This document discusses cervical spine injuries. It begins by providing epidemiological data on cervical spine injuries, including common causes, levels of injury, and classifications of complete vs incomplete spinal cord injuries. It then discusses neurological assessment techniques, airway management considerations, importance of breathing and circulation support, clinical criteria for clearing the cervical spine, and immobilization guidelines. Recommendations are provided for tracheal intubation methods, criteria for cervical spine imaging, and guidelines for cervical spine clearance. Early removal of cervical collars is also recommended to reduce complications.
EMGuideWire's Radiology Reading Room: Hypertrophic CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Hypertrophic Cardiomyopathy and is brought to you by Ashley Moore-Gibbs, DNP, Claire Lawson, NP, Laszlo Littmann, MD, and John Symanski, MD.
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: March CasesSean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Emphysematous cholecystitis
• Pyelonephritis
• Perinephric abscess
Cervical spine clearance lecture given to 1st-year emergency medicine residents at Duke University. Covers indications for applying cervical collar, types of collars, types of imaging of the spine, and when to remove the collar.
EMGuideWire's Radiology Reading Room: Hypertrophic CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Hypertrophic Cardiomyopathy and is brought to you by Ashley Moore-Gibbs, DNP, Claire Lawson, NP, Laszlo Littmann, MD, and John Symanski, MD.
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: March CasesSean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Emphysematous cholecystitis
• Pyelonephritis
• Perinephric abscess
Cervical spine clearance lecture given to 1st-year emergency medicine residents at Duke University. Covers indications for applying cervical collar, types of collars, types of imaging of the spine, and when to remove the collar.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: November CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: Pericardial Effusion, Vaping Lung Injury, Cavitary Pulmonary Abscess, Esophageal Foreign Body, Dilated Cardiomyopathy, Acute Aortic Dissection, Pneumomediastinum, Massive Pneumoperitoneum, Malignant Pleuarl Effusion, Right Sided Aortic Arch, RLL pneumonia
The poly traumatized patient the role of orthopedic surgeonMohamed Abulsoud
The management of polytraumatized patient is multidisplinary team .
Orthopaedic surgeon in the striker of the team
Resuscitation and survey is a key for excellent outcome
Timing of surgery is very crucial
ETC Vs. DCO should be considered carefully
Dr. Escobar’s CMC X-Ray Mastery Project: December CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Blunt hemothorax
- Pulmonary contusion
- Lung Cancer with Bone Metastases
- Pneumomediastinum
- Pneumopericardium
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: August C...Sean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Splenic Rupture
• Obstructive jaundice
• Ovarian Torsion
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: December...Sean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
- Bladder Rupture
- Small Bowel Diverticula
- Type B Aortic Dissection
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #3 CasesSean M. Fox
Dr. Michael Gibbs is a Professor of Emergency Medicine and interested in educating others. Radiology is a passion of his. Follow along with the EMGuideWire.com team as they post Dr. Gibbs's weekly educational, self-guided radiology slides on: Pericardial effusions, Pneumothorax, Marfan Syndrome, Malignant pleural effusion, Pulmonary Metastatic Disease, Cardiomegaly, Necrotizing Pneumonia, Bronchogenic Carcinoma
EMGuideWire's Radiology Reading Room: Blunt Aortic InjurySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Blunt Aortic Injury and is brought to you by Rachel Plate, MD and Oriane Longerstaey, MD. It is has special guest editors: Bryant Allen, MD
EMGuideWire's Radiology Reading Room: Septic Pulmonary EmboliSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Septic Pulmonary Emboli and is brought to you by Victoria Serven, MD, Travis Barlock, MD, and Katherine Sillman, NP.
this is a talk about the ongoing debate of what to do in the management of pelvic fractures with haemodynamic instability
a revision of literature to see the best sequence of events ..
Drs. Milam and Thomas's CMC X-Ray Mastery Project: November CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: Pericardial Effusion, Vaping Lung Injury, Cavitary Pulmonary Abscess, Esophageal Foreign Body, Dilated Cardiomyopathy, Acute Aortic Dissection, Pneumomediastinum, Massive Pneumoperitoneum, Malignant Pleuarl Effusion, Right Sided Aortic Arch, RLL pneumonia
The poly traumatized patient the role of orthopedic surgeonMohamed Abulsoud
The management of polytraumatized patient is multidisplinary team .
