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lamalefix · 3 years ago

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Hey the anon who asked for angst here! I want what you did wirh Eddie in your story with Buck now. Like stopping functioning and things like that... But i'm a sucker for happy endings! Maybe even bittersweet and uncertain. So to answer you, yes yes yes. I know what I'm asking fpr. I want you to hurt my feelings. do your worst!! and thank you!!

Hey there angsty anon! (now that's your name)

You asked for this, so... here we go, this is going to be a multichapter thing, but somehow i was inspired? So please read it carefully.

thank you for your words, I hope you find this of your taste

Relationship: Evan "Buck" Buckley/Eddie Diaz (9-1-1 TV) Characters: Eddie Diaz (9-1-1 TV),Evan "Buck" Buckley Tags: Medical Procedures, Blood, Major Character InjuryDeveloping Relationship, Angst with a Happy Ending, Post-Episode: s04e13 Suspicion

Can’t have you disappear [1/3] (also on ao3)

When deployed, soldiers need to complete a range of physically demanding tasks. And they train for those tasks. It occurs that you have to move under fire, carry equipment, transfer ammunition and… well, the worst of all evacuate casualties. A casualty drag is excruciatingly challenging and involves dragging a fellow soldier from a hazardous environment to a safe location as quick as possible.

That’s what comes to Buck’s mind after a few seconds. He’s on the ground. Asphalt tastes weird in his mouth, copper-like, strong and salty.

He blinks and takes in, drinks in, the body, the pair of eyes that look lost, not so far away.

There’s the voice of someone barking orders in the radio, the same person that’s holding him down. And when Buck blinks again, he clearly sees that person, that body, not so far away.

Eddie. That’s Eddie. That’s Eddie in the middle of the road, a pool of blood under his face. Hand outstretching slightly, fingers trembling. Eyes fixed on something. On him maybe? Or maybe lost.

Asphalt doesn’t have that weird, coppery and salty taste. But… blood has.

He needs to do something.

Do something.

He blinks again ad remembers his preparation as a Navy SEALS before the other one as a firefighter. Close down, bottle up, no emotion. Nothing.

He needs to move. Do something.

When he first started casualty drags simulation during training, he dragged dummies all covered in gears that could even weigh 132 kg total, crawling as fast as he could.

And at some point, he moves.

He doesn’t even notice when he does, with an impossible ache, urgency, he just moves. It’s like muscle memory, it’s like some other part of him kicks in and takes his place. It’s like the gear rolls backwards and clicks in that very spot, the right one and he reacts as he knew, as he was before. A Evan Buckley that was so long forgotten in his new almost-happy life over here. The Evan Buckley who at some point decided that being a Navy Seal was a good idea, that maybe was even good at suppressing emotions and being like a robot.

It’s fun that at some point you need to do what you resent the most, uh?

But, well.

He needs to do something.

That’s how he grovels and takes Eddie, dragging him while crawling back between the ambulance and the firetruck. Muscle memory, soldier training, casualty evacuation.

Fast.

He needs to be fast. Faster maybe. The fastest he can.

That captain, whose name he doesn’t remember, barks something and he growls a guttural, raw sounds that escapes his throat and sounds like an echo from another distant memory. But that gear runs backwards again, and clicks back in.

He needs to do something.

Do something.

And so, he focuses on the wound.

Not on the blood that soaks Eddie’s uniform and spatters on his own white shirt, that wedges in the bed of his fingernails, that moistens his palms.

He needs to focus on the wound.

He tears Eddie’s uniform shirt, and assesses the breathing, uneven, labored, almost strangled, there’s a sound like a hiss.

Sucking chest wounds happen when an injury causes a hole to open in the chest, usually are caused by stabbing, gunshots or other injuries that penetrate the chest.

It’s about the size of a coin, the blood looks like boiling, at every hissing breath, as it’s being sucked back in the chest at every inhale and sputtered out at every exhale. And the blood doesn’t even look like blood anymore, around the wound, it’s more like foam, bright red, maybe pinkish.

When he moved, when he dragged Eddie in a safer place, between the truck and the ambulance, Eddie made a weird sound, like a protest, that ended up with coughing blood.

But he needs to move, he needs to move, he needs to do something.

And it’s became a silent mantra.

No emotion, get your shit together.

He would stop, a part of him would stop and talk, because he talks a lot, a whole lot, and that’s maybe what he does best, but now there’s Eddie bleeding out, so he has to focus and do something.

So he repeats the drill. Sucking chest wounds care. He knows how it works. He just needs to act.

Sterilize your hands. No time for soap and water, but he has a sanitizer gel in his pocket (thanks covid-19?), he doesn’t have time to put on gloves, he couldn’t even find ‘em if he wanted now. He has to focus.

Maybe he mutters something, a silent prayer, Eddie is someone who prays so he should do that for him, or maybe he just says sorry, sorry, sorry when he points his hand hard over the wound. You’d usually ask someone else to keep a hand over the wound while preparing a dressing, maybe even the patient, but Eddie lies there, still, not even moving his chest to breath, eyes open.

