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By: Rasheed Adebayo Gbadegesin, MBBS

  • Professor of Pediatrics
  • Professor in Medicine
  • Affiliate of Duke Molecular Physiology Institute


It should be used as a quick-reference tool in the evaluation of a trauma patient and in the planning of the surgical repair and/or reconstruction medications used for depression purchase genuine coversyl line. This manual supplements symptoms multiple myeloma discount 4mg coversyl overnight delivery, but does not replace symptoms 2 weeks pregnant buy 8 mg coversyl with amex, more comprehensive bodies of literature in the feld symptoms narcolepsy coversyl 8mg without a prescription. The editors would like to administering medications 7th edition answers 4mg coversyl overnight delivery thank all of the authors who generously gave their time and expertise to symptoms hepatitis c buy coversyl cheap online compose excellent chapters for this Resident Manual in the face of busy clinical and academic responsibilities and under a very narrow timeframe of production. These authors, experts in the care of patients who have sustained trauma to the face, head, and neck, have produced practical chapters that will guide resident physi cians in their assessment and management of such trauma. The authors have a wide range of clinical expertise in trauma management, gained through community and military experience. Additionally, this manual could not have been produced without the expert copyediting and design of diverse educational chapters into a cohesive, concise, and practical format by Joan O?Callaghan, Director, Communications Collective, of Bethesda, Maryland. The editors also wish to acknowledge the unwavering support and encouragement from: Rodney P. It is important to review with the trauma team the potential for an unstable airway in any patient with craniofacial or neck trauma. When in doubt, the otolaryngologist should consider himself or herself the defnitive airway expert. The importance of an ear, nose, and throat evaluation has been proven to be critical. Otolaryngologists have the airway,1 endoscopy, and neck exploration skills necessary to take care of the most critically injured patients. This includes the airway, breathing, circulation, neurologic, and bodily assessments. Patients with severe or life-threatening head, chest, abdominal, or orthopedic injuries are challenging. A cursory head and neck exam performed by the trauma team may miss foreign bodies, facial nerve, parotid duct, ocular, inner ear, and basilar skull injuries, which can be time-sensitive matters for diagnosis and intervention. If possible, the otolaryngologist should make every efort to obtain an accurate and complete head and neck exam as soon as possible to mitigate potential threat and damage, and optimize outcomes through timely repair. For example, a patient with facial lacerations may be mistakenly triaged to the facial trauma service for repair, neglecting a mechanism that should prompt further scrutiny to rule out cervical spine or intracranial injury. Communication between teams is critical for optimal management of the polytrauma patient. The mechanism (blunt versus blast versus penetrating), time, degree of contamination, and events since the injury should be documented. When secondary to a motor vehicle accident, information related to the status of the windshield, steering column, and airbags should be elicited. Details related to extrication and whether exposure to chemi cal, fre, smoke, or extreme temperatures were encountered are important. Information related to events preceding the event, such as timing of the last meal or use of medications or substances that might alter mental status and ability to respond coherently, are relevant. For penetrating injuries related to gunshot wounds, information related to the type of frearm, number of shots, and proximity of the victim can predict the extent of damage and the level of threat to internal organs. For stabbing injuries, possession of the weapon and information about the assailant can predict potential damage. When able, the patients should be asked about any new defcits or changes to their hearing, vision, voice, occlusion, or other neurologic defcits, as well as if they have new rhinorrhea or epistaxis. They should specifcally be asked about and observed for signs of difculty breathing, and whether they feel short of breath. Sometimes patients come from a referring institution, where initial wound washouts, packing, or other interventions have taken place. Operative reports from those encounters are a vital piece of information in these instances. When a patient arrives intubated with an injury pattern concerning for facial nerve injury, every attempt should be 22 resident Manual of trauma to the Face, head, and Neck made to identify whether the patient was able to display facial nerve function in the interval between injury and intubation. Confrmation that the patient had normal facial nerve function prior to the injury is extremely helpful in managing such injuries. Details from premorbid photos or history provided from family and friends is often helpful. These patients must be assured of their security, and their treatment should only be discussed with appropriate persons. When children are involved, it is imperative to enlist the resources of the hospital (social work, childhood protection agencies, etc. Knowledge of the ballistics of the penetrating object can help determine the management plan and predict risk of injury. Military rifes, on the other hand, have high-muzzle velocity and can transmit energy to surrounding tissue. A cavity of up to 30 times the size of the missile may be created and may pulsate over 5 to 10 centi meters. Some may not cause an exit wound, or may fragment with partial projectiles, causing injury far from the primary direct path. Shotguns are typically low-muzzle velocity, but the severity of shotgun wounds will vary, depending on the proximity to the victim. This examination should become routine for the otolaryngologist to over come assumptions and avoid missing unexpected but signifcant injury. Still, the otolaryngologist will more frequently be consulted as the airway expert. Airway compromise may come from signifcant swelling as a result of skeletal fracture, from hemorrhage, or even from superfcial trauma. Once the status of the airway is secured or confrmed to be safe, the rest of the head and neck exam can proceed. Information obtained from fexible laryngoscopy can prove to be a vital tool in the airway assessment when time and stability permit. The exact order of the head and neck exam may vary, but this Resident Manual will illustrate the anatomic top-down? approach. Before beginning this secondary exam, the resident physician should carefully clean the wounds and surrounding skin. This not only decreases the risk for infection but also improves visualization of wounds. Many times the otolaryngologist may fnd these patients intubated, in a cervical collar, with