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ANAPHYLACTIC SHOCK

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:40 AM Comments comments (3)

Acute hypersensitivity reaction

 

Cause

 

z

Allergy to pollens, some drugs (eg. penicillins,

vaccines, aspirin) or certain foods (eg. eggs, fish,

cow’s milk, nuts, some food additives)

 

z

Reaction to insect bites, eg. wasps and bees

 

Clinical features

 

z

Sudden collapse

z

Hypotension

z

Excessive sweating

z

Thin pulse

 

Differential diagnosis

 

z

Other causes of shock, eg. bleeding, severe

dehydration

 

Management

HC2

 

f

Determine and remove the cause

 

f

Keep patient warm

 

f

Secure the airway

 

f

Restore the BP: lay the patient flat and raise the

feet

 

f

adrenaline (epinephrine) injection 1 in 1000

(1mg/mL) 0.5-1mg IM

 

- repeat initially (several times if necessary)

every 10 minutes according to BP, pulse rate and

respiratory function until improvement occurs

-child: see dose table below

f

Administer 100% oxygen

-this is of prime importance

f

Give an antihistamine as useful adjunctive

treatment, eg. promethazine hydrochloride

25-50mg by deep IM or slow IV (give <25mg/min

as a diluted solution of 2.5mg/mL in water for

injections, max: 100mg)

 

393

UCG 2010

 

 

 

18. Miscellaneous conditions

child

1-5 yrs: 5mg by deep IM

5-10 yrs:6.25-12.5mg by deep IM

 

- repeat dose every 8 hours for 24-48 hours to

prevent relapse

To prepare the diluted solution: dilute each 1mL

of promethazine hydrochloride injection

25mg/mL with 9mL of water for injections

 

In severely affected patients:

 

f

hydrocortisone 200mg IM or slow IV stat

child <1 yr: 25mg; 1-5 yrs: 50mg; 6-12 yrs:

100mg

 

- helps to prevent further deterioration

f

Repeat adrenaline and hydrocortisone every

2-6 hours prn depending on the patient's

progress

 

f

sodium chloride 0.9% infusion 20mL/kg by IV

infusion over 60 mins

 

- start rapidly then adjust rate according to BP

Child adrenaline doses for IM injection

 

Age Vol of adrenaline 1 in 1000 (mL)

(yrs) Normal Underweight

<1 0.05 0.05

1 0.1 0.1

2 0.2 0.1

3-4 0.3 0.15

5 0.4 0.2

6-12 0.5 0.25

>12 0.5-1 0.5-1

 

Note:

 

.

Adrenaline: IM is the route of choice

 

- absorption is rapid and more reliable than SC

394

UCG 2010

 

 

 

18. Miscellaneous conditions

 

TECHNIQUES FOR REGIONAL ANAESTHESIA

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:40 AM Comments comments (0)

Detailed knowledge of anatomy, technique, and

possible complications is important for correct

injection placement.

 

 

Preoperative assessment and preparation of the

 

 

patient should be done.

Patient refusal and local sepsis are the only

absolute contraindications.

 

 

Select the appropriate technique for operation.

 

 

Precautions:

 

Discuss the procedure with the patient

Identify the injection site using appropriate

landmarks

Observe aseptic conditions

Use small bore needle which cause less pain

during injection

Select concentration and volume of drug

according to the technique

Aspirate before injection to avoid accidental

intravascular injection

Inject slowly and allow 5-10 min. for onset of

drug action

Confirm desired block effect before surgery

commences

The patient must be monitored throughout the

procedure

Note:

 

Supplemental agents should be available for

analgesia or anaesthesia if technique is

inadequate.

Resuscitative equipment, drugs and oxygen

must be at hand before administration of any

anaesthetic.

 

UCG 2010

430

 

 

 

18. Miscellaneous conditions

Management of the surgical patient with

special condition

 

1. Internal haemorrhage

As may occur in ruptured spleen, ruptured tubal

pregnancy

An emergency condition with unstable vital

signs

Invasive surgical intervention in whatever state

the patient is in is life saving

Do not delay operation in attempt to stabilize

the patient as this may not be achieved

Prompt resuscitative operation is required which

includes:

1.

Establish an IV line and infuse fluids rapidly

2.

Rapid sequence induction of general

anaesthesia

-Use drugs with no or minimal cardiac

depression

 

3.

Laparotomy to achieve surgical haemostasis

2. Intestinal obstruction

Preoperative fluid therapy

 

Fluid deficit, the electrolyte abnormalities and

acid-base disturbances must be corrected

Replace on going fluid losses e.g. vomit,

fistula, NG- tube drainage

Give maintenance fluid

Duration, depending on urgency of surgery,

may be as long as 6 hours to achieve cellular

hydration

Monitoring outcome

The following signs will show the effectiveness

of the therapy

-

Pulse rate a gradual decline

-

BP may rise

-

Urine output good if it is 0.5 to 1ml /kg/hr

 

UCG 2010

431

 

 

 

18. Miscellaneous conditions

-

CVP arise of 2-3 cmH20 with rehydration

-

CNS patient more rational

-

Mouth less dry

-

Skin turgor increased

 

The fluid to use: balanced solution e.g. Ringers

Lactate. Physiological saline may be used.

Operative fluid therapy

 

Blood loss, fluid aspirated from the gut and

other fluid losses must be replaced

Maintenance fluid be given 5ml/kg/hr

Postoperative fluid therapy

 

Replace all fluid losses

Maintenance fluid

Monitor for adequate rehydration

3. Co-existing medical conditions

Principle:

The medical condition must be stabilized as much

as possible before surgery

Preoperative management

 

Establish whether condition is stable or

unstable

If unstable then control or correct the

condition

Operative and postoperative management

 

Anaesthesia technique based on condition

and nature of surgery

Maintain the stable condition

4. Hypertension

Diastolic of 90 mmHg is acceptable

If poorly controlled patient may have

 

Vasoconstriction and hypovolaemia

Exaggerated vasoactive response to stress

leading to hypotension or hypertension

Hypertensive complications under

anaesthesia

UCG 2010

432

 

 

 

18. Miscellaneous conditions

Management

 

Control hypertension preoperatively

Take antihypertensive drugs on schedule

even on the day of operation

General anaesthesia technique is preferred

Ensure adequate-depth of anaesthesia and

analgesia

- oxygenation

 

 

-ventilation

- circulatory volume replacement

5. Anaemia

Condition of reduced 02 carrying capacity, patient

prone to hypoxia

Heart failure may occur

Hypotension or hypoxia can cause cardiac arrest

This should be corrected to acceptable level

depending on urgency of surgery

Regional anaesthesia is the preferred method

If general anaesthesia - is used avoid myocardial

depressant e.g. Thiopentone

-

use small doses of drugs

-

use high oxygen concentration

-

intubate and ventilate except for very short

 

procedures

-

replace blood very carefully

-

extubate patient when fully awake

-

give o2 in the postoperative period

 

For the sickle cell anaemia the above also apply as

well as avoiding use of tourniquet

 

6. Asthma

Avoid drugs and other factors likely to trigger

bronchospasms e.g. Thiopentone

Regional anaesthesia is the preferred method

If general anaesthesia selects drugs accordingly,

maintain adequate depth of anaesthesia

 

UCG 2010

433

 

 

 

18. Miscellaneous conditions

7. Diabetes mellitus

Achieve control using standard treatment

preoperatively

If diabetic ketoacidosis -delay surgery even in

emergency for 8-12 hours

 

- correct and control all associated disturbances

Hyperglycaemia under general anaesthesia is safer

than hypoglycaemia.

 

Patient should be operated early in the morning

 

where possible.

