1. The document discusses pulmonary embolism, including its definition, signs and symptoms, risk factors, diagnosis using tests such as CT scans and ventilation-perfusion scans, and treatment including anticoagulation therapy.
2. Diagnostic tests discussed include CT pulmonary angiography, ventilation-perfusion scans, and pulmonary angiograms. Treatment focuses on anticoagulation using heparin or warfarin to prevent further clotting as well as supporting respiratory and cardiovascular function.
3. Complications of anticoagulation therapy are addressed, including bleeding during heparin treatment and heparin-induced thrombocytopenia, along with strategies for monitoring patients and managing issues that arise.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise boosts blood flow, releases endorphins, and promotes changes in the brain which help enhance one's emotional well-being and mental clarity.
Diagnostic catheters for coronary angiography Aswin Rm
Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
This document discusses diastolic dysfunction, its diagnosis using echocardiography, and anesthetic considerations. It defines diastolic dysfunction as the inability of the ventricle to fill at low atrial pressures. The key aspects of diastolic function evaluation by echocardiography include trans-mitral flow patterns, pulmonary venous flow, tissue Doppler imaging, and mitral annular velocities. Anesthetic goals are to maintain preload and afterload while avoiding drugs that may worsen diastolic function. Specific drugs like milrinone and levosimendan can have beneficial effects on diastolic function in patients with heart failure. Careful preoperative evaluation and postoperative monitoring are important for patients with diast
Non invasive estimation of pulmonary vascular resistance in patients of pulmo...Arindam Pande
Context : Pulmonary vascular resistance (PVR) is a critical and essential parameter during the
assessment and selection of modality of treatment in patients with congenital heart
disease accompanied by pulmonary arterial hypertension.
Aim : The present study was planned to evaluate non-invasive echocardiographic parameters
to assess pulmonary vascular resistance.
Settings and
Design
: This prospective observational study included 44 patients admitted in the cardiology
and pediatric cardiology ward of our institution for diagnostic or pre-operative catheter
based evaluation of pulmonary arterial pressure and PVR.
Materials and
Methods
: Detailed echocardiographic evaluation was carried out including tricuspid regurgitation
velocity (TRV) and velocity time integral of the right-ventricular outflow tract (VTIRVOT).
These parameters were correlated with catheter-based measurements of PVR.
Results : The TRV/VTIRVOT ratio correlated well with PVR measured at catheterization
(PVRcath) (r = 0.896, 95% confidence interval [CI] 0.816 to 0.9423, P < 0.001). Using
the Bland-Altman analysis, PVR measurements derived from Doppler data showed
satisfactory limits of agreement with catheterization estimated PVR. For a PVR of 6
Wood units (WU), a TRV/VTIRVOT value of 0.14 provided a sensitivity of 96.67% and
a specificity of 92.86% (area under the curve 0.963, 95% confidence interval 0.858 to
0.997) and for PVR of 8 WU a TRV/VTIRVOT value of 0.17 provided a sensitivity of
79.17% and a specificity of 95% (area under the curve 0. 0.923, 95% confidence interval
0.801 to 0.982).
Conclusions : Doppler-derived ratio of TRV/VTIRVOT is a simple, non-invasive index, which can be
used to estimate PVR.
Central Venous Catheterization without Ultrasound guidanceRunal Shah
In this modern era of USG, you will hardly attempt Central lines blindly. So when your USG machine breaks down, how will you resuscitate the patient? Know your basics about Central venous catheterization.
This document discusses chronotropic incompetence, which is the heart's inability to regulate its rate appropriately in response to physiological stress. It defines chronotropic incompetence and notes that it is a class I indication for pacemaker implantation. The prevalence of chronotropic incompetence in the pacemaker population is approximately 42%. Chronotropic incompetence is progressive over time and worsens cardiac output during exercise. An ideal sensor for rate-responsive pacing would be reliable, consistent, durable, efficient, easily implanted, and physiologically appropriate. Minute ventilation and accelerometer sensors are discussed as options for rate-responsive pacing and restoring chronotropic competence.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise boosts blood flow, releases endorphins, and promotes changes in the brain which help enhance one's emotional well-being and mental clarity.
Diagnostic catheters for coronary angiography Aswin Rm
Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
This document discusses diastolic dysfunction, its diagnosis using echocardiography, and anesthetic considerations. It defines diastolic dysfunction as the inability of the ventricle to fill at low atrial pressures. The key aspects of diastolic function evaluation by echocardiography include trans-mitral flow patterns, pulmonary venous flow, tissue Doppler imaging, and mitral annular velocities. Anesthetic goals are to maintain preload and afterload while avoiding drugs that may worsen diastolic function. Specific drugs like milrinone and levosimendan can have beneficial effects on diastolic function in patients with heart failure. Careful preoperative evaluation and postoperative monitoring are important for patients with diast
Non invasive estimation of pulmonary vascular resistance in patients of pulmo...Arindam Pande
Context : Pulmonary vascular resistance (PVR) is a critical and essential parameter during the
assessment and selection of modality of treatment in patients with congenital heart
disease accompanied by pulmonary arterial hypertension.
Aim : The present study was planned to evaluate non-invasive echocardiographic parameters
to assess pulmonary vascular resistance.
Settings and
Design
: This prospective observational study included 44 patients admitted in the cardiology
and pediatric cardiology ward of our institution for diagnostic or pre-operative catheter
based evaluation of pulmonary arterial pressure and PVR.
Materials and
Methods
: Detailed echocardiographic evaluation was carried out including tricuspid regurgitation
velocity (TRV) and velocity time integral of the right-ventricular outflow tract (VTIRVOT).
These parameters were correlated with catheter-based measurements of PVR.
Results : The TRV/VTIRVOT ratio correlated well with PVR measured at catheterization
(PVRcath) (r = 0.896, 95% confidence interval [CI] 0.816 to 0.9423, P < 0.001). Using
the Bland-Altman analysis, PVR measurements derived from Doppler data showed
satisfactory limits of agreement with catheterization estimated PVR. For a PVR of 6
Wood units (WU), a TRV/VTIRVOT value of 0.14 provided a sensitivity of 96.67% and
a specificity of 92.86% (area under the curve 0.963, 95% confidence interval 0.858 to
0.997) and for PVR of 8 WU a TRV/VTIRVOT value of 0.17 provided a sensitivity of
79.17% and a specificity of 95% (area under the curve 0. 0.923, 95% confidence interval
0.801 to 0.982).
Conclusions : Doppler-derived ratio of TRV/VTIRVOT is a simple, non-invasive index, which can be
used to estimate PVR.
Central Venous Catheterization without Ultrasound guidanceRunal Shah
In this modern era of USG, you will hardly attempt Central lines blindly. So when your USG machine breaks down, how will you resuscitate the patient? Know your basics about Central venous catheterization.
This document discusses chronotropic incompetence, which is the heart's inability to regulate its rate appropriately in response to physiological stress. It defines chronotropic incompetence and notes that it is a class I indication for pacemaker implantation. The prevalence of chronotropic incompetence in the pacemaker population is approximately 42%. Chronotropic incompetence is progressive over time and worsens cardiac output during exercise. An ideal sensor for rate-responsive pacing would be reliable, consistent, durable, efficient, easily implanted, and physiologically appropriate. Minute ventilation and accelerometer sensors are discussed as options for rate-responsive pacing and restoring chronotropic competence.
