In the Name of God

Obstetrics Study Guide 4

Mitra Ahmad Soltani2008

References 1•  ACOG committee opinion. Ethics in Obstetrics and Gynecology.second edition.2004

• Anderoli Thomas E, et al. Cecil Essentials of Medicine. 5th edition. W.B.Saunders; 2001

See: www.merckmedicus.com/ppdocs/us/common/cecils/chapters/106_006.htm

• British guideline on the management of asthma in adults, The British Thoracic Society & Scottish Intercollegiate Guidelines Network Thorax 2008 May; 63 (Suppl 4) : 1-121.

See: http://www.brit-thoracic.org.uk/ClinicalInformation/ Asthma/AsthmaGuidelines/tabid/83/Default.aspx

• www.cdc.gov/asthma/speakit/slides/managing_asthma

• Braunwald Eugene, et al. Harrison's Principles of Internal Medicine. 16th edition. McGrawHill; 2005

• Braunwald et al. IHD clinical practice guidelines. 2002

• Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22nd Ed . New York : Mc Graw Hill, 2005.

• Gibson P. HTN in Pregnancy. emedicine.DEC 13. 2007

• Hogg K, Dawson D, Mackway K. Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study .2006

See: emj.bmjjournals.com/cgi/content/full/23/2/123

• Iranian Council for Graduate Medical Education. Exam questions.1998-2007

• Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006

• Katzung Bertram G. Pharmacology: Examinatoin & Board Review.7th edition Mcgrawhill. 2005

• Marsha D. Ford. Cecil text book of medicine. Acid-Base disorder. Saunders company.2004

• Massel D, Klein GJ. Guidelines & Policies At The London Health Sciences Centre. 2002. see: www.lhsc.on.ca/uwodoc/pages/policy.htm

• Yanowitz.ECG learning center.2006

• Regional ALS Treatment Protocols and Procedures.EMT-Paramedics,1998

• Safeer ,Richard S., Lacivita ,Cynthia L. Choosing Drug Therapy for Patients with Hyperlipidemia American Family Physician. Vol. 61/No. 11 (June 1, 2000)

 

References 2

• mentor.wnmeds.ac.nz/groups/rmo/asthma/asthma5.htm(2006)

• www.rnceus.com/abgs/abgmethod.html. ABG interpretation method.(2006)

• www.umary.edu/faculty/rschulte/ABG web page cases.doc. (2006)

• www.lakesidepress.com/pulmonary/books/physiology/chap10a.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 decisionfor a pregnant case

For Obstetrics cases, a physician faces complexities stemming from the fetus, a woman in a narrower definition of health indices, and the setting. All these are proceeding dynamically interacting with one another. There are priorities that should be considered. This makes “ethics” of outmost importance in Obstetrics.

Ethical approaches

1-Principle-based approach: It seeks to identify the principles and rules pertinent to a case.

2-A virtue-based approach : It is focusing on one course of action would best express the character of a good physician.

3-Ethic of care: It situates a doctor’s duties in the context of a pregnant woman’s values and concerns instead of specifying abstract principles.

Ethical Approaches- cont.

4- Feminist Ethics approach: seeks to change factors that limit a woman’s options.

5-A case-based approach: It considers if there are any relevantly similar cases that constitute precedents for a given case.

A caseA 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 mmHg. Which drug should not be prescribed for her?

a- Methyldopab- ACE inhibitorc- Hydralazined- Nifedipine

Answer:b

What drug is not used for the treatment of pre-eclampcia?

a- Betablockerb- Methyldopac- ACE inhibitord- Hydralazine Answer:C

Which statement about treatment of HTN with ACE inhibitors is wrong?

a- They are drugs of choice in diabetics.b- They can be used in mild renal failure.c- In unilateral renal artery stenosis, they can be

prescribed if the other kidney has a normal function

d- They are drugs of choice for pregnancy

Answer:D

What is the accepted screening test for diagnosis of PIH?

A-Rollover test

B-nitric oxide measurement

C-vascular endothelial growth factor

D-angiotensin test

Ans:A

For a case of severe preeclampsia (BP=180/95) Mg SO4 and C/S is ordered. An hour after C/S BP falls to 110/75. What is the reason of BP fall?

A-Delivery removes the effect of vasospasm

B-anesthetic drugs

C-hemorrhage

D-MgSO4 effect

Ans: C

Which is true about edema of preeclmpsia?

A- it has an unknown etiologyB-it is because of increased aldosterone levelC- it worsens the prognosis of preeclampsiaD- it is because of increased DOC

Ans:A

A woman 48 yrs old/ G3/ BP=150/115/ has a high cholesterol level . Her sister and brother had heart attacks in the age of 40. Which is wrong about the management of this case?

A-Beta blocker

B- diet

C-methyl dopa

D-regular checking of lab results

Ans: A

In a woman with chronic HTN Which factor has the least effect in development of superimposed PIH?

A- PIH history

B- low dose aspirin

C- severity of HTN

D-the need for combined drug therapy

Ans:B

What is the most common complication of eclampsia?

A- abruption

B-aspiration pneumonia

C-pulmonary edema

D- direct maternal mortality

Ans:A

Which is true about blindness after eclampsia?

A-It has a bad prognosis

B-It lasts about 1 month

C-it is transient and lasts from 4 hours to 8 days

D-in some people it causes permanent blindness

Ans:C

Which is wrong about eclampsia?

A- eclampsia can cause coma without seizureB- All patients with eclamsia have had signs of

preeclampsiaC-After seizures respiratory rate is reduced and

cyanosis happensD- In all cases of eclampsia severe proteinuria is

present Ans:C

Which therapy can prevent preeclampsia?

A-Low dose aspirin

B-calcium

C-fish oil

D-Antioxidants

Ans:D

A 40 years old woman / G3/P2 /GA=35 wks/ BP=210/110 is in seizure. What is the best way to control her seizure?

A-Phenytoin loading dose of 1000 mg/h IV

B- Diazepam and creatinin measurement

C- amobarbital sodium 250 mg IV

D- MgSO4 4-6 gr as loading dose

Ans:D

What is the cause of platelet change in preeclampsia?

A- increased production

B- decreased consumption

C- increased platelet aggregation

D- decreased platelet- adhering IG

Ans:A

A woman 25 years old / G1 suffers HELLP syndrome. What is true about her next pregnancy?

