This document summarizes the case of a 23-year-old male patient who presented with headaches, visual symptoms, and an intraventricular lesion. The patient underwent neurosurgery to remove a meningioma. Intraoperatively, the patient was closely monitored and received various anesthetics, fluids, and blood products. Post-operatively, the patient had an excellent recovery without neurological deficits. The document also discusses the use of albumin in neurosurgical patients and compares outcomes of albumin versus saline resuscitation in patients with traumatic brain injury based on a previous clinical trial.
Possible causes of death (Multiorgan failure)
VT/VF intraoperatively
Acute on chronic Heart failur
Respiratory failure
Acute Liver failure
Acute renal failure
Sepsis with septic shock
Concern for Intestinal infarction
Brain tumor is an abnormal growth of the tissue in the brain.
The brain tumors can be mainly divided into two primary brain tumors and secondary/metastatic brain tumor
This patient has class III heart failure with an ejection fraction of 28% and was recently hospitalized for decompensated heart failure. She has been adherent to guideline directed medical therapy including diuretics, beta blockers, ACE inhibitors, and has a cardiac resynchronization device. Given her recent hospitalization and high BNP, adding an aldosterone inhibitor would be a reasonable next step to further optimize her medical management.
The patient is a 13-year-old male who went into cardiac arrest after being accidentally elbowed in the chest during a baseball game. Paramedics found him in ventricular fibrillation and he regained consciousness after defibrillation. Tests showed mild abnormalities but no underlying heart conditions. The likely diagnosis is commotio cordis, a rare condition where a blunt chest impact causes cardiac arrest through mechanoelectric effects on the heart during a specific part of the cardiac cycle.
Stroke is a major cause of death and disability in the United States and worldwide. While intravenous tissue plasminogen activator (tPA) can effectively treat acute ischemic stroke, few patients receive it due to its narrow time window and contraindications. Endovascular therapies including mechanical clot retrieval may extend the treatment window and benefit more patients, especially those with severe or large vessel strokes. New devices and techniques continue to improve revascularization rates and outcomes for acute stroke.
Dr. Saumya Agarwal presented a case of a 75-year-old female who was brought to the hospital semiconscious after a motor vehicle accident. She had a past medical history of diabetes, hypertension, and heart disease. Despite treatment for her injuries including a fracture of the right elbow and left shoulder, her condition deteriorated and she went into cardiac arrest. Resuscitation efforts were unsuccessful and she was declared dead due to cardiogenic shock resulting from her injuries sustained in the accident.
preoperative cardaic evaluation for non cardiac surgeryguest0fe90c4e
1. A 40-year-old man presented with cough, swelling of the lower limbs and abdomen, and shortness of breath. Examination found signs of right heart failure and rapid atrial fibrillation.
2. Further history revealed symptoms of hyperthyroidism. Tests confirmed Graves' disease.
3. The patient's pulmonary hypertension and right heart failure were found to be caused by severe thyrotoxicosis, a reversible condition if treated. Studies show up to 47% of patients with hyperthyroidism can develop pulmonary hypertension.
Possible causes of death (Multiorgan failure)
VT/VF intraoperatively
Acute on chronic Heart failur
Respiratory failure
Acute Liver failure
Acute renal failure
Sepsis with septic shock
Concern for Intestinal infarction
Brain tumor is an abnormal growth of the tissue in the brain.
The brain tumors can be mainly divided into two primary brain tumors and secondary/metastatic brain tumor
This patient has class III heart failure with an ejection fraction of 28% and was recently hospitalized for decompensated heart failure. She has been adherent to guideline directed medical therapy including diuretics, beta blockers, ACE inhibitors, and has a cardiac resynchronization device. Given her recent hospitalization and high BNP, adding an aldosterone inhibitor would be a reasonable next step to further optimize her medical management.
The patient is a 13-year-old male who went into cardiac arrest after being accidentally elbowed in the chest during a baseball game. Paramedics found him in ventricular fibrillation and he regained consciousness after defibrillation. Tests showed mild abnormalities but no underlying heart conditions. The likely diagnosis is commotio cordis, a rare condition where a blunt chest impact causes cardiac arrest through mechanoelectric effects on the heart during a specific part of the cardiac cycle.
Stroke is a major cause of death and disability in the United States and worldwide. While intravenous tissue plasminogen activator (tPA) can effectively treat acute ischemic stroke, few patients receive it due to its narrow time window and contraindications. Endovascular therapies including mechanical clot retrieval may extend the treatment window and benefit more patients, especially those with severe or large vessel strokes. New devices and techniques continue to improve revascularization rates and outcomes for acute stroke.
Dr. Saumya Agarwal presented a case of a 75-year-old female who was brought to the hospital semiconscious after a motor vehicle accident. She had a past medical history of diabetes, hypertension, and heart disease. Despite treatment for her injuries including a fracture of the right elbow and left shoulder, her condition deteriorated and she went into cardiac arrest. Resuscitation efforts were unsuccessful and she was declared dead due to cardiogenic shock resulting from her injuries sustained in the accident.
preoperative cardaic evaluation for non cardiac surgeryguest0fe90c4e
1. A 40-year-old man presented with cough, swelling of the lower limbs and abdomen, and shortness of breath. Examination found signs of right heart failure and rapid atrial fibrillation.
2. Further history revealed symptoms of hyperthyroidism. Tests confirmed Graves' disease.
3. The patient's pulmonary hypertension and right heart failure were found to be caused by severe thyrotoxicosis, a reversible condition if treated. Studies show up to 47% of patients with hyperthyroidism can develop pulmonary hypertension.
Acute coronary syndrome (ACS) results from an imbalance between myocardial oxygen supply and demand due to diminished blood flow from an occlusive coronary artery thrombus. ACS is classified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS), which includes non-STEMI and unstable angina. Treatment involves antiplatelet and anticoagulant medications, revascularization procedures like percutaneous coronary intervention (PCI), and lifestyle modifications to prevent recurrent events.
