Drowning: Specific Points

Drowning is death while submerged in water, and near-drowning is suffocation while submerged with survival (at least temporary).

If water does not enter the airway, asphyxia is the main complication.

If the patient inhales water, marked intrapulmonary shunting & significant V/Q mismatching because of loss of pulmonary surfactant (wash-out) and reflex laryngobronchospasm are also mechanisms

Significant volumes of hypotonic fresh water aspiration fresh can lead to hyponatremia and hemodilution.

Cold water drowning leads to loss of consciousness at a temperature below 32°C and ventricular fibrillation can occur at 28° to 30°C. Resuscitation efforts may be very prolonged after cold water aspiration

Aspiration of gastric contents because of unconsciousness and lack of airway reflexes can further complicate lung injury and risk of death.

All patients will have hypoxemia, hypercarbia, and metabolic acidosis from lack of oxygen delivery and subsequent lactic acid production.Also Cerebral edema, ALI, and ARDS can complicate medical courses

Treatment: restore spontaneous circulation and ventilation, focus on improving oxygen delivery further to decrease metabolic acidosis. Because of a significant risk of ALI and ARDS, airway management and lung protection ventilation strategies should be initiated as soon as possible. Cerebral protection maneuvers should also be followed and neurosurgical consultation obtained when appropriate. Electrolyte and temperature derangements should be treated. Patients’ clinical courses will be labile.

NERVE SUPPLY OF AIRWAY / LARYNX

Morphine and Hydromorphone

• Morhine is metabolised via hepatic system and excreted by renal system
• It can get accumulated in hepatic/renal dysfunction and obesity
• Morphine has 2 metabolites:
• Morphine 6 glucoronide- Active metabolite: responsible for analgesia and sedation
• Morphine 3 glucoronide: Can cause seizures
• Morphine has histamine releasing property
• Hydromorphone is more potent than morphine
• Hydromorphone doesnt have active metabolites
• Hydromorphone lacks histamine release

FUNCTIONAL RESIDUAL CAPACITY [FRC]

The functional residual capacity of the infant’s lungs is only one half that of an adult in relation to body weight. This difference causes excessive cyclical increases and decreases in the newborn baby’s blood gas concentrations if the respiratory rate becomes slowed because it is the residual air in the lungs that smooths out the blood gas variations.

The functional residual capacity  equals the expiratory reserve volume  plus the residual volume.  This is the amount of air that remains in the lungs at the end of normal expiration (about 2300 milliliters).

CLOSING CAPACITY

INTRAPLEURAL PRESSURE

• The resting position of the lungs and chest wall occurs at FRC.
• If isolated, the lungs, being elastic, would collapse to a volume <FRC.
• The isolated thoracic cage would normally have a volume >FRC.
• Since the chest wall is coupled to the lung surface by the thin layer of intrapleural fluid between parietal and visceral pleura, opposing lung and chest wall recoil forces are in equilibrium at FRC.
• This produces a pressure of about −0.3 kPa [−2 mmHg ] in the pleural space.
• Normal inspiration reduces intrapleural pressure further to −1.0 kPa [−6 mmHg] but with forced inspiration it can reach negative pressures of −4.0 kPa or more.
• Intrapleural pressure may be measured by an intrapleural catheter or from a balloon catheter placed in the mid-oesophagus [Oesophageal pressures
• tend to reflect intrapleural pressures]
• In the upright adult the intrapleural pressure at the base of the lung is approximately 0.7 kPa greater than the pressure at the apex
• It will increase during coughing
• -1.0 kPa intrapleural pressure is equivalent to a distending transpulmonary pressure of +1.0 kPa

