Hepatic Failure

Definition:
It occur due to severe cause of hepatic encephalopathy.
Types of Hepatic Failure:

1. Fulminant hepatic failure.
2. Subfulminant hepatic failure.

1. Fulminant hepatic failure:

Defined as severe hepatic failure with development of hepatic encephalopathy within 8 weeks after the onset of acute liver disease.

Causes:

In the absence of evidence of pre-existing in chronic liver disease that also lead to hepatic encephalopathy.

2. Subfulminant hepatic failure:
It is term used when encephalopathy occur between 8 weeks and 6 months after the onset of acute liver disease and carries an equally poor prognosis.
Causes:
About 70% cases are caused  by acute viral hepatitis.
50% due to hepatitis B.
Other causes are hepatitis A. E & D.

Clinical Features:
Jaundice.
Hepatic encephalopathy.
Small live on examination.

Investigation:
Aminotransferases.
Prothrombin time.
Decreased Coagulation Factors.
Electrocardiography.

* Liver biopsy is contraindicated.

Management:

1. Hepatic Encephalopathy.
2. Cerebral Edema.
3. Nutritions.
4. Cardiovascular functions.
5. Hemorrhage.
6. Infections.
7. Renal failure.
8. Acetylcysteine.
9. Liver Transplantaion.

1. Hepatic Encephalopathy:

It occur due to nitrogenous substances e.g. Ammonia it enters in portal circulation that by-pass the liver and lead to cerebral dysfunction.

* Because liver becomes unable to detoxify them.

2. Cerebral Edema:

It is major cause of the death in Hepatic failure.

Its due to signs present of Increased Intracranial Pressure (ICP).

3. Nutitions:

Maintain glucose and other diet balance.

4. Cardiovascular functions:

To maintain the blood pressure, pulse and urine output.

5. Hemorrhage:

Impaired homeostasis due to failure of coagulation factor production can result in bleeding from any site especially from GIT.

* It should need to manage by Different drugs.

6. Infection:

For infection use the broad spectrum drugs.

7. Renal failure:

Perform Dialysis, if there is renal failure.

8. Acetylcysteine:

It is an anidot of Paracetamol (Local Name Pk)

It is helpful for managing Liver / Hepatic failure.

9. Liver Transplantation:

It is perform at the end stage of Hepatic failure.

Thyroid Crisis

Definition:
Thyroid crisis is a medical emergency in which there is rapid deterioration of thyrotoxicosis.
Clinical Findings:
Hyperpyrexia.
Severe tachycardia.
Nausea.
Vomiting.
Diarrhea.
Dehydration.
Extreme restlessness.
Precipitating Factors:
Stress.
Infection.
Surgery in the unprepared patient.
Radioiodine therapy.

Management:
Propranolol - 0.5-2 mg IV 4 hourly.
or
20 - 120 mg orally 6 hourly.

Carbimazole - 25 mg 6 hourly.

Iodine - given 1 hour later as Lugol's solution/ sodium iodine.

Steroids - Hydrocortisone 50 mg 6 hourly.

* Aspirin should be avoided.

Types of Thyroid Crisis:

• Toxic Solitary Thyroid Nodules.
• Toxic Multinodular Goiter.
• Subacute Thyroiditis.
• Hashimoto's Thyroiditis.

Hospital Acquired Pneumonia

Definition:

The Hospital acquired pneumonia (HAP) or nosocomial pneumonia is said to be any pneumonia that can occur to the patient in a hospital at least 48–72 hours after admission.
It is usually caused by a bacterial infection, instead of a viral infection.
HAP is the second most common nosocomial infection (urinary tract infection is the most common) and accounts for 15–20% of the total.
HAP typically lengthens a hospital stay by 1–2 weeks.

Sign & symptoms:

Fever > 37.8 °C (100 °F).
Sputum Purulent.
Leucocytosis > 10.000 cells/μl.

Types:

Bacterial pneumonia;
The majority of cases related to various gram-negative bacilli and S.aureus,.
Usually of the MRSA type.
Others are Haemophilus spp.
In the ICU results were S.aureus(17.4%).
P.aeruginosa (17.4%).
Klebsiella pneumoniae.
Enterobacter spp. (18.1%),.
Haemophilus influenzae (4.9%).[1]
Viral pneumonia;
influenza and respiratory syncytial virus.
In the immunocompromised host, cytomegalovirus- cause 10-20% of infections

Diagnosis:
In respiratory insufficiency; chest X-Ray (CXR).
Increasing leucocyte count.
In case of pleural effusion thoracentesis; is performed for examination of pleural fluid.

