HEALTH TRIBUNE Wednesday, May 17, 2000, Chandigarh, India
 
How fit is your heart?
The condition of your heart at rest and the way it responds during and after physical exercise are reliable indications of your overall fitness level. By performing a few simple tests, such as taking your resting pulse and measuring your pulse recovery 30 seconds after intense activity, you can easily assess the fitness of your heart.

Rubella is dangerous
Watch out, ladies!
By Dr Nirja Chawla
R
ubella is a viral infection, first recognised by German authors in the eighteenth century and known by its popular name as German measles or scarlet fever. It was originally considered a mild self-limiting disease. But later it was identified as one of the most common infections of the unborn baby, with severe potential for physical and mental damage (teratogenesis).

Trauma: learn to manage the airway 
By Dr Suman Sharma Grover
It has been established beyond doubt that the morality and morbidity of trauma patients improve considerably with prompt initiation of pre-hospital care. As more time elapses between the point at which an injured person develops serious post-traumatic shock and the start of resuscitation, the percentage of serving patients decreases. The "golden hour" is the time during which the resuscitation of the severely injured patient must begin in order to achieve the maximal survival rate.


 
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How fit is your heart?

The condition of your heart at rest and the way it responds during and after physical exercise are reliable indications of your overall fitness level. By performing a few simple tests, such as taking your resting pulse and measuring your pulse recovery 30 seconds after intense activity, you can easily assess the fitness of your heart.

Heart rates vary greatly. The resting pulse of a very fit person can be as low as 40. The average, however, is about 80. After exercise, the pulse of a trained athlete will recover in under a minute. For most people, however, it will take between four and five minutes, depending on the person's age.

You can gauge how hard you need to exercise to improve the functional efficiency of your heart by calculating your so-called "target heart rate". The target for each individual can be worked out using a simple mathematical formula based on their age and resting pulse.

If you regularly exercise hard enough to achieve your target pulse, you can monitor the improvement in the fitness of your heart. Take the measurements of your resting and recovery pulse rate every few weeks, or months, and compare it with your previous pulse rates.

What is your resting pulse?

Your resting pulse is the pulse you take when you first wake up in the morning. In general, as the fitness of your heart improves, your resting pulse becomes slower, stronger, and more regular. Women tend to have a slightly higher resting pulse than men. The resting pulse also increases a little with advancing years.

Taking your pulse

The easiest place to locate and record your pulse is on the front of your wrist, at the base of your thumb. Use your fingertips to press firmly over the pulsating artery. Count the beats for 15 seconds — then multiply by four to get a heart rate per minute.

Interpreting your pulse rate

The table here shows the relationship between your age, sex, resting pulse, and level of fitness. A resting pulse over 100 beats per minute could indicate a problem. you should therefore consult your doctor.

What is your pulse recovery time?

Another indicator of the fitness of your heart is how quickly your pulse returns to normal after it has speeded up during a period of vigorous exercise. If you exercise regularly, your pulse recovery time will gradually speed up, so that after 30 seconds of rest, your pulse rate comes down closer to your normal resting value.

How to measure it

Using the step-up routine, strenuous exercise is possible even indoors. It does not require any specialised equipment. Find a stair, about 20 cm (8 in) high, and step up and down off it, moving one foot after another. Aim for about 24 step-ups a minute for three minutes. After 30 seconds’ rest, take your pulse at the wrist: count over a 15 second period and then multiply by four to get a heart rate per minute.

How to interpret it

The table here shows the relationship between your age, sex, pulse recovery at 30 seconds, and level of fitness.

(Courtesy: Dorling Kindersley)

Warning

Do not attempt this test if your resting pulse is over 100 or if you feel unwell. Stop if you feel faint or develop chest pain, pain in the neck or arms, severe breathlessness, palpitations, or dizziness.

 

Target heart rates

To make your heart fitter, you must raise your pulse as near as possible to your target heart rate while exercising. Calculate your target heart rate as shown below. At first, it may be hard to meet your target; as you get fitter, it will become easier.

220 minus your age = Theoretical maximum pulse

Theoretical maximum pulse minus resting pulse = Pulse range

Pulse range divided by two plus resting pulse =Target heart rate during exercise

For example, a woman of 50 years of age who has a resting pulse of 80, will have a theoretical maximum pulse of 220 minus 50, which equals 170. Her pulse range is therefore between the resting value of 80 and this maximum of 170, a difference of 90. Half of this difference (which equals 45), added to her resting pulse (80), produces a target heart rate of 125 beats per minute.

Monitoring your exercise pulse
Take your pulse after exercising hard for a few minutes. Count your pulse rate for 15 seconds; any longer and your pulse will start slowing down. Multiply by four to get a heart rate per minute.  

