Podcasts about mallampati

Bom dia, boa tarde, boa noite! Seja bem vindo a mais uma pílula do Medicina do Conhecimento. Juntos compartilhamos ciência e informação a qualquer momento e em todo lugar. Eu sou Pablo Gusman, o Anestesiador e como compartilhar é multiplicar convido você ouvinte a conversarmos sobre assuntos sem fronteiras no mundo do conhecimento. Por aqui você ouve tendências, dicas e a prática da medicina, além de assuntos que nos proporcionam qualidade de vida! Você já pensou em usar o ultrassom para verificar a dificuldade de ventilação sob máscara facial? A triagem para a probabilidade de ventilação difícil com uso de máscara facial pode sim incluir um exame ultrassonográfico. Os resultados de um estudo recente descobriram que a medição da anatomia das vias aéreas com ultrassom em região submandibular pela metodologia (POCUS – Point of Care UltraSound) pode ajudar a identificar possíveis cenários de ventilação difícil com máscara, o que, segundo os pesquisadores, pode nos ajudar a estarmos preparados com uma via aérea difícil. O ultrassom também ajudou a identificar pacientes com apneia obstrutiva do sono. Na nossa prática, a ventilação com máscara é uma técnica crítica para a anestesia geral porque nos fornece o tempo adequado para a intubação em momento apropriado. Atualmente, nós usamos avaliações tradicionais à beira do leito, como classificação de Mallampati, abertura da boca e o gesto de morder o lábio superior para determinar se a ventilação com máscara será difícil. Um grupo da Escola de Medicina e Ciências da Saúde da Universidade George Washington, em Washington, D.C., inscreveu 91 pacientes adultos no estudo prospectivo, submetidos a cirurgia com anestesia geral que necessitaram de ventilação com máscara facial. Os pesquisadores usaram o que chamaram de POCUS submandibular pré-operatório para medir seis parâmetros das vias aéreas: espessura da língua; espessura do músculo gênio-hióideo; a distância entre as artérias linguais; espessura da parede lateral da faringe; distância hiomental; e altura da cavidade oral. Para determinar se um paciente era preditível de uma ventilação com máscara difícil, foi usado o escore de ventilação com máscara conforme descrito por Richard Han em 2004 [Anesthesiology 2004;101(1):267]. No estudo, usou-se uma sonda curvilínea de 3 a 8 MHz para varredura com ultrassom submandibular e com a sonda diretamente sob o queixo do paciente. Os resultados mostraram que quatro medições foram significativamente maiores em pacientes com risco moderado/alto de apneia obstrutiva do sono moderada a grave (STOP-Bang, 3- 8) em comparação com aqueles com baixo risco (STOP-Bang, 0-2): espessura da língua, espessura do músculo gênio-hióideo, distância entre as artérias linguais e distância hiomentoniana. Os resultados sugerem que múltiplas medições pré-operatórias usando ultrassom submandibular podem preparar melhor os anestesiologistas para ventilação difícil com máscara, seja exigindo uma via aérea oral ou a presença de um segundo profissional na sala. Embora possamos relacionar o POCUS à previsão de ventilação difícil com máscara, a tecnologia ainda não é comum o suficiente para ser considerada uma parte rotineira da prática clínica. A idéia é que em futuro próximo, Sondas de ultrassom portáteis podem um dia se tornar tão comuns quanto os estetoscópios. E particularmente, acredito que isso não esteja tão longe Gostou do assunto? Ative a notificação para ser informado quando um novo podcast for publicado e a qualquer momento e em todo lugar, escute a rádioweb no www.medicinaconhecimento.com.br

In this episode, Dr. Aaron Fritts interviews Dr. Christopher Beck about gastrostomy tubes, including the evolution of his method, tips for patients who pull their tubes out, and why g-tubes are such a controversial topic in IR. --- CHECK OUT OUR SPONSOR Laurel Road for Doctors https://www.laurelroad.com/healthcare-banking/ --- SHOW NOTES We begin by discussing indications and contraindications for gastrostomy tubes. Frequent indications are stroke patients, head and neck cancer patients, and trauma patients. Contraindications include uncorrectable coagulopathy, ascites, peritoneal carcinomatosis, or something interposed between the abdominal wall and the stomach, such as liver or bowel. Dr. Beck prefers having imaging to review, which most patients have. If no prior imaging is available, he will get a non-contrast CT abdomen the day of the procedure. He likes all his patients to drink barium for visualization of bowel during the procedure, but will not cancel the procedure if they didn't drink it, as the insufflation should move bowel out of the way and there should be enough bowel gas to identify and avoid the bowel. Next, Dr. Beck reviews the details of his method. He likes to use monitored anesthesia care (MAC), because frequently he has patients with bad Mallampati scores. Additionally, anesthesia is very helpful with NG placement. Furthermore, it makes the procedure much more comfortable for the patient. He always checks liver margins with ultrasound prior to starting the procedure. He always gives 1 mg glucagon before insufflation and antibiotics per the SIR Guidelines App. As for equipment, he uses t-fasteners from Avanos, a dilator set, and a 20Fr G-tube. He used to start with 16Fr but found he frequently had to size up to a 20Fr. He uses a 24Fr peel away sheath. For the procedure, he insufflates, marks his entry point with a hemostat, and then numbs in all 3 spots where he will place his gastropexies. He uses 1/2 syringe of contrast for his gastropexy placement. He uses 2 t-tags, and prefers the C-arm in RAO rather than AP during this step. For G-tube placement, he aims 20 degrees toward the pylorus, and always makes sure he sees wire touching two walls of the stomach to ensure he is intraluminal. He uses sterile water to inflate the balloon rather than saline or contrast. Lastly, he always makes sure to get a good final image to confirm placement in the stomach. For post-care, on inpatients he rounds the next morning, checking that the tube flushes and then clears it for use. For outpatients, he recommends no feeding (via G or NG) for three hours and a consult with a dietician before discharge. After this, the patient can receive nutrition via NG. If the patient has no peritoneal signs, the G-tube can be used the next day. For tube management, he exchanges the tube every 6 months or sooner if there is an issue, such as the tube being pulled out or becoming clogged beyond the point of a bedside fix. --- RESOURCES BackTable YouTube Gastrostomy Tube Demo: https://www.youtube.com/watch?v=17ep0AEkKqs Early Initiation of Enteral Feeding: https://pubmed.ncbi.nlm.nih.gov/24674218/ SIR Guidelines App: https://apps.apple.com/us/app/sir-guidelines/id1552455529