Left ventricular angiography is used to assess global and regional left ventricular function and anatomy. It involves inserting a catheter into the left ventricle and injecting contrast dye to visualize the ventricle on x-ray imaging. The procedure provides key information on mitral valve function, ventricular shape and wall motion abnormalities, and congenital defects like VSD. LV volumes and ejection fraction are calculated from the images to quantify function. Regional wall motion is graded and correlated to coronary artery territories. Characteristic appearances are seen in conditions like cardiomyopathy, mitral regurgitation, and septal defects. Potential complications include arrhythmias and endocardial injury.
Intracranial pressure - waveforms and monitoringjoemdas
The document discusses intracranial pressure (ICP) waveforms and monitoring. It defines the components of the intracranial vault and describes the normal ICP waveform consisting of P1, P2, and P3 waves representing arterial pulsation, intracranial compliance, and venous pulsation, respectively. It also discusses Lundberg waves including A waves resulting from increased cerebrovascular volume due to vasodilation, B waves related to respiratory fluctuations in PaCO2, and C waves corresponding to Traube-Hering-Meyer fluctuations. The gold standard for ICP monitoring is external ventricular drainage connected to an external strain gauge, which allows CSF drainage but carries risks of infection and hemorrhage. Int
This document discusses pressure changes that can occur during coronary angiography, specifically damping and ventricularization. Damping is defined as a significant decrease in pressure at the coronary ostium when the catheter is placed, accompanied by the disappearance of pressure waveforms, suggesting no antegrade flow. Ventricularization occurs when blood circulates within a coronary artery like a closed system, deforming the aortic pressure waveform. The document emphasizes the importance of the operator recognizing abnormal pressure changes to avoid complications, and provides solutions like catheter replacement or intracoronary nitroglycerin to address issues.
Temporary cardiac pacing is used to treat acute bradyarrhythmias or tachyarrhythmias until the underlying condition resolves or permanent pacing can be initiated. It aims to re-establish normal hemodynamics compromised by abnormal heart rates. Transvenous pacing is the preferred method, involving insertion of endocardial leads through veins to the heart. Precise lead placement is important and is confirmed with imaging. Pacing parameters like threshold, rate and sensing are optimized. Complications include those related to vascular access and device malfunction requiring troubleshooting. Close monitoring is needed to ensure proper pacing and detect any issues.
This document provides an overview of monitoring depth of anesthesia. It discusses the aims of monitoring to ensure patient safety and prevent awareness during surgery. It reviews the historical background of defining anesthesia stages. Modern concepts view anesthesia as a complex interaction between stimuli, patient responses, and drug-induced effects. Factors like patient characteristics, drug combinations, and surgery duration impact correct drug dosing. Memory is gradually impaired with deeper anesthesia levels before autonomic responses. The document outlines stages of awareness and discusses specific drugs' relationships to anesthesia depth.
This document provides an overview of using ultrasound (ECHO/FOCUS) in the intensive care unit (ICU). It discusses using ultrasound to assess cardiac function, volume status, and diagnose medical emergencies at the bedside. Ultrasound can be used to monitor hemodynamics, fluid responsiveness, and detect issues like cardiac tamponade. The document reviews ultrasound views of the heart and techniques for assessing volume status using the inferior vena cava. It also discusses using chest ultrasound to identify pleural effusions, pneumothorax, consolidation and quantify pleural fluid. The summary provides a concise high-level view of the key applications and techniques discussed in the document.
Double lumen tubes were developed in the 1950s-60s to enable lung isolation during thoracic surgery. The Carlens and Bryce-Smith tubes were some of the earliest designs, featuring curves and cuffs to isolate the left or right mainstem bronchus. Modern tubes like the Robertshaw are widely used and come in varying sizes from 26-41 French. Placement requires careful advancement and confirmation via auscultation, cuff inflation, and bronchoscopy to avoid malposition and injury. Double lumen tubes allow selective ventilation and treatment of each lung but require replacement with a single tube after surgery.
This document provides an overview of electrocardiography (ECG) basics for technicians. It discusses the heart's conduction system and how ECGs work to record electrical activity. The 12 standard ECG leads and their placements are described. Key aspects of normal ECG waveforms and intervals like P waves, QRS complex, T waves, and QT interval are explained. Common abnormalities that can cause changes in axis or abnormal complexes are also summarized. The document concludes with tips on interpreting ECGs and the important aspects to include in an ECG report.
This document discusses atrial fibrillation (AF), specifically perioperative AF (POAF). It defines the different types of AF and reviews the pathophysiology and risk factors for developing POAF. Surgery-related and patient-related risk factors are examined. The impact of POAF includes increased morbidity, mortality, and costs. Strategies for preventing, managing, and treating POAF during the preoperative, intraoperative, and postoperative periods are outlined. These include addressing modifiable risk factors, using rate control medications, and considering anticoagulation therapy on a case-by-case basis. Further research opportunities are proposed to better understand and reduce the incidence and impacts of POAF.
Anesthetic Management of a Patient with Peripartum Cardiomyopathy for LUCSMd Rabiul Alam
Peripartum cardiomyopathy is one of the leading causes of death in obstetric patients since it is usually diagnosed incidentally. Echocardiogram remains the mainstay to diagnose it. Many of the peripheral hospitals are deficient of echocardiogram facilities, so there are possibilities to send the patient to OR without diagnosis. To manage such a case and bring out the success depends on quick detection of the problems & immediate medical intervention after confirming the diagnosis. Obviously, any surgical intervention requires lot of clinical experiences of the whole team, particularly the anesthesiologists.
A ventricular assist device (VAD) is a mechanical pump that helps the ventricles pump blood through the body. VADs are used to treat heart failure and cardiogenic shock. They can partially or completely replace the function of a failing heart. VADs are designed to assist the right ventricle, left ventricle, or both ventricles. Common uses of VADs include bridging patients to transplant, bridging to recovery or decision, and destination therapy for patients who are not eligible for transplant. Complications of VAD therapy include bleeding, infection, thromboembolism, device malfunction, and right heart failure.
Pregnancy poses significant risks for patients with mitral stenosis due to physiological changes that can exacerbate the condition. Careful medical management is needed to minimize risks during pregnancy, labor, delivery and postpartum. Anesthesia goals are to avoid tachycardia, maintain preload and systemic vascular resistance. Epidural analgesia and invasive monitoring are recommended for labor and cesarean delivery. Close monitoring in the postpartum period is also important due to risks of pulmonary edema from autotransfusion.
Cardiovascular physiology for anesthesiamarwa Mahrous
This document discusses cardiovascular physiology including the structure and function of the heart, regulation of the cardiovascular system, blood flow through the pulmonary and systemic circulations, factors that influence cardiac output and stroke volume, and regulation of the systemic vasculature. Key points include:
- The cardiovascular system consists of the heart, blood vessels, and mechanisms that regulate blood circulation and pressure.
- Cardiac output is determined by stroke volume and heart rate. Stroke volume depends on preload, afterload, and contractility.
- The pulmonary circulation has low pressure and resistance while the systemic circulation has higher pressure and resistance.
- Autonomic nervous system and chemical factors regulate heart rate and contractility. Venous return and vascular
This document provides an overview of cardiopulmonary bypass (CPB), including:
- A brief history of CPB and its components from early open heart surgeries using hypothermia to modern equipment.
- Descriptions of the main components of the CPB circuit including pumps, oxygenators, heat exchangers, cannulae, and how they function together to support the heart and lungs during surgery.
- Explanations of different types of pumps, oxygenators, and other equipment used in CPB and how they have evolved over time.
