ࡱ> QSLMNOPq`0`bjbjqPqP ::::%```````twww84xPy4t={|"4|4|4|}&} }=======Bh;Et=`k}"}=``4|4|7=ΧΧΧ`4|`4|=Χ=ΧΧB'``n=4|{ zg w6f==0= 7NEEn=E`n=0}~Χ!t}}}==jd}}}=rtttxtttxttt`````` University of sulaymany  college of medicine for (forth, fifth, sixth ) stage medical student Prepared & collected by: Dr .Soran Mohamad Gharib 2008 Clinical Assessment of a case Of head injury Head injuries; "No head injury is so slight that it should be neglected, or so sever that life should be despaired of" Trauma imparted to the cranium can take the form of: Translational acceleration force Translational deceleration force Rotational force Direct, focal, sharp penetrating force Blunt force Why most cerebral contusions occurs with out skull fractures and why patients with skull fractures are often awake with only a minor neurological dysfunction? What is Coups and Countercoups injury? Things to remember.. *Letters in the word "scalp" can define different layers of the scalp that may be injured; S stands for Skin C stands for subcutaneous tissue A stands for Aponeurosis L stands for loose areolar tissue P stands for Pericranium *identify the severity of the primary brain injury and record a base line of neurological disability. *Get initial information from the witnesses and ambulance crew about the nature and the velocity of the trauma, initial state of consciousness, post-traumatic amnesia, headache, vomiting or fits. Things to remember.. *consider the possibility of other life threatening injuries *record initially any history of drug intake or concomitant medical illness. *Decide, as early as possible, when to refer to a specialist neurosurgical care, and, to the same degree, not to refer without a good indication. *Patient must be reexamined many times at frequent intervals. *Understand the standard "Evaluation score" so called Glasgow Coma Scale. *Consider the need for "advance trauma life support system protocol (ATLS)" along with stabilization of airway, breathing, circulation, disability and exposure (ABCD and E). *You may need to immobilize the cervical spine, as there is a high possibility of associated cervical spine injury. Things to remember.. *Perform a correct, informative and reliable detailed neurological examination to pick up, as early as possible, signs of focal neurological damage and that of rise in intracranial pressure. *Not to aim always at referring the victim without recording the result of your observations. *Use your armamentariums, a "narrow spot" torch light, a hammer, gloves, little of neuroanatomy and neurophysiology, and a real will to be helpful. *Keep on looking to a copy of "Glasgow Coma Scale", repeat applying it for all head injury cases. Glasgow Coma Scale;  Factors affecting Glasgow coma scale other than cerebral injury; Limitation of eye opening may occur in facial trauma and periorbital Edema affecting assessment of eye opening. Upper limb is more representative of the motor reflex than the lower limb. Presence of fracture, that may be missed, can affect interpretation of motor response. Language and endotracheal intubations may affect assessment of verbal responses Scalp injuries; Scalp never gapes unless the galea aponeurotica has been divided. Collection of blood beneath the Aponeurosis tends to involve the whole area between the occipitofrontalis muscles. Effusions beneath the Pericranium are limited to the suture lines Subpericranial heamatoma may feels exactly like a depressed fracture Scalp injuries Proper examination need complete shaving of the scalp hair. Bleeders from the scalp injury can be controlled by pressure application, hemostat application or by eversion of the galea. Depressed skull fractures may underlie a scalp injury. Scalp heamatoma always overlie a skull fracture in infants. Scalp lacerations tend to bleed very heavily Common types of skull fracture; Simple linear; It may be confused with suture lines. Those that cross the middle meningeal artery can cause extradural hemorrhage. Depressed; It needs suturing of overlying scalp wound before referral for debridement and elevation. Base of the skull fractures; may present with "Raccoon eyes, Mastoid bruises or CSF leak. Orbital blow-out fractures; Cause diplopia and require repair. Fracture base of the skull; Anterior Cranial fossa #....danger of CSF Rhinorrhoea  Middle Cranial Fossa Fracture; Suspected when there is blood or blood diluted with CSF escaping from the external auditory meatus. In tympanic membrane rupture, blood will clot, but will not in case of blood mixed with CSF There may be an associated facial palsy, deafness or nystagmus in cases of fracture middle cr. Fossa. Bruises over the mastoid process (Battle's sign) appearing one or two days after trauma confirm the diagnosis of middle cr. Fossa fracture Fracture Posterior Cranial Fossa; The main danger is the torn of a venous sinus. Deep coma may be present. Pupils become dilated and inactive. Periodic "Chyne-Stockes" respirations are present. Irregular pulse indicate brain stem lesion and the case is fatal. If a slowly developing heamatoma accumulate, nystagmus and ataxia is present. Brain injuries; Primary; 1. Concussion; defined by a period of amnesia 2. Cortical contusions and lacerations 3. Bone fragmentation injury 4. Diffuse axonal injury 5. Brain stem contusions. Secondary; 1. Intracranial heamatoma 2. Cerebral edema 3. Hypoxemia 4. Ischemia 5. Infections 6. Epilepsy 7. metabolic-endocrine disturbances. Types of intra cranial heamatoma; Intracerebral; Hyper dense on CT-scan, small ones may enlarge. Large ones may need evacuation. Extradural; Result From bleeding middle meningeal artery. Trauma may be trivial. Lucid interval is characteristic. Surgery without delay is essential. Acute subdural; It is the most common. Develop from torn bridging veins or from cortical lacerations. It May be sub acute. Chronic subdural; It is most common in children and elderly, and present with progressive neurological deficit. They should be drained if continue to enlarge. Indications for CT scan; The patient is persistently drowsy or has a more seriously depressed consciousness level There are lateralizing neurological signs There is neurological deterioration There is clinical evidence of fracture base of skull Category of head injury; Category I: The patient is unconscious; Examine the scalp. Inspect the nostril and back of the throat. Examine the external auditory meatus. Compare the size of the pupils and reaction to light. Make a general survey of the body for other injuries. Assess how deep the patient is unconscious. Coma is a state of absolute unconsciousness in which the patient dose not respond to any stimuli and reflexes (including the corneal and swallowing reflexes) are absent. Semi coma means that the patient responds only to painful stimuli and reflexes are present. Search for paralysis. Pinch the soles of the feet; only one leg may be drawn up. Palpate and Percuss the lower abdomen