ADVANCED ANAESTHETICS
ADVANCED ANAESTHETICS
Introduction
This essay will be presented as a case study and explore the roles of an anesthetist ODP taking handover for a surgical patient presented into a theatre with polytrauma. The author aims to develop a clinical picture of what led to the patient presenting the given gas values together with giving an interpretation of each blood gas value and stating the standard value. The essay will also try to determine the patient's diagnosis and the likely cause of the imbalance, anesthetic interventions/ management in intraoperative and postoperatively care and develop the critical appraisal. This essay will also address significant hemorrhage, respiratory distress syndrome, how to manage the patient's care, primary and secondary trauma and trauma management surveys, and shock-physiological changes. This will assist the learner in understanding how to care for traumatic patients due to injuries and patients suffering from various types of shock. It will also help the learner gain in-depth knowledge of their roles as operating department practitioners (ODPs).
Background:
A 21-year-old Chelsea (therein: the patient) was undergoing an open reduction, internal fixation (ORIF) of the patient's pelvis following a horse-riding accident. According to Healthline (2019), ORIF is used for severe fractures that cannot be managed using a cast or splint. The incidence of operative treatment has increased over time for these fractures (Nellans KW et al., 2012), and the decision to provide treatment with open reduction and internal fixation (ORIF) over other options may be more likely amongst those with hand surgery training background (Chung KC et al., 2011). ORIF is more expensive than other treatment alternatives, with 61% of all fracture care payments attributed to the surgical encounter (Shauver MJ. et al., 2011 & Karantana A et al., 2015). These fractures are usually displaced, unstable, or involve a joint. About the same site, open reduction indicates that an orthopedic surgeon has to make an incision to re-align the bone.
In contrast, internal fixation refers to joining bones (fractured ones) with hardware, usually metal pins, rods, plates, and screws (Nuelle C. W. et al., 2019). If the patient were stable, the team would have proceeded with the event on the patient's additional injuries. It was reported that the patient had fallen off a horse from approximately six feet and landed on her right side on a concrete road. The patient was reported unresponsive on paramedics' arrival but regained partial consciousness en route to the accident and emergency department (A&E). Typically, the patient is fit and non-allergic, with a body mass of 82 kilograms.
Methods and results
Paramedics used oropharyngeal airway and non-rebreather 02 masks, with 15L high flow O2 for airway support. On arrival at the accident and emergency department (A&E), the patient was intubated by the on-call anesthetist. Before being transferred to the theatre, the patient was taken for a C.T. scan which showed that the c-spine was clear and a lateral compression injury to the right side of the pelvis. The paramedics' report stated that the injury was stabilized with a pelvic splint on the incident scene. C.T. scan also diagnosed the patient with a closed tibia/fibular fracture of the right leg, a right compounded ankle fracture, and dislocated right shoulder. The scan cleared cranial/ soft tissue injury/ bleeding. ABCDE (A-E) assessment was done with findings as below:
Airway (A): the patient had a 7.0 ETT in situ, taped at 22cm. The patient's sats were 94%.
Breathing (B): the patient had no obvious chest trauma and had a bilateral air entry. Mechanically ventilated pressure-targeted assist control ventilation (PC-CMV) was done with the settings in the table below (Mechanical ventilation in the acute respiratory distress syndrome, 2016).
Feature
setting
Peak-inspired pressure (P.I.P.)
24 cm H2O
Inspiratory Time (T.I.)
0.90 s
FiO2 (%)
84%
R.R. (f)
12 bpm
PEEP
6.0 cm H2O
Circulation (C): the patient's heart rate (H.R.) was 89, and blood pressure (B.P.) was 105/58. E.C.G. indicated a normal sinus rhythm, and the patient had an arterial line in situ. On arrival at the theatre, a urinary catheter was inserted. The patient's Hb was 6.4 g/dl before the transfusion of R.B.C. One unit of R.B.C. was transfused to the patient through a warmed circuit. Another unit of R.B.C. was cross-matched and made available in case needed.
Disability (D): the patient's B.M. of 5.2 mmol/l was reported. The anesthetist used Ketamine infusion, and atracurium, tranexamic acid, morphine, and flucloxacillin had been given to this point.
