Few facts in india

Indian bison. ...

 The Indian Bison which is the largest and the tallest in the family of wild cattle, even bigger than water buffalo and bison. Since 1986, the IUCN has listed the Indian Bison as vulnerable because of the declining population. Nowadays, this animal is kept well – protected in some of the famous national parks of India like Nagarhole, Bandipur, Kabini, Masinagudi and BR Hills. These national parks give tourists good sightings of the Indian Bison

INDIAN BISON FACTS

Scientific Name	Bos gaurus
Species	B. gaurus
Diet	Herbivore
Lifestyle	Herd
Lifespan	Up to 26 years in captivity
Predators	Due to huge size they have few enemies. However, leopards, dholes, crocodiles can attack an unguarded cattle and kill a full – grown adult also
Top speed	56 km/h
Status	Endangered

Physical Characteristics: The Indian Bison is massively built animal and is very strong. They have a convex shape in the forehead. The limbs are very strong and sturdy. The adult male weighs around 600 kg to 1500 kg. and the adult female weighs about 400 kg to 1000 kg. The Indian Bison is about 240 cm to 340 cm in length with the sole tail length of about 70 cm to 105 cm. Their height is about 170 cm to 230 cm. They have a prominent ridge running along their back. The back has very sparsely distributed hair. They have a typically short tail, shorter than an oxen also. Both the males and females possess horns. The horns are pale green or yellowish brown in color and are not pointed upward but possess a slightly inward curvature. The eyes are brown in color. The newly born bison is light golden yellow in color which later changes to light brown and then to reddish brown. The forehead is creamy white or yellowish in color.

Habit:  A social animal. They generally live in group size of about 30 to 40. They have an alarm call also which is a high pitched snort followed by a growling boo.

Habitat and Diet: The Indian Bison is very much prevalent in the Western Ghats. They prefer evergreen forests and moist deciduous forests. However, they can survive in dry deciduous forests also. They are not found in the Himalayas with an altitude greater than 6,000 ft. They generally stick to the foothills only. They are attracted to grounds which are impregnated with salts and minerals.

The Indian Bison is a grazing animal and love to munch on leaves, fruits, stems, flowers and seeds. They generally feed in the early morning and in the late evenings. Sometimes during shortage of food, they complete their nutrition and minerals by debarking trees. 

Conservation Acts: The Indian Bison is deemed as vulnerable according to the IUCN list. Hence, the Indian Government has already included the protection of wild bison in the Schedule I of the Wild Life Protection Act, 1972. The Act calls for clearing of invasive plants ad reintroduction of native plants in the area. It also calls for the proper regulation in the indiscriminate grazing of cattle around the areas where the gaurs stay.

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bandipur muthumalai check post

Wild elephant and kid crossing road at Bandipur mudumalai tiger reserve check post

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night drive through forest

 Night drive through Tiger Reserve.. ..its fantastic experience.. .with my family


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MAILANCHI

Milanchi is a temporary art of skin decoration for women.mehandi or henna is the leaf of the plant "MARUTHONI".this leaf is made into a paste and applied in the fingertips,palms,nails,hands and the soles of feet.after a few hours, it is washed off.it will leave behind some dark red impression on the applied area.it signifies life and prosperity at the time of various special occasions.mehandi is yet another traditional yet exciting pre wedding ceremony.mehandi is one of the sixteen adornments of bride and her beauty is incomplete without it according to muslim beliefs.

CARDIAC SURGICAL PROCEDURES.......

