Immunity, Shock, and Ulcers Notes

Immunity Murtadha khadhm What is immunity ? the immune system's way of protecting the body against an infectious disease. The three types of immunity are innate, adaptive, and passive. Innate immunity Innate, or nonspecific, immunity is the defense system with which you were born. It protects yo...

Immunity Murtadha khadhm What is immunity ? the immune system's way of protecting the body against an infectious disease. The three types of immunity are innate, adaptive, and passive. Innate immunity Innate, or nonspecific, immunity is the defense system with which you were born. It protects you against all antigens. Innate immunity involves barriers that keep harmful materials from entering your body. These barriers form the first line of defense in the immune response.. Adaptive immunity Adaptive immunity involves specialized immune cells and antibodies that attack and destroy foreign invaders and are able to prevent disease in the future by remembering what those substances look like and mounting a new immune response. Passive immunity Passive Immunity. Passive immunity is provided when a person is given antibodies to a disease rather than producing them through his or her own immune system Surgery Shock Dr.Murtdha khadim jwad Sugery What is Shock? is a systemic state of low tissue perfusion, which is inadequate for normal cellular respiration. Imbalance between oxygen delivery and oxygen consumption which leads to: •cell death, •end organ damage, •multi-system organ failure, and death Surgery The most common cause & most important cause of death in surgical pts. Death may occur: –Rapidly : due to profound state of shock –Delayed : due to organ ischemia or reperfusion injury Inadequate tissue perfusion can result in: o generalized cellular hypoxia o widespread impairment of cellular metabolism o Tissue damage organ failure . o death . Clinical Presentation: Generalized Shock Vital signs Hypotensive: (may be WNL or due to compensatory mechanism) < 90 mmHg MAP < 60 mmHg Tachycardia: Weak and Thready pulse Tachypneic : blow off CO2 Respiratory alkalosis Clinical Presentation: Generalized Shock Mental status: (LOC) restless, irritable, apprehensive unresponsive Decreased Urine output < 30ml / hr TYPES OF SHOCK SYNDROMES Hypovolemic Shock : blood VOLUME problem Cardiogenic Shock : blood PUMP problem Distributive Shock [septic;anaphylactic;neurogenic] blood VESSEL problem Clinical Presentation Hypovolemic Shock Tachycardia and tachypnea Weak, thready pulses Hypotension Skin cool & clammy Mental status changes Decreased urine output: dark & concentrated Initial Management Hypovolemic Shock Restore circulating volume, tissue perfusion, & correct cause: Early Recognition- Do not relay on BP! Control hemorrhage Restore circulating volume Optimize oxygen delivery Vasoconstrictor if BP still low after volume loading Sinus & fistula Dr.murtadha kadhim Sinus Def: Blind ending tract lined by granulation tissue leading from an epithelial surface down into the tissues. Causes Congenital • Preauricular sinus • Umbilical • Coccygeal • Sacral Acquired • TB sinus • Pilonidal sinus • Median mental sinus • Actinomycosis Fistula Def: A fistula is an abnormal communication between two epithelium lined surfaces. This communication or tract may be lined by granulation tissue Types/Classification Congenital: • Branchial • Tracheoesophageal • Umbilical Acquired: •Fistula in ano. •Enterocutaneous fistula. •Aretriovenous fistula. Causes for persistence of sinus (or) fistula 1.Presence of a foreign body. e.g., suture material 2.Presence of necrotic tissue e.g.,sequestrum 3.Epithelialisation (or) endothelisation of the track. 4.Malignancy. 5.Irradiation 6.Malnutrition 7.Specific causes. e.g., DM,TB, actinomycosis 8.Ischemia 9.Drugs. e.g., steroids C/F: Usually asymptomatic, but when infected manifest as1.Recurrent/ persistent discharge. 2. Pain. 3. Constitutional symptoms Clinical examination: Inspection: Site, number, discharge, surrounding skin Palpation: Temperature, tenderness, Discharge, Induration, Fixity Iymph nodes Treatment principle 1. Antibiotics. 2. Adequate rest. 3. Adequate excision. 4. Adequate drainage. Ulcer Dr.murtadha kadhim Ulcer: is a dissolution of the continuity of an epithelium How to take History about ulcer 1-Duration of ulcer 2-When it first noted ? 