Anesthesiology and Intensive Care Medicine Answers For Exam

Anesthesiology,and,Intensive,care,
Medicine'Exam'Questions'!
Part%A%–%CPR%and%first%aid%
!
1. CPR,%chain%of%survival%
!
Basic(life(support(
!
Basic!life!support!
Are!you!awake!?!
2!rescue!breaths!! "unresponsive"!
30!chest!
compressions! Shout!for!help!
Call!113!or! Open!airway!:!
whatever!in!your! Chin!lift!&!jaw!
country! thrust!
Not!breathing! Look,!listen!&!
normally?! feel!!
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!
!
!
!
!
!
Ilackiya(Elaiyarajah(5GM(2014/2015(
CPR:(
• Cardiopulmonary(rescucitation:((
• ER!procedure!
• Aim:!! !
o Preserve!brain!function!
o Restore!spontaneous!blood!circulation!
o Indicated!when!unresponsive!w/!no!breathing!
Chest(compression:(
• Rate!!!100/min!(30!compressions!in!17s)(
• Depth!!!5:6cm(
• Equal!compression(
(
Rescue(breath:(
• Pinch!nose!
• Take!normal!breath(
• Breathe!in!1!sec(
• Allow!the!chest!to!fall(
(
Timing:(
• Look,!listen!and!feel!!!no!more!than!10s(
• Change!CPR!partners!after!2!mins(
• Change!over!should!not!take!more!than!5:10s(
(
Defibrillators:(
• Automated,!external!defibrillators!(AED)(
o Used!by!any!w/o!training(
o If!more!than!one!rescuer!present,!continue!CPR!while!AED!is!
switched!on.!If!alone,!stop!CPR!and!switch!on!AED(
o Follow!voice,!visual!prompts!
o Attach!electro!pads!to!patients!chest!w/o!disrupting!CPR(
" 1!–!below!the!right!clavicle(
" 2!–!10cm!under!the!left!axilla!(midaxillary!line)(
o Screen!will!tell!you(
" Shock!indicated(
• Tell!everyone!to!stay!back(
• Push!button!on!command(
" No!shock!indicated(
• Continue!CPR(
• Follow!visual/voice!prompts(
• AED!will!automatically!analyse!ECG!every!2!mins.!During!that!time,!noone!
should!touch!the!body(
(
Agonal(breathing:(
• Abnormal,!gasping!or!laboured!breathing!
• Shortly!after!heart!stops!in!upto!40%!og!CA!
• Has!low!tidal!volume!
• Patients!with!cardiac!arrest!
• Dont!confuse!it!with!normal!breathing!
Chain(of(survival:(
# Early!access!to!ER!services(
# Early!BLS!–!upto!4!mins(
# Early!defibrillation!–!upto!8!mins(
# Early!advanced!care!to!stabilize(
!
Series&of&actions&that&decrease&mortality&
(
Cardiac(arrest:(
• Clinical(manifestations:(
o Loss!of!cardiac!output!due!to!systolic!dysfunction.!State!vill!lead!to!
cessation!of!breathing!causing!cardio:resp!arrest.!!
• Etiology:!
o IHD! o Poisoning!
o HTN! o Drowning!
o Valvular! o Hypothermia!
o Trauma!
!
!
!
!
!
!
2. Cardiac%Arrest%and%Life;threatening%Arrhythmias%
Cardiac'arrest'
(
Definition:(
• Cardiac!arrest!is!the!abrupt!loss!of!heart!function!
Etiology:!
• IHD!
• HTN!
• Valvular!
• Trauma!
Arrhthmias:%
• Shockable(
o Pulseless!v:tachycardia!
o V!fibrillation!
• NonLshockable(
o Asystole!
o Pulseless!electrical!activity!
!
Shockable((unsynchronized(shock)(
1. Pulseless!v:tach!
a. Polymorphic(vtac((
i. Torsades!de!pointes!
ii. Beat!variations!in!morphology!
iii. *Don’t!shock!in!TDP*!!
iv. Tx!:!MgSO4,!same!as!monomorphic!vtac!
b. Monomorphic(vtac(
i. Regular!broad!complex!
tachycardia(
ii. Most!common!cause!of!
myocardial!scarring!secondary!
to!acute!MI(
iii. Normal!QRS,!but!quick(
c. Both!have!(
i. Wide!QRS(
ii. High!HR!–!200:300!bpm(
d. Clinical(manifestations(
i. Cold!&!clammy(
ii. Low!BP(
iii. Palpitation(
Etiology:!
• Hypokalemia!!
o Flattened!T!waves,!prominent!U!waves,!!prolonged!PR!interval,!ST!
depression!
o Tx!–!KCl!!
!
• Hyperkalemia!
o Tall!peaked!T!waves,!small!p!waves!
o Wide!QRS!
o Tx!–!insulin!with!6%!glucose!
• Hydrogen(ions((
o Acidosis(
• Hypoxia!
o Decreased!oxugen!supply!to!regions!of!body!and!tissue!
o Minimize!by!ventilating!patient!w/!o2!and!bag!value!mask!or!
advanced!airway!(ETT,!subglottic!airway)!
• Hypovolemia!
o Due!to!hemorrhagic!or!fluid!loss!
• Hypothermia((
o Excluded!with!low!reading!thermometer(
o Tx!:!external,!internal!warming(
• Tension(pneumothorax(
o During!central!venous!cannula!or!following!chest!trauma(
o Tx!–!thoracocentesis(
• Tamponade(((cardiac)(
o Acute!type!of!pericardial!effusion!in!which!fluid,!pus,!blood,!clots,!
or!gasaccumulates!in!the!pericardium(!(compression(of(the(
heart(
o Tx!–!pericardiocentesis(
• Toxins(and(therapeutic(disturbances(
o Tx!–!antidotes(
• Thrombembolism(
(
2. Ventricular(–(fib(
• Bit!of!a!mess!on!ECG!
• The!sooner!you!shock,!greater!is!the!chance!of!
survival!
• Amplitude!of!waves!–!decreased!o2!starvation!(size!of!waves!correlates!to!
O2!starvation!
• Possible!to!work!out!roughly!getting!them!back!round!
• Ex!–!little!amplitude,!decreased!chance!of!getting!them!back!
(
NonLshockable(
1. Asystole(
• Complete!lack!of!electrical!activity!
• Rarely!seen!as!a!total!flat!line,!often!wondering!of!a!baseline!and!possibly!
P!wave!activity.!!
• If!asystole!seen,!check!electrode!contact!and!that!defibrillator!monitor!is!
set!to!monitor!via!pads.!
• Always!check!leads!!!when!present!in!2!or!more!leads!=!ASYSTOLE!
(
(
(
(
Dobutamine, a synthetic catecholamine, is most tory signs, and will provide valuable information
commonly used. Its actions are predominantly via of significant myocardial ischaemia or infarction.
b-adrenoceptors, increasing myocardial con- A rapid irregular pulse is likely to be due to atrial
tractility and causing arteriolar vasodilatation in fibrillation. This may need additional treatment
skeletal muscle reducing afterload via b2-adreno- with either anti-arrhythmic drugs (e.g. digoxin,
ceptors. amiodarone) or synchronized electrical cardiover-
2. patients
Such Pulseless(electril(activity((
should be considered as being at sion using a defibrillator (see page 106). Patients
very •high=(Pulseless!ventricular!activity!,!electromechanical!dissociation(
risk of cardiac arrest from which the causing serious concern should be continuously
prognosis is likely to be poor. They must be monitored by ECG, pulse oximeter and invasive
• Shows!a!rhythm!that!supports!cardiac!output.!Rhythm!can!be!sinusrhythm!
managed in a high dependency area (e.g. CCU) by arterial monitoring.
experiencedto!3 rd!degree!AV!nodal!block!with!LBBB!
clinicians. Acute heart rhythm disturbances and their im-
• So!rhythm!is!present,!but!no!pulse! mediate management are summarized in Table 5.8.
• Electrically!–!QRS!is!present,!SV!is!weak!
Cardiac arrhythmias
• Tx!–!NON(SHOCKABLE!
Common tachycardias and sinus bradycardia and
o Never!shock!patient!
their causes have been covered on pages 77–78.
o Give!1mh!adrenaline!iv!
( heart rhythm disturbances and their immediate management
Table 5.8 Acute
Sinus tachycardia Sinus bradycardia

Usually an appropriate cardiovascular response to Identify and treat the underlying cause:
maintain cardiac output and blood pressure—treat • Impending cardiac arrest
the cause, not the tachycardia itself: • Hypoxia
• Hypovolaemia • Drug toxicity
• Myocardial ischaemia/infarction • Hypothermia
• Sepsis • May be normal in young fit adults
• Severe pain • Raised intracranial pressure
• Anxiety • Heart block
• Thyrotoxicosis • May pre-exist or be associated with acute myocardial
ischaemia/infarction
Supraventricular tachycardia
• Second- and third-degree heart block may quickly
• In critically ill patients usually atrial fibrillation,
progress to ventricular standstill (cardiac arrest)
particularly the elderly
• Needs insertion of a temporary transvenous pacing
• Often indicates inadequate intravascular volume
wire
• Treat using synchronized electrical cardioversion or
drugs depending on the degree of urgency (see Ventricular tachycardia
page 77) • Usually associated with acute myocardial
ischaemia/infarction
• Relatively uncommon presentation in critical illness due
to other causes
• Potentially compatible with a pulse but may also rapidly
deteriorate into a cardiac arrest
• Requires immediate treatment, usually by defibrillation
unless ‘well tolerated’ by the patient, when drugs (e.g.
amiodarone) may be tried initially
Ventricular fibrillation, asystole and pulseless

electrical activity
See pages 105–108
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122
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Antiarrhythmics:!!
We!have!5!classes!of!antiarrhythmic!agents:!!
+(
• Class!1:!Na channel(blockers!→!same!mechanism!of!local!anesthetics!
(binding!to!open!!or!inactivated!sodium!channels!→!good!in!tachycardia).!
It!has!3!subtypes:!
!Ia:!quinidine!→!prevent!sodium!influx.!!
Ib:!lidocaine!→!slow!phase!3!repolarization!
Ic:!same!as!Ia!→!propafenone.!!!
• Class!2:!Beta!blockers!→!diminish!phase!4!repolarization!→!prolong!AV!
conduction!and!depress!automaticity!→!reduce!heart!rate!and!
contractility!→!propranolol,!esmolol,!metoprolol.!!!
• Class!3:!K+(channel(blocker!→!diminish!phase!3!repolarization!→!
amiodarone.!!!
• Class!4:!Ca2+(channel(blockers!→!decrease!phase!4!→!bind!only!to!
depolarized!!channels!(less!dangerous)!→!verapamil,!diltiazem.!!!
• Class!5:!other!antiarrhythmics.!!
! ! ➢!!Digoxin!→!from!fox:glove!plant!→!highly!toxic!→!positive!
inotropic!→!use!we!extreme!caution.!!!
! ! ➢!!Adenosine!→!decrease!conduction!velocity!and!prolong!the!
refractory!period.!!!
3. Airway%Management%without%Airway%Devices%
Problem:!
• In!unconscious!victims!!!airway!can!become!obstructed!at!the!level!of!
hypopharynx!because!of!decreased!mucle!tone!in!muscles!of!tongue,!jaw!
and!neck!that!allows!the!tongue!to!fall!against!the!post!phalangeal!wall.!
Correction:!
• Correction!usin!following!techniques!
• Allows!recovery!w/o!!need!for!further!more!!methods!
!
Head(tilt(&(chin(lift(
• Rescuers!hand!placed!on!the!forehead!!!gently!push!backwards(
• Chin!is!lifted!using!index!and!middle!fingers!of!the!other!hand(
• If!mouth!closes!,!the!lower!lip!should!be!retracted!downwards!by!thumb(
(
Jaw(thrust(
• Use(if(
o Above!techniques!fails(
o Suspected!cervical!spine!injury(
o Patients!jaw!is!thrust!upwards!by!the!rescuer!applying!pressure!
behind!angles!of!the!mandible(
4. Basic%Life%Support%–%Adults%
CPR:(
• Cardiopulmonary(rescucitation:((
• ER!procedure!
!
!
• Aim:!! !
o Preserve!brain!function!
o Restore!spontaneous!blood!circulation!
o Indicated!when!unresponsive!w/!no!breathing!
Chest(compression:(
• Rate!!!100/min!(30!compressions!in!17s)(
• Depth!!!5:6cm(
• Equal!compression(
(
Rescue(breath:(
• Pinch!nose!
• Take!normal!breath(
• Breathe!in!1!sec(
• Allow!the!chest!to!fall(
(
Timing:(
• Look,!listen!and!feel!!!no!more!than!10s(
• Change!CPR!partners!after!2!mins(
• Change!over!should!not!take!more!than!5:10s(
(
Defibrillators:(
• Automated,!external!defibrillators!(AED)(
o Used!by!any!w/o!training(
o If!more!than!one!rescuer!present,!continue!CPR!while!AED!is!
switched!on.!If!alone,!stop!CPR!and!switch!on!AED(
o Follow!voice,!visual!prompts!
o Attach!electro!pads!to!patients!chest!w/o!disrupting!CPR(
" 1!–!below!the!right!clavicle(
" 2!–!10cm!under!the!left!axilla!(midaxillary!line)(
o Screen!will!tell!you(
" Shock!indicated(
• Tell!everyone!to!stay!back(
• Push!button!on!command(
" No!shock!indicated(
• Continue!CPR(
• Follow!visual/voice!prompts(
• AED!will!automatically!analyse!ECG!every!2!mins.!During!that!time,!noone!
should!touch!the!body(
(
Agonal(breathing:(
• Abnormal,!gasping!or!laboured!breathing!
• Shortly!after!heart!stops!in!upto!40%!og!CA!
• Has!low!tidal!volume!
• Patients!with!cardiac!arrest!
• Dont!confuse!it!with!normal!breathing!
5. Basic%&%Advanced%Life%Support%;%Newborns,%Infants%&%Children%
Mostly!same!as!adults,!but!remember!that!children!have!altered!anatomy!and!
physiology!
(
Head(and(chin(tilt(
• In!infant,!the!tilt!should!be!just!sufficient!to!place!the!head!in!a!neutral!
position.!!
• The!fingers!of!the!other!hand!should!then!be!placed!under!the!chin,!lifting!
it!upwards.!!
• Care!should!be!taken!not!to!injure!the!soft!tissue!by!gripping!too!hard.!It!
may!be!necessary!to!use!the!thumb!of!the!same!hand!to!part!the!lips!
slightly.!!
!
Jaw(thrust((
• Two!or!three!fingers!under!the!angle!of!the!mandible!bilaterally,!and!
lifting!the!jaw!upwards.!This!technique!may!be!easier!if!the!rescuer’s!
elbows!are!resting!on!the!same!surface!as!the!child!is!lying!on.!A!small!
degree!of!head!tilt!may!also!be!applied.!!
• The!finger!sweep!technique!often!recommended!for!adults!should!not!be!
used!in!children.!The!child’s!soft!palate!is!easily!damaged,!causing!
bleeding,!and!foreign!bodies!may!become!impacted!in!the!child’s!cone:
shaped!airway!and!be!even!more!difficult!to!remove.!!
!
The(technique(of(expiredLair(ventilation(!
• The!airway!is!kept!open!using!the!techniques!described!above.!If!the!
mouth!of!the!child!alone!is!used,!then!the!nose!should!be!pinched!closed!
using!the!thumb!and!index!fingers!of!the!hand!that!is!maintaining!the!
head!tilt.!In!infants!and!small!children,!mouth:to:mouth!and!nose!
ventilation!should!be!used.!Each!breath!should!provide!sufficient!volume!
to!make!the!child’s!chest!rise.!!
• Since!children!vary!in!size,!only!general!guidance!can!be!given!regarding!
the!volume!and!pressure!of!inflation!!
• If!the!chest!does!not!rise!then!the!airway!is!not!clear:!!
o Readjust!the!head!tilt/chin!lift!position!
o Try!a!jaw!thrust;!
o If!both!fail!to!provide!a!clear!airway,!suspect!that!a!foreign!body!is!
causing!obstruction.!!
(
(
The(technique(of(external(cardiac(compression(in(children((
• Children!vary!in!size,!and!the!technique!used!must!reflect!this.!In!children!
over!8!years!of!age,!the!method!used!in!adults!can!be!applied!with!
appropriate!modifications!for!their!size.!!
Infants!!
• The!infant!heart!is!lower!compared!to!external!landmarks;!the!area!of!
compression!is!found!by!imagining!a!line!running!between!the!nipples!
and!compressing!over!the!sternum!one!finger’s!breadth!below!this!line.!
Two!fingers!are!used!to!compress!the!chest!to!a!depth!of!approximately!
1.5–2.5cm.!!
Chapter 4 Management of perioperative emergencies and cardiac arrest
at a rate of at least 100 times per minute. One ventila-

Larger children
tion should be delivered for every five compres-
The area of compression is two fingers’ breadth
sions. Clearly, time spent readjusting the airway or
above the xiphisternum. The heels of both hands
re-establishing the correct position for compres-
• An!alternative!in!infants!is!the!hand:encircling!technique.!The!infant!is!
are used to compress the sternum to a depth of ap-
sions will seriously decrease the total number of
held!with!both!the!rescuer’s!hands!encircling!the!chest.!The!thumbs!are!
proximately 3–4 cm, depending on the size of the
compressions given per minute. This can be a very
child.
placed!over!the!correct!part!of!the!sternum!(see!above)!and!compression!
real problem for the solo rescuer and there is no
Infants and children have a requirement for
carried!out.!!
higher rates of ventilation and compression than
easy solution. The CPR manoeuvres recommended
Small&children&(
adults. The aim should be to compress the sternum
for infants and children are summarized in Table
4.3.
• The!area!of!compression!is!one!finger’s!breadth!above!the!xiphisternum.!
The!heel!of!one!hand!is!used!to!compress!the!sternum!to!a!depth!of!
approximately!2.5–3.5!cm!! Further reading
Larger&children&( Adnet PJ, Gronert GA. Malignant hyperthermia:
• The!area!of!compression!is!two!fingers’!breadth!above!the!xiphisternum.!
advances in diagnostics and management.
Current Opinion in Anaesthesiology 1999; 12:
The!heels!of!both!hands!are!used!to!compress!the!sternum!to!a!depth!of!
353–8.
approximately!3–4cm,!depending!on!the!size!of!the!child.!!
Marik PE. Aspiration pneumonitis and aspiration
• Infants!and!children!have!a!requirement!for!higher!rates!of!ventilation!
pneumonia. New England Journal of Medicine
and!compression!than!adults.!The!aim!should!be!to!compress!the!sternum!!
2001; 344: 665–7.
at!a!rate!of!at!least!100!times!per!minute.!One!ventilation!should!be!
Mendelson CL. The aspiration of stomach
delivered!for!every!five!compressions.!Clearly,!time!spent!readjusting!the!
contents into the lungs during obstetric
anesthesia. American Journal of Obstetrics and
airway!or!re:establishing!the!correct!position!for!compressions!will!
Figure 4.11 Cardiac compression in a small child. Gynecology 1946; 52: 191–205.
seriously!decrease!the!total!number!of!compressions!given!per!minute.!
This!can!be!a!very!real!problem!for!the!solo!rescuer!and!there!is!no!easy!
solution.!!
Table 4.3 Summary of CPR manoeuvres in children
Infant Small child Larger child
Airway Neutral Sniffing Sniffing

