Shalya part 1 B

Shalya Tantra –Part 1-B
• Presented By –
• Prof.Dr.R.R.Deshpande (M.D in Ayurvdic
Medicine & M.D. in Ayurvedic Physiology)
• www.ayurvedicfriend.com
• Mobile – 922 68 10 630
• professordeshpande@gmail.com
8/20/2018 Prof.Dr.R.R.Deshpande 1

Contents of PPT
• 1) Sterilization
• 2) Anaesthesia
• 3) Positions
• 4) Incisions
• 5) Bandages
• 5) IV Fluids
• 6) Shock
8/20/2018 2Prof.Dr.R.R.Deshpande

Sterilization –Methods
• I) Physical Method --a) Heat -(i) Dry Heat - 1)
Flaming method used for blunt instrument. 2)
Hot air oven (160-180° C) 1 or 1.5 hour eg. For
sharp instrument.
• (ii) Moist Heat - 1) Heat below 100° C
• 2) Heat at 100° C (Boiling)-eg. Syringe, surgery
instrument, 3) Heat more than 100° C -eg.
Autoclaving.

Autoclave Sterlizer

• Radiation --2 methods –
• 1) Ionizing Radiation - X-rays & gamma- rays
• 2) Non Ionizing Radiation - Infrared & UV rays
• Disadvantages –
• 1) It is injurious to skin
• 2) Expensive
• 3) It causes conjunctiva damage

• Gas Sterilization (Fumigation)Uses - To fumigate
O.T., wards, heart-lung machine, blankets, pillows.
• Disadvantages – More irritant to eyes.
• II) Chemical Methods - irritant to eyes --Advantages -
1) It is used to sterilize instrument, which are
damage, by heat. 2) It is an easy method.--Phenol,
(Carbolic Acid), Lysol, Formaline, Savlon, Dettol &
Spirit

Boiling Dettol

Local Anesthesia (L.A.)
• 1) Infiltration Anesthesia - Injection of local
anesthetic drug into area which is to be incised in a
circular manner.
• Indications - Excision of lipoma, polyp, dermal cyst,
etc.
• 2) Field Block - Injection of local anesthesia so as to
create a zone of analgesia around the operative field.
Indications --Minor surgery, where the life of the
patient becomes fatal due to unconsciousness

Finger Block Field Block

• 3) Nerve Block - Injection of local anesthetic
drug near the nerve supplying area which will
be operated. eg. Brachial block, Finger (ring)
block, Intercostal nerve block etc.
• 4) Surface Anesthesia - Surface skin is
anaesthetized by local anesthetic agents used
as spray, ointment, cream & jelly, lotion. eg.
Catheterization, Cystoscope, Ryle’s tube, etc.

Local Anesthesia
Infiltration Anesthesia Surface Anesthesia

• 5) Spinal Anesthesia (S.A.) - Spinal
anesthesia is a type of Local anesthesia
• 6) Epidural Anesthesia - It is a type of
local anesthesia

Advantages of local anesthesia
• Simple administration , Easily available
• Undisturbed body metabolism ,
• Less Hemorrhage ,Patient’s cooperation-more
• No explosive , Easily sterilized
• Quick onset , Safe
• Cheap
• No special attention required

Local anesthesia
• A) Low potency with short acting - eg.
Procaine
• B) Intermittent potency with duration -
eg. Lignocaine
• C) High potency & long duration - eg.
Bupivacaine ,Marcaine, Tetracaine

General anesthesia (G.A.)
• A) Inhalation –
• a) Gas eg. N2O (Nitrous oxide)
• b) Liquid eg. Ether
• B) Intra venous
• a) Inducing agent eg. Thiopentone sodium
• b) Slow acting anesthesia eg. Ketamine

Muscle Relaxants
Sr No Medicines Dose & Duration
1 Curare It is given in dose of 15 to 18
mg (I.V.)
It takes about 2 to 3 minutes
to exert full effect & lasts for
about 45 min.
2 Gallamine (Flaxedil) It is generally given in a dose
of 80 to 120 mg.
Its effect lasts for about 1/2
hour

