PG Module 8

AYOGA LAKṢAṆA

तद्दुष्टं शोणितमनिर्ह्रियमाणं शोफदाहरागपाकवेदना जनयेत् ||२९||[i]

Ayoga Symptoms include: –

• Śopha (oedema)
• Dāha (burning sensation)
• Rāga (redness)
• Pāka (suppuration)
• Vedana (excessive pain)

Reasons that can produce Ayoga

तत्र, दुर्दिने दुर्विद्धे शीतवातयोरस्विन्ने भुक्तमात्रे स्कन्दत्वाच्छोणितं न स्रवत्यल्पं वा स्रवति ||२७||

मदमूर्च्छाश्रमार्तानां वातविण्मूत्रसङ्गिनाम् | निद्राभिभूतभीतानां नृणां नासृक् प्रवर्तते ||२८||[ii]

• Durdina (in auspicious time)
• Durvidha (improper puncture)
• Śīta vāta samsprishya (exposure to cold breeze)
• Aswinnata (improper/ less sudation)
• Buktamatre skandatwat (immediately after food)
• Madārta (intoxicated)
• Mūrchārta (fainting)
• Vāta mūtra sanginām (obstruction in urine and flatus)
• Nidra atibhūtanām (excessive sleepness)

ATIYOGA LAKṢAṆA

तदतिप्रवृत्तं शिरोऽभितापमान्ध्यमधिमन्थतिमिरप्रादुर्भावं धातुक्षयमाक्षेपकं दाहं पक्षाघातमेकाङ्गविकारं हिक्कां श्वासकासौ पाण्डुरोगं मरणं चापादयति ||३०||[iii]

Atiyoga lakṣaṇa include: –

• Shiro Abhitāpa (increase in temperature of shira)
• āndhya (blindness)
• Adhimantha (defective vision)
• Timira pradurbhāva (eye disorders)
• Dhātu kshaya (depletion in dhātus)
• ākshepaka (tremors)
• Dāha (burning sensation)
• Pakshaghāta (hemiplegia)
• Ekānga vikāra (paralysis body parts)
• Hikka (hiccup)
• Swāsa (breathing difficulty)
• Kāsa (cough)
• Pāndu roga (anaemia)
• Marana (death)

Reasons that can produce Atiyoga

अत्युष्णेऽतिस्विन्नेऽतिविद्धेऽज्ञैर्विस्रावितमतिप्रवर्तते |[iv]

• Ati uṣṇa (excessive heat)
• Ati swinna (excessive sudation)
• Ati viddha (excessive puncturing)
• Ajñāna (lack of knowledge)

SAMYAK LAKṢAṆA

सम्यग्गत्वा यदा रक्तं स्वयमेवावतिष्ठते |

शुद्धं तदा विजानीयात् सम्यग्विस्रावितं च तत् ||३२||[v]

In proper puncturing the blood flows continuously and after the removal of Śastra the blood stops automatically.

[i] Su. Su 14/29

[ii] Su. Su 14/28

[iii] Su. Su 14/30

[iv] Su. Su 14/32

[v] Su. Su 14/32

अथ खल्वप्रवर्तमाने रक्ते एलाशीतशिवकुष्ठतगरपाठाभद्रदारुविडङ्गचित्रकत्रिकटुकागारधूम हरिद्रार्काङ्कुरनक्तमालफलैर्यथालाभं त्रिभिश्चतुर्भिः समस्तैर्वा चूर्णीकृतै र्लवणतैलप्रगाढै र्व्रणमुखमवघर्षयेत्, एवं सम्यक् प्रवर्तते ||३५||