Head tilt position
Breathing 5 5 5
Initial slow breaths
Circulation
Pulse check Brachial or femoral Carotid Carotid
Landmark 1 finger’s breadth 1 finger’s breadth 2 fingers’ breadth

below nipple line above xiphisternum above xiphisternum
Technique 2 fingers or encircling 1 hand 2 hands
Depth 1.5–2.5 cm 2.5–3.5 cm 3–4 cm
CPR
Ratio 1:5 1:5 1:5
Cycles per minute 20 20 20
!
6. Advanced%Life%Support%Adults%
110
AIM:!!
• Identify!and!reverse!the!underlying!cause!of!the!cardiac!arrest!using!a!
defibrillator,!airway!devices,!oxygen,!intravenous!cannulation!and!drugs,!
correcting!reversible!causes.!The!most!important!first!step!is!to!identify!
the!cardiac(arrest(rhythm,!which!can!belong!to!one!of!two!groups:!!
o Shockable:!Ventricular!fibrillation!(VF),!pulseless!ventricular!
tachycardia!(VT)!
o Non8shockable:!Asystole!and!pulseless!electrical!activity!(PEA).!!
!
!
VT/VF(persists:(
• If!VT/VF!persists!after!1st!shock,!deliver!2nd!shock!
• If!VT/VF!persists!after!2nd!shock!deliver!3rd!shock!
• Resume!chest!compressions!immediately!and!then!give!
o 1mg!adrenaline!iv.!
o 300mg!amiodarone!iv!
• Perform!further!CPR!for!2!mins!
!
PreLcordial(thump(
• Low!success!rate!for!cardioversion,!changes!vT!!!sinusrhythm!
• Only!likely!to!succeed!if!given!in!first!few!second!of!onset!of!a!shockable!
rhythm.!
• Ulnar!edge!of!fist!on!lower!half!of!sternum!from!a!length!of!20cm!
o This!delivers!a!small!amount!of!mechanical!energy!to!the!
myocardium!and,!if!done!early!enough!after!the!onset!of!VF,!may!
cause!the!rhythm!to!revert!to!one!capable!of!restoring!the!
circulation.!
PEA(–(sequence:(
• Start!CPR!30:2!
• Give!adrenaline!1mg!as!soon!as!iv!access!is!achieved!
• Continue!CPR!until!airway!secured,!then!continue!chest!compressions!
• Consider!possible!reversible!causes!of!PEA!and!correct!
• Recheck!after!2!mins!!!ECG!appearance!
o Still!no!pulse!&!no!changes!on!ECG!!!continue!CPR!
o After!2!mins!!!adrenaline!1mg!iv!every!3:5!mins!
(
Etiology(of(PEA((5H´s!&!5!T´s)
• Hypoxia! • Tension!pneumothorax!
• Hypovolaemia! • Tamponade!(cardiac)!
• Hypo/hyperkalaemia!and! • Toxic/therapeutic!
metabolic!disorders! disorders!!
• Hypothermia! • Thrombo:embolic!and!
! mechanical!obstruction!!
!
Asystole(
• This!represents!electrical!standstill!of!the!heart!with!no!contractile!
activity!and!is!seen!on!the!ECG!as!a!gently!undulating!baseline.!!
• Start!CPR!30:2!
• W/o!stopping!CPR!check!leads!if!they!are!attached!correctly!to!
defibrillator!and!monitor.!Always!check!on!2!leads!if!asystole!is!present!
• Give!1mg!of!adrenaline!iv!
• Continue!CPR!until!airway!is!secure,!then!continue!chest!compression!
w/o!pausing!
• Consider!5H!and!5T!
• Give!adrenaline!1mg!every!3:5!min!
!
7. Airway%Management%with%Airway%Devices%
Basic(tecniques:(
• Combination!of!head!tilt!and!jaw!thrust.!
!
Simple(adjuvants:(
Following!techniques!are!used!in!cojunction!with!basic!tecniques!
!
1. Oropharyngeal(airway(
• Curved!plastic!tubes(
• Lie!over!tongue,!preventing!it!from!falling!back!into!pharynx(
• Available!for!neonates!!!adults(
• Insert!upside!down!as!far!as!hard!palate,!rotate!180!degree!and!fully!
insert!until!the!flange!lies!in!front!of!the!teeth,!or!gums!in!an!edentulous!
patient!!
2. Nasopharyngeal(airway(
• Round!plastic!tube!which!is!bevelled!at!pharyngel!end!and!flanged!at!
nasal!end.!
• Prior!to!insertion,!the!patency!of!the!nostril!(usually!the!right)!should!be!
checked!and!the!air:!way!lubricated.!!
• The!airway!is!inserted!along!the!floor!of!the!nose,!with!the!bevel!facing!
medially!to!avoid!catching!the!turbinates!
• A!safety!pin!may!be!inserted!through!the!flange!to!prevent!inhalation!of!
the!airway.!!
• If!obstruction!is!encountered,!force!should!not!be!used!as!severe!bleeding!
may!be!provoked.!Instead,!the!other!nostril!can!be!tried.!!
!
3. Tracheal(intubation(
• Best!method!
• Requires!abolition!of!the!laryngeal!reflexes!
• Indications:!!
o Where!muscle!relaxants!are!used!to!facilitate!surgery!
o Input!with!full!stomach!to!protect!against!aspiration!
o Difficult!airway!maintenance!in!patients!
o Controlled!ventilation!is!utilized!to!improve!surgical!access!:!
neurosurgery!
o During!CPR!
• Equipment:!
o Laryngoscope,!tracheal!tube,!syringe,!catheter,!suction!
• Technique:!
o Preoxygenation!
o Positioning!!
o Laryngoscope!
o Intubation!!
• Complications:!
o Hypoxia!
o Trauma!
o Reflex!activity!
4. Laryngeal(mask(airway(
• Tube!which!protrude!from!the!mouth!and!connects!directly!to!the!
anesthetic!breathing!system!
• Patients!can!be!ventilated!via!LMA!provided!that!high!inflation!pressure!is!
avoided!because!leakage!can!occur!at!the!cuff!!!decreased!ventilation!
• Contraindicated!in!increased!risk!of!regurgitation;!
o Emergency!cases!
o Pregnancy!!
o Patients!with!a!hiatus!hernia!!
• A!type!of!supraglottic!airway!device!
(
Emergency(techniques(
• Needle(cricothyroidectomy(!(›(provides!short!term!oxygenation.(
o Cricothyroid!membrane!is!identified!and!punctures!using!a!bore!
cannula(
o Aspiration!of!air!confirms!that!tip!of!cannula!is!within!trachea(
o Cannula!is!angled!45!and!needle!advanced!into!trachea(
o High!flow!o2!supply!is!attached,!expiration!is!via!upper!airway(
o This!technique!oxygenates!pateients,!but!minimal!CO2!elimination!
!!limited!to!30!min!use,!until!definitive!airway!is!created.(
• Surgical(cricothyroidectomy(
o Incision!through!cricothyroid!membrane(to!allow!introduction!of!
tracheostomy!or!tracheal!tube(
o More!difficult!to!perform(
o Results!in!mora!bleeding(
o Once!ventilated!!!allows(
" Oxygenation(
" Elimination!of!CO2(
" Suction!of!airway!to!remove!any!blood!or!debris(
8. Drugs%for%CPR%&%Routes%of%Drugs%Administration%
!
Epinephrine((adrenaline)(
• Natural!occuring!catecholamine(
• Alpha(1,2,3,!beta!2!properties(
• Low!dose!!!B1!agonist!!!Increased!FOC,!HR!!
o ADR:!tachycardia,increased!o2!demand,!tachyarrhytmia,!
• High!dose!!!A1!agonist!vasoconstiction;!increased!tpr!–!BP!
o ADR:!Decreased!CO2!in!high!…!
• Give!1mg!iv!!
o Shockable:!after!3rd!shock,!then!every!3:5min!
o Non!shockable!–!straight!away!
!
Amiodarone:!
• Anti!arrhythmic!drug!
• Class!III!antiarrhytmics!that!block!K+!channel.!
• They!block!the!opening!of!the!K!channels!and!delaying!the!exflux!of!K!
• Result:!delayed!release!of!K!
o Increased!AP!duration!!!prlong!each!AP!makes!myocardium!
resistant!to!arrhythmia!
o Increased!ERP!
• ADR:!peripheral!vaso!dilation!!!decreased!BP!
• Toxicity:!
o Accumulation!:!
" Lungs!!!pulmonary!fibrosis!!
" Eye!!!corneal!deposits!!!decreased!visual!acuity!
" Thyroid!!!(:)!conversion!T4!T3!!!hypo:
/hyperthyroidism!
• Given!in!shockable!arrythmias!
o 300mg!flushed!with!20mL!og!0,9%!NaCl!
o Given!preferably!via!central!line!or!alternatively!a!peripheral!line.!!
!
Mg(Sulphate(
• Given!Iv!
• Mg!is!needed!for!Na/K!pumps!in!myocytes!
• Decreased!Mg!!!Increased!intracellular!K!
• Use:!
o First!line!–!Torsades!Des!pointes!
o Given!in!refactory!VF!if!fue!to!hypomagnesium!
o Digoxin!toxicity!
!
NaBicarbonate(
• Use:!
o Tx!for!hyperkalemia!
o TCA!
• TCA!results!in!anaerobic!respiration!because!of!pulmonary!GE!stops.!
Resulting!in!MAC.!Bicarbonate!causes!generalation!of!CO2!when!diffuse!
into!cells.!
!
Calcium!
• Ca!important!for!myocardial!contraction!
• Given!only!if!Ca!due!to!
o Increased!K!
o Decreased!Ca2+!
o OD!on!calcium!channel!blockers!
((
Routes(of(drug(administration:(
Intravenous%route:%
• Peripheral!venous!cannulation!is!quicker,!easy!to!perform!and!safer.(
• Drugs!injected!into!periphery!must!be!followed!with!a!flush!of!at!least!
20mL!saline.(
• CVL!!!only!attempted!by!skilled!and(competent!in!technique(
• Achieve!with!minimal!interruption!to!chest!compression.(
!
Intraosseous%route%
• If!you!cant!get!iv!access!within!2!mins!of!rescusitation!then!consider!io!
• Traditionally!used!in!children!because!of!difficulty!in!getting!iv!access!
• Uses:!
o Tibial!
o Humeral!!!both!provide!equal!flow!rate!of!fluid.!
!
Tracheal%route%%
• Administration!via!tracheal!tube!
• But!plasma!concentration!vary!and!are!lower!than!10!&!iv!particularly!
with!adrenaline!
• No!longer!recommended.!!
9. Defibrillation,%cardioversion,%cardiostimulation%
Defibrillation%
• Technique!used!to!treat!life!threatining!arrhytmias:!!
o V.!Fib!
o Pulseless!v.tach!
• Aim!is!to!shock!them!back!to!sinusrhythm!
• Process!
o When!defibrillator!is!charged!
o High!voltage!field!envelopes!heart!
o Which!depolarizes!heart!and!allows!a!normal!sinus!rhythm!to!be!
established!by!bodus!natural!pacemaker,!in!SA!node!of!heart!
• Resistance!by!gel!pad!placed!on!thorax!
!
Types(
• Conventional(defibrillators(
o Energy!is!discharged!via!paddles!placed!on!chest!wall!
• Automated(external(defibrillators(
o Automatic(diagnosis!of!treatable!rhythms(
o Recognize!vfib!&!vtac!automatically!and!give!shock!is!needed(
(
Location:(
• R!–!just!below!clavicle(
• L!–!10cm!under!axilla(
(
Cardioversion:%
• When!used?!
o Afib!
o Aflutter!
o Sustained!vtach!
o Junctional!tachycardia!
!
!
• Method!
o When!the!rhythm!is!pulseless!VT,!the!shock!is!best!delivered!
coordinated!with!the!‘r’!wave,!that!is!synchronized.!
o When!patients!had!definitive!QRS!comples,!deliver!shock!with!
down!stroke!of!QRD!complex!
• A.fib/flutter(
o If!afib/flutter!is!for!>!48h!
o Then!anticoagulate!patient!for!3!weeks!before!elective!
cardioversion!to!decrease!risk!of!embolism!
• Chemical(cardioversion(
o Venous!antiarrhythmics!used!to!return!heart!to!sinusrhythm!
• Sedation:!
o Almost!always!performed!under!induction!of!sedation!
Cardiostimulation%
• The!output!generated!by!direct!compression!of!the!heart!is!two!to!three!
times!greater!than!closed!chest!compression!and!coronary!and!cerebral!
perfusion!pressures!are!significantly!higher.!!
• The!procedure!is!performed!via!a!left!thoracotomy!through!the!fourth!or!
fifth!intercostal!space.!It!is!of!most!use!following!penetrating!trauma,!but!
unlikely!to!benefit!those!in!which!cardiac!arrest!follows!blunt!trauma.!
• !It!can!also!be!considered!in!those!patients!in!whom!closed!chest!
compression!is!less!effective,!namely!severe!emphysema,!a!rigid!chest!
wall,!severe!valvular!heart!disease!or!recent!sternotomy.!!
10. First%Aid%in%near;drowning%
• Death!by!drowning!occurs!when!air!cannot!get!into!the!lungs,!usually!
because!of!a!small!amount!of!water!has!entered!the!lungs.!This!may!also!
cause!spasm!of!the!throat!
!
Phases:!
• Aquatic!rescue!
• BLS!
• ALS!
• Post!rescucitation!care!!
!
Aquatic(rescue:(
• Aware!of!person!safety!and!minimize!danger!to!yourself!and!victim!at!all!
times!
• Try!!attempt!to!save!patients!without!entry!into!water!
o Stick!
o Buoyant!
o Rope!
• If!entry!into!water!it!is!essential!to!take!floatation!device!
• Cervical!spine!injury!is!very!low!!
!
!
!
BLS(
• Rescue(breathing(
o AIM:!alleviate!hypoxemia!
o Rescue!breaths!x!5!–!out!of!water!+!shallow!water!
" Can!give!in!shallow!water!provided!safety!of!victim!not!
compromised!
" Close!nose!for!mouth:mouth!
" Mouth:nose!ventilation!
o Deep!water!
" Open!airway!and!if!no!spontaneous!breathing!then!in!water!
rescue!if!trained.!
" 10:15!x!breaths!over!1!min!
" if!normal!breathing!doesnt!start,!continue!rescue!breaths!
while!towing!if!<5mins!from!land!
" >5!mins!from!land!,!redo!another!1!min!rescue!breaths!
!
• Chest(compression(
o On!firm!surface!
o Unresponsive!!!!30!compression!!!2!ventilation!
!
• AED!
o Dry!victims!chest!
o Attach!pads!
o And!follow!
!
• Regurgiattion:!
o Regurgitation!of!stomach!contents.!Swallowed/inhaled!water!is!
common!
o If!prevents!ventilation!then!turn!on!side!and!remove!regurgitated!
material!
!
ALS(
• Airway(+(breathing(
o High!flow!oxygen!via!bag(
o Use!pulse!oxymetry!and!ABG!to!titrate!inspired!oxygen(
o Consider!tracheal!intubation!and!controlled!ventilation!for!those!
that!fail!above!and!have!decreased!consciousness.(
o Intubation(–(success(
" Titrate!o2!to!achieve!SaO2!94:96%!
" PEEP!
• Circulation(and(defibrillation:(
o Differentiate!between!WCA!from!resp.!Arrest!by!pulse!:>!pulse!
abscent!in!CA!
o ECG!
o End:tibial!Co2!
o ECHO!
!
!
!
o CA!
" ALS!protocol!
" Core!<30!degree!!!limit!defib!to!3!attempts!and!withhold!
iv!drugs!until!T!>30!degree!
• Post(rescucitation(care(
o Lung(injury(
" Increased!risk!of!developing!ARDS(
" Protective!ventilation!can!help!increase!survival!in!patients!
w!/!ARDS(
" Pneumonia!!!prophylactic!ATB(
o Hypothermia(
" Icy!water(
" <5!degree(
" rapidly!developed!hypothermia!&!provide!some!protection!
against!hypoxia(
o CNS(
" Barbiturate(
" ICP!monitoring(
" Steroids!(
• !!may!improve!neurologic!outcome(
(
11. First%Aid%in%Electrical%Current%Injury%
Introduction:!
• Infrequent!
• High!mobidity!and!mortality!
!
Cause:!!
• Adults!!!workplace!with!high!voltage!
• Kids!!!home!with!low!voltage!
• Lightening!!=!rare!
!
Mechanism:!
• Direct!effect!of!current!on!vascular!smooth!muscle!and!cell!membranes!
!
Factors:!
• Currrent!type!!!!alternating!/!direct!
• Voltage!
• Resistance!to!current!flow!!!electricity!follows!least!resistance!=!limbs!
• Pathway!of!current!
• Area!and!duration!of!current!
!
Death!
• Resp!arrest!!!due!to!paralysis!of!central!resp.!center!or!resp!muscles!
• CA!
!
!
Rescue:!
• Power!source!switched!off!
• Dont!approach!patients!till!safe!
!
Rescucitation!
• Start!BLS!and!ALS!without!delay!
o Airway!
" Difficult!if!burns!around!face!and!neck!
" Early!tracheal!intubation!as!edema!may!develop!and!
obstruct!
" Immobilize!spine!!
o Breathing!
" Muscle!paralysis!occurs!after!high!voltage!!!ventilatory!
support!
o Circulation!
o Defibrillation:!
" V.fib!!!most!common!initial!arrhytmia!after!high!voltage,!
may!persist!for!7h!!!shock!
" High!voltage!!!asystole!common!
o Environment:!
" Remove!clothing!and!shoes!to!prevent!further!thermal!
injury!
" Fluid!therapy!!
12. First%Aid%in%Burn%Trauma%
Stop!burning!process!
• Remove!heat!source!
• Flames!
o Water!or!blanket!–!roll!victim!on!ground!
• Clothing!!!remove!ASAP!
• Tar!burns!!!cool!with!water!
• Electrical!burns!!!disconnect!from!electricity!source!
!
Cool!the!burning!
• Active!coolinng!prevents!burn!progression!
• Effective!within!20mins!
• Running!water!
o 15!degrees!
o remove!agents!
o decrease!pain!and!edema!
o dont!use!ice!water!!!vasoconstriction!can!cause!burn!progression!
!
Analgesia!
• exposed!nerve!endings!!!pain!
• cooling!and!covering!!!pain!
• opiods!usually!to!control!pain,!but!after!first!aid!!!NSAID!
!
Covering!the!burn!
• dressings!should!cover!burn!and!keep!patient!warm!
• polyvinylchloride!
o sterile!!
o non:adherent!
o transparent!for!inspection!
o layer!around,!dont!wrap!
!
ABC(of(burns(
• Major!burns!
o >25%!of!TSB!area,!but!any!injury!>10%!should!be!treated.!
!
History(taking(
• Type!of!injury!!
• Depth!of!injury!
• Probability!of!other!injury!
!
Must!be!obtained!in!admission!as!swelling!may!develop!around!the!airway!in!hrs!
after!injury!and!require!intubation,!making!impossible!for!verbal!communication!
!
Airway:(
• Is!airway!compromised!or!increased!risk!of!?!
• Protect!C:spine!ubless!definately!not!injured!
• Inhalation!of!gases!can!injure!vocal!cord!
• A!patent!airway!may!ooclude!afyer!admission!because!of!edematous!
changes!after!hrs!especially!after!fluid!rescuitation!
• Intubation!!!concern!about!patency!of!airway!
(
Breathing:!
• All!patients!should!receive!100%!O2!via!humidified!face!mask!
• Breathing!problems!!!below!vocal!cords!
• Ex!of!burns!affect!respiration:! !
o !Mechanical!restriction!of!breathing!
" deep!dermal!or!full!thickness!
" prevent!ventilation!
o Blast!injury!
" In!explosions!
" Can!cause!tension!pneumothorax!
" Lun!and!alveolar!trauma!!!ARDS!
o Smoke!inhalation!
" Products!
" Irritants!to!lung!causing!
• Bronchospasm!
• Inflammation!!
• Bronchorrhea!
• Ciliary!action!improvement!
" Inflammated!exudate!is!not!cleared!!!atelectasis!or!
pneumonia!
" Tx!–!nebulizers,!positive!PV!w/!PEEP!
o Carboxyhemoglobin!
" CO!binds!to!!
• O2!x!40!affinity!
• Cytochrome!oxide!pathway!
" Result!hypoxia!
" Pulse!ox!cant!differentiate!between!oxyhemoglobin!and!
carboxyhempglobin!&!give!normal!results!
" BGA!!!metabolic!acidosis,!increased!carboxyhemoglobin,!
doesnt!show!hypoxia!
" Tx!–!100%!o2!which!displaces!CO!from!bound!proteins!x6!
faster!than!atmosphere!pressure!
o Neurologic!diasbility!
" All!patients!should!be!accessed!with!GCS!
" Maybe!confused!because!of!
• Hypoxia!
• Hypovolemia!
o Exposure!with!environmental!control!
" Entire!patient!examined!
• Including!back!to!get!accurate!estimate!of!burns!
" Children!become!hypothermic!leading!to!hypoperfuxion!
and!deepening!of!burn!wounds!
!
13. First%Aid%in%Hyper;%Hypothermia%
Definition:!
• Core!body!temp!<35 °!
!
Classification:!
• Mild!35:32 °!
• Mod!32:28 °!
• Severe!<!28 °!
!
Stage!1!–!conscious!and!shivering!
Stage!2!–!impaired!conscious!w/o!shivering!
Stage!3!–!unconscious!!
Stage!4!–!no!breathing!!
Stage!5!!:!death!due!to!irreversible!hypothermia!
!
Resucitation:!
• Cooling!of!body!
o Decreased!O2!taken!up!by!6%!per!1° decrease!in!core!temp!
• Diagnosing!death!in!hypothermic!patient!
o Be!careful!
o Stage!5!alone!is!unreliable!for!confirming!death!
• Same!BLS!and!ALS!
o Same!algorythm!
o Same!30:2!
o Chesy!wall!maybe!stiff!and!makes!ventilation!&!chest!compression!
harder.!
!
1. Airway!
a. Clear!airway!
b. No!spontaneous!brathing!
i. Ventilation!with!high!concentration!of!O2!
ii. Intubation!in!ALS!
2. Breathing:!
3. Circulation!
a. Palpate!artery!–!check!for!1!min!before!concluding!death!
b. Look!at!ECG!
c. ECHO!
d. US!with!doppler!–!used!to!see!if!there!is!CO!or!peripheral!blood!
flow!
e. Any!doupt!–!start!CPR!
4. Drugs!
a. Cold!temps!=!decreased!metabolism!of!drug!and!increased!amount!
in!plasma!!!can!be!toxic!
b. Dont!give!drugs!until!temp!is!over!30 °!
i. When!achieved,!intervals!between!giving!drugs!should!be!
doubled!than!normothermia!
ii. As!normothermia!approaches!–!give!standard!protocols!
!
Arrhythmia!
• Sinus!bradycardia!
• Afib!
• Vfib!
• Asystole!
!
• As!core!temp!increases,!all!arrhythmia!(except!vfib)!normally!revert!to!
sinus!rhythm!
!
Rewarming!
1. Remove!from!cold!
2. Prevent!further!heat!loss!
3. Rapid!transfer!to!hospital!
!
Stage(1( Stage(2(
• Mobilize!as!exercise!warms! • Immobilize!patient!
them!up!rapidly! • Oxygenate!
• Remove!clothes! • Monitor!core!temp!and!ECG!
! • Body!dried!and!insulated!
! • Wet!clothes!cut!off!
! (
! (
! (
! (
Stage(3( • Protect!airway!because!of!
• Imobilize!and!kept!horizontal! unconsciousness!
to!prevent!after!drop!or!
cardiac/vascular!collapse!
!
Rewarm:!
• Full!body!insulation!–!out!of!hospital!
o Wool!blankets!
o Aluminium!foil!
o Chemical!heatpacks!to!abdomen!and!trunk!
• In!hospital! !
o Forced!air!rewarming!
o Warmed!iv!fluids!(42 °)!
!
In(hospital:(
• Continous!hemodynamic!monitoring!
• Lots!of!fluid!
o Because!of!vasodilation:!
!
Hyperthermia(
Definition:(
• Bodys!thermoregulator!fails!and!core!temp!rises(
• Can!be!due!to!environmental!or!endogenous!..!production(
(
Heat(stroke(L(!a!systemic!inflamatory!response!w/!core!T!°>!40,6 °
• Ex.!of!environmental!source!
• 2!types!
o Classic!!!high!environment!T °!
o Exertional!!strenous!physical!excertion!
!
Clinical(manifestation:(
• Core!T(°(>(46(°!
• Hot,!dry!skin!
• Early!CF!–!fatique,!faint,!flushed,!V+D!
• Arrhythmias!
• Decreased!BP!
!
Management:(
• ABCDE!+!cool!patient!
• Core!T ° aim!<39 °!
• Cooling!methods!
o !Drinking!cool!fluids!
o Fan!!
o Undress!!
o Spray!water!on!patient!
o Ice!packs!where!large!superficial!blood!veins!–!axilla,!groin,!neck!
o Cold!iv!
!
Malignant(hypethermia(
• Rare!
• After!halthogen!anaesthetics!&!depolarising!relaxing!agents!
!
Clinical(manifestation:(
• Respiratory!acidosis!!
• Heart!involvement!(unexplained!sinus!tachycardia,!ventricular!
tachycardia!or!ventricular!fibrillation)!
• Metabolic!acidosis!
• Muscle!rigidity!(generalized!rigidity!including!severe!masseter!muscle!
rigidity)!
• Muscle!breakdown!!
• Temperature!increase!(rapidly!increasing!temperature,!T!>38.8!°C)!
• Other!(rapid!reversal!of!MH!signs!with!dantrolene,!elevated!resting!serum!
CK!levels)!
• Family!history!(autosomal!dominant!pattern)!
(
Treatment:!
• Stop!trigger!agents!immediately!
• Give!O2!
• Correct!acidosis!and!electrolytes!disturbances!
• Start!cooling!!
• Dantrolene!
14. Cardiac%Arrest%in%Pregnancy%
General!
• Physiologic!changes!
o Increased!CO!
o Increased!circulatory!volume!
o Increased!min!ventilation!
o Increased!O2!consumption!
• Effect!
o Gravid!uterus!
" Compress!iliac!and!abdominal!vessels!when!sitting!and!
decreased!CO!and!decreased!BP!
Etiology:!
• Heart!dx!
• PE!
• HTN!in!pregnancy!
• Hemorrhage!
• Amniotic!fluid!embolism!
• Ectopic!pregnancy!
!
Treatment:!
• ABCDE(approach(
• Compression!of!IVC!cause(
o Put!in!L!lateral!!position!or!manually!displace!uterus(
o High!flow!O2!guided!by!pulse!oxymetry(
o If!BP!low!or!hypovolemia!give!fluid(
o Get!expert!help!early(
• Cardiac(arrest(
o Help(immediatley(
" For!effective!resucitation!of!mum!&!fetus(
" Need!expert!obstetrician!and!neonatologist(
o CPR(
" <20!weeks!=!follow!algorythm(
" >20weeks(
• uterus!presses!down!against!IVC!&!aorta!and!
effecting!VR,!CO!and!uterine!perfusion(
• manually!displace!uterus!to!left!to!remove!
compression!!!add!lateral!tilt!!!now!compression!
and!ER!C!section(
• Fetus!delivered!of!initial!rescucitation!fails(
o Intubation(
" Early!intubation!decrease!the!risk!od!aspiration!of!gastric!
contents(
o Defibrillation(
" Standard!energy(
o 5Hs(&(5Ts(
" Hemorrhage!!!!hypovolemia(
• Ectopic!pregnancy(
• Placental!abruption(
• Placent!praevia(
• Uterine!rupture(
" Stop!bleeding(
" Fluid!rescucitation! (
• Rapid!transfusion(
• Coagulopathy(
• Oxytocin!–!to!correct!uterine!tone(
• Compression!sutures(
• Interuterine!balloon!device(
• Clamp/compress(
• Hysterectomy!(
(
" Drugs(!(toxic(
• In!ecclampsia!with!MgSO4!!!tx:!calcium(
• Anaesthesia!causing!SNS!blockade(
" CVS!dx!!!thrombolism(
• Ex.(MI,!PCI,!thrombolysis(
• Amniotic!fluid!embolism!(amniotic!membrane!
rupture)(
(
Peri(mortem(CLsection(
• Rescucitation!fails,!delivary!of!child!may!increase!chance!of!survival!for!
mum!and!child(
• Depends!on!gestational!age(
o <20!weeks(
" don’t!think!of!c:section(
" Because!of!gravid!uterus!unlikely!cause!compression(
o 20:23!weeks(
" Do!C:section!for!survival!of!mum!not!fetus!because!unlikely!
to!survive!at!this!age.(
o >24!weeks!(
" help!to!save!both(
• Delivery(allows(
o Relieves!caval!compression(
o Access!to!abdomen!so!aortic!compression!is!available(
o Internal!cardiac!massage(
(
15. First%Aid%in%Anaphylaxis%
Definition:!
• Anaphylaxis!is!a!severe!allergic!reaction!and!potentially!life!threatening.!It!
should!always!be!treated!as!a!medical!emergency,!requiring!immediate!
treatment.!Most!cases!of!anaphylaxis!occur!after!a!person!with!a!severe!
allergy!is!exposed!to!the!allergen!they!are!allergic!to!(usually!a!food,!
insect!or!medication)!
• Generalized!or!systemic!hypersensitivity!reaction!
(
Etiology:(
• Broad!range!of!triggers(
o Food!(
" Nuts,!fruit,!etc(
o Drugs(
" Muscle!relaxants,!ATB,!anaesthetics,!NSAID(
o Venom!(
Recognition(
• Develops!sudden!illness!after!exposed!to!allergen!!!ususllay!in!mins!
• With!rapidly!progressing!skin!changes!!
o Angioedema!
o Redness!
o Hives!
o Itching!
• With!circulatory!problems!!!decrease!BP!
!
Timing:!
• IV!triggers!!!rapid!onset!
• Stings!more!rapid!than!ingested!trigger!
!
Differential(diagnosis:(
• Life!threatning!asthma!
• Low!BP!with!petechia!or!rash!!!septic!shock!
!
Airway!swelling!:!
Phaaryngeal/laryngeal!
edema!
Difvicult!breathing!
Airway!
Difvicult!swallowing!
Stridor!:!throat!feels!closing!
up!
SOB!:!cyanosis!
Breathing! High!RR!:!Resp.!arrest!
Wheeze!
Signs!of!shock!:!Pale/clamy!
Anaphylactic!Shock?!
High!HR!
Circulation!
Low!BP!!
Hypoxia!due!to!confusion!::
>!low!CBP!
Confusion!!
Because!of!low!brain!
Disability! perfusion!causes!! Agitation!
Skull!or!mucosal!changes! Loss!of!consciousness!
Erythema!
Exposure!
Urticaria!
Angioedema!
Help! CALL!for!help!
ADRENALINE!
Drugs!
1. Adrenaline(
a. Low!doses!(
i. Alpha!agonist!!!vasoconstriction<!Increase!SVR>!increae!
BP(
ii. Beta!agonist(
1. Bronchodilation(
2. Increase!FOC!
3. (:)!histamine!&!leukotriene!release!! !
b. Given!!
i. i.m!!!auto!injectors,!docs!
ii. i.v!!!anaesthesists,!ER!dr.,!ICU!dr!
c. Dose:!
i. i.m:!0,5mg!!!further!dose!given!at!about!5!min!intervals!
according!to!response!
1. Given!anterolateral!middle!1/3!of!thigh!
2. Autoinjectors!given!to!patients!
ii. i.v:!50mcg!!!titrate!iv!50mcg!(0,05mg)!
2. Anti(histamine((
a. Anti!H:1!blockers!
b. Dont!use!alone!
c. Chlorphenamine!10mg!im!or!iv!slowly!
3. Corticosteroids!
a. Can!help!shorten!reactions!
b. Hydrocortisone!200mg!im!or!iv!slowly!
4. Bronchodilators!
a. Asthma!like!features!
i. Salbutamol!)inhaled!or!iv)!
ii. Ipratropium!(inhalator)!
iii. Aminophylline!(iv)!
Diagnosis:!
• Confirm!diagnosis!of!anaphylaxis!with!mast!cell!tryptase!
o Mast!cell!degranualtion!=!high!tryptase!concentration!
(
Skills(and(equipment:(
• Establish!airway(
• High!flow!O2(
• Iv!challenge(
• Monitor!–!pulse!Ox,!ECG!and!BP(
(
Fluid(challenge(
• Adult:!500:1000mL!
• Child:!crystalloid!20mL/kg!
• Dont!do!this!if!you!think!fluid!is!the!trigger!
!
16. Acute%Poisoning%;%First%Aid,%Elimination%methods,%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Support%
First(aid(
(
• Airway(!(early!intubation!decrease!risk!of!aspiration!
• Breathing!
• Circulation(
• Disbility!!
o Alert!
o Voice!
o Pain!
o Unresponsive!
" GCS?!
" Glucose?! !
• Exposure!
o History!
" What!
" How!much!
" When!
" What!else!?!Alcohol?!
" Why!?!(accident,!suicide)!
o Physical!examination!
" Look!!!track!marks,!pupil!size!
" Feel!!!T!
" Smell!!!alcohol! !
o Ix!
" Electrolytes!
" T!
!
Recovery(position(
• Easy!to!keep!airway!open!in!case!of!regurgitation!
!
General(management:(
1. Decrease!drug!absorption!
a. Gastric!lavage!
i. Aim:!protect!airway!
ii. May!push!drug!through!pylorus!into!small!bowel!
b. Absorbants!
i. Activated!charcoal!
ii. Absorbs!most!drugs!
iii. Within!1h!!
!
Specific(management:(
1. Increased!drug!elimination!
a. Aspirin!–!toxicity!because!of!ABB!–!RAL!&!MAC!
i. Urine!alkalization!
1. With!iv!Na:bicarbonate!
2. Hemodialysis!
a. Removes!drugs!or!metabolites!that!are!
watersoluble!&!low!volume!of!distribution!&!
low!plasma!protein!binding!(high!plasma!
protein!bindind!then!use!HEMOPERFUSION)!
2. Antidotes!
a. Benxodiazepine!OD!
i. CF:!loss!of!consciousness,!resp!depression,!hypotension!
ii. Tx!–!Flumazenil!
b. Opioids!
i. CF:!Resp!depression!!!resp!arrest,!pinpoint!pupils,!coma!
ii. Tx!–!Naloxone!
1. 0,4mg!
2. high!affinity!opiod!
3. effect!2:4h!
4. im/iv!
5. ADRE!–!pulmonary!edema!
c. Tricyclic!antidepressant!!!effects!worse!with!alcohol!
i. Amitriptyline,!deslpramine!
ii. CF:!low!BP,!seizures,!coma,!confusion,!delirium,!arrhythmias!
(QT!–!wide!interval,wide!QRS),!anticholinergic!effects!
