Management of the Airway, Management of a Traumatic Brain Injury, Benefits, and Risks of Pharmacological Agents, Their Routes of Administration - Assignment Example

Critical Thinking Questions Student’s Name Institutional Affiliation Critical Thinking Questions Question 1 A fundamental skill in paediatric support is the management of the airway. The paediatric airway differs in many ways to that of an adult. Discuss two of these differences, how they impact on airway assessment and the management tools and techniques that can be used. The paediatric airway has the same anatomical elements as seen in the adult airway. The size and position of some of the anatomical components in children differ from adults in various ways when it comes to airway anatomy. When the adult upper airway is compared to that of infant and neonate child airway, the differences are notable. For a child in the infancy stage, one of the most distinct anatomical differences is that the tongue is larger, and the mandible is shorter (Fiadjoe, Stricker & Litman, 2012). The paediatric having a large tongue reduces the amount of space in the oropharynx. The fact that paediatrics has large tongue leaves little room to allow the swelling of the airway. Furthermore, it offers a significant probability for airway occlusion. Children are obligate nasal breathers because of the large size of their tongues. Breathing through the nose is easier for the children. Air flows in a direct path, without any inconveniences of obstructions that may be caused by a large tongue (Harless, Ramaiah & Bhananker, 2014). The fact that paediatrics has larger tongues and a shorter mandible may impact assessment and management of airways in various ways. One of the ways is that the nasal passages have smaller diameters, and therefore, reductions of the total airflow can be caused by fewer swellings and amount of secretions. Obstructions can, therefore, be caused easily by small amounts of secretions and swellings. During clinical assessment and management of an infant airway, improperly placed face masks can create obstructed airways. All systems of adult airway assessment cannot, therefore, be applied to children always (Straumann, Aceves, Blanchard, Collins, Furuta, Hirano & Simon, 2012). The second and one of the most important anatomical differences of the upper airway in paediatrics and adults is the diameter of the cricoid ring. In adult's upper airway, the vocal cords are the narrowest portion of the airway. In a neonate, infant or young child, on the contrary, the cricoid cartilage is the narrowest part of the upper airway. The difference causes the larynx of the neonate and infant child to be funnel shaped the larynx of the adolescents and adults, on the other hand, is cylindrical shaped. Due to this, the uncuffed endotracheal tubes create a subglottic seal. The feature caused by the narrowing of the airway below the vocal cords presses the sides of the tube, creating a seal. This difference may bring challenges to the assessment of a paediatric patient because the epiglottis 's hard to displace using a laryngoscope (Straumann, Aceves, Blanchard, Collins, Furuta, Hirano & Simon, 2012). Furthermore, it becomes difficult to view the glottis inlet when the anaesthetic provider is performing laryngoscopy. The different anatomical differences in a paediatric patient are essential to the provider of anaesthesia. The assessment techniques of the adult airway are not always applicable to the neonate, infant, and young children. For example, Mallampati classification procedure is not consistently applicable to the paediatric population. The Mallampati classification system can, however, be applied to children between the ages of four to eight years of age. Furthermore, other assessments and measurements tools used to assess the adult airway such as inter incisor and thyromental distance do not relate to the paediatric population (Straumann, Aceves, Blanchard, Collins, Furuta, Hirano & Simon, 2012). The differences found in the paediatric airway as compared to the adult airway require the anaesthesia provider to rely on their physical assessments. The anaesthesia giver can also rely on surgeon’s history and the physical examinations. All assessments processes have to begin with a thorough review of the chart. Any previous anaesthetic records are also necessary, as well as the reports from surgeons and the current state of airway according to physical examination findings. Paediatric patients are predominantly nose breathers. They may, therefore, have respiratory distress, caused by upper respiratory tract infection and have ventilatory patterns that are ineffective. For such patients, a simple nasal suction may reduce or diminish the suffering. In most cases, the distress is just caused by upper airway congestion or stuffiness. During the management of paediatric airway, the epiglottis may be difficult to displace using the laryngoscope because the uncuffed endotracheal tubes seem create a seal. The best technique used to manage the paediatric airway in such a case is through the use of Wisconsin or Miller Laryngoscope. The blade of the Miller and Wisconsin laryngoscope is the best for intubation because it lifts the entire epiglottis clearing the field of view (Finucane, Tsui & Santora, 2011). References Fiadjoe, J. E., Stricker, P. A., & Litman, R. S. (2012). Paediatric airway management. Gregory's Paediatric Anesthesia, Fifth Edition, 300-329. Finucane, B. T., Tsui, B. C., & Santora, A. H. (2011). Paediatric airway management. In Principles of Airway Management (pp. 415-513). Springer New York. Harless, J., Ramaiah, R., & Bhananker, S. M. (2014). Paediatric