Laughter is the Best Medicine - A Healthcare Design JokeSara Marberry
Laughter can help relieve stress. In fact, researchers believe a hearty guffaw has many health benefits — including boosting your heart rate and sending oxygen to tissues to give you a mild workout, burning calories in the process. It’s also been found to increase blood flow, boost the immune system, keep blood sugar levels low, and improve sleep. So, to get you laughing and improve your health, I offer the only healthcare design joke I know (origins unknown).
Northern Hemisphere vrs Southern. Two teams put it all on the line in the ultimate challenge, testing their knowledge, skills, communication and teamwork in a three section extravaganza. SMACCDUB speakers will test them on content from talks they've just given, serving to distill the finer points they wanted to convey. The teams will then test their non-technical skills in a crisis resource management challenge - not only against one another but also against a team of "gladiators" (SMACCDUB speakers / celebs), followed by a debrief from Vic Brazil. Finally the teams will run a procedure gauntlet, having to demonstrate key learning points on their procedures as well as beat the clock. The winners walk away with fame, glory, SMACC '17 tickets and much more. The losers face the ultimate Irish punishment: a leprechaun pie attack. Hosted by Harris, Nickson and Flower, and with an all-star faculty, this is one you have to see. You'll laugh. You'll cry. You'll cheer. And you'll definitely learn something!
Hospital & Rehabilitation Centre for Disabled Children (HRDC) a 100 bedded tertiary level pediatric orthopedic hospital operated by the Friends of the Disabled (FoD) a not for profit organisation in Nepal since 1985 and so far over 80,000 children with physical disability have been served.
RADIATION PROTECT trial: a randomized controlled trial of radiation protection with a patient lead shield and a novel non-lead surgical cap for operators performing coronary angiography or intervention
Paediatric research and surgery - Journals gselva739
This journals about the laparoscopy in paediatric surgery- Dr. Prakash Agarwal has sharing the experience in SRMC. He explanied paddiatric surgery and its diagnosis and procedure for analysis of children who underwent laparoscopy surgery.
Laughter is the Best Medicine - A Healthcare Design JokeSara Marberry
Laughter can help relieve stress. In fact, researchers believe a hearty guffaw has many health benefits — including boosting your heart rate and sending oxygen to tissues to give you a mild workout, burning calories in the process. It’s also been found to increase blood flow, boost the immune system, keep blood sugar levels low, and improve sleep. So, to get you laughing and improve your health, I offer the only healthcare design joke I know (origins unknown).
Northern Hemisphere vrs Southern. Two teams put it all on the line in the ultimate challenge, testing their knowledge, skills, communication and teamwork in a three section extravaganza. SMACCDUB speakers will test them on content from talks they've just given, serving to distill the finer points they wanted to convey. The teams will then test their non-technical skills in a crisis resource management challenge - not only against one another but also against a team of "gladiators" (SMACCDUB speakers / celebs), followed by a debrief from Vic Brazil. Finally the teams will run a procedure gauntlet, having to demonstrate key learning points on their procedures as well as beat the clock. The winners walk away with fame, glory, SMACC '17 tickets and much more. The losers face the ultimate Irish punishment: a leprechaun pie attack. Hosted by Harris, Nickson and Flower, and with an all-star faculty, this is one you have to see. You'll laugh. You'll cry. You'll cheer. And you'll definitely learn something!
Hospital & Rehabilitation Centre for Disabled Children (HRDC) a 100 bedded tertiary level pediatric orthopedic hospital operated by the Friends of the Disabled (FoD) a not for profit organisation in Nepal since 1985 and so far over 80,000 children with physical disability have been served.
RADIATION PROTECT trial: a randomized controlled trial of radiation protection with a patient lead shield and a novel non-lead surgical cap for operators performing coronary angiography or intervention
Paediatric research and surgery - Journals gselva739
This journals about the laparoscopy in paediatric surgery- Dr. Prakash Agarwal has sharing the experience in SRMC. He explanied paddiatric surgery and its diagnosis and procedure for analysis of children who underwent laparoscopy surgery.
Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine.