That’s when Buck moves his hand to cup his cheek. That’s when he finds his voice back.

“Eddie? Eddie, stay with me? Please, please, please. Stay with me” it’s all he manages to say. “We need to get you back home to Chris, y’know?”.

And that’s when Eddie coughs again, and blinks, and his eyes roll back for a moment, a weird staggering sound that comes from his mouth.

“Hey, hey, no. Okay, no weird sounds. Just stay awake for me” he murmurs, and moves to get something from Eddie’s medic bag. Because God, he has that bag with him! There should be a fucking Halo Chest Seal, there better be one.

But he needs to focus, he needs to.

The best way to do this is to spill the contents of the bag on the ground, maybe not the right choice, but the only one if you are working with only a hand, while the other is still applying pressure on the wound.

The gear rolls back in place. And he repeats the drill from where he left off.

Find a chest seal or a sterile, medical tape or plastic to seal up the wound.

“Eddie breathe, please. Breathe out” he asks, and Eddie, ever the good soldier, breathes out, a broken, painful breath.

Someone is barking orders around them, but Buck has to move. Buck has to do something.

Do something. Faster. Faster. The fastest you can. Even faster than that.

That’s his mantra. He doesn’t have that much time. Eddie doesn’t have that much time.

The Halo Chest Seal is one of the very first chest seals made commercially. It’s no-frills, and works very simply. It’s essentially a sterile piece of plastic with an adhesive backing.

He cleans the wound, wiping off the blood with a gauze he found in the bag before spilling its content on the ground, so that the adhesive can stick and he murmurs something that sounds to his hears like a prayer, but then again is maybe something he is asking Eddie. Stay awake. Stay with me.

When he applies the right pressure Eddie groans softly.

Then he needs to move him on one side, he needs to be fast. Faster. Because Eddie lost a lot of blood, and even if he just coughed up blood only once, once too many.

He tears the remnants of the shirt off, and uses another gauze to wipe again the blood and the dirt, from the entry hole on his back, and this time Eddie groans louder.

And maybe in his head he plays a weird conversation with him, maybe a reassuring one. I know it hurts. But you are safe now. We are going to save you.

The captain of 133, Matha? Metha? Whatever barks something again and that makes the other gear, the one on which he usually moves slip in the place and take over.

But Eddie does a thing, a odd sound with his mouth. Shortness of breath, eyes lost and glassy. The seal is trapping air that’s escaping from the lungs. No. Not the right time to develop a pneumothorax. Not while there’s a fucking shooter on a roof. Not while their aid isn’t here yet.

A needle, he needs a needle. A fourteen, or maybe a sixteen gauge needle, an eight centimeter needle is more successful than a five centimeter one, but increase a risk of injury to underlying structures. He maneuvers him back supine, and when Eddie does that sound again, Buck just moves faster.

Do something.

Faster.

The preferred insertion site is the second intercostal space, in the mid-clavicular line, not even a inch above his wound, so he will have to insert the needle anywhere in that same hemithorax to decompress the developing pneumothorax. He just uses his antiseptic gel to prepare the area. And he should really find lidocaine to provide anesthesia, but there’s no time, Eddie has no time. And even if it will hurt like hell, periosteum and parietal pleura are highly pain-sensitive, he can’t waste time.

He pierces the skin over the rib below the target interspace, a couple of inches below his wound, and then directs the needle cephalad over the rib until the pleura does that little pop, that’s hard to hear when your heart beats like Buck’s now, but there’s the sudden decrease in resistance.

It’s when Eddie breathes better and doesn’t do that ominous, strangled sound again, that he inserts the chest tube. And while he does that, there’s the whistle of the ambulance siren that fills the air.

He shouldn’t hop on the ambulance, but that’s what he does, when the paramedics start to move Eddie. They are all under held targets, but they need to move, and bring Eddie to the nearest hospital.

His legs tremble when he sits near Eddie, his hand in his, his fingers trembling.

He outstretched his hand as if to come to Buck, to comfort him somehow, as he always does, with his touchy-feely show of affection. But what communicates the most, of Eddie, are his eyes. Expressive, soft, caring. Every single thing Eddie tells, comes before in his eyes, and seeing that the only thing he could do at that point was to look, glance at Buck maybe, it was his own personal way to comfort him.

And out of muscle memory, now, Buck 4.0 kicks in, and just lowers his gaze. Emotions showering over him, intense like a hurricane, but he can't, he can't break. No emotion, not now. Maybe it's time for Buck 5.0. The only thing he can do is focus on that hand, clammy and still, fingers cold and his. And he sturts humming voiceless prayers, an invocation to whoever is God and Holy to not take Eddie away.

Not from him, not for himself. He wouldn’t ask anything like that, not of Eddie, because he is very serious with Ana, but for Chris.

That’s how prayers work, right?

Something that’s not for you, asking for something that’s for someone else. And what’s more important than a child’s sake?

