This document discusses the management and treatment of patients with advanced heart failure who require admission to the intensive care unit (ICU). It defines advanced heart failure and provides criteria for determining which heart failure patients should be admitted to the ICU. It covers monitoring in the ICU, classification of heart failure, medical treatment including diuretics and inotropic drugs, and mechanical circulatory support options. The future of treatments like ventricular assist devices is also mentioned.
Heart Failure (Dr Vosik Presentation) Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Heart Failure (Dr Vosik Presentation) Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Hospital Readmissions Reduction Program: Keys to SuccessHealth Catalyst
Avoidable readmissions are a major financial major problem for the healthcare industry, especially for government payers. To tackle this problem, CMS launched the Hospital Readmissions Reduction Program (HRRP). While some hospitals may be able to absorb the financial penalties under HRRP, they still need to track increasingly complex reporting metrics. Most tracking solutions are inadequate for today’s complicated reporting needs. A healthcare enterprise data warehouse and analytics applications, however, are designed to solve the numerous reporting burdens. When used together, they also deliver a robust solution that enables hospitals to track and drive real cost and quality improvement initiatives, all without the need for users to be technical experts.
Current management of Spontaneous intracerebral haemorrhage 2016Woralux Phusoongern
Reference : Dastur CK, Yu W. Current management of spontaneous intracerebral haemorrhage. Stroke and Vascular Neurology 2017;00: e000047. doi:10.1136/svn- 2016-000047
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
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
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Heart Failure management in ICU
1. By Dr. Ahmad Y. Alansi
Althawra Modern General Hospital
Cardiac surgery department
Anesthesia & ICU unite
2. Definitions
Which heart failure patient should be
admitted in ICU?
Monitoring
Classification and plan
Medical treatment
Mechanical support
The future
Summary
3. Definition of Advanced HF
A subset of patients with chronic HF will
continue to progress and develop persistently
severe symptoms despite maximum therapy
.Various terminologies have been used to
describe this group of patients who are
classified with ACCF/AHA stage D
HF, including “advanced HF,” “end-stage
HF,” and “refractory HF.
9. ● Nonadherence with medication regimen, sodium and/or fluid restriction
● Acute myocardial ischemia
● Uncorrected high blood pressure
● AF and other arrhythmias
● Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem,
beta blockers)
● Pulmonary embolus
● Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones,
NSAIDs)
● Excessive alcohol or illicit drug use
● Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)
● Concurrent infections (e.g., pneumonia, viral illnesses)
● Additional acute cardiovascular disorders (e.g., valve disease endocarditis,
myopericarditis, aortic dissection
10. Hypotension systolic BP < 90 mmHg
SpO2 < 90 %
PH < 7.35
Lactate > 2.0
Oliguria, BUN > 30
Worsening renal function
VsO2 < 50 %
11. So the following patients should be admitted to
ICU :
All pateints with NYHA class III-IV.
Suspected or diagnoseed ACS .
Potential life threatening arrhythmia (VF, VT, high
grade a- v block, persistent symptomatic tachy or
brady).
Requiring or at risk of requiring invasive ventilatory
support .
Cardiogenic shock or otherwise requiring chemical
or mechanical circulatory support (dopmamine
, dobutamine,….IABP,LVAD….etc)
Multisystem Failure .
14. 3- Pulmonary artery catheterization
(PAC)
Indicated in patients with left ventricular
dysfunction
. In patients requiring inotropic or
vasoconstrictor drugs.
For monitoring
Cardiac output
Estimation of systemic vascular resistance
Mixed venous oxygen saturation
Lost popularity because of Invasiveness and no different in
mortality rate
15. 4- Transoesophageal Echocardiography
Recently gained popularity as a haemodynamic
monitoring tool for ventilated intensive care patients.
It provides valuable information about morphology
and haemodynamic state,
but interpretation of data requires considerable
training and experience.
So Transthoracic Echo
Is more performed and remain the main tool .