a nasogastric tube in place, and face covered with dried blood and debris. It is imperative to cleanse the patient, and ask for assistance to remove the cervical collar and maintain inline stabilization to examine the neck, and to examine the hair-bearing scalp and back of head. These wounds may be irrigated with warm saline solution under moderate pressure, and diluted hydrogen peroxide. When there is concern for foreign bodies, it may be helpful to use loupe magnifcation to remove small debris from the wounds. Upper Third For the upper third of the head: y Evaluate the forehead for sensation and motor function. Failure of the pupil to respond may indicate injury to the aferent system (optic nerve) or eferent system (third cranial nerve 24 resident Manual of trauma to the Face, head, and Neck and/or ciliary ganglion), or it may indicate a more serious intracranial injury. If abnormalities are discovered, then these fndings must be communicated to a neurosurgeon or ophthalmologist. Gaze or positional nystagmus may indicate an otic capsule violating temporal bone fracture, but could also be associated with intoxication or medication. Chemosis, subconjunctival hemorrhage, and periorbital ecchymosis are signs of orbital injury. Extraocular motility must be examined?both with voluntary gaze when able, and with forced duction testing when not. Forced duction testing will be quite helpful in diferentiating true entrapment of orbital structures from neuropraxia and muscle edema and contusion. The globe position should be assessed in the anteroposterior and vertical dimensions. If the patient is alert, visual acuity and visual felds should be tested, and new defcits confrmed with the patient history. Any injury to the orbit that predis poses the patient to corneal exposure and abrasion should be appropri ately treated with artifcial tears and coverage. Inability to close the eyelid with a risk of drying from suspected facial nerve injury should be covered by a noncompressive shield. Despite this preliminary workup, it is always recommended to have ophthalmologic evaluation when compromised function is suspected or before any orbital fracture repair, because subtle injuries, such as retinal tears, may be a contraindication to surgery. Additionally, the presence of a hyphema in the anterior chamber may require postponement of the surgical procedure until the eye is cleared by the ophthalmologist. Palpation of the Bony Fragment of the Midface Next, the bony framework of the midface is palpated. While zygomatic malposition may be discovered, it also may be obscured by swelling. Nasal fractures may reveal obvious displacement, and crepitus may be palpated with comminuted fractures. If present, a septal hematoma must be drained before it results in necrosis of septal cartilage. Injury to the second division of the trigeminal nerve, V2, may result in cheek and nasal numbness. This displacement can be determined by measuring the horizontal palpebral widths and the intercanthal distance, which should be equal. Evaluation of the lacrimal collecting system usually takes place during surgery with probing of lacrimal punctum and ducts by lacrimal probes. The Jones dye test is carried out either preoperatively or intraoperatively, depending on the condition of the patient. Palpation of the Palate and Maxillary Dentition the palate and the maxillary dentition are inspected and palpated for instability. Any missing dentition should alert the physician to the possibility of a fracture. If this is not possible, the patient needs a chest x-ray to rule out aspiration of any missing teeth. Lower Third Patients often do not have premorbid Class 1 occlusion, as defned by Angle. The oral mucosa should be evaluated for any lacerations or hematomas, with special consideration for the foor of mouth and airway patency. The teeth should again be examined for injury and, when noted, a dental consult should be obtained. Otoscopy Examination of the ears is a necessary part of the exam that may be overlooked by frst responders and not prioritized due to other facial injuries. The halo sign is manifested by a clear ring extending beyond blood spotting of otorrhea on tissue paper. Lacerations and hematoma of the pinna are noted and repaired to prevent cartilaginous injury, malformation, and necrosis. When observed, perichondritis generally spares lobule involvement, and should be treated expeditiously. Otoscopy may reveal blood, dirt, or other foreign bodies or material within the external auditory canal that can compromise further examination and necessitates careful removal. When able, these patients should be tested at bedside with a 512-Hertz tuning fork, and should undergo an audiogram as soon as possible. Perforation of the tympanic membrane should be identifed, and imploded faps should be externalized or patched to prevent cholesteatoma formation. Any concern for defcit should be appropriately documented and related with the history of the trauma and the injury pattern to assess for facial nerve injury. If the patient can cooperate, perform a thorough evaluation of all cranial nerves. Any concern for exposed brain matter should be investigated in the operating room with the neurosurgeon. Wounds treated within 8 hours of the event and those created surgically are considered clean? and can be closed primarily. In the face, the window for wound closure can be extended to 24 hours, because the face is a highly vascular area. However, limited data exist regarding precise cutof points to determine which wounds are too contaminated to safely close. In massive facial trauma, three-dimensional reconstructions of facial injuries may prove instrumental when planning repair. There is also increasing support for using ultrasound to detect radiolucent foreign bodies. Choice of the appropriate imaging study will be a function of the suspected injuries determined on the primary assessment. These tests are especially important in preparation for taking the patient to the operating room. Each hospital facility generally has guidelines and rules for operative photography. Typically, there is a ban on using cell phone photography, so a dedicated patient photography camera should be used. Experience of frst deployed otolaryngology team in Operation Iraqi Freedom: the changing face of combat injuries. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. Massive facial trauma following improvised explosive device blasts in Operation Iraqi Freedom. Injuries to the head, face, mouth, and neck in physically abused children in a community setting. Foundational is the knowledge of mechanisms of injury, tissue damage, and implications for surgical repair, based on the etiology of the trauma. Concomitant injuries of associated structures, such as the brain, spinal cord, and soft tissues, require a comprehensive knowledge of the anatomy, functional physiology, and potential risks and complica tions. These general principles will be reinforced in the subsequent sections of this Resident Manual for emphasis.

