Ten Leading Causes of Death in

world due to Severe illnesses

HEART DISEASE

MALIGNA NT NEOPLASM

CEREBROVASCULAR DISEASE

CHORIC LOWER RESP. DISEASE

ACCIDENTS

ALZHEIMER’S DISEASE

DIABETES MELLITUS

INFLUENZA AND PNEUMONIA

NEPHRITIS,NEPRITIC SYNDROME,NEPHROSIS

SEPTICEMIA

MALIGNA

NT

NEOPLASM

Cancer Patient according to

geographic

Cancer Patient

Cancer vs heart disease

Risk factor

Smoking Tobacco smoking is a strong, modifiable risk

factor for cardiovascular disease, pulmonary

disease, and cancer. Smokers have an

approximately 1 in 3 lifetime risk of dying

prematurely from a tobacco-related cancer or

cardiovascular or pulmonary disease. Tobacco

use causes more deaths from cardiovascular

disease than from cancer. Lung cancer and

cancers of the larynx, oropharynx, esophagus,

kidney, bladder, pancreas, and stomach are all

tobacco-related.

Diet Modification diets high in fat are associated with increased risk

for cancers of the breast, colon, prostate, and

endometrium. These cancers have their highest

incidence and mortalities in western cultures,

where fat comprises an average of one-third of

the total calories consumed

Suspected

Carcinogens

Screening

Recommendations

for Asymptomatic

Normal-Risk

Subjects

TUMOR MARKERS

TREATMENT

Staging and treatment planning Cancer stage is an assessment of the extent of

tumor spread and treatment is based on staging.

Most malignancies are staged by the tumor, lymph

node, and metastasis (TNM) system from stages I

to IV. The T classification is based on the size and

extent of local invasion. The N classification

describes the extent of lymph node involvement,

and the M classification is based on the presence or

absence of distant metastasis.

Staging and treatment planning Appropriate radiologic staging must be performed

before therapy, usually including computed tomographic(CT) imaging. Fluorodeoxyglucose-positron emission tomography (FDG-PET) adds to CT in select malignancies. Brain imaging with magnetic resonance imaging ([MRI] preferable) or CT with intravenous contrast should be considered in advanced melanoma and lung and kidney cancer. See tumor type discussion for further details.

Complete surgical staging provides more accurate extent of the disease than clinical staging and is possible only in patients with resectable disease when surgery is performed with an intent to cure.

Tumor grade is an assessment by the pathologist of the tumor's similarity to the cell of origin and the proliferation rate, usually low, moderate, or high grade.

Principles of radiation

Curative intent radiotherapy is used in several settings. Neoadjuvant: Preoperative therapy intended to reduce

both the extent of surgery and the risk of local relapse.

Adjuvant: Postoperative intended to reduce the risk of local relapse.

Definitive: High dose with curative intent, usually not followed by surgery.

Concurrent chemo radiation: Chemotherapy with definitive radiation significantly increases toxicity but increases efficacy in some settings.

Palliative radiotherapy

is used in lower dosing to

reduce symptoms, including

bony pain, obstruction

(esophageal, bronchial),

bleeding (GI, gynecologic,

bronchial, cutaneous), and

neurologic symptoms (brain

metastasis)

Principles of chemotherapy Traditional, cytotoxic chemotherapy targets all dividing

cells and has broad toxicities.

Chemotherapy is typically given in 2-, 3-, or 4-week “cycles.” In most regimens, intravenous treatment is given on the first day of the cycle, with no further treatment until the next cycle. In other regimens, treatments are weekly for 2 or 3 weeks, with 1 week off prior to the next cycle.

Curative intent chemotherapy includes neoadjuvant, adjuvant, and chemoradiation protocols in solid tumors. Chemotherapy alone is curative in many lymphomas, leukemias, and germ cell tumors (GST).

Palliative chemotherapy is used in advanced solid tumors and hematologic malignancies, with a focus on prolonging survival without overly affecting quality of life. Should only be used in patients with a good performance status.

Chemotherapy on various disease

Surgical Management Goals of therapy, cure versus palliation, must guide

any surgical intervention.

Surgical resection is often performed only when there

is a possibility of cure, though palliative surgery is

performed to relieve discomfort (mastectomy for local

control in a patient with metastatic disease) in some

malignancies.

Complete lymph node staging provides useful

information for postoperative treatment planning

(adjuvant therapy).

Surgical resection of isolated metastatic sites in

select patients can improve survival. Examples

include solitary brain metastases, pulmonary

metastases from colorectal cancer or sarcomas, and

liver metastases from colorectal cancer

Hormonal Therapy

Endocrine or hormonal therapy for cancer, the

earliest form of systemic therapy, is almost

entirely limited to breast cancer and prostate

cancer . Many premenopausal breast cancers

are thought to be under the influence of

estrogens, and hormonal deprivation

(ablation) may produce long-term responses

in properly selected patients (those with

estrogen and/or progesterone receptor

positivity who have predominantly soft tissue

or bone disease).

Aromatase Inhibitors

Patients who have experienced a prolonged

objective response or stable disease with

hormonal therapy may be candidates for

second, third-, or fourth-line hormonal

therapy.

