[starttext] Neonatal seizures are often the most difficult thing to identify, specially wen seizures are subtle.
In newborns, Seizure can present with following features-

  1. Autonomic instability- Tachycardia, respiratory changes, High BP
  2. Sucking movements of lips
  3. Tonic eye deviation
  4. Vacant staring episodes
  5. Paddling/Cyclical limb movements
  6. Stiffening of the body
  7. In case of myoclonic seizures- head drops, salam spells.
  8. Sometimes electrical seizures can occur that is identified on EEG only.



Neonatal Seizure : Video

[starttext] Pill rolling tremor (Parkinsonism): Patient attempts to maintain body position at rest. Flexed elbow, wrist and MCP joint with flexion-extension and rotatory movement between thumb and finger (thumb moving across tips of all fingers). It is improved by activity and worsened at rest. Proximal muscles, lips and tongues are also frequently involved. [endtext] http://www.youtube.com/watch?v=rHuRiRHe5_Iendofvid

Pill rolling tremor

[starttext] Examination of Cardiovascular System in standard method as demonstrated by Macleods. Watch the video for a systematic and serial approach to examination of the patient.
Cardiovasular Examination Includes-
General Status
Related Examination
Precordial Examination
- Inspection
- Palpation
- Percussion
- Auscultation
Abdominal examination for Liver and abnormal aortic pulsations
Peripheral pulses examination.


Examination of Cardiovascular System : Standard clinical bedside method

[starttext] Emergency decompression of a Tension Pneumothorax can be a life saving procedure. A simple needle decompression can be worthy enough to save a life. Knowing the right procedure and site of insertion of needle is demonstrated in this video. For the definite treatment, Intercostal drainage insertion should be planned for after this. [endtext]


Emergency decompression of Tension pneumothorax: Tutorial video

 [starttext ]Lumbar is a relatively common procedure in children, specially in infants. As Meningeal signs may not be evident in infants and there is always higher risk of Meningeal infection in bacteremia in Infants, LP is sometimes mandatory as a part of treatment.
LP is a part of work-up for Late-onset neonatal sepsis.

1. CNS infection - Bacterial Meningitis, Congenital Syphilis, Encephalitis

1. Raised ICP
2. Bleeding disorders or bleeding tendency- DIC, thrombocytopenia
3. Local Infection

Here is an excellent demonstration of the procedure in infant. Though it is not shown there, using a sterile gloves is a must.


Lumbar Puncture in Infants- Procedure Video

 [starttext] Standard Cardiovascular system examination demonstrated by Macleod's Clinical Examination. The examination sequence is rationale handy and is less time consuming than conventional styles. Few techniques changed in examination. Follow the video and comment on any doubts. [endtext] http://www.youtube.com/watch?v=IrIZyf3wNvsendofvid

Cardiovascular System Examination: Clinical Medicine

[starttext] The fate of your child depends upon how you start and maintain your child's feeding habit and lifestyle. Here is one insightful video that has re-winded the life of a patient with heart attack. Think and decide, is this what you want your child to meet at the end. Less TV, more outdoor games, regular exerciser, healthy diet and cut off sweets and drinks. [endtext] 

Heart Attack Patient Time travels to his Past: What went wrong? Video

[starttext] Sleep is a necessity of body homeostasis. Inadequate sleep or sleep lapse can cause tremendous amount of consequence on brain and bodily performance. How many hours of sleep per day is required is a big question. The requirement is variable but on an average a normal human needs an 8 hour sleep. The video given below is self explanatory.

The hazards of Sleep deprivations- Read symptoms and signs of sleep deprivation.



How much sleep do we need in a day?

[starttext]Tracheotomy and tracheostomy are surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe). It is performed in emergency situations, in the operating room , or at bedside of critically ill patients. This procedure, technically called a cricothyroidotomy, should be undertaken only when a person with a throat obstruction is not able to breathe at all-no gasping sounds, no coughing-and only after you have attempted to perform the Heimlich maneuver three times without dislodging the obstruction.

  1. Find the person's Adam's apple (thyroid cartilage).
  2. Move your finger about 1 inch down the neck until you feel another bulge. This is the cricoid cartilage. The indentation between the two is the cricothyroid membrane, where the incision will be made.
  3. Take the razor blade or knife and make a 1/2 inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood.
  4. Pinch the incision open or place your finger inside the slit to open it.
  5. Insert your tube in the incision, roughly one-half to one inch deep.
  6. Breathe into the tube with two quick breaths. Pause 5 seconds, then give 1 breath every 5 seconds.
  7. You will see the chest rise and the person should regain consciousness if you have performed the procedure correctly. The person should be able to breathe on their own, albeit with some difficulty, until help arrives.

