ARTERIAL BLOOD GAS ANALYSIS PDF

ARTERIAL BLOOD GAS ANALYSIS : ○ 35-45 mmHg normal range Applications : PaO2 or partial pressure of oxygen : To document respiratory failure and assess PAO2 indicates the amount of...

ARTERIAL BLOOD GAS ANALYSIS : ○ 35-45 mmHg normal range Applications : PaO2 or partial pressure of oxygen : To document respiratory failure and assess PAO2 indicates the amount of oxygen its severity. available to bind with hemoglobin To monitor patients on ventilators and ○ 80 to 100 mmHg assist in weaning. SO2 or oxygen saturation : To assess acid-base imbalances in critical measured in percentage, is the amount illness, of oxygen in the blood that combines with To assess response to therapeutic hemoglobin interventions and mechanical ventilation. HCO3 or bicarbonate ion : To assess pre-operative patients. is an alkaline substance that comprises over half of the total buffer base in the Sampling : blood. (metabolic determinant) BE. Base excess or BE value is routinely checked with HCOз value Normal Values (at sea level) Range pH 7.35 - 7.45 pCO2 35-45 mmHg pO2 80-100 mmHg O2 Saturation 95-100% HCO3- 22-26 mEq/L Dorsalis pedis Base Excess + or -2 Femoral Brachial Goals of ABG Analysis : Considerations : 1. Acidosis/ Alkalosis 1. Excessive Heparin - ↓HCO3 ↑pCO2 2. Metabolic/ Respiratory 2. Inadequate Specimen - 25% lower values 3. Fully compensated/ Compensated/ if only 1mL sample is taken using a 10mL Uncompensated syringe Acid - Base Disorders : 3. Excessive Air bubbles - ↑pO2 ↓CO2 1. Respiratory Alkalosis : 4. Body temperature-↑↓HCO3 and c02 Central Respiratory Stimulation 5. Delayed Analysis ○ Structural Causes (TBI, Glioma, a. Cold Chain CVA) Change/10 Uniced (37 C) Iced (4 C) ○ Non-structural Causes (Pain, minutes Anxiety, Fever, Voluntary) pH 0.01 0.001 Peripheral Respiratory Stimulation pCO2 1 mmHg 0.1 mmHg ○ Pul V/Q imbalance pO2 0.1% 0.01% ○ Hypotension ○ High Altitude Components : Intrathoracic Structural Causes PaCO2 or partial pressure of carbon dioxide : ○ Reduced movement of chest wall shows the adequacy of the gas exchange & diaphragm between the alveoli and the external ○ Reduced compliance of lungs environment ○ Irritative lesions of conducting ○ alveolar ventilation airways ○ respiratory determinant  Mixed/ Unknown Mechanisms provide Mechanical V/entilation through ○ Drugs (Salicylates, Nicotine, Oxygen supplementation hormones) Manage Hyperkalemia through ○ Cirrhosis Kayexalate ○ Pregnancy Maintain adequate hydration ○ Heat exposure Risk Factors : ○ Mechanical Ventilation Hypoventilation Manifestations : COPD Lightheadedness, confusion Respiratory Condition Decreased intellectual function Drug Intake/Overdose : (Morphine, Syncope, seizures tramadol heroin, fentanyl or Magnesium Paraesthesias (circumoral, extremities) sulfate (MgSo4) Muscle twitching, cramps, tetany 3. Metabolic Acidosis : Hyperreflexia HCO3 loss Tachycardia ○ Renal Management : ○ GIT Breath into a paper bag Decreased bicarbonate production in the Treat underlying condition: pancreas ○ Medication- Pain reliever or 3 main root causes : anti-anxiety ○ Ketoacids ○ Relaxation technique ○ diarrhea ○ Safety ○ Kidney disorder ○ Lavage Risk Factors : ○ Correction of hypokalemia and Diabetic Ketoacidosis (DKA) hypocalcemia Chronic Renal Failure (CRF) ○ Oxygenation as indicated Chronic Hypoxia 2. Respiratory Acidosis : Obesity Perfusion problems Diarrhea Cardiac Arrest Dehydration Ventilation problems Aspirin Toxicity ○ FBAO Methanol Poisoning ○ Severe pulmonary edema Management : ○ ARDS Sodium Bicarbonate ○ COPD Treat the underlying condition: Manifestations : ○ Hydration for Diabetic Ketoacidosis Altered level of consciousness ○ Dialysis for Chronic Renal Failure Confusion ○ Use Diuretics Disorientation ○ Initiate safety measures Coma 4. Metabolic Alkalosis : Tremors Bicarbonate ion concentration increases Asterixis ( Inability to maintain the posture Elevation in blood pH of the part of the body) Excessive vomiting, dehydration, or Management : endocrine disorders Medication Risk Factors : Weight loss Vomiting Sodium Bicarbonate Overdose  Nasogastric suction Manifestations : Numbness Vomiting Diarrhea Swelling in the lower legs (Edema) Fatigue Disorientation Seizure Coma Management : Antiemetic Ammonium chloride Acetazolamide (Diamox) Analysis : Compensation is the attempt by the body to maintain homeostasis by correcting the pH. The opposite system will do this. If the pH remains abnormal , then it is considered as partial compensation. If the pH is within normal range, then it is considered as full compensation. No activity of the compensating system (within normal range) is said to be uncompensated. Respiratory system : Fast and deep breathing "blows off" CO2 Conversely, low and shallow breathing "retains" CO2. Renal system : A patient in shock will undergo anaerobic metabolism, which produces lactic acid. The production of lactic acid will bind or use up available HCO3 and will be manifested by a decrease in the HCO3 level. Airway Management : ET Intubation Equipment : ET Intubation : is performed to establish and maintain a patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration, and assist with the clearance of secretions. ET Intubation include : Different sizes of cuffed Laryngoscope Inadequate oxygenation and ventilation and plain ETT Altered mental status (e.g. head injury, drug overdose) for airway protection Anticipated airway obstruction (e.g. facial burns, epiglottitis, major facial or oral trauma) Upper airway obstruction (e.g. secondary to swelling, trauma, tumor, bleeding) Apnea Magill’s forceps Syringe to inflate cuff Respiratory distress or respiratory failure (different sizes) Ineffective clearance of secretions High risk for aspiration What are different types of intubation? : 1. Endotracheal intubation. This involves the insertion of a plastic tube into the windpipe to help a person breathe. 2. Nasogastric intubation. ET Intubation Risk : Unlike intubation to help a patient Aspiration : breathe, this intubation uses a tube If a patient inhales blood, vomit, or other placed through the mouth or nose down fluid while intubated, this is aspiration. into the stomach. Aspiration can lead to pneumonia. 