ae bleeding from the nose by jennyyingdi


 EMERGENCY MEDICINE                                                                                                  Should be followed by formal pleural drainage
                                                                                                                      and +/- thoracotomy when condition stabilised.
 BASIC FIRST AID                                                                                                      Once pleural cavity is drained, wound can be
 Check for a SAFE ENVIRONMENT, then ABCDE…                                                                            sutured or covered with an occlusive dressing.
 Airway          Check airway is patent. Open mouth- Check for foreign bodies.      Circulation         Look for clinical S&S of shock: SHOCCCC…
                 Immobilise neck if head / neck injury suspected                                                 Sinus Tachycardia & SOB
                 Do not move casualties until skilled help and equipment arrive.                                 Hypotension (when 30% lost)
                 Passengers ejected from vehicles likely to have serious injuries                                Oligouria
                  including to cervical spine                                                                     Cold
                 If victim not breathing and no hint of cervical damage,                                         Clammy
                  hyperextend head.                                                                               Confused
 Breathing       CPR? Give oxygen if available.                                                                  Capillary Refill 
 Circulation     Check pulse. Look for haemorrhages, and control by pressure                            Insertion of 2x Large Bore Cannulae and X Match.
                  and elevation (do not use tourniquets as they occlude collateral                       On reassessment of circulatory state, one of three
                  circulation  tissue destruction).                                                       possibilities:
 Disability      Quick assessment of neurological status. Use "AVPU system"                             1) Vital S&S  N. Pt lost < 20% blood
                  in primary survey: A=alert, V=responds to voice, P=responds to                         2) Vital S&S  Improve, but then . Pt lost > 20% +
                  pain, U=unresponsive.                                                                    bleeding!
 Exposure        EYES- Observe size of pupils, symmetry, and response to light.                         3) Vital S&S  Do not improve: Pt lost >40% blood or are
      +          NOSE AND EARS- Presence of blood or CSF are signs of                                     in shock not caused by hypovolaemia.
 Secondary        fracture of base of skull. Other 2 signs that suggest this are     Disability          AVPU / GCS…See Consciousness below.
   Survey         ‘raccoon’ eyes and haematoma in mastoid region.                    GLASGOW COMA SCALE
                 MOUTH- Check for blisters, burns, or spots (Sign of poisoning).    MOTOR (The M6 Motorway) Learn the Dance…Wave, Point in, Point out,
                 HEAD- Haematomas and skull asymmetry can indicate                  Hands up, Hands Down, Fall Over!
                  presence of fractures. Trauma of skull increases possibility of    6: Request               Carrying Out Request
                  vomiting, with which patient risks compromising their airways.     5: Localises             Pain  Localising Response.
                 THORAX- Explore ventilation symmetry and explore their rib                                  Nail-bed with pencil, supraorbital, sternal pressure.
                  cage to check for possible fractures.                              4: Withdraws             Pain  Pulls limb away.
                 ABDOMEN- Painful / hard regions can be indication of
                                                                                     3: Flexor                Pain  Abnormal flexion of limbs (nail-bed pressure).
                  haemorrhages or organ damage.
                                                                                                              DECORTICATE POSTURE
                 PELVIS- Hip pain- Fracture? (May haemorrhage > 1L blood).
                                                                                     2: Extensor              Pain  Limb extension (adduction, int shoulder rotation,
  After examination, and if no signs of bone damage, lie patient down on side to
                                                                                                              forearm rotation)
   avoid possible accumulation of secretions / blood in mouth.
                                                                                                              DECEREBRATE POSTURE
  During Exposure, also important to get medical details: AMPLE: Allergies,
                                                                                     1: No Response           Self Explanatory.
   Medication, PMHx, Last Meal, Events leading up to emergency.
                                                                                     VERBAL (V = 5 in Roman)
                                                                                     5: Oriented              Who, where, why, year, season, month.
                                                                                     4: Confused              Conversational manner, but some disorientation.
 Primary Survey (ABCDE)  Secondary Survey  Definitive Care
                                                                                     3: Inappropriate         Random / exclamatory speech, no conversational .
                                                                                     2: Incomprehensible      Moaning. No words.
 Airway           Assume cervical injury (if suspicion of injury above
                      clavicles, Hx of high speed impact).                           1: None                  Self Explanatory.
                  Open mouth: Remove foreign bodies with forceps and                EYE OPENING (4 Eyes!)
                      suction.                                                       4: Spontaneous           Self Explanatory.
                  If vomiting: Turn entire body to side using spinal board (if      3: Speech                Any speech / shout. Not necessarily to open eyes.
                      not in place, tip trolley down by 20o and suction).            2: Pain                  Pain to limbs as above.
                  NG tube (unless evidence of skull fracture) / Intubate.           1: None                  Self Explanatory.
                  100% O2.                                                          Definition of coma: Failure to open eyes in response to verbal command (E2),
 Breathing       Inspect, Auscultate and Percuss Chest Wall. Immediately life        perform no better than weak flexion (M4), and utter only unrecognisable sounds
                 threatening thoracic conditions: PHOTO!...                          in response to pain (V2)
                  TENSION PNEUMOTHORAX                                              Add all together…Severe: 8, Moderate: 9-12, Mild: 13-15.
                             S&S:  RR, mediastinal (& tracheal) shift away        Abbreviated coma scale is AVPU: Alert, Voice, Pain, Unresponsive
                                from affected side, hyper resonance,  breath        GCS is of no Dx value, but is reliable way of objectively monitoring the clinical
                                sounds on affected side.                             course of the patient with an acute cranial insult without elucidating cause.
                             Tx initially by needle decompression of pleural        PAEDIATRIC GCS: For children <2:
                                cavity at 2nd intercostal space in MCL  Pleural        5: Smiles, Listens, Follows
                                drainage + underwater seal.                             4: Cries, Consolable
                              Simple pneumothorax may  Tension when a                3: Inappropriate persistent cry
                                pt is ventilated  Insert prophylactic chest drain      2: Agitated & Restless
                                prior ventilation.                                      1: No response
                  MASSIVE HAEMOTHORAX                                               Exposure            Remaining clothes should now be removed. Cover with
                              Breath sounds, dullness to percussion, Shift of                            blanket. Do not overheat. AMPLE (See Fist Aid)
                                mediastinum away from affected side +/- CV           SECONDARY SURVEY
                                instability.                                         HEAD            SCALP:
                             Tx: Pleural drainage and if initial volume of blood                        Lacerations, Swellings, Depressions.
                                > 1500mls or bleeding persists at a rate >                               Exam of occiput will have to wait until pt is turned.
                                200ml/hr …thoracotomy indicated.                                         Do not probe blindly as may  further damage.
