Page 1
Page 2
Page 3
Page 4
Page 5
Page 6
Page 7
Page 8
Page 9
Page 10
Page 11
Page 12
Page 13
Page 14
Page 15
Page 16
Page 17
Page 18
Page 19
Page 20
Page 21
Page 22
Page 23
Page 24
Page 25
Page 26
Page 27
Page 28
Page 29
Page 30
Page 31
Page 32
Page 33
Page 34
Page 35
Page 36
Page 37
Page 38
Page 39
Page 40
Page 41
Page 42
Page 43
Page 44
Page 45
Page 46
Page 47
Page 48
Page 49
Page 50
Page 51
Page 52
Page 53
Page 54
ThomasW.BarkleyJr.CharleneM.MyersSecondEditon AbAbortionsCVACerebrovascularaccidentABGArterialbloodgasCVPCentralvenouspressureACEIAngiotensinconvertingenzymeinhibitorCXRChestx-rayACLSAdvancedcardiaclifesupportDDAVPSyntheticvasopressinposteriorpituitaryhormoneACTHAdrenocorticotropichormoneDICDisseminatedintravascularcoagulationADL.aurisdextraRightearDIPDistalinterphalangealjointADHAntidiuretichormoneDKADiabeticketoacidosisADLActivityofdailylivingDMDiabetesmellitusAGNAcuteglomerulonephritisDOEDyspneaonexertionALTAlanineaminotransferasetransaminaseDPDorsalispedispulseAMIAcutemyocardialinfarctionDTRDeeptendonreexANAAntinuclearantibodyDVTDeepvenousthrombosisAntiHBeHepatitisBeantibodyD50W50dextroseinwaterAntiHBsHepatitisBantibodyECGElectrocardiogrammayalsoseeEKGAPAnteroposteriorEEGElectroencephalogramASL.aurissinistraLeftearEENTEye-ear-nose-throatASAAspirinENTEar-nose-throatphysicianspecialistASCUSAtypicalsquamouscellofundeterminedsignifcanceEOMExtraocularmovementASTAspartatetransaminaseEPSExtrapyramidalsymptomAUBothearsorL.auriesuterqueeachearESRErythrocytesedimentationrateAVAtrioventricularETOHAlcoholdrinkingBPBloodpressureFBGFastingbloodglucoseBPHBenignprostatichypertrophyFEVForcedexpiratoryvolumeBpmBeatsperminuteFHFamilyhistoryBUNBloodureanitrogenFTA-ABSBloodtestforsyphilisCABGCoronaryarterybypassgraftGABAGammaaminobutyricacidCADCoronaryarterydiseaseGABHSGroupAbetahemolyticstreptococcusCBCCompletebloodcountGFRGlomerularfltrationrateCCChiefcomplaintGIGastrointestinalCDCCentersforDiseaseControlandPreventionGTTGlucosetolerancetestCFCysticfbrosisGUGenitourinaryCFSChronicfatiguesyndromeHAHeadacheCHFCongestiveheartfailureHAVHepatitisAvirusCHIClosedheadinjuryHbA1CHemoglobinA1CglycosylatedHgbCICardiacIndexHbcAgHepatitisBcoreantigenCISCarcinomainsituHbCVHaemophilusinfuenzaeBconjugatevaccineCKCreatininekinaseHBeAgHepatitisBeantigenCMTCervicalmotiontendernessHBsAgHepatitisBsurfaceantigenCMVCytomegalovirusHBVHepatitisBvirusCNCranialnervehCGHumanchorionicgonadotropinCNSCentralnervoussystemHCO3-BicarbonateCOCardiacoutputHctHematocritCOPDChronicobstructivepulmonarydiseaseHCVHepatitisCvirusCPPCerebralperfusionpressureHDLHigh-densitylipoproteinCPRCardiopulmonaryresuscitationHfuHaemophilusinfuenzaebbacteriaCRFChronicrenalfailureHgbHemoglobinCSCultureandsensitivityHIVHumanimmunodefciencyvirusCSFCerebrospinaluidHLAHumanleukocyteantigenCTComputedtomographyx-rayexaminationHPFHigh-poweredfeldAbbreviationsContinuedoninsidebackcover AbbreviationscontinuedHPIHistoryofpresentillnessPMIPointofmaximalimpulseHPVHumanpapillomavirusPMSPremenstrualsyndromeHRHeartratepulsePPDPuriedproteinderivativeTBtestHRTHormonereplacementtherapyPSAProstate-specicantigenHSILHigh-gradesquamousintraepitheliallesionsmayalsoseeHGSILPTPosteriortibialispulseprothrombintimeHSVHerpessimplexvirusPT-INRPT-internationalnormalizedratioHTNHypertensionmayalsoseeHPTNPTTPartialthromboplastintimeICPIntracranialpressurePUDPepticulcerdiseaseICSIntercostalspacePVCPrematureventricularcontractionIgImmunoglobulinPVDPeripheralvasculardiseaseIGTImpairedglucosetoleranceRBCRedbloodcellINRInternationalnormalizedratioRORuleoutIUDIntrauterinecontraceptivedeviceROMRangeofmotionIVPIntravenouspyelogramRPRRapidplasmareagintestforsyphilisJVDJugularvenousdistentionRRRespiratoryratebreathsperminuteKOHPotassiumhydroxideRSVRespiratorysyncytialvirusKUBKidneyureterbladderx-rayexaminationSBESubacutebacterialendocarditisself-breastexaminationLDHLactatedehydrogenaselaboratorytestSCASicklecellanemiaLDLLow-densitylipoproteinSCISpinalcordinjuryLESLoweresophagealsphincterSIADHSyndromeofinappropriateantidiuretichormoneLFTLiverfunctiontestSILSquamousintraepitheliallesionLHLuteinizinghormoneSLESystemiclupuserythematosusLOCLevelofconsciousnessSOBShortnessofbreathLPLumbarpunctureSSSignssymptomsLSILLow-gradesquamousintraepitheliallesionmayalsoseeLGSILSSRISelectiveserotoninreuptakeinhibitorMAPMeanarterialpressureSTISexuallytransmittedinfectionMCHCMeancorpuscularhemoglobinconcentrationSVRSystemicvascularresistanceMCPMetacarpophalangealjointT3TriiodothyronineMCVMeancorpuscularvolumeT4ThyroxineMDIMetereddoseinhalerTdapTetanusdiphtheriaandpertussisvaccineMIMyocardialinfarctionTBTuberculosisMMRMeasles-mumps-rubellavaccineTCATrichloroaceticacidMMSEMini-MentalStateExaminationTdTetanusanddiphtheriavaccineMRIMagneticresonanceimagingx-rayexaminationTIATransientischemicattackNPHIntermediate-actinginsulinTIBCTotaliron-bindingcapacityNSAIDNonsteroidalantiinammatorydrugTMJTemporomandibularjointNVNauseavomitingTMP-SMZTrimethoprim-sulfamethoxazoleOPOvaandparasitesTPNTotalparenteralnutritionOCOralcontraceptiveTSHThyroid-stimulatinghormoneODL.oculusdexterRighteyeUAUrinalysisOSL.oculussinisterLefteyeUCGUrinechorionicgonadotropinpregnancytestOTCOverthecounterURIUpperrespiratorytractinfectionOUL.oculusuterqueeacheyeUSUltrasoundPAPosteroanteriorUTIUrinarytractinfectionPCWPPulmonarycapillarywedgepressureVDRLVenerealdiseaseresearchlaboratoriesPEPulmonaryembolismVLDLVery-low-densitylipoproteinPFTPulmonaryfunctiontestVQVentilation-perfusionratioPIPProximalinterphalangealjointWBCWhitebloodcellPMHPastmedicalhistoryWNLWithinnormallimits PracticeConsiderationsforAdult-GerontologicalAcuteCareNursePractitioners2ndEditionVolumeIThomasW.BarkleyJr.PhDACNP-BCFAANPProfessorDirectorofNursePractitionerProgramsCaliforniaStateUniversityLosAngelesSchoolofNursingandPresidentBarkleyAssociatesLosAngelesCaliforniaCharleneM.MyersDNPACNP-BCCNSAssociateClinicalProfessorAdultAcuteCareNursePractitionerProgramCoordinatorUniversityofSouthAlabamaCollegeofNursingMobileAlabama InternationalStandardBookNumber978-0-578-14831-1ManagingEditorCharlieWangAssistantEditorTaylorSpiningProjectManagerAustinButlerStaffCoordinatorAzadouhiGarabedianP.O.Box69901WestHollywoodCA90069PRACTICECONSIDERATIONSFORADULT-GERONTOLOGYACUTECARENURSEPRACTITIONERSISBN978-0-578-14831-1Copyright2015byBarkleyAssociatesAllrightsreserved.Nopartofthispublicationmaybereproducedortransmittedinanyformorbyanymeanselectronicormechanicalincludingphotocopyingrecordingoranyinformationstorageandretrievalsystemwithoutpermissionfromthepublisher.PermissionsmaybesoughtdirectlyfromBarkleyAssociatesbythefollowingphone1.866.938.5557or1.323.656.1606fax1.323.656.1620e-mailContact_Usnpcourses.com.NoticeKnowledgeandbestpracticesaresubjecttochangeasnewresearchandfurtherexperienceexpandknowledge.Changesinpracticetreatmentanddrugtherapymaybewarrantedorappropriate.Itisrecommendedthatreadersverifythemostup-to-dateinformationregardingproceduresfeaturedorcheckthemanufacturersofadministeredproductssoastoverifytherecommendeddoseformulamethodsofadministrationandcontradindications.Itisthedutyofpractitionersrelyingontheirexperienceandknowledgeofthepatientscircumstancestodeterminedosagesandthebesttreatmentforeachpatientwhiletakingallsafetyprecautions.TothefullestextendofthelawneitherthePublishernortheEditorsandAuthorsassumeanyliabilityforanyinjuryandordamagetopersonsorpropertyarisingoutoforrelatedtoanyuseofthecontentinthisbook.ThePublisher