Limb ischemia is a severe blockage in the arteries of the lower extremities, which significantly reduces blood flow. Acute limb ischemia is a sudden and rapid decrease in lower limb blood flow. 

TYPES

• Acute limb ischmia
• Chronic limb ischemia
• Critical limb ischemia

Acute limb ischemia

• Acute limb ischemia is a sudden and rapid decrease in lower limb blood flow. 

Chronic limb ischemia

• Chronic limb ischaemia is peripheral arterial disease that results in a symptomatic reduced blood supply to the limbs.
• It is typically caused by atherosclerosis (rarely vasculitis) and will commonly affect the lower limbs (however the upper limbs and gluteals can also be affected)
• Chronic limb ischaemia is a common condition, ranging in severity across the population, associated with several cardiovascular risk factors
• Whilst a clinical diagnosis, it can be quantified by ABPI testing, following by angiogram imaging
• Surgical intervention can be offered if conservative management options fail or those presenting with critical limb ischaemia.

Critical limb ischemia

Critical limb ischaemia is the advanced form of chronic limb ischaemia.

It can be clinically defined in three ways:

• Ischaemic rest pain for greater than 2 weeks duration, requiring opiate analgesia
• Presence of ischaemic lesions or gangrene objectively attributable to the arterial occlusive disease.
• ABPI less than 0.5

There are three main stages of acute limb ischemia: 

• Stage 1: Viable
  • Limb is not immediately threatened
  • No sensory loss
  • No muscle weakness
  • Doppler signals of arteries and veins are audible
• Stage 2: Threatened 
  • Stage 2a: Marginally threatened 
    • Limb is salvageable if promptly treated
    • Minimal sensory loss (toes) or no sensory loss
    • No muscle weakness
    • Doppler signals of arteries are often inaudible; veins are audible
  • Stage 2b: Immediately threatened 
    • Limb is salvageable with immediate revascularization
    • Sensory loss is more than toes, associated with rest pain
    • Mild to moderate muscle weakness
    • Doppler signals of arteries are usually inaudible; veins are audible
• Stage 3: Irreversible 
  • Limb has major tissue loss or permanent nerve damage inevitable
  • Profound sensory loss, numbness
  • Profound weakness, paralysis 
  • Doppler signals of arteries and veins are inaudible

EPIDEMOLOGY

The major cause of acute limb ischaemia is arterial embolism (80%), while arterial thrombosis is responsible for 20% of cases. In rare instances, arterial aneurysm of the popliteal artery has been found to create a blood clot or embolism resulting in ischaemia.

ETIOLOGY

Causes of acute limb ischemia include: 

• Blockage in a blood vessel (embolism) by such as by a blood clot, a fat globule, a bubble of air or other gas, or foreign material
• Blood clot (thrombosis)
• Peripheral artery disease due to atherosclerosis
• Tear in the lining of an aortic or peripheral artery (dissection)
• Major trauma
• Conditions that cause vasospasm 
  • Raynaud phenomenon
  • Shock (e.g., meningococcal sepsis, cardiogenic shock)
  • Administration of vasoactive drugs

Most acute limb ischemia is caused by embolism, thrombosis, peripheral artery disease due to atherosclerosis, or major trauma.

SYMPTOMS

Acute limb ischaemia can occur in patients through all age groups. People who smoke tobacco cigarettes and have diabetes mellitus are at a higher risk of developing acute limb ischaemia.Most cases involve people with atherosclerosis problems.

Symptoms of acute limb ischaemia include:

• Pain
• Pallor (pale appearance of the limb)
• Paresthesias (abnormal sensations in the limb)
• Pulselessness
• Paralysis

DIAGNOSIS

Acute limb ischemia diagnosed with a patient history and physical examination. The blockages associated with limb ischemia are located using one or more of the following methods:

• Auscultation
• Ankle-brachial index (ABI)
• Doppler ultrasound 
• Computerized tomography (CT) angiography
• Magnetic resonance angiography (MR angiography)
• Invasive Angiogram

ALI is diagnosed on the basis of medical history, visual examination, palpation, and Doppler examination of the peripheral arterial pulse using vascular ultrasonography and contrast-enhanced computed tomography (CT) as imaging tests

Investigation –

Suspected cases should be initially investigated with beside Doppler ultrasound scan (both limbs), followed by considering a CT angiography.

If the limb is considered to be recoverable, a CT arteriogram can provide more information regarding the anatomical location of the occlusion and can help decide the operative approach

• In order to treat acute limb ischaemia there are a series of things that can be done to determine where the occlusion is located, the severity, and what the cause was.
• To find out where the occlusion is located one of the things that can be done is simply a pulse examination to see where the heart rate can be detected and where it stops being sensed. Also, there is a lower body temperature below the occlusion as well as paleness.
• A Doppler evaluation is used to show the extent and severity of the ischaemia by showing flow in smaller arteries.
• Other diagnostical tools are duplex ultrasonography, computed tomography angiography (CTA), and magnetic resonance angiography (MRA).
• The CTA and MRA are used most often because the duplex ultrasonography although non-invasive is not precise in planning revascularization. CTA uses radiation and may not pick up on vessels for revascularization that are distal to the occlusion, but it is much quicker than MRA.^[1] In treating acute limb ischaemia time is everything.
• In the worst cases, acute limb ischaemia progresses to critical limb ischaemia, and results in death or limb loss.
•  Early detection and steps towards fixing the problem with limb-sparing techniques can salvage the limb.
• Compartment syndrome can occur because of acute limb ischaemia because of the biotoxins that accumulate distal to the occlusion resulting in edema.

Immediate treatment is needed for limb ischemia to re-establish blood flow to the affected area and to preserve the limb.