                              Before Dx in ventilated patient, check ET tube                       NEUROLOGICAL STATE:
                                is in trachea and not entered right main bronchus                        GCS, Pupilliary response, Lateralising S&S.
                                as this may mimic some of the above signs.                               Hypoxia / Hypovolaemia must be excluded before
                  Obvious FLAIL CHEST                                                                     considering intracranial injury.
                             Part of chest wall is able to move independently                       BASE OF SKULL: (Line runs from orbit to mastoid process).
                                to remainder and occurs when ribs are fractured                          EYES: Raccoon Eyes (bilateral periorbital haematoma),
                                in at least 2 places. Flail segment falls during                           Subhyaloid haemorrhage, Scleral Haemorrhage
                                inspiration as rest of chest rises. Assoc with                           EARS / NOSE: Haemotympanium, CSF Rhinorrhoea
                                significant pulmonary contusion  hypoxia. If                              /Otorroea
                                respiratory failure supervenes despite O2 therapy                        BATTLE’S SIGN- Bruising over Mastoid Process.
                                and adequate analgesia (preferably epidural /                        If CSF mixes with blood and dropped onto sheet, clotting time is
                                intercostal blockade) …ventilation is required.                      delayed and double ring pattern displayed.  Otoscope exam C/I
                  CARDIAC TAMPONADE                                                                 as may  Meningitis.
                             S&S: Becks Triad:  JVP (on inspiration-                               EYES:
                                Kussmauls’s sign), Muffled HS,  BP                                      PEARL. Retinal detachment, Haemorrhages, Foreign
                             Also:  HR, Pulsus Paradoxicus (a 15%  in                                   bodies under lids. Simple acuity test. If unconscious,
                                systolic BP during inspiration), Distended neck                            corneal reflex.
                                veins, Confusion.                                                    FACE:
                             Tx: Needle pericardiocentesis. If caused by                                Palpate. Nasal septal haematoma, loose teeth.
                                penetrating implement, leave for surgeons.                               Instability of maxilla IDd with traction on upper incisors.
                  OPEN CHEST WOUND                                                                  NECK: With head held firmly by assistant…
                             Tx: Cover and seal on 3 sides immediately. One                             Ears: Pinna trauma, external canal, perforation. Check
                                way valve is formed by flapping motion of free                             hearing.
                                edge of dressing  prevents air being sucked                             Bone: Palpation of spinous processes. XR (may still miss
                                into pleural cavity from outside.                                          15%)

WILL WESTON                                                                                                                                             Page 1 of 7
 THORAX            Inspect for bruising, signs of obstruction, asymmetry,                Hypo / Hyperglycaemia
                    wounds.                                                               Hypo / (Hypercalcaemia…if severe)
                 Palpate for crepitus, tenderness, subcutaneous                          Hypo / (Hypernatraemia…if severe)
                    emphysema.                                                            Hypoxia / Ischaemic brain injury
                 Potentially life threatening thoracic conditions:                       Hypoadrenalism
                                o     Pulmonary contusion                                 Renal Failure
                                o     Cardiac contusion                                   Hepatic Failure
                                o     Ruptured diaphragm                                  Respiratory Failure with CO2 retention
                                o     Aortic Tear                                       NEUROLOGICAL
                                o     Oesophageal Rupture                                 Subarachnoid Haemorrhage
                                o     Airway Obstruction                                  Hypertensive encephalopathy
                Bruise from diagonal seatbelt may overlay:                               Encephalitis, Cerebral malaria
                 Fractured clavicle, thoracic aortic tear, pulmonary                   BRAINSTEM LESIONS
                    contusion, pancreatic laceration.                                     Tumour
                Mark caused by impact with steering wheel suggests:                      Haemorrhage, Infarction
                 Sternal fracture with cardiac contusion.                                Demyelination, e.g. MS
 ABDO            GI: Rectal exam, then catheter insertion. Suspect an                    Trauma
                    intraabdominal bleed if ribs are fractured (5-11…overlie              Wernicke-Korsakoff Syndrome
                    liver, spleen), marks from seat belt.                               CORTICAL / CEREBELLAR LESIONS
                 RENAL: Injury S&S: Flank Pain / Mass / Bruising,                        Tumour
                    Haematuria.                                                           Haemorrhage, Infarction
                 PELVIC: Squeezing iliac crest will only ID major injury                Abscess
                     US                                                                  Encephalitis
 LIMBS           Bruising, wounds, deformities. Vascular / Neurological
                 Palpate all bones, including metacarpal, metatarsal,
                 Swab any open fractures and cover with sterile dressings.
 SPINE           Signs of a Spinal Injury:
                                o      BP + Relative HR
                                o      Motor power & sensation below lesion.
                                o      Anal sphincter tone
                                o     Priapism (painful erection of penis)
                 Taking care if injury suspected, palpate bones and
 SOFT            Inspect any breach in skin to ascertain site, depth and
 TISSUE             underlying structural damage.

 (Neurological Assessment Of Coma: Neurol Neurosurg Psychiatry 2001)
                                                                                        ASSESSMENT OF COMA
 DEFINITION: Consciousness- State of awareness of self & environment,                     Where is the lesion responsible for coma?
 determined by 2 separate functions dependant upon separate physiological &               What is its nature?
 anatomical systems:                                                                      What is it doing?
     AWARENESS (content of consciousness)
           Sum of cognitive and affective mental function, dependent on an
             intact cerebral cortex. (The absence of all content of
             consciousness is the basis for the vegetative state)
   AROUSAL (Level of consciousness).
           Coma is caused by disordered arousal.
           Arousal depends on an intact ascending reticular activating
             system and connections with diencephalic structures. Like
             awareness, arousal is not an all or nothing concept and
             gradations in awareness can be objectively assessed using
             measures such as GCS.
 Def    Profound or deep state of unconsciousness. An individual in a state of
        coma is alive but unable to move or respond to his or her
        environment. Cf Persistent Vegetative State… See elsewhere.
 PP       
           Coma is caused by either or both of
                     Diffuse bilateral hemisphere damage
                     Failure of the ascending reticular activating (RA)
           The RA system is a core of grey matter continuous caudally
              with the reticular intermediate grey lamina of the spinal cord
              and rostrally with the subthalamus, hypothalamus, and thalamic      Inv   Temp           Hypothermia
              nuclei. It runs in the dorsal part of the brain stem in the               Trauma         Haematoma, laceration, bruising, CSF / blood in nose /
              paramedian tegmental zone.                                                               ears, Skull fracture (strep deformity), subcut
           A unilateral hemisphere lesion will not result in coma unless                              emphysema.
              there is secondary brain stem compression, caused by                      Skin:          Needle marks, cyanosis, pallor, rashes, turgor
              herniation, compromising the ascending RA system.                         Breath         OH, ketosis, uraemia.
