Tuesday, June 15, 2010

Standard initial management in Heart failure

  • Supplemental Oxygen
  • Endotracheal intubation with mechanical ventilation is indicated if instability
  • Cardiac monitoring
  • pulse oximetry
  • 12-lead electrocardiogram
  • Intravenous access
  • Frequent vital sign assessments.
  • Chest radiography
  • Complete blood cell count
  • Electrolytes
  • BNP level
  • Cardiac markers
Acute Pulmonary Edema
  • Intravenous diuretics, diuresis can begin 10 to 15 min after intravenous furosemide. If urine output is inadequate in 20 to 30 min, the diuretic dose is increased and repeated.
  • Furosemide Dose  
              No prior use: 40 mg IVP
              If prior use: Double last 24-h usage (range, 80–180 mg)
              If no effect by 20–30 mins: re-double dose

Natriuretic Peptide Assay(BNP levels) in Heart Failure

These proteins are released by ventricular pressure or volume stimulus.
Age < 50    BNP level cut point = 450 pg/ml
Age 50-75  BNP level cut point = 900 pg/ml
Age >75     BNP level cut point = 1900 pg/ml

There are confounders to BNP as an HF test. BNP is increased in the elderly, women, those with cirrhosis or renal failure, possibly those on hormone replacement therapy, and probably those with pulmonary embolus and primary pulmonary hypertension. 

Precipitating Heart failure

  • Hypertension
  • Endocrine
  • Anemia
  • Rheumatic heart disease
  • Toxin
  • Failure to take meds
  • Arrhythmia
  • Infection
  • Lung (pulmonary embolism)
  • Electrolytes
  • Diet (excess Na+)

Sunday, May 23, 2010

Inferior vena caval (IVC) filters in Deep vein thrombosis

DVT occurring in deep knee or thigh veins, known as proximal DVT, require hospitalization and anticoagulation because of increased risk of pulmonary embolus.

Most experts agree with placing an inferior vena caval (IVC) filters in patients with acute proximal DVT and an absolute contraindication to anticoagulation. If the contraindication to anticoagulation is temporary (eg, perisurgical patients), placement of a retrievable IVC filter should be considered so that the device can be removed once anticoagulation has been started and has been shown to be tolerated. 

Complications of IVC filters include local thrombosis, tilting, migration, and inability to retrieve the device.

Child-Turcotte-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems for staging cirrhosis.

and Model for End-Stage Liver
Disease (MELD) scoring systems for staging cirrhosis.

Child-Turcotte-Pugh scoring system
Numerical Score
AscitesNoneSlightModerate to severe
EncephalopathyNoneSlight to moderateModerate to severe
Bilirubin (mg/dL)< 2.02–3> 3.0
Albumin (g/dL)> 3.52.8–3.5< 2.8
Prothrombin time (seconds increased)1–34–6> 6.0
Total numerical score and corresponding Child-Turcotte-Pugh
Score Class 
MELD scoring system 
MELD = 11.2 loge (INR) + 3.78 loge (bilirubin [mg/dL]) + 9.57 loge (creatinine [mg/dL]) + 6.43 (Range 6–40).

INR, international normalized ratio.


  • Factors determining survival include ability to stop alcohol intake and the Child-Turcotte-Pugh class
  • The Model for End-Stage Liver Disease (MELD) is used to determine priorities for liver transplantation

Wednesday, May 19, 2010

Ranson's Criteria

Table 33-4 Ranson's
Prognostic Signs of Pancreatitis

Criteria for acute pancreatitis not due to gallstones 
At admissionDuring the initial 48 h
  Age >55 y  Hematocrit fall >10 points
  WBC >16,000/mm3
  BUN elevation >5 mg/dL
  Blood glucose >200 mg/dL  Serum calcium <8 mg/dL
  Serum LDH >350 IU/L  Arterial PO2 <60
mm Hg
  Serum AST >250 U/dL  Base deficit >4 mEq/L
     Estimated fluid sequestration >6 L
Criteria for acute gallstone pancreatitis 
At admissionDuring the initial 48 h
  Age >70 y  Hematocrit fall >10 points
  WBC >18,000/mm3
  BUN elevation >2 mg/dL
  Blood glucose >220 mg/dL  Serum calcium <8 mg/dL
  Serum LDH >400 IU/L  Base deficit >5 mEq/L
  Serum AST >250 U/dL  Estimated fluid sequestration >4 L

AST = aspartate
transaminase; BUN = blood urea nitrogen; LDH = lactate
dehydrogenase; PO2 = partial pressure
of oxygen; WBC = white blood cell count.

Source: Data from Ranson JHC: Etiological and prognostic factors
in human acute pancreatitis: A review. Am J Gastroenterol 77:633,
1982. From Macmillan Publishers Ltd. Ranson JH, Rifkind KM, Roses
DF, et al: Prognostic signs and the role of operative management
in acute pancreatitis. Surg Gynecol Obstet 139:69,

MRCP (Magnetic resonance cholangiopancreatography )

Evaluation of intra- and extra-hepatic biliary and pancreatic duct dilatation, and the cause of obstruction.

Noninvasive. No ionizing radiation. Imaging in all planes. Can image ducts beyond the point of obstruction.
Evaluates extra-luminal disease.

Special instrumentation required for patients on life support.

Contraindications and risks: Contraindicated in patients with cardiac pacemakers, intraocular metallic foreign bodies, intracranial aneurysm clips, cochlear implants, and some artificial heart valves.

Preferably NPO for 6 hours.