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| ==In Progress== | | ==HIV-TB Coinfection== |
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| | 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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| The best approach to prevent [[measles]] is by active [[immunization]].<ref name="MossGriffin2012">{{cite journal|last1=Moss|first1=William J|last2=Griffin|first2=Diane E|title=Measles|journal=The Lancet|volume=379|issue=9811|year=2012|pages=153–164|issn=01406736|doi=10.1016/S0140-6736(10)62352-5}}</ref> Ever since the introduction of the [[vaccine]] in the developed world, there has been a marked reduction in the [[incidence]] of [[measles]]. | | 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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| * The [[vaccination]] is generally not given earlier than this because children younger than 18 months usually retain anti-measles [[immunoglobulins]] (antibodies) transmitted from the mother during [[pregnancy]].
| | 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. |
| * A "booster" vaccine is then given between the ages of four and five.
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| * Vaccination rates have been high enough to make measles relatively uncommon.
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| * Even a single case in a college dormitory or similar setting is often met with a local vaccination program, in case any of the people exposed are not already immune.
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| Measles vaccine (contained in MMR, MR and measles vaccines) can prevent this disease. The MMR vaccine is a live, attenuated (weakened), combination vaccine that protects against the measles, mumps, and rubella viruses. It was first licensed in the combined form in 1971 and contains the safest and most effective forms of each vaccine. It is made by taking the measles virus from the throat of an infected person and adapting it to grow in chick embryo cells in a laboratory. As the virus becomes better able to grow in the chick embryo cells, it becomes less able to grow in a child’s skin or lungs. When this vaccine virus is given to a child it replicates only a little before it is eliminated from the body. This replication causes the body to develop an immunity that, in 95% of children, lasts for a lifetime. A second dose of the vaccine is recommended to protect those 5% who did not develop immunity in the first dose and to give "booster" effect to those who did develop an immune response.
| | 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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| ;Children should get 2 doses of MMR vaccine:
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| * The first dose at 12-15 months of age
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| * The second dose at 4-6 years of age
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| These are the recommended ages. But children can get the second dose at any age, as long as it is at least 28 days after the first dose.
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| ''' Adults DO NOT need the measles, mumps, rubella vaccine (MMR) if:'''
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| * Blood tests show immunity to measles, mumps, and rubella.
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| * You are a man born before 1957.
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| * You are a woman born before 1957 who is sure she is not having more children, has already had rubella vaccine, or has had a positive rubella test.
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| * You already had two doses of MMR or one dose of MMR plus a second dose of measles vaccine.
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| * You already had one dose of MMR and are not at high risk of measles exposure.
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| '''Adults SHOULD get the measles vaccine if you are not among the categories listed above, and:'''
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| * You are a college student, trade school student, or other student beyond high school.
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| * You work in a hospital or other medical facility*.
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| * You travel internationally, or are a passenger on a cruise ship.
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| * You are a woman of childbearing age.
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| ==Random notes==
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| ------------------
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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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| | 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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| |}
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| ==References==
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| {{Reflist|2}}
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