Fitness level   Beats per minute after exercise

Age

20-29 yrs

30-39 yrs

40-49 yrs

50+ yrs

Men 

Excellent

under 76

under 80

under 82

under 84

Good

76-85

80-87

82-89

84-91

Fair

86-101

88-103

90-105

92-107

Poor

over 101

over 103

over 105

over 107

Women 

Excellent

under 86

under 88

under 90

under 92

Good

86-93

88-95

90-97

92-99

Fair

94-110

96-112

98-114

100-116

Poor

over 110

over 112

over 114

over 116

 

Fitness level

Beats per minute at rest

Age

20-29 yrs

30-39 yrs

40-49 yrs

50+ yrs

Men

Excellent

under 60

under 64

under 66

under 68

Good

60-69

64-71

66-73

68-75

Fair

70-85

72-87

74-89

76-91

Poor

over 85

over 87

over 89

over 91

Women

Excellent

under 70

under 72

under 74

under 76

Good

70-77

72-79

74-81

76-83

Fair

78-94

80-96

82-98

84-100

Poor

over 94

over 96

over 98

over 100



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Rubella is dangerous
Watch out, ladies!
By Dr Nirja Chawla

Rubella is a viral infection, first recognised by German authors in the eighteenth century and known by its popular name as German measles or scarlet fever. It was originally considered a mild self-limiting disease. But later it was identified as one of the most common infections of the unborn baby, with severe potential for physical and mental damage (teratogenesis).

The commonly used name, German measles, was misleading in the sense that it created a false sense of security as far as India was considered. Although exact data are not available, it is believed to be extremely common in India. Many studies have reported that 50-94% of the children and young adults are exposed to Rubella.

The most susceptible age groups are, therefore, children and young adults. Humans are apparently the only host for the Rubella virus and thus continued cycling in them is the only means whereby the virus is maintained in nature.

The Rubella virus enters the body through the nasopharynx, replicates in the local lymph nodes and is released in the blood stream after seven days. At this time the only symptom may be mild fever and other flu — like symptoms. About two weeks later, there is the appearance of rash and the enlargement of the local lymph nodes. Upto this point the patient can pass infection to others unknowingly.

The symptoms of the Rubella infection are mild, easily missed and so remain undiagnosed. But it is the growing, unborn foetus that bears the brunt of the infection. The highest risk of infection is thus in the pregnant women. Infected, especially in the first three months of pregnancy, there is a 60-75% chance of the baby having hearing loss. About 50-90% of the babies have eye defects like congenital cataract and blindness and 40-50% are born with heart defects. About 40% have psychomotor retardation.

Of all the malformations that constitute the Congenital Rubella Syndrome, microcephaly (small head) is the only one that can be diagnosed on ultrasound of the pregnant patient. But the failure to document microcephaly does not rule out other malformations of the baby. Having such a baby can be devastating for the entire family and is a burden to society in general.

Once infected, there is no treatment. The only way out is to prevent the infection. There has been a strong plea by several authorities for the immunisation of girls with the Rubella vaccine between the age group of 10-14 years as the MMR (Measles, Mumps, Rubella) vaccine given in infancy may have lost its protective efficacy. The Rubella vaccine is very cheap and easily available. It provides life-long protection to the mothers-to-be.

We, as parents, should try to prevent a heartbreak for our girls later on. Rubella vaccination is a vital part of the school immunisation programme in several countries. Till it becomes so of our country's policy, all adolescent girls should be vaccinated at the individual or school level.

Dr Nirja Chawla was a consultant at the PGI, Chandigarh, for many years. Now she is a senior consultant at the Gynae Endoscopy Centre, Sector 44, in the city.
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Trauma: learn to manage the airway 
By Dr Suman Sharma Grover

It has been established beyond doubt that the morality and morbidity of trauma patients improve considerably with prompt initiation of pre-hospital care. As more time elapses between the point at which an injured person develops serious post-traumatic shock and the start of resuscitation, the percentage of serving patients decreases. The "golden hour" is the time during which the resuscitation of the severely injured patient must begin in order to achieve the maximal survival rate.

In the trauma patients at least 50 per cent deaths occur within the first hour and additional 30 per cent within the first four hours of sustaining injury. The intensive treatment given at this time is, therefore, of vital importance. This depends on the immediate availability of the skilled staff who are experts in the techniques of resuscitation, diagnosis of multiple injuries and recognition of priorities in emergency treatment. A vast majority of early hospital deaths in our country can be prevented if the basic principles of the maintenance of the airway and adequate alveolar ventilation, along with the adequate replacement of blood loss, are strictly adhered to. Since in India we do not have adequate accompanying medical staff in ambulances, the paramedical personnel and, if possible, the general public can be taught the most effective and easy way of airway control.

The main philosophy behind the initial management in trauma is to do "as little as possible; as quickly as possible; and for as many as possible". If facilities are available, resuscitation should begin immediately (stay and stabilise); but when facilities are not proper, the patient should be shifted earliest (load and go) and precious time should not be wasted.