Muscle Relaxants
Sr No Medicines Dose & Duration
3 Scoline
(Suxamethonium)
It is generally given in the dose
of 50 to 70 mg.
Its action lasts for 5 min.
4 Pavulon
(Pancuronium)
It is used in the dose of about 6
mg.
Action acts as a fast & lasts for
one hour

Comparison of LA & GA
Sr.No LA GA
1 Site of action is -peripheral nerve CNS
2 Restricted Area Whole body
3 Retention of Consciousness Loss
4 No need to care vital organs Essential
5 Safe for poor health patient Risky
6 Not possible for non co-operative
patient
Possible
7 Not for major operation For major operation

Positions
• 1) Dorsal Position
• 2) Lateral Position --operations on kidney &
related region
• 3) Left Lateral Position (Sims’ Position) --Used
to give spinal Anaesthesia. It helps in
straightening the lower & upper curves of the
rectum in ano rectal examination
• 4) Right Lateral Position -Preferred in a suspected
growth at pelvi rectal junction

Positions
• 5) Prone Position- For operations of the
back, Used for Pilonidal sinus
• 6) Lithotomy Position - For operations of
the perineum, for proctoscopic or
sigmoidoscopic examination, Bimanual
examination of the abdomen

Positions
• 7) Trendelenburg’s Position (Head - low
position) --useful in management of shock,
operations of the pelvis including prostate
• 8) Reverse Trendelenburg’s Position -
operations of the upper abdomen & brain
• 9) Knee Elbow Position -for Palpating the
prostate & seminal vesicle

Positions
• 10) Knee - chest Position (Genupectoral Position) --
For introduction of proctoscope or sigmoidoscope.
• 11) Neck Extended position - For operations on the
anterior aspect of the neck like Thyroidectomy
• 12) Head Extended position -For operations inside
the mouth eg. Tonsillectomy, cleft palate etc.
• 13) Sitting position - It is useful for spinal
anaesthesia

Positions

Pre-Operatives
• 1) History -
• a) Illness b) Diabetes c) Asthma & Koch’s d)
Hypertension & MI e) Drug intake like -
Steroid, Insulin, f) Anti epileptic drug
• 2) Examination –Nutritional status & built
,Hydration ,Anemia, Jaundice, Oral hygiene
,Presence of loose & artificial teeth
,Pulmonary functions ,CVS, CNS, Pulse, BP,
heart sound (murmur)

Pre-Operative
• 3) Investigations
• Routine investigations for all patients
above 40 yrs of age are
• Hb%, WBC, ESR, BT, CT, Blood grouping
• Blood urea, Serum creatinine
• BSL ,Chest X- Ray , ECG
• Urine , Stool

Pre -Operative
• 1) NBM at least before 8-10 hrs.
• 2) For major surgery like anastomosis, colostomy ---
bowel wash is necessary.
• 3) For minor operations --- soap water enema is
given early in the morning on the day of operation.
• 4) Give Tab. Diazepam -- before sleep at previous
night.
• 5) Complete bath with dettol soap-- in night & early
in the morning

Pre-Operative
• 1) Inj. T.T. 0.5 cc
• 2) Inj. Atropine 0.6mg --- before 1/2 hrs of operation
• 3) Before entering patient into O.T. -- empty bladder
is must
• 4) In known case of DM, insulin dose is omitted in the
morning of the day of operation.
• 5) In Hypertension & IHD give -- regular dose
according to schedule.

