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Postural headache   Think low CSF pressure headache, Postdural puncture headache (PDPH). History of similar headaches Think migrane ,1/3 to half of women with migraine will have a postpartum headache and the nature of symptoms are similar to their previous headaches. Headache associated with antenatal/post-natal history of hypertension, proteinuria or seizure  Think  Postpartum Preeclampsia. Abrupt headache   think aneurysm subarachnoid haemorrhage, cerebral venous thrombosis and a vascular cause.

Intermittent claudication (calf) Calf muscles Cramping pain After same degree of exercise Quickly relieved None Reproducible Chronic compartment syndrome Calf muscles Tight, bursting pain After much exercise (e.g., jogging) Subsides very slowly Relief speeded by elevation Typically heavy-muscled athletes Venous claudication Entire leg, but usually worse in thigh and groin Tight, bursting pain After walking Subsides slowly Relief speeded by elevation History of iliofemoral deep venous thrombosis, signs of venous congestion, edema Nerve root compression (e.g., herniated disk) Radiates down leg, usually posteriorly Sharp lancinating pain Soon, if not immediately after onset Not quickly relieved (also often present at rest) Relief may be aided by adjusting back position History of back problems Symptomatic Baker's cyst Behind knee, down calf Swelling, soreness, tenderness With exercise Present at rest None Not intermittent Intermittent claudication (hip, thigh, buttock) Hip, thi...

A 28-year-old Man with Air in the Mediastinal Space after  a Car Accident (Anesthesiology, Oct 2012) A 28-YR-OLD man was admitted to a level I trauma center because of blunt high-energy chest trauma. The chest radiograph ray showed a radiolucent line left of the heart, suggestive of pneumomediastinum (fig. A: radiograph on admission; fig. B: magnification of the white rectangle in fig. A; white arrows mark the radiolucent line. In figs. A and B, an electrocardiogram cable is visible). Chest and pericardial drains were inserted, after which hemodynamic function improved. Bronchoscopy revealed a 2-cm full-thickness longitudinal airway tear. The lesion began at the carina and continued into the right main bronchus (RB) (fig. C: a bronchoscopic picture of the right main bronchus; the outlined area shows the bronchial lesion [LB left bronchus]). Tracheobronchial injuries are life threatening and often are no...

Risks The risk of developing post-herpetic neuralgia increases with age.   Post-herpetic neuralgia primarily affects people over the age of 60. According to a review by Brannon, 6.9% of patients 60 to 69 years old who developed herpes zoster, developed post-herpetic neuralgia, and 18.5% of patients over 70 years old who developed herpes zoster, developed post-herpetic neuralgia. Other risk factors for developing post-herpetic neuralgia include: the presence of high-intensity pain at the time of the herpes zoster rash and the presence of a significantly severe herpes zoster rash. Treatment The qualities and intensities of pain vary amongst patients.  Thus, the treatment plan for post-herpetic neuralgia needs to be individualized and tailored to address all of the aspects of a patient’s symptoms. The therapeutic regimen for the pain associated with post-herpetic neuralgia is similar to the therapeutic regimen for the pain of herpes zoster.  The American A...

Emergency Neurological Life Support is a series of protocols suggesting important steps to take in the first hour of a neurological emergency. These emergencies include Ischemic Stroke, Intracerebral Hemorrhage, Status Epilepticus, Subarachnoid Hemorrhage, Meningitis and Encephalitis, Airway Management including intubating a patient with high intracranial pressure, Traumatic Brain Injury, Traumatic Spine injury and Spinal Cord Compression. All of these protocols are available at no charge online at the following link                                                         CLICK here

Reduction in spinal-induced hypotension with ondansetron in parturients undergoing caesarean section: a double-blind randomised, placebo-controlled study. Abstract BACKGROUND : Subarachnoid block is the preferred method of anaesthesia for caesarean section, but is associated with hypotension and bradycardia, which may be deleterious to both parturient and baby. Animal studies suggest that in the presence of decreased blood volume, 5-HT may be an important factor inducing the Bezold Jarisch reflex via 5-HT3 receptors located in intracardiac vagal nerve endings. In this study, we evaluated the effect of ondansetron, as a 5-HT3 receptor antagonist, on the haemodynamic response following subarachnoid block in parturients undergoing elective caesarean section. METHODS : Fifty-two parturients scheduled for elective caesarean section were randomly allocated into two groups. Before induction of spinal anaesthesia Group O (n=26) received intravenous ondansetron 4 mg; Grou...