Orthopaedic surgeon in the striker of the team
Resuscitation and survey is a key for excellent outcome
Timing of surgery is very crucial
ETC Vs. DCO should be considered carefully
Dr. Escobar’s CMC X-Ray Mastery Project: December CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Blunt hemothorax
- Pulmonary contusion
- Lung Cancer with Bone Metastases
- Pneumomediastinum
- Pneumopericardium
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: August C...Sean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Splenic Rupture
• Obstructive jaundice
• Ovarian Torsion
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: December...Sean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
- Bladder Rupture
- Small Bowel Diverticula
- Type B Aortic Dissection
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #3 CasesSean M. Fox
Dr. Michael Gibbs is a Professor of Emergency Medicine and interested in educating others. Radiology is a passion of his. Follow along with the EMGuideWire.com team as they post Dr. Gibbs's weekly educational, self-guided radiology slides on: Pericardial effusions, Pneumothorax, Marfan Syndrome, Malignant pleural effusion, Pulmonary Metastatic Disease, Cardiomegaly, Necrotizing Pneumonia, Bronchogenic Carcinoma
EMGuideWire's Radiology Reading Room: Blunt Aortic InjurySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Blunt Aortic Injury and is brought to you by Rachel Plate, MD and Oriane Longerstaey, MD. It is has special guest editors: Bryant Allen, MD
EMGuideWire's Radiology Reading Room: Septic Pulmonary EmboliSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Septic Pulmonary Emboli and is brought to you by Victoria Serven, MD, Travis Barlock, MD, and Katherine Sillman, NP.
this is a talk about the ongoing debate of what to do in the management of pelvic fractures with haemodynamic instability
a revision of literature to see the best sequence of events ..
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: 43rd Case SeriesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Traumatic Pneumothorax
- Flail Chest And Surgical Rib Fixation
- Traumatic Pulmonary Pseudocyst
- Stab Wound To The Heart
Sternal Fractures & Dislocations - EMGuidewire Radiology Reading RoomSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Sternal Fractures and Dislocations and is brought to you by Carrie Bissell, MD, Aaron Fox, MD, Kendrick Lim, MD, Stephanie Jensen, MD, and Olivia Rice, MD. It is has special guest editor: Sean Dieffenbaugher, MD and Laurence Kempton, MD
These slides are from versions of a talk I gave at ESTRO in 2014 and again in Lille in 2015.
The talk aims to explain the importance of correctly defining the CTV with respect to nodes in curative radiotherapy planning.
The lecture makes some important points about the function of lymph glands and their potential to act as stem cell 'rests' for malignant cells: this fact might explain whilst lymph node failure rates don't necessarily equate to disease failure rates.
The lecture then goes on to emphasise the utility of the best imaging technologies may more accurately identify involved nodes.
Shrinking fields with confidence may be the best way to reduce radiation toxicity.
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.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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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.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
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
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
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Colonic and anorectal physiology with surgical implications
Narain c-spine injury 2
1. CERVICAL SPINE INJURY
Narain Chotirosniramit MD.
Trauma and critical care unit
Department of surgery
Faculty of medicine Chiangmai University
2. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
4. EPIDEMIOLOGY
Incidence : 28-50 cases per million
Male to Female ratio 4:1
The most common cause of spinal injury
Motor vehicle accident 40%-50%
Falls 20%-25%
Gunshot wounds 10-14%
Sport 10%
5. EPIDEMIOLOGY
Level of injury ,commonly
Cervical 55%
Thoracic 30%
Lumbar 15%
95% one spinal region
Two thirds: cervical
6. PATHOPHYSIOLOGY
• Primary injury : Most of the damage
– Concussion
– Contusion : Hemorrhage and swelling
– Laceration : Tissue Disruption
• Secondary injury
– Biologic response processes
– Cause ischemia and hypoxia of the cord
– Lead to secondary tissue degeneration.
7. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
8. NEUROLOGICAL ASSESSMENT
• The examination should include :
Sensory
Motor
Proprioception
Perianal sensation
Rectal sphincter tone
Bulbocavernous reflex
9. Frankel classification
Simple & acceptable classification of SCI :
A. Complete absence of motor and sensory function.
B. Sensation present but no motor function
C. Sensation + motor function 2–3/5.
D. Sensation present with motor function of 4/5.
E. Normal sensory and motor function
Browner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma: Fractures, Dislocations,
Ligamentous Injuries. Philadelphia: WB Saunders, 1998
10.
