Sherif F. Nagueh, MD, FACC, FAHA
They also may report sensory disturbances such as numbness in a characteristic of distribution androgen releasing hormone . Those with cervical and periscapular myofascial pain may try to find a comfortable sleeping position prostate cancer va disability compensation . Typically androgen hormone production , subsequent acute manifestations are precipitated by exposure to cold androgen hormone function , or by overstretching/overloading the same region of muscle frequently seen in people with poor posture. Symptoms are suggestive of neurologic disorders including: diffuse pain and tenderness, headache, vertigo, visual disturbances, paresthesias, incoordination, and referred pain and are characterized by the presence of myofascial trigger points. Subjective Findings Dull aching pains in muscles rather than joints Patient complains of a diffuse area of pain/stiffness covering an area adjacent to the main area of complaint May report "knots" or "bumps" in the involved muscles Objective Findings Objective findings may include: Scope of Examination Examine the musculoskeletal system for possible causes, or contributing factors to the complaint. Differential Diagnoses Fibromyalgia Radiculopathy Physical/Occupational Therapy Management Therapy must show measurable functional progress. Treatment Methods Therapy focuses on correction of muscle shortening by targeted stretching and strengthening of affected muscles and correction of aggravating postural and biomechanical factors. Modalities such as electrical muscle stimulation can be useful to decrease pain to allow participation in an active exercise program. Corrections of leg length discrepancies with a heel lift or use of dynamic insoles also may be helpful. Home Medical Equipment Hot packs/cold packs Theraband for therapeutic exercises Gymball for therapeutic exercises Home electrical stimulation unit 237 of 937 Self-Care Techniques Postural advice, instruction in proper body mechanics Instruction in energy conservation techniques Stretching exercises Aerobic conditioning exercises to increase strength and endurance Heat applications, if needed, to relieve discomfort/stiffness Alternatives/Adjuncts to Physical/Occupational Therapy Management Osteopathic manipulation Massage therapy with aggressive deep myofascial therapy Physiatry with aggressive deep myofascial therapy Medication Chiropractic Medicare References 1. Hauten A, Olsen W, Butts S, Nowicki N: Effectiveness of a home program of Ischemic pressure followed by sustained stretch for treatment of Myofascial trigger points, Physical Therapy; 2000. Myofascial Pain and Dysfunction:The Trigger Point Manual: the Lower Extremities 1999. This occurs as an abnormal healing response after a trauma, or chronic irritation to the muscle. Patient History Patient history may include: Patient Data Condition most frequently arises when an existing muscle contusion is treated too vigorously, or when patient is returned to activity before complete muscle healing has occurred. Red Flag Possible Consequence or Cause Severe trauma Fracture, ligament tear Fever, severe pain Infection, Osteomyelitis Popliteal fossa pain, sudden onset Popliteal aneurysm Diabetes Neuropathy Multiple joint involvement Rheumatologic diseases Unilateral edema Deep vein thrombosis Cancer, osteosarcoma Cause of symptoms (metastatic or primary) Discoloration of extremity Arterial occlusion, vascular insufficiency Immune-compromised state Infection Palpable mass Hemangioma, soft tissue tumor, foreign body Presentation Palpable mass in a muscle belly (commonly reported in the quadriceps or biceps brachialis muscles), although definitive diagnosis usually comes via radiography. Neurological signs: altered reflexes and/or sensations 244 of 937 Treatment frequency and duration must be based on: Severity of clinical findings, Presence of complicating factors, Natural history of condition, and Expectation for functional improvement. Treatment Methods Therapy program goals are to: minimize hematoma in acute phase, normalize pain-free range of motion, prevent muscular atrophy, and maintain proprioception and cardiovascular fitness. Expected Outcome Procedures/Modalities Such As Restore flexibility of affected muscles Iontophoresis (with acetic acid), ultrasound to affected muscles to soften the bony mass Gentle pain-free passive range of motion Active range of motion Avoid forceful or sustained stretching Enhance neuromuscular performance Begin with isometric exercises during functional activities Begin light resistance exercises as 246 of 937 range of motion increases Add closed chain exercises Improvement in body mechanics and Body mechanics training postural stabilization Postural stabilization activities Balance and proprioception exercises Endurance exercises Ability to perform physical actions, tasks or Gradual resumption of activities activities related to self-care, home relating to work, community and management, work, community and leisure leisure Gait training Functional Training Teach application of passive, active range of motion and strengthening program Use of protective pad to area when sports resumes Note: Not all of the above modalities are appropriate for each individual case; they require the skill and judgment of persons properly