This document discusses disorders of fluid and electrolyte imbalances. It covers isotonic imbalances like hypovolemia and hypervolemia, osmotic imbalances like hyponatremia and hypernatremia, and compositional imbalances like hypokalemia and hyperkalemia. It describes the causes, clinical manifestations, pathophysiology, diagnostic evaluations, and treatment of each of these conditions. It also discusses fluid distribution in the body, fluid movement between plasma and tissues, and edema.
ABGs or VBGs interpretation made simple straight forward easy to remember and easy to apply. The presentation is designed to help the residents and junior ER physicians. The second part will discuss the oxygenation and the third part will review the "Stewart Approach" while fourth and last part is meant for the Experts.
Acute respiratory failure is defined by the sudden onset of severe impairment of pulmonary gas exchange
Characterized by the inability of the lungs to meet the body’s metabolic needs for the transport of oxygen (O2) into the blood and/or removal of carbon dioxide (CO2) from the blood.
Respiratory failure results from inadequate gas exchange by the respiratory system - Meaning that the arterial oxygen, carbon dioxide or both cannot be kept at normal levels.
Hypertension is also known as high blood pressure. There are mainly two type of blood pressure i.e. systolic and another one is diastolic . The hypertension are categories into two parts that is primary hypertension and secondary hypertension. People are suffering from 3 stage during the condition of hypertension. There are following agents are used to treat hypertension like calcium channel blockers, ACE inhibitors, beta blocker, alpha + beta blockers these are commonly used.
ABGs or VBGs interpretation made simple straight forward easy to remember and easy to apply. The presentation is designed to help the residents and junior ER physicians. The second part will discuss the oxygenation and the third part will review the "Stewart Approach" while fourth and last part is meant for the Experts.
Acute respiratory failure is defined by the sudden onset of severe impairment of pulmonary gas exchange
Characterized by the inability of the lungs to meet the body’s metabolic needs for the transport of oxygen (O2) into the blood and/or removal of carbon dioxide (CO2) from the blood.
Respiratory failure results from inadequate gas exchange by the respiratory system - Meaning that the arterial oxygen, carbon dioxide or both cannot be kept at normal levels.
Hypertension is also known as high blood pressure. There are mainly two type of blood pressure i.e. systolic and another one is diastolic . The hypertension are categories into two parts that is primary hypertension and secondary hypertension. People are suffering from 3 stage during the condition of hypertension. There are following agents are used to treat hypertension like calcium channel blockers, ACE inhibitors, beta blocker, alpha + beta blockers these are commonly used.
Last year by end of the lecture Dr Medinna gave cases to solve for Fluid and electrolytes....
He had a seperate slide for the cases..
Lecture slides are taken from Schwartz Textbook of surgery....
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This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
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http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
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Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
2. OBJECTIVES
At the end of this presentation, the student will be able to;
Discuss the causes, clinical manifestation, and pathophysiology of following
Isotonic imbalance:
1. Hypovolemia.
2. Hypervolemia.
Discuss the causes, clinical manifestation, and pathophysiology of following
Osmotic imbalance
1. Hyponateremia.
2. Hypernateremia.
3. CONT…
Discuss the causes, clinical manifestation, and pathophysiology of following
Compositional Imbalance:
1. Hypokalemia.
2. Hyperkalemia.
4. FLUID DISTRIBUTION
Intracellular Fluid Compartment:
Fluid inside the cells cytoplasm or membranes
Extracellular Fluid Compartment:
o Interstitial (tissue) spaces.
o Plasma (vascular) compartment
o Transcellular compartment
• Cerebrospinal fluid
o Cavities:
peritoneal (gut), pleural (lungs), pericardial (heart), joints (synovial)
5. DISTRIBUTION WATER IN THE BODY
Water is 60% of body weight in a healthy male 50% in a healthy female.
75% to 80% in infants.
Total body water decreases with ageing.
o Increased Adipose tissues due to fats accumulation.
o Decreased muscle mass.
o Renal Decline due to which more water lost in urine.
o Diminished thirst perception.
About 2/3 of the body fluid content is present intracellular.
About `1/3 of the body fluid content is present extracellular (plasma water
and interstitial water).
Transcellular compartments usually contain less than 1% .
6.
