Hi! Today i'am going to show you how to have all Adobe programs for free.
Installation is very simple
First step is
Download Adobe Creative Cloud from official Adobe site.
Sing up, download program you need to crack.
When you download programs you need
You need to go to my comuter or this computer
Disc "C" or place where you installed program
Default is disc "C", program files, adobe
And there are folders with default installed Adobe Programs
Go, for examlpe in photoshop folder
In case of other installation program it looks the same
Go to my discription, download crack you need
Take this to photoshop
Go to photoshop crack
And then you need amtlib.dll
And transfer to main adobe photoshop folder
And this is whole instalation
Very simple
In case of After Effects it looks the same
Look for After Effects crack and transfer amtlib.dll to main folder
So that's all. It's nothing hard. Everyone can do this
Programs will work very well
Do not update programs by Creative Cloud, just in case
I recommend to download all cracks, even, when you don't need it right now
Thanks you for watching. I hope you enjoy. Hit like and subscribe. To next time!
For more infomation >> Adobe Photoshop, After Effects and more FOR FREE! [JUNE WORKING] - Duration: 2:24.-------------------------------------------
THINGS A GIRLFRIEND WILL DO FOR YOU - Duration: 10:10.
little things in relationships if you want to help the other person out it's
good to go run some errands for them make their life easier
Hey you guys. Good Afternoonish kind of.
Sorry we started this vlog super late
it's been kind of a stressful morning
Yeah, Ryan had a quiz
and
no
I had a quiz, discussion
and two chapters of homework
and a midterm yesterday
then work after that
and now I have work soon
then tomorrow I'm working again
Hen House gives free tea. Complimentary
It's good tea
Very relaxing
love you
we just went to the store. Got some bananas bananas and Ryan had to get some
ice cream it took in like five minutes and eight
ball app to decide whether or not he should go get ice cream and when you
shuck the eight ball app. Oh, here he'll show you.
So when I saw that I was like, Okay! fine.
got his ice cream
I didn't eat most of it. I ate like 1/8 of it
1/4.
right?
1/4
I remember before I used to eat ice cream everyday
Now it feels like a sin
but it's good to limit myself
E: you deserve it though because you got an A on your midterm
I hope. I hope
I feel like it was an A, but I hope so
But an A or a high B for sure
E: Was the test hard?
It was easier than what I was studying for
Studied for a whole week
But the test was like, what?
Well like for example. You know how you study for a test in depth
But then on the test it's superficial?
no, what's it called?
just on the surface?
that's it
So like what? wow.
E: oh, I see
E: but better safe than sorry
no no no. Better to know it than not know it
E: yeah that's what I meant
now its in my head
E: mm-hmm yeah that's what I meant
Now I have to go to work. It's time to go, babe
E: Time to go
E: But babe you haven't been in the vlogs for so long
E: Everyone's sick of Ellen
I'm sorry but I've been really busy studying and working
with everything. But next week I promise I will be there!
E: well you're going to go to work then I hope you have a good day at work. Love you
BTW if you haven't added us on SnapChat or Instagram. Do it!
Both are the same name. S-I-G-
Sign Duo
If you haven't followed or added me go ahead and do it
Because we use it a lot and it's lit!
bye
hi guys I'm sorry that the vlog is kind of like jumbled and we weren't really
like vlogging Ryan if you don't know Ryan moved out of his house he used to
live with his parents but he moved out and he's been living with his friend
but he needs to find a place to move into because where he's living now you
can't stay there much longer so we've been looking for places and this morning
went to go see a house there's that and then also my parents don't really want
us be vlogging in the house that much I mean of course they have their own
privacy and they're very nice about it but it just makes it a little bit
difficult when we possibly have to be careful or like you know make sure that
like certain things aren't or aren't are not showing so it just makes vlogging a
little bit difficult especially when I'm just home all day but I wasn't feeling
it today Ryan left for work and then we just took a nap I just fell asleep
Ryan asked me to go to Daiso for him to get these gloves that he needs for work
and I didn't really feel like going but he won't get them if I don't go and buy
them now because when he gets off of work it'll be closed already and Daiso
is this Japanese one dollar store that we both love and we love going together
and it's like one of those stores where you go in wanting nothing and come out
spending $30 but everything was only $1.50 or like $1 so we're going to go
there and I'm going to try to make this day
I'm just going to try try to make this day a little bit better I mean go get
some gas for the car because it's empty right now my engine light is
on so me go get gas and then we're going to go to Daiso. yep
I'm glad I didn't
have to wait for gas
It's like really empty around here
Not a lot of people are out
It's weird. Weird
Okay! Let's go to Daiso!
okay, before we go in there. I have to make a
promise to you guys and to myself that I'm not going to buy anything else but those
gloves okay
Hold me accou..
hold me. hold me
responsible for that okay
you guys have to hold me responsible
I had to walk in with blinders on. Don't look at anything look at anything else just go
straight to the gloves
I have to wait in this long line for Ryan
I must really love Ryan
whole $1.62
I'm so proud of myself I only got the gloves and the line the
line was pretty long but I don't mind waiting
Ryan needs these for work and I love him, and I need to do more things for him. You know
or you know. I do things for him, but the little things in relationships if you
want to help the other person out it's good to go run some errands for them
make their life easier
cause I love him
and I'm out of focus. Everytime
I'm so out of it today
Hi you guys
I just got off work
and I cam over
She's so sweet. She picked up some gloves for me
because I work really early tomorrow
here you
thank you. thank thank thank you
Is that the right one?
nope
no?!
What?! Why?!
I'm just kidding
I'm just playing. Thank you
You're welcome. what do you need those for?
For work tomorrow
What are you going to be doing?
moving stuff
dirty stuff
oh, I see
I don't want to get my hands dirty
yeah, after I came home
from Daiso I was just editing all night and I tried YouNow - I think we're going to
go ahead and do that we'll keep you informed good night you
guys have a good sleep
bye love you!
