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The Protocol Book for Intensive Care
Soumitra Kumar
CHAPTER 1:
Acute ST-Elevation Myocardial Infarction
Third Universal Definition of Myocardial Infarction (Joint ESC/ACCF/AHA/WHF Task Force 2012)
Definition of Myocardial Infarction
Criteria for Acute Myocardial Infarction
Criteria for Prior Myocardial Infarction
Classification of Myocardial Infarction
Type I: Spontaneous Myocardial Infarction
Type 2: Myocardial Infarction Secondary to an Ischemic Imbalance
Type 3: Myocardial Infarction Resulting in Death when Biomarker Values are Available
Type 4a: Myocardial Infarction Related to Percutaneous Coronary Intervention
Type 4b: Myocardial Infarction Related to Stent Thrombosis
Type 5: Myocardial Infarction Related to Coronary Artery Bypass Grafting
Prehospital Issues
Initial Hospital Management
Selection of Reperfusion Strategy
In Hospitals with PCI Capability
Fibrinolytic Therapy
Status of Different Thrombolytic Agents
ECG Features Justifying Fibrinolytic Therapy
Contraindications to Fibrinolysis
Absolute Contraindications
Relative Contraindications
Assessment of Reperfusion (Noninvasive)
ST-Segment Resolution
Biomarkers
Noninvasive Imaging
Prehospital Thrombolysis
Requisites for Prehospital Thrombolysis
Rescue PCI
As per ACC/AHA Guidelines (2004)
Class IIa indications for rescue PCI
Facilitated PCI
Early PCI
Delayed PCI
Indications of CABG in Patients
Other Complications of Acute Myocardial Infarction
Secondary Prevention after STEMI
CHAPTER 2:
Management of Unstable Angina and Non-ST Elevation Myocardial Infarction
Cardiac Biomarkers in Acute Coronary Syndrome
Risk Stratification in UA/NSTEMI
Established Biomarkers
Emerging Biomarkers
RISK STRATIFICATION IN UA/NSTEMI
Beta-Blockers
Other Anti-Ischemic Therapies
Antiplatelet Treatment in Non-ST Elevation ACS (NSTE-ACS)
Aspirin
Clopidogrel
Newer Thienopyridine Derivatives
Newer Antiplatelet Drugs
Thrombin-Receptor Antagonist (TRAS)
Glycoprotein IIb/IIIa Inhibitors (GPIIb/IIIa Inhibitors)
GP IIb/IIIa Inhibitors in a Consecutive Strategy
GP IIb/IIIa Inhibitors in an Invasive Strategy
Glycoprotein (GP) IIb/IIIa Inhibitors and Coronary Artery Bypass Graft
Adjunctive Therapy
What is the best time to initiate therapy? (Upstream or in the catheterization laboratory)
Is Addition of GPIIb/IIIa Inhibitors Necessary during PCI in Patients Pretreated with High-Dose Clopidogrel?
Can Direct Thrombin Inhibitors be used as an Alternative to GpIIb/IIIa Inhibitors?
Antithrombin Treatment in Patients with NSTE-ACS
Unfractionated Heparin (UFH)
Low Molecular Weight Heparin (LMWH)
Direct AntiXa Inhibitor: Fondaparinux
Dosage of Fondaparinux in ACS: 2.5 mg Once Daily
Direct Thrombin Inhibitors
Newer Antithrombotics
Direct Thrombin Inhibitors
Anticoagulants
Other Therapies
Inhibitors of the Renin-Angiotensin-Aldosterone System
Lipid-lowering Therapy
Recommendations for Oral Antiplatelet Agents
Recommendations for GP IIb/IIIa Receptor Inhibitors
Recommendations for Anticoagulants
Difference between ESC (2011) and ACCF (2011)
NSTE-ACS Guidelines
Coronary Revascularization Procedures
Comparison of Early Invasive and Conservative Strategies
Indications of Urgent Invasive Strategy
Indications of Early Invasive Strategy
Conservative (No PCI/Elective PCI) Strategy
Emerging Role of CT-coronary Angiography
Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting
Recommendations for Patients with CKD (ESC 2011 NSTE—ACS Guidelines)
Medical Regimen on Discharge
Risk Factor Modification
CHAPTER 3:
Cardiogenic Shock
Definition
Etiology
Risk Factors
In Patients with Ischemic Cause of Cardiogenic Shock
Diagnosis
Management
Class I
Class II
Mechanical Support Devices
IABP
Contraindications
Complications
Does IABP Extend Life in CS?
