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. 5 th 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/Clinical. Information/ Asthma/Asthma. Guidelines/tabid/83/Default. aspx • • • www. cdc. gov/asthma/speakit/slides/managing_asthma Braunwald Eugene, et al. Harrison's Principles of Internal Medicine. 16 th edition. Mc. Graw. Hill; 2005 Braunwald et al. IHD clinical practice guidelines. 2002 Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22 nd 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. 7 th 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 5. ht m(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 hap 10 a. 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 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, head ache and peripheral edema within the last week. Her BP is 150/105 mm. Hg. 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 pre eclampcia? 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 SO 4 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-Mg. SO 4 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/ G 3/ 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 / G 3/P 2 /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- Mg. SO 4 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 / G 1 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 Mg. SO 4 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 Mg. SO 4. She is agitated. What drug is appropriate for her agitated state? A-2 gr Mg. SO 4 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 Mg. SO 4 as the loading dose and then 2. 5 gr q 4 h up to 24 h after delivery B-7 gr of Mg. SO 4 as the loading dose and then 2. 5 grq 4 h up to 24 h after the last seizure C-14 gr of Mg. SO 4 as the loading dose and then 2. 5 gr q 4 h up to 24 h after the last seizure D-7 gr of Mg. SO 4 as the loading dose and then 2. 5 gr q 4 h up to 24 h after delivery Ans: C
Which is not among pathophysiological changes of preeclampsia? A-reduction in PGE 2 B-reduction in prostacyclin C-increased thromboxane A 2 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 mm. HG 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 Mg. SO 4 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/G 2/L 1/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 Mg. SO 4 Ans: D
HTN drugs of importance
Drug safety Dosage Explanation SNP Group C- possibly unsafe in lactation (2 cc/50 mg) 0. 3 -0. 5 mcg/kg/min It should be diluted in 250 -1000 cc DW 5% 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 (1 cc/5 mg) -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 50 cc DW 5% 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 Amp minutes IV, propranolol followed by 40 -80 mg at 1 mg/ml 10 min intervals
Hydralazine Contraindicated in: -Hypersensitivity -Rheumatic heart disease of Mitral valve 10 -20 mg/dose IV or IM q 4 -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 mm. Hg (tab of 40 and 80 mg) 240 -480 mg/d/tid. Clonidine Group C (Tab 0. 2 mg) Not to Unknown safety in 0. 1 mg bid po exceed 1. 2 lactation 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 Group 3 -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 2 B 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 G 3/ P 3/ with GA=38 wks. 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 4 th week after NVD comes to ED. JVP raised with prominant X and Y waves. Kussmul sign is positive. S 1 and S 2 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 4 th 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 mm. Hg / 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 S 3 And S 4. (DCMP=dilated cardiomyopathy/ JVP= jugular vein pressure/ HCMP=hypertrophic cardiomyopathy/ RCMP=restrictive cardiomyopathy)
S 3 & S 4 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 S 3 and S 4 gallop
Different causes of S 3 & S 4 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 mm. Hg +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 mm. Hg below baseline.
drug contraindications dosage explanation Norepinephrine Hypersensitivity OHCM Vascular thrombosis (Vial 10 mg) 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 Group x in pregnancy (Tab 5 mg) but safe in lactation. 5 mg/d Contraindicated in: Bleeding Peptic ulcer Open wound Liver and kidneydisease Carvedilol Group C Safety in lactation is unknown. Contraindications: Cardiogenic shock Pulmonary edema Bradycardia AV block Uncompensated -HF (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) (400 mg/250 cc 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
ECG 1 ECG 2 ECG 3
ECG 4 ECG 5 ECG 6 ECG 7
ECG 8 ECG 9 ECG 10 ECG 11
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 20 mg/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 P=150 - tachycardia P= 100 -150 250
Drug Dosage Adenosine (6 mg/2 cc vial) 6 mg Atropine (1 mg/10 cc syringe) 1 mg Explanation Repeat in 3 minutes
Bicarbonate (50 Eq/50 cc syringe) 1 meq/kg Digoxin 0. 25 mg Diltiazem 25 mg Dopamine (400 mg/10 cc syringe) 5 -20 mcg/kg/min Epinehrine (1 mg/cc ampule) 2 -10 mcg/min
Esmolol 0. 5 mg/kg Isoprotrenol 2 -10 mcg/min Lidocaine 2% (100 mg/5 cc syringe) 0. 5 mg/kg Magnesium 1 mg/kg bolus Repeat 0. 5 mg/kg until PVC suppressed If successful: Base drip rate on total given: 1 mg/kg, drip 2 mg/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/2 cc vial) 20 mg/min Verapamil Then titrate to 0. 05 -2 mg/min drip (10 mg/2 cc vial) 5 mg 20 mg/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 V 1 V 4. 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 S 3 B S 4 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 mm. Hg with chest pain B Cerebral Hemorrhage 3 years ago C pregnancy D Aortic dissection Ans: C