Screening patients is not just about the form you use.It isn't about the Mallampati or the Epworth.It's all about the daily impact on the patient. Unfortunately, patients are often skeptical or confrontational about their issues.Dr. Mona Patel explores the depths of Sleep Related Breathing disorders' comorbidities. We are going deeper than forms and intra-oral signs. We will show you the impact this has on the patient so that when you recommend a test you can clearly explain the alternatives to the patient.No more excuses. Learn to treatment plan Home Sleep Tests like a filling. Objectives:Define Temporomandibular Joint Disorder (TMD) and how to screen patientsUnderstand the relationship between TMD and sleepExplore treatment options for patients with TMDIdentify appliances that reduce TMD for patients while treating OSA simultaneouslyLearn how to get started managing OSA patientsSponsored by ProSomnus Inc., Kettenbach USA, and Dental Sleep Profits

This is the question and answers session following the "TMD and Sleep - Understanding the Overlap" webinar with Dr. Mona Patel and Michael CowenDescription: Screening patients is not just about the form you use.It isn't about the Mallampati or the Epworth.It's all about the daily impact on the patient. Unfortunately, patients are often skeptical or confrontational about their issues.Dr. Mona Patel explores the depths of Sleep Related Breathing disorders' comorbidities. We are going deeper than forms and intra-oral signs. We will show you the impact this has on the patient so that when you recommend a test you can clearly explain the alternatives to the patient.No more excuses. Learn to treatment plan Home Sleep Tests like a filling. Objectives:Define Temporomandibular Joint Disorder (TMD) and how to screen patientsUnderstand the relationship between TMD and sleepExplore treatment options for patients with TMDIdentify appliances that reduce TMD for patients while treating OSA simultaneouslyLearn how to get started managing OSA patientsSponsored by ProSomnus Inc., Kettenbach USA, and Dental Sleep Profits