iii. Tx!–!Na:Bicarbonate!corresct!acidosis,!hypoxia!!O2!
d. Cocaine!!
i. SNS!overstimulation! !
1. Agitation!
2. Tachucardia!
3. HTN!crisis!
4. Hyperthermia!
e. Paracetamol!
i. Toxic!dose!>7g/adult!(>14!tbl)!
ii. MOA!
1. Toxic!metabolite,!M:acetyl:bezoquinamine!builds!up!and!binds!irreversibly!
to!hepatic!cell!?!hepatonecrosis!
iii. Tx!–!N:acetylcysteine!
!
!
!
!
!
!
!
!
!
!
!
!
17. Specificity%of%In;hospital%Cardiac%Arrest,%Rapid%
Response%Teams%
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(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
18. Pre;hospital%&%In;hospital%Transport%of%critically%ill%
!
19. Ethical%&%Legal%Issues%of%CPR%&%Intensive%Care%
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20. Emergency%Services%–%Organisation,%Personal%&%
Technical%Equipment%
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Part%B%–%Anaesthesiology%
1. Pre;anaesthetic%Evaluation%&%Preparation%before%
Anaesthesia%
(
1.
History!
2.
Physical!exam!
3.
Labor!tests!
4.
Patient!instructions!
5.
Recommendation!next!preoperative!preparing!
6.
ASA!classification!
7.
Premedication!
8.
Type!of!anesthesia!
9.
Drugs!&!equipment!for!anesthesia !
!
The(preoperative(check(
• Prior!to!administration!of!the!premedication!the!medical!staff!needs!to!
check!if!the!consent!form!for!surgery!is!signed!and!that!the!site!of!
operation!has!been!marked!on!the!patient’s!skin(
• Any!dentures!should!be!removed!and!an!identification!tag!should!be!
attached!to!the!patient’s!wrist(
• Before!planned!surgery,!patient!will!have!been!fasted!overnight!→!easy!
induction!of!anesthesia!without!regurgitation(
• In!emergency!surgery!the!fasting!period!may!be!reduced!and!sometimes!
stomach!content!has!to!be!emptied(
• When!loss!of!more!than!15%!of!blood!is!expected,!cross:matched!blood!
should!be!available(
(
Premedication(
• Premedication!should!aim!to:(
o Reduction!of!anxiety!and!pain.!
o Promotion!of!amnesia.!
o Reduction!of!secretions.!
o Reduction!of!volume!and!pH!of!gastric!contents!(to!avoid!
Mendelson!syndrome)!
o Reduction!of!postoperative!nausea!and!vomiting.!
o Enhancing!the!hypnotic!effects!of!general!anaesthesia.!
o Reduction!of!vagal!reflexes!to!intubation.!
o Specific!indications!:!eg,!prevention!of!infective!endocarditis.!
(
(
(
(
(
Drugs:(
(
• Anxiolytics!such!as!benzodiazepines!(diazepam,!midazolam)!are!used!to!
provide!preoperative!sedation!and!relieve!anxiety!→!they!also!induce!
anterograde!amnesia(
• AntiLemetic:(Ranitidine!–!decrease!risk!of!regurgitation,!metoclopramide!
–!increase!gastric!emptying!and!post!surgery!induced!nausea(
• Opioid(analgesics!(morphine!and!fentanyl)!are!used!to!relieve!pain!and!
can!be!administered!together!with!neuroleptics!(phenothiazine)!and!
antihistaminics!to!increase!analgesic!action!and!provide!further!sedation!
• Anticholinergics!(atropine,!scopolamine,!hyoscine)!are!used!to!reduce!
bronchial!and!salivary!secretions!and!to!prevent!bradycardia!and!
hypotension!
• Amnesia(Lorazepam!and!Midazolam)(L(Especially!useful!in!the!young!or!
those!who!have!repeated!general!anaesthetics.!May!allow!a!lighter!depth!
of!anaesthesia!by!reducing!the!risk!of!awareness!during!surgery.!!
• Neuroleptics!(phenothiazines)!are!used!to!sedate!and!have!also!
antiemetic!properties!
• Special(medications:!some!patients!may!require!special!medication!
because!of!an!underlying!pathology!→!bronchodilators!(asthmatics),!
corticosteroids!(steroid:dependent!patients),!ATBs!(valvular!disease)!
• Premedication!should!be!administered!at!least!1!hour!before!surgery!
(
The(preoperative(visit(
• During!the!preoperative!visit,!the!anesthetist!should!discuss!all!the!events!
concerning!anesthesia,!premedication,!timing!of!operation!and!
postoperative!discomfort!→!anxiety!should!be!reassured(
(
General(assessment(
• An!objective!measure!of!patient’s!physical!status!is!the!ASA(physical(
status(index!(American!Society!of!Anesthesiologists)(
o Class!I!–!healthy!patient(
o Class!II!–!patient!with!mild!to!moderate!systemic!disease(
o Class!III!–!patient!with!severe!systemic!disease!(not!disabling)(
o Class!IV!–!patient!with!disabling!systemic!disease!that!threatens!
his/her!life(
o Class!V!–!patient!that!will!not!survive!>24!hours!with/without!the!
operation(
o Class!VI!–(organ!donor(
o E!–(emergency!procedures(
(
(
(
• Factors(causeing(difficult(intubation(
o Overweight!(BMI>26)(
o Bearded(
o Elderly!>55(
o Snorers!(
o Without!full!set!of!teeth(
(
Cardiovascular(assessment(
• Deep!anesthesia!reduces!cardiac!output!and!causes!vasodilation!→!
decreased!BP!and!decreased!perfusion!of!vital!organs(
• Light!anesthesia!produces!tachycardia!and!hypertension!→!reduced!
coronary!perfusion!during!diastole(
• Patients!with!risk!factors!such!as!smoking,!DM,!hypertension,!
hyperlipidemia,!history!of!MI!may!need!preoperative!ECG!evaluation,!
chest!X:ray,!echocardiography(
• If!MI!has!occurred,!surgery!should!be!delayed!for!6!months!if!possible(
• Goldman!has!constructed!a!cardiac!scoring!system!for!patients!over!40!
years!with!a!maximal!score!of!46!points!→!Goldman!recommended!that!in!
risk!patients!(≥26!points)!only!life:saving!procedures!should!be!
performed(
• Atrial!fibrillation!will!require!anticoagulation(
• ATB!prophylaxis!is!used!to!prevent!endocarditis!in!patients!with!valvular!
disease(
(
Respiratory(assessment(
• 2!points!need!special!consideration!in!patients!with!chronic!lung!disease!
→!sputum!production!and!dyspnea!(
• Excessive!or!purulent!sputum!is!indication!for!surgical!postponement(
• Grade!IV!dyspnea!(dyspnea!at!rest)!is!not!a!contraindicator!for!surgery!
but!needs!a!good!approach!to!the!patient!(preoperative!physiotherapy,!
postoperative!artificial!ventilation,!etc.)(
• Pulmonary!function!tests!should!be!performed!→!VC!<1.5!l!and/or!FEV1!
<1!l!and/or!PEFR!<!200!l/min!should!concern!the!anesthetist(
• Arterial!blood!gases!are!the!cornerstone!of!respiratory!assessment!→!
PaO2!should!be!80:100!mmHg!while!PaCO2!should!be!35:45!mmHg!(
• PaO2!depends!on!the!FiO2!(PaO2!in!kPa!is!10!kPa!lower!than!the!FiO2)!(
• PaCO2!predicts!postoperative!respiratory!problems!→!if!there!is!renal!
compensation!it!indicates!a!chronic!problem!and!is!less!dangerous(
(
(
(
(
Renal(assessment(
• Impaired!renal!function!may!present!with!oliguria!(<500!ml/day)!or!as!
increased!urea,!creatinine!or!potassium!in!blood(
• In!the!case!of!renal!failure,!fluid!over/underload!should!be!corrected!and!
hyper/hypotension!should!be!reversed(
• Drug!therapy!should!be!used!with!caution!→!avoid!renal!elimination(
• Hyperkalemia!>6!mmol/l!will!contraindicate!all!surgery!except!the!most!
important!ones(
• In!renal!failure!always!assess!blood!count,!urea!and!electrolytes!as!well!as!
acid:base!balance(
(
Hepatic(assessment(
• Hepatic!function!should!be!assessed!with!!hepatic!scoring!systems!(Child!
and!Pugh)!→!assess!serum!bilirubin,!serum!albumin,!PT!and!
encephalopathy(
• Child!class!C!or!Pugh!>10!points!need!special!attention!→!lower!drug!
doses!and!correction!of!coagulopathy!(i.m!administration!of!Vit.K)(
(
Assessment(of(special(conditions(
• Obstetric!patients(
• Aorto:caval!compression!should!be!avoided!→!appropriate!lateral!tilt(
• There!is!increased!risk!for!gastric!regurgitation!and!aspiration(
• There!is!increased!plasma!volume!and!increased!hemoglobin!→!more!O2!
is!required(
• Head!injury(
• In!head!injured!patients!the!cerebral!blood!flow!depends!on!the!
difference!between!MAP!and!ICP!→!CPP!=!MAP!–!ICP(
• CPP!<!60!mmHg!is!critical!and!ischemia!with!hypoxia!develops(
• Muscle!weakness!
• Careful!assessment!of!coughing!and!swallowing!reflexes!to!make!sure!that!
aspiration!does!not!occur!
• Patients!receiving!medication!
• β:blockers!may!cause!severe!bradycardia!
• Long:term!use!of!steroid!therapy!may!cause!adrenal!crisis!if!not!
supplemented!with!steroids!during!surgery!
• Severe!diabetics!may!require!intraoperative!infusion!of!insulin!and!
glucose!
!
!
!
!
2. Premedication.%Risk%of%Anaesthesia,%Anaesthetic%Chart%
Premedication:!!
( (
Aims:(( Routes:!!
• sedation!! • per!oral!
• analgesia! • IM!!
• (anticholinergic)! • IV!!
• (!reduction!of!anaesthetics)! • rectal!!
! • nasal!!
( • transdermal!!
(
!
Definition:!!
Premedication!is!administration!of!medication!before!anaesthesia.!To!prepare!
the!patient!for!anaesthesia!and!to!help!provide!optimal!conditions!for!surgery.!!
!
This(includes:(
• Reduction!of!anxiety!and!pain.!
• Promotion!of!amnesia.!
• Reduction!of!secretions.!
• Reduction!of!volume!and!pH!of!gastric!contents!(to!avoid!Mendelson!
syndrome)!
• Reduction!of!postoperative!nausea!and!vomiting.!
• Enhancing!the!hypnotic!effects!of!general!anaesthesia.!
• Reduction!of!vagal!reflexes!to!intubation.!
• Specific!indications!:!eg,!prevention!of!infective!endocarditis.!
!
Premedication(is(traditionally(given(intramuscularly.!Orall!route!is!preffered!
for!children!and!!those!with!bleeding!disorders.!And!is!usually!given!1:3!hours!
pre:operatively.!!
!
We!are!using!intravenous!and!inhalational!anaesthetic!agents,!which!have!fever!
side:effects!and!a!faster!onset!of!action.!!
The!choice!of!drug!used!for!premedication!depends!on!the!procedure,!patient!
and!anaesthetic!technique.!Some!patients!prefer!not!to!have!premedication!and!
potential!benefits!may!be!outweighed!by!potential!problems.!
!
• Anxiety(
o Careful!discussion!of!the!patient's!concerns!is!essential,!including!
at!the!pre:operative!assessment.!
o Benzodiazepines!are!ideal!agents!to!reduce!anxiety.!They!provide!
anterograde!amnesia!and!light!sedation.!In!children,!oral!
antihistamines!may!be!used!for!sedation.!
!
!
!
!
!
• Amnesia(
o Especially!useful!in!the!young!or!those!who!have!repeated!general!
anaesthetics.!May!allow!a!lighter!depth!of!anaesthesia!by!reducing!
the!risk!of!awareness!during!surgery.!The!most!effective!agents!are!
Lorazepam!and!Midazolam.!
!
• Analgesia!
o Opioids,!paracetamol!and!NSAIDS!reduce!the!required!dose!of!
anaesthetic!agent!and!improve!patient!comfort!in!the!immediate!
postoperative!period.!Caution!must!be!taken!when!considering!the!
use!of!cyclo:oxygenase:2!(COX2)!inhibitors,!because!of!their!
association!with!increased!risk!of!myocardial!infarction!and!
stroke.!!
o Opioids!are!the!drugs(of(choice!in!acute(pain.!They!also!cause!
variable!sedation!and!cardiorespiratory!depression.!All!opioids!
cause!nausea!and!vomiting!and!this!may!outweigh!any!beneficial!
effects.!Opioids!may!also!precipitate!bronchospasm!or!anaphylaxis.!
!
• Antivagal(effects(
o Response!to!surgery!often!includes!vagally!mediated!bradycardia.!
Intramuscular!atropine!or!hyoscine!is!therefore!often!prescribed!
together!with!an!opioid.!!
o Hyoscine!is!the!most!potent!agent!available,!with!the!added!
advantage!of!amnesia!and!sedation.!However,!it!can!cause!
significant!perioperative!confusion!in!elderly!patients.!
!
• Antiemetics!are!used!either!to!reduce!the!emetic!effects!of!anaesthetic!
agents!(antihistamines,!butyrophenones,!hyoscine)!or!to!enhance!gastric!
emptying!(metoclopramide).!Those!with!a!risk!of!regurgitation!of!gastric!
contents!or!undergoing!procedures!with!a!high!incidence!of!nausea!and!
vomiting!(eg,!laparoscopy)!should!receive!agents!to!reduce!gastric!acidity.!
Can!use!H2:receptor!antagonist!or!proton!pump!inhibitors!several!hours!
pre:operatively.!!
!
!
Risk/complications(of(anaesthesia((
• Pain!!
• nausea!and!vomiting!!
• damage!to!the!teeth!(due!to!endotracheal!intubation!for!sedation)!
• sore!throat!and!larryngeal!damage!!
• anaphylaxis!to!anaesthetics!agents!!
• cardiovascular!collapse!!
• respiratory!depression!!
• aspiration!pneumonia!
• hypothermia!!
• hypoxic!brain!damage!!
• nerve!injury!!
• awareness!during!anaesthesia,!higher!in!obstretics!and!cardiac!patients!!
• embolism,!thrombosis,!venous!,!arterial!!
• backache,!headache!(epidural,!spinal!anesthetics)!
• idiosyncratic!realations!to!spesific!agents!!
• iatrogenic(!eg.!Pneumothorax!related!to!central!line!insertion)!
• death!
(
Charts:((
Used!to!consciously!check!if!all!things!are!in!order!berfore!administering!
anesthesia.!There!is!a!checklist!used!taken!from!pilots!who!leave!the!aircraft!to!
check!out!important!points!on!the!chart!to!make!sure!everything!is!done!in!
order.!!
3. Patient%Monitoring%During%Anaesthesia%
(
Observation(&(evaluation(
• Clinical!examination!of!patient!by!visual,!palpation,!auscultation,!
percussion!
• Laboratory!(x:ray,!ultrasound)!
• Central!venous!pressure,!invasive!blood!pressure,!capnography,!
respiration,!pH,!MAC!(minimal!alveolar!concentration),!temperature,!fluid!
loss,!!
!
Capnography!is!the!most!important!graph!on!the!monitor!because!it!gives!us!
information!about!3!systems:!
1. Respiratory!system!
2. Metabolic!system!
3. Circulatory!system!
(
(
(
(
Cardiovascular(system(is(also(monitored(by:(
!
• ECG!(arrhythmias,!shape),!arterial!BP!syst.!diast,!mean,!non:invasive,!
invasive.!!
• Haemodynamics!monitoring!:!Swan!–!Ganz!catheter!is!used!to!monitor!
the!heart's!function!and!blood!flow!
• Arrhythmia!monitoring,!Holter,!telemetry,!pulse!palpation!!
!
Basic(monitoring(during(general(anesthesia(
During!general!anaesthesia!with(muscle(relaxation:!
• Pressure!!
• Rate!!
• Sweating!!
• Tears!
Monitoring(anesthesia(care:(
• NIBP!(á!5!min)!!!
• PR!!!
• SpO !!
2!
• Consciousness!level!!!
• Pulse!oximetry!!!
!
Others:!
• Sensors!
• Zeroing,!calibration!
• Alarms!(upper!and!lower!limits)!
• Trends!(time,!monitor!memory)!
• Artefacts!
(
Registration(and(evaluation(of(results:((
• Physician,!nurse,!!
• Critical!care!protocol!
• Anesthetic!chart!!
• Automatic!printing!in!alarm!time!!
The!patient!must!be!monitored!by!the!use!of:!
o Direct!clinical!monitoring!(looking,!feeling!and!listening)!
o Non:invasive!monitoring!equipment!
o Invasive!monitoring!methods!→!only!when!specifically!indicated!
(
(
(
(
Direct(clinical(monitoring(
• Looking!
• Chest!rise!and!fall!with!every!breath!→!movements!should!be!symmetrical!and!
should!be!synchronized!with!reservoir!bag!
• Tracheal!tug!(downward!movement!of!trachea!during!spontaneous!respiration)!
may!indicate!incomplete!recovery!from!myorelaxants!or!metabolic!acidosis!
• Movement!of!only!one!side!of!the!chest!may!indicate!deep!endotracheal!tube!
placement!into!one!bronchus!
• Cyanosis!is!a!sign!of!hypoxia!
• Inadequate!anesthesia!→patient!may!be!aware!(movements,!tears,!sweating)!
• Feeling!
• Chest!movements!by!hands!
• Pulses!to!assess!heart!rate!and!rhythm!→!can!also!indicate!hypovolemia!(a!fast!
and!thread!pulse)!or!hypervolemia!(full!pulse)!
• Listening!
• Confirmation!of!correct!placement!of!endotracheal!tube!by!auscultation!→!
confirmed!by!capnography!
• Place!the!stethoscope!to!the!left!hypochondrium!to!listen!if!air!enters!the!
stomach!→!esophageal!intubation!
!
NonLinvasive(monitoring!
• Includes!heart!rate,!BP,!pulse!oximetry!for!O2!saturation,!end:tidal!CO2!
concentration!(capnography),!ECG!as!well!as!airway!pressure,!tidal!volume!and!
minute!ventilation!and!body!temperature!(with!electrical!thermometer)!
• These!parameters!should!be!monitored!continuously!
• Assessment!of!extent!of!myorelaxation!can!be!performed!intermittently!by!
applying!electrical!stimulation!to!a!peripheral!motor!nerve!(common!site!is!
ulnar!nerve!at!the!wrist)(
(
Invasive(and(specialized(monitoring(
• These!include!direct!measurement!of!arterial!pressure,!central!venous!or!
pulmonary!artery!pressures,!urine!output!and!blood!loss!→!used!in!operations!of!
heart,!lungs!or!CNS!or!when!major!blood!loss!is!expected!
• Hematological!and!biochemical!analyses!(pH,!serum!electrolytes!and!blood!
coagulation!tests)!should!also!be!available!
• Additional!monitoring!for!special!circumstances,!e.g.!serum!glucose!
concentrations!during!operations!on!severe!diabetics!
!
!
!
!
!
4. Vascular(Accesses,(Indications,(Complication,(CVP(
measurement(
• During!anesthesia,!and!whenever!the!oral!route!is!unavailable,we!give!fluids!
parenterally.!
• As!long!as!we!need!to!give!only!physiologic!solutions,we!can!administer!them!
subcutaneously;!however,!the!uptake!and!distribution!of!such!a!depot!of!fluids!
takes!time.!Much!preferred!and!much!faster!is!the!intravenous!route.!Thus,!
vascular!access!assumes!a!critically!important!role!in!the!peri:operative!care!of!
patients.!The!vascular!bed!also!offers!an!ideal!route!for!many!drugs!that!need!to!
be!distributed!throughout!the!body.!
• Finally,!intravascular!pressures!provide!information!on!cardiovascular!function.!
Thus,!vascular!access!has!become!a!skill,!and!fluid!management!a!science,!
mastered!by!anesthesiologists.!
• Our!skin!is!a!wonderful!organ.!It!wraps!us!securely!into!an!elastic,!fairly!tough,!
self:repairing,!protective!envelope.!When!we!break!this!envelope,!we!expose!the!
patient!to!considerable!risks.!!
• In!addition!to!hazards!associated!with!the!actual!placement!of!needles!and!
catheters,!infectious!complications!contribute!significantly!to!morbidity!and!
mortality!of!the!hospitalized!patient,!particularly!in!the!intensive!care!unit!
where!we!frequently!employ!central!venous!access.!Infectious!complications!
include!local!site!infection,!catheter:related!bloodstream!
!
CVP!
• Central!venous!pressure!(CVP)!is!the!pressure!recorded!from!the!right!
atrium!or!superior!vena!cava!and!is!representative!of!the!filling!pressure!
of!the!right!side!of!the!heart!
• CVP!monitoring!in!the!critically!ill!is!established!practice!but!the!
traditional!belief!that!CVP!reflects!ventricular!preload!and!predicts!fluid!
responsiveness!has!been!challenged!by!a!large!body!of!evidence!
• CVP!represents!the!driving!force!for!filling!the!right!atrium!and!ventricle!
• normal!is!0:6mmHg!in!a!spontaneously!breathing!non:ventilated!patient!
!
Measurement:!
• recorded!at!the!end!of!expiration!
• measured!by!transducing!the!waveform!of!a!central!venous!line!
• electronic!transducer!placed!&!zeroed!at!the!level!of!the!RA!(the!
“phlebostatic!axis”!–!usually!the!4th!intercostal!space!in!the!mid:axillary!
line!is!used)!
(
Cause(of(increased(CVP(
• Right!ventricular!failure!
• Tricuspid!stenosis!or!regurgitation!
• Pericardial!effusion!or!constrictive!pericarditis!
• Superior!vena!caval!obstruction!
• Fluid!overload!
• Hyperdynamic!circulation!
• High!PEEP!settings(
5. Inhalational(Anaesthesia(
!
• Are!used!primarily!for!maintenance!of!anesthesia!after!administration!of!
an!i.v.!agent!
• They!do!not!act!on!specific!receptors!(volume!expansion!theory)!
• They!must!pass!from!alveolar!air!into!the!blood!and!then!into!the!CNS!
• This!depends!on!the!concentration!of!anesthetic!agent!(the!partial!
pressure),!the!solubility!(low!solubility!produces!rapid!induction!and!
recovery)!and!pulmonary!physiology!(ventilation,!blood!flow,!etc.)!as!well!
as!circulation!(cardiac!output)!
• Most!inhalation!agents!are!volatile!liquids!at!room!temperature!and!
require!to!be!vaporized!in!a!carrier!gas!
• The!only!gas!at!room!temperature!(anesthetic!gas)!is!N2O.!
(
Nitrous(Oxide((N2O)!
• Is!not!a!halogenated!hydrocarbon!
• It!has!strong!analgesic,!but!weak!anesthetic!properties.!
• It!cannot!produce!surgical!anesthesia!alone!and!has!to!be!combined!with!
more!potent!agents!(halothane,!isofluorane)!
• Does!not!depress!respiration!nor!cause!myorelaxation!
• Has!to!be!administered!with!at!least!21%(O2!→!has!small!MAC!(minimum!
alveolar!concentration)!
• Side(effects:!hematotoxicity!(pernicious!anemia)!
(
Halothane!
• It!is!a!halogenated!agent!
• It!is!a!potent!anesthetic!with!weak!analgesic!properties!(usually!
administered!with!N2O)!
• Side(effects:!hepatotoxicity,!cardiac!arrhythmias!(increases!the!
myocardial!sensitivity!to!catecholamines),!malignant!hyperthermia!
(
Isoflurane/Desflurane/Sevoflurane(
• They!are!halogenated!agents!
• They!are!potent!anesthetics,!but!weak!analgesics!with!low!solubility!in!
blood!
• They!decrease!the!vascular!resistance!(decrease!BP)!and!perfuse!major!
tissues!→!good!for!patients!with!CHD!
• They!do!not!cause!cardiac!arrhythmias,!but!can!be!nephrotoxic!or!
hepatotoxic!
• Cardiovascular!effects:!↓!BP,!↓!sympathetic!activity;!↓!O2!consumption;!↓!
blood!flow!to!liver,!kidneys,!gut!and!↑!blood!flow!to!brain,!muscles!and!
skin;!sensitization!of!myocardium!to!catecholamines!(not!for!
iso/des/sevoflurane)!
• Respiratory!effects:!↓!tidal!volume;!cause!bronchodilation;!irritate!
respiratory!tract;!cause!respiratory!depression!(N2O>HAL>ISO>DES)!
• CNS!effects:!vasodilation!of!cerebral!arteries,!↑!ICP,!decreased!cerebral!
metabolism;!CNS!depression!
(
Advantages(of(inhalation(agents:!!
• Easy!regulation!of!depth!of!anesthesia!
• Elimination!by!expiration!
• Potentiation!of!muscle!relaxation!
• Ability!to!use!re:breathing!systems!(cheap!)!
• Possible!ambulatory!anesthesia!
!
Important(distinguishing(characteristics(of(inhalation(drugs:(
• Solubility!in!blood!and!lipid! concentration)!
phases!of!the!body! • Muscle!relaxation!
• MAC!value!(minimal!alveolar!
• Volatility! • Effect!on!vital!functions!
• Irritation!of!the!respiratory! • Serious!cardiac!arrhythmias!
tract! • Toxicity!
! • Availability!!
6. Intravenous(Anaesthesia,(Sedation(
• Are!often!used!for!rapid!induction!of!anesthesia!which!is!then!maintained!
by!an!inhalation!agent!→!intravenous!anesthesia!(IVA)(
• Can!also!be!used!alone!for!both!induction!and!maintenance!of!anesthesia!
→!total!intravenous!anesthesia!(TIVA)!where!all!anesthetic!agents!are!
administered!i.v.(
(
I.v(anesthesia(indications:(!
• Induction!before!inhalation!anesthesia;!out:patient!anesthesia;!difficult!or!
impossible!administration!of!inhalation!anesthetics!(head:and!neck!
surgeries,!bronchoscopies)(
(
Important(factors(for(the(usefulness(of(IV(anesthetics:(
• Speed!of!onset!of!action!
• Speed!of!recovery!
• Disposal!in!the!body!
• Quality!of!anesthesia!
• Minimal!cardiovascular!and!respiratory!depression!
• Ease!of!administration!
• Risk!of!hypersensitivity!reaction!
• Compatibility!with!other!drugs!
(
(
(
(
Disadvantages(of(intravenous(anesthesia:!!
• Difficulty!in!assessment!of!depth!of!anesthesia;!difficult!to!correct!
overdoses;!several!i.v.!accesses!are!needed;!drug!interactions;!O2!supply!
is!still!required.(Usually!administered!by!pump.(
(
Thiopental:(
• It!is!a!barbiturate!
• It!is!a!potent!anesthetic!but!weak!analgesic!
• It!depresses!the!respiratory!center!and!decreases!its!sensitivity!to!CO2!
but!has!minor!effects!on!CVS!
• Can!causes!apnea,!cough,!bronchospasm,!laryngospams!→!
contraindicated!in!asthmatics!
(
(
Propofol(
• It!is!a!potent!anesthetic!with!weak!analgesic!activity!
• It!is!the!first!choice!for!induction!of!anesthesia!→!has!replaced!thiopental!
because!it!produces!euphoria!and!does!not!cause!post:anesthetic!nausea!
and!vomiting!
• Has!rapid!onset!and!rapid!elimination!and!is!therefore!suitable!for!out:
patient!anesthesia!(endoscopy,!gastroscopy)!
(
Ketamine(
• It!induces!a!dissociated!anesthesia!→!patient!is!unconscious,!does!not!feel!
pain!but!appears!to!be!awake!!
• It!increases!the!sympathetic!nervous!system!activity,!causing!↑!BP!and!↑!
cardiac!output!→!good!for!hypotensive!patients!or!asthmatics!but!
contraindicated!for!patients!with!hypertension!or!stroke!
(
Etomidate(
• It!is!a!hypnotic!agents!that!lacks!analgesic!activity!
• Has!little!or!no!effect!on!CVS!→!used!in!patients!with!CHD!or!cardiogenic!
shock!
• Prolonged!use!can!lead!to!depression!of!adrenal!cortex!
(
Midazolam(
• It!is!a!BZD!→!antagonist!is!flumazenil!
• Causes!sedation!and!amnesia!
• Has!enormous!variability!in!patient!response!to!the!drug!
!
7. Neuraxial%Technics%of%Regional%Anaesthesia%
(
Neuraxial(anesthesia!is!injection!of!anesthesia!in!fatty(tissue(surrounding(the(
nerve(roots(in(the(spinal(cords,!also!known!as!epidural,!or!an!injection!into!
the!cerebrospinal(fluid,!also!known!as!spinal(anesthesia.!
!
This!numbs!the!body!from!the!abdomen!to!the!toes!and!often!eliminates!the!
need!for!general!anesthesia.!!
!
The!injection!is!performed!with!local!anesthesia!or!sometimes!with!intravenous!
sedation.!!
(
Spinal:(
• Injection!location!!!lumbar!only!
• Duration!of!block!!!short!
• Procedure!time!!!brief!!
• Quality!of!block!!!high!
• Disadvantages!!!increased!risk!of!hypotention,!dural!puncture!headache!
• Advantages!!!ability!to!produce!segmental!block,!greater!control!over!
analgesia,!possibility!of!long!term!analgesia!!
Indications(for(spinal:(
" Lower!abdominal,!!
" Perineal!
" LE!surgery!
Technically!one!could!use!it!for!upper!abdominal!surgery!however!because!
these!procedures!impact!breathing!so!profoundly,!general!anesthesia!is!
generally!preferred.!!
Epidural:(
• Injection!location!!!anywhere!
• Duration!of!block!!!prolonged!
• Procedure!time!!!longer!!
• Quality!of!block!!!not!as!good!as!spinal!
Curvature!is!key!in!spinal!anesthetics.!The!sitting!position!is!commonly!
employed.!Instruct!the!patient!rest!his!or!her!legs!on!a!step!stool!and!hold!a!
pillow.!
The!lumbar!level!of!insertion!for!epidural!anesthesia!is!used!for!postoperative!
analgesia!for!lower!abdominal,!pelvic,!and!lower!extremity!procedures.!Usually!
terminal!point!of!12th!ribs!is!at!L2.!The!line!across!the!iliac!crests!crosses!L4!VB.!
This!is!one!of!the!points!to!insert!the!epidural!anesthetics.!!
Indications(for(epidural:(
" Abdominal!or!lower!extremity!surgery!
" Suboptimal(for!procedures!involving!lower!sacral!regions!because!of!its!
segmental!nature!
" Epidural!anesthesia!is!also!often!used!as!a!supplement!to!general!
anesthesia,!as!well!as!for!labor!pain!
Short(acting(local(anesthesia((used(in(epidural(and(spinal):(
" Chloroprocaine!
o Low!doses!are!excellent!for!short!duration!
" Lidocaine!
o Duration!60:90!minutes!
o Good!sensory!and!motor!block!
o Favorable!recovery!profile.!
Longer(acting(local(anesthesia:(
" Bupivacaine!!
o Similar!dose!and!duration!as!tetracaine!(5:20!mg,!90:120!mins),!!
o Slightly!more!intense!sensory!anesthesia!(and!less!motor!
blockade)!than!tetracaine.!
o Good!for!labour!
!
" Tetracaine!!
" Opiates!can!be!added!and!affect!the!dorsal!horn.!Morphine!(0.1!–!0.5!mg)!
can!be!used!and!provides!24!hours!of!relief,!but!unlike!fentanyl,!requires!
in:hospital!monitoring!for!respiratory!depression!
8. Peripheral%Neural%Blocks%
Peripheral!nerve!blocks!are!a!type!of!regional!anesthesia!that!involves!injection!
of!anesthetic!medications!near!a!cluster!of!nerves!so!that!only!the!area!of!your!
body!that!requires!surgery!will!be!numb.!
!
• Are!typically!performed!for!surgeries!of!the!upper!or!lower!extremities!
• Can!also!be!used!for!surgeries!around!the!neck!(e.g.!carotid!artery!
endarterectomy)!or!groin!(hernia).!
Indications!—!There!are!no!specific!indications!for!peripheral!nerve!blocks.!
Often!used!to!avoid!the!effects!of!alternative!anesthetics!or!analgesics.!The!most!
commonly!used!to!avoid!side!effects!and!complications!of!general!anesthesia,!!
