Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. CPR involves a combination of mouth-to-mouth rescue breathing and chest compression that keeps oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.
When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you're helping an unconscious person who isn't breathing.
Remember the ABCs
Airway, Breathing and Circulation — to remember the steps explained below.
AIRWAY: Clear the airway
1. Put the person on his or her back on a firm surface.
2. Kneel next to the person's neck and shoulders.
3. Open the person's airway using the head tilt-chin lift. Put your palm on the person's forehead and gently push down. Then with the other hand, gently lift the chin forward to open the airway.
4. Check for normal breathing, taking no more than 10 seconds: Look for chest motion, listen for breath sounds, and feel for the person's breath on your cheek and ear. Do not consider gasping to be normal breathing. If the person isn't breathing normally or you aren't sure, begin mouth-to-mouth breathing.
BREATHING: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened.
1. With the airway open (using the head tilt-chin lift), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.
2. Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head tilt-chin lift and then give the second breath.
3. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
2. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest 1 1/2 to 2 inches. Push hard and push fast — give two compressions per second, or about 100 compressions per minute.
3. After 30 compressions, tilt the head back and lift the chin up to open the airway. Prepare to give two rescue breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest rises, give a second rescue breath. If the chest doesn’t rise, repeat the head tilt-chin lift and then give the second rescue breath. That's one cycle. If someone else is available, ask that person to give two breaths after you do 30 compressions.
4. If the person has not begun moving after five cycles (about two minutes) and an automated external defibrillator (AED) is available, open the kit and follow the prompts. If you're not trained to use an AED, a 911 operator may be able to guide you in its use. Trained staff at many public places are also able to provide and use an AED. Use pediatric pads, if available, for children ages 1 to 8. If pediatric pads aren't available, use adult pads. Do not use an AED for infants younger than age 1. If an AED isn't available, go to Number 5 below.
5. Continue CPR until there are signs of movement or until emergency medical personnel take over.
To perform CPR on a child:
The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The differences are as follows:
Perform five cycles of compressions and breaths on the child — this should take about two minutes — before calling 911 or the local emergency number, unless someone else can call while you attend to the child.
Use only one hand to perform heart compressions.
Breathe more gently.
Use the same compression/breath rate as is used for adults: 30 compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. Continue until the victim moves or help arrives.
To perform CPR on a baby:
Most cardiac arrests in infants occur from lack of oxygen, such as from drowning or choking. If you know the infant has an airway obstruction, perform first aid for choking. If you don't know why the infant isn't breathing, perform CPR.
To begin, assess the situation. Stroke the baby and watch for a response, such as movement, but don't shake the child.
If there's no response, follow the ABC procedures below and time the call for help as follows:
If you're the only rescuer and CPR is needed, do CPR for two minutes — about five cycles — before calling 911 or your local emergency number.
If another person is available, have that person call for help immediately while you attend to the baby.
AIRWAY: Clear the airway
1. Place the baby on his or her back on firm, flat surface, such as a table. The floor or ground also will do.
2. Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.
3. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear.
If the infant isn't breathing, begin mouth-to-mouth breathing immediately.
BREATHING: Breathe for the infant
1. Cover the baby's mouth and nose with your mouth.
2. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head tilt-chin lift and then give the second breath.
3. If the chest still doesn't rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking infant.
4. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest.
2. Gently compress the chest to about one-third to one-half the depth of the chest.
3. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of about 100 times a minute.
4. Give two breaths after every 30 chest compressions.
5. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby.
6. Continue CPR until you see signs of life or until a professional relieves you.
Monday, June 25, 2007
Sunday, June 24, 2007
The Gallbladder or Cholecyst
Anatomy
The gallbladder is about 7-10 cm long in humans and appears dark green because of its contents (bile), rather than its tissue. It is connected to the liver and the duodenum by the biliary tract.
The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct.
The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.
Microscopic anatomy
The different layers of the gallbladder are as follows:
The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining.
Under the epithelium there is a layer of connective tissue (lamina propria).
Beneath the connective tissue is a wall of smooth muscle (muscularis muscosa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
There is essentially no submucosa separating the connective tissue from serosa and adventitia.
Stained section of a gall bladder showing the highly convoluted mucosal folds
Function
The gallbladder stores about 50ml of bile (1.7 US fluid ounces / 1.8 Imperial fluid ounces), which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.
Role in disease
Cholestasis is the blockage in the supply of bile into the digestive tract. It can be "intrahepatic" (the obstruction is in the liver) or "extrahepatic" (outside the liver). It can lead to jaundice, and is identified by the presence of elevated bilirubin level that is mainly conjugated.
Biliary colic is when a gallstone blocks either the common bile duct or the duct leading into it from the gallbladder.
