Introduction:
Patients in any healthcare setting can quickly become acutely unwell, and assessment and management of the airway is always the priority in any clinical situation (Resuscitation Council UK, 2021). When patients are critically unwell, there is a high risk of respiratory deterioration, and many patients require an artificial airway to facilitate their treatment. Knowing how to assess and manage the airway is a key skill for the nurse working in critical care.
Surgical management of the failed airway a guide to percutaneous cricothyrotomyEmergency Live
Surgical Management Of the Failed Airway: A guide to precutaneous cricothyrotomy
Guidelines from Hoan E. Spiegel, MD
Assistant Professor
Beth Israel Ddeaconess Medical Center
Harvard medical School Boston, MS
Vipul Shah, MD
Western Washington Medical Group
Everett, Washington
The first-known mention of an attempted surgical airway, a tracheostomy, was depicted on Egyptian tablets as early as 3600 BCE. History has condemned the emergent surgical airway when it has failed, but when successful, the physicians who performed it have risen in esteem to become "on a footing with the gods".
Il 100 BCE, the Persian physician Asclepiades described in detail a tracheal incision for improving the airway. Yet most who advocated surgical approaches to the airway, including Asclepiades, were severely criticized. Vicq d'Azyr, a French surgeon and anatomist, first described cricothyrotomy in 1805. Emergent cricothyroidotomy /also known as cricothyrotomy, minitracheostomy, and high tracheostomy) became widely acknowledged and accepted in 1976 when Brantigan and Grow confirmed the relative safety of the procedure. A decade later, the Seldinger technique, a wire-over-needle procedure commonly used for intra-vascular cannulation, was adapted for use in obtaining both emergent and nonemergent surgical airways.
History of Tracheostomy
Techniques Types Tubes of Trachesotomy
Open Vs Percutaneous Dilatational Technique
Early vs Late Trachestomy in ICU Setup
Trachesotomy Care
Suctioning Guidelines Techniques
Humidification
Woundcare
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Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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Introduction:
Patients in any healthcare setting can quickly become acutely unwell, and assessment and management of the airway is always the priority in any clinical situation (Resuscitation Council UK, 2021). When patients are critically unwell, there is a high risk of respiratory deterioration, and many patients require an artificial airway to facilitate their treatment. Knowing how to assess and manage the airway is a key skill for the nurse working in critical care.
Surgical management of the failed airway a guide to percutaneous cricothyrotomyEmergency Live
Surgical Management Of the Failed Airway: A guide to precutaneous cricothyrotomy
Guidelines from Hoan E. Spiegel, MD
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Beth Israel Ddeaconess Medical Center
Harvard medical School Boston, MS
Vipul Shah, MD
Western Washington Medical Group
Everett, Washington
The first-known mention of an attempted surgical airway, a tracheostomy, was depicted on Egyptian tablets as early as 3600 BCE. History has condemned the emergent surgical airway when it has failed, but when successful, the physicians who performed it have risen in esteem to become "on a footing with the gods".
Il 100 BCE, the Persian physician Asclepiades described in detail a tracheal incision for improving the airway. Yet most who advocated surgical approaches to the airway, including Asclepiades, were severely criticized. Vicq d'Azyr, a French surgeon and anatomist, first described cricothyrotomy in 1805. Emergent cricothyroidotomy /also known as cricothyrotomy, minitracheostomy, and high tracheostomy) became widely acknowledged and accepted in 1976 when Brantigan and Grow confirmed the relative safety of the procedure. A decade later, the Seldinger technique, a wire-over-needle procedure commonly used for intra-vascular cannulation, was adapted for use in obtaining both emergent and nonemergent surgical airways.
History of Tracheostomy
Techniques Types Tubes of Trachesotomy
Open Vs Percutaneous Dilatational Technique
Early vs Late Trachestomy in ICU Setup
Trachesotomy Care
Suctioning Guidelines Techniques
Humidification
Woundcare
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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
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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
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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.
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Fitness Regimen
Workout Routine
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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.
