This set of slide was presented during the Kelantan Resuscitation Update 22 Nov 2015 in accordance to the latest ACLS/ILCOR 2015 Guidelines. However, I have emphasized on certain important aspects relevant within the Malaysian context. Nonetheless, in general, there are no major changes for this year 2015
Pain relief has significant physiological benefit, such as earlier discharge from hospital and reduce the onset of chronic pain syndrome.
Surgical pain produce complexity neurohumoral, infammation and amplifying responses and should be treated according to WFSA Analgesic Ladder.
Multimodal Pain Therapy should be done to reduced doses of each analgesic, improved pain relief due to synergistic or additive effects and reduce severity of side effects of each drug.
Differences between Paediatric and Adult airway gourav_singh
These slides contain a brief discussion about what all common differences between pediatric and adult airway can be found if you are in an ENT OPD or during Anesthesia.
Just a brief discussion.
Edward Fohrman | Introduction to NeuroanesthesiaEdward Fohrman
Edward Fohrman MD is an experienced anesthesiologist who runs Fohrman Anesthesiology. Here he shares his thoughts about neuroanesthesia.
Visit EdwardFohrman.com for more.
This slide was first presented during the Malaysian 1st Emergency Medicine Annual Scientific Meeting, in conjunction with the Academy of Medicine Malaysia, Academy of Medicine Singapore and the Academy of Medicine Hong Kong Tripartite Meeting in Aug 2016.
Pain relief has significant physiological benefit, such as earlier discharge from hospital and reduce the onset of chronic pain syndrome.
Surgical pain produce complexity neurohumoral, infammation and amplifying responses and should be treated according to WFSA Analgesic Ladder.
Multimodal Pain Therapy should be done to reduced doses of each analgesic, improved pain relief due to synergistic or additive effects and reduce severity of side effects of each drug.
Differences between Paediatric and Adult airway gourav_singh
These slides contain a brief discussion about what all common differences between pediatric and adult airway can be found if you are in an ENT OPD or during Anesthesia.
Just a brief discussion.
Edward Fohrman | Introduction to NeuroanesthesiaEdward Fohrman
Edward Fohrman MD is an experienced anesthesiologist who runs Fohrman Anesthesiology. Here he shares his thoughts about neuroanesthesia.
Visit EdwardFohrman.com for more.
This slide was first presented during the Malaysian 1st Emergency Medicine Annual Scientific Meeting, in conjunction with the Academy of Medicine Malaysia, Academy of Medicine Singapore and the Academy of Medicine Hong Kong Tripartite Meeting in Aug 2016.
An Introduction To Pre-Hospital Care in MalaysiaChew Keng Sheng
This lecture was delivered to a group of dental students. As such, in this lecture, this subject was dealt with in an as-objective-as-possible manner, and devoid of much socio-political sentiments associated with the problems of pre-hospital care in Malaysia.
My presentation slides during the 1st National Symposium in Emergency and Acute Care (S.E.M.A.C). I presented some of the obstacles and challenges in scientific writing in emergency medicine within the Malaysia context as academic emergency medicine is still progressing in Malaysia,
Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and ...Chew Keng Sheng
This is the talk I gave during ICEM 2010 under the International Experience of Cardiology Track. In this presentation, I highlighted some of the challenges I see within the Malaysian setting, I focus mainly on prehospital and A&E setting. Issues that are conventionally under the care of the cardiologists are not discussed.
My talk in April 2015 in Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
An introduction to the rationale and the two types (Write-in and Select-Menu) of Key Feature Questions. This presentation is based on an original article by Page and Bordage (1995).
My talk in April 2015 Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
Survival after cardiac arrest is poor but some therapies can make a difference. This presentation discusses the evidence for therpauetic hypothermia, normoxia, management of blood pressure and early cardiac catherterisation. It also makes the case that these might be elements of a bundle of care.
Quelle est la place de l'Optiflow aux urgences ?
Où en est-on des études cliniques ?
Peut-on traiter les patients des urgences comme ceux de réanimation avec l'oxygénation haut-débit ?
De nouvelles perspectives avec l'Optiflow ?
