Simple Maneuvers Research Articles

Paralysies faciales périphériques d’origine dysbarique

Facial baroparesis is an ischemic neurapraxia of the facial nerve. It occurs after airplane trips or prolonged diving. This paralysis is due to the tympanic promontory. Several promoting factors have been identified, including tubal dysfunction, hypotension, and neurotropic virus. Simple maneuvers can make it disappear: yawning, swallowing, or a Toynbee maneuver. Treatment is based on normobaric or even hyperbaric oxygen therapy. During airplane flights, the paralysis often disappears at landing.

Simple provocative maneuvers in renal transplant scintigraphy for detecting urine leak

Urine leak in the early postoperative period following renal transplantation is a serious complication requiring early identification and aggressive intervention, which significantly reduces the morbidity and mortality. Renal transplant scintigraphy is a noninvasive method to evaluate the perfusion and function of a transplanted kidney and urinary drainage including urine leak. Here, we reported two cases in which the standard transplant renogram failed to demonstrate urine leak. The cases were referred for a diethylenetriaminepentaacetic acid renogram following the transplantation to evaluate the cause of symptoms or elevated serum creatinine level. In both the cases, urine leak was successfully detected following simple maneuvers such as diuretic administration or Foley catheter irrigation. Renal transplant scintigraphy is an effective and safe technique and the use of these simple maneuvers can enhance the diagnostic sensitivity of the transplant renogram in the detection of urine leak.

A reply

We thank Dr Brown for her interest in our editorial. She is, of course, correct in stating that the vast majority of cases of laryngospasm are managed successfully with the application of CPAP and other simple manoeuvres. The thrust of our article was, however, the serious case of laryngospasm, when these simple manoeuvres have been tried and the situation is slipping out of control, that is, when the oxygen saturation continues to drop rapidly or the patient becomes bradycardic before intravenous access has been achieved. We did not intend to discuss those simple manoeuvres in detail. Dr Brown states that ‘complete laryngospasm can quickly progress to hypoxia and bradycardia, and intubation may become necessary’. We are aware that many anaesthetists may choose to intubate at this stage and this may resolve the situation. However, if unsuccessful, especially in the older child or adult, valuable time is wasted. We feel that it is an important principle in the management of such a situation that we must not get fixated on intubation, but on oxygenation. Is full muscle relaxation necessary to facilitate intubation? We state in our editorial that the time to maximal twitch depression for intramuscular suxamethonium is in the region of 3–4 min, but that ‘oxygenation is the initial goal, and therefore, full relaxation is probably not necessary’. This relates specifically to the ability to oxygenate by CPAP and manual inflation of the lungs, not to intubation. Dr Brown states ‘this implies that one need not wait for the full effects of suxamethonium before attempting intubation’. We have based our logic on the work of Donati [1], that central muscles such as the muscles of the larynx and diaphragm relax earlier than peripheral muscles and therefore oxygenation by the application of tight CPAP and manual inflation will be possible before full relaxation is present at the adductor pollicis muscle. Therefore, it does not necessarily follow that one can intubate at this point. We believe that when faced with this life-threatening situation one should administer suxamethonium by one of the routes discussed and maintain CPAP until laryngospasm breaks. Oxygenate and then, if necessary, intubate. Likewise, the use of topical lidocaine in this situation, although reported, could make the situation worse and, again, wastes precious time. The rapidly deteriorating child or adult allows no time to ‘consider’ different options. The anaesthetist must have a plan and act on that plan rapidly. Experience is little protection in this situation. This can happen to anyone, at any time and it is our belief that the administration of suxamethonium by the intramuscular, intra-osseous or intralingual route is of paramount importance to prevent serious complications from laryngospasm.