Tall R in lead V 1 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: Dx 23 -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 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 d. L (0. 9 mmol per L); subtract 1 risk factor if HDL >60 mg per d. L 0 to 1 point: <160 mg per d. L (<4. 15 mmol per L). If more than 190 needs drug therapy. 2 or more points: <130 mg per d. L (<3. 35 mmol per L)If more than 160 needs drug therapy. Patients with history of CHD: <100 mg per d. L (<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 5 mm is positive 10 mm is + HIV positive Drug abusers HIV 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 5 mg/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 Pa. O 2 and Pa. CO 2. Her ABG half an hour after treatment is: no change in Pa. O 2 but a normal level Pa. CO 2. 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 m. L
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 cough. T 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 q 6 hrs 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 G 1/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 q 8 hrs 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 PGF 2 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 PGE 2 is better tolerated than PGF 2 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 7 wk pregnant woman with history of infertility receives heparin for DVT. Her platelet is 50000. Which statement is wrong about heparin induced 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 FEV 1 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 beta 1 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 mm. Hg/ PR=110 bpm. 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 mm. Hg /T=36 c / PR=120 bpm /Rr=30 /min. Her cardiac rhythm is sinus tachycardia. Pulse oximetry shows Sa. O 2=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 cm. H 2 O. 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. Pa. CO 2 51 mm Hg, Pa. O 2 76 mm Hg, and p. H 7. 31 b. A 29 year old woman who is alert but in respiratory distress; she is breathing 42 times/min. Pa. CO 2 is 38 mm Hg. p. H is 7. 42, and Pa. O 2 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. Pa. O 2 is 75 mm Hg while breathing nasal oxygen at 2 L/min, Pa. CO 2 is 59 mm Hg, and the p. H is 7. 37. Her chest x ray is clear. Cont.
d. A 29 year old woman suffering from diabetic ketoacidosis. Her p. H is 7. 10, Pa. CO 2 is 26 mm Hg and Pa. O 2 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. Pa. CO 2 is 31 mm Hg. p. H is 7. 38, and Pa. O 2 is 89 mm Hg while breathing nasal oxygen at 3 L/min. Answers: Cases a, b, d need mechanical ventilation+intubation
A comatose 20 year 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 FIO 2 of 0. 50. The patient has no spontaneous breathing. Blood gas results obtained (1) before intubation and (2) 20 minutes later show the following: p. H Pa. CO 2 Pa. O 2 FIO 2 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 FIO 2, 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 Pa. CO 2 above 50 mm Hg and a p. H less than 7. 30. Answer: false During controlled positive pressure ventilation, each breath is initiated by the patient. Answer: false During ventilation with positive end expiratory 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 H 2 O. Answer: false
The appropriate FIO 2 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: p. H= 7. 44 /Pa. CO 2= 28 /HCO 3= 24 /Pa. O 2= 54
Problems: • Pa. CO 2 is low. • p. H is on the high side of normal, therefore compensated respiratory alkalosis. • Also, Pa. O 2 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 CO 2. Improve Pa. O 2 and a normal respiratory rate should normalize the p. H. • High Fi. O 2 can help, but if she has interstitial lung fluid, she may need intubation and PEEP, or a Bi. PAP to raise her Pa. O 2. • 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: p. H= 7. 48 , Pa. CO 2= 28, HCO 3= 22, Pa. O 2= 85 Define the problem and suggest a solution.
Problem: • p. H is high, • Pa. CO 2 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 CO 2. This will increase Pa. CO 2 and trigger her normal respiratory drive to take over breathing control. • * this will not work on a person with chronic CO 2 retention, such as a COPD patient. These people develop a hypoxic drive, and do not respond to CO 2 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: p. H= 7. 33 , Pa. CO 2= 25, HCO 3=12, Pa. O 2= 89 Define the problem and suggest a solution.
Problem: • The p. H is acidotic, • Pa. CO 2 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, p. H 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 /Pa. CO 2= 47 /Pa. O 2= 80 / HCO 3=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% O 2 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 10 mg IVP * MORPHINE SULFATE 2 10 mg IVP * MIDAZOLAM 0. 5 2. 0 mg Slow IVP * LIDOCAINE 1. 0 1. 5 mg/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 O 2. EKG Monitor. 3. IV of Normal Saline at KVO if clinically indicated. 4. If asthma is working diagnosis, ALBUTEROL 2. 5 mg/3 cc normal saline via nebulizer, may repeat once in 15 minutes.