Good morning and welcome to your Friday dose of Your Daily Meds.Bonus Review: What is erythropoietin? Where is it produced? Answer: It is a glycoprotein hormone and is the main factor controlling red cell production.Regulation of erythropoietin (EPO) production controls red cell mass and then blood oxygen carrying capacity.In adults, EPO is produced mostly in the kidneys. In the foetus, the liver.(Us adults only have 10-15% of our EPO being produced in our livers)Case:A 45-year-old male presents with a 5-day history of malaise, productive cough and right-sided chest pain with fevers.He has a 20 pack-year history of smoking.On examination, his temperature is 38.1, HR 112, BP 115/78, RR 23/min, SpO2 93% on room air.Which of the following is the most likely diagnosis?Bronchial carcinomaCommunity acquired pneumoniaSarcoidosisTuberculosisWegener’s granulomatosisHave a think.Scroll for the chat.Query:During preoperative airway assessment, a clinician asks a patient to open his mouth and protrude his tongue as far as possible. During this process, the clinician visualises the following:Which of the following scores correctly describes this result?Mallampati 1Mallampati 2Mallampati 3ASA 1ASA 2Have a think.Open your mouth in front of a mirror.More scroll for more chat.Cough-y:Note that this man has symptoms of an acute infection. These include the history of fevers, and malaise with a likely chest focus. His smoking history also puts him at risk of community-acquired pneumonia, most commonly Streptococcus pneumoniae. Note that he has no signs of confusion nor any severe prognostic signs such as systolic BP < 90 or RR >30/min. Given these signs and this man’s age, it is likely that he will be able to be managed without admission. This man has a significant smoking history, however he is relatively young to be developing lung cancer. Further, the history is that of an acute illness not that of gradual decline. Sarcoidosis is unlikely as it rarely presents with an acute infective picture. Tuberculosis may be a reasonable diagnosis given the systemic symptoms and productive cough. Further travel and contact history would need to be taken. Further investigation of sputum, such as testing for acid-fast bacilli would be required. The short time course of the illness, however, makes a pneumonia more likely. Wegener’s granulomatosis is a vasculitis that can present with cough and haemoptysis on a chronic background, rather than acute onset.Wide Open:This question asks for assessment of the Mallampati score for preoperative assessment of an airway in the context of predicting difficult intubation. The Mallampati classification has four levels illustrated by the following:When asked to open the mouth and protrude the tongue as far as possible, the clinician judges the Mallampati score based of visualisation of features in the oral cavity and oropharynx as follows:Class 1 – Soft palate, uvula, fauces, pillars visibleClass 2 – Soft palate, uvula, fauces visibleClass 3 – Soft palate, base of uvula visibleClass 4 – Only hard palate visibleThe ASA score references the American Society of Anaesthesiologists physical status classification. It is a subjective assessment of a patient’s overall health:ASA I – patient is completely fit and healthyASA II – patient has mild systemic diseaseASA III – patient has severe systemic disease that is not incapacitatingASA IV – patient has incapacitating disease that is a constant threat to lifeASA V – a moribund patient who is not expected to live 24 hours without surgeryASA VI – a declared brain-dead patient whose organs are being removed for donor purposes(E – emergency surgery, an ‘E’ is placed after the Roman numeral)So this was Mallampati 2.Bonus: What are the actions of erythropoietin?Answer in Monday’s dose.Closing:Thank you for taking your Meds and we will see you Monday for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!Luke.Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks. Just credit us where credit is due. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Thanks for covering the dreaded statistics objectives for the exam!The diagrams and info are from these articles.Aust Prescr 2003;26:111–3Moving beyond sensitivity and speci!city: using likelihood ratios to help interpret diagnostic testandCritical Care 2004 8:508-512Statistics review 13: Receiver operating characteristic curvesPlease support us on our Patreonhttps://www.patreon.com/anaesthesiaAll proceeds will go to Fund a Fellow to help train anaesthetists in developing countries whilst acknowledging the work it takes to keep creating this educational resource.If you enjoyed this content please like and subscribePlease post any comments or questions below. Check out www.anaesthesiacollective.com and sign up to the ABCs of Anaesthesia facebook group for other content.Any questions please email lahiruandstan@gmail.comDisclaimer: The information contained in this video/audio/graphic is for medical practitioner education only. It is not and will not be relevant for the general public.Where applicable patients have given written informed consent to the use of their images in video/photography and aware that it will be published online and visible by medical practitioners and the general public.This contains general information about medical conditions and treatments. The information is not advice and should not be treated as such. The medical information is provided “as is” without any representations or warranties, express or implied. The presenter makes no representations or warranties in relation to the medical information on this video. You must not rely on the information as an alternative to assessing and managing your patient with your treating team and consultant. You should seek your own advice from your medical practitioner in relation to any of the topics discussed in this episode' Medical information can change rapidly, and the author/s make all reasonable attempts to provide accurate information at the time of filming. There is no guarantee that the information will be accurate at the time of viewingThe information provided is within the scope of a specialist anaesthetist (FANZCA) working in Australia.The information presented here does not represent the views of any hospital or ANZCA.These videos are solely for training and education of medical practitioners, and are not an advertisement. They were not sponsored and offer no discounts, gifts or other inducements. This disclaimer was created based on a Contractology template available at http://www.contractology.com.

What is the Mallampati Score?Health professionals use the Mallampati score in anesthesia to predict the ease of intubation. However, it can also be an indicator for determining whether or not your child suffers from Obstructive Sleep Apnea.The physical exam to determine a patient's Mallampati score is simple. The patient should be sitting upright with their head in a neutral position, facing forward. Then, ask the patient to open their mouth and extend their tongue. The examiner will look to see what structures can clearly be visualized in the back of the throat.The degree to which the soft palate, or back of the throat is made visible, determines the Class number of their score. The higher the class number, the less you can see of the back of the throat. The higher their score, the more likely they will have sleep apnea, although it is not 100% predictive.Obstructive sleep apnea (OSA) symptomsObstructive sleep apnea (OSA) symptoms in children can include the following:Abnormal breathing during sleepFrequent awakenings or restlessnessFrequent nightmaresEnuresisDifficulty awakeningExcessive daytime sleepinessHyperactivity/behavior problemsDaytime mouth breathingPoor or irregular sleep patternsOSA DiagnosisHowever, to truly determine whether or not your child has obstructive sleep apnea, you'd have to have an overnight polysomnographic evaluation in the sleep laboratory. The evaluation would determine abnormalities in oxygen desaturation, observe patient's sleep state, include an electrooculogram and electrocardiogram, measure the airflow at nose and mouth, and observe the chest and abdominal wall motion among other data collections.In the pediatric age range, abnormalities include oxygen desaturation under 92%, more than one obstructive apnea per hour, and elevations of End-tidal carbon dioxide (ET CO2) measurements of more than 50 mm Hg for more than 9% of sleep time or a peak level of greater than 53 mm Hg.If you suspect that your child may suffer from sleep apnea, contact Airway and Sleep Group for a consultation for a definitive diagnosis. We are here to help!To learn more visit this link: https://emedicine.medscape.com/article/1004104-overview

