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MOH Pocket Manual in Critical Care PDF
MOH Pocket Manual in Critical Care PDF
Critical Care
MOH Pocket Manual in Critical Care
TABLE OF CONTENTS
INTRACRANIAL HEMORRHAGE 9
ISCHEMIC STROKE9 10
TRAUMATIC BRAIN INJURY11 11
CNS INFECTION15 12
STATUS EPILEPTICUS18 13
GUILLIAN-BARˊ́RÉ SYNDROME21 14
MYASTHENIA GRAVIS23 15
HYPERTENSIVE CRISIS26 16
ACUTE CORONARY SYNDROME29 17
VENTICULAR TACHYCARDIA 35 18
SUPRAVENTRICULAR TACHYCADIA39 19
BRADYARRHYTHMIAS42 20
HEART FAILURE 43 21
SHOCK 45 22
ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE
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PULMONARY DISEASE48
STATUS ASTHMATICUS 24
ACUTE RESPIRATORY DISTRESS SYDROME 25
PNEUMONIA 26
PULMONARY EMBOLISM 27
CHEST TRAUMA 28
MECHANICAL VENTILATION 29
GASTROINTESTINAL BLEEDING 30
VARICEAL BLEEDING 40
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Intracranial hemorrhage
Overview
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Clinical Presentation
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• Laboratory Studies
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• Parenchymal imaging
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• Vessel imaging
• Procedures
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Management
• Medical Care:
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- Avoid hyperthermia.
• Medications Summary :
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• Surgical Care :
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Ischemic Stroke
Overview
Clinical Presentation
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Work Up
Laboratory studies
Laboratory tests performed in the diagnosis and evaluation
of ischemic stroke include the following:
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• Pathophysiology:
A. Primary brain Injury — Primary brain injury oc-
curs at the time of trauma. Common mechanisms in-
clude direct impact, rapid acceleration/deceleration,
penetrating injury, and blast waves. Although these
mechanisms are heterogeneous, they all result from ex-
ternal mechanical forces transferred to intracranial con-
tents. The damage that results includes a combination
of focal contusions and hematomas, as well as shearing
of white matter tracts (diffuse axonal injury) along with
cerebral edema and swelling.
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- Electrolyte imbalances
- Mitochondrial dysfunction
- Inflammatory responses
- Apoptosis
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CLASSIFICATION:
- Skull fracture
- Epidural hematoma
- Subdural hematoma
- Subarachnoid hemorrhage
- Intraparenchymal hemorrhage
- Cerebral contusion
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- Intraventricular hemorrhage
- Focal and diffuse patterns of axonal injury with cerebral
edema
- Two currently used CT-based grading scales are the
Marshall scale and the Rotterdam scale.
Management
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- ADVANCED NEUROMONITORING — In
order to supplement ICP monitoring, several technol-
ogies have recently been developed for the treatment
of severe TBI. These techniques allow for the measure-
ment of cerebral physiologic and metabolic parameters
related to oxygen delivery, cerebral blood flow, and me-
tabolism with the goal of improving the detection and
management of secondary brain injury.
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CNS infection
Overview
Common bacterial
Antimicrobial therapy
pathogens
N. meningitidis, S. pneu- Vancomycin plus a third-genera-
2-50 years
moniae tion cephalosporin
S. pneumoniae, N.
meningitidis, L. Vancomycin plus ampicillin plus
>50 years
monocytogenes, aerobic a third-generation cephalosporin
gram-negative bacilli
Head trauma
S. pneumoniae, H. influ-
Vancomycin plus a third-genera-
Base skull fracture enzae, group A beta-he-
tion cephalosporin
molytic strept.
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Staphylococcus aureus,
c o a g u l a s e - n e g a t i v e Vancomycin plus cefepime; OR
staphylococci (espe-
Penetrating trauma vancomycin plus ceftazidime; OR
cially Staphylococcus
epidermidis), aerobic G vancomycin plus meropenem
–vebacilli
Vancomycin plus cefepime; OR
Aerobic gram-negative vancomycin plus ceftazidime; OR
bacilli (including P. vancomycin plus meropenem
aeruginosa), S. aureus,
Post-neurosurgery
coagulase-negative
staphylococci (especial-
ly S. epidermidis)
S. pneumoniae, N.
meningitidis, L.
Vancomycin plus ampicillin plus
Immunocompro- monocytogenes, aerobic
cefepime; OR vancomycin plus
mised state gram-negative bacilli
ampicillin plus meropenem
(including P. aerugi-
nosa)
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• Clinical Presentation
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Neu-
rosyph-
T.B ilis Some
cases of
Some mumps Encepha-
Fungal T.B. _ Encephalitis
viral litis
infection
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Management
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Status Epilepticus
Overview
• Epidemiology
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- New-onset epilepsy.