* ALBUTEROL 2. 5 mg/3 cc normal saline via nebulizer, repeat as directed. * METAPROTERENOL 0. 1 0. 3 cc/3 cc normal saline via nebulizer, repeat as directed. * TERBUTALINE 0. 25 mg subcutaneous, repeat as directed. * EPINEPHRINE 1: 1, 000 0. 3 mg subcutaneous, repeat as directed. * MAGNESIUM SULFATE 1 2 gm IV over 5 minutes. * METHYLPREDNISOLONE 125 mg/50 cc 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. O 2, IV of Normal Saline, EKG Monitor, Blood Sample if possible (glucose level). 3. If the patient is having sustained seizures, DIAZEPAM is administered 5 10 mg IV over 1 2 minutes. If IV route not available, give rectally, via syringe w/out needle up to 10 mg; may be repeated once after 10 minutes.
4. For suspected hypoglycemia, DEXTROSE 50% 50 cc IVP or GLUCAGON 1 mg IM; THIAMINE 100 mg slow IVP or IM. 5. If above actions do not terminate seizure, or respirations are depressed, attempt intubation. * DIAZEPAM 5 10 mg IV injection, may be repeated up to 20 mg or rectally via syringe w/out needle, up to 20 mg. * NALOXONE 2. 0 mg IV injection, may be repeated up to 8 mg. • INTUBATION.
SYSTEMIC ALLERGIC REACTIONS, ANAPHYLAXIS 1. Routine Medical Care / 2. O 2, EKG Monitor. 3. If signs of shock or imminent airway obstruction, EPINEPHRINE 1: 1, 000 0. 3 cc SQ; may be repeated once after five (5) minutes. 4. If generalized urticaria or anaphylaxis DIPHENHYDRAMINE 25 50 mg 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. 0 mg is given slow IVP or via ET. May be repeated every 5 minutes per Medical Control. * EPINEPHRINE 1: 1, 000 0. 1 0. 5 mg is given subcutaneously. May be repeated every 5 minutes per Medical Control. * DIPHENHYDRAMINE 25 50 mg IM or IV. * ALBUTEROL 2. 5 mg via nebulizer. • DOPAMINE INFUSION 400 mg/250 cc Normal Saline and started at 5 10 mcg/kg/min. then titrated to desired BP (maximum of 25 mcg/kg/min. ). • * GLUCAGON 1 mg IV or IM.
Is Pa. O 2 increased? Yes=hypoventilation Is PAo 2 -Pa. O 2 increased? Is PAO 2 Pa. O 2 increased? If yes then find out if low PO 2 is Decreased correlatable with O 2? inspired PO 2 Yes=hypoventil Hypoventilati ation +another on alone mechanism Yes=V/Q mismatch Shunt
Reduced Vital Capacity Low FEV 1/FVC But Normal TLC Bronchial obstruction Normal FEV 1/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 Lymphangioleiomyomato sis Alveolar Proteinosis
variables Normal Adjustment criteria 1 -Inspiratory pressure limit 50 cm H 2 O 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 an. FIO 2 over 0. 6 5 -FIO 2 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 Barotrauma. Post thoracic surgery. Severe pneumonia. Low 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 PCO 2 mm. Hg HCO 3 meq/L Change 1. 5 (HCO 3)+8± 2 1 Metabolic Alkalosis Acute res. acidosis Chronic res. acidosis Acute res. alkalosis Chronic res. Alkalosis 0. 5 10 10 1 1 3 5 1 2 5
Check if the blood is from an artery (CO 2=15+HCO 3) Calculate Anion Gap (AG=Na – (Cl +HCO 3) Calculate if the response is compensatory or not If there’s no significant AG (more than 10 -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 125 u/10 kg im
Pneumonia treatment in non pregnant states
Pneumonia Community acquired Low risk out patient High risk out patient Hospital acquired No risk Anaerobic factor Ceftriaxone Clarithro. + Clarithro. Amoxiclav Staph Psuedo. 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 of. Consider the diagnosis of breath • chest tightness in patients with some asthma • cough 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 some pollens, dust, animals, or all of these features exercise, viral infections, chemicals, irritants • pattern and severity of symptoms and exacerbations
Objective measurements • >20% diurnal variation Diagnosis of asthmadaysadults on 3 in 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 FEV 1 15% (and 200 ml) increase after short acting ß 2 agonist or steroid tablets • or FEV 1 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 • 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 800 mcg/day in adults and 400 mcg/day in children) • Step down therapy to lowest level consistent with maintained 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 (FEV 1 and/or PEF >80% predicted or best)
Asthma in pregnancy
• 5 to 9 percent of pregnant women suffer from asthma • PGF 2 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 • PCO 2 more than 35 is considered as abnormal (non pregnant state is 40 mm. Hg) • No change in PEF or FEV 1 • 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. 5 mg per day for more than 2 weeks prior to delivery should receive parenteral hydrocortisone 100 mg 6 -8 hourly during labor Use prostaglanding F 2 with extreme caution in women with asthma because of the risk of inducing bronchoconstriction
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