7. FORCES MOVE IN AND OUT OF CAPILLARIES
Hydrostatic Pressure (push):
o This is the pressure exerted by a
fluid, e.g. blood
o The hydrostatic pressure in this
example is the blood pressure,
generated by the contraction of the
heart muscle
o Capillary filtration pressure –pushes
water out through
aquaporin's(water pores).
o Pressure in the interstitial fluid
resists-essentially pushing back.
o Normally water flows out of the
capillary.
8. CONT…
Colloidal Osmotic/Oncotic pressure
(pull):
o This is the osmotic pressure exerted
by plasma proteins within a blood
vessel
o Plasma proteins lower the water
potential within the blood vessel,
causing water to move into the
blood vessel by osmosis
o Solutes “pull” water from both the
capillary and the interstitial fluid.
o Normally more water is pulled into
the capillary unless there is a
buildup of proteins or other
particles in the interstitial fluid.
9. At the arterial end:
o When blood is at the arterial end of
a capillary the hydrostatic
pressure is great enough to force
fluid out of the capillary
o Proteins remain in the blood as
they are too large to pass through
the pores in the capillary wall
o The increased protein
content creates a water
potential gradient (osmotic
pressure) between the capillary
and the tissue fluid
o At the arterial end the hydrostatic
pressure is greater than the
osmotic pressure so the net
movement of water is out of the
capillaries into the tissue fluid.
At the venous end:
o At the venous end of the capillary
the hydrostatic pressure within the
capillary is reduced due to
increased distance from the heart
and the slowing of blood flow as it
passes through the capillaries
o The water potential
gradient between the capillary and
the tissue fluid remains
the same as at the arterial end
o At the venous end the osmotic
pressure is greater than the
hydrostatic pressure and water
begins to flow back into the
capillary from the tissues fluid
10. CONT…
o Roughly 90 % of the fluid lost at the arterial end of the capillary is
reabsorbed at the venous end
o The other 10 % remains as tissue fluid and is eventually collected
by lymph vessels and returned to the circulatory system
o If blood pressure is high (hypertension) then the pressure at the arterial
end is even greater
o This pushes more fluid out of the capillary and fluid begins to accumulate
around the tissues. This is called Edema.
12. EDEMA
Accumulation of fluid within the interstitial spaces
Edema may be of two types:
1. Pitting edema:
When pressure is applied to the skin of the swollen area
and released back an indentation is left behind (e.g. when skin is pressed
with a finger or when stockings or socks induce indentation.
o Pitting edema indicates that fluid flow to the area is somehow restricted
(trouble refilling
1. non-pitting edema:
may indicates fluid is not being drained properly,
mostly protein rich fluid is present in interstitial spaces.( lymphedema due
to blockage of lymph nodes)
13. SOME COMMON CAUSES OF EDEMA
Increased capillary Hydrostatic pressure:
Increased vascular volume ( more blood in vessels) ,Heart failure or kidney disease
may lead to increased fluid retention.
Venous obstruction (blood clot lodged in a vein thrombophlebitis.
Decreased plasma colloidal oncotic (osmotic) pressure:
kidneys disease may lead to protein loss into urine (less in capillaries)
Liver disease may cause less protein secretion into blood (also malnutrition)
Increased capillary permeability:
Inflammation, Allergic reactions, capillary damage from malignancy, tissue injury or
burns.
Obstruction of Lymphatic ducts:
Malignancy or removal of lymph nodes.
14. FLUID VOLUME DEFICIT( HYPOVOLEMIA)
Definition:
Hypovolemia is defined as the condition that occurs when loss of
extracellular fluid volume exceeds the intake of fluid.
o Both fluids and electrolytes are lost together in isotonic fashion.
o Other names FVD, hypovolemia, volume depletion, volume contraction or
oligemia.
Extracellular fluid:
o Fluid outside the cells. It contains sodium, chloride, bicarbonates ions,
oxygen, carbon dioxide, glucose, fatty acids and amino acids plus cellular
wastes.
o ECF:
Interstitial fluid, intravascular fluid and transcellular fluid.
15. CAUSES AND RISK FACTORS
FVD results from the loss of body fluids and occurs more rapidly when coupled
with decrease fluid intake. Obvious causes of hypovolemia includes:
Abnormal fluid losses
such as those resulting
from:
o Traumatic accidents
o Extensive vomiting
o Sever Diarrhea
o GI Suctioning
o Profuse Sweating
o Internal bleeding and
Dehydration
o Ruptured ectopic
pregnancy
o Drainage from wounds
or fistula
o Burns and Diuretic
therapy
And decreased intake
as in:
o Nausea
o Poor intake of fluids
o Long term NPO
o Fever
Additional Risk factors:
o Diabetes insipidus
o Adrenal insufficiency
o Osmotic diuresis
o Hemorrhage
o coma
16. COMPLICATION
When someone losses about 20% (1/5) of blood volume, anyone can enter to
such type of circumstances called hypovolemic shock.
