Epinephrine? Anaphylaxis?

Le Fort (Maxilla fracture)

Le Fort I

• HORIZONTAL maxillary fracture
• Floating palate

Le Fort II

• PYRAMIDAL fracture
• Floating maxilla

Le Fort III

• CRANIOFACIAL dysfunction
• Floating face

CSWS, SIADH, ID

Spinal Cord Injury

American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification) :

• A = Complete: No sensory or motor function is preserved in sacral segments S4-S5
• B = Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5
• C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3
• D = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3
• E = Normal: Sensory and motor functions are normal
  
  
  
  
  
  
  

JNC 8

9 RECOMMENDATIONs

Thrombolysis in STEMI

• Patients with STEMI and onset of symptoms within 12 hours if PCI delay > 120 minutes (class I)
• Patients with STEMI and onset of symptoms between 12-24 hours if continued symptoms or ECG changes and PCI unavailable (class IIa) 

 Door to needle time <30 minutes
 Not indicated for patients with ST depression

Absolute contraindications for fibrinolytic use in STEMI include the following:^[16]

• Prior intracranial hemorrhage (ICH)
• Known structural cerebral vascular lesion
• Known malignant intracranial neoplasm
• Ischemic stroke within 3 months
• Suspected aortic dissection
• Active bleeding or bleeding diathesis (excluding menses)
• Significant closed head trauma or facial trauma within 3 months
• Intracranial or intraspinal surgery within 2 months
• Severe uncontrolled hypertension (unresponsive to emergency therapy)
• For streptokinase, prior treatment within the previous 6 months

Relative contraindications for fibrinolytic use in STEMI include the following:^[16]

• History of chronic, severe, poorly controlled hypertension
• Significant hypertension on presentation (systolic blood pressure > 180 mm Hg or diastolic blood pressure > 110 mm Hg
• Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation (CPR) or major surgery less than 3 weeks previously
• History of prior ischemic stroke not within the last 3 months
• Dementia
• Recent (within 2-4 weeks) internal bleeding
• Noncompressible vascular punctures
• Pregnancy
• Active peptic ulcer
• Current use of an anticoagulant (eg, warfarin sodium) that has produced an elevated international normalized ratio (INR) higher than 1.7 or a prothrombin time (PT) longer than 15 seconds

Well Score for DVT and Pulmonary Embolism

TIMI (Thrombolysis in Myocardial Infarction)

Modified Early Warning Score (MEWS)

Score	3	2	1	0	1	2	3
Systolic BP	<45%	30%	15% down	Normal for patient	15% up	30%	>45%
Heart rate (BPM)	—	<40	41-50	51-100	101-110	111-129	>130
Respiratory rate (RPM)	—	<9	—	9-14	15-20	21-29	>30
Temperature (°C)	—	<35	—	35.0-38.4	—	>38.5	—
AVPU	—	—	—	A	V	P	U

A score >= 5 is statistically linked to increased likelihood of death or admission to an ICU

Early Goal-Directed Therapy in Sepsis

In hypotension persists despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl), goals in the first 6 hours of resuscitation include:

• CVP of 8-12 mmHg. Mechanical ventilation, increased abdominal pressure, and preexisting impaired ventricular compliance may require higher CVP targets of 12-15 mmHg^[5]

• Superior vena oxygen saturation (ScvO2) of > 70% OR mixed venous oxygen saturation (SvO2) of > 65%. If initial fluid resuscitation fails to achieve adequate oxygen saturation additional options include dobutamine infusion (maximum 20 µg/kg/min) or transfusion of packed red blood cells to a hematocrit ≥ 30%. If a ScvO2 is unavailable, lactate normalization may be used as a surrogate marker. A reduction in lactate by ≥ 10% is noninferior to achieving a ScvO2 of ≥ 70% ^[6]

• Achieve MAP ≥ 65mmHg^[5] The presence of atherosclerosis or pre-existing uncontrolled hypertension may necessitate a higher MAP target.
• Achieve Urine output ≥ 0.5 mL/kg/h^[5]

Successful targeting the above goals in the first 6-hour period results in a 15.9% absolute reduction in 28-day mortality rate.

