1. Adrenaline: DOSE: Infusion rate: 1-4 microgram /min. initially, titrate to effect 2. Sodium Nitroprusside Doses :0.5-10microgram/kg/min. 3.

Dopamine: Dose: Low infusion rate (renal dose): 0.5 -2 gm/kg/min High infusion rate: 2-5 gm/kg/min (0.5-1 gm/kg/min and is raised until an acceptable urinary flow, blood pressure or heart rate is achieved; 4. Dobutamine: Dosage: Infusion rate: 2.5 -10 gm/kg/min Rarely up to 40 gm/kg/min 5. Streptokinase: Dosage: 1.5 million units over 1 hour 6. Heparin: Dosage: IV 5000 units bolus 700-2000 units/hour 7. Amiodarone: Dosage: 1.5 mg/kg over 10 mins 1 kg/min over 6 hours 0.5 mg/min infusion 8.Lidocaine (Xylocaine;Xylocard) Dose: loading dose: 1 mg /kg over 2 minutes Followed by 0.5 mg /kg every 8-10 minutes to a total of 3 mg /kg (Loading dose of 75-100 mg i/v with in 2 minutes followed after 30 minutes by 2nd loading dose or 400 mg intramuscularly. Thereafter lidocaine is infused at 2-4 mg /min for 24-36 hours aiming at 3mg/min. 9. Aminophylline: Dosage: Loading dose: If not previously on theophylline: 6mg/kg over 20 minutes If previously taking theophylline: 3mg/kg over 20 minutes 10. Isoprenalline Dosage: 0.5- 20 ugrams/min to a max of 30 grams/min

Dopamine

Dopamine is a catecholamine-like agent Dopamine stimulates the heart by both beta and alpha-adrenergic responses and cause vasodilatation through dopamine receptors. Low infusion rate (renal dose): 0.5 -2 gm/kg/min High infusion rate: 2-5 gm/kg/min 0-2mcg/kg/mn: DA1 receptor action leading to renal vasodialtion (Renal dose) 2-5mcg/kg/min: Beta and DA1 receptors leading to increase in force of contraction but not heart rate. (Cardiogenic shock) 5-10mcg/kg/min: Alpha receptors action leading to vasoconstriction (look for peripheral cynosis) >10mcg/kg/min: High Risk of developing cardiac arrythmias Dilution: 1 ampoule of dopamine contains = 200 mg Add 1 ampule of Dopamine in 50ml of NS 50ml of NS = 200mg of Dopamine 1ml of NS = 200/50 = 4mg = 4000mcg Therefore 4000mcg = 1ml of NS CALCULATION OF DOSAGE For Example IF the person is of 50kg and we want to start Dopamine on Cardiac dose (2-5mcg/kg/min) Taking the average of 3.5mcg/kg/min, the required dose would be = 3.5X50 =175 mcg/min Then dose can be calculated as follows: 50mcg/min=50X60 = 3000mcg/hr =3000/4000 ml/hr =3/4ml/hr=0.75 ml/hr 100 mcg/min= 6000 mcg/hr=6000/4000ml/hr=1.5 ml/hr 150 mcg/min=150x 60 =9000 mcg/hr=9000/4000 =2.25 ml/hr 175 mcg/min=175x60 mcg/hr=10500 mcg/hr=10500/4000 ml/hr=2.62 ml/hr 200 mcg/min=200x60 mcg/hr=12000 mcg/hr=12000/4000 ml/hr =3 ml/hr 250 mcg/min=250x60 mcg/hr=15000 mcg/hr=15000/4000 ml/hr=3.75 ml/hr 300 mcg/min=300x 60 =18000 mcg/hr=18000/4000 ml/hr=4.5 ml.hr 350 mcg/min=350x60= 21000 mcg /hr =21000/4000 ml/hr=5.25 ml/hr 400 mcg/min=400x60 =24000 mcg/hr=24000/4000 ml/hr=6 ml/h 500 mcg /min =500x 60=30000 mcg/hr =30000/4000 ml/hr =7.5 ml/hr 600 mcg/min=600x60 =36000 mcg/hr=36000/4000 ml/hr=9 ml/hr Precautions, side effects and contraindications: Dopamine must not be diluted in alkaline solutions Blood pressure, ECG and urinary flow should be monitored constantly. For oliguria first correct hypovolemia, try frusemide. Dopamine is contraindicated in ventricular arrhythmias and pheochromocytoma. Use dopamine with care in AS. Watch for nausea, vomiting, headache, palpitation, anginal pain, HTN, tachycardia & arrhythmias Required Dose x weight x 60 = x ml/hr or udrps/min 4000 Xugm = ML x 4000 60 x weight

DOPAMINE:

Dose :(1 amp in 200 mg) Renal Dose: 2.5mcg/kg/min Mild dose: 5-10 mcg/ kg/ min Pressure dose: 10- above mcg/kg/min (If the dose above 50 mcg/ kg/min urine output must be checked) INDICATION: shock syndrome due to MI endotoxic septicemia chr. Cardiac decompositions renal failure open heart surgery trauma any hypotension condition assect hypovolemic shock CONTRAINDICATIONS: Pheochromocytoma. Tachyarrhythmias or ventricular fibrillation. SIDE EFFECTS: ventricular arrhythmia (at very high doses) ectopicbeats,tachycardia,anginal, pain,palpitation,cardiac conduction abnormalities,bradycardia, hypotension, hypertension, vasoconstriction dyspnea nausea vomiting azotemia headache anxiety piloerection

Dobutamine: Dosage: Infusion rate: 2.5 -10 gm/kg/min Rarely up to 40 gm/kg/min Dilution: 1 ampoule of dobutamine contains = 250 mg Add 2 ampoules of Inj. Dobutamine in 500 ml of fluid (NS or 5% DW) Thus 500 ml of fluid contains 500 mg 1 ml = 500 mg/500 = 1 mg = 1 x 1000 gm = 1000 gm i.e. 1ml = 1000 gm 1 gm = 1 ml /1000 =15 major drops/1000 = 15 x 4 drops/1000 = 60/1000 drops = 0.06 drops 1gm = 0.06 drops , 1 gm/kg/min = 0.06 drops/kg/min Drops calculation 40 kg 50 kg 60 kg 70 kg 2.5 gm/kg/min 6ds/min 7.5 9 10.5 3.0 7.2 9 10.8 12.6 3.5 8.4 10.5 12.6 14.7 4.0 9.6 12 14.4 16.8 4.5 10.8 13.5 16.2 18.9 5.0 12 15 18 21 6.0 14.4 21 21.6 25.2 7.5 18 22.5 27 31.5 10 2.1 30 36 42 Do watch for: Arrhythmias Hypotension Myocardial ischemia Allergies rarely Infusion rate: 2.5 -100 gm /min

80 kg 12 14.4 16.8 19.2 21.6 24 28.8 36 48

Infusion Pump
1amp dopamine (200mg) in 50ml of NS

Dose (2-5ugm/kg/min) x wt x 60 = X ml/hr or udrops/min 4000

DOBUTAMINE It increases the stroke volume & increase cardiac output without marked increase in heart rate & systemic vascular resistance is usually reduced. Dose: 2.5-10 mcg/kg/min (250mg in 1 amp)