16. Low Output Failure in which there is decreased
contractility of heart leading to decreased
cardiac output
High Output Failure in which demands of body
are high, which are not met even with increased
cardiac output like in case of severe Anemia ,
Thyrotoxicosis and Thiamine deficiency
17.
18. Which side of heart is affected
– Left (more common)
– Right (right-sided MI, pulmonary HTN)
Which heart function is affected
– Systolic (↓ contraction and EF, dilated LV)
– Diastolic (↓ relaxation,)
Failure of LV filling
Contractile function and EF usually normal
19.
20.
21. The management of heart failure described here
is meant for patients with advanced or
decompensated heart failure. The approach
here is specifically designed for ICU patients: it
is based on invasive hemodynamic
measurements rather than symptoms and uses
only drugs that are given by continuous
intravenous infusion
23. Left-Sided (Systolic) Heart Failure :
1- High Blood Pressure (e.g. early period
after cardiopulmonary bypass surgery )
Profile: High PCWP/Low CO/High BP
Treatment: Vasodilator therapy with
nitroprusside or nitroglycerin. If the PCWP remains
above 20 mm Hg, add diuretic therapy with
furosemide.
24. Left-Sided (Systolic) Heart Failure :
2- Normal Blood Pressure: e.g. ischemic
heart disease, acute myocarditis, and the advanced
stages of chronic cardiomyopathy.
Profile: High PCWP/Low CO/Normal BP
Treatment: Inodilator therapy with dobutamine or
milrinone, or vasodilator therapy with nitroglycerin. If
the PCWP does not decrease to <20 mm Hg, add diuretic
therapy with furosemide.
25. Left-Sided (Systolic) Heart Failure :
3- Low Blood Pressure is the sine qua
non of cardiogenic shock. e.g. associated
with cardiopulmonary bypass surgery, acute myocardial
infarction, viral myocarditis, and pulmonary embolus.
Profile: High PCWP/Low CO/Low BP
Treatment: Dopamine in vasoconstrictor doses or
combination with Dubtamin.
Mechanical assist devices can be used as a temporary
measure in selected cases.
26. Diastolic Heart Failure :
Incidence of purely diastolic HF in nature is not
known.
no general agreement about the optimal treatment but
two recommendations seems to be valid :
1- positive inotropic agents have no role in the
treatment of diastolic heart failure.
2- diuretic therapy can be counterproductive,
vasodilator agents, such as nitroglycerin and milrinone,
Calcium channel blockers like verapamil are effective.
27. Right Heart Failure
The strategies below pertain only to primary right
heart failure (e.g., following acute myocardial
infarction) and not to right heart failure secondary
to chronic obstructive lung disease:
1- If PCWP is below 15 mm Hg, infuse volume until the PCWP
or CVP increases by 5 mm Hg or either one reaches 20 mm Hg .
2- If the RVEDV is less than 140 mL/m2, infuse volume until
the RVEDV reaches 140 mL/m2 .
3- If PCWP is above 15 mm Hg or the RVEDV is 140 mL/m2 or
higher, infuse dobutamine, beginning at a rate of 5
mg/kg/minute .
In the presence of AV dissociation or complete heart block,
institute sequential A-V pacing and avoid ventricular pacing .
28. Diuretics in Hospitalized Patients: Recommendations
Class I
1. Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with intravenous loop diuretics to reduce
morbidity (Level of Evidence: B)
2. If patients are already receiving loop diuretic therapy, the initial
intravenous dose should equal or exceed their chronic oral daily dose and
should be given as either intermittent boluses or continuous infusion.
