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These possible causes are remembered as the 6 Hs and the 6 Ts. See Hs and Ts
- Hypovolemia
- Hypoxia
- Hydrogen ions (Acidosis)
- Hyperkalemia or Hypokalemia
- Hypoglycemia
- Hypothermia
- Tablets or Toxins (Drug overdose)
- Cardiac Tamponade
- Tension pneumothorax
- Thrombosis (e.g., myocardial infarction, pulmonary embolism)
- Tachycardia
- Trauma (e.g., hypovolemia from blood loss)
This list is not fully comprehensive. Most notably, it does not include anaphylaxis. Pressure effects associated with artificial ventilation may also contribute to significant reduction in cardiac output, resulting in a clinical diagnosis of PEA.
The possible mechanisms by which the above conditions can cause pulseless in PEA or the same as those recognized as producing circulatory shock states. These are (1) impairment of cardiac filling, (2) impaired pumping effectiveness of the heart, (3) circulatory obstruction and (4) pathological vasodilation causing loss of vascular resistance and excess capacitance. More than one mechanism may be involved in any given case.
Pulseless electrical activity leads to a loss of cardiac output, and the blood supply to the brain is interrupted. As a result, PEA is usually noticed when a person loses consciousness and stops breathing spontaneously. This is confirmed by examining the airway for obstruction, observing the chest for respiratory movement, and feeling the pulse (usually at the carotid artery) for a period of 10 seconds.
In the human heart the sinoatrial node is located at the top of the right atrium. The sinoatrial node is the first area of the heart to depolarize and to generate the action potential that leads to depolarization of the rest of the myocardium. Sinoatrial depolarization and subsequent propagation of the electrical impulse suppress the action of the lower natural pacemakers of the heart, which have slower intrinsic rates.
The accelerated idioventricular rhythm occurs when depolarization rate of a normally suppressed focus increases to above that of the "higher order" focuses (the sinoatrial node and the atrioventricular node). This most commonly occurs in the setting of a sinus bradycardia.
Accelerated idioventricular rhythm is the most common reperfusion arrhythmia in humans. However, ventricular tachycardia and ventricular fibrillation remain the most important causes of sudden death following spontaneous restoration of antegrade flow. Prior to the modern practice of percutaneous coronary intervention for acute coronary syndrome, pharmacologic thrombolysis was more common and accelerated idioventricular rhythms were used as a sign of successful reperfusion. It is considered a benign arrhythmia that does not require intervention, though atrioventricular dyssynchrony can cause hemodynamic instability, which can be treated through overdrive pacing or atropine.
AIVR appears similar to ventricular tachycardia with wide QRS complexes (QRS >0.12s) and a regular rhythm. It can most easily be distinguished from VT in that the rate is less than 120 and usually less than 100 bpm. There may or may not be AV dissociation depending on whether it is due to ventricular escape or AV block.
Symptoms are typically precipitated ("triggered") by exercise-induced ventricular arrhythmias during periods of physical activity or acute emotional stress.
CPVT typically start manifesting during the first or second decade of life. The majority of events occur during childhood with more than 60% of affected individuals having their first episode of syncope or cardiac arrest by age 12-20.
Individuals with MVP are at higher risk of bacterial infection of the heart, called infective endocarditis. This risk is approximately three- to eightfold the risk of infective endocarditis in the general population. Until 2007, the American Heart Association recommended prescribing antibiotics before invasive procedures, including those in dental surgery. Thereafter, they concluded that "prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis."
Many organisms responsible for endocarditis are slow-growing and may not be easily identified on routine blood cultures (these fastidious organisms require special culture media to grow). These include the HACEK organisms, which are part of the normal oropharyngeal flora and are responsible for perhaps 5 to 10% of infective endocarditis affecting native valves. It is important when considering endocarditis to keep these organisms in mind.
Prior to the strict criteria for the diagnosis of mitral valve prolapse, as described above, the incidence of mitral valve prolapse in the general population varied greatly. Some studies estimated the incidence of mitral valve prolapse at 5 to 15 percent or even higher. One study suggested MVP in up to 35% of healthy teenagers.
Recent elucidation of mitral valve anatomy and the development of three-dimensional echocardiography have resulted in improved diagnostic criteria, and the true prevalence of MVP based on these criteria is estimated at 2-3%. As part of the Framingham Heart Study, for example, the prevalence of mitral valve prolapse in Framingham, MA was estimated at 2.4%. There was a near-even split between classic and nonclassic MVP, with no significant age or sex discrimination. MVP is observed in 7% of autopsies in the United States.
The pathophysiology of excited delirium has been unclear, but likely involves multiple factors. These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal cardiac arrhythmias.
Excited delirium occurs most commonly in males with a history of serious mental illness or acute or chronic drug abuse, particularly stimulant drugs such as cocaine and MDPV. Alcohol withdrawal or head trauma may also contribute to the condition.
A majority of fatal case involved men.
People with excited delirium commonly have acute drug intoxication, generally involving PCP, methylenedioxypyrovalerone (MDPV), cocaine, or methamphetamine. Other drugs that may contribute to death are antipsychotics.
Respiratory alkalosis is caused by hyperventilation, resulting in a loss of carbon dioxide. Compensatory mechanisms for this would include increased dissociation of the carbonic acid buffering intermediate into hydrogen ions, and the related excretion of bicarbonate, both of which lower blood pH. Hyperventilation-induced alkalosis can be seen in several deadly central nervous system diseases such as strokes or Rett syndrome.
Metabolic alkalosis can be caused by repeated vomiting, resulting in a loss of hydrochloric acid in the stomach contents. Severe dehydration, and the consumption of alkali are other causes. It can also be caused by administration of diuretics and endocrine disorders such as Cushing's syndrome. Compensatory mechanism for metabolic alkalosis involve slowed breathing by the lungs to increase serum carbon dioxide, a condition leaning toward respiratory acidosis. As respiratory acidosis often accompanies the compensation for metabolic alkalosis, and vice versa, a delicate balance is created between these two conditions.
Alkalosis is the result of a process reducing hydrogen ion concentration of arterial blood plasma (alkalemia). In contrast to acidemia (serum pH 7.35 or lower), alkalemia occurs when the serum pH is higher than normal (7.45 or higher). Alkalosis is usually divided into the categories of respiratory alkalosis and metabolic alkalosis or a combined respiratory/metabolic alkalosis.
The most comprehensive assessment so far has estimated RBD prevalence to be about 0.5% in individuals aged 15 to 100. It is far more common in males: most studies report that only about a tenth of sufferers are female. This may partially be due to a referral bias, as violent activity carried out by men is more likely to result in harm and injury and is more likely to be reported than injury to male bed partners by women, or it may reflect a true difference in prevalence as a result of genetic or androgenic factors. The mean age of onset is estimated to be about 60 years.
Various conditions are very similar to RBD in that sufferers exhibit excessive sleep movement and potentially violent behavior. Such disorders include sleepwalking and sleep terrors, which are associated with other stages of sleep, nocturnal seizures and obstructive sleep apnea which can induce arousals from REM sleep associated with complex behaviors. Because of the similarities between the conditions, polysomnography plays an important role in confirming RBD diagnosis.
It is now apparent that RBD appears in association with a variety of different conditions. Narcolepsy has been reported as a related disorder. Both RBD and narcolepsy involve dissociation of sleep states probably arising from a disruption of sleep control mechanisms. RBD has also been reported following cerebrovascular accident and neurinoma (tumor), indicating that damage to the brain stem area may precipitate RBD. RBD is usually chronic. However, it may be acute and sudden in onset if associated with drug treatment or withdrawal (particularly with alcohol withdrawal). 60% of RBD is idiopathic. This includes RBD that is found in association with conditions such as Parkinson's disease and dementia with Lewy bodies, where it is often seen to precede the onset of neurodegenerative disease. Monoamine oxidase inhibitors, tricyclic antidepressants, Selective serotonin reuptake inhibitors, and noradrenergic antagonists can induce or aggravate RBD symptoms and should be avoided in patients with RBD.
The causes of PTSD are: Natural or human disasters, war, serious accident, witness of violent death of others, violent attack, being the victim of sexual abuse, rape, torture, terrorism or hostage taking.
Predisposing factors
The predisposing factors are: Personality traits and Previous history of Psychiatric illness.
Adie's syndrome is not life-threatening or disabling. As such, there is no mortality rate relating to the condition; however, loss of deep tendon reflexes is permanent and may progress over time.
It most commonly affects younger women (2.6:1 female preponderance) and is unilateral in 80% of cases. Average age of onset is 32 years.
Hypoxemia (or hypoxaemia in British English) is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, often respiratory disorders, and can cause tissue hypoxia as the blood is not supplying enough oxygen to the body.
"Hypoxemia" refers to low oxygen in the blood, and the more general term "hypoxia" is an abnormally low oxygen content in any tissue or organ, or the body as a whole. Hypoxemia can cause hypoxia (hypoxemic hypoxia), but hypoxia can also occur via other mechanisms, such as anemia.
Hypoxemia is usually defined in terms of reduced partial pressure of oxygen (mm Hg) in arterial blood, but also in terms of reduced content of oxygen (ml oxygen per dl blood) or percentage saturation of hemoglobin (the oxygen binding protein within red blood cells) with oxygen, which is either found singly or in combination.
While there is general agreement that an arterial blood gas measurement which shows that the partial pressure of oxygen is lower than normal constitutes hypoxemia, there is less agreement concerning whether the oxygen content of blood is relevant in determining hypoxemia. This definition would include oxygen carried by hemoglobin. The oxygen content of blood is thus sometimes viewed as a measure of tissue delivery rather than hypoxemia.
Just as extreme hypoxia can be called anoxia, extreme hypoxemia can be called anoxemia.
Psychiatric consultation: Exploration of memories of the traumatic event, relief of associated symptoms and counseling.