Esophageal strictures may be caused duce considerably less pain medicine 013 purchase coversyl overnight delivery, eliminate the need for a tube tho by a number of insults but are frequently related to symptoms copd order 8mg coversyl fast delivery gastroe racostomy medicine nobel prize coversyl 4mg online, utilize smaller incisions which decrease the risk sophageal reflux symptoms weight loss coversyl 4 mg without prescription. Gastroesophageal reflux is a common disor of postoperative incisional hernias symptoms 0f gallbladder problems buy coversyl 4 mg without a prescription, and provide visualization der and depending on diet and lifestyle treatment diverticulitis coversyl 8 mg visa, may affect up to 80% for the diagnosis of other intra-abdominal pathology. The distal esophagus and the esophagogastric ical therapy, esophageal stricture, pulmonary symptoms such junction are mobilized with preservation of the vagus nerve and as asthma and chronic cough, and severe erosive esophagitis. Hiatal her dilator orally and advances it through the gastroesophageal nias include the sliding hiatal hernia (type I) and paraesopha junction. Sliding a 2 cm fundoplication wrap is created with the fundus of the hiatal hernias are most common and occur when the gastroe stomach. The dilator is removed and the fundoplication wrap sophageal junction and part of the fundus of the stomach her placed below the diaphragm without tension. Nissen fundoplication yields a high patient satisfaction reducing barrier pressure between the esophagus and stomach, rate (90?95%) when the procedure is performed by experi which in turn promotes reflux. The transthoracic partial fundoplica stomach, typically the fundus, herniates into the thorax ante tion (Belsey) is similar to the Nissen fundoplication but the rolateral to the distal esophagus (see Figs. Note widening of the muscular hiatal orifice that allows cephalad herniation of the gastric cardia. Esophageal strictures that are not amenable a transthoracic approach, aims to lengthen the esophagus to to dilation may require esophagoplasty or esophagectomy. Through a thoracotomy incision the esophagus can be easily isolated and encircled, the hernia sac opened, its contents reduced to the abdomen, and the hiatus narrowed. Esophageal lengthening and fundoplication procedures are also frequently performed as part of the same procedure. Esophageal Perforation and Rupture Esophageal perforation typically occurs in the hospital and is often iatrogenic. Perforation or disruption of the esophagus may also occur from external trauma, typically gunshot wounds or Fig. Chest radiograph demonstrating a large left-sided type 4 less commonly, from blunt trauma, from a foreign body, or paraesophageal hernia. Surgical procedure Surgical incision(s)/approach Anesthetic considerations Transthoracic total fundoplication (Nissen) Left thoracotomy Pain control Transthoracic partial fundoplication (Belsey) One lung ventilation Collis gastroplasty Aspiration risk Thoracoscopic esophagomyotomy Left thoracoscopy (4?5 ports) Pain control Heller myotomy and modified Heller myotomy Left thoracotomy One lung ventilation High aspiration risk Intraoperative esophagoscopy Transhiatal esophagectomy Midline laparotomy Aspiration risk Left cervical Incision Risk of tracheobronchial injury, bleeding, cardiac compression, and dysrhythmias Transthoracic esophagectomy (Ivor Lewis) Midline laparotomy Aspiration risk Right thoracotomy One lung ventilation Three hole esophagectomy (McKewin) Right thoracotomy Protective ventilation Midline laparotomy Fluid and hemodynamic management to optimize Left cervical incision oxygen delivery Pain control Early extubation Minimally invasive esophagectomy Right thoracoscopy (4 ports) Aspiration risk Laparoscopy (5 ports) Protective ventilation Left cervical incision (variable) Procedure duration 30. This rupture of the distal esophagus occurs under high glion cells in the myenteric plexus. This causes an imbalance pressure which forces gastric contents into the mediastinum between excitatory and inhibitory neurons which results in and pleura [9]. Other primary motor Clinical presentation may be related to the mode of injury disorders of the esophagus include nutcracker esophagus and but is often nonspecific. Secondary achalasia is most often [10], though fever, dyspnea, and crepitus also present not caused by Chagas? disease, a systemic disease due to infection uncommonly. Other secondary motor disor taneous esophageal rupture includes chest pain, vomiting, ders are associated with systemic disease processes such as and subcutaneous emphysema. These Achalasia progresses slowly and thus when patients finally patients may present with septic shock and are likely to dete present for treatment they are often at advanced stages of the riorate rapidly, particularly without aggressive resuscitation disease. As the esophagus dilates, regurgita Evaluation for esophageal perforation or rupture includes a tion becomes a more frequent problem. Treatment of esophageal rupture or perforation depends mainly on the extent and location of the tear and the disease state of the esophagus. The time interval between injury and repair may also play a role in determining the appropriate strategy for treatment. Perforation of the cervical esophagus may be treated solely by drainage; surgical repair is preferred for thoracic or abdominal esophageal perforations. In a stable patient without severe esophageal pathology, primary clo sure of a thoracic or abdominal esophageal perforation can be attempted. Conservative nonoperative therapies emphasizing aggressive drainage of fluid collections and appropriate antibiotic therapy are preferred by some clini cians for stable patients with contained esophageal leaks [12] and may be associated with acceptably low morbidity and mortality [12, 13]. Case reports and small case series have also demonstrated the efficacy of treating esophageal perfora tion and esophageal anastomotic leaks with self-expandable plastic and metallic stents [14?16]. This thoracic level barium swallow esophagogram illus Achalasia is a disease of impaired esophageal motility, most trates a classic radiologic feature of achalasia bird-beak appearance often affecting the distal esophagus. The superiority of surgical myotomy with Esophageal diverticula are classified according to their ana fundoplication is supported by a recent systematic review and tomic location (cervical or thoracic) and pathophysiology meta-analysis [22]. Most