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Culture Documents
....2
...18
...33
......41
....53
...59
EKG-1).81
EKG-2 ()...106
EKG-3 ()....120
.144
CGMH R3
# -lactam
Penicillin
Cephalosporin
Carbapenem
Monobactam
@ -lactam
------------------------------------------------------------------------------------------------------------------------------------------
Penicillin
Natural Penicillin
1Penicillin G
# IV
# Group A StreptococcusSyphilisNeurosyphilis
#
@ Penicillin G 3,000,000U/vial
2Benzathine Penicillin
# IM
# Syphilis
#
@ Benzathine Penicillin G (IM) 240 IU/4ml/syringe
Staphylococcus Penicillinase Penicillin
1Penicillinase-resistant PenicillinOxacillin
2 -lactamase inhibitorAugmentin
Penicillinase-resistant Penicillin
1Oxacillin
# MSSA
# Penicillin
#
@ Oxacillin 1g/vial
2
1Oxacillin1G/PC1PC Q6H ~ 2PC Q6H
2CeftriaxoneRocephin1G/PC1PC Q12H
3Moxifloxacin400mg/PC1PC QD
4Clindamycin300mg/PC2PC Q8H
5Tigecycline50mg/PC1PC Q12H
6Linezolid600mg/PC1PC Q12H
2Methicillin
#
3Dicloxacillin
# Oxacillin
#
@ Dicloxacillin sodium 250mg/cap
Amino-Penicillin
1Ampicillin
# Streptococcus GNB
# Listeria Enterococcus
#
@ Ampicillin sodium 500mg/vial
@ Ampicillin 500mg/cap
2Amoxicillin
# Ampicillin
#
1
22g 1 hour before & after
#
@ Amoxicillin 500mg/cap
@ Amoxicillin 250mg/cap
3AugmentinAmoxicillin + Clavulanate
# -lactamase inhibitor MSSAEnterobacteriaceae
E. coliK.p.
#
#
@ Amoxicillin 1000mg + Clavulanic acid 200mg)/vial
@ Amoxicillin 500mg + Clavulanic acid 100mg)/vial
@ Clavulanic acid 125mg + Amoxicillin 875mg) 1Gm/tab
@ Curam 625mg/f.c. tab (Clavulanic acid 125mg + Amoxicillin 500mg)
3
4UnasynAmpicillin + Sulbactam
#
@ Ampicillin 1gm + Sulbactam 500mg)/vial
Carboxy-Penicillin
1Carbenicillin
2Ticarcillin
3TimentinTicarcillin + Clavulanate
# PseudomonasHAPStenotrophomonas
# Fluid overload
#
Ureido-Penicillin
1Piperacillin
2TazocinPiperacillin + Tazobactam
# PseudomonasHAP
#
@ Piperacillin sodium 2gm/vial
@ Piperacillin 2gm + Tazobactam 0.25gm)/vial (Pfizer)
@ PIPERACILLIN 2GM + TAZOBACTAM 0.25GM)/VIAL (Sandoz)
------------------------------------------------------------------------------------------------------------------------------------------
Cephalosporin
1Cefazolin
2Cefadroxil
# GPC + GNB PECKProtiusE. coliKlebsiella
# MSSA
# Staphylococcus Oxacillin Group A Streptococcus Penicillin
Cefazolin
#
@ Cefazolin sodium 1GM/vial
@ Cefazolin sodium 500mg/vial
@ Cefadroxil monohydrate 500mg/cap
Streptococcus
#
1Cefazolin + Clindamycin
2Penicillin + Clindamycin
# Clindamycin cover Streptococcus M protein
4
1Cefuroxime
# GPC + GNBPECK + HiMENH. influenzaeMoraxellaEnterobacterNeisseria
#
#
@ Cefuroxime 750mg/vial
@ Cefuroxime 250mg/tab
2Cefoxitin
# GPC + GNBPECK + HiMEN+ Bacteroid fragilis
#
#
1CeftriaxoneRocephin
# GPC + GNBPECK + HiMEN + S/SSalmonellaShigella
# BBB Metronidazole SBP
UrosepsisNeisseria gonorrhea
#
#
@ Ceftriaxone 1GM/vial
2CeftazidimeFortum
# GPC GNB Pseudomonas
# PseudomonasNeutropenic fever
#
@ Ceftazidime 1g/vial
@ Ceftazidime 500mg/vial
3Flomoxef
# Rocephin + Metronidazolecover
#
@ Flomoxef 1G/vial
1Cefepime
# GPC + GNB Rocephin Fortum
# PseudomonasNeutropenic fever
#
@ Cefepime 500mg/vial
5
E.coliK.p.
1AmpC -lactamase
# 1~3 Cephalosporin
# CephalosporinCarbapenem
2Extended-spectrum -lactamaseESBL
# Penicillin1~4 CephalosporinMonobactam
# Carbapenem
------------------------------------------------------------------------------------------------------------------------------------------
Carbapenem
1ImipenemTienam
# GPCGNBAmpC -lactamase ESBL
# Pseudomonas
# Seizure
#
@ Tienam (Imipenem 500mg + Cilastatin 500mg)/vial
Tienam Tazocin pneumonia Teicoplanin + Tazocin
Teicoplanin + Tienam
2Meropenem
#
# Pseudomonas
# BBB CNS
#
@ MEROPENEM TRIHYDRATE 500mg/vial (Meropenem Sandoz, SANDOZ)
@ Meropenem trihydrate 250mg/vial (Mepem, Dainippon)
3Doripenem
#
# Pseudomonas
#
@ Doripenem 250mg/vial
4Ertapenem
# PseudomonasAcinetobacter
# BTI
#
@ Ertapenem 1gm/vial
6
Monobactam
1Aztreonam
# GNB Aminoglycoside
# Pseudomonas
#
------------------------------------------------------------------------------------------------------------------------------------------
Glycopeptides
1Vancomycin
# GPC
# MRSAARE (Ampicillin-resistant enterococcus)PRSP (Penicillin-resistant Streptococcus
pneumoniae)
# GPC GPC meningitisCONS
CONS CONS
# Red man syndrome
#
@ Vancomycin HCl 1GM/vial
@ Vancomycin HCl 500mg/vial
2Teicoplanin
# Loading dose2PC Q12H x 3 doses
# Maintain dose2PC QD
2PC QODClCr < 50 mL/min
2PC Q3DClCr < 20 mL/min, H/D, CAPD
#
@ Teicoplanin 200mg/vial
ORSA &
BBB
Lung
Vancomycin
10%
20~30%
20~30%
Teicoplanin
<5%
50~60%
40~50%
Daptomycin
<10%
>60%
Linezolid
>40%
70~80%
>60%
7
------------------------------------------------------------------------------------------------------------------------------------------
Bacitracin
1Bacitracin-Neomycin
# Bacitracin for GPC
# Neomycin for GNB
#
@ Neomycin & Tyrothricin oint 10gm/tube
@ Neomycin & Tyrothricin oint 40gm/tube
Neomycin
# 4# Q6H
#
@ Neomycin sulfate 250mg/cap
50S
Macrolide
1Erythromycin
# GPCLegionellaChlamydiaMycoplasma H. influenzae
# Penicillin
#
@ Erythromycin 500mg/vial
@ Erythromycin 250mg/cap
2Clarithromycin
# GPCH. influenzae
# No-comorbidity CAP
#
@ Clarithromycin 500mg/fc tab
3Azithromycin
# GPCH. influenzae
# No-comorbidity CAP
# HIV MACMycobacterium avium complex
G(-)H.p.VibrioCampylobacter
# H.p.PPI + Amoxicillin + Clarithromycin
# Comorbidity CAP
- Augmentin + Clarithromycin
- Augmentin + Azithromycin
- Moxifloxacin
#
@ Azithromycin 250mg/tab
------------------------------------------------------------------------------------------------------------------------------------------
Lincosamide
1Clindamycin
# Erythromycin
# Metronidazole
# Pseudomembranous colitis
#
@ Clindamycin phosphate 300mg/2ml/pc
@ Clindamycin HCl 150mg/cap
9
------------------------------------------------------------------------------------------------------------------------------------------
Oxazolidinones
1Linezolid
# MRSAVRE
#
# MAOi SSRITriptanMeperidine serotonin syndrome
#
@ Linezolid 600mg/300ml/bag
@ Linezolid 600mg/tab
------------------------------------------------------------------------------------------------------------------------------------------
Chloramphenicol
1Chloramphenicol
# GPCGNB
# Gray baby syndrome
#
------------------------------------------------------------------------------------------------------------------------------------------
30S
Aminoglycoside
1Gentamicin
# GNB GPC
# Penicillin Cefazolin
#
# IrreversibleGentamicin > Tobramycin > Amikacin
#
@ Gentamicin sulfate 80mg/2ml/vial
@ Gentamicin 0.1% cream 15gm/tube
@ Gentamicin oph oint 0.3%, 5gm/tube
2Tobramycin
3Amikacin
# Mycobacterium Norcardia
#
@ Amikacin 500mg/vial
-----------------------------------------------------------------------------------------------------------------------------------------10
Tetracycline
1Tetracycline
# Q feverLyme disease
H.p.