Work Up
• Emergency investigations
- Emergency investigations should include assessment of
the following: blood gases, glucose, renal and hepatic
function, calcium, magnesium, full blood count, clot-
ting screen, and anticonvulsant concentrations. Serum
should be saved for toxicology or virology or other fu-
ture analyses. An electrocardiogram (ECG) should be
performed.
Management
• Cardiorespiratory function
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Red Flag
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Guillain-Barré syndrome
Overview
Differential Diagnosis
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Work Up
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Management
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• Plasma exchange
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Myasthenia Gravis
Overview
Clinical Presentation
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Work Up
• Nerve stimulation
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Management
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• Treatment
A. Oral anticholinesterases
B. Thymectomy
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C. Immunosuppressant drugs
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Red Flg
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HYPERTENSIVE CRISIS
OVERVIEW
• DEFINITIONS
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CLINICAL PRESENTATION
A. History
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WORK-UP
• Laboratory evaluation
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• Electrocardiogram
• Chest radiography
• ECHO
• CT Head
• Doppler Renal arteries
TREATMENT
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• Perioperative hypertension
- PHARMACOLOGIC AGENTS
A. Direct vasodilator
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Non-dehydropyridines:
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E. Others Agents
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OVERVIEW
• A 12-lead ECG
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DIFFERENTIAL DIAGNOSIS
• Pulmonary embolism
• Esophageal rupture
• Tension pneumothorax
• Acute pericarditis
• Gastroesophageal reflux disease
• Costochondritis
• Esophageal spasm
• Pleurisy
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MANAGEMENT OF UA/NSTEMI
A. Goals
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- Active asthma
• Antiplatelet therapy
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• Anticoagulant therapy
- LMWH enoxaparin
• Revascularization
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• Technique
- PCI
- CABG
• Statins
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CLINICAL PRESENTATION
• History
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• Physical examination
WORK-UP
• ECG
• Cardiac Biomakers
MANAGEMENT
Performance therapy
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• CONTRAINDICATION TO FIBRINOLYTIC
THERAPY
• AGENTS
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Alteplase Tenecteplase
Steptokinase Reteplase
(tPA) (TNK-tPA)
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• ANTIISCHEMIC THERAPY
- Β-blocker (BB)
• Nitrates
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• Aldosterone antagonist
• Statins
- As NSTMI
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VENTICULAR TACHYCARDIA
OVERVIEW
A. Definitions
B. Classification
• Polymorphic VT
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- Etiologies
- Electrolyte disturbance
- Drug toxicity
- Torsade de pointes
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DIFFERENTIAL DIAGNOSIS
MANAGEMENT
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- Amiodarone
- Procainamide
- Lidocaine
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- Cardiac ischemia
- Metabolic abnormalities
- Treatment:
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• β-blocking
- Indications
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- Bradycardia
- Aggravation of bronchospasm
• Amiodarone
- Indications
- Dosing
- Adverse effects
- Causes QT prolongation
- Hypotension
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- Bradycardia
• Procainamide
- Adverse effects
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• Lidocaine (IB)
- Indication
- Adverse effects:
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SUPRAVENTRICULAR TACHYCARDIA
OVERVIEW
• MECHANISMS
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- Stable patients
A. Atrial Fibrillation
- Atrial fibrillation is the most common.
- Acute treatment
- Unstable: Synchronized DC cardioversion is
the treatment of choic.
- Stable pharmacologic rate control
- β1-Selective adrenergic receptor antago-
nists in nonashmatic patients.
- Nondihydropyridine calcium channel
blockers (e.g., verapamil, diltiazem)
may be used in absence of ventricular
dysfunction.
- Digitalis may be used with relative safe-
ty in patients with poor ventricular func-
tion but provides only modest control of
ventricular rate.
- Amiodarone effectively controls ven-
tricular rate response during atrial fibril-
lation when administered IV and is safe
for use in patients.
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B. Atrial Flutter
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D. Atrioventricularreently tachycardia
E. Wolf-Parkinson/white syndrome
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- Acute treatment
- B-Blockade
- Amiodarone.
G. MAT
- B-Blockade
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BRADYARRHYTHMIAS
CAUSES
DIAGNOSIS
• SINUS BRADYCARDIA
• HEART BLOCK
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TREATMENT
• Hypoxaemia must be corrected in all symptomatic
bradycardias. First line drug treatment is usually atro-
pine 0.3mg. If the arrhythmia fails to respond, 0.6mg
followed by 1.0mg atropine may be given. Failure to
respond to drugs requires temporary pacing. This may
be accomplished rapidly with an external system. If
there is haemodynamic compromise or by transvenous
placement.