Cardiac surgical procedures

Cardiopulmonary bypass

Most of the cardiac operations rely on extra corporeal circulation to perfuse the body so that the heart is stopped for precise and accurate repair. Cannulation of aorta for arterial inflow and of the inferior venacava (IVC) and superior venacava (SVC) for venous drainage is the most common form of CPB. After the sternum has been opened, a longitudinal incision is made in the pericardium from the pericardial reflection at the aorta to the diaphragmatic portion of the pericardium. Two purse string sutures are inserted in the ascending aorta just below the great vessels. Aortic canula is inserted and tightened with tie to the purse string tourniquets. Commonly venous blood is drained from the right side of the heart via the SVC and the IVC, oxygenates and pumped back into the systemic circulation. The circulatory system is heparinised to avoid thrombus formation. Cardiotomy suction lines aspirate blood directly back to the pump where it is filtered, oxygenated and reinfused with the rest of the bypass volume into the arterial circulation.

After the CPB is established the heart is stopped by giving high potassium cardioplegia solution in to the aorta proximal to the aortic canula after aortic cross clamp. Systemic hypothermia is used during CPB to reduce the metabolic rate, and subsequently the energy demands of the organs. Cooling of the myocardium is achieved by using ice chilled Ringer Lactate or Normal Saline topically.

After the surgical repair has been completed, the surgeon prepares to discontinue bypass. Patient would have been rewarmed to normothermia and the heart will be contracting in a regular manner. The anaesthesiologist starts to ventilate the lungs and the surgeon occludes the venous line allowing blood to enter the right atrium (RA). When heart’s pumping action is judged to be sufficient and systemic blood pressures are stable, the venous line is clamped completely, and the heart resumes responsibility for maintaining the circulation. After bypass has been discontinued, and heparin reversal with protamine sulphate is begun, the CPB cannula is removed. Defibrillation by the internal application of a direct current (DC) electrical shock to the myocardium is instituted when the heart fibrillates.  

Coronary artery bypass graft (CABG)

CABG is done to bypass the blocked or diseased coronary arteries using the saphenous vein and the internal mammary artery and radial artery. This is done as beating heart surgery or using CPB machine.            

i. On pump CABG, we need to stop the patient’s heart and connect the patient to heart lung machine. This machine takes over the patients’ cardiac and pulmonary function and delivers oxygenated blood through out the body and brain while bypass is performed. 

ii.Off pump CABG (beating heart) eliminates the need for stopping the heart and use of CPB. It is mostly done for patients with lesions in the left anterior descending, diagonal and occasionally the right coronary arteries. Surgeon operates directly on the beating heart using Octopus, a coronary stabilizer placed around the target coronary artery, minimizes cardiac motion and allows the surgeon to perform the anastomosis.

            Endoscopic vein harvesting is a minimally invasive approach to saphenous veinharvesting.In this, 1-3 incisions are made on the leg and the vein is located under direct vision using a camera attached to the video externally. The remaining length of vein is excised via the video assistance with endoscopic scissors and clips. The benefit of using vasoview desection are small incision instead of vein length incision, less post operative pain, less scarring and less infection.

Cardiac ablation

This is done using epicor ultra cinch ablation device. This is performed in patients with AV reentry tachycardia (WPW syndrome). In cardiac ablation a radio frequency energy is rendered to inactivate the accessory pathway.

Valve surgeries

All valve surgeries are done after establishing CPB. The usual valve prostheses used are TTK chitra valve, St.Jude mechanical valve, Starr-Edwards mechanical valve, Medtronic valves and Perimount bioprosthetic valve.

i. Aortic valve replacement -Aorta is opened under CPB, diseased valve is removed and replaced with a prosthetic or bioprosthetic valve. The prosthetic valve is placed using non absorbable sutures.

ii. Mitral valve replacement-Diseased mitral valve is removed and replaced with artificial prosthetic or bioprosthetic valve. Single valve replacement and double valve replacement are usually performed here.

 iii. Valve repairs-Mitral valve reparative procedure is also being done because of the complications associated with prosthetic replacement and anticoagulation. Carpentier Edwards mitral and tricuspid rings (DE-VEGA suture annuloplasty) are used for annuloplasty.

Surgical repair of ASD is done under CPB

Tanned pericardial patch is used to close the defect.In sinus venosus defect, redirection of anomalous pulmonary venous return is also done. In ostium primum defect mitral valve cleft is sutured.

