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Emergency In Head and NeckSurgery
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Emergency In Head and Neck
SurgeryDr. Khalid AL-Qahtani
MD,MSc,FRCS(c)
Assistant ProfessorConsultant of Otolaryngology
Advance Head and Neck Oncology , Thyroid and
Parathyroid,Microvascular Reconstruction,
Skull Base Surgery
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Why Am I Here?
New treatment available .
Know whatto do, whento do it, and how
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Recognize symptoms signs ofcommon H&N emergency.
Team work
To be decisive
Learn to ACT FAST and EFFICIENT
What Should I Learn?
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What Emergency I mean
Emergency related to specific
disease
Emergency related to the
procedure
Emergency not related to both
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Example Airway obstruction laryngeal Ca
Trauma to carotid in ND
Strock
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Classification
Surgical Operative
Post operative
Medical
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PREVENTION
Correction of nutritional status
Preop preparation for hyperthyroid
patientsReview of medicationpreoperatively
Avoid trifurcation on top of the
carotidNo skeletenizition of the carotid
Patient education
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Airway obstruction
Congenital
Infectious
Inflammatory
Trauma
Tumour
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Airway Emergency
A difficultairwayis defined as the
clinical situation in which a
conventionally trainedanesthesiologist experiences
difficulty with face mask ventilation
of the upperairway, difficulty with
tracheal intubation, or both
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Difficult mask ventilation
(1) Inability of unassisted
anesthesiologist to maintain SpO2> 90% using 100% oxygen and
positive pressure mask ventilation
in a patient whose SpO2 was 90%
before anesthetic intervention; or
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2) Inability of the unassisted
anesthesiologist to prevent or
reverse signs of inadequateventilation during positive pressure
mask ventilation.
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Difficult laryngoscopy
Not being able to see any part of the
vocal cordswith conventional
laryngoscopy
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Difficult intubation
Proper insertion with conventional
laryngoscopy requires either
(1)More than three attempts or(2)More than ten minutes
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Suspect airwayobstruction Dyspnea
Stridor
Inspiratory - Usually a supraglottic
obstruction being sucked into the glottis
with inspiration
Expiratory - Usually a subglottic
obstruction being blown up into the glottis
during expiration Biphasic - Both of the above or a lesion
isolated to the glottis (eg, edema)
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Voice change
Decreased or absent breath
sounds Bleeding
Drooling
Restlessness Hemodynamic instability (late)
Loss of consciousness (very late)
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The patient should be asked a
simple question
If he responds appropriatelyThe airway is patent
Ventilation is intact
The brain is being adequatelyperfused
Agitation is often a sign of hypoxia
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Airway Management
OBJECTIVE: Maintain Patent AirwayOpen Airway
Head-tilt/chin-lift method
(big tongue, forward jaw displacementcritical)
Jaw thrust method with possible neckinjury
Suction
Artificial AirwaysOropharyngeal
Nasopharyngeal
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Breathing
Objective: Maintain Gas Exchange
Rescue Breathing
Mouth to mouth/nose-mouth
Bag and MaskSelf-inflating Bag-Mask
w/o reservoir 30 -80 % O2with reservoir 60-95 % O2
Do NOT use demand valve
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Best Sign of Effectiveventilation
Chest Rise
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Intubation
If no cervical spine fracture
orotracheal intubation is preferred If cervical spine injury can not be
excluded consider nasotracheal
intubation
The position of the tube should be
checked
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Complications include:
Oesophageal intubation
Intubation of right main bronchus Failure of intubation
Aspiration
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Awake intubation
Awake trache
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Cricothyrotomy
Tracheotomy
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Surgical airway CricothyrotomySlash trache
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Needle Surgical
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Contraindication
Known laryngeal pathology
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Needlecricothyrotomy Cricothyroid membrane is
punctured with a 12 or 14 Fr
cannula
Connected to oxygen supply via
a Y connector
Oxygen supplied at a rate of 15
l/min
Jet insufflation achieved by