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HEART FAILURE
OVERVIEW
• Type: Systolic
Diastolic
MAJOR CAUSES:
- Muscles fatigue
- Confusion, agitation, drowsiness
- Oliguria
- Increasing metabolic acidosis, arterial hypoxeimia.
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- Pulmonary oedema&dyspnoea
- Hypoxaemia
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WORK-UP
Test Diagnosis
• BASIC MEASURES
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- Furosemide
• DIRECTED MANAGEMENT
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• TREATMENT ENDPOINTS.
- Symptomatic relief.
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SHOCK
OVERVIEW
• Definition
• Description
• Hypovolemic shock
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• Obstructive shock
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• Cardiogenic shock
• Distributive shock
• RESUSCITATION ENDPOINTS
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- Base deficit
TREATMENT
Rapid recognition and restoration of perfusion is the key to
preventing multiple organ dysfunction and death with shock.
In all forms of shock, rapid restoration of preload with infu-
sion of fluids is the first treatment. Crystalloid is first infused
and then blood if shock is secondary to hemorrhage. Shock
must be treated while identifying its cause.
• HYPOVOLEMIC SHOCK
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• OBSTRUCTVE SHOCK
• CARDIOGENIC SHOCK
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• DISTRIBUTIVE SHOCK
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- Dyspnea increases
PRESENTATION
• acute asthma
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• pneumonia
• PE
• heart failure
• pneumothorax
WORKUP
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TREATMENT GOALS
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• Inhaled medications :
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B. Anticholinergic agents:
C. Glucocorticoids Dose :
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• Antibiotic Therapy
- Common organism H.influenza, strep pneumonia, mo-
raxilla catarrhalis, pseudomonas.
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cin, cefepime, ceftazidime, and piperacillin-tazobac-
tam. Hospitalized patients without risk factors for
Pseudomonas can be treated with a respiratory fluoro-
quinolone (levofloxacin, moxifloxacin) or a third-gen-
eration cephalosporin (ceftriaxone or cefotaxime).
• Antiviral Therapy
• Mechanical Ventilation
A. Noninvasive ventilation
B. Invasive ventilation
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STATUS ASTHMATICUS
OVERVIEW
PRESENTATION
• History:
- Previous history of wheezing, known asthmatic, non
Compliant Previous hospitalizations or intubations his-
tory.
• Physical Examination Vital signs
- Temperature: fever may indicate URI, pneumonia,
other source of infection
- Pulse: Usually tachycardic, bradycardia is an om-
inous sign
- Respiratory rate: tachypneic > 30 breaths/min.
- Blood pressure: Pulsus paradoxus
• Presence of hypoxia, bilateral wheeze or silent chest and
mental confusion with impending collapse.
• Peak flow a peak flow rate below 200 L/min indicates severe
obstruction for all but unusually small adults.
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DIFFERENTIAL DIAGNOSIS
• Laryngeal edema
WORKEUP
MANAGEMENT
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MECHANICAL VENTILATION
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- Drug overdos
- Postperfusion injury after cardiopulmonary bypass
- Pancreatitis
- Fat embolism
PRESENTATION
• History
• Examination
- Reveal severe hypoxia and the lungs reveal bilateral
rales and Mechanical ventilation is almost required.
DIFFERENTIAL DIAGNOSIS:
• Acute pulmonary edema
• Acute eosinophilic pneumonia
• Acute interstitial pneumonia
• Acute pneumocystic pneumonia in HIV
• Diffuse alveolar hemorrhage.
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WORKUP
• Bronchoscopy
- can be done if FIO2 not high and early of the disease
course
- Bronchoscopy to evaluate the possibility of infection,
alveolar hemorrhage, or acute eosinophilic pneumonia
bronchoalveolar lavage (BAL) can be optained. The
fluid is analyzed for cell differential, cytology, silver
stain, and Gram stain and is quantitatively cultured. the
finding of a high percentage of eosinophils (>20%) in
the BAL fluid is consistent with the diagnosis of acute
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TREATMENT
• Supportive Care
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• Fluid management:
• Mechanical Ventilation
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• Trachestomy
- Allows the establishment of a more stable airway,
which may allow for mobilization of the patient and
may facilitate weaning from mechanical ventilation.
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PNEUMONIA
OVERVIEW
• Definitions
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• Aspiration Pneumonia
- Causative organisms:
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PRESENTATION
• Symptoms
• Physical Examination
- Signs of bacterial pneumonia may include the
following: Hyperthermia (fever, typically >38°C)
[ or hypothermia (< 35°C) ,Tachypnea ,Use of ac-
cessory respiratory muscles, Tachycardia ,Central
cyanosis, Altered mental status
- Physical findings may include the following: Ad-
ventitious breath sounds, such as rales/crackles,
signs of consolidation, Pleural friction rub.
