Diabetic foot ulceration

Background

• Diabetes mellitus has reached epidemic proportions worldwide and its epicenter is in South Asia.
• One of its main complications is lower extremity ulceration and infection leading to amputation. And this is the main contributor to lower limb amputations outside trauma. The good news is foot ulceration is preventable.
• Furthermore aggressive appropriate management of early lesions prevents amputation.
• This is achieved only with good knowledge and understanding of the pathophysiological processes involved.
• This would be best achieved by teaching the subject as a stand-alone module.
• It is important to remember that diabetics do not lose their limb overnight and 70-90% of amputations are preceded by ulceration.
• It is a major contributor to amputation, ironically 30-50% of amputees lose the other limb within 5 yrs moreover approximately 100% die within 5 years of the second amputation.

Cardiopulmonary Resuscitation

Adult Cardiopulmonary Resuscitation                                       

Introduction

Cardio-respiratory arrest is cessation of mechanical activity of the heart. It is a clinical diagnosis evidenced by unresponsiveness, apnoea or agonal respirations and absence of a detectable central pulse. Immediate and systematic action is essential to prevent death or permanent cerebral damage.

Survival after cardiac arrest out of hospital is extremely low. Coronary artery disease is the commonest cause for sudden cardiac arrest, affecting nearly 700,000 people a year in Europe and one third of people developing a myocardial infarction die before reaching the hospital. The commonest presenting rhythm is rapid ventricular tachycardia or ventricular fibrillation. In the absence of immediate bystander initiated cardio-pulmonary resuscitation this deteriorates to asystole.

In- hospital cardiac arrest occurs in a sicker group of patients and only 20% of them will survive to leave the hospital. The presenting rhythm is either asystole or pulseless electrical activity.

Causes of cardiac arrest

Cardio-pulmonary arrest may occur due to airway obstruction, breathing inadequacy or cardiac abnormalities.

Lumbar Puncture

INTRODUCTION

• Lumbar puncture and analysis of cerebrospinal fluid is widely used as a diagnostic tool in neurological diseases.
• Lumbar puncture (LP) is the insertion of a needle into the subarachnoid space in the lumbar region to obtain cerebrospinal fluid (CSF) for diagnostic or therapeutic purposes.
• The CSF obtained by LP can provide crucial data in the diagnosis of life threatening conditions such as meningitis and encephalitis and evaluation of other disease conditions such as demyelinating diseases.
• Lumbar puncture is alsoperformed for therapeutic reasons, such as the treatment of benign intracranial hypertension. 
•  The spinal cord ends at the lower border of L1 vertebrae (Fig 1).
• Below this are nerve roots – the cauda equina. Lumbar puncture can be safely done below L1-2 vertebral space, as there is no risk of injuring the spinal cord.

Management of a difficult airway and failed intubation

Introduction

• Probably the most important job of an anaesthetist is to maintain a safe airway of an anaesthetised patient
• Difficulty in airway management is the single most important cause of anaesthesia related morbidity and mortality     
• If a difficult airway is detected and appropriate measures are taken to face it before anaesthetising a patient, morbidity and mortality associated with airway related problems can be minimised
• Hence the importance of assessing the airway during the pre-operative visit

What is a Difficult Airway?

• An airway which is difficult to be maintained or intubated or unable to be intubated in an anaesthetised or unconscious patient

IV Cannulation

Indications

1. Administration of IV fluids
2. Administration of blood products
3. Administration of IV therapy

Procedure

1. Confirm patient identity
   
2. Communicate with the patient
• Explain the procedure to the patient and get his/her verbal consent
• Try to minimize the patient distress
• Answer any questions the patient has
      
3. Gather the equipment needed
• Non sterile pair of gloves
• Kidney tray
• Tourniquet
• Sterile alcohol swabs
• IV Cannula of appropriate size

o Large bore cannulas are needed for rapid / thick fluid administration. E.g. 16 gauge gray canula

o The commonest used in day to day practice for IV fluid administration and drug administration are gauge 18 and 20