#
#
@ Tetracycline HCl 250mg/cap
@ Tetracycline hcl 1% eye oint 5gm/tube
2Doxycycline
#
#
#
@ Doxycycline 100mg/cap
Orchitis& Epididymitis
# Rocephin + Doxycycline
#
- Rocephin 1PC Q12H Neisseria gonorrhoeae
- Doxycycline 1# BID Chlamydia
# Guideline 18~50 Sexual active
# E.coli Rocephin
Vibrio vulnificus
# Fortum + Doxycycline
#
- Fortum 2PC Q8H Vibrio vulnificus
- Doxycycline 1# BID Synergic effect
# Vancomycin cover GPC DC
------------------------------------------------------------------------------------------------------------------------------------------
Glycylcycline
1Tigecycline
# GPCGNB
# MDRABMDRKPCRKPMRSAVREPRSP Tetracycline
# Pseudomonas
# Tetracycline
#
@ Tigecycline 50mg/vial
11
MDRAB
# Colistin + Tigecycline
#
- Colistin 1PC Q12H
- Tigecycline 1PC Q12H
# Colistin
1IV1PC Q12H
2Inhalation1PC BID
# MDRAB Colistin + Tienam synergic effect
12
TMP/SMX
1Trimethoprim/Sulfamethoxazole
# BaktarBacideSeptrinSevatrim
#
# PJPNocardiosis
# Stenotrophomonas multophiliaCVPDouble lumenHickmanA-line
Baktar
#
@ Cotrimoxazole (SMZ 400mg + TMP 80mg)/5ml/amp
@ Cotrimoxazole (SMZ 400mg + TMP 80mg)/tab
------------------------------------------------------------------------------------------------------------------------------------------
Fluoroquinolone
# DNA
1Ciprofloxacin
# GNB
# PseudomonasSalmonella
#
@ Ciprofloxacin 2mg/ml, 50ml/bot
@ Ciprofloxacin HCl 250mg/fc tab
2Levofloxacin
# GNBGPC
#
#
@ Levofloxacin 500mg/100ml/bot
@ Levofloxacin 500mg/tab
3Moxifloxacin
# GNBGPC
#
# Pseudomonas
# UTI
#
@ Moxifloxacin 400mg/250ml/bot
@ Moxifloxacin 400mg/tab
13
4Gemifloxacin
# GNBGPC
# Moxifloxacin
#
@ Gemifloxacin 320mg/f.c. tab
Quinolone
GPC
GNB
Anaerobes
Pseudomonas
TB
Ciprofloxacin
+++
+++
Levofloxacin
+++
+++
++
Moxifloxacin
+++
+++
+++
Gemifloxacin
+++
+++
+++
------------------------------------------------------------------------------------------------------------------------------------------
Metronidazole
1Metronidazole
# DNA
# Bacteroides fragilisClostridium perfringensClostridium difficile
ProtozoaGiardiaEntamoiba histolyticaTrichomonas vaginalis
#
@ Metronidazole (IVF) 500mg/100ml/bot
------------------------------------------------------------------------------------------------------------------------------------------
Rifampin
1Rifampin
# DNA-dependent RNA polymerase
#
#
@ Rifampicin 300mg/cap
@ Rifampicin 150mg/cap
14
TB
# &
HIsoniazid (INAH)
300mg QD
Vit-B6Lupus-like syndrome
EEthambutol (EMB)
15~25mg/kg QD
Optic neuritis
RRifampin (RIF)
600mg QD
HypersensitivityFever
GI upset
>13
---------------------------------------------------------------------------------------------------------------------------------------#
@ HERZ x 2 months, then HER x 4 months (Total 6 months)
@ HRZ x 2 months, then HR x 4 months (Total 6 months)
Ethambutol Ethambutol
@ HR 9
---------------------------------------------------------------------------------------------------------------------------------------#
@ Isoniazid 100mg/tabH
@ Ethambutol 400mg/tabE
@ Rifampicin 300mg/capR
@ Rifampicim 150mg/capR
@ Pyrazinamide 500mg/tabZ
15
Penicillin
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Penicillin G
Oxacillin
1~2g Q6H
1~2g Q6H
1~2g Q6H
1~2g Q6H
Ampicillin
250mg~2g Q6H
250mg~2g Q6~12H
250mg~2g Q12H~QD
Amoxicillin
200~500mg Q8H
200~500mg Q8~12H
200~500mg QD
Amoxicillin/Clavulanate
1g/0.2g Q8H
1g/0.2g Q12H
1g/0.2g QD
Ampicillin/Sulbactam
2g/1g Q6H
2g/1g Q8~12H
2g/1g QD
Piperacillin/Tazobactam
4g/0.5g Q6H
2g/0.25g Q6H
2g/0.25g Q8H
2g/0.25g Q6H
------------------------------------------------------------------------------------------------------------------------------------------
Cephalosporin
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Cefazolin
1~2g Q8H
1~2g Q12H
1~2g QD~QOD
1~2g Q12H
Cefuroxime
0.75~1.5g Q8H
0.75~1.5g Q8~12H
0.75~1.5g QD
0.75~1.5g Q8~12H
Ceftriaxone
1g Q12H
1g Q12H
1g Q12H
1g Q12H
Ceftazidime
2g Q8~12H
2g Q12H~QD
2g QD~QOD
2g Q12H~QD
Flomoxef
1g Q8H
1g Q12H
1g QD
1g Q12H
Cefepime
2g Q8H
2g Q12H~QD
1g QD
2g Q12H~QD
------------------------------------------------------------------------------------------------------------------------------------------
Carbapenem
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Imipenem
500mg Q6H
250mg Q6H
250mg Q12H
(Tienem)
(1PC Q6H)
(0.5PC Q6H)
(0.5PC Q12H)
Meropenem
1g Q8H
1g Q12H
0.5g QD
1g Q12H
Ertapenem
1g QD
0.5g QD
0.5g QD
Doripenem
500mg Q8H
250mg Q8~12H
------------------------------------------------------------------------------------------------------------------------------------------
Aminoglycoside
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Gentamicin
1.7mg/kg Q8H
1.7mg/kg Q12H~QOD
1.7mg/kg QOD~Q3D
1.7mg/kg Q12H~QOD
Amikacin
7.5mg/kg QD
7.5mg/kg QD
7.5mg/kg Q3D
7.5mg/kg QD
16
------------------------------------------------------------------------------------------------------------------------------------------
Quinolone
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Ciprofloxacin
400mg Q12H
400mg QD
400mg QD
Levofloxacin
750mg QD
750mg QOD
500mg QOD
Moxifloxacin
400mg QD
400mg QD
400mg QD
Gemifloxacin
320mg QD
160mg QD
160mg QD
------------------------------------------------------------------------------------------------------------------------------------------
Glycopeptide
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Vancomycin
1g Q12H
1g QD
1g Q5D
Teicoplanin
400mg QD
400mg QOD
400mg Q3D
(Loading dose)
(400mg Q12H)
(400mg Q12H)
(400mg Q12H)
------------------------------------------------------------------------------------------------------------------------------------------
Anaerobic
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Metronidazole
7.5mg/kg Q8H
7.5mg/kg Q12H
7.5mg/kg QD
7.5mg/kg Q12H
Clindamycin
600mg Q8H
600mg Q8H
600mg Q8H
600mg Q8H
------------------------------------------------------------------------------------------------------------------------------------------
GFR >50
GFR 10~50
GFR <10H/DP/D
CRRT
Daptomycin
4~6mg/kg QD
6mg/kg QQD
6mg/kg QOD
8mg/kg QOD
Linezolid
600mg Q12H
600mg Q12H
600mg Q12H
600mg Q12H
Tigecycline
50mg Q12H
50mg Q12H
50mg Q12H
50mg Q12H
(Loading dose)
(100mg STAT)
(100mg STAT)
(100mg STAT)
(100mg STAT)
Colistin
2PC Q12H
1PC Q12H
0.5PC Q12H
3.5PC Q12H
Baktar (TMP-SMX)
(>50kg) 3PC QD
(Cotrimoxazole)
(<50kg) 2PC QD
17
CGMH R3
SBP (mmHg)
DBP (mmHg)
Normal SBP
<120
<80
Pre-HTN
120~140
80~90
Stage 1 HTN
140~160
90~100
Stage 2 HTN
>160
>100
>140
<90
=====================================================================================
Essential HTN95%
# 30~60
# 60 resistant arteriole
# 60
Isolated systolic HTN
Pulse pressure
# Isolated systolic HTN
-
-
------------------------------------------------------------------------------------------------------------------------------------------
Secondary HTN5%
# < 30 > 60
#
18
#
14%
a. 2%
- Atherosclerosis
- Fibromuscular dysplasia medial fibroplasia
- Bruit ACEi/ARB
-
- Captopril Renography
b. 2%
- DM nephropathyRenal cystPKDRenal tumor
20.5%
- HyperaldosteronismCushing syndromePheochromocytoma
30.2%
- renin volume expansion
-
# Obstructive sleep apneaPreeclampsiaEclampsia
ACEi/ARB
RAA system
19
=====================================================================================
AACEi/ARB
ACEi
#
1CaptoprilCapoten TID !
2EnalaprilSynbot
3FosinoprilFonosil
4LisinoprilZestril
5RamiprilTritace
# RAA system
#
2
a. preloadafterload
b. Post-MI remodeling
@ ARBValsartanCandesartan
#
20
B-blocker
# 1 Renin 12
#
ISA (-)
ISA (+)
1 blocker
AtenololTenorminBisoprololMetoprolol
Acebutolol
Non-selective -blocker
PropranololInderalNadololTimolol
Pindolol
CarvedilolDilatrendLabetalolTrandate
# -blockerBisoprololMetoprololCarvedilol
# ISA (+)Intrinsic sympathetic activity
# ISA (-)
# Selective 1 blockerAtenololBisoprololMetoprolol
# PropranololInderal
1Rate control
2Hyperthyroidism
3Portal hypertension
21
# HR
#
1-blocker
2 Thiazide
3 CCBACEi Isolated systolic HTN
CCB > ACEi > -blocker
42 blockage effect claudication
5 -blocker
6
-blocker TCA tremorAtenolol
CNS tremor tremor Propranolol
#
1 blocker
@ Atenolol 100mg/tab1# QD
@ Bisoprolol hemifumarate 1.25mg/tab1# QD 1.25mg 10mg
@ Bisoprolol 5mg/tab (Concor, Merck)1# QD 1.25mg 10mg
@ BISOPROLOL FUMARATE 5mg/tab (Sinbisol,)1# QD 1.25mg
10mg
@ Metoprolol 25mg/tab1# QD
Non-selective -blocker
@ Propranolol 10mg/tab1# TID
1 blocker + Non-selective -blocker
@ Carvedilol 6.25mg/tab (Dilatrend, Roche)1# BID
@ CARVEDILOL 6.25mg/tab (Carvedilol HEXAL, Sandozs)1# BID
@ CARVEDILOL 25mg/tab (Carvedilol HEXAL, Sandozs)1# BID
@ Labetalol 200mg/tab1# BID
@ Labetalol HCl 25mg/5ml/ampfor Hypertensive Emergency
------------------------------------------------------------------------------------------------------------------------------------------
CCCB
#
DHP
1NifedipineAdalet TID ! 10mg/cap
2AmlodipineNorvasc
3FelodipinePlendil
4LercanidipineZanidip
5NicardipineNicarpine for Hypertensive Emergency!
Non-DHP
1DiltiazemHerbesser
2VerapamilIsoptin
22
#
1DHP >
DHP > Diltiazem > Verapamil
2Non-DHP Atrial fibrillation rate control
Verapamil > Diltiazem > DHP
#
1 ACEi-blocker CCB > ACEi > -blocker
2 Isolated systolic HTN Vasodilator
#
1ankle edema>
2 Non-DHP
Nifedipine Hypertensive
Urgency
Nifedipine
Amlodipine 3~4 Onset3~4 Peak7
Amlodipine
#
DHP
@ Nifedipine 10mg/cap1# TID BP
@ Nifedipine ex. release 30mg/tab (Adalat OROS, Bayer)1# QD
@ NIFEDIPINE slow release film-coated 30mg/tab ()1# QD
@ Amlodipine 5mg/tab (Norvasc, Pfizer)1# QD~BID 2# QD
@ AMLODIPINE 5mg/tab (Amlodipine, Sandoz, Sandoz)1# QD~BID 2# QD
@ Felodipine 5mg/tab1# QD~BID
@ FELODIPINE 5mg/tab (Stapin,)1# QD~BID
@ Lercanidipine 10mg/tab1# QD~BID 2# QD
@ Nicardipine HCl 10mg/10ml/amp ()for Hypertensive Emergency
Non-DHP
@ Diltiazem HCl 30mg/tab (Herbesser, Tanabe)1# TID
@ DILTIAZEM HCl 30mg/tab (Cartil,)1# TID
@ Diltiazem long acting 90mg/tab (Cardizem)1# QD
@ Verapamil HCl 40mg/tab1# TID~QID
@ Verapamil s.r 240mg/f.c tab oral1# QD
@ Verapamil HCl 5mg/2ml/amp
ACEi + CCB
@ Amtrel (Amlodipine 5mg + Benazepril HCl 10mg)/tab
ARB + CCB
@ Exforge 5/160 tab (Amlodipine 5mg + Valsartan 160mg)1# QD
@ Telmisartan 80mg + Amlodipine 5mg)/tab1# QD
@ Sevikar 5/20 tab (Amlodipine 5mg + Olmesartan Medoxomil 20mg)1# QD
23
------------------------------------------------------------------------------------------------------------------------------------------
DDiuretics
#
Acetazolamide
Amiloride
MannitolIICP
FurosemideLasix
ThiazideHCTZBehyd
AmilorideTriamterene
Spironolactone
Bumetanide
IndapamideNatrilix
Conivaptan
#
24
25
#
FurosemideLasix
ThiazideHCTZBehyd
+
Na -K -2Cl
Na+-Cl-
Bartters syndrome
Gitelmans syndrome
26
Q1 Thiazide Nephrogenic DINDI?
