OxygenThe 10 Most Abundant Elements in the UniverseSource: Exploring Chemical Elements and their Compounds; David L. Heiserman, 1992

Element Abundancemeasured relative to silicon

Hydrogen 40,000

Helium 3,100

Oxygen 22

Neon 8.6

Nitrogen 6.6

Carbon 3.5

Silicon 1

Magnesium 0.91

Iron 0.6

Sulphur 0.38

Composition of the Earth's AtmosphereSource: Definition of the U.S. Standard Atmosphere (1976)

CRC Handbook of Chemistry and Physics, 77th Edition

Gas Formula Abundancepercent by volume

Abundanceparts per million by volume

Nitrogen N2 78.084% 780,840

Oxygen O2 20.9476% 209,476

Argon Ar 0.934% 9,340

Carbon Dioxide

CO2 0.0314% 314

Neon Ne 0.001818% 18.18

Helium He 0.000524% 5.24

Methane CH4 0.0002% 2

Krypton Kr 0.000114% 1.14

Hydrogen H2 0.00005% 0.5

Xenon Xe 0.0000087% 0.087

Oxygen

• Production– Photosynthesis

• Where it has all come from

– Heating mercuric oxide and nitrates• How it was discovered

– Fractional distillation of air• Supply for medicine and industry

– Colourless gas, pale blue liquid

Oxygen

• Oxygen Cascade– Oxygen moves down a stepwise series of partial

pressure gradients from the inspired air to the body's cells and their mitochondria.

Oxygen

• Oxygen cascade interference – At 19,000 feet (just above base camp at Mount

Everest, the barometric pressure is half that at sea level, and thus, even though the FiO2 is 21%, the PIO2 is only 70mmHg, half that at sea level

– Increased barometric pressure such as in hyperbaric chambers, the PIO2 will actually be higher

• More oxygen…but dissolved not on haemoglobin

OxygenDr Mark B Smith

Oxygen

• The amount of oxygen in the bloodstream is determined by;– serum haemoglobin level– percentage of this haemoglobin saturated with

oxygen– cardiac output– the amount of oxygen dissolved (see below).

EMERGENCY MOBILE MEDICAL UNIT Training Weekend

HYPOVENTILATION

• A RISE IN PaCO2 CAUSES A FALL IN PaO2

THIS IS THE BASIS OF THE ALVEOLAR GAS EQUATION

PaO2 = FiO2(Pb-PaH2O)-PaCO2/0.8

EMERGENCY MOBILE MEDICAL UNIT Training Weekend

• TREATMENT– OXYGEN TO OBTAIN SaO2>90%

• IF THE PATIENT BECOMES TIRED THE PaCO2 MAY RISE

• IF RISING PaCO2 OR DROWSY PROVIDE ASSISTED VENTILATION

EMERGENCY MOBILE MEDICAL UNIT Training Weekend

HIGH CONCENTRATIONS OF INSPIRED OXYGEN DO NOT DEPRESS VENTILATION IN PATIENTS WITH ACUTE RESPIRATORY FAILURE

EMERGENCY MOBILE MEDICAL UNIT Training Weekend

• OXYGEN THERAPY ON GENERAL WARDS MUST BE PRESCRIBED

• TYPE OF OXYGEN DELIVERY SYSTEM• FLOW RATE OF OXYGEN (OR %)• DURATION OF THERAPY• MONITORING TO BE UNDERTAKEN

Oxygen is a drug

EMERGENCY MOBILE MEDICAL UNIT Training Weekend

OXYGEN DELIVERY SYSTEMS

• VARIABLE PERFORMANCE

• FIXED PERFORMANCE

VARIABLE PERFORMANCE SYSTEMS

NASAL CANNULA

• 24-40% DEPENDING ON FLOW RATE• INSPIRED CONCENTRATION VARY BETWEEN

BREATHS• DEPENDS UPON RATE AND DEPTH• MAXIMUM FLOW RATE APPROX 4 l/min

VARIABLE PERFORMANCE SYSTEMS

SIMPLE FACE MASK

• MASK INCREASES RESERVOIR • MINIMAL FLOW RATE APPROX 4 l/min• NO INCREASED INSPIRED OXYGEN ABOVE 15 l/min• INSPIRED OXYGEN OF UP TO 60%