Vascular surgeries

Aneurysm repair

An aneurysm is the weakening of an artery. We usually deal with aortic aneurysms. Aortic aneurysms are named by the site where it occurs. An aortic root aneurysm, or aneurysm of sinus of Valsalva, appears on the sinuses of Valsalva or aortic root. Thoracic aortic aneurysms are found on the thoracic aorta; these are further classified as ascending, aortic arch, or descending aneurysms depending on the location on the thoracic aorta involved. Abdominal aortic aneurysms, the most common form of aortic aneurysm, are found on the abdominal aorta, and thoracoabdominal aortic aneurysms involve both the thoracic and abdominal aorta.

Surgical repair of the aneurysm depends on the location. Usually involves excision of the bulging section and replacing the weakened section of the vessel with a prosthetic graft. If the aneurysm is located in the ascending aorta just above the heart, the heart-lung machine will be used. In ascending aortic aneurysm with aortic valve involvement, a conduit is used to replace the diseased aorta and valve and the coronary arteries are stitched to the graft at separate openings (Bentall-De Bono procedure).

Embolectomy         

It is the rapid removal of emboli and thrombi from the vascular system. An embolectomy is the surgical removal of an embolus in a blood vessel and is done by using Fogarty’s embolectomy catheter.

Aortofemoral bypass graft

Peripheral artery bypass is the surgery to reroute the blood supply around a blocked artery in the legs mainly for chronic occlusions from atherosclerosis. The common procedures include aorto- femoral bypass and femoropopletial bypass using artificial grafts.

Carotid endarterectomy

 It is the surgery used to remove plaque from the carotid artery. During the operation, the surgeon peels off the plaque from the carotid artery. Once the plaque is removed from the carotid artery, the artery is repaired using saphenous vein. During the operation the blood flow to the brain is maintained using a special shunt (Pruitt-Inahara shunt).

Vascular access for hemodialysis

An arteriovenous fistula (A-V fistula) is made by joining an artery and a vein usually in the forearm (radial artery and vein). This is done for subjects who need long-term dialysis, and is done under local anesthesia.

We perform open heart, closed heart as well as thoracic and vascular surgeries. Open-heart surgeries are mostly done with the help of cardio pulmonary bypass (CPB) /heart lung machine. Beating heart surgeries are also being done here. Approach to open heart surgery is mainly through a median sternotomy incision, which provides excellent exposure for surgery of the heart and great vessels and facilitates canulation for a CPB.

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Stroke assessment

Assessment of the secerity of stroke

The level of stroke severity as measured by NIHSS scoring system:

·                     0 – No stroke

·                     1 to 4 – Minor stroke

·                     5 to 15 – Moderate stroke

·                     16 to 42 – Severe stroke

1a	Level of Consciousness
	Alert	0
	Drowsy	1
	Stuporous	2
	Coma	3
1b	LOC questions
	Answers both questions correctly	0
	Answers one question correctly	1
	Answers neither correctly	2
1c	LOC commands
	Performs both task correctly	0
	Performs one task correctly	1
	Performs neither task correctly	2
2	Best Gaze
	Normal	0
	Partial gaze palsy	1
	Forced deviation	2
3	Visual
	No visual loss	0
	Partial hemianopia	1
	Complete hemianopia	2
	Bilateral hemianopia (Blind including cortical blindness)	3
4	Facial palsy
	Normal (Symmetrical movement)	0
	Minor paralysis (flattened nasolabial fold, asymmetry in smiling)	1
	Partial paralysis (total or near total paralysis of lower face)	2
	Complete paralysis of one or both sides	3
5	Motor arm	5a left		5b right
	No drift (Holds limb for 45 or 90 degrees for full 10 seconds)	0		0
	Drift (Holds limb 45 or 90 degrees, but drifts down before 10 sec)	1		1
	Some effort against gravity	2		2
	No effort against gravity	3		3
	No movement	4		4
	Amputation joint fusion explain	A		A
6	Motor leg	5a left		5b right
	No drift (Holds limb for 45 or 90 degrees for full 10 seconds)	0		0
	Drift (Holds limb 45 or 90 degrees, but drifts down before 10 sec)	1		1
	Some effort against gravity	2		2
	No effort against gravity	3		3
	No movement	4		4
	Amputation joint fusion explain	A		A
7	Limb ataxia
	Absent	0
	Present in one limb (Right Arm Yes/No; Left Arm Yes/No)	1
	Present on both limbs	2
	Amputation or Joint fusion	A
8	Sensory
	Normal (No sensory loss)	0
	Mild to moderate sensory loss (Patient feels pinprick is less sharp or dull on the affected side; is aware of being touched)	1
	Severe to total loss (is not aware of being touched)	2
9	Best language
	No aphasia	0
	Mild to Moderate (Some obvious loss of fluency)	1
	Severe aphasia (All communication through expression)	2
	Mute or global aphasia	3
10	Dysarthria
	Normal	0
	Mild to Moderate	1
	Severe	2
	Intubated or other physical barrier explain	A
11	Extinction and Inattention
	No abnormality		0
	Visual, tactile auditory, spatial (Inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities)		1
	Profound hemi attention/ Hemi inattention to more than one sensory modality (Does not recognize on hand or oriented to only one side of the body)		2

Table.39.1. National Institute of Health Stroke Scale (NIHSS)

Modified Rankin scale is another tool used to assess the severity of stroke (Table 39.2).

0	No symptoms at all
1	No significant disability despite symptoms; is able to carry out all usual duties and activities
2	Slight disability; Unable to carry out all previous activities; but able to look after own affairs w/o assistance
3	Moderate disability; require some help, but able to walk w/o assistance
4	Moderately severe disability; unable to walk w/o assistance and unable to attend own bodily needs w/o assistance
5	Severe disability; Bed-ridden, incontinent and requiring constant nursing care and attention
6	Dead

Table.39.2. Modified Rankin scale

Investigations

1.  Blood studies: complete blood cell count (CBC), electrolytes, coagulation profile,
random blood sugar, renal function tests, liver function tests.

2.   CT Scan/ CT angiography

3.   ECG

4.   MRI brain with magnetic resonance angiography (MRA)

5.   Transcranial doppler study

6.   Ultrasonography

7.   Cardiac evaluation

Classfication of stroke

Fig.39.1. Classification of Stroke

Treatment options available at SCTIMST

Emergency treatment

Intravenous thrombolysis: Recombinant tissue plasminogen activator (rtPA) for ischemic stroke if the window period (the time period calculated from the time the patient was last seen well until found to have deficits) is < 4.5 hrs and if there are no contra-indications for rtPA.

Intra-arterial thrombolytics (Urokinase): This is the treatment option if the window period is between 4.5-6 hrs and if there are no contraindications for Urokinase

Decompressive craniectomy: For massive cerebral infarct the treatment of choice is surgical decompression.

Medical management

Antiedema measures includes administration of mannitol, diuretics, and hyperventilation. Management of hypertension is another goal of medical management.

Secondary prevention

1.  Antiplalelets-Aspirin/Clopidogrel

2.  Statins

3.  Aggressive physiotherapy and general supportive care

4.  Treatment for Deep vein thrombosis (DVT)

5.  Carotid endarterectomy

6.  Treat cardiac causes if any.

Protocol for thrombolytic therapy

The administration of rtPA improves the outcome after stroke when given very early, and within 4.5 hours of onset of stroke in carefully selected persons. If the 4.5 hour time window can be met, treatment can be beneficial irrespective of patient's age, gender, ethnicity, or presumed cause of stroke. A significant increase in improvement at 24 hours and favorable outcomes at 3 months were noted among persons treated with rtPA.The administration of thrombolytic drugs to persons with acute ischemic stroke can be complicated by bleeding. Symptomatic intracranial hemorrhage was significantly increased with treatment but despite the hemorrhage, the rate of death or severe disability was less in the actively treated groups. The benefit of intravenous rtPA for acute ischemic stroke beyond 4.5 hours from the onset of symptoms is not established and cannot be recommended. Intravenous rtPA is not recommended when the time of onset of stroke cannot be ascertained reliably, including strokes recognized upon awakening (“wake up stroke”).

