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Lack o f evidence for systemic anticonvulsant syndrom e associated autistic disorder order montelukast 10 mg otc asthmatic bronchitis 15. Clinical m anifestation of prenatal exposure to based casc-control tcratologic study of oral chloram phenicol treat­ valproic acid using case reports and cpidcm iologic inform ation buy montelukast 4mg online asthma treatment 6 year old. Clinical application of prostaglandins in hum an Ocular m anifestations and related deform ities cheap montelukast 10mg free shipping asthma definition by who. Pregnancy outcom e after the children of women treated with carbamazcpinc during pregnancy purchase montelukast 10 mg amex asthma young living oil. M cthotrcxatc-induccd congenital m alform a­ with treatm ent with carbam azcpinc during pregnancy. O cular m anifestations o f the fetal and cytarabinc cmbropathy: Is apoptosis the com m on pathway? Acta tum or necrosis factor therapy for inflam m atory arthropathies Ophthalm ol Scand 1999;77:530-5. In normal individuals, the medial intcr- migration of the orbits in embryonic development. Orbital canthal distance is equivalent to the palpebral length, and hypertelorism is present in several hundred syndromes and the ratio between the medial inter-canthal distance and the disorders, such as Waardenburg syndrome and Crouzon lateral inter-canthal distance is approximately 1:3. Normal values head malformations such as the morning glory disk anomaly, of this index for infants, children, and adults are around 0. Telecanthus is believed to result from overgrowth in width of the fronto-nasal process. Telecanthus is present in a number of multisystem malformation syndromes/’ Surgical repair of telecanthus consists of separate approaches to the three soft tissue elements responsible for creating the deformity: the cpicanthal fold, underlying subcutaneous tissue, and the medial canthal tendon. Ihe subcutaneous tissue, which is often abnormally thick, is excised under direct visualiza­ tion, and the medial canthal tendon can be shortened by a tuck, resection, or transnasal wiring, as described below. It is often useful to excise the fibrous band of tissue that runs beneath the skin and muscle and contributes to the fold. Note gray hair, increased inter-inner canthal distance (telecanthus) with lateral displacement of the Figure 3. The tendon is then secured with a 30-gauge stainless steel wire, which is passed transnasally. For bilateral cases, the wire will exit a similarly created hole in the bone on the opposite side; for unilateral cases, the wire passes through two small holes drilled just above the opposite medial canthal tendon and lacrimal sac. Abnormal insertion of the lateral canthal tendon may be due to deficiency of the tendon itself or to an abnormal position of an otherwise normal tendon. Lateral dystopia of moderate severity (congenital leukoderma), iris (heterochromia irides and requires a tarsal strip procedure. In more severe cases, the hypo isochromia irides), and hair (white forelock and lateral canthal tendon or lateral tarsal strip should be premature graying) (Fig. After reflecting the lacrimal sac, an opening is and skin extends continuously from the forehead to the aterial corr cheek, passing in front of the orbit, where it forms a small depression (Fig. In the second, incomplete, atypical or partial form of cryptophthalmos, there arc rudimentary eyelid structures and a conjunctival sac may be present temporally. There is localized corneal to the eyeball, does not carry lashes, and continues over opacification. Cases such as those reported by Key1-’ and Sugar," where there is typical cryptophthalmos on one side and abortive cryptophthalmos on the other, indicate that the two anomalies are equivalent. Cases have been reported with typical cryptophthalmos on one side and a dermoid, microphthalmos, or eyelid coloboma on the other side. Л fourth type of isolated cryptophthalmos exists where the eyelids are formed with a full complement of adnexal accessories. The eyelid fissure is displaced inferiorly close to the inferior orbital rim, but the conjunctival sac is rudimentary and the globe is not visible. The skin of the upper [ Ж eyelid is elongated, adheres to the underlying globe with a dimple over the cornea, and fuses with the shortened lower eyelid. True ano­ toes and/or fingers, renal anomalies, and malformations of phthalmia is the total absence of the tissues of the eye and the genital organs, especially in females. Other less common can be distinguished from extreme microphthalmia only malformations include anal atresia and umbilical hernias by histologic examination. Renal malformations such as renal term “clinical anophthalmia” when referring either to cases agenesis or dysplasia may occur, resulting in spontaneous of true anophthalmia or