• Examination findings that may indicate a specific etiol-
ogy for consideration are as follows:
- Bradycardia may indicate a Legionella.
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• Severity index
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WORK-UP
• Blood cultures
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TREATMENT
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• For antibiotics for HAP and VAP, The prevalence and resistance
patterns of MDR pathogens vary between institutions and even
between ICUs within the same hospital. So embirical coverage
depends on the resistance. Taking a considerations of MDR
gram negative (consider colistin, tigecycline and carbapenem)
and MRSA ( vancomycin or lienozolid )
• Piperacillin-tazobactam
• Imipenem
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PULMONARY EMBOLISM
OVERVIEW
• PE is an obstruction of the pulmonary artery or one of its
branches by ( thrombus, tumor, air, or fat) that originated
elsewhere in the body.
- Blood hypercoagulability
PRESENTATION
• Massive PE
- Patients are in shock. They have systemic hypo-
tension, poor perfusion of the extremities, tachy-
cardia, and tachypnea. In addition, patients appear
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WORK-UP
• Chest Xray
- Common radiographic abnormalities include atelecta-
sis, pleural effusion, parenchymal opacities, and eleva-
tion of a hemidiaphragm. The classic radiographic find-
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• Echocardiography (Echo)
- May allow diagnosis of other conditions that may be
confused with pulmonary embolism, such as pericardi-
al effusion and left ventricular failure . ECHO allows
visualization of the right ventricle and assessment of
the pulmonary artery pressure. ECHO has a prognostic
value . the presence of right ventricular dysfunction can
be used to support the clinical suspicion of pulmonary
embolism.
• COMPUTED TOMOGRAPHY ANGIOGRA-
PHY (CTA)
- Is the initial imaging modality of choice for stable
patients with suspected pulmonary embolism. Vi-
sualizing a filling defect in the pulmonary arteries
confirm the diagnosis. Sensitivity is lower with
subsegmental branches of the pulmonary artery.
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• V/Q SCAN:
- Diagnostic accuracy was greatest when the V/Q
scan was combined with clinical probability,
which was determined by the clinician prior to
the V/Q scan :
• ANGIOGRAPHY
- Pulmonary angiography is the definitive diagnostic
technique or “gold standard” in the diagnosis of acute
PE.
TREATMENT
• Anticoagulation
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• Thrombolysis
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CHEST TRAUMA
OVERVIEW
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• Causes
• Physical Findings
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• Treatment
B. TENSION PNEUMOTHORAX
• Occurs when air enters the pleural space from lung in-
jury or through the chest wall without a means of exit.
The affected lung collapses completely with sub se-
quent mediastinal shift, kinking of superior and inferior
vena cava,decreased cardiac output. Ventilation of the
contralateral lung is also decreased by the mediastinal
shift.
• Causes
• Work-Up
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- Cyanosis (preterminal).
MANAGEMENT
C. PERICARDIAL TAMPONADE
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• Work-Up
• Treatment
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D. OPEN PNEUMOTHORAX:
• Treatment :
E. MASSIVE HEMOTHORAX
• Work-UP
- Hemorrhagic shock.
- Dullness to percussion.
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• Treatment:
F. FLAIL CHEST
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• Work-Up
• Treatment:
- Pain Control
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• Work-Up
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• Treatment:
- Establish airway.
B. TRACHEOBRONCHIAL INJURIES
• Location
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- Subcutaneous emphysema.
b. Specific finding:
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- Peribonchial air.
Treatment:
- Airway management.
- Endotracheal intubation with double lumen tube to
isolate affected lung
- Immediate bronchoscopy if patient condition is stable.
- CT scan chest with contrast
- Surgical repair according to site of injury.
C. BLUNT MYOCARDIAL INJURY
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D. DIAPHRAGMATIC TEARS
• Blunt Trauma
• Penetrating Trauma
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Work-Up
- Chest X-ray:
- Stomach, colon, or small bowel in chest, blurred
diaphragmatic contour and left pleural effusion.
- Nasogastric tube in left hemithorax.
- Hemidiaphragm elevation or lower lobe atelec-
tasis.
- C.T may miss diaphragmatic injury.
- Laparoscopy or thoracoscpy is more useful in diagno-
sis.
Treatment
E. ESOPHAGEAL INJURY
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Work-Up
• Treatment:
F. PULMONARY CONTUSION:
Work-Up
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• Treatment:
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MECHANICAL VENTILATION
Indications for initiation of mechanical ventilarory support
• Oxygenation abnormalities ( Type I respirato-
ry failure)
- Refractory hypoxemia
- Need for positive end-expiratory pressure
(PEEP)
- Excessive work of breathing
• Ventilation abnormalities( Type II respiratory
failure)
- Respiratory muscle dysfunction
- Respiratory muscle fatigue
- Chest wall abnormalities
- Neuromuscular disease
- Decreased ventilarory drive
- Increased airway resistance and / or obstruc-
tion
• General considerations
- To permit heavy sedation and / or neuromus-
cular blockade
- To decease systemic or myocardial oxygen
consumption
- To protect the airway in patients with decrease
level of consciousness
- Need for mild hyperventilation as in increase
ICP.