Going to go home now
Sign Duo
OUT!
Oh
-------------------------------------------
Scientists Observe Black Holes Orbiting Each Other for First Time - Duration: 0:57.
For more infomation >> Scientists Observe Black Holes Orbiting Each Other for First Time - Duration: 0:57. -------------------------------------------
Session 2: "Brain Trauma Foundation Guidelines for Acute Care" by Dr. Monica Vavilala - Duration: 41:48.
MONICA S. VAVILALA: Good morning.
Hopefully the five minutes gave you a little bit of time
to get some water, get some coffee,
check emails, et cetera.
So the second presentation is going
to focus on the Brain Trauma Foundation Guidelines
for The Care of Infants and Children With Severe Traumatic
Brain Injury.
And I am Dr. Monica Vavilala.
And I am the director at the Injury Center
here, for those of you who are joining in a little bit later.
And I've been interested in traumatic brain injury
work for nearly two decades, focusing
on understanding cerebral physiology, understanding
in hospital care processes, and how those two relate
to improving outcomes.
My initial work focused on cerebral blood flow
and other regulation.
And we then expanded to working in the area
of looking at guideline adherence and outcomes.
So it's my pleasure to be here with you today.
And I serve on the Brain Trauma Foundation Guidelines Committee
for adult and pediatric TBI.
It's been a very interesting experience
to get folks together, clinical investigators together,
to try to come to consensus on how we ought
to be treating these children.
So I'm looking for sharing some of that information with you
today.
My practice is at Harborview Medical Center.
It is the only level one adult and pediatric trauma
center in the Pacific Northwest, covering Washington, Alaska,
Montana, and Idaho.
And these are a little bit dated numbers,
but similar to what we had last year.
Our total trauma admissions are over 5,000.
They're probably 6,000 last year.
We are comparable to Baltimore Shock Trauma,
in terms of our numbers.
Our pediatric numbers you can see here.
We take care of children too.
And many of these kids are admitted
with injuries from falls.
We are a burn center.
And then these other mechanisms.
So what I want to talk about today
is really a little bit about the TBI burden, some of which
you heard from Dr. Rivara, the evidence based guidelines
and the pediatric guideline adherance and outcomes program
that we started here at Harborview Medical
Center in 2015.
And I'd like to share with you some of that data.
So this is the CDC breakdown of unintentional motor vehicle
traffic injuries, how common they are, and the top two
leading cause of cause of unintentional injury deaths
across the lifespan.
Very significant problem and one that requires
continued efforts in all our public sectors.
In 2008 the World Health Organization
and UNICEF's report on child injury prevention
reported 1 million pediatric injury deaths a year.
And this is probably an underestimate,
given that many countries don't have a good reporting system.
And because of our trauma systems here in the United
States, and because of injury prevention efforts,
the number of deaths in the United States
has actually reduced significantly since the 1980s.
The problem is it's still growing, dramatically,
in low, middle income countries.
In fact, the estimates are there's
one severe pediatric trauma every six to nine minutes
worldwide.
That's staggering.
And the leading trauma is traumatic brain injury,
making this, not only a local, but a global problem
to deal within.
In the United States, the medical cost,
work loss cost for families who have to take care of kids
with severe TBI, and the combined cost
is extremely large.
And daily we have 133 people dying from TBI.
Falls is the most common cause of TBI.
But in fact, over 50% of TBI deaths
are from motor vehicle crashes.
So falls in MVC still are a big problem.
This map here is from the CDC website.
And it shows the mortality rate for pediatric traumatic brain
injury.
You can see here, there's a lot of variation.
And one of the themes for this presentation today
is going to be variation, because that
is something we want to reduce.
We want to understand best practice.
We want to understand how to reduce the high mortality
rates and the high poor outcome rates,
and kind of have this map of the United States
be a little bit more homogeneous.
So let's start with, what is a TBI?
The CDC defines this as caused by a bump, bolt,
or blow, or jolt to the head that
disrupts normal brain function.
And the severity can range from mild to severe.
Now, clinicians define severe TBI using the Glasgow Coma
Scale score.
There are different classifications.
But I think the idea here is that if you
have a mild traumatic brain injury,
you have a brief change in mental status or consciousness,
as opposed to severity where there's
an extended period of unconsciousness or memory loss
after the injury.
It's important to remember that not all blows or jolts
to the head results in a TBI.
But the more severe the mechanism there's
the higher likelihood of having a severe traumatic brain
injury.
The population burden is from mild TBI,
also known as concussion.
Some of it may be sports related.
Some of it may not be.
And we're just now really starting
to understand what are some of the long term
outcomes after mild TBI.
Nonetheless, this classification is important
because it has implications for triage of patients from scene
to care.
And also the kinds of capacity that health systems
need to have to care for children with severe TBI.
So the typical classification is phenotypic,
meaning we evaluate a patient either at the scene, in the ED,
or in hospital.
And we use this Glasgow Coma Scale score to say, well,
are you a 3, 4, 5, 10, 11, 12, 15?
And this is the traditional classification.
3 to 8 is severe.
9 to 13 is moderate.
And 14 to 15 is mild.
Although, I will say, there's some emerging conversations
suggesting that the GCS of 13, or the GCS of 13, really--
the mild category should be 13 to 15
some folks feel that the Glasgow Coma Scale score of 13
really belongs in the moderate category
because they have more impairment than patients
who have GCS of 14 or 15.
This is why I have, sort of, classified it as such.
Although you will hear some folks
argue that GCS 13 should be mild TBI.
But again, this is an area of controversy.
This classification's really important
because the initial triage and treatment is based
on clinician assessment of GCS.
Of the GCS types, which the subcategories of eye, verbal,
and movement, the post resuscitation GCS motor
is most predictive of poor outcomes.
And important to remember this GCS score
is modified for non-verbal children for crying,
and other things, so that there is
a difference between the adult and pediatric GCS scoring
subscales.