for evidence of over filled bladder. Set half- hourly Chart for pulse rate, respiratory rate, and temperature. Make a behaviors chart Place and have the patient kept on his side with a clear air way (remove blood and mucus from mouth and nose). Consider at any time the need for endotracheal intubations Arrange for safe referral with an informative preliminary report. Category II: The patient is conscious or semiconscious; Record the degree of mental confusion Assess for; Stupor; No sensible answers can be obtained but the patient obeys simple commands. Delirium; Appear out of touch from his surroundings, relevant answers to obvious questions are possible, but irritable when disturbed, may be aggressive, noisy and try to get out of bed. Confusion; Overall, some degree of coherent conversation is possible. **Any impairment of consciousness, when combined with radiological evidence of skull fracture, is associated with high incidence of intracranial bleeding and heamatoma. Quick Cranial N examination; Olfactory (1st) use non irritant smell. Optic (2nd) test for visual fields. Ocuolomotor (3rd) lid and eye movements, pupillary reflex and laccommodation. Trochlear (4th) diplopia on looking downwards. Trigeminal (5th) inability to clench teeth Abducent (6th affected eye does not follow an object laterally Facial (7th) facial m. paralysis. Acoustic (8th) hearing and caloric test. Glossopharangeal (9th) loss of test in the posterior third of the tongue. Vagus (10th) loss of soft palate movement. Uvula to the opposite side. Accessory (11th) Failure to shrug the shoulder Hypoglossal (12th) Deviation of the protruded tongue to the affected side. Significant Signs occurring during the period of observation of a case of Head; "To wait until the clinical diagnosis is certain is to wait until the patient is near death" Monitor the followings during observation period: Pulse rate Temperature Respiration Fits Neck rigidity Lucid interval Lateralizing Neurological signs Signs of Cerebral irritation Lucid Interval; * Classical sign of middle meningeal bleeding and formation of extradural heamatoma. * Very variable, occurring for few minuets up to several days. * Completely absent in cases of: Alcoholism Severe concomitant brain injury. Combination of extradural and intracerebral bleeding. * In this case, you may suspect this by: Presence of heamatoma of the temporalis muscle on the affected side. The gradual onset of hemi paresis and hemiplagia. Deepening coma. Presence of "Hutchinson's pupil". Differential Diagnosis of Lucid interval; In cases of subdural hemorrhage, its occurrence is more common, and it is not associated with lucid interval, however, lateralizing neurological signs may be present. Sub arachnoids hemorrhage can be suspected from signs of cerebral irritation and positive tap of blood with CSF. Intracerebral bleeding may be associated with extra or sub dural heamatoma or may occur alone. Lateralizing signs are usually absent. Lateralizing neurological signs; Contra lateral hemiplagia of extradural heamatoma associated with absent abdominal reflexes, increased triceps jerks, and positive "Babaniski's" sign. Difficulty in speech (Aphasia), which may be the first lateralizing sign if the lesion is left sided in a right handed patient because "Broca's" speech area is left sided in right handed. Inequality of the pupils, The so called "Hutchinson's pupil, occurring in extradural heamatoma Hutchinson's pupil;  Cerebral irritation; Patient is found curled up in bed avoiding light (Photophobia) eye lids are closed temperature is moderately raised the patient is irritable This indicates blood in the CSF. Delayed effects of head injury; Post traumatic epilepsy Cerebrospinal fluid fistula Post-concussion symptoms Neurological and Neuro-psychological deficits Neuroendocrine and metabolic disturbances  Examination of the Vascular System Examination of the Arterial Circulation Arteries accessible for clinical examination are: Common Carotid and bifurcation in the neck the facial and superficial temporal over the skull the subclavian artery behind the clavicle the axillary artery in the axilla the Brachial artery at the elbow the radial and ulnar arteries at the wrist the femoral artery below the mid inguinal point the popliteal artery in the popletial fossa the posterior tibial artery behind the medial malleolus the anterior tibial artery between the two malleoli the dorsalis pedis artery between the first and second metatarsals just medial to the flexor hallusis longus tendon the abdominal aorta in thin subject when compressed against the vertebral column Clinical assessment of the arterial circulation Examine in warm environment Examine the heart Assess Blood pressure in both arms Assessment of ischemic limb Inspection Skin; white marble, redness or blueness. A purple blue cyanosis may be obvious. When cyanotic areas become fixed, the ischemia is irreversible. Gangrene turn skin permanent blue/black colour first seen caudally in the toes Clinical assessment of the arterial circulation The Vascular (Buerger's) angle Capillary filling time and Buergers positional test Inspect for venous filling-Guttering of veins Inspect carefully pressure areas for Thickening of the skin, a purple or blue discoloration, blistering, ulceration or patches of black, red, dead gangrene. Pressure areas are: bottom, back and lateral surface of the heal and ball of the foot skin over the malleoli skin over the head of the fifth metatarsal tips of the toes and areas between the toes Clinical assessment of the arterial circulation Palpation Assess temperature Capillary refilling time Felling the pulse Auscultation An audible bruite is caused by turbulent flow beyond a stenosis or irregularity in the artery wall. Blood flow in the vessel is assessed by a hand-held Doppler probe which can detect pulstile flow when the pulse pressure is impalpable to the fingers. Symptoms and signs of acute ischemia (remember the letter P) Pain, severe, sudden onset as a result of ischemia of muscles and nerves Parasthesia progressing to Paralysis Pallor of the limb Pulselessness Perishingly cold limb Poor capillary circulation resulting in Prolonged capillary refilling time Perceptively empty veins Poor power, sensation and limb reflexes Pulse Doppler flowmetry confirm absent pulsation Persistent ischemia lead to hardness of muscles, blistering of the skin and development of gangrene starting in the toe and spreading proximally Clinical manifestations of chronic ischemia Intermittent claudication (limping) Pre-gangrene Gangrene Ischemic ulcers Ischemic ulcers Site tips of the toes and over pressure points Size small to large flat Shape often elliptical Tenderness mild, moderate or sever Temperature; surrounding tissue is usually cold due to ischemia Edge punched-out or sloping Floor grey-yellow slough covering flat pale granulation tissue Depth; is often very deep and penetrating Discharge