Recently, aromatase inhibitors (e.g.,

anastrazole, letrozole, exemestane), which

decrease the conversion of metabolites in fat

and muscle into estrogen, have been found to

be more effective than tamoxifen as first-line

therapy in both the adjuvant and metastatic

settings

Corticosteroids

The corticosteroids, typically

prednisone or dexamethasone,

are widely used in the treatment

of hematologic and oncologic

cancers. In Hodgkin's disease ,

the non-Hodgkin's lymphomas ,

and multiple myeloma

,corticosteroids have antitumor

activity.

Immunotherapy

Two cancers that are

characterized by often

unpredictable clinical behavior,

melanoma and renal cell

carcinoma , are treated with

interferon or interleukin-2 or both

, Dramatic responses are

uncommon, and immunotherapy

is only a minor component of

cancer therapy.

Molecularly Targeted Agents

Targeted agents are drugs directed at a

specific molecular point, such as a protein

tyrosine kinase, or at the presence of a

specific antigen on a tumor cell. Tyrosine

kinase inhibitors include imatinib and

erlotinib. The current best example of the

success of tyrosine kinase inhibitor

therapy is the dramatic response of

chronic myelogenous leukemia (CML ) to

imatinib (Gleevec). Imatinib also has

activity against gastrointestinal stromal

cell tumors.

Bone Marrow/Stem Cell

Transplantation Because the major dose-limiting

toxicity of most chemotherapeutic

agents is myelosuppression,

approaches have been developed to

harvest the pluripotent stem cells

found in bone marrow, peripheral

blood, or, less often, cord blood before

marrow-damaging chemotherapy, so

that the stem cells can be reinfused

later . This technique is most effective

for acute leukemias , relapsed

lymphomas, and germ cell tumors.

CANCER OF UNKNOWN

PRIMARY ORIGIN

The first signs or symptoms of cancer are frequently the result of metastases to visceral or nodal sites. In most such patients, routine clinical evaluation with a comprehensive history, physical examination, complete blood cell count, screening chemistries, and directed radiologic evaluation of specific symptoms or signs identifies the primary tumor. Patients who have no primary tumor located after this routine clinical evaluation are defined as having cancer of unknown primary site. Further clinical and pathologic evaluation will identify the primary site in only a few patients, and approximately 80% will never have a primary site identified during their subsequent clinical course.

The initial clinical and pathologic evaluation

should focus on identifying a primary site

when possible and on identifying patients for

whom specific treatment is indicated. In most

patients with cancer of unknown primary site,

the diagnosis of advanced cancer is strongly

suspected after the initial history and physical

examination.

Biopsy

The diagnosis of metastatic cancer should be

confirmed by biopsy of the most accessible

metastatic lesion. Fine-needle aspiration may

or may not provide sufficient material for

optimal histologic examination and special

pathologic procedures. If tissue is inadequate,

a larger biopsy sample should be obtained so

all necessary stains and procedures can be

performed.

RECOMMENDED EVALUATION FOLLOWING INITIAL LIGHT MICROSCOPIC DIAGNOSIS

SPECIFIC

PATIENT

SUBSETS AND

RECOMMENDED

TREATMENT

Curability of Cancers with

Chemotherapy

A. Advanced Cancers With Possible

Cure

Acute lymphoid and acute myeloid

leukemia (pediatric/adult)

Hodgkin's disease (pediatric/adult)

Lymphomas—certain types

(pediatric/adult)

Germ cell neoplasms

Embryonal carcinoma

Teratocarcinoma

Seminoma or

. Advanced Cancers With Possible

Cure

Choriocarcinoma

Gestational trophoblastic neoplasia

Pediatric neoplasms

Wilms' tumor

Embryonal rhabdomyosarcoma

Ewing's sarcoma

Peripheral neuroepithelioma

Neuroblastoma

Small cell lung carcinoma

Ovarian carcinoma

Advanced Cancers Possibly Cured by Chemotherapy and Radiation Squamous carcinoma (head and neck)

Squamous carcinoma (anus)

Breast carcinoma

Carcinoma of the uterine cervix

Non-small cell lung carcinoma (stage III)

Small cell lung carcinoma

Cancers Possibly Cured With

Chemotherapy as Adjuvant to

Surgery

Breast carcinoma

Colorectal carcinomaa

Osteogenic sarcoma

Soft tissue sarcoma

Cancers Possibly Cured with

"High-Dose" Chemotherapy With

Stem Cell Support

Relapsed leukemias, lymphoid and myeloid

Relapsed lymphomas, Hodgkin's and non-

Hodgkin's

Chronic myeloid leukemia

Multiple myeloma

Cancers Responsive With Useful Palliation, But Not Cure, by

Chemotherapy

Bladder carcinoma

Chronic myeloid

leukemia

Hairy cell leukemia

Chronic lymphocytic

leukemia

Lymphoma—certain

types

Multiple myeloma

Gastric carcinoma

Cervix carcinoma

Endometrial

carcinoma

Soft tissue sarcoma

•Head and neck

cancer

•Adrenocortical

carcinoma

•Islet-cell

neoplasms

•Breast

carcinoma

•Colorectal

carcinoma

•Renal

carcinoma

Tumor Poorly Responsive in

Advanced Stages to

Chemotherapy

Pancreatic carcinoma

Biliary-tract neoplasms

Thyroid carcinoma

Carcinoma of the vulva

Non-small cell lung carcinoma

Prostate carcinoma

Melanoma

Hepatocellular carcinoma

Salivary gland cancer

SEPTICEMIA

Septic shock

OVERVIEW

• Septic shock is the most common cause of mortality

in the intensive care unit. It is the 10th leading cause

of death overall.

