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163 Cards in this Set
- Front
- Back
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What is an anaphylaxis? |
A life threatening reaction to a chemical/foreign antigen affecting multiple organs or body systems. (Means without protection) |
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Anaphylaxis - Non pharmaceutical triggers |
■ mismatched blood ■ latex ■ foods ■ insect stings ■ exercise ■ exposure to extreme cold |
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Anaphylaxis - signs/symptoms - mucocutaneous |
《 erythema 《urticaria 《 puritis 《Angiodema |
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Anaphylaxis - signs/symptoms - eyes |
■ itching ■ lacrimation ■ oedema of eye lid ■ oedema of conjunctiva |
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Anaphylaxis - signs/symptoms - respiratory |
■ oedema ■ cough ■laryngospasm ■ dyspnoea ■ congestion ■ sneezing ■ rhinorrhoea ■ wheezing |
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Anaphylaxis - signs/symptoms - GI |
■ abdominal pain ■ nausea ■ vomiting ■ diarrhoea |
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Anaphylaxis - signs/symptoms - cardiovascular |
■ hypotension ■ dizziness ■ syncope ■ tachycardia or brady |
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Anaphylaxis during GA- initial treatments |
■ stop admin of possible antigen ■ maintain airway with 100% O2 ■ turn off all volatile agents ■ start IV volume expansion (2-4L) ■ admin adrenaline and titrated as necessary. ■ continue secondary drug therapies |
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Anaphylaxis during GA - secondary treatments |
■ Vasopressors - adrenaline, noradrenaline, dopamine ■ Antihistamines - pseudoephedrine ■ Corticosteroids - Hydrocortisone ■ bronchodilators - amiodarone, sabutamol |
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Anaphylaxis - Anaesthetic Triggers includes |
■ MR's (62%) - Sux, Vec, Roc, Miv ■ Antibiotics (8%) - Blactams(Penicillin), Glycopeptides (Vanc), Macrolides (Erythromycin) ■ Induction Agents (8%) - Thio, Ketamine, Propofol, Midaz ■ LA's (3%) - Lignocaine, Bupivacaine, EMLA ■ Opioid Analgesics (3%) - Morphine, Remi, Fentanyl ■ Other Pharmacological Triggers - Furosemide, Ketorolac, Paracetamol |
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What is Latex? What is Latex Allergy? |
Natural elastic product derived from the sap of the Hevea rubber tree found in Africa and South East Asia Allergy A reaction to certain proteins found in natural rubber latex ranging from mild skin reactions to Life Threatening conditions |
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Latex Allergy Causes |
Immune system identifies latex as a harmful substance and triggers certain antibodies to fight the allergen. ■ The antibodies signal the immune system to release histamine and other chemicals into the bloodstream - producing signs and symptoms |
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Latex Routes of Admin |
■ Direct Contact - touching latex-containing products ■ Inhalation - latex products like gloves shed latex particles which can be inhaled when airborne |
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Latex Allergy - Classifications |
■ Type I - Allergic reaction is caused by latex protein allergen (known as True Allergy) ■ Type II - Allergic reaction caused by chemicals used in the manufacturing process. |
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Latex may be found in what Anaesthetic Equipment/Materials |
■ Gloves/Attire ■ Catheters / Drains ■ IV Ports ■ Syringes ■ Rebreathing bags, Bellows and circuits ■ Stethoscopes ■ Eye Sheilds ■ Dressings / Tapes ■ Tourniquets ■ Drug Vial Stoppers ■ Airways ■ Matresses ■ Face Masks ■ Urinary Catheters ■ TEDS ■ BP Cuff hoses |
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Prevention/Management -Determine History (Do theses cause itching rash or swelling?) |
■ Inflating Ballons ■ Contraceptive Devices ■ Gloves |
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Prevention and Management |
■ Theatre prepared the night before ■ Patient schedule 1st on list ■ Include latex allergy information on Patients ID Bracelet ■ Apply latex allergy signage ■ Use only guaranteed latex free products ■ Remove all non-essential equipment ■ Limit Traffic ■ Resus equipment must be latex free and follow patient through stay |
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High Risk Groups |
■ Health Care Workers ■ Patients who have had multiple surgeries ■ Individuals with atopy (hay fever) ■ Patients with specific food allergies |
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What is a laryngospasm? When Does it Occur? |
A reflex closure of the vocal cords that may occur in anaesthetised patients Occurs ■ Emergence ■ Induction ■ Maintenance ■ Recovery |
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Laryngospasm - Causes |
■ Painful surgical stimuli ■ Laryngeal irritation ■ Inhalational Agent ■ Excessive airway secretions/blood ■ Laryngoscopy |
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Laryngospasm - Signs/Symptoms - Incomplete Airway obstruction |
■ Stridor - audible inspiratory/expiratory sound ■ Tracheal Tug ■ Abnormal Chest Movements |
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Laryngospasm - Signs/Symptoms - Complete Airway Obstruction |
■ No Breath Sounds ■ Tracheal Tug ■ Paradoxial respiratory movements |
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Laryngospasm - Risk Factors |
■ Surgical Type - Oral, Endoscopy, Surgical stimuli (anal stretch, cervical dilation) ■ Patient Age - Overall incidence of 8.7/1000 patients, Children (0-9yrs) 17.4/1000 x2, Infants (birth-3mth) 28.2/1000 x3. ■ Pre-exist Conditions - Asthma, Upper airway infection, History of complications, NG tube in stitu. ■ Anaesthetic Technique - Light Anasethesia, Irritant Volatiles, Barbiturates, Post Ex soiling of larynx (Blood, pus, saliva) |