A- there is no increased risk in her next pregnancy

B-the is increased risk of abruption and preeclampsia

C-there is no increased risk of preterm labor or C/S

D-there is no increased risk of IUGR

Ans:B

Which test has a more PPV for detecting PIH?

A-urinary excretion of Kallikrein

B- roll over test

C- angiotensin II

D- hypocalciuria

Ans:A

A pregnant woman GA=29 wks / severe headache/ blurred vision/ BP= 200/120 has gone through routine tests and MgSO4 infusion. What other steps should be taken?

A-IV hydralazine 20 mg + IV verapamil 10 mg

B-IV hydralazine 5 mg

C- IV labetalol 80 mg

D- sublingual nifedipine 10 mg +thiazide 10 mg

Ans:B

A case of eclampsia with seizure is given MgSO4. She is agitated. What drug is appropriate for her agitated state?

A-2 gr MgSO4 IVB- 250 mg amobarbital IVC- 10 mg diazepam IMD-no treatment is needed

Ans:B“A” would be appropriate if a second seizure

occurs

A woman with high blood pressure, proteinuria, Cr>1.5 mg/dl, has an episode of seizure after 4 hours from her delivery. What treatment do you suggest?

A-14 gr of MgSO4as the loading dose and then 2.5 gr q4h up to 24 h after delivery

B-7 gr of MgSO4 as the loading dose and then 2.5 grq4h up to 24 h after the last seizure

C-14 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after the last seizure

D-7 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after delivery

Ans:C

Which is not among pathophysiological changes of preeclampsia?

A-reduction in PGE2

B-reduction in prostacyclin

C-increased thromboxane A2

D-increased resistance to angiotensin

Ans: D

Which is wrong about proteinuria of preeclampsia?

A-Some women deliver before proteinuria occurs

B-1+ proteinuria equals 300 mg protein in a 24 hour sample

C-NPV of a trace or negative dipstick test is about 30 %

D-PPV of 3+/4+ proteinuria is 70%

Ans:D

For a primigravida in 30 weeks gestation a roll-over test is done. An increase of 35 mmHG has occurred in diastolic BP. Which is wrong for this case?

A- She has a high probability of developing HTN

B-She is abnormally sensitive to angiotensin II

C-increased BP is because of hyperactivity of parasympathetic system

D-33% of these patients will develop preeclampsia

Ans:C

Which is wrong for visual disturbances of preeclampsia?

A-it is because of occipital region lesionsB-if blindness does not resolve within a week , it

will remain permanentlyC- It is because of retinal artery spasm that can

resolve by MgSO4D-it is because of retinal detachment that is most

often unilateral

Ans:B

Which is wrong about superimposed preeclampsia?

A-it occurs earlier in pregnancy and most often is accompanied by IUGR

B- BP changes remain through life

C-some women have increased BP after 24 weeks gestation

D- above 90% of them have a history of essential HTN

Ans:B

A woman GA=38 wks/G2/L1/history of chronic HTN is diagnosed as a case of severe preeclampsia. Her pregnancy is terminated. Her BP and proteinuria and edema are improved but she has developed orthopnea. What is your first diagnosis?

A-ATN and overloadB- hypoalbuminemiaC-peripartum cardiomyopathyD-MS signs aggravated by fluid shift

Ans:C

What drug has the complication of tachycardia?

A-methyl dopa

B-propranolol

C-nifedipine

D-hydralazine

Ans: D

27-Which does not happen in preeclampsia?

A-reduced renal perfusion and GFR

B-increased renin-angiotensin level

C-constant electrolyte concentration

D- increased microangiopathic hemolysis

Ans:B

A woman 32 years old/ NP /obese / 38 wks GA/ mild preeclampsia delivers her child . BP does not decrease after several IV doses of hydralazine. Which is not a good management?

A-Im hydralazine

B-oral labetalol

C-thiazides

D-IV MgSO4

Ans:D

HTN drugs of importance

Drug safety Dosage Explanation

SNP Group C- possibly unsafe in lactation

(2cc/50 mg) 0.3-0.5 mcg/kg/min

It should be diluted in 250-1000 cc DW5% or NS. It should be covered to light by aluminum foils.Titrate to desired effect. Rates>10 mcg/kg/min may lead to cyanide toxicity.

TNG(Isosorbide dinitrate10-80 mg po bid/qid)

-Group C-safety unknown in lactation- Contraindicated for Low blood pressure-Anemia-Head trauma-Closed Angle Glucoma-Cerebral hemorrhage

(1cc/5mg) 0.2-10 mcg/kg/min

It should be diluted in 50cc DW5% or NS.

Labetalol -Group CProbably safe during lactationContraindicated in:-Cardiogenic shock-Pulmonary edema-Bradycardia-AV block-Uncompensated CHF

20-30 mg It should be injected in 2 minutes IV,followed by 40-80 mg at 10 min intervals

Amp propranolol1mg/ml

Hydralazine Contraindicated in:-Hypersensitivity-Rheumatic heart disease of Mitral valve

10-20 mg/dose IV or IM q4-6 hrs prn

Not to exceed 300 mg/dose

Verapamil -Group C-Safe in lactation-Contraindicated in: CHF-SSS-1 &2 degree block-SBP<90 mmHg

(tab of 40 and 80 mg)240-480 mg/d/tid.

Clonidine Group CUnknown safety in lactation

(Tab 0.2 mg) 0.1 mg bid po

Not to exceed 1.2 mg/day

Which is true about a 12 wk pregnant woman with Eisenmenger syndrome?

A- therapeutic abortion is indicatedB-heparin throughout pregnancy should be

givenC-pregnancy should be terminated when the

fetus is viableD- she has to be hospitalized throughout

pregnancyAns:A

A pregnant woman with artificial valve on heparin has undergone C/S. When should the anticouagulant be started after the operation?

A- 6 hoursB- 8 hoursC-24 hoursD- immediately after C/SAns: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 factorB-ICM has the symptoms of congestive heart

failureC-ICM is more prevalent in pregnancy than non

pregnant stateD-dyspnea is an important symptomAns: cTherapy is hydralazine and heparin. ACE inhibitors are

contraindicated during pregnancy

Which is more fatal to a pregnant woman?