A1+
exLasix Thiazide
-------------------------------------------------------------------------------------------------------------------------------------Q2Lasix Thiazide ?
------------------------------------------------------------------------------------------------------------------------------------------
Vasodilator
#
1HydralazineApresoline
- NO
- tolerate ACEi/ARB
- Lupus syndrome 200mg
2MinoxidilLaniten
-
-
-
-
3Nitroprusside+
- NO
-
a. NTGSTAT
b. Isosorbide dinitrate (Isodil)TID~QID
c. Isosorbide-5-mononitrate (Imdur)QD HS
- Cyanide
4Fenoldopam
- D1 receptorD1 agonist vasodilatation
#
Hydralazine
@ HydrALAZINE HCl 10mg/tab1# TID~QID
@ HydrALAZINE HCl 50mg/tab1# TID~QID
@ Hydralazine HCl 20mg/ml/amp
Minoxidil
@ Minoxidil 10mg/tab1# QD 0.25#~0.5#
@ Minoxidil 5% Foaming solution 50mg/ml, 90ml/pc1660
Nitroprusside
@ NTG 0.6mg/tab, 25'S/package
@ NTG 5mg/10ml/ampfor Hypertensive Emergency
@ NTG tts 25mg/patch
@ Isosorbide dinitrate 10mg/tab (Isodil)1# TID~QID
@ Isosorbide-5-mononitrate cr 60mg/tab (Imdur, AstraZeneca)1# QD 1# HSfor PND
30mg 2# QD
@ ISOSORBIDE-5-MONONITRATE CR 60mg/tab (IBIMO,)1# QD 1# HSfor PND
30mg 2# QD
28
1-Blocker
#
1Terazosin
2Doxazosin
3Prazosin
4Tamsulosin BPH
#
# Postural hypotensionVasovagal syncope Risk factor
First dose phenomenon
#
@ Terazosin HCl 2mg/tab1# HS
@ Doxazosin XL 4mg/tab (Doxaben XL, Pfizer)1# HS
@ Tamsulosin D 0.2mg/tab (Astellas, Harnalidge)1# QD
@ TAMSULOSIN HCL SR O.D. 0.2mg/tab (Hanlosin,)1# QD
@ Tamsulosin prolonged release 0.4mg/tab1# QD
2-Agonist
#
1ClonidineCatapres
- Vasopressor Center 2 receptor NE
- Rebound hypertension
- = NEor 5-HT
2MethyldopaAldomet
- Methyldopa prodrug -methylnorepinephrine
Vasopressor Center 2 receptor NE
-
-
- = NEor 5-HT
#
@ Clonidine 75mcg/tab1# BID
@ Methyldopa 250mg/tab1# QID
Neuron Blocker
#
1Reserpine
- NE NE
- = NEor 5-HT
2Guanethidine
-
- = NEor 5-HT
29
=====================================================================================
NICE Guideline
Step-1
< 55
> 55 or
C or D
Step-2
A+C or A+D
Step-3
A+C+D
Step-4
A+C+D+
30
------------------------------------------------------------------------------------------------------------------------------------------
#
#
#
#
#
#
#
ACEi/ARB
ACEi/ARB-blockerISA (-)
Isolated Systolic HTNCCBDHP DiureticsThiazide
-blockerCCBNon-DHP
DiureticsThiazide
-blocker
MethyldopaHydralazineLabetalolNifedipine
------------------------------------------------------------------------------------------------------------------------------------------
# ACEi/ARB
# ACEi/ARB
# -blocker2
#
#
#
#
#
#
#
-blocker2
-blocker2-agonistNeuron blocker
-blocker + Thiazide Diabetogenic potential
-blocker + Thiazide
DiureticsLasixThiazide
-blockerCCBNon-DHP
CCBNon-DHP
=====================================================================================
Hypertensive Emergency
#
#
# 220/140
mmHg
# NTG Labetalol 160/100 mmHg
#
1 220/130 mmHg
2 180/130 mmHg
3 185/110 mmHg
4SAHMAP 130 mmHg
5SBP 120 mmHg
31
------------------------------------------------------------------------------------------------------------------------------------------
Hypertensive Urgency
#
# SBP >180 mmHgDBP >120 mmHg
#
#
1
2 Nifedipine
Hypertensive emergency
1~2 160/100 mmHg
3
=====================================================================================
# ACEi/ARB
# Methyldopa
# HydralazineLabetalol Nifedipine
32
CGMH R3
OHA
QD
HbA1c
Sulfonylurea
Glimepiride
1.5
Glibenclamide
Gliclazide
QD~BID
Glipizide
GI
GI
Lipid profile
Lipid profile
Glinide
Repaglinide
1.5
Nateglinide
Mitiglinide
DPP-4
Incretin inhibitor
0.8
Biguanide
TID
Sitagliptin
Metformin
QD
TID
1.5
TZD
Rosiglitazone
1.0
Pioglitazone
QD
-glucosidase
inhibitor
0.7
Acarbose
TID
Pancreatic -cell
33
GI
------------------------------------------------------------------------------------------------------------------------------------------
Sulfonylurea
#
1GlimepirideAmarylQD
2GlibenclamideDiabetin, Euglucon, GlyburideQD
3GliclazideDiamicronQD~BID
4GlipizideMinidiabQD~BID
# -cell ATP-sensitive K+ channel
# HbA1C 1.5
# Days~Weeks
# Onset
#
1
Glinide
Glibenclamide active metabolites
2
#
MeglitinideGlinide
#
1RepaglinideNovonormTID
2NateglinideStatlixTID
3MitiglinideTID
#
#
#
#
1
2
34
#
1
2
# Sulfonylurea Glinide
#
@ Repaglinide 1mg/tab (Novonorm, Novo Nordisk)1# TID
@ REPAGLINIDE 1mg/tab (Rovo,)1# TID
@ Mitiglinide 10mg/tab1# TID
------------------------------------------------------------------------------------------------------------------------------------------
DPP-4 Inhibitor
#
1SitagliptinJanuvia
2VildagliptinGalvus
3SaxagliptinOnglyza
4LinagliptinTrajenta
# Incretin GLP-1
GLP-1 DPP-4 GLP-1
Glucagon-like peptide-1GLP-1Dipeptidyl peptidase-4DPP-4
# HbA1C 0.8
# Days~Weeks
#
1Incretin
2Incretin
3Linagliptin
4PotencySaxagliptin > Linagliptin
# GFR > 50100mg/dGFR 25~5050mg/d
GFR < 2525mg/d
#
@ Sitagliptin 100mg/tab1# QD
@ Vildagliptin 50mg/tab1# BID
@ Saxagliptin 5mg/tab1# QD
@ Linagliptin 5mg/tab1# QD
Biguanide
#
1MetforminGlucophage
#
1
2 Metformin
# HbA1C 1.5
# Days~Weeks
#
1
2 Lipid profileUKPD
3
#
1
2
#
@ Metformin 500mg/tab1# TID
------------------------------------------------------------------------------------------------------------------------------------------
TZDGlitazone
#
1RosiglitazoneAvandia
2PioglitazoneActos
# PPAR-
GLUT-4
Peroxisome proliferative-activated receptor-PPAR-
# HbA1C 1.0
# Weeks~Months
#
1
2 Lipid profile
#
1
2 sodium retention
TZD
3 Rosiglitazone
4
5
6
36
-glucosidase inhibitor
#
1AcarboseGlucobay
# -glucosidase
# HbA1C 0.7
#
#
1
2
-glucosidase
#
1
2
#
@ Acarbose 50mg/tab1# TID
37
------------------------------------------------------------------------------------------------------------------------------------------
OHA
#
1Sulfonylurea
2Biguanide TZD
3NPHDetemirGlargine
#
1Glinide
2 Incretin DPP-4 inhibitor
3-glucosidase inhibitor
4AspartLisproRI
#
1Sulfonylurea Glinide
2TZD
#
1Biguanide
2DPP-4 inhibitor
#
1Sulfonylurea
2Biguanide
3TZD
#
1Sulfonylurea
2DPP-4 inhibitor
3Biguanide
4-glucosidase inhibitor
------------------------------------------------------------------------------------------------------------------------------------------
OHA
1. OHA contraindication Metformin
1# BID~1# TID
2. 1# TID Sulfonylurea
3. DPP-4 inhibitor
4. TZD
Basal insulin
5. OHA Basal insulin
6. Metformin DPP-4 inhibitor Basal insulin
Glinide Acarbose
38
=====================================================================================
Insulin
# 0.5~1 U/kg/day2/3 1/3
-----------------------------------------------------------------------------------------------------------------------------------------
Onset
Peak
Duration
Rapid
AspartNovoRapid
3~4
LisproHumalog
GlulisineApidra
Short
RI
~1
2~3
3~6
Intermediate
NPH
1~4
6~10
10~16
Basal
DetemirLevemir
1~4
6~14
12~20
GlargineLantus
1~4
6~24
24
Rapid
Short
Intermediate
Basal
10
12
14
16
18
20
Rapid
1AspartNovoRapid
#
@ Insulin Aspart 100IU/ml, 3ml/pc TID HS
@ NovoMix 30 penfill 100U/ml, 3ml/pc30% Insulin Aspart + 70% Insulin Aspart Protamine
BID
@ NovoMix 50 penfill 100U/ml, 3ml/pc50% Insulin Aspart + 50% Insulin Aspart Protamine
BID
2LisproHumalog
#
@ Insulin Lispro 100IU/ml, 3ml/penfill TID HS
@ Humalog 100IU/ml, 3ml/penfill TID HS
@ Humalog Mix25 100IU/ml, 3ml/pen25% Insulin Lispro + 75% Insulin Lispro Protamine
BID
@ Humalog Mix50 100IU/ml, 3ml/pen50% Insulin Lispro + 50% Insulin Lispro Protamine
BID HS
39
3GlulisineApidra
#
@ Insulin GLULISINE (Apidra) 100IU/ml, 3ml/pen TID HS
------------------------------------------------------------------------------------------------------------------------------------------
Short
1Regular InsulinRI
# RI 1U 30
#
@ Regular HM insulin 100IU/ml, 10ml/vial TID HS
------------------------------------------------------------------------------------------------------------------------------------------
Intermediate
1Neutral Protamine HagedornNPHInsulin
# NPH 1U 20
#
@ NPH human insulin 100IU/ml, 10ml/vial BID HS HS
TID
------------------------------------------------------------------------------------------------------------------------------------------
Basal
1DetemirLevemir
#
@ Insulin detemir 300u/3ml/ HS TID
2GlargineLantus
#
@ Insulin glargine (Lantus) 100iu/ml, 3ml/pen HS TID
@ Insulin glargine 100iu/ml, 10ml/vial HS TID
------------------------------------------------------------------------------------------------------------------------------------------
1
- Basal insulin
2
- intensive insulin management
- AspartGlargine RINPH
3
-
4DKAHHS
40
CGMH R3
Hyponatremia
#
------------------------------------------------------------------------------------------------------------------------------------------
Plasma Osmolality
1Hypotonic
2Isotonic
3Hypertonic
# Osm (B)
Hypotonic Volume
1Hypovolemic
2Euvolemic
3Hypervolemic
Hypotonic Hyponatremia
#
41
Hypotonic hyponatremia
Hypovolemic
Euvolemic
Hypovolemic
Hyponatremia
UNa > 20
UNa < 10
FENa > 1%
FENa < 1%
Hypervolemic
Euvolemic
Hyponatremia
Hypervolemic
Hyponatremia
Uosm var.