3-what is the first symptom of ulcer ? 4- progression of ulcer ? Increase in size or decrease ? 5- other symptoms ? 6-Is the ulcer persist ?or disappear ? 8-ask patient what do you think about the cause? In rural area bite of sand flies lead to leishmaniasis ... Etiological classification • Traumatic ulcers • Vascular ulcers • Neoplastic ulcers • Ulcers due to malnutrition • Inflammatory ulcers • Infective ulcers O Miscellaneous ulcer Examination of ulcer 1- depth of ulcer Deep (about 1cm) 2- base of ulcer (contain what ?? Granulation tissue or pus or slough material ) > Serous ? (occure in healing ulcer ) Slough (dead material mostly in ischemia ) 3-Discharge? Serosagenous (infection ) - Pus (infection and mostly bacterial 1- Sloping The ulcer is shallow & the epithelium is growing in from the edge in an attempt to heal 2- Punched-out or square cut: It results from rapid death & loss of the whole thickness of the skin with minimal attempt of healing 3- Undermined edge When infection is affecting the subcutaneous tissue more than the skin, the edge becomes undermined 4- Rolled Develops when there is slow growth of tissue in the edge of the ulcer 5- Everted edge Develops when the tissue in the edge of the ulcer is growing quickly and spilling out of the ulcer to overlap the normal skin. This edge is typical of carcinoma at any site Surgery Shock 3 Dr.Murtdha khadim jwad Sugery Vasogenic/Distributive Shock Etiologies : ●Septic Shock (Most Common) ●Anaphylactic Shock ●Neurogenic Shock Surgery Anaphylactic Shock ●A type of distributive shock that results from widespread systemic allergic reaction to an antigen ●This hypersensitive reaction is LIFE THREATENING Pathophysiology Anaphylactic Shock Antigen exposure body stimulated to produce IgE antibodies specific to antigen drugs, bites, contrast, blood, foods, vaccines Reexposure to antigen IgE binds to mast cells and basophils Anaphylactic response Clinical Presentation ●Almost immediate response to inciting antigen ●Cutaneous manifestations urticaria, erythema, pruritis, angioedema ●Respiratory compromise stridor, wheezing, resp. distress ●Circulatory collapse tachycardia, vasodilation, hypotension Managment Anaphylactic Response Vasodilatation ● ●Increased vascular permeability ●Bronchoconstriction ●Increased mucus production ●Increased inflammatory mediators recruitment to sites of antigen interaction Managment Anaphylactic Shock ●Early Recognition, treat aggressively ●AIRWAY SUPPORT ●IV EPINEPHRINE (open airways) ●Antihistamines ●Corticosteroids ●IMMEDIATE WITHDRAWAL OF ANTIGEN IF POSSIBLE ●PREVENTION Septic shock SEPSIS + Hypotension despite adequate fluid resuscitation Hypotension SBP < 90 or > 40 reduction from baseline Clinical Manifestations ●EARLY---HYPERDYNAMIC STATE---COMPENSATION ➢Pink, warm, flushed skin ➢Increased Heart Rate ➢Tachypnea ➢Massive vasodilation ➢Increased CO ➢Crackles Clinical Manifestations Late hypodynamic state ---- decompansation: ➢Vasoconistriction ➢Skin is pale & cold ➢Tachycardia ➢Decrease BP ➢Change LOC Managment Prevention !!! Find and kill the source of the infection Fluid Resuscitation Vasoconstrictors Inotropic drugs Maximize O2 delivery Support Nutritional Support Comfort & Emotional support Surgery Shock 2 Dr.Murtdha khadim jwad Sugery CAROIOGENIC SHOCK The impaired ability of the heart to pump blood Pump failure of the right or left ventricle. Mortality rate of 80 % or MORE Surgery Symptoms Poor appetite. increased work of breathing. exercise. intolerance. fatigue. lethargy. altered mental status. poor urine output. Vital signs Tachycardia, arrhythmia, heart block tachypnea hypotension Managment Emergency treatments may include delivering enriched oxygen via a tube or mask; breathing assistance, using a ventilator; and intravenous (IV) fluids and medications to support blood pressure or heart function. Depending on the cause of cardiogenic shock, an array of drugs may be used as part of treatment. Fluids By : Dr.Murtadha khadhum I Fluids imbalances • Isotonic loss of water and electrolytes = Hypovolaemia. • Isotonic gain of water and electrolytes = Hypervolaemia. • Hyperosmlar loss of only water = Dehydration Fluids calculation • According to the weight of the patient 25-30 