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Revision as of 09:25, 18 September 2020 by Sara Zand (talk | contribs)
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Management of cyanotic congenital heart disease:

❑ Checking oxygen saturation at rest( about 5 min) rather than after walking
❑ Using air filter for all venous access
Cerebral imaging in the presence of new headache or any neurologic signs for evaluation of brain abcesss,hemorrhage, stroke
❑ Checking serum uric acid in patients with history of gout
❑ Supplement oxygen
❑ Avoidance of excess oxygen supplement or narcotic due to reduction hypoxia-mediated derived to ventilation
❑ Adequate hydration and movement during the long flight, NO need for checking oxygen saturation before flight
❑ Measurement of coagulation parameters(Activated partial thromboplastin time,international normalized ratio,thrombin time) in hematocrite>55%
 
 
 
 


CYANOSIS.https://doi.org/10.1016/j.chest.2017.11.003 PMID: 19561940 PMID: 16764526

 
 
 
 
Important points in treatment of eisemenger disease:

Bosentan for treatment of symptomatic VSD, ASD, PDA,Aortopulmonary window,Complex congenital heart disease,Down syndrome(CLASS 1 Recommendation)
Phosphodiesterase-5 inhibitor( Tadalafil,sildenafil) for treatment of Symptomatic ASD, VSD, Great artries shunt(CLASS 2a Recommendation)
family tree/end
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eisemenger disease
 
Increased pulmonary vascular resistant leading to right to left shunt, systemic arterial desaturation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tamponad
 
low cardiac output, low stroke volume, elevated cardiac filling pressures, increased sympathetic tone( tachycardia, peripheral vasoconstriction)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mechanism of Cyanosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary thromboembolism
 
Pulmonary artery vasoconstriction, hypoxia, right ventricle pressure overload, right to left shunt via patent foramen ovale
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiogenic shock
 
Decreased myocardial perfusion, muscle hypoxia,necrosis, impaired myocardial contraction., decreased cardiac out put, Increased vasoconstrictor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tetralogy of fallot
 
Episods of Tet spell between 2-4 months of age, aggravated with crying ,feeding stooling,dehydration,in patients with severe pulmonary stenosis and large VSD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obstructive sleep apnea
 
Pulmonary hypertension, increased capillary hydrostatic pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Renal disease
 
Increased plasma volume, decreased plasma oncotic pressure from protein loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protein losing entropathy
 
Decreased plasma oncotic pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Deep vein thrombosis
 
Increased capillary permeability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cellulitis
 
Increased capillary permeability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy
 
Increased plasma volume
 
 
 
 
 
 































{{familytree | | | | | | | | | |)|-| R1 |-| R2 | | | | | | | | |R1=Lymphedema |R2=Lymphatic obstruction,lymph node dissection,[[malignancy],filariasis| }}

{{familytree | | | | | | | | | |)|-| G01 |-| G02 | | | | |G01=Cellulitis| G02=Increased [[capillary permeability]}}

 
 
 
 
 
 
 
 
 
 
 
 
Heart failure
 
Increased capillary permeability from Systemic venous hypertension,volume overload
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hepatic disease
 
Increased capillary permeability from systemic venous hypertension, decreased oncotic pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mechanism of Edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic venous insufficiency
 
venous reflux, poorly functioning venous valves, incompetent venous valves, reduced venous return, blood pooling, hypoxia, and inflammation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obstructive sleep apnea
 
Pulmonary hypertension, increased capillary hydrostatic pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Renal disease
 
Increased plasma volume, decreased plasma oncotic pressure from protein loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protein losing entropathy
 
Decreased plasma oncotic pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Deep vein thrombosis
 
Increased capillary permeability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cellulitis
 
Increased capillary permeability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy
 
Increased plasma volume
 
 
 
 
 
 





 
 
 
 
 
 
 
 


 
 
 
 
 
 
 
 

Do's

References


Template:WikiDoc Sources


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Diagnostic tools:

Duplex sonography in patients with unilateral lower limb swelling and positive D-dimer, or high clinical suspicion of thrombosis
❑ Abdominal or pelvic CT scan in patients with lower limb swelling and evidence of malygnancy
Magnetic resonance venography of the lower leg in patients with unilateral leg swelling

with out evidence of thrombosis on duplex ultrasonography if there is high clinical suspicion for deep venous thrombosis

Echocardiography in patients with obesity, obstructive sleep apnea, and edema for evaluation of pulmonary arterial pressures and also in patients with evidence ofheart failure for assessment ofejection fraction and pulmonary artery pressure and structural heart disease.
Ankle-brachial index in patients with chronic venous insufficiency and cardiovascular risk factors before compression therapy, which is contraindicated in peripheral arterial disease
 
 
 
 
{{{end}}}
 
 
 
 
 
 
 
 
 
 
 
 
Congestive heart failure
 
diuretic,sodium restriction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nephrotic syndrome
 
diuretic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Edema treatment
 
 
 
 
Lymphedema
 
compression stocking, skin care,manual lymphatic derenage,bandage,exercise program with compression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic venous insufficiency
 
compression stocking,bandage/wraps,adjunctive devices,pneumatic pumps
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lipedema
 
Suction lipectomy
 
 
 
 
 
 






 
 
 
 
 
 
 
 
 
 
 
 
Congestive heart failure
 
loop diuretic,sodium restriction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nephrotic syndrome
 
Loop diuretic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Edema treatment
 
 
 
 
Lymphedema
 
Compression stocking,skin care,manual lymphatic deraning,bandage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic venous insufficiency
 