Up to 25% of all people have gallstones (cholelithiasis), composed of lecithin and bile acids. These can cause abdominal pain, usually in relation with the meal, as the gallbladder contracts and gallstones pass through the bile duct.
Acute or chronic inflammation of the gallbladder (cholecystitis) causes abdominal pain. 90% of cases of acute cholecystitis are caused by the presence of gallstones. The actual inflammation is due to secondary infection with bacteria of an obstructed gallbladder, with the obstruction caused by the gallstone.
When gallstones obstruct the common bile duct (choledocholithiasis), the patient develops jaundice and liver cell damage. It is a medical emergency, requiring endoscopic or surgical treatment such as a cholecystectomy.
A rare clinical entity is ileus (bowel) obstruction by a large gallstone, or gallstone ileus. This condition develops in patients with longstanding gallstone disease, in which the gallbladder forms a fistula with the digestive tract. Large stones pass into the bowel, and generally block the gut at the level of Treitz' ligament or the ileocecal valve, two narrow points in the digestive tract. The treatment is surgical.
Cancer of the gallbladder is a rare but highly fatal disease. It has been associated with gallstone disease, estrogens, cigarette smoking, alcohol consumption and obesity. Despite aggressive modern surgical approaches, advanced imaging techniques, and endoscopy, nearly 90% of patients die from advanced stages of the disease and experience pain, jaundice, weight loss, and ascites.
Polyps (growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 mm to 15 mm have a lower risk but they should still discuss removal of their gallbladder with their physician. Of special note is a condition called primary sclerosing cholangitis, which causes inflammation and scarring in the bile duct. It is associated with a lifetime risk of 7% to 12% for gallbladder cancer. The cause is unknown, although primary sclerosing cholangitis tends to strike younger men who have ulcerative colitis. Polyps are often detected in this condition and have a very high likelihood of malignancy.
References
^ Physiology at MCG 6/6ch2/s6ch2_30
The gallbladder is about 7-10 cm long in humans and appears dark green because of its contents (bile), rather than its tissue. It is connected to the liver and the duodenum by the biliary tract.
The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct.
The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.
Microscopic anatomy
The different layers of the gallbladder are as follows:
The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining.
Under the epithelium there is a layer of connective tissue (lamina propria).
Beneath the connective tissue is a wall of smooth muscle (muscularis muscosa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
There is essentially no submucosa separating the connective tissue from serosa and adventitia.
Stained section of a gall bladder showing the highly convoluted mucosal folds
Function
The gallbladder stores about 50ml of bile (1.7 US fluid ounces / 1.8 Imperial fluid ounces), which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.
Role in disease
Cholestasis is the blockage in the supply of bile into the digestive tract. It can be "intrahepatic" (the obstruction is in the liver) or "extrahepatic" (outside the liver). It can lead to jaundice, and is identified by the presence of elevated bilirubin level that is mainly conjugated.
Biliary colic is when a gallstone blocks either the common bile duct or the duct leading into it from the gallbladder.
Up to 25% of all people have gallstones (cholelithiasis), composed of lecithin and bile acids. These can cause abdominal pain, usually in relation with the meal, as the gallbladder contracts and gallstones pass through the bile duct.
Acute or chronic inflammation of the gallbladder (cholecystitis) causes abdominal pain. 90% of cases of acute cholecystitis are caused by the presence of gallstones. The actual inflammation is due to secondary infection with bacteria of an obstructed gallbladder, with the obstruction caused by the gallstone.
When gallstones obstruct the common bile duct (choledocholithiasis), the patient develops jaundice and liver cell damage. It is a medical emergency, requiring endoscopic or surgical treatment such as a cholecystectomy.
A rare clinical entity is ileus (bowel) obstruction by a large gallstone, or gallstone ileus. This condition develops in patients with longstanding gallstone disease, in which the gallbladder forms a fistula with the digestive tract. Large stones pass into the bowel, and generally block the gut at the level of Treitz' ligament or the ileocecal valve, two narrow points in the digestive tract. The treatment is surgical.
Cancer of the gallbladder is a rare but highly fatal disease. It has been associated with gallstone disease, estrogens, cigarette smoking, alcohol consumption and obesity. Despite aggressive modern surgical approaches, advanced imaging techniques, and endoscopy, nearly 90% of patients die from advanced stages of the disease and experience pain, jaundice, weight loss, and ascites.
Polyps (growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 mm to 15 mm have a lower risk but they should still discuss removal of their gallbladder with their physician. Of special note is a condition called primary sclerosing cholangitis, which causes inflammation and scarring in the bile duct. It is associated with a lifetime risk of 7% to 12% for gallbladder cancer. The cause is unknown, although primary sclerosing cholangitis tends to strike younger men who have ulcerative colitis. Polyps are often detected in this condition and have a very high likelihood of malignancy.