Presentación realizada por el Dr. José Manuel García Pinilla en el directo online ‘Lo mejor del Congreso ACC Orlando 2018’, celebrado en la SEC el 13 de marzo de 2018
Presentación "Manejo de la antiagregación ajustada a las pruebas de reactividad plaquetaria. Experiencia, Resultados y futuro de un programa nacional" del Dr. Daniel Aradi durante la Mesa Redonda de Antiagregación de la XXV Reunión Anual de la Sección de Hemodinámica y Cardiología Intervencionista (SHCI) de 2014 en Córdoba.
Novedades en el manejo del paciente con FA: actualización tras AHA 2016
22/11/2016 19:30h Casa del Corazón, Madrid
http://manejofa.secardiologia.es
#manejoFA
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria percutánea. Guías y preguntas abiertas
Dr. Antonio Fernández Ortiz, Hospital Universitario Clínico San Carlos (Madrid)
Fundación EPIC _ Left atrial appendage closure. Clinical evidence; where we a...Fundacion EPIC
Presentación de la ponencia "Cierre Percutáneo de Orejuela Izquierda. Evidencia clínica: dónde estamos?" realizada por Raul Moreno en los Diálogos EPIC_Cierre Percutáneo de la Orejuela Izquierda el 15 de Marzo de 2018 en Madrid (España)
Left atrial appendage closure. Clinical evidence; where we are? by Raul Moreno at Diálogos EPIC_Percutaneous left atrial appendage closure, March 15th 2018 in Madrid (Spain)
Similar to ACLS 2015 Updates - The Malaysian Perspective (20)
Disaster and Mass Casualty Incidents (updated 7th July 2020)Chew Keng Sheng
A new updated slide on an overview of disaster management in Malaysia, including the formation of NADMA as the dedicated agency to coordinate disaster management in Malaysia.
Predatory publishing is a relatively recent phenomenon that seems to be exploiting some key features of the open access publishing model, sustained by collecting APCs that are far less than those found in legitimate open access journals. This CME aims to introduce to the participants on the phenomenon of predatory journals, why they continue to thrive, characteristics that are suggestive of a predatory journal, and how one can take step to minimize the risk of faling into predatory journal publication
A short sharing on doctor-patient communication to First year medical students in Universiti Malaysia Sarawak, to be supplemented with anecdotal accounts.
Sensitivity, specificity and likelihood ratiosChew Keng Sheng
A short tutorial on sensitivity, specificity and likelihood ratios. In this presentation, I demonstrate why likelihood ratios are better parameters compared to sensitivity and specificity in real world setting.
New or Presumed New LBBB To Be Treated As a STEMI Equivalent? A Contra Argume...Chew Keng Sheng
My 6-page notes to go along with the "debate" of whether new or presumed new LBBB per se (without any other qualification) should be treated as STEMI equivalent
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
5. 1
• Take out your smartphone
2
• Make sure you are connected
3
• Go to: pollev.com/cksheng74
www.PresentationPro.com
6.
7.
8. Effect of Hyperoxia On Post-CA: A Meta-
Analysis
Wang CH et al. Resuscitation. 2014;85(9):1142-8.
9. Methods
• 10 studies, N = 32,993
• No language limitation in article selection
• P = Post-ROSC patients
• I = Hyperoxia (PaO2 >300 mmHg)
• C = Non-hyperoxia or Normoxia (60 – 300 mmHg)
• O = In-hospital mortality (primary)
www.PresentationPro.com
11. Poor Neurological Outcome
OR, 1.62; 95% CI, 0.87–3.02
HyperoxiaNon-Hyperoxia
Wang CH et al. Resuscitation. 2014;85(9):1142-8.
12. Why Too Much Oxygen is Bad?
Cornet AD et al. Critical care. 2013;17(2):313
13. Mechanisms of Injury of Hyperoxia
• Hyperoxia leads to generation of reactive oxygen
species
– This decreases the bioavailability of nitric oxide and
results in vasoconstriction.