अथातिप्रवृत्ते रोध्रमधुकप्रियङ्गुपत्तङ्गुपत्तङ्गगैरिकसर्जरसरसाञ्जनशाल्मलीपुष्पशङ्खशुक्ति माषयवगोधूमचूर्णैः शनैः शनैर्व्रणमुखमवचूर्ण्याङ्गुल्यग्रेणावपीडयेत् सालसर्जार्जुनारिमेद मेषशृङ्गधवधन्वनत्वग्भि र्वा चूर्णिताभिः क्षौमेण वा ध्मापितेन समुद्रफेनलाक्षाचूर्णैर्वा, यथोक्तर्व्रणबन्धनद्रव्यैर्गाढं बध्नीयात्, शीताच्छादनभोजनागारैः शीतैः प्रदेहपरिषेकैश्चोपचरेत्, क्षारेणाग्निना वा दहेद्यथोक्तं, व्यधादनन्तरं तामेवातिप्रवृत्तां सिरां विध्येत्; काकोल्यादिक्वाथं वा शर्करामधुमधुरं पाययेत्, एणहरिणोरभ्र शशमहिषवराहाणां वा रुधिरं; क्षीरयूषरसैः सुस्निग्धैश्चाश्नीयात्; उपद्रवांश्च यथास्वमुपचरेत् ||३६||[i]

• If blood is not flowing out properly (less in amount), Ela, Śītashiva, Kuṣṭa, Takara,Pāda, Bhadradāru, Vidanga, Chitraka, Trikatu, Agāradhūma, Haridra, Arka flowers, Naktamāla, etc drugs have to be powdered and mixed with more amount of Lavana and Taila and applied over the site to facilitate more blood flow. All the above drugs in combination or 3-4 drugs available can also be chosen for the procedure.
• When the blood flows excessively, powders of Rodra, Madhuka, Priyangu, Patanga, Gairika, Sarjarasa, Śālmali Puśpa, Anka, Śanka, Śuki, Māṣa, Yava and Godhūma should be sprinkled over the wound and pressed with the tip of the finger.
• Powder of bark of Śālā, Sarja, Arjuna, Arimeda, Meṣaśṛṅgi, Dhava and Dhanvana may also be used for dusting.
• A bandage is to be applied rigidly. The patient should be covered with moist cloth, placed in a cold room, treated with applications of Śīta Pradeha and Pariṣeka. The area can also be cauterised with Kshāra and Agnikarma.
• If the blood flows excessively, a counter incision is to be made on the same vein some distance apart.
• Decoction of Kakolyādi Gana can be taken along with Śarkara and Madhu.
• Blood of deer, antelope, camel, rabbit, buffalo and pig are given to drink.
• Kṣīra Yūṣa and Māṃsarasa which are mixed with Snehas are also advised.
• Other symptomatic care also has to be given.

शीतमधुरकषायान्नपानसेकप्रदेहप्रवातवेश्मभिर्वा स्कन्दनायोपचरेत्|

पद्मकादिक्वाथं शर्करामधुमधुरं क्षीरमिक्षुरसमेणहरिणाजोरभ्रमहिषवराहाणामन्यतमस्य सिरां विद्ध्वा रुधिरमामं ग़ृतभृष्टं वा पानं दद्यात्|

तेनैव वा दर्भपादमृदितेनानुवासयेत्|[ii]

Vāgbhaṭa Ācārya also mentioned similarly. After Śīta Madhura Kaṣāya Annapāna, Seka, and Pradeha, Skandana has to be adopted.

Padmakadi Kvātha is advised along with Śarkara and Madhu. Kṣīra and Ikshu Rasa also advised.

The blood of animals was advised in Pāna form with Ghṛta as well as anuvāsana with rakta triturated with darbha.

[i] Su. Su. 14/34-36

[ii] AS. Su. 36/19

WATER & ELECTROLYTE IMBALANCE

Electrolytes play a vital role in maintaining homeostasis within the body. They help to regulate myocardial and neurological functions, fluid balance, oxygen delivery, acid-base balance and much more. Electrolyte imbalances can develop by the following mechanisms: excessive ingestion; diminished elimination of an electrolyte; less drinking or excessive elimination of an electrolyte.