TREATMENT

Treatments for acute limb ischemia include: 

• Intravenous (IV) injection of unfractionated heparin (15–20 units/kg)

Upon the diagnosis of ALI, as long as heparin therapy is not contraindicated,an intravenous injection of unfractionated heparin (50–100 units/kg) is immediately administered to prevent the proximal and distal progression of secondary thrombosis to the site of occlusion, and a systemic administration of thrombolytic agents is not recommended. 

• Surgical treatment 
  • Thromboembolectomy
  • Bypass surgery
• Endovascular treatment 
  • Catheter-directed thrombolysis (CDT)
  • Percutaneous thrombus aspiration
  • Stent placement

extensive ischemia due to high occlusion and when time has passed since its onset, there is a high risk of severe ischemia–reperfusion injury; thus, limb amputation might be necessary to prioritize the patient’s life.

• Hybrid treatment that combines both therapies

Hybrid interventions in vascular surgery are defined as the utilization of both open surgical and endovascular techniques simultaneously in a single setting operation.

Red flags

missing stage 2 presentation

Pit falls –

window period causing peripheral limb loss

Pearls –

prompt mangement in stage -1 will save patient limb

• Daibetic control
• Frequent monitoring of limb

• Low back pain can result from many different injuries, conditions or diseases — most often, an injury to muscles or tendons in the back.
• Pain can range from mild to severe.
• In some cases, pain can make it difficult or impossible to walk, sleep, work or do everyday activities.
• Usually, lower back pain gets better with rest, pain relievers and physical therapy (PT).
• Some back injuries and conditions require surgical repair.

RISK FACTORS:

• Age: People over 30 have more back pain. Disks (soft, rubbery tissue that cushions the bones in the spine) wear away with age. As the disks weaken and wear down, pain and stiffness can result.
• Weight: People who are obese or carry extra weight are more likely to have back pain. Excess weight puts pressure on joints and disks.
• Overall health: Weakened abdominal muscles can’t support the spine, which can lead to back strains and sprains. People who smoke, drink alcohol excessively or live a sedentary lifestyle have a higher risk of back pain.
• Occupation and lifestyle: Jobs and activities that require heavy lifting or bending can increase the risk of a back injury.
• Structural problems: Severe back pain can result from conditions, such as scoliosis, that change spine alignment.
• Disease: People who have a family history of osteoarthritis, certain types of cancer and other disease have a higher risk of low back pain.
• Mental health: Back pain can result from depression and anxiety.

SYMPTOMS:

• Symptoms of lower back pain can come on suddenly or appear gradually.
• Pain may be sharp or dull and achy, and it may radiate to your bottom or down the back of your legs.
• If you strain your back during an activity, you may hear a “pop” when it happened.
• Pain is often worse in certain positions (like bending over) and gets better when you lie down.
• Other symptoms of lower back pain include:
  • Stiffness
  • Posture problems
  • Muscle spasms.

CAUSES:

• Strains and sprains
• Fractures
• Disk problems
• Structural problems
• Arthritis
• Infections and tumors
• Spondilolisthesis

DIAGNOSIS:

• Spine X-ray
• MRI
• CT scan

TREATMENT:

• Lower back pain usually gets better with rest, ice and over-the-counter pain relievers. After a few days of rest, you can start to get back to your normal activities. Staying active increases blood flow to the area and helps you heal.
• Other treatments for lower back pain depend on the cause. They include:
• Medications: Your provider may recommend nonsteroidal anti-inflammatory drugs (NSAIDs) or prescription drugs to relieve pain. Other medications relax muscles and prevent back spasms.
• Physical therapy (PT): PT can strengthen muscles so they can support your spine. PT also improves flexibility and helps you avoid another injury.
• Hands-on manipulation: Several “hands-on” treatments can relax tight muscles, reduce pain and improve posture and alignment. Depending on the cause of pain, you may need osteopathic manipulation or chiropractic adjustments. Massage therapy can also help with back pain relief and restore function.
• Injections: Your provider uses a needle to inject medication into the area that’s causing pain. Steroid injections relieve pain and reduce inflammation.
• Surgery: Some injuries and conditions need surgical repair. There are several types of surgery for low back pain, including many minimally invasive techniques

PREVENTION:

• You can’t prevent lower back pain that results from disease or structural problems in the spine.
• To reduce your risk of a back injury, you should:
• Maintain healthy body weight
• Strengthen your abdominal muscle

• Lift in a right way.

RED FLAGS :

• Weakness of upper limb/lowerlimb
• Numbness
• Bowel or bladder disturbances
• Radiating pain to upper limb/lower limb

Their symptoms may need surgical intervention after evaluation

Objects in the mouth may be swallowed or breathed (aspirated) into the lungs

Objects in the ears and nose can make it hard to hear or breathe and can cause infection

FOREIGN BODIES IN THE EAR:

Foreign bodies in the ear canal be anything a child can push into his or her ear

Some of the items that are commonly found in the ear canal include

Food

Insects

Toys

Buttons

Pieces of crayon

Small batteries

« Some objects placed in the ear may not cause symptoms

« Other objects such as food and insects may cause pain in the air,redness or drainage

« Hearing may be affected if the object is blocking the ear canal

Techniques that may be used to remove the object from the ear canal:

Instruments such as long, thin tweezers or forceps may be put in the ear to grab and remove object

Magnets are sometimes used to remove the object if it is metal

The ear canal may be flushed with water

A machine with suction may be used to help pull the object out

After removal of the object, re-examine the ear to determine if there has been any injury to the ear canal

Antibiotic drops for the ear prescribed to treat any possible outer ear infections

FOREIGN BODIES IN THE NOSE:

Objects that are put into the childs nose are usually soft things

These include

Ÿ Tissue

Ÿ Clay

Ÿ Pieces of toys

Ÿ Erasers

« The most common symptom of a foreign body in the nose is nasal drainage

« Often has a bad odour

« In some cases, the child may also have a bloody nose

Techniques :

Sedating the child is sometimes needed to remove the object successfully

Suction machines with tubes attached may be used

Instruments may be inserted in the nose

The object may be blown out of the nose

After removal of the object, prescribe nose drops or Antibiotic ointment to treat any possible infections

FOREIGN BODIES IN THE THROAT :

A foreign body in the throat can cause choking and is a medical emergency that needs immediate attention. The foreign body can get stuck in many different places within the Airway.