A-bioprosthetic valve replacementB-corrected fallot tetralogyC-pulmonary or tricuspid diseaseD- mitral stenosis with AF

Ans:D

Risks of various types of heart dis.

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 administrationB-spinal analgesia to reduce painC-immediate pregnancy terminationD- beta blocker to reduce heart rateAns:DAF caused by MS is treated by 5-10 mg

verapamil IV or cardioversion

An 8 wk pregnant woman is a known case of Marfan disease . She has MVP without regurgitation . AR is not present either. Which is true about this case?

A- Termination of pregnancy is not indicated.B-She is in class 2B NYHA.C- The best route of delivery is C/S.D- The probability of her child suffering from the

same illness is 10%.

Ans:A

Which is wrong about arrhythmia in pregnancy?

A-arrhythmia is increased by pregnancy.B-most arrhythmias in pregnant women are not

because of organic lesions.C-Arrhythmia treatment is the same for

pregnant and non pregnant.D- women with pacemaker should terminate

pregnancy. Ans:D

Which is not recommended for a pregnant woman with Mitral Stenosis?

A-Spinal analgesia and IV fluid B-Beta blockers in tachyarrhythmiaC-heparin for AFD-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/SB-no intervention except for vital stability in the

motherC- glucocorticoids and induction of laborD- emergency color Doppler for fetal circulation

Ans:B

Which is an indication for C/S ?

A-fallot tetralogyB- aortic stenosisC-Marfan with aorta involvementD- prosthetic mitral valve

Ans:C

A 37 year old woman suffers cardiac disease. She is G3/ P3/ with GA=38wks. She had an NVD. She asks for TL. Which is not necessary for TL?

A- temperature should be normalB-anemia should not be presentC- 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+ heparinB- C/S + FFP + heparinC- d/c of heparin, vena cava filter , C/SD-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 diureticB-digoxin if arrhythmia is not presentC- low dose heparinD- enalapril to reduce afterload

Ans:D

A 35 year old woman with exertional dyspnea in the 4th week after NVD comes to ED. JVP raised with prominant X and Y waves. Kussmul sign is positive. S1 and S2 plus another high pitched extra sound can be heard on the apex. Pulsus Paradox is not detected. Which is the best diagnosis?

a- Tamponadeb-Constrictive pericarditisc-Restrictive cardiomyopathyd- Right ventricle infarct

Ans:B

What sign is the least prevalent for constrictive pericarditis?

a- kussmul signb- prominent Y wavec- prominent X wave4- pulsus paradox

Ans: D

What is among the signs of Temponade?

a- Kussmulb-prominent Xc-pericardial knockd-4th heart sound Ans:B

For what type of heart failure Carvodilol is a betablocker of choice?

a- class IVb- Failure with a normal Ejection Fraction c- previous pulmonary edema stable at presentd- 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 Digoxinb-loop diuretic is the diuretic of choicec-aminophilyne to enhance heart contractilityd-ACE inh to lower afterload

Ans:D

A pregnant woman had seizure after delivery . When her condition was stabilized she complained of dyspnea and exertional chest pain. BP=160/100 mmHg / PR=90 bpm heart rhythm= irregular JVP= raised Pitting edema =2+Rales are present. Liver is palpable and tender. No pericardial effusion is detected. No stenosis or regurgitations of valves can be detected. What should not be prescribed for this case?

a- Digoxinb- Nitratesc- Betablockersd- Diuretic

Ans:A

Differential Diagnosis of S3 And S4.(DCMP=dilated cardiomyopathy/ JVP= jugular vein pressure/ HCMP=hypertrophic cardiomyopathy/ RCMP=restrictive cardiomyopathy)

S3 & S4

Diastolic Dysfunction

Systolic

Examine JVP

Not raised Raised

HCMPCheck for Pulsus

Paradox

Negative=Constrictive pericarditis

Positive= check for Kussmaul sign

Positive= RCMP Negative=

Tamponade

Treatment of different causes of S3 and S4 gallop

Different causes of S3 & S4 gallop

Treatment

HCMP DefibrillatorAmiodarone for AF rhythm is unsafe during lactation and is in group D in pregnancy. Verapamil is used instead.Endocarditis prophylaxisAnticoagulant

Constrictive Pericarditis Salt restrictionDiureticpericardiotomy

RCMP AnticoagulantDiuretic

Tamponade Thoracotomy (in an ordinary tamponade NS or Blood or vasopressor may be indicated)

Acute pulmonary edema Furosemide IV 0.5 to 1 mg/kgMorphine IV 2 to 4 mgNTG SL Oxygen/intubation as needed

Low output cardiogenic shock SBP<70 mmHg +sign/symptoms of shock:Noreinephrine IV 0.5 to 30 mcg/min

SBP=100-70+sign/symptoms of shock:DOPAMINE: 5-15 mcg/kg/min IV

SBP=100-70 no sign/symptoms of shock:Dobutamine: 2-20 mcg/kg/min IV

SBP>100NTG=10-20 mcg/min IV Consider SNP: 0.1-5 mcg/kg/min IVACEinh. if SBP is not<30 mmHg below baseline.

drug contraindications dosage explanation

Norepinephrine HypersensitivityOHCMVascular thrombosis

(Vial 10mg)0.5-1 mcg/min IV inf.

Titrate not to exceed 30 mcg/min

Furosemide Group CUnknown in lactationContraindicated in:Hepatic comaAnuriaElectrolyte depletion

(Amp 20 mg)20-80 mg/day

Titrate up to 600 mg/d for severe edema

Warfarin Group x in pregnancy but safe in lactation.Contraindicated in: BleedingPeptic ulcerOpen woundLiver and kidney-disease

(Tab 5mg)5 mg/d

for 2-4 days subsequent doses determined by INR

Carvedilol Group CSafety in lactation is unknown. Contraindications:Cardiogenic shockPulmonary edemaBradycardiaAV blockUncompensated -HF

(Tab 6.25 mg)3.125-0.375 mg po qd

Digoxin Group CSafe in lactation.Contraindications:IHSSBeriberiDiastolic heart-dysfunctionCarotid sinus-syndrome

(Tab 0.25 mg)0.125-0.375 mg po qd

Dopamine Chart

Dopamine Chart (gtts/min)(400mg/250cc Normal Saline)

KGS 40 50 60 70 80 90 100

MCG/MIN

5 8 10 12 13 15 17 19

10 15 19 22 26 30 33 37

15 22 28 33 39 44 50 56

20 30 37 44 52 59 67 74

25 37 46 56 65 74 82 93

Try to diagnose and suggest treatment for the following ECG strips in pregnant cases.