Arterial Blood Gases (ABGs)

Definition:
Measurement of PaCO2 and PaO2 and H+ Conc. in arterial blood is valuable in assessment of hypoxemia or acid-base balance in respiratory failure and asthama.

Procedure:
Heparinize syringe with 0.1 ml heparin to prevent clot formation.
Draw blood from radial or brachial or femoral artery.
The sample should be immersed in ice bag immediately to prevent metabolism that can reduce PaO2 and increase PaCO2.

Normal values:
PH: 7.35 - 7.45
PaO2: 75 - 100 mm Hg
PaCO2: 35 - 45 mm Hg
HCO3: 24 - 28 mmol/L
O2 saturation: 95 - 100%

Types:
Respiratory Acidosis.
Respiratory Alkalosis.
Metabolic Acidosis.
Metabolic Alkalosis.

1- Respiratory Acidosis:
PH  < 7.35
PaCO2 increases > 45 mm Hg
HCO3 < 24 mmol/L

* If PH is normal, HCO3 is > 28 mmol/L, then it will be compensatory Respiratory Acidosis.

2- Respiratory Alkalosis:
PH > 7.45
PaCO2 < 35 mm Hg
HCO3 is normal or > 28 mmol/L

3- Metabolic Acidosis:
PH  < 7.35
PaCO2  is normal or < 35 mm Hg
HCO3 < 22 mmol/L

*  If PH is normal, PaCO2 is < 35 mm Hg, then it will be compensatory Metabolic Acidosis.

4- Metabolic Alkalosis:

PH > 7.45
PaCO2  35 - 45 mm Hg
HCO3 is > 28 mmol/L

Mechanical Ventilation

Definition:
When Patient fails to improvement in breathing by other measures, they should need oxygen therapy by Some respiratory support with mechanical ventilation, that improves the elimination of CO2.

Types of Mechanical Ventilation:
There are two types of mechanical ventilation;

• Non- Invasive mechanical ventilation.
• Invasive mechanical ventilation.

1- Non- Invasive mechanical ventilation:
In NIMV respiration is supported with face mask or nasal cannula and Endotracheal intubation avoided.
In this, Patient should be conscious, cooperative and be able to breath spontaneously and cough effectively by him or her self.
This Technique is commonly performed in COPD and Pneumonia.
2- Invasive mechanical ventilation:
In IMV Endotracheal tube is passed.
Patient may require;
* Full support and Partial support ventilator.
Full support Ventilator:
In this, all respiration controlled by ventilator.
In this case, Ventilator does not allow the spontaneous breathing.
Patient deeply sedative with short acting IV general anesthesia and paralyzed with muscles relaxant.
Partial support ventilator:
In this, all respiration does not controlled by ventilator, while patient also have his/her own effort.
It does not require deeply sedation or paralyses with muscles relaxant.

Indications:
Respiratory failure (Type II) that does not response to the medical treatment.
Head Injury- Patient have altered in mental status, and it controlled hyperventilation that reduce the Intra-cranial pressure.
Chest Injury- Flail chest, Pneumothorax and Hemothorax etc that reduces the breathing.
Severe Pulmonary edema.

Complications:
Tube insertion in one lung cause collapse of other lung.
Ventilator can induce the lung injury that leads to lungs infection.
It can cause Nosocomial, Hospital Acquired Pneumonia )HAP).
Abdominal Distention.
Fall in cardiac output (CO) due to positive pressure in lungs and thorax that reduce the venous return.

Monitoring and Pulse oximetery

Monitoring:
The cardiac monitoring commonly known as continue monitoring of the heart activity. Generally it shows, Electrocardiography (Relatively cardiac rhythm, Heart rate etc), It can also measure the hemodynamically status of patient via pressure of blood flow within the circulatory system, and can record also the patient's temperature, respiration and pulse oximetery.

Electrocardiography:

Heart rate
Rhythm
Diagnostic values

Hemodynamically status:
Blood Pressure;

Systolic BP
Diastolic
Mean BP

Temperature:

Normal value is;

98.6 F

37 C

* It is usually measured by anal canal.