Exposure (E): the patient's temperature was reported to be 35.7o. The patient was warmed with a fluid/ blood warmer and an upper body bair hugger.
Arterial blood gas sample was taken and analyzed upon the anesthetist's request, which gave the results in the table below:
Blood gas
Result
Normal values
PaO2
18.6 kPa (FiO2 85%)
10.5-13.5 kPa
pH
7.17
7.35-7.45
PaCO2
10.4 kPa
5.1-5.6 kPa
HCO3
23.3 mmol
22-26 mmol
BE
-2.5 mmol
-/+ 2 mmol
Hb
7.0 g/dl
13.5-17.5g/dl in males and 12.0-15.5g/dl in females
Arterial Blood Gas Analysis:
Arterial blood gas analysis is an essential routine investigation to monitor the acid‑base balance of patients, the effectiveness of gas exchange, and the state of their voluntary respiratory control (Verma AK & Paul R, 2010). The arterial blood gas (ABG) is used to measure the pH (acid-base balance) and the oxygenation of an arterial blood sample (Yannawar, D.A, 2019). The analysis may assess respiratory obstructions, peri-cardiopulmonary and post-cardiopulmonary arrest, and other medical conditions that may cause metabolic impairment. It may also be used to test the effectiveness of oxygen treatment, ventilator support, perioperative and postoperative patient care, and fluid & electrolyte infusion (replacement).
The pH, which is the acidity or alkalinity of a solution (in this case, blood), is determined by the concentration of the hydrogen ions. The value of the pH changes inversely to the hydrogen ion concentration. A decrease in the blood pH (<7.35) indicates an increase in hydrogen ions above the normal, resulting in a condition known as acidaemia (Kaufman, 2020). On the other hand, an increase in the blood pH (>7.45) denotes a decrease in hydrogen ions below the normal, causing a health condition referred to as alkalemia. The term acidosis is commonly used by clinicians when referring to acidaemia and alkalosis for alkalemia.
Carbon dioxide (CO2) is a critical body waste product of metabolism excreted during expiration. Under average metabolic production of carbon dioxide, the rate at which it is removed by alveolar ventilation is the only factor affecting the blood amount (Berman et al., 2017). A decrease in alveolar ventilation reduces the excretion of CO2, thus resulting in an increase in PaCO2 and the production of more hydrogen ions. If this causes, a decrease in the pH <7.5 and acidaemia is produced. Consequently, respiratory acidosis occurs if the primary cause of acidaemia becomes a problem for the respiratory system. An increase in alveolar ventilation results in the removal of CO2 faster than it is produced, resulting in a decrease in PaCO2, causing a reduction in hydrogen ions concentration (Respiratory Acidosis, 2020). This increases the pH above 7.45, resulting in the development of alkalemia. Again, a rise in pH causes a problem in the respiratory system resulting in a problem referred to as respiratory alkalosis (Kaufman, 2020).
Bicarbonate (HCO3-) is the most crucial buffer produced by the kidney. When the HCO3- buffers, hydrogen ions, CO2, and water are produced, and it is through this process that acids get excreted from the body (Berman et al., 2017).
HCO3- + H+ CO2 + H2O
In case of an acute increase in the acid load, bicarbonate decreases as it buffers the excess hydrogen ions. As reserved bicarbonate is used, hydrogen ions accumulate, thus decreasing the body's pH. Suppose the kidney fails to generate enough bicarbonate, which results in metabolic acidosis, which causes acidaemia in return (Kraut, J. A., & Madias, N. E., 2012). Occasionally, if there is excess bicarbonate in the body, there is excessive buffering of hydrogen ions causing metabolic alkalosis and alkalemia.
Base excess is the measure of the value of excess acid or base in the blood caused by metabolic derangement. Generally, it is determined as the amount of either strong acid or base that may be added to a blood sample with abnormal pH to restore it to the average value/range. A base excess (B.E.) below -2 mmol-1 denotes a metabolic acidosis, while that greater than +2 mmol-1 shows metabolic alkalosis (Altalag A. et al., 2018).