11.
12. NEUROLOGICAL ASSESSMENT
• To assess the patient : must be defined:
1. Complete SCI:
No motor or sensory function
caudal to the level of injury
The bulbocavernous reflex is
present.
13. NEUROLOGICAL ASSESSMENT
2. Spinal shock:
Complete SCI with absent bulbocavernous
reflex.
Not neurogenic shock.
Revaluate the neurologic status after the
reappearance of the bulbocavernous reflex
16. Formal Types of ICSCI
• Central cord syndrome
Most common ICSCI
Quadriplegia with
perianal & sacral sparing.
75% : partial recovery of
the motor function.
17. Formal Types of ICSCI
• Brown-Sequard syndrome
Unilateral SCI (usually due
to penetration)
Motor deficit ipsilateral to
the injury combined with
contralateral sensory deficit.
Most : gain partial recovery
with bowel and bladder continence
& usually walking ability.
18. Formal Types of ICSCI
• Anterior cord syndrome
Relatively common
Complete motor & sensory
loss
Some remnant of trunk and
lower extremity deep sensation &
proprioception.
Poor prognosis : only 10%
some motor recovery.
19. Formal Types of ICSCI
• Posterior cord syndrome
Rare ICSCI
Loss of proprioception &
deep sensation
Intact motor functioning.
“tabes dorsalis gait”.
20. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
21. AIRWAY MANEUVERS
• Both basic and advanced airway maneuver :
cause movement in different segments of the
cervical spine.
• Even chin lift and jaw thrust : cause movements
cervical spine.
22. AIRWAY MANEUVERS
• Advanced airway : Blind NT intubation & direct
laryngoscopy & OT intubation (DLOI)
Cause relative segmental cervical spine movement
Atlanto-occipital and atlantoaxial joints : most often
Aprahamian C, et al. Ann Emerg Med 1984; 13: 584–7.
Sawin PD, et al. Anesthesiology 1996; 85: 26–36
23. AIRWAY MANEUVERS
No significant different in movement was
found between curved or straight laryngoscope
blades.
Gerling MC, et al. Ann Emerg Med 2000; 36: 293–300.
24. AIRWAY MANEUVERS
Manual in-line stabilization :
Most common
Most effective in limiting segmental movement to
1–3 mm in various airway maneuvers.
Lennarson PJ, Smith D, Todd MM, et al. J Neurosurg (Spine 2) 2000; 92: 201–6.
Brimacombe J, Keller C, Kunzel KH, et al. Anesth Analg 2000; 91: 1274–8.
25. AIRWAY MANEUVERS
• Summary and recommendations:
No Level I clinical data.
Airway management in suspected CSI may cause
relative spinal segmental movement.
Manual in-line stabilization : Safely applied &
significantly limit the dangerous spine motion
( Recommendation grade: B.)
26. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
27. TRACHEAL INTUBATION
12 retrospective series :
395 DLOI in patients with CSI
(most of them unstable)
Only 2 : Neurological deterioration (not attributed
to the airway intervention)
Crosby ET. Anesthesiology 2006; 104: 1293–318.
28. TRACHEAL INTUBATION
Awake nasotracheal intubation :
Many anesthesiologists prefered for definitive airway
control in suspected CSI patients.
Rosenblatt WH, et al. Anesth Analg 1998; 87: 153–7.
29. TRACHEAL INTUBATION
• Fiber optic endoscope.
Minimal spine movement
Maintaining airway protective reflexes
Disadvantages : Slow learning curve that causes many doctors
to be uncomfortable with the procedure
Ezri T, et al. J Clin Anesth 2003; 15: 418–22.
Potential for desaturation : might aggravate secondary cord injury.
Fuchs G, et al. J Neurosurg Anesth 1999; 11: 11–16.
30. TRACHEAL INTUBATION
• Summary and recommendations:
Both DLOI and fiber optic awake NT intubation are safe &
effective options for securing the airway in a trauma patient
with suspected CSI.
(Recommendation grade: B).
DLOI : No special equipment or advanced expertise
Preferred in emergency situations
Fiber optic : elective procedures.
(Recommendation grade: C.)
31. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
32. BREATHING AND CIRCULATION
• Cervical spinal cord injury : May have respiratory
failure and hemodynamic compromise.
• Hypoxemia & hypotension : increase the chance
for secondary cord injury and worsening the
neurological outcome.
33. BREATHING AND CIRCULATION
• Risk for ventilatory failure : based on the level and
completeness of injury.
• Ventilatory support : majority of patients > C5 injuries
> C3 injuries. Adequate fluid resuscitation &
hemodynamic improvement : correlated to better
neurological outcome
Vale FL, Burns J, Jackson AB, et al. J Neurosurg 1997; 87: 239–46.
34. BREATHING AND CIRCULATION
• High SCI (above T6) :
Disruption of sympathetic chain
Hypotension & bradycardia. (neurogenic shock)
Found to be 19.3%
Guly HR, Bouamra O, Lecky FE. Resuscitation 2008; 76: 57–62.
35. BREATHING AND CIRCULATION
• If SBP < 90 mmHg, MABP < 85 mmHg.
• Early administration of vasoactive drug should be
considered.
Hadley MN, et al. Neurosurgery 2002; 50(suppl): 58–62.
36. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
37.
38. CLINICAL CRITERIA
• The NEXUS study : 34,069 patients.
• 5 criteria for the definition a low probability of CSI:
1. No midline cervical tenderness
2. No focal neurological deficit
3. Normal alertness
4. No intoxication
5. No painful, distracting injury
Hoffman JR, Mower WR, Wolfson AB, et al. N Engl J Med 2000; 343: 94–9.
39.
40.
41. CLINICAL CRITERIA
• The results were 100% sensitivity
(95% CI, 98–100%)
and 42.5% specificity (95% CI, 40–44%) for
identifying clinically important C-spine injuries.
Stiell IG, et al. JAMA 2001; 286: 1841–8.
42.
43. CLINICAL CRITERIA
The Canadian C-spine rule :
More sensitive than the NEXUS (99.4% versus
90.7%, p < 0.001)
More specific (45.1% versus 36.8%, p < 0.001)
Lower radiography rates.
Stiell IG, Clement CM, McKnight RD, et al. N Engl J Med 2003; 349: 2510–18.
44. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
45.
46. IMMOBILIZATION
Cervical spine injuries : may be impaired by pathological
motion of the injured vertebrae.
3 to 25% of SCI : Occur during transit or early in the
course of management .
Brunette DD, et al. J Trauma 27:445–447, 1987.
Burney RE, et al. J Trauma 29:1497–1499, 1989.
Geisler WO, et al. Med Serv J Can 22:512–523, 1966.
Hachen HJ. Paraplegia 12:33–37, 1974.
Prasad VS, et al. Spinal Cord 37:560–568, 1999
Totten VY, et al. Prehosp Emerg Care 3:347–352, 1999.
47. IMMOBILIZATION
The optimal device has not yet been identified by
careful comparative analysis.
American College of Surgeons :
Hard backboard
Rigid cervical collar
Lateral support devices
Tape or straps to secure the patient
48. IMMOBILIZATION
Occipital padding combined with a rigid
backboard : a better neutral position than a flat
backboard alone
Schriger DL, et al. Ann Emerg Med 20:878–881, 1991.
Stauffer ES. Clin Orthop 102: 92–99, 1974.
50. IMMOBILIZATION
• Compare immobilization :
Soft collar
Hard collar
Extrication collar
Philadelphia collar
Bilateral sandbags with 3-inch cloth tape across forehead
Combination of sandbags, tape, and a Philadelphia collar.
Podolsky S, et al.J Trauma 23:461–465, 1983.
51. IMMOBILIZATION
• Hard foam & hard plastic collars were better at limiting
cervical spine motion than soft foam collars
• Neither collars alone nor sandbags and tape in
combination provided satisfactory restriction of
cervical spine motion
• Sandbags and tape combined with a rigid cervical
collar were the best
Podolsky S, et al.J Trauma 23:461–465, 1983.
52. IMMOBILIZATION
• Spine immobilization increases the risk of pressure
sores.
• Pressure sores were associated with immobilization
(patients who were not turned during the first 2 hours
after injury).