trained and licensed for safe use. Arkansas, Colorado, Delaware, District of Columbia, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, 248 of 937 Oklahoma, Pennsylvania, Texas. Patient History Patient history may include: Patient Data While the cause remains unclear, the most common history is that of recent invasive pelvic procedures. Men may be more likely to develop osteitis pubis, perhaps due to greater involvement in sports. Men tend to be affected most commonly in the age group of 30-50, while women are affected in their thirties. Subjective Findings Complains of pain that radiates to the medial thigh, into the groin or abdomen, clicking or popping in the hip joint, increase in pain when weight-bearing and impaired gait secondary to lower extremity weakness. Arkansas, Colorado, Delaware, District of Columbia, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, 258 of 937 Oklahoma, Pennsylvania, Texas. Definition Osteoporosis is the reduction in the number and size of bony trabeculae resulting in weakened bone, deformity, and, when associated with trauma or other pathology pain. It is more frequent in women, generally beginning after menopause, and often leading to fractures in the spine (occasionally spontaneous), hip and wrist. The vertebral body tends to fracture and compress to a wedge shape resulting in thoracic kyphosis and flattening of the lumbar lordosis. Subjective Findings Pain typically worse with flexion of the spine when osteoporosis involves the vertebrae. Note: Extra spinal diseases that may refer pain to the back include: aortic aneurysm, colon Cancer, endometriosis, hip disease, kidney stones, ovarian disease, pancreatitis, pelvic infections, tumors or cysts of the reproductive tract, uterine cancer. A bone mineral density test measures bone mass and it is considered the most important predictor of fractures caused by osteoporosis. The therapeutic goals of this phase are reduction and 263 of 937 management of symptoms with a goal of maximizing function over time. Conditions Severity Criteria Table Criteria Mild Moderate Severe Condition Condition Condition Mode of Onset Variable Variable Severe Anticipated duration of care 1-6 weeks 6-10 weeks 10 or more weeks Loss of work days No loss of 0-4 days of work 5 or more days of work days lost work lost Work restriction None Possible, Restriction, depends on depending on 264 of 937 occupation; 0-2 occupation; 2 or weeks more weeks Functional deficits: Mild/no loss Mild to moderate Considerable loss 1. Treatment Methods Depending on level of pain, modalities to address pain may be utilized in the initial therapy visits. Expected Outcome Procedures/Modalities Such As Reduce pain and muscle spasm Modalities i. Bennell, K, Matthews, B, Greig, A, Briggs, A, Kelly, A, Sherburn, M, Larsen, J, Wark, J. Cooper, Cyrus and Reeve, Jonathan, editors, State of the Art Reviews, Vertebral Osteoporosis, Handley and Belfus, Inc. Hongo M, Itoi E, Sinaki M, Miyakoshi N, Shimada Y, Maekawa S, Okada K, Mizutani, Y. Patient History Patient history may include: Patient Data General demographics Medical/dental history History of current condition Functional status as it relates to eating and speech (prior level of function) Medications Other tests and measurements (laboratory and diagnostic tests) Past history (including history of prior therapy and response to prior treatment) Prior level of function Specific Considerations Rule out red flags (require medical management). Subjective Findings Patient presents with a complaint of Pain, Clicking or locking of the joint, and Swelling. History of Grinding their teeth, Extensive dental procedures, Trauma, and Lifestyle stresses. Frequently they also complain of Difficulty chewing, Neck pain, and Feeling of fullness in the ear. Objective Findings Objective findings may include: Scope of Examination Examine the musculoskeletal system for possible causes, or contributing factors to the complaint. Muscle Strength Mild/no loss Mild to moderate Considerable loss 275 of 937 loss 3. Treatment Methods Provide symptomatic relief, and restore normal joint function. Referral Guidelines Refer patient to their primary care provider for evaluation of alternative treatment options if: Further deterioration such as increasing pain, further limitation of movement and increased joint sounds Dental and otic infections occur Paratrigeminal syndrome occur Management/Intervention Use of modalities and/or passive treatments should be limited. It is a combination of direct care and with an emphasis on home management consisting of patient motivation and compliance. Intensity of care is guided by the condition of healing tissue structures, and generally includes less frequent therapeutic visits gradually tapering over a short period of time. Friction massage, ultrasound, Transcutaneous electrical nerve stimulation, biofeedback Relaxation exercises Restore flexibility of the affected Active/ passive stretching exercises musculature and restore normal Soft tissue mobilization joint mechanics Joint mobilization techniques Improve posture awareness and Correct body mechanics balance of the upper quadrant Postural control Correct body positioning of cervical spine and masticatory muscles Improve swallow sequence Instruction on normal resting position of tongue and