They saved a kid today, they earned this. Right?

#lamalefixwrites #s04x13 coda #911 spoilers #evan buck buckely #eddie diaz #major character injury #blood #graphic depiction of medical procedures #angst with a happy ending #angsty anon's tag #askbox always open

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stefanduell · 4 years ago

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ANATOMICAL PLANES & DIRECTIONS OF THE BODY 🌐 Medical professionals often refer to sections of the body in terms of anatomical planes (flat surfaces). These planes are imaginary lines – vertical or horizontal – drawn through an upright body. The terms are used to describe a specific body part. Anatomical Planes: ▪️Coronal Plane or Frontal Plane ▪️Sagittal Plane or Lateral Plane ▪️Transverse Plane or Axial Plane Anatomical Terms & Directions: ▪️Medial ➡️ Toward the midline of the Body ▪️Lateral ➡️ Away from the midline of the body ▪️Proximal ➡️ Toward a reference point (extremity) ▪️Distal ➡️ Away from a reference point (extremity) ▪️Inferior ➡️ Lower or below ▪️Superior ➡️ Upper or above ▪️Cranial or Cephalad ➡️ Head ▪️Caudal or Caudad ➡️ Tail, tail end ▪️Anterior ➡️ Toward the front ▪️Posterior ➡️ Toward the back ▪️Dorsal ➡️ Posterior ▪️Ventral ➡️ Anterior https://www.instagram.com/p/CO7XuF1gB3g/?igshid=1m5roqt80ofpx

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lupinepublishers · 4 years ago

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Lupine Publishers | Continuous Spinal Anesthesia with Spinocath® Catheter. A Retrospective Analysis of 455 Orthopedic Elderly Patients in the past 17 years

Lupine Publishers | Orthopedics and Sports Medicine

Abstract

Background and Objectives: Database analysis in general cost less and require less time as compared to large randomized controlled trials. This retrospective study with a catheter outside the cutting-tip needle for continuous spinal anesthesia for femur and hip surgery in elderly patients from 1998 to 2015, with the aim of determine possible advantages and disadvantages of this technique.

Methods: Anesthetic records of 455 patients receiving continuous spinal anesthesia over a 17-year period were analyzed retrospectively. All blockades were performed with patients in the left lateral position and by the two authors. Doses of 0.5% isobaric bupivacaine were administered according to the patient’s height. Evaluated parameters were: puncture success, highest level of anesthesia, lower limb motor block, quality of anesthesia, need for additional doses, failures incidence, paresthesia, postdural puncture headache, cardiovascular changes, mental confusion and delirium, blood transfusion and mortality.

Results: Seven patients were excluded for failure to puncture and accidental perforation of the duramater. The mean time for puncture and placement of the catheter was 2.66±1.03 min. The kit was easy to use in 376 patients and difficult in 42 patients. In all patients the catheter was inserted from 1 to 2 cm in the subarachnoid space. The mode of dispersion cephalad analgesia was T12. In 360 patients, the initial dose was sufficient to reach T12 and 88 patients required to supplement the dose. Mean isobaric bupivacaine initial dose was 7.74±1.78 mg and total dose was 8.58±2.60 mg. Hypotension occurred in 32 patients and bradycardia in 21 patients. Low intensity headache lasting for 3 days has been observed in seven patients. There has been no cauda equina syndrome or transient radicular irritation. Mental confusion occurred in 29 patients.

Conclusions: Our results with 455 patients over 17 years suggest that continuous spinal anesthesia with the catheter outside the needle for elderly orthopedic patient’s shows minor insertion problem, a low incidence of hypotension, paresthesia and headache. No neurological complications were observed, such as cauda equina syndrome or transient neurological symptoms.

Keywords: Anesthetics; Local: Isobaric Bupivacaine; Anesthetic Techniques; Regional: Continuous Spinal Block; Surgery; Orthopedic

Introduction

With the appearance of microcatheters (calibers 28 to 32G) in 1990 there was a resurgence of interest in continuous spinal anesthesia (CSA) [1]. Microcatheters are difficult to handle, the appearance CSF is slow or impossible, injection of the local anesthetic is slow, can break and provide inadequate blocks due to poor anesthetic distribution hyperbaric in the subarachnoid space, which can cause cauda equina syndrome [2, 3]. In 1995, a new spinal anesthesia catheter was used in Europe [4]. This 22G and 24G caliber catheter, 73 cm long, is mounted outside a spinal anesthesia needle caliber 27G and 29G, with Quincke point. It has terminal opening and only one side hole 0.5 cm from the tip, requiring only an inch of your length is introduced into the subarachnoid space. Three years after its initial use in Germany, it arrived in Brazil and one year after, the first article was published with this new catheter for CSA in 40 patients with orthopedic lower limb surgery, suggesting CSA with the catheter outside the needle shows minor insertion problems and a low incidence of hypotension [5]. Subsequently, we compared CSA with combined spinal-epidural anesthesia and sing shot spinal anesthesia (SSA) in a retrospective study [6] and compared with combined spinal-epidural anesthesia in a prospective study [7], provided good surgical conditions with a low mortality rate in the first postoperative month and to a low incidence of complications. And finally in 2006, we used it for labor analgesia with the 29G needle and 24G catheter set in five pregnant patients [8]. The catheter to perform CSA arrived in Brazil in 1998 and was discontinued in 2016 by the company that marketed it. In Brazil our group published several articles with the kit for CSA. Thus, we retrospectively assessed the number of CSA performed by our study group. Our objectives were to evaluate the use of CSA, its efficacy, ease to use and safety over the 17 year period.