Respiration:

It is normally 12 to 20 breathes in Adult.

20 to 25 in Childrens.

25 to 40 in Infants.

Pulse Oximetery:

It is use to measure the oxygen saturation and the pulse rate in the peripheral circulation.

Work:
By a low intensity light beamed, from a light emitting diode (LED) to a light receiving photo-diode.
Two thin beam of light, one of them is; Red and other is; Infrared are transmitted through blood and body tissues, and  Some of portion of light is absorbed by blood and body tissue, a photo-diode measure the proportion of the light that passes through the blood and body tissues, that show the pulse oximetery on monitor.
The relatively light absorbed by oxygenated blood is differ from the deoxgenated blood.

Unreliable:
If patient have poor peripheral perfusion, by vasoconstiction, hypotension, BP cuff inflated by the sensor, hypothermia, other causes of poor blood flow the pulse oximetery not show the accurate results.

Venous Access

Introduction:
To familiarize to the physician with the importance of Short and long caliber peripheral lines are preferred for rapid volume resuscitation.
Access to Circulation:
Its use in the management of traumatized patient.
Venous access can use for investigation, blood sampling, fluid resuscitation and medication via injection.
There are Following Places in body that use for the Venous Access;

• Percutaneous peripheral venous access.
• Central access.
• Surgical cut-down.
• Intra-osseous access.

Percutaneous peripheral venous access:
Most Suitable site for PVA is Forearm, Cubital fossal vein.
Mainly there are used two large bore IV catheters (14 and 16 gauge).
Sterilize technique should be use in emergency and urgency situation.
Lower limbs can also be used for the venous access but complication can occur like thrombosis, cellulitis and phlebitis.

Central access:
It is use in traumatized unstable patient or in shocked patient.
There is use of CV line, in size of (8 to 12 French).
They provide high flow rate because of large diameter (2.5 to 4 mm) of catheter (Swan Sheath).
It can also use for the monitoring, assessing, to check volume status and for resuscitation.

* There are some sites where you can perform the central venous access;

1. Subclavian vein.
2. Internal Jugular vein.
3. Femoral vein.

1. Subclavian vein:
Criteria : Its selection depend on an experienced physician.

Advantages:
Easily accessible
It maintain CV line in fixed position due to fibrous tissue (Attached to the 1st Rib, clavicle and subclavicle muscles).
Allows the measurement of CVP (Central venous pressure).

Disadvantages:
It can cause suspected cervical spine injury.
In Complication Pneumothorax, arterial puncture, Hemothorax etc can occur.

2. Internal Jugular vein:
Criteria : IJV is most popular in CV line insertions.
But this site is not preferred in neck trauma (C-spine).

Advantages:
Right IJV have extra advantages rather than left IJV;
It Provide the straight route to the right heart.
It is Slightly larger than left IJV.
The dome of pleura is lower on the right side.

Disadvantages:
On left side it can cause thoracic duct injury which not occur on right side.

3. Femoral vein:
Criteria : Its is easy to cannulation because it is large in diameter of vein.

Advantages:
Ease of insertion.
No risk of thoracic injury.

Disadvantages:
Limits the flexion of leg at the hip.
Thrombosis.
Femoral artery puncture.

Surgical cut-down:
The procedure in which a vein is exposed through an incision and cannulated under the direct vision.
It is particularly performed in those patient in whom Percutaneous and central access are contraindicated that are traumatized patient and this procedure normally performed in children.

Sites for venous Cut-down:
It is mostly performed in superficial veins;

1. Long/Greater saphenous vein at the ankle.
2. Proximal long/Greater saphenous veins.
3. Antecubital veins.

1. Long/Greater saphenous vein at the ankle:

It is Approx. 1 cm above and anterior to the center of the medial malleolus.
This is safe site and have low morbidity.
It is of smaller in size at the ankle difficult to perform the procedure.
It is away from the central circulation.
It is not beneficial in leg fractures and splinting etc.

2. Proximal long/Greater saphenous veins:
It is Approx. 5 cm inferior to the inguinal ligament and 5 cm medial to the femoral pulse (or 5 cm medial to the mid point of the inguinal ligament in a pulse less patient).
It is better alternative to the ankle venous cut-down, it is near to the central circulation.