3. Fiberoptic intubation. Improper intubation : A tube with a tiny camera on the end is The breathing tube inadvertently enters inserted into the throat. This can examine the bronchi (tubes that connect to the the throat or assist with endotracheal lungs) or the esophagus (the food tube). intubation. Injury : ET Intubation Tube sizes : The mouth, teeth, tongue, vocal cords, Tubes range in size from 2.0 mm for and trachea are damaged during neonates to 10.0 mm for large adult. intubation. ○ 0.1 y/o → 2.5 mm to 3.5 mm (plain) Infection : ○ 1-3 y/o → 4 mm to 5 mm Sinus infections are the most typical ○ 4-6 y/o → 5 mm to 6 mm infection risk with intubation. ○ 6-10 y/o → 6 mm to 7 mm (cuffed) ○ Adult female – 7 mm to 8 mm ○ Adult male – 8 mm to 9 mm ET Intubation can be done via the nasal or oral routes. Endotracheal tube Suctioning in Ventilated Patient ○ Odor What is ET tube suctioning? : Cough characteristics/effort Perform in sterile procedure to prevent Intracranial pressure HAP Ventilator parameters Suctioning may result in serious ○ Peak inspiratory pressure and plateau complications, such as pressure ○ hypoxemia, ○ Tidal volume ○ arrhythmias, ○ Pressure, flow, and volume graphics, ○ hypertension or hypotension, ○ FIO2 ○ increased ICP. ○ bronchospasms, Necessary Equipment : ○ trauma to the mucosa, Vacuum source with adjustable regulator ○ pain, and anxiety. suction jar ALERT!! : Stethoscope Suction the patient's artificial airway only Sterile Gloves for open suction/ Clean as clinically indicated and not as a gloves for closed suctioning routine, fixed-schedule treatment Sterile Catheter If the patient develops respiratory distress Sterile normal saline or cardiac decompensation during the Bag valve mask (if necessary) for pre suctioning procedure, immediately oxygenate the patient withdraw the catheter and supply Suction tray additional oxygen as needed. Suctioning can cause elevations in Close suction Recommendation : intracranial pressure (ICP) in patients with It is recommended that endotracheal head injuries. suctioning should be performed only when Close suction : secretions are present, and not routinely. The closed-suction technique is the It is suggested that pre-oxygenation be preferred method for suctioning because considered if the patient has a clinically it facilitates continuous mechanical important reduction in oxygen saturation ventilation and oxygenation during the with suctioning. suctioning procedure. Performing suctioning without Administering 100% oxygen pre-suction disconnecting the patient from the and post-suction reduces hypoxemia. ventilator is suggested. Close suction Monitoring : Use of shallow suction is suggested instead The following should be monitored prior of deep suction, based on evidence from to, during, and after the procedure: infant and pediatric studies. Breath sounds It is suggested that routine use of normal Oxygen saturation saline instillation prior to endotracheal Skin color suction should not be performed. Pulse oximeter The use of closed suction is suggested for Respiratory rate and pattern adults with high FIO2, or PEEP, or at risk for Hemodynamic parameters (Pulse rate, lung derecruitment and for neonates. Blood pressure) Endotracheal suctioning without Sputum characteristics disconnection (closed system) is ○ Color suggested in neonates. ○ Volume Avoidance of disconnection and use of ○ Consistency lung recruitment maneuvers are  suggested if suctioning induced lung derecruitment occurs in patients with acute lung injury It is suggested that a suction catheter is used that occludes less than 50% of the lumen of the ETT in children and adults, less than 70% in infants. It is suggested that the duration of the suctioning event be limited to less than 15 seconds. ANIMAL BITES : Rabies: A Global Concern. What is animal bites?. Through this, nations are expected to be An animal bite is a wound caused by the liberated from the burdens of this dreaded teeth that usually results in a break in the infection. skin due to the excessive pressure on the The global plan notably calls for three key body tissue from the bite. actions: It includes injuries not only from teeth of ○ Making human vaccines and reptiles, animals but fish and amphibians. antibodies affordable; Most cases involve children rather than ○ Ensuring people who get bitten adults being injured. receive prompt treatment; Animals that may bite include dogs, cats, ○ Implementing mass dog rodents, rabbits, ferrets, farm animals, vaccinations in at-risk areas. monkeys and reptiles. The ASEAN Response. What causes animal bites? : Number of human rabies cases from dog Dog bites. bites continues to be alarmingly high at Dogs are usually the domestic pets that 95%. cause animal bites. ASEAN perspectives recognize that ○ Rabies is a deadly virus spread to eliminating the virus from its animal host people from the saliva of infected remains to be the most cost-effective way animals. to contain the infection. Mosquito bites. Vaccination to cover 70% of dog Mosquito is an insect belonging to a fly population at high-risk area. family. A mosquito bite can cause Responsible dog ownership and dog diseases like malaria which can be life population management practices. threatening. ○ Dog vaccination Fire ant bites. Rabies in the Philippines. Fire ants are small, red or black venomous Rabies is endemic in the Philippines, and ants with a painful, stinging bite. They can remains to be a public health concern. cause a severe allergic reaction in some Fatality rate of almost 100%. people. At least one-third of these deaths occur in Bees. children aged 15 years old and below. Bees are the most dangerous insect that Data show that the number of animal bite can cause pain, redness, and swelling at cases reported in the country increased the site of the sting. by 462% from 2009 (206, 253 bite cases) to Scorpion bites. 2018 (1, 159, 711 bite cases). If they bite, a very intense pain, The confirmed number of positive human numbness, tingling, and swelling occurs rabies cases increased by 13.5% in the last around the sting. 9 years, from the 243 cases reported in Human bites. 2009 to 276 in 2018. Human bites can be the most dangerous Republic Act No. 9482 – An Act providing wounds that contain a lot of bacteria and for the control and elimination of human carry a high risk of infection. These and animal rabies infections can develop quickly and result in serious problems. Rabies Transmission : ○ Vomiting 1. Rabies in Human : ○ Generalized body malaise Bites : ○ Headache and abdominal pain Most common mode of transmission of ○ Paresthesia or pain at the site of a rabies to humans. Exposure to rabies may bite is due to viral multiplication at come from bites of infected dogs, cats, the spinal ganglion just before it other domestic and wild animals including enters the brain. bats. 2. Acute Neurologic : Non-bite exposures : The acute neurologic stage is the stage are less important and are infrequent when the virus reaches the CNS and modes of transmission. However, replicates most exclusively within the gray scratches, open wounds or mucous matter. membranes that are licked by an infected Autonomic manifestations such as animal, can be points of entry of the hypersalivation appear during this stage. rabies virus. The virus passes centrifugally among 1. Contamination of intact mucosa autonomic nerves to reach other (eyes, nose, mouth, genitalia) with tissues—the salivary gland, adrenal saliva of infected animal; medulla, kidney, lung, liver, skeletal 2. Licks on broken skin; and muscle, skin and heart. 3. Inhalation of aerosolized virus in Passage into the salivary gland facilitates closed areas. further transmission of the disease through infected saliva. Manifestation : Coma - begins within 4-10 days after symptoms start; Cardiac arrhythmias is common. Hyperventilation which leads to periodic and ataxic respiration to apnea. Haematemesis is experienced by 30-60% Clinical Stages : of patients before death. 