All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality.
In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease.
A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001).
This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time).
If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance.
As Katrin explains, over testing and over diagnosis have serious consequences. Not only for patients but also for the healthcare system.
In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low.
Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low.
There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.
The Problem with Hospital Systems: Alex PsiridesSMACC Conference
Alex Psirides discusses the problem with major hospitals and the systems that they use.
Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system.
As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches.
The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world.
Many staff lack acute medical skills.
Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs.
Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.
Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care.
Unfortunately, junior doctors often call for help when it is too late.
Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’
The Problem with Hospital Systems: Alex Psirides
For more like this, head to our podcast page. #CodaPodcast
How to Spot the Sick Child in the Emergency DepartmentSMACC Conference
Ffion Davies gives her take on how to spot the sick child in the Emergency Department.
Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.
So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.
Ffion breaks her thinking into two main areas: physiology and psychology.
Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child.
Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease.
Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.
Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.
Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.
Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.
Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.
For more like this, head to our podcast page. #CodaPodcast
A presentation given by Luke Wainwright and myself about some of the trials and tribulations and eventual successes with integrating simulation into hospital education programs.
Presentation from the SWEETs 16 conference, Sweden. This presentation works on the applications of simulation for a major change management project in becoming ready for the closure of a paediatric hospital and the impact on an adult emergency department.
This Talk is a Summary of:
1. Review the Importance of Quality in CPR
2. Discuss the Safety of “Hands-on” Defibrillation
3. Evaluate Manual vs Mechanical CPR
Anyone Can Intubate, or Not: Teaching airway skills the antifragile waySMACC Conference
Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.
GEMC: Meningitis and Other CNS Infections: Resident TrainingOpen.Michigan
This is a lecture by Dr. Frank Madore from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Deirdre talks ‘bad blood’ – the complex world of critical care haematology.
Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human.
When they run riot, or the fine balance between pro- and anti-inflammatory states is shifted, there can be significant morbidity and mortality.
Deirdre presents three patients to highlight these issues and what you can do about it. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients.
Platelets make up a tiny percentage of blood – just 0.01%. However, they have a crucial role to play. A low platelet count can be due to reduced production or increased destruction.
Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications. Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic haemolytic anaemia (MAHA) will also be described including the role of ADAMST13.
The knowledge of what is what, is critical, as it will dictate treatment. Heparin-Induced Thrombocytopaenia (HIT) is an uncommon but important condition which is difficult to diagnose in a critically ill patient. It is a heparin dependent pro-thrombotic disorder. There is no good test for HIT.
Have you always wondered about NETs (neutrophil extracellular traps) and their importance? If so this whistle-stop tour of non-malignant hematology in the ICU is for you!
Deirdre drives home the message that low platelets are common in the critically ill and the causes are multifactorial.
Finally, for more like this head to our podcast page. #CodaPodcast
Stuart Lane on prognostication post out of hospital cardiac arrestSMACC Conference
Always controversial, always entertaining, the fearsome but loveable Geordie Stuart Lane gives an excellent summary of a core ICU topic: managing out of hospital cardiac arrests. Nearly at the end of the BCC3 series - and in only a month we're doing it all again, this time in tropical Cairns - come and join us.
Prehospital Care of the Pediatric Trauma Patient dpark419
An evidence based review of prehospital care of the pediatric trauma patient. This lecture was given to EMS personnel at the Medical University of South Carolina on 12/3/14.
Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine.
All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality.
In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease.
A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001).
This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time).
If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance.
As Katrin explains, over testing and over diagnosis have serious consequences. Not only for patients but also for the healthcare system.
In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low.
Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low.
There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.
The Problem with Hospital Systems: Alex PsiridesSMACC Conference
Alex Psirides discusses the problem with major hospitals and the systems that they use.
Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system.
As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches.
The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world.
Many staff lack acute medical skills.
Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs.
Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.
Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care.
Unfortunately, junior doctors often call for help when it is too late.
Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’
The Problem with Hospital Systems: Alex Psirides
For more like this, head to our podcast page. #CodaPodcast
How to Spot the Sick Child in the Emergency DepartmentSMACC Conference
Ffion Davies gives her take on how to spot the sick child in the Emergency Department.
Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.
So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.
Ffion breaks her thinking into two main areas: physiology and psychology.
Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child.
Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease.
Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.
Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.
Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.
Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.
Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.
For more like this, head to our podcast page. #CodaPodcast
A presentation given by Luke Wainwright and myself about some of the trials and tribulations and eventual successes with integrating simulation into hospital education programs.
Presentation from the SWEETs 16 conference, Sweden. This presentation works on the applications of simulation for a major change management project in becoming ready for the closure of a paediatric hospital and the impact on an adult emergency department.
This Talk is a Summary of:
1. Review the Importance of Quality in CPR
2. Discuss the Safety of “Hands-on” Defibrillation
3. Evaluate Manual vs Mechanical CPR
Anyone Can Intubate, or Not: Teaching airway skills the antifragile waySMACC Conference
Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.
GEMC: Meningitis and Other CNS Infections: Resident TrainingOpen.Michigan
This is a lecture by Dr. Frank Madore from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Deirdre talks ‘bad blood’ – the complex world of critical care haematology.
Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human.
When they run riot, or the fine balance between pro- and anti-inflammatory states is shifted, there can be significant morbidity and mortality.
Deirdre presents three patients to highlight these issues and what you can do about it. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients.
Platelets make up a tiny percentage of blood – just 0.01%. However, they have a crucial role to play. A low platelet count can be due to reduced production or increased destruction.
Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications. Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic haemolytic anaemia (MAHA) will also be described including the role of ADAMST13.
The knowledge of what is what, is critical, as it will dictate treatment. Heparin-Induced Thrombocytopaenia (HIT) is an uncommon but important condition which is difficult to diagnose in a critically ill patient. It is a heparin dependent pro-thrombotic disorder. There is no good test for HIT.
Have you always wondered about NETs (neutrophil extracellular traps) and their importance? If so this whistle-stop tour of non-malignant hematology in the ICU is for you!
Deirdre drives home the message that low platelets are common in the critically ill and the causes are multifactorial.
Finally, for more like this head to our podcast page. #CodaPodcast
Stuart Lane on prognostication post out of hospital cardiac arrestSMACC Conference
Always controversial, always entertaining, the fearsome but loveable Geordie Stuart Lane gives an excellent summary of a core ICU topic: managing out of hospital cardiac arrests. Nearly at the end of the BCC3 series - and in only a month we're doing it all again, this time in tropical Cairns - come and join us.
Prehospital Care of the Pediatric Trauma Patient dpark419
An evidence based review of prehospital care of the pediatric trauma patient. This lecture was given to EMS personnel at the Medical University of South Carolina on 12/3/14.
Preparing for Microbial Threats to Health: What Every Professional Should KnowTomas J. Aragon
In this presentation I introduce the "SFDPH Population Health Division Controlling Infectious Diseases Model." This model integrates concepts from understanding transmission mechanisms, transmission dynamics, and transmission containment. The Model is most useful when facing novel microbial threats and we need simple framework for public health action.
Methods: Retrospectively, the file records of the patients who underwent sleeve gastrectomy were examined. Demographic features, Body Mass Index (BMI), the mouth opening, Mallampati score, thyromental distance, sternomental distance, neck circumference measurements and videolaryngoscopic examination results were recorded Results: In a total of 140 consecutive patients (58 male, 82 female) were included in the study. The mean age of the study participants was 35.40 ± 9.78 and the mean BMI of the patients was 44.33 ± 7.52 kg/m2
. The mean mouth opening of the patients was 4.82 ± 0.54 cm
and the mean neck circumference was 43.52 ± 4.66 cm. The mean thyromental distance was 8.02 ± 1.00 cm and the mean sternomental distance was16.58 ± 1.53 cm. Difficult intubation was determined in 8 (5.7%) patients. In logistic regression analysis, age (p : 0.446), gender (p : 0.371), BMI (p : 0.947), snoring (p : 0.567), sleep apnea (p : 0.218), mouth opening (p : 0.687), thyromental distance (p :0.557), sternomental (p : 0.596) and neck circumference (p : 0.838) were not the independent predictors of difficult intubation. However, Mallampati score (p : 0.001) and preoperative direct laryngoscopy findings (p : 0.037) performed in outpatient clinic were the significant
predictors of difficult intubation. Interestingly, all patients with grade 4 laryngoscopy findings had difficult intubation.