INDICATION: inotropic support in infraction cardiac surgery cardio myopathy septic shock radiogenic shock hypotension CHF ROUTE: I/V E T Tube Intracardiac CONTRAINDICATION: Trachydysrhythmias Hypovolemia Cardiac arrhythmias SIDE EFFECTS: > Increased Heart Rate, Blood Pressure, and Ventricular Ectopic Activity > Hypotension > Reactions at Sites of Intravenous Infusion Phlebitis, Local inflammatory changes, cutaneous necrosis ( > Miscellaneous Uncommon Effects The following adverse effects have been reported in 1% to 3% of adult patients: nausea, headache, anginal pain, nonspecific chest pain, palpitations, and shortness of breath. Isolated cases of thrombocytopenia have been reported. Dobutamine, like other catecholamines, can produce a mild reduction in serum potassium concentration,

NITROGLYCERINE: Dilution: 1 ampoule of nitroglycerine contains = 25 mg

Add 1 ampoules of Inj. Nitroglycerine in 500 ml of fluid (NS or 5% DW) Thus 500 ml of fluid contains 25 mg 500 ml = 25 mg ,1 ml = 25 mg/500 =1/20 mg=1/20x1000gm = 50gm 1 ml = 50 gm 1 gm = 1ml/50 = 15major drops/50= 15x4 drops/50= 60/50 drops = 1.2 drops 1 gm =1.2 drops/min= 1.2 ml/hr 500 ml/ns

drops calculation : gm/min 2.5 5 7.5 10 12.5 15 20 25 30 35 40 50 100 drops/min 3 6 9 12 15 18 24 30 36 42 48 60 120 ml/hr 3 6 9 12 15 18 24 30 36 42 48 60 120 If sol. Prepared in 50 ml N/S, i.e. :25 mg NTG in 50 ml N/S 0.3 0.6 0.9 1.2 1.5 1.8 2.4 3.0 3.6 4.2 4.8 6.0 12.0

If sol. Prepared in 100 ml N/S, 25 mg in 100 ml NS 1gm/min =0.24 ml hr 0.6 ml/hr 1.2 ml/hr 1.8 2.4 3 3.6 4.8 6 7.2 8.4 9.6 12 24

NITRATES Vasodilator INDICATION: -Acute Angina -HTN - LVF CONTRAINDICATION: -Hypotension - Hypovolemia - Intracranial bleeding - Aortic Stenosis SIDE EFFECTS: -Hypotension - Syncope - Tachycardia - Flushing NTG I/V 5ug / min Increase by 5-10ug /min for 5 minutes until desired effects

Thrombolytic Therapy In MI Indications

Chest pain consistent with Acute MI. Electrocardiographic changes ST segment elevation 0.1 mm in at least 2 contiguous limb leads Or ST elevation 2mm in at least 2 contiguous chest leads New Left Bundle Branch Block Time from chest pain to thrombolytic therapy : Less than 6 hours : most beneficial 6-12 hrs - lesser but still important benefits 12-24 hrs - diminishing benefits but may be useful in selected pts (eg. Those with ongoing chest pain)

Absolute contraindications for Thrombolytic Therapy in MI: Any prior intracranial haemorrhage. Known structural cerebral vascular lesion (e.g. arteriovenous malformation) Know malignant intracranial neoplasm (Primary or metastasis) Ischemic stroke within 3 months EXCEPT acute ischemic stroke with in 3 hrs. Suspected aortic dissection. Active bleeding or bleeding diathesis (Excluding menses) Significant closed head or facial trauma within 3 months. Relative contraindications History of poorly controlled hypertension. Severe uncontrolled hypertension on presentation (SBP > 180 or DBP > 110 ) History of prior ischemic stroke greater than 3 weeks, dementia, or known intracranial pathology not covered in contraindications. Traumatic or prolonged ( > 10 mines) CPR or major surgery (< 3 weeks) Recent (within 2-4 weeks) internal bleeding. Non compressive vascular punctures. Prior exposure (more than 5 days ago) or prior allergic rxn to these agents. Pregnancy Active peptic ulcer. Current use of anticoagulants, the higher the INR the higher the risk of bleeding. Treatment Regimen: Aspirin or Acetylsalicylic Acid 300mg stat and OD Diphenhydramine 50mg IV Hydrocortisone 100-200mg IV Steptokinase 1.5 M IU in 100ml 0.9 NaCl over 1 hour (100ugtts/min) PTT stat and 6hourly for 24 hours then 12 hourly Optional (Associated with Increased bleeding risk) : Heparin 5000 units IV boulus then 500-1000Units/hr/IV to maintain PTT at 1.5-2x the control NOTE: Watch for Hypotension, Reperfusion Arrhythmias, no IM injections or arterial punctures. Watch or IV sites for bleeding.

Streptokinase

FOR MYOCARDIAL ISCHEMIA Dosage: 1.5 million Units over 1 hour Dilution: 1 ampoule of STK contains = 1.5 million units Take 95 ml of normal saline in a micro drip set Dilute 1 amp STK with 5 ml of normal saline, gentle roll but don't shake & add it to the micro drip set Now the micro drip set contains 100 ml of 1.5 million units of STK This is to be given in an hour. Drop calculation: 100 ml to be given in 1 hour (60 minutes) I.e. in 1 minute = 100 ml/60 = 100 x 15 major drops/60 = 100 x 15 x 4 microdrops/60 = 100 x 60 microdrops/60 = 100 microdrops Hence, infusion rate = 100 microdrops/min Management : ECG before and after STK Vital Monitoring every 15 minutes Watch for Gum bleeding or bleeding from any sites Hold Thrombolysis on any abnormalities and restart when patient is stable

Do watch for: Bleeding, Hypotension, Allergic reaction (rigors), Hypertension, Reperfusion arrhythmia, Vomiting,

HEPARIN FOR STEMI Bolus Dose = 60 units/kg ( Max 5000 units ), 60 U x wt x 5 = x ml 25000 Maintenance / Infusion= 12units/kg/hr ( Max 1000 units/hr) 1 vial in 500ml NS ; 12U x wt = x ml/hr 50

. FOR PULMONARY EMBOLISM STREPTOKINASE : 1 Vial 1500,000 IU 2.5 lakhs in 1 hour 1 Lakh for next 24 hours 15,00,000 IU --------- 50ml NS 1ml ---------------------- 30, 000 IU BOLUS----- 8.3ML/ hour for 1 hour (2.5 Lakhs) MAINTENANCE----- 3.3 ml/hr for next 24 hours

Heparin: FOR DVT: USE FULL VIAL (25,000 UNIT) IN 500 ML NS Postoperatively until INR is above 2 after the inclusion of T .Warfarin. 1 vial = 5 ml contains 25000 units of heparin So,1 ml=5000 units DVT: Bolus: 5000 UNITS of heparin =1 ml without dilution OR