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Assist it.
- Fio2:
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• Tidal Volume
• Respiratory Rate
• Peep
- Inspiratory flow
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• Initiation of PEEP:
• Barotraumas/ volutrauma.
• Increase in Paco2
• Worsening oxygenation
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- Pneumonia or ARDS.
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• Decreasing VT
• Fio2
• Minute ventilation:
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• Peep :
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COMMON PROBLEMS:
• Decrease oxygenation:
- Increase FiO2.
- Increase PEEP.
- Increase sedation.
- Prone position
- Increase PO2:
- Decrease FiO2
- Decrease PEEP
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• High PCo2:
• Increase TV.
• Increase rate.
- Increase sedation.
• Low PCo2:
• Decrease TV.
• Decrease Rate.
DEFINITIONS
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• SB : Spontaneous breathing.
• pressors.
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• ( acceptable electrolytes)
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- Tachypnoeic >35/min
- Tachycardic >110/min
• When the patient met the criteria for weaning but failed,
this failure is predominantly due to inspiratory muscle fa-
tigue.
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GASTROINTESTINAL BLEEDING
OVERVIEW
ETIOLOGY
Upper GI bleeding
A. Common causes:
- Esophagitis
B. Uncommon causes
- Angiodysplasia
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- Cancer
- Portal Gastropathy
- Aortoenteric fistula
Lower GI bleeding
A. Common causes
- Diverticulosis
- Angiodysplasia
- Hemorrhoids
B. Uncommon causes
- Vasculitis
- Meckel’s diverticulum
- Colonic varices.
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CLINICAL PRESENTATION
• Melena can persist for several days, and the stool may
remain positive for occult blood for up to 2 weeks after
GI bleeding has ceased.
WORK-UP
• Nasogastric aspiration
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• Endoscopy
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• Imaging studies
MANAGEMENT
• Initial approach
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• Resuscitation
• Acid suppression
• Octreotide
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• Endoscopy
• Angiographic Therapy
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• Surgery
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VARICEAL BLEEDING
OVERVIEW
CLINICAL PRESENTATION
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WORK-UP
MANAGEMENT
• Initial resuscitation
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• Pharmacotherapeutic agents
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• Endoscopic therapy
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• Sclerotherapy
• Balloon tamponade
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- ALF (8 to 28 days)
• Etiology
- Hepatitis A
Cytomegalovirus
- Hepatitis B
Varicella zoster virus
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- Hepatitis C
Adenovirus
- Delta Agent
Ebsteinbarr virus
- Hepatitis E
Herpes virus
B. Metabolic disorders
- HELLP syndrome
- Wilson’s disease
C. Cardiovascular disorders
- Cardiovascular shock
- Hyperthermia
- Acetaminophen
- Sodium valproate
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- Isoniazid
- Halothane
CLINICAL PRESENTATION
• Coagulopathy
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• Cardiorespiratory complications
• Renal Failure
• Metabolic disorder
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• Infection
WORK-UP
• CBC
• LFT’s
• Renal profile
• Coagulation profile
• ABG
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• Hepatitis screen
• Drug screen
• General measures
• Sepsis
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• Metabolic disorders
183
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184
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of the following
Unfavorable cause
Drug reaction
Wilson’s disease
2. Acetaminophen-related ALF
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HEPATIC ENCEPHALOPATHY
GRADING
• Inappropriate, drowsy.
MANAGEMENT
187
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ACUTE PANCREATITIS
OVERVIEW
• Definitions
• Etiology
- Ethanol abuse
- Drugs:
188
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- Pancreatic cysts
- Ductal strictures
- Parasites: Ascaris
- Traumatic
- Idiopathic pancreatitis
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CLINICAL PRESENTATION
• Physical examination
DIFFERENTIAL DIAGNOSIS
• Cholecystitis/cholangitis
• Bowel obstruction
• Mesenteric ischemia/infarction
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WORK-UP
• Amylase
• Routine radiography
191
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192
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PROGNOSIS
194
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195
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• Etiology
196
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CLINICAL PRESENTATION
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WORK-UP
• Laboratory
- CBC
- Renal Hepatic coagulation profiles
- Amylase
- ABG Serum lactate
- Elevation of serum amylase concentration
- Elevation of serum lactate, often implies se-
vere ischemia or bowel infarction
- Most common laboratory abnormality is a
persistent and profound leukocytosis.