particularly!respiratory:related!effects,!and!to!provide!analgesia!while!
minimizing!opioid!use.!
!
!
!
!
!
The!cases!in!which!this!method!is!preferable:!
• Patients!at!risk!of!respiratory!depression!related!to!GA!(e.g,!obstructive!
sleep!apnea,!severe!obesity,!underlying!pulmonary!disease,!advanced!age)!
!
Paresthesia(technique,!in!which!placement!of!a!needle!in!close!proximity!to!a!
nerve!causes!a!“pins!and!needles”!sensation!in!the!nerve’s!peripheral!
distribution.!
Depending!on!the!area!of!the!intended!block,!specific!paresthesias!can!
be!sought!with!manipulation!of!the!needle.!This!technique!can!be!uncomfortable!
for!the!patient,!yet!requires!the!patient!to!be!sufficiently!awake!to!
respond.We!need!to!watch!the!patient!while!gauging!the!pressurewe!apply!to!
the!plunger!of!the!syringe.!The!patient!will!let!us!know!if!he!feels!an!“electric!
shock”!or!pain!–!signs!we!associate!with!the!intraneural!placement!of!the!
needle,!at!which!point!we!do!not!proceed!to!inject!drug!under!high!pressure,!
which!would!compress!the!nerve!in!its!sheath,!causing!nerve!ischemia!and!
injury.!
!
Nerve!stimulator(technique,!in!which!we!apply!a!small!electrical!current!to!
an!insulated!needle,!causing!motor!stimulation!when!near!a!nerve.We!adjust!the!
needle!position!to!achieve!the!maximal!motor!response!in!the!desired!
distribution.!This!technique!enables!us!to!exploit!anatomical!cues!to!direct!
needlemovement.!For!example,!stimulation!of!the!phrenic!nerve!(the!patient!
will!hiccup)whenperforminganinterscalene!block!tells!us!the!brachial!plexus!
lies!just!a!centimeter!lower!in!the!neck!
!
9. Local%Anaesthetics%Pharmacology,%Toxic%Reaction%
Treatment%
Definition:!
• Local!anesthetics!are!applied!locally!and!block!nerve!conduction!of!pain!
stimuli!from!the!periphery!to!the!CNS!→!interrupt!pain!impulses!at!
specific!regions!of!the!body!without!the!loss!of!patient’s!consciousness!
!
They!are!weak!bases!and!can!be:!
• Esters!
o Include!cocaine,!procaine,!tetracaine,!chloroprocaine!
o They!are!hydrolyzed!in!plasma!to!PABA!(paraaminobenzoic!acid)!
that!can!cause!allergic!reactions!
• Amides!
o Include!lidocaine,!bupivacaine,!mepivacaine!and!prilocaine!
o Allergic!reactions!are!rare!
o They!penetrate!the!nerve!fibres!and!block!sodium!channels,!
preventing!entry!of!sodium!into!the!cells!→!block!membrane!
depolarization!
!
Sites(of(administration(of(local(anesthetics(may(be:((
o Cutaneous!(EMLA)!
o Mucosal!
o Local!injection!(spinal!anesthesia,!epidural!anesthesia,!plexus!block,!
peripheral!nerve!block,!infiltration!anesthesia,!Bier’s!block)!
(
General(principles(
• When!injecting!local!anesthetics,!there!should!always!be!equipment!for!
resuscitation!(ET!tube,!ventilation!machine)!in!case!of!systemic!toxicity!
• I.v.!access!must!be!ensured!when!using!more!than!minimal!doses!of!local!
anesthetics!and!recommended!doses!must!not!be!exceeded!
• Injection!must!always!be!preceded!by!careful!aspiration!(not!to!inject!it!in!
vessels)!
• The!anesthetic!agent!should!be!administered!together!with!adrenalin!to!
reduce!uptake!into!systemic!circulation!and!potentiate!the!local!effect!
• The!anesthetic!agent!should!be!administered!slowly!while!observing!the!
patient’s!reaction!→!check!for!adverse!reactions!
!
10. Anaesthesia%for%Day;Case%Surgery%
• Patient!who!is!admitted!for!investigation!or!operation!on!a!planned!
non!resistent!basis!and!need!facilities!for!recovery!
• Surgical!procedures!with!no!stay!in!hospital!overnight!
• General,!regional!local!anesthetics!is!given!
• Sedation!is!also!given!
• Advantages(
o Cheaper!
o Less!anxiety!
o Less!infection!
o Better!convenience!
• Prerequisite(
o ASA!I/II!
o >6months!<70y!
o surgery!<90min!
o low!post!operative!complications!
o BMI!?!
• Examples(
o Gyn!
" Colposcopy!
o Orthopedics!
" Fractures!
o General! !
" Hernias!
o Peds!
" Dental!extaction! !
11. Specificity%of%Paediatric%Anaesthesia%
• Infants,!particularly!neonates!and!especially!the!premature!ones!
present!special!problems!for!the!anesthetist(
(
Anatomy(and(physiology(
The!major!differences!between!children!and!adults!are!greatest!in!the!
neonatal!period(
• Veins!are!much!smaller!and!after!6!months!are!covered!with!
subcutaneous!fat!→!common!sites!for!i.v.!access!are!dorsum!of!the!
hand!or!foot!as!well!as!scalp!veins(
!
Intubation!may!be!complicated!due!to:!
• Large(head!and!short(neck;!small!mouth!with!large!tongue;!larynx!is!
higher!and!more!anterior!(at!C3!rather!than!C6!in!adults);!epiglottis!is!
large!and!V:shaped;!trachea!is!short;!infants!<6!months!are!mandatory!
nose!breathers!
• Respiratory!rate!is!much!faster!(30:40!breaths/min)!but!tidal!volume!
is!relatively!the!same!(7!ml/kg)!as!in!adults!
• Oxygen!consumption!is!higher!in!neonates!than!in!adults!
• Respiration!is!mostly!diaphragmatic!→!abdominal!distention!may!lead!
to!respiratory!failure!
• At!birth,!HR!is!130:160/min!and!BP!is!lower!than!in!adults!
• At!birth,!Hb!is!170!g/l!and!falls!rapidly!within!6!weeks!to!110!g/l!→!
physiological!anemia!
• The!infant!is!at!higher!risk!for!bleeding!due!to!reduced!platelet!
function!and!reduced!plasma!coagulation!factors!(II,!VII,!IX,!X)!→!
prophylactic!Vitamin!K!administration!
• Because!the!cerebral!cortex!and!the!blood:brain!barrier!are!
underdeveloped,!the!infants!are!more!sensitive!to!opioids!and!general!
anesthesia!
• Infants!lose!heat!rapidly!in!a!cool!environment!→!large!surface!area!
relative!to!weight!and!lack!of!subcutaneous!fat!
(
Premedication(
• Usually!administered!i.v.,!i.m.,!oral!and!rectal!
• Types!of!premedication!
• EMLA!cream!(mixture!of!lidocaine!and!prilocaine)!to!provide!topical!
dermal!anesthesia!
• Analgesics!→!drugs!used!include!pethidine!and!papaveretum!
(mixture!of!3!opioids!–!morphine,!codeine!and!papaverine)!→!not!for!
infants!<6!months!of!age!
• Sedatives!→!commonly!used!are!diazepam!and!lorazepam!
• Anticholinergics!(atropine,!hyoscine,!scopolamine)!→!children!up!to!8!
months!receive!only!atropine(as(premedication!
Facemasks(
• The!Rendell:Baker:Soucek!mask!is!used!because!of!its!face:fitting!
shape!
(
Laryngoscopes(and(endotracheal(tubes(
• For!children!below!puberty,!uncuffed!tubes!must!be!used!to!reduce!
mucosal!edema!→!may!lead!to!fibrosis(
• The!size!(diameter)!of!the!tube!must!always!be!chosen!carefully!to!
ensure!that!a!leak!is!present!→!age!(years)/4!+4!=!internal!diameter!
(mm)!
• The!length!of!the!tube!should!also!be!careful!checked!→!age!(years)/2!
+!12!=!length!in!cm!(oral!intubation)!
• Some!types!of!tubes!used!include:!PVC!Magill!tubes,!RAE!tubes,!
armoured!tubes!
• Laryngoscopes!should!have!straight!blade!to!visualize!the!anterior!
larynx;!light!weight!and!be!small;!
Intravenous(cannulae(
• I.v.!access!is!mandatory!for!infants!and!children!→!cannulae!as!small!as!
24!gauge!are!used!
• All!fluids!administered!should!be!warmed!and!carefully!calculated!
Anesthetic(breathing(systems(
• An!Ayre’s!T:piece!system!with!an!expiratory!limb!and!an!open!ended!
500!ml!bag!is!used!for!children!under!20!kg!
• Advantages:!simple!and!light!weight;!small!dead!space;!no!valves;!low!
resistance!of!flow!
• Disadvantages:!high!flow!of!fresh!gas!is!necessary;!humidification!is!
difficult!
• For!children!>20!kg!any!conventional!adult!breathing!system!can!be!
used!
!
12. Specificity%of%Obstetric%Anaesthesia%&%Analgesia%
The!difficulties!of!obstetric!analgesia!include:!!
• The!wide!pain!ranges!that!have!to!be!covered(
• The!effects!of!analgesia!on!the!fetus,!the!neonate!and!the!labour!
process!itself(
• The!side!effects!of!analgesia!on!the!mother!(e.g.!vomiting!as!a!side!
effect)(
Systemic(analgesia(
• Opioids!have!been!widely!used!to!treat!labour!pain!→!the!combination!
of!pethidine!and!phenothiazine!started!in!the!60s!and!is!still!used(
• Because!opioids!cross!the!placental!barrier,!they!also!affect!the!fetus!
→!cause!sedation!(poor!muscle!tone)!and!cerebral!depression,!
respiratory!depression!and!poor!maintenance!of!body!temperature!→!
drug!metabolism!is!poor!in!the!newborn!and!therefore!these!effects!
last!longer!than!in!the!mother(
• Other!drugs!administered!include!anxiolytics!and!antiemetics(
• Side(effects!of!systemic!analgesics!can!be!minimized!by!keeping!the!
dose!small!→!but!reduces!analgesic!action(
• It!is!important!to!assess!the!Apgar!score!→!will!be!lower!if!the!fetus!is!
under!the!influence!of!drugs(
Epidural(anesthesia(
• Has!become!the!anesthesia!of!choice!for!C:sections!
• The!anesthetic!is!administered!between!dura(mater!and!the!bones(of(
vertebral(canal!→!not!in!the!CSF!and!can!therefore!not!reach!the!
brain!
• Advantages!include:!the!mother!is!awake!and!experiences!the!birth!of!
her!child;!the!partner!can!give!emotional!support;!gastric!content!
aspiration!is!almost!eliminated;!there!is!decreased!incidence!of!
postoperative!morbidity!and!thromboembolism!
• Disadvantages!include:!takes!time!to!ensure!an!adequate!block;!
hypotension;!nausea!and!vomiting;!pain!at!operation!
(
Spinal(anesthesia(
• There!is!injection!of!a!small!dose!of!local!anesthetics!into!the!
subarachnoid!space!(between!L3/L4!or!L4/L5)!
• Advantages!include:!it!results!in!a!more!effective!surgical!block!than!
epidural!anesthesia;!has!quicker!onset!of!action;!!
• Disadvantages!include:!causes!vasodilation,!bradycardia!and!severe!
hypotension!
(
General(anesthesia(
• The!major!danger!is!the!regurgitation!of!gastric!contents!of!the!
mother!which!can!cause!gastric!aspiration!
• In!order!to!avoid!gastric!aspiration,!the!mother!is!preoxygenated!
before!induction!with!a!rapidly:acting!anesthetic!such!as!propofol!(or!
thiopental)!→!followed!by!a!full!dose!of!succinylcholine!
• The!application!of!cricoid!pressure!should!occur!as!soon!as!possible!
and!before!the!onset!of!unconsciousness!
• Aorto:caval!compression!(compression!of!vena!cava!and!aorta!by!
uterus)!must!be!avoided!by!a!lateral!tilt!of!the!mother!
• It!is!the!most!rapid!and!certain!anesthetic!technique!available!→!used!
mostly!for!emergency!C:sections!with!fetal!distress!
13. Anaesthesia%in%Trauma%Injuries%
!
14. Specificity%of%Cardioanaesthesia%
!
• The!main!purpose!of!the!circulatory!system!is!to!deliver!O2!and!nutrients!
to!the!body!and!to!remove!the!waste!products!of!metabolism!→!other!
functions!include!thermoregulation(
• The!circulation!depends!on!the!function!of!the!heart!and!the!status!of!the!
vessels!→!the!heart!receives!both!sympathetic!and!parasympathetic!input!
while!the!vessels!are!mainly!under!sympathetic!control(
(
(
Factors(influencing(the(cardiac(output(
• The!average!adult!has!a!blood!volume!of!5:6!l!and!a!cardiac!output!of!5.5!
l/min!
• Cardiac(output!is!the!blood!ejected!to!the!circulation!every!minute!→!CO!
=!stroke(volume!(70!ml)!x!HR!(60:80/min)!
• Stroke!volume!depends!on!the!size!of!the!heart,!the!contractility!of!the!
myocardium!and!on!the!venous!return!
• The!size!of!the!heart!depends!on!the!blood!volume!and!the!PVR!
• The!contractility!depends!on!the!myocardial!cells!as!well!as!sympathetic!
stimulation!→!drugs!such!as!catecholamines,!cardiac!glycosides!increase!
myocardial!contractility!while!trauma!or!hypoxia!decrease!myocardial!
contractility!
• The!venous!return!is!influenced!by!the!venous!tone!and!venous!blood!
volume!as!well!as!gravity!
• The!normal!heart!rate!is!60:80!bpm!and!is!generated!by!the!sinoatrial!
node;!it!is!influenced!by!the!balance!between!sympathetic!and!
parasympathetic!nervous!system!
• Baroreceptors!(carotid!sinus,!aortic!arch)!→!most!of!them!are!vagally!
innervated!and!provide!a!negative:feedback!mechanism!for!HR!control!(↓!
BP!leads!to!block!of!vagus!nerve!and!↑!heart!rate)(
• Chemoreceptors!(carotid!body)!are!influenced!by!hypoxia!and!
hypercapnia!as!well!as!H+!→!cause!reflex!vasoconstriction,!reflex!
hypertension!and!bradycardia!
• Others:!hormones!such!as!thyroxine!and!catecholamines!(NA/adrenaline)!
will!also!influence!heart!rate!(↑)!
(
Factors(influencing(peripheral(resistance!
• Peripheral(resistance!(PVR)!depends!on!the!blood!viscosity!and!size!of!
blood!vessels(
• Blood(viscosity!increases!with!cooling!and!with!a!rise!of!hematocrit!
more!than!45%!→!a!rise!in!plasma!proteins!reduces!blood!viscosity(
• Blood!vessels!respond!to!sympathetic!innervations!of!the!vasomotor!
center!(medulla!oblongata)!that!receives!input!from!chemoreceptors,!
baroreceptors,!higher!centers,!sensory!centers!and!the!respiratory!center!
and!also!directly!in!response!to!hypoxia!and!hypercapnia!→!increased!
sympathetic!activity!causes!vasoconstriction!while!decreased!activity!
causes!vasodilation(
• They!respond!directly!(without!vasomotor!center)!to!circulating!
catecholamines!but!also!other!substances!such!as!bradykinin,!histamine,!
serotonin!and!NO!
!
!
!
15. Cardiovascular%Complications%in%General%
Anaesthesia%
• Cardiac!arrhythmias!are!common!→!bradycardia!due!to!inhalation!
anesthetics!or!surgical!manipulation!of!autonomic!nerves!(treated!
with!atropine)!
• Tachycardia!due!to!stress!of!surgery!
• Hypotension!is!common!during!maintenance!→!treated!with!
atropine,!fluids!or!vasoconstrictors!
• Cardiac(arrest!due!to!air,!amniotic!fluid!or!thrombotic!embolism!
!
Arrhythmias(
• Rhythm!disturbances!occur!in!up!to70%of!patients!subjected!to!
general!anesthesia.!
• Fortunately,!the!majority!of!these,!in!the!otherwise!healthy!patient,!are!
benign!and!transient.!A!number!of!factors!can!be!blamed:!the!effects!of!
anesthetic!agents!on!the!SA!and!AV!nodes,!peri:operative!ischemia,!
and!increased!sympatheticactivity!during!light!anesthesia,!e.g.,!
laryngoscopy,!hypoxemia,!and!hypercarbia!(not!uncommon!during!
induction!of!general!anesthesia).!!
• In!addition!to!adhering!to!ACLS!protocols,!potential!triggers!must!be!
sought!and!eliminated:!correct!ventilation,!alter!anesthetic!agent!
selection!(no!halothane),!increase!oxygenation,!deepen!anesthetic,!etc.!
(
Hypertension(
• The!differential!diagnosis!of!intraoperative!hypertension!is!lengthy,!
but!should!be!approached!by!considering!the!patient!and!procedure!
first!!
• Management!of!intra:operative!hypertension!should!focus!on!three!
things:!
o Fix!the!underlying!problem!
o Correct!anesthetic!depth!
o Treat!hypercarbia!
o Drain!the!bladder,!etc.!
• Where!correction!is!not!possible:!treat!according!to!the!physiologic!
derangement.!
o For!example,!volume!overload!should!not!be!treated!with!
betablockade!nor!anxiety!with!diuretics.!
• Consider!the!time!course!of!the!treatment:!if!a!patient’s!hypertension!
results!from!a!transient!surgical!stimulus,!a!long:acting!anti:
hypertensive!may!cause!refractory!hypotension!when!the!stimulus!
ends.!
!
!
!
!
!
!
!
1. Hypotension(
a. Hypovolemia(
i. Preop:!trauma,!fracture,!bowel!prep,!diuretics!
ii. Postop:!blood!loss,!fluid!shift,!tissue!edema!
iii. CF!
a. Tachycardia!
b. Peripheral!vasoconstriction!
c. Low!BP!
d. Cold,!clammy!
e. Low!urine!output!–!oliguria!(400ml/24h)!
b. Impaired!myocardial!contractility!
i. Drugs!
a. All!anaesthetics!
(i) Inhalation!agents!
(ii) Iv!drugs!–!thiopental,!ketamine,!
propofol!
(iii) Opioid!–!pethidine!
ii. Heart!failure!
a. CAD!!!Mi,!cardiogenic!shock!
b. Valvular!heart!dx!
c. CHF!
iii. Obstructive!lesions!
a. Obstruction!to!heart!or!cardiac!chamber!or!
great!vessels!!!decreased!stroke!volume!
b. Ex:!cardiac!tamponade,!tension!
pneumothorax,!PE!
c. Treatment!
i. Find!cause!
ii. Iv!fluid!
iii. Increase!O2!
iv. Vasopressors!!
v. Trendelenburg!position!
!
2. Hypertension(
a. Intra!op!!
i. Response!to!laryngoscope!and!intubation!
ii. Light!anaesthesia!
iii. Hypercarbia!
iv. Hypoxemia!
b. Post!op!
i. Pain!
ii. Full!bladder!
iii. Hypothermia!
c. Treatment:!
i. Find!cause!&!treat!
ii. Elevated!head!table!
iii. If!not!–!propranolol,!hydralazine!
!
!
3. Arrhythmia!
a. Physiologic!disturbances!during!anaesthesia!
i. Anaesthesia!modify!
a. Body!mechanism!
b. Vagal!tone!
c. Acidosis!
d. Hypoxia/hypercarbia!
e. Electrolytes!
f. Hypovolemia!
b. Pathological!disturbances!
i. CAD!–heart!block!
ii. Thyrotoxicosis!
iii. Phemochromocytoma!
c. Pharmacological!
i. Ketamine!
16. Respiratory%Complications%in%General%Anaesthesia%
Complications during maintenance of anesthesia
• Respiratory complications:
o Bronchospasms or bronchial secretions → bronchospasms may need
bronchodilators and hydrocortisone
o Pneumothorax may occur due to lung-tissue rupture resulting in high-airway
pressure
Complications during induction of anesthesia
• Respiratory complications:
o Respiratory depression must be controlled by artificial ventilation and
increased FiO2
o Respiratory tract irritation (hiccup, coughing) may lead to dangerous spasm
→ common with inhalation anesthetics
o Bronchospams are severe but rare and may indicate anaphylaxis
Respiratory problems
• Are the most common problems in the recovery room
• Airway obstruction may occur if the patient is still unconscious → avoided by head
tilt/chin lift as well as placing the patient in recovery position (also avoids aspiration
after regurgitation or vomiting)
• Laryngospasms may occur due to irritation of the larynx by blood or secretions and
presents with inspiratory stridor and cyanosis → suction and O2 administration by
facemask
• Hypoventilation is common and may be due to opioid overdose, persistent
myorelaxation → check ABC
!
1. Respiratory!obstruction!
2. Hypoventilation!
3. Xoughing!
4. Tachypnoea!
5. Pneumothorax!
6. Bronchitis!
7. Co2!retention!
8. Collapse!of!lung!
9. PE!
17. Acute%Pain%Treatment%
!
Defined!by!IASP!as:!
" An!unpleasant!sensory!and!emotional!experience!associated!with!actual!
or!potential!tissue!damage,!or!described!in!terms!of!such!damage!
" Subjective!phenomenon!
!
Why!we!treat!pain:!
" Humanitarian!reasons!
" Can!have!adverse!effects!on!organ!systems!
!
• Acute!pain!has!resent!onset,!transient!in!nature,!usually!with!an!identifiable!
cause.!!
The!types!of!analgetics!consists!of:!!
• nonopioid!analgesics!
• Opioid!analgesics!
• Coanalgesics!(or!adjuvant!analgesics).!
!
We!use!VAS!visual!analogue!scala!(Husskison)!to!determine!the!severity!of!pain.!
!
The!pain!is!managed:!
" IM!
" IV!(pump)!
" Epidural!(pump)!
" Orally!
" Rectally!
" Transdermal!
!
Analgetic!ladder!according!to!WHO:!
1. Moderate(pain!!!nonopioid!analgetics!+/:!co!analgetics!
" Aspirin,!acetaminophen,!NSAID’s!+/:!adjuvants!
2. Medium(pain!!!weak!opioids!+!nonopioid!!
" Acet!or!ASA,!codein,!hydrocodone,!oxycodone,!tramadol!+/:!
adjuvants!
3. Severe(pain!!!strong!opioids!+/:!nonopioid!analgetics!
" Morphin,!hydromorphone,!methadone,!fentanyl,!oxycodone!+/:!
adjuvants!
!
!
!
!
18. Chronic%Pain%Treatment%
!
• Opiate!is!a!drug!that!is!naturally!obtained!from!the!juice!of!the!opium!poppy!
→!morphine,!codeine!and!papaverine!
• Opioids!are!semisynthetic!or!synthetic!compounds!that!produce!morphine:
like!effects!by!binding!to!opioid!receptors!in!the!CNS!and!antagonize!
naloxone!→!pethidine,!fentanyl,!sufentanil,!etc.!
• There!are!3!receptor:subtypes!to!which!opioids!bind!→!µ,!κ,!δ!!
(
Opioid(agonists!
• Morphine!is!the!major!analgesic!drug!of!this!category!
• Effects!of!morphine!
o Analgesia!and!euphoria!
o Respiratory!depression!→!reduces!the!sensitivity!of!the!respiratory!
center!to!CO2!
o Cough!suppression!!
o Nausea!and!vomiting!→!are!dopaminergic!agonists!on!the!medullary!
CTZ!
o Hypotension!and!bradycardia!!
o Myosis!→!pinpoint!pupils!because!of!excitement!of!Edinger:Westphal!
nucleus!in!brainstem!
o Decreased!GIT!and!UT!motility!→!constipation!and!urinary!retention!
• Opioids!are!contraindicated!in!head:injured!patients!because!they!can!cause!
increased!ICP!(respiratory!depression!causes!hypercapnia!and!cerebral!
vasodilation);!patients!with!bronchial!asthma!(can!cause!bronchospasm!due!
to!histamine!release)!
• Examples!of!agonists!
o Codeine:!less!potent!analgesic!than!morphine!but!has!efficient!
antitussive!effect!
o Fentanyl:!100!times!as!potent!as!morphine!→!used!for!epidural!
analgesia!during!labor!
o Pethididne:!has!anticholinergic!action!and!less!histamine!release!
o Others:!sufentanil,!afentanil,!heroin!
(
Mixed(agonistsLantagonists!
• In!nave!patients!they!act!as!agonists!while!in!opioid:dependent!patients!they!
act!as!antagonists!
• Examples!include!
o Pentazocine:!powerful!analgesic!which!produces!dysphoria;!can!
antagonize!the!respiratory!depression!caused!by!fentanyl!and!still!
maintain!analgesia!
o Buprenorphine:!its!major!use!is!in!the!treatment!of!opioid!
dependence;!can!be!administered!sublingually!to!avoid!first:pass!
effect!in!the!liver!
(
(
(
(
Opioid(antagonists(
• Naloxone:!it!is!used!for!the!reversal!of!opioid:induced!respiratory!
depression;!it!has!rapid!action!(within!60!secs!after!i.v.!administration)!but!a!
short!half:life!(30:100!mins)!and!patients!with!long:acting!opioid!overdose!
may!relapse!to!respiratory!depression!
• Naltrexone:!has!similar!actions!to!those!of!naloxone!but!has!longer!duration!
of!action!(one!oral!dose!blocks!opioid!receptors!for!up!to!48!hours)!
19. Post;Anaesthesia%Care%in%Recovery%Room%
• At!the!end!of!anesthesia,!the!anesthetist!must!make!sure!that!all!the!
records!are!filled!and!up!to!date!and!must!give!written!and!verbal!
instructions!for!postoperative!monitoring!and!continuing!care!to!the!
person!responsible!for!the!recovery!of!the!patient!(usually!recovery!
nurse)(
• The!monitoring!should!be!appropriate!to!the!patient’s!condition!and!
the!anesthetic!that!was!used!for!surgery(
(
Transfer(of(patients(
• Patients!may!be!transferred!from!one!hospital!to!another!or!between!
two!parts!of!the!hospital,!including!X:ray!department,!accident!and!
emergency!department,!wards,!recovery!room!or!operation!theatre.!
• During!the!transfer!of!patients!similar!monitoring!standards!as!in!the!
operating!room!or!recovery!room!should!be!available!for!early!
detection!of!complications!and!rapid!intervention!
!
1. Observations!!
a. General!appearance!
b. Vital!signs!
2. Drainages!
3. Pain!
4. Respiration!
5. CVS!!!BP!
6. GIT!!!N+V!
7. Late!post!op!
a. PE!
b. Lung!collapse!
!
!
!
!
!
!
!
!
!
20. 10%Remarkable%Moments%from%History%of%A&ICM%
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1974!–!first!guidland!published!in!US!
1876!–!first!ventilator!–!(:ve!pressure)!used!to!treat!polio!
1. Indications%for%Admission%to%ICU,%Vital%Function%Failure% %
o Intensive(care((
• Intensive!care!describes!the!management!of!the!patient!who!
requires!special!expertise!that!is!not!normally!available!on!the!
general!wards(
• A!general!intensive!care!unit!is!a!place!to!which!the!patient!is!
admitted!for!the!treatment!of!organ!failure!that!may!require!
technical!support!including!mechanical!ventilation!of!the!lungs!
and/or!invasive!monitoring(
• Specialized!areas!may!also!exist!like!coronary!care,!pediatric,!
neonatal,!post:oprative!recovery,!renal!and!neurosurgical!units(
• An!ICU!should!have!4:10!beds!and!should!be!situated!closely!to!the!
emergency!department,!operating!theatre!and!recovery!room!as!
well!as!X:ray!departments!and!CT:scans(
o Admission(policy(
• Patients!should!be!admitted!to!the!ICU!if!they!require!aggressive!
therapy!for!a!life:threatening!condition!that!is!potentially!
reversible!or!require!organ!support!until!a!definite!diagnosis!is!
made.(
• Patients!requiring!ventilatory!support!have!priority!for!admission(
• In!general,!patients!admitted!to!the!ICU!suffer!from!respiratory!
and/or!circulatory!failure.(
• They!may!also!suffer!from!sepsis,!hematological!disorders,!
neurological!disorders,!gut!dysfunction!and!liver!or!renal!failure(
• ICU!is!not!for!patients!with!hopeless!prognosis!or!to!prolong!the!
process!of!dying(
2.%Shock%–%Pathophysiology%&%Principals%of%Treatment%
Definition:!
• Shock!is!an!acute!circulatory!failure!with!inadequate!tissue!perfusion!
resulting!in!generalized!cellular!hypoxia!and/or!an!inability!of!the!cells!to!
utilize!oxygen(
(
Types(of(shock(
• Hypovolemic!shock!(loss!of!circulatory!volume)!→!most!common(
o Results!from!blood!loss!(endogenous!or!exogenous),!extravasation!of!
fluids!as!well!as!GIT!losses(
• Cardiogenic!shock!(failure!of!the!heart!to!act!as!an!effective!pump)(
o Commonly!caused!by!left!ventricular!failure!as!a!consequence!of!MI!
• Obstructive!shock!(mechanical!disturbances!to!forward!flow)!
o Obstruction!of!outflow!(e.g.!PE)!or!restricted!cardiac!filling!(e.g.!
cardiac!tamponade,!tension!pneumothorax)!
• Distributive!shock!(abnormalities!of!peripheral!circulation)!
o Septic!shock!or!anaphylactic!shock!
Treatment(
• The!underlying!cause!of!shock!should!be!corrected!→!control!hemorrhage,!
eradicate!infection,!remove!allergens,!etc.!
• Whatever!the!cause!of!shock,!airway!patency!(intubation!and!O2!
administration)!must!be!maintained!and!tissue!blood!flow!must!be!restored!
by!maintaining!adequate!cardiac!output!and!by!optimizing!arterial!BP!
• Volume!replacement!is!essential!for!hypovolemic!and!distributive!shock!
• Increases!preload!and!in!that!way!the!cardiac!output!
• Blood!components!such!as!red!cell!concentrates,!FFP,!etc.!can!be!used!in!
hemorrhagic!shock!
• Crystalloids!(saline,!Hartmann!solution,!Ringer!lactate,!5%!glucose)!and!
colloids!(dextrane,!gelatin,!hydroxyethylstarch)!are!used!in!other!types!of!
shock!
• Vasopressors!and!inotropic!agents!should!be!administered!to!increase!
cardiac!output!and!blood!pressure!if!shock!persists!despite!volume!
replacement!
o Include:!adrenaline,!noradrenaline,!dopamine,!dobutamine!(β1:
action),!ADH!
• Additional!treatment!
o Vasodilators!(sodium!nitroprusside,!nitroglycerine)!reduce!the!
afterload!and!are!used!to!increase!stroke!volume!and!decrease!
myocardial!oxygen!requirements!→!used!for!cardiogenic!shock!
o Hydrocortisone!200!mg!i.m.!as!well!as!0.5!mg!adrenaline!i.m.!are!
administered!for!anaphylactic!shock!
• ATB!treatment!for!sepsis!
!
!
!
!
!
!
2. Cardiogenic%Shock.%Causes,%Diagnosis,%Treatment.%Acute%
Myocardial%Infarction.%
Decreased cardiac output is the main feature and may be caused by pump failure as in
myocardial infarction or myocardial contusion, or by mechanical constriction as in cardiac
tamponade, tension pneumothorax, or pulmonary embolism.
Causes(of(cardiogenic(shock:(
: Valvular!diseases!
: Arrhythmias!
: Decreased!contractility!(due!to!hypertrophy!of!the!heart,!most!commonly!
because!of!MI).!
• Reduced(Cardiac(Contractility(!
o Myocardial!infarction!!
o Myocarditis!!
o Cardiomyopathy!!
o Toxins!or!poisons!eg!drug!overdoses,!carbon!monoxide!poisoning!!
• Inflow(Obstruction((
o Pericardial!tamponade!!
o Mitral!stenosis!!
• Outflow(Obstruction((
o Pulmonary!embolism!(!right!heart!outflow!obstruction)!!
o Acute!mitral!or!aortic!regurgitation!!
o Acute!ventricular!septal!defect(
Symptoms(consists(of:(
: Pulmonary!congestion!(dyspnea)!
: Increased!JVD!(distended!jugular!vein)!
: Angina!
: Cool!skin!(due!to!perfusion!focused!on!vital!organs)!
1. Evidence of poor tissue perfusion:

o cold clammy skin
o capillary refill <2 seconds
o poor urine output
o altered level of consciousness
2. Hypotension - This is a relative term eg an elderly person whose BP is 190/100 may
be in shock with a BP of 120/80
Diagnosis:(
: Serum!lactate!
: Troponins!(MI!markers)!
: Chest!x:ray!!
: EKG!(arrhythmias,!MI)!
: Echo!cardiography!to!detect!contractility,!valvular!problems!
: Important!to!obtain!the!value!of!Cardiac!output!
: CVP!(measure!central!venous!pressure)!
!
!
Treatment:(
: Oxygen!
: CV!support!!!vasopressor,!beta!blockers!increase!contractility!
: Repair!the!heart!if!repairable!(occluded!vessels,!arrhythmias,!valvular!
repair)!
!
!
3. Hypovolemic%Shock.%Causes,%Diagnosis,%Treatment%
Decreased!tissue!perfusion!due!to!low!blood!volume.!Usually!compensating!with!
increased!heart!rate.!
A!clinical!syndrome!characterised!by:!!
1. Depleted!intravascular!volume!!
2. Inadequate!tissue!perfusion!(mottled!skin,!decreased!level!of!
consciousness,!oliguria,!acidosis)!!
3. Cellular!hypoxia!!
Causes:((
: Blood!loss!
o Hemoptysis!
o Internal/external!bleeding!
!
: Fluid!loss!
o Excessive!sweating!
o Burns!!
o Vomiting!
o Diarrhea!!
o 3rd!space!fluid!(ascites)!
Symptoms:((
1. Pulse rate - tachycardia is a reliable sign in the young. It is not so reliable in the
elderly or in patients on beta blockers or calcium blockers.
2. Blood pressure - hypotension is a late sign. Postural hypotension should be sought as
an early warning sign, especially in the young who have good compensatory
mechanisms. Hypotension is a relative term. An elderly person whose usual blood
pressure is 190/100 may be in shock with a BP of 120/80. An infant's normal BP may
be 80/60.
3. Capillary refill - in shock is < 2 seconds in the finger tips.
4. Evidence of inadequate tissue perfusion - altered level of consciousness, oliguria,
acidosis, and mottled skin.
: Tachycardia!
: Low!BP!
: Low!organ!perfusion!
: Cold!hand!!!due!to!vasoconstriction!
: Dryness!(xerostomia,!or!dry!skin)!
: Paleness!(conjuctival!pallor)!
Diagnosis:(
: Serum!lactate!(shows!low!oxygenation)!
: ABG!(arterial!blood!gases)!
: CBC!(complete!blood!count)!
: Tachycardia!!
!
Treatment:(
: Vasopressors!!
: IV!fluids!
o A!blood!loss!of!up!to!30%!is!replaced!by!administration!of!
crystalloids!(normal!saline!or!Ringer’s!lactate)!and!colloids!
(dextrane!6%,!haemaccel!3.5%)!(100%!of!colloids!stay!in!blood!
while!only!¼!of!crystalloids!stay!in!blood)!
o For!a!blood!loss!of!40%,!crystalloids!and!colloids!plus!RBC!
concentrates!are!administered!
o For!blood!losses!of!70%!crystalloid/colloids,!RBC!concentrates!
plus!albumin!and!FFP!are!administered!
o For!blood!losses!>!80%,!crystalloids/colloids,!RBC!concentrates,!
albumin!and!FFP!plus!platelet!concentrates!are!administered!
: !
: Replete!blood!content!(transfusion,!platelets,!coagulation!factors!(fresh!
frozen!plasma)!
: Stop!hemorrhage!by!physical!pressure!or!surgery!(if!internal)!
!
!
5. Distributive%Shock.%Causes,%Diagnosis,%Treatment.%
Anaphylactic%Shock.%Septic%Shock%
!
Distributive!shock!results!from!excessive(vasodilation!and!the!impaired!
distribution!of!blood!flow.!Septic(shock(is(the(most(common!form.!In!the!
United!States,!this!is!the!leading!cause!of!non:cardiac!death!in!intensive!care!
units.!!
!
Distributive(shock(L(causes:(
" Spinal!lesion!
" High!level!spinal!anesthesia!
" Anaphylactic!shock!
" Septic!shock!
!
Common(symptoms:(
" Tachycardia!
" Tachypnea!
" Hypotension!
" Altered!mental!status!
" Oliguria!
!
!
Anaphylactic(shock,(causes:(
" Insect!bites/stings!
" Foods!(specially!nuts,!seed!fruits,!etc)!
" Medications!(penicillins,!other)!
!
Symptoms:(
" Skin!redness!
" Swelling!of!airways!!!difficulties!breathing!
" Swelling!of!face,!eyes,!tongue!
" Difficulties!swallowing!
" Itchiness!!
" Rhinorrhea!!
" Unconsciousness!!
This!is!an!emergency!condition!and!must!be!treated!immediately.!!
(
Treatment/management:(
" Disconnect!allergen!!
" Administer!fluids!(infusion,!blocking!absorption!–!infiltration!by!lidocain!
c.!adren,!cooling...)!
" Oxygen!!!artificial!ventilation!(if!necessary)!
" Head:down!position!
" Volume!administration!–!colloids,!crystalloids!
" Adrenalin!slowly!1,0!mg/500!ml!i.v.!or!0,5(mg(i.m.!
" Glucocorticoid!(Hydrocortison)!300!mg!i.v.!
!
Septic!shock!is!severe!Sepsis!with!hypotension,!despite!adequate!fluid!
resuscitation.!Septic!shock!occurs!most!often!in!the!very!old!and!the!very!young.!
It!may!also!occur!in!people!with!weakened!immune!systems.!
!!
To!meet!SIRS!criteria!the!patient!must!have!two!or!more!of!these:!
: Temp!>38°C!or!<!36°C!
: Heart!Rate!>!90!
: Respiratory!Rate!>!20!or!PaCO2!<!32!mm!Hg!
: WBC!>!12,000/mm>3,!<!4,000/mm>3,!or!>!10%!bands!
!
SIRS(is(nonspecific!and!can!be!caused!by!ischemia,!inflammation,!trauma,!
infection,!or!several!insults!combined.!Thus,!SIRS!is!not!always!related!to!
infection!
!
# Sepsis:!SIRS!+!confirmed!infection!
# Severity!is!assessed!by!the!degree!of!organ!damage.!
# Septic!shock:!sepsis!+!low!blood!pressure!(In!spite!of!adequate!fluid!
resuscitation.!Other!signs!include!oliguria!and!altered!mental!status.)!
!
Signs(of(systemic(hypoperfusion:(
" Organ!dysfunction!
" Serum!lactate!greater!than!4!mmol/dL!
" Oliguria!and!altered!mental!status.!!
!
Patients!are!defined!as!having!septic!shock!if!they!have!sepsis!plus!hypotension!
after!aggressive!fluid!resuscitation!(typically!upwards!of!6!liters!or!40!ml/kg!of!
crystalloid).!
!
Goals(during(the(first(6(hrs(of(resuscitation:(
a) Central!venous!pressure!8:12!mmHg!!
b) Mean!arterial!pressure!(MAP)!≥!65!mmHg!!
c) Urine!output!≥!0.5!mL/kg/hr!!
d) Central!venous!(superior!vena!cava)!or!mixed!venous!oxygen!saturation!
70%!or!65%,!respectively!!
!
6. Obstructive%Shock.%Causes,%Diagnosis,%Treatment.%Acute%
Lung%Injury%
Obstructive(shock!is!a!form!of!shock!associated!with!physical!obstruction!of!
the!great!vessels!or!the!heart!itself.!!Pulmonary!embolism!and!cardiac!
tamponade!are!considered!forms!of!obstructive!shock.!
Obstructive!shock!has!much!in!common!with!cardiogenic!shock,!and!the!two!are!
frequently!grouped!together.!
!
Some!sources!do!not!recognize!obstructive!shock!as!a!distinct!category,!and!
categorize!pulmonary!embolism!and!cardiac!tamponade!under!cardiogenic!
shock.!
(
(
Acute(lung(injury!(ALI)!is!a!diffuse!heterogeneous!lung!injury!characterized!
by!hypoxemia,!non!cardiogenic!pulmonary!edema,!low!lung!compliance!and!
widespread!capillary!leakage.!ALI!is!caused!by!any!stimulus!of!local!or!
systemic!inflammation,!principally!sepsis.!
Treatment!
The!cornerstone!of!treatment!is!to!keep!the!PaO2!>!60!mmHg!(8.0!kPa),!without!
causing!injury!to!the!lungs!with!excessive!O2!or!volutrauma.!
• Pressure!control!ventilation!(PC)!is!more!versatile!than!volume!control:!
but!a!volume!limited!strategy!should!be!used!to!prevent!stretch!injury!to!
the!alveoli.!A!number!of!adjunct!therapies!are!available,!none!have!proven!
effective.!Of!these,!inhaled!nitric!oxide!and!prone!positioning!are!most!
frequently!used.!Current!ventilation!strategies!involve!using!low!tidal!
volumes!with!or!without!high!levels!of!PEEP.!The!open!lung!approach!
attempts!to!optimize!lung!mechanics!and!minimize!phasic!damage!by!
strategically!placing!PEEP!above!Pflex.!Ventilator!induced!lung!injury!is!
caused!by!volutrauma!and!excessive!use!of!oxygen!
!
• Steroids!may!have!a!role!in!chronic!ARDS!in!patients,!without!infection,!
with!high!O2!requirements!days!to!weeks!into!the!disease!process.!It!was!
historically!known!as!"double!pneumonia"!
!
7. Oxygen%Therapy%&%Inspiratory%Gas%Preparation%
• Oxygen is necessary for all cellular metabolism → after anesthesia and surgery,
O2 delivery to the tissues may be markedly impaired and therefore additional O2
(30-40%) is administered to all patients postoperatively to prevent tissue hypoxia
REASONS(OF(HYPOXEMIA(IN(POSTOPERATIVE(PERIOD:(
" FiO2!decrease?!•!!
" V/Q!disturbances!–!the!most!frequent!
" Lung!shunts!–!secretions,!atelectasis!
" Hypoventilation!–!anesthesia!effects!!
" Diffusion!disturbances!–!interstitial!lung!edema!!
" Hypoxia!from!diffusion!!
!
Situations!for!longer!oxygen!therapy!during!postoperative!period:!
" Hypotension!
" IHD!(ischemic!Heart!disease)!
" Decreased!C.O.!(cardiac!output)!
" Anemia!
" Obesity!
" Shivering!
" Hypothermia!
" Hyperthermia!
" Lung!edema!
" Airway!obstruction!
" After!large!surgery!
!
Oxygen(therapy:(
Every!pt.!10!min!after!general!anesthesia!should!contain!100%!oxygen!
•!Cave:!Recovery!room!Postoperative!dpt.,!ICU.!
!
EQUIPMENT!FOR!OXYGEN!THERAPY!
•!Nasal!lines!!
•!Face!mask!!
•!Venturi!mask!!
•!CPAP!»10!cmH20!!
•!Artificial!ventilation!
(
Types(of(hypoxia(
• Hypoxia!is!a!state!in!which!aerobic!metabolism!is!reduced!as!a!result!
of!fall!in!the!PaO2!within!the!mitochondria(
!
!
!
(
• Hypoxia!is!classified!as:(
o Hypoxic(hypoxia:!it!is!the!result!of!reduction!in!the!PaO2!of!
inspired!air,!alveolar!hypoventilation,!ventilation:perfusion!
mismatch,!impaired!diffusion!of!gas!between!alveoli!and!
pulmonary!capillaries(
o Anemic(hypoxia:!it!is!the!result!of!reduced!oxygen!capacity!of!
the!blood!→!usually!due!to!decreased!hemoglobin!but!also!in!
CO!poisoning!(Hb!is!occupied!by!CO)!
o Ischemic(hypoxia:!it!occurs!when!there!is!inadequate!
perfusion!of!tissues!(reduced!blood!flow!to!tissues)!
o Histotoxic(hypoxia:!occurs!when!there!is!an!inability!of!cells!
to!utilize!O2!due!to!poisoning!of!mitochondrial!enzyme!
pathways!(e.g.!cyanide!poisoning!→!inhibits!cytochrome!
oxidase)!
(
Assessment(of(tissue(hypoxia!
• The!tissue!O2!availability!depends!on!3!major!factors:!Hb(
concentration,!Hb(saturation(and(cardiac(output.(
• Measurement!of!arterial!PaO2!is!a!reasonable!indicator!of!oxygenation!
provided!that!!Hb!concentration!is!normal!and!cardiac!output!is!not!
reduced!(because!PaO2!is!in!immediate!relationship!with!O2!
saturation!of!Hb!→!O2!hemoglobin!dissociation!curve)!
• The!best!indicator!for!tissue!oxygenation!is!the!mixed!venous!PO2!
obtained!from!the!pulmonary!artery!via!a!SwanLGanz(catheter(
Oxygen(therapy!
• It!is!indicated!whenever!there!is!a!potentially!harmful!degree!of!
hypoxia!→!PaO2!<!60!mmHg!or!Hb:O2!<!90!%!
• Most(common(causes!of!postoperative!hypoxia!are:!ventilationL
perfusion(mismatching!and!alveolar(hypoventilation;!lung!collapse!
(atelectasis);!interstitial(edema!
• In!healthy!patients!the!respiration!is!largely!controlled!by!CO2!
concentration!(hypercapnia)!but!there!may!be!a!small!influence!of!O2!
→!in!patients!obstructive!lung!disease!(COPD)!respiration!is!
controlled!by!O2!concentration!(hypoxic!drive)!→!in!such!patients,!
high!levels!of!O2!can!cause!respiratory!depression!
• Correct!position!of!the!patients!improves!ventilation!and!thereby!
oxygenation!
• Humidification!of!inhaled!gases!is!important!especially!when!O2!is!
administered!for!a!prolonged!time!
• Delivery!of!O2!is!achieved!either!by!using!masks!or!nasal!catheters!
(for!children,!O2!tents!can!be!used)!
• O2:delivery!systems!may!be!classified!as:!
o FixedLperformance(devices:!allow!accurate!control!of!O2!
concentration;!most!practical!system!is!the!Vicker’s!Ventimask!
(air!from!the!room!is!sucked!in!from!side!holes!and!mixes!with!
O2!flow)!→!can!deliver!low!concentration!of!O2!that!is!
important!for!patients!with!hypoxic!drive!
!
o VariableLperformance(devices:!there!is!a!fixed!flow:rate!of!
O2!and!the!inspired!O2!depends!on!the!O2!flow!as!well!as!the!
patients!minute!ventilation;!they!can!be!no:capacity!systems!
(nasal!‘specs’),!small!capacity!systems!(MC!or!Hudson!mask)!or!
large!capacity!systems!(Polymask)!
8. Acute(Respiratory(Insufficiency,(Principles(of(artificial(Lung(
Ventilation(
• Respiratory(Failure:((
Is!inadequate!gas!exchange!by!the!respiratory!system,!with!the!result!of!
abnormal!rates!of!O2+CO.!
• The!normal!reference!values!are:!oxygen!PaO2!more!than!80!mmHg!
(11!kPa),!and!carbon!dioxide!PaCO2!lesser!than!45!mmHg!(6.0!kPa).!!
!
Type(I:!Hypoxia!WITHOUT(hypercapnia!
• Caused!by!V/Q!mismatch!
• Flow!of!air!flowing!in!and!out!of!the!lungs!is!not!matched!with!the!blood!
to!the!lungs.!!
PaO2! decreased!(<!60!mmHg!(8.0!kPa))!
PaCO2! normal!or!decreased!(<50!mmHg!(6.7!kPa))!
PA:aO2! increased!
!
Type(II:!Hypoxia!WITH!hypercapnia!
• caused!by!inadequate!alveolar!ventilation!!
• both!O2!and!CO2!are!affected!
• The!organism!builds!up!CO2!with!no!way!of!eliminating!it.!!
PaO2! decreased!(<!60!mmHg!(8.0!kPa))!
PaCO2! increased!(>!50!mmHg!(6.7!kPa))!
PA:aO2! normal!
pH! decreased!
!
Treatment:!!
1. CPR!
2. Endotracheal!Intubation!!
3. Mechanical!Ventilation!!
4. Medication:!If!the!respiratory!failure!resulted!from!an!overdose!of!
sedative!drugs,!then!the!appropriate!antidote!is!given.!
!
Artificial(lung(ventilation(
Mechanical(ventilation!is!a!method!to!mechanically!assist!or!replace!
spontaneous!breathing.!
• This!may!involve!a!machine!called!a!ventilator!or!the!breathing!may!be!
assisted!by!a!suitable!person!compressing!a!bag.!Mechanical!ventilation!is!
termed!"invasive"!if!it!involves!any!instrument!penetrating!through!the!
mouth!(such!as!an!endotracheal!tube)!or!the!skin!(such!as!a!tracheostomy!
tube).!!
• There!are!two!main!modes!of!mechanical!ventilation!within!the!two!
divisions:!positive(pressure(ventilation,!where!air!(or!another!gas!
mixtures)!is!pushed!into!the!trachea,!and!negative(pressure(ventilation,!
where!air!is,!in!essence,!sucked!into!the!lungs.!
!
Common(medical(indications!for!use!include:!
• Acute!lung!injury!(including!ARDS,!trauma)!
• Apnea!with!respiratory!arrest,!including!cases!from!intoxication!
• Acute!severe!asthma,!requiring!intubation!
• Chronic!obstructive!pulmonary!disease!(COPD)!
• Acute!respiratory!acidosis!with!partial!pressure!of!carbon!dioxide!!
• Increased!work!of!breathing!as!evidenced!by!significant!tachypnea,!
retractions,!and!other!physical!signs!of!respiratory!distress!
• Hypoxemia!with!arterial!partial!pressure!of!oxygen!!
• Hypotension!including!sepsis,!shock,!congestive!heart!failure!
• Neurological!Diseases!
(
Complications(
Mechanical!ventilation!is!often!a!life:saving!intervention,!but!carries!potential!
complications!including:!
• !Pneumothorax!!
• Airway!injury!!
• Alveolar!damage!!
• Ventilator:associated!pneumonia.!!
• Other!complications!include!diaphragm!atrophy,!decreased!cardiac!
output,!and!oxygen!toxicity.!!
9. Artificial%Lung%Ventilation%
• Mechanical!ventilation!can!be!noninvasive,!involving!various!types!of!
face!masks,!or!invasive,!involving!endotracheal!intubation.!!
Indications:(&
• There!are!numerous!indications!for!endotracheal!intubation!and!
mechanical!ventilation.!!
• Mechanical!ventilation!should!be!considered!when!there!are!clinical!
or!laboratory!signs!that!the!patient!cannot!maintain!an!airway!or!
adequate!oxygenation!or!ventilation.!!
o The!patient!may!be!ventilated!by!a!facemask,!through!a!tracheal!tube!
passed!through!the!nose!or!mouth!or!via!tracheostomy.(
(
(
(
(
(
(
(
(
Initial(management(of(a(patient(on(a(ventilator(
• After!the!patient!has!been!intubated!and!attached!to!the!machine,!
the!position!of!the!endotracheal!tube!(ETT)!must!be!secured!and!
checked!to!secure!that!it!is!correctly!situated!in!the!trachea!→!both!
sides!of!the!chest!must!move!equally!on!inflation,!capnography!
may!also!be!used!to!confirm!the!correct!placement!of!ETT!
• The!correct!position!has!to!be!reevaluated!every!time!the!patient!
has!been!moved!
(
Observations(and(monitoring(of(the(ventilated(patient(
• General(observations:!mental!status,!adequate!pain!relief,!
patients!color,!anxiety!control,!chest!movements(
• Monitoring(the(ventilator!(every!30!min!–!1!hour)(
$ Switch!on!the!machine,!set!the!required!FiO2!(fraction!of!
inspired!O2),!set!tidal!volume!(10!ml/kg)!and!monitor!both!
inspired!and!expired!volumes,!set!respiratory!rate!(12:
14/min),!monitor!inflation!pressure!(15:20!cmH2O),!check!
humidifier(
• Monitoring(the(patient!(every!15:30!min)!
$ Pulse,!BP,!CVP!and/or!pulmonary!artery!pressure,!pulse!
oxymetry,!capnography,!spontaneous!respiratory!rate,!tidal!
volume!and!minute!ventilation,!body!temperature!(hourly),!
urinary!output!(hourly),!fluid!balance!
• Other(investigations(
$ Arterial!blood!gases!(on!known!FiO2),!urea,!creatinine!and!
electrolytes,!Hb,!platelets,!clotting!factors,!serum!protein!and!
albumin,!chest!X:ray!
Patient(problems(on(a(ventilator(
• Inability!to!speak!
• Cardiovascular!problems!–!reduction!of!cardiac!output!leads!to!
reduced!BP!(dangerous!if!hypovolemia!is!present);!impairment!of!
pulmonary!circulation!that!leads!to!right!heart!failure!
• Pulmonary!problems!–!rupture!of!alveoli!in!patients!at!risk!(e.g.!
COPD);!right!ETI!(collapse!of!the!left!lung);!infections!
• Metabolic!problems!–!hyperventilation!may!reduce!PCO2!and!
cause!alkalosis!(causes!difficulty!in!weaning!patients!with!COPD);!
hypoventilation!may!increase!PCO2!and!cause!acidosis!
• Long:term!effects!–!O2!toxicity!(100%!O2!for!long!periods);!
tracheal!stenosis;!tracheal!dilation!
(
Ventilator(problems(
• Obstruction!–!leads!to!increase!in!inspiratory!pressure!or!a!
decrease!in!tidal!volume(
$ Caused!by:!mucous!in!ETT;!patient!biting!on!ETT;!foreign!body!
in!bronchus;!bronchospasm;!pneumothorax!
• Leak!–!leads!to!decrease!in!inspiratory!pressure!or!a!decrease!in!
tidal!volume!
$ Caused!by:!improper!attachment!of!the!tubes!to!ventilator!or!
humidifier;!a!leaking!expiratory!valve;!ETT!in!esophagus!
Modes(of(ventilation(
• Controlled!mechanical!ventilation!(CMV)!–!fully:controlled!
mechanical!ventilation!by!intermittent!positive!pressure!
• Intermittent!mandatory!ventilation!(IMV)!–!allows!the!patient!to!
breath!spontaneously!in!between!mandatory!tidal!volumes!
delivered!by!the!ventilator!
• Positive!end:expiratory!pressure!(PEEP)!and!continuous!positive!
airway!pressure!(CPAP)!–!they!both!aim!to!elevate!the!airway!
pressure!during!expiration!in!order!to!improve!the!FRC!and!
improve!arterial!oxygenation;!PEEP!is!used!for!mechanical!
ventilation!while!CPAP!is!used!for!spontaneous!breathing!
(
Weaning(patients(from(ventilator(support(
• Should!be!considered!as!soon!as!the!problems!requiring!
ventilation!have!begun!to!resolve!
• Factors!that!prevent!weaning!of!the!patient!from!ventilator!
$ Respiratory,!circulatory,!neurological!or!metabolic!failure!
$ Fluid!and!electrolyte!imbalance!
$ Feeding!problems!
$ Fever!and!infection!
• Methods!of!weaning!
$ Weaning!process!should!start!with!patient!in!sitting!position!
and!aspiration!of!all!bronchial!secretions!
$ Patients!on!ICU!are!weaned!using!IMV!with!PEEP/CPAP!as!
needed!
$ After!the!patient!has!been!fully!weaned!from!the!ventilator,!
he/she!can!be!extubated!→!only!when!the!tube!is!no!longer!
required!for!airway!maintenance,!airway!protection!or!
bronchial!toilet!and!physiotherapy!!
10. Systemic%Inflammatory%Response%Syndrome,%Sepsis%
!
Sepsis.!!
Defined!as!SIRS!in!response!to!a!confirmed!infectious!process.!Infection!can!be!
suspected!or!proven!(by!culture,!stain,!or!polymerase!chain!reaction!(PCR)),!or!a!
clinical!syndrome!pathognomonic!for!infection.!Specific!evidence!for!infection!
includes!WBCs!in!normally!sterile!fluid!(such!as!urine!or!cerebrospinal!fluid!
(CSF));!evidence!of!a!perforated!viscus!(free!air!on!abdominal!xray!or!CT!scan;!
signs!of!acute!peritonitis);!abnormal!chest!x:ray!(CXR)!consistent!with!
pneumonia!(with!focal!opacification);!or!petechiae,!purpura,!or!purpura!
fulminans.!
(
Severe(sepsis.!Defined!as!sepsis!with!organ!dysfunction,!hypoperfusion,!or!
hypotension.!
!
Septic(shock.!!
Defined!as!sepsis!with!refractory!arterial!hypotension!or!hypoperfusion!
abnormalities!in!spite!of!adequate!fluid!resuscitation.!!
To!meet!SIRS!criteria!the!patient!must!have!two!or!more!of!these:!
: Temp!>38°C!or!<!36°C!
: Heart!Rate!>!90!
: Respiratory!Rate!>!20!or!PaCO2!<!32!mm!Hg!
: WBC!>!12,000/mm>3,!<!4,000/mm>3,!or!>!10%!bands!
!
SIRS(is(nonspecific!and!can!be!caused!by!ischemia,!inflammation,!trauma,!
infection,!or!several!insults!combined.!Thus,!SIRS!is!not!always!related!to!
infection!
!
# Sepsis:!SIRS!+!confirmed!infection!
# Severity!is!assessed!by!the!degree!of!organ!damage.!
# Septic!shock:!sepsis!+!low!blood!pressure!(In!spite!of!adequate!fluid!
resuscitation.!Other!signs!include!oliguria!and!altered!mental!status.)!
!
Signs(of(systemic(hypoperfusion!may!be!either!end:organ!dysfunction!or!
serum!lactate!greater!than!4!mmol/dL.!Other!signs!include!oliguria!and!altered!
mental!status.!Patients!are!defined!as!having!septic!shock!if!they!have!sepsis!plus!
hypotension!after!aggressive!fluid!resuscitation!(typically!upwards!of!6!liters!or!
40!ml/kg!of!crystalloid).!
!
11. Differential%Diagnosis%of%Coma%&%Qualitative%
Cerebral%functions%Disturbances%
DEFINITION
• Victim is unresponsive to verbal stimuli
Quantitative:
• GCS <8 points
• Somnolence – stupor – coma
Qualitative:
• Vigilant coma (coma depassé, apalic sy
COMA - PATIENT EXAMINATION