Regional anaesthsia is the method of choice where

applicable

 

a) Minor surgery

 

Stop usual antidiabetic dose on the morning of

surgery

Start infusion of 5%dextrose infusion rate of

2ml/min in theatre

Monitor blood sugar

Usual medication is resumed as soon as the patient

is able to take orally

 

b) Major surgery

 

Control on sliding scale of insulin

Infusion of 5%dextrose started on the morning of

surgery

Or

Glucose insulin potassium infusion

Monitor blood sugar =200mg/

 

UCG 2010 434

TECHNIQUES OF GENERAL ANAESTHESIA

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:40 AM Comments comments (0)

Requirements for all:

 

Take and record baseline vital signs

Establish intravenous line and commence

infusions

1. General anaesthesia with spontaneous

respiration

Induce anaesthesia by:

 

Intravenous route (adults)

UCG 2010

427

 

 

 

18. Miscellaneous conditions

Or

 

Inhalation route (children, patient with difficult

airway)

Maintenance

 

Secure a clear airway using an oropharyngeal

airway

The mask is placed on the face

Titrate concentration of inhalation against

response of the patient

Monitor, record every 5 min. or more

frequently, BP, Pulse, Respiration, Colour,

oxmetry

Indication:

 

This technique may be used for operations on

limbs, perinium, superfial wall of chest and

abdomen

Suitable for operations lasting less than 30 min

2. General anaesthsia with controlled

ventilation

Induce anaesthesia:

 

Intravenous/ inhalation (see above)

Tracheal intubation

-

when spontaneously breathing (for children)

or

-

under relaxation by suxamethonium and

laryngoscopy

-

confirm correct tube placement by presence

of breath sounds on both chest sides

-

connect the breathing / delivery system to

the endotracheal tube

 

Maintenance

 

Titrate concentration of inhalation agent against

response of the patient

A selected long acting muscle relaxant is given

Intermittent positive pressure ventilation is

done

Monitor vital signs (as above)

UCG 2010

428

 

 

 

18. Miscellaneous conditions

At the end of the operation when the patient

shows signs of respiratory effort

Neostigmine is given to reverse the effects of the

long acting muscle relaxant

 

Indication:

 

All operations that require a protected airway and

controlled ventilation e.g. intraabdominal,

intrathoracic and intracranial operations

 

3. Rapid sequence induction of general

anaesthesia

Also called crash induction

 

 For patients with “full stomach” and at risk of

regurgitation e.g. emergency surgery, distended

abdomen.

Crash induction steps

 

Establish an intravenous line and commence

infusions

Preoxygenation for > 3 min.

Induce with selected intravenous anaesthetic

agent

Assistant applies cricoid pressure

IV suxamethonium is given

Laryngosopy is done

Trachea is intubated and correct tube

placement confirmed

The cuff of the endotracheal tube is inflated

then cricoid pressure released

The position of the tube is fixed by strapping

and an airway is inserted.

Then connect to breathing circuit/ system to

maintain anaesthesia.

 

SELECTION OF TYPE OF ANAESTHESIA FOR THE PATIENT

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:35 AM Comments comments (0)

Consider

 

Patient factors: medical state, time of last meal,

mental state, wish of patient if applicable

Surgical factors: nature of surgery, site of

operation, estimated duration of surgery,

position in which the surgery is to be performed

Anaesthetic factors: availability of drugs,

experience and competence of the anaesthetic

provider

 

LOCAL ANAESTHETIC AGENTS

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:35 AM Comments comments (0)

Lignocaine:

 

Solution concentrations of lignocaine commonly

used:

 

Topical-larynx pharynx 20-40mg/ml or

100mg/ml

Infiltration 2.5- 5mg/ml ± with adrenaline

1:2.000.000

Nerve block 10- 20mg/ml ± adrenaline

1:2.000.000

Spinal 50mg/ml hyperbaric solution

Action:

fast onset

Plain lignocaine 40 – 60 min

Lignocaine with adrenaline 60 – 90 min

 

Dose: lignocaine with adrenaline 6-7mg/kg body

weight

Plain lignocaine 3mg/kg body weight

 

It is important to calculate the volume of lignocaine

that could be used safely

Note: lignocaine toxicity-

 

Signs and symptoms

CNS stimulation followed by depression

o

Stimulation –restlessness, tremor,

convulsions

o

Depression – semi consciousness, coma

Treatment

Give sufficient/ titrate IV diazepam to

control convulsions

Thiopentone may be used e.g. 50mg

Oxygen is given

Support airway, breathing and circulation

as indicated

Admit the patient to ward to continue

treatment and observation as needed.

 

Bupivacaine:

 

Solution concentration 5mg/ml

Action: slow onset but long duration 4-6 hours or

longer

 

UCG 2010

426

 

 

 

18. Miscellaneous conditions

Dose: 2mg/kg body weight

 

Indication:

all regional anaesthesia except

intravenous regional anaesthesia. Use

hyperbaric bupivacaine solution for

spinal anaesthesia.

 

Other drugs:

 

Analgesics, Naloxone, Noestigmine, Atropine,

Diazepam

 

Drugs for managing the following condition:

 

Anaphylaxis, Cardiac arrhythmias, Pulmonary

oedema, Hypotension, Hypertension,

Bronchospasm, Respiratory depression,

Hypoglycaemia, Hyperglycaemia, Adrenal

dysfunction, Raised intracranial pressure, uterine

atony, Coagulopathies: (Refer to the relevant

sections)

 

GENERAL ANAESTHETIC AGENTS

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:35 AM Comments comments (0)

Intravenous agents: thiopentone, ketamine,

propofol

Thiopentone

 

Solution concentration: 2.5% or 25 mg/ml

Route: intravenous

Dose: 3 to 5mg/kg body wt.

Indication: induction of anaesthesia,

anticonvulsant

Contraindication: airway obstruction, shock,

hypersensitivity to barbiturates, severe

heart disease

Side effects: drowsiness, depression of

cardio respiratory system( in clinical doses)

Complication: hypotension, apnoae (dose

dependent), tissue necrosis in case of

extravasation of the solution

Ketamine

 

Solution concentration: 50mg/ml, 10mg/ml

Route: intravenous, intramuscular

Dose: I.V. 1-2mg/kg body wt

I.M. 5-7mg/kg body wt

Indication: induction of anaesthesia,

maintenance of anaesthesia (infusion),

Analgesia

Contraindication: hypertension, epilepsy,

raised intracranial pressure e.g. head injury

Side effects: emergency delirium,

hallucinations, increased salivation,

increased muscle tone

Prevent salivation by atropine

premedication, treat emergency delirium by

giving diazepam

UCG 2010

423

 

 

 

18. Miscellaneous conditions

Propofol

 

Solution (emulsion): 1% or 10mg/ml

Route: intravenous

Dose: 1-2.5mg/kg body wt titrated at a rate

of 4mls/sec.

Indications: induction of anaesthesia,

maintenenance of anaesthesia

Contraindication: hypersensitivity,

hypotension, obstetrics, paediatrics

Side effects: pain at site of injection

2. Inhalational anaesthetic agents

Halothane

 

A volatile liquid at room temperature

 

Indication: induction of anaesthesia ( in

children, patients with airway obstruction)

Maintenance of anaesthesia

Precaution: -always use at least 30%

0xygen with halothane,

-

It is safe to avoid use of adrenalin to

prevent high incidence of arrhythmias

 

Adverse effects which may occur include:

-

Atony of the gravid uterus

-

Postoperative shivering

-

Severe cardiopulmonary depression

Ether

 

A highly volatile and inflammable liquid

 

Indication: maintenance of anaesthesia

Side effects: nausea and vomiting,

increases salivation, irritates the airway

Precaution: -Avoid sparks e.g. diathermy, in

the ether risk zone

- Give atropine to prevent salivation

MUSCLE RELAXANTS

 

Used to provide muscle relaxation to facilitate a

procedure

Precaution before using a muscle relaxant:

 

UCG 2010

424

 

 

 

18. Miscellaneous conditions

Have means of supporting the airway and

respiration

 

used in a patient who is unconscious e.g.

general anaesthesia, or sedated

Short acting muscle relaxant

Suxamethonium:

 

Solution concentration: 50 mg/ml

Action: fast onset and short duration

Route: intravenous or intramuscular

Dose: 1-2mg/kg body weight

Indication: muscle relaxation for short procedure

 

e.g. tracheal intubation, reduction of fracture

Contraindications: airway obstruction,

hyperkalaemia conditions e.g. tetanus, burns

>3days old.

Long acting muscle relaxants

Pancuronium:

 

Solution concentration: 2mg/ml

Action: slow onset and long duration (45 min.)

Route: intravenous

Dose: 4-6 mg initially thereafter 2mg or 0.08-

0.1mg/kg

Indication: muscle relaxants for long procedure e.g.

laparotomy

 

Atracurium:

 

Solution concentration: 10mg/ml

Action: duration=20 – 40 min.

Route: intravenous

Dose: 0.3- 0.6 mg/kg

Indication: muscle relaxation for operation of

intermediate duration

 

ANAESTHESIA GUIDELINES

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:25 AM Comments comments (0)

Anaesthesia main objectives during surgery are:

 

To relieve pain

To support physiological functions

To provide good conditions for the operation

GENERAL CONSIDERATIONS

The facilities for administering anaesthesia

must be:

 

Available and in a state of readiness at all times

Appropriate in quality and quantity

Compatible with safety

Staffing requirement for anaesthesia

 

Anaesthesia provider

An assistant for the anaesthesia provider

Adequate assistance in positioning the patient

Adequate technical assistance to ensure proper

functioning and servicing of all equipment

Before anaesthesia

 

Read the notes/ medical records of the patient

 

Assess the patient very carefully

The drugs, equipment, instruments and materials to

be used must be known

 

Prepare properly:

 

The workplace

The patient

During anaesthesia

 

Anaesthesia is administered (induction and

maintenance)

The patient must be monitored meticulously:

 

 

To ensure his/her wellbeing

UCG 2010

419

 

 

 

18. Miscellaneous conditions

To detect dangerous signs as soon as they arise

and appropriately treat them

Expertise in resuscitation is obligatory

If in trouble ask for help

 

After anaesthesia

 

The patient

 

Recovers from effects of anaesthesia

Has stable vital signs

Is returned to the ward in the fully conscious

state, no worse, or if at all possible, even better

than before operation.

