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The electric activity associated with the twitch is termed a fasciculation potential fetal arrhythmia 38 weeks trusted 25mg esidrix. Glossary of Electrophysiologic Terms 849 Historically blood pressure chart according to age discount 12.5 mg esidrix amex, the term fibrillation was used incorrectly to arrhythmia dizziness esidrix 25 mg lowest price describe fine twitching of muscle fibers visible through the skin or mucous membranes heart attack female 12.5mg esidrix amex. Fasciculation Potential: the electric activity associated with a fasciculation which has the configuration of a motor unit activation potential but which occurs spontaneously. Instead, the configuration of the potentials, peak-topeak amplitude, duration, number of phases, stability of configuration, and frequency of occurrence, should be specified. Muscle fatigue is a reduction in contraction force following repeated voluntary contraction or electric stimulation. Fiber Density: (1) Anatomically, a measure of the number of muscle or nerve fibers per unit area. Fibrillation: the spontaneous contractions of individual muscle fibers which are not visible through the skin. This term has been used loosely in electromyography for the preferred term, fibrillation potential. Fibrillation Potential: the action potential of a single muscle fiber occurring spontaneously or after movement of a needle electrode. Consists of biphasic or triphasic spikes of short duration (usually less than 5 ms) with an initial positive phase and a peak-to-peak amplitude of less than 1 mV. May also have a biphasic, initially negative phase when recorded at the site of initiation. Firing Pattern: Qualitative and quantitative descriptions of the sequence of discharge of electric waveforms recorded from muscle or nerve. The relationship of the frequency to the occurrence of other potentials and the force of muscle contraction may be described. Flexor Reflex: A reflex produced by a noxious cutaneous stimulus, or a train of electrical stimuli, that activates the flexor muscles of a limb and thus acts to withdraw it from the stimulus. Frequency Analysis: Determination of the range of frequencies composing a waveform, with a measurement of the absolute or relative amplitude of each component frequency. Involves inverting all the waveforms below the isopotential line and displaying them with opposite polarity above the line. Generator: In volume conduction theory, the source of electrical activity, such as an action potential. Refers to a motor unit action potential with a peak-to-peak amplitude and duration much greater than the range found in corresponding muscles in normal subjects of similar age. Giant Somatosensory Evoked Potential: Enlarged somatosensory evoked potentials 850 Glossary of Electrophysiologic Terms seen as a characteristic of cortical reflex myoclonus and reflecting cortical hyperexcitability. Grid 1: Synonymous with G1, input terminal 1 (E-1), or active or exploring electrode. Used as a common return for an electric circuit and as an arbitrary zero potential reference point. Grouped Discharge: Term used historically to describe three phenomena: (1) irregular, voluntary grouping of motor unit action potentials as seen in a tremulous muscular contraction, (2) involuntary grouping of motor unit action potentials as seen in myokymia, (3) general term to describe repeated firing of motor unit action potentials. H Wave: A compound muscle action potential with a consistent latency recorded from muscles after stimulation of the nerve. Regularly found in adults only in a limited group of physiologic extensors, particularly the calf muscles. Compared to the M wave of the same muscle, has a longer latency and thus is one of the late responses (see A and F wave). A stimulus intensity sufficient to elicit a maximal amplitude M wave reduces or abolishes the H wave. Thought to be due to a spinal reflex, with electric stimulation of afferent fibers in the mixed nerve and activation of motor neurons to the muscle mainly through a monosynaptic connection in the spinal cord. Habituation: Decrease in size of a reflex motor response to an afferent stimulus when the latter is repeated, especially at regular and recurring short intervals. Hemifacial Spasm: Clinical condition characterized by frequent, repetitive, unilateral, involuntary contractions of the facial muscles. Electrodiagnostic studies demonstrate brief discharges of groups of motor unit action potentials occurring simultaneously in several facial muscles.
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The surgeon involved in the pre-operative planning must carefully consider and set up the points of trocar insertion blood pressure 5545 generic esidrix 12.5 mg amex. We normally use four trocars for all laparoscopic procedures including adnexal surgery pulse pressure in athletes cheap 25mg esidrix amex. Using this method systematically is helpful in anticipating the procedure and reducing operating times hypertension and kidney disease purchase esidrix 25 mg with amex. On the other hand prehypertension is defined by what value cheap esidrix 25 mg online, adding a fifth trocar can be justified if this facilitates or shortens the operation. The position of the trocars: did you ever stop to think why laparoscopic instruments are 43 cm in length? The balance between force (= fatigue) and precision depends on the ratio between the intra-abdominal and the extra abdominal part of the instrument: the more the ratio is shifted in favor of the extraabdominal part, the more precision will be gained, but the greater length means larger movements of the hands, which brings on fatigue more rapidly. The afore-mentioned ratio can be altered easily by shifting the point of trocar insertion away from the operating field. The most efficient balance is achieved when the ratio is 1:1, because the hand can feel the pressure of the tissue and the force exerted. This is why it is important to take your time to plan each point of trocar insertion; this time is not wasted. Other ergonomic rules, which may shorten operating times, are: placing two lateral trocars in a triangle with the primary trocar, never introducing more than one trocar parallel to the primary trocar, taking into account the axis of work and angles of approach (especially while suturing), etc. Letting the assistant perform some tasks that are better performed from his side. A very important property that is often forgotten is being able to introduce instruments into the trocar without looking away from the screen. For this to happen, the trocar must be at a right angle to the skin when there is no instrument inside it and it must have a wide opening. This means that trocars should be inserted not in the direction of the pelvis but at a right angle to the skin, the muscles and the aponeurosis, as shown in. Other surgeons, who frequently apply