WARNING: This talk will be ineffective if you have no sense of humour.
In Karim’s hilarious and wonderfully sarcastic way, he takes on the Tranexamic Acid debate which (bizarrely) continues to spark controversy.
CRASH 2 had over 20,000 enrolled patients and demonstrated a 15% mortality relative risk reduction by using tranexamic acid in trauma.
There remain some haters out there, including the authors of this amusing review paper who not only slam TXA but the way in which social media has distributed the results. After openly criticising discussion about CRASH 2 on FOAMed resources such as EMCRIT, St Emlyns and on Twitter in general, the papers author, Sophia Binz, calls for “professional and productive scientific debate” - PLEASE feel free to engage with the authors by discussion in the forum below and this shall be fed back in a professional and productive way.
In this talk Karim presents “The Tranexamic Acid Denier’s Handbook”, which describes the multiple strategies we can employ to deny the results of CRASH 2. He tells you how to deflect, how to disrespect the study, how to disrespect the results, how to disrespect the design, how to disrespect the ethics, disrespect the subjects, disrespect the investigators, how to be a scaremonger and finally how to publish (anything) to throw people off the scent.
Now you are empowered to deny the evidence and not use a cheap and effective drug that has been shown to save lives. Go for it!
Karim is currently being headhunted by the UN for his skills in diplomacy.
This document summarizes a study examining drug-induced hepatotoxicity in acute lymphoblastic leukemia patients undergoing chemotherapy. The study found that liver enzymes including bilirubin, ALT, ALP, and GGT increased significantly after one month of induction chemotherapy compared to before treatment. Additionally, hematological parameters like hemoglobin, RBC count, and neutrophil count improved after chemotherapy, while blast cells decreased. The study concludes that chemotherapy can cause hepatotoxicity in ALL patients during the induction phase.
This document discusses the impact of underlying liver disease on postoperative liver failure after surgery. It covers cirrhosis, chemotherapy-induced liver toxicity, and cholestasis.
For cirrhosis, it recommends patient selection based on Child-Pugh and MELD scores. It suggests limiting major resections to Child A patients without varices or thrombocytopenia. Portal vein embolization can help optimize liver remnant volume.
For chemotherapy-induced toxicity, it warns of increased morbidity from extensive preoperative chemo (>6 cycles) due to sinusoidal injuries. Optimization may include stopping bevacizumab.
For cholestasis, it recommends optimizing patients preoperatively with endoscopic
carcinoma de celulas renales y diferenciales en métodos diagnósticos de imagenKaren Meza
This document provides information about renal cell carcinoma (RCC), including its epidemiology, clinical presentation, risk factors, staging system, diagnostic imaging, and differential diagnosis. RCC is the most common malignant renal tumor, typically presenting in patients ages 50-70 years old with macroscopic hematuria, flank pain, or palpable flank mass. Imaging such as CT and MRI can be used to diagnose and stage RCCs based on characteristics such as enhancement patterns, necrosis, and tumor thrombus. The differential diagnosis for a renal mass includes renal oncocytoma, angiomyolipoma, and renal adenoma.
1. Aggressive HCC requiring wide margins and anatomical resection include satellite nodules, rapid AFP kinetics, and poor differentiation.
2. Minor hepatectomy is feasible for MELD <12 and FibroScan <17-20 kPa, while major hepatectomy requires preoperative portal vein embolization, especially for abnormal liver parenchyma.
3. Surgery may be useful for select BCLC C patients, though adjuvant treatments need further exploration to improve outcomes.
Laparoscopic right hepatectomy is a technically challenging procedure that requires specific training and expertise. While it provides short-term benefits over open surgery such as reduced blood loss and hospital stay, it remains an innovative procedure that should be introduced cautiously. The requirements to perform a safe laparoscopic right hepatectomy include careful patient selection, specialized equipment, and following a standardized technique. Recommendations are that all liver surgery centers should implement laparoscopic liver resection programs after surgeons receive proper training through fellowships in high-volume centers.