ALWAYS PAY ATTENTION TO DETAIL.

The anaesthetist, surgeon and theatre staff

are on the same team.

Know your limits. Seek help Consult or refer to

a higher level of care

 

Types of Anaesthesia

 

Anaesthesia may be produced in a number of ways:

 

a) General anaesthesia

 

Basic elements: loss of consciousness, analgesia,

prevention of undesirable reflexes and muscle

relaxation

 

b) Regional or Local anaesthesia

 

Sensation of pain is blocked without loss of

consciousness.

The conduction of stimulus from a painful site to the

brain can be interrupted at one of the many points:

 

 

Surface Anaesthesia

Infiltration Anaesthesia

Intravenous regional anaesthesia

Nerve block/Plexus block

Epidural Anaesthesia

Spinal Anaesthesia

Preparation in the operating theatre

 

Should be in a constant state of preparedness for

anaesthesia

 

UCG 2010

420

 

 

 

18. Miscellaneous conditions

The following should be available, checked and

ready:

 

Oxygen source

Operating table that is adjustable and with its

accessories

Anaesthesia machine with accessories

Self inflating bag for inflating the lungs with O2

Appropriate range of face masks

Suction machine with appropriate range of

suction catheters

Appropriate range of oropharyngeal airways,

endotracheal tubes and other airways e.g.

Laryngeal mask airway

Laryngoscope with suitable range of blades

Magill’s forceps

Intravenous infusion equipment, appropriate

range of cannulae and fluids (solutions)

Equipment for regional anaesthesia

Adequate lighting

Safe disposal of items contaminated with body

fluids, sharps and waste glass

Refrigeration for storage of fluids, drugs and

blood

Anaesthetic drugs: general and local

anaesthetic agents

Muscle relaxants

Appropriate range of sizes of syringes

Monitors: stethoscope, sphygmomanometer,

pulseoximeter

Appropriate protection of staff against biological

contaminants. this includes: gowns, gloves,

masks and eye shields

Drugs necessary for management of conditions

which may complicate or co-exist with

anaesthesia must be at hand

UCG 2010

421

 

 

 

18. Miscellaneous conditions

Preoperative Management

 

Aim is to make the patient as fit as possible in the

given circumstance before surgery.

 

Assessment of the patient

 

Identify the patient and establish rapport

A standard history is obtained and an

examination done

Emphasis is on the cardio-respiratory systems

Investigations appropriately interpreted e.g.,

Hb

Establish health status/condition of the patient

Classify physical status of the patient according to

 

A.S.A. (ASA classification 1-5+ or - E).

Make a plan for anaesthesia based on the

information obtained.

Preparation of the patient

 

Explain the procedure to the patient and ensure

understanding

Ensure informed consent form is signed

Weight of every patient should be taken

check site and side of the operation

check period of fasting

remove

-

Ornaments /prosthesis that may injure the

patient

-

Make ups that may interfere with monitoring

 

rest of preparation according to condition of the

patient and nature of the operation (Condition

of deficits / imbalances should be corrected,

control chronic conditions)

Ability of the patient to withstand the stresses and

adverse effects of anaesthesia and the surgical

procedure will depend on how well prepared he is.

 

UCG 2010

422

 

 

 

18. Miscellaneous conditions

The commonly used drugs in anaesthetic

practice

 

FLUID & ELECTROLYTE IMBALANCE

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:20 AM Comments comments (0)

A condition where losses of bodily fluids from

whatever cause has led to significant disturbance in

the normal fluid and electrolyte levels needed to

maintain physiological functions.

 

Water and electrolyte exchange

 

z

Fluid consumption is 2-2.5L in 24 hours (1.5L by

mouth and 0.5-1L in solid food)

 

z

Daily fluid loss is through:

-

urine (800-1,500mL)

-

stool (250mL)

-

insensible loss through skin and lungs (600mL)

 

which is affected by hyperventilation, fever and

 

high environmental temperatures

z

Daily sodium intake is 100-200mmol

z

Daily potassium intake is 50-100mmol

z

There will be a deficiency of salts if:

 

-

there are increased losses, eg. excess sweating,

urinary losses or GIT losses through diarrhoea

and vomiting

 

-

there is reduced intake, eg. post-operative

patients

 

 

Disorders of fluid and electrolytes

 

Disorders may occur in the fluid volume,

concentration (sodium composition) and distribution

of fluid and other electrolytes and PH. The main

disorders likely to cause such problems are:

z

Diarrhoea -prolonged

z

Vomiting -prolonged

z

Burns - excessive

z

Haemorrhage -severe

z

Intestinal obstruction

z

Peritonitis

z

Diabetes

z

Nasogastric drainage

z

Paralytic ileus

 

UCG 2010

415

 

 

 

18. Miscellaneous conditions

z

Fistula drainage (especially if high output)

z

Third spacing eg. Peritonium

z

Major organ failure (eg. renal, hepatic, cardiac)

 

 

Caution

 

U

Over-infusion of IV fluids may also cause fluid

 

and electrolyte imbalance

Mild to moderate fluid loss will lead to varying

degrees of dehydration

 

Severe fluid loss will lead to shock

 

IV fluid and electrolyte therapy HC2

 

This has three main objectives:

z

To replace lost body fluids and continuing losses.

z

To correct electrolyte and acid-base disturbances

z

To maintain daily fluid requirements

 

 

Always use an IV drip in patients who are seriously ill

(except patients in congestive heart failure – for these

use only an indwelling needle) and may need IV drugs

or surgery.

If the fluid is not needed urgently, run it slowly to keep

the IV line open.

 

 

f

Administer daily fluid and electrolyte

requirements to any patient not able to feed

 

f

The basic 24-hour requirement for a 60kg adult

is 3L and for children is 150mL/kg

 

f

One third of these daily fluids (1L in an adult)

should be (isotonic) sodium chloride 0.9%

infusion

 

f

The other two thirds (2L in an adult) should be:

glucose 5% infusion

or half-strength Darrow’s solution in glucose

2.5% infusion or compound sodium lactate

infusion (Ringer-Lactate solution)

 

f

As well as the daily requirements replace

increased fluid lost due to the particular condition

according to the assessed degree of dehydration.

 

UCG 2010 416

 

 

 

18. Miscellaneous conditions

Caution

 

U

Closely monitor all IV drips to ensure that the

rate is adjusted as required and that the drip is

not allowed to run dry as this will introduce air

bubbles into the circulation with the potentially

fatal risk of air embolus.

 

U

If the drip has been neglected and allowed to run

dry, remove it and set up a new drip at another

site.

 

U

Check the drip site daily for any signs of

infection, change drip site every 2-3 days or

when the drip goes into tissues (extravasation).

 

Clinical features of severe dehydration

 

z

Inelastic skin (loss of skin turgor)

z

Low urinary output

z

Rapid, thready pulse

z

Low BP

z

Reduced level of conciousness

 

Clinical features of hypovolaemia

 

z

Tachycardia (rapid pulse, often thready, small

volume)

 

z

Low BP

 

z

Postural change (eg. supine to sitting/standing –

change in heart rate and BP)

 

In diarrhoea and vomiting with severe

dehydration, paralytic ileus, etc:

 

f

Replace fluid losses with isotonic solutions

containing potassium, eg. compound sodium

lactate infusion (Ringer-Lactate solution) or

half-strength Darrow’s solution in 2.5%

glucose infusion (see also Dehydration)

 

If there is blood loss and the patient is not in

shock:

 

f

Use sodium chloride 0.9% infusion for blood

volume replacement giving 0.5-1L in the 1st hour

and not more than 2-3L in 4 hours

 

UCG 2010

417

 

 

 

18. Miscellaneous conditions

If there is blood loss >1L:

 

f

Give 1-2 units of blood to replace volume and

concentration

 

In severe burns:

 

f

See pError! Bookmark not defined. for calculation

of IV fluid requirements and details of

rehydration regimes

 

In patients undergoing aspiration of fluid in

the non-functioning compartments:

 

e.g. in ascites, pleural effusion and chronically

distended urinary bladder

z

intravascular fluid redistribution will lead to a fall

in BP

 

f

Give isotonic solutions to correct this:

eg. sodium chloride 0.9% infusion

or compound sodium lactate infusion

(Ringer-Lactate solution)

 

In patients with shock:

 

f

Give compound sodium lactate infusion

(Ringer-Lactate solution) or sodium chloride

0.9% infusion 20mL/kg IV over 60 mins for

initial volume resuscitation

 

- start rapidly, closely monitor BP

-reduce the rate according to BP response

In patients with severe shock and significant

haemorrhage:

 

.. Give a blood transfusion

 

In Intestinal obstruction:

 

.. patient may be dehydrated due to vomiting; if

dehydration is severe, replace fluid losses with

isotonic solutions containing potassium, eg.

compound sodium lactate infusion (Ringer-

Lactate solution) or half-strength Darrow’s

solution in 2.5% glucose infusion

 

¾

aspirate upper gastrointestinal fluids using a

nasogastric tube and large syringe

 

UCG 2010

418

 

 

 

18. Miscellaneous conditions

¾

consult a surgeon

 

¾

give pain relief parenterally

 

¾

avoid metoclopramide as it would worsen colic,

instead use haloperidol 1 – 2 mg nocte sc.