3. Antecubital veins:
Basilic vein, Proximal and distal cephalic veins in the arm can be used for a cut-down.
Basilic vein, because of its less acute union with the Subclavian vein is preferred site.
In complication damage to the brachial artery and median nerve.

Intra-osseous access:
The ability of the bone marrow to accept an infusion of fluids and drugs with subsequent effects like those of an intravenous infusion has been well documented.
Criteria: This route should be utilized for initial resuscitation.
Sites: Any marrow containing cavity is a potential site for infusion, These are the commonly recommended sites;

1. Proximal Tibia.
2. Distal Tibia.
3. Distal Femur.

1. Proximal Tibia:

Anteromedial surface, 2-3 cm below the tibial tuberosity.

2. Distal Tibia:

Anterior surface of the distal tibia, approximately 2 cm above the medial malleolus.

3. Distal Femur:

Antero-lateral surface, 3 cm above the lateral condyle of femur.

Advantages:
This route can be quickly, safely and reliably established and permits rapid venous uptake of the drugs and fluids.

Complications:
It can cause infections like local cellulitis and abscess.
Osteomyelitis.
Fracture of the bone.
Compartment syndrome.
Epiphyseal plate injury.

Bradycardia Vs Tachycardia and Management

(Bradycardia):
Definition:
The heart rate less than 60 beats per minute or more, is known as Bradycardia.

Sinus Bradycardia:
A sinus rate is < 60 bpm during day or < 50 bpm during sleep is known as sinus Bradycardia.

Causes:
1- Physiological:
i-In athletes.
ii-During Sleep.

2- Pathological:
Extrinsic causes:
Uses of drugs (beta blockers, Digoxin and verapamil), Increased ICP, hypothyroidism and hypothermia.
Intrinsic causes:
Sick sinus syndrome and Acute Ischemia or Infarction of sinus node.

Management:
Treat the cause of Bradycardia.
TPM in Symptomatic bradycardia, if there is reversible causes.
PPM in Symptomatic bradycardia, if there is irreversible causes.
Acute Symptomatic bradycardia can respond to the (Atropine 0.6 mg).

(Tachycardia):
Definition:
The heart rate more than 100 beats per minute or more, is known as Tachycardia.

Sinus Tachycardia:
Resting sinus rate is > 100 bpm is called as sinus tachycardia.

Causes:

Non-Cardiac:
Acute:
Fever, pain, hypovolemia, infection and emotions.
Chronic:
Pregnancy, Anemia and Beta agonist (salbulamol).

Cardiac:
HF with compensatory sinus tachycardia.

Management:
Treatment of cause.
Symptomatic Sinus tachycardia can be reduced with beta blockers such as Verapamil.

Advance Life Support

Definition:
The management of airway, breathing and circulation with advance trauma life support in which use of advance techniques of management.

Protocols:

1. Access to the primary survey.
2. Resuscitation.
3. Adjacent to the primary survey.
4. Access to the Secondary survey.
5. Adjacent secondary survey.

1. Access to the Primary survey:
Airway maintenance and cervical spine protection.
Breathing and ventilation.
Circulation with hemorrhage control.
Disability neurological evaluation (GCS).
Exposure and environmental control.

2. Resuscitation:
Airway.
Breathing.
Ventilation.
Oxygenation.
Circulation.
and
Bleeding control.

3. Adjacent to the Primary survey:
ECG monitoring.
Urinary and gastric cathetrization.
Other monitoring.
X. ray examination
and
Diagnostic studies.

4. Access to the Secondary survey:
History (in detail).
Examination (Systemic approach).

5. Adjacent Secondary survey:
Investigation;
X.Ray.
Ultrasound.
CT-Scan.
ECG
CBC (Complete blood account)
Medication.

Basic Life Support

Definition:
The need of basic life support is necessary when the patient is unconscious and have no breathing and pulse.

Protocols:
Access the patient.
Personal protection.
Remove the patient from contaminated area.
Confirm the diagnosis i.e; unconscious, death like appearance, no pulsation.

• Check the response (Shake the patient).
• Check pulse from carotid artery.
• Check airways and breathing.

If there is no pulse call the EMS for help (In Pakistan EMS call 1122)

Make the position of patient for the management of ABC (Airway, breathing, circulation) in basic life support (BLS).