Percutaneous Cardiopulmonary Support
Left Ventricular Assist Devices
Advantage over IABP
Disadvantages over IABP
Extracorporeal Life-support
SHOCK Trial Registry
Dosage
Ionotropes
Vasodilators
Newer Agents
Some Formulae
CHAPTER 4:
Acute Heart Failure
Etiology
Mechanisms Underlying Decompensation of Chronic Heart Failure*
Diagnosis of Acute Heart Failure (AHF)
Decompensation of Pre-existing Chronic HF
Investigations
Class-I Indications
Electrocardiogram
Brain Natriuretic Peptide
Bedside Echocardiography
Echocardiography in AHF
Hemodynamic Assessment by Echocardiography
Assessment of Ventricular Function
Load Dependent Variable
Load Independent Variables
Estimation of LV Filling Pressure
Pulmonary Artery Systolic Pressure
Pulmonary Vascular Resistance
RV Function Assessment
Hemodynamic Monitoring in AHF
Normal Range of Right Heart Pressures
Some Calculations
Hemodynamic Parameters in Different Conditions
Approach to the Patient with Acute Heart Failure
Approach to AHF with Systolic Dysfunction
Approach to AHF with Hypotension
Further Management of Hypotension Depending on Hemodynamic Subsets
Recommendation for Hospitalization Patients with Acute Docompensated Heart Failure (ADHF)
Hospitalization Recommended
Hospitalization should be Considered
Treatment Goals for Patients Admitted for ADHF
PHASE OF MANAGEMENT
Phase I : Management in ED
O2 and I/V Morphine
Noninvasive Ventilation (NIV)
Diuretics
Vasodilators
Glyceryl Trinitrate (GTN)
Nesiritide
Phase-II management
Revascularization
Recommendation Prior to Discharge
Phase-III management (after discharge and during vulnerable phase)
Potential New Therapies
Discharge Criteria for Patients with AHF
Recommemded for all AHF Patients
Should be Considered for Patients with Advanced HF/ recurrent admission for HF
Cardiac Disease and AHF Requiring Surgical Treatment
Scope of LV Assist Devices in AHF
Acute Heart Failure and Normal Left Ventricular Ejection Fraction (HFNEF)
Evidence Base of Treatment of AHF with NEF
Treatment Guidelines in AHF with PLVEF
Risk-scoring in AHF
The Kidney in Heart Failure
Cardiorenal Syndrome
CHAPTER 5:
Management of Chronic Heart Failure
Chronic HF
Definition
Principles of Treatment
History
Clinical Examination
Investigation
Biomarkers in Heart Failure
Established Biomarkers
Stages of Heart Failure
Outline of Treatment of CHF
Pharmacotherapy of Congestive Heart Failure
Diuretics
Proven Indication of Diuretics (Always Acceptable)
Acceptable Indication but of Uncertain Efficacy and may be Controversial
Not Proven: Potentially Harmful or Contraindicated
Guidelines for Use of Diuretics
Initial Diuretic Treatment
Insufficient Response
Potassium Sparing Diuretics (Other than Spironolactone or Eplerenone)
Are All Loop Diuretics Equal in Terms of Prognosis?