According to the American Academy of Pediatrics death by choking  is leading cause of death and injury among children younger than 4 yrs of age

Ÿ Seeds                         

Ÿ Toy parts

Ÿ Grapes

Ÿ Hot dogs

Ÿ Pebbels

Ÿ Nuts

Ÿ Buttons

Ÿ Coins

Symptoms that may mean a child is choking

« Choking or gagging when the object is first inhaled

« Coughing at first

« Wheezing (A whistling sound usually made when the child breaths out)

 Symptoms may mean that the foreign body is still blocking an airway

« Stridor ( A high pitched sound usually heard when the child breathes)

« Cough that gets worse

« Child unable to speak

« Pain in the throat area or chest

« Hoarse voice

« Blueness around the lips

« Not breathing

« The child becoming unconscious

If the FB is visualised in the oropharynx and the patient can tolerate the procedure, removal may be attempted using Magill forceps. Otherwise, removal should be attempted with endoscopy under GA (either via pharyngoscopy / laryngoscopy or rigid oesophagoscopy).

The urgency of endoscopy is outlined below:

• Emergency endoscopy
  • Any red flag signs
  • Any sharp or long (>5cm) object in the oesophagus
• Urgent endoscopy (within 24 hours)
  • Oesophageal obstruction (unable to swallow saliva)
  • Blunt oesophageal FB
  • Magnets proximal to the duodenum
• Non-urgent endoscopy
  • Disc or cylindrical batteries which have passed into stomach without signs injury
  • coins may be observed for upto 24 hours before removal if asymptomatic

To prevent choking:

Cut foods into small pieces

Never let small children run, play or lie down while eating

Keep coins and small items out of reach of your children

Read warning labels on toys

Learn first aid for choking

Submitted by

P.Bharathi

• These are life threatening situations in obestric/midwifery practice which are unexpected, develop rapidly, relatively uncommon and fatal for women & foetus.

Conditions (severe)

1. Hypertensive disorders
2. Hemorrhage
3. Embolism threaten- risk of mother life
4. Prolapse umbilical cord- risk of foetus life 
5. In 20 th century death’s of mothers due to OBG emergency is very common

Essential qualities of mid wife in handling  OBG emergencies :

• Recognize problem and initiate emergency
• Remain alert
• Decision making skills
• Address both physiological & psychological needs of mother
• Reassure, explain & support the family
• Proper record maintaining & skillful in reporting
• Positive attitude
• Updated skills 

Check progress -1

1. Define obstetric emergency
2. List conditions included

OBG EMERGENCIES &THEIR MANAGEMENT:

• Rupture of uterus
• Vasa Previa cord presentation & cord prolapse
• Amniotic fluid embolism
• Shoulder dystocia
• Shock .
• RUPTURE OF UTERUS :
• Break in continuity of uterine wall any time beyond 28 weeks of pregnancy.

A.Uterine rupture during antenatal period

  Signs&symptoms

• Right abdominal pain ,shock, intrauterine death of foetus,vaginal bleed,

Fainting attack,collapse, absence of foetal heart rate.

Diagnosis- Laprotomy

Management-  resuscitation of mother

                            Preparation of emergency Laprotomy

                        Laprotomy include-repair of scar , repair with sterilization , hysterectomy.

B.Uterine rupture during intra natal period

         Signs & symptoms-severe constant lower Abdominal pain, vomiting, increase heart rate,foetal tachycardia,

• Some times scar rupture & women goes into shock

 Management– immediate C-section,                                                                                             

  Repair of year/hysterectomy , manage shock &give blood transfusion

C.Uterine rupture following obstructed labour

Signs& Symptoms – Severe& constant abdominal pain , Severe foetal distress .

Management – Treat shock, prepare for hysterectomy.

D.Incomplete rupture –

Treating of uterine wall but not perimetrium found after delivery, during caesarean , previous c.section.

  Signs& symptoms – Shock during 3 Rd stage of labour , abdominal pain

 Management -Immediate caesarean to deliver alive baby, management of shock, hysterectomy .

Check progress- 2

      1.Define rupture of uterus

      2.Cause of uterine rupture.

2.VASA PRAEVIA :

• Some of the Blood vessels that connect the umbilical cord to the placenta lie over /near the entrance of birth canal.
• When membranes around baby rupture these blood vessels can rupture to cause baby to lose a lot of blood 

Signs & symptoms – bleeding,foetal bradycardia, tachycardia, increase foetal movement

Management-

• Active labour vaginal delivery should be expedited
• Emergency C.section is permitted -If foetus is alive & mother is in first stage of labour
• Cord blood is collected for estimation of foetal HB 

3.CORD PRESENTATION & PROLAPSE :

Cord presentation- Presence of umbilical cord between fetal presenting part &the cervix with/without membrane rupture

Cord prolapse- Before/during birth,the umbilical cord can drop through the open cervix into vagina ahead of body.

Predisposing factors- Multiparity ,prematurity , malpresentations that is breech, shoulder,brow,face,high head,long cord, multiple pregnancy.

