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| ==Management== | | ===Diagnosis=== |
| {{familytree/start |summary=PE diagnosis Algorithm.}} | | {{familytree/start}} |
| {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=Altered mental status & PT prolongation by 4-6 sec or INR ≥1.5<BR>presenting w/ nonspecific abdominal Sx<BR>w/o preexisting chronic liver disease, cirrhosis & any illness of <26 wks duration}} | | {{familytree | | | | | | A01 | |A01='''Check vitals'''<br>'''Stabilize ABC'''<br>'''Brief Hx'''<br>'''Rapid physical exam''' - neuro exam, '''NIHSS'''<br>'''Activate stroke team'''<br>'''Stat fingerstick'''<br>'''Basic labs,''' troponin, EKG<br>'''NPO'''<br>'''Obtain stroke protocol'''}} |
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| {{familytree | | | | | | | | | | | | | | | B01 | | | | | | |B01=Acute liver failure}} | | {{familytree | | | | | | B01 | | | |B01=Non-contrast CT (or MRI)}} |
| {{familytree | | | | | | | | | | | | | | | |!| | | | | | | |}} | | {{familytree | | | | | | |!| | | ||}} |
| {{familytree | | | | | | | | | | | | | | | C01 | | | | | | |C01=Mandatory hospital admission}} | | {{familytree | | | | | | C01 | | | |C01='''Bleed'''}} |
| {{familytree | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | |}} | | {{familytree | | | |,|-|-|^|-|-|.| | | |}} |
| {{familytree | | | | | | | | D01 | | | | | | | | | | | | D02 | | |D01=w/o altered mental status, significant coagulopathy & abnormal LFT|D02=w/ altered mental status}} | | {{familytree | | | D01 | | | | D02 |-| D03 | | |D01=Positive|D02=Negative|D03=Ischemic Stroke}} |
| {{familytree | | | | | | | | |!| | | | | | | | | | | | | |!| | | |}} | | {{familytree | |,|-|^|-|.| | | |!| | |}} |
| {{familytree | | | | | | | | E01 |-|-|-|-| E02 |-|-|-|-| E03 |-|-| E04 |-|-| E05 |E01=High dependency ward admission|E02=Worsening mental status|E03=ICU admission|E04=w/ or progression to grade I/II hepatic encephalopathy|E05=Transfer to transplant center}} | | {{familytree | E01 | | E02 | | E03 | | | |E01='''Intracerebral Hemorrhage'''|E02='''Subarachnoid Hemorrhage'''|E03=Strong Suspicion for SAH}} |
| {{familytree | | | | | | | | |`|-|-|-|-|-|-|v|-|-|-|-|-|-|'| | | | | | | | |}} | | {{familytree | |!| | | |!| | | |!|}} |
| {{familytree | | | | | | | | | | | | | | | F01 | | | | | | | | | | |F01='''Initial evaluation:'''<BR>Detailed H/o and PE<BR>Labs: CBC, PT/INR, serum BCH, ABG, ammonia, acetaminophen & tox screen for other drugs/toxins, viral serology (A-E), autoimmune markers, amylase, lipase, bilirubin:alkaline phosphatase, blood grouping & typing, HIV status}} | | {{familytree | F01 | | |!| | | F02 | | |F01=Management of ICH|F02=May consider lumber puncture}} |
| {{familytree | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| |}}
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| {{familytree | | | | | | | | |!| | | | | | |!| | | | | | |!| |}} | | {{familytree | | | | | G01 | | G02 | | | |G01=Management of SAH|G02=Xanthochromia or bloody CSF}} |
| {{familytree | | | | | | | | G01 | | | | | G02 | | | | | G03 |G01=General management|G02=Etiology specific management|G03=Complication specific management}} | | {{familytree | | | | | |!| |,|-|^|-|.| | | |}} |
| {{familytree/end}} | | {{familytree | | | | | |`| H01 | | H02 |-| H03 | | |H01=Yes|H02=No|H03='''No SAH'''}} |
| | | {{familytree | | | | | | | | | | | |!| | |}} |
| | | {{familytree | | | | | | | | | | | I01 | | |I01=Strong Suspicion for SAH}} |
| ===General Management===
| | {{familytree | | | | | | | | | | | |!| |}} |
| {{familytree/start |style=font-size:85%; line-height: 120%; |summary=PE diagnosis Algorithm.}} | | {{familytree | | | | | | | | | | | J01 | |J01=Traumatic tap?<br>Poor Technique?}} |
| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Continuous monitoring under quite environment w/ preventive treatment strategies}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
| | {{familytree | | | | | | | | | K01 | | K02 | |K01=Yes|K02=No}} |