ACE-Inhibitors
Proven Indications of ACEIs in HF: Always Acceptable
Acceptable Indication but Uncertain Efficacy and may be Controversial
Not Proven: Potentially Harmful or Contraindicated
Evidence-base of ACEIs
Angiotensin-Receptor Blockers
Proven Indications of ARBs in HF: Always Acceptable
Acceptable Indications but of Uncertain Efficacy and may be Controversial
Evidence Base of ARBs
Guidelines for Use of ACEIs and ARBs
Beta-blockers
Proven Indications of Beta-blockers in Heart Failure
Acceptable Indication but of Uncertain Efficacy and may be Controversial
Not Proven: Potentially Harmful or Contraindicated
Guidelines for Use of β-blocker
Evidence Base of Beta-blockers in CHF
Digitalis
Proven Indications of Digitalis in Heart Failure
Acceptable Indications but Somewhat Controversial
Evidence-base of Digitalis in CHF: PROVED, RADIANCE, DIG Trials
Aldosterone Antagonist
Recommendations for Use in Systolic Heart Failure Proven indications
Potentially harmful or contraindicated
Administration and Dosing Consideration with Aldosterone Antagonists (Spironolactone, Eplerenone)
Evidence Base of Aldosterone Antagonists
Vasodilators in CHF
Other Options in Medical Management
Positive Inotropic Therapy in CHF
Antithrombotics in CHF
Antiarrhythmics in CHF
Worsening Heart Failure
Management of End-Stage Heart Failure (NYHA CLASS IV)
Cardiac Resynchronization Therapy
ESC Recommendations in Patients with Heart Failure in NYHA Class II
Follow-up of CRT
Clinical Parameters
Echocardiographic Parameters
Implantable Cardioverter Defibrillator
Indications of ICD
Surgical Options in Heart Failure
Coronary Artery Bypass Grafting
Decision-making in Ischemic Cardiomyopathy
Ventricular Remodeling Surgeries
Ventricular Assist Devices
Mitral Valve Surgery in Heart Failure
Ventricular Restraining Devices
Cardiac Transplantation
Stem Cell Therapy
Monitoring in Heart Failure
Potential Measurements for Heart Failure Monitoring
Ultrafiltration in End-stage Heart Failure
Metabolic Therapy
Gene Therapy
Immunomodulation
CHAPTER 6:
Syncope
Causes of Syncope
Cardiac Syncope
Echocardiogram
Noninvasive ECG Monitoring
Electrophysiological Study
Key Points in History Taking
Situation
Prodrome
Witnessed Appearance
Postevent Residua
Differentiation of Seizures from True Syncope
Syncope in the Athletic Patients
Risk Stratification
The ROSE rule
Treatment of Syncope
CHAPTER 7:
Atrial Fibrillation
Definition
Patterns of Atrial Fibrillation
Clinical Evaluation of AF Patient
Additional Testing (As Indicated)
Management of Newly Discovered AF (Duration Known to be ≤ 48 hours)
Management of Newly Discovered AF (Duration Known to be ≥ 48 hours or of Uncertain Duration)
Pharmacological Management of Patients with Recurrent Paroxysmal AF
Pharmacological Management of Patients with Recurrent Persistent AF or Permanent AF
Antiarrhythmic Drug Therapy to Maintain Sinus Rhythm in Patients with Recurrent Paroxysmal or Persistent AF
Electrical Cardioversion
Stroke Risk in Patients by CHA2DS2 VASc Score
Thromboprophylaxis in AF
Clinical Characteristics of HAS-BLED Bleeding Risk Score
Special Issues in Anticoagulation
Alternatives to Warfarin
Rate versus Rhythm Control
Guidelines for Rate Control
Acute Rate Control in Atrial Fibrillation
Rhythm Control in Atrial Fibrillation
Newer Antiarrhythmic Drugs
Atrial-selective Antiarrhythmic Drugs
Dronedarone
Non-pharmacological Treatment of AF
Pacemakers
Left Atrial Catheter Ablation
Surgical Ablation
Hybrid Therapy of Atrial Fibrillation
Upstream Therapy
Absolute Indications for Lifelong Oral Anticoagulation
Management of Antithrombotic Perioperatively
A Practical Approach to Bridge Therapy
Before Surgery
After Surgery
When to Stop Warfarin
If Warfarin is Stopped for Minor Procedures, Bridging may be Counterproductive
Possible Scenarios
Antithrombotic Therapy for the Secondary Prevention of Noncardioembolic Stroke
Initiation/Resumption of Oral Anticoagulation After an Ischemic Stroke
Breakthrough Embolic Stroke Acute management
Long-term Management of Breakthrough Embolic Stroke
Antithrombotic Therapy for Secondary Prevention of Cardioembolic Stroke
Intracerebral hemorrhage
Some Important Points to be Noted
Dosages
Studies of in-hospital anticoagulation after ICH
When to Start Anticoagulation?