Diagnosis- foetal bradycardia ,loop of cord may be visible at vulva ,

      Vaginal examination-immediately

Management-

• Delivery in possible speed to reduce mortality
• If foetus is alive and women in first stage of labour , immediate c.section
• Oxygen by mask – decrease foetal hypoxia
• 2^nd stage of labour- episiotomy 

Positions- 1.Knee- chest position

                   2.Exaggerated sims lateral position

                   3.Trendlenburg position 

    Check progress-3

  1.Explain signs& symptoms of Vasa praevia

 2.differentiate between cord presentation &prolapse

 3.How can you diagnose cord prolapse

 4.Explain to positions used to relieve pressure on umbilicus 

4.SHOULDER DYSTOCIA :

One /both of your babys  shoulder get stuck during vaginal delivery

Risk factors- Maternal age over 35 years ,high parity,past dated pregnancy, maternal pregnancy, maternal diabetes& gestational diabetes, large foetus with increased birth weight , oxytocin augmentation,prolonged labour& prolonged 2^nd stage of labour 

Warning signs& diagnosis: 

• Initially delivery may have been complicated,but the head may have advanced slowly
• Once head is delivered, it may look head is trying to recede back of vagina caused by reverse traction . usually diagnosed/suspeced when usual method used by midwife fails to deliver the baby
• Mac Roberts position .

5.AMNOTIC FLUID EMBOLISM :

• When amniotic fluid is forced into maternal circulation via uterus/ placental site forming embolism which obstructs pulmonary vessel’s leading to respiratory distress, circulatory collapse 

Causes: advanced maternal age , over estimation of uterus by drugs , uterine trauma, while performing c.section.

Signs& symptoms- Sudden onset of respiratory distress,chest pain,cough with pink sputum, hypotension & tachycardia,shock, vomiting, restless, anxiety, convulsions

Diagnosis- Detection of amniotic fluid in blood/on post-mortem examination of lungs

     Management- 

• Call for medical help
• Assist in immediate resuscitation
• Prepare for intubation & mechanical ventilation
• Arrange for I.V infusion of fluids & aminophylline
• Urinary catheter-measure hourly output
• Oxygen 8-10lit/min or resuscitation bag delivery 100% oxygen
• Prepare for emergency birth-once maternal condition stabilized

Check progress-4

1. What are risk factors involved in shoulder dystocia
2. Mention-warning signs& diagnosis of shoulder dystocia
3. Role of midwife in handling shoulder dystocia
4. Explain amniotic fluid embolism
5. What are predisposing factors for amniotic fluid embolism
6. List 3 signs & symptoms of amniotic fluid embolism

6.SHOCK :

• It is a condition of collapse due to failure of mother’s circulation system

Causes- Greyish blue / pale skin ,cold clammy skin, shivering,rapid breathing,rapid weak/slow pulse

      Flushed skin, decrease urinary out put 

Signs& symptoms-  hemorrhage ,

Non hemorrhagic shock due to – trauma, prolonged labour/psychological distress, fluid loss,septaecimia, pulmonary embolism.

Management-  Start resuscitative measures immediately ,

                            Maintain airway, Replace fluids &start I.v infusion

                           Administer oxygen

                           Record intake & output  

   Check progress-5

         1.Explain shock        2.Explain role of midwife in management of shock .

Some legal implications for emergency care : 

1. Take informed written consent before any treatment /action
2. Explain conditions to the patients family & possibility of death
3. Be sure about what, how, where &when of your actions
4. Reach help in time,take prompt & immediate action
5. Give BLS whenever indicated
6. Use standard protocol
7. Must complete the referral from
8. Record all drugs, intervention done on women
9. Maintain records- clear,legible,concise, accurate, pertinent & complete 

Check progress-6

1.list 6 legal tips for emergency care

2.Prepare a referral from to transfer a mother with any one OBG emergencies to a nearly community health center

In this OBG there are divided into types

ECLAMPSIA:

Eclampsia is the new onset of seizures or coma in a pregnant woman with pre eclampsia. These seizures are not related to an existing brain condition.

Causes

The exact cause of eclampsia is not known. Factors that may play a role include:

• Blood vessel problems
• Brain and nervous system (neurological) factors
• Diet
• Genes

Eclampsia follows a condition called pre-eclampsia. This is a complication of pregnancy in which a woman has high blood pressure and other findings.

               Most women with pre-eclampsia do not go on to have seizures. It is hard to predict which women will. Women at high risk of seizures often have severe pre-eclampsia with findings such as:

• Abnormal blood tests
• Headaches
• Very high blood pressure
• Vision changes
• Epigastic pain

In pre -eclampsia it mainly causes the hypertension  during in the pregnancy time especially placenta  narrow and less blood flow it may leads to fetal death and also released pro-inflammatory proteins .

If patient with seizures in emergency :

ABC approach

Side rails, mouth gap to prevent

Inj.MGSO4

Inj.MGSO4 5grm dl plus 4 grms MGSO4 diluted to 20cc to given over 5to1

Foleys catheterisation  inj.mgso4 5mg deep IM every 4^th helt for jolus

Immediately delivery should be planned

Signs of MGSO4 toxicity

Values are:

V.o- less than 100

RR less than 18 min Absence of patellar re flux     

Post -partum hemorrhage :

Postpartum hemorrhage (also called PPH) is when a woman has heavy bleeding after giving birth. It’s a serious but rare condition. It usually happens within 1 day of giving birth, but it can happen up to 12 weeks after having a baby. About 1 to 5 in 100 women who have a baby (1 to 5 percent) have PPH.