Today's episode is dedicated to the approach to thyroid storm. It's the first in our Mini-Case series. Show Highlights: Our case, symptoms, and diagnosis: A 12-year-old female presents to the PICU with chest discomfort. She was noted to be anxious by her parents over the past few days. They felt she was a bit "off," as she would constantly drop items and have a tremor. A few weeks prior to these symptoms, she was noted to have rhinorrhea, congestion, and progressive neck swelling. Her parents became increasingly concerned this morning as her temperature was 104F. Per her parents, she was agitated throughout the night and became increasingly somnolent in the early morning.  To summarize key elements from this case, this patient has: Chest pain likely due to a cardiac etiology or musculoskeletal cause. Tremor likely due to a primary neurologic cause or increased metabolic drive. Neck swelling with fever after a prodrome of URI symptoms which could be concerning for lymphadenitis or thyroid goiter. Synthesizing these symptoms together, this patient likely has a systemic etiology such as hyperthyroidism, with the most severe manifestation being thyroid storm, a toxidrome, or a pheochromocytoma. Given the fever and altered mental status, considering sepsis is key. Key history features in this child with tachycardia and signs of hyperthyroidism: High fevers up to 104F Altered mental status Neck swelling  Red flag symptoms and physical exam components in a patient with severe hyperthyroidism include: Airway Check for dyspnea or stridor when the patient is supine. Do a Mallampati assessment. Auscultate for a bruit in the neck.  Cardiovascular system Concerns include congestive heart failure and cardiac dysrhythmias. Widened pulse pressure is common  The American Thyroid Association has advocated for the Burch-Wartofsky Point Scale (BWPS) for severe thyrotoxicosis. A score of 45 or higher indicates thyroid storm. A case-control study published in 2015 in the Journal of Endocrinology noted that the BWPS may overdiagnose up to 20% of patients. Clinical criteria on the BWPS include the following: Thermoregulatory dysfunction Central nervous system effects Gastrointestinal-hepatic dysfunction Cardiovascular dysfunction Congestive heart failure Presence or absence of a precipitant history of URI or underlying thyroid condition Back to our specific case, the patient's labs are consistent with low TSH and elevated free T4, indicating primary hyperthyroidism, positive for TSH-receptor antibodies, and the diagnosis of thyroid storm was confirmed. Other lab findings included elevated WBC, high ALT and AST, elevated glucose, and elevated cortisol. Her cardiac evaluation was notable for sinus tachycardia with occasional PACs. Other important labs include a coagulation panel, BNP and lactate, CRP, procalcitonin, blood cultures, and basic blood chemistries. Let's quiz ourselves with a multiple choice question: A patient with thyroid storm is admitted to the PICU. He is started on thyroid modulating therapy. Which of the following mechanisms of action does this medication likely work by?  A. Activate Thyroid Peroxidase  B. Inhibit Thyroid Peroxidase  C. Inhibit Iodine Uptake within the Thyroid  D. Increase conversion from T4 to T3    The correct answer is B. The most likely medication which is used in thyroid storm is methimazole or propylthiouracil. Both of these medications block thyroid peroxidase.  In terms of differential in our case, you want to think about other causes of fever, tachycardia, and CNS dysfunction, including, but not limited to sepsis, serotonin syndrome, neuroleptic malignant syndrome, heatstroke, and drug intoxication.  The diagnostic approach for our patient should focus on her history and physical examination. Be sure to include thyroid function tests, cardiac evaluation via EKG or Echo, chest x-ray, blood culture, urine...

What is the Mallampati Score?Health professionals use the Mallampati score in anesthesia to predict the ease of intubation. However, it can also be an indicator for determining whether or not your child suffers from Obstructive Sleep Apnea. The physical exam to determine a patient's Mallampati score is simple. The patient should be sitting upright with their head in a neutral position, facing forward. Then, ask the patient to open their mouth and extend their tongue. The examiner will look to see what structures can clearly be visualized in the back of the throat. The degree to which the soft palate, or back of the throat is made visible, determines the Class number of their score. The higher the class number, the less you can see of the back of the throat. The higher their score, the more likely they will have sleep apnea, although it is not 100% predictive.Obstructive sleep apnea (OSA) symptomsObstructive sleep apnea (OSA) symptoms in children can include the following:Abnormal breathing during sleepFrequent awakenings or restlessnessFrequent nightmaresEnuresisDifficulty awakeningExcessive daytime sleepinessHyperactivity/behavior problemsDaytime mouth breathingPoor or irregular sleep patterns OSA DiagnosisHowever, to truly determine whether or not your child has obstructive sleep apnea, you'd have to have an overnight polysomnographic evaluation in the sleep laboratory. The evaluation would determine abnormalities in oxygen desaturation, observe patient's sleep state, include an electrooculogram and electrocardiogram, measure the airflow at nose and mouth, and observe the chest and abdominal wall motion among other data collections.In the pediatric age range, abnormalities include oxygen desaturation under 92%, more than one obstructive apnea per hour, and elevations of End-tidal carbon dioxide (ET CO2) measurements of more than 50 mm Hg for more than 9% of sleep time or a peak level of greater than 53 mm Hg.If you suspect that your child may suffer from sleep apnea, contact Airway and Sleep Group for a consultation for a definitive diagnosis. We are here to help!

