35Years old female pt k/c/o valvular heart disease, admitted in icu c/o sob since morning, p-146/min,BP -60systolic, spo2 -60,RR-46,RS-BILATERAL crepts,

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X Ray Chest: 1) Bilateral fluffy shadows suggestive of Pulmonary edema 2) Cardiomegaly with Right ventricular hypertrophy pattern. Straightening of left heart border suggestive of mitralisation of cardiac silhouette. ECG:Right axis Deviation,Right ventricular hypertrophy. Sinus tachycardia. Background of Valular heart disease with above mentioned clinical details and X Ray ECGs,most probably has Severe Mitral Stenosis with Pulmonary hypertension with TR with Pulmonary edema,cardiogenic shock. She is critically ill ,hypotensive,hypoxic,tachypnoeic and in pulmonary edema. 1) Start Inotropic support with Dobutamine/ Nor adrenaline. 2) Put on BiPAP & watch for saturation%, consciousness.If she does not maintain saturation will need intubation and mechanical ventillation. 3) Central line insertion. 4) Send ABG,Electrolytes,Creatinine. 5) Catheterization with foley's. 6) Once BP improves, Most importantly needs Diuretics (Inj Lasix or Inj Dytor)Start Diuretic infusion after bolus, if BP is sustained and maintained .Monitor Urine output. 7) Controlled careful fluid balance. Aim at negative fluid balance. 8) Bedside 2 D ECHO & Doppler for valvular affection,severity of lesion,PA pressure,LVEf,presence of any Clot/Ruptured cordae/vegetation also check for status of Inferior vena cava collapsible or not? Antibiotic to prevent infection. Her overall Clinical outcome will be guarded. If she responds well to treatment and hemodynamics get settled,manage her later on Diuretics,Beta blocker,Digoxin depending upon rhythm,rate. Advise fluid and salt restriction and avoid physical exertion. Repeat ECHO after tachycardia is controlled. Once she improves, the next step will be to define the severity of her valular lesion,potential reversibility of symptoms depending upon severity of pulmonary hypertension ,and her operative suitabilty. Depending upon valvular pathology definitive treatment options like valve repair/replacement or ballon valvulotomy etc. can be considered.

Agree Dr Arun, if severe MS AND IF FEASIBLE CONSIDER FOR EMERGENCY BMV
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RAD LPHB S.TACHYCRDIA Widespread st depression with St elevation in avr, v1 Suggestive of ischemia D / D Demand supply mismatch coronary arthroslerosis but here picture is different if we add clinical corelation than my bet on PULMONARY ODEMA P.E Echo is the answer

MULTI FOCAL ATRIAL TACHYCARDIA. RAD LPFB RVH WITH STRAIN PATTERN. BI ATRIAL ENLARGEMENT. MOST PROBABLY RHD.MS.PHT.MAT .. BUT PT IS UNSTABLE. as per the ACLS tachycardia algorithm any tachycardia with pt unstable ..give shock. .100 joules DC cardioversion can b given

Dr suresh I totally disagree ...pt has got sinus tachycardia as reflex mechanism to heart failure and shock. This is compensation. DC will not revert it and pt condition will deteriorate further , had it been AFIB , ATACH agreed . Here noradr ,digoxin BIPAP dos ventilation . If pure MS NO MUCH MR NO CLOT EMERGENCY BMV , even if valve not ideal . Pt in LOw cardiac output state even increase in MV area by 0.5 will benefit her a lot. Mortality very high
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There are features of pul.infiltrations likely ARDS. so give O2 support and BiPAP support for respiratory distress.titrate according to . need limited fluid challenge being k/c/o vulvolar disease,infact better to put CVP line and give fluid management accordingly. intubate her if GCS is less than8 or if chances of aspiration. put on ventilatory support with high peep and low tidal volume. send pan cultures antibiotis pipracilin tazobactam and levoflox/ticoplanin. inotrops Norad if BP not improved after fluid challenge. bronchodilators and other supportive measures. ECho f/b cardiology openion. and last but not least CT chest.

thx dear Dr. Shah
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ECG s/o hr 150, normal sinus rythm, Rt ward axis, Bi atrial enlargement, RVH with strain pattern wid few supra ventricular ectopics and cxr s/o cardiomegaly wid rv apex, straightening of left heart border with pulmonary edema

Abg, central line,start ionotropic support and maintain MAP b/w 65-70, watch for hourly urine output, control heart rate with digoxin, if sbp reaches 90 mmHg load her with lasix...if pt is alert give bipap support...

she is in sinus and hence digoxin will not be helpful.
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Admit atrial fibrillation irregular rhythm & anterolateral wall ischemia copd cardiac oedema 2 decho

Sir. u have mentioned diuretic bolus .then drip ..what about the dosage of bolus and in drip

Inj.Lasix 40-60 mg iv stat &repeat SOS Infusion= Inj Lasix each ampoule ,20 mg/2 ml (i.e.10 mg= 1 ml) Putting 20 ampoules in infusion pump will make volume 40ml.(without any dilution) Now each 1 ml constitutes 10 mg. Infusion pump rate can be set at rate of 1-2 ml per hour (i.e.10-20 mg) and titrate up and regulate depending upon patients response and parameters,i.e.Urine output and BP. Such Diuretic infusions (Lasix or dytor) are commonly employed in ICU settings,particularly when diuresis is required in significant amount and in sustained manner. Checking Potassium daily is very important for Hypokalemia.
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The ECG shows severe tachycardia this could be either Sirius tachycardia or Atrial flutter with 2:1 block in which case the rate will be nearly fixed at 250/min. whereas in sinus tachycardia the rate is variable. Second there is Right axis deviation with RVH ( tall R in V1).In valvular heart disease this is very strongly suggestive of Severe MS with severe PAH. As the patient is in shock the first step is to correct BP with preferably norad and also to control the rate if sinus tachycardia with small doses of diltiazem or beta blocker. Having settled these two diuretic to be started. May need elective ventilation.

close watch on s.sodium,potassium,calcium and magnesium levels

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