           Extensive bilateral damage or disturbance of the hemisphere
                                                                                        Heart,Lung     Murmurs, rubs, wheeze, creps, consolidation, collapse.
              function is required to produce coma.
                                                                                        Abdomen        Organomegaly, Ascites, Bruising, Peritonism, Melaena
           Bilateral thalamic and hypothalamic lesions also cause coma
                                                                                        Infection      Foci: Abscesses, Bites, Middle Ear infection
              by interrupting activation of the cortex mediated through these
              structures.                                                               Meningitis     Neck stiffness, rash, focal neurology
           In hypothalamic lesions, phenomena associated with sleep,                   Eyes                             SHIT! MALE TB 
              such as yawning, stretching, and sighing, are prominent.                  UNILATERAL FIXED DILATED PUPIL: Herniation of temporal lobe
           The speed of onset, site, and size of a brainstem lesion                    (coning) through tentorial hiatus & compression of 3rd CN. Surgery!
              determine whether it results in coma, so brain stem infarction or         BILATERAL FIXED DILATED PUPIL: Cardinal sign of brain death.
              haemorrhage often causes coma while other brain stem                      Also: Deep coma of any cause (esp barbiturate intox / hypothermia)
              conditions such as multiple sclerosis or tumour rarely do so.             PINPOINT PUPILS: Opiate overdose or pontine lesions (that interrupt
              Lesions below the level of the pons do not normally result in             sympathetic pathways to dilator muscle of pupil).
              coma. Drugs and metabolic disease produce coma by a                       MIDPOINT PUPILS (that react to light ): Characteristic of coma of
              depression of both cortex and ascending RA system function.               metabolic origin / CNS depressant drugs.
 Cause  TOXINS                                                                          FUNDI: Examine for papilloedema (indicates  ICP)
           Drug overdose, OH, anaesthetic gases, CO poisoning.                         MOVEMENTS: LATERAL DEVIATION OF EYES:
        METABOLIC: CAN GO FAILURE                                                        Look AWAY from paralysed limbs: Ipsilateral cerebral haemorrhage

WILL WESTON                                                                                                                                     Page 2 of 7
              / infarction                                                              S&S       Individuals in such a state have lost thinking abilities and awareness
             Look TOWARDS paralysed limbs: Contralateral pontine lesion                          of surroundings, but retain non-cognitive function and normal sleep
            MOVEMENTS:                                                                            patterns. Even though those in a PVS lose higher brain functions,
             Passive head rotation  ocular deviation in opposite direction                      other key functions such as breathing and circulation remain relatively
              (Doll’s head reflex). This normal reflex is lost in v. deep coma and                intact. Spontaneous movements may occur, and eyes may open in
              absent in brainstem lesions.                                                        response to external stimuli.
             Caloric response: Normal = Ice cold water  external auditory
              meatus  Eye deviation towards affected side + Nystagmus away.            RULES & REGULATIONS SURROUNDING DEATH
 Mx                                    ABC of Life Support                               ENGLISH LAW…
                                                                                         Does not require a doctor to confirm death has occurred or that 'life is
                                          O2, IV Access                                     extinct' …VERIFICATION OF DEATH
                                                                                         Does not require a doctor to view the body of a deceased person
                                     Stabilise Cervical Spine                             Does not require a doctor to report the fact that death has occurred
                                                                                         Does require the doctor who attended the deceased during the last
                                          Blood Glucose                                     illness to issue a death certificate detailing the cause of
                                                                                           death…CERTIFICATION OF DEATH
                                         Control Seizures                                 Certifying doctor required to enter:
                                                                                                  PART 1: Conditions which led directly to death in, so disease /
                     Consider IV Glucose, Thiamine, Nalaxone, Flumazenil                               condition which started sequence is in lowest used line.
                                                                                                  PART 2: Any other significant conditions which may have
                                         Brief Examination                                             contributed to death.
                                                                                         EXPECTED DEATH
                                                                                          If the death occurs in the patient's own home then it is wise to visit as
                           ABG, FBC, U&E, LFTs, ESR, TFTs, Cortisol
                                                                                            soon as the urgent needs of living patients permit.
                               Ethanol, Toxic Screen, Drug Levels
                                                                                          If the death occurs in a nursing or residential home and the GP who
                             Blood Cultures, Urine Culture, Malaria
                                                                                            attended the patient during last illness is available, then it is sensible for
                                                                                            GP to attend when practicable and issue a death certificate
                                                                                          If 'on-call' doctor is on duty, unlikely any useful purpose will be served by
                            Reassess and plan further investigations
                                                                                            that particular doctor attending. In such cases, recommended that GP
      ABC of Life Support             Airway
                                                                                            advises home to contact undertaker if they wish body to be removed and
                                     Breathing
                                                                                            ensure GP with whom patient registered is notified as soon as practicable
                                                                                         UNEXPECTED / SUDDEN DEATH
                                      Disability i.e. GCS (Don’t forget Glucose)
                                                                                          If in patient's home, or nursing / residential home, recommended that
                                                                                            there is visit by GP with whom patient is registered, to examine body and
         O2, IV Access                 Hypoxic
                                                                                            confirm death, (although this is not a statutory requirement). GP should
                                                                                            then report patient's death to coroner - Generally through local police.
    Stabilise Cervical Spine
                                                                                          In any other circumstances, request to attend is likely to have been
                                                                                            generated by police / ambulance service. Generally wise (Esp for 'on-call'
         Blood Glucose                 Hypo / Hyperglycaemia                               doctor), to decline to attend and advise services of a retained police
                                                                                            surgeon be obtained by caller.
        Control Seizures
                                                                                       CONFUSION: See CCC Delirium (Psychiatry)
       Thiamine, Glucose               THAMINE   Lactic acid  Enceph-
            Nalaxone                    alopathy(Wernickes),Numbness,Weakness.          INTRACRANIAL PRESSURE AND CEREBRAL BLOOD FLOW
      Flumazenil: If airway            NALAXONE: Opioid antagonist
                                                                                         REMEMBER: CPP = MAP – ICP                            World Anaesthesia, Oxford.
         compromised                   FLUMAZENIL: Benzodiazepines antagonist
                                                                                        Blood flows to brain via carotid and vertebral arteries  Anatomise at COW.
       Brief Examination                                                                 ICP: Intracranial Pressure is pressure within rigid skull.
                                                                                        CPP: Cerebral Perfusion Pressure is pressure driving blood through brain.
                                                                                         MAP: Mean Arterial Pressure is diastolic pressure + one third of pulse
                ABG                    Hypoxaemia, CO
                                                                                          pressure (difference between systolic and diastolic). MAP is thus between
                FBC                    Trauma
                                                                                          systolic and diastolic pressures, nearer diastolic.