to extreme forms of microphthal­ abortions, stillbirths, or neonatal deaths. It is our belief, however, that identified causative mutations in 17 of the 40 families, and outward appearance greatly affects social interactions. The eyelid fissure forms in the sixth month of gestation, increased as needed with a dermis fat graft (Fig. As a last resort, craniofacial surgery may be neces­ often malformed both in its anterior and posterior segments, sary to expand the bony orbit to permit adequate soft tissue rendering visual prognosis very guarded even if a good expansion. Visual potential may be estimated with the aid of ultrasound, computed tomography, magnetic resonance imaging, visual evoked response, and electroretinography. Procedures should be aimed at obtaining a clear visual axis in addition to creating some form of functioning Eyelid colobomas are full-thickness notch defects of the eyelid structures. Surgical from a nearly complete abscncc of the eyelid to only a incision in the area of the palpebral fissure, for instance, may small notch in the lateral aspect of the lower eyelid, as seen open directly into the anterior segment of the eye. Eyelid colobomas absence of a conjunctival sac and hence of a normal ocular may be triangular or quadrilateral (Fig. Upper eyelid defects (the majority of colobomatous viable option for this severe deformity in some cases. In par­ eyelid defects) are usually nasal and occur between the tial or abortive cryptophthalmos, surgical intervention may inner and middle third of the eyelid. Colobomas of the upper eyelids arc seen in 12% to 20% of patients with Goldenhar syndrome, a variant of the oculo- auriculo vertebral dysplasia syndromes. The coloboma usually overlies an epibulbar dermoid, and patients may have preauricular skin tags, microtia, deafness, facial asym­ metry, macrostomia, microstomia, and vertebral anomalies (Fig. Goldenhar syndrome results from faulty devel­ opment of structures derived from the first and second branchial arches and the first branchial cleft between the sixth and eighth week of gestation. Patient was extensively investigated and did not have any associated malformations. Defect was repaired by primary approximation with excellent cosmetic and functional result. Lower eyelid colobomas are usually temporal, located between the middle and outer thirds. Colobomas of the eyelid may be due to failure of the mesodermal folds to fuse completely during devel­ opment. Additional fairly common findings include a tendency toward macrostomia, maloc­ clusion, high palate, and a high nasal root. The hair growth patterns are unusual, often showing tongue-like extensions of hair onto the cheeks, There may be grooves, clefts, or pits on the cheek between the mouth and the ear. This syndrome represents the most extensive abnormality of A the first branchial arch.

Temperature: When the ambient temperature is warm montelukast 5mg mastercard asthma definition easy, the extremities should be warm cheap 5mg montelukast fast delivery asthma exacerbation icd 10. Assessment of the temperature of the trunk and the extremities should be done simultaneously as cooling occurs from the periphery to the center effective montelukast 4mg asthmatic bronchitis quizlet. Color: Color of the skin reflects skin perfusion and indirectly respiratory and circulatory status montelukast 5 mg mastercard asthma treatment zones. Skin of palm and fingers may be pink (normal), pale, cyanosed, mottled or ashen grey depending on the degree of compromise. The extremity being tested should be raised above the level of the heart to make sure that only venous refill is not being tested. Brain: Brain perfusion can be assessed by features already described in appearance, i. Renal: Urine output may not be useful in initial assessment in a critically ill child, but is useful in monitoring the child and in evaluation of renal perfusion. Blood pressure: Shock can be present with normal, increased or decreased blood pressure. Progression to irreversible/refractory shock or multiple organ failure or death rapidly follows. Lower limit (5th percentile) of blood pressure is: Newborn 60 mm Hg systolic Up to 1 year 70 mm Hg systolic 2 to 10 years 70 + (2 × age in years) mm Hg Beyond 10 years 90 mm Hg systolic Pulse Oximetry Oxygen saturation assessment is an important adjunct to identify oxygenation state in an acutely ill child. Based on the appearance, breathing and circulatory status, the physiologic status of a critically ill child is classified as: 1. Cardiorespiratory failure is characterized by agonal respirations, bradycardia and cyanosis. Based on this physiologic status the severity of the compromise is classified and the child is managed further accordingly. For example; if a fluid bolus has been given then assess the child for any improvement as indicated by improved