80 units/kg i.e 80U x wt x 5 25000 Maintenance: Dilution, 1 vial in 500ml of NS = 500ml of NS = 25,000 Units of Heparin 1ml = 25,000/500 =50 units of Heparin Dosage: 16-18 units/kg/hr For example for 50 kg patient Maintenance = 16X50 = 800 units/hr Drops calculation 1 ml/hour = 1microdrop/minute. Ml/hour 400 U/hour / 50Uofheparin 8x60(udrps)/60(min) 600 U/hour 12 800 U/hour 16 1000 U/hour 20 1200 U/hour 24 1400 U/hour 28 1600 U/ hour 32 Usually while treating any patient with Heparin Baseline APTT, PT, INR Monitoring of APTT 6 hrly Target APTT = 2 X Control APTT. ( Unless ordered target is more )

Micro drops/min 8 12 16 20 24 28 32

Adjustment of Heparin Infusion: APTT < 40 40-54 55-80 81-99 >99 Adjustment Increase infusion by 4 units/kg/hour Increase infusion by 2 units/kg/hour No change Decrease infusion by 2 units/kg/hour Hold for 1 hours, decrease infusion by 3 units/kg/hour

Heparin: FOR PROSTHETIC METALLIC VALVE: USE HALF VIAL (12,500) IN 500 ML NS Prosthetic Metal Valve No Bolus Dose Maintenance Dose vial of Heparin=12,500Uof heparin in 500ml of NS , 500ml = 12,500U, 1ml = 12,500/500 =25 U Weight x dose (16-18Units expected dose) = X U/hr 25 Dosage: 16-18 units/kg/hr For example for 50 kg patient Maintenance = 16X50 = 800 units/hr Drops calculation 1 ml/hour = 1microdrop/minute. Ml/hour Micro drops/min 200 U/hour 8 ml/hr 8 micro drops /min 400 U/hour 16 ml/hr 16 micro drops /min 600 U/hour 24 ml/hr 24 micro drops /min 800 U/hour 32 ml/hr 32 micro drops /min 1000 U/hour 40 ml/hr 40 micro drops /min 1200 U/hour 48 ml/hr 48 micro drops /min 1400 U/hour 56 ml/hr 56 micro drops /min 1600 U/h 1600 U/ hour 64 ml/hr 64 micro drops /min Do watch for: Bleeding from any site, Sudden deterioration of Pts orientation, and neurological symptom. Anemia HTN Alcohol abuse Old Age Hepatic and Renal disease Skin necrosis APPT to be done BD (usually) & dosage adjusted accordingly. Draw APPT 6 hours after any bolus or change in infusion rate.

Patients receiving Heparin may develop major bleeds which may be completely reversed by Protamine Sulphate. Where potential benefits outweigh the risks (Intracranial bleed, Epidural Haematoma, Retinal bleed) HEPARIN ANTAGONIST: Protamine Sulphate (1mg neutralizes approximately 100u heparin) Protamine Sulphate = Amount of Heparin mg 100 HEPARIN : Anticoagulant INDICATION: Acute MI Deep Vein Thrombosis CONTRAINDICATION - Severe Thrombocytopenia Hemorrhagic CVA Aneurysm Severe HTN Uncontrolled bleeding SIDE EFFECTS Bleeding Thrombocytopenia(decreased platelets) Itching

Amiodarone: Dosage: 1.5 mg/kg over 10 mins 1 kg/min over 6 hours 0.5 mg/min infusion Dilution: 1 ampoule (3 ml) of amiodarone contains 150 mg Amiodarone always diluted with 5% dextrose Dosage usually given: Bolus : 300 mg over 1 hour then Maintenance: 900 mg over next 24 hours or 300 mg over 1 hour 8 hourly Drops calculation: Bolus: 2 ampoules (300 mg) mixed with 100 ml of dextrose. This 100 ml is given over 1 hour @ 25 major drops/min i.e. 100 micro drops/min Maintenance: If order is 300 mg 8 hourly over 1 hour calculation same as above (100 microdrops/min) If order is 900 mg over 24 hours. 6 ampules (900 mg is mixed with the remaining 400 ml dextrose & given over 24 hours 24 hours = 400 ml 1 hour = 400/24 ml 1 min = 400 x 15 x4 /24 x 60 microdrops 400 x 60/24x 60 microdrops 400/24 microdrops 1 min = 16 microdrops. Do watch for: Neuropathy, deranged liver function tests, hepatitis.

AMIODARONE: DRUGS: cordarone, amiodar, DOSE: 100 & 200 mg in tab form INDICATION: ventricular fibrillation, ventricular tachycardia, atrial fibrillation CONTRAINDICATION: Pregnant Sinus nodal bradycardia AV block SIDE EFFECT: Abnormal thyroid function (hyper & hypo both) therefore check every 6 months Optic neuropathy, optic disk swelling Abnormal liver enzyme Skin discoloration Interstitial lungs disease

Lidocaine (Xylocaine;Xylocard) Lidocaine has become the standard intravenous agent for suppression of serious ventricular arrhythmias associated with AMI and with cardiac surgery. Lidocaine has no value in treating supraventricular tachyarrthmias. Dose: Loading dose: 1 mg /kg over 2 minutes Followed by 0.5 mg /kg every 8-10 minutes to a total of 3 mg /kg (Loading dose of 75-100 mg i/v with in 2 minutes followed after 30 minutes by 2nd loading dose or 400 mg intramuscularly. Thereafter lidocaine is infused at 2-4 mg /min for 24-36 hours aiming at 3mg/min. Drugs for the heart 7th edition)

Weight (kg) 30 40 50 60 70 80 90 Weight (kg) 30 40 50 60 70 80 90

Initial Bolus : 1 mg/kg over 2 min mg Ml 30 1.5 40 2 50 2.5 60 3 70 3.5 80 4 90 4.5 Subsequent bolus : 0.5 mg/kg every 8-10 min mg Ml 15 0.75 20 1 25 1.25 30 1.5 35 1.75 40 2 45 2.25

Dilution: 1 vial of 2% Xylocard contains= 1000 mg Add 1 vial (1000 mg) in 500 ml NS or 5% dextrose 500 ml = 1000 mg 1 ml = 1000 mg /500 = 2 mg 1 mg = 1/2 ml = 16/2 drops = 8 drops, 1 mg/min = 8 drops/min Drops Calculation : Mg/min Drops/min 2 16 3 24 4 32 Side effects: Convulsions, confusion, stupor rarely respiratory arrest Drowsiness, numbness, speech disturbance ,dizziness Sinus arrest, AV block a systole Rapid ventricular rate (in AF or flutter)

Contraindications: Known hypersensitivity to lidocaine 2nd and 3rd degree AV block in the absence of pacemaker

LIDOCAINE 2% (XYLOCAINE):

Arrhythmic
DOSE: For cardiac arrest, VT/VF 1. 5mg/kg IVP. Repeat 5-10mins, Maximum 3mg /kg After conversion to NSR Start drip at 2-4mg/min INDICATION -VT with pulse - PVCs CONTRAINDICATION II & III degree AV block Hypotension Adams Syndrome SIDE EFFECTS Seizure Altered mental status Slurred speech