1. Prodromal : Pituitary dysfunction is also present as part This stage lasts for 0-10 days with of disordered water balance. non-specific manifestations: Death - without intensive supportive care, ○ Fever respiratory depression, cardiorespiratory ○ Sore throat arrest, and death occur in almost 100% of ○ Anorexia cases. ○ Nausea Cause of death includes circulatory insufficiency with myocarditis, cardiac  arrhythmia or congestive heart failure ○ Other victims of the same animal (RITM). within the past 24 hours. Laboratory Diagnosis : Physical Examination : Often the diagnosis of rabies is based on Routine the clinical manifestations and a history of Include excoriation of animal bites. exposure to a rabid animal. Look for myxedema at percussion sites, Hydrophobia and/or aerophobia are usually in the region of the chest, deltoid present, the diagnosis is straightforward. muscle and thigh, Rabies diagnosis can be performed on Check patient for possible piloerection fresh tissue specimens stored at and fasciculation appropriate temperatures, preferably Neurologic : refrigerated. Observe for fluctuating consciousness The specimens to be collected depend on Note autonomic stimulation signs the test to be performed. Watch for paralysis Collection of samples Hyperactive episodes Ante mortem (saliva) Wait for aerophobia/hydrophobia to Post Mortem Collection - CSF, Nuchal skin manifest biopsy, brain tissues Medical Management : Handling of Specimen/Transport - Any of the following medications may be Specimens should be frozen at -200 C. given: Diazepam, Midazolam, Haloperidol Check first with the courier company if plus Diphenhydramine their delivery vehicles have refrigeration or Supportive Care : freezers that can bring the specimen to A patient diagnosed to have rabies should the lab. receive adequate sedation and comfort Clinical Diagnosis of Human Rabies : care in a medical facility. History Taking : Patients should be admitted in a quiet, Determine the History of exposure to dogs, draft-free, isolation room. cats, bats, domestic animals (bite & non IVF may be given. bite) Invasive and Heroic procedures must be The following are not considered avoided. (Intubation, Mechanical exposures to rabies - sharing food with Ventilation, Cutdown) rabies patient, licks on intact skin, Provide suitable emotional and physical; Observe the status of biting animals at support. time of bite and after 14 days. Discuss and provide important information Determine the vaccination status of biting to relatives concerning transmission of animal disease and indication for post-exposure Take note of the incubation period prophylaxis of contacts. Watch out for the following clinical Honest and gentle communication symptoms: concerning prognosis should be provided ○ Pain/numbness/itching at bite site to. ○ Encephalitic symptoms- Be sure to Isolation room note and document/list them Referral and transporting of patient to ○ Paralytic symptoms - Document/list other hospitals these as well. Consider other contributory information such as: First Aid : with body fluids through splattering and Wash with soap and water - Immediate mouth-to-mouth resuscitation. wound treatment is an indispensable 4. Unprotected handling of infected carcass 5. Ingestion of raw infected meat component of bite management. 6. Exposure to bats Antimicrobial prophylaxis could be 7. All Category II exposures on head and considered for higher risk of injuries neck area Categories of Rabies Exposure with Corresponding Management : Management : Wash the wound with soap and water. Category I : Start the vaccine regimen. 1. Feeding/touching an animal Complete vaccination regimen until day 2. Licking of intact skin (with reliable history 7 regardless of the status of the biting and thorough physical examination) animal 3. Exposure to patient with signs and Administer RIG immediately after the symptoms of rabies by sharing of eating vaccination against rabies. or drinking utensils Post Exposure Prophylaxis under Special : 4. Casual contact (talking to, visiting and Consideration : feeding suspected rabies cases) and 1. Pregnancy and infancy shall NOT be routine delivery of health care to patient contraindications to treatment with with signs and symptoms of rabies purified cell culture vaccines (PVRV, Management : PCECV) and RIG. Wash exposed skin immediately with soap and water. 2. Babies who are born of rabid mothers shall No vaccine or RIG needed. be given rabies vaccination as well as RIG Pre-exposure prophylaxis may be as early as possible at birth. considered for high-risk persons. 3. Patients with hematologic conditions Category II : where IM injection is contraindicated shall 1. Nibbling of uncovered skin with ot without receive rabies vaccine by ID route. bruising/hematoma 4. Patients with chronic liver disease and 2. Minor/superficial scratches/abrasions without bleeding, including those those taking chloroquine, and systemic induced to bleed steroids shall be given standard IM. 3. All Category II exposures on the head 5. Immunocompromised individuals (such as and neck area are considered Category those with HIV infection, cancer/transplant III and shall be managed as such. patients, patients on immunosuppressive Management : therapy etc.) shall be given vaccine using Wash wounds immediately with soap and water for at least 10 minutes. standard IM regimen and RIG for both Start the vaccine immediately. Category II and III exposures. Complete vaccination regimen until day 6. Exposed persons who present for 7. evaluation or treatment weeks or months No RIG needed. after the bite shall be treated as if Category III : exposure has occurred recently. 1. Transdermal bites (puncture wounds, 7. Changes in the human rabies vaccine lacerations, avulsions) or scratches/abrasions with spontaneous product and/or the route during the same bleeding. PEP course are acceptable. Restarting PEP 2. Licks on broken skin or mucous is not necessary. membrane 8. Bites by rodents, guinea pigs and rabbits 3. Exposure to a rabies patient through bites, shall not require rabies post- exposure contamination of mucous membranes prophylaxis. (eyes, oral/nasal mucosa, genital/anal mucous membrane) or open skin lesions  9. Bites by domestic animals (dog, cat) and National Rabies and Control Program : livestock (cows, pigs, horses, goats, etc) as R.A. 9482 (The Anti-Rabies Act of 2007) well as wild animals (bats, monkeys, etc) Mass Dog Vaccination shall require PEP. Health Promotion Immunization : ○ Significant activities in the Active Immunization : conducting the information and Administration - Vaccine is administered to education campaign on the induce antibody and T-cell production in prevention and control of rabies. order to neutralize the rabies virus in the Celebration of Rabies Awareness Month body. under