Stents are used to support the inside of a tubular passage or lumen, such as coronary and peripheral arteries, oesophagus, biliary duct, colon or an airway. They are placed temporarily or permanently in the strictured region where the lumen’s diameter is narrowed due to a disease. This presentation describes design characteristics of self-expandable stents.
Cardioversion is a procedure that uses electric shock or drugs to convert an abnormal heart rhythm back to normal. There are two main types - electrical cardioversion, which delivers a synchronized electric shock, and pharmacological cardioversion, which uses antiarrhythmic drugs. Electrical cardioversion can be elective or emergency, while pharmacological cardioversion utilizes various classes of drugs like beta blockers, sodium channel blockers, and calcium channel blockers to restore normal rhythm. The document outlines the differences between cardioversion and defibrillation, indications and contraindications for cardioversion, recommendations, procedure steps, complications, and drug options for pharmacological cardioversion.
1) Intra-aortic balloon counterpulsation (IABP) provides systolic unloading and diastolic augmentation to improve cardiac output.
2) IABP is indicated for cardiogenic shock, high-risk PCI/CABG, and mechanical complications.
3) Potential complications include limb ischemia, infection, bleeding, and aortic injury.
4) Optimal IABP waveform analysis and timing are important to maximize hemodynamic support.
This document discusses using ultrasound to identify the cricothyroid membrane (CTM) for emergency airway access. Clinically identifying the CTM has a low success rate, especially in obese patients, but ultrasound identification can be nearly 100% accurate with brief training. Two recommended techniques are presented: the transverse/TACA method and longitudinal/string of pearls method. A structured one-hour training program leads to a clinically useful skill level and skills are retained after 6 months. Ultrasound identification of the CTM is unaffected by neck position changes and allows marking of the membrane in under 40 seconds on average. Ultrasound should be used to identify the CTM before any airway management if clinical identification is uncertain.
- Pulmonary embolism affects approximately 500,000 individuals per year in the US, with around 50,000 deaths annually.
- Deep vein thrombosis accounts for over 95% of pulmonary emboli. Risk factors for DVT and thus PE include surgery, trauma, cancer, prolonged immobility, and genetic or acquired hypercoagulable states.
- Diagnosis is suggested by symptoms like dyspnea and chest pain but requires imaging tests like CT pulmonary angiogram, ventilation-perfusion scanning, or echocardiogram to confirm the presence of emboli. Treatment involves anticoagulation with heparin or warfarin.
This document discusses pulmonary embolism (PE), a potentially lethal condition caused by blood clots in the lungs. PE is often missed due to nonspecific symptoms but can lead to death if untreated. Risk factors include immobilization, surgery, cancer, pregnancy, and oral contraceptives. Symptoms range from nonspecific chest pain to circulatory collapse. Diagnosis involves tests like CT scans, VQ scans, echocardiograms and D-dimer levels. Treatment involves oxygen, anticoagulants like blood thinners, and potentially thrombolytics for severe cases. Outcomes depend on early detection and treatment, but PE can still lead to complications like pulmonary hypertension if not addressed.
Left ventricular angiography is used to assess global and regional left ventricular function and anatomy. It involves inserting a catheter into the left ventricle and injecting contrast dye to visualize the ventricle on x-ray imaging. The procedure provides key information on mitral valve function, ventricular shape and wall motion abnormalities, and congenital defects like VSD. LV volumes and ejection fraction are calculated from the images to quantify function. Regional wall motion is graded and correlated to coronary artery territories. Characteristic appearances are seen in conditions like cardiomyopathy, mitral regurgitation, and septal defects. Potential complications include arrhythmias and endocardial injury.
Intracranial pressure - waveforms and monitoringjoemdas
The document discusses intracranial pressure (ICP) waveforms and monitoring. It defines the components of the intracranial vault and describes the normal ICP waveform consisting of P1, P2, and P3 waves representing arterial pulsation, intracranial compliance, and venous pulsation, respectively. It also discusses Lundberg waves including A waves resulting from increased cerebrovascular volume due to vasodilation, B waves related to respiratory fluctuations in PaCO2, and C waves corresponding to Traube-Hering-Meyer fluctuations. The gold standard for ICP monitoring is external ventricular drainage connected to an external strain gauge, which allows CSF drainage but carries risks of infection and hemorrhage. Int
This document discusses pressure changes that can occur during coronary angiography, specifically damping and ventricularization. Damping is defined as a significant decrease in pressure at the coronary ostium when the catheter is placed, accompanied by the disappearance of pressure waveforms, suggesting no antegrade flow. Ventricularization occurs when blood circulates within a coronary artery like a closed system, deforming the aortic pressure waveform. The document emphasizes the importance of the operator recognizing abnormal pressure changes to avoid complications, and provides solutions like catheter replacement or intracoronary nitroglycerin to address issues.
Temporary cardiac pacing is used to treat acute bradyarrhythmias or tachyarrhythmias until the underlying condition resolves or permanent pacing can be initiated. It aims to re-establish normal hemodynamics compromised by abnormal heart rates. Transvenous pacing is the preferred method, involving insertion of endocardial leads through veins to the heart. Precise lead placement is important and is confirmed with imaging. Pacing parameters like threshold, rate and sensing are optimized. Complications include those related to vascular access and device malfunction requiring troubleshooting. Close monitoring is needed to ensure proper pacing and detect any issues.
This document provides an overview of monitoring depth of anesthesia. It discusses the aims of monitoring to ensure patient safety and prevent awareness during surgery. It reviews the historical background of defining anesthesia stages. Modern concepts view anesthesia as a complex interaction between stimuli, patient responses, and drug-induced effects. Factors like patient characteristics, drug combinations, and surgery duration impact correct drug dosing. Memory is gradually impaired with deeper anesthesia levels before autonomic responses. The document outlines stages of awareness and discusses specific drugs' relationships to anesthesia depth.
This document provides an overview of using ultrasound (ECHO/FOCUS) in the intensive care unit (ICU). It discusses using ultrasound to assess cardiac function, volume status, and diagnose medical emergencies at the bedside. Ultrasound can be used to monitor hemodynamics, fluid responsiveness, and detect issues like cardiac tamponade. The document reviews ultrasound views of the heart and techniques for assessing volume status using the inferior vena cava. It also discusses using chest ultrasound to identify pleural effusions, pneumothorax, consolidation and quantify pleural fluid. The summary provides a concise high-level view of the key applications and techniques discussed in the document.
Double lumen tubes were developed in the 1950s-60s to enable lung isolation during thoracic surgery. The Carlens and Bryce-Smith tubes were some of the earliest designs, featuring curves and cuffs to isolate the left or right mainstem bronchus. Modern tubes like the Robertshaw are widely used and come in varying sizes from 26-41 French. Placement requires careful advancement and confirmation via auscultation, cuff inflation, and bronchoscopy to avoid malposition and injury. Double lumen tubes allow selective ventilation and treatment of each lung but require replacement with a single tube after surgery.
This document provides an overview of electrocardiography (ECG) basics for technicians. It discusses the heart's conduction system and how ECGs work to record electrical activity. The 12 standard ECG leads and their placements are described. Key aspects of normal ECG waveforms and intervals like P waves, QRS complex, T waves, and QT interval are explained. Common abnormalities that can cause changes in axis or abnormal complexes are also summarized. The document concludes with tips on interpreting ECGs and the important aspects to include in an ECG report.