 

PAIN

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:15 AM Comments comments (0)

‘Pain is what the patient says hurts’

This is the most common symptom of disease. The nature, location and cause of pain differ in each case. Pain requires a holistic approach as it can be affected by spiritual, psychological, social and cultural factors which may need to be addressed after physical pain is controlled

Important categories of physical pain are: Nociceptive pain: the pain pathways are intact

- these pains respond to the analgesic ladder

Neuropathic pain: there is damage to nerves or the pathways

- these pains respond only partially to the analgesic ladder and need adjuvants of amitryptiline or phenytoin (see below)

Causes

Acute: postoperative, acute infection or trauma

Chronic pain:

-constant and usually increasing: cancer

-recurrent sickle-cell crisis, arthritis, HIV/AIDS

-drug side-effect or toxicity eg peripheral neuropathy due to isoniazid (anti-TB drug) or D4T (stavudine, antiretroviral drug)

Clinical features

Those of the underlying disease

Further therapeutic clues to the nature and management of pain may be elicited by:

Duration

Severity – can assess using the Numerical Rating Scale, where the patient grades his/her pain on a scale of 0= no pain to 5= worst pain ever experineced

Site and radiation

Nature (eg. stabbing, throbbing, crushing, cramp-like)

Periodicity (constant or intermittent)

Relieving or aggravating factors

Accompanying symptoms

Remember there may be more than one pain-ask the patient and get a detailed history as above for each pain

Management

Reasons for poor management of pain

Pain, especially if chronic, is often poorly managed for a number of reasons including:

Waiting for the patient to complain about pain rather than asking the patient about it

Failure to obtain details of pain from attending nurses and relatives who often know the patient better than the clinician

Prescribing the right drug in the wrong dose or with the wrong frequency or duration

Failure to prescribe an appropriate adjuvant drug, eg. antidepressant or anticonvulsant in neuropathic pain

Failure to make adequate use of strong opioids (eg. morphine) where indicated, because of misplaced fear of causing addiction, respiratory

depression or death

Failure to use other forms of therapy where appropriate, eg. radiotherapy, steroids, cytotoxic chemotherapy, antibiotics, muscle relaxants, etc

Failure to regularly review the patient’s condition and the drug regime prescribed

Lack of the right medicines

The aim of pain management is to:

Diagnose and treat the disease causing the pain

Achieve total pain relief with minimal side-effects and therefore enable the patient to live as normal a life as possible

Non-drug treatment may include:

Lifestyle adjustment

Patient counselling

Massage with aromatherapy oils – may be useful for neuropathic pain and muscular pain

Reflexology

Application of heat or cold packs

Relaxation

Distraction e.g. listening to radio

Non-pharmacological treatment of underlying cause e.g. surgery or radiotherapy of cancer

Important management points

Health professionals specially trained in palliative care should supervise management of chronic pain in advanced or incurable conditions (eg. cancer, AIDS)

Morphine is usually the drug of choice for severe pain

See also Pain and Symptom Control in the Cancer and/or AIDS patient in Uganda and other African Countries, 4th edition, HOSPICE AFRICA

UGANDA, 2006

In continuous pain, analgesics should be given:

-by the clock (i.e. according to a regular dose schedule)

-by the patient (i.e. self-administered)

-by the mouth (i.e. as oral dose forms)

Nociceptive or Somatic pain

Pain arising from any organ of the body with intact nerves:

-the commonest type of pain (may occur in any patient)

Medicines required depend on intensity of pain and are selected in steps according to the WHO analgesic ladder

Step 1: Non-opioids

paracetamol 1g every 4-6 hours (max: 4g daily) or aspirin 600mg every 4-6 hrs

- do not give aspirin in 3rd trimester of pregnancy or NSAIDS (give doses after food) eg. ibuprofen 1.2–1.8g daily in 3-4 divided doses

- max: 2.4g daily or indomethacin 50-200mg daily in divided doses or diclofenac 75-150mg daily in 2-3 divided doses

Child:

(ENDED HERE TO EDIT)f

paracetamol 10 – 15 mg/kg every 4-6 hours

or ibuprofen 20 mg/kg every 4-6 hours (give

after food)

 

-max 500 mg per day in children < 30 kg.

-not recommended for children under 1 year

old

 

Note on antipyretic effect

 

The above doses of aspirin, paracetamol and

ibuprofen may also be used for antipyretic therapy

 

Step 2: Weak opioids

 

ALWAYS GIVE WEAK OPIOIDS WITH A LAXATIVE

UNLESS SEVERE DIARRHOEA IS PRESENT

 

 

f

codeine phosphate 30-60mg every 4 hours

child 1–12 yrs: 3mg/kg daily in divided doses

or dihydrocodeine 30mg every 4-6 hours

child >4 yrs: 0.5-1mg/kg every 4-6 hours

 

f

+/-Step 1 drug

 

UCG 2010 408

 

 

 

18. Miscellaneous conditions

Step 3: Strong opioids

 

ALWAYS GIVE STRONG OPIOIDS WITH A LAXATIVE

UNLESS SEVERE DIARRHOEA IS PRESENT

 

 

Notes

 

z

Morphine 10mg parenteral is equivalent to 30mg

by mouth (i.e. multiply parenteral dose by 3 to

get oral equivalent).

 

z

Morphine 5mg by mouth is equivalent to 1.6mg

parenteral (i.e. divide oral dose by 3 to get the

parenteral equivalent).

 

z

Regular injections are not indicated in chronic

pain.

 

z

Chronic pain is more manageable when

controlled using small doses of oral morphine

titrated to control pain without causing

drowsiness. It is due to accumulation of

metabolites which are also active analgesics.

 

z

Respiratory depression has not been recorded

when morphine is given orally and titrated

against pain and drowsiness - however it has

occurred due to regular parenteral dosing.

 

f

morphine (as oral solution 1mg/ml): initially

2.5-5mg orally (see also note below) every 4

hours

 

-

then titrate the dose according to response

-

continued drowsiness indicates too much and

the dose should be titrated down slowly

-

oral morphine solution is absorbed from the

buccal mucosa and can be dripped into the

mouth in adults and children

or morphine (as slow-release tablets, eg

morfine SR).

-

start with 10mg orally or rectally every 12

hours

-

adjust the dose (but not the frequency) to

 

UCG 2010

409

 

 

 

18. Miscellaneous conditions

achieve satisfactory pain control

-

if the patient is changing from oral liquid to

slow-release tablet preparation, add the total

taken in 24 hours to control pain and divide

this by 2 to get the nearest equivalent dose

as morfine SR (10mg and 30 mg available

in Uganda)

f

Leave patient with a few extra doses of oral

morphine to take for breakthrough pain and

calculate needs at next visit. (Breakthrough pain

is a temporary exacerbation of pain after pain

has been controlled on a regular dose of oral

morphine.

f

The breakthrough dose is equivalent to the 4

hourly dose of oral liquid morphine being taken.

If the patient needs regular breakthrough doses,

then add the number of breakthrough doses

given in a day to the total daily dose, then divide

by six to get the new 4 hourly dose. For example,

a patient on 5mg oral morphine every 4 hours

(=30 mg in 24 hours) requiring 3 breakthrough

doses in a day (=3 x 5mg, total 15 mg) would

need a new total of 45 mg of oral morphine in a

 

day = 45/6 or 7.5 mg every 4 hours).

