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Interesting case from recently I thought I’d share… a 71 year old female brought by EMS with an unusual report (never happens, right?). Initial call went out for hip pain for the past couple days and well as shortness of breath and not acting right today. Was initially awake, alert, and speaking normally on EMS arrival but developed acute respiratory distress en route and required intubation. On arrival was tachycardic to 130s-140s and had SBP of 100s. Skin was cool and mottled appearing. No obvious external signs of trauma. Pupils equal and reactive. No reported fall but family was unsure. Pretty broad differential at this point, anywhere from PE to intracranial injury to sepsis to MI to …, especially difficult due to lack of context and inconsistent reports.
Chest xray in room 9 showed what appeared to be a widened mediastinum. To fully evaluate for PE vs dissection, we proceeded from room 9 with CTA of chest and abdomen, to also cover for intra-abdominal injury. CT head and cspine were also done and negative. Lactic was elevated at 5, WBC was 32, and troponin was 0.5. Blood pressure began to trend downward, so we continued fluids. CTAs were quickly viewed and demonstrated ascending aortic pseudoaneurysm with rupture due to penetrating ulcer, resulting in mediastinal hematoma and hemopericardium. Blood pressure continued to trend downward into the 70s systolic. We continued fluids, and started blood. Bedside US demonstrated the aforementioned hemopericardium but no signs of tamponade, so we could hold off on pericardiocentesis.. Also placed central line and started pressors. Transferred to Jewish for OR and had definitive repair.
So that went pretty quickly but had some interesting findings. Penetrating aortic ulcer is something I hadn’t seen before but usually occurs secondary to atherosclerosis. Basically the intima of the aorta becomes denuded due to atherosclerotic plaque formation and can progress through the aortic wall, leading to intramural hematoma and eventually dissection and/or perforation. Interestingly, this is not a common cause of dissection, being the initiating lesion in less than 5% of dissection.
Dissection is something we’ve all learned about and something we always have to be concerned for, as they can go pretty badly pretty quickly. Classically, these patients have “tearing chest pain radiating to the back” and are hypertensive, but as this case demonstrates that is not always the case. They can nonspecific complaints or nonspecific exams. CT is the gold standard for diagnosis, chest xray can show the widened mediastinum or obscuration of aortic knob but these are unreliable. If you have a suspicion, best to order CT and act quickly. D-dimer is also emerging as a possible screening modality, as it has demonstrated 97% sensitivity, but has poor specificity (56%). We all know the classic teaching on how to treat these as well, with rate control first (esmolol or labetalol) and BP control if needed (nitroprusside or nicardipine). However, this presumes that they are hypertensive, so what about the hypotensive patient, like we saw? Definitely something to act on quickly and correct. A 2005 study showed that hypotension is not a common characteristic of dissection (29% of patients studied), but had significantly higher mortality than patients without hypotension.
So what can cause hypotension in the dissecting patient? First off, it’s much more common in type A dissections than type B. The most common reasons for these patients to become hypotensive are acute cardiogenic failure and tamponade. The cardiogenic failure can result from involvement of the coronary arteries causing a STEMI, or from aortic valve involvement causing aortic regurgitation. If blood collects in the pericardium, it can cause tamponade, and pretty quickly at that. Tamponade is relatively rare, but has a very high early mortality. Other possible reasons for hypotension can include hypovolemia from blood loss into the chest, or spinal ischemia that can lead to a neurogenic shock.
Awesome, right? So many reasons for hypotension in an already really sick patient. Having these in mind though is very important as it guides management and can be crucial for rapid intervention. Bedside US is quick and can identify a tamponade, and quick pericardiocentesis can stabilize for surgical intervention. Early pressor use can be beneficial in acute cardiogenic or neurologic shock. Of course all of these are stabilizing measures until you can get the patient to a surgeon, but it’s always important to preserve perfusion to those vital organs. Fluids and blood can help with the possibility of volume loss, although that’s a much less common reason. Also be judicious in the patient that is in acute cardiogenic failure.
Thanks for sticking with me on that one. I’ve also included links to video for pericardiocentesis, as it is a procedure we don’t get a ton of practice with. Enjoy!