UNa < 10
UNa > 20
FENa < 1%
FENa > 1%
Renal loss
Extra-renal
SIADH
Primary
Reset
C.H.F
Renal
Mineralocorticoid
loss
Hypothyroidism
Polydipsia
osmostat
Cirrhosis
failure
Glucocorticoid
Low salt
deficiency
Nephrosis
deficiency
Isotonic Hyponatremia
#
# HyperlipdemiaHyperproteinemiaMultiple myeloma
------------------------------------------------------------------------------------------------------------------------------------------
Hypertonic Hyponatremia
#
# 100 mg/dl 2.4 mEq/L
------------------------------------------------------------------------------------------------------------------------------------------
#
# Hypotonic hyponatremia
Hypervolemic
# Lasix
Hypovolemic
#
Euvolemic
#
1 Lasix
43
@
[Na] per 1L infusate = ([Na] infusate - [Na] serum) / (TBW + 1)
TBW = BW x 0.6 x 0.5
= BW x 0.5 x 0.45
70 110 mEq/L 1L 3%NaCl
ANSTBW = 70 x 0.6 = 42
[Na] = (513 - 110) / (42 + 1) = 9.4 mEq/L
Hypernatremia
#
------------------------------------------------------------------------------------------------------------------------------------------
Hypervolemic
# HydrationD5W+
44
Euvolemic
# ADH
#
1Central diabetes insipidus
- ADH
- DDAVP 50%
- DDAVP
2Nephrogenic diabetes insipidus
- ADH
- DDAVP 10%
- Thiazide
Hypovolemic
# HydrationD5W
@
TBW x = (TBW + X) x
70 160 mEq/L 140 mEq/L
ANS70 x 0.6 x 160 = (70 x 0.6 + X) x 140
X=6L
@
10~12 mEq/L 8 mEq/L
ANS70 x 0.6 x 160 = (70 x 0.6 + X) x (160 - 8)
X = 2.2 L
------------------------------------------------------------------------------------------------------------------------------------------
Urine Osmolality
# Dehydration
#
Uosm
Complete DI
< 300
Partial DI
300~800
GI lossRemote diuretics
> 800
45
------------------------------------------------------------------------------------------------------------------------------------------
Polyuria
Water diuresis
Uosm < 250
> 140
Solute diuresis
Uosm > 300
NG
Salt-wasting nephropathy
=====================================================================================
Hypokalemia
# 98% 2%
# Paralysis
------------------------------------------------------------------------------------------------------------------------------------------
# ST T U
46
------------------------------------------------------------------------------------------------------------------------------------------
Transcellular shift
# Insulin-agonistThyrotoxicosisTheophylline
Extra-renal loss Renal loss
# Extra-renal lossGI loss
- UK < 15 mEq/L
- UK < 25 mEq/day
Insulin
-agonist
Thyroxine
Digoxin
Theophylline
-blocker
- TTKG < 3
# Renal loss
- UK > 15 mEq/L
- UK > 30 mEq/day
- TTKG > 7
@ TTKG = (UK/PK) / (Uosm/Posm)
Transtubular K gradient
Alkalosis
Renal loss
Acidosis
Hypokalemia
Poor intake
Transcellular Shift
UK < 15 mEq/L
UK > 15 mEq/L
UK < 25 mEq/day
UK > 30 mEq/day
TTKG < 3
TTKG > 7
Extra-renal loss
Insulin
-agonist
Renal loss
GI loss
Thyrotoxicosis
Theophylline
Alkalosis
Diarrhea
Laxative abuse
Villous adenoma
Aldosterone
UCl < 20
UCl > 20
DKA
Vomiting
Diuretics
Type I RTA
NG tube
Bartters syndrome
Type II RTA
Amphotericin B
Aldosterone
1st hyperaldosteronism
- Conns syndrome
2nd hyperaldosteronism
Gitelmans syndrome
47
Liddles syndrome
Apparent mineralocorticoid
Excess (AME)
Licorice
------------------------------------------------------------------------------------------------------------------------------------------
Transcellular shift
1 H+-K+
# Alkalosis K+
2Na+-K+ ATPase
# Insulin Na+-K+ ATPase Na+ K+
exDKA Insulin
# -agonist Na+-K+ ATPase Na+ K+
exAsthma COPD -agonist
# Thyrotoxicosis periodic paralysis, TPP
Na+-K+ ATPase Na+ K+
shift
3Ca DHP
# Hypokalemia periodic paralysis, HPP
shift
20
------------------------------------------------------------------------------------------------------------------------------------------
Extra-renal loss
#
- UK < 15 mEq/L
- UK < 25 mEq/day
- TTKG < 3
# DiarrheaLaxative abuseVillous adenoma
------------------------------------------------------------------------------------------------------------------------------------------
Renal loss
#
- UK > 15 mEq/L
- UK > 30 mEq/day
- TTKG > 7
48
# Aldosterone
1Primary hyperaldosteronismRenin Aldosterone
- Conn's syndrome
2Secondary hyperaldosteronismRenin Aldosterone
- Renal artery stenosis
- Renin-secreting tumor
# Aldosterone
1Liddle's syndrome Na Na K
2Apparent Mineralocorticoid ExcessAME
3Licorice
#
1DKA
2RTA type IDistalH+ Sjogren syndrome
3RTA type IIProximalHCO3- Multiple myeloma
4Amphotericin B
#
1LasixThiazide
2Bartter's syndrome
3Gitelman's syndrome
Bartters syndrome
Gitelmans syndrome
+
Na -K -2Cl Na+-Cl-
Lasix
Thiazide
Spironolactone
NSAID
Spironolactone
NSAID
------------------------------------------------------------------------------------------------------------------------------------------
#
1
2 Slow K
3 Potassium
49
=====================================================================================
Hyperkalemia
# Paralysis
------------------------------------------------------------------------------------------------------------------------------------------
#
- Diffuse peaked T waves
- PR prolong
- P wave
- QRS widening
- Sine wave pattern QRS T
- VF or PEA
Peaked T Wave
QRS widening
PR prolong
P Wave
@ VF cardiac arrest
------------------------------------------------------------------------------------------------------------------------------------------
Transcellular shift
# -blockerDigoxin
# CKD
TTKG
50
Hyperkalemia
Transcellular Shift
-blocker
Digoxin
Acidosis
CKD
TTKG > 10
TTKG < 5
Aldosterone
Aldosterone
C.H.F
Cirrhosis
Aldosterone
Aldosterone
Fludrocortisone
Fludrocortisone
TTKG > 10
TTKG < 10
Renin
Spironolactone
Renin
Baktar
Calcineurin inhibitor
DM nephropathy
Addisons disease
NSAIDS
ACEi/ARB
-blocker
Heparin
Ketoconazole
Cyclosporine
HIV
51
------------------------------------------------------------------------------------------------------------------------------------------
Transcellular shift
1H+-K+
# AcidosisH+K+
2Na+-K+ ATPase
# -blocker Na+-K+ ATPase
# Digoxin Na+-K+ ATPase
------------------------------------------------------------------------------------------------------------------------------------------
Calcium gluconate
Glucose + RI
15~30
DiureticsLasixThiazide
30
2-agonist
30~90
Kalimate
1~2
Hemodialysis
52
CGMH R3
pH
# pH7.36~7.44HCO3-24PaCO240
# pH < 7.36
- HCO3- Metabolic Acidosis
- PaCO2 Respiratory Acidosis
# pH > 7.44
- HCO3- Metabolic Alkalosis
- PaCO2 Respiratory Alkalosis
# pH
- PaCO2 + HCO3- +
- PaCO2 + HCO3- +
- PaCO2HCO3- AG
------------------------------------------------------------------------------------------------------------------------------------------
1.25
0.75
0.1
0.2
0.3
0.4
# HCO3-
- PaCO2 = 1.25 x ( HCO3-)
- PaCO2 < 1.25 x ( HCO3-) +
- PaCO2 > 1.25 x ( HCO3-) +
HCO3- = 16 HCO3- = 8
- PaCO2 = 30 PaCO2 = 1.25 x ( HCO3-)
- PaCO2 > 30 PaCO2 < 1.25 x ( HCO3-) +
- PaCO2 < 30 PaCO2 > 1.25 x ( HCO3-) +
53
# PaCO2
- HCO3- < 0.1 x ( PaCO2) +
-
PaCO2 = 50 PaCO2 = 10
- HCO3- < 25 HCO3- < 0.1 x ( PaCO2) +
- HCO3- = 25 HCO3- = 0.1 x ( PaCO2)
- HCO3- = 25~27 HCO3- = 0.1~0.3 x ( PaCO2)
- HCO3- = 27 HCO3- = 0.3 x ( PaCO2)
- HCO3- > 27 HCO3- > 0.3 x ( PaCO2) +
# HCO3-
- PaCO2 = 0.75 x ( HCO3-)
- PaCO2 < 0.75 x ( HCO3-) +
- PaCO2 > 0.75 x ( HCO3-) +
HCO3- = 32 HCO3- = 8
- PaCO2 = 46 PaCO2 = 0.75 x ( HCO3-)
- PaCO2 < 46 PaCO2 < 0.75 x ( HCO3-) +
- PaCO2 > 46 PaCO2 > 0.75 x ( HCO3-) +
# PaCO2
- HCO3- < 0.2 x ( PaCO2) +
- HCO3- = 0.2 x ( PaCO2)
- HCO3- = 0.2~0.4 x ( PaCO2)
- HCO3- = 0.4 x ( PaCO2)
- HCO3- > 0.4 x ( PaCO2) +
PaCO2 = 30 PaCO2 = 10
-
------------------------------------------------------------------------------------------------------------------------------------------
AG AG/ HCO3-
AGAnion Gap= [Na+] - ( [Cl-] + [HCO3-] )
#
+ = +
- = -
[Na+] - ( [Cl-] + [HCO3-] ) = ( [Albumin] + [] ) - ( [K+] + [Ca2+] + [Mg2+] )
[Na ]
( [Cl ] +
[HCO3 ]
( [Albumin] + [] )
2+
2+
( [K ] + [Ca ] + [Mg ] )
@ AG
@ Albumin mask
Corrected AG = Measured AG + (4 - Albumin) x 2.5
@ K+ Ca2+ Mg2+ AG
# AG = 10 2
# AG AG/ HCO3- HCO3- AG
- AG/ HCO3- = 1~2AG = HCO3- HCO3-
High AG
- AG/ HCO3- < 1AG < HCO3- HCO3- loss
High AG + Normal AG
- AG/ HCO3- > 2AG > HCO3- HCO3- gain
High AG +
AG = 20 AG = 10
- HCO3- = 14 HCO3- = 10 AG/ HCO3- = 1 High AG
- HCO3- = 4 HCO3- = 20 AG/ HCO3- < 1 High AG + Normal AG
- HCO3- = 20 HCO3- = 4 AG/ HCO3- > 2 High AG +
=====================================================================================
High AG
1KetoacidosisDKA
# Ketone Body (U)Blood Ketone Quantitative Test (B)
2Lactic AcidosisSepsis
# Lactate
55
3Uremia
# Creatinine
4MethanolEthanolEthylene glycolIsopropanol
# Osmolality gapOG > 10
5SalicylateParaldehyde
# Osmolality gapOG < 10
OGOsmolality Gap= Measured Osmoles - Calculated Osmoles
Calculated Osmole =2[Na-] + [Glucose]/18 + [BUN]/2.8
------------------------------------------------------------------------------------------------------------------------------------------
Normal AG
# UAGUrine Anion Gap
UAG = (UNa + UK) - UCl
#
+ = +
- = -
=====================================================================================
# UCl < 20
1VomitingNG drainage H+ loss
@ H+Cl-K+HCO32Volume depletion RAA system
# UCl > 20
1HyperaldosteronismPrimarySecondary
2Bartter's syndromeGitelman's syndrome
=====================================================================================
AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 140 - ( 106 + 14 ) = 20
High AG
AG/ HCO3- = 10/10 = 1
High AG
High AG +
------------------------------------------------------------------------------------------------------------------------------------------
AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 140 - ( 102 + 18 ) = 20
High AG
AG/ HCO3- = 10/6 = 1~2
High AG
High AG +
57
------------------------------------------------------------------------------------------------------------------------------------------
AG AG/ HCO3-
+