ECG strips are taken from the site:

Yanowitz.ECG learning center.2006

With permission

ECG1

ECG2

ECG3

ECG4

ECG5

ECG6

ECG7

ECG8

ECG9

ECG10

ECG11

Diagnosis Treatment Avoid1-Atrial Fibrillation In Patient With Wpw Syndrome

Direct Cardioversion +Lidocaine Or ProcainamideorEibotinide

DigoxinAmiodaroneVerapamil

2-WPW And Pseudo-Inferior Mi –(Q Wave Is Negative Delta In Lead III)

BetablockerCCBquinidineFelcainide

PaceDigoxinVerapamil

3-Atrial Flutter With 2:1 Av Conduction-Kh

Digoxin 0.25Esmolol 0.5 Mg/Kg

QuinidineAmiodaron is not used in pregnancy

4-V Tach Procainamide 20mg/MinLidocain 1 Mg/Kg

VerapamilAdenosineAmiodaron is not used in pregnancy

Diagnosis Treatment Avoid

5-V-Tach Magnesium-SulphateProcainamideLidocaineIf failed:Cardioversion

VerapamilAdenosineAmiodaron is not used in pregnancy

6-Unifocal Pvc LidocaineProcainamide

7-PAC SedativeBetablocker

8-PVC LidocaineProcainamide

9-PSVT BetablockerVerapamilAdenosine

10-Junctional Stop DigoxinLidocaineBetablockerPhenytoin

Cardioversion

11-AF DigoxinEsmololverapamil

Amiodaron is not used in pregnancy

QRS>=150

P>QRS P<QRSP

waves=QRS

PSVTP=150-

250

Sinus tachycardia

P= 100-150

PAT with block

P=150-250

FlutterP=250-

350

AFP=350-

600VT

Drug Dosage Explanation

Adenosine (6mg/2cc vial)6 mg

Atropine (1 mg/10cc syringe)1mg

Repeat in 3 minutes

Bicarbonate (50Eq/50cc syringe)1 meq/kg

Digoxin 0.25 mg

Diltiazem 25 mg

Dopamine (400mg/10cc syringe)5-20 mcg/kg/min

Epinehrine (1mg/cc ampule)2-10mcg/min

Esmolol 0.5 mg/kg Then titrate to 0.05-2 mg/min drip

Isoprotrenol 2-10mcg/min

Lidocaine 2% (100mg/5cc syringe)0.5mg/kg

1 mg/kg bolusRepeat 0.5mg/kg until PVC suppressedIf successful:Base drip rate on total given:1 mg/kg, drip 2mg/min1-2 mg/kg, drip 3 mg/min2-3 mg/kg, drip 4 mg/min

Magnesium (5 gram/10 cc vial)2-4 gram

Procainamide (1 gram/2cc vial)20mg/min

20mg/min until PVC suppressed then 1-4 mg/min

Verapamil (10 mg/2cc vial)5 mg

Prophylaxis of endocarditis

GI or GU

High Risk patient

Moderate Risk

Standard

Allergy

Standard Allergy

Ampicillin +Gentamycin before the procedure and have to repeat Ampicillin after 6 hours

Gentamycine +

Vancomycine

AmoxycillinVancomycine

Should be infused One hour

before to 3 minutes after the

procedure

A woman develops chest pain for three days after her delivery. The peak lasted for 3 hours. In her ECG, Q wave can be seen in leads V1-V4. what lab test is good for a diagnosis?

A- SGOTB-CPK-MBC-LDHD-ESR Ans:C

Which one is not considered as acute coronary syndrome?

A-Non-Q wave MIB- Stable Angina PectorisC- Q wave MID-Unstable Angina • Ans:B

Which does not imply a poor prognosis for angina pectoris:

A- S3B-S4 C-MR murmursD-lower lung rales Ans:B

Which is not among the absolute contraindications for thrombolytic agents in acute MI?

A- SBP> 180 mmHg with chest painB- Cerebral Hemorrhage 3 years agoC- pregnancyD-Aortic dissection Ans:C

Tall R in lead V1 points to the diagnosis of:

A- Posterior MIB- Inf MIC- Anterior MiD- Right Ventricular MI

Ans:A

Which is not used as a secondary prevention in MI?

A- beta blockersB- CCBC- ACE inhibitorsD- 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 syndromeB- HCMPC- Prolonged QT syndromeD- 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&gemfibrozil23- 45 year old woman with chronic hepatitis,

TG=148 ,HDL=45 ,Total Chol=292?Ans:Dx23-DX=hypercholesterolemia/TX=cholestyramine24- 45 year old woman with a CAD history, TG=450,HDL=40,Total

chol=450?Ans:DX=dysbetalipoproteinemia/TX=Niacin&Gemfibrozil&Statins25-45 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 LDL

High TG(>150 mg/dl)

(hypertriglyceridemia)

VLDL/TG<3/10

(Dysbetalipoproteinemia)

High TG(Hyperlipidemia)

Normal TG(hypercholeste

rolemia)

Niacingemfibrozil

NiacinGemfibrozil

statins

NiacinGemfibrozil

statinsNiacinStatin

cholestyramine

Risk-factor score* LDL goal, by risk-factor score†

Age: men > 45 years; women >55 years or postmenopausal without ERTCurrent smokerHypertensionDiabetesCHD in first-degree relative (male relative <55 years; female relative <65 years)HDL <35 mg per dL (0.9 mmol per L); subtract 1 risk factor if HDL >60 mg per dL

0 to 1 point: <160 mg per dL (<4.15 mmol per L).If more than 190 needs drug therapy.2 or more points: <130 mg per dL (<3.35 mmol per L)If more than 160 needs drug therapy.Patients with history of CHD: <100 mg per dL (<2.60 mmol per L).If more than 130 needs drug therapy

A 17 wk pregnant woman had contact with an active TB patient. She had no BCG vaccine. Her PPD test measures 7 mm . Her CXR is normal. Which is true about this patient?