PULMONARY CIRCULATION

Protamine

BURNS AND THE ANESTHESIOLOGIST

• First degree burns don't penetrate the epidermis and the areas of involvement should not be considered when calculating for fluid volume for resuscitation 
• Second degree burns penetrates the epidermis & extends into the dermis and will cause blisters
• Third degree burns involve epidermis, full thickness of dermis, deeper tissues, blood vessels and nerves
• The “rule of nines” is used to calculate the total body surface area (TBSA) .
• The Parkland formula recommends 4 mL/kg/% TBSA burned, to be given in the first 24 hours (half of this should be given in the first 8 hours and the rest over the following 16 hours).
•  The Modified Brooke protocol recommends 2 mL/kg/%TBSA.
•  Fluid leak may occur when patients are given volume beyond the intended calculations. This can lead to abdominal compartment syndrome, pulmonary edema, or pneumonia.
•  Carbon monoxide (CO) poisoning should be considered in all major burn injuries. 
• CO binds to hemoglobin (HbCO) with an affinity of 250 times that of oxygen and shifts the oxygen–hemoglobin dissociation curve to the left. 
• Pulse oximetry causes falsely elevated oxygen saturation because it is unable to distinguish HbO from HbCO, as CO-Hb has similar absorption spectra as that of oxy-Hb
• HbCO levels below 10% are not usually clinically significant, levels of 20% may require mechanical ventilation, and death from CO poisoning occurs at HbCO levels of 60%.
• In cases where CO poisoning is suspected, treatment should be with highflow 100% oxygen, which increases the speed of elimination of CO. Hyperbaric chambers are used to further increase the speed of CO removal.
• Burns patients have an inability to regulate body temperature and must be kept warm.
• Urgent airway management may be indicated by the presence of a hoarse voice, dyspnea, tachypnea, or altered level of consciousness.
• Succinylcholine can cause lethal elevations in potassium after the first 48 hours.
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THE AUTONOMIC NERVOUS SYSTEM (ANS) IN GENERAL: RANDOM POINTS RELEVANT FOR THE ANESTHESIOLOGIST

➿The autonomic nervous system is a division of the nervous system that controls the activity of internal organs.

➿The sympathetic division prepares the body for fight or flight reactions. The parasympathetic system promotes ‘rest and digest’ (restorative) functions.

➿Acetylcholine is the principal transmitter released by the preganglionic fibres of both the sympathetic and the parasympathetic nervous systems. The parasympathetic postganglionic fibres secrete acetylcholine onto their target organs, whereas norepinephrine is principally secreted by the postganglionic sympathetic fibres.

➿The central portions of the autonomic nervous system are located in the hypothalamus, brainstem and spinal cord. The limbic system and parts of the cerebral cortex send signals to the hypothalamus and lower brain centres, which can also influence the activity of the ANS

➿The posterior and lateral hypothalamic areas increase blood pressure and heart rate, whereas the preoptic area decreases blood pressure and heart rate. These effects are mediated by cardiovascular centres in the pontine and medullary reticular formation.

➿An autonomic nerve pathway involves two nerve cells. It is connected by nerve fibers to the other cell, which is located in a cluster of nerve cells (called an autonomic ganglion). Nerve fibers from these ganglia connect with internal organs.

➿In the ANS, the connection between the CNS and its effector consists of two neurons—the preganglionic neuron and the postganglionic neuron. The synapse between these two neurons lies outside the CNS, in an autonomic ganglion [The cell bodies of the post ganglionic neuron, located in chains alongside the vertebral column, in plexuses in the abdomen (Sympathetic) or within the innervated target organ (Parasympathetic)]. The axon of a preganglionic neuron enters the ganglion and forms a synapse with the dendrites of the postganglionic neuron. The axon of the postganglionic neuron emerges from the ganglion and travels to the target organ #TheLayMedicalMan

➿The sympathetic system has short preganglionic fibres and long
postganglionic fibres. As the parasympathetic ganglia are located near or within their effector organs, the parasympathetic postganglionic fibres are short.

➿The pre-ganglionic fibres are slow-conducting B or C fibres. The postganglionic fibres that originate from the ganglia and innervate target organs are largely slow-conducting, unmyelinated C fibres. #TheLayMedicalMan

➿There are more postganglionic fibres than preganglionic nerves and so the stimulation of a single preganglionic neuron can activate many postganglionic nerves, resulting in divergence. But in the superior cervical ganglion, numerous preganglionic fibres converge on a single postganglionic neuron, resulting in convergence.

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