Total body water is distributed in two major compartments: 55.755 is intracellular fluid (ICF), and 25-45% is extracellular fluid (ECF). The ECF is further subdivided into intravascular (plasma water) and extravascular (interstitial) spaces in a ratio of 1:3 extracellular fluid volume deficit is a common fluid disorder in surgical patients. The fluid deficit is not water only, but water and electrolytes in approximately the same percentage as they exist in normal extracellular fluid.

Functions of body water

• Transportation of nutrients and waste metabolites
• Water transports Hormones, Enzymes, blood platelets, and red and white blood cells
• Regulates body temperature
• Water act as reactant in many hydration (Hydrolytic reactions of metabolic pathways.)
• Water act as a solvent for Electrolytes and Non electrolytes
• Water Facilitates Digestion and promoting Elimination of ingested food
• Water serves as a tissue Lubricant
• Body gain water: Ingestion of liquids and moist foods (2300mL/day), Metabolic synthesis of water during cellular respiration (200mL/day)
• Body loss water: Kidneys (1500mL/day), Evaporation from Skin (600mL/day), Exhalation from Lungs (300mL/day), Faeces

Types of dehydration

• Primary Dehydration /Due to pure water depletion
• Mixed Type Dehydration /Due to both Water and Salt depletion
• Secondary dehydration/Due to pure salt depletion

Management of Water imbalance

(A) Water deficit

• Intake of water
• IV 5% Dextrose or Dextrose saline or Normal saline
• Intake output chart should always be maintained to properly adjust the fluid administration and to prevent water intoxication.

(B) Water excess

• Fluid intake should be stopped, particularly IV fluid
• IV 200ml hypotonic (5.85%) saline solution should be given. This may be added with a diuretic (patient remain in stupor with renal insufficiency)

Electrolyte Imbalance

An Electrolyte is a substance when dissolved in solution dissociates into ions or can be defined that an Electrolyte is a substance, which develops an electrical charge when dissolved in water.

Functions of body electrolytes

• Electrolytes in the medium/compartments produce osmotic pressure. This osmotic pressure helps in maintaining water balance.
• Na⁺ : Most abundant electrolyte in the ECF.
• K⁺ : Essential for normal membrane excitability for nerve impulse
• Cl^– : Regulates osmotic pressure and assists in regulating acid-base balance
• Ca2+ : Promotes nerve impulse and muscle contraction/relaxation
• Mg2+ : Plays role in carbohydrate and protein metabolism, storage and use of intracellular energy and neural transmission. Important in the functioning of the heart, nerves, and muscles

1. a) Sodium

Hyper natraemia

Clinical features include: –

• Puffiness of the face,
• Pitting oedema in the sacral region & ankle region,
• Increased weight & polyuria,
• In infants increased tension in anterior fontanelle

Management

• Stoppage of infusion
• Diuretics if oedema present
• Treatment of apparent hypernatremia should be according to the merit of the individual cases

Hyponatraemia

Clinical features include: –

• Sunken eyes,
• Anxious,
• Dry tongue, hard & reddish brown,
• Dry skin, wrinkled & subcutaneous tissue feel laxed,
• BP reduced,
• Pulse will be fast,
• Urine becomes dark & scanty with high specific gravity

Management

• IV normal saline (0.9%)
• Ringer’s solution may be administered in case normal saline is not available.
• Renal function should be monitored
• When there is severe loss of plasma volume, infusion of plasma or plasma substitutes should be considered.

1. b) Potassium

Hyperkālaemia

Clinical features include: –

• Nausea,
• Vomiting,
• Intermittent intestinal colic & diarrhoea,
• Low bp,
• Low heart rate,
• Poor peripheral circulation and Cyanosed skin.

Management

• Exogenous administration of potassium should be stopped
• Temporary lowering of serum potassium & suppression of myocardial effect of hyperkālaemia can be accomplished by IV administration of 10% solution of calcium gluconate.