Causes of post-partum hemorrhage:

The causes of postpartum hemorrhage are called the four Ts (tone, trauma, tissue and thrombin).

The most common causes of PPH are:

• Uterine atony: Uterine atony (or uterine tone) refers to a soft and weak uterus after delivery. This is when your uterine muscles don’t contract enough to clamp the placental blood vessels shut. This leads to a steady loss of blood after delivery.
• Uterine trauma: Damage to your vagina, cervix, uterus or perineum (area between your genitals and anus) causes bleeding. Using instruments like forceps or vacuum extraction during delivery can increase your risk of uterine trauma. Sometimes, a hematoma (collection of blood) can form in a concealed area and cause bleeding hours or days after delivery.
• Retained placental tissue: This is when the entire placenta doesn’t separate from your uterine wall. It’s usually caused by conditions of the placenta that affect your uterus’s ability to contract after delivery.
• Blood clotting condition (thrombin): If you have a coagulation disorder or pregnancy condition like eclampsia, it can interfere with your body’s clotting ability. This can make even a tiny bleed uncontrollable.

The most common drugs used are oxytocin, methylergonovine or prostaglandins like carboprost or misoprostol,INJ.Tranexa

Ruptured ectopic pregnancy:

Ruptured ectopic pregnancy is a devastating consequence of the implantation of embryos outside the uterus. The classic triad of ectopic pregnancy includes abdominal pain, amenorrhea, and vaginal bleeding, Progression of symptoms to severe abdominal tenderness, peritoneal signs, and shock is indicative of a ruptured ectopic pregnancy.

Causes of Ruptured ectopic pregnancy:

              An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. Almost all ectopic pregnancies—more than 90%—occur in a fallopian tube. As the pregnancy grows, it can cause the tube to burst

Conformation of pregnancy by UPT or USG for haematoperitoneum, Arrange

uterine inversion:

               Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. It is a rare complication of vaginal or cesarean delivery, but when it occurs, it is a life-threatening obstetric emergency.

• A muscle cramp is a sudden and involuntary contraction of one or more of your muscles. These contractions are often painful and can affect different muscle groups.
• Commonly affected muscles include those in the back of your lower leg, the back of your thigh, and the front of your thigh,abdominal wall,arms,hands&feet.
• The intense pain of a cramp can awaken you at night or make it difficult to walk.
•  A sudden, sharp pain, lasting from a few seconds to 15 minutes

CAUSES

• Inadequate blood supply. Narrowing of the arteries that deliver blood to your legs can produce cramp-like pain in your legs and feet while you’re exercising. These cramps usually go away soon after you stop exercising.
• Nerve compression. Compression of nerves in your spine (lumbar stenosis) also can produce cramp-like pain in your legs. The pain usually worsens the longer you walk. Walking in a slightly flexed position such as you would use when pushing a shopping cart ahead of you may improve or delay the onset of your symptoms.
• Aging: Over time, losing muscle mass can put more strain on your muscles. These changes can lead to more frequent muscle cramps as you age.
• Dehydration: Losing body fluids while exercising (especially in hot temperatures) can cause muscles to cramps
• Hypothyroidism: Having a thyroid gland that is less active than normal can lead to muscle cramps.
• Low electrolyte levels: Low levels of substances such as calcium or potassium in the blood can cause muscle cramps.
• Medication: Taking certain medicines, including pseudoephedrine (a drug used to treat nasal congestion) and statins (medications that treat high cholesterol), can cause involuntary muscle cramping.

TYPES OF MUSCLE CRAMPS

• Skeletal muscle cramps: Can be voluntarily controlled. Skeletal muscles that cramp the most often are the calves, thighs, and arches of the foot, Around 40% of people who experience skeletal cramps are likely to endure extreme muscle pain.
• Nocturnal leg cramps:These leg cramps are involuntary muscle contractions that occur in the calves, soles of the feet, or other muscles in the body during the night or (less commonly) while resting. The duration of nocturnal leg cramps is variable, with cramps lasting anywhere from a few seconds to several minutes.
• Smooth Muscle Cramps: Contractions may be symptomatic of endometriosis.Menstrual cramps may also occur during a menstrual cycle, as a result of uterine contractions as the uterus sheds its lining. Menstrual pain is common and most menstruating women experience it at some point, with more than 40% experiencing pain every period. Severe pain is less common, but still significant

CLINICAL PRESENTATION

• Weakness
• Swollen Joints
• Joint Pain
• Firmness,
• Tenderness,
• Bulging of the muscle,
• Swelling,
• Soreness, and
• Gait disturbances (if the cramp occurs in the leg or foot).

DIAGNOSTIC TESTS

• Blood test to check the levels of potassium and calcium in your blood, as well as your kidney and thyroid function.
• Electromyography :This is a test that measures muscle activity and checks for muscle abnormalities.
• MRI may also be a helpful test. It’s an imaging tool that creates a picture of your spinal cord.
• Urine tests to find the cause of muscle cramps. These tests can identify underlying conditions such as liver or kidney disease that may cause cramps.

RISK FACTORS

• Tight, inflexible muscles.
• Poor physical condition.
• Poor muscle tone.
• Inadequate diet.
• Physical overexertion.
• Physical exertion of cold muscles.
• Muscle injury.
• Muscle fatigue.

TREATMENT

• Stretch the affected area.
• Massage the affected area with your hands or a massage roller.
• Stand up and walk around.
• Apply heat or ice. Put an ice pack together or apply a heating pad, or take a nice warm bath.
• Take painkillers such as ibuprofen and acetaminophen,vitamin B12 complex.

