Anatomy Notes Referred pain. Updated July 2. 00. If you woke up with a pain in your shoulder, youd probably think something was wrong with your shoulder, rightThe Medical Front, WWI all medical aspects, military and civilian, of World War One, the Great War, including the Flu Pandemic of 19181919. Are you involved in technologyenhanced learning, teaching and research, learning design, applications development, interactive media or senior management responsible. Maybe you slept on it the wrong way, maybe youre a weekend warrior who threw the football a few too many times. In most cases, your hunch is probably right. Pain in the shoulder usually indicates an injury or disease that affects a structure in your shoulder, such as, say, your subacromial bursa or a rotator cuff tendon. Makes sense, doesnt it But you might be way off. Sometimes the brain gets confused, making you think that one part of the body hurts, when in fact another part of the body, far removed from the pain, is the real source of trouble. This curious and clinically important phenomenon is known as referred pain. For example, its unlikely but possible that your shoulder pain is a sign of something insidious happening in your liver, gall bladder, stomach, spleen, lungs, or pericardial sac the connective tissue bag containing the heart. Strange, isnt itConditions as diverse as liver abscesses, gallstones, gastric ulcers, splenic rupture, pneumonia, and pericarditis can all cause shoulder pain. How is that possibleNeuroscientists still dont know precisely which anatomical connections are responsible for referred pain, but the prevailing explanation seems to work pretty well. In a nutshell, referred pain happens when nerve fibers from regions of high sensory input such as the skin and nerve fibers from regions of normally low sensory input such as the internal organs happen to converge on the same levels of the spinal cord. The best known example is pain experienced during a heart attack. Nerves from damaged heart tissue convey pain signals to spinal cord levels T1 T4 on the left side, which happen to be the same levels that receive sensation from the left side of the chest and part of the left arm. The brain isnt used to receiving such strong signals from the heart, so it interprets them as pain in the chest and left arm. So what about that shoulder pain All of organs listed above bump up against the diaphragm, the thin, dome shaped muscle that moves up and down with every breath. What is an endoscopy Definition An endoscopy is a medical procedure used to view the digestive tract,and other internal organs, non surgically. The diaphragm is innervated by two phrenic nerves left and right, which emerge from spinal cord levels C3, C4, and C5 medical students remember these spinal cord levels using the mnemonic, C3, 4, 5 keeps the diaphragm alive. The phrenic nerves carry both motor and sensory impulses, so they make the diaphragm move and they convey sensation from the diaphragm to the central nervous system. Most of the time there isnt any sensation to convey from the diaphragm, at least at the conscious level. But if a nearby organ gets sick, it may irritate the diaphragm, and the sensory fibers of one of the phrenic nerves are flooded with pain signals that travel to the spinal cord at C3 C5. It turns out that C3 and C4 dont just keep the diaphragm alive neurons at these two spinal cord levels also receive sensation from the shoulders via the supraclavicular nerves. So when pain neurons at C3 and C4 sound the alarm, the brain assumes quite reasonably that the shoulder is to blame. Usually thats a good assumption, but sometimes its wrong. Illustration showing sites of referred pain from abdominal organs. From Moore and Dalleys Clinically Oriented Anatomy. Please note that I added the tighty whities with Photoshop hey, this is a family friendly site. Another example that seems bizarre until you know the anatomy is disease in the stomach causing pain between the shoulder blades. A classmate told me that one of her college professors complained to his doctor about pain in his upper back that wouldnt go away. It turns out that the professor had gastric cancer, a relatively aggressive and often incurable disease unless its caught early. Unfortunately it wasnt caught early enough and it ended up taking his life. Maybe the outcome would have been different if the doctor had remembered that some of the nerve fibers to the stomach specifically, visceral afferents that travel in the greater splanchnic nerve convey pain signals to the same spinal cord levels especially T5 and T6 that receive pain signals from the skin between the shoulder blades. This variety of referred pain is rare, but it happens often enough to be mentioned in anatomy textbooks. Not all cases of referred pain are easy to find in textbooks. Take the appendix, for instance. That wormy little appendage of the colon is usually located in the right lower quadrant of the belly, nowhere near the diaphragm. Typically people with appendicitis feel diffuse pain or discomfort around the belly button, or sharp pain in the right lower quadrant if the appendix is getting ready to burst. But occasionally the pain refers to the right shoulder. Why Note that I said the appendix is usually located in right lower quadrant. Sometimes, early in embryological development, the colon doesnt rotate as much as it should, and the appendix ends up in the right upper quadrant or even on the left side of the belly. That malrotation isnt necessarily a problem for the patient until the appendix becomes swollen with infection, irritating both the diaphragm and the doctor who is trying to make a diagnosis So if your shoulder happens to hurt right now, should you be worrying about something bad in your bellyProbably not. The most common causes of shoulder pain are, by far, musculoskeletal problems like osteoarthritis, adhesive capsulitis, and rotator cuff tendinitis. Often, with the help of taking it easy and a few rounds of ibuprofen, the pain goes away on its own. But