1. Causalities - history
2. Clinical examinations
• Patient responded to requests, contacts, painful
stimuli.
• Performance: Injuries, foetor, convulsions, body
position, ocular signs, head stiffness, lateralisation,
fever, breathing, signs of organ failure... BP, P
3. SpO2
4. Laboratory tests: Glycaemia, K, Na, Hb, ABG,
BUN, creatinine, AST, ALT, osmolality, toxicology
5. Brain CT...
CAUSES OF COMA
• Traumatic brain injury
• Intoxications with CNS depressants
• Metabolic encephalopathy (MOSF, post
• CPR sy, hepatic, uremic, diabetic, hyperosmotic, hypoglycaemic...)
• Cerebral bleeding (apoplexy, SH)
• Collapse, syncope, hypoxia
• Epilepsy
• CNS infection (encephalitis, meningitis)
• Hypothermia
• General anaesthesia, deep analgosedation
!
Test(brainstem(dysfunction(
•Pupillary!response!
•Corneal!reflex!
•Spontaneous!eye!movements!
•Oculocephalic!response/Doll’s!head!
manoeuvre!
•Oculovestibular!response!
•Swallowing!
•Respiratory!pattern!
!
Diseases(that(cause(no(focal(or(lateralizing(neurologic(signs,(usually(with(
normal(brainstem(functions;(CT(scan(and(cellular(content(of(the(CSF(are(
normal!
" Intoxications:!alcohol,!sedative!drugs,!opiates,!etc.!
" Metabolic!disturbances:!
anoxia,!hyponatremia,!hypernatremia,!hypercalcemia,!diabetic!
acidosis,!hypoglycemia,!uremia!etc.!
" Severe!systemic!infections:!pneumonia,!septicemia,!typhoid!fever,!
malaria,!Waterhouse:Friderichsen!syndrome!
" Shock!!
" Post!seizure!states,!status!epilepticus,!subclinical!epilepsy!
" Hypertensive!encephalopathy,!eclampsia!
" Severe!hyperthermia,!hypothermia!
" Concussion!
" Acute!hydrocephalus!
!
Somnolence!is!a!person!who!shows!excessive!drowsiness!and!responds!to!
stimuli!only!with!incoherent!mumbles!or!disorganized!movements.!
Stupor(means!that!only!vigorous!and!repeated!stimuli!will!arouse!the!individual,!
and!when!left!undisturbed,!the!patient!will!immediately!lapse!back!to!the!
unresponsive!state.!
Coma(is!a!state!of!unarousable!unresponsiveness.!
!
!
12. Comatose%Patient%Care%
(
Coma!is!a!state!of!unconsciousness!from!which!the!patient!cannot!be!aroused.!It!
is!defined!by!Glasgow!coma!scale.!There!will!be!no!evidence!of!arousal!which!
means:!no!spontaneous!eye!opening,!no!speech!or!voluntary!limb!movement!!
Patient!will!be!unresponsive!to!external!stimuli.!Seizurs!may!occur!
GCS!<!8!patients!is!in!coma!
!
Causes!can!be!metabolic,!infective,!traumatic!or!neurological.!!
!
Stabilize(the(patient(ABC:(
" Open!the!airway,!breathing,!give!oxygen!and!stabilize!the!cervical!spine!as!
required!
" Consider!intubation!if!the!GCS!is!<8,!to!protect!the!airway.!
" Support!the!circulation:!Correct!the!hypotension!
" Treat!seizures!(Diazepam,!phenytoin)!
" Take!blood!for!glucose,!U+Es,!calcium,!liver!enzymes,!albumin,!clothing!
screen,!FBC,!toxicology!(+Urine)!
!
Consider(giving:((
Thiamine!if!Wernickes!enchalopathy!is!present!
Glucose!(40!ml!40%!glucose)!
Nalaxon!if!opiate!intoxication!
Flumazenil!if!there!is!benzodiazepine!intoxication!
!
!
!
!
!
!
Examine(the(patient:((
• Take!history!from!family!or!witness!
• General!examination:!Core!temperature,!Heart!rate,!rhythm,!BP,!
Respiratory!pattern,!breath,!skin,!heart,!abdomen!and!fundi.!
• Check!for!meningitis:neck!stiffness!
• Asses!Glasgow!coma!scale!
• Look!for!evidence!of!brainstem!dysfunction:!
o Pupillary!response!
o Corneal!reflex!
o Spontanous!eye!movements!
o Oculocephalic!response!
o Oculovesticular!response!
o Swallowing!reflex!!
o Respiratory!pattern!
• 8)Check!for!lateralizing!signs!
!
Further!investigation!should!be!done,!like:!
CT!scan,!lumbar!puncture,!CSF!analysis!
!
13. Traumatic%Brain%Injury.%Brain%Oedema,%
Management%of%Intracranial%Pressure%
CEREBRAL OEDEMA
• Signifies an increase in the brain water content.
• There are three different types of cerebral oedema - vasogenic, cytotoxic, and
interstitial.
• Cerebral oedema must be distinguished from brain swelling, which is due to an
increase in cerebral blood volume (congestion).
Aims of TBI treatment