• Despite aggressive treatment mortality ranges from

15% in patients with sepsis to 40-60% in patients

with septic shock.

Reference Diseases

Incidence in US (cases per 100,000)

AIDS1 17

Colon and rectal cancer2 48

Breast cancer2 112

Congestive heart failure3 ~196

Severe sepsis4 ~300

Number of deaths in US each year

Acute myocardial infarction5 218,000

Severe sepsis4 215,000

1Centers for Disease Control and Prevention. 2000. Incidence rate for 1999. 2American Cancer Society. 2001. Incidence rate for 1993-1997.4Angus DC et al. 2001. Crit Care Med 29:1303-1310. 5National Center for Health Statistics. 2001.

SIRS

Sepis

Severe sepsis-SIRS

Septic shock

MODS

(Systemic Inflammatory Response Syndrome) is a systemic

inflammatory response to non specific insults

SIRS

SIRS is either due to Infection or others (major

burn-major traume-pancreatitis –hypovolemic shock)

Clinically?!

1. hyperthermia >38°C or hypothermia <36°C

2. • tachycardia >90 bpm

3. • tachypnoea >20 r.p.m. or PaCO2 <4.3 kPa

4. • neutrophilia >12 × 10–9 l–1 or neutropenia <4

000

Clinically?!

• Known or suspected infection,

plus

• >2 SIRS Criteria.

Sepis

•The systemic inflammatory response to infection.

Severe sepsis-SIRS

•Severe sepsis resulting in at least one organ

failure

Clinically?!

•Sepsis plus >1 organ dysfunction.

Septic shock

•Sepsis induced shock with hypotension

despite adequate resuscitation along with the

presence of perfusion abnormalities which may

include, but are not limited to lactic acidosis,

oliguria, or an acute alteration in mental status.

MODS

(multiple organ dysfunction syndrome) The presence of

altered organ function in an acutely ill patient such that

homeostasis cannot be maintained without intervention.

SIRSsystemic

inflammatory

response

syndrome

SEPSISSIRS with a presumed or confirmed

infectious process

•Severe sepsisSepsis with ≥1 sign of organ failure

Septic shockSIRS + Infection + Organ

Failure + Refractory

Hypotension

Caustive organisms

• Gram –ve the commonest

• Staphylococcus

• Candida

Sources of infection

• Endogenus source

1. Causes ofPeritonitis

2. Perforated viscous

3. Gangrenous bowel

4. Genitourinary infection

• Exogenus source

Infected CVP

Predisposing factors

• Old age

• DM

• Corticosteroid therpy

• Malignancy

• Major operation

It is not precisely understood, but it involves a complex interaction

between the pathogen and the host's immune system.

Physiological response to localized infection:o Influx of activated PMN leukocytes & monocytes release of inflammatory

mediators

o Local vasodilatation & increased endothelial permeability

o Activation of the coagulation cascade.

The same occurs in septic shock but at a systemic level. Diffuse endothelial disruption