So one main important point I want to, sort of, make here
is that it really does take all of us
to take good care of the severely injured child
with traumatic brain injury, because we
encounter these patients at different times.
We bring our expertise.
And I'd say nursing and pre-hospital providers
are really critical to, sort of, being the hub
for the care of these kids.
Typically if a child has a mild TBI,
they're triaged, or transferred, or brought
by pre-hospital providers, to a non-trauma center.
They could be seen at a trauma center.
They could also be evaluated and treated
at a community hospital that has no trauma designation.
They could be seen at a clinic.
If you have a moderate TBI, our data-- this is not published,
but we just submitted this for publication.
Almost 30% of kids with moderate TBI
are actually receiving care at non-trauma centers.
And we don't know if this is appropriate or not appropriate
yet.
We're in the beginning of this investigation.
But if they have poor outcomes and some of them
deteriorate in hospital, they really
may need to be taken care of at a high level trauma center,
because they then fall into this category.
So what I'm trying to elucidate here
is that these classifications of mild, moderate, severe,
they're typically made at admission.
But there is a continuum.
And patients who have one TBI severity when
assessed at one period of time may actually
transition in and out.
So if we're, as clinicians, or as health systems,
taking care of kids with moderate TBI,
recognize that some of them will deteriorate
and will have severe TBI in hospitals.
So one landmark paper I do want to talk about here
is Head CT Decision Rules.
This is a Lancet paper, published in 2009.
This is important, because, like Washington state,
those of you who are not from here
can look at your department of health websites, where
people are really starting to recommend judicious use of head
CT.
So if you don't have mental status changes,
if you don't have a non-severe mechanism,
the trend is moving towards not routine imaging of kids
who otherwise look normal.
And this is to reduce the radiation risk.
The Washington State Department of Health
has a really wonderful explanation
of these of when Head CTs should be performed
for the evaluation of children with traumatic brain injury.
And I just want to direct you to there, as well.
So let's talk about a patient.
This is a patient who I took care of
and will move towards talking about the guidelines.
And he's a four-month-old male with a subdural hematoma
presented to Harborview for emergent craniotomy.
And I happened to be the anesthesiologist
next up, if you will, to take care of this patient.
And the story was that this baby was found,
by grandmother, vomiting.
Was taken to a local hospital, intubated at the index hospital
with a 4.5 uncuffed endotracheal tube,
and had intractable seizures that
seems to be controlled with benzodiazepines.
The patient had a right pupil that was dilated
and that the baby received mannitol.
And, I think, appropriately, and consistent
with our Washington State Department of Health
transfer guidelines, the patient was
transferred to our level one pediatric trauma center.
And what worked really well for us was we
knew this patient was coming.
The ED spoke to the operating room.
The patient spent less than five minutes
in the emergency department, because what this baby needed
was a decompressive craniotomy.
It was urgent.
It was an emergency.
We shouldn't really delay this.
So this is what the admission head CT looked like.
You can see the subdural hematoma here taking up space.
And you can see this midline.
And they're shifting.
This is the ventricle and this is shifted over.
And there seems to be, literally,
loss of gray, white matter differentiation
that you could typically see on a CT.
Again, indicating severe TBI.
And this, I described to you as the anesthetic course.
But you could imagine this kind of a scenario occurring
in the ED or in the ICU, as well I'm an anesthesiologist,
so I'm sharing my clinical experience here.
While the surgeon's working on the decompressive craniotomy
to relieve the subdural, we're taking care of physiology,
making sure the patient is alive.
And it was really hard to do in this case.
The patient was very acidemic, high lactate levels,
bled a lot, had a low hematocrit.
And despite transfusions, the baby had V fib arrest
and needed CPR.
He was hyperkalemic.
And the bad stuff, the recommendations
that are in the guidelines, in terms of what not to do,
we encountered.
So unwanted hyperventilation.
The patient was cold and the patient
was also very hyperglycemic.
We had other problems.
Poor vascular access.
There was a huge leak, because the tube was uncuffed.
There was significant hemorrhage.
And these are all what we call secondary insults to the brain.
So you have the initial injury.
And then you have these other things
happen that worsen the injury, lead to more cerebral ischemia,
and more poor outcomes.
And unfortunately, the surgery was successful,
in the sense that the subdural hematoma was evacuated.
But the patient expired on the day of surgery,
one hour after arrival in the peds ICU from a refractory VF
arrest.
As some of you may be suspecting,
the patient had multiple rib fractures, left femur fracture,
and was diagnosed with having abusive head trauma.
So what I've described you so far is the patient.
And there's a lot of variability in how patients present.
There's also variability in how patients
do after they have severe TBI.
And this is a study that we conducted here looking
at 30 day hospital mortality.
And you can see, if you look at the region, some of you
are from very far away.
Some of you are here in Washington state.
There's variability in terms of how
patients do after severe TBI.
And in the northeast, outcomes seem to be better.
Maybe this is due to rapid transport to a trauma center.
We're not quite sure.
But the worst outcomes are really here
in the south and the southeast, followed
by the midwest and the west.
And so I think we have a lot to learn from what what's
happening in the organizational context, triage context, et
cetera., treatment contexts, in different regions of the United
States.
There's also variation in discharge to rehabilitation.
So if you say one is the relative risk
of being discharged to rehab, which is what the goal is.
You want patients to receive rehabilitation.
It's not equal all across the country.
And this is because there aren't enough rehab facilities.
This is it because the rehab criteria aren't clear.
This is because people don't recognize
that early rehabilitation is good.
So again, some variation here.
So the intent of the TBI guideline process
is to really provide recommendations
on standardization in hospital hospital care for kids
with severe TBI.
The first edition was published in 2003.
It was then revised in 2012.
And I will tell you that we are getting
ready to publish the new recommendations, which
are scheduled to come out in 2017
towards the end of the year.
So what happens is, there's a team,
an evidence based review team.