Contraindications

·      Age less than 18 years

·      Evidence of intracranial hemorrhage on pretreatment CT.

·      Coma or severely altered sensorium.

·      Symptoms rapidly improving or minor (not measurable by the NIHSS).

·      Known bleeding diathesis, including but not limited to:

1.        Platelet count < 100,000

2.        Current use of oral anticoagulants or,

3.        Prothrombin time (PT) > 15 sec, INR > 1.7,

4.        Use of heparin in the previous 48 hours and a prolonged partial thromboplastin time (PTT).

·      Serious head trauma or previous stroke within 3 months.

·      Seizure at the onset of stroke.

·      Major surgery or major trauma within 14 days.

·      Arterial puncture at a noncompressible site or lumbar puncture within 7 days.

·      Gastro Intestinal or urinary tract bleeding within 21 days.

·      Pretreatment systolic blood pressure (SBP) > 185 or diastolic blood pressure (DBP) > 110, despite simple measures.

·      History of intracranial hemorrhage.

·      Abnormal blood glucose (< 50 or > 400 mg/ dL)

·      Recent myocardial infarction complicated by pericarditis.

·      Pregnant or lactating females (menstruation is not a contraindication).

·      Early changes on CT such as sulcal effacement, mass effect, or edema are not absolute contraindications. If these signs are present, then it suggests a longer interval between stroke onset and the CT scan than 3 hours. Immediate efforts must be made to re-establish the time of onset of neurological symptoms.

For patients presenting with new onset stroke

Determine exact time of onset of symptoms and document in medical record.

Activate the Acute Stroke Service and act promptly.

1.   Order non-contrast head CT immediately. CT Scan will be read by a neurologist or radiologist.

2.   Obtain blood samples for CBC, electrolytes, (BUN), creatinine, glucose, PT, PTT, INR, fibrinogen and blood group. Write "STROKE STAT" on lab slips to expedite handling and processing for faster turn around time of lab results.

3.   Obtain urine for human chorionic gonadotropin in all women of child-bearing age.

4.   Obtain ECG and chest X-ray.

5.   Insert 2 large peripheral intravenous lines (18 gauge).

Administration of rtPA

The neurologist will check all inclusion and exclusion criteria on the thrombolysis check list for ischemic stroke, sign it, and put in medical record. Informed consent is necessary. Because of the risk of major bleeding, the risks and benefits of treatment should be discussed with the patient and/or family prior to administration of rtPA. Document the discussions.

Total rtPA dose = 0.9 mg/ kg (max 90 mg). 10% is given as a bolus over 60 seconds and then the remaining is infused over one hour. Example: A 100 kg patient would receive a 9mg bolus in the first minute followed by 81mg over the next hour via. infusion pump. Do not move the patient until infusion is complete unless absolutely necessary. 

Monitoring and care during and after rtPA infusion

Vital signs should be checked  every 15 minutes for 2 hours after starting infusion. Then every 30 minutes for 6 hours. Then every hour until 24 hours after starting infusion. Maintain SBP between 110 and 185mm Hg. Insertion of indwelling Foley’s catheter should be avoided during the infusion and for at least 30 minutes after infusion ends. Insertion of a nasogastric tube should be avoided, if possible, during the first 24 hours. Central venous access, arterial punctures and intramuscular injections should be avoided. NPO except medicines for 24 hours. Test all urine, stool, and emesis for occult blood. Prophylactic H2 blockers are strongly recommended. No anticoagulants or anti inflammatory drugs should be administered for 24 hours. After 24 hours, if anticoagulant or antiplatelet therapy is to be given, a follow up CT scan or MRI should be free of hemorrhage. Ahead CT for any worsening of neurologic condition is very necessary.

