The document discusses various pitfalls that can occur in the management of trauma patients, including failure to recognize hemorrhage, errors in diagnosis, and not addressing the lethal triad of hypothermia, acidosis, and coagulopathy which can further exacerbate bleeding and poor outcomes. It provides guidance on properly assessing for shock through vital signs, lab markers, and fluid resuscitation responses and emphasizes the importance of aggressively treating the lethal triad to prevent life-threatening coagulopathy.
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
The four phases of intravenous fluid therapy: Manu MalbrainSMACC Conference
Manu Malbrain presents the four phases of intravenous fluid therapy. He takes you through the big questions of fluids - What, when, why and how?
To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation
Drug
Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs.
Dose
As Paracelsus famously said “The dose makes the poison”
This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement.
Duration
When do you start and stop? You must weigh up the benefit and risk of fluid administration.
Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved.
De-escalation
Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia.
Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!)
We need to make good fluids better
So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D’s and remember the four phases of ROSE.
For more like this, head to our podcast page. #CodaPodcast
The Deteriorating Patient and National Early Warning Score (NEWS) programme, marks the two year anniversary of the launch of the West of England Patient Safety Collaborative. These slides focus on celebrating our impact and demonstrable results across the region.
The triage protocol creates an objective process to guide healthcare professionals in making the difficult determination of how to allocate resources to critically ill adult and pediatric patients when there are not enough critical care resources for everyone.
This highly energetic lecture presents the pathophysiology of S-T elevation myocardial infarction in an easy to understand style to help you best identify, triage and treat patients presenting with acute coronary syndromes. Using the latest research behind the AHA Guidelines changes, AHA National Faculty Rom Duckworth will help you better coordinate with you partners along the continuum of cardiac care. Emphasis is placed on risk factors, recognizing truly sick patients and coordinating care with hospital personnel.
Learning Objectives: Students will learn:
-The pathophysiology of S-T elevation myocardial infarction.
-The difference between STEMI, NSTEMI and unstable angina.
-Differing treatment methods and priorities for different cardiac syndromes.
-The function and importance of 12 lead ECG and prehospital diagnostic testing.
-The roles and responsibilities of EMS providers as the key element in “door-to-balloon” and “door-to-needle” time for STEMI patients.
www.romduck.com
www.RescueDigest.com
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
This slide was first presented during the Malaysian 1st Emergency Medicine Annual Scientific Meeting, in conjunction with the Academy of Medicine Malaysia, Academy of Medicine Singapore and the Academy of Medicine Hong Kong Tripartite Meeting in Aug 2016.
The four phases of intravenous fluid therapy: Manu MalbrainSMACC Conference
Manu Malbrain presents the four phases of intravenous fluid therapy. He takes you through the big questions of fluids - What, when, why and how?
To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation
Drug
Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs.
Dose
As Paracelsus famously said “The dose makes the poison”
This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement.
Duration
When do you start and stop? You must weigh up the benefit and risk of fluid administration.
Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved.
De-escalation
Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia.
Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!)
We need to make good fluids better
So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D’s and remember the four phases of ROSE.
For more like this, head to our podcast page. #CodaPodcast
The Deteriorating Patient and National Early Warning Score (NEWS) programme, marks the two year anniversary of the launch of the West of England Patient Safety Collaborative. These slides focus on celebrating our impact and demonstrable results across the region.
The triage protocol creates an objective process to guide healthcare professionals in making the difficult determination of how to allocate resources to critically ill adult and pediatric patients when there are not enough critical care resources for everyone.
This highly energetic lecture presents the pathophysiology of S-T elevation myocardial infarction in an easy to understand style to help you best identify, triage and treat patients presenting with acute coronary syndromes. Using the latest research behind the AHA Guidelines changes, AHA National Faculty Rom Duckworth will help you better coordinate with you partners along the continuum of cardiac care. Emphasis is placed on risk factors, recognizing truly sick patients and coordinating care with hospital personnel.
Learning Objectives: Students will learn:
-The pathophysiology of S-T elevation myocardial infarction.
-The difference between STEMI, NSTEMI and unstable angina.
-Differing treatment methods and priorities for different cardiac syndromes.
-The function and importance of 12 lead ECG and prehospital diagnostic testing.
-The roles and responsibilities of EMS providers as the key element in “door-to-balloon” and “door-to-needle” time for STEMI patients.
www.romduck.com
www.RescueDigest.com
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
This slide was first presented during the Malaysian 1st Emergency Medicine Annual Scientific Meeting, in conjunction with the Academy of Medicine Malaysia, Academy of Medicine Singapore and the Academy of Medicine Hong Kong Tripartite Meeting in Aug 2016.