Executive Order No. 84 It induces an active immune response in March is Rabies Awareness Month 7-10 days after vaccination, which may Celebration of World Rabies Day - persist for years provided that primary September 28 has been declared as immunization is completed World Rabies Day. Development of IEC Materials - All agencies involved in the implementation of the program are encouraged to conceptualize, produce/reproduce and distribute IEC materials and collaterals. Massive Health Information Campaign Passive Immunization : using Tri-Media Rabies immune globulins or RIG (also Integration of Rabies Program into the called passive immunization products) School Curriculum - collaborative effort of shall be given in combination with rabies DOH and DepEd to educate school vaccine to provide the immediate children who are the most vulnerable to availability of neutralizing antibodies at the animal bites. site of the exposure before it is Prevention and Control of Human Rabies : physiologically possible for the patient to 4 R's in Animal Rabies Risk Assessment begin producing his or her own antibodies 1. Recognizing : after vaccination. possibility of rabies virus transmission and This is especially important for patients recognize the clinical signs of rabies in with Category III exposures. RIGs have a domestic animals half-life of approximately 21 days. 2. Recording : Record information in a manner that is accurate, complete, consistent and legible. 3. Reporting : Classified by the PIDSR as Category 1 or immediately notifiable disease, rabies should be reported within 24 hours after a case is suspected to be one. 4. Referral : Caution and careful decision must be observed at all times when referring a rabies patient to another facility. ○ The patient's detailed history must be recorded at the receiving facility, while  a copy should be provided at the Site Intradermal Schedule referral facility. Day of PVRV/ Site of Injection ○ For the referral facility, it is necessary Immuni PCEV that its staff has the training to handle zation Day 0 0.1 ml Left and right deltoids or suspected rabies cases and the anterolateral thighs in infants knowledge on the other procedures, Day 3 0.1 ml Left and right deltoids or especially laboratory anterolateral thighs in infants expertise/capabilities to confirm Day 7 0.1 ml Left and right deltoids or whether the case is rabies or not. anterolateral thighs in infants Routine Wound Management : Day 28 0.1 ml Left and right deltoids or The most common organism isolated from anterolateral thighs in infants dog and cat bites is Pasteurellamultocida. Other organisms include S. aureus, For WHO prequalified vaccines, the day 28 dose Bacteroidessp, Fusobacterium and may be omitted following the IPC Institute Pasteur Capnocytophaga. Antimicrobials shall be Du Cambridge (IPC) intradermal regimen recommended for the following (2-2-2-0-0). conditions: ○ All frankly infected wound Alternative Intramuscular Regimens approved by ○ All category III cat bites WHO ○ All category bites that are either deep Zagreb Regimen Schedule (2-0-1-0-1) and penetrating Intramuscular Schedule Vaccination : Day of PVRV PCEV Site of Injection Immuni General Principles : zation Storage : Day 0 0.5 1.0 Left and right deltoids or Vaccines shall be stored at +2 to + 8 °C in ml ml anterolateral thighs in a refrigerator, not freezer. infants Once reconstituted, vaccines shall be Day 7 0.5 1.0 One deltoid or kept in the refrigerator and used within 8 ml ml anterolateral thigh in hours. infants Administration Area : Day 21 0.5 1.0 One deltoid or ml ml anterolateral thigh in Injections shall be given on the deltoid infants area of each arm in adults or at the anterolateral aspect of the thigh in infants. Shortened Intramuscular Schedule (CDC) Vaccine shall never be injected in the (1-1-1-1-0) gluteal area as absorption is unpredictable Day of PVRV PCEV Site of Injection Treatment Regimen Schedule : Immuni 1. Updated 2-Site Intradermal Schedule zation (2-2-2-2-0) Day 0 0.5 1.0 One deltoid or One dose for ID administration is ml ml anterolateral thigh in equivalent to 0.1 ml for PVRV and PCECV infants One dose shall be given on each deltoid Day 3 0.5 1.0 One deltoid or ml ml anterolateral thigh in on Days 0, 3, and 7 infants One intradermal dose should have at least Day 7 0.5 1.0 One deltoid or 0.5 IU vaccine potency ml ml anterolateral thigh in  infants Day 14 0.5 1.0 One deltoid or ml mll anterolateral thigh in infants Surveillance of Animal Rabies : Surveillance of canine rabies and submission of laboratory reports of suspected cases is essential for management of potential human exposures and for veterinarians to adopt appropriate measures towards animals who were in contact with the suspected animal case. Hemodialysis : ❖ normal GFR = 60 to 90 Hemodialysis is the removal of body ❖ pitting plus CKD do not elevate wastes or metabolites ( Creatinine lUrea ❖ elevate if not pitting and ,excess water & electrolytes , poisons) in Gastrointestinal - Enteric edema, dec. the blood stream using the dialysis absorption ,dec. Bowel function, ascites, machine. hepatic compartment syndrome Indications for hemodialysis : Studies : on Fluid overload : 1. Excessive electrolytes - : Fluid overload - an increase in body Hyperkalemia ( above 6.5 mEq/L can cause weight of over 10 % can cause respiratory life threatening arrhythmias or weakness or failure (Del Granado& Mehta 2016). paralysis hence the need for urgent hemodialysis High incidence of hypoalbuminemia and an increased capillary permeability, systemic inflammation and endothelial dysfunction are related to extracellular fluid overload (FO). Dekker et.al.,2018 ) 3. Severe acidosis : PH- below 7.2 ; NaHco3 below 12 Gross imbalance in sodium bicarbonate from acute kidney injury or failure that can cause severe metabolic acidosis affecting many vital functions 2. Fluid overload : cardiovascular system -causes arterial especially those unresponsive to diuretics dilatation with hypotension, decreased from acute or chronic kidney failure can arterial oxygen tension , oxygen delivery & threaten major systems in the body. predisposition to arrhythmias Respiratory effects : Pulmonary edema endocrine effects - causing Insulin ,pleural effusion ,SOB difficult weaning resistance Bat wing edema in a 71-year-old woman CNS - leading to seizures and impairment with fluid overload and cardiac failure of the immune response 4. Ingestion of toxic doses of drugs and poisons B-Barbiturates: serum level more than 30 mg /l ( less than 10 mg/dl) L- Lithium: serum levels greater than 4.0 mmol/l (0.6 to 1.2 mEq/L.) I- Isoniazid- more than >20 ug/ml S-Salicylates: 250 mg/kg can lead to moderate toxicity 500 mg/kg is a severe toxicity - fatal to the patient. T- Theophyline/Caffeine (both are CNS -cerebral edema ,inc. ICP causing methylxanthines) impaired cognition , delirium M- Methanol: > 300 mg/dl or > 65 mmol/L Cardiovascular :conduction disturbances, (SI units( N-0-50 mg/dl or 0%-0.05% myocardial