iiiPrefacePracticeConsiderationsforAdultGerontologyAcuteCareNursePractitioners2ndeditionisacomprehensivetextbookforadvancedpracticenurses.Thetextisorganizedinasystematicfashionaddressingover350ofthemostcommonconditionsexperiencedbyadultpatientsinacutecare.Usinganeasy-to-readoutlineformatcoverageofeachconditionincludesdeningtermsincidencepredisposingfactorssubjectiveandphysicalexaminationndingsdiagnostictestsandmanagementstrategies.Thetexthasbeenwrittentoprovidethepractitionerwithathoroughoverviewofevidence-basedpracticeguidelines.Inthislightthetextbuildsonpreviousknowledgeofanatomyphysiologyandpathophysiologyconceptsthathavenotbeenseparatelyemphasized.Althoughmanypractitionersmaybehighlyspecializedthistextwasdesignedasausefultoolfortheentirescopeofacutecarenursingpracticeincludingsettingssuchasclinicsemergencydepartmentsmedicalsurgicaldepartmentsinhospitalsaswellascriticalcareunits.Althoughthistextwasdevelopedbasedonresearchandexpertisewealsofeelstronglythatcollaborativepracticewithotherexpertsandcliniciansisessentialtosuccessfullymeetingpatientgoals.ThomasW.BarkleyJr.CharleneM.Myers ivacknowledgmentsWegratefullyacknowledgethepreviousauthorsoftherstandsecondeditionsofPracticeGuidelinesforAcuteCareNursePractitionerswhoseknowledgeanddedicationprovidedthefoundationfortheexpansionofthistextbook.Wewouldadditionallyliketothanktheoutstandingcontributorsandreviewersofthistext.Withouttheexpertiseofthesescholarsthisworkwouldnothavebeenpossible.WealsothankthefollowingpeopleatBarkleyandAssociatesPharmacologyEditorRobertFellinManagingEditorCharlieWangAssistantEditorTaylorSpiningProjectManagerAustinButlerStaffCoordinatorAzadouhiGarabedianCoverDesignAndresMorganwhosecombinedeffortshaveproducedwhatwebelieveisastate-of-theartevidence-basedexcellentresourcefortheprofession.ThomasW.BarkleyJr.CharleneM.Myers vBimbolaF.AkintadePhDACNP-BCMBAMHAAssistantProfessorOrganizationalSystemsandAdultHealthSpecialtyDirectorAdultGerontologyAcuteCareNursePractitionerClinicalNurseSpecialistProgramUniversityofMarylandBaltimoreMaryland23.MeasuresofOxygenationandVentilation31.Pneumothorax86.ManagingtheSurgicalPatientKimberlyAlvaMSNACNP-BCCCRNAcuteCareNursePractitionerNeurosurgicalIntensiveCareUnitCedarsSinaiMedicalCenterLosAngelesCalifornia4.NeurologicTraumaSusanJ.AppelPhDACNP-BCFNP-BCCCRNFAHAProfessorTheUniversityofAlabamaCapstoneCollegeofNursingTuscaloosaAlabama47.DiabetesMellitus48.Diabetes-RelatedEmergenciesAmitaAvadhaniDNPDCCACNP-BCANP-BCAPNCCRNAssistantProfessorTrackCoordinatorAdultGerontologyAcuteCriticalCareNursePractitionerProgramRutgersSchoolofNursingRutgersBiomedicalandHealthSciencesUniversityNewarkNewJerseyCriticalCareNursePractitioner-AdultICUSaintPetersUniversityHospitalNewBrunswickNewJersey22.DiagnosticConceptsofOxygenationandVentilation35.MechanicalVentilatorySupportThomasW.BarkleyJr.PhDACNP-BCFAANPProfessorDirectorofNursePractitionerProgramsCaliforniaStateUniversityLosAngelesSchoolofNursingPresidentBarkleyAssociatesLosAngelesCalifornia3.PeripheralNeuropathies11.CardiovascularAssessment12.Hypertension13.CoronaryArteryDiseaseandHyperlipidemia14.AnginaandMyocardialInfarction15.AdjunctEquipmentDevices16.PeripheralVascularDisease17.InfammatoryCardiacDiseases18.HeartFailure19.ValvularDisease20.Cardiomyopathy21.Arrhythmias24.TheChestX-Ray25.PulmonaryFunctionTest-ing26.ObstructiveVentilatoryLungDiseases27.RestrictiveInfammatoryLungDiseases28.PulmonaryHypertensionandPulmonaryVascularDisorders29.ChestWallandSecondaryPleu-ralDisorders30.RespiratoryFailure31.Pneumothorax32.LowerRespiratoryTractPathogensdistinguishedcontributors vi33.ObstructiveSleepApnea34.OxygenSupplementation35.MechanicalVentilatorySupport47.DiabetesMellitus48.Diabetes-RelatedEmergencies49.ThyroidDisease50.CushingsSyndrome51.PrimaryAdrenocorticalInsufciencyAddisonDiseaseandAdrenalCrisis52.Pheochromocyto-ma53.SyndromeofInappropriateAntidiureticHormone54.DiabetesInsipidus67.HIVAIDSandOpportunisticInfectionsAmongOlderAdults68.AutoimmuneDiseases69.IntegumentaryDisor-ders70.EctopicPregnancyandSTIs71.EyeEarNoseandThroatDisorders72.Headache73.Fever74.Pain76.ManagementofthePatientinShock77.NutritionalConsiderations78.FluidElectrolyteandAcid-BaseImbalances79.PoisoningandDrugToxicities80.WoundManagement81.Infections82.TraumaConsiderations83.SolidOrganTransplantation84.Burns85.HospitalAdmissionConsiderations86.ManagingtheSurgicalPatient87.GuidelinesforHealthPromotionandScreening89.ImmunizationRecommendationsCatherineBlacheMSNRNCCRCOwnerDirectorofResearchPrecisionClinicalResearchLLCMobileAlabama80.WoundManagement84.BurnsBobBlessingDNPACNP-BCConsultingAssociateProfessorDukeUniversitySchoolofNursingDurhamNorthCarolinaLeadNursePractitionerNeuroscienceCriticalCareUnitDukeUniversityHealthSystemDurhamNorthCarolina3.PeripheralNeuropathies76.ManagementofthePatientinShockKellyBlessingMSNFNP-BCNeurologyProviderDukeUniversityHealthSystemDurhamNorthCarolinaFamilyNursePractitionerCerebrovascularCenterDukeUniversityHealthSystemDurhamNorthCarolina3.PeripheralNeuropathiesLorrisJ.BouzigardDNPACNP-BCANP-CDCCAcuteCareNursePractitionerInternalMedicineClinicLouisianaHeartHospitalMedicalGroupLacombeLouisianaAdjunctClinicalInstructorUniversityofSouthAlabamaMobileAlabama73.FeverTravisBradleyMSNACNP-BCCENAcuteCareNursePractitionerNeuro-SurgicalIntensiveCareUnitCedars-SinaiMedicalCenterLosAngelesCalifornia1.CerebrovascularAccidentsBrainAttack2.StructuralAbnormalities viiStevenW.BranhamPhDRNACNP-BCFNP-BCFAANPCCRNAssistantProfessorAcuteCareNursePractitionerProgramTexasTechUniversityCollegeofNursingLubbockTexas43.AcuteKidneyInjuryandChronicKidneyDiseaseBarbaraAnnSheltonBroomePhDRNCNSFAANDeanKentStateUniversityCollegeofNursingKentOhio88.MajorCausesofMortalityintheUnitedStatesFredrickCarlstonMSNACNP-BCAcuteCareNursePractitionerCardiovascularMedicineKeckHospitalofUSCLosAngelesCaliforniaAcuteCareNursePractitionerCardiologyNuclearMedicineCedars-SinaiMedicalCenterLosAngelesCalifornia21.ArrhythmiasJenniferCoatesMSNACNP-BCMBAACNPCAssistantClinicalProfessorAdultGerontologyAcuteCareNursePractitionerProgramDrexelUniversityCollegeofNursingHealthProfessionsPhiladelphiaPennsylvania29.ChestWallandSecondaryPleuralDisorders33.ObstructiveSleepApneaMarlaCoutureMSNACNP-BCCCRNClinicalInstructorAcuteCareDepartmentTheUniversityofAlabamaatBirminghamSchoolofNursingBirminghamAlabama46.NephrolithiasisR.MichaelCulpepperMDProfessorChiefDivisionofNephrologyUniversityofSouthAlabamaCollegeofMedicineMobileAlabama78.FluidElectrolyteandAcid-BaseImbalancesRitaA.DelloStrittoPhDACNP-BCCNSENPAssociateProfessorTexasWomansUniversityNeldaC.StarkCollegeofNursingHoustonTexas49.ThyroidDisease50.CushingsSyndrome51.PrimaryAdrenocorticalInsufciencyAddisonDis-easeandAdrenalCrisis54.DiabetesInsipidus