Common Vasopressors and Inotropes
Norepinephrine (NE)
- Indication: Distributive shock (1st line for septic shock), Cardiogenic shock (mild ↑CO)
- Side effects: Arrythmias, Peripheral ischemia
Vasopressin
- Indication: Distributive shock, Shock where ↑ HR is not desired (e.g., cardiogenic shock in patients with HCM)
- Side effects: Peripheral ischemia, Splanchnic vasoconstriction
Epinephrine
- Indication: Anaphylactic shock (1st line), Refractory shock (distributive, septic), Bradyarrhythmias
- Side effects: Arrhythmias, Peripheral ischemia
Phenylephrine
- Indication: Distributive shock (esp., vagally-mediated or med-induced), Shock where ↑ HR is not desired (e.g., cardiogenic shock in patients with HCM)
- Side effects: Reflex bradycardia
Dobutamine
- Indication: Cardiogenic shock, Bradyarrhythmias, Some cases of septic shock
- Side effects: Tachyarrhythmias, Cardiac ischemia
Isoproterenol
- Indication: Bradyarrhythmias
- Side effects: Tachyarrhythmias, Cardiac ischemia
Dopamine
- Indication: Can be used in all types of shock, Bradyarrhythmias
- Side effects: Tachyarrhythmias, Cardiac ischemia
#Vasopressors #Inotropes #comparison #table #pharmacology #criticalcare
Orthopedic Dislocations (Shoulder, Elbow and Hip) - Diagnosis and Management Summary
Shoulder Dislocation
• Fall on the out stretch hand with rotation
• Posterior dislocation (due to internal rotation)
• Anterior dislocation (due to external rotation of ABDucted arm)
Shoulder Reduction Methods:
A. Hippocratic method
1. The patient lies supine.
2. The physician's foot is placed in the patient's axilla against the chest wall while leaning backward.
3. Slow, steady and gentle longitudinal traction is applied to the affected arm in 30-40° abduction for about one minute.
4. The foot acts as a counterforce and as a lever to push the humeral head laterally while the physician pulls the head toward the patient's foot along the surface of the glenoid, effectively adducting the affected arm.
5. Put patient on arm sling
B. Kocher method
T – Traction in line of humerus
E – External Rotation of humerus
A – Adduction of arm
M – Medial rotation
Elbow Dislocation
• Fall on outstretched hand with elbow slightly flexed
• Types: Posterior (most common), Anterior, Lateral, Medial Divergent
• Elbow Reduction: Dislocation reducing the dislocation by traction and pressure flexing the elbow fully as a test of reduction immobilizing the limb in an above-elbow plaster slab (margin shown by dotted line) and a sling.
Hip Dislocation
Usually occurs in an MVA as a result of dash board injury
Hip Reduction Methods (SHOULD BE DONE ASAP TO REDUCE THE CHANCE OF AVN OF HEAD):
A. Bigelow method: FLEX, ABDUCT, EXTERNAL ROTATION, EXTENSION, NEUTRAL ROTATION
B. Allis method
1. The patient is supine
2. Affected hip and knee are flexed in 90 degree
3. In neutral rotation of hip, an upward traction is applied along the axis of femur and the same counter traction is given by holding the pelvis.
C. Stimsons’ gravity method: The patient is laid prone with the lower limb hanging over the other end of the table. Femoral head is pushed down into the acetabulum and at the same time the traction is applied downward along the axis of femur
#Orthopedics #Dislocations #Shoulder #Elbow #Hip #Diagnosis #Management #Summary #reduction
Red Blood Cell (RBC) Morphology
Microcytic RBC: Pyridoxine deficiency, Thalassemia, Iron deficiency anemia, Chronic disease anemia (sometimes), Sideroblastic anemia (sometimes)
Macrocytic RBC: Vitamin B12 or Folate deficiency, Liver Disease, MDS, Chemotherapy (e.g. methotrexate)
Spurr Cell RBC (Acanthocyte): Abetalipoproteinemia, Liver disease, McLeod blood group phenotype, Post-splenectomy, Etc.
Burr Cell RBC (Echinocyte): Artifact, Uremia, Liver disease, Etc.
Schistocyte: Microangiopathic Hemolytic Anemia, Mechanical valve induced, Etc.