Sgarbossa criteria in left bundle branch block in a hypertensive emergency ya...YasserMohammedHassan1
Rationale: Left bundle branch block and hypertensive emergency are very common conditions in clinical cardiovascular and emergency practice. Hypertensive emergency encompasses a spectrum of clinical presentations in which uncontrolled blood pressure leads to progressive end-organ dysfunction. Suspected acute myocardial infarction in the setting of a left bundle branch block presents a unique diagnostic and therapeutic challenge to the clinician. The diagnosis is especially difficult due to electrocardiographic changes caused by altered ventricular depolarization. However, reports on the use of Sgarbossa’s criteria in the management of hypertensive emergency is rare. Patient concerns: A middle-aged married heavy-smoker Egyptian male worker presented to the emergency department with a hypertensive emergency patient with acute chest pain and left bundle branch block. Sgarbossa’s criteria were initially very weak and, over time, became highly suggestive of acute ST-segment elevation myocardial infarction. Interestingly, chest pain increased as Sgarbossa’s diagnostic criteria were met. Thrombolytic therapy was strongly indicated because of a higher development of Sgarbossa criteria scoring. Intervention; Electrocardiography, oxygenation, streptokinase IVI, and echocardiography Diagnosis: Developing acute ST-segment elevation myocardial infarction in the presence of left bundle branch block post- hypertensive emergency. Outcomes: The dramatic response to developing acute myocardial infarction in left bundle branch block with hypertensive emergency to streptokinase. Lessons: The higher Sgarbossa criteria scoring in the case was the only indication for thrombolytic. Therefore, how did Sgarbossa criteria develop during case management to indicate the need for thrombolytic therapy?
Acute coronary syndrome (ACS) describes conditions caused by reduced blood flow in the coronary arteries including unstable angina, NSTEMI, and STEMI. ACS results from formation of thrombi on atherosclerotic plaques in the coronary arteries. Several studies show that glycoprotein IIb/IIIa inhibitors like abciximab given with percutaneous coronary intervention (PCI) reduce mortality, reinfarction, and major adverse cardiac events in ACS patients compared to PCI alone or medical therapy alone. Long term follow up of trials also demonstrate reduced rates of target vessel revascularization with early use of abciximab during PCI for ACS.
Edward Fohrman | Anesthetic Considerations in Vascular Neurosurgery Edward Fohrman
Edward Fohrman discusses what to take into consideration during vascular neurosurgery. Dr. Fohrman is the CEO of Fohrman Anesthesia Services & Consulting, Inc., which he founded in 2010.
Visit EdwardFohrman.com for more.
Fainting: Causes and Ways to Minimize RiskSummit Health
Fainting may cause physical injury, lead to hospitalization and be a sign of an underlying cardiac disorder. Our cardiac electrophysiologist will review the causes of fainting, tell who's at risk, and discuss methods to minimize the chances of fainting. Presentation by Summit Medical Group Cardiologist Roy Sauberman, MD FACC
96091164 Slice Ct And Cerebral Atherosclerosis02calaf0618
1. Carotid endarterectomy reduces the risk of stroke compared to medical therapy alone in patients with symptomatic moderate (50-69%) carotid stenosis, with an absolute risk reduction of about 5-10% over 5 years.
2. For asymptomatic carotid stenosis ≥60%, carotid endarterectomy provides a relative risk reduction of 53% compared to aspirin alone, but medical therapy is still usually recommended due to the low baseline risk.
3. Carotid artery stenting is recommended for patients who are not suitable for surgery due to high surgical risk from conditions like severe cardiac or pulmonary disease.
A 76-year-old male underwent a persantin PET/CT scan which showed a positive ECG and nuclear perfusion, revealing a distal left main blockage and severe coronary artery disease, leading to CABG surgery. A 70-year-old male with chest pain underwent a cardiac CTA showing a significant right coronary artery lesion, which was treated with stent placement. A third patient was found to have a left anterior descending coronary artery fistula.
Charge syndrome hallmarked with wpws and pda; 20 years post repairing-yasser ...YasserMohammedHassan1
CHARGE syndrome or Hall-Hittner syndrome is a pleiotropic disorder, in which the name is derived from the abbreviation epitomizing its six clinical criteria: ocular coloboma, cardiac defects, choanal atresia, growth or developmental retardation, genital hypoplasia, and ear anomalies or deafness. Wolff-Parkinson-White syndrome is the most frequent pattern of ventricular pre-excitation. Patent ductus arteriosus is one of the most frequent congenital heart diseases due to failure of closure of the ductus arteriosus within 72 hours of birth. CHARGE syndrome, Wolff-Parkinson-White syndrome, and patent ductus arteriosus are so difficult to be present in a single entity.
This document presents a case study of a 70-year-old woman who presented with progressive shortness of breath over 4 hours. Upon examination, she was found to be in severe respiratory distress. Tests revealed signs of a heart attack and congestive heart failure. She was diagnosed with a ST-elevation myocardial infarction and treated with oxygen, medications, and supportive care in the intensive care unit. Her condition gradually improved and she was discharged after 6 days with a full recovery.
Intracranial hemorrhages account for 8-11% of all acute strokes and have a high mortality rate. The main causes are hypertension, amyloid angiopathy, AVMs, anticoagulation, and tumors. Management involves stabilizing the patient, controlling blood pressure, stabilizing the clot, managing cerebral edema and seizures. Surgery is generally not beneficial except for cerebellar hemorrhages. Clinical trials have found no clear benefit of aggressive blood pressure control or clot evacuation surgery over medical management alone.
This document presents a cardiology case of a 56-year-old Hispanic male with a history of heart failure, ischemic cardiomyopathy, myocardial infarctions, hypertension, and strokes who was transferred for outpatient IV antibiotics and cardiology consultation. The patient's medical history, medications, physical exam findings, assessments, and treatment plans are summarized. Discussion topics include the patient's heart failure stage, electrocardiogram and chest x-ray findings, and automatic implantable cardioverter-defibrillator.
This document discusses acute coronary syndrome (ACS). It describes the pathophysiology of plaque rupture and thrombosis in ACS. It outlines risk factors for high-risk ACS features and discusses tools for risk stratification including ECG findings, cardiac biomarkers like troponin and CRP, and clinical scoring systems. It also reviews the diagnostic performance and prognostic value of troponin for detecting myocardial infarction.