diverticula are acquired Laparoscopic esophagomyotomy is performed with the and occur in an elderly patient population. Pulsion or pseudodi patient in modified lithotomy, reverse Trendelenberg position verticula are the most common form and consist of a localized and includes an anterior longitudinal myotomy of the distal outpouching which lacks a muscular covering; that is, the wall esophagus, esophagogastric junction, and proximal stomach. Epiphrenic diverticula are ization of the lower esophagus and cardioesophageal junction located within the thoracic esophagus, typically in the distal [23, 24]. True or traction diverticula occur within the are performed via a left thoracotomy incision and differ in the middle one third of the thoracic esophagus as a result of parae extent of the myotomy incision and the inclusion of a fun sophageal granulomatous mediastinal lymphadenitis usually doplication to minimize reflux. The Heller procedure utilizes due to tuberculosis or histoplasmosis and are characterized by a shorter myotomy incision extended only 1 cm or less onto full-thickness involvement of the esophageal wall. The modified Heller myotomy includes a 10 cm ticula are typically small and most are asymptomatic. Patients may also complain of hali to be safe, effective, and durable treatments for achalasia tosis, gurgling associated with swallowing, and symptoms [25?37]. Patient outcomes after minimally invasive myo associated with aspiration such as nighttime cough, hoarse tomy surgery for achalasia generally favor the laparoscopic ness of voice, bronchospasm, and chronic respiratory infec approaches, however. Diagnostic confirmation is accomplished with barium patients experience superior dysphagia relief and less postop contrast study which clearly demonstrates the diverticulum. This difference accomplished via a left cervical incision and includes a cri may result from the limitations in extending the myotomy copharyngeal myotomy. While the myotomy may be sufficient incision into the stomach and creating a fundoplication wrap therapy for small diverticula, larger sacs require diverticulec from the thoracoscopic approach. Placement of an esopha symptoms may include dysphagia, chest pain, regurgitation geal stent may provide suitable palliation [48] and survival of ingested foods, and symptoms of aspiration. While squamous cell carcinoma still accounts for the vast majority of esophageal cancers worldwide, the incidence of adenocarcinoma has risen sharply throughout the Western world, now accounting for nearly half of esophageal cancers in many countries [57, 58]. Potential etiologic and predisposing factors identified through epidemiologic study include tobacco use and excessive alco hol ingestion, gastroesophageal reflux, obesity, achalasia, and low socioeconomic status [57]. Clinical presentation of patients with esophageal cancer is variable; patients may present with symptoms of dysphagia, odynophagia, and progressive weight loss. Patient evaluation should include a thorough history and physical examination with attention to local tumor effects, possible sites of metasta sis, and general health. Clinical investigations include the bar ium contrast swallow study to define esophageal anatomy and esophagogastroscopy to permit biopsy and definitive identifi cation of tumor type. A thoracic level barium swallow esophagogram which dem associated with esophagectomy, many centers are employing onstrates a large mid-esophageal diverticulum filled with contrast. The close surveillance of many patients with premalignant disease of the swallow examination (see Fig. Advances to delineate any associated pathology such as motility disorder, in the use of minimally invasive endoscopic techniques permit malignancy, or stricture. Patients with incapacitating symptom the staging of superficial esophageal cancers by endoscopic profiles are referred for surgery. The failure of surgery to cure surgical approach has been through a left thoracotomy inci most advanced local and regional disease and the early systemic sion, through which the diverticulum is dissected and excised; dissemination of esophageal cancers has led to significant inter a myotomy and a fundoplication may also be performed. Chemotherapies Results of surgical therapy are favorable, completely elimi are now routinely used in the context of esophageal cancer both nating symptoms in 74% of patients [56]. Thoracoscopic and for palliation of locally advanced and metastatic disease and laparoscopic approaches have also been described but the increasingly as an adjunct to surgical resection. Combination therapy may improve survival but appears to also increase the risk of serious therapy-associated Malignant Disease of the Esophagus complications [64]. Neoadjuvant chemotherapy with or without and Esophagectomy radiotherapy is widely used and is believed to improve curative resection rate, though survival differences have been difficult to demonstrate in small studies. A recent review of meta-analyses Esophageal Cancer investigating neoadjuvant chemotherapy with radiation suggests Malignant esophageal tumors can be classified on the basis an improved pathologic response which may improve survival of histologic types squamous cell carcinoma and adeno but also underscores the need for additional high quality clinical carcinoma, which differ with respect to affected populations, trials to confirm these findings [65]. Esophagectomy gous to the open procedures, several variants are possible; the most popular are the minimally invasive equivalents of Esophagectomy is indicated for the resection of esopha the Ivor Lewis and three hole esophagectomies. Thus far, out geal cancer without local invasion or metastasis [66], cura come data are limited, but encouraging. Esophagectomy surgery can be performed be required before definitive benefits can be declared, but it is via a transhiatal approach by laparotomy, a two incision sur conceivable that advantages with regard to pain control, respi gery utilizing both laparotomy and right thoracotomy (Ivor ratory complications, length of stay, total cost, and quality of Lewis), a three incision approach (McKewin) which also life may yet be demonstrated. However, the stomach may not be a suitable avoids a thoracotomy and the possibility of an intrathoracic conduit in the case of prior gastric surgery or tumor involve anastomotic leak. The upper abdominal incision which is used to mobilize the stom pedicled colonic interposition utilizes a segment of colon with