capillary refill, stronger pulses, improved urine output and a lower heart rate. Stabilization Depending on the physiologic status of the child, the following stabilization measures can be undertaken. Airway It should be assessed whether the airway is maintainable or unmaintainable. If the airway is unmaintainable, nasopharyngeal or oropharyngeal airway or intubation is required. The patency of the airway is to be assessed and excessive secretions should be cleared. Breathing Hundred percent oxygen should be provided to any critically ill child irrespective of the physiologic status. If the child has Respiratory Distress the child is kept with the caregiver, is allowed to maintain a position of comfort, and oxygen is provided in a non-threatening manner. Turbulent airflow leads to increased airway resistance; hence the child should be kept calm. In case of inadequate chest expansion or respiratory arrest, bag and mask ventilation should be given with 100 % oxygen. Tracheostomy or cricothyrotomy may be required in cases of complete upper airway obstruction caused by diphtheria, severe orofacial injuries or laryngeal fractures. Circulation Once airway and breathing have been stabilized, vascular access is to be secured. Any drug can be infused using this route provided it is followed by a flush of fluid to get the drug in the central circulation. Blood products should be administered only when specifically indicated for replacement o f blood loss or for replacement of components. When the circulation does not improve with fluid boluses alone, inotropes are used. During stabilization the priority is to address the Airway first followed by Breathing and Circulation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular Care: Part 10: Pediatric advanced life support. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Cerebral resuscitation after traumatic brain injury and cardiopulmonary arrest in infants and children in the new millennium. Critical illness causes alteration of physiologic status and biochemical parameters. The relationship between physiologic status and mortality risk may change as new treatment protocols, therapeutic interventions and monitoring strategies are introduced. Contribution of each variable and its ranges to mortality prediction were evaluated and the system was derived. The physiologic variables and their ranges were re-evaluated, eliminating some ranges that did not contribute significantly to mortality risk. A formal, operational method for assessing mental status is also included to account for frequent use of sedation and paralysis. The likely reasons for this could be difference in patient profile and greater load of severity of illness managed with lesser resources, both physical and human and also difference in quality of care. But there is no clear-cut threshold that directly predicts mortality and categorization of patients into different levels of risk is not possible. Score Probability of death (%) 5 9 10 15 15 23 20 35 25 49 30 63 35 75 How to Use the Score? This information is useful for optimum interventions and treatment to improve the outcome of critical illness. Tissue oxygenation is determined by the formula: O2 delivered = O2 carrying capacity of blood × cardiac output = ( Hb in gm × 1. In adults, the stroke volume can increase significantly while in the pediatric age group there are minimal stroke volume reserves and increased heart rate compensates maximally. If the demands increase beyond the compensatory mechanisms (decompensation), tissue oxygenation is jeopardized and anaerobic metabolism ensues with generation of lactate–the cascade of metabolic acidosis–negative inotropism–circulatory maldistribution is stimulated and ends up in multi-organ failure. In a stressful condition this failure cascade can be prevented or at least delayed, by timely oxygen supplementation. Oxygen is a life saving drug; and being a medication it carries a recommended dose. Overuse of oxygen can lead to serious longstanding side effects; so while using it, exact indications need to be defined and it should be used judiciously. Adequate tissue oxygen supply is the end result of adequate ventilation through the upper airways, lower airways and lung parenchyma; optimum perfusion across alveolar and capillary membrane, proper flow of blood across heart and pulmonary vasculature, uninterrupted systematic distribution of blood by cardiovascular system to all tissues and adequate oxygen carrying capacity of blood. Commonly the terms hypoxia and hypoxemia are used interchangeably but there is a theoretical difference where hypoxia indicates tissue under-oxygenation, while hypoxemia indicates decreased oxygen content of blood. A patient may be hypoxic but not hypoxemic as in severe septic shock and vice versa as in hemodynamically stable cyanotic heart disease.