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Laryngospasm - Emergency Management - incomplete obstruction |
■ Stop Stimuli ■ Remove Debris from larynx ■ 100% 02 ■ Apply gentle airway manoeuvres - chin lift, jaw thrust, laryngeal notch. |
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Laryngospasm - emergency management - Complete Obstruction |
■ Deepen Anaesthesia with IV agent ■ Administer MR ■ Intubation ■ Ventilate - cricothyrotomy |
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Laryngospasm - Preventions |
■ Identify at risk patients ■ Avoid manipulations of airway ■ Non-invasive airway ■ Adequate level of anaesthesia ■ TIVA ■ Admin Anticholinergics (decrease secretions) ■ Constant Oropharyngeal and tracheal suction ■ Awake Extubation |
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What is Stidor |
High pitched sound caused by rapid turbulent flow through a narrowed airway (More common in Paediatrics than adults) |
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Stridor - Causes (2 groups) |
■ Congenital Abnormalities ■ Narrowed Cricoid Ring ■ Laryngeal Abnormalities (clefts/webs) ■ laryngealomalacia (collapse of supraglotic structures on inspiration) ■ Laryngeal Stenosis ■ Acquired Conditions ■ Smoking ■ Diseases ■ Infections ■ Trauma ■ Laryngeal Irritation ■ Laryngeal Stimulation ■ Foreign Body ■ Allergic Reactions |
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What is a Bronchospasm and when does it occur? |
A reversible reflex spasm of the smooth muscle in the Bronchi Occurs at: ■ Induction ■ Maintanence ■ Emergence ■ Recovery |
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Bronchospasm - Signs and Symptoms |
■ Wheezing ■ Increasing circuit pressure ■ Rising ETCO2 ■ Reduction in Tidal Volumes |
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Immediate treatment of bronchospasm |
■ 100% O2 ■ Ventilate by hand ■ Stop Stimulation/Surgery ■ Consider Allergy/Anaphylaxis |
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Immediate Management to prevent hypoxia and reverse bronchoconstriction |
■ Deepen Anaesthesia ■ Check tube position and exclude blocked/misplaced tube ■ Eliminate breathing circuit occlusion by using self-inflating bag ■ Drug Therapies (Bronchodilators) ■ Salbutamol ■ Aminophyline ■ Adrenaline ■ Magnesium |
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What is ARDS (Adult Respiratory Distress Syndrome) |
A sudden progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged. Causes: ■ Pneumonia ■Aspiration ■ Sepsis ■ Trauma ■ Inhalation of toxic Substances |
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What is Asthma? Asthma Types? |
Chronic pulmonary disease that causes inflammation and obstruction of the small airways of the lungs - (most common chronic disease among children.) ■ Exercise induced asthma ■ Cough - variant Asthma ■ Occupational Asthma ■ Night Time Asthma |
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What is an Asthma attack? Signs and Symptoms? |
When exhalation becomes difficult and patients must force air out past constricted airways (produces wheezing sound on exhalation) ■ Wheezing ■ Bronchospasm ■ Cough ■ Dyspnoea |
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Asthma Attack - Classifications |
■ Intermittent - ■ Symptoms occur fewer than 2days/wk ■ Do not interfere with normal activities ■ Night time symptoms less than 2days/month ■ Mild Persistant ■Symptoms more than 2days/wk ■ Do not interfere with activities ■ Night time symptoms 3-4 times/month Moderate Persistant Severe Persistent ■ occur each day ■ Severely limit daily activities ■ Night time symptoms occur often/every night |
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Asthma Triggers |
■ Infection ■ Allergies dust mites, animal/dander,cockroaches, Moulds, Pollens ■ Exercise ■ Irritants Non Allergic Triggers Smoke, exercise, cold air, perfumes, intense emotions |
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Asthma - Treatments - medication can be divided into two broad categories |
■ Quick Relief Medications Short Acting beta2 agonists, Anticholinergics ■ Long Term Control Medicines Antileukotriens, Corticosteroids, long acting beta2 agonists, methylxanthines |
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Anaesthetic Meds Safe for Asthmatics |
Induction: Prop, Ket, Midaz Opioids: Pethidine, Fentanyl, Alfentanil MR: Vec, Roc, Sux Volatile Agents: Iso, Des, Sevo |
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What is COPD? |
■ A lung condition that is characterised by persistent blockage of airflow from the lungs. ■ Under-diagnosed, life threatening lung disease that interferes with normal breathing and is not fully reversible. |
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COPD Causes |
■ Emphysema ■ Chronic Bronchitis ■ Refractory (irreversible) Asthma ■ Smoking ■ Occupational Pollutants (Asbestos, Silica, Dust) ■Environmental Pollutants (soil, air) ■ Genetics (very rare) |
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COPD Lungs |
■ Airways and air sacs lose their elastic quality ■ Walls between many air sacs are destroyed ■ Walls of some airways become thick & inflamed ■ airways make more mucus than usual (clogs) |
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COPD Signs and Symptoms |
■ Breathlessness ■ Abnormal Sputum ■ Chronic Cough ■ Wheezing |
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COPD Treatments |
■ Long Term Oxygen Therapy (LTOT) ■ Bronchodilators ■ Antibiotics ■ Corticosteroids ■ Leukotriene ReceptorAntagonists ■ Lung expansion manuvers (exercise) ■ Lung volume reduction surgery ■ Lung Transplant |
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What is Cystic Fibrosis?