Hypovolemic shock:
Hypovolemic shock is a life-threatening condition during
which organs learn to fail due to reduced blood and oxygen supply.
17. PATHOPHYSIOLOGY
Decreased circulating volume and a subsequent reduction in the amount of
blood reaching the tissues of the body.
In order to properly perform their functions, tissues require oxygen
transported through blood.
A decrease in circulating volume can lead to decrease in blood flow to the
brain, resulting in headache and dizziness.
Baroreceptors in the body sense the reduction of circulating fluid and send
signals to the brain to increase sympathetic response.
18. CONT…
Sympathetic response is to release epinephrine and norepinephrine, which
results in peripheral vasoconstriction, in order to conserve the circulating
fluid for vital organs to survive.
Peripheral vasoconstriction accounts for cold extremities, increased heart
rate, increased cardiac output.
Eventually, less perfusion to the kidneys, resulting in oliguria.
19. CLINICAL MANIFESTATION
FVD can develop rapidly and can be mild, moderate, or sever depending on the degree of
fluid loss.
o Thirst
o Weight loss
o Cyanosis
o Poor skin turgor
o Dry skin and dry mouth
o Low blood pressure
o Increased body
temperature
o Decreased urine output
(oliguria)(400-
500ml/day)
o Concentrated urine
o Change in mental
status
o Muscle weakness and
cramps
o Postural hypotension
o Weakness and rapid
heart rate
(tachycardia)
o Chest pain
o Decreased central
venous pressure
o Headache
o Dizziness
o Cool, clammy skin
o Sunken eyes
o Dry eye
o Restlessness
20. ASSESSMENT AND DIAGNOSTIC FINDINGS
Elevated blood urea nitrogen (BUN) level (greater than 25mg/dl.
Elevated hematocrit level (greater than 55%)
Specific gravity of urine also increases (greater than 1.030)
Hypokalemia occurs with GI and Renal losses.
Hyperkalemia occurs with adrenal insufficiency.
Hyponatremia occurs with increasing thirst and ADH release.
Hypernatremia results from increased insensible losses and diabetes insipidus.
21. MEDICAL MANAGEMENT
Emergency resuscitation to assure adequate tissue perfusion.
History to detect cause of hypovolemia.
Physical exam to confirm hypovolemia and to assess severity.
MILD: oral fluids will given to treat hypovolemia.
MODERATE TO SEVERE: IV therapy is used.
Electrolytes solution (e.g. lactated Ringer’s ), 500ml to 1000ml normal saline .
22.
23. HYPERVOLEMIA
It is also called fluid volume excess.
DEFINITION:
Hypervolemia or fluid overload or over hydration is the medical
condition where there is too much fluid in the body.
o FVE refers to an isotonic expansion of the ECF caused by the abnormal
retention of water and sodium in approximately the same proportions in
which they normally exist in the ECF. It is always secondary to an increase in
the total body sodium content, which in turn leads to an increase in total in
total body water.
24. CAUSES
o Excessive intake of sodium
containing fluids
o Excessive salt intake
o Excessive sodium bicarbonate
therapy
o Congestive heart failure
o Renal failure
o Cirrhosis of liver
o Primary polydipsia
o Cushing syndrome
o Long term use of corticosteroids
o Fluid remobilization after burn
treatement
25. PATHOPHYSIOLOGY
Contributing factors can include heart failure, renal failure, and cirrhosis of
the liver.
Another contributing factor is consumption of excessive amount of table or
sodium salts.
Excessive administration of sodium-containing fluids in a patient with
impaired regulatory mechanism.
Diminished function of the homeostatic mechanism responsible for regulating
fluid balance.
26. CONT
Sodium retention and build up of too much fluid in the intravascular space.
Fluid volume excess or hypervolemia or over hydration.