Antiplatelet Therapy after Hypertensive Intracranial Hemorrhage
Perioperative Antithrombotic Therapy for Spinal Surgery
Key to Management: Assessing and Balancing
Surgical Hemorrhagic Risk
Cerebro- and Cardiovascular Risk
Management of Anticoagulants in Pregnancy
Anticoagulants in Pregnancy
CHAPTER 8:
Tachycardias
Approach to the Patient with Narrow QRS Complex Tachycardia
Initial Treatment of AVNRT (AV Nodal Re-entry Tachycardia)
Management of Narrow QRS Tachycardia
Management of Patients with AVNRT
Acute Treatment, Stable
Acute Therapy, Unstable (Chest Pain, Severe Dyspnea, Hypotension, Syncope, Impaired Consciousness)
Congestive Heart Failure
Recurs Shortly after Conversion to Sinus Rhythm
Chronic Prevention in Infrequent, Well-tolerated, Short-lived Episodes
Chronic Prevention in all others (Frequent Episodes, Poorly Tolerated or Rapid Rates (>220/mm)
Nonresponder
Management of Patients with Pre-excitation
AF with Ventricular Pre-excitation and Rapid Ventricular Rates: Acute Therapy Unstable (Hypotension, Angina, Heart Failure Symptoms)
AF with Ventricular Pre-excitation and Controlled Ventricular Rates without Hemodynamic Instability: Acute Therapy
Orthodromic AVRT: Acute Therapy
Antidromic AVRT: Acute Therapy
Long-term Therapy: WPW Syndrome due to an Accessory Pathway
Mahaim Fiber Tachycardias
Lown-Ganong-Levine Syndrome (with SVTs)
Permanent Junctional Reciprocating Tachycardia (PJRT)
Atrial Flutter
Typical Counter Clockwise Atrial Flutter with Variable AV Block
Typical Clockwise Atrial Flutter
Atypical Atrial Flutter
Other Forms of Atrial Flutter
Management of Atrial Flutter
Acute Therapy for Poorly Tolerated Atrial Flutter (AFL) or Continuous High Ventricular Rate
Long-term Prevention
Nonresponders having Severe Symptoms
Wide Complex Tachycardia
Clinical Assessment
History
Physical Assessment
Investigations
Classic Morphology Criteria for Ventricular Tachycardia
Classification of Ventricular Tachyarrhythmias
Classification of Ventricular Tachyarrhythmias by Electrocardiography
Pharmacological Aids for the Diagnosis of Wide QRS Tachycardia
Caution
Incessant Ventricular Tachycardia
Ventricular Tachycardia Related to Ischemic Heart Disease
Postmyocardial Infarction
Recommendations of Electrophysiological Testing in Patients with Coronary Heart Disease
ACC/AHA/ESC Guidelines 2006
Class I
Class IIa
Recommendations for Treatment of Ventricular Arrhythmias in Patients with Prior MI
Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Cardiomyopathy
Identification
Ventricular Arrhythmias in Hypertrophic Cardiomyopathy
Brugada Syndrome
Spectrum of Individuals Who Exhibit Brugada ECG Pattern
Brugada Syndrome
Brugada ECG Pattern and High-risk Features
Brugada ECG Pattern Provoked by
Brugada ECG Pattern without above Features
Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Genetic Pattern of CPVT
Digoxin Induced Toxic Fascicular Tachycardia
Ventricular Tachycardia in Normal Heart
Idiopathic Ventricular Tachycardia
Repetitive Monomorphic Ventricular Tachycardia
Identification
Annular Ventricular Tachyardia
Idiopathic Left Ventricular Tachycardia
Identification
Classification of Polymorphic VT (PMVT)
Prolonged QT Interval (Torsade De Pointes)
Congenital Long Q-T Syndrome
PMVT Associated with Ischemic Heart Disease
Long Q-T Syndrome—Rx
Short QT Syndrome
Class I
Class IIa
Class IIb
CHAPTER 9:
Cardiopulmonary Resuscitation
Definition
Goals
Key Principles in Resuscitation: Stengthening the Links in the Chain of Survival
Adult Basic Life Support
Advanced Cardiac Life Support (ACLS)
Advanced Cardiac Life Support (ACLS)
Cardio-cerebral Resuscitation
Three Pillars of Cardiocerebral Resuscitation
Prognostic Factors after CPR
Therapeutic Hypothermia after Cardiac Arrest
Three stages of therapeutic hypothermia
Common Interventions and Medications Used in ACLS
A. Interventions
B. Medications
CHAPTER 10:
Percutaneous Coronary Intervention in Acute Myocardial Infarction
Why Primary PCI is different from an Elective PCI?