- Electrolyte derangement from dehydration
and acidosis seen in the advanced stage of
intestinal infarction.
• Imaging
• Others
- ECG, ECHO
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TREATMENT
• SMA embolism
• SMA thrombosis
• NOMI
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200
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INTESTINAL PERFORATION/OBSTRUCTION
OVERVIEW
• Frequency
• Etiology
201
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vehicle-related trauma
202
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CLINICAL PRESENTATION
• History
- Abdominal pain
- Vomiting
• Physical
203
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changes.
- Abdominal examination:
DIFFERENTIAL DIAGNOSIS
• Gastritis
• Acute pancreatitis
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• Acute gastroenteritis
• Ovarian torsion
WORK-UP
• CBC
• Hepatic profile
• Renal profile
• Coagulation profile
MANAGEMENT
205
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CONTRAINDICATIONS
206
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COMPARTMENT SYNDROMES
COMPARTMENT SYNDROMES OF THE EXTREMITIES
OVERVIEW
• Etiology
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CLINICAL PRESENTATION
• Clinical examination:
WORK-UP
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TREATMENT
• Fasciotomy
RED FLAG
- Rhabdomyolysis
- Ischemic neourapthy
- Reperfusion syndrome
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• Etiology
A. Primary ACS
B. Secondary ACS
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• Pathophysiology
- Respiratory dysfunction
- Cardiovascular dysfunction
211
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CLINICAL PRESENTATION
WORK-UP
• Methods of measurement
• Bladder pressure
TREATMENT
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- Vacuum pack
- Close abdomen
RED FLAG
- Renal failure
- Pulmonary failure
- Cardiovascular failure
213
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• Etiology
214
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- Cyclosporin A.
215
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CLINICAL PRESENTATION
• This definition, which goes by the acronym of RIFLE,
divides renal dysfunction into the categories of injury,
and failure (Fig. 1)
216
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217
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WORK-UP
• Biochemical assessment
218
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• Radiolgy studies:
- Renal scan
- Renal MRI
MANAGEMENT
219
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• Haemodynamic management
• Metabolic management
220
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- Glomerular disease
- Dialysis for:
- Fluid overload
- Hyperkalemia
221
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Red Flag
222
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RHABDOMYOLYSIS
OVERVIEW
• Causes
WORK-UP
223
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• Myoglobin in Urine:
MANAGEMENT
224
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• Alkalinizing the urine can also help to limit the renal inju-
ry, by using NaHco3 infusion to keep urine PH> 8.
225
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DISSEMINATED INTRAVASCULAR
COAGULATION (DIC)
OVERVIEW
• Causes
- Vascular abnormalities.
• Pathophysiology
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CLINICAL PRESENTATION
WORK-UP
227
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MANAGEMENT
228
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229
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CLINICAL PRESENTATION
• Chronic features
230
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WORK-UP
•
MANAGEMENT
231
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COMPLICATIONS
232
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SEPTIC SHOCK
OVERVIEW
- than 32 mm Hg
• Sepsis
233
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typically included:
- Alteration in mental state
• Bacteremia
- is defined as the presence of bacteria in the blood.
• Septic shock
234
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• Etiology
PRESENTATION
DIAGNOSIS
235
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MANAGEMENT
A. General
236
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• Circulatory support
237
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238
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• Coverage of methicillin-resistant
S au-
reus (MRSA) with an agent such as vancomycin
or linezolid.
239
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240
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241
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242
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ANAPHYLAXIS
OVERVIEW
• Mechanisms:
- IgE-mediated
- Nonimmunologic anaphylaxis.
- Histamine—
- Tryptase—
- Nitric oxide(NO)—
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- Respiratory system—
RECOGNITION
244
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PRESENTATION
• Skin symptoms and signs, occur in up to 90 percent of
episodes.
DIFFERENTIAL DIAGNOSIS
• syncope/faint, and
• anxiety/panic attacks.
245
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WORK-UP
MANAGEMENT
- Supplemental oxygen
• Initial assessment
— Interventions to be instituted
concomitantly
- ABC’s, Examination of the skin.
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• Medications:
247
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to 15 minute intervals.
248
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SEVERE MALARIA
OVERVIEW
249
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and myalgias .
• Brucellosis
• TB
• Dengue fever
• HIV
• Meningio encephalitis
WORK-UP
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- Circulatory collapse
- Metabolic acidosis
- liver failure
- Hypoglycemia
MANAGEMENT
251
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• Quinine-Quinidine
- Intravenous quinine dihydrochloride 20 mg salt/
252
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253
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TETANUS
OVERVIEW
254
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drugs
- Stiff neck
- Opisthotonus
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- Dysphagia
256
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257
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HYPERNATRAEMIA
OVERVIEW
• Causes
- Gastrointestinal losses
- Osmotic diuresis
solutions.