The term tracheostomy is sometimes used interchangeably with tracheotomy. Strictly speaking, however, tracheostomy usually refers to the opening itself while a tracheotomy is the actual operation.


Tracheotomy Procedure with Animation tutorial

[starttext] Comedones are also called whiteheads and blackheads. Blackheads are open comedones, and whiteheads are closed comedones. Many people have them in their skin, but this severity of blackheads?
Watch this blackhead removal using special instrument. This video shows removal of big black heads from nasal area of an old patient, that slip out like live worms [endtext]

Blackhead or comedone: Removal or extraction

[postlink]http://tube.medchrome.com/2010/11/nasal-myiasis-maggots-in-your-nose.html[/postlink] [starttext]This post includes a video of maggots in nose and the removal of maggots using ether.

Myiasis is the infestation of tissue with fly larvae, commonly referred to as maggots. Maggots infest nose, nasopharynx and paranasal sinuses causing extensive destruction and obvious deformity.

  1. Visible maggots should be picked up with forceps
  2. Instillation of chloroform water/ether and oil (liquid paraffin) kills them
  3. Nasal docuhe with warm saline is used to remove slough, crusts and dead maggots
  4. Avoid contact of the patient with flies by use of mosquito nets
  5. Nasal hygiene for prevention
For complete information about nasal myiasis: http://medchrome.com/minor/ent/nasal-myiasis-maggots-in-nose/


Nasal Myiasis Removal Video

http://www.youtube.com/watch?v=jTsjCZ9QxW8endofvid [starttext]

Systolic blood pressure normally falls during quiet inspiration in normal individuals. It is the accentuation of normal physiology where there is an inspiratory fall in systolic blood pressure more than 10 mmHg.

Pulsus paradoxus is defined as a fall of systolic blood pressure of more than 10 mmHg during the inspiratory phase. [Eur Respir J. 2012 Dec 6. Pulsus paradoxus. [Hamzaoui O Et Al]

1.Inflate the cuff beyond the point where you hear any Korotkoff sounds.
2.Slowly deflate the cuff until you start hearing any sounds. At the highest BP when you hear sounds intermittently (rather than with every heart beat), note the blood pressure. (This corresponds to the higher systemic blood pressure which is occurring during expiration).
3.Keep slowly deflating the cuff until you reach the highest BP in which you hear sounds every beat.
4.The difference between #2 and #3 is the “pulsus paradoxus.” If it is >10 mmHg, it is considered significant.

Cardiac causes
Cardiac tamponade
Pericardial effusion
Constrictive pericarditis
Restrictive cardiomyopathy
Pulmonary embolism
Acute myocardial infarction
Cardiogenic shock

Extracardiac pulmonary causes
Bronchial asthma
Tension pneumothorax

Early recognition of pulsus paradoxus can help to diagnose rapidly cardiac tamponade, assess the severity of acute asthma as well as its response to therapy. Its essential to have good clinical skill inspite of development of newer technology [endtext]

Pulsus Paradoxus- Correct technique of measurement

[starttext]Indication: Evaluation of dry eye (Measures aqueous tear production)

1. Schirmer 1 (without anesthetic): measures baseline and reflex secretion
  • function of main lacrimal gland, whose secretory activity is stimulated by the irritating nature of filter paper
2. Schirmer 2 (without anesthetic): measures baseline secretion
  • function of accesory lacrimal glands (the basic secretors)
Materials required: 5 X 35 mm of Schirmer's strip or Whatman filter paper no. 41

  1. The eye is gently dried of excess tears
  2. The schirmer strip is folded 5 mm from one end and kept in the lower fornix at the junction of lateral 1/3 and medial 2/3 (do not touch cornea or lashes)
  3. The patient is asked to close the eyes.
  4. Tears in the conjunctival sac will cause progressive wetting of the paper strip.
  5. After 5 minutes, the filter paper is removed and the distance between the leading edge of wetness and the initial fold is measured, using a millimeter ruler.
Normal: >15 mm
Mild-moderate Keratoconjunctivitis sicca (KCS): 5-10 mm
Severe KCS: <5 mm
<10 mm is considered abnormal in Schirmer 1 and < 5 mm in Schirmer 2
Causes of KCS:
  1. Idiopathic
  2. Congenial alacimia
  3. Xerophthalmia
  4. Lacrimal gland ablation
  5. Sensory denervation
  6. Collagen vascular disease: Sjogren syndrome, SLE, RA

Schirmer's test I & II: Dry Eye Screening

1. Write the Root values C5, C6, C7, C8 and T1 leaving almost equal space between the 2 consecutive points.

2. Join C5 and C6 like in the video to get image similar to greater than sign. Join C8 and T1 in the same manner. Leave C7 alone in between.