                U&E                    Uraemic Encephalopathy
               LFTs                    Hepatic Encephalopathy                           Principle constituents within the skull: Brain (80%), Blood (12%) CSF (8%).
                ESR                    Infection                                        v.intracranial (constant) = v.brain + v.CSF + v.blood + v.mass lesion
         TFTs, Cortisol                Hypothyroidism, Hypoadrenalism                   If mass lesion / oedematous brain expands some compensation is possible as
 Ethanol, Toxic Screen, Drugs          OH, Drugs                                         CSF and blood move into spinal canal and extracranial vasculature
   Blood C, Urine C, Malaria           Septicaemia, Meningitis                           respectively. Beyond this point, further compensation is impossible 
                CXR                    Pneumothorax, Cancer, Infection                   Dramatic  ICP .
                                                                                        Normal CPP is 80 mmHg. If < 50 mmHg there is metabolic evidence of
   Reassess and plan further           CT (mass lesion, IC haemorrhage)                  ischaemia and  electrical activity. CPP of <70 mmHg gives poor prognosis!
         investigations                CSF (Only if mass lesion excluded on CT:         Normal brain autoregulates its blood flow to regardless of blood pressure by
                                        SA haemorrhage, meningoencephalitis)              altering resistance of cerebral blood vessels.
 Prog       Depends on cause.                                                            CAUSES OF  ICP:                                      THIN, BB
                                                                                                      o      Oedema
                                                                                                      o      CSF                               Trauma
 BRAIN DEATH                                                                                          o      Hypoxia (Vasodilation)             Hydrocephalus
 Def      BRAIN DEATH: Irreversible loss of capacity for consciousness,                               o      Hypercapnia (Vasodilation)         Infection
          combined with irreversible loss of capacity to breathe.                                     o      Pain                               Neoplasia
 PRECONDITIONS FOR CONSIDERING BRAIN DEATH DX                                                         o      Cerebral perfusion pressure.      Bleeding
    Patient is deeply comatose: I.e. Not due to following…                                           o      Exaggerated hypertension.          Benign intracranial HT
             Drug induced (E.g. narcotics, hypnotics, tranquillisers)                   S&S OF  ICP:
             Hypothermia ( Rectal T must > 35oC)                                                    o      Headache - typical of raised intracranial pressure
             Metabolic Conditions: E.g. Electrolytes, Acid Base, Glucose                             o      Vomiting
    A disorder that can cause BD has been firmly established (e.g. SAH) and                          o      Confusion and  Conscious level.
      there is irremediable structural brain damage.                                                  o      Visual Disturbances:
    Pt is maintained on ventilator since spontaneous respiration inadequate.                                           Blurring
 TESTS FOR CONFIRMING BRAIN DEATH                                                                                       Obscuration - transient blindness
    Pupils fixed and unreactive to light.                                                                              Papilloedema ( pressure around optic nerve)
    Reflexes absent:                                                                                 o      Retinal haemorrhages if the rise in ICP has been rapid
             Corneal, Gag, Cough (suction catheter in trachea), Doll’s Head,                         o      Cushing's peptic ulceration
                 Ice Water Calorics                                                                   o      Slowly  head size (children)
    Spontaneous respiration absent                                                     Classic Hx:  Conscious level after an insult, followed by improvement then
             Pt disconnected from ventilator long enough to allow CO2 to              progressive drowsiness. The situation is an acute medical emergency.
                 above threshold for stimulating respiration (PaCO2 = 6.7kPa)            After brain injury, cerebral blood flow may  (MAP falls due to escaped
 WHO MAY MAKE THE DECISION                                                                blood +/or ICP increases due to swelling / lesion size). To prevent
    2 Experienced doctors (1 Consult and + 1 SpR or above). Tests usually                neuronal death (secondary brain injury), flow of well oxygenated blood must
      repeated after 6-24 hrs, before brain death finally confirmed.                      be restored.
 CORTICAL BRAIN DEATH (PVS)                                                              CPP may be maintained by  MAP or  ICP.
 Def      Cortex destroyed. Often brainstem still intact, e.g. persistent                ICP should be controlled when CPP is < 70mmHg +/or ICP > 20mmHg.
          vegetative state, i.e. Pt can survive indefinitely if sufficient nutrition.    Measures to increase MAP should be instituted prior to starting more complex
 Inv      To be diagnosed must be demonstration of no perfusion of cortex via             methods of ICP control.
          cerebral angiography. Not sufficient to just show no EEG activity.            MAP CONTROL:

WILL WESTON                                                                                                                                                 Page 3 of 7
  Control of other sites of haemorrhage has highest priority (with oxygenation).                           Intracerebral
  Further  MAP, once normovolaemia is achieved, is usually accomplished                                   Diffuse injuries
   with adrenaline, though dopamine may be used.                                     S&S       
  VENTILATION: Carbon dioxide dilates cerebral blood vessels   volume of
   blood in intracranial vault   ICP.  Ventilate to normocapnia.
  INTRAVENOUS FLUID THERAPY: Hypertonic solutions and osmotic diuretics             Inv /                       
   e.g. Mannitol,  water content of brain tissue. Mechanism requires intact
                                                                                     Dx                          
   BBB. Mannitol is a fluid and so will of course   circulating volume.            Mx
  POSITIONING: Helps drain CSF…Position with head at no > 30 to horizontal.         Prog
   Further elevation seems to produce a paradoxical  in ICP.
                                                                                     SUBARACHNOID HAEMORRHAGE (SAH)
 HEAD INJURY                                                                         Def   Acute condition involving sudden haemorrhage into space b/w
 Def                                                                                      arachnoid membrane and pia mater (adjacent to brain).
           Christmas Present Analogy…Wrapping Layers:                                      Subarachnoid space contains the cerebrospinal fluid.
                  Jelly                 …Brain                                       PP       8/100,000/yr; Typical age: 35-65
                  Cling film            …Arachnoid                                            Aneurysm assoc conditions: connective tissue diseases, AVM,
                  Paper bag             …Dura                                                     FHx (SAH:3-5x risk), bact endocarditis.
                  Cardboard box         …Skull                                                Risk Factors for aneurismal rupture: BP, Smoking
                  Brown paper           …Scalp                                       Cause Trauma > intracerebral aneurysms [80% of non traumatic] >
 Phys      Brain floats within CSF  Brain undergoes significant                          arteriovenous malformations (AVM) [15%], tumour,
             translation & deformation when head subjected to forces.                      perimesencephalic haemorrhage, pituitary apoplexy
           Forces that result from either deceleration / acceleration of            Path
                                                                                            Common sites of berry aneurysms:
             brain can  injury by direct mechanical effects or by shear-type
             forces on axons. In addition to translational forces, brain can
             experience rotational forces, which can  shear injuries.