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Drawer test – With the patient’s knees flexed to 45° 4mg montelukast free shipping asthma disease definition, inform and then sit on the patient’s feet (Figure 7 cheap 5mg montelukast amex asthma levels of severity. Excessive anterior draw is due to laxity of the anterior cruciate and posterior lag is associated with laxity of the posterior cruciate ligament discount 10mg montelukast visa asthmatic bronchitis uk. Hold the lower end of the thigh in your one hand and the upper end of the tibia with the other cheap 4 mg montelukast otc asthma symptoms menopause. Push the lower thigh in one direction and pull the tibia in the opposite direction and then in the reverse directions (Figure 7. Menisci McMurray’s test – Flex and externally rotate the knee and then slowly extend the knee to stress the medial meniscus. Flex and internally rotate the knee and then slowly extend the knee to stress the lateral meniscus. Palpate for click and assess for focal tenderness during the test as it may suggest a tear. Patella Lateral apprehension test – With the patient’s knee in extension, apply pressure against the medial border of the patella. Maintain the pressure, whilst flexing the knee to 30°and assess the degree of patella movement. Complete the knee joint examination Assess the neurovascular status of the lower limbs. The examination of the shoulder (ball and socket) joint follows the same logical pattern as examination of any other joint. This includes Look Feel Move Special tests Look General Look around bed for aids (slings). Specific Whilst the patient is standing: Inspect for swelling, muscle wasting, signs of inflammation and sinus formation. Anterior – Arthroscopic scars, sinuses, contour of the shoulder/squaring off, muscle wasting of deltoid and trapezius. Inspect for winging of the scapula (serratus anterior muscle supplied by long thoracic nerve of Bell, C5/6/7). Feel (ask the patient whether they are in pain before you begin) Temperature of the joint (with the back of the hand). Continue posteriorly to assess the greater tuberosity of humerus, spine of scapula, inferior pole of scapula, supraspinatus and infraspinatus. With the patient’s arm by the side, ask the patient to flex the shoulder forward (90°). Flex the patient’s elbows to 90° and then ask the patient to place their hands behind their head. Ask the patient to place their hands behind their back (normally one should be able to reach up as high as the sixth thoracic vertebrae). Special tests Rotator cuff muscles Supraspinatus (thumbs down test/Jobe’s test/Empty can test). To exclude rupture, passively abduct the patient’s arm to 40°, then the patient should be able to continue active abduction. Impingement test – This is impairment of rotator cuff function within the subacromial bursa. Impingement is characterised by pain and weakness on abduction and internal rotation. Neer’s sign and test – With the patient’s thumb down, place your hand on their shoulder and with your other hand passively lift up their hand in the plane of the scapula (forward flexion) until they express pain (Figure 7. Pain during this manoeuvre is a positive Neer’s sign and pain abolished with local anaesthetic is a positive Neer’s test. Hawkin’s test – Raise the patient’s arm to 90° forward flexion and bend the elbow to 90°. Jobe’s test (empty can) – Ask the patient to abduct the arc to 90° elevation in the scapula plane with full internal rotation (empty can). Ruptured head of biceps Assess for a ‘biceps bulge’ on flexing the patient’s elbow against resistance. Axillary nerve function Assess for deltoid muscle power and sensation (fine touch) in regimental badge area (Figure 7. Complete the shoulder joint examination Offer to perform apprehension test to test for shoulder instability (Figure 7. Impingement pain is reproduced when the shoulder is internally rotated with 90° of forward flexion, thereby locating the greater tuberosity underneath the acromion; (b) Neer’s impingement test. The patient’s upper limbs should be fully exposed and their hands resting on a pillow. The hand examination may represent a rheumatologic, orthopaedic, neurological or vascular case. The examination of the hands follows the same logical pattern as examination of any other joint. This includes Look Feel Move Special tests Look General Look around bed for aids and supports. Ensure you assess for extra-articular manifestations of systemic disease (see below). Assess for a dropped finger/thumb (evidence of extensor tendon rupture) and wrist drop. Palpate each joint to ascertain the levels affected in the hand and whether active inflammation or inactive disease is present. Palpate for tendon ruptures (start your palpation on the ulnar side of the hands). Ask the patient to perform the following movements: Grip and squeeze two of your fingers and perform a fine pinch. Place their hands in a ‘pray position’ to demonstrate wrist dorsiflexion (Figure 7. Place their hands in a ‘reverse pray position’ to demonstrate wrist flexion (Figure 