Thank you welcome to be i am your host dr. daniel hauler we have quite a show for you today let’s get on with the news tpa haters the new a subclinical policy for administration of tpa and ischemic stroke are here hot off the presses and let me tell you i can feel the hatred coming at me through this camera right now really nothing’s changed considering the risk of
A inter-cranial hemorrhage has moved to now eight level b recommendation so i guess we just might want to kind of consider that tpa may be given the wording of that has changed to should be offered in may be given level b recommendation of 3 to 4.5 hours from the time of onset has remained unchanged that coming from eks 3 and a new level c recommendation of shared
Decision-making when feasible has been added whatever when feasible means a new study in jama surgery reports that erythromycin improved stomach clearance in non-traumatic emergent surgeries think your appendectomy cholecystectomy ‘he’s the study showed that 3.4 times greater likelihood of having stomach clearance after given erythromycin after six hours so if you
Want your stomach minty clean take some erythromycin i just made it up from the new england journal of medicine and new ongoing study reverse ad shows that there is a new pradaxa reversal agent your dick zynga mad or does it go mad it’s been shown to be only five billion times more expensive than vitamin k that is the news let’s get on with the rest of the show
I’m jim picked all out this is clay smith he clearly has adjusted shoulder right children and since we cover the fair’s technique last week on keeping up we’re going to actually do a little bit on how the how it actually how they did it the fair’s technique basically keep the arms fully extended hold their hand form in a neutral position and without any medicine
Or sedation just going to start these oscillating movements about five centimeters up and down and slowly kind of abduct the arm just keep going i like to talk to people about their family their into sports hunting evil i’m not a hunter politics religion all those taboo topics to get them off the fact that their shoulders just get it and you’re just slowly kind
Of abducting the arm out creating these oscillating movements kind of every five swimmers up and down have a little bit of traction on once you get up to about 90 degrees you then do a little bit of external rotation and keep ab ducting you come up about 120 degrees of abduction that’s kind of point where they got the well a jeweler hammer will join reduced right
About here he’s in is in like flynn all right then you just kind of put the arm back down across the chest now some of the other techniques a tweet that we’ve had and was even discussed in the paper they compared to the coker method the coker method he was a surgeon he he described in the late early 1900s it’s actually been around for about three thousand years
Is actually in the egyptian tomb in case you’re interested in that so was the head of the head images showing it i’m full of useless facts so it starts differently with with external rotation so an external rotation itself can be a reduction technique keep the arm fully ad ducted elbow flexed at 90 degrees and slowly actually rotate the arm then when you meet
Resistance you can do two things you can add scapular manipulation which is where you take the the tip of the meat of the scapula and push it immediately you can use that with any reduction technique for that especially taking that tip and pushing it meeting that rotates the glenoid fossa for you or you can do the fellows coger describe its then take the arm you
Flex in the sagittal plane and then you internally rotate the arm like this so conquer method again actually rotate flex and anjali rotate not as a big a fan of the copra method because that you levert against acromion on that it seems a little traumatic to me so i don’t generally do that if i’m not sedating someone a couple other techniques have been described
More recently it’s called the spasso technique it’s really good if you’re on the field like an athletic event or if you’re out in the wilderness and some anticipates your shoulder because we’re laying down the ground it’s easy to do this on the ground with someone we basically ford flex the arm to 90 degrees and you fully actually rotate and then just you pull
Traction longitudinal traction while you’re holding counter traction you can use your leg and you can use your foot to kind of hold down traction just hold it gently down down retraction and just pull traction up like this and it works fairly well slowly petite that’s definitely slow and easy as how the turtle won the race that’s how the shoulder goes back in
The most common method at uc is the traction counter traction that’s simply basically you have a cheaper cheat ramp this way someone’s pulling that direction through the axilla your kind of pulling actual traction here i won’t pull them off the table you can also internally nationally rotate when i do this i should like to hold the arm and kind of a figure eight
Because that way it’s easier to actually rotate initially rotate and i can pull a lot of traction through his elbow now if you can even abduct all the way out and once you get up to this position is kind of melding between that and the milk and even the end end result of affairs well there’s a lot of overlap between these reduction techniques now lastly if external
Rotation doesn’t work and kepler manipulations spazz those are the affairs what i do especially if i was working by myself i flip them over to induced in sins technique so i’m clip-on over for me but and this basically is the arm is hanging off the side use hang weights so i start with 10 pounds i go see another patient i come back i put five more pounds on i go see
Another patient come back to put five pounds on come back see another patient and come back and see them after about 20 pounds you can either just add just a little bit of gentle tug downward traction and that reduce it or you can push the tip of his scapula medially that will help as well now there is a modified stinson’s where you flex the elbow flex like this
And what that does it takes it removes tension off the biceps tendon which is a primary stabilizer the giller normal joint that’s why the deflection of the elbow and that’s sometimes will help you get it back in the jira i found just by hanging wait a little bit of scapular manipulation it comes back in and those are kind of basic techniques that we do shoulders
Thank you which one’s your favorite techniques to do now it’s the fair’s yeah hit it actually a couple of days ago on an autistic patient no sedation no analgesia and when in about two minutes add the shoulder back in yeah it was great yeah i loved it was better than cats i’m going to do it again again good i like i’m ready use affairs i also like external rotation
With scapular manipulation i like the spaz oh technique and then flip them over i’m too old to be pulling and sweating so much with the direction counter traction little comment on the hippocratic methods so the way they described it in the paper is not technically corrected it the hippocratic method actually is as the medieval of all techniques must medieval and
That basically your foot is in their excellent action through your foot and you have someone else on the arm with a band that’s pulling this play guaranteed to rip out their brachial plexus that’s the true hippocratic method they describe it more as a traction counter traction emma in the paper thanks for that clarification yeah problem just want to keep a ride
You want to keep your old epidemz correct yeah hope is help for you yeah and yeah enjoy this listener if you have any comments
Transcribed from video
EMTV S01E05 July 1st 2015 – idarucizumab By Daniel Hohler
