Right-sided ECG’s or electrocardiogram (as opposed to the standard left-sided ECG) are used when a right ventricular infarct or MI is suspected.

They are considered the single most accurate rapid assessment tool in determining is a right ventricular heart attack has occurred and are 90% sensitive and specific for this condition.

Because right-sided ECG’s are not as frequently used as the standard, left-sided ECG there is often confusion about where the chest leads are placed. The key fact to remember is that the positions of V1 and V2 are the same for both left and right-sided ECG’s.

Leads V3-V6 are placed along the right anterior chest wall in a mirror position as the V3-V6 leads in a normal left-sided ECG.

V1 for both right and left-sided ECG’s is placed to right fifth intercostal space at the sternal junction and in both ECG’s V2 is placed to the left of the sternum at the fifth sternocostal margin.

Stages of Wound Healing – Stage 1

Healing of wounded tissue is generally considered to occur in four phases. In order, these are coagulation, inflammation, proliferation, and remodeling.

The first coagulation phase of wound healing occurs seconds to one hour after injury. Platelets are the first cellular components to move to the wounded tissue. After platelets aggregate, clot formation occurs with release of the inflammatory mediators platelet-derived growth factor (PDGF) and tissue growth factor. PDGF causes neutrophils, fibroblasts, and macrophages to enter the wound.

Steve Jobs Liver Transplant Surgeon Denies Special Treatment

Dr. James Eason denies that Apple CEO and founder bypassed other patients on the waiting list when he received a liver transplant earlier this year for a metastatic neuroendocrine tumor to the liver.

Korean Surgeons Use Robot To Remove Thyroid Cancers

Dr. Woong Youn Chung and his colleagues at Yonsei University College of Medicine have successfully removed over thirty cancerous thyroids using a robot that allows for precise control of the surgical instruments and small incisions.

Penicillin was one of the first commercially available antibiotics and is a still widely used class of antimicrobrial. The spectrum of action of these drugs is as follows:

1. Very little coverage for Staphylococcus

2. Very little coverage for gram negative bacteria

3. Good Streptococcus coverage

4. Good coverage for syphilis, Lyme disease, and Neiserria meningitidis

5. Can be used in anaerobic infections occurring in the thorax and more cephalad

Weaning Parameters

Deciding when to remove an endotracheal (i.e., breathing tube) from a patient in the ICU is in part governed by the patient’s weaning parameters. Although there are many protocols used, most intensive care physicians focus on three factors to evaluate the patient’s ability to tolerate removal of the ET tube. These are:

1. Rapid shallow breathing index (RSBI or Tobin score) of less than 105 and optimally less than 85 on no ventilator support. This value is usually calculated by the ventilator is the frequency of breaths divided by the tidal volume in liters.

2. Negative inspiratory force (NIF) of > than -30 mmHG. This is a physiological measure of the patient’s ability to cough and clear secretions.

3. A vital capacity of > 10cc/kg on miminal ventilator support.

Generally, the “foot of the bed” test should not be used to decide on intubation without consideration of the above parameters.

Tricks For Intubating A Difficult Airway

Patients with respiratory failure requiring intubation are commonplace in the intensive care unit. If at all possible, an experienced anesthesia provider who likely has thousands of previous intubations should perform this procedure. The patient should be given well-performed bag/mask ventilation while the anesthesia team is being summoned.

However, occasionally, even an experienced intubater will use the following tricks to improve visualization of the airway, especially if a glide scope is not available at bedside.

1. Repositioning the head and neck.

2. Placing folded towels under the shoulders to increase neck extension.

3. Placing a laryngeal mask airway until a more experienced anesthesia is present.

4. Use of cricoid pressure.

5. Paralyzing the patient even in the setting of unresponsiveness.

Etomidate

Etomidate is a commonly used drug for intubations in the intensive care unit. It is a sedative-hypnotic that acts on the GABA receptors in the brain to block neuroexcitation.

The time to effect for etomidate is 15-45 seconds. The duration of action is 3-12 minutes. The typical dose is .3-.4mg/kg.

When using etomidate, it must be remembered that it has no analgesic effect (i.e., does not provide pain control) and it suppresses adrenal function (and thus skews a cortisol stimulation test) for up to 24 hours

Alcoholic Hallucinosis

For patients who are withdrawing from alcohol, alcoholic hallucinosis is often confused with delirium tremens. Alcoholic hallucinosis is marked by hallucinations that occur 12-24 hours after last alcohol intake and resolve within 24 to 48 hours – before onset of delirium tremens.

Most commonly, the hallucinations are visual followed by auditory and lastly tactile. They occur in patients who are otherwise awake and alert and who do not have clouding of their sensorium.

Groin Hernias

Groin hernias (inguinal hernias) are extremely common and have a lifetime incidence of 10% in men. They are five times more common in men than in women.

Inguinal hernias are classified as direct or indirect, depending on where the intraabdominal contents pass through the abdominal wall. Indirect hernias protrude lateral to the epigastric vessels (i.e., in close association with the spermatic cord cords) and direct inguinal hernias protrude through the floor of the inguinal canal.

Femoral hernias do occur in both men and women but are more frequent in women (but still relatively rare.)

Even experienced examiners have difficulty differentiating direct from indirect inguinal hernias on exam. The best test method to detect a hernia is having the examiner place their forefinger into the inguinal canal and evaluating for a bulge when the patient coughs.

Pre-operative Risk For Myocardial Infarction

The best risk factor for estimating pre-operatively the risk for a myocardial infarction (MI or heart attack) is the occurence of a myocardial infarction in the previous 6 months.

Truly elective surgery should be delayed at least six months after a previous MI.

Although the phrase “cardiology cleared the patient for surgery” is often used, there is no such thing as “cardiac clearance.” More accurately, clinicians and patients should refer to a risk stratification for the patient.