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torturing-characters-101 · 3 years

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maybe this is a little vague, but how long would it take for a coma patient to die after their life support is withdrawn?

Very interesting question. It depends on what life support measures are being implemented, and how dependent on them the person is.

Life support is a range of different machines and therapies designed to keep a person alive. This ranges from something called ECMO, which effectively takes over for the heart and lungs for temporary periods, to simply a tube that goes from the nose to the stomach to deliver food and water to a person who cannot eat or drink.

As stated above, the most intensive life support is ECMO, which is essentially a machine that takes over the functions of the heart and lungs temporarily- oxygenating blood outside the body and circulating it. This is usually used in open heart surgery, though it can be used in some ICUs for longer periods of time. Assuming the person is entirely dependent on ECMO (as in, they do not have heart or lung function on their own), they would begin to die within minutes of ECMO being withdrawn.

Next down might be something like a ventilator. Ventilators have different modes that allow a person who has some respiratory function on their own to continue exercising it while being supported mechanically.

For example, someone may be on a ventilator only to provide extra pressure to overcome the resistance from a tube that goes from their mouth to their lungs to hold open their airway, and sometimes it adds pressure to make it easier for the person to pull in breaths. This person can probably breathe on their own for an indeterminate amount of time and would not necessarily die if the ventilator was withdrawn, though they may have trouble keeping their airway open or they may tire out easily trying to breathe.

Another vent setting involves the patient breathing as much as they can, and the ventilator serving as a backup. If the person doesn't take a breath in a set number of seconds, the ventilator gives them one. This person may survive for a while afterwards, but would likely eventually die due to high levels of carbon dioxide in their blood. It might be any time between an hour or less to several days before the person's death.

The highest setting on most vents still allows the patient to initiate breaths, but every breath they take is assisted to ensure it is a complete breath, and the machine also delivers a set number of breaths every minute. Someone who is dependent on this mode may pass within minutes of being taken off the vent and likely wouldn't live more than an hour or so, dying from lack of oxygen or buildup of carbon dioxide.

Another life support device is a cooling blanket. When certain parts of the brain are damaged (such as the parts that are damaged after a long period without oxygen), the person cannot control their own temperature, and they tend to get extremely overheated by their own metabolism. Temps can get into the 110's *F, which kills pretty quickly. Fever-reducing drugs are not effective. This would also be someone who could last anywhere from an hour or so to a couple of days, though their brain would quickly become more and more damaged during this time.

The least intensive form of life support would be the provision of food or water through an NG tube- a tube that goes from the nose to the stomach and allows medications and tube feed (water and basic nutrition) to be delivered to the stomach. If this is withdrawn and IV fluids are not provided, the person may live a week or more before dying of dehydration. If they are, for some reason, given IV fluids, they may live months.

Note that a person may be on a combination of modalities (like it would be weird for someone to be on a ventilator without an NG tube).

-Ross ( @macgyvermedical)

#whump reference #writing reference #whump #ventilators #ECMO #life support #NG tube

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scottmaymon-blog · 5 years

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disastermedicineer-blog · 7 years

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Biological Disaster

Biological disaster -------------------- ( BDLS & ADLS)

Factors that compose the "chain of infection" 1. Infectious agent - the greater virulence,invassiveness & pathogenicity --> the greater possibility organism will cause infection

2. Reservoirs - the infectious agent normally lives & multiply , can reproduce itself & transmitted to susceptible host

3. Portal of exit - biological agent leave the reservoir

4. Mode of transmission - mechanism which infectious agent is spread - can be airborne,droplet , direct & indirect physical contact, fecal oral transmission , vector mediated transmission

5. Portal of entry - infectious agent enter host through skin,mucous membrane, lung. GIT, genito urinary , placenta , invasive procedure

6. Susceptible host - influence by factors: 1, hod defense characteristic 2. Medical condition immunocompramised 3. Malnutrition 4. Pregnancy 5. Age 6. Increase exposure risk 7. Behavior factors

Biological disaster --------------------- Epidemic: - illness that occur in higher number that expected within a country & region.

Pandemic: - worldwide epidermic disease - 3 condition: 1. New disease emerges to a population has little or no immunity. 2. Disease is infectious for humans 3. Disease spreads easily among humans

Bioterrorism Criminal act that causes illness, both law enforcement & public health authorities have responsibility to responds .