ach and through which transhiatal esophageal dissection is an attached vascular pedicle as an esophageal replacement carried out and a cervical incision through which the conduit conduit. While the pedicled colon graft has adequate mobility is introduced and the anastomosis is made. The transhiatal its use is associated with numerous complications including approach to esophagectomy requires the manual dissection of conduit redundancy and symptoms related to inadequate food the esophagus from the mediastinum blindly via the abdomi transit [75?79] which may impact quality of life [76] and long nal hiatus. Secondly, morbidity and mortality advantages demonstrated [71, 72] it is generally disease free. It is also not clear whether surgical approach tic activity may improve food transit and reduce symptoms affects long-term survival; a meta-analysis of multiple com postoperatively [84?88]. Use of the jejunum for interposition parative studies demonstrated equivalent (20%) 5-year sur has previously been limited by the vascular anatomy of the vival in both groups [71], though a trend towards an improved jejunum. Anesthesia for Esophageal Surgery 423 for construction of jejunal interposition grafts for esophageal or proton pump inhibitors is known to reduce gastric volume reconstruction demonstrated a 92% success rate for discharge and acidity [94?99] and is thus likely to reduce the incidence with an intact flap. Ninety-five percent of patients were and severity of pneumonitis should aspiration occur. Despite some successes, this technique remains the ing received neoadjuvant chemotherapy which may improve purview of highly specialized centers with multidisciplinary survival [63, 65]. The chemotherapeutic agents used to treat teams and is considered only in the absence of a suitable gas esophageal cancer cause bone marrow suppression and tric conduit. The need for optimizing patient status prior to major surgery should be balanced with the risk of delaying the Anesthetic Management of Esophageal resection of malignant tumors. Occasionally, severe throm bocytopenia may preclude the preoperative placement of an Surgery Patients epidural catheter in which case alternative plans for analgesia should be made. Preoperative Evaluation and Preparation A thorough history and physical examination should be per Intraoperative Monitoring formed prior to anesthetizing a patient for esophageal surgery. Comorbid conditions should be evaluated and optimized prior In general, intraoperative monitoring for esophageal surgery to surgery. Symptoms of obstruction, particularly dysphagia and and severity of patient comorbidity. Routine monitoring odynophagia, may lead to reduced oral intake and malnutri should include pulse oximetry, noninvasive blood pressure tion which can lead to increased morbidity and mortality [91, monitoring, and electrocardiography. Transthoracic approaches to the esophagus generally man guidelines for perioperative cardiovascular evaluation [93]. An indwelling the risk of cardiovascular complications during major surgi arterial catheter for continuous measurement of systemic arte cal procedures of the esophagus may be increased by a number rial blood pressure is the standard of care for these procedures. Oxygenation, to the development of dysrhythmias, all of which can com ventilation, and weaning from mechanical ventilation may be promise cardiac output and hemodynamic status. Point of care testing of arte cardial ischemia and arrhythmias and provides a baseline for rial blood samples can aid in the assessment and maintenance comparison in the event of perioperative cardiac complica of adequate arterial oxygenation, acid base status, as well as tions. Patients In the patient with normal cardiovascular reserve, central with a history of morbid obesity or chronic lung disease venous access is not generally necessary and does not provide should also undergo preoperative pulmonary function testing useful information for volume management. Euthermia can be achieved by use sider the dermatomal range of incision(s), the impact of inci of commercially available forced warm air heating blankets sional pain on respiratory function, the likelihood and impact and fluid warmers. Since the thoracoabdominal esophagectomy requires both tho Pain Control racotomy and laparotomy incisions, any plan for postoperative Pain control after esophageal surgery is dictated largely by pain control should address this fact. Most patients under strategies have been reported, but most centers which perform going endoscopic surgery of the esophagus have little pain transthoracic and thoracoabdominal esophageal surgeries uti postoperatively and thus do not require an aggressive plan for lize a multimodal approach to pain management including analgesia. Similarly, a laparoscopic approach is generally not preoperative placement of a thoracic epidural catheter unless associated with high analgesic requirement postoperatively. As such, anesthetic techniques for ral bolus of preservative free morphine may provide a wider postoperative pain control play an extremely important role neuraxial spread and may provide synergism with the infused in optimizing outcomes after transthoracic esophageal pro local anesthetics, but requires postoperative respiratory moni cedures. Although a variety of pain control approaches have toring because of the possibility of delayed respiratory depres been utilized, most centers favor the use of thoracic epidural sion. Arguments that a preemptive initiation of in improving outcomes after transthoracic esophageal surgery analgesia might provide better acute and chronic pain control [103?107], and as a component in multimodal strategies to have been based largely on theoretical considerations. Results expedite patient mobilization and recovery after esophagec thus far are mixed, suggesting that preoperative dosing of epi tomy [108?111]. Although acute pain after thoracotomy has been shown provides superior analgesia after esophagectomy [100, 101] to predict chronic pain [124], the efficacy of preemptive epi and is considered by many surgeons and anesthesiologists to dural analgesia on preventing chronic postthoracotomy pain is represent the gold standard? with regard to postoperative pain not supported by a recent meta-analysis [123]. However, for technical and safety reasons, not all patients are suitable candidates for Induction and Airway Management the placement of thoracic epidural catheters. Tracheobronchial compression or obstruction and [142] but apply to healthy patients undergoing elective surgi cardiovascular collapse associated with anesthetic induction cal procedures. Airway compromise Rapid sequence induction and intubation has been widely has also been reported spontaneously or during the conduct of advocated in patients thought to be at elevated risk of regurgi anesthesia in patients with posterior [125?129] and superior tation and aspiration. Posterior mediastinal masses, to the rapid intravenous administration of induction agent and including those of esophageal origin [125?127] and the muscle relaxant, accompanied by the application of cricoid dilated esophagus itself [133] may impinge on the airway and pressure (Sellick maneuver) and immediate laryngoscopy cause obstruction. The trachea is most easily compressed pos and tracheal intubation without intervening positive pressure teriorly because of the lack of cartilaginous support, and thus ventilation. The rationale underlying this approach is that posterior compression can result in near complete expiratory (1) the cricoid cartilage is positioned anterior to the esopha obstruction [129].

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The listings for Attendance at labour and delivery? and for Attendance of obstetric consultant(s) at delivery? may not be claimed by any physician when a patient is transferred to medicine woman order coversyl master card a second physician for normal obstetrical care medications side effects prescription drugs purchase coversyl visa. Ordinary immediate care of the newborn is included in the labour-delivery fee and when the service is rendered by the anaesthetist 5 medications post mi discount 4 mg coversyl otc, it is included in the anaesthetic benefit medicine escitalopram cheap 8 mg coversyl amex. A life threatening emergency situation requiring active resuscitation of the newborn provided by any physician may be claimed under codes G521 treatment 5cm ovarian cyst buy coversyl 8 mg, G522 symptoms vitamin b deficiency buy 8mg coversyl amex, G523. When indicated, endotracheal intubation and tracheo-bronchial toilet should be billed under G211 and not as G521, G522, G523. When an obstetrician routinely transfers all newborns to another physician, the latter may not claim a consultation for these transferals. If the baby is well, the physician should claim newborn care in hospital plus attendance at maternal delivery (H007/ H267) if this service is provided. If the baby is sick, the physician may claim a general assessment and attendance at maternal delivery (H007/H267) if this service is provided plus daily visits for as long as his/her services are required. If an obstetrician who normally cares for newborns him/herself or transfers the care of newborns to a family physician, refers a newborn to a paediatrician because of the complexity, obscurity or seriousness of the case, the latter may claim for this service according to the following guidelines: a. If attendance at maternal delivery is provided, C263 may be claimed in addition to H267 if a general assessment of the baby is carried out. A postnatal consultation of the baby, (C265) may not be claimed in addition to attendance at maternal delivery (H267). If attendance at maternal delivery (H267) is not provided, a postnatal consultation (C265) may be claimed, if rendered, whether or not a prenatal consultation has already been claimed. Physicians may claim for assisted breech delivery (P020) when the service includes spontaneous delivery to the umbilicus, with extraction of the shoulders, arms and head. If claims are being submitted in coded form, the obstetrician should add the suffix A? to the listed procedural code, the assistant should add the suffix B? to the listed procedural code, and the anaesthetist should add the suffix C? to the listed procedural code. P005 rendered same patient same day same physician as any other consultation or visit except P003 and P004 is an insured service payable at nil. Medical management of early pregnancy initial service Medical management of early pregnancy initial service when a physician renders an initial assessment and administration of cytotoxic medication(s) for the termination of early pregnancy or missed abortion. Medical management of ectopic pregnancy initial service Medical Management of ectopic pregnancy initial service when a physician renders an initial assessment and administration of cytotoxic medication(s) for the termination of an ectopic pregnancy. Services described as consultations, assessments or counselling (and those procedures that are generally accepted components of this service) are not eligible for payment when rendered the same day to the same patient by the same physician as A921. P001 Medical management of non-viable fetus or intra-uterine fetal demise between 14 and 20 weeks gestation. P001 is only eligible for payment if the length of gestation is confirmed by ultrasound. Services described as consultations, assessments or counselling (and those procedures that are generally accepted components of this service, including cervical ripening and oxytocin infusion if rendered) are not eligible for payment when rendered the same day to the same patient by the same physician as P001. Z774 is eligible for payment in addition to P001 if uterine curettage is required for postpartum hemorrhage due to retained products. It is not payable when the fetus delivers spontaneously prior to initiating intervention. For vaginal deliveries of two or more infants, P006 or P020 as appropriate is eligible for payment for the first delivery, in addition to 85% of P006 or P020 as appropriate for the second delivery, and E500 for the third and each subsequent delivery. For vaginal delivery of the first infant followed by caesarean section, one of P018, P041 or P042 as appropriate is eligible for payment, in addition to 85% of P006 or P020 as appropriate, and E500 for the third and each subsequent delivery. For multiple deliveries by caesarean section only (with or without trial of labour), one of P018, P041 or P042 as appropriate is eligible for payment, in addition to E499 for the second delivery and E500 for the third and each subsequent delivery. Despite payment rules above, for spontaneous vaginal deliveries between 20 and 23 weeks gestational age, only P006 is eligible for payment, regardless of the number of fetuses delivered. Despite payment rules above, for multiple deliveries by caesarean section only between 20 and 23 weeks gestational age, only one of