We review the evidence.
We update it.
This should say 2012 not 2016, sorry.
And then we have it reviewed by national policy bodies
and other peer reviewers.
And then we publish these findings.
So the 2017 update is really a work in progress.
And there are representers from all over the country here
on this guideline, representing different specialties
of physicians, nurses and other investigators who
are a part of this, again, national representation.
So the evidence that we considered
for development of the guidelines
are that you should be under age 18 years.
You should have TBI.
Your GCS should be three to eight, or under nine.
It's the same thing.
And we want this to be multi-disciplinary.
So different perspectives.
We wanted this to be a living document.
We reviewed the evidence in more real time
than we did initially.
And some of the recommendations are rooted in strong evidence
and some of them are rooted in expert consensus,
because of the absence of data.
So in 2003 there were 18 chapters.
The problem was here there were no standards.
So no level one RCTs that were conducted
to result in level one recommendations.
Four guidelines were at the level 2,
primarily from cohort studies.
And then 14 options.
So clinicians could consider these options.
There were level 3 recommendations,
because the strength of evidence didn't
suggest that those recommendations belonged
in a higher level of recommendation.
So what I want to show you here is the current state.
This is today.
We are following the 2012 guidelines,
or this is what's out here.
So compared to 2003, the SBP recommendations were deleted.
Some people argued that, really, we needed a systolic blood
pressure definition, because early in the care of these kids
we don't have cerebral perfusion pressure data.
Unfortunately, the strength of evidence
didn't allow us to put something in here.
So my personal recommendation is that we use--
70 plus 2 times the age is the ATLS guideline recommendations,
because we didn't provide one for use.
ICP monitoring is recommended at the level three level for GCS
under nine or less than or equal to eight.
Cerebral perfusion pressure, the recommendations
are to maintain them at or greater than 40.
We also recognize that there was probably
an optimal CPP somewhere between 40 and 50
across the age spectrum.
But we were not able to specify what that should be.
But I will say that if we were able to achieve this,
a CPP of greater than or equal to 40, for our kids
with severe TBI, that would be really great.
We don't want to hyperventilate kids,
because that causes cerebral ischemia.
So there's some recommendations on keeping PaCO2 greater than
or equal to 30.
We want to maintain oxygenation, either via bag mask valve
or tracheal intubation, depending on what phase of care
the patient is in.
If advanced neuromonitoring is used,
our recommendations are to maintain
PbO2, which is brain tissue oxygenation, greater
than or equal to 10 millimeters of mercury.
And there weren't really good recommendations
in the 2012 guidelines on glucose and nutrition.
What we are drafting currently drafting language
for in the 2017 guidelines is to recommend early nutrition.
We're not able to really talk about glucose early
versus not, because of the strength of evidence.
I can tell you our current practice
is not to just routinely give glucose in the first 48 hours,
unless the patient is hypoglycemic, which
means we need to be testing for glucose, particularly in babies
who don't have good reserve.
But we are aiming towards timely nutrition start,
whether that be enteral or parenteral.
We are not prophylactically cooling kids anymore,
because the trial showed that it didn't work.
We also want to prevent fever of temperature greater than 38
in these kids, because we know that hyperthermia is associated
with poor outcomes.
Steroids are not recommended--
and this is actually a level 2 recommendation,
we're going to be adding this to the 2017 guidelines--
unless they're deficient.
Now, we're not always testing patients.
But the centers that do test for cortisol deficiency,
if those patients are deficient then
we are recommending replacement, only in that circumstance.
The barbiturate chapter recommended barbiturates
for refractory ICP.
But you have to be hemodynamically stable.
And we need to be doing continuous arterial blood
pressure monitoring to really use barbiturates
in a meaningful way.
The 2017 guidelines will recommend
specific recommendations about thiopental,
because those data are very old, but retains some of the content
here.
Decompressive craniectomy has, I would say,
fallen a little bit out of favor as a first line
therapy, second line therapy.
It's considered by clinicians if you have refractory ICP,
or if there's deterioration, or herniation at the level three,
as a level three recommendation.
Hyperosmolar therapy is recommended
as a level 2 recommendation for ICP greater than 20
with a dose of two to five milliliters
per kilo over 10 to 20 minutes.
We are really discouraging routines head CT
as a matter of routine practice after admission
and initial diagnosis after 24 hours after admission,
because of the radiation risk.
So there really needs to be some justification for this.
CSF drainage is really dependent on the institution
that you're at.
It is an option for refractory ICP.
Either EVD, or as a lumbar drain.
Although, I would say, most people are using EVDs
and not lumbar drains for CSM drainage, when they're
draining the CSF, provided that the ventricles will
allow you to do that.
We don't really have good recommendations on sedation.
The 2012 guidelines called for pentasol or etomidate
for high ICP.
I think there's a lot of equipoise and opportunity
for work looking at the best sedation for ICP.
And then there's equipoise around
whether we should be using leveticracetam or phenytoin
for seizures.
So in terms of the seizures-- now,
this is a question that was asked of Dr.
Rivara on the previous talk--
we are recommending either of these
to prevent early seizures.
There's no good data that it prevents late seizures.
Now, there are other best practice recommendations
that are not in the guidelines.
But I feel compelled to mention them, which are,
we really ought to be trying to get patients to the CT scan
within 30 minutes of arrival, because we need to know
if they need surgery or not.
We need to know how sick they are.
Evidence suggests we should be conducting blood alcohol
and urine tox screens in kids over age 12.
We're not regularly doing that.
EtCo2 monitoring should be a standard monitoring guideline.
And we should be aiming for normocarbia,
unless there's evidence of herniation or impending
herniation.
We should be aiming for ED length of stays
less than two hours so they can get the advanced care that they
need in an intensive care unit or an operating room.
Of course, if it's an emergency craniotomy,
they need to really be discharged the OR OR quickly.
We need to develop good checklists, I think.