------------------------------------------------------------------------------------------------------------------------------------------
AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 140 - ( 95 + 25 ) = 20
High AG
AG/ HCO3- = 10/1 > 2
High AG +
High AG +
------------------------------------------------------------------------------------------------------------------------------------------
AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 135 - ( 110 + 10 ) = 15
High AG
AG/ HCO3- = 5/14 < 1
High AG + Normal AG
High AG + Normal AG +
58
CGMH R3
Hemodialysis
- Arterial needle
- Arterial pressure monitor
- Blood pump
- Heparin syringe
- DialyzerHollow fiber AK
- Venous pressure monitor
- Air detector / clamp
- Venous needle
Blood Flow
Dialysate out
Heparin
Syringe
Blood Flow
Dialyzer
Blood
Pump
Dialysate in
Arterial
Pressure
Monitor
Venous
Pressure
Monitor
Air detector / Clamp
Blood Flow
Artery
AV Shunt
Vein
> 6 re-circulation
59
------------------------------------------------------------------------------------------------------------------------------------------
1Sign Permit
- H/D permit
- Double lumen catheter permit Double lumen
2Frequency
- QW135
- QW246
- QW15
- QW26
- ex: 7/6, 7/8, 7/10
#
3Vascular Access
1. AV Shunt
a. AV fistulaAVF
- brachial artery radial artery cephalic vein
- Venous arterialization
- CCr = 10~15 ml/min
Hickman
- 2~3
b. AV graftGortexAVG
-
- AVF
- 1
2. Hickman catheter
- Tunnel-cuffed catheterTCC
PERM catheter
- 1~3
- Internal jugular vein
-
3. Double lumen catheter
- Non-cuffed catheter
- 14
- Femoral vein
- Bedside
60
4Location
- AV ShuntForearm or Arm
- Hickman catheter Internal jugular vein Subclavian vein
- Double lumen catheter Femoral vein
5DialyzerHollow Fiber AK
# Dialyzer
- FB 170G
- FB 210U
#
# Disequilibrium syndrome
Brain edema
#
- BUNCreatinineUric acid
- NaKCaPMg
- Pyrogen
- H+
- H2O
#
- RBCWBC
61
6Duration
- 2.5 hrs x 1, then 3.0 hrs x 2, then 4.0 hrs
- 4.0 hrs
# 4
# 2.5
7Dialysate
Na+
K+
Ca2+
Mg2+
Cl-
CH3COO-
HCO3-
Dextrose
No.16
103.00
2.0
3.5
109.5
3.0
100
No.100
100.00
2.0
2.5
0.75
105.25
2.0
200
No.110
103.00
2.0
3.0 1
109.0
3.0
200
Ca2+
Glucose
K+
No.8
3.5
200
2.0
No.9
2.5
100
2.0
No.10
3.0 0
2.0
No.11
3.0 100
2.0
#
-
-
-
# 2.0
7 KCl 3.0
8Blood flow
- 150 ml/min x 3, then 200~250 ml/min
- 200~250 ml/min
# Blood flow
9Dry weightDW
#
#
10UltrafiltrationUF
#
#
#
50 kg
53 kg
Dry weight
48
48
Ultrafiltration
62
11Heparin
#
1. Heparin none
- Heparin
2. Heparin drained out5000u AK
- Heparin normal saline
Heparin coating
- bleeding tendency
3. Heparin free5000u AK
- Heparin normal saline
Heparin
- bleeding tendency
-
4. Heparin loading/maintain
- Heparin
Loading dose20~30u/kgMaintain doseLoading dose
- Ex1000u/500u1500u/750u2000u/1000u
# Heparin 1 2 3 4
12Mannitol
- Mannitol 150ml IVF x 3 times
# Mannitol
13Blood transfusion
- Blood transfusion with voluven 250cc priming and during H/D
- Blood transfusion with SFP 2u priming and during H/D
# Colloid
Albumin
TetrastarchVoluven
SFP
FFP
63
------------------------------------------------------------------------------------------------------------------------------------------
Modality
# Modality
1Intermittent hemodialysisIHD
2Continuous renal replacement therapyCRRT
3Sustained low efficiency dialysisSLED
#
# 24 CVVHCVVHDCAVHCAVHD
C ContinuousVV veno-venoAV arterio-veno
H HemofiltrationHD Hemodialysis
24
# Hybrid therapy
8 12 Blood flow
150~180 ml/min
------------------------------------------------------------------------------------------------------------------------------------------
135~155
132
H/D
0~4
P/D
2.5~3.5
2.5~3.5
0~0.20
1.5/2.5/4.0/25
P/D
25~40
Bicarbonate acetate
35~40
pH 5.2~5.6
64
------------------------------------------------------------------------------------------------------------------------------------------
1Intradialytic hypotension
-
a. 100 mmHg
b. 100 mmHg 25%
-
a.
b.
c.
-
a.
b. 140 mEq/L 150 mEq/L
c. NO
d.
e. 1-agonistMidodrine
f.
2Dialysis-related amyloidosis
- 2-microglobulin carpal tunnel
syndromebone cystcervical pseudotumorarthropathy
65
=====================================================================================
Peritoneal Dialysis
#
# fluid overload
#
1
2
3
4
5
# Peritoneal equilibrium test
1High transporter
2Average transporter
3Low transporter
------------------------------------------------------------------------------------------------------------------------------------------
1
a. CAPD peritonitis
- Cloudy effluentAscites WBC > 100Neutrophil > 50%
- CONSStaphylococcus epidermidis GNB
- Cefazolin + FortumIP
b. Exit-site infection
- Less well-definedPainDischarge from exit site
- Staphylococcus aureus
2Encapsulating peritoneal sclerosis
-
- Ileus
- High peritoneal permeability state
- TPN
3
- 60~80%
4
-
66
CAPD peritonitis
Cefazolin
#
Loading dose1000 mg/each bag2Lx 8 hrs
Maintain dose250 mg/each bag2L
#
@ Cefazolin sodium 1GM/vial
@ Cefazolin sodium 500mg/vial
CeftazidimeFortum
#
Loading dose1000 mg/each bag2Lx 8 hrs
Maintain dose250 mg/each bag2L
#
@ Ceftazidime 1g/vial
@ Ceftazidime 500mg/vial
Loading Dose
(Per liter of dialysate)
Maintain Dose
(Per liter of dialysate)
500mg
125mg
Ceftazidime
500mg
125mg
Cefepime
500mg
125mg
Amoxicillin
250 to 500mg
50mg
Ampicillin
None
125mg
Oxacillin
None
125mg
Nafcillin
None
125mg
Penicillin G
50,000 units
25,000 units
Vancomycin
1g
25mg
Teicoplanin
400mg
20mg
Aztreonam
1g
250mg
Ciprofloxacin
50mg
25mg
Daptomycin
100mg
20mg
None
Cephalosporins Cefazolin
Penicillins
Others
Linezolid
ONCE daily
Combinations
Unasyn
1g
100mg
Tienem
250mg
50mg
67
=====================================================================================
RIFLE
AKIN
KDIGO
RRisk
Cr > 50%7
Cr > 50%48
Cr > 50%7
Stage 1
IInjury
Cr > 100%7
Cr > 100%48
Cr > 100%7
Stage 2
FFailure
Cr > 200%7
Cr > 200%48
Cr > 200%7
Stage 3
LLoss
EEnd-stage
------------------------------------------------------------------------------------------------------------------------------------------
GFR
1Estimated GFRCockcroft-Gault formula140 - Agex BW / 72 x PCr x 0.85
2CCr = UCr x 24h / PCr x 1440
3MDRD-Simplify GFR
- 186 x PCr - 1.154 x Age - 0.203
- 186 x PCr - 1.154 x Age - 0.203 x 0.742
------------------------------------------------------------------------------------------------------------------------------------------
Pre-renal55%
#
#
-
Septic shock
Dehydration
Heart failure
Hepatorenal syndrome
NSAID ACEi/ARB GFR
68
Intrinsic renal40%
#
- RPGN
- ATN
- AIN
#
Diagnostic Index
Pre-renal
Intrinsic renal
Spot
FENa
<1
>1
urine
UNa
<20
>40
FEUrea
<35
>55
U/P Cr ratio
>40
<20
UOsm
>500
<350
Serum
BUN/Cr ratio
>20
10~15
U/A
>1.020
~1.010
Urinary sediment
Transparent hyaline
casts
=====================================================================================
1
2
3 CKD
- DM nephropathy
- Amyloidosis
- Polykidney diseasePKD
- Renal vein thrombosis
-
------------------------------------------------------------------------------------------------------------------------------------------
CKD
120
0
Stage
GFR
Stage 1
>90
comorbid condition
Stage 2
60~90
Stage 3
30~60
Stage 4
15~30
Stage 5
<15 or
Stage 5
15
Stage 1
Stage 4
90
Stage 2
30
Stage 3
60
------------------------------------------------------------------------------------------------------------------------------------------
CKD
1
2
3Chronic glomerulonephritisCGN
4Chronic interstitial nephritisCIN
------------------------------------------------------------------------------------------------------------------------------------------
24
# Nitrogen Nitrogen intake = Urinary nitrogen excretion
# Urinary nitrogen excretion = Urine urea nitrogen + Nonurea nitrogen
Nonurea nitrogen 30mg/kg/day Nitrogen Protein
6.25 Estimated protein intake = 6.25 (Urine urea nitrogen + Nonurea nitrogen)
5 g/day 1 g/day
# 60 Urine urea nitrogen = 8. 2 = 3.5 g/day
Estimated protein intake = 6.25 (8.2 + 1.8) = 62.5 g/day
70
------------------------------------------------------------------------------------------------------------------------------------------
CKD
# <40g/day<40mEq/day<3g/day
# EPO
# D2 D3
-
- SevelamerRenagelLanthanum
- PTH Oral ergocalciferolD2
- PTH CalcitriolD3
# CKD ACEi/ARB
- DM < 130/80 mmHg
- DM + < 125/75 mmHg
# DM CCr<10ml/min DM CCr<15ml/min
1Folic acid
-
- 1# QD
2Vitamin B complexHi-Beston
-
- 1# QD~TID
3Calcium carbonate
-
-
- 1# TIDCC
- 2# TID AC CC
4EPO
-
a. Cr > 6
b. Hct<28<36
- 20000u 5000u QW 2000u TIW
5Sennoside
-
71
-------------------------------------------------------------------------------------------------------------------------------------CKD
CKD Hepatic encephalopathy
BUN Low protein diet HE
progressionGuidelineCKD 0.8 g/kg/dayCKD
Hyperkalemia CKD Fluid overload
-------------------------------------------------------------------------------------------------------------------------------------
DM 1ml 1
=
-------------------------------------------------------------------------------------------------------------------------------------
1ml 1
-------------------------------------------------------------------------------------------------------------------------------------&
1ml 2
-------------------------------------------------------------------------------------------------------------------------------------&
-------------------------------------------------------------------------------------------------------------------------------------
1ml 1
-------------------------------------------------------------------------------------------------------------------------------------
diet
73
=====================================================================================
Glomerular disease
1GlomerulonephritisGN
-
a. Acute GN
b. Rapid progressive GNRPGNCrescent formation
c. Chronic GN
- U/ADysmorphic RBCRBC castWBC cast
-
2Nephrotic syndrome
-
-
a. Proteinuria> 3.5 g/d
b. Hypoalbuminemia< 3.5 mg/dL
c. Edema
d. Hypercholesteralemia
e. Hypercoagulable status
24 ?