viiiLisaEvansDNPACNP-BCHospitalistNursePractitionerDirectorofSkilledNursingFacilityServicesPulmonaryConsultantsPrimaryCarePhysiciansOrangeCALecturerAdultGerontologyAcuteCareNursePractitionerProgramCaliforniaStateUniversityLosAngelesLosAngelesCalifornia61.Anemias62.SickleCellDiseaseCrisis63.CoagulopathiesRobertFellinPharmDBCPSPharmacistCedars-SinaiMedicalCenterLosAngelesCaliforniaFacultyBarkleyAssociatesLosAngelesCalifornia9.ParkinsonsDisease12.Hypertension18.HeartFailure19.ValvularDisease21.ArrhythmiasAlisonForbesMSNACNP-BCCCRNAcuteCareNursePractitionerDivisionofNeurocriticalCareDepartmentofSurgeryHarborUCLAMedicalCenterTorranceCaliforniaLecturerAdultGerontologyAcuteCareNursePractitionerProgramCaliforniaStateUniversityLosAngelesLosAngelesCalifornia81.Infections82.TraumaConsiderationsCatherineL.FungMSNACNP-BCGeneralSurgeryAcuteCareNursePractitionerDivisionofUpperGIandGeneralSurgeryKeckHospitalofUSCLosAngelesCalifornia40.AnatomicIntestinalDisordersDonnaGullettePhDACNP-BCAPRNProfessorDirectorofMasterofNursingScienceProgramsAssociateDeanforPracticeUniversityofArkansasforMedicalSciencesCollegeofNursingLittleRockArkansas69.IntegumentaryDisorders72.HeadacheHaleyHoyPhDACNP-BCInterimAssociateDeanGraduateProgramsUniversityofAlabamaHuntsvilleHuntsvilleAlabamaAcuteCareNursePractitionerLungTransplantationVanderbiltMedicalCenterNashvilleTennessee25.PulmonaryFunctionTesting28.PulmonaryHypertensionandPulmonaryVascularDisorders ixAliciaHuckstadtPhDAPRNFNP-BCGNP-BCFAANPProfessorDirectorofGraduateProgramsWichitaStateUniversitySchoolofNursingWichitaKansas36.PepticUlcerDisease89.ImmunizationRecommendationsLisaA.JohnsonDrNPCRNPACNP-BCAssistantProfessorDirectorAGACNPProgramDeSalesUniversityDepartmentofNursingandHealthCenterValleyPennsylvania39.InammatoryGastrointestinalDisorders68.AutoimmuneDiseasesJoanE.KingPhDACNP-BCANP-BCFAANPProfessorAdult-GerontologyAcuteCareNursePractitionerProgramDirectorVanderbiltUniversitySchoolofNursingNashvilleTennessee11.CardiovascularAssessment13.CoronaryArteryDiseaseandHyperlipidemia14.AnginaandMyocardialInfarction18.HeartFailureHonoreKotlerMSNACNP-BCLeadAcuteCareNursePractitionerComprehensiveTransplantCenterCedarsSinaiMedicalCenterLosAngelesCalifornia83.SolidOrganTransplantationVictoriaKuMSNACNP-BCCCRNAcuteCareNursePractitionerThoracicSurgeryKeckHospitalofUSCLosAngelesCaliforniaClinicalInstructorWestCoastUniversityOntarioCalifornia24.TheChestX-RayJudiKuricDNPACNP-BCCNRNAssistantProfessorUniversityofSouthernIndianaCollegeofNursingandHealthProfessionsEvansvilleIndianaAcuteCareNursePractitionerNeurosurgicalPrivatePracticeLouisvilleKentucky5.CentralNervousSystemDisorders8.MultipleSclerosis9.ParkinsonsDisease10.AmyotrophicLateralSclerosis85.HospitalAdmissionsConsiderations xPatrickA.LairdDNPACNP-BCAPRNAssistantProfessorofClinicalNursingAdult-GerontologyAcuteCareNursePractitionerProgramDirectorTheUniversityofTexasHealthScienceCenteratHoustonSchoolofNursingHoustonTexas6.SeizureDisordersMoniqueLambertDNPACNP-BCDirectoroftheAdvancedPracticeInstituteRUSHUniversityMedicalCenterChicagoIllinois52.Pheochromocytoma53.SyndromeofInappropriateAntidiureticHormonePaulaMcCauleyDNPACNP-BCAPRNCNEAssistantClinicalProfessorAssociateDeanforAcademicAffairsUniversityofConnecticutSchoolofNursingStorrsConnecticutAcuteCareProgramCoordinatorUniversityofConnecticutSchoolofNursingStorrsConnecticut77.NutritionalConsiderationsSheilaMelanderPhDACNP-BCFCCMFAANPProfessorUniversityofKentuckyCollegeofNursingLexingtonKentucky15.AdjunctEquipmentDevices17.InammatoryCardiacDiseases20.CardiomyopathyHelenMileyPhDACNP-BC.AGACNP-BCClinicalAssociateProfessorSpecialtyDirectorAdultGeriatricAcuteCareNursePractitionerProgramRutgersTheStateUniversityofNewJerseyNewarkNewJerseyAdultGeriatricAcuteCareNursePractitionerMedicalIntensiveCareUnitRobertWoodJohnsonUniversityHospitalNewBrunswickNewJersey12.Hypertension87.GuidelinesforHealthPromotionandScreeningDavidA.MillerMDFCCPAssociateProfessorFamilyNursePractitionerProgramTexasAMUniversity-CorpusChristiCollegeofNursingandHealthSciencesCorpusChristiTexas26.ObstructiveVentilatoryLungDiseases27.RestrictiveInammatoryLungDiseases30.Respi-ratoryFailure32.LowerRespiratoryTractPathogens67.HIVAIDSandOpportunisticInfectionsAmongOlderAdults71.EyeEarNoseandThroatDisorders xiCharleneM.MyersDNPACNP-BCCNSAssociateClinicalProfessorAdultAcuteCareNursePractitionerProgramCoordinatorUniversityofSouthAlabamaCollegeofNursingMobileAlabama1.CerebrovascularAccidentsBrainAttack2.StructuralAbnormalities4.NeurologicTrauma5.CentralNervousSystemDisorders6.SeizureDisorders7.Dementia22.DiagnosticConceptsofOxygenationandVentilation23.MeasuresofOxygenationandVentilation25.PulmonaryFunctionTesting29.ChestWallandSecondaryPleuralDisorders34.OxygenSupplementation35.Mechan-icalVentilatorySupport36.PepticUlcerDisease37.LiverDisease38.BiliaryDysfunction39.InammatoryGastrointestinalDisorders40.AnatomicIntestinalDisorders41.GastrointestinalBleeding42.UrinaryTractInfections43.AcuteKidneyInjuryandChronicKidneyDisease44.BenignProstaticHyperplasia45.RenalArteryStenosis46.Nephrolithiasis71.EyeEarNoseandThroatDisorders72.Headache73.Fever74.Pain76.ManagementofthePatientinShock77.Nu-tritionalConsiderations78.FluidElectrolyteandAcid-BaseImbalances80.WoundManagement86.ManagingtheSurgicalPatient87.GuidelinesforHealthPromotionandScreening89.Immuni-zationRecommendationsMarcieNomuraMSNACNP-BCCCRNAcuteCareNursePractitionerHepatobiliarySurgeryCedars-SinaiMedicalCenterComprehensiveTransplantCenterLosAngelesCalifornia74.PainMichalynPelphreyMSNACNP-BCCCTCAcuteCareNursePractitionerLiverTransplantCedars-SinaiMedicalCenterLosAngelesCalifornia37.LiverDisease38.BiliaryDysfunctionNicolePerezMSNACNP-BCCCRNCriticalCareIntensivistNursePractitionerHarborUCLAMedicalCenterTorranceCaliforniaLecturerAdultGerontologyAcuteCareNursePractitionerProgramCaliforniaStateUniversityLosAngelesLosAngelesCalifornia41.GastrointestinalBleedingTobiasP.RebmannMSNACNP-BCCCRNAcuteCareNursePractitionerTrinityClinicCardiothoracicSurgeryLouisandPeachesOwenHeartHospitalCardiothoracicIntensiveCareUnitTylerTexas26.ObstructiveVentilatoryLungDiseases27.RestrictiveInammatoryLungDiseases