Urine output and signs and symptoms of congestion should be serially
assessed, and the diuretic dose should be adjusted accordingly to relieve
symptoms, reduce volume excess, and avoid hypotension (Level of
Evidence: B)
3. The effect of HF treatment should be monitored with careful
measurement of fluid intake and output, vital signs, body weight that is
determined at the same time each day, and clinical signs and symptoms
of systemic perfusion and congestion. Daily serum electrolytes, urea
nitrogen, and creatinine concentrations should be measured during the
use of intravenous diuretics or active titration of HF medications. (Level of
Evidence: C)
29. Diuretics in Hospitalized Patients: Recommendations
Class IIa
1. When diuresis is inadequate to relieve symptoms, it is reasonable
to intensify the diuretic regimen using either:
a. higher doses of intravenous loop diuretics (Level of Evidence: B);
b. addition of a second (e.g., thiazide) diuretic (Level of Evidence: B).
Class IIb
Low-dose dopamine infusion may be considered in addition
to loop diuretic 1 therapy to improve diuresis and better
preserve renal function and renal blood flow (Level of
Evidence: B)
30. Short term therapeutic options
( Nondurable)Bridge to recovery
Long term therapeutic options
Bridge to transplantation ( durable)
Destination therapy (permanent)
Percutaneous devices
IABP
Impella
ECMO and centrifugeal pump devices
Implantable devices (cardiotomy)
LVAD, RVAD, BiVAD, total artificial heart (different models, different
indications)
31. Class IIa
MCS is beneficial in carefully selected* patients with stage
D HFrEF in whom definitive management (e.g., cardiac
transplantation) or cardiac recovery is anticipated or planned
. (Level of Evidence: B)
Nondurable MCS, including the use of percutaneous and
extracorporeal ventricular assist devices (VADs), is
reasonable as a “bridge to recovery” or “bridge to decision”
for carefully selected* patients with HFrEF with acute,
profound hemodynamic compromise . (Level of Evidence: B)
Durable MCS is reasonable to prolong survival for carefully
selected* patients with stage D HFrEF (672-675). (Level of
Evidence: B)
32. selected* patients are those with
LVEF <25% and NYHA class III-IV functional
status despite GDMT, when CRT indicated , with
either high predicted 1- to 2-y mortality or
dependence on continuous parenteral inotropic
support.
33. Intra-Aortic Balloon Counterpulsation
Intra-aortic balloon counterpulsation was introduced
in 1968 as a method of promoting coronary blood
flow .
It is available in various lengths to match body height.
Hemodynamic Effects
Inflation begins at the onset of diastole, just after the aortic
valve closes that cause Increase in diastolic pressure
which should also augment coronary blood
flow, because the bulk of coronary flow occurs during
diastole.
Deflation at the onset of ventricular systole, just before the
aortic valve opens so Deflation of the balloon reduces
the end-diastolic pressure, This decreases ventricular
afterload and promotes ventricular stroke output.
34. IABP Indication:
when cardiac pump failure is life-threatening and
either pump function is expected to improve
spontaneously, or a corrective procedure is planned.
Cardiogenic shock following CPB
Acute MI .
Unstable angina,
Acute mitral insufficiency,
Planned cardiac transplantation.
Support PCI & reduce size of Infarction
??!!! controversy
35.
36. Yemeni future
Get to international standards of treatment (new drugs,
assist devices programs)
Transplantation
International future
Genetics
Stem cell cultures and implantation
Truly viable total artificial heart
37. The approach to advanced or decompensated heart failure in the ICU
is best guided by invasive hemodynamic measurements and by the
type of heart failure involved (systolic, diastolic, left-sided, or right-
sided failure).
The management of acute, decompensated heart failure should
augment cardiac output and reduce ventricular filling pressures
while producing little or no increase in myocardial O2 consumption.
Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with intravenous loop diuretics to
reduce morbidity .
Diuretic therapy should not play a major role in the management of
acute heart failure, particularly if the failure is due to diastolic
dysfunction.
Low-dose dopamine infusion may be considered in addition to loop
diuretic 1 therapy to improve diuresis and better preserve renal
function and renal blood flow .
If cardiogenic shock is identified, mechanical cardiac support should
be initiated as soon as possible, if indicated.