PREVENTION

• Perform flexibility exercises on a regular basis.
• Work towards better overall fitness.
• Stretch your muscles regularly. Do this especially for those most prone to muscle spasms.
• Drink fluids frequently. Choose water and avoid alcohol and caffeine.
• Avoid exercising in hot weather.
• Wear shoes that fit you properly.
• Keep your weight at a healthy range. Experiment with mild exercise right before bed to prevent nocturnal leg cramps.
• Avoid medications that may cause muscle spasms as a side effect.
• To prevent leg cramps, use pillows to keep your toes pointed upwards if you sleep on your back. If you sleep on your chest, hang your feet over the end of the bed.
• Stretch your muscles before you go to sleep. When you sleep, keep the sheets and blankets loose around your legs.

• An increase in frequency of defecation urgency, or decrease in stool consistency (typically >3loose stools per day) for >4weeks.
• Abnormal stool form is the most important defining factor frequent defecation with normal consistency is termed pseudo diarrhoea.
• Etiologies include osmotic, secretory, malabsorptive, inflammatory, infectious, and hyper motility.
• Infectious causes of chronic diarrhea are uncommon in immunocompetent patients. Parasitic etiologies are more common than bacterial.

 STAGES OF DIARRHOEA

• Mild-2-5 times in a day, Sudden onset
• Moderate-10-12 times a day, Gradually  

·       Severe-More than 12 times in a day ,Sudden &gradually

 OSMOTIC DIARRHEOA

Absorption of water in the intestines is dependent on adequate absorption of solutes. If excessive amounts of solutes are retained in the intestinal lumen, water will not be absorbed and diarrhoea will result. Osmotic diarrhoea typically results from one of two situations:

• Ingestion of a poorly absorbed substrate: The offending molecule is usually a carbohydrate or divalent ion. Common examples include mannitol or sorbitol, Epson salt (MgSO₄) and some antacids (MgOH₂).
• Malabsorption: Inability to absorb certain carbohydrates is the most common deficit in this category of diarrhoea, but it can result virtually any type of malabsorption. A common example of malabsorption, afflicting many adults humans and pets is lactose intolerance resulting from a deficiency in the brush border enzyme lactase. In such cases, a moderate quantity of lactose is consumed (usually as milk), but the intestinal epithelium is deficient in lactase, and lactose cannot be effectively hydrolysed into glucose and galactose for absorption. The osmotically-active lactose is retained in the intestinal lumen, where it “holds” water. To add insult to injury, the unabsorbed lactose passes into the large intestine where it is fermented by colonic bacteria, resulting in production of excessive gas.

SECRETORY DIARRHEOA

Large volumes of water are normally secreted into the small intestinal lumen, but a large majority of this water is efficiently absorbed before reaching the large intestine. Diarrhoea occurs when secretion of water into the intestinal lumen exceeds absorption.

Many millions of people have died of the secretory diarrhoea associated with cholera. The responsible organism, Vibrio cholera, produces cholera toxin, which strongly activates adenylyl cyclase, causing a prolonged increase in intracellular concentration of cyclic AMP within crypt enterocytes. This change results in prolonged opening of the chloride channels that are instrumental in secretion of water from the crypts, allowing uncontrolled secretion of water. Additionally, cholera toxin affects the enteric nervous system, resulting in an independent stimulus of secretion.

Exposure to toxins from several other types of bacteria (e.g. E. coli heat-labile toxin) induce the same series of steps and massive secretory diarrhoea that is often lethal unless the person or animal is aggressively treated to maintain hydration.

 TYPES OF DIARRHOEA

ACUTE DIARRHOEA: The most common, acute diarrhoea is loose watery diarrhoea that lasts one to two days. This type doesn’t need treatment and it usually goes away after a few days.

 CAUSES:

• Viral infections. Many viruses cause diarrhoea, including norovirus. Viral gastroenteritis is a common cause of acute diarrhoea.
• Bacterial infections. Several types of bacteria can enter body through contaminated food or water and cause diarrhoea. Common bacteria that cause diarrhoea include Campylobacter, Escherichia coli.
• Parasitic infections. Parasites can enter your body through food or water and settle digestive tract. Parasites that cause diarrhoea include Cryptosporidium enteritis, Endamoeba histolytica, and Giardia lamblia, Cyclospora&Isosopra

TREATMENT:

Diet: Patient takes adequate oral fluids containing carbohydrates &electrolytes.

        Patients find it more comfortable to rest the bowel by avoiding high fibre foods ,fats, milk products ,caffeine and alcohol.

Rehydration: Severe   diarrhoea ,dehydration can occur quickly, especially in children and older adults.Oral rehydration with fluids containing glucose,Na+,K+,CL-

 Antibiotic Therapy

Empiric Treatment-Ciprofloxacin 500mg OD for 3days

                                    Ofloxacin 400mg OD

CHRONIC DIARRHOEA:

Diarrhoea that lasts for more than four weeks or comes and goes regularly over a long period of time is called chronic diarrhoea.

CAUSES:

Viruses– Norwalk virus, enteric adenoviruses, Arbovirus, cytomegalovirus and viral hepatitis. Rotavirus is a common cause of childhood diarrhoea.

Bacteria and   parasites. E. coli or parasites through contaminated food or water, leads to diarrhoea. When traveling in developing countries, diarrhoea caused by bacteria and parasites is often called traveller’s diarrhoea.