Intention use of biological agent to harm human or living organism. - inexpensive - easy to produce - easy to disguised - difficult to defend

Potential BT threats ---------------------- Category A: high priority agents - easily disseminated - high mortality - causes public panic - require public health for special action

Eg antarax,botulism,plaque,small pox & tularemia, viral haemorrhagic fevers

Category B: second priority agents - moderate easy to disseminate - moderate morbidity & low mortality - require enhancement of CDC

Eg brucelosis Clostridium perfrongens E. coli Meliodosis Q fever Viral encephalitis

Category C: third priority - easily available - easily produced or disseminated - potential for high morbidity & mortality Eg Nipah virus, SARS

Situational awareness & detection ---------------------------------------- - high index of suspicious - usually multiple report - simultaneously outbreak of different diseases in same locale - large number of casualties in hours to days

Clue for bioterrorism attack -------------------------------- 1. Increase in unexplained deaths 2. Unusual age distribution of patient - severe illness 20-50 years

3. Unusual seasonality 4. Unusual manusfestation of disease or occurrence of animal die off - antarax: inhalation

Clinical decision making ---------------------------- Characteristic clinical symptoms of selected potential BT agents

1. CXR: Widening mediastinum - anthrax

2. Symmetrical flaccid paralysis - botulism

3. Hemoptypsis - pneumonic plaque

4. Pox like rash - small pox

5. Diarrhoea - cholera - shigelosis

Transmission based infection control ------------------------------------------- (I) Droplet precaution ------------------------ - transmitted by large particle droplet >5um - through cough, sneeze, talk or resp care procedure.

Rx 1. 3 feet away 2, surgical mask or respiratory care procedure

(II) contact precaution -------------------------- - transmitted by direct contact with patient or indirect contact with potentially contaminated surfaces

Rx Wear gloves Gown Remove gown before enter Wash hand

(iIi) Airborne precaution ---------------------------- - limit transmission airborne droplet <5um of evaporated droplet containing microorganism that remain suspended in air for long time or dust particles.

Rx N95 Powered air purifying respirators m Negative pressure room with minimum six air exchanges per hour - exhaust direct outside or high efficient particulate air filtration

If source unknown: Contact precaution & N95 or better respiratory

Triage -------- Goal - prevent 2' transmission through implementation non medical strategy

Triage model SEiRV - Susceptible: person not yet exposed but susceptible

- exposed: susceptible & have in contact with infected person, they maybe infected but not contagious

- infectious: symptomatic & contagious

- removed: no longer transmit disease as they survived or died

- vaccinated : prophylactic medication intervention to protect them from infection

Rx Self protective measures Designated evacuation areas ABCs

Clinical assessment & diagnosis ------------------------------------ Fbc ABG Nasal swab for culture & pcr Blood for bacterial culture & pcr Serum for serological studies Sputum for c&s Blood & urine Tox Throat swab for viral culture, Pcr & enzyme linked immunosorbent assay Environment samples

Theurapeutic intervention Established diagnosis Prompt therapy Eg antarax & plaque / treatment within 24H ( longer - grim prognosis)

Biological agent - specific issues ( I) Anthrax ------------- Causative agent: bacillus anthracis

Site of infection : 1. Cutaneous 2. Inhalation 3. GIT

Incubation period: 1-7 days ( as long as 12/7)

Presentation Small itchy papule or vesicles 2nd day : ulcer Usually on exposed area of body Non render swelling around ulcer Small vesicles may surround ulcer Then black scab or ESCAR x 2/52 80-90% resolves LN + Fever +

Inhalation antarax Incubation: 2-43/7

Presentation *** classical : fever & respiratory distress + shock + widening mediastinum

Flu like illness - fever - fatique - cough - sob - headache - anorexia

Then Sudden increase in fever Respiratory distress Diaphoresis Shock

CXR Widening mediastinum Inflitrates Pleural effusion

GI anatarx Ingestion contaminated meat Nausea Vomiting Bloody diarrhoea

Ix Blood culture - gram positive bacilli

Gram stain Sputum CXR: widening mediastinum

Rx IV ciprofloxacin 400mg bd Or IV doxycycline 100mg bd

Standard barrier precaution only No need airborne precaution

Mneumonic: AB CD ( Anthrax bacillus cipro doxy )

Botulism Causative: toxin by C.botulinum One of the most poisonous substance known

Clinical features Onset: 12-36Hv

1. Bulbar palsy 2. Blepharoptosis 3. Bluring vision 4. Dry mouth 5. Difficulty speaking 6. Trouble swallowing

( descending pattern paralysis) " descending type of paralysis"

No fever Not confused Not obtunded Rapid onset Severity depends on amount toxin absorbed

7. Descending symmetrical skeletal muscle paralysis 8. Respiratory muscle paralysis

Diagnosis " clinical presentation" Confirmatory : blood toxin assay

Treatment ----------- Supportive - intensive care + close monitoring respiratory failure & feeding

May take 1-3/12 for the toxin to resolved. Hence; need ventilatiry support if intubated.

Antitoxin - only stop the progression paralysis but will not reverse the existing paralysis.

No prophylaxis

Standard precaution for infectious control. - no person to person transmission

Pneumonia plaque -------------------- Causative agent: Y. pestis

Highly fatal Person to person

Via flea vector

Route; aerosolization ( common)

Clinical features ------------------ Incubation period: 1-6/7

Classical: fever + chills + intense swelling LN in one area.