Method

After obtaining institutional approval and informed consent from the subjects, this retrospective analysis was conducted the period from June 1998 to December 2015. All patients who submitted to femur osteosyntesis and partial or total hip replacement and received CSA carried out in this period were noted in an Excel spreadsheet designed for this monitoring and were reviewed. Patients’ demographic profiles, ASA physical status, comorbidities and clinical outcome were noted in the Excel spreadsheet. Details of the CSA, performance parameters, duration of surgery, intraoperative hemodynamic status and the usage of vasopressor and atropine were obtained from the anesthesia records. Inclusion criteria are shown in (Table 1). Associated diseases and drugs in use were also recorded. No patient was premedicated. Monitoring in the operating room consisted of continuous ECG in CM5, non-invasive blood pressure and pulse oximetry. All patients had an upper limb vein punctured with an 18G venous catheter and a 3 L.min-1 oxygen catheter or Hudson mask installed. After venous puncture, patients were given intravenous midazolam (0.5-1 mg). To place the patient in the blockade position, 0.1 mg/kg dextroketamine IV were injected, or anterior plexus lumbar blockade was performed with 20 mL of 2% lidocaine with epinephrine 1:200.000 + 20 mL of 0.5% bupivacaine. In patients operated for partial or total hip arthroplasty, they received dextroketamine and posterior lumbar plexus block with 40 mL of 0.25% bupivacaine for postoperative analgesia. Using the previously described technique [5], the epidural puncture was paramedially performed in the left lateral position at L2-L3 or L3-L4 interspace with an 18G Crawford needle. After that, dura was punctured with a Spinocath® device (B. Braun Melsungen AG) with a 27G needle and 22G catheter set. With the patient still in the puncture position, 5 to 10mg of 0.5% isobaric bupivacaine was injected, depending on patient’s height, when they were immediately placed in the supine position (Table 2). The following data were recorded: time taken for catheter insertion, perception of dural puncturing by spinal needle, difficulty of technique (“easy”, “difficult”, “impossible” or “perforation duramater”), highest level of sensory blockade, quality of motor blockade according to the Bromage scale, incidence of paresthesia, duration of the surgical procedure and neurologic complications. In case of pain or inadequate level, 2.5 mg of 0.5% bupivacaine were injected through the spinal catheter, until problem correction, which was removed at the end of surgery.

If accidental dural puncture were to occur during attempts to use an epidural approach with Crawford or Tuohy needles, the catheter would have to be introduced into the subarachnoid space and such patients would be excluded from the study. In the event of failure to access the epidural space within 15 minutes, singleshot spinal anesthesia would be administered with 15 mg of 0.5% isobaric bupivacaine and such patients would be excluded. All anesthesia’s were performed by or in the presence of the two authors (LEI, MAG). Hypotension (defined as a 30% decrease in systolic blood pressure, in comparison with preoperative control levels) was treated with ethylphenylephrine 1 mg intravenously. Bradycardia (defined as HR less than 50beats/min) was treated with atropine 0.5 mg intravenously. The patients were followed up by telephone regarding the appearance of cauda equina syndrome or transient neurological symptoms. The results were evaluated by the descriptive analysis of studied variables (frequencies, percentages, scatter plots and concentration ellipses) and, when possible, by the mean and standard deviation

Results

Four hundred and fifty-five underwent patient’s surgery using CSA during 17 years of the studied period. Of these, 298 (65.9%) were females. All of these CSA were carried out by the two authors. The 27G needle and 22G catheter were used in all patients. Only seven patients had to be excluded because of unintended dural perforation with the epidural needle in two patients or failure to access the epidural space with the Crawford needle in five patients. Demographic data are shown in (Table 3) and (Figure 1). The different doses used in the 448 patients are shown in (Table 4). Mean isobaric bupivacaine initial dose was 7.74±1.78 mg and total dose was 8.58±2.60 mg. The time to perform CSA was 2.36±1.03 minutes and the duration of surgery was 2.17±0.82 hours. In 376 patients, epidural puncture with Crawford needle was easy; in 72 patients it was difficult. The subarachnoid catheter was inserted easily in 407 patients and with difficulty in 42 and in all patients the catheter was inserted only 1 to 2 cm in the subarachnoid space. Paresthesia was observed in only 27 patients. In the seven patients where there was accidental perforation of the dura mater or failure to identify the epidural space, simple spinal anesthesia was performed with 15 mg of 0.5% isobaric bupivacaine (Table 5).

