetwork.com for more.
This presentation is designed to cover some of the principles of Basic Life Support & First Aid for Children as of May 2014. It follows the Australian Resuscitation Guidelines and uses the DRSABCD approach.
D - Danger
R - Response
S - Send for Help
A - Airways
B - Breathing
C - CPR
D - Defib.
It is intended for lay-people and healthcare students.
Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children.
Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department.
70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia.
These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process.
Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia.
This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint.
There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it.
The production of Oxygen may only happen in a few places.
Poor cylinder quality leads to leaks and therefore, low supply.
Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available.
Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia.
Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy.
Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy.
Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world.
Trish Woods guides you through some clinical pearls in the intensive care management of neonates.
The complex physiology of the transitioning required in the journey from foetal life to neonatal presents many challenges and scary moments.
Trish helps you to navigate these challenges and to unlock the key to providing quality neonatal intensive care.
Many things can go wrong in the neonatal period as babies transition to life in the real world. Trish highlights her thoughts on the use of positive end expiratory pressure (PEEP), how deep to intubate, when to clamp the cord and the use of ultrasound.
When babies arrive early their lungs can be full of meconium or fluid. Due to this, Trish recommends using PEEP – without which there is distal airway collapse and fluid accumulation.
Aeration of the lungs is vital. To this end, how deep should intubation be aimed? The depth may not be overly important. This is because regional lung aeration triggers widespread, global increase in pulmonary blood flow.
There is little definitive evidence to guide clinicians on when to clamp the cord – early or late. Trish recommends considering the physiology of clamping the cord.
After clamping the cord there is a massive drop in cardiac output. Ventilatory support will turn this around – something to remember.
In a compromised baby, perhaps we should aim to clamp the cord sooner and then initiate ventilation.
Finally, Trish highlights the utility of ultrasound. Viewing the heart and lungs provides crucial information for the clinician.
Furthermore, Trish discusses actively looking for aeration, collapse, consolidation and pneumothorax in the lungs and thorax.
Overall, don’t forget the essentials. Trish reminds you to keep life sweet, warm, and tempting and help neonates to transition into the big world.
Neonatal Intensive Care: Trish Woods
For more like this, head to our podcast page. #CodaPodcast
Fran Lockie, provides a useful update on paediatric drowning sequalae and outcomes. This talk was recorded at Bedside Critical Care Conference.
For audio for this and similar talks, please visit www.intensivecarenetwork.com
The next BCC will be held in Cairns, 29th September - 3rd of October: http://bedsidecriticalcare.com/
Presentation at the SRMO weekly teaching for Shellharbour Hospital ED - by Dr Mahsa Fateminayyeri, MD - trainee, who covers an approach to sepsis in the ED setting, and highlights the value of a sepsis pathway to expedite antibiotic treatment and provide early resuscitation in order to promote good outcomes
Scared of paediatrics? How do be Mr Spock or Roger Federer with kids.Coda Change
This talks gives some guidance on how to deal with your anxiety and fear when dealing with children. We will also cover some key topic areas: sepsis, fluids, seizures, asthma and bronchiolitis
Acute Shortness of Breath at 36 weeks of PregnancySujoy Dasgupta
lecture delivered by Dr Sujoy Dasgupta at BOGSCON 42, the Annual Conference of Bengal Obstetric and Gynaecological Society, where he was invited as Faculty in a session on "Difficult Clinical Scenario in Pregnancy"
Interactive Cases in Clinical Medicine (SPHMMC production) Episode 01ahmedx20
An interactive case where we discuss the diagnosis and management of Acute Rheumatic Fever, Rheumatic Heart Disease and Heart Failure in general.
Presented at Saint Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramAllina Health
David Tierney, MD. How bedside ultrasound is changing the practice of medicine and how Abbott Northwestern Hospital has become a national leader in integrating bedside ultrasound in its Internal Medicine Residency Program. "As internal medicine physicians, we are finding that everything we do with our hands, eyes and stethoscopes can be done a little better with ultrasound. That means our physical exam, which we consider our bread and butter, has more sensitivity and specificity. This gives us better diagnostic ability and results in earlier and more appropriate treatment."