1. Thrombolytic therapy through pharmacological agents like rTPA, urokinase, and streptokinase is one of the most effective ways to treat acute ischemic stroke through revascularization.
2. A study of 36 patients who received thrombolytic therapy found that outcomes were best for anterior circulation minor strokes and posterior circulation strokes, and when intravenous thrombolysis was administered within 3 hours of onset of symptoms.
3. Complications from thrombolytic therapy like hemorrhaging were found to be dose-related, with normal CT scans before treatment not guaranteeing outcomes but abnormal CT scans relating to poorer prognosis.
Calcium dramatically reverse the hypocalcaemia induced qt prolongation in mul...YasserMohammedHassan1
- A 25-year-old female patient presented to the emergency department with irritability, rapid breathing, and dizziness after a suicide attempt using multiple oral drug strips containing propranolol, amitriptyline, paracetamol, pseudoephedrine, caffeine, and chlorpheniramine.
- She was found to have hypocalcemia-induced QT prolongation on electrocardiography. Calcium supplementation reversed her symptoms and ECG abnormalities.
- This case report describes the first reported occurrence of these adverse drug reactions, including hypocalcemia, QT prolongation, and respiratory effects, resulting from an overdose of these multiple drugs. Close monitoring of electrolytes and drug interactions is important
Mrs. N.O, a 35-year-old woman, was admitted for cervical ripening and induction of labor in her 38th week of pregnancy following subfertility. She delivered a live male newborn but began bleeding heavily after an episiotomy and repair of a cervical laceration. Attempts to control the bleeding were unsuccessful and she underwent an emergency laparotomy and total abdominal hysterectomy, but died approximately 1 hour after surgery due to primary postpartum hemorrhage from uterine atony.
The document summarizes the EMPULSE clinical trial which evaluated the use of empagliflozin in patients hospitalized for acute heart failure. The trial randomized approximately 500 patients within 5 days of hospitalization to empagliflozin 10mg or placebo once daily. The primary endpoint was a composite of death, heart failure events and change in symptoms after 90 days. Key results showed the primary endpoint was met with empagliflozin reducing the risk of the composite endpoint compared to placebo. Empagliflozin also showed benefits on secondary endpoints including time to cardiovascular death or heart failure event and was found to have an excellent safety profile in acute heart failure patients.
A 50-year-old man with poorly controlled diabetes presented with fever, headache, and right-sided facial swelling. He was found to be septic and further examination revealed tender sinuses. Imaging and biopsy of sinus tissue showed fungal rhinosinusitis caused by zygomycetes. The patient underwent sinus surgery and was started on aggressive antifungal therapy including amphotericin B and iron chelation drugs. Repeat imaging showed the infection spreading in the brain despite initial treatment. His symptoms improved after switching to a higher dose of amphotericin B lipid complex therapy.
A 64-year-old male farmer presented with right hip pain after a fall. He had a history of right hemiplegia and hypertension. Examination revealed tenderness and limited range of motion of the right hip. Investigations showed anemia. He was admitted for skin traction and surgery. The night before surgery, he developed respiratory distress. His condition deteriorated and he suffered cardiopulmonary arrest. Resuscitation efforts were unsuccessful and he was declared dead due to a suspected pulmonary thromboembolism.
Cardiogenicshock by Dr.Afroza Prioty -140123092109-phpapp02Afroza Prioty
1) Cardiogenic shock is a clinical condition caused by the heart's inability to pump an adequate amount of blood to vital organs, resulting in inadequate tissue perfusion.
2) The document discusses the causes, pathophysiology, clinical manifestations, diagnosis, and management of cardiogenic shock, with a focus on cardiogenic shock caused by acute myocardial infarction.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting is recommended for suitable patients with cardiogenic shock due to acute myocardial infarction, along with supportive therapies like intra-aortic balloon pump counterpulsation or ventricular assist devices.
This document discusses endovascular treatment for acute ischemic stroke. It describes the goals of endovascular treatment as expanding the treatment window, including patients resistant to IV treatment or who have exclusion criteria, and increasing recanalization rates. Various endovascular treatments are discussed such as thrombolytic drugs, mechanical thrombectomy devices, and angioplasty. Complications of treatment like hemorrhagic transformation are also reviewed. Clinical trials demonstrating the safety and efficacy of endovascular therapies like the MERCI Retriever and Solitaire device are summarized.
Acute coronary syndrome (ACS) results from an imbalance between myocardial oxygen supply and demand due to diminished blood flow from an occlusive coronary artery thrombus. ACS is classified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS), which includes non-STEMI and unstable angina. Treatment involves antiplatelet and anticoagulant medications, revascularization procedures like percutaneous coronary intervention (PCI), and lifestyle modifications to prevent recurrent events.
Sgarbossa criteria in left bundle branch block in a hypertensive emergency ya...YasserMohammedHassan1
Rationale: Left bundle branch block and hypertensive emergency are very common conditions in clinical cardiovascular and emergency practice. Hypertensive emergency encompasses a spectrum of clinical presentations in which uncontrolled blood pressure leads to progressive end-organ dysfunction. Suspected acute myocardial infarction in the setting of a left bundle branch block presents a unique diagnostic and therapeutic challenge to the clinician. The diagnosis is especially difficult due to electrocardiographic changes caused by altered ventricular depolarization. However, reports on the use of Sgarbossa’s criteria in the management of hypertensive emergency is rare. Patient concerns: A middle-aged married heavy-smoker Egyptian male worker presented to the emergency department with a hypertensive emergency patient with acute chest pain and left bundle branch block. Sgarbossa’s criteria were initially very weak and, over time, became highly suggestive of acute ST-segment elevation myocardial infarction. Interestingly, chest pain increased as Sgarbossa’s diagnostic criteria were met. Thrombolytic therapy was strongly indicated because of a higher development of Sgarbossa criteria scoring. Intervention; Electrocardiography, oxygenation, streptokinase IVI, and echocardiography Diagnosis: Developing acute ST-segment elevation myocardial infarction in the presence of left bundle branch block post- hypertensive emergency. Outcomes: The dramatic response to developing acute myocardial infarction in left bundle branch block with hypertensive emergency to streptokinase. Lessons: The higher Sgarbossa criteria scoring in the case was the only indication for thrombolytic. Therefore, how did Sgarbossa criteria develop during case management to indicate the need for thrombolytic therapy?
