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Concise surgery

Concise surgery

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Notes in general surgery
Notes in general surgery

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Published by: Mohammed Awad Hassan on May 19, 2011
Copyright:Attribution Non-commercial

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10/22/2013

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Road traffic accidents, burn, surgical operations, heat stroke, surgery,anaesthesia and all medical illnesses are examples of stress.
Response of the normal body to stress occurs in two ways:1- Neural pathway. 2- Hormonal pathway.
1- The neural response:
The neural response occurs through the sympathetic and parasympatheticsystems: e.g. Pain is carried by the peripheral sensory nerves through thespinothalamic tracts to the brain. The cerebrum part of the limbic system is activated(the reticular-activating system). This stimulates the sympathetic system(sympathetic chain ganglia + fibres) that release norepinephrine.
 Actions of the activated sympathetic system:
1-Sympathetic fibres supplying the arteries release norepinephrine that leadsto vasoconstriction. Vasoconstriction increases the peripheral resistance.
The blood pressure = the stroke volume X peripheral resistance.
Therefore, asvasoconstriction increases the peripheral resistance raises the blood pressure.
This is how the body responds to defend itself against hypotension
.2- The sympathetic stimulus passes through the sympathetic chain to the adrenalmedulla which secretes adrenaline and postganglionic membranes that secretenorepinephrine. These hormones are released into the circulation and when theyreach the heart they lead to increases the heart rate. Also they increase thegeneralized vasoconstriction and rise in blood pressure in an attempt to preventhypotension.3- The skin temperature and the reddish colour of the skin and mucosmembranes are due to blood in blood vessels. Therefore whenvasoconstriction occur 
the skin and mucous membranes become pale andcold.
1
 
3- In the skin
the sweat glands are supplied by the sympathetic system
.Therefore sympathetic stimulation leads to sweating.The early clinical features of severe stress (e.g. multiple injuries) are:
1- Tachycardia 2- Sweating 3- Pallor 4- Cold skin.
This is how the body tries to defend itself against hypotension. If this defensefails the patient goes in shock.
BP
: The normal systolic pressure is >100mmHg.The normal diastolic pressure is 60-90mmHg.Hypotension (shock) is diagnosed if the systolic pressure is less than100mmHg. This is the time to give intravenous fluids to correct anyhypovolaemia resulting from loss of blood (as in trauma), plasma (as in burn)or water (as in diarrhoea and vomiting). If intravenous fluids are not givenearly the patient’s responses may become exhausted and he/she developshypotension.If the diastolic blood pressure is more than 90mmHg then hypertension isdiagnosed, but if diastolic blood pressure is less than 30mmHg poor  perfusion of the cardiac muscle occur because the coronary arteries fillduring diastole. Therefore, poor filling of coronary arteries in severehypotension leads to myocardial insufficiency.So, we need the diastolic pressure to fill the coronary arteries for cardiac perfusion and we need the systolic pressure for perfusion of the rest of the peripheral body tissues.
 Adrenaline and 
norepinephrine c
ause generalized vasoconstriction but it also lead to coronary vasodilatation.
Elderly people have arterial sclerosis and any stress e.g. due to postoperative pain
vasoconstriction
poor peripheral tissue perfusion andearly shock. So they should avoid all types of stress.Stress
Sympathetic stimulation
vasoconstriction
cold extremities, because the blood carries blood and heat.2
 
Also stress
stimulation of the sweat glands
sweating. Therefore the early signsof impending shock occur during the period of compensation by the sympatheticstimulation to guard against the blood pressure falls are:1- tachycardia 2-palor 3- cold clammy (sweaty) skin.If the compensatory mechanism fails blood pressure will drop to less than90mmHg and shock ensues.
Shock:
 Definition:
 
Inadequate tissues perfusion.It occurs when the systolic blood pressure is < 90mmHg.If the systolic pressure is < 70mmHg, vasoconstriction of the renal afferentarteriole occurs resulting in acute renal failure (acute tubular necrosis).If the diastolic pressure is <30mmHg
decreased blood supply to the heartand brain.If BP remained low for long time the oxygen reaching tissues will be lowtherefore metabolism in tissues become anaerobic metabolism resulting in lacticacid and keto acid production. The liberation and accumulation of these acidsleads to metabolic acidosis.
The normal range of the arterial partial pressure of oxygen is morethan 95mmHg (PO2=>95mmHg) and the normal arterial bloodsaturation of oxygen is >95% (Sat O2 =>95%)
The normal range of the PH of the arterial blood is 7.34 - 7.43
PH less than 7.34 means acidosis which will be compensated by the lungsthrough increasing the respiratory rate to wash out carbon dioxide.Carbonic acid (H2CO3)
H2O + CO2Hypotension leads to metabolic acidosis
depressing of the myocardium. If PHis < 7.2 cardiac arrest may occur.The acid base status of the blood can be detected by taking arterial bloodgases (ABG) from radial or femoral arteries for analysis.3

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