Professional Documents
Culture Documents
Megawe
Dept. of Anesthesiology & Reanimation
Airlangga University School of Medicine
Surabaya
I.
BASIC PRINCIPLES :
a.
b.
c.
d.
e.
f.
g.
:A
:B
- Unresponsive to voice/pain
Posture
Pupils : size/reaction
Conscious level
Convulsions
E = EXPOSSURE :
- Rash
- Purpura
- Swelling
- Urticaria
- Fever
- Angio-edema
LOSS
MALDISTRIBUTION
RESPIRATORY
DISTRESS
RESPIRATORY
DEPRESSION
BLOOD LOSS
SEPTIC SHOCK
FOREIGN BODY
CONVULSIONS
GASTROENTERITIS
CARDIAC DISEASE
CROUP
RAISED ICP
BURN
ANAPHYLAXIS
ASTHMA
POISONING
CIRCULATORY
FAILURE
CARDIAC ARREST
RESPIRATORY
FAILURE
VASCULAR ACCESS
Preferred options :
A. Intra venous
B. Intra osseous
A. Preferable via the superior v. cava
Via the inferior v. cava takes longer to reach the heart
Via the periph. route fluid flush
First priority : accurate
safety
rapidly
B. Intra osseous :
- Easy & safe
- Reach the heart = periph. ven. access
- Also in older age & adults
C. Tracheal :
Third place
For first drug adrenaline
D. Intracardiac : not recommended
Colloid
20 ml/kg
Assess
response
Blood
Urgent
Surgical opinion
V.
VI. PLAN
FULL STOMACH
HYPOVOLEMIA
Ongoing bloodloss
Pending blood availability
5% Albumine
- femoral nerve
- axillary
Providing analgesia
As a primary anesthetic
(avoid risks of general anesth. = aspiration)
Supplement for postop analgesia
CAUTIONS
Titrate sedative in small increments to avoid loss
of airway reflexes
Appear alert & Sedation sleepy
After the block : painfull stimuli is removed
Close communication with surgeons = ability to
perform sensory and motor examinations
Skill
Essential for the anesthesiologist
Knowledge
Urgent diagnosis & treatment
Additional signs :
- drooling
- difficulty in swallowing
Favoured approach worldwide : Endotracheal intubation
Avoid = inspection increase obstruction (dynamic airway collapse
Radiographic = - Only when stable
- Skilled personnel
- Adequate resuscitation equipment
In the operationg room :
Calm, sitting on the lap o/t mother
Induction overface :
- Halothane
- Sevoflurane
Looses consciousness supine
Head up slightly
Intubation tehnique
Lifting the base of the tongue
Without touching the epiglottis
Exposure of the rimaglottidis
Partially obstructed orifice
0,5 mm ID smaller choosen sprayed beforehand
A stylet within the endotracheal tube
Failure : - tracheostomy
- cricothyorotomy
Adequate sedation to prevent extubation
* Titrated opioids
- Breathe spontanneously
- ETT remains in place for 24 48 hours, until swelling decreased
- Extubation
(peanut, popcorn)
A wheezing child :
Not always asthmatic
May be foreign body aspiration
Agitation : due to seriously underlying hypoxemia
Radiographic examination
If the child is stable
Helpful to localize & identify
Mostly are not radiopaque
Hyperinflation
Clues of presence of foreign body
Atelectasis
Principle of anesthetic management = epiglottitis
Tachypnea
Retractions
Wheezing
Hyperinflated chest & diffuse crepitations
Progressive exhaustion hypercarbia respiratory failure (silent ches
Focus of treatment = correct hypoxemia
Pulse oxymetry :
- degree of hypoxemia
- respons to therapy
Nebulized mist
Not proven beneficial
Bronchodilators
Titrated I.V, fluids not able to drink
Ribavirin : antiviral agent
Caution : Particles tend to disk, obstructing the ventilator
No absolute PaCO2 value that dictates the course of action
Management :
a. Support oxygenation
b. Reduce airway obstruction
c. Support ventilation
d. Prevent complication (e.g. pneumothorax)
e. Inhaled & I.V. drugs
Anesthesia :
Optimize oxygenation, control brochospasm
Standard agents
Ketamine : - Bronchodilating
- Hypersecretion
Avoid histamine release agents :
- Morphine
No sciencetific data yet
- Curare
- Thiopental
Drying of secretions intra-operatively :
- Atropine
- Glycopyrrolate
May exacerbate mucous plugging post-operatively
Wheezing during anesthesia mechanical problem :
- endobronchial intubation
- plugging, kinking
- cuff herniation
Mechanical ventilation is difficult
High Airway Pressure:
- air trapping
- pneumomediastinum
- pneumothorax
Controlled mechanical ventilation:
- Degree of hypercarbia is pernitted/acc
- Adequate oxygenation
- Adequate cardiac output
CIRCULATION :
1. Hypovolemia : Most common cause of shock