VARIABLE PERFORMANCE SYSTEMS

PARTIAL REBREATHING MASKS

• FACEMASK AND RESERVOIR BAG

• INSPIRED OXYGEN >60%

• FLOW RATES OF APPROX 15 l/min REQUIRED

FIXED PERFORMANCE SYSTEMS

VENTURI MASK• ENTRAINS AIR

• HIGH FLOW MAINTAINS HIGH INSPIRED OXYGEN CONCENTRAION THROUGHOUT RESPIRATORY CYCLE

• COLOUR CODED VENTURI HEADS

FIXED PERFORMANCE SYSTEMS

ANAESTHETIC MACHINE– Open system

• Magill Circuit• Bains system• Maplesons C

– Closed system• Circle

EMERGENCY MOBILE MEDICAL UNIT Training Weekend

SUMMARY

ALL CRITICALLY ILL PATIENTS REQUIRE OXYGEN

Fluids

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patient

GIFTASUP

2006

Jeremy Powell-Tuck (chair)1, Peter Gosling2, Dileep N Lobo1,3 Simon P Allison1, Gordon L Carlson3,4, Marcus Gore3, Andrew J Lewington5, Rupert M Pearse6, Monty G Mythen6

On behalf of 1BAPEN Medical - a core group of BAPEN, 2the Association for Clinical Biochemistry, 3the Association of Surgeons of Great Britain and Ireland, 4the Society of Academic and Research Surgery, 5the Renal Association and 6the Intensive Care Society.

www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf

Intravenous fluid

• Not one Rx for all• Calculate approximate volume required• Choose the most appropriate IV fluid for task• Dextrose containing solutions should not be

used to replace ECF or blood losses• Monitor fluid status

Intravenous fluids• Monitor

– Physiological parameters• Cardiovascular

– Pulse– Blood pressure– Central venous pressure– Left sided pressures

» Pulmonary Artery» Pulmonary Capillary Wedge Pressure

• Renal– Urine output

» Fluid balance– Blood test

» Urea and Electrolytes

Body water compartments. The ability of a solution to expand the plasma volume is dependent on the volume of distribution of the solute, so that while colloids are mainly distributed in the intravascular compartment, dextrose containing solutions are distributed through the total body water and hence have a limited and transient volume expanding capacity. Isotonic sodium-containing crystalloids are distributed throughout the extracellular space and in practice the efficiency of these solutions to expand the plasma volume is only 20-25%, the remainder being sequestered in the interstitial space.

Intravenous fluids

Maintenance1000 N Saline 8 hourly + KCl 20mmol1000 5% Dextrose 8 hourly + KCl 20mmol1000 5% Dextrose 8 hourly + KCl 20mmol

Or 1000 Dextrose Saline 8 hourly + KCl 20mmol 1000 Dextrose Saline 8 hourly + KCl 20mmol 1000 Dextrose Saline 8 hourly + KCl 20mmol

Intravenous Fluids

Resuscitation500mls N Saline Stat

Review500mls N Saline Stat

Review500mls N Saline Stat

ReviewColloid

Gelofusin Voluven Blood

Body Secretion Na+ K+ Cl- HCO3- Volume L/24 hr Saliva 2-85 0-20 16-23 14 0.5-1.5 Gastric Juice 20-60 14 140 0 – 15 2 – 3 Pancreatic Juice 125-138 8 56 85 0.7-2.5 Bile 145 5 105 30 0.6 Jejunal Juice 140 5 135 8 - Ileal Juice 140 5 125 30 - Ileostomy 50 4 25 - 0.5 Colostomy 60 15 40 - 0.1 – 0.2 Diarrhoea 30 – 140 30 – 70 - 20 – 80 Variable Normal Stool 20 – 40 30 - - 0.1-0.25 Sweat 47-60 9 30-40 0-35 0.5 + variable Visible Sweat 58 10 45 - 0.5