P018, P041 or P042 as appropriate is eligible for payment, in addition to E499 for the second delivery. For delivery of one or more fetuses known to be stillborn in addition to delivery of one or more live fetuses, only the delivery of live fetuses is eligible for payment in accordance with the payment rules above. If all fetuses are known to be stillborn, only one of P006, P018, P020, P041 or P042 as appropriate, is eligible for payment. Attendance at labour P038 when patient transferred to another centre for delivery. P009 or P038 is not payable if any of these component services of attendance at labour are not rendered. Special visit for first obstetrical delivery with sacrifice of office hours Payable in addition to first obstetric delivery in calendar day. C989 special visit for first obstetrical delivery with sacrifice of office hours. Repair of a tear or episiotomy extension that does not extend into the perianal sphincter (third degree) is included in the labour and delivery fee (P006 and P020) and does not constitute P045 or P046. Repair of the superficial transverse perineal muscle constitutes a repair of a second degree tear or episiotomy extension and does not constitute P045 or P046. Claims submission instructions: Claims for P046 submitted by a provider with a specialty other than Obstetrics and Gynecology (20) must be submitted for manual review. Performing the procedure(s), by any method, or assisting another physician in the performance of the procedure and carrying out appropriate recovery room procedures, being responsible for the transfer of the patient to the recovery room, ongoing monitoring and detention during the immediate post-operative and recovery period. Making arrangements for any related assessments or procedures, including obtaining any specimens from the patient and interpreting the results where appropriate. Providing premises, equipment, supplies and personnel for the specific elements: a. Pre-operative Care and Visits Pre-operative hospital visits which take place 1 or 2 days prior to surgery. Post-operative Care and Visits Post-operative care and visits associated with the procedure for up to two weeks post-operatively, and making arrangements for discharge, to a hospital in-patient except for: a. The specific elements for pre and post-operative visits are those for assessments. With the exception of the listings in the Consultations and Visits? section, all references to surgeon in this Schedule are references to any physician performing the surgical procedure. If the surgeon is required to perform a service(s) not usually associated with the original surgical procedure, he/she may claim for these on a fee-for-service basis. If special visits to hospital are required at any time post-operatively, the surgeon may claim the minimum special visit premiums even if the basic hospital visit fees may not be claimed (under these circumstances the hospital visits should be claimed on an N/C ($00. The surgical benefit as noted above does not include the major pre-operative visit i. The hospital or day care admission assessment (consultation, repeat consultation, general or specific assessment or re? assessment, partial assessment) may not be claimed by the surgeon unless it happens to be the major pre-operative visit as defined above. Routine subsequent hospital visits may be claimed for visits rendered more than two days prior to surgery. Other visits (excluding admission assessments) prior to admission may be claimed for in addition to the surgical fee. Because the number of hospital visits is limited to three per week after the fifth week of hospitalization and six per month after the thirteenth week of hospitalization, the starting point for calculating the number of hospital visits is based on the date of admission if the operating surgeon has admitted the patient or the date of referral if the patient has been referred to the operating surgeon while in hospital. The listed benefit for a procedure normally includes repair of any iatrogenic complications occurring during the course of the surgery performed by the same surgeon. The surgical benefit includes the generally accepted surgical components of the procedure. When a physician makes a special visit to perform a non-elective surgical procedure, he/she may claim the following benefits for procedures commencing: a. When more than one procedure is carried out by a surgeon under the same anaesthesia or within 14 days during the same hospitalization for the same condition, the full benefit applies to the major procedure and 85% of the listed benefit(s) applies to the other procedure(s) performed unless otherwise stated in the Preamble(s) or Schedule. The above statement applies to staged or bilateral procedures but does not apply when a normal appendix or simple ovarian or para-ovarian cyst is removed incidentally during an operation, for which no claim should be made. When a subsequent operation becomes necessary for the same condition because of a complication or for a new condition, the full benefit should apply for each procedure. When a subsequent non-elective procedure is done for a new condition by the same surgeon, the full benefit will apply to each procedure. When a subsequent elective procedure is done for a different condition within 14 days during the same hospitalization by the same surgeon, the benefit for the lesser procedure shall be reduced by 15%. When different operative procedures are done by two different surgeons under the same anaesthesia for different conditions, the benefit will be 100% of the listed benefit for each condition. Except where otherwise provided in this Schedule, if the nature or complexity of a procedure requires more than one operating surgeon, each providing a separate service in his/her own specialized field. This statement applies when the additional procedure(s) are not the usual components of the main procedure. If one surgeon, in addition to performing a specialized portion of a procedure, acts as an assistant during the remainder of the procedure, he/she may also claim time units for assisting. When a procedure is performed, a procedural benefit, if listed, should be claimed. Substitution of consultation and/or visit benefits for procedural benefits (except as in paragraph 11), is not in keeping with the intent of the benefit schedule. However, to avoid the consultation being counted as such under the Ministry of Health and Long-Term Care limitation rules on the number of consultations allowed per year, the