Increased vascular permeability

Vasodilatation

Thrombosis of end organ capillaries

Infection

Inflammatory

Mediators

Endothelial

DysfunctionVasodilation

Hypotension Vasoconstriction Edema

Maldistribution of Microvascular Blood Flow

Organ Dysfunction

Microvascular Plugging

Ischemia

Cell Death

Inadequate

Resuscitation

Preoperative Illness

Trauma or

Operation

Tissue Injury

optimal oxygen

delivery and

support

Recovery

Excessive

Inflammatory

Response

SIRS/MODS

Pathogenesis of SIRS/MODS in

surgical patients

Lungs

Kidneys

CVS

CNS

PNS

Coagulation

GI

Liver

Endocrine

Skeletal Muscle

Adult Respiratory Distress Syndrome18%

Acute Tubular Necrosis 50%

Shock

Metabolic encephalopathy

Critical Illness Polyneuropathy

Disseminated Intravascular Coagulopathy

38%

Gastroparesis and ileus

Cholestasis

Adrenal insufficiency

Rhabdomyolysis

Acute Organ Dysfunction

Identifying Acute Organ Dysfunction

as a Marker of Severe Sepsis

Tachycardia

Hypotensio

n

CVP

PAOP

Jaundice

Enzymes

Albumin

PT

Altered

Consciousness

Confusion

Psychosis

Tachypnea

PaO2 <70 mm

Hg

SaO2 <90%

PaO2/FiO2 300

Oliguria

Anuria

Creatinine

Platelets

PT/APTT

Protein C

D-dimer

• You must suspect sepsis in patient with predisposing

factors,dont wait for septic shock

• The diagnosis of sepsis requires the taking of an

EXCELLENT history, physical examination,

appropriate laboratory tests, and a close follow-up

of hemodynamic status

• Early recognition is live saving in such rapid

overwhelming situation

Hyperdynamic- Warm- Early

Septic Shock

Restlness & confusion

Vitals

1. Temperature fever

more than 38 chills

2. Mild decrease ABP

3. Tachycardia

4. Tachypnea

Skin warm ,dry ,flushed

High cardiac output

Hypodynamic- Cold- Late Septic Shock

Semicomatosed

Vitals

1. Temperature

decreased

2. Tachycardia

3. Tachypnea

4. SBP<90mmHg

Oliguria & low COP

Multiorgan failure start at

this stage

Work-up… Laboratory studies

o CBC

o Coagulation studies

o Blood & urine cultures

Imaging studies

o Chest radiography

o Abdominal radiography

o Others according to the suspected cause.

• Glucose control is important in the management of sepsis,

with hyperglycemia associated with higher mortality

• LFTs and bilirubin, alkaline phosphatase, and lipase

levels are important in evaluating multiorgan

dysfunction or a potential source (eg, biliary disease, pancreatitis, hepatitis).

• Serum lactate …It is the best serum marker for tissue perfusion.

Lactate levels >2.5 mmol/L are associated with an increase in mortality.

Septic Shock &

MODSSeptic

• Control Infection Source

Shock

• Optimize Organ Perfusion

(Resuscitation)

MODS

• Support Dysfunctional Systems & Monitoring

Shock

• Optimize Organ Perfusion

(Resuscitation)

1)Circulatory supportI. Fluid replacment to achieve cvp 10-12

cm H2oII. Packed RBCS if low HCTIII. Drugs Inotropes & vassopressor

2)Respiratory support3)Renal support haemodyalisis in ARF

4)TTT of DIC fresh frozen plazma

EGDT is a 3-step protocol

aimed at optimizing tissue

perfusion

Septic• Control Infection Source

Eliminate surgical causes?!

Huge abscess

Peritonitis

gangernous bowel

Antibiotic therapyParentral ,compined ,broad spetrum.

• Antibiotics should be administered within the first hour of

recognition of septic shock, and delays in antibiotic

administration have been associated with increased

mortality.

• Selection of particular antibiotic agents is empirically based

on an assessment of the patient's underlying host defenses,

the potential source of infection, and

the most likely responsible organisms.

• One regimen for septic shock of unknown cause is

ogentamicin or tobramycin 5.1 mg/kg IV

once/day

o3rd generation cephalosporin “cefotaxime 2 g q

6 to 8 h or ceftriaxone 2 g once/day”oor if pseudomonas is suspected ceftazidime 2

g IV q 8 h”

•Renal replacement therapies (dialysis).

•Cardiovascular support (pressors, inotropes).

•Mechanical ventilation.

•Blood Transfusion for hematologic dysfunction.

MODS

• Support Dysfunctional Systems & Monitoring

Recent guidline is that steroids should be administered only in

patients with septic shock whose hypotension is poorly

responsive to fluid resuscitation and vasopressor therapy.

NEVER resuscitate with glucose 5%

Sudden Cardiac

DeathRisk factors & Managements

Risk Factors for SCD Old aged

Male

Has PMHx of Coronory Artery Diseases

High total cholesterol level

Arterial hypertonia (Hypertrophy of Left Ventricle)

Diet factors

Has active physical lifestyle

Smoking

Tachycardia / Variable heart rhythm

Prolonged Q-T segment

Stages of SCD

Prodromal

Period

Acute Cardiac

Symptoms

Disturbances in

blood circulation

Biological

Death

Evidence of clinical death

Main Features

• Asystolic

• Absent of pulsation at major vessels

(Carotid artery)

Additional Features

• Dilated pupils

• Areflexia ( Absent Corneal Reflex and

Pupil reflex towards light )

• Skin paleness (pallor)

SCD Management1. Primary evaluation of patient’s condition

2. Basic Life Support (CPR)

3. Advanced measures to maintain life

support &

full resuscitation of patient

4. Treatment during post- resuscitation

period

5. Long- term treatment

Criteria of adequate

CPR 1. Returning of pulse on major

vessels, synchronous with

compression

on chest.

2. Present of pupil reflex

3. Pink condition of patient

Algorithm of management of

ventricular tachycardia

1. 3 - multiple defibrillator (200 J, 300 J, 360 J)

(if not effective)

2. Continue resuscitation method, tracheal

intubation, prepare lines for IV

(If not effective)

3. Introduce Adrenaline IV 1 mg bolus

(if not effective)

4. Second defibrillator (360 J)

(if not effective)

5. Antiarrhythmic Drugs

Amiodarone ( 300mg IV)

Lidocaine (2.0 -1.5 mg/kg IV)

Magnesium Sulfate (1.0-2.0 g IV)

Antiarrhythmic Drugs

1. It is to stabilize patient’s condition

2. If patient’s condition is still unstable,

continue with defibrillator

3. All Anti-arrhythmic drugs have pro-

arrhythmic effects.

