Spinal CORD Syndrome

Spinal CORD Syndrome

The spinal cord ends at the intervertebral disc between the first and second lumbar vertebrae as a tapered structure called the conus medullaris, consisting of sacral spinal cord segments. The upper border of the conus medullaris is often not well defined. The fibrous extension of the cord, the filum terminale, is a nonneural element that extends down to the coccyx.

The cauda equina (CE) is a bundle of intradural nerve roots at the end of the spinal cord, in the subarachnoid space distal to the conus medullaris. Cauda is Latin for tail, and equina is Latin for horse (ie, the "horse's tail"). The CE provides sensory innervation to the saddle area, motor innervation to the sphincters, and parasympathetic innervation to the bladder and lower bowel (ie, from the left splenic flexure to the rectum).

AF Amiodarone Or Digoxin

AF Amiodarone Or Digoxin

Atrial Fibrillation (AF) is by far the most commonly encountered in the Emergency Department and is associated with the potential for serious consequences including stroke, deterioration of underlying cardiac disease, prolonged hospital stay, and increased mortality. 

AF is an irregular, disorganized, electrical activity of the atria characterized by absent P waves and an irregular baseline on ECG.

ADRENAL Crisis

ADRENAL Crisis

Adrenal crisis and severe acute adrenocortical insufficiency are often elusive diagnoses that may result in severe morbidity and mortality when undiagnosed or ineffectively treated.

Although it is thought by experts that more than 50 steroids are produced within the adrenal cortex, cortisol and aldosterone are by far the most abundant and physiologically active. Regulation of the adrenal cortex is illustrated in the image below.

ADDISON Hyperpigmentation

ADDISON Hyperpigmentation

Addison disease is an autoimmune disorder in which the body attacks the adrenal glands, effectively shutting them down. Patients end up with a whole host of problems, including hypotension (from the lack of mineralocorticoids) and hypoglycemia (from the lack of cortisol). 

As the disease progresses, the adrenals put out less and less cortisol. The pituitary sees that drop in cortisol levels and responds by making more ACTH. ACTH is derived from a bigger precursor molecule called pro-opiomelanocortin (POMC). POMC is also a precursor for beta endorphin and melanocyte stimulating hormone (MSH) , so if you make more POMC (in order to make more ACTH), you’ll make more beta endorphin and MSH.

The beta endorphin doesn’t do much, as far as I know, but the MSH stimulates melanocytes, giving the skin a bronze color. Sometimes it’s an all-over bronze, like a tan (as in the photo above), and sometimes it’s more localized (in the gums, or in areas subjected to increased pressure, like over the knuckles or in skin folds).

However the bronze color manifests, it’s a telltale sign that the patient’s adrenal failure is primary (localized to the adrenal) and not secondary (due to hypopituitarism). In adrenal failure due to hypopituitarism, the whole problem is that the patient isn’t making ACTH (and thus the adrenals aren’t putting out their products) – so there’s no increase in MSH production and no hyperpigmentation.

START Triage

START Triage : Sorting of Patients

1. You can’t commit to “one-on-one” care 
2. You have to be fast – 30 sec or less per patient 
3. Very limited treatment is provided 

• Manually open airways 
• Clear airway with finger sweep 
• Control major bleeding Primary and Secondary Triage

Count Irregular Rhythm HEART Rate

Count Irregular Rhythm HEART Rate

How to count heart rate of irregular heart rhythm?

Count the number of R waves in a 6 second strip and multiply by 10.

For example, if there are 7 R waves in a 6 second strip, the heart rate is 70 (7x10=70).

Atropine Resistant BRADYCARDIA

Atropine Resistant BRADYCARDIA

Symptomatic sinus bradycardia is routinely treated in the emergency department with atropine and pacing. The current cases illustrate the importance of considering hyperkalamia, particularly in the presence of atropine-resistant symptomatic bradycardia. 

The administration of calcium in such cases acts to stabilise the myocardium and resolve the bradycardia. Blood gas analysis provides a rapid estimate of serum potassium concentrations, facilitating timely treatment. 

Pneumothorax

Pneumothorax

Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the potential space between the visceral and parietal pleura of the lung), which can impair oxygenation and/or ventilation.

