SAH treatment

Medical stabilization is aimed at preventing early complications, including brain edema, hydrocephalus, and rebleeding, as well as the late complication of vasospasm. Treatment options include bed rest with elevation of the head of the bed to 30 degrees, nimodipine (a calcium channel blocker to prevent vasospasm), seizure prophylaxis, antiemetics, analgesia, and labetalol or other agents as needed for blood pressure control.

Bronchiectasis

check out the following video for Bronchiectasis CXray...

http://www.youtube.com/watch?v=Kk4x7DPJtRI&feature=player_embedded

Hypertensive emergency

Case: we had one patient presented with epistaxis from left nose and blood pressure of 210/130--------pt had nasal septum surgery 1 week back.....pt dint have any altered consciousness nor pappiloedema...U/a was normal...
Dx: As there is vascular injury but no end organ damage..so he has hypertensive urgency...
Rx: he was give hydralazin...bp came down to 160/100..... was given anterior nasal packing and Abx for nasal packing: ampi+sulbactam....
after 2 days he improved and was discharged...


A sudden rise in blood pressure to >180/120 mm Hg that is associated with end-organ damage is termed a hypertensive emergency

• Accelerated HTN is a sudden, marked elevation in blood pressure associated with end-organ damage but no papilledema (although retinal hemorrhage and exudates are often present).
• Malignant hypertension is a sudden, marked elevation in blood pressure accompanied by end-organ damage including papilledema.
• Hypertensive encephalopathy is a malignant HTN accompanied by cerebral edema, which presents with headache, nausea, vomiting, restlessness, and confusion.
  
  Hypertensive encephalopathy versus stroke: Onset is usually sudden in ischemic or hemorrhagic stroke but insidious in hypertensive encephalopathy..
  
  
  What is the difference between urgency and emergency?
  Urgency denotes severe hypertension (HTN), typically with diastolic blood pressure (DBP) > 130 mmHg, without symptoms or evidence of end-organ damage. The term accelerated hypertension falls in this category, where retinal exudates and hemorrhages are often present.
  Emergency is an acute, life-threatening elevation in BP with evidence of vascular injury + end-organ damage. The term malignant hypertension falls in this category, typified by papilledema.
  
  
  What causes the end-organ damage?Failure of autoregulation to regulate pressure in the arterioles and capillaries with increasing HTN results in disruption of the vascular endothelium. Fibrinoid necrosis results from deposition of plasma elements in the vascular wall, causing narrowing of the vascular lumen. Tissue ischemia as well as leakage of blood and plasma from affected vessels then results, causing end-organ damage.
  
  
  
  What is the treatment for specific hypertensive emergencies?
  

  Goal is the rapid lowering of mean arterial pressure by approximately 20-25% or to a DBP of 100-110 mmHg over 2-6 hours. However, in aortic dissection, the goal is to lower SBP to 100-120 mmHg and MAP below 80 mmHg ASAP, while patients with acute ischemic stroke or hypertensive encephalopathy may require slightly higher BP initially due to cerebral autoregulation.

  
  

  Malignant hypertension with retinal changes and/or hypertensive encephalopathy - Treatment of choice is a rapid, short-acting IV agent, such as nitroprusside (dose: 0.25-0.5 m g/kg/min to a max of 8-10 m g/kg/min; acts within seconds and lasts only a few minutes). Acts as both a veno- and vasodilator. Limited by cyanide or thiocyanate toxicity, especially with prolonged use or in renal insufficiency; do not use for more than 48 hours if possible (antidote is sodium thiosulfate). Other rapid-acting IV agents include labetolol (20mg IV bolus, 0.5-2 mg/min IV gtt), which is both an alpha- and beta-adrenergic blocker; and nicardipine (5-15 mg/hr IV gtt), which is a peripherally-acting calcium-channel antagonist. A newer medication, fenoldopam (0.1-1.6 m g/kg/min IV gtt), which is a pure dopamine agonist, has the advantage increasing renal blood flow and sodium excretion.

  What about hypertensive urgency?
  
  

  The goal is a reduction in blood pressure to 160/110 over several hours with conventional oral therapy. The oral medication used may vary with the clinical scenario - for example, beta-blockers and nitrates would be preferred in patients with coronary disease, while ACE-inhibitors might be useful in patients with a history of diabetes, scleroderma, or congestive heart failure. Loop diuretics are often very helpful initially in asymptomatic patients who are not volume-depleted. Nifedipine is generally not recommended due to rapid hypotension and possible precipitation of ischemic events, while clonidine often causes sedation and dry mouth as well as orthostatic hypotension and may require careful monitoring. There is no proven benefit in the rapid reduction of blood pressure in asymptomatic patients with severe HTN.

  
  

  
  

  check out this link for info: http://intmedweb.wfubmc.edu/blurbs/cards/hypertensive.html

Cold air causing cough

One of my friend always complain that her son starts coughing if he is exposed to cold air/windy weather....I saw him coughing even if he passes frozen section in grocery stores....

The cold weather cough can be caused from a couple of sources.

When you breath in cold air, your lungs contract (tighten) just like any tissue does when exposed to cold. Once you come inside and start breathing warm air, the lung tissue rapidly expands. That sudden expansion can cause the cough reflex. It is a similar reaction to what new runners experience when their lungs start to grow and expand. You'll often see new runners chuging along and hacking out a few coughs.


Your body will work as best it can to deal with the sudden change as best as it can. Taking a moment to cool down before heading inside is excellent advice. If you have a garage or somewhere that would serve as a step between the two extreme temps it would be a good place to cool down in. (Assuming there aren't too many fumes from cleaners etc. in there.)

Only other thing that comes to mind is to try and inhale through your nose while you are cooling down. Conchae inside your nose that serve to adjust the temp/humidity of your inhaled breath to a more acceptable level. They also work as a bit of a 'screen' or filter to help keep some of the junk we breathe out of your lungs.

I'm guessing the tea/coffee you drink would assist your upper airway (mouth/nose) in warming the air you inhale by increasing the temperature in those areas. 

Renal

Some Lab Values to remember

1. Acute Renal Failure:  When Cr starts increasing at a rate > 0.3mg/dl/ 48 hrs...or increase in s.Cr by 25% from baseline..
2. BUN/ Cr ratio:   10-15-----------------Intrarenal etiology,     <10 ------------------Pre renal
3. Normal Cr-  0.7 to 1.2 mg/dl ( but in pregnance it never goes more then 1mg/dl)
4. Normal BUN  = 20 to 24
5. Normal GFR = 120 ml/ min

• Whne pt is having ARF dont forget to check serum k+ level..give keyxalate and insulin+ d50.
• In diabetic patient keep checking Urine protein, microalbumiuria--------if present suggest low protein, Low salt diet and Give ACE inhibitors...maintain blood glucose level...also check for retinopathy which is uaually associated with diabetic nephropathy
• In hypertensive patient also check for proteinuria...
• in chronic renal failure pt, donr forget to prescribe Vit D and Iron.
• The fractional excretion of sodium (FENa) is useful in diagnosing pre-renal ARF. FENa is less than 1 % in many patients with prerenal ARF. Intravenous hydration is the mainstay of treatment.

NASH

obese pt with elevated LFTs but normal viral hepatitis profile and not taking hepatitis induced medication ...

with elevated lipid profile-----------consider Non alcoholic steatotic hepatitis....

Hepatitis c and Alcohol abuse

we all know that treatment of Hep c is INF and Ribavarin but if pt is alcoholic dont start the treatment ....send him for drug abuse counselling...once pt stops EToh ---u can start treatment