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Esta publicação só está disponível em inglês até o momento.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
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3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
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2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
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STATEMENT OF NEED
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mortality, and public health costs than all illicit drugs combined. The
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3. DIFFICULT AIRWAY GUIDELINES
The reported incidence of difficult intubation
infants- 0.24%–4.7% and older children- 0.07%–0.7%
ADULT PAEDIATRIC-SPECIFIC
-ASA,
-DAS(UK),
-ANZCA,
-Canadian Royal College of
-AIDAA, and
-Others
-AIDAA,2016
-Polish Society of Anaesthesiology
and Intensive Therapy,
-Polish Society of Neonatology, -
Association of Paediatric
of Great Britain and Ireland &
-ASA in 2022
4. -Challenges with managing the paediatric airway compared to the adult airway
-Narrow margin of safety leading to increased morbidity and mortality
Anatomy
Large occiput
Long, omega-shaped epiglottis
Vocal cords that are angled more anteriorly
Decreased subglottic diameter and stenosis
Larger percentage of narrowing of airway with same degree of oedema
Cone-shaped, cephalad larynx
Comorbidities encountered in the paediatric age group (Pierre-Robin
sequence, Down syndrome)
PHYSIOLOGY
High oxygen consumption and reduced FRC
Resource-specific
Burden of stocking different-sized airway equipment
Scarcity of highly specialized airway experts in this age group, especially in
resource-limited settings
5. Stepwise approach to the difficult paediatric airway is globally
comparable to adult algorithms.
Some notable differences include-
Greater emphasis on constant maintenance of oxygenation
(key factor in prevention of rapid hypoxia and subsequent
bradycardia and cardiopulmonary arrest) and
Switching to the most experienced paediatric anaesthesia
provider after a failed intubation.
(reflects the importance to reduce potential airway
trauma and subsequent oedema, which can result in significant
obstruction in smaller airways).
8. UNANTICIPATED DIFFICULT FACEMASK VENTILATION
Steps Notes
-Maintain adequate depth of
anaesthesia
-Upper airway is kept patent with chin
lift and jaw thrust during mask
ventilation
-head is maintained in neutral
position for children and use of a
shoulder roll in children <6 months
- 2-person bag mask ventilation
- Rule out laryngospasm
- Gastric decompression
-Ensure that soft tissue is not being
pushed by the fingers holding the
mask
Avoid compressing the external nares
while holding the face mask
- Consider lateral position in the
presence of adenotonsillar
hypertrophy or lingual tonsil or
when mask ventilation is not
improved by other techniques
- Correct sizes of oropharyngeal and
nasopharyngeal airways may be
helpful
- Obese, syndromic and
micrognathic patients
- Avoid inadequate depth
- NM blockers
10. - Appropriate laryngoscopy equipments
- Optimal positioning
- External laryngeal manipulation
- Videolaryngoscopes
- Bimanual laryngoscopy
- Intubation aids- malleable stylets, soft gum elastic bougie,
Frova
5Fr 50 cm bougie- neonates and infants,
8 Fr bougie/Frova- up to 5–6 years of age (ETT size 5 mm ID)
11 Fr bougie- children over 6 years of age
15. Recommendations for unanticipated
difficult airway
Call for help.
Optimize oxygenation.
When appropriate, refer to an algorithm and/or cognitive aid.
Upon encountering an unanticipated difficult airway:
• Determine the benefit of waking and/or restoring spontaneous
breathing.
• Determine the benefit of a noninvasive versus invasive approach to
airway management.
16. If a noninvasive approach is selected, identify a preferred sequence of
noninvasive devices to use for airway management.
▪If difficulty is encountered with individual techniques, combination
techniques may be performed.
▪Be aware of the passage of time, the number of attempts, and oxygen
saturation.
▪Provide and test mask ventilation after each attempt, when feasible.
▪Limit the number of attempts at tracheal intubation or supraglottic airway
placement to avoid potential injury and complications.
17. •If an invasive approach to the airway is necessary (i.e., cannot intubate,
cannot ventilate), identify a preferred intervention.
◦Ensure that an invasive airway is performed by an individual trained in
invasive airway techniques, whenever possible.
◦Ensure that an invasive airway is performed as rapidly as possible.
◦If the selected invasive approach fails or is not feasible, identify an alternative
invasive intervention.
▪Initiate ECMO when/if appropriate and available.
18.
19.
20. The airway manager’s assessment and choice of techniques should be based
on-
- Their previous experience;
- available resources, including equipment,
availability and competency of help; and
- the context in which airway management will occur.
21. Pediatric patients may restrict particularly options that involve
awake intubation.