Liver Transplantation with severe steatotic graft and postoperative organ dys...Eric Vibert, MD, PhD
This document summarizes the case of a 54-year-old man who underwent an initial liver transplantation with a graft that was found to have over 50% macrosteatosis and 10% microsteatosis, resulting in severe postoperative organ dysfunction requiring a second liver transplantation. Despite a long postoperative course including 12 weeks in the ICU and pancreatic complications, the patient survived and was asymptomatic with normal liver function tests at a 3-year follow up.
WARNING: This talk will be ineffective if you have no sense of humour.
In Karim’s hilarious and wonderfully sarcastic way, he takes on the Tranexamic Acid debate which (bizarrely) continues to spark controversy.
CRASH 2 had over 20,000 enrolled patients and demonstrated a 15% mortality relative risk reduction by using tranexamic acid in trauma.
There remain some haters out there, including the authors of this amusing review paper who not only slam TXA but the way in which social media has distributed the results. After openly criticising discussion about CRASH 2 on FOAMed resources such as EMCRIT, St Emlyns and on Twitter in general, the papers author, Sophia Binz, calls for “professional and productive scientific debate” - PLEASE feel free to engage with the authors by discussion in the forum below and this shall be fed back in a professional and productive way.
In this talk Karim presents “The Tranexamic Acid Denier’s Handbook”, which describes the multiple strategies we can employ to deny the results of CRASH 2. He tells you how to deflect, how to disrespect the study, how to disrespect the results, how to disrespect the design, how to disrespect the ethics, disrespect the subjects, disrespect the investigators, how to be a scaremonger and finally how to publish (anything) to throw people off the scent.
Now you are empowered to deny the evidence and not use a cheap and effective drug that has been shown to save lives. Go for it!
Karim is currently being headhunted by the UN for his skills in diplomacy.
This document summarizes a study examining drug-induced hepatotoxicity in acute lymphoblastic leukemia patients undergoing chemotherapy. The study found that liver enzymes including bilirubin, ALT, ALP, and GGT increased significantly after one month of induction chemotherapy compared to before treatment. Additionally, hematological parameters like hemoglobin, RBC count, and neutrophil count improved after chemotherapy, while blast cells decreased. The study concludes that chemotherapy can cause hepatotoxicity in ALL patients during the induction phase.
This document discusses the impact of underlying liver disease on postoperative liver failure after surgery. It covers cirrhosis, chemotherapy-induced liver toxicity, and cholestasis.
For cirrhosis, it recommends patient selection based on Child-Pugh and MELD scores. It suggests limiting major resections to Child A patients without varices or thrombocytopenia. Portal vein embolization can help optimize liver remnant volume.
For chemotherapy-induced toxicity, it warns of increased morbidity from extensive preoperative chemo (>6 cycles) due to sinusoidal injuries. Optimization may include stopping bevacizumab.
For cholestasis, it recommends optimizing patients preoperatively with endoscopic
carcinoma de celulas renales y diferenciales en métodos diagnósticos de imagenKaren Meza
This document provides information about renal cell carcinoma (RCC), including its epidemiology, clinical presentation, risk factors, staging system, diagnostic imaging, and differential diagnosis. RCC is the most common malignant renal tumor, typically presenting in patients ages 50-70 years old with macroscopic hematuria, flank pain, or palpable flank mass. Imaging such as CT and MRI can be used to diagnose and stage RCCs based on characteristics such as enhancement patterns, necrosis, and tumor thrombus. The differential diagnosis for a renal mass includes renal oncocytoma, angiomyolipoma, and renal adenoma.
1. Aggressive HCC requiring wide margins and anatomical resection include satellite nodules, rapid AFP kinetics, and poor differentiation.
2. Minor hepatectomy is feasible for MELD <12 and FibroScan <17-20 kPa, while major hepatectomy requires preoperative portal vein embolization, especially for abnormal liver parenchyma.