Protocol for Primary PCI
Preprocedural Protocol
Adjunctive Pharmacology
Procedural Protocol
Choice of Guiding Catheter
Size of Guiding Catheters
Choice of Balloon Dilatation Catheters
Coronary Stenting
Management of Thrombus
Thrombectomy and Thrombus Aspiration
Management of No-reflow
Treatment of No-reflow
Prevention of No-reflow
Pharmacological Strategies
Management of Reperfusion Injury
Supportive Management in the Cath-Lab
Vascular Access Management
Discharge
CHAPTER 11:
Vascular Emergencies
Venous Thromboembolic Disorders
Etiology
Clinical Diagnosis of Deep Venous Thrombosis of Lower Limb
Clinical Model for Predicting Pretest Probability of DVT
Differential Diagnosis of Deep Venous Thrombosis
Investigations for DVT
Treatment of DVT
Initial Treatment
Thrombolytic Regimens
Long-term Treatment of Acute-DVT
Complications of Anticoagulant Therapy
Use of Compression Therapy
Pulmonary Embolism
Clinical Features
Investigations
Principal Markers Useful for Risk Stratification
Risk Stratification in Pulmonary Embolism
Aortic Dissection
Etiology/Associations
Presentation
Symptoms
Signs
Few Important Facts
Investigations
Medical Treatment
Management of Pericardial Tamponade
Acute Limb Ischemia
Management Strategies
Clinical History
Lab
Imaging
Classification
Management Pathways
Heparinization
Thrombolysis
Endovascular therapy
CHAPTER 12:
Acute Cardiac Care in Pediatric Practice
Case 1
Management
Case 2
Management of Hypoxic Spell
Step 1
Step 2
Step 3
Step 4
Step 5
Case 3
Management of Supraventricular Tachycardia
Case 4
Case 5
Common Cause of Cardiac Syncope in Pediatric Age Range
Work Up
Case 6
Common Causes of CHF in Early Infancy
1st day of life
1st week of life
1st 2 months of life
Routine Investigation
Management for CHF was Started as per Protocol
Infant with CHF: Initial “Normal Echo”
CHAPTER 13:
Hypertensive Crisis
Caution
Management of Specific Situations
Patients with Coronary Artery Disease with Hypertension
Aortic Dissection
Hypertensive Crisis after Coronary Artery Bypass Surgery
Pheochromocytoma
Poorly Controlled Hypertension in Surgical Patients
Hypertensive Emergency in Pregnancy
Acute Stroke and Hypertension
CHAPTER 14:
Acid-base Disturbances
Types of Acid-base Disorder
Normal Values
Approach to Diagnose Mixed Acid-base Disorders
Individual Acid-base Disorders
Metabolic Acidosis—High AG and Normal AG
Metabolic Alkalosis
Causes
Diagnostic Clue of Metabolic Alkalosis
Treatment
Respiratory Acidosis
Respiratory Alkalosis
Management of Respiratory Alkalosis
CHAPTER 15:
Electrolyte Imbalance
Hyponatremia
Clinical Approach
What is Pseudohyponatremia?