xiiJacquelineRhoadsPhDAPRN-BCCNL-BCPMHNP-BEFAANPProfessorTulaneUniversitySchoolofTropicalMedicineCenterofAppliedEnvironmentalPublicHealthNewOrleansLA64.LeukemiasIvanRobbinsMDProfessorDirectorPulmonaryVascularCenterVanderbiltMedicalCenterNashvilleTennessee28.PulmonaryHypertensionandPulmonaryVascularDisordersJenniferJavierRobergMSNACNP-BCStaffEducationResearchConsultingKaiserPermanenteSouthBayHarborCityCalifornia44.BenignProstaticHyperplasiaJennaRushMSNACNP-BCCCTCHeartTransplantCoordinatorCedars-SinaiMedicalCenterComprehensiveTransplantCenterLosAngelesCalifornia65.LymphomaValerieK.SabolPhDACNP-BCGNP-BCAssociateProfessorSpecialtyDirectorAdult-GerontologyAcuteCareNursePractitionerMastersProgramDukeUniversitySchoolofNursingDurhamNorthCarolina76.ManagementofthePatientinShockAngelaStarkweatherPhDACNP-BCCNRNAssociateProfessorandChairDepartmentofAdultHealthandNursingSystemsVirginiaCommonwealthUniversitySchoolofNursingRichmondVirginia7.Dementia70.EctopicPregnancyandSTIsMicheleTalleyMSNACNP-BCClinicalInstructorSpecialtyTrackCoordinatorAdult-GerontologyAcuteCareNursePractitionerProgramUniversityofAlabamaatBirminghamSchoolofNursingBirminghamAlabama42.UrinaryTractInfections45.RenalArteryStenosis xiiiCarolThompsonPhDDNPACNP-BCFNP-BCProfessorUniversityofKentuckyCollegeofNursingLexingtonKentucky34.OxygenSupplementationElizabethA.VandeWaaPhDProfessorAdultHealthNursingDepartmentUniversityofSouthAlabamaCollegeofNursingMobileAlabama79.PoisoningandDrugToxicitiesPaulaK.VuckovichPhDPMHCNS-BCAssociateProfessorPsychiatricMentalHealthGraduateOptionCoordinatorDoctorofNursingPracticeProgramCoordinatorCaliforniaStateUniversityLosAngelesSchoolofNursingLosAngelesCalifornia75.PsychosocialProblemsinAcuteCareTheresaM.WadasPhDDNPACNP-BCFNP-BCCCRNAssistantProfessorUniversityofAlabamaCaptoneCollegeofNursingTuscaloosaAlabama16.PeripheralVascularDisease19.ValvularDiseaseColleenR.WalshDNPACNP-BCONCONP-CCSContractAssistantProfessorofGraduateNursingUniversityofSouthernIndianaCollegeofNursingandHealthEvansvilleIndiana55.Arthritis56.SubluxationsandDislocations57.SoftTissueInjury58.Fractures59.Compart-mentSyndrome60.BackPainSyndromes66.OtherCommonCancers xivLauraKierolAndrewsPhDACNP-BCAssistantProfessorYaleUniversitySchoolofNursingOrangeConnecticutSeniorAcuteCareNursePractitionerDepartmentofCriticalCareMedicineHospitalofCentralConnecticutNewBritainConnecticutSusanJ.AppelPhDACNP-BCFNP-BCCCRNFAHAProfessorTheUniversityofAlabamaCapstoneCollegeofNursingTuscaloosaAlabamaKellyArashinMSNACNP-BCAssociateProfessorofGraduateNursingArmstrongAtlanticStateUniversitySchoolofNursingSavannahGeorgiaAcuteCareNursePractitionerCriticalCareClinicalNurseSpecialistHiltonHeadHospitalApolloMarylandMelanieSchwartzBinshtokMSACNP-BCAACCAdjunctFacultyVirginiaCommonwealthUniversitySchoolofNursingRichmondVirginiaInpatientCardiologyNursePractitionerBonSecoursRichmondHealthSystemRichmondVirginiaValeriaK.BisigMSNACNP-BCFNP-BCAcuteCareNursePractitionerTriHealthCorporateHealthCincinnatiOhioJenniferM.BlakeMSNACNP-BCCNRNNeuroscienceNursePractitionerSetonBrainandSpineInstituteAustinTexasShariW.BryantMSNACNP-BCAOCNPAdjunctFacultyAcuteCareNursePractitionerProgramUniversityofSouthernIndianaCollegeofNursingandHealthEvansvilleIndianaHospitalistAcuteCareNursePractitionerSt.MarysMedicalCenterEvansvilleIndianaMeganM.ButtsMSNACNP-BCNeuroCriticalCareNursePractitionerNeuroscienceIntensiveCareUnitTheUniversityofMississippiMedicalCenterJacksonMississippiSandraK.CallaghanMSNNP-CFamilyNursePractitionerSpecialtyinNeurosurgeryandPainManagementAntelopeValleyNeuroscienceMedicalGroupLancasterCaliforniaUniversalPainManagementCEOCallaghanInc.PalmdaleCaliforniaJaimeCannonMSNACNP-BCAcuteCareNursePractitionerMontgomeryPulmonaryConsultantsMontgomeryAlabamaMelanieA.CaustritaMSNACNP-BCHospitalistNursePractitionerMiamiValleyHospitalDaytonOhioLocumTenensNursePractitionerStaffCareInc.IrvingTexasGraceCourregesMSNACNP-BCAcuteCareNursePractitionerSierraMedicalCenterElPasoTexasPatriciaCunninghamDNScPMHNP-BCPMHCNS-BCFNP-BCAssociateProfessorCoordinatorofthePsychiatricMentalHealthDoctorofNursingPracticeProgramUniversityofTennesseeHealthScienceCenterCollegeofNursingMemphisTennesseedistinguishedreviewers xvCarolineLloydDohertyMSNAGACNP-BCAACCAssociateProgramDirectorAdult-GerontologyAcuteCareNursePractitionerandAdult-GerontologyClinicalNurseSpecialistProgramsUniversityofPennsylvaniaSchoolofNursingPhiladelphiaPennsylvaniaLisaEvansDNPACNP-BCHospitalistNursePractitionerDirectorofSkilledNursingFacilityServicesPulmonaryConsultantsPrimaryCarePhysiciansOrangeCaliforniaLecturerAdultGerontologyAcuteCareNursePractitionerProgramCaliforniaStateUniversityLosAngelesLosAngelesCaliforniaMaryFranklinPhDACNP-BCClinicalAssistantProfessorWayneStateUniversityCollegeofNursingDetroitMichiganConnieL.LeonardGeimerMSNACNP-BCCRNPCCRNAcuteCareNursePractitionerPegasusEmergencyGroupGadsdenRegionalMedicalCenterGadsdenAlabamaDonnaL.GerberPhDACNP-BCAOCNAcuteCareNursePractitionerDepartmentofSarcomaUniversityofTexasM.D.AndersonCancerCenterHoustonTexasDarlaGowanDNPFNP-BCAssistantProfessorDivisionofGraduateStudiesinNursingFamilyNursePractitionerProgramIndianaWesleyanUniversitySchoolofNursingMarionIndianaLauraGrifnDNPACNP-BCCCRNAdjunctProfessorAdult-GerontologyAcuteCareNursePractitionerProgramTexasWomansUniversitySchoolofNursingDentonTexasChiefNurseExecutiveChiefClinicalOfcerKindredSugarLandHospitalSugarLandTexasAcuteCareNursePractitionerHoustonMethodistSugarLandHospitalSugarlandTexasTonjaM.HartjesDNPACNP-BCCCRNCSCClinicalAssociateProfessorAdult-GerontologyAcuteCareNursePractitionerProgramUniversityofFloridaCollegeofNursingGainesvilleFloridaConstanceW.HartmanMSNACNP-BCCCRNPulmonaryandSleepNursePractitionerCentralOhioPulmonaryDiseaseIncColumbusOhioMelissaHillMSNACNP-BCAPRNCNRNCCRNSCRNClinicalInstructorAcuteCareNursePractitionerNeuroscienceIntensiveCareUnitMedicalUniversityofSouthCarolinaCharlestonSouthCarolinaSusanHuntMSNACNP-BCAdjunctAssistantProfessorAdult-GerontologyAcuteCareNursePractitionerProgramCoordinatorIndianaUniversitySchoolofNursingIndianapolisIndianaLindsayIversonDNPACNP-BCAssistantProfessorAdult-GerontologyAcuteCareNursePractitionerProgramCoordinatorCreightonUniversityCollegeofNursingOmahaNebraskaCarolynI.JohnsonMSNACNP-BCARNP-BCPost-AcuteRehabilitationNursePractitionerAdvancedRegisteredNursePractitionerManorCarePost-AcuteRehabilitationWaterlooIowa