Gas Man
Operating Theatres !!!!!
Joined August 2010
- Tweets4.5K
- Following576
- Followers126
- Likes10.5K
H retweeted
Executing a child and then murdering the father who ran to hold his body is not defense.
This is livestreamed genocide
ACP treating DKA. pH of 6.8. Absolutely no idea how dry the pt is. Her tongue, looked like a dry rock, 41 breaths/min to compensate for acedemia but ACP insisting on following DKA protocol and not using wit to give "extra fluid". ED consultant "supervising" him
Modern day NHS ED.
H retweeted
1. Optimise patient position
Ear-to-sternal notch horizontal alignment with neck flexion never lets you down. Also called 'flextension' this is identical to the optimal direct laryngoscopy position
H retweeted
Reducing waste #OBAnes
Does this plastic filter have any value??
Please send evidence or guidelines advocating or dismissing its use!
Do they reduce risk or increase (disconnect)?
#WCA2024 #WCASingapore – at Central Region, Singapore
H retweeted
the prophet sallallaahu alayhi wasallam was not a perfectionist. he would always choose the easier option as long as it wasn't a sin. he was chill, never stressed or acted with urgency. He was emotionally stable and grounded. A lighthouse. An ecosystem.
he did not like making people unsettled, overwhelmed, frightened. He was never demanding of people, never fussy. he was fully attuned to the people that would come to him. He mirrored people, made them feel seen. he'd listen with his whole body, made them feel like the center of the universe.he'd remember small details about people, even about little kids, and bring it up at a later time, asking them about it or playfully inquiring the kids about it.
he wouldn't shout, he was never defensive over personal attacks. never vengeful. He never shamed, judged, alienated, bullied or embarrassed people. He was never misogynistic, never condescending, never belittling children or cruel to animals. He cared about every living thing, including the plants and trees. He disliked wastefulness and extremity in everything. Always sought out the balance in all things. He was very humble, always refused to be treated like a king. He was down in the trenches with people, ate what they ate, starved when they did. First to practice before he preached. always weighed the consequences of his actions against not only the people around him but the generations that would come. he would refrain from damning the very people who would attack and injure him, choosing instead to see redemption in them even if generations down the line.
he was a safe, trustworthy, extremely humble man. very lowkey, very compassionate and an immense bandwidth for co-regulation and a stabilizing force. the deen didn't spread and still spreads over a millennium and a half later bc of the teachings alone. but bc people felt his care, and how he made them feel.
@shahamfarooq once said something so profound; that the function/purpose of da'wah is to make God accessible, to become like a channel through which people can feel that they can come Him closer.
that's what the prophet sallallaahu alayhi wasallam's core trait; he made the mercy of Allaah incredibly accessible bc of how his own mercy was so present and consistent in every situation. He embodied the divine reality we learn about through the teachings. He, may Allaah's peace & blessings be upon him and his family, was a portal, a bridge. a key unlocking the door to jannah. he paved a path where there was none, dug a tunnel through obstacles in the way, bridged abysses, walled off terror. he was a microcosm.
the world is safer, calmer, more hopeful just bc he existed.
may Allaah reunite us with him at our rendezvous by the fountain.
H retweeted
5 years old - Dad knows everything!
7 years old - Dad knows.
10 years old - Maybe dad doesn’t know?!
12 years old - Dad doesn’t know.
14 years old - Dads gone crazy!
16 years old - Can’t take dad seriously.
18 years old - What does dad know?!
22 years old - Dads talking rubbish!
24 years old - I know more than dad!
26 years old - Dad seems to know some things after all.
30 years old - Think I should ask dad about this?!
40 years old - It’s amazing how dad went through all this!
45 years old - Dads been right all along.
50 years old - If dad was here, I could have learned a lot.
H retweeted
Ankle Block:
#Tibialnerveblock #PNS #ultrasound
Our latest publication:
Hot off the press 🔥 @IJA_web
Full text link:
journals.lww.com/ijaweb/full…
For Ankle block video:
PNS guided:
youtu.be/qHCFRVw-Y8U?si=qTtS…
Ultrasound guided:
youtu.be/ccWAAPuajC8?si=KN-m…
H retweeted
Our APS nurses have been tracking (from the medical record) various conditions that have been suggested to be caused by the epidural! Enjoy! @ASRA_Society @ESRA_Society @EMARIANOMD @NarouzeMD
H retweeted
“RA in OBGY Surgeries”
#RAinOBGYsurgeries
#RAinLSCS
#Laboranalgesia
#RAinuterinesurgeries
#RAinFemaleGenitalSx
My 10 points:
A. FUNCTIONAL ANATOMY
1. Female reproductive system:
a. Parts: External genitalia/Vulva - Mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, & vestibular glands. Internal genitalia - Vagina, uterus, uterine tubes, & ovaries).
b. Blood supply: External genitalia- External & internal pudendal artery. Internal genitalia- Branches of internal iliac A. (Vaginal, uterine, ovarian).