• Hyperoxia results in closure of K+ATP channels,
inducing vasoconstriction
– Ischemia ! fall intracellular ATP !induce opening of K+
channels ! hyperpolarization of the vasc sm ms cells !
vasodilation
– In hyperoxia ! the closure of K+ channels !
vasoconstriction.
www.PresentationPro.com
14. Mechanisms of Injury of Hyperoxia
• Hyperoxia induce vasoconstriction by acting directly
on L-type Ca2+ channels
• Hyperoxia increases releases of angiotensin II
– AT II promotes endothelin-1 release ! vasoconstriction.
• Hyperoxia increases 20-hydroxyeicosatetraeonic
acid (20-HETE)
– 20-HETE is an arachidonic acid metabolite and a potent
vasoconstrictor
www.PresentationPro.com
16. Oxygen Use During Cardiac Arrest
• Observational study
• 145 OHCA
• PaO2 level and CPR outcomes
• Results:
– PaO2 <61 mmHg: 18.8% survival to hosp adm
– PaO2 61 – 300 mmHg: 50.6% survival to hosp adm
– PaO2 > 300 mmHg: 83.3% survival to hosp adm
– No statistical difference in overall neurologic survival
Spindelboeck W, Schindler O, Moser A et al. Increasing arterial oxygen partial pressure during
cardiopulmonary resuscitation is associated with improved rates of hospital admission.
Resuscitation. 2013;84(6):770-5.
17. Authors’ Conclusion
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We describe a significantly increased rate
of hospital admission associated with
increasing PaO2. We found that the
previously described potentially harmful
effects of hyperoxia after return of
spontaneous circulation were not
reproduced for PaO2 measured during
CPR.
18. AHA 2015 Guidelines
• When supplementary oxygen is available, it may be
reasonable to use the maximal feasible inspired
oxygen concentration during CPR.
• Evidence for possible detrimental effects of
hyperoxia in the immediate post-cardiac arrest
period should not be extrapolated to CPR context
www.PresentationPro.com
19. AHA 2015 Guidelines
Post-CPR:
• When resources are available to titrate FiO2, it is
reasonable to decrease FiO2 when SaO2 is 100%
provided the SaO2 is maintained at 94% or greater.
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23. Is Adrenaline Really Beneficial In Cardiac
Arrest?
www.PresentationPro.com
Lin S et al. Resuscitation. 2014;85(6):732-40.
24. Meta-Analysis (Lin et al, 2014)
• Meta-analysis, 14 RCTs, 12,246 patients
• P = OHCA patients
• I = Standard dose adrenaline 1 mg q3min
• C = various comparators
– vs placebo (1), n = 534
– vs high dose adrenaline (6), n = 6,174
– vs vasopressin (1), n = 336
– vs adrenaline + vasopressin (6), n = 5202
• O = survival to hospital discharge (primary)
www.PresentationPro.com
Lin S et al. Resuscitation. 2014;85(6):732-40.
25. Lin S et al. Resuscitation. 2014;85(6):732-40.
Standard
dose
adrenaline
vs
High dose
adrenaline
27. Results
• Adrenaline* vs placebo (1), n = 534
– No difference in survival or neuro outcome
• Adrenaline vs high dose adrenaline* (6), n = 6,174
– No difference in survival or neuro outcome
• Adrenaline vs vasopressin (1), n = 336
– No difference in ROSC, admit, survival or neuro outcome
• Adrenaline vs adre + vasopressin (6), n = 5,202
– No difference in ROSC, admit, survival or neuro outcome
www.PresentationPro.com
* Higher ROSC, higher admission
28. Authors’ Conclusion
“There was no clear advantage of SDA over placebo, HDA,
adrenaline and vasopressin combination, or vasopressin
alone, in survival to discharge or neurological outcomes
after OHCA. There were improvements in rates of survival to
admission and ROSC with HDA over SDA and with SDA over
placebo. Thus, the efficacy of vasopressor use in OHCA
remains unanswered. Future trials are needed to determine
the optimal dose of adrenaline for OHCA.”
*SDA = standard dose adrenaline;
HAD = high dose adrenaline Lin S et al. Resuscitation. 2014;85(6):732-40.