           In DECELERATION injury (head impacts stationary
             object…windshield) skull stops moving almost instantly, but
             brain continues to move within skull toward direction of impact
             for a very brief period  forces acting on the brain as it
             undergoes both translation and deformation.
           In ACCELERATION injury (direct blow to head), force applied
             to skull causes skull to move away from applied force. Brain
             does not move with skull, and skull impacts brain  translation
             and deformation of the brain.
           Intracranial compartment divided into 3 compartments by 2
             major dural structures: Falx Cerebri and Tentorium Cerebelli.
           TENTORIUM CEREBELLI divides posterior fossa or
             infratentorial compartment (the cerebellum and the brainstem)
             from supratentorial compartment (cerebral hemispheres).                                                                              Junctions of:
           FALX CEREBRI divides supratentorial compartment into 2                                                                                Post comm + int
             halves and separates left and right hemispheres of brain.                                                                            carotid;
           Both falx and tentorium have central openings and prominent                                                                           Ant comm + ant
             edges at borders of each of these openings. When a significant                                                                       cerebral;
                                                                                                                                                  Bifurcation of
              in ICP occurs, caused by either a large mass lesion or                                                                             middl cerebral.
             cerebral edema, brain can slide through these openings within                                                                        15% are multiple
             falx or tentorium, a phenomenon known as herniation. As brain
             slides over free dural edges of tentorium or falx, it is frequently
             injured by dural edge. Several types of herniation exist:
           1) TRANSTENTORIAL HERNIATION occurs when medial                          S&S           Sudden onset of worst ever HEADACHE (> occipital)
             aspect of the temporal lobe (uncus) migrates across free edge                         Nausea +/- Vomiting
             of tentorium. This causes pressure on third CN, interrupting                          Syncope
             parasympathetic input to eye and resulting in dilated pupil. This                     Photophobia
             unilateral dilated pupil is classic sign of transtentorial herniation                  Mental status
             and usually (80%) occurs ipsilateral to side of the transtentorial                    Collapse +/- Seizures  Coma
             herniation. In addition to pressure on third CN, transtentorial                        BP
             herniation compresses brainstem.                                                      Ocular Haemorrhage (Terson syndrome)
           2) SUBFALCINE HERNIATION occurs when cingulate gyrus on                                Neck stiffness (Kernigs +ve [takes 6 hrs to develop]: Each hip
             the medial aspect of frontal lobe is displaced across midline                          is flexed in turn, & then attempt to straighten the knee while
             under free edge of falx. This may compromise blood flow                                keeping the hip flexed = pain)
             through anterior cerebral artery complexes (located on medial                        FOCAL NEUROLOGY
             side of each frontal lobe). Subfalcine herniation does not cause        DDx      Only 25% with sudden severe headache have SAH.
             same brainstem effects as caused by transtentorial herniation.                   Migraine, Meningitis, Intracerebral haemorrhage
           3) CENTRAL HERNIATION occurs when diffuse  ICP occurs                   Inv /    Hx                + Physical Examination
             and each of cerebral hemispheres is displaced through                   Dx       CT                Non contrast CT of brain (misses 2% of small
             tentorium  significant pressure on the upper brainstem.                                               bleeds)
           4) UPWARD, OR CEREBELLAR, HERNIATION occurs when                                  LP                If –ve CT for haematoma / hydrocephalus
             either a large mass or  pressure in posterior fossa is present                                    Bloody  Yellow (Xanthochromia)
             and cerebellum is displaced in an upward direction through the                                      RBC count (> 100 000 / mm3)
             tentorial opening  Significant upper brainstem compression.                     Angiogrm          Cerbral angiogram: Gold Standard
           5) TONSILLAR HERNIATION occurs when  pressure                           Mx       Bed Rest + BP monitor + CNS re-examine
             develops in posterior fossa. In this form of herniation, cerebellar               Clip aneurysm to prevent rebleeds
             tonsils are displaced in a downward direction through foramen                     Control severe BP
             magnum,  compression on lower brainstem and upper                                Analgesia for headache + bedrest +/- sedation for 4/52
             cervical spinal cord as they pass through foramen magnum.                         Nimodipine (Ca ant): for 2-3/52 if BP allows
 PP                                                                                 Comp     Rebleeding: cause of death (30% risk in 1 few days)
 Cause                                                                                       Vascular spasm: follows bleed  ischaemia +/- CNS deficit
 Class    MECHANISM                                                                  Prog     Mortality Grading
           Blunt Trauma: High / Low Velocity                                                 Grade         Signs                                       Mortality
           Penetrating Injury: Stabbing / Shootings / Other foreign bodies                   I             None                                        0%
          SEVERITY                                                                            II            Neck stiff + cranial nerve palsy            11%
           Mild:         14-15                                                               III           Drowsiness                                  37%
           Moderate: 9-13                                                                    IV            Drowsiness + Hemiplagia                     71%
           Severe:         3-8                                                               V             Prolonged Coma                              100%
          MORPHOLOGY                                                                                                st
                                                                                              Almost all mortal = 1 month. Post 1/12, 90% survive ≥ 1 yr
           Skull Fracture:
                    Open
                                                                                     ACUTE DRUG OVERDOSE / POISONING
                    Closed
                                                                                     S&S    Common Drugs: See BNF for more
           Intracranial Lesion:
                                                                                            Fast / Irregular Pulse Salbutamol, Tricyclics
                    Extradural
                                                                                            Hyperthermia           Cocaine
                    Subdural

WILL WESTON                                                                                                                                            Page 4 of 7
           Coma                       Benzodiazepines, OH, Opiates, Tricyclics                                   fat.
           Pupils Constricted         Opiates                                             STRAW                  Clotting Disorders:
           Pupils Dilated             Cocaine, Tricyclics                                                       Dark Skinned: May mask bruising. UV light needed
           Hypoglycaemia              Insulin, Alcohol                                DISAPPEARS                 Clotting Disorders:
           Renal Failure              Salicylate, Paracetamol                           14-15 days              o Haemophilia, Leukaemia and Platelet disorders)
           Met Acidosis               OH, Paracetamol, CO poisoning                   (range 1-4 /52)           o Some Infections (meningitis)
 Inv /     History      HPC + Psychiatric: Intended action? Previous / Current                                  o Liver Disease ( including alcoholism)
 Dx                     Disorders. Suicide risk? Nb: Pt may not be telling truth.                               o Vitamin C deficiency
                                                                                                                o Poor nutrition
           Indexes      MIMS, eMIMS, BNF, TICTAC.
                                                                                                                o Medications.