Key Characteristics? |
■ Hereditary disease (gene mutation on chroma some 7) that leads to a progressive disability. ■ Typically presents and diagnosed in early childhood (7% are diagnosed as Adults. Characteristics ■ Fibrous scar tissue develops in pancreas ■ Inability to move salt & water in and out of cell ■ Lungs & Pancreas secrete thick sticky mucus |
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CF - Effective Organs |
■ Sinuses ■ Lungs ■ Skin ■ Liver ■ Intestines ■ Pancreas ■ Testis ■ Ovaries |
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CF - Prognosis Improving and Median Survival Rates |
■ 38% of patients are older than 18 ■ 13% are older than 30 Males: 37yrs Females: 33yrs |
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CF - Common Presentations (nose and sinuses) |
■ Nasal Obstruction ■ Rhinorrhoea ■ Nasal Polyps (25%) |
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CF - Common Presentation - Lungs |
■ Thick viscous secretions ■ Pneumothorax ■ Chronic Lung Infections ■ Persistant cough with viscous, purulent, green sputum. |
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CF- Common Presentations - Pancreas |
■ Pancreatitis ■ Insulin Deficiency ■ Diabetes (DM) |
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CF - Common Presentations - other |
■ Infertility ■ Growth Failure ■ Jaundice |
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CF - Diagnosis - Sweat Test |
■ Measures the amount of chloride in sweat, children with CF can have 2-5 times the normal amount of chloride in their sweat. ■ The skin is stimulated to produce enough sweat to be absorbed into a special collector and then analysed. |
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CF - Management |
■ Preventing and controlling lung infections ■ Loosening and removing thick, sticky mucus in lungs ■ Preventing or treating blockages in intestines ■ Providing enough nutrition |
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CF - Treatments |
■ Antibiotic Therapy ■ Physiotherapy (chest/airway therapy) ■ Bronchodilators and decongestants ■ Mucolytic (Mucus thinners) |
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Pleural Emergencies include |
■ Pneumothorax ■ Pleural Effusion ■ Flail Chest ■ Cardiac Tamponade |
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What is a Pneumothorax? Types of Pneumothorax? |
■ The presence of air or gas in the pleural space, this results in the collapse of the lung on the effected side. Types ■ Closed/Simple - Opening in the lung tissue that leaks air into chest cavity - no communication with atmosphere. ■ Open - Opening in chest cavity allows air to enter pleural cavity - communication with atmosphere. |
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Signs and Symptoms - closed/simple pneumothorax? |
■ Sudden CHest Pain ■ Dyspnoea ■ Tachypnea ■ Decreased breath sounds on effected side |
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Pneumothorax - General Management - ATLS principles of resuscitation |
■ Primary Survey and early assessment ■ Simultaneous Aggressive Resus ■ Secondary Survey with full examination |
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ATLS Principles of Resuscitation - Airway |
■ Access for airway potency and gas exchange ■ Access fore intercostal and supraclavicular muscle retractions ■ Access oropharynx for foreign body obstacles |
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ATLS - Breathing |
■ Access respiratory movements and quality of respirations - look, listen, feel. |
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ATLS - Circulation |
■ Assess capillary refill ■ Assess pulses ■ Assess the BP |
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Closed Pneumothorax - treatment/management |
■ ABC's with C-spine control if required ■ Usually small and self resolving ■ Observation ■ Supportive Management |
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Open Pneumothorax - Signs and Symptoms |
■ Sudden sharp pain ■ Dyspnoea ■ Tachypnoea ■ Subcutaneous Emphysema ■ Decreased breath sounds (on effected side) ■ Red Bubbles on exhalation from wound |
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Subcutaneous Emphysema - Features |
■ Air collects in subcutaneous tissues ■ Feels like rice crisps ■ Can be seen from neck to groin area ■ Usually occurs on chest, neck and face |
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Open Pneumothorax - Treatment/management |
■ABC'S with c-spine control ■ Three sided occlusive dressing ■ Chest Intubation ■ Pleurectomy ■ Thoracotomy |
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Open Pneumothorax - 3 sided occlusive dressing |
■ On Inspiration: Dressing seals wound preventing air entering ■ On Expiration: Dressing allows trapped air to escape through untapped section of dressing. |
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Pneumothorax Types |
■ Primary Spontaneous Pneumothorax (PSP) - no underlying lung disease ■ Secondary Spontaneous Pneumothorax (SSP) - complications of underlying disease ■ Traumatic Pneumothorax - Penetrating/Blunt Trauma ■ Iatrogenic Pneumothorax - complication of diagnostic or therapeutic intervention |