3. As demonstrated in the video, from green, blue and orange figures obtained from step 2, extend 3 curved parallel lines that drop into the same imaginary horizontal line.

4. From the end of the green line extend a line (brown) to the orange line slightly above the end of the orange line as shown in the picture below.

5. In between the green and blue line draw a cross touching both lines. Draw a branch from orange line on the blue line such that it meets the green line of the cross.

6. For branches and labelling, follow the video or picture.

Mnemonic: Real Teenager Drinks Cold Beer (R=Root, T=Trunk, D=Division, C=Cord and B=Branches)

How to draw brachial plexus : Video

[starttext]Originally designed for use in spontaneously breathing patients, it consists of a ‘mask’ that sits over the laryngeal opening, attached to which is a tube that protrudes from the mouth and connects directly to the anaesthetic breathing system. On the perimeter of the mask is an inflatable cuff that creates a seal and helps to stabilize it.

The use of the laryngeal mask overcomes some of the problems of the simple adjuncts:

  1. It is not affected by the shape of the patient’s face or the absence of teeth.
  2. The anaesthetist is not required to hold it in position, avoiding fatigue and allowing any other problems to be dealt with.
  3. It significantly reduces the risk of aspiration of regurgitated gastric contents, but does not eliminate it completely.

Relative contraindication: 

  1. Increased risk of regurgitation, for example in emergency cases, pregnancy and patients with a hiatus hernia. 

Technique for insertion of the standard LMA:

  1. The patient’s reflexes must be suppressed to a level similar to that required for the insertion of an oropharyngeal airway to prevent coughing or laryngospasm.
  2. The cuff is deflated and the mask lightly lubricated.
  3. A head tilt is performed, the patient’s mouth opened fully and the tip of the mask inserted along the hard palate with the open side facing but not touching the tongue.
  4. The mask is further inserted, using the index finger to provide support for the tube.
  5. Eventually, resistance will be felt at the point where the tip of the mask lies at the upper oesophageal sphincter.
  6. The cuff is now fully inflated using an air-filled syringe attached to the valve at the end of the pilot tube.
  7. The laryngeal mask is secured either by a length of bandage or adhesive strapping attached to the protruding tube.
  8. A ‘bite block’ may be inserted to reduce the risk of damage to the LMA at recovery.

[endtext] http://www.youtube.com/watch?v=rnTLqhd6cwkendofvid

Laryngeal Mask Airway (LMA) Insertion Technique

[starttext] [endtext]Seizure is any clinical event caused by an abnormal electrical discharge in the brain, whilst epilepsy is the tendency to have recurrent seizures.


A. Partial seizure: Focal, only part of cortex involved

  1. Simple: No loss of consciousness (LOC), no postictal state
  2. Complex: Postictal state present, LOC may or may not be present

B. Generalized seizure: Always associated with LOC, whole cortex is involved

  1. Absence (petit mal): Brief episode of nonresponsiveness to external or internal stimuli; motor tone is preserved
  2. Tonic–clonic (grand mal): Generalized convulsion - brief tonic phase (stiffening) followed by clonic phase (rhythmic jerking) 


Classification of Seizure

1. Maintenance of a patent airway:

  • When an awkward intraoperative position is required (eg. lateral decubitus, prone, sitting)
  • When the airway is inaccessible (eg. during head and neck operations)
  • When difficulties with the face mask are anticipated (eg. in grossly obese or edentulous patients or those with unusual facial features).

2. Protection of the airway: from contamination by blood, pus, debris, or stomach contents

3. Controlled ventilation

Technique of laryngoscopy and Tracheal intubation:

1. Position: The patient is positioned supine with the head resting on a pillow, in the so-called 'sniffing the morning air position' (flexion of the lower cervical spine and extension of head at atlanto-occipital junction). The position aligns the oral, pharyngeal and laryngeal axis so that the pathway from the lips to the glottis is nearly a straight line.