Discussion

This retrospective study has shown that for femur and hip surgeries in elderly patients, CSA with catheter designed for this procedure provides less cephalad dispersion (mode T12), lower incidence of arterial hypotension and less local anesthetic requirement, without any neurological complications. The failure rate was low (1.5%) and need for complementation of the initial dose of 19.6%. Femur and hip fractures are major issues for health services. Incidence increases with age, with predominance of women due to association to osteoporosis. In our study, this was confirmed by the 65.9% presence of women in the groups. The utilization rate of CSA technique only in elderly patients with hip or hip fracture by our group for 17 years averaged 30 patients per year [5-7]. In 2006, we used the set (24G catheter and 29G needle) for labor analgesia in five parturients, with excellent results [8]. In 2016 we stopped using CSA with Spinocath® has been discontinued from the market. In a previous study comparing CSA with continuous epidural anesthesia (CEA), the time to perform it was significantly shorter with CSA (2.6±0.9 min) than with CEA (2.9±1.2 min) [7]. In this retrospective study with 448 patients, the time to perform the CSA was shorter (2.36±1.03 min) than that obtained in the previous article. Using the same kit for CSA (n=50) compared to CEA, the performance time was significantly longer with CSA (6.09±2.20 min) and practically three times that obtained in our studies [9]. In most of our patients, they received an inguinal lumbar plexus block before CSA. For this reason, we do not evaluate the latency time of the first dose of 0.5% isobaric bupivacaine. In a study comparing CSA versus CEA, the time to reach sensory level T10 was significantly lower with CSA (8.40±3.96 min x 18.80±6.59 min) [9]. Sensory block level and motor blockade may be easily obtained and controlled with CSA, in the same way allows early recognition of insufficient level or insufficient time for the surgical procedure. Because of the incremental doses in 19.6% of the patients, either to produce the required analgesia or to extend analgesia, it would be useless to study the final dermatome level of analgesia. CSA was introduced in 1907 [10]. It is a well-established technique that has been used successfully in orthopedic surgical procedures [5-7]. The technique allows titration of the local anesthetic dose according to surgical needs and provides safe anesthesia, particularly for elderly or high-risk patients with unstable hemodynamic status [5, 11]. CSA depends on how the catheter is introduced into the subarachnoid space. It is more difficult when a microcatheter is used [1-3]. We found difficulties during catheter insertion in 9.2% of the patients in the CSA group, an incidence 3.6 times higher than in a previous study [7]. In three studies comparing CSA with CEP, it showed a significantly lower dose in the CSA group [6, 7, 9]. The total mean dose of 0.5% isobaric bupivacaine was similar in the three studies and practically the same in this group of 448 patients (8.58±2.60 mg). In a recent study, it was found that CSA took longer with a Spinocath® with 29G Quincke needle and 24G catheter (6.3±3.2 min) than with a microcatheter 22G Sprotte needle and 27G catheter (3.9±1.2 min) [12]. This time was 2.6 times longer than what we found in our study, using the Spinocath® with 27G Quincke needle and 22G catheters. It is well known that the time taken for cerebrospinal fluid to flow through a 29G needle with Quincke bevel (80.45 seconds) is three times longer than through a 27G needle (27.21 seconds) [13]. The use of different types and sizes of needles may explain this difference. Some studies used the CSA for post-operative analgesia for abdominal, vascular, hip surgery [14] and severe aortic stenosis with hip fracture [15]. Because we used lumbar plexus block (anterior and posterior) with neurostimulator, the use of CSA for postoperative analgesia was not practiced in our routine and all catheters were removed at the end of surgery. CSA using small titrated dose provides better hemodynamic stability than SSA [6] and CEA [6, 7] in elderly orthopedic patients. Although transoperative hypotension (7.1%) may occur, it was easily treated with small doses of vasopressors without any major adverse event reported. Because it has a larger diameter than the needle 27G and the catheter 22G occludes the duramater orifice and prevents CSF loss and develops a reaction with fibrin deposit at the puncture site, which has already been shown to be animal [11]. There was no presence of CSF in the dressing during the removal of the catheter from the subarachnoid space. The direction of the catheter introduced into the subarachnoid space cannot be predicted. In this work, with professionals over 45 years of practice and introduction of less than 2 cm of the catheter, a 6% incidence of paresthesia was observed. Post dural-puncture headache (PDPH) is a commonly reported complication of spinal anesthesia. A decrease in the size of the puncture needle and an increasing age of the patient are thought to reduce its incidence, but also factors such as thickness of the dura, a thicker dura tends to retract more rapidly than thin dura and gender of the patient, females have a higher incidence, are to be taken into consideration [16]. In a 1999 study with a catheter outside the needle, there were two patients with mild post dural-puncture headache after CSA, who did not require any invasive therapy, and two patients who received a blood-patch [11]. In another study with the same kit for CSA in 50 patients, no case of PDPH was observed [9]. In our study with 448 patients, PDPH was observed in only 7 patients (1.5%) of medium intensity and short duration (3 days). Postoperative urinary retention is a common event following surgical procedures. As criteria for inclusion in the study, patients who had a bladder catheter were automatically excluded from the study. Likewise, no patient received opioids subarachnoid ally and analgesia was performed with lumbar plexus block. In this study, only 1.7% of patients needed a urinary catheter during the postoperative period.

