Ep-PAINE-nym



Ishihara Test

 

Other Known AliasesPseudo-isochromatic plates

DefinitionTest for detecting color blindness using different color dots to outline numbers

Ishihara 9.png

Clinical SignificanceAllows for quick assessment of color blindness using different styles plates (a full test is 38 plates) and even differentiate between different types of color blindness.  Research has proven that a score of 12 out of 14 red/green plates indicates normal color vision with a sensitivity of 97% and a specificity of 100%.

History – Named after Shinobu Ishihara (1879-1963), who developed these while working as a military surgeon for the Japanese army during World War I as a better way of assessing color blindness in troops.  He first published these findings in 1917 in Japan and it was first translated and reviewed in the American Journal of Ophthalmology in June 1918 extolling its usefulness.


 


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Ishihara S.  Tests for Color Blindness.  AJO. 1918;1(6):457 [article]
  6. Ishihara S.  Tests for Color Blindness.  1972 [book]
  7. http://www.eyemagazine.com/feature/article/ishihara

PAINE #PANCE Pearl – HEENT



Question

 

What do you expect to find on Weber and Rinne tests in sensorineural hearing loss (SSNHL)?

 



Answer

 

Both of these tests are easy bedside maneuvers to perform in the early evaluation of hearing loss and only require a 256 Hz tuning fork.  The main thing to remember is that in the Rinne test, air conduction is supposed to be greater than bone conduction….but because the problem with SSNHL is the conversion of sound waves to neural impulses, AC will still be greater than BC because the sound waves can still travel through the canal uninhibited.  So AC>BC can be both normal and abnormal, which is why it always done in tandem with the Weber to help figure out which side is affected.

Ep-PAINE-nym



Epstein’s Pearls

 

Other Known Aliasesnone

DefinitionSmall, fluid filled cysts on the hard palate of newborns that are most commonly found along the median palatal raphae.

Image result for epstein's pearls

 

Clinical SignificanceNone.  These are completely normal and occur in 65-80% of newborns.  The are formed by epithelium that becomes trapped during palatal development.

Image result for epstein's pearls

 

History – Named after Alois Epstein (1849-1918), who was a Czechoslovakian pediatrician, graduating from the University of Prague in 1873.  His career was highlighted by becoming the first physician-in-chief for the University of Prague hospital in 1873 and being appointed to professor at the University of Prague in 1884.  He first described these findings in 1880.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Lewis DM. Bohn’s nodules, Epstein’s pearls, and gingival cysts of the newborn: a new etiology and classification. Journal – Oklahoma Dental Association. ; 101(3):32-3. [pubmed]
  6. Singh RK, Kumar R, Pandey RK, Singh K. Dental lamina cysts in a newborn infant. BMJ case reports. 2012; 2012:. [pubmed]
  7. Epstein A. Ueber die Gelbsucht bei Neugeborenen Kindern. Leipsic. 1880. [book]

PAINE #PANCE Pearl – HEENT



For HEENT block, lets talk a little about about hearing loss:

 

#36 – Basics of the Ventilator with Wes Johnson, PA-C



***LISTEN TO THE PODCAST HERE***

 



Guest Information

 

Wes Johnson, MSPAS, PA-C, (soon to be), DHSc was a former student of mine at UAB and was a respiratory therapist prior to PA school.  He is the Regional Director of Clinical Education for Island Medical Management Emergency group in North Alabama.  He won the Preceptor of The Year award from UAB in 2016 and currently finishing up his doctorate degree from A.T. Still University.

Twitter – @wesj2288



Disclaimer

 

For the purposes of this podcast and post, we will be using the Puritan Bennett 840 ventilator (pictured below).  All the term we use are synonymous with all vents, but the screens will be different.

