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Revision as of 15:36, 26 March 2014 by Vidit Bhargava (talk | contribs)
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Characterize symptoms

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Medication history

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Past medical history

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Possible triggers

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Physical examination

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Labs and tests

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Imaging studies

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnostic features

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Syncope

 
 
 
 
 
 
 
 
 

Non syncope loss of consciousness

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
{{{ A11 }}}
 
 
 
 

Unknown etiology
Determine if there are any high risk criteria:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

High risk

 
 
 

low risk

 
 
 

Consider alternative diagnoses

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Immediate in-hospital monitoring

 
 
 

Recurrent syncopes

 
 
 

Single syncope

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If suspicion of structural hear disease:
Order an echocardiography

 
 
 
 

Was it in high risk setting?
Potential risk of physical injury
Occupational implications

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Structural heart disease present
Treat accordingly

 
 

No structural heart disease

 
 
 

Yes

 

No: No further evaluation

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Tilt testing

 
 
 
 
 
 
 

Characterize the symptoms



DrugAdult dosage
Inhaled Short Acting β Agonists (SABA)
Albuterol/Bitolterol/Pirbuterol
a) Nebulizer solution
b) MDI

♦ 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed or 10-15 mg/hour continuously.
♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Levalbuterol
a) Nebulizer solution
b) MDI

♦ 1.25-2.5 mg every 20 mins for 3 doses, then 1.25-5 mg every 1-4 hours as needed.
♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Anticholinergics
Ipratropium bromide
a) Nebulizer solution
b) MDI

♦ 0.5 mg every 20 mins for 3 doses, then as needed.
♦ 8 puffs every 20 mins as needed for upto 3 hours.
Ipratropium with albuterol
a) Nebulizer solution (each 3 ml containing 0.5 mg ipratropium and 2.5 mg albuterol)
b) MDI (each puff contains 18 mcg ipratropium and 90 mcg albuterol)

♦ 3 ml every 20 mins for 3 doses, then as needed.
♦ 8 puffs every 20 mins as needed for 3 hours
Systemic corticosteroids
Prednisone/Prednisolone/Methylprednisolone ♦ 40-80 mg/day in 1 or 2 divided doses until peak expiratory flowrate (PEF) reaches 70% of personal best.


Clinical courseUnstable
Physical examination Signs of heart failure
Functional class IV
6MWD Less than 400 m
EchocardiogramRV Enlargement
HemodynamicsRAP high
CI low
BNPElevated/Increasing
TreatmentIntravenous prostacyclin and/or combination treatment
Frequency of evaluation Q 1 to Q 3 months
FC assessment Every clinic visit
6MWT Every clinic visit
Echocardiogram2Q 6 to Q 12 months/center dependent
BNPcenter dependent
RHCQ 6 to Q 12 months or clinical deterioration