clear fluid, serum or pus Ischemic ulcers Base may be stuck or may be part of any underlying tissue Lymph Nodes: not enlarged unless there is secondary infection State of local tissue: surrounding tissue may show signs of ischemia. Distal pulses are invariably absent Doppler pressure index is reduced Neurological examination numbness, Parasthesia, and absent sensation may indicate trophic ulcer General examination may show evidence of vascular disease or diabetes Examination of the venous circulation Veins are either superficial or deep. In the upper limb flow is from peripheral to proximal veins. In the lower limb, in addition, flow is also from superficial to deep veins Valves are sited at any junction between superficial and deep veins in the perforating veins along the deep and superficial veins limb veins have three principle functions pathway to return blood to the heart blood storage thermoregulation. Thrombosis of superficial veins (superficial thrombophlebitis) Clinically, the vein become Firm, Palpable Redness and stiffness in the overlying skin which become warm and tender . It may be complicated by suppuration or extension of the thrombus along a perforating vein to the deep veins causing deep venous thrombosis. Examination of a case of deep vein thrombosis Observe for inequality of circumference and any prominent veins over the dorsum of foot. Examine the ankle for pitting Oedema Dorsiflexion of the foot produce pain in the calf muscle (Homan's sign) Tender calf muscles Palpate the popliteal space for tenderness in full leg extension position Seek for tenderness in the thigh along the course of the femoral vein Comparative circumferential measurement at identical points Examination of a case of varicose veins By inspection: Inspect from back and front for varicosities of long, short or both saphenous veins. Inspect the site of perforators which produce discrete venous bulges. Inspect for the presence of swelling, skin pigmentation, pre-ulcerative lesions, ulcer mainly just above the medial malleolus and any scars due to healed ulcers. Examination of a case of varicose veins By palpation: Palpate over the course of long and short saphenous veins Perform the "cough impulse test" Perform the percussion or "Tap" sign. Perform Brodie-Trendelenburg test Seek for the site of perforators (Fegan's method) Test for the patency of deep vein (Perthe's test Examination of the arterial circulation of the lower limbs -Examination should be in aworm room. -Exposure: -from goin to toes,preserving his dignity by keeping his underwear on. Inspection: -colour:white/red. Vascular angle:buergers angle Lift the leg above the bed,raises it above the heart level. Normal leg can be raised to 90 degree and still remain perfused. The angle between the horizontal and the leg when it become white is vascular angle. If the angle less than 20 it indicate sever ischemia Capillary filling time: After elevating the legs,ask the patient to sit up and dangle the foot over the site of the couch. Anormal leg and foot remain healthy pink in colour. Ischaemic leg slowly turns from white to pink and thentakes on a suffused purple-red colour.the time taken for the colour of the foot to change from white to pink is the capillary filling time. In sever ischaemia it may be as long as15-30 seconds -Venous filling: in an ischaemic foot the veins collapse and sink below the skin surface to look like pale-blue gutter.this is called guttering of the veins. -look at the-look at the pressure areas. Trophic changes: -loss of skin. -loss of hair. -Gangrene. Ulcers: Arterial(ischaemic) ulcers are found typically in the least well perfused areas and over the pressure points. The lesions are punched out because there is no attempt at healing,and well described,may be very tender and the surrounding skin is cold. They may vary in size but are usually smaller than venous ulcer. There is no granulation tissue but may be a thin layer of slough at the base ,otherwise the base is flat and pale. They may be very deep and penetrate surrounding tissue like bone.. Commenest differencial is with the neuropathic ulcer. Palpation -feel for skin temperature., use the back of hands ,comparing one side with other. -examine the toes for capillary refill,use thmb to push hard over the pulp of the big toe on both sides.,normally the toe blunches but then return to the normal colour withn 2 seconds,.any longer than this is abnormal. Only after all had been completed should you move on to examine the pulses Femoral pulse: -can be identified by the level of the groin skin crease . anatomically dscribed at the mid- inguinal point ,halfway between Anterior superior iliac spine and the pubic symphysis. -compare one side with the other. Popliteal pulse: -the most convenien technique for feling the popliteal pulse is to extend the patient knee fully and place both haqnds around the top of the calf with the thumbs placed on the tibial tuberosity and the tips of the fingers of each hand touching behind the knee,over the lower part of the popliteal fossa.,the pulse demonstrated when the popliteal artery is compressed against the posterior aspect of the tibia. -flexing the knee to 135 degree may make the lower half of the artery easier to feel but may make palpation of the upper half of the artery more difficult. -sometime it can be feel by turning the patient in to the prone position and feeling along the course of the artery. -when it is easy to feel it may be aneurysmal. -compare. Foot pulses -the dorsalis pedis and the posterior tibial pulses can be palpated bilaterally and simultaneously. -demonstrate the tendon of extensor hallucis longus. -the DPA is immidately lateral to this tendon. -swing your hand down to the medial malleolus and run your fingers posteriorly ,posterior tibial artery lie1/3 of the way along aline between the tip of the medial malleolus and the point of the hill. Auscultate: -check for bruit . -measure blood pressure. complete your examination by: -examine the abdomen for an aneurysm. -measure the ankle brachial pressure indicies on each side. The pressure cuff is inflated over the upper arm and the systolic pressure measured at the brachial artery using a Doppler probe. The cuff is then placed over the calf. When the dorsalis pedis pulse has been located with the Doppler,the cuff is inflated until the pressure is high enough to occlude the artery and thus the Doppler sound disappear. Slowly lower the cuff pressure until the Doppler sound restart,this is the ankle pressure. The index is the ankle pressure dividedby the brachial pressure. Normal index is 1. In patient with the peripheral vascular disease the ratio begin to fall. Patient with the intermittent claudication have an index of 0.5-0.8,. Patient with the rest pain have an index<0.5 Antibiotics in Surgical Practice General Terms Antimicrobials Chemotherapeutics Antibiotics Bactericidal Bacteriostatic Broad spectrum Narrow