 

f

+/-Step 1 drug

 

Notes

 

Dose titration:

 

z

When titrating the dose upwards because pain is

not controlled, increase by 50-75% of the

previous dose

 

Pethidine:

 

z

Avoid this in treating chronic pain because:

-

it accumulates with severe side-effects on the

gut

-

it does not work well by mouth except in large

doses with resultant severe side-effects

 

UCG 2010

410

 

 

 

18. Miscellaneous conditions

z

Use for analgesia in labour: 50-150 mg orally

every 4 hours prn or 50-100mg SC repeated prn

after 1-3 hours

 

-max: 400mg/24 hrs

Child >6 mths: 0.5-2mg/kg/dose

-

only use as one off-dose for acute severe pain if

morphine not available

 

Respiratory depression:

 

z

This side-effect of opioids does not occur when

oral small doses are used initially, and gradually

titrated according to response

 

z

If mistakenly given in large doses by injection,

respiratory depression can be reversed by

 

naloxone

 

Nausea and vomiting:

 

z

Rarely occurs in Africans, commoner in

Caucasians

z

Occurs only in the first five days (it is self-

limiting)

 

z

Control with an oral antiemetic (for 5 days only),

eg.

haloperidol 1mg every 12 hours

or metoclopramide 10mg every 12 hours

 

z

Vomiting later on is usually due to another cause

in the illness

 

Use of morphine in dyspnoea and severe diarrhoea:

 

z

Use in small oral doses to relieve dyspnoea in

respiratory diseases such as lung cancer, pleural

effusion, COAD, heart failure and pneumonia

-

it increases relaxation and oxygenation

-

start with 2.5mg orally every 4 hours or add

 

2.5mg every 4 hours to present analgesic dose

z

Use similar small doses for severe diarrhoea in

HIV/AIDS patients

 

UCG 2010

411

 

 

 

18. Miscellaneous conditions

Cautions on use of opioids

 

z

Contraindicated in respiratory depression and

head injury

 

z

Use with care in the following conditions

-

advanced liver disease (but can be used in

hepatocellular carcinoma [HCC] when titrated

as above)

-

acute asthma

-

acute abdomen (can use while awaiting

diagnostic tests - never leave the patient in

pain)

-

hypothyroidism

-

renal failure (reduce starting dose and/or

reduce dose frequency)

-

elderly or severely wasted patient (reduce

starting dose and/or reduce dose frequency)

 

z

Use with extreme care (i.e. start with small doses

and use small incremental increases) in:

-

hypovolaemic shock: start with 10mg IV (as

absorption is slow due to hypovolaemia)

-

recurrent or concurrent intake of alcohol or

other CNS depressants

 

18.4.2. Neuropathic pain

Occurs as a result of damage to nerve tissue. There

 

are two clinical kinds of pain:

 

z

Stabbing-type pain in a nerve distribution with

minimal pain in between (eg. trigeminal

neuralgia) but can occur with any nerve

 

-responds to phenytoin

z

Paraesthesia, dysaesthesiae or burning-type pain

eg. post-herpetic neuralgia

 

- responds well to small doses of amitriptyline

z

Both elements may be combined

a) Trigeminal neuralgia or stabbing-type pain

 

Acute phase:

f

phenytoin 200-400mg daily in 1-2 divided doses

 

UCG 2010

412

 

 

 

18. Miscellaneous conditions

-

drug of choice because has minimal side-effects

 

and does not need monitoring

-

may need up to 600mg daily

-

avoid if patient is on antiretroviral therapy due

 

to interactions (Nevirapine and Protease

inhibitors)

or carbamazepine initially 100mg 1–2 times

daily

 

-

increase gradually according to response

-

causes white cell depression

-

needs monitoring

-

more expensive than phenytoin

-

usual dose: 200mg 3-4 times daily (up to 1.6g

 

daily may be needed)

 

-

avoid if patient is on antiretroviral therapy due

to interactions (Nevirapine and Protease

inhibitors)

 

f

±

amitriptyline 12.5-25mg at night or every 12

hours depending on response

 

b) Post-herpetic neuralgia

 

Acute phase:

f

amitriptyline 12.5-25mg at night or every 12

hours depending on response

 

If stabbing element to pain:

 

f

add phenytoin (doses as above)

 

18.4.3. Back or bone pain

z

Pain in the lumbar region of the spine

 

- is a symptom not a disease entity

z

Bone pain anywhere

Causes

 

z

Disc degeneration (often has a neuropathic

element because of pressure on sciatic or other

nerve)

 

z

Osteoporosis (if collapse of vertebrae or fracture)

 

z

Infection, eg. TB, brucellosis

 

z

Metastatic disease, eg. breast or prostate cancer

 

UCG 2010

413

 

 

 

18. Miscellaneous conditions

z

Cervical cancer

z

Strain

z

Congenital abnormalities

z

Spondylolisthesis (forward shirt of one vertebra

 

upon another, due to defect of the joints which

 

normally bind them together)

z

Renal disease

z

Pelvic infection

z

Retroperitoneal infection

 

Clinical features

 

z

Depend on the cause

z

In infections: pain is throbbing and constant

z

Sciatica -if sciatic nerve roots involved

 

Differential diagnosis

 

z

See distant causes above

 

Investigations

 

¾

As far as possible try to establish the cause and

type of pain (nociceptive or neuropathic)

¾

X-ray: spine and pelvis

-

if available, is affordable and will aid

management

 

Management

f

analgesics (see management of somatic pain)

-

give a Step 1 drug for 7 days or as long as

required according to patient

-

NSAIDs are the Step 1 drug of choice in bone

pain

-

may have to add a Step 2 or 3 drug especially

in metastatic disease

 

For acute back pain:

 

f

Rest the back on a firm but not hard surface

 

For neuropathic element:

 

f

Manage as for neuropathic pain above

 

Hypoglycemia

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:15 AM Comments comments (0)

A clinical condition due to reduced levels of blood sugar (glucose).

Causes

Overdose of insulin or anti-diabetic drugs

Excessive alcohol intake

Starvation

Operations to reduce the size of the stomach (gastrectomy)

Tumours of the pancreas (insulinomas)

Certain drugs, eg. quinine

Hormone deficiencies (cortisol, growth hormone)

Clinical features

Profuse sweating

Nervousness

Fainting

Palpitations

Poor sight

Weakness

Hunger

Abdominal pain

Vomiting

Convulsions

Loss of consciousness

Differential diagnosis

Other causes of loss of consciousness

Investigations

Blood sugar

Specific investigations

- to exclude other causes of hypoglycemia

Management

Oral glucose or sugar (before coma sets in) 10-20g in 200mL water (2-4 teaspoons) is usually taken initially and repeated after 15 minutes if necessary or if patient is unconcious, glucose 50% 2050mL IV, followed by 10 % dextrose solution by drip at 5-10 mg /kg/min until patient regains conciousness, then encourage oral sugary drinks. HC3

Where possible, treat the cause of the hypoglycemia.

Prevention

Educate patients at risk of hypoglycaemia e.g. Diabetics, patients who have had a gastrectomy, on recognition of symptoms of hypoglycemia.

Advise patients at risk to have regular meals and always to have glucose or sugar with them for emergency treatment of hypoglycaemia.

 

FEBRILE CONVULSIONS

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:10 AM Comments comments (0)

A disorder mainly affecting children between 6 months and 6 years characterised by generalized tonic-clonic seizures in a febrile illness

Cause 

Malaria fever

Respiratory tract infections

Urinary tract infections

Other febrile conditions

Clinical features

Elevated temperatures (>38°C)

Convulsion is usually brief (<15 minutes) but may recur if temperature remains high

No CNS infection or neurological abnormality in the period between convulsions

Differential diagnosis

Epilepsy

Meningitis

Encephalitis

Brain lesions

Trauma

Hypoglycaemia

Hypocalcaemia

Investigations

Blood: slide for malaria parasites; haemogram LP and CSF examination

Full blood count

Random blood glucose

Urinalysis , culture and sensitivity

Chest xray

Management HC2

Treat the cause

Lie prone

Use tepid sponging to help lower the temperature

Give an antipyretic:

paracetamol 10mg/kg every 8 hours prn

Give diazepam 500 micrograms/kg rectally

- maximum dose: 10mg

- repeat prn after 10 minutes

-if diazepam rectal dose-form is not available use diazepam injection solution and give the same dose rectally using the syringe after

removing the needle

 

DEHYDRATION

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:10 AM Comments comments (0)

A condition brought about by the loss of significant

quantities of fluids and salts from the body

Cause

 Diarrhoea

Vomiting

Excessive sweating as in high fever Respiratory distress

Management in children HC2

Management with Plan A, B or C is based on an

assessment of the degree of dehydration according

to key clinical signs - see table below. Refer to

Management of Childhood Illness MoH 2000 for

further details.