A-PPD is negative. No action is needed.B- She should receive INH prophylaxis for one year after

her delivery at term.C-one month INH ,then repeat of PPDD-PPD should be repeated after delivery at term.Ans:BWhen CXR is normal no treatment is necessary until

after delivery.

PPD readingVery High risk 5 mm is positive

High risk10 mm is +

No risk factor15 mm is +

HIV positive Drug abusers- HIV neg

Ab CXR Predisposing medical conditions

Recent contact with an active case

Foreign born

Low income

Treatment

• +PPD and no evidence of active TB are not treated until postpartum.

• Known recent skin-test convertors are treated.

• Skin test positive women exposed to active infection are treated.

• HIV positive women are treated.

Treatment is 9 months “HRE”:• Isoniazide 5mg/kg with pyridoxine 50 mg daily• +Rifampine 10 mg/kg • +Ethambutol 5-20 mg/kg daily--------------------------------------------------------------• Streptomycin is contraindicated in pregnancy• Pyrazinamide is only given to HIV infected women

who should not receive rifampin.• Isoniazide should be discontinued if liver enzymes is

increased fivefold over normal level.

An 8 wk pregnant woman is HIV positive. Her PPD test is 5 mm and she has abnormal CXR. What is your mangement?

A-treatment should be delayed till after deliveryB-HRE for 9 monthsC-treatment should be started 3 to 6 months

after deliveryD- 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 pregnancyB-These are signs of chronic pulmonary disease.C-These are signs of heart failureD-These are signs of ARDS due to pulmonary

fibrosis.Ans:ARespiratory rate is not changed during preg.

A pregnant woman has the history of bronchial asthma. Her ABG results shows: PH=7.55 and reduced PaO2 and PaCO2. Her ABG half an hour after treatment is: no change in PaO2 but a normal level PaCO2. PH is now 7.30. Which is true for this case?

A-She is recovering. IV should be changed to POB-She is deteriorating and needs mechanical

ventilationC-ABG should be repeated six hours laterD-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 involvementAns: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 patientB-cefotaxime or ceftizoxime for one weekC-beta lactam for three daysD-cefotaxime and erythromycin after

hospitalization

Ans:DLeukocytosis in pregnancy is defined as more than 15000 WBC in

mL

A 20 wk pregnant woman has severe left calf muscle pain. In physical Exam her left foot is edematous and Homan sign is positive . There is diminished pulsations in the affected foot. What is the best diagnostic procedure?

A-Impedance PlethysmographyB- Magnetic Rresonance ImagingC- venographyD-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 prophylaxisB- HRE C- no prophylaxisD-streptomycin 1 gr daily for 10 days

Ans:B

A 30 wk pregnant woman complains of coughT T=39 c and chest pain after a cold. RR is 34 per min. CXR shows radiologic changes of pneumonia in both lungs lower lobes. What should be done?

A- This is viral pneumonia. Rest and fluid is all needed.B- Erythromycin 1 gr q6hrs IV . If not responsive

amantadine 200 mg dailyC-hospitalization and administration of ceftizoxime.D-Levofloxacin PO BD. If not responsive hospitalization

and erythromycin IV

Ans:C

A 25 year old G1/GA=39 wk pregnant asthmatic woman is in labor. She takes oral coricosteroid. Which is a correct management?

A- she needs stress dose of steroid stat and that should be repeated q8hrs

B-meperidine or morphine are the drugs of choice for analgesia.

C-general anesthesia is a good choice is she has to undergo C/S

D-PGF2 is a good treatment of postpartum hemorrhage.

Ans:A

Which is the earliest sign of ARDS?

A- hyperventilationB-radiologic changesC-alveolar edemaD-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- surfectantB-NOC- Methylprednisolone D-immunotherapy

Ans:C

Which is a cause of cardiac arrest in ARDS?

A-metabolic and respiratory AcidosisB-increased residual volumeC-interalveolar fibrosisD-intra pulmonary shunts

Ans:A

Which is not happening in the fetus of an asthmatic pregnant woman with hypoxemia?

A-reduced umbilical blood flowB-increased systemic vascular resistanceC-reduced pulmonary vascular resistanceD-reduced cardiac output

Ans:C

Which is correct about DVT?

A-MRI is a common diagnostic procedureB-DVT is accompanied by PE in prenatal periodC-PE due to DVT is more in postpartum period

compared to prenatal periodD-DVT is usually manifested by diminished

pulsation

Ans:C

Which is a better analgesic in an asthmatic patient?

A- fentanylB-meperidineC-morphineD-valium

Ans:A

Which is wrong about status asthmaticus?

A-It doesn’t respond to treatmentB- PGE2 is better tolerated than PGF2C-stress dose of a steroid is needed in a patient

who takes systemic steroid for more than 4 wks

D-fentanyl is contraindicated for analgesia

Ans:D

A 25 year old 7wk pregnant woman with history of infertility receives heparin for DVT. Her platelet is 50000. Which statement is wrong about 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 durationB-respond to beta agonistsC-ABGD-FEV1 measurement

Ans:B

Which is true about amniotic fluid embolism?

A-The first sign is HypotensionB-detecting trophoblasts and meconium in

blood is the best way of diagnosisC- right ventricle becomes contracted and

smallerD-fetal survival is about 70 %Ans:D

What is the side effect of LMWH?

A- fetal abnormalityB- LBWC-IUFDD-maternal osteopenia

Ans:D

What drug triggers bronchospasm in asthma?

A-salysylamideB-propoxyphenC-Mefenamic acidD-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 scanB- EchocardiographyC- CT scanD- D-dimer and ultrasound of the lower limb Ans:A

Which drug is safe in an asthma patient?

A-Timolol for glucomaB-Atenolol beta1 receptor blockerC- PropoxyphenD-Tartrazine Ans:C

What asthma drug can be used during pregnancy?

A-Salbutamol and beclomethasoneB-salbutamolC-BeclomethasoneD- Neither can be used Ans:A

An obese woman suffers dyspnea after delivery. BP=115/75 mmHg/ PR=110bpm .RR=22/min. Lung auscultation is normal. Her perfusion scan is normal. Which statement about her is correct?