3. Surgery may be useful for select BCLC C patients, though adjuvant treatments need further exploration to improve outcomes.
Laparoscopic right hepatectomy is a technically challenging procedure that requires specific training and expertise. While it provides short-term benefits over open surgery such as reduced blood loss and hospital stay, it remains an innovative procedure that should be introduced cautiously. The requirements to perform a safe laparoscopic right hepatectomy include careful patient selection, specialized equipment, and following a standardized technique. Recommendations are that all liver surgery centers should implement laparoscopic liver resection programs after surgeons receive proper training through fellowships in high-volume centers.
Liver Transplantation with severe steatotic graft and postoperative organ dys...Eric Vibert, MD, PhD
This document summarizes the case of a 54-year-old man who underwent an initial liver transplantation with a graft that was found to have over 50% macrosteatosis and 10% microsteatosis, resulting in severe postoperative organ dysfunction requiring a second liver transplantation. Despite a long postoperative course including 12 weeks in the ICU and pancreatic complications, the patient survived and was asymptomatic with normal liver function tests at a 3-year follow up.
Trauma induced coagulopathy (TIC) starts early due to shock and hypoperfusion which activates the thrombomodulin-protein C pathway. TIC is associated with higher mortality, transfusion requirements, and organ dysfunction. Assessment of TIC requires thromboelastometry rather than standard coagulation tests due to confounding factors like hypothermia, acidosis, and dilution of clotting factors from fluid resuscitation. Treatment focuses on replacing depleted clotting factors, with fibrinogen and prothrombin concentrates highly recommended, as well as consideration of antifibrinolytics and recombinant factor VIIa in specific cases.
Trauma-Induced coagulopathy: Methods, Trigger and Mechanism of Early TIC
< a href="http://www.emergency-live.com
">read on Emergency Live</a>
Trauma is the leading cause of death among people under the age of 44. Hemorrhage is a major contributor to deaths related to trauma in the first 48 h.
This document discusses clinical judgement and gestalt thinking. It references several studies and articles on cognitive problems in medical diagnosis, the role of immediate impressions in specialties like emergency medicine, and decreased facial expressions as an indicator of serious illness. Teaching clinical judgement is discussed, including using questions, readings on heuristics and biases, and models of diagnostic reasoning. Gestalt is defined as integrated patterns that are more than the sum of parts. Clinical gestalt is shown to predict massive transfusion after trauma based on a study.
This document discusses principles of damage control resuscitation for traumatic hemorrhage. It describes how hemorrhage can lead to hypovolemic shock and coagulopathy, exacerbating blood loss. Damage control resuscitation aims to rapidly restore blood volume while limiting blood pressure increases to prevent further bleeding. It emphasizes early use of blood products rather than crystalloids to avoid dilutional coagulopathy, and maintaining hemostasis through permissive hypotension, tranexamic acid, and ratio-based blood component resuscitation. While controversial, this approach may improve outcomes compared to aggressive crystalloid resuscitation in severely bleeding trauma patients.
Holley analyses the cascade of events in bleeding trauma patients leading to Australia's latest evidenced-based guidelines on transfusion protocols in critical bleeding.
The Sick and the Dead: Evidence-Based Trauma Resuscitation in 2016SMACC Conference
Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.
Short Review regarding Metabolic Acidosis
The Causes, anion gap,urine osmolal gap, Renal Tubular Acidosis, approach to Metabolic Acidosis in Final Slide
This document discusses the effective and ineffective uses of educational technology tools, referred to as "gizmos." It notes that while gizmos can be innovative and engaging, they can also lead to distraction, imbalance, and idolatry if overused or relied upon too heavily. For learning to be effective, the document emphasizes self-direction, spaced repetition of information, practice testing, and engagement with the information and learning process itself rather than just the technological tools.
The Coagulopathy of Trauma: A Review of MechanismsEmergency Live
Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways.