Similar to Big Trouble, Little People: Paeds Retrieval by Lockie (20)
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical careSMACC Conference
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew UdySMACC Conference
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories workSMACC Conference
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne LeeSMACC Conference
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?SMACC Conference
After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference.
Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways.
Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions.
Hypertensive therapy is relatively safe and easy to implement but not without risk.
Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same CoinSMACC Conference
Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
9. 15 month old male with fever
• NVD at term, BW 2.7kg
• Previously fit and well
• No meds, NKDA
• Immunisations UTD
• Family all coryzal
10. Country Hospital
• At triage
– Alert and playful
– Temp 39, Hr 160, Rr 40
– Good central perfusion
– Mottled peripherally
11. 4hrs later Seen by RMO
• Given panadol with resolution of fever, HR
never < 170 since triage
• Bloods sent
• Urine NAD
12. 4 hrs after that…
• Given panadol with resolution of fever, HR
never < 170 since triage
• Bloods
• Urine NAD
• 2 small vomits in waiting room, then a small
area of petechiae
13.
14. 22:00
• A BVM with high flow O2
• B RR 60, marked increased resp effort
• C peripheral CRT: absent, central >5 secs
• Multiple attempts at iv access unsuccessful
• D alert, talking to mum
15. Rapid deterioration
– AVPU
– Increasing respiratory distress
– HR >200, Only femoral pulse palpable
– IO sited
– Aggressive filling
– DA started
22. • Audit of 17 PICU’s
• 107 patients with septic shock
• 8% received care c/w ACCM guideline
– 21% not given >60ml/kg despite ongoing shock
– 15% not given dopa/ dobu despite fluid refractory
shock
– 23% not given catechol for dopa/ dobu refractory
shock
– 30% not given steroid despite catechol resistant
shock
Arch Dis Child 2009
23. Early Resuscitation of Children with
Moderate to severe TBI
Pediatrics 2009
• 299 kids with mod-severe TBI
• 39% became hypotensive
– Of these only 48% were treated
• 44% became hypoxic
– Of these 92% were treated
52. Is lactate really the ‘Holy Grail’ of
sepsis biomarkers?
No, but sepsis often masquerades
as respiratory disease in kids
I
n
53. Sugar and temperature
• Large SA: body wt (2-2.5 x BW)
• Thin skin and subcut fat (less insulation)
• No shivering
• Immature thermoregulatory center
• Sugar ALWAYS goes down in critical illness…
Declaration.
I am not the other Francis Lockie, Sydney Based Health prof.
If you came to see her, you are in the wrong talk!
She, disappointingly is google hits 1-20
So get in there early, establish your web presence, don’t make the same mistake I have
998 miles
GC map.com
I am lucky enough to live and work in Adelaide, capital of South Australia
Overlapmaps.com
To put in a UK perspective
1 million sq kn
1.6 million people largely based in Adelaide
Roughly the size of Texas
When we look at the population density map, we can see Australia virtually disappears into a thin slither in the SE corner of the world map, compared to the bloated areas of the SC, china and even the UK
Population density
Makes my life interesting as I am luck enough to have a split roles in PEM and Paeds / neonatal retrieval
With the retrieval work MedSTAR travels as far afield as Darwin and Alice Springs, to Melbourne for our cardiac babies. Of course we serve regional SA and metro Adelaide too.
We are the only Children’s Hospital in the sate so of course all cases of critical illness and trauma comes through our department.
My role has put me in a good position to notice recurring themes
Yes, we live in a post imms era, with air bags, pool fences and child proof screw tops kids
There is still the burdon of critical illness – it’s rarity makes the challenge greater if anything
It’s great that that cardiac anaesthetist can tube kids with one arm tied behind his back, but he or she isn’t in the community hospital at midnight
Doesn’t matter if we’re sitting in our ivory towers or we’re in the outback
In fact in the outback I’ve met some of the most talented doctors in rural areas going above and beyond
Didn’t mean to put the solutions on the horizon..but that’s sometimes where it feels like they are.