Conlusion

The main advantage of CSA is the possibility to gradually inject the local anesthetic and control dispersion in the CSF, providing security and control over the needs of each patient. This objective was achieved in this study. The frequency of headache with this technique and in this age group is very low. No serious neurological complications were observed, especially cauda equina syndrome. Thus, we can say that CSA when correctly used with a catheter outside the needle is a safe technique, especially in elderly patients with hip or hip fractures. The CSA with high doses of hyperbaric anesthetics through the catheter outside the needle, poor distribution was not observed or risk of cauda equina syndrome were not observed. 17 Unfortunately this catheter was discontinued by the manufacturer and we anesthetists have lost an excellent product in our therapeutic arsenal.

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mcatmemoranda · 4 years ago

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There are 3 types of diaphragmatic hernia that may be seen in CXR. By far the most common is a hiatal hernia - the stomach slips through the esophageal hiatus into the chest. A Bochdalek hernia is through a weakness in the diaphragm, and usually occurs on the left side posteriorly (Bochdalek - back and to the left). Morgagni hernias typically occur medially. Weakness of the diaphragm can occur without frank herniation of abdominal contents. This is termed an eventration, and it usually occurs on the right with a portion of the liver bulging cephalad.

https://www.med-ed.virginia.edu/courses/rad/cxr/pathology16chest.html

#mnemonics #diaphragmatic hernia #Bochdalek #Morgagni #hiatal hernia #eventration

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thegaitguys · 6 years ago

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Increased unilateral foot pronation can cause cephalad asymmetries.

Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking. Nothing earth shaking here, we should all know this as fact. When a foot pronates more excessively, the arch can flatten more, and this can accentuate a leg length differential between the 2 legs. But it is important to note that when pronation is more excessive, it usually carries with it more splay of the medial tripod as the talus also excessively plantarflexes, adducts and medially rotates. This action carries with it a plantar-ward drive of the navicular, medial cuneiforms and medial metatarsals (translation, flattening of the longitudinal arch). These actions force the distal tibia to follow that medially spinning and adducting talus and thus forces the hip to accommodate to these movements. And, where the hip goes, the pelvis must follow . . . . and so much adaptive compensations. So could a person say that sometimes a temporary therapeutic orthotic might only be warranted on just one foot ? Yes, of course, one could easily reason that out. -Shawn Allen, one of The Gait Guys

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #LLD, #leglength, #pronation, #archcollapse, #orthotics, #gaitcompensations, #hippain, #hipbiomechanics

Gait Posture. 2015 Feb;41(2):395-401. doi: 10.1016/j.gaitpost.2014.10.025. Epub 2014 Nov 3. Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking. Resende RA1, Deluzio KJ2, Kirkwood RN3, Hassan EA4, Fonseca ST5.

#foot pronation #unilateral arch collapse #pelvis asymmetry #LLD #internal limb spin #gait #gait problems #gait analysis #gait compensations #the gait guys

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biomedgrid · 2 years ago

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Biomed Grid | Biomechanical Principles of Multipoint Suture Fixation for Abdominal Wall Reconstruction

Introduction

In the United States, approximately 400,000 ventral hernias are repaired every year with an estimated cost of about 3 billion dollars [1] . Ventral hernias are a relatively morbid condition given that an intact abdominal wall is necessary for dynamic activities such as rotation of the torso, respiration, defecation/urination, emesis, and childbirth.

The management of ventral hernias has evolved over the past several decades with advances in technology and knowledge. The first significant improvement was the use of prosthetic mesh reinforcement to simple suture repair alone [2] . As reported by Luijendijk, randomized controlled trials demonstrated a decrease in hernia recurrence rates from 43 percent to 24 percent [3, 4].

Another major advancement was the popularization of the component separation technique as escribed by Ramirez [5] . This technique was found to be particularly useful in the case of large hernias where primary closure of the hernia defect is not possible otherwise. In addition, it eliminates the need for prosthetic mesh and its associated risks, while providing comparable or superior reduction in hernia recurrence [6, 7, 8]. Perhaps more importantly, the component separation technique provides a dynamic abdominal wall reconstruction, using innervated muscle which is critical to reducing hernia recurrence. In addition, component separation procedures provide an anatomic alignment of the muscles, which enhances abdominal wall function.