Compression stocking,bandage,wraps,adjunctive devices,pneumatic pumps
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Deep vein thrombosis
 
Anticoagulant therapy,early walking, compression stocking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cellulitis
 
Antibiotic theraphy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lipedema
 
Suction lipectomy
 
 
 
 
 
 











 
 
 
 
 
 
 
 
 
 
 
 
 
Pulse examination
 
 
 
 
 
 
 
 
 
 
 
Ulcer
 
 
 
 
 
 
 
 
lymphadenopathy/masses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pitting
 
 
 
 
 
Physical examination
 
 
 
 
 
Unilateral/bilateral
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Skin condition,texture,color
 
 
 
 
 
 
 
 
Distribution
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Temperature
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



 
 
 
 
 
 
 
 
 
 
 
 
 
Associated injury/illness
 
 
 
 
 
 
 
 
 
 
 
Recent surgery/procedure
 
 
 
 
 
 
 
 
Malygnancy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Painful
 
 
 
 
 
History
 
 
 
 
 
Onset(acute,chronic)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aggravated by activity
 
 
 
 
 
 
 
 
Underlying illness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Change in medications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


{{familytree | | | | | C01 | | | | | C01=
Laboratory test:<be>


❑ Complete blood count
❑ Urinalysis
❑ Blood sugar
❑ Creatinine
❑ Thyroid-stimulating hormone
❑ Serum Albumin
❑ D-dimer
❑ BNP
❑ AST
❑ ALT
❑ Total Bilirubin
❑ Prothrombin time
❑ Alkaline phosphatase









Overview

❑Pioglitazone,roziglotazone
❑ Levofeloxain


 
 
 
 
Medications associated with edema:<be>
❑ Monoamine oxidase inhibitors, trazodone
❑ Beta-adrenergic blockers, calcium channel blockers, clonidine , hydralazine, methyldopa, minoxidil
❑ Acyclovir
❑ Cyclophosphamide, cyclosporine (Sandimmune), cytosine arabinoside, mithramycin
❑ Androgen, corticosteroids, estrogen, progesterone, testosterone
❑ Celecoxib, ibuprofen
 
 
 
 
{{familytree | | | | | B01 | | | | | B01=
mechanisms of edema :

Cardiac disease: Increased capillary permeability from systemic venous hypertension; increased plasma volume
Hepatic disease: Increased capillary permeability from systemic venous hypertension; decreasedplasma oncotic pressure from reduced protein synthesis
Malabsorption/protein-caloriemalnutrition: Reduced protein synthesis and decreased plasma oncotic pressure
Obstructive sleep apnea : Pulmonary hypertension, increasedcapillary hydrostatic pressure
Pregnancy and premenstrual edema: increased plasma volume
Renal disease: Increased plasma volume, decreased plasma oncotic pressure from protein loss
❑ Chronic venous insufficiency: venous reflux, poorly functioning venous valves, incompetent venous valves, reduced venous return, blood pooling, hypoxia, and inflammation
Lymphedema: lymphatic obstruction in upper extremities due to breast cancer and lymph nodes dissection, rich in protein
Cellulitis: Increased capillary permeability
Deep vein thrombosis: Increased [[capillary permeability]/div}}







 
 
 
 
Diagnostic approach:

❑ Magnetic resonance venography of the lower extremity and pelvis should be obtained in patients with unilateral left leg swelling and negative results on duplex ultrasonography if there is high clinical suspicion for deep venous thrombosis
❑ Echocardiography should be performed in patients with obesity, obstructive sleep apnea, and edema to evaluate pulmonary arterial pressures.
❑ Ankle-brachial index should be measured in patients with chronic venous insufficiency and cardiovascular risk factors before initiation of compression therapy, which is contraindicated in peripheral arterial disease/div>
 
 
 
 


















 
 
 
 
Treatment:

❑ Compression stockings should be used in patients following deep venous thrombosis to prevent postthrombotic syndrome
❑ Pneumatic compression devices should be used in conjunction with standard therapy in patients with lymphedema
❑ Daily hydration with emollients and short courses of topical steroid creams for severely inflamed skin should be used to treat eczematous (stasis) dermatitis associated with chronic venous insufficiency>
❑ Anticoagulation therapy in deep vein thrombosis/div
 
 
 
 
Inherited causes of cardiac arrest and malignant arrhythmia associated covid-19 long QT syndrome Brugada syndrome Short QT syndrome Cathecolaminergic polymorphic ventricular tachaycardia
Gene mutation


  • loss of function in SCN5A in %30 of patients
EKG finding
  • QTc>450ms in men
  • QTc>470ms in women
  • Coved-type ST-segment elevation
  • T-wave inversion

in lead V1 and/or V2

Specific considerations in COVID19 patients
  • Controlling the fever for prevention of QT prolongation
  • Avoidance of using≥ one drugs inducing QT prolongation
  • Controlling the fever as the main cause of cardiac arrest in brugada syndrome, especially in children less than 5 year old


  • Avoidance of administration of epinephrine, isoproterenol, and dobutamine, all α and/or B1 receptor agonists inducing ventricular arrhythmia
  • Controlling the sress related to COVID-19
  • Safety of flecainide without any interaction with lopinavir, ritonavir and chloroquine.
fatal arrhythmia Ventricular fibrillation


  • Corrected QT(QTc)=1000(QT/1000+0.154(1-RR)
  • QT, QTc are measured in milliseconds)
  • RR is measured in seconds and is the interval from the onset of one QRS complex to the onset of the next QRS complex