Acute coronary syndrome (ACS) describes conditions caused by reduced blood flow in the coronary arteries including unstable angina, NSTEMI, and STEMI. ACS results from formation of thrombi on atherosclerotic plaques in the coronary arteries. Several studies show that glycoprotein IIb/IIIa inhibitors like abciximab given with percutaneous coronary intervention (PCI) reduce mortality, reinfarction, and major adverse cardiac events in ACS patients compared to PCI alone or medical therapy alone. Long term follow up of trials also demonstrate reduced rates of target vessel revascularization with early use of abciximab during PCI for ACS.
Edward Fohrman | Anesthetic Considerations in Vascular Neurosurgery Edward Fohrman
Edward Fohrman discusses what to take into consideration during vascular neurosurgery. Dr. Fohrman is the CEO of Fohrman Anesthesia Services & Consulting, Inc., which he founded in 2010.
Visit EdwardFohrman.com for more.
Fainting: Causes and Ways to Minimize RiskSummit Health
Fainting may cause physical injury, lead to hospitalization and be a sign of an underlying cardiac disorder. Our cardiac electrophysiologist will review the causes of fainting, tell who's at risk, and discuss methods to minimize the chances of fainting. Presentation by Summit Medical Group Cardiologist Roy Sauberman, MD FACC
96091164 Slice Ct And Cerebral Atherosclerosis02calaf0618
1. Carotid endarterectomy reduces the risk of stroke compared to medical therapy alone in patients with symptomatic moderate (50-69%) carotid stenosis, with an absolute risk reduction of about 5-10% over 5 years.
2. For asymptomatic carotid stenosis ≥60%, carotid endarterectomy provides a relative risk reduction of 53% compared to aspirin alone, but medical therapy is still usually recommended due to the low baseline risk.
3. Carotid artery stenting is recommended for patients who are not suitable for surgery due to high surgical risk from conditions like severe cardiac or pulmonary disease.
A 76-year-old male underwent a persantin PET/CT scan which showed a positive ECG and nuclear perfusion, revealing a distal left main blockage and severe coronary artery disease, leading to CABG surgery. A 70-year-old male with chest pain underwent a cardiac CTA showing a significant right coronary artery lesion, which was treated with stent placement. A third patient was found to have a left anterior descending coronary artery fistula.
Charge syndrome hallmarked with wpws and pda; 20 years post repairing-yasser ...YasserMohammedHassan1
CHARGE syndrome or Hall-Hittner syndrome is a pleiotropic disorder, in which the name is derived from the abbreviation epitomizing its six clinical criteria: ocular coloboma, cardiac defects, choanal atresia, growth or developmental retardation, genital hypoplasia, and ear anomalies or deafness. Wolff-Parkinson-White syndrome is the most frequent pattern of ventricular pre-excitation. Patent ductus arteriosus is one of the most frequent congenital heart diseases due to failure of closure of the ductus arteriosus within 72 hours of birth. CHARGE syndrome, Wolff-Parkinson-White syndrome, and patent ductus arteriosus are so difficult to be present in a single entity.
This document presents a case study of a 70-year-old woman who presented with progressive shortness of breath over 4 hours. Upon examination, she was found to be in severe respiratory distress. Tests revealed signs of a heart attack and congestive heart failure. She was diagnosed with a ST-elevation myocardial infarction and treated with oxygen, medications, and supportive care in the intensive care unit. Her condition gradually improved and she was discharged after 6 days with a full recovery.
Intracranial hemorrhages account for 8-11% of all acute strokes and have a high mortality rate. The main causes are hypertension, amyloid angiopathy, AVMs, anticoagulation, and tumors. Management involves stabilizing the patient, controlling blood pressure, stabilizing the clot, managing cerebral edema and seizures. Surgery is generally not beneficial except for cerebellar hemorrhages. Clinical trials have found no clear benefit of aggressive blood pressure control or clot evacuation surgery over medical management alone.
This document presents a cardiology case of a 56-year-old Hispanic male with a history of heart failure, ischemic cardiomyopathy, myocardial infarctions, hypertension, and strokes who was transferred for outpatient IV antibiotics and cardiology consultation. The patient's medical history, medications, physical exam findings, assessments, and treatment plans are summarized. Discussion topics include the patient's heart failure stage, electrocardiogram and chest x-ray findings, and automatic implantable cardioverter-defibrillator.
This document discusses acute coronary syndrome (ACS). It describes the pathophysiology of plaque rupture and thrombosis in ACS. It outlines risk factors for high-risk ACS features and discusses tools for risk stratification including ECG findings, cardiac biomarkers like troponin and CRP, and clinical scoring systems. It also reviews the diagnostic performance and prognostic value of troponin for detecting myocardial infarction.
1. Thrombolytic therapy through pharmacological agents like rTPA, urokinase, and streptokinase is one of the most effective ways to treat acute ischemic stroke through revascularization.
2. A study of 36 patients who received thrombolytic therapy found that outcomes were best for anterior circulation minor strokes and posterior circulation strokes, and when intravenous thrombolysis was administered within 3 hours of onset of symptoms.
3. Complications from thrombolytic therapy like hemorrhaging were found to be dose-related, with normal CT scans before treatment not guaranteeing outcomes but abnormal CT scans relating to poorer prognosis.
Calcium dramatically reverse the hypocalcaemia induced qt prolongation in mul...YasserMohammedHassan1
- A 25-year-old female patient presented to the emergency department with irritability, rapid breathing, and dizziness after a suicide attempt using multiple oral drug strips containing propranolol, amitriptyline, paracetamol, pseudoephedrine, caffeine, and chlorpheniramine.
