WRIST , DIGITAL , PENILE , FACIAL BLOCK

WRIST , DIGITAL , PENILE , FACIAL BLOCK

=================================
WRIST BLOCK
=================================

(Reference:
https://osler.ucalgary.ca/ume/proskills/NBlockWrist/NBWristArticle.htm
http://bentollenaar.com/_MM_Book/Ch.17.htm)

(Netter 461, 467, 468 참조)

Injection for the Median Nerve
-----------------------------
Find the Palmaris longus, at 1cm proximal to the distal wrist flexion crease.
[The Palmaris longus can be found as follows:
find the radial artery, roll your fingers toward the ulnar side to feel for the first tendon
(this will be the flexor carpi radialis), now roll and feel for the second tendon which will be the Palmaris longus.]
(Note that palmaris longus may be absent in some people)

Move and aim just off the radial side of the Palmaris longus (and medial to the flexor carpi radialis).
Insert the needle perpendicularly and advance slowly until a ‘pop’ through the transverse carpal ligament (aka flexor retinaculum).

Inject 3-5mL just deeper than the Palmaris longus tendon.

Inject some subcutaneously to block superficial branch of median nerve.


Injection for the Ulnar Nerve
-----------------------------

Two ways: lateral approach and volar approach (volar approach is more difficult and is omitted here)

Lateral Approach:

At the proximal palmar crease, insert the needle on the ulnar aspect of the flexor carpi ulnaris tendon.
[The flexor carpi ulnaris can be found as follows: find the ulnar artery, and roll your fingers in an ulnar direction over the first tendon

which will be the flexor carpi ulnaris.]

Advance horizontally under the tendon 1.0-1.5cm (paresthesia should be elicited to confirm proper position close to the nerve within

the thick neurovascular bundle). Alternatively, advance the needle toward the ulnar bone deep to the flexor carpi ulnaris and inject

as needle is being withdrawn.

Cutaneous nerves branch off the ulnar nerve to wrap around the wrist and supply the dorsum of the hand. Block these with a 5-10mL

SQ(subcutaneous) band of anesthetic from the lateral boarder of the flexor carpi ulnaris to the dorsal midline. Note: if the lateral

approach is used, the same injection site can be used to block these dorsal branches.


Injection for the Radial Nerve
-----------------------------

Block branches with a 5-10mL SQ band of anesthetic from the primary injection site to the dorsal midline


주의
------------------------------

Nerve 안에 주사하면 안됨. (causes intense pain)

Nerve 주위에 주사하는 것임. (causes sensation of pins and needles)


(Elicitation of Paresthesias

It is important to ascertain that the needle is making contact with the nerve rather than penetrating it, and that the injection is in

proximity to the nerve (perineural) rather than within its substance (intraneural).
The high pressures generated by a direct intraneural injection can cause hydrostatic (ischemic) injury to nerve fibers. A perineural

injection may produce a brief accentuation of the paresthesia, whereas an intraneural injection produces an intense, searing pain

that serves as a warning to immediately terminate the injection and reposition the needle.
Pain intensity and duration help differentiate between accentuation and intraneural injection.)


Local anesthetic
---------------------------------

Lignocaine(Xylocaine):
-onset: 2~5 min
-duration: 1 hr
-max dose: 3 mg /kg

Bupivacaine(Marcain):
-onset: 15 min
-duration: 4 hrs
-max dose: 2 mg /kg


=================================
DIGITAL BLOCK
=================================

http://www.youtube.com/watch?v=25kZWI_MYrg


=================================
PENILE BLOCK
=================================

Key anatomical area:
The triangular space lying deep to the fascia, bounded above by the symphysis pubis and below by the corpora cavernosa

Area to watch out:
Avoid 12 o'clock dorsum - has vessels. if penetrated can cause hematoma.