• Medications. Antibiotics, can cause diarrhoea called Pseudomembranous colitis Antibiotics alleviate infections by killing bad bacteria, but they also kill good bacteria. This disturbs the natural balance of bacteria in intestines, leading to diarrhoea. Other drugs that cause diarrhoea are anti-cancer drugs and antacids with magnesium.
• Lactose intolerance. Lactose is a sugar found in milk. People who have difficulty digesting lactose have diarrhoea after eating dairy products.
• Fructose. Fructose is a sugar found naturally in fruits and honey. It’s sometimes added as a sweetener to certain beverages. Fructose can lead to diarrhoea in people who have trouble digesting it.
• Artificial sweeteners. Sorbitol, erythritol and mannitol artificial sweeteners are nonabsorbable sugars found in chewing gum and other sugar-free products  can cause diarrhoea in some otherwise healthy people.
• Surgery. Partial intestine or gallbladder removal surgeries can sometimes cause diarrhoea.

Digestive disorders. Irritable bowel syndrome, Crohn’s disease, ulcerative colitis, celiac disease, microscopic colitis and small intestinal bacterial overgrowth (SIBO).

SIGNS&SYMPTOMS

SIGNS                                                

• Sunken eye ball
• Dry tongue& mucosa
• Poor skin turgor
• Low blood pressure
• Lethargy
• Weight loss

SYMPTOMS

• Passage of loose stool
• Increased frequency of passage of stool
• Loose, watery consistency of stool
• Low urine output
• Increased volume of stool
• Vomiting

RISK FACTORS:

1.Osmotic

• Excess ingestion of non-absorbable carbohydrates, lactose intolerance & celiac disease

2.Secretory

• -Post surgical: extensive small bowel resection/ileal surgery, vagotomy, bile acid malabsorption.
• History of neuroendocrine disease
• History of stimulant laxative abuse
• Dysmotility syndromes.

3.Malabsorptive

• Chronic alcohol abuse
• Chronic pancreatitis
• Celiac disease

4.Inflammatory

• IBD, NSAID use
• Thoracoabdominal radiation, HIV/AIDS
• Antibiotic use

5.Hypermotility

• Psychosocial stress
• Preceding infection

COMPLICATIONS:

• Fluid and electrolyte abnormalities, Acute kidney injury
• Malnutrition, anaemia, unintentional weight loss
• Malignancy (colon cancer in IBD,small bowel cancer in celiac disease)
• Infection with immunomodular, biologic and corticosteroid therapies for IBD

PHYSICAL EXAMINATION

General: Volume depletion ,nutritional status ,recent weight loss

Skin: Flushing, erythema nodosum, pyodema gangrenosum, ecchymoses, dermatitis herpetiformis, hyperpigmentation.

Neck: Goiter, lymphadenopathy(whipple disease)

CVS: Tachycardia,heart murmur

Pulmonary:  Wheezing

Abdomen: Hyperactive bowel sounds,abdominal distension,diffuse tenderness.

Anorectal: anorectal fistulas,fissures,fecal impaction

Extremitis: arthritis

Neurologic: tremor

DIAGNOSTIC TESTS:

• Initial tests (lab, imaging)
• Test patients with alarm symptoms or persistent symptoms and no identifiable cause.
• Blood :CBC,electrolytes,total protein,albumin,TSH,T4,erythrocyte sedimentation rate,C-reactive protein,IgA anti-tissue transglutamine,iron studies
• Stool:  WBCs or fecal calprotein,culture,ova and parasites,Giardia stool antigen,,  electrolytes,occult blood,osmolality,quanlitative fecal fat .
• CT or MRI to evaluate the structure of the GI tract

MANAGEMENT:

• Plenty of fluids to prevent dehydration
• Oral rehydration drinks to replace lost salts and minerals. An alternative is one part unsweetened pure fruit juice diluted with four parts of water.
•  Nutrition rich foods-the vicious circle of malnutrition &diaarhoea can be broken by continuing to give nutrient rich foods
• ORT: They contain 2-3 g/dL of glucose, 45-90 mEq/L of sodium, 30 mEq/L of base, and 20-25 Me q/L of potassium. Osmolality is 200-310 mOsm/L.-1liter 1day.
• In children with severe acute malnutrition and diarrhea, low osmolarity oral rehydration solution (ORS) ( osmolarity:  245, sodium: 75 mEq/L) with added potassium (20 m mol/L) 
• Diarrhoea 30 episodes give IV fluids-Ringer lactate TID
• Ofloxacin+ornidazole 200+500mg BD for 5days
• Racecodotril 100mg BD 3days
• Sporlac sachets-TID for 3-5days
• Entero germinal respules-BD for 3-5days
• If abdominal pain-adults-Buscopan&,Peadiatrics-Cyclopam syrup

DIET:

• Elimination diet: avoid gluten-containing foods,non absorbable carbohydrates,lactose containing products&food allergens depending on etiology of diarrhoea.
• Low FODMAP (Fermentable oligosaccharides, disaccharides,monosaccharides&polyols)diet helps symptoms in upto 75% of IBS patients.
• High carbohydrate intake and obesity have been linked to chronic diarrhoea.

PATIENT EDUCATION:

Wide variation in normal bowel habits

Diarrhoea is generally defined as 3 or more loose bowel movements per day for over 4 weeks.

• Drink plenty of liquids, including water, broths and juices. Avoid caffeine and alcohol.
• Add semisolid and low fiber foods gradually as your bowel movements return to normal. Try soda crackers, toast, eggs, rice or chicken.
• Avoid certain foods such as dairy products, fatty foods, high-fiber foods or highly seasoned foods for a few days.

RED FLAGS Hypotension,sunken eyes

PEARL: ORS therapy

REFERENCE:

5 minutes consultant.com

• Periodontitis is a disease which categorized under periodontal diseases.
• The word periodontitis comes from periodontium means surrounding(peri) the tooth (odont)
• A serious gum infection that damages gums & can destroy the jawbone.Around 40%of people suffer from periodontitis, among adults, it is estimated that around 70%of tooth loss is caused by periodontitis.
• It is a disease which affects more than one or all the constituents of the periodontum.The constituents of the periodontum are gingiva,periodontal ligaments,cementum and alveolar bone.