- She was found to have hypocalcemia-induced QT prolongation on electrocardiography. Calcium supplementation reversed her symptoms and ECG abnormalities.
- This case report describes the first reported occurrence of these adverse drug reactions, including hypocalcemia, QT prolongation, and respiratory effects, resulting from an overdose of these multiple drugs. Close monitoring of electrolytes and drug interactions is important
Mrs. N.O, a 35-year-old woman, was admitted for cervical ripening and induction of labor in her 38th week of pregnancy following subfertility. She delivered a live male newborn but began bleeding heavily after an episiotomy and repair of a cervical laceration. Attempts to control the bleeding were unsuccessful and she underwent an emergency laparotomy and total abdominal hysterectomy, but died approximately 1 hour after surgery due to primary postpartum hemorrhage from uterine atony.
The document summarizes the EMPULSE clinical trial which evaluated the use of empagliflozin in patients hospitalized for acute heart failure. The trial randomized approximately 500 patients within 5 days of hospitalization to empagliflozin 10mg or placebo once daily. The primary endpoint was a composite of death, heart failure events and change in symptoms after 90 days. Key results showed the primary endpoint was met with empagliflozin reducing the risk of the composite endpoint compared to placebo. Empagliflozin also showed benefits on secondary endpoints including time to cardiovascular death or heart failure event and was found to have an excellent safety profile in acute heart failure patients.
A 50-year-old man with poorly controlled diabetes presented with fever, headache, and right-sided facial swelling. He was found to be septic and further examination revealed tender sinuses. Imaging and biopsy of sinus tissue showed fungal rhinosinusitis caused by zygomycetes. The patient underwent sinus surgery and was started on aggressive antifungal therapy including amphotericin B and iron chelation drugs. Repeat imaging showed the infection spreading in the brain despite initial treatment. His symptoms improved after switching to a higher dose of amphotericin B lipid complex therapy.
A 64-year-old male farmer presented with right hip pain after a fall. He had a history of right hemiplegia and hypertension. Examination revealed tenderness and limited range of motion of the right hip. Investigations showed anemia. He was admitted for skin traction and surgery. The night before surgery, he developed respiratory distress. His condition deteriorated and he suffered cardiopulmonary arrest. Resuscitation efforts were unsuccessful and he was declared dead due to a suspected pulmonary thromboembolism.
Cardiogenicshock by Dr.Afroza Prioty -140123092109-phpapp02Afroza Prioty
1) Cardiogenic shock is a clinical condition caused by the heart's inability to pump an adequate amount of blood to vital organs, resulting in inadequate tissue perfusion.
2) The document discusses the causes, pathophysiology, clinical manifestations, diagnosis, and management of cardiogenic shock, with a focus on cardiogenic shock caused by acute myocardial infarction.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting is recommended for suitable patients with cardiogenic shock due to acute myocardial infarction, along with supportive therapies like intra-aortic balloon pump counterpulsation or ventricular assist devices.
This document discusses endovascular treatment for acute ischemic stroke. It describes the goals of endovascular treatment as expanding the treatment window, including patients resistant to IV treatment or who have exclusion criteria, and increasing recanalization rates. Various endovascular treatments are discussed such as thrombolytic drugs, mechanical thrombectomy devices, and angioplasty. Complications of treatment like hemorrhagic transformation are also reviewed. Clinical trials demonstrating the safety and efficacy of endovascular therapies like the MERCI Retriever and Solitaire device are summarized.
This document provides information on pheochromocytoma, including:
1) It describes the history, epidemiology, clinical features, differential diagnosis, and "10% tumor rule" characteristics.
2) Biochemical testing using urine or plasma tests for metanephrines is described as the primary diagnostic method. Localization uses CT, MRI, or MIBG scans.
3) Extensive pre, intra, and postoperative management is outlined to prevent hemodynamic instability, including alpha-blockade, IV fluids, and monitoring. The goal of treatment is surgical removal which is often curative.
This document discusses intracranial pressure and cerebral edema in the neuro-ICU setting. It covers how patients with brain injuries present, mechanisms of primary and secondary brain injury, pathophysiology of increased intracranial pressure and cerebral edema, imaging techniques like CT scans to diagnose brain injuries, and guidelines around monitoring intracranial pressure in severe traumatic brain injury patients.
From vertigo to coma basilar artery occlusion بالاتر از سیاهی رنگی نیستramtinyoung
This document discusses standards of care for acute management of posterior circulation stroke patients. It summarizes that the patient presented with vertigo, blurred vision and other symptoms from an occlusion of the basilar artery, and received IV thrombolysis followed by a drug to promote recanalization, with improvement in symptoms. It also reviews general treatment approaches for posterior circulation strokes, including antiplatelet therapy, anticoagulation, management of blood pressure, and cautions around hemorrhagic transformation.
This document summarizes evaluation and management of elevated intracranial pressure in adults. It discusses causes of increased intracranial pressure including brain masses, edema, hydrocephalus, and venous obstruction. It covers monitoring of intracranial pressure, indications for monitoring, and types of monitors. It also provides an overview of general management strategies and specific therapies to lower intracranial pressure such as osmotic therapy, glucocorticoids, hyperventilation, barbiturates, and decompressive craniectomy.
The document summarizes guidelines from the Brain Trauma Foundation (BTF) for the management of severe traumatic brain injury (TBI). The BTF released the 4th edition of these guidelines in 2016 to provide evidence-based recommendations for treating severe TBIs. The guidelines provide recommendations on various treatment strategies, such as decompressive craniectomy, hypothermia, hyperosmolar therapy, cerebrospinal fluid drainage, ventilation, anesthetics/sedatives, and monitoring thresholds. Each recommendation is assigned a level depending on the quality of evidence.
Cerebral edema and intracranial hypertension after traumatic brain injury can be managed through various interventions to control increased intracranial pressure. These include cerebral resuscitation, intracranial pressure monitoring, hyperosmolar therapy with mannitol or hypertonic saline, mild hyperventilation, CSF drainage, temperature control, surgical decompression, and in refractory cases high-dose barbiturates or calcium channel blockers. Nutritional support and anti-seizure prophylaxis may also be considered as part of the management approach.