Dr Sachin Gupta an intensivist at Peninsula Health presents on the difficulties we currently face in predicting bleeding and how this might change in the future.
The ultrasound scan showed a small nodule on the pleural edge near the ribs and cardiac shadow, indicating the probe was close to the midline with part of the heart visible to the right. No other abnormalities were seen on the scan.
This document discusses lead poisoning in children in Zamfara, Nigeria caused by mining activities. It provides details on blood lead levels found in children, which were as high as 109-370 mcg/dL. Nearly 97% of children tested had blood lead levels exceeding 45 mcg/dL. The challenges in addressing this crisis included fear and misunderstandings between communities and aid organizations, as well as differing agendas among stakeholders. Over time, remediation efforts helped reduce mortality and the number of children requiring treatment, though some challenges remained such as recontamination and new outbreaks in other areas. Effective communication, understanding local cultures, and providing consistent information were emphasized as important to resolving crises like this.
The document discusses the lethal triad of acidosis, coagulopathy, and hypothermia that can occur in trauma patients and cause a rapid decline towards death. It outlines a case study of a patient who arrived at the emergency department after a shooting and provides details on their resuscitation care, including addressing acidosis, hypothermia, coagulopathy and stopping bleeding through fluid administration, blood products, and other therapies to reverse the lethal triad and stabilize the patient.
This document discusses acute care of elderly patients in emergency departments. It notes that elderly patients make up a large proportion of emergency department visits, often arriving by ambulance. Elderly patients are more likely to have unnecessary emergency department visits and longer lengths of stay. The document advocates for improved pre-hospital interventions to prevent emergency department visits for falls in elderly patients. It also suggests implementing comprehensive geriatric assessments and observation units in emergency departments to help determine if admissions are necessary and reduce admissions, readmissions, and return visits for elderly patients.
Fluid and blood resuscitation in abdominal traumaimran80
This document discusses fluid and blood resuscitation in abdominal trauma, providing guidelines for surgeons. It outlines factors related to different levels of blood loss and clinical signs of shock. It recommends using lactated Ringer's solution as the crystalloid fluid of choice and hydroxyethyl starch as the preferred colloid. Close clinical monitoring of vital signs, urine output, oxygen saturation, and bicarbonate levels is emphasized to guide fluid resuscitation and determine need for blood transfusion to maintain a hemoglobin of 7gm% or higher.
This document discusses radiotherapy (RT) for hepatocellular carcinoma (HCC) in the Asia-Pacific region. It compares outcomes between sorafenib and RT for intermediate/advanced HCC. Helical tomotherapy (HT) improves long-term survival and increases radiation dose without increased toxicity for HCC with macrovascular invasion compared to 3D conformal radiotherapy (3DCRT). HT allows delivery of higher radiation doses in a shorter treatment period with acceptable toxicity for HCC with macrovascular invasion.
PRESENTACION TROPONINA. Analytical consideration for high sensitivitty tropon...manuelgn4
This document discusses analytical considerations for high sensitivity troponin assays. It explains that troponin is superior to other cardiac biomarkers due to its high myocardial tissue content. Next-generation troponin assays can measure levels in healthy individuals and improve risk stratification for cardiac events. Serial testing of troponin levels and determining changes based on biological variation can help distinguish cardiac injury from chronic conditions. Point-of-care troponin tests have advantages of rapid results but currently lack the sensitivity of high-sensitivity laboratory assays. Overall, heightened troponin assay sensitivity requires correlating results closely with clinical presentation to properly interpret potential cardiac injury.
Trauma induced coagulopathy (TIC) starts early due to shock and hypoperfusion which activates the thrombomodulin-protein C pathway. TIC is associated with higher mortality, transfusion requirements, and organ dysfunction. Assessment of TIC requires thromboelastometry rather than standard coagulation tests due to confounding factors like hypothermia, acidosis, and dilution of clotting factors from fluid resuscitation. Treatment focuses on replacing depleted clotting factors, with fibrinogen and prothrombin concentrates highly recommended, as well as consideration of antifibrinolytics and recombinant factor VIIa in specific cases.