29. AHA 2015 Recommendations
• Standard-dose epinephrine (1 mg every 3 to 5
minutes) may be reasonable for patients in cardiac
arrest (Class IIb, LOE B-R).
• High-dose epinephrine is not recommended for
routine use in cardiac arrest (Class III: No Benefit,
LOE B-R).
30. How early should adrenaline be given?
• IHCA
• N = 25095, non-shockable rhythms.
• Adjusted OR (survival to discharge):
– OR = 1.0 for 1-3 min (reference group)
– OR = 0.91 (95% CI 0.82 to 1.00; P=0.055) for 4-6 min
– OR = 0.74 (95% CI 0.63 to 0.88; P<0.001) for 7-9 min
– OR = 0.63 (95% CI 0.52 to 0.76; P<0.001) for >9 min
Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, et al. Time to
administration of epinephrine and outcome after in-hospital cardiac arrest with non
shockable rhythms: retrospective analysis of large in-hospital data registry. BMJ
2014;348:g3028.
31. OHCA setting
• Shockable rhythm:
– Cantrell et al (2013)
• ROSC achiever: shorter scene arrival-to-first adrenaline than
non-ROSC (8.1 vs. 9.8 min, p < 0.01)
• Non-shockable rhythm
– Goto et al (2013), N = 209577
• improved 1-month survival; adrenaline <9 min, EMS-initiated
CPR vs adrenaline >10 min
– Nakahura et al (2012), N = 212228
• improved survival to discharge; adrenaline<10 min, EMS-initiated
CPR vs no adrenaline
– Koscik et al (2013), N = 686
• improved ROSC in adrenaline <10 min, PEA
32. AHA 2015 Recommendations
• For initial non-shockable rhythm: It may be
reasonable to administer adrenaline as soon as
feasible after the onset of cardiac arrest (Class IIb,
LOE C-LD).
• For initial shockable rhyhtm: There is insufficient
evidence to make a recommendation as to the
optimal timing of adrenaline, particularly in relation
to defibrillation
www.PresentationPro.com
37. Amiodarone vs Placebo (ARREST study)
• Compared to placebo, amiodarone has better
survival to adm (44% vs. 34%, P =0.03); adjusted
OR 1.6 (95% CI: 1.1 to 2.4). No difference in
survival to discharge and survival with good neuro
(not powered)
www.PresentationPro.com
Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, et al. Amiodarone
for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med
1999;341(12):871-8.
38. Amiodarone vs Lidocaine (ALIVE)
• Compared to lidocaine, amiodarone has better
survival to adm (22.8% vs. 12%, P =0.009); OR
2.17 (95% CI: 1.21 to 3.83). No difference in
survival to discharge and survival with good neuro
Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared
with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med 2002;346(12):
884-90.
40. AHA 2015 Recommendations
• Amiodarone may be considered for VF/pVT that is
unresponsive to CPR, defibrillation, and a
vasopressor therapy (Class IIb, LOE B-R).
• Lidocaine may be considered as an alternative to
amiodarone for VF/pVT that is unresponsive to
CPR, defibrillation, and vasopressor therapy (Class
IIb, LOE C-LD).
www.PresentationPro.com
41. AHA 2015 Recommendations
“…none (of the antiarrhythmics) have yet
been proven to increase long term
survival or survival with good neurologic
outcome. Thus establishing vascular
access to enable drug administration
should not compromise the quality of CPR
or timely defibrillation, which are known to
improve survival.”
42. AHA 2015 Recommendations on
Ultrasound Use
Ultrasound (cardiac or noncardiac )may be
considered during the management of
cardiac arrest, although its usefulness has
not been well established (Class IIb, LOE C-
EO). If a qualified sonographer is present and
use of ultrasound does not interfere with the
standard cardiac arrest treatment protocol,
then ultrasound may be considered as an
adjunct to standard patient evaluation (Class
IIb, LOE C-EO).
