Sandbox/22

Gas gangrene

Infection Preferred Regimen ▸ Drug A 50 mg/kg IV q8h PLUS ▸ Drug B 50 mg/kg IV q8—12h Alternative Regimen ▸ Drug C 50 mg/kg IV q8h PLUS ▸ Drug D 2.5 mg/kg IV q8h OR ▸ Drug E 2.5 mg/kg IV q8h

CHF

Diuretic therapy

ACE inhibitors AND Beta blockers

Intolerant to ACE-I

Cough

Renal insufficiency or angioedema

ARBs

Hydralazine/isosorbide dinitrate

Persistent symptoms?

Yes

No

Add: ❑ Aldosterone or eplerenone if: ❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women ❑ Estimated glomerular filtration rate >30 mL/min/1.73 m2 ❑ Serum potassium ≤ 5.0 mEq/L ❑ NYHA class II–IV HF with LVEF ≤ 35% OR ❑ Hydralazine/isosorbide dinitrate ❑ African Americans with NYHA class III–IV HFrEF on GDMT OR ❑ ARBs

Persistent symptoms?

Add digoxin

Persistent symptoms?

Yes

No

❑ LVEF ≤ 35% ❑ Sinus rhythm or LBBB ❑ NYHA III - IV

LVEF ≤ 35%?

Yes

No

Yes

No

Cardiac resynchronization therapy (CRT) ± Implantable cardioverter defibrillator (ICD)

Implantable cardioverter defibrillator ❑ As primary prevention of sudden cardiac death in: ❑ Post MI with LVEF ≤ 35%, NYHA II or III on chronic GDMT ❑ Post MI with LVEF ≤ 30%, NYHA I on chronic GDMT

Continue GDMT

Persistent symptoms (Advanced heart failure)

IV inotropes or vasodilators

Mechanical circulatory support (MCS): Intra-aortic balloon pump LVAD - as bridge to recovery, transplant, or as definitive therapy ❑ General indications: ❑ LVEF ≤ 25% ❑ NYHA III or IV on chronic GDMT ❑ Predicted 1-2 year mortality

Cardiac transplantation

Hypertension

Warm & Dry ❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ Smoking cessation ❑ Alcohol abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity Although ACE inhibitors and beta blockers should not be administered to patients with acute decompensated heart failure, if the patient is compensated in the outpatient setting then administer: ❑ ACE inhibitors or (ARBs) if LVEF is ≤ 40% ❑ Beta blockers

Warm & Wet ❑ Diuretic therapy ❑ Treat co-morbidities HTN, DM, CAD, AF

Cold & Wet ❑ CCU admission ❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) ❑ Intravenous inotropic drugs (e.g., dobutamine) ❑ Diuretic therapy while monitoring blood pressure ❑ IV vasodilators

Cold & Dry ❑ CCU admission ❑ Intravenous inotropic drugs (e.g., dobutamine) ❑ Persistent organ hypoperfusion (e.g., low urine output or persistent low SBP<85) ❑ Norepinephrine 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of

Indications for implantable cardioverter defibrillator (ICD) ❑ As primary prevention of sudden cardiac death in: ❑ Post MI with LVEF ≤ 35%, NYHA II or III on chronic GDMT (Class I, level of evidence A) ❑ Post MI with LVEF ≤ 30%, NYHA I on chronic GDMT (Class I, level of evidence B) ❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III Contraindications ❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year ❑ Incessant ventriculat tachycardia or ventricular fibrillation ❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up ❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or cardiac resynchronization therapy ❑ Ventricular tachycardia due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma)

General measures ❑ Low sodium diet ❑ Monitor blood pressure, congestion, oxygenation ❑ Daily weights using same scale after 1st void at same time of day ❑ Intake and output charts ❑ Convert all IV diuretic to oral forms in anticipation of discharge ❑ Continue or initiate ❑ ACE inhibitors ❑ Beta blockers ❑ Omega-3 fatty acid ❑ Daily serum electrolytes, urea & creatinine ❑ DVT prophylaxis ❑ Influenza & pneumococcal vaccination ❑ Encourage physical activity in stable patients

Discharge and follow-Up ❑ Patient and family education ❑ Prior to discharge, ensure: ❑ Low salt diet ❑ Oral medication plan is stable for 24 hours ❑ No IV vasodilator or inotropic drugs for 24 hours ❑ Weighing scale is present in patient's home ❑ Smoking cessation counseling ❑ Follow-up clinic visit scheduled within 7 to 10 days ❑ Ambulation prior to discharge to assess functional capacity ❑ Telephone follow-up call usually 3 days post discharge ❑ Potassium monitoring and repletion Click here for the detailed management of hyperkalemia and hypokalemia