- The ANTIBIO study investigated the effects of 6 weeks of roxithromycin (300mg daily) treatment versus placebo in 872 patients hospitalized for an acute myocardial infarction.
- The study found no significant reduction in 12-month mortality or morbidity with roxithromycin treatment compared to placebo across various analyses.
- Routine treatment with roxithromycin cannot be recommended for patients after an acute myocardial infarction based on the results of this study.
- The ANTIBIO study investigated the effects of 6 weeks of roxithromycin (300mg daily) treatment versus placebo in 872 patients after an acute myocardial infarction.
- The study found no significant reduction in 12-month mortality or morbidity with roxithromycin treatment compared to placebo. Subgroup and adjusted analyses did not change these results.
- Due to the study terminating early with only 872 patients enrolled out of the intended 3922, the results indicate it is very unlikely a clinically meaningful benefit of roxithromycin treatment was missed. Therefore, routine roxithromycin treatment for AMI patients is not advised.
Café Au Lait Spot is A Marker for Pheochromocytoma in Hypertensive Crisis Wit...YasserMohammedHassan1
Café au lait Spot is a marker for pheochromocytoma in hypertensive crisis but with a wide-differential diagnosis. Labetalol may be chosen in hypertensive crisis due to pheochromocytoma.
Splanchnic blood flow
- Takes up to one third of cardiac output in normal physiology
- Is increased postprandially, and in septic shock
Splanchnic microcirculation
- Indirect assessment via clinical signs and biomarkers
- Role for sublingual videomicroscopy in the future?
Optimisation of splanchnic blood flow
- Fluid management
- Intra-abdominal pressure and abdominal perfusion pressure are important
- Vasopressors and inotropes, depending on status
- Hypovolemia and hypotension vs venous congestion
- Little coherence between macro- and microcirculation
Monitoring macro and microcirculation (Joel Starkopf WSACS session ESA 2018 #...WSACS
Splanchnic blood flow
- Takes up to one third of cardiac output in normal physiology
- Is increased postprandially, and in septic shock
Splanchnic microcirculation
- Indirect assessment via clinical signs and biomarkers
- Role for sublingual videomicroscopy in the future?
Optimisation of splanchnic blood flow
- Fluid management
- Intra-abdominal pressure and abdominal perfusion pressure are important
- Vasopressors and inotropes, depending on status
- Hypovolemia and hypotension vs venous congestion
- Little coherence between macro- and microcirculation
1) Cardiogenic shock is defined as hypotension, hypoperfusion, and elevated filling pressures caused by depressed left ventricular function following myocardial injury. Mortality from cardiogenic shock remains high at 50-70%.
2) Risk factors for cardiogenic shock include age over 65, female gender, large myocardial infarction, anterior infarction location, prior infarction history, diabetes, and hypertension. Post-mortem studies show extensive myocardial damage in patients who die from cardiogenic shock.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting may improve survival outcomes for cardiogenic shock, especially in patients under age 75, according to the landmark SHOCK trial. Adjunctive therapies including intra
A 73-year-old man presented with a 3-year history of progressive memory loss, poor balance, and recent urinary incontinence. Examination showed impaired memory and difficulties with calculations and gait. Brain imaging showed enlarged ventricles and white matter changes. Laboratory tests did not reveal a treatable cause of dementia. The patient's gait improved transiently after lumbar puncture. This document discusses normal pressure hydrocephalus (NPH) and reviews tests to diagnose NPH such as CSF pressure measurement, CSF removal tests, and CSF resistance measurement. It also discusses predictors of shunt response and treatment options for NPH.
A 58-year-old man presented with a seizure and loss of consciousness. Neuroimaging revealed a highly vascularized 5.7 x 5 cm solid mass in his right temporo-parietal region. Biopsy determined the mass was a solid supratentorial hemangioblastoma, a rare tumor. Further tests ruled out Von Hippel-Lindau disease. The patient underwent partial resection of the mass, improving his symptoms. Solid supratentorial hemangioblastomas occurring as single lesions unrelated to Von Hippel-Lindau disease are infrequent and atypical clinical presentations like this case are rarely reported.
1) Intracerebral hemorrhage is now understood as a dynamic process that evolves over days rather than a single event. Recent studies have provided insights into hematoma expansion, edema formation, and optimal blood pressure control.
2) Ongoing clinical trials are exploring intensive blood pressure control, induced hypothermia, hypertonic saline use, and other therapies to reduce hematoma growth and edema, with the goal of improving outcomes.
3) For anticoagulant-related hemorrhages, rapidly reversing coagulopathy through agents like prothrombin complex concentrates or recombinant factor VIIa may help limit expansion and improve prognosis over traditional fresh frozen plasma therapy alone.
Rhabdomyolysis is a condition characterized by the breakdown of skeletal muscle fibers and release of muscle contents into the bloodstream. It can be caused by trauma, exertion, medications, toxins, infections, and metabolic disorders. Symptoms may include muscle pain, weakness, and dark urine. Diagnosis is based on markedly elevated creatine kinase levels and presence of myoglobin in urine. Complications can include electrolyte abnormalities, acute kidney injury, compartment syndrome, and disseminated intravascular coagulation. Management involves fluid resuscitation and monitoring for complications.
The document discusses the pathophysiology of brain death in pediatric patients. It begins with a brief history of the concept of brain death and outlines the key findings required for a diagnosis, including coma, absence of brainstem reflexes, and apnea. The document then describes the specific brainstem reflexes and other tests used in the clinical examination, including precautions that must be taken. It emphasizes that determination of brain death requires two examinations by different physicians, separated by an observation period, as well as an apnea test. The role of ancillary tests is also outlined.
Early recurrence and cerebral bleeding in patients with acute ischemic stroke...Prudhvi Krishna
(1) This study evaluated the risk of recurrent stroke and bleeding in patients with acute ischemic stroke and atrial fibrillation treated with different types and timings of anticoagulation.
(2) It found that initiating anticoagulation between 4-14 days had the lowest risks, with a 7.6% risk of recurrent stroke and 3.6% risk of symptomatic bleeding.
