The document discusses a case of a 60-year-old woman presenting with lightheadedness, chest tightness, tachycardia, and hypotension. The case involves managing a patient in atrial fibrillation who is nearly in cardiac arrest. Treatment options discussed include cardioversion, antiarrhythmic drugs like amiodarone and digoxin, and calcium channel blockers like diltiazem to control the heart rate. Evidence from studies is presented regarding the effectiveness of different rate control medications. The case highlights challenges in treating unstable patients when evidence-based guidelines do not directly address the clinical scenario.
2. pharmacokinetics ( By Dr. Takele Beyene, DVM, MSc,PhD,@AAU)AAU
This document discusses pharmacokinetics and the processes involved in the absorption, distribution, metabolism and excretion of drugs in the body. It defines pharmacokinetics as the changes that occur to drugs inside the body, including absorption through the gastrointestinal tract, distribution to tissues, biotransformation primarily in the liver, and excretion of metabolites. Several factors are described that can influence the rate and extent of absorption, such as drug properties like solubility and ionization, as well as patient factors like gastrointestinal pH and blood supply to absorbing tissues.
This document summarizes guidelines for treatment of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) from the American Diabetes Association (ADA) and Joint British Diabetes Societies Inpatient (JBDS IP). Key points include:
1) Bedside beta-hydroxybutyrate testing is now the best way to monitor treatment response in DKA.
2) For DKA, guidelines recommend fixed rate insulin infusion of 0.1 unit/kg/hr without a priming dose and adjustments to meet metabolic targets.
3) For HHS, the goal of initial therapy is to expand intravascular volume and restore perfusion by replacing approximately 50
This document discusses simulation in medical education. It defines simulation as presenting problems authentically to allow trainees to respond as they would in real situations while receiving feedback. Simulation provides controlled, safe practice opportunities and helps develop clinical skills. Factors driving increased simulation use include problems with clinical teaching, new medical technologies, assessing competence, improving patient safety, and enabling deliberate practice. Effective simulation provides feedback, repetitive practice of varying difficulty, integration into the curriculum, and clearly defined learning outcomes.
This document discusses the use of point-of-care ultrasound in emergency and critical care settings. It provides an overview of using ultrasound to diagnose pneumothorax, pulmonary edema, and other conditions. Examples are given of ultrasound findings for a pneumothorax including the lack of lung sliding and presence of a lung point. Signs of pulmonary edema on ultrasound include A-lines and B-lines. The document emphasizes that ultrasound is a rapid, noninvasive tool that can help clinicians diagnose and treat patients, but should be used along with medical history, exams, and clinical judgment.
2. pharmacokinetics ( By Dr. Takele Beyene, DVM, MSc,PhD,@AAU)AAU
This document discusses pharmacokinetics and the processes involved in the absorption, distribution, metabolism and excretion of drugs in the body. It defines pharmacokinetics as the changes that occur to drugs inside the body, including absorption through the gastrointestinal tract, distribution to tissues, biotransformation primarily in the liver, and excretion of metabolites. Several factors are described that can influence the rate and extent of absorption, such as drug properties like solubility and ionization, as well as patient factors like gastrointestinal pH and blood supply to absorbing tissues.
This document summarizes guidelines for treatment of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) from the American Diabetes Association (ADA) and Joint British Diabetes Societies Inpatient (JBDS IP). Key points include:
1) Bedside beta-hydroxybutyrate testing is now the best way to monitor treatment response in DKA.
2) For DKA, guidelines recommend fixed rate insulin infusion of 0.1 unit/kg/hr without a priming dose and adjustments to meet metabolic targets.
3) For HHS, the goal of initial therapy is to expand intravascular volume and restore perfusion by replacing approximately 50
This document discusses simulation in medical education. It defines simulation as presenting problems authentically to allow trainees to respond as they would in real situations while receiving feedback. Simulation provides controlled, safe practice opportunities and helps develop clinical skills. Factors driving increased simulation use include problems with clinical teaching, new medical technologies, assessing competence, improving patient safety, and enabling deliberate practice. Effective simulation provides feedback, repetitive practice of varying difficulty, integration into the curriculum, and clearly defined learning outcomes.