- Resources:
- Tintinalli’s Emergency Medicine 8th Edition, Chapter 59, pages 412-415
- Uptodate: Overview of acute aortic dissection and other acute aortic syndromes
- Tsai, T, et al. Clinical Characteristics of Hypotension in Patients with Acute Aortic Dissection. The American Journal of Cardiology Vol 95. January 2005
- Isselbacher, E., Cigarroa, J., Eagle, K. Cardiac Tamponade Complicating Proximal Aortic Dissection. Circulation. American Heart Association Journals. Volume 90, No 5. Novemnber 1994
Good case and great review! I saw a Stanford Type A dissection recently that presented with only AMS and nausea/indigestion. There is definitely heterogeneity in presentation. Normotensive but elderly, suspect the etiology may have been age/atherosclerosis related rather than due to excessive shear forces. Complicated by pericardial effusion without tamponade physiology. She shortly after progressed to code and unfortunately expire. Thanks for the review and glad you had a good outcome!
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It entails using your individual physique weight to perform an inverted row, which
targets the primary and secondary muscle tissue of the higher
back. TRX rows are a wonderful train for constructing strength and firming your back muscle tissue.
Yes, a straight-arm pulldown is an efficient exercise for power training.
Face pulls are another efficient way to target similar muscular tissues as
these used throughout a straight arm pulldown. The straight arm pulldown exercise is a good way to target the back muscles.
While benefiting from being a unilateral train, you can also use heavier weights to problem your core
more. Another sign of too-heavy weights is not going by
way of the full vary of movement. Your arms ought to be extending all the way
in which out, and then your elbows and shoulder blades must be coming all the method in which
back. Not going through the full range isn’t simply
dishonest the rep rely, it’s additionally cheating your physique and your gains.
The single-arm seated cable row (also often known as the “one-arm cable row”) is a seated cable row different
that you carry out utilizing a single handle attachment and one arm at
a time.
Initiate the motion by pulling your shoulder blades together,
making certain that the emphasis is on the again muscles.
This strategy is important for long-term progress of muscle cells and overall higher physique strength.
Focus on using a lighter weight stack that permits
you to carry out the exercise with proper approach, making certain maximum muscle
activation. Before performing any rowing movement, ensure to set your scapula
properly. This simple adjustment ensures higher activation of your again muscles, making
your rowing exercises more effective. Try this system, and you need to
discover an immediate improvement. It’s not just
about aesthetics; the short head of the biceps is essential for varied arm and
upper body actions.
During a cable row, you lengthen your again and hold it on this place all through the exercise.
This causes you to continually contract your erector
spinae to take care of spinal stability. Performing a straight arm pulldown frequently can lead to improved
upper-body power and muscle definition. Cable rows are an effective train for building
energy and measurement in the back, and with these three variations you’ll have the ability to add selection to your routine.
Cable rows present a good way to focus on your again muscles and build power, while additionally bettering posture, core stability, and total muscle mass.
In this weblog submit we’ll take a glance at how cable rows work completely different areas of your back,
their advantages for total well being, and variations on the
standard kind. The main difference is the dearth of (or lower) loading of the decrease again.
To perform a Resistance Band Fly, you’ll stand together with your feet shoulder-width apart, holding the band in each hand,
together with your arms slightly bent. You will then elevate your arms out to the sides in a wide arc, keeping your arms at
shoulder height. This train is nice for strengthening and firming the chest muscular
tissues. The point of the exercise is to intensely work the breadth of the back, to
not raise probably the most weight potential.
By including a vertical pulling movement (like the
pull-up or lat pulldowns) and an train for the back extensors,
(like the deadlift or a again extension), you’ve a whole again workout.
Using a wider grip and adjusting your kind slightly emphasizes slightly totally different muscular tissues than the
usual seated cable row. Particularly, the wide-grip seated cable row trains your upper back and rear delts more than your lats.
Now, i’m NO skilled, and it could just be a placebo affect, so correct me if I’m mistaken. One of the primary selections to make
if you got down to carry out a standing cable row is which grip you should use.
With so many grips out there to use at a cable machine, it could be overwhelming, so here’s a quick rundown of your options.
Are you bored with the identical old shoulder workout routines that solely work the entrance and
side of your shoulders? It’s time to change things up and target the
often-neglected rear deltoids with the rear delt row.
Rowing exercises can target totally different muscle
groups relying on the type of row that’s carried out.