Hypokālaemia

Clinical features include: –

• Gradual onset of drowsiness,
• Speech becomes slow & slurred,
• Muscular hypotonia & weakness,
• Incontinence of urine, peripheral bp is lowered & pulse rate becomes slow,
• Skin remains warm & dry,
• Reddish flush of face,
• Severe thirst.

Management

• Oral administration of potassium is always chosen first
• Potassium salt should be administered orally or potassium chlorides in the form of effervescent tablets 2gm 6 hourly.
• When patient is comatose or nauseous & has difficulty in swallowing, iv administration is unavoidable.
• If potassium deficit is due to excessive vomiting – potassium chloride is administered
• If urine volume is adequate – 2gm of potassium chloride may be administered IV over a period of 4 hours.
• If potassium deficit is due to diarrhoea – orally potassium citrate 2gm is administered every 6 hourly. The IV solution should contain sodium acetate in addition to potassium chloride.

1. c) Magnesium

Deficiency of Magnesium

Clinical features include: –

• Hyperactive tendon reflexes
• Muscle tremors
• Tetany
• Irritable, aggressive & restlessness.

Management

Magnesium deficiency is best treated by parenteral administration of magnesium chloride or sulphate solution about 2mEq of magnesium per kg body weight administered daily when the renal function is good.

Excess of Magnesium

Clinical features include:

• Excess of mg leads to lethargy,
• Weakness, and
• Progressive loss of deep reflexes

Management

• Acute symptoms may be controlled by slow iv administration of 5 to 10meq of calcium chloride or gluconate,
• Persistence of symptoms, peritoneal dialysis or haemodialysis should be done.

1. d) Calcium

Hypercalcaemia

Clinical features include: –

Early-stage symptoms:

• Anorexia,
• Nausea,
• Vomiting,
• Fatigue,
• Lassitude &
•  

Later stage symptoms:

• Headache,
• Pain in the back & extremities,
• Thirst,
• Polyuria,
• Polydipsia,
• Stupor, and
• Coma

Management

• Intravenous phosphate should be given slowly over a period of 12 hours once daily for more than 2 to 3 days.
• Corticosteroids

Hypocalcaemia

Hypocalcaemia presents with clinical features like:

• Numbness,
• Tingling sensation in the circumoral region & the tip of fingers &toes,
• Hyper tendon jerk,
• Muscle cramp with carpopedal spasms & tetany
• The Chvostek’s sign will be positive.

Management

• IV administration of calcium gluconate or chloride
• Calcium lactate may be given orally with supplement of vitamin D

SHOCK

Hypovolemic shock is an emergency condition in which severe blood and fluid loss make the heart unable to pump enough blood to the body due to decreased preload. It leads to multiple organ failure.

Causes includes: Haemorrhage, Severe diarrhoea and vomiting, Excessive diuresis, Burns etc

Classification

• Class 1: Blood loss up to 750ml

Symptoms

• BP : Normal
• Pulse rate : <100
• Pulse pressure : Normal/ Increased
• Urine output : >30ml/hr
• Respiratory rate : 14-20/min
• Mental status/ CNS : Slightly anxious
• Class 2: BL of 750-1500ml

Symptoms

• BP : Normal
• Pulse rate : 100-120
• Pulse pressure : Decreased
• Urine output : 20-30ml/hr
• Respiratory rate : 20-30/min
• Mental status/ CNS : Mildly anxious

• Class 3: BL of 1500-2000ml

Symptoms

• BP : Decreased
• Pulse rate : 120-140
• Pulse pressure : Decreased
• Urine output : 5-15ml/hr
• Respiratory rate : 30-40/min
• Mental status/ CNS : Anxious/ Confused

• Class 4: BL above 2000ml

Symptoms

• BP : Decreased
• Pulse rate : >140
• Pulse pressure : Decreased
• Urine output : Negligible
• Respiratory rate : >35/min
• Mental status/ CNS : Confused/Lethargic

Management

Initial treatment for shock states includes:

1. Causative treatment or arrest blood losses

Can be surgical measures as well as bandaging and cauterisation, based on cause of ongoing haemorrhage.