Aminophylline: (Theophylline derivative, bronchodilator) Dosage: 1 ampoule (10 ml) of aminophylline contains 250 mg 10 ml = 250 mg, 1 ml = 250/10 = 25 mg Loading dose: If not previously on theophylline : 6mg/kg over 20 minutes Weight (kg) Mg ML (Approx) 40 240 10 50 300 12 60 360 14 70 420 16 80 480 18 90 540 20 If previously taking theophylline : 3mg/kg over 20 minutes Weight (kg) Mg ML (Approx) 40 120 5 50 150 6 60 180 7 70 210 8 80 240 9 90 270 10 Maintenance dose Smoking adult Non smoking adult Elderly Cor pulmonale Pregnant Congestive heart failure Liver disease Dilution: 1 ampoule (10 ml) of aminophylline contains 250 mg Add 2 ampoules in 500 ml NS or 5% dextrose 500 ml = 500 mg 1 ml = 500 mg/500 = 1 mg 1 ml = 1 mg Drops calculation : Since 1mg = 1ml = 40ml/hr = 40x15drops/60min =1drps/min Mg/Kg/Hour 40kg 50mg 0.1x40kg 1 drops/min 1.25 0.2 2 drops/min 2.5 0.3 3 drops/min 4

Mg/Kg/Hour 0.8 0.5 0.3 0.3 0.3 0.1 - 0.2 0.1 - 0.2

60kg 1.5 3 5

70kg 1.75 3.5 5.5

80kg 2 4 6

90kg 2.25 4.5 7

0.5 0.8

5 drops/min 8 drops/min

6 10

7.5 12

9 14

10 16

11 18

Do watch for : Hypotension if rapid IV injection Seizures, neurotoxicity, GI irritation, nausea, vomitting, abdominal pain, GI bleeding, insomnia, headache, anxiety, restlessness, vertigo, palpitations.

Isoprenalline (Beta agonist, Sympathomimetics, stimulates the heart) Dosage: 0.5- 20 grams/min to a max of 30 grams/min Dilution : 1 ampoule (1 ml) of isoprenaline contains 2 mg Add 1 ampoule to 500 ml of 5% dextrose or normal saline; 500 ml = 2 mg ml = 2/500 mg = 1/250 mg= 1000grams/250 = 4 grams 1 gram = 1/4 ml = 16/4 major drops = 4 major drops = Start at 16 major drops minute Drops calculation: g/min 0.5 1 2 4 5 6 8 10 12 15 20 Major drops/min 2 4 8 16 20 24 32 40 48 60 80

Do watch for:

Hypotension due to hypovolemia

Sodium Nitroprusside Doses 0.5-10microgram/kg/min. But infusion at the maximum doses should never last for more than 10 minutes. If the blood pressure has not been adequately controlled after 10 minutes of infusion at the maximum rate, the drug should be stopped immediately. Nitroprusside should not be abruptly withdrawn during the treatment of heart failure because of the danger of rebound hypertension. Indication 1. Severe acute on chronic heart failure especially with regurgitate valve disease to rescue the patient or to act as a bride to transplantation or to a mechanical assist device (2) in hypertensive crises (3) in dissecting aneurysm (4) for controlled hypotension in anesthesia (maximum dose 1.5 ug/kg/minute); (5) after coronary bypass surgery, when patients frequently have reactive hypertension as they contraindications, Preexisting hypotension. All vasodilators are contraindicated Mitral stenosis or obstructive cardiomyopathy. Hepatic or renal failure. Side effects cyanide toxicity, excessive drop in LV end dismissed, vomiting and disorientation caused by toxicity, and thiocyanate accumulates, hypothyroidism. Treatment of cyanide toxicity Keep infusion rate low. Discontinue the infusion once the diagnosis in suspected nitrite 3% solution at less than 2.5 ml/minute to total dose of 10 to 15 ml/minute, sodium hyposulfite 12.5 g in 50 ml of 5% dextrose water over 10 minutes.

Adrenaline: DOSE: Infusion rate: 1-4 microgram /min. initially, titrate to effect DILUTION: 1 ampoule of Adrenaline = 1.8 mg Add 3 amps. Of Adrenaline in 500ml NS or 5% Dextrose I.e. 5 mg of Adrenaline in 500 ml of NS or 5% Dextrose 10 micrograms of adrenaline in 1 ml of NS or 5% Dextrose 1 micrograms of adrenaline =15 major drops/10 /min. = 1.5 X 4 micro drops /min. = 6 micro drops /min. Micrograms/min. 1 2 3 4 5 6 7 8 9 10 Side Effect: Arrhythmia Pulmonary edema CNS disorder Indications: Bronchospasm Shock Anesthesia Micro drops /min. 6 micro drops/min. 12 micro drops/min 18 micro drops/min 24 micro drops/min 30 micro drops/min 36 micro drops/min 42 micro drops/min 48 micro drops/min 56 micro drops/min 60 micro drops/min

ADRENALINE: INDICATION: acute hypersensitivity (anaphylactoid reactions to drugs, animal serums and other allergens) acute asthmatic attacks to relieve bronchospasm not controlled by inhalation OR subcutaneous administration of other solutions of the drug Prophylaxis of cardiac arrest and attacks of transitory atrioventricular (A-V) heart block with syncopal seizures (Stokes-Adams Syndrome). (In acute attacks of ventricular standstill, physical measures should be applied first. When external cardiac compression and attempts to restore the circulation by electrical defibrillation or use of a pacemaker fail, intracardiac puncture and intramyocardial injection of epinephrine may be effective.) CONTRAINDICATIONS: Known hypersensitivity to sympathomimetic amines, Patients with angle closure glaucoma, non-anaphylactic shock SIDE EFFECT: 1. Anxiety, headache,palpitations occur with therapeutic doses, especially in hyperthyroid individuals. 2. Cardiac arrhythmias and excessive rise in blood pressure 3. Cerebral hemorrhage, hemiplegia, subarachnoid hemorrhage, 4. Angina pectoris, 5. Anxiety, restlessness, throbbing headache, tremor, weakness dizziness, pallor 6. Respiratory difficulty.

Noradrenaline 1Vial =2mg, 2 vial (4mg) in 50ml NS 1ml= 4000mcg / 50ml NS = 80 mcg Loading Dose: 8-12 mcg/ min 1 min 10 mcg, In 60min = 600mcg in 1 hour 80mcg = 1ml 1 mcg= 1/80 ml 600mcg = 1/80 x 600 ml/hr = 7.5 ml/hr Maintanence Dose: 2-5 mcg/min 1min 3mcg , In 60min 180mcg in 1 hour 80mcg = 1 ml 1 mcg= 1/80 ml 180 mcg = 1/80 x 180 = 2.2ml/hour NOR ADRENALINE INDICATIONS cardiac arrest and profound hypotension. Restoration of Blood Pressure In Acute Hypotensive States CONTRAINDICATIONS: 1. Hypotensive. 2. Mesenteric or peripheral vascular thrombosis 3. Hyperthyroid SIDE EFFECTS 1. Ischemic injury due to potent vasoconstrictor action and tissue hypoxia. 2. Bradycardia, probably as a reflex result of a rise in blood pressure, arrhythmias. 3. Anxiety, transient headache. 4. Respiratory difficulty. 5. Extravasation necrosis at injection site. Overdoses or conventional doses in hypersensitive persons (e.g., hyperthyroid patients) cause severe hypertension with violent headache, photophobia stabbing retrosternal pain, pallor, intense sweating, and vomiting.