The management of raised intracranial pressure: A multidisciplinary approach

Raised intracranial pressure (ICP) impairs cerebral perfusion, resulting in cerebral ischaemia if the pressure is not controlled. In the normal brain cerebral blood fl ow is autoregulated. Brain tissue is dependent on a constant supply of blood, glucose and oxygen to maintain normal function; it lacks any substrate storage ability. In acute brain injury the normal cerebral homeostatic mechanisms fail, hypoperfusion and hypoxia will severely exacerbate neuronal damage. Treatment of raised ICP should be multi-modal and involve the manipulation of intra-cranial contents (cerebrospinal fl uid, blood and brain volumes) through a combination of simple manoeuvres, pharmacological therapies and surgical interventions, in an attempt to reduce the potential for continued neurological damage.

Emergency Department Procedural Sedation with Propofol: Is it Safe?

Propofol is a sedative agent gaining popularity for Emergency Department Procedural Sedation (EDPS). However, some institutions across the country continue to restrict the use of propofol secondary to safety concerns. The purpose of our study was to evaluate the complication rate of EDPS with propofol. We conducted a prospective, observational, multi-center study of EDPS patients aged ≥ 18 years, consenting to procedural sedation with propofol. Eighty-two patients from two Level I trauma centers were enrolled between August 1, 2002 and January 31, 2003. Transient hypoxemia was the only noted sedation complication. Nine patients (11%) had brief hypoxemia. The combined average hypoxemia time was 1.2 min (SD 0.4), and in all instances responded to simple airway maneuvers or increased oxygen concentration. No patient required advanced airway maneuvers such as intubation or even positive pressure ventilation. EDPS with propofol seems to be safe in our population.

Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is a fascinating disease entity in which hypertrophy of the myocardium occurs, primarily as a result of mutations of genes encoding the cardiac sarcomere.1–3 Our knowledge of patients with this unique disease of the heart muscle has advanced significantly. Once thought to be a rare malignant disease with a high risk of sudden death, population studies have revealed hypertrophic cardiomyopathy to be a more common disease with a benign outlook in the majority of affected patients.4 Hypertrophic cardiomyopathy is now recognized to comprise a wide spectrum of disease processes, with varying genetics, anatomy, clinical presentation, and prognosis. The dynamic left ventricular outflow tract obstruction that was initially the hallmark of hypertrophic cardiomyopathy continues to be a source of controversy. Article p 2232 The pathophysiology of hypertrophic cardiomyopathy is complex and still not completely understood. The first description of hypertrophic cardiomyopathy came in 1957 when Sir Russell Brock5 found a functional subvalvular obstruction in patients undergoing aortic valvotomy for clinically suspected valvular aortic stenosis. In 1958, Teare6 described the cardiac anatomy of 8 young patients who died suddenly with severe asymmetric left ventricular hypertrophy with bizarre muscle bundle orientation. In the 1960s, Braunwald et al7 defined a specific disease process in which asymmetric septal hypertrophy, myofibril disarray, and dynamic outflow tract obstruction were found. Thus, the early focus of hypertrophic cardiomyopathy was on this dynamic obstruction; the response of the obstruction to changes in preload, afterload, and contractility formed the basis for diagnosis. With the advent of echocardiography, which allowed direct visualization of the hypertrophied myocardium, it became apparent that obstruction was not necessary for the diagnosis of hypertrophic cardiomyopathy. The entire relationship of obstruction to hypertrophic cardiomyopathy was subsequently questioned. Some thought that hypertrophic cardiomyopathy was primarily a disease of diastole, with obstruction …

Unsteady Rolling Moment Characteristics for a Fighter Oscillating with Yawing-Rolling Coupled Motion

