3 systemic factor that impaired wound healing
- Increasing age
- Malnutrition
- Diabetes
Describe serosanguineous fluid
- Discharge that contain both blood and a blood serum
- Due to damaged capillary
- Old dressing might damaged the capillary close to skin when pulling off
Normal urine output
- 800 to 2000ml per day if intake around 2 liter per day
How long did it take for Vit K to correct INR
- IV route: onset within 2 hours
Nutritional status assessment
- Unintentional weight loss
- Body mass index (BMI)
- Bitemporal wasting
- Mid-arm circumference
- Triceps skinfold thickness
- Serum albumin (half-life: 18-20 days), transferrin (half-life: 8-9 days; indicator of protein status only in setting of normal serum iron)
- Electrolyte, glucose, and BUN/Cr to assess fluid volume status before parenteral nutrition given
Definition of refeeding syndrome
- The clinical complications that can occur as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patient
- Potentially fatal when not detected/ treated early
Pathogenesis of refeeding syndrome
- Hypophosphatemia: stores of phosphate depleted during starvation; when nutritional replenishment, glucose cause insulin release, which trigger cellular uptake of phosphate -> tissue hypoxia, myocardial dysfunction, inability for diaphragm to contract, rhabdomyolysis, hemolysis, seizure
- Hypokalemia: c/b insulin same as above
Which access to choose for nutritional replenish
- Typically do not start feeding parenterally before 1-2 weeks due to increase risk of infection in malnutrition patient (no added benefit as well comparatively) unless contraindicated for enteral nutrition (eg: bowel obstruction/ both hemodynamically unstable and have not had their IV volume fully resuscitated -> predisposed to bowel ischemia)
- Central venous catheter if TPN given for more than few days because its high osmotic load is not tolerated by peripheral veins
- Peripheral venous catheter rarely indicated due to lack of benefit from short term TPN and ease of obtaining central access
Type of NG tube feeding content
- Standard
- Concentrated: if required fluid restriction (eg: respiratory failure, volume overload)
- Predigested: protein hydrolyzed to short-chain peptide, carbohydrate are in less complex form (eg: malabsorptive syndromes)
- Critical illness: (eg: renal formula for patient with fluid and electrolyte restriction; glycemic control formula for patient receiving bolus feeding)
A-delta vs C nerve fiber
A-delta:
- Pain (mechanical and thermal)
- Myelinated, conduction speed fast
C:
- Pain (mechanical, thermal and chemical)
- Non-myelinated, conduction slow
Levels of sympathetic and parasympathetic outflow
> Sympathetic
- T1-L1
> Parasympathetic
- CN 3, 7, 9, 10
- S2-4
- Cervical don’t have autonomic outflow
Sympathetic cardiac innervation at which level
- T6
- So injury above might cause neurogenic shock
Triad of neurogenic shock
- Bradycardia
- Hypotension
- Autonomic dysfunction (eg: hypothermia)
Location of baroreceptor
- Carotid sinus
- Aortic arch
Total blood volume
5L
Definition of hypotension for child - Formula
<70 + 2*(Age of child)
Definition for oliguria
Infants: <1 ml/kg/h
Children: <0.5 ml/kg/h
Adults: <400ml/day
Causes of altered mental status
AEIOU TIPS
- Acidosis
- Electrolyte
- Infection
- Oxygen/ Opioid
- Uremia
- Trauma
- Insulin (hypo/hyperglycemia)
- Poisoning, Psychiatric
- Stroke
Formula for mean arterial pressure
[(2*DBP) + SBP] / 3
- DBP is multiplied by 2 because diastolic phase last longer than systolic phase
2 local factors cause impaired wound healing
- Infection
- Foreign body or contamination
3 example of opioid agonist
- Morphine
- Codeine
- Oxycodone
3 systemic side effect of morphine
- CNS depression
- Nausea, vomiting
- Respiratory depression
Condition causing air under diaphragm
- Hollow viscus perforation
- Post-laparotomy
- Vaginal insufflation for tubal pregnancy test
- Entero-biliary fistula
Classification of wound healing
- Primary: occurs in wounds with dermal edge that are close together
- Secondary: sides of wound not opposed, therefore healing occur from the bottom of the wound upwards
- Tertiary: occurs when a wound is initially left open after debridement of all nonviable tissue