 

Clinical features of dehydration in children

Signs

Degree of dehydration

None/Mild

Some Severe

General

condition

Well,

Alert

Restless,

irritable

Lethargic or

unconscious or very drowsy Eyes

Not sunken

Sunken Sunken

Fontanelle

Not sunken

Sunken Sunken

Ability to drink

Drinks normally

Drinks eagerly

thirsty

Drinks poorly or not able to drink

Skin pinch Goes back quickly

Goes back slowly

Goes back very slowly

Treatment Plan A Plan B Plan C

 

Plan A (No dehydration and for prevention):

Counsel the mother on the 3 rules of Home

Treatment

 - extra fluids, continue feeding, when to return

Give extra fluids - as much as the child will take Advise the mother to:

Continue/increase breastfeeding: -if child exclusively breastfed, give ORS or clean water in addition to milk

-if child not exclusively breastfed, give one or more of:

ORS, soup, rice-water, yoghurt drinks, clean water

In addition to the usual fluid intake, give ORS after each loose stool or episode of vomiting: <2yrs: 50-100mL; 2yrs and over: 100-200mL

- give the mother 2 packets to use at home

- giving ORS is especially important if the child has been treated with Plan B or Plan C during current visit

- give frequent small sips from a cup

-if child vomits, wait 10 minutes, then give more slowly

In a child with high fever or respiratory distress, give plenty of fluids to counter the increased fluid losses in these conditions

Continue giving extra fluid as well as ORS until the diarrhoea or other cause of dehydration stops

Counsel the mother on:

Correct breastfeeding and other feeding during sickness and health Increasing fluids during illness

How to maintain her own health

When to return to the health worker

Plan B (Some dehydration):

Give ORS in the following approximate amounts during the first 4 hours: Age (mths) < 4 4-12 13-24 25-60

Weight (kg) < 6 6-9.9 10-11.9 12-19

ORS (mL) 200-400 400-700 700-900 900-1400

.Only use child’s age when you don’t know the weight

.You can also calculate the approx. amount of

ORS to give a child in the first 4 hours as weight (kg) x 75mL

Show the mother how to give the ORS

- give frequent small sips from a cup

-if the child wants more than is shown in the table, give more as required

-if the child vomits, wait 10 minutes, then continue more slowly

For infants <6 months who are not breastfed, also give 100-200mL of clean water during this first 4 hours

Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment Plan

After 4 hours:

Reassess the patient

Reclassify the degree of dehydration Select the appropriate Treatment Plan A, B or C

Begin feeding the child in the clinic

If the mother must leave before completing the child’s treatment:

Show her how to prepare ORS at home and how much ORS to give to finish the 4-hour treatment

Give her enough packets to complete this and 2 more to complete Plan A at home

Counsel the mother on the 3 rules of home treatment

- extra fluids, continue feeding, when to return

Plan C (Severe dehydration):

a) If you are able to give IV fluids:

Set up an IV fluids line immediately

-if the child can drink, give ORS while the drip is set up

Give 100ml/kg of compound sodium lactate infusion (Hartmann’s solution or Ringer’s Lactate solution) or half-strength [HS] Darrow’s solution in glucose 2.5% or sodium chloride infusion 0.9%

-divide the IV fluid as follows:

Age

First give 30mL/kg in:

Then give 70mL/kg in:

Infants (<12 months) 1 hour* 5 hours*

Children (12 mths-5yrs) 30 minutes* 2½ hours*

* Repeat once if radial pulse still very weak/undetectable

Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment Plan If the patient is not improving:

Give the IV drip more rapidly

As soon as the patient can drink- usually after 3-4 hours in infants or 1-2 hours in children:

Also give ORS 5mL/kg/hour.

Continue to reassess the patient frequently, classify the degree of dehydration and select appropriate Plan A, B or C to continue treatment

b) If you are unable to give IV fluids but IV treatment is available nearby (i.e. within 30 minutes):

Refer urgently for IV treatment

If the child can drink:

Provide the mother with ORS and show her how to give frequent sips during the trip to the referral facility

c) If you are unable to give IV fluids and this therapy is not available nearby (i.e. not within 30 minutes ORS) but you can use a nasogastric tube (NGT) or the child can drink:

 

 

Start rehydration with ORS by NGT or by mouth: give 20mL/kg/hour for 6 hours (total = 120mL/kg)

Reassess the child every 1-2 hours:

-if there is repeated vomiting or increasing abdominal distension, give the more slowly

-if hydration status is not improving within 3 hours, refer the child urgently for IV therapy

 After 6 hours, reassess the child

Classify the degree of dehydration

Select appropriate Plan A, B or C to continue treatment

Note:

If possible, observe the child for at least 6 hours after rehydration to ensure that the mother can correctly use ORS to maintain hydration Management in Older Children & Adults HC3 & HC4

Assess the level of dehydration using the table below: linical features of dehydration older children and adults

Clinical feature

Degree of dehydration -Mild, Moderate, Severe

General appearance

Thirsty, alert

Thirsty, alert

Generally conscious, anxious, cold extremeties, clammy, cyanosis, wrinkly skin of fingers, muscle cramps, dizzy if standing

Pulse Normal Rapid

Rapid, thready, sometimes absent

Respiration Normal Deep, may be rapid

Deep and rapid Systolic BP Normal Normal Low, may be unmeasurable

Skin pinch

Returns rapidly

Returns slowly

Returns very slowly (>2 seconds)

Eyes Normal Sunken Very sunken

Clinical feature

Degree of dehydration

Mild Moderate Severe

Tears Present Absent Absent

Mucous membranes -Moist, Dry, Very dry

Urine output Normal

Reduced, dark urine

Anuria, empty bladder

•at least 2 of these signs must be present

Rehydrate the patient as follows

Degree of dehydration

Rehydration fluid

Route

Volume to give in first 4 h (1) Mild ORS (2) Oral 25mL/kg

Moderate ORS Oral 50mL/kg (3)

Severe SLC inf (4) IV 50mL/kg (5)

Notes on table

 1. Volumes shown are guidelines only – if necessary volumes can be increased or the initial high rate of administration maintained until clinical improvement occurs.

2. As well as ORS, other fluids such as soup, fruit juice and clean water may be given.

3. Initially adults can usually take up to 750mL ORS/hour.

4. If sodium lactate compound IV infusion (Ringer-Lactate) is not available:

use half-strength [HS] Darrow’s solution in glucose 2.5% or sodium chloride infusion 0.9%

-however, both of these are less effective

5. In severe dehydration, give IV fluids as rapidly as possible at first until radial pulse can be felt then slow down the rate of administration.

Volumes which may be given over the first 24 hours (60kg adult) are as follows:

Time period Volume of IV fluid

First hour                               1L

Next 3 hours                          2L

Next 20 hours                        3L

After 4 hours, evaluate rehydration in terms of clinical signs (and not in terms of volumes of fluid given).

As soon as signs of dehydration have gone (but not before) start fluid maintenance therapy with as much alternating ORS and water (to avoid hypernatraemia) as the patient wants

Continue this for as long as the cause of the original dehydration persists Note:

Continued nutrition is important – there is no physiological reason to discontinue food during treatment for dehydration

 

RHEUMATIC HEART DISEASE

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:55 PM Comments comments (0)

A valvular complication of rheumatic fever.

 

The valves commonly involved are:

 

z

Mitral valves leading to stenosis, incompetence

or both

 

z

Aortic valve leading to stenosis and incompetence

 

Cause

 

z

As for acute rheumatic fever

 

Clinical features

 

z

Heart failure

 

z

Arrythmias

 

z

Thromboembolic problems eg. stroke

 

z

Palpitations

 

z

Heart murmurs depending on valves affected and

nature of effect caused

 

z

The patient may be asymptomatic and the

valvular lesion discovered as an incidental finding

 

z

Increased cardiac demand as in pregnancy and

anaemia may lead to congestive cardiac failure

as a presentation

 

UCG 2010

207

 

 

 

9. Cardiovascular diseases

Differential diagnosis

 

z

Other causes of cardiac failure

 

Investigations

 

¾

Chest X-ray

¾

ECG where available

¾

Echocardiography

 

Management

 

f

Treat heart failure if present

 

f

benzathine penicillin 2.4 MU IM once monthly

or phenoxymethylpenicillin (Penicillin V)

750mg every day

 

Child:

 

f

benzathine penicillin <30kg: 0.6 MU once

monthly

>30kg: 1.2 MU once monthly

-

continue either medicine up to 30 years of

age

-

If allergic to penicillin give

erythromycin 250 mg per day

 

 

PULMONARY OEDEMA

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:55 PM Comments comments (0)

Congestion of the lung tissue with fluid

 

Cause

 

z

Cardiogenic: CCF

z

Inflammatory diseases, eg. cancer, TB

z

Fibrotic changes

 

Clinical features

 

z

Dyspnoea, breathlessness

z

Rapid breathing rate

z

Cough with frothy blood stained sputum

 

Differential diagnosis

 

z

Pneumonia

z

Plural effusion

z

Foreign body

z

Trauma

 

Investigations

 

¾

Chest X-ray

¾

ECG

¾

Echocardiography

 

Management H

Acute

 

f

Find cause of left ventricular failure & treat

 

accordingly

f

Give high concentration oxygen

f

plus furosemide 40-80mg IM or slow IV

 

