Acute Pulmonary Embolism

"D" sign:

In a physiologically normal heart, LV pressure > RV pressure. When viewing heart in a parasternal short

 axis during systole the LV maintains a circular appearance, bowing the intraventricular septum into the

 right ventricle. A D-shaped left ventricle or flattening of the interventricular septum with a D-shaped

 configuration is a feature described with significant RV overload / right heart strain such as that occurring

 with complications of a sizable pulmonary embolic event.

McConnell's sign:

An echocardiographic finding of segmental right ventricular wall‐motion abnormality with apical sparing,

 is highly specific in acute pulmonary embolism and may guide rapid intervention when other testing is

 not feasible.

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Thyroid storm

 

Thyroid storm is a rare and life-threatening condition characterized by an acute exacerbation of

 thyrotoxicosis (elevated free triiodothyronine or free thyroxine and suppressed thyrotropin) with severe

 clinical symptoms. It often results in multiorgan failure involving one or more organ systems such as the

 central nervous, cardiac, hepatic, pulmonary, respiratory, digestive, and gastrointestinal excretory

 systems.

Specific Strategic Steps for Treatment

• Therapy to control increased adrenergic tone: Beta-blocker
• Therapy to reduce thyroid hormone synthesis: Thionamide
• Therapy to reduce the release of thyroid hormone: Iodine solution
• Therapy to block peripheral conversion of T4 to T3: Iodinated radiocontrast agent, glucocorticoid, PTU, propranolol
• Therapy to reduce enterohepatic recycling of thyroid hormone: Bile acid sequestrant

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Urinalysis & Urine Sodium

     

Theophilus Protospatharius, a seventh-century physician who wrote the first manuscript focused

 exclusively on urine called "De Urinis", determined heating urine would precipitate proteins,

 documenting proteinuria as a disease state. French scholar named Gilles de Corbeil (12th century)

 classified 20 different types of urine, recording differences in urine sediment and color and introduced the

 "matula," a glass vessel in which a physician could assess color, consistency, and clarity.

Following includes the complete analysis of urine:

Visual exam

• Color. 

• Clarity

Dipstick test

• Acidity (urine pH). 

• Bilirubin. 

• Blood (hemoglobin). 

• Glucose. 

• Ketones

• Leukocyte esterase.

• Nitrites. 

• Protein

• Urine specific gravity test. 

Microscopic exam

• Crystals. 

• Epithelial cells. 

• Bacteria, yeast and parasites (infections). 

• Red blood cells (RBC). 

• Urinary casts: 

• White blood cells 

Fractional excretion of Sodium (FE Na).

• [(U Na x P Cr) / (P Na x U Cr)] x 100
• U = Urine, P = Plasma, Cr = Creatinine, Na = Sodium.
• Re-absorption and filtration accounted (Both).
• Should not be used with normal renal function.

Acute Kidney Injury (AKI)

• FE Na < 1%
• Urine sodium < 20 mEq/L.

Acute Tubular Necrosis (ATN)

• FE Na > 2%
• Urine sodium > 40 mEq/L.

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Capnography

CAPNOGRAPHY V/S PULSE OXIMETRYCAPNOGRAPHY 

• Provides a measure of ventilation – or concentration of CO2 exhaled air
• (aka end tidal CO2 or etCO2).
• Not effected by supplemental oxygen.
• Reflects breath-to-breath ventilation.
• Appear not normal if the patient has stopped breathing.
• Apnea or hypoventilation is detected immediately by capnography

PULSE OXIMETRY 

• Measures oxygenation or arterial blood oxygen saturation & pulse rate.
• Detects oxygen deficiency (hypoxia).
• May appear normal even if the patient has stopped breathing.
• Takes time to detect Apnea or hypoventilation.

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Hypoglycemia

Hypoglycemia In Diabetics

Type 1 DM/Type 2 DM,
Kidney disease: insulin not cleared out of circulation well.
Medications for Diabetic.