The partial pressure of oxygen in inspired air is 21 kPa which gradually decreases as the air moves down the respiratory tract to 13 kPa. Typically, the partial pressure of oxygen in the arterial blood (PaO2) is lower than the alveolar. For a hypoxic patient (a patient with low PaO2), increasing inhaled oxygen concentration can be used to increase the PaO2 and correct hypoxemia (Edriss H., 2014). Those administering oxygen must monitor the patient to keep the saturation levels within the required target range. Oxygen should be reduced or discontinued in stable patients with satisfactory oxygen saturation levels (Altalag A. et al., 2018). Some of the most common reasons for starting oxygen treatment include acute hypoxemia relating to shock, pulmonary embolus, myocardial infarction due to hypoxemia, postoperative states, and abnormalities in the quality and quantity of hemoglobin. According to (Edriss, H., 2014), there are no contraindications to oxygen treatment if indications are present.
Based on the above information, it is clear that the patient in this case study had developed acidosis due to decreased pH, respiratory alkalosis due to increased levels of PaCO2, metabolic acidosis resulting from reduced B.E. (-2.5), and was hypoxemic.
Major hemorrhage:
Major hemorrhage can be defined as loss of more than one blood volume within 24 hours, loss of 50% of the total blood volume in less than 3 hours, or bleeding of more than 150ml per minute. It can also be defined as bleeding, which leads to a systolic blood pressure below 90 mmHg or an H.R. above 110 bpm (Adam, S. et al.,2017). Based on the world health organization's (WHO) mortality data and systematic review of the literature, approximately 400,000 in-hospital deaths worldwide are caused by massive bleeding (WHO, 2010). This suggests that uncontrolled bleeding is the leading immediate cause of death among trauma patients, which could have been prevented. Significant hemorrhage results in severe tissue damage, inflammatory mediators release, anticoagulant activation, and fibrinolytic pathways.
According to (Adam S. et al., 2017), managing a patient with significant hemorrhage entails three elements: assessment and resuscitation following advanced life support principles; local control of bleeding including surgical, radiological, and endoscopic techniques; and hemostatic including transfusion support. This management practice involves several steps as listed: call for help and inform theatre team of the problem and note the time of incidence, increase FiO2 and consider cautiously reducing inhalational/intravenous anaesthetics, check and expose intravenous access, call blood bank and assign one of the team member to liaise with them (activate primary haemorrhage protocol, communicate how quickly blood is required and communicate the volume of blood required), start warming patient actively (rapid infusion and fluid warming equipment are used), discuss management plan between surgical, anaesthetic and nursing teams (liaise with haematologist if necessary, consider interventional radiology and/or consider use of cell salvage equipment), monitor patient's progress (use point of care testing: Hb, lactate, coagulation among others and/or use lab testing: including calcium and fibrinogen), substitute calcium with tranexamic acid if necessary, if bleeding persist consider giving recombinant factor VIIa liaising with haematologist, lastly plan ongoing care in an appropriate clinical area. The goals of transfusion are to maintain Hb >80gl-1; maintain platelet count; avoid D.I.C. by maintaining B.P.; treat/preventing acidosis, avoiding hypothermia; treat hypocalcemia and hyperkalemia, and maintain fibrinogen, and maintaining P.T. and APTT. Recent meta‐analyses have indicated that in hospitalized patients, a restrictive red cell transfusion policy was associated with a reduced risk of healthcare-associated infections (Green, R., & Curry, N., 2014)
Respiratory distress syndrome
Respiratory distress occurs when fluid builds up in the alveoli obstructing the lung from filling with enough air and causing decreased oxygen reaching the bloodstream (Ibrahim O. & slain K., 2019). According to Gattinon L. & Carlesso E. (2018), respiratory distress syndrome is associated with the below-listed causes:
- Inhaling toxic substances, such as saltwater, chemical, smoke, and vomit.
- Severe blood infection
- Severe lung infections such as pneumonia.
- Injury to the chest or head, and
- Overdosing on sedatives or tricyclic antidepressants.
Some factors that increase the risk of developing respiratory distress syndrome are age (above 65 years), chronic lung infection, alcohol misuse, and smoking.
