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1st year Master ED presentation

cellular and tissue injury & wound healing, sedative / induction agents, anatomy of UL & LL,

norhayati mohamad amin

on 13 July 2011

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Transcript of 1st year Master ED presentation

WOUND HEALING Ang Yong Hau Sedative / Induction Agents Norhayati M.Amin Contents
JCAHO protocol
Sodium Thiopantone definition of procedural
technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allow a patient to tolerate unpleasant procedures while maintaining Cardirespiratory function increased affinity of GABA receptors -> inhibitory neurontransmitter -> enhanced opening of Cl gating channels -> increased Cl conductance -> produce hyperpolarization of the postsynaptic cell membrane & rendering postsynaptic neurons more resistant to excitation JCAHO Protocol for sedation in ED Sufficient qualified individual to perform the procedure & monitor the patient
Appropiate equipment for care & resuscitation
Appropiate monitoring of vital signs, esp HR,RR, BP, oxygenation
Documentation of care
Monitoring of outcomes types of induction agents midazolam benzodiazepine group
water soluble at pH <4
lipid soluble at pH >4
clear, colourless Pharmacokinetics Distribution:
96% protein bound
highly lipid soluble
cross blood brain barrier
T1/2 half life -> 2-4 hr metabolisme:
rapidly metabolized by liver to active metabolite
excretion -> urine Pharmacodynamic CNS
anti convulsant effect
anterograde amnesia
reduce cerebral consumption CVS
reduce SVR -> lower BP, increase HR by 18%
central depression
reduce diaphragm movement
impairs ventilatory response to hypercapnia
Veins -> venous pain 5%
Thrombosis 10% side effects Dose/route 0.01 mg /kg ~ IV or IM
0.1 mg/kg ~ PO
onset ~ 30 - 60 sec
duration ~ 0.5 - 2 hrs Ketamine phencyclidine derivate
produce " dissociative anesthesia" -> trancelike a cataleptic state charaterized by profound analgesia & amnesia, with retention of protective airway reflexes, spontaneous respirations & cardiopulmonary stability
cause minimal respiratory distress
water soluble
act on NMDA receptor, opiod receptor, monoaminergic receptor, muscarinic receptor N-Methyl-D-Aspartate receptor -> an ion channel with excitatory properties
ketamine is noncompetitive antagonist of the NMDA receptor
also inhibit activity wth phecyclidine binding site monoaminergic recptr:
descending inhibitory monoaminergic pain pathway
opiod rcptr :
kappa agonist
Mu antagonist
muscarinic rcptr:
partially antagonized by anticholinesterase drug
produce anticholinergic symptoms (emergence delirium, bronchodilatation, sympathomimetic action) pharmacokinetics pharmacodynamic CVS
sympathomimetic stimulation -> cathecolamines -> increase TPR, BP, , HR, CO, pulmonary artery pressure
increase CBF -> increase ICP
increase intra ocular pressure

respiratory depression in large dose
increase mucus gland secretion -> increase bronchial secretion
increase GI secretions, salivation
increase circulating cathecolamine
increase uterine tone Side effect hallucinatory emergence reaction (3-5%) in older children & adults
increase ICP, CBF
anorexia, nausea, vomiting, well absorbed orally with bioavailability of 20%
highly lipid soluble
cross blood brain barrier
20-50% protein bound
t1/2 half life ~ 2-3 hrs
metabolized extensively in liver by N-demethylation & hydroxylation
conjugated metabolize in urine
excretion -> urine dose/route contraindication propofol etomidate A carboxylated imidazole derivate
cardiovascular stability
minimal histamine release
minimal repiratory effects
side effect of repiratory depression, myoclonus white crystalline powder
soluble in water but unstable (formulated in 0.2% solution with 35% propylene glycol -> incidence of pain during injection dose/route IV bolus ~ 0.3 mg/kg
onset ~ 15 - 30 sec
duration ~ 15 - 30 min pharmacokinetics absorbed orally
75% albumin bound
lipid soluble, cross blood brain barrier
rapidly metabolized in liver & plasma
hydrolysis of the ethyl ester chain to carboxylic acid ester
3% excreted unchanged in urine
metabolites -> 85% by kidney, 17% by bile
t1/2 life ~ 2-5 hrs
less likely had cumu;ative effect pharmacodynamic CVS
lack negative ionotrope effect
reduce sympathetic nervous system & baroreceptor function
decrease SVR
mild hypotension effect
quick recovery (no hangover) - arousable in 6 minutes
reduce cerebral oxygen consumption
reduce CBF
reduce ICP
suppress ventilation, no histamine release, cough & hiccups
( adrenal suppresion cause cortisol reduction ) -> potent steroidgenesis for 24hrs -> reduce cortisol + aldosterone synth CONTENTS
Causes of cell injury
Cellular responses
Types of injury
Pathophysiology of wound healing
Classification Normal cell
narrow range of function
ablility to handle normal physiologic demands ( Homeostasis )
exceeds limits of adaptive response leads to cell injury Causes of cell injury
1) O2 deprivation / hypoxia
cardiorespiratory failure
CO poisoning Causes of cell injury
2) Physical agents
mechanical trauma
burns / cold
radiation Causes of cell injury
3) Chemical agents / drugs
glucose or salt ( hypertonic concentration)
poisons eg. arsenic,cyanide,mercury
therapeutic drugs Causes of cell injury
4) Infectious agents
parasites Causes of cell injury
5) Immunologic reactions
anaphylactic reaction
autoimmune diseses
6) Genetic derangements
7) Nutritional imbalances Cellular response to injury
1) Cellular adaptations: excessive stress (physiologic or pathological)