T HE maneuvering flight of an aircraft is very complicated. It usually consists of coupled motions about three body axes; therefore, it is very important to simulate maneuvering flight and measure the unsteady aerodynamics in the wind tunnel. Simple flight maneuvers such as the cobra maneuver [1] and the wing rock can be simulated easily, and tests have been conducted in many wind tunnels [2,3]. However, for the complicated flight maneuvers, such as theHerbstmaneuver [4], there is a yawing–rolling coupledmotion about the body axes when the aircraft encounters high angles of attack. Up to now, the wind-tunnel test data for such complicated coupled motions are very few. The method of the linear superposition is usually used to calculate the unsteady forces and moments of coupled motion to analyze the maneuvering characteristics of the aircraft. The linear superposition model is suitable at low angles of attack, but whether it is suitable at high angles of attack is still not clear. In [5], Zhongjun and Edward adopted the quasi-steady aerodynamic model and the unsteady aerodynamic model to simulate the coupled motion of the aircraft. The results of the two methods are very different. In this investigation, an aircraft configuration with a strake wing was tested in a 3-m low-speedwind tunnel at NanjingUniversity ofAeronautics and Astronautics (NUAA) with large amplitude oscillation. The unsteadiness of the rolling moment as the model oscillates in a yawing–rolling coupled motion is compared with that of in pure yawing motion and rolling motion. The lateral dynamic derivatives were obtained using a mathematical model with the fuzzy logic algorithm and the dynamic derivative simulation. The unsteady rolling moment for the yawing–rolling coupledmotion was obtained by using the quasi-steady aerodynamic model or the unsteady aerodynamic model, respectively, and the results are compared with the experimental data. It is shown that the wind-tunnel tests can provide better results for the unsteady aerodynamics of coupled motion at large angles of attack.

Development and Experimental Validation of a Shipboard Helicopter On-Deck Maneuvering Simulation

Routine shipboard helicopter operation on many classes of ships requires that helicopters be maneuvered and traversed along the ship deck using installed helicopter securing and handling equipment. This paper describes the derivation, implementation, and validation of a four-degrees-of-freedom mathematical model for predicting and analyzing the behavior of shipboard aircraft under the influence of external aircraft handling forces. The resulting model is suitable both for engineering analysis and training applications. The helicopter model includes the coupled dynamics of the aircraft, landing gear, and optionally steerable or castorable auxiliary wheel assembly. Detailed tire modeling addresses the transient development and release of tire deflection and cornering forces related to yawed and unyawed relaxation lengths as well as direct application of forces by the handling system. Verification and both qualitative and full-scale experimental validation of the model, performed using a number of simple maneuvers to validate specific aspects of the simulation, are discussed. It is shown that the resulting HeliMan simulation captures the underlying dynamics of the shipboard helicopter maneuvering process. Full-scale validation data show that in many cases the simulation is able to reproduce closely the measured data. The effect of tire side loading on longitudinal rolling resistance has been identified as a shortcoming of existing rolling tire models and the most probable cause for differences that exist between simulated and measured results in some validation cases. Nomenclature A = vector representing the accelerations for the two bodies

Managing the difficult airway in children

The small diameter of a child's airway makes it more susceptible to obstruction, and the limited respiratory reserve and high oxygen consumption lead to rapid desaturation. Try to predict problems by careful assessment. Check for syndromes and diseases associated with airway problems, and any history suggestive of airway narrowing. Look in particular for mandibular abnormalities and signs of increased work of breathing. Prepare equipment, experienced assistance, the anaesthetic plan, and the child and parents for the mode of induction. Management is generally gas induction with sevoflurane or halothane in oxygen deepening anaesthesia until laryngoscopy is possible. Maintain spontaneous ventilation until the airway is secured. Simple airway manoeuvres or adjuncts may be needed to maintain a good airway. The laryngeal mask airway (LMA) is often very useful in difficult situations. If oxygenation is easy, a range of intubating techniques can be used. There is a well described technique for fibreoptic intubation via the LMA, which maintains oxygenation and allows small infants to be intubated using an adult-size fibreoptic scope. In the situation of ‘can't intubate, can't ventilate’ with worsening hypoxia and bradycardia, a transtracheal airway is the only option. For children aged more than 8 years, adult equipment can be used, but in young children a cannula cricothyroidotomy is recommended. A 14 or 16G cannula is inserted through the cricothyroid membrane, and jet ventilation delivered from a high pressure source. There are numerous complications of cricothyroidotomy and jet ventilation.