In this weblog publish, we’ll talk about rows muscle tissue labored, fundamental anatomy of the
rowing motion, forms of rows and variations in addition to different exercises for working the same muscular tissues
as rows. Whether Or Not you’re seeking to construct energy or add selection into your exercise routine – understanding what’s involved in rowing might
help maximize outcomes. They goal the muscular tissues of
the higher and mid-back, helping to build power and
enhance posture. The exercise additionally helps to cut back pressure on the lower again by taking strain off it through the motion.
Moreover, as a outcome of you’re in a seated position together with your
chest supported, you can focus extra on correct type and method while nonetheless getting an efficient exercise.
The latissimus dorsi, or lats, are the most important muscular
tissues within the again and are liable for shoulder extension and adduction.
Keeping your arms straight out in front of you and
maintaining good posture all through, pull back on each ends of the attachment until
they touch both facet of your chest. This exercise requires you
to hold a barbell with an overhand grip and bend on the waist till
your torso is parallel to the floor. When it involves back training, many lifters mistakenly consider that the
one factor they need is pull-ups and pulldowns.
And whereas vertical pulls ARE good for constructing back width,
they don’t often do much for again thickness.
Slowly return them to their beginning position before repeating for a quantity of reps.
Then attach both a brief straight deal with or V-bar attachment, depending on what kind of grip you prefer (overhand vs
underhand). For this model of low rows, you’ll want two dumbbells
that match in weight. Keeping your again straight, bend on the hips
till your torso is parallel to the floor whereas
preserving your arms extended down towards the floor.
For a seated row, this would depend upon the machine weight or the resistance band weight.
This problem options testing how a lot weight you’ll find a way
to row and launch safely. Earlier Than making an attempt this problem, it’s important
to warm up first to get your muscles prepared and use a spotter in case you are testing heavier weights.
The proper form for the seated row involves preserving your core engaged from
the moment you get into position. Supporting your
core primes you for keeping your arms and back muscle tissue totally
engaged with out damage. A seated row is mostly performed on a selected seated row machine or
with a resistance band.
You ought to really feel your lats doing rather more of
the work compared to when your wrists are in a
neutral or forward-curling position. Assume of it because the Barbell Row’s versatile cousin, delivering the identical muscle activation but with the added bonus of continuous
resistance. It is a again exercise that is almost universally accessible and adaptable inside a exercise
routine.
In this guide, we’ll break down all features
of the cable row to have the ability to get probably the most out of it.
Cable rows activate the infraspinatus, which is another key muscle that makes up the rotator cuff.
Along with externally rotating the shoulder, it also stabilizes the shoulder joint.
For other straightforward to learn cable exercises, check out our analysis of the most
effective cable again workouts. Anticipate expert-backed workouts,
vitamin advice, the latest in power sports, and a whole
lot of motivation heading your method. This content material is for informational and educational functions only and doesn’t represent individualized recommendation.
Sitting up tall with a straight spine, brace your abdominals and glutes; holding the bar in your palms.
Retract your shoulders backward and maintain them like this all through the period of the exercise.
By standing, your body has to steadiness itself in opposition to the tension of the cable whereas also standing—which means more
muscle activation within the legs and abdominals.
But if you are consistent, you won’t need the
cables for for a lot longer. The Resistance Band Chest Press is a superb complementary train to the Seated Underhand Cable Row.
It works the opposing muscle group of the chest and shoulders
whereas the Seated Underhand Cable Row works the again and biceps.
Resistance Band Chest Press helps to steadiness out the muscles and
ensure an entire higher physique exercise.
Avoid flaring your elbows as it’s going to remove tension out
of your lats and put it on other upper back
muscular tissues like the traps, rhomboids, and posterior deltoids.
The seated cable row is a superb compound motion for building muscle and energy in your again. It is a beginner-friendly
exercise appropriate for exercisers of various
coaching experience. Bent-over dumbbell rows are a traditional back-strengthening
move is a rhomboid exercise pick from Gallucci.
“A tip for this is to focus on pulling via the elbows rather than simply shifting the weights along with your arms,” he says.
“The rhomboid muscular tissues play a vital role in maintaining correct posture by retracting the shoulder blades towards the backbone.