This document discusses the use of point-of-care ultrasound in emergency and critical care settings. It provides an overview of using ultrasound to diagnose pneumothorax, pulmonary edema, and other conditions. Examples are given of ultrasound findings for a pneumothorax including the lack of lung sliding and presence of a lung point. Signs of pulmonary edema on ultrasound include A-lines and B-lines. The document emphasizes that ultrasound is a rapid, noninvasive tool that can help clinicians diagnose and treat patients, but should be used along with medical history, exams, and clinical judgment.
ACTEP2014: Therapeutic hypothermia for ACTEP 2014taem
This document discusses therapeutic hypothermia after cardiac arrest and suggests starting it in the emergency department. It defines therapeutic hypothermia and reviews studies showing improved neurological outcomes when mild hypothermia is induced after cardiac arrest. The benefits of therapeutic hypothermia are explained. Methods for inducing hypothermia in the emergency department are presented, including cold intravenous fluids and surface cooling techniques. The document recommends inducing therapeutic hypothermia for comatose cardiac arrest patients with initial rhythms of ventricular fibrillation or pulseless ventricular tachycardia.
This document discusses sepsis markers and their clinical use. It summarizes several biomarkers that show potential for diagnosing and monitoring sepsis, including procalcitonin (PCT), C-reactive protein (CRP), and soluble CD14 subtype (sCD14-ST). sCD14-ST shows diagnostic value in distinguishing infection from SIRS and sepsis from severe sepsis. Studies found sCD14-ST levels correlated with severity of illness and organ dysfunction in sepsis patients. The document reviews several clinical trials and studies that evaluated these biomarkers for diagnosing and predicting outcomes in sepsis, abdominal infections, febrile neutropenia, and burns.
ACTEP2014: Sepsis management has anything change taem
This document discusses sepsis management and what has changed. It begins with an introduction to the pathophysiology of sepsis, severe sepsis, and septic shock. It then discusses early goal directed therapy (EGDT) and landmark studies like Rivers 2001 that promoted protocolized resuscitation to targets like central venous pressure, mean arterial pressure, ScvO2, and transfusion thresholds. However, later large trials like ProCESS 2014 found no difference in mortality between EGDT, standard therapy, and usual care. Targets like CVP are not accurate predictors of fluid responsiveness. Studies also found no difference in outcomes between higher and lower blood pressure or hemoglobin transfusion thresholds. There remains uncertainty around optimal fluid type, vas
ACTEP2014: How to maximise resuscitation in trauma 2014taem
This document discusses various strategies for optimizing resuscitation of trauma patients, including permissive hypotension, bedside monitoring, and hemostatic resuscitation. It provides details on the Bickell study which found delayed fluid resuscitation improved outcomes for patients with penetrating torso injuries. Bedside monitoring techniques like focused assessment with sonography for trauma (FAST) and limited trauma ultrasound exam (LTTE) can help guide fluid management. Hemostatic resuscitation involving balanced use of blood products aims to address coagulopathy often seen in severe trauma. Target blood pressures of 60 mmHg may optimize outcomes with hypotensive resuscitation.
1) A medic responds to an IED explosion where his convoy was attacked. The person next to him has bilateral mid-thigh amputations with heavy bleeding from one leg. 2) The medic's top priority is to return fire and take cover since they are still under attack. 3) Once there is suppressive fire from the rest of the convoy, the medic applies a tourniquet to the leg with arterial bleeding to control the life-threatening hemorrhage.
This document discusses the use of hemodynamic ultrasound in critical care. It describes how ultrasound can be used to diagnose various types of shock such as hypovolemic, distributive, cardiogenic, and obstructive shock. Specific conditions that can be identified include tamponade, pulmonary embolism, and reduced left or right ventricular function. The document provides guidance on assessing volume responsiveness and fluid management in critically ill patients.
The document discusses the roles and responsibilities of an emergency department director. It covers topics such as developing leadership and communication skills, implementing effective peer review and physician profiling, dealing with problem physicians, improving customer relations and patient satisfaction, managing physician and hospital contracts, recruiting and orienting new physicians, measuring productivity and compensation, managing staffing and scheduling, conducting meetings, and managing risk. The emergency department director must balance both leadership and management functions to effectively run the emergency department.
This document discusses Mindray's ceiling supply units used in emergency rooms. It provides an overview of Mindray as a company and their products, including several models of ceiling supply units or "pendants" used in ERs and ICUs. The pendants are designed to organize medical devices at the patient bedside and provide benefits like easier patient access and care, cable management, and hygiene. Customization options and features are described such as suspension systems, finishes, outlets, and accessories. 3D design services are also mentioned for visualizing hospital layouts.