Trauma-Induced coagulopathy: Methods, Trigger and Mechanism of Early TIC
< a href="http://www.emergency-live.com
">read on Emergency Live</a>
Trauma is the leading cause of death among people under the age of 44. Hemorrhage is a major contributor to deaths related to trauma in the first 48 h.
This document discusses clinical judgement and gestalt thinking. It references several studies and articles on cognitive problems in medical diagnosis, the role of immediate impressions in specialties like emergency medicine, and decreased facial expressions as an indicator of serious illness. Teaching clinical judgement is discussed, including using questions, readings on heuristics and biases, and models of diagnostic reasoning. Gestalt is defined as integrated patterns that are more than the sum of parts. Clinical gestalt is shown to predict massive transfusion after trauma based on a study.
This document discusses principles of damage control resuscitation for traumatic hemorrhage. It describes how hemorrhage can lead to hypovolemic shock and coagulopathy, exacerbating blood loss. Damage control resuscitation aims to rapidly restore blood volume while limiting blood pressure increases to prevent further bleeding. It emphasizes early use of blood products rather than crystalloids to avoid dilutional coagulopathy, and maintaining hemostasis through permissive hypotension, tranexamic acid, and ratio-based blood component resuscitation. While controversial, this approach may improve outcomes compared to aggressive crystalloid resuscitation in severely bleeding trauma patients.
Holley analyses the cascade of events in bleeding trauma patients leading to Australia's latest evidenced-based guidelines on transfusion protocols in critical bleeding.
The Sick and the Dead: Evidence-Based Trauma Resuscitation in 2016SMACC Conference
Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.
Short Review regarding Metabolic Acidosis
The Causes, anion gap,urine osmolal gap, Renal Tubular Acidosis, approach to Metabolic Acidosis in Final Slide
This document discusses the effective and ineffective uses of educational technology tools, referred to as "gizmos." It notes that while gizmos can be innovative and engaging, they can also lead to distraction, imbalance, and idolatry if overused or relied upon too heavily. For learning to be effective, the document emphasizes self-direction, spaced repetition of information, practice testing, and engagement with the information and learning process itself rather than just the technological tools.
The Coagulopathy of Trauma: A Review of MechanismsEmergency Live
Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways.
Dr Sachin Gupta an intensivist at Peninsula Health presents on the difficulties we currently face in predicting bleeding and how this might change in the future.
The ultrasound scan showed a small nodule on the pleural edge near the ribs and cardiac shadow, indicating the probe was close to the midline with part of the heart visible to the right. No other abnormalities were seen on the scan.
This document discusses lead poisoning in children in Zamfara, Nigeria caused by mining activities. It provides details on blood lead levels found in children, which were as high as 109-370 mcg/dL. Nearly 97% of children tested had blood lead levels exceeding 45 mcg/dL. The challenges in addressing this crisis included fear and misunderstandings between communities and aid organizations, as well as differing agendas among stakeholders. Over time, remediation efforts helped reduce mortality and the number of children requiring treatment, though some challenges remained such as recontamination and new outbreaks in other areas. Effective communication, understanding local cultures, and providing consistent information were emphasized as important to resolving crises like this.
The document discusses the lethal triad of acidosis, coagulopathy, and hypothermia that can occur in trauma patients and cause a rapid decline towards death. It outlines a case study of a patient who arrived at the emergency department after a shooting and provides details on their resuscitation care, including addressing acidosis, hypothermia, coagulopathy and stopping bleeding through fluid administration, blood products, and other therapies to reverse the lethal triad and stabilize the patient.
