This document discusses the current management of cardiogenic shock. It defines cardiogenic shock and describes its causes, predictors of mortality, and pathophysiology. Treatment involves hemodynamic support, volume management, inotropic drugs, and early revascularization, which significantly reduces mortality. Mechanical circulatory support devices like IABP, Tandem Heart, Impella, and ECMO can further improve hemodynamics and outcomes when used as adjuncts to optimal medical therapy. Timing of revascularization is critical, with survival benefits seen for up to 48 hours after myocardial infarction onset. Special considerations are discussed for managing shock in the elderly, from mechanical causes, and with specific device therapies.
Definition of shock
Initial Assessment of shock – ABC
Types of Shock
Stages of Shock
Physiologic Determinants of Shock
Common Features of Shock
Work-up of shock
General Approach to management of shock
A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.
Definition of shock
Initial Assessment of shock – ABC
Types of Shock
Stages of Shock
Physiologic Determinants of Shock
Common Features of Shock
Work-up of shock
General Approach to management of shock
A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.
Investigated the market for cardiovascular medical devices and clinical research organizations (CROs) to understand what roles play in the development and FDA approval process for therapeutics.
Cardiogenic shock : Medical Surgical NursingRaksha Yadav
This
presentation is designed for Nursing students and it gives a brief
about what you should know while caring for a client with Cardiogenic
shock and also its prevention.
The 2016 edition of the largest annual study in strategic communication, corporate communications and public relations worldwide is based on responses from 2,710 communication professionals from 43 European countries. Conducted by an international research team from renowned universities, the research provides insights about big dat, algorithms and automation in communication, social media influencers, stakeholder engagement, strategic issues and development of communication channels over a decade (2007-2016), skills and competency development of communicators, characteristics of excellent communication departments and much more. A joint project by the European Public Relations Education and Research Association (EUPRERA), the European Association of Communication Directors (EACD) with partner PRIME Research. Lead researcher: Prof Dr Ansgar Zerfass, University of Leipzig, Germany, & BI Norwegian Business School, Oslo.
PDF downloads and previous versions of this annual survey are available at http://www.communicationmonitor.eu.
To watch my animated viedo on YouTube visit
http://www.youtube.com/watch?v=nVHDGWfQhSU
To download my animated presentation visit:
https://www.dropbox.com/s/bbtayufrn1clnvh/Anaphylaxis.pptx
Heart Disease & Chest Pain Treatment At NT Cardiovascular Center Georgiamelvillejackson
http://www.ntcardiovascularcenter.com NT Cardiovascular Center providing latest cutting edge and comprehensive technology for heart disease, chest pain treatments, congestive heart failure, coronary artery disease monitoring, or any critical heart condition.
Post-Cardiac Arrest Syndrome:
Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation
Circulation. 2008;118:2452-2483
Everolimus eluting stents or bypass surgery finalGOPAL GHOSH
Trials and registry studies have shown lower long-term mortality after CABG than after PCI among patients with multivessel disease.These previous analyses did not evaluate PCI with second-generation drug-eluting stents
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
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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.
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
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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.
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
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.
2. DEFINITION
• Cardiogenic shock is a state of end-organ
hypoperfusion due to cardiac failure
• Pulmonary artery (PA) catheterization;
Doppler echocardiography used to confirm
elevation of LV filling pressures
Circulation. 2008;117:686-697
3. • Persistent hypotension (systolic blood pressure <80 to 90 mm
Hg or mean arterial pressure 30 mm Hg lower than baseline)
• Severe reduction in cardiac index (<1.8 L / min/m2
without support or <2.0 to 2.2 L/ min/m 2 with support)
• Adequate or elevated filling pressure (eg, left
ventricular [LV] end-diastolic pressure >18 mm Hg or right ventricular [RV] end-
diastolic pressure >10 to 15 mm Hg)
• Clinically by cool extremities, decreased urine output, and/or alteration in
mental status.