spectrum Principles of antimicrobial therapy Antimicrobials are either used as Therapeutic Prophylactic Therapeutically, only spreading infection or signs of systemic infection justify the use of antibiotics. Organism and its sensitivity should be determined prior to commencement of active therapy. Empirical antibiotic therapy may confuse the clinical picture and affect the opportunity to make a precise diagnosis. Approaches to antibiotic treatment Narrow spectrum antibiotic is used to treat a known sensitive infection Combination of broad spectrum antibiotics can be used when the organism is not known or when it is suspected that more than one organism may be responsible for the infection. Alternatives for single drugs are always available Mono-therapy (single drug) as an alternative to triple therapy Approaches to antibiotic treatment In the surgical units, in which commensal organisms have become as "resident opportunists", it may be necessary to rotate antibiotics between broad spectrums Alternatives of combinations of antibiotics should be monitored by "Infection Control Team" New antibiotics should be used with caution and, whenever possible, sensitivities should first be obtained The concept of prophylactic antibiotic therapy used when local wound defenses are not yet activated so called "decisive period maximum blood and tissue levels should be present at the time that the first incision is made Intra-venous administration at induction of anesthesia is optimal, the so called per-operative administration pre- and peri-operative administration can also be used The concept of prophylactic antibiotic therapy 5. when contamination is expected, the dose of antibiotic that has started preoperatively may be continued postoperatively repeated 6 or 8 hourly 6. The choice of antibiotics for prophylaxis depend on the expected spectrum of organism the cost of treatment local hospital policies based on experience of local resistance trends 7. The use of newer, wide spectrum antibiotics should be avoided Antibiotics in current use for treatment and prophylaxis of surgical infections Penicillins (Benzyl Pencillin) Broad spectrum Effective against G+ve Streptococci, Clostridia and non beta-lactamase Staphylococci. It is still effective against Actinomycosis spp. Flucloxacillin and Methicillin Narrow spectrum Beta-lactamase-resistant Penicillins Effective against Staphylococcal beta-lactamase producing organisms Antibiotics in current use for treatment and prophylaxis of surgical infections Ampicillin and Amoxicillin Broad spectrum beta-lactam penicillins. Effective against Enterobacteriaceae, Enterococcus faecalis and the majority of group D Streptococci Mezlocillin and Azlocillin Broad spectrum ureido-penicillins with good activity against Enterobacter and Klebsiella and Pseudomonas. have some activity against Bactroids and Enterococci. usually combined with an Aminoglyciside for sever mixed infections caused by G-ve organisms. Antibiotics in current use for treatment and prophylaxis of surgical infections Clavulanic acid is combined with amoxicillin (Amoxiclav) taken orally, protect amoxicillin from being inactivated by beta-lactamase producing bacteria. It is effective against Klebsiella and staphylococcus in animal and human bites Cephalosporins Broad spectrum. The types important in surgical practice are the beta-lactamase-stable Cefuroxime, Cefotaxime and Ceftazidime. The first two are effective against Staphylococcus aureus and most Entrobacteria. Ceftazidime is active against G-ve organisms but most effective against Pseudomonous aeroginosa. usually combined with Aminoglycoside or an Imidazole for perfect anaerobic cover. Antibiotics in current use for treatment and prophylaxis of surgical infections Aminoglycosides Broad spectrum Gentamicine and Tobramycin. Particularly effective against G-ve Enterobacteria, Pseudomonas, Anaerobs and Streptococci. Ototoxicity and Nephrotoxicity may follow sustained high toxic levels. Vancomycin A narrow spectrum antibiotic of the glycopeptide type. most effective against G+ve and MRSA. It is the drug of choice orally against Clostridium Difficile which cause Pseudomembranous enterocolitis Antibiotics in current use for treatment and prophylaxis of surgical infections Imidazoles The most widly used is the Narrow spectrum Metranidazol active against all anaerobic bacteria including anaerobic cocci, Bactroids and Clostridia. Carbapenems Broad spectrum Meropenem, Ertapenem and Imipenem Beta-lactamase resistant, anti-anaerobic and anti-G+ve Expensive drugs. Quinolones Narrow spectrum Ciprofloxacin. It is potent bactericidal against Pseudomonas spp. Dressings in Surgery General indications for application of surgical dressings To prevent contamination from external environment. Example; dressing of surgical wounds. To cover and absorb heavily exudating wounds. Example; dressing of burns. To eliminate dead space and prevent collections. Example; packing deep wounds. General indications for application of surgical dressings To activate fibrinolysis and liquefy pus. Example dressing of chronic skin ulcers. To debride necrotic skin. Example; dressing of necrotic sloughing skin ulcers. To remove bacteria and excessive moisture. Example; dressing of deep granulating wound. General indications for application of surgical dressings To absorb harmful materials. Example; pus of infected wounds and discharges of different fistulae and sinuses. To maintain moist environment and to promote epithelialization and formation of granulation tissue. either with gaseous exchange; using semipermiable dressings or without gaseous exchange; using complete occlusive dressings General indications for application of surgical dressings To cover the entry site of different surgical drains. To stop bleeding by the technique of Dry Pack Pressure Dressing. Example; in lacerated heavily bleeding liver injuries. Types of dressings used in surgical practice I Simple dressings: Dry plain Gauze; cotton mesh only. Dry packs; gauze and cotton with or without non-adherent coating of Melolin. Tulles; cotton thread mesh impregnated with non-adherent Paraffin. The addition of non-adherent coating facilitates removal. Charcoal is added to some act as an absorbent and reduce swelling. Relatively cheap Types of dressings used in surgical practice II Hydrogel polymers (Geliperm and Intrasite) maintain a moist environment. semi-permeable and allow gas exchange. Hydrocolloids (Comfeel and Granuflex) used for complete occlusion technique. promotes epithelialization of granulating tissue. maintain a moist environment but with out gas exchange across them. Fibrous polymers (Kaltostat and Sorban) absorptive alginate dressings that are derived from natural sources. All are used to pack deep wounds in order to promote epithelization of newly forming granulation tissue. Types of dressings used in surgical practice III Foams (Silastic, Lyofoam and allevyn) These