Hyponatremia: Treatment
Goals
Individual Situations
Repleting the Sodium Deficit
Uses of Vasopressin Receptor Antagonists (Vaptans)
Hypernatremia - Plasma (Na+) > 145 mmol
Clinical Features
Clinical Approach
Example
Hyperkalemia
Plasma [K+] > 5.0 mEq/L
Clinical Features
Clinical Approach
Treatment
Hypokalemia
Plasma [K+] < 3.5 mEq/L
Clinical Approach
Treatment
To Correct K+ Deficit and Decreased Ongoing Losses
Hypermagnesemia
Clinical Features
Therapy
Hypomagnesemia
Etiology
Clinical Features
Therapy
Hypercalcemia
Causes of Hypercalcemia
Clinical Features
Diagnosis
Treatment
Hypocalcemia
Causes of Hypocalcemic
Clinical Features
Treatment
Chronic Treatment
Hypophosphatemia
Clinical Features
Investigation
Treatment
Hyperphosphatemia
Clinical Features
Treatment
CHAPTER 16:
Management of Adult Severe Acute Asthma
Diagnosis of Asthma
Differential Diagnosis of Acute Asthma
Levels of Severity of Acute Asthma Exacerbations
Assessment
Features of Acute Severe Asthma
Life-threatening Features
Blood Gas Markers of a Life-threatening Attack
Near Fatal Asthma (NFA) Acute Asthma
Immediate Treatment
If Life-threatening Features are Present
Subsequent Management
If Patient is Improving Continuously
If Patient Not Improving After 15 to 30 Minutes
If Patient is Still Not Improving
Monitoring
Referral of Adults with Acute Asthma to Intensive Care
Noninvasive Ventilation in Asthma
Discharge
Other Treatments
Advanced in Current Management and Future Therapy
Sedation, Analgesia, Paralysis in Patients with Status Asthmatices
Specific Pharmacological Therapy of Ventilated Patients with Status Asthmaticus
CHAPTER 17:
Management of Acute Exacerbation of COPD
Diagnosis—Is it AECOPD?
Precipitating Factors for AECOPD
Infectious Process
Environmental Conditions
Host Factor
Differential Diagnosis
Is it only AECOPD?
Levels of Severity of COPD Exacerbations
Relative Contraindications for Noninvasive Ventilation
Noninvasive Ventilation in AECOPD
Subsequent Management
If Patient is Improving
If Patient not Improving
Indications for Invasive Mechanical Ventilation
Preparation for Discharge from Hospital
Prevention of Future Exacerbations
CHAPTER 18:
Mechanical Ventilation
Indications for Mechanical Ventilation
Invasive Ventilation in Asthma
Ventilation Strategy
Minimize Dynamic Hyperinflation (DHI)
Acute Cardiogenic Pulmonary Edema Protocol
Acute Exacerbation of COPD
Weaning
Criteria for Attempting Spontaneous Breathing Trial
Clinical Assessment
Objective Measurements
Criteria for Failure of Spontaneous Breathing Trial
Objective Measurements
Complications of Ventilation
Ventilator Associated Pneumonia
Clinical Pulmonary Infection Score (CPIS) Calculation*
Temperature (°C)
Blood Leukocytes, mm3
Tracheal Secretions
Oxygenation: PaO2/FiO2, mmHg
Pulmonary Radiography
Progression of Pulmonary Infiltrate
Culture of Tracheal Aspirate
Prevention of VAP
General Prophylaxis
Intubation and Mechanical Ventilation
Aspiration, Body Position, and Enteral Feeding
Modulation of Colonization: Oral Antiseptics and Antibiotics
Stress Bleeding Prophylaxis, Transfusion, and Hyperglycemia
Barotrauma (Pneumothorax and Pneumomediastinum)
Hypotension during Initiation of Positive-Pressure Ventilation
Hypotension (in a Previously Stable, Intubated Patient)
Acute Respiratory Distress (Fighting the Ventilator)
Assess for Ventilator Malfunction
Pneumothorax
Repeated High-pressure Alarm
Hypoxia
Blood from the Endotracheal Tube
CHAPTER 19:
Acute Respiratory Distress Syndrome/Acute Lung Injury
Causes of Acute Respiratory Distress Syndrome/Acute Lung Injury
Imitators of ARDS [with Broncho-alveolar Lavage Findings]