Sedation monitoring and post sedation recovery and dischargetaem
This document outlines guidelines for procedural sedation and analgesia. It recommends having appropriate monitoring equipment and administering analgesics before sedatives. Patients should be monitored until recovery to their baseline mental status. At minimum, procedural sedation requires one clinician to perform the procedure while another continuously monitors the patient. Regular monitoring of vital signs, oxygen saturation, and ventilation is important. The use of capnography may help detect respiratory complications earlier than pulse oximetry alone. Patients must meet discharge criteria related to symptoms, vital signs, and orientation before being discharged.
Procedural analgesia and sedation adverse eventtaem
This document discusses procedural analgesia and sedation, complications, and adverse events. It provides an overview of adverse events including lack of sedation, oversedation, hypoxemia, respiratory depression, and more. It also discusses factors that can predispose patients to adverse events like clinical status, fasting time, depth of sedation, and type of agents used. Finally, it reviews evidence on adverse events and provides terminology used to describe airway, breathing, and circulation complications from sedation.
ACTEP2014: Therapeutic hypothermia for ACTEP 2014taem
This document discusses therapeutic hypothermia after cardiac arrest and suggests starting it in the emergency department. It defines therapeutic hypothermia and reviews studies showing improved neurological outcomes when mild hypothermia is induced after cardiac arrest. The benefits of therapeutic hypothermia are explained. Methods for inducing hypothermia in the emergency department are presented, including cold intravenous fluids and surface cooling techniques. The document recommends inducing therapeutic hypothermia for comatose cardiac arrest patients with initial rhythms of ventricular fibrillation or pulseless ventricular tachycardia.
This document discusses sepsis markers and their clinical use. It summarizes several biomarkers that show potential for diagnosing and monitoring sepsis, including procalcitonin (PCT), C-reactive protein (CRP), and soluble CD14 subtype (sCD14-ST). sCD14-ST shows diagnostic value in distinguishing infection from SIRS and sepsis from severe sepsis. Studies found sCD14-ST levels correlated with severity of illness and organ dysfunction in sepsis patients. The document reviews several clinical trials and studies that evaluated these biomarkers for diagnosing and predicting outcomes in sepsis, abdominal infections, febrile neutropenia, and burns.
ACTEP2014: Sepsis management has anything change taem
This document discusses sepsis management and what has changed. It begins with an introduction to the pathophysiology of sepsis, severe sepsis, and septic shock. It then discusses early goal directed therapy (EGDT) and landmark studies like Rivers 2001 that promoted protocolized resuscitation to targets like central venous pressure, mean arterial pressure, ScvO2, and transfusion thresholds. However, later large trials like ProCESS 2014 found no difference in mortality between EGDT, standard therapy, and usual care. Targets like CVP are not accurate predictors of fluid responsiveness. Studies also found no difference in outcomes between higher and lower blood pressure or hemoglobin transfusion thresholds. There remains uncertainty around optimal fluid type, vas
ACTEP2014: How to maximise resuscitation in trauma 2014taem
This document discusses various strategies for optimizing resuscitation of trauma patients, including permissive hypotension, bedside monitoring, and hemostatic resuscitation. It provides details on the Bickell study which found delayed fluid resuscitation improved outcomes for patients with penetrating torso injuries. Bedside monitoring techniques like focused assessment with sonography for trauma (FAST) and limited trauma ultrasound exam (LTTE) can help guide fluid management. Hemostatic resuscitation involving balanced use of blood products aims to address coagulopathy often seen in severe trauma. Target blood pressures of 60 mmHg may optimize outcomes with hypotensive resuscitation.
1) A medic responds to an IED explosion where his convoy was attacked. The person next to him has bilateral mid-thigh amputations with heavy bleeding from one leg. 2) The medic's top priority is to return fire and take cover since they are still under attack. 3) Once there is suppressive fire from the rest of the convoy, the medic applies a tourniquet to the leg with arterial bleeding to control the life-threatening hemorrhage.
This document discusses the use of hemodynamic ultrasound in critical care. It describes how ultrasound can be used to diagnose various types of shock such as hypovolemic, distributive, cardiogenic, and obstructive shock. Specific conditions that can be identified include tamponade, pulmonary embolism, and reduced left or right ventricular function. The document provides guidance on assessing volume responsiveness and fluid management in critically ill patients.
