[CK] Warfarin reversal addon. FFP 2units vs 4 units <-> preferred PCC (units per INR) + Vitamin K 10mg IV infusion. Recheck INR in 1hour(30minutes for PCC)

RECOMMENDATIONS • Level 1 Fresh Frozen Plasma (FFP) should be used for emergent reversal of elevated INRs. • Level 2 Dosing of phytonadione (Vitamin K) should be based on the patient’s current INR, risk of bleeding, and future need for anticoagulation (Tables 1 & 2). Reversal of warfarin with Vitamin K should be reserved only for the most serious bleeding events or patients who will not be restarted on warfarin. Vitamin K should be administered either orally or intravenously (IV) only. Oral Vitamin K is the safest and most reliable route. IV Vitamin K should be reserved for rapid reversal in serious bleeding events only. Subcutaneous and intramuscular administration of Vitamin K should be avoided. • Level 3 Initial dose of FFP based on risk of bleeding: Low to moderate risk – FFP 2 units High risk or active bleeding – FFP 4 units INR should be rechecked 1 hour after administration of FFP. Prothrombin Complex Concentrate (PCC) should be administered to patients on warfarin with an INR >2 AND evidence of intracranial hemorrhage on CT scan (Table 3). FEIBA NF 1000 units (one vial) IV push over 5 minutes Check INR 30 minutes after administration Vitamin K should not be administered to patients with prosthetic heart valves, only low doses (1mg) should be used if absolutely necessary. The use of recombinant Factor VIIa may be consider

[CK] Cerebral T-waves (TWI deep symmetric in precordial leads) > 5mm and more than 4 contiguous precordial leads.

neurally induced;
 transient T-wave inversion of ≥5 mm depth in ≥4 contiguous precordial leads.

[R] AAD algorithm.

[CK] Vtach management- lidocaine 1.5mg/kg at 20-50mg/min and repeated 5-10minutes + infusion possible. (same as procaineamide 20-50mg/min - continues. max 17mg/kg) cf) amio 150 1 0.5.

• Intravenous lidocaine (1 to 1.5 mg/kg [typically 75 to 100 mg] at a rate of 25 to 50 mg/minute; lower doses of 0.5 to 0.75 mg/kg can be repeated every 5 to 10 minutes as needed), which may be more effective in the setting of acute myocardial ischemia or infarction
• Intravenous procainamide (20 to 50 mg/minute until arrhythmia terminates or a maximum dose of 17 mg/kg is administered)
• Intravenous amiodarone (150 mg IV over 10 minutes, followed by 1 mg/minute for the next six hours; bolus can be repeated if VT recurs)

HF - Amio or Tikosyn - DOC





normal: sotalol, procainacmide, lido+amio
but
<40% : lido + amio. (Tikosyn?

[CK] Anaphylaxis. 0.5mg EPI IV/IM 3 times and infusion + Methylpred 125mg + Albu 5mg in 3mL Neb. + Benadryl. => IVF and CICU.

Diagnosis is made clinically:

The most common signs and symptoms are cutaneous (eg, sudden onset of generalized urticaria, angioedema, flushing, pruritus). However, 10 to 20% of patients have no skin findings.

Danger signs: Rapid progression of symptoms, respiratory distress (eg, stridor, wheezing, dyspnea, increased work of breathing, persistent cough, cyanosis), vomiting, abdominal pain, hypotension, dysrhythmia, chest pain, collapse.

Acute management:

The first and most important treatment in anaphylaxis is epinephrine. There are NO absolute contraindications to epinephrine in the setting of anaphylaxis.

Airway: Immediate intubation if evidence of impending airway obstruction from angioedema. Delay may lead to complete obstruction. Intubation can be difficult and should be performed by the most experienced clinician available. Cricothyrotomy may be necessary.

Promptly and simultaneously, give:

IM epinephrine (1 mg/mL preparation): Give epinephrine 0.3 to 0.5 mg intramuscularly, preferably in the mid-outer thigh. Can repeat every 5 to 15 minutes (or more frequently), as needed. If epinephrine is injected promptly IM, most patients respond to one, two, or at most, three doses. If symptoms are not responding to epinephrine injections, prepare IV epinephrine for infusion.

Place patient in recumbent position, if tolerated, and elevate lower extremities.

Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as needed.

Normal saline rapid bolus: Treat hypotension with rapid infusion of 1 to 2 liters IV. Repeat, as needed. Massive fluid shifts with severe loss of intravascular volume can occur.

Albuterol (salbutamol): For bronchospasm resistant to IM epinephrine, give 2.5 to 5 mg in 3 mL saline via nebulizer. Repeat, as needed.