are Elastomeric dressings can be shaped to fit deep cavities and granulating wounds. absorbent and non-adherent Polymeric films (Opsite and Bioclusive) primary adhesive transparent dressings. used to cover sutured surgical wounds and donor sites Bead dressings (Debrisan and Iodosorb) It removes bacteria and excessive moisture by capillary action in deep granulating wounds. Diathermy(Cautery) Diathermy is the use of high frequency electric current to produce heat Used to either cut or destroy tissue or to produce coagulation Mains electricity is 50 Hz and produces intense muscle and nerve activation Electrical frequency used by diathermy is in the range of 300 kHz to 3 MHz Patients body forms part of the electrical circuit Current has no effect on muscles Monopolar diathermy Electrical plate is placed on patient and acts as indifferent electrode Current passes between instrument and indifferent electrode As surface area of instrument is an order of magnitude less than that of the plate Localised heating is produced at tip of instrument Minimal heating effect produced at indifferent electrode  INCLUDEPICTURE "http://www.surgical-tutor.org.uk/pictures/diagrams/monopolar.gif" \* MERGEFORMATINET  Bipolar diathermy Two electrodes are combined in the instrument (e.g. forceps) Current passes between tips and not through patient  INCLUDEPICTURE "http://www.surgical-tutor.org.uk/pictures/diagrams/bipolar.gif" \* MERGEFORMATINET  Effects of diathermy The effects of diathermy depends on the current intensity and wave-form used Coagulation Produced by interrupted pulses of current (50-100 per second) Square wave-form Cutting Produced by continuous current Sinus wave-form Risk and complications Can interfere with pacemaker function Arcing can occur with metal instruments and implants Superficial burns if use spirit based skin preparation Diathermy burns under indifferent electrode if plate improperly applied Channeling effects if used on viscus with narrow pedicle (e.g. penis or testis) Surgical drains Drains are inserted to: Evacuate establish collections of pus, blood or other fluids (e.g. lymph) Drain potential collections Indications for their use include: Drainage of fluid removes potential sources of infection Drains guard against further fluid collections May allow the early detection of anastomotic leaks or haemorrhage Leave a tract for potential collections to drain following removal Arguments against their use include: Presence of a drain increases the risk of infection Damage may be caused by mechanical pressure or suction Drains may induce an anastomotic leak Most drains abdominal drains infective within 24 hours Types of drains Drains can be: Open or closed Active or passive Drains are often made from inert silastic material They induce minimal tissue reaction Red rubber drains induce an intense tissue reaction allowing a tract to form In some situations this may be useful (e.g. biliary t-tube) Open drains Include corrugated rubber or plastic sheets Drain fluid collects in gauze pad or stoma bag They increase the risk of infection Closed drains Consist of tubes draining into a bag or bottle They include chest and abdominal drains The risk of infection is reduced Active drains Active drains are maintained under suction They can be under low or high pressure Passive drains Passive drains have no suction Function by the differential pressure between body cavities and the exterior Gastricintubation Gastricintubation via the nasal passage (i.e. nasogastric route) is a common procedure that provides access to the stomach for diagnostic and therapeutic purposes.A nasogastric (NG) tube is used for the procedure. The placement of a NG tube can beuncomfortable for the patient if the patient is not adequately preparedwith anesthesia to the nasal passages and specific instructions on how to cooperate with the operator during the procedure. INDICATIONS Diagnostic: - Evaluation of upper gastrointestinal (GI) bleeding(i.e. presence, volume). - Aspiration of gastric fluid content. - Identification of the esophagus and stomach on a chest radiograph. - Administration of radiographic contrast to the GI tract. Therapeutic: - Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often viathe oropharynx - Relief of symptoms and bowel rest in the setting of small-bowel obstruction - Aspiration of gastric content from recent ingestion of toxic material - Administration of medication - Feeding - Bowel irrigation CONTRAINDICATIONS Absolute contraindications: Severe midface trauma Recent nasal surgery Relative contraindications: Coagulation abnormality Esophageal varices or stricture Recent banding orcautery of esophageal varices Alkaline ingestion EQUIPMENT Nasogastric tube Adult- 16-18F Pediatric- In pediatric patients, the correct tube size varies with the patients age. To find the correct size, add 16 to the patients age in years and then divide by 2 (eg, [8 y + 16]/2 = 12F) Viscous lidocaine 2% Oral analgesic spray (Benzocaine spray or other) Oral syringe, 12 mL Equi. Cont.. Glass of water with a straw Water-based lubricant Toomey syringe, 60 mL Tape Emesis basin or plastic bag Wall suction, set to low intermittent suction Suction tubing and container POSITIONING Position the patient in the sitting upright position. TECHNIQUE Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient's representative. Examine the patients nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards, and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate anesthetic effect. Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump nasogastric tube (Kendall, Mansfield, Mass)in adults, the estimated length usually falls between the second and third preprinted black lines on the tube. Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in his or her hand and put the straw in his or her mouth. Lubricate the distaltip of the nasogastric tube. Gently insert the nasogastric tube along the floor of the nose and advance it parallel to the nasal floor (ie, directly perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through the straw and start to swallow. Continue to advance the nasogastric tube until the distance of the previously estimated length is reached. Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient experiences respiratory distress, is unable to speak,has significant nasal hemorrhage, or if the tube meets significant resistance. Verify proper placement of the nasogastric tube by auscultating a rush of air over the stomach using the 60 mL Toomey syringe or by aspirating gastric content. The authors recommend always obtaining a chest radiograph in order to verify correct placement, especially if the nasogastric tube is to be used for medication or food administration. Tape the nasogastric tube to the nose to secure it in place. If clinically indicated, attach the nasogastric tube to wall suction after verification of correct placement. During insertion, ifconcern exists thatthe tube is in the incorrect place, ask the patient to speak.Ifthe patient isable to speak, then the nasogastric tube has not passed through the vocal cords and/or lungs. The nasogastric tube may coil in the nasopharynx or oropharynx.If this occurs, or if the tube is difficultto pass in general, one can trycurling the distal end and partially freezing it in a cup of ice in order to temporarily hold its curled shape better.Insert the lubricated tube tip through the nose with the curled end pointing downwards. Once the distal tippasses into the hypopharynx, the curved tip will be facing anteriorly. Rotate the tube 180 degrees so that the curved end is pointing posteriorly toward the esophagus. Continue to insert in the usual manner by having the patient swallow water. Another option (in paralyzed patients only) is to place 2-3 fingers through the patients mouth into the oropharynx. The fingers are used to guide the nasogastric tube into the hypopharynx. Lifting the thyroid cartilage anterior and upward might open the esophagus and allow passage into the proximal esophagus. COMPLICATIONS Patient discomfort Generous lubrication, the use of topical anesthetic, anda gentletechniquemay reduce the patients level of discomfort. Throat irritation may be reduced with administration of anesthetic lozenges (eg, benzocaine lozenges[Cepacol]) prior to the procedure. Epistaxis may be prevented by generouslylubricating the tube tip andusing a gentle technique. Respiratory tree intubation Esophageal perforation Urethral catheterization Is a routine medical procedurethat hasboth diagnostic and therapeutic purposes. INDICATIONS 1. Diagnostic: - Collection of uncontaminated urine specimen. - Monitoring of urine output. - Imaging of the urinary tract. 2. Therapeutic: - Acute urinary retention (e.g., benign prostatic hypertrophy, blood clots). - Chronic obstruction that causes hydronephrosis. - Initiation of continuous bladder irrigation. - Intermittent decompression for neurogenic bladder. - Hygienic care of bedridden patients. CONTRAINDICATIONS Urethral catheterization is contraindicated in the presence of HYPERLINK "http://www.emedicine.com/med/TOPIC3082.HTM"traumatic injury to the lower urinary tract (e.g. urethral tear). This condition may be suspected in male patients with a pelvic or straddle-type injury. Signs that increase suspicion for injury are a high-riding prostate, perineal hematoma, or blood at the meatus. When any of these findings are present in the setting of concerning trauma, a retrograde urethrogram should be performed to rule out a ureteral tear prior to placing a catheter into the bladder. EQUIPMENT - Povidone iodine. - Sterile cotton balls. - Water-soluble lubrication gel. - Sterile drapes. - Sterile gloves. - Urethral catheter. - Prefilled 10-mL saline syringe. - Urinometer connected to a collection bag. - Sterile anesthetic lubricant (e.g. lidocaine gel 2%) with a blunt tip urethral applicator or a plastic syringe (5-10 mL). POSITIONING Place the patient supine, in the frog leg position, with knees flexed. TECHNIQUE Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient's representative. Position the patient supine, in bed, and uncover the genitalia. Open the iodine/chlorhexidine preparatory solution and pour it onto the sterile cotton balls. Open a sterile lidocaine 2% lubricant with applicator or a 10-mL syringe and sterile 2% lidocaine gel and place them on the sterile field. Wear sterile gloves and use the nondominant hand to hold the penis and retract the foreskin (if present). This handis the nonsterile hand and holds the penis throughout the procedure. Use the sterile hand and sterile forceps to prep the urethra and glans in circular motions with at least 3 different cotton balls. Using a syringe with no needle, instill 5-10 mL of lidocaine gel 2% into the urethra. Place a finger on the meatus to help prevent spillage of the anesthetic lubricant.Allow 2-3 minutes before proceeding with the urethral catheterization. While holding the penis at approximately 90 and stretching it upward to straighten out the penile urethra, slowly and gently introduce the catheter into the urethra. Continue to advance the catheter until the proximal Y-shaped ports are at the meatus. Wait for urine to drain from the larger port to ensure that the distal end of the catheter is in the bladder. The lubricant jellyfilled distal catheter openings may delay urine return. If no spontaneous return of urine occurs, try attaching a 60-mL syringe to aspirate urine. If urine return is still not visible, withdraw the catheter and reattempt the procedure (preferably after using ultrasonography to verify the presence of urine in the bladder). After visualization of urine return (and while the proximal ports are at the level of the meatus), inflate the distal balloon by injecting 5-10 mL of 0.9% NaCl (normal saline) through the cuff inflation port. Inflation of the balloon inside the urethra results in severe pain, gross hematuria, and, possibly, urethral tear. Gently withdraw the catheter from the urethra until resistance is met. Secure the catheter to the patient's thigh with a wide tape. If the patient is uncircumcised, makesure to reduce the foreskin, as failure to do so can cause paraphimosis. COMPLICATIONS 1. Infections - HYPERLINK "http://www.emedicine.com/emerg/TOPIC623.HTM"Urethritis - Cystitis - HYPERLINK "http://www.emedicine.com/med/TOPIC2843.HTM"Pyelonephritis - Transient bacteremia 2. HYPERLINK "http://www.emedicine.com/med/TOPIC2874.HTM"Paraphimosis, caused by failure to reduce the foreskin after catheterization 3. Creation of false passages 4. HYPERLINK "http://www.emedicine.com/med/TOPIC3075.HTM"Urethral strictures 5. Urethral perforation 6. Bleeding Prophylactic antibiotics are recommended for patients with prosthetic heart valves, artificial urethral sphincters, or penile implants. Catheter types and sizes: Adults: Foley (16-18 F) Adults with obstruction at the prostate: Coud (18 F) Children: Foley (5-12 F) Infants younger than 6 months: Feeding tube (5 F) with tape. Bed-side Surgical procedures General Principles Definition How to approach? ObservePractice.Pass on Experience General principles Confidence and competency Equipments Consent Checking patients details Reassure and explain Additional arrangements Sedation Assistance Expert opinion Documentation Dangers to the operator Signing by name and rank Vein puncture Indications and procedure Tips and problems Poor veins Agitated patient Obese patient Failed attempts Obtaining blood for culture and sensitivity testing Intravenous cannulation Indications and procedure Tips and complications Poor veins Agitated patient Obese patient Selection of the site Failed attempts Blood transfusion Venous cut down (Vein section) Indications and method Tips and problems Freeing enough segment of vein Caution not to injure the posterior wall Securing the cannula Central venous access I