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CLINICAL PRESENTATIONS
MANAGEMENT
• Rate Of Correction
• Hypovolaemia
259
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260
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- may be necessary
Causes of Hypernatraemia
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[Na+] variable
hypo-, iso- or
Normal total bodyNa hypertonic
R e n a l
losses: Di-
abetes In-
Extra-renal losses: s i p i d u s [Na+] variable hyper-
Respiratoryand Renal tonic
insensible losses
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HYPONATRAEMIA
OVERVIEW
CLINICAL PRESENTATION
WORK-UP
263
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MANAGEMENT
- mmol/L/h thereafter.
264
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265
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- Established.
- (1.8%) saline.
• General points
266
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CAUSES OF HYPONATRAEMIA
Urine
Etiology Type
(Na+)
267
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mmol/
l20 <
ECF volume depletion
Renal losses: diuretic
excess, osmotic di-
uresis (glucose,
mmol/
l20 < Water intoxication ,
post-operative TURP Modest ECF volume
syndrome,
excess (no edema)
inappropriate ADH
secretion, hypothy-
roidism, drugs (e.g
268
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mmol/
Nephrotic syndrome, ECF volume excess
l10 >
Cirrhosis, Heart fail-
ure )oedema(
269
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HYPERKALAEMIA
OVERVIEW
• Causes
- Potassium poisoning
CLINICAL PRESENTATION
270
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WORK-UP
• ECG.
MANAGEMENT
271
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272
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HYPOKALAEMIA
OVERVIEW
• Causes
- Inadequate intake
- Haemofiltration losses
273
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CLINICAL PRESENTATION
• Metabolic alkalosis
• Constipation
• Ileus
• Muscular Weakness
WORK-UP
• ECG.
• Cortisol level
274
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MANAGEMENT
OVERVIEW
275
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CLINICAL PRESENTATION
DIFFERENTIAL DIAGNOSIS
276
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WORK-UP
MANAGEMENT
B. Specific:
277
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HYPOGLYCEMIA
OVERVIEW
- Sepsis,
- Adrenal insufficiency
CLINICAL PRESENTATION
• Diaphoresis, tachypnea
278
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DIFFERENTIAL DIAGNOSIS
WORK-UP
• specific :
279
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DKA
OVERVIEW
- acute pancreatitis
- myocardial infarction,
CLINICAL PRESENTATION
280
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• On examination:
WORK-UP
MANAGEMENT
281
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THYROTOXIC CRISIS
OVERVIEW
- Causes
282
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CLINICAL PRESENTATION
• History
• Physical
- Excessive sweating
- Cardiovascular signs
283
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- Neurologic signs
• Laboratory Studies
• Thyroid studies
- Test results may not come back quickly and are usu-
ally unhelpful for immediate management.
284
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• Sepsis
• Malignant hyperthermia
• Acute mania
MANAGEMENT
• Medical tratment
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286
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perthyroidism.
• Surgical treatment
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Author
Coauthor(s)
288
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289
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Chief Editor
290
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References
291
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292
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16. Ngo AS, Jung Tan DC. Thyrotoxic heart disease. Re-
suscitation. Jun 26 2006;[Medline].
293
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line].
23. Yoon SJ, Kim DM, Kim JU, et al. A case of thyroid
storm due to thyrotoxicosis factitia. Yonsei Med J. Apr
30 2003;44(2):351-4. [Medline].
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MYXEDEMA COMA
OVERVIEW
CLINICAL PRESENTATION
296
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297
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WORK-UP
298
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299
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300
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301
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• Etiologies
302
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- Tachycardia.
- Tachypnea.
- Rhabdomyolysis.
303
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MANAGEMENT
• ABC.
304
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• Control Convulsion.
305
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HYPOTHERMIA
OVERVIEW
• Etiology
• Complications
306
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- Hypoxaemia
- Acute pancreatitis,
WORK-UP
• ECG changes:
MANAGEMENT
307
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• Passive rewarming:
308
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309
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OPIOID POSITIONING
OVERVIEW
CLINICAL MANIFESTATION
310
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• CNS: sedation,euphoria,seizure
• Eye: miosis.
DIFFERENTIAL DIAGNOSIS
WORK-UP
• Toxicology screen.