Brodmann areas

http://en.wikipedia.org/wiki/Brodmann_area

Brodmann areas for human & non-human primates

• Areas 3, 1 & 2 - Primary Somatosensory Cortex (frequently referred to as Areas 3, 1, 2 by convention)
• Area 4 - Primary Motor Cortex
• Area 5 - Somatosensory Association Cortex
• Area 6 - Premotor cortex and Supplementary Motor Cortex (Secondary Motor Cortex)(Supplementary motor area)
• Area 7 - Somatosensory Association Cortex
• Area 8 - Includes Frontal eye fields
• Area 9 - Dorsolateral prefrontal cortex
• Area 10 - Anterior prefrontal cortex (most rostral part of superior and middle frontal gyri)
• Area 11 - Orbitofrontal area (orbital and rectus gyri, plus part of the rostral part of the superior frontal gyrus)
• Area 12 - Orbitofrontal area (used to be part of BA11, refers to the area between the superior frontal gyrus and the inferior rostral sulcus)
• Area 13 and Area 14^* - Insular cortex
• Area 15^* - Anterior Temporal Lobe
• Area 17 - Primary visual cortex (V1)
• Area 18 - Secondary visual cortex (V2)
• Area 19 - Associative visual cortex (V3,V4,V5)
• Area 20 - Inferior temporal gyrus
• Area 21 - Middle temporal gyrus
• Area 22 - Superior temporal gyrus, of which the caudal part is usually considered to contain the Wernicke's area
• Area 23 - Ventral Posterior cingulate cortex
• Area 24 - Ventral Anterior cingulate cortex.
• Area 25 - Subgenual cortex (part of the Ventromedial prefrontal cortex)^[4]
• Area 26 - Ectosplenial portion of the retrosplenial region of the cerebral cortex
• Area 27* - Piriform cortex
• Area 28 - Posterior Entorhinal Cortex
• Area 29 - Retrosplenial cingulate cortex
• Area 30 - Part of cingulate cortex
• Area 31 - Dorsal Posterior cingulate cortex
• Area 32 - Dorsal anterior cingulate cortex
• Area 33 - Part of anterior cingulate cortex
• Area 34 - Anterior Entorhinal Cortex (on the Parahippocampal gyrus)
• Area 35 - Perirhinal cortex (on the Parahippocampal gyrus)
• Area 36 - Parahippocampal cortex (on the Parahippocampal gyrus)
• Area 37 - Fusiform gyrus
• Area 38 - Temporopolar area (most rostral part of the superior and middle temporal gyri)
• Area 39 - Angular gyrus, considered by some to be part of Wernicke's area
• Area 40 - Supramarginal gyrus considered by some to be part of Wernicke's area
• Areas 41 & 42 - Primary and Auditory Association Cortex
• Area 43 - Primary gustatory cortex
• Area 44 - pars opercularis, part of Broca's area
• Area 45 - pars triangularis Broca's area
• Area 46 - Dorsolateral prefrontal cortex
• Area 47 - Inferior prefontal gyrus
• Area 48 - Retrosubicular area (a small part of the medial surface of the temporal lobe)
• Area 49 - Parasubiculum area in a rodent
• Area 52 - Parainsular area (at the junction of the temporal lobe and the insula)

(*) Area only found in non-human primates.

Medial view

Lateral view

Antibiotic Use in Infants Ups Risk for Childhood Obesity

Clinical Implications

• Exposure to antibiotic use in children younger than 6 months is associated with elevated body mass scores at ages 10 months, 20 months, and 38 months and overweight at age 38 months. However, such exposure is not linked with overweight or obesity at age 7 years.

http://www.medscape.org/viewarticle/769506?src=cmemp

Does a Healthy Diet Prevent Chronic Disease?

Clinical Implications

• The DASH and Mediterranean diets are examples of healthy eating patterns that have been shown to have beneficial effects on a number of chronic health outcomes.