The technique involves inserting the needle until ittouches the pubic symphysis.  This gives a guide todepth.
The needle is then withdrawn and redirected to pass below the symphysis and 3-5 millimetres deeper depending on the size of the patient. It is preferable to direct it slightly laterally into the pear shaped space and then to re-insert in on the other side depositing equal volumes on each side. Avoiding the midline injection reduces the chance of penetrating the dorsal vessels of the penis and causing haematoma. If a short beveled needle the fascia may be felt as a slight resistance when it is penetrated, but in small children this is not always felt as it is thin and may offer little resistance.

(reference:
http://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&ved=0CDMQFjAB&url=http%3A%2F%2Fupdate.anaesthesiologists.org%2Fwp-content%2Fuploads%2F2009%2F10%2FPenile-Block.pdf&ei=dOmoUeCcLqKu7AbEzYHIDg&usg=AFQjCNGH4R1wqGV4e94fC-noyknDWV4vcQ&sig2=EH8mZAFk-afpO7MRhJsN3A
http://pgmedic.blogspot.com/2011/11/dorsal-penis-block.html)

=================================
FACIAL BLOCK
=================================

 

(REFERENCE:

 http://johnpaoli.com/post/459714022/facial-nerve-blocks-injection-sites-and)

Erythema nodosum / Behcet's disease

===================
Erythema nodosum
===================

In the majority of cases,
painful,
erythematous nodules
develop on the anterior surfaces of both legs,
that resolve without scarring over a two- to eight-week period.

Polyarthralgia, fever, and malaise frequently accompany the eruption.
erythrocyte sedimentation rate is often elevated.

antistreptolysin-O titer


Cause:
-------
streptococcal pharyngitis is the most common cause of erythema nodosum.
Erythema nodosum and hilar adenopathy: consider - sarcoidosis, TB, etc as the cause
oral contraceptives


=================
Behcet's disease
=================

clinical features:
---------------
oral ulcer / genital ulcer / erythema nodosum
uveitis / red eye

(unlike other erythema nodosum cases, Behcet's-associated lesions may ulcerate.)

Lab tests:
There is no lab test to confirm Becet's disease.
But exclude other conditions. In Becet's:
ANA is negative
RF is negative

{ 간단히

-ANA: neg
-RF: neg
}

Dx criteria:
International Study Group (ISG) criteria -
recurrent oral ulcer ( > 3 times a year ) plus one of the following:
-recurrent genital ulcer
-skin lesion (e.g. erythema nodosum)
-eye lesion (e.g. uveitis)
-positive pathergy test

(pathergy test: Pathergy is defined by a papule 2 mm or more in size developing 24 to 48 hours after oblique insertion of a 20 gauge

needle 5 mm into the skin, generally performed on the forearm.)

{ 간단히: muco- cutaneous + eye

-Oral
-Genital
-Skin
-Eye
}



Rx:
prednisone 1 mg/kg/day PO
azathioprine 2.5 mg/kg/day PO

corticosteroids can be tapered after active disease has been controlled.
immunosuppressants are continued for 1 year.

initial therapy: prednisone (40 to 60 mg PO daily) and azathioprine (50 mg PO daily). The prednisone dose is maintained at its initial

level for one month and then tapered off over three to four months. Azathioprine is increased as tolerated over four to six weeks to a

daily dose of 2.5 mg/kg.

{ 간단히

prednisone - 60 mg  for 1 month and then taper over 3 to 4 months
azathioprine - start with 50 mg. increase to 2.5 mg/kg over 1 month. continue for 1 year.
}


Complication:

CNS: impairment in - memory, speech, balance, etc
GIT: GIT ulcer, diarrhoea
Vessel: aneurysm (e.g. of major vessles including pulmonary vasculature -> hemoptysis.), large vessel arteritis, venous thrombosis

CCF Rx

CCF

Acute:

-three catagories
1)hemodynamically stable
2) hypotensive
3) hypertensive

in all types:

-Oxygen + supportive therapy

----
Hemodynamically stable:

Nitroglycerine
Furosemide
Asprin + revascularization if indicated
----

----
Hypotensive:

Inotropes ( sys bp 100~85: dobutamine, sys bp <  85: dopamine or noradrenaline - memtip: do BETTER(buta) mine - BP is "better" )
Asprin + revascularization if indicated
----

----
Hypertensive:

Nitroglycerine
Beta blocker
----

Mem tip:
furosemide, inotrope, b blocker.  - unique to each cases
shared by 2 cases - nitroglycerine, aspirin


Chronic:

-ACEI
-Beta blocker

optional: digoxin, furosemide

Breast mass

Triple test
1) physical exam
2) imaging
3) cytology/histology

physical exam

///////

note and document:

breast symmetry
skin changes (peau d'orange, retraction)
nipple inversion, discharge
tenderness.

mass (size, border, mobility, consistency, location, etc)

///////



Imaging

////////

if age > 30 -> mammogram

if age < 30 -> sonar

////////


Needle aspiration / Core needle biopsy

////////

Do needle aspiration
-> mass is cyst (fluid is aspirated)
--> if fluid is bloody -> refer to surgeon
--> if fluid is non-bloody AND seen to be completely decompressed on U/S -> follw up
--> if fluid is non-bloody AND the mass is not completely decompressed on U/S -> do core needle biopsy

-> mass is solid (fluid is not aspirated) -> do core needle biopsy

///////

ESSENTIAL ANESTHETIC DRUGS

working out expected weight:
<= 9 yr:  kg = 9 + ageX2
> 9 yr :  kg = ageX3

phenylephrine 1~2 ug/kg, usually  50 ug bolus,  infusion: 0.1 ug/kg/min then titrate
adrenaline  0.1~1 ug/kg/min,  10 ug/kg bolus
ephedrine  0.1~0.2 mg/kg,  usually 5 mg bolus

propofol  2~2.5mg/kg  bolus
ketamine  2 mg/kg bolus
etomidate  0.1~0.2 mg/kg  bolus

morphine  100 ug~ 1 mg /kg - onset: 20 min, duration: 4 hrs
alfentanyl  10 ~ 20 ug/kg
fentanyl 1~ 3 ug/kg - onset: 2 min, duration: 20 min
sufentanyl  0.1 ug~ 0.3 ug /kg
remifentanyl 0.1~1 ug/kg/min

naloxone  6 ug /kg  (usually 0.4 mg)

suxamethonium  1~2 mg/kg
atracurium  0.5 mg/kg
rocuronium  0.4 ~ 1.2 mg/kg

neostigmine 40 ug/kg (usually 2.5 mg bolus)
atropine 20 ug /kg  (usually 0.5 mg bolus)
glycopyrrolate 10 ug/kg (usually 0.4 mg bolus)

DM

Diabetes
----------

Dx
---
HbA1C > 6.5 %


Fasting (> 8hr) glucose >7 mmol/L


Random glucose >11 mmol/L

Oral glucose tolerance test >11 mmol/L
(give 75 g oral glucose. measure level after 2 hrs)

---
Other exam:
Kidney function (albuminuria & GFR): Random spot urine Albumin/Creat ratio. GFR from Serum Creat.
Heart: ECG, lipogram
Eye: fundoscopy
Foot: foot exam.


(Blood tests to order: glucose, HbA1c, Cr, Lipogram)


Rx
---

Life style - exercise, lose weight, eat vegetable, stop smoking





1. BP control:

ACEI /ARB -> THIAZIDE -> Ca blocker -> Beta blocker  (에이스 두 꺼 비 - ace thi ca be)

(The American Diabetes Association recommends the following step therapy: ACE inhibitor or angiotenin-II receptor blocker as the

initial agent; to add thiazide if not well controlled; then if needed add calcium channel blocker; then if needed add beta-blocker.)

2. lipid control

simvastatin 40mg dly PO

+- 3. antiplatelet

aspirin 75 mg dly PO


Insulin therapy can be initial therapy (i.e. skip oral hypoglycemic trial) when fasting glucose > 16.5 mmol/L or random glucose > 19.5

mmol/L.