The advent and implementation of biologic mesh or acellular dermal matrices (ADM) has offered an additional valuable tool in the reconstructive armamentarium for ventral hernias [9] . ADM is superior to prosthetic mesh in setting of contaminated and highrisk cases and is a valuable adjunct to the component separation technique [10, 11, 12]. Abdominal wall reconstruction with human acellular dermal matrices (HADM) has also been described [13] . However, since it has increase elasticity as compared to porcine or bovine ADMs, it can leave a significant bulge if used as an inter-positional bridge when myofascial continuity cannot be reestablished (Figure 1A) (Figure 1B)

Figure 1A: Initial inset HADM over the anterior rectus sheath

Figure 1B: Progressive tension stretching the HADM laterally on each side with multiple fixation points with interrupted sutures

Although component separation with biologic mesh reinforcement is effective, there is still not universal agreement as to the technique and location for mesh fixation [14].For standard mesh fixation, the retro-muscular or underlay placements are most commonly used and are associated with lower recurrence rates [15, 16]. There has been some difference in outcomes with different types of fixation for underlay indicating that the method of fixation is important [17] .Placement of sutures lateral to the junction of the linea alba and the anterior rectus sheath have been found to provide the greatest support and tolerance for tissue tension in studies on laparotomy closure [18] .

The multipoint suture fixation offers a technique that combines these advantages for the patient undergoing abdominal wall reconstruction for ventral wall hernia, including the largest and most complex hernias as well as those with infected mesh and soft tissue deficiencies. The multipoint suture fixation technique is a physiologic approach to hernia reconstruction. The technique utilizes wide exposure to avoid injury to the hernia sac or contents. In patients who have had a prior midline incision, that is used. However, in patients without incisions on the abdomen, an abdominoplasty type incision has been found to have a number of advantages [19] . Local anesthesia with epinephrine is injected along the planned incisions to minimize bleeding and facilitate the dissection. The hernia sac and defect are circumscribed, and dissection is continued cephalad to the xyphoid.

Component release incisions are made lateral to the lateral border of the rectus muscles to mobilize the rectus muscles to the midline. The location of the component release is determined by the width of the anterior rectus sheath. It is made at least 8 cms lateral to the midline inset of the rectus sheath. The fascia is released, and the external oblique muscle preserved. In patients in whom the loss of domain is greater, posterior release of the rectus sheath can be added as well. The two abdominal rectus muscles are brought together in the midline with several interrupted 0 Vicryl sutures to ensure alignment of the muscles. This is critical for two reasons, first as indicated previously, a lower recurrence rate is associated with patients in whom myofascial continuity is reestablished. Second, the proper alignment of is important for proper function of the muscles in the actions on the abdominal wall. Even a small deviation of the line of action can have a significant impact on the how effectively muscles function [20] . A looped 1 PDS is used as a continuous running horizontal mattress suture to imbricate the anterior fascia, which is the most effective suture technique [21] . This facilitates securing the anterior fascia just lateral to the junction of the linea alba and anterior rectus sheath where it is strongest [22] .

The intentional selection of HADM to reinforce the abdominal wall fascia offers several advantages. Fascia takes approximately two months to gain 40% of its original strength, but original strength is never regained [23] . The addition of HADM provides not only a temporary increase in tensile strength of the abdominal, but as it integrates, it reinforces the native abdominal wall structure.

As compared to non-crosslinked xenograft ADMs, HADM provide more rapid vascular ingrowth and integration and greater tensile strength of the musculo-fascial interface [24] . The HADM has greater elasticity than non-cross-linked xenograft ADMS or any of the crosslinked ADMs. While this elasticity is a disadvantage for standard inset or interposition graft placement, with the multipoint fixation it offers the advantage of increased abdominal wall compliance.

The wide exposure open approach facilitates careful placement of the HADM. It is secured along the midline imbrication to bolster the inset of the two rectus abdominus muscles. Additional sutures are then placed in an offset row pattern working from the midline out laterally in each direction. Progressive tension sutures have been well-described to fix soft tissue in abdominoplasties to decrease seroma formation [25] . With each row additional traction displaces the HADM laterally as compared to the underlying fascia. This helps fix the HADM to the fascia to decrease the risk of seroma formation between the HADM and the fascia. In addition, the number of sutures strands used for fixation had been demonstrated to have a critical effect on the strength of fixation [26] . Perhaps more importantly, each row progressively offloads the tension on the midline inset of the muscles.

This technique specifically addresses the underlying concept that recurrences most often occur at the mesh-fascia interface. The structural design provides maximum interface of the anterior rectus sheath and the HADM. The progressive tension sutures provide an increased number of fixation points and off-load the inset of the muscles. The clinical results of this technique show that a multipoint fixation suture technique for abdominal wall reconstruction with component separation and onlay biologic mesh is reproducible and effective with low recurrence rates.

Read More About this Article: https://biomedgrid.com/fulltext/volume7/biomechanical-principles-of-multipoint-suture-fixation.001115.php

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cephalad-art · 2 years ago

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It’s Zukka Week!

I really want to participate in Zukka Week, but I have limited time and brain, so I’ll be posting full story ideas/ outlines in response to the prompts. These are free use, but please credit me (I’m “cephalad” on AO3). Much love my friends.