Every five years, Texas conducts inspections of any practice that uses sedation. Some practices have recently undergone their initial inspections. From what I’ve heard, most have gone pretty well. Some are getting busted for things they consider nit-picky—like missing information on their preoperative checklist—but that the state board takes seriously. So in this episode of Talking with the Toothcop, Andrea and I chat about preoperative checklist requirements, the Electronic Prescribing of Controlled Substances (EPCS), as well as continuing education requirements. These are things you NEED to stay on top of—so don’t miss it! Outline of This Episode [4:10] Texas: Updates regarding sedation [10:34] Physical examination subsection C [13:09] Anesthesia-specific examination subsection B [13:48] Special pre-op considerations: pediatric or high-risk [15:25] Rules on equipment and use [16:24] EPCS: Electronic Prescribing of Controlled Substances [29:48] Continuing Education: Human Trafficking Training [33:17] How to keep everything straight The required preoperative checklist for nitrous oxide + sedation + anesthesia You can find the preoperative checklist in its entirety HERE. I’m referencing specific line items in this checklist that must NOT be neglected. Firstly, do NOT remove anything from the pre-op checklist. If you don’t heed this warning, the state board will make you fix it.  At a minimum the preoperative checklist must include documentation of the following when applicable (summarized):  Medical history (allergies, surgical history, review of family surgical history, medications) Confirmation that pre and post-operative instructions were delivered to the patient Medical consults were conducted if needed Physical examination and documentation (weight, blood pressure, pulse, respiration rate)  Anesthesia specific physical exam (airway assessment, ventilation and respiratory rate) Pre-procedure equipment readiness check Confirmation of pre-procedure treatment review Special preoperative considerations as indicated for sedation/anesthesia administered to pediatric or high-risk patients. So where are things getting missed? The physical examination section clearly states that you must obtain: preoperative vitals, including height, weight, blood pressure, pulse rate, and respiration rate. This applies to every level of sedation, from nitrous oxide to general anesthesia. The issue that’s coming up most frequently during inspections is that dentists and their staff aren’t documenting the respiratory rate. Now, a lot of pediatric dentists are not taught that they’re required to document the respiratory rate. You may not be accustomed to it—but you need to start doing it. Not only that, but vital signs need to be recorded every ten minutes or less. It’s the rules. So is recording the height and weight of an adult patient every appointment. It may not feel necessary, but you can’t just say “It’s not that big of a deal because it’s only nitrous.” You have to comply with the rules to stay out of trouble.  You must also make sure you’re recording the Mallampati score and/or Brodsky score. The state board is looking for how you verified the respiratory or ventilation rate. They want that to be clear (and it can be documented by observation, auscultation, or capnography). Keep listening to hear more about pediatric and high-risk patients as well as equipment and use instructions that are being missed. Want the latest version of my checklist? Shoot me an email at toothcop(at)dentalcompliance.com and I’ll happily share it with you. EPCS: Electronic Prescribing of Controlled Substances Electronic prescribing of controlled substances is already a requirement in many states. As of January 1st, 2021 Texas will join the list. It will require dentists, physicians, and healthcare providers to e-prescribe schedule 2 drugs. If you need help finding a prescribing platform that works best for you, I’ve linked many options below.  But wait—don’t confuse this with your PMP responsibilities. According to the state board rule 111.2: “Each dentist who is permitted by the Drug Enforcement Agency to prescribe controlled substances shall annually conduct a minimum of one self-query regarding the issuance of controlled substance through the Prescription Monitoring Program of the Texas State Board of Pharmacy.” You can log in to PMP Aware to check your prescribing history to make sure there haven’t been mistakes. If you find something blatant, figure out if you need to address it.  Another change? Until September 1st, you were required to do a 2-hour CE once every 3 years (use and prescribing in the course of dentistry). Now it’s an annual requirement to do the CE and a self-query check. Every time you issue a prescription it needs to be justifiable and you have to perform a patient history search—every time. What are the exclusions from this? Who can do the PMP check? What is the maximum you can prescribe? Listen to find out! Continuing Education: Human Trafficking Training Human trafficking is becoming a pandemic in its own right. Texas isn’t the first state to require it, but every healthcare provider—who is not a physician—is now required to complete a course on human trafficking. There are a lot of courses available online, but as of right now the state requires a Health and Human Services Commission approved course. It’s required training before your next license renewal.  Are you wondering how you’re supposed to keep everything straight? How do you track all the training, continued education, and compliance measures you’re supposed to take? I’ve linked a detailed list below that should help you stay on track! Resources & People Mentioned Required Preoperative Checklist iPrescribe  Allscripts iCoreConnect Veradigm MD Toolbox Surescripts https://texas.pmpaware.net/login Texas State board rule 111.2 Blx Training CE Dental Anesthesia CE Human Trafficking Training Continued Education Requirements Connect With Duane https://www.dentalcompliance.com/ toothcop(at)dentalcompliance.com On Facebook On Twitter On LinkedIn On Youtube

BASICS! Today we discuss airway assessment and airway equipment. Make sure you understand airway anatomy (Episode 12) before moving on to this episode. Mallampati, ULBT, Cormack, ETTs, LMAs and more! To become a premium member go to Patreon.com, search "student nurse anesthesia" and become a member. You will then have access to all of our episodes right here on Apple Podcasts!