And we need to make some recommendations around that.
I think the ICUs are really good around the country
about monitoring when they're in the ICUs.
But when we're transporting patients from the ICU
to other locations, we need to continue that same level
of intra-hospital monitoring, including ICP monitoring
when those are placed.
And then early rehabilitation.
And then for those families who don't speak English,
interpreters services and early engagement with social work,
probably, all together, constitute other best practice
recommendations.
And so even though we think this,
and we've had these guidelines, data suggests that
there's a large variation in how often ICP monitoring--
as an example of a key performance indicators
of care--
is done across centers.
So adjusting for injury severity and type of injury
that we have, ICP monitoring tends
to be less common in infants than in older children.
And in fact, compared to adult centers,
pediatric center hospitals tend to perform less ICP monitoring.
And this is quite surprising to us,
because we thought it would be the other way around.
But this may have to do with more exposure and use of ICP
monitoring in adult patients.
So if you received care at a mixed facility,
you're probably receiving more ICP monitoring
than a pediatric only facility.
And then there's some really interesting data
that how you design your pediatric neurocritical care
unit, which is really an emerging field, is associated
with better guideline adherence.
So this is a Lancet study published,
showing the probability of ICP monitoring
when you develop a pediatric neurochemical critical care
unit.
And it's clearly higher after program implementation.
So the center variation that I talked about here,
this is a study that we did looking at five centers.
And you can see the overall survival rate was
87% for very similar patients.
But there's variability in survival.
And there's also variability in guideline adherence rate.
This is pre-hospital, ED, OR, and ICU.
So there are opportunities, again,
to adopt guidelines and reduce that unwanted variation.
And this is important, because in this study,
we found that there's, overall, a 6% decrease in mortality
with every 1% increase in guideline adherence rate.
So the guidelines are effective.
And I think there are many reasons why people
don't use the guidelines.
But they work.
And they work in, kind of, we think, a dose dependent manner.
So the better you adhere, the better the survival.
And these data are shown here.
Again, you can look at-- one is the reference group.
This mortality decreases, and Glasgow outcome scale improves
with higher adherence rates.
So specific key protective indicators
are avoidance of pre-hospital hypoxia,
use of mannitol or hypertonic saline in the operating room.
Believe it or not, many ORs don't have these available.
This is a problem.
Maintenance of cerebral perfusion pressure,
as recommended, greater than, or equal to 40
millimeters of mercury.
Timely start of ICU nutrition within 72 hours of admission.
And not prophylactically ventilating people.
These are all critical.
And they drive the relationship between guideline adherence
and outcomes.
And if you're asking the question,
does guideline adherence cost more money?
It does not.
There's no difference between these dollar values.
But the guideline adherence, you can
see that 92,000 for 50%, 100,000 for higher adherence rates.
These are hospital costs.
These are ICU costs.
So it's really about workflow and organization.
But we don't always do it.
And the data would suggest that there are clinician barriers,
guideline barriers, institutional barriers,
that we need to overcome.
Degree of collaboration between services.
People don't believe the guidelines work.
We don't know what the guidelines really say.
And frankly, some of the guidelines
are not easy to digest.
So we're working on that.
But what families tell us is that they really
want family centered care after pediatric head injury.
They want the providers to get along, first of all.
Some of you may be smiling right now.
They want they want communication
with their providers.
And they want communication between teams.
They want to learn how to take care of their children.
And they want care coordination.
So this is a study that we published a couple of years
ago, and I think, adds a lot of insight
into what should go into a program.
So I just want to spend the last few minutes
talking about a program that we developed at Harborview called
the Pegasus Program Guideline Adherence And Outcomes Program.
And our goals were to increase TBI guideline adherence
to improve communication between families and providers,
to decrease non-value added time, and to improve outcomes.
So this is what goes into the program.
The protocols, which is the guidelines, the Pegasus study
findings, the stakeholder perspectives.
We've integrated the program into our hospital QI metrics.
And we revise these annually.
We had a lot of Kumbaya moments.
We had to get along.
We had to get to talk to each other.
The nurses were critical to making this work.
They wanted paper packets pathways.
They didn't want to do things on the computer.
And every patient who is now admitted to Harborview
with a severe TBI diagnosis is put on the pathway.
And the pathways get used by the nurses.
And they provide us with wonderful information on what
works and what doesn't.
So we have 93 patients adopted on the pathways, so far,
which are guideline based.
93 percent have been adopted in the first 24 hours.
The 7% who didn't were very early in the implementation
and so we had some learning.
Our guideline adherence rate has increased 17%
over the last year.
And our discharge outcomes have improved by 21%.
This is because the guidelines work
and because we figured out how to work it at our system.
And the key performance indicators
that I mentioned earlier, they're important.
Look at our compliance to ventilation.
It went up significantly.
We were already high with our nutrition key performance
indicators.
And so we made improvements.
The CPP indicator.
We didn't verily make significant headway here.
And I want to talk about that just
to say that we didn't because the kids were
really sicker than the pre-implementation time point.
But the nurses documented more efforts
made to actually maintain CPP.
So I think there's achievement but there's also
effort that really matters.
And this is nursing feedback on the pathway.
They love it.
They think it has reduced conflict in the ICU
and has gotten everybody on the same page,
in terms of what are our daily goals of care?
So what can we do?
As practitioners, as public health providers,
we can encourage guideline use.
Well, first of all, I think if the kid really has severe TBI,
we need to transport them to a level one pediatric trauma
center.
We need to really develop a culture around guideline
adherence.
And we need to be looking forward
to the 2017 guidelines that are going to be published
later this year.
And we do this because we care for our kids.
So adherence to guidelines is cost effective
and improves outcomes.
And I'd like to thank the sponsors for the opportunity
to actually conduct some of this research
and share this information with you.
Thank you very much.
And I think we're going to transition to the question
and answer phase.
Please post your questions to the Q&A box
and then we can have a good discussion here.