More frequently:
Meglitinides, 
Sulfonylureas,
Insulin 
Very infrequently:
Metformin,
GLP-receptor agonists,
SGLT-2, and 
DPP-4 inhibitor

Hypoglycemia In Non-Diabetics:

Hormonal dysfunction             

Addison's disease

Hypopituitarism

Non-B cell tumors.

Post-gastric bypass

Insulinomas.

Drugs: 

NSAID’s, phenylbutazone, propoxyphene,  

Quinine 

Lithium, TCA, chlorpromazine,   

Fluoxetine, sertraline,

ACE-inhibitors, arbs, beta-blockers.

Levofloxacin, trimethoprim-sulfamethoxazole, 

Mifepristone, 

Heparin

Mercaptopurine.

Haloperidol, pentamidine, 

Disopyramide, 

isoniazid, methotrexate, 

fenfluramine, thiazide diuretics,        

Opioid analgesic tramadol.

                                                          

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Liver Abscess

 

• Pyogenic abscess, accounts for 80% of abscess.
• Amebic abscess due to Entamoeba histolytica, accounts for 10%.
• Fungal abscess, accounts for < 10%.
• 50% of solitary liver abscesses occur in the right Liver lobe.
• Right hepatic lobe (~75%), less commonly left (20%) or caudate (5%) lobes.
• Pyogenic abscesses are usually polymicrobial.
• 50% of the bacterial cases develop by cholangitis. 
• Pyogenic Abscess- initial manifestation of an occult intra‐abdominal malignancy (up to 15%).
• Positive blood cultures in up to 50%.
• Most common organisms: E. coli, Klebsiella, Streptococcus, Staphylococcus, & anaerobes.
• K pneumoniae thought to be associated with colorectal cancer.
• Fever in 90% & abdominal pain in about 50-75%.
• In-hospital mortality estimated at 2.5% -19%

       Drainage of the abscess & antibiotic treatment are the cornerstones of treatment.

• Antibiotic Therapy: 

        If the size of the abscess < 3-5 cm
        Oral antibiotics are given after intravenous antibiotics are first administered. 

• Percutaneous Drainage: 

         Abscess > 5 cm
         Continuous fever despite 48-72 hours of ABX therapy
         Indications that the abscess may rupture
         U/S or CT-guided aspiration & drainage- first-line treatment. 

• Surgery:

          Where percutaneous drainage is impractical.
          When there are complications like rupture or numerous abscesses. 
          Open surgery or laparoscopic surgery.

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Electrolyte Replacement

Significant electrolyte depletion can result in serious complications. These guidelines are meant to assist with empiric dosing of electrolytes for inpatients. Doses may need to be adjusted based on patient-specific factors, including creatine & cardiac status; & responses to initial doses.

• Goal serum potassium concentration 4.0 – 5.0 mEq/L
• Goal serum ionized calcium concentration 1.12 – 1.3 mmol/L
• Goal serum magnesium concentration 2.0 – 2.4 mg/dL
• Goal serum phosphorus concentration 2.7 – 4.6 mg/dL

IV electrolyte replacement can produce life-threatening complications, serious arrhythmias & phlebitis; therefore, supplementation must be carefully monitored.  There are multiple underlying factors for electrolyte disorders in adult inpatients, including alterations in absorption, distribution, hormonal, and/or homeostatic mechanisms that can all cause disturbances. Treating the underlying cause and prescribing adequate therapy is essential for repletion. In addition, the intracellular vs. extracellular electrolyte concentrations must be considered. Due to distribution variances, labs may not directly correlate with true electrolyte levels. Therefore, continuous monitoring is essential to properly replete patients.

 

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Fluid Analysis

A systematic approach to the analysis of the fluid in conjunction with the clinical presentation helps to understand the etiology, narrow the differential diagnoses, & design a management plan. Includes biochemistry, microscopic examinations & infectious disease tests.