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PSP - Causes |
■ Ruptured Pulmonary Blebs - pocket of air within visceral pleura ■ Smoking ■ Listening to loud music ■ Changes in atmospheric pressure |
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SSP - Causes |
■ COPD ■ TB ■ Asthma ■ CF |
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Traumatic Pneumothorax - Causes |
■ Blunt Trauma ■ Penetrating trauma ■ Compression Injury ■ Barotrauma |
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Iatrogenic Pneumothorax Causes |
■ Traumatic Intubation ■ Insertion of CVP ■ CPR ■ Pleural Biopsies |
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Tension Pneumothorax Features |
■ Develops when air leak occurs from lung or through chest wall/ ■ Air is forced into thoracic cavity without means of escape creating a "one way valve". |
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Tension Pneumothorax Signs and Symptoms |
■ Deviation of the trachea away from the side with the tension ■ Shift of the mediastinum ■ Depression of the diaphragm ■ A hyper-expanded chest that moves little with respiration ■ Raised CVP ■ Distended jugular veins ■ Tachycardia ■ Tachypnoea |
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Tension Pneumothorax - Treatment |
■ ABC;s with c-spine control ■ Needle Decompression - converts injury to simple pneumothorax ■ Chest Intubation ■ Supportive Management |
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Site for Needle Decompression |
■ 2nd Intercostal space ■ Medclavicular Line |
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Causes of Pneumothorax |
■ Penetrating Crush Trauma ■ Pulmonary Diseases ■ Sub Pleural Blebs ■ Lung Fistula ■ Barotrauma ■ CVP ■ CPR ■ PE ■ Loud Music ■ Pulmonary Oedema ■ Air Travel ■ Forceful Laughter ■ Positive mechanical ventilation ■ Smoking ■ Congenital Abnormalities ■ Traumatic Intubation ■ Laparoscopic Surgery |
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Pneumothorax - Diagnostic Methods |
■ Observation of chest movement ■ Examination with Stethoscope ■ Chest X Ray ■ MRI ■ CT |
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Pneumothorax - stethoscope examination |
■ Asymmetric Chest Expansion ■ Diminished Breath Sounds unilaterally ■ Hyper-resonance (dullness) unilaterally ■ Decreased tactile remits (palpable vibrations) |
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What is Pleural Effusion and it's types? |
■ Excess fluid that accumulates in the pleural cavity. Types. ■ hemothorax (blood) ■ Urinothorax (urine) ■ Pyothorax (pus) ■ Hydrothorax (serous fluid) |
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Pleural Effusions - Causes |
■ CHF ■ Liver Cirrhosis ■ Peritoneal dialysis ■ Obstructive Uropathy ■ End stage Kidney Disease |
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Hemothorax Key Characteristics |
■ Occurs when pleural space fills with blood ■ Usually due to lacerated blood vessel in thorax ■ Puts pressure on heart and other vessels in chest cavity ■ Each lung can hold 1.5 L of blood. |
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Hemothorax - signs and symptoms |
■ Tracheal deviation to unaffected side ■ Dull resonance on percussion ■ Unequal chest rise ■ Tachycardia ■ Hypotension ■ Hypovolemic Shock signs - pale, cool, clammy skin ■ Frothy blood sputum ■ Flat neck veins |
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Hemothorax Treatment |
■ ABC's with C-spine control ■ General shock care due to blood loss ■ Chest Intubation ■Thoracotomy <1500ml initial drainage |
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Flail Chest Featurs |
■ Free floating chest segment ■ fractures of 3 or more ribs in 2 or more places ■ Flail section moves in opposites direction to rest of the chest wall (paradoxical breathing) ■ 50% mortality |
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Flail Chest - Paradoxical Movement |
■ Flail portion of chest is sucked in with inspiration, instead of expanding outward ■ Flail portion balloons out with expiration, instead of collapsing inward |
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FLAIL CHEST Types |
■ Sternal Flail ■ Lateral Flail |
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Flail Chest Signs and Symptoms |
■ Paradoxical motion ■ Shortness of breath ■ Haematoma ■ Crepitus (grinding of bone ends on palpation) ■ Tachycardia ■ Hypotension |
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Flail Chest treatment |
■ ABC's with C-spine control ■ Analgesia - intercostal blocks ■ Positive Pressure Ventilation ■ Chest Intubation ■ Surgical Fixation |
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Pericardial Tamponade Features |
■ Rapid accumulation of blood in space between heart, pericardium ■ Heart compressed ■ Blood entering heart decreases ■ Decreased Cardiac Output |
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Pericardial Tamponade - Signs/Symptoms - Becks triangle |
