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| ==In Progress== | | ==HIV-TB Coinfection== |
| According to the cases studied until now, referse transcriptase polymerase chain reaction testing of specimens from the lower respiratory tract, such as tracheal aspirates or bronchoalveolar lavage, detain the highest sensitivity for the detection of MERS-CoV.<ref name="pmid23041020">{{cite journal| author=Corman VM, Eckerle I, Bleicker T, Zaki A, Landt O, Eschbach-Bludau M et al.| title=Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. | journal=Euro Surveill | year= 2012 | volume= 17 | issue= 39 | pages= | pmid=23041020 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23041020 }} </ref><ref name="pmid23718156">{{cite journal| author=Memish ZA, Zumla AI, Al-Hakeem RF, Al-Rabeeah AA, Stephens GM| title=Family cluster of Middle East respiratory syndrome coronavirus infections. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 26 | pages= 2487-94 | pmid=23718156 | doi=10.1056/NEJMoa1303729 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23718156 }} </ref>
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| [24,26,31,32,36,79,90,93,94]. In the largest of these reports, which included 112 patients with MERS-CoV infection, lower respiratory tract specimens (bronchoalveolar lavage fluid, tracheal aspirates) yielded significantly higher MERS- CoV loads and genome fractions than nasopharyngeal swabs or sputum [94]. However, upper respiratory tract specimens are still useful for diagnosing MERS-CoV. As an example, in a series of 47 patients with MERS-CoV, the majority of patients were diagnosed using nasopharyngeal swabs [44]. | | Recommendations for the treatment of tuberculosis in [[HIV]]-infected adults: |
| | The recommended treatment of TB disease in HIV-infected adults (when the disease is caused by organisms that are known or presumed to be susceptible to first-line drugs) is a 6-month regimen consisting of: |
| | *For the first 2 months: An initial phase of [[isoniazid]] (INH), a [[rifamycin]], [[pyrazinamide]] (PZA), and [[ethambutol]] (EMB). |
| | *For the last 4 months: A continuation phase of INH and a rifamycin. |
| | *Patients with advanced HIV (CD4 counts < 100/µl) should be treated with daily or three-times-weekly therapy in both the initial and the continuation phases. |
| | *Twice weekly therapy may be considered in patients with less-advanced immunosuppression (CD4 counts ≥ 100/µl). |
| | *Once-weekly INH/rifapentine in the continuation phase should not be used in any HIV-infected patient. |
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| In a detailed analysis of a patient with multiple myeloma and MERS-CoV infection who succumbed after developing acute respiratory distress syndrome and septic shock, high concentrations of MERS-CoV were detected by rRT-PCR from respiratory specimens (BAL fluid or tracheobronchial secretions), peaking at 1.2 x106 copies/mL [32]. MERS-CoV was also detectable from oronasal secretions, stool, and urine, but at low concentrations. Only one of two oronasal specimens was positive by rRT-PCR (5370 copies/mL). No virus was detected from the blood of this patient, but it has been detected from the blood of another reported patient [36]. The low concentration of MERS-CoV detected from stool is notably different from the experience with severe acute respiratory syndrome coronavirus (SARS-CoV); patients with SARS-CoV had high virus concentrations and prolonged excretion from stool. (See "Severe acute respiratory syndrome (SARS)", section on 'Polymerase chain reaction'.)
| | Recommendations for the treatment of tuberculosis in [[HIV]]-infected adults are, with a few exceptions, the same as those for HIV-uninfected adults. The [[INH]]--[[rifapentine]] once weekly continuation phase is contraindicated in HIV-infected patients because of an unacceptably high rate of relapse, frequently with organisms that have acquired resistance to [[rifamycin]]s. The development of acquired [[rifampin]] [[drug resistance|resistance]] has also been noted among HIV-infected patients with advanced [[immunosuppression]] treated with twice weekly rifampin- or [[rifabutin]]-based regimens. Consequently, patients with [[CD4]]+ cell counts <100/µl should receive daily or three times weekly treatment. DOT and other adherence-promoting strategies are especially important for patients with HIV-related tuberculosis. |
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| Three rRT-PCR assays for routine detection of MERS-CoV have been developed [79]. Currently described tests are an assay targeting a region upstream of the E protein gene (upE) [24] and assays targeting the open reading frame 1b (ORF 1b) [24] and the open reading frame 1a (ORF 1a) [95]. In some cases, sequencing should be performed for confirmation.