ADENOSINE: When given for the evaluation or treatment of an SVT, the initial dose is 6 mg, given as a fast IV/IO push. Due to adenosine's extremely short half-life, the IV line is started as proximal to the heart as possible, such as the antecubital fossa. The IV push is often followed with an immediate flush of 5-10ccs of saline. If this has no effect (e.g., no evidence of transient AV block), a 12mg dose can be given 1-2 minutes after the first dose. If the 12mg dose has no effect, a second 12mg dose can be administered 1-2 minutes after the previous dose. Some clinicians may prefer to administer a higher dose (typically 18 mg), rather than repeat a dose that apparently had no effect. When given to dilate the arteries, such as in a "stress test", the dosage is typically 0.14 mg/kg/min, administered for 4 or 6 minutes, depending on the protocol.
INDICATION: PSVT CONTRAINDICATION: Poison/Drug induced tachycardia, Asthma (relative contraindication), 2nd or 3rd degree heart block, Atrial fibrillation, atrial flutter, Ventricular tachycardia, Sick sinus syndrome, Stokes-Adams Attack, Wolf-Parkinson-White syndrome, bradycardia with Premature Ventricular Contractions (PVCs).

In Wolf-Parkinson-White syndrome adenosine may be administered if equipment for cardioversion is immediately available as a backup. SIDE EFFECTS: 1. Facial flushing, 2. Lightheadedness, 3. Asystole, 4. Diaphoresis 5. Nausea.

Milirone 1ml= 1mg 1ampule = 10ml= 10mg= 10000 mcg

MORPHINE Analgesic INDICATION: Analgesia Pulmonary edema (1-5mg I/V may repeat every 5minutes up to 10mg) CONTRAINDICATION: Head injury Excerbated COPD Hypotension Decrease LOC SIDE EFFECTS: Respiratory depression Decreased BP Decrease LOC Decreased HR OVERDOSE MAY BE REVERSED WITH NALOXONE.

IABP (INTRA AORTIC BALLOON PUMP) IABP is put in desending aorta. Inflate in diastole

Intra aortic balloon (IAB) during systole and diastole

INDICATION: Carcinogenic shock Left ventricular failure Unstable angina, Failure to separate a patient from cardiopulmonary bypass and prophylactic applications including stabilization of preoperative cardiac patients as well as stabilization of preoperative non cardiac surgical patients Procedural support during coronary angiography and PTCA Bridge to heart transplantation septic shock and drug induced cardiovascular failure

CONTRAINDICATION: Acute trauma to the descending aorta Aortic regurgitation (mild - severe ) severe peripheral vascular disease aortic dissection severe aortic valvuler insufficient irreversible brain damage PURPOSE: life save procedure(bridging procedure should be implanted than only planned to do some invasive / surgery procedure)

It increases the coronary perfusion by diastolic augmentation & decrease the after load.

BLOOD GASES: NORMAL ARTERIAL VALUES: PH - 7.35-7.45mm of Hg PO2 - 85-100 mm of Hg PCO2 - 35-45 mm of Hg SPO2 - 96-100% HCO3 - 22-26 mEq/L SN. 1. 2. 3. 4. 5. pH Low High Low High Low PaCo2 High Low normal normal Hco3 Normal Normal low high high Acid base inbalance Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis Resp. acidosis with Metabolic compensation

Normal Venous Value: PH - 7.31-7.41mm of Hg PO2 - 30-40 mm of Hg PCO2 - 41-51 mm of Hg SPO2 - 60-85% HCO3 - 22-29 mEq/L GLASGOW COMA SCALE: EYE OPENING: Spontaneously- 4 To command-3 To pain 2 No response 1 VERBAL RESPONSE Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible 2 No response 1 MOTOR RESPONSE: Spontaneously- 6 Localize pain 5 With draws from pain 4 Flescion 3 Extension 2 No response 1

NORMAL GCS: 15/15 MINIMUM: 03/15

PRESSURE SORE (BED SORE) DEFINITION: A pressure sore is the result of tissue necrosis caused by impairment of the local blood supply . it can occure on any part of the body which bears the body weight for prolonged period thus impairing the blood flow to the area. As conscious patient constantly keep changing his position, it occurs in those who cant control their movement . Most prominent pressure points are: occipital scapula spine- spinus process sacrum coccyx crest greater & lesser trochanters
VENTRICULAR TACHYCARDIA (VT) CAUSE VT is the most frequently encountered life threatening arrhythmia. CRITICAL Prompt recognition and acute Rx. It is defined as a series of 3 or more ventricular complexes at a rate of 100-250bpm. The origin of activation is within the ventricle. Wide QRS (<120ms) T wave polarity opposite that of major QRS Sustained VT- tachycardia lasting>30 secs with haemodynamic compromise. Monomorphic VT- single QRS morphology Polymorphic VT- ever changing QRS morphology. CAD with MI ( most common) Nonischaemic cardiomyopathies Infiltrative disease Infectious disease Congenital myocardial defects SLE RA

SYMPTOMS Asymptomatic Palpitation Breathlessness Lightheadedness Syncope Angina

# may degenerate to VF resulting in haemodynamic collapse and death. Therapy Synchronized DC cardioversion for sustained VT with hemodynamic compromise, severe HF or ongoing ischemia or infarction. Pharmacologic cardioversion (lidocaine, brtylium, amiadarone- for stable VT). # Lidocaine- class 1b: effect on fast Na+ channels. # Amiadarone- class III: prolong action potential duration.

Ventricular fibrillation Rapid, repitative activation of the ventricles from multiple coalescing and fractionating wave fronts of depolarization. Associated with disorganized mechanical contraction, haemodynamic collapse and sudden death. ECG: irregular and rapid iscillations (250-400bpm) or variable amplitude without uniquely identifiable QRS complexes or T waves.

THERAPY Unsynchronized DC CV- Primary. Continuous IV infusion with antiarrythmic drugs. # VF occurring within the first 72 hours of an acute MI is not associated with an elevated risk of recurrence and does not require antiarrythmic therapy. #VF without identifiable cause- implantation of automatic defibrillator. ECG Coarse VF (chaotic, irregular electrical activity.) Fine VF (low amplitude, irregular activity.)

