7. What is a Lactated Ringer's solution?

 According to National Center for Biotechnology Information (NCBI), Ringer's lactate

solution (RL), also known as sodium lactate solution and Hartmann's solution, is a type of
isotonic, crystalloid fluid further classified as a balanced or buffered solution used for fluid
replacement. The contents of Ringer's lactate include sodium, chloride, potassium, calcium, and
lactate in the form of sodium lactate, mixed into a solution with an osmolarity of 273 mOsm/L
and pH of about 6.5. Ringer's lactate is largely used in aggressive volume resuscitation from
blood loss or burn injuries; however, Ringer's lactate is a great fluid for aggressive fluid
replacement in many clinical situations, including sepsis and acute pancreatitis.

8. How does the administration of Lactated Ringer's help with a burn patient?

 Because our body is made up of about 60% water, its normal amount is essential for the healthy
functioning of every one of our cells such as regulating internal body temperature, transporting
protein and carbohydrates, elimination of waste as well as act as shock absorber for our brain
and spinal cord. Furthermore, 64% of the total water in our body is found in the skin. Thus, if
burns occur, one of its major complication is the loss of body fluids. This can result to electrolyte
imbalance, decreased urine output and other result of dysregulation in our homeostasis. To
correct this problems, fluids should be administered to maintain a urine output of 30-50ml/hr in
adults. Lactated Ringer’s solution is the fluid of choice for burn resuscitation as it is a crystalloid
solution. This means that they have small molecules that can easily flow through membranes,
such as the cell membranes in our body's tissues. It is also an isotonic solution which make it
similar to plasma in the number of dissolved particles it contain. Thus, treating both
intravascular volume losses and extracellular sodium losses cause by burn. Additionally, its Na
lactate content acts as an alkalinising agent which normalises the pH of the acid-
base balance of the body.

15. What causes stridor?

It is possible to develop stridor at any age. However, stridor is more common in children than adults
because children’s airways are softer and narrower.

Causes of stridor in children can include:

 Laryngotracheobronchitis. Commonly known as croup, is a condition that causes

inflammation of the vocal cords and windpipe. The cause is usually viral.
 Inhaled object. This may become lodged in the windpipe or in the bronchi — the tubes that
carry air to the lungs. Usually, foreign bodies are food (eg,nuts, hot dogs, popcorn, or hard
candy) that is inhaled.
 Laryngomalacia. It softens the floppy tissues of the voice box, allowing them to drop into the
airways when the child breathes in. It is the most common cause of inspiratory stridor in the
neonatal period and early infancy and accounts for as many as 75% of all cases of stridor.
 Vocal cord paralysis. Refers to a lack of movement in one (unilateral) or both (bilateral) vocal
cords. This paralysis can be due to a nerve injury or an infection.
 Subglottic stenosis. Narrowing of the airways within the voice box. It is usually due to scarring in
this area.
  Subglottic hemangioma. Benign or noncancerous tumor made up of capillaries and other small
blood vessels. These benign tumors may grow in the airway, causing a blockage.
 Vascular rings. A type of congenital abnormality in which rings of blood vessels form around the
windpipe or the food pipe. As the blood vessels grow in size, they may compress the windpipe,
causing stridor.
 Epiglottitis. A bacterial infection causing inflammation of the epiglottis, or soft tissue that closes
off the windpipe. It is a medical emergency that occurs most commonly in children aged 2-7
years.

Stridor in adults is most commonly caused by the following conditions:

 An object blocking the airway

 Swelling in your throat or upper airway
 Trauma to the airway. Such as a fracture in the neck or an object stuck in the nose or throat
 Thyroid, chest, esophageal, or neck surgery
 Being intubated (having a breathing tube)
 Inhaling smoke
 Swallowing a harmful substance that causes damage to the airway
 Vocal cord paralysis
 Bronchitis. An inflammation of the airways leading to the lungs
 Tonsilitis. An inflammation of the lymph nodes at the back of the mouth and top of the throat by
viruses or bacteria
 Epiglottitis. An inflammation of the tissue covering the windpipe caused by the H.
influenza bacterium
 Tracheal stenosis, a narrowing of the windpipe
 Tumors. Such as cancer of the vocal cords
 Abscesses, a collection of pus or fluid