Airway:

Clear the airway from blood, denture, mucous, and any other danger material should be removed.

Open the mouth and extent it to back in position of head tilt chin lift or in a traumatized unconscious patient as jaw thrust.

clean the mouth with little finger.

Breathing:

Access the patient's breathing with LLF (Look, listen and feel).

If there is no breathing i.e; no rise and fall in chest and no breath sound.

Give the 12 artificial breaths to the patient with mouth-mouth method.

Then again check the breathing with LLF pulse carotid artery.

Circulation:

If there is no pulse start the CPR (Cardiopulmonary resuscitation).

Make the patient position in supine.

Expose the chest, now make position of your hands.

(Horizontal to the nipple line that cross the vertical line of sternum)

Start CPR, with 30 compression and 2 breaths.

* If one Rescuer, there is 30 compression and 2 breaths.

* If two Rescuer, there is 15 compression and 2 breaths.

Capnography (End tidal Carbon dioxide)

Definition:
It is the monitoring of the conc. or PaCO2 in the respiratory gases, its a main tool to measure CO2 during Anesthesia ans Intensive care.
It is recorded in form of graph that plot;  expiration against time.

Main Uses:
The Capnogram directly use for the monitoring of inhaled and exhaled Conc. or partial pressure of CO2.
The Capnogram indirectly use for the monitoring of the CO2 Partial pressure of Arterial blood.

* In a healthy individual there is very small difference between arterial blood and exhaled gas CO2 partial pressure.
* In presence of lung disease and congenital heart diseases, there is more than 1 kPa is difference between arterial blood and exhaled gas CO2 partial pressure

Diagnostic Uses:
It provides the information about Carbon-dioxide production i.e;

• Pulmonary perfusion.
• Alveolar ventilation.
• Respiratory pattern.
• Elimination of CO2 from anesthesia breathing circut and ventilators.

The graph can be effected by some lung disease, i.e;

Bronchitis,

Emphysema,

Asthma.

The graph cannot be affected by pulmonary embolism and some heart disease, i.e;

There is no change in graph relation, but actual they effects the relation between exhaled carbon-dioxide partial pressure and arterial blood.

* Increase production of CO2 is seen in Fever and in shivering.

* Decrease production of CO2 is seen in Anesthesia and hypothermia.

Central Venous Cathetrization

Definition:
Central venous line is large bore cannula that use to administer the large volume of fluid and medication.

Indications:
In open heart surgery.
Fluid replacement in Shock.
Total Parenteral Nutrition (TPN).
Administration of irritant medication.
Hemodialysis.
Aspiration of Air embolism.
Venous assessing during CPR.

Contra-Indications:
Thrombocytopenia (Platelet less than 40 thousand).
Increased PT, APTT, INR.

Site of Insertions:
Right & left Internal Jugular vein.
Right & left Subclavian vein.
Femoral vein.

Technique:
Seldinger technique.

CVP Line Pressure:
Normal CVP line Pressure is 6 to 12 cm of water.

CVP Increased in :
Fluid overload.
Pulmonary air embolisms.
Cardiac temponade.
pleural Infusion.
Hemothorax.
During Coughing.

CVP Decreased in :
In Hypovolemia/ Shock.
Vasodilators.

Material that Uses:
Small Needle 16-18 G.
Guide wire.
10cc syringe.
CVP line (Double, three lumen).
Hepranized flushed solution.
Lignocaine 1%.
Pyodine-iodine Sol.
Sterile Towels.
4 X 4 gauze sponge.
21 G needle to draw the Lignocaine.
Mask.
Gloves and gown.

Intravenous Therapy & Burn Management

Definition:
Intravenous therapy Or an IV therapy is directly infuse in the veins.

Uses:
Its is use to;
Correct electrolyte imbalance.
To deliver medication.
For blood transfusion.
Fluid replacement.
Use for chemotherapy.

Types:
There are mainly two types of solution;

1. Crystalloids.
2. Colloids.

* Both are commonly known as volume expander.

1. Crystalloids:
These are the aqueous solution of mineral salts (Normal saline) or other water soluble molecules.
OR
A substance or solution that can pass easily semi permeable membrane.

Solutions:
Normal Saline (0.9% or 0.45% of NaCl)-(Isotonic).
Lactate Ringer's (Ringer's Lactate).
Ringer's acetate (Hyper-tonic)

Benefits:
Most effective.
Safest.
Most economical.
Plasma vol.expander.

