SAFE triangle for ICD placement

1. Anterior border of the latissimus dorsi
2. Lateral border of pectoralis major muscle
3. A line superior to the horizontal level of the nipple and an apex below the axilla

Leukocoria is seen in

·         Retinoblastoma

·         Congenital cataract

·         Inflammatory deposits in the eye

·         Coloboma of choroid

·         Retrolental fibroplasia (Retinopathy of prematurity)

·         Persistent hyperplastic primary vitreous

·         Toxocara endopthalmitis

·         Exudative retinopathy of coats

·         Tuberculoma of choroid

·         Retinal detachment

tumors in children

·         Astrocytoma are the most common brain tumors in children.

·         Juvenile pilocytic astrocytoma is the most common astrocytoma in children , comprising 20% of all brain tumors.

·         Neuroblastoma is the most common intraabdominal solid tumor in children.

·         Rhabdomyosarcoma is the most common soft tissue sarcoma in children under 15 years of age .

·         The most common primary site for rhadomyosarcoma in children in head and neck region.

·         The most common malignant bone tumor in children is osteosarcoma.

·         Retinoblastoma is the most common primary ocular tumor of childhood.

 

Dobutamine Stress Echocardiogram

Dobutamine Stress Echocardiogram

What is a Dobutamine Stress Echocardiogram (Echo)?

• A Dobutamine Stress Echo is a non-invasive test used to evaluate coronary artery disease in patients who are unable to exercise on a treadmill.
• Dobutamine is a medication that increases heart rate and blood pressure similar to the effect of exercise.
• The rise in heart rate increases the oxygen demand of the heart and helps to determine if the heart muscle is getting enough blood and oxygen.
• The test includes an echocardiogram done at rest and again at peak heart rate. This procedure uses sound waves (ultrasound) to produce an image of the internal structures of the heart.
• In order to produce an image of the heart muscle, gel is applied to the patient's chest area and a transducer (a wand-like apparatus) is moved over the chest.
• Electrodes are placed on the chest to record an electrocardiogram (EKG) which monitors the heart's rate and rhythm.
• An IV line will be started and Dobutamine will be administered by a nurse.
• The cardiologist will observe for any symptoms, irregular heart rhythms, an inappropriate heart rate or blood pressure responses.
• The test takes about an hour.
• This test must be ordered by a doctor.

Why is a Dobutamine Stress Echo Done?

• This test will help the doctor evaluate the patient's cardiac condition related to the following:
  • How well the heart muscle and valves are working and how they function under stress.
  • The size of the heart's pumping chambers (ventricles).
  • Abnormal heart function: coronary artery disease and/or inadequate coronary blood supply.

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Pollicisation of the index finger

Pollicisation of the index finger

Pollicisation of the index finger is the treatment of choice

for reconstruction in children with congenital hypoplasia of

the thumb.1-5 Good outcomes have been reported for range

of movement, power, appearance and sensation,

 

Figure 1a – A 40-year-old man with bilateral congenital absence of the thumb with an associated

radial club hand on the right. Figures 1b and 1c – Radiographs showing pollicisation of the index finger

of the left hand in isolated congenital absence of the thumb (b) and of the right hand in radial club hand

(c).

Suture materials

The purpose of a suture

• to hold a wound together in good apposition until such time as the natural healing process is sufficiently well established to make the support from the suture material unnecessary and redundant.

 

Choice of a suture

• Choice of suture depends on:
  • Properties of suture material
  • Absorption rate
  • Handling characteristics and knotting properties
  • Size of suture
  • Type of needle

Natural suture materials

• Absorbable
  • Catgut - Plain or chromic
• Non-Absorbable
  • Silk
  • Linen
  • Stainless Steel Wire

Synthetic suture materials

• Absorbable
  • Polyglycolic Acid (Dexon)
  • Polyglactin (Vicryl)
  • Polydioxone (PDS)
  • Polyglyconate (Maxon)
• Non-Absorbable
  • Polyamide (Nylon)
  • Polyester (Dacron)
  • Polypropylene (Prolene)

Absorbable suture are broken down by either:

• Proteolysis (e.g. Catgut)
• Hydrolysis (e.g. Vicryl, Dexon)

Catgut

• Made from the submucosa of sheep gastrointestinal tract
• Broken down within about a week
• Chromic acid delays hydrolysis
• Even so it is destroyed before many wounds have healed

Silk

• Strong and handles well but induces strong tissue reaction
• Capillarity encourages infection causing suture sinuses and abscesses

Vicryl

• Tensile strength
  • 65% @ 14 days
  • 40% @ 21 days
  • 10% @ 35 days
• Absorption complete by 70 days

Polydioxone

• Tensile strength
  • 70% @ 14 days
  • 50% @ 28 days
  • 14% @ 56 days
• Absorption complete by 180 days

Management of Diabetic Ketoacidosis

1. Confirm diagnosis (­ plasma glucose, positive serum ketones, metabolic acidosis).

2. Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH < 7.00 or unconscious.

3. Assess:  Serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate)

                 Acid-base status¾pH, HCO3-, PCO2

                 Renal function (creatinine, urine output)

4. Replace fluids: 2-3 L 0.9% saline over first 1-3 h (5-10 mL/kg per hour); subsequently, 0.45% saline at 150-300 mL/h; change to 5% glucose and 0.45% saline at 100-200 mL/h when plasma glucose reaches 14 mmol/L (250 mg/dL).

5. Administer regular insulin: 10-20 units IV or IM, then 5-10 units/h by continuous IV infusion; increase 2- to 10-fold if no response by 2-4 h.

6. Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction, cocaine)? Initiate appropriate workup for precipitating event [cultures, chest x-ray, electrocardiogram (ECG)]

7. Measure capillary glucose every 1-2 h; measure electrolytes (especially K+, bicarbonate, phosphate) and anion gap every 4 h for first 24 h.

8. Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1-4 h.

9. Replace K+: 10 meq/h when plasma K+ < 5.5 meq/L, ECG normal, urine flow, and normal creatinine documented; administer 40-80 meq/h when plasma K+ < 3.5 meq/L or if bicarbonate is given.

10. Continue above until patient is stable; glucose goal is 8.3-13.9 mmol/L (150-250 mg/dL), until acidosis is resolved. Insulin infusion may be decreased to 1-4 units/h.

11. Administer intermediate or long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and subcutaneous insulin injection.