(3) Oral anticoagulants alone were associated with the lowest bleeding risk, while low molecular weight heparin followed by oral anticoagulants or low molecular weight heparin alone had higher bleeding risks.
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it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
4. Enfermedad actual
• Paciente quien consulta por cuadro clínico de
aproximadamente 3 meses de evolución, consistente en
episodios de cefalea biparietal tipo presión que en
ocasiones lo han despertado, asociado a fosfenos y tinitus
en forma intermitente. Refiere que en el último mes ha
presentado problemas con la expresión verbal y la
organización sintáctica del lenguaje, visión borrosa, por lo
que fue estudiado documentándose lesión localizada en el
atrio ventricular cerebral izquierdo. Ingresa para manejo
quirúrgico.
6. Examen físico
• Buen estado general, afebril, sin signos de dificultad respiratoria ni
respuesta inflamatoria sistémica.
• TA: 129/78 FC: 82 FR: 18 SaO2: 98% T: 36ºC
EVA: 0 Peso : 74 Talla : 172 IMC: 25.01
• Neurológico: alerta, consciente, orientado en persona, tiempo y
lugar. Resto de funciones mentales superiores conservadas. Pares
craneanos con isocoria de 3mm normorreactivas, campimetría por
confrontación normal. Agudeza visual 20/20 sin corrección.
Sensibilidad y simetría facial cosnervadas. Resto de pares bajos sin
alteraciones. Motor con fuerza 5/5 en 4 extremidades, reflejos ++/
++++ simétricos, respuesta plantar flexora bilateral. Sensibilidad
conservada. No dismetría ni disdiadococinesia. Nistagmo
optoquinético conservado. No signos meníngeos.
8. Imágenes
• TAC y resonancia magnética contrastada muestran
lesión intraventricular en atrio izquierdo, probable
meningioma, que produce importante edema
vasogénico y dilatación ipsilateral de los cuernos
tempora y occipital del ventrículo lateral.
16. Intraoperatorio
• Monitoreo: saturación de oxígeno, tensión arterial, visoscopio, lineas
invasivas (arterial y pvc), monitoria de la relajacion (tren de cuatro), de la
profundidad anestesica con electroencefalograma procesado (bis),
capnografia y termometro esofagico.
• Inducción anestesica con propofol (TCI) remifentanil (TCI) y lidocaina
(mg/kg/hora)
• Relajación muscular con rocuronio
• Videolaringoscopia grado I/IV con C-MAC. Tubo flexoanillado número 8.
• Mantenimiento anestésico con propodol (TCI), remifentanil (TCI),
dexmedetomidina (mcg/kg/hora), lidocaina (mg/kg/hora).
• Linea arterial, CVC YEI, bloqueo cuero izquierdo y cervicar superficial.
• Profilaxis antiemetica: dexametasona, ondansetron, omeprazol.
17.
18.
19. • GASES VENOSOS
• 10:58 SAT 84,2% HB 15,4 LAC 2,2 HTO 47,2
• GASES ARTERIALES
• 11:20 PH 7,4 PCO2 35,1 PO2 220 HCO3 22,8 BE
-1,6 GLU 111 LAC 2,2 HB 15,4 HTO 47,2 CA 1,1
CL 106 K 3,7 NA 139
Intraoperatorio
20.
21. • GASES VENOSOS
• 12:07 SAT 82,2% HB 14,7 LAC 2,1 HTO 44,9
• GASES ARTERIALES
• 12:05 PH 7,4 PCO2 34,6 PO2 242 HCO3 21,5 BE
-2,8 GLU 116 LAC 2,2 HB 15,2 HTO 46,5 CA 1,1
CL 109 K 3,5 NA 141
Intraoperatorio
22.
23. • GASES ARTERIALES
• 14:05 PH 7,34 PCO2 40,2 PO2 224 HCO3 21,7 BE
-3,8 GLU 129 LAC 2,3 HB 13,4 HTO 41,1 CA 1,1
CL 111 K 4,3 NA 144
Intraoperatorio
24.
25. • GASES ARTERIALES
• 15:00 PH 7,34 PCO2 39,1 PO2 174 HCO3 21,4 BE -4,0
GLU 127 LAC 2,3 HB 12,9 HTO 39,7 CA 1,1 CL 112 K
4 NA 147
• MANITOL 20%: 185 CC.
• DIURESIS: 3400
• SANGRADO: 400
• LIQUIDOS: 300 ML ALBUMINA, 2600 ML DE SSN.
Intraoperatorio
26. Intraoperatorio
• Finaliza procedimiento quirúrgico.
• Analgesia multimodal con infucion intraoperatoria de
dexmedetomidina y lidocaina, mas acetaminofen.
• Se extuba paciente sin complicaciones y se traslada a
unidad de cuidados intensivos.
• Signos vitales: frecuencia cardíaca 72/minuto, tensión
arterial 146/82 , saturación 99%, frecuencia
respiratoria 18/minuto
27. Post-Operatorio
• Resonancia magnética de control sin evidencia de
lesión residual, cambios postquirúrgicos.
• Paciente con excelente evolución postoperatoria, sin
déficit neurológico posterior a intervención,
hemodinámicamente estable. Se decide egreso. Se dan
recomendaciones y signos de alarma, los cuales
comprende y acepta.
28. Que conoce del uso de Albumina
en pacientes Neuroquirúrgicos?
29. Subgrupo Trauma: Beneficio SSN
0.9% sobre albúmina
RR muerte > Pacientes con lesión
cerebral asociada
Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R: A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004, 350:2247–2256.
No diferencias en mortalidad
Análisis subgrupos: Tendencia <
Mortalidad en Sepsis con Albúmina
Ensayo multicéntrico
SSN 0.9% Vs Albúmina
6.997 Pacientes
(Saline versus Albumin Fluid Evaluation)
32. Que conoce del uso de
Soluciones Balanceadas en
pacientes Neuroquirúrgicos?