occlusion of Y connection
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Insufflation provided one second
on and four seconds off
Jet insufflation can result insignificant hypercarbia
Should only be used for 30 - 40
minutes
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Quiz
Laryngeal ca
Bilateral cord palsy
Complex facial trauma Ludwig angina
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Tracheoinnominate fistula
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Respir Care. 2001 Oct;46(10):1012-8
Prolonged intubation
Long term tracheotomy
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the mortality is nearly 100 %
without operation& 15-20% if
treated incidence of TIF is only 0.6 %
it accounts for most deaths
resulting from tracheostomy
72% of TIF presenting within the
first 3 weeks
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factors known tocontribute to the formation
of TIF Tracheostomies below the third or fourth tracheal ring
bring the cuffs closer to the innominate artery
Overinflated cuffs erode the tracheal cartilage
Sharply bent cannulas
Tracheostomy tube with adjustable flange
Addition of CPAP
Vascular anomalies Auris Nasus LarynxVolume 32, Issue 2 , June 2005, Pages 195-198
http://www.sciencedirect.com/science?_ob=JournalURL&_cdi=4978&_auth=y&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=b5c5c3de760ea6ff3ddfccde8fce03c7http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=JournalURL&_cdi=4978&_auth=y&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=b5c5c3de760ea6ff3ddfccde8fce03c7http://www.sciencedirect.com/science?_ob=JournalURL&_cdi=4978&_auth=y&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=b5c5c3de760ea6ff3ddfccde8fce03c7 -
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Signs of impending
bleeding Aspiration of blood
Pulsating cannula
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DD
Tracheitis
Wound bleeding
Pneumonia Traumatic suctioning
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Postoperative wound bleeding
usually occurs less than 48 hours
after placement of thetracheostomy,
Pneumonia is usually associated
with increased secretions and
fever.
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Diagnostic modalities such as
chest radiograph or flexible
bronchoscopy can be used toconfirm these other conditions but
cannot rule out TIF
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PREVENTION
Tracheostomy should beperformed at the second or thirdtracheal ring
Avoiding hyperextension of theneck
The pressure in the tracheal cuffshould be below 20 mmHg
The patient has to be weaned fromthe ventilator early
Thorac cardiovasc Surg 2002; 50: 249-250
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Jones et al recommend that
patients with tracheostomies
longer than 48 hours with bleedingin excess of 10 mL be given the
diagnosis of TIF and treated
accordingly until proven otherwise
Ann Surg. 1976;2:194-204
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Management
Airway
Control of bleeding
Fluid and blood resus CVT + O.R
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Overinflation of the cuff, which has
been successful in temporary
control of bleeding in 85 % ofcases .
Ped emerge care Volume 21(11), November 2005, pp 763-766
http://gateway.ut.ovid.com/gw1/ovidweb.cgi?View+Image=00006565-200511000-00012|FF1&S=IDNJHKJOCBBPBN00D&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00006565-200511000-00012 -
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Direct digital compression against
the sternum of the innominate
artery succeeds in 89 % of patientswhen overinflation of the cuff fails
Ped emerge care Volume 21(11), November 2005, pp 763-766
http://gateway.ut.ovid.com/gw1/ovidweb.cgi?View+Image=00006565-200511000-00012|FF2&S=IDNJHKJOCBBPBN00D&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00006565-200511000-00012 -
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Definitive treatment
Median sternotomy with resection
of the segment of the innominate
artery involved and removal of any
inflamed or necrotic segment of the
arterial wall
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Carotid blowout
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Classification
Threatened carotid blowout
Sentinel hemorrhage/impending
carotid blowout Acute carotid blowout
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Group 1 patients have a visibly
exposed segment of the carotid
artery that invariably will rupture if
not promptly covered with healthy,
well-vascularized tissue
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Group 2 patients present with a
short-lived acute hemorrhage that
resolves either spontaneously or
with simple surgical packing
Group 3 patients present with an
acute, profuse hemorrhage
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Prevention of carotidartery rupture
Do not traumatize the carotid
vessel. Adequate handling of the
carotid artery and preservation of
the adventitia are most important.
Avoid suction catheters that lie
adjacent to the carotid artery.