monopolar electrosurgery during which a lot of smoke is generated, prefer a trocar with a valve that allows to connect a smoke evacuation system. When an instrument of appropriate size is used, the contact point between the trocar and the abdominal wall corresponds with the pivot point, whereas the use of an instrument of smaller diameter involves that there are two contact points with the trocar (in the reducer and at the trocar tip). A third contact point is located between the trocar and the abdominal wall, and between the trocar and the reducer. As a result, there are two pivot points, one between the trocar and abdominal wall, and the other between the trocar and the reducer. It is better to begin the operation with 5 mm-trocars and change to 11 mm-trocars when a 10 mm-instrument is needed. Changing the trocar to 11 mm for suturing is not done automatically and depends on the number of sutures. If the need arises to make four or less sutures, it is preferable to maintain the small incisions for faster suturing although it is essential to change the trocar if a greater number of sutures is required. All of these actions can be performed easily when multifunctional instruments are used (such as bipolar forceps or monopolar scissors) in the following order: the surgeon holds the bipolar forceps in one hand and curved scissors, connected to the monopolar electrosurgical generator, in the other. In this way, the dominant hand is able to dissect, grasp, apply traction and coagulate while the non-dominant hand can cut (mechanically or electrically), coagulate by use of monopolar technique, lateralize and dissect. Thus, the surgeon is able to perform nine different actions and rarely needs to change instruments so as to enable performing a specific action. There are other acceptable ways of holding laparoscopic instruments provided this is done logically. Having a second bipolar forceps readily available allows the clean instrument to be used at all times without delay. Every surgeon must be responsible for checking the condition of the instruments in use to ensure their effective function. It should be decided upon during the first few minutes of the operation immediately after examining the operating field. It is not rare to see surgeons start on one side and then change sides when faced with an obstacle that frequently needs to be overcome, and probably could have been anticipated through careful strategy planning. An operation with a lot of stops, changes and pauses is much slower than a planned operation. Because of its special nature, laparoscopy requires that a few basic rules be observed.
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The location of most nerves can be identified reasonably well from anatomical landmarks for each nerve 10 purchase esidrix 25 mg. However heart attack pulse generic esidrix 12.5mg on-line, it must always be remembered that the exact location of a nerve can vary significantly among normal subjects pulse pressure in cardiac tamponade order esidrix 25mg without prescription. The most striking example is the peroneal nerve at the ankle; its position can vary from 0 heart attack xi cheap esidrix 12.5mg online. Therefore, when attempting to stimulate a motor nerve, the nerve must be localized to minimize stimulus intensity for lessened patient discomfort and to decrease the likelihood of current spread to other nerves. The stimulating electrode is then moved medially or laterally perpendicularly to the nerve without changing the stimulus intensity. However, if the amplitude decreases, the electrode is being moved away from the nerve. The electrode continues to be moved until the maximal amplitude is obtained with the original stimulus intensity. Needle electrodes can be placed immediately adjacent to the nerve, but this may require considerable probing in the tissue. The optimal location of a needle electrode can be obtained by repeated stimulation to identify the region of minimum threshold. When the anode and cathode are both immediately adjacent to the nerve, stimuli of less than 2 mA are adequate for activating all the motor axons. An anode at some distance from the nerve, either on the surface or elsewhere in the tissue, may be used with the needle cathode near the nerve. A distant anode can result in a somewhat higher threshold for activation, a greater risk of current spreading to 334 Clinical Neurophysiology the surrounding nerves, and a less accurate site of stimulation. These disadvantages are generally outweighed by the advantage of not having to probe the tissue with the anode to find the optimal location near the nerve. The invasive nature of needle stimulation and the time it takes to achieve optimal location of the stimulating electrode have made it less accepted than surface stimulation, unless a deep, focal conduction block is likely. In obese subjects or in cases of particularly deep nerves and in patients with peripheral nerve disease, a greater intensity of current may be needed to activate motor nerves. The intensity of a stimulus applied to a motor nerve is defined by total current flow, which is a function of the intensity of the applied voltage, the resistance to current flow, and the duration of the stimulus. It is characterized by several specific measurements, each of which reflects the physiologic activity occurring in the muscle or nerve. Both of these variables reflect the total number of muscle fibers that contribute to the potential. Ulnar (upper two traces) and peroneal (lower two traces) motor nerve conduction studies in severe critical illness myopathy. A1, stimulation at elbow (ulnar) and knee (peroneal); A2, stimulation at wrist (ulnar) and ankle (peroneal). The latency defines the time it takes the action potential to travel from the stimulation site to the recording site and depends mainly on the conduction time in the peripheral axons. If the electrodes are not over the end plates, latency also includes the time for conduction along the muscle fiber to the recording electrode. The reproducibility of latency measurements can be enhanced by automated measurement at a fixed voltage above baseline (200 V/cm is often recommended). The upper waveform is the response from stimulation at the elbow and the lower waveform from stimulation at the wrist. Because the latency measurements are made to the initial negativity, the conduction velocity measurement is that of the fastest conducting fibers. Paired stimulation techniques, in which the action potentials in the fast conducting fibers are obliterated by collision, have been used to measure conduction velocity in slower conducting axons. However, the additional clinical data provided by paired stimulation are not sufficiently useful clinically to make it a standard procedure. Top, Location of the active recording electrode with the reference electrode on the fifth digit.
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