edema, pericardial effusion - ○ Metformin- more than 5 mcg/ml ( CHF N-less than 1 mg/dl) Renal - renal interstitial edema, dec. GFR ( E-Ethylene glycol: >20 mg/dL is toxic less than 30 %) urine output is less than 400ml. /24 hours, inc. salt & water retention  D-Depakote more than 100 mcg /ml(50-100 mcg/MI), Others - Carbamazepine - more than 4.ug/ml ( N= 0.5 - 4.0 ug/ml) Signs of Uremia : abnormally high levels of waste products especially urea and creatinine in the blood due to kidney failure causes Central Venous Access Device (CVC) : intractable nausea and vomiting ;progressive decline in alertness ;cause confusion, stupor or coma Creatinine level : more than 4 mg/dl ( N =0.5-1.3 mg/dl) CBC : Hgb is 8g/dl or below , high reticulocyte count and LDH, low haptoglobin level as well as fragmented RBC 's and schistocytes on peripheral blood smear (PBS); causes coagulation problems and Care of the Intrajugular catheter / central venous bleeding. access device : Patient preparation for dialysis : Inspect the insertion site. Look for any signs a. Informed Consent : of infection (e.g. redness, swelling or pain). the patient is explained the need and Ensure an occlusive dressing is intact to justification for the dialysis reduce risk of infection. Identify how many Rationale : This is an invasive procedure lumens are present. that is needed to extend his life when the Ensure all intravenous lines are securely kidney is not functioning. This is costly as connected to the lumens the patient will have to do it regularly 2 -3 Measure the length of the line from the time per week with the need for regular skin to the first hub medications like Epoproetin to help ○ this clarifies how far the line is in the increase the production of red cells with vein and indicates any potential occasional blood transfusions. This can displacement. also have risks like disequilibrium syndrome Refer to hospital protocol if this is the case. ;infection with hepatitis and HIV and other Trace back each line to the infusion pump blood borne infections so the patient to ensure each medicine is connected to should be fully disclosed the right line. b. Creation of hemodialysis access : Ensure lines are labeled clearly at the site 1. Intrajugular or central line access : of the lumens, and the fluid bags containing the medications are also for temporary or emergency dialysis labeled correctly. Identify when each line Care for the intrajugular catheter/ central was last changed and label it accordingly. venous access device Follow hospital protocol. Possible complications of Central Catheters (ATS 2019; ACS 2016; McCarthy 2016; ACI 2013; ACI : 2014) : Infections, as catheters inserted into the body make it easier for bacteria from the skin to enter the bloodstream; Blood clots forming in the catheter; Pneumothorax (collapsed lung) caused by the needle accidentally piercing the lung during insertion; Air embolism caused by air entering the AV fistula care : bloodstream through the catheter. 1. Daily inspection for signs of infection or This occurs rarely but is a serious medical bleeding /hematoma emergency 2. No BP taking / blood extraction at arm Damage to the blood vessel; side of fistula Side effects caused by the incompatibility 3. Clean with antimicrobial soap and water. of medicines that are being administered 4. Instruct patient to avoid sleeping on hand together on one lumen; side with fistula Catheter fluid leak; 5. Assess /feel for bruits (signs that AV fistula is 2. Arterio -venous fistula : functioning properly.) 3. Arteriovenous graft : synthetic & elastic rubber tube connected to the vessels Post-Operative care of AVF or AVGs : Immediately following surgery (half-hourly at first). the site of AVF should be checked for: Excessive bleeding, haematoma, swelling, Indications for arteriovenous graft : pain and later signs of infection such as " for chronic dialysis clients who do not raised temperature. have adequate blood vessels for the Check radial pulse, color, movement, creation of a fistula warth, and sensitivity of affected limb to Procedure involves the anastomosis of the ensure blood flow reaches extremities graft to the artery, a tunneling under the (peripheral circulation). skin, and anastomosis to a vein. Mature AV fistula : Can be used 2 wks after insertion Mature fistula is about approximately 2 Complications: clotting aneurysms and weeks to 4 months infection Care for arteriovenous graft : Keep the dressing dry for the first 2 days Bathe or shower is allowed after the dressing is removed AVF may be damaged after repeated Look for signs of infection such as: fever cannulation with sharp needles. Be gentle ,pain and tenderness at site of implant Avoid putting pressure on the access area  No blood test extractions in the side of Videos : graft Setting up the machine No BP taking at side of graft ○ https://www.youtube.com/watch? Hemodialysis machine preparation and priming : v=9Onov2Z4LQ4 1. Before patient comes for dialysis , Patient Cannulation/ Connecting Patient check machine is properly cleaned and to the machine sterilized and calibrated. Use dedicated ○ https://www.youtube.com/watch? machines labeled for infectious v=Z_ZcDE-PTgl patients(i.e. Hepa B and HIV patients ) Initiation of dialysis treatment Breach of protocols resulted in Hepa C Patient Assessment for Dialysis : outbreaks in dialysis patients in the US( Check the following before sending patient to Mbaeyi & Thompson, 2013) hemodialysis 2.Aseptically assemble the blood lines & attach to 1. a.Vital signs : the saline priming solution. Connect dialyzer to : any hypotension , arrhythmias or chest the machine : pain; systemic problems like fever need to be addressed first before dialysis. Priming : 1. b. Check comorbidities : Turn on the enter mode /blood pump to many patients with kidney failure are prime the tubings and dialyzer as directed diabetics - blood glucose monitoring to to remove all the air adjust insulin is important to prevent hyper Testing HD machine : or hypoglycemia Run the machine test mode to check and Other common problems ( Charnow compare the specified doctors orders are ,2018) compatible with machine operations ○ Hypertension and cardiac disorders I.E - How many CC per minute is the cycle ○ Anemia ( 150 -200 ml per minute) ○ Hyperlipidemia How many hours is the cycle -(2-4 hours )- 2. Weight : depends on patient condition( vital signs , serves as basis for fluid removal laboratory results ) i. E - dry weight is 65 kilos ( Previous weight Contraindications for hemodialysis : on record after last dialysis when excess Significant cardiovascular insufficiency- fluid was taken out ) you weigh pt. now may cause further cardiac ischemia as and is 68 kilos.The expected order is to blood is being drawn out of the remove 3 liters intravascular system for filtration. 