A- PE is R/O by a negative perfusion scanB- Perfusion scan should be repeatedC-Ventilation scan should be doneD- LMWH should be prescribed Ans:A

A 35 year old woman has an acute asthma attack. What is the most effective treatment?

A- Glucocorticoids IVB- Aminophyline IVC- Adrenaline SCD- beta agonist aerosol Ans:D

Which mechanical ventilation is better for a post thoracic surgery patient?

A- Assist Control ModeB- Positive End Expiratory Pressure Ventilation

+Intermittent Mandatory VentilationC- Pressure Control VentilationD- 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 hoursB- adding Beclomethasone 12 puffs /6 hoursC- prednisolone PO 10 mg /dayD- leukotrien antagonists 2 tablets/day Ans:C

A near drowning pregnant woman is in ED. CPR is done. She is ventilated by mask and ambu bag. She is alert. BP=90/60 mmHg /T=36c / PR=120 bpm /Rr=30 /min.Her cardiac rhythm is sinus tachycardia. Pulse oximetry shows SaO2=83%. Which is the best way to restore her respiratory function?A-BicarbonateB- AcetazolamideC- OxygenD- CPAP +oxygenE- Suction of aspirated material and Oxygen Ans:D

A patient with ARDS is treated by PEEP of 10 cmH2O. Now she develops pneumothorax. What is her best treatment at this stage?

A- Assist Control ModeB- Positive End Expiratory Pressure Ventilation

+Intermittent Mandatory VentilationC- Pressure Control VentilationD- 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

Which of the following cases would warrant immediate intubation and mechanical ventilation?

a. A comatose patient from drug overdose. PaCO2 51 mm Hg, PaO2 76 mm Hg, and pH 7.31

b. A 29-year-old woman who is alert but in respiratory distress; she is breathing 42 times/min. PaCO2 is 38 mm Hg. pH is 7.42, and PaO2 is 47 mm Hg while breathing 60% oxygen through a face mask

c. A woman who has severe emphysema who is alert but is in moderate respiratory distress; RR=24/min. PaO2 is 75 mm Hg while breathing nasal oxygen at 2 L/min, PaCO2 is 59 mm Hg, and the pH is 7.37. Her chest x-ray is clear.

Cont.

d. A 29-year-old woman suffering from diabetic ketoacidosis. Her pH is 7.10, PaCO2 is 26 mm Hg and PaO2 is 110 mm Hg while breathing room air.

e. A 31-year-old drug addict who responds briefly to administration of Narcan by opening her eyes and crying out and then lapses back into a state of semi-stupor. PaCO2 is 31 mm Hg. pH is 7.38, and PaO2 is 89 mm Hg while breathing nasal oxygen at 3 L/min.

Answers: Cases a, b, d need mechanical

ventilation+intubation

A comatose 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 FIO2

of 0.50. The patient has no spontaneous breathing. Blood gas results obtained (1)

before intubation and (2) 20 minutes later show the following:

pH---PaCO2---PaO2 ----FIO2 ---------VT------ RR

(1) 7.10 79 38 Room air 0 0

(2) 7.25 56 117 50% oxygen 700 12

Following the second blood gas analysis, would you change the FIO2, the tidal volume,

or the respiratory rate'? If so, what settings would you choose?

Answer

• a= <0.4/ b=700 /c=50 /d=18 / e= / PEEP is not needed

State whether each of the following is true or false . Mechanical ventilation is indicated for any patient with a

PaCO2 above 50 mm Hg and a pH less than 7.30.

Answer:false

During controlled positive pressure ventilation, each breath is initiated by the patient.

Answer:false During ventilation with positive 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 H2O.

Answer:false

The appropriate FIO2 during the initial stages of

mechanical ventilation is always 1.00 (100%). Answer:false

Successful ventilatory weaning requires the patient to have a VD/VT of less than 0.45

Answer:false

A 35-year-old single mother, just getting off the night shift reports to the ED in the early morning with shortness of breath. She has cyanosis of the lips. She has had a productive cough for 2 weeks. Her temperature is 102.2, blood pressure 110/76, heart rate 108, respirations 32, rapid and shallow. Breath sounds are diminished in both bases, with coarse rhonchi in the upper lobes. Chest X-ray indicates bilateral pneumonia. Define the problem and suggest a solution.

ABG results are: pH= 7.44 /PaCO2= 28 /HCO3= 24 /PaO2= 54

Problems:• PaCO2 is low. • pH is on the high side of normal, therefore compensated

respiratory alkalosis. • Also, PaO2 is low, probably due to mucous displacing air in the

alveoli affected by the pneumonia. Solutions: • She most likely has ARDS along with her pneumonia. • The alkalosis need not be treated directly. She is hyperventilating

to increase oxygenation, which is incidentally blowing off CO2. Improve PaO2 and a normal respiratory rate should normalize the pH.

• High FiO2 can help, but if she has interstitial lung fluid, she may need intubation and PEEP, or a BiPAP to raise her PaO2.

• Expect orders for antibiotics, and possibly steroidal anti-inflammatory agents.

• Chest physiotherapy and vigorous coughing or suctioning will help the patient clear her airways of excess mucous and increase the number of functioning alveoli.

A 52-year-old widow is retired and living alone. She enters the ED complaining of shortness of breath and tingling in fingers. Her breathing is shallow and rapid. She denies diabetes; blood sugar is normal. There are no EKG changes. She has no significant respiratory or cardiac history. She takes several antianxiety medications. While being worked up for chest pain an ABG is done:

ABG results are: pH= 7.48 , PaCO2= 28, HCO3= 22, PaO2= 85

Define the problem and suggest a solution.

Problem: • pH is high, • PaCO2 is low • respiratory alkalosis. Solution: • If she is hyperventilating from an anxiety attack, the

simplest solution is to have her breathe into a paper bag. She will rebreathe some exhaled CO2.This will increase PaCO2 and trigger her normal respiratory drive to take over breathing control.

• * this will not work on a person with chronic CO2 retention, such as a COPD patient. These people develop a hypoxic drive, and do not respond to CO2 changes.

You are in critical care unit about to receive a 24-year-old DKA (diabetic ketoacidosis) patient from the ED. The medical diagnosis tells you to expect acidosis. In report you learn that her blood glucose on arrival was 780. She has been started on an insulin drip and has received one amp of bicarb. You will be doing finger stick blood sugars every hour.