2 types of insulin:

1. bolus (ultra fast and fast acting insulin)
2. basal (intermediate and long acting insulin) - given before meal.


insulin type according to duration:

-ultra fast acting -> 방금 먹은 끼니에 작용 (given 5 min before meal or even immediatelty after meals)

-fast acting -> 다음 끼니 혈당을 잡음 (given 30 min before meal - due to slower onset than ultra fast insulin)

-intermediate acting -> 두끼 앞 혈당을 잡음

-long acting 

(ultra-fast & long-acting insulins are more expensive.)

insulin trade name examples:
e.g.) fast : actrapid,   intermediate: protaphane,    biphasic: actraphane (actrpaid + protaphane in 30:70)
        fast : humalin R,    intermediate: humalin N,    biphaisc: humalin  30/70  (humalin R + humalin N in 30:70)
참고: NPH = isophane insulin


4 strategies to give insulin:

1) basal alone (long acting)
2) basal + bolus
3) basal + bolus (intermediate + fasting acting)
4) insulin in combination with oral agent


insulin 의 투여 시기:

-아침, 점심, 저녁, 취침전 - 넷중에 하나
-fast 는 끼니(아침, 점심, 저녁)때에
-Intermediate, long acting 은 아침이나 취침전에 투여




initiation and adjustment of insulin in typeII DM:

---
Step1:

bed time long acting insulin(glargine(Lantus) better than determir(Levemir))
dose: 10 U or 0.2 U/kg

increase dose by 2 U every 3 days until fasting glucose lies in target range.
(increase by 4 U every 3 days if fasting glucose > 10 mmol/L)

If hypoglycemia:
reduce dose by 4 U or 10 % (whichever is greater)

Step2:

check HbA1c in 3 months:
if < 7 -> good. check again in 3 months.

if > 7: then

check glucose at: pre-lunch, pre-dinner, pre-bed time:
--
high pre-lunch glucose
-> add rapid acting insulin at breakfast

high pre-dinner glucose
-> add rapid acting insulin at lunch
OR - add intermediate acting(NPH) at breakfast

high pre-bed time glucose
-> add rapid acting insulin at dinner
< ?? OR - add intermediate acting(NPH) at lunch ? -> not mentioned. Intermediate is not used during lunch?? >

how much to add?
-usually 4 U.
and adjust by 2 U every 3 days until glucose lies within range.
--

---


Type 1 DM


"conventional insulin therapy" : single or two injections per day
"intensive insulin therapy": three or more injections per day (now considered standard therapy for type 1 DM) provides more

physiologic profile of insulin.


total daily insulin dose = 0.2~0.4 U / kg

one half of this total is given as basal insulin using either:
-long acting insulin (either in the morning or at bedtime.)  or
-intermediate acting insulin (two-thirds of the half of the total given in the morning, one third given at night)
(lunch bolus may be omitted if twice daily intermediate acting insulin is used)

remaining half of the total is distributed over 3 meals, using fast acting insulin. (maybe adjusted depending on size of the meal,

glucose level)

storage of insulin
-in cool place. Don't expose to direct sunlight.
-unopend, regrigerated insulin can last until expiry date.
-all types of unopend insulin can be left in room temperature ( < 30 degree C) and still maintain potency for 28 days.
-Once opened, the vials (whether refrigerated or kept at room temperature) should be discarded after 28 days.
-pens and cartridges should be stored at room temperature and discarded within the following periods:
mistures of insulin ( 70/30.. etc) : 10 days
insulin suspensions ( NPH ) : 14 days
Rapid acting insulin (Humalog, etc) : 28 days



Gesetational diabetes
def: glucose intolerance with onset and first recognition during pregnancy.

Dx:

75g oral glucose test after overnight fasting of 8hrs

Fasting level > 5 mmol/L
@ 1 hr level > 10 mmol/L
@ 2 hr level > 8.5. mmol/L

Dx made when any of the above values are exceeded.


Rx:
insulin therapy requires highly individualized titration.