311
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MANAGEMENT
• Specific :
312
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ORGANOPHOSPHATE POISONING
OVERVIEW
CLINICAL PRESENTATION
313
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- Genitourinary :Incontinence
WORK-UP
314
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MANAGEMENT
• Specific :
315
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PARACETAMOL POISONING
OVERVIEW
CLINICAL MANIFESTATION
316
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DIFFERENTIAL DIAGNOSIS
WORK-UP
317
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MANAGEMENT
• Specific :
318
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INHALED POISONING CO
OVERVIEW
CLINICAL MANIFESTATION
• Acute CO poisoning:
319
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DIFFERENTIAL DIAGNOSIS
WORK-UP
320
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MANAGEMENT
• Specific :
- Supportive management
321
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- Pregnancy
- Cardiac ischemia
322
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ALCOHOL TOXICITY
OVERVIEW
CLINICAL MANIFESTATION
• Methanol (MeOH)
323
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- Ophthalmologic: Blindness
• Isopropanol
WORK-UP
• Specific :
324
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MANAGEMENT
• Specific :
ETHANOL
ETHANOL
OVERVIEW
CLINICAL MANIFESTATION
325
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• Withdrawal:
326
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WORK-UP
DIFFERENTIAL DIAGNOSIS
• DKA , Hypoglycemia
MANAGEMENT
• Specific :
327
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REFERENCES
328
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329
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- Lim WS, van der Eerden MM, Laing R, et. al. Defining com-
munity acquired pneumonia severity on presentation to hos-
pital: an international derivation and validation study. Tho-
rax. 2003 May; 58(5):377-82.
- Biffl WL, Moore FA, Moore EE, etal: cardiac enzymes are
irrelevant in the patient with suspected myicardial injury.Am
J Surg169:523-528, 1994.
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Management Guideline2012.
331
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- Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Or-
ganization anaphylaxis guidelines: summary. J Allergy Clin-
Immunol 2011; 127:587.
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333
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334
M.O.H
DRUG LIST
ALPHAPITICAL
DRUG INDEX
MOH Pocket Manual in Critical Care
atorvastatin carbimazole
carboplatin cyclophosphamide
carboprost tromethamine cycloserine
carboxymethyl-cellulose cyclosporine
carmustine cyprotone acetate + ethinyl estradiol
carteolol hcl cytarabine for injection
carvedilol )D(
caspofungin acetate dabigatran
cafaclor dacarbazine
cefepime hydrochloride dactinomycin
cefixime dalteparin
cefixime sodium danazol
ceftazidime pentahydrate dantrolene sodium
ceftriaxone sodium dapsone
cefuroxime darunavir
celecoxib dasatinib monohydrate
cephalexin monohydrate daunorubicin hcl
cephradine desmopressin acetate
cetuximab dexamethasone
chloral hydrate Dextran (dextran40) + sodium chlorid
chlorambcil dextromethorphan
chloramphenicol dextrose
chlordiazepoxide hcl diazepam
chlorhexidine gluconate diazoxide
chloroquine diclofenac
chlorpheniramine maleate didanosine
chlorpromazine hcl diethylcarbamazine citrate
chlorthalidone digoxin
dihydralazine mesilate or hydralazine
chlorzoxazone
hcl
)cholecalciferol (vitamine d3 diloxanide furoate
cholestyramine )diltiazem hcl (sustainad release
cincalcet hydrochloride dimenhydrinate
cinnararizine dinoprostone
ciprofloxacin diphenhydramine hcl
cispltin )diphetheria,tetanus,pertussis (dpt
citalopam hydrobromide diphetheria,tetanus vaccine for adult
diphetheria,tetanus vaccine for
clarithromycin
children
clindamycin diphetheria antitoxine
cyclophosphamide carboplatin
cycloserine carboprost tromethamine
cyclosporine carboxymethyl-cellulose
cyprotone acetate + ethinyl estradiol carmustine
cytarabine for injection carteolol hcl
(D) carvedilol
dabigatran caspofungin acetate
dacarbazine cafaclor
dactinomycin cefepime hydrochloride
dalteparin cefixime
danazol cefixime sodium
dantrolene sodium ceftazidime pentahydrate
dapsone ceftriaxone sodium
darunavir cefuroxime
dasatinib monohydrate celecoxib
daunorubicin hcl cephalexin monohydrate
desmopressin acetate cephradine
dexamethasone cetuximab
Dextran (dextran40) + sodium chlo-
chloral hydrate
rid
dextromethorphan chlorambcil
dextrose chloramphenicol
diazepam chlordiazepoxide hcl
diazoxide chlorhexidine gluconate
diclofenac chloroquine
didanosine chlorpheniramine maleate
diethylcarbamazine citrate chlorpromazine hcl
digoxin chlorthalidone
dihydralazine mesilate or hydralazine
chlorzoxazone
hcl
corticorelin (corticotrophin-releasing
edrophonium chloride
factor,crf)
efavirenz cromoglycate sodium
electrolyte oral rehydration salt (ors) cyanocobalmin (vit b12)
emtricitabine cyclopentolate hcl
tropicamide vigabatrin
valsartan (Z)
vinorelbine
vitamine B complex
vitamine E
voriconazole
Authors
Illustration