■ Decreased Arterial Pressure ■ Distended Jugular Veins ■ Distant heart sounds |
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Pericardial Tamponade Treatments |
■ ABC's with c-spine control ■ Pericardiocentesis ■ Thoracotomy |
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Chest Tube Drainage Indications |
■ Pneumothorax ■ Tension Pneumothorax ■ Hemothorax ■ Post-op cardiothoracic surgery ■ Pleural Effusion |
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Chest Tube Drainage 3 stage principles |
■ Stage 1: Remove fluid and air from pleural as promptly as possible ■ Stage 2: Prevent drained air and fluid from returning to the pleural space ■ Stage 3: re-build negative intracellular pressure to ensure lung expansion |
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Chest Tube Types and insertion methods |
Types ■ Pleural ■ Mediastinal Insertion Methods ■ Trochar based - allows for easier insertion, greater risk ■ Blunt Dissection - safest method |
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Chest Drainage System Components and Types |
Components ■ Collection chamber ■ Water Seal Chamber ■ Suction Control Chamber Types ■ Water seal chest drain (collection,waterseal, wet suction chambers) (features: Additional suction and intermittent bubbling indicates proper functioning) ■ Dry seal chest drain (collection,waterseal, wet suction chambers) Feature: regulated suction, indicator for suction pressure, quiet ■ Dry seal with 1 way valve - ambulatory patient |
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What is a thrombus? |
Blood clot that forms locally in a vessel obstructing the flow of blood through the circulatory system |
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What is deep vein Thrombosis (DVT) Signs and Symptoms? |
Blood clot that forms in the deep veins of the leg or pelvis. (DVT in thigh carries high risk of PE) ■ Leg pain ■ Tenderness ■ Ankle Oedema ■ Dilated Veins ■ Warmth |
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Virchows triad describes the 3 broad categories of factors that are thought to contribute to thrombosis |
■ Venous Stasis (flow) ■ Endothelial damage ■ Hyper-coagulable state |
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Venous Stasis Risk Factors |
■ Anaesthesia ■ Varicose Veins ■ Obesity ■ Pregnancy ■ Immobility or paralysis |
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Immobility clinical causes |
■ Prolonged bed rest (preeclampsia) ■ Limb Paralysis ■ External fixator on limb/pelvic girdle ■ Extended travel ■ Long term ventilation |
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Hypercoagubility Risk Factors |
■ Trauma and surgery ■ Pregnancy and post partum period ■ Increased Oestrogen ■ Oral contraceptive Pill ■ Thrombophilia |
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Endothelial Damage risk Factors |
■ Surgery ■ Trauma ■ Venepuncture ■ Indwelling catheters (subclavian central lines) ■ Atherosclerosis |
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DVT - Diagnostic Testing |
■ Venogram ■ Duplex Scanning (ultrasound and doppler) ■ Nuclear medicine studies ■ MRI |
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DVT Complications |
■ PE ■ Skin Ulcers ■ Chronic Venous insufficiency - retrograde flow ■ Post thrombotic syndrome (PTS) |
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What is PTS? |
Post thrombotic syndrome ■ Long term swelling and pain, usually accompanied by skin colour changes that persist at DVT site (even if DVT is gone) ■ May occur sometimes much later (up to 2 years) after DVT has gone. |
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DVT Preventions |
■ Aggressive Mobilisation ■ Foot Pumps ■ Intermittent Pneumatic Leg compression devices ■ Graduated compression stockings (TEDS) |
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DVT Treatments |
Pharmacologic ■ Unfractionated Heparin ■ Low molecular weight heparin (LMWH) - lovenox ■ Factor X inhibitor - Arixtra ■ Warfarin - Coumadin Surgical Treatments ■ Catheter Aspiration thrombectomy ■ Mechanical Thrombectomy ■ EmbolicProtection devices - filter |
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What is an embolism? What is a Pulmonary Embolism |
(Obstruction) detached intravascular solid, liquid or gaseous mass that obstructs blood flow. ■ Obstruction of the pulmonary artery or one or more of its branches usually by a thrombus that breaks loose from a DVT. |
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PE Pathophysiology |
■ Emboli travels to lungs ■ Lodges in pulmonary vasculature ■ Blood flow is obstructed ■ Leading to decreased perfusion and ischemia |
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Origin of Emboli? |
Thrombotic (95%) - Venous Thrombosis (DVT) Non- thrombotic - tumor, air, gas, amnio, cholesterol, bone marrow, fat, foreign body |
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PE Symptoms |
■ Dyspnoea ■ Pleuritic Pain ■ Calf or thigh pain ■ Calf or thigh oedema Signs ■ Tachycardia■ Tachypnoea■ Crackles■ Decreased breath sounds ■ raised JVP (xray - clear = less blood flow (clot) |