Management of respiratory distress syndrome includes administration of oxygen via mask to prevent organ failure, pulmonary rehabilitation to strengthen the respiratory system and increase lung capacity, and management of fluid intake to ensure an adequate fluid balance (Mechanical ventilation in the acute respiratory distress syndrome, 2016). Medication can also be given to deal with side effects. These medications include pain inducers to relieve discomfort, antibiotics to treat an infection, and blood thinners to prevent clotting in the lungs or legs.
Primary and secondary surveys in trauma and trauma management.
Primary trauma surveys are designed to assess and treat life-threatening injuries rapidly. In contrast, the secondary surveys are rapid but thorough head-to-toe examination assessments aiming at identifying potentially significant injuries. The secondary survey should not be conducted until the primary survey has been completed, resuscitation has been started, all life-threatening conditions have been identified and controlled, and normalization of vital signs has started (Michael R. et al., 2021). The purpose of the secondary survey is to obtain pertinent historical data about the patient and his or her injury and to evaluate and treat all significant injuries not found during the primary survey by performing a systematic, complete examination (Galvagno SM & Nahmias JT, 2019). The primary survey in trauma includes ABCDE assessment, which aims to address life-threatening conditions in the airway, breathing, circulation, disability, and exposure (Godboley S. et al., 2015). The ABCDE method is relevant for rapid assessment and treatment in emergency scenarios. Specialists globally accept this method in A&E, and it is expected to improve the outcome by helping medical professionals to concentrate on the most dangerous clinical problems (Stewart RM & Rotondo MF, 2020). In the primary survey, the level of responsiveness may be assessed using the AVPU (alert, respond to verbal stimuli, respond to painful stimuli, and unresponsive to any stimuli) scale. According to Kelly CA, Upex A, and Bateman DN (2004) Alert\Verbal\Painful\Unresponsive (AVPU) responsiveness scale is the most widely used. The secondary survey involves a complete systematic examination, vital signs monitoring, and special diagnostic tests (arterial blood gas sample), among others (Akihiro Hamanaka, Y. Y, 2014).
A.T.M. trauma management (handover).
The main objective of the handover is to achieve effective communication of high-quality clinical at any time when transferring a patient's responsibility. The quality of handover may have an impact on patient care (Resuscitation Council-UK, 2015). There is a significant variation in the quality of handovers from pre-hospital to A&E medical teams.
Template of a handover (Dr. Davy Green, Handovers)
A
Age, name, and date of birth
Name:
Age:
D.O.B.:
T
Time of incidence
M
Mechanism of injury
I
Injuries
S
signs
G.C.S.:
AVPU:
Reps:
B.M.:
H.R.:
B/P:
O2 sats:
Temp:
E.C.G. attached
(please tick)
Yes
NEWS score
No
T
Treatment given
Drug given:
Quantity:
Time given:
Clinician
Name:
Date
Surgery:
Tel:
Shocks:
Shock is a life-threatening condition resulting from impaired blood flow in the body, which causes deprivation of oxygen and nutrients to the cells and other body organs (Ahmed T., 2019). A shock is a life-threatening condition that occurs when the circulatory system fails to result in the deprivation of oxygen in the heart and brain. It can also result from decreased practical circulating blood volume or body fluids due to an injury or illness (Green, R., & Curry, N., 2014). Shock can vary from faintness to complete collapse. Some of the effects of shock are progressive loss of blood from the circulation, which may lead to a failing heart output, and insufficient oxygen to the cells that are vital for survival; sustained low blood pressure may lead to organ failure-renal and liver failure; and early loss of consciousness that may involve the nervous system and may be fatal.
Cardiogenic shock
This is a life-threatening condition in which the heart suddenly cannot pump enough blood to meet the amount needed by the body (Shin J, 2018). It can be caused by problems outside the heart, which include fluid buildup in the chest causing tamponade, internal bleeding or blood loss, or pulmonary embolism. The heart muscle no longer imparts sufficient pressure to circulate blood (Ballas, J., & Roberts, S, 2018).