This document discusses acute care of elderly patients in emergency departments. It notes that elderly patients make up a large proportion of emergency department visits, often arriving by ambulance. Elderly patients are more likely to have unnecessary emergency department visits and longer lengths of stay. The document advocates for improved pre-hospital interventions to prevent emergency department visits for falls in elderly patients. It also suggests implementing comprehensive geriatric assessments and observation units in emergency departments to help determine if admissions are necessary and reduce admissions, readmissions, and return visits for elderly patients.
Fluid and blood resuscitation in abdominal traumaimran80
This document discusses fluid and blood resuscitation in abdominal trauma, providing guidelines for surgeons. It outlines factors related to different levels of blood loss and clinical signs of shock. It recommends using lactated Ringer's solution as the crystalloid fluid of choice and hydroxyethyl starch as the preferred colloid. Close clinical monitoring of vital signs, urine output, oxygen saturation, and bicarbonate levels is emphasized to guide fluid resuscitation and determine need for blood transfusion to maintain a hemoglobin of 7gm% or higher.
This document discusses radiotherapy (RT) for hepatocellular carcinoma (HCC) in the Asia-Pacific region. It compares outcomes between sorafenib and RT for intermediate/advanced HCC. Helical tomotherapy (HT) improves long-term survival and increases radiation dose without increased toxicity for HCC with macrovascular invasion compared to 3D conformal radiotherapy (3DCRT). HT allows delivery of higher radiation doses in a shorter treatment period with acceptable toxicity for HCC with macrovascular invasion.
PRESENTACION TROPONINA. Analytical consideration for high sensitivitty tropon...manuelgn4
This document discusses analytical considerations for high sensitivity troponin assays. It explains that troponin is superior to other cardiac biomarkers due to its high myocardial tissue content. Next-generation troponin assays can measure levels in healthy individuals and improve risk stratification for cardiac events. Serial testing of troponin levels and determining changes based on biological variation can help distinguish cardiac injury from chronic conditions. Point-of-care troponin tests have advantages of rapid results but currently lack the sensitivity of high-sensitivity laboratory assays. Overall, heightened troponin assay sensitivity requires correlating results closely with clinical presentation to properly interpret potential cardiac injury.
Cardiovascular PET-CT uses positron emission tomography and computed tomography to non-invasively image the heart and blood vessels. FDG-PET shows promise for detecting vulnerable plaques by measuring vascular inflammation. A study found FDG uptake in carotid plaques correlated with histological evidence of inflammation, such as macrophage staining. This suggests PET may help characterize plaque inflammation and identify high-risk patients. However, structural imaging like CT is also needed to detect plaques and guide PET measurements. Further research in larger populations is still needed to verify FDG-PET's ability to measure vascular inflammation in humans.
This document compares the risk of microembolization during diagnostic coronary angiography between single catheter and double catheter strategies. In the first study, a left radial approach was found to have a lower rate of microembolization than a right radial approach, likely due to less catheter manipulation and exchanges. Independent predictors of high microembolization included a greater number of catheters used. A second study found that using a single "Tiger" catheter halved the rate of microembolization compared to using a double catheter "Judkins" strategy, mainly by reducing catheter exchanges. Minimizing catheter exchanges may help reduce the risk of air embolism and microembolization during coronary angiography procedures.
Prof Karim Brohi Major haemorrhage & CoagulopathyRahul Goswami
1. Trauma-induced coagulopathy (TIC) is a major cause of death from hemorrhage in trauma patients, accounting for over 90% of deaths.
2. TIC results from the interaction of trauma, hemorrhage, shock and other factors which activate protein C and impair coagulation.
3. The goal of haemostatic resuscitation is to control hemorrhage early, limit fluid administration to avoid dilution of clotting factors, and target coagulopathy through techniques like rapid administration of cryoprecipitate to replace lost fibrinogen.
Primary PCI is superior to thrombolysis for STEMI treatment, with lower mortality and reinfarction rates. Stents provide better outcomes than balloon angioplasty alone. Door-to-balloon times under 120 minutes are optimal. For facilities without PCI capabilities, rapid transfer for primary PCI within 2 hours is recommended over thrombolysis if possible. Facilitated PCI, using drugs to establish early reperfusion before angioplasty, combines benefits of early reperfusion and easier intervention. Pre-procedural TIMI flow grade is a determinant of PCI success and outcomes.