However by keeping things simple and doing the basics well – we can change the trajectory for our sick kids
Lives with me and affects the way I practice medicine on a daily basis
How good are we at implementing ACCM guidelines. C/W ACCM guideline NOT timeline! Replicated in other setting including surviving sepsis campaign audit’s.
Sub-optimal treatment related to FAILURE to RECOGNISE SHOCK
Unsupervised juniors / lack of paediatric consultant supervision
Failure to start inotrope
This study from UTAH worried me a lot
OBJECTIVES: Traumatic brain injury is a leading cause of death and
disability in children. Guidelines have been established to prevent secondary UTAH
brain injury caused by hypotension or hypoxia. The purpose of
this study was to identify the prevalence, monitoring, and treatment of
hypotension and hypoxia during “early” (prehospital and emergency
department) care and to evaluate their relationship to vital status and
neurologic outcomes at hospital discharge.
METHODS: This was a retrospective study of 299 children with moderate-
to-severe traumatic brain injury presenting to a level 1 pediatric
trauma center. We recorded vital signs and medical provider response
to hypotension and/or hypoxia during all portions of early care.
RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded
during some portion of “early care.” Documented hypotension
occurred in 118 children (39%). An attempt to treat documented hypotension
was made in 48% (57 of 118 children). After adjusting for
severity of illness, children who did not receive an attempt to treat
hypotension had an increased odds of death of 3.4 and were 3.7 times
more likely to suffer disability compared with treated hypotensive children.
Documented hypoxia occurred in 131 children (44%). An attempt
to treat hypoxia was made in 92% (121 of 131 children). Untreated
hypoxia was not significantly associated with death or disability, except
in the setting of hypotension.
CONCLUSIONS: Hypotension and hypoxia are common events in pediatric
traumatic brain injury. Approximately one third of children are
not properly monitored in the early phases of their management. Attempts
to treat hypotension and hypoxia significantly improved outcomes
And look at the effect on mortality!
Adjusted OR for death and GOS
Growing body of evidence that secondary insults occur frequently and exert a powerful, adverse influence on outcomes from severe TBI.
Enemies are hypoxaemia and hypotension
Trauma Coma Data Bank: hypoxaemia occurred in 22.4% of severe TBI patients: asociated with significantly increased morbidity and mortality.
HEMS series 55% of patients were hypoxic prior to intubation. 46% normal BP.
In non-hypoxic pts mort 14.3% and 4.8% disability. If SaO2 < 60% mort rate 50% with 100% severely disabled.
Hypoxaemia <90% in an inhospital study of 124 TBI patients independent RF for mortality
HYPOTENSION. Single pre-hospital obseration of hypotension SBP < 90 was amoung 5 most powerful predictors of outcome. Incr morbidity and doubled mortality
Induction of anaesthesia is risky:
Recurring themes in the Sim Lab
75 Simulations
12.4 doctors / nurses per session
194 incidents of subobtimal care
Knowledge deficit: delay starting inotropes, dose of dextrose for hypoglycaemia, delay starting fluid bolus
This is not just in paeds
THIS IS THE CFIT OF THE MEDICAL WORLD
ED staff
Anaethetics
Theatre staff
Standardised scenarios
Causes of error
75 Simulations
12.4 doctors / nurses per session
194 incidents of subobtimal care
Knowledge deficit: delay starting inotropes, dose of dextrose for hypoglycaemia, delay starting fluid bolus
This is not just in paeds
This is the (hopefully present)
Examples of scenarios
Knowledge
Clinical skills
Leadership
Communication
Resourse utlisation
Anticipation and planning
Situational awareness
At medstar we run joint scenarios.
We as paediatric specialists can learn lots from the trauma and CCM delivery outside theatre / Particularly in the vital areas of clinical decision making, CRM, leadership and teamwork
Hopefully our holistic view and what we consider good communication skills are useful to the adult teams
Training with the SOT paramedics has been a revelation to me not something I would do anywhere else in the world.
