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jspdf multiple pages angular: Option to add page numbers · Issue #75 · simonbengtsson/ jsPDF ...



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The severity of cardiac dysfunction is proportionate to the extent of myocardial necrosis but is exacerbated by preexisting dysfunction and ongoing ischemia Patients who have normal BP, no signs of heart failure, and normal urinary output have a good prognosis Those with hypotension or evidence of more than mild heart failure should have bedside right heart catheterization and continuous measurements of arterial pressure These measurements permit the accurate assessment of cardiac function, facilitate the correct choice of therapy, and provide important prognostic information Table 10 6 categorizes patients based on these hemodynamic findings 1 Acute LV failure Basilar rales are common in acute myocardial infarction, but dyspnea, more diffuse rales, and arterial hypoxemia usually indicate LV failure Because both the physical examination and chest radiograph correlate poorly with hemodynamic measurements and because the central venous pressure does not correlate with the pulmonary capillary wedge pressure (PCWP), right heart catheterization may be useful in cases of suspected cardiogenic shock General measures include supplemental oxygen to increase arterial saturation to above 95% and elevation of the trunk Diuretics are usually the initial therapy unless RV infarction is present Intravenous furosemide (10 40 mg) or bumetanide (05 1 mg) is preferred because of the reliably rapid onset and short duration of action of these drugs Higher dosages can be given if an



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V = V1 = I A1 ( jX T ) = ( 2500 90 )( j 010) = 0250 0

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3 This step requires a little binary knowledge You convert the second hexadecimal digit, in this example the second 0, into binary: 0 in hex = 0000 in binary You take the third binary digit and complement it, which means that if it s a 0, as in this example, you make it a 1, and if it s a 1, you make it a 0 Then convert it back to hexadecimal: 0010 = 2 in hexadecimal 4 Put that value back in the second position:





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boluses of 100 mL of normal saline until PCWP reaches 15 18 mm Hg to determine whether cardiac output and BP respond Pericardial tamponade due to hemorrhagic pericarditis (especially after thrombolytic therapy or cardiopulmonary resuscitation) or ventricular rupture should be considered and excluded by echocardiography if clinically indicated RV infarction, characterized by a normal PCWP but elevated RA pressure, can produce hypotension This is discussed below Most patients with cardiogenic shock will have moderate to severe LV systolic dysfunction, with a mean EF of 30% in the SHOCK trial If hypotension is only modest (systolic pressure > 90 mm Hg) and the PCWP is elevated, diuretics and an initial trial of nitroprusside (see above for dosing) are indicated If the BP falls, inotropic support will need to be added or substituted Such patients may also be treated with IABC This device unloads the LV during systole and increases diastolic coronary artery filling pressure It often facilitates the use of vasodilators in patients who previously did not tolerate them Dopamine is the most appropriate pressor for cardiogenic hypotension It should be initiated at a rate of 2 4 mcg/kg/min and increased at 5-minute intervals to the appropriate hemodynamic end point At low dosages (< 5 mcg/kg/min), it improves renal blood flow; at intermediate dosages (25 10 mcg/kg/min), it stimulates myocardial contractility; at higher dosages (> 8 mcg/kg/min), it is a potent 1-adrenergic agonist In general, BP and cardiac index rise, but PCWP does not fall Dopamine may be combined with nitroprusside or dobutamine (see above for dosing), or the latter may be used in its place if hypotension is not severe Milrinone has hemodynamic effects similar to those of dobutamine, but the longer duration of action precludes rapid dosage adjustment Norepinephrine (01 05 mcg/kg/min) is the usual pressor of last resort, since isoproterenol and epinephrine produce less vasoconstriction and do not increase coronary perfusion pressure (aortic diastolic pressure), but both tend to worsen the balance between myocardial oxygen delivery and utilization Patients with cardiogenic shock not due to hypovolemia have a poor prognosis, with 30-day mortality rates of 50 80% If they do not respond rapidly, IABC should be instituted Surgically implanted ventricular assist devices may be used in extreme cases Emergent cardiac catheterization and coronary angiography followed by percutaneous or surgical revascularization offer the best chance of survival, particularly in patients under 75 years of age.

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