Abdullah Ebrahim Laher

A review of hemodynamic monitoring techniques, methods and devices for the emergency physician

ABSTRACT The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end‐organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini‐fluid challenge, the end‐expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.

HIV prevalence among first-presentation psychotic patients

First‐episode psychosis is a frequent emergency department (ED) presentation that may potentially be secondary to an underlying life‐threatening HIV‐related condition. The aim of this study was to determine the prevalence of HIV infection in patients presenting with a first episode of psychosis.

The ultrasonographic “whirlpool sign” in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis

PurposeA positive whirlpool sign (WS) is defined as the presence of a spiral-like pattern when the spermatic cord is assessed during ultrasonography (US), using standard, high-resolution ultrasonography (HRUS) and/or color Doppler sonography (CDS), in the presence of testicular torsion. The objective of this review was to assess the validity and accuracy of this sign by performing a comprehensive systematic literature review and meta-analysis.MethodsIn accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive literature search was performed (August, 2017), using the following databases: BMJ Best Practice, Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Selected studies were further assessed for relevance and quality using the Oxford 2010 Critical Appraisal Skills Program (CASP).ResultsOf the studies assessed, a total of 723 participants were included, with a mean of 72.3 (SD 71.9) participants. Of the participants, 226 (31.3%) were diagnosed with testicular torsion (TT). Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity of the WS of 0.73 (95% CI, 0.65–0.79) and 0.99 (95% CI, 0.92–0.99), respectively. Removal of all neonates increased the pooled sensitivity to 0.92 (95% CI, 0.70–0.98) while the pooled specificity remained almost unchanged at 0.99 (95% CI, 0.95–1.00). The estimated summary effect of all studies with sufficient data was 4.34 (95% CI, 1.01–7.67; n = 394; p = 0.001). A large degree of heterogeneity was suggested by an I2 statistic of 88.27% (95% CI, 68.60–98.68%). Removal of neonatal subjects increased the estimated summary effect to 5.32 (95% CI, 1.59–9.05; n = 375; p = 0.001).ConclusionThe WS, when correctly diagnosed, may be viewed as a very definitive sign for TT in the pediatric and adult populations. However, its role in neonates is limited.

Essential lessons in a potential sarin attack disaster plan for a resource-constrained environment

Sarin is a potent nerve agent chemical weapon that was originally designed for military purposes as a fast-acting anti-personnel weapon that would kill or disable large numbers of enemy troops. Its potent toxicity, ease of deployment, and rapid degradation allow for rapid deployment by an attacking force, who can safely enter the area of deployment a short while after its release. Sarin has been produced and stockpiled by a number of countries, and large quantities of it still exist despite collective agreements to cease manufacture and destroy stockpiles. Sarins ease of synthesis, which is easily disseminated across the Internet, increases the risk that terrorist organizations may use sarin to attack civilians. Sarin has been used in a number of terrorist attacks in Japan, and more recently in attacks in the Middle East, where nonmilitary organizations have led much of the disaster relief and provision of medical care. In the present article, we examine and discuss the available literature on sarins historical use, delivery methods, chemical properties, mechanism of action, decontamination process, and treatment. We present a management guideline to assist with the recognition of an attack and management of victims by medical professionals and disaster relief organizations, specifically in resource-constrained and austere environments. (Disaster Med Public Health Preparedness. 2018;12:249-256).

Finding the mental foramen

The mental foramen and mental nerve are clinically important landmarks for clinicians across various disciplines including dentists, oral maxillofacial surgeons, emergency physicians and plastic and reconstructive surgeons. To minimize complications related to procedures in the vicinity of the mental foramen and nerve, knowledge of its anatomy and anatomical variations is cardinal to concerned clinicians. In this review, basic anatomy, procedural complications, hard and soft tissue relations, variations between population groups, asymmetry, accessory mental foramina and the use of various radiological modalities to determine the position of the mental foramen are reviewed to provide a more thorough understanding of this important landmark.

The ultrasonographic determination of the position of the mental foramen and its relation to hard tissue landmarks

OBJECTIVE The goal of this ultrasound based cross-sectional study was to make use of ultrasound to determine the position of the mental foramen in relation to hard tissue landmarks. MATERIAL AND METHODS One hundred Black and Caucasian subjects were included. An ultrasound transducer was used to locate the mental foramina. Distances to various landmarks were measured and compared. RESULTS All mental foramina were visualised ultrasonographically. The mean distances to various landmarks from the mental foramen for the entire group on the right and left sides respectively were as follows: a) 22.8 mm (SD 2.04 mm) and 22.8 mm (SD 2.0 mm) to the cusp of the related tooth, b) 13.2 mm (SD 1.6 mm) and 13.2 mm (SD 1.6 mm) to the inferior border of the mandible. The mean position of the mental foramen was found to be 63.4% (SD 1.8%) of the distance from the cusp of the related tooth to the inferior border of the mandible on the right and 63.3% (SD 1.7%) on the left. There were statistically significant differences between race groups and genders, but not between age groups. CONCLUSION These results suggest that ultrasound is a sensitive modality to locate the mental foramen. There are minor, statistically significant (but clinically insignificant) differences in the position of the mental foramen with regard to various hard tissue landmarks.