• To respect primary cerebral insult
• Secondary damage prophylaxis
• Cerebral oedema treatment
o (ICP-targeted therapy)
• Brain perfusion
o autoregulation disturbances
• (CPP-targeted therapy)
o ↑ chance for recovery
• Raised ICP:
o immediate management
o Open the airway, intubation, mechanical ventilation, keep PaCO2 3,3 –
4,0 kPa (25-30mmHg)
o Correct hypotension: colloids, infusions of inotropes
o Treat seizures
o Take blood for glucose, U+Es, calcium, liver enzymes,albumin, clotting
screen
• TREATMENT OF TRAUMATIC BRAIN INJURY
o ABC CPR
o Ventilation (paCO2, paO2)
o Cerebral perfusion (BP, anaemia...)
o Head position (medial line,15-30o)
o Venous drainage from head
o Anti-oedematous therapy
o Convulsions, cough (sedation, analgesia...)
o Artificial sleep (analgosedation)
o Decompressive craniectomy
o Mannitol 20% 0.25-1.0 g/kg bw
o PaCO2 4-4,5 kPa
o MgSO4
o Lidocain
o Furosemide
o Hypertonic Saline (3-25
14. Brain%Death.%Organ%Donation.%Transplant%
Programme.%
Brain(death(
• Is!irreversible!loss!of!the!capacity!for!consciousness!combined!with!
irreversible!loss!of!capacity!to!breathe(
Preconditions!
• No!doubt!that!pt.!has!structural!brain!damage!which!has!been!diagnosed!
• Pt!must!be!in!apnoeic!coma!(on!mechanical!ventilator)!
• No!possibility!of!drug!intoxication,!no!significant!metabolic,!endocrine,!
electrolyte!l,!FB!
!
(BRAIN(DEATH(
• Brain(death(=!death(of(person(
• Brain!death!versus!cardiac!death!
• Organ!donation!from!deceased(donors((HBD(L(NHBD).(
• Relatives!organ!donation!from!living!donors.!
• Opting(out(
o anyone!who!has!not!refused!is!a!donor!
• Opting(in((
o anyone!who!has!not!given!consent!is!not!a!donor!!
(
Test(for(confirmation(of(brain(death(
All(brainstem(reflexes(must(be(absent((12(pairs)(
•!Pupils!fixed!and!unresponsive!to!bright!light!
•!Absent!cornel!reflexes!
•!Absent!vestibulo:ocular!reflexes!
•!No!motor!response!within!the!cranial!nerve!
distribution!
•!No!reflex!response!to!touching!the!pharynx,!nor!to!a!suction!catheter!
passed!into!the!trachea!
!
CLINICAL(BENCHMARKS(FOR(BRAIN(DEATH(
1.(Coma,(GCS!=!3,!known!irreversible!cerebral(lesion!
(Cave:!intoxication,!metabolic!disturbances,!
hypothermia,!myorelaxants).!Absent!functions!of!
brain!stem.!
2.(Apnoe(without!artificial!ventilation,!positive!apnoeic!
test.!
3.!Lack!rr!of!all(cerebral(nerves.(
4.!No!spontaneous!muscle!movements!(spinal(rr!
sometimes!are!present)!
5.(Absent(panangiographic(cerebral(perfusion!(
Panangiography!is!confirmation!test!(no!mandatory!
in!Slovakia!
!
DONOR(MONITORING(
: Continual!EKG!
: NIBP!á!10!min,!CVT!á!4:6!h,!
: Diuresis/h,!fluid!balance!
: K,!Na,!ABG!á!4!h,!SpO2,!(ETCO2)!
: Body!temperature!(core)!
: BP!measurement!invasive,!(S:G!catheter?)!
!
Tx(PROGRAM(
ORGANS! !
•!Kidney! TISSUES!
•!Heart! •!(Blood)!
•!Liver! •!(Bone!marrow)!
•!Lungs! •!Cornea!
•!Pancreas! •!Bones
!
15. Acid;Base%Balance%&%Fluids%Disturbances%
•!Water!–!hyper!or!dehydration!
•!Osmolality!(Na)!–!hyper!and!hypo:osmolality!
•!Oncotic!changes!
•!Ions!disturbances!
•!ABB!changes!
!
DAILY(WATER(BALANCE(IN(ADULTS(WATER(INTAKE(
Water!intake!in!form!of!fluids!(volumes!of!drinks!including!soups)!:1000:
1500!ml!
Water!intake!in!form!of!semi:solid!and!solid!foods!:!700!ml!
Water!of!oxidation!300!ml!
Total!daily!water!intake!2000:2500!ml!
(
WATER(OUTPUT(
water!loss!in!urine!1000:1500!ml!
water!loss!through!skin!500!ml!
water!loss!through!lungs!400!ml!
water!loss!in!stools!100!ml!
Total!daily!output!2000:2500!ml!
!
Water!
1.!basal!requirements!
2.!deficit!(excess)!
3.!increased!looses!
•!30!:!50!ml/kg/day!=!2100!:!3500!ml/70!
kg/day!
•!Metabolic!water!=!300!(:1000)!ml/24!h!
•!Non:measurable!physiological!looses!
are!800!:!1000!ml/24!h!
!
DAILY(DIURESIS(
•!Max!concentration!renal!capacity!=!
500!:!600!ml/24!h!
(sp.!grav.!1032!:!1026)!=!1100!:!800!
mosmol/kg!
•!Without!stress!daily!requirements!for!
excretion!=!600!mosmol/kg!
•!In!stress!cca!3x!more!
=!cca!2,5!litre!urine!
!
An!acid!is!a!hydrogen!ion!donor!(proton!donor)!while!a!base!accepts!hydrogen!
ions.!
(
Terminology(and(definitions(
• pH!is!the!negative!log!of!hydrogen!ion!concentration!→!pH!=!:log10!
[H+]!
• The(normal(ECF!pH!is!7.35:7.45!→!acidosis!is!pH!<7.35!and!
alkalosis!is!pH!>7.45!
• The!body!tries!to!maintain!the!physiologic!range!of!pH!by!several!
systems:!blood!buffers!(bicarbonate,!Hb,!protein!and!phosphate!
buffer!systems),!respiratory!mechanisms!and!renal!mechanisms!
• Respiratory(acidosis!is!defined!as!a!fall!in!pH!as!the!result!of!
increased!PCO2!→!e.g.!due!to!hypoventilation!and!CO2!retention!
seen!in!COPD!etc.!
• Respiratory(alkalosis!is!defined!as!a!rise!in!pH!as!the!result!of!
decreased!PCO2!→!e.g.!due!to!hyperventilation!seen!in!psychiatric!
patients!
•Metabolic(acidosis!is!defined!as!a!fall!in!pH!due!to!anything!other!
than!CO2!retention!(there!is!retention!or!gain!of!H+!or!HCO3:!loss)!
→!e.g.!in!renal!failure,!diabetic!ketoacidosis,!lactic!acidosis!
• Metabolic(alkalosis!is!defined!as!a!raise!in!pH!due!to!anything!
other!than!decreased!CO2!(there!is!either!gain!of!HCO3:!or!loss!of!
H+)!→!e.g.!in!severe!vomiting!
• In!primary!respiratory!acidosis/alkalosis,!the!kidney!will!retain!or!
excrete!HCO3:!to!compensate!for!the!acidosis/alkalosis!
respectively!→!causes!secondary!or!compensatory!metabolic!
alkalosis!or!acidosis!
• In!primary!metabolic!acidosis/alkalosis,!the!response!will!be!
hyperventilation!(excretion!of!CO2)!or!hypoventilation!(retention!
of!CO2)!respectively!
o Interpretation(of(acidLbase(changes(
• For!the!evaluation!of!acid:base!changes,!blood!gases!are!essential:!
pH,!HCO3:!and!PCO2!→!pH!and!PCO2!(and!PO2)!are!measured!
directly!by!the!blood:gas!machines!while!HCO3:!is!calculated!via!
Henderson:Hasselbach!equation!
• HCO3:!should!normally!be!22:26!mmol/l!and!PCO2!should!be!35:
45!mmHg!
• Base!excess!(BE)!is!informative!about!the!metabolic!status!of!the!
patient!→!BE!should!be!:3/+3!mEq/l!(it!is!really!positive!in!
metabolic!alkalosis!and!really!negative!in!metabolic!acidosis)!
• Anion!gap!helps!to!distinguish!between!MAC!with!high!or!normal!
anion!gap!→!AG!=!Na!–![Cl!+!HCO3:]!should!normally!be!12!+/:!4!
mmol/l!
o Treatment(of(acidLbase(disturbances(
• Treat!the!underlying!cause!
• If!there!is!primary!respiratory!acidosis/alkalosis!it!can!be!
corrected!by!artificial!ventilation!(corrects!PCO2!by!adjusting!the!
minute!ventilation)!
• Metabolic!acidosis!can!be!corrected!with!sodium!bicarbonate!→!
only!in!severe!cases!and!if!respiration!is!not!impaired!(CO2!
excretion!should!be!ensured)!
(
16. Blood%Loss%Supplementation,%Infusion%Therapy%
o When!prescribing!fluid!regimens!for!patients!one!has!to!consider:(
• The!basal!requirements(
• Additional!ongoing!losses!(
• Preexisting!dehydration!and!electrolyte!losses(
(
o Basal(requirements(
• The!basal!requirements!of!water!are!2600!ml/day!(~!30:40!
ml/kg/day)!while!sodium!and!potassium!require!1!mmol/kg/day!
each(
• Fluid!regimens!that!meet!the!basal!requirements!include:!normal!
saline!(0.9%!NaCl!–!300!mOsm/l),!Hartman’s(solution!(Ringer’s!
lactate!–!280!mOsm/l),!5%!dextrose!(5%!glucose!–!280!mOsm/l),!
dextrose!saline!(glucose!4%!plus!NaCl!–!280!mOsm/l)(
• Potassium!chloride!is!added!to!the!solution!bags!(should!never!be!
injected!as!bolus!)!→!should!be!used!with!caution!to!avoid!
hyperkalemia!(especially!in!anuric!patients)(
o Continuing(loss(
• Patients!with!continuing!losses!above!the!basal!requirements!need!
extra!fluid!→!common!cause!is!bowel!obstruction(
• Saline!with!added!potassium!is!used!to!replace!the!losses!→!avoid!
the!use!of!dextrose!saline!or!5%!glucose!(has!low!Na!content)!
because!hyponatremia!can!ensure(
• To!keep!track!of!the!fluids,!a!fluid:balance!chart!should!be!kept!
(records!all!fluids!in!and!out!of!the!body)(
• Every!patient!who!receives!i.v.!fluids!needs!reevaluation!of!fluid!
and!electrolyte!balance!every!day!→!new!regimen!has!to!be!
prescribed(
o Correction(of(preexisting(dehydration(
• Patients!with!preexisting!dehydration!need!to!be!resuscitated!with!
i.v.!fluid!above!their!basal!requirements(
• The!challenge!is!to!identify!from!which!compartments!the!fluid!has!
been!lost!and!to!assess!the!extent!of!dehydration(
• Assessment!of!fluid!deficit(
$ Is!done!with!the!help!of!history,!clinical!examination!and!
laboratory!tests(
$ On!physical!examination!dehydrated!patients!present!with:!
thirst,!dry!mucous!membranes,!sunken!eyes,!loss!of!skin!
elasticity,!weakness,!tachycardia,!oliguria,!cold!extremities!
(peripheral!vasoconstriction)!→!eventually,!BP!and!CO!will!fall!
and!vital!organs!are!hypoperfused(
$ Weight,!pulse,!BP!and!urine!output!are!essential!measurements!
for!the!assessment!of!fluid!loss(
• Central(venous(pressure(
$ CVP!is!measured!by!inserting!a!catheter!into!a!central!vein!
(jugular,!subclavian)!→!the!tip!lies!in!the!superior!vena!cava!or!
the!right!atrium!→!the!CVP!is!obtained!by!an!electronic!
transducer!or!by!connecting!the!patient!to!an!open:ended!
column!of!fluid!and!measuring!the!height!above!0!with!a!ruler!
(the!zero!point!is!the!5th!rib!in!the!mid:axillary!line!with!the!
patient!supine)!
$ The!normal!range!of!CVP!is!3:8!cmH2O!→!negative!value!
indicates!dehydration!
$ CVP!measurement!is!a!useful!guide!for!the!adequacy!of!
treatment!→!the!CVP!initially!rises!but!then!falls!due!to!
vasodilation!
$ If!CVP!remains!high!(does!not!fall)!this!indicates!the!overfilling!
or!a!failing!heart!
• Quantification!of!plasma!and!ECF!losses!
$ Changes!in!plasma!albumin!and!hematocrit!provide!a!good!
guide!to!ECF!losses!→!hematocrit!for!plasma!loss!only!
• Water!and!electrolyte!replacement!
$ ECF!losses!of!water!and!electrolytes!should!be!corrected!by!
normal!saline!or!Ringer’s!lactate!with!added!potassium!
• Plasma!replacement!and!plasma!substitutes!
$ If!plasma!has!been!lost!it!can!be!either!replaced!by!FFP!or!one!
of!the!synthetic!plasma!substitutes!(human!plasma!protein!
fraction)!as!well!as!by!solutions!that!generate!an!oncotic!
pressure!(colloids)!
$ These!colloids!include!dextrans!(interfere!with!coagulation),!
gelatins,!hetastarch!(can!cause!coagulation!problems)!
$ Crystalloids!(e.g.!saline)!can!also!be!used!but!only!¼!stays!in!
the!blood!vessels!
• Blood(loss(and(transfusions!→!always!consider!risks!and!
benefits;!whole!blood!or!blood!components!can!be!transfused!(RBC!
concentrates,!platelet!concentrates,!FFP,!cryoprecipitate,!etc.)!
o Intraoperative(fluid(balance!
• During!surgery!variable!mechanisms!can!lead!to!fluid!loss!→!water!
and!electrolyte!loss,!blood!loss,!plasma!loss,!ECF!loss!!
• In!intraabdominal!surgery,!Hartmann’s!solution!5!ml/kg/h!can!be!
given!up!to!2!liters;!blood!or!colloids!may!have!to!be!given!in!
addition!
• For!the!first!36!hours!after!surgery!there!is!water!and!Na+!
retention!but!obligatory!potassium!loss!!
• Postoperatively,!the!patient!should!receive!the!basal!requirements!
(30:40!ml/kg!water!plus!1!mmol/kg!of!sodium!and!potassium)!→!
start!potassium!only!when!urine!output!is!reestablished!
!
!
17. Life;threatening%Haemorrhage.%Haemorrhagic%
Shock%
Hemorrhagic!shock!is!a!condition!of!reduced!tissue!perfusion,!resulting!in!the!
inadequate!delivery!of!oxygen!and!nutrients!that!are!necessary!for!cellular!
function.!Whenever!cellular!oxygen!demand!outweighs!supply,!both!the!cell!
and!the!organism!are!in!a!state!of!shock.!
!
On!a!multicellular!level,!the!definition!of!shock!becomes!more!difficult!
because!not!all!tissues!and!organs!will!experience!the!same!amount!of!oxygen!
imbalance!for!a!given!clinical!disturbance.!Clinicians!struggle!daily!to!
adequately!define!and!monitor!oxygen!utilization!on!the!cellular!level!and!to!
correlate!this!physiology!to!useful!clinical!parameters!and!diagnostic!tests.!
18. Patient%Management%with%Multiple%Injuries.%
• Multiple!injuries!or!polytrauma!is!a!medical!term!describing!the!
condition!of!a!patient!who!has!been!subject!to!multiple!traumatic!
injuries.(
• Multiple!injuries!can!be!assessed!with!an!Injury!Severity!Score!(ISS)!→!
1!to!75!points!(75!is!maximally!injured)!→!major!trauma!or!
polytrauma!is!defined!as!an!ISS!score!>15(
• When!a!patient!with!multiple!injuries!is!brought!to!the!hospital!always!
assess:(
• ABCDE!–!Airway,!breathing!circulation,!disability!and!exposure!
• Airway(management!–!is!indicated!if!patient!is!unconscious;!most!
trauma!patients!will!have!a!full!stomach!and!therefore!there!is!the!risk!
of!aspiration!(perform!cricoids!pressure)!
• Breathing!–!fractured!ribs!penetrating!the!pleura!or!lungs!or!
pneumothorax!may!influence!breathing!
• Circulation!–!hypotension!and!tachycardia!may!be!a!sign!of!
hypovolemia!→!administration!of!fluids!and!vasopressors!may!be!
required;!other!causes!of!reduced!cardiac!output!include!cardiac!
tamponade!or!tension!pneumothorax,!fat!embolism!
• Disability!(neurological!status)!–!assess!GCS!or!AVPU;!might!predict!
the!neurological!outcome;!can!indicate!massive!blood!loss!as!well!as!
cerebral!hypoperfusion!due!to!raised!ICP!in!patients!with!head!trauma!
• Exposure!–!evaluate!other!parameters!(glucose,!arterial!blood!gases,!
acid:base!balance,!etc.);!find!the!source!of!blood!loss;!treat!the!injuries!
according!to!their!priority!
• An!i.v.!access!is!always!mandatory!
• For!induction!of!anesthesia,!a!rapid!induction!technique!is!preferred!
to!reduce!the!risk!of!gastric!aspiration!
19. Parenteral%&%Enteral%Nutrition.%
• If GIT tract work :Use enteral nutrition
• If GIT tract does not work: Use parenteral nutrition
!
It!is!best!to!use!the!enteral!route!if!possible,!however!adequate!calorie!intake!is!
often!difficult!to!achieve.!
!
Malnutrition!in!critically!ill!after!extensive!surgery!causes:!
•!Decrease!of!immune!functions!
•!Improper!wound!healing!
•!Higher!frequency!postoperative!complications!
•!Longer!LOS!
!
Aims(of(nutritional(support:(
: Maintain!lean!body!mass!
: Immune!system!support!
!
Daily(demands:(
•!Sacharides!55%!(3:6!g/kg)!
•!Proteins!15%!(1:2!g/kg)!
•!Fett!30%!(0,5!–!1,5g/kg)!
!
Routes(of(enteral(feeding(
• Nasogastric!feeding!is!the!most!commonly!used!route,!but!it!relies!on!
adequate!gastric!emptying.!Sometimes!it!is!impossible!to!pass!the!
nasogastric!tube!or!maintain!its!position.!Feed!is!usually!started!at!about!
20!ml/hour!via!a!continuous!infusion!pump!and!increased!slowly,!
provided!the!gastric!residue!after!4!hours!does!not!exceed!200!ml.!!
• Nasojejunal!feeding!avoids!the!pylorus!and!is!used!in!patients!with!
gastric!stasis.!Nasojejunal!tubes!are!more!difficult!to!pass!and!often!
require!insertion!under!direct!fibre:optic!observation.!Feeds!are!started!
at!about!30!ml/hour.!Absorption!is!assessed!by!checking!for!abdominal!
discomfort!and!distension.!
• Percutaneous(gastric(feeding(–!using!an!endoscopic!technique,!a!tube!is!
passed!percutaneously!into!the!stomach!to!avoid!the!discomfort!of!a!
nasogastric!tube.!These!can!be!used!for!continuous!or!bolus!feeds.!They!
are!commonly!used!in!patients!requiring!long:term!enteral!feeding,!such!
as!those!with!cerebral!palsy,!after!head!injury!and!following!major!
maxillofacial!surgery.!
• Percutaneous(jejunal(feeding(–!the!percutaneously!placed!tube!passes!
from!the!stomach!into!the!jejunum.!This!route!is!sometimes!used!for!
postoperative!feeding!if!gastric!stasis!is!likely!and!a!nasojejunal!tube!
cannot!be!passed.!
!
Parenteral(feeding((TPN)((usually(central(line)(
• When!the!bowel!is!not!functioning,!unable!to!be!used!or!all!attempts!at!
feeding!using!this!route!have!failed,!parenteral!nutrition!is!indicated.!
• Insertion!of!a!feeding!line!is!usually!undertaken!by!doctors!and!cared!for!
by!nurses;!the!dietitian!can!advise!on!nutritional!requirements!and!the!
pharmacist!can!recommend!nutritional!preparations!and!additives.!
!
(
(
Common(reasons(for(requiring(TPN(are:(
–!post!surgery!–!if!bowel!function!is!likely!to!be!disturbed!
–!Short:bowel!syndrome!
–!Gastrointestinal!fistulae!
–!Prolonged!paralytic!ileus!
–!Inflammatory!bowel!disease!
–!Preoperatively!–!in!malnourished!patients!with!ineffective!bowel!function.!
Sepsis,!severe!burns!and!pancreatitis!were!also!considered!reasons!for!using!the!
parenteral!route,!but!enteral!nutrition!is!now!recognized!as!more!appropriate.!
!
TPN!solutions!should!contain!a!balanced!mix!of!AA,!carbohydrate!and!lipid,!
together!with!water,!vitamins,!electrolytes!and!minerals.!Generally!TPN!is!
produced!in!large!bags!containing!all!the!requirements!for!24!hours.!
!
Monitoring!is!important.!
Venous(access(
• Ideally,!TPN!should!be!given!via!a!tunnelled!subclavian!vein!central!line.!
The!incidence!of!catheter:associated!infection!can!be!reduced!by!
meticulous!care!during!insertion,!using!a!full!aseptic!technique.!A!post:
insertion,!chest!radiograph!should!be!taken!to!exclude!a!pneumothorax!
and!to!check!that!the!catheter!tip!lies!in!the!inferior!vena!cava!(such!
positioning!reduces!the!risk!of!thrombosis).!!
• To!reduce!the!risk!of!catheter:related!sepsis,!the!feeding!line!should!be!
used!for!TPN!only,!and!no!other!drugs!or!fluids!should!be!given!through!
the!catheter!nor!should!the!line!be!used!for!blood!sampling.!Some!
mixtures!of!TPN!are!specially!formulated!to!be!given!peripherally!for!
short:term!treatment,!but!intravenous!lines!used!for!such!a!purpose!
generally!have!a!short!life.!
(
Recent(advances(
• The!constituents!of!TPN!have!been!modified!and!simplified!over!the!past!
few!years.!
• The!use!of!a!single!bag!(AIO)!every!24!hours!reduces!the!infection!risk!by!
reducing!the!need!to!handle!the!line!connections.!Several!companies!have!
special!bags!that!allow!mixing!of!the!constituents!immediately!before!use!
without!the!risk!of!contamination,!this!increases!the!shelf:life!of!the!
product!and!enables!the!pharmacy!to!supply!TPN!almost!on!demand.!
• The!vitamins!and!minerals!required!are!available!in!single:day!vials!for!
addition!immediately!before!use.!Recent!research!on!immunotherapy!
suggests!that!the!addition!of!substances!such!as!glutamine,!arginine!and!
the!omega:3!fatty!acids,!may!enhance!the!immune!response!during!
critical!illness.!Recent!work!suggests!that!blood!sugar!control!in!a!tight!
range!(<10!mmol/l)!reduces!mortality!in!critical!care!patients.!
!
!
20.%Acute%Kidney%Injury,%Elimination%Methods%
Renal Assessment:
Impairment of renal function may present preoperatively as:
• Oliguria (<400 ml urine / 24 hours).
• Rising blood urea, creatinine or potassium.
The problem may be Acute (as a result of prerenal, renal or postrenal factors) or
chronic in which case patient maybe on dialysis or kidney transplantation.
Renal failure:
o Fluid underload or overload should be corrected and any hypotension /
hypertension reversed.
o Drug therapy should be used with caution, especially the nephrotoxic
antibiotics and digoxin whose excretion will depend upon renal function.
o Blood transfusion in the anemic patient maybe necessary but can cause a high
haematocrit and thus compromise renal blood flow.
In Acute renal failure, there is often considerable difficulty in differentiating