It build strengths that translates into loads of different workout routines, such as pullups and deadlifts. Building energy by way of our back muscles helps us preserve proper posture and protect the backbone. To effectively target and strengthen the erector spinae, incorporating a selection of workouts is essential. Using a cable machine with totally different cable attachments, such as a V-grip bar or rope cable row gear, ensures steady pressure for optimum muscle activation. The major rhomboid muscle retains your shoulder blade attached to your ribcage and is answerable for serving to you rotate your shoulder. Since seated row correct form requires keeping your shoulders down and again, it engages and strengthens the rhomboids, protecting your shoulder’s range of motion. The proper type for a seated row on a machine includes sitting upright on the machine, knees barely bent with out curling your decrease back.
As such, they could be a priceless addition to your training library, and you should use them anytime you want an alternative selection to rear delt rows. Using heavy weights – dumbbell rear delt rows usually are not meant to be carried out with ultra-heavy weights. Utilizing big dumbbells will undoubtedly result in more lat and less rear delt engagement. If you wish to carry heavy, and battle to maintain your ego in verify, you might discover that this train turns into just one other rowing exercise and your rear delts won’t get a lot benefit.
If the load is simply too heavy, you can’t properly do the full range of movement. Additionally, the biceps receive a larger exercise with the next range of movement. Keep your again neutral all through the range of movement to avoid stressing your lower again. Even when leaning back slightly on the high of the motion, make sure you don’t overextend your spine. This train is superb for people that prepare of their garage health club and don’t have access to a cable pulley. Furthermore, it can be utilized by novices to drill the movement or people undergoing habilitation.
Chest-supported rows are extra evenly distributed, and also you have more of a continuing load in your again muscular tissues all through the entire vary of movement. This train may be performed in varied methods to focus on again muscular tissues from different angles. Similar to the teres minor, a stronger infraspinatus may cut back the danger of shoulder dislocations. Regardless of your arm motion, corresponding to throwing, pushing, or pulling, the infraspinatus actively keeps the humeral head in the glenoid fossa. The upper fibers are responsible for scapular elevation, the center fibers perform scapular retraction, and the lower fibers help with scapular melancholy. Throughout a cable row, you perform scapular retraction, so the center fibers are probably the most activated.
If you have ever seen it called a Hammer Power high row and wondered why here’s why. Hammer Energy is probably considered one of the premier power and conditioning corporations that produce glorious equipment for machine exercises. They are especially famous for his or her row machines as they’ve a large variety, including the excessive row. Sure, the exercise is a secure way to construct strength and muscle in the again and arms. The t-bar row is like a extra stable model of the barbell row, but it still requires more core activity and static work on your legs than the cable row variants. The rear delts work as stabilizer muscular tissues, ensuring correct scapular retraction and enhancing shoulder health. Whereas the Seated Cable Row primarily targets your again muscles, it additionally engages your shoulders to some degree, notably the posterior deltoids.
Cable are very efficient for increasing the scale and power of assorted again muscle tissue. Not solely do they aim the lats, but in addition they engage the rhomboids, decrease and center traps, teres minor, and teres major. Preserving shoulder blades down and again throughout the motion engages the lats. Keep Away From using too much weight, which causes the shoulders to shrug and pull with the arms as an alternative of engaging the again. Since the seated cable row involves motion on the shoulder joint, you will expertise deltoid engagement while performing this train. This exercise leads to posterior deltoid engagement during eccentrics and anterior deltoid stimulation on concentrics. Prolong your hips to return your torso to the upright position while pulling the bar to your stomach button by driving through your elbows.
They pull the scapula again and maintain it in place, which provides you a strong foundation to tug from. Again rows and big backs go collectively like the bench press and an enormous chest. They are an especially simple and efficient motion that trains the posterior muscle tissue in a pure and useful method. The king of again rows would be the barbell row as it permits massive loads and full body muscle activation.
Sure, rows do work rear delts, however the degree of their involvement depends on a couple of factors, similar to row type, type and Grip. The chest-supported row can be performed with totally different grip positions and using totally different angles and attachments. Utilizing cables retains rigidity on the rear delts, which may be very useful for maximizing muscle hypertrophy. This train is similar to a primary one-arm dumbbell row for the lats, apart from some essential modifications. The inverted row has been shown to work lots of the muscular tissues within the again simply in addition to the barbell row, but with much less load on the spine. The chest-supported T-bar row presents related advantages to the single-arm dumbbell row in the sense that lower back fatigue isn’t a difficulty. Bear In Mind, the quality of your type is extra essential than the burden you pull.