27. CLINICAL MANIFESTATION
o Edema
o Unexplained and rapid weight gain
o Swelling in arms and legs
o Distended neck veins
o Crackles
o Tachycardia
o Shortness of breath(dyspnea)
o Increased blood pressure
o Increased pulse pressure
o Increased central venous pressure
o Increased weight
o Increased urine out put
o Shortness of breath and wheezing
o Fluid in abdominal cavity(ascites)
o Pulmonary edema
o Headache
o Confusion
o Lethargy
28. DIAGNOSTIC EVALUATIONS
Physical examination
Medical history
Abdominal Ultrasound
Albumin level
Chest x-rays
Electrocardiogram (ECG or EKG)
Glomerular filtration rate (GFR)
Liver enzymes
Urinalysis
BUN level and hematocrit (tends to
decrease because of hemodilution)
Urine sodium level are increased if
the kidneys are attempting to
excrete excess volume.
Urine sodium can be decreased in
case of cirrhosis, heart failure,
nephrotic syndrome.
Specific gravity of urine dimishes.
29. MEDICAL MANAGEMENT
Diuretics:
Furosemide (Lasix) is a loop diuretic that causes kidneys to excrete
sodium and water.
Thiazide diuretics:
Thiazide diuretics (hydrochlorothiazide), (trichloromethi- -
-azide), (methychothiazide), block sodium reabsorption in distal tubules.
Discontinuation of sodium containing fluids if administered.
Restricting fluids and sodium
Hemodialysis:
If kidneys are severely impaired.
30. HYPONATREMIA
Decreased serum sodium levels (<135mEq/L.
Sodium and chloride has the highest extracellular concentration,
Deficits in kidneys functions are often the cause: drugs, disease, age, etc.
Sodium deficits cause plasma/fluid hypo-osmolality and cellular swelling,
Osmolality is defined as “the concentration of particles dissolved in a fluid.”
The osmolality of serum can help diagnose several medical conditions such as
dehydration, diabetes, and shock.
CAUSES:
Pure sodium loss
Low intake
Dilutional hyponatremia
31. CLINICAL MANIFESTATION
Remember, sodium is involved
with action potentials in neurons
and muscles, overall cell volume
(osmotic) as well as other cell
functions.
Most life-threatening cerebral
edema, and increased intracranial
pressure.
Lethargy , confusion, decreased
reflexes, seizures, and coma.
If leads to loss of ECF and
hypovolemia, hypotension,
tachycardia, decreased urine out
put.
If dilutional from excess water
(hypervolemic hyponatremia), see
weight gain, edema, Ascites, jugular
vein distention
32. DIAGNOSTIC EVALUTION
Physical examination.
Medical history
Serum sodium level
Decreased serum osmolality
Increased urinary sodium secretion
Urine R/E
Decreased Urine specific gravity
Fluid status
34. HYPERNATREMIA
Increased serum sodium level from normal level >135-145 mEq/L
High sodium causes an increase in ECF tonicity which draws water out of the
cell resulting in cellular dehydration
Generally caused by decreased water intake or increased water loss
More common in infants and those who can’t express thirst (elderly)
Hypodipsia : Inability to express thirst.
35. CLINICAL MANIFESTATIONS
o Dry skin
o Decreased tissue turgor
o Decreased salivation
o Elevated body temperature
o Hypovolemic hypernatremia
Thirst
Confusion, seizures, coma.
Nausea, vomiting, excessive
sweating.
Weight loss, generalized weakness
Pitting edema
Agitation
Hyper reflexia
Subcortical and subarachnoid
hemorrhage
38. HYPERKALEMIA
Normal level is 3.5 to 5.0 mEq/L.
Maintains intracellular osmolarity (high concentration in cells).
Increased ECF potassium levels >5.0 mEq/L.
Caused by excessive intake or decreased excretion in urine in the kidneys.
MANIFESTATIONS:
Initially causes hyper excitability, but at a very high level of
potassium the membrane potential approaches to threshold and may prevent
repolarization and subsequently depolarization.
Weakness, fatigue, muscle cramps, decrease cardiac response
Hyperkalemia is a rare disorder because of efficient renal excretion.
39. DIAGNOSTIC EVALUATION
Elevated Serum level.
Blood tests
Urinalysis
ECG
TREATEMENT:
Treatment should be started with calcium gluconate to
stabilize cardiomyocyte membranes, followed by insulin injection, and b-
agonists administration. Hemodialysis remains the most reliable method to
remove potassium from the body and should be used in cases refractory to
medical treatment.