According to (Eric D, Perakslis, & Stanley M., 2021) (patient care & health information, 2021), medications are given to manage/treat cardiogenic shock aimed at increasing the heart's pumping ability and reducing the risks of blood clots. The patient may need vasopressors to treat low blood pressure, including dopamine, epinephrine, norepinephrine, etc. An inotropic agent such as dopamine, dobutamine, and milrinone to improve the heart's pumping function may be given until other treatments prove effective (Shin. J, 2018). Aspirin should be given to the patient immediately to reduce blood clotting and keep moving through a narrowed artery.
Hypovolemic shock
It is a life-threatening condition due to losing more than 20% of blood or body fluids. It may also be loss of body fluids with a change in the biochemical equilibrium, as seen in diabetes insipidus, vomiting, fistula drainage, hyperglycemia, and diarrhea (Ballas, J., & Roberts, S, 2018). The loss of excess fluid may make it impossible for the heart to pump enough volume of blood—relative hypovolemia results when fluid volume moves out of the vascular space into extravascular space.
The management of the patient suffering hypovolemic shock involves several steps, as listed below;
- Have the patient lie flat with their feet elevated about 12 inches
- Refrain the movement of the patient in case of head, neck, or back injury
- Keep the patient warm to prevent hypothermia
- Avoid giving the patient fluids via the mouth as this may cause choking.
Treatment of hypovolemic shock may involve blood transfusion, platelet transfusion, red blood cell (R.B.C.) transfusion, and intravenous crystalloids (Green, R., & Curry, N., 2014). The doctor may also administer medications to improve hearty pumping strength improve circulation. These medications may include dopamine, epinephrine, dobutamine, and norepinephrine (Green, R., & Curry, N., 2014). Administer antibiotics to prevent septic shock and bacterial infections.
Conclusion
In summary, the patient had acute respiratory acidosis with insufficient ventilation. This was evident due to increased values of PaO2 (18.6 kPa), the increased value of PaCO2 (10.4 kPa), and a low pH (7.17). Generally, there is an excess of bicarbonate. This affects the excessive buffering of H+, produces metabolic alkalosis, and increases the pH above average, resulting in alkalemia. PaO2 decreases slightly with age, at around 75 years of age at around 10 kPa, then rises again and plateaus at around 11 kPa because of the situation's acuteness. There was no metabolic disturbance or compensation. Primary surveys (ABCDE assessment) in trauma and trauma management were necessary to address airway obstruction, breathing, circulation, disability, and exposure in this patient and help the patient regain consciousness. Also, a secondary survey (head-to-toe examination) was required to address all the physical injuries sustained during the incident. All these surveys aimed at improving the health of the patient. The patient developed two significant shocks, namely cardiogenic and hypovolemic.
Cardiogenic shock results from internal bleeding caused by a closed fracture of the tibia/fibula in the patient's right leg and right-compound ankle, causing heart failure in pumping enough blood required by the body (Eric D, Perakslis & Stanley M., 2021). To address this shock, the patient was given one unit of R.B.C. via a warmed circuit and another unit preserved in case needed (Green, R., & Curry, N., 2014). The hypovolemic shock was due to low body fluids due to internal bleeding. The urinary catheter was used to help the patient with excretion. The patient was given PEEP with a 6.0 cm H2O setting to address hypovolemic shock.
The patient was hypothermic. Active warming with a fluid/blood warmer was also necessary for this patient to raise the temperature from 35.7 to normal. To bring this patient to homeostasis, the ability of the body to maintain a stable internal environment requires continuous body monitoring of internal conditions (Green, R., & Curry, N., 2014). Bodyworks to maintain homeostasis through a process referred to as a feedback loop (negative and positive feedback loop). The essential components of the feedback loop are the sensor (receptor), control center, and effector (Neuroendocrinology of Hydromineral Homeostasis, 2013).
Action plan:
Multiple studies report increased complications after ORIF, such as fixation loosening, nonunion or malunion, refracture, and infection (Nilika et al., 2016). To prevent all these problems, the below postoperative management scheme is recommended (Miguel AF et al., 2015).
Management aspect
purpose
Close follow-up visit
Excluding a time interval of 1 week, the patient must undergo a routine examination every six months to discover complications in time.
Progressive rehabilitation
Adoption of antibiotics during extended treatment to protect the body against microbial infections
Retain internal fixation
This will help in healing and reduce the chance of refracture, malunion and nonunion.