I just want to remind you that the talk here
focused on in hospital care.
And Dr. Jamie Chandro, in the afternoon,
is going to be talking about emergency medicine.
So please post your questions to the Q&A box.
The first question is, what are your recommendations
for interventions for a level 2 trauma center, prior
to transport to a level one?
This is really a great question.
And the 2003 guidelines addressed transfer.
And the recommendations were direct transfer
to a pediatric trauma center.
It did not really specify which level.
I think that every state has their Department of Health
criteria for transfer.
And the Washington state talks about critically ill children
needing to be treated not at a level three.
So I would say that if we're transporting a child to a level
one trauma center, I think it's back to ABC.
So I think we need to make sure that these kids with severe TBI
are tracheally intubated.
I think that's something a level two trauma center can do.
Having two peripheral IVs that are functional
are really critical.
Sometimes we receive patients from other hospitals
where there are two IVs that are in place, but they don't work.
So and so ensuring that they work, or functional.
I think that hemodynamics, blood pressure, volume resuscitation,
is important.
And then choosing ventilation parameters
that are associated with normocarbia oxygenation
are important.
Use of hyperosmolar therapy can certainly be provided.
We just have to make sure that the patients are
hemodynamically stable before, during,
and after mannitol administration.
There's some good data showing that hypertonic saline results
in better preservation of cerebral perfusion pressure.
And in fact, national trends are suggesting
that the use of hypertonic saline is more common.
You can give 2% hypertonic saline through a peripheral IV.
And so I think that's a very viable option for maintaining
hemodynamic stability.
And I think, in terms of sedation and relaxation
for transport, I would suggest fentanyl and midazolam,
because using other kinds of agents
really can cause hemodynamic instability.
And I think if you're starting something and transporting
a patient, fentanyl, midazolam, and use of a muscle relaxant
for transport, so we're not dislodging
the tracheal tube during, would be playing it safe.
And then, of course, ALS transporting mechanism
to a level one trauma center.
And then, I would say, we are currently
working with some of our community partners
at Harborview to develop these recommendations.
If you're interested in what we develop,
please contact contact us.
And we'd be happy to be in touch, as well, because I think
that community centers are very interested in stabilizing
patients, as well.
And I think that's a needed area.
The second question is for pediatric neuroimaging,
does Harborview use a quick brain MRI instead of CTs?
Is this something we should be moving towards?
I think there are many people who
feel that we should be moving towards it.
Part of this is staffing, and logistics,
and availability of this.
I think if the patient is receiving an ICP monitor then
that poses a problem for MRI scanning.
So there's some timing things there.
There are some facilities on the East Coast
who are currently studying quick brain
MRI in severe pediatric traumatic brain injury.
And I think the paper on that is scheduled
to come out sometime soon.
So I would look for a paper from Mass General
to provide some information on the logistics
and how that really worked.
I think that if we're looking for bleed and the need
to proceed to the operating room,
I'm not so sure it's critical for a quick brain MRI.
I think if we're looking at it as a prognosticator,
then it is something that is a very good question.
The next question is, what's the best tool
to monitor and prevent hypoxia in the pre-hospital field
in a patient with poor perfusion?
This is a really good question too.
So there are two parts to this.
One is hypoxia.
And first I think back to basics.
I think we need to look at our patients
and make an assessment.
This may be a composite evaluation.
I think that combined use of clinical examination and pulse
oximetry is critical.
We conducted an audit a couple of years
ago of Washington State, looking at documentation
of oxygenation and ventilation in the pre-hospital arena.
And in fact, documentation is not
there sometimes, which makes it really hard for us
to retrospectively assess how often patients
are truly hypoxic during the pre-hospital period.
So I think pulse oximetry is standard.
End tidal CO2 monitoring really ought
to be a critical piece of evaluating
oxygenation and ventilation.
At the end of the day, I think the clinician
has to use their judgment to figure out if somebody is
adequately oxygenated or not.
So do you have a leak at the tube?
Are you able to move the chest?
Is the patient pink?
What does the sat say?
Is the saturation waveform good?
And what is the blood pressure?
And I think I would say, there are some emerging tools,
which looks like a pulse oximeter
that you put on the thenar eminence
to capture perfusion to the thumb and the hand.
But those are in developmental and testing phases
at Harborview looking at perfusion to muscle groups.
The next question is on your 4-month-old case
with an uncuffed ET tube with a lead,
do you recommend changing out with
a bougie continuous ventilation to cuff the endotracheal tube?
So yes we did that.
Now, when the patient came to the operating room,
we opted to proceed with the craniotomy
and not change the tube beforehand,
because the patient was herniating.
We did try to use some gauze to, sort of,
pack the back of the pharynx.
You have to remember to take that out
at the end of the procedure.
And then at the end of the operation,
we did change out the tube to a cuffed ET tube,
because we knew that gauze was not a permanent solution.
So I think if you have a child with severe TBI,
yes, the best approach is to use a cuffed endotracheal tube.
So there are some more questions.
I have about a minute left.
So the question is, how can we improve
serving patients in rural areas that don't have access
to trauma centers and often experience increased time
after injury in accessing care?
So a couple of thoughts on that.
One, I think, bring your experts in early.
If you know that you're receiving
a child from the field who has severe TBI,
I think there should be some trauma team activation
criteria where you call your pediatric support,
your anesthesiology support, your ICU support, your surgery
support, et cetera., to meet you in the emergency department
so that all decks can be on board to provide
their expertise for stabilization.
Second, I think we are going to be seeing
increased use of telemedicine.
And I think this is an opportunity for trauma centers
to provide stabilizing support to rural centers in this area.
And third is really calling the trauma center hotline
and asking to speak to an emergency medicine
physician or clinician who is in charge,
who can actually guide one through that sources of care.
And then, of course, there's being
familiar with the ATLS guidelines,
and also with the Brain Trauma Foundation Guidelines,
because there are excellent physicians out in the community
who, I think, provide fantastic stabilizing care.