airway management. International Journal of critical illness and injury science, 4(1), 65. Straumann, A., Aceves, S. S., Blanchard, C., Collins, M. H., Furuta, G. T., Hirano, I., ... & Simon, H. U. (2012). Paediatric and adult eosinophilic esophagitis: similarities and differences. Allergy, 67(4), 477-490. Question 2 Discuss the benefits and risks of pharmacological agents, including their routes of administration for paediatric patients with moderate to severe pain. Pain on its own is a problem and not just an indication that there is an underlying disease. Pain extracts on individuals and the community as a whole. There are, however, many pharmacological agents that can be used to manage pain and improve the quality of life for patients. Various benefits are associated with the management of moderate and severe pain through administering pharmacological agents. First, the use of pharmacological agents to relieve pain helps in removing the barriers that are created by pain. For example, pain can create barriers when a doctor is trying to obtain adequate physical exam and medical history. When such is the case, pharmacological agents should be used to make the patient comfortable. Dworkin, et al. (2012) states that medications obtained from morphine are very effective painkillers. They mimic the analgesic system of the body and bind to opioid receptors to work with the central nervous system. Some of the drawbacks of using pharmacological agents to relieve moderate to severe pain is the adverse side effects related with their use. For example, opioid receptors are present throughout the body, and they interact with the opiate drug. The interaction consequently causes the side effects associated with the drug, such as nausea and vomiting. Some of the pain relieving pharmacological drugs reduce the sensitivity of the brain system respiratory centers to CO2, which later leads to respiratory depression (Schmidtko, Lötsch, Freynhagen & Geisslinger, 2010). Patients using pain relieving pharmacological agents experience nausea and vomiting due to reduced gut motility and constipation. Furthermore, overdosing the drugs accidentally is a significant risk. Pharmacological agents can be administered through various routes. Various factors, such as the type of pain, location, severity and aetiology determine the best route of pharmacological drugs administration. The characteristics of the chosen route of administration and the overall condition of the patient also determine the technique of administration. Analgesic agents can be administered through oral administration. One of the benefits of oral administration is that it is non-invasive and simple. In the treatment of moderate and some cases of severe pain, oral administration of analgesic agents has good efficacy. The patient also portrays high acceptability of oral route of administration. Oral administration is the route of choice because it is cheap, pain-free and the patient can self-administer (Finnerup, Sindrup & Jensen, 2010). Oral administration, however, has some few limitations. One of the limitations is delayed emptying of gastric and vomiting. Absorption is, therefore, likely to be impaired. When the normal gastric motility has not returned, giving multiple doses of analgesic drugs may cause them to be accumulated in the small intestines when emptying returns. Consequently, there could be a significant systematic absorption of the drug increasing the risk of adverse effects. To achieve the more rapid action of analgesic drugs, the use of the intravenous route is preferred as compared to the oral route of administration. The use of intravenous routes is beneficial when treating severe acute pain using opioids. Titration of opioids through the use of intravenous administration allows a rapid titration. Furthermore, the use of intravenous avoids the uncertainties of the drug being absorbed through other routes. One of the disadvantages associated with intravenous mode of administration of pharmacological drugs is irritation and cellulitis. Furthermore, there is a need for technical assistance. According to Finnerup, Sindrup and Jensen (2010), there exists the risk of getting an infection and repeat injections not always being feasible. Finally, intravenous mode of administration of pharmacological drugs is painful and less convenient. There are a few benefits associated with the use of intramuscular route of pharmacological drug administration. First, the absorption of the drugs is reasonably uniform; therefore, there is a rapid onset of drug action. In addition, the route of administration allows for gastric factors and first passes to be avoided. The disadvantages associated with this route of administration are the presence of pain and abscess, the risk of infection and nerve damage is high and up to 10ml of the drug can be administered (Caraceni., et al. 2010). Finally, the route of administration is expensive. References Caraceni, A., Hanks, G., Kaasa, S., Bennett, M. I., Brunelli, C., Cherny, N., ... & European Association for Palliative Care (EAPC. (2012). Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. The lancet oncology, 13(2), e58-e68. Dworkin, R. H., O'Connor, A. B., Audette, J., Baron, R., Gourlay, G. K., Haanpää, M. L., ... & Wells, C. D. (2010, March). Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. In Mayo Clinic Proceedings (Vol. 85, No. 3, pp. S3-S14). Elsevier. Finnerup, N. B., Sindrup, S. H., & Jensen, T. S. (2010). The evidence for pharmacological treatment of neuropathic pain. Pain, 150(3), 573-581. Schmidtko, A., Lötsch, J., Freynhagen, R., & Geisslinger, G. (2010). Ziconotide for the treatment of severe chronic pain. The Lancet, 375(9725), 1569-1577. Question 3 Management of a Traumatic Brain Injury (TBI) used to include hyperventilation and diuretics to lower intracranial pressure (ICP) as a standard first-line treatment. When and why did this change as a first line management strategy? Traumatic Brain Injury is a major source of morbidity and mortality. Managing Traumatic Brain Injury in the intensive care and emergency departments involves effective management of intracranial hypertension. Avoiding factors that aggravate and precipitate intracranial pressure is essential to managing traumatic brain injury (Sande & West, 2010). Hyperventilation to lower intracranial pressure was being used as a standard first-line treatment during management of Traumatic Brain Injury, but the practice stopped. The practices ended after modern methods of monitoring and controlling the pressure were discovered. Hyperventilation acts by decreasing PaCO2 (Sande & West, 2010). Consequently, there can be an induction of cerebral arteries when the CSF is alkalized. The reduction in cerebral blood volume then reduces intracranial pressure. The practice of using hyperventilation and diuretics as standard first-line treatment of intracranial hyperventilation stopped after it was discovered that it had limited use in the management of intracranial pressure (Nakagawa & Smith, 2011). When hyperventilation is used, it allows for other definitive methods of treatment to be used. The use of hyperventilation and diuretics, however, can be controversial. The reduction in the flow of CBF can be sufficient enough to induce ischemia in an injured brain. The first line therapy for reducing intracranial hypertension is through intravenous sedation and use of analgesia. Patients suffering from severe Traumatic Brain Injuries are in most cases agitated, and they require to be sedated, regardless of the condition of their intracranial hypertension. Due to the brain injury, it is often difficult to determine whether the cause of the agitation is pain or other causes. In case the patient is experiencing a lot of pain, the doctors will give opioids and sedatives to control the pain. Agitation can increase intracranial hypertension, in addition to other dangers such as self-extubation and pulling out intravenous lines (Einhäupl, et. al, 2010). Prevention and treatment of factors that aggravate or increase intracranial hypertension are essential to the management of Traumatic Brain Injury. To manage intracranial hypertension successfully, effective management, such as sedation, osmotherapy and drainage of cerebrospinal fluid are used to calm the patient and facilitate care giving. According to researchers, monitoring of intracranial pressure through effective means that do not increase aggravation of the brain plays a critical role of reducing mortality rate of patients suffering from severe traumatic brain injuries (Einhäupl, et. al, 2010). There are risks involved with some of the methods used to control intracranial hypertension. Some of the ICU methods include mechanical ventilation; surgical interventions and use of diuretics are potential causes of pain. In place of such interventions, the use of narcotics, such as morphine, remifentanil and fentanyl are used as first line treatments of Traumatic Brain Injury because they provide mild sedation, analgesia and depression of airway suppresses. Using adequate sedation techniques in place of hyperventilation and use of diuretics as first line treatment of Traumatic Brain Injury increases levels of comfort for the patient. When the patient is comfortable, nursing care becomes easy to administer. Other procedures such as mechanical ventilation can then be used to monitor intracranial hypertension. Use of sedatives as first line treatment reduces the consumption of oxygen and production of carbon dioxide (Einhäupl, et. al, 2010). The probability of harmful movement by the patients is reduced, thus, decreasing chances of aggravation of the brain injury. According to Ropper (2012), hyperventilation is not applicable as the first line treatment of Traumatic Brain Injury. Hyperventilation should be avoided during the first twenty four hours after the occurrence of atraumatic brain injury. Furthermore, hyperventilation may compromise an already critically injured patient by reducing cerebral perfusion. Hyperventilation is, therefore, recommended as a temporal measure to reduce increased intracranial pressure. To manage severe traumatic brain injury effectively, treatment should include comprehensive and meticulous intensive care. The care includes haemodynamic support, fluid management and respiratory care. The avoidance of using diuretics and hyperventilation as the standard first line care for traumatic brain injury is meant to prevent secondary brain injuries and maintain cerebral oxygenation (Einhäupl, et. al, 2010). References Einhäupl, K., Stam, J., Bousser, M. G., De Bruijn, S. F. T. M., Ferro, J. M., Martinelli, I., & Masuhr, F. (2010). EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. European Journal of Neurology, 17(10), 1229-1235. Nakagawa, K., & Smith, W. S. (2011). Evaluation and management of increased intracranial pressure. CONTINUUM: Lifelong Learning in Neurology, 17(5, Neurologic Consultation in the Hospital), 1077-1093. Ropper, A. H. (2012). Hyperosmolar therapy for raised intracranial pressure. New England Journal of Medicine, 367(8), 746-752. Sande, A., & West, C. (2010). Traumatic brain injury: a review of pathophysiology and management. Journal of veterinary emergency and critical care, 20(2), 177-190. Read More