- repeat prn up to 2 hourly according to response

- doses >50mg should be given by IV infusion

child: 0.5-1.5mg/kg daily (max: 20mg daily)

f

plus glyceryl trinitrate 500mcg sublingually

every 4-6 hours

 

UCG 2010 206

 

 

 

9. Cardiovascular diseases

f

Give morphine 5-15mg IM or 2-4mg slow IV

child: 0.1mgs/kg slow IV single dose

 

f

plus prochlorperazine 12.5mg by deep IM

 

- avoid in children

f

Repeat these every 4-6 hours till there is

improvement

 

Caution

 

U

No digitalization if patient has had digoxin within

the past 14 days but give maintenance dose

 

Prevention

 

z

Early diagnosis and treatment of cardiac

conditions, respiratory tract infections

 

z

Avoid (narcotic) medicine abuse

PERICARDITIS

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:55 PM Comments comments (0)

Inflammation of the heart membrane (pericardium)

which may be:

z

Acute and self-limiting, sub-acute or chronic

z

Fibrinous, serous, haemorrhagic or purulent

 

 

UCG 2010

204

 

 

 

9. Cardiovascular diseases

Causes

 

z

Viral, eg. Coxsackie A & B, influenza A & B,

Varicella

 

z

Bacterial, eg. mycobacterium, staphylococcus,

meningococcus, streptococcus, pneumococcus,

gonococcus

 

z

Fungal: histoplasmosis

 

z

Mycoplasma

 

z

Uraemia (less common)

 

z

Hypersensitivity such as acute rheumatic fever,

myocardial infarction

 

z

Radiation

 

z

Trauma

 

z

Neoplasms

 

Clinical features

 

z

Pericardial inflammation: retrosternal pain

radiating to shoulder and much worse on deep

breathing, movement, change of position or

exercise

 

z

Pericardial rub is a diagnostic sign

 

z

Pericardial effusion: reduced cardiac impulses,

muffled heart sounds, acute cardiac compression

 

z

Effects on cardiac function: chronic constrictive

pericarditis, acute cardiac compression (cardiac

tamponade), dyspnoea, restlessness, rising

pulmonary and systemic venous pressure, rapid

heart rate, pulsus paradoxus, low BP and low

output cardiac failure.

 

Differential diagnosis

 

z

Any cause of central retrosternal chest pain eg.

pneumonia, ischaemic heart disease, peptic ulcer

 

Investigations

 

¾

ECG

¾

X-ray: chest

¾

Echo cardiography

 

UCG 2010

205

 

 

 

9. Cardiovascular diseases

Management H

 

f

According to cause and presenting clinical features

f

If there is fluid, perform tapping

 

Prevention

 

z

Early detection and treatment of infections

SCHAEMIC HEART DISEASE (Coronary heart disease)

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:55 PM Comments comments (0)

A condition in which there is insufficient blood flow

through the coronary arteries of the heart thus

leading to ischaemia and/or infarction

 

Cause/risk factors

 

z

Deposition of fatty material (cholesterol plaques)

inside the coronary arteries

z

Enlarged heart following hypertension

z

Diabetes mellitus, obesity and hypertension

z

Smoking

z

Hyperlipidemia

z

Family history of heart disease

 

Clinical features

 

z

Chest pain which may be localised on the left or

central part of the chest ranging from mild to

severe deep pain

 

z

Tightness in the chest or a sense of oppression

worsening on exertion and relieved by rest and

lasting only a few minutes

 

UCG 2010

203

 

 

 

9. Cardiovascular diseases

z

There may be associated anxiety, vomiting and

sweating

 

z

Signs of sympathetic activation

eg. pallor and tachycardia

 

z

Low BP

 

z

shortness of breath

 

z

Arrythmias - may cause sudden death

 

Differential diagnosis

 

z

Indigestion

z

Peptic ulcers

z

Pleurisy

z

Pericarditis

z

Severe anaemia

z

Dissecting aneurysm

 

Management HC4

f

Give aspirin 150mg single dose (to be chewed)

f

glyceryl trinitrate 500 micrograms sublingually

 

Repeat after 5 min if no response

 

f

give propranolol 10-40mg daily for as long as is

required

 

- ensure close observation of the pulse rate and

circulatory status

´

avoid in patients with shock or hypotension

¾

Refer to higher level of care.

Prevention

 

z

Low-fat, low-cholesterol diet

 

z

Stop smoking

 

z

Effective control of hypertension and diabetes

mellitus

HYPERTENSION

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:55 PM Comments comments (0)

Persistently high resting blood pressure (>140/90mm Hg

at least two measurements five minutes apart with

patient seated).

 

Classification of Blood pressure (BP)*

 

Category SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120-139 or 80-89

Hypertension,

stage 1

140-159 or 90-99

Hypertension,

stage 2

=160 or =100

 

key: SBP=systolic blood pressure DBP=diastolic

blood pressure

 

Causes

 

z

In the majority of cases the cause is not known

(essential hypertension)

 

Secondary hypertension is associated with:

 

z

Kidney diseases

z

Endocrine diseases

z

Eclampsia

z

Medicines (steroids and decongestants containing

 

caffeine and pseudoephedrine)

z

Others

 

Clinical features

 

z

The majority of cases are symptomless and are

only discovered on routine examination

 

May present as a complication affecting:

 

z

Brain (stroke)

z

Eyes (impairment of vision)

z

Heart (heart failure)

z

Kidney (renal failure)

 

UCG 2010

200

 

 

 

9. Cardiovascular diseases

General symptoms include:

 

z

Headache

z

Palpitations, dizziness

z

Shortness of breath

 

Differential diagnosis

 

z

Pre-eclampsic toxaemia (PET)

z

Eclampsia

z

Other causes of stroke

 

Investigations

 

¾

Urine analysis

¾

Blood sugar

¾

Plasma urea and electrolytes

¾

Chest X-ray

¾

ECG

 

Management: Treat to maintain optimal

blood pressure

 

Mild hypertension (stage 1)

 

f

Do not add extra salt to cooked food

f

Increase physical activity / exercise

f

Reduce body weight

f

Stop smoking

f

Decrease alcohol intake

 

If all the above fail (within 3 months) initiate

medicine therapy:

 

 

f

Give bendrofluazide 2.5mg-5mg each morning

 

- avoid in pregnancy and breastfeeding

Moderate and Severe hypertension (stage 2)

 

f

bendrofluazide 2.5-5mg each morning

 

f

plus ACE inhibitor (e.g. Captopril, Lisinopril or

enalapril) or CCB (e.g. Nifedipine or amlodipine)

or ARB (e.g.Lorsatan or Candesartan) or Beta

blockers (e.g. Atenolol or propranolol)

 

see table on the next page for dosages.

 

UCG 2010 201

 

 

 

9. Cardiovascular diseases

Hypertensive emergencies

 

f

Treatment depends on whether there is acute

target organ damage e.g. encephalopathy,

unstable angina, myocardial infarction,

pulmonary oedema or stroke.

 

f

If acute end target organ damage present admit

and give parenteral medicnes. Give IV

furosemide 40-80 mg stat.

 

f

Plus IV Hydralazine 20mg slowly over 20

minutes. Check blood pressure regularly at least

3 hourly.

 

f

If without acute target organ damage treat with

combination oral antihypertensive therapy as

above for severe hypertension.

 

f

Special Considerations.(Compelling

indications)

Patients with hypertension and other

comorbidities require special attention and

medicine therapy may differ from that above.

The table below indicates the suitable medicines

for such patients.

 

 

UCG 2010 202

 

 

 

9. Cardiovascular diseases

Caution

 

U

Propranolol, atenolol: do not use in heart failure

 

or asthma

U

Diuretics: do not use in pregnancy or

breastfeeding except in case of pulmonary

oedema or pre-eclampsia

Note:

 

.

Bendrofluazide: potassium supplements are

seldom required - only use in susceptible patients

.

Methyldopa: use in hypertension with renal

failure and in pregnancy and breastfeeding

 

Prevention

 

z

Regular physical exercise

z

Reduce salt intake

CONGESTIVE HEART FAILURE

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:50 PM Comments comments (0)

Inadequate cardiac output for the body’s needs

despite adequate venous return - may be due to

failure of both left and right ventricles.

 

Causes

 

z

Hypertension

z

Valvular heart disease, eg. rheumatic heart disease

z

Anaemia

z

Myocarditis

z

Prolonged rapid heart beat (Arrythimias)

z

Thyroid disease

z

Cardiomyopathy

z

Myocardial infarction

z

Congenital heart disease

 

Clinical features

 

Infants and young children

 

z

Respiratory distress with rapid respiration,

cyanosis, subcostal, intercostal and sternal

recession.