Adjunctive therapies:

H1 antihistamine*: Consider giving diphenhydramine 25 to 50 mg IV (for relief of urticaria and itching only).

H2 antihistamine*: Consider giving ranitidine 50 mg IV.

Glucocorticoid*: Consider giving methylprednisolone 125 mg IV.

Monitoring: Continuous noninvasive hemodynamic monitoring and pulse oximetry monitoring should be performed. Urine output should be monitored in patients receiving IV fluid resuscitation for severe hypotension or shock.

Treatment of refractory symptoms:

Epinephrine infusion¶: For patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion, beginning at 0.1 mcg/kg/minute by infusion pumpΔ. Titrate the dose continuously according to blood pressure, cardiac rate and function, and oxygenation.

Vasopressors¶: Some patients may require a second vasopressor (in addition to epinephrine). All vasopressors should be given by infusion pump, with the doses titrated continuously according to blood pressure and cardiac rate/function and oxygenation monitored by pulse oximetry.

Glucagon: Patients on beta-blockers may not respond to epinephrine and can be given glucagon 1 to 5 mg IV over 5 minutes, followed by infusion of 5 to 15 mcg/minute. Rapid administration of glucagon can cause vomiting.

[CK] Amiodarone induced liver failure: stop and MUCOMYST ! 150mg/kg for 1 hour! then 50mg/kg 4hr and 100mg/kr for 16hr.

Concern for hyper acute liver injury secondary to amiodarone

Plan to start Mucomyst--N  acetyl cystine-150 mg IV over 1st our and then 50 milligram/kg infused over 4 hr then 100 milligram/kg infused over 16 hr
Will also start pyridoxine 25 mg p.o. Once daily

[CK] Postcardiac surgery Afib: >24hr = 4 weeks .at 4weeks point = reeval(chads, afib or not, etc.)

SUMMARY AND RECOMMENDATIONS

●Atrial fibrillation (AF) and atrial flutter occur frequently after cardiac surgery. Most episodes occur by the third postoperative day. (See 'Incidence and time course' above.)

●Potential adverse outcomes of these atrial arrhythmias include a longer length of stay, stroke, or death. (See 'Adverse outcomes following AF' above.)

●Beta blockers, sotalol, amiodarone, atrial pacing, and antioxidant vitamins lower the risk of the development of AF and atrial flutter after cardiac surgery and may reduce the length of stay and lower the risk of in-hospital stroke. (See 'Prevention of AF and complications' above.)

•We recommend therapy to prevent the development of adverse events associated with the development of postoperative AF and atrial flutter (Grade 1B). (See 'Our approach to prevention' above.)

•We recommend beta blockers rather than amiodarone or sotalol (Grade 1B). Beta blocker therapy should be started prior to surgery and continued at least until the first postoperative visit unless contraindicated. We prefer oral metoprolol 25 mg twice daily. For patients who cannot take beta blockers, either amiodarone or sotalol may be used, with the decision based on patient characteristics and physician familiarity. (See 'Our approach to prevention' above.)  

•We suggest antioxidant therapy in addition to beta blocker therapy (Grade 2C). We start this therapy two days prior to surgery and continue until discharge. We prefer the regimen of vitamin C (1 gram) and vitamin E (400 international units), each given daily. (See 'Our approach to prevention' above.)  

●For hemodynamically stable patients who develop postoperative AF, the optimal ventricular rate range should be determined for each patient. In many patients, this rate will be less than 110 beats per minute.

●For patients who develop well-tolerated postoperative AF and whose rate is well controlled, we suggest not performing cardioversion within the first 24 hours of its development (Grade 2B). Cardioversion may be required within this time frame for those whose AF is poorly tolerated or whose rate is not well controlled. (See 'Rhythm control' above.)

Cardioversion in asymptomatic patients may be reasonable when well-tolerated AF is present near the time of anticipated hospital discharge, or when it does not spontaneously terminate within 24 to 48 hours, so that oral anticoagulation can be avoided.

●For patients with multiple episodes of AF or one episode that lasts more than 24 to 48 hours, and if the perioperative bleeding risks are considered reasonable, we recommend oral anticoagulation (Grade 1B). (See 'Our approach to postoperative anticoagulation' above.)

We suggest anticoagulation with warfarin (international normalized ratio 2 to 3) rather than either a direct thrombin or factor Xa inhibitor (Grade 2C).

For patients in whom anticoagulation is started and irrespective of the rhythm status at the time of discharge from the hospital, we suggest continuation of anticoagulation for at least four weeks, rather than stopping at the time of discharge (Grade 2C).