proper swallowing Maintenance of correct head on neck posture Patient education and self Avoid large bites, clenching teeth, keep jaw management relaxed. Zajko J, Satko I, Hirjak D: [Treatment of dysfunction of the temporomandibular joint by an occlusion splint]. Procedure usually involves an intra-articular autograft of the middle third of patellar tendon, or tendons of semitendinosus/gracilis. The frequency of this type of injury is approximately 1 in 3000 per year in the U. Red Flag Possible Consequence or Cause Severe trauma, post operatively Fracture Fever, severe pain Infection Popliteal fossa pain, sudden onset Popliteal aneurysm Diabetes Neuropathy Multiple joint involvement Rheumatologic diseases, gout Unilateral edema Deep vein thrombosis Cancer Cause of symptoms (metastatic or primary) Discoloration of foot, or leg, exertional Arterial occlusion; vascular insufficiency; leg, or foot pain compartment syndrome Immune-compromised state Infection 282 of 937 Presentation Patient usually has had trauma to the knee involving a twisting motion, and may also be a non-contact injury, as in cutting, sidestepping, or landing from a jump. The therapeutic goal 284 of 937 of this phase is to improve functional status by increasing existing range of motion and muscle strength and reducing signs and symptoms associated with the condition or injury. Severe conditions mostly result 285 of 937 from accidents or injuries, symptoms are intense, may result in loss of work, and will have a pronounced decrease in the ability to perform activities of daily living. Historically, protocols placed conservative restrictions on patients, which when ignored by the non-compliant group, actually improved patient outcomes over the compliant group. This led to the development of more aggressive protocols or accelerated protocols. Clinician must balance the need to protect reconstructed ligament with activities needed to reach goals of functional restoration. Unless the scoliosis is purely functional (secondary to bad posture) man health malaysia , the condition cannot be corrected by massage therapy alone prostate cancer metastasis to bone . Getting Started Positioning for client comfort is extremely important prostate nodule , so be sure to have plenty of pillows ready prostate cancer cure rate . Remember to call your client the day after the frst few sessions to make sure your work has not caused reactive spasms. Carry a backpack (making sure to keep your back upright) rather than a heavy purse on one shoulder. Include use of your two work multiple regions fat hands pushing in opposite directions, deep compres randomly. Start superfcially, advance to me and release the rib dium depth, and then work as deeply as the client will allow. Flow easily tumor, and the client up into the base of the skull at the occipital ridge, move should be referred down to the top of the shoulders, glide deeply into the to a physician before thoracolumbar fascia, and work into the cervical and massage therapy thoracic laminar grooves. Try to grip and move them as you per form detailed cross-fber work along the bottom of the ribs and the superior crest of the pelvis. If you are trained in trigger point work, you will have ample opportunities to use your skills, because there will be multiple regions of long-standing hypertonicity that have created knots. Be careful not to be overly aggressive or focused, because trigger point work, performed without control and for too long, will cause post-session pain. The gluteal complex has worked hard to help hold the lower back muscles in response to the abnormal spinal curve. The tensor fasciae latae will be hypertonic secondary to the gluteal hypertonicity. Use the heel of your hand or your forearm to compress, strip, and move this tough, dense tissue. Your client will have adjusted to her scoliosis by adapting ineffcient breathing patterns. She may lie supine on the table, while spreading her arms out to either side and then bringing them over and above her head as she deeply inhales and exhales. She can also stand at the side of the table, lean over the table, and, using the table as a resisted breathing device, take several deep breaths. If the client is constipated secondary to an ineffciently functioning diaphragm and inactivity, offer to perform colon massage. Impact of massage therapy in the treatment of linked pathologies: scoliosis, costover tebral dysfunction, and thoracic outlet syndrome. Clinical Massage Therapy: Understanding, Assessing and Treating over 70 Conditions, Toronto: Talus Incorporated, 2000. Although rarely life threatening by itself, the secondary effects of a sprain or strain on soft tissue or bone, combined with compensatory movements, can signifcantly hinder complete, or cor rectly aligned, joint healing. In addition, slings, removable casts, or crutches can create hypertonicity or hypotonicity. With or without aids, the sprain or strain itself cre ates immediate protective voluntary splinting and/or spasm. If the person returns to activity too quickly, a secondary overuse injury can compromise complete healing. Adhesions naturally and quickly form in and around an injured joint; they can prolong healing and cause a limited, painful limb. Both adhesions and scar tissue slow healing and can lead to