Linares HA, et al. Orthopedics 10:571–573, 1987
53. IMMOBILIZATION
• Summary :
Immobilization of the entire spinal column is
necessary until a spinal column injury has been
excluded, or until appropriate treatment has been
initiated
54. IMMOBILIZATION
• Summary :
It seems that a combination of rigid cervical
collar with supportive blocks on a rigid backboard
with straps is effective at achieving safe, effective
spine immobilization for transport.
55. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
56. Practice management guidelines for
identification of cervical spine injuries
following trauma
2009
update from the Eastern Association for the Surgery of Trauma
Practice
Management Guidelines Committee
57. C-spine clearance
• Search from PubMed
• Articles regarding the identification of CS injury from
1998-2007
78 articles were identified.
52 articles were selected
58. C-spine clearance
• The questions posed were:
1. Who needs CS imaging
2. What imaging should be obtained;
3. When should CT, MRI, or F/E radiographs be used.
4. How is significant ligamentous injury excluded in
the comatose patient?
60. C-spine clearance
A. Removal of cervical collars:
Cervical collars should be removed as soon as
feasible after trauma (level 3)
61. A. Removal of cervical collars
• Early removal of cervical collars may decrease :
Collar-related decubitus ulceration
Incidence of increase Intracranial pressure (ICP)
Ventilator days
Intensive care unit (ICU) and hospital days
The incidence of delirium and pneumonia.
62. A. Removal of cervical collars
• Chendrasekhar and colleagues
38% : Collar-related decubitus ulceration in head-injured
patients who survived greater than 24 hours.
• A significantly longer duration of cervical collar use than
those who did not
Chendrasekhar A, Moorman DW, Timberlake GA.
An evaluation of the effects of semirigid cervical collars in patients with severe
closed head injury.
Am Surg 1998; 64:604-606
63. A. Removal of cervical collars
• Powers et al
Skin breakdown in 6.8% of ICU patients (with a cervical
collar >24 hours).
Most significant predictor of breakdown was time in a
cervical collar.
Powers J, Daniels D, McGuire C, et al.
The incidence of skin breakdown associated with the use of cervical collars.
J Trauma Nurs 2006; 13:198-200
64. A. Removal of cervical collars
Hunt and co-workers applied cervical collars to
patients with traumatic brain injury and found a
significant rise from the baseline ICP when the collars
were applied
Hunt K, Hallworth S, Smith M. Anaesthesia 2001; 56:511-513
65. C-spine clearance
B. In the patient with penetrating trauma to the
brain:
Immobilization in a cervical collar is not
necessary unless the trajectory suggests direct
injury to the cervical spine (CS) (level 3)
66. B. Penetrating trauma to the brain
• Retrospective studies
105 patients with GSW to the cranium : no CS
injury
Kennedy FR, Gonzalez P, Beitler A, et al. South Med J 1994; 87:621-623.
67. B. Penetrating trauma to the brain
• Kaups and co-workers :
Reviewed 215 patients with a GSW to the head : no
patient sustained indirect (blast or fall-related) spinal
column injury
J Trauma 1998; 44:865-867.
68. C-spine clearance
C. In awake, alert trauma patients without
neurologic deficit or distracting injury who have no
neck pain or tenderness with full range of motion of
the CS:
CS imaging is not necessary and the
cervical collar may be removed
69. C. Awake, alert trauma patients
• National Emergency X-Radiography Utilization Study (NEXUS)
Required patients to have
1) No midline cervical tenderness
2) No focal neurologic deficit,
3) Normal alertness
4) No intoxication
5) No painful distracting injury.
Hoffman JR, Mower WR, Wolfson AB, et al.
Validation of a set of clinical criteria to rule out injury to the cervical spine in patients
with blunt trauma. N Engl J Med 2000; 343:94-99.
70. C-spine clearance
D. All other patients in whom CS injury is suspected
must have radiographic evaluation
1. The primary screening modality is axial
computed tomography (CT) from the occiput to T1 with
sagittal and coronal reconstructions
2. Plain radiographs contribute no additional
information and should not be obtained
71. D. CS injury is suspected
• In the past : initial radiographic screening test was
A 3-view ( lateral, AP & odontoid views)
CS series supplemented by swimmer’s views
and CT CS for poorly-visualized areas.
72. D. CS injury is suspected
• A prospective study of 58 blunt trauma patients with CS
imaging and a CT of another body region.
• Both plain radiography and CT CS.
20 patients (34.4%) : CS injuries.