CAUSES:

Periodontitis is typically caused by poor dental hygiene.Our mouths are full of bacteria,along with mucus and other particles,constantly form a sticky,colorless plaque on teeth.

• If you don’t remove the plaque by brushing, the bacteria deposit minerals within the plaque over time.
• This mineral deposit is known as tartar, which will encourage more bacterial growth toward the root of the tooth

• Your body’s immune response to this bacterial growth leads to inflammation in your gums.
• The attachment of the gum to the root of a tooth is disrupted over time, and a periodontal pocket (gap) may form between the gum and root.

STAGES OF PERIODONTAL DISEASE:

1. GINGIVITIS:1^st stage of periodontal disease.Inflammation of the gums.This is the body’s response to bacteria that has been accumulated on the teeth.usually involve red,swollen gums&bleeding especially while brushing.

• SLIGHT PERIODONTAL DISEASE: At this stage, the infection has spread to the bone and begins to attack bone tissues with stronger, highly aggressive bacteria. Symptoms of

slight periodontal disease include increased swelling or redness of the gums and bleeding during brushing or flossing

• MODERATE PERIODONTAL DISEASE: The symptoms of moderate periodontal disease are the same as slight periodontal disease, although probing depths will be deeper, between six and seven millimeters.

With those deeper pockets between your teeth and gums, even more bacteria attacks your teeth and jawbone. At this stage, the bacteria can make its way into your bloodstream and immune system as well.

• ADVANCED PERIODONTAL DISEASE: If you ignore the symptoms of earlier stages of periodontal disease, you will shift into stage 4, which threatens a 50-90% chance of irreversible bone loss. Symptoms of this final stage include red, swollen gums that ooze pus, painful chewing, extreme cold sensitivity, severe bad breath, and loosened teeth. The only remedy at this point is periodontal surgery or periodontal laser therapy, which will clean out the deep pockets of bacteria beneath the gums and allow the infected tissue to heal.

CLINICAL PRESENTATION:

• Bleeding gums caused due to brushing.
  • Bad breath(Halitosis), Changes in the positioning of teeth in the jaws
  • Receding gums-Where teeth appear longer
  • Constant unbearable pain
  • Teeth sensitivity

RISK FACTORS:

• Smoking:Smokers are much more likely to develop periodontitis than non -smokers. In smokers ,gum bleeding may be less noticeable because of the effect of nicotine on blood vessels, which means that the progress of the disease may be hidden.
  • Genetics, Age
  • Diabetes, Poor diet, Stress

COMPLICATIONS:

Painful abscesses

Loose teeth or loss of teeth

DIAGNOSIS:

• Review medical history–To identify any factors that could be contributing to your symptoms
  • Take dental Xrays, Measure the pocket depth.

TREATMENT:

1.Deep cleaning 2.Medications 3.Surgical Treatment

1. DEEP CLEANING:

• The dentist,periodontist, or dental hygienist removes the plaque through a deep cleaning method called scaling&root planning.
  • Scaling means scraping off the tartar from above&below the gum line.
  • Root planing gets rid of rough spots on the tooth root where the germs gather,and helps remove bacteria that contribute to the disease.
  • In some cases a laser may be used to remove plaque and tartar.This procedure can result in less bleeding,swelling,and discomfort compared to traditional deep cleaning methods.

2. MEDICATIONS:

PRESCRIPTION ANTIMICROBIAL MOUTHRINSE:

• A prescription mouth rinse containing an antimicrobial called chlorhexidine.
  • To control bacteria when treating gingivitis and after gum surgery
  • Its used like a regular mouthwash.

ANTIBIOTIC GEL:

• A gel that contains the antibiotic doxycycline
  • To control bacteria and reduce the size of periodontal pockets.
  • The periodontist puts it in the pockets after scaling and root planing. The antibiotic is released slowly over a period of about 7days.

ANTIBIOTIC MICROSPHERES:

• Tiny,round particles that contain the antibiotic minocycline.
  • To control bacteria and reduce the size of periodontal pockets.
  • The periodontist puts the microspheres into the pockets after scaling and root planing. The particles release minocycline slowly over time.

ENZYME SUPPRESSANT:

• A low dose of the medication doxycycline that keeps destructive enzymes in check.
  • To hold back the body enzyme response if not controlled certain enzymes can break down gum tissue.
  • This medication is in tablet form.it is used in combination with scaling &root planing.

ORAL ANTIBIOTICS:

• Metronidazole-500mg tid for 7 days,Doxycycline 200mg qid for 21 days.

3. SURGICAL TREATMENT:

FLAP SURGERY:To remove tartar deposits in deep pockets or to reduce the periodontal pocket and make it easier for the patient,dentist ,hygienist to keep the area clean.

BONE AND TISSUE GRAFT:In this dentist regenerate any bone or gum tissue lost to periodontitis.

 PREVENTION:

• Consistent good dental hygiene
  • Brush twice daily with a fluoride toothpaste(be sure to replace toothbrushes every 1-3 months)
  • Clean between the teeth with floss or an interdental cleaner.
  • Eat a well balanced diet and limit between meal snacks.
  • Have regular visits with a dentist for teeth cleaning and oral examinations
  • If you smoke,you should quit smoking is a major risk factor for gum disease.

RED FLAGS:

           Bleeding gums&tooth sensitivity

PEARLS:

           Early diagnosis&treatment

REFERENCES:

• J.D Da Saliva et al Oxford American Hand book of clinical Dentistry.
  • PubMed

https://youtu.be/G93lPrHGZdo

https://youtu.be/G93lPrHGZdo