Management of Heart Failure in the ED Setting:
An Evidence-Based Review of the Literature
J Emerg Med, 2018 Sep 26.
doi: 10.1016/j.jemermed.2018.08.002
This talk covers the most important aspects of treatment of acute ischemic stroke, such as thrombolysis, use of antiplatelets, BP and sugar control and general supportive care.
Stroke is a leading cause of death and disability. All doctors should have a basic knowledge about stroke management. This presentation gives a summary of treatment options in acute brain stroke.
This talk covers the most important aspects of treatment of acute ischemic stroke, such as thrombolysis, use of antiplatelets, BP and sugar control and general supportive care.
Stroke is a leading cause of death and disability. All doctors should have a basic knowledge about stroke management. This presentation gives a summary of treatment options in acute brain stroke.
Stroke is a medical emergency, with a mortality rate higher
than most forms of cancer. It is the second leading cause of
death in developed countries and is the most common cause
of serious, long-term disability in adults. The incidence of
stroke is increasing with the aging of populations and hence
there is a major challenge to health planners.
Children at very low risk of brain injuriesSun Yai-Cheng
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Lancet 2009; 374: 1160–70
Stroke is common. This presentation discusses the broad outlines of acute stroke management, especially in the first 24 hours after onset of symptoms. It would be useful for physicians as well as neurologists.
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
Stroke. 2015;46:3020-3035.
Effect of Blood Pressure Lowering in Early Ischemic Stroke, Time to Change Pr...Ersifa Fatimah
Seorang rekan residen neuro sampai mengirim (via e-mail) sebuah jurnal yang baru ditelaahnya di larut malam. Kepada si cip, dia menyatakan bagaimana jurnal ini membuat pikirannya bergejolak, “Seperti dipaksa untuk menerima sebuah pemikiran baru yang melawan apa yang telah kita yakini bersama dalam proses belajar kita selama 5 tahun terakhir ini!”
Artikel itu berjudul Effect of Blood Pressure Lowering in Early Ischemic Stroke: Meta-Analysis oleh Lee et al., dan dipublikasi dalam jurnal Stroke Juli 2015.
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary
Circulation. published online September 23, 2014
Acute ischemic stroke is an emergency. There are good thrombolytic agents available now. Aspirin or clopidogrel along with statins should be given to all stroke patients. Control of BP and sugar is of paramount importance.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
Stroke is a medical emergency, with a mortality rate higher
than most forms of cancer. It is the second leading cause of
death in developed countries and is the most common cause
of serious, long-term disability in adults. The incidence of
stroke is increasing with the aging of populations and hence
there is a major challenge to health planners.
Children at very low risk of brain injuriesSun Yai-Cheng
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Lancet 2009; 374: 1160–70
Stroke is common. This presentation discusses the broad outlines of acute stroke management, especially in the first 24 hours after onset of symptoms. It would be useful for physicians as well as neurologists.
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
Stroke. 2015;46:3020-3035.
Effect of Blood Pressure Lowering in Early Ischemic Stroke, Time to Change Pr...Ersifa Fatimah
Seorang rekan residen neuro sampai mengirim (via e-mail) sebuah jurnal yang baru ditelaahnya di larut malam. Kepada si cip, dia menyatakan bagaimana jurnal ini membuat pikirannya bergejolak, “Seperti dipaksa untuk menerima sebuah pemikiran baru yang melawan apa yang telah kita yakini bersama dalam proses belajar kita selama 5 tahun terakhir ini!”
Artikel itu berjudul Effect of Blood Pressure Lowering in Early Ischemic Stroke: Meta-Analysis oleh Lee et al., dan dipublikasi dalam jurnal Stroke Juli 2015.