chronic, long-term pain. Sprains and strains usually heal completely within days, weeks, or months, de pending on severity. Although localized tenderness, regional stiffness, radiating pain, and/or weather-dependent aching may persist over the long term, the injured area generally returns to full functioning and strength. Joint and muscle movement is possible because the (soft, mobile) muscles ter minate in tendon, and then attach to a (hard, stationary) bone, giving the sanguinous (blood-flled) muscle something to hold onto and work against. An excellent example of a readily palpable muscle-tendon complex is the distal end of the gastrocnemius, which terminates in the Achilles tendon, which then attaches to the calcaneus (heel bone). Palpable examples of ligaments are those 281 282 Step-by-Step Massage Therapy Protocols for Common Conditions found on either side of the malleoli and knees. Visible or invisible swelling and Massage bruising immediately follow interstitially and/or subcutaneously; these signs may Therapist not be noticeable for minutes or hours. X-rays will not indicate soft tissue damage, however, and swelling can of the following symptoms adversely affect the accuracy of an X-ray reading; therefore, diagnostic X-rays are occurs, immediate medical often taken a few days post-injury. The most ef fective treatment a massage therapist can offer an immediate traumatic injury that involves swelling is lymphatic drainage techniques. All the following information regarding sprains and strains assumes the massage therapist is attending to subacute pain, swelling, and stiffness and/or chronic pain, stiffness, and scarring secondary to an initial (now past) sprain or strain injury. Rest means the affected joint is used little or not at all, and weight bearing is limited. A compression bandage is wrapped around the affected joint, but not so tightly as to compromise circulation. Although the use of a healing joint is imperative for proper healing to occur, premature overuse may Chapter 37 Sprain and Strain 283 lead to reinjury. Internal injured structures need time to heal, even in the absence of obvious symptoms. Imaging studies are necessary if symptoms persist or worsen, or if surrounding It Through structures will not heal. Surgery is rare and indicated only for signifcant tendon or ligament tears, or if surrounding bony structures must be rebuilt or stabilized. This exercise that new or recent, still swollen joints will not be addressed with massage therapy; will help clarify the treatment the therapist can consider the following assessment points before treatment. Condi unable to bear weight, tions might include osteoporosis, frailty, arthritis, previous injury to the same which proximal joint will or nearby joint, or compensating from an earlier injury. How ever, if the injury remains untreated or unmoved, debilitating scar tissue and adhe sions will lead to long-term chronic pain. Your job in treating sprains or strains is to use your palpation, listening, and diplomacy skills to discern whether your client has suffciently healed to allow you to work. . Fat-Blasting Battle Rope 10-Min Workout | BURNER | Men's Health.
This medial hamstring also contributes to the the hip joint angle has a large effect on increasing the production of internal rotation in the joint mens health hair loss . It is the opposite for medial hamstring mens health nutrition manual , the semitendinosus prostate 180 at walmart , is part of the pes the rectus femoris androgen hormone 3 ep , which is more influenced by a change anserinus muscular attachment on the medial surface of in the knee angle (163). It is the most effective flexor of the pes anseri knee also changes with a change in hip positioning. If the hamstrings become tight, they offer greater resistance to extension of the knee the extensors at the knee joint are usually stronger than joint by the quadriceps femoris. The position of maximum strength varies with and the gracilis, also contribute 19% and 34% to the flex the speed of movement. The quadriceps femoris group may also be exercised A generally acceptable ratio is 0. Caution Near full extension, the quadriceps femoris muscles must be observed when using this ratio because it applies become inefficient and must exert greater force to move only to slow, isokinetic testing speeds. Even at the isometric testing level, the hamstring the terminal extension exercise is good for individuals to-quadriceps ratio is 0. Also, the terminal extension exercise does not At low hip flexion angles and in the neutral position, the selectively exercise the medial quadriceps more than the sartorius is the most effective lateral rotator. The inter the flexors of the knee are not actively recruited in the nal rotation torque is greater than the external rotation performance of a flexion action with gravity because the torque (125). Fortunately, the hamstrings are extensors of the hip as well as flexors of the knee joint. The squat Examples of stretching and strengthening exercises for the generates twice as much activity in the hamstrings as a leg extensors are presented in Figure 6-27. When one lowers role as extensors at the hip, the hamstrings group would into a squat, the force coming through the joint, directed be considerably weaker than the quadriceps