-5
ml
g/day
------------------------------------------------------------------------------------------------------------------------------------------
Nephrotic Syndrome
Minimal Change DiseaseMCD
-
a. Lipoid nephrosis
b. Nil disease
- 80%
-
a. idiopathic
b. NSAIDRifampinHodgkins disease
-
a.
b. /
effacement/fusion of podocyte foot process
c. Heparan sulfate proteoglycan
Albumin
-
a. Prednisolone1mg/kg
b. CyclosporinCyclophosphamideMycophenolate mofetil
74
Membranous NephropathyMGN
-
- 30~50 = 21
-
a. idiopathic
b. HBVSLERALupus nephritis Class VNSAID
-
a. subepithelium
b. /spike & dome appearance
c.
Diabetic Nephropathy
- CKD
-
Stage 1
GFR 20~40%
Hyperfiltration stage
Stage 2
Silent stage
5~15
Stage 3
24 30~300 mg
Microalbuminuria stage
Incipient nephropathy
10
UACR30~300 mg/g
Stage 4
24 > 300 mg
15
GFR 10 ml/min
UACR> 300 mg/g
Gross proteinuria
Overt nephropathy
Stage 5
ESRD
7 25
-
a. Kimmelstiel-Wilson Nodular Sclerosis
b.
c. hyalinization
d.
75
-
a.
- DM < 130/80 mmHg
- DM + < 125/75 mmHg
b. ACEi/ARB
-
Glomerulonephritis
Post-Streptococcal GlomerulonephritisPSGN
- 2~6
- A
- sub-epithelium
- ASLO (+)
- C3
- &
Goodpastures Syndrome
- 5~40 = 61
-
- Anti-GBM disease
Anti-GBM antibody
Goodpastures syndrome
Anti-GBM disease
- + Cyclophosphamide + Plasmapheresis
76
Hereditary Nephritis
- Alports syndrome
- Triad + +
Rapid Progressive GlomerulonephritisRPGN
- Crescentic glomerulonephritis
- Crescent formation
-
Type I
Goodpastures syndrome
Type II
Type III
Pauci-immune
ANCA vasculitisWegeners granulomatosisMicroscopic polyarteritis nodosa
Churg-Strauss syndrome
------------------------------------------------------------------------------------------------------------------------------------------
+
Lupus Nephritis
- WHO
- Class Irare
- Class II20%mesengium
- Class III25%10~50%Focal GN
- Class IV40%>50%Diffuse GN
- Class V15%Secondary MGN
-
- Class IImesengium
- Class IIIIVsubendotheliumWire-loop
- Class Vsubepithelium
- ANA (+)Anti-dsDNA (+)
- C3
77
Membranoproliferative GlomerulonephritisMPGN
-
- Type I
- C3subendothelium
Tram-track
- C3C4
- Type II
- C3IntramembranousDense deposit
- C3C4
- C3 nephritic factor (+) = Auto-antibody to C3 convertase = C3 convertase
IgA IgA Nephropathy
- Burgers disease
-
- 1~3
- C3
-
- 1/3 20
Henoch-Schonlein H-S Purpura
- Anaphylactoid purpura
- IgA nephropathy + purpura
- C3
Cryoglobulinemia
- Cryoprecipitate (+)
- C3
- Anti-HCV Ab (+)
ANCA Vasculitis
- RPGN Type III
-
ANCA
ANCA (+)
Wegeners granulomatosis
80%
90%
c-ANCA
90%
90%
50%
p-ANCA
70%
Churg-Strauss syndrome
45%
70%
p-ANCA
50%
78
=====================================================================================
Tubular disease
Acute Tubular NecrosisATN
-
a. Ischemia
-
b. Nephrotoxin
- NSAIDAminoglycosideCisplatinAmphotericinCyclosporin
-
- MyoglobinHemoglobin
- Ig light chainmultiple myeloma
- CCl4Chloroform
- HgPbAs
Contrast-Induced NephropathyCIN
-
-
a.
b.
c.
- 24 3~5 7~10
-
- non-ionic
- HydrationN/S half saline
- Acetylcysteine 2# BID
- Sodium bicarbonate
- MetforminNSAID
79
=====================================================================================
Interstitial disease
Acute Interstitial NephritisAIN
-
a. AllergySulfa drugs-lactamNSAIDPPI
b. InfectionAcute pyelonephritisLegionella
c. InfiltrativeLymphomaLeukemiaSarcoidosis
d. AutoimmuneSjogrens syndromeSLE
- TriadFever + Rash + Eosinophilia 5~10
- U/AWBC cast
Analgesic Nephropathy
- PhenacetinAspirin Caffeine
-
- Papillary necrosis
- Chronic interstitial nephritis
- Urothelial malignancy
Chinese Herbs Nephropathy
- Aristolochic acid
-
-
-
80
EKG-1
CGMH R3
Part-1
------------------------------------------------------------------------------------------------------------------------------------------
#
1Pacemaker cell
2Electrical conducting cell
3Myocardial cell
81
# Action potential
------------------------------------------------------------------------------------------------------------------------------------------
# 0.04 0.2
# 0.1 mV
mV
1.0 mV
0.5 mV
s
0.2
0.2
------------------------------------------------------------------------------------------------------------------------------------------
P
82
QRS
83
QRS
# Q
#
#
#
#
R
R'
S
QS
QRS
RS
RSR
QR
QS
# Segment
# Interval +
QRS
ST
PR
PR QRS
QT
84
------------------------------------------------------------------------------------------------------------------------------------------
#
#
#
------------------------------------------------------------------------------------------------------------------------------------------
#
#
#
85
------------------------------------------------------------------------------------------------------------------------------------------
# 0
# 60
# 120
# AVL -30
# AVR -150
# AVF 90
AVR
AVL
III
II
AVF
------------------------------------------------------------------------------------------------------------------------------------------
# V1
# V2
# V3 V2 V4
# V4
# V5 V4 V6
# V6
V6
V5
V4
V1
V2
86
V3
------------------------------------------------------------------------------------------------------------------------------------------
#
#
#
#
V1V2V3V4
IAVLV5V6
IIIIIAVF
AVR
------------------------------------------------------------------------------------------------------------------------------------------
P
#
# IAVLV5V6IIAVF
# IIIV1
# II P
# AVR P
# V2V3V4
PR
#
# 3~5 0.12~0.20
PR
#
PR
PR
87
Q
#
# IAVLV5V6
# IIIIIAVFV3V4
QRS
#
# IAVLV5V6IIIIIAVF R
# AVRV1 S
# R R wave progression V1 R V5 R V6
V5 Transition zone V3~V4
R wave progression
# CWR & CCWR
- CWRClockwise rotationTransition zone V5~V6
- CCWRCounter-clockwise rotationTransition zone V1~V2
88
QRS
#
# 1.5~2.5 0.06~0.1
QRS
ST
#
ST
T
#
# R T
R T
QT
#
# QT QT
# QT RR
# QT prolongQT interval > 50% RR interval
# QTc = QT /RR
QT
89
=====================================================================================
Part-2
#
AVF
- 90o
- 90o
180o
0o
180o
0o
90o
90o
AVF
#
QRS QRS
30 -150 AVF
30
- 90o
- 150o
180o
0o
30o
120o
90o
III
AVF
90
#
- Right axis deviationRAD90 ~180
- Left axis deviationLAD0 ~-90
- Extreme right axis deviationERAD-90 ~180
- 90o
LAD
ERAD
180o
0o
Normal
Axis
RAD
90o
#
------------------------------------------------------------------------------------------------------------------------------------------
RAE
# P IIIIIAVF 2.5
# P
#
Lead II
91
------------------------------------------------------------------------------------------------------------------------------------------
LAE
# P V1 1 1
Lead V1
------------------------------------------------------------------------------------------------------------------------------------------
RVH
#
- QRS
#
- V1 R S
- V6 S R
92
------------------------------------------------------------------------------------------------------------------------------------------
LVH
#
-V5 V6 R V1 V2 S 35
- V5 R 26
- V6 R 18
- V6 R V5 R
@
#
- AVL R 13
- AVF R 21
- R 14
- R S 25
@
93
------------------------------------------------------------------------------------------------------------------------------------------
T
1
2
3RBBB & LBBB
4
94
=====================================================================================
Part-3
AV Block
First Degree AV Block
# PR 5
Mobitz Type II
# PR QRS
95
------------------------------------------------------------------------------------------------------------------------------------------
LBBB
#
- QRS 0.12
- IAVLV5V6 R
- IAVLV5V6 ST T
- V1V2 S
96
------------------------------------------------------------------------------------------------------------------------------------------
Hemiblock
#
- R
- S
-
#
- S
- R
-
97
------------------------------------------------------------------------------------------------------------------------------------------
Bifascicular Block
+
#
- QRS 0.12
- V1V2 RSR'
-
+
#
- QRS 0.12
- V1V2 RSR'
-
------------------------------------------------------------------------------------------------------------------------------------------
Pacemaker
#
-
- Mobitz type II
- Sick sinus syndrome
-
-
98
=====================================================================================
Part-4
# Accessory pathway
------------------------------------------------------------------------------------------------------------------------------------------
Delta
Wave
Kent
Bundle
Fast
Pathway
------------------------------------------------------------------------------------------------------------------------------------------
James
Fiber
99
------------------------------------------------------------------------------------------------------------------------------------------
# WPW PSVTAf
WPW + PSVT
#
1Orthodromic AVRT slow pathway Short RP interval QRS
2Antidromic AVRT fast pathway Long RP interval QRS VT
WPW + Af or AF
# Atrial fibrillationAf 20% WPW syndrome
# Atrial flutterAF 7% WPW syndrome
# 300
Vf
100
=====================================================================================
Part-5
Peaked T wave
PR prolong
P wave
QRS widening
101
# ST T U
# U T U
U wave
# QT interval
------------------------------------------------------------------------------------------------------------------------------------------