References
^ Physiology at MCG 6/6ch2/s6ch2_30
Friday, June 22, 2007
The VISA Score for Grading Patellar Tendinosis (Jumper's Knee)
Overview :
The VISA (Victorian Institute of Sport Assessment) score can be used to grade the severity of symptoms in patients with patellar tendinosis (jumper's knee). It can be used to monitor patient's over time and to assess the impact of various interventions.
The Victorian Institute of Sport is in South Melbourne, Victoria, Australia.
Questionnaire
(1) How many minutes can you sit pain free?
• points = INTEGER (MINIMUM (100, (minutes/10))
(2) Do you have pain walking downstairs with a normal gait cycle?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(3) Do you have pain at the knee with full active non-weight bearing knee extension?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(4) Do you have pain when doing a full-weight bearing lung?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(5) Do you have problems squatting?
• points from 0 to 10
• unable: 0 points
• no problems: 10 points
(6) Do you have pain during immediately after doing 10 single leg hops?
• points from 0 to 10
• strong severe pain/unable: 0 points
• no pain: 10 points
(7) Are you currently undertaking sport or other physical activity?
• not at all: 0 points
• modified training +/- modified competition: 4 points
• full training +/- competition but not at same level as when symptoms began: 7 points
• competing at the same or higher level as when symptoms began: 10 points
(8) Complete EITHER 8a, 8b, OR 8c, selecting as follows:
• If you have no pain while undertaking sport, please complete 8A only.
(8a) If you have no while undertaking sport, for how long can you train/practice?
• If you have pain while undertaking sport but it does not stop you from completing the activity, please complete 8b only.
(8b) If you have some pain while undertaking sport, but it does not stop you from completing your training/practice, for how long can you train/practice?
• If you have pain that stops you from completing sporting activities, please complete 8c only.
(8c) If you have pain that stops you from completing your training/practice, for how long can you train/practice?
Question nil 0-5 mts 6-10 mts 11-15 mts > 15 minutes
8a 0 7 14 21 30
8b 0 4 10 14 20
8c 0 2 5 7 10
total VISA score =
= SUM(points for responses to all 8 questions)
Interpretation:
• minimum score: 0
• maximum score: 100
• The higher the score, the better the patient's condition.
• Patients may be categorized into groups based on 81-100, 61-80, and < name="ref">References:
Visentini PJ, Khan KM, et al. The VISA Score: An index of severity of symptoms in patients with jumper's knee (patellar tendinosis). J Science and Medicine in Sport. 1998; 1: 22-28.
The VISA (Victorian Institute of Sport Assessment) score can be used to grade the severity of symptoms in patients with patellar tendinosis (jumper's knee). It can be used to monitor patient's over time and to assess the impact of various interventions.
The Victorian Institute of Sport is in South Melbourne, Victoria, Australia.
Questionnaire
(1) How many minutes can you sit pain free?
• points = INTEGER (MINIMUM (100, (minutes/10))
(2) Do you have pain walking downstairs with a normal gait cycle?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(3) Do you have pain at the knee with full active non-weight bearing knee extension?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(4) Do you have pain when doing a full-weight bearing lung?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(5) Do you have problems squatting?
• points from 0 to 10
• unable: 0 points
• no problems: 10 points
(6) Do you have pain during immediately after doing 10 single leg hops?
• points from 0 to 10
• strong severe pain/unable: 0 points
• no pain: 10 points
(7) Are you currently undertaking sport or other physical activity?
• not at all: 0 points
• modified training +/- modified competition: 4 points
• full training +/- competition but not at same level as when symptoms began: 7 points
• competing at the same or higher level as when symptoms began: 10 points
(8) Complete EITHER 8a, 8b, OR 8c, selecting as follows:
• If you have no pain while undertaking sport, please complete 8A only.
(8a) If you have no while undertaking sport, for how long can you train/practice?
• If you have pain while undertaking sport but it does not stop you from completing the activity, please complete 8b only.
(8b) If you have some pain while undertaking sport, but it does not stop you from completing your training/practice, for how long can you train/practice?
• If you have pain that stops you from completing sporting activities, please complete 8c only.
(8c) If you have pain that stops you from completing your training/practice, for how long can you train/practice?
Question nil 0-5 mts 6-10 mts 11-15 mts > 15 minutes
8a 0 7 14 21 30
8b 0 4 10 14 20
8c 0 2 5 7 10
total VISA score =
= SUM(points for responses to all 8 questions)
Interpretation:
• minimum score: 0
• maximum score: 100
• The higher the score, the better the patient's condition.
• Patients may be categorized into groups based on 81-100, 61-80, and < name="ref">References:
Visentini PJ, Khan KM, et al. The VISA Score: An index of severity of symptoms in patients with jumper's knee (patellar tendinosis). J Science and Medicine in Sport. 1998; 1: 22-28.
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