femoris. Thus, in a deep squat position places the hip in flexion, thus optimizing their position, most of the original compressive force is directed performance. With the ligaments and and the pes anserinus muscles, are important for knee muscles unable to offer much protection in the posterior stability because they control much of the rotation at direction at the full squat position, this is considered a vul the knee. This position of maximum knee flexion strings should be half as strong as the quadriceps femoris is contraindicated for beginner and unconditioned lifters. It is also impor musculature and uses good technique at the bottom of tant to maintain flexibility in the hamstrings because if the lift will most likely avoid any injury when in this posi they are tight, the quadriceps femoris muscles must work tion. Good technique involves control over the speed of harder and the pelvis will develop an irregular posture descent and proper segmental positioning. It is clear that if 1, 500 If the rotators are to be selectively stretched or strength foot contacts are made per mile of running, the potential ened as they perform the rotation, it is best to do the for injury is high. Toeing in the foot contracts the internal rotators force causing a twisting action of the knee. Different levels of or uneven surfaces are usually associated with increased resistance can be added to this exercise through the use of ligamentous injury. The reason behind this is that closed-chain which are usually caused by a twisting action while the exercises have been shown to produce significantly less knee is flexed, internally rotated, and in a valgus position posterior shear force at all angles and less anterior shear while supporting weight. Examples from sport in which this ligament is been shown to be similar in both open and closed-chain often injured are skiers catching the edge of the ski; a exercises (16), supporting the inclusion of both types of football player being blocked from the side; a basketball exercise in the rehabilitation protocol. In a closed-chain usually anterior, rotatory instabilities can occur in a variety squat, it is opposite, with the patellofemoral force zero at of directions, depending on the other structures injured full extension and increasing with increases in knee flexion (22). Activities the tibia up against the dashboard in a car crash or falling associated with most of the injuries were soccer and skiing. Injuries in the knee have been the collateral ligaments on the side are injured upon attributable to hindfoot and forefoot varus or valgus, tibial receipt of a force applied to the side of the joint. The menisci can be torn through leg, tight hamstrings, tight gastrocnemius, a long patel compression associated with a twisting action in a weight lar tendon (termed patella alta), a short patellar tendon bearing position. They can also be torn in kicking and (termed patella baja), a tight lateral retinaculum or ilio other violent extension actions. Weak hip compression is a result of the femur grinding into the tibia abductor muscles can allow excessive motion of the pelvis and ripping the menisci. A meniscal tear in rapid extension in the frontal plane and cause a characteristic gait called is a result of the meniscus getting caught and torn as the Trendelenburg gait (. Lateral meniscus tears have been associated with a forced axial movement in the flexed posi tion; a forced lateral movement with impact on the knee in extension; a forceful rotational movement; a movement incorporating varus, flexion, and internal rotation of the support limb; and the hyperflexed position (147). Muscle strains to the quadriceps Hip femoris or the hamstrings muscle groups occur frequently. A hamstring strain is usually associated with inflexibility in the hamstrings or a stronger quadriceps fem oris that pulls the hamstrings into a lengthened position. Sprinting when the runner is not in condition to handle Dynamic the stresses of sprinting can lead to a hamstring strain. Iliotibial band syndrome is seen in individuals who run on cambered roads, specifically affecting the downhill limb. It has also been identified in individuals who run more than 5 miles per session, in stair climbing and downhill Ankle running, and in individuals who have a varum alignment eversion in the lower extremity (57). Medial knee pain can be asso ciated with many structures, such as tendinitis of the pes anserinus muscle attachment and irritation of the semi membranosus, parapatellar, or pes bursae (57). Posterior pain can also be nal rotation gives a characteristic gait pattern that can result in poor associated with strain or tendinitis of the gastrocnemius patellar tracking and excessive pronation. The proximal joint of the foot is the talocrural joint, or the dislocation occurs in flexion as a result of a faulty knee ankle joint (. This joint is designed for stability tibia at the tibial tuberosity is another site for injury and rather than mobility. The tensile force of the are absorbed through the limb, when stopping and turn quadriceps femoris can create tendinitis at this insertion ing, and in many of the lower limb movements performed site. If any of the anatomical support structures jumping, such as in volleyball, basketball, and track