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Dr KK Aggarwal

From the Desk of Editor in Chief
Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Member Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR


Dear Colleague

20th April, 2010 Tuesday

Heat stroke (High temperature with no sweating and fever where paracetamol will not work

  1. Hyperthermia is elevation of core body temperature above the normal diurnal range of 36°C to 37.5°C due to failure of thermoregulation.

  2. The most important causes of severe hyperthermia (greater than 40°C or 104°F) caused by failure of thermoregulation is heat stroke.

  3. Heat stroke is when the core body (rectal) temperature in excess of 40.5°C (105°F) with associated central nervous system dysfunction. Complications include acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation, renal or hepatic failure, hypoglycemia, rhabdomyolysis, and seizures.

  4. There are two types of heat stroke:
  • Classic (nonexertional) heat stroke: affects people with underlying chronic medical conditions that either impair thermoregulation or prevent removal from a hot environment. These include cardiovascular disease, neurologic or psychiatric disorders, obesity, anhidrosis (no sweating), extremes of age, and use of drugs such as anticholinergic agents or diuretics.

  • Exertional heat stroke — occurs in young healthy people who engage in heavy exercise during periods of high ambient temperature and humidity. Typical patients are athletes and military recruits in basic training.


Rectal temperature should be determined in all patients. Abnormalities of vital signs include sinus tachycardia, tachypnea, a widened pulse pressure, and hypotension.

The chest X Ray may show pulmonary edema, while the ECG may reveal dysrhythmias, conduction disturbances, nonspecific ST–T wave changes, or heat–related myocardial ischemia or infarction.

Management requires ensuring adequate airway, breathing, and circulation; initiation of rapid cooling; and treatment of complications. Central venous pressure monitoring is useful for assessing volume status and for fluid resuscitation. Alpha–adrenergic agonists should be avoided, since the resultant vasoconstriction decreases heat dissipation. Continuous rectal temperature monitoring is mandatory, and cooling measures should be stopped once a temperature of 39.5°C (103°F) has been achieved in order to reduce the risk of iatrogenic hypothermia.

Cooling measures

  1. Augmentation of evaporative cooling is the treatment modality of choice. It is effective, noninvasive, and easily performed.

  2. The naked patient should be sprayed with a mist of lukewarm water while air is circulated with large fans.

  3. Shivering may be suppressed with IV diazepam (5 mg IV) or lorazepam (1–2 mg IV) or, if not contraindicated with chlorpromazine (25 to 50 mg IV).

  4. Immersing the patient in ice water (cold water immersion) is the most effective method of rapid cooling. It results in rapid cooling but complicates monitoring and access.

  5. Applying ice packs to the axillae, neck, and groin is effective, but is poorly tolerated in the awake patient.

  6. Cold peritoneal lavage results in rapid cooling, but it is an invasive technique that is contraindicated in pregnant patients or those with previous abdominal surgery.

  7. Cold oxygen, cold gastric lavage, cooling blankets, and cold intravenous fluids may be helpful adjuncts.

  8. There is no role for antipyretic agents such as paracetamol or aspirin in the management of heat stroke, since the underlying mechanism does not involve a change in the hypothalamic set–point.

  9. Alcohol sponge baths should be avoided because large amounts of the drug may be absorbed through dilated cutaneous vessels and produce toxicity.

  10. Drugs: are not effective in heat stroke.

Main points (Paracetamol not effective)

  1. Measure the recatal temperature

  2. If rectal temp is > 105 move the patient to a cooler place, remove clothing’s. 

  3. Put cold packs on the neck, axillae, and groin.

  4. Fan continuously (or open the ambulance windows)

  5. Spray the skin with water at 25°C to 30°C

  6. Stop cooling measures once the temp is 103

  7. Promote cooling by conduction and evaporation

  8. Position an unconscious patient on his or her side and clear the airway

  9. Minimize the risk of aspiration

  10. Administer oxygen at 4 liters/min

  11. Start IV Saline

  12. Do not give paracetamol or aspirin

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

Photo feature

Dr KK Aggarwal being felicitated by Brahma Kumaris during the inauguration of National Seminar on Stress Prevention held on Saturday 17th April, at ORC Manesar. Also in the picture are BK Asha and BK Brij Mohan Ji.

Dr k k Aggarwal

News and views (Dr Monica and Brahm Vasudeva)

Obese men more likely to sustain serious upper body injuries during vehicular accidents

Researchers at the Medical College of Wisconsin found that in automobile accidents, obese men are much more likely to sustain serious upper body injuries than are normal–weight men. (March 2010 issue of PLoS Medicine)

Elastography may help identify malignant tumors without biopsy

A technique called elastography is being tested that can distinguish between malignant and benign tissues without using a needle or scalpel. Elastography uses software that produces pictures that enhance the edges and texture of a tumor; and, in advanced elastography systems, it uses sophisticated transducers that further improve the visibility of the tumor and provide data to measure tissue stiffness.

Cholesterol drug to be marketed as preventive medication

Rosuvastatin calcium is now approved as a preventive measure for people who do not have cholesterol problems. The drug’s new label says it may be prescribed for apparently healthy people if they are older –– men 50 and over and women 60 and over –– and have one risk factor like smoking or high blood pressure, in addition to elevated inflammation in the body. The FDA "approved the new criteria last month.

Dark chocolate may lower risk of heart attacks, strokes

According to a study published March 31 in the European Heart Journal, a daily nibble of dark chocolate may slash the risk of heart attacks and strokes by more than one-third. In "a study of 20,000 middle–aged" people, investigators from the German Institute of Human Nutrition tracked participants for a decade to unravel the ties between chocolate and heart disease, and unexpectedly found the biggest benefit lay in warding off strokes. People who had an average of six grams of chocolate per day –– or about one square of a chocolate bar –– had a 39 percent lower risk of either a heart attack or stroke. Experts think the flavonols contained in chocolate are responsible. People who ate the most chocolate also had blood pressure that was about one point systolic and 0.9 point diastolic...lower than people who ate the least amount of chocolate.

Link Between Anticonvulsants and Suicide Reaffirmed

New use of anticonvulsants is associated with an increased risk of suicidal acts. Gabapentin, lamotrigine, oxcarbazepine, and tiagabine were all linked to an elevated risk of attempted or completed suicide compared with topiramate, (HRs ranging from 1.42 to 2.41) (Dr Elisabetta Patorno, Brigham and Women’s Hospital in Boston April 14 issue of the Journal of the American Medical Association).

Conference Calendar

National Conference on Medical Response to Mass Casualty Management 2010
Date: 6th and 7th May, 2010;
Venue DRDO Bhavan, New Delhi
Hosts: NDMA, MoH & FW, CDC Atlanta, AIIMS, DRDO
Website http://jpnatc.com/conference/mrmcm2010

Mnemonic of the Day (Dr Prachi Garg)

Altered Mental State – AEIOU TIPS

Alcohol (drugs)





Toxins / Trauma / Tumor

Infections Psychosis / Porphyria

Space occupying lesion / Stroke / Seizure / Shock

What’s New

0.5 percent erythromycin ophthalmic

Due to a shortage of 0.5 percent erythromycin ophthalmic ointment in the US, the Food and Drug Administration (FDA) recommends that this ointment be used only for neonatal prophylactic eye care.

If 0.5 percent erythromycin ophthalmic ointment is unavailable, the Center of Disease Control (CDC) recommends 1 percent azithromycin ophthalmic solution (1 to 2 drops placed in the conjunctival sac of each eye) for neonatal prophylactic eye care.

1. Food and Drug Administration. Erythromycin Ophthalmic Ointment Shortage. www.fda .gov/ Drugs/ DrugSafety/ Postmarket Drug Safety Informationfor Patientsand Provi ders/ucm 181113.htm. (Accessed September 30, 2009).

2. Centers for Disease Control and Prevention. CDC Guidance on Shortage of Erythromycin (0.5%) Ophthalmic Ointment – September 2009. www.cdc.gov/ std/ treatment/ 2006/ erythromycin Ointment Shortage.htm. (Accessed September 30, 2009).

Quote of the day

"Passion makes the old medicine new: Passion lops off the bough of weariness.
Passion is the elixir that renews: How can there be weariness
when passion is present?
Oh, don’t sigh heavily from fatigue: seek passion, seek passion, seek passion!" – Rumi

Diabetes Fact

Normal BP < 120/80 mm Hg; in diabetes keep it lower than < 130/80 mm Hg; keep it lower than 110/70 (when urinary proteins are > 1 gram in 24 hours)

Public Forum (Press Release for use by the newspapers)

Heart disease may present with asthma like symptoms

Heart disease may present with asthma like symptoms said Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

Dr Aggarwal said that the commonest cause of breathlessness is not asthma. Both obesity and anemia can also cause exertional breathlessness. Uncontrolled blood pressure, diastolic dysfunction inability to relax of the heart and enlarged heart can also cause breathlessness.

The thumb rule is that any breathlessness appearing for the first time in life after the age of 40 is cardiac in nature unless proved otherwise.

Impaired relaxation function of the heart is a new epidemic of the society where the heart arteries do not have any blockages but the heart cannot relax properly.

Diastolic functions of the heart can be evaluated by tissue Doppler Echocardiography examination. Ordinary echo exam may miss the diagnosis as it usually detects the contracting systolic functions of the heart.

Question of the day

What’s the first line of therapy for multiple plane warts on the face in adults and children?

When affordability is not a problem, I topical imiquimod cream (5%) can be used as first line therapy. In a patient who cannot afford it, I use topical tretinoin (0.05%) can be used to induce minimal irritation.

eMedinewS Try this it Works

Tremor in Graves’ disease

Placing a sheet of paper on the patient’s outstretched palms provides helpful information. This "paper shaker" phenomenon illustrates tremor more clearly than does viewing the hands alone.

Dr Good Dr Bad

Situation: An elderly patient came with low energy levels.

Dr Bad: It may be due to diabetes.

Dr Good: Get TSH done.

Lesson: Diabetes mellitus and primary hypothyroidism are common disorders in elderly subjects. Since the clinical features of hypothyroidism in the elderly are often atypical, it is recommended that elderly subjects should be screened for hypothyroidism. (Eur J Epidemiol 2000;16(1):43–6)

Make Sure

Situation: A 62–year–old diabetic with coronary artery disease, on treatment for the same, comes for follow up.

Reaction: Oh my God! Why didn’t you put him on antioxidants?

Make Sure
to add anti–oxidants to the prescription because of their free radical scavenging and other beneficial effects.


Laughter the best medicine

As the doctor completed an examination of the patient, he said, "I can’t find a cause for your complaint. Frankly, I think it’s due to drinking." "In that case," said the patient, "I’ll come back when you’re sober"

Formulae in Critical Care

Plasma volume

Formula: Plasma volume = 43–44 ml/kg lean body weight

Milestones in Medicine

Louis Pasteur’s unveiling of the rabies vaccine in 1885 paved the way for every other vaccine. The discovery has saved millions of lives.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Iron Deficiency Anemia

Iron deficiency anemia is the most common cause of anemia.Tests include a complete blood count (CBC) with a detailed blood smear report, Serum iron, Ferritin, Total iron–binding capacity (TIBC) and transferrin and Fecal occult blood test (FOBT).

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name


Approval Date

Hydroxy ethyl starch 10% Solution for infusion

For the treatment of imminent or manifest hypovolemia and shock.


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Contact: drkk@ijcp.com or emedinews@gmail.com

eMedinewS–PadmaCon 2010 

Will be organized at Maulana Azad Medical College, New Delhi on July 4, 2010, Sunday to commemorate Doctors’ Day. The speakers, chairpersons and panelists will be doctors from NCR, who have been past and present Padma awardees.

eMedinewS–revisiting 2010

The second eMedinewS–revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, cultural hungama and live webcast. Suggestions are invited.

IMANDB Annual Day Meet : Scientific feast

Date: Sunday April 25, 2010,  Venue: Moolchand Medcity Auditorium, New Delhi

Scientific Program: 4–7 PM

4 PM–5.00 PM: Fatty Liver, Workshop for GPs: Dr KK Aggarwal

5.00 PM–6.00 PM

a. Cardiac Interventions: Dr Mohan Bhargava

b. Endovascular Approach to Aortic Disorders

6.00 PM – 7.00 PM

Medical Ethics: A panel discussion: Dr Ashok Seth, Dr Sudesh Ratan, Dr Rajiv Khosla, Dr KK Aggarwal, Dr Girish Tyagi, Dr Sanjiv Malik, Dr H K Chopra, Dr Madhu Handa

Annual Day Function: 7–8 PM

Eminent Guests: Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, Dr Narender Saini (President DMA), Dr Vinod Khetrapal (President Elect DMA), Dr Ashwini Dalmiya (Secretary DMA), Dr Girish Tyagi (Secretary DMC), Dr Madhu Handa

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Readers Responses

  1. Dear Dr KK, Rightly informed by you. Alcohol and smoking is a lethal combination. As per Goodman Gilman text book of pharmacology, people who take alcohol and simultaneously smoke have 14 time higher risk of cerebral stroke. With regards: Dr Satish Chugh
  2. Congratulations Sir, saw the programme on TV and felt really proud to be your student: Dr. Pranjali
  3. Only two types of people are happy in the world first the Madcap and second is a child. Be mad enough to achieve what you desire and be a child to enjoy what you have achieved. Congratulations: Chitra

  4. Hi Sir, Congrats: Capt. M K Tayal, The Correspondent