After close examination and interpretation of the patient's clinical status, there is a need for advanced postoperative patient monitoring. The patient is also advised to defer full weight-bearing walk to reduce the risk of delayed union.
Due to the patient clinical condition linked to significant hemorrhage, respiratory distress syndrome, and both cardiogenic and hypovolemic shock, it would be necessary to place the patient in the Intensive Treatment Unit (I.T.U.) for at least five days. This will facilitate patient monitoring progress and also prevent developing a complication. During this period, the dead part can also be removed.
References
Adam, S., Osborne, S., & Welch, J. (2017). Cardiac arrest and cardiopulmonary resuscitation. Oxford Medicine Online. https://doi.org/10.1093/med/9780199696260.003.0006
Adam, S., Osborne, S., & Welch, J. (2017). Trauma and major hemorrhage. Oxford Medicine Online. https://doi.org/10.1093/med/9780199696260.003.0011
Ahmed, T. (2019). MedlinePlus at 21: A website devoted to consumer health information. Information Services & Use, 39(1-2), 5-14. https://doi.org/10.3233/isu-180038
Akihiro Hamanaka, Y. Y. (2014). Bilateral adrenal hemorrhage secondary to heparin-induced Thrombocytopenia in a trauma patient. Journal of Trauma and treatment, 04(01). https://doi.org/10.4172/2167-1222.1000230
Alibrahim, O., & Slain, K. (2019). Noninvasive respiratory support in pediatric acute respiratory distress syndrome. Pediatric Acute Respiratory Distress Syndrome, 101–115. https://doi.org/10.1007/978-3-030-21840-9_9
Altalag, A., Road, J., Wilcox, P., & Aboulhosn, K. (2018). Arterial blood gas (ABG) interpretation. Pulmonary Function Tests in Clinical Practice, pp. 169–194. https://doi.org/10.1007/978-3-319-93650-5_8
Anne Kelly, C., Upex, A., & Bateman, D. (2004). Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow coma scale. Annals of Emergency Medicine, 44(2), 108–113. https://doi.org/10.1016/j.annemergmed.2004.03.028
Ballas, J., & Roberts, S. (2018). Hypovolemic shock. Critical Care Obstetrics, pp. 533–545. https://doi.org/10.1002/9781119129400.ch35
BASICS (N.I.) | Antrim ED Meducation. (n.d.). https://gcs3.co.uk/ed/ni-trauma/basics-ni/
Edriss, H. (2014). Acute respiratory distress syndrome, metabolic acidosis, and respiratory acidosis associated with citalopram overdose. The Southwest Respiratory and Critical Care Chronicles, 2(5). https://doi.org/10.12746/swrccc2014.0205.058
Farfán, M. A., Olarte, C. M., Pesantez, R. F., Suárez, S., & Vallejo, L. (2015). Recommendations for fracture management in patients with osteopetrosis: A case report. Archives of Orthopaedic and Trauma Surgery, 135(3), 351-356. https://doi.org/10.1007/s00402-014-2144-z
Galvagno, S. M., Nahmias, J. T., & Young, D. A. (2019). Advanced trauma life support® update 2019. Anesthesiology Clinics, 37(1), 13-32. https://doi.org/10.1016/j.anclin.2018.09.009
Godbole, S., Sahani, A., & Mohapatra, D. P. (2015). Undefined. Procedia Computer Science, 62, 266-273. https://doi.org/10.1016/j.procs.2015.08.449
Green, R., & Curry, N. (2014). Simulation training improves clinical knowledge of significant hemorrhage management in Foundation year doctors. Transfusion Medicine, 24(6), 379–384. https://doi.org/10.1111/tme.12161
Karnataka, A., Scammell, B. E., Davis, T. R., & Whines, D. K. (2015). Cost-effectiveness of volar locking plate versus percutaneous fixation for distal radial fractures. The Bone & Joint Journal, 97-B(9), 1264–1270. https://doi.org/10.1302/0301-620x.97b9.35560