In isolated fasting hyperglycemia:
-Start with 10 U intermediate acting insulin at bed time then titrate.

In post-prandial hyperglycemia:
-Start with follwing:
work out total dose with 0.7 U / kg
give two-thirds of the total in the morning and one-third before supper.
morning dose consists of two-third intermediate acting insulin and one-third fast acting insulin.
evening dose consists of one-half intermediate acting insulin and one-half fast acting insulin.




High glucose in the morning:
-can be either one of the two:
1) Somogyi phenomenon -> hypoglycemia while sleeping -> counter regulatory hormone secretion -> hyperglycemia in the morning
therefore, Somogyi needs decrease in insulin dose.
2) Dawn phenomenon -> increase insulin dose

Somogyi -> 3 am glucose is low
Dawn -> 3 am glucose is high

Red eyes

=================================

Eye drops/ointment

Ofloxacin ophthalmic 0.3 % 4 times a day * 7 days (or till 1 more day after the eye heals)

Conjunctival infection:
Drops - 1 drop every 4 hrs (or 4 times a day while awake)
Ointment - 3 times a day into conjunctival sac(space between cornea and palpebral and ocular conjunctiva)

Corneal infections require more frequent instillation of drops - every 30 to 60 min.

The volume of conjunctival sac is less that that of one drop. So it is wasteful to use more than 1 drop at a time.
If two or more drops are required to be instilled, allow 5 min before giving the next drop.

Don't squeeze the eyelid closed after instillation -> drops leak out of conjunctival sac.


==================================

Danger of using steroid eye drops:

- aggrevate infection
1. unrecognized herpes simplex corneal ulceration may be aggrevated leading to corneal
perforation. - never use ocular steroids in red eye with keratitis unless slit lamp and fluorescein exam have excluded hepes simplex infection.

2. fungal or bacterial infection.

---
3. raised intraocular pressure / steroid induced glaucoma

4. cataract (with chronic use > 1yr)


CGI - cataract, glaucoma, Infection

My conclusion: stay away from ophthalmic steroid. Rather leave it to specialist.


====================================

PT WITH RED EYES

-before making Dx of conjunctivitis exclude 3 conditions: keratitis(def: inflammation of the transparent cornea - mostly infectious), iritis, glaucoma(acute angle closure). These should be referred urgently.

(It's actually 5 conditions that needs to be excluded, with the below two conditions added:
- hypopyon (def: pus in the anterior chamber of the eye)
- hyphema (def: blood in the anterior chamber of the eye)
But both seem to be quite obvious on presentation..
Let's focus on the above three)


Q's to ask pt:
---
-"Can you see well?" -decreased visual acuity is a warning sign.

-"Are you sensitive to bright light?" - photophobia can be present in keratitis, iritis, glaucoma but not in conjunctivitis.

-"Did something get into your eye?" - Hx of trauma

-"Are you wearing contact lenses?" - Contact lens wear increases suspicion of keratitis

-"Can you open your eyes spontaneously and keep it open?" - objective foreign body sensation (objective foreign body sensation - pt unable to spontaneously open the eye or keep the eye open.-> suggests corneal abrasion or foreign body.
subjective foreign body sensation - "like sand in my eyes", "grittiness" -> suggests allergy, viral conjunctivitis, dry eyes. Usually no need for referral.)

-"Do you have headache, nausea, vomitting?" - suggests angle closure glaucoma
---




Helpful examination - vision / pupil/corneal opacity / pattern of redness
---
VISION
-Measuring vision in triage setting:
 It is not important to determine exactly whether the vision is 20/30 or 20/40 at 12 or 14 inches, but rather to document visual acuity in crude categories: reading vision (small print versus large print); form vision only (hand motions or count fingers); or light perception.

The fundus examination is typically not helpful in the differential diagnosis of the red eye.
( Although the pupil is midsize in angle-closure glaucoma, the fundus examination becomes increasingly difficult to perform.)