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PE diagnostic testing
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■ Angiography
■ Echocardiogram ■ ECG - ST/T changes, new RBBB ■ Ventilation perfusion lung scan ■ Computed tomography |
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PE Initial treatments |
Phamacologic ■Unfractionated Heparin ■ Low molecular weight heparin - lovenox ■ Factor X inhibitor - Arixtra ■ Warfarin - Coumadin Surgical ■ Pulmonary embolectomy (requires cardiopulmonary bypass) ■ Transvenous catheter embolectomy Surgical Preventions ■ Embolic protection devices (IVC filter) |
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PE - what is an IVC filter |
■ Endovascular deployed device used to catch emboli in patients that have contraindication to anticoagulants. ■ filter is pushed through the catheter and deployed into the desired location, small barbs on each leg secure the filter to the vessel wall. |
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What is a Fat embolism?' What is Fat Embolism Syndrome? (FES) |
■ A process by which fat globules pass into bloodstream and obstruct pulmonary vessels. Syndrome ■ FE with clinical manifestations |
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FES - Trauma related causes |
■ long bone fractures ■ Pelvic fractures ■ Rib fractures (flail chest) ■ Burns |
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FES - non trauma related causes |
■ Infections ■ CABG ■ Fatty Liver ■ Pacreatitis ■ Sickle-Cell anaemia ■ Parenteral lipid infusion ■ Orthopaedic Procedures ■ Liposuction |
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FES - Signs/Symptoms |
There is usually a late period of 24-72hrs between injury and onset. Includes... ■ Dyspnoea (95%) ■ Cerebral Dysfunction (60%) ■ Petechial Rash (33%) |
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FES - treatment - prophylaxis |
■ Early immobilization ■ Prompt surgical fixation ■ Steroids ■ Albumin - binds with fatty acids and may decrease extent of lung injury |
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What is an Air Embolism? Types? |
pathological condition caused by a gas bubble, or bubbles entering a vessel and causing an obstruction. Types ■ Venous Air Embolism (VAE) - occurs when atmospheric air/gas enters systemic venous system causing obstructions, resulting in ischemia ■ Arterial Air Embolism (AAE) - occurs when atmospheric air/gas enters systemic arterial system, causing obstructions, resulting in ischemia. |
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What is a burn? Burns classifications? |
A wound caused by an exogenous agent leading to coagulative necrosis of the tissue. ■ mechanism ■ depth ■ extent (TBSA) ■ Severity |
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Pathophysiology of burn |
■ 1) immediate histamine release ■ 2) Intense vasoconstriction ■ 3) vasodilation ■ 4) increased capillary permeability ■ 5) plasma escapes into wound ■ 6) damaged cells swell ■ 7) platelet and leukocyte aggregation ■ 8) Thrombotic ischemia occurs ■ 9) further damage occurs |
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Burns mechanisms |
■ chemical ■ UV ■ radiation ■ Cold (cryo) ■ Thermal ■ friction ■ inhalational ■ electrical (classed as high/low) □ low voltage - sustained in domestic settings (240V single phase AC) □ High voltage - sustained as result of contact with overhead power lines and other sources of high voltage electrical currents. |
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What is a depth legend and what does it include? |
Depth of burn determines the potential for successful wound healing and will therefore help guide the initial treatment regime. ■ superficial epidural - 1st degree ■ superficial dermal - 2nd degree ■ mid dermal - 2nd degree ■ deep Dermal - 2nd degree ■ full thickness - 3rd degree |
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Superficial epidermal key characteristics |
■ involves epidermis only ■ dry, red, blanches to pressure, no blisters ■ painful ■ heals within 7-10days |
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Superficial dermal key characteristics |
■ involves epidermis and upper dermis ■ pale, pink blanched with pressure, small blisters ■ intense pain ■ heals 7-14days |
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Deep dermal characteristics |
■ involves epi and most of dermis ■ blotchy red/pale deeper dermis where blisters have ruptured ■ diminished pain ■ over 21 days to heal |
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Full thickness characteristics |
■ involves epidermis, dermis and subcutaneous tissues ■ white, waxy charred, no blisters, no capillary refill. ■ no sensation ■ does not heal spontaneously |
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Extent of injury and 3 tools to estimate extent of burn |
Is best described using percentage of TBSA effected by burn. ■ Wallace rule of nines(adult/paed) ○ Used to determine % of TBSA that has been burnt. ■ Land and burrow charts (paed) ■ Rule of Palm (paeds) |