  Table 1. DASH Diet Food Group Servings for a 2000-Calories-Per-Day Diet

Food Group	Target Serving	Examples of 1 Serving
Low-fat dairy	2-3/day	1 cup milk or yogurt
Grains (mostly whole)	6-8/day	1 slice bread 1 oz dry cereal 1/2 cup cooked rice, pasta, or cereal
Lean meats, poultry, fish	≤6/day	1 oz cooked lean meat, poultry, or fish 1 egg
Nuts/seeds/legumes	4-5/week	1/3 cup or 1 1/2 oz nuts 2 Tbsp peanut butter 2 Tbsp or 1/2 oz seeds 1/2 cup cooked legumes
Fruits	4-5/day	1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 1/2 cup fruit juice
Vegetables	4-5/day	1 cup raw leafy vegetables 1/2 cup cut-up raw or cooked vegetables

Adapted from the 2010 Dietary Guidelines for Americans


Table 2. Mediterranean Diet

High in fresh fruits and vegetables, olive oil, legumes, unrefined grains

Moderate in low-fat dairy

Low in meat

Moderate to high in fish

Moderate alcohol intake

http://www.medscape.org/viewarticle/769479?src=cmemp 

Can Long-Acting Beta-Agonists, ICS Cut Asthma Exacerbations?

Clinical Implications

• It did not differ significantly in children receiving Long Acting Beta Agonists (LABAs) plus Inhaled Corticosteroid) ICS vs children receiving higher doses of ICS.
• Compared with children receiving higher ICS doses, those receiving LABAs plus ICS had significantly higher PEF, less use of rescue medication, and greater short-term growth. Adverse events were not significantly different between the groups. 

http://www.medscape.org/viewarticle/770166?src=cmemp

Does Adding Clopidogrel to Aspirin Reduce Stroke Risk?

Clinical Implications

• Among patients with recent lacunar strokes, adding clopidogrel to aspirin did not significantly lower the risk for recurrent stroke.
• Among patients with recent lacunar strokes, adding clopidogrel to aspirin did significantly increase the risk for hemorrhage and death.

http://www.medscape.org/viewarticle/770170?src=cmemp

Kebutuhan cairan

Pada dehidrasi berat, berikan 100 mg/kg cairan Ringer Laktat, dibagi sebagai berikut : 

Kebutuhan rumatan per hari :

100cc/kg : untuk 10 kg pertama
  50cc/kg : untuk 10 kg kedua
  20cc/kg : untuk selanjutnya

Appendisitis : MANTRELS / Alvarado score

Migration of pain from central area to RLQ  1
Anorexia or acetonuria                              1
Nausea with vomiting                                1
Tenderness in the right lower quadrant        2
Rebound tenderness                                 1
Elevated temperature ≥38°C (100.4°F)        1
Leukocytosis (>10,400 cells/mm3)             2
Shifted WBC count (>75% neutrophils)       1

5 - 6 : Compatible
7 - 8 : Probable
9 - 10 : Very probable

Skor DALDIYONO

Defisit cairan (cc) = SKOR/15 x Berat Badan (kg) x 100

Skor DALDIYONO

Haus/Muntah                      (1)
TD Sistolik 60-90 mmHg      (1)
TD Sistolik <60                   (2)
Frekuensi Nadi >120x          (1)
Kesadaran Apatis                (1)
Somnolen/sopor/koma         (2)
Frekuensi nafas >30x/menit (1)
Facies Cholerica                 (2)
Vox Cholerica                     (2)
Turgor kulit menurun            (1)
"Washer Woman Hand"       (1)
Ekstremitas dingin               (1)
Sianosis                             (2)
Umur 50-60 tahun               (-1)
Umur >60 tahun                  (-2)


Facies Cholerica : mata cekung, pipi cekung
Vox Cholerica : suara sesak dan parau/serak
Sianosis : bibir dan ujung jari berwarna biru
Washer Woman Hand : ujung jari keriput