4. Do not use more than 1 anti-

arrhythmic drug

Atropine in Sudden Cardiac

Death

Indications

1. Asystolic

2. Heart arrest or bradyarrythmia

1st bolus dose 0.6 - 1.0 mg

If atropine is not effective, change to

adrenaline or euphiline.

Alzheimer’s Disease

What is Alzheimer’s Disease

(AD)?

Of all the diseases to be diagnosed with, Alzheimer’s strikes the most fear into people’s hearts.

It is progressive and debilitating.

It will rob you of: The ability to communicate

Think clearly

Function

Awareness of yourself and environment

All controls including the ability to dress yourself, eat or keep up on personal hygiene.

Memories of your family and loved ones.

Will eventually lead to death.

60-80% cases of dementia fall under

Alzheimer’s Disease In AD Patients:

The areas that control memory &

thinking are affected first.

Plaques form when protein pieces

called beta-amyloid clump together.

These are dense and mostly insoluble.

Neurofibrillary tangles are aggregates

of the protein tau which has

accumulated inside the cells.

Where tangles form the transport

system falls apart and disintegrates.

Nutrients and essential supplies

can’t move through cells and they

die.

This process spreads throughout the

brain.

Deficient in an important

neurotransmitter, acetylcholine, which

is involved in memory function and

may help to preserve nerve cell

Clusters of plaques and dying

nerve cells in a person with AD

Healthy Brain (L) AD Brain (R)

The bottom image shows the two brains together to see the difference in size.

Diagnosing AD

Diagnosis is not a simple process and includes:

Brain Scans

Cognitive Assessments

Laboratory Tests

On average, patients with AD live 7-10 years after

initial diagnosis.

The disease can last as long as 20 years.

4.5 million Americans have

AD.

Affects women more than

men:

2/3 of those diagnosed are women.

Signs & Symptoms

Depression can be a symptom and may begin

occurring up to 3 years prior to diagnosis of AD.

Most people put this off as not a big deal when it

could mean a great difference in outcome if

examined.

Memory Loss

Behavioral Issues not normal to the patient.

Confusion about time and place.

Trouble finding appropriate words or loss of

speech.

Poor judgment.

Changes in mood and personality, such as

suspicion.

Types of Alzheimer’s

Early Onset Alzheimer’s

Diagnosed before the age of 65.

Rare

Late Onset Alzheimer’s

Occurs after the age of 65.

Most common

Familial Alzheimer’s

Entirely inherited

Extremely rare

Cures There are no known cures for Alzheimer’s.

There are many studies underway with some promising results in slowing the disease down. Memantine has shown encouraging results among

those in advanced stages of AD.

Melatonin has also shown some promise but needs further study.

Antioxidants are extremely important.

Exercise for the body & brain at any stage.

A blue dye, methylene blue (MTC), slowed progression by 81%. It causes tau filaments to dissolve.

Prevention The general consensus is that prevention is the

key in dealing with AD. Exercise regularly both body and mind.

Maintain a normal healthy body weight.

Enjoy leisure activities.

Stay connected and social.

Practice stress reduction techniques.

Consume a diet rich in antioxidants.

Avoid trans fat and saturated fat.

Eat a diet that is 75% raw.

Avoid toxins as much as possible in your food and environment.

CEREBROVASCULAR

DISORDERS

CEREBROVASCULAR

DISORDERS

refers to any functional

abnormality of the central

nervous system that occurs

when the normal blood supply

to the brain is disrupted.

STROKE

a sudden neurological

event which results in

the new onset of

neurological

symptoms.