3. Check Lab results : a. Chemistry : higher levels of sodium, potassium, phosphorus, blood urea nitrogen, and creatinine. These are usually compared to post dialysis lab works b. CBC : if hemoglobin, and hematocrit levels are too low. anticipate receiving other orders- to give packed RBC c. Hepa screening : HBsAg / HIV test periodically 4.Check the AVF : 3. Monitor serum electrolytes, blood chemistries, a. Gently put fingertips or palm over the hematology studies patient's access site to feel the vibration or Potassium levels can be measured in the bruit. Report if no vibration ( could mean dialysate blockage or loss of function ). Assess the distal Fatigue -from anemia and electrolyte pulse after the graft. imbalances can be profound that can b. Note color of blood and/or obvious weaken capacity for ADLs separation of cells and serum. 4. Administer medications as ordered c. Palpate skin around shunt for warmth ie. Epoproetin ,Iron sucrose ( Venofer) d. Assess any bleeding , tenderness or swelling ,Calcium carbonate phosphate binder ), ,pain or discharges or coldness distal to fistula. antiarrhythmics (as required) Insulin if Report if any of these as they need to be diabetic managed first 5. Maintain cannula alignment to prevent 5. Check Medications : needle / sharp injury during dialysis , Limit all antihypertensive drugs should be activity of extremity withheld before hemodialysis 6. Assess patient frequently for pain/discomfort antiarrhythmic medications are given as Nausea & vomiting - from high metabolic scheduled due to the high incidence of wastes or sudden reduction of fluid patients developing arrhythmias during volume hemodialysis Muscle cramps - sudden fluid removal water-soluble vitamins pass through the includes electrolytes check for dialyzer so they should also be held before hypokalemia treatments.( Pipracillin , Vit D) Restless leg syndrome - from uremic Insulin doses are adjusted -Intravenous neuropathy and low iron warm packs may insulin adjusted every 30 minutes to an help hour achieve 5.5 t 1.1-mmol/L ( Barclay 7. Notify the physician if any sign of bleeding, 2010) severe abdominal pain and respiratory distress Studies found that : ( Heparin is added to the blood to prevent medication error, other medication errors clotting) Apply enough pressure to access site after during hemodialysis administration tubings are removed from access site involved heparin infusion mistakes, Complications of hemodialysis : inadequate handoff of information about 1. Cardiovascular complications : patients medications during transitions a. Intradialytic hypotension : between the hemodialysis unit and other care areas, and miscommunication of 24 to 44 % of patients (Andrulli et al.,2002); medication orders. Kliger Emili et.al (1999), IDH was found in 608 (2014),https://cjasn.asnjournals.org/ (24%) of 2559 dialysis Higher among patients history of : Intra dialysis care : ○ Left ventricular hypertrophy 1. Maintain aseptic techniques during pricking ○ Diastolic dysfunction or entry to AVF access ○ Arrhythmias Infection is a complication of hemodialysis ○ Pericardial tamponade 2. Monitor vital signs every 15 min initially and ○ Autonomic neuropathy subsequently at hourly intervals. ( Many b. Ventricular arrhythmias and ectopics : patients may go hypotensive during dialysis) prevalence of 35 % Support lower extremities ( decreases hypotension and promote comfort) c. Chest pain : Other studies found also release of from ischemia ;( Sudden death in rare inflammatory cytokines and other cases) inflammatory chemicals that cause the 2. Complications associated with use of : brain to swell (cerebral edema) anticoagulant therapy : Occur in ARF or CRF if blood urea levels a. Heparin associated thrombocytopenia - are reduced too fast, in those with very heparin administration stimulates marked uremia, or pre-existing alterations antibodies that binds to platelets factor 4 in mental state to increase the clearance of platelets Manifestations : b. Bleeding diathesis : headache, nausea, disorientation, 3. Infection : restlessness blurred vision, asterixis, fits, a. Blood borne infections can be transmitted : coma hepatitis B/C/D/E even death, occurring during or after b. Dialysis pericarditis, endocarditis : dialysis Endocarditis -S.aureus, 20%, poor Milder symptoms prognosis, ageing + valve calcification( ○ cramps, nausea, dizziness Epomedicine,2016://epomedicine.com/m Management of disequilibrium syndrome : edical students/complications-of Stop dialysis long-term-dialysis/) Support ABCs if with seizures 4.Catheter clotting : Administer hypertonic saline including 5.Central venous thrombosis : mannitol to raise blood osmolality 6.AVF aneurysm : Application of ventilation to hyperventilate Ischemia of affected limb ( from the patient - reduces cerebral edema ( thrombosis in AVF) Connect to mech vent if unconscious) Hemorrhage related to accidental Prevention of disequilibrium syndrome : disconnection Slow dialysis / filtration 7. Nutritional deficiencies : Administer mannitol or glucose to prevent Hemodialysis patients have higher levels of drastic alteration in osmolarity CRP, inflammation, oxidative stress and mannitol is given via push because increased protein muscle breakdown immediate administration allows it to go when compared to other patients. through the blood brain barrier, to prevent (lorember,2018). crystallization and faster absorption. ○ low Na Potassium Low phosphorus Post dialysis Nursing Care & Responsibilities : 8. Disequilibrium syndrome : 1. Monitor vital signs : Etiology report hypotension , any chest pain the rapid correction of the high BUN or dizziness uremic signs and hyperosmolar state 2.Take weight after dialysis : during dialysis. ( May occur in first time reflects how much fluid was taken out dialysis ) during the dialysis 80 the blood osmolarity falls faster than the 3.Assess the access site : cerebrospinal fluid that leads to fluid shift Early detection and treatment can from intravascular compartment to the prevent life-threatening hemorrhaging cerebrospinal fluid compartment causing that could result from heparin used during cerebral edema and raised intracranial treatments pressure leading to neurologic Lower GI bleeding in ESRD : manifestations especially among those ESRD patients account for 19-32% of LGI with acute kidney injury bleeds in those with chronic kidney  disease compared with 5-6% of LGI bleeds in the general population ( Saaed ,et.al. 2011) https://doi.org/10.4061/2011/272535 4. Administer the medications that were held : before sending your patient to hemodialysis. 5. Monitor for elevations in temperature and white blood cell count : blood stream infections can be serious and costly Infections in Dialysis Patients : Bloodstream infections are a serious complication of dialysis 1 in 4 patients who get a bloodstream infection caused by S. aureus (staph) bacteria can face complications such as: ○ Endocarditis (infected heart valve) ○ Osteomyelitis (infected bone) Total costs for each infection can be more than $20,000 Bloodstream infections can cause sepsis (a potentially deadly condition) Up to 1 in 5 patients with an infection die within 12 weeks 6. Check next ordered labs to be collected and : check for the results. should be done only after the patient has stabilized, which is usually within 2 to 4 hours after treatment. 