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| | {{familytree | | | | | | | | | |!| | | |!| | |}} |
| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
| | {{familytree | | | | | | | | | L01 | | L02 | | | |L01=CTA/MRA<br>Consult to Neurosurgeon<br>Talk with superior|L02=Normal CSF}} |
| {{familytree | B01 | | | B02 | | | B03 | | | B04 | | | B05 | | | B06 | | | B07 | | | B08 | | | B09 | | | B10 | | | B11 |B01=Cerebral edema & increased ICP|B02=Coagulopathy|B03=Drugs|B04=GI bleeding|B05=Hemodynamic instability|B06=Hepatic encephalopathy|B07=Infections|B08=Metabolic disturbances|B09=NAC|B10=Nutritional deficiency|B11=Renal failure}}
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| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
| | {{familytree | | | | | | | | | | | | | M01 | | | |M01=Obtain more Hx and Investigation<br>Rule out other causes<br>Analgesia}} |
| {{familytree | C01 | | | C02 | | | C03 | | | C04 | | | C05 | | | C06 | | | C07 | | | C08 | | | C09 | | | C10 | | | C11 |C01=Monitor ICP, CPP & cerebral oxygenation<BR>Elevate head end to 30°<BR>Monitor fluid status<BR>3% NS<BR>Avoid NGT and suction|C02=Platelet count & coagulation profile (12th hourly)<BR>Inj. Vit. K<BR>Cryoprecipitate|C03=Discontinue medications<BR>Avoid nephrotoxic & hepatotoxic drugs|C04=Ranitidine|C05=Monitor CVP w/ central venous catheter|C06=Frequent monitoring of mental status|C07=CBC (12th hourly)<BR>CXR; sputum, blood & urine cultures (daily)<BR>Cefotaxime, meropenem, fluconazole or vancomycin|C08=Serum BCH, ABG, lactate (12th hourly)<BR>Serum glucose (2nd hourly)|C09=NAC (i.v × 2d then P.O.)|C10=Eternal feeding<BR>Parental feeding|C11=Urinary I/O}}
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| ===Etiology Specific Management===
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| {{familytree/start |style=font-size:80%; line-height: 120%;| summary=Etiology specific alogorithm}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Etiology specific management}}
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| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
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| {{familytree | B01 | | | B02 | | | B03 | | | B04 | | | B05 | | | B06 | | | B07 | | | B08 | | | B09 | | | B10 | | | B11 |B01=H/o acetaminophen intake<BR>Consider if no H/o but elevated aminotransferase (>3500 IU/L)|B02=Jaundice, coagulopathy, thrombocytopenia ± hypoglycemia<BR>Hypertension & proteinuria<BR>+ Steatosis during liver imaging or biopsy|B03=Elevated aminotransferase responding to fluid resuscitation<BR>Associated renal dysfunction & muscle necrosis|B04=+ Serum autoantibodies<BR>+ Liver biopsy|B05=Abdominal pain, ascites and hepatomegaly<BR>+ Liver imaging (CT/MRV/venogram/doppler USG)|B06=H/o hepatotoxic drug intake (<6m)<BR>Unlikely if H/o intake >1 or 2 years|B07=Massive hepatomegaly<BR>+ Liver imaging & biopsy|B08=H/o mushroom intake<BR>Suspect if no H/o but severe GI Sx (NVD)|B09=+ Hepatitis serology<BR>+ Liver biopsy for HSV<BR>|B10=Serum bilirubin >20g/dL, bilirubin:alkaline phosphatase >2.0, low serum ceruloplasmin, elevated serum & urine copper, + KF ring, + liver biopsy|B11=Etiology undetermined}}
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| {{familytree | C01 | | | C02 | | | C03 | | | C04 | | | C05 | | | C06 | | | C07 | | | C08 | | | C09 | | | C10 | | | C11 |C01=Acetaminophen toxicity|C02=Acute fatty liver of pregnancy/HELLP|C03=Acute ischemic injury|C04=Autoimmune|C05=Budd-Chiari|C06=Drug induced|C07=Malignant infiltration|C08=Mushroom poisoning|C09=Viral|C10=Wilson's disease|C11=Intermediate etiology}}