and around the ankle joint are injured, however, the joint can field (105). The medial side of the of the growing tibial tuberosity that can also avulse the mortise is the inner side of the medial malleolus, a projec epiphysis. On the lateral side is cause of both of these conditions is overuse of the exten the inner surface of the lateral malleolus, a distal projec sor mechanism (105). The lateral malleolus projects more Overuse of the extensor mechanism can also cause irri distally than the medial malleolus and protects the lateral tation of the plica. It also acts as a bulwark against any blow, a valgus rotary force applied to the knee, or weak lateral displacement. The plica becomes more distally, it is also more susceptible to fracture with thick, inelastic, and fibrous with injury, making it difficult an inversion sprain to the lateral ankle. The medial patella may snap and catch during flexion and extension with injury to the plica. Phalanges the Ankle and Foot the foot and ankle make up a complex anatomical struc Forefoot ture consisting of 26 irregularly shaped bones, 30 synovial joints, more than 100 ligaments, and 30 muscles acting Metatarsals on the segments. All of these joints must interact harmo niously and in combination to achieve a smooth motion. Most of the motion in the foot occurs at three of the syno vial joints: the talocrural, the subtalar, and the midtarsal joints (102).
It is subdivided into two lobes by a single fissure and contains eight bronchial segments prostate cancer markers . The right lung lacks a notch prostate gland , is subdivided into three lobes by two fissures mens health 747 workout , and contains 10 bronchial segments prostate nomogram . The inferior base of the lung has a diaphragmatic surface in contact with the diaphragm. The top of the lung is the apex, and the broad, rounded surface in contact with membranes covering the ribs is the costal surface. Objective J To describe the pleurae and to explain their respiratory significance. They are composed of sim Survey ple squamous epithelium and fibrous connective tissue. The inner layer, or visceral pleura, is attached to the surface of the lungs; the outer layer, or parietal pleura (fig. Pleurae serve to lubricate the lungs, and they assist in creating respiratory pressure. Air pressure in each pleural cavity (the intrathoracic pressure) is slightly below atmospheric pressure (2. Pleurisy, or inflammation of the pleurae, may be secondary to some other respiratory disease or due to an autoimmune reaction associated with viral infections or autoimmune diseases. Anti-inflammatories, such as aspirin, ibuprofen, and corticosteroids, are used in treating pleurisy. Under normal conditions the visceral and parietal pleurae are pressed tightly against one another due to the relative negative pressure in the space. Air in the pleural space (from a hole in the chest wall or a hole in the visceral pleura) disturbs this vital homeostasis so that the lung collapses despite active expansion of the chest wall. Air enters the lungs when intrapulmonic pressure falls below atmospheric pressure (760 mmHg at sea level). Expiration follows passively as thoracic volume decreases and intrapulmonic pressure rises above atmospheric, with recoil of the rib cage and contraction of the lungs. Contraction of the dome-shaped diaphragm downward increases the thoracic vertical dimension. During deep inspiration or forced breathing, the scalenes and sterno cleidomastoid muscles (see fig. During forced expiration, the internal intercostal muscles are contracted, depressing the rib cage. These are the Survey tidal volume, the volume of air moved into and out of the lungs during normal breathing; inspiratory reserve, the maximum volume beyond the tidal volume that can be inspired in one deep breath; expiratory reserve, the maximum volume beyond the tidal volume that can be forcefully exhaled following a normal expiration; and residual volume, the air that remains in the lungs following a forceful expiration. Clinically speaking, it is important to know the amount of air that is breathed in at a given time and to be aware of difficulty in breathing. The amount of air exchanged during pulmonary ventilation varies from person to person according to age, sex, activity, and general health. Minute respiratory volume is the volume of air moved in normal ventilation in 1 minute. Of the oxygen transported in the blood, only a small amount is dissolved in the blood plasma. Survey Up to 99% is carried on hemoglobin molecules in the erythrocytes (see problem 14. Carbon dioxide carried in the blood is mostly converted to bicarbonate ions in the erythrocytes and released into the blood plasma; unconverted carbon dioxide is also carried dissolved in the blood plasma and on hemoglobin molecules and certain plasma proteins. Hemoglobin is converted from bluish red deoxyhemoglobin (Hb) to scarlet oxyhemoglobin (HbO2) according to the reaction Hb O2 HbO2 18. In a mixture of gases, each component gas exerts a partial pressure that is proportional to its concentra tion in the mixture. For example, because air is 21% O2, this gas is responsible for 21% of the atmos pheric pressure. Because 21% of 760 mmHg is equal to 160 mmHg, the partial pressure of O2, symbolized by pO2, in atmospheric air is 