           Bloods       FBC, U&Es (Renal F), Glucose, ABGs, LFTs (Liver F,
                                                                                     ABRASION             Portion of body surface from which skin / mucous
                        Pancreatitis), ECG,
                                                                                     Syn:                 membrane has been crushed or removed by rubbing. A
           Tox          Check 4 hourly Serum / Urine: Paracetamol and
                                                                                     Scratch, Graze       superficial injury, confined to epidermis/dermis. Due to (1)
                        Salicylate levels (plot on graph) +/- other assays.
                                                                                                          Direct impact: imprint (may reflect pattern of causative
           Monitor      Temp, Pulse, RR, BP, Glucose, Sats, Urine OP, ECG
                                                                                                          surface) or (2) Tangential impact: graze or scratch (may
           Care         Urinary Catheter, ITU if respiration.                                            reflect direction of impact)
 Tx                                            ABC                                   LACERATION           Full thickness tearing of skin / tissue due to stretching &
                                                                                    Latin: to tear       crushing by blunt force. Characteristics: Ragged edge,
                                  Ventilation? Any of below:                                              Associated bruising/abrasion, Tissue bridges
                                          If RR< 8/min                                                    Provides little specific information about the causal object.
                               PaO2 < 8kPa when on 60% O2
                                                                                     INCISION             Clean division of full thickness of skin (or other tissue) by
                                  Airway at risk e.g. GCS < 8
                                                                                     Latin: to cut into   sharp-edged instrument. Characteristics: Clean cut edges,
                                                                                                          No associated bruising/abrasion, No tissue bridges. Incised
                                           Treat shock
                                                                                                          wound is LONGER > DEEP. Provides little specific
                               Unconscious? Nurse semi prone
                                                                                                          information about causal object
                                  Investigations: See above                          PENETRATING          Small hole made with a sharp point. DEPTH > LENGTH on
                                                                                                         body surface. Due to sharp/flat instrument, e.g. knife
                                     Supportive Measures:                                                 (STAB), a sharp/thin, e.g. needle (NEEDLE PUNCTURE) or
                Absorption: Consider Gastric Lavage +/- Activated charcoal                               blunt/long/rigid, e.g. wooden stake (PUNCTURE). Shape
                        Specific measures: Antidotes. See Oxford HB                                       and size of wound often indicate dimensions of weapon.
                              NB: NEVER INDUCE VOMITING!                             THERMAL              Application of dry / moist heat :burns & scalds. Cold injury
 G Lav     INDICATION:                                                               ELECTRICAL           Heat produced by electrical flow.
              Only of use if presentation within 1 hour of poisoning and if         FIREARM              Small mass, high velocity projectile fired from gun.
                 potentially toxic dose of drug has been taken.
           CONTRAINDICATIED:                                                         COMMON SIGNS / SYMPTOMS AFTER AN RTA
              Ingestion of petroleum products, corrosives, acids, alkalis,          CONTRIBUTORY FACTORS IN CRASHES
                 bleach, descalers (exception: paraquat).                            Intoxication            Alcohol, Drugs, Carbon Monoxide.
              Unconscious / Unable to protect airway (unless intubated)             Human factors           Reckless, Speeding, Fatigue, Inexperience, Shoes.
           PROCEDURE                                                                 Environmental           Fog, Rain, Ice, Snow, Leaves, Sun, Visual Obstruction.
              Monitor O2, Suction apparatus to hand, Pt in L Lateral Position       Mechanical failure      Tyres, Brakes, Steering
              Raise foot of bed by 20cm                                             Natural disease         Ischaemic Heart Disease, Stroke, Epilepsy.
              Pass lub tube (14mm ext diam) via mouth with pt swallow               PEDESTRIAN Most vulnerable road user (Esp children / elderly)!
              Confirm position of tube: Blow air and auscultate over stomach        Dynamics of crash depend on relative heights above ground of impact site and
              Siphon contents: Check pH with litmus paper.                          centre of gravity (COG) of pedestrian.
              Perform Lavage: Use 300-600mL tepid water. Massage Left                  IMPACT BELOW COG throws victim onto bonnet (or roof at > speed).
                 Hypochondrial area.                                                        Victim acquires velocity of vehicle only to be thrown onto road surface by
              Repeat until no tablets in siphoned fluid.                                   violent braking.
              Leave activated charcoal in stomach unless OH, Fe, Li,                   IMPACT AT COG shunts victim in direction of travel
                 Ethylene glycol ingested.                                              IMPACT ABOVE COG throws victim under vehicle
              Pull out tube: Occlude end – prevents aspiration of fluid left in.
                                                                                     PRIMARY INJURIES: Due to direct impact of vehicle against victim.
 A Chr     ACTIVATED CHARCOAL:                                                          Car bumper injury to lower leg, if fixed by weight bearing (bruise,
               Absorption of drugs from gut with single dose:                             abrasion, laceration, fracture). Height of injury above heel of shoe is
                        Salicylates, Paracetamol                                           important. Primary injuries may harbour trace evidence (paint, metal) of
               Absorption of drugs from blood with repeated doses:                        evidential value in 'hit and run' collisions.
                        Carbemazepine, Dapsone, Theophyllines, Quinine,                A high fronted van will hits the thigh.
                           Digoxin, Phenytoin, Phenobarbitol, Paraquat.                 Flat fronted lorry or bus hits torso.
 Prog                                                                                SECONDARY INJURIES: Due to impact against bonnet, windscreen, road
                                                                                     surface or other object/vehicle.
 FORENSIC MEDICINE: USEFUL FOR A&E!...USEFUL DEFINITIONS                                Bonnet & windscreen frame may fracture skull or injure chest & abdomen.
 WOUND: (legal)      Breach of full thickness of skin (or lining of lip). Excludes      Thrown  Road injures head, chest, abdomen  Sliding abrasions,
                     abrasions, bruises, internal injuries and fractures!                   lacerations.
 WOUND               Disruption of continuity of tissues produced by external           Running over  Flaying lacerations to the limbs.
 (medical)           mechanical force.                                                  Speed of impact cannot be estimated from severity of injuries. Can only
 INJURY:             Often used synonymously with wound but can have a wider                state whether injuries were mild, moderate or severe. Skid marks offer
 Latin: injuria (not use, incl damage to tissues by heat, cold, chemicals,                  only objective evidence of vehicle speed.
 the law)            electricity, radiation, in addition to mechanical force                  SPEED OF IMPACT                                 % FATALITIES
 LESION:             Originally meant injury, now more widely applied to include                    19-24 mph                                      10%
 Latin: laesio       any area of injury, disease or local degeneration in tissue                    24-30 mph                                      47%
 (hurt)              causing a change in its function or structure''                                31-36 mph                                      73%
 TRAUMA:             Bodily harm with / without structural alterations resulting        50% of fatalities are hit < 30 mph. 50 % serious injured are hit < 21 mph
                     from interaction with physicochemical agents, imparting         VEHICLE OCCUPANTS: Occupants move towards the point of impact.
                     energy to tissues. May  morphologically apparent               There are 5 main patterns of impact:
                     damage (wound) or produce physiological imbalance (eg           1-HEAD ON INTO A STATIONARY OBJECT (Speeds + Impact energy additive)
                     reflex cardiac arrest by neural stimulation) & 2o effects (eg      E.g. Tree, another vehicle ()
                     thrombosis, infection, obstruction of tubular organs)              Driver and front passenger may strike
 CLASSIFICATION OF INJURIES                                                                        Dashboard, windscreen & pillars (skull & brain).