Indications CVP TPN Special drugs Poor or failed peripheral access Cautions Clotting disturbances Hypovolemia Central venous access II Preparation Lie patient supine with head supported by one pillow. If a patient is shocked, tilt the head of the bed down Tilt the patient head away from the side of insertion Ensure that each port of the cannula is "primed" with heparinized saline Identify the site of entry before scrubbing up If possible, place the patient on cardiac monitor Central venous access III Approach the right side is used to avoid damaging the thoracic duct. If a chest tube is there, use the same side for cannulation. For the subclavian vein identify the mid- point of right clavicle pass the needle under and closely applied to the lower border of the clavicle aiming to supra-sternal notch. For the internal jugular vein identify the carotid pulse at the level of the thyroid cartilage insert the needle at the medial border of the sternomastoid muscle 0.5-1 cm lateral to the artery and advanced at 450, aiming for the ipsilateral nipple. Central venous access IV Tips and problems Line in the neck on chest x-ray Pnemothorax on x-ray Infection Cardiac arrhythmias Blocked cannula Measurement of the CVP Arterial puncture (cannulation) Cautions Clotting disturbances Approaches Radial A ( apply Allans test) Femoral A Tips and problems Poorly palpable artery Venous sample Bleeding from puncture site Endotracheal intubation Indications Cardiac arrest Serious head injury Certain acute respiratory and trauma settings Prior to surgical operations Tips The patient is pre oxygenated Ensure that the laryngoscope and endotracheal tube cuff are functioning Remove any dentures from the mouth. Excess saliva or secretions must be suctioned. Assess the correct positioning Nasogastric tube insertion Indications Intestinal obstruction Paralytic ileus Peri operative gastric decompression Enteral feeding Check the position of the tube by: Aspirating gastric contents that turn the blue litmus in to red Blow air down the tube and auscultate for the bubbling over the stomach and problems Patients has problem in swallowing: ask the patient to swallow sips of water as the tube is passed Constant coiling in to the mouth: the tube may be too soft; cool in fridge Resistance to passage: there may be an anatomical reason for this, e.g. esophageal stricture. The tube may need to be passed under X-ray control Obtain an X-ray: prior to commencing Enteral feeding in order to confirm the position of the tube and avoid iatrogenic aspiration. Sengestaken-Blakmore tube Method The tube is passed through the mouth, advanced in to the esophagus inflate the gastric balloon slowly to a pressure of 60 mmHg Pull the tube back until resistance is met, as the balloon reaches the cardia. Inflate the esophageal balloon to 40-50 mmHg and secure the tube under mild tension. Aspirate the gastric and esophageal ports every 30 min. the esophageal balloon must be deflated every hour to prevent mucosal ulceration or necrosis. Urethral catheterization Indications Perioperative monitoring of urinary output Acute urinary retention Chronic urinary retention Prior to abdominal or pelvic surgery Incontinence Tips and problems No urine immediately Inability to insert Decompression of grossly distended bladder Urine is bypassing the catheter Catheter stops draining Female catheterization Suprapubic catheterization Indications Failed or contraindicated transurethral catheterization Cautions patient with known bladder tumor or previous bladder surgery Ensure clinically (and by US if available) that the bladder is full and distended. Tips and problems Bypassing urine No urine or faeculent matter in the catheter Pleurocentesis Indications Drainage of pleural effusion Drainage of early empyema Tips and problems Diagnostic tap Dry tap Pnemothorax Very bloody tap Marking the proposed site Thoracostomy tube drainage Indications Pnemothorax Haemothorax Post-thoracotomy Tips and problems Agitated or anxious patient Securing the drain Do not clamp the drain Blocked drain Persistent bubbling Removal of the drain Paracentesis abdominis Indications Diagnostic evaluation of ascitis Therapeutic drainage of ascitis Tips and problems Identify a suitable tap site Amount aspirated Unable to aspirate adequate amount of fluid Blood or faeculent material Considering Peritoneal catheter Rigid sigmoidoscopy Indications Investigation of the lower GI symptoms Visualization of the rectum and lower sigmoid colon prior to barium enema Tips and problems Advancing slowly under direct vision Recto-sigmoid junction Biopsy Withdrawal Local anesthesia Indications Minor procedure Postoperative infiltration Cautions Allergy Infection at the proposed site for infiltration Increased risk of toxicity: heart block, low cardiac output, epilepsy, myasthenia gravis, hepatic impairment, porphyria, beta-blockers, and cimitidien therapy all increase this risk. Adrenaline containing solution (decrease blood loss, prolong duration of anesthesia and delay absorption of agent) Agents Lignocaine: for short procedures Concentrations: 0.5%, 1%, and 2% Plain or with adrenaline. Duration of action: rapid onset (2-3) minutes, effect last for 30-90 minutes depending on the site and the dose. Maximum dose: plain solution 200 mg or 20 ml of 1% solution for an adult, 3 mg/kg for a child. Bupivacaine: for longer procedures Concentrations: 0.25-0.75 % plain solutions, 0.25-0.5 % with adrenaline. Duration of action: slower onset of action than lignocaine. Its Effect last for 3-8 hours. Maximum dose: 150 mg or 30 ml 0.5% solution for an adult, 2 mg/kg for a child. Toxicity Symptoms mainly neurological. Drowsiness, confusion, slurred speech, light-headedness, tinnitus, and numbness of the tongue or mouth may all occur. If sever, convulsion and coma may follow. Signs may include early tachycardia and hypertension. Later bradycardia, hypotension, cardiac arrhythmias and cardiac arrest may occur. Treatment Stop procedure Maintain airway and provide oxygen Ensure IV access Perform an ECG Give valium 5-10 mg IV, slowly for convulsions. Raise the bed and initiate IV fluids for hypotension Bradycardia: usually resolve, atropine is rarely needed. Inadequate analgesia Intercostals nerve block Indications Painful fractured rib Post-thoracotomy pain relief Position the patient as for pleural aspiration Tips For a broken rib: inject medial to the site of fracture on the posterior aspect of the chest wall For post-thoracotomy pain relief: inject medial to the posterior edge of the scar on the posterior chest wall Multiple blocks: ensure that you did not reach a toxic dose Air or blood is aspirated: withdraw needle slowly and re-aspirate. Nasotrachieal intubation Indication; Contraindication; Pregnancy Coagulopathy Nasal occlusion Deviated septum C.S.F Rhinorrhea Technique; Awake patient , spontaneously breathing Signs of correct advancement Complications; Esophageal