An introduction to the rationale and the two types (Write-in and Select-Menu) of Key Feature Questions. This presentation is based on an original article by Page and Bordage (1995).
Sensitivity, specificity and likelihood ratiosChew Keng Sheng
A short tutorial on sensitivity, specificity and likelihood ratios. In this presentation, I demonstrate why likelihood ratios are better parameters compared to sensitivity and specificity in real world setting.
My presentation slides during the 1st National Symposium in Emergency and Acute Care (S.E.M.A.C). I presented some of the obstacles and challenges in scientific writing in emergency medicine within the Malaysia context as academic emergency medicine is still progressing in Malaysia,
Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and ...Chew Keng Sheng
This is the talk I gave during ICEM 2010 under the International Experience of Cardiology Track. In this presentation, I highlighted some of the challenges I see within the Malaysian setting, I focus mainly on prehospital and A&E setting. Issues that are conventionally under the care of the cardiologists are not discussed.
A Free Paper Presentation in the 16th International Symposium in Critical Care and Emergency Medicine, Grand Hyatt, Bali, Indonesia (30th July - 1st August 2009). Won one of the best paper awards.
My talk in April 2015 in Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
Is clinician gestalt undervalued in chest pain assessment in EDkellyam18
This presentation discusses the role of clinician gestalt in assessment of emergency department chest pain patients. Is it accurate? How does it compare with risk scores? What are its weaknesses? Can we teach it?
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
Evidence based decision making in periodonticsHardi Gandhi
INTRODUCTION TO EVIDENCE BASED DENTISTRY
EVIDENCE BASED PERIODONTOLOGY
NEED, PRINCIPLES, GOALS AND ADVANTAGES OF EBDM
SKILLS NEEDED FOR EBDM
ASSESING THE EVIDENCE
INCORPORATING INTO THE PRACTICE
How health analytics are changing the way we understand and manage healthcare. Presented by Professor Enrico Coiera, Faculty of Medicine at the University of NSW, Australia, at HINZ 2014, 11 November 2014, 10am, Plenary Room
IV Jornada. Sp y práctica reflexiva f borrell_pompeu fabra_2011Sano y Salvo
Es la conferencia inaugural de la IV Jornada, de Borrell-Carrió. Hizo una revisión muy interesante de como nuestros automatismos mentales pueden poner en riesgo la práctica de un diagnóstico acertado, sobretodo en los casos en los que la primera impresión no es la acertada.
A Value-Based Approach to Clinical Pathology and InformaticsCirdan
A presentation delivered by Dr. Glenn Edwards, SA Pathology at the Pathology Horizons 2017 conference in Cairns, Australia.
Pathology Horizons is an annual CPD conference organised by Cirdan on the future of pathology. More information on Pathology Horizons can be accessed at www.pathologyhorizons.com
Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.
Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include:
Analysis of best available data
Use of best available judgement
Gathering of different opinions
An understanding that you won’t always make the right decision
To document the 'crap' out of it!
And to remember you’ll never know what you prevented from not occurring.
Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases).
Touching on the processes designed to prevent missed injuries such as;
Territory Trauma Survey
Roles of clinical decision rules
To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).
Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces.
Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.
Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.
Disaster and Mass Casualty Incidents (updated 7th July 2020)Chew Keng Sheng
A new updated slide on an overview of disaster management in Malaysia, including the formation of NADMA as the dedicated agency to coordinate disaster management in Malaysia.
Predatory publishing is a relatively recent phenomenon that seems to be exploiting some key features of the open access publishing model, sustained by collecting APCs that are far less than those found in legitimate open access journals. This CME aims to introduce to the participants on the phenomenon of predatory journals, why they continue to thrive, characteristics that are suggestive of a predatory journal, and how one can take step to minimize the risk of faling into predatory journal publication
A short sharing on doctor-patient communication to First year medical students in Universiti Malaysia Sarawak, to be supplemented with anecdotal accounts.
ACLS 2015 Updates - The Malaysian PerspectiveChew Keng Sheng
This set of slide was presented during the Kelantan Resuscitation Update 22 Nov 2015 in accordance to the latest ACLS/ILCOR 2015 Guidelines. However, I have emphasized on certain important aspects relevant within the Malaysian context. Nonetheless, in general, there are no major changes for this year 2015
My talk in April 2015 Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
New or Presumed New LBBB To Be Treated As a STEMI Equivalent? A Contra Argume...Chew Keng Sheng
My 6-page notes to go along with the "debate" of whether new or presumed new LBBB per se (without any other qualification) should be treated as STEMI equivalent
- 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
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
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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
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
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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.
