+ Cricoid pressure is applied during Rapid sequence induction, ‘This technique is employed to guard against regurgitation of aspiration of gastric conten, «The creo cartage isthe only cartilage inthe upper away to form a complete ring. + rico pressure isa backward pressure on this cartilage, with ‘the head extended on the neck. The pressure oocludes the ‘esophagus by pinching it between the cricoid cartilage in font ‘andthe vertebral bodies behind and thus prevents regurgitation. Incieations for encoid pressure 4. Pregnant patients undergoing General Anesthesia with ful stomach and 2s prophylaxis against aspration of gastic ‘contents (Mendelson's syndrome) especially in pregnant status. 2. tnany patient with ful stomach undergoing General Anesthesia, 4, Patents wth Raised intra abdominal pressure Identification of ericold cariiag. The easiest and best way to identi the cricoidcartlage Is 1. Postion the patient with neck flexed and head extended, 2 Palpate the sternal notch '3. Keeping the palpating fingar inthe midline, move it cephalad ntl the frst hard tracheal bump is felt. This isthe ercoid cariiage 4. Confimation ofthe cartlage can be achieved by moving the finger a few mm cephaloid, where the creothyrokd membrane cam be fot as a small depression between the lower cicaid and Upper thyroid cartiage. Technique: ‘One hand technique: + 3s of the hand usually the thumb and frst and second ‘ingers Two to maintain the trachea inthe midline and one finger ta exert the force, ‘Two hand technique: One hand is positioned comfortably behing the neck fo maintain neck flexion and head extension. The other hand is used as described +The cricold pressure is applied once the patients induced just before consciousness |s lost and should be maintained unt vache! placement of the ETT is confirmed and the cuff has been infated. This is an Important concept to stress when traning supporting staf ‘So the correc technical standard has to be taught and practiced bath by the anesthetists and by ther assistants. + The correct amount of force to be applied for effective crcoid ressute is said to be 30N or 3kg oF 66 Ib. The digital sensation of ‘applying this force can be mimicked by pressing on weighting scales to produce a reading of 3 kg. Complications: General: 4. Dificult to monitor 2. May be applied inaccurately. 3. Can contribute to aifcut intubation, 4. Can contuibute to esophageal rapture. ‘Two hande Roques two assistants, one dedicated to cricoid pressure [12. Post Dural Puncture Headache - PDPH Post spinal headache was first documented by August Bier ini899, Any breach of the dura may result in PDPH — may follow 4) Diagnostic LP b) Myelograma_c) Spinal anesthetic, 4) epidural ‘wet’ tap e) Epidural catheter may puncture dura, Description: Headache is bilateral frontal or retro orbital, occipital extending into neck - throbbing / croissant ~ association with photophobia and nausea / association with body position > aggravated by sitting or standing, relieved or lessened by lying down flat. Onset and duration: Soon after assumption of a head up position ie. 12-72 hrs following the procedure / duration > range from / day to 1 yr. usual period 4 days by end of 1 week 75% would have subsided. Severity classified into 3 categories. + Mil: Incidence 8%, no significant inconvienience, patient mobile, hydration + analgesics / codeine ~ sufficient. + Moderately severe: incidence 3%% some degree of inconvenience, only partially mobile, does not like to recline. + Severe headache: incidence 2.9%, interruption of normal activity, prefers to remain supine, treatment with blood patch. Mechanism of PDPH: \mbalance in CSP dynamics. + Continuos loss of CSF occurs ~ rate of loss greater than rate of production, (30-50 mi loss critical point, 10 mifhr loss). + Diminished CSF — fallin spinal / CSF pressure ~ brain loses its “water cushion” and sags especially in upright position — Traction on pain ~ ‘sensitive supporting structures including blood vessels + Stimull from superior surface of tentarium cerebell transmitted thraugh V. ON. + Pain in anterior part of head. + Stimull arising from below the tentorium and transmitted through IX and X. CN. And upper 3 cervical nerve - pain in posterior part af head and ‘nuchal region, + Vascular component — to fil space backing in fluid, vasodilation of the intracranial vessel oocurs and is accompanied by perivascular edema — pain stimuli arising from dilated vessels. “Treatments Almad at restoring normal CSF dynamics, Conserve measures are 1 bnyeholagial support ans pestve resecursnce. ‘ con®nemert to Red - Haag down postin, + Apolicstion af lee beg to head ‘General body hydration ~ oral / LY. | Sasation and /or analgesia: chiral hydrate, Sod amytal asprin codeine. * Catfene soeium benzoate 0.56 iv/im (effective in 70-75% patents, caffeine causes marked ‘cerebral vasoconstriction. * Cardiovascular stimulsrs: Ephedrine sulfate 50mg tv, Amphetamine sulfate 5:10 mgTIO, Ergotarine tartrate orally me NV. 2ulds— dext 50% Sm every 12s, 5% OW infusion 4102 mnaletion Jeo inal compression —torelesperidural venous plenus and thus nereste CSF pressure ‘Special therapeutic mesures « Suaracenoldsline jection: small guage nese inserted -sgluces,-physolope saline falution introduced in Sm fractions 15-20 m restores normal SF pressure, reket mmesate but short ath recurrences ris of second dural puncte. * Periira saline solution injection performed at site of orignal puncture, caudal inetions are ao effective, reli shorted + Epeual blood patch 2st proposed by Gromelyin 1860 ‘ Pavert postioned lumbar area aseptically repared for epural puncture. + Venous soed (10-20 ml withdrawn from antecubital ven. ‘epidural puncture performed ~at orginal puncture ‘ coldurl space ern7ed ~ autologous blacdislowh inectec and needle remoied Rete of le a KE a Gb Ak TUR cA 1