Severe calcified, eccentric CFA lesion in non-stenting zone is one of the toughest case for EVT. I would like to introduce you to a novel flossing method “Crossvac” which enables us to reduce eccentric calcification, gets enough lesion modification, and would even make it possible to avoid stenting.
The document discusses strategies for early treatment of acute myocardial infarction. It provides evidence that pre-hospital thrombolytic therapy can significantly reduce mortality rates compared to in-hospital thrombolytic therapy by reducing treatment delays. Studies show administering thrombolysis within 30-60 minutes of symptoms onset can save 11-60 lives per 1000 patients. Combined strategies using both pre-hospital thrombolysis and immediate angioplasty have demonstrated high rates of coronary reperfusion and good long-term outcomes.
This document discusses the use of multi-modality imaging in evaluating ischemic stroke. It compares CT and MRI for 5 objectives: 1) excluding hemorrhage, 2) eliminating other diagnoses, 3) detecting the infarct core, 4) evaluating salvageable tissue, and 5) assessing intracranial circulation. MRI is generally superior to CT for objectives 2-4 due to its increased sensitivity, while CT is comparable or better for objectives 1 and 5 due to its wider availability and faster scan times. The optimal imaging approach depends on the specific situation and capabilities of the facility.
Intraluminal coronary thrombus aspiration in patients with STEMI. Prof. Andre...Chaichuk Sergiy
Intraluminal coronary thrombus aspiration in patients with STEMI was studied in randomized trials. Results showed thrombus aspiration before stenting improved myocardial perfusion scores and ST-segment resolution compared to conventional PCI alone. Meta-analyses found manual thrombus aspiration reduced distal embolization and improved angiographic and electrocardiographic outcomes, while its effect on mortality is unclear. Larger randomized trials are still needed to definitively establish the benefits of routine thrombus aspiration in STEMI.
La tromboaspiración se correlaciona con un menor índice de resistencia de la microcirculación. Dr. Dejan Orlic, MD. Congreso euroPCR 2013, Paris, Francia. Encuentre más presentaciones en la web de SOLACI: www.solaci.org/
Omer Goktekin - TransradialApproach is BetterEuro CTO Club
The document discusses the advantages of the transradial approach for percutaneous coronary interventions including CTO PCI, with benefits such as reduced vascular complications, patient comfort, and early ambulation compared to the transfemoral approach. While the transradial approach is technically more challenging, studies have shown comparable success rates for CTO PCI between the two approaches. The document also reviews data demonstrating the feasibility and safety of using large bore guides and bilateral transradial access for complex CTO PCI cases.
Ostial lesions involve areas near the origin of coronary arteries. They represent around 3% of all CTO lesions and are more complex to treat than non-ostial lesions. Aorto-ostial lesions involving the origins of the RCA, LMS, and bypass grafts have higher J-CTO scores and require longer stents than other lesions. Retrograde wiring requires extra care to avoid incorrect vessel selection or subintimal wiring. Case examples demonstrate the technical challenges of ostial CTOs, with meticulous planning and imaging needed due to ambiguity of the proximal cap and vessel course.
Novel RT techniques for treating lung cancer 1403Yong Chan Ahn
- Novel RT techniques such as SBRT, IMRT, IGRT and particle beam therapy can provide high local control rates for lung cancer with reduced toxicity compared to conventional RT.
- SBRT achieved 90% local control and favorable 5-year survival for primary and metastatic lung cancers at SMC with very low complication risks.
- IMRT may be beneficial for large or centrally-located tumors but further study is needed due to the study's retrospective nature and heterogeneous patient population.