Mechanically Ventilating the Severe Asthmatic

The management of the critically ill patients with asthma can be rather challenging. Potentially devastating complications relating to this presentation include hypoxemia, worsening bronchospasm, pulmonary aspiration, tension pneumothorax, dynamic hyperinflation, hypotension, dysrhythmias, and seizures. In contrast to various other pathologies requiring mechanical ventilation, acute asthma is generally associated with better outcomes. This review serves as a practical guide to the physician managing patients with severe acute asthma requiring mechanical ventilation. In addition to specifics relating to endotracheal intubation, we also discuss the interpretation of ventilator graphics, the recommended mode of ventilation, dynamic hyperinflation, permissive hypercapnia, as well as the role of extracorporeal membrane oxygenation and noninvasive mechanical ventilation.

The Ultrasonographic Determination of the Position of the Mental Foramen and its Relation to the Mandibular Premolar Teeth

INTRODUCTION The position of the mental foramen has been well researched in cadaver specimens, radiographically as well as intraoperatively. To our knowledge, this landmark study is the first to make use of ultrasonography in a study population to determine the position of the mental foramen in relation to the mandibular premolar teeth. Ultrasonography has great potential to further revolutionize the practice of medicine and dento-maxillofacial surgery. AIM To make use of ultrasound to determine the position of the mental foramen and its relation to the mandibular premolar teeth. MATERIALS AND METHODS One hundred Black and Caucasian subjects were enrolled. A high frequency (8MHz) transducer (PLF.805ST) of a diagnostic ultrasound system (model SSA-510A) was applied above the inferior border of the mandible, just lateral to the mentum. With the marker of the transducer pointing cranially, the position of the mental foramen in relation to the closest mandibular premolar tooth was determined. The position was compared across race, sex and age groups. RESULTS All mental foramina (100%) were visualised. Overall the most frequent position of the mental foramen was in line with the long axis of the second premolar on the right (44%) and between the first and second premolars on the left (44%). There were no statistical differences (p >0.05) between race groups, sex and age groups with regard to the position of the mental foramen in relation to the mandibular premolars. However, in Blacks, the most frequent position of the mental foramen was in line with the long axis of the second premolar and in Caucasians the most common position was between the first and second premolars. The most frequent position of the mental foramen in females was in line with the long axis of the second premolar on the right and between the first and second premolars on the left. In males, the most frequent position of the mental foramen was in line with the long axis of the second premolar bilaterally. The most common position of the mental foramen in the age group category 18-30 years was between the first and second premolars. In patients aged 31-60 years the most frequent position was in line with the long axis of the second premolar. CONCLUSION Ultrasound is a sensitive modality to locate the mental foramen. There are differences in the most common position of the mental foramen with regard to the long axis of the premolar teeth. Ultrasonography has the potential to revolutionize the practice of dento-maxillofacial surgery.

A Somalia mission experience

Reports about The Horn of Africa Famine Crisis in 2011 flooded our news bulletins and newspapers. Yet the nations of the world failed to respond and alleviate the unfolding disaster. In August 2011, the Gift of the Givers Foundation mobilised what was to become the largest humanitarian mission ever conducted by an African organisation. Almost a year later, the effort continues, changing the face of disaster medicine as we know it.

HTLV-1, ATLL, severe hypercalcaemia and HIV-1 co-infection: an overview

HIV and HTLV (Human T-ymphotropic Virus) are the only known retroviruses responsible for causing infection in humans. HTLV-1 and HIV-1 are frequent co-pathogens, however, despite its potential for accelerated progression of HIV disease and the risk of developing adult T-cell lymphoma/leukemia (ATLL), HTLV-1 is seldom considered for investigation in the HIV-1 positive individual. Severe/refractory hypercalcaemia, unresponsive to conventional calcium lowering therapy may complicate up to 70% of cases of ATLL. In addition, HTLV-1 and ATLL have both been associated with a rise in dysfunctional CD4 lymphocytes, thereby conveying a false sense of immune competence in the HIV-1 infected individual.