ABG results are: pH= 7.33 , PaCO2= 25, HCO3=12, PaO2= 89

Define the problem and suggest a solution.

Problem: • The pH is acidotic, • PaCO2 is 25 (low) which should create alkalosis. • This is a respiratory compensation for the metabolic

acidosis. • The underlying problem is, of course, a metabolic

acidosis. Solution: • Insulin, so the body can use the sugar in the blood

and stop making ketones, which are an acidic by-product of protein metabolism.

• In the mean time, pH should be maintained near normal so that oxygenation is not compromised .

A 26 year-old pregnant woman complains of severe vomiting for five days. She appears extremely fatigued, and has sunken eyes, dry mucous membranes, a heart rate of 110 and a blood pressure of 90/50. When she stands, her blood pressure falls, and her heart rate increases.

ABG is :PH= 7.50 /PaCO2= 47 /PaO2= 80 / HCO3=38Identify 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 drainageb- observationc- small bore catheterd- chest tube Ans: D

RESPIRATORY ARREST/IMMINENT RESPIRATORY ARREST/INTUBATION

1. Airway control with intubation, 100% O2 with BVM. 2. EKG Monitoring. 3. IV of Normal Saline at KVO. 4. Refer to appropriate protocol for further assessment and

treatment. MEDICAL CONTROL OPTIONS * DIAZEPAM 5-10mg IVP * MORPHINE SULFATE 2-10mg IVP * MIDAZOLAM 0.5-2.0mg Slow IVP * LIDOCAINE 1.0-1.5mg/kg IVP

OBSTRUCTED AIRWAY, UNCONSCIOUS

1. BLS procedure. 2. Direct laryngoscopy and remove foreign body using

Magill forceps. 3. If unable to ventilate, intubate. 4. If unable to intubate because of obstruction,

cricothyrotomy with large bore over-the-needle catheter. 5. Refer to appropriate protocol, or contact medical control.

RESPIRATORY DISTRESS ASTHMA /BRONCHOSPASM/ COPD

1. Airway control and O2. 2. EKG Monitor. 3. IV of Normal Saline at KVO if clinically

indicated. 4. If asthma is working diagnosis, ALBUTEROL

2.5mg/3cc normal saline via nebulizer, may repeat once in 15 minutes.

* ALBUTEROL 2.5mg/3cc normal saline via nebulizer, repeat as directed.

* METAPROTERENOL 0.1-0.3cc/3cc normal saline via nebulizer, repeat as directed.

* TERBUTALINE 0.25mg subcutaneous, repeat as directed. * EPINEPHRINE 1:1,000 0.3mg subcutaneous, repeat as directed. * MAGNESIUM SULFATE 1-2gm IV over 5 minutes. * METHYLPREDNISOLONE 125mg/50cc normal saline over 3-5

minutes. CAUTION: Use Epinephrine with caution in patients with history

of or presence of hypertension, heart disease, current pregnancy, beta blockers. Avoid Methylprednisolone if suspect varicella.

STATUS EPILEPTICUS(Two or more seizures without a lucid interval or a continuous seizure lasting more than 5 minutes).

1. Routine Medical Care . 2. O2, IV of Normal Saline, EKG Monitor, Blood Sample

if possible (glucose level). 3. If the patient is having sustained seizures, DIAZEPAM

is administered 5-10mg IV over 1-2 minutes. If IV route not available, give rectally, via syringe w/out needle up to 10mg; may be repeated once after 10 minutes.

4. For suspected hypoglycemia, DEXTROSE 50% 50cc IVP or GLUCAGON 1mg IM; THIAMINE 100mg slow IVP or IM.

5. If above actions do not terminate seizure, or respirations are depressed, attempt intubation.

* DIAZEPAM 5-10mg IV injection, may be repeated

up to 20mg or rectally via syringe w/out needle, up to 20mg.

* NALOXONE 2.0mg IV injection, may be repeated up to 8mg.

• INTUBATION.

SYSTEMIC ALLERGIC REACTIONS, ANAPHYLAXIS

1. Routine Medical Care / 2. O2, EKG Monitor. 3. If signs of shock or imminent airway obstruction,

EPINEPHRINE 1:1,000 0.3cc SQ; may be repeated once after five (5) minutes.

4. If generalized urticaria or anaphylaxis DIPHENHYDRAMINE 25-50mg IM or IV.

5. IV of Normal Saline at KVO if no signs of shock, wide open if signs of shock

* EPINEPHRINE 1:10,000 0.1-1.0mg is given slow IVP or via ET. May be repeated every 5 minutes per Medical Control.

* EPINEPHRINE 1:1,000 0.1-0.5mg is given subcutaneously. May be repeated every 5 minutes per Medical Control.

* DIPHENHYDRAMINE 25-50mg IM or IV. * ALBUTEROL 2.5mg via nebulizer. • DOPAMINE INFUSION 400mg/250cc Normal Saline and

started at 5-10mcg/kg/min. then titrated to desired BP (maximum of 25mcg/kg/min.).

• * GLUCAGON 1mg IV or IM.

Is PaO2 increased?

Yes=hypoventilation

Is PAO2-PaO2

increased?

Is PAo2-PaO2 increased?

Hypoventilation alone

Yes=hypoventilation +another

mechanism

Decreased inspired PO2

If yes then find outif low PO2 is

correlatable with O2?