7. Monitor your patient closely for signs : of:confusion, decreased level of consciousness , and sudden severe headaches : potentially life-threatening complications if it is disequilibrium syndrome and must be reported immediately.) 8. Diet : Reinforce about fluid restrictions- patients will be on 1 L fluid restriction Renal diet -limit Potassium, sodium, phosphorus Toxicology : Organophosphates tend to be more toxic Toxicologic emergencies require you to due to the "ageing" process. think critically to identify the substances ○ Ageing is the irreversible loss of an alkyl involved. side chain which results in irreversible ○ Formulate your treatment based on permanent binding to AChE. Once the anticipated clinical course of your "ageing" has occurred AChE can not patient be reactivated by the antidote Types of Toxicologic Emergencies : pralidoxime. Time for ageing occurs is Intentional : variable between agents Suicide SIGNS AND SYMPTOMS (cholinergic syndrome) : Criminal activities DUMBBELS mnemonic : Involved in chemical Diarrhea warfare Urination Unintentional : Miosis Can occur in many ways Bronchorrhea Common in children who mistakenly put Bradycardia poison in their mouths Emesis Can occur in the workplace Lacrimation Organophosphate Poisoning : Salivation Organophosphates SLUDGEM mnemonic : ○ Classified as acetylcholinesterase salivation, lacrimation, urination, inhibitors defecation, emesis A major component in many insecticides ○ Include:Acephate, Diazinon, In moderate to severe organophosphate Malathion, Carbamates, Nerve agents poisoning it could result to: Common exposure causes: ○ Muscle fasciculations ○ Suicide, typically ingestions ○ Severe respiratory distress ○ Accidental agricultural exposure ○ Seizures ○ Manufacturing ○ Flaccid paralysis Risk factors : In children any ingestion is potentially insecticides/fertilizers life-threatening. surface and room sprays Patient Assessment of Organophosphate : baits for cockroaches Poisoning : shampoos against head lice Scene safety is paramount pet preparations Look for clues such as pill bottles, crop protection and livestock dipping household cleaners, or handwritten notes fumigation and unpleasant or odd odor.. nerve agents (sarin) Patients who have taken an overdose Pathophysiology : may be dangerous Organophosphates exert their effects at Call for law enforcement or a crisis unit if junctions of the nerve cells of the necessary. autonomic nervous system. Primary Survey : ○ It inhibits acetylcholinesterase (AChE) Begins with a general impression. enzymes and increases acetylcholine Do not be fooled into thinking that a concentration at both muscarinic and conscious, alert, and oriented patient is in nicotinic cholinergic receptors. stable condition. Identify any life threats. Emergency Medical Care of Organophosphate Airway and breathing. poisoning : Ensure that the patient has an open Ensure scene safety. airway and adequate ventilation. ○ Take standard precautions. Do not hesitate to begin oxygen therapy. ○ Contact Poison Control if possible Patient's circulatory status : ○ Decontaminate before initiating care Assess the pulse and skin condition. Remove poison fragments from the Check for bleeding. patient's mouth. Assess for disability. Wash or brush the poison from the Alterations in ABCDEs or poor general impression patient's skin. require immediate management. Establish and maintain the airway. Consider decontamination of the patient Suction as needed before providing intervention depending Administer high-flow oxygen to maintain on the poison. SpO2 of 94% History Taking : Emergency Medical Care of Organophosphate : Use PQRST and SAMPLE history Establish vascular access. Ask the following: Administer atropine 1.0 mg IV push every ○ What is the substance? 3-5 minutes until symptom reversal occurs ○ When was it ingested, injected, ○ Antagonizes acetylcholine absorbed, or inhaled? ○ Treats bradycardia, hypotension and ○ How much was taken, injected, secretion production absorbed, or inhaled? Administer pralidoxime 2 grams in 100 ml ○ What else was taken? of 0.9% saline IV over 15 minutes ○ Has the patient vomited or aspirated? ○ Used to reactivate cholinesterase ○ Why was the substance taken? ○ Rapid administration can cause Secondary Assessment : laryngospasm Patients may have alterations in mental Administer benzodiazepines such as status and be prone to nausea and Diazepam, Lorazepam or Midazolam to vomiting treat seizures. For trauma, perform the appropriate Administer activated charcoal within 1-2 trauma assessment based on whether the hours.e patient has a significant MOl Perform gastrointestinal decontamination Apply the ECG monitor, pulse oximeter, ACTIVATED CHARCOAL : and capnometer (ETCO2) Decontamination agent Monitor Vital signs It is activated by an oxidizing gas flow to Reassessment : the carbonaceous matter (coconut, Reassess the adequacy of the ABCDEs. pulverized peat or sawdust) at 600-900 Retake vital signs and compare with degree Celsius passed over its surface to baseline set. make a fine network of pores Evaluate your interventions Mechanism of Action : Repeat the assessment of vital signs. Reduces the amount of medication being ○ Every 15 minutes for stable patient absorbed by the body by binding the drug ○ Every 5 minutes or more for patient to its surface (adsorption) who has consumed a harmful or lethal Frequently suspended with sorbitol (acts as dose sweetener and laxative) INDICATIONS : CONTRAINDICATIONS : give if the toxic agent is still within the Gl Ingestion of corrosive substances (acids or tract (within 1 hour) and potential benefits alkalis) outweigh risks. Esophageal disease useful in overdose from: Presentation many hours after ingested ○ aspirin poisoning ○ paracetamol Equipment. ○ barbiturates ○ TCA'S ○ digoxin ○ amphetamines ○ morphine ○ cocaine ○ Phenothiazines CONTRAINDICATIONS : Patients who: Technique : Have ingested an acid, an alkali, or a 1. Place patient in left lateral decubitus position petroleum product with head 20 degrees downward Have a decreased level of consciousness 2. Insert the NGT after proper sizing (NEX) and cannot protect their airway Adults and adolescents: 36-40 French Are unable to swallow Children: 22-28 French Dose : 3. Using funnel or lavage syringe, aspirate any 1 g of activated charcoal per kilogram of stomach contents body weight 4. Gently instill 200 - 300 mL warned saline into ○ Adult 50 - 100 g the stomach for adults, or 10 - 15 mL/kg for ○ Children 25 -50g children (to maximum 250 mL) ○ Infant 10 - 25 g 5. Allow instilled saline to flow out of tube and Side effects of activated charcoal : into bucket below the level of the stomach Black stools (siphon phenomenon) Nausea and vomiting 6. Repeat instillation and drainage until effluent Possible airway problems is clear GASTRIC LAVAGE : 7. Once effluent is