This week on Get a Gasp Gina Pepitone-Mattiello continues to cover clinical perils and provides some information about periodontal disease and sleep disordered breathing. Get a Gasp will take a break for season 3 of The Dental Podcast Network. If you have questions for Gina please contact her via the email address at the bottom of the show notes!   Episode Highlights  A statement on COVID-19 Bleeding/Inflammation/ Periodontal Disease Factors  The why and “what that means” relating to factors you see in your patients Mallampati Scores/Stages Tonsils    Quotes   “We are in the healthcare field, we are at really high risk, we need to take care of the people we care about… and those we don’t”    “A lot of the things you see with periodontal disease, are the same factors you see with sleep disordered breathing”   “Their conclusion was there is a strong connection between periodontitis and obstructive sleep apnea”   “This is something we see everyday, that is what we do… we treat periodontal disease”    “That tongue is falling and taking up space, making it hard for you to breath”    “People with a higher Mallampati score, are more at risk for having airway disorders”    “If your mouth is the garage, and you can only fit a Fiat in the garage, and now you have a Hummer or SUV… what is it doing? It’s taking up too much space”    “We can go sometime without food, a little time without water, but we can not go very long without breathing”    Links Gina’s Email gpmrdh@gmail.com The Dental Podcast Network Channel One homepage: http://dentalpodcastnetworkchannelone.otcpn.libsynpro.com/  The Dental Podcast Network Channel Two homepage: https://podcasts.apple.com/us/podcast/the-dental-podcast-networks-channel-two/id1478530429 Long Island Dental Sleep Medicine homepage:   http://lidentalsleepmedicine.com/

Merhabalar, Dünya üzerinde tüm hekimlerin olduğu gibi acil tıp hekimlerinin de steteskopu haline gelen  ve acil servis hayatında oldukça farklı ve geniş bir kullanım alanına sahip olan ultrasonografinin havayolu yönetimi ile ilgili kullanım alanlarını sizlere bu yazıda özetlemeye çalışacağım. İyi okumalar... Hepimiz acillerimizde kritik hasta yönetimimiz sırasında havayolunun değerlendirilmesi için oldukça yetersiz zamana ve kötü hasta dinamiklerine sahibiz. Kalıcı havayolunun tanımlanırken ''vokal kordlar altında bir balon şişirilmesi'' olarak ifade edilmesi de göz önüne alındığında endotrakeal entübasyon ve cerrahi havayolu yöntemleri daha kesin ve kalıcı çözümler olarak karşımıza çıkmakta. Literatüre bakıldığında acil havayolu yönetimi gerektiren vakaların yaklaşık %10' unun zorlu entübasyon olarak tanımlandığını görmekteyiz.​1​ Acil hastanın elektif hastalardan farklı olarak hemodinamik anlamdaki hazırsızlığı ve yetersiz oksijen rezervi acil hava yolu yönetimi sırasında bizlere özefageal entübasyon, ana bronş entübasyonu, hipotansiyon, kardiyak arrest olarak dönmekte ve bu da hastalarımız için yüksek morbidite ve mortalite ile sonuçlanmaktadır. Sonografik ölçümler zor havayoluna sahip hastaların prosedürel sedasyon veya endotrakeal entübasyon öncesinde yardımcı olabilmektedir. Aynı zamanda ultrason, end tidal karbondioksit ölçümünün güvenli olamayacağı, kardiyak arrest gibi durumlarda endotrakeal tüp yerinin doğru yerleşimi konusunda bilgi verebilir. Trakeal entübasyon doğrulandıktan sonra, ultrason  uygun endotrakeal tüp derinliğini doğrulamak için kullanılabilir. Olası entübasyon başarısızlığı ve yardımcı diğer havayolu yöntemlerinin yetersizliği durumunda ''CICO- Can not Intubate, Can not Oxygenate'' senaryosu söz konusu olduğunda, krikotiroidotomi için krikotiroid membranın yerinin belirlenmesi konusunda ultrason bize yardımcı olabilir. Havayolunun Değerlendirilmesi Hepimiz hastalarımızın havayolu değerlendirmelerini yatak başlarında ilk olarak LEMON kriterleri ve Mallampati skorlama sistemleri ile yapmaktayız. Bu uygulamalara acil hasta uyumunun oldukça zor olması ve özellikle obez hastalarda bu kuralların daha kötü tanısal doğruluğa sahip olması ​2​kullanılabilirliklerini azaltmakta. ''POCUS - Point of Care Ulltrasound- hedefe yönelik ultrason'' bu anlamda bizlere yardımcı olmaktadır. ''Artan yumuşak doku derinliği, daha zorlu entübasyon ile ilişkilendirilmiştir.'' Yapılan bir çalışmada cilt ve vokal korlar (2.8 cm - 1.75 cm) arasındaki ve ciltle suprasternal çentik arasındaki (3.3 cm - 2.7 cm)  mesafelerin zorlu entübasyonu yüksek oranda öngördükleri gösterilmiştir. ​3​ Yapılan başka bir çalışmada cilt ile tirohyoid membran arasındaki (3.5 cm - 2.4 cm) mesafenin zorlu entübasyon için prediktif değere sahip olduğu ortaya konmuş ve zorlu entübasyonun tespiti için  >2.8 cm' lik bir eşik değerinin kullanılması önerilmiştir.​4​ Ayrıca cilt ile epiglot arasındaki mesafe zorlu balon valf mask ventilasyonunu öngörebilmektedir.​5​ POCUS, epiglotit veya epiglotal genişleme düşünülen hastaların değerlendirilmesi için de kullanılabilir.​6​​7​POCUS,aynı zamanda subglotik stenozu ve uygun endotrakeal tüp çapının tahmin edilmesi için kullanılabilmektedir. Subglotik stenoz, krikoid kartilajın  iç çapının ölçülmesi ve aşağı doğru en küçük alanın tespiti için takip edilmesi yolu ile değerlendirilebilir. Yapılan çalışmalar POCUS' un havayolu boyutunun ölçününde BT ve MRG ile kıyaslandığında oldukça  başarılı olduğunu göstermiştir. ​8,9​ Pediatrik hastalar arasında  POCUS endotrakeal tüp için geleneksel yaşı temel alan ''(yaş/4+4 )'' ve  uzunluk bazlı formüller ile kıyaslandığında daha başarılı sonuçlar vermektedir.​10​ Krikoid kartilajın prob ile tespiti sonrası ölçülen transkrikoid hava sütununun çapı  uygun endotrakeal tüp çapının tespit edilmesi için pediatrik hastalarda kullanılabilir Transkrikoid Boşluğun Sonografik Olarak Değerlendirilmesi Entübasyonun Doğrulanması