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If a fistula is present, it is diverted
away from the carotid area.
Use adequate dressings that retainmoisture.
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Cover the carotid artery
Treat infection aggressively with
drainage, culture, and appropriateantibiotics
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Apply direct and firm pressure to
the affected area. The operating
room should be prepared for neck
surgery. Suctioning, good
illumination, and adequate
instrumentation are imperative.
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Cannulize a peripheral vein in each
of the patient's arms with a large-
bore catheter for immediate
administration of fluids (Ringer
lactate or isotonic sodium chloride
solution). Controlling blood
pressure and blood volume beforethe ligation is important.
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The airway should be adequate
and stable. If the patient does not
undergo a tracheotomy,
orotracheal intubation may be
necessary.
Type blood and cross-match it for
4-6 units.
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Move the patient to the operating
room.
If the bleeding cannot be controlledby pressure, clamp the common
carotid artery as an emergency
procedure after the blood pressure
and pulse are within the referencerange
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Definitive treatment forcarotid artery rupture
Ligate the carotid artery.
Avoid repair or diversion in an area
of infection. Use general endotracheal
anesthesia.
Have adequate instrumentation
ready
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Endovascular therapeutic management of CBS
by John C et al in 1999
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12 patients
20 RECURRENT
13 PD 7 TF
32 EPISODES
5SUCCESS12 success
12 SINGLE
EPISODE
2 Surgical
1 died
10 success2 surgical
American Journal of Neuroradiology20:1069-1077
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Seven exposed carotids
Seven carotid pseudoaneurysms
Eight small-branchpseudoaneurysms
Five tumor hemorrhages
Three hyperemic/ulcerated wounds
One aortic arch rupture
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Intraoperativeemergency
Bleeding
Carotid sinus reflux
Pneumothorax Air embolus
Embolism
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IntraoperativeHemorrhage
Severe blood loss is uncommon
Major vessel trauma, laceration, tear, or
transection frominternal jugular vein,
junction of internal jugular vein and
subclavian
and/or carotid artery .
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Inernal jugular bleeding
A small tear or laceration requires primary closure
with a 6-0 continuous vascular suture
If the lower end of the jugular vein bleeds
excessively : pressure is the first aid
followed by adequate visualization and suctioning
until the stump is identified, dissected, and ligated
uncontrollable may need thoracic surgeon assistance
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If the upper end of the vein bleeds and the stump
has retracted into the temporal bone :
packing the jugular foramen with large pieces ofSurgicel
plicating with the posterior belly of the digastric
muscle
or both are sufficient to solve the problem
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Carotid sinus reflux
Hypotension caused by carotid sinus reflux
This may be avoided by
careful dissection at the carotid bifurcationwithout manipulation,
injection of 2 mL of local anesthetic into the
adventitia at the carotid bifurcation
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Air embolus
Air embolism can occur when a large vein is
inadvertently opened
A large volume of air enters rapidly into the openvein by negative pressure and passes directly
into the right atrium
leading to tamponade of the heart and even
death
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Clinically:
cyanosis
hypotensiona loud churning noise over the precordial area
appear suddenly
the peripheral pulse disappears
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Treatment
Packing or clamping the offending vein
immediately
Turning the patient onto the left side with thehead down
Cardiac arrest may occur, requiring aspiration
of the air from the heart, massage, and
standard resuscitation procedures.
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Embolism
Embolism may occur and lead to stroke
Most patients with cancer are of the age at whichCVA is common
Careful handling of the carotid in the neck with
gentle retraction, and manipulation is the key for
prevention.