It is useful to divide pneumothoraces into three categories :

• primary spontaneous: no underlying lung disease 
• secondary spontaneous: underlying lung disease is present 
• iatrogenic/traumatic 

Clinical RISK Management

Clinical Risk Management

Definition :

- focus strategy
- aim:
1. Individual
2. Process
3. System

- to deliver safe error free patient care

Damage Control Resuscitation DCR

Damage Control Resuscitation DCR

Damage control resuscitation consist of 3 main component :

I.  Hemostatic resuscitation

II. Permeasive hypotension

III. Damage control surgery

SMOKE Inhalation Injury

SMOKE Inhalation Injury

Smoke inhalation injury is generally defined as the inhalation of thermal or chemical irritants , can be divided into : 

1. Types of injury : 

•            Thermal injury 
•            Chemical irritation 
•            Systemic toxicity

2. The location of the injury : 

• The upper airway 
• The tracheobronchial system or lower airway 
• The lung parenchyma 
• Systemic toxicity 

Personal Protective Equipment PPE

Personal Protective Equipment PPE

Personal protective equipment, or PPE, is designed to provide protection from serious injuries or illnesses resulting from contact with chemical, radiological, physical, electrical, mechanical, or other hazards. Careful selection and use of adequate PPE should protect individuals involved in chemical emergencies from hazards effecting the respiratory system, skin, eyes, face, hands, feet, head, body, and hearing.

No single combination of protective equipment and clothing is capable of protecting against all hazards. Thus PPE should be used in conjunction with other protective methods, including exposure control procedures and equipment.

Malaysian LAW Child Act 2001

Malaysian Child Act 2001

Malaysia enacted the Child Act 2001 [Act 611] to fulfill its obligation under the Convention on the Rights of the Child (CRC). Act 611 repealed the Juvenile Courts Act 1947 [Act 90], the Women and Girls Protection Act 1973 [Act 106] and the Child Protection Act 1991 [Act 468].

Act 611’s preamble provides that every child is entitled to protection and assistance in all circumstances without regard to distinction of any kind, such as race, colour, sex, language, religion, social origin or physical, mental or emotional disabilities or any status. The provisions of Act 611 are based on the four core principles of the CRC that is, non-discrimination, best interest of the child, the right to life, survival and development and respect for the views of the child.

BRAINSTEM Stroke Syndromes

BRAINSTEM Stroke Syndromes

Brainstem stroke syndromes refer to a group of syndromes that occur secondary to occlusion of small perforating arteries of the posterior circulation. The resulted infarction has characteristic clinical picture according to the involved area however, generally there is ipsilateral cranial nerve palsy and contralateral hemiplegia/hemiparesis and sensory loss.

INDUCTION Agents RSI

INDUCTION Agents RSI

Different clinical scenarios lend themselves to the use of certain induction agents when rapid sequence intubation (RSI) is needed.

Head injury or stroke — In the patient with potentially elevated intracranial pressure (ICP) from head injury or stroke or other conditions, adequate cerebral perfusion pressure must be maintained to prevent secondary brain injury. This means avoiding elevations in ICP and maintaining adequate mean arterial pressure. For these reasons, we suggest etomidate or ketamine be used for induction of these patients. 

The HEART Score

The HEART Score

Chest pain is a common presentation complaint to the emergency department (ED) and has a wide range of etiologies including urgent diagnoses (i.e. acute coronary syndrome (ACS), pulmonary embolism, aortic dissection) and non-urgent diagnoses (i.e. musculoskeletal pain, gastroesophageal reflux disease (GERD), pericarditis).

Some HINTS On Vertigo

Some HINTS on vertigo

Cerebellar infarction represents approximately 2.3 % of acute strokes overall.29 These can result from occlusion of the superior cerebellar artery (SCA), anterior inferior cerebellar artery (AICA), or the posterior inferior cerebellar artery (PICA). Larger cerebellar infarcts produce symptoms and signs localizing to the brainstem, such as diplopia, dysarthria, limb ataxia, dysphagia, and weakness or numbness. 

Approximately 10% of patients with cerebellar infarction can present with isolated vertigo, that is, vertigo with no localizing findings on motor, sensory, reflex, cranial nerve, or limb coordination examination. Most of these are infarcts of the medial branch of the PICA (96%).