#
-
- J waveJ Osborne wave ST
- Af
J wave
Osborne wave
102
------------------------------------------------------------------------------------------------------------------------------------------
1Therapeutic Level
# Digitalis Effect
# ST T
#
- ST
2Toxic Level
# Digitalis Intoxication
# ErythromycinTetracyclineVerapamilAmiodaroneSpironolactone
#
- Sinus arrestSinus exit block
-
- Paroxysmal Atrial Tachycardia, PAT
PVCAfAF
- PAT
21
QT
# QT
- Class Ia QuinidineProcanamideDisopyramide
- Class III AmiodaroneSotalolDofetilide
- Macrolide ErythromycinClarithromycinAzithromycin
- Quinolone CiprofloxacinLevofloxacinMoxifloxacinGemifloxacin
- TCACitalopramSSRI
- ThioridazineChlorpromazineHaloperidolPhenothiazine
- Arsenic trioxideTacrolimusIndapamide
Domperidone
# QT
# QT QTc 500ms2.5 QTc = QT /RR
103
------------------------------------------------------------------------------------------------------------------------------------------
COPD
#
- Lung volume
- Lung volume
P
- R Poor R wave progression
104
------------------------------------------------------------------------------------------------------------------------------------------
Pericarditis
#
- ST T
- Pericardial effusion
- Pericardial effusion
Electrical alternans
QRS
#
- ST T
- T ST T ST
- Q
- PR
Hypertrophic Obstructive CardiomyopathyHOCM
#
- IAVLV5V6IIIIIAVFQ
Myocarditis
#
-
------------------------------------------------------------------------------------------------------------------------------------------
#
- T U
------------------------------------------------------------------------------------------------------------------------------------------
#
- Sinus bradycardia
- Mobitz type I
- Non-specific ST-T change ST T
-
- IRBBB
- Multifocal Atrial Tachycardia, MAT
105
EKG-2
CGMH R3
Part-6
------------------------------------------------------------------------------------------------------------------------------------------
(Angina
106
------------------------------------------------------------------------------------------------------------------------------------------
(NSTEMI& (STEMI
107
------------------------------------------------------------------------------------------------------------------------------------------
(
1
2
3
------------------------------------------------------------------------------------------------------------------------------------------
Onset
Peak
Decline
Troponin-I
4~6h
24h
7 days
CK-MB
4~6h
18h
2 days
Trop-I
CK-MB
6
108
------------------------------------------------------------------------------------------------------------------------------------------
T
# 0~4 T Peaked THyperacute TT
T
# T Ischemia
T T
# T
# Pseudo-normalization T T
109
T
1
2
3RBBB & LBBB
4
110
Q
# Q NecrosisQ
#
# Q 3~6
12 Primary PCI
# Q
# Q
1 Q
- IAVLV5V6IIIIIAVF Q
2 Q
- Q Pathologic Q wave Q Significant Q wave
-
- Q
- Q R
- AVR Q AVR Q
Reciprocal Change
#
- R Q
- ST T ST T
#
111
------------------------------------------------------------------------------------------------------------------------------------------
# RCA
# IIIIIAVF
112
# LCX
# IAVLV5V6
# LAD
# V1~V4
# V1~V4 ST elevationR
Q
# LAD
113
# RCA
#
# V1ST T R R > S
# RCA
------------------------------------------------------------------------------------------------------------------------------------------
- Reperfusion
Indication
# 30 ST Reciprocal change
# New LBBB
Thrombolytic Therapyt-PA
< 6
Door-to-Needle30
Primary PCI
< 12
Door-to-balloon90
Coronary revascularization
114
- t-PATissue plasminogen activator
- PCIPercutaneous coronary intervention
- CABGCoronary artery bypass graft
- PTCAPercutaneous transluminal coronary angioplasty
- BMSBare metal stent
- DESDrug-eluting stent
CABG PCI
- Left main disease
- 3VD + LVEF < 50%
- 2VD + LAD + LVEF < 50%
- DM
CATH
- STEMI
- NSTEMI with
- Hemodynamic unstable or cardiogenic shock
- Severe LV dysfunction
- VT/Vf
- Angina persisted despite medication treatment
- New MR or VSD
Killip Classification
Motality
Killip I
MI
0~5%
Killip II
10~20%
Killip III
35~45%
Killip IV
MI + Cardiogenic shock
60~80%
History
65
3 CAD
7 Aspirin
ST
@ CATH
@ TIMI risk score unstable angina NSTEMI
115
------------------------------------------------------------------------------------------------------------------------------------------
ACS
# Heparin line
- Heparin 25000u in N/S 500ml run 16 ml/hr, 2 ml/hr to keep APTT 1.5~2.0 66
- Heparin 25000u in N/S 500ml run 20 ml/hr, 2 ml/hr to keep APTT 1.5~2.0 83
- Heparin 25000u in N/S 500ml run 24 ml/hr, 2 ml/hr to keep APTT 1.5~2.0 100
# Check APTT Q6H Q12H QD
#
@ Heparin sodium 25000u/5ml/vial
2Enoxaparin
# 1mg/kg
#
- Q12H
- CCr 30~50 x 0.7Q12H
- CCr < 30 x 0.7QD
# > 65 x 0.7
# 80 60 CCr = 20 30mg QD
#
@ Enoxaparin sodium 6000iu/60mg/0.6ml (prefilled syringe)
Nitrite + -blocker CCBNon-DHP
#
1Nitrite
#
# NTG continued IV dripNTG line
# NTG line
- For run 3~6 ml/hr
- For run 10~20 ml/hr
#
@ NTG 0.6mg/tab, 25s/package
@ NTG 0.2mg/ml in 5% dextrose 250ml50mg/bot NTG line
0.2mg/ml
@ NTG 5mg/10ml/amp10PC in N/S 500ml0.1mg/ml
2-blocker
#
# Bisoprolol
#
@ Bisoprolol 5mg/tab (Concor, Merck)CAD 5mg
@ Bisoprolol hemifumarate 1.25mg/tab
CHF 1.25mg 5mg
117
3CCBNon-DHP
# Non-DHP CCB Diltiazem Non-Q infarction with good LV function
Verapamil
# STEMI Non-DHP CCB -blocker
#
@ Diltiazem HCl 30mg/tab (Herbesser, Tanabe)
@ Diltiazem long acting 90mg/tab (Cardizem)
Statin
#
#
@ Atovastatin 10mg/tab (Lipitor, Pfizer)
@ Atovastatin 40mg/tab (Lipitor, Pfizer)
@ Rosuvastatin 10mg/tab (Crestor, AstraZeneca)
@ Rosuvastatin 5mg/tab (Crestor, AstraZeneca)
@ SIMVASTATIN 40mg/tab (Simvahexal, Sandoz)
@ Pitavastatin 2mg/tab (Livalo,KOWA)
@ PITAVASTATIN 2mg/tab (Pitator,)
ACEi/ARB
# Remodeling
#
ACEi
@ Captopril 25mg/tab 4~6hr
@ Enalapril 5mg/tab
@ Enalapril 20mg/tab
@ Fosinopril sodium 10mg/tab
@ Ramipril 10mg/tab (Tritace, Sanofi)
ARB
@ Losartan potassium 50mg/tab
@ Valsartan 160mg/f.c tab
@ Candesartan 8mg/tab
@ Irbesartan 300mg/tab (Aprovel, Sanofi)
@ IRBESARTAN 300mg/tab (IRBESARTAN, Sandoz)
@ Telmisartan 80mg/tab
@ Olmesartan 20mg/tab
@ Azilsartan medoxomil 40mg/tab
118
------------------------------------------------------------------------------------------------------------------------------------------
Arrhythmia
1VT/Vf
- PrimaryIschemic induced
- SecondaryDue to CHF
2PVC
3AIVRAccelerated idioventricular rhythm
- reperfusion
4Supra-ventricular tachycardia
5AV block
Acute MR
# Due to papillary muscle dysfunction
Ventricular septal rupture
# Left-to-right shunt
Apical aneurysm formation
# ST
119
EKG-3
CGMH R3
Part-7
#
- 300 R
- 1500 R
# R 0.2 5 300
# R 0.4 2.5 150
#
- 100
- 75
- 60
- 50
------------------------------------------------------------------------------------------------------------------------------------------
Arrhythmia
# Normal sinus rhythm
#
# HIS DEBS
Hypoxia
COPD
Ischemia
Sympathetic stimulation
Drug
Electrolyte imbalance
Bradycardia
Stretch
120
------------------------------------------------------------------------------------------------------------------------------------------
1
2Ectopic Rhythm
3Reentrant Rhythm
4
5
------------------------------------------------------------------------------------------------------------------------------------------
Sinus Tachycardia
# HR > 100
Sinus Bradycardia
# HR < 60
Sinus Arrhythmia
#
-
-
121
Sinus Arrest
# Asystole
# Escape rhythm
P P
QRS
Sinus Exit Block
# Sinus arrest
Sinus arrest
122
------------------------------------------------------------------------------------------------------------------------------------------
Ectopic Rhythm
#
#
123
------------------------------------------------------------------------------------------------------------------------------------------
Reentrant Rhythm
# A B
# B
A
B B
# Reentry loop
# PSVTAF
AFast Pathway
BSlow Pathway
124
------------------------------------------------------------------------------------------------------------------------------------------
125
------------------------------------------------------------------------------------------------------------------------------------------
Supraventricular Arrhythmia
#
# QRS
Atrial Premature BeatPremature Atrial ContractionPAC
# P
#
126
Reentrant loopAVNRT
P IIIIIAVFV1V2
QRS T
# P
- Pseudo Rwave in V1V2
- Pseudo S wave in IIIIIAVF
#
1AVNRTAV nodal reentrant tachycardia AV node
2AVRTAV reentrant tachycardia
#
#
#
#
127
#
1Carotid Massage
- Carotid sinus
- EKG monitor
2Adenosine61212
- SA node AV node
-
- 6mg IV push3 N/S
- 3 12mg
- 3 12mg
3Unstable sign 50~100
4Radiofrequency Ablation
128
PSVT
PSVT Reentrant loop
1AVNRT loop AV node
2AVRT loop WPW syndrome
AVNRT AVRTloop slow pathway fast
pathway
--------------------------------------------------------------------------------------------------------------------------------------AVNRT
AVNRT slow pathway fast pathway QRS loop
P loop
P
slow pathway QRS RP intervalQRS
P fast pathway QRS
RP interval
--------------------------------------------------------------------------------------------------------------------------------------AVRT