Cardiogenic pulmonary edema
Chest X-rays in ARDS
Management of ARDS
I. Ventilatory Protocol for ARDS Management
CHAPTER 20:
Management of Upper Gastrointestinal Bleeding
History
Clinical Examination
Assess Severity of Bleeding
Causes of Upper GI Bleeding
Initial Risk Assessment and Triage
Blatchford Score
Rockall Score
Age
Hemodynamic state
Major Comorbidities
Diagnosis
Recent Hemorrhage
Management
General Support
Fluid Resuscitation
Blood Transfusion
Place of Nasogastric Tube
Management of Non-variceal Bleeding
Endoscopic Therapy
High-Risk Endoscopic Stigmata
Intermediate Risk Endoscopic Stigmata
Low-Risk Endoscopic Stigmata
Repeat Endoscopy
Pharmacological
Helicobacter pylori
NSAID induced/Drug induced
Angiography and Surgery
Management of Variceal Bleeding
Mallory Weiss Tear
Obscure GI Bleeding
Common Causes
Dieulafoy's Lesion
Angiodysplasia
Treatment
Hemobilia
Treatment
CHAPTER 21:
Stroke
Classification of Ischemic Stroke
TOAST (Trial of Org 10172 in Acute Stroke Treatment) Classification
Intracerebral Hemorrhage
Prehospital Assessment of Stroke
Emergency Assessment of Acute Stroke
Management of Acute Ischemic Stroke
Guidelines for Use of rtPA in Acute Ischemic Stroke
Intravenous rtPA Eligibility Criteria
Procedure Prior to tPA Use
Experience with newer fibrinolytics
Management of Blood Pressure for Thrombolyzed Patients
Treatment of Hyperglycemia
Treatment of Elevated Temperature
DVT/PE Prophylaxis
Use of Antiplatelets in Acute Stroke
Use of Statins in Stroke
Antiedema Measures
Decompressive Hemicraniectomy
Anticonvulsants in Ischemic Stroke
11. Anticoagulants
Antibiotics
Intra-arterial Thrombolysis
Management of Intracerebral Hemorrhage
Blood Pressure management in Intracerebral Hemorrhage Guidelines:
Management of Raised Intracranial Pressure
Seizure Prophylaxis
Recombinant Factor Vlla in ICH
Surgery in ICH (AHA Guidelines)
Non-surgical Candidates
Surgical Candidates
Algorithm for Management of Cerebellar Hemorrhage
Management of Intraventricular Hemorrhage
Treatment of Cerebral Venous Thrombosis
Treatment of Arterial Dissection
Appendix 1 NIH STROKE SCALE
Appendix 2 POST-tPA INTRACRANIAL HEMORRHAGE ALGORITHM
CHAPTER 22:
Acute Kidney Injury
Diagnosis and Management Protocol
Definition
Assessment of Severity of AKI
AKIN Criteria
Classification
Points for Early Detection of Impairment of Renal Function
Risk Factors
To Exclude Possibility of Chronic Kidney Disease by
Differentiating points between AKI and CKD
Check List for Evaluation of a Patient with Suspected Acute AKI
Diagnosis
Investigations
Examination of Urine
Consideration for Kidney Biopsy
Novel Biomarkers
Fluid Balance
To Correct Electrolyte Imbalance
Salient Features
Nutrition
Nutritional requirement
Renal Replacement Therapy (RRT)
Indications of RRT
Biochemical Indications
Clinical Indications
Prevention of AKI
CHAPTER 23:
Endocrine Emergencies
ADRENAL CRISIS
(Acute Adrenal Insufficiency)
Primary Adrenal Crisis
Secondary Adrenal Insufficiency
Sign and Symptoms
Treatment: Acute adrenal insufficiency
HPA Suppression
Pituitary Apoplexy
History and Clinical Features
Precipitating Cause
Treatment
Medical
Surgical
Pheochromocytoma and Hypertensive Crisis
Crisis
Treatment
Postoperative Period
Thyroid Storm/Thyrotoxic Crisis
Clinical Examination Shows
Laboratory Confirmation
Treatment
Myxedema Coma
Cause
Clinical Features
Other Features
Thyroid Function Test
Treatment
“High dose” Regimen
“Low dose” Regimen
Other Aspects of Management
Diabetic Emergencies
Diabetic Ketoacidosis
Introduction
Diabetic Ketoacidosis
Pathophysiology
History and Clinical Features
Symptoms of DKA
Signs
Bedside Assessment
Where to Manage?