Circulation. 2008;117:686-697
4. Causes of Cardiogenic Shock
Predominant LV Failure
74.5%
Acute Severe MR
8.3%
VSD
4.6%
Isolated RV Shock
3.4%
Tamponade/rupture
1.7%
Other
7.5%
Shock Registry
JACC 2000 35:1063
5. OTHER CAUSES
• Acute myopericarditis
• Tako-tsubo cardiomyopathy
• Acute valvular regurgitation (trauma, degenerative
disease)
• Aortic dissection
• Acute stress in the setting of aortic or mitral stenosis
• Massive pulmonary embolism
6. Incidence
• Complicate approximately 5% to 8% of
STEMI and 2.5% of non-STEMI cases
• Incidence is on the decline (Increasing
number of myocardial infarction diagnosed
due to use of troponin & increase use of
reperfusion therapy )
The Global Registry of Acute Coronary
Events (GRACE). Heart. 2007;93:177–182
7.
8. • Historic mortality rate for CS complicating an acute
myocardial infarction (MI) was 80 to 90 percent
(1975 to 1988)
N Engl J Med 1991; 325:1117
• Shortterm mortality rates between 42-48 %
Circulation 2009; 119:1211
• Swiss registry (1997-2006): showing similar trends
Ann Intern Med 2008; 149:618
9.
10. Predictors
• GUSTOI database identified the following
predictors of 30day survival (receive initial fibrinolysis)
o Increasing age (odds ratio 1.49 for each 10 year
increase)
o Prior MI
o Physical findings at the time of diagnosis (the
presence of altered sensorium and cold, clammy skin)
o Oliguria
Am Heart J 1999; 138:21
16. Hemodynamic assessment
• Pulmonary artery catheterisation
• Non-invasive Doppler measurement:
Short mitral deceleration time (<140 ms) is
highly predictive of pulmonary capillary
wedge pressure >20 mm Hg in CS
Am Heart J. 2006;151:890 e9–e15
17. Volume management
• Intravenous fluid replacement:
PCWP, arterial oxygen saturation(SaO2),
systemic arterial pressure, and cardiac output
• The usual value in CS is between 18 and 25
mmHg
J Am Coll Cardiol 2000; 36:1071
18. Pharmacological Treatment
• Pharmacological support: inotropic and
vasopressor agents, lowest possible doses
• Higher vasopressor doses poorer survival
• ACC/AHA guidelines recommend
norepinephrine for more severe hypotension
because of its high potency
Circulation. 2004;110:588–636
Int J Cardiol. 2007;114:176–182
20. Kaplan-Meier Curves for 28-Day Survival in the Intention-to-Treat Population
De Backer D et al. N Engl J Med 2010;362:779-789
21. Forest Plot for Predefined Subgroup Analysis According to Type of Shock
De Backer D et al. N Engl J Med 2010;362:779-789
22. Mechanical Support: IABP
• Not every patient has a hemodynamic response
to IABP
• Response predicts better outcome
Circulation. 2003;108(suppl I):I-672
25. Figure 2. Time-to-event curves for all-cause mortality up to 12 months Event rates represent Kaplan-
Meier estimates. Two patients in the IABP group died at days 388 and 419 postrandomisation, which is
represented in the Kaplan-Meier curves.
Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic
shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial
The Lancet, Volume 382, Issue 9905, 16–22 November 2013, Pages
31. Reperfusion
• Survival benefit of early revascularization
• Thrombolysis
PCI is impossible
If a delay has occurred in transport for PCI and
when MI and CS onset were within 3 hours
32. REVASCULARISATION
• Early revascularization decreases mortality
rates
− SMASH (Urban P et al. Eur Heart J
1999;20:1030-8)
− SHOCK (Hochman JS et al. N Engl J Med
1999;34:625 -34)
− ACC/AHA guidelines on acute myocardial
infarction (Ryan TJ et al. Circulation
1999;100;1016-30)
39. Timing of PCI
• Presentation 0 to 6 hours after symptom onset
was associated with the lowest mortality
[ ALKK registry(German). door-to-angiography times were <90 minutes in
approximately three fourths of patients. ]
• SHOCK trial: increasing long-term mortality
as time to revascularization increased from 0
to 8 hours
• Survival benefit as long as 48 hours after MI
and 18 hours after shock onset
40. Stenting and Glycoprotein
IIb/IIIa Inhibition
• Stenting and glycoprotein IIb/IIIa inhibitors
were independently associated with improved
outcomes
ADMIRAL. N Engl J Med. 2001;344:1895–1903
42. Treatment of CS Due to Mechanical
Complications
• Mechanical complications of MI, including
rupture of the ventricular septum, free wall, or
papillary muscles, cause 12% of CS cases
• Ventricular septal rupture has the highest
mortality, 87%
• Strongly suspected in patients with small
infarct size and shock
43. Survival from mechanical causes
94%
71%
47%
39%
28%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
VSD Acute Severe MR
In-hospitalMortality(%)
No Surgery
Surgery
Percutaneous closure
Shock Registry JACC 2000;36:1104 & 36: 1110
GUSTO 1 Circulation 2000;101:27
Holzer R CCI 2004;61:196
44. Management of Special Conditions
• Treatment of CS with hypertrophic
obstructive cardiomyopathy: volume
resuscitation and betablockade. Pure alpha-
agonists may be used to increase afterload,
increasing cavity size and decreasing
obstruction
• Outflow obstruction: seen in tako-tsubo
cardiomyopathy
45. Other mechanical devices
• Left ventricular and biventricular assist device
: surgically placed, bridge to therapy & bridge to
transplantation
• Percutaneous left atrialto-
femoral arterial ventricular assist device(Tand
em heart)
• ECMO
• Percutaneous transvalvular left ventricular ass
ist device (LVAD)[Impella]
49. Tandem Heart Outcome Data
42%
47%
45%
36%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Thiele (n=41) Burkhoff (n=33)
30daymortality(%)
Tandem Heart
IABP
Improved haemodynamic parameters
Increase in bleeding, limb ischaemia, and sepsis
Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1
50. Impella
Axial flow pump
Much simpler to use
Increases cardiac output & unloads LV
LP 2.5
12 F percutaneous approach; Maximum
2.5 L flow
LP 5.0
21 F surgical cutdown; Maximum 5L
flow
51. Impella outcome data
• 1 RCT of Impella 2.5 in AMI Cardiogenic Shock
• ISAR-SHOCK
– 26 patient RCT Impella vs IABP
– Cardiac Index, MAP (by 10mmHg) vs IABP
– Complications ≤ IABP
– No difference in mortality
52.
53.
54. Percutaneous ECMO
• CARDIOHELP & LIFEBRIDGE-B2T
system (FDA approved)
• Advantage: over other modern PVADs is the
lack of need for transseptal puncture or
transfer to a cardiac catheterization laboratory
55. Indications
• Short-term cardiopulmonary support in
patients with postcardiotomy CS
Doll N et al. Ann Thorac Surg. 2004; 77: 151–157
• Bridge-to-recovery device in patients with
fulminant myocarditis
Asaumi Y et al. Eur Heart J. 2005; 26: 2185–2192
• Improves 30-day outcomes when used for
hemodynamic support during primary PCI in
patients presenting with STEMI and profound
CS
Sheu JJ et al. Crit Care Med. 2010; 38: 1810–1817
56. Timing of Implantation
• Rather than continued escalation of medical
therapy, early institution of mechanical
circulatory support via IABP and/or PVAD-
mediated circulatory support should strongly be
considered
57. Goals of Support and Weaning
• Maintain mean arterial pressure >60 mm Hg
and a mixed venous oxygen saturation of
>70%
• Minimal/no pressor requirement and
improving end-organ function.
• Average duration was 5.8±4.75 days
Tallaj JA et al. J Am Coll Cardiol. 2011; 57: 697–699
58. What we should do about STEMI
Cardiogenic Shock
• Emergency angiography and revascularisation: Primary PCI preferably
– All patients <75 years
– Selected patients ≥75 years
• On-table echo to rule out mechanical defects
• Stabilise the patient in the lab before revascularisation
– IABP
– Pressors if required (Norepinephrine/dopamine)
– Anaesthetic support
• Consider calling the surgeon for true surgical disease
• PCI culprit artery. Other vessels if shock persists
• Use abciximab for PCI
• Consider percutaneous LVAD if shock persists with IABP + multi-vessel
revascularisation