between Pre-renal and Renal failure in the acutely ill and oliguric surgical patient.
Blood and urine chemistry maybe useful.
Urine and Plasma values in renal failure:

Pre-renal Failure Renal Failure
Osmolality mOsm/L >500 <350
Urine sodium mmols/L <20 >40
U/P urea ratio >8 <3
U/P creatinine ratio >40 <20
In!Preparation!of!acute!renal!failure!patient!for!operation!theatre,!the!
Anesthetist!wants!a!comprehensive!work!up!of!general!and!specific!renal:
function!test.!
# Measurement!of!urea!and!electrolytes!will!give!an!indication!of!the!
severity!of!the!disorder!and!may!reveal!dangerous!hyperkalaemia.!!
Potassium!of!>!6!mmol/L!will!contraindicate!all!but!the!most!important!
surgery.!
# Full!blood!count!will!detect!any!amaemia!and!may!provide!evidence!of!
infection!or!blood!dyscrasia.!Blood!gases!will!give!a!useful!insight!into!
acid:base!status,!as!well!as!the!ventilator!ability!of!the!patient!to!
compensate!(by!hyperventilation!)!for!any!metabolic!acidosis.!!
# When!sever!metabolic!acidosis!exists!(!pH!<!7.2!)!,!preoperative!
haemodialysis!or!haemofiltration!maybe!necessary!.!
# In!the!fluid!overloaded!patient,!the!difference!between!actual!and!
predicted!PaO2(may!provide!a!more!sensitive!measure!of!incipient!
pulmonary!oedema!than!clinical!examination!or!chest!radiograph.!
# Finally,!measurement!of!central!venous!pressure!(CVP)!may!resolve!any!
lingering!doubts!about!whether!the!renal!failure!is!hypovolaemic!in!
origin.!!
(
Management(of(the(Ventilated(patient:(((renal(function()(
Patients!requiring!ventilatory!support!and!are!critically!ill!will!require!
Catheterization!of!the!bladder!to!monitor!the!urinary!output!per!hour.!
$ This!should!be!maintained!at!1ml/kg!per!hour!using!appropriate!fluid!
challenges!in!the!first!instance.(
$ Diuretics!should!never!be!used!to!treat!a!low!urinary!output!in!the!
presence!of!hypovolaemia.(
(
Renal!function!must!be!monitored!by!measuring!the!serum!creatinine!and!urea!
every!day.!
$ Creatinine!is!an!important!measurement!with!which!to!diagnose!
impending!renal!failure!as!the!presence!of!an!elevated!urea!maybe!due!to!
number!of!other!factors!such!as!catabolic!states.(
(
Elimination(Methods:(
(
A.(Extracorporeal(dialysis((Dialysis!by!a!hemodialysis)!
1.!Continuous(VenoLVenous(Hemodialysis((CVVHD):(most!common.!
2.!Intermittent(dialysis:!also!common.!
4.(Continuous(VenoLVenous(Hemofiltration((CVVH).(
5.!Continuous(ArterioLVenous(Hemofiltration((CAVH).(
(
B.(Forced(Diuretics:(Furosemide((
!
!

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Anesthesiology,and,Intensive,care,

Sinus tachycardia Sinus bradycardia

Ventricular fibrillation, asystole and pulseless

at a rate of at least 100 times per minute. One ventila-

Infant Small child Larger child

Airway Neutral Sniffing Sniffing

Landmark 1 finger’s breadth 1 finger’s breadth 2 fingers’ breadth

Technique 2 fingers or encircling 1 hand 2 hands

Depth 1.5–2.5 cm 2.5–3.5 cm 3–4 cm

1. Evidence of poor tissue perfusion:

COMA - PATIENT EXAMINATION

Aims of TBI treatment

In Acute renal failure, there is often considerable difficulty in differentiating

Urine and Plasma values in renal failure:

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