2. Volume repletion

Solution for volume replacement includes: –

• Isotonic crystalloid solutions

E.g.: Normal saline, Ringer solution, Lactated ringer solutions

• Hypertonic crystalloid solutions

E.g.: Hypertonic saline

• Colloid solutions

E.g.: Dextrans, Gelatines, Hetastarch, Human albumin

3. Inotropic therapy

Only after volume replacement

Used to improve Cardiac Output

E.g.: Dobutamine

4. Vasomotor therapy

• Only used as temporary method
• Used in case of haemorrhages which outruns the Volume replacement
• Used only until surgical procedure stops the haemorrhage

E.g.: Noradrenaline, Dopamine, Adrenaline

BLEEDING PER RECTUM

It is the condition in which the blood is lost through Rectum. Blood in the stool can be bright red or maroon in colour. There are chances that patient may complain of pain per rectum and anus and abdominal pain or cramping. The bleeding may arise from any part of the GI-Tract including rectum.

Management

1. Diagnostic procedures, such as endoscopy, colonoscopy or angiography, may be done to pin point the source of bleeding.
2. Blood transfusions to combat blood loss in severe rectal bleeding,
3. Drainage of stomach contents.
4. Intravenous fluid replacement.
5. Surgery may be required in severe cases.

HAEMATEMESIS

Hematemesis is the vomiting of blood. The vomited blood volume in excess of 5.5 litres could be life threatening.

Management

Minimal blood loss

• Kept NPO (nil per os)
• Proton pump inhibitor (e.g omeprazole)
• Blood Transfusion (if Hb% <8.0gdl)

Significant blood loss

• Resuscitation
• Fluid/Blood is administered preferably by central venous catheter
• Patient has to be prepared of immediate endoscopy.

EPISTAXIS

The bleeding or haemorrhage from the nose, referred to as epistaxis, is caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. It is common in all age groups.

Common site of epistaxis is the anterior septum, where three major blood vessels enter the nasal cavity:

• the anterior ethmoidal artery on the forward part of the roof (Kessel Bach’s plexus)
• the sphenopalatine artery in the posterosuperior region, and
• the internal maxillary branches (the plexus of veins located at the back of the lateral wall under the inferior turbinate).

Types of Epistaxis

1. Anterior Epistaxis (Most common, less severe and easy to control)
2. Posterior Epistaxis (Less common, more severe and difficult to control)

Management of epistaxis

Management of Epistaxis depends on the location of the bleeding site. A nasal speculum or headlight may be used to determine the site of bleeding in the nasal cavity. Most nosebleeds originate from the anterior portion of the nose. Initial treatment may include applying direct pressure.

• Little’s area – pinching the nose with thumb and index finger for about 5 minutes- compression of vessels.
• Trotter’s method – patient is made to sit, leaning a little forward over a basin to spit any blood, and breathe quietly from mouth- cold compresses should be applied to nose to cause reflex vasoconstriction.
• Anterior nasal pressure with joined tongue depressors.

If these measures are unsuccessful, additional treatment is indicated.

1. In anterior nosebleeds, the area may be treated with a silver nitrate applicator and Gel foam, or by electrocautery. Topical vasoconstrictors, such as adrenaline or cocaine (0.5%), and phenylephrine may be prescribed.
2. If bleeding is occurring from the posterior regions, cotton pledgets soaked in a vasoconstricting solution may be inserted into the nose to reduce the blood flow and improve the examiner’s view of the bleeding site.
3. Alternatively, a cotton tampon may be used to try to stop the bleeding. Suction may be used to remove excess blood and clots from the field of inspection.
4. Nasal packing with bayonet forceps and ribbon gauze.
5. When the origin of the bleeding cannot be identified, the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic ointment; a topical anaesthetic spray and decongestant agent may be used prior to inserting the gauze packing, or a balloon-inflated catheter may be used.
6. The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding.
7. Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.