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| {{familytree | D01 | | | D02 | | | D03 | | | D04 | | | D05 | | | D06 | | | D07 | | | D08 | | | D09 | | | D10 | | | D11 |D01=Activated charcoal<BR>NAC|D02=Deliver immediately|D03=Manage the cause of ischemia|D04=Prednisolone<BR>Transplantation|D05=Transplantation|D06=Discontinue all possible medications except essential drugs|D07=Supportive Rx|D08=Activated charcoal & gastric lavage<BR>Penicillin G or Silibinin<BR>Fluid resuscitation|D09=Supportive Rx<BR>Lamivudine or adefovir<BR>Acyclovir|D10=Dialysis or hemofiltration or plasmapheresis or plasma exchange<BR>Transplantation|D11=Incomplete drug or toxin intake H/O<BR>Transjugular biopsy to R/O mailgnancy, Wilson's disease, autoimmune hepatitis or viral hepatitis}}
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| ===Complication Specific Management===
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| {{familytree/start |style=font-size:85%; line-height: 120%; | summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Complication specific management}}
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| {{familytree | | |,|-|-|-|-|-|-|v|-|-|-|-|-|-|v|-|-|-|-|-|-|-|+|-|-|-|-|-|-|v|-|-|-|-|-|-|v|-|-|-|-|-|-|.| |}}
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| {{familytree | | B01 | | | | | B02 | | | | | B03 | | | | | | B04 | | | | | B05 | | | | | B06 | | | | | B07 | | | |B01=Ascites|B02=Cerebral edema & increased ICP|B03=Coagulopathy|B04=Hemodynamic instability|B05=Hepatic encephalopathy|B06=Metabolic disturbances|B07=Renal failure}}
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| {{familytree | | C01 | | | | | C02 | | | | | C03 | | | | | | C04 | | | | | C05 | | | | | C06 | | | | | C07 |C01=Therapeutic paracentesis w/ 25% albumin<BR><br> <3 mEq/Kg of Na daily<BR><br> Lasix & aldactone|C02=ICP >25 mmHg|C03=+ Bleeding or prior to surgery|C04=Colloid, dextrose in crystalloid (if hypoglycemic) & 1/2 NS w/ 75 mg/L HCO3 (if acidotic)<BR><br> Norepinephrine±vasopressin<BR><br> Hydrocortisone|C05=Grade|C06=Rx acidosis, alkalosis, hypophosphatemia, hypomagnesemia, hypokalemia or hypoglycemia accordingly|C07=Continuous venovenous hemodialysis}}
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| {{familytree | | | | | | | | | D01 | | | | | D02 | | | | | | D03 | | | | | D04 | | | | | D05 | | | | | | | | | | | | | | |D01=SpO2|D02=Platelet transfusion (if ≤50,000/mm2)<BR><br> FFP /+ rFVIIa (if INR≥1.5)|D03=I|D04=II|D05=III/IV}}
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| {{familytree | | E01 | | | | | | | | | | | | E02 | | | | | | E03 | | | | | E04 | | | | | E05 | | | | | | | | | | | | | | | | |E01= <80 |E02= >80 |E03= 2nd hourly monitoring in quiet environment in high dependency ward|E04=ICU management<BR><br> Stat CT to R/O ICH<BR><br> Short acting BZD<BR><br> Lactulose|E05=ICU management<BR><br> Intubation & mechanical ventilation<BR><br> Propofol<BR><br> Elevate head end to 30°<BR><br> Quiet environment monitoring for CVP, hemodynamic & renal parameters, serum electrolytes, acid base status & neurological status}}
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| {{familytree | | F01 |-|-|-|-| F02 |-|-|-|-| F03 | | | | | | F04 | | | | | | | | | | | | | | | | | | | | | | |F01=20% mannitol|F02=No improvement|F03=Hyperventillation|F04=Worsening}}
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| {{familytree | | G01 | | | | | | | | | | | | | | | | | | | | G02 | | | | | | | | | | | | | | | | | | | | | | | |G01=3% NS|G02=Transfer to ICU}}
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| {{familytree | | H01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |H01=Reduce core temperature to 32°-34° (monitor for arrhythmias)}}
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| {{familytree | | I01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |I01=Thiopental 125 mg i.v bolus}}
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| {{familytree | | J01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |J01=Improvement or refractory}}
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| {{familytree | | K01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |K01=Transplantation}}
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| {{familytree/end}} | | {{familytree/end}} |