a new altered state (atrophy,hypertrophy,hyperlasia,metaplasia)

2) Cellular injury
irreversible Cellular response to injury
Depends on:
Type of injury,duration,severity
Nutritional and hormonal status Mechanism of injury
ATP depletion
O2 free radicals
Intracellular Ca and loss of Ca homeostasis
Defects in membrane permeability
Irreversible mitochondrial damage Type of cellular injury
1) Reversible cell injury
cellular swelling
fatty change
2) Irreversible injury
necrosis (gross and histologic cell death from irreversible exogenous injury)
apoptosis (programmed cell death) Functions of skin
metabolic functions Pathophysiology of wound healing
3 phases:
1) acute inflammatory response
2) proliferaive phase
3) remodelling phase Acute inflammatory response
immediate to 2-5 days
platelet activation,clot formation
vasodilation,increased vascular permeability
phagocytosis - neutrophils,macrophages Proliferative phase
2 days - 3 weeks
fibroblast proliferation
extracellular matrix deposition
wound contraction Remodelling phase
3 weeks to 2 years
new collagen increases tensile strengh to wound
80% of normal tissue Classification of wound healing
1) First / Primary intention
2) Second / Secondary intention
3) Third / Tertiary intention First intention
uncontaminated wound,easily approximated
rapid epithelialisation,minimal scar Second intention
substantial tissue loss
wound left open and allowed to heal from deep
more inflammatory response
poor scar quality and cosmetic result Third intention
closed several days after its formation
may follow a period of healing by secondary intention Clavicle:
medial 2/3: sternocleidomastoid
lateral 1/3: pectoralis major
if fractured, ventral rami of C8 & T1 of medial cord may be lacerated Acromioclavicular joint
Coracoclavicular ligament
Pectoral (shoulder) girdle Glenohumeral Joint: ball-and-socket
Flexion, Extension, Abduction, Adduction
Medial & Lateral rotation, Circumduction
In dislocation, humeral head displaces inferior to coracoid process, stretching the axillary or radial nerve
Rotator cuff: SITS muscles Surgical neck of humerus:
Axillary nerve & Posterior circumflex artery
Humeral tubercle:
Subscapularis & Glenohumeral joint
Shaft of humerus:
Radial nerve & Profunda brachial artery
Supracondylar humerus:
Shortening of triceps & brachioradialis - Median nerve Elbow joint:
Humeroradial = capitulum + radius
Humeroulnar = trochlea (H) + trochlear notch (U)
Proximal radioulnar = ulnar notch + radial head
Flexion + Extension (humeroradial & humeroulnar)
Pronation + Supination (proximal radioulnar) Lateral epicondyle - extensor
Tennis elbow
Medial epicondyle - flexor
Golfer's elbow
Ulnar nerve Carpal bones:
Proximal - Scaphoid, Lunate, Triquetrum, Pisiform
Distal - Trapezium, Trapezoid, Capitate, Hamate
"Some Lovers Try Positions That They Can't Handle" Carpal tunnel (CTS) - median nerve + 9 tendons
3 flexor digitorum superficialis
3 flexor digitorum profundus
3 flexor digitorum longus
Flexor retinaculum
Medially - pisiform & hamate
Laterally - scaphoid & trapezium
Canal of Guyon
Between pisiform & hook of hamate
Passing of ulnar nerve, artery & vein side effect excitatory phenomenon ~ myoclonus (50-80%)
nausea & vomiting (40-50%)
venous thrombosis (8%)
adrenal suppresion cause cortisol reduction
pain on injection 2,6-diisopropylphenol
phenol derivative
insoluble in water, highly lipid soluble
supplied in emulsion of soybean, with no preservatives,
therefore risk of bacterial growth effects -> within a minute / 1 arm-brain circulation
sedatives effect last less 10 minutes
provides sedative & hypnotic properties at subanesthetic dosages, although it has no analgesic properties
possesses antiemetic properties & decreases intracranial pressure
may cause significant cardiovascular depression -> up to 25% - 40% of SBP drop enhances inhibitory of neurontransmitter -> transmembrane chloride conductance increase -> hyperpolarisation of post synaptic cell & functional inhibition post synaptic neuron pharmacokinetic absorbed orally
97% protein bound
lipid soluble, cross blood brain barrier
t1/2 half life ~ 4 - 22 hrs
rapid distribution
metabolized in liver & extrahepatic metabolisme
conjugated to glucuronide & sulphate
renal elimination
< 1% excreted in urine, 2% excreted in faeces pharmacodynamic CVS
BP decrease by 30%
SVR decrease
CO decrease
HR variable ~ tachycardia, bradycardia, heart block due to sympathetic > parasympathetic
rapid recovery,
cerebrovascular resistance increase 51-55%
CBF reduce by 26-51%