 

UCG 2010

197

 

 

 

9. Cardiovascular diseases

z

Rapid pulse, gallop rhythm

z

Excessive sweating

z

Tender hepatomegaly

z

Difficulty with feeding

z

Cardiomegaly

z

Wheezing

 

Older children and adults

 

z

Palpitations, shortness of breath, exercise in tolerance

z

Rapid pulse, gallop rhythm

z

Raised jugular venous pressure (JVP)

z

Dependent oedema

z

Enlarged tender liver

z

Fatigue, orthopnea, exertional dyspnoea

z

Basal crepitations

z

Wheezing

 

Differential diagnosis

 

z

Severe anaemia

z

Protein Energy Malnutrition (PEM)

z

Nephrotic syndrome

z

Asthma

z

Severe pneumonia

 

Investigations

 

¾

Chest X-ray

¾

Blood: haemogram

¾

Urea and electrolytes

¾

Echocardiogram

¾

ECG

 

Management HC4

 

f

Bed rest with head of bed elevated

f

Prop up patient in sitting position

f

Reduce salt intake

f

furosemide 20-40mg IV or oral increasing as

 

required to 80-160mg daily or every 12 hours

according to response

child: 1mg/kg IV or IM repeated prn according to

response (max: 4mg/kg daily)

 

UCG 2010 198

 

 

 

9. Cardiovascular diseases

f

ACE inhibitors start with small dose captopril

 

6.25 mg 8 hourly aiming for a maintainance dose

of 50 mg 8 hourly. Child: 1mg/kg daily. (Avoid if

systolic BP is less than 90 mmHg.)

Plus

 

f

Spironolactone for heart failure 25-50mg once

a day

child: initially 1.5-3mg/kg daily in divided doses

 

For acute pulmonary oedema:

 

f

morphine 5-15mg IM (0.1 mg/kg for children)

f

plus prochlorperazine 12.5mg IM

f

Repeat these every 4-6 hours till there is

 

improvement

f

Beta-blockers like carvedilol at specialised centers.

 

In urgent situations:

 

f

digoxin injection loading dose 250 micrograms

IV 3-4 times in the first 24 hours

Maintenance dose: 250 micrograms daily

child: 10 micrograms/kg per dose as above

 

In non-urgent situations:

 

f

digoxin loading dose 0.5-1mg orally daily in 2-3

divided doses for 2-3 days

maintenance dose: 250 micrograms orally daily

 

- elderly patients: 125 micrograms daily

child: loading dose: 15 micrograms/kg orally 3-4

times daily for 2-4 days

maintenance dose: 15 micrograms/kg daily for 5

days

Note

 

.

Ensure patient has not been taking digoxin in the

past 14 days before digitalizing, because of risk

of toxicity due to accumulation in the tissues

 

Prevention

 

z

Early diagnosis and treatment of the cause

z

Effective control of hypertension

INFECTIVE ENDOCARDITIS

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:50 PM Comments comments (0)

An infection of the heart valves and lining of the

heart chambers by microorganisms which is difficult

to diagnose and treat. It is classified into 3 types:

 

.

Sub-acute endocarditis: caused by low virulence

organisms such as Streptococcus viridans

.

Acute endocarditis: caused by common pyogenic

organisms such as Staphylococcus aureus

 

.

Post-operative endocarditis: following cardiac

surgery and prosthetic heart valve placement.

The commonest organism involved is

 

Staphylococcus albus

 

UCG 2010

195

 

 

 

9. Cardiovascular diseases

Clinical features

 

z

Acute or chronic illness

 

z

Fatigue

 

z

Weight loss

 

z

Low grade fever and chills

 

z

Embolic phenomena affecting various body organs

 

z

Congenitally abnormal or previously damaged

heart valve predisposes to this condition

 

z

Heart failure may occur

 

z

The disease may be of short duration if due to

acute endocarditis and the patient may be

critically ill

 

z

Prominent and changing heart murmurs may occur

 

z

Splenomegaly, hepatomegaly

 

z

Anaemia

 

z

Finger clubbing

 

Note:

 

.

Any unexplained fever in a patient with a heart

valve problem should be regarded as endocarditis

 

Differential diagnosis

 

z

Cardiac failure with heart murmurs

z

Febrile conditions associated with anaemia

 

Investigations

 

¾

Blood cultures: these are usually positive and all

efforts should be made to identify the responsible

pathogen and obtain sensitivity data before

starting treatment

 

¾

At least 3 sets of blood cultures 8 mls each

should be obtained (each from a separate

venepucture) at least one hour apart.

 

¾

Blood: haemogram, ESR

 

¾

Urinalysis for microscopic haematuria, protenuria

 

¾

Echocardiography

 

¾

ECG

 

UCG 2010

196

 

 

 

9. Cardiovascular diseases

Initial empirical therapy HC4

f

benzylpenicillin 4 MU IV every 4 hours

 

plus gentamycin 1mg/kg IV every 8 hours

child: Benzyl Penicillin 50,000 IU/kg per dose

every 6 hours and Gentamycin 2.5mg/kg per

dose every 8 hours

´

gentamycin is contraindicated in pregnancy

 

Once a pathogen has been identified:

 

f

Amend treatment accordingly

 

Prevention

 

z

Prophylactic Amoxicillin 2g (50mg/kg for

children) plus gentamycin 1 hour before plus

500 mgs 8 hourly for 48 hrs after dental

extraction and tonsillectomy in individuals with

cardiac valve defects.

 

z

Prompt treatment of skin infections

DEEP VEIN THROMBOSIS (DVT)

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:50 PM Comments comments (1)

Clot formation within the deep venous system

usually of the calf, thigh or pelvic veins. The clot

can cause a local problem at site of formation or

dislodge leading to thromboembolism in various

parts of the body, particularly the lungs.

 

Causes

 

z

Venous stasis (immobilization, prolonged bed

rest, surgery, limb paralysis)

 

z

Heart failure, myocardial infarction

 

z

Blunt trauma

 

z

Venous injury including cannulation

 

z

Increased coagulability states such as those

associated with some medicines – oral

contraceptive pills, chemotherapy

 

z

Malignant disease of pancreas, lung, stomach,

prostate

 

z

Pregnancy and postpartum

 

z

Polycythaemia

 

z

Anaesthesia – general

 

z

Stroke

 

z

Long distance air travel

 

Clinical features

 

z

50% of cases may be clinically silent

 

z

Painful swelling of the calf, thigh and groin with a

positive Homans’ sign (unreliable for diagnosis)

 

z

Dislodgment of the thrombus may lead to a

greater risk of pulmonary embolism characterized

by fever, pleuritic chest pain, haemoptysis,

dyspnoea.

 

Differential diagnosis

 

z

Cellulitis

z

Myositis

z

Contusion

 

UCG 2010

193

 

 

 

9. Cardiovascular diseases

z

Sarcoma of the underlying bone

z

Phlebitis

z

Karposis sarcoma of the leg

 

Investigations

 

¾

Blood: haemogram, clotting/bleeding time,

fibrinogen degredation products. Prothrombin time

(PT) and International Normalised Ratio (INR).

 

¾

In case of pulmonary embolism: ECG, chest X-ray,

 

echo cardiogram.

¾

Venogram

¾

Ultrasound (at specialised centres)

 

Management

HC4

f

Fibrinolysis at specialised centers

f

Unfractionated heparin given as: IV bolus

5000 IU stat then 250 IU units per kg

subcutaneuosly12 hourly for 5 days adjust dose

according to APTT maintain INR between 2 - 3.

 

f

Low molecular weight heparin (enoxaparin)

 

1mg/kg daily (LMWH) for 5 days can be used as

an alternative

 

f

plus warfarin

 

5mg single dose given in the evening,

commencing on day 3.

-

maintenance dose: 2.5-7.5mg single dose

daily, adjusted according to the INR 2 -3.

f

Check for bleeding and monitor Prothrombin

Time (PT) and INR.

 

f

Starting therapy with warfarin alone

increases the risk of thrombus progression

and embolisation.

 

Antidotes for anticoagulants HC4

 

For heparin:

 

f

protamine sulphate: 50mg slow IV (over 10

minutes) will neutralise the action of 5,000 IU of

heparin when given within 15 minutes of heparin

 

UCG 2010 194

 

 

 

9. Cardiovascular diseases

-

1mg protamine neutralises approx 80-100 IU

heparin (max dose: 50mg)

 

-

if protamine is given longer than 15 minutes

after heparin, less is required as heparin

is rapidly excreted

 

For warfarin:

 

f

phytomenadione (vitamin K) usually 2-5mg

SC, or oral

-

in severe haemorrhage transfusion with fresh

frozen plasma (15mls/kg) or fresh whole

blood.

-

dose depends on INR and degree of

haemorrhage; large doses may reduce

response to resumed warfarin therapy for a

week or more

 

Note:

 

.

Check for bleeding and monitor INR and PT

 

Prevention:

 

.

Early ambulation

 

.

Prophylaxis with Heparin in any acutely ill

medical patient and prolonged admission.


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