Yes=V/Q mismatch

Shunt

Reduced Vital Capacity

Low FEV1/FVCBut

Normal TLC

Bronchial obstruction

Normal FEV1/FVC But

Low TLC

Low Mean Inspiratory

Pressure

Normal Mean Inspiratory

Pressure

Muscular etiology(Residual Volume is

increased)

Low RV Parenchymal

disease

High RVChest wall

disease

Tachypnea + fine crackles + clubbing

With fever:Hypersensitive Pneumonitis

X ray- Induced Sarcoidosis

Eosinophilic GranulomaDrug induced

BOOP

Without fever:Pneumoconiosis

Rheumatoid ArthritisLymphangioleiomyomato

sisAlveolar Proteinosis

variables Normal Adjustment criteria

1-Inspiratory pressure limit

50 cm H2O Blood PH

2-Tidal Volume 10-20 cc/kg Body weight

3-RR in a minute 8-30 Blood PH

4-PEEP ---- When the patient is hypoxic despite anFIO2 over 0.6

5-FIO2 0.21-1 For resuscitation=1For 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 positive airway pressure)

Pressure WeaningOr when the patient is intubated

e-Prone Position Least invasive ARDS

PCO2 mmHgChange

HCO3 meq/LChange

Metabolic Acidosis 1.5 (HCO3)+8±2 1

Metabolic Alkalosis 0.5 1Acute res. acidosis 10 1Chronic res. acidosis 10 3-5Acute res. alkalosis 10 1-2Chronic res. Alkalosis 10 5

Check if the blood is from an artery (CO2=15+HCO3)

Calculate Anion Gap(AG=Na – (Cl +HCO3)

Calculate if the response is compensatory or not

If there’s no significant AG (more than10-12), then it must be either RTA or GI loss. In GI loss this formula

applies => Urinary Cl>Urinary Na +K

Pneumonia treatment in pregnancy

• Uncomlicated: erythromycin 500-1000 mg every 6 hours

• Haemophilia:cefotaxime,ceftizoxime,Cefuroxime• Penicilline resistance: levofloxacin• Influanza:amantadine 200 mg daily if begun within

48 hours of symptoms• Varicella:acyclovir iv 10 mg/kg every 8 hours• VZIG:within 96 hrs of exposure 125u/10kg im

Pneumonia treatment in non pregnant states

Pneumonia

Community acquired

Hospital acquired

Low risk out

patient

High risk out

patient

No risk factor

Anaerobic Staph Psuedo.

Clarithro.Clarithro. + Amoxiclav

Ceftriaxone

Ceftriaxone + Clinda

Ceftriaxone +

Vanco

Ceftriaxone +

Aminoglycosides

AsthmaAsthma 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 asthmaDefinition 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.”

Consider the diagnosis of Consider the diagnosis of asthma in patients with asthma in patients with

some or all of these featuressome or all of these features

Symptoms (episodic/variable)

•wheeze•shortness of breath•chest tightness•cough

Diagnosis of asthma in adultsDiagnosis of asthma in adultsSymptoms (episodic/variable)• wheeze• shortness of breath• chest tightness• cough

Signs•none (common)•wheeze – diffuse, bilateral, expiratory ( inspiratory)

•tachypnea

Consider the diagnosis of Consider the diagnosis of asthma in patients with asthma in patients with

some or all of these featuressome or all of these features

Diagnosis of asthma in adultsDiagnosis of asthma in adultsHelpful 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

Signs• none (common)• wheeze – diffuse, bilateral,

expiratory ( inspiratory)• tachypnea

Consider the diagnosis of Consider the diagnosis of asthma in patients with asthma in patients with

some or all of these featuressome or all of these features

Diagnosis of asthma in adultsDiagnosis of asthma in adults

Objective measurements

•>20% diurnal variation on 3 days ina week for 2 weeks on PEF diary

•or FEV1 15% (and

200ml) increase after short acting ß2 agonist or

steroid tablets•or FEV1 15% decrease

after 6 minutes of running exercise

•histamine or methacholine challenge in difficult cases

Symptoms (episodic/variable)• wheeze• shortness of breath• chest tightness• cough

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

Consider the diagnosis of Consider the diagnosis of asthma in patients with asthma in patients with

some or all of these featuressome or all of these features

Differential diagnosis ofDifferential diagnosis ofasthma in adultsasthma in adults

Differential diagnoses include:

•COPD•cardiac disease• laryngeal,

tracheal or lung tumour

•bronchiectasis• foreign body

• interstitial lung disease

•pulmonary emboli

•aspiration•vocal cord

dysfunction•hyperventilation

Indications for referral ofIndications for referral ofadults with suspected asthmaadults 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 Non-pharmacological managementmanagement

Potential strategies forPotential strategies forprimary prophylaxisprimary 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 secondaryPotential strategies for secondaryprophylaxisprophylaxisIn 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-pharmacologicalNon-pharmacologicalmanagement of asthmamanagement 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 Pharmacological managementmanagement

•Add inhaled long-acting 2

agonists rather than increasing the dose of inhaled steroids (above 800mcg/day in adults and 400mcg/day in children)

•Step down therapy to lowest level consistent with maintained control

Asthma controlAsthma control

Asthma control means:Asthma control means:•minimal symptoms during day and minimal symptoms during day and nightnight

•minimal need for reliever medicationminimal need for reliever medication•no exacerbationsno exacerbations•no limitation of physical activityno limitation of physical activity•normal lung function (FEVnormal lung function (FEV

11 and/or PEF and/or PEF

>80% predicted or best)>80% predicted or best)

Asthma in pregnancyAsthma in pregnancy

• 5 to 9 percent of pregnant women suffer from asthma

• PGF2 alfa is contraindicated in asthmatic women/ LT inhibitors are contraindicated in pregnancy

• Asthma is a risk factor for preeclampsia, preterm labor, LBW babies, and perinatal mortality

Changes in respiratory system in pregnancy

• Reduced FRC• PCO2 more than 35 is considered as

abnormal (non pregnant state is 40 mmHg)• No change in PEF or FEV1• Stress dose of hydrocortisone (100 mg IV TDS)

for those who receive systemic steroids• Fentanyl as narcotic• NVD is preferred- Epidural is a better choice

than general anesthesia

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

Management of acute asthmaManagement of acute asthmain pregnancyin pregnancy

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

Drug therapy for asthmaDrug therapy for asthmaduring pregnancy and lactationduring pregnancy and lactation

Advise women that acute asthma is rare in labor

Advise women to continue their usual asthma medications in labor

In the absence of acute severe asthma, reserve caesarean section for the usual obstetric indications

If anaesthesia is required, regional blockade is preferable to general anaesthesia in women with asthma

Women receiving steroid tablets at a dose exceeding prednisolone 7.5mg per day for more than 2 weeks prior to delivery should receive parenteral hydrocortisone 100mg 6-8 hourly during labor

Use prostaglanding F2 with extreme caution in women with asthma because of the risk of inducing bronchoconstriction

Management of asthma during laborManagement of asthma during labor