V1- 4th interspace, just to the right of the sternum. V2- 4th interspace, just to the left of the sternum. V3- halfway between V2 and V4. V4- 5th intercostals space, mid clavicular line. V5- anterior axillary line, horizontal with V4. V5- mid axillary line , horizontal with V

MCL1- red lead on V1, black lead on left arm- lead 3 Mcl6- red lead on V6, black lead on left arm lead 3 Mc4R- red lead on 5th ICS right mid clavicular line, black lead on left arm

DIABETES MELLITUS Definition: Disorder of carbohydrate metabolism caused by relative or absolute deficiency of Insulin. Diagnosis: Symptoms with Plasma Glucose >200mg/dl or FBS> 126 mg/dl in two occasion. Glycosylated Hemoglobin A1c (HgA1C) - Produced by nonenzymatic condensation of glucose molecules with free amino groups on the globin component of hemoglobin. It is not used for diagnosis but for follow up compliance treatment and glucose control. Goal < 7% First Line therapy: SU 2. Biguanides 3. Thiazolidinediones

INSULIN INFUSION Preparation Add 50 units (R) insulin in 50 ml NS According to RBS Bolus dose if more than 200 Bolus Dose = BS/100 units Regular Insulin IV Maintenance dose BS/100 units Regular Insulin per hr. Note for patients with PO Diet Patient should receive Regular Insulin 0.05-0.1 units/kg/meal And IV infusion rate should not be increased to cover meals. Pre meal Correction Dose Algorithm Pre meal BS Additional Insulin 150-200 2 units 200-250 4 units 250-300 6 units >300 Start Infusion Post Meal Correction dose Algorithm Postmeal BS Additional Insulin 4 units 6 units 8 units >300 Start Infusion Considerations IF Pt on Infusion RBS monitoring 1 hrly. If Pt on Sliding scale RBS monitoring 4-6 hrly, Sugar Profile = FBS + Pre and Post meal (BBF, L, D) by GM or Lab. Always remember 2am sample to be sent when doing Sugar profile. Alert for Symptomatic Hypoglycemia, Hyperglycemia. HYPOGLYCEMIA Defination: Plasma glucose of <2.5 mmol/L or 45mg/dl associated with symptoms of neuroglycopenia .

Clinical features: Adrenergic symptoms: pallor, sweating, tremor, tachycardia Neuroglycopenic symptoms: Poor concentration, double vision, irritability, violent behavior, changes in personality, seizures and coma. Majority of symptoms of acute hypoglycemia are adrenergic but neuroglycopenic symptoms occur with subacute and chronic hypoglycemia. Deterioation in neuropsychological performance occurs at 54-63 mg/dl, subjective perception at 48.6-52.2 mg/dl and EEg changes at 36mg/dl. Management: If unconscious 25-50 ml of 50% glucose iv into large vein, followed by saline flush as high concentration of glucose is irritant. OR Glucagon 1mg im if no iv access. Effect lasts 30mins. However it is ineffective in hepatic dysfunction and alcohol related hypoglycemia. Oral glucose is ideal, should be administered as soon as patient is alert and conscious. Secondary cerebral edema should be considered in case of prolonged coma despite normalization of plasma glucose. Mannitol or dexamethasone may be helpful.

DRUGS SULFONYLUREA Glyburide, Glipizide, Glimiperide, Gliclazide Tolbutamide, Choloropromide

Brand Name

MODE OF ACTION Increases Insulin secretion

SIDE EFFECTS Hypoglycemia

DOSE

Amaryl, Glucoryl Zoryl Glycigon Glizid

Hypoglycemia

1, 2, 3, 4

choloroformin

Hypoglycemia Steven J. syndrome CI- RF & HF Increases endogenous Insulin Secretion Decreases glucose production from liver Hypoglycemia GI intolerance CI- RF. LD. Lactic Acidosis Hypoglycemia GI, Edema, CI- HF Edema, WT Gain, Osteoporosis, visual disturbance, CI- HF, DKA Flatulance, diarrhea CI- RF & LD

10mg

NON SULFONYLUREA BIGUANIDES Metformin Glyciphage Glycomet Metlong Riomet

500mg 1000mg

THIAZOLIDINE Rosiglitazone Pioglitazone Increases Insulin Sensitivity

2mg 4 mg 10mg 15mg 30mg

Alpha Glucosidase Inhibitor Acarbose

Glycubay, Diabose Glubose

25mg 50mg

Meglitinides Repaglinide Nateglinide

Hypoglycemia GI Intolerance CI- HI, DKA

0.5mg 1mg 2mg

Hepamerz (L Ornithine L Aspartate Infusion) Indications: Treatment for hyperammonemia as a result of acute and chronic liver disease; especially for disturbances of consciousness (precoma) or neurological complications (HE). It enhances the detoxification of the urea cycle. Contraindications: Severe Renal insufienciency (Serum creatinine > 3mg/100ml) Side Effect: GI discomfort, Dosage and administration: Unless prescribed otherwise 4 ampules daily. High grade of HE COMA 8 ampules daily

HYPERKALEMIA: DEFINITION: It is defined as potassium level greater than 5.5 mmol/L. Ranges are as follows: 5.5-6.0mmol/L mild condition 6.1-7.0mmol/L moderate condition 7.0mmol/L & greater severe condition CAUSES: Ac.& chronic Renal failure Drugs ACE I, potassium sparing drugs like spironolactone, aldactone Massive blood transfusion Rhabdomyolosis Burns Metabolic Acidosis SIGN & SYMPTOMS: 1. AV block / bradycardia 2. Cardiac arrest 3. Tall tended T wave in ECG MANAGEMENT: discontinue potassium-sparing drugs or dietary potassium find out the causes & correct check urine output Monitor K+ level frequently take the ECG monitor the pt in cardiac monitor 10 % calcium gluconate 10 mg I/V over 5 mins 50ml 50% dextrose with 10 unit insulin give than check k+ level after 30 mins. 5% D with 10 U insulin Mild Hyperkalemia <5.5mmol/L Restrict Potassiumintake Mod Hperkalemia 5.5-6.5mmol/L Kalimate Sachet in water TDS Diuretics- Frusemide 40-80mg B-2 agonist (salbutamol) nebulisation Severe Hyperkalemia > 6.5mmol/L 1.Glucose- Insulin:50ml of 50% Dex in water + 10U RI slow IV in 5min 500ml of 10% Dext +10U RI 2.5% Calcium gluconate 10ml IV slow 3.Sodium Bicarbonate 1amp in 10cc D5W slow in 10min 4. Salbutamol Nebulisation

Hypokalemia
Etiology: Diarrhea, laxative abuse, diuretics, vomiting, Renal tubular acidosis, Hypertension (Hyperaldosteronism, glucocorticoid excess), Hypokalemic Periodic paralysis, Hyperthyroidism Management: Identify etiology, Level Of Renal Function, Assess Acid Base Balance, Assess and correct level of magnesium, Estimation of Potassium Deficit: 1.4.0-3. meq/L--- Body deficit is 200-300meq/70kg body wt 2. 2.5 meq/L---- 500meq/70kg body wt 3. 2.0 meq/L---- 700meq/70kg body wt Oral route- Oral KCL 15-30cc TDS IV route- Peripheral vein is better than Central Vein.10-20meq/hr, cautions: higher concentrations burn of KCL may cause skin burn.