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship Common Scenarios Cardioversion Orthopedic reductions Painful procedures Three Step Approach to Procedural Sedation Step 1: Risk stratify the patient Mallampati score (aka “How visible is the uvula?”) Level 1: Can visualize THE WHOLE uvula Level 2: Can […]

Introducción Hoy día uno de los mejores métodos para realizar la intubación endotraqueal de emergencia en un paciente consciente y respirando es la intubación en secuencia rápida. Sin embargo, este procedimiento puede tener complicaciones. Es importante poder anticiparlas y evitarlas. En pacientes sin ningún tipo de complicaciones, el proceso de asegurar la vía aérea puede ser peligroso por un número de motivos: El reflejo nauseoso impide que se pueda realizar una laringoscopía. El reflejo nauseoso y/o la combatividad de un paciente puede producir un aumento en la presión intracraneal. La laringoscopía puede estimular un tono vagal excesivo, provocando bradicardia, hipotensión o paro cardiorespiratorio. El proceso de laringoscopía puede retrasar significativamente la ventilación del paciente, resultando en un aumento en la hipoxemia. La pobre visualización de las cuerdas vocales durante la laringoscopía puede aumentar las posibilidades de una intubación esofágica, que a su vez está asociada a complicaciones fatales si no se reconoce a tiempo. En adición, intentos repetitivos de laringoscopías fallidas pueden resultar en traumas a la orofaringe y estructuras sensibles tales como epiglotis (edema) y tráquea (laceración). Hay que sopesar los riesgos y beneficios de optar por manejar la vía aérea por intubación endotraqueal. Nadie fallece porque no lo intuban. Fallecen porque no lo ventilan. En un capítulo exclusivamente sobre técnicas de manejo de vía aérea, el mejor método para asegurar la vía aérea sería la intubación endotraqueal. Pero esto no significa que el mejor método para asegurar la ventilación en determinadas circunstancias sea la intubación endotraqueal. El objetivo no debe ser colocar un dispositivo en específico, sino garantizar una ventilación efectiva. Nadie fallece porque no lo intuban. Fallecen porque no lo ventilan.  Ventilación manual es una destreza básica El método de ventilación inicial de excelencia es el resucitador manual (dispositivo bolsa-mascarilla). Es posible ventilar a la mayoría de los seres humanos, en circunstancias normales, con un dispositivo bolsa-mascarilla por un tiempo significativamente prolongado. En ocasiones es imposible ventilar efectivamente con un dispositivo bolsa-mascarilla y se hace necesario realizar un procedimiento más avanzado. Es fundamental que todo profesional de la salud que trabaje en un entorno de emergencias y/o cuidado crítico pueda realizar una ventilación manual de forma efectiva. De lo contrario, estará sometiendo al paciente a la "necesidad" de realizar un procedimiento más avanzado...y que tiene más riesgos. La ventilación con bolsa mascarilla es una destreza básica. Solo porque es una destreza básica no significa que nuestro nivel de destreza debe ser básico. Plan A ---> Plan B ---> ¿Plan A? Si su plan A fue ventilar con bolsa mascarilla pero fue inefectivo, entonces tendrá que pasar al plan B, que bien podría ser tener que intubar al paciente. Si la intubación fracasa, la mayoría de los operadores tienen solo una alternativa: regresar a la ventilación con bolsa mascarilla, ¡que fue el método que les falló poco antes de intentar intubar! Si usted quiere realizar procedimientos avanzados de la vía aérea, es críticamente importante que usted domine a la perfección el arte y ciencia de ventilar con un dispositivo bolsa-mascarilla. Recuerde que esto es lo que le va a salvar la vida a su paciente...