intubation. bleeding Nasal packs Indication; Anaesthesia; Position; Technique; -Assessment of the patient; Pinch the nostrils.10 minutes. Apply ice pack. Cotton swabs soaked with 2% Lidocaine +1:1000 epinephrine Chemical cauterization Complications and management; Persistent or recurrent bleeding Infection hypoxima Internal jugular venous access Indications; C.V.P monitoring Total Paranteral nutrition Long term drug infusion Haemodialysis Contraindications; Previous ipsilateral neck surgery Untreated sepsis Venous thrombosis Positioning; Technique (central approach); Localization. If there is no venous blood return? If air or arterial blood is encountered. Complications and management; Carotid puncture Air embolus Pneumothorax Malpositioning Horner's syndrome Dysrhythmias Femoral venous access Indications; Emergent central access. Haemodialysis. Unable to obtain other venous access Contraindications; Prior groin surgery (relative) Patient must maintain bed rest. Technique; Position and anaesthesia Surface anatomy and localization; If no venous return If arterial blood aspirated. Complications and management; Femoral artery puncture/haematoma pericardiocentesis Indications; To prevent further cardiac compression For diagnosis Contraindications; Coagulopathy Post coronary bypass surgery Acute traumatic haemopericardium Small pericardial effusion<200ml Absence of anterior effusion or loculated effusion. Positioning; Technique; Site of the needle introduction. Advance the needle toward the left shoulder Contact with epicardium negative deflection of the QRS. Contact with the myocardium ST-segment elevation. Laboratory test (cell count, amylase, Protein, glucose, culture) 6. Monitoring of the patient 7. Success in reducing tamponade; Decrease right atrial pressure Increase cardiac output Disappearance of pulsus paradoxus. Complications and management; Cardiac puncture or laceration. Air embolism. Cardiac arrhythmia Haemothorax or Pneumothorax infection Anoscopy Indication; Anal lesion diagnosis. Rectal bleeding Rectal pain Banding or injection of haemorrhoids Contraindication; Anal stricture Acute perianal conditions Acutely thrombosed haemorrhoid. Positioning; Technique; -Digital examination first. Complications and management; Fissure bleeding Diagnostic peritoneal lavage Indication; Blunt abdominal trauma with equivocal or unreliable abdominal examination. Unexplained hypotension or blood loss. Unstable patient. Absolute contraindication; Indication for laparotomy. Pregnancy. Relative contraindication; Cirrhosis Morbid obesity. Retroperitoneal injury Prior to abdominal surgery. Anaesthesia; Positioning; Supine. Decompress stomach. Decompress bladder. Technique; -Preparation and anaesthesia -Indication for immediate laparotomy; Gross blood(5ml or more) Gross enteric contents Dialysat in chest tube or foley catheter -Positive finding; RBC>500/mm3 Amylase>175 Complications and management; Bladder injury Injury to bowel or other abdominal organs. Haemorrhage. Peritonitis Wound infection. Lumber puncture Indications; C.S.F evaluation C.S.F drainage Intracranial pressure measurement Intra thecal drug administration Contraindication; Non communicating hydrocephalus. Intracranial mass Coagulopathy Cellulitis Complete spinal block Tethered cord syndrome Anaesthesia; Positioning; Lateral (fetal position) Sitting position Technique; -Space; L4-L5 L3-L4 L5-S1 -Needle directed cranially and parallel to midline -The stylet should always be in the needle..? If blood clears.Traumatic Not clear+ clotsReattempt Not clear+ not clotsSubarachnoid haemorrhage -If the bone is encountered -C.S.F flow; Measure C.S.F pressure; Normal<15cm H2O Borderline 15-20cm H2O Abnormal>20mmH2O -Sample send to; Cell count. Protein and amylase Culture and sensitivity Cell count (comparison) Complications and management; 1-Tonsillar herniation Altered mental state Cranial nerve abnormality (third nerve+ respiratory difficulty) Cushing response (increase B.P +decrease P.R+ respiratory depress) Management; Position of the patient. Manitol 1gm/Kg I.V Intubation..PCO2=30mmHg Neurosurgical consultation. 2-Nerve root injury. 3-Spinal haedache 4-Aortic /arterial puncture Culdocentesis Indication; Suspected pelvic abscess. Suspected rupture ectopic pregnancy Contraindications; Obliterated cul-de-soc Severely retroverted uterus Anaesthesia; 2%Lidocaine jelly 1%Lidocaine solution Positioning; Technique; Complication and management; bleeding Tourniquets A/Finger tourniquet; Indications Contraindication Anaesthesia Positioning Technique Complications and management; Ischemia. B/Arm tourniquet. Measurement of compartment pressure Indication Sign of ischemia Pain.early sign Pallor Parasthesia Paralysis.late sign Pulselessnesslate sign Compartments of the leg; Anterior compartment Lateral compartment Superficial posterior compartment Deep posterior compartment Indications; Contraindications; Coagulopathy Infection Anaesthesia; No need why? Positioning; Technique (white side's technique); pressure>40mmHg--------fasciatomy. Complications; Error in reading Infection Arthrocentesis , intraarticular and periarticular injections Indications; A/Diagnostic; Septic arthritis Differentiate inflammatory and noninflammatory condition Synovial biopsy B/Therapeutic; Intraarticular injection Aspiration lavage Contraindication; Local infection Systemic infection Coagulopathy Allergy Prosthetic joint Distorted joint Anaesthesia; Positioning and approach; Metacarpopharangeal joint Wrist joint carpel tunnel syndrome Elbow joint Shoulder joint Knee and ankle joint Technique; Complications; Infection Bleeding Allergy Post injection flare cutaneous atrophy Tendon rupture Weakness of extremity Vasovagal syncope Steroid arthropathy Avascular necrosis Steroid induced osteoporosis Steroid available; Hydrocortisone--------25-100mg Prednisolone-------------5-40mg Methyl prednisolone acetate-----4-40mg Triamcinolone acetomide--------5-40mg Needle biopsies Advantage; Diff. benign and malignant Follow benign condition Biopsy(+/- ultrasound) Sensitive ,inexpensive, noninvasive. Types of needle biopsy; Fine needle aspiration (FNA) Large needle cutting biopsy (LNCB) Fine needle aspiration of thyroid nodule; Indication Contraindication Anaesthesia Positioning Technique; Non suction technique Suction technique Complications and management; Bleeding and haematoma Tracheal puncture Infection NB; FNA of the breast , soft tissue and lymph nodes. Note: These information has been taken from the lectures of (Dr.Ibtisam K. Salih ) and (Dr. Mohamad Kamil) and some other sources Prepared by : Dr. Soran Mohamad Gharib      PAGE  PAGE 1  35hijsĹxi]i]i]N>h<5>*CJ0OJQJ\aJ0hih<5>*CJ,\aJ,h<5>*CJ,\aJ,h~h<5>*CJ,\aJ,h<5>*CJ(\aJ(hih<5CJ(\aJ(hih<5CJ,\aJ,h<5CJH\aJHhQh<5CJH\aJHh<5CJ8\aJ8h~h<5CJH\aJH#jhQh<5CJHU\aJHh<5>*CJH\aJHhhxh<5>*CJH\aJH 45hijK ||]|^|gdod|]|gd<$||]|^|a$gdod$a$gd<gd<:_K  = > ? - .  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