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Analysis exhibits performing shoulder workouts is the best way to combat this.
A study showed that shoulder train individuals had decreased ache, improved shoulder movement,
and elevated shoulder perform. Whether Or Not you’re lifting, working out on a rowing machine, or playing different sports, strong shoulders could make a world
of distinction. If you are excited about increasing your
health journey, take a look at Hydrow’s workout library for more exercises and routines tailor-made
to your objectives.
Push towards the body as hard as attainable
and hold the stress for at least seconds. All you want is willpower,
motivation, dedication, and an arsenal of bodyweight workout routines that truly work.
The capability to work one aspect of your body at a time can help you to build a balanced physique,
addressing any disparities and helping you to mitigate and work
around accidents. As A Result Of of this, it’s
crucial to know which one you are utilizing so you’ll be able to train all three
equally. Unbalanced shoulder improvement can affect your appearance,
posture, and joint operate. Instead of attempting to raise too heavy, focus
on retracting the scapula and contracting the target muscle with
each rep, says Saini. When you’re doing supersets, you could
have an inclination to barrel by way of these units and reps.
However that’s not going to assist you.
Spiderman push-ups are a cracking bodyweight train that targets your front
delts (anterior deltoids), chest, triceps, and core,
while also giving your hips some extra mobility work. As you
lower into the push-up, you convey one knee in the path of
the same aspect elbow, adding more engagement in your core
and shoulders. It’s bloody efficient for constructing
shoulder power, especially in your entrance delts, and helps with coordination and adaptability, too.
Planche leans are an absolute ripper for targeting your front delts (those anterior deltoids), while additionally getting your chest, triceps, and core working exhausting.
Not solely does it strengthen your shoulders, however it also
helps you improve your stability and management, setting you up for more superior planche strikes down the observe.
The bear crawl is a full-body exercise that hits your front delts (that’s your anterior deltoids), core, and quads.
The rear delts usually get overlooked, but face pulls bring them into
the spotlight. This move balances shoulder growth, boosts posture,
and provides depth to the higher again. Named after a bodybuilding icon, the Arnold press
is a dynamic transfer that hammers every angle of the shoulder muscles.
Kicking issues off is the overhead barbell press, a basic that reigns supreme.
This transfer targets all three heads of the shoulder muscle tissue (front,
side, and back) while forging uncooked energy.
Actions like handstand push-ups and pike push-ups are challenging methods to strengthen the
deltoids. They permit for a variety of motion, which is important for muscle
development and activation. Dumbbells provide flexibility and freedom of
movement, making them excellent for working out your deltoid muscular tissues.
Our subsequent exercise choice works the posterior chain, focusing on the hinge
movement pattern with this lift. More importantly, we’ll be working on creating
the ignored facet of gluteal muscle participation in a hinge.
Constructing one greatest total physique workout program is a problem when you assume about all the larger muscle
groups that you want to hit in that workout. This is
why many people have overdeveloped entrance delts relative
to their aspect and rear delts.
Stability calls for increase when the alternative arm and leg are extended.
Utilizing an exercise ball gives you an uneven surface to increase the problem of
the exercise, which helps to involve the shoulder and triceps extra.
Machine presses have advantages over free-weight presses, offering higher stability and security.
Now, it’s a pretty simple exercise, and anybody can do it effectively, making it perfect for measurement and
power positive aspects. This exercise requires coordination between completely different muscle teams and helps develop explosive energy, which is beneficial for athletic efficiency.
They also hit all the rotator cuff muscles, together with the infraspinatus, subscapularis, teres minor,
and supraspinatus muscular tissues.
Working on teres main and minor muscles helps scale back any ache or discomfort in the neck and shoulder space.
Overhead press variations must be accomplished by gym goers with a great understanding of
proper kind, enough stability, and enough energy within the shoulder, core, and upper body.
Readers with shoulder pain or injuries ought to consult with a doctor
previous to attempting overhead press variations.
Beginners can also want to start with lighter weights, specializing in perfecting
their type and technique earlier than progressing to heavier weights.
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