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Medical emergency
Hyperthyroidism: indications for
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Hyperthyroidism: indications foremergency management
Acute coronary syndrome
Heart failure
Thyroid storm fever
agitation or stupor
severe concomitant illness
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Confirm hyperthyroidism (free T4, TSH)
Propylthiouracil (PTU) 200-300 mg PO Q 6 hr
Iodine (SSKI) 2 gtt (80 mg) PO Q 12 hr
Beta- adrenergic antagonist if not in CHF propranolol 40 mg Q 6 hr
adjust dose to HR
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Intensive therapy of concomitant disease
Follow free T4 Q 4-6 days
When free T4 normal, schedule RAI therapy
stop iodine 2-4 weeks beforestop PTU 3-5 days before
Hypothyroidism: emergent
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Hypothyroidism: emergenttherapy
Indications:
Hypoventilation
BradycardiaHypotension
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Hypothyroidism: emergent therapy
Confirm diagnosis: FT4, TSH
T4 50-100 mg IV Q 6 hr x 24 hr,
then T4 75-100 mg IV Q 24 hr
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Thyroid storm
More recent series have yielded fatality
rates between 20% and 50% dropped
from 100% noted by Lahy
It more likely represents improvements inearly recognition and the beneficial
effects of the serial addition of
antithyroid, corticosteroid, and
antiadrenergic therapies to the treatmentof this disorder
Ann Surg 1931; 93: 1026-30.
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Risk factors
Infections, especially of the lung
Thyroid surgery in patients withoveractive thyroid gland
Stopping medications given for
hyperthyroidism
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Too high of thyroid dose
Treatment with radioactive iodine
Pregnancy
Heart attack or heart emergencies
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symptoms
Palpitation
Greatly increased body temperature
Chest pain
Shortness of breath
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Anxiety and irritability
Disorientation
Increased sweating
Weakness
Heart failure
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Laboratory findings in thyroid storm
are consistent with those of
thyrotoxicosis
Presently, no specific diagnostic
criteria to establish the diagnosis of
thyroid storm exist
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Elevated T3 and T4 levels
Elevated T3 uptake
Suppressed TSH levels
Elevated 24-hour radioiodine
uptake
Oth b l
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Other abnormallaboratory values
Increased BUN and creatinine kinase
Electrolyte imbalance from dehydration,
anemia, thrombocytopenia, and
leukocytosis Hepatocellular dysfunction as shown by
elevated levels of transaminases, lactate
dehydrogenase, alkaline phosphatase,
and bilirubin
Elevated calcium levels
Hyperglycemia
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TREATMENT
Medical
supportive
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Blocking Thyroid Hormone
Synthesis
Blocking Thyroid HormoneSecretion
Blocking Peripheral Action of
Thyroid Hormone
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Supportive Measures
Pressor agents
Add glucose
central cooling Multivitamins
Acetaminophen
Cooling blankets Steroid
Digitalization
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Hypercalcemia
Primary hyperparathyroidism
Malignancy: Breast carcinoma
Squamous lung carcinoma, head & neckcarcinoma
Myeloma
Renal carcinoma
Miscellaneous: vitamin D intoxication milk-alkali syndrome (calcium carbonate)
Indication of emergent
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Indication of emergenttherapy
Severe symptoms of
hypercalcemia
Plasma [Ca] >12 mg/dl
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Therapy
Restore ECF volume
Normal saline rapidly
Positive fluid balance >2 liters in first 24 hr
Loop diuresis
Normal saline 100-200 ml/hr
Replace potassium
Zoledronic acid 4 mg IV over 15 min ( malignancy) if plasma [Ca] >14 mg/dl or >12 mg/dl after rehydration
Monitor plasma calcium QD
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Hypocalcemia
Hypoparathyroidism Surgical
Autoimmune
Magnesium deficiency
PTH resistance
Vitamin D deficiency
Vitamin D resistance
Other: renal failure, pancreatitis, tumorlysis
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Signs
Paresthesiae
Tetany
Trousseaus, Chvosteks signs Seizures
Chronic: cataracts
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Indication for therapy
Symptomatic or Trousseasus
positive
Plasma calcium
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Therapy
IV calcium infusion 100-300 mg of elemental calcium should
be given over 5-10 minutes
Calcium infusion drips should be startedat 0.5 mg/kg/h and increased to 2mg/kg/h as needed
Follow plasma Ca & P Q 4-6 hr & adjustrate
Oral calcium 1-2 gm BID - TID
Oral calcitriol 0.25-2 mcg/day
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Take home message
Careful preop evaluation
Team work
Avoid unnecessary moves Apply you basic skills
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