Plain radiography : missed 8 injuries (3
unstable)
CT CS : missed only 2 injuries (stable).
• The sensitivity for plain CS : 60%, CT CS : 90%
Berne JD, Velmahos GC, El-Tawil Q, et al. J Trauma 1999; 47:896-903
73. D. CS injury is suspected
• Cohort of 1,199 blunt trauma patients with posterior neck tenderness,
altered mental status, or neurologic deficit that underwent both plain
films and CT CS for CS evaluation.
• 116 patients : CS injury.
Detected by both plain films & CT CS : 75 patients.
Detected by CT CS but missed by plain radiography : 41 patients
• CT CS missed no injuries.
• There was no apparent role for screening with plain CS radiography.
Griffen MM, Frykberg ER, Kerwin AJ, et al.
J Trauma 2003; 55:222-227.
74. D. CS injury is suspected
• A prospective study of 1,006 hemodynamically stable patients with
either altered mental status or distracting injury who underwent 5-view
plain films and CT CS.
• Plain films of the CS missed 90 of 172 (52.3%) injuries.
Also missed 5 of 29 (17.2%) of patients with unstable
injuries.
• CT CS missed 3 injuries, none of which were unstable.
• CT CS outperformed plain films in this group of patients
Diaz JJ, Gillman C, Morris JA Jr., et al. J Trauma 2003; 55:658-664
75. D. CS injury is suspected
• 2005 : Holmes and Akkinepalli published a meta-analysis
comparing plain films to CT CS.
• The pooled sensitivity
Plain radiography was 52%
CT CS it was 98%.
Holmes JF, Akkinepalli R.
Computed tomography versus plain radiography to screen for cervical spine
injury: a meta-analysis.
J Trauma 2005; 58:902-905
76. D. CS injury is suspected
CT CS must :
Include axial images from the occiput to T1
Sagittal and coronal reconstructions.
CT CS :
More accurate than plain radiography
Time, effective, cost effective
Does not require additional plain films
77. C-spine clearance
All other patients in whom CS injury is suspected must
have radiographic evaluation
iii. If CT of the CS demonstrates injury:
1. Obtain spine consultation.
iv. If there is neurologic deficit attributable to a CS injury:
1. Obtain spine consultation.
2. Obtain magnetic resonance imaging (MR)
78. C-spine clearance
• v. For the neurologically-intact awake and alert patient
complaining of neck pain with a negative CT:
1. Options
A. Continue cervical collar.
B. Cervical collar may be removed after negative
MR (ideally within 72 hrs)
C. Cervical collar may be removed after negative
and adequate flexion/extension films
79. C-spine clearance
• Vi. Obtunded patient with a negative CT and gross motor function of
extremities:
1. Flexion / extension radiography should not be performed
2. The risk / benefit ratio of obtaining MR in addition to CT is not
clear, and its use must be individualized in each institution options are:
A. Continue cervical collar immobilization until a clinical
exam can be performed.
B. Remove the cervical collar on the basis of CT alone.
C. Obtain MR.
3. If MR is negative, the cervical collar may be safely removed
80. 1. F/E radiography should not be
performed
• The incidence of ligamentous injury identified by
dynamic fluoroscopy in patients with altered mental
status was 0.7%.
Davis JW, Kaups KL, Cunningham MA, et al.
Routine evaluation of the cervical spine in head-injured patients with dynamic
fluoroscopy: a reappraisal.
J Trauma 2001; 50:1044- 1047
81. CT vs MR
• Negative CT : The incidence of ligamentous injury is
very low (<5%)
• The incidence of clinically-significant injury is : much
less than 1%.
• MR is very expensive, and obtaining MR may put the
obtunded ICU patient at significant risk.
82. CT vs MR
• Retrospective 51 obtunded patients who had received both CT
CS and MR CS
10 of 46 patients (22%) with a normal CT CS had an
abnormal MR CS.
4 disk herniations
2 ligamentous injuries
A meningeal tear : potentially unstable
Ghanta MK, Smith LM, Polin RS, et al.
An analysis of Eastern Association for the Surgery of Trauma practice guidelines for cervical spine
evaluation in a series of patients with multiple imaging techniques. Am Surg 2002; 68:563-568.
83. CT vs MR
• 46 obtunded patients with a normal CT CS : All had MR CS.