This document discusses atrial fibrillation (AF), specifically perioperative AF (POAF). It defines the different types of AF and reviews the pathophysiology and risk factors for developing POAF. Surgery-related and patient-related risk factors are examined. The impact of POAF includes increased morbidity, mortality, and costs. Strategies for preventing, managing, and treating POAF during the preoperative, intraoperative, and postoperative periods are outlined. These include addressing modifiable risk factors, using rate control medications, and considering anticoagulation therapy on a case-by-case basis. Further research opportunities are proposed to better understand and reduce the incidence and impacts of POAF.
Anesthetic Management of a Patient with Peripartum Cardiomyopathy for LUCSMd Rabiul Alam
Peripartum cardiomyopathy is one of the leading causes of death in obstetric patients since it is usually diagnosed incidentally. Echocardiogram remains the mainstay to diagnose it. Many of the peripheral hospitals are deficient of echocardiogram facilities, so there are possibilities to send the patient to OR without diagnosis. To manage such a case and bring out the success depends on quick detection of the problems & immediate medical intervention after confirming the diagnosis. Obviously, any surgical intervention requires lot of clinical experiences of the whole team, particularly the anesthesiologists.
A ventricular assist device (VAD) is a mechanical pump that helps the ventricles pump blood through the body. VADs are used to treat heart failure and cardiogenic shock. They can partially or completely replace the function of a failing heart. VADs are designed to assist the right ventricle, left ventricle, or both ventricles. Common uses of VADs include bridging patients to transplant, bridging to recovery or decision, and destination therapy for patients who are not eligible for transplant. Complications of VAD therapy include bleeding, infection, thromboembolism, device malfunction, and right heart failure.
Pregnancy poses significant risks for patients with mitral stenosis due to physiological changes that can exacerbate the condition. Careful medical management is needed to minimize risks during pregnancy, labor, delivery and postpartum. Anesthesia goals are to avoid tachycardia, maintain preload and systemic vascular resistance. Epidural analgesia and invasive monitoring are recommended for labor and cesarean delivery. Close monitoring in the postpartum period is also important due to risks of pulmonary edema from autotransfusion.
Cardiovascular physiology for anesthesiamarwa Mahrous
This document discusses cardiovascular physiology including the structure and function of the heart, regulation of the cardiovascular system, blood flow through the pulmonary and systemic circulations, factors that influence cardiac output and stroke volume, and regulation of the systemic vasculature. Key points include:
- The cardiovascular system consists of the heart, blood vessels, and mechanisms that regulate blood circulation and pressure.
- Cardiac output is determined by stroke volume and heart rate. Stroke volume depends on preload, afterload, and contractility.
- The pulmonary circulation has low pressure and resistance while the systemic circulation has higher pressure and resistance.
- Autonomic nervous system and chemical factors regulate heart rate and contractility. Venous return and vascular
This document provides an overview of cardiopulmonary bypass (CPB), including:
- A brief history of CPB and its components from early open heart surgeries using hypothermia to modern equipment.
- Descriptions of the main components of the CPB circuit including pumps, oxygenators, heat exchangers, cannulae, and how they function together to support the heart and lungs during surgery.
- Explanations of different types of pumps, oxygenators, and other equipment used in CPB and how they have evolved over time.
Stents are used to support the inside of a tubular passage or lumen, such as coronary and peripheral arteries, oesophagus, biliary duct, colon or an airway. They are placed temporarily or permanently in the strictured region where the lumen’s diameter is narrowed due to a disease. This presentation describes design characteristics of self-expandable stents.
Cardioversion is a procedure that uses electric shock or drugs to convert an abnormal heart rhythm back to normal. There are two main types - electrical cardioversion, which delivers a synchronized electric shock, and pharmacological cardioversion, which uses antiarrhythmic drugs. Electrical cardioversion can be elective or emergency, while pharmacological cardioversion utilizes various classes of drugs like beta blockers, sodium channel blockers, and calcium channel blockers to restore normal rhythm. The document outlines the differences between cardioversion and defibrillation, indications and contraindications for cardioversion, recommendations, procedure steps, complications, and drug options for pharmacological cardioversion.
1) Intra-aortic balloon counterpulsation (IABP) provides systolic unloading and diastolic augmentation to improve cardiac output.
2) IABP is indicated for cardiogenic shock, high-risk PCI/CABG, and mechanical complications.
3) Potential complications include limb ischemia, infection, bleeding, and aortic injury.
4) Optimal IABP waveform analysis and timing are important to maximize hemodynamic support.
This document discusses using ultrasound to identify the cricothyroid membrane (CTM) for emergency airway access. Clinically identifying the CTM has a low success rate, especially in obese patients, but ultrasound identification can be nearly 100% accurate with brief training. Two recommended techniques are presented: the transverse/TACA method and longitudinal/string of pearls method. A structured one-hour training program leads to a clinically useful skill level and skills are retained after 6 months. Ultrasound identification of the CTM is unaffected by neck position changes and allows marking of the membrane in under 40 seconds on average. Ultrasound should be used to identify the CTM before any airway management if clinical identification is uncertain.
- Pulmonary embolism affects approximately 500,000 individuals per year in the US, with around 50,000 deaths annually.
- Deep vein thrombosis accounts for over 95% of pulmonary emboli. Risk factors for DVT and thus PE include surgery, trauma, cancer, prolonged immobility, and genetic or acquired hypercoagulable states.
- Diagnosis is suggested by symptoms like dyspnea and chest pain but requires imaging tests like CT pulmonary angiogram, ventilation-perfusion scanning, or echocardiogram to confirm the presence of emboli. Treatment involves anticoagulation with heparin or warfarin.
This document discusses pulmonary embolism (PE), a potentially lethal condition caused by blood clots in the lungs. PE is often missed due to nonspecific symptoms but can lead to death if untreated. Risk factors include immobilization, surgery, cancer, pregnancy, and oral contraceptives. Symptoms range from nonspecific chest pain to circulatory collapse. Diagnosis involves tests like CT scans, VQ scans, echocardiograms and D-dimer levels. Treatment involves oxygen, anticoagulants like blood thinners, and potentially thrombolytics for severe cases. Outcomes depend on early detection and treatment, but PE can still lead to complications like pulmonary hypertension if not addressed.
Pulmonary embolism - Diagnosis and managementDr Vivek Baliga
Pulmonary embolism is a common problem seen in medical practice. This presentation by Dr Vivek Baliga discusses the basic aspects and evidence behind current management.
Pulmonary embolism (PE) is a common and potentially fatal condition where blood clots block arteries in the lungs. An estimated 5 million venous thromboses occur annually worldwide, with 10-30% of PE cases correctly diagnosed. Risk factors include cancer, obesity, pregnancy, prolonged immobility, and genetic hypercoagulable states. Diagnosis involves assessing clinical probability, d-dimer testing, imaging like CT scans or V/Q scans, and echocardiography. Treatment consists of anticoagulants like heparin or warfarin to prevent further clotting while the body breaks down existing clots.
Pulmonary embolism (PE) is a common and potentially fatal condition where blood clots block arteries in the lungs. An estimated 5 million venous thromboses occur annually worldwide, with 10-30% of cases resulting in PE. Risk factors include immobilization, surgery, cancer, and estrogen use. Diagnosis involves assessing clinical probability based on symptoms and risk factors, followed by tests like D-dimer, chest imaging, ultrasound, V/Q scan, CT, or angiogram. Treatment aims to prevent further clotting with anticoagulants like heparin and warfarin, provide supportive care, and in some severe cases utilize thrombolysis or embolectomy.