B. INNERVATION
2. External genitalia: IIN, GFN, Pudendal N., PCNT (sensory), uterovaginal plexus (parasympathetic).
a. Anterior vulva (Mons pubis & Labia majora): Branches from IIN (Anterior labial Ns.).
b. Posterior vulva: Branches from Pudendal N. (Posterior labial Ns. & dorsal N. of the clitoris) and from PCNT.
3. Internal genitalia: Thoracolumbar Ns. (T12-L1), Lesser splanchnic N., hypogastric N. (sympathetic), Pelvic splanchnic N., vagus N. (parasympathetic).
a. VAGINA: From the inferior hypogastric plexus via uterovaginal N. plexus. Sympathetic-Thoracolumbar (T12-L1), Parasympathetic- Pelvic splanchnic Ns. (S2-S4). Only the inferior 1/5th of the vagina receives somatic innervation via deep perineal N. (branch of pudendal N.).
b. UTERUS: From the inferior hypogastric plexus via the uterovaginal nervous plexus. Sympathetic- Lower lumbar spinal segments via lumbar splanchnic N. and intermediate plexuses. Parasympathetic- Pelvic splanchnic Ns. (S2-4) via pelvic plexus. Afferent- Pain from the body and fundus ascends through plexuses to lumbar splanchnic Ns. to T10-L1 segments. Pain from the cervix – Parasympathetic fibers.
c. UTERINE TUBES: Sympathetic- Superior hypogastric plexus (T10-L2) via the hypogastric N. Parasympathetic- Pelvic splanchnic Ns. and vagus N.
d. OVARIES: Innervated by the ovarian plexus contributed by fibers from aortic, renal, & hypogastric (superior, inferior) plexuses. Sympathetic- Lesser splanchnic Ns. (T10-T11). Parasympathetic- Pelvic splanchnic Ns. (S2-S4).
C. LABOR PAIN
4. PAIN PATHWAYS
a. First stage: Visceral pain (uterine contraction + cervix stretching). Referred pain - Areas (Skin, abdominal wall, lumbosacral region, iliac crease, gluteal region, and thighs) supplied by involved spinal segments T10-L1.
b. Second stage: Visceral (uterus + cervix) and Somatic (stretching of the vagina, pelvic ligaments, and pressure on pelvic floor). Involved spinal segments: S3-S4.
5. RA options for Labor Analgesia:
a. Neuraxial (SA, EA, CSEA): Suitable for labor (all stages) and episiotomy repair.
b. Lower thoracic PVB (T11/T12): Suitable for the first stage of labor.
c. Pudendal N. block: Suitable for the second and third stages of labor and episiotomy repair.
D. RA in LSCS
6. Dermatomes of Incisions:
a. Midline Vertical (Above & below umbilicus mainly for large babies/twins) -T8-L1.
b. High Transverse Incision (Below umbilicus) - T10-L1.
c. Low Transverse (Pfannenstiel) - T12-L1.
7. Pain Components & management:
a. Visceral pain: T10-T12 & S2-S4 segments via Preaortic, Hypogastric, Pelvic, and Uterovaginal plexuses.
b. Somatic Pain: ACNs supplying the lower abdominal region & LP branches (IHGN, IIN, & GFN) supplying skin over the inguinal region, Genitals, and inner thigh.
c. Analgesia: Visceral pain can be covered with MMA. Somatic pain can be covered either with simple LA infiltration or RA techniques.
8. RA techniques for LSCS: Target segments (T8/10-L1 & S2-S4)
a. TAP block: Commonly performed, covering only somatic pain/cutaneous patches. Types and Coverage- Subcostal (T6-T8), Oblique (T8-T10), Lateral (T8-T12), Dual (T6-T12), and Posterior (T8-T10/T12). Lateral & Posterior TAP also covers LCNs (of ICN).
b. IHN & IIN block: Covers skin over incision only if it's Pfannenstiel. It won't involve ACN of T11-T12 Supplying the midline area.
c. QL Block: Covers T6-L2 (Blocks ACN + LCN). Being a proxy PVB, QLB acts as an indirect PVB (>30ml) and can also involve autonomic components.
d. Most suitable RA Combinations: QLB (somatic + visceral pain) > Lateral TAP + IHN+ IINB (Somatic only) > IIN+ IHNB + midline infiltration (Somatic only) > Subcutaneous LA infiltration over incision during closure.
9. Other Supplementary RA Techniques:
a. IIN+IHN block: Landmark guided- Needle entry point is 2cm medial and 2 cm superior to ASIS. USG guided - Probe is kept obliquely on a line joining ASIS with umbilicus and visualizing both Ns. between IOM-TAM adjacent to deep circumflex iliac A.
b. Paracervical block: 2 ml of LA injected over 12, 2, 4, 8, and 10 O'clock positions of the cervix. For visceral pain arising from the uterus. Targets uterosacral plexus (Lee-Frankenhauser plexus) located within the uterosacral ligament.
c. Pudendal N. block: Innervate external genitalia through dorsal N. for the clitoris, perineal N. for external genital, and inferior rectal N. Landmark guided - Palpate Ischial spine transvaginally and deposit LA posterior to it. USG guided – Patient in the lithotomy, Probe kept medial to the bony ridge of ischiopubic ramus of the IT. LA deposited next to the pulsating internal pudendal A.
