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EM M4 SAEM
Terms in this set (11)
treatment of PE
Anticoagulation may be started before imaging confirmation in patients with a high pre-test probability of the disease. Either unfractionated heparin or low-molecular weight heparins (e.g. enoxaparin) may be used in most cases.
Warfarin (Coumadin) has a transient hypercoagulable effect; therefore, patients starting warfarin are placed on heparin until warfarin reaches a therapeutic level (INR 2-3).
DOAC (rivaroxaban, apixaban, dibigatran) ideal for outpatient treatment of DVT/PE because they require no additional monitoring and have a quick onset of action, providing anti-coagulation much sooner than warfarin therapy.
contraindications to anticoagulation
- Active pathological bleed
- Coagulation disorder
- Hepatic dysfunction w/ hi PT or INR
- Severe thrombocytopenia
- Malignant HTN
- Hypersensitivity to meds
what are massive and submassive PE
ICU admission is warranted for patients with "massive" PE and should be considered in patients with "submassive" PE. Massive PE is defined as causing persistent hypotension (including relative hypotension in patients with a history of hypertension) and does not refer to the size of the thrombus itself.
Submassive PE is defined as normotensive but with increased work of breathing, hypoxia <90%, new altered mental status, and evidence of right heart strain: elevated troponin or BNP, new RBBB, or evidence of RVs train on echocardiography.
NYHA CHF Classification
Class I - Ordinary activity not limited by symptoms
Class II - Ordinary activity leads to dyspnea, fatigue, etc
Class III - Marked limitation of ordinary activity
Class IV - Symptoms at rest or with any physical activity
In high output heart failure the cardiac output is____. High output HF can be caused by
high or normal, but remains insufficient to supply oxygen demands.
hyperthyroidism, pregnancy, anemia, AV fistulas, beriberi, or Paget's disease.
Low output heart failure
decreased cardiac output secondary to myocardial damage, such as with ischemia, dilated cardiomyopathy, valvular disease, or chronic hypertension
where does fluid build up in right sided HF
increased pressure and fluid build up in the right ventricle, results in hepatic enlargement, increased jugular venous distention, and dependent peripheral edema of the extremities.
where does fluid build up in left sided HF
left ventricle, resulting in pulmonary congestion
Nitroglycerin will have more effect ____ Nitroprusside is a more ____
as a venous dilator than arterial dilator.
balanced venous and arterial dilator.
initial actions in CHF
100% O2 by non-rebreather
if fails to raise O2 to at least 95%, then noninvasive oxygenation/ventilation (NIPPV) such as CPAP or BiPAP may assist in correcting hypoxia
if failure to improve oxygenation, if the patient cannot tolerate the mask, or has a decline in mental status such that they are unable to protect their airway, then endotracheal intubation is required.
CHF treatment in normotensive patients
First give rapid acting nitrates to vasodilate and reduce afterload. These may be given sublingual, IV, or transdermal as nitroglycerin tabs/spray, push/gtt, paste/patch respectively. IV Morphine can be given for chest pain and anxiety, and may increase vasodilation. IV diuretics, such as furosemide, can increase urine output, lessening fluid overload, and may also contribute to vasodilatory effects.
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