Recently, the FDA approved an IV formulation of acetaminophen (OFIRMEV ) for the management of postoperative pain. The argument for the IV route was to avoid the slow onset of the analgesic effects after oral delivery. Since the introduction of the injectable formulation, there have been a large number of robust clinical trials on the efficacy of IV acetaminophen (Jones, 2011). Meta-analyses provide a strong indication of the efficacy of the IV formulation in single-dose, randomized, controlled clinical trials, for acute postoperative pain in adults or children. In one series, 37% of patients receiving i.v. acetaminophen experienced at least 50% pain relief over 4 h compared with 16% (68/527) receiving placebo, with larger effects when baseline pain was greater; fewer patients receiving acetaminophen required rescue medications than those receiving placebo (McNicol et al., 2011). Other analyses demonstrate a significant reduction in postoperative morphine ...

CPAP: For patients with suspected ACPE its reasonable to set the CPAP pressure at 10cm H2O. This pressure can be adjusted up or down depending on patient comfort. Oxygen should be titrated based on PCO2, PaO2 and titrated to the patient SpO2 at the bedside. BiPAP: For patients receiving BiPAP start with an IPAP of between 12-15cm  H2O, and and EPAP of between 4-7cm H2O. These pressure can be titrated up or down depending on the combination of clinical effect as well as patient comfort. Failure to improve oxygenation should prompt sn increase in fractional inspired oxygen and EPAP. Failure to improve the hypercarbia should lead to an increase in IPAP. Take Home Points: Based on current evidence pressures should not exceed 25cm H2O at any point regardless of the mode of NIV being used. In order to maintain the pressures, it is important to achieve a good seal with the NIV mask.

Continuous positive airway pressure (CPAP): CPAP is a  fixed positive pressure throughout the respiratory cycle. CPAP appears to be more effective in reducing the need for tracheal intubation and possibly mortality in patients presenting with with acute cardiogenic pulmonary oedema (ACPE). Bi-level positive airway pressure (BiPAP): BiPAP is when the ventilator delivers different levels of pressure during inspiration (IPAP) and expiration (EPAP). BiPAP ventilation appears to be more effective in reducing mortality and the need for tracheal intubation in patients with an acute decompensation of COPD.

How non-invasive ventilation (NIV) works -Improves laminar flow of air- stents open smaller airways -This decreases atelectasis which improves pulmonary compliance and decreases the patient’s work of breathing -For pulmonary edema- does not “blow the fluid out of the lungs” -Increases intrathoracic pressure -> decreases venous return -Decreases preload and afterload When to use NIV -Any patient with respiratory distress who is not responding to simple interventions , like in exacerbation of  COPD, Asthma, CHF, Pulmonary edema, -Can also use NIV to pre-oxygenate prior to intubation -Don’t need to figure out the diagnosis before you start NIVshoot first and ask questions later- use it early and often -Least evidence for use in asthma -Can also use for patients with DNR/DNI to relieve air hunger and/or buy time to address resuscitation status

Non-invasive Ventilation -Provides positive pressure to the patient via a tight fitting facemask CPAP- Continuous Positive Airway Pressure -Provides a constant level of positive pressure that doesn’t vary based on the patient’s breathing - Example- CPAP at a pressure of 10 centimeters of water BiPAP- Bi-Level Positive Airway Pressure -Provides a baseline level of pressure all the time and increases pressure above that baseline with each inhalation -Technically BiPAP is a proprietary term but it is often used universally to encompass all modes of non-invasive ventilation -Example- BiPAP at a pressure of 10/5 (centimeters of water) -Pressure of 5 all the time, 10 when the patient inhales BiPAP vs. CPAP -No differences in any clinically important outcomes in studies -BiPAP may be more comfortable since it lets patient “rest” in between breaths -CPAP tends to be more portable

 Charcot's triad for multiple sclerosis 1. Nystagmus 2. Intention tremor 3. Scanning or staccato speech Charcot's triad for ascending cholangitis 1. Jaundice 2. Fever, usually with rigors 3. Right upper quadrant abdominal pain. Cushing's triad  (not to be confused with the  Cushing reflex ) is a sign of increased intracranial pressure. It is the triad of: 1.  Hypertension  (progressively increasing systolic blood pressure) 2.  Bradycardia 3.  Widening pulse pressure  (an increase in the difference between systolic and diastolic pressure over time) Virchow's triad presents the three broad categories of factors that are thought to contribute to thrombosis. The triad consists of: 1. Alterations in normal blood flow 2. Injuries to the vascular endothelium 3. Alterations in the constitution of blood (hypercoagulability) Alteration in blood flow can include turbulence, stasis, mitral stenosis, and varicose v...