xviKarinJonczakMSNACNP-BCCRNPCNRNNeurovascularNursePractitionerNeurovascularAssociatesofAbingtonNeurosciencesInstituteComprehensiveStrokeCenterAbingtonMemorialHospitalAbingtonPennsylvaniaVanessaM.KalisDNPACNP-BCPNPCNSAssistantProfessorDirectoroftheAdult-GerontologicAcuteCareDoctorofNursingPracticeProgramBrandmanUniversityIrvineCaliforniaKimberlyJ.LangerMSNACNP-BCAssociateProfessorandProgramCoordinatorAcuteCareNursePractitionerProgramWinonaStateUniversityRochesterMinnesotaMayoClinicDivisionofBloodandMarrowTransplantRochesterMinnesotaBeatriceK.LauniusMSNACNP-BCCCRNAdjunctfacultyCoordinatorAdult-GerontologyAcuteCareNursePractitionerProgramNorthwesternStateUniversityShreveportLouisianaClinicalinstructorChiefNursePractitionerDivisionofTraumaandCriticalCareSurgeryLouisianaStateUniversityHealthSciencesCenterShreveportShreveportLouisianaGailAnnLisDNPACNP-BCProfessorMadonnaUniversityCollegeofNursingandHealthLivoniaMichiganLisaMarchettiMSNACNP-BCNursePractitionerSurgicalIntensiveCareUnitWilliamBeaumontHospitalRoyalOakMichiganTaraMcEnanyDNPACNP-BCFNP-BCAssistantProfessorAllenCollegeUnityPointHealthWaterlooIowaTaylorA.MercierMSNACNP-BCFNP-BCAcuteCareNursePractitionerEmergencyCareSpecialistSpectrumHealthButterworthEmergencyDepartmentGrandRapidsMichiganDeidreMeyerMSNACNP-BCAcuteCareNursePractitionerProMedicaPhysiciansGroupTheToledoHospitalToledoOhioRebeccaL.MogensenMSNACNP-BCAPNPAcuteCareNursePractitionerDivisionofHospitalMedicineUniversityofWisconsinMedicalFoundationUniversityofWisconsinHospitalandClinicsMadisonWisconsinS.LoriNealMSNACNP-BCFNP-BCTraumaNursePractitionerErlangerTraumaServicesChattanoogaTennesseeJeniPageMSNACNP-BCAcuteCareNursePractitionerNeurosurgerySwedishNeuroscienceInstituteSeattleWashingtonElizabethPalermoMSNACNP-BCANP-BCAssistantProfessorofClinicalNursingAcuteCareNursePractitionerProgramSpecialtyDirectorUniversityofRochesterSchoolofNursingRochesterNewYorkAcuteCareNursePractitionerHospitalMedicineDivisionStrongMemorialHospitalRochesterNewYorkCarmenPaniaguaEdDACNP-BCAGACNP-BCAPNG-BCFAANPClinicalInstructorDepartmentofEmergencyMedicineUniversityofArkansasforMedicalSciencesCollegeofMedicineLittleRockArkansasAdultAcuteCareNursePractitionerandAdult-GerontologyAcuteCareNursePractitionerGastroenterologyAssociatesofSoutheastArkansasGASAPineBluffArkansas xviiPattyPawlowMSNACNP-BCLecturerCourseDirectorAdultGerontologyAcuteCareNursePractitionerProgramUniversityofPennsylvaniaSchoolofNursingPhiladelphiaPennsylvaniaLeslieKarnsPaynePhDACNP-BCFNPAssistantProfessorBaylorUniversityLouiseHerringtonSchoolofNursingDallasTexasDanielJ.RauhMSNAGACNP-BCCCRNEMT-PEmergencyDepartmentNursePractitionerGoodSamaritanHospitalCincinnatiOhioRosalynR.ReischmanPhDACNP-BCAdult-GerontologyAcuteCareNursePractitionerProgramCoordinatorUniversityofFloridaCollegeofNursingGainesvilleFloridaPattiRenaudMSNACNP-BCAcuteCareNursePractitionerHepatobiliaryandTransplantSurgeryHenryFordHealthSystemDetroitMichiganMollyK.RothmeyerDNPAPRNFNP-BCPNP-ACFellowNAPNAPAdjunctFacultyGraduateNursingProgramMaryvilleUniversityCatherineMcAuleySchoolofNursingCollegeofHealthProfessionsSt.LouisMissouriAdjunctFacultyGraduateNursingProgramBrandmanUniversityMarybelleandS.PaulMuscoSchoolofNursingandHealthProfessionsIrvineCaliforniaLoriRubioDNPACNP-BCMBAHCMAcuteCareNursePractitionerUniversityMedicalCenterYsletaClinicElPasoTexasKaraRumleyMSNACNP-BCVascularSurgeryAcuteCareNursePractitionerRegionalHemodialysisAccessCoordinatorEvansvilleSurgicalAssociatesEvansvilleIndianaAlexandraE.SaborioMSNACNP-BCAcuteCareNursePractitionerInpatientSpecialtyProgramCedars-SinaiMedicalCenterLosAngelesCaliforniaKristineAnneScordoPhDACNP-BCFAANPProfessorandDirectorAdult-GerontologyAcuteCareNursePractitionerProgramWrightStateUniversityCollegeofNursingDaytonOhioJulieSettlesMSNACNP-BCCENClinicalResearchScientistIndianapolisIndianaMichelleR.SmithMSNAGACNP-BCHospitalistNursePractitionerIndianaUniversityHealthBallMemorialHospitalHospitalistDepartmentMuncieIndianaMaryBethTombesMSNACNP-BCCCRCClinicalResearchNursePractitionerVirginiaCommonwealthUniversityMasseyCancerCenterRichmondVirginiaColleenR.WalshDNPACNP-BCONCONP-CCSContractAssistantProfessorofGraduateNursingUniversityofSouthernIndianaCollegeofNursingandHealthEvansvilleIndianaMarjorieG.WebbDNPACNP-BCAssociateProfessorInterimDepartmentChairCommunityandProfessionalStudiesMetropolitanStateUniversitySchoolofNursingCollegeofHealthSaintPaulMinnesotaBrettWhaleyMSNACNP-BCAdjunctProfessorEvolutionHealthTransitionalCareandUrgentCareProgramDeveloperManagerandClinicianTexasWomansUniversityCollegeofNursingDentonTexas xviiiJulieL.YerkeMSNACNP-BCAcuteCareNursePractitionerFloydMedicalCenterRomeGASheilaZielinskiDNPACNP-BCFNP-BCCCRNCENIntensiveCareUnitNursePractitionerIndianaUniversityHealthPhysiciansPulmonaryCriticalCareIndianaUniversityHealthMethodistIndianapolisIndiana xixSECTIONONEManagementofPatientswithNeurologicDisorders1CerebrovascularAccidentsBrainAttack3TRAVISBRADLEYANDCHARLENEM.MYERSTransientIschemicAttack3StrokeBrainAttack7IschemicStroke8HemorrhagicStroke132StructuralAbnormalities21TRAVISBRADLEYANDCHARLENEM.MYERSAneurysm21OtherAbnormalities24Hydrocephalus25Space-OccupyingLesionsBrainTumors263PeripheralNeuropathies31ROBERTBLESSINGKELLYBLESSINGANDTHOMASW.BARKLEYJR.Guillain-BarrSyndrome31MyastheniaGravis354NeurologicTrauma40KIMBERLYALVAANDCHARLENEM.MYERSHeadTraumaTraumaticBrainInjury40SpinalCordTrauma465CentralNervousSystemDisorders56JUDIKURICANDCHARLENEM.MYERSMeningitis56CerebralAbscess60Encephalitis61Encephalopathy636SeizureDisorders65PATRICKA.LAIRDANDCHARLENEM.MYERS7Dementia72ANGELASTARKWEATHERANDCHARLENEM.MYERStableofcontentsVolumeI xx8MultipleSclerosis79JUDIKURIC9ParkinsonsDisease85JUDIKURICANDROBERTFELLIN10AmyotrophicLateralSclerosis90JUDIKURICSECTIONTWOManagementofPatientswithCardiovascularDisorders11CardiovascularAssessment95JOANKINGANDTHOMASW.BARKLEYJR.12Hypertension100THOMASW.BARKLEYJR.HELENMILEYANDROBERTFELLIN13CoronaryArteryDiseaseandHyperlipidemia111JOANKINGANDTHOMASW.BARKLEYJR.14AnginaandMyocardialInfarction119JOANKINGANDTHOMASW.BARKLEYJR.FibrinolyticThrombolyticTherapy127PercutaneousTransluminalCoronaryAngioplastyPTCAPercutaneousCoronaryInterventionPCI132CoronaryArteryBypassGraftCABGSurgery134CardiacTamponade135ImplicationsfortheElderly13615AdjunctEquipmentDevices139SHEILAD.MELANDERANDTHOMASW.BARKLEYJR.Intra-AorticBalloonPumpIABP139Pacemakers142AutomaticInternalCardioverterDefbrillatorAICD14916PeripheralVascularDisease152THERESAM.WADASANDTHOMASW.BARKLEYJR.PeripheralVascularDiseaseOverview152SpecifcDisorders156VenousDisease15817InammatoryCardiacDiseases162SHEILAMELANDERANDTHOMASW.BARKLEYJR.Pericarditis162Endocarditis16318HeartFailure168JOANKINGROBERTFELLINANDTHOMASW.BARKLEYJR.19ValvularDisease186THERESAM.WADASROBERTFELLINANDTHOMASW.BARKLEYJR.20Cardiomyopathy193SHEILAMELANDERANDTHOMASW.BARKLEYJR. xxi21Arrhythmias198FREDRICKCARLSTONROBERTFELLINANDTHOMASW.BARKLEYJR.CommonCardiacRhythmsArrhythmiasandTreatment198SECTIONTHREEManagementofPatientswithPulmonaryDisorders22DiagnosticConceptsofOxygenationandVentilation221AMITAAVADHANIANDCHARLENEM.MYERSPulmonaryPerfusion221Ventilation221AlveolarDiffusion222OxygenTransportintheCirculation223VentilatorAdjustments22523MeasuresofOxygenationandVentilation226BIMBOLAAKINTADEANDCHARLENEM.MYERSOxygenationandVentilation226PulseOximetry228MeasurementofClinicalPerfusion229FluidResuscitation23124TheChestX-ray234VICTORIAF.KUANDTHOMASW.BARKLEYJR.GeneralPrinciples234ReadingaChestX-ray235SpecifcDiseaseEntities23725PulmonaryFunctionTesting240HALEYM.HOYTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERS26ObstructiveVentilatoryLungDiseases245THOMASW.BARKLEYJR.ROBERTFELLINANDTOBIASP.REBMANNChronicObstructivePulmonaryDiseaseCOPD245Asthma252COPDandAsthmaDualDiagnosis254Bronchiectasis255ObstructiveAirwayLesions25527RestrictiveInammatoryLungDiseases261THOMASW.BARKLEYJR.TOBIASP.REBMANNANDDAVIDA.MILLERPneumonia261TuberculosisTB264AcuteRespiratoryDistressSyndromeARDSAcuteLungInjuryALI266IdiopathicPulmonaryFibrosisIPF267Sarcoidosis269HeartFailureCardiogenticPulmonaryEdema27128PulmonaryHypertensionandPulmonaryVascularDisorders275HALEYM.HOYANDTHOMASW.BARKLEYJR.PulmonaryHypertension275PulmonaryVascularDisorders27729ChestWallandSecondaryPleuralDisorders285JENNIFERCOATESTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSDisordersoftheChestWall285PleuralDisorders286 xxii30RespiratoryFailure289DAVIDA.MILLERANDTHOMASW.BARKLEYJR.DefnitionsandConcepts289TheEffectsofAgingontheNeedforRespiratoryAssistanceIncludingIntubation290VentilatoryFailure290RespiratoryFailure291Treatment29131Pneumothorax293BIMBOLAAKINTADEANDTHOMASW.BARKLEYJR.32LowerRespiratoryTractPathogents296DAVIDA.MILLERANDTHOMASW.BARKLEYJR.33ObstructiveSleepApnea305JENNIFERCOATESANDTHOMASW.BARKLEYJR.CharacteristicsofBreathingandSleep305ObstructiveSleepApneaOSA30534OxygenSupplementation308CAROLTHOMPSONTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSBasicPrinciplesofOxygenSupplementation308FacilitationofVentilation310DevicesforOxygenSupplementation31135MechanicalVentilatorySupport314AMITAAVADHANITHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSIndicationsforMechanicalVentilation314GeneralPrinciplesofVentilation315VariablesforMechanicalVentilators315ModesofMechanicalVentilation317SpecialAspectsofVentilatorManagement317SECTIONFOURManagementofPatientswithGastrointestinalDisorders36PepticUlcerDisease325ALICIAHUCKSTADTANDCHARLENEM.MYERSPepticUlcerDisease325GastroesophagealReuxDiseaseGERD33237LiverDisease338MICHALYND.PELPHREYANDCHARLENEM.MYERSMajorLiverDiseases33838BiliaryDysfunction355MICHALYND.PELPHREYANDCHARLENEM.MYERSCholecystitis351AcutePancreatitis35439InammatoryGastrointestinalDisorders364LISAA.JOHNSONANDCHARLENEM.MYERSDiverticulitis364InammatoryBowelDisease365Peritonitis370Appendicitis371 xxiii40AnatomicIntestinalDisorders374CATHERINEFUNGANDCHARLENEM.MYERSSmallBowelObstruction374LargeBowelObstruction377MesentericIschemia37841GastrointestinalBleeding381NICOLEA.PEREZANDCHARLENEM.MYERSEsophagealVarices381UpperGastrointestinalBleeding383LowerGastrointestinalBleeding385SECTIONFIVEManagementofPatientswithGenitourinaryDisorders42UrinaryTractInfections388MICHELEH.TALLEYANDCHARLENEM.MYERSUrinaryTractInfections38843AcuteKidneyInjuryandChronicKidneyDisease394STEVENW.BRANHAMANDCHARLENEM.MYERSPrimaryKidneyRegulationofPhysiologicFunctions394AcuteKidneyInjury394ChronicKidneyDisease402ModicationofDrugDosages40944BenignProstaticHyperplasia411JENNIFERJ.ROBERGANDCHARLENEM.MYERS45RenalArteryStenosis417MICHELEH.TALLEYANDCHARLENEM.MYERS46Nephrolithiasis422MARLACOUTUREANDCHARLENEM.MYERSRenalCalculi-Nephrolithiasis422APPENDIXICD-9andICD-10Codes xixSECTIONSIXManagementofPatientswithEndocrineDisorders47DiabetesMellitus427THOMASW.BARKLEYJR.ANDSUSANJ.APPELDiabetesMellitusOverviewofPrinciples427Type1DiabetesMellitus430Type2DiabetesMellitus43348Diabetes-RelatedEmergencies442THOMASW.BARKLEYJR.ANDSUSANJ.APPELDiabeticKetoacidosis442HyperosmolarHyperglycemicNonketosis444Hypoglycemia44549ThyroidDisease447RITADELLOSTRITTOANDTHOMASW.BARKLEYJR.HyperthyroidismThyrotoxicosis447ThyroidStormThyrotoxicCrisis448HypothyroidismMyxedemaComa44950CushingsSyndrome452RITADELLOSTRITTOANDTHOMASW.BARKLEYJR.51PrimaryAdrenocorticalInsufciencyAddisonDiseaseandAdrenalCrisis454RITADELLOSTRITTOANDTHOMASW.BARKLEYJR.52Pheochromocytoma457MONIQUELAMBERTANDTHOMASW.BARKLEYJR.53SyndromeofInappropriateAntidiureticHormone461MONIQUELAMBERTANDTHOMASW.BARKLEYJR.54DiabetesInsipidus464RITADELLOSTRITTOANDTHOMASW.BARKLEYJR.tableofcontentsVolumeII xxSECTIONSEVENManagementofPatientswithMusculoskeletalDisorders55Arthritis469COLLEENR.WALSHOsteoarthritis469RheumatoidArthritis471Gout47356SubluxationsandDislocations488COLLEENR.WALSHSubluxations488Dislocations48957SoftTissueInjury492COLLEENR.WALSH58Fractures497COLLEENR.WALSH59CompartmentSyndrome502COLLEENR.WALSH60BackPainSyndromes505COLLEENR.WALSHLowBackPain505HerniatedDisk507SECTIONEIGHTManagementofPatientswithHematologicDisorders61Anemias513LISAEVANSInitialAnemiaWorkup513PerniciousAnemia515VitaminB12Defciency517IronDefciency518FolicAcidDefciency520AnemiaofChronicDiseaseACD521Thalassemia523GerontologyConsiderations52562SickleCellDiseaseCrisis527LISAEVANS63Coagulopathies533LISAEVANSIdiopathicThrombocytopenicPurpuraITP533Heparin-InducedThrombocytopeniaHIT535DisseminatedIntravascularCoagulationDIC537 xxiSECTIONNINEManagementofPatientswithOncologicDisorders64Leukemias534JACQUELINERHOADSAcuteLymphocyticLeukemia534ChronicLymphocyticLeukemia547ChronicMyelogenousLeukemia55065Lymphoma554JENNARUSHStaging554Non-HodgkinLymphoma557HodgkinLymphoma55966OtherCommonCancers563COLLEENR.WALSHLungCancer563ColorectalCancer567BreastCancer569CervicalCancer571OvarianCancer573ProstateCancer576BladderCancer578EndometrialCancer580SECTIONTENManagementofPatientswithImmunologicDisorders67HIVAIDSandOpportunisticInfectionsAmongOlderAdults587DAVIDA.MILLERANDTHOMASW.BARKLEYJR.HIVBackgroundInformation587HIVInfection587DocumentingHIVDisease588ClinicalEvaluationofthePatientatRiskforHIVInfection590InitiationofAntiretroviralTherapyART592AntiretroviralTherapyART593ProphylaxisAgainstSelectOpportunisticInfections2013Guidelines595AIDSDefningConditions59668AutoimmuneDiseases601LISAA.JOHNSONANDTHOMASW.BARKLEYJR.GiantCellArteritis601SystemicLupusErythematosusSLE602SECTIONELEVENManagementofPatientswithMiscellaneousHealthProblems69IntegumentaryDisorders607DONNAGULLETTEANDTHOMASW.BARKLEYJR.General607DermatitisMedicamentosaDrugEruption610Cellulitis613HerpesZosterShingles615SkinCancer617Melanoma619 