33. RESEARCH Open Access
Balanced versus chloride-rich solutions for fluid
resuscitation in brain-injured patients: a
randomised double-blind pilot study
Antoine Roquilly1†
, Olivier Loutrel1†
, Raphael Cinotti2
, Elise Rosenczweig3
, Laurent Flet4
, Pierre Joachim Mahe1
,
Romain Dumont1
, Anne Marie Chupin1
, Catherine Peneau1
, Corinne Lejus1
, Yvonnick Blanloeil2
, Christelle Volteau5
and Karim Asehnoune1*
Abstract
Introduction: We sought to investigate whether the use of balanced solutions reduces the incidence of
hyperchloraemic acidosis without increasing the risk for intracranial hypertension in patients with severe brain injury.
Methods: We conducted a single-centre, two-arm, randomised, double-blind, pilot controlled trial in Nantes,
France. Patients with severe traumatic brain injury (Glasgow Coma Scale score ≤8) or subarachnoid haemorrhage
(World Federation of Neurosurgical Society grade III or higher) who were mechanically ventilated were randomised
within the first 12 hours after brain injury to receive either isotonic balanced solutions (crystalloid and hydroxyethyl
starch; balanced group) or isotonic sodium chloride solutions (crystalloid and hydroxyethyl starch; saline group) for
48 hours. The primary endpoint was the occurrence of hyperchloraemic metabolic acidosis within 48 hours.
Results: Forty-two patients were included, of whom one patient in each group was excluded (one consent
withdrawn and one use of forbidden therapy). Nineteen patients (95%) in the saline group and thirteen (65%) in
the balanced group presented with hyperchloraemic acidosis within the first 48 hours (hazard ratio = 0.28, 95%
confidence interval [CI] = 0.11 to 0.70; P = 0.006). In the saline group, pH (P = .004) and strong ion deficit
(P = 0.047) were lower and chloraemia was higher (P = 0.002) than in the balanced group. Intracranial pressure
was not different between the study groups (mean difference 4 mmHg [-1;8]; P = 0.088). Seven patients (35%) in
the saline group and eight (40%) in the balanced group developed intracranial hypertension (P = 0.744). Three
patients (14%) in the saline group and five (25%) in the balanced group died (P = 0.387).
Conclusions: This study provides evidence that balanced solutions reduce the incidence of hyperchloraemic
acidosis in brain-injured patients compared to saline solutions. Even if the study was not powered sufficiently for
this endpoint, intracranial pressure did not appear different between groups.
Trial registration: EudraCT 2008-004153-15 and NCT00847977
The work in this trial was performed at Nantes University Hospital in Nantes, France.
Roquilly et al. Critical Care 2013, 17:R77
http://ccforum.com/content/17/2/R77
Figure 2 Kaplan-Meier curves for hyperchloraemic acidosis. Hyperchloraemic acidosis was defined as the association of hyperchloraemia
(>108 mmol/L) with strong ion difference (SID) (<40 mmol/L). SID = (Na + K + Ca + Mg) - (Cl + lactate). Na; sodium, K; potassium; Ca: calcium;
Mg: magnesium; Cl: chloride.
Roquilly et al. Critical Care 2013, 17:R77
http://ccforum.com/content/17/2/R77
Page 7 of 13
Figure 4 Time course of (A) blood osmolarity, (B) natraemia and (C) intracranial pressure in the saline group and the balanced g
Results are given as medians (IQR). *P < 0.05 versus saline group (significant group effect).
HR: 0.28, [CI] = 0.11 to 0.70; P = 0.006)
MD 4 mmHg [-1;8]; P = 0.088
7(35%) vs 8 (40%) à HTEC (P = 0.744)
3(14%) vs 5 (25%) à Muerte (P = 0.387)
34. Que situaciones especiales de
alteraciones del sodio y el agua
corporal conoce, que puedan
presentarse en pacientes
Neuroquirúrgicos?
35. ↑ AMPc
Canales de
aquaporina 2 en mem
celular
Reabsorción
Luz nefrona
a cel TC
Aquaporina 3-4
Intersticio Renal –
Circulación
> Osm intersticial
Reabsorción úrea del
Luz medular Osmolaridad plasmática regula ADH
Schreckinger M. Diabetes insipidus following resection of pituitary tumors. Clin Neurol Neuros 2013
(115)
36. DI NEFROGÉNICA
• Respuesta inadecuada ADH en túbulos
renales
• Inhabilidad [Orina]
• Medicamentos, hipercalcemia,
enfermedad renal primaria
DI NEUROGÉNICA
• Secreción inadecuada ADH en
hipotálamo
• Hereditaria, idiopática o lesión
• Autoinmune, radiación, trauma,
infección, isquemia, Cx
Schreckinger M. Diabetes insipidus following resection of pituitary tumors. Clin Neurol Neuros 2013 (115)
37. • 24H POP. >80% Células destruidas
• 25% DI transitoria. 0.5%
Permanente
• Poliuria (GU 2mL/Kg/h)
• Orina hipotónica (Gravedad especifica
<1.005)
• Osm U <300 mosm/L. S > 300
mosm/L.
• Hipernatremia (<145mmol/L)
Anesthetic management of patients undergoing pituitary surgery. Acta Clin Croat 2011 (50)209-216
TRATAMIENTO
Desmopresina 0.2 mcg IV-IM
(100-800mcg TID VO)
SS 0.45% o Ingesta agua libre
Monitoreo electrolítico
SÍNTOMAS
Polidipsia/Poliuria
DHT, letargo
Convulsiones
38. • 9-25% Cx trans-esfenoidal
• Manifestaciones 1 sem
• Secreción inadecuada ADH.
Independiente de Osm
• Na <135 mmol/L
• Osm sérica < 280 mmol/L
• Orina concentrada
• Euvolemia
• Función renal normal
Restricción hídrica 800-1000mL/día
SS Hipertónica (Si Na<120mmol/L)
Anesthetic management of patients undergoing pituitary surgery. Acta Clin Croat 2011 (50)209-216
Liberación no controlada ADH por
neuronas hipotalámicas secretoras
de ADH en vías de degeneración,
dañadas en intervención del soma
celular o en sus axones que integran
el tallo hipotálamo-hipofisario