The document discusses the roles and responsibilities of an emergency department director. It covers topics such as developing leadership and communication skills, implementing effective peer review and physician profiling, dealing with problem physicians, improving customer relations and patient satisfaction, managing physician and hospital contracts, recruiting and orienting new physicians, measuring productivity and compensation, managing staffing and scheduling, conducting meetings, and managing risk. The emergency department director must balance both leadership and management functions to effectively run the emergency department.
This document discusses Mindray's ceiling supply units used in emergency rooms. It provides an overview of Mindray as a company and their products, including several models of ceiling supply units or "pendants" used in ERs and ICUs. The pendants are designed to organize medical devices at the patient bedside and provide benefits like easier patient access and care, cable management, and hygiene. Customization options and features are described such as suspension systems, finishes, outlets, and accessories. 3D design services are also mentioned for visualizing hospital layouts.
Sedation monitoring and post sedation recovery and dischargetaem
This document outlines guidelines for procedural sedation and analgesia. It recommends having appropriate monitoring equipment and administering analgesics before sedatives. Patients should be monitored until recovery to their baseline mental status. At minimum, procedural sedation requires one clinician to perform the procedure while another continuously monitors the patient. Regular monitoring of vital signs, oxygen saturation, and ventilation is important. The use of capnography may help detect respiratory complications earlier than pulse oximetry alone. Patients must meet discharge criteria related to symptoms, vital signs, and orientation before being discharged.
Procedural analgesia and sedation adverse eventtaem
This document discusses procedural analgesia and sedation, complications, and adverse events. It provides an overview of adverse events including lack of sedation, oversedation, hypoxemia, respiratory depression, and more. It also discusses factors that can predispose patients to adverse events like clinical status, fasting time, depth of sedation, and type of agents used. Finally, it reviews evidence on adverse events and provides terminology used to describe airway, breathing, and circulation complications from sedation.
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
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
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.
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
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.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
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).
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7
What about nearly arrest patient?
1. What about the nearly
arrest patient?
Where evidence based medicine has yet to go but
where we often find ourselves
SP-ER conference 9 Aug 2009
Suthaporn Lumlertgul M.D.
King Chulalongkorn Memorial hospital
Sunday, August 9, 2009
2. Reference:
Harvard Shock symposium
Sunday, August 9, 2009
3. Reference:
Harvard Shock symposium
Sunday, August 9, 2009
4. Objective
• Manage case that is nearly dead, guideline
yet go there
•
Sunday, August 9, 2009
6. Example case
• A 60 year old woman with complaint
lightheadness, chest tightness
• HR= 150/min, BP=200/110 RR=36/min O2
Sat 96% Temp=37.4
Sunday, August 9, 2009
8. What are you examining in AF patient?
Sunday, August 9, 2009
9. What are you examining in AF patient?
• A 60 year old
woman with
complaint
lightheadness,
chest tightness
• HR= 150/min,
BP=200/110
• RR=36/min O2
Sat 90%
Temp=37.4
Sunday, August 9, 2009
11. Define Unstable
• Patients as those with ventricular rates 150,
• ongoing chest pain, or with evidence of critical
perfusion:
• systolic BP 90 mm Hg, heart failure, or reduced
consciousness.