xxii70EctopicPregnancyandSexuallyTransmittedInfections622ANGELASTARKWEATHERANDTHOMASW.BARKLEYJR.EctopicPregnancy622PIDSalpingitis624Vaginitis627ChlamydiaTrachomatisInfection629Gonorrhea632HerpesSimplexVirus634HumanPapillomavirusHPV636Syphilis63871EyeEarNoseandThroatDisorders641DAVIDA.MILLERTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSSignsandSymptomsthatSuggestProblemsoftheEyesEarsNoseandThroat641Conjunctivitis641CornealAbrasion644DiabeticRetinopathy645RetinalDetachment646CentralandBranchRetinalArteryObstruction646Glaucoma648BellsPalsy650OtitisExterna651OtitisMedia652Vertigo653AllergicRhinitis654Epistaxis656Sinusitis657Pharyngitis658EpiglottitisSupraglottitis660TemporomandibularJointDisorder661TrigeminalNeuralgiaTicDouloureux66172Headache664DONNAGULLETTETHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSSECTIONTWELVECommonProblemsinAcuteCare73Fever683LORRISJ.BOUZIGARDTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERS74Pain693MARCIENOMURATHOMASW.BARKLEYJR.ANDCHARLENEM.MYERS75PsychosocialProblemsinAcuteCare711PAULAK.VUCKOVICHViolence711Depression713SubstanceUseDisorder716Anxiety724CrisisIntervention727Grief727Sexuality728DeliriumintheAcuteCareSetting729AcuteAgitationPsychosisRelatedtoMentalIllness73176ManagementofthePatientinShock734VALERIEK.SABOLROBERTBLESSINGTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSShock734TypesofShock741 xxiii77NutritionalConsiderations757PAULAMCCAULEYTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERS78FluidElectrolyteandAcid-BaseImbalances764R.MICHAELCULPEPPERTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSHyponatremia764Hypernatremia767Hypokalemia768Hyperkalemia770Hypocalcemia772Hypercalcemia773Hypomagnesemia774Hypermagnesemia775Hypophosphatemia776Hyperphosphatemia777Acid-BaseDisorders778MetabolicAcidosis778MetabolicAlkalosis780RespiratoryAcidosis781RespiratoryAlkalosis783IntravenousFluidManagement78479PoisoningandDrugToxicities788ELIZABETHVANDEWAAANDTHOMASW.BARKLEYJR.AcetaminophenToxicity788AlcoholEthanolToxicity789AntidysrhythmicDrugOverdose790BarbiturateOverdose791BenzodiazepineOverdose791BetaBlockerOverdose792CalciumChannelBlockerOverdose793CarbonMonoxidePoisoning794DigoxinToxicity795LithiumToxicity795SalicylateToxicity796OpioidToxicity797OrganophosphateInsecticidePoisoning797AntipsychoticToxicity798AntidepressantToxicity799StimulantToxicity801TheophyllineToxicity802AnticoagulantOverdose803MethanolToxicity803EthyleneGlycolToxicity804OtherIntoxicants805BitesandStings805GerontologicalConsiderations80880WoundManagement810CATHERINEBLACHETHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSTypesofWounds-Denitions810KeyFactorsinDelayedHealing810SubjectiveFindings810GeneralPhysicalExaminationGuidelinesforWoundAssessment811Wound-SpecicPhysicalExaminationFindings811LaboratoryDiagnosticFindings812Management813SelectedTreatmentOptions81581Infections819ALISONFORBESANDTHOMASW.BARKLEYJR.Hospital-AcquiredInfections819Community-AcquiredInfections825 xxiv82ChestAbdominalandEyeTraumaTraumaConsiderations828ALISONFORBESANDTHOMASW.BARKLEYJR.InitialAssessmentandManagement828ChestTrauma829AbdominalTrauma832PenetratingEyeTrauma83583SolidOrganTransplantation837HONOREGARRINKOTLERANDTHOMASW.BARKLEYJR.SolidOrganTransplantation837ImmunosuppressionandOrganRejection838CommonMedicalComplicationsinSolidOrganTransplantation839CommonInfections843KidneyTransplantation844LiverTransplantation845LungTransplantation846HeartTransplantation847PancreasTransplantation847IntestinalTransplantation84884Burns851CATHERINEBLACHEANDTHOMASW.BARKLEYJR.85HospitalAdmissionConsiderations855JUDIKURICANDTHOMASW.BARKLEYJR.HistoryandPhysicalExamination855AdmissionOrders863ProgressNote864PresentationofPatientDuringRoundswithTeamFacility864ProcedureNote864DischargeSummary865PrescriptionsBox85.3866GeneralGuidelinesforAdmissiontoanIntensiveCareUnitICU867GeneralGuidelinesforDischargefromanICU868GeneralGuidelinesforElectronicMedicalRecordsEMR86986ManagingtheSurgicalPatient871BIMBOLAF.AKINTADEANDTHOMASW.BARKLEYJR.PreoperativeAssessment871PostoperativeCare875SECTIONTHIRTEENHealthPromotion87GuidelinesforHealthPromotionandScreening881HELENMILEYTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSVisionaryPlanforHealth881Prevention883PreventionandHealthPromotioninClinicalPractice88488MajorCausesofMortalityintheUnitedStates898BARBARAA.S.BROOMELeadingCausesofDeathintheUnitedStates898RiskAssessment90389ImmunizationRecommendations905ALICIAHUCKSTADTTHOMASW.BARKLEYJR.ANDCHARLENEM.MYERSImmunization905APPENDIXICD-9andICD-10Codes 3CHAPTER1TRAVISBRADLEYCHARLENEMYERSCerebrovascularAccidentsBrainAttackTRANSIENTISCHEMICATTACKI.DefnitionA.Classicdenitionsuddenorrapidonsetofneurologicdecitcausedbyfocalischemiathatlastsforafewminutesandresolvescompletelywithin24hrB.Ithasbeenfoundthatwithmorewidespreaduseofmodernimagingtechniquesforthebrainuptoonethirdofpatientswithsymptomslastinglessthan24hractuallyhaveasmallinfarct.C.UpdateddenitionatransientepisodeofneurologicaldysfunctioncausedbyfocalbrainspinalcordorretinalischemiawithoutacuteinfarctionII.IncidenceprevalenceA.Incidenceis160100000prevalenceis135100000III.EtiologyA.Atheroscleroticdisease1.Aorta2.Carotidarteries3.Vertebralarteries4.IntracranialatherosclerosisB.CardiacemboliasseeninarrhythmiaatrialbrillationmyocardialinfarctionMIcongestivecardiomyopathyandvalvulardiseaseC.VasculitisconditionssuchasmoyamoyadiseasebromusculardysplasialupusandothersD.Hematologiccauses1.RedbloodcellRBCdisordersa.Increasedsludgingb.Decreasedcerebraloxygenationsuchasinsevereanemiac.Polycythemiasicklecellanemia2.Plateletdisordersa.Thrombocytosisb.Thrombocytopenia3.Increasedviscosityhypercoagulableconditionsa.Antiphospholipidantibodysyndromee.g.lupusanticoagulantanticardiolipinantibodyb.Oralcontraceptiveandorestrogenusec.AntithrombinIIIdeciencyd.ProteinSandCdeciency 4SECTIONONEManagementofPatientsWithNeurologicDisorderse.Tissue-typeplasminogenactivatort-PAandplasminogendecienciesf.Patientsparticularlyatriskforahypercoagulablestatei.Olderthan45yearsii.Historyofthrombolyticeventiii.Historyofspontaneousabortioniv.Relatedautoimmuneconditionse.g.lupusv.Strokeofunknowncausevi.Familyhistoryofthromboticevents4.Myeloproliferativedisordersleukemiawithwhitebloodcellcountgreaterthan150000E.Intracranialcauses1.Braintumor2.Focalseizure3.Hemorrhagea.SubduralhematomaSDHb.SubarachnoidhemorrhageSAHc.IntracerebralhemorrhageICHwhichmaycausecerebrovasculardysfunctionduetoleakageofbloodoutsidethenormalvesselsF.Subclavianstealsyndrome1.Localizedstenosisorocclusionofasubclavianarteryproximaltothesourceofthevertebralarterysothatbloodisstolenfromthatartery2.BloodpressureBPissignicantlylowerintheaffectedarmthanintheoppositearm.G.Others1.Transienthypotension2.Osteophytesthatcausecompressionofneckvessels3.Cocaineabuse4.Hypoglycemia5.MigrainesIV.RiskfactorsA.AtransientischemicattackTIAisanimportantpredictorofstroke.1.The90-dayriskofstrokeafteraTIAisashighas172.Thegreatestriskiswithintherstweek3.ApproximatelyonethirdofstrokepatientshaveahistoryofTIAB.HypertensionC.Cardiacdiseasesuchasthefollowing1.Mitralvalvedisease2.AnteriorwallMI3.Congestivemyopathy4.Arrhythmiae.g.atrialbrillationD.SmokingE.ObesityF.HyperlipidemiaG.ElevatedhomocysteinelevelsintheelderlyH.AdvancedageI.DiabetesJ.AlcoholandrecreationaldrugabuseV.ClinicalmanifestationsA.Carotidarterysyndrome1.Hemianopiaipsilateralmonocularblindnessamaurosisfugaxdescribedassimilartoashadecomingdownoveroneeye2.Visualeldcut3.Paresthesiaweaknessofcontralateralarmlegandfacemaybeepisodic4.Dysarthriatransientaphasia 