Pulmonary and Cardio Treatments Flashcards
PE treatment
Provoked DVT of calf or upper extremity: 3 months of anticoagulation
Provoked DVT of proximal leg: 6 months of anticoagulation
Unprovoked, malgnancy or antiphospholipid: indefinite
IVC filter: prevents recurrent PE, during active bleeding or other contraindication
Primary: clot dissolution with thrombolysis or surgical removal reserved for those with high risk of adverse outcomes: RHF or hypotension
Secondary: Anticoagulation-unfractionated heparin (must be monitered every 4-6 hrs) right away
subcutaneous LMWH (enoxaprin or tinzaparin) or direct factor Xa inhibitor (fondaparinux)
Warfarin-overlapped with UFH or LMWH for 5 days-INR goal of 2.5 for 2 consecutive days
Duration of treatment relates to risk of recurrence
PE imaging choice
chest CT with intravenous contrast
CT contraindicated (renal insufficiency or contrast allergy)-use V/Q scan
Both negative but still have a suspicion=lower extremity ultrasound
Hemodynamically unstable patient in A. Fib
Meaning shock or hypotension symptoms
Urgent direct cardioversion
Electrical better than pharmocological
Pharm if electrical failed: procainamide, flecainide, sotalol or amiordarone
Hemodynamically stable patient in A. fib
Ventricular rate control-IV Beta blockers, CCBs or digoxin
Persistently symptomatic A. fib
electrical cardioversion with 3 to 4 weeks of anticoagulation prior to and after cardioversion
Goal INR or 2-3
Wolf Parkinson Wright Diagnosis and treatment
Diagnosis: narrow complex tachycardia, short PR interval, delta wave
Treatment: procainamide, quinidine or amiordarone
Radiofrequency catheter ablation
drugs to avoid in wolf parkinson wright syndrome
Beta blockers
Verapamil
Other AV nodal blockers
May paradoxically increase the ventricular rate
Best initial test for all forms of chest pain
ECG
Treatment of Angina
Mild (normal EF,, mild angina, single vessel disease)
Nitrates and B blockers
Moderate (normal EF, moderate angina, two vessel disease)
Try nitrates and B blockers
consider coronary angiography to assess suitability for revascularization-PCI or CABG
Severe (decreased EF, severe angina, and three vessel/LAD)
Coronary angiography and consider CABG-decrease symptoms
Treatment of unstable angina
Acute Aspirin +Clopidogrel-9-12 mos BB blockers Enoxaparin (LMWH)-2 days Nitrates Oxygen Abciximab, tirofiban
After acute
Continue aspirin, B blockers, and nitrates
Reduce smoking, weight, diabetes, HTN, hyperlipidemia
Treatment of cardiac tamponade
relief of pericardial pressure either echocardiographically guided pericardiocentesis or surgical pericardial window
While waiting treat with IV fluids (cardiac tamponade is preload dependent)
Treatment of constrictive pericariditis
Resection of pericardium
Treatment of acute MI
Aspirin/heparin Beta blockers Nitrates morphine supplemental O2
ST segment elevation-thrombolytics within 1-3 hours
PCI perferred within 90 mins
when to use angioplasty in acute MI
less than 1 hour Contraindication to lytic therapy-major recent surgery active internal bleeding, or suspected acortic dissection, severe hypertension, or a prior history of hemorrhagic stroke Cardiogenic shock Refractory ventricular arrythmia large infract size
Treatment of COPD
Most importantly smoking cessation
B2 agonists for symptomatic relief
Anticholinergic (ipratropium bromide)-longer acting
Both together work better than separate
Inhaled corticosteroids (budesonide, fluticasone)-significant symptoms or repeated exacerbations
Systemic Corticosteroids and antibiotics (azithromycin/levofloxacin) for acute exacerbations, change in sputum, or increased SOB (IV methylpredinsolone)
Possible noninvasive positive pressure ventilation may be necessary
Theophylline if unresponsive to everything else
O2-imporves survival and QOL of those with COPD and chronic hypoxemia (pO2 55%)
Flu vaccine annually
Strep pnemo vaccine every 5-6 yrs if >65 or have severe disease
intubation Acute respiratory acidosis and CO2 retention
Treatment of asthma
Inhaled B2 agonists for acute attacks Long acting (salmeterol)-nighttime and exercise induced
Inhaled corticosteroids for moderate to severe asthma
Montelukast-prophylaxis of mild exercise induced and moderate persistent asthma
Cromolyn sodium/nedocromil sodium-prophylaxis
Treatment of acute exacerbation of asthma requiring hospital admission
Inhaled B2 agonist with ipratropium-first line
Corticosteroids-IV or orally
IV Mg- if not responsive to other therapies
Antiobiotics
Endotracheal intubation if in respiratory failure-hypercapnia
Treatment of Bronchiectasis
antiobiotics for acute exacerbations
Hydration
Chest physiotherapy-postural drainage, chest percussion
Inhaled bronchodilators
Treatment of CF
pancreatic enzyme replacement Fat soluble vitamin supplements Chest physical therapy Vaccinations-influenza and pneumococcal Antibiotics Inhaled recombinant human deoxyribonuclease
Treatment of pleural effusions
Transudative (CHF, cirrhosis, nephrotic syndrome)
Diuretics and sodium restriction
Therapeutic thorancentesis if causing dyspnea
Exudative: treat underlying disease
Thorancentesis
Pleural effusion with pneumonia
Antibiotics
Complicated or empyema: chest tube drainage, intrapleural injection of thromboytic agents, surgical lysis of adhesions
Treatment of empyema
aggressive drainage of the pleura sometimes repetitive
If severe and persistent rib resection and open drainage
Treatment of pneumothorax
Primary spontaneous
small and asymptomatic: observation or one way valve chest tube
Large or patient is symptomatic: supplemental O2
Chest tube
Secondary complicated pneumothoraxx
chest tube drainage
Treatment of tension pneumothorax
medical emergency-do not obtain CXR
Chest decompression with large bore needle (2nd or 3rd intercostal space in MCL)
Followed by chest tube placement
Sarcoidosis treatment
Systemic corticosteroids
Methotrexate for those refractory to corticosteroids
Wegener’s granulomatosis treatment
immunosuppressive agents and glucocorticoids
churg-strauss syndrome treatment
glucocorticoids
Treatment of berylliosis
glucocorticoid therapy
Treatment of Goodpastures syndrome
Plasmapharesis, cyclophosphamide, and corticosteroids
Treatment of idiopathic pulmonary fibrosis
Most do not respond to anything
Supplemental O2
Corticosteroids with or without cyclophosphamide
lung transplantation
Hypercarbic respiratory failure treatment
High flow venturi mask preferred because one can control oxygenation more precisely
NPPV given to patients in impending respiratory failure in an attempt to avoid intubation and mechanical ventilation -patient should be neurologically intact, awake and cooperative
Treatment of ARDS
O2 saturation above 90%-FiO2 levels of 50-60% are desirable
Mechanical ventilation with PEEP
Vasopressors to maintain BP
Tube feedings preferred over parenteral nutrition
Treatment of primary pulmonary hypertension
IV prostacyclines (epoprostenol) and CCBs
Possible vasodilators ( inhaled NO, IV adenosine, oral CCB)
Anticoagulation with warfarin
Lung transplantation
Bosentan
Diagnosis and treatment of MI
Diagnosis: ECG: peaked T waves-early, ST segment elevation: transmural q waves-late, T wave inversion, ST segment depression (subendocardial injury)
Cardiac enzymes: gold standard for Myocardial injury
Troponins: increases 3-5 hours and returns to nromal in 5-14 days, reaches peak in 24-48 hours
Get on admission and every 8 hours for 24 hrs
Ck-MB: increases within 4-8 horus and retursn to normal in 48-72 hours
Treatment: Supplemental O2 Aspirin-reduces mortality B-blockers-reduce mortality and remodeling (carvedilol for post MI LV dysfunction) ACE inhibs: reduce mortality (ramipril) Statins-atorvastatin Nitrates (IV if persistent pain, hypertension, or HF) Morphine IV Heparin-enoxaparin (LMWH)
Revascularization
thrombolytics-up to 24 hours after onset best within 6 hrs (altepase)
PCI-within 90 minutes
CABG: if mechanical complications, cardiogenic shock, life threatening v. fib, after failure of PCI
Stress test before discharge to determine need for CABG
Clopidiogrel-especially after PCI with stent
Cardiac rehab: physician supervised regmien of exercise and risk factor reduction-reduce symptoms and prolong survival
Contraindications to thrombolytic therapy
recent head trauma or traumatic CPR Previous stroke Recent invasive procedure or surgery Dissecting aortic aneurysm Active bleeding or bleeding diathesis
Papillary muscle rupture treatmetn
Mitral regurgitation produced
Mitral valve replacement surgery
Afterload reduction: sodium nitroprusside or intraarotic balloon pump
Treatment of dressler’s syndrome
aspirin and maybe ibuprofen
Diagnosis and treatment of CHF
Diagnosis:
CXR: Cardiomegaly, Kerley B lines, pleural effusion, prominent interstitial markings
ECHO: Initial test of choice
systolic dysfunction-EF less than 40%, chamber dilation and/or hypertrophy
BNP
ECG: no specific changes
Radionucleotide ventriuclography using technetium-99m:
Cardiac catherization if CAD could be cause of CHF
stress testing
Treatment:
(standard)
Systolic dysfunction: lifestyle modification-sodium restriction, weight loss, smoking cessation, restrict alcohol, exercise, monitor weight, annual flu and pneumoccoal vaccine recommended
Diuretics-(furosemide and spironolactone-reduces mortality in advanced CHF)-symptomatic
ACE inhibs or ARBs-reduce mortality
B-Blockers: reduce mortality post MI-metoprolol, bisoprolol and carvediolol
(additional consdiersations)
Digitalis-EF less than 40% -sypmtomatic for dyspnea
Hydralazine adn isosorbide dinitrates: can’t tolerate ACE inhibs
ICD lowers mortality by preventing sudden cardiac death-40 dyas post MI, EF less than 35%, class II or III Cardiac resyndchonization therapy-lowers mortality-40 dyas post MI, EF less than 35%, class II or III and lon QRS (>120)
Contraindicated medications in CHF
Metformin-lactic acidosis
Thiazolidinediones: fluid retention
NSAIDs: increase risk of exacerbation
Anitarrhthmics that have negative inotropic effects
Diastolic dysfunction CHF treatment
B blockers and diuretics
Treatment of acute decompensated heart failure
Oxygenation and ventilatory assistance with non-rebreather face mask, NPPV, or event intubation
Diuretics: IMPORTANT
Dietary sodium restriction
Nitrates (IV)
Dobutamine if nothing else works with pulmonary edema
Diagnosis and treatment of PACs
Diagnosis: early P waves that differ in morphology from other P waves
Treatment: Asymptomatic or B blockers if palpitations
Diagnosis and treatment of PVCs
wide QRS with P wave not seen
Treatment: asymptomatic: observation
Symptomatic: B blockers
Underlying heart disorder may require ICD
Indications for cardioversion vs. defibrillation vs Automatic implantable defibrillator
cardioversion: A fib, a flutter, VT with a pulse, SVT
Defib: V Fib, FT without a pulse
AID: V fib and VT not controlled by medical therapy
Diagnosis and treatment of A. Fib (A flutter)
Diagnosis: EKG-irregularly irregular rhythym with no P waves
treatment:
hemodynamically unstable-cardioversion
Hemodynamically stable:
Rate control-B blockers
Cardioversion-worsening symptoms or first ever (electrical over pharmacological-procainamide, flecainide, sotalol, amiordarone)
Anticoagulation: A fib greater than 48 horus-3 weeks before cardioversion and 4 weeks after or TEE with no thrombus and only 24 hours of IV heparin and 4 weeks after
Chronic A Fib
B blocker
Anticoag: warfarin if over 60 or with other heart abnormalitites
Diagnosis and treatment of MAT
Diagnosis: variable P wave morphology and variable PR and RR intervals
Treatmetn: improve oxygenation and ventilation
LV function preserved: CCBs, BBs, digoxin, amiordarone, IV flecainide, IV propafenone,
LV function not preserved: digoxin, diliatizem, or amiordarone
Diagnosis, causes and treatment/prevention of paraoxysmal SVT
Causes: digoxin toxicity, caffeine and alcohol
Treatment: valsalva maneuver, carotid sinus massage, breath holding, head immersion in cold water
IV adenosine-agent of choice
IV verampil and IV esmolol or digoxin if LV function preserved
DC cardioversion if drugs not effective or if unstable
Prevention:
Digoxin-drug of choice
Vearpamil or B blockers alternative
Radiofrequency catheter ablation if symptomatic or recurrent
Diagnosis and treatment of V tach
Diagnosis: wide and bizarre QRS complexes
Treatment:
Sustained
Hemodynamically stable and mild symptoms and systolic BP>90=IV amiodarone, IV procanamide, IV Sotalol
Hemodynamically unstable or severe symptoms:
Immediate cardioversion followed with IV amiodarone
All should get ICD unless EF is normal
Nonsustained
No underlying heart disease and asymptomatic: do not treat
Symptomatic, underlying heart disease or inducible: ICD placement
Amiodarone second line
Diagnosis and treatment of V Fib
Diagnosis: no atrial P waves, No QRS complexes
Treatment:
Immediate defibrillation and CPR are indicated
Cardoversion immediately, CPR in interim
If VF persists:
Continue CPR
Intubation
Epinephrine every 3-5 minutes
Attempt to defibrillate again 30-60 secs after epi
Can also try amiodarone followed by shock
If successful
IV infusion of amiadarone
Implantable Defibrillatiors for chronic therapy
Indications ofr cardiac pacemakers
Sinus node dysfunction (sick sinus syndrome)
Symptomatic heart block-Mobitz type II and complete heart block
Symptomatic bradyarrhythmias
Tachyarrthymias to interupt rhythm disturbances
Causes, diagnosis and treatment of dilated cardiomyopathy
Causes: acohol, doxorubicin, adriamycin, CAD, thiamine or selenium deficiency, thryoid, chagas, lyme, SLE, scelroderma, cocaine
Diagnosis: signs of R. and L HF Cardiomegaly S3, S4 mitral and tricuspid regurgitation Atrial or ventricular arrhythmia EKG, CXR and ECHO consistent with CHF
Treatment:
Similar to CHF: digoxin, diuretics, vasodilators, cardiac transplantation
Anticoagulation
Diagnosis and treatment of hypertrophic cardiomyopathy
Increased murmur on Valsalva and standing
Decreased murmur on squatting, handgrip, lying down or straight leg raise
ECHO establishes diagnosis
Treatment: None for asymptomatic
Sympotomatic: B Blockers
Diruetics if fluid retention
Possible A fib treatmetn
surgery: myometcomy-excision of part of myocardial septum
Avoid strenuous exercise
Diagnosis and treatment of restrictive cardiomyopathy
Diagnosis:
ECHO: thickened myocardium and possible systolic ventricular dysfunction
Increased R. atrium and L. atrium size with normal LV and RV size
Amyloidosis has brighter or sparkled appearance
ECG: low voltages or conduction abnormalities, arrhytmias, a Fib
Endomyocardial biopsy may be diagnostic
Treatment:
Treat underlying disease
Give digoxin if systolic dysfunction if present (except in amyloidosis)
Diagnosis and treatment of acute pericarditis
Diagnosis: EKG-diffuse ST elevation and PR depression
T wave inverts
ECHO if pericardial effusion suspected
Treatment:
Can be self limited within 2-6 weeks
NSAIDs and colcichine
Admit if fever, leukocytosis and worrisome features such as pericardial effusion present
Constrictive pericarditis diagnosis and treatment
Diagnosis:
Fibrous scarring of the pericardium
JVD-prominent x and y descents
Kussmaul’s sign: JVD fails to decrease during inspiration
Pericardial knock: abrupt cessation of ventricular filling
EKG: low QRS voltages, generalized T wave flattening, left atrial abnormalities (a. fib)
ECHO: increased pericardial thickness, sharp halt in ventricular diastolic filling and atrial enlargement
CT scan and MRI: pericardial thickening and calcificatiotns
Cath: elevated and equal diastolic pressures in all chambers
Ventricular pressure tracer: rapid y descent
Treatment:
Diuretics
Treat underlying condition
Possible pericardiectomy
Pericardial effusion diagnosis and treatment
Diagnosis:
ECHO-imaging procedure of choice-performed in all patients with acute pericarditis to rule out effusion
CXR-enlargment of cardiac silhouette when >250 mL of fluid has accumulated (an enlarged heart with no pulmonary vascular congestion)
EKG: low QRS voltages, and T wave flattening, electrical alternans
Pericardial fluid analysis
Treatment:
Pericardiocentesis not indicated unless evidence of cardiac tamponade
if small and clinically insignificant repeat echo in 1-2 weeks
Cardiac tamponade diagnosis and treatment
Diagnosis:
Ventricular filling is impaired during all of diastole
Pressures in RV, LV, RA, LA, pulmonary artery and pericardium equalize during diastole
Beck’s triad: hypotension, JVD, and muffled heart sounds
Prominent x descent with absent y descent
Pulsus paradoxus-decrease in arterial pressure during inspiration (greater than 10 mm Hg drop)
ECHO: diagnosis of choice
CXR: enlargement of cardiac silhouette when >250 mL has accumulated, clear lung fields
EKG: electrical alternans
Cath: equalization of all chamber pressures, increased RAP with loss of y descent
Treatment:
nonhemorrhagic tamponade:
Hemodynamically stable-ECHO, CXR, ECG monitoring
Renal failure-dialysis
Not hemodynamically stable: pericardiocentesis indicated, no change then fluid challenge may improve symptoms
Hemorrhagic tamponade-emergent surgery do not delay with pericardiocentesis
Diagnosis and treatment of mitral stenosis
Opening snap followed by diastolic rumble
loud s1
Heard best with bell in left lateral decubitus position
Diagnosis: CXR: left atrial enlargement ECHO: left atrial enlargement Thick, calcified mitral valve Narrow fish mouth shaped orifice
Treatment:
Diuretics-for pulmonary congestion and edema
B-blockers: decrease heart rate and cardiac output
Infective endocarditis prophylaxis
Chronic anticoagulation with warfarin
surgery: percutaneous balloon valvuloplasty
Aortic stenosis diagnosis and treatment
Diagnosis:
crescendo-decrescendo systolic murmur, heard in right intercostal space, radiates to carotid arteries
soft S2 and maybe single
S4
Parvus et tardus-diminished and delayed carotid upstrokes
Sustained PMI
CXR: calcific aortic valve, enlarged LV/LA
EKG: LVH, LA abnormality
ECHO: diagnostic-thickened, immobile aortic valve and dilated aortic root
Cath: definitive-measures valve area (less than .8 cm indicates severe stenosis) useful before surgery
Treatment: aortic valve replacement if symptomatic
Aortic Regurgitation diagnosis and treatment
Diagnosis: palpitations worse when lying on left side, head bobbing, uvula bobbing, pistol shot sound heard over femoral arteries
Cyanosis and shock in acute AR
Widened pulse pressure
Diastolic decrescendo murmur best heard at left sternal border
Water hammer pulse-wrist and femoral arteries
Displaced PMI, S3
CXR: LVH, dilated aorta
ECG: LVH
ECHO: assess LV size and function, dilated aortic root and reversal of blood flow in aorta
Cath: to assess severity and degree of LV dysfunction
Treatment
Asymptomatic: salt restrictiotn, diuretics, vasodilators, digoxin, afterload reduction (ACE inhibs, or arterial dilators) and restriction on strenuoues activity
Symptomatic: aortic valve replacement-significant LV dysfunction on ECHO
Endocarditis prophylaxis before dental and GI/genitourinary procedures
Diagnosis and treatment of tricuspid regurgitation
Diagnosis:
Asymptomatic unless development of RHF/pulmonary HTN
Pulsatile liver
Prominent V waves in jugular venous pulse with rapid y descent
Blowing holosystolic murmur at LLSB
A fib
ECHO: measures pulmonary pressures and extent of TR
ECG: RA and RV enlargement
Treatment:
Diuretics for volume overload and venous congestion/edema
Treat underlying disease
Surgery if there is no pulmonary HTN-native valve repair or valvuloplasty of tricuspid ring
Mitral Valve prolapse diagnosis and treatment
Diagnosis:
midsystolic or late systolic clicks
Mid to late systolic murmur
Increases with valsalva and standing, decreases with squatting
ECHO
Treatment:
Asymptomatic: reassurance
Chest pain: B blockers
Generally benign
Rheumatic heart disease diagnosis and treatment
Diagnosis: JONES Migratory polyarthrtis Cardiac involvement-pericarditis, CHF, valve disease Nodules Erythema marginatum Sydenham's chorea
Fever, increased ESR, polyarthralgias, prior history of rheumatic fever, prolonged PR interval, previous strep. infection
Treatment:
treat with strep pharyngitis-penicillin or erythromycin
Acute RF treated with NSAIDs-monitored by CRP
Patient with a history of RF should receive prophylactic erythromycin and amoxicillin for dental/GI/genitourinary procedures
Infective endocarditis diagnosis and treatment
Diagnosis:
Major:
Sustained bacteremia by organism known to cause endocarditis
Endocardial involvement: TRANSESOPHAGEAL echo-vegetation, abscess, valve perforation, prosthetic dihiscence,
New valvular regurgitation
Minor:
Predisposing condition
Fever
Vascular phenomena-arterial or pulmonary emboli, intracranial hemorrhages, janway lesions
Immune phenomena-osler nodes, Roth spots, glomerulonephritis, RF
Positive blood cultures
Positive echo
Treatment:
parenteral antiobiotics depending on organism for 4-6 weeks
Cultures negative but high suspicision-treat empirically with penicillin (or vanco) plus an aminoglycoside
prophylactic amoxicllin before oral, GI or GU surgery
Location of Libman-Sacks endocarditis
Aortic valve on both sides
Diagnosis and treatment of hypertensive emergency
Systolic BP greater than 220 and/or diastolic BP>120 in addition to end-organ damage-immediate treatment indicated
Without end organ damage=urgency
End organ damage
Eyes: papilledema
CNS: altered mental status or intracranial hemorrhage
hypertensive encephalopathy
Kidneys: renal failure, hematuria
Heart: unstable angina, MI, CHF with pulmonary edema, aortic dissection
Lungs: pulmonary edema
Treatment:
Lower BP by 25% in 1-2 hours
Severe (diastolic pressure >130) or hypertensive encephalopathhy-IV hydralzine, esmolol, nitroprusside, labetaolol, or nitroglycerin
Less immediate danger-oral captopril, clonidine, labetalol, nifedipine and diazoxide
Urgency: BP lowered within 24 hours using oral agents
Then perfrom CT to rule out intracranial hemorrhage and then LP if no bleeding
Urgency
Long term prophylaxis for COPD
Anticholinergic not corticosteroids
Diagnosis of ventricular aneurysm
5-3 months post no
Persistent ST elevation and deep Q waves
Echo
Diagnosis and treatment of aortic dissection
Diagnosis: CXR shows widened mediastinum
TEE has high sensitivity and specificity-can be performed acutely at bedside
CT or MRI are both accurate
Treatment: IV B Blockers and IV sodium nitroprusside
Type A: surgical management to prevent MI, aortic regurgitation and cardiac tamponade
Type B: Lower BP with IV B blockers-labetalol, esmolol or propanolol