PUPIL/CORNEA
-Keratitis: white spot on cornea. spot stains with fluorescein
-Iritis: mitotic pupil
-Glaucoma(acute angle): fixed, mid-dilated pupil

PATTERN OF REDNESS
diffuse injection suggests conjunctivitis
ciliary flush (a type of injection where redness is most prounounced in a ring around limbus. the limbus is the transitional zone between cornea and sclera) suggests keratitis, iritis or angle closure glaucoma.
---

-Keratitis is characterized by : corneal opacity, decreased vision, photophobia, extremely painful eye.

-Pts with bacterial conjunctivitis should respond to therapy in 1 to 2 days with decrease in discharge, redness, irritiation. Pts who do not respond needs to be referred to an ophthalmologist.

Glaucoma

Glaucoma

2 types:

- Open angle glaucoma
- Angle closure glaucoma

Open angle
-mostly asymptomatic.
-progressive visual FIELD loss
-no pain

Angle closure
-painful eye, headache,
-Red eye (The pain of angle closure is a dull ache that is more likely reported as unilateral headache rather than eye pain.)
-seeing halos around lights
-nausea, vomitting
-Migraine 과 헷갈릴 수 있음.

<nausea, vomitting headache>
<red painful eye with halo>

Glaucoma DX:

안압 >= 21 mmHg
두눈의 안압차 >= 5 mmHg

Cup-Disc ratio >= 0.6

RX:

Angle closure:
응급:
- 0.5 % timolol (b blocker)
- 1 % aproclonidine (alpha agonist)
- 2 % pilocarpine (cholinergic)

One drop of the each of the above into the eye.

+- acetazolamide po or iv

when acute attack is over: iridotomy


MEM TIP:
<팀, 앞으로 파일로 정리해 - 에이씨>
timolol, apraclonidine, pilocarpine, acetazolamide

Anaphylaxis

Anaphylaxis

:life-threatening allergic reaction.

Rx:
-----------------------------------------

-Epinephrine IMI: (on anterolateral thigh rather than deltoid or buttock)
(epinephrine 1:1000 -> 1mg/ml)
Adult: 0.3 ~ 0.5 mg IMI every 5~15 min
Child: 0.01 mg/kg <max 0.3 mg>
(add 1ml of 1:1000 epinephrine to 9 ml sterile water then give 0.1 ml /kg of the mixed solution)

-IV normal saline

+- intubation / cricothyroidotomy

-Inhaled beta-2 agonist. Adult: sabultamol inhaled  5 mg every 20 min.


Adjunct therapy - Antihistamine & corticosteroids
-------------------------------------------

Antihistamines relieve itching & hives but has no effect on severe symptoms such as
airway obstruction and shock.
H1 and H2 antihistamine in combination are more effective in palliating the skin allergy.

( diphenhydrajmine 1 mg/kg IM/IVI  Adult: 50 mg
ranitidine 1 mg/kg IVI over 5 min Adult: 50 mg )


Corticosteroids have slow onset of action. It has no effect for 4 to 6 hrs even when given IVI.
Used as preventative treatment after stabilization.

(predisolone 1 mg/kg/day orally)

Acute MI

Acute Myocardial infarction


MONA
--------
morphine 2 mg every 5 minutes IVI  (upto 15 mg)
oxygen 100%
nitrate (glyceryl trinitrate) (e.g. Angised) 0.5 mg every 5 minutes (upto X 3)
aspirin 300 mg oral


B S
---------
betablocker - metoprolol 25 mg PO
Statin - atorvastatin 80 mg PO



REPERFUSION STRATEGY
------------------------
PCI / Fibrinolysis

PCI can be done upto 36 hrs after the onset of symptoms. - ideally should be done within 90 min after presentation.