The most common site of airway obstruction in a traumatised/comatosed patient is the hypopharynx, occurring when the relaxed tongue and neck muscles fail to lift the base of the tongue and epiglottis from the posterior phyryngeal wall. Another cause of airway obstruction is the presence in the upper airway of foreign matter such as vomitus or blood that the unconscious patient cannot eliminate by swallowing or coughing. Such airway obstruction may be complete or partial. Complete obstruction is silent and leads to asphyxia, apnoea and cardiac arrest if it is not corrected within five to 10 minutes. Partial obstruction is noisy. This too must be promptly corrected as it can result in cerebral or pulmonary oedema, exhaustion, secondary apnoea, cardiac arrest and hypoxic brain damage.

The complete airway obstruction is recognised when one cannot hear or feel airflow at the mouth or nose. When there are spontaneous breathing movements, the presence of inspiratory retraction of supraclavicular and intercostal areas, and absent chest expansion with inhalations provide additional clues. During apnoea, when such spontaneous breathing movements are absent, complete airway obstruction can be recognised by the difficulty encountered in inflating the lungs, while attempting to ventilate the patient with positive pressure.

On the other hand, partial airway obstruction is recognised by noisy airflow which, during spontaneous breathing, may be accompanied by the retraction of intercostal muscles and suprasternal area. Snoring suggests that partial obstruction is hypopharygeal due to the base of the tongue falling back. Crowing suggests laryngospasm while gurgling points to the presence of foreign matter. Wheezing signals bronchial narrowing.

The immediate sequelae of airway obstruction may also be suspected on clinical grounds. Hypercarbia or an increase in blood carbon dioxide is suspected when there is somnolence and is confirmed by the measurement of increased arterial carbondioxide. Hypoxaemia is suspected when there is tachycardia, restlessness, sweating or cyanosis and is confirmed by the measurement of decreased arterial oxygen. The absence of cyanosis, however, does not rule out severe hypoxaemia. Needless to say that during acute airway obstruction, attempts at clearing the airway and reoxygenate have absolute priority over arterial blood gas determination.

The emergency airway control measures or emergency oxygenation of non-incubated patients is an art that is best acquired through guided clinical experience and these manoeuvres are being improved continuously. These measures include a backward tilt of the head, a triple airway manoeuvre (including head tilt, mouth opening and jaw thrust, the manual clearing of the airway, clearing airway with suction, positive pressure inflation attempts, pharyngeal intubation, oesophageal obturator airway insertion, laryngeal mask airway insertion, tracheal intubation, cricothyrotomy and transtracheal jet ventilation. All these measures, except the last two mentioned, can be taught with ease to the paramedical staff and even the general public. The best course is to impart such training at the high school level.

When the victim is unconscious, the backward tilt of the head, the forward displacement of mandible, or both, prevent hypopharyngeal obstruction by the base of the tongue. The chin lift prevents sagging of the chin which helps in keeping the mouth slightly open. Chin support does not displace the mandible forward as does the jaw thrust. In a trauma victim, do not turn the head to the side, do not flex the head and do not tilt the head maximally backwards as the patient may have cervical spine injury. Any movement in such a patient may damage the spinal cord.

In case the patient's dentures are firmly in place, leave them in position as they maintain the contour of the mouth and make artificial ventilation somewhat easy. If they are loose remove them. Airway patency can be assessed by lung inflation attempts using exhaled air, for example mouth to mouth, mouth to nose. It may be mouth to adjunct, for example a mask with oxygen or a bad valve mask with oxygen.

When the victim is unconscious and breaths inadequately with a backward tilt of the head alone, add jaw thrust and slight opening of the mouth. When vomit or foreign matter appears in the mouth, suspect airway obstruction by foreign matter. This calls for forcing open the mouth and cleaning foreign material from the mouth and pharynx by finger sweep, back blows and abdominal or chest thrusts. If possible, pharyngolargynogoscopic suction, extraction under vision and tracheal intubation should be carried out.

The oesophageal obsturator airway is a tube meant to be passed blindly into the oesophagus of a relaxed, comatosed apnoeic patient by the personnel unable to, not permitted to or not trained to incubate, the trachea. The cuff of the oesophageal tube is used to prevent gastric regurgitation and reduce gastric insufflation during positive pressure artificial ventilation without endotracheal intubation. The endotracheal tube can isolate the airway, keep it patent, prevent aspiration and facilitate ventilation, oxygenation and suctioning.

Cricothyroid membrane puncture (cricothyrotomy) and oxygen insufflation are alternative steps of last resort when endotracheal intubation is impossible in an asphyxiated patient and necessary equipment for these alternative techniques is immediately available.

It is also necessary to teach the paramedical staff the most effective and easiest way of airway control. Combitube, oesophageal obturator airway and laryngeal mask airway can be helpful in such a difficult situations as they can be inserted easily and without much training.

In conclusion, airway management is the most important part of trauma care. Mortality among such patients can be dramatically reduced if respiratory care is instituted early.

(The writer is a reputed expert in anaesthesiology and resuscitation. She is based in Chandigarh.)

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