TYPES

ofSTRO

KE

ISCHE

MIC

STROK

E

“BRAIN

MOTOR LOSS-disturbance of voluntary

motor control on the side of

the body opposite the location

of the stroke lesion

•Hemiplegia

•Hemiparesis

COMMUNICATION LOSS

•Dysarthria

•Apraxia

•Agnosia

•Dysphasia or Aphasia

PERCEPTUAL DISTURBANCES

•Homonymous Hemianopsia

•Disturbance in Visual-Spatial Relations

- Unilateral Neglect

•Loss of Peripheral Vision

•Night Blindness

•Diplopia

•Horner’s Syndrome

SENSORY LOSS

•Slight Impairment of Touch

•Loss of Proprioception

•Difficulty in interpreting visual,

tactile, and auditory stimuli

COGNITIVE IMPAIRMENT &

PSYCHOLOGICAL EFFECTS

Memory Loss

Poor Comprehension

Limited Attention Span

Forgetfulness

Lack of Motivation

Depression

Emotional Lability

Hostility

Frustration

Resentment

Lack of Cooperation

ASSESSMENT &

DIAGNOSTICS

•Patient History

•Complete Physical and Neurologic Examination

•Initial Assessment: Airway Patency,

Cardiovascular Status, Gross Neurologic Losses

•Stroke Time Course Classification

STROKE TIME COURSE

CLASSIFICATION

Stage 1: Transient Ischemic Attack

Stage 2: Reversible Ischemic Neurologic Deficits

Stage 3: Stroke in Evolution

Stage 4: Completed Stroke

DIAGNOSTIC TESTS•CT Scan

•12-Lead ECG

•Carotid ultrasound

•Cerebral Angiography

•Transcranial Doppler Flow Studies

•Transthoracic or Transesophageal Echocardiography

•MRI of the brain and/or neck

•Xenon CT

•Single Photon Emission CT

MEDICAL MANAGEMENT

1. Treatment of TIA from atrial fibrillation or

suspected embolic or thrombotic causes

2. Thrombolytic Therapy for Ischemic Stroke

3. Therapy for Patients with Ischemic Stroke

NOT Receiving Thrombolytic Therapy

4. Managing Potential Complications

NURSING MANAGEMENT

•Improving Mobility and Preventing Joint Deformities

•Managing Sensory-Perceptual Difficulties

•Attaining Bowel and Bladder Control

•Improving Thought Processes

•Improving Communication

•Maintaining Skin Integrity

•Improving Family Coping

•Helping the Patient Cope with Sexual Dysfunction

SURGICAL MANAGEMENT

CAROTID ENDARTERECTOMY

- Main surgical procedure for the management of

TIAs and small stroke

- Indicated for patients with symptoms of TIA or

mild stroke found to be due to carotid stenosis

- Complications: stroke, cranial nerve injuries,

infection, hematoma at the incision site, carotid

artery disruption

HEMMORH

AGIC

STROKE

CEREBRAL

ANEURYSM

SUBARACHNOID

HEMORRHAGE

Elements of

Communicating

Bad News the P-

SPIKES

Approach

Acronym Steps Aim of the Interaction

PPreparation Mentally prepare for the interaction with the

patient and/or family.

S Setting of the interaction Ensure the appropriate setting for a serious

and potentially emotionally charged discussion.

P Patient's perception and

preparation

Begin the discussion by establishing the

baseline and whether the patient and family

can grasp the information.

Ease tension by having the patient and family

contribute.

I Invitation and information

needs

Discover what information needs the patient

and/or family have and what limits they want

regarding the bad information.

K Knowledge of the condition Provide the bad news or other information to

the patient and/or family sensitively.

E Empathy and exploration Identify the cause of the emotions—e.g., poor

prognosis.

Empathize with the patient and/or family's

feelings.

Explore by asking open-ended questions.

S Summary and planning Delineate for the patient and the family the next

steps, including additional tests or

Common Physical and

Psychological Symptoms of

Terminally Ill Patients

Palliative Care

What is Palliative Care?

Medical care that focuses on alleviating the

intensity of symptoms of disease.

Palliative care focuses on reducing the

prominence and severity of symptoms.

What is Palliative Care?

The World Health Organization describes

palliative care as "an approach that improves the

quality of life of patients and their families facing

the problems associated with life-threatening

illness, through the prevention and relief of

suffering by means of early identification and

impeccable assessment and treatment of pain

and other problems, physical, psychosocial and

spiritual."

WHO Definition of Palliative Care

Palliative care:

provides relief from pain and other distressing

symptoms;

affirms life and regards dying as a normal

process;

intends neither to hasten or postpone death;

integrates the psychological and spiritual aspects

of patient care;

offers a support system to help patients live as

actively as possible until death;

offers a support system to help the family cope during the patients illness and in their own bereavement;

uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;

will enhance quality of life, and may also positively influence the course of illness;

is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

WHO Definition of Palliative Care

(cont.)

What is the goal of Palliative

Care?

The goal is to improve the quality of life for

individuals who are suffering from severe

diseases.

Palliative care offers a diverse array of assistance

and care to the patient.

The History of Palliative Care

Started as a hospice movement in the 19th

century, religious orders created hospices that

provided care for the sick and dying in London

and Ireland.

In recent years, Palliative care has become a

large movement, affecting much of the

population.

Began as a volunteer-led movement in the United

states and has developed into a vital part of the

health care system.

Palliative vs. Hospice Care

Division made between these two terms in the

United States

Hospice is a “type” of palliative care for those who

are at the end of their lives.

Palliative vs. Hospice Care

Palliative care can be provided from the time of

diagnosis.

Palliative care can be given simultaneously with

curative treatment.

Both services have foundations in the same

philosophy of reducing the severity of the

symptoms of a sickness or old age.

Other countries do not make such a distinction

Who receives Palliative Care?

Individuals struggling with various diseases

Individuals with chronic diseases such as cancer,

cardiac disease, kidney failure, Alzheimer's,

HIV/AIDS,etc

Cancer and Palliative Care

It is generally estimated that roughly 7.2 to 7.5 million people worldwide die from cancer each year.

More than 70% of all cancer deaths occur in developing countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent.

More than 40% of all cancers can be prevented. Others can be detected early, treated and cured. Even with late-stage cancer, the suffering of patients can be relieved with good palliative care.

Palliative Care and Cancer Care

Palliative care is given throughout a patient’s

experience with cancer.

Care can begin at diagnosis and continue through

treatment, follow-up care, and the end of life.

Palliative Care and Cancer

"Everyone has a right to be treated, and die, with

dignity. The relief of pain - physical, emotional,

spiritual and social - is a human right," said Dr

Catherine Camus, WHO Assistant Director-

General for Noncommunicable Diseases and

Mental Health. "Palliative care is an urgent need

worldwide for people living with advanced stages

of cancer, particularly in developing countries,

where a high proportion of people with cancer are

diagnosed when treatment is no longer effective."

“Cancer Control: Knowledge Into

Action”

Excerpts from the WHO guide for Palliative Care:

“Palliative care is an urgent humanitarian need

worldwide

for people with cancer and other chronic fatal

diseases.

Palliative care is particularly needed in places where

a high proportion of patients present in advanced

stages

and there is little chance of cure.”

Who Provides Palliative Care? Usually provided by a team of individuals

Interdisciplinary group of professionals

Team includes experts in multiple fields: Doctors

Nurses

social workers

massage therapists

Pharmacists

Nutritionists

Patient

and

Family

VolunteersPhysicians

Spiritual

Counselors

Social Workers

Pharmacists

Home Health

Aides

Therapists

Nurses

Kübler-Ross model

The Kübler-Ross model,

or the five stages of grief,

is a series of emotional

stages experienced when

faced with impending

death or death of

someone.

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

No I am not

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Why me?

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

Bargaining

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

Make deals

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

Bargaining

Depression

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

Bargaining

Sense of lose

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

Bargaining

Depression

Acceptance

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

Bargaining

Depression

Make peace with death

KUBLER ROSS - REACTION TO

TERMINAL ILLNESS

Denial

Anger

Bargaining

Depression

Acceptance

Children grieving in divorce

Denial Children feel the need to believe that their

parents will get back together, or will change their

mind about the divorce. Example: “Mom and Dad

will stay together.”

AngerChildren feel the need to blame someone for

their sadness and loss. Example: “I hate Mom for

leaving us.”

Children grieving in divorce

Bargaining In this stage, children feel as if they have some

say in the situation if they bring a bargain to the

table. This helps them keep focused on the

positive that the situation might change, and less

focused on the negative, the sadness they’ll

experience after the divorce. Example: “If I do all

of my chores maybe Mom won’t leave Dad.”

Children grieving in divorce

DepressionThis involves the child experiencing sadness

when they know there is nothing else to be done,

and they realize they cannot stop the divorce.

The parents need to let the child experience this

process of grieving because if they do not, it only

shows their inability to cope with the situation.

Example: “I’m sorry that I cannot fix this situation

for you.” Acceptance

Children grieving in divorce

Acceptance This does not necessarily mean that the child will

be completely happy again. The acceptance is

just moving past the depression and starting to

accept the divorce. The sooner the parents start

to move on from the situation, the sooner the

children can begin to accept the reality of it

Approaches to Palliative Care

Not a “one size fits all approach”

Care is tailored to help the specific needs of the

patient

Since palliative care is utilized to help with various

diseases, the care provided must fit the

symptoms.

SUGGESTED QUESTIONS FOR THE CLINICAL

INTERVIEW WITH PATIENTS FACING THE END OF

LIFE

Tell me the story of your illness. [the

patient's perspective]

Tell me how you first found out about your

illness. [hearing bad news]

What is your understanding now about the

illness? [patient's understanding or

explanatory model]

What do you want to be told about your

illness? [shared decision making and

information preferences]

How has the illness affected you?

[patient's coping]

SUGGESTED QUESTIONS FOR THE

CLINICAL INTERVIEW WITH PATIENTS

FACING THE END OF LIFE

How has your family (or close friends) been affected? [family's coping] What have you discussed with them?

How have you been helped? [supports]

Have there been other tough times you have had to face? [previous coping]

Do you have a religious or spiritual practice or set of beliefs?

Have you been thinking about dying?[addressing death and dying] What kinds of thoughts have you had? What worries?

FEW NURSING

INTERVENTIONS Pain –

limit unnecessary painful procedures

sedation and giving pre-emptive analgesia prior to a

procedure (e.g., including sucrose for procedures in

neonates)

Address coincident depression, anxiety, sense of fear or

lack of control.

Consider guided imagery, relaxation, hypnosis,

art/pet/play therapy, acupuncture/acupressure,

biofeedback, massage, heat/cold, yoga, transcutaneous

electric nerve stimulation, distraction.

Dyspnoea or air hunger-

Suction secretions if present

positioning, comfortable loose clothing, fan to

provide cool, blowing air.

Limit volume of IV fluids, consider diuretics if fluid

overload/ pulmonary oedema present.

Behavioural strategies including breathing

exercises, guided imagery, relaxation, music

Management of Dyspnea

Fatigue –

Sleep hygiene

Gentle exercise

Address potentially contributing factors (e.g.,

anaemia, depression, side effects of medications)

Nausea/vomiting –

Consider dietary modifications (bland, soft, adjust

timing/ volume of foods or

feeds) Aromatherapy: peppermint, lavender;

acupuncture/

Constipation - Increase fibres in diet, encourage

fluids

Oral lesions/dysphagia –

Oral hygiene and appropriate liquid, solid and oral

medication formulation

(texture, taste, fluidity). Treat infections,

complications (mucositis, pharyngitis, dental

abscess, esophagitis).Orophayngeal motility

study and speech (feeding team) consultation

Anorexia–

Manage treatable lesions causing oral pain,

dysphagia, and anorexia.