HYPONATREMIA
DEFINITION: It is defined as a serum sodium concentration is less than 130 mEq / L in the blood. Normal value of sodium is 135-145mmol/L CAUSE: Excessive perspiration, 2.Excessive intake of water 3. Gastro - intestinal suction 4. prolong use of diuretics 5. Diarrhea\ vomiting SIGN & SYMPTOMS: Confusion, 2. Seizures, 3.hypertension, 4.rapid weak pulse, 5.abdominal cramp

Serum Osmolality=2Na+Glucose/1.8+BUN/2.8 mosm/kg H2O

Normal (280-295) Hyperlipidemia, hyperproteinemia Low (<280) Hypovolemia Urine Na UrineNa >20mg/L <10mg/L Dehydration Vomiting Diarrhea Isotonic solution Diuretics ACE Isotonic solution High (>295) Hyperglycemia Mannitol

Euvolemia Urine Na Urine Na >20mg/L <10mg/L SIADH Hypothy Renal F Addisons Polydipsia water intoxication

Hypervolemia Urine Na Urine Na >20mg/L <10mg/L ARF CRF CHF, Liver cirrhosis, Nephrotic syndrome Tx- water Restriction

Tx- water Restriction

Hypovolemia: Sodium deficit = 0.6 x weight in kg x (Desired Na- Actual NA) Correct at a rate not > 0.5 meq/liter/hr Give 50% of calculated Amt sodium in 1st 8 hours and other 50% in next 16hrs Avoid sudden Correction because of Central Pontine Myelinosis. Use NS, Do not give hypotonic fluid until serum sodium is >125

EUVOLEMIA: Acute Treatment (Na<120) 1.PNSS 1L x 10hrs + 20meq/KCL, 2. High salt diet 8gm NaCl /day, 3. Furosemide Chronic treatment Restrict Water, Keep sodium Levels > 120 Hypervolemia 1.Restrict water, 2. Salt restriction of 2gm/d 3.Diuresis

Atrail Fibrillation: Atrial fibrillation (AF or A-fib) most common cardiac arrhythmia (abnormal heart rhythm), and involves the two upper chambers (atria) of the heart. Its name comes from the fibrillating (i.e., quivering) of the heart muscles of the atria, instead of a coordinated contraction. However, a stronger indicator of AF is the absence of P waves on an electrocardiogram (ECG or EKG). In AF, the normal electrical impulses that are generated by the sinoatrial node are overwhelmed by disorganized electrical impulses that originate in the atria and pulmonary veins, leading to conduction of irregular impulses to the ventricles that generate the heartbeat. People with AF usually have a significantly increased risk of stroke (up to 7 times that of the general population). Stroke risk increases during AF because blood may pool and form clots in the poorly contracting atria and especially in the left atrial appendage (LAA). Atrial fibrillation may be treated with medications which either slow the heart rate or revert the heart rhythm back to normal. Synchronized electrical cardioversion may also be used to convert AF to a normal heart rhythm. Surgical and catheterbased therapies may also be used to prevent recurrence of AF in certain individuals. People with AF are often given anticoagulants such as warfarin to protect them from stroke. Classification AF Category First detected Paroxysmal Persistent Permanent Defining Characteristics only one diagnosed episode recurrent episodes that self-terminate in less than 7 days. recurrent episodes that last more than 7 days an ongoing long-term episode

Lone atrial fibrillation (LAF) - absence of clinical or echocardiographic findings of other cardiovascular disease (including hypertension), related pulmonary disease, or cardiac abnormalities such as enlargement of the left atrium, and age under 60 years Nonvalvular AF - absence of rheumatic mitral valve disease, a prosthetic heart valve, or mitral valve repair Secondary AF - occurs in the setting of a primary condition which may be the cause of the AF, such as acute myocardial infarction, cardiac surgery, pericarditis, myocarditis, hyperthyroidism, pulmonary embolism, pneumonia, or other acute pulmonary disease

Causes: chest pain or angina, hyperthyroidism, weight loss, diarrhea, lung disease, stroke or TIA, hypertension , diabetes, heart failure and rheumatic fever. coronary artery disease, rheumatic heart disease, mitral valve prolapse, mitral regurgitation, hypertrophic cardiomyopathy (HCM), pericarditis, congenital heart disease, previous heart surgery, Lung diseases (such as pneumonia, lung cancer, pulmonary embolism, sarcoidosis), Excessive alcohol consumption ("binge drinking" or "holiday heart syndrome, Hyperthyroidism, Carbon monoxide poisoning, Dual-chamber pacemakers in the presence of normal atrioventricular conduction.A family history of AF may increase the risk of AF, Friedreich's ataxia

R- Rheumatic Heart Disease I- Ischemic Heart disease T- Thyroid H-Hypertension (Most Common) A- Alcohol Management Main article: Management of atrial fibrillation The main goals of treatment are to prevent circulatory instability and stroke. Rate or rhythm control are used to achieve the former, while anticoagulation is used to decrease the risk of the latter.] If cardiovascularly unstable due to uncontrolled tachycardia, immediate cardioversion is indicated. Anticoagulation Anticoagulation can be achieved through a number of means including the use of aspirin, heparin, warfarin, and dabigatran. Rate control versus rhythm control using drugs There are two ways to approach these symptoms using drugs: rate control and rhythm control. Rate control seeks to reduce the heart rate to one that is closer to normal, usually 60 to 100 bpm, without trying to convert to a regular rhythm. Rhythm control seeks to restore with cardioversion the regular heart rhythm and maintain it with drugs. Studies suggest that rhythm control is mainly a concern in newly diagnosed AF, while rate control is more important in the chronic phase. As far as mortality is concerned, the AFFIRM trial showed that there is no statistical difference with rate control treatment versus rhythm control treatment. In patients with a fast ventricular response, intravenous magnesium significantly increases the chances of successful rate and rhythm control in the urgent setting without significant side-effects. A patient with hemodynamic instability, mental status changes, preexcitation, or angina will require urgent synchronized DC cardioversioN. Otherwise the decision of rate control versus rhythm control using drugs is made. This is based on a number of criteria that includes whether or not symptoms persist with rate control. Rate control Rate control is achieved with medications that work by increasing the degree of block at the level of the AV node, effectively decreasing the number of impulses that conduct down into the ventricles. This can be done with :

Beta blockers (preferably the "cardioselective" beta blockers such as metoprolol, atenolol, bisoprolol, nebivolol) Non-dihydropyridine calcium channel blockers (i.e. diltiazem or verapamil) Cardiac glycosides (i.e. digoxin) - have limited use, apart from in the sedentary elderly patient

In addition to these agents, amiodarone has some AV node blocking effects (particularly when administered intravenously), and can be used in individuals when other agents are contraindicated or ineffective (particularly due to hypotension). Diltiazem has been shown to be more effective than either digoxin or amiodarone. Cardioversion Cardioversion is a noninvasive conversion of an irregular heartbeat to a normal heartbeat using electrical or chemical means. Electrical cardioversion involves the restoration of normal heart rhythm through the application of a DC electrical shock. Chemical cardioversion is performed with drugs, such as amiodarone, dronedarone, procainamide, ibutilide, propafenone or flecainide. Vernakalant has been found to safely and rapidly covert new onset atrial fibrillation.

Ablation If rhythm control is desired and cannot be maintained by medication or cardioversion then catheter ablation may be attempted.

