Cricopharyngeal spasm

Cricopharyngeal spasm is dysfunction of the upper most valve of the esophagus. This muscular valve normally allows the esophagus to open during swallowing. In cricopharyngeal spasm, this valve does not open properly, causing difficulty swallowing and resulting in a significant collection of liquid or food in the back of the throat.

It may be be due to dysfunction of the muscular valve that allows the esophagus to open, resulting in significant collection of liquid or food in the back of the throat.

Severe pooling of saliva (arrow) secondary to cricopharyngeal spasm.

Tumors can also present as trouble swallowing. This patient developed a lymphoma of the left tongue base (arrow).

About MS - Symptoms

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Laparoscopic Robotic assisted resection of duodenal and small bowel diverticula

Treatment of Hyperkalemia

continuous cardiac monitoring is mandatory if the patient has severe hyperkalemia (serum potassium > 6.5 MEq/L) or cardiac arrhythmias.
a patient with mild-moderate hyperkalemia (serum potassium < qid =""> the patient can be discharged and followed-up in 48 - 72 hours.
a patient with moderate hyperkalemia (serum potassium 6.0 - 6.5 mEq/L) should probably be admitted to hospital for supervised lowering of the serum potassium with a potassium-binding resin.
treat hyperkalemia more emergently if the serum potassium is > 6.5 meq/L or if there are any ECG changes suggestive of hyperkalemia => use sodium polystyrene sulfonate as first line therapy +/- insulin/glucose +/- calcium gluconate.

The following drug order sequence is recommended for life-threatening hyperkalemia (absent P waves + widened QRS complex, and/or serum potassium > 8 meq/L, and/or significant cardiovascular symptoms or arrhythmias, and/or severe neuromuscular symptoms)

1) Calcium gluconate
(there is no "correct" dose)
- 10 ml of 10% calcium gluconate solution over 10 minutes IV (rule of "tens") is a common approach.
(* calcium should preferably be administered in large veins because it is sclerosing)
- works in 1 - 3 minutes and lasts 30 - 60 minutes
- repeat dose in 5 - 10 minutes if no ECG change/improvement
(* calcium only antagonises potassium's deleterious electrical effect on the myocardium and it does not decrease the serum level of potassium - it is used temporarily until the serum potasium can be decreased by insulin + glucose administration)
- special warnings:-

* calcium should be given slowly over 20 - 30 minutes in a digitalised patient by diluting the calcium in 100 ml of normal saline and giving the calcium by an infusion pump - high risk of increased myocardial toxicity in the digitalised patient
* calcium is contra-indicated in digoxin-toxic patients and hypercalcemic states
* don’t give calcium in solutions containing bicarbonate

2) Insulin + Glucose
used to drive potassium into the cells
- 10 units insulin by rapid IV bolus + 50ml of 50% dextrose IV over 20 - 30 minutes; or the insulin can be mixed with 100 ml of 20% dextrose solution and administered IV over 20 - 30 minutes

- glucose should not be given to diabetics without first giving insulin - because insulin is needed to move potassium into the cells; also avoid giving 50% glucose by rapid IV bolus injection.
- onset occurs within 15 - 60 minutes and effect lasts 4 - 6 hours.

3) Albuterol by nebuliser
- 10 - 20mg in 4 ml saline over 10 - 20 minutes (large doses required)
- decreases serum potassium by about 0.5 - 1.0 meq/L

4) Bicarbonate
- only indicated when the patient is significantly acidotic (serum bicarb < depleted =""> use 3 amps of bicarb in 1L of 5DW at desired rehydration rate


5) Kayexalate - sodium polystyrene sulfonate
- defer if the patient is going to be dialysed within 2 hours to avoid a "colonic laundry"
- po route preferred if possible (greater degree of cation exchange)
- 15 - 50g in 100cc of 70% sorbitol po (or use commercial preperation)
- onset within 1 - 2 hours and lasts 4 - 6 hours
- use a retention enema if po administration is not preferable/possible

6) Lasix
- 40 - 80 mg of lasix IV to all patients who can produce urine

7) Dialysis
- primary therapy when renal function is absent
- prompt dialysis may also be required in patients with ARF + associated rhabdomyolysis (large potasssium load)
- also used for intractable hyperkalemia unresponsive to conservative pharmacological measures

8) Treat any underlying cause of the hyperkalemia

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The Femoral Sheath

The femoral vein and artery (but not the nerve) are surrounded, for a short distance, by the femoral sheath. This is a sleeve of tissue which is a continuation of fascia from within the abdomen. There is no sheath present at birth, but it is pulled down as the limb grows..........

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