Support caloric intake during phase of illness

when anorexia is reversible.

Acknowledge that anorexia is intrinsic to the

dying process and may not be reversible.

Prevent/treat coexisting constipation

Pruritus –

Moisturize skin, Try specialized anti-itch lotions,

Apply cold packs, Counter stimulation, distraction,

and relaxation.

Medications for Constipation

Diarrhoea –

Evaluate/treat if obstipation, Assess and treat

infection, Dietary modification.

Depression –

Psychotherapy, behavioural techniques

Anxiety –

Psychotherapy (individual and family),

behavioural techniques

Agitation/terminal restlessness –

Evaluate for organic or drug causes, Educate

family, Orient and reassure child; provide calm.

Medications for the Management of

Delirium

NURSING CARE

Answering the question

Helping the parents

Helping the dying child

Benefit another human being

irreversible cessation of neurologic function of the

brain

discuss the topic with family

Healthy child who dies unexpectedly, children

with cancer, chronic disease etc should be

considered for organ donation

ORGAN DONATION

PATIENTS' PERSPECTIVE ON

A “GOOD DEATH”

Control pain and other

symptoms

Avoid inappropriate

prolongation of dying when life

is no longer enjoyable

Relieve burden on the family

Achieve a sense of control

Strengthen relationships with

loved ones

Common

and

uncommo

n clinical

courses in

the last

days of

terminally

ill patients

GRIEF AND

BEREAVEMENT

Grief is the emotional response to

that loss.

Bereavement is the

acknowledgment of the objective

fact that one has experienced a

death.

BEREAVEMENT

The word 'bereavement' comes from the ancient

German for 'seize by violence'.

Today the word 'bereavement' is used to describe

the period of grief and mourning we go through after

someone close to us dies.

Bereavement is about trying to accept what

happened, learning to adjust to life without that

person

Ways to mournand

express the loss

Accepting the loss

Experiencing pain that comes with grief

Trying to adjustwithout that person

Finding new place to putemotional energy

STAGES OF BEREAVEMENT

The importance of mourning

Mourning allows to say goodbye.

Seeing the body, watching the burial, or scattering

the ashes is a way of affirming what has happened.

Sometimes we need to see evidence that a person

really has died before we can truly enter into the

grieving process.

COUNSELLING

DEFINITION

Counselling is a definitively structured

permissive relationship which allows the client to

gain an understanding of himself to a degree

which enables him to take new positive steps in

the light of his new orientation.

- ROGES

Characteristics

2 individual

Self

realization

Realistic goals

Attitude & action

Bereavement counselling

-to help people cope more effectively with the death of

their patient or a loved one. Specifically,

bereavement counselling can:

offer an understanding of the mourning process

explore areas that could potentially prevent you from

moving on

help resolve areas of conflict still remaining

help you to adjust to a new sense of self

address possible issues of depression or suicidal

thoughts

CONCLUSION

Knowledge about hospitalization,

terminally ill child and the nursing

management help nurses to provide the

adequate and quality care, to support

the family and child and to help her by

self satisfaction. Even though time heals

the wound, an adequate support

accelerates the process.

What does Palliative Care Provide to

the Patient?

Helps patients gain the strength and peace of

mind to carry on with daily life

Aid the ability to tolerate medical treatments

Helps patients to better understand their choices

for care

What Does Palliative Care

Provide for the Patient’s Family?

Helps families understand the choices available

for care

Improves everyday life of patient; reducing the

concern of loved ones

Allows for valuable

support system

Image courtesy of mdanderson.org

Approaches to Palliative Care

A palliative care team delivers many forms of help

to a patient suffering from a severe illness,

including :

Close communication with doctors

Expert management of pain and other symptoms

Help navigating the healthcare system

Guidance with difficult and complex treatment choices

Emotional and spiritual support for the patient and

their family

Palliative Care Is Effective Successful palliative care teams require

nurturing individuals who are willing to

collaborate with one another.

Researchers have studied the positive effects

palliative care has on patients. Recent studies

show that patients who receive palliative care

report improvement in:

Pain and other distressing symptoms, such as

nausea or shortness of breath

Communication with their doctors and family

members

Emotional and psychological state

Where to find Palliative Care?

In most cases, palliative care is provided in the

hospital.

The process begins when doctors refer

individuals to the palliative care team.

In the hospital, palliative care is provided by a

team of experts.

Settings for Palliative Care

Outpatient practice

Hospital Inpatient

Unit based

Consultation Team

Home care

Nursing Home

Hospice

Cost of Palliative Care

Most insurance plans cover all or part of the

palliative care treatment given in hospitals.

Medicare and Medicaid also typically cover

palliative care.

WPRO Palliative Care Systems