Prognosis Thromboembolism CHADS score In atrial fibrillation, the lack of an organized atrial contraction can result in some stagnant blood in the left atrium (LA) or left atrial appendage (LAA). This lack of movement of blood can lead to thrombus formation (blood clotting). If the clot becomes mobile and is carried away by the blood circulation, it is called an embolus. An embolus lodged in an artery of the brain results in a stroke or transient ischemic attack (TIA). The formation of a thrombus, movement of the embolus, and plugging of an artery, is called a thromboembolism. The LAA is the site of thrombus formation in more than 90% of cases of thrombi associated with non-valvular atrial fibrillation. However, the LAA lies in close relation to the free wall of the left ventricle and thus the LAA's emptying and filling, which determines its degree of blood stagnation, may be helped by the motion of the wall of the left ventricle, if there is good ventricular function. If the LA is enlarged, there is an increased risk of thrombi that originate in the LA. Moderate to severe, nonrheumatic, mitral regurgitation (MR) reduces this risk of stroke. This risk reduction may be due to a beneficial stirring effect of the MR blood flow into the LA. Mitral valve The somewhat circular perimeter of the mitral valve is defined by the mitral annulus. Atrial fibrillation and a corresponding enlargement of the left atrium may cause an increase in the size of the mitral annulus. With a normal sinus rhythm, the mitral annulus undergoes dynamic changes during the cardiac cycle. For example, at the end of diastole the annular area is smaller than at the end of systole. A possible reason for this dynamic size difference is that the coordinated contraction of the left atrium acts like a sphincter about the mitral annulus and reduces its size. This may be important for mitral valve competence so that it does not leak when the left ventricle pumps blood. However, when the left atrium fibrillates, this sphincter action is not possible and may contribute to, or result in, mitral regurgitation in some cases.

CHADS2 score Condition C Congestive heart failure Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on H medication) A Age 75 years D Diabetes Mellitus S2 Prior Stroke or TIA Points 1 1 1 1 2

The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with nonrheumatic atrial fibrillation (AF), a common and serious heart arrhythmia associated with thromboembolic stroke. It is used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy. CHA2DS2-VASc C H A2 D S2 V A Sc Condition Points Congestive heart failure (or Left ventricular systolic dysfunction) 1 Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on 1 medication) Age 75 years 2 Diabetes Mellitus 1 Prior Stroke or TIA or thromboembolism 2 Vascular disease (eg. peripheral artery disease, myocardial infarction, aortic plaque) 1 Age 65-74 years 1 Sex category (ie female gender) 1

The CHA2DS2-VASc score is a refinement of CHADS2 score and extends the latter by including additional common stroke risk factors, as discussed below. The maximum CHADS2 score is 6, whilst the maximum CHA2DS2-VASc score is 9. Stroke Risk Assessment, and Antithrombotic Therapy Annual Stroke Risk[2] CHADS2 Score Stroke Risk % 95% CI 0 1.9 1.23.0 1 2.8 2.03.8 2 4.0 3.15.1 3 5.9 4.67.3 4 8.5 6.311.1 5 12.5 8.217.5 6 18.2 10.527.4 According to the findings of the initial validation study, the risk of stroke as a percentage per year for the CHADS2 score is shown in the Table. The CHADS2 score does not include some common stroke risk factors and its various pros/cons have been carefully discussed [4]. Nonetheless, this score is simple and thus, it has become widely used. To complement the CHADS2 score, by the inclusion of additional 'stroke risk modifier' risk factors, the CHA2DS2-VASc score has been proposed [5]. These additional non-major stroke risk factors include age 65-74, female gender and vascular disease. In the CHA2DS2-VASc score score, 'age 75 and above' also has extra weight, with 2 points. The CHA2DS2-VASc score has been used in the new European Society of Cardiology guidelines for the management of atrial fibrillation [6]. The European Society of Cardiology (ESC) guidelines recommend that if the patient has a CHADS2 score of 2 and above, oral anticoagulation therapy (OAC, eg. with warfarin(INR2-3) or one of the new OAC drugs, such as dabigatran)should be prescribed. If the CHADS2 score is 0-1, other stroke risk modifiers could be considered: (i) If we have 2 or more risk factors (essentially a CHA2DS2-VASc score score of 2 or more), OAC is recommended; and (ii) If we have 1 risk factor (essentially a CHA2DS2-VASc score score=1), antithrombotic therapy with OAC or aspirin (OAC preferred) is recommended, and patient values and preferences should be considered. If patients have a CHA2DS2-VASc score score=0, such patients are truly low risk[7][8], and thus, the recommendation is to prescribe either aspirin or no antithrombotic therapy, but 'no antithrombotic therapy' is preferred[9].

Stroke risk assessment should always include an assessment of bleeding risk. This can be done using validated bleeding risk scores, such as the HEMORR2HAGES or HAS-BLED scores. The latter is recommended in the ESC and Canadian guidelines[10]. If the patient is taking warfarin, then knowledge of INR control is needed to assess the 'labile INR' criterion in HAS-BLED; otherwise for a non-warfarin patient, this scores zero. [edit] Anticoagulation based on the CHADS2 score Anticoagulation Score Risk Considerations Therapy 0 Low Aspirin Aspirin daily Aspirin daily or raise INR to 2.0-3.0, depending on factors 1 Moderate Aspirin or Warfarin such as patient preference Raise INR to 2.0-3.0, unless contraindicated (e.g. clinically 2 or Moderate or Warfarin significant GI bleeding, inability to obtain regular INR greater High screening) Treatment strategies recommended based on the CHADS2 score are shown in the table [1][2]. How the treatment recommendations based on the CHADS2 score are modified by considering additional 'stroke risk modifier' risk factors using the CHA2DS2-VASc score, see ESC guideline recommendations, which recommend the management as shown in the following table: [edit] Anticoagulation based on the CHA2DS2-VASc score Anticoagulation Score Risk Considerations Therapy No antithrombotic 0 Low No antithrombotic therapy (or Aspirin 75-325mg daily) therapy (or Aspirin) Oral anticoagulant, either new oral anticoagulant drug eg Oral anticoagulant (or dabigatran or well controlled warfarin at INR 2.0-3.0 (or 1 Moderate Aspirin) Aspirin 75-325mg daily, depending on factors such as patient preference) Oral anticoagulant, using either a new oral anticoagulant 2 or High Oral anticoagulant drug (eg dabigatran) or well controlled warfarin at INR 2.0greater 3.0 Based on the ESC guidelines on Atrial Fibrillation, OAC is recommended or preferred for patients with one or more stroke risk factors (ie. a CHA2DS2-VASc score of 1 and above). This is consistent with a recent decision analysis model showing how the 'tipping point' on the decision to anticoagulate has changed with the availability of new 'safer' OAC drugs [11].

Chronic Renal Failure: Etiology : Chronic glomerularnephritis, Chronic pyelonephritis, DM, Polycystic disease, HTN, Drugs 1.Chronic Renal Failure: Decrease glomerular filtration rate or Increased Creatinine>3months Small Kidney size <10cm and increased echogenicity Anemia in absence of blood loss Creatinine Clearance = 140- Age x Weight (Kg) / (72 in males, 85 in females) x serum creatinine (mg/dl)