Pain control with morphine or dilaudid
Diagnosis and treatment of abdominal aneurysm
Diagnosis
palpable pulsatile abdominal mass on physical exam
Ultrasound-test of choice
CT scan-preoperative planning
Treatment:
Aneurysm is >5 cm diameter or symptomatic: surgical resection wiht synthetic graft placement
Aneurysm less than 5 cm than periodic imaging is indicated
Ruptured AAA: emergency surgical repair
Peripheral Vascular disease diagnosis and treatment
Diagnosis: ankle to brachial index Normal ABI=.9-1.3 ABI > 1.3=noncompressible vessels and indicates severe disease Claudication=ABI less than .7 Rest pain =ABI is less than .4
pulse volume recordings:
Excellent assessment of segmental limb perfusion
Arteriography: gold standard (arteriogram)
Treatment: Stop smoking Graduated exercise program Atherosclerotic risk factor reduction Avoid temperature extremes Aspirin with ticlopidine/clopidogrel Cilostazol
Surgery:
indications: rest pain, ischemic ulcerations, severe symptoms refractory to conservative treatment
Angioplasty-first
Surgical bypass grafting
Diagnosis and treatment of acute arterial occlusion
Pain, pallor, polar, paralysis, paresthesias, pulselessness
Diagnosis
Arteriogram,
ECG to look for MI, Afib
Echo-to look for clots, evaluate valves, MI
Treatment:
Assess viability of tissues to salvage the limb
Skeletal muscle can tolerate 6 hrs. of ischemia
Immediately anticoagulate with IV heparin
Emergent surgical embolectomy
Thrombolytics are possible
Diagnosis and treatment of DVT
Diagnosis:
Doppler ultrasound
Venography-most accurate for calf veins
D-dimer has high sensitivity but low specificity
High/Intermediate pretest probability of DVT:
Doppler ultrasound +=begin antigcoagulation
Non diagnositic=repeat US every 2-3 days for up to 2 weeks
Low/intermeidated pretest probability
Doppler ultrasound negative-no need for anticoagulation
Repeat ultrasound in 2 days
Treatment
Anticoagulation: heparin bolus and titrated to maintain PTT at 1.5-2x the aPTT
Start warfarin and continue for 3-6 months once INR is 2-3 for 48 hours
Thrombolytics
indicated with massive PE, hemodynamically unstable, evidence of RHF, no contraindcations
Prophylactic IVC filter-high risk
Diagnosis and treatment of cardiogenic shock
Diagnosis right atrial pressure: increased O2 saturation: decreased CO: decreased SVR: increased PCWP: increased EKG: St elevation indicating MI or arrhytmia ECHO: estimates EF Hemodynamic monitoring: swan Ganz catheter
Treatment: MI treatment if indicated Dopamine-initial drug used dobutamine-further increases CO NO fluids instead use diuretics intraaortic balloon pump possibly
Diagnosis and treatment of hypovolemic shock
Diagnosis: Right atrial pressure: decreased O2 saturation: decreased CO: decreased SVR: increased PCWP: decreased decreased central venous pressure Central venous line or pulmonary artery catheter can help monitor
Treatment:
probably requires intuation and mechanical ventilation
IV hydartion
Crystalloid with appropriate electrolytes for hemorrhage
Diagnosis and treatment of septic shock
Diagnosis: Right atrial pressure: decreased O2 saturation: increased CO: increased SVR: decreased PCWP: decreased Blood cultures warm extremities EF decreased
Treatment:
broad spectrum antibiotics at max doses
Surgical drainage
Fluid adminstartion to increase mean BP-may not respond
Dopamine (first line) and NE (second line)
Neurogenic shock diagnosis and treatment
Diagnosis Decreased CO Decreased SVR Decreased PCWP Warm extremities Bradycardia
Treatment IV fluids Vasoconstrictors=cautiously Supine or tranelenburg position Maintain body temp
SIRS criteria
fever >38 or hypothermia less than 36
Hyperventlation: rate >20 or PaCO2 less than 32
tachycardia >90
increased WBC count