| | Management of HIV-related tuberculosis is complex and requires expertise in the management of both HIV disease and tuberculosis. Because HIV-infected patients are often taking numerous medications, some of which interact with antituberculosis medications, it is strongly encouraged that experts in the treatment of HIV-related tuberculosis be consulted. A particular concern is the interaction of [[rifamycin]]s with [[antiretroviral agent]]s and other antiinfective drugs. [[Rifampin]] can be used for the treatment of tuberculosis with certain combinations of antiretroviral agents. [[Rifabutin]], which has fewer problematic drug interactions, may also be used in place of rifampin and appears to be equally effective although the doses of rifabutin and antiretroviral agents may require adjustment. As new antiretroviral agents and more pharmacokinetic data become available, these recommendations are likely to be modified. |
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| ==Random notes==
| | On occasion, patients with HIV-related tuberculosis may experience a temporary exacerbation of symptoms, signs, or radiographic manifestations of tuberculosis while receiving antituberculosis treatment. This clinical or radiographic worsening (paradoxical reaction) occurs in HIV-infected patients with active tuberculosis and is thought to be the result of immune reconstitution as a consequence of effective [[antiretroviral therapy]]. Symptoms and signs may include high [[fever]]s, [[lymphadenopathy]], expanding [[central nervous system]] lesions, and worsening of [[chest radiographic]] findings. The diagnosis of a paradoxical reaction should be made only after a thorough evaluation has excluded other [[etiologies]], particularly tuberculosis treatment failure. [[Nonsteroidal antiinflammatory agent]]s may be useful for symptomatic relief. For severe paradoxical reactions, [[prednisone]] (1--2 mg/kg per day for 1--2 weeks, then in gradually decreasing doses) may be used, although there are no data from controlled trials to support this approach. |
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| <ref name=CDC>{{cite web | title = Middle East Respiratory Syndrome (MERS) | url = http://www.cdc.gov/CORONAVIRUS/MERS/INDEX.HTML }}</ref>
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| CS Ultrasound: [[Echocardiography]] is an important imaging modality in the evaluation of the patient with cardiogenic shock. In cardiogenic shock complicating acute-[[MI]], findings such as poor wall motion may be identified. Mechanical complications such as [[papillary muscle rupture]], pseudoaneurysm, and a [[ventricular septal defect]] may also be visualized. [[Valvular heart disease]] such as [[aortic stenosis]], [[aortic insufficiency]] and [[mitral stenosis]] can also be assessed. Dynamic outflow obstruction such as [[HOCM]] can also be indentified and quantified. The magnitude of left ventricular dysfunction in patients with cardiomyopathy can be evaluated. It allows the clinician to distinguish cardiogenic shock from [[septic shock]] and [[neurogenic shock]]. In [[septic shock]], a hypercontractile ventricle may be present.
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| *Differential diagnosis - "Cardiogenic shock may be difficult, at least initially, to distinguish from hypovolemic shock. Both forms of shock are associated with decreased cardiac output and compensatory upregulation of the sympathetic response. Both entities also respond initially to fluid resuscitation. The syndrome of cardiogenic shock is defined as the inability of the heart to deliver sufficient blood flow to meet metabolic demands. The etiology of cardiogenic shock may be intrinsic or extrinsic. In Case 1 , the development of class IV shock may be due to hemorrhage, such as an aortic injury, or may be cardiogenic, such as a myocardial contusion from blunt injury to the chest. Echocardiography would evaluate the possibility of intrinsic or extrinsic myocardial dysfunction. Intrinsic causes of cardiogenic shock include myocardial infarction, valvular disease, contusion from thoracic trauma, and arrhythmias. For patients with myocardial infarction, cardiogenic shock is associated with loss of greater than 40% of left ventricular myocardium. The normal physiologic compensation for cardiogenic shock actually results in progressively greater myocardial energy demand that, without intervention, results in the death of the patient . A decrease in blood pressure activates an adrenergic response that leads to increased sympathetic tone, stimulates renin-angiotensinaldosterone feedback, and potentiates antidiuretic hormone secretion. These mechanisms serve to increase vasomotor tone and retain salt and water. The resultant increase in systemic vascular resistance and in left ventricular end-diastolic pressure leads to increased myocardial oxygen demand in the face of decreased oxygen delivery. This, in turn, results in worsening left ventricular function, a perceived reduction in circulating blood volume, and repetition of the cycle."