Changed the way we run in the kids hospital where it’s often difficult to generate the momentum to make things happen quickly
MCDonalds – I probably shouldn’t be promoting this as a paediatrician!
One thing they are famous for – in addition to childhood obsesity is the consistency of their product!
In fact, the strength of a nation’s currency is often judged aginst the price of a big mac!
I know that if I travel to London and order a Big Mac – I will get:
I just won’t be allowed to donate blood again!
If I jump on the Eurostar and order Un Big Mac, I will get Ummm hopefully: albeit with a bit of surly attitude thrown in.
Consistent approach to out of theatre anaesthesia to be applied to all patients from 90 years to newborn and all in between
Indispensible for certain situations
Generates a degree of muscle memory and automaticity that is vital when it all goes wrong.
Creat Space: look how this adult team has created space.
The scene is secure: they can get to work
Everyone knows there place, literally where to stand and their role.
We use this in PED and it has been revolutionary
Patient assessment
Often predictable
Every moment spent on patient position is time well spent!
Dump bag: everything laid out and ready.
Amazing the effect on the room when a piece of kit is not available: what was a calm environment becomes visible tense: everything changes
This is a key CRM moment: everything is calm, everyone is focussed
Leadership
Build confidence in the team that is both Immediate and latent
I authorise the c-spine controller to relax their death grip of the head to flex the neck and allow me to visualise the larynx
These techniques of preparation are often amazingly eye opening for our trainees rotating through. They take them with them for the rest of their careers and always feedback that this was the most powerful message of their MedSTAR rotation.
Our nursing staff love it too and feel empowered to trouble shoot and guide less experienced medical staff
The most effective Graded assertivess I have encounterred was on retrieval in the middle of the night when I was being particularly physicianly when a baby patently needed a chest drain. Beard stroking was not getting the job done.
I was fresh off the boat from England and shocked to be told to just “fucking do it Fran”
Amazing to see that CRM is still not featuring highly in Medical education
Time
Checks
Briefs
Leadership
Build confidence
Immediate
Latent
Keep the momentum going: not pause to high five each other and nip out for coffee
Amazingly hard to derail this process
We did a sim recently where I was trying to be an incompetent team leader.
The nurses feel so empowered in their CRM skills: worst doctor nurse, wost doctor, worst patient, worst day
And still be safe.
10 different induction agents,
20 different LMA including one you’ve never seen before
Limited AP expansion, limited lateral expansion. Ventilation depends on the diaphragm: fatigues easily, lacks Type 1 muscle fibres. Any restriction of diaphragm movement results in resp difficulties
Ie stomach inflation due to forced inflation
Lung compliance 5ml/cm H2O, 1/12 adult value, chest compliance 260ml/cm H2O (5x aduly value. High risk of barotrauma
Small lung vol rel to body size Small FRC: high RR to maintain the FRC
Under GA anaesthesia FRC declines by 10-25% in health adults and 35-45% in 6-18yo.
Stress: ratio of MV to FRC is doubled, FRC is diminished and desat occurs
PEEP important in kids <3, essential in infants <9m. Mean pee to respore FRC to normal:
Infants < 6 months 6, children 6-12
Higher O2 consumption 6-7ml/kg, adults 3-4 ml / kg
Rapid desatiration
Smaller FRC
Greater VO2 per unit weight than adults
Critical hypoxia rapid after apnoea
Consider 1 month old
no pre-oxygenation = 90% sats in 15 seconds
Pre –oxygenation for 1 min = 90% sats in 90 seconds
Patterns of Injury
Size and shape
Smaller body mass - greater force per unit body area
Less protective tissues and close proximity of organs
Frequently multiple organs injured
Skeleton
Pliable skeleton often deforms without fracture allowing significant injury to underlying organs
Presence of rib fractures suggests massive force and high risk multiple organ injury
Psychological
Developmental stages
Language skills – difficult to communicate symptoms; may deny symptoms
Fear – alters normal vital signs making them difficult to interpret
Parents – help and hindrance
Long term effects
Growth and development
Psychological – child and family
Size
Proportions
Breathing
Circulation
Stress
Sugar
Family
Scared
Lonely
What can we do to overcome this rapid desaturation after apnoea?