2. Colloids:
Those solutions that contains large insoluble molecules, e.g; Gelatin and blood are colloids.

Importance:
Also known as true solutions.
Capable to passing through semi Permeable membrane.
They are physically opposite to Colloids.
Preserve high colloid osmotic pressure in blood.
These are costly solutions.

Nasogastric Tube

Definition:
It is a medical procedure that performed by a tube that enter from nose to throat to esophagus to end stomach.

Uses of Nasogastric Tube:
Its use for the feeding.
Administration of medication.
For other agents like; activated Charcoal.
Nasogastric aspiration (gastric lavage).
To empty the stomach from poisoning substances or other secretions, bag attached and maintain below the patients position gravity helps to empty the stomach.
To prevent the aspiration of stomach contents.

How to Inserted?
Before the insertion take the size from patient, from the tip of the nose to ear loop, then down toward the xiphoid sternum to roughly below 5 cm.
Use the local anesthesia ( 2% Xylocaine gel) before insertion, at the end tip of tube.
Enter the tube in this pathway; Nose __Throat__Esophagus__Stomach.
Size Varies: 12-14 Gauge in Green Color, 16-18 Gauge in Red Color.
There are four marking on NG tube;
1st at 18" (46 cm)
2nd at 22" (56 cm)
3rd at 26" (66 cm)
4th at 30" (76 cm)
When you enter the tube from mouth to stomach patient may awake or show gag reflexes.
Say patient to mimic like swallowing, give him/her water to sip with straw.
And during this procedure enter the tube in stomach.

Caution:
NG tube must be inserted by an experienced person.
Avoid to enter the NG tube into the trachea.

Confirmation:

1. It can confirm by Air syringe to enter air in stomach it will be distended.
2. Aspirate the stomach content check its pH by litmus paper; it should be 5.5 or below acidic.
3. You can perform an x-ray.

Contraindications:
Its is contraindicated in Skull fractures (Basal), Severe facial fracture, Obstruction on esophagus and nose too and in gastric bypass surgery.

Complications:

1. Its can cause nose bleeding.
2. Sinusitis.
3. Its lead to sore throat and swelling in nose.
4. Perforation of esophagus.
5. Aspiration of Lungs.
6. Lungs Collapsed.
7. If not propered sized it can go in duodenum (confirmed by gastric enzymes).

Endotracheal Intubation

Definition:
Endotracheal intubation (ETT) is place in trachea to maintain airway by invasive ventilation, for anesthesia administration and for other medication.
Indications:

1. It is use in;
2. Breathlessness (Respiratory arrest).
3. Respiratory failure (Type II RF).
4. Any airway obstruction.
5. In traumatized patient for ventilatory support.
6. Shock Patient with poor perfusion (Class III and IV of hemorrhage).
7. Severe chest injury (e.g; Flail chest).
8. Altered mental status in multiple traumas.
9. Protection from aspiration.
10. Swelling in vocal cord due to edema/ erythema.

Precautions:

An operating table use for intubation.

Patient in laying position with pillow below head.

An experienced anesthetic is necessary for intubation.

Personal protective equipment (PPE) are necessary (e.g; gloves, gown and goggles etc).

For intubation patient should be unconscious or give general anesthesia to the conscious patient.

Procedure:

Make the position, open the patient's mouth with hand and jaw with index finger.

Hold laryngoscope in your left hand or non-dominant hand, enter it in patient's mouth.

Take direct it to in line to see epiglottis, glottis and vocal cord for intubation in trachea.

Often an assistant is use to press the trachea to direct view of larynx.

Anesthetic take ETT to enter in trachea with eyes view in optic light with his/her right or dominant hand.

Tube enter from the side of balloon till the end of trachea above 2 cm of Carina.

Inflate the balloon by cuff with syringe full of air.

Confirmation:

1. Anesthetic Confirmed by stethoscope to listen the breaths sound.
2. It can also confirmed by chest x-ray (CXR).

Complications:
ETT intubation can cause edema in trachea.
Bleeding from airway.
Perforation of Tracheal and esophageal.
It also can cause pneumothorax.
Aspiration from lungs.
Also can cause chest pain.
subcutaneous emphysema.