• An injury was detected by MR CS in 5 patients (11%).
4 : ligamentous injuries
1 : a herniated disk.
None of these injuries required surgery.
Sarani B, Waring S, Sonnad S, et al. Magnetic resonance imaging is a useful adjunct in the evaluation
of the cervical spine of injured patients. J Trauma 2007; 63:637-640.
84. CT vs MR
• MR CS is not reliable for identifying osseous injury. It
missed 45% of fractures.
Holmes JF, Mirvis SE, Panacek EA, et al.
Variability in computed tomography and magnetic resonance imaging in patients
with cervical spine injuries.
J Trauma 2002; 53:524-530.
85. CT vs MR
• MR CS should only be used to clear the CS in the
obtunded patient after a CT CS has cleared the CS of
any bony abnormality.
• MR CS should be obtained within 72 hours of injury
Ability to detect soft-tissue injury may
diminish after this time.
D’Alise MD, Benzel EC, Hart BL.
Magnetic resonance imaging evaluation of the cervical spine in the comatose or
obtunded trauma patient.
J Neurosurg 1999; 91:54-59.
86. C-spine clearance
• Vi. Obtunded patient with a negative CT and gross motor function of
extremities:
1. Flexion / extension radiography should not be performed
2. The risk / benefit ratio of obtaining MR in addition to CT is not
clear, and its use must be individualized in each institution options
are:
A. Continue cervical collar immobilization until a clinical
exam can be performed.
B. Remove the cervical collar on the basis of CT alone.
C. Obtain MR.
88. NEUROLOGICAL ASSESSMENT
AIRWAY MANEUVERS ON C-SPINE MOVEMENT
WAY TO ACHIEVE TRACHEAL INTUBATION
BREATHING AND CIRCULATION
CLINICAL CRITERIA FOR CLEARING C-SPINE
CERVICAL SPINE IMMOBILIZATION
C-SPINE CLEARANCE GUIDELINE
CORTICOSTEROIDS WITH SCI
89. CORTICOSTEROIDS
• A survey of 60 Canadian neurosurgeons and
orthopedic spine surgeons :
75% : Routinely prescribe steroids for acute SCI
70% : Fear from litigation or peer criticism.
17% : Believe that steroids actually
improve their patient’s neurological outcome.
Hurlbert RJ, Moulton R. Can J Neurol Sci 2002; 29: 236–9.
90.
91. CORTICOSTEROIDS
• Moderate vs low-dose methylprednisolone, 10-day regi-men
1 trial (Bracken 1984/85).
No difference in the neurologic outcome scores at 6 weeks,
6 months
Only wound infection was elevated in the high dose regimen
(RR = 3.50, 95% CI 1.18 to 10.41)
92. CORTICOSTEROIDS
• High-dose methylprednisolone vs placebo or none, 24-hr regimen
3 trials (Bracken 1990/93, Otani 1994, Petitjean 1998).
Analysis restricted to patients treated within 8 hour
High-does methylprednisolone : Greater motor function recovery
at 6 wks, 6 mths and the final outcome (WMD= 4.06, 95% CI 0.58 to
7.55).
Pinprick sensation : Significantly improved at 6 mths (WMD =
3.37, 95% CI 0.74 to 6.00) but not at one year
93. CORTICOSTEROIDS
• High-dose methylprednisolone for 48 versus 24 hours
1 trial (Bracken 1997/98).
Patients treated within 3 hours : did not differ in their recovery from 24
or 48-hour methylprednisolone (Bracken 1997/98).
Patients treated within 3 - 8 hours :
Improved motor function if treated with 48-hr
No differences for pinprick or touch sensation
Severe pneumonia & severe sepsis tended to be elevated in the
48-hr but overall mortality at 1 year was not
94. CORTICOSTEROIDS
• Implications for practice
Methylprednisolone sodium succinate (MPSS) enhance
sustained neurologic recovery in a phase three randomized trial.
Therapy must be started within 8 hours of injury
Initial bolus of 30 mg/kg by IV for 15 mins
Followed 45 mins later by a continuous infusion of
5.4mg/kg/hour for 24 hrs.
95. CORTICOSTEROIDS
• Implications for practice
Further improvement in motor function recovery when
the maintenance therapy is extended for 48 hours.
This is particularly evident when the initial bolus dose
could only be administered 3-8 hours after injury.