7. Special tests Functional assessment: Power grip Pincer grip (pick up a coin or key) Button and unbutton shirt Hold a pen and write Neurological assessment (Sensation): Radial nerve (dorsum of first interosseous webspace) Median nerve (palmar/volar aspect of index finger) Ulnar nerves (palmar/volar aspect of little finger) Table top test: Ask the patient to place their hands flat on a table. Extra-articular manifestations of rheumatoid disease: Systemic – Weight loss, fever, malaise, vasculitis and amyloidosis Skin – Subcutaneous (rheumatoid) nodules Eyes – Keratoconjunctivitis sicca, scleritis, episcleritis Cardiovascular – Pericardial effusion, pericarditis, myocarditis Respiratory – Pleurisy, pleural effusion, nodules and fibrosing alveolitis Neurological – Entrapment neuropathy (carpal tunnel syndrome), atlantoaxial instability and multifocal neuropathies Abdominal – Splenomegaly, Felty’s syndrome Haematological – Anaemia, leucopenia and lymphadenopathy Muscular-Skeletal – Knees (valgus/varus deformity, popliteal ‘Baker’s’ cysts), scars for shoulder, knee or hip replacements Complete the hand examination Perform a full neurological assessment of the upper limbs. Assess for extra-articular manifestations of rheumatoid disease (eyes, respiratory, cardiovascular, neurological systems). The examination of the spine follows the same logical pattern as examination of any other joint. This includes Look Feel Move Special tests Look General Look around bed for walking aids and supports (Miami J collar, thoracolumbar brace). Specific Whilst the patient is standing, inspect Skin – Scars, sinuses, hairy tufts, café au lait spots Soft tissues – Muscle wasting Bone – Scoliosis, kyphosis, lumbar lordosis, gibbus Feel Ask the patient whether they are in pain before you begin.

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Diet-controlled diabetic patients For minor surgery effective montelukast 4mg asthma definition yeah, no additional precautions are required 10 mg montelukast with amex asthma definition 4th. For major surgery cheap montelukast 5mg fast delivery asthmatic bronchitis that wont go away, monitor blood glucose and if elevated commence an insulin sliding scale discount montelukast 4 mg otc asthma symptoms neck pain. Oral hypoglycaemic-controlled diabetic patients For minor surgery, the morning dose of the oral hypoglycaemic agent should be omitted. For major surgery, patient should be commenced on an insulin sliding scale when they are nil by mouth and stopped when they have resumed eating and drinking. Insulin-controlled diabetic patients For all surgeries, the insulin dose should not be given whilst the patient is fasted. Intra-operative period: Anaesthesia combined with surgical stress has a definite hyperglycaemic effect. Post-operative period: Aim to have the patient’s blood glucose levels within normal range. Oral fluids once started should be followed by a soft diet and then a diabetic diet. The patient was neuropathic but not ischaemic and it was possible to salvage a functional foot by ‘filleting’ the hallux and using the soft tissues to cover the defect. Whilst treating patients, we are commonly exposed to bodily fluids (including blood). This can occur with needle stick injuries, mucosal contact and bodily fluid spillages and splashes. Route Estimated infections/10,000 % exposures to an infected source Blood transfusion 9000 90 Needle-sharing 67 0. When there is a risk of splashing, particularly with power tools, use of a full face mask is recommended, or protective glasses. Use of fully waterproof, disposable gowns and drapes, particularly during seroconversion. A set protocol should be followed: Immediate action Following any exposure, the site is washed liberally with soap and water (without scrubbing). Exposed mucous membranes, including conjunctivae, should be irrigated copiously with water, before and after removing any contact lenses. Risk assessment This assessment needs to be made urgently by someone other than the exposed worker about the appropriateness of starting treatment. The decision for prophylaxis is based on the exposure potential, the type of body fluid or substance involved, and the route and severity of the exposure. There are two principles involved: Differential light absorption by deoxyHb and oxyHb at two wavelengths, usually 660 nm (red, where deoxyHb > oxyHb) and 940 nm (near infrared, where oxyHb > deoxyHb). Since the pulsating blood in the artery is the only substance that is changing, the stable substances (skin, tissue etc. Increased surgical bleeding (the enzymes in the clotting cascade are slowed down) Increased incidence of myocardial infarcts and arrhythmias (hypothermia and shivering increases oxygen consumption and vascular resistance) Delayed recovery from anaesthetic/prolonged drug metabolism Excessive sympathetic nerve stimulation on waking Negative nitrogen balance (protein catabolism) Impaired immune function Increased wound infection Patient discomfort Describe measures to reduce heat loss in patients undergoing surgery. The