DVT complete diagnostic approach resident survival guide

Probability of infective endocaritis	Characteristics
Definite diagnosis by pathological criteria	❑ Microorganisms demonstrated by culture or histological examination of a vegetation, OR ❑ Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis
Definite diagnosis by clinical criteria	❑ 2 major criteria; OR ❑ 1 major criterion and 3 minor criteria; OR ❑ 5 minor criteria
Possible diagnosis	❑ 1 major criterion and 1 minor criterion; OR ❑ 3 minor criteria
Rejected diagnosis	❑ Firm alternative diagnosis explaining evidence of IE, OR ❑ Resolution of IE syndrome with antibiotic therapy for 4 days, OR ❑ No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for 4 days, OR ❑ Does not meet criteria for possible IE as above

Criteria	Definite Infective Endocarditis According to Modified Duke Criteria
Pathological Criteria	Microorganisms demonstrated by culture or histological examination of a vegetation Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis
Clinical Criteria	2 major criteria; or 1 major criterion and 3 minor criteria; or 5 minor criteria
Possible IE	1 major criterion and 1 minor criterion; or 3 minor criteria
Rejected	Firm alternative diagnosis explaining evidence of IE; or Resolution of IE syndrome with antibiotic therapy for 4 days; or No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for 4 days; or Does not meet criteria for possible IE as above

Identify cardinal findings that increase the pretest probability of wide complex tachycardia ❑ Palpitations ❑ Heart rate > 100 beats/min ❑ QRS complex > 120 ms

Does the patient have any of the following findings that require urgent cardioversion? ❑ Hemodynamic instability ❑ Hypotension ❑ Cold extremities ❑ Peripheral cyanosis ❑ Mottling ❑ Altered mental status ❑ Chest discomfort suggestive of ischemia ❑ Decompensated heart failure

❑ Yes

❑ No

❑ Urgent synchronized cardioversion ❑ Provide an initial shock of 100 Joules ❑ If there is no response to the first shock, increase the dose in a stepwise fashion (eg, 100 J, 200 J, 300 J, 360 J) ❑ If a patient has polymorphic VT and is unstable, treat the rhythm as VF and deliver high-energy unsynchronized shocks ❑ Provide an initial shock of 200 Joules ❑ Increase the dose if no response to the first shock (eg, 300 J, 360 J, 360 J) ❑ Give IV sedation if the patient is conscious ❑ Consider expert consultation

❑ Continue with the complete diagnostic approach below

❑ After the stabilization of the patient, continue with the complete diagnostic approach below