5CerebrovascularAccidentsBrainAttackCHAPTER15.Confusion6.Gaitdisturbance7.Carotidbruitmaybepresent8.MicroembolihemorrhageandexudatemaybevisualizedintheipsilateralretinaB.Vertebrobasilararterysyndrome1.Visualbilateraldisturbancesblurredvisiondiplopiaandcompleteblindness2.Vertigoandataxia3.Nauseaandorvomiting4.Suddenlossofposturaltoneinallextremitieswhileconsciousnessremainsintactdropattacks5.Dysarthria6.Facialparesthesia7.GaitinstabilityVI.DiagnosticslaboratoryfndingsA.Laboratoryevaluationmayincludethefollowing1.CompletebloodcountCBCplateletcountprothrombintimePTpartialthromboplastintimePTTandinternationalnormalizedratioINRtodetecttheseconditionsa.Anemiab.Polycythemiac.Leukemiad.Thrombocytopeniae.Hypercoagulopathy2.Electrolytesglucosetodetectthefollowinga.Hyponatremiab.Hypokalemiac.Hypoglycemiad.Hyperglycemia3.Lipidproflea.Detectshyperlipidemia4.InselectedpatientsantinuclearantibodyVenerealDiseaseResearchLaboratoryVDRLtestandtoxicologyscreen5.Sedimentationratetodetecttheseconditionsa.Vasculitisb.Infectiveendocarditisc.Hyperviscosityd.Giantcellarteritis6.Homocysteinelevela.Anaminoacidb.Elevatedplasmalevelassociatedwithincreasedriskofvascularevents7.AnticardiolipinantibodiesimmunoglobulinIgGIgMandIgAandassayforlupusanticoagulantforsuspectedantiphospholipidantibodysyndromes8.AssaysforantithrombinIIIproteinsSandCplasminogenandt-PAB.ComputedtomographicCTscanofthehead1.MayrevealsilentischemiaorischemicimagesaswellashemorrhageorinfarctandSDHC.MagneticresonanceimagingMRIparticularlydiffusion-weightedimagingandperfusion-weightedimaging1.MoresensitivethanCTscantoearlypathologicchangesofischemicinfarctionbecauseofitsexcellentdetectionofbrainedema2.MRIisalsopreferredforthedetectionoflacunarorvertebrobasilarTIAsorwhenvascularterritoryisnotwelldefned. 6SECTIONONEManagementofPatientsWithNeurologicDisorders3.UptoonethirdofpatientswithTIAshaveaninfarctintheterritoryrelevanttotheirsymptomsD.Duplexultrasonography1.85sensitivityand90specicity2.UsefulinidentifyinghemodynamicallysignicantcarotidstenosisE.CTangiographyCTA1.Evaluationofneckandbrainvessels2.Requiresuseofcontrastmateriala.Normalrenalfunctionb.AdequateintravenousaccessF.MagneticresonanceangiographyMRA1.AlternativetoultrasoundorCTstudies2.Nocontrastmediumisneeded3.CanbeobtainedatthesametimeasanMRIscan4.GoodmeansforassessmentofextracranialandintracranialvesselsG.Echocardiographyanda24-hrHoltermonitorareusedtoevaluateforacardiacsourceofemboli.H.TransesophagealechocardiographyTEEtoevaluatetheaorticarchleftatriumandforpatentforamenovaleI.CerebralangiographyforpatientswhosesymptomssuggestinvolvementofthecarotidcirculationandwhoarecandidatesforcarotidendarterectomyCEAJ.Chestx-rayforenlargedheartK.BloodculturestomonitorforinfectiveendocarditisL.TemporalarterybiopsytodetectgiantcellarteritisM.CardiacenzymestodetectanacuteMIN.Electroencephalographyindicatedinpatientssuspectedofhavingaseizuredisorderassociatedwithstrokeaswellasanunderlyingtoxic-metabolicdisorderthatmaycauseseizureactivityVII.ManagementA.Addressthefollowingunderlyingriskfactors1.Hypertension2.DiabetesmellitusDM3.Obesity4.Hyperlipidemia5.SmokingB.CarotidTIAs1.Greaterthan7080obstructioninterventionisindicatedforthosewhoareagoodsurgicalrisk2.Controversyexistsaboutpatientswhohave5069obstructionbutaresymptomaticshouldbeevaluatedonacase-by-casebasisbyavascularspecialist.3.Lessthan50obstructionsurgeryisnotindicated4.CarotidangioplastyandstentingCASisanalternativetoCEA5.SeveralrecenttrialssuchastheStentingandAngioplastywithProtectioninPatientswithHighRiskforEndarterectomySAPPHIREandtheCarotidRevascularizationEndarterectomyversusStentTrialCRESTrevealthatCASissafeandeffective.a.DeterminationofCASversusCEAislargelybasedonavailabilityoftrainedpersonalandinstitutionalexpertiseC.Anticoagulationifcausedbyacardioemboliceventfromatrialbrillationorparoxysmalatrialbrillation1.Maypreventrecurrentcardioembolicevents2.TraditionaltreatmenthasbeenabridgingofheparintowarfarinCoumadin.Althoughwithnewer-generationanticoagulantstheheparinbridgemaynotbenecessary. 7CerebrovascularAccidentsBrainAttackCHAPTER13.Beginwithheparin12unitskghr4.TargetPTTshouldbe1.52.5timespatientsbaselinevalue5.Followwithwarfarin510mgPOorallywhichisindicatedforthefollowinga.TIAcausedbyembolismarisingfromamuralthrombusafteranMIb.TIAcausedbyembolusinpatientswithmitralstenosisorprostheticheartvalvesc.RecurrentTIAsdespiteplateletantiaggregantagentsd.INRof23isconsideredtherapeuticD.Commonantiplatelettherapy1.Aspirinacetylsalicylicaciddecreasesincidenceofsubsequentstrokeby1530inmalepatientswithTIAsdoseof81325mgdayisaseffectiveashigherdosesandcausesfeweradverseeffects2.ClopidogrelPlavixa.IndicatedforsecondarypreventionofischemicstrokeMIandothervasculareventsinpatientswhocannottolerateaspirinorinpatientswhoweretakingaspirinatthetimeoftheeventb.Dosageis75mgdayPOc.Maycausethromboticthrombocytopeniapurpuraduringtherst2weeksoftreatment3.Aspirin25mgextended-releasedipyridamole200mgAggrenoxa.Bothdrugssuppressplateletaggregationbutdosothroughdifferentmechanismsb.Combinationtreatmentismoreeffectivethaneitherdrugalonec.RecommendeddoseisonecapsulePOtwiceadayd.Signicantlymoreexpensivethanaspirintherapye.MainsideeffectisheadacheSTROKEBRAINATTACKI.DenitionA.Rapidonsetofaneurologicdecitinvolvingischemiatoacertainvascularterritoryandlastinglongerthan24hrB.Astrokeinevolutionisanenlarginginfarctionmanifestedbyneurologicdefectsthatincreaseover2448hrC.Becauseofadvancesinearlyrecognitionandtreatmentstrokedroppedfrombeingthethirdleadingcauseofdeathtothefourth.Itremainstheleadingcauseofdisability.D.StrokecanbeclassiedasischemicandhemorrhagicE.Eightypercentofstrokesarecausedbybloodclotsthatproduceischemicareasinthebrainremaining20ofstrokesarecausedbyICHII.EtiologyandriskfactorsA.SameasforTIAB.Cocaine-relatedstrokeisincreasinglycommonC.WomenwhouseoralcontraceptivesandwhosmokeareathighriskD.HyperlipidemiaraisestheriskofischemicstrokeE.LowcholesterolincreasestheriskofhemorrhagicstrokeIII.PubliceducationA.NeedtoincreasepublicawarenessofthewarningsignsofstroketofacilitateearlytreatmentB.Fivesuddensofstroke1.Suddenweakness2.Suddenspeechdifculty3.Suddenvisualloss4.Suddendizziness5.SuddensevereheadacheC.Needtocall9-1-1andoractiveemergencymedicalsystemsEMStoexpeditebestchanceofmeetingtreatmentwindowlimits 8SECTIONONEManagementofPatientsWithNeurologicDisordersD.ShouldbetreatedlikeaheartattackbrainattackmaybecomenewnomenclatureIV.PrehospitalstrokemanagementA.Implementationstrategiesforemergencymedicalserviceswithinstrokