Transcript Study Guide 4 - Medical Education Online

In the Name of God
Obstetrics Study Guide 4
Mitra Ahmad Soltani
2008
References 1
•
ACOG committee opinion. Ethics in Obstetrics and Gynecology.second edition.2004
•
Anderoli Thomas E, et al. Cecil Essentials of Medicine. 5th edition. W.B.Saunders; 2001
See: www.merckmedicus.com/ppdocs/us/common/cecils/chapters/106_006.htm
•
British guideline on the management of asthma in adults, The British Thoracic Society & Scottish Intercollegiate Guidelines Network
Thorax 2008 May; 63 (Suppl 4) : 1-121.
See: http://www.brit-thoracic.org.uk/ClinicalInformation/ Asthma/AsthmaGuidelines/tabid/83/Default.aspx
•
www.cdc.gov/asthma/speakit/slides/managing_asthma
•
Braunwald Eugene, et al. Harrison's Principles of Internal Medicine. 16th edition. McGrawHill; 2005
•
•
•
•
Braunwald et al. IHD clinical practice guidelines. 2002
Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22nd Ed . New York : Mc Graw Hill, 2005.
Gibson P. HTN in Pregnancy. emedicine.DEC 13. 2007
Hogg K, Dawson D, Mackway K. Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary
Embolism Diagnosis) study .2006
See: emj.bmjjournals.com/cgi/content/full/23/2/123
•
Iranian Council for Graduate Medical Education. Exam questions.1998-2007
•
Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006
•
Katzung Bertram G. Pharmacology: Examinatoin & Board Review.7th edition Mcgrawhill. 2005
•
Marsha D. Ford. Cecil text book of medicine. Acid-Base disorder. Saunders company.2004
•
Massel D, Klein GJ. Guidelines & Policies At The London Health Sciences Centre. 2002. see: www.lhsc.on.ca/uwodoc/pages/policy.htm
•
Yanowitz.ECG learning center.2006
•
Regional ALS Treatment Protocols and Procedures.EMT-Paramedics,1998
•
Safeer ,Richard S., Lacivita ,Cynthia L. Choosing Drug Therapy for Patients with Hyperlipidemia American Family Physician. Vol.
61/No. 11 (June 1, 2000)
References 2
• mentor.wnmeds.ac.nz/groups/rmo/asthma/asthma5.htm
(2006)
• www.rnceus.com/abgs/abgmethod.html. ABG
interpretation method.(2006)
• www.umary.edu/faculty/rschulte/ABG web page
cases.doc. (2006)
• www.lakesidepress.com/pulmonary/books/physiology/c
hap10a.htm.(2006)
• www.en.wikipedia.org/wiki/mechanical_ventilation.
(2006)
• www.hoslink.com/ Laboratory Findings in Heart Disease.
Cardiac Enzymes .(2006)
The process of making decision
for a pregnant case
For Obstetrics cases, a physician faces
complexities stemming from the fetus, a
woman in a narrower definition of health
indices, and the setting. All these are
proceeding dynamically interacting with one
another. There are priorities that should be
considered. This makes “ethics” of outmost
importance in Obstetrics.
Ethical approaches
1-Principle-based approach: It seeks to identify
the principles and rules pertinent to a case.
2-A virtue-based approach : It is focusing on one
course of action would best express the
character of a good physician.
3-Ethic of care: It situates a doctor’s duties in
the context of a pregnant woman’s values and
concerns instead of specifying abstract
principles.
Ethical Approaches- cont.
4- Feminist Ethics approach: seeks to change
factors that limit a woman’s options.
5-A case-based approach: It considers if there
are any relevantly similar cases that constitute
precedents for a given case.
A case
A 22 wk pregnant woman is a known case of ROM. FHR can be
heard. She had a 10 year history of infertility. She says:” I want
to put my life in danger for the very rare chance that may be
the leakage stop”. So she rejects the option of pregnancy
termination. What are possible managements?
A- Termination of pregnancy despite the woman’s objection.
(Principle-based approach)
B-continuation of pregnancy with close observation (Feminist
Ethics approach)
C-Termination of pregnancy telling the woman that her fetal
heart is no longer heard.(This is against virtue-based
approach!)
For a better understanding of how to
implement our knowledge of internal
medicine in a pregnant case, this section of
Obstetrics comes with cases.
HTN
A 25 year old 28 week pregnant woman has developed weight gain, headache and peripheral edema within the last week. Her BP is 150/105 mmHg.
Which drug should not be prescribed for her?
a- Methyldopa
b- ACE inhibitor
c- Hydralazine
d- Nifedipine
Answer:b
What drug is not used for the treatment of preeclampcia?
a- Betablocker
b- Methyldopa
c- ACE inhibitor
d- Hydralazine
Answer:C
Which statement about treatment of HTN with ACE
inhibitors is wrong?
a- They are drugs of choice in diabetics.
b- They can be used in mild renal failure.
c- In unilateral renal artery stenosis, they can be
prescribed if the other kidney has a normal
function
d- They are drugs of choice for pregnancy
Answer:D
What is the accepted screening test for diagnosis of
PIH?
A-Rollover test
B-nitric oxide measurement
C-vascular endothelial growth factor
D-angiotensin test
Ans:A
For a case of severe preeclampsia (BP=180/95) Mg SO4 and C/S
is ordered. An hour after C/S BP falls to 110/75. What is the
reason of BP fall?
A-Delivery removes the effect of vasospasm
B-anesthetic drugs
C-hemorrhage
D-MgSO4 effect
Ans: C
Which is true about edema of preeclmpsia?
A- it has an unknown etiology
B-it is because of increased aldosterone level
C- it worsens the prognosis of preeclampsia
D- it is because of increased DOC
Ans:A
A woman 48 yrs old/ G3/ BP=150/115/ has a high cholesterol
level . Her sister and brother had heart attacks in the age of 40.
Which is wrong about the management of this case?
A-Beta blocker
B- diet
C-methyl dopa
D-regular checking of lab results
Ans: A
In a woman with chronic HTN Which factor has the least effect
in development of superimposed PIH?
A- PIH history
B- low dose aspirin
C- severity of HTN
D-the need for combined drug therapy
Ans:B
What is the most common complication of eclampsia?
A- abruption
B-aspiration pneumonia
C-pulmonary edema
D- direct maternal mortality
Ans:A
Which is true about blindness after eclampsia?
A-It has a bad prognosis
B-It lasts about 1 month
C-it is transient and lasts from 4 hours to 8 days
D-in some people it causes permanent blindness
Ans:C
Which is wrong about eclampsia?
A- eclampsia can cause coma without seizure
B- All patients with eclamsia have had signs of
preeclampsia
C-After seizures respiratory rate is reduced and
cyanosis happens
D- In all cases of eclampsia severe proteinuria is
present
Ans:C
Which therapy can prevent preeclampsia?
A-Low dose aspirin
B-calcium
C-fish oil
D-Antioxidants
Ans:D
A 40 years old woman / G3/P2 /GA=35 wks/ BP=210/110 is in
seizure. What is the best way to control her seizure?
A-Phenytoin loading dose of 1000 mg/h IV
B- Diazepam and creatinin measurement
C- amobarbital sodium 250 mg IV
D- MgSO4 4-6 gr as loading dose
Ans:D
What is the cause of platelet change in preeclampsia?
A- increased production
B- decreased consumption
C- increased platelet aggregation
D- decreased platelet- adhering IG
Ans:A
A woman 25 years old / G1 suffers HELLP syndrome.
What is true about her next pregnancy?
A- there is no increased risk in her next
pregnancy
B-the is increased risk of abruption and
preeclampsia
C-there is no increased risk of preterm labor or
C/S
D-there is no increased risk of IUGR
Ans:B
Which test has a more PPV for detecting PIH?
A-urinary excretion of Kallikrein
B- roll over test
C- angiotensin II
D- hypocalciuria
Ans:A
A pregnant woman GA=29 wks / severe headache/ blurred
vision/ BP= 200/120 has gone through routine tests and MgSO4
infusion. What other steps should be taken?
A-IV hydralazine 20 mg + IV verapamil 10 mg
B-IV hydralazine 5 mg
C- IV labetalol 80 mg
D- sublingual nifedipine 10 mg +thiazide 10 mg
Ans:B
A case of eclampsia with seizure is given MgSO4. She is
agitated. What drug is appropriate for her agitated state?
A-2 gr MgSO4 IV
B- 250 mg amobarbital IV
C- 10 mg diazepam IM
D-no treatment is needed
Ans:B
“A” would be appropriate if a second seizure
occurs
A woman with high blood pressure, proteinuria,
Cr>1.5 mg/dl, has an episode of seizure after 4 hours from her
delivery. What treatment do you suggest?
A-14 gr of MgSO4as the loading dose and then 2.5 gr
q4h up to 24 h after delivery
B-7 gr of MgSO4 as the loading dose and then 2.5
grq4h up to 24 h after the last seizure
C-14 gr of MgSO4 as the loading dose and then 2.5 gr
q4h up to 24h after the last seizure
D-7 gr of MgSO4 as the loading dose and then 2.5 gr
q4h up to 24h after delivery
Ans:C
Which is not among pathophysiological changes of
preeclampsia?
A-reduction in PGE2
B-reduction in prostacyclin
C-increased thromboxane A2
D-increased resistance to angiotensin
Ans: D
Which is wrong about proteinuria of preeclampsia?
A-Some women deliver before proteinuria
occurs
B-1+ proteinuria equals 300 mg protein in a 24
hour sample
C-NPV of a trace or negative dipstick test is
about 30 %
D-PPV of 3+/4+ proteinuria is 70%
Ans:D
For a primigravida in 30 weeks gestation a roll-over test is done.
An increase of 35 mmHG has occurred in diastolic BP. Which is
wrong for this case?
A- She has a high probability of developing
HTN
B-She is abnormally sensitive to angiotensin II
C-increased BP is because of hyperactivity of
parasympathetic system
D-33% of these patients will develop
preeclampsia
Ans:C
Which is wrong for visual disturbances of
preeclampsia?
A-it is because of occipital region lesions
B-if blindness does not resolve within a week , it
will remain permanently
C- It is because of retinal artery spasm that can
resolve by MgSO4
D-it is because of retinal detachment that is most
often unilateral
Ans:B
Which is wrong about superimposed preeclampsia?
A-it occurs earlier in pregnancy and most often
is accompanied by IUGR
B- BP changes remain through life
C-some women have increased BP after 24
weeks gestation
D- above 90% of them have a history of essential
HTN
Ans:B
A woman GA=38 wks/G2/L1/history of chronic HTN is
diagnosed as a case of severe preeclampsia. Her pregnancy is
terminated. Her BP and proteinuria and edema are improved but
she has developed orthopnea. What is your first diagnosis?
A-ATN and overload
B- hypoalbuminemia
C-peripartum cardiomyopathy
D-MS signs aggravated by fluid shift
Ans:C
What drug has the complication of tachycardia?
A-methyl dopa
B-propranolol
C-nifedipine
D-hydralazine
Ans: D
27-Which does not happen in preeclampsia?
A-reduced renal perfusion and GFR
B-increased renin-angiotensin level
C-constant electrolyte concentration
D- increased microangiopathic hemolysis
Ans:B
A woman 32 years old/ NP /obese / 38 wks GA/
mild preeclampsia delivers her child . BP does not decrease after
several IV doses of hydralazine. Which is not a good
management?
A-Im hydralazine
B-oral labetalol
C-thiazides
D-IV MgSO4
Ans:D
HTN drugs of importance
Drug
safety
Dosage
Explanation
SNP
Group C- possibly
unsafe in lactation
(2cc/50 mg)
0.3-0.5
mcg/kg/min
It should be diluted in
250-1000 cc DW5% or
NS. It should be
covered to light by
aluminum foils.
Titrate to desired effect.
Rates>10 mcg/kg/min
may lead to cyanide
toxicity.
TNG
(Isosorbide
dinitrate
10-80 mg po
bid/qid)
-Group C
(1cc/5mg)
-safety unknown in
0.2-10
lactation
mcg/kg/min
- Contraindicated for
Low blood pressure
-Anemia
-Head trauma
-Closed Angle
Glucoma
-Cerebral hemorrhage
It should be
diluted in 50cc
DW5% or NS.
Labetalol
-Group C
20-30 mg
Probably safe
during lactation
Contraindicated
in:
-Cardiogenic
shock
-Pulmonary edema
-Bradycardia
-AV block
-Uncompensated
CHF
It should be injected in 2
minutes IV,
followed by 40-80 mg at
10 min intervals
Amp
propranolol
1mg/ml
Hydralazine Contraindicated
in:
-Hypersensitivity
-Rheumatic heart
disease of Mitral
valve
10-20
mg/dose IV
or IM q4-6
hrs prn
Not to exceed
300 mg/dose
Verapamil -Group C
-Safe in lactation
-Contraindicated in:
CHF
-SSS
-1 &2 degree block
-SBP<90 mmHg
(tab of 40 and
80 mg)
240-480
mg/d/tid.
Clonidine Group C
Unknown safety in
lactation
(Tab 0.2 mg) Not to
0.1 mg bid po exceed 1.2
mg/day
Which is true about a 12 wk pregnant woman with
Eisenmenger syndrome?
A- therapeutic abortion is indicated
B-heparin throughout pregnancy should be
given
C-pregnancy should be terminated when the
fetus is viable
D- she has to be hospitalized throughout
pregnancy
Ans:A
A pregnant woman with artificial valve on heparin has
undergone C/S. When should the anticouagulant be
started after the operation?
A- 6 hours
B- 8 hours
C-24 hours
D- immediately after C/S
Ans:c
-24 hrs after C/S and 6 hrs after vaginal delivery.
(Warfarin has no contraindication during
lactation)
Which is wrong about idiopathic cardiomyopathy in
pregnancy?
A- terbutaline is a predisposing factor
B-ICM has the symptoms of congestive heart
failure
C-ICM is more prevalent in pregnancy than non
pregnant state
D-dyspnea is an important symptom
Ans: c
Therapy is hydralazine and heparin. ACE inhibitors are
contraindicated during pregnancy
Which is more fatal to a pregnant woman?
A-bioprosthetic valve replacement
B-corrected fallot tetralogy
C-pulmonary or tricuspid disease
D- mitral stenosis with AF
Ans:D
Risks of various types of heart dis.
Group 1-min risk:
ASD,
VSD,
PDA,
Pul or tri dis
FT corrected
MS NYHA I, II
Group 2-mod :
MS class III,IV
AS
Aortic Coarctation
FT uncorrected
MI HX
Marfan syn.
MS with AF
Artificial valve
Group3-major:
Pul. HTN
Coarctation +valve
involvement
Marfan +aortic
involvement
A 39 wk pregnant woman in labor has a history of VSD
corrected without a patch. She states a history of
bradycardia and permanent pacemaker six months
prior to her pregnancy. What is true about this case?
A- There is no need for endocarditis prophylaxis.
B- She is in moderate risk group and needs
prophylaxis.
C-She is high risk and needs prophylaxis.
D- Prophylaxis depends on her heart functional
class.
Ans:A
A patient with Mitral Stenosis in class II NYHA suffers
hypotension and tachycardia during labor. Which is a
better management?
A- fluid and electrolyte administration
B-spinal analgesia to reduce pain
C-immediate pregnancy termination
D- beta blocker to reduce heart rate
Ans:D
AF caused by MS is treated by 5-10 mg
verapamil IV or cardioversion
An 8 wk pregnant woman is a known case of Marfan
disease . She has MVP without regurgitation . AR is not
present either. Which is true about this case?
A- Termination of pregnancy is not indicated.
B-She is in class 2B NYHA.
C- The best route of delivery is C/S.
D- The probability of her child suffering from the
same illness is 10%.
Ans:A
Which is wrong about arrhythmia in pregnancy?
A-arrhythmia is increased by pregnancy.
B-most arrhythmias in pregnant women are not
because of organic lesions.
C-Arrhythmia treatment is the same for
pregnant and non pregnant.
D- women with pacemaker should terminate
pregnancy.
Ans:D
Which is not recommended for a pregnant woman with
Mitral Stenosis?
A-Spinal analgesia and IV fluid
B-Beta blockers in tachyarrhythmia
C-heparin for AF
D-cardioversion for AF
Ans: A
The fetus of a 34 wk pregnant woman under general
anesthesia shows persistent bradycardia for 4 hours.
What should be done?
A- C/S
B-no intervention except for vital stability in the
mother
C- glucocorticoids and induction of labor
D- emergency color Doppler for fetal circulation
Ans:B
Which is an indication for C/S ?
A-fallot tetralogy
B- aortic stenosis
C-Marfan with aorta involvement
D- prosthetic mitral valve
Ans:C
A 37 year old woman suffers cardiac disease. She is G3/
P3/ with GA=38wks. She had an NVD. She asks for TL.
Which is not necessary for TL?
A- temperature should be normal
B-anemia should not be present
C- mother should not be in class III or IV
D-48 hrs should pass from delivery
Ans:D
Which is wrong about pregnant women with aortic
stenosis?
A-preload should not decrease and output
should be stable.
B-epidural anesthesia with narcotics should be
used.
C-endocarditis prophylaxis is necessary.
D-surgery is recommended for those resistant to
medical therapy.
Ans:D
A pregnant woman is under heparin therapy for PE. She
is a case of ROM /GA=35 wks /presentation=complete
breech. Which is the best route for pregnancy
termination?
A-vaginal delivery+ heparin
B- C/S + FFP + heparin
C- d/c of heparin, vena cava filter , C/S
D-d/c of heparin + protamine sulfate+ C/S
Ans: C
Which is not a good therapy for an idiopathic
cardiomyopathy in pregnancy?
A- salt restriction and diuretic
B-digoxin if arrhythmia is not present
C- low dose heparin
D- enalapril to reduce afterload
Ans:D
A 35 year old woman with exertional dyspnea in the 4th week after NVD
comes to ED. JVP raised with prominant X and Y waves. Kussmul sign is
positive. S1 and S2 plus another high pitched extra sound can be heard on the
apex. Pulsus Paradox is not detected. Which is the best diagnosis?
a- Tamponade
b-Constrictive pericarditis
c-Restrictive cardiomyopathy
d- Right ventricle infarct
Ans:B
What sign is the least prevalent for constrictive
pericarditis?
a- kussmul sign
b- prominent Y wave
c- prominent X wave
4- pulsus paradox
Ans: D
What is among the signs of Temponade?
a- Kussmul
b-prominent X
c-pericardial knock
d-4th heart sound
Ans:B
For what type of heart failure Carvodilol is a betablocker of choice?
a- class IV
b- Failure with a normal Ejection Fraction
c- previous pulmonary edema stable at present
d- within a short interval of MI
Ans:C
All of the following can be used for cases of pulmonary edema with
systolic left ventricular dysfunction except:
a- IV Digoxin
b-loop diuretic is the diuretic of choice
c-aminophilyne to enhance heart contractility
d-ACE inh to lower afterload
Ans:D
A pregnant woman had seizure after delivery . When her condition was
stabilized she complained of dyspnea and exertional chest pain. BP=160/100
mmHg / PR=90 bpm
heart rhythm= irregular
JVP= raised
Pitting edema =2+
Rales are present. Liver is palpable and tender. No pericardial effusion is
detected. No stenosis or regurgitations of valves can be detected. What
should not be prescribed for this case?
a- Digoxin
b- Nitrates
c- Betablockers
d- Diuretic
Ans:A
Differential Diagnosis of S3 And S4.
(DCMP=dilated cardiomyopathy/ JVP=
jugular vein pressure/
HCMP=hypertrophic cardiomyopathy/
RCMP=restrictive cardiomyopathy)
S3 & S4
Diastolic
Dysfunction
Systolic
Examine JVP
Not raised
Raised
HCMP
Check for Pulsus
Paradox
Negative=
Constrictive
pericarditis
Positive= check for
Kussmaul sign
Positive= RCMP
Negative=
Tamponade
Treatment of different causes of S3 and
S4 gallop
Different causes of S3 &
S4 gallop
HCMP
Treatment
Defibrillator
Amiodarone for AF rhythm
is unsafe during lactation
and is in group D in
pregnancy. Verapamil is
used instead.
Endocarditis prophylaxis
Anticoagulant
Constrictive Pericarditis
RCMP
Salt restriction
Diuretic
pericardiotomy
Anticoagulant
Diuretic
Tamponade
Thoracotomy (in an ordinary
tamponade NS or Blood or
vasopressor may be indicated)
Acute pulmonary edema
Furosemide IV 0.5 to 1 mg/kg
Morphine IV 2 to 4 mg
NTG SL
Oxygen/intubation as needed
Low output cardiogenic shock
SBP<70 mmHg +sign/symptoms of
shock:
Noreinephrine IV 0.5 to 30
mcg/min
SBP=100-70+sign/symptoms of
shock:
DOPAMINE: 5-15 mcg/kg/min IV
SBP=100-70 no sign/symptoms of
shock:
Dobutamine: 2-20 mcg/kg/min IV
SBP>100
NTG=10-20 mcg/min IV
Consider SNP: 0.1-5 mcg/kg/min
IV
ACEinh. if SBP is not<30 mmHg
below baseline.
drug
contraindications
dosage
explanation
Norepinephrine
Hypersensitivity
OHCM
Vascular
thrombosis
(Vial
10mg)
0.5-1
mcg/min
IV inf.
Titrate not to exceed
30 mcg/min
Furosemide
Group C
(Amp 20 mg)
Unknown in
20-80 mg/day
lactation
Contraindicated in:
Hepatic coma
Anuria
Electrolyte depletion
Titrate up to
600 mg/d for
severe edema
Warfarin
Carvedilol
Group x in pregnancy
but safe in lactation.
Contraindicated in:
Bleeding
Peptic ulcer
Open wound
Liver and kidneydisease
Group C
Safety in lactation is
unknown.
Contraindications:
Cardiogenic shock
Pulmonary edema
Bradycardia
AV block
Uncompensated -HF
(Tab 5mg)
5 mg/d
(Tab 6.25 mg)
3.125-0.375 mg po
qd
for 2-4
days
subseque
nt doses
determine
d by INR
Digoxin
Group C
Safe in lactation.
Contraindications:
IHSS
Beriberi
Diastolic heartdysfunction
Carotid sinus-syndrome
(Tab 0.25 mg)
0.125-0.375 mg po qd
Dopamine Chart
Dopamine Chart (gtts/min)
(400mg/250cc Normal Saline)
KGS
40
50
60
70
80
90
100
MCG/MIN
5
8
10
12
13
15
17
19
10
15
19
22
26
30
33
37
15
22
28
33
39
44
50
56
20
30
37
44
52
59
67
74
25
37
46
56
65
74
82
93
Try to diagnose and suggest treatment for the
following ECG strips in pregnant cases.
ECG strips are taken from the site:
Yanowitz.ECG learning center.2006
With permission
ECG1
ECG2
ECG3
ECG4
ECG5
ECG6
ECG7
ECG8
ECG9
ECG10
ECG11
Diagnosis
1-Atrial Fibrillation
In Patient With Wpw
Syndrome
Treatment
Direct Cardioversion
+Lidocaine Or
Procainamide
or
Eibotinide
2-WPW And Pseudo- Betablocker
Inferior Mi –(Q Wave CCB
Is Negative Delta In quinidine
Lead III)
Felcainide
3-Atrial Flutter With Digoxin 0.25
2:1 Av Conduction- Esmolol 0.5 Mg/Kg
Kh
Avoid
Digoxin
Amiodarone
Verapamil
4-V Tach
Verapamil
Adenosine
Amiodaron is not used
in pregnancy
Procainamide 20mg/Min
Lidocain 1 Mg/Kg
Pace
Digoxin
Verapamil
Quinidine
Amiodaron is not used
in pregnancy
Diagnosis
Treatment
Avoid
5-V-Tach
Magnesium-Sulphate
Procainamide
Lidocaine
If failed:
Cardioversion
Lidocaine
Procainamide
Sedative
Betablocker
Lidocaine
Procainamide
Betablocker
Verapamil
Adenosine
Stop Digoxin
Lidocaine
Betablocker
Phenytoin
Digoxin
Esmolol
verapamil
Verapamil
Adenosine
Amiodaron is not used in
pregnancy
6-Unifocal Pvc
7-PAC
8-PVC
9-PSVT
10-Junctional
11-AF
Cardioversion
Amiodaron is not used in
pregnancy
QRS>=150
P>QRS
PAT with
block
P=150250
Flutter
P=250350
P<QRS
AF
P=350600
VT
P
waves=Q
RS
Sinus
PSVT
tachycardia
P=150P= 100250
150
Drug
Dosage
Adenosine
(6mg/2cc vial)
6 mg
Atropine
(1 mg/10cc
syringe)
1mg
Explanation
Repeat in 3 minutes
Bicarbonate
(50Eq/50cc syringe)
1 meq/kg
Digoxin
0.25 mg
Diltiazem
25 mg
Dopamine
(400mg/10cc syringe)
5-20 mcg/kg/min
Epinehrine
(1mg/cc ampule)
2-10mcg/min
Esmolol
0.5 mg/kg
Isoprotrenol
2-10mcg/min
Lidocaine 2% (100mg/5cc
syringe)
0.5mg/kg
Magnesium
1 mg/kg bolus
Repeat 0.5mg/kg until PVC suppressed
If successful:
Base drip rate on total given:
1 mg/kg, drip 2mg/min
1-2 mg/kg, drip 3 mg/min
2-3 mg/kg, drip 4 mg/min
(5 gram/10 cc
vial)
2-4 gram
Procainamide (1 gram/2cc vial)
20mg/min
Verapamil
Then titrate to 0.05-2 mg/min drip
(10 mg/2cc vial)
5 mg
20mg/min until PVC suppressed then
1-4 mg/min
Prophylaxis of
endocarditis
GI or GU
High Risk
patient
Standard
Ampicillin
Allergy
+Gentamycin
before the
Gentamycine
procedure and
+
have to repeat
Vancomycine
Ampicillin after 6
hours
Moderate Risk
Standard
Amoxycillin
Allergy
Vancomycine
Should be
infused One hour
before to 3
minutes after the
procedure
A woman develops chest pain for three days after her delivery.
The peak lasted for 3 hours. In her ECG, Q wave can be seen in
leads V1-V4. what lab test is good for a diagnosis?
A- SGOT
B-CPK-MB
C-LDH
D-ESR
Ans:C
Which one is not considered as acute coronary syndrome?
A-Non-Q wave MI
B- Stable Angina Pectoris
C- Q wave MI
D-Unstable Angina
• Ans:B
Which does not imply a poor prognosis for angina
pectoris:
A- S3
B-S4
C-MR murmurs
D-lower lung rales
Ans:B
Which is not among the absolute contraindications for
thrombolytic agents in acute MI?
A- SBP> 180 mmHg with chest pain
B- Cerebral Hemorrhage 3 years ago
C- pregnancy
D-Aortic dissection
Ans:C
Tall R in lead V1 points to the diagnosis of:
A- Posterior MI
B- Inf MI
C- Anterior Mi
D- Right Ventricular MI
Ans:A
Which is not used as a secondary prevention in MI?
A- beta blockers
B- CCB
C- ACE inhibitors
D- anti platelet drugs
Ans:B
A 20 year old woman has the chief complaint of palpitations.
Each episode lasts for some hours with a chest pain. What is the
most probable diagnosis?
A- WPW syndrome
B- HCMP
C- Prolonged QT syndrome
D- Psychogenic
Ans:D
Indications for echocardiography
• Holosystolic or late systolic murmur
• Grade 3 or midsystolic murmurs
• Murmurs associated with an abnormal ECG or
chest x-ray
• Physical signs of LV dysfunction or CHF
• Enlarged cardiac silhouette and/or signs of
pulmonary venous congestion on chest x-ray
• New Q-waves in 2 or more contiguous leads or
new LBBB
Absolute contraindication for
thrombolytic drugs
• aortic dissection
• acute pericarditis
• active bleeding
• cerebral hemorrhage , known
intracerebral vascular disease
(malignancy , AV malformation) at
any time.
How do you manage these cases of hyperlipidemia:
22- 45 year old woman with no adverse history, TG=300
,HDL=40, Total Cholesterol=200?
Ans:DX=hypertriglyceridemia/TX=niacin&gemfibrozil
23- 45 year old woman with chronic hepatitis, TG=148 ,HDL=45
,Total Chol=292?
Ans:Dx23-DX=hypercholesterolemia/TX=cholestyramine
24- 45 year old woman with a CAD history, TG=450,HDL=40,Total
chol=450?
Ans:DX=dysbetalipoproteinemia/TX=Niacin&Gemfibrozil&
Statins
25-45 year old woman with DM and obesity, TG=280, HDL=36,
total chol=220?
25-DX=hypertriglyceridemia/TX=Niacine&Gemfibrozil
Estimate LDL
level according
to risk factors*
Low LDL
High TG
(>150 mg/dl)
(hypertriglyceride
mia)
Niacin
gemfibrozil
High LDL
VLDL/TG<3/
10
Normal TG
High TG
(Dysbetalipopr
(hypercholeste
(Hyperlipidemia)
oteinemia)
rolemia)
Niacin
Gemfibrozil
statins
Niacin
Gemfibrozil
statins
Niacin
Statin
cholestyramine
Risk-factor score*
LDL goal, by risk-factor score†
Age: men > 45 years; women
>55 years or postmenopausal
without ERT
Current smoker
Hypertension
Diabetes
CHD in first-degree relative
(male relative <55 years; female
relative <65 years)
HDL <35 mg per dL (0.9 mmol
per L); subtract 1 risk factor if
HDL >60 mg per dL
0 to 1 point: <160 mg per dL (<4.15 mmol
per L).If more than 190 needs drug therapy.
2 or more points: <130 mg per dL (<3.35
mmol per L)If more than 160 needs drug
therapy.
Patients with history of CHD: <100 mg per
dL (<2.60 mmol per L).If more than 130
needs drug therapy
A 17 wk pregnant woman had contact with an active TB
patient. She had no BCG vaccine. Her PPD test
measures 7 mm . Her CXR is normal. Which is true
about this patient?
A-PPD is negative. No action is needed.
B- She should receive INH prophylaxis for one year after
her delivery at term.
C-one month INH ,then repeat of PPD
D-PPD should be repeated after delivery at term.
Ans:B
When CXR is normal no treatment is necessary until
after delivery.
PPD reading
Very High risk
High risk
5 mm is positive 10 mm is +
HIV positive
Drug abusersHIV neg
Ab CXR
Recent contact
with an active
case
Predisposing
medical
conditions
Foreign born
Low income
No risk factor
15 mm is +
Treatment
• +PPD and no evidence of active TB are not
treated until postpartum.
• Known recent skin-test convertors are treated.
• Skin test positive women exposed to active
infection are treated.
• HIV positive women are treated.
Treatment is 9 months “HRE”:
• Isoniazide 5mg/kg with pyridoxine 50 mg daily
• +Rifampine 10 mg/kg
• +Ethambutol 5-20 mg/kg daily
-------------------------------------------------------------• Streptomycin is contraindicated in pregnancy
• Pyrazinamide is only given to HIV infected
women who should not receive rifampin.
• Isoniazide should be discontinued if liver
enzymes is increased fivefold over normal
level.
An 8 wk pregnant woman is HIV positive. Her PPD test
is 5 mm and she has abnormal CXR. What is your
mangement?
A-treatment should be delayed till after delivery
B-HRE for 9 months
C-treatment should be started 3 to 6 months
after delivery
D- treatment should be started 12 wks after
delivery.
Ans:B
A 26 wks pregnant woman complains of dypnea. Vital
capacity and tidal volume are increased. Functional
residual capacity and residual volume is reduced. What
is the etiology of her dyspnea?
A- These are physiological changes in pregnancy
B-These are signs of chronic pulmonary disease.
C-These are signs of heart failure
D-These are signs of ARDS due to pulmonary
fibrosis.
Ans:A
Respiratory rate is not changed during preg.
A pregnant woman has the history of bronchial asthma. Her ABG
results shows: PH=7.55 and reduced PaO2 and PaCO2. Her ABG
half an hour after treatment is: no change in PaO2 but a normal
level PaCO2. PH is now 7.30. Which is true for this case?
A-She is recovering. IV should be changed to PO
B-She is deteriorating and needs mechanical
ventilation
C-ABG should be repeated six hours later
D-She is recovering. IV route should be
continued.
Ans:B
Which is wrong about cystic fibrosis?
A- pregnancy can happen despite high rate of
infertility
B- abnormal cervical mucus and delayed
puberty are the causes of infertility
C-the most common colonized microorganism is
staph aureus
D- All patient suffer lung involvement
Ans:C
A 28 wk pregnant woman T=38.5 c /RR=32 per
min/rales in the right lung/productive cough/hb=10
g/dl and Cr=1.8 mg/dl. What is your management?
A-erythromycin 400-1000 mg PO out patient
B-cefotaxime or ceftizoxime for one week
C-beta lactam for three days
D-cefotaxime and erythromycin after
hospitalization
Ans:D
Leukocytosis in pregnancy is defined as more than 15000 WBC in
mL
A 20 wk pregnant woman has severe left calf muscle
pain. In physical Exam her left foot is edematous and
Homan sign is positive . There is diminished pulsations
in the affected foot. What is the best diagnostic
procedure?
A-Impedance Plethysmography
B- Magnetic Rresonance Imaging
C- venography
D-real time and doppler US
Ans:D
A 30 year old 16 wk pregnant woman had close contact
with an active TB. PPD is 5 mm. CXR is negative. What is
your management?
A-INH prophylaxis
B- HRE
C- no prophylaxis
D-streptomycin 1 gr daily for 10 days
Ans:B
A 30 wk pregnant woman complains of coughT T=39 c
and chest pain after a cold. RR is 34 per min. CXR
shows radiologic changes of pneumonia in both lungs
lower lobes. What should be done?
A- This is viral pneumonia. Rest and fluid is all needed.
B- Erythromycin 1 gr q6hrs IV . If not responsive
amantadine 200 mg daily
C-hospitalization and administration of ceftizoxime.
D-Levofloxacin PO BD. If not responsive hospitalization
and erythromycin IV
Ans:C
A 25 year old G1/GA=39 wk pregnant asthmatic woman
is in labor. She takes oral coricosteroid. Which is a
correct management?
A- she needs stress dose of steroid stat and that
should be repeated q8hrs
B-meperidine or morphine are the drugs of
choice for analgesia.
C-general anesthesia is a good choice is she has
to undergo C/S
D-PGF2 is a good treatment of postpartum
hemorrhage.
Ans:A
Which is the earliest sign of ARDS?
A- hyperventilation
B-radiologic changes
C-alveolar edema
D-hypoxemia
Ans:A
A 30 wk pregnant woman is diagnosed to suffer from
ARDS after severe hemorrhage. Which can reduce her
chance of moratlity?
A- surfectant
B-NO
C- Methylprednisolone
D-immunotherapy
Ans:C
Which is a cause of cardiac arrest in ARDS?
A-metabolic and respiratory Acidosis
B-increased residual volume
C-interalveolar fibrosis
D-intra pulmonary shunts
Ans:A
Which is not happening in the fetus of an asthmatic
pregnant woman with hypoxemia?
A-reduced umbilical blood flow
B-increased systemic vascular resistance
C-reduced pulmonary vascular resistance
D-reduced cardiac output
Ans:C
Which is correct about DVT?
A-MRI is a common diagnostic procedure
B-DVT is accompanied by PE in prenatal period
C-PE due to DVT is more in postpartum period
compared to prenatal period
D-DVT is usually manifested by diminished
pulsation
Ans:C
Which is a better analgesic in an asthmatic patient?
A- fentanyl
B-meperidine
C-morphine
D-valium
Ans:A
Which is wrong about status asthmaticus?
A-It doesn’t respond to treatment
B- PGE2 is better tolerated than PGF2
C-stress dose of a steroid is needed in a patient
who takes systemic steroid for more than 4
wks
D-fentanyl is contraindicated for analgesia
Ans:D
A 25 year old 7wk pregnant woman with history of
infertility receives heparin for DVT. Her platelet is
50000. Which statement is wrong about heparininduced thrombocytopenia?
A-It will turn to normal state after 5 days from
the cessation of heparin.
B-In severe cases it may cause thrombosis.
C-platelets should be count in the first 5 days
after initiation of treatment and then after
two wks.
D-Heparin should be d/c and LMWH should be
initiated.
Ans:B
Which is a better indicator of asthma severity in a 28
wk pregnant woman?
A-oxygen therapy duration
B-respond to beta agonists
C-ABG
D-FEV1 measurement
Ans:B
Which is true about amniotic fluid embolism?
A-The first sign is Hypotension
B-detecting trophoblasts and meconium in
blood is the best way of diagnosis
C- right ventricle becomes contracted and
smaller
D-fetal survival is about 70 %
Ans:D
What is the side effect of LMWH?
A- fetal abnormality
B- LBW
C-IUFD
D-maternal osteopenia
Ans:D
What drug triggers bronchospasm in asthma?
A-salysylamide
B-propoxyphen
C-Mefenamic acid
D-choline salycylate
Answer:c
A 30 year old woman after delivery suffers a sudden
attack of dyspnea and chest pain. What can R/O the
PE better?
A- ventilation scan
B- Echocardiography
C- CT scan
D- D-dimer and ultrasound of the lower limb
Ans:A
Which drug is safe in an asthma patient?
A-Timolol for glucoma
B-Atenolol beta1 receptor blocker
C- Propoxyphen
D-Tartrazine
Ans:C
What asthma drug can be used during pregnancy?
A-Salbutamol and beclomethasone
B-salbutamol
C-Beclomethasone
D- Neither can be used
Ans:A
An obese woman suffers dyspnea after delivery.
BP=115/75 mmHg/ PR=110bpm .RR=22/min. Lung
auscultation is normal. Her perfusion scan is normal.
Which statement about her is correct?
A- PE is R/O by a negative perfusion scan
B- Perfusion scan should be repeated
C-Ventilation scan should be done
D- LMWH should be prescribed
Ans:A
A 35 year old woman has an acute asthma attack.
What is the most effective treatment?
A- Glucocorticoids IV
B- Aminophyline IV
C- Adrenaline SC
D- beta agonist aerosol
Ans:D
Which mechanical ventilation is better for a post
thoracic surgery patient?
A- Assist Control Mode
B- Positive End Expiratory Pressure Ventilation
+Intermittent Mandatory Ventilation
C- Pressure Control Ventilation
D- Intermittent Mandatory Ventilation
Ans:C
An asthmatic patient uses beclomethasone aerosol 8
puffs every 6 hours and salbutamol 2 puffs PRN. He
states he uses sabutamol 4 times a day. He has two
dyspnea attack at night each week. What should be
done for him?
A- adding salmetrol 2 puffs /12 hours
B- adding Beclomethasone 12 puffs /6 hours
C- prednisolone PO 10 mg /day
D- leukotrien antagonists 2 tablets/day
Ans:C
A near drowning pregnant woman is in ED. CPR is done.
She is ventilated by mask and ambu bag. She is alert.
BP=90/60 mmHg /T=36c / PR=120 bpm /Rr=30 /min.
Her cardiac rhythm is sinus tachycardia. Pulse oximetry
shows SaO2=83%. Which is the best way to restore her
respiratory function?
A-Bicarbonate
B- Acetazolamide
C- Oxygen
D- CPAP +oxygen
E- Suction of aspirated material and Oxygen
Ans:D
A patient with ARDS is treated by PEEP of 10 cmH2O.
Now she develops pneumothorax. What is her best
treatment at this stage?
A- Assist Control Mode
B- Positive End Expiratory Pressure Ventilation
+Intermittent Mandatory Ventilation
C- Pressure Control Ventilation
D- Intermittent Mandatory Ventilation
Ans:C
Causes of pulmonary edema in
pregnancy
•
•
•
•
•
Preeclampsia
Preterm labor
Fetal surgery
Infection
Use of beta agonists to forestall labor
Causes of ARDS in pregnancy
•
•
•
•
•
•
•
Pneumonia
Sepsis
Hemorrhage
Arsenic poisoning
Preeclampsia
Embolism
Connective tissue
disease substance
abuse
• Irritant inhalation and
burns
• Pancreatitis
• pheochromocytoma
Which of the following cases would warrant immediate
intubation and mechanical ventilation?
a. A comatose patient from drug overdose. PaCO2 51 mm Hg,
PaO2 76 mm Hg, and pH 7.31
b. A 29-year-old woman who is alert but in respiratory distress;
she is breathing 42 times/min. PaCO2 is 38 mm Hg. pH is 7.42,
and PaO2 is 47 mm Hg while breathing 60% oxygen through a
face mask
c. A woman who has severe emphysema who is alert but is in
moderate respiratory distress; RR=24/min. PaO2 is 75 mm Hg
while breathing nasal oxygen at 2 L/min, PaCO2 is 59 mm Hg,
and the pH is 7.37. Her chest x-ray is clear.
Cont.
d. A 29-year-old woman suffering from diabetic
ketoacidosis. Her pH is 7.10, PaCO2 is 26 mm Hg
and PaO2 is 110 mm Hg while breathing room air.
e. A 31-year-old drug addict who responds briefly to
administration of Narcan by opening her eyes and
crying out and then lapses back into a state of
semi-stupor. PaCO2 is 31 mm Hg. pH is 7.38, and
PaO2 is 89 mm Hg while breathing nasal oxygen at
3 L/min.
Answers: Cases a, b, d need mechanical
ventilation+intubation
A comatose 20year old patient is brought to the emergency room
following an overdose of sleeping pills. Because of very shallow
respirations and cyanosis, the patient is intubated before her blood
gas results are known. Initial ventilator settings include a tidal volume
(VT) of 700 cc, a respiratory rate (RR) of 12/min, and an FIO2 of 0.50.
The patient has no spontaneous breathing. Blood gas results obtained
(1) before intubation and (2) 20 minutes later show the following:
pH---PaCO2---PaO2 ----FIO2 ---------VT------ RR
(1) 7.10
79
38
Room air
0
0
(2) 7.25
56
117
50% oxygen
700
12
Following the second blood gas analysis, would you change the FIO2,
the tidal volume, or the respiratory rate'? If so, what settings would
you choose?
Answer
• a= <0.4/ b=700 /c=50 /d=18 / e= / PEEP is
not needed
State whether each of the following is true or false .
Mechanical ventilation is indicated for any patient with a
PaCO2 above 50 mm Hg and a pH less than 7.30.
Answer:false
During controlled positive pressure ventilation, each breath is
initiated by the patient.
Answer:false
During ventilation with positive endexpiratory pressure (PEEP),
the pressure in the upper airways is always above
atmospheric pressure.
Answer:true
A patient receiving intermittent mandatory ventilation (IMV)
is able to alternate spontaneous breathing with machine
breaths.
Answer:true
Continuous positive airway pressure (CPAP) is defined as a
PEEP pressure maintained above 10 cm H2O.
Answer:false
The appropriate FIO2 during the initial stages of
mechanical ventilation is always 1.00 (100%).
Answer:false
Successful ventilatory weaning requires the patient
to have a VD/VT of less than 0.45
Answer:false
A 35-year-old single mother, just getting off the night
shift reports to the ED in the early morning with
shortness of breath. She has cyanosis of the lips. She
has had a productive cough for 2 weeks. Her
temperature is 102.2, blood pressure 110/76, heart
rate 108, respirations 32, rapid and shallow. Breath
sounds are diminished in both bases, with coarse
rhonchi in the upper lobes. Chest X-ray indicates
bilateral pneumonia. Define the problem and suggest
a solution.
ABG results are: pH= 7.44 /PaCO2= 28 /HCO3= 24
/PaO2= 54
Problems:
• PaCO2 is low.
• pH is on the high side of normal, therefore compensated
respiratory alkalosis.
• Also, PaO2 is low, probably due to mucous displacing air in the
alveoli affected by the pneumonia.
Solutions:
• She most likely has ARDS along with her pneumonia.
• The alkalosis need not be treated directly. She is hyperventilating
to increase oxygenation, which is incidentally blowing off CO2.
Improve PaO2 and a normal respiratory rate should normalize the
pH.
• High FiO2 can help, but if she has interstitial lung fluid, she may
need intubation and PEEP, or a BiPAP to raise her PaO2.
• Expect orders for antibiotics, and possibly steroidal antiinflammatory agents.
• Chest physiotherapy and vigorous coughing or suctioning will help
the patient clear her airways of excess mucous and increase the
number of functioning alveoli.
A 52-year-old widow is retired and living alone.
She enters the ED complaining of shortness of
breath and tingling in fingers. Her breathing is
shallow and rapid. She denies diabetes; blood
sugar is normal. There are no EKG changes. She
has no significant respiratory or cardiac history.
She takes several antianxiety medications.
While being worked up for chest pain an ABG is
done:
ABG results are:
pH= 7.48 , PaCO2= 28, HCO3= 22, PaO2= 85
Define the problem and suggest a solution.
Problem:
• pH is high,
• PaCO2 is low
• respiratory alkalosis.
Solution:
• If she is hyperventilating from an anxiety attack, the
simplest solution is to have her breathe into a paper
bag. She will rebreathe some exhaled CO2.This will
increase PaCO2 and trigger her normal respiratory
drive to take over breathing control.
• * this will not work on a person with chronic CO2
retention, such as a COPD patient. These people
develop a hypoxic drive, and do not respond to CO2
changes.
You are in critical care unit about to receive a
24-year-old DKA (diabetic ketoacidosis)
patient from the ED. The medical diagnosis
tells you to expect acidosis. In report you learn
that her blood glucose on arrival was 780. She
has been started on an insulin drip and has
received one amp of bicarb. You will be doing
finger stick blood sugars every hour.
ABG results are:
pH= 7.33 , PaCO2= 25, HCO3=12, PaO2= 89
Define the problem and suggest a solution.
Problem:
• The pH is acidotic,
• PaCO2 is 25 (low) which should create alkalosis.
• This is a respiratory compensation for the metabolic
acidosis.
• The underlying problem is, of course, a metabolic
acidosis.
Solution:
• Insulin, so the body can use the sugar in the blood
and stop making ketones, which are an acidic byproduct of protein metabolism.
• In the mean time, pH should be maintained near
normal so that oxygenation is not compromised .
A 26 year-old pregnant woman complains of
severe vomiting for five days. She appears
extremely fatigued, and has sunken eyes, dry
mucous membranes, a heart rate of 110 and a
blood pressure of 90/50. When she stands, her
blood pressure falls, and her heart rate increases.
ABG is :PH= 7.50 /PaCO2= 47 /PaO2= 80 / HCO3=38
Identify this condition in regard to the ABG Data.
Answer: metabolic acidosis not compensated
A 35 year old woman is under mechanical ventilation for
severe pulmonary infection. Her RR increases and right sided
pneumothorax develops. What should be done?
a- needle drainage
b- observation
c- small bore catheter
d- chest tube
Ans: D
RESPIRATORY ARREST/IMMINENT RESPIRATORY
ARREST/INTUBATION
1. Airway control with intubation, 100% O2 with BVM.
2. EKG Monitoring.
3. IV of Normal Saline at KVO.
4. Refer to appropriate protocol for further assessment and
treatment.
MEDICAL CONTROL OPTIONS
* DIAZEPAM 5-10mg IVP
* MORPHINE SULFATE 2-10mg IVP
* MIDAZOLAM 0.5-2.0mg Slow IVP
* LIDOCAINE 1.0-1.5mg/kg IVP
OBSTRUCTED AIRWAY, UNCONSCIOUS
1. BLS procedure.
2. Direct laryngoscopy and remove foreign body using
Magill forceps.
3. If unable to ventilate, intubate.
4. If unable to intubate because of obstruction,
cricothyrotomy with large bore over-the-needle
catheter.
5. Refer to appropriate protocol, or contact medical
control.
RESPIRATORY DISTRESS ASTHMA
/BRONCHOSPASM/ COPD
1. Airway control and O2.
2. EKG Monitor.
3. IV of Normal Saline at KVO if clinically
indicated.
4. If asthma is working diagnosis, ALBUTEROL
2.5mg/3cc normal saline via nebulizer, may
repeat once in 15 minutes.
* ALBUTEROL 2.5mg/3cc normal saline via nebulizer, repeat as
directed.
* METAPROTERENOL 0.1-0.3cc/3cc normal saline via nebulizer,
repeat as directed.
* TERBUTALINE 0.25mg subcutaneous, repeat as directed.
* EPINEPHRINE 1:1,000 0.3mg subcutaneous, repeat as directed.
* MAGNESIUM SULFATE 1-2gm IV over 5 minutes.
* METHYLPREDNISOLONE 125mg/50cc normal saline over 3-5
minutes.
CAUTION: Use Epinephrine with caution in patients with history
of or presence of hypertension, heart disease, current
pregnancy, beta blockers. Avoid Methylprednisolone if
suspect varicella.
STATUS EPILEPTICUS
(Two or more seizures without a lucid interval or a
continuous seizure lasting more than 5 minutes).
1. Routine Medical Care .
2. O2, IV of Normal Saline, EKG Monitor, Blood Sample
if possible (glucose level).
3. If the patient is having sustained seizures, DIAZEPAM
is administered 5-10mg IV over 1-2 minutes. If IV
route not available, give rectally, via syringe w/out
needle up to 10mg; may be repeated once after 10
minutes.
4. For suspected hypoglycemia, DEXTROSE 50%
50cc IVP or GLUCAGON 1mg IM; THIAMINE
100mg slow IVP or IM.
5. If above actions do not terminate seizure, or
respirations are depressed, attempt intubation.
* DIAZEPAM 5-10mg IV injection, may be repeated
up to 20mg or rectally via syringe w/out needle,
up to 20mg.
* NALOXONE 2.0mg IV injection, may be repeated
up to 8mg.
• INTUBATION.
SYSTEMIC ALLERGIC REACTIONS, ANAPHYLAXIS
1. Routine Medical Care / 2. O2, EKG Monitor.
3. If signs of shock or imminent airway obstruction,
EPINEPHRINE 1:1,000 0.3cc SQ; may be repeated
once after five (5) minutes.
4. If generalized urticaria or anaphylaxis
DIPHENHYDRAMINE 25-50mg IM or IV.
5. IV of Normal Saline at KVO if no signs of shock,
wide open if signs of shock
* EPINEPHRINE 1:10,000 0.1-1.0mg is given slow IVP or
via ET. May be repeated every 5 minutes per Medical
Control.
* EPINEPHRINE 1:1,000 0.1-0.5mg is given
subcutaneously. May be repeated every 5 minutes
per Medical Control.
* DIPHENHYDRAMINE 25-50mg IM or IV.
* ALBUTEROL 2.5mg via nebulizer.
• DOPAMINE INFUSION 400mg/250cc Normal Saline
and started at 5-10mcg/kg/min. then titrated to
desired BP (maximum of 25mcg/kg/min.).
• * GLUCAGON 1mg IV or IM.
Is PaO2
increased?
Yes=hypoventilation
Is PAo2-PaO2
increased?
Is PAO2PaO2
increased?
If yes then find out
if low PO2 is
Decreased
correlatable with O2?
inspired PO2
Yes=hypoventil
Hypoventilati ation +another
on alone
mechanism
Yes=V/Q
mismatch
Shunt
Reduced Vital
Capacity
Low FEV1/FVC
But
Normal TLC
Bronchial
obstruction
Normal FEV1/FVC
But
Low TLC
Low Mean
Inspiratory
Pressure
Muscular etiology
(Residual Volume is
increased)
Normal Mean
Inspiratory
Pressure
Low RV
Parenchymal
disease
High RV
Chest wall
disease
Tachypnea + fine crackles +
clubbing
With fever:
Hypersensitive
Pneumonitis
X ray- Induced
Sarcoidosis
Eosinophilic Granuloma
Drug induced
BOOP
Without fever:
Pneumoconiosis
Rheumatoid Arthritis
Lymphangioleiomyomatos
is
Alveolar Proteinosis
variables
Normal
Adjustment criteria
1-Inspiratory pressure
limit
50 cm H2O
Blood PH
2-Tidal Volume
10-20 cc/kg
Body weight
3-RR in a minute
8-30
Blood PH
4-PEEP
----
When the patient is hypoxic
despite anFIO2 over 0.6
5-FIO2
0.21-1
For resuscitation=1
For hypercapnea <0.4
6-Inspiratory Flow rate
40-100 l/min
Patient’s own inspiratory effort
7-Sensitivity
*Controlled mode=automatic
*Assistcontrol=patient can initiate
breathing
*Intermittent= patient-machine
interaction
-Mechanical ventilation
options:
What we should adjust
Application
a-PCV(pressure control
ventilation)
Inspiratory pressure
BarotraumaPost thoracic surgerySevere pneumoniaLow compliance states
b-ACMV(Assist Control
mechanical ventilation)
Respiratory Rate+ tidal
volume
Initiation of ventilation
c-SIMV(synchronous
intermittent ventilation)
Respiratory Rate+ tidal
volume
Weaning
d-CPAP(continuous
Pressure
positive airway pressure)
Weaning
Or when the patient is
intubated
e-Prone Position
ARDS
Least invasive
Metabolic Acidosis
PCO2 mmHg
HCO3 meq/L
Change
Change
1.5 (HCO3)+8±2 1
Metabolic Alkalosis
Acute res. acidosis
Chronic res. acidosis
Acute res. alkalosis
Chronic res. Alkalosis
0.5
10
10
10
10
1
1
3-5
1-2
5
Check if the blood is from an artery (CO2=15+HCO3)
Calculate Anion Gap
(AG=Na – (Cl +HCO3)
Calculate if the response is compensatory or not
If there’s no significant AG (more than10-12), then it
must be either RTA or GI loss. In GI loss this formula
applies => Urinary Cl>Urinary Na +K
Pneumonia treatment in
pregnancy
• Uncomlicated: erythromycin 500-1000 mg
every 6 hours
• Haemophilia:cefotaxime,ceftizoxime,
Cefuroxime
• Penicilline resistance: levofloxacin
• Influanza:amantadine 200 mg daily if begun
within 48 hours of symptoms
• Varicella:acyclovir iv 10 mg/kg every 8 hours
• VZIG:within 96 hrs of exposure 125u/10kg im
Pneumonia treatment in
non pregnant states
Pneumonia
Community
acquired
Low risk
out
patient
High risk
out
patient
Hospital
acquired
No risk
factor
Anaerobic
Ceftriaxone
Clarithro. +
Clarithro. Amoxiclav
Staph
Psuedo.
Ceftriaxone
Ceftriaxone
+
Ceftriaxone +
+
Aminoglyc
Clinda
Vanco
osides
Asthma
Adapted from:
British guideline on the management of asthma in
adults, The British Thoracic Society & Scottish
Intercollegiate Guidelines Network Thorax 2008
May; 63 (Suppl 4) : 1-121
with permission
Definition of asthma
“A chronic inflammatory disorder of the
airways … in susceptible individuals,
inflammatory symptoms are usually
associated with widespread but variable
airflow obstruction and an increase in
airway response to a variety of stimuli.
Obstruction is often reversible, either
spontaneously or with treatment.”
Symptoms
(episodic/variable)
•wheeze
•shortness ofConsider
breath
the diagnosis of
•chest tightness
asthma in patients with
•cough some or all of these features
Diagnosis of asthma in adults
Symptoms (episodic/variable)
• wheeze
• shortness of breath
• chest tightness
• cough
Consider the diagnosis of
asthma in patients with
some or all of these features
Signs
•none (common)
•wheeze –
diffuse, bilateral,
expiratory (
inspiratory)
•tachypnea
Helpful additional
Diagnosis of asthma in adults
information
Signs
•personal/family history of
• none (common)
• wheeze – diffuse, bilateral,
asthma or atopy
expiratory ( inspiratory)
• tachypnea
•history of worsening after
aspirin/NSAID,
 blocker use
Consider the diagnosis of
•recognised triggers –
asthma in patients with
pollens, dust, animals,
some or all of these features
exercise, viral infections,
chemicals, irritants
•pattern and severity of
symptoms and
exacerbations
Objective measurements
•>20% diurnal variation
Diagnosis of asthma
in adults
on 3 days
in
Symptoms (episodic/variable)
• wheeze
• shortness of breath
• chest tightness
• cough
Consider the diagnosis of
asthma in patients with
some or all of these features
Helpful additional information
• personal/family history of asthma or atopy
• history of worsening after aspirin/NSAID,
 blocker use
• recognised triggers – pollens, dust, animals,
exercise, viral infections, chemicals, irritants
• pattern and severity of symptoms and
exacerbations
a week for 2 weeks on
PEF diary
•or FEV1 15% (and
200ml) increase after
short acting ß2 agonist
or steroid tablets
•or FEV1 15% decrease
after 6 minutes of
running exercise
•histamine or
methacholine challenge
in difficult cases
Differential diagnosis of
asthma in adults
Differential diagnoses include:
• COPD
• interstitial lung
• cardiac disease disease
• laryngeal,
• pulmonary
tracheal or lung
emboli
tumour
• aspiration
• bronchiectasis • vocal cord
• foreign body
dysfunction
• hyperventilation
Indications for referral of
adults with suspected asthma
• Diagnosis unclear or in doubt
• Unexpected clinical findings e.g. crackles, clubbing, cyanosis,
heart failure
• Spirometry or PEF measurements do not fit the clinical picture
• Suspected occupational asthma
• Persistent shortness of breath (not episodic, or without
•
•
•
•
•
•
associated wheeze)
Unilateral or fixed wheeze
Stridor
Persistent chest pain or atypical features
Weight loss
Persistent cough and/or sputum production
Non-resolving pneumonia
Non-pharmacological
management
Potential strategies for
primary prophylaxis
Breast-feeding should be
encouraged as protects against
early life wheezing
Parents and parents-to-be who
smoke should be advised to stop
and given appropriate support as
there is increased wheezing in
infants exposed to smoke
Potential strategies for secondary
prophylaxis
In committed families with evidence of
house dust mite allergy and who wish to
try mite avoidance, the following are
recommended:
• complete barrier bed covering systems
• removal of carpets
• removal of soft toys from bed
• high temperature washing of bed linen
• acaricides to soft furnishings
• dehumidification
Non-pharmacological
management of asthma
Use of ionisers cannot be encouraged as no
evidence of benefit and suggestion of adverse
effect
In difficult childhood asthma, may be a role for
family therapy as adjunct to pharmacotherapy
Weight reduction recommended in obese
patients with asthma
Treat gastro-oesophageal reflux if present but
generally no impact on asthma control
Pharmacological
management
• Add inhaled long-acting 2
agonists rather than increasing
the dose of inhaled steroids
(above 800mcg/day in adults and
400mcg/day in children)
• Step down therapy to lowest level
consistent with maintained control
Asthma control
Asthma control means:
•minimal symptoms during day and
night
•minimal need for reliever medication
•no exacerbations
•no limitation of physical activity
•normal lung function (FEV1 and/or PEF
>80% predicted or best)
Asthma in pregnancy
• 5 to 9 percent of pregnant women suffer from
asthma
• PGF2 alfa is contraindicated in asthmatic
women/ LT inhibitors are contraindicated in
pregnancy
• Asthma is a risk factor for preeclampsia,
preterm labor, LBW babies, and perinatal
mortality
Changes in respiratory system in pregnancy
• Reduced FRC
• PCO2 more than 35 is considered as
abnormal (non pregnant state is 40 mmHg)
• No change in PEF or FEV1
• Stress dose of hydrocortisone (100 mg IV TDS)
for those who receive systemic steroids
• Fentanyl as narcotic
• NVD is preferred- Epidural is a better choice
than general anesthesia
Management of acute asthma
in pregnancy
Give drug therapy for acute asthma as for the
non-pregnant patient
Acute severe asthma in pregnancy is an
emergency and should be treated vigorously in
hospital
Deliver oxygen immediately to maintain saturation
above 95%
Continuous fetal monitoring is recommended for
severe acute asthma
Drug therapy for asthma
during pregnancy and lactation
Use 2 agonists, inhaled steroids and oral/IV
theophyllines as normal during pregnancy
Check blood levels of theophylline in acute severe
asthma and in those critically dependent on therapeutic
theophylline levels
Use steroid tablets as normal when indicated during
pregnancy for severe asthma. Steroid tablets should
never be withheld because of pregnancy
Do not commence leukotriene antagonists during
pregnancy
Encourage women with asthma to breast feed. Use
asthma medications as normal during lactation
Management of asthma during labor
Advise women that acute asthma is rare in labor
Advise women to continue their usual asthma
medications in labor
In the absence of acute severe asthma, reserve
caesarean section for the usual obstetric indications
If anaesthesia is required, regional blockade is preferable
to general anaesthesia in women with asthma
Women receiving steroid tablets at a dose exceeding
prednisolone 7.5mg per day for more than 2 weeks prior
to delivery should receive parenteral hydrocortisone
100mg 6-8 hourly during labor
Use prostaglanding F2 with extreme caution in women
with asthma because of the risk of inducing
bronchoconstriction