if youre still concerned, make an appointment with your family physician. Red flags include more ominous symptoms like fever, unexplained weight loss, and pain in the left shoulder or scapular area that gets worse with exertion. Your doctor will want to know all about the pain. Was there a specific injury or did the pain come on slowly Does the pain occur without movement of the shoulder Can you make it worse with specific movements Are there any other symptoms or chronic medical problems The answers to these questions, along with a physical exam and appropriate imaging studies, will provide the information your doctor needs to understand the problem and create a treatment plan. Cccam Ipk Blackhole. The odds are good that the problem is relatively common and treatable. But if your doctor seems stumped, it wouldnt hurt to ask, Is there any chance this could be referred pain. Top Ten Precautions In Using Automated External Defibrillator AEDThe AED available in KLIA Airport International Departure Hall. Not sure whether AED is available in Domestic Departure. Anyone knows For that matter, actually AED should be easily available and placed at many strategic places. Top Ten Precautions in Using Automated External Defibrillators AEDThis article is edited and re published from an article found in content. It can also be found here. Electrical Substation Engineering Practice S Rao Pdf'>Electrical Substation Engineering Practice S Rao Pdf. The precaution and proper use of defibrillators is one important chapter, and it is included in the standardized curriculum of the AED basic training course. The American Heart Association, the American Red Cross and the National Safety Council approved and published these precautions for the safety of both the patient and the user of the AED. After the occurrence of the incident you have to look for an AED emergency kit right away. It is likely that you will find one at the building entrance if you are in a public place or building, because this is the standard place for these kits. Make sure you are familiarized with the contents of the kit. Youll probably find two pads, a CPR barrier mask, a piece of cloth or a towel, scissors, a pair of gloves and possibly a razor. So go though these automated external defibrillator precautions in order to avoid other accidents from happening. First of all, check the patient for pulse. If you cannot sense the pulse you may proceed, and let the AED determine if there are heartbeats at all. In most of the cases the AED will indicate if there is a pulse and if defibrillation is needed. You might want to try to perform a cardiopulmonary resuscitation CPR before taking any further action. But make sure that the AED device is not analyzing the rhythm. This may cause some unpleasant accidents. Many AED devices possess motion and CPR detector, but you wont have time to determine that in a crisis. My comment This is in line with the AHA 2. CPR first rather than shock first for non witnessed out of hospital cardiac arrest cases3. The AED device should be used with great care if the patient is in a moving means of transportation. The movement of a vehicle may affect the analysis the AED makes, which wont be accurate and consequently it will perform incorrect tasks. However, if employed while transporting the patient to hospital, stop and take the pulse several times and do monitoring checks with the help of the AED. Some AED models are smart enough to distinguish between external movement and cardiac movement. Beware of water Before performing the defibrillation, make sure the chest of the patient is completely dry. In the AED kit you will find a piece of cloth or a towel that is set there exactly with the purpose of drying the patients chest. Sweat or water spots make certain parts of the chest be less resistant and the defibrillation might not be very effective. Besides, the presence of water may lead to local burns. Also make sure that the patient has no contact with water. It the patient is in a pool or outside, in wet weather, take the patient under a safe shelter and dry the chest before taking any further action. However, do not use alcohol to dry the chest of the patient. As you may probably know, alcohol is very flammable. Take a close look at the patients chest. It should be free of nitroglycerine patches or any other patches or materials. Get rid of any patches before performing the defibrillation. The nitroglycerine patches may cause explosion when in contact with the AED pads. Make sure the patient does not lie on a conductive surface like sheet metal or metal bleachers. These conductors may transmit the shock to other people that are in the patients neighborhood. Keep your hands off the patient while performing the defibrillation. Also make sure no one else touches the patient. If these rules are not respected, you or others might get the electric shock. Touching the patient while the AED performs the analysis will not give accurate results. An AED should not be used on children under the age of 8, or under 5. Some AEDs are not able to adjust to the low energy settings that are required for children. Anyway, there are several AED devices on the market that may resuscitate even children under 8. So check the packaging of the device before using it. Take a look at the environment where you will perform the resuscitationYou shouldnt perform a defibrillation if you are among flammable supplies such as gasoline or free flowing oxygen. Also, the AED should be used with prudence when there is strong electromagnetic interference EMI. The AED might detect false cardiac rhythm when there is electromagnetic interference. Careful with the cell phones and portable radios the waves cause troubleIt is highly important to notify an ambulance of the incident and the cell phone is the most effective device, but make sure you keep all cell phones at least 6 feet away from the patient and the AED. The cell phone may influence the analysis. Radios have the same effect on the AED, so keep all radios away.