Pulmonary and Cardio Treatments Flashcards Preview

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Flashcards in Pulmonary and Cardio Treatments Deck (77):
1

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

2

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

3

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


4

Hemodynamically stable patient in A. fib

Ventricular rate control-IV Beta blockers, CCBs or digoxin

5

Persistently symptomatic A. fib

electrical cardioversion with 3 to 4 weeks of anticoagulation prior to and after cardioversion

Goal INR or 2-3

6

Wolf Parkinson Wright Diagnosis and treatment

Diagnosis: narrow complex tachycardia, short PR interval, delta wave

Treatment: procainamide, quinidine or amiordarone
Radiofrequency catheter ablation

7

drugs to avoid in wolf parkinson wright syndrome

Beta blockers
Verapamil
Other AV nodal blockers

May paradoxically increase the ventricular rate

8

Best initial test for all forms of chest pain

ECG

9

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

10

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

11

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)

12

Treatment of constrictive pericariditis

Resection of pericardium

13

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

14

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

15

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

16

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

17

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

18

Treatment of Bronchiectasis

antiobiotics for acute exacerbations

Hydration
Chest physiotherapy-postural drainage, chest percussion

Inhaled bronchodilators

19

Treatment of CF

pancreatic enzyme replacement
Fat soluble vitamin supplements
Chest physical therapy
Vaccinations-influenza and pneumococcal
Antibiotics
Inhaled recombinant human deoxyribonuclease

20

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

21

Treatment of empyema

aggressive drainage of the pleura sometimes repetitive
If severe and persistent rib resection and open drainage

22

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

23

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

24

Sarcoidosis treatment

Systemic corticosteroids

Methotrexate for those refractory to corticosteroids

25

Wegener's granulomatosis treatment

immunosuppressive agents and glucocorticoids

26

churg-strauss syndrome treatment

glucocorticoids

27

Treatment of berylliosis

glucocorticoid therapy

28

Treatment of Goodpastures syndrome

Plasmapharesis, cyclophosphamide, and corticosteroids

29

Treatment of idiopathic pulmonary fibrosis

Most do not respond to anything
Supplemental O2
Corticosteroids with or without cyclophosphamide
lung transplantation

30

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

31

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

32

Treatment of primary pulmonary hypertension

IV prostacyclines (epoprostenol) and CCBs
Possible vasodilators ( inhaled NO, IV adenosine, oral CCB)
Anticoagulation with warfarin
Lung transplantation
Bosentan

33

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

34

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

35

Papillary muscle rupture treatmetn

Mitral regurgitation produced
Mitral valve replacement surgery
Afterload reduction: sodium nitroprusside or intraarotic balloon pump

36

Treatment of dressler's syndrome

aspirin and maybe ibuprofen

37

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)

38

Contraindicated medications in CHF

Metformin-lactic acidosis
Thiazolidinediones: fluid retention
NSAIDs: increase risk of exacerbation
Anitarrhthmics that have negative inotropic effects

39

Diastolic dysfunction CHF treatment

B blockers and diuretics

40

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

41

Diagnosis and treatment of PACs

Diagnosis: early P waves that differ in morphology from other P waves

Treatment: Asymptomatic or B blockers if palpitations

42

Diagnosis and treatment of PVCs

wide QRS with P wave not seen

Treatment: asymptomatic: observation
Symptomatic: B blockers

Underlying heart disorder may require ICD

43

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

44

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

45

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

46

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

47

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

48

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

49

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

50

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

51

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

52

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)

53

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

54

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

55

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

56

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

57

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

58

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

59

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

60

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

61

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

62

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

63

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

64

Location of Libman-Sacks endocarditis

Aortic valve on both sides

65

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

66

Long term prophylaxis for COPD

Anticholinergic not corticosteroids

67

Diagnosis of ventricular aneurysm

5-3 months post no
Persistent ST elevation and deep Q waves
Echo

68

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

69

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

70

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

71

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

72

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

73

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

74

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

75

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)

76

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

77

SIRS criteria

fever >38 or hypothermia less than 36
Hyperventlation: rate >20 or PaCO2 less than 32
tachycardia >90
increased WBC count