And I think keeping these guidelines at the forefront
and having a card, maybe, in the ED,
and say, look, these are the goals
that people can aim to achieve, would really
provide a lot of support.
So with that, I think I've been told
that it's time to transition to the next speaker.
I'm sorry I didn't get to all of the questions.
But what we are going to be doing
is archiving these questions.
And those that we don't think we answered,
we will try and respond back to you.
Thank you very much for your time.
I would like to take this opportunity--
I think we're going to transition to the next speaker.
And then I'll come back and introduce Dr. Ebell.
-------------------------------------------
Kennedy Space Center rebuilds dock for super-sized rocket - Duration: 1:23.
For more infomation >> Kennedy Space Center rebuilds dock for super-sized rocket - Duration: 1:23. -------------------------------------------
5 Little Speckled Frogs| Part 2 | Nursery Rhymes | Songs for Kids | Easy Subtraction - Duration: 1:37.
Hip Hop Frogs
Five Little Hip Hop Frogs
Danced on a hip hop log Eating some most delicious bugs
(yum, yum) One jumped into the pool where it was nice and cool
Then there were four hip hop frogs
(glub, glub)
Four Little Hip Hop Frogs Danced on a hip hop log
Eating some most delicious bugs (yum, yum)
One jumped into the pool where it was nice and cool
Then there were three hip hop frogs (glub, glub)
Three Little Hip Hop Frogs Danced on a hip hop log
Eating some most delicious bugs (yum, yum)
One jumped into the pool where it was nice and cool
Then there were two hip hop frogs (glub, glub)
Two Little Hip Hop Frogs Danced on a hip hop log
Eating some most delicious bugs (yum, yum)
One jumped into the pool where it was nice and cool
Then there was hip hop frog (glub, glub)
One Little Hip Hop Frog Danced on a hip hop log
Eating some most delicious bugs (yum, yum)
One jumped into the pool where it was nice and cool
Then there were zero hip hop frogs (glub, glub)
-------------------------------------------
Vanilla Air Apologizes for Making Disabled Passenger Climb to Aircraft - Duration: 0:53.
For more infomation >> Vanilla Air Apologizes for Making Disabled Passenger Climb to Aircraft - Duration: 0:53. -------------------------------------------
Fast VS Slow Reps For Building Muscle Mass FAST? (THE TRUTH!) - Duration: 9:26.
What's up Champ! I'm Vince Del Monte of GeneExpressionTraining.com and in this
video we're going to discuss a question I've been getting asked very frequently.
It's what's better for building muscle mass fast? Slow reps or fast reps?
Alright. in this video we are going to teach you what the perfect rep speed is
so that you get faster muscle building results.
So what I want to share with you guys is not based on my own opinion. This is based on physics and we are going to
show you guys with our fish-scale. Alright. I have got five pounds attached
to a fish (laugh) I can't say that Frishscale (laugh) oh my gosh fish scale. Maybe I'm dehydrated.
Alright so, as you guys can see it weighs five pounds. Do we have
verification of that? So the question is... is what happens when we change our
lifting speed? If we go fast, is the weight still five pounds? If we go slow.
is the weight still five pounds? Alright. This videos in context to
building muscle right. And I find that's where a lot of people get confused in
terms of how they need to train. People don't know what their end goal is
alright. If your end goal is to be an athlete, to be a great power lifter, those
are very specific goals. Those are performance-based sport. Alright. They
require performance-based variables to be achieved. However if you want to build
a great physique. If you want to be a bodybuilder. You just want to be really
proportional, you just want look really sexy for the ladies, a lot of the methods used
to achieve sport based performance are not necessary and that's why I wanted to
shoot this video because for me, like I'm never going to play professional sports.
I'm never going to do powerlifting. I just want a good body. To look good to
feel good. Alright. So if that's my goal to have an
aesthetic physique, a balanced physique, a muscular physique, one that doesn't get
hurt, I want to eliminate all the risks possible. Does that make sense? That's why
I'm so passionate teaching guys how to use baby weights. Alright. And we're
going to take a look here at this thing called the fish scale and we're going to
find out when five pounds doesn't weigh five pounds and when it does so that
you can make more intelligent training decisions. Alright. There's no point
beating up your joints if you don't have to. Alright. So as you guys can see
let's just get right into the demonstration. We're going to have to get
some really good camera shots of this so you guys can see this but when the
weight's here, I'm going to drop the weight quickly okay. Any exercise you're doing
when you're lowering the weight, if you're lowering the weight too fast,
let's take a look at what happens to the weight. It's no longer five pounds. You see how
depending again on how fast I drop the weight, the force is no longer five
pounds. Alright. I mean if you can catch that it's going from five pounds to
close to ten pounds and if I go even faster you can see that the force is
magnified. So if you guys don't know the equation of force, its mass times
acceleration. Alright. So the mass here is five pounds depending on how much the
acceleration is, is going to dictate how much force you're actually putting into
your joints. So a lot of people, what happens, they go to the gym and they get
hurt. How many of you guys know somebody's been hurt lifting weights.
Well I believe that you should never get hurt if you train the way I teach you
alright. I believe you should never get hurt because I don't teach this. I don't
teach how to magnify the force into your joints with acceleration alright. I
teach you how to control the weight which we'll get to in a second. Now
that's one issue. Another issue is if we're going too fast
on the way up, alright. So now we're doing the concentric portion of your
movement. You're doing your press on the benchpress. You're doing your press on
your shoulder press. You're doing your pull on the pull-up. You're doing your
curl on the bicep curl. You're doing your press down on the tricep press down. What
happens if we use too much speed on the way up? Now watch the needle. Five pounds,
when it's not in motion, you see how the needle goes inward. It's literally going
to almost zero. So you're literally putting your muscles through a state of
weightlessness alright. Again, this is fantastic if you're an athlete or
performance-based person. You don't want to feel the weight. You want to get the
rep done, right. You want the weight to be light. So this whole thing of speed is
fantastic if you don't want tension, if you don't want fatigue in the muscles. If
you want an advantage, go fast. If you want an advantage go fast. My shoulder's
getting sore so I'm going to put this down. So the title of this video is how
do you build muscle faster? Slow reps or fast reps? Um, well, do we want more
tension in the muscle? Yes or no. Yes. So does going fast serve us? No. We're
actually making the weight lighter. Alright. If you want to build muscle tissue,
we need what's called muscle disadvantages, not muscle advantages. Alright.
