ANESTHESIA

I. ANESTHETIC EQUIPMENT & MONITORS

HISTORY OF ANESTHESIA

• Dioscorides – used the term anesthesia

• Oliver Wendell Holmes – 1846 – termed anaesthesiology

• William T. G. Morton (The father of modern anaesthesia) – October 16, 1846 (World Ether day)

demonstrated general anesthetic effects of ether.

• Carl Koller-1884- introduced cocaine as an ophthalmic anesthetic

• Niemann-1860- introduced cocaine as a local anesthetic

• Joseph Priestley – produced Nitrous oxide- 1772

• Horace Walls: demonstrated use of Nitrous oxide for tooth extraction-1844

• On December 21, 1846, Robert Liston performed first surgical operation under ether anesthesia

• W. E. Clarke in 1841 administered anesthesia for a dental extraction [not made widely noted]

• August Bier- 1898-first spinal anesthesia/ father of spinal anesthesia

• Simpson: first to use chloroform

• John Lundy first used IV anesthetic thiopentone -1934

• Ferdinand Cathelin – 1901 – caudal epidural anesthesia

• Fidel Pages – 1921 – Lumbar epidural anesthesia

• Alexander Wood-1855 – invented needle & syringe

• Harold Griffith- 1942 – used curare

• Lofgren-1943- introduced Lidocaine

• John Lundy & Ralph waters: coined 'balanced anesthesia'

• Ketamine: first used by Domino & Corsen

• Succinyl choline: synthesized by Bovet

• First Boyle's machine: Edmund Gaske Boyle in 1917

• First endotracheal intubation: Ivan Magill

• First nasal intubation: Stanlers Rowbothon

Preoperative Physical Status Classification of Patients According to the American Society of

Anesthesiologists

Class Definition

P1 A normal healthy patient

P2 A patient with mild systemic disease (no functional limitations)

P3 A patient with severe systemic disease (some functional limitations)

P4 A patient with severe systemic disease that is a constant threat to life (functionality incapacitated)

P5 A moribund patient who is not expected to survive without the operation

P6 A brain-dead patient whose organs are being removed for donor purposes

E If the procedure is an emergency, the physical status is followed by "E" (for example "2E")

American Society of Anesthesiologists Physical Status Classification

ASA 1 Healthy patient without organic, biochemical, or psychiatric disease

ASA 2 A patient with mild systemic disease, e.g., mild asthma or well-controlled hypertension. No

significant impact on daily activity. Unlikely to have an impact on anesthesia and surgery

ASA 3 Significant or severe systemic disease that limits normal activity, e.g., renal failure on dialysis

or class 2 congestive heart failure. Significant impact on daily activity. Probable impact on

anesthesia and surgery

ASA 4 Severe disease that is a constant threat to life or requires intensive therapy, e.g., acute

myocardial infarction, respiratory failure requiring mechanical ventilation. Serious limitation

of daily activity. Major impact on anesthesia and surgery

ASA 5 Moribund patient who is equally likely to die in the next 24 hours with or without surgery

ASA 6 Brain-dead organ donor

THE ANESTHESIA MACHINE

PNEUMATIC SYSTEM

High pressure system Intermediate pressure system Low pressure system

• Receives gases from the

cylinder at high, variable

pressures and reduces to

lower, constant pressures

• Includes hanger yokes,

pressure indicators and

pressure regulators

• Receives gases from the pressure regulator or

the pipeline inlet to the anesthesia machine.

• Includes master switch, pipeline inlet

connections, pipeline pressure indicators, piping,

gas power outlet, O2 pressure failure devices, O2

flush, additional pressure regulator & flow

control valves

Consists of flow

meters

• The high pressure system is a cylinder, pressure regulator and yoke assembly.

• The intermediate pressure system is from yoke of assembly to flow control valve

• Low pressure system is downward from the flow control valve to common gas outlet

GAS SUPPLY

Pipeline inlets

• Oxygen, nitrous oxide, and often air are delivered to the operating room through a piping network

• The tubing is color coded and has diameter index safety system fitting that prevents incorrect hose

attachment.

Cylinder inlets

• Cylinders are attached to the machine via hanger-yoke with a pin index safety system to prevent errors.

• Cylinder pressure is usually measured by a Bourdon pressure gauge.

• A flexible tube within this gauge straightens when exposed to gas pressure, causing a gear mechanism to

move a needle pointer.

Flow Control Circuits

Pressure Regulators

• To reduce the cylinder gas pressure to 45-47 psig before it enters the flow valve.

• Oxygen is reduced to 20 psig and nitrous oxide is reduced to 38 psig.

Oxygen Supply Failure Protection Devices

• Safety devices sense oxygen pressure via a small "piloting pressure" line that may be derived from the gas

inlet or secondary regulator.

• Proportionately reduce the pressure of nitrous oxide and other gases except for air.

• They completely shut off nitrous oxide and other gas flow below a set minimum oxygen pressure (eg, 0.5

psig for nitrous oxide and 10 psig for other gases).

Flow Valves & Meters

• Gas lines proximal to flow valves are in the high-pressure circuit

• Gas lines between the flow valves and the common gas outlet are part of the low-pressure circuit

• To reduce the risk of providing a hypoxic gas mixture in case of leak, oxygen flowmeters are always

positioned downstream to all other flowmeters (nearest to the vaporizer).

Minimum Oxygen Flow

• The oxygen flow valves deliver a minimum flow of 150 mL/min.

• Some machines are designed to deliver minimum flow or low-flow anesthesia (< 1 L/min) and have minimum

oxygen flows as low as of 50 mL/min (eg, Datex-Ohmeda Aestiva/5)

Oxygen/Nitrous Oxide Ratio Controller

• Ensure a minimum oxygen concentration of 21-25%.

• Does not affect the flow of a third gas (eg, air, helium, or carbon dioxide).

Oxygen Analyzers

• GA should never be administered without an oxygen analyzer in the breathing circuit.

• Three types are available: polarographic (Clark electrode), galvanic (fuel cell), and paramagnetic.

DELIVERY OF MEDICAL GASES

PIN INDEX SAFETY SYSTEM [PISS]

• Inter link between the anesthesia machine and gas cylinder.

• In high pressure system [valve outlets of cylinders]

• High pressure (H) cylinders are made of Molybdenum Steel.

• Chromium is added to decrease the weight of cylinders.

• Aluminium cylinders are MRI compatible

• Gas pipes are made of seamless copper tubing

Gases Entonox Air CO2 > 7.5% Oxygen CO2 < 7.5% N2O Cyclopropane

Pin index Single central hole 1,5 1,6 2,5 2,6 3,5 3,6

Causes of failure of PISS:

• D/t multiple washers placed between the cylinder and yoke, which prevents proper engagement of the pins

and holes.

• Also ineffective if yoke pins are damaged or the cylinder is filled with the wrong gas.

DIAMETER INDEX SAFETY SYSTEM [DISS]

• In low pressure system & in outlets of central piping systems.

COLOUR CODING SYSTEM

Cylinder Colour

N2O Blue (Liquid form)

Cyclopropane Orange

Oxygen Black body with white shoulder (International code), Green (USA

code)

Thiopentone Yellow

CO2 Grey

Entonox (O2 & N2O in equal

volumes)

Blue body with blue and white shoulder

Halothane Amber (Purple- Red)

Air Grey body with Black & white shoulder

N2 Black

Helium Brown

OXYGEN DELIVERY SYSTEMS

Fixed performance masks

• Patient receives a constant inspired oxygen concentration (FiO2) despite any changes in minute

• Ventilation.

• These include:

o Closed or semi-closed anaesthetic breathing systems with a reservoir bag, attached to

o anaesthetic machine with pressurised gas supply.

o Head boxes for neonates

o High Air Flow Oxygen Enrichment (HAFOE) Devices e.g. Venturi mask, delivers an inspired

o oxygen concentration between 24% and 40%.

• Venturi Mask

o High flow delivery system

o Flow rate b/w 4 - 12 L/min

o FiO2 can be set specifically with different flow rate and air ports

o FiO2 can be 24, 28, 31, 35, and 40%

o COPD patient that requires specific oxygen concentrations to administer high FiO2

but not

o too high such that the hypoxic drive to breath is blunted; titrate to keep saturation about 88%.

Variable performance masks/devices

• The oxygen concentration delivered depends on patient minute ventilation, peak inspiratory flow rate and

oxygen flow rate.

• Examples:

o Nasal Prongs:

� Low flow delivery system, > 6 L/min cause nasal mucosal drying

� Flow rate: 1 - 6 L/min

� FiO2 starts at 24% for 1L/min and increases 4% for each L/min up to 44% for 6 Lmin

� Well tolerated

� Use: minimal or no respiratory distress or oxygenation problem

o Nasal cannula:

� These do not increase dead space.

� Deliver 100% oxygen, but because the patient also breathes room air, the oxygen

� concentration ultimately delivered to the alveoli ranges from 24% to 44%.

� Inspiratory oxygen concentration depends on the flow rate

� No rebreathing occurs.

o Nasal catheters, 8FG

� Can be inserted into the nose as far as the pharynx

� A gas flow of 150m1/kg/min gives an inspired oxygen concentration of 50% in

� children less than 2 years

� No rebreathing occurs.

o Simple (Hudson) Face Mask (Rebreather)

� Have a small dead space.

� There is usually a small amount of rebreathing.

� Low flow delivery system

� Flow rate b/w 5 - 8 L/min

� FiO2: 5 - 6 is 40%, 6 - 7 is 50%, 7 - 8 is 60%

� Mask doesn't need tight seal

� Use: as per nasal prongs but require higher concentrations

BREATHING SYSTEMS

Insufflation

• Blowing of anesthetic gases across a patient's face.

• Avoids direct connection between a breathing circuit and a patient's airway.

• Valuable during pediatric inductions with inhalation anesthetics.

• There is no rebreathing of exhaled gases if the flow is high enough.

• Disadvantage: Ventilation cannot be controlled.

Open-Drop Anesthesia

• A highly volatile anesthetic—most commonly ether or halothane—is dripped onto a gauze-covered mask

(Schimmelbusch mask) applied to the patient's face.

• The vaporization lowers mask temperature, resulting in moisture condensation and a drop in anesthetic

vapor pressure

• May be used in locations or situations in which compressed medical gases are unavailable

Draw-Over Anesthesia

• In its most basic application, air is drawn through a low-resistance vaporizer as the patient inspires.

• Patients spontaneously breathing room air and a volatile, halogenated agent (nitrous oxide is never used

with draw-over devices) often manifest an oxygen saturation (Sp02) < 90%

• The devices can be fitted with connections and equipment that allow intermittent positive-pressure

ventilation (IPPV) and passive scavenging, as well as continuous positive airway pressure (CPAP) and positive

end-expiratory pressure (PEEP).

Properties of Draw-Over Devices

• Portable

• Robust

• Low resistance to gas flow

• Usable with any agent

• Controllable vapor output

Semi Closed Breathing System

Mapleson System

Mapleson A / Magill system

Modified variant: LACK system

• Efficient for spontaneous ventilation because fresh gas flow

equal to minute volume is sufficient to prevent rebreathing

• Most popular & widely used.

• Poor choice during controlled ventilation.

• Enclosed Magill system is a modification that improves

efficiency.

• Coaxial Mapleson A (Lack breathing system) provides waste-gas

scavenging.

• Flow rate : about 5 L/min

Mapleson C system/ Water's system Post operative recovery

Mapleson D system Most efficient for controlled ventilation, since fresh gas flow forces air

away from patient and towards pressure relief valve.

Mapleson E system/Ayre's T piece

system

Primarily used in infants & young children. Main advantage of T piece is

absence of resistance to expiration, a factor of crucial importance to

children

Mapleson's F system/ Jackson- Rees

modification of Ayre's T piece.

Popular in pediatric anesthesia, requires 2-3 times minute ventilation.

Efficiency of system with spontaneous respiration: A>D&E>C>B

Efficiency of system with IPPV : D&E> B > C > A

Mapleson B & C are more efficient than Mapleson A during IPPV

Most commonly used version of Mapleson-D: Bain Coaxial system

Mapleson

Class

Other Names Required Fresh Gas Flows

Spontaneous Controlled

A Magill attachment Equal to minute ventilation (80

mL/kg/min)

Very high and difficult to predict

B 2 x minute ventilation 2-21/2

x minute ventilation

C Waters' to-and-fro 2 x minute ventilation 2-21/2

x minute ventilation

D Bain circuit 2-3 x minute ventilation 1-2 x minute ventilation

E Ayre's T-piece 2-3 x minute ventilation 3 x minute ventilation (I:E =1:2)

F Jackson-Rees'

modification

2-3 x minute ventilation 2 x minute ventilation

Fresh Gas Flow = 1.5 times minute volume for controlled ventilation and 2.5 times of minute volume for

spontaneous ventilation

Characteristics of Breathing Circuits

Insufflation and Open Drop Mapleson Circle

Complexity Very simple Simple Complex

Control of anesthetic depth Poor Variable Good

Ability to scavenge Very poor Variable Good

Conservation of heat and humidity No No Yes

Rebreathing of exhaled gases No No Yes

Closed Breathing System/ Rebreathing system

• It is a circle system in which the CO2 is absorbed by soda lime and the exhaled gases can be reused.

• Eliminates exhaled CO2.

• CO2 absorbents:

� Sodalime:

o 94% of Ca (OH)2 + 5% NaOH + 1% KOH + 0.2% silica + 14-19% moisture.

o Sodalime is contraindicated with chloroform & trilene (forms phosphogene, a neuro poisonous

gas)

o Disadvantages:

o Forms Carbon monoxide

o With sevoflurane, forms compound-A (penta fluoro isopropenyl fluoro methyl ether), But

sevoflurane is not contraindicated with sodalime

o Possibility of fire in breathing circuit

� Baralyme:

o 80% of Ca (OH)2 + 20% BaOH + <1% KOH + moisture

� Amsorb: Ca(OH)2+ CaCl2 + CaSO4 & polyvinylpyrrolidone

o Disadvantage: very costly, less CO2 absorptive capacity [CO2 absorption: soda lime> barylime>

amsorb.

NOTE: Compound-A formation occurs more with barylime than sodalime

Comparison of Soda Lime and Barium Hydroxide Lime

Soda Lime Barium Hydroxide Lime

Mesh size 4-8 4-8

Method of hardness Silica added Water of crystallization

Content Calcium hydroxide, Sodium hydroxide &

Potassium hydroxide

Barium hydroxide

Calcium hydroxide

Usual indicator dye Ethyl violet Ethyl violet

Absorptive capacity (liters of

CO2/100 g)

14-23 [231/100gm] 9-18 [10.2 1/100gm]

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH (NIOSH)

• Recommends limiting the room concentration of nitrous oxide to 25 ppm and halogenated agents to 2 ppm

(0.5 ppm if nitrous oxide is also being used)

• The vacuum control valve on an active system should be adjusted to allow the evacuation of 1015 L of waste

gas per minute.

Essential Safety Features on a Modern Anesthesia Workstation.

Essential Features Purpose

Diameter Index Safety System (DISS) with

pressure gauges, filter, and check valve

Prevent incorrect pipeline attachments; detect

failure, depletion, or fluctuation

Pin index safety system for cylinders with

pressure gauges, and at least one oxygen cylinder

Prevent incorrect cylinder attachments; provide

backup gas supply; detect depletion

Minimum oxygen/nitrous oxide ratio controller

device (hypoxic guard)

Prevent delivery of less than 21% oxygen

Oxygen failure safety device (shut-off or

proportioning device)

Prevent administration of nitrous oxide or other

gases when the oxygen supply fails

Oxygen must enter the common manifold

downstream to other gases

Prevent hypoxia in event of proximal gas leak

Oxygen concentration monitor and alarm Prevent administration of hypoxic gas mixtures

Automatically enabled essential alarms and

monitors (eg, oxygen concentration)

Prevent use of the machine without essential monitors

Vaporizer interlock device Prevent simultaneous administration of >1 volatile

agent

Capnography and anesthetic gas measurement Guide ventilation; prevent anesthetic overdose

Oxygen flush mechanism that does not pass through

vaporizers

Rapidly refill or flush the breathing circuit

Breathing circuit pressure monitor and alarm Prevent pulmonary barotrauma and detect

sustained positive, high peak, and negative airway

pressures

Exhaled volume monitor Assess ventilation and prevent hypo- or

hyperventilation

Pulse oximetry, blood pressure, and ECG monitoring Provide minimal standard monitoring

Mechanical ventilator Control alveolar ventilation

Scavenger system Prevent contamination with waste anesthetic gases

ASSESMENT OF AIRWAY

The 1-2-3 test:

• On opening the mouth, one should insinuate one finger in the temporo mandibular joint.

• There should be atleast two finger breadths distance between his incisors.

• There should be atleast three finger breadths distance between chin and thyroid cartilage of the patient.

MALLAMPATI TEST:

• Devised by Mallampati & Samson-Young

• Widely used & simpler classification of the pharyngeal view.

• Patient is made to sit upright, open his mouth wide and protrude his tongue.

• Failure to visualize posterior pharyngeal walls indicate difficult airway establishment.

o Class: I- Uvula, Faucial pillars & soft palate visible.

o Class: II- Faucial pillars & soft palate visible

o Class: Ill- Soft palate & Hard palate visible

o Class: IV- Only hard palate visible

Thyromental distance

• Normal thyromental distance is > 6.5 cms.

• If < 6cm – intubation is difficult

AIRWAY MANAGEMENT

NONDEFINITIVE AIRWAY MANAGEMENT

• Foreign body removal: blind finger sweep for foreign body is acceptable in adults but is NOT acceptable i

pediatric cases.

• Maintenance of C-spine control imperative in trauma

• Maneuvers:

o Head tilt - chin lift: NOT acceptable with possible C-spine injury

o Jaw thrust - chin lift: acceptable with possible C-spine injury

o Heimlick

• Oropharyngeal Airway

o Use: temporary ventilation of unconscious patient while preparing to intubate

o Not be tolerated by conscious patient b/c gag reflex and produces vomiting

o Proper size: corner of mouth to external auditory canal

• Nasopharyngeal Airway

o Use: temporary airway management in pt who would not tolerate an oropharyngeal airway or if it is

difficult to insert (trismus, mouth trauma, etc); less likely to induce vomiting

• Jet Insufflation (Needle Cricothroidotomy)

o Short term oxygenation until more definitive AW can be established

• Other

o Esophageal Obturator AW (EOA), Esophogastric Tube AW (EGTA), Pharygotracheal Lumen AW (PTLA),

Esophageal Tracheal Combitube, (ETC)

DEFINITIVE AIRWAY MANAGEMENT

• Endotracheal Intubation

o Indications:

� For supporting ventilation in patient with pathologic disease:

� Upper airway obstruction,

� Respiratory failure,

� Loss of consciousness

� For supporting ventilation during general anaesthesia (most common):

� Type of surgery:

� Operative site near the airway,

� Thoracic or abdominal surgery,

� Prone or lateral surgery,

� Long period of surgery

� Patient has risk of pulmonary aspiration

� Difficult mask ventilation

Tracheal Tube

• Used to deliver anesthetic gases directly into the trachea and allow the most control of ventilation and

oxygenation.

• Us are most commonly made from polyvinyl chloride.

• The shape and rigidity of TTs can be altered by inserting a stylet.

• Murphy tubes have a hole (the Murphy eye) to decrease the risk of occlusion should the distal tube opening

abut the carina or trachea.

• Uncuffed tubes are usually used in children to minimize the risk of pressure injury and postintubation croup.

Airway Equipment for Pediatric Patients

Premature Neonate Infant Toddler Small

Child

Large Child

Age 0-1 month 0-1

month

1-12

months

1-3 years 3-8 years 8-12 years

Weight (kg) 0.5-3 3-5 4-10 8-16 14-30 25-50

Tracheal (ET)

tube (mm i.d.)

2.5-3 3-3.5 3.5-4 4-4.5 4.5-5.5 5.5-6

(cuffed)

ET depth (cm

at lips)

6-9 9-10 10-12 12-14 14-16 16-18

Suction

catheter (F)

6 6 8 8 10 12

Laryngoscope

blade

00 0 1 1.5 2 3

Mask size 00 0 0 1 2 3

Oral airway 000-00 00 0 (40 mm) 1 (50 mm) 2 (70 mm) 3 (80 mm)

Laryngeal

mask airway

(LMA)

— 1 1 2 2.5 3

Confirmation of placement:

• IIs chest rising? Does reservoir bag fill?

• What is the pulsox?

• Is the tube fogging up?

• Listens over lung fields and epigastrium

• End - Tidal CO2

• CXR: tip should be 1/2 way b/w thoracic inlet and carina (at level of aortic knob)

Oral Tracheal Tube Size Guidelines

Age Internal Diameter

(mm)

Cut Length (cm)

Full-term

infant

3.5 12

Child 4 + [ Age/4 ] 14 + [ Age/2 ]

Adult

Female 7.0-7.5 24

Male 7.5-9.0 24

• Nasotracheal Intubation

o Requires a spontaneously breathing patient

o Good for pt with tightly clenched teeth, unstable C-spine injury

o Contraindications: apneic patient, severe maxillofacial fractures, suspected basilar skull fracture (racoon

eyes, battle signs, ottorhea, rhinorhea, hemotympanum, nasal fracture)

• Surgical Cricothryoidotomy: NOT recommended for children < 12yo b/c of potential damage to the cricoid

cartilage which is the only circumferential support to the upper trachea

• Tracheostomy: time consuming but indicated for disrupted larynx or cervical trachea

OTHERS:

C-spine Immobilization

o Must protect C-spine

o Loosening of hard collar to allow for movement of the mandible will greatly facilitate visualization of the

cords with minimal cervical mobility

Assume a full stomach

o Use sellick's maneuver to occlude the esophagus and decrease aspiration

o Also helps to visualize cords

o BURP to help visualize cords: Push Back and Up with the Right Pressure

Choose a method of intubation

o Rapid Sequence Induction (RSI) is easiest and most popular method and should be used unless a difficult

airway is expected where there is suspicion that both intubation and bagvalve-mask ventilation after

paralysis may be difficult.

o Awake oral intubation: preferred method if difficult airway suspected

o Unconscious patients for whatever reason (even cardiac arrest) do NOT require pretreatment, induction, or

paralysis

NOTE:

o Gag reflex is an unreliable indicator of airway reflexes and should not be used.

o BURP MANEUVER: Manipulation of the thyroid cartilage, to improve laryngoscopic view

o SELLICK'S MANEUVER: Pressure on the cricoid ring to occlude esophagus, to decrease aspiration.

o Use the cricoid ring because it is the only complete tracheal ring.

LARYNGEAL MASK AIRWAY

Discovered by Dr.Archie Bain in 1980

Indications Contraindications

• To facilitate ventilation & passage of & tube in

patient

• with a difficult airway

• Difficult airway management during CPR

• Difficult intubation is anticipated

• Oropharyngeal abscess or mass

• High risk of aspiration

• Pregnancy

• Pharyngeal obstruction

• Low pulmonary compliance

Advantage Disadvantage

• Easy to insert

• Does not require laryngoscope & muscle relaxants

• Can be used in cervical injuries

• Protects the larynx from pharyngeal secretions (but

not gastric regurgitation)

• Aids in ventilation during fiberoptic bronchoscopy as

well as placement of the bronchoscope.

• Does not prevent aspiration

• High incidence of laryngospasm &

bronchospasm

Advantages & Disadvantages of the LMA compared with Face Mask Ventilation or Tracheal Intubation

Advantages Disadvantages

Compared with

face mask

Hands-free operation

Better seal in bearded patients

Less cumbersome in ENT surgery

Often easier to maintain airway Protects

against airway secretions Less facial nerve

and eye trauma Less operating room

pollution

More invasive

More risk of airway trauma

Requires new skill

Deeper anesthesia required Requires some TMJ

mobility

N2O diffusion into cuff

Multiple contraindications

Compared with

tracheal

intubation

Very useful in difficult intubations

Less tooth and laryngeal trauma

Less laryngospasm and bronchospasm Does

not require muscle relaxation Does not

require neck mobility

No risk of esophageal or endobronchial

intubation

Increased risk of gastrointestinal aspiration

Less safe in prone or jackknife positions

Limits maximum PPV

Less secure airway

Greater risk of gas leak and pollution Can cause

gastric distention

ROCEDURE OF INTUBATION

• Preparation: good oxygenation, check equipment, explain to patient

• Anesthetize the airway: 4cc 4% lidocaine spray liberally with xylocaine spray just before

• Sedate the patient with

o Midazolam 1 - 2mg

o Fentanyl 50 - 100ug

o Propofol

o Ketamine

o Thipentothal

o Etomidate

TERIA FOR INTUBATION

Subjective Criteria

Airway obstruction real or impending (epiglotitis,

burn, tumors, etc)

Objective Criteria

Oxygenation (Pa02 measures oxygenation)

• PaO2 < 70 mmHg with FiO2 at least 70%

• A - a gradient > 350 mmHg (normal 15, up to 37

w/ age)

Aspiration real or impending (decreased LOC, drug

OD, etc)

Ventilation (PCO2 measures ventilation)

• PaCO2 > 60 mmHg in normal adults (not

• COPD)

• RR > 35/min in adults

• PaCO2 > 35 mmHg in status asthmaticus

Clinical respiratory failure (tachypnea, tachycardia,

AMU, indrawing, cyanosis, diaphoresis, decreased

LOC, pulsus paradosus)

Tracheal bronchial toilet (unable to clear

secretions; COPD w/ pneumonia)

Mechanics

• Vital capacity < 15 ml/kg (normal is 70

Shock not responsive to medical management w/I 30

min (resp muscles may use up to 25% of cardiac

output; septic shock is an example)

Anesthesia indications

LARYNGOSCOPY

Direct laryngoscopy:Laryngoscope is inserted into the mouth on the right side and flipped to the left to trap and

move the tongue out of the line of sight, and, depending on the type of blade used, inserted either anterior or

posterior to the epiglottis and then lifted with an upwards and forward motion.

Indirect laryngoscopy: performed whenever the provider visualizes the patient's vocal cords by fiberoptic

bronchoscopes, video laryngoscopes, fiberoptic stylets and optically-enhanced laryngoscopes.

Laryngoscope: consists of a handle (Patil-Syracuse handle) & blade

Types of blades:

Curved blade Mac Intosh type Used in adults

Straight blade Miller type Used in children & in adults with difficult airway

Size markings for laryngoscopes:

000 Small premature

infant 00 Premature infant

0 Neonate

1 Small child

2 Child

3 Adult

4 Large adult

5 Extra large adult

PATIENT MONITORS

Cardiac Monitoring

Central Venous Pressure Monitoring:

• Normal CVP is 6-8mm of Hg

• Monitoring of JVP / CVP is done from Rt. Internal jugular vein (valveless vein).

• Pulmonary artery catheterization is done by Swan Ganz catheter.

• Swan Ganz catheter measures mixed venous pressure:

o Pressure in right atrium (0-8 mm of Hg)

o Pressure in right ventricle (15 – 25/0-8mm of Hg)

o Pressure in pulmonary artery (15-25/5-15 mm Hg)

o Pulmonary capillary wedge pressure (4 -12 mm Hg)

o Left atrium (4-12mm Hg).

• The best indicator for tissue perfusion or cardiac output is mixed venous O2 saturation.

• Best clinical guide for cardiac output is urinary output.

Transesophageal Echocardiography:

• Most sensitive for wall motion abnormalities and to detect ischemia and air embolism during intraoperative

period.

• For detecting arrhythmias in ECG lead II is preferred.

• For detecting ischemia in ECG lead V5 is preferred.

• Inferior wall MI shows abnormality in lead II,III and aVF.

BP Monitoring:

• For invasive BP monitoring, radial artery is most preferred.

• For radial artery cannulation, Allen's test should be performed to assess the patency of ulnar artery.

• Allen's Test:

o Hand circulation is stopped by occluding both radial and ulnar arteries.

o The pressure over ulnar artery is released while maintaining pressure on radial artery.

o Note the return of normal color of palm.

o If color returns to normal in < 7 sec, then radial artery cannulation can be done.

o If refill time is >15 sec then radial artery cannulation is contra-indicated.

o 7 – 14 sec is borderline.

Respiratory Monitoring

Pulse Oximeter:-

• It is used to detect hypoxia in intra – operative and post – operative period.

• Pulse oxymeter measures percentage saturation of oxygen.

• The normal O2 saturation is 98%

• Oximetry depends on the observation that oxygenated and reduced hemoglobin differ in their absorption of

red and infrared light (Lambert–Beer law)

• Oxyhemoglobin (HbO2) absorbs more infrared light (960 nm)

• Deoxyhemoglobin absorbs more red light (660 nm) and appears blue or cyanotic to the naked eye.

• Change in light absorption during arterial pulsations is the basis of oximetric determinations.

• Following factors lead to inaccurate reading in pulse oxymeter:

o Methemoglobin (shows 85% saturation always)

o Carboxy hemoglobin (shows 95% saturation always, over read d/t Hb CO)

o Fetal hemoglobin (at very high levels only)

o Cyanide poisoning (higher values)

o Anemia (lower values)

o Hemoglobin S

o Mal positioning of sensor

o Poor peripheral pulsation

o Skin pigmentation

o Dyes- methylene blue, indocyanine green

o Optical interference

o Electrical interference

o Nail polish & covering

• Severe Hyperbilirubinemia does not affect readings of pulseoximetry.

ETCO2 (capnography):

• The most commonly used type of capnograph plots Pco2 versus time.

• Capnography uses infrared light which is absorbed by CO2

Phases:

Expiratio

• Phase 0: inspiratory phase

• Phase I: dead space and little or no C

• Phase II: mixture of alveolar and dead

• Phase III: alveolar plateau, with the p

• Normal end-tidal PCO2 is approximat

• Alpha angle is the transition from Ph

• Beta angle is the transition from Pha

• Additional phase IV (terminal upstrok

Uses Of Capnography:

• Surest sign of correct intubation

• Diagnosis of malignant hyperthermia

• Detecting obstruction of Endotrachea

• Indicates cardiac output

• Diagnoses pulmonary embolism

� Persistent detection of CO2 by a capn

cannot exclude bronchial intubation)

� The earliest manifestation of bronchi

Blood Gas Analysis:

• The blood sample is taken from radia

• Normal values on room temperature

pH: 7.38 – 7.42

� Partial Pressure of air: 96 - 98 m

� Partial Pressure of Coe: 35 –45 m

� Bicarbonate: 24 – 28 mEq / L

� O2 saturation: 95 – 98%

� Base deficit: (-3 to + 3)

Neuro Muscular Monitoring

• M/c muscle used: Adductor pollicis s

• Most accurate measurement for NM

• Neuromuscular monitoring is done cl

o 4 stimuli are given each of 2 Hz w

recording are taken.

o Absence of Train 4 response me

• Train of 4 is best utilized during main

• Succinylcholine (Depolarizing Blocke

ration ▬▬ Inspiration…….

no CO2

dead space gas

he peak representing end-expiratory (end-tidal) CO2 (PE

imately: 38 mmHg (35-45 mm Hg) or 5%

Phase II to Phase III

Phase III to Phase I (the start of inspiration)

stroke before phase 0) may be seen in pregnancy.

rmia

cheal tube

capnograph is the best confirmation of tracheal placem

ion)

nchial intubation is an increase in peak inspiratory pres

adial artery preferably in a heparinized glass syringe

ture.

8 mm Hg

45 mm Hg

cis supplied by ulnar nerve.

NM monitoring is orbicularis oculi supplied by facial ne

ne clinically by train of 4.

Hz with a gap of 0.Ssec between each stimuli and repea

means 75% receptors and blocked and is sufficient for

aintenance phase of anesthesia.

ocker)

(PETCO2)

cement of a TT (but it

pressure.

al nerve.

epeated every 10-12 sec,

for most surgeries.

• Tubocurarine non – depolarizing blocker)

• Train of 4 differentiates depolarizing and non-depolarizing blockers

• Fading is property of non-depolarizing blockers.

• If a patient on succinyl choline shows fading, It is pathognomic of phase 2 block

Temperature Monitoring

• The most accurate measurement of core body temperature is provided by pulmonary artery.

• Tympanic membrane is the most accurate measure of brain temperature.

• Hypothermia is common thermal abnormality during anesthesia and temperature monitoring is mandatory.

• Core body temperature > rectal temperature > surface temperature.

• Hypothermia is temperature < 35°C.

o < 28 - 35°C is mild hypothermia

o 21 – 27° C is moderate hypothermia

o < 20° C is severe / profound hypothermia.

• Induced Hypothermia: O2 consumption and metabolic rate falls by 7% with each degree fall in temperature.

• Brain protection can be done for 10 mins at 30° C and for 60 mins at 15° C.

• Induced hypothermia protects against tissue ischemia during cardiac surgeries.

PNEUMOTACHOGRAPH

• A fixed-orifice flowmeter that can function as a spirometer.

• A parallel bundle of small-diameter tubes in chamber (Fleisch pneumotachograph) or mesh screen provides a

slight resistance to airflow.

• Pneumotachographs measure the flow according to the Venturi principle.

• Venturi principle: gas particles accelerate when their circulation zone is reduced. At the same

• time a drop in pressure occurs.

• 2 types of pneumotachographs: Fleisch and Lilly.

• The Lilly type measures the difference in pressure over before and after a membrane with known

• resistance.

• Fleisch types (more reliable) use a series of parallel capillaries.

• Wall mountable type of pneumotachograph- venturi pneumotachograph

Operating room air conditioning efficiency:

• In surgical theatres, the concentration of bacteriologically contaminated air borne particles in the operation

room averaged over any 5-min period should notexceedi80-per m3.

• Minimum of 15 changes/hour [20/hr is satisfactory]

POSITIONS

Trendelenburg's position • Patient is supine on a bed with head end low (30-45°)

• FRC & VC decreased

• Preferred for abdominal surgery, Ryle's tube aspiration

• Increase ICP & lOP

Reverse trendelenburg • Patient is supine on bed with head up

Fowler's position • Head end of patient's bed is raised about 11/2 feet (46 cm)) & knee are

elevated Sitting position • Used for neurosurgery

Prone position • Hypotension may occur

• Increased WOB, increased total lung compliane

Sim's position • Position for PR examination

• Pt rests on left lateral side with right knee & thigh drawn well up above left

Rose position • Tonsillectomy

Sniffing position • Intubation (flexion at neck 5 extension at atlantooccipital joint)

Lithotomy position • Used for gynaecolocial and urological procedure

• Maximum decrease in vital capacity

• Increased likelihood of aspiration

• Increased preload and cardiac output

Physiological Effects of Common Patient Positions.

Position Organ System Effects

Supine

Horizontal Cardiac Equalization of pressures throughout the arterial system; increased right-

sided filling and cardiac output; decreased heart rate and peripheral vascular

resistance.

Respiratory Gravity increases perfusion of dependent (posterior) lung segments;

abdominal viscera displace diaphragm cephalad. Spontaneous ventilation

favors dependent lung segments, while controlled ventilation favors

independent (anterior) segments. Functional residual capacity decreases and

may fall below closing volume in older patients.

Trendelenburg Cardiac Activation of baroreceptors, generally causing decreased cardiac output,

peripheral vascular resistance, heart rate, and blood pressure.

Respiratory Marked decreases in lung capacities from shift of abdominal viscera;

increased ventilation/perfusion mismatching and atelectasis; increased

likelihood of regurgitation.

Other Increase in intracranial pressure and decrease in cerebral blood flow

because of cerebral venous congestion; increased intraocular pressure

in patients with glaucoma.

Reverse Cardiac Preload, cardiac output, and arterial pressure decrease. Baroreflexes

Trendelenburg increase sympathetic tone, heart rate, and peripheral vascular resistance.

Respiratory Spontaneous respiration requires less work; functional residual capacity

increases.

Other Cerebral perfusion pressure and blood flow may decrease.

Lithotomy Cardiac Autotransfusion from leg vessels increases circulating blood volume and

preload; lowering legs has opposite effect. Effect on blood pressure and

cardiac output depends on volume status.

Respiratory Decreases vital capacity; increases likelihood of aspiration.

Prone Cardiac Pooling of blood in extremities and compression of abdominal muscles

may decrease preload, cardiac output, and blood pressure.

Respiratory Compression of abdomen and thorax decreases total lung compliance

and increases work of breathing.

Other Extreme head rotation may decrease cerebral venous drainage and cerebral

blood flow.

Lateral Cardiac Cardiac output unchanged unless venous return obstructed (eg, kidney

decubitus rest). Arterial blood pressure may fall as a result of decreased vascular

resistance (right side > left side).

Respiratory Decreased volume of dependent lung; increased perfusion of dependent

lung. Increased ventilation of dependent lung in awake patients (no V/Q

mismatch); decreased ventilation of dependent lung in anesthetized patients

V/Q mismatch). Further decreases in dependent lung ventilation with

paralysis and an open chest.

Sitting Cardiac Pooling blood in lower body decreases central blood volume. Cardiac

output and arterial blood pressure fall despite rise in heart rate and

systemic vascular resistance.

Respiratory Lung volumes and functional residual capacity increase; work of

breathing increases.

Other Cerebral blood flow decreases.

POST ANESTHESIA DISCHARGE SCORING SYSTEM (PADSS)

Criteria Points

Vital signs

Within 20% of preoperative baseline

2

Within 20-40% of preoperative baseline 1

> 40% of preoperative baseline 0

Activity level

Steady gait, no dizziness, at preoperative level 2

Requires assistance 1

Unable to ambulate 0

Nausea and vomiting

Minimal, treated with oral medication 2

Moderate, treated with parenteral medication 1

Continues after repeated medication 0

Pain: minimal or none, acceptable to patient, controlled with oral medication

Yes 2

No 1

Surgical bleeding

Minimal: no dressing change required 2

Moderate: up to two dressing changes 1

Severe: three or more dressing changes

VENTILATION MODES

Controlled CMV

Fully or partially assisted SIMV, SIPPV, A/C / PTV, PSV, SIMV + PSV, SIPPV + PSV

CONTROLLED MECHANICAL VENTILATION (CMV)

• Every breath is fully supported by the ventilator

• In classic control modes, patients were unable to breathe except at the controlled set rate

• In newer control modes, machines may act in assist-control, with a minimum set rate and all triggered

breaths above that rate also fully supported.

INTERMITTENT MECHANICAL VENTILATION (IMA)

• Patient triggered (PTV)/ Synchronous intermittent positive pressure ventilation (SIPPV)/assist control

(A/C):

o Patient triggers a positive pressure inflation with each breath

• Synchronized Intermittent Mandatory Ventilation (SIMV):

o Patient is able to trigger only a pre-set number of positive pressure inflations.

POSITIVE END EXPIRATORY PRESSURE (PEEP)

• Mechanical ventilatory maneuver of exerting a supra-atmospheric pressure in the lungs at end exhalation.

• PEEP is not a ventilator mode by itself.

• It is an adjunctive treatment that can be applied to all forms of mechanical ventilation; controlled, assisted

or spontaneous.

• Creation of a positive pressure at end exhalation increases the functional residual capacity (FRC) of the

lungs by decreasing the collapse of the small airways thus, reducing atelectasis.

• The major effect of PEEP on the lungs is to increase FRC.

• Recruitment (reexpansion) of collapsed alveoli occurs at PEEP or CPAP levels above the inflection point.

• Indications of PEEP:

o Physiological PEEP

o Pulmonary edema

o Best value of PEEP is at which P02> 60mm Hg.

o Shunt fraction is minimum & C.0 is minimally depressed

o ARDS

o Cardiothoracic surgery

• Significance:

o Shifts the tidal volume to a more compliant portion of the pressure volume curve.

o Prevents the intermittent loss of compliance during mechanical ventilation.

o Reduces the work of breathing.

o Capable of increasing arterial oxygenation.

• Hazards of inappropriate application of PEEP:

o Impaired gas exchange

o Decreased cardiac output, splanchnic and renal blood flow.

Key Contraindications of PEEP

• Pneumothorax without pleural catheter

• Intracranial hypertension

• Hypovolemia (unless concomitantly treated)

• Bronchopleural fistula

• Recent pulmonary resection surgery

Term Description

Allodynia Perception of an ordinarily nonnoxious stimulus as pain

Analgesia Absence of pain perception

Anesthesia Absence of all sensation

Anesthesia dolorosa Pain in an area that lacks sensation

Dysesthesia Unpleasant or abnormal sensation with or without a stimulus

Hypalgesia (hypoalgesia) Diminished response to noxious stimulation (eg, pinprick)

Hyperalgesia Increased response to noxious stimulation

Hyperesthesia Increased response to mild stimulation

Hyperpathia Presence of hyperesthesia, allodynia, and hyperalgesia usually

associated with overreaction, and persistence of the sensation after the

stimulus

Hypesthesia

(hypoesthesia)

Reduced cutaneous sensation (eg, light touch, pressure, or emperature)

Neuralgia Pain in the distribution of a nerve or a group of nerves

Paresthesia Abnormal sensation perceived without an apparent stimulus

Radiculopathy Functional abnormality of one or more nerve roots

Preemptive analgesia • Formulated by Crile.

• Involves the introduction of an analgesic regimen before the

onset of noxious stimuli, with the goal of preventing

sensitization of the nervous system to subsequent stimuli that

could amplify pain.

• Administration of long-lasting analgesics before surgery to help

to avoid the establishment of a sensitized state and result in

diminished postoperative pain.

II. CLINICAL PHARMACOLOGY OF ANESTHETIC DRUGS

STAGES OF ANESTHESIA (Guedel's staging based on ether)

• Stage I: Analgesia:

o Loss of pain sensation results from interference with sensory transmission in the Spinothalamic tract.

o The patient is conscious and conversational.

o Amnesia and a reduced awareness of pain occur as Stage II is approached.

• Stage II: Excitement:

o The patient experiences delirium and possibly violent, combative behavior.

o There is a rise and irregularity in blood pressure.

o The respiratory rate may increase.

o To avoid this stage of anesthesia, a short-acting barbiturate, such as thiopental, is given intravenously

before inhalation anesthesia is administered.

• Stage III: Surgical anesthesia:

o Regular respiration and relaxation of the skeletal muscles occur in this stage.

o Eye reflexes decrease progressively, until the eye movements cease and the pupil is fixed.

o Surgery may proceed during this stage.

• Stage IV: Medullary paralysis:

o Severe depression of the respiratory and vasomotor centers occurs during this stage.

o Death can rapidly ensue unless measures are taken to maintain circulation and respiration.

CLASSIFICATION OF GENERAL ANESTHETICS

Inhalational agents Intravenous agents

Gaseous Volatile Inducing agent Slower acting

Nitrous

oxide

Xenon

Alkanes:

Halothane

Ethers: Ether,

Enflurane,

Desflurane,

Isoflurane,

Sevoflurane

Propofol

Methohexitone

Thiopentone

Etomidate

Benzodiazepines

Dissociative anesthesia: Ketamine

Neurolept analgesia: Fentanyl +

Droperidol

INHALATION ANESTHETICS

IMPORTANT FACTS:

• IDEAL GAS Obeys Charles, Boyle's & Avogadro's law

• Charles's law: at constant pressure V a T.

• Boyle's law: at constant temperature V a 1/P.

• Unitary hypothesis: all inhalation agents share a common mechanism of action at the molecular level.

• Meyer—Overton rule: Anesthetic potency of inhalation agents correlates directly with their lipid solubility.

• General anesthesia typically reduces both VO2 and VCO2 by about 15%.

• The greatest reductions are in cerebral and cardiac O2 consumption.

• Three factors affect anesthetic uptake:

� Solubility in the blood

� Alveolar blood flow

� Difference in partial pressure between alveolar gas and venous blood.

MINIMAL ALVEOLAR CONCENTRATION

• MAC is alveolar concentration of an inhaled anesthetic that prevents movement in 50% of patients in

response to a standardized stimulus (eg:- surgical incision)

• MAC is a useful measure as it measures the potency of inhalational agents.

• 0.3 to 0.4 MAC is associated with awakening from anesthesia (MAC awake)

• There is 6% decrease in MAC per decade of age.

Anaesthetic MAC (% atm) Blood gas partition coefficient

Halothane

Enflurane

Isoflurane

Desflurane

Sevoflurane

Cyclopropane

Nitrous oxide

Trilene

Ether

Chloroform

Methoxyflurane

0.74

1.68

1.15

6.0

2.05

9.2

104

0.2

1.92

0.8

0.16

2.3

1.8

1.4

0.42

0.69

0.44

0.47

9

12

8

15

• MAC for nitrous oxide is 104%, and it must be given in a pressurized chamber due to safety considerations.

Factors Increasing MAC Factors Decreasing MAC Factors does not affect

MAC

• ↑CNS metabolic activity

• ↑CNS neurotransmission

• ↑CNS neurotransmitter

levels

• Up-regulation of CNS

response

• ↓CNS metabolic activity

• ↓CNS neurotransmission

• ↓CNS neurotransmitter levels

• Down-regulation of CNS response

• Thyroid disease

• Gender (M/F)

• Young patient

• Chronic alcohol abuse

• Hypernatremia

• Acute amphetamine

poisoning

• Cocaine

• Ephedrine

• Elderly patient

• Acute alcohol intoxication

• Hyponatremia

• Chronic amphetamine

• Hypercalcemia, Hypokalemia

• Hypo and hyperthermia

• L.A , I.V induction agents

• Opioids, Clonidine

• Anemia

• Lithium, Methyl dopa, Reserpine

• MAP < 40mm of Hg

• Pregnancy

• Hypoxia (pao2 < 40m of Hg) &

hypercarbia (paco2 > 90mg Hg)

PARTITION CO-EFFICIENT

• Measures the solubility of the gas.

• Blood gas partition coefficient: measures solubility of general anesthetic

• Oil-gas partition coefficient: measures anesthetic potency.

EFFECT OF INHALATIONAL AGENTS

Respiratory System

• All Inhalational agents are bronchodilators and depress the respiratory system.

• Maximum bronchodilation: Halothane (agent of choice in asthmatics)

• Maximum respiratory depression: Enflurane.

• Maximum blunting of ventilatory response is with halothane.

Cardiovascular System

• All inhalational agents decrease cardiac output except isoflurane and desflurane.

• Maximum decrease in C.O- halothane

• C.0 is best maintained by isoflurane because of reflex tachycardia.

• All inhalational agents are pulmonary vasodilators except N2O which is pulmonary vasoconstrictor

• All inhalational agents reduce mucociliary activity of airways except ether.

• Maximum inhibition of baroreceptor reflexes is with Halothane.

• All inhalational agents reduce BP except cyclopropane.

• Isoflurane is the agent of choice for controlled hypotension.

• Isoflurane is agent of choice for cardiac patients because of maintenance of C.O and minimum response on

baroreceptor reflexes.

• Maximum inhibition of myocardial contractility - Halothane.

• Halothane sensitizes the heart to arrhythmogenic action of adrenaline

• Halothane is contraindicated in patients with Pheochromocytoma

Central Nervous System

• All inhalational agents increase intracranial tension.

• Maximum increase in intracranial tension is with enflurane.

• Minimum increase in ICT is isoflurane and Desflurane < 6%

• Inhalational agent of choice for neurosurgeries is Isoflurane.

Kidneys

• Nephrotoxicity is d/t fluoride content.

• Anesthetics are fluorinated to make them non-inflammatory.

• Maximum fluoride content is seen in methoxyflurane (maximum nephrotoxicity)

• Methoxyflurane produces vasopressin resistance, polyuric renal failure

Others

• N2O can cause bone marrow suppression, Vitamin B12 deficiency and megaloblastic anemia

• All inhalational agents relaxes the uterus.

• Maximum uterine relaxation - halothane and thus halothane is agent of choice for internal version and

manual removal of placenta.

• Hyperglycemia is produced by ether, cyclopropane and desflurane.

• All inhalational agents increase intra ocular pressure

• All inhalational agents are good skeletal muscle relaxants except N2O.

• Maximim skeletal muscle relaxation is by ether

• Ether and cyclopropane are highly inflammable. Cautery should not be used with these agents.

• All inhalational agents undergo metabolism by oxidation.

• Halothane is metabolized by reduction and oxidation.

Extent of metaholism of inhalational anesthetics

• Methoxyflurane > 70% (maximum metabolism)

• Halothane > 40%

• Enflurane 8%

• Sevoflurane 2-5%

• Isoflurane < 2%

• Desflurane < 0.05% (least metabolism)

• N2O does not undergo any metabolism

PHARMACOLOGY OF INDIVIDUAL AGENTS

NITROUS OXIDE (laughing gas)

• Has second gas effect during induction & diffusion hypoxia after discontinuation of anesthesia in recovery

phase.

• As N2O is used in high concentration (70-80%) it leads to entry of N2O in blood at a rate higher than minute

(1 lit/min) volume.

• N2O has low blood solubility. So it rapidly diffuse into alveoli & dilutes the alveolar air-Partial Pressure of O2

in alveoli is reduced i.e. diffusion hypoxia

• Diffusion hypoxia is prevented by administering 100% oxygen for 5-10 min after discontinuing N2O

• Poynting effect: Entonox (50% O2 & 50% N2O) & mixture of gases (O2 & N2O) keeps them in gaseous form.

• If another potent anesthetic eg. Halothane is added, it also will be delivered to the blood at a rate higher

than minute volume & the induction will be faster.

• N2O is a good analgesic but weak anaesthetic and poor muscle relaxant. Hence it is not a complete

anaesthetic.

• N2O has blood gas coefficient of 0.47 and has fast induction

• It has MAC value of 104; Hence Potency is low

• N2O is used as a carrier gas given in a mixture of 33% O2 and 66% N2O

• Contraindications for N2O :

o Middle ear surgeries and tympanoplasty

o Laparoscopic surgeries, Eye surgeries

o Acute intestinal obstruction and volvulus

o Microlaryngeal surgeries

o Pneumothorax, pneumoperitonium

o Pneumoencephalos.

• It should be avoided in patients with pulmonary hypertension

• Adverse effects: bone marrow depression (agranulocytosis, megaloblastic anemia) and even neurological

deficiencies (peripheral neuropathies and pernicious anemia).

ENTONOX

• 50-50 mixture of N2O & O2

• Cylinder is blue coloured with white shoulder

• Uses - analgesia for wound dressing, chest physiotherapy, removal of chest drains labour analgesia, & dental

surgery

• It is good analgesic (d/to N2O)

XENON

• Manufactured by fractional distillation of air �costly

• MAC � 71% [more potent that NO]

• Blood gas partition coefficient � 0.14 [emergence is rapid than with desflurane/propofol]

• Minimal cardiovascular & hemodynamic side effects

o Cardio protective & Neuro protective

o Non teratogenic

o Not metabolized in liver/ kidney

o No malignant hyperthermia

• Density of xenon � 5.887g/dl (more than N2O & air)

o Increases pulmonary resistance & breathing

o Cautiously used in moderate to severe COPD, morbidly obese & premature infants

Advantages of Xenon (Xe) Anesthesia Disadvantages of Xenon (Xe) Anesthesia

Inert (probably nontoxic with no metabolism) High cost

Low blood solubility Low potency (MAC = 70%)

Rapid induction and recovery No commercially available anesthesia equipment

Environmentally friendly, Nonexplosive

HALOTHANE (2, bromo, 2 chloro, 1, 1, 1 trifluoroethane)

• Least expensive & least pungent.

• Potent anesthetic, no analgesia.

• Dissolve rubber and corrodes metals.

• Drager Narko test is done for halothane.

• Contains 0.01% thymol for stability.

• Decomposed by light but is stable in amber coloured bottles.

• 15-20% is metabolized.

• May persist in the liver upto 12 days & not given in same patient within 3 months (potent hepato toxic).

• Relaxes skeletal and uterine muscle & blood vessels.

• Not hepatotoxic in children and combined with its pleasant odor, suitable in children for inhalation

induction.

• Causes 5’H’

o Malignant Hyperthermia,

o Hepatitis (centrilobular necrosis) extremely rare (1 per 35,000 cases)

o Hypotension

o Hypercapnia

o Heart rate decreases (myocardial depression)

• Decreases 10P, but ICT is increased

• Shivering & tremors common (H-shakes) in early post-operative period

• Myocardial depression of halothane is exacerbated by β-blockers and calcium channel-

• blocking agents.

• The combination of halothane and aminophylline � serious ventricular arrhythmias.

Contraindications for halothane:

• Pregnancy because it increases the risk of post -partum hemorrhage

• Liver dysfunction & Previous use within 3 months: due to halothane hepatitis

• Hypovolemia & severe cardiac disease (aortic stenosis); due to negative ionotropic effect

• Pheochromocytoma & exogenous catecholamines administration as it sensitize heart to catecholamines.

� Best uterine relaxant is Halothane followed by ether.

� Best muscle relaxant is ether followed by halothane.

FLURANES

• Enflurane

� Contraindicated in epilepsy

� Increases cerebral blood flow, secretion of CSF, resistance to CSF flow & intra cranial pressure

� High voltage high frequency EEG changes can progress to spike & wave pattern that culminates in frank

tonic clonic seizures.

� This epileptiform activity is exacerbated by high anesthetic concentrations & hypocapnia, so

hyperventilation is not recommended to attenuate Enflurane induced intracranial hypertension.

• Isoflurane

� AOC in neurosurgery

� Causes coronary steal syndrome

� Least effect on myocardial contractility [most cardio stable volatile agent]

• Enflurane & Halothane: myocardial depressants

• Desflurane: transient sympathetic activation, broken down to carbon monoxide by dry barium hydroxide

���� carbon monoxide poisoning.

• Sevoflurane

� Sweet odour

� Metabolized to HFIP [Hexa flour !so propyl]

� Induction agent of choice in children

• Halothane and isoflurane: sensitizes the heart to circulating catecholamines (adr/NA)

• Seizures are seen in enflurane & desflurane (lesser extent)

HEPATOTOXICITY OF ANESTHETIC AGENTS:

• Depends on

o Gender (Female> male)

o Age (middle age adults)

o Obesity

o Enzyme induction

o Prior anesthetic exposure

o Genetics

• Hepatotoxicity of inhalational agents is due to TFA [Tri flour acetyl] metabolite.

• Therefore, hepatotoxicity is proportional to the percentage of metabolism.

• % metabolism: halothane (20%) > Sevoflurane (2-5%)> Enflurane (2-4%)> Isoflurane (0.2%)>desflurane

(0.02%)

• But sevoflurane does not cause hepatotoxicity because its metabolite is HFIP (not TFA)

NEPHROTOXICITY OF ANESTHETIC AGENTS:

• Methoxyflurane:

o Most potent inhalation agent, but its high solubility and low vapor pressure limited its rate of induction

and emergence

o Highly nephrotoxic (high fluoride content)

o Causes polyuric (High output), vasopressin-resistant renal failure

o Tendency of oxalate stone formation

• Prolonged use of Enflurane: Leads to significant fluoride production and nephrotoxicity.

• Though sevoflurane produces fluoride, nephrotoxicity is rare in usual therapeutic doses

• Halothane, Isoflurane Desflurane: fluoride production is negligible, Can be used in Renal failure.

• Halothane & Isoflurane decreases renal blood flow, GRF & urinary output but Desflurane do not.

TRICHLOROETHYLENE (TRILENE)

• It is potent nerve poison.

• Vth & VII th CN are most commonly involved

• Produces analgesia in distribution of 5th

cranial nerve & relieves trigeminal neuralgia.

• It is not used in closed circuit (Soda lime ) because toxic product may be formed

• At 125°C or in presence of O2 as by cautery it decomposes into phosgene (COCl2) & Hcl

• Does not depress myocardium & respiration (like N2O)

• Not inflammable.

• Disadvantage : Sensitizes heart to adrenaline (Occasional dysrhythmia)

• Highly potent analgesic because MAC is low 17% (MAC α�

�������)

• Used for labour analgesia

ETHER

• Ether has slow induction with slow recovery and is very unpleasant.

• Induces laryngeal spasm and makes induction even slower.

• Stimulates salivary and bronchial secretions. So atropine pre medication is required.

• Highly inflammable and explosive, it should not be used when diathermy is needed in the airway

• Muscle relaxants need no to be used as ether itself produce excellent relaxation.

• Ether liberates catecholamines and tends to maintain blood pressure.

• No sensitization of myocardium to circulating catecholamines.

• It is a complete anaesthetic nearer to ideal anaesthetic.

• Ether does not affect the mucociliary action and is good bronchodilator.

• Ether has good anaesthetic, good analgesic, good skeletal muscle relaxant.

• Ether does not cause depression of myocardium but instead causes tachycardia and hypertension.

• Ether has highest instance of nausea and vomiting among inhalational agents.

• Ether causes hyperglycemia and is contraindicated in diabetes

• Guedel's 4 stages of anaesthesia were based on ether.

• Ether is safe in unskilled professionals and is very economical.

Preservatives

• Halothane: 0.01% thymol

• Ketamine: Benzethonium chloride

• Thiopentone: Anhydrous sodium carbonate (6%) & nitrogen gas

• Ether: propyl galate/ hydroquinone/ diphenylamine

NONVOLATILE ANESTHETIC AGENTS

PROPOFOL

Cardiovascular Neurologic Metabolic

• Depresses entricular

systolic function

• Vasodilatation results

from calcium channel

blockade.

• In patients undergoing

coronary artery bypass

surgery, it decreases

mean arterial blood

pressure, stroke volume

and increases heart rate

• Reduce neuronal

damage by

depressing cerebral

metabolism.

• Decreases cerebral

oxygen

consumption,

cerebral blood flow

and cerebral glucose

use

• The emulsion used as the vehicle for propofol

contains soybean oil and egg lecithin and

supports bacterial growth; iatrogenic

contamination leading to septic shock.

• Currently available preparations contain EDTA,

metabisulfite, or benzyl alcohol as a

bacteriostatic agent.

• Because EDTA chelates trace metals,

particularly zinc, serum zinc levels should be

measured daily during continuous infusions

• Hyperlipidemia may occur in infants and small

children

• Water-soluble phosphorylated prodrug: fospropofol [hydrolyzed by endothelial cell surface alkaline

phosphatases]

• Hypnotic agent associated with pleasant emergence and little hangover.

• 1% xylocaine is also given along with it to reduce pain on injection.

• Preferred agent for sedation and hypnosis and in particular for patients with altered level of consciousness.

• Anesthetic of Choice

o Malignant hyperpyrexia

o Day care surgery

o Total IV anesthesia (used along with alfentanil)

• Has anti-oxidant, anti- emetic, anti convulsant, bronchodilator & anti pruritic property.

• The rapid recovery of neurologic status makes it a good sedative in ICU patients.

• Diprivan (1% formulation): contains 10% soya oil, 1.25% egg phophatide & 2.25 %glycerol.

PROPOFOL INFUSION SYNDROME-PRIS:

• Occurs if given at the rate of 4mg/kg/hour or more for 48hrs or longer.

• Lethal disorder as it interferes with mitochondrial oxidation.

• Features:

o Acute refractory bradycardia leading to asystole

o Metabolic acidosis

o Rhabdomyolysis

o Hyperlipidemia

o Enlarged/fatty liver

o Cardiomyopathy with acute cardiac failure, skeletal myopathy

THIOPENTONE

• Ultra short acting barbiturate used for induction.

• The duration of action of highly lipid-soluble barbiturates (thiopental, thiamylal, and

methohexital) is determined by redistribution, not metabolism or elimination.

• Although thiopental is highly protein bound (80%), its great lipid solubility and high nonionized fraction

(60%) account for maximal brain uptake within 30 s.

Actions:

CNS:

• Cerebro protective

• Decreases cerebral blood flow & intra cranial tension.

• Decreases cerebral O2 consumption & increases the perfusion pressure.

• Anti-analgesic (can produce hyperalgesia by reducing the threshold of pain)

• It has anticonvulsant / anti-epileptic property

Eye:

• Pupils first dilate & then constrict.

• Decrease in IOT

• Loss of eye lash reflex- sign of adequate induction

Musculo - skeletal system: Tremors, twitching, respiratory excitation including cough, hiccup

Respiratory system: Transient apnea, respiratory depression [double apnea], upper airway obstruction

Larynx: Laryngospasm & hiccups

Other Features:

• It is not a muscle relaxant.

• Has anti-thyroid properties because it has thiourilene structure.

• Ringer lactate should not be used for reconstitution as it gets precipitated with it.

• IV agent of choice for cerebral protection.

• It crosses BBB and Placental barrier

Complications:

• Induces ALA synthetase ���� acute intermittent porphyria.

• Perivenous and IM injections cause tissue necrosis and ulcerations due to high alkalinity

• Intra-arterial injections lead to arterial spasm which is prevented by using 2.5% solution, injecting very

slowly and in incremental doses.

• Thiopentone should be avoided in asthmatics, hypotension, and shock, patients on Beta blockers,

hypokalemia, heart blocks, valvular stenosis and dystrophia myotonia.

METHOHEXITONE

• Ultra short acting barbiturate. More potent than thiopentone.

• Induces seizures and is the agent of choice for electroconvulsive therapy

ETOMIDATE

• Used to induce anesthesia.

• Hypnotic agent but lacks analgesic activity.

• Water solubility is poor, so etomidate is formulated in a propylene glycol solution.

• Induction is rapid, and the drug is short-acting.

• Only used for patients with coronary artery disease or CVS dysfunction, such as shock.

• Etomidate is hydrolyzed in the liver, no effect on the heart and circulation.

• Adverse effect: decrease in plasma cortisol and aldosterone levels due to inhibition of 11-α-ahydroxylase.

KETAMINE

• A short-acting, non barbiturate anesthetic

• Structural analogue of phencyclidine

• N-methyl-D-aspartate receptor (NMDA) a subtype of the glutamate receptor antagonist.

• Causes profound analgesia, dissociative anesthesia and catatonia

• Anesthesia of choice in shock.

• It is associated with emergence psychoto mimetic side effects "DISSOCIATIVE ANESTHESIA" (delirium,

illusions, hallucination) it is less common in children and pretreatment with lorazepam (drug of choice)

• Only IV anesthetic agent with both anesthetic and analgesic activity

It is a sympathetic stimulant

• Cardiac stimulation (sensitizes the heart to adrenaline) � Increased HR, BP, Oxygen demand & cardiac

output.

• Increases all pressure � ABP, 10T, ICT

• Increased muscle tone � myalgia

• Potent bronchodilator���� AOC in bronchial asthma

• Upper airway reflexes are intact (beneficial in patients with either hypovolemic or cardiogenic shock as well

as in patients with asthma)

• Salivation is increased so anticholinergic (atropine )is always given in premedication

• Contraindicated in raised intracranial pressure & intracranial pathology with mass effect.

• Avoided in: CHF, coronary artery disease, hypertension, CVA & Arterial aneurysm.

FENTANYL

• More potent analgesic than morphine

• Rapid onset & rapid recovery so used for day care surgery

• Produces significant musculoskeletal rigidity (Wooden chest syndrome)

• Can be given in hepatic & renal disease

• Fentanyl "lollipop" is an effective method of producing analgesia and sedation.

• Provides rapid onset (10 min) of analgesia and sedation in children and adults

• Low molecular weight and high lipid solubility � transdermal absorption (fentanyl patch).

• Serum concentrations reach a plateau within 14-24 h of application and remain constant for 72 h.

• A high incidence of nausea and variable blood levels have limited the acceptance of fentanyl patches for

postoperative relief of pain.

ANESTHETICS CAUSING

Increased ICT Sevoflurane, Desflurane, Isoflurane, Enflurane, Methoxyflurane, Halothane,

Ketamine, Nitrous Oxide (N2O), Althesin, Succinyl choline

Decreased ICT Barbiturates, Cyclopropane, Droperidol, Etomidate, Lidocaine, Propofol

Increased IOT Barbiturates, Cyclopropane, Etomidate, Succinyl Choline, Ketamine,N2O

Decreased IOT Morphine, Thiopentone, Halothane, Hexamethonium, Trimethaphan

Increased BP Ketamine, Pentazocine, Pancuronium

Bronchodilatation (preferred in asthmatics)

Ketamine (most potent), Halothane, Promethazine, d-TC

Broncho spasmodic (contraindicated in asthmatics):Ether, N2O,Thiopentone

Effects of Anesthetic Agents on Cerebral Physiology

Agent Metabolic rate Blood flow Blood volume Intracranial tension

Halothane ↓↓ ↑↑↑ ↑↑ ↑↑

Isoflurane ↓↓↓ ↑ ↑↑ ↑

Desflurane ↓↓↓ ↑ ↑ ↑↑

Sevoflurane ↓↓↓ ↑ ↑ ↑

Nitrous oxide ↓ ↑ ± ↑

Barbiturates ↓↓↓↓ ↓↓↓ ↓↓ ↓↓↓

Etomidate ↓↓↓ ↓↓ ↓↓ ↓↓

Propofol ↓↓↓ ↓↓↓↓ ↓↓ ↓↓

Benzodiazepines ↓↓ ↓ ↓ ↓

Ketamine Little or no effect ↑↑ ↑↑ ↑↑

Opioids Little or no effect

Lidocaine ↓↓ ↓↓ ↓↓ ↓↓

• When combined with intravenous agents, nitrous oxide has minimal effects on CBF, CMR, and ICP.

PAIN ON INJECTION

• On intra arterial injection: Thiopental

• On intravenous injection

o With Thrombophlebitis: Etomidate (80%)

o Without Thrombophlebitis: Propofol (40%), Methohexitol (20%), Thiopental (10%)

• Incidence is greatly reduced if a large vein is used, if a small dose of lidocaine (10mg) is injected shortly

before.

ANAESTHETIC AGENTS OF CHOICE FOR VARIOUS CONDITIONS

Day care Propofol

Ischemic heart disease Etomidate

Congenital heart disease

-Left to right shunt

-Right to left shunt

Isoflurane

Ketamine

CH F Ketamine

Shock Ketamine

To produce deliberate hypotenion Isoflurane

Asthma and COPD Ketamine

Epilepsy Thiopentone

For electroconvulsive therapy Methohexitone

Thyrotoxicosis Thiopentone

Cardiac surgery Isoflurane

Neurosurgery Isoflurane

• Liver disease:

o Induction agent: Isoflurane (least effect on hepatic blood flow)

o Relaxant: Cisatracurium, atracurium (unique nonhepatic metabolism)

• Renal Disease:

o Induction agent: Isoflurane

o IV anesthetics: thiopental & propofol.

o Opioids – Remifentanil, fentanyl, sufentanil

o Relaxant: Cisatracurium, atracurium

• Renal Disease:

o Induction agent: halothane, sevoflurane, ketamine

• Neurosurgery:

o Total intravenous anesthesia (TIVA) is preferred – propofol with opioids in anesthetic of choice.

o Among volatiles, isoflurane is agent of choice

Anesthetic drugs contraindicated in

• Acute intermittent porphyria: Thiopentone

• Acute asthma & Acute intermittent porphyria (ATP) : Althesin (Steroidal)

• Renal failure: Methoxyflurane, Galamine, Morphine, Metocurine

• Hepatic Failure: Chloroform, Halothane

BALANCED ANESTHESIA

• Thiopental: induction

• N2O: amnesia

• Meperidine: analgesia

• Curare: muscle relaxation

DAYCARE / OUT PATIENT ANESTHESIA

General anesthesia

• Inducing agents: Propofol, Methohexital, Thiopentone, etomidate

• Muscle relaxant: Mivacurium (agent of choice) , Succinyl choline

• Analgesic: Alfentanyl, Remifentanyl, Fentanyl

• Volatile inhalation agent: Isoflurane, Sevo/Desflurane

• Total intravenous anesthetic technique: Propofol/ Remifentanil/ Alfentanil/ Sufentanil

• Switch technique: Induction with Propofol, maintenance with Isoflurane, Sevoflurane, change to Propofol or

Desflurane at the end for rapid emergence.

Monitored Anesthesia

• Initial sedation & anxiolysis with a Benzodiazepine (Midazolam) followed by Propofol then local anesthesia

• For breast biopsy, ophthalmic procedure & minor plastic surgery.

� No Analgesia = Halothane

� Only Analgesia = N2O

� Profound Analgesia = Ketamine

� Best / Maximum analgesia = Trilene

MUSCLE RELAXANTS

Directly acting Neuro muscular blocking agent Centrally acting agent

• Dantrolene

• Quinine

Depolarizing (Non-competitive):

• Succinyl choline/ Scoline/ Suxamethonium

• Decamethonium

Non depolarizing (competitive):

• Gantacurium [Ultra-short acting]

• Mivacurium [Short acting]

• Vecuronium, Rocuronium, Atracurium,

Cisatracurium [intermediate acting]

Others: Galamine, d-tubo curarine, Pancuronium,

Pipecuronium, Doxacurium

Acts on cerebrospinal axis

without altering

consciousness

• Benzodiazepine

• Mephensin

• GABA derivatives

as Baclofen

DIRECT ACTING SKELETAL MUSCLE RELAXANTS

• Dantrolene inhibits release of Ca2+

from sarcoplasmic reticulum, by inhibiting Ryanodine receptors.

• Dantrolene is DOC for malignant hyperthermia and neurolept malignant syndrome.

• S/E of Dantrolene – Muscle weakness and hepatitis

• Quinine is used to treat nocturnal leg cramps.

NEURO MUSCULAR BLOCKING AGENT

• Maximum histamine release, contraindicated in Asthma: d-TC

• Minimum histamine release, used in Asthma: Vecuronium

• Shortest acting non-depolarizing muscle relaxant = Mivacurium

• Shortest acting depolarizing muscle relaxant = Succinyl choline

• Overall shortest acting muscle relaxant = Succinyl choline

• Longest acting Neuromuscular blocker = Pancuronium

• Most commonly used muscle relaxant = Vecuronium

• Most potent skeletal muscle relaxant = Doxacurium

• Least potent skeletal muscle relaxant = Succinyl choline

• Least potent Non-depolarising skeletal relaxant = Rocuronium

• Metabolized by pseudo cholinesterase: Succinyl choline & Mivacurium

• Muscle relaxant of choice in obstetrics & to decrease BP: d-Tubo curare (does not cross placenta)

• Muscle relaxant of choice to increase BP: Pancuronium

• Muscle relaxant with ganglion block: Curare, Galamine, Trimethaphan & Pancuronium

• Fastest acting non-depolarising neuromuscular blockers - Rocuronium

• Vagal & Ganglion stimulation caused by Succing choline

• Maximal vagal block & Tachycardia- Pancuronium

• Histamine release & maximal vagal blockagle- d – Tubocuramine

Depolarizing block Non depolarising block

Effect on single twitch height Depression Depression

Train of four fade Absent Present

Tetanic fade Absent Present

Post tetanic facilitation Absent Present

Effect of anti cholinesterase Potentiation of block Reversal of block

Effect of non depolarizing agent Less blockade More blockade

SUCCINYL CHOLINE

• The only depolarizing (noncompetitive) muscle relaxant in use.

• Rapid onset of action ( 30-60 seconds)

• Over all shortest duration of action (3-5 min) due to rapid hydrolysis by pseudo choline esterase.

• Succinylcholine is two acetylcholine molecules linked end-to-end.

• Scoline is metabolized completely into succinic acid + choline

• Dibucaine inhibits pseudo choline esterase activity.

• The percentage of inhibition of pseudo choline esterase activity is termed the dibucaine number.

• % of abnormal /normal pseudo choline esterase is determined by Dibucaine number & fluoride number.

• Under standardized test conditions, dibucaine inhibits the normal enzyme by 80% and the abnormal enzyme

by only 20%.

• Dibucaine-resistant (variant) gene, is m/c recognized abnormal pseudocholinesterase genes.

• Normal Dibucaine no = 75 – 85.

Drugs Known to Decrease Pseudocholinesterase Activity

Description Drug

Organophosphate use for glaucoma Echothiophate

Cholinesterase inhibitors Neostigmine,Pyridostigmine

Monoamine oxidase inhibitor Phenelzine

Antineoplastic agent Cyclophosphamide

Antiemetic/prokinetic agent Metoclopramide

β-Blocker Esmolol

Nondepolarizing muscle relaxant Pancuronium

Various agents Oral contraceptives

• Scoline transiently increases muscle tone in the masseter muscles

• Causes dual or biphasic block with doses more than 500 mg [or > 6mg/kg]

Phase I Block Features of classical depolarization block

Phase II Block Results from desensitization of receptor to Ach. & resembles competitive / non

depolarization block and partially antagonized by anticholinesterases

Side effects:

• Increases muscle tone, Intraocular pressure, Intra-abdominal pressure

• Muscle fasciculation/Muscle soreness or ache

• Hyperkalemia ���� diastolic cardiac arrest.

• Sudden Cardiac Arrest After Intubation And Succinylcholine ���� Hyperkalemia

• Increases temperature i.e. Malignant Hyperpyrexia

Conditions causing susceptibility to Succinylcholine-induced Hyperkalemia

• Burns • Parkinson's disease , Polyneuropathy

• Massive trauma • Tetanus

• Severe intraabdominal infection • Prolonged total body immobilization

• Spinal cord injury • Ruptured cerebral aneurysm

• Encephalitis • Closed head injury

• Stroke • Hemorrhagic shock with metabolic acidosis

• Guillain-Barre syndrome • Myopathies (eg, Duchenne's dystrophy)

NONDEPOLARIZING MUSCLE RELAXANTS

Relaxant Chemical

Structure

Metabolism Primary

Excretion

Histamine

Release

Vagal Blockade

Atracurium Benzyl-

isoquinolone

+++ Insignificant + 0

Cisatracurium +++ Insignificant 0 0

Mivacurium +++ Insignificant + 0

Doxacurium Insignificant Renal 0 0

Pancuronium Steroidal + Renal 0 ++

Pipecuronium + Renal 0 0

Vecuronium + Biliary 0 0

Rocuronium Insignificant Biliary 0 +

ATRACURIUM

A. Hofmann Elimination: [depends on pH & temperature]

• Inactivated in plasma by spontaneous non enzymatic degradation & by choline esterases.

• Major metabolite - laudanosine (CNS stimulant) produce epileptiform fits.

• It's duration of action is not altered in patients with hepatic and renal in sufficiency

• Muscle relaxant of choice in renal failure, anephric patients & liver disease

B. Histamine release leading to flushing of skin.

CISATRACURIUM

• Undergoes Hoffman elimination & also metabolized by kidneys.

• 4-5 times more potent than atracurium

• Laudanosine production is 5 times lesser than atracurium

PANCURONIUM

• Causes vagal blockade and releases noradrenaline.

• Produces tachycardia and hypertension.

• It is muscle relaxant of choice in shock and hypotension.

• It is metabolized by the kidney, so avoided in renal failure.

VECURONIUM

• Most commonly used muscle relaxant for routine surgery.

• Most cardio stable. It is the muscle relaxant of choice for cardiac patients.

• Contraindicated in liver disease and in biliary obstruction.

• Causes polyneuropathy on long term use.

PIPECURONIUM

• Long acting

• No vagolytic activity (or) ganglion blockade activity.

ROCURONIUM

• Earliest onset of action among non-depolarising muscle relaxant.

• Muscle relaxant of choice for pre-curarization

• Non- depolarizing muscle relaxant of choice for intubation.

ASYMMETRIC MIXED-ONIUM CHLOROFUMARATES (GANTACURIUM)

• Ultra short acting muscle relaxant.

• Degraded by two chemical mechanisms, neither of which is enzymatic:

o Rapid formation of an apparently inactive cysteine adduction product, with cysteine replacing chlorine.

o Slower hydrolysis of the ester bond adjacent to the chlorine substitution, presumably to inactive

hydrolysis products.

SUGAMMADEX

• Sugammadex is the first selective relaxant binding agent

• Sugammadex exerts its effect by forming very tight complexes in a 1: 1 ratio with steroidal neuromuscular

blocking agents (rocuronium > vecuronium >> pancuronium).

� Tubocurarine, the first muscle relaxant used clinically, produces hypotension and tachycardia through

histamine release.

� Patients allergic to iodine (eg, shellfish allergies) could exhibit hypersensitivity to metocurine preparations as

they too contain iodide.

� Gallamine has potent vagolytic properties and is entirely dependent on renal function for elimination.

� Rapacuronium is not used anymore because of severe bronchospasm.

DISEASES WITH ALTERED RESPONSES TO MUSCLE RELAXANTS

Disease Response to Depolarizers Response to Non depolarizers

Amyotrophic lateral sclerosis Contracture Hypersensitivity

Autoimmune disorders (SLE, polymyositis,

dermatomyositis)

Hypersensitivity Hypersensitivity

Cerebral palsy Slight hypersensitivity Resistance

Hemiplegia Hyperkalemia Resistance on affected side

Muscular dystrophy (Duchenne type) Hyperkalemia and malignant

hyperthermia

Hypersensitivity

Myasthenia gravis Resistance and proneness to

phase II block

Hypersensitivity

Myasthenic syndrome Hypersensitivity Hypersensitivity

Myotonia (dystrophica, congenita,

paramyotonia)

Generalized muscular

contractions

Normal or hypersensitivity

Severe chronic infection (tetanus, botulism) Hyperkalemia Resistance

Sequence of muscle blockade after muscle relaxants therapy

• First muscle to be blocked: Central muscles (muscles of face) followed by jaw � pharynx larynx �

respiratory muscles � peripheral muscles

• In general, larger muscles (eg, abdominal, trunk, paraspinous, diaphragm) are more resistant to

neuromuscular blockade and recover more rapidly than smaller muscles (eg, facial, foot, hand).

• The diaphragm is usually the last muscle to be paralyzed

• Recovery occurs in the reverse order.

• Muscle monitored for activity during blockade: Adductor pollicis

Reversal of Muscle Relaxation

• Depolarizing (Non- competitive) agents are not antagonized

• Non-Depolarizing (Competitive) MR are antagonized by Acetyl choline or Anti Choline EsteraseNeostigmine,

Pyridostigmine and Edrophonium.

• Atropine is given to prevent muscarinic effects.

• Recent drug: Sugammadex [sugar, gamma cyclo dextrin]

o Causes quick & complete recovery, reverses profound neuromuscular blockade

o Has hydrophobic cavity with hydrophilic exterior [soluble in water � traps drug in the center]

MALIGNANT HYPERTHERMIA

• Drug- or stress-induced hypermetabolic syndrome.

• Vigorous muscle contractions, an abrupt increase in temperature, subsequent cardiovascular collapse

• Uncontrolled release of Ca2+

from the sarcoplasmic reticulum due to defect in the ryanodine receptor

(RYR1) is the initiating event

• Inherited as autosomal dominant fashion, with variable penetrance & expressivity.

• Triggers: Stress, excitement, anoxia, viral infections, lymphoma, ischemia or hypoxia.

Drugs known to trigger malignant hyperthermia Drugs safe in malignant hyperthermia

• Halothane

• Methoxyflurane

• Enflurane, isoflurane

• Succinylcholine

• Decamethonium

• Gallamine

• Diethyl ether, Ethylene, Ethyl chloride

• Trichloroethylene

• Ketamine

• Phencyclidine

• Cyclopropane

• Nitrous oxide

• Barbiturates

• Diazepam

• Tubocurarine

• Pancuronium, vecuronium

• Opiates

• Early signs: masseter muscle contracture, muscle rigidity, metabolic acidosis, sinus tachycardia,

supraventricular tachyarrhythmias, mottling or cyanosis of the skin, increased cot production, and

hypertension.

• Two signs helpful in making a prehyperthermic diagnosis

o Increased end-tidal CO2

o Masseter spasm

• M/C with combination of depolarizing blocking agent and anesthetic.

Management of Malignant Hyperthermia

• Discontinue volatile anesthetic and succinylcholine.

• Hyperventilate with 100% O2 at high flows.

• Administer sodium bicarbonate, 1-2 mEq/kg intravenously.

• Mix dantrolene sodium with sterile distilled water and administer 2.5 mg/kg iv

• Institute cooling measures (lavage, cooling blanket, cold intravenous solutions).

• Administer additional doses of dantrolene if needed.

• Treat severe hyperkalemia with dextrose, 25-50 g IV, and regular insulin, 10-20 U intravenously (adult dose).

NEUROLEPTIC MALIGNANT SYNDROME

• Rare complication of antipsychotic therapy, meperidine and metoclopramide

• Mechanism: dopamine blockade in the basal ganglia and hypothalamus and impairment of

thermoregulation.

• Muscle rigidity, hyperthermia, rhabdomyolysis, autonomic instability, altered consciousness

• Laboratory findings: increased WBC count and increased levels of creatinine phosphokinase, liver enzymes,

plasma myoglobin and myoglobinuria

• Deaths occur primarily as a result of renal failure or arrhythmias

Diagnostic criteria:

A. Developmental of severe muscle rigidity & elevated temperature associated with use of neuroleptic

medication.

B. Two or more of the following

1. Diaphoresis (sweating)

2. Dysphagia

3. Tremors

4. Tachycardia

5. Incontinence

6. Mutism

7. Change of level of consciousness from confusion to coma

8. Elevated or labile B.P

9. Leucocytosis

10. Laboratory evidence of muscle injury (e.g. elevated CPK), renal function test

C. Symptoms are not due to phencyclidine, viral encephalitis or mood disorder with catatonic features.

Treatment: Dantrolene (drug of choice) or Bromocriptine/Amantadine

LOCAL ANESTHETICS

• Interfere with the excitation process in a nerve membrane in one or more of the following ways:

• Altering the basic resting potential of the nerve membrane

• Altering the threshold potential (firing level)

• Decreasing the rate of depolarization

• Prolonging the rate of repolarization

Classification of Local Anesthetics according to Biological site and Mode of action

Type Definition Chemical substance

A Acting at receptor site on external surface of nerve membrane Biotoxins (tetrodoxins,

saxitoxins)

B Acting at receptor site on internal surface of nerve membrane

.

Quaternary ammonium analogs

of lidocaine, Scorpion venom

C Acting by a receptor independent physico-chemical

mechanism

Benzocaine

D Acting by combination of receptor and receptor- independent

mechanisms

Most LA's (articaine, lidocaine,

mepivacaine, prilocaine)

• LA's are weak bases carrying a positive charge at the tertiary amine group at physiological pH.

• Mechanism of action: Blocks voltage gated Na+ channels from inside of cell membrane by binding to a-

subunit.

• Nerve block produced by local anesthetics is called a nondepolarizing nerve block.

Classification of Local Anesthetics based on chemical structure

ESTERS AMIDES Quinoline

Esters of benzoic acid Esters of para-aminobenzoic acid Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

Centbucridine

Butacaine

Cocaine

Ethyl aminobenzoate

(benzocaine)

Hexylcaine

Piperocaine

Tetracaine

Chloroprocaine

Procaine

Propoxycaine

Local anesthetic

Ester linked Amide linked

Metabolism By pseudocholinesterase N-dealkylation and hydroxylation by

microsomal P-450 enzymes in the

liver.

Shorter duration (< 30

min)

Procaine (low potency)

Chlorprocaine (intermediate

potency)

Intermediate duration

& potency (30-90 min)

- Lidocaine, Mepivacaine, Prilocaine

Long duration &

potency ( > 120 min)

Tetracaine, Benzocaine Bupivacaine, Ropivacaine, Dibucaine,

Etidocaine

Alkalinization of local anesthetics by adding sodium bicarbonate

• Speeds onset

• Improves the quality of the block

• Prolongs blockade by increasing the amount of free base available.

• Most useful for agents such as lidocaine, mepivacaine, and chloroprocaine.

• Sodium bicarbonate is usually not added to bupivacaine, which precipitates above a pH of 6.8.

Sensitivity of nerve fibres for local anesthetics

• Small myelinated axons (Ay motor & Aδ sensory fibers) are most susceptible to local anesthetics.

• Next in order of block are the large myelinated (Aα and Aβ) fibers

• Least susceptible are the small, nonmyelinated C fibers.

• Among sensory fibres temperature (cold > heat ) > pain > touch > deep pressure > proprioception

Effects of addition of a Vasoconstrictor to Local Anesthetic

(Eg: adrenaline, Concentration: 1:50,000 to 1:200,000)

• Prolongs duration of action by decreasing their rate of removal from the local site

• Reduces systemic toxicity of LAs: rate of absorption is reduced

• Makes the injection more painful

• Provides a more bloodless field for surgery.

• Increases the chances of subsequent local tissue edema and necrosis as well as delays wound healing by

reducing oxygen supply and enhancing oxygen consumption in the affected area

LIGNOCAINE

• Lignocaine should not be used in patients with history of malignant hyperthermia

• Lignocaine is used for ventricular fibrillation specially after MI

• Lignocaine can produce cauda equina syndrome

• Preservative free lignocaine called as xylocard is preferred for IV injection.

• Lidocaine transdermal patch: (LIDODERM) - relief of pain associated with postherpetic neuralgia.

Lignocaine dose:

• With adrenaline: 7 mg/kg

• Without adrenaline: 4 mg/kg

Concentration of Lignocaine

• IV Regional anaesthesia 0.5%

• Nerve block 1%

• Epidural / Jelly 2%

• Topical 4%

• Spinal 5%

Lignocaine with adrenaline SHOULD NOT be used for:

• Areas with end arteries e.g. for ring block of fingers, toes, penis, pinna (absolute contraindication)

• When an inhalational agent especially halothane which sensitizes myocardium to adrenaline is used

• Myocardial ischemic patients

• Hyperthyroid patient

• Severe hypertensives

• Intravenous regional anaesthesia (Bier's block)

Anticonvulsive Blood Levels of Lidocaine:

Clinical Situation Lidocaine Blood Level μg/mL

Anticonvulsive level 0.5-4

Preseizure signs and

symptoms

4.5-7

Tonic—clonic seizure >7.5

DOSE OF ADRENALINE:

Condition Route of administration Adrenaline dose

Branchial asthma Inhalational 1 in 100

Anaphylactic shock I.M, S.0 1 in 1000

I.V 1 in 10,000

Cardiac arrest Intra-cardiac 1 in 10,000

With Local anaesthesia Subcutaneous 1 in 2,00,000

Epinephrine 1:1000 contains 1 mg of epinephrine per ml. 1:1000 solution adrenaline

= ig adrenaline in 1000m1 solution

= 1000mg adrenaline per 1000mIsolution

= 1mg per ml

OTHER LOCAL ANESTHETIC AGENTS Cocaine:

• First discovered LA

• Only naturally occurring LA

• Vasoconstrictor action

• Not to be used with adrenaline d/t cardiac arrhythmias & ventricular fibrillation.

Prilocaine:

• Safest

• Maximum Methemoglobinemia

• O-Toludine metabolites accumulate after large doses & convert hemoglobin to methemoglobin

• Treatment of Methemoglobinemia: IV methylene blue (1-2mg/ kg of 1% solution) which reduces

methemoglobin (Fe3+) to hemoglobin (Fe2+)

• Most suitable for Bier's IV block

Bupivacaine:

• Most potent

• Best for isobaric anesthesia and regional block

• Contraindicated in regional IV anesthesia

• Long duration of action plus its differential blockade (sensory> motor) has made it a popular drug for

providing prolonged analgesia during labor or the postoperative period.

• Bupivacaine is a racemic mixture of (R) & (S) isomers while Levobupivacaine (Chirocaine) contains single (S)

stereoisomer, both containing butyl groups.

• The most common ECG finding with bupivacaine intoxication is slow idioventricular rhythm with broad QRS

complexes and eventually, electromechanical dissociation.

• Bupivacaine is the most cardiotoxic local anesthetic - should not be used for Bier's block.

• Recent recommendation for treatment of bupivacaine induced cardiotoxicity: 20% intralipid [4m1/kg

followed by 0.5m1/kg/min infusion]

• Bupivacaine is LA of choice for isobaric spinal anesthesia.

• It is most commonly used for a carpal tunnel release.

• Newer drug: Depobupivacaine- multivesicular liposomal formulation of bupivacaine with long lasting effect

(72 hours).

Procaine:

• LA of choice in malignant hyperthermia

• 15t synthetic LA

Chlorprocaine:

• When injected into the subarachnoid space or intradurally it may cause paraplegia, d/t preservative,

sodium bisulfate (now replaced with an antioxidant, a derivative of EDTA).

• Severe back pain following epidural administration.

Mepivacaine: not metabolized by neonates so C/I neonates & labour

� Shortest acting LA – Chlorprocaine

� Longest acting LA – Dibucaine > Tetracaine > Bupivacaine

� All LAs are vasodilators except lignocaine (no vasogenic action) & Cocaine (vasoconstrictor)

LA used in surface anesthesia Never used as surface anesthetic

Hexycline, Lignocaine,Dibucaine, Tetracaine Procaine, Mepivacaine

Prilocaine, Cocaine Bupivacaine

• Articaine (Septocaine) is a recently introduced amino amide, approved in the U.S. for dental and

periodontal procedures. It exhibits a rapid onset (1-6 minutes) and duration of action of –1 hour.

• Benzocaine a common ingredient in local anesthetic sprays also can cause Methemoglobinemia.

• Ropivacaine: contains propyl group, made of single (S) stereoisomer

• Compared to bupivacaine, Ropivacaine is less cardiotoxic, less potent with shorter duration of action

• LA's are myotoxic (bupivacaine > lidocaine > procaine, Least with Ropivacaine), if injected directly into a

muscle

EMLA cream (Eutectic [easily melted] Mixture of Local Anesthetics)

• 5% emulsion containing 2.5% lidocaine and 2.5% prilocaine

• Used as an anesthetic prior to venipuncture, skin graft harvesting, laser removal of portwine stains,

lithotripsy and circumcision.

• EMLA cream should not be used on mucous membranes, broken skin, infants less than 1 month old, or

patients with a predisposition to methemoglobinemia

ADJUNCTS TO ANESTHESIA

General principles

• Stop ACEI/ ARB 24 hours before surgery.

• Stop metformin 24 hours before surgery.

• Stop sulfonylureas the night before surgery.

• Stop diuretics once the patient is NPO.

• Continue statins.

• Continue CNS-active drugs.

• Insulin may require adjustment.

• Stop OCPs and HRT four weeks before surgery, if possible.

• Stop nonselective NSAIDs two to three days before surgery, but continue COX-2 inhibitors.

• Continue outpatient dosing of corticosteroids and add a stress dose.

• Stop DMARDs and biologics one week before surgery.

• Stop herbal medicines one to two weeks before surgery.

PRE ANAESTHETIC MEDICATION

• Opioids - Morphine

• Anxiolytics – Diazepam

• Hypnotic – Barbiturate

• Anti cholinergics- Atropine, Hyoscine

• Neuroleptic – chlorpromazine

ADJUNCTS FOR ANESTHESIA

• H2 blocker - Metoclopramide, Ondansetron: reduce the risk of aspiration pneumonia.

• Diphenhydramine: antimuscarinic or atropine-like activity or antiserotonergic activity (antiemetic)

• Metoclopramide increases lower esophageal sphincter tone, speeds gastric emptying, and lowers gastric

fluid volume.

• Serotonin 5-HT3 receptor blockers like Ondansetron, granisetron, dolasetron - anti emetic effects.

• Clonidine: an adjunct for epidural infusions in pain management. Most useful in neuropathic pain.

• Dexmedetomidine is a parenteral selective a2-agonist with sedative properties.

• Selective activation of carotid chemoreceptors by low doses of doxapram stimulates hypoxic drive,

producing an increase in tidal volume and a slight increase in respiratory rate.

• Patients are at risk if their gastric volume is greater than 25 mL (0.4 mL/kg) and their gastric pH is less than

2.5.

Post Anesthetic Muscular Complications

• Catatonia: Droperidol

• Muscle spasm & Rigidity: Fentanyl (opioids)

• Fasciculation, Soreness and Ache: Suxamethonium

• Increased muscle tone: Ketamine & Suxamethonium

IMPORTANT FACTS

• Post operative shivering: treated by pethidine/pentazocine.

• Intravenous meperidine (25 mg) - most effective opioid for decreasing shivering.

• Inhalational anesthetic that boils at room temperature: Desflurane

• Primary site of action of ketamine: Thalamoneocortical projection

• Abnormal spike discharges in epileptic patients: Methohexitone

• Steroid anesthetic: Althesin, Minaxolone

• Heid brink meter indicates: flow rate of gases

• Armoured ET tube: used in neurosurgery

• Aspiration of gastric contents: Mendelson's syndrome

• First reflex to appear during recovery from anesthesia: swallowing

• 5 % CO2 is used for creating pneumoperitoneum during laparoscopy

• A mixture of 80% helium and 20% O2 is used for tracheal obstruction.

• M/C complication in pediatric anesthesia: laryngospasm.

• M/C complication in adult patients under GA: Dysarhythmias & Hypotension

• Neurolept analgesia: Fentanyl + Droperidol

• Neurolept anesthesia: Fentanyl + Droperidol + 65% N2O + 35% O2

III. REGIONAL ANESTHESIA & PAIN MANAGEMENT

Baricity of Anesthetic Agents

• Higher the dosage or site of injection, the higher the level of anesthesia obtained.

• Migration of the drug in CSF depc.t.ius on its specific gravity relative to CSF (baricity).

• A hyperbaric solution is denser (heavier) than CSF, whereas a hypobaric solution is less dense (lighter) than

CSF.

• Solutions can be made hyperbaric by adding glucose or hypobaric by adding sterile water.

• In head-down position, a hyperbaric solution spreads cephalad and a hypobaric anesthetic solution moves

caudad; and vice-versa in head-up position

• Anesthetic agents are mixed with CSF (at least 1:1) to make their solutions isobaric.

• Hyperbaric bupivacaine and tetracaine are most commonly used agents for spinal anesthesia.

• Both are relatively slow in onset (5-10 min) and have a prolonged duration (90-120 min).

• Hyperbaric spinal anesthesia is more commonly used than the hypobaric or isobaric techniques.

• The level of anesthesia is dependent on the patient's position during and immediately following the

injection.

• In the sitting position, "saddle block" can be achieved by keeping the patient sitting for 3-5 min following

injection so that only the lower lumbar nerves and sacral nerves are blocked.

INTRAVENOUS REGIONAL ANESTHESIA (BIER'S BLOCK)

• It consists of injection of LA in a vein of a tourniquet occluded limb.

• 0.5% Lidocaine is most commonly used in drug

• Mainly used for upper limb orthopedic procedures as it is most difficult to obstruct blood supply of lower

limb.

SPINAL ANESTHESIA

• The principal site of action for neuraxial blockade is the nerve root.

• Neuraxial anesthesia does not block the vagus nerve.

• The drug is injected in subarachnoid space (piamater and arachnoid membrane)

• Injection below L1 in adults and L3 in children avoids trauma to the spinal cord.

• Quincke needle is a cutting needle with end injection.

• Blunt tip (pencil-point) needles decrease the incidence of postdural puncture headache.

• Heavily myelinated, small preganglionic sympathetic fibers and pain fibers are blocked first.

• Motor fibers are blocked last.

• The level of motor block is two to four dermatomes lower than the level of sensory anesthe

• Sequence of blockade autonomic � sensory � motor

Confirmation of spinal needle: feel of two "pops".

• The first is penetration of the ligamentum flavum

• The second is penetration of the dura-arachnoid membrane.

Factors Affecting the Level of Spinal Anesthesia

Most important factors Other factors

• Baricity of anesthetic solution

• Position of the patient during &

• Immediately after injection

• Drug dosage

• Site of injection

• Age, Patient height, Pregnancy

• Cerebrospinal fluid

• Curvature of the spine

• Drug volume

• Intra -abdominal pressure

• Needle direction

• MOA- Local anesthetic acts on spinal nerves and dorsal ganglia

• Unconsciousness, apnea, and hypotension resulting from high levels of spinal anesthesia are referred to as a

"high spinal" or "total spinal."

• Complications of SAB:

o Hypotension –M/c complication of SAB. Preventive measures are head low position to increase venous

return, fluid preloading with RL, prophylactic vasopressor, oxygen supplementation

o Bradycardia –M/c arrhythmia

o Apnea

o Cardiac arrest

o Anaphylaxis

o Nausea & Vomiting

o 6th

cranial nerve is M/c nerve involved due to longest intracranial course.

o Transient neurological symptoms (TNS), also called as transient radicular irritation

o Post Dural puncture Headache (PDPH)

Post Dural Puncture Headache (PDPH)

• Presents 12-24hrs after spinal block

• Usually occipital but can also be frontal

• Increases on sitting & relieved on lying down

• Lasts for 7-10 days but may be for 3 weeks

• Cause – Due to CSF leakage through dural rent

• Treatment:

o Small size needle

o Adequate hydration

o Prone or supine position

o Analgesic

o Oral or I/V caffeine

o Autologous epidural blood patch (most effective): stop further leakage of CSF by either mass effect or

coagulation

Factors that may increase the incidence of Post–spinal Puncture Headache

Age Younger more frequent

Gender Females > males

Needle size Larger > smaller

Needle bevel Less when the needle bevel is placed in the long axis of the neuraxis

Pregnancy More when pregnant

Dural punctures (no.) More with multiple punctures

Factors not increasing the incidence of Post–spinal Puncture Headache

Continuous spinals

Timing of ambulation

Contraindications to spinal anaesthesia

Absolute Relative

• Raised intracranial pressure

• Patient refusal

• Shock: Hypotension and hypovolemia

• Infants and children- control of level is difficult.

• Bleeding disorders

• Patient's on anticoagulants

• Infection of the local site and

• Septicemias

• Vertebral abnormalities (kyphosis, lordosis, etc.)

• Aortic and mitral stenosis

• MI

• Heart block

• Spinal deformities

• Psychiatric and CNS disorders

Agents used in Spinal Anesthesia

• Bupivacaine: 0.5% in 8.25% dextrose, 0.5% plain

• Lidocaine: 2% plain, 5% in 7.5% dextrose

• Procaine: 10% plain, 2.5% in water

• Tetracaine: 0.5% in water, 0.5% in D5W

Parameter Spinal Anesthesia Epidural Anesthesia

Level performed Lumbar Any Level

Cost Cheaper Expensive

Onset of Effect 2- 3 minutes 15 – 20 minutes

Duration of Effect Lesser Prolonged

Quality of block Total Patchy

Post spinal head ache Present Absent

Epidural hematoma Less common More common

Total spinal Rare High chances

Intravascular injection Rare High chances

Drug toxicity Less common More common

Catheter complication Absent Present

EPIDURAL BLOCK

• Drug is injected in the epidural space between the ligamentum flavum and the duramater.

• The standard (Tuohy needle, directional needle) epidural needle has a blunt bevel with a gentle curve of 15-

30° at the tip.

• Straight needles without a curved tip (Crawford needles): higher incidence of dural puncture but facilitate

passage of an epidural catheter.

• Methods to locate epidural space (negative pressure test)

− Hanging drop technique

− Loss of resistance (preferred)

− Macintosh extradural space indicator

• Indications for Epidural Anesthesia:

o Mainly used for controlling post – operative pain & Chronic cancer pain

o Painless labor

o Can be used for all surgeries done by spinal anesthesia

• Advantages of epidural anaesthesia

o Less hypotension

o No postspinal headache

o Level of block can be extended

o Any duration of surgery can be performed

CAUDAL BLOCK (EPIDURAL SACRAL BLOCK)

• Sacral epidural anesthesia is referred to as a caudal block.

• Drug penetrates the sacrococcygeal ligament covering the sacral hiatus that is created by the unfused S4

and S5 laminae.

• Also employed for labor and postoperative analgesia.

• Mainly used in children for perineal and genitourinary surgery.

• Within the sacral canal, the anesthesia bathes the S2–S4 spinal nerve roots, including the pain fibers from

the uterine cervix and superior vagina, and the afferent fibers from the pudendal nerve.

• The entire birth canal, pelvic floor, and majority of the perineum are anesthetized

• Lower limbs are not usually affected.

• The pain fibers from the uterine body (superior to the pelvic pain line) ascend to the inferior thoracic-

superior lumbar levels; these and the fibers superior to them are not affected by the anesthetic, so the

mother is aware of her uterine contractions.

• With epidural anesthesia, no " spinal headache" occurs because the vertebral epidural space is not

continuous with the cranial extradural (epidural) space

PUDENDAL NERVE BLOCK

• Peripheral nerve block that provides local anesthesia over the S2-S4 dermatomes.

• Blocks the majority of the perineum and the inferior quarter of the vagina.

• Does not block pain from the superior birth canal (uterine cervix and superior vagina), so the mother is able

to feel uterine contractions.

INFILTRATION ANESTHESIA

• Lidocaine (0.5-1%), procaine (0.5-1%), and bupivacaine (0.125-0.25%).

• When used without epinephrine, up to 4.5 mg/kg of lidocaine, 7 mg/kg of procaine, or 2 mg/kg of

bupivacaine can be employed in adults.

• When epinephrine is added, these amounts can be increased by one-third.

CERVICOTHORACIC (STELLATE) BLOCK

• Used in patients with head, neck, arm and upper chest pain.

• The paratracheal technique is most commonly used.

• Confirmation of block: increase in the skin temperature of the ipsilateral arm and the onset of Horner's

syndrome.

• Complications: hematoma, pneumothorax, epidural anesthesia, brachial plexus block, hoarseness due to

blockade of the RLN and rarely, osteitis or mediastinitis following esophageal puncture.

Advantages of post operative analgesics:

• Patient comfort

• Increase mobility

• Fewer pulmonary and cardiac complications

• Reduced risk of DVT

• Less likelihood of developing neuropathic pain

• reduced cost of care

PATTERNS OF REFERRED PAIN

Location Cutaneous Dermatome

Central diaphragm C4

Lungs T2—T6

Heart T1—T4

Aorta T1—L2

Esophagus T3-18

Pancreas and spleen T5—T10

Stomach, liver and gallbladder T6—T9

Adrenals T8—L1

Small intestine T9—T11

Colon T10—L1

Kidney, ovaries, and testes T10—L1

Ureters T10—T12

Uterus T11—L2

Bladder and prostate S2—S4

Urethra and rectum S2—S4

Jannetta procedure: Microsurgical decompression of the trigeminal nerve for trigeminal neuralgia (tic douloureux).

IV. PHYSIOLOGY, PATHOPHYSIOLOGY OF ANESTHETIC MANAGEMENT

Average Blood Volumes

Age Blood Volume

Neonates

Premature 95 mL/kg

Full-term 85 mL/kg

Infants 80 mL/kg

Adults

Men 75 mL/kg

Women 65 mL/kg

Characteristics of Neonates and Infants that differentiate them from Adult Patients

Physiological Anatomical

• Heart-rate-dependent cardiac output

• Faster heart rate

• Lower blood pressure

• Faster respiratory rate

• Lower lung compliance

• Greater chest wall compliance

• Lower functional residual capacity

• Higher ratio of body surface area to body

weight

• Higher total body water content

• Noncompliant left ventricle

• Residual fetal circulation

• Difficult venous and arterial cannulation

• Large head and tongue

• Narrow nasal passages

• Anterior and cephalad larynx

• Long epiglottis

• Short trachea and neck

• Prominent adenoids and tonsils

• Weak intercostal and diaphragmatic muscles

• High resistance to airflow

Pharmacological

• Immature hepatic biotransformation

• Decreased protein binding

• Rapid rise in FA/FI (Fractional alveolar concentration/fractional inspired concentration)

• Rapid induction and recovery

• Increased minimum alveolar concentration

• Larger volume of distribution for water-soluble drugs

• Immature neuromuscular junction

Anatomical dead space is increased

by

Anatomical dead space is decreased

by

Alveolar dead space is increased

by

• Old age

• Neck extension

• Jaw protrusion

• Bronchodilators (Atropine)

• Halothane

• Increased lung volume

• Anesthesia mask & Circuits

• IPPV

• PEEP

• Intubation

• Tracheostomy

• Hyperventilation

• Neck flexion

• Bronchoconstrictors

• Massive pleural effusion

• IPPV

• PEEP

• General anesthesia

• Hypotension

• Lung pathologies affecting

diffusion like interstitial

lung disease, Pulmonary

embolism, pulmonary

edema, ARDS

Physiological dead space is decreased by

• Supine posture

• Neck flexion

• Bronchoconstrictor

• Artificial airway (Eg: intubation, tracheostomy).

� Induction of anesthesia consistently produces 15-20% reduction in FRC (400m1 in most patients).

� M/C cause of airway obstruction in unconscious patients - tongue falling back against posterior pharynx.

FLUID MANAGEMENT & TRANSFUSION

CRYSTALLOIDS COLLOIDS

• RL (slightly hypotonic)

• NS & 5% Dextrose (isotonic)

• DNS & Hypertonic saline (Hypertonic)

• Intravascular half life – 30 mins. Expands plasma

volume for less time

• For replacing blood loss 3 times the lost fluid

should be given

• Albumin, Gelatin, Dextran, Hydroxyethyl

starch, blood – Hypertonic

• Expands plasma volume for 2 - 4 hours

• Given in 1:1 ratio

• NS – preferred over RL for hypochloremic metabolic alkalosis, brain injury (as calcium ions increase

neuronal injury), hyponatremia, to maintain BP in hypovolemia

• DNS – best used maintenance fluid intraoperatively

• Hypertonic saline – hyponatremia, cerebral and pulmonary edema

• Dextran – LMW dextran improves microcirculation; can interfere with blood grouping and cross matching

• Blood - the ideal fluid to be used in hemorrhagic shock.

Composition of Crystalloid Solutions

Solution Tonicity

(mOsm/L)

Na+

(mEq/L)

CI-

(mEq/L)

K+

(mEq/L)

Ca 2+

(mEq/L)

Glucose

(g/L)

5% dextrose in water

(D5W)

Hypo (253) 50

Normal saline (NS) Iso (308) 154 154

D51/4 NS Iso (355) 38.5 38.5 50

D51/2 NS Hyper

(432)

77 77 50

D5NS Hyper

(586)

154 154 50

Lactated Ringer's (RL) Iso (273) 130 109 4 3

D5LR Hyper

(525)

130 109 4 3 50

1/2NS Hypo (154) 77 77

INTRAOPERATIVE FLUID THERAPY

• Fluid loss due to starvation: 2mL/kg/hr

• Maintenance fluid: 2mL/kg/hr

• Third space losses – fluid accumulation in the tissues in the form of edema

� 4mL/kg/hr – for surgeries with minimum dissection. e.g: Herniorrhaphy

� 6mL/kg/hr – moderate dissection. e.g: Gastrojejunostomy and vagotomy

� 8mL/kg/hr – heavy dissection.e.g: Whipple's procedure

• Blood loss to be replaced by compatible blood transfusion, when the hematocrit falls below 25%

OBSTETRIC ANESTHESIA

• Ephedrine: vasopressor of choice for hypotension during pregnancy

• a-adrenergic agonists (phenylephrine and metaraminol) - less fetal acidosis than ephedrine.

• The greatest strain on the parturient's heart occurs immediately after delivery (increase in cardiac output as

much as 80% above prelabor values)

• Caesarean section in CVS disease complicating pregnancy - mainly done for obstetric indications

• In coarctation of aorta, elective CS - to prevent rupture of the aorta or mycotic cerebral aneurysm.

• Needle for epidural block: Tuohy's needle.

• Average blood loss during vaginal delivery is 400-500 mL (800-1000 mL in cesarean section)

• Blood volume does not return to normal until 1-2 weeks after delivery.

Induction in Pediatric patients

Inhalation Intravenous Intramuscular

Single Breath induction

Sevoflurane in N2O for rapid induction

Classical method N2O & O2 &

Sevoflurane / halothane is added

Rapid acting barbiturate or

Propofol followed by non

depolarizing muscle relaxant (eg;

rocuronium, atracurium,

mivacurium) or Succinyl choline

IM Ketamine –combat

children

CONTROLLED HYPOTENSION

• Elective lowering of arterial blood pressure.

• Maintaining the mean arterial pressure at the level of 50-65 mmHg.

• Reduction in baseline MAP by 30%.

• Advantages: minimization of surgical blood loss and better surgical visualization

• Methods:

o Positioning: elevation of the surgical site � blood pressure at the wound is selectively reduced

o Positive-pressure ventilation

o Ganglion blockers: Trimethaphan is the drug of choice.

o Due to their rapid onset and short duration of action, sodium nitroprusside and nitroglycerin have the

advantage of precise control.

o Creation of a high sympathetic block with an epidural or spinal anesthetic.

o Hypotensive anesthetics like propofol can be used clinically

• Indications: cerebral aneurysm repair, brain tumor resection, total hip arthroplasty, radical neck dissection,

radical cystectomy and other operations associated with significant blood loss.

• Contraindications: Severe anemia, hypovolemia, atherosclerotic cardiovascular disease, renal or hepatic

insufficiency, cerebrovascular disease, or uncontrolled glaucoma.

V. SPECIAL PROBLEMS

CARDIOPULMONARY RESUSCITATION

THE 2010 AHA GUIDELINES FOR CPR

• Recommend a change in the BLS sequence of steps from A-B-C (Airway, Breathing, Chest compressions) to

C-A-B (Chest compressions, Airway, Breathing) for adults, children, and infants (excluding the newly born).

• Continuous quantitative waveform capnography is recommended for confirmation and monitoring of

endotracheal tube placement.

• Atropine is no longer recommended for routine use in the management of pulseless electrical activity

(PEA)/asystole.

• Increased emphasis on physiologic monitoring to optimize CPR quality.

• Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable

undifferentiated regular monomorphic wide-complex tachycardia.

New Recommendations

• Hands Only CPR.

• CPR is the only treatment for sudden cardiac arrest.

• Don't stop pushing. Every interruption in chest compressions interrupts blood flow to the brain, which leads

to brain death if the blood flow stops too long.

• Defibrillation using biphasic electrical current works best.

• Bretylium is no longer recommended.

• Glucose & calcium solutions are to be avoided ���� hypercalcemia & hyperglycemia results in neuronal

damage.

• Vasopressin has been added and amiodarone has gained new emphasis in these newest guidelines.

CHEST COMPRESSION

• At least 100 compressions per minute (30 compressions in 18 seconds)

• Chest compression to ventilation ratio is 30:2

• Sufficient force is applied to depress the sternum 4-5 cm (1 1/2 to 2 inches)

• In newborns, the depth of chest compressions should be one third of the AP diameter of the chest.

• Allow complete recoil of chest

• Switching rescuers every 2 mins

< 2 months Infants & children Adult

Compression 90/min 100/min 100/min >100/min

Compression ventilation ratio 2 Rescuer: 3:1 Single rescuer: 30:2 Two rescuer: 15:2 30:2

High quality CPR:

• Minimize interruptions during compressions

• Avoid hyperventilations

• Higher the CPR - Better the surrival

• Not > 10 secs for pulse check

• EtCO2 <10 mm Hg - No ROSC

• EtCO2 <20 mm Hg – Inefficient compression

• Tidal volume 500-600 ml

� In CPR, breaths are delivered slowly with a smaller tidal volume of 700-1000m1, smaller (400-600m1) if

supplemental 0 2 is used.

� A rescuer's exhaled air has an oxygen concentration of only 16-17% and contains significant CO2

� Cricoid pressure (Sellick's maneuver) decreases the possibility of regurgitation and aspiration during

intubation.

Cardiac Massage :

• Adults: Compressions over lower third of sternum (2 fingers above xiphoid process)

• Children: Two thumbs technique for compressions

• Newborns: Two thumbs with encircled chest technique for compressions.

• Pregnant: External cardiac massage with lateral tilt..

Airway management

• Laryngoscope:

o The most commonly used laryngoscope is Macintosh which has curved blades.

o Position of head and neck during laryngoscopy is "Extension at atlanto occipital joint 7585 degrees and

flexion at cervical spine 15-25 degrees – Magill position"

o Complication – MC injury during laryngoscopy is damage to upper incisors

• Endotracheal tubes:

o Increases dead space in adult (by 70mL)

o Decreases dead space in children.

o In small children < 10 years uncuffed tube should be used but with the advent of newer cuffs, cuffed

tubes can be used even for children.

Size of endotracheal tubes:

Premature baby 2.5 mm

0 -6 Months 3 to 3.5 mm

6 Months –1 Year 3.5 to 4 mm

Children < 6 Year Age in years + 3.5 mm

3

> 6 years – 15 year Age in Years + 4.5 mm

4

Adult females 7.5 to 8 no.

Adult males 8.5 to 9 no.

• Reflex response to intubation – tachycardia, hypertension, laryngospasm, ↑ICT, ↑ Cortisol and

catecholamines

• Methods to inhibit reflex response – xylocaine spray, xylocard injection, opioids, Ca Channel blockers

• RAE tube – used for oral and dental surgeries like cleft lip and cleft palate

• Robert Shaw and Carlen tube

o Used for thoracic surgeries or single lung ventilation.

o To prevent spillage of pus and malignant cells during bronchopleural lavage

o The major side effect is hypoxia due to malposition and ventilation perfusion mismatch.

o Confirmation is done by bronchoscopy.

Indications for Nasal

intubation

Contraindications of nasal intubation Contraindications for both oral and

nasal intubation

• Oral surgeries

• Fracture of Mandible

• Awake intubation

• Prolonged intubation

• Basal skull fractures

• CSF Rhinorrhea

• Nasal mass

• Adenoids

• Any coagulopathies

• Laryngeal edema

• Epiglottitis

• Laryngeo – tracheo bronchitis - In

such pt's tracheostomy is preferred

Advantages of nasal over oral intubation Blind nasal intubation is done in

• Better fixation

• Less chances of extubation

• Better tolerated

• Temporo – mandibular joint ankylosis

• Christmas or locked jaw

• Neck contractures

Breathing / Ventilation :

• Mouth to Mouth

• Mouth to airway – Safar or Brook airway

• Bag and mask – Increases aspiration, increases dead space, exhaustive

• Advanced methods – Endotracheal tube (Best method), LMA, Combitube, Tracheostomy tube

• Automatic ventilators

Contra-Indications for Bag and Mask Ventilation :

• Full stomach

• Aspiration Risk (Pregnancy, Hiatus Hernia)

• Intestinal Obstruction

• Unconscious / Semiconscious patients

• Diaphragmatic Hernia

• Tracheo – Esophageal fistula

• Meconium aspiration

Monitoring of CPR

• Capnography – Most reliable, best indicator

• Palpation of Carotid pulse – Most effective clinical indicator

• Invasive blood pressure

• Central venous oxygen saturation

VENTRICULAR FIBRILLATION OR PULSELESS

VENTRICULAR TACHYCARDIA

Complications of CPR

• Rib fracture

• Pneumothorax, pneumomediastinum, pneumopericardium

• Injury to diaphragm, stomach, lungs, major vessels, abdominal organs.

Drugs Used in CPR

• Vasopressors - Adrenaline, Noradrenaline

• Inotropes - Dopamine, Dobutamine

• Beta Blockers

• Anticholinergics

• Vasodilators

• Anti-arrhythmics

Drugs Contraindicated in CPR :-

• Calcium – only indications: Hypocalcemia, Hyperkalemia

• Sodium bicarbonate – only indications: metabolic acidosis, Hyperkalemia

DEFIBRILLATION

• DC cardioversion: Rx of choice for pulseless tachycardia & ventricular fibrillation.

• Ventricular fibrillation - most common in adults who experience nontraumatic cardiac arrest.

• The time from collapse to defibrillation is the most important determinant of survival.

• Only defibrillation can reverse a ventricular fibrillation.

• Early defibrillation is most likely to improve survival

• Shock should be delivered within 3 min (± 1 min) of arrest.

• Biphasic waveforms are recommended for cardioversion.

Indications Shocks (J)

Unstable atrial fibrillation 50-100

Unstable atrial flutter/tachycardia 30-50

Monomorphic ventricular tachycardia 100

Polymorphic ventricular tachycardia or ventricular fibrillation 120-200

BASIC LIFE SUPPORT TECHNIQUES

Infant (1-12 months) Child (>12 months) Adult

Breathing rate 20 breaths/min 20 breath/min 10-12 breath/min"

Pulse check Brachial Carotid Carotid

Compression rate >100/min 100/min 100/min

Compression method Two or three fingers Heel of one hand Hands interlaced

Compression/ventilation

ratio

30:2 30:2 30:2

Foreign body

obstruction

Back blows and chest

thrusts

Heimlich maneuver Heimlich maneuver

ADVANCED LIFE SUPPORT

Components of ALS

• Cardiac monitoring

• Cardiac defibrillation

• Transcutaneous pacing

• Intravenous cannulation (IV)

• Intraosseous (10) accPss and intraosseous infusion

• Surgical cricothyrotomy

• Needle cricothyrotomy

• Needle decompression of tension pneumothorax

• Advanced medication administration through parenteral and enteral routes (IV, 10, PO, PR, ET,

• SL, topical, and transdermal)

• Advanced Cardiac Life Support (AILS)

• Pediatric Advanced Life Support (PALS) or Pediatric Emergencies for Pre-Hospital Providers

• (PEPP)

• Pre-Hospital Trauma Life Support (PHTLS), Basic Trauma Life Support (BTLS) or International

• Trauma Life Support (ITLS)

Forms of potentially reversible causes for cardiac arrest, commonly abbreviated as "6Hs & 5Ts"

Hs Ts

• Hypoxia:

• Hypovolemia:

• Hyperkalemia or hypokalemia

• Hypothermia/Hyperthermia

• Hydrogen ions (Acidosis)

• Hypoglycemia:

• Tension pneumothorax

• Tamponade

• Toxic and/or Therapeutic

• Thromboembolism and related

• mechanical obstruction

INVASIVE RESPIRATORY SUPPORT

Intermittent positive-pressure ventilation (IPPV) May be given with positive end-expiratory pressure (PEEP)

Continuous positive airway pressure (CPAP) Given via endotracheal tube

Synchronized intermittent mandatory

ventilation (SIMV) (volume or pressure

controlled)

May be given with pressure support and CPAP

Pressure support ventilation (PSV) Usually given with CPAP

'Lung-protective' ventilatory strategies to

minimize ventilator-associated lung injury

Low tidal volume, reduced airway pressures. Used with

SIMV, PEEP and prolonged inspiratory phase

High-frequency jet ventilation (HFJV) May be useful in those with lung leak (e.g. bronchopleural

fistula)

Extracorporeal techniques May be useful in severe acute respiratory failure

NON-INVASIVE RESPIRATORY SUPPORT

Continuous positive airway pressure (CPAP) Inspiratory and expiratory pressures the same

Non-invasive positive support ventilation ± CPAP

Bilevel positive airway pressure (BiPAP) Inspiratory and expiratory pressures set separately

WEANING METHODS:

• The most useful weaning parameters are

o Arterial blood gas tensions

o Respiratory rate

o Rapid shallow breathing index (RSBI).

• The most common techniques to wean a patient from the ventilator include

o SIMV

o Pressure support

o Periods of spontaneous breathing alone on a T- Piece or on low levels of CPAP.

o Noninvasive positive-pressure ventilation

• The traditional method is to allow the patient to breathe entirely spontaneously for a short time, following

which respiratory support is reinstituted.

MANAGEMENT OF PRE EXISTING DRUG THERAPIES DURING ANAESTHESIA

Oral Hypoglycemic Drugs Omit morning dose in case of minor surgery

For major surgeries: shift to Insulin 48 hrs before surgery

OCP's Stop 4 weeks before to decrease thromboembolism

Oral Anti-coagulants Stop 4 days ahead of surgery & shift to LMW heparins. Heparin should

be stopped one day before surgery.

In case of emergency Vit K is given if at least 6 hrs are available.

If the surgery is to be performed immediately fresh frozen plasma is to

be given.

Unfractionated heparin stop 6 hrs before surgery

LMWH stop 12 hrs before surgery

Anti hypertensive drugs Should be continued. For ACE inhibitors and ARBS's morning dose is

withheld

Anti Anginal Drugs Antithyroid

Drugs, Anti Epileptic Drugs

Levodopa Anticholinesterases

Should be continued and even morning dose is given.

Antiplatelet Drugs Clopidogrel- stop 1 week before surgery. In emergency platelet

transfusion should be given prior to surgery.

Aspirin can be continued on the day of surgery.

Lithium Should be stopped 48 -72 Hrs before.

Smoking Should be ideally stopped 6-8 weeks before (complete ciliary recovery )

Antitubercular Drugs Should be continued with monitoring of liver function test

Aminoglycosides Has neuromuscular blocking activity so it is shift to another antibiotic

48 hrs prior to surgery

Fasting guidelines before surgical procedures

Adults Children

• Clear fluids – 2 hours

• Semisolids – 4 hours

• Solid foods – 6hours

• Clear fluids – 2 hours

• Breast milk – 4 hours

• Formula milk, solid foods – 6 hours

Indications for Central Venous Catheterization

Pulmonary artery catheterization (with coagulopathy) External jugular vein

Hemodialysis

Plasmapheresis

Preoperative preparation

Fluid management of ARDS (CVP monitoring)

Internal jugular vein

Pulmonary artery catheterization [with pulmonary compromise or high-level

positive end-expiratory pressure (PEEP)]

Emergency transvenous pacemaker

Right internal

jugular vein

Total parenteral nutrition (TPN)

Hypovolemia, inability to perform peripheral catheterization

General purpose venous access, vasoactive agents, caustic medications, radiologic

procedures

Subclavian vein

Cardiopulmonary arrest

Hypovolemia, inability to perform peripheral catheterization

Emergency airway management

Inability to lie supine

Central venous oxygen satuation monitoring

Femoral vein

*****END*****

DERMATOLOGY

I. FUNDAMENTALS OF DERMATOLOGY

Layers of Skin

• Skin is the largest organ in the body.

• Total surface area: 1.7m2.

• The layers of the skin are

o Epidermis

o Dermis

o Subcutaneous fat/ hypodermis

EPIDERMIS

• 0.4 -1.6 mm in thickness

• Layers of epidermis:

Stratum corneum (Horny cell layer) • Outermost layer

• Made of flat, anucleated cells

• No cell organelles

• Underdeveloped in preterm infants for 2-3 weeks.

Stratum lucidum • Transparent layer

• Seen only in palm & sole

Stratum granulosum • Made of intracellular basophilic kerato hyaline granules

• Forms a water impermeable layer

• Contains abundant Odland bodies.

• Layer absent in nail bed & matrix

Stratum spinosum or

Prickle cells layer [Malphigian layer]

• Provides mechanical strength to the skin

• Langerhan cells present.

Stratum basale or

Stratum germinatum

• Single layer of columnar/ cuboidal cells

• Contains mitotically active keratinocytes & melanocytes

• Langerhans cells – antigen-presenting cells, derived from bone-marrow and found in the prickle cell layer.

• Langerhans cells are found scattered evenly throughout the epidermis.

• Merkel cells are normally located in the basal layer

• Merkel's (Tastzellen) cells – slow adapting mechanoreceptors found in prickle cell layer.

• Keratin filaments are hallmark of keratinocyte

• Keratinization: conversion of keratinocyte into keratin (4 weeks)

• Adamson's fringe: beginning of Keratinization

• Abrupt Keratinization: seen in pilomatricoma

• Keratin expressed in basal layer: K5, K14

• 1 epidermal melanocyte unit: 36 keratinocytes

• Skin doubling time: 4 weeks

• Epidermal turn over time: 1 month

• Accelerated cell turnover: psoriasis and ichthyosiform erythroderma [2 to 4 days]

• Lichen planus: the granular cell layer is focally increased.

• Nail first develops at: 3 months of intra uterine life

• Finger nail growth: 0.1mm/day

• Scalp hair growth: 0.35 mm/day

• Number of hair normally lost pev day:50-100

• Factors stimulating skin development (Epidermopoiesis): EGF, TGF-a, IL-II & fibroblast growth factor.

• Factors inhibiting skin development: Chalones, TGF-B, a and y interferons, TNF

• Grenz zone: narrow clear zone B/W epidermis & dermis.

• The stratum corneum of the palms and soles is about 0.5 mm thick and much thicker than that on the trunk

and limbs.

• Stratum corneum is permeable in preterm infants and becomes similar to the adult and full term infant after

2-3 weeks, postnatal maturation.

• Acantholytic cells are derived from stratum basale in pemphigus vulgaris.

• In humans there are two classes, the brown-black eumelanin, and the red-yellow phaeomelanin, both

derived from the substrate tyrosine.

• Most natural melanins are mixtures of eumelanin and phaeomelanin, and phaeomelanic pigments,

trichochromes, occur in red hair.

• Racial variations in pigmentation are due to differences in melanocyte morphology and activity rather than

to differences in frequency or distribution

DERMIS

• Consists of connective tissue, cellular elements, and ground substance.

• Contains pilosebaceous, apocrine and eccrine structures.

• Anatomically, it is divided into two compartments.

� Adventitial dermis: consists of thin collagen (Type III/reticulin) fibers located beneath the epidermis

(papillary dermis) and surrounding adnexal structures (periadnexal dermis).

� Reticular or deep dermis: composed of thick collagen (Type I) bundles & comprises the bulk of the dermis.

• Type IV collagen is a major constituent of the basal lamina of the dermo-epidermal junction.

SUBCUTANEOUS TISSUE

• Constitutes the largest volume of adipose tissue in the body.

• It provides protection from physical trauma and insulation to temperature changes.

Blaschko's Lines:

• Represent the developmental growth pattern of skin.

• Do not correspond to any known nervous, vascular or lymphatic structures.

• Blaschko's lines are characteristic of mosaicism and lionization.

BLOOD SUPPLY OF SKIN

• No blood vessels in epidermis

• Necessary oxygen + nutrients diffuse from capillaries in the dermal papillae.

• Glomus body: most commonly seen on the tips of the fingers and the toes, and under the nails.

• Each glomus body consists of a venous and arterial segment, called the Sucquet-Hoyer canal.

SKIN GLANDS/APPENDAGES

Sebaceous glands:

• Small saccular structures lying in the dermis.

• Hair follicle + Sebaceous glands + arrector pill muscle � Pilosebaceous unit

• Present everywhere on the skin, except the palms and the soles.

• In most areas they are associated with hair follicles.

• Sebaceous glands that are not associated with hair follicles:

o Buccal mucosa and vermillion border of the lip

o Nipple, and areola of the breast, labia minora

o Eyelids (Meibomian glands).

• The sebaceous glands are holocrine glands.

• Secretion of sebum is not under any neurologic control but is a continuous outflowing of the material of cell

breakdown.

• The sebum is mildly bacteriostatic and fungistatic and retards water evaporation.

• The scalp and the face may contain as many as 1000 sebaceous glands per square centimetre

Apocrine glands:

• Found in the axillae, genital region, external ear canal (ceruminous glands) and eyelid (Moll's glands).

• Breast (mammary gland) is also modified apocrine gland.

• Apocrine glands are adrenergic; stimulated by epinephrine > nor epinephrine

• Do not develop until the time of puberty.

• The secretions may act as pheromones (responsible for the production of body odor).

• Obstruction results in Fox Fordyce's disease

• Hidradenitis suppurativa, an inflammatory process that results from follicular obstruction and

retention of follicular products, usually occurs in patients with the acne-seborrhea complex.

Eccrine sweat (merocrine) glands:

• Distributed everywhere on the skin surface

• Most numerous on sole of foot (620/cm2) and least abundant on the back (64/cm9

• Glands first appear on volar surface of hands & feet in 3.5 month old fetus

• Develop as a downgrowth from the primitive epidermis.

• The eccrine sweat glands and the vasculature of the skin maintain stable internal body temperature.

• Their prime stimulus is heat and their activity is under the control of hypothalamus.

• Both adrenergic and cholinergic fibers innervate the glands.

• Blockage of the eccrine ducts results in miliaria (prickly heat).

• If eccrine glands are congenitally absent, as in anhidrotic ectodermal dysplasia, a life-threatening

hyperpyrexia may develop.

Fox Fordyce's Spot (Disease)

• Fordyce spots are visible sebaceous glands without hair follicles.

• Extremely common, benign condition.

• Tiny white / yellowish focally grouped papules in buccal mucosa and vermilion border of lips, scrotum, shaft

of penis and labia

• No treatment is indicated other than reassurance.

Epidermal Stem Cells

• Three main locations of epidermal stem cells in the adult skin

o Bulge region of the hair follicle

o Interfollicular epidermis (IFE)

o Sebaceous gland

� Stem cells of small blood vessels: Pericytes

� Skin stem cells occur in the basal layer of the epidermis and at the base of hair follicles.

TERMINOLOGIES

• Acantholysis: loss of cohesion between epidermal cells, seen in all types of pemphigus.

• Acanthosis: increased thickness of the prickle cell layer due to stimulation of basal layer.

• Dyskeratosis: premature keratinization of epidermal cells.

• Foam cells: lipid-laden macrophages containing dead lepra bacilli.

• Hydropic degeneration of basal cells: vacuolization of basal cells seen in LE, dermatomyositis, early lichen

planus.

• Hyperkeratosis: Increased thickening of stratum corneum.

• Parakeratosis: presence of immature nucleated cells in stratum corneum.

• Spongiosis: accumulation of fluid between epidermal cells, seen in acute eczema.

Skin Lesions

Flat lesions:

• Macule: < 2 cm, colored. Examples: white (vitiligo), brown (café au lait spot), purple (petechia).

• Patch: > 2 cm, colored.

• Purpura: Extravasation of RBCs in the skin, blanches on pressure.

• Telangiectasia: Permanent dilatation of superficial vessels.

Elevated lesions:

• Papule: < 1 cm, solid. Examples: acne, warts, small lesions of psoriasis.

• Nodule: 1-5 cm, solid. Examples: tumors, granuloma annulare

• Tumor: > 5 cm, solid.

• Plaque: > 1 cm, flat topped. Example: psoriasis.

• Vesicle: < 1 cm, fluid-filled. Example: blisters of herpes simplex.

• Bullae: > 1 cm, fluid-filled. Example: bullous impetigo.

• Pustule: Vesicle filled with leukocytes. Examples: acne, folticulitis.

• Wheal: circumscribed, flat-topped, firm elevation of skin resulting from tense edema of the papillary dermis.

Example: urticaria

Secondary changes

Scales Dry, thin plates of keratinized epidermal cells (stratum corneum) Example: psoriasis,

Lichenification Induration of skin with exaggerated skin lines and a shiny surface resulting from chronic

rubbing of the skin. Example: atopic dermatitis.

Impetiginization Bacterial infection resulting in exudation and golden-yellow crusting

Erosion and

oozing

A moist, circumscribed, slightly depressed area representing a blister base with the roof of

the blister removed. Examples: burns, impetigo. Most oral blisters present as erosions.

Crusts Dried exudate of plasma on the surface of the skin following acute dermatitis. Examples:

impetigo, contact dermatitis.

Fissures A linear split in the skin extending through the epidermis into the dermis. Example: angular

cheilitis.

Scars A flat, raised, or depressed area of fibrotic replacement of dermis or subcutaneous tissue.

Atrophy Depression of the skin surface caused by thinning of one or more layers of skin.

Example: lichen sclerosis.

Configuration of lesions

Annular

(circular)

Annular nodules represent granuloma annulare; annular scaly papules are more apt to be

caused by dermatophyte infections.

Linear (straight

lines)

Linear papules represent lichen striatus; linear vesicles, incontinentia pigmenti; linear

papules with burrows, scabies.

Grouped Grouped vesicles occur in herpes simplex or zoster.

INTRA-EPIDERMAL BLISTERS:

Granular layer Spinous layer Supra basal layer Basal Layer

Friction blister

Pemphigus foliaceous

Sub corneal pustular

dermatosis

Staphylococcal skin scald

syndrome / Bullous impetigo

Eczematous

dermatitis

Herpes virus infection

Familial benign

pemphigus

Pemphigus vulgaris

Darier's disease

Lupus erythematosus

Lichen planus

Epidermolysis bullosa simplex

BLISTERS AT DERMAL EPIDERMAL JUNCTIONS:

Junctional (at the lamina lucida) Dermolytic (Below basal lamina)

Bullous Pemphigoid

Erythema multiforme

Junctional Epidermolysis bullosa

Epidermolysis bullosa dystrophicans

Epidermolysis bullosa acquisita

Porphyria cutanea tarda

Dermatitis herpetitiformis

DIAGNOSTIC TECHNIQUES

Disease Diagnosed by

Atopic Dermatitis

Contact Dermatitis

Donovanosis (GI)

Chancroid

Clinical evaluation

Patch Test

Microscopy (Donovan bodies/Safety pin appearance)

Gram staining(gram negative rods/ school of fish / rails road appearance

• Grattage test: Psoriasis

• Pethergy test: Behcet's syndrome

• Patch test: Contact dermatitis

• Dermatoscopy (Epiluminescence microscopy, dermoscopy): method of observing superficial layers of skin

using 10-100 X magnification under oil immersion.

Tzanck Smear

• Most commonly used in the diagnosis of herpes virus infection – shows multinucleated giant cells.

• Also used in pemphigus – shows acantholysis.

SKIN BIOPSY

There are four principal techniques for performing skin biopsies:

• Surgical excision with suturing:

o Good cosmetic result

o Entire lesion is removed.

o Disadvantage: most time consuming of the three techniques, removal of the sutures.

• Punch biopsy:

o Inadequate for evaluation of vesiculobullous diseases

o Should be deep enough to include subcutaneous fat if used for diagnosis of panniculitis or

o tumors in a subcutaneous location.

o Pigmented lesions should not be punched unless they can be completely excised.

• Excision with scissors:

o Useful for certain types of elevated lesions and in areas in which the cosmetic result is not too

important.

o Advantage of this procedure is the speed and the simplicity with which it can be done.

• Shave biopsy:

o Can be performed superficially or deeply.

o Hemostasis can be accomplished by pressure, light electrosurgery, Monsel solution, or aluminium

chloride solution.

o Not recommended for excision of melanocytic lesions or other potentially malignant tumor where

margin assessment is required.

WOOD'S LAMP

It is a source of ultra violet light (mainly long wave UV-A, at a wavelength of 360nm), from which virtually all variable

rays have been excluded by filter (made of nickel oxide i.e. Ni02 and Si). It is used in:

• Fungal infections like:

o Tinea capitis = yellow green fluorescence.

o Pityriasis versicolor = golden yellow / apple green

• Bacterial infections like:

o Erythrasma & Acne = Coral red / pink

o Pseudomonas pyocyanea = yellow-green

• Pigmentary disorder

o Vitiligo = total white

o Ash-leaf macules in tuberous sclerosis = blue white

• Urine examination in Porphyria (red / pink urine)

• Squamous cell carcinoma of skin = red fluorescence

Type of collagen Location

I Bone

II Cartilage, vitreous tumour, Intervertebral disc

III Extensive - skin, lung, hollow organ (vascular system)

IV Basement membrane, Eye lens

VII Anchoring fibrils at Dermo-epidermal junction

VIII Endothelium

X Hypertrophic cartilage

XVII Skin, hemidesmosomes

XVIII Liver, kidney

XIX Rhabdomyasarcoma cells

Distributions of Glycosaminoglycans (GAGS):

Hyaluronic acid Synovial fluid, Vitreous humour, Loose connective tissue

Chondroitin sulphate Cartilage, bone, cornea

Keratan sulphate-I Cornea

Keratan sulphate-II Loose connective tissue

Heparin Mast cells

Heparan sulfate Skin, Fibroblasts

Dermatan sulphate Wide distribution

PANNICULUS ADIPOSUS

• The panniculus adiposus is the fatty layer of the subcutaneous tissues, superficial to a deeper vestigial layer

of muscle, the panniculus carnosus.

• It includes structures that are considered fascia by some sources but not by others.

• Eg: Fascia of Camper, superficial cervical fascia.

II. SOLAR INJURY

ULTRA VIOLET RADIATIONS

• UVR of wavelength 250-400 nm is of major importance as far as skin is concerned.

• Narrow-band UVR is UVR at a wavelength of 311 nm

UV-A

(Long-wave UVR)

UV-B

(Medium-wave UVR)

UV-C

(Short-wave UVR)

320-400 nm 280-320 nm 250-280 nm

• 1000-fold less effective at causing

erythema

• Penetrate to the dermis

• Play a role in causing the dermal

degeneration known as solar

elastosis, which is responsible for the

appearance of ageing & the cause of

skin cancer

• Responsible for photosensitivity

reactions

• UV-B [around 290 nm]: mainly

responsible for sunburn, suntan and

• skin cancer.

• UVB penetrates as far as the basal

layer of the epidermis, but causes the

death of scattered keratinocytes

(sunburn cells) & damages others �

release cytokines and mediators.

• 2 days after UVR injury, there is an

increase in the rate of melanin

synthesis.

• Mostly filtered

Out by the

ozone layer

Polymorphic light eruption (PMLE)

• A common disorder, occurring in young and middle-aged women

• Itchy papules and papulovesicles on exposed sites — particularly the forearms

• The rash develops shortly after sun exposure throughout the spring and summer months

• PMLE is chronic in nature

• The action spectrum of PMLE may also extend into the long ultraviolet wavelengths (UVA; 320-400 nm)

• Patients improve when they avoid sun exposure and use sunscreens blocking UVA

• Treatment: Weak topical corticosteroids

• For severe rashes — hydroxychloroquine or even azathioprine

Photodermatitis

• Painful or pruritic erythema, edema, or vesiculation on sun-exposed surfaces: the face, neck, hands, and "V"

of the chest.

• These eruptions may become generalized with time to involve even photoprotected areas

• Sunscreens with an SPF of 30-60 and broad UVA coverage, containing dicamphor sulfonic acid, avobenzone,

titanium dioxide, and micronized zinc oxide, are useful

• Photosensitivity due to porphyria is not prevented by sunscreens and requires barrier protection (clothing)

to prevent outbreaks.

Dermatoses aggravated by solar exposure: Lupus erythematosus, Rosacea, Atopic dermatitis

Dermatoses improved by sun exposure: Psoriasis, Acne

III. SKIN INFECTIONS

� The stratum corneum is an excellent barrier to pathogenic micro-organisms

� The following organism live in the follicular lumina without normally causing harm

o Gram-positive cocci (Staphylococcus epidermidis)

o Gram-positive lipophilic microaerophilic rods (Propionibacterium acnes)

o Gram-positive yeast-like organism (Pityrosporum ovale or Malassezia furfur)

� Dermatophyte infections are restricted to the stratum corneum, the hair and the nails (i.e. horny structures).

PITYRIASIS VERSICOLOR

• Caused by yeast-like micro-organism Pityrosporum ovale (orbiculare) or Malessezia furfur

• Becomes pathogenic when its growth is encouraged by increased sebum secretion or depressed immunity

• Pale, scaling hypopigmented macules develop over the skin of the chest and back in young adults (Picture

III-E)

• Fine velvety scales that are not visible but are seen by scraping the lesion.

• Central upper trunk the most frequent site.

• Microscopy: grape-like clusters of spores and a meshwork of pseudomycelium in skin scrapings made more

transparent by soaking the scales for 20 minutes in 20 per cent potassium hydroxide.

• Skin surface biopsy

o Permanent preparation made using cyanoacrylate adhesive to remove a strip of superficial stratum

corneum from the skin surface on a glass slide

o The slide is 'rolled off' the skin after 20 seconds and then stained with periodic acid- Schiff reagent

o The skin patches often fluoresce an apple green in long-wave UVR (Wood's light).

• Treatment

o Topical imidazole creams (e.g. miconazole, clotrimazole, econazole) for 6 weeks or

o Ketoconazole shampoo to wash the affected areas once daily for 5 days

TINEA INFECTIONS

• Also called Dermatophytoses or Ring worm

• Trichophyton, Microsporon and Epidermophyton species are responsible for this group of infections.

• T. rubrum, T. mentagrophytes and E. floccosum are the M/c causes of dermatophyte infection

• Inflammatory ringworm can be caught from cattle (T. verrucosum) and horses (T. equinum).

• Hypersensitivity to fungal antigens – vesicular lesions - dermatophytids (id reaction)

• Hypersensitivity can be demonstrated by skin testing with fungus antigen – trichophytin

• Favus - chronic type of ring worm which leads to alopecia and scarring

• Kerion – scalp infection with marked inflammation producing severe boggy swellings

• The diagnosis is confirmed by microscopy of skin scrapings, hair or nail clippings treated with 20% potassium

hydroxide for 20 minutes and identification of fungal hyphae.

• Use of the cyanoacrylate 'skin surface biopsy technique' makes identification quite easy.

TRICHOPHYTON MICROSPORUM EPIDERMOPHYTON

• Infects Hair, nail and skin

• Abundant microconidia

• Scanty macroconidia

(pencil shaped)

• Infect hair and skin but not nails

• Scanty microconidia

• Abundant macroconidia (spindle

shaped)

• Infects skin and nails but not hair

• Microconidia absent

• Macroconidia are pear or club

shaped

Tinea corporis or Tinea circinata (Body ring worm)

• Pruritic, ring-shaped lesions with an advancing scaly border and central clearing

• Can be distinguished from eczema or psoriasis by history and the presence of mycelium in the scales.

Tinea cruris or Groin ring worm (Jock itch or Dhobis's itch)

• A disorder of young men

• Marked itching in intertriginous areas, usually sparing the scrotum.

• Peripherally spreading, sharply demarcated, centrally clearing erythematous lesions asymmetrically on the

medial aspects of both groins

• These gradually extend down the thigh and on to the scrotum unless treated

Tinea manuum

• One palm is involved which is usually dull red with silvery scales in the palmar creases

• T. rubrum is the usual cause

Tinea capitis

• Ringworm of the scalp occurs in children exclusively

• Mainly due to M. canis or Trichophyton tonsurans

• It invades the hair cuticle (ectothrix infection), causing pink, scaling patches on the scalp skin

• There is patchy loss of hair (only broken hair) with variable degrees of inflammation (to differentiate from

alopaecia areata - no inflammation and total loss of hair from the root)

• It is easily spread by the sharing of hairbrushes.

• Infected areas sometimes fluoresce a light green under long-wave UVR (Wood's light)

• Scalp ringworm caused by T. schoenleini, invades the interior of the hair shaft (endothrix) and causes

intense inflammation on the scalp, with swelling, pus formation and scalp scarring.

Tinea unguium (Onychomycosis)

• Ringworm infection of the nail plate and the nail bed.

• The fungi responsible are T. rubrum, T. metagrophytes or E. floccosum.

• Onycholysis occurs and subungual debris collects

• More common in the toenails than in the fingernails

Tinea incognito

• Eextensive ringworm with an atypical appearance

• Due to the inappropriate use of topical corticosteroids.

Tinea barbae

• Also called barber's itch or Tinea Sycosis

• Caused by T. Mentagrophytes & T. Verrucosum

Dermatophytoses Causative agent

Tinea capitis Microsporum, Trichophyton

T corporis T rubrum

T cruris E floccosum, T rubrum

T pedis (atheletes foot) E floccosum, T rubrum

Favus T schoenleinii, T violaceum

Treatment

• Topical imidazole-containing preparation (miconazole, econazole and clotrimazole) used twice daily for a 3-

4-week period is usually adequate

• When topical treatment fails

o Griseofulvin (500 mg b.d.) - only active in ringworm infections

o Ketoconazole (200 mg daily) or Itraconazole - active in both yeast and dermatophyte infections.

CANDIDIASIS (MONILIASIS, THRUSH)

• Caused by a yeast pathogen - Candida albicans

• A commensal of oral cavity, lower GIT and vagina

• Inflammatory papules and plaques with satellite pustules, frequently in intertriginous areas

• Treatment with the imidazole preparations, topical and systemic

• Serious Candida infections respond to systemic fluconazole.

Bacterial infection of the skin

Staphylococcus aureus

• Impetigo contagiosa

• Bullous impetigo

• Ecthyma

• Botryomycosis

• Superficial folliculitis (follicular or Bockhart impetigo)

• Folliculitis (sycosis barbae)

• Furncle (boil), carbuncle

• Blistering distal dactylitis

• Paronychia

Group A Streptococci

• Impetigo

• Ecthyma

• Blistering distal dactylitis (in nonintertriginous skin) and intertrigo

• Vulvovaginitis

• Perianal cellulitis

� Pyoderma gangrenosum, pyoderma faciale & impetigo herpetiformis are not pyodermas.

� Trichomycosis axillaris & pubis is a bacterial (aerobic corynebacterium) not fungal infection of hair shaft.

� Erythrasma is superficial bacterial infection of skin caused by corynebacterium minutissimum.

IMPETIGO (PYODERMA)

• It is a contiguous, superficial pyogenic infection of skin

• Pyodermas are infection in epidermis, just below the stratum corneum or in hair follicles.

• Two main clinical forms

o Bullous impetigo caused by S. aureus mostly

o Nonbullous impetigo (or impetigo contagiosa or Tilbury Fox) may be caused by Staphylococcus aureus

(most common); by group A-beta haemolytic streptococci (mainly in developing nations) or by both.

• Most commonly affects children

• Most common bacterial infection of children

• Occurs in all age including adults and neonates (called pemphigus neonatorum)

• Spread by close contact (contagious).

• Bullous impetigo

o Bullae are less rapidly ruptured

o Larger (1-2cm)

o Persist for 2-3 days

o After rupture thin, flat brownish crusts are formed.

• Streptococcal impetigo may lead to

o Post streptococcal acute glomerulonephritis (AGN)

o Scarlet fever

o Erythema multiforme

• Rheumatic fever is not a complication of streptococcal impetigo

IMPETIGO CONTAGIOSA

• Caused by Staphylococcus aureus and/or beta hemolytic Streptococci

• It is mostly a disorder of prepubertal children

• Initial lesion is a very thin walled vesicle on an erythematous base which ruptures so rapidly that its seldom

seen

• Gradual, irregular, peripheral extension occurs without central healing

• Lesions are usually not painful, heals without scarring, no fever and patient is not ill

• Characteristic feature

o Golden or Honey colored crust

o Neutrophils beneath stratum corneum

• Face around nose and mouth) and limbs are most commonly affected

Erysipelas

• Caused by the beta-haemolytic Streptococcus

• Sudden onset of a well-marginated, painful and swollen erythematous area, on the face or lower limbs.

• The inflammation may be very intense and the area may become haemorrhagic and even blister.

• There is usually an accompanying pyrexia and malaise.

Pyoderma faciale

• Also called rosacea fulminas or rosacea conglobate

• Occurs mainly in adult women (in 20s)

• Sudden, severe eruption of confluent papules, nodules, pustules, cystic swellings which may be

interconnected by draining sinuses usually confined to face, involving checks, chin, nose, & forehead

• Comedones are usually absent or inconspicuous, as are other features of acne vulgaris or rosacea

• Some cases may develop during pregnancy or medication (interferon alpha-2B & ribavirin therapy for

hepatitis C)

TOXIC EPIDERMAL NECROLYSIS/ STAPHYLOCOCCAL SCALDED SKIN SYNDROME (SSSS)

Also called LyeII syndrome

• Caused by ET (Exfoliative / Erythematogenic toxin) producing Staph. aureus (phage group II)

• Most common site of infection is extracutaneous

• Wide spread erythematous blisterous eruption with striking desquamation of large areas of skin (Nikolsky

sign positive) as seen in scald or burn.

• Mucosa is not involved.

• Initial findings are redness & tenderness of central face, neck, truck & interiginous zone followed by short

lived flaccid bullae & slough or exfoliation or peeling of superficial epidermis.

• Treated by IV antibiotics

CUTANEOUS TUBERCULOSIS

Lupus Vulgaris

• Slowly progressive, granulomatous plaque on the skin

• It slowly increases in size, over one, two or three decades.

• Blanching with a glass microscope slide (diascopy) will reveal grey-green foci (apple jelly nodules)

Tuberculosis Verrucosa Cutis (Warty Tuberculosis)

• Seen on the backs of the hands, knees, elbows and buttocks whenever abrasive contact with the earth and

tubercle bacilli has been made.

• Thickened, warty plaques are present - sometimes misdiagnosed as viral warts

Different types of cutaneous TB

• Lupus vulgaris (Apple-jelly nodules)

• Lupus miliaris disseminate faciei

• Lichen scrofulosoeum

• Scrofuloderma (skin T.B. secondary to underlying structure)

• Tuberculosis cutis orificalis (TB. of orifices - oral, anal, urogenital)

• Papulo necrotic tuberculids

• Erythema nodosum

• Erythema induratum

• Acne agmination

Other Mycobacterial Infections

Swimming pool granuloma

• Caused by Mycobacterium marinum

• Causes plaques, abscesses and erosions on the elbows and knees in particular.

• The condition responds to minocycline or a trimethoprimsulphamethoxazole combination.

Buruli ulcer

• Mycobacterium ulcerans is responsible for this disorder

• Surgical removal is currently the best treatment.

SARCOIDOSIS

• Bluish chilblain-likeswellings of the fingers, nose and ears (lupus pernio) – infiltrated by typical sarcoid tissue

• Erythema nodosum – not infiltrated by typical sarcoid tissue

• Histologically of the typical Sarcoid lesion: 'naked' tubercle, which contains foci of macrophages and giant

cells without many surrounding lymphocytes.

LYME DISEASE

• Caused by the Borrelia burgdorfii

• Early stages - erythema chronicum migrans

• Late stages - skin atrophy (acrodermatitis chronica atrophicans), or fibrosis

Viral infection of the skin

HERPES SIMPLEX

• Type I is responsible for the common herpetic infection of the face and oropharynx

• Type II herpes simplex infects the genitalia

• 20 % suffer from recurrent 'cold sores', precipitated by minor pyrexial disorders or sun exposure.

• Commonly, the lesions occur around the mouth or on the lip.

• Genital herpes affects the glans penis and the shaft of the penis.

• In women, the vulval region or labia minora is usually involved

HERPES ZOSTER (SHINGLES)

• Mostly affects those past the age of 50 years

• Also affects immunosuppressed individuals

• Due to the reactivation of a latent virus in a posterior root ganglion of a spinal nerve

• Starts with paraesthesiae or pain in the distribution of one or more dermatomes (Picture III-F)

• Dermatome frequently affected - thoracic

• Involvement of one of the branches of the trigeminal ganglion, with lesions in the distribution of the

maxillary, mandibular or ophthalmic sensory nerves, is common

• Lesions are confined to the skin innervated by the dorsal primary root (s) infected

VIRAL WARTS

• Caused by a member of the human papillomavirus family

• Epidermodysplasia vericuformis

o Congenital condition

o Plane warts spread extensively on the arms, face, trunk and limbs

o Some lesions can transform to squamous cell carcinoma

• Verruca vulgaris (Picture III-G)

Treatment

• Cryotherapy (tissue freezing with liquid nitrogen or solid carbon dioxide)

• Curettage

• Cautery

• Chemical destruction with topical preparations containing salicylic acid, lactic acid, podophyllin or

glutaraldehyde.

• Intracutaneous injections of cytotoxics such as bleomycin and injections of recombinant interferon.

MOLLUSCUM CONTAGIOSUM

• Caused by virus of pox virus group

• Transmitted by skin to skin contact and is a STD.

• Typical lesion is pink or skin colored, umbilicated papule containing a grayish central plug

• Face & genitals are commonly involved

• Face is most commonly involved in children

• Pathology: Cup shaped epidermal thickening with characteristic degenerative change in granular cell layer &

Molluscum bodies on giemsa stain is pathognomic.

LEISHMANIASIS

• Cutaneous form seen in Mediterranean and North America (Old World leishmaniasis)

o Ccaused by Leishmania major and L. tropica.

o A boil-like lesion appears, usually on an exposed site ('Baghdad boil')

o Later, this breaks down to produce a sloughy ulcer ('oriental sore'), which persists for some

months before healing spontaneously, with scarring and the development of immunity.

• Mucocutaneous forms occur mainly in South America (New World leishmaniasis)

o Caused by L. mexicana and L. brasiliensis.

o Small ulcers develop (Chiclero's ulcer) that seem more destructive than the Old World types

o Also more persistent, and later in the disease destructive lesions appear, affecting nasal mucosa in

about half of the patients

IV. SKIN INFESTATIONS

ECTOPARASITES

Phthirus pubis Pubic lice infestation

Pediculus humanus Pediculosis

Sarcoptes scabiei Scabies

SCABIES

Epidemiology:

• Infestation caused by Acarus hominis/Sarcoptes scabie.

• Incubation period is 2-4 weeks.

• Itching worse at night is most common symptom.

• Family history of similar itchy eruptions in close contact

• On an average, an adult has 12 mites and an infant 20 mites.

Primary lesions:

• Serpentine (S-shaped) burrows traversed by parasite in stratum corneum (pathognomic lesion)

• Most common sites involved: Inter digital space, Anterior wrist, Ulnar border of hand

• An imaginary circle intersecting the main sites of involvement—axillae, elbow flexures, wrists and

• hands and groins - 'circle of Hebra'.

• In infants and elderly: Scalp, Face, Neck, Palms & Soles, Penis also involved

• Papules & papulo-vesicles: due to hypersensitivity to the mite.

• Fine pin head size follicular papules

Secondary lesions:

• Pustules due to 2° infection is one of commonest form of presentation.

• Eczematized crusted lesion, in infants & children are predominant lesions.

• Nodular lesions are seen on scrotum (most common), groin, and anterior axillary fold (Nodular scabies).

Types:

• Crusted or Norwegian scabies

o Most severe form

o The average number of mites in these cases is 2 million

o Seen in immuno compromised, mentally ill patients, GVDH, leprosy, leukemia

o Psoriatiform or warty lesions accompanied by nail hyperkeratosis

o No burrows

o Minimal itching

o Highly contagious

o Ivermectin is the treatment of choice

• Scabies incognetio - wrongly treated with steroids.

Treatment

• Drug of choice : 5% Permethrin (1st

) BHC (2nd

).

• Oral drug (Only): Ivermectin.

• Other drugs : Benzyl benzoate 25%, Crotamiton 10%, Malathion, Monosulfiram.

• Drug safe in pregnancy & infants < 2 months: precipitated sulfur 5-10%.

• Scabicides should be applied to the whole body (below jaw line in adults) to all members of family whether

symptomatic or not.

PEDICULOSIS

• Macula cerulea (bluish stain on the skin d/t louse bite) is a typical lesion of Pediculosis

P. Capitis

• Transmitted by Head louse

• Involves scalp � mobile dandruff

• Common in girls with long hairs

• The diagnosis is made by seeing the lice in the scalp or more often, nits glued to the hair shaft

P. Corporis (Vagabond's disease.)

• Transmitted by Body louse

• The body louse transmits

o Epidemic typhus

o Trench fever

o Relapsing fever

• The diagnos s is positively established by finding the lice or nits in the seams of clothing

• Treatmeot: disinfection of clothes with 10% DDT or 1% BHC + Pediculocide drug application

Pthirus Pubis (Pubic louse):

• Is a STD, can also infest body, axillary, and eyelash hairs

• In children the common areas of involvement are the eyebrows and eyelashes (pediculosis palpebrum)

• Diagnosis is made on seeing black speck like bodies attached to the root of hair at an angle—t.,e crab lice

V. IMMUNE MEDIATED SKIN DISORDERS

URTICARIA (nettlerash, 'weals' and 'hives')

• Urticaria is a vascular reaction pattern characterised by transient, erythematous, oedematous papules or

plaques (wheals) of varying sizes and shapes which are usually pruritic.

• Angioedema is the same process but involves the deep dermis, subcutaneous and submucosal tissues

• Urticaria — dermal edema

• Angioedema — subcutaneous, submucosal edema

• Result of histamine release from mast cells in the skin.

• Type I hypersensitivity mediated by histamine.

• Lesions are itchy, red papules and plaques of variable size that arise suddenly, often within a few minutes

THE 'PHYSICAL' URTICARIAS

Cold urticaria

• Occur after exposure to the cold.

• The reaction can be elicited by an ice block.

• There is a familial form.

Pressure urticaria

• Lesions develop some time (up to several hours) after pressure on the skin

• For example from belts or other tight clothing, or from the rungs of a ladder.

Dermographism

• Many patients with urticaria mark easily when their skin is rubbed firmly, for example with a key.

• This is an exaggerated 'triple response' and is quite troublesome to some patients

Solar urticaria

• Urticaria spots develop on exposed skin a few minutes after exposure to the sun.

• It is a skin sign of one systemic disease— erythropoietic protoporphyria

Cholinergic Urticaria

• Irritating, small urticaria spots develop after exercise, hot baths, emotions

• Occurs after stimuli that evoke sweating from the post-ganglionic cholinergically enervated sweat glands.

DRUG-INDUCED URTICARIA

• Penicillin

• NSAIDs

• Sulphonamides

• Aspirin

Urticaria lesions are seen in patients with

• Mastocytosis (urticaria pigmentosa)

• Hypo- or hyperthyroidism

• Systemic-onset juvenile idiopathic arthritis (Still's disease)

ERYTHEMA MULTIFORME (EM)

• EM minor: an acute, self-limiting, usually mild, often recurrent inflammatory syndrome characterised by

symmetrically distributed erythematous papular, urticaria and typical iris/target shaped lesions (Picture:V-

A)

o Cause: Herpes simplex virus – most common cause of recurrent EM

• EM major: more severe variant with extensive mucous membrane involvement and constitutional symptoms

o Cause: HSV, Mycoplasma, Drugs (sulfonamides, phenytoin, barbiturates, aminopenicillins, non-

nucleoside reverse transcriptase inhibitors, and carbamazepine)

o Hemorrhagic crusts of lips

• The term "erythema multiforme major" has been replaced by three terms

o Stevens-Johnson syndrome (SJS), with < 10% BSA skin loss

o Toxic epidermal necrolysis (TEN) when there is > 30% BSA skin loss

o SJS/TEN overlap for cases with between 10% and 30% BSA denudation.

• Skin biopsy is diagnostic.

• Direct immunofluorescence studies are negative

ERYTHEMA NODOSUM

• Painful crops of nodules develop in response to antigenic stimuli mostly in shins & forearms.

• Women are predominantly affected by a ratio of 10:1 over men

Causes of erythema nodosum

• Tuberculosis – most common

• Sarcoidosis

• Leprosy (lepromatous type LL & BL)

• Brucellosis

• Streptococcal infection

• Ulcerative colitis & Crohn's disease

• Oral contraceptives

LUPUS ERYTHEMATOSUS

• Skin involvement is the 2nd

most common clinical manifestation after joint inflammation and is found in up to

70% of patients

• The two most common forms of chronic cutaneous lupus erythematosus (CCLE) are

o Chronic scarring (discoid) lesions (DLE)

o Erythematous non-scarring red plaques (Subacute cutaneous LE) (SCLE).

• Discoid LE (DLE) or Chronic cutaneous LE

• The lesions are most commonly found on face and neck

• Permanent hair loss (scarring alopecia) and loss of pigmentation are common sequelae of discoid lesions.

• There is atrophy, telangiectasia, depigmentation, and follicular plugging by scales

• When the scale is removed, its underside shows small excrescences that correlate with the openings of hair

follicles (carpet tacking or thumbtack like)

• The disorder may be aggravated or initiated by exposure to the sun.

• Histology: epidermal degenerative changes are more marked, with scattered cytoid body formation and

patchy epidermal atrophy and thickening

Treatment

• Sun avoidance and use of sunscreens

• Individual lesions sometimes respond to potent topical corticosteroid

• For unresponsive lesions - hydroxychloroquine (200-400 mg per day) is often helpful.

SYSTEMIC SCLEROSIS

Progressive systemic sclerosis

• The disease is mostly seen in young women

• Gradual thickening and stiffening of the skin of the hands and face

• This causes a characteristic beak-like facial appearance, with narrowing of the mouth

• There are pigmentary changes over the face and neck in the form of hyperpigmentation and depigmentation

(pepper-salt pigmentation) (Picture V-B)

• Telangiectatic macules appear over the face and deposits of calcium develop in the skin.

• Fingers: sclerodactyly or sausage shaped fingers with taut skin over the fingers and thimble pitted scars over

fingertips

• Raynaud's phenomenon is almost a constant feature

• CRST syndrome (Calcinosis cutis, Raynaud phenomenon, Sclerodactyly, and Telangiectasia)

• When there is also dysphagia due to Esophageal involvement - CREST syndrome

Morphoea or Localized Scleroderma.

• Linear scleroderma - involvement of the face and/or forehead manifesting as Parry-Romberg syndrome and

'en coup de sabre (depressed sclerotic groove over the frontal/frontoparietal region of the scalp)

• Anti-topoisomerase II antibodies have been detected in 76% of patients with localised scleroderma and in

85% of cases of generalised morphea

• These antibodies, in contrast to antitopoisomearsel/scl-70 antibodies have been found in 14% of the patients

with systemic scleroderma.

DERMATOMYOSITIS

• An idiopathic inflammatory myopathy of striated muscles along with characteristic cutaneous findings

• Linked to human leucocyte antigen (HLA) DR3, DRS, DR7

• The pathognomonic cutaneous features

o Heliotrope rash (periorbital confluent macular mauve or violaceous erythema)

o Gottron's papules (papules having violaceous hue overlying the dorsolateral aspect of interphalangeal

or metacorpophalangeal joints)

• Other cutaneous features are

o Malar erythema

o Poikiloderma (variegated telangiectasia along with atrophy and hyperpigmentation)

o Periungual and cuticular changes (cuticular hypertrophy with haemorrhagic infarcts)

o Mechanics hands (fingertip erythema and scaling).

o Calcinosis cutis - firm yellow or flesh coloured nodules extruding calcium through the skin

IMMUNE MEDIATED BULLOUS DISORDERS:

Intra-epidermal bullae Sub-epidermal bullae

• Pemphigus vulgaris

• Pemphigus vegetans

• Pemphigus foliaceous

• Pemphigus erythematosus

• Drug induced pemphigus

• Paraneoplastic pemphigus

• Bullous pemphigoid

• Cicatricial pemphigoid

• Dermatitis herpetiformis

• Linear IgA buloous dermatosis

• Pemphigoid gestationis

• Epidermolysis bullosa aquisita

Clinical Histology Immunopathology Auto antigens

Pemphigus

foliaceous

Crusts and shallow

erosions on scalp,

central face, upper

chest and back

Acantholytic blister

formed in

superficial

layer of epidermis;

Cell surface deposits

of IgG on

keratinocytes

(epidermis)

Desmogleins (Dsg1)

Pemphigus

vulgaris

Picture: V-C

Flaccid blisters,

Painless,

MC site: buccal

mucosa

Nikolsky sign: + ve

Acantholytic blister

formed in supra

basal layer of

epidermis

Cells surface

deposits

of IgG on

keratinocytes

(epidermis)

Dsg 3 (+ Dsg 1 in

patient with skin

involvement)

Bullous

Pemphigoid

Picture: V-D

(Senile

Large tense blisters,

Painless

MC site: extremities

Nikolsky sign: - ye

Blister formed in

sub epidermal

region; eosinophil-

rich infiltrate

Linear band of IgG

and C3 across the

basement embrane

zone (BMZ)

Proteins in basal

keratinocytes

Bullous Pemphigoid

AntiGen. Two

pemphigoid)

Pemphigoid

gestationis

Associated with

Lymphoma

Pruritic, urticaria

plaques, rimmed by

vesicles & bullae on

the trunk and

extremities

Acantholysis: - ye

Teardrop-shaped,

sub epidermal

blister in dermal

papillae; eosinophil-

rich infiltrate.

Linear band of C3 in

epidermal BMZ.

important BP

antigens: BP 230

and BP180 (BPAG 1,

BPAG 2)

BPAG2 (plus BPAG1

in some patients).

Linear IgA

bullous

disease or

large tense bullae

filled with clear or

haemorrhagic fluid on

Sub epidermal

blister with

neutrophils in

Linear band of IgA,

in epidermal BMZ

LAD

Chronic

bullous disease

of childhood

or near genitalia,

arciform blister,

cluster of jewels

appearance

dermal papillae

Cicatricial

pemphigoid

Erosive and / or

blistering lesions of

mucous membranes

and possibly the skin;

Sub epidermal

blister

Linear band of IgG,

and /or C3 in

epidermal BMZ

BPAG2

Epidermolysis

bullosa

acquisita

Blisters, erosions,

scars, and milia on

sites exposed to

trauma;

nflammatory,

tense blisters seen

initially

Sub epidermal

blister

Linear band of IgG,

and /or C3 in

epidermal BMZ

Type VII collagen.

Dermatitis

herpetiformis

Extremely pruritic

small and vesicles

mostly on elbows,

knees, buttocks

Sub epidermal

blister with

neutrophils in

dermal papillae

Granular deposits of

IgA in dermo-

epidermal junction.

Epidermal

transglutaminase

Pemphigus histology

• The superficial portion of epidermis sloughs off, leaving the bottom layer of cells on the "floor" of the blister

• This bottom layer of cells is said to have a "tombstone appearance".

� The Asboe-Hansen sign (bullae spread sign) — characteristic of pemphigus

DERMATITIS HERPETIFORMIS

• Intensely itchy vesicles, papulovesicles and urticaria papules symmetrically distributed over extensor

surfaces (elbows, knees, buttocks, back, scalp, and posterior neck)

• Almost all have an associated, usually subclinical, gluten-sensitive enteropathy

• >90% express the HLA-B8/DRw3 and HLA-DQw2 haplotypes

• Biopsy of new lesions - vesicle forms subepidermally and develops from collections of inflammatory cells in

the papillary tips (the papillary tip abscess)

• Direct IF- presence of IgA in the papillary tips in the skin around the lesions

• Treatment

o Gluten-free diet

o Dapsone therapy

• Patients are at increased risk for development of gastrointestinal lymphoma

MASTOCYTOSIS (URTICARIA PIGMENTOSA)

• Systemic mastocytosis is defined by a clonal expansion of mast cells that in most instances is indolent and

nonneoplastic

• Cutaneous mastocytosis (CM)

o Urticaria pigmentosa (UP)/maculopapularcutaneous mastocytosis (MPCM)

o Variants: plaque form, nodular form; telangiectasia macularis eruptiva perstans (TMEP); diffuse

cutaneous mastocytosis (DCM)

o Solitary mastocytoma of skin

• The cutaneous lesions of urticaria pigmentosa are reddish-brown macules or papules that respond to

trauma with urtication and erythema (Darier's sign).

• Urticaria pigmentosa is the most common manifestation of mastocytosis, both in adults & children.

Diseases with numerous telangiectasias

• cirrhosis of the liver,

• Osler-Weber-Rendu disease, which also has mucous membrane involvement,

• lupus erythematosus

• scleroderma,

• dermatomyositis,

• cutaneous polyarteritis,

• metastatic carcinoid syndrome,

• ataxia telangiectasia,

• angiokeratoma corporis diffusum,

• telangiectasia macularis eruptiva perstans, and

• rosacea.

• overlying basal cell cancers

VI. SEXUALLY TRANSMITTED DISEASES

Sexually transmitted agents

Bacteria Virus

• Neisseria gonorrhoeae

• Chlamydia trachomatis (D-K)

• Chlamydia trachomatis (L1, L2, L3)

• Treponema pallidum

• Haemophilus ducreyi

• Calymmatobacterium granulomatis

• Mycoplasma hominis

• Ureaplasma urealyticum

• Gardnerella vaginalis

• Group B β-haemolytic Streptococcus

• Herpes simplex virus 1, 2

• Human papilloma virus

• Hepatitis B virus

• Cytomegalovirus

• Molluscum contagiosum virus

• Human immunodeficiency virus

• Human T-lymphotropic virus

Protozoa Fungi Ectoparasites

• Trichomonas vaginalis • Candida albicans • Phthirus pubis

• Sarcoptes scabiei

DISTINGUISHING FEATURES OF GENITAL ULCERS

Features Syphilis

(1° chancre)

Chancroid Lympho -

granuloma

venereum

Donovanosis

(Granuloma

inguinale)

Herpes genitalia

Organism Treponema

palladium

Haemophilus

ducreyi

Chlamydia

trachomatis

(L1, L2,L3)

Calymmato

bacterium

granulomatosis

Herpes simplex

virus type II (rarely

type I)

No. of attacks Only one (1) 1 or 2 Only one (1) Only one (1) Recurrent

No. of lesions Usually 1 Usually

multiple may

coalesce

Usually 1 Variable Multiple, may

coalesce

Early 1° lesion

Diameter

Depth

Edges

Papule

5-15 mm

Superficial or

deep

Sharply

demarcated,

elevated,

round / oval

Pustule

Variable

Excavated

Undermined,

ragged,

irregular

Papule, Pustule

2-10 mm

Superficial or

deep

Elevated, round

or oval

Papule

Variable

Elevated

Elevated, irregular

serpiginous

Vesicle

1-2 mm

Superficial

Erythematous

Base Smooth, non-

purulent,

non-vascular

Purulent,

bleeds easily

Variable

nonvascular

Red & velvety

(beefy red),

bleeds easily,

with exuberant

granulation tissue

Serous,

Erythematous,

nonvascular

Features Syphilis

(1° chancre)

Chancroid LGV Donovanosis

(Granuloma

inguinale)

Herpes genitalis

Induration Firm Soft Occasionally

firm

Firm None

Pain Uncommon Usually very

tender

Variable Uncommon Frequently tender

Lymphadenopath

Y

Firm, non

tender,

shotty,

bilateral

Tender, may

suppurate,

loculated,

usually

unilateral

(Bubo)

Tender, may

suppurate,

loculated, uni

or bilateral

(Bubo)

Nodes enlarge

above & below

Poupart's

ligament, -

Groove sign

(Pic: VI-A)

No

lymphadenopathy

pseudo buboes

(subcutaneous

nodules in

inguinal region,

may ulcerate)

Firm, tender often

bilateral

Diagnosis -Dark field

Microscopy

-Serological

tests

-Clinical

features

-Gram

Staining

(gram-ye

cocco-bacilli

with rail road

appearance)

-Demonstration

of LGV as

elementary &

inclusion bodies

-Frie's test

-Hyper gamma-

globulinemia

-Complement

fixation +ve

-Tissue smear &

histopathological

microscopy show

1. Donovan

bodies

2.Safety pin

appearance

-Multinucleated

giant cell on

Tzanck smear

-Culture is

confirmatory

Treatment Penicillins/

Doxycycline /

tetracycline

Azithromycin

Erythromycin

Ceftriaxone

Ciprofloxacin

Doxycycline

Tetracycline

Erythromycin

Doxycycline /

tetracycline

Azithromycin /

erythromycin (in

pregnancy)

Acyclovir

PIC: Groove sign in LGV

Lymphadenopathy Ulcer

DONOVANOSIS Nil Indurated, painless, bleeding

SYPHILIS Painless lymphadenopathy Painless, non bleeding, indurated, usually single

LGV Painful, suppurated, matted (BUBO) Asymptomatic, painless, non bleeding ulcer

CHANCROID Painful. fluctuant, suppurative nodes Multiple, painful, bleeding, r, indurated

HERPES Painful lymph nodes Multiple, painful. Bleeding, non indurated

STDs & Incubation Period (mean)

• Primary chancre : 9 to 90 days (21 days)

• Chancroid : One to several weeks (5 to 8 days)

• Donovanosis : 9 to 50 days (17 days)

• Lymphogranuloma venereum : 5 to 30 days (10 days)

• Herpes genitalis (primary) : 5 to 7 days (5 days)

• Genital warts : 1 to 8 months (3 months)

• Gonococcal urethritis : 1 to 14 days (2 to 5 days)

• Non-gonococcal urethritis : 7 to 21 days (10 days)

� Esthiomine: vaginal & rectal strictures & elephantiasis of the vulva. (Seen in LGV)

� Lipschutz ulceration: Non veneral ulcer of the vulva or lower vagina. (Ulcus Vulvae acutum) seen in Behcet's

disease. Similar to aphthous ulcers

MANAGEMENT OF STD's

CHANCROID:

• Based on history: sexual exposure with infected person, short incubation period & morphology.

• Confirmed by demonstration of organisms from smears taken from bubo.

• Smears are stained with gram's or Pappenheim's stain.

• Ito-Reenstierna intradermal test: becomes positive 1 or 2 weeks after appearance of sore & persists positive

for life.

• Injection of 0.1ml of suspension of killed organism & inferred as positive if a nodule of > 5mm appears after

24 hours.

• Treatment: erythromycin & Ceftriaxone.

LGV:

• History of occurrence of herpetiform lesions on the genitals, few days after intercourse, followed by painful

unilateral, multilocular inguinal bubo.

• Culture, Frei's intrademal test, complement fixation test can be done.

• Tetracyclines are the DOC.

GRANULOMA INGUINALE:

• Confirmed by demonstration of Donovan bodies in the tissue smears & also by HPE.

• Giemsa stain.

• Few large cells containing cystic spaces, often with nuclei pushed to one side & darkly staining (cells of

Greenblatt) are conspicuous.

• Rx: streptomycin, tetracyclines & cotrimoxazole.

REACTIVE ARTHRITIS (REITER'S SYNDROME)

• 50 – 80% are HLA B27 positive

• Oligoarthritis, conjunctivitis, urethritis, and mouth ulcers most common features

• Most cases of reactive arthritis develop within 1-4 weeks after either a gastrointestinal infection (with

Shigella, Salmonella, Yersinia, Campylobacter) or a sexually transmitted infection (with Chlamydia

trachomatis or Ureaplasma urealyticum)

• Psoriasiform skin lesions develop on the soles and toes

• These are often severe, persistent, aggressive and pustular (keratoderma blenorrhagica)

• Inflamed, red, scaling patches may also develop on the glans penis (circinate balanitis)

VII. ECZEMA AND DERMATITIS

Types of eczema

Endogenous eczema Exogenous eczema

• Atopic dermatitis

• Seborrhoeic dermatitis

• Nummular eczema

• Pompholyx (Dyshidrotic eczema)

• Asteatotic eczema

• Stasis dermatitis

• Juvenile plantar dermatitis

• Lichen simplex chronicus

• Irritant contact dermatitis

• Allergic contact dermatitis

• Photodermatitis

• Infectious eczematoid dermatitis

ATOPIC DERMATITIS

• Synonyms: Neurodermatitis, Besnier's prurigo, Infantile eczema

• Positive family history of allergic rhinitis, asthma or eczema

• Pruritis is the most common symptom

• Course marked by exacerbations and remissions

• Clinical course lasting longer than 6 weeks

• Lichenification of skin

• Infantile pattern: involves face, neck, extensor surfaces and groin.

• Childhood and adolescent pattern: involves flexural skin, particularly in the antecubital fossa and popliteal

fossa.

• Cutaneous stigmata of AD

o Perioral pallor

o Extra fold of skin beneath the lower eyelid (Dennie-Morgan folds)

o Increased palmar skin markings

o Increased incidence of cutaneous infections, particularly Staphylococcus aureus

• Diagnosis: clinically - dry skin, severe itching, flexural lichenification, hand eczema, nipple eczerr and eyelid

eczema in adults, history of atopy in the family/patient, and raised IgE serum levels.

CONTACT DERMATITIS

Irritant contact dermatitis

• Synonyms: Occupational dermatitis, Housewive's eczema

• Materials may injure by direct toxic action (irritants)

• Due to contact with irritants like detergents, acids, alkaline chemicals, oils, organic solvents etc

• Housewife's eczema, diaper dermatitis and industrial dermatitis are examples of cumulative irritant contact

dermatitis.

• Most common site affected is hand.

• Most common cause of contact dermatitis in Indian women – detergent.

Allergic contact dermatitis

• May induce immunological reaction of delayed hypersensitivity type (allergens) – Allergic contact dermatitis

• Most common metal causing contact dermatitis is nickel.

• Most common cause of air-borne contact dermatitis– parthenium.

• Barloque dermatitis due to cosmetics.

• Diagnosis: Patch test.

o Skin hypersensitivity test (delayed type).

o Readings are made after 48 hours.

Differences Between Irritant and Allergic Contact Dermatitis

Irritant CD Allergic CD

Symptoms Acute Stinging, smarting ���� itching Itching ���� pain

Chronic Itching/pain Itching/pain

Lesions Acute Erythema ���� vesicle ���� erosion ����

crust ���� scaling

Erythema ���� papules ���� vesicles ���� erosions

���� crust ���� scaling

Chronic Papules, plaques, fissures, scaling,

crusts

Papules, plaques, scaling, crusts

Margination

and site

Acute Sharp, strictly confined to site of

exposure

Sharp, confined to site of exposure but

spreading in the periphery; usually tiny

papules; may become generalized

Chronic III-defined III-defined, spreads

Evolution Acute Rapid (few hours after exposure) Not so rapid (12 to 72 h after exposure)

Chronic Months to years of repeated

exposure

Months or longer; exacerbation after every

reexposure

Causative

agents

Dependent on concentration of

agent and state of skin barrier;

occurs only above threshold level

Relatively independent of amount applied,

usually very low concentrations sufficient

but depends on degree of sensitization

Incidence May occur in practically everyone Occurs only in the sensitized

Hand Eczema

• Caused by chronic exposure to water and detergent.

• Dryness and cracking of the skin of hands with variable erythema and edema

• Diagnosis: Scratch test with latex extract.

Nummular (Discoid) Eczema

• Characterized by circular or oval 'coin-like' lesion.

• Most common sites are – trunk and extensor surfaces of extremities (pretibial skin and dorsum of hands)

• Most commonly affects men in middle age group.

Asteatotic Eczema

• Also called the 'Winter-itch' or Xerotic eczema or Eczema craquelee

• Seen in elderly people in dry season.

• Characterized by fine cracks in the areas of dry skin over the anterior surface of legs.

Venous eczema (Gravitational eczema or Stasis Dermatitis)

• Due to venous incompetence and chronic edema.

• Site – over the medial aspect of the ankle.

Seborrheic Dermatitis

• Most common in infants and very young. Most common location is the scalp.

• Greasy scales overlying erythematous patches or plaques

• Scaling of the external auditory canal is common

• In the first week of life, it typically occurs in the scalp ("cradle cap"), face, or groin

• In adults, it is seen in patients with Parkinson's disease, CVA and HIV infection

• Leser-Trelat sign: Sudden eruption of multiple seborrheic keratosis lesions in associated internal malignancy

Lichen Simplex Chronicus (Circumscribed neuro dermatitis)

• End stage of various eczematous disorders

• Lichenification (thickening) of skin due to chronic scratching and rubbing.

• Most common sites – nuchal region, dorsum of feet and ankles

Pompholyx (Dyshidrotic Eczema)

• Affects young adults

• Characterised by sudden crops of highly pruritic, deep-seated sago-like vesicles on the palms, sides of fingers

and/or soles

PELLAGRA

• Deficiency disease caused by lack of niacin (nicotinic acid), occurs chiefly in countries where corn (maize), a

poor source of tryptophan is basic food stuff.

• Its clinical presentations is "3-D"

� Dementia

� Diarrhea

� Dermatitis

o Most characteristic manifestation

o Occurs in form of pigmented, scaly, sharply demarcated & frequently changing cracked skin on parts

exposed to sunlight

o Various types on location

� Pellagrous glove [lesion on hand]

� Pellagrous boot [lesion on boot]

� Casal necklace [lesion around neck]

� Deficiency of vitamin A leads to follicular hyperkeratosis and roughening of the skin (phrynoderma).

ACRODERMATITIS ENTEROPATHICA

• Autosomal recessive

• Inherited form of zinc deficiency

• Result of a mutation in a zinc transport protein - decreased ability to absorb zinc from dietary sources

• Triad of

o Acral dermatitis (face, hands, feet, anogenital area)

o Alopecia

o Diarrhea

• Requires lifelong zinc supplementation

• 1-3 mg/kg of zinc gluconate or sulfate is administered orally each day

� Acrodermatitis chronica atrophicans: skin atrophy in Lyme's disease

� Acrodermatitis continua/ Acrodermatitis pustulosa: form of pustular psoriasis

EXFOLIATIVE DERMATITIS (EXFOLIATIVE ERYTHRODERMA)

• Generalized redness and scaling of the skin of >30% BSA.

• A preexisting dermatosis is the cause of exfoliative dermatitis in two-thirds of cases, including

� Psoriasis

� Atopic dermatitis

� Contact dermatitis

� Pityriasis rubra pilaris

� Seborrheic dermatitis.

• Reactions to topical or systemic drugs account 20-40% of cases

• Cancer (lymphoma, solid tumors and, most commonly, cutaneous T cell lymphoma) for 10-20%.

VIII. PAPULOSQUAMOUS DISORDERS

PSORIASIS

• Typical lesions are erythematous (red), raised, scaly, well demarcated plaques

• Characteristically presents with silvery mica scales.

• Sites: extensor aspect of trunk & limbs preferentially

• Due to increased cell turn over resulting in marked epidermal skin thickening (acanthosis)

• 50% have positive family history

• Associated with HLA-Cw6 (most common)

• Deletion of 2 late cornified envelope (LCE) genes, LCE3C and LCE3B, is a common genetic factor for

susceptibility to psoriasis

• Obesity is another factor associated with psoriasis. Weight loss results in significant improvement

Triggering factors

• Trauma (Koebner phenomenon)

• Season (worsens in winter)

• Emotional stress

• Upper respiratory tract infections

• Drugs like beta-blockers, lithium and chloroquine

• Withdrawal of systemic steroids can lead to precipitation of pustular psoriasis.

Variants

Plaque type

• Most common type

• Slow, indolent course

• The most commonly involved areas: elbows, knees and scalp

Inverse psoriasis

• Affects the intertriginous regions including the axilla, groin, submammary region, and navel

• May be moist and without scale due to their locations

Guttate psoriasis (eruptive psoriasis)

• Most common in children and young adults

• It develops acutely in individuals without psoriasis or in those with chronic plaque psoriasis

• Patients present with many small erythematous, scaling papules, frequently after upper respiratory tract

infection with β-hemolytic streptococci

Pustular psoriasis

• Generalized eruption of sterile pustules

• Fever

• Intense erythema

• Local irritants, pregnancy, medications, infections, and systemic glucocorticoid withdrawal can precipitate

this form of psoriasis

• Types

� Palmo plantar

� Acrodermatitis continua

� Pustular bacterids

� Generalized pustular (Von Zumbusch disease)

Psoriatic arthritis (PsA)

Occurs in 5 – 10% of patients with psoriasis. There are five subtypes

• Symmetric: resembles rheumatoid arthritis, but is usually milder

• Asymmetric: can involve any joint; present as sausage digits (Pencil in cup or Opera glass deformity)

• Distal interphalangeal predominant (DIP): the classic form

• Spondylitis

• Arthritis mutilans: severe and deforming, affects primarily the small joints of the hands and feet.

� Scalp psoriasis: Pityriasis amaintaceae

� Rupoid psoriasis: classically present in Reiter's syndrome (HLA-B 27)

Koebner's / Isomorphic phenomenon

• Psoriasis appears at the site of minor injury such as scratch or graze.

• Koebner phenomenon is also seen in

� Lichen planus

� Vitiligo

� Toxic Epidermal Necrolysis

� Molluscum contagiosum

� Kaposi sarcoma

� Necrobiosis lipoidica

� Discoid lupus erythematosus.

• Appears usually 7 to 14 days after injury (i.e. trauma or surgery).

• It is an all or none phenomenon (i.e. if psoriasis occurs at one site of injury it does so means will occur at all

sites of injury)

� Reverse Koebner phenomenon (reaction) is clearing of existing psoriasis lesions following injury. It also

obeys an all or none rule, and Koebner and reverse Koebner reactions are mutually exclusive.

� Pseudo – isomorphic phenomenon is due to autoinoculation & is seen in infections like

� Plane warts

� Molluscum contagiosum

• Auspitz sign -a characteristic finding of psoriasis in which removal of scales leads to pinpoint bleeding

• Removal of scales reveals a glistening red membrane of Berkeley

• Grattage Test — on scratching scales appear

• Wornoff Ring — White halo around lesion

• Candle grease sign

• In nails

� Onycholysis (separation of nail plate from nail bed)

� Thimble-pitting of nail plate

• Not seen in psoriasis

� Alopecia

� Mucosal involvement

� CNS involvement

• Histological features

� Elongation of rete-ridges

� Parakeratosis

� Hypogranulosis

� Munro's micro abscesses in the horny layer

� Spongiform pustules of Kogoj

• The psoriatic epidermis shows rapid transition of epidermal cells in as fast as 2 days as compared to 13 days

in normal epidermis

• Itching may or may not present

Key diagnostic points for psoriasis

� Erythematous scaly plaques

� Well-defined border

� Scales dry loose and micaceous

� Koebner phenomenon seen

� Auspitz sign positive

� Regular, circular pits on nail plates

� Involvement of DIP joints of fingers and toes

� Histopathological: Spongiform pustules of Kogoj

Treatment

• Treatment of choice: PUVA therapy

• DOC for psoriatic arthropathy: Methotrexate

• Tar preparations, Vit-D3 analogs like calcipotriol, Anthralin etc... can be used locally

• DOC in AIDS with psoriasis & pustular psoriasis: Synthetic retinoid — acitretin

• Biological agents used in the treatment of psoriasis

� Alefacept (anti-CD2)

� Etarnacept, Adalimumab, Infliximab (anti-TNFα)

Differential diagnosis of round, red, scaling patches

Disease Features

Psoriasis Well-defined, thickened, scaly plaques, usually multiple

Discoid eczema Moderately well-defined edge; slightly scaly, pink patches, limited in number

Ringworm Annular with central clearing; microscopy and culture of scales will reveal fungal mycelium

Bowen's disease Often slightly irregular in shape; edge is well defined; biopsy is decisive

PHOTO CHEMOTHERAPY (PUVA)

• Photosensitizing drug Psoralen + UV-A (300-400nm)

• The UV-A is supplied by special fluorescent lamps housed in cabinets or special frames over beds

• The main psoralen used is 8-methoxy psoralen

• Psoralen is given orally 2 hours before exposure & the dose 0.6 mg/kg

• Decrease DNA synthesis in psoriasis & increase melanin synthesis in Vitiligo

• UV-light therapy is contraindicated in patients receiving cyclosporine

Uses Side effects

• Psoriasis

• Vitiligo

• Cutaneous T Cell Lymphoma (Mycosis fungoides)

• Pityriasis lichenoides chronica

• Atopic dermatitis

• Pompholyx

• Long term (Major):

� Skin cancer

� Cataract

� Photo (premature) aging

• Minor (Short term): Nausea, Burning, Pruritis,

Xeroderma

LICHEN PLANUS

• Affects the skin, scalp, nails, and mucous membranes

• The primary cutaneous lesions are pruritic, polygonal, flat-topped, violaceous papules.

• Close examination of the surface of these papules reveals a network of gray lines (Wickham's striae)

• The skin lesions but have a predilection for the wrists, shins, lower back, and genitalia

• Buccal mucosa is particularly involved

Variants

• Hypertrophic lichen planus- commonest variant, thickened, mauvish papules or nodules of irregular shape

with a warty or scaling surface.

• Annular lichen planus: ring-type configuration, on the male genitalia and lower abdomen.

• Lichen nitidus: is a rare variant, numerous tiny, pink, flat-topped papules develop.

• Bullous lichen planus: blistering occurs on some lesions.

• Lichen plano-pilaris: predominantly involves the hair follicles. Affected sites lose their terminal hair and

develop horny spines. Involvement of scalp results in scarring alopecia

Clinical presentation of Lichen planus

Lesions Characteristic features Histology

• Plain (flat) topped

• Polygonal

• Purple (violaceous)

• Pruritic

• Papule

• Pterygium (thinning) of

nails

• Pigmentation on healing

• Wickham's stria

• Lace-like pattern due to

involvement of buccal and

vaginal mucosa

• Koebner's phenomenon

• Scarring alopecia

• Band-like infiltration of lymphocytes

in the upper dermis

• Formation of saw tooth profile &

cytoid (civatte) body.

• Epidermal thinkening

• Subepidermal lichenoid band

• Max Joseph histological cleft

� Associated with: Squamous cell carcinoma, Hepatitis — C

� Treatment: topical steroids are the mainstay of treatment

PITYRIASIS ROSEA

• The exact aetiology of PR is not known though HHV-6 and 7 have been implicated.

• First manifestation is an annular lesions of 2-6 cm diameter (the herald patch)

• The centers of the lesions have a crinkled or "cigarette paper" appearance

• Followed by smaller annular or papular lesions, predominantly on the trunk along the cleavage lines.

• The eruption has a characteristic 'bathing suit' distribution (trunk and proximal parts of limbs)

• Lesions on the back are parallel to ribs giving 'Christmas tree' appearance or 'hanging curtain sign'

• PR shares many clinical features with the eruption of secondary syphilis, but palm and sole lesions are

extremely rare in PR and common in secondary syphilis.

• Course — usually self-limiting.

PITYRIASIS RUBRA PILARIS

• Reddish orange scaly plaques

• Palmoplantar keratoderma

• Keratotic follicular papules

• Disease begins on the face and scalp, with pinkness and scaling

• The histological appearance: distinctive accentuation of the dermal papillae and the undulations of the

dermoepidermal junction are much less marked than in psoriasis.

IX. DISORDERS OF SKIN APPENDAGES

MILIARIA

• Results from blockage of the acrosyringium, the long thin duct that carries sweat from the coiled

secretory portion located in the reticular dermis and the subcutaneous fat to the skin surface

• There is secondary leakage of sweat in the epidermis and papillary dermis.

Types

• Miliaria crystalline (sudamina)

� Obstruction is superficial in stratum corneum

� Vesicle is subcorneal.

� It is common in infants in warm ICU conditions where cholinergic & adrenergic agents are employed.

• Miliaria rubra (prickly heat):

� Leakage of sweat into epidermis & upper dermis

� Papules around sweat pores

� Intense itching

� Miliaria pustulosa: miliaria rubra becoming pustular

• Miliaria profunda

� Obstruction of acrosyringium at deeper level

� Sweat leaking into deeper dermis

� Papules are non-itchy

ACNE VULGARIS

• A self-limited disorder primarily of teenagers and young adults

• The earliest feature is an increased rate of sebum secretion, making the skin look greasy (seborrhoea)

• A disorder in which hair follicles develop obstructing horny plugs (comedones).

• Small pseudocysts, called comedones, form in hair follicles due to blockage of the follicular orifice

• The clinical hallmark is the comedone, which may be closed (whitehead) or open (blackhead)

• The activity of bacteria (Propionibacterium acnes) within the comedones releases free fatty acids from

sebum, causes inflammation within the cyst, and results in rupture of the cyst wall

• The first lesions, usually comedones, develop on the forehead (pre-adolescent acne)

• At its peak, acne covers the entire face (adolescent acne)

• In mature adults (25 years plus) it settles on the jaw area and the adjacent neck (adult acne).

• The scars formed after healing are often quite irregular and tend to form 'bridges'

• Even the smaller inflamed papules can cause scars - pock-like or triangular indentations (ice-pick scars).

• Acne fulminans

� Lesions quite suddenly become very inflamed

� Affected individual is unwell and develops fever and arthralgia.

• Treatment:

� Oral tetracycline or erythromycin.

� Topical — retinoic acid (for nodulocystic acne), benzoyl peroxide, salicylic acid.

� Sebum production is decreased by sebotrophic agents (directly) and antiandrogens (indirectly)

o Tretinoin (all trans retinoic acid)-1st generation (1G)

o Isotretinoin (13-cis isomer of tretinoin)-2G

o Adapalene — 3G

o Tazarotene — 4th

generation

ROSACEA (ACNE ROSACEA)

• Common chronic inflammatory acneiform disorder of the facial pilosebaceous units, coupled with an

increased reactivity of capillaries leading to flushing and telangiectasia.

• It is seen almost exclusively in adults, rarely affecting patients <30 years.

• Rosacea is more common in women

• But those most severely affected are men

• Characterized by the presence of erythema, telangiectases, and superficial pustules

• Comedones are not seen

• Predisposing factors: History of flushing associated with heat, emotional stimuli, alcohol, hot drinks or spicy

foods.

• Site: typically involves the central face. This does not affect the trunk.

• Complications

� Nose – connective tissue overgrowth (Rhinophyma – sebaceous gland hypertrophy)

� Eye – keratitis, uveitis, chalazion.

� Chloracne- extremely severe form of industrial acne due to exposure to complex chlorinated naphthalenic

compounds and dioxin.

PHASES OF HAIR GROWTH

• Anagen: Phase of normal active growth, lasts for 3 years, 90% of hairs are in this phase

• Catagen: Brief transition phase (between anagen and telogen) during which hair growth stops, lasts for 3

weeks

• Telogen: Resting phase, lasts for 3 months

• Exogen: Hair shedding phase (relationship between hair shaft and base of telogen follicle)

• Duration and rate of growth of anagen phase determine the ultimate length of hair in that area.

• Eyebrows, eyelashes, and axillary pubic hair: anagen phase is short; telogen phase prolonged.

• Scalp, beard: relatively long anagen phase.

• Terminal scalp hair follicles: 100,000 at birth; genetically determined to produce long, thick pigmented hairs.

• Vellus hairs: present over most of the body; genetically predestined to produce hairs that are short, fine,

non-pigmented.

HAIR LOSS (ALOPECIA)

• Shedding of hair is termed effluvium or defluvium

PATTERN ALOPECIA or MALE ALOPECIA or ANDROGENIC ALOPECIA

• Most common type

• Autosomal dominant

• Progressive form of alopecia

• Mostly seen in men

• The earliest changes occur at the anterior portions of the calvarium on either side of the "widow's peak" and

on the crown (vertex).

• Loss of hair starts in both temporal regions.

Treatment:

• Chemical castration with anti-androgen-prostagen combination in women by cyproterone acetate &

ethinylestranol – Dianette.

• Anti hypertensive (Vasodilator) – Minoxidil & Tretinoin

• 5-alpha-reductase inhibitor – Finasteride.

ALOPECIA AREATA

• Autoimmune disorder of hair follicles causing loss of hair in sharply defined areas of skin

• Results from arrest of hair follicles in late anagen phase.

• 10-20% patients give a family history

• Polygenic inheritance

• HLA DR4, DR5, DQ3 are associated with severe alopecia

• HLA DQ3 and DR11 – associated with alopecia totalis & universalis

• 'Exclamation mark' hairs at the margin of the lesions.

• Non scarring & non patterned alopecia

• Particularly common between the ages of 15 and 30 years.

• Alopecia totalis is total or almost total loss of scalp hair.

• Alopecia universalis is loss of all body hair.

o Sites of Predilection: Scalp, eyebrows, eyelashes, pubic hair, beard.

o Nails: Fine pitting ("hammered brass") of dorsal nail plate, mottled lunula, trachyonychia (rough nails),

onychomadesis (separation of nail from matrix).

• Ophiasis is alopecia along scalp margin. (band-like hair loss in the occipital and temporal scalp),

• Sisaipho (predilection for parietal scalp mimicking androgenetic alopaecia),

• Classical feature is sparing of gray/white hairs.

• Positively associated with autoimmune disorders

• Alopecia Aerata + Vitiligo + Uveitis Vogt Koyanagi syndrome

• Dense 'bee swarm'-like cluster of lymphocytes can be seen around the follicles in biopsies.

• Treatment: Potent topical steroids or systemic steroids, PUVA, dithranol, allergic sensitization with

diphencyprone and topical minoxidil

TELOGEN EFFLUVIUM

• Transitory increase in the number of hairs in the telogen (resting) phase of the hair growth cycle.

• This may occur spontaneously, may appear at the termination of pregnancy, may be precipitated by crash

dieting, high fever, stress from surgery or shock, malnutrition, or hormonal contraceptives.

• Telogen effluvium usually has a latent period of 2-4 months

• The prognosis is generally good

ALOPECIA MUCINOSA

• Non scarring alopecia

• Mucin deposition in hair follicles & sebaceous glands causing epithelial reticular degeneration

• MC site: face & scalp

SCARRING/CICATRICAL ALOPECIA

• Due to inflammatory process like discoid lupus erythematosus and lichen planus

• Result in permanent loss of hair in the affected area.

• Most common congenital cicatrial alopecia is aplasia cute's congenita (i.e. focal absence of epidermis with

or with or with out other layers).

• Pseudopelade - small, rounded patches of scarring alopecia without any inflammation.

DISORDERS OF NAILS

Koilonychia (Spoon nail)

The nail is concave with raised edges

Iron deficiency anemia

Lichem planus

Hypothyroidism

Racquet Nail

Width of nail bed & nail plate is greater than their length

Premature obliteration of epiphyseal line

Anonychia

Absence of all or part of one or several nails

Lichen panus

With tong. bone anomalies

Beau's Line

Poor nutrition to matrix 1/t a defective band of nail

formation resulting in transverse groove of thin nail

plate.

Any severe systemic illness

Onychomadesis : Separation of nail from matrix

Longitudinal ridges with beaded and/or Fir tree

appearance

Median canaliform dystrophy of Heller

Trachyonychia (Rough sand paper nail) 20 nail dystrophy (alopecia areata)

External chemical treatment

Leuconychia : White discolouration of nail Nail matrix dysfunction

Apparent leuconychia

White appearance d/t changes in underlying tissue

Tery's nail, half & half nail

Muehrck's paired narrow white band

Onychogryphosis (Ram's horn or Oyster – Nail)

Nail is severly distorted, thickened, opaque, brownish,

sparaled & with out attachment to nail bed

Pressure from foot wear in elderly

Hook Nail Lack of support from short bony phalynx

Pterygium Dorsal pterygium in lichen planus

Ventral pterygium in scleroderma with Raynaud's

phenomenon, causalgia of median nerve,

formaldehyde containing nail cosmetics.

Onycholysis : Detachment of nail plate from its bed

starting at its distal &/or lateral attachment

Psoriasis

Reiter's syndrome

Onychorrhexis : Splitting & roughness of nail plate Lichen planus

Onychoptosis defluvium (Alopecia unguim)

Component of alopecia

Alopecia areata

Koenen's Periungal Fibroma Tuberous sclerosis (50% cases)

Mee's Line Arsenic Poisoning.

Pitting Deep & irregular pits: psoriasis, atopic dermatitis

Superficial & geometric pits in alopecia areata.

Melanonychia

Presence of melanin in nail plate presenting as single /

multiple longitudinal brown — black band.

-Single band: nail matric nevus or melanoma

(deserve biopsy), trauma (usually in 4/5th toe nail)

-Multiple band: dark race, pregnancy, inflmatory

nail disorder, Lauiger — Huntziker syndrome (with

pigmented macules on lip & genitals), AIDS,

Addison syndrome

Muehrck's lines Hypoalbuminemia

Brown nail Arsenic poisoning

Addison's disease

Blue nail Wilson's disease

X. GENODERMATOSES & DISORDERS OF KERATINIZATION

Genodermatoses: diseases which are transmitted genetically from parents to children.

NEUROFIBROMATOSIS (VON RECKLINGHAUSEN'S DISEASE)

• Autosomal dominant

• Plexiform neurofibroma - soft, doughy, subcutaneous swelling having a bag of worm feeling and run along

nerves

• Multiple, brownish macules (Café au lait macules)

• Tiny specks of brownish macules in the axilla (axillary freckling)

TUBEROUS SCLEROSIS (SYN. BOURNEVILLES DISEASE)

• Two third cases – sporadic, others - Autosomal dominant,

• Multiple, brown, soft, grouped papules present in the perinasal area and cheeks in a butterfly distribution

These are called facial angiofibromas (misnamed as adenoma sebaceum)

• Ungual or subungual fibromas, (Koenen's tumours) are small fleshy tumours that grow around and under

the toenails or fingernails

• Hypomelanotic macules ('ash leaf spots') are white or light coloured patches on skin (only visible sign of

tuberous sclerosis at birth)

• Shagreen patches are areas of thick leathery skin which is dimpled like an orange peel and is usually found

on the lower back or nape of the neck

• Café au lait macules can be seen

ICTHYOSIS

• Characterised by the accumulation of 'fish-like' scales due to abnormal epidermal cell kinetics

• Autosomal dominant Icthyosis

� Icthyosis vulgaris – most common type

� X-linked icthyosis (seen in boys only)

• Autosomal recessive Icthyosis – more severe than the dominant form

� Lamellar icthyosis

� Icthyosiform erythroderma

Icthyosis vulgaris

• Begins in the first year of life

• Dry, scaly skin over the extensor aspects of the arms and legs

• The scales are larger over the lower extremities

• Mild keratoderma or (thickening of the skin over the palms and soles)

• The dryness becomes worse during winters and improves in summers and humid weather

• Histologically, the only abnormality detectable is a much diminished granular cell layer.

X-linked ichthyosis

• Deficiency of steroid sulphatase

• The scales are dirty brown in colour and affect both the extensor and flexural surfaces of the extremities

with prominent involvement of the neck and trunk

• These male children are often the products of postmature pregnancies and difficult labours.

• Associated disorders: cryptorchidism, ectropion

� Acquired icthyosis: The most important cause underlying malignant disease – particularly lymphoma –such

as Hodgkin's disease

� Tylosis: Marked thickening of palmar and plantar skin due to localized abnormality of keratinization.

XERODERMA PIGMENTOSUM

• An autosomal recessive disorder of DNA repair

• The most common defect - nucleotide excision repair (NER) enzymes are mutated.

• History - the child cries on exposure to light

• Skin turns erythematous on exposure to sun

• Development of freckles and lentiginosis on the exposed area of the body, such as the extensor aspect of

arms, face and the neck are early signs

• Later by adulthood squamous cell carcinoma, basal cell carcinoma, and malignant melanoma may form

EPIDERMOLYSIS BULLOSA

• An inherited defect in the keratin formation

• Characterised by the formation of multiple blisters on gentle rubbing or on minimal skin trauma especially

over the trauma prone areas of the body

• There may be blisters in the pharynx, larynx, eyes and the genital mucosa.

• There may be contractures and mitten like deformities of hands in the severe variants

• Pyloric stenosis and squamous cell carcinoma are other complications

PALMOPLANTAR KERATODERMA

• Inherited defects due to mutations in the enzymes involved in the synthesis of keratin

• Skin over palms and soles becomes hard, thick, dry and hyperkeratotic

REFSUM'S SYNDROME (HEREDOPATHIA ATACTICA NEURITIS FORMIS)

• Autosomal recessive,

• Accumulation of phytanic acid in all the tissues

• Cerebellar ataxia, polyneuritis, retinitis pigmentosa, nerve deafness, generalized ichthyosiform scaling.

DARIER'S DISEASE (KERATOSIS FOLLICULITIS)

• Inherited as an autosomal dominant disorder, but also occurs sporadically.

• Appearance of groups of brownish, horny papules over the central trunk, shoulders, face and elsewhere

• Oral cavity shows: Cobble stone appearance

• V shaped nicking of nails seen

• Presence of tiny pits on the palms

• There is a curious loss of cohesion between keratinocytes above the basal layer

XI. PEDIATRIC DERMATOLOGY

NEONATAL DERMATOLOGY

Transient Neonatal Pustular Melanosis

• Onset at birth

• Common in darkly pigmented infants

• Smear of sterile pustule shows numerous neutrophils

• Histology: subcorneal pustules with neutrophils

Erythema Toxicum Neonatorum

• Onset typically 24 – 48 h after birth

• Occurs in half of all full-term infants

• Presents with blotchy erythematous macules, papules, pustules, and wheals

• Smear of sterile vesicle/pustule shows eosinophils

• Histology: subcorneal pustules with eosinophils, associated with pilosebaceous unit

Neonatal Cephalic Pustulosis (Neonatal Acne)

• Onset typically within first 30 days

• Malassezia spp. implicated in pathogenesis

• Presents with erythematous follicular comedones, papules, and pustules on face

• Histology: follicular pustules with neutrophils

Sclerema Neonatorum

• Onset usually within first week of life

• Form of panniculitis in severely ill, premature infants; often fatal

• Presents with diffuse woody hardening of skin

• Spares genitalia, palms, and soles

• Histology: needle-shaped clefts with necrotic adipocytes with little surrounding inflammation

Seborrheic Dermatitis

• Onset typically 1 week after birth; lasts several months, mostly resolves by 1 year of age

• Presents with ill-defined erythematous patches with waxy scale over scalp ("cradle cap"), ± axillae and groin

Aplasia Cutis Congenita (ACC)

• Onset before birth

• Localized defect in epidermis, dermis and/or fat

• Typically along midline

• Presents with erosion, ulceration, scar, or membranous defect (ovoid lesion covered by an epithelial

membrane)

• Hair collar sign: ring of dark long hair encircling lesion; ± marker of underlying neural tube defect

Cutis Marmorata Telangiectatica Congenita (CMTC)

• Onset at birth

• Typically improves with age

• Presents with blanching reticulated vascular pattern on trunk/extremities with segmental distribution

• Associated anomalies in 1/2 of patients (varicosities, nevus flammeus, macrocephaly, ulceration, hypoplasia,

and/or hypertrophy of soft tissue and bone)

Congenital Infections of the Newborn

PAPULOSQUAMOUS AND ECZEMATOUS DERMATOSES

Psoriasis

• 25% patients will have presentation before age 15

• Guttate psoriasis more common in children

• Presents with raindrop-like papules in an eruptive pattern

Acropustulosis of Infancy

• Onset from 6 months to 2 years; resolves by age 3

• Presents with recurrent crops of pruritic pustules on palms, soles, distal extremities (may mimic scabies

infection so prudent to perform mineral oil scraping)

• Treatment: topical corticosteroid

PIGMENTED LESIONS

Lentigines

• Presents as brown macules with increased number of melanocytes

• No relationship to sunlight

• Multiple lentigines may be associated with the following:

LEOPARD Syndrome

Autosomal dominant

PTPN11 gene mutation

Café-noir macules

ECG changes

Hypertelorism

Pulmonary stenosis

Abnormal genitalia

Growth retardation

Deafness

Carney Complex (LAMB or NAME syndrome)

Autosomal dominant

PRKAR1A gene mutation

Psammomatous melanotic schwannomas,

Cardiac/cutaneous myxomas

Blue nevi

Endocrine overactivity

Peutz–Jeghers Syndrome

Autosomal dominant

STK11 gene (serine threonine kinase)

Mucocutaneous (oral/acral) lentigines

ntestinal polyposis, ± intussusception

Various malignancies

Laugier–Hunziker Syndrome Mucocutaneous lentigines

Longitudinal melanonychia

Genital melanosis

Bannayan–Riley-- Ruvalcaba Syndrome

Autosomal dominant

PTEN gene mutation

Penile > vulvar lentigines

Lipomas

Hemangiomas

Ephelides (Freckles)

• Light brown macules in sun-exposed areas

• More prominent in children with fair skin and during summer time

• Onset typically within first 3 years of age

• Can be a marker for UV-induced damage if acquired

• Histology: normal number of melanocytes, increased pigment in keratinocytes

Congenital Nevus (CN)

• Onset at birth or first year typically

• Slight ↑ risk of melanoma (highest in large CNs)

• Axial nevi with greatest risk of developing melanoma

• Neurocutaneous melanosis: ↑ intracranial pressure, leptomeningeal melanoma, spinal cord compression

Spitz Nevus (Epithelioid or Spindle Cell Nevus)

• Presents as dome-shaped red-brown or tan-pink smooth surfaced papule

• Typically occurs within first two decades

• Histology: K amino bodies (PAS + globules)

• Characteristic starburst dermoscopic finding in pigmented Spitz nevi

Becker's Nevus (Becker's Melanosis)

• Acquired unilateral lesion found in males (second or third decade) typically on shoulder, upper chest, or back

• Hyperpigmented hypertrichotic patch or plaque associated with underlying smooth muscle hamartoma

(arrector pili)

• Histology: ↑ melanin in epidermis, often smooth muscle hamartoma present in dermis

Blue Nevus

• Congenital or acquired (typically early childhood)

• Multiple blue nevi associated with Carney complex (LAMB/NAME syndrome)

• Histology: normal epidermis, many elongated dendritic melanocytes within dermis, large amounts of

melanin often seen within melanocytes

Nevus of Ota (Nevus Fuscoceruleus Ophthalmomaxillaris, Oculodermal Melanocytosis, Congenital melanosis bulbi)

• Onset either near birth or during puberty

• Mostly in women

• Caused by the entrapment of melanocytes in the upper third of the dermis

• Presents as unilateral (90%), blue-gray hyperpigmented macules in the face (forehead, temple, malar area,

or periorbital skin)

• Typically involving ophthalmic and maxillary branches of trigeminal nerve

• Most common extracutaneous sites: sclera (increased risk of glaucoma)

• Malignant melanoma develops very rarely

• Mongolian spot - a birthmark caused by entrapment of melanocytes in the dermis but is located in the

lumbosacral region.

Nevus of Ito (Nevus Fuscoceruleus Acromiodeltoideus)

• Similar presentation to nevus of Ota

• Usually unilateral

• Typically occurs in shoulder region (supraclavicular, scapular, and deltoid)

Hori's Nevus (Acquired Nevus of Ota-like Macules)

• Onset in late adolescence

• Bilateral nevus of Ota-like macules of the zygomatic region

• May be misdiagnosed as melasma

Nevus achromicus (Nevus depigmentosus)

• An uncommon birthmark characterised by a well-defined pale patch.

• Often, smaller hypopigmented macules arise around the edges, resembling a splash of paint

• Achromic naevus is not completely white (differentiates from vitilligo)

• Achromic naevi are usually solitary (in contrast to tuberous sclerosis, where multiple pale patches occur and

are called ash-leaf spots)

• Most commonly seen on the upper chest, but may also arise on the limbs

Congenital Dermal Melanocytosis (Mongolian Spot)

• Common in infants with pigmented skin

• Presents with blue-gray macules or patches typically over lumbosacral skin or buttocks

TELANGIECTASIAS

Spider Angioma (Spider Nevus)

• Common acquired lesion seen in children and adults

• Comprised of central arteriole with radiating thin walled vessels

• Temporary obliteration seen with compression

• Multiple lesions associated with liver disease, pregnancy, and estrogen therapy

XII. DISORDERS OF PIGMENTATION

� Normal human skin colour is primarily related to size and the arrangement of melanosomes in melanocytes.

HYPO PIGMENTATION

Melanocytopaenic

(Melanocytes decreased or absent)

Melanopaenic

(Melanin decreased or absent)

Non-melanotic

(No melanin defect)

� Piebaldism

� Vitiligo

� Vogt-Koyanagi-Harada syndrome

� Xeroderma pigmentosum

� Mycosis fungoides

� Pityriasis lichenoides chronica

� Halo naevus

� Leucoderma acquisitum centrifugum

� Burns (Ionising, Thermal, UV)

� Trauma

� Alopaecia areata

� Scleroderma

� Albinism

� Homocystinuria

� Nevus of Ito

� Nevus depigmentosus

� Tuberous sclerosis

� Leprosy

� Pityriasis alba

� Pityriasis versicolour

� Discoid lupus (Post-

inflammatory)

� Melanoma

� Post-dermabrasion

� Post-laser

� Nevus anemicus

� Woronoff's ring

(hypopigmentation

around psoriasis

lesions)

VITILIGO

• A typical vitiligo macule has a chalk or milky white colour, round to oval in shape often with convex margins

which are usually well defined

• Associated with various autoimmune diseases, most commonly thyroid disorders

• Localized Vitiligo – focal, segmental or mucosal

• Generalized Vitiligo is the most common type characterised by few to many to widespread macules

� Acrofacial: distal fingers and periorificial areas

� Vulgaris: scattered patches that are widely distributed

� Mixed

• Universal Vitiligo indicates almost total involvement of the body with few remaining areas of pigmentation -

associated with various endocrinopathy syndromes.

• In the sharply demarcated, symmetrical macular lesions there is loss of melanocytes and melanin.

Treatment

• Limited disease: Topical corticosteroids (triamcinolone)are the 1st line treatment

• Topical tacrolimus (0.03% and 0.1%) ointment - safe and effective in childhood vitiligo.

• Generalised Vitiligo: Narrow band UVB

• Topical or oral psoralen (8 methoxy psoralen) with UV-A (320 – 400nm) radiation (PUVA)

o Topical PUVA is used for old lesion involving <20% of body surface area

o Oral psoralen is used in extensive disease or in patients not responding to topical PUVA

Albinism

• Genetic abnormalities of melanin synthesis (in hair, skin and eye)

• Normal number and structure of melanocytes

• Characteristic albino with white hair, white skin and blue eyes.

Piebaldism

• Autosomal dominant

• Congenital

• Stable leucoderma

• Characterised by chalk or milk-white macules like that of vitiligo

• Typical white forelock.

White patch of skin: differential diagnosis (Mnemonic: "Vitiligo PATCH")

• Vitiligo

• Pityriasis alba/ Post-inflammatory hypopigmentation

• Age related hypopigmentation

• Tinea versicolor/ Tuberous sclerosis (ash-leaf macule)

• Congenital birthmark

• Hansen's (leprosy)

HYPERPIGMENTATION

Melanocytotic

(increase in number of melanocytes)

Melanotic

(increase in melanin)

• Lentigines

• Peutz-Jegher syndrome

• PUVA therapy

• Lentigo, solar, UV (radiation tanning)

• Café-au-lait macules

• Freckles

• Naevus spilus

• Hemochromatosis

• Melasma

• Exogenous ACTH

• Chronic pruritis

• Post inflammatory

• Melanoma,

• Mastocytosis

• Acanthosis nigricans

MELASMA

• Dark areas appear symmetrically across the cheeks, around the eyes and over the forehead, giving a mask-

like appearance

• It is much more common in women

• Seen more often in people with dark skin

• The majority of cases appear related to pregnancy or oral contraceptives

• High expression of α-MSH in the lesional keratinocytes plays an important role in the melanisation of skin

• Topical hydroquinone (2% to 4%) with retinoids and or steroids is the usual treatment

XIII. SKIN IN SYSTEMIC DISEASES & MISCELLANEOUS

PARANEOPLASTIC SIGNS OF INTERNAL MALIGNANCY

• Acanthosis nigricans - Brown-back velvety plaques over neck and flexures

• Acute febrile neutrophilic dermatosis - Tender, red plaques over limbs and face in a middle-aged lady

• (Sweet's syndrome)

• Acquired Ichthyosis - Dry fish-like skin most commonly in Hodgkin's lymphoma

• Clubbing - Severe grades of clubbing with lung carcinoma

• Dermatomyositis - 10% cases have associated with internal malignancy

• Erythema gyratum repens - Concentric rings of erythema and scaling over trunk (Ca bronchus)

• Hypertrophic osteoarthropathy - Subperiosteal new bone formation

• Migratory thrombophlebitis – Pancreatic cancer

• Myeloma-associated amyloidosis - Skin nodules and purpura

Associated with endocrine neoplasm

• Necrolytic migratory Erythema – Glucagonoma

• Necrobiosis lipoidica diabeticorum – Diabetes mellitus

• Addisonian pigmentation - Adrenal corticotropin hormone (ACTH) secreting neoplasms

• Carcinoid tumours - Flushing of face and upper trunk

ACANTHOSIS NIGRICANS

• It is a velvety hyperpigmentation, thickening & increased rugosity of skin

• Primarily involves flexures – axilla & groin.

• Thickened areas bear skin tags & seborrheic warts

• In majority of patients, it is associated with obesity (pseudo acanthosis nigricans) and insulin resistance

• The skin changes are reversible on weight reduction.

• It can reflect internal malignancy – most commonly gastrointestinal malignancy

• Also seen in: Endocrine diseases like Cushings syndrome, Acromegaiy, Poiycystic ovarian disease, insulin

resistant DM

• HAIR- AN syndrome: in women, the triad of

� Hyperandrogenism

� Insulin-resistance

� Acanthosis nigricans

NECROBIOSIS LIPOIDICA DIABETICORUM

• A disorder of collagen degeneration with a granulomatous response, thickening of blood vessel walls, and

fat deposition

• The main complication of the disease is ulceration, usually occurring after trauma

• Strongly associated with diabetes mellitus

• Usually present with shiny, asymptomatic patches that slowly enlarge over months to years

• The patient's main complaint is the unsightly cosmetic appearance of the lesions.

• Most cases of necrobiosis lipoidica occur on the pretibial area

ERYTHEMA MARGINATUM

• Major criteria for diagnosis of rheumatic fever

• Extremely rare in Indians

• Erythematous pink rashes with a clear center and round or serpiginous margin.

• Not raised above the skin

• They are brought on by application of heat

• Most commonly seen on the trunk and proximal parts of extremities, but never on face.

SKIN CANCER

BASAL CELL CARCINOMA, SQUAMOUS CELL CARCINOMA & MALIGNANT MELANOMA

Refer SPEED VISION— PATHOLOGY SECTION

MYCOSIS FUNGOIDES

• Also known as cutaneous T cell lymphoma

• More common in males and in blacks.

• An indolent lymphoma with patients often having several years of eczematous or dermatitic skin lesions

before the diagnosis is finally established

• Pruritus is a frequent complaint

• In advanced stages, the lymphoma can spread to lymph nodes and visceral organs

• Lymph node enlargement may be due to benign expansion of the node (dermatopathic lymphadenopathy)

or by specific involvement with mycosis fungoides.

• Patients may develop generalized erythroderma and circulating tumor cells, called Sezary's syndrome, a

picture sometimes referred to as L'Homme rouge

• The skin biopsy remains the basis of diagnosis

• Circulating malignant T cells (Sêzary cells) can be detected in the blood (T cell gene rearrangement test)

Diseases that pyoderma gangrenosum may occur with

• Ulcerative colitis

• Crohn's disease

• Rheumatoid arthritis

• Monoclonal gammopathy

• Leukaemia

XANTHOMA & LIPOPROTEIN DISTURBANCES

Xanthoma tendineum Familial hypercholesterolemia (typella)

Xanthelasma palpebrarum Normolipemic (50%)

Familial hypercholesterolemia

Familial dybetalipidemia

Xanthoma eruptivum (or tubero

eruptivum)

Familial dybetalipidemia

Familial combined hypertriglyceridemia

Familial lipoprotein lipase deficiency (rare)

Xanthoma striatum palmare Familial dybetalipidemi (type Ill)

Xanthoma planum (generalized) Patients often develop a monoclonal gammopathy associated

with myeloma (type Ill), macroglobulinemia, or lymphoma, and

with normal plasma lipid levels. Less commonly, FHT may be present.

CONDITION CAUSE

Necrotizing fasciitis

Erysipelas

Strep. Pyogenes

Ecthyma Pseudomonas

Erythrasma Corynebacterium minuttissmus

Erythema migrans Borrelia burgdorferi

Erythema Ab Igne Repetitive exposure to infrared rays

Erythema annulare centifugum Hypersensitivity [gyrate erythema]

Erythema gyratum repens Associated with malignancy [M/C: lung, esophagus, breast]

Erythema dyschromicum perstans Ashy dermatosis, idiopathic

Erythema chronicum migrans Cutaneous manifestation of stage I Lyme disease

Erythema elevatum diutinum Localized fibrosing small vessel vasculitis

Erythema induratum of Bazin Tuberculosis

Erythema infectiosum Parvovirus B 19

Lesion Found in

Erythema pernio (chill blain) Cold

Lupus pernio & Epitheloid granuloma Sarcoidosis

Lupus profundus SLE

Lupus Vulgaris Cutaneous TB

Phrynoderma Vit-A deficiency

Essential fatty acid deficiency

Sauroderma/Crocodile skin Icthyosis Vulgaris

Weldt sores Desert areas

Black hairy tongue Broad spectrum antibiotics

Oral Hairy Leukoplakia AIDS (not candidiasis)

Rain drop pigmentation Chronic Arsenic Poisoning

Pyoderma Gangrenosa Ulcerative Colitis

Slapped Cheek appearance Erythema infectiosum

Honey Crust Impetigo

Angioid Streak Pseudoxanthoma Elasticum

Axillary freckling & Lisch nodule (Iris hamartoma) Neurofibromatosis

Cradle cap appearance Seborrheic Dermatitis (Pityriasis capitis)

Coyenne pepper stippling (d/t hemosiderin) Plasma cell balenitis of Zoom

NIKOLSKY SIGN: Positive in

• Pemphigus Vulgaris / foliaceous & Epidermolysis bullosa congenita

• Staphylococcal Skin Scald Syndrome (SSSS) & Toxic Epidermal Necrolysis (TEN)

• Stevens Johnson Syndrome

• Leukemia

• Herpes

� The Asboe-Hansen sign ("indirect Nikolsky sign" or "Nikolsky II sign") refers to the extension of a blister to

adjacent unblistered skin when pressure is put on the top of the bulla

SIGNS IN DERMATOLOGY

• Antenna sign – Keratosis Pilaris

• Asboe Hansen sign (Bulla spread sign) – Pemphigus

• Auspitz sign – Psoriasis

• Button hole sign – Neurofibromatosis.

• Birbeck's granules: Langhan cell histiocytosis

• Chandelier's sign - Gonorrhea in women

• Candle sign & last cuticle sign: Psoriasis

• Carpet tack's sign – DLE

• Cerebriform tongue sign – Pemphigus vegetans

• Coup'd'ongue sign –Tinea versicolor

• Crowe's sign – Axillary freckling in Neurofibromatosis

• Comby sign: Measles

• Russell's sign: Bulimia Nervosa

• Premalatha Sign: Pemphigus Vulgaris

• Deckchair sign: Papulo erythrodema

• Dimple sign (Fitzpatrick sign ) – Dermato fibro sarcoma protuberans, differentiates dermatofibroma

• from malignant melanoma

• Dubois sign – Short little finger in congenital syphilis

• Dory flap sign: Primary chancre

• Flag sign – Kwashiorkor

• Forscheimer sign – Enanthema on soft palate in Rubella

• Groove sign of Greenblat – LGV

• Head light sign – Perinasal and periorbital pallor in Atopic dermatitis

• Hertoghe's sign – Loss of lateral third of eyebrow in Atopic dermatitis

• Higouminaki's sign – Congenital syphilis; thickened sternal portion of clavicle.

• Leopard sign: Onchocerciasis

• Milian's ear sign – Erysipelas can spread into the pinna (being cuticular infection), whereas cellulitis cannot

spread to the pinna due to close adhesion of skin to cartilage of ear (without any areolar tissue.)

• Oil drop sign – Discoloration of nail bed in Psoriasis.

• Ollendorf sign – Papule is very tender to touch in secondary syphilis

• Osler's sign – Alkaptonuria

• Pillow sign – Netherton's syndrome; hair shaft defect patient sees hair on pillow on getting up in the morning

• Trichrome sign – Vitiligo

• Romana's sign -T.Cruzi; Chaga's disease

• Shawl sing – Erythema over the upper back and shoulders in dermatomyositis

• Wrist sign , Thumb sign or Steinberg's thumb – Marfan syndrome

IMPORTANT PEARLS:

• Area of skin: 1.7m2, constitutes 4kg of body weight in adult man.

• Spongiform pustule of Kogoj: accumulation of neutrophils in Malphigian layer.

• Tzanck cell: keratinocyte.

• Clue cells: vaginal epithelial cells

• Fordyce spots: ectopic sebaceous glands

• Target lesions: Erythema multiforme

• Binkley's spots: Diabetic dermatopathy

• Muehrcke's nail: seen in chronic hypoalbuminemia

• Circle of Hebra: seen in scabies

• Ritter's disease: caused by Staph. aureus

• Lichen nitidus: claw clutching a ball appearance

• Anatomist's wart: Tuberculosis verrucosa cutis/Warty TB

• Remote reverse Koebner phenomenon: Vitiligo

• Dermographism: Urticaria

• White dermographism: Atopy

• Myrmecia warts: Plantar warts

• Dermatomyositis: Helitrope rash/ Gottron sign/ Gottron papule

• Most common form of oral candidiasis: acute pseudo membranous

• M/c dermatophyte producing favus: T. schoenleinii

• M/c photodermatoses: Polymorphic Light Eruptions (PLE)

• M/c form of cutaneous TB: Lupus Vulgaris

• M/c manifestation of gonococcal infection in males: Anterior urethritis

• M/c manifestation of acute gonococcal infection in females: endocervicitis

• M/c cause of vaginal discharge in India: Bacterial vaginosis

• M/c cosmetic allergen: fragrances > hair dye

• M/c site of trophic ulcer: ball of great toe

• M/c teeth affected in leprosy: upper incisors

• Black Piedra/ Trichomycosis nodularis: Piedraia hortae.

• White piedra: Trichosporon ovoides

• Copper penny bodies: Chromomycosis

• Endothrix dermatophytosis in India is due to: T. Violaceum

• Profeta's law: fetus maybe born normal but may develop signs of early congenital syphilis during first few

weeks/months

• Colle's law: syphilitic infant may not infect its own mother but is capable of infecting others.

• Truck driver's disease: Hydradenitis suppurative of perianal region in males

• Kligman's formula/ Triluma cream: 5% hydroxyquinone, 0.1% dexamethasone, 0.1% Tretinoin (For

Chloasma)

• Thinning of nails : involves nail matrix

• Dilapidated brick walls: Hailey-Hailey disease

• Syringoma: Tadpole like appearance

• Miescher's granuloma: Erythema nodosum

• Cork screw hair: Scurvy

• Selenium deficiency: Pseudoalbinism

• Louis bar syndrome: Ataxia telangiectasia

• Pseudo-Hutchinson's sign: Bowen's disease

• Hutchinson's sign: Melanoma in nail matrix

• Keratosis follicularis squamosa: lotus leaves on water appearance

• Jigsaw puzzle appearance: cylindroma

• Trimethylamine: fish odour syndrome

• Urbach Wiethe disease: lipoid proteinosis

• Mauserung phenomenon: icthyosis bullosa of Siemens

• Basal cell carcinoma: Bazex syndrome

• Erythema induratum affecting legs of young women: Bazin's disease

• Mouse ear appearance: X- ray feature of psoriatic arthritis

• Least affected in Atopic dermatitis: Mid chest

• Pharyngeal dysmotility: seen in polymyositis

• Green nail syndrome with fruity odor: Pseudomonas aeruginosa

• Haverhill fever/ erythema arthriticum: Streptobacillus moniliformis

• Jungle sore: cutaneous diphtheria

• Woody fibrosis: actinomycosis

• Mickey mouse ears: Cockayne syndrome

• Subcutaneous fat necrosis: Carcinoma pancreas

• Cigarette paper scars: Ehler Danlos Syndrome

• Hot tub follicles: Pseudomonas aeruginosa

• Slavic leprosy: Rhinoscleroma

• Pretibial fever: leptospirosis

• Alkaptonuria: sweat that stains

• Pseudo-Cushing's disease: chronic alcoholism

• Angel's kiss: Nevus flammeus

• Bath itch: Polycythemia rubra vera

• Nostalgia parasthetica: itch in interscapular region

• Effective drug for pruritus due to polycythemia rubra vera: Aspirin

• Mediator of pruritus in Hodgkin's Lymphoma: Leukopeptidase

• Syphilitic gumma: involves left atrium & septum

• Secondary syphilis never involves: bone

• Photopatch testing: patch testing + UV irradiation [to document photoallergy]

• Worm eaten skull: Gummatous osteoperiosteitis of skull bones in syphilis

• Earliest feature of congenital syphilis: nasal discharge

• Pseudo paralysis of parrot in congenital syphilis: due to osteochondritis.

• Olympian brow: Supra orbital thickening in syphilis

• Wooly headedness: adverse effect of Dapsone

• Blaschko's lines: system of lines along which many linear nevus & dermatoses arrange themselves.

• Weber Christian panniculitis: seen in pancreatic disorders

• Shell nail: seen in bronchiectasis

• Foshay test: 48-hour intradermal test that, if positive, indicates tularemia.

• The intradermal reaction (sporotriquin test) - confirm the diagnosis for sporotrichosis.

• Berloque dermatitis: increased pigmentation due to cosmetics

• Treatment of choice for pruritis due to Uremia: UV light

• Acantholytic cells can be seen in bedside Tzanck test

• Pigmented purpuric dermatoses: shows recent pinpoint cayenne pepper—colored hemorrhages associated

with older hemorrhages and hemosiderin deposition.

*****END*****

PSYCHIATRY

I. HISTORY OF PSYCHIATRY

PIONEERS IN THE FIELD OF PSYCHIATRY

• Emil Kraepelin: Divided major mental illness into Dementia precox and Manic depressive insanity

• Sigmund Freud:

o Founder of Psychoanalysis

o Dream interpretation

o Theory of infantile sexuality

o Structural and topographical model of mind

o Theory of instincts

o Ego defence mechanisms

o Id, ego and superego

o Stages of psychosexual development

• Eugen Blueler: Gave 4 A's of schizophrenia. (Autism, Affective flattening, Ambivalence, loosening of

Association)

• Leo Kanner defined autism

• Skinner – operant conditioning

• Pavlov- classical conditioning

• John F cade - Lithium

• Reserpine – First drug used in treating psychosis

• Ugo Cerletti and Lucio Bini - ECT

• Egas Moniz and Almenda Lima – Psychosurgery (prefrontal leucotomy)

• Emil Durkeim – Sociology theory of suicide

• Thomas Sydenham – Hysteria

• Adolf Meyer: founder of psychobiology

• John Broadus Watson: founder of behaviorism

• Philippe Pinel: abandoned forceful restraints, proposed morale & humane Rx of the mentally ill.

• Paolo Zacchia – first forensic psychiatrist

• Johann Weyer – Father of modern psychiatry

Personality Coined the term

Eugen Bleuler Schizophrenia

James Braid Hypnosis

Reil Johan Christian Psychiatry

Eward Hecker Hebephrenia

Emil Kraeplin Dementia precox

Sigmund Freud Free association

Oedipus complex, Electra complex

Penis envy, Psychoanalysis

Ego defence mechanism

Pleasure principle, Reality principle

Alfred Adler Inferiority complex

II. FUNDAMENTALS IN PSYCHIATRY

Diagnosis and Classification in Psychiatry

The Five Axes of DSM-IV-TR

• AXIS I: Clinical Psychiatric Diagnosis

• AXIS II: Personality Disorder and Mental Retardation

• AXIS III: General Medical Conditions

• AXIS IV: Psychosocial and Environment Problems

• AXIS V: Global Assessment of functioning: Current and in past one year (Rated on a scale)

Normal experiences

• Hypnagogic hallucinations (Abnormal perception at the time of falling asleep)

• Hypnopompic hallucinations (Abnormal perception at the time of waking up)

• Near death experiences (complex hallucinatory phenomenon in people who perceive death to be imminent)

• Pseudo hallucinations

• Ideas of reference

• Panoramic memory

THINKING PROCESSES

• Abstract thinking: thinker can conceptualize or generalize, understanding that each concept can have

multiple meanings.

• Concrete thinking: thinking is limited to what's in front of the face, and the here and now.

Freud's Primary and Secondary thinking processes:

Primary Process:

• Drive-dominated, prelogical, preverbal, imaginative thinking

• Consists of those mental processes which are directly related to functions of the primitive life forces

associated with the Id

• The Id has no contact with reality and works on the Pleasure Principle.

• Primary Process is characteristic of unconscious mental activity; marked by unorganized, non-logical

thinking and by the tendency to seek immediate discharge and gratification of instinctual urges.

• When Primary Process plays a significant role in a person's thinking he is incapable of being inner-directed.

Secondary Process:

• Reality oriented, goal-directed, logically ordered, rational, concrete and/or abstract conceptual thinking

• Consists of those mental processes which are directly related to learned and acquired functions of the Ego

• Characteristic of conscious and preconscious mental activity; marked by logical thinking and by the

tendency to delay gratification by regulation of the discharge of instinctual demands.

TERMINOLOGIES IN PSYCHIATRY

• Apraxia: Inability to perform skilled motor movements in the presence of normal comprehension, muscle

strength and coordination

• Aphasia: Loss or impairment of linguistic ability as a result of brain damage

• Agnosia: Deficits in self-experience (anosognosia – denial of illness)

• Anhedonia: Lack of interest in pleasurable activities (depression)

• Catastrophic reaction: Sudden agitation, anger when demented persons or persons with head injury are

asked to perform tasks beyond their capacity

• Compulsion: An act performed repeatedly to reduce anxiety in response to obsessive thought

• Confabulation: falsification of memory in clear consciousness (Korsakoff's psychosis)

o Due to hypothalamic-diencephalic lesions

o Does not occur in bilateral hippocampal lesions (insight also preserved)

o Two types:

1. Momentary - brief in content and has to be provoked; can be traced to a time-dislocated true

memory

2. Fantastic - sustained; spontaneous and elaborate with grandiose, far-fetched content

• Coprolalia: Forced vocalization of obscene words or phrases (Tourette's syndrome)

• Deja vu: Familiarity of unfamiliar situation

• Jamais vu: Unfamiliarity of the familiar situation (temporal lobe epilepsy/schizophrenia)

• Echolalia: Repetition of phrases or sentences (schizophrenia/Mental retardation/learning

disability/dementia/head injury/Tourette's syndrome)

• Echopraxia: Repetition of acts done by examiner

• Perseveration: Persisting with same reply beyond point of relevance (Organic brain lesions) "where do you

live?", "London", "How old are you", "London"...

• Palilalia – perseverated word is repeated with increasing frequency

• Logoclonia – perseveration of the last syllable of the last word

• Neologism: New word formation (schizophrenia)

• Palimpsest: Also called as alcoholic black out

• Stereotypy: Repetitive and bizarre movement, non- goal directed (schizophrenia, autism)

• Verbal stereotypy - repetition of a word or phrase (Stock word) which has no immediate relevance to the

context.

• Abreaction: A process by which repressed material, particularly painful experience or a conflict is brought

back to consciousness.

• Alexithymia: Inability to describe or being aware of one's emotions.

• Mood is the pervasive feeling tone which is sustained (lasts for some length of time) and colours the total

experience of the person.

• Affect is the outward objective expression of the immediate, cross-sectional experience of emotion at a

given time.

Neurotransmitters & Associated Disorders

• OCD: decrease in serotonin.

• Alzheimer's disease: decrease in Ach & Nor-adrenaline.

• Schizophrenia: increased serotonin, nor adrenaline & dopamine.

• Depression: decreased serotonin, nor adrenaline & dopamine.

Features Psychosis Neurosis

Judgment

Insight

Personality

Contact with reality

Lacking or impaired Present

Delusions/ Hallucinations Common Usually not present

Examples 1. Schizophrenia

2. Delusional disorder

3. Mood disorder

� Mania

� Depression

� Bipolar disorder

1. Phobia

2. Dissociative disorder

3. Conversion / somatoform disorder

4. OCD (Obsession Compulsive Disorder)

5. Anxiety: Generalized anxiety & Panic

disorder

DISORDERS OF PERCEPTION

• Hallucination

• Illusion

• Derealization

• Depersonalization

Hallucination

• Perceptions which arise in the absence of any external stimulus.

• Characteristics:

o Unwilled - not subject to conscious manipulation

o Has the same qualities of a real perception, i.e. Vivid, solid

o Perceived as being located in the external world occurs in five sensory modalities (auditory, visual,

olfactory, gustatory, tactile)

• Auditory hallucination — commonest type in psychiatric disorders

• Visual hallucination - Suspect organic etiology/ withdrawal states)

o Unformed hallucinations - flashing or steady spots, colored lines and shapes

o Formed hallucinations - vivid objects, flowers, animals and persons

o Visual hallucinations of temporal lobe are usually complex, formed hallucinations

o Unformed hallucinations are common with disorders of the occipital lobe

• Olfactory hallucination- Temporal lobe epilepsy

• Tactile hallucination - Cocaine/alcohol abusers

• Gustatory hallucination - schizophrenia/temporal lobe epilepsy/ Lithium/disuifiram users

• Hypnagogic hallucinations (Abnormal perception at the time of falling asleep)

• Hypnopompic hallucinations (Abnormal perception at the time of waking up)

• Extracampine hallucinations: hallucinations outside the field of sensory perception (eg: outside visual

field).

HALLUCINATIONS PSEUDOHALLUCINATIONS

Bright vivid perception just like reality The lack of vividness (e.g., impossible to distinguish

male and female voices)

Patient gets it with natural way of perception (with

eyes, ears etc.) from the real perpetual space (extra-

projection)

Patient got it with other perception (internal vision

or hearing) from out of perpetual space (e.g., intra-

projection)

Confidence in the fact that other people have the

same perceptions

Ideas of distant influence organized especially for

the patient

Excitement or attempts to act with the false objects.

More frequent in the evening and night

Indifferent behavior or passive defence (e.g.,

attempts to shield with metal net or screen)

Typical delirium and other organic disorders Typical for paranoid schizophrenia

Charles Bonnet Syndrome (CBS)

• A disorder in which patients with normal cognition experience consistent or periodic complex (formed) visual

hallucinations

• Have no evidence of dementia, drug abuse, neurological or psychiatric abnormalities

Illusion three types

• A type of false perception in which the perception of a real world object is combined with internal imagery

to produce a false internal perception

• Affect illusion: Misperception + heightened emotion (e.g., while walking across a lonely park at night, briefly

seeing a tree moving in the wind as an attacker)

• Completion illusion: it depends on inattention such as misreading words in newspapers

• Pareidolic illusion: These are meaningful perceptions produced when experiencing a poorly defined stimulus

(seeing faces in fire or clouds)

Depersonalization-Derealisation syndrome

• Depersonalization - alteration in the perception of self, so that feeling of one's own reality is temporarily

changed or lost

• The person affected is not delusionally convinced about the change, and instead describes it to have

occurred, as-f

• Derealisation – alteration in the perception of the external world, so that feeling of reality of external world

s temporarily changed or lost

• Both are 'as – if' phenomenon

• Insight is present

• Episodes occur in the presence of a clear sensorium

DISORDERS OF CONTENT OF THOUGHT

• Thought insertion/withdrawal

• Thought broadcast

• Delusion

• Passivity phenomenon: Made action/Made impulse/Made affect

DELUSION

• Disorder of thought

• Fixed, (usually) false or firm unshakeable idea, held in the face of evidence to the contrary, and out of

keeping with the patient's social milieu'

Primary (Autochthonous) delusions

• Arise de novo

• Cannot be explained on the basis of other experiences or perceptions

• Characteristic of schizophrenia (early stages)

• Types

o Delusional intuition (autochthonous)

o Delusional perception

o Delusional atmosphere

o Delusional memory.

Secondary delusions

• Commonest type

• Can be seen in other psychoses

• Types:

o Persecutory (most common type) – believe that people are conspiring against them.

o Grandiose – believe they have a special ability or mission.

o Poverty – believe they have been rendered penniless.

o Guilt – believe they have committed a crime and deserve punishment.

o Nihilistic – believe they are worthless or non-existent.

o Reference – believe they are being referred to by magazines/television.

o Amorous – believe another person is in love with them.

o Passivity experiences – believe they are being made to do something, or to feel emotions, or are being

controlled from the outside; somatic passivity – feel as though they are being moved from outside.

o Capgras syndrome (Delusion of doubles) – thinks that a familiar person is replaced by an identical

looking stranger

o Fregoli syndrome – thinks that a stranger is replaced by a familiar person

o Othello syndrome or Conjugal paranoia: When the content of delusion is predominantly jealousy or

infidelity involving the spouse

o Hypochondriacal paranoia or Delusional dysmorphophobia – delusion of body parts being ugly

o Clerambault's syndrome or Erotomania

� Mostly in women

� She thinks that a person (usually a higher status) is in love with her

Catatonia (Karl Kahlbaum, 1874)

• Predominantly motor disorder thought to be related to affective disorder

• May be found as part of chronic schizophrenia and occasionally in organic cerebral disorders

• Core features are

o Posturing

o Stereotypies

o Waxy flexibility

Stupor

• Absence of relational functions, i.e. action and speech

• Usually involves clouding of consciousness

• Occurs in:

o Schizophrenia (30 %)

o Depression (25 %)

o Psychological trauma (psychogenic stupor)

o Mania

o Organic brain lesions (20 %):

� Diencephalon and upper brain stem

� Frontal lobe

� Basal ganglia

• The 'locked in' syndrome is due to lesions in the ventral pons

• Severe stupor seems to have a better prognosis

• Spontaneous resolution occurs in 30 % of cases

Sigmund Freud's psychoanalytic theories

Topographic theory of mind

Mind is divided into

• The unconscious

• The preconscious

• The conscious

Structural theory of mind

The mental apparatus is divided into

• The Id

• The Ego

• The Super-ego

COMMONLY USED EGO DEFENSE MECHANISMS:

Defense Mechanism Clinical situations

Narcissistic Denial Psychoses

Alcohol dependence

Projection Persecutory delusions

Hallucinations

Distortion Hallucinations

Delusion of grandiosity

Immature Acting out Impulse control disorders

Hypochondriasis Hypochondriasis

Introjection Depression

Regression Neuroses, Psychoses

Severe, prolonged physical illness

Schizoid fantasy Schizoid personality disorder

Schizotypal personality disorder

Somatization Somatoform disorders

Neurotic Displacement Phobia

OCD

Inhibition OCD

Phobia

Reaction formation OCD

Dissociation Dissociative disorders disorder

Isolation Obsessional thoughts

Repression Psychogenic amnesia

Conversion Conversion disorder (Hysteria)

Undoing Compulsive acts in OCD

Others: Intellectualization, Rationalization, Externalization, Controlling, Sexualization

Mature Altruism

Anticipation

Asceticism

Suppression

Sublimation

Humour

Theory of Psychosexual development

Oral phase Birth – 18 months Mouth is the site of gratification (schizophrenia, mood disorder,

alcohol dependence)

Anal phase 1– 3years Involved in bladder and bowel control Fixation at this phase leads

to

OCD

Phallic phase 3 – 5 years Genital area is the site of satisfaction.

Oedipus complex – fear that the wish to get rid of the rival father

will result in retaliatory castration

Latency phase 5 to 11 years Formation of superego

Genital phase 11 years –

adulthood

Capacity for true intimacy

Duration criteria of Mental illness (ICD-10)

Adjustment disorder Onset < 1 month till 6 months

Persistent delusional disorder 3 months

Acute psychosis (brief psychotic disorder in DSM-

IV)

2 weeks (less than 1 month in DSM IV)

Dementia 6 months

Schizophrenia 1 month (6 months as per DSM IV)

Schizotypal disorder

(included under personality disorders in DSM-IV

and under schizophrenia in ICD-10)

2 years

Somatisation disorder 2 years

PTSD Onset within 6 months of trauma, Duration of the

disturbance is more than 1 month.

Acute stress reaction Onset within minutes of life event resolves within

3

days Hypomania 4 days

Mania 1 week

Obsessive compulsive disorder 2 weeks

Panic disorder 1 month

Dysthymia 2 years

Depression 2 weeks

Kubler-Ross stages of Death and Dying

• Stage 1: Shock and Denial

• Stage 2: Anger

• Stage 3: Bargaining

• Stage 4: Depression

• Stage 5: Acceptance

COMMON EMERGENCIES IN PSYCHIATRY

Syndrome Emergency Manifestations Treatment Issues

Abuse of child or adult Signs of physical trauma Management of medical problems;

Acquired immune deficiency

syndrome (AIDS)

Changes in behavior secondary to

organic causes; changes in behavior

secondary to fear and anxiety;

suicidal behaviour

Management of neurological illness;

management of psychological

concomitants; reinforcement of

social support

Adolescent crises Suicidal attempts and ideation;

substance abuse, truancy, trouble

with law, pregnancy, running away;

eating disorders; psychosis

Crisis-oriented family and individual

therapy; hospitalization if necessary;

consultation with appropriate

extrafamilial authorities

Agoraphobia Panic; depression Alprazolam, propranolol;

antidepressant medication

Agranulocytosis (clozapine-induced) High fever, pharyngitis, oral and

perianal ulcerations

Discontinue medication immediately;

administer granulocyte colony-

stimulating factor

Akathisia Agitation, restlessness, muscle

discomfort; dysphoria

Reduce antipsychotic dosage;

propranolol; benzodiazepines;

diphenhydramine orally or IV;

benztropine IM

Alcohol-related emergencies

Alcohol delirium Confusion, disorientation, fluctuating

consciousness and perception,

autonomic hyperactivity; may be

fatal

Chlordiazepoxide; haloperidol

Alcohol intoxication Disinhibited behavior, sedation at

high doses

With time and protective

environment, symptoms abate

Alcohol persisting amnestic disorder Confusion, loss of memory even for

all personal identification data

Hospitalization; hypnosis;

amobarbital interview; rule out

organic cause

Alcohol persisting dementia Confusion, agitation, impulsivity Rule out other causes for dementia;

no effective treatment;

hospitalization if necessary

Alcohol psychotic disorder with

hallucinations

Vivid auditory (fat times visual)

hallucinations with affect

appropriate to content (often

fearful); clear sensorium

Haloperidol for psychotic symptoms

Alcohol seizures Grand mal seizures; rarely status

epilepticus

Diazepam, phenytoin; prevent by

using chlordiazepoxide during

detoxification

Alcohol withdrawal Irritability, nausea, vomiting,

insomnia, malaise, autonomic

hyperactivity, shakiness

Fluid and electrolytes maintained;

sedation with benzodiazepines;

restraints; monitoring of vital signs;

100 mg thiamine IM

Idiosyncratic alcohol intoxication Marked aggressive or assaultive

behaviour

Generally no treatment required

other than protective environment

Korsakoff's syndrome Alcohol stigmata, amnesia,

confabulation

No effective treatment;

institutionalization often needed

Wernicke's encephalopathy Oculomotor disturbances, cerebellar

ataxia; mental confusion

Thiamine, 100 mg IV or IM, with

MgSO4

given before glucose loading

Amphetamine (or related substance)

intoxication

Delusions, paranoia; violence;

depression (from withdrawal);

anxiety, delirium

Antipsychotics; restraints;

hospitalization if necessary; no need

for gradual withdrawal;

antidepressants may be necessary

Anorexia nervosa Loss of 25% of body weight of the

norm for age and sex

Hospitalization; electrocardiogram

(ECG),

fluid and electrolytes;

neuroendocrine Anticholinergic

intoxication

Psychotic symptoms, dry skin and

mouth, hyperpyrexia, mydriasis,

tachycardia, restlessness, visual

hallucinations

Discontinue drug, IV physostigmine

0.5 to 2 mg, for severe agitation or

fever, benzodiazepines;

antipsychotics contraindicated

Anticonvulsant intoxication Psychosis; delirium Dosage of anticonvulsant is reduced

Benzodiazepine intoxication Sedation, somnolence, and ataxia Supportive measures; flumazenil, 7.5

to 45 mg a day, titrated as needed,

should be used only by skilled

personnel with resuscitative

equipment available

Bereavement Guilt feelings, irritability; insomnia;

somatic complaints

Must be differentiated from major

depressive disorder; antidepressants

not indicated; benzodiazepines for

sleep; encouragement of ventilation

Borderline personality

disorder

Suicidal ideation and gestures;

homicidal ideations and gestures;

substance abuse; micropsychotic

episodes; burns, cut marks on body

Suicidal and homicidal evaluation (if

great, hospitalization); small dosages

of antipsychotics; clear follow-up

plan

Brief psychotic disorder Emotional turmoil, extreme lability;

acutely impaired reality testing after

obvious psychosocial stress

Hospitalization often necessary; low

dosage of antipsychotics may be

necessary but often resolves

spontaneously

Bromide intoxication Delirium; mania; depression;

psychosis

Serum levels obtained (>50 mg a

day); bromide intake discontinued;

large quantities of sodium chloride IV

or orally; if agitation, paraldehyde or

antipsychoticis used

Caffeine intoxication Severe anxiety, resembling panic

disorder; mania; delirium; agitated

depression; sleep disturbance

Cessation of caffeine-containing

substances; benzodiazepines

Cannabis intoxication

Delusions; panic; dysphoria;

cognitive impairment

Benzodiazepines and antipsychotics

as needed; evaluation of suicidal or

homicidal risk; symptoms usually

abate with time and reassurance

Catatonic schizophrenia Marked psychomotor disturbance

(either excitement or stupor);

exhaustion; can be fatal

Rapid tranquilization with

antipsychotics; monitor vital signs;

amobarbital may release patient

from catatonic mutism or stupor but

can precipitate violent behavior

Cimetidine psychotic disorder Delirium; delusions Reduce dosage or discontinue drug

Clonidine withdrawal Irritability; psychosis; violence;

seizures

Symptoms abate with time, but

antipsychotics may be necessary;

gradual lowering of dosage

Cocaine intoxication and withdrawal Paranoia and violence; severe

anxiety; manic state; delirium:

schizophreniform psychosis;

tachycardia, hypertension,

myocardial infarction,

cerebrovascular disease; depression

and suicidal ideation

Antipsychotics and benzodiazepines;

antidepressants or ECT for

withdrawal depression if persistent;

hospitalization

Delirium Fluctuating sensorium; suicidal and

homicidal risk; cognitive clouding;

visual, tactile, and auditory

Evaluate all potential contributing

factors and treat each accordingly;

reassurance, structure, clues to

orientation;

hallucinations; paranoia benzodiazepines and low-dosage,

high- potency antipsychotics must be

used with extreme care because of

their potential to act paradoxically

and increase agitation

Delusional disorder Most often brought in to emergency

room involuntarily; threats directed

toward others

Antipsychotics if patient will comply

(IM if necessary); intensive family

intervention; hospitalization if

necessary

Dementia Unable to care for self; violent

outbursts; psychosis; depression and

suicidal ideation; confusion

Small dosages of high-potency

antipsychotics; clues to orientation;

organic evaluation, including

medication use; family intervention

Depressive disorders Suicidal ideation and attempts; self-

neglect; substance abuse

Assessment of danger to self;

hospitalization if necessary,

nonpsychiatric causes of depression

must be evaluated

L-Dopa intoxication Mania; depression; schizophreniform

disorder, may induce rapid cycling in

patients with bipolar I disorder

Lower dosage or discontinue drug

Dystonia, acute Intense involuntary spasm of

muscles of neck, tongue, face, jaw,

eyes, or trunk

Decrease dosage of antipsychotic;

benztropine or diphenhydramine IM

Group hysteria Groups of people exhibit extremes of

grief or other disruptive behavior

Group is dispersed with help of other

health care workers; ventilation,

crisis- oriented therapy; if necessary,

small dosages of benzodiazepines

Hallucinogen-induced psychotic

disorder with hallucinations

Symptom picture is result of

interaction of type of substance,

dose taken, duration of action, user's

premorbid personality, setting;

panic;

agitation; atropine psychosis

Serum and urine screens; rule out

underlying medical or mental

disorder; benzodiazepines (2 to 20

mg) orally; reassurance and

orientation; rapid tranquilization;

often responds spontaneously

Homicidal and assaultive behavior Marked agitation with verbal threats Seclusion, restraints, medication

Homosexual panic Not seen with men or women who

are comfortable with their sexual

orientation; occurs in those who

adamantly deny having any

homoerotic impulses; impulses are

aroused by talk, a physical overture,

or play among same-sex friends,

such as wrestling, sleeping together,

or touching each other in a shower

or hot tub; panicked person sees

others as sexually interested in him

or her and defends against them

Ventilation, environmental

structuring, and, in some instances,

medication for acute panic (e.g.,

alprazolam, 0.25 to 2 mg) or

antipsychotics may be required;

opposite-sex clinician should

evaluate the patient whenever

possible, and the patient should not

be touched save for the routine

examination; patients have attached

physicians who were examining an

abdomen or performing a rectal

examination (e.g., on a man who

harbors thinly veiled unintegrated

homosexual impulses)

Hypertensive crisis Life-threatening hypertensive

reaction secondary to ingestion of

tyramine-containing foods in

combination with MAOls; headache,

stiff neck, sweating, nausea,

vomiting

Adrenergic blockers (e.g.,

phentolamine); nifedipine 10 mg

orally; chlorpromazine; make sure

symptoms are not secondary to

hypotension (side effect of

monoamine oxidase inhibitors

[MAOls] alone)

Hyperthermia Extreme excitement or catatonic

stupor or both; extremely elevated

temperature; violent hyperagitation

Hydrate and cool; may be drug

reaction, so discontinue any drug;

rule out infection

Hyperventilation Anxiety, terror, clouded

consciousness; giddiness, faintness;

blurring vision

Shift alkalosis by having patient

breathe into paper bag; patient

education; antianxiety agents

Hypothermia Confusion; lethargy; combativeness;

low body temperature and shivering;

paradoxical feeling of warmth

IV fluids and rewarming, cardiac

status must be carefully monitored;

avoidance of alcohol

Incest and sexual abuse of child Suicidal behavior; adolescent crises;

substance abuse

Corroboration of charge, protection

of victim; contact social services;

medical and psychiatric evaluation;

crisis intervention

Insomnia Depression and irritability; early

morning agitation; frightening

dreams; fatigue

Hypnotics only in short term; e.g.,

triazolam, 0.25 to 0.5 mg, at

bedtime; treat any underlying

mental disorder; rules of sleep

hygiene

Intermittent explosive disorder Brief outbursts of violence; periodic

episodes of suicide attempts

Benzodiazepines or antipsychotics

for short term; long-term evaluation

with computed tomography (CT)

scan, sleep- deprived

electroencephalogram (EEG),

glucose tolerance curve

Jaundice Uncommon complication of low-

potency phenothiazine use (e.g.,

chlorpromazine)

Change drug to low dosage of a low-

potency agent in a different class

Leukopenia and agranulocytosis Side effects within the first 2 months

of treatment with antipsychotics

Patient should call immediately for

sore throat, fever, etc., and obtain

immediate blood count; discontinue

drug; hospitalize if necessary

Lithium toxicity Vomiting; abdominal pain; profuse

diarrhea; severe tremor, ataxia;

coma; seizures; confusion;

dysarthria; focal neurological signs

Lavage with wide-bore tube; osmotic

diuresis; medical consultation; may

require ICU treatment

Major depressive episode with

psychotic features

Major depressive episode symptoms

with delusions; agitation, severe

guilt; ideas of reference; suicide and

homicide risk

Antipsychotics plus antidepressants;

evaluation of suicide and homicide

risk; hospitalization and ECT if

necessary

Manic episode Violent, impulsive behavior;

indiscriminate sexual or spending

behavior; psychosis; substance abuse

Hospitalization; restraints if

necessary; rapid tranquilization with

antipsychotics; restoration of lithium

levels

Marital crises Precipitant may be discovery of an

extramarital affair, onset of serious

illness, announcement of intent to

divorce, or problems with children or

work; one or both members of the

couple may be in therapy or may be

psychiatrically ill; one spouse may be

seeking hospitalization for the other

Each should be questioned alone

regarding extramarital affairs,

consultations with lawyers regarding

divorce, and willingness to work in

crisis- oriented or long-term therapy

to resolve the problem; sexual,

financial, and psychiatric treatment

histories from both, psychiatric

evaluation at the time of

presentation; may be precipitated by

onset of untreated mood disorder or

affective symptoms caused by

medical illness or insidious-onset

dementia; referral for management

of the illness reduces immediate

stress and enhances the healthier

spouse's coping capacity; children

may give insights available only to

someone intimately involved in the

social system

Migraine Throbbing, unilateral headache Sumatriptan 6 mg IM

Mitral valve prolapse Associated with panic disorder;

dyspnea and palpitations; fear and

anxiety

Echocardiogram; alprazolam or

propranolol

Neuroleptic malignant syndrome Hyperthermia; muscle rigidity;

autonomic instability; parkinsonian

symptoms; catatonic stupor;

neurological signs; 10% to 30%

fatality; elevated creatine

phosphokinase

Discontinue antipsychotic; IV

dantrolene; bromocriptine orally;

hydration and cooling; monitor CPK

levels

Nitrous oxide toxicity Euphoria and light-headedness Symptoms abate without treatment

within hours of use

Nutmeg intoxication Agitation; hallucinations; severe

headaches; numbness in extremities

Symptoms abate within hours of use

without treatment

Opioid intoxication and withdrawal Intoxication can lead to coma and

death; withdrawal is not life-

threatening

IV naloxone, narcotic antagonist;

urine and serum screens; psychiatric

and medical illnesses (e.g., AIDS) may

complicate picture

Panic disorder Panic, terror; acute onset Must differentiate from other

anxiety- producing disorders, both

medical and psychiatric; ECG to rule

out mitral valve prolapse;

propranolol (10 to 30 mg);

alprazolam (0.25 to 2.0 mg); long-

term management may include an

antidepressant

Paranoid schizophrenia Command hallucinations; threat to

others or themselves

Rapid tranquilization; hospitalization;

long-acting depot medication;

threatened persons must be notified

and protected

Parkinsonism Stiffness, tremor, bradykinesia,

flattened affect, shuffling gait,

salivation, secondary to

antipsychotic medication

Oral antiparkinsonian drug for 4

weeks to 3 months; decrease dosage

of the antipsychotic

Perioral (rabbit) tremor . Perioral tumor (rabbitlike facial

grimacing) usually appearing after

long-term therapy with

antipsychotics

Decrease dosage or change to a

medication in another class

Phencyclidine (or phencyclidine-like

intoxication)

Paranoid psychosis; can lead to

death; acute danger to self and

others

Serum and urine assay;

benzodiazepines may interfere with

excretion; antipsychotics may

worsen symptoms because of

anticholinergic side effects; medical

monitoring and hospitalization

for severe intoxication

Phenelzine-induced psychotic

disorder

Psychosis and mania in predisposed

people

Reduce dosage or discontinue drug

Phenylpropanolamine toxicity Psychosis; paranoia; insomnia;

restlessness; nervousness; headache

Symptoms abate with dosage

reduction

or discontinuation (found in over-

the-

counter diet aids and oral and nasal

decongestants)

Phobias Panic, anxiety; fear Treatment same as for panic

disorder Photosensitivity Easy sunburning secondary to use of

antipsychotic medication

Patient should avoid strong sunlight

and

use high-level sunscreens

Pigmentary retinopathy Reported with dosages of

thioridazine (Mellaril) of 800 mg a

day or above

Remain below 800 mg a day of

thioridazine

Postpartum psychosis Childbirth can precipitate

schizophrenia, depression, reactive

psychoses, mania, and depression;

affective symptoms are most

common; suicide risk is reduced

during pregnancy but increased in

the postpartum period

Danger to self and others (including

infant) must be evaluated and

proper precautions taken; medical

illness presenting with behavioral

aberrations is included in the

differential diagnosis and must be

sought and treated; care must be

paid to the effects on father, infant,

grandparents, and other children

Posttraumatic stress disorder Panic, terror; suicidal ideation;

flashbacks

Reassurance; encouragement of

return to responsibilities; avoid

hospitalization if possible to prevent

chronic invalidism; monitor suicidal

ideation

Priapism (trazodone

[Desyrel]-induced)

Persistent penile erection

accompanied by severe pain

Intracorporeal epinephrine;

mechanical or surgical drainage

Propranolol toxicity Profound depression; confusional

states

Reduce dosage or discontinue drug;

monitor suicidality

Rape Not all sexual violations are

reported; silent rape reaction is

characterized by loss of appetite,

sleep disturbance, anxiety, and,

sometimes, agoraphobia; long

periods of silence, mounting anxiety,

stuttering, blocking, and physical

symptoms during the interview when

the sexual history is taken; fear of

violence and death and of

contracting a sexually transmitted

disease or being pregnant

Rape is a major psychiatric

emergency; victim may have

enduring patterns of sexual

dysfunction; crisis-oriented therapy,

social support, ventilation,

reinforcement of healthy traits, and

encouragement to return to the

previous level of functioning as

rapidly as possible; legal counsel; if a

woman, methoxyprogesterone or

diethylstilbestrol orally for 5 days to

prevent pregnancy; if the victim has

contracted a venereal disease,

appropriate antibiotics; witnessed

written permission is required for

the physician to examine,

photograph, collect specimens, and

release information to the

authorities; obtain consent, record

the history in the patient's own

words, obtain required tests, record

the results of the examination, save

all clothing, defer diagnosis, and

provide protection against disease,

psychic trauma, and pregnancy;

Reserpine intoxication Major depressive episodes; suicidal

ideation; nightmares

Evaluation of suicidal ideation; lower

dosage or change drug;

antidepressants of ECT may be

indicated

Schizoaffective disorder Severe depression; manic symptoms;

paranoia

Evaluation of dangerousness to self

or others; rapid tranquilization if

necessary; treatment of depression

(antidepressants alone can enhance

schizophrenic symptoms); use of

antimanic agents

Schizophrenia Extreme self-neglect; severe

paranoia; suicidal ideation or

assaultiveness; extreme psychotic

symptoms

Evaluation of suicidal and homicidal

potential; identification of any illness

other than schizophrenia; rapid

tranquilization

Schizophrenia in exacerbation Withdrawn; agitation; suicidal and

homicidal risk

Suicide and homicide evaluation;

screen for medical illness; restraints

and rapid tranquilization if

necessary; hospitalization if

necessary; reevaluation of

medication regimen

Sedative, hypnotic, or anxiolytic

intoxication and withdrawal

Alterations in mood, behavior,

thought-delirium; derealization and

depersonalization; untreated, can be

fatal; seizures

Naloxone to differentiate from

opioid intoxication; slow withdrawal

with phenobarbital or sodium

thiopental or benzodiazepine;

hospitalization

Seizure disorder Confusion; anxiety; derealization and

depersonalization; feelings of

impending doom; gustatory or

olfactory hallucinations; fuguelike

state

Immediate EEG; admission and

sleep- deprived and 24-hour EEG;

rule out pseudoseizures;

anticonvulsants

Substance withdrawal Abdominal pain; insomnia,

drowsiness; delirium; seizures;

symptoms of tardive dyskinesia may

emerge; eruption of manic or

schizophrenic symptoms

Symptoms of psychotropic drug

withdrawal disappear with time or

disappear with reinstitution of the

substance; symptoms of

antidepressant withdrawal can be

successfully treated with

anticholinergic agents, such as

atropine; gradual withdrawal of

psychotropic substances over two to

four weeks generally obviates

development of symptoms

Sudden death associated with

Antipsychotic medication

Seizures; asphyxiation;

cardiovascular causes; postural

hypotension; laryngeal-pharyngeal

dystonia; suppression of gag reflex

Specific medical treatments

Sudden death of psychogenic origin Myocardial infarction after sudden

psychic stress; voodoo and hexes;

hopelessness, especially associated

with serious physical illness

Specific medical treatments; folk

healers

Suicide Suicidal ideation; hopelessness Hospitalization, antidepressants

Sympathomimetic withdrawal Paranoia; confusional states;

depression

Most symptoms abate without

treatment; antipsychotics;

antidepressants if necessary

Tardive dyskinesia Dyskinesia of mouth, tongue, face,

neck, and trunk; choreoathetoid

movements of extremities; usually

but not always appearing after long-

term treatment with antipsychotics,

especially after a reduction in

dosage; incidence highest in the

elderly and brain-damaged;

symptoms are intensified by

antiparkinsonian drugs and

masked but not cured by increased

dosages of antipsychotic

No effective treatment reported;

may be prevented by prescribing the

least amount of drug possible for as

little time as is clinically feasible and

using drug-free holidays for patients

who need to continue taking the

drug; decrease or discontinue drug at

first sign of dyskinetic movements

Thyrotoxicosis Tachycardia; gastrointestinal

dysfunction; hyperthermia; panic,

anxiety, agitation; mania; dementia;

psychosis

Thyroid function test (T3, T4, thyroid-

stimulating hormone [TSH]); medical

consultation

Toluene abuse Anxiety; confusion; cognitive

impairment

Neurological damage is

nonprogressive and reversible if

toluene use in discontinued early

Vitamin B12 deficiency Confusion; mood and behavior

changes; ataxia

Treatment with vitamin B12

Volatile nitrates Alternations of mood and behavior;

light-headedness; pulsating

headache

Symptoms abate with cessation of

use

PSYCHOLOGICAL TESTING

• Reliability assesses the reproducibility of results.

• Validity assesses whether the test measures what it purports to measure.

• The two types of tests are:

• Objective tests:

o Typically pencil-and-paper tests based on specific items and questions.

o Yield numerical scores and profiles easily subjected to mathematical or statistical analysis.

• Projective tests:

o Have no right or wrong answers.

Objective Measures of Personality in Adults Projective Measures of Personality

Minnesota-Multiphasic Personality Inventory (MMPI) Rorschach test

Minnesota Multiphasic Personality Inventory-2

(MMPI-2)

Thematic Apperception Test (TAT)

Million Clinical Multiaxial Inventory (MCMI) Sentence Completion Test

Million Clinical Multiaxial Inventory-II (MCMI-11) Holtzman Inkblot Technique (HIT)

16 Personality Factor Questionnaire (16 PF) Figure drawing

Personality Assessment Inventory (PAI) Make-a-Picture Story (MAPS)

California Personality Inventory (CPI) The Draw-a-Person test

Jackson Personality Inventory (JPI)

Edwards Personal Preference Schedule (EPPS)

Psychological Screening Inventory (PSI)

Eysenck Personality Questionnaire (EPQ)

Adjective Checklist (ACL)

Comrey Personality Scales (CPS)

Tennessee Self-Concept Scale (TSCS)

III. DELIRIUM AND DEMENTIA

DELIRIUM

• Most common organic mental disorder seen in clinical practice

Etiology:

• Seen in approximately 10 to 30 % of medically ill patients who are hospitalized

• The incidence is higher in postoperative patients

• Predisposing factors

� Preexisting brain damage (e.g., dementia, cerebrovascular disease, tumor)

� History of delirium

� Alcohol or drug dependence & withdrawal

� Generalized or focal cerebral lesion

� Chronic medical illness

� Surgical procedure and postoperative period

� Treatment with psychotropic medicines

� Present or past history of head injury

� Diabetes, Cancer

� Sensory impairment (e.g., blindness)

� Male gender

Diagnostic Criteria for Delirium, Not Induced by Alcohol and Other Psychoactive Substances

A. There is clouding of consciousness, i.e., reduced clarity of awareness of the environment, with reduced

ability to focus, sustain, or shift attention.

B. Disturbance of cognition is manifest by both:

1. impairment of immediate recall and recent memory, with relatively intact remote memory;

2. disorientation in time, place, or person.

C. At least one of the following psychomotor disturbances is present:

1. rapid, unpredictable shifts from hypoactivity to hyperactivity;

2. increased reaction time;

3. increased or decreased flow of speech;

4. enhanced startle reaction.

D. There is disturbance of sleep or of the sleep-wake cycle, manifest by at least one of the following:

1. insomnia, which in severe cases may involve total sleep loss, with or without daytime drowsiness, or

reversal of the sleep-wake cycle;

2. nocturnal worsening of symptoms;

3. disturbing dreams and nightmares, which may continue as hallucinations or illusions after awakening.

E. Symptoms have rapid onset and show fluctuations over the course of the day.

F. There is objective evidence from history, physical and neurological examination, or laboratory tests of an

underlying cerebral or systemic disease (other than psychoactive substance-related) that can be presumed

to be responsible for the clinical manifestations in Criteria A to D.

Comments

• Emotional disturbances such as depression, anxiety or fear, irritability, euphoria, apathy, or wondering

perplexity, disturbances of perception (illusions or hallucinations, often visual), and transient delusions are

typical but are not specific indications for the diagnosis. A fourth character may be used to indicate whether

or not the delirium is superimposed on dementia

o Delirium, not superimposed on dementia

o Delirium, superimposed on dementia

o Other delirium

o Delirium, unspecified

Clinical Features:

• Sudden onset with fluctuating course

• Cognitive impairment

• Clouding of consciousness — decreased awareness of surroundings and decreased ability to respond to

environmental stimuli

• Disorientation (mostly in time)

• Perceptual disturbances - Illusions, hallucinations

• Delirium may first present with daytime drowsiness and night time insomnia (sun downing)

• Motor symptoms: asterixis, incoordination, carphologia or floccillation (picking movements at cover-sheets

and clothes), Multifocal myoclonus

• When a psychiatric illness causes symptoms of delirium, patients are said to have a pseudodelirium

• Delirium can occur in older patients wearing eye patches after cataract surgery (black-patch delirium)

Treatment

• Primary goal: treat the underlying cause.

• Commonly used drug: haloperidol.

DEMENTIA

• Impairment of intellectual functions

• Impairment of memory (predominantly of recent memory, especially in early stages),

• Deterioration of personality with lack of personal care.

• Impairment of judgment and impulse control

• Impairment of abstract thinking.

• No impairment of consciousness

Additional features:

• Emotional lability (marked variation in emotional expression)

• Catastrophic reaction (when confronted with an assignment which is beyond the residual intellectual

capacity, patient may go into a sudden rage).

• Thought abnormalities, e.g. perseveration, delusions.

• Urinary and faecal incontinence may develop in later stages.

• Disorientation in time; disorientation in place and person may also develop in later stages.

• Neurological signs may or may not be present, depending on the underlying cause.

Dementia Pseudodementia (Depression)

Patient rarely complains of cognitive

impairment

Patient usually always complains about memory

impairment Patient often emphasizes achievements Patient often emphasizes disability

Patients often appears unconcerned Patient very often communicates distress

Usually labile affect Severe depression on examination

Patient makes errors on cognitive examination Do not know' answers are more frequent

Impairment of recent memory Rarely impaired

Confabulation may be present Confabulation very rare

Consistently poor performance on similar tests Marked variability in performance on similar tests

History of depression less common Past history of manic and/ or depression episodes

Features Cortical Dementia Subcortical Dementia

Site of lesion Cortex (frontal and temporo parieto-

occipital association areas, hippocampus)

Subcortical grey matter (thalamus, basal

ganglia, and rostral brain stem)

Examples Alzheimer's disease, Pick's disease Huntington' chorea, Parkinson's disease,

Progressive supranuclear palsy, Wilson's

disease

Severity Severe Mild to moderate

Motor system Usually normal Dysarthria, flexed/extended posture, tremors,

dystonic, chorea, ataxia, rigidity

Other features Simple delusions; depression uncommon;

severe aphasia, amnesia, agnosia,

apraxia, acalculia, slowed cognitive speed

(bradyphrenia)

Complex delusions; depression common;

rarely mania

Memory deficit

(Short-term)

Recall helped very little by cues Recall partially helped by cues and recognition

tasks

Reversible causes of dementia:

• Hypothyroidism

• Infections

• B1 B12 deficiency

• Wilsons disease

• NPH

Feature Dementia Delirium

Onset Slow Rapid

Duration Months to years Hours to weeks

Consciousness Normal Clouded

Orientation Normal until late stages Disturbed

Memory Immediate retention and recall

normal

Recent memory disturbed

Impaired remote memory in late

stages

Impaired recent and immediate memory

Attention and

concentration

Usually normal Disturbed

Comprehension Impaired only in late stages Impaired

Speech Word-finding difficulty Incoherent (slow or rapid)

Sleep-wake cycle Normal Frequent disruption (e.g., day & night

reversal)

Thoughts Impoverished Disorganized

Awareness Unchanged Reduced

ALZHEIMER'S DISEASE

• Most common cause of dementia (> 50%)

NINCDS-ARDRA CRITERIA used for diagnosis

• Presence of dementia

• Deficits in at least two areas of cognition

• Progressive deterioration

• No clouding of consciousness

• Age between 40 and 90

• Absence of systemic disorders

• Neurofibrillary tangles

• Beta amyloid plaques

• Apolipoprotein E4

Clinical features:

• Delayed recall is the best overall discriminator for early Alzheimer's disease

• Early dementia is probable with a MMSE score of 24-27

• CT- cortical atrophy over parietal and temporal lobes

• MRI- atrophy of grey matter (hippocampus, amygdala, medial temporal lobe)

Multi — infarct Dementia

• Second most common cause of dementia (10-15%)

• Some studies indicate that multi-infarct dementia is probably far more common in India.

• It is also one of the important treatable causes of dementia.

• Characterized by :

o An abrupt onset

o Acute exacerbations (due to repeated infarctions),

o Stepwise clinical deterioration (step-ladder pattern),

o Fluctuating course,

o Presence of hypertension (most commonly) or any other significant cardiovascular disease, and

o History of previous stroke or transient ischemic attacks (TIAs).

• Focal neurological signs are frequently present.

• Insight into the illness is usually present in the early part of the course.

• Emotional lability is common.

• EEG - focal area of slowing

• CT scan or MRI - multiple infarcts

AIDS Dementia Complex

• Seen in about 50-70% of patients suffering from AIDS

• Triad of cognitive, behavioral and motoric deficits of subcortical dementia type.

• Cranial CT scan can show cortical atrophy 1-4 months before the onset of clinical dementia

Lewy Body Dementia

• Second most common cause of the degenerative dementias

• Typically, the clinical features include:

o Fluctuating cognitive impairment over weeks or months

o Lucid intervals can be present in between fluctuations.

o Recurrent and detailed visual hallucinations.

o Spontaneous extrapyramidal symptoms such as rigidity and tremors.

o Neuroleptic sensitivity syndrome - marked sensitivity typical doses of antipsychotic drugs (resulting in

severe extrapyramidal side-effects with use of antipsychotics).

� Antipsychotics (Haloperidol and Risperidone) use to treat disruptive behavior in dementia has decreased

markedly due to possible association with increased mortality

� Antipsychotics should be avoided if Lewy body dementia is suspected

ORGANIC HALLUCINOSIS

• Presence of persistent or recurrent hallucinations due to an underlying organic cause.

• Usually visual (most common) or auditory in nature.

Etiology

• Drugs: Hallucinogens (LSD, psilocybin, mescaline), cocaine, cannabis, phencyclidine etc.

• Alcohol: In alcoholic hallucinosis, auditory hallucinations are usually more common.

• Sensory deprivation.

• 'Release' hallucinations due to sensory pathway disease, e.g. bilateral cataracts, otosclerosis, optic neuritis.

• Brain stem lesions (peduncular hallucinosis).

Neurofibrillary tangles

Seen in Not in

• Alzheimer's disease

• Punch-drunk' syndrome

• Postencephalitic Parkinsonism

• Amyotrophic lateral sclerosis

• Progressive supranuclear palsy

• Lewy body dementia

• Pick's disease

Amyloid plaques

Seen in Not in

• Alzheimer's disease

• Lewy body dementia

• Pick's disease

• `Punch-drunk' syndrome

Lewy bodies

Seen in

• Alzheimer's disease

• Ataxia-telengectasia

• Progressive supranuclear palsy

• Lewy body dementia

Clinical Tests of Attention and Concentration:

• Subtract sevens or threes, serially, from 100

• Reverse the days of the week or months of the year

• Spell simple words backwards (eg, world ).

• Repeat digits (two, three, four, or more) forward and backward

• Perform mental arithmetic (Number of nickels in $1.35? Interest on $200 at 4% for 18 months?

IV. PSYCHOACTIVE SUBSTANCE ABUSE

Complications of alcoholism

DELIRIUM TREMENS

• Most severe alcohol withdrawal syndrome

• It occurs usually within 2-4 days of complete or significant abstinence from heavy alcohol drinking

• The course is short, with recovery occurring within 3-7 days.

• This is an acute organic brain syndrome (delirium) with characteristic features of:

o Clouding of consciousness

o Disorientation in time and place.

o Poor attention span and distractibility.

o Visual (also auditory) hallucinations and illusions, which are often vivid and very frightening.

o Marked autonomic disturbance - tachycardia, fever, hypertension, sweating, mydriasis

o Psychomotor agitation and ataxia.

o Insomnia, with a reversal of sleep-wake pattern.

o Dehydration with electrolyte imbalance.

• It is extremely important not to administer 5% dextrose in delirium tremens without thiamine

Alcoholic seizures ('rum fits')

• Generalized tonic clonic seizures

• Usually occurs 12-48 hours after a heavy bout of drinking

• Often these patients have been drinking alcohol in large amounts on a regular basis for many years.

• Multiple seizures (2-6 at one time) are more common than single seizures.

• In 30% of the cases, delirium tremens follows.

Alcoholic hallucinosis

• Presence of hallucinations (usually auditory) during partial or complete abstinence

• They occur during clear consciousness

WERNICKE'S ENCEPHALOPATHY

• An acute reaction to a severe deficiency of thiamine

• Commonest cause - chronic alcohol use.

• Ophthalmoplegia with bilateral external rectus paralysis

• Higher mental function disturbance: disorientation, confusion, recent memory disturbances, poor attention

span and distractibility

• Apathy and ataxia.

• Neuronal degeneration and haemorrhage are seen in thalamus, hypothalamus, mammillary bodies and

midbrain.

• Completely reversible with treatment

Korsakoff's psychosis

• Often follows Wernicke's encephalopathy; and referred to as Wernicke-Korsakoff syndrome.

• Gross memory disturbances, with confabulation

• 20 percent of patients with Korsakoff's syndrome recover

• Insight is often impaired.

• Neuropathological lesions are symmetrical and paraventricular, involving the mammillary bodies, the

thalamus, the hypothalamus, the midbrain, the pons, the medulla, the fornix, and the cerebellum.

Marchiafava — Bignami disease

• Disorientation, epilepsy, ataxia, dysarthria, hallucinations, spastic limb paralysis, and deterioration of

personality and intellectual functioning

• There is a widespread demyelination of corpus callosum, optic tracts and cerebellar peduncles.

� Legal limit for driving in India: 30 mg/100 ml (Section 185 of the Motor Vehicle Act, 1988)

Screening test for alcoholism:

• MAST (Michigan Alcoholism Screening Test)

• CAGE questionnaire test

CAGE Questionnaire

• Ever had to Cut down the amount of alcohol

• Been Annoyed by people's criticism of alcoholism

• Felt Guilty of drinking.

• Need of an Eye opener.

Withdrawal syndrome: Drugs of 1st choice — Chlordiazepoxide (diazepam 2nd)

Treatment of Alcohol Dependence

• Behaviour therapy

• Psychotherapy

• Group therapy

• Deterrent agents

� The deterrent agents are also known as alcohol sensitizing drugs.

� Disulfiram (tetraethyl thiuram disulfide) — most commonly used

� Other deterrent agents: Citrated calcium carbimide (CCC), Metronidazole. animal charcoal, a fungus

(coprinus atramentarius), sulfonylureas and certain cephalsoporins

• Anti — craving agents

� Acamprosate - interacts with NMDA receptor — mediated glutamatergic neurotransmission in the

various brain regions and reduces Ca++ fluxes through voltage — operated channels.

� Naltrexone - probably interferes with alcohol — induced reinforcement by blocking opioid receptors

� SSRIs (such as fluoxetine)

OPIUM ABUSE

• Opium use has increased markedly all over the world in the past few decades

• India is surrounded both sides by the infamous routes of illicit transport – Golden triangle (BurmaThailand-

Laos) and Golden Crescent (Iran-Afghanistan-Pakistan)

• Heroin (Di-acetyl-morphine) can be smoked or chased (chasing the dragon)

• Tolerance to heroin occurs very rapidly

Withdrawal syndrome

• Occurs typically within 12-24 hours

• Lacrimation, rhinorrhea, pupillary dilation. sweating, diarrhea, yawning, tachycardia, insomnia, raised

body temperature, muscle cramps, piloerection

Treatment

• Overdose: Naloxone

• Withdrawal: Methadone (1st choice), Clonidine (2' choice); others: LAAM, buprenorphine

• Maintenance: Methadone

Nicotine withdrawal

• Anxiety, restlessness, poor concentration, decreased sleep, increased appetite, exacerbation of psychiatric

symptoms

• Drugs used in smoking cessation: Bupropion (amfebutamone), Varenicline

Substance Characteristic feature

Cocaine Magnus symptom (cocaine bugs/tactile hallucinations)

Cannabis Run amok, Amotivation syndrome, Flash backs, Hemp insanity,

Alcohol Mc-Evan's sign, Morbid jealousy

LSD Bad trips, Flash backs

Amphetamine Paranoid hallucinatory syndrome (like paranoid schizophrenia)

Phencyclidine (angel dust) Dissociative anesthesia

� LSD: No withdrawal syndrome

� Cannabis: No physical dependence; mild to marked psychological dependence

� Cocaine: Mild physical dependence; severe psychological dependence

� Amok is an episode of acute violent behavior for which the person claims amnesia. Seen in cannabis abuse.

V. SCHIZOPHRENIA

• Emil Kraeplin- In 1896, described dementia precox

• Eugen Bleuler- renamed dementia precox as schizophrenia (fundamental symptom), developed 4 A's of

schizophrenia

• Kurt Schneider- First rank symptoms

• Point prevalence: 0.5-1%

• Incidence: 0.5 per 1000

• 8-10% of first degree relatives of patients can present with schizophrenia

Schneider's first rank symptoms Schneider's second rank symptoms

• Hallucination

o Audible thoughts (thought echo)

o Voices heard arguing

o Voices commenting on one's action

• Delusional perception

• Thoughts Alienation phenomena

o Thoughts withdrawal

o Thoughts insertion

o Thought diffusion / broadcasting

• Passivity phenomena

o Made feeling (affect)

o Made impulses

o Made volition or act

o Somatic passivity

• Other disorders of perception

• Sudden delusional ideas

• Perplexity

• Depressive and euphoric mood changes

• Feelings of emotional impoverishment

• Several others as well

Bleuler's '4-A'

• Ambivalence (inability to decide for or against)

• Autism (withdrawal into self)

• Affect disturbance

• Association disturbance

DSM-IV CRITERIA FOR DIAGNOSIS OF SCHIZOPHRENIA:

Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if

successfully treated):

• Delusions

• Hallucinations

• Disorganized speech (e.g., frequent derailment or incoherence)

• Grossly disorganized or catatonic behavior

• Negative symptoms, i.e., affective flattening, alogia, or avolition

Only one Criterion symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a

running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

• All patients with schizophrenia have psychotic symptoms (reality distortion or disorganization) at some

point in the course of their illness, but there is no single pattern of psychotic symptoms.

• Continuous signs of the disturbance persist for at least 6 months.

• This 6-month period must include at least 1 month of symptoms.

Types

• Commonest type – Paranoid

• Amphetamine induced - Paranoid

• Early onset & bad prognosis – Hebephrenic

• Late onset & best prognosis – Catatonic

• Very late (3rd

4th

decade) – Paranoid

• Worst prognosis & most difficult to diagnosis – Simple

• Associated with mental retardation – Ptropf

DSM-IV-TR Diagnostic Criteria for Schizophrenia Subtypes

Paranoid type (Paraphrenia)

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. Absence of disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Disorganized type (Hebephrenic)

Prominence of disorganized speech, disorganized behavior & flat or inappropriate affect

Catatonic type: Presence of at least two of:

1. Catalepsy (including waxy flexibility) or stupor

2. Excessive motor activity (purposeless and not influenced by external stimuli)

3. Negativism or mutism

4. peculiarities of posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped

5. movements, prominent mannerisms, or prominent grimacing

6. echolalia or echopraxia

Undifferentiated type

Residual type: Absence of prominent delusions, hallucinations, disorganized speech, and grossly

disorganized or catatonic behavior.

• Schizophreniform disorder -patients who meet the symptom requirements but not the duration

• Schizoaffective disorder -manifest symptoms of schizophrenia and independent periods of mood

disturbance.

• Other subtypes:

• Bouff Dlirante (Acute Delusional

• Psychosis)

• Latent schizophrenia

• Oneiroid state

• Pseudoneurotic schizophrenia

• Deficit schizophrenia

• Early onset schizophrenia

• Late onset schizophrenia

CATATONIC SCHIZOPHRENIA

Excited catatonic:

• Known as Acute lethal catatonic or pernicious catatonia

• Increased psychomotor activity

• Death may occur.

Retorted (stupor) catatonic:

• Decreased psychomotor activity

• Mutism: absence of speech

• Rigidity 2

• Waxy flexibility: parts of body placed in position that will be maintained for long period even if very

uncomfortable

• Stupor: no movement with mutism but preservation of consciousness.

• Negativism

• Echolalia, Echopraxia

• Mannerism & Grimacing

• Automatic obedience

• Ambitendancy: due to ambivalence, tentative actions occurs

• Verbigeration: Incomprehensible speech

� All specific terminologies like Echolalia, Echopraxia, waxy flexibility, grimacing etc... are seen in catatonic

schizophrenia except senseless giggling and mirror gazing (hebephrenic schizophrenia).

Characteristic Hallucinations

• Most common - Auditory Hallucinations.

• 3rd

person hallucinations - consist of voice keeping up a running commentary on the person's behavior or

thoughts or two or more voices conversing with each other

• The oneiroid state - a dream-like state in which patients may be deeply perplexed and not fully oriented in

time and place.

• Cenesthetic hallucinations are unfounded sensations of altered states in bodily organs. Examples: a burning

sensation in the brain, a pushing sensation in the blood vessels.

• Hallucination - 1st

symptom to go with treatment & the 1st

symptom to reappear after resistance

Symptom clusters in Schizophrenia

Positive symptoms Negative symptoms Disorganized symptoms

• Delusions

• Hallucinations

• Affective flattening

• Attentional impairment

• Avolition-apathy (lack of initiative

associated with psychomotor

slowing)

• Asociality (social withdrawal)

• Alogia (lack of speech output)

• Anhedonia

• Inappropriate affect

• Disorganized behavior

• Thought disorder

• Loosening of association

• The delusions included in 1st rank symptoms are primary or autoconthous delusions - characteristic of

schizophrenia.

• Von-Gogh syndrome- is dramatic self-mutilation in schizophrenia (named after famous painter Von Gogh

who had cut his ear during active schizophrenia)

• Schizophrenia is thought to be due to a functional increase of dopamine at the postsynaptic receptor

• Other neurotransmitters – serotonin, GABA, acetylcholine may also be involved

• PET scan: hypofrontality and decreased glucose utilization in the dominant temporal lobe

Pharmacological treatment

• First drug used with beneficial effect: Reserpine (not used now)

• Atypical or second generation antipsychotics - are more commonly used

• Atypical antipsychotics are more useful when negative symptoms are prominent

• Clozapine – effective in patients who had no response to commonly used drugs

Prognosis

Good Prognosis Poor Prognosis

Late onset > 35 years Early onset < 20 years

Obvious precipitating factors No precipitating factors

Acute onset Insidious onset

Good premorbid social, sexual &work histories Poor premorbid social, sexual & work histories

Short duration < 6 months Chronic course > 2 years

Fat physique Thin physique

Female sex Male sex

Good social support Poor social support

Married Single, divorced, or widowed

Family history of mood disorders Family history of schizophrenia

Presence of depression Absence of depression

Confusion, perplexity, disorientation Flat or blunt affect

Positive symptoms Negative symptoms

Neurological signs and symptoms

History of perinatal trauma /assaultiveness

Many relapses/No remissions in 3 years

Catatonic subtype

Paranoid – intermediate prognosis

Disorganized, simple, undifferentiated, chronic

catatonic subtypes

Outpatient treatment Long term hospitalization

Normal cranial CT scan Evidence of ventricular enlargement

Indications for ECT in schizophrenia

• Catatonic stupor

• Uncontrolled catatonic excitement

• Acute exacerbation not controlled with drugs

• Severe side effect with drugs, in presence of untreated schizophrenia

Psychosurgery

• Very rarely performed

• Limbic leucotomy — is the procedure of choice

Acute (brief) psychotic disorder

• Differentiated from other related disorders by its sudden onset, relatively short duration (< 1 month), and

the full return of functioning

• Abrupt onset of one or more of the following symptoms

o Delusions

o Hallucinations

o Bizarre behavior and posture

o Disorganized speech

VI. ANXIETY & STRESS RELATED DISORDERS

TYPES OF ANXIETY DISORDERS (DSM-IV-TR)

• Panic disorder with or without agoraphobia

• Agoraphobia with or without panic disorder

• Specific phobia

• Social phobia

• Obsessive-compulsive disorder (OCD)

• Posttraumatic stress disorder (PTSD)

• Acute stress disorder

• Generalized anxiety disorder

Anxiety

• It is the most common psychiatric symptom

• Physical symptoms

o Motor: tremors, muscle twitching

o Autonomic and visceral: sweating, palpitation, tachycardia, flushes, hyperventilation, dry mouth,

dizziness, diarrhea, mydriasis

• Psychological symptoms

o Cognitive: poor concentration, hyperarousal, vigilance or scanning, negative automatic thoughts

o Perceptual: derealisation, depersonalization

o Affective: fearfulness, irritability, inability to relax, fear of impending

o Others: insomnia, increased sensitivity to noise, exaggerated startle response

DIFFERENTIAL DIAGNOSIS OF ANXIETY:

Medical Illnesses Substance Use/Abuse Psychiatric Disorders

Cardiac Endocrinologic Prescription or over-the-

counter drug use

• Adjustment

disorders

• Affective disorder

• Dissociative

disorders

• Personality

disorders

• Somatoform

disorders

• Schizophrenia

(and other

psychotic

disorders)

• Angina

• Arrhythmias

• Congestive failure

• Infarction

• Mitral valve

prolapse

• Paroxysmal atrial

tachycardia

• Hyperthyroidism

• Cushing's disease

• Hyperparathyroidism

• Hypoglycemia

• Premenstrual

• syndrome

• Antidepressants

• Fenfluramine/phentermine

• Psychostimulants (eg,

methylphenidate,

amphetamine)

• Steroids

• Sympathomimetics

Neoplastic Neurologic Substance abuse

• Carcinoid

• Insulinoma

• Pheocromocytoma

• Huntington's disease

• Meniere's disease

• Migraine

• Multiple sclerosis

• Seizure disorder

• Transient ischemic

attack

• Vertigo

• Wilson's disease

• Alcohol/sedative

withdrawal

• Caffeine

• Hallucinogen

• Stimulant abuse (eg,

cocaine)

Pulmonary Other

• Asthma

• Embolism

• Obstruction

• Obstructive

• pulmonary

disease

• Porphyria

• Uremia

PANIC DISORDER

Panic attacks

• Occur in panic disorder, specific phobia, social phobia and PTSD

• Unexpected panic attacks occur at any time and are not associated with identifiable situational stimulus

• A discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop

abruptly and reached a peak within 10 minutes.

o Palpitations, pounding heart, or accelerated heart rate

o Sweating

o Trembling or shaking

o Sensations of shortness of breath or smothering

o Feeling of choking

o Chest pain or discomfort

o Nausea or abdominal distress-

o Feeling dizzy, unsteady, lightheaded, or faint

o Derealization or depersonalization

o Fear of losing control or going crazy

o Fear of dying

o Paresthesias (numbness or tingling)

o Chills or hot flashes

Panic disorder

• Recurrent panic attacks

• Extreme fear and sense of impending death and doom

• Patients usually cannot name the source of their fear

• Generally lasts 20-30 minutes

• Depression and depersonalization may be seen

• Mental status examination: rumination, difficulty speaking, impaired memory

• Between attacks they have anticipatory anxiety about another attack

PHOBIA

• Insight is present.

• Agoraphobia

o Fear of open places, crowded places or any place from where there is no escape to safe place

o Most common & most disabling type

o More common in women

o Only one or two persons are relied upon - phobia companions.

• Social phobia – irrational fear of activities or social interaction

o Shy-Bladder: fear of urinating in public lavatory

o Erythro phobia: Fear of blushing.

• Simple (specific) phobia – irrational fear of objects or situations

o Claustro phobia- Fear of closed spaces

o Acrophobia – fear of high places.

o Algophobia – fear of pain

o Arachnophobia- fear of spiders

o Xeno phobia –fear of strangers

o Zoophobia – fear of animals

o Sito phobia - fear of eating

o Thanatophobia – fear of death

o Cynophobia: fear of dogs

o Mysophobia: fear of dirt & germs

o Pyrophobia: fear of fire

o Ailurophobia: fear of cats

Behavior therapy for phobia

• Flooding

• Systematic desensitization

• Exposure and response prevention

• Relaxation techniques

OBSESSIVE COMPULSIVE DISORDER

• Prevalence in the world 2-3%

Obsessions Compulsions

• An idea, impulse or image which intrudes into

the conscious awareness repeatedly

• It is recognized as one's own idea, but perceived

as ego-alien (foreign to one's personality)

• It is recognized as irrational and absurd (insight

present)

• Patient tries to resist but is unable to

• Failure to resist leads to marked distress

• A form of behaviour which usually follows

obsessions

• It is aimed at preventing or neutralizing the distress

or fear arising out of obsession

• The behaviour is not realistic and is either irrational

or excessive

• Insight is present

• The behaviour is performed with a sense of

subjective compulsion (urge or impulse to act)

Delusion is differentiated from obsession by

• The thought is not recognized as ego-alien

• The thought is not recognized as irrational

• The thought is never resisted

Clinical Manifestations

• Washers

o Most common type

o Obsession is of contamination with dirt, germs

o Compulsion — washing hands or body repeatedly, many times a day

o Spreads on to washing clothes, bathroom, bedroom, personal articles etc

• In all cases obsessive-compulsive activities take up >1 hour per day

• Depression is very commonly associated with OCD

• The disorder usually has a waxing and waning course

Psychodynamic theory of Freud

• Explains OCD by a defensive regression to anal-sadistic phase of development

• New defences are needed as reaction formation is not enough

• Isolation of affect � Obsessive thoughts

• Undoing � Compulsive acts

• Displacement � Phobias

Treatment of choice:

• First: Behavior therapy - Exposure & response prevention

• Second: Systematic desensitization

Medical treatment:

• Fluoxetine (Drug of choice) & other SSRI

• Fluvoxamine: Specific anti-obsession actions.

• Clomipramine (this TCA is most selective for serotonin reuptake) (Drug of IInd

choice)

POST —TRAUMATIC STRESS DISORDER (PTSD)

• Arises as a delayed/protracted response to an exceptionally stressful or catastrophic life event or situation

(e.g. war, rape, torture, serious accident)

• Recurrent and intrusive recollections of the stressful event either in flashbacks (image, thoughts or

perceptions) and/or in dreams

• Avoidance of the events or situations that arouse recollections of the stressful event

• Numbing of general responsiveness

• Amnesia for some aspects of the event

• Anhedonia (inability to experience pleasure)

• Hyperarousal

DSM-IV-TR definitions

• Acute stress disorder: symptoms appear within 4 weeks of the event and remits within 2 days to 4 weeks

• PTSD: occurs after 4 weeks of a stressful event and duration of symptoms > 1 month

• Delayed onset PTSD: occurs after 6 months

• Acute PTSD - duration of symptoms < 3 months; chronic PTSD: duration - > 3 months

Treatment

• SSRIs

• MAO inhibitors

• Benzodiazepines

• Behavior therapy, cognitive therapy

VII. MOOD DISORDERS

MOOD DISORDERS

• Manic episode

• Depressive episode

• Bipolar mood disorder

• Recurrent depressive disorder

• Persistent mood disorder

MANIC EPISODE Symptoms should last for atleast 1 week for diagnosis

• Elevated, Expansive or Irritable mood:

o Euphoria: mild elevation of mood, seen in hypomania [STAGE-1]

o Elation: moderate elevation of mood, seen in mania (STAGE-2]

o Exaltation: severe elevation of mood, seen in severe mania [STAGE-3]

o Ecstasy: very severe elevation of mood, seen in delirious/ stuporous mania [STAGE-4]

• Psychomotor activity

o Increased

o Rarely - manic stupor

• Speech and though

o Flight of ideas

o Prolixity

o Mood congruent psychotic features

o hallucinations

• Goal directed activity

• Reduced sleep

Treatment:

• Atypical antipsychotics (Risperidone, olanzapine, quetiapine, haloperidol)

• Mood stabilizers (Sodium valproate, Carbamazepine, Benzodiazepines, Lithium, Lamotrigine)

DEPRESSION Diagnostic Criteria

A. At least 2 weeks of duration

B. > 5 features should be present most of the day

• Depressant mood

• Loss of interest/pleasure (Absence of pleasure in normally pleasurable environment: Anhedonia) (Among

these two, one is essential for the diagnosis), plus

• Decrease or increase in appetite or significant weight loss/ gain

• Decrease / increase psychomotor activity (psychomotor retardation or agitation)

• Decrease / increase sleep (Insomnia/ hypersomnia)

• Fatigue

• Feeling of worthlessness or guilt

• Decreased concentration

• Recurrent thoughts of death.

Depressive ideation/Cognition:

• Sadness of mood (depression) is usually associated with pessimism, which can result in

o Hopelessness

o Helplessness

o Worthlessness

• Difficulty in thinking, concentration, indecisiveness

• Nihilistic delusions (e.g: world is coming to an end)

Somatic syndrome (Melancholia) in depression

• Significant decrease in appetite or weight

• Early morning awakening (atleast 2 hours early than the usual time)

• Diurnal variation (depression worst in the morning)

• Pervasive loss of interest and loss of reactivity to pleasurable stimuli

• Psychomotor agitation or retardation

Other features

• Pseudo-dementia

• Otto veraguth fold

• Depression is seen in - Myxedema, AIDS, Cancer, post MI, surgery & post-partum

• Depression is most common in middle age females

Theories

• Cognitive theory: Postulated by Aaron Beck consists of the following triad

o About self - Negative self-precept

o About the environment - Tendency to experience the world as hostile and demanding

o About the future — the expectation of suffering and failure

• Learned helplessness theory

Sleep studies

• Decreased REM latency (the time between falling asleep and the first REM period is decreased)

• Increased duration of the first REM period

• Delayed sleep onset

SUICIDE

• Suicide is intentional self-destruction.

• The term parasuicide refers to suicidal attempts or gestures.

• Patients suffering from severe depression with suicidal intent or attempt have a marked decrease in the

serotonergic function

• Official suicide rate in India in 2008 — 10.8 per 100000 population per year

• Most common mode of committing suicide — ingestion of poison (35%) hanging (32%)

• The psychiatric disorder with greatest risk of suicide in both sexes — Mood disorder

• Widely accepted theory for suicide:

o Sociological factors: Durkheim's Theory:

� Egoistic suicide applies to those who are not strongly integrated into any social group

� Altruistic suicide applies to those susceptible to suicide stemming from their excessive integration

into a group, with suicide being the outgrowth of the integration., for example, a soldier who

sacrifices his life in battle.

� Anomic suicide applies to persons whose integration into society is disturbed so that they cannot

follow customary norms of behavior.

o Psychological Factors: Freud's Theory/ Menninger's Theory

Evaluation of Suicide Risk

Variable High Risk Low Risk

Demographic and Social Profile

Age Over 45 years Below 45 years

Sex Male Female

Marital status Divorced or widowed Married

Employment Unemployed Employed

Interpersonal relationship Conflictual Stable

Family background Chaotic or conflictual Stable

Health

Physical Chronic illness Good health

Hypochondriac Feels healthy

Excessive substance intake Low substance use

Mental Severe depression Mild depression

Psychosis Neurosis

Severe personality disorder Normal personality

Substance abuse Social drinker

Hopelessness Optimism

Suicidal activity

Suicidal ideation Frequent, intense, prolonged Infrequent, low intensity, transient

Suicide attempt Multiple attempts First attempt

Planned Impulsive

Rescue unlikely Rescue inevitable

Unambiguous wish to die Primary wish for change

Communication internalized (self-

blame)

Communication externalized (anger)

Method lethal and available Method of low lethality or not readily

available Resources

Personal Poor achievement Good achievement

Poor insight Insightful

Affect unavailable/ poorly

controlled

Affect available and appropriately controlled

Social Poor rapport Good rapport

Socially isolated Socially integrated

Unresponsive family Concerned family

Risk Factors

• Age> 40 years

• Male sex

• Staying single

• Previous suicidal attempts

• Suicidal pre occupation (e.g. a written suicidal note)

• Depression

• Alcohol/ drug dependence

• Severe/ painful physical illness

• Recent serious loss or major stressful event

• Social isolation

• High degree of impulsivity

Risk factors for suicide in depression

• Early stages of depression

• Recovering from depression

• With mood disorder, personality disorder, psychosis, hypochondriac

• Child with conduct disorder or substance abuse

• 45 years male, unemployed, single, separated, divorced, widowed, recently bereaved, chronically ill

• Positive family history

Treatment

• Tricyclic anti-depressants: imipramine, amitriptyline

• SSRIs: fluoxetine, sertraline, citaprolam

• SNRIs: venlafaxine, duloxetine

Neurotransmitters

• Mania: increased norepinephrine at the synaptic cleft

• Depression: decreased norepinephrine and/or 5-HT

BIPOLAR MOOD DISORDER

• Previous called as Manic depressive psychosis (MDP)

• Unpredictable swings in mood from mania to depression at different times

• In the intervening period, patient may be normal

o Bipolar-1: episodes of severe mania and depression.

o Bipolar-2: episodes of hypomania and severe depression

• Rapid cyclers: > 4 episodes per year; mostly women

• Ultra-rapid cycling: episodes of mania and depression alternate very rapidly (in hours or days)

Good prognostic factors Poor prognostic factors

• Acute or abrupt onset

• Typical clinical features

• Severe depression

• Well-adjusted premorbid

personality

• Good response to treatment

• Comorbid medical disorder, personality disorder or

alcohol dependence

• Double depression (acute depressive episode

superimposed on chronic depression or dysthymia)

• Catastrophic stress or chronic ongoing stress

• Unfavorable early environment

• Marked Hypochondriacal features

• Mood incongruent psychotic features

• Poor drug compliance

Other forms of depression

� Atypical depression – a term that has been applied to a variety of presentations, but particularly to patients

who present with mild to moderate depression, some mood reactivity, reverse diurnal variation in mood (i.e.

worse in the evening), overeating, hypersomnia and fatigue.

� Dysthymia – depressive symptoms which are insufficient to meet the criteria for a clinical depression. The

patient's symptoms are present for 2 or more years. Can be associated with other psychiatric conditions

such as borderline personality disorder. Sufferers often go on to develop more serious mood disorder.

� Cyclothymic disorder – chronic mood fluctuations over at least 2 years with episodes of elation and of

depression insufficient to meet the criteria for a hypomanic depressive episode.

� Masked depression – a state in which depressed mood is not particularly prominent, but other features of

depressive disorder are present, e.g. sleep disturbance, diurnal mood variation, depressive cognitions.

� Mild depressive disorders – milder forms of the symptoms of depression, with less disruption to social

functioning. These are likely to be accompanied by prominent anxiety, phobic or obsessional symptoms.

� Recurrent brief depressive disorder – lasts for <2 weeks, usually around 2-3 days. Occurs around once per

month, with complete recovery between episodes. The actual symptoms collectively may fulfil the criteria

for mild, moderate or severe depression, but the difference is in the duration of the episode.

� SAD – a temporal relationship between the season of the year and the onset of depression. The depression

starts in autumn/winter and resolves in spring/ summer. There may be symptoms of depression and

additional atypical biological features such as carbohydrate craving, fatigue and hypersomnia.

Note:

� Dysthymia – if the symptoms consist of persistent mild depression

� Cyclothymia –frequent mood swings of mild depression and mild elation.

VIII. SOMATOFORM, DISSOCIATIVE & PERSONALITY DISORDERS

Type of Somatoform Disorder Features

Hypochondriasis • Persistent preoccupation with fear or belief of having serious

disease based on own interpretation

• Detailed physical examination and investigations do not reveal

any abnormality

• Belief persists even after seeing his normal lab reports

• The fear or belief is not a delusion

Somatization disorder or

Briquet Disorder or

Brissaud Marie Syndrome

• Multiple somatic symptoms

• 4 pain symptoms (2 in GIT, 1 sexual, 1 pseudo neurological)

• Atleast 2 years duration needed for diagnosis

• Frequent change of treating physicians

• Refusal to accept reassurance

• More common in females

Conversion disorder

• Symptoms/sign affecting motor or

sensory function or convulsions

suggesting a neurological disorder

• No ANS involvement

• Not intentionally produced

Features common to Conversion and Dissociative disorders

• Sudden onset

• Presence of precipitating stress

• Clear temporal relationship between stressor and development

of symptoms

• There is usually a secondary gain

• Detailed physical examination and investigations do not reveal

any abnormality that can explain the symptoms adequately

• More common in women

• Onset usually in 2nd or 3rd decade

Dissociative disorder

• Disturbance in normally integrated

functions of consciousness,

identity and/or memory

Body dysmorphic disorder Preoccupation with an imagined defect in appearance.

Somatoform pain disorder Pain does not vary in intensity & insensitive to emotional, cognitive

attentional & situational influence.

• The word Hysteria is removed from ICD-10 and replaced by 'Conversion and Dissociative disorders'

Dissociative disorders

DISSOCIATIVE AMNESIA

• Circumscribed amnesia (M/C form) - failure to recall all events occurring during a circumscribed period of

time.

• Selective amnesia - failure to recall some but not all of the events during a circumscribed period of time.

• Continuous amnesia — failure to recall all personal events following a stressful event, till the present time

• Generalized amnesia - failure of recall all personal events of the whole life, in the face of a stressful life

event

• Systematized amnesia is a loss of memory for specific categories of information, such as all memory relating

to one's family or a particular person.

DISSOCIATIVE FUGUE

• Episodes of wandering away (usually away from home)

• During the episode, the person usually adopts a new identity with complete amnesia for the earlier life

• Sudden onset, often in the presence of severe stress

• Abrupt termination of the episode and followed by amnesia for the episode with recovery of memories of

earlier life

• The characteristic feature – assumption of a purposeful new identity, with absence of awareness of

amnesia

• Complex partial seizures – no assumption of new identity, confusion present during the episode, no

precipitating stress

Clinical features Epileptic seizures Dissociative convulsions (Hysterical fits )

Attack pattern Stereotyped, known clinical patterns Absence of any established clinical pattern

Purposive body movements occur

Place of occurrence Any where Usually indoor or at safe places

Sleep Can occur during sleep Never occur during sleep

Tongue bite Present Absent

Incontinence of

urine and faeces

Present Absent

Neurological signs Present Absent

Post ictal confusion Present Absent

Injury Can occur Very rare

Speech No verbalization during seizure Verbalization can occur during seizure

Duration Short (30 – 70 secs) Prolonged

Head turning Unilateral Side to side

Eye gaze Staring, if eyes are open Avoidant gaze

Amnesia Complete Partial

EEG Abnormal Normal

Serum prolactin Increased in post ictal period (15-20

minutes after seizure, returns to

normal in one hour)

Normal

GANSER SYNDROME (HYSTERICAL PSEUDODEMENTIA)

• Commonly found in prison inmates

• Characteristic feature – vorbeireden (approximate answers)

• The answers are wrong, but show that the person understands the nature of question asked

La Belle Indifference

• Patient's lack of concern towards serious symptoms, despite the apparent severity of the disability produced

• Previously thought as hallmark of dissociative (conversion) disorders, it is now known to be present even in

physical illness

Treatment of conversion and dissociative disorders

• Aversion therapy (liquor ammonia, electrical stimulus, pressure just above eyeballs or tragus of ear etc)

• Psychotherapy with abreaction

PERSONALITY

• The four components in the concept of personality are:

• Adjustment

• Agreeableness

• Sociability

• Openness

PERSONALITY DISORDERS

• Cluster A (paranoid, schizoid, schizotypal), which includes individuals who are odd or eccentric.

• Cluster B (antisocial, borderline, histrionic, narcissistic), which includes individuals with dramatic, acting-out

behaviors and who have problems with empathy.

• Cluster C (avoidant, dependent, obsessive-compulsive), which includes personality styles marked by

prominent anxiety and novelty avoidance.

DSM-IV-TR and ICD-10 classifications of personality disorder

DSM-IV-TR ICD-10 Description

Paranoid Paranoid Excessive sensitiveness, tendency to bear grudges persistently,

suspiciousness, preoccupied with conspiratorial explanations, self-

referential, distrust of others.

Schizoid Schizoid Emotional coldness, lack of pleasure from activities, little interest

in sex, excessive preoccupation with introspection and fantasy.

Schizotypal (classified with

schizophrenia and

related disorders)

Inappropriate affect, odd, eccentric or peculiar behavior, social

withdrawal, magical thinking, obsessive ruminations, transient

quasi-psychotic episodes

Antisocial Dissocial Callous lack of concern for others, irresponsibility, aggression,

inability to maintain enduring relationships, disregard and

violation social norms, evidence of childhood conduct disorder.

Borderline Emotionally unstable—

borderline type

Disturbance of identity, unstable relationships, unpredictable

affect, acts of self-harm, suicidal gestures, impulsivity, unstable

emotions

Histrionic Histrionic Self-dramatization, exaggerated emotions, shallow affect, attention

seeking, easily influenced by others, over-concern for physical

attractiveness

Narcissistic Grandiosity, lack of empathy, need for admiration, preoccupation

with fantasies of unlimited success

Avoidant Anxious (avoidant) Tension, self-consciousness, fear of negative evaluation by others,

timid, insecure.

Obsessive-

compulsive

Anankastic Doubt, indecisiveness, caution, pedantry, rigidity, perfectionism,

preoccupation with orderliness and control.

Dependent Dependent Clinging, submissive, excess need for care, feels helpless when not

in relationship.

IX. MISCELLANEOUS

EATING DISORDERS

ANOREXIA NERVOSA

• More often in females, Common age of onset is adolescence (13-19 years)

• It is seen with greatest frequency among young women in professions that require thinness (modeling and

ballet)

• Intense fear of becoming obese

• There is often a body-image disturbance (inability to perceive size of body image correctly)

• Significant weight loss occurs, usually > 25% of the original weight.

• The final weight is usually 15% less than the minimum limit of normal weight (for that age, sex and height) or

a BMI of 17.5 or less

• No known medical illness, which can account for the weight loss, is present

• Amenorrhea, primary or secondary, is often present

• Absence of primary psychiatric disorder

• Depressive symptoms are common and so are obsessive-compulsive personality traits.

• Anorexia (a misnomer) — no decrease in appetite

• Poor sexual adjustment

• In severe cases, fine lanugo hair may develop all over the body.

• Bulimic episodes

o Rapid consumption of large amount of food in a relatively short period of time, usually occurring when

alone (binges or binge-eating)

o These binges are followed by intense guilt and attempts to remove eaten food, for example, by self-

induced vomiting, laxative abuse, and/or diuretic abuse

• Death may occur due to hypokalemia (caused by self-induced vomiting), dehydration, malnutrition or

congestive cardiac failure (caused by anemia)

BULIMIA NERVOSA

• Onset in early teens or adolescence

• Intense fear of becoming obese and h/o anorexia nervosa present sometimes

• There is often a body-image disturbance.

• There is a persistent preoccupation with eating and an irresistible craving for food.

• There are attempts to 'counteract' the effects of overeating by one or more of the following

o Self-induced vomiting

o Purgative abuse

o Periods of starvation

o Use of drugs such as appetite suppressants.

FEATURES ANOREXIA NERVOSA BULIMIA NERVOSA

Feature Refusal to maintain body

weight above a minimal normal

Irresistible craving for food with episodes of

over eating in less time (being eating)

Method of weight control Very less eating Attempts to counter act the effects of over

eating

Weight Markedly decreased Usually normal

Binge eating 25-50% Required for diagnosis

Amenorrhea 100% 50%

Ritualized exercise,

decreased vitals (BP, PR),

hypothermia, skin changes

(hirsutism)

Common Rare

Patient believes that their

body as a whole, or some part

of their body, is too fat.

-Dental caries are frequent

-Antisocial behavior &drug abuse is common

-Prognosis is worse

CULTURE BOUND SYNDROMES

• Dhat syndrome � fear of losing semen

• Amok � sudden, unprovoked episode of rage

• Koro � strong belief that his penis is shrinking

• Wihtigo (windigo) � belief that he has been transformed to a cannibal.

• Pibloktoq � Arctic Hysteria� Eskimos, extreme excitement of as long as 30 minutes' duration and

frequently followed by convulsive seizures and coma lasting as long as 12 hours

• Suchi-bai ���� purity mania

• Hwa-Byung / Wool-Hwa-Byung: Korean folk syndrome [anger syndrome] and is attributed to the

suppression of anger.

• Latah: hypersensitivity to sudden fright, often with echopraxia, echolalia, command obedience, and

dissociative or trance-like behavior.

• Locura: severe form of chronic psychosis [inherited vulnerability, the effect of multiple life difficulties, or a

combination of both factors]

• Mal de ojo: evil eye

• Ideas of nerves/Nervios: general state of vulnerability to stressful life experiences and to a syndrome

brought on by difficult life circumstances.

FACTITIOUS DISORDER (MUNCHAUSEN SYNDROME)

• Also known as hospital addiction, hospital hoboes, professional patients

• Simulate or fake diseases for the sole purpose of obtaining medical attention.

• No other recognized motive.

• Pseudologia fantastica - distort their clinical histories, lab reports and even facts about their lives

• Drug abuse is common

• They have superficial knowledge of medical terms

• Evidence of earlier treatment, usually surgical procedures, is often found in the form of multiple scars (e.g:

grid iron abdomen)

• They often tell lies and leave the hospital against medical advise

SLEEP

Two phases:

1. D-Sleep (desynchronized or dreaming sleep) OR REM-sleep (rapid eye movement sleep), active sleep or

paradoxical sleep.

2. S-Sleep (synchronized sleep), or NREM – sleep (non-REM sleep), quiet sleep, or orthodox sleep. S-sleep or

NREM-sleep is further divided into four stages, 1 to 4.

The EEG recording

• During the awake state shows alpha waves of 8-12 cycles/sec. frequency

• The onset of sleep is characterized by a disappearance of the alpha – activity.

• NREM –sleep

o Stage 1: first and the lightest stage of sleep, absence of alpha-waves, and low voltage, predominantly

theta activity.

o Stage 2: characterized by two typical EEG changes:

� Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0

seconds, with a characteristic waxing and waning amplitude.

� K-complexes: High voltage spikes present intermittently.

o Stage 3: appearance of high voltage, 751.1V, 6-waves of 0.5-3.0 cycles/sec.

o Stage 4: predominant δ-activity

The important time periods of the various sleep stages

• In an 8 hour sleep, usually 6-61/2

hours are spent in NREM –sleep & 11/2

– 2 hours in REM-sleep.

• Out of 6-6112 hours NREM-sleep period, only about 70-80 minutes are spent in Stage 4 sleep.

• The maximum Stage 4 sleep occurs in the first one-third of the night

• In the later part, the REM-sleep follows the Stage 3 NREM –sleep directly.

• REM-sleep occurs maximally in the last one-third of the night.

• REM-sleep occurs regularly after every 90-100 mins, with progressive lengthening of each REM period.

• The first REM period typically lasts for less than 10 minutes.

• Usually, there are 4-5 REM periods in the whole night of sleep.

• The usual sleep duration in newborn children is 16-18 hours/day, with nearly 8-10 hours spent in the REM-

sleep.

DISORDERS OF SLEEP

Nightmares

• Almost always occur during REM sleep and usually after a long REM period late in the night.

• The awakening may occur during any part of the sleep period, but typically during the second half.

Sleep terror: Arousal in the first third of the night during deep NREM (stages III and IV) sleep.

Kleine Levin syndrome

• Recurrent periods of prolonged sleep (from which patients may be aroused) with intervening periods of

normal sleep and alert waking

PARASOMNIAS

• Sleep walking and sleep terrors

• Common in preschool (3-6years) children

Characteristic Sleep walking Sleep terrors Night mares Nocturnal seizures

Timing during sleep First third First third Last third Variable, often during

sleep-wake transition

Stage of sleep Slow wave Slow wave REM Non REM > SWS

Arousal threshold High High Low High

Day time sleepiness None None Yes Probable '

Recall of event None None Frequent, vivid None

Incidence Common Rare Very common Rare

Family history Common Common None Variable

GENDER IDENTITY DISORDERS

• Common feature is a strong, persistent preference for living as a person of the other sex.

• Discontent with one's designated birth sex and a desire to have the body of the other sex, and to be

regarded socially as a person of the other sex.

• Gender identity disorder in adults ���� transsexualism.

• Cross-dressing is commonly known as transvestism, and the cross-dresser as a transvestite.

IMPULSE CONTROL DISORDERS

Kleptomania (pathological stealing)

• Failure to resist the impulse to steal useless objects that have little monetary value.

• Usually women

• No apparent motive

• Usually there is a feeling of tension before the act and sense of relief afterwards

• Differential diagnosis: Shoplifting (actions are usually well-planned and motivated by need or monetary

gain)

Pyromania (pathological fire-setting)

• Deliberate and purposeful fire setting on two or more occasions

• No apparent motive

• 90% are male.

� Pathological Gambling : Two or more gambling episodes per year which have not profitable outcome

� Trichotillomania: Recurrent pulling out of one's hair resulting in noticeable hair loss

� Dipsomania – irresistible urge to drink alcohol at regular intervals

� Mutilomania – irresistible urge to mutilate animals

• De Clerambult's syndrome: Erotic delusions

• Alice in Wonderland syndrome: Disturbance of one's view of self.

• Couvade syndrome: experiencing the symptoms of pregnancy in males

• Kanner's syndrome is autism with a normal ICI.

Asperger's syndrome, or schizoid personality of childhood, may be a mild form of autism and comprises eccentric

isolated behavior with circumscribed interests and stilted speech:

X. TREATMENT MODALITIES

ANTIPSYCHOTIC DRUGS

TYPICAL (Neuroleptics, D2 blockers) ATYPICAL

Phenothiazines Thioxanthines Butyrophenones Miscellaneous Clozapine , Olanzapine

Quetiapine,

Risperidone

Ziprasidone,

Iloperidone,

Lurasidone,

Aripiprazole,

Asenapine

Chlorpromazine

Thioridazine

Trifluoperazine

Fluphenazine

Flupenthixol

Thiothixene

Haloperidol

Droperidol

Penfluridol

Pimozide

Loxapine

• Longest acting: Fluphenazine (2-4 weeks), Penfluridol (1 week).

• Longest half- life: Aripiprazole (75 hours)

• Shortest half-life: Quetiapine (6 hours)

• Least potent: Chlorpromazine

• With antidepressant action: Flupenthixol.

• More emetic potential: Clozapine/ Olanzapine/ Risperidone/ Molindone

Actions

Extra pyramidal symptoms Sedation Hypotension Anti emetic

Maximum: Haloperidol

Least: Thioridazine

Almost nil: Clozapine,

Risperidone

Maximum: Chlorpromazine,

Triflupromazine,

Thioridazine, Clozapine &

Quetiapine

Maximum:

Thioridazine,

Clozapine &

Risperidone

Triflupromazine,

Trifluoperazine

Fluphenazine,

Haloperidol

• All anti psychotics are potent antiemetics except Thioridazine & atypical drugs.

• Low potency drugs possess significant α blocking (maximum with chlorpromazine) and anticholinergic

(maximum with thioridazine) properties.

• D2 receptors blockage in hypothalamus & pituitary � increase prolactin release � galactorrhoea &

amenorrhea.

• Aripiprazole: acts as a partial agonist at 5-HT1A and D2 receptors and antagonist at 5-HT2A receptors. It is

also known as dopamine- serotonin stabilizer.

• Ziprasidone: D2 +5-FIT2A/2c + H1-α 1 blocker

• Thioridazine: interferes with ejaculation, can cause cardiac arrhythmias and retinal damage.

• Asenapine: used sublingually for schizophrenia & acute mania.

• Amisulpiride: congener of sulpiride (typical antipsychotic) is categorized with the atypical antipsychotics

because it produces few extrapyramidal side effects and improves many negative symptoms of

schizophrenia as well. However, it retains high affinity for D2 (and D3) receptors and has low-affinity for 5-

HT2 receptors.

Clozapine:

• Most potent with least extrapyramidal S.E. & least antiemetic property

• Has weak D2 blocking action

• Reserve drug for resistant schizophrenia

• Most important side effect is agranulocytosis.

SIDE EFFECTS

• Extra pyramidal symptoms are due to D2 blockade in limbic system.

• Perioral movements [Rabbit syndrome]

� Within 7 days of starting or rapidly raising the dose of drugs — Neuroleptic induced dystonia

� Drugs is taken for less than 3 months (or 1 month if > 60 years), within 4 weeks of withdrawal from drug

— Neurolept induced — tardive dyskinesia.

• Neuroleptic induced akathisia

� Inner restlessness (feeling of discomfort & agitation)

� External restlessness (compulsion to move extremities, pacing, rocking, fidgety movements)

� β-Blocker (Propanolol) is the drug of choice.

• NEUROLEPTIC MALIGNANT SYNDROME

� More common with high potency D2 antagonists

� Severe muscle rigidity & elevated temperature with diaphoresis (sweating), tachycardia, elevated or

labile BP, leucocytosis & lab

� Evidence of muscle injury e.g. elevated CPK

• Hyperprolactinemia is associated with blockade of D2 receptors in the tuberoinfundibular dopamine system

� hypogonadism, infertility, amenorrhea, galactorrhoea and gynecomastia.

• Hyperprolactinemia is more common with typical antipsychotics and risperidone

Reaction Features Time of

maximal risk

Mechanism Treatment

Acute dystonia Spasm of muscles of

tongue, face, neck,

back, may mimic

seizures, not hysteria

1-5 days Unknown Anti parkinsonian agents

are diagnostic

and curative

Akathisia Motor restlessness,

not anxiety or agitation

5-60 days Unknown Reduce dose or change

drug; anti parkinsonian

drugs, BDZ / propranolol

may help

Parkinsonism Bradykinesia, rigidity,

variable tremor, mask

facies, shuffling gait

5-30 days; can

recur even after

a single

dose

Antagonism of

dopamine

Anti parkinsonian

agents helpful

Neuroleptic

malignant

syndrome

Catatonia, stupor,

fever, unstable BP,

myoglobinemia, can be

fatal

Weeks; can

persist for days

after stopping

neuroleptic

Antagonism of

dopamine

Stop neuroleptic;

Dantrolene /

bromocriptine may

help. Anti parkinsonian

agents not useful

Perioral tremor "

rabbit syndrome"

Perioral tremor (may

be a late variant of

parkinsonism)

After months

or years of

treatment

Unknown Anti parkinsonian

agents often help

Tardive dyskinesia Oral- facial dyskinesia;

Widespread

choreoathetosis or

dystonia

After months

or years of

treatment

(worse on

withdrawal)

Excess function

of dopamine

hypothesized

Prevention crucial;

Treatment

unsatisfactory

Adverse effect Maximum with Minimum with

Dry mouth, constipation, cycloplegia Chlorpromazine Haloperidol, Risperidone

Impotence, orthostatic hypotension Chlorpromazine Aripiprazole

Impaired ejaculation Thioridazine Haloperidol

Parkinsonian features [tremor] Haloperidol Clozapine, quetiapine, aripiprazole

Akathisia, acute dystonia, rabbit

syndrome

Haloperidol Clozapine, quetiapine

Tardive dyskinesia - Clozapine

Neuroleptic malignant syndrome Probably haloperidol -

Seizures Clozapine, chlorpromazine Trifluperazine

Sedation Clozapine, chlorpromazine Haloperidol , aripiprazole

Weight gain Clozapine , olanzapine Haloperidol , aripiprazole

Diabetes Clozapine , olanzapine Ziprasidone, aripiprazole

Agranulocytosis Clozapine -

ECG changes Thioridazine, pimozide Aripiprazole

Ocular granular deposits Chlorpromazine Haloperidol

Pigmentary retinopathy Thioridazine -

Contact dermatitis, photosensitive

reactions, Blue- gray metallic

discoloration

Chlorpromazine -

ANTI ANXIETY DRUGS

• Reduction in the GABAergic activity or increase in serotonergic activity � anxiety.

BENZODIAZEPINES

• Chlordiazepoxide is used for chronic anxiety states

• Oxazepam, lorazepam, alprazolam and diazepam for short lasting anxiety.

AZAPIRONES

• Buspirone, gepirone and ipsapirone (partial agonists of presynaptic 5-HT1A) � decrease the release of

serotonin.

• Sedation, cognitive impairment, abuse potential, muscle relaxant, anticonvulsant activity are not seen

• Ineffective in acute anxiety states like panic attacks.

• These are indicated for mild to moderate generalized anxiety states.

BETA BLOCKERS - Propranolol is indicated for performance anxiety.

Other drugs

• Hydroxyzine is H1 antihistaminic having anti-anxiety activity but profound sedation limits its usefulness.

• SSRIs like Fluoxetine - agent of choice for acute conditions like panic attacks.

ANTI-DEPRESSANTS

ANTIDEPRESSANTS/ MOOD ELEVATORS/ THYMOLEPTICS:

Cyclic anti-

depressants

Tricyclic tertiary amines Imipramine, amitriptyline, doxepine,

Clomipramine, Dothiepine [Dosulepin]

Tricyclic secondary amines Nortriptyline, protriptyline, desipramine

Tetracyclic Mianserin, maprotiline, amoxapine

Bicyclic Viloxazine

Selective serotonin reuptake inhibitor [SSRIs] Fluoxetine, paroxetine, fluvoxamine,

sertraline, citalopram, escitalopram

Serotonin norepinephrine reuptake inhibitors [SNRIs] Venlafaxine, duloxetine

Norepinephrine serotonin reuptake enhancers [NSRE's] Tianeptin

Noradrenergic and specific serotonergic antidepressant [NaSSA] Mirtazepine

Norepinephrine dopamine reuptake inhibitors [NDRIs] Bupropion

Serotonin antagonists and reuptake inhibitors [SARIS] Trazadone, nefazodone

Noradrenergic reuptake inhibitors [NARIs] Reboxetine

Mono amine

oxidase

inhibitors

Irreversible

Reversible MAGI-B Selegiline

MAGI-A Moclobemide

• Bupropion's most potent blocker of DA reuptake, indicated for cessation of smoking.

• Venlafaxine is a potent inhibitor of NE reuptake and a weak inhibitor of DA reuptake.

• Mirtazapine enhances central noradrenergic and serotonergic activity through the antagonism of central

presynaptic β2-adrenergic autoreceptors and heteroreceptors.

• St John's Wart, an herbal over-the-counter medication, may be effective for mild to moderate depression,

but it is associated with several drug interactions.

• Maprotiline and Amoxapine are inhibitors of NE reuptake, with less effect on 5-HT reuptake.

NOTE:

• Other noradrenaline reuptake inhibitors: atomoxetine

• Most potent blocker of 5-HT reuptake – Paroxetine

• Least potent blocker of 5-HT reuptake – Bupropion

• Most potent blocker of NA reuptake – Desipramine

• Least potent blocker of NA reuptake – Mirtazapine

• Most selective inhibitor of 5-HT reuptake – Escitalopram

• Most selective inhibitor of DA reuptake – Bupropion

• Most selective inhibitor of NA reuptake – Oxaprotiline

• Maximum antimuscarinic activity – Amitriptyline

• Maximum antihistaminic activity – Nefazodone

• Maximum α1 blocking activity – Doxepin

• Minimum antimuscarinic, α1 blocking and antihistaminic activity – Venlafaxine

• Doxepin contains high antimuscarinic, antihistaminic and α – blocking (maximum) activities.

• Fluoxetine is longest acting and nefazodone is shortest acting antidepressant.

• Amoxapine: chemically related to the antipsychotic drug loxapine, has mixed antidepressant +neuroleptic

properties-offers advantage for patients with psychotic depression.

• Atomoxetine is the first drug for ADHD that is not a stimulant under the Controlled Substances Act.

• Many other drugs like Protriptyline, Maprotiline, Nafazodone, etc. are marketed in other countries.

MOOD STABILIZERS

Drugs used in prophylaxis of bipolar disorder (Mood Stabilizers)

Established New

• Lithium

• Carbamazepine

• Valproate

• Lamotrigine

• Levo thyroxine (T3)

• Calcium channel blockers

• Clorgyline

• Clonazepam

• Gabapentin

LITHIUM

• Discovered in 1817 by Arfeudson

• First used in the treatment of gout & salt replacement in cardiac disease

• Starting dose for acute mania: 900-2100 mg/day lithium carbonate.

Blood lithium levels:

• Therapeutic levels [for treatment of acute mania]: 0.6 -1.2 mEq /1;

• Prophylactic levels [for relapse prevention in bipolar disorder]: 0.6 –1.0 mEq/L

• Toxic levels: > 1.5 mEq/L

Effects:

• Most affected organ is kidney > thyroid, Least affected organ is liver.

• Most common side effect is tremor

• Lithium can induce a fine postural tremor of the hands (8 to 12 Hz)

• Most common ECG finding: T wave depression

• Secreted in breast milk & hence contra indicated in pregnancy and lactation.

• Reduce thyroxine synthesis & leads to goiter & hypothyroidism.

Indications

• Acute mania

• Bipolar mood disorders

• Schizo-affective disorder

• Prophylaxis of unipolar mood disorder

• Cyclothymia

• Acute depression

• Chronic alcoholism (in the presence of significant depressive symptoms)

• Impulsive aggression

• Kleine-Levin syndrome

• Chemotherapy induced leucopenia & agranulocytosis (Leucocyte count is increased)

• SIADH (Inhibits ADH action on distal tube)

ELECTRO CONVULSIVE THERAPY

• Developed by Cerletti & Beni in 1938 as electro shock therapy.

Indications

• Major severe depression with

• Suicidal risk - first, most important and most common indication

o Stupor

o Poor intake of food and fluids

o Melancholia

o Psychotic features

o Unsatisfactory response to drug therapy

o Contraindication to drugs

• Severe psychosis (Schizophrenia or mania) with

• Risk of suicide, homicide or physical assault

o Unsatisfactory response to drug therapy

o Contraindication to drugs

o Prominent depressive features (e.g: schizo-affective disorder)

• Severe catatonia (non-organic) with

• Stupor

• Poor intake of food and fluids

• Unsatisfactory response to drug therapy

• Contraindication to drugs

Contraindications:

• ABSOLUTE: Raised intra cranial tension (fear of brain herniation)

• Relative

o Cerebro vascular accident (CVA)

o Recent MI

o Severe hypertension

o Pheochromocytoma

o Severe pulmonary disease

o Retinal detachment

Types:

• Direct ECT (unmodified): ECT is given without muscle relaxants and anesthesia. Direct ECT causes decreased

intra ocular tension.

• Modified ECT: given with drug induced muscle relaxation and anesthesia.

Complications:

• ECT- Direct: Most common side effect is fracture T4T8 spine

• Modified —ECT: Most common is retrograde amnesia (ante grade amnesia is also found)

Light & melatonin therapy

• Based on the concept that humans are subject to circadian rhythms that affect physiological processes in

predictable ways

• By varying light exposure, circadian rhythms can be altered

• The concentration of melatonin in blood is highest at night and lowest or absent during the daylight

• Artificial bright light therapy is a proved method to treat depressive disorder with seasonal pattern which is

seen in winter months when daylight hours are reduced

BEHAVIOR THERAPY

Type Based on Used in

Systemic

desensitization

Reciprocal inhibition Phobias (treatment of choice)

OCD (treatment of choice)

Psycho-sexual dysfunctions

Aversion therapy Pairing of pleasant stimulus with an

unpleasant responses e.g. Pairing alcohol with

electric shock

Drug abuse

Sexual deviations

Flooding Direct exposure to phobia but escape not

possible

Phobias

Operant conditioning

for increasing a

behavior

Positive reinforcement

Negative reinforcement

Modeling

For augmenting an adaptive

behavior

Operant conditioning

for decreasing a

behavior

Time out

Punishment

Satiation(negative practice procedure)

For demoting maladaptive

behavior

Other physical treatments for Depression

Light therapy (phototherapy):

• For the treatment of "seasonal affective disorder" (SAD) by Rosenthal

• Effects of phototherapy may be independent of melatonin and produce a "phase advance" in circadian

rhythms (hence treatment may be best given first thing in the morning).

• Usually administered by use of a light box.

• Optimal intensity of light appears to be 10,000 lux.

• Ideal treatment duration is for 30 minutes (at 10,000 lux) a day.

• Although treatment response is generally noticeable within five days.

• For patients with seasonal depressive symptoms, maintenance therapy is recommended throughout the

winter months

Vagus nerve stimulation (VNS) therapy:

• Approved for severe, recurrent unipolar and bipolar depression in July 2005.

• Left cervical vagus nerve stimulation is accomplished through leads attached to a pulse generator implanted

in the left chest area.

• Response rates of 40-46% have been shown for treatment-resistant depressive disorder after 10 weeks to 9

months, with a remission rate of 29% at one year, suggesting that the effectiveness of VNS may have a slow

trajectory.

• VNS may be combined with essentially all existing treatments for depressive disorders.

• It has been safely used with antidepressants (including MAOIs) and can be temporarily shut off to allow for

ECT and restarted immediately post-ECT.

*****END*****

RADIODIAGNOSIS

&

RADIOTHERAPY

I. IMAGING TECHNIQUES

X- RAYS

• Are electromagnetic radiation

• Have penetrating power less than gamma rays but more than alpha and beta rays

• Can pass through human body, Cannot be absorbed completely

• Produced by Coolidge tube when fast moving stream of electrons produced by a cathode(Tungsten

filament) strikes the anode(tungsten/ molybdenum containing copper plate)

• X-rays are most scattered by H+ ions.

• Causes ionization in 3 ways: Photoelectric effect, Compton effect & Pair production

• Contrast can be increased by increasing the current (mA)

• Penetration can be increased by increasing the voltage (mV)

• Machine is kept at 6 feet distance form photographic plate to prevent magnification.

• Optimum distance of target film: 90-100cm

• Best chest X ray is done at: 120-150 kilovolt peak.

• Gunson method: X- ray of soft tissues of neck

• Cyclotron produces Gamma rays

ULTRASOUND (USG)

• Based on piezoelectric effect of crystals made up of lead zirconate titanate.

• Ian Donald - father of obstetric ultrasound. Also invented the B-mode scanner.

• Dr. John Wild and John Reid: invented an A-mode scanner for the detection of ovarian cancer.

• John Wild ("father of medical ultrasound") first used ultrasound to assess the thickness of bowel tissue.

• Contains waves with frequencies>20,000 Hz.

• In medical USG frequencies commonly used are 2-10 MHz

• Frequencies used:

• Trans abdominal ultrasound: 3-5 MHz,

o Trans-vaginal: 5-7.5MHz,

o Breast: 15 MHz,

o Gut wall: 7.5-20 MHz

o Vessels: 20 MHz

• Types of image display

o A –Mode � one dimensional picture, used only in eye scan

o B- Mode- � two dimensional picture, commonly used

o Real time scan � gives moving picture

o M-Mode � motion display (e.g. in ECHO)

• USG causes delirious effect on small micro-organisms by acoustic cavitation.

• Investigation of choice for obstetric conditions

DOPPLER

• Based on Doppler Effect (change in the perceived frequency of sound emitted by a moving source measures

blood flow). It provides both audio and video signals.

• Types: Continuous waves & Pulsed waves

• In Doppler imaging colour displays direction of blood flow. It is

Red --- when direction of flow is towards the transducer.

Blue --- if flow is away from transducer.

CT- scan or CAT scan

• Invented by God Frey Hounsfield in 1963, awarded Nobel Prize.

• Basic principle of CT is linear attenuation of x-rays.

• Incident x-rays are linearly attenuated by their interaction with orbital electrons of tissues.

• Measurement of attenuation of emerging / detected beam gives density of intervening tissues and this

density forms basis of signal intensity variation obtained in x-ray tomograms.

• Electron density of tissues in numbered as Hounsfield number (H.N.) or Hounsfield units.

o Air have a value of -1000 HU

o Fat of -120 to -200 HU

o Water – 0 HU

o Soft tissue of 20-60 HU

o Blood of 50-60 HU

o Bone of +1000 HU

• Two type of contrast agents are used

o Ionic – water soluble iodide dyes (e.g. Na- diatrizoate, megliumine, conray, urograffin, angiografin) –

may cause anaphylaxis

o Non ionic- Safer but expensive e.g. iohexol (Omnipaque), lopamiro

• Uses of various contrast agents:

Contrast Procedure Contrast Procedure

Dionosil (Tantalum) Bronchography Hypaque, sodium

diatrizoate

IVP

Myodil DSA, Myelography Methylene blue Lymphangiography

lopanoic acid

(Telepaque)

Oral

cholecystography

(OCG)

Conray 280 Aortography, cerebral

angiography

Biligrafin IV cholecystography Conray 280/420 HSG

Metrizamide, lohexol

(Omnipaque)

Ventriculography Conray 420 CT scan, coronary

angiography

Gastrografin (Dionosil) Oesophagoscopy Gadolinium MRI

• Spiral CT, also known as helical or volumetric-acquisition CT: Technique by which the volume area is

scanned as the patient continuously travels through the scan field, while data is acquired along the spiral

path.

• Advantages:

o Spiral CT will produce a clearer, more defined image and provides better details.

o Spiral CT is 8 to 10 times faster than a traditional CT scanner. This saves time and reduces radiation

exposure by eliminating the need for multiple scans.

o Spiral CT can digitally reconstruct more than one image from a single slice and allows for multiplaner

reformatting (overlapping structure).

o Spiral CT has the ability to scan an entire region in a single breath hold, averaging about 30 seconds or

less. Shorter scan time allows coordination of peak contrast enhancement, which results in clearer

images and about 1/3 less dye load.

MRI

• Based on gyromagnetic property of protons (or hydrogen nucleus, H+)

• Described first by Bloch & Purchell, applied as human tool by Damadian & Lauterbeur (1972)

• It can be plain MRI or contrast MRI.

• Most common contrast agent used is i.v. Gadolinium.

• Proton density and relaxation time are assessed by radiofrequency pulse and the computer generates a gray

scale image from this data.

• Magnetic field used in the range of 0.15-3 tesla

• MRI spectroscopy provides in vivo characterization of chemical composition and metabolic activity of brain.

• Relaxation time:

o T1time taken to return to original axis (T1 images are used to find out normal anatomical details)lt has

got high soft tissue discrimination (CSF looks black)

o T2: Time taken by proton to displace. Used to assess pathological processes (fluid looks white).

The induction (transmitter/receiver coil) used in MRI are Maxwell coils.

• Water (CSF) looks white (hyperintense) on T2.

• CSF looks hyperintense on T2 weighted image and hypointense on T1 weighed image.

MRI EVALUATION OF HEMORRHAGES

Biochemical form Stage of

haemorrhage

Time T1 T2

Oxyhemoglobin in

RBCs

Hyperacute Immediate to

first few hours

Isointense Hyperintense

Deoxyhemoglobin in

RBCs

Acute Hours to days Isointense to

hypointense

Hypointense

Methoxyhemoglobin

in RBCs

Early subacute First several

days

hyperintense Hypointense

Extracellular metHb Late subacute Days to

months

Hyperintense Hypointense

Ferritin and

hemosedrin

Chronic Days to infinite

time

!so to

hypointense

Hypointense

Substance T1 weighted T2 weighted

Water/vitreous/CSF Black Light grey or white

Fat White Light grey

Muscle Grey Grey

Air Black Black

Fatty bone marrow White Light grey

Brain: white matter Light grey Grey

Brain: grey matter Grey Very light grey

Common Contraindications to MR Imaging

• Cardiac pacemaker or permanent pacemaker leads, Internal defibrillatory device

• Cochlear prostheses, Bone growth stimulators, Spinal cord stimulators

• Electronic infusion devices

• Intracranial aneurysm clips (some but not all)

• Ocular implants (some) or ocular metallic foreign body

• McGee stapedectomy piston prosthesis

• Duraphase penile implant

• Swan-Ganz catheter

• Magnetic stoma plugs, Magnetic dental implants

• Magnetic sphincters

• Ferromagnetic IVC filters, coils, stents—safe 6 weeks after implantation

• Tattooed eyeliner (contains ferromagnetic material and may irritate eyes)

PET

• PET produces tomographic images.

• A cyclotron is required to generate positron-emitting isotopes that can be made from compounds, such as F,

C, N and O.

• Radiopharmaceuticals for PET imaging: FDG, C methionine and [18]

Fα-methyl tyrosine.

• Disadvantages of PET: limited availability and high cost due to the necessity of a cyclotron

• Positron emitting radio nuclides are used:- O2- informs 02 uptake, CO2 - informs blood flow, 18 FDG —

informs glucose utilization and is most frequently used moiety,

• Indications:

o To distinguish radiation necrosis from recurrent glioblastoma

o To evaluate transformation of brain tumor from low grade to high grade

o To evaluate the potential for recurrence of meningioma

o To assess tumor viability and monitor treatment response

o For diagnosing occult metastasis & recurrent cancers

o To differentiate benign from malignant pulmonary nodules

o To evaluate staging, restaging, and response to therapy; local and distant metastasis; and response to

treatment in patients with breast cancer

o For the diagnosis, staging, and restaging of colorectal, esophageal, head and neck, breast and lung

cancers and lymphoma and melanoma.

o For restaging of recurrent or residual thyroid cancers, of follicular cell origin,

o In stroke PET is useful to differentiate viable from non — viable tissue

SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY

• Detection of emitted gamma rays by a gamma camera.

• Requires radiopharmaceuticals that cross the blood–brain barrier.

• Radiopharmaceuticals used are133

Xe, 123

I isopropyl iodoamphetamine (IMP), 99m

Tc ethyl cysteinate dimer

(ECD) or 99m

Tc hexamethylpropylene amine oxide (HMPAO).

• Clinical applications include dementia, cerebrovascular disease, epilepsy, encephalitis, head injury, and other

less common disorders that result in abnormal cerebral perfusion.

• SPECT can also be used to image uptake at neurotransmitter receptors using various radiopharmaceuticals

usually labeled with 123

I.

• Many different SPECT radiopharmaceuticals are taken up into intracranial tumours, including 201

TI chloride, 99m

Tc MIBI, 123

Iα-methyl tyrosine and 111

In octreotide.

• Because of the requirement for lead collimation, SPECT has inherently poorer resolution than PET and

absolute quantitation is not possible.

• SPECT is relatively inexpensive and has good patient acceptability.

CT and MRI Imaging Characteristics of Various Tissues:

Tissue CT Gray Scale MRI T1 Signal MRI T2 Signal

Brain Gray Gray Gray

Air Black Black Black

CSF Black Black White

Fat Black White Black

Calcium White Black Black

Bone Very white Black Black

Extravasated blood White White Black

Inflammation Contrast enhancing Gray, gadolinium enhancing White

Edema Dark gray Gray White

Tumor Gray or white and contrast

enhancing

Gray or white and gadolinium

enhancing

White

• FLAIR (fluid-attenuated inversion recovery) imaging is a technique that gives a high signal for parenchymal

lesions and a low signal for CSF.

• It is sensitive to calcium and iron within brain tissue, shows early stages of infarction, and accentuates

inflammatory demyelinating lesions.

EFFECTS OF RADIATION

• Maximal permissible radiation dose: The dose of radiation which if received each year for a 50 yrs working

life time would not be expected to produce any harmful effect.

• The LD50/30 (i.e., a dose that causes a 50% mortality rate at 30 days) is approximately 4 Gy[1 Gy=100 rad]

for whole-body exposure without medical support.

• For most of the conditions, a min. dose of about 1000 cGy is required for whole body irradiation.

• Whole- body exposure to doses >9-10 Gy is almost always fatal.

• In addition to the GI syndrome associated with very large exposures, patients may develop a neurovascular

syndrome; the latter dominates with whole- body doses >20 Gy.

• With medical support, the LO50/30 ranges between 8 and 10 Gy.

• The recommended occupational limit of maternal exposure to radiation from all sources is 500 mill Rads

for entire 40 weeks of gestation

• 10 days rule advices that any x ray examination involving the abdomen of a women of child bearing age

should be carried out within 10 days of menstruation.

• Deterministic effects: develop due to cell killing by high dose radiation.

• Stochastic effects: develop due to mutation effect of low dose radiation.

• Fetus is most sensitive to the effects of radiation during 8 – 15 weeks of gestation.

• Amount of radiation received from out space = 0.1 rad/year. Additional permissible dose = < 5 rads/ year.

• Radiation exposure: CT scan> Bone scan> X ray

• No radiation hazard: MRI & USG.

Latest ICRP recommendations for maximum permissible dose for various groups are:

• Occupational exposure(radiation workers) � 50 mSv/year

• Public (in general) � 20 mSv/year

• Pregnancy � 40.5 mSv for declared term

II. NORMAL FEATURES

View (Chest- X-ray) Structure seen

RAO (Right Anterior Oblique) Rt lung, Lt. atrium, Gall bladder ,Mitral valve

Left Anterior Oblique Tracheal bifurcation

Right Posterior Oblique Right retro cardiac space

Right decubitus view Right middle lobe of the lung

Lardotic view Apex, Lingual lobe

Reverse lardotic view Interlobar effusions

View Structure seen

Cald well (Occipito-Frontal)

view

• Superior orbital fissure ,foramen rotundum & superior margin of

• orbit

• Lamina papyracea, Maxillary sinus, ethmoid sinus, frontal sinus

Water (O-M: Occipito mental)

view

• Maxillary sinus, sphenoid sinus,-frontal sinus

• Intra Temporal fossa, zygoma & zygomatic arch

Basal submentovertical view • Sphenoid, posterior ethmoid , maxillary sinus, Zygoma & zygomatic

arch

• Mandible along with coronoid & condyloid process

Holman Miller sign (Antral sign): anterior bowing of the posterior wall of the maxillary antrum seen on lateral skull

films.

SPECIFIC VIEWS IN RADIOLOGY:

Features View Features View

Supraorbital fissure Cald well view Patella Skyline view

Recurrent shoulder

dislocation

Strikers view Minimal pleural effusion Lateral Decubitus

Sella turcica Lateral skull view Pneumothorax PA view in full

expiration Scaphoid Oblique view Internal auditory meatus Periorbital view

CARDIAC BORDERS

THE BASE OF HEART: forms the posterior surface. It is formed mainly by the left atrium and by small part of right

atrium.

MEDIASTINAL/ HEART BORDER ON X-RAY:

Right Border: Formed by superior vena cava, Rt atrium, Inferior vena cava

Left Border: Formed by Aortic arch, Left ventricle, Main pulmonary artery, Left atrial appendages.

• The left heart is formed by the main pulmonary artery and heart (left atrial appendage and left ventricle)

• The knob-like shadow of the aortic arch in superior mediastinum is formed by the posterior part of arch,

which is absent or deformed in coarctation of aorta.

• A small "nipple" may occasionally be seen projecting laterally from aortic knuckle or knob due to the

presence of left superior intercostal vein and this normal nipple should not be misinterpreted as adenopathy

(aortopulmonary window). Below the aortic knuckle or knob is a concavity, the pulmonary bay, the floor of

which is formed by the main pulmonary artery beyond the pulmonary valve.

• The pulmonary bay may be filled in by PDA.

• Below the pulmonary bay, the left ventricle forms the left heart border.

• Just below pulmonary bay is the left bronchus, below which is the left atrial appendage, not forming a

discrete shadow unless enlarged, and below that is the level of right ventricular infundibulum, azygous vein

lesion on right side and does not contribute to left heart border.

• However, a coronary artery aneurysm can cause abnormal bulging of left heart border.

RADIOLOGICAL FEATURES OF INTESTINE

Useful differentiating features B/W SI & LI includes Size & distribution of loops

• Dilated small bowel loops are numerous & arranged centrally in the abdomen

• Loops show small radius of curvature & the presence of solid feces is the only reliable sign that the loop is

large bowel.

• The other signs can be misleading.

Features Small bowel Large bowel

Haustra Absent Present

Valvulae conniventes Present in jejunum Absent

Number of loops Many Few

Distribution of loops Central Peripheral

Diameter of loops Small Large

Radius of curvature of loop 30-50mm 50mm

Solid feces (only reliable sign) Absent May be +

III. SIGNS IN RADIOLOGY

RADIOLOGICAL SIGNS OF THORAX

SIGN/ SPECIFIC FEATURE SEEN IN

Meniscus/moon/air crescent/double arch

sign/combo sign/water lilly/camalotte

sign/serpent sign/ rising sun sign/ empty cyst

sign

Hydatid cyst of lung

Popcorn calcification Hamartoma, Mediastinal nodes of histoplasmosis

Westermark sign, Hapton's hump, Palla sing

Fleishner lines, Felson's sign

Pulmonary thrombo-embolism

Sail sign, Mulvay wave sign, Notch sign Thymic enlargement

Comet tail sign Rounded atelectasis

Golden S sign Right Upper Lobe collapse secondary to a central

mass Luftsichel sign, Broncholobar sign Left Upper Lobe collapse

Ring around artery sign

Continuous diaphragm sign

Tubular artery sign, Double bronchial wall

sign

V sign of Naclerio, Spinnaker sail sign

Pneumo-mediastinum

Deep sulcus sign, Visceral pleural line Pneumothorax

Thumb sign Epiglottitis

Steeple sign Croup

Air crescent sign, Monod sign Aspergilloma

Bulging fissure sign Klebsiella pneumonia

Batwing sign Pulmonary edema on CXR

Collar sign, Dependant viscera sign Diaphragmatic rupture

Feeding vessel sign Pulmonary septic emboli

Finger in glove sign ABPA

Halo sing Aspergillosis

Head cheese sign Subacute hypersensitivity pneumonitis

Juxtaphrenic peak sign Right Upper Lobe atelectasis

Reversed halo sign Cryptogenic organized pneumonia

Saber sheath sign COPD

Sandstorm lungs Alveolar microlithiasis

Signet ring sign Bronchiectasis

Superior triangle sign Right Lower Lobe atelectasis

Split pleura sign Empyema

Tree in bud sign on HRCT Endo bronchial spread in TB

CHEST X-RAY OF ECHINOCOCCUS

• Oval mass

• Meniscus/ moon/ crescent / double arch sign

• Rising sun sign/empty cyst sign

• Water Lilly / camalotte sign

• Serpent sign/ Cumbo sign

Superior rib notching Inferior rib notching

• Poliomyelitis, Osteogenesis imperfect

• Restrictive lung disease

• Neurofibromatosis, Marfan's syndrome

• Connective tissue disease- RA, SLE,

Scleroderma

• Sjogren's syndrome, Hyper parathyroidism

• Coarctation of Aorta [M/C cause]

• Pulmonary- oligemia/ A-V malformation

• Aortic thrombosis

• Subclavian obstruction

• Tausig Blalock operation

RADIOLOGICAL SIGNS OF CARDIOVASCULAR SYSTEM

Radiological feature Disorder

Four bump heart MS/ MR due to left atrial appendage

enlargement

Glassy heart on ECHO Amyloidosis

Double cardiac shadow, Double density sign, Bedford

sign

Left atrial enlargement

Dock's sign, E-sign , figure of 3 sign, reversed E sign,

inverted 3 sign

Coarctation of aorta

Double aortic knuckle Aortic dissection

Jug handle appearance Primary pulmonary hypertension

Maladie de roger effect Small VSD

Hilar dance (pulmonary plethora) ASD

Box shaped heart Tricuspid Atresia

Water bottle/ flask shaped heart/ leather bottle/pear

shaped/money bag heart/ purse like heart/ Epicardial

fat pad sign

Pericardial effusion

Coeur en sabot i.e. boot shaped heart Tetralogy of Fallot

Spade like deformity on ECHO Atypical HOCM

Egg in cup appearance, square root sign Constrictive pericarditis

Inverted moustache sign Mitral stenosis

Egg on side appearance ,Egg shaped heart, Egg in string D- Transposition of great arteries (D- TGA)

Convex left heart border L-TGA

Ground glass ventricular septum Hypertrophic Obstructive Cardiomyopathy

(HOCM)

Straight left upper cardiac border Ebstein's Anomaly

Concave main pulmonary segment & right aortic arch Persistent Truncus arteriosus

Snowman sign, Figure of 8 sign, Cottage loaf sign Total Anomalous Pulmonary Venous

Connection (TAPVC) — supra cardiac variety

Goose neck sign Atrioventricular septal defect

Tubular heart Emphysema

Stag antler / hands up sign CCF

Schimitar sign / Turkish sword appearance Congenital venolobar syndrome

Sitting duck heart Persistent truncus arteriosus

Yin yang sign Pseudo aneurysms

Small heart sign Tension pneumopericardium

High attenuating crescent sign Impending rupture of abdominal aortic

aneurysm

Draped aorta sign Contained rupture of abdominal aortic

aneurysm

RADIOLOGICAL SIGNS OF ALIMENTARY TRACT

Sign Disease

Single Air Bubble sign Pyloric stenosis/ obstruction

Double bubble sign Ladd band / Malrotation, Annular

pancreas

Duodenal atresia/ stenosis/ web/

duplication cyst

Multiple air fluid level Ileal obstruction

Triple bubble sign Jejunal obstruction

String of beads sign, Stepladder appearance, Concertina effect, Small bowel obstruction

Candy-cone appearance, Snake head appearance on barium study

Gas under diaphragm, Liver edge sign, Falciform ligament sign, Gall

bladder sign, Diaphragmatic muscle slip sign/ leaping dolphin sign,

Luscent liver sign, Anterosuperior bubble sign

Doge's cap sign, Riglers double wall sign, American footballs sign,

Cupola's sign, Triangle sign, Visible transverse mesocolon sign,

Visible small bowel mesentery sign, Pneumo-omentum/ pneumo-

mesocolon, Urachus sign, Medial/ lateral umbilical fold sign,

Inverted V sign, pneumoscrotum

Pneumoperitoneum

Birds beak appearance (barium meal), hurst phenomenon Oesophageal Achalasia

Cork screw appearance (barium meal) Diffuse oesophageal spasm

Beak sign, Double track or Tram track sign, Shoulder sign, string

sign, diamond sign, Twinning recess, pyloric test, test sign,

mushroom sign, caterpillar sign

Hypertrophic pyloric stenosis

Seagull / Mercedes Benz/ Crow feet sign Radiolucent gall stone with gas

Multiple gas fluid level (step ladder pattern) Intestinal obstruction

Cigar bundle appearance on X- ray, Winding highway railway tract

on USG & Medusa Head colonies on CT scan

Round worm

Whirlpool sign in USG, corkscrew sign Midgut volvulus

Coffee Bean sign, Bent tyre tube sign, Liver overlap sign, Pelvis

overlap sign, Left flank overlap sign

Sigmoid volvulus

Shark mouth appearance Ileocecal valve

Lead pipe appearance/ Stippled appearance/ Pipe stem appearance Ulcerative colitis

String of Kantor, Bull's eye or Target lesion Crohn's disease (regional Ileitis)

Thumb printing sign Ischemic colitis (Also in amoebic &

ulcerative colitis)

Saw tooth appearance (on barium enema)/ Champagne glass sign,

Bowlers hat sign

Diverticulitis of colon

Apple core lesion & Napkins sign (on barium enema) Ca-colon

Pincer sign, Claw sign, Coiled spring appearance, target sign,

Meniscus sign, crescent in Doughnut Sign, Pseudokidney sign,

Sandwich sign, Hay fork sign

Hamburger sign, Signa de dance, Dance sign

Intussusception

Bubbly / frothy/ soap bubble/apple sauce appearance Meconium ileus

Pulled up caecum/ obtuse ileo caecal angle/ filling defect/

incompetent ileocaecal valve Fleishner sign, Inverted umbrella

defect, Steirlin sign, Amputed cecum, Goose neck deformity

Ileocaecal TB

Hamptons line Benign gastic ulcer

Carmens meniscus sign;Kirkland complex Malignant gastric ulcer

Apple peal appearance Ileal atresia

Moulage sign Coeliac sprue

Arrowhead sign, Rovsings sign Acute appendicitis

Straight line sign HCC

Comet-tail sign on USG Adenomyomatosis of gall bladder

Central dot sign Caroli's disease

Triangular cord sign Biliary Atresia

Shaggy esophagus Esophageal candidiasis

Accordion sign Pseudomembranous colitis

Champagne sign Emphysematous cholecystitis

Cluster of grapes sign Pneumatoses cystoides coli

Corkscrew sign Midgut volvulus

Dependant viscera sign Diaphragmatic rupture

Fat ring sign Mesenteric panniculitis

Molar tooth sign Extraperitoneal bladder rupture

Ribbon bowel appearance on barium Graft versus host disease

Spokewheel sign Small bowel volvulus

Straight line sign on PET Peritoneal carcinomatosis

RADIOLOGICAL SIGNS IN PANCREATIC DISORDERS

• In chronic pancreatitis, cholangio pancreatography (ERCP) is the most sensitive imaging modality.

• The positive findings are: Chain of lakes appearance, String of pearls appearance, Beading appearance.

• On x-ray numerous irregular calcification are pathognomic of chronic pancreatitis.

• String of beads sign -small bowel obstruction.

• Double bubble sign - in annular pancreas.

Disease Pathognomic sign

Chronic pancreatitis

(On ERCP)

Beaded appearance, Sting of pearls appearance, Rat tail stricture of CBD,

Chain of lakes appearance

Acute Pancreatitis

(Abdominal X-Ray)

Renal Halo sign, Gasless abdomen, Colon cut off ,Sentinel loop

Carcinoma pancreas Double contour of medial border of duodenal C loop, Double duct

sign(ERCP) dilated/ widened Duodenal-C loop, mucosal irregularity,

Rose

thorning of medial wall of 2nd part of duodenum, Scramble Egg

appearance, Inverted/ Reverse-3 sign of frost berg

BLUNT TRAUMA

• Spleen is the most commonly injured organ in blunt injury abdomen.

• Contrast- enhanced CT is the investigation of choice for detecting splenic injuries.

• Kehr sign (after elevating foot end, referred pain over left shoulder d/t irritation of under surface of

diaphragm by blood) is seen in splenic ruptures.

• On X- ray:

� Fracture of left lower ribs,

� Obliteration of splenic & psoas shadows

� Elevation of left diaphragm

� Indentation of stomach & presence of free fluid between coils of intestine.

PHEOCHROMOCYTOMA

• Arises from para ganglion cells of ANS.

• Most common site of origin –adrenal medulla

• Most common extra-adrenal site: organ of zuckerkandl

• Investigation of choice for: is CT scan followed by MRI.

• IOC for locally recurrent, metastatic, Ectopic & Extra – adrenal pheochromocytoma is MIBG scan (Using I123

or I131)

• Sensitivity: MIBG > MRI > CT > USG

RADIOLOGICAL SIGNS OF EXCRETORY SYSTEM

Radiological feature Disease

Rim/ crescent sign & Soap bubble appearance Hydronephrosis

Flower vase appearance of ureter Horse shoe kidney

Yo yo phenomenon Duplex ureter of kidney

Putty kidney, autonephrectomy, moth eaten appearance,

Kerr's kink, irregular cavity, phantom calyx

TB kidney

Corkscrew ureter, beaded ureter, pipe stem ureter TB ureter

Golf hole ureter TB bladder

Drooping flower appearance Ectopic ureter

Cobra head appearance/ adder head/ Spring onion

appearance

Ureterocele

Egg in cup appearance, Signet ring sign on IVU

Lobster claw sign on IVU, Ball on tee sign on IVU

Analgesic nephropathy causing papillary

necrosis

Thimble bladder Tubercular/ chronic cystitis

Fir tree appearance/pine cone bladder or christmas tree

bladder

Neurogenic bladder

Sandy patches Schistosomiasis of bladder

Chalice/ Bergman sign Ureteric dilatation distal to neoplasm

Fish hook bladder BPH

B/L spider leg appearance, Swiss- cheese/ black

nephrogram,

Autosomal dominant Polycystic kidney

Sun burst nephrogram/ Patchy chaotic nephrogram Autosomal recessive Polycystic kidney

Renal fascia sign Acute renal artery occlusion

Bunch of flowers appearance, Paintbrush appearance Medullary sponge kidney

Edling sign Pseudoureterocle

Wind in the sail appearance, Keyhole appearance Posterior urethral valves

Sunburst appearance, Bladder in bladder appearance,

Molar tooth sign

Extra peritoneal bladder rupture

Nubbin sign Reflux nephropathy involving the lower

pole of a duplicated collecting system

Goblet sign, Bergmans coiled catheter sign Ureteral transitional cell carcinoma

• Pseudo ureterocele: malignant stricture of distal ureter.

INVESTIGATIONS IN RENAL TUBERCULOSIS

PLAIN FILM

• Focus on calcification, which is seen in 25-45%, at various stages of disease.

o triangular in papillary necrosis

o focal or amorphous : putty kidney (endstage)

• Fluoroscopy - IVP

• Traditional plain film IVP is quite sensitive to renal tuberculosis with only 10% of affected patients having

normal imaging. Features include:

o Parenchymal scars 50%

o Moth eaten calyces: early finding

o Irregular caliectasis

o Phantom calyx

o Hydronephrosis

• Other lower urinary tract signs include:

o Kerr kink 3

o Saw-tooth ureter

o Pipe-stem ureter

o Beaded or corkscrew ureter

o Thimble bladder

ULTRASOUND

Sonographic appearances are non-specific and variable, depending on the stage of disease.

Early

• Normal kidney or small focal cortical lesions with poorly defined border + / - calcification.

• Progressive papillary destruction with echogenic masses near calyces.

• Distorted renal parenchyma.

• Irregular hypoechoic masses connecting to collecting system; no renal pelvic dilatation.

• Mucosal thickening + / - ureteric and bladder involvement.

• Small, fibrotic thick-walled bladder.

• Echogenic foci or calcification (granulomas) in bladder wall near ureteric orifice.

• Localised or generalised pyonephrosis.

End stage

• Small, shrunken kidney, "paper-thin" cortex and dense dystrophic calcification in collecting system.

• May resemble chronic renal disease.

Ultrasound is less sensitive than CT in detection of:

• Calyceal, pelvic or ureteral abnormalities.

• lsoechoic parenchymal masses.

• Small calcifications.

• Small cavities that communicate with collecting system.

CT

• CT is the most sensitive modality for visualizing renal calcifications.

• CT IVP is more sensitive at identifying all manifestations of renal tuberculosis.

Early

• Papillary necrosis (single or multiple) resulting in uneven caliectasis

• Progressive multifocal strictures can affect any part of the collecting system

• Generalised or focal hydro nephrosis.

• Mural thickening and enhancement

• Poorly enhancing renal parenchyma, either due to direct involvement or due to hydronephrosis

End stage

• Progressive hydronephrosis results in very thin parenchyma, mimicking multiple thin walled cysts.

• Amorphous dystrophic calcification eventually involves the entire kidney (known as putty kidney).

RADIOLOGICAL SIGNS IN ORTHOPEDICS

Classical radiological feature Condition

Sunray appearance, Codman's triangle Osteosarcoma

Onion peel appearance Ewing's sarcoma

Soap bubble appearance Osteoclastoma

Speckled/ Mottled/ Patchy calcification Chondrosarcoma

Wormian bones Osteogenesis imperfect

Trethowan's sign Slipped capital femoral epiphysis

Aneurysmal sign TB Spine

Honey comb appearance Adamantinoma

Moth-eaten appearance in bone (permeative

process of bone)

• Multiple myeloma

• Primary lymphoma of bone (reticulum cell

sarcoma)

• Ewing sarcoma

• Infection

• Eosinophilic granuloma

• Malignant fibrous histiocytoma

• Metastases, especially Burkitt lymphoma

• Mycosis fungoides

Driven snow appearance Pindborg tumor

IMPORTANT FEATURES:

Sutural diastasis, copper beaten skull Raised intracranial tension

Bracket calcification Lipoma of corpus callosum

Dawson fingers on brain MRI Multiple sclerosis

Tram track/ rail road track gyriform cortical calcifications Sturge weber syndrome

Hyperdense MCA sign, Insular ribbon loss sign

Light bulb sign on MR diffusion

Acute stroke

Pseudo delta sign, Cortical vein sign SAH

Sugar icing appearance , Zuckerguss appearance Medulloblastoma

Dural tail sign, Mother-in-law sign, Sunburst/ spoke wheel

tumour vascularity

Meningioma

Geographic lytic skull, Vertebra plana Eosinophilic Granuloma

Multiple punched out lesion in skull vault Multiple myeloma

Hair-on-end skull vault Thalassemia

Picture frame vertebra Pagets disease

Fish mouth vertebra Sickle cell anemia, Homocystienuria

Bat wing 4th

ventricle Joubert syndrome

Boxcar ventricles Huntington's disease

Clover leaf skull Thanatophoric dysplasia

Cord sign, Empty delta sign Intravertebraldural sinus thrombosis

Corduroy appearance, Polka dot appearance Intravertebral hemangioma

Eye of the tiger sign Hollaverden spatz syndrome

Flat tyre sign, Umbrella sign Ruptured globe

Figure of 8 appearance Pachygyria

Fish vertebrae Sickle cell disease

Hot cross bun sign Multisystem atrophy

Inverted napoleon hat sign Spondylolisthesis

Scottie-terrier dog sign Spondylolysis

Mount fuji sign Tension pneumocephalus

Reversal sign Anoxic brain injury

Salt and pepper pattern Vascularity in glomus tumours

Sandwich vertebra Osteopetrosis

Strawberry skull on antenatal USG Trisomy 18

Tau sign Persistent trigeminal artery

X-ray features of Osteosarcoma:

• Area of irregular destruction of metaphyses

• Erosion of the overlying cortex

• New bone formation in the matrix of the tumor

• Irregular periosteal reaction

• Codman's triangle

• Sun-ray appearance

Disease

Radiological feature

Osteosarcoma Variable mixture of radio opacities & radiolucency (hall mark)

Sun burst/ sun ray appearance (11nd). Codman's triangle (non specific)

Osteoclastoma Ewing's

sarcoma

Paget's disease

Soap bubble appearance

Onion peel appearance

In osteo lytic hot phase: Advancing wedge/ Blade of grass/ candle flame appearance

In mixed phase: cotton ball skull, picture frame vertebrae

In cool phase: bowing, bone density increased

Features Disorders

Geographic lytic skull /Vertebrae

plana

Eosinophilic granuloma/ Hans- Schuller Christian disease/Histiocytosis

Multiple punched out lesions Multiple myeloma

Chicken wire calcification Chondroblastoma (CODMAN'S TUMOR)

Hair on end skull vault Thalassemia, sickle cell anemia

Erosion of dorsum Sella Raised ICT (earliest & most common)

Salt peeper skull Hyperparathyroidism

Silver beaten app. Of vault Raised ICT

Sunray calcification with spicules Meningioma

Epiphyseal dysgenesis, Punctate/ fragmented epiphysis Hypothyroidism

Epiphyseal enlargement with squaring and angulation Juvenile chronic arthritis

• Small epiphysis marginated by sclerotic rim (Wimberger sign)

• Radiodense calcification at growing metaphyseal end (Frankel's

line),

• Radiolucent zone due to lack of mineralization of osteoid

(Trumerfeld zone),

• Pelkan's spur & Subperiosteal hemorrhage

Scurvy

Epiphyseal widening, Cupped & frayed metaphysic Rickets

PUNCHED OUT LESIONS OF SKULL

• Infectious Disorders

o Fungal osteomyelitis

o Blastomycosis

o Coccidioidomycosis

• Granulomatous, Inflammatory Disorders

o Sarcoidosis

o Hand-Schuller-Christian syndrome

• Neoplastic Disorders

o Metastatic bone disease

o Adenocarcinoma of prostate

o Multiple myeloma

• Metabolic, Storage Disorders

o Gout

o Histiocytosis X

• Congenital, Developmental Disorders

o Bony cystic angiomatosis

• Hereditary, Familial, Genetic Disorders

o Ollier's enchondromatosis

• Vegetative, Autonomic, Endocrine Disorders

o Primary Hyperparathyroidism

• Reference to Organ System

o Systemic mastocytosis

HAIR ON END SKULL

(HINEST)

• Hereditary spherocytosis

• Iron deficiency anemia

• Neuroblastoma

• Enzyme (G-6PD) deficiency

• Sickle cell disease

• Thalassemia major

Radiological signs of vertebral diseases:

Vertebra piano Eosinophilic Granuloma

Rugger jersey spine Osteopetrosis, osteodystrophy due to CRF

Fish mouth vertebra Homocystinuria, Sickle cell anemia

Cod mouth vertebra Osteoporosis, osteomalacia &

Hyperparathyroidism

Picture frame vertebra, "cotton wool," or osteoporosis

circumscripta

Paget's disease

Calcification of intervertebral disc Alkaptonuria

CAUSE OF HAIR ON END SKULL VAULT

Hemolytic anemias: Thalassemia major/ Cooley's anemia (most common) & Sickle cell anemia, Neoplastic:

Hemangioma: Meningioma; Metastasis

Others: Cyanotic heart disease; Iron deficiency anemia; Ewing's sarcoma, syphilis, infantile cortical hyperostosis

(Caffey's disease).

RADIOGRAPHIC FINDINGS IN ARTHRITIS

Disease State Findings in Hip or Knee

Osteoarthritis Joint space narrowing, subchondral sclerosis, osteophytes,

subchondral cysts

Hip: Superior or medial narrowing

Knee: Early narrowing on Rosenberg views; flattening of femoral

condyles

Rheumatoid arthritis or SLE Uniform joint narrowing, erosion near joint capsule

Ankylosing spondylitis Osteopenia, Osteophytes, ankylosis of sacroiliac joints

Gout Tophi, erosions

Calcium pyrophosphate

deposition disease

Calcification of menisci and hyaline cartilage

Osteonecrosis Crescent sign, spotty calcification

Gaucher disease Erlenmeyer flask appearance, distal femora

Neuropathic joint Four Ds: destruction, debris, dislocation, densification (sclerosis,

hypertrophy)

Hemophilic arthropathy Epiphyseal widening, sclerosis, cysts, joint space narrowing

• Erosive osteoarthritis: gull's wing/ angel wing appearance.

A B C

FIG: BAMBOO SPINE APPEARANCE OF ANKYLOSING SPONDYLITIS

Figure: The characteristic differences between osteoporosis, osteomalacia, and hyperparathyroidism in the spine.

(A) Osteoporosis manifests as a biconcave vertebral body with prominent vertical trabeculae.

(B) Osteomalacia manifests as uniform deossification with a loss of trabecular detail and anterior wedge-shaped

compression fractures.

(C) The "rugger jersey" spine of secondary hyperparathyroidism manifests as increased density adjacent to the

vertebral end plates.

Shiny corner sign Ankylosing spondylitis

Pseudo shiny corner sign Degenerative spondylosis

Waldenstrom sign Osteoarthritis hip

Patellar tooth sign Patella-femoral joint OA

Movie sign Chondromalacia patellae

Licked candy stick appearance, Jigsaw vertebra

Tumbling building block spine

Atrophic neuropathic arthritis

Migrating mouse sign

Apple core deformity of hip

Synovio-chondro-metaplasia

Cocktail sausage digit, spindle digit, ivory phalanx, Pencil in cup/

pestle and mortar/ mushroom and stem/ balancing pagoda/ cup in

saucer appearance, opera glass hand, whittling effect, mouse ears

sign

Psoriatic arthropathy

Bone in bone appearance, Sandwich vertebra, Rugger-jersey spine

Erlenmeyer flask deformity

Osteopetrosis

Flowing candlewax appearance Melorrhosteosis

Hot cross bun skull Cliedo-cranial dysplasia

Paired posterior iliac horns nail patella syndrome

Elephant ears, Mickey mouse ears, Clinodactyly Downs syndrome

Bare orbit, Empty orbit sign Neurofibromatosis-1

Hook shaped vertebral bodies, Cut corner sign MPS l/ hurler syndrome

Central beaking of vertebrae, Ape like pelvis MPS IV/ morquio syndrome

Gull wing sign Erosive OA

Steinberg sign Marfan syndrome

Pelkan spur/ Pencil thin cortex/ Corner sign of Parke

Trummerfield zone of rarefaction/ White line of Frankel/ Wimberger

sign

Scurvy

Looser zone/ lines, Milkmans fracture, Osteoid seams

Increment fracture, Umbau zones

Osteomalacia

Rugger jersey spine/ Brown tumours/ Pepper pot skull/ Subperiosteal

resorption of phalanges

Hyperparathyroidism

Cotton wool appearance, Candle flame/ blade of grass lysis

Picture frame vertebra

Pagets disease

Penumbra sign Brodies abscess

Inverted napoleon hat sign, Gendarme's cap sign

Bowline of Brailsford, Broken collar/ neck of scotty dog, Scottish

terrier sign

Spondylolisthesis

Button sequestrum, Floating teeth sign, Hole with hole appearance Histiocytosis-X

Swan neck deformity, Boutonniere deformity, Hitch hiker thumb

Hammer toes

RA

Trident hand, Tomb stone iliac bone, Cheuron sign Achondroplasia

Intervertebral disc calcification Alkaptonuria

Pear shaped vertebra Spondylo-epiphyseal dysplasia

congenita Hump shaped vertebra, Heaped up vertebra Spondylo-epiphyseal dysplasia

tarda Inferiorly beaked vertebra MPS l/ hurler syndrome

Centrally beaked vertebra MPS IV/ hunter syndrome

Biconcave lens vertebra Osteogenesis imperfecta

Spool shaped vertebra Pyknodysostosis

Bullet nose vertebra Achondroplasia

Vertebra with central anterior tongues Pseudochondroplasia

H shaped vertebra Thanatophoric dwarfism

FEATURES OF BRAIN HEMATOMA ON CT SCAN

Extradural Subdural Subarachnoid: (SAH)

• Biconvex (Lens

shaped/

lenticular)

• Hyper dense

in acute cases.

• Hypo dense in

Chronic cases

• Crescent

(Concavo-

Convex)

• Hyper dense

(<2 weeks)

• Isodense (2-4

wks)

• Hypo dense (> 4

wks)

• Non- contrast CT is investigation of choice for diagnosing

the hematoma.

• Four vessels (both carotids & both vertebra's) Digital

subtraction angiography (DSA) is the investigation of

choice for determining etiology.

• The hallmark of SAH is blood in CSF detected by lumbar

puncture.

• Lysis of blood in CSF causes Xanthochromia which is peak

at 48 hours.

• Most common intracranial lesion after head injury is subdural hematoma.

• Most common cause of SAH is head trauma.

• Investigation of choice for SAH is Non- contrast CT

• M.C. cause of spontaneous SAH is ruptured saccular aneurysm.

Diffuse axonal injury (DAI)

• It is caused by shearing of the white matter, often at the gray-white junction.

• May be due to the differing tissue density or fixation between two structures in differing response to

rotation, acceleration, and deceleration.

• Detection is often associated with changes in the lobar white matter, brainstem, and corpus callosum with

ovoid or elongated regions of decreased density.

• Patients usually present with severe impairment of consciousness from the moment of impact.

• MRI (FLAIR or T2 weighted) - most useful in defining the extent of axonal shearing and non-hemorrhagic

injury.

• CT results -often negative, but acute areas of petechial hemorrhage & cerebral edema have been seen in

early stages.

IMPORTANT SIGNS IN RADIOLOGY

• Puff of smoke sign: Moyamoya disease

• Polka dot sign: vertebral hemangioma

• Dripping candle wax sign: melorheostosis

• Accordion sign: pseudomembranous colitis

• Air crescent sign: aspergilloma

• Angelwing sign: pulmonary edema [bat wing sign]

• Air bronchogram sign: pneumonia

• Anteater's nose sign: tarsal coalition

• Apple core appearance: Ca Colon

• Blade of grass sign [Flame sign]: Paget's disease

• Bevelled edge appearance: eosinophilic granuloma

• Bowler hat sign, Mexican hat sign: colonic polyp

• Black pleura sign: alveolar microlithiasis

• Bird of prey sign: sigmoid volvulus

• Bone within bone appearance: osteopetrosis

• Breast within breast appearance: hamartoma of breast

• Bear paw sign: xanthogranulomatous Pyelonephritis

• Pelvic brim sign: Paget's disease

• Bite sign, crescent sign: avascular necrosis of femur

• Bulging fissure sign: Klebsiella pneumonia

• Banana sign/ lemon sign: neural tube defect

• Carman meniscus sign: Ca stomach

• Cotton wool appearance: Paget disease

• Cobra head appearance: Ureterocele

• Coblestone appearance: Crohn's disease

• C sign: tarsal coalition

• Coffee bean sign: sigmoid volvulus

• Colon cut off sign: acute pancreatitis

• Comb sign: Crohn's disease

• Comet tail sign: round atelectasis

• Comet sign: pelvic phlebolith

• Continuous diaphragm sign: pneumomediastinum

• Corduroy sign: vertebral hemangioma

• Corkscrew oesophagus: diffuse esophageal spasm

• Crazy paving sign: pulmonary alveolar proteinosis

• Champagne glass pelvis: Achondroplasia

• Celary stalk sign: rubella, osteopathia striata, anterior cruciate ligament degeneration

• Corkscrew sign: midgut volvulus

• Cottage loaf sign: diaphragmatic rupture

• Codfish vertebra: sickle cell disease

• Jerry Thomas sign: scapho lunate dislocation

• Dense MCA sign: hyperacute stroke(CT sign)

• Double bubble sign: duodenal atresia, annular pancreas

• Double density sign: enlarged left atrium (mitral stenosis)

• Doughnut sign: testicular torsion(nuclear scan)

• Draping aorta sign: leaking abdominal aortic aneurysm

• Deep sulcus sign: pneumothorax

• Double duct sign: periampullary, pancreatic Ca

• Erlenmeyer flask deformity: Gaucher's disease, thalassemia, osteopetrosis, pyle's disease

• Fat pad sign: pericardial effusion

• Foot ball/ falciform ligament sign: Pneumoperitoneum (infant)

• Fallen lung sign: fracture bronchus

• Fishhook ureter: BPH

• Flat waist sign: left lower lobe collapse

• Gloved finger sign: allergic bronchopulmonary aspergillosis

• Gull wing sign: erosive osteoarthritis

• Goose neck sign: endocardial cushion defect

• Hampton line: benign gastric ulcer

• Hampton hump: pulmonary infarction

• Honda sign: sacral insufficiency fracture

• Hide bound appearance: scleroderma

• Hair on end appearance: hemolytic anemia

• Hot nose sign: brain death

• Holly leaf appearance: asbestosis

• Hot cross bun sign: multi system atrophy-C

• Half moon/ light bulb sign: posterior shoulder dislocation

• Head cheese sign: hypersensitivity pneumonitis

• Ivory vertebra: osteoblastic vertebral metastasis

• Insular ribbon sign: acute cerebral infarct

• Ivory phalanx: psoriasis

• Molar tooth sign: extra peritoneal bladder rupture

• Mercedes Benz sign: gall stone

• Micky mouse sign: Paget's disease

• Napoleon hat sign: spondylolisthesis

• 1-2-3 sign: Sarcoidosis

• Pie in the sky sign: urethral injury

• Pyloric teat, pyloric beak, caterpillar sign, double triple track sign, string sign: hypertrophic pyloric stenosis

• Rugger Jersey spine: secondary hyperparathyroidism

• Rigler sign: Pneumoperitoneum

• Rice grain calcification: cysticercosis

• Ring sign: renal papillary necrosis

• Sandwich sign: lymphoma

• Spine sign: lower lobe pneumonia

• String of beads sign: mechanical small bowel obstruction

• Stack of coins: scleroderma

• Trough sign: posterior shoulder dislocation

• Westermark sign: pulmonary embolism

• Yin yang sign: partly thrombosed aneurysm

• Wimberger's sign: congenital syphilis

IMPORTANT FACTS

• FARADAY CAGE: prevent the passage of electromagnetic waves. Contain Mu-copper foils which can be

applied as wall papers.

• Contrast used in CT: lohexol (non ionic),Metrizamide- not used now

• Dye of choice for myelography: lopamidol

• Pindborg tumor: calcifying Epithelial Odontogenic Tumor (CEOT)

• M/C cause of intra cranial calcification: Pineal body calcification

• M/c endocrine abnormality following intracranial radiotherapy: Growth hormone deficiency

• M/C calcifying brain tumor in child: Craniopharyngioma followed by oligodendroglioma

• Suprasellar calcification with cystic appearance: Craniopharyngioma

• M/C solid renal neoplasm in neonates: Mesoblastic nephroma

• M/C malignant abdominal neoplasm in children: Wilm's tumor (nephroblastoma)

• M/C malignancy in children: Leukemia > Brain tumors > Nephroblastoma

• M/C renal mass in childhood: Hydronephrosis > multicystic dysplastic kidney> Nephroblastoma

• Hyperparathyroidism: Brown's tumor (m/c in mandible), Subperiosteal erosion (Hallmark), Salt pepper

appearance & basket work appearance.

• Williams syndrome/ Idiopathic hypercalcemia of malignancy: Supravalvular aortic stenosis, Mental

retardation & Elfin facies(round faces with full cheeks & lips)

• Emergency radiotherapy given in:

o Neoplastic cardiac tamponade

o Acute epidural spinal cord compression

o Tumor lysis syndrome

o Severe hypercalcemia

o SVC syndrome.

• M/C radiation induced secondary cancer: Leukemia

• M/C radiation induced secondary cancer following treatment for head & neck cancers: Thyroid cancer

• Neutron beams are more effective in treating salivary gland tumors.

• Soap bubble appearance in abdominal x-ray -Meconium ileus

• Soap bubble appearance in head CT-Cryptococcal meningitis

• Soap bubble calcification in x-ray-Osteoclastoma

• Puffed rice appearance on CT-Scan head-neurocysticercosis

• Soap bubble cerebral calcification in head CT-Toxoplasmosis (Congenital)

COMMON CAUSES OF EGG SHELL CALCIFICATION OF NODES

• Egg shell calcification means peripheral rim calcification of lymph nodes.

• Pneumoconiosis (M.C): Silicosis (M.C), Coal workers pneumoconiosis: not seen in Asbestosis, berylliosis,

baritosis, talcosis.

• Sarcoidosis & Lymphoma following radiotherapy

• Rare causes are: Fibrosing mediastinitis, Fungal + Bacterial infections: histoplasmosis, Coccidiodomycosis,

Blastomycosis, Tuberculosis, Amyloidosis

TYPES OF CALCIFICATIONS:

Popcorn calcification Pulmonary hamartoma, Mediastinal nodes in acute histoplasmosis,

fibroadenoma

Pericardial calcification Constrictive pericarditis

Cardiac calcification Carcinoid syndrome

Basal ganglia calcification Idiopathic(M/C), Hypoparathyroidism

Egg shell calcification Silicosis, Sarcoidosis, TB, lymphoma after radiation

Rice grain calcification Cysticercosis

Tram track(rail road)calcification Sturge Weber syndrome

Calcification of menisci Pseudogout

Adrenal & ear pinna calcification Addison's disease

Cardiac wall calcification Endomyocardial fibrosis

Most common primary CNS neoplasm Glioblastoma multiforme

2nd

most common primary CNS neoplasm Meningioma

Most common intracranial germ cell tomour Germinoma

Most common mixed glioma Oligo-astrocytoma

Most common site of schwannoma Vestibular division on 8th nerve

Most common intracranial tumour in neonates Teratoma

M/C primary intracranial neoplasm in sellar/ parasellar

region

Pituitary adenoma

Most common intraaxial posterior fossa tumor in adults Metastasis from extracranial sites

Most common of all primary intracranial neoplasms Glioblastomamultiforme

Most common supretentorial neoplasm in adults Glioblastomamultiforme

Most common intracranial tumour to calcify Oligodendroglioma

Most common site of cellular ependymoma in brain 4th

ventricle

Most common nonglial primary brain tumour Meningioma

Most common intracranial extraaxial tumour Meningioma

most common spinal extradural neoplasm Metastasis

Most common benign spinal neoplasm Vertebral hemangioma

Most common malignant extradural neoplasm Metastasis

Most common spinal intramedullary tumour in adults Ependymoma

Most common spinal intramedullary tumour in children Astrocytoma

CEREBRAL RING ENHANCING LESIONS

DR MAGIC LNT

• Demyelinating disease

• Radiation

• Metastasis (2nd

m/c)

• Abscess

• Glioblastoma multiforme (m/c cause)

• Infarct

• Contusion

• Lymphoma

• Neurocysticercosis

• Tuberculoma

• Toxoplasmosis

• Syphilis

• Behcet disease

A B

Cysticercosis; contrast-enhanced CT. Sections at the levels of the third ventricle (A) and the lateral ventricles (B).

Lesions are at different stages of development: homogeneously enhancing ring with calcified scolex; some are

associated with vasogenic oedema.

A B

Tuberculoma: CT. Axial sections before (A) and after (B) IV contrast medium: a superficial mass slightly denser than

brain is surrounded by vasogenic oedema in the frontal and temporal lobes; it shows marked contrast enhancement.

IV. INVESTIGATION OF CHOICE

RADIO NUCLIDE IMAGING

• 99Tc is the most commonly used radiopharmaceutical, for imaging in nuclear medicine; it is used with

different ligands for imaging of different sites.

Radio nuclide Uses

Tc 99m

labeled serum albumin Detection of pulmonary embolism

Tc 99m

labeled RBC's Spleen imaging

Tc 99m

labeled DMSA Renal morphology

Tc 99m

labeled DTPA Measures GFR

Tc 99m

labeled HIDA/ PIPIDA Functions of hepato biliary tree

Tc 99m

labeled MAG-3 Diagnostic of transplant rejection

Thallium 201 chloride Cardiac imaging (cold spots in myocardial studies)

Ga-67 nitrate To detect tumours, inflammation, abscess cavities

COLD NODULE

• Area of decreased radio isotope intake.

• 15 — 20 % of cold nodules may be malignant.

• Multiple cold nodules with interfering regions of increased uptake indicates a multi nodular gland with low

incidence of associated malignancy.

HOT NODULE

• Area of increased radio-isotope uptake

• Almost never harbors malignancy, represent a benign condition

• Represents either autonomous or hypertrophic area

Exception: Warthin's tumor & oncocytoma- malignant tumour showing hot nodule on radionuclide scan

TECHNETIUM-99M BONE SCAN

• The bone scan labels the osteoblast activity with the radioactive tracer, technetium-99.

• An increase in osteoblastic activity results in the incorporation of more of the diphosphonate molecule into

the mineral matrix of bone, causing it to appear "hot" or "dark";

• Absence of osteoblastic activity produces a "cold" or photopenic ("photon poor") area, due to decreased

radiotracer localization and photon emission.

INDICATIONS:

• Malignant Tumors : Primary and Metastatic

• Benign Bone Tumors: Osteoid Osteoma

• Trauma: Occult Fractures, Domestic Violence/Abuse

• Infection: Osteomyelitis, Arthritis

• Metabolic diseases: Paget's , Bone (Avascular) Necrosis

• Soft Tissue diseases: Myositis Ossificans

• Unexplained bone Pain

"HOT" BONE SCAN:

• Seen in any disorder that results in increased bone formation.

• Areas of active bone metabolism, such as the epiphyseal growth plate, most metastatic bone lesions,

osteoarthritis and osteomyelitis.

• In normal cases, the "hottest" areas are those undergoing the most rapid growth, including the distal

femur, the proximal tibia, and the proximal humerus. In the adult, greater activity is seen in the axial

skeleton than in the appendicular skeleton

• Regional Hyperactivity may be due to:

o Normal bone growth and remodeling

o Increased blood flow(trauma, heterotopic ossification)

o Reactive osteoblastic activity (active infections, tumors)

o Reparative bone process(healing fractures, tumors, infections)

o Hyper-metabolic activity(metabolic disorders)

• Lesions that appear hot on bone scan include healing fractures and osteoblastic tumors, such as osteogenic

sarcoma.

COLD BONE SCAN:

• A loss of blood flow to the bone, or a bone infarction, can cause this type of spot.

• When a person suffers a bone infarction, the part of the bone that no longer receives blood can die, leading

it to collapse.

• Multiple myeloma may not show up on a bone scan because only osteoclastic activity is involved in the

majority of lesions.

• Malignant Tumors

o Lung (2-4%)

o Breast (5%)

o Renal (10%)

o Neuroblastomas (bone marrow metastasis)

o Thyroid (most cases)

o Multiple Myeloma (most cases)

• Bone Abscesses (they are surrounded by activity)

• Bone ischemia (AVN, sickle cell, etc.)

• Hemangiomas(normal or decreased activity)

BONE SCAN IN METASTATIC LESIONS:

• Most sensitive routine imaging modality to try and identify both sclerotic and lytic lesions.

• In most cases they demonstrate increased uptake (hot spot) although occasionally (in very aggressive purely

lytic lesions) a photopaenic defect (cold spot) may be visible.

SUPERSCAN:

• Greater than normal activity in the kidneys is most commonly due to urinary tract obstruction, and bilaterally

decreased activity most often reflects renal failure.

• An important exception to the latter is the absence of renal activity in the so-called superscan, in which

diffuse skeletal uptake is so avid that renal uptake is undercut.

• A common condition producing a superscan is diffusely metastatic prostate carcinoma.

INVESTIGATION OF CHOICE

USG CT-Scan HRCT MRI PET/SPECT

Cystic lesions,

fluid

accumulation

Adrenals, pancreas,

mediastinum,

calcification, cerebral

hemorrhage

Lung pathology like

bronchiectasis,

interstitial lung

disease

Posterior fossa,

spine CNS,

muscle, soft

tissue, joints,

etc.,

Occult

metastasis

INVESTIGATION OF CHOICE IN CARDIAC CONDITIONS

Cardiac conditions Investigation of choice

Aortic dissection: Stable patient

Unstable patient

MRI

Trans esophageal Echo with CT scan

Pericardial effusion Echo (Investigation of choice), CT/MRI (second choice)

Valvular disease Trans esophageal echo cardiogram

Constrictive pericarditis MRI

Coarctation of aorta Gadolinium-enhanced 3D MRA

Myocardial function Tc-Albumin scan

Cardiac tamponade/ Cardiomyopathy Echo cardiogram

• Gold standard test for ventricular function in heart: MRI.

INVESTIGATION OF CHOICE IN RESPIRATORY CONDITIONS

• Pleural effusion- lateral decubitus

• Pneumothorax - CXR PA view on full expiration.

• Bronchiectasis in ILD: HRCT

INVESTIGATION OF CHOICE FOR OTHER CONDITIONS

• Single Bone Metastasis — CT

• Multiple Bone Metastasis — Bone scan

• Spine Metastasis — MRI

• Avascular necrosis- MRI

• Bone Density/Osteoporosis- DEXA (Dual energy x ray absorptiometry)

• Aneurysm/ AV Fistula- Angiography

• Dissecting Aneurysm (Stable) - MRI (Unstable)-Trans oesophageal USG

• Pericardial Effusion- Echocardiography

• Lobulated pericardial effusion- MRI > CT

• Minimum Pericardial Effusion- Echocardiography

• Ventricular Function- Echocardiography

• Radiotherapy/Chemotherapy induced cardiotoxicity- Endomyocardial Biopsy

• Pulmonary Embolism- CECT> Pulmonary Angiography > V/Q Scan

• Interstitial lung disease(Sarcoidosis)- HRCT

• Bronchiectasis- HRCT scan

• Solitary Pulmonary Nodule- High resolution CT (HRCT)

• Posterior Mediastinal Tumor- MRI

• Pancoast Tumor (Superior Sulcus Tumor) — MRI

• Minimum Ascites/Pericardial effusion/Pleural effusion — USG

• Traumatic Paraplegia- MRI

• Posterior Cranial Fossa — MRI

• Acute Haemorrhage- CT

• Chronic Haemorrhage- MRI

• Intracranial Space Occupying Lesion- MRI

• Primary brain tumour- contrast MRI (Gold standard however remains to be biopsy)

• Metastatic brain tumor- (Gadolinium) contrast enhanced MRI

• Temporal Bone-CT

• SAH Diagnosis- unenhanced CT

• SAH aetiology- 4 vessel MR Angiography > CT Angiography > DSA

• Nasopharyngeal angiofibroma- CECT scan

• Acoustic neuroma- Gadolinium DTPA enhanced MRI

• Obstetrics- USG

• Calcifications- CT

• Blunt abdominal Trauma- CT

• Acute Pancreatitis- CT

• GERD- pH manometer > endoscopy

• Dysphagia- Endoscopy

• Congenital hypertrophic pyloric stenosis- USG

• Extrahepatic biliary atresia- perioperative cholangiogram

• Obstructive Jaundice/GB Stones- USG

• Diverticulosis — barium enema

• Diverticulitis — CT scan

• Renal TB (early) —IVP (Late)- CT

• Posterior Urethral Valve- MCU

• Ureteric stone- non contrast CT

• Renal Artery Stenosis- Percutaneous Angiography

• Extraintestinal Amoebiasis- ELISA

• Discrete swelling(solitary nodule) of thyroid- FNAC

• MRI is the investigation of choice for imaging traumatic spine (ex paraplegia). CT is second best investigation.

• The most important imaging modality in suspected or known acute head trauma is the noncontrast CT. CT is

superior to MRI for the detection of acute blood and fractures,

Small intestinal tumor CT contrast

Early renal TB IVP

Advanced renal TB CT> IVP> USG

Pregnant lady with abdominal mass MRI

Dental & TM joint pathology Ortho pantomography [OPG]

Meckel's diverticulum

• Most common type of omphalomesenteric duct remnant.

• Results from failure of the yolk sac to close during fetal life

• Present in 0.5-3% of the population.

• Occur 30-90 cm from the ileocaecal valve and range in size from 0.5 to 13 cm in diameter.

• About 20-40% cause symptoms.

• Complications: ulceration, bleeding, perforation, inflammation, intussusception, internal hernia, volvulus,

and adhesions.

• Ectopic gastric mucosa is present in the diverticulum in about 20% of all patients who present with bleeding

and in 95% of children who bleed.

• Radionuclide imaging with 99mtechnetium pertechnetate is more accurate (sensitivity-85%) in the

paediatric age group than in adults.

• Meckel's diverticula which haemorrhage contain ectopic gastric mucosa in 95% of cases and 99m

Tc

scintigraphy is useful in this subset of patients.

• A characteristic angiographic feature: demonstration of a persistent vitellointestinal artery in who present

with chronic gastrointestinal bleeding.

FOREIGN BODIES

• IOC: conventional film-screen radiography

• Glass objects: plain radiography, xeroradiography, CT and MRI.

• Gravel: all methods except MRI where ferromagnetic streak artefacts may obscure visualization. Plastic:

easily detected by MRI.

• Wooden foreign bodies, especially when wet, are only seen by CT and MRI.

• Xeroradiography does not have any benefit over plain radiography in identifying foreign bodies.

• FB in children: USG

GOLD STANDARD METHODS

For diagnosis of breast cancer Mammography

For staging of breast cancer Axillary lymph node dissection

For evaluation of a stable patient with suspected

vascular injury

Angiography

For diagnosis of GERD Ambulatory 24 hr pH monitoring

For the diagnosis of GI perforation Finding pneumoperitoneum

For diagnosis of Zollinger-Ellison syndrome Serum gastrin levels( most patients have

serum gastrin levels above 1000pennl)

For diagnosis of colonic mucosal disease Colonoscopy

For diagnosis of steatorrhoea Timed quantitative stool fat determination

For treatment of incontinence with an isolated

sphincter defect

Overlapping sphincteroplasty

For diagnosis and method of management of acute

arterial occlusion

Laparotomy

For confirmation of mesentric arterial occlusion Mesentric angiography

For diagnosis of celiac disease Small intestine biopsy

For identifying choledocholithiasis ERCP

For diagnosis of primary sclerosing cholangitis ERCP

For diagnosis of hepatitis C HCV RNA assay

For diagnosis of invasive amoebiasis ELISA

Of diagnosis of Klatskin tumor Cholangiography

For assessment of function of sphincter of Oddi Manometry

For assessing degree of liver injury and fibrosis Liver biopsy

For diagnosis of intraluminal bile duct abnormalities ERCP

For estimating resting energy expenditure Indirect calorimetry

For diagnosis of iron deficiency anemia Estimation of serum ferritin

For proving that the life span of red cell is decreased (

useful in hemolytic anemia)

Red cell survival study

For evaluation of stem cell transplantation therapy Hemopoietic stem cell transplantation

For diagnosis of acute pharyngitis Throat culture

For diagnosis of pertussis Culture of nasopharyngeal secretions

For diagnosis of DVT Contrast venography

For differentiating allograft rejection and reactivation

of disease after heart transplantation

Endo-myocardial biopsy

For diagnosis of otitis externa caused by p. Aeruginosa Technetium99 bone scan

For diagnosis of acoustic neuroma Gadolinium MRI

Investigation for diagnosis of shigella infection Isolation and identification of pathogen from

fecal material

For diagnosis of tuberculous meningitis Culture of CSF

For diagnosis of HSV encephalitis Brain biopsy (CSF PCR largely replaced brain

biopsy in recent times)

For diagnosis of histoplasmosis Fungal culture

For diagnosis of hypertrophic cardiomypathy and atrial

myxoma

Echocardiogram

For imaging heart valves and valve motion

abnormalities

2D echocardiography

For assessment of myocardial viability (identification of

ischemic or hibernating myocardium)

PET

For assessment of LV mass and volume MRI

For evaluation of renal arteries and identification of

renal artery lesions

Contrast arteriography

For evaluation of respiratory gas exchange ABG

For assessment of albuminuria 24 hr urine collection

For diagnosis of PNH Flow cytometry

For diagnosis of ATTR and other AF mutations DNA sequencing

For identifying and quantifying atherosclerosis in

cerebral arteries

X-ray cerebral angiography

For evaluating anatomy of arterio-venous

malformation

X-ray angiography

For diagnosis and classification of ataxia Genotype

For diagnosis of lung infection (radiotherapy induced)

in a cancer patient

Open-lung biopsy

For assessment of visual impairment Snellen's chart

For bacterial stain analysis Pulse-field gel electrophoresis

For resection of anterior and middle mediastinal

masses

Median or lateral thoracotomy

Of treatment of coarctation of aorta Surgical repair

For evaluation of coronary artery disease Cardiac catheterization

For culture of v. Cholerae o139 Conventional culture method

To determine cut-off titer of widal test for diagnosis of

typhoid fever

Nested PCR

For diagnosis of chronic arterial mesentric ischemia Angiography

For evaluation of imaging modalities for liver tumors Intraoperative ultrasonography

For diagnosis of common bile duct stones Endoscopic cholangiography

For measurement of GFR lnulin clearance

For diagnosis and treatment of ventilator associated

pneumonia (VAP)

Broncho alveolar lavage

To differentiate follicular and papillary carcinoma of

thyroid gland

Histology

Radiopharmaceuticals currently used and their common clinical applications

Organ system Clinical

application

Radiopharmaceuti

cal

Biological behaviour

Cardiovascular system

Myocardial

perfusion

Detection of

ischaemia,

infarction, and

viability

assessment

201TI (thallous

chloride)

K+ analogue extracted in proportion to

bloodflow 99m

Tc isonitriles Cationic complexes taken up by myocytes

in

proportion to blood flow 99mTc teboroxime Lipophilic compound which accumulates by

diffusion

99mTc phosphines Uptake proportional to blood flow

Myocardial

metabolism

Viability

assessment

123I fatty acids Enters primary metabolic pathway in viable

cells: limited catabolism 18

F-deoxyglucose Enter metabolic pathway in viable cells

demonstrates secondary shift to anaerobic

glycolysis

Cardiac

ventriculograph

y

Quantification of

right and left

ventricular

function at rest

and with

exercise

99mTc-red blood

cells

Characterization of cardiac chambers

motion, localization of red cells within

cardiac chambers

Detection of wall

motion

abnormalities

99mTc-albumin

Quantification

and detection of

shunts (and

valvar

regurgitation)

Cellular blood components

Red blood cells Detection of

haemangioma

99mTc-labelled red

blood cells

Red cell pooling

Cardiac

ventriculography

Gastrointestinal

bleeding

Red cell extravasation

Red cell survival 51

Cr (sodium

chromate)

Red cell disappearance from the blood

White blood

cells

Localization of

sites of infection

or inflammation

99mTc-mln-labelled

cells

Cellular diapedesis

99m

Tc-labelled

antigranulocyte

antibody

Platelets Platelet survival 111

In-labelled

platelets

Platelet sequestration and degradation

Localization of

sites of active

thrombosis

Central nervous system

Cerebral blood

flow

Blood flow

distribution

99mTc-HMPAO Diffusion through the blood–brain barrier

(BBB) and brain extraction

Tumours 99m

Tc-ECD

seizure

disorders

Dementia

brain death

studies

Regional blood

flow at rest and

upon activation

H215

O BBB diffusible flow tracer

Cerebral

metabolism

Functional and

regional

mapping of

neuronal activity

at rest

18F-deoxyglucose Enter metabolic pathway in viable cells

at rest

upon activation

during seizure

in the interictal

state

Staging of brain

tumour

18F-deoxyglucose

Follow-up of

therapy

201TI

Cerebrospinal

fluid

CSF shunt

patency

111ln-DTPA Follows cerebral spinal fluid (CSF) flow

dynamics

Localization of

CSF leaks

Differentiation

of normal

pressure

hydrocephaly

from atrophy

Gastrointestinal system

Liver—spleen

imaging

Space-occupying

lesions, organ

sizing, RES

function

99mTc-sulphur

colloid

Phagocytosis by reticulo-endothelial cells

Spleen imaging Detection of

ectopic splenic

tissue

Heat-damaged 99m

Tc-

labelled red blood

cells

Splenic trapping of damaged cells

Hepatobiliary

imaging

Assessment of

biliary ducts

patency

99mTc-iminodiacetic

acid derivatives

Active uptake—follows bilirubin

conjugation

and excretion pathway

Evaluation of

gallbladder

contractility

Diagnosis of

acute vs chronic

cholecystitis

Differentiation

between biliary

atresia and

neonatal

hepatitis

Bowel transit

studies

Oesophageal

transit and reflux

99mTc-sulphur

colloid

Transit of labelled material

Gastric emptying

and antral

motility

99mTc-sulphur

colloid

Compartmental localization of labelled

material

111

ln-DTPA

Gastric emptying 13or14

TC-labelled

substrates

Detection in breath of exhaled 13°'14CO2

metabolite

Duodenogastric

reflux

99mTc-iminodiacetic

acid derivatives

Bile detection and localization

Small bowel and

colon transit

111ln-DTPA Transit of labelled material

13 or 14

C-labelled

substrates

Detection in breath of exhaled 13 or 14

CO2

metabolite

Helicobacter

pylori (HP)

infection

Detection of HP

Urease

production

13 or 14C-labelled

urea

Detection in breath of exhaled 13 or 14

CO2

metabolite

Gastrointestinal Acute and 99m

Tc-sulphur

colloid

Extravasation in the bowel

bleeding chronic bleeding 99m

Tc-labelled

RBC's

Peritoneovenou

s

shunts

Determination

of shunt patency

99mTc-sulphur

colloid

Compartmental localization

Salivary glands Evaluation of

salivary function

and ducts

patency

99mTc-

pertechnetate

Active uptake and secretion

Gastric mucosa Detection and

localization of a

Meckel's

diverticulurn

containing

gastric mucosa

99mTc-

pertechnetate

Active uptake by gastric mucosa

Genitourinary system

Renal perfusion Evaluation of

arterial blood

flow

99mTc-DTPA Early intravascular localization

Diagnosis of

transplant

rejection

99mTc-MAG3

99mTc-DTPA

Renal function GFR

measurement

51Cr-EDTA Clearance by glomerular filtration

Measurement of

effective renal

plasma flow;

tubular function

Tubular uptake

99mTc-MAG3

Renal

morphology

Detection of

renal infarct

99mTc-DMSA Retention in renal cortex

Global renal

morphology

Bladder Quantitation of

bladder residual

vesicoureteral

reflux

99mTc-DTPA Compartmental localization

Scrotum Differentiation

between acute

testicular torsion

99mTc-

pertechnetate

Early intravascular localization

Pulmonary system

Ventilation scan Evaluation of

regional

ventilation

133Xe gas Distributes in lungs in proportion to

regional

ventilation 81Kr

m gas

99mTc aerosols

Perfusion scan Detection of

pulmonary

emboli, right to

left shunts;

preoperative

and transplant

evaluation of

relative lung

perfusion

99mTc albumin

macroaggregates

Pulmonary capillary blockade

Parenchymal Interstitial lung 67

Ga Binds to transferrin in the intravascular

tissue disease staging

and therapeutic

evaluation

compartment,

Musculoskeletal

system

Detection of soft

tissue vs primary

bone disorders

during Phases I

and II of study

Detection of

benign, alignant,

and

infectious bone

lesions

99mTc-

polyphosphate

compounds

Intravascular and early soft tissue

distribution (Phase I and II)

Fixed to hydroxyapatite crystals (Phase Ill)

Thyroid-parathyroid

Thyroid Evaluation of

gland size,

morphology and

function

(uptake).

Iodine-123 Active uptake (123

I and 99m

Tc) followed by

organification (123

I)

99m

Tc- ertechnetate

Determination

of functional

status of nodules

Detection of

thyroid cancer

and metastases,

thyroid cancer

treatment

Iodine-131 Active uptake and organification

Parathyroid Localization of

parathyroid

adenoma and

carcinoma

99mTc-M IBI Cationic complexes taken up in proportion

to

blood flow and trapped in mitochondria

Tumour markers

Neuroendocrine

tissue

Somatostatin

receptor positive

tumours

111In-pentetreotide

(Octecotide®)

Binds to somatostatin receptors

Lymphopoietic

tissue

Staging and

localization of

lymphoma

67Ga (gallium

citrate)

Binds to transferrin in the intra-vascular

compartment, taken up by cancer cells,

binds to lactoferrin and ferritin, and

concentrates in lysosomes

Brain neoplasia Brain tumour

staging and

therapeutic

follow up

201TI (thallous

chloride)

Concentrates in tumour cells following BBB

damage

Adenocarcinom

a

Tumour

detection and

staging

111In-Satumomab

pendetide

Antigen-antibody recognition

Miscellaneous

neoplasia

Tumour

detection and

staging

18F-deoxyglucose Uptake proportional to tumour

GOLD STANDARD METHODS

• Gold standard for treatment of organ confined, muscle invasive, bladder cancer is – Radical

cystoprostatectomy in men and anterior pelvic exenteration in woman

• Gold standard method for management of hydatid disease – Surgery

• Gold standard method for management of blunt hepatic trauma – Non-operative management

• Gold standard for treatment of femoral shaft fractures – Reamed locked intramedullary nailing

• Gold standard method in case of difficult intubation – Flexible fibreoptic intubation scope

• Gold standard treatment of hyperparathyroidism – Surgery

• Gold standard procedure for thymectomy – Trans cervical mediastinoscopy and surgery

• Gold standard for treatment of adrenal tumors – Laparoscopic adrenalectomy

• Gold standard method for treatment of GERD – Laparoscopic Nissens fundoplication

• Gold standard for evaluating cure rate in duodenal ulcer patients – Vagotomy

• Gold standard method of treatment of Symptomatic cholelitiasis – Lap cholecystectomy

MAMMOGRAPHY

• Diagnostic accuracy – 90 – 95 %

• 45% of breast cancers can be seen on mammography before they are palpable.

Indications:

• Coarse nodular breast, Fibro adenosis, Woman, aged 40yrs with family H/o cancer

FEATURES BENIGN MALIGNANT

Opacity -Smooth margin

-Low Density, Homogenous

-Thin Halo

Ill defined margin(Spiculated)

High density, Wide halo

Calcification -macro calcification (>0.5mm in diameter)

-egg shell curvilinear, -Popcorn(Fibro adenoma), -

Floating calcification, -Tramline/ tortuous

calcification, -Rod like Wide spread calcification

Micro calcification (<0.5mm in

diameter)

Skin Normal Thickened

Nipple/ Areola +retracted

_

+retracted

_ Duct Normal Focal dilatation

Subcutaneous retro

mammary space

Normal Obliterated

Surrounding

parenchyma

Normal Disrupted

BARIUM STUDIES

Study of GIT by instillation/ ingestion of barium suspension made from pure barium sulphate.

Procedure Organ studied

Barium swallow Oesophagus

Barium meal From stomach to proximal jejunum

Barium follow through From stomach to ileocaecal junction

Barium enema Large intestine (administration of contrast via rectum)

Small bowel enema (Enteroclysis) From jejunum to ileocaecal junction

DTPA (Reno gram) DMSA (Isotope scanning)

• DTPA is useful for evaluating perfusion and

function

• of each kidney

• Indications:

1. Measurement of relative renal function in

each kidney.

2. Urinary tract obstruction

3. Diagnosis of renovascular cause of

hypertension

4. Investigation of renal transplant

• Tc 99 DMSA is used for Renal morphological

imaging

• This compound gets fixed in renal tubules &

images may be obtained after 1-2 hours of

injection- Lesions such as tumors & benign

lesions as show filling defect

• Used to assess cortical function of kidney

• MCU is the most accurate method of demonstrating vesicoureteric reflux, and as this is important in children

with urinary tract infection and reflux nephropathy.

• The ascending urethrogram gives excellent anatomical information concerning the distal urethra as far as the

distal sphincter mechanism.

• Ultrasound and CT are the investigations of choice in the diagnosis and staging of renal tumours.

• Dynamic CT is more accurate than angiography in detecting a small neoplasm.

• Antegrade pyelography is an accurate method of demonstrating precisely the site of an obstruction to the

upper urinary tract.

V. RADIOTHERAPY

• Radioactivity was discovered by Henry Becquerel in 1896.

• J.J. Thompson- discovered electrons

• W.K.Roentgen- discovered X Rays in 1895.

• Madam Marie Curie- discovered radioactive substances radium, uranium etc.

• Rutherford- discovered nucleus, alpha & beta rays

• Chadwick- discovered neutrons

• Maxwell- discovered electromagnetic waves

Radiotherapy is treatment of malignant tumor with ionizing radiation, most commonly by using y rays; which causes

excitation or ionization of electron (ejection of electron from orbit) and kills tumor cells by producing double strand

breaks in DNA (direct) or free radicals (indirect).

• The DNA molecules present along the chromosomes are the critical targets for radiation damage.

• Chromosomal abnormalities occur in cells irradiated in G1 phase before doubling of genetic material.

• Chromatid aberration occurs in cells irradiated in G2 phase.

• Most sensitive phase to radiation is M> G2M interphase

• Most resistant phase is end of S phase.

• Lymphocyte analysis provides evidence of recent total body exposure.

• A typical course of radiation therapy should be described as 4500 cGy delivered to a particular target (e.g.,

mediastinum) over 5 weeks in 180-cGy fractions.

• Most curative radiation treatment programs are delivered once a day, 5 days a week in 150- to 200cGy

fractions.

• Therapeutic radiation is delivered in three ways:

o Teletherapy, with beams of radiation generated at a distance and aimed at the tumor within the patient

o Brachytherapy, with encapsulated sources of radiation implanted directly into/adjacent to tumor

tissues

o Systemic therapy, with radionuclides targeted in some fashion to a site of tumor.

• Teletherapy is the most commonly used form of radiation therapy.

• X-rays and gamma rays are the forms of radiation most commonly used to treat cancer.

Radiation Content Penetrating

power

Ionizing

power

Damaging power Sources

α- Particle Helium nuclei

(i.e. 2 protons

& 2 neutrons

Poorest Maximum Most damaging Uranium,

Plutonium

β-Particle Either high

energy

electron or

antimatter

counterpart

positron

Greater than α -

particle (100)

Lesser than

α particle

< α particle Phosphorous-

32,strontium-

89,samarium-

132,1-131

X-Ray Low energy

photons

More than β-

particles

Lesser than

Β particle

<β Particle

Y-

Radiation

Very high

Energy

photons

More than X-

Rays 10000 i.e.,

Most penetrating

Minimum

ionizing

Least damaging Co-60, radium -

126.

Penetration power: y- ray > x ray > β particle > α particle

Ionizing & Damaging Power: α- particle> β-particle> x-ray > y ray

• Gamma rays are produced by decay of atomic nuclei in radioisotopes like cobalt & caesium.

• For deep seated tumors, X rays & Gamma rays are used, as high energy penetrating beam deliver a less

intense superficial dose & causes less skin damage.

• Electron beams have very low penetrance & used to treat mycosis fungoides.

• I-131: emits both beta & gamma rays.

• Californium: emits neutron.

• Heating of tungsten filament by battery produces electron beam which is targeted towards positive charged

tungsten or molybdenum containing copper block; this produces X-rays

• Linear accelerator and betatron are used to produce x-ray by accelerating electrons.

Neutrons

• Uncharged particulate radiation.

• Present in nuclear reactors and at high altitudes.

• Have highest penetrating power.

• Water and paraffin wax are effective in absorbing it.

• Predominant neutron emitter: californium.

BRACHYTHERAPY

• First proposed by Forssell in 1931.

• Delivered by two methods:

o Intra cavitatory therapy: Eg: Manchester system for Rx of Ca. cervix

o Interstitial implantation: Eg. HDR therapy for Ca. Bronchus & ca. Oesophagus.

• Radionuclides used in brachytherapy:

o Caesium 137, Cobalt 60, Iridium 192, Iodine 125, Radium 226, Radon 222, Strontium 90, Samarium 145,

Palladium 103, Gold 198, Yetrium 169.

• The characteristic features of Brachytherapy are:

o Maximum radiation effect can be obtained in diseased tissue.

o Minimum risk of to the normal tissue.

o It requires trained personnel & Invasive

o It is often used in brain tumours & cervical cancers.

UNITS OF RADIATION

Feature S.I. Unit Non S.I. Unit

Radioactivity Becquerel (Bq) Curie

Absorbed dose Gray (Gy) Rad

Dose equivalent Sievert (Sv) Rem

Exposure Coulombs/ kg Roentgen

ISOTOPES USED IN MEDICINE

Reactor Radioisotopes (half-life indicated in brackets):

• Molybdenum-99 (66 h): Used as the 'parent' in a generator to produce technetium-99m.

• Technetium-99m (6 h): Used in to image the skeleton and heart muscle in particular, but also for brain,

thyroid, lungs (perfusion and ventilation), liver, spleen, kidney (structure and filtration rate), gall bladder,

bone marrow, salivary and lacrimal glands, heart blood pool, infection and numerous specialized medical

studies.

• Uses of Technetium 99 tagged RBC's:

o Commonly indicated in Acute Lower Gastrointestinal Bleeding.

o Relatively sensitive & very specific imaging method for noninvasive diagnosis of liver hemangioma.

o Measurement of left ventricular ejection fraction. Assessment of regional wall motion (left and right

ventricles).

• Chromium-51 (28 d): Used to label RBC's and quantify gastro-intestinal protein loss.

• Cobalt-60 (10.5 months): Formerly used for external beam radiotherapy.

• Copper-64 (13 h): To study genetic diseases affecting copper metabolism. Eg: Wilson's and Menke's diseases.

• Dysprosium-165 (2 h): Used as an aggregated hydroxide for synovectomy treatment of arthritis.

• Erbium-169 (9.4 d): Use for relieving arthritis pain in synovial joints.

• Holmium-166 (26 h): Being developed for diagnosis and treatment of liver tumours.

• Iodine-125 (60 d): Used in brachytherapy (prostate and brain), to evaluate the filtration rate of kidneys and

to diagnose DVT in the leg. It is also used in radioimmuno-assays to show the presence of hormones in tiny

quantities.

• Iodine-131 (8 d): Used in treating thyroid cancer, imaging the thyroid; in diagnosis of abnormal liver

function, renal (kidney) blood flow and urinary tract obstruction. A strong gamma emitter, but used for beta

therapy.

• Iridium-192 (74 d): Supplied in wire form for use as an internal radiotherapy source for cancer treatment

• Iron-59 (46 d): Used in studies of iron metabolism in the spleen.

• Lutetium-177 (6.7 d): emits just enough gammas for imaging while the beta radiation does the therapy on

small (eg endocrine) tumours. Its half-life is long enough to allow sophisticated preparation for use.

• Palladium-103 (17 d): Used to make brachytherapy permanent implant seeds for early stage prostate cancer.

• Phosphorus-32 (14 d): Used in the treatment of polycythemia vera (excess red blood cells). Beta emitter.

• Potassium-42 (12 h): Used for the determination of exchangeable potassium in coronary blood flow.

• Rhenium-186 (3.8 d): Used for pain relief in bone cancer. Beta emitter with weak gamma for imaging.

• Rhenium-188 (17 h): Used to beta irradiate coronary arteries from an angioplasty balloon.

• Samarium-153 (47 h): Sm-153 is very effective in relieving the pain of secondary cancers lodged in

the bone, sold as Quadramet. Also very effective for prostate and breast cancer. Beta emitter.

• Selenium-75 (120 d): Used as seleno-methionine to study the production of digestive enzymes.

• Sodium-24 (15 h): For studies of electrolytes within the body.

• Strontium-89 (50 d): Very effective in reducing the pain of prostate & bone cancer. Beta emitter.

• Xenon-133 (5 d): Used for pulmonary (lung) ventilation studies.

• Ytterbium-169 (32 d): Used for cerebrospinal fluid studies in the brain.

• Ytterbium-177 (1.9 h): Progenitor of Lu-177.

• Yttrium-90 (64 h): for brachytherapy and as silicate colloid for relieving pain of arthritis. Pure beta emitter.

• Radioisotopes of caesium, gold and ruthenium are also used in brachytherapy.

Cyclotron Radioisotopes:

• Carbon-11, Nitrogen-13, Oxygen-15, Fluorine-18: positron emitters used in PET.

• F-18 in FDG in detection of cancers and the monitoring of progress in their treatment, using PET.

• Cobalt-57 (272 d): Used as a marker to estimate organ size and for in-vitro diagnostic kits.

• Gallium-67 (78 h): For tumour imaging & localization of inflammatory lesions (infections).

• Indium-111 (2.8 d): Used for specialist diagnostic studies, eg brain studies, infection and colon transit

studies.

• Iodine-123 (13 h): Used for diagnosis of thyroid function, a gamma emitter without the beta radiation of 1-

131.

• Krypton-81m (13 sec) from Rubidium-81 (4.6 h): Kr-81m gas can yield functional images of pulmonary

ventilation, e.g. in asthmatic patients, and for the early diagnosis of lung diseases and function.

• Rubidium-82 (65 h): Convenient PET agent in myocardial perfusion imaging.

• Strontium-92 (25 d): Used as the 'parent' in a generator to produce Rb-82.

• Thallium-201 (73 h): for diagnosis of coronary artery disease, other heart conditions such as heart muscle

death and for location of low-grade lymphomas.

T1/2 in hours T1/2 in days T1/2 in years

I132

-2.3 hours

Tc99

-6 hours

I123

-13 hours

I131

- 8 days; Gold- 2.7 days

Thallium-3.2 days; Radon-3.8 days

Xenon-5.2 days; P32

- 14 days

I125

- 60 days

Co60

- 5.2 years

Tritium- 12 years

St 90

- 28 years ; Cs132

- 30 years

Ra- 1622 years; U– 701 x 108 yrs

Co- 60 has the following features:

• Naturally occurring isotope

• Atomic. No. 27

• Atomic. Wt. 58.93

• Half- life 5.3 years

• Emits β and y- rays

• Used in both brachy & Teletherapy

Internal Contaminant Radionuclides: Properties and Treatment

Isotope

Name

Symbol Common

Usage

Radiation

Type, t%

Radiologic

t1/2

Biologic,

days

Exposure

Type

Focal

Accumulation

in Body

Treatment

Manganese Mn-56 Reactors,

research

laboratories

β, y, 2.6 h

5.7

External,

internal

Liver N/A

Cobalt Co-60 Medical

radiotherapy

devices,

commercial

food

irradiators

β, y, 5.26 y

9.5

External,

internal

Liver Gastric lavage,

purgatives;

penicillamine in

severe cases

Strontium Sr-90 Fission

product of

uranium

β, 28 y

18,000

Internal Bones—

similar to

calcium

Strontium, calcium,

Ammonium chloride

Molybdenum Mo-99 Hospitals—

scans

β, y, 66.7

h 3

External,

internal

Kidneys N/A

Technetium Tc-99m Hospitals—

scans

β, y, 6.049

h 1

External,

internal

Kidneys, total

body

Potassium

perchlorate to

reduce thyroid dose

Cesium Cs-137 Medical

radiotherapy

devices

β, y„ 30 y

70

External,

internal

Renal

excretion

Ion-exchange

resins, Prussian

blue

Gadolinium Gd-153 Hospitals β, y, 242 d

1000

External,

internal

N/A N/A

Iridium Ir-192 Commercial

radiography

0, y, 74 d

50

External,

internal

Spleen N/A

Radium Ra-226 Instrument

illumination,

industrial

applications,

old medical

equipment,

former Soviet

Union

military

equipment

α, β, y,

1602 y

16,400

External,

internal

Bones MgSO4 lavage,

ammonium

chloride, calcium

alginates

Tritium H-3 Luminescent

gun sights,

muzzle-

velocity

detectors,

nuclear

weapons

β, 12.5 y

12

Internal Total body Dilution with

controlled water

intake, diuretics

Iodine-131 131

I Reactor

accidents,

thyroid

ablators

β, y, 8.1 d

138

Internal Thyroid Potassium/sodium

iodide,

propylthiouracil,

methimazole

Uranium U-235 Depleted

uranium,

natural

uranium, fuel

rods,

weapons-

grade material

α, β, y,

108 y 15

Internal Kidneys,

bones

NaHCO3, chelation

with EDTA

Plutonium Pu-239 Produced

from uranium

in reactors,

nuclear

weapons

α, 2.2 x

104y

73,000

Internal Lungs, bones,

bone marrow,

liver, gonads

Chelating with

DTPA or EDTA

Americium Am-

241

Smoke

detectors,

nuclear

weapon

detonation

fallout

α, 458 y

73,000

Internal Lungs, liver,

bones, bone

marrow

Chelating with

DTPA or EDTA

Polonium Po-210 Calibration

source

α, 138.4 d

60

Internal Spleen,

kidneys

Lavage,

dimercaprol

Thorium Th-232 Calibration

source

α, 1.41 x

1010

y

73,000

Internal N/A N/A

Phosphorus P-32 Research

laboratories,

medical

facilities

B,14.3 d

1155

Internal Bones, bone

marrow,

rapidly

replicating

cells

Lavage, aluminum

hydroxide

CRANIOSPINAL IRRADIATION

Craniospinal irradiation is used for patients who have, or are at risk for, disseminated disease throughout the CNS

that is not sufficiently responsive to chemotherapy (typically methotrexate).

Aim is to irradiate the entire sub arachnoid space,

Indications:

• Medulloblastoma

• PNET (pineoblastoma, ependymoblastomas, unclassified).

• Germ Cell tumour with CSF and/or MRI positive for malignant cells.

• Pure germinoma.

• Non Hodgkins Lymphoma with CSF positive for malignant cells.

Total Body Irradiation (TBI)

• Used as a systemic treatment since 1900 for palliating symptoms or obtaining short term remissions.

• Done for: acute leukemia in adult, high grade lymphomas (intensive cytoreductive chemo radiotherapy

followed by Bone Marrow Transplant)

• Prophylactic Craniospinal irradiation is useful in CNS malignancy which disseminates via CSF or any

malignancy with high risk of CNS spread.

• They are: Medulloblastoma, Glioblastoma, Germinoma, Small cell lung Carcinoma, ALL, Non Hodgkin's

lymphoma & Leptomeningeal rhabdomyosarcoma.

INDICATIONS FOR TOTAL BODY IRRADIATION

MALIGNANT NON MALIGNANT

Leukemias: ALL, AML, CML, hairy cell leukemia Immune disorders- aplastic anemia

Lymphoma's: NHL, refractory Hodgkin's lymphoma,

myelodysplasia, multiple myeloma, mycosis fungoides

Genetic disorders- osteopetrosis,

Fanconi's anemia, wiskott-aldrich

syndrome Pediatric solid tumors: Ewing sarcoma, Neuroblastoma

Adult solid tumors: testicular Ca, Small cell Ca of lung

• The standard treatment for brain metastases has been whole-brain radiotherapy (WBRT) usually

administered to a total dose of 3000 cGy in 10 fractions.

• This affords rapid palliation; approximately 80% of patients improve with glucocorticoids and radiation

therapy.

STEREOTACTIC RADIOSURGERY (SRS)

• Introduced by Lekshell in 1951.

• Treats brain disorders with a precise delivery of a single, high dose of radiation in a one-day session.

• Ideally confined to a lesion of 3-5cm size.

• Stereotactic radiosurgery (SRS) delivered through a variety of techniques including the gamma knife, linear

accelerator, proton beam and CyberKnife can deliver highly focused doses of RT, in a single fraction.

• Focused radiation beams are delivered to a specific area of the brain.

• It does not remove the tumor or lesion, but it distorts the DNA of the tumor cells.

• The cells then lose their ability to reproduce and retain fluids.

• Most of the beams used today are 4MV or 6MV beams.

• The three basic forms of stereotactic radiosurgery are:

o Particle beam (proton)

o Cobalt-60 based (photon), most well-known machine is the Gamma Knife.

o Linear accelerator based (linac)

Indications

• Arteriovenous Malformations

• Acoustic

• Neuromas

• Meningiomas

• Pineal and Pituitary Tumors

• Glial Tumors and Astrocytomas

• Low grade tumors

• Metastatic Brain Tumors

• Trigeminal Neuralgia

• Essential Tremor

• Parkinson's Tremor/Rigidity

• Current research areas include epilepsy,

headaches and neuro-psycho conditions.

INTENSITY MODULATED RADIATION THERAPY (IMRT)

• High precision radiotherapy by computer controlled X-ray accelerator to deliver precise radiation doses to a

malignant tumor or specific areas within the tumor.

• IMRT used in treatment of tumours of:

o Breast, Thyroid, lung, Prostate & Gynecological cancers

o Head & neck cancers

o Liver & brain cancers

o Lymphoma, sarcoma

INTRA OPERATIVE RADIOTHERAPY

• Applied with ortho voltage X —ray

• Specialized radiation technique for treating deeply located cancers with large single dose, avoiding damage

to the normal tissues.

• Intra operative electron beam followed by photons via X- rays & Gamma rays is the recent regimen.

• Used in pancreatic, gastric & rectal cancers; head & neck cancers, genitor urinary & gynecological cancers,

retroperitoneal sarcomas.

FAST NEUTRON RADIOTHERAPY (FNRT)

• Uses neutrons of megaelectron volts (MeV) energy.

• Generated by accelerating either protons or deuterons with cyclotrons or particle accelerators and then

delivering them to appropriate target (mostly beryllium).

• Fission neutrons (1-2MeV) from nuclear reactors can also be used to treat patients.

• For neutrons of energies used in RT, about 85% of deposited energy is via a knock on reaction (billard ball

type collision) involving the hydrogen nucleus ('H).

• Kinetic energy release in matter (KERMA) is larger in high hydrogen content tissue such as fat or myelin.

• It is the higher energy transfer that gives rise to the different radiobiological properties of FNRT.

• Fast neutrons have RBEs 3 to 3.5 in terms of most normal tissue late effects, RBEs 4 to 4.5 in terms of

damage to CNS and RBEs 8 for salivary gland malignant tumors.

• Neutron therapy is best used in the treatment of certain tumor that exhibit a resistance to standard low

LET radiotherapy — a small niche, but it remains a very important treatment option for small number of

patients for whom it appears to be better than tradition forms of treatment.

• Examples.

o Patients with inoperable or recurrent salivary gland malignant tumors or in high risk situations where

there has been an incomplete surgical extirpation or

o Where inoperable or incompletely resected sarcomas of bone, cartilage and soft tissue or locally

advanced prostate cancers particularly those that are not hormonally responsive have been found.

o May also be beneficial in metastases from melanoma & renal cell carcinoma.

Boron Neutron Capture Therapy (BNCT)

• Pure beams of very low energy neutrons do not directly deposit much energy in tissue. The basic idea is to

selectively attach a nuclide with a large cross section for capturing thermal neutrons [eg boron 40(10

B) or

gadolinium – 157 (157

Gd)] to the cancer cells.

• The nucleide then undergoes a nuclear reaction with the localized release of substantial amount of energy

and kills the tagged cancer cells but does not damage the surrounding untagged normal cells.

• At present moderated neutron beams from nuclear reactors are used but there is ongoing work in

developing high current particle accelerator to produce low energy thermal or epithermal beams for BNCT.

Californium – 252 (252

CF) Neutron Brachytherapy

• Beneficial for tumors in which hypoxia is thought to be a factor in limiting tumor control with standard

treatment.

METHODS FOR ORGAN PRESERVATION

QUART Technique Breast

Intra operative Brachytherapy Soft tissue sarcomas

Stereotactic radiosurgery Small brain tumors

Chemo irradiation Bladder cancer

Concurrent chemotherapy Anal cancer

Plaque therapy Uveal melanoma

External radiotherapy Retinoblastoma & laryngeal cancers

External radiotherapy/ brachytherapy Prostate, head & neck, gynecological cancers

RADIOSENSITIVITY

Very high High Intermediate Low

Bone marrow (most),

Testes & ovary,

Growing cartilage/

growth plate/

epiphysis, Breast, Lens

Skin, growing muscles, bones, Brain,

spinal cord, Pituitary, thyroid ,

salivary gland, Stomach, small

intestine, intestine, colon, rectum,

Liver, lung, heart, kidney, cornea

Adult bone, Adult

cartilage, Oral

mucosa,

Oesophagus Urinary

bladder

Pancreas,

Uterus

Vagina,

Adrenals

M/C affected – skin (more commonly moist areas)

Most common skin manifestation- Erythema

Most sensitive blood cell – lymphocyte

Most resistant blood tissue- platelets

Most sensitive body tissue- bone marrow

Most resistant body tissue- CNS

Most sensitive cell in CNS- neuron

Most sensitive CNS part – mid brain, medulla, spinal cord

Most sensitive abdominal organ- kidney

Most sensitive hormone: growth hormone

Most sensitive mucosa – intestinal mucosa

RADOSENSITIVITY OF TUMOURS:

High Moderate Relatively Resistant Highly resistant

Ewing's sarcoma

Seminoma

Lymphoma

Wilm's tumor

Multiple myeloma

Nasopharyngeal Ca

Dysgerminoma, Teratoma &

Ovarian Ca

Medulloblastoma

Small cell Ca lung

Ca. breast

Basal cell Ca

Renal cell Ca

Rectal / colon Ca

Ca Cervix

Hepatoma

Pancreatic Ca

Osteosarcoma

Melanoma

MOST RADIOSENSITIVE TUMORS

• Ovarian tumor: Dysgerminoma > Teratoma

• Brain tumor: Medulloblastoma

• Testicular tumor: Seminoma

• Lung tumor: small cell CA

• Kidney tumor: Wilm's tumor

• Bone tumor: Ewing's Sarcoma & multiple myeloma

RADIOSENSITIZERS RADIOPROTECTIVE

AGENTS

RADIATION

POTENTIATOR

• Anti-cancer drugs: Cisplatin , 5-FU, Hydroxyurea

Vincristine, Bleomycin

• Metronidazole, Misonidazole, Etanidazole,

Pimonidazole

• Hyperbaric O2 (Most potent) (not -

cyclophosphamide)

• Amifostine

• Sodium butyrate

• IL-1

• GM-CSF

• Doxorubicin

• Dactinomycin

• Amifostine reduces cisplatin-induced nephrotoxicity & also reduces xerostomia in patient with head & neck

Ca.

• Sodium butyrate when given topically improves the symptoms of radiation proctitis.

RADIO IODINE THERAPY IN THYROID CANCER

• Well differentiated thyroid cancer still incorporates radio iodine, but less efficiently than normal tissue.

• Indication- For tumor that takes up iodine, I131

treatment can reduce or eliminate residual disease.

• Thyroid ablation + I133

-Treatment in:

o Large papillary tumor

o Lymph node involvement

o FCT

o Evidence of metastasis

WILM'S TUMOUR

• The postoperative radiotherapy in Wilm's tumour should be started within 10 days of surgery.

• Delay in starting RT beyond 10 days leads to tumour cell repopulation and increase in relapse rate.

• Recommended dose: 1.2 to 1.5 Gy per fraction

• Indications of RT in Wilm's tumour are:

� Stage II, Ill, IV with unfavorable histology (UH)

� Stage III & IV with favorable histology (FH)

� Metastatic disease

� Clear cell sarcoma of kidney in all stages.

MEDULLOBLASTOMAS

• Most common malignant brain tumor of childhood, approximately 20% of all primary CNS tumors among

children.

• Arise from granule cell progenitors or from multipotent progenitors from the ventricular zone.

• Associated syndromes: Gorlin syndrome, Turcot's syndrome and familial adenomatous polyposis.

• Histology: highly cellular tumors with abundant dark staining, round nuclei, and rosette formation (Homer-

Wright rosettes).

• Features: headache, ataxia, and signs of brainstem involvement.

• MRI: densely enhancing tumors in the posterior fossa, sometimes associated with hydrocephalus.

• Seeding of the CSF is common.

• Treatment: maximal surgical resection, craniospinal irradiation, and chemotherapy with agents such as

cisplatin, lomustine, cyclophosphamide, and vincristine.

BONE SECONDARIES

Ca. Prostate produce mainly osteoblastic (Osteosclerotic) secondaries.

• Mostly blastic: Bladder, bowel, breast, bronchial, Carcinoid, lymphoma & Prostate [4 Bees Can lick Pollen

• Usually lytic but frequently blastic: Breast

Invariably lytic: Kidney/Thyroid

WEDGE ANGLE

"The angle which the 50 per cent isodose curve makes with the normal to the axis or "the angle through which the

50 per cent isodose curve has been turned at the central axis"

Internal Contaminant Radionuclides: Properties and Treatment

Isotope Common Usage Exposure

Type

Mode of

Contamination

Focal

Accumulation in

Treatment

Manganese Reactors, research

laboratories

External,

internal

N/A Liver N/A

Cobalt Medical

radiotherapy

devices,

commercial food

irradiators

External,

internal

Lungs Liver Gastric lavage,

purgatives;

penicillamine in

severe cases

Strontium Fission product of

uranium

Internal Moderate GI

tract

Bones—similar

to calcium

Strontium, calcium,

ammonium chloride

Molybdenum Hospitals—scans External,

internal

N/A Kidneys N/A

Technetium Hospitals—scans External,

internal

IV

administration

Kidneys, total

body

Potassium perchlorate

to reduce thyroid dose

Cesium Medical

radiotherapy

devices

External,

internal

Lungs, GI tract,

wounds,

follows

potassium

Renal excretion Ion-exchange resins,

Prussian blue

Gadolinium Hospitals External,

internal

N/A N/A N/A

Iridium Commercial

radiography

External,

internal

N/A Spleen N/A

Radium Instrument

illumination,

industrial

applications, old

medical

equipment,

former Soviet

Union military

equipment

External,

internal

GI tract Bones MgSO4 lavage,

ammonium chloride,

calcium alginates

Tritium Luminescent gun

sights, muzzle-

velocity detectors,

nuclear weapons

Internal Inhalation, GI

tract, wounds

Total body Dilution with

controlled water

intake, diuretics

Iodine-131 Reactor accidents,

thyroid ablators

Internal Inhalation, GI

tract, wounds

Thyroid Potassium/sodium

iodide,

propylthiouracil,

methimazole Uranium Depleted

uranium, natural

uranium, fuel

rods, weapons-

grade material

Internal GI tract Kidneys, bones NaHCO3, chelation

with EDTA

Plutonium Produced from

uranium in

reactors, nuclear

weapons

Internal Limited lung

absorption,

high retention

Lungs, bones,

bone marrow,

liver, gonads

Chelating with DTPA

or EDTA

Americium Smoke detectors,

nuclear weapon

detonation fallout

Internal Inhalation, skin

wounds

Lungs, liver,

bones, bone

marrow

Chelating with DTPA

or EDTA

Polonium Calibration source Internal Inhalation,

wounds

Spleen, kidneys Lavage, dimercaprol

Thorium Calibration source Internal N/A N/A N/A

Phosphorus Research

laboratories,

medical facilities

Internal Inhalation, GI

tract, wounds

Bones, bone

marrow, rapidly

replicating cells

Lavage, aluminum

hydroxide, phosphate

Abbreviations : DTPA, diethylenetriamine pentaacetic acid; EDTA, ethylenediamine tetraacetic acid

MANAGEMENT PROTOCOL OF RADIATION INJURY

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