AVRT slow pathway QRS
fast
pathway VT QRS
P
RP interval AVNRT slow pathway
loop P RP interval
fast pathway
loop P RP interval
129
Atrial FlutterAF
# IIIIIAVF
#
#
#
#
#
#
#
250~350
P
Af
AV Block 21
Carotid Massage 31 51
Rate controlAnticoagulant Af
Unstable sign 50~100
41 Atrial Flutter
Carotid massage 31 51
Carotid massage
130
Attial FibrillationAf
#
# 350~500 AF
#
Irregularly irregular
#
- P P
- QRS
# Carotid Massage
131
Af
1Thromboembolic prevention
- CHADS2 score
- CCongestive heart failure1
- HHypertension1
- AAge > 751
- DDM1
- S2Prior stroke or TIA2
@
- 0 Low risk Aspirin
- 1~2 Moderate risk Aspirin or Warfarin Prior stroke or TIA Warfarin
- 3~6 High risk Warfarin
- CHADS2-VAS score
- risk factorVascular disease1 Age 65~741
Female sex1
- Age > 75 2
- low risk group
# Carotid Massage
#
- P
- PR
-
# Rate control-blocker Non-DHP CCB
133
100~200
134
------------------------------------------------------------------------------------------------------------------------------------------
Ventricular Arrhythmia
#
# QRS
Premature Ventricular ContractionPVC
#
# PVC
#
1Periodic PVC
2Bigeminy PVC
3Trigeminy PVC
4Triplet PVC
Periodic PVC (
Bigeminy (21
Trigeminy (31
Triplet (
135
# PVC VTVf
- PVC
- PVC
- PVC
- R on T PVC T VT
- PVC
Ventricular TachycardiaVT
# PVC
# 120~200
#
1VT associated with structural heart disease
- VT
- Peri-infarctScar reentry monomorphic VT
- Ischemic polymorphic VTVf
- CardiomyopathyArrhythmogenic right ventricular dysplasiaARVD VT
2VT in the absence of structural heart disease
- Brugada syndromeLong-QT syndrome
polymorphic VT
- idiopathic VT right ventricular outflow tractRVOT
LVOT VTfascicular VT
136
#
1 VTMonomorphic VT
- Unstable sign 100
- Amiodarone
- Amiodarone
- Loading dose150mg IVF run 10 mins
- Maintain dose1 mg/min x 6 hrs, then 0.5 mg/min
- Amiodarone
- Loading dose1PC in D5W 50cc run 10 mins
- Maintain dose6PC in D5W 500cc run 33 ml/hr x 6 hrs, then 17 ml/hr
- VTLidocaineIV MexiletinePO
- VTBidirectional VTPhenytoinIV
2 VTPolymorphic VT
- Unstable sign 360 120~200
- Amiodarone
3 VTPulseless VT
- CPR + ACLS 360 120~200
Monomorphic VT
Polymorphic VT
Ventricular FibrillationVf
#
#
- CPR + ACLS 360 120~200
137
VT & SVT
Brugada algorithm
( Precordial lead V1~V6
YES ( Q
1. RS ?
VT
NO ( RS
2. RS ?
> 0.1 (
VT
< 0.1 (
3. AV dissociation?
YES
VT
NO
4. QRS
( VT
RBBB configuration
LBBB configuration
V1
V6
Capture beat
(
Fusion beat
(
IAVF ( Favor VT
Favor VT
( Apex VT
( Base VT
139
Torsades De Pointes
# VT QT PVC T
R on T
# VT QRS VT
# MgSO4 1~2g in 5~60
------------------------------------------------------------------------------------------------------------------------------------------
+ Aberrant conduction
# QRS
+ Aberrant conduction
#
- QRSSVT with aberrant conduction
- QRSAf with aberrant conduction
140
141
=====================================================================================
Part-8 ACLS
142
------------------------------------------------------------------------------------------------------------------------------------------
Tachycardia
------------------------------------------------------------------------------------------------------------------------------------------
Bradycardia
143
CGMH R3
Part-1
Anatomy
-
-
-
-
144
(Mitral stenosis X
Mitral Stenosis
Normal
------------------------------------------------------------------------------------------------------------------------------------------
MCL
2
3
4
PV
AV
RA
PV
AV
MV
TV
RV
LA
3
4
LV
5
MV
TV
6
7
145
------------------------------------------------------------------------------------------------------------------------------------------
A
V
C
Y descent
X descent
X descent
Y descent
146
Cannon A Wave
Giant A Wave
V
C
C-V Wave
Y descent
Deep Y descent
X descent
Giant A Wave
Cannon A Wave
C-V Wave
Deep Y descent
(TR
147
------------------------------------------------------------------------------------------------------------------------------------------
Arterial Pulse
Hypokinetic Pulse
# Shock
#
Hyperkinetic Pulse
# AR
#
#
- Bounding pulse
- Water-hammer pulse
- Collapsing pulse
- Corrigans pulse
- Aortic run off
Pulsus Parvus et Tardus
# AS
#
Pulsus Bisferiens
# HOCM (Hypertrophic obstructive cardiomyopathy
# HOCM ( muscle hypertrophy
(
148
Pulsus Alternans (
#
#
Bigeminal Pulse
# PVC
# PVC (
Pulsus Paradoxicus (
# Cardiac tamponade
# Cardiac tamponade ( 10 mmHg
( 10 mmHg
#
- (VR
-
Cardiac tamponade
- (
-
Cardiac tamponade Pulsus paradoxicus
AS & HOCM Valsalva maneuver
Valsalva maneuver venous return LV
1ASmurmur
2HOCMmurmur
149
Valsalva maneuver
Valsalva maneuver venous return ?
venous return
venous return
vena cava chest wall
SVCIVCRARV
transmural pressure
venous return
150
------------------------------------------------------------------------------------------------------------------------------------------
PMI
# MCL Localize 2~3 cm
# BriefTappingNot forceful
# Early systole
PMI in LV Pressure Overload
# MCL Localize 2~3 cm
# Pulpable S4
# Sustained thrust during systole
PMI in LV Volume Overload
# Diffuse 3~5 cm
# Pulpable S3
# Hyperdynamic with quick thrust followed by retraction
------------------------------------------------------------------------------------------------------------------------------------------
Heart Sound
151
S1
MV TV
Apex
MV
AV PV
S2
AVPV
S3
AR
Volume Overload
MR
LV compliance
VSD
Hyperdynamic Heart
@
@ M mode E
S4
Atrial Contraction
LVH
Pressure Overload
LV compliance
@ M mode A
Aortic Election Click
Valvular AS
Apex
MV
AV
Valvular PS
PV
Mid-systolic Click
Apex
MV
Opening Snap
MV
Apex
MS
MV
RHD
# S2 A2P2
#
- VR A2P2
- LVA2P2
Wide Splitting S2
# Pulmonary Valve
# ASDPSCRBBBType ALeftpre-excitation
@ MR Wide Splitting S2 Aortic Valve
Paradoxical Splitting S2
# Aortic Valve
# AnginaSevere ASCLBBBType BRightpre-excitation
152
153
------------------------------------------------------------------------------------------------------------------------------------------
Heart Murmur
Systolic Murmur
ASPS
MRTRVSD
Diastolic Murmur
ARPR
MSTS
AR Austin flint murmur
MSTS
Continuous Murmur
Continuous Murmur
PDA
154
=====================================================================================
Part-2
2D Mode ( Cardiac Window
Para-Sternal Approach
Para-sternal long axis view
Apical Approach
Apical four chamber view
155
Sub-Costal Approach
Subcostal short axis view
Supra-Sternal Approach
------------------------------------------------------------------------------------------------------------------------------------------
M mode
156
------------------------------------------------------------------------------------------------------------------------------------------
Y.C.Chen 2012.02.23
157
=====================================================================================
Part-3
Mitral StenosisMS
4~6 cm2
Mild
1.5~2.0 cm2
Moderate
1.0~1.5 cm2
Severe
1Opening SnapOS
@ MS S2 OS MV
2S1
@ MS S1 MV
#
- -blockerNon-DHP CCB
- Warfarin
1MS with Af
2MS with prior embolic event
3MS with left atrial thrombus
- MS
# Percutaneous mitral balloon valvotomyPMBV
- Moderate to severe MSMVA < 1.5 cm2 PMBVClass I
- LA thrombusModerate to severe MREcho score > 8
# Mitral valve replacementMVR
- PASP > 60 mmHg MVRClass IIa
158
------------------------------------------------------------------------------------------------------------------------------------------
Mitral RegurgitationMR
1Pansystolic murmurAxilla
1 S1ARMR
2Wide Splitting S2
#
- Acute MR afterload IV Nitroprusside IABP
- Organic MR ACEi/ARB-blocker
- Functional MR ACEi/ARB-blocker
#
- Severe MRRegurgitation >50%
- + LVEF > 30% / LVESD < 55mm Class I
- + LVEF < 60% / LVESD > 40mm Class I
------------------------------------------------------------------------------------------------------------------------------------------
1Mid-systolic Click
#
- -blocker
159
------------------------------------------------------------------------------------------------------------------------------------------
Aortic StenosisAS
1/Degenerative/Calcified 70~90
2/Congenital/Bicuspid 60~80
3 AS+AR 30~50
3~4 cm2
Mild
1.5~2.0 cm2
Moderate
1.0~1.5 cm2
Severe
2Gallavardin phenomenon
@ MR
2Paradoxical Splitting S2
# TriadHeart failurSyncopeAngina
#
- DigoxinDiuretics
- Vasodilator-blocker
#
- Severe ASAVA < 1 cm2Vmax > 4 m/sMean pressure gradient > 40 mmHg
- Class I
- + LVEF < 50% Class I
160
------------------------------------------------------------------------------------------------------------------------------------------
Aortic RegurgitationAR
1Valvular 2/31/3
2Root
@
2Austin flint murmurLow-pitchedMid-diastolic rumbling murmur
1 S1ARMR
2Hyperkinetic pulseBounding pulseWater-hammer pulseCollapsing pulse
Corrigans pulseAortic run off
3De Mussets sign Pulse Head bobbing
4Quinckes sign Pulsating capillary in nail bed, alternating flushing and paling
5Traubes sign Pistal-shot sound over femoral artery
6Duroziezs sign To-and-fro murmur
#
- VasodilatorACEi/ARBCCB
#
- Severe ARRegurgitation >50%
- Class I
- + LVEF < 50% Class I
- + LVEDD > 75mm Class IIa
161