44. Why Therapeutic Hypothermia?
1. reduce the cerebral metabolic rate for oxygen
(CMRO2) (6% for q1°C reduction in brain
temperature >28°C)
2. suppression of free radical production in
reperfusion injury
3. suppression of excitatory amino acids release,
and calcium shifts, which can in turn lead to
mitochondrial damage and apoptosis
• Adverse effects: arrhythmias, infection, and
coagulopathy. Nolan JP. et al. Circulation. 2003;108(1):118-21.
45. Historical Perspective
• 2 studies in Feb 2002 NEJM show improved
survival and neurological outcomes with induction
of mild therapeutic hypothermia for survivors of
OHCA
www.PresentationPro.com
46. Historical Perspective
• The Hypothermia after Cardiac Arrest Study Group
study – OHCA with ROSC: 32-34ºC over 24 hours
(n=137) improved functional recovery at discharge
(55% vs 39%; NNT = 6), lower 6-mo mortality rate
vs with normothermic patients (41% vs 55%)
(NNT=7)
• In Bernard et al, 77 OHCA with ROSC: hypothermia
(33°C for 12 hours) vs normothermia: Good neuro
at discharge in 49% of hypothermic patients vs 26%
normothermic
www.PresentationPro.com
47. Therapeutic Hypothermia – Colder Is Not
Better
Nielsen N et al. N Engl J Med. 2013;369(23):2197-206.
48. Nielsen N et al. N Engl J Med. 2013;369(23):2197-206.
49. Conclusion: Preventing Post-arrest
Hyperthermia?
• “…No significant differences between the two
groups in overall mortality at the end of the trial or
in the composite of poor neurologic function or
death at 180 days.”
• “…..Nevertheless, it is important to acknowledge
that there may be a clinically relevant benefit of
controlling the body temperature at 36°C, instead of
allowing fever to develop in patients who have been
resuscitated after cardiac arrest.”
www.PresentationPro.com
Nielsen N et al. N Engl J Med. 2013;369(23):2197-206.
50.
51.
52. New therapy in cardiac
arrest:
Combo of adrenaline-
vasopressin-steroids?
53. Post-resuscitation as sepsis-like?
• During and after CPR, it has been found that there
are
– activation of blood coagulation
– platelet activation with formation of thromboxane A2 and
– alteration of soluble E-selectin and P-selectin
www.PresentationPro.com
54. Post-resuscitation as sepsis-like?
• Four phases post-resuscitation:
1. First 24 hrs - microcirculatory dysfunction from
multifocal hypoxia leading to rapid release of toxic
enzymes & free radicals into CSF and blood
2. 1 to 3 days - cardiac function & systemic function
improved, but increased intestinal permeability
predisposes to sepsis syndrome and MODS
3. Days later – serious infection, patient declines
rapidly
4. Death
www.PresentationPro.com
57. Vasopressin
• Non-survivors of CPR have lower plasma
vasopressin level compared to those who survived
• Vasopressin acts directly on V1 receptors on
vascular contractile elements
• In cardiac arrest, vasopressin is released as
adjunct vasopressor to adrenaline
www.PresentationPro.com
58. Steroids
• Cardiac arrest – lower cortisol levels during and
after CPR
• ROSC is associated with increased plasma
cytokine elevation, endotoxemia, coagulopathy,
adrenal insufficiency resulting in post-resus shock
• Steroids may be beneficial to improve
hemodynamics and reduce intensity of post-resus
SIRS and MODS
www.PresentationPro.com
60. VSE vs control
• VSE – higher ROSC > 20 min (83.9% vs 65.9%;
OR, 2.98; 95%CI, 1.39-6.40; P = 0.005)
• VSE – higher survival to discharge with good neuro
(CPC score of 1 or 2) (13.9% vs 5.1%; OR, 3.28;
95%CI, 1.17-9.20; P = 0.02).
• Post-resus shock: VSE – higher survival to
discharge with good neuro (21.1% vs 8.2%; OR
3.74; 95% CI 1.20 – 11.62; p = 0.02), improved
hemodynamics; less oran dysfunction
Post-resus shock: sustained post-resus shock >4 hours or required >50% increase of
vasopressor to maintain MAP>70 mmHg post-resus