Now, if we're trying to build muscle tissue and we're lowering the
weight too fast, is that good for our joints? No. If we're hurt and not in the
gym can we build muscle? No. Right. One of the best ways to build muscle is just not
to get hurt. Alright. A lot of guys peak in their 20s. They look their best in
their 20s and it's all downhill. I take pride in looking better since I
started and I think I'm going to look even better my 40s and 50s because I'm
playing the long game and I'm avoiding these risks of lowering the weights too
quickly. Alright. And I'm not going so fast that
I'm losing tension in my muscles so they'll have to keep adding more weight
to try and get something into the muscle. Does that makes sense? So let's wrap this
video up and let's find out when five pounds actually weighs five pounds. I
think you've probably figured this out by now, but five pounds weighs five
pounds when we're going what is the needle moving at all?
Do you see the needle move when I'm going slow? Hardly moving. So five pounds is five
pounds when we eliminate the acceleration component. Alright. So the
force going into your muscles is in fact what it says on the weight when we go
slow. So I could have wrapped up that entire video in two words. GO SLOW.
Alright. Now some of you guys are thinking slow is like so slow that like you're
not even getting a good workout in but that's not the truth. If you watch guys
work with a slow tempo or controlled tempo, it's a harder workout guys.
Swinging weight is easy. That's not a hard workout because you're cutting the
weight in half or depend on how fast you're moving, you're reducing the amount
of force you're putting into your muscles. So everyone thinks going slow is
for whimps. It's not hard. It's harder. You put that load all into your muscle. It feels
completely different. You're going to get an incredible pump. You're going to get
an incredible burn. You're going to break down muscle tissue and the best part is
you're not going to bang up your joints. So if your goal is to build muscle
tissue, to build muscle mass, the name of the game is going slow. Going control.
Alright. Fast lifting is great if you're an
athlete. It's great if you're a performance-based sport, but when it
comes to the world of bodybuilding, you've got to control it. You got to own
it.Alright. If you can't control it, you can't challenge it. You can't challenge
it, you can't build it. Next time you're in the gym with your buddy, I want you to
coach him by just using those two words. Slow it down.
Control. Stop swinging it. Squeeze it. Own it. Contract it. Alright. If your goal is
to build muscle that's the name of the game. Alright. And as you start to build
more muscle tissue, you will get stronger. Alright. That's the cool thing. You guys
who want to get stronger, you will get stronger, but you're going to be doing it
safely, alright, and you're actually going to be using your muscles to move
the weight. So if you're ready to improve your exercise execution so you get more
from less, so that you actually put tension in the muscle, I created a course
called Mass Mechanics. It's an exercise
execution video library. 215 00:08:23,870 --> 00:08:28,670 You get five hours of video coaching where
I take you through 113 different exercises. Ones you're probably familiar
with and we show you how to own the weight. How to execute your movements so
you build muscle faster and you don't get hurt in the process. It was my
best-selling program last year. People absolutely love it. They say I wish I
discovered this when I first got into lifting. Alright. It took me five years
to put this thing together until I was comfortable with all the tips that I put
in the program. It's very different than what you've probably been taught. Alright.
And this video resource can be picked up through the link on the page
here or the first link in the description box and you're going to
start getting better results without banging up your joints. Alright guys.
Thank you so much for watching. I look forward to doing this again soon. If
you've got any feedback for upcoming videos you know what to do. Read them.
Read them. Post them in the comment section below. I'll see you guys next
time
-------------------------------------------
US Issues New Visa Rules for Muslim Nations - Duration: 0:55.
For more infomation >> US Issues New Visa Rules for Muslim Nations - Duration: 0:55. -------------------------------------------
The Best Method for Designing and Developing a Curriculum - Duration: 2:21.
Good morning or good afternoon my name is Tom Langtry and I am the director of
Education Associates. We've developed in three areas: language instruction,
curriculum design, and writing and editing. For today's pro tip we'll discuss the
best method for designing and developing a curriculum. First of all, what's a
curriculum? Well if a lesson plan is the plan for a single class session, then the
syllabus is a collection of all the lesson plans for a semester, and the
curriculum would be the collection of all the syllabi for a university or a
school or an academic department or even a corporate training center. We have
found that the ADDIE model is a very effective method of designing a
curriculum for virtually any environment. An example of an ADDIE based curriculum
design is this book that I wrote it is an award-winning book, designed in order
to help staff of a state agency improve process and workflow. The ADDIE model can
be broken down into five steps: Analysis, Design, Development, Implementation and
Evaluation. So we have a A-D-D-I-E, the ADDIE model. Briefly, here's how it works. In the
Analysis phase we determine the learning gap or the skills gap, which is the
difference between what your staff or students already know and what they need
to know to reach your learning objective. Once we determine the learning gap, we
move into Design. And find a way to address that learning gap. From there we
move into Development and we take what we've determined in the design phase and
develop it by finding materials and building lesson plans. The Implementation
phase is when we take that work we've accomplished so far and move into the
classroom. And finally in Evaluation we take a look over kind before and afters
to ensure that the curriculum we've developed is actually accomplishing the
goals we've set. Thanks for watching BBB Pro Tips. Please
subscribe to watch more videos. To learn more about accredited businesses, check
out bbb.org/sacramento.
Không có nhận xét nào:
Đăng nhận xét