Initial Investigations
Classification of Diabetic Ketoacidosis
Treatment—Fluid therapy
Management — (ICU or Ward)
Management Ideally in ICU
Hypoglycemia
Under-production
Over-utilization
Oral Treatment
Hyperglycemia : Its Impact on Infections in the ICU Patient
Complications of Hyperglycemia in the ICU Patient
Glycemic Control in ICU
Acute Hypercalcemia
Cause
Manifestations
Treatment
Hypocalcemia
Cause
Manifestations
Treatment
CHAPTER 24:
Rheumatological Emergencies
Approach to a Rheumatologic Emergency
Laboratory Work-up
Individual Entities
Lupus Flare
Catastrophic Antiphospholipid Syndrome
Pulmonary Renal Syndrome
Conclusion
CHAPTER 25:
Antimicrobial Therapy Including Management of Septic Shock
General Principles of Antimicrobial Therapy
Sepsis and Septic Shock
Control of the Septic Focus
Identification of the Septic Focus
Procalcitonin
C-Reactive Protein
Presepsin
Heparin Binding Protein
Eradication of Infection
Resuscitation and Hemodynamic Support of the Septic Patient
Fluid Therapy
Choice of Fluid Crystalloid Versus Colloid
Vasopressor and Inotropes
Antimicrobial Regimen
Recombinant Activated Protein C [Drotrecogin Alfa Activated (DrotAA)]
Corticosteroids
Nutrition
Glucose Control
Mimics of Sepsis
Evaluation of Sources of Sepsis
Source Control in Sepsis
Special Infective Diseases in the ICU
Antibiotic Resistance in the ICU
Commonly Prevalent Resistant Bacteria in the ICU
Polymyxins (Colistin and Polymyxin B)
Fungal Infections in the ICU
Antifungal Agents
Tropical Infections in the ICU
CHAPTER 26:
Cardiac Surgery: Postoperative Care
Postoperative Care
Department of Cardiac Surgery
Postoperative Care
General Principles
Reception from the Operating Theater
Routine Care during the Early Postoperative Period
Cardiac Output and its Determinants
Causes of Acute Dysfunction (Low Cardiac Output) After Cardiac Surgery
Acute Cardiac Tamponade
Treatment of Low Cardiac Output
CHAPTER 27:
Drugs Used in Cardiovascular Emergency
Adenosine
Amiodarone
Alprostadil (Prostaglandin E1)
Atropine
Beta-blockers for Acute Indications
Digoxin for Acute Indications
Diltiazem (IV)
Dobutamine
Dopamine
Epinephrine (Adrenaline)
Fibrinolytic Agents
GPIIb/IIIa Inhibitors
Heparin (Unfractionated and Low Molecular Weight Heparin)
Isoprenaline (Isoproterenol)
Levosimendan
Lignocaine (Lidocaine)
Magnesium Sulfate
Milrinone
Morphine Sulfate
Nitroglycerin (Acute)
Nitroprusside
Norepinephrine
Phenoxybenzamine
Phenylephrine
Verapamil (Intravenous)
Vasopressin
INDEX
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