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.
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
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Pitfalls in the management of trauma patients2
1. PITFALLS IN THE
MANAGEMENT OF
TRAUMA PATIENTS
Keng Sheng Chew, MD, MMED (Emerg Med)
Senior Lecturer/Emergency Medicine Physician,
School of Medical Sciences, Universiti Sains Malaysia
2. “The emergency department's unique
operating characteristics make it a
natural laboratory for the study of
error.”
- Croskerry P, Sinclair D. Emergency medicine: A
practice prone to error? CJEM 2001; 3 (4):271-6.
3. Only a fool learns from his
own mistakes, a wise man
from the mistakes of others.
- Otto von Bismarck
4.
5.
6. Introduction
• Acute trauma care is often resource-
intensive and time-sensitive
• Patient inflow is unpredictable with periodic
and abrupt surges in volume and/or acuity
• Often doctors in emergency department are
forced to make decisions with limited
information
7. Sources of Failure (Adapted from Rosen
et al, 2009)
Cognitive properties of Prolonged waiting
the mind for bed
Affective state Meds errors
Admit
EMS Fatigue & Shift Procedural errors
ED Design work
Patient
Triage Assessment – Diagnosis –Management - Disposition
Presentation
Discharge
Triage cueing Teamwork Issues
Inadequate D/c
Overcrowding
Lab error plan
Information gap Report Delays Follow-up failure
8. Human Errors (Rasmussen and Jensen
Model 1974)
• Categorize human errors into three basic groups:
• Skill-based errors
– Technical errors (chipping a tooth during endotracheal
intubation
• Rule-based errors
– Deviations from guidelines or established practice
patterns
• Knowledge-based errors
– Example: errors in judgment and decision-making related
to patient management caused by incorrect interpretation
of data, insufficient knowledge, etc
9. Three Erroneous Attitude In Diagnostic
Evaluation of Trauma Patients
• Diagnostic Labeling
– The use of a premature (and often presumptive)
diagnostic „label‟ on a patient
• False-negative prediction
– Attributing an inappropriately high negative predictive
value on a given physical findings or investigations
• False attribution
– Erroneously linking a clinical finding to an
unsubstantiated cause/diagnosis
10. DIAGNOSTIC LABELLING
• Is the use of a premature (and often presumptive)
diagnostic „label‟ on a patient
• Labeling can be potentially one of the most
tempting and hazardous errors
• Subsequent healthcare staffs may tend to refer to
the patient by this „label‟ despite the lack of
confirmatory data
• Even when subsequent information conflicts with
the „labeled‟ diagnosis, changing the label may be
impeded by „confirmation‟ bias
11. EXAMPLES OF BIASES
• Confirmation bias
– the tendency to look for confirming evidence to support a
diagnosis rather than look for disconfirmation evidence to
refute it, despite the latter often being more persuasive
and definitive
• Blind spot bias
– general belief people have that they are less susceptible
to bias than others
• Ego bias
– overestimating the prognosis of one‟s own patients
compared to a population of similar patients
12. FALSE-NEGATIVE PREDICTION
• Attributing an inappropriately high negative
predictive value on a given physical findings or
investigations
• Most of these have insufficient sensitivity to
definitely rule out serious injuries at initial
presentation
• Examples:
– Abdomen soft, non-tender intra-abd unlikely
– Heart rate normal hemorrhagic shock unlikely
13. FALSE ATTRIBUTION
• Refers to erroneously linking a clinical finding
to an unrelated cause.
• Often due to selectively using certain clinical
information
• For example: attributing loss of
consciousness due cerebral concussion in a
patient with post-MVA without considering
other causes.
14. CAUSES OF ALTERED MENTAL STATUS
• A – Alcohol, acidosis
• E – Electrolyte imbalances, endocrine
• I – Infective, insulin
• O – Opiates, oxygen
• U – Uremia
• T – Trauma, toxins
• I – Inflammatory MNEMONIC:
• P – Psychiatric ‘AEIOU TIPS’
• S – Seizures, sepsis
15. HOW TO REDUCE HUMAN ERRORS
• Patients should generally be managed according to
the worst “reasonable case”
• Listen carefully, but always remain a bit skeptical
about the history
– Falls are not always falls
• Constantly reassess, never assume “stability”
• Never become married to the initial diagnosis
• Maintain the “clock speed”
• Constantly upgrading your knowledge bank
17. FAILURE TO RECOGNIZE EARLY
HEMORRHAGE
• An early presentation of normotension may create
the illusion of hemodynamic stability, even when
30% to 40% circulating blood volume loss may
have lost before the onset of hypotension
• A normal BP may be abnormal in the setting of
acute pain and stress (sympathetic overactivity)
• BP = CO * TPR
18.
19. HYPOTENSION
• Fit, young patients may lose 40% of their blood
volume before the systolic blood pressure (SBP)
drops below 100 mmHg
• Elderly may become hypotensive with volume loss
of as little as 10%
• Committee on Trauma, American College of Surgeons. Advanced
trauma life support program for doctors. Chicago: American College of
Surgeons; 1997.
20. INDICATORS OF HYPOPERFUSION
Cocchi MN, Kimlin E, Walsh M et al. Identification and resuscitation of the trauma patient in shock.
Emerg Med Clin North Am 2007; 25 (3):623-42, vii.
21. TACHYCARDIA
• In a study by Victorino et al, up to 35% of trauma
patients with hypotension did not display
tachycardia.
• Trauma patients without hypovolemia may display
tachycardia because of fear, pain etc whereas
those with extreme age and on meds (beta
blockers) may have „„relative bradycardia‟‟
• Victorino GP, Battistella FD, Wisner DH. Does tachycardia correlate with
hypotension after trauma? J Am Coll Surg 2003;196(5):679–84.
22. SHOCK INDEX
• Ratio of heart rate to SBP
• Shock Index = HR/SBP
• Help identify hypoperfused patients with more
subtle vital sign abnormalities.
• A shock index of >0.9 has been found to be more
sensitive than traditional vital sign
• Rady MY, Smithline HA, Blake H, et al. A comparison of the shock index
and conventional vital signs to identify acute, critical illness in the
emergency department. Ann Emerg Med 1994;24(4):685–90.
23. SHOCK INDEX
• A large retrospective study was unable to
demonstrate an advantage of shock index over
traditional vital sign analysis in trauma patients
• King RW, Plewa MC, Buderer NM, et al. Shock index as a marker for significant injury in
trauma patients. Acad Emerg Med 1996;3(11):1041–5.
• While the presence of vital sign abnormalities may
indicate shock, the absence of these
abnormalities does not completely exclude
occult hypoperfusion in the traumatic patient.
• Blow O, Magliore L, Claridge JA, et al. The golden hour and the silver day: detection and
correction of occult hypoperfusion within 24 hours improves outcome from major trauma. J
Trauma 1999;47(5):964–9.
24. MEAN ARTERIAL PRESSURE (MAP)
• Mean arterial pressure (MAP) is a better
representation than SBP for organ perfusion status
• MAP = Diastolic BP + 1/3(Systolic BP – Diastolic
BP).
• MAP = 1/3(Systolic BP) + 2/3(Diastolic BP)
• Using MAP avoids the deception of a seemingly
normal systolic blood pressure.
– A patient with a BP of 80/60 (MAP=66) is actually
perfusing their organs better than a patient with a BP
of 110/30 (MAP=56).
25. METABOLIC MARKERS
• Metabolic markers of hypoperfusion include
bicarbonate, base deficit, and lactic
acidosis.
• With inadequate perfusion, cells will begin
anaerobic metabolism and generate lactic acids
• Callaway et al report a mortality of 38% in
normotensive elderly trauma patients with
initial lactic acid levels of >4 mmol/dL.
• Callaway D, Rosen C, Baker C, et al. Lactic acidosis predicts mortality in
normotensive elderly patients with traumatic injury. Acad Emerg Med
2007;14(S152).
26. LACTATE
• Effective lactate clearance has been found
to be associated with lower mortality levels
in trauma, sepsis, and postcardiac arrest
• Husain FA, Martin MJ, Mullenix PS, et al. Serum lactate and base deficit
as predictors of mortality and morbidity. Am J Surg 2003;185(5):485–91.
• Abramson D, Scalea TM, Hitchcock R, et al. Lactate clearance and
survival following injury. J Trauma 1993;35(4):584–8, [discussion: 588–
9].
27. LACTATE
• Although normal pH is a good indicator of
adequate fluid volume, serum lactate level
is a better indicator of the depth and
duration of shock.
• The rate at which shock patients normalize
lactate is correlated strongly with outcome.
• Abramson D, Scalea TM, Hitchcock R, et al. Lactate clearance and
survival following injury. J Trauma 1993;35:584–8.
28. CONFOUNDING FACTORS
• Some patients with significant hypoperfusion
without high lactate level.
• Conditions are associated with elevated lactic acid
levels without associated tissue hypoperfusion
– Seizure
– severe respiratory distress
– certain medications (ie, anti-retrovirals, metformin, linazolid,
albuterol)
– thiamine deficiency
– carbon monoxide or cyanide toxicity, and diabetic
ketoacidosis
29. RESPONSES TO INITIAL FLUID
RESUSCITATION
Rapid Response Transient Minimal or No
Response minimal Response
Vital signs Return to normal Transient Remain abnormal
improvement, then
recur
Estimated blood 10 – 20% 20 – 40% Severe, >40%
loss
Need for more Low High High
crystalloid
Need for blood Low Moderate to high High
Need for operative Possibly Likely Highly likely
intervention
30. PEDIATRIC TRAUMA
• Knowledge about age-specific vital signs is
important to prevent misguided assumption
• Hypotension is defined as systolic BP below 5th
percentile specific for age:
SBP < 70 + (2 * age) mmHg
[Normal SBP ~ 80 + (2*age) mmHg]
• Estimating the weight for a child in kg:
Less than 8 years: (2*age) + 8
8 years and above: (3*age)
31. GERIATRIC TRAUMA: POTENTIAL
PITFALLS
• Minimal or limited physiologic reserve.
– Profound hypovolemia can occur even in
setting of “normal” blood pressure
• Narrow therapeutic window for cardiac
preload
• Cortical atrophy potentially delay clinical
manifestations of serious intracranial
hemorrhage
32. GERIATRIC TRAUMA: POTENTIAL
PITFALLS
• Ventilatory failure & respiratory arrest
may occur suddenly concurrently with
chest/abdominal trauma, etc.
• Myocardial demand ischemia may results
from severe pain, etc.
• Decrease in connective tissue integrity,
less tamponade effect
– The blood loss can be excessive and is often
overlooked
33. GERIATRIC TRAUMA: POTENTIAL
PITFALLS
• Clinical manifestations of serious injuries –
minimal
• Failure to adjust medication dosages, e.g.
sedative-hypnotics
• Elderly abuse/chronic malnutrition
35. WHY ACIDOSIS?
1. Poor perfusion to the tissues
2. Decreased cardiac output, anemia, and
hypoxemia anaerobic metabolism lactic
acidosis.
3. Resuscitation with unbalanced crystalloids
such as normal saline hyperchloremic
acidosis
• Ho, A.M., et al., Excessive use of normal saline in managing
traumatized patients in shock: a preventable contributor to
acidosis. J Trauma, 2001. 51(1): p. 173-7.
36. THE DANGERS OF ACIDOSIS
• Severe acidosis can further diminish
cardiac output and make catecholamines
less effective
• Adrogue, H.J. and N.E. Madias, Management of life-threatening
acid-base disorders. Second of two parts. N Engl J Med, 1998.
338(2): p. 107-11.
• The most dangerous effect of acidosis is the
induction of coagulopathy
– Hess, J.R. and J.H. Lawson, The coagulopathy of trauma versus
disseminated intravascular coagulation. J Trauma, 2006. 60(6
Suppl): p. S12-9.
37. THE DANGERS OF ACIDOSIS
• Our body‟s coagulation system does not
work in an acidic milieu.
• When the pH drops from 7.4 to 7.0, the
activity of portions of the coagulation
cascade decreases by 55-70%
• Meng, Z.H., et al., The effect of temperature and pH on the activity of
factor VIIa: implications for the efficacy of high-dose factor VIIa in
hypothermic and acidotic patients. J Trauma, 2003. 55(5): p. 886-91.
38. DANGERS OF HYPOTHERMIA
• The reactions of the coagulation cascade are
all temperature dependent; as temperature
drops, bleeding increases dramatically.
• Hypothermia can cause relative
thrombocytopenia by inducing platelet
sequestration and also causes qualitative
platelet dysfunction.
• Ferrara, A., et al., Hypothermia and acidosis worsen
coagulopathy in the patient requiring massive transfusion. Am J
Surg, 1990. 160(5): p. 515-8.
39. COAGULOPATHY
• In addition to the coagulopathy induced by
acidosis, hypothermia, and the direct loss of
clotting factors from bleeding, the ability to
clot is further compromised by dilution and
consumption.
• Dilutional coagulopathy takes place any time
we infuse fluid or products that do not
contain clotting factors (e.g. crystalloid,
colloid, PRBCs, and platelets)
40. COAGULOPATHY
• Traumatized tissues and the shock state
can abnormally activate the clotting cascade
and cause fibrinolysis out of proportion to
the injury and in areas distant to the site of
bleeding - consumptive coagulopathy
(DIVC)
• Gando, S., et al., Posttrauma coagulation and fibrinolysis. Crit Care
Med, 1992. 20(5): p. 594-600.
• Kapsch, D.N., et al., Fibrinolytic response to trauma. Surgery, 1984.
95(4): p. 473-8.