2. Laryngoscopy: The laryngoscope is held in the left hand, whilst the right hand is used to stabilize the head and open the mouth. The laryngoscope is inserted into the right side of the patient's mouth avoiding the incisor teeth and pushing the tongue to the left. The tip of the blade is advanced in the midline over the back of the tongue until the epiglottis comes into view. The tip of Macintosh laryngoscope blade should be positioned above the epiglottis, into the vallecula (the space between the base of tongue and the epiglottis). The tongue and pharyngeal soft tissues are then lifted, pulling the epiglottis up without directly touching it, exposing the glottic opening. You should use your arm and shoulder to lift the laryngoscope handle in an anterior and forward direction (along the long axis of handle containing the batteries). The tendency to lever the laryngoscope against the upper incisor teeth or upper gum should be avoided to prevent trauma.

The Miller blade, which is straight, is less commonly used. The tip of Miller blade is passed beneath the laryngeal surface of the epiglottis and the epiglottis itself is then lifted to expose the vocal cords. There is more risk of trauma to the epiglottis and stimulation of the laryngeal surface of the epiglottis.

3. Intubation: The size of the tracheal tube used depends on the patient's age and body build. Usually an 8mm internal diameter cuffed tube is used for women and a 9mm tube for men. The tube is held in the right hand as one would hold a pencil and advanced through the oral cavity through the right corner of the mouth and then through the vocal cords. External pressure on the cricoid or thyroid cartilage may be required to help visualize the laryngeal inlet. The proximal end of the tube cuff is placed so that the cuff is below the vocal cords, and the length markings on the tube are noted in relation to the patient's lips. The cuff is inflated to obtain a seal in the presence of 20-30 cm H20 pressure of gas in the breathing system.

4. Verification of position of tube: The next step is to verify the position of the tracheal tube. The best method to determine the position of the tube is by detection of carbon dioxide in expired gas. It is possible for gas in the stomach to contain carbon dioxide but this will only be present in the first few 'breaths'. Visulaization of the end of the tube advancing through the vocal cords is also taken as a sign of correct palcement. However, tubes may be displaced after 'correct' insertion. Auscultation of both lung fields in the axilla and over the stomach may also be used to confirm correct placement, but is less reliable. Asymmetrical breath sounds may indicate that the tip of the tube lies in one or other of the main bronchi (usually the right_. The tube should be withdrawn until breath sounds are heard bilaterally.

Complications of orotracheal intubation include:

  • Injury to lips, tongue or teeth
  • Injury to larynx (especially the arytenoid cartilages and the vocal cords)
  • Tracheal mucosa tear
  • Sympathetic stimulation

Attempting laryngoscopy or tracheal intubation in lightly anesthetized patients who are not fully relaxed can result in laryngospasm, coughing and bronchospasm. The laryngoscope should be removed, face-mask ventilation should be continued and anesthesia deepened or more muscle relaxant given to achieve adequate conditions. A peripheral nerve stimulator can be used to ensure complete neuromuscular blockade before commencing laryngoscopy and intubation.[endtext]

Intubation procedure: Video

[starttext]There are 5 commonly used brushing techniques: Bass or modified bass, Charters, Modified Stillman, Rolling stroke and Modified stroke. While the rolling technique is commonly used by the children, Bass or modified bass is the commonest technique for the adults. 

  1. Hold the toothbrush sideways against your teeth with some of the bristles touching your gums.
  2. Tilt the brush so the bristles are at 45 degree angle and pointing at your gum line.
  3. Move the brush back and forth, using short strokes. The tips of the bristles should stay in one place, but the head of the brush should wiggle back and forth. You also can make tiny circles with the brush. This allows the bristles to slide gently under the gum. Do this for about 20 strokes or 20 circles. 
  4. Repeat for every tooth, on the insides and outsides.
  5. The toe bristles of the brush can be used to clean the lingual (tongue) surface of the anterior teeth.

Modified Bass:
  1. Follow all the steps of the Bass technique.
  2. After the vibratory motion has been completed in each area, sweep the bristles over the crown of the tooth, toward biting surface of the tooth.
Importance of these methods:
  1. Most effective in cleaning cervical 1/3 & beneath gingival margins
  2. Suitable for everyone – Periodontally healthy & periodontally disease
  3. Periodontal maintenance
  4. Cleanses sulcus (space between tooth and gums)[endtext] http://www.youtube.com/watch?v=LqCpZm6s_dEendofvid

Brushing technique: Bass and Modified Bass Methods