Airway management in the uncooperative or pediatric patient
may require an approach of Intubation attempts after induction
of general anesthesia
22.
23. A. Time out
Time Out for identification of the airway management plan.
A team-based approach with identification of the following is preferred:
-the primary airway manager and backup manager and role assignment,
-the primary equipment and the backup equipment, and the person(s) available to
help.
-Contact an ECMO team/otolaryngologic surgeon if noninvasive airway management
is likely to fail (e.g., congenital high airway obstruction, airway tumor, etc.)
24. B. Color scheme
The colors represent the ability to oxygenate/ventilate:
Green-easy oxygenation/ventilation;
Yellow- difficult or marginal oxygenation/ventilation; and
Red,-impossible oxygenation/ventilation.
Reassess oxygenation/ventilation after each attempt and move to the appropriate box
based on the results of the oxygenation/ventilation check.
25. C. Nonemergency pathway (oxygenation/ventilation adequate)
Deliver oxygen throughout airway management;
Attempt airway management with the technique/device most familiar to the primary airway
manager;
Select from the following devices: supraglottic airway, videolaryngoscopy, flexible
bronchoscopy, or a combination of these devices (e.G., Flexible bronchoscopic intubation
through the supraglottic airway); other techniques (e.G., Lighted stylets or rigid stylets may be
used at the discretion of the clinician);
Optimize and alternate devices as needed;
Reassess ventilation after each attempt;
Limit direct laryngoscopy attempts (e.G., One attempt) with consideration of standard blade
videolaryngoscopy in lieu of direct laryngoscopy;
Limit total attempts (insertion of the intubating device until its removal) by the primary airway
manager (e.G., Three attempts) and one additional attempt by the secondary airway manager;
After four attempts, consider emerging the patient and reversing anesthetic drugs if feasible.
Clinicians may make further attempts if the risks and benefits to the patient favor continued
attempts.
26. D. Marginal/emergency pathway (poor or no
oxygenation/ventilation
treat functional (e.g., airway reflexes with drugs) and anatomical
(mechanical) obstruction;
attempt to improve ventilation with facemask, tracheal intubation, and
supraglottic airway as appropriate;
and if all options fail, declare CICV
consider emerging the patient or using advanced invasive techniques.
(rigid bronchoscopy, emergency invasive techniques, ECMO)
27. E. Team Debrief
Consider after all difficult airway encounters:
Identify processes that worked well and opportunities for system
improvement and
Provide emotional support to members of the team, particularly when
there is patient morbidity or mortality
28. Extubation of difficult airway
Includes interventions that may be used to facilitate airway management
associated with extubation of a difficult airway. Extubation intervention
include:
assessment of patient readiness for extubation,
the presence of a skilled individual to assist with extubation,
selection of an appropriate time and location for extubation,
planning elective tracheostomy,
awake extubation or awake supraglottic airway removal,
supplemental oxygen throughout the extubation process, and
extubation with an airway exchange catheter or supraglottic airway (for
possible reintubation)
The task force regards the concept of an extubation strategy as a logical
extension of the intubation strategy.
29. Follow-up care includes :
(1) post extubation care(i.e., Steroids, racemic epinephrine),
(2) post extubation counseling (i.E., Informing and advising the
patient or responsible individual of the occurrence and potential
complications associated with a difficult airway)
(3) documentation of difficult airway and management in the
medical record and to the patient, and
(4) registration with a difficult airway notification service.
30. AIDAA 2016 • ASA2022
• Continuous nasal oxygenation throughout
• (Maintaining spo2 >95%)
• Menitoned Sequence of use of non-invasive
devices
• Maximum attempts at intubation – 3
• Maximum SAD attempts- 2
• Face mask ventilation with NM blockade- one
attempt
• Age wise invasive airway management
• Supplemental O2 administration before
initiating and throughout difficult airway
management, including the extubation
process.(No mention of cutoff for spo2)
• Recommend to use the device you are most
familiar with
• Attempts total 3+1
• No age wise invasive airway approach
mentioned
• ECMO
• Robust recommendations for extubation of
difficult airway
• Team Debriefing
31. Priority is to maintain ventilation and
oxygenation and not just intubation.
-If intubation attempt fails, DON’T
FORGET TO bag-mask ventilate the
patient and keep the spO2 >95%
-supplemental oxygenation throughout
the procedure