Post –Operative Pain – Either of --
• 1) Inj. Diclofenac Sodium 75 mg I/M
• 2) Inj. Piroxicam 40 mg I/M
• 3) Inj. Tramadol 100 mg I/M
• 4) Inj. Morphine 15 mg I/M
• 5) Inj. Ketorolac 30 mg I/M
• 6) Inj. Pentazocine 30 mg I/M

Abdominal Incision
• 1) Mid-Line Incision –
• Equal assess to both sides
• Number of layers is less --- so incision can
made very quickly
• Incision passes through avascular area of
abdomen so bleeding will be less
• In lower abdomen this incision is widely used
by gynecologist

Abdominal Incision
• 2) Oblique Sub-costal Incision / Kocher’s
Incision –
• This incision provides good access to
upper abdominal organ such as gall
bladder & common bile duct of right
side while on left side for spleen

Abdominal Incisions
• 3) Lanz’ Incision --used for Appendectomy
when position of appendix is confirmed
• 4) Grid Iron Incision –
• This muscle splitting incision is commonly used
for Appendectomy
• This incision is an oblique & perpendicular to
Mc Burney’s point, which is 1/3 above & 2/3
below the spino umbilical line

Abdominal Incisions
• 5) Battle’s Incision --Used for transverse
colostomy or any operation on large intestine
• 6) Transverse Incision --This incision have
reputation that they heal quickly because of
less muscular tension on suture line -- during
coughing & rise in intra-abdominal pressure
• Hence greater value in cosmetic &
postoperative complication

Abdominal Incisions
• 7) Lt. Iliac Muscle Cutting Incision –
• Used to expose ureter, can be performed
on both side of abdomen
• 8) McBurney’s incision –
• It is Useful in Appendectomy

Abdominal Incisions

Ideal Surgeon
• 1) Lady’s Fingers - gentle handling
• 2) Lion’s Heart - boldness
• 3) Eagle’s eye – watchfulness
• 4) Horse’s leg - Stamina
• 5) Camel’s belly - ability to carry on with
out food & water

Use of Bandage
• 1) To stop bleeding by pressure.
• 2) To give rest & support to the affected
part.
• 3) To retain dressing
• 4) To prevent edema or swelling.
• 5) To correct deformity as a tourniquet

Sizes of Bandage
• One inch (1") wide bandage for --finger
& toe.
• Two inch (2") wide bandage for – head
• 4 inch wide bandage for --- limbs or
trunk
• 6 inch wide bandage for --Abdomen

Types of Bandage
• Circular --used in head
• Spiral -- mostly used in limb
• Reverse spiral
• Recurrent --used to cover the
amputation stump or tip of the finger
• Figure of eight (8) -- used for joint

Types of Bandage
• Barrel Bandage --To support the mandible
fracture
• Scrotal Bandage --It is a cup shaped device--i)
After operation of scrotum, testis, spermatic
cord.ii) After trauma, hematoma, epididymo
orchitis,cellulitis, Fourniers gangrene, scrotal
edema
• ‘T’ Bandage -To keep the dressing in the
position in perianal & perineal region.

Types of Bandage

Bandage Types

Elasto crepe Bandage
• 1) Treatment of varicose vein
• 2) Treatment of sprain
• 3) Skin graft for immobilization
• 4) As a haemostasis.
• 5) To reduce edema in the fracture

Skin Graft -Indications
• 1) After excision of sacro coccygeal teratoma
• 2) Ulcer having diameter more than 2.5 cm
• 3) After excision of big Lipoma
• 4) After excision of malignant ulcer & radiation
therapy.
• 5) To cover donor area of full thickness graft.

Intravenous fluids-Indications
• 1) Patient where oral intake isn’t
possible like surgery, severe
vomiting, diarrhea, uncooperative
patient & un-conscious patient
• 2) Severe dehydration & shock where
urgent & fast fluid is needed

Intravenous fluids-Indications
• 3) In special conditions like
hypoglycemia where D 25% is infused
• 4) As a vehicle for various problems like
asthma, shock
• 5) Hydration or flushing therapy
(Forceful diuresis in renal stone)

Intravenous fluids- Contra Indications
• a) I.V. F1uids should be avoided if
patient is able to take oral fluid
• b) In CHF, cerebral oedema, cirrhosis
of liver, renal failure, raised ICP