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What is an Air Embolism? |
also called a gas embolism is a pathological condition caused by a gas bubble, or bubbles entering a vessel and causing obstruction |
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Air Entry Mechanisms - Non-Iatrogenic Causes |
■ Scuba Diving - decompression sickness/ Barotrauma ■ Penetrating chest wall/neck injuries |
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(Air Entry Mechanisms) - Iatrogenic causes? - Surgical Causes? |
■ Central Venous line removal - presence of a persistent catheter tract ■ Rapid blood transfusion under pressure ■ Haemodialysis - catheters inadvertently open to air ■ Initiation of cardiac bypass ■ Diagnostic Studies - radio contrast injection ■ Laparoscopic insufflations ■ Lung Biopsy ■ High pressure mechanical ventilation Surgical iatrogenic causes ■ Orthopaedic Surgeries (femoral reaming/cement) ■ Neurosurgeries ■ Vascular neck surgeries ■ C-sections |
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Air Embolism - Two Prerequisites |
■ Direct communication between source of air and vasculature (air bubbles inside IV infusion line) ■ Pressure gradient favouring the passage of air into the circulation (surgical wound elevated +5cm above R atrium) - Neurosurgery procedures conducted in sitting position |
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Air Embolism - Signs and Symptoms |
■ Dyspnoea ■ Respiratory Failure ■ Cardiac Failure ■ Myalgia ■ Stoke ■ LOC ■ Hypotension ■ Cyanosis |
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Air Embolism Presentation under GA |
■ Exponential decrease in ETCO2
■ Low cardiac Output ■ Hypoxia ■ Bradycardia |
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Air embolism - diagnosis |
■ Capnography ■ Doppler ■ Oesphageal stethoscope - mill wheel murmur ■ Desaturation Mill Wheel Murmur ■ Continuous loud, churning, drum like cardiac murmur caused by R.Atrium and R.Ventricular outflow obstruction. (airlock) |
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Air Embolism - 3 goals |
■ Stop Source ■ Flood air entry point with saline■ Release all insufflation gases■ Turn off pressure infuser device ■ Disconnect infusion line ■ Prevent Further injury Head down left lateral decubitus position - lying on left side helps prevent air from travelling through the right side of the heart into pulmonary arteries. ■ Resuscitate ■ Ventilated with high O2 flow■ Vasopressors■ Aggressive IV Fluids■ Commence CPR■ Hyperbaric o2 therapy |
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Air Embolism Treatment - stop source |
■ Ventilated with high O2 flow ■ Vasopressors ■ Aggressive IV Fluids ■ Commence CPR ■ Hyperbaric o2 therapy |
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What is Aspiration? What is Aspiration Syndrome? |
■ The inhalation of material into the airway below the level of the true vocal cords. ■ first recognised as cause of Anaesthetic related death in 1848) ■ Mendeleson first described relationship between solid and liquid matter in 1946. ■ Accounts for 10-20% of Anaesthesia deaths. ■ Syndromes refer to a group of pulmonary diseases resulting from aspiration of foreign material into the lungs. |
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Aspiration types? |
■ Oropharyngeal contentsBacterial pneumonia ■ Gastric Contents - Chemical Pneumonitis (Mendelson's Syndrome) Aspiration Syndromes ■ Aspiration pneumonitis ■ Airway Obstruction ■ Lung Abscess ■ Lipid Pneumonia |
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Aspiration Syndrome Causes |
■ Altered level of consciousness (Anaesthesia, stroke, Seizure, Head Trauma) ■ Mechanical disruption of usual defences (nasogastric Tube, Endotracheal intubation, trachy, Upper GI endoscopy, bronchoscopy) ■ Neuromuscular disease (MS, Motor Neuron Disease, Parkinson's Myasthenia Gravis) ■ Gastroesophageal disorders (incompetent cardiac sphincter, oesophageal stricture, Neoplasm, Protracted Vomiting) |
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What is Mendelson's Syndrome? |
■ Curtis Mendelson (1947) first described aspiration pneumonitis in patients who had aspirated gastric contents while receiving GA during obstetrical procedures. Child Emergencies: 1/400 (adult 600-800) GA C sections: 1/400-900 Elective Adult: 1/3000 (child 2600) |
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Pulmonary Aspiration of Gastric Contents - Severity Risk Factors |
■ Volume: greater than 250ml (severe) ■ pH: less than 2.5 (fatal) ■ Nature: bile/gastric acid |
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Aspiration of gastric contents: early signs? And later signs? |
■ Cyanosis ■ Tachycardia ■ Bronchospasm ■ Massive Pulmonary Oedema ■ Hypotension Later Signs ■ Cardiac Failure ■ Metabolic Acidosis ■ Increased Pulmonary Artery Pressure ■ Reduced Lung Complience ■ Consolidation |
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Aspiration of gastric contents - Follow Up and Other Procedures? |