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Myasthenia gravis

 

 Chronic, constantly progressive disease. Initially, it affects the muscle tissues of the face, then spreads to the trunk. The following types of MG are distinguished:

• Ocular – the nerve endings in the cranial region are affected, and the eyelids fall asymmetrically. The patient complains of double vision and deterioration in visual acuity. Gradually focusing on one subject becomes difficult.
• Bulbar – the lesion extends to the masticatory muscles and tissues of the larynx. The patient’s voice changes, speech becomes quieter and nasal. Some consonants are very difficult to pronounce, and stuttering develops. Due to the penetration of fluid into the respiratory tract, the risk of pneumonia increases.
• Lambert-Eaton – the muscles of the arms, legs, and neck do not receive nerve impulses. It is difficult for the patient to coordinate these areas of the body. This form is diagnosed in the elderly and is characterized by rapid progression.
• Generalized – the muscles of the eyes are immediately affected, then the process spreads to the larynx, arms, legs, and hips. The main danger of this form is that the respiratory muscles are affected over time.

The disease is characterized by constant progression. 

Plasma exchange (PLEX) is first-line for severe exacerbation & usually causes improvement in a few days. It directly removes anti-acetylcholine receptor antibody from the body. May be more effective in MuSK+ patients.

IVIG may be useful for less severe exacerbations; takes longer to work (e.g., 2-3 weeks), but the efficacy may be more sustained. The dose of IVIG is 2 grams/kg, usually divided over 2 or 5 days.

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Drug-induced thrombocytopenia

1. Immune-mediated: Some drugs can trigger an immune response in the body, leading to the production of antibodies that attack and destroy platelets. This immune-mediated destruction of platelets is one of the common mechanisms in drug-induced thrombocytopenia. Examples of drugs associated with immune-mediated DITP include certain antibiotics (such as penicillin and sulfonamides), anti-inflammatory drugs (such as nonsteroidal anti-inflammatory drugs, or NSAIDs), and anticonvulsants.

2. Non-immune-mediated: Other drugs can cause thrombocytopenia through non-immune mechanisms, such as direct toxicity to the bone marrow where platelets are produced. Chemotherapy drugs, for example, can suppress bone marrow function and lead to a decrease in platelet production.

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Mean Arterial Pressure (MAP)

Average arterial pressure throughout one cardiac cycle, systole, and diastole. 

Surrogate indicator of blood flow and believed to be a better indicator of tissue perfusion.

To perfuse vital organs requires the maintenance of a minimum MAP of 60 mmHg. 

MAP = [Cardiac Output (CO) x Systemic Vascular Resistance (SVR)] + Central Venous Pressure (CVP)

MAP = (CO × SVR) + CVP

Because CVP is usually at or near 0 mmHg, this relationship is often simplified to:

MAP ≈ CO × SVR.

Cardiac output (CO) = Heart Rate (HR) X Stroke Volume (SV).

Stroke Volume is by ventricular inotropy and preload. 

Preload is affected by blood volume and the compliance of veins. 

Increasing the blood volume increases the preload, increasing the stroke volume and therefore increasing cardiac output. 

Afterload also affects the stroke volume in that an increase in afterload will decrease stroke volume. 

Heart rate is affected by the chronotropy, dromotropy, and lusitropy of the myocardium. 

Systemic vascular resistance is determined primarily by the radius of the blood vessels. 

Decreasing the radius of the vessels increases vascular resistance. 

Increasing the radius of the vessels would have the opposite effect. 

Blood viscosity can also affect systemic vascular resistance. 

An increase in hematocrit will increase blood viscosity and increase systemic vascular resistance. 

Viscosity, however, is considered only to play a minor role in systemic vascular resistance.

Common formula:

MAP = Diastolic blood pressure + 1/3 (Systolic Blood pressure – Diastolic Blood Pressure)

          = DBP + 1/3(SBP – DBP) or 

MAP = DBP + 1/3(Pulse Pressure)

MAP = [Systolic Blood Pressure + (2 x Diastolic Blood Pressure)]

                                                      3

Example, if blood pressure is 82 mm Hg/50 mm Hg,

MAP = SBP + 2 (DBP) = 82 +2 (50) = 182 = 60.67 mmHg; or

                3                              3              3

MAP = 1/3 (SBP – DBP) + DBP = 1/3 (82-50) + 50 = 10.67 + 50 = 60.67 mmHg

In sepsis, vasopressors are often titrated based on the MAP. 