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary
Circulation. published online September 23, 2014
Acute ischemic stroke is an emergency. There are good thrombolytic agents available now. Aspirin or clopidogrel along with statins should be given to all stroke patients. Control of BP and sugar is of paramount importance.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
CONCLUSIONS:
- Cardiologist, obstetrician and anestesiologist should cooperate to each other
- The advantage of regional anesthesia is patients can communicate if symptoms occur
- If palpitations, chest pain and shortness of breath happened, immediate action should be performed
- RA should be given using lower dose of local anesthetics opioids and slow induction
- GA : standard technique “rapid sequence induction”
During atrial fibrillation, the heart's upper chambers — called the atria — beat chaotically and irregularly. They beat out of sync with the lower heart chambers, called the ventricles. For many people, AFib may have no symptoms. But AFib may cause a fast, pounding heartbeat, shortness of breath or light-headedness.
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
The European Guideline on Management of Major Bleeding and Coagulopathy Follo...Sun Yai-Cheng
The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: Fourth Edition
Rossaint et al. Critical Care (2016) 20:100
DOI 10.1186/s13054-016-1265-x
ACEP Policy for Fever Infants and Children Younger than 2 Years of Age in EDSun Yai-Cheng
Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever
Ann Emerg Med. 2016;67:625-639
With the Proliferation of Mobile Medical Apps, Which Ones Work Best in the Emergency Department?
Annals of Emergency Medicine, August 2015 Vol. 66, Issue 2, A13–15
Use of tPA for the Management of Acute Ischemic Stroke in the ED: ACEP PolicySun Yai-Cheng
ACEP Clinical Policy
Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department
Ann Emerg Med. 2015;66:322-333
Evaluation and Management of Acute Aortic Dissection: ACEP PolicySun Yai-Cheng
ACEP Clinical Policy
Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection
Ann Emerg Med. 2015;65:32-42
C-Spine Collar Clearance In The Obtunded Adult Blunt Trauma PatientSun Yai-Cheng
Cervical Spine Collar Clearance In The Obtunded Adult Blunt Trauma Patient A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma
J Trauma Acute Care Surg. 2015;78: 430-441.
ASA Guidelines for Management of the Difficult AirwaySun Yai-Cheng
Practice Guidelines for Management of the Difficult Airway
An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Anesthesiology 2013; 118(2):251-270
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
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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
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.
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.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. Management of Heart
Failure in the ED Setting:
An Evidence-Based
Review of the Literature
J Emerg Med, 2018 Sep 26.
doi: 10.1016/j.jemermed.2018.08.002
2. Why is this topic important?
Acute heart failure (AHF) exacerbation
is a common presentation to the ED, with
the potential to cause significant morbidity
and mortality.
It is important to tailor treatments to the
appropriate type of heart failure.
3. What does this review
attempt to show?
This review provides an evidence-based
summary of the current ED management
of AHF.
4. Methods
Searched PubMed and Google Scholar
for articles using the keywords
‘‘heart failure,’’ ‘‘management,’’
‘‘treatment,’’ and ‘‘emergency.’
A total of 129 articles were selected for
inclusion in this narrative review.
5. Discussion
The primary management of AHF includes
hemodynamic stabilization and
symptom relief.
Initial management should focus on
assessment and management of the
patient’s airway, breathing, and
circulation.
6. 1. Mild AHF Exacerbation
with Systemic Overload
2. Hypertensive AHF with
Pulmonary Edema
3. Hypotensive AHF with
Cardiogenic Shock
4. High-Output Heart Failure
9. A diuretic (e.g., furosemide) can be
provided at an i.v. dose of 1–2 times the
patient’s known oral dose (furosemide at
20–40 mg i.v. or bumetanide at 1 mg i.v.),
with diuresis typically occurring within 30–
60 min of i.v. administration.
Decisions on bolus or continuous infusion
and high- vs. low-dose strategies remain
controversial.
10. There is variation in the recommendations
for high- vs. low-dose furosemide.
Patients receiving high-dose furosemide
have demonstrated a trend toward higher
rates of diuresis and improved overall
outcomes, but they also experience
increases in creatinine at greater rates.