10. RA options for other surgical procedures:
a. Uterine procedures (like MTP) or surgeries: Neuraxial>Paracervical block.
b. Episiotomy: LA infiltration > Neuraxial > Pudendal N. block.
c. Cervical cerclage: Neuraxial>Pudendal N. block.
d. Labioplasty/Vulval Sx: Neuraxial > IINB + GFNB + Pudendal N. block + Perineal infiltration (PCNT territory)
e. Vaginoplasty: Neuraxial> QLB + Pudendal N. block
H retweeted
*"Knowing it, B4 Blocking It" : ABCD of Peripheral Nerves*
#PeripheralNerveInjuries
#NerveInjuries
#Nervefibres
#TypesofNerveInjuries
#PreventionofNerveInjuries
#SHEDapproach
#DiagnosisOfPNI
*My 10 points:*
A. NERVE ANATOMY & PHYSIOLOGY
1. The *Epineurium* is absent around monofascicular Ns.& at Free nerve endings.
The tough *Perineurium* acts as a semipermeable barrier to LA.
During nerve injury, the *Endoneurial* fluid increases, causing nerve edema - detected by Magnetic resonance neurography (MRN).
2. The *Paraneurium* protects the nerve from stretching/compression during body movements.
This *Sweet spot* of the N. can be an ideal site for LA deposition.
3. Most impulses arise at the *Trigger zone* - A junction of the axon hillock with the initial segment.
A nerve transmits these electrochemical impulses from one neuron to another by crossing a synapse.
The message is converted from electrical to chemical and then back to electrical.
4. The arrangement of the peripheral mantle to inner core fibers in the nerve is responsible for *differential block* by LA.
The diffusion of LA from the mantle to the core fibers depends on the concentration gradient.
The sequence of blockade includes *B fibers> C fibers = Aδ fibers> Aγ fibers> Aβ fibers> Aα fibers.*
B. NERVE INJURY TYPES AND PATHOPHYSIOLOGY
5. *Neurapraxia* is associated with reversible conduction blockade due to localized myelin degeneration (without affecting the axon/ neural tube/connective tissues) due to transient ischemia, mainly due to compression.
*Axonotmesis* involves complete interruption of axons (without affecting neural connective tissues), leading to conduction loss in the nerve fiber beyond the zone of injury - Common with crush and stretch injuries.
*Neurotmesis*, a most severe form of nerve injury, involves complete transection of the nerve - Observed after massive trauma, sharp injuries, traction or avulsion injuries, & the injection of noxious drugs.
6. Following nerve injury, the nerve undergoes Degeneration followed by regeneration.
*Degeneration* proximal to injury site - primary/retrograde Degeneration. Degeneration distal to the injury site -secondary/anterograde/Wallaerian Degeneration.
*Regeneration* is not possible when the cell body is damaged, but it is possible with axonal damage. The ER and ribosome responsible for protein synthesis are present in the cell body cytoplasm but absent in the axoplasm.
C. PREVENTION OF NERVE INJURIES
7. *Subjective monitoring* (paresthesia, pain on injection, or syringe feel) can be unreliable than *Objective monitoring* (injection port pressure display, PNS, compressed air injection technique (CAIT), real-time visualization under ultrasound, and injection pressure manometers such as BSmart, NerveGuard, and SAFIRA).
8. *Dual guidance* (USG + PNS) helps reduce the risk of nerve injury. In addition, *Triple guidance* (USG + PNS + injection pressure monitoring) further improves RA safety and gives the confidence to administer PNBs without nerve injury.
D. TREATMENT OF NERVE INJURIES
9. The *SHED* (Symptoms categorization-History taking-Examination-Diagnostic evaluations) approach can be helpful when approaching nerve injury patients.
Available diagnostic tools for PNI include high-resolution US, MRI/MRN, CT scan, and electrophysiological testing.
The choice of diagnostic tests depends on the time since nerve injury and the time required to complete post-injury physiological processes (like Degeneration, regeneration, remyelination, and reinnervation).
10. *NCS* detects and *EMG* locates the nerve lesion.
Initial NCS is performed only after 1-2 days of injury and can be repeated in 10-14 days if the symptoms persist.
EMG study is conducted 2-4 weeks after the injury. After 4 weeks, the beginning of the reinnervation process can interfere with the EMG study.
H retweeted
Save this image!
YouTube education: youtube.com/playlist?list=PL…
Ref: nysora.com/.../nysora-educat…
#regionalanesthesia #nerveblock #anesthesia #painmanagement