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| ===Cardiogenic shock and Inflammatory Mediators===
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| [[Image:Cardiogenic_shock.JPG|center|500px]]
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| ===The Pathophysiologic "Spiral" of Cardiogenic shock===
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| Among patients with acute MI, there is often a downward spiral of hypoperfusion leading to further ischemia which leads to a further reduction in cardiac output and further hypoperfusion. The [[lactic acidosis]] that develops as a result of poor systemic perfusion can further reduce cardiac contractility. Reduced cardiac output leads to activation of the sympathetic nervous system, and the ensuing [[tachycardia]] that develops further exacerbates the myocardial ischemia. The increased left ventricular end diastolic pressures is associated with a rise in wall stress which results in further myocardial ischemia. [[Hypotension]] reduces epicardial perfusion pressure which in turn further increases myocardial ischemia.
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| Patients with cardiogenic shock in the setting of [[STEMI]] more often have multivessel disease, and myocardial ischemia may be present in multiple territories. It is for this reason that multivessel angioplasty may be of benefit in the patient with cardiogenic shock.
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| The multifactorial nature of cardiogenic shock can also be operative in the patient with critical [[aortic stenosis]] who has "spiraled": There is impairment of left ventricular outflow, with a drop in [[cardiac output]] there is greater [[subendocardial]] ischemia and poorer flow in the coronary arteries, this leads to further [[left ventricular systolic dysfunction]], given the subendocardial ischemia, the left ventricle develops [[diastolic dysfunction]] and becomes harder to fill. Inadvertent administration of [[vasodilator]]s and [[venodilator]]s may further reduce cardiac output and accelerate or trigger such a spiral.
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| ===Pathophysiologic Mechanisms to Compensate for Cardiogenic shock===
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| [[Cardiac output]] is the product of [[stroke volume]] and heart rate. In order to compensate for a reduction in stroke volume, there is a rise in the heart rate in patients with cardiogenic shock. As a result of the reduction in [[cardiac output]], peripheral tissues extract more oxygen from the limited blood that does flow to them, and this leaves the blood deoxygenated when it returns to the right heart resulting in a fall in the mixed venous oxygen saturation.
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| ===Pathophysiology of Multiorgan Failure===
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| The poor perfusion of organs results in [[hypoxia]] and [[metabolic acidosis]]. Inadequate perfusion to meet the metabolic demands of the brain, kidneys and heart leads to multiorgan failure.
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| ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
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| Differential Diagnosis
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| {| style="border: 2px solid #A8A8A8; font-size: 70%;" align="center"
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| |+ <SMALL>''Classification of shock based on hemodynamic parameters.'' (CO, cardiac output; CVP; central venous pressure; PAD, pulmonary artery diastolic pressure; PAS, pulmonary artery systolic pressure; RVD, right ventricular diastolic pressure; RVS, right ventricular systolic pressure; SVO2, systemic venous oxygen saturation; SVR, systemic vascular resistance.)<ref name="isbn0-683-06754-0">{{Cite book | last1 = Parrillo | first1 = Joseph E. | last2 = Ayres | first2 = Stephen M. | title = Major issues in critical care medicine | date = 1984 | publisher = William Wilkins | location = Baltimore | isbn = 0-683-06754-0 | pages = }}</ref><ref name="isbn9781405179263">{{cite book | author = Judith S. Hochman, E. Magnus Ohman | authorlink = | editor = | others = | title = Cardiogenic Shock | edition = | language = | publisher = Wiley-Blackwell | location = | year = 2009 | origyear = | pages = | quote = | isbn = 9781405179263 | oclc = | doi = | url = | accessdate = }}</ref></SMALL>
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| | align="center" style="background: #A8A8A8; width: 100px;"| '''Type of Shock'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''Etiology'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''CO'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''SVR'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''PCWP'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''CVP'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''SVO2'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''RVS'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''RVD'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''PAS'''
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| | align="center" style="background: #A8A8A8; width: 50px;" | '''PAD'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC; width: 80px;" align=center rowspan=4 | '''Cardiogenic'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC; width: 20%;" | '''[[Ventricular septal defect|Acute Ventricular Septal Defect]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Mitral regurgitation|Acute Mitral Regurgitation]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Myocardium|Myocardial Dysfunction]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[RV infarction|Right Ventricular Infarction]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓ — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓ — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓ — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" rowspan=2 align=center | '''Obstructive'''
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" | '''[[Pulmonary embolism|Pulmonary Embolism]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓ — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓ — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓ — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" |'''[[Cardiac tamponade|Cardiac Tamponade]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓ — ↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |N — ↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" rowspan=2 align=center | '''Distributive'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Septic shock|Septic Shock]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓ — ↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
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| |-
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" | '''[[Anaphylactic shock|Anaphylactic Shock]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓ — ↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↑ — ↑↑
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" rowspan=1 align=center | '''Hypovolemic'''
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" | '''[[Volume depletion|Volume Depletion]]'''
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↑
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |N — ↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
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| | style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=center |↓
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| ==References==
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| {{Reflist|2}}
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