Pulmonary embolism (PE) is a common and potentially fatal condition where blood clots block arteries in the lungs. An estimated 5 million venous thromboses occur annually worldwide, with 10-30% of PE cases correctly diagnosed. Risk factors include older age, cancer, obesity, surgery, trauma, and genetic or acquired hypercoagulable states. Diagnosis involves assessing clinical probability, blood tests like D-dimer, imaging like CT scans or ventilation-perfusion scans, and echocardiography. Treatment focuses on anticoagulation to prevent further clotting and allow natural lysis, along with supportive care and thrombolysis or embolectomy in severe cases.
Pulmonary embolism (PE) is a common and potentially fatal condition where blood clots block arteries in the lungs. An estimated 5 million venous thromboses occur annually worldwide, with 10-30% of PE cases correctly diagnosed. Risk factors include cancer, obesity, pregnancy, prolonged immobility, and genetic predispositions. Diagnosis involves evaluating symptoms, physical exam findings, blood tests like D-dimer, imaging like CT scans and V/Q scans, and echocardiograms. Treatment focuses on anticoagulation with heparin or warfarin to prevent further clotting while the body breaks down existing clots.
Pulmonary embolism (PE) is a common and potentially fatal condition where blood clots block arteries in the lungs. An estimated 5 million venous thromboses occur annually worldwide, with 10-30% of cases resulting in PE. Risk factors include cancer, obesity, pregnancy, prolonged immobility, and genetic predispositions. Diagnosis involves evaluating symptoms, medical history, imaging tests like CT scans and ventilation-perfusion scans, and blood tests. Treatment focuses on anticoagulation to prevent further clotting and allow natural dissolution, with thrombolysis or embolectomy for severe cases.
Pulmonary embolism (PE) is a common and potentially fatal condition where blood clots block arteries in the lungs. An estimated 5 million venous thromboses occur annually worldwide, with 10-30% of PE cases correctly diagnosed. Risk factors include older age, cancer, obesity, surgery, trauma, and genetic or acquired hypercoagulable states. Diagnosis involves assessing clinical probability based on symptoms and risk factors, then confirming with tests like D-dimer, chest imaging, ventilation-perfusion scanning, pulmonary angiography, or CT pulmonary angiography. Treatment focuses on anticoagulation to prevent further clotting while allowing natural lysis of existing thrombi.
This document discusses the pathophysiology and treatment of acute pulmonary embolism (PE). It covers:
- The pathophysiological effects of PE on right ventricular function and hemodynamics.
- Clinical prediction rules and diagnostic strategies for PE including D-dimer testing and imaging modalities like CT, VQ scan, and angiography.
- Treatment options for PE including anticoagulants like heparin, low molecular weight heparin, fondaparinux, and newer oral agents; as well as thrombolytics, vena cava filters, and embolectomy. LMWH is recommended as first-line treatment due to superior safety compared to unfractionated heparin
This document provides an overview of pulmonary embolism (PE). It discusses the historical context, pathophysiology, risk factors, clinical presentation, diagnostic testing and treatment of PE. Some key points include:
- PE is a common cause of preventable death, with over 600,000 cases annually in the US.
- Virchow's triad of hypercoagulability, stasis, and endothelial injury contributes to the development of PE.
- Clinical presentation is often nonspecific, and the classic triad of symptoms occurs in less than 20% of cases.
- Diagnostic testing includes D-dimer, chest CT, ventilation-perfusion scanning and pulmonary angiography. Early treatment with antico
Acute pulmonary embolism is a form of venous thromboembolism that occurs when a blood clot breaks off and lodges in the pulmonary arteries of the lungs. The clinical presentation of PE can be variable and non-specific, making diagnosis challenging. It is important to efficiently evaluate patients suspected of having a PE to diagnose and treat it quickly in order to reduce morbidity and mortality. Treatment involves hemodynamic and respiratory support, initial anticoagulation with drugs like heparin, and potentially reperfusion therapies for more severe cases including thrombolysis or embolectomy.
1. Pulmonary embolism is an obstruction of the pulmonary artery or its branches by a thrombus originating in the venous system or right side of the heart.
2. The annual incidence of PE ranges from 23-69 cases per 100,000 population in India. Globally, the incidence of venous thromboembolism remains relatively constant at 117 cases per 100,000 person-years.
3. Diagnosis involves using criteria like Wells criteria and PERC rule to determine pre-test probability, D-dimer testing, and imaging like CT pulmonary angiography or lung scan if needed based on risk level and test results. Management involves anticoagulation with heparin or low molecular weight he
This document discusses acute pulmonary embolism (PE), which results from blood clots (deep vein thromboses or DVTs) breaking off and traveling to the lungs. PE is a leading cause of preventable hospital death. The document covers risk factors for PE like immobility, surgery, cancer, and inherited conditions. It also discusses methods for diagnosing PE like the Wells criteria, D-dimer testing, chest imaging like CT scans, and treatment including anticoagulation and thrombolysis for hemodynamically unstable patients. Poor prognostic signs of PE include hypotension, cardiac biomarkers indicating injury, and imaging findings of right ventricular dysfunction. Prevention through appropriate DVT prophylaxis is emphasized.
This document discusses acute pulmonary embolism (PE), including its presentation, risk factors, diagnostic workup, and management. PE is a potentially life-threatening condition that is often missed or difficult to diagnose due to vague symptoms. Timely treatment is important as untreated PE has a 20-30% mortality rate. Diagnostic tests include D-dimer, CT pulmonary angiogram, ventilation-perfusion scan, and angiogram. Initial treatment involves anticoagulation with heparin or fondaparinux. Long-term anticoagulation with warfarin is recommended to prevent recurrence. Thrombolysis or embolectomy may be considered for massive PE with hemodynamic instability.
This document discusses pulmonary embolism (PE), including its definition, epidemiology, risk factors, pathophysiology, clinical features, diagnosis, and management. Some key points:
- PE is an obstruction of the pulmonary artery or its branches by a thrombus originating in the venous system or right heart. It is a common cause of preventable death in hospitalized patients.
- The annual incidence of PE ranges from 23-69 cases per 100,000 people in India. Worldwide, the incidence of venous thromboembolism (which includes PE and DVT) is 117 cases per 100,000 person-years.
- Risk factors for PE include hereditary clotting disorders, immobil
The document discusses acute pulmonary embolism (PE). PE is common but difficult to diagnose, with nonspecific symptoms. It describes a case of a 48-year-old woman presenting with sudden dyspnea, tachycardia, and leg swelling who may have PE. Risk factors for PE include recent surgery or trauma, prolonged immobilization, and inherited or acquired hypercoagulable states. Diagnosis involves clinical scoring, D-dimer, imaging like CTPA, and treatment includes anticoagulation with heparin or warfarin.
This document discusses pulmonary embolism (PE). It notes that PE is a common disorder that can be deadly if left untreated. The presentation of PE is often vague and nonspecific. While the classic triad of symptoms is hemoptysis, dyspnea, and pleuritic pain, this occurs in less than 20% of patients. The document reviews risk factors, clinical features, diagnostic testing options including Wells criteria, imaging studies, D-dimer testing and their limitations. Treatment involves anticoagulation with heparin or warfarin to prevent clot extension and recurrence while educating patients.
This document discusses herpes zoster (shingles), which is caused by reactivation of the varicella zoster virus (VZV) that also causes chickenpox. It most commonly occurs in older adults and children. Symptoms include a painful, unilateral vesicular rash in a dermatomal distribution. Treatment involves antiviral drugs and analgesics. Complications can include postherpetic neuralgia and dissemination in immunosuppressed patients.