transient apnea , tachypnea
supress laryngeal reflexes
reduce adrenal steroid production side effect bradycardia
pain on injection
allergic reaction indication induction & maintenance of anesthesia
anticonvulsant & anti emetic
simple fracture reduction
abscess drainage
removal of auricular foreign bodies
short laceration repair dose /route adult
IV 2-4 mg/kg
IVI 4 - 12 mg/kg/hr
IV 2.5 mg / kg (induction)
onset ~ 30 sec
duration ~ 10 min Anatomic snuffbox:
Lateral - extensor pollicis brevis & abductor pollicis longus
Medial - extensor pollicis longus
Floor - scaphoid & trapezium
Passing of radial artery & superficial radial nerve branches Volkmann's Ischemic Contracture:
Caused by supracondylar fracture of humerus
Compresses brachial artery
Causes severe wrist & interphalangeal flexion
Dupuytren's Contracture:
Caused by fibrosis & shortening of palmar aponeurosis
Causes flexion of ring & little fingers Median nerve lesions:
CTS - pain over palmar aspects of thumb, index & middle fingers
Cutaneous sensation from lateral aspect is spared
Thenar weakness - adducted & extended
Also weakness in pronation & flexing fingers Axillary nerve lesion:
Weakness, numbness & possible atrophy of deltoid
Weakness in lateral rotation (teres minor)
Anterior Interosseous Nerve (AIN) lesion:
Weakness in pronation (pronator quadratus)
Weakness in flexion of DIPJ of thumb, IF & MF Ulnar nerve lesion:
Ulnar claw hand - weakness to flex MPJ & extend IPJ of RF & LF
Weakness to flex, abduct & oppose thumb to LF
Radial nerve lesion:
Wristdrop - weakness to extend wrist & MPJ of all digits
Weakness in supination (not loss in biceps brachii - MCN)
Possible pain & parasthesia of skin over 1st dorsal interosseous muscle between thumb & IF BS suffers a fracture of supracondylar humerus that compresses on a nerve and an accompanying artery.
What might you observe in the patient?
a) Clawing of the ring & little fingers
b) Altered sensation in skin over anatomic snuffbox
c) Instability to extend the thumb
d) Dupuytren's contracture
e) A hand of benediction Pelvic Girdle (limited mobility):
Ilium + Ischum + Pubis = Acetabulum
Sacroiliac & Hip joints
Articular capsule, strengthened by ligaments:
Iliofemoral - anterior, resists extension
Pubofemoral - anterior & inferior, resists excessive abduction
Ischiofemoral - posterior, screws in head of femur Neck of Femur:
Medial circumflex femoral artery - causes AVN of head if disrupted
If fractured - thigh laterally rotated (vastus lateralis & gluteus maximus)
Head of Femur:
Posterior dislocation commonest (gluteus maximus & minimus)
Sciatic nerve may be compressed, causing:
- Weakness of posterior thigh, leg & foot muscles
- Parasthesia over posterior & lateral leg + dorsal & plantar aspects of foot Knee:
ACL = APEX (resists hyperextension)
Anterior of tibia + goes Posteriorly & EXternally (lateral)
PCL = PAIN (resists excessive flexion)
Postrior of tibia + goes Anteriorly & INternally (medial)
Collateral ligaments - tibial & fibular
Menisci - medial ("C", less mobile) & lateral ("O", mobile)
The "Terrible Triad" = TCL + MM + ACL Ankle Joint:
Talocrural (hinge, dorsiflex) - trochlea + talus + medial & lateral malleolus
Subtalar (ball-and-socket, supinate, pronate) - talus + calcaneum
Transverse Tarsal (inversion, eversion) - navicular + calcaneus + cuboid Cruciate anastomosis in posterior thigh:
Medial & lateral circumflex femoral arteries
Inferior gluteal artery
Provides collateral if femoral artery occluded
Dorsalis pedis pulse - to compress against tarsal bones lateral to tendon of extensor hallucis longus Obturator nerve lesion:
Unable to adduct hip
Parasthesia at medial thigh
Femoral nerve lesion:
Weakness to flex hip & extend knee
Diminished patellar tendon reflex
Saphenous nerve lesion:
Pain & paresthesia in medial aspect of leg & foot Lateral Femoral Cutaneous nerve lesion:
"Meralgia Paresthetica" in anterolateral thigh
Superior Gluteal nerve lesion:
Weakness to abduct hip - waddling/Trendelenburg gait
Inferior Gluteal nerve lesion:
Weakness to lateral rotate & extend hip - gluteus maximus gait Sciatic nerve lesion:
IM injection lower medial quadrant of gluteus maximus
Compressed by posterior dislocation of femur
Affects tibial & common fibular nerves
Tibial nerve lesion:
Weakness to flex knee & plantar flex ankle
Common Fibular nerve lesion:
Footdrop + pain & paresthesia in lateral leg & dorsal foot A traumatic injury to the lateral aspect of a patient's knee tears several structures at the knee joint. An examination reveals a positive anterior drawer sign and a clicking when the patient extends the leg at knee.
Of the following structures, which one was most likely spared from being stretched or torn from this injury?
a) Medial meniscus
b) Tibial collateral ligament
c) Fibular collateral ligament
d) Anterior cruciate ligament
e) Tendon of the sartorius muscle COMPARTMENTS OF EXTREMITIES
finally... Compartments of the hand:
dorsal interossei (4 compartments)
palmar interossei (3 compartments)
adductor pollicis
thenar and hypothenar Compartments of the Forearm:
Superficial Layer:
Pronator Teres
Flexor Carpi Radialis
Palmaris Longus
Flexor Carpi Ulnaris
Middle Layer:
Flexor Digitorum Superficialis
Deep Layer:
Pronator Quadratus
Flexor Digitorum Profundus
Flexor Pollicis Longus
Supinator Applied Anatomy Of
Upper & Lower Extremities
Stacy Y. Wong, MD Compartments of the Leg:
Peroneus Brevis, Peroneus Longus
Superficial posterior:
Gastrocnemius, Soleus, Popliteus, Plantaris
Deep posterior:
Tibialis posterior, FDL, & FHL
Tibialis Anterior, EDL, EHL, Peroneus Tertius Compartments of the Foot:
Intrinsic Compartment:
4 intrinsic muscles between the 1st and 5th metatarsals
Medial Compartment:
Abductor Hallucis, Flexor Hallucis Brevis
Central (Calcaneal)Compartment:
Flexor Digitorum Brevis, Quadratus Plantae, Adductor Hallucis
Lateral Compartment:
Flexor Digiti Minimi Brevis, Abductor Digiti Minimi Absorbed oraly
bioavailablity 44% 1 - 2 mg /kg ~ IV (induction)
0.5 - 1 mg /kg ~ IV ( sedation)
0.25 - 0.5 mg/kg ~ IV (analgesic )
paed :
1-2 mg/kg ~ IV
3-5 mg/kg~ IM
5-10mg/kg ~ PO / PR
onset ~ 15 - 30 sec
duration ~ 15-30 min children 3 months & younger, & those with airway abnormalities
h/o -> CHF or HPT
acute closed head or eye injury
altered mental status or psychosis, CNS mass, poorly controlled seizure disorder or glaucoma thiopentone short acting barbiturate
induction of anesthesia
MOA ~ GABA at GabaA receptor in neuronal membrane IV bolus 4 - 6 mg /kg
onset ~ 15 -30 sec (one arm-brain circulation)
duration ~ 5 - 15 min pharmacodynamic CNS
CNS depressant
reduce CPP / CMRO2 / ICP ~ cerebroprotective
anti convulsant effect
hypotension 2 ' reduce SVR -> reduce CO
negative inotrope effect
potent respi depression -> apnea
bronchoconstriction -> histamine release
reduce GIT activity
no effect on uterine tone pharmacokinetic absorbed orally & rectally
highly lipid soluble
low degree of ionisation
easily cross blood brain barrier
- short duration despite slow metabolisme 2'
rapid redistribution to peripheral tissue
zero order kinetic -> fixed amount of drug eliminated per unit time
-> regardless of plasma concentretion
t1/2 ~ 18 - 22 hrs side effect hypotension
severe anaphylactoid reaction -> histamine release dose/route references 1. Emergency Medicine, 6th edition; pg : 275-279
2. Pharmacology & physiology in Anesthetic Practice, 2nd edition hypotension
withdrawal after prolonged infusion 3. Robbins Pathologic Basis of Disease
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