¡y a usted! Criterios para asegurar la vía aérea En su forma más elemental, podríamos decir que existen tres criterios para asegurar la vía aérea de un paciente: Fallo en mantener o proteger la vía aérea Fallo en ventilación y oxigenación Futuro clínico anticipado ¿Podría ser difícil? Luego de analizar los riesgos y beneficios de realizar la intubación, cuando se toma la decisión de intubar es necesario considerar si hay algún factor que pueda hacerla notablemente más difícil en su paciente en particular. ¿Podría ser difícil... ventilar con resucitador manual (dispositivo bolsa-mascarilla)? realizar la laringoscopía? realizar una cricotirotomía? Existen diferentes formas de estimar si la vía aérea puede ser difícil. Vea algunos ejemplos aquí. Su vía aérea podría ser un LIMON. Luce difícil Identificar 3-3-2 Mallampati >3 Obstrucción / Obesidad No puede mover el cuello Luce difícil Si luce difícil, posiblemente lo es. Algunos factores que hacen que la vía aérea sea difícil incluyen: trauma maxilofacial mandíbula corta lengua grande cuello corto dientes grandes Identificar 3-3-2 Trate de colocar: 3 dedos entre los dientes del paciente 2 dedos en distancia tiromental 2 dedos entre el hioide y tiroide Si puede colocar los dedos, hay un espacio suficientemente grande para desplazar la lengua. Mallampati Esta prueba no está validada en un paciente acostado y poco cooperador, por lo tanto su utilidad es muy limitada excepto en los pacientes donde la intubación es programada de emergencia. Una escala de Mallampati de 3 o más sugiere que habrá poca visibilidad de las estructuras. Obstrucción / Obesidad La obstrucción en la vía aérea puede hacer que la colocación del tubo sea difícil o imposible. Algunos signos de obstrucción en la vía aérea pueden ser: Alteración súbita y reciente en la voz Dificultad en pasar secreciones Estridor Uno de los principales factores para lograr el éxito en la intubación endotraqueal en el primer intento es poder visualizar la laringe (propiamente llamado laringoscopía). La obesidad puede hacer que los ejes visuales no estén alineados. Si los ejes no están alineados es físicamente imposible poder realizar la laringoscopía sin una cámara de video. No puede mover el cuello La hiperextensión del cuello permite alinear adecuadamente y más fácilmente los ejes. Algunos pacientes no pueden mover el cuello debido a problemas crónicos o trauma a las vértebras cervicales. Es posible realizar la laringoscopía sin mover el cuello...pero esto requiere más práctica. Todo operador de la vía aérea debe practicar la laringoscopía en situaciones de poco movimiento del cuello, y practicarlo hasta el punto de que se sienta cómodo(a) al realizar este procedimiento bajo estas condiciones. Si sospecho que es difícil, ¿qué hago? Una intubación difícil no es razón para no considerar intubar al paciente. El verdadero problema es no poder ventilar al paciente si la intubación es fallida. Si hay la posibilidad de que la ventilación con bolsa-mascarilla sea difícil, que la laringoscopía sea difícil y/o que realizar una vía aérea quirúrgica sea difícil, entonces uno debe contemplar si podrá ser posible ventilar al paciente en el caso de que la intubación sea fallida. Evite buscar problemas si puede evitarlos. Si usted cree que podría no poder ventilar al paciente, puede considear alternativas como una intubación despierta u otros métodos de rescate. Referencias https://www.resus.com.au/blog/the-lemon-approach-for-predicting-the-difficult-airway/ http://www.ncems.org/pdf/AppI-DifficultAirwayEvaluation.pdf http://www.acep.org/content.aspx?id=33992 http://medind.nic.in/iad/t05/i4/iadt05i4p257.pdf http://www.medscape.com/viewarticle/430201_2 http://lifeinthefastlane.com/ccc/difficult-airway-algorithms/ http://lifeinthefastlane.com/own-the-airway/

This week resident Ameer Farooq talks about the Anesthetic pre-operative assessment.  After listening to the podcast learners will be able to: Understand the Purpose of the Pre-operative history Know the important aspects of the history and physical exam to focus on. Describe two important classification systems that medical students should be aware of: the ASA score and Mallampati score.

Dr A. Quinn, from Leeds General Infirmary in the UK, lead author of a recent BJA paper on failed tracheal intubation in obstetric anaesthesia talks us through this important UK national prospective survey. Using the UK Obstetric Surveillance System (UKOSS) of data collection, Dr Quinn and colleagues confirm the expected incidence of failed tracheal intubation in obstetrics at one in 224, and that the incidence of failed intubations hasn't decreased in the last 20 years, despite advances in airway techniques. Age, BMI, and a recorded Mallampati score were signi?cant independent predictors of failed tracheal intubation.