Kaufman, J. A., & Kaufman, C. S. (2020). undefined. Image-Guided Interventions, 42-61.e1. https://doi.org/10.1016/b978-0-323-61204-3.00007-5
Kraut, J. A., & Madias, N. E. (2012). Treatment of acute metabolic acidosis: A pathophysiologic approach. Nature Reviews Nephrology, 8(10), 589-601. https://doi.org/10.1038/nrneph.2012.186
Langford, N., Good, A., Laing, W., & Bateman, D. (2004). Author's reply. British Journal of Clinical Pharmacology, 57(6), 817–817. https://doi.org/10.1111/j.1365-2125.2004.02135.x
Mechanical ventilation in the acute respiratory distress syndrome. (2016). Acute Respiratory Distress Syndrome, 353-376. https://doi.org/10.3109/9781420088410-21
Nellans, K. W., Kowalski, E., & Chung, K. C. (2012). The epidemiology of distal radius fractures. Hand Clinics, 28(2), 113-125. https://doi.org/10.1016/j.hcl.2012.02.001
Neuroendocrinology of Hydromineral homeostasis. (2013). Neurobiology of Body Fluid Homeostasis, 53-82. https://doi.org/10.1201/b15544-7
Nigam, P. K. (2020). undefined. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2020/46934.14329
Nuelle, C. W., Nuelle, J. A., & Balldin, B. C. (2019). Open reduction internal fixation of a traumatic Osteochondral lesion of the patella with Bioabsorbable screw fixation. Arthroscopy Techniques, 8(11), e1361-e1365. https://doi.org/10.1016/j.eats.2019.07.012
Open reduction and internal fixation lateral tibial plateau fractured lateral tibial plateau fracture, open reduction and internal fixation of fracture lateral tibial plateau, open reduction and internal fixation of36 lateral tibial plateau fracture: Open reduction and internal fixation. (2018). Fundamental Techniques in Orthopaedic Surgery. https://doi.org/10.1055/b-0038-162549
Perakslis, E. D., & Stanley, M. (2021). The patient is a mobile healthcare consumer. Digital Health, 201-206. https://doi.org/10.1093/oso/9780197503133.003.0017
Respiratory acidosis. (2020). Definitions. https://doi.org/10.32388/zu9258
Roberts, S., & Rac, M. W. (2018). Cardiogenic shock. Critical Care Obstetrics, pp. 631-639. https://doi.org/10.1002/9781119129400.ch39
Shauver, M. J., Yin, H., Banerjee, M., & Chung, K. C. (2011). Current and future national costs to Medicare for distal radius fracture treatment in the elderly. The Journal of Hand Surgery, 36(8), 1282-1287. https://doi.org/10.1016/j.jhsa.2011.05.017
Shin, J. (2018). Cardiogenic shock. Essentials of Shock Management, 35-43. https://doi.org/10.1007/978-981-10-5406-8_3
Stewart, C., Stewart, B., & L. Ware, M. (2020). Innovations in metastatic brain tumor treatment. Brain and Spinal Tumors - Primary and Secondary. https://doi.org/10.5772/intechopen.86047
Udwadia, F. (2014). Hypovolemic and hemorrhagic shock. Principles of Critical Care, 160-160. https://doi.org/10.5005/jp/books/12233_14
Wang, K., & Zeng, R. (2019). Arterial blood gas analysis and determination of acid and alkali. Handbook of Clinical Diagnostics, 331-336. https://doi.org/10.1007/978-981-13-7677-1_54
Wijeratne, N., Choy, K. W., Lu, Z. X., Brown, J., & Doery, J. C. (2016). A girl with bone sclerosis and fracture. Clinical Chemistry, 62(5), 684-687. https://doi.org/10.1373/clinchem.2015.244616
Wijesuriya, J. D., & Keogh, S. (2017). Integrated significant hemorrhage management in the retrieval setting: Damage control resuscitation from referral to receiving facility. Emergency Medicine Australasia, 29(4), 470-475. https://doi.org/10.1111/1742-6723.12742
Yannawar, D. A. (2019). A prospective study of arterial blood gases in bronchial asthma in a tertiary care hospital. Journal of Medical Science And clinical Research, 7(12). https://doi.org/10.18535/jmscr/v7i12.17
Comments