In the guidelines of the Surviving Sepsis Campaign, it is recommended that MAP be maintained ≥ 65 mm Hg.

Chronotropy = Heart Rate

Dromotropy = Speed of electrical conduction in the Heart

Lusitropy = Rate of myocardial relaxation

Inotropy = Contractility

Mean Arterial Pressure (MAP) = 70-100 mmHg

Cardiac Index (CI) = Cardiac Output (CO)/ Body Surface Area (BSA) 

                               = 2.5-4 L/min/m2.

Stroke volume (SV) = Cardiac output / Heart Rate 

                                 = 60-120 mL/beat.

Systemic vascular resistance (SVR) = (MAP – Mean Right Atrial Pressure) x 80 / CO 

                                                          = 800-1200 dynes x sec/cm3.

Pulmonary Vascular Resistance = (Mean Pulmonary Artery Pressure – Mean Pulmonary Capillary Wedge Pressure) X 80 / Cardiac Output 

                                                 =125-250 dynes X sec/cm3.

Pulse Pressure (PP)

Pulse Pressure (PP) = Systolic Blood Pressure – Diastolic Blood Pressure

Normal pulse pressure, approximately 40 mmHg.

Change in pulse pressure (Delta Pp) = Volume change (Delta-V) = Stroke volume (SV)

                                                                 Arterial compliance (C)     Arterial compliance (C)

                                                                         

                                                            = Approximately 80 mL = Approximately 40 mm Hg

                                                                       2 mL/mm Hg

Arterial compliance (C) = Delta V/Delta P

Because the aorta is the most compliant portion of the human arterial system, the pulse pressure is the lowest. Compliance progressively decreases until it reaches a minimum in the femoral and saphenous arteries, and then it begins to increase again. 

Narrowed PP (Low) < 25% of the SBP.

Widened PP (High) > 100 % of SBP.

Widened (High) Pulse Pressure (PP)

> 100 % of SBP

Indicative of a noncompliant stiff aorta with a reduced ability to distend and recoil.

With age there is a decrease in compliance of the aorta & small arteries.

In majority, SBP increase while DBP remain near normal. 

In aortic regurgitation (AR), backward, or regurgitant flow, increase SBP and decrease DBP, and therefore increased PP.

Heart valve conditions (Aortic regurgitation, Aortic sclerosis)

Reduced blood viscosity (Severe Iron deficiency anemia)

Increased systolic pressure (Hyperthyroidism), 

Less compliant arteries (Arteriosclerosis)

Narrow (Low) Pulse Pressures (PP)

< 25% of the SBP

Decreased pumping (Heart failure), 

Decreased Stroke Volume (Aortic Stenosis)

Decreased Blood Volume (Blood loss), 

Decreased Filling Time (Cardiac Tamponade/Pericarditis). 

Dysautonomia/postural orthostatic tachycardia syndrome (POTS)

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Rheumatoid Lung Disease

• RA-associated interstitial lung disease (RA-ILD).
• Pleural disease (pleural thickening/effusions).
• Airway disease (Both upper & lower airway).
• Rheumatoid nodules
• Drug-induced lung toxicity (i.e., Methotrexate-induced lung injury)
• Fibro-bullous disease
• Thoracic cage immobility
• Venous thromboembolic disease
• Vasculitis
• Pneumonia.

RHEUMATOID EFFUSION:

• WCC <5000/mm3
• Fluid glucose <60 mg/Dl
• Pleural fluid to serum glucose ratio < 0.5
• pH < 7.3
• High pleural LDH level (ie, > 700 IU/L)
• Cytology: Slender or elongated multinucleated macrophages, round giant multinucleated macrophages, and necrotic background debris.

Pulmonary function testing in ILD (PFT):

• Reduced VC, lung volumes, & DLCO.
• Oxygen desaturation during exercise.
• Restrictive abnormalities common (poor muscle strength or kyphosis due to osteoporosis rather than ILD).

 

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