Pain asymbolia, also called pain dissociation, is a condition in which pain is experienced without unpleasantness. This usually results from injury to the brain, lobotomy, cingulotomy or morphine analgesia. Preexisting lesions of the insula may abolish the aversive quality of painful stimuli while preserving the location and intensity aspects. Typically, patients report that they have pain but are not bothered by it; they recognize the sensation of pain but are mostly or completely immune to suffering from it.
Most people with PNES (75%) are women, with onset in the late teens to early twenties being typical.
Some studies have reported an elevated frequency of childhood abuse in people with PNES. However, others that have controlled for other demographic factors have failed to find a higher rate of reported childhood abuse than in a comparable groups with organic disease (usually epilepsy).
A number of studies have also reported a high incidence of abnormal personality traits or personality disorders in people with PNES such as borderline personality. However, again, when an appropriate control group is used, the incidence of such characteristics it not always higher in PNES than in similar illnesses arising due to organic disease (e.g., epilepsy).
Other risk factors for PNES include having a diagnosis of epilepsy, having recently had a head injury or recently undergone neurosurgery.
Symptomatic RBD is the more characteristically seen disorder. This category of RBD is strongly associated with neurodegenerative diseases. About 15% of Parkinson's patients also have RBD, 70% of multiple system atrophy patients also have RBD, and about 85% of Lewy body dementia patients also have RBD. Other reported neurological associations include Shy–Drager syndrome, olivopontocerebellar atrophy, multiple sclerosis, vascular encephalopathies, Tourette's syndrome, and Guillain–Barré syndrome. It is uncertain whether RBD precedes these neurodegenerative disorders, whether they coincide, or whether it follows these disorders. However, Mayo Clinic researchers have characterized RBD as the strongest predictor of whether a male patient is developing Lewy body dementia.
Causes of such breakdowns are varied. A 1996 study found that problems with intimate relationships, such as divorce or marital separation, contributed to 24% of nervous breakdowns. Problems at work and school accounted for 17% of cases, and financial problems for 11%. Surveys suggest that in the United States, health problems have decreased in importance as a contributor to nervous breakdowns. Health problems accounted for 28% of nervous breakdowns in 1957, 12% in 1976, and only 5.6% in 1996.
A nervous breakdown is very similar to a panic attack. Stress is a major cause in both cases and they are both temporary. During a nervous breakdown, a person's emotional state of being shifts from an ability to cope with life stresses to a state of being totally overwhelmed to a point that normal functioning is disrupted. Excessive worry, nervousness, fear, anxiety are symptomatic. These states of being are accompanied by a variety of uncomfortable feelings often summarized as bad or sad. If these feelings become so intense they are perceived as life-threatening, the defense system blocks awareness. These mechanisms while protective can also be limiting to successful living. Overwhelming stress, therefore, is causative. Whether that stress is self-created or external requires different approaches and has different implications to the individual.
A nervous breakdown is not limited to any one type of person: anyone can have this breakdown, but if someone is under a lot of stress and has a family background of mental disorders, they can be more likely to have one.
There are a number of recommended steps to explain to people their diagnosis in a sensitive and open manner. A negative diagnosis experience may cause frustration and could cause a person to reject any further attempts at treatment. Ten points recommended to explain the diagnosis to the person and their caregivers are:
1. Reasons for concluding they do not have epilepsy
2. What they do have (describe dissociation)
3. Emphasise they are not suspected of "putting on" the attacks
4. They are not 'mad'
5. Triggering "stresses" may not be immediately apparent.
6. Relevance of aetiological factors in their case
7. Maintaining factors
8. May improve after correct diagnosis
9. Caution that anticonvulsant drug withdrawal should be gradual
10. Describe psychological treatment
Psychotherapy is the most frequently used treatment, which might include cognitive behavioral therapy, insight-orientated therapy, and/or group work. There is some tentative evidence supporting selective serotonin reuptake inhibitor antidepressants.
Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level. Hypoxia may be classified as either "generalized", affecting the whole body, or "local", affecting a region of the body. Although hypoxia is often a pathological condition, variations in arterial oxygen concentrations can be part of the normal physiology, for example, during hypoventilation training or strenuous physical exercise.
Hypoxia differs from hypoxemia and anoxemia in that hypoxia refers to a state in which oxygen supply is insufficient, whereas hypoxemia and anoxemia refer specifically to states that have low or zero arterial oxygen supply. Hypoxia in which there is complete deprivation of oxygen supply is referred to as anoxia.
Generalized hypoxia occurs in healthy people when they ascend to high altitude, where it causes altitude sickness leading to potentially fatal complications: high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). Hypoxia also occurs in healthy individuals when breathing mixtures of gases with a low oxygen content, e.g. while diving underwater especially when using closed-circuit rebreather systems that control the amount of oxygen in the supplied air. Mild, non-damaging intermittent hypoxia is used intentionally during altitude training to develop an athletic performance adaptation at both the systemic and cellular level.
Hypoxia is also a serious consequence of preterm birth in the neonate. The main cause for this is that the lungs of the human fetus are among the last organs to develop during pregnancy. To assist the lungs to distribute oxygenated blood throughout the body, infants at risk of hypoxia are often placed inside an incubator capable of providing continuous positive airway pressure (also known as a humidicrib).