Sunday, August 9, 2009
12. Rapid AF
• AHA guideline for management of a patient
with hypotension and AF with RVR would
be cardioversion
• DC Cardioversion
Sunday, August 9, 2009
19. What are you using?
Amiodarone Diltiazem
Adenosine
Digoxin
Beta blocker
Sunday, August 9, 2009
20. What are you using?
Digoxin
Beta blocker
5 min
Sunday, August 9, 2009
21. What are you using?
Digoxin
Cardiovert
Beta blocker
5 min
Sunday, August 9, 2009
22. What are you using?
Digoxin
Cardiovert
Diltiazem
Beta blocker
5 min
Sunday, August 9, 2009
23. What are you using?
Amiodarone Digoxin
Cardiovert
Diltiazem
Beta blocker
5 min
Sunday, August 9, 2009
24. What are you using?
Amiodarone Digoxin
Cardiovert
Diltiazem
Beta blocker
5 min
Sunday, August 9, 2009
25. Diltiazem
• Schreck et al compared the effectiveness of IV
Diltiazem receive
diltiazem with digoxin. In this open-label RCT,
consecutive patients with acute AF were assigned to more rapid rate
receive either diltiazem (0.25 mg/kg initial bolus
followed by 0.35 mg/kg 15 min after, and then an
control in 5 min
infusion of 10 to 20 mg/h to maintain a heart rate thank digoxin
100), digoxin (0.25-mg boluses at 0 and 30 min),
or both digoxin and diltiazem. Follow-up was for 180
min. Treatment with diltiazem achieved a rapid
reduction in ventricular rate compared to digoxin,
the results becoming statistically significant by 5 min
Sunday, August 9, 2009
26. Diltiazem
• Rate-limiting calcium channel antagonists have
therefore been shown to be effective in ventricular
rate reduction in acute AF. The major adverse event
reported from the RCTs was the precipitation of
symptomatic hypotension (18% of patients)
Sunday, August 9, 2009
28. Digoxin
• Double-blind RCT recruited 40 patients to receive either digoxin (total IVdose
of 1.25 mg in divided doses) or placebo.
• At 12 h posttherapy, there was no significant difference between the rates of
conversion between the digoxin
• Ventricular rate reduction was 30 min
Sunday, August 9, 2009
29. Maintain sinus Rate + anticoag
⇑Hemodynamic Avoid pro
Pro
⇓Thromboembolic arrhythmia
⇓Hemodynamic
Pro arrhythmic Bleeding
Con
Fatality Residual embolic
Sunday, August 9, 2009
31. RV
LV
Loss of atrial kick sign?
Sunday, August 9, 2009
32. •LV systolic function looks
depressed (subcostal long axis
view)
RV
LV
Loss of atrial kick sign?
Sunday, August 9, 2009
33. •LV systolic function looks
depressed (subcostal long axis
view)
RV •Reduce SV by reducing diastolic
time / by absence of atrial kick).
LV
Loss of atrial kick sign?
Sunday, August 9, 2009
34. •LV systolic function looks
depressed (subcostal long axis
view)
RV •Reduce SV by reducing diastolic
time / by absence of atrial kick).
•In this patient with acute onset
of FA and subsequent
hypotension .
LV
Loss of atrial kick sign?
Sunday, August 9, 2009
35. •LV systolic function looks
depressed (subcostal long axis
view)
RV •Reduce SV by reducing diastolic
time / by absence of atrial kick).
•In this patient with acute onset
of FA and subsequent
hypotension .
LV •After prompt cardioversion,
sinus rhythm is restored and LV
systolic function looks now much
better
Loss of atrial kick sign?
Sunday, August 9, 2009
37. Loss of atrial kick
What does it cause?
Sunday, August 9, 2009
38. Blood don’t go into
Loss of atrial kick
atrium
What does it cause?
Sunday, August 9, 2009
39. Blood don’t go into
Loss of atrial kick It reflux into neck vein
atrium
What does it cause?
Sunday, August 9, 2009
40. • Patient was administered Digoxin IV
• After not improving the clinical patient was
administered Diltiazem IV
• Patient has less lightheadesness but still
have chest tightness
• Heart rate was slower from 170 to 130/
min but BP still 200/100
Sunday, August 9, 2009
42. • Patient was treated with Nicardipine IV
• He feel less lightheadeness still chest
discomfort
• Old ECG show no atrial fibrillation
Sunday, August 9, 2009
44. Take home message
• Remember for the unstable signs in limited
time Heart failure, poor perfusion
• How fast do you think the patient will
survive on this rhythm
• Pick the choice of treatment from that
Sunday, August 9, 2009
45. Case II
• BP=110/60 HR=130 RR=20 T=37.3
• Complaint of chest tightness,
Sunday, August 9, 2009
49. What would you do?
• Any reason to change rhythm?
• Dead now or later?
•
Sunday, August 9, 2009
50. Case III
• A man with acute dyspnea come in ER with
expiratory wheezing and sound of
secretion, profound sweating
• Switching Taxi driver to passenger
• RR=35 PR=130/min BP=220/110 T=37
StO2=70%
Sunday, August 9, 2009
51. What is your diagnosis?
Next Management?
Sunday, August 9, 2009
52. What will you do in
this patient?
• Physical examinaiton
• Further investigation?
• Further Management
Sunday, August 9, 2009
65. Take home message
• Don’t be afraid to use adjuncts in life
threatening patients
• This is 2009, ER is all about proove it and
treat it.
Sunday, August 9, 2009