Bite Cell RBC: G6PD deficiency, Unstable hemoglobin disorders, Oxidative drugs
Elliptocyte: Hereditary elliptocytosis, Severe iron deficiency anemia
Spherocyte: Hereditary spherocytosis, Autoimmune hemolytic anemia
Stomatocyte: Hereditary stomatocytosis, Liver disease
Target Cell RBC: Thalassemia, Hemoglobinopathies, Post-splenectomy, Liver disease, Artifact
Sickle Cell RBC: Hemoglobin SS disease, Hemoglobin SC disease, Hemoglobin SD disease, S-beta thalassemia
Teardrop: Myelofibrosis, Underlying marrow process/infiltrate, Etc.
Hemoglobin C Crystals: Hemoglobin C disease, Hemoglobin SC disease
Red Cell Agglutinate: Cold autoimmune hemolytic anemia, Paroxysmal cold hemoglobinuria, IgM associated lymphoma, Multiple myeloma
Rouleaux: Chronic liver disease, Malignant lymphoma, Multiple myeloma, Chronic Inflammatory Diseases
#Red #BloodCell #RBC #Morphology #differential #diagnosis #hematology #microscopy #atlas #nomenclature
Neonatal Resuscitation – Circulation and Drugs
Consider drugs (k) if heart rate beats/min in spite of adequate ventilation and chest compression, though evidence for their efficacy is lacking
Rarely needed.
Drugs should be given via an umbilical venous catheter, or, if not possible, via an intra-osseous needle.
Drugs given via a peripheral vein are unlikely to reach the heart. Giving standard doses of epinephrine (adrenaline) down the endotracheal tube does not appear to be effective, so drug dosage is increased for this route.
A newborn baby who looks white and has poor skin and peripheral perfusion due to acidosis and peripheral vasoconstriction may have had acute blood loss. There may be a history of antepartum haemorrhage or acute twin-to-twin transfusion.
Immediate blood transfusion with Group O rhesus negative blood is required.
#Neonatal #Resuscitation #Drugs #Medications #Pharmacology #management #peds #pediatrics
Indications for Transfusion
Packed RBCs
• Hgb <7 g/dL or hematocrit <21% in a patient with uncompromised cardiovascular function
• Hgb <10 /dL or hematocrit in a patient with cardiovascular disease, sepsis, or hemoglobinopathy
Platelets
• Prophylactically for platelet count < 10,000 (adults), or < 50,000 (neonate)
• < 30,000 and bleeding or minor bedside procedure
• < 50,000 and intraoperative or postoperative bleeding
• < 100,000 and bleeding post cardiopulmonary bypass
• Do not transfuse platelets in setting of thrombocytopenic thrombotic purpura, heparin-induced thrombocytopenia. Platelet transfusions are unlikely to be useful in idiopathic thrombocytopenic purpura or posttransfusion purpura
Fresh frozen plasma
• Bleeding in patients with INR > 2
• Bedside procedure and INR > 2
• Prophylaxis (nonbleeding) with INR > 10
• FFP is not indicated for patients with INR <1.5
• Thrombotic thrombocytopenic purpura
Cryoprecipitate - Bleeding in the setting of:
• Dysfibrinogenemia
• Fibrinogen <100 mg/dL
• von Willebrand disease
#Transfusion #Indications #Thresholds #Management #RBCs #Platelets #FFP
Esophageal Atresia and Tracheoesophageal Fistula- An infant had an apneic episode at birth and received positive-pressure ventilation in the delivery room during neonatal resuscitation...Prenatal ultrasonography had not revealed fetal abnormalities. The Apgar scores were 1 point at 1 minute and 9 points at 5 minutes. Owing to the infant’s copious oral secretions, a nasogastric tube was inserted but met resistance at 11 cm. A chest radiograph showed the catheter coiled in the esophagus (arrow) at the level of the second thoracic vertebra and air in the stomach. Esophageal atresia with tracheoesophageal fistula, type C, was diagnosed. Type C, the most common type, is characterized by a proximal esophageal pouch with a distal tracheoesophageal fistula. Esophageal atresia and tracheoesophageal fistula may be associated with congenital vertebral, anorectal, cardiovascular, renal, and limb defects (collectively known as the VACTERL association)...Primary esophagoesophagostomy and ligation of the tracheoesophageal fistula were performed on day 2. The patient began feeding by mouth on day 9 and was discharged on day 33. At follow-up visits at 2, 4, and 6 months of age, the infant was growing and developing well. #NEJM #clinical #radiology #esophageal #atresia #tracheoesphageal #fistula #type #C #chest #Xray