IV Fluids
• 1) Maintenance Fluids – D 5%
• 2) Replacement Fluids - RL, Isolyte M
• 3) Special Fluids – D 25%

Dextrose 5 % (D 5 %)
• 1) 1 lit. of fluid contains glucose 50 gm
• 2) Best agent to correct deficiency of
water but not electrolyte.
• 3) Useful in --Dehydration due to less
water intake or excessive water loss.
• 4) Pre operative -- It protects against
toxic substances

Dextrose 5 % (D 5 %) – Contra Indications
• 1) CHF
• 2) Circulatory overload
• 3) Hypovolumic shock
• 4) Cerebral oedema
• 5) Increased Intra cranial pressure

Normal Saline (NS) –
Isotonic Saline or 0.9% NaCl.
• 1) Each 100 ml contains sodium chloride 0.9
gm
• 2) To correct both fluid and electrolyte
deficiency & also increased BP in patient of
hypo volemic shock
• 3) Useful in -- Diarrhea, Vomiting
• 4) Do not use in --- Hypertensive patient, CHF,
Renal disease, Cirrhosis

Dextrose Normal Saline (DNS)
• 100 ml contains ----
• Glucose 5 gm & NaCl 0.90 gm

Ringer Lactate (RL)
• 1) Sodium 130 m Eq., K+ 4 m Eq, Cl– - 10 m Eq,
Ca+ -3 m Eq, Bicarbonate - 20 m Eq
• 2) It is high Sodium Concentration.
• 3) RL rapidly expands intra vascular volume &
hence it is very effective in treatment of
severe hypo-volumia.
• 4) It is most physiological fluid( Similar to
ECF)

IV Fluids
• 1) Isolyte G – corrects metabolic alkolosis of any
nature.
• 2) lsolyte – M --corrects Hypokalemia secondary to
diarrhea & ulcerative colitis
• 3) Isolyte – P -designed for children requirement, it
provides electrolyte & replace water deficit
• 4) Isolyte – E -- extra cellular replacement solution.
contain Mg+ & used in Mg deficiency

IV Fluids –Avoid
• 1) In Renal Failure --Isolyte - P, Isolyte - G,
Isolyte - E, RL ----- due to fear of developing
hyperkalemia
• 2) In Liver Failure --RL, Isolyte – G .
• Isolyte – G leading to accumulation of
ammonium chloride & precipitate hepatic
coma.

With -- Ideal IV Fluids
• 1) B. P. > 100 / 70 mm of Hg
• 2) Pulse rate less than 120/min.
• 3) Urine flow 30 - 50 ml / hr.
• 4) Normal temperature
• 5) Warm skin, normal respiration
• 6) Normal sensorium

Mild Shock
• 1) Blood loss is less than 750ml
• 2) Extremities become pale & cool
• 3) Sweating in forehead, thirst but
urinary output is normal
• 4) Pulse rate, blood pressures is
normal

Moderate Shock
• 1) Blood loss of 800-1500ml
• 2) Pulse rate < 100/min.
• 30 The systolic pressure may remain
normal but diastolic pressure may
increase.
• 4) Oliguria
• 5) Extremities look pale

Moderate Shock
• 1) Blood loss of 1500-2000 ml
• 2) Systolic & diastolic pressure fall
• 3) Pulse is thready & rate is 120/min
• 4) Respiratory rate < 20/min
• 5) Low urinary out put
• 6) patient is pale & drowsy

Severe Shock
• 1) Blood loss > 2000 ml
• 2) Clinically blood pressure is un recordable or
low
• 3) Low urinary out put
• 4) Rapid pulse
• 5) Peripheral extremities are cold
• 6) Absence of peripheral pulse
• 7) Lastly result in multi organ failure

Prof.Dr.R.R.Deshpande
• Sharing of Knowledge
• FOR
• Propagating Ayurved

Shalya part 1 B

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