160 mmHg. The difference between the pO2 in the alveolus and in the pulmonary capillary (pO2 40) is about 60 mmHg and therefore favors diffusion of oxygen from the alveolus into the blood. A similar calculation of the difference between the pO2 in the pulmonary capillary (pO2 45) and in the alveolus demonstrates a gradient of 5 mmHg, favoring diffusion of carbon dioxide from the blood to the alveolar air (fig. An increased body temperature Capillary blood flow (perfusion) through the alveoli is carefully regulated at the tis sue level. This shunts pulmonary blood away from poorly ventilated alveoli and toward well-ventilated ones. As these ions leave erythrocytes, they cause an excess of negative charge, which is relieved by the diffusion of chloride ions (Cl) from the blood into the cells. Lung disease or decreased mental status resulting in hypoventilation may cause respiratory acidosis. The locations of the respiratory centers in the central nervous system are shown in fig. The rhythmicity area of the medulla oblongata is actually composed of sep arate expiratory and inspiratory centers. The medulla oblongata also contains chemorecep tors concerned with respiration (fig. The rhythmicity area of the medulla oblongata consists of two intermingled groups of neurons. When the inspiratory group is excited (via the apneustic center), the respiratory muscles are signaled to accomplish inbreathing; at the same time, the expiratory group is inhibited. After about 2 seconds, the reciprocal process occurs: the pneumotaxic center stimulates the expiratory group to signal for exhaling, with simul taneous inhibition of the inspiratory group. Almost immediately, an increase in pH caused by a loss of acid (through vomiting stomach secretions. Anoxia of the brain results in cell destruction within 30 seconds and in death generally within 5 to 10 minutes. It may be aggravated by inhaled allergens, viral or bacterial upper respiratory infections, cold air, or exercise. The attacks are provoked by constriction of the airways and inflammation of the bronchial mucosa. Viral and bacterial infections, air pollution, and allergies may be causative or contributing factors. Bronchitis, chronic Excessive mucus production in the bronchial tubes that leads to productive cough, shortness of breath, and lung damage. Cleft lip A genetic developmental disorder in which the two sides of the upper lip fail to fuse; also referred to as harelip. Cleft palate A developmental deformity of the hard palate, resulting in a persistent opening between the oral and nasal cavities. Emphysema A breakdown of the alveolar walls that decreases the alveolar surface area and increases the size of air spaces distal to the terminal bronchioles. It is a frequent cause of death among heavy cigarette smok ers and may also result from severe air pollution. Hiccup A spasmodic contraction of the diaphragm causing a rapid, involuntary inhalation that is stopped by the sudden closure of the glottis and accompanied by a distinctive sound; also spelled hiccough. Pneumonia Acute infection and inflammation of the lungs, with exudation of fluids into, and consolidation (collapse) of, lung tissue. Tuberculosis An inflammatory disease of the lungs, caused by the tubercle bacillus, in which the tissue caseates (becomes cheesy) and ulcerates. Ask the child to choose face that best describes their own pain and record the appropriate number prostate oncology specialists nj . Vigorous Cry Loud scream; rising mens health of the carolinas , shrill man health urban athlon on , continuous (note: silent cry may be scored if baby is intubated prostate cancer lupron , as evidenced by obvious mouth and facial movements). Change in Breathing Indrawing, irregular, faster than usual; gagging; breath holding. For mild to moderate pain therapy, use nonpharmacological meth In the clinical practice of the All India Institute of Medi ods, and a formula of 30% sucrose with a pacier. It is absorbed family members proper information about the mecha rapidly (within less than 30 minutes), and the concen nisms and appropriate treatment of pain, to help them tration prole supports an eective clinical duration in better cope with the situation and encourage better the region of 7 hours. For neonates and nasal opioids might become an interesting alternative infants up to 3 months old, oral glucose/sucrose. Opioids are the rst line of systemic therapy in moder Non-parenteral route ate to severe pain, with morphine being the most fre The most commonly used nonopioid analgesic in chil quently used. For the use of morphine and fentanyl in the pe maximum daily dose should not be given longer than 48 diatric patient, and especially in neonates and infants, hours in infants under 3 months, and not longer than no strong correlation between dose/serum plasma levels 72 hours in children over 3 months old. If a suppository and analgesic eects has been shown, due to the high is used, it should not be cut, because drug distribution variability in individual opioid metabolism. Multiple suppositories can be used reason it is advisable not to rely on specic dose recom to obtain the desired dose. Often, rectally applied Total body morphine clearance is 80% of adult val paracetamol does not provide therapeutic drug serum ue at 6 months of