Composition of some bodily fluids

Typical properties intravenous fluidsType of Fluid* Sodium Potassium Chloride Osmolarity Weight Plasma volume

Mol wt Duration hoursPlasma 136-145 3.5-5.0 98-105 280-300 - -

5% Dextrose 0 0 0 278 - -

Dextrose 4% saline 0.18% 30 0 30 283

0.9% “normal” saline 154 0 154 308 - 0.2

0.45% “half normal” saline 77 0 77 154 -

Ringer’s Lactate 130 4 109 273 - 0.2

Hartmann’s 131 5 111 275 - 0.2

Gelatine 4% 145 0 145 290 30,000 1-2

5% albumin 150 0 150 300 68,000 2-4

20% albumin - - - - 68,000 2-4

HES 6% 130/0.4 154 0 154 308 130,000 4-8

HES 10% 200/0.5 154 0 154 308 200,000 6-12

HES 6% 450/0.6 154 0 154 308 450,000 24-36

Crystalloids

• Provide water and electrolytes• Rapidly equilibrate through ECF

– Maintenance requirements– Good for replacing ECF depletion– Intravascular expansion short lived

• Cheap• Hypoallergenic• Long shelf life

Colloids

• Contain larger molecules that remain in the plasma longer– Gelatins– Starches

• Exert oncotic pressure• Less volume required to generate intravascular

expansion• Allergic reactions• Expensive• Shorter shelf life

Intravenous fluid

Summary

Fluids have specific rolesMaintenanceReplacement of losses

Monitor

After ABC

Mark B Smith

After ABC

• What can go wrong– Respiration– Cardiovascular– Neurological

After ABC

• Symptoms– Pain– Confusion– Shortness/difficulty breathing

• Signs– Tachycardia/hypotension/capillary refill– AVPU/GCS– Respiratory rate– Oxygen saturation

After ABC

• Looking for– Respiratory

• Pneumothorax/Haemothorax• Aspiration/obstruction

– Cardiovascular• Haemorrhage• Cardiac failure

After ABC

• Neurological– Loss of consciousness– Pupils– Space occupying lesion

• Blood sugar– Hyperglycemia and hypoglycemia should be avoided– Keep the blood glucose value in the range of 80 to 110

mg/dl (4-8mmols/l)– Is the patient a diabetic? Sugar tablets/drinks v insulin– 5% population are diabetic

After ABC

• Pneumothorax– Trachea deviation– Hyper-resonant

• Haemothorax– Tracheal deviation– Hypo-resonant/dull

Pneumothorax

Tension pneumothorax

Surgical emphysema

Surgical emphysema

Chest drain

• Chest drain insertion– http://www.youtube.com/watch?v=B0wGmWn8Ubs

– http://www.youtube.com/watch?v=hQlt57AyQmg

• Needle aspiration

– http://www.youtube.com/watch?v=UvHJ4pjNh2Q&feature=related

Intravenous access

• Difficult– Cold– Vaso-constricted– Access

Leads to FAILURE!!

And cross medical staff!!!!

Intra osseous cannulation• Demonstration1 Rep and lady

– http://www.youtube.com/watch?v=VrQppt6sMiM

– http://www.youtube.com/watch?v=sirU0Q1TEcU&feature=related

• Demonstration 2 Pain– http://www.youtube.com/watch?feature=endscreen&v=ff_vqePp_jw&NR=1

• Demonstration 3 Leg– http://www.youtube.com/watch?v=NPwmoRScJ-U&feature=related

• Demonstration 4 Company/long– http://www.youtube.com/watch?v=jBtm3MUv-B0&feature=related

• Demonstration 5 Mistakes– http://www.youtube.com/watch?v=YXfyL8kvFTg&feature=related

• http://www.youtube.com/watch?v=nt56jMvA71c&feature=related

• http://www.youtube.com/watch?v=qYQn4TSjge4&feature=related

• http://www.youtube.com/watch?feature=endscreen&v=3ZDpiZHbrW4&NR=1

After ABC

Thank youAny questions