 BRUISE              Escape of blood from ruptured small vessels into                              Steering wheel (chest-lacerated lung & heart).
 Syn: Contusion,     surrounding tissues. Resulting discolouration seen through                    Parcel Shelf (# knees & pelvis)
 Ecchymosis          overlying intact skin. Due to blunt force trauma.                             Pedals trap the ankles
                     Site, shape, size, severity are very variable.                     Rear passenger hits seatback or over into front
    DARK RED          Petechiae- Pin head size bruise < 2mm                            Deceleration  whiplash (flex/extension) neck, DAI brain injury and
                    Extravasated blood tracks along natural/traumatic planes of            ruptured thoracic aorta.
     PURPLE          < resistance, influenced by gravity & body movement. e.g.       2-REAR IMPACT (Speeds Subtractive)
                       Blow on temple  Bruise on cheek                               Whiplash (extension/flexion) with no restraint- Seats and head restraints
      BROWN             Fractured jaw  Bruising on neck                                   support torso and neck
                       Fractured hip  Bruise on thigh                                Risk of petrol fire
      GREEN          Bruising increased in following:                                3-SIDE IMPACT -Direct
      4-5 days          Infants: Loose, delicate, fatty tissues which bruise           Risk of side intrusion
                           easily.                                                     Left: Limb, Spleen, L Kidney, Lung
     YELLOW             Elderly: Degeneration of vessels & connective tissue.          Right: Limb, Liver, R Kidney, Lung
     7-10 days          Female / Obese: Greater proportion of subcutaneous          4-SIDE SWIPE -Glancing
WILL WESTON                                                                                                                                              Page 5 of 7
    -Less risk of side intrusion                                                              SUPPLEMENTARY BLOOD TESTS:
 5-ROLL OVER -less damaging                                                                    Grp, XMatch
    Rolling spreads time of impact) unless occupant is ejected.                               LFT's: Jaundice, Malignancy
 SEATBELTS: V Effective in  mortality / injury in low - medium speed impacts:                 Clotting: Haemorrhage, Warfarin / Heparin, Liv Disease
    Diagonal strap restrains upper torso (prevents impact with steering wheel,                Sickle Cell Test: depending on ethnic origin
       upper dash)                                                                             TFT's: Thyroid Disorders
    Horizontal strap restrains lower torso and pelvis, (prevents impact with                  ECG INDICATIONS:
       lower dash, parcel shelf)                                                               IHD, HT, RhF, Resp Disease: Smoker, Pulm HT
    Area of straps spreads deceleration force over a wider area than                          Recommended for all over 40 or 50 years old.
       localised impact                                                               Consent (check surgical and verbal anaesthetic)
    Stretching of strap fabric increases the time over which deceleration            Optimise
       forces are spread                                                              Premedicate
    Prevents ejection through windscreen or burst door
                                                                                                ANXIETY - Depending on needs of patient - Use anxiolytics
    HOWEVER…Seat belt injuries are common
                                                                                                PARASYMPATHETIC excretion which is normally enhanced
              Bruising across chest & abdomen
                                                                                                  by general anaesthetics, e.g. salivary, lacrimal - use
              Neck injury and carotid artery rupture                                             anticholinergics, e.g. hyoscine
              Fractured sternum, ribs, clavicles                                               AUTONOMIC NERVOUS SYSTEM reflexes, which is
              Lacerated mesentery, bowel                                                         particularly useful in eye and gonadal surgery
              Lumbar spinal injury                                                            AMNESIA AND ACTIVE SEDATION - e.g. anxiolytics which
     Rarely more damaging than if a seatbelt is not worn.                                       produce orthograde amnesia such as lorazepam, temazepam
 Other safety features:                                                                        ADJUVANTS TO ANAESTHESIA, depending on circumstances:
    Airbags                                                                                              Antacids, particularly H2-receptor antagonists
    Crumple zones absorb impact energy and increase the duration of impact                               Antibiotics
    Laminated windscreens deform without shattering and prevent ejection                                 Antiemesis
    Side impact bars                                                                                     Analgesia
    Burstproof door locks to prevent ejection                                                            Bronchodilators
    Padded steering wheel and collapsable column                                                         Steroids, e.g. adrenal insufficiency
    Breakable controls and mirrors                                                                       Local Anaesthetic, e.g. EMLA for siting IV lines
 MOTORCYCLIST                                                                         Transfer to theatre – bed/chair/oxygen etc
    High speeds, unstable, no protection, difficult to see.                       INTRAOP – (AIMS) – HONE
    PRIMARY impact injury may be to leg.                                             Haemodynamic stability
    SECONDARY impact injury: head, neck, chest and abdominal injury.                 Optimal fluid management
    Helmet and leathers provide the only protection.                                 Normocarbia, Normoglycaemia, Normothermia, Normoxia
    Energy must be dissipated by sliding or rolling along the road.                  Excellent pain control
                                                                                   METHODS – (ANAESTHETIC ROOM) – MISTS, DAM, TIA
 ANAESTHESIA                                                                          Machine
                                                                                      Instruments
 MNEUMONICS                                                                           Suction
 Enzyme Inducers: GAP PRICE       Enzyme Inhibitors: MC FEED CAKE                     Tilting trolley
   Griesofluvin                    Metronidazole                                    Skilled assistance
   Alchohol (chronic)              Ciprofloxacin                                    Drugs
   Phenytoin                       Fluconazole                                      Access
   Primidone                       Erythromycon                                     Monitoring
   Rifampicin                      Ethanol (acute)                                  Transfer to theatre for induction?