Puritan Bennett 840


Big Concepts of The Ventilator

 

  1. Mode
    1. Assist Control (AC)
      1. Every breath is either a machine driven (set by rate) or fully assisted (initiated by the patient)
        1. Uses either pressure (ACPC) or volume (ACVC)
    2. Synchronized Intermittent Mechanical Ventilation (SIMV)
      1. Set number of machine driven breaths, and patient intitated breaths are partially assisted
    3. Pressure Support (PS)
      1. No machine driven breaths and all breaths are initiated by the patient and partially assisted
  2. Delivery
    1. Pressure
      1. Static Controls
        1. Pressure
        2. Time (inspiratory)
        3. Peak flow
      2. Variable Factors
        1. Volume
        2. Total flow
    2. Volume
      1. Static Controls
        1. Tidal volume (cc)
        2. Flow (L/min)
      2. Variable Factors
        1. Pressure
  3. Positive End Expiratory Pressure (PEEP)
    1. The pressure left in the circuit at the end of expiration
    2. Prevents alveolar collapse and improves oxygenation
    3. Can cause barotrauma and affect hemodynamics

Static Controls

 

(For this section, refer back to the vent picture above)

  1. Fraction of Inspired Oxygen (FiO2)
    1. Start at 100% and titrate down to 21%
  2. f (machine breath rate)
  3. Control
    1. Pressure Control (PC)
      1. Inspiratory pressure (Pi)
        1. Peak pressure in circuit
        2. Initial setting = < 20 cm H20
      2. Inspiratory time (I-time)
        1. Initial setting = 1.25 seconds
    2. Volume Control (VC)
      1. Vt (tidal volume of each breath)
        1. Initial setting = 6-8 cc/kg IBW
      2. Vmax (flow rate)
  4. Spontaneous Support
    1. Trigger for spontaneous support
      1. Volume = V-trig
      2. Pressure = P-trig
    2. Pressure Support (PS)
      1. I was always taught at least 5 cm H20 to overcome circuit resistance

Real-Time Controls

 

  1. Flashing “C” and “S”
    1. Lets you know what breaths are controlled (machine) or spontaneous (patient)
  2. Airway Pressure
    1. Ppeak (max airway pressure)
      1. A marker of resistance
    2. Pmean (average airway pressure)
      1. A measure of alveolar pressure
    3. Pplat (small airway and alveoli pressure)
      1. A measure of compliance
  3. fTotal (machine + spontaneous breaths)
  4. I:E (inspiratory:expiratory ratio)
    1. Normal = 1:2 (at rest)
    2. Inverse ratio (2:1) can improve oxygen due to intention auto-PEEP

Wes Johnson’s Approach to Setting Up a Ventilator (after RSI)

 

Mode: AC

Vt: 6-8 mL/kg based on pt’s IBW

Rate: 12-16 bpm

FiO2: 100%

PEEP: 5.0

At the 5-minute mark:

  • Check an ABG
    • Titrate FiO2 off of PaO2 and pulse oximeter
    • Adjust minute ventilation off of PaCO2 and/or ETCO2


References

  1. Respiratory Review YouTube Channel https://www.youtube.com/channel/UCtaRF58UDVthvH36YYCttng
  2. Deranged Physiology.  Mechanical Ventilation. http://www.derangedphysiology.com/main/core-topics-intensive-care/mechanical-ventilation-0
  3. Weingart SD – “Spinning Dials – How to Dominate the Ventilator” – https://emcrit.org/wp-content/uploads/vent-handout.pdf
  4. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Annals of emergency medicine. 2016; 68(5):614-617. [pubmed]
  5. Air Link Regional West – “Initial Adult Ventilator Settings” – https://www.rwhs.org/sites/default/files/airlink-factsheet-ventsettings.pdf
  6. Open Anesthesia. Modes of Mechanical Ventilation. https://www.openanesthesia.org/modes_of_mechanical_ventilation/
  7. Modern Medicine Network.  A Quick Guide to Vent Essentials. http://www.modernmedicine.com/modern-medicine/content/tags/copd/quick-guide-vent-essentials
  8. Tobin MJ. Extubation and the myth of “minimal ventilator settings”. American journal of respiratory and critical care medicine. 2012; 185(4):349-50. [pubmed]