- Particle beam therapy, such as proton therapy, can further reduce dose to organs-at-risk compared to photon therapies and may allow dose escalation for improved outcomes, particularly for locally advanced lung cancers.
1) The document discusses a masterclass on non-small cell lung cancer (NSCLC) surgery.
2) It presents a case study of a 59-year-old female with an incidental chest X-ray finding and questions regarding her diagnosis, staging, and treatment options.
3) The document reviews NSCLC staging statistics, survival rates based on stage, and concepts in personalized and integrated therapy for NSCLC.
Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern ...Allina Health
This document summarizes the neurointerventional treatment of acute stroke using mechanical thrombectomy. It discusses how earlier trials in 2013 that compared IV t-PA to intra-arterial therapy found no difference in outcomes due to outdated technology, inclusion of non-large vessel occlusions, and low recanalization rates. The MR CLEAN trial in 2015 showed improved outcomes with mechanical thrombectomy for large vessel occlusions when using modern stent retrievers in patients treated within 6 hours. Several other 2015 trials also demonstrated the benefits of mechanical thrombectomy. As a result, IV t-PA plus endovascular treatment is now standard of care for acute ischemic stroke due to large vessel occlusions.
This document discusses the potential for PET-CT to characterize plaque inflammation in atherosclerosis. It begins by establishing that inflammation plays a key role in all phases of atherosclerotic disease. Studies have shown FDG uptake on PET correlates with histological evidence of inflammation in carotid plaques and animal models. Additional challenges for characterizing coronary plaques include suppressing myocardial FDG uptake, addressing motion issues, and the smaller size of coronary plaques. However, with gating, diet modification, and higher target-to-background ratios from novel tracers or improved instrumentation, PET-CT may help identify high-risk inflamed plaques and guide more preventative treatment approaches.
Similar to Not all bleeding stops: acute coagulopathy of trauma by Brohi (20)
Systematic review of 26 studies with 55,792 patients found that dedicated neurocritical care (NCC) was associated with decreased risk of mortality (17% relative risk reduction) and decreased risk of poor functional outcomes (17% relative risk reduction) in critically ill brain-injured adults. A survey of Australian ICUs found limited availability of NCC, with only 4 centers specializing in it and 9 employing an intensivist subspecializing in NCC. Continuous EEG monitoring was found to have higher sensitivity for detecting nonconvulsive seizures than routine EEG monitoring, and was associated with reduced in-hospital mortality, though barriers to its universal use include infrastructure and personnel requirements.
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical careSMACC Conference
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew UdySMACC Conference
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories workSMACC Conference
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne LeeSMACC Conference
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?SMACC Conference
This document discusses the concept of maintaining higher blood pressure levels, known as hypertension, after a spinal cord injury to improve spinal cord perfusion pressure and reduce secondary injury. It notes that while animal studies and some human trials have shown improved neurological outcomes, the evidence is still limited. It calls for larger randomized controlled trials in humans that also incorporate multi-modal monitoring and standardized outcome measures to further evaluate if inducing hypertension after spinal cord injury should be considered the gold standard of care.
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same CoinSMACC Conference
Undertreatment of sepsis can lead to mortality, while overdiagnosis and overtreatment can increase future risk of antimicrobial resistance. Antimicrobial stewardship aims to balance these risks by prioritizing patient safety and appropriate antimicrobial use. Data shows variability in appropriateness of antimicrobial prescribing between different types of hospitals. Embedding antimicrobial stewardship principles throughout sepsis diagnosis and treatment, from initial microbiology testing to post-treatment review, can help standardize care and optimize outcomes.
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Not all bleeding stops: acute coagulopathy of trauma by Brohi
1. ACUTE TRAUMATIC COAGULOPATHY
Centre for Trauma Sciences
Queen Mary University of London
www.c4ts.qmul.ac.uk
Royal London Major Trauma Centre
Barts Health NHS Trust
KARIM BROHI, FRCS FRCA
Professor of Trauma Sciences, QMUL