But if terrorist attack with spray: Fever , cough ---> rapid pneumonia

1. Abrupt onset high fever 2. Chills 3. Malaise 4. SOB 5. Cough with bloody sputum 6. Sepsis 7. Nausea 8. Vomiting 9. Diarrhoea 10. Severe rapidly progressive pneumonia

Diagnosis CXR: pathchy infiltrates Culture blood & sputum Gram stain : safety pun bipolar staining

Rx IM Streptomycin iM /IV gentamicin

Pregnant: gentamicin preferred

Prophylaxis Doxycycline Or Ciprofloxacin

Infectious control: Droplet precaution for 48H - must be 3 feet away

Mneumonic: PSG Department Plaque streptomycin gentamicin droplet precaution

SARS ------- Causative agent ------------------- SARS associated coronavirus

Clinical features ----------------- IP: 2-7 days

1. Flu like prodromal 2. Fever with chills & rigors 3. Headache 4. Muscle aches 5. May hv diarrhoea

Day 3-7: Cough SOB

Diagnosis

Probable SARS: Severe respiratory illness Unknown etiology Epidemiology of exposure Lab criteria used to confirm

Suspected SARS: Moderate respiratory illness Unknown etiology Epidemiology for exposure Lab criteria to confirm

Moderate respiratory illness - temp > 100.4'c - respiratory findings 1. Cough 2. Sob 3. Hypoxia

Severe respiratory illness - moderate respiratory illness + one findings as below: 1. X-ray: pneumonia 2. Respiratory distress syndrome 3. Autopsy: pneumonia or RDS w/o cause

Epidemiology - exposure to SARS in travel within 10/7 to area with current,documented or suspected SARS.

Treatment No proven Tx Antibiotic to cover CAP & atypical pathogens

Prophylaxis No known

Infection control - standard precaution ( hand wash) - contact precaution ( gown & gloves) - airborne precaution ( -ve pressure room & N95) - eye protection

Smallpox ----------- Mortality rate 30%

Clinical features IP: 7-17 days

Prodromal ( more severe than chicken pox) ( look sick before rashes appear) - lasting 2-3/7 - fever - myalgia - prostration - nausea - vomiting - delirium

Rash ( all same stages of maturity) ( more rounded) ( more in face & extremities while chicken pox more in trunk ) ( chicken pox less on palm & soles) ( start periphery then go centrally) " outside to inside" " all same stage"

- start on face & extremities including palm & soles Then spread to trunk ( macular --> papular--> vesicles--> pustules ) - form,deep & umbilicated - rash scan over 1-2/52 resulting in scars

Diagnosis 1. Clinical recognition 2. History 3. Confirmatory test in CDC

Treatment Vaccination small pox - very effective if within 3/7 exposure

Supportive care Daily eye rinsing Adequate hydration & nutrition Start penicillase resistant antibiotic if : 1. Secondary infected 2. Bacterial endangers the eyes 3. Eruption very dense & widespread

Specific therapy No specific therapy If corneal lesions: topical isoxuridine

Cidofovir

Infection control ------------------ Airborne & contact precaution Treated in negative pressure room

Tularemia ------------- Agent Francisella tularensis

Spread: Ticks or biting flies Direct bite by rabbits

Clinical features ------------------ Classical; fever + tender papule --> ulcer with eschar + tender LN

If terrorist by spray; fever + shock + pneumonia

IP: 3-5/7

1. Acute febrile illness with prostration 2. Conjunctivitis or skin ulcer with regional adenopathy 3. X-ray: pneumonia (80%)

Diagnosis ----------- Blood C&S Gram -ve coccobacillus

Treatment ------------ IV streptomycin + gentamicin

Alternative: Doxycycline Ciprofloxacin Chromphenicol

Prophylaxis Doxycycline Ciprofloxacin X 14/7

Infection control ------------------ - not spread from person to person - standard precaution. - no need any isolation - notification immediately

Viral haemorrhaguc fever ----------------------------- Examples 1. Filovirus Ebola Marburg

2. Arenavirus Lassa Machupo

Transmitted Infected animal or arthopods

Mortality rate Ebola: 90%

Clinical features ------------------- IP: 2-21/7

Presentation: 1. Non specific prodromal 2. Hypotension 3. Relative bradycardia 4. Rapid breathing 5. Conjunctivitis 6. Pharyngitis 7. Generalized bleeding problems - mucous membrane haemorrhage - shock - hematemesis - hemoptypsis - hematochezia

2 haemorrhagic symptoms in severely ill patient with t >101F <3/52 with no other alternate diagnosis

Diagnosis ----------- High index suspicious Thrombocytopenia Leukopenia aST raised Lab detection of antigen & antibodies

Treatment ------------ Supportive Ribavirin

Prophylaxis ---------------- None

Isolation ----------- Contagious after contact blood & bodily fluids

Liquid impervious protective coverings ( leg & shoe coverings) + double gloves

N95 or better

Face shield Googles

Negative pressure room

Clinical consideration for pediatric casualties ---------------------------------------------------- More vulnerable - breathes more per min than adults - skin thinner & larger surface area ratio

- small fluid reserve - some agents have shorter incubation period in children - present with different symptoms - preventive & theurapeutic regime not studiesbin infant & children

#Biological #CBRNE #TOPCOM

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