Reversal of Hypermetabolic Brown Adipose Tissuein F-18 FDG PET Imaging

With the increasing application of F-18-fluorodeoxyglucose (FDG) positron emission imaging, there has been an evolving appreciation for the range of normal variants and the realization that false-positives can lead to serious consequences. One of the most common causes of a false-positive study is the uptake of FDG in areas of hypermetabolic brown adipose tissue (HBAT). Areas of involvement are often spatially closely related to important lymph node groups in the neck, axilla, and upper mediastinum, making critical differentiation difficult, even with PET-CT. FDG uptake in HBAT has been noted to occur more frequently in cold months and benzodiazepines have been proposed for its prevention. The use of these drugs is, in our experience, of limited value and may complicate patient care in both inpatient and outpatient populations. In this report, we describe considerable success by completely reversing HBAT in 9 of 10 sequential patients with simple core warming maneuvers, which obviate the use of benzodiazepines.

Inappropriate Use of Intravenous Pantoprazole: Extent of the Problem and Successful Solutions

Indications for intravenous proton pump inhibitors (IV PPI) include upper gastrointestinal bleeding (UGIB) from peptic ulcer disease with high-risk stigmata and patients receiving nothing by mouth (NPO). The objectives were to assess the extent of errors in indications for IV PPI use and to determine whether multidisciplinary interventions could improve IV PPI use and costs. Part 1: Patients prescribed IV PPI during a period of 4 months were divided into 2 settings, UGIB or non-UGIB. The setting-specific appropriateness of the IV PPI indication and dosing regimen was determined. Part 2: Patients prescribed IV PPI before and after multidisciplinary interventions (educating physicians, a computerized dose template, pharmacists altering IV PPI orders in non-UGIB patients who were not NPO, and recommending a GI consult when a continuous infusion was ordered) were studied. Incidence of prescribing errors, IV PPI costs, and potential confounders were compared. Part 1: Only 50% of UGIB (n = 145) patients received IV PPI for an appropriate indication. Both indication and dosing regimen were appropriate in 21%. In the non-UGIB group (n = 95), 33% were truly NPO; 51% had a correct dosing frequency. Part 2: The postintervention (n = 105) group (vs the preintervention group, n = 113) showed a significant absolute reduction in the degree of inappropriate indication in the UGIB (26%; 95% confidence interval [CI], 10%-42%; P < .0001) and in the non-UGIB (41%; 95% CI, 24%-58%; P < .0001) subgroups. However, a greater improvement in underspending than overspending meant that overall costs were unchanged. IV PPI was frequently prescribed inappropriately and incorrectly; simple maneuvers resulted in reductions in errors.