11. Morphine is not recommended, as it is
associated with an increased risk of
mortality and need for ICU admission
when it is given in AHF.
12. Ultrafiltration (UF) should be reserved
for patients who are refractory to standard
diuretic therapy.
Compared with standard diuresis, UF
controls fluid removal rate and may
remove more total body sodium.
15. The primary focus of treatment for these
patients includes respiratory support with
noninvasive positive pressure
ventilation (NIPPV) and vasodilators
(specifically, nitrates), followed by
diuretics if the patient is systemically
volume overloaded.
16. NIPPV increases intra-thoracic pressure,
thereby decreasing preload and lowering
pulmonary interstitial fluid, as well as
decreasing the work of breathing.
17. Nitrates rapidly reduce preload at lower
doses and systemic afterload at higher
doses.
Initial sublingual NTG 0.4 mg per dose.
i.v. NTG should be reserved for cases
where the SBP remains > 160 mmHg
Nitrates are contraindicated in patients
who have recently used
phosphodiesterase-5 inhibitors
(e.g.,sildenafil, vardenafil), who have LV
obstruction, or who are hypotensive.
18. Bolus doses of i.v. NTG have been
demonstrated to be safe and associated
with improved outcomes.
NTG 0.5-2 mg i.v. bolus every 3 min, with
decreased mortality, rates of intubation,
and need for ICU admission.
Initiating i.v. NTG at doses > 0.1 mg/min
with rapid titration to patient response.
21. If patients with AHF present with
reduced EF and a low BP, immediate
resuscitation is required with initiation of
inotropic agents.
A small fluid bolus (i.e., 250–500 mL)
is recommended prior to initiating an
inotropic agent.
22. Norepinephrine may be initially utilized to
increase BP and preload in the presence
of hypotension (similar to septic shock).
It can be used in conjunction with
dobutamine to increase cardiac output.
23. NIPPV should be considered in patients
with respiratory distress and cardiogenic
shock.
NIPPV may further reduce preload and
afterload, causing acute decompensation.
Endotracheal intubation.
24. Mechanical circulatory support (MCS)
should be considered in patients with
persistent cardiogenic shock, if immediate
stabilization is required to provide recovery
of the cardiac system, if time is required
for definitive therapy.
IABP, VAD, V-A ECMO.
28. More than 80% of AHF patients are
admitted from the ED.
Several studies suggest that the use of
observation units is safe and reduces
overall costs.
29. For patients with hemodynamic instability,
significant systemic congestion,
inadequate response to medical therapy,
new-onset AHF, electrolyte disturbances,
elevated BUN or creatinine, ischemia on
ECG, or inability to follow up should be
admitted.
31. Ottawa Heart Failure Risk Scale
History
• Stroke or TIA
• Intubation for
respiratory distress
Examination
• Heart rate ≥ 110
on ED arrival
• Saturation ≤ 90%
on arrival
• Heart rate ≥ 110
during 3-min walk test
(or too ill)
Investigations
• New ischemia on ECG
• BUN ≥ 33 mg/dL
• Serum CO2 ≥ 35 mEq/L
• Troponin I/T meeting
criteria for MI
• NT-proBNP ≥ 5000 ng/L
32. Emergency Heart Failure
Mortality Risk Grade
• Age
• Systolic BP (triage or initial)
• Heart rate (triage or initial)
• Oxygen saturation (lowest triage or initial)
• Creatinine
• Potassium
• Transportation by EMS
• Positive troponin
• Active malignancy
• On outpatient metolazone
35. If the dysrhythmia is the primary cause of
heart failure with hemodynamic instability,
then the patient should undergo
cardioversion.
If the dysrhythmia is not the primary cause
of the exacerbation, immediate
cardioversion may be associated with
adverse outcomes.
Digoxin can be utilized in patients with
decompensated heart failure, with doses
0.25 mg i.v. at one time, up to a maximum
of 1.5 mg over 1 day.