C/f- pain, edema, warmth, tenderness over sting site, nausea, vomiting, urticarial rash, tachypnoea, wheezing, respiratory arrest, hypotension, shock, airway obstruction due to laryngeal edema
Usually encountered are cases involving snake, honeybees,wasps,spiders,scorpion, etc.
Patients with no history of angioedema, bronchospasm, urticaria or anaphylaxis should be observed for 1 to 2 hrs and carefully monitored for evidence of evolving
anaphylaxis.The wound must be examined for a stinger, which should be removed by gentle scraping with blade to prevent further envenomation. Do not grasp with forceps or fingers in order to avoid expressing more venom from the poison sac into the skin.The wound should be thoroughly cleaned, tetanus prophylaxis administered if appropriate, and ice applied. Patient who remain asymptomatic 2 hrs after the injury may be discharged with instructions to return immediately if shortness of breath, wheezing, generalized pruritus, oropharyngeal swelling, or rash occurs. In scorpion stings, advise elevation for 24 to 48 hrs
Rx
Check airway, Inj avil, Inj efcorlin, Inj adrenaline(if bronchospasm), remove stings, apply ice , elevate extremity to limit edema
Scorpion stings are very painful, so infiltrate the area with lignocaine 2% through the puncture wound.
Look for systemic symptoms. If present refer. Snake bite-first aid
If an extremity is involved, it should be placed in neutral position below the heart;
intravenous access should n’t be established in the bitten extremity. Wounds should n’t be incised and oral suction is not recommended. The placement of an arterial
interrupting tourniquet is not advised; alternatively compression or constriction bands which are placed proximally around the bitten extremity and interrupt venous and lymphatic flow may be helpful. The band is placed so that a finger slips under
the
bandand distal arterial pulsations are easily palpated. Bands may be made from clothing, rope, rubber gloves etc. O2should be administered and the patient transported as soon as possible.
CARDIOPULMONARY RESUSCITATION (CPR)
First confirm cardiac arrest; absence of repiratory efforts, absence of major pulse like
carotid is diagnostic of cardiopulmonary arrest.If pulse +, open the airway & give ventilation.
Healthcare providers, should perform all 3 components of CPR (chest compressions, airway, and breathing).For an unconscious adult, CPR is initiated using 30 chest compressions.
Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing. Before beginning ventilations, rule out airway obstruction by looking in the patient’s mouth for a foreign body blocking the patient’s airway. CPR in the presence of an airway obstruction results in ineffective ventilation/oxygenation and may lead to worsening hypoxemia.
Positioning
CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum.
The health care provider giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest.
Chest compression
The heel of one hand is placed on the patient’s sternum, and the other hand is placed on top of the first, fingers interlaced. The elbows are extended and the provider leans directly over the patient. The provider presses down, compressing the chest at least 2 inches. The chest is released and allowed to recoil completely.Chest compressions are to be delivered at a rate of at least 100 compressions per minute.
With the hands kept in place, the compressions are repeated 30 times at a rate of 100/min.
The key thing to keep in mind when doing chest compressions during CPR is to push fast and hard. Care should be taken to not lean on the patient between compressions, as this prevents chest recoil and worsens blood flow.
After 30 compressions, 2 breaths are given (see Ventilation). Of note, an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute or 1 breath/6-8 seconds. This entire process is repeated until a pulse returns or the patient is transferred to definitive care.
When done properly, CPR can be quite fatiguing for the provider. If possible, in order to give consistent, high-quality CPR and prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR).
Ventilation
If the patient is not breathing, 2 ventilations are given via the provider’s mouth or a bag-valve-mask (BVM).
The mouth-to-mouth technique is performed as follows :
The nostrils of the patient are pinched closed to assist with an airtight seal.The provider puts his mouth completely over the patient’s mouth.The provider gives a breath for approximately 1 second with enough force to make the patient’s chest rise. Effective mouth-to-mouth ventilation is determined by observation of chest rise during each exhalation. Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion. As noted , 2 such exhalations should be given in sequence after 30 compressions (the 30:2 cycle of CPR). When breaths are
completed, compressions are restarted. If available, a barrier device (pocket mask or face shield) should be used.More commonly, a BVM can be used, which forces air into the lungs when the bag is squeezed. Several adjunct devices may be used with a BVM, including oropharyngeal and nasopharyngeal airways.The BVM or invasive airway technique is performed as follows:The provider ensures a tight seal between the mask and the patient’s face.The bag is squeezed with one hand for approximately 1 second, forcing at least 500 mL of air into the patient’s lungs.Next, the provider checks for a carotid or femoral pulse. If the patient has no pulse, chest
compressions are begun.
Fluid Balance and IV fluid therapy Fluid requirement
In a normal person fluid requirement over 24 hr is roughly 2500 ml. Normal daily losses are through urine(1500 ml), stool(200 ml), & insensible losses(800 ml). This requirement is normally met through food(1000 ml) & drink (1500 ml).
Intravenous fluids are given if sufficient fluids can’t be given orally. About 2500 ml fluid containing roughly 100 mmol Na+ & 70 mmol K+ per 24 hr are required. Thus a good regimen is 2L of 5% Dextrose and 1 L of 0.9% saline every 30 hr with 20 mmol of K+
per litre of fluid.
Remember that all cannulae carry a risk of MRSA infection, so always resume oral fluid intake as soon as possible.
In sick pt’s, don’t forget to include additional sources of fluid loss when calculating daily fluid requirements, such as drains, fever, or diarrhoea
Assessing fluid balance Underfilled
Tachycardia, postural drop in BP, ↓ capillary refill time, ↓ urine output, cool peripheries, dry mucous membrane, ↓ skin turgor, sunken eyes
Over filled
Pitting edema of the sacrum, ankles, or even legs & abdomen, tachypnoea, bibasal crepitations, pulmonary edema on CXR, ↑ JVP
Pottasium in IV fluids
Pottasium can be given with 5% dextrose, or 0.9% saline, usually 20 mmol/L or 40mmol/L.
K+ may be retained in renal failure, so beware giving too much IV. GI fluids are rich in K+, so increased fluid loss from the gut(eg diarrhoea, vomiting, high-output stoma, intestinal fistula) will need increased K+ replacement.
The maximum concentration of K+ that is safe to infuse via a peripheral line is 40 mmol/L, at a maximum rate of 20 mmol/h.
Note
Elderly pt’s are more prone to fluid overload, so give iv fluids with care Pancreatitis: aggressive fluid resuscitation is required in a/c pancreatitis Fever, burns: large amounts of fluid can be lost unseen through transpiration.
Liver failure: these pt’s often have a raised total Na+, so restrict 0.9 % saline Heart failure: use IV fluids with care to avoid fluid overload.
Shock: resuscitate with colloid or 0.9% saline via large bore cannulae.
Hypertonic dextrose(10% or 50%): irritant to veins, so infusion sites inspected & flushed with 0.9% saline after use.
In children- Maintenance requirement
Upto 10 kg: 100 ml/kg/24 hr; 10-20 kg: 1000 ml + 50 ml/kg/24 hr for the weight above 10 kg; more than 20 kg: 1500 ml + 20 ml/kg/24 hr for the weight above 20 kg.
Add approx. 1ml 15% KCl(=2mEq) per 100 ml fluids like NS. Isolyte-P already contains K+, & hence K+ need not be added to isolyte-P.
In case of significant dehydration, poor pulse etc., give NS 20-30 ml/kg & reassess.