Apnoeic oxygenation and PEEP
Mapleson F, Jackson-Rees modification to the Ayer’s T-piece.
Compact Inexpensive No valves Minimal dead space Minimal resistance to breathing Economical for controlled ventilation
Disadvantages
The bag may get twisted and impede breathing High gas flow requirement
Uses
Children under 20 kg weight
Mapleson F, Jackson-Rees modification to the Ayer’s T-piece. Cildren under 20KgCompact Inexpensive No valves Minimal dead space Minimal resistance to breathing Economical for controlled ventilation
Disadvantages
The bag may get twisted and impede breathing High gas flow requirement
Uses
Children under 20 kg weight
ABSTRACT
Background: A crossover study was performed in
healthy volunteers to compare the efficacy of a selfinflating
bag with the Mapleson C breathing system for
pre-oxygenation.
Method: 20 subjects breathed 100% oxygen for 3 min
using each device, with a 30 min washout period. The
end tidal oxygen concentration and subjective ease of
breathing were compared.
Results: There was a statistically significant difference in
performance between the two devices, with the
Mapleson C providing higher end expiratory oxygen
concentrations at 3 min. The mean (SD) end expiratory
oxygen concentration was 74.2 (3.8)% for the selfinflating
bag (95% CI 72.4% to 75.9%) and 86.2 (3.7)% for
the Mapleson C system (95% CI 84.5 to 88.0);
p,0.0001. The 95% CI of the difference between the
mean values for end expiratory oxygen concentration at
3 min was 10.0% to 14.2%. There was also a statistically
significant difference in the subjective ease of breathing,
favouring the Mapleson C system.
Conclusion: The Mapleson C breathing system is more
effective and subjectively easier to breathe through than a
self-inflating bag when used for pre-oxygenation.
However, these benefits must be weighed against the
increased level of skill required and possible complications
when using a Mapleson C breathing system.
Pre-oxygenation is an established prerequisite to
rapid sequence induction of anaesthesia and
tracheal intubation.1 It is undertaken to maximise
the oxygen fraction of the functional residual
capacity by displacing nitrogen with oxygen. This
delays the onset of oxygen desaturation of arterial
blood after induction of apnoea. Good pre-oxygenation
is essential in the emergency department
before rapid sequence induction of anaesthesia,
because intubation is often undertaken in patients
with significant acute morbidity who are therefore
prone to early and rapid desaturation.2 3 Preoxygenation
must therefore be optimal in this
environment4 and emphasised during training.5
Adequate pre-oxygenation is indicated by achieving
an end expiratory oxygen concentration of
.90%.6 7
Pre-oxygenation in the emergency department is
often achieved using a self-inflating bag with a
valve-mask assembly and a reservoir bag with highflow
supplemental oxygen. In some centres a
Mapleson C breathing system is used for this
purpose (fig 1). The Mapleson C system can also be
used for oxygenation during sedation.8
Self-inflating bags are universally available in UK
emergency departments because they are easy to
use and will function without an oxygen supply.
They are appropriate for use during assisted
ventilation, but during spontaneous breathing they
may increase the resistance to breathing.9
Furthermore, a self-inflating bag may deliver a
lower inspired oxygen concentration than an
anaesthetic breathing system.10
We aimed to determine whether a self-inflating
bag with reservoir and supplemental oxygen
supply provides the same degree of pre-oxygenation
as a Mapleson C anaesthetic breathing system
when both are used correctly. We also compared
the subjective ease of breathing for patients preoxygenated
using these devices.
METHODS
Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
Solutions:
Recognise the physiology.
Not rely on concensus based dogma about fixed physiological limits across many ages
Solutions:
Recognise the physiology.
Not rely on concensus based dogma about fixed physiological limits across many ages
We Say the physiology never lies: except sometimes it does!
Don’t intubate Jonny because he’s scared and misses his mum