Algorithm for identifying and separating beats from arterial pulse records

BackgroundThis project was designed as an epidemiological aid-selecting tool for a small country health center with the general objective of screening out possible coronary patients. Peripheral artery function can be non-invasively evaluated by impedance plethysmography. Changes in these vessels appear as good predictors of future coronary behavior. Impedance plethysmography detects volume variations after simple occlusive maneuvers that may show indicative modifications in arterial/venous responses. Averaging of a series of pulses is needed and this, in turn, requires proper determination of the beginning and end of each beat. Thus, the objective here is to describe an algorithm to identify and separate out beats from a plethysmographic record. A secondary objective was to compare the output given by human operators against the algorithm.MethodsThe identification algorithm detected the beat's onset and end on the basis of the maximum rising phase, the choice of possible ventricular systolic starting points considering cardiac frequency, and the adjustment of some tolerance values to optimize the behavior. Out of 800 patients in the study, 40 occlusive records (supradiastolic- subsystolic) were randomly selected without any preliminary diagnosis. Radial impedance plethysmographic pulse and standard ECG were recorded digitizing and storing the data. Cardiac frequency was estimated with the Power Density Function and, thereafter, the signal was derived twice, followed by binarization of the first derivative and rectification of the second derivative. The product of the two latter results led to a weighing signal from which the cycles' onsets and ends were established. Weighed and frequency filters are needed along with the pre-establishment of their respective tolerances. Out of the 40 records, 30 seconds strands were randomly chosen to be analyzed by the algorithm and by two operators. Sensitivity and accuracy were calculated by means of the true/false and positive/negative criteria. Synchronization ability was measured through the coefficient of variation and the median value of correlation for each patient. These parameters were assessed by means of Friedman's ANOVA and Kendall Concordance test.ResultsSensitivity was 97% and 91% for the two operators, respectively, while accuracy was cero for both of them. The synchronism variability analysis was significant (p < 0.01) for the two statistics, showing that the algorithm produced the best result.ConclusionThe proposed algorithm showed good performance as expressed by its high sensitivity. The correlation analysis demonstrated that, from the synchronism point of view, the algorithm performed the best detection. Patients with marked arrhythmic processes are not good candidates for this kind of analysis. At most, they would be singled out by the algorithm and, thereafter, to be checked by an operator.

Where Does Fitness Fit In?

Cardiorespiratory fitness, as measured by a number of relatively simple and inexpensive clinical maneuvers, provides strong and independent prognostic information about the overall risk of illness and death, especially that from cardiovascular causes. This relationship extends to men, women, and adolescents. It is valid in apparently healthy persons; in patients with a broad range of maladies, including several types of cancer and cardiovascular disease; and in at-risk patients with diabetes mellitus, the metabolic syndrome, and hypertension.1–3 However, despite the profoundly important prognostic information provided by simple clinical assessments of fitness, they are rarely used in the clinical setting and . . .

Newborn life support

All health care providers attending deliveries should be able to initiate neonatal resuscitation. Based on physiology and the recently developed Dutch guidelines, the Newborn Life Support Course teaches a system for the initial approach with emphasis on simple airway maneuvers. The aim of the course is to improve knowledge, skills, and management needed to resuscitate babies.

The Subtle Cavus Foot, “the Underpronator,” a Review

Subtle cavus foot deformity is ubiquitous, yet it continues to be commonly missed. Simple physical examination maneuvers can provide information that allows well-planned nonoperative care and selection of operative procedures to correct the underlying cause as well as presenting pathology.

Autonomic modulation and clinical outcome in patients with chronic heart failure

Objective Several studies documented the relevance of autonomic activity in the pathophysiology of heart failure. In our study we evaluated the adjustment of this activity under different stimuli, by means of heart rate variability (HRV), and correlated these findings with long-term mortality and sustained VT occurrence. Patients and method Fifty-three patients (mean age 54±9 years) with heart failure were submitted to time and frequency domain HRV analysis. This latter analysis was performed at rest, during paced breathing and during passive tilt. Results Lower standard deviation of RR intervals (76.76±24 versus 107.70±43, p=0.02), mean of the 5-min standard deviations of RR intervals (35.14±15 versus 62.39, p<0.01), standard deviation of the 5-min average RR intervals (69.42±19 versus 91.79±30, p=0.02), and baseline Low-Frequency (LF) power (15.15±12 versus 40.39±24 nu, p=0.001) characterized patients who died. Paced breathing induced a significant reduction of LF (40.39±24 to 20.12±18 nu, p<0.0001) and increase of High Frequency power (HF) (47.31±23 to 70.63±16 nu, p<0.0001) in survivors, while tilting induced a reduction of HF (47.31±23 to 29.80±16 nu, p<0.0001). Patients who died did not show significant variation of HRV neither during paced breathing nor during tilt. Reduced time domain indexes were significantly correlated to sustained VT occurrence. Conclusions Patients with heart failure with a better prognosis are characterized by a responsiveness of autonomic modulation. Simple maneuvers, such as tilting and paced breathing, seem to provide more useful information, than the baseline evaluation of autonomic status, in identifying patients with a higher mortality. Time domain analysis was more helpful to estimate arrhythmic risk.