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.
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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 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
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
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- 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
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
1. GETTING IT RIGHT
FIRST TIME
or
“IntubatingKiddies in Helicopters” LukeRegan
@lukeandrewregan
2. “60% of the time....it works every time!”
WHO is referring to WHAT here?
Let’s start with a groovy MCQ
3. A) Noted airway expert Dr Minh le Cong describing use
of cricoid pressure
B) Noted gaseous induction expert Brian Fantana
describing use of “Sex Panther”
C) Noted oral sedation expert Dr John Glasheen
describing use of Guinness in fracture manipulations
D) Dr Hyuk Joong Choi (et al) describing the alarming
baseline rate of first pass success intubating
children across 13 Korean Emergency Departments
from 2006-2010
4. D) Dr Hyuk Joong Choi (et al) describing the alarming
baseline rate of first pass success intubating
children across 13 Korean Emergency Departments
from 2006-2010
35. REFERENCES
(1) Harris T, Lockey D. Success in physician prehospital rapid sequence intubation: what is the effect of base
speciality and length of anaesthetic training? Emerg Med J 2011 Mar;28(3):225-229.
(2) Lossius HM, Roislien J, Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: a
comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care 2012 Feb
11;16(1):R24.
(3) Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Pre-hospital advanced airway management by
experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med 2013
Jul 25;21:58-7241-21-58.
(4) Bano S, Akhtar S, Zia N, Khan UR, Haq AU. Pediatric endotracheal intubations for airway management in
the emergency department. Pediatr Emerg Care 2012 Nov;28(11):1129-1131.
(5) Choi HJ, Je SM, Kim JH, Kim E, Korean Emergency Airway Registry Investigators. The factors associated
with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-
emergency-department registry study. Resuscitation 2012 Nov;83(11):1363-1368.
(6) Green SM. A is for airway: a pediatric emergency department challenge. Ann Emerg Med 2012
Sep;60(3):261-263.
(7) Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and predictors of
difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth 2012 Aug;22(8):729-736.
36. REFERENCES
(8) Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric
emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann
Emerg Med 2012 Sep;60(3):251-259.
(9) Nishisaki A, Turner DA, Brown CA,3rd, Walls RM, Nadkarni VM, National Emergency Airway Registry for
Children (NEAR4KIDS), et al. A National Emergency Airway Registry for children: landscape of tracheal
intubation in 15 PICUs. Crit Care Med 2013 Mar;41(3):874-885.
(10) Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing
orotracheal intubation in the emergency department. Acad Emerg Med 2013 Jan;20(1):71-78.
(11) Sukys GA, Schvartsman C, Reis AG. Evaluation of rapid sequence intubation in the pediatric
emergency department. J Pediatr (Rio J) 2011 Jul-Aug;87(4):343-349.
(12) Gerritse BM, Draaisma JM, Schalkwijk A, van Grunsven PM, Scheffer GJ. Should EMS-paramedics
perform paediatric tracheal intubation in the field? Resuscitation 2008 Nov;79(2):225-229.
(13) Eich C, Roessler M, Nemeth M, Russo SG, Heuer JF, Timmermann A. Characteristics and outcome of
prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians.
Resuscitation 2009 Dec;80(12):1371-1377.
(14) Sanders RC,Jr, Giuliano JS,Jr, Sullivan JE, Brown CA,3rd, Walls RM, Nadkarni V, et al. Level of trainee
and tracheal intubation outcomes. Pediatrics 2013 Mar;131(3):e821-8.
(15) R.Bloomer,B.Burns,S.Ware,K.Habig. Improving documentation in pre-hospital rapid sequence
intubation. Emerg Med J. 2012 Apr 13