■ FBC ■ ABGs ■ Microbiology work-up ■ CXR Other procedures ■ Bronchoscopy ■ Tracheal Aspiration Sample ■ Pulmonary Artery Catheterisation ■ Mechanical Ventilation |
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Patient Risk Factors (Pulmonary Gastric Aspiration) |
■ Full stomach (Emergency Surg, No fasting, Gastrointesinal obstruction) ■ Delayed Gastric Emptying: (Recent trauma, opioids, raised ICP, Previous gastro surgery, Pregnancy) ■ Incompetent lower oesophageal sphincter: Hiates Hernia, Pregnancy, Dyspepsia, previous gastro surgery. ■ Oesophageal diseases: Previous gastro surgery, Morbid Obesity |
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Fasting times |
■ 2 hours for clear fluid ■ 4 hours for breast milk ■ 6 hours for light meals (sweets, milk and clear fluids) |
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Surgical Factors (Pul. Aspir. Gastric) |
■ Upper Gastrointestinal surgery ■ Lithotomy or head down position ■ Laparoscopy ■ Cholecystectomy ■ LSCS |
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Anaesthetic Risk Factors (Pul. Aspir. Gastric) |
■ Prolonged Anaesthesia
■ High pulmonary inflation pressures ■ Ventilation controlled through LMA ■ Emergence: removal of airway before spontaneous recovery ■ Light Anaesthesia - gagging or recurrent swallowing ■ Difficult Airway |
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Device Risk Factors |
■ First Generation supraglottic devices ( classic LMA - decreased the lower oesophageal sphincter tone. |
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Pulmonary Aspiration of gastric contents: Preventions? |
■ Pharmacological preventions ■ Antacids (reduce gastric acidity - SODIUM CITRATE) ■ Proton-Pump Inhibitors (PPIs) (reduce gastric secretions: PRILOSEC) H2 Blockers: reduceAcidProduction: RANITIDINE ■ Non-pharmacological preventions ■ Preop fasting ■ RSI / Cricoid Pressure ■ NG tube ■ Regional Anaesthesia ■ Tracheal Intubation ■ 2nd Gen Supra-glottics ■ Head Up induction ■ Cuffed Airway ■ Awake Extubation/Intubation |
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Pulmonary Aspiration of gastric contents: Immediate Management |
■ Head Down tilt (left lateral head) ■ Suction ■ 100% O2 ■ Apply Cricoid (if not actively vomiting) ■ Ventilate ■ Deepen Anaesthesia ■ RSI ■ Intubate Trachea ■ Release Cricoid when airway secured ■ Tracheal Suction ■ Consider Bronchoscopy ■ Bronchodilators if necessary |
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What is Meconium Aspiration? Meconium Composition? |
A rare respiratory emergency caused by the inhalation of meconium in amniotic fluid into tracheal bronchial tree (first infant stool, normally stored in the intestines of the neonate until after birth) ■ Bile ■ Fetal Hair ■ Mucus ■ Residue from intestinal secretions |
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Meconium Passage - Intra-uterine causes |
■ Fetal Hypoxia ■ Increased Intestinal Peristalsis ■ Asphyxia ■ Acidosis |
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Meconium Passage: MAternal Causes |
■ Increased Maternal Age ■ Prolonged Gestation ■ Obesity ■ Anaemia |
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Meconium Aspiration Signs and Symptoms |
■ Laboured Breathing ■ Cyanosis ■ Limpness ■ Skin, nails, umbilical cord/placenta stained green |
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Meconium Apsiration Syndrome Complications |
■ Aspiration Pneumonia ■ Collapsed Lung ■ Brain Damage ■ Persistent Pulmonary Hypotension |
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Meconium Aspiration Treatment |
■ Suction trachea immediately ■ Direct Laryngoscopy ■Intubate/Ventilate ■ Antibiotics |
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What is an escherotomy? |
▲ full thickness incision of burn down to subcutaneous fat, in order to release unyeilding constricting eschar. |
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Escherotomy indicators ♥ extremities? ♥ chest wall/abdomen? |
▲ loss of distal circulation/pulses ▲ cool limbs ▲ numbness or pain ▲ reduced peripheral pulse ox chest wall/abdomen ▲ decreased lung complience ▲ decreased chest expansion ▲ decreased tidal volume |
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Methods to prevent hypothermia |
▲Cool burn, warm patient ▲ cover wounds/exclude air and prevent evaporative cooling with cling wrap ▲ warm fluids ▲ heat room ▲ warming air blankets (children have larger TBSA and are more ay risk of hypothermia) |
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what are circumferential burns? |
Full thickness burns of an extremity or around the chest or abdomen. Should be carefully monitored. Limb: interference with distal blood flow chest/abdomen: restrict chest expansion/movement and interfer with ventilation |
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Criteria for referal to state burns |
Inhalational burns greater than 10% TBSA chemical burns electrical burns Circumferential chest/limbs burns Very young/old trauma burns full thickness (+5% tbsa) special areas (genitalia, face) |