   Inhalation agents               Dextropropoxyphene                               Induction
   Carbamazapine                   Cimetidine                                       Airway
   Ethanol                         Amiodarone                                    THEATRE – PMR
                                    Ketoconazole                                     Positioning
                                    Etomidate                                        Maintenance
 CAUSES OF NEUTROPHILIA: PAMMI’S BITS                                                 Reversal
   Pregnancy                                                                      POSTOP – ABCD, AFTER
   Acute haemorrhage                                                                 Airway
   Malignancy                                                                        Breathing
   Myeloproliferative disorders                                                      Circulation
   Iatrogenic – prednisolone                                                         Drugs, Disability, DVT (is clexane prescribed)
   Severe metabolic disease e.g DKA                                                  Analgesia
   Bacterial infections                                                              Fluids
   Inflammatory disesae                                                              Temperature
   Trauma                                                                            Endocrine – check blood sugar
   Surgery                                                                           Recovery site – ITU / HDU / recovery

 FITNESS FOR ANAESTHESIA                                                           Can be adapted e.g for RSI: ‘In place of safety I ensure I have MISTS, DAM’
 Fitness classified by American Society of Anesthesiologists (ASA) as follows:
                                                                                   CONDITIONS WHICH REQUIRE SPECIAL ATTENTION / PREPARATION
  1.    Normal healthy patient                                                     ANGINA
  2.    Mild systemic disease                                                          From the history, distance walked before onset
  3.    Severe systemic disease that limits activity but is not incapacitating         Exercise tolerance tests, e.g. Bruce protocol on treadmill
  4.    Incapacitating systemic disease; threat to life                                Angina at rest is high risk.
  5.    moribund patient not expected to survive 24 hours +/- surgery              ASTHMA
                                                                                       Presents few problems to anaesthetist if condition well-controlled.
 Groups 1 - 3 have No / Little  risk with Normal Anaesthesia. Important to note       Medication taken at normal doses up to surgery. Only pre-operative
 that none of these are an absolute CI to anaesthesia. Instead, they are ways of           investigation of note is use of a peak flow meter. Possible postponement
 comparing wellbeing of patient with importance of the procedure: Production of            or change in medication may be warranted by:
 a risk-benefit concept for surgery and anaesthesia.                                              PEFR < 50% of the normal maximum
                                                                                                  PEFR less than 200l/minute
                                                                                                  Significant decrease in the morning PEFR
 PREOP – I,E,HEMI,COPT                                                                 Severe asthmatic usually on a maximal drug regimen before assessment.
   Introduction &                                                                         Tailored dose of steroids may be used e.g. 30-60mg prednisolone once
   Explanation of role                                                                    daily, before and after surgery.
   History: Especially:                                                           COPD
            RED JAM HATS, Existing CardioResp Disease                             COAD requires intensive preoperative assessment and Tx in order to minimise
            PMHx / PSHx: + Dental procedures - caps, bridges or reactions         risk of postoperative complications. Assessment includes:
              to anaesthetic, any recent general anaesthetic or "awareness"            SPUTUM CULTURE: Growth and sensitivity to antibiotics
              while under general anaesthesia                                          PEAK FLOW: Before and After bronchodilators to determine whether
   Examination…Especially:                                                                reversible element of airways obstruction
            HT, SOB, LVH, Peripheral oedema, Murmurs, Cough                           ABGs: to determine hypoxic or hypercapnic drive
            Hydration: Skin turgor, Urine OP, Fluid intake, BP, HR.                   SPIROMETRY: ? Cancel if FVC < 2 L or FEV < 1L or FEV1/FVC i< 0.5
   Medications and allergies                                                          Subsequently, preoperative antibiotics and physiotherapy are provided.
   Investigations                                                                         Pain relief is particularly important if abdominal surgery is undertaken,
            STANDARD BLOOD TESTS:                                                         e.g. epidural analgesia may be used to permit the patient to cough.
            U&Es, Hb, Hct, FBC, Glucose                                           DIABETES
WILL WESTON                                                                                                                                           Page 6 of 7
             Admit >24 hrs before surgery
             Begin / Continue a bd regimen of medium & short acting insulin
             On day of surgery commence i.v. Glucose and Insulin therapy
             stop oral agents on morning of operation
             If fasting blood [glucose] < 7.0 mM then no action required
             If fasting blood [glucose] > 11 mM, or operation prolonged, then
               IV glucose and insulin therapy indicated
             All admitted for emergency surgery require IV control of blood
               glucose irrespective of severity of their diabetes.
             If patient is in DKA crisis, effective control of metabolic disorder
               will be advantageous in two ways:
                       Vomiting and abdominal pain will be relieved; these
                         may have been original indications for surgery
                       Surgery will be safer
             A few hours spent correcting ketoacidosis is essential unless
               patient is in extremis: usually, there are electrolytes and acid-
               base abnormalities.
   Risk of a fatal reinfarction during a general anaesthetic is greatly
      increased up to 6 months after MI  Delay Elective procedures until then.
   Concurrent drug therapy                 Chronic respiratory infection
   Arrhythmias                             Coryzal symptoms
   Heart failure                           Obesity
   Hypertension                            Liver disease
   Valvular heart disease                  Sickle cell anaemia

 ROUTES: INH, IV, IM, PO (Rare), PR (Rare)
 HALOTHANE: Volatile anaesthetic gas, with many advantageous:
    Potent at relatively low concentration
    Smooth induction
    Non-irritant
    Pleasant to inhale
    Causes bronchodilation
 However, its use has declined as a result of a number of disadvantages:
    Associated with severe hepatotoxicity, cardiorespiratory depression,
      peripheral vasodilatation and sensitisation of the myocardium to
      catecholamines ( risk of arrhythmias)
    Little analgesia or muscular relaxation
    Can imitate malignant hyperpyrexia
 ENFLURANE: Volatile anaesthetic with a similar activity to halothane, but…
    Less potent at both induction and maintenance. This extends to its SEs:
      Like halothane,  Cardiorespiratory depression but < risk of arrhythmias.
    Usually given as an adjunct to NO-Oxygen mixtures.
    May  Epileptiform seizures  Should be avoided in epileptics.
    Used at low dose for inhalational analgesia, e.g. carried by a 50% oxygen
      mixture (Entonox) or at higher concentrations with other agents for
      induction and maintenance of balanced anaesthesia.
    NO may be best avoided for inhalational anaesthesia in following cases:
              When need for high inspired oxygen concentrations
              First four weeks of pregnancy
              Long operations on patients with closed gaseous compartments
                - there is a  diffusibility   volume  e.g. a pneumothorax
                may enlarge to compromise respiration
              Cerebral vasodilation, increase in intracranial pressure
              Where alternative would suffice with < atmospheric pollution
    Chronic exposure to NO may interfere with folate metabolism, so --> in all
      of signs of deficiency, e.g. megaloblastic anaemia, neuropathy.

   Central venous cannulation is performed for vascular access, total
     parenteral nutrition, infusion of irritant drugs, measurement of central
     venous pressure, cardiac catheterisation, pulmonary artery
     catheterisation and transvenous cardiac pacing.
   Internal jugular vein
   Subclavian vein
   Femoral vein
   External jugular vein
   Antecubital veins

WILL WESTON                                                                                                       Page 7 of 7

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