ml/kg EX: 70 KG patient need (70*25-30 ml/kg ) = 1750 - 2100 ml per day Dehydration • loss of body fluids --> increase concentration of solutes in the blood and rise in serum Na+ levels . • Fluids shift outside of the cell to restore balance . cell shrink and no longer function properly. Types Mild = Weight loss - 5% Moderate = Weight loss - 10% Sever = Weight loss - 15% What Do You See ? • Irritability • Confusion • Dizziness • Weakness • Thrist • Dry skin/mucous • Sunken eyes • Poor skin turgor • Tachycardia There are 2 types of fluid used in surgery depending on molecular weight • 1-Crystaloid • 2-Colloid < 30.000 molecular weight . > 30.000 molecular weight . A- CRYSTALOIDS : Which is most commonly used contain water + small molecules which can easily pass through blood vessels . • 1-hypertonic : which contain more solutes than water . • 2-hypotonic : which contain more water than solutes. • 3-Isotonic : water = solute. Isotonic : water = solute • No net fluid shifts occur between isotonics solutions because the solutions are equally concetrated . • Examples of isotonic solutions include normal saline (0.9% sodium chloride), lactated Ringer's solution, 5% dextrose in water (D5W), and Ringer's solution. 1-Normal saline 0.9 NaCl • NaCl = water • Used in Extracellular fluid replacement (e.g., dehydration, hypovolemia, hemorrhage, sepsis) • Treatment of metabolic alkalosis in the presence of fluid loss. • Mild sodium depletion • Deslove most types of chemical materials (Drugs , Electrolytes ) 2-Ringer lactate : water + NaCl + KCl +CaCl2 • Ringer's lactate is largely used in aggressive volume resuscitation from blood loss or burn injuries. • Contraindications : Hypercalcemia (high calcium level in the blood) Hypokalemia (low potassium levels in the blood) . Kidney stones. Metabolic acidosis (eg, lactic acidosis). 3-Dextrose : Water + Glucose • Dextrose 5% in water is used to treat low blood sugar (hypoglycemia), insulin shock, or dehydration (fluid loss). hypertonic : which contain more solutes than water • Has a higher solute concentration than another solution. • Fluid from the second solution would shift into the hypertonic solution until the two solution had equal concentrations. Eg : 3% NaCl (normal saline/sodium chloride) 5% NaCl – normal saline/sodium chloride. Mannitol The solute concentration is higher outside the cell -> Free water flows outside the cell . Mannitol • It helps you make more urine and to lose salt and excess water from your body. It treats swelling from heart, kidney, or liver disease. It also treats swelling around the brain or in the eyes. Hypotonic : which contain more water than solutes. • Has a lower solute concentration than another solution. • Fluid from the hypotonic solution would shift into the second solution until the two solution had equal concentrations. Eg : 0.45% sodium chloride 0.25% sodium chloride , 2.5% dextrose solution • The solute concentration is higher inside the cell -> Free water flows into the cell B-Colloids > 30.000 molecular weight • Colloids are gelatinous solutions that maintain a high osmotic pressure in the blood. Particles in the colloids are too large to pass semi-permeable membranes such as capillary membranes. • Colloids are of two types: Natural, i.e., human albumin. Artificial, i.e., gelatin and dextran solutions. • 1ml of blood loss = 1 ml of colloids = 3ml of crystaloids Surgery Hemorrhage Murtdha khadim jwad Sugery It is the loss of blood or blood escape from the circulatory system. It must be recognised and managed aggressively to reduce the severity and duration of shock and avoid death and/or multiple organ failure. Surgery Pathophysiology 1-Acidosis 2-coagulpathy 3-hypothermia Volume 01 Summer 2022 Revealed hemorrhage Concealed hemorrhage Obvious external hemorrhage Within the body Cavity Haemorrhage control: Pressure and packing: Pressure dressing from anything handy which is soft and clean(used as 1st aid treatment) Digital pressure (the use of forefinger and thumb) examples of packing to control haemorrhage: Rolls of wide gauze. Position and rest:  examples : o Elevation of limbs (e.g. in ruptured varicose vein). thyroidectomy where the patient tilted feet downwards(reverseTrendelenburg position)  Operation, angioembolisation and endoscopic control