age. If paracetamol is used, the oral route should be infants than adults, primarily because of higher hepatic the rst choice. Ketorolac rectal suppositories have been found to has a prolonged elimination half-life compared to mor be useful in children with a narrow therapeutic margin phine. In children older than 1 year, clearance is similar 264 Dilip Pawar and Lars Garten to adults, but in neonates it is almost twice as long as No evidence for the eectiveness and safety of these in adults. Alfentanil is eective at a dose of 50 g/ deliver a top-up dose whenever the patient feels the kg followed by an infusion of 1 g/kg/min. The pump can be programmed to prevent delivery of What are some ways to reduce opioid toxic doses by using a lockout interval and a maximum side eects It has been found to be eective in popliteal and fascia ili What is the maximum dose of morphine aca blocks as well as in epidural blocks. If an addition es should be longer than 30 minutes because the time al reduction in pain without dangerous medication side needed for the bolus dose to be eective is longer. If tolerance develops after some time, the dose will What is the therapeutic value of regional blocks need to be increased to maintain the same degree of in children In recent years, there has been a resurgence in the pop What are parenteral nonopioid analgesics ularity of regional blocks in children because of their to consider Ketorolac has suf cal anesthetics, such as lidocaine (lignocaine) and bupi cient analgesic potency for most day care cases and vacaine, are available even in the least auent countries. Table 3 Common regional blocks practiced in children Caudal epidural Hernia repair, orchidopexy, urethro plasty, circumcision Lumbar epidural All upper and lower abdominal surgery, thoracotomy Ilioinguinal/iliohypogastric Hernia repair Dorsal nerve of penis Circumcision, advancement of prepuce Axillary Surgery of hand and forearm Femoral/iliac Tigh and femur surgery Pain Management in Children 265 Note: wound inltration can be as good for a hernia, anatomical dierences, and much easier than in adults. Subcutaneous tunneling of the cau dal catheter reduces the rate of bacterial contamination. Is there a maximum dose of local anesthetics that is safe when the drug is used for local anesthesia No more than 4 mg/kg of lidocaine without epi It is important to have a plan for pain relief from the nephrine, or 7 mg/kg with epinephrine, should be beginning of the perioperative period until such time used when inltrating for local anesthesia. Factors should not exceed 2 mg/kg or 8 mg/day; it is commonly that need to be considered for eective planning are used in concentrations of 0. Maximum doses are generally an issue when The chronologic and neurodevelopmental age of the suturing large wounds or when using higher concentra patient should be considered. The degree of pain is often associated with the type of 3) Morphine, when administered through the cau surgery. The type of surgery often is the deciding fac dal route, is eective even for upper abdominal and tho tor in choosing a particular pain relief measure. For racic surgery, and can be eective and safe at a dose of surgeries in areas that are moved regularly, such as the 10 mg/kg through the epidural route. It is her respon needed for the caudal block would be close to toxic sibility to monitor and coordinate with the surgical levels. Her education in pain man vide continuous analgesia for a long period of time (if agement is important. The cath not available or a high-dependency area is not avail eter can be placed at the lumbar, caudal, or thoracic able, more aggressive methods of pain relief may not level. In children, often the caudal child, and it is important to discuss the plan with the route is preferred because it is safest technically due to parents to elicit their support. In such situations, the strategy should be to devise simple tech Plan 2 niques, which do not require precision equipment and A newborn baby with an anorectal anomaly is scheduled intensive monitoring in the postoperative period. Paracetamol and ketamine have been ex is administered general anesthesia, ketamine (0. Local premature babies, opioids should be avoided due to im anesthetics can be applied by wound inltration, mature respiratory function. Although ketamine is used prior to incision, before closure, or continuously in many places, there is no good evidence for the eec in the postoperative period. In the postopera after peripheral nerve blocks should encour tive period, the baby can be given oral paracetamol. In single-injection regional nerve blocks, postopera Plan 3 tive analgesia is limited to 12 hours or less. Con A 5-year-old boy is admitted to the emergency ward tinuous peripheral nerve blocks provide an eec with acute burns and severe pain. If all patients received a re nation of these drugs, along with low-dose midazolam gional block intraoperatively, that would obviate to avoid post-traumatic stress, but not for analgesia. The dura Once acute pain subsides, oral medication may be initi tion of analgesia provided by a caudal block can ated with paracetamol 20 mg/kg. The child sia might prove to be simple, safe, and economi and his parents should be prepared with an explanation cal. Additional information: |