This document discusses the causes, approach, and evaluation of chest pain. It notes that only 15-20% of patients presenting with chest pain actually have acute coronary syndrome, while 10% have life-threatening non-cardiac causes like gastrointestinal issues. A quick history, physical exam, ECG, and biomarkers are recommended to evaluate stability and rule out high-risk conditions. Further diagnostic testing may include echocardiography, CT angiography, or MRI based on risk stratification of the patient.
Treatment of acute pulmonary embolism (PE) involves risk stratification and both primary therapy and secondary prevention. For massive PE with hypotension, resuscitation with fluids, oxygen, and empiric anticoagulation is critical. Primary therapy may include thrombolysis or embolectomy to reduce clot burden. Secondary prevention focuses on anticoagulation to prevent recurrence, using unfractionated heparin, low molecular weight heparin, warfarin or newer oral anticoagulants. Duration of anticoagulation depends on provoking factors and bleeding risk. Prevention of venous thromboembolism involves assessing risk and providing appropriate prophylaxis for moderate to high risk patients, especially with surgery
This document discusses the evaluation and management of chest pain. It begins with an overview of the magnitude of the problem, common causes of chest pain, and the recommended approach. Epidemiology data shows that chest pain is a common reason for emergency department visits. Only 15-20% of chest pain patients actually have acute coronary syndrome, while 10% have life-threatening non-cardiac causes like gastrointestinal issues. The document then covers the history, physical exam, investigations like ECG and biomarkers, and diagnostic approach for stable versus unstable patients. Common cardiac and non-cardiac causes of chest pain are reviewed along with their typical characteristics to help determine etiology.
The EMPA-KIDNEY trial aims to evaluate whether empagliflozin can benefit patients with chronic kidney disease (CKD) and cardiovascular disease outcomes in patients with or without diabetes. The trial plans to enroll approximately 6,000 patients with CKD at risk of progression and randomly assign them to receive empagliflozin or placebo in addition to standard of care. The primary outcome is a composite of cardiovascular death, end-stage kidney disease, or sustained decline in kidney function. Key secondary outcomes include hospitalization for heart failure or cardiovascular death, all-cause hospitalization, and all-cause mortality. The estimated trial completion is in 2022 and will provide important data on the efficacy of empagliflo
This document summarizes a grand rounds presentation on hypothyroidism. Dr. Samir Abdi moderated while Dr. Abdirisak Jacda presented on the case of a 20-year-old woman with a known history of recurrent ascites who was experiencing worsening body swelling. On examination, she displayed signs of profound anasarca. Laboratory tests found low T3 and T4 levels with a low TSH, consistent with hypothyroidism. The presentation reviewed the classification, pathogenesis, signs and symptoms, complications, and treatment of hypothyroidism.
This document outlines the principles and management of upper gastrointestinal tract bleeding. It begins with introducing common causes such as peptic ulcers, esophagitis, and variceal bleeding. It then discusses the initial assessment and resuscitation of patients, including classifying hemorrhagic shock. Risk stratification scores are described to predict the need for interventions. Specific therapies for causes like peptic ulcers, stress gastritis, and variceal bleeding are covered. Endoscopy is highlighted as the primary diagnostic and therapeutic tool. The conclusion emphasizes the multidisciplinary nature and importance of determining the bleeding source for directing treatment.
This document summarizes a seminar presentation on ICU care bundles. The presentation outlines several care bundles including the ABCDEF bundle. The ABCDEF bundle focuses on assessing, preventing, and managing pain; both spontaneous awakening trials and spontaneous breathing trials; choice of sedation and analgesia; assessing, preventing, and managing delirium; and early mobility and exercise. Implementing bundles like the ABCDEF bundle can help optimize patient outcomes by reducing ICU delirium and the duration of mechanical ventilation and ICU stays.
Cardiomyopathy refers to diseases of the heart muscle. There are several types including dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy. Dilated cardiomyopathy is characterized by enlarged heart chambers and poor systolic function, while hypertrophic cardiomyopathy involves thickened heart muscle walls, often asymmetrically involving the septum. Restrictive cardiomyopathy causes stiffening of the heart muscle resulting in diastolic dysfunction. Echocardiography and cardiac MRI are important diagnostic tools to classify and characterize cardiomyopathies. Treatment involves managing symptoms, reducing risk of complications like arrhythmias, and potentially treating underlying causes.
This document provides an overview of cirrhosis and its complications. It defines cirrhosis as a chronic liver disease characterized by diffuse fibrosis and nodular regeneration. The main causes are chronic viral hepatitis, alcohol, and non-alcoholic fatty liver disease. Complications include portal hypertension, ascites, hepatic encephalopathy, and hepatorenal syndrome. Diagnosis involves clinical evaluation, labs, imaging, and sometimes biopsy. Treatment focuses on managing complications, addressing the underlying cause, and potentially liver transplantation for decompensated cirrhosis.
This document summarizes risk factors and screening recommendations for pancreatic cancer. It notes that the major risk factors are age, diabetes, smoking, diet high in fat/meat and lack of fruits/veggies, chronic pancreatitis, hereditary pancreatitis, familial pancreatic cancer and certain gene mutations. Screening is recommended for those with high familial risk or known genetic mutations starting at age 40-50 depending on family history. The majority of pancreatic cancers arise from ductal cells and present as ductal adenocarcinoma in the head of the pancreas in 60-70% of cases. Only about 15% of patients are candidates for potentially curative resection with 5-year survival of 10-25% for
This document provides an overview of hypertrophic cardiomyopathy (HCM). It defines HCM as marked thickening of the left ventricle not caused by other conditions like hypertension. HCM can cause chest pain and shortness of breath due to obstructed blood flow. Diagnosis is made via echocardiogram showing thickened walls. Treatment focuses on symptom management with medications and potentially surgery. Implantable cardioverter-defibrillators are recommended for high-risk patients to prevent sudden cardiac death from arrhythmias. The document reviews genetic causes, clinical presentation, diagnostic tests and surgical/medical management options for HCM in detail over multiple sections.
This document provides an overview of gastritis, including its classification, causes, symptoms, and treatment. It discusses acute gastritis caused by infection, and chronic gastritis, which can be type A (body-predominant) or type B (antral-predominant). Type B gastritis is usually caused by H. pylori infection and can progress to gastric atrophy and cancer. Rare forms like lymphocytic, eosinophilic, and granulomatous gastritis are also covered. Treatment focuses on underlying causes, vitamin supplementation for pernicious anemia, and H. pylori eradication.
This journal club presentation summarizes the EMPEROR-Preserved trial which evaluated the effects of empagliflozin in patients with heart failure and preserved ejection fraction (HFpEF). The randomized, double-blind trial assigned 5,988 patients to empagliflozin 10 mg daily or placebo in addition to standard care. The primary outcome of cardiovascular death or hospitalization for heart failure occurred in 26.9% of empagliflozin patients versus 30.1% of placebo patients, representing a 21% relative risk reduction with empagliflozin. Empagliflozin also reduced hospitalizations for heart failure alone. The effects were generally consistent across subgroups and empagliflozin was well-
This document outlines the design of a randomized controlled trial testing the effects of empagliflozin versus placebo in patients with heart failure with preserved ejection fraction. Over 5,900 patients were enrolled and followed for a median of 26 months. The primary outcome was a composite of cardiovascular death or hospitalization for heart failure. Empagliflozin reduced the primary outcome compared to placebo and was generally well tolerated aside from higher rates of genital infections.