physician should claim the consultation fee under the surgical procedure nomenclature or code. Since the consultation is replacing a procedural benefit which includes the pre and post-operative and surgical care, no additional claims beyond the consultation should be made. If a physician performs a minor surgical procedure and during the same visit assesses and treats the patient for another completely unrelated and significant problem involving another body system, the physician should claim for the procedure as well as the appropriate assessment. When procedures are specifically listed under Surgical Procedures, surgeons should use these listings rather than applying one of the plastic surgery listed fees under Skin and Subcutaneous Tissue in the Integumentary System Surgical Procedures section of this Schedule. Independent Consideration also will be given (under code R990) to claims for other unusual but generally accepted surgical procedures which are not listed specifically in the Schedule (excluding non-major variations of listed procedures). Cosmetic or esthetic surgery: means a service to enhance appearance without being medically necessary. Reconstructive surgery: is surgery to improve appearance and/or function to any area altered by disease, trauma or congenital deformity. Although surgery solely to restore appearance may be included in this definition under certain limited conditions, emotional, psychological or psychiatric grounds normally are not considered sufficient additional reason for coverage of such surgery. Appendix D of this Schedule describes the conditions under which surgery for alteration of appearance only may be a benefit. Additional claims for biopsies performed when a surgeon is operating in the abdominal or thoracic cavity will be given Independent Consideration. When a listed procedure is performed and no anaesthetic is required, the procedure should be claimed under the local anaesthetic? listing. Except as described in the paragraph below, when a physician administers an anaesthetic, nerve block and/or other medication prior to, during, immediately after or otherwise in conjunction with a diagnostic, therapeutic or surgical procedure which the physician performs on the same patient, the administration of the anaesthetic, nerve block and/or other medication is not eligible for payment. A major or minor peripheral nerve block, major plexus block, neuraxial injection (with or without catheter) or intrapleural block (with or without catheter) for post-operative pain control (with a duration of action more than 4 hours) is eligible for payment as G224 when rendered in conjunction with a procedure which the physician performs on the same patient. If claims are being submitted in coded form, the surgeon should add the suffix A to the listed procedural code, the surgical assistant should add the suffix B to the listed procedural code and the anaesthetist should add the suffix C to the listed procedural code. When Z222/Z223 is claimed for a patient for whom the physician submits a claim for rendering another insured service on the same day, the amount payable for Z222/Z223 is reduced to nil. When a surgical procedure is attempted laparoscopically in the digestive system or the female genital system, but requires conversion to a laparotomy, unless otherwise specified, the diagnostic laparoscopic fee E860 is payable in addition to the procedural fee. Morbidly obese patients E676 is eligible for payment once per patient per physician in addition to the amount eligible for payment for the major surgical procedure(s) where a morbidly obese patient undergoes major surgery to the neck, hip, peritoneal cavity, pelvis or retroperitoneum and: a. E673 less than 60 minutes in duration or rendered in conjunction with E718 is an insured service payable at nil. Payment for all surgical procedures includes payment for any intraoperative monitoring of the patient, if rendered. If the procedure is cancelled prior to induction of anaesthesia, the service constitutes a subsequent hospital visit. If the operation is cancelled after surgery has commenced but prior to its completion, the service is eligible for payment under independent consideration (R990). Bariatric surgery S120 (gastric bypass or partition), S189 (intestinal bypass) and S114 (sleeve gastrectomy) are insured services only when all of the following four criteria are satisfied: 1. Presence of morbid obesity that has persisted for at least the preceding 2 years, defined as: a. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); 2. The patient has attempted weight loss in the past without successful long-term weight reduction; and 4. The patient must be recommended for the surgery by a multidisciplinary team at a Regional Assessment and Treatment Centre in Ontario. Paring of a lesion by any method, including curetting, and/or electrocoagulation, without complete removal of the lesion does not constitute Z159, Z160 or Z161 and is not eligible for payment. Excision or removal by electrocoagulation and/or curetting of plantar verrucae is not an insured service. Group 2 nevus (see Appendix D Surface Pathology, Section 4) Removal by excision and suture Z162 single lesion. Dysplastic Nevus (nevus with dysplastic features, atypical melanocytic hyperplasia, atypical melanocytic proliferation, atypical lentiginous melanocytic proliferation or premalignant melanosis) 2. Note: A pre-malignant lesion is not a malignant lesion for the purposes of payment. C Note: Physicians treating vascular ectasias by laser may obtain from their Ministry of Health and Long-Term Care Medical Consultant the current Ministry policy regarding conditions approved for coverage under the Plan. Chemical and/or cryotherapy treatment of skin lesions Z117 Chemical and/or cryotherapy treatment, one or more lesions. Z117 includes paring and/or debulking of a lesion prior to or subsequent to chemical and/or cryotherapy treatment, when rendered. R081 and E524 are eligible for payment only to physicians with generally accepted specialized training in Mohs surgery. R081 is eligible for payment only when the preparation of slides is rendered or supervised by the physician claiming R081 and all microscopic tissue sections are personally reviewed and interpreted by the physician claiming R081. If a pathologist interprets or submits a claim for analyzing histological slides prepared by the physician claiming R081, R081 and E524 are not eligible for payment.

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