#zukka week #prompts

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ourhaileydavies · 4 years ago

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Juniper Publishers-Open Access Journal of Head Neck & Spine Surgery

Submental Endotracheal Intubation: A Useful Alternative

Authored by Kanwaldeep Singh Soodan

Abstract

Submental endotracheal intubation is a simple, useful and safe technique in maxillofacial trauma when oral and nasal endotracheal intubation cannot be performed. It prevents need for tracheostomy and its consequent morbidity. Airway management in patients with panfacial trauma is challenging due to disruption of components of upper airway. Most patients have associated nasal fractures where use of nasal route of intubation contra-indicated. Intermittent intra-operative dental occlusion is needed to check alignment of the fracture fragments, which contraindicates the use of orotracheal intubation. The anesthesiologist has to share the airway with the surgeons. Submental intubation provides intra-operative airway control, avoids use of oral and nasal route, with minimal complications. Submental intubation allows intra-operative dental occlusion and is an acceptable option, especially when long-term postoperative ventilation is not planned. This technique has minimal complications and has better patients and surgeons acceptability.

Keywords: Intubation; Panfacial trauma; Contraindication; Complication

Introduction

Francisco Hernandez Altemir in 1986 first reported Submental intubation. According to him, it's a procedure that avoids tracheotomy and allow for the concomitant restoration of occlusion and reduction of facial fractures in patients ineligible for nasotracheal intubation [1]. This procedure consists of exteriorizing an oral endotracheal tube through the floor of the mouth and submental triangle. The surgical procedure involves a 2cm incision in the Submental, paramedial region extending cephalad until the lingual mucosa was tented with a hemostat after which another 2 cm incision parallel to the mandible is made in the lingual gingiva. The breathing circuit is briefly disconnected as the tube is externalized through the Submental region and reconnected to the circuit and secured to the patient. Submental intubation is a surgical adjunct in facial trauma, pathology and elective facial surgery.

Oral intubation interferes with maxillomandibular reduction. In situations where maxillomandibular fixation is required and nasoendotracheal intubation is contraindicated, cricothyrotomy or tracheostomy has been the traditional method of airway control [2]. Submental intubation technique consists of passing the tube through the anterior floor of mouth, allowing free intra-operative access to oral cavity and nasal pyramid without endangering patients with skull base trauma. Submental intubation can be used when short term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion.

Case Report

A 35 year old male patient with 70kg weight met with a road traffic accident and was admitted to hospital. On admission patient was conscious with a Glasgow coma score of 15. On examination, there was facial swelling, laceration at Naso-orbito- ethmoid region and epistaxis was present. There was tenderness at zygomatic buttress region and mouth opening was restricted. Radiological examination revealed Nasal bone fracture with presence of high Lefort I fracture on the right side (Figure 1).

The patient was scheduled for surgical correction of multiple facial fractures. Nasal endotracheal intubation was contraindicated in the presence of nasal bone fracture. Oral endotracheal intubation was not possible because the surgical procedure involved intraoperative intermaxillary fixation to obtain occlusion. In order to avoid tracheostomy, submental endotracheal intubation was planned. Patient was kept fasting for 8 hours preoperatively. He was premedicated in preoperative room and then in operation theatre was preoxygenated with 100% oxygen for three minutes. A 2cm incision was made in left submental region parallel and medial to inferior border of mandible by the surgeon (Figure 2).

It was extended intraorally through the mylohyoid muscle by blunt dissection. The endotracheal tube was briefly disconnected from the breathing circuit and the tube connector was removed from the tube. The pilot balloon followed by endotracheal tube was gently pulled out through the incision. The tube connector was re-attached and the endotracheal tube reconnected to an aesthesia breathing circuit (Figure 3).

Bilateral air entry was rechecked and found to be equal and the tube was fixed with 1'0 silk suture. Intraoperatively, the endotracheal tube was away from the surgical field and the surgeons could easily do the intermaxillary fixation to check occlusion. The total duration of surgery was five hours. At the end of surgery, submental intubation was converted to oral intubation. First the pilot balloon and then the endotracheal tube were pulled intraorally. The submental incision was closed using two skin sutures so as to allow certain degree of drainage. Patient was extubated uneventfully. After two months, submental scar was almost invisible.

Discussion

Submental intubation is a simple, secure and effective procedure for operative airway control in maxillofacial trauma surgery. It allows surgeons to avoid the risk of epistaxis, iatrogenic meningitis or trauma of the anterior skull base after nasotracheal intubation as well as complications such as tracheal stenosis, injury to cervical vessels or the thyroid gland, subcutaneous emphysema, or recurrent laryngeal nerve injury related to tracheostomy [3,4]. The scar from the submental incision is thought to be less visible than a tracheostomy scar and is well tolerated by patients [5].

For more articles in Open access Journal of Head Neck & Spine Surgery | Juniper Publishers please click on: https://juniperpublishers.com/jhnss/index.php

#Head and neck surgery #Panfacial trauma #intubation #complication #contraindication #endotracheal

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