most likely reasons are sepsis (including the presence of an intra-abdominal collection), a pulmonary embolus or an anastomotic leak. Bleeding is unlikely at day 7 post-operative and also note the patient has an associated fever. This patient is acutely unwell and requires urgent resuscitation and investigation to determine the cause (Table 4. The system is composed of three allelic genes-A, B and O, which control synthesis of enzymes that add carbohydrate residues to the cell surface glycoprotein. The system allows for six potential genotypes although there are only four possible phenotypes. Blood group O is the universal donor type, as it contains no antigens to provoke a reaction. Rhesus system the rhesus D (Rh (D)) antigen is strongly antigenic and is present in approximately 85% of the population in the United Kingdom. Antibodies to the D antigen are not naturally present in the serum of the remaining 15% of individuals, but their formation may be stimulated by the transfusion of Rh-positive red cells, or acquired during the delivery of an Rh (D)-positive baby. Acquired antibodies can cross the placenta in pregnancy and if present in an Rh (D)-negative mother may result in severe haemolytic anaemia and even death (hydrops fetalis) in an Rh (D)- positive fetus in utero. An annual report is published and guidelines are issued to try and improve transfusion practice in hospitals nationwide. What is the legal position on Jehovah’s Witness patients and the use of blood products? Wherever possible, consultants should be involved and a second medical opinion should be sought. The Royal College of Surgeons and the Association of Anaesthetists have produced guidelines: Adults Competent adult patients of sound mind have the right to refuse medical treatment (however irrational this may be perceived to be) even if the consequences of such refusal may lead to the patient’s death or serious injury. To administer blood in the face of refusal by a patient may be unlawful and could lead to criminal and/or civil proceedings. In an emergency if the patient is able to give an informed, rational opinion, or if an applicable advance directive exists, this should be acted upon. If this is not the case, the clinical judgement of a doctor should take precedence over the opinion of relatives or associates. Children In the case of children, the situation is more complicated: If a child needs blood in a life-threatening emergency, despite the surgeon’s best efforts to contain haemorrhage, it should be given. The surgeon who stands by and allows a ‘minor’ patient to die in circumstances where blood might have avoided death may be vulnerable to criminal prosecution. Although children of 16 and over may consent to treatment, as can mature children under 16 (Gillick competency), this does not give such children the right to refuse treatment which is required in their best interests. However, it is always necessary to ascertain the views of the child so that they may be taken into account. In an elective, or semi-elective situation, where the child requires a blood transfusion, refusal by the parents may be overridden by an application to the High Court for an Order that the child receive a blood transfusion or other necessary medical treatment. What strategies do you know of for avoiding or reducing the need for blood transfusions? Advantages: Release of inpatient beds (resources) Increase the potential number of patients treated Greater efficiency of operating list scheduling A firm date and time for operation with reduced cancellation risk Reduced disruption to patient’s lives Reduced incidence of nosocomial infections Cost efficacy Disadvantages: Requirement for adequate aftercare Experienced and trained surgical and anaesthetic staff mandatory Requirement for inpatient admission or readmission in cases of unexpected complications, inadequate analgesia etc. How would you manage a multiply injured patient who was brought in to the emergency department following a road traffic accident? Further evaluation: Carry out continuous assessment and reassessment of the patient to detect any changes in their condition Documentation and legal considerations Definitive care and transfer * For further reading, see Bailey and Love’s Short Practice of Surgery 27th editio, Chapter 18, ‘Anaesthesia and Pain Relief’ * For further reading, see Bailey and Love’s Short Practice of Surgery, 27th edition, Chapter 20, ‘Postoperative care’. An understanding of basic physiological principles is essential to competently answer the probing management-style questions. Manoeuvres – Suction, head-tilt, chin lift, jaw thrust Adjuncts – Oro/naso-pharyngeal airways Definitive – Oro/naso-tracheal intubation, surgical airway (cricothyroidotomy, tracheostomy) What types of tracheostomy do you know of? Elective versus emergency Cuffed versus uncuffed Fenestrated versus unfenestrated Open versus percutaneous Silver metal versus plastic What complications should you be aware of with a tracheostomy?

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