Management of common symptoms of advanced lung cancer

Disease-directed treatment of lung cancer reduces the morbidity and extends life for patients. However, as providers we must recognize that treating the symptoms of the disease may be as important as the treatment of the disease itself. This is particularly true in advanced disease and after disease-directed therapies have been exhausted. Aggressive assessment of symptoms and use of palliative therapies can significantly reduce the symptomatology of advanced lung cancer. Though the impact of these symptoms (ie, pain, dyspnea, and cachexia) are well known, they tend to be under-treated. In addition, simple maneuvers such as opiate rotation for pain relief are underutilized. The diagnosis of lung cancer and its associated symptoms may result in severe psychosocial stress for the patient and further exacerbate the symptoms in a vicious cycle. Understanding of coping strategies may aid the medical provider in assisting the patient during his or her illness.

Artefacts in continuous ECG recordings – Provoking and preventing manoeuvres

Objectives. A systematic estimation of the effects of some clinically important artefact provoking and artefact-preventing manoeuvres. Design. A test protocol for the evaluation of technical modifications of continuous ECG recordings was tested in 17 patients. The programme comprised ECG recordings during five artefact-provoking manoeuvres (slight shaking of the ECG cables, rotating shoulders, slight electrode touching, washing, teeth-brushing) and two simple artefact-preventing manoeuvres (taping ECG cables and covering electrodes with paper cups). Results. The artefact-provoking manoeuvres induced a substantial increase in artefactual ECG. The artefact-preventing manoeuvres only incompletely prevented this increase. Conclusion. There is a great need of technical improvements to reduce the distortion of ECG by artefacts. The test protocol developed by us exposes a broad spectrum of different categories of ECG qualities and is therefore suitable for evaluating technical improvements concerning artefactual ECG.

Conventional and sutureless techniques for management of the pulmonary veins: Evolution of indications from postrepair pulmonary vein stenosis to primary pulmonary vein anomalies

We have previously reported a limited but favorable experience with a novel sutureless technique for surgical management of postoperative pulmonary vein stenosis occurring after repair of total anomalous pulmonary venous drainage. Because this technique requires integrity of the retrocardiac space for hemostasis, extension of the technique to the primary repair of pulmonary vein anomalies requires evaluation. This analysis reviews our experience with the sutureless technique in patients with postrepair pulmonary vein stenosis, as well as our extension of the technique into primary repair of pulmonary vein anomalies. Retrospective univariable-multivariable analysis of all pulmonary vein stenosis procedures and sutureless pulmonary vein procedures over a 20-year period was performed. Cox proportional hazards modeling was used to identify variables associated with freedom from reoperation or death. Sixty patients underwent 73 procedures, with pulmonary vein stenosis present in 65 procedures. The sutureless technique was used in 40 procedures. Freedom from reoperation or death at 5 years after the initial procedure was 49%. Unadjusted freedom from reoperation or death was greater with the sutureless technique for patients with postrepair pulmonary vein stenosis ( P = .04). By using multivariable analysis, a higher pulmonary vein stenosis score was associated with greater risk of reoperation or death. After adjustment, the sutureless repair was associated with a nonsignificant trend toward greater freedom from reoperation or death ( P = .12). Despite the absence of retrocardiac adhesions, operative mortality was not increased with the sutureless technique ( P = .64). Techniques to control bleeding (intrapleural hilar reapproximation) and improve exposure (inferior vena cava division) were identified. The sutureless technique for postrepair pulmonary vein stenosis is associated with encouraging midterm results. Extension of the indications for the technique to primary repair appears safe with the development of simple intraoperative maneuvers.

Treatment of Traumatic Brain Injury: One Size Does Not Fit All

Treatment of Traumatic Brain Injury: One Size Does Not Fit All