16. What is a mechanical ventilator and how is a patient connected to the ventilator?

 Mechanical ventilator is a machine that helps a patient breathe (ventilate) by delivering volumes
of gas into a patient's lungs over an extended period of time to remove metabolically produced
carbon dioxide. It is used to provide the pulmonary system with the mechanical power to
maintain physiologic ventilation, to manipulate the ventilatory pattern and airway pressures for
purposes of improving the efficiency of ventilation and/or oxygenation, and to decrease
myocardial work by decreasing the work of breathing.
 The patient is connected to the ventilator with a hollow tube (artificial airway) that goes in their
mouth and down into their main airway or trachea. In the case, the patient has been intubate
through endotracheal. The steps for Endotracheal Intubation using Direct Laryngoscopy are:
1. Place the patient in the “sniffing” position, with neck flexed and head extended;
obese patients will require shoulder roll or ramp.
2. Preoxygenate the patient with 100% oxygen through the bag-valve-mask device
until saturations are maintained at >95% for 3–5 min and suction oral secretions as
necessary.
 3. During preoxygenation, ensure that all equipment necessary is present and
functional: check the endotracheal tube cuff with inflation and deflation and that
the light of the laryngoscope is functional.
4. Administer intravenous (IV) sedation; once the patient is appropriately sedated,
open the mouth with the right hand and insert the laryngoscope blade into the right
side of mouth with the left hand, sweeping the tongue to the left.
5. Advance the blade to the base of the tongue and then lift vertically to visualize the
vocal cords; do not tilt the laryngoscope.
6. If vocal cords are visible, insert the endotracheal tube with the stylet with the right
hand; once the cuff is past the vocal cords, remove stylet. Do not attempt intubation
if the vocal cords are not visible.
7. Advance the endotracheal tube until it is at 21 cm at the gum/teeth for women and
22 cm for men and inflate the cuff.
8. Check tube location with end-tidal carbon dioxide colorimeter, auscultation over the
chest and abdomen, AND chest radiograph.

17. What are some of the risks of mechanical ventilation?

 Infection. As the artificial airway (breathing tube) may allow germs to enter the lung.  This risk of
infection increases the longer mechanical ventilation is needed and is highest around two
weeks. This type of infection is called ventilator-associated pneumonia, or VAP. 
 Lung damage. Caused by either over inflation or repetitive opening and collapsing of the small
air sacs alveoli) of the lungs. Very high levels of oxygen may be harmful to the lungs as well and
can cause damage to the lungs. This is also called ventilator-associated lung injury (VALI).
 Collapsed lung (pneumothorax). Sometimes, a part of the lung can become weak and develop a
hole, letting air leak out and causing a collapsed lung. If the lung collapse is severe enough, it can
cause death.
 Barotrauma. Rupture of the alveolus with subsequent entry of air into the pleural space
(pneumothorax) and/or the tracking or air along the vascular bundle to the mediastinum
(pneumomediastinum). 
 Volutrauma. Local overdistention of normal alveoli. This overdistention sets off an inflammatory
cascade that augments or perpetuates the initial lung injury, causing additional damage to
previously unaffected alveoli.
 Oxygen toxicity. Due to the production of oxygen free radicals, such as superoxide anion,
hydroxyl radical, and hydrogen peroxide. Oxygen toxicity can cause a variety of complications
ranging from mild tracheobronchitis and absorptive atelectasis to diffuse alveolar damage that is
indistinguishable from ARDS.
 Intrinsic positive end-expiratory pressure (PEEP) or auto-PEEP. Complication of mechanical
ventilation that most frequently occurs in patients with COPD or asthma who require prolonged
expiratory phase of respiration. If this goes unrecognized, the patient's peak airway pressure
may increase to a level that results in barotrauma, volutrauma, hypotension, patient-ventilator
dyssynchrony, or death.
 Cardiovascular effects. Positive-pressure ventilation can decrease preload, stroke volume, and
cardiac output. The incidence of stress ulcers and sedation-related ileus is increased when
patients receive mechanical ventilation. Positive pressure maintained in the chest may decrease
 venous return from the head, increasing intracranial pressure and worsening agitation, delirium,
and sleep deprivation.
 Inability to discontinue ventilator support. Sometimes, the illness which led a person to need a
ventilator does not improve despite treatment. In situations where a person is not recovering or
is getting worse, a decision may be made to discontinue ventilator support and allow death to
occur.

18. Why is this patient being intubated?

 The patient presented with tachypnea and tachycardia but remained conscious. She also has
stridor upon auscultation which may indicate that they might be an obstruction, infection or
inflammation in her airway causing less oxygen reach the lungs. Thus, Anna was intubated and
placed on mechanical ventilation to maintain an open airway, deliver high concentrations of
oxygen into the lungs, get rid of carbon dioxide, and decrease the amount of energy a patient
uses on breathing so their body can concentrate on fighting infection or recovering.

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