Fibrinolysis can be done if PCI can't be done within 90 min after presentation, symptoms < 12 hrs, no contraindication (e.g. Hx of intracranial hemorrhage, stroke within last 3 months, head injury within last 3 months)

Antiplatelet therapy (in addition to aspirin)
-------------------------------------
Clopidogrel 300 mg

Anticoagulant therapy
--------------------
Enoxaparin 30mg IV loading then 1 mg/kg bd SC


mem tip:
MONO
B S
-> 모(노)비스 <농구팀 이름>
reperfusion strategy
antiplatelet, anticoagulation

Cardiomyopathy

Definition:
"A myocardial disorder in which the heart muscle is structurally and functionally abnormal in the absence of coronary artery disease, hypertension, valvular disease and congenital heart disease sufficient to explain the observed myocardial abnormality"

즉,
- 심장근육의 병.
- 허혈, 판만, 고혈압에 의한 질환이 아님. (predominantly idiopathic/ genetic/toxin)

Three main types:
1. Hypertrophic cardiomyopathy
2. Dilated cardiomyopathy
3. Restrictive cardiomyopathy

--------------------------
Hypertrophic cardiomyopathy
--------------------------

Def:
genetic disorder characterized by
left ventricular hypertrophy (LVH)
without identifiable cause

-most common cause of sudden cardiac death in young people

Classification:
classifed into 1. obstructive and 2. non obstructive
based on left ventricular outflow tract obstruction. (as seen on echo)

Dx:
Hx of unexplained syncope
Family Hx of sudden death

Rx:
All pt should refrain from high-intensity competitive sports.

Pt at risk of sudden cardiac death:
(i.e. ventricular tachy on Holter monitoring, prior cardiac arrest)
-> ICD (implantable cardiverter defibrillator) placement


Asymptomatic pt:
-> no treatment

Symptomatic pt:

-pt with systolic dysfunction / end-stage heart failure:
--> standard heart failure therapy ( B blocker, ACEI/ARB, digoxin, +- diuretic(cautiously) )

-pt with preserved systolic function:
in obstructive type:
--> B blocker, disopyramide, surgery
in non-obstructive type
--> B blocker, verapamil (don't use disopyramide)

Atiral fibrillation

Atrial fibrillation

three pillars of therapy:

1. rate control (slow it down)

2. anticoagulation

3. rhythm control (restoration of sinus rhythm)

Q's to ask:

1. is pt stable? or unstable?

2. (if stable,) is pt symptomatic or asymptomatic?

3. is there a thrombus or no thrombus (on trans-esophageal echo<TEE>)

Hemodynamically unstable AF (hypotension, SOB, chest pain)

-> DC cardioversion under short general anesthesia

if there's thrombus on TEE:

Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks before cardioversion.

Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks or more after cardioversion.

if there's no thrombus on TEE

AND:

-----

Symptomatic for < 48 hrs:

if low thromboembolic risk

-> DC cardioversion or pharmacological cardioversion

if high thromboembolic risk

-> Heparin before cardioversion.

Heparin + warfarin (stop Heparin once INR 2-3) till 4 weeks after cardioversion

------

Symptomatic for > 48 hrs:

if low thromboembolic risk

-> Heparin (aPTT of 45-60 sec) before cardioversion.

long term aspirin after cardioversion

if high thromboembolic risk

-> Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks before cardioversion.

Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks or more after cardioversion.

--------

Asymptomatic:

if low thromboembolic risk

-> rate control & observe (usu. spontaneously revert to sinus rhythm in 24hrs)

-> if not recovered spontaneously  then cardioversion.

if high thromboembolic risk

-> anticoagulation & rate control for 4 wks before cardioversion

-> anticoagulation for 4 wks after cardioversion.

Mem Tip:

- thromboembolic risk = 0.5 점

- > 48 hrs = 0.5 점

합계가 0.5 점 인 경우-> heparin before cardioversion. anticoagulation for 4 wks after cardioversion

합계가 1 점 인 경우-> heparin + warfarin for 4 wks before and 4 wks after cardioversion



All pt get rate control:

if  no heart failure -> b blocker (metoprolol, esmolol) and/or CCB (diltiazem, verapamil)
if  heart failure -> amiodarone or digoxin