clear, may instill activated A decontamination technique that aims charcoal (1 g/kg)if indicated to empty the stomach of toxic substances by the sequential administration and aspiration of small volumes of fluid via an orogastric tube. ○ Previously widely favored method but is no longer used as a routine decontamination methods in toxicology due to lack of evidence of efficacy and risk of complications INDICATIONS : Ingestion of lethal doses of drugs or substances such as organophosphates within 4 hours. COMPLICATIONS : Aspiration of gastric contents Esophageal rupture/ perforation of GIT Electrolyte imbalance Hypохia Laryngospasm Hypothermia Profound bradycardia, cardiac arrest, and asystole may be precipitated by lavage in poisonings with beta blockers, calcium channel blockers and other drugs affecting cardiac conduction. POISONING : 2. INGESTED : FACTS AND FIGURES : Corrosive poisons: alkaline and acid POISON: is any substance which when agents that can cause tissue destruction ingested, inhaled, absorbed, applied to when in contact with mucous membranes the skin, or produced within the body ALKALINE POISONS: dye, drain cleaners, injures the body by its chemical action toilet bowl cleaners, bleach, non - ANTIDOTE: is any chemical physiologic phosphate detergents, oven cleaners, antagonist that neutralizes poison button batteries GOALS : ACID POISONS: toilet bowl cleaners, pool To remove or inactivate the poison before cleaners, metal cleaners, rust removers, it is absorbed battery acid To provide supportive care in maintaining MANIFESTATION : vital organ systems administer a specific burning pain in mouth or throat antidote to difficulty swallowing To neutralize a specific poison vomiting To implement treatment that hastens the drooling elimination of the poison respiratory distress MECHANISM : altered LOC 1. INHALED : MANAGEMENT : Carbon Monoxide poisoning ABC's results from industrial household incidents, Close monitoring of ECG /VS, neuro status or attempted suicide binds to hemoglobin IFC insertion decreasing its capacity to carry oxygen Assess: affinity is 230-270x ○ what substance was taken, MANIFESTATION : ○ Amount VITAL SIGNS: tachycardia, hypotension, ○ time of ingestion hyperthermia, marked tachypnea ○ evidence of redness or burns in mouth SKIN: progress from pink, cherry red, then or throat pallor ○ pain on swallowing, drooling, age OPHTHALMOLOGIC: bright red retinal veins, Obtain blood and urine test for toxicology papilledema, homonymous hemianopsia Monitor T & E imbalance NEUROLOGIC/NEUROPSYCHIATRIC: If corrosive: give milk or water to dilute memory disturbance, emotional lability, Initiate large-bore IV impaired judgment, decreased cognition, O2 for respiratory depression stupor, coma, gait disturbances, Monitor and treat shock movement disorders, rigidity Prevent aspiration by positioning, airway, MANAGEMENT : suctioning carry client to fresh air Support patients with seizures open all doors and windows Monitor and treat for complications loosen tight clothing and do CPR prn hypotension, coma, cardiac dysrhythmia, prevent chilling seizures keep client calm and quiet Promote gastric emptying through: 100% oxygen until carboxyhemoglobin is ○ syrup of ipecac - w/in 30 mins of less than 5% ingestion (Adult=30 ml + 2 glasses hyperbaric chamber water; Child=15ml + 8-16 oz) ○ cathartic  administration of antidote (chemical or Lithium Carbonate Mannitol physiologic antagonist that neutralizes a poison) Benzodiazepines Flumazenil Hemoperfusion (process of passing blood 3. CONTACT : through an extracorporeal circuit and exposure or injuries from exposure to cartridge containing an adsorbent) chemicals Hemodialysis Severity depends on: Analgesics for pain ○ mechanism of action If it was a suicide attempt; psychological ○ Penetrating strength and consult concentration Poison proofing ○ amount and duration of exposure FOOD POISONS : to the chemical ingestion of contaminated food or drink is MANAGEMENT : Botulism is the serious form if chemical is dry, brush off substance MANAGEMENT : before flushing identify the type and source of food Drench skin immediately with running sample should be brought in for analysis water- hose, shower food, gastric contents, and feces are constant stream of water as patient collected for exam removes clothes neuro check, V/S, muscular activity identify the chemical monitored antibiotics assess for F and E imbalance, antiemetic tetanus shot if mild, let client take weak tea, debridement carbonated drinks 4. INJECTED : Poison and Antidotes : venom allergy, IgE mediated response Poison Antidotes Hymenoptera (bees, hornets, yellow jackets fire ants, wasps) Acetaminophen N-Acetylycysteine MANIFESTATION : Generalize urticaria Calcium Channel Calcium Blocker itching Malaise Carbon monoxide Oxygen Nausea, vomiting, diarrhea, Coumadin Vitamin K Drowsiness Seizures Iron Deferoxamine Anxiety due to laryngeal edema bronchospasm Isonicotinic acid Pyridoxine hydrazide (Isoniazid) shock death MANAGEMENT : Methanol Ethanol removal of stinger wound care, wash with soap and water Opiates/Narcotics Naloxone avoid scratching Organophosphates Atropine Sulfate, ice application Pralidoxime oral antihistamine and analgesic Epinephrine for severe / anaphylactic Tricyclic Physostigmine antidepressants reaction encourage desensitization therapy  prevent exposure to stinging insects may also cause hemolysis, hemorrhage avoid perfumes, scented soaps, bright and local tissue destruction colors SIGNS AND SYMPTOMS : A.FIRE ANTS (SOLENOPSIS INVICTA) : severe and immediate pain Ant bites with its mandibles then stings with erythema and swelling its venom apparatus in its hindquarters tachycardia SIGNS AND SYMPTOMS : increased secretions immediate burning pain locally fasciculations becomes a sterile pustule in 6 hrs nausea and vomiting with multiple stings in sensitized individuals blurred vision nausea, sweating, dizziness dysphagia Anaphylaxis roving eye movements TREATMENT : opisthotonos ABC’s respiratory failure Local cleansing syncope Anesthesia Death Ice TREATMENT : For systematic reactions: treat as for bee ABC'S sting Sedation with benzodiazepines B. BLACK WIDOW SPIDER : No opiates- may potentiate venom venom is a neurotoxin Tetanus prophylaxis identified by a red-orange hourglass on Local wound care the abdomen Antivenin- unlicensed female is 2x size of male, has design, the D. MARINE LIFE TRAUMA AND ENVENOMATION : only one that can envenomate humans stingrays SIGNS AND SYMPTOMS : starfish local pinprick sensation, red, swollen scorpion fish slow progression of painful muscle spasm sea urchin of large groups catfish lasts a few hrs, resolves spontaneously lionfish hypertension cone shell shock NEMATOCYSTS respiratory failure ○ microscopic "spring-loaded" coma and death venom gland, discharged by TREATMENT : physical contact or osmotic pain control, muscle relaxants (narcotics, gradient benzodiazepines) ○ gland found on tentacles tetanus contracts when touched, striking local wound care repetitively,