If hemorrhage is suspected, stop infusion of the thrombolytic drug

If the patient develops severe headache, acute hypertension, nausea or vomiting; discontinue the infusion and prepare for an emergency CT/ MRI scan, blood investigations, blood product transfusion and possible transfer for surgical intervention. Send repeat CBC, platelet, INR, PTT, PT, fibrinogen, D-dimer. Prepare for administration of 6 to 8 units of cryoprecipitate containing factor VIII and 6 to 8 units of platelets. Plan for non-contrast CT in 24 hours. Document all vital signs, assessment, medication intervention and response to interventions in the medical records.

Nursing management

This can be dealt with in the following categories:

1.   High risk for ineffective breathing pattern related to
hypoxia, neuro muscular impairment

       To overcome the problem, maintain a patent airway. Monitor respiratory functions and provide respiratory support. Position the patient on his side and give chest physiotherapy and suctioning whenever required. Frequent assessment of vital
signs including neurological signs, and hemodynamic status is essential.

2.   High risk for aspiration related to reduced level of consciousness, depressed cough and gag reflex and presence of tracheotomy or endotracheal tube

       Provide suction whenever necessary. Assess the gag reflex and provide nasogastric feeding as necessary. Elevate head of bed at least 300 and keep patient upright for 30-45 min after feeding. Assist patient with oral intake to detect abnormalities early.

3.   Impaired physical mobility

       Change position every 2 hours and take care of pressure points by gentle massage. Provide pressure relieving devices. Keep side rails up to promote safe environment. Encourage and facilitate early ambulation and other activities of daily living.

4.   High risk for impaired verbal communication

       Anticipate the patient needs. Modulate personal communication by using body language and simple directions. Encourage family to attempt communication with patient. Visual aids like writings, picture boards and gestures will be helpful at times.

5.   Impaired nutrition related to inadequate intake

       Consult dietician regarding diet planning. Assist patient with meals as needed. Prevent dehydration and constipation. Nasogastric tube feeding may be required.

6.   Self care deficit

       Anticipate and meet all the basic needs in bedridden patients. Assist in feeding, grooming, bathing and toiletry needs. Preserve and protect all functions.

7.   Impaired coping related to anxiety

       Provide thorough explanation and demonstrations before any procedure. Continuous reassurance and psychological support helps to develop positive attitude. Orient to any new environment. Provide positive feedback and repetition when the patient is trying to re-learn a skill.

8.   High risk for infection/injury

       Maintain aseptic precautions in all invasive procedures. Ensure hand hygiene to prevent health care associated infection. Ensure twice daily catheter care to prevent urinary tract infection. Frequent change of position prevent pressure ulcers, and thrombophlebitis. Keep the side rails up to prevent falls. Keep head end elevation of at least 300 to prevent ventilator associated pneumonia. Ensure regular bowel elimination. Maintain oral hygiene. Take measures to prevent exposure keratitis and other eye infection.

9 .  Rehabilitation within the hospital

       Focus on restoration of function and initiate bowel and bladder retraining.  Initiate physical therapy to restore functions, and passive range of motion exercises to prevent contractures. Occupational and speech therapy helps the client speedy return to productive life. Provide nutrition counseling, life style modification hints and need to control blood pressure and compliance with medication to prevent future stroke.

10.       Discharge planning

       Teach the family members about feeding and nutrition, physiotherapy and mobility, diversion and sleep, preventing falls, pressure ulcers and infection. Discharge to a nursing home or a rehabilitation center is recommended for those who require additional care.

CONCLUSION

Brain attack or stroke leads to lasting cognitive and emotional consequences in more than half of the patients. They experience high levels of morbidity. Every minute is precious when someone is developing a stroke. Most effective nursing care is required in the initial period of stroke.

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