The EMPA-KIDNEY trial aims to evaluate whether empagliflozin can benefit patients with chronic kidney disease (CKD) and cardiovascular disease outcomes in patients with or without diabetes. The trial plans to enroll approximately 6,000 patients with CKD at risk of kidney disease progression, defined as an eGFR of 20-45 mL/min/1.73 m2 or an eGFR of 45-90 mL/min/1.73 m2 with albuminuria above 200 mg/g. Patients will be randomly assigned to receive empagliflozin 10 mg daily or placebo daily in addition to standard of care. The primary outcome is a composite of cardiovascular death, end-stage kidney disease,
Tetanus is caused by Clostridium tetani bacteria and causes painful muscle spasms. It is characterized by muscle rigidity and spasms. The bacteria produces a neurotoxin that is transported to the spinal cord where it blocks inhibitory neurotransmitter release, causing increased muscle tone and spasms. Treatment involves wound management, antibiotics, antitoxin antibodies, sedation and management of autonomic dysfunction and spasms. Complications can include ventilator-associated pneumonia and infections from prolonged treatment.
This document presents a case discussion of a patient with tuberous sclerosis. Key details include:
- The patient is a 32-year-old woman presenting with gross hematuria and other symptoms.
- Her history and exam findings are consistent with tuberous sclerosis, including skin lesions, ungual fibromas, and lung cysts seen on imaging.
- Tuberous sclerosis is caused by mutations in TSC1/TSC2 genes and is characterized by benign tumors in multiple organs. Common features include skin and brain lesions, epilepsy, and lung cysts.
- The discussion reviews the patient's diagnosis and management, focusing on tuberous sclerosis as the most likely diagnosis to explain her
Interstitial lung diseases (ILDs) represent a heterogeneous group of over 200 lung disorders that involve the parenchyma of the lungs. ILDs can be caused by various factors including hazardous exposures, autoimmune diseases, infections, and idiopathic factors. Clinically, ILDs present with dyspnea, cough, and crackles on exam. Diagnosis involves imaging such as chest X-ray and HRCT which show patterns of reticular opacities, honeycombing, and fibrosis. Pulmonary function tests typically show a restrictive defect. Precise diagnosis requires consideration of clinical features, imaging patterns, and sometimes lung biopsy.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- 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
low birth weight presentation. Low birth weight (LBW) infant is defined as the one whose birth weight is less than 2500g irrespective of their gestational age. Premature birth and low birth weight(LBW) is still a serious problem in newborn. Causing high morbidity and mortality rate worldwide. The nursing care provide to low birth weight babies is crucial in promoting their overall health and development. Through careful assessment, diagnosis,, planning, and evaluation plays a vital role in ensuring these vulnerable infants receive the specialize care they need. In India every third of the infant weight less than 2500g.
Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
5. Patient with suspect symptomatic
Acute lower extremity DVT
Venous duplex scan negative Low clinical probability observe
High clinical probability
Repeat scan /
Venography
negative
positive
Evaluate coagulogram /thrombophilia/ malignancy
Anticoagulant therapy
contraindication
yes IVC filter
No
pregnancy LMWH
OPD LMWH
hospitalisation UFH
+ warfarin
Compression treatment
6. Thrombophilia screening
Factor V leiden, Prot C/S deficiency
Antithrombin III deficiency
Idiopathic DVT < 50 years
Family history of DVT
Thrombosis in an unusual site
Recurrent DVT
7. Recommendation for
duration of warfarin
3-6 months first DVT with reversible
risk factors
At least 6 months for first idiopathic
DVT
12 months to lifelong for recurrent DVT
or first DVT with irreversible risk factors
malignancy or thrombophilic state
10. 10
50,000 individuals die from PE each
year in USA
The incidence of PE in USA is 500,000
per year
11. 11
Incidence of Pulmonary Embolism Per Year in the United States*
Total Incidence
630,000
Death within 1 hr
67,000
11%
Survival >1hr
563,000
89%
Dx not made
400,000
71%
Dx made, therapy
instituted 163,000
29%
Survival
280,000
70%
Death
120,000
30%
Survival
150,000
Death
120,000
92% 8%
*Progress in Cardiovascular
Diseases, Vol. XVII, No. 4
(Jan/Feb 1975)
12. 12
Risk factor for venous
thrombosis
Stasis
Injury to venous intima
Alterations in the coagulation-fibrinolytic
system
13. 13
Source of emboli
Deep venous thrombosis (>95%)
Other veins:
Renal
Uterine
Right cardiac chambers
14. 14
Risk factors for DVT
General anesthesia
Lower limb or pelvic injury or surgery
Congestive heart failure
Prolonged immobility
Pregnancy
Postpartum
Oral contraceptive pills
Malignancy
Obesity
Advanced age
Coagulation problems
15. 15
Clinical features
Sudden onset dyspnea
Pleuritic chest pain
Hemoptysis
Clinical clues cannot make the diagnosis
of PE; their main value lies in
suggesting the diagnosis
16. 16
Signs or symptoms observed in patients with thromboembolism
Study
Stein et al., %
(n= 117)
Anderson et
al., % (n= 131)
Pulmonary
embolism
Dyspnea 73 77
Tachypnea 70 70
Chest pain 66 55
Cough 37 —
Tachycardia 30 43
Cyanosis 1 18
Hemoptysis 13 13
Wheezing 9 —
Hypotension — 10
17. 17
Signs or symptoms observed in patients with thromboembolism
Study
Stein et al., %
(n= 117)
Anderson et
al., % (n= 131)
Pulmonary
Embolism
Syncope — 10
Elevated jugular
venous pulse
— 8
Temperature
>38.5°C
7 —
S-3 gallop 3 5
Pleural friction
rub
3 2
18. 18
Signs or symptoms observed in patients with thromboembolism
Study
Stein et al., %
(n= 117)
Anderson et
al., % (n= 131)
Deep vein
thrombosis
Swelling 28 88*
Pain 26 56
Tenderness — 55
Warmth — 42
Redness — 34
Homan’s sign 4 13
Palpable cord — 6
19. 19
Massive Pulmonary
Embolism
It is a catastrophic entity which often results
in acute right ventricular failure and death
Frequently undiscovered until autopsy
Fatal PE typically leads to death within one to
two hours of the event
20. 20
Pathophysiology
Massive PE causes an increase in PVR right
ventricular outflow obstruction decrease left
ventricular preload Decrease CO
In patients without cardiopulmonary disease,
occlusion of 25-30 % of the vascular bed
increase in Pulmonary artery pressure (PAP)
Hypoxemia ensues stimulating vasoconstriction
increase in PAP
21. 21
Pathophysiology
More than 50% of the vascular bed has to be
occluded before PAP becomes substantially elevated
When obstruction approaches 75%, the RV must
generate systolic pressure in excess of 50mmHg to
preserve pulmonary circulation
The normal RV is unable to accomplish this acutely
and eventually fails
27. 27
Diagnosis
The diagnosis of massive PE should be explored
whenever oxygenation or hemodynamic parameters
are severely compromised without explanation
CXR
ABG:
Significant hypoxemia is almost uniformly present when
there is a hemodynamically significant PE
V/Q
Spiral CT
Echo
Angio
36. 36
The use of ventilation perfusion scan in diagnosing pulmonary
embolism
High probability
=2 large segmental (>75% of a segment) perfusion defects without
corresponding ventilation or radiographic abnormalities or substantially larger
than matching ventilation or radiologic abnormalities
OR
=2 moderate segmental (>25% and <75% of a segment) perfusion defects
without matching ventilation or chest radiographic abnormalities plus one
large unmatched segmental defect
OR
=4 moderate segmental perfusion defects without matching ventilation or
chest radiologic abnormalities
37. 37
The use of ventilation perfusion scan in diagnosing pulmonary
embolism
Intermediate probability
Scans that do not fall into normal, very low, low, or high probability categories
38. 38
The use of ventilation perfusion scan in diagnosing pulmonary
embolism
Low probability
Nonsegmental perfusion defects
OR
Single moderate mismatched segmental perfusion defect with normal chest
radiograph
OR
Any perfusion defect with a substantially larger abnormality on chest
radiograph
OR
Large or moderate segmental perfusion defects involving no more than four
segments in one lung and no more than three segments in one lung region
with matching or larger ventilation/radiographic abnormalities
OR
More than three small segmental perfusion defects (<25% of a segment) with
a normal chest radiograph
39. 39
The use of ventilation perfusion scan in diagnosing pulmonary
embolism
Very low probability
Three or fewer small segmental perfusion defects with a normal chest
radiograph
Normal
No perfusion defects present
43. 43
Prospective Investigation of Pulmonary
Embolism Diagnosis (PIOPED) results
Prospective investigation of pulmonary embolism diagnosis results
Scan
category
PE present PE absent PE
uncertain
No
angiogram
Total
High
probability
102 14 1 7 124
Intermediate
probability
105 217 9 33 364
Low
probability
39 199 12 62 312
Near normal
or normal
5 50 2 74 131
Total 251 480 24 176 931
54. 54
Dosage and monitoring of anticoagulant
therapy
Dosage and monitoring of anticoagulant therapy
After initiating heparin therapy, repeat APTT every 6 h for first 24 h and then
every 24 h when therapeutic APTT is achieved
Warfarin 5 mg/d can be started on day 1 of therapy; there is no benefit from
higher starting doses
Platelet count should be monitored at least every 3 d during initial heparin
therapy
Therapeutic APTT should correspond to plasma heparin level of 0.2–0.4
IU/mL
Heparin is usually continued for 5–7 d
Heparin can be stopped after 4–5 d of warfarin therapy when INR is in 2.0–
3.0 range
55. 55
Important drug interactions with warfarin
Drugs that decrease warfarin
requirement
Drugs that increase warfarin
requirement
Phenylbutazone Barbiturates
Metronidazole Carbamazepine
Trimethoprim-sulfamethoxazole Rifampin
Amiodarone Penicillin
Second- and third-generation
cephalosporins
Griseofulvin
Clofibrate Cholestyramine
Erythromycin
Anabolic steroids
Thyroxine
56. 56
Complications of anticoagulation
Complication Management
Heparin Bleeding Stop heparin infusion.
For severe bleeding,
the anticoagulant
effect of heparin can
be reversed with
intravenous protamine
sulfate 1 mg/100 units
of heparin bolus or 0.5
mg for the number of
units given by constant
infusion over the past
hour; provide
supportive care
including transfusion
and clot evacuation
from closed body
cavities as needed.
57. 57
Complications of anticoagulation
Complication Management
Heparin Heparin-induced
thrombocytopenia and
thrombosis
Carefully monitor
platelet count during
therapy. Stop-heparin
for platelet counts
<75,000. Replace
heparin with direct
inhibitors of thrombin-
like desirudin if
necessary. These
agents do not cause
heparin-induced
thrombocytopenia.
Avoid platelet
transfusion because of
the risk for thrombosis.
58. 58
Complications of anticoagulation
Complication Management
Heparin Heparin-induced
osteoporosis (therapy
>1 mo)
LMWHs may have
lower propensity to
cause osteoporosis as
compared with
unfractionated heparin;
consider LMWH if
prolonged heparin
therapy is necessary.
59. 59
Complications of anticoagulation
Complication Management
Warfarin Bleeding Stop therapy. Administer
vitamin K and fresh-
frozen plasma for severe
bleeding; provide
supportive care including
transfusion and clot
evacuation from closed
body cavities as needed
Skin necrosis (rare) Supportive care.
Teratogenicity Do not use in pregnancy
or in patients planning to
become pregnant.
60. 60
Risks and benefits of thrombolytics vs heparin therapy for
pulmonary embolism
Thrombolytic
therapy
No difference Heparin
Improved resolution at 2-4 h after onset of therapy
Angiography + - -
Pulmonary artery
pressure
+ - -
Echocardiography
+ - -
Resolution at 24 h
Lung scan + - -
Angiography + - -
61. 61
Risks and benefits of thrombolytics vs heparin therapy for
pulmonary embolism
Thrombolytic
therapy
No difference Heparin
Echocardiograp
hy
+ - -
Pulmonary
artery pressure
+ - -
Resolution at 1
wk and 30 d
(lung scan)
- + -
Rate of
confirmed
recurrent
pulmonary
embolism
- + -
62. 62
Risks and benefits of thrombolytics vs heparin therapy for
pulmonary embolism
Thrombolytic
therapy
No difference Heparin
Hospital
mortality
- + -
Late mortality - + -
Less severe
bleeding
- - +
Less intracranial
hemorrhage
- - +
Lower cost - - +
63. 63
Approved thrombolytics for pulmonary embolism
Approved thrombolytics for pulmonary embolism
Streptokinase
250,000 IU as loading dose over 30 min, followed by
100,000 U/h for 24 h
Urokinase
4400 IU/kg as a loading dose over 10 min, followed
by 4400 IU/kg/h for 12-24 h
Recombinant tissue-plasminogen activator
100 mg as a continuous peripheral intravenous
infusion administered over 2 h
64. 64
Indications and contraindications for thrombolytic
therapy in pulmonary embolism
Indications
Hemodynamic instability
Hypoxia on 100% oxygen
Right ventricular dysfunction by echocardiography
65. 65
Contraindications
Relative
Recent surgery within last 10 d Previous arterial punctures within 10 d
Neurosurgery within 6 mo Bleeding disorder (thrombocytopenia, renal failure, liver
failure)
Ophthalmologic surgery within 6 wk
Hypertension >200 mm Hg systolic or 110 mm Hg diastolic Placement of central venous
catheter within 48 h
Hypertensive retinopathy with hemorrhages or exudates Intracerebral aneurysm or
malignancy
Cardiopulmonary resuscitation within 2 wk
Cerebrovascular disease
Major internal bleeding within the last 6 mo Pregnancy and the 1st 10 d postpartum
Infectious endocarditis Severe trauma within 2 mo
Pericarditis
Absolute
Active internal bleeding
67. Indications for inferior vena caval (IVC) filters
Absolute contraindication to anticoagulation
(eg, active bleeding)
Recurrent PE despite adequate anticoagulant
therapy
Complication of anticoagulation (eg, severe
bleeding)
Hemodynamic or respiratory compromise that
is severe enough that another PE may be
lethal
67
68. EMBOLECTOMY
Embolectomy (ie, removal of the emboli) can
be performed using catheters or surgically.
It should be considered when a patient's
presentation is severe enough to warrant
thrombolysis (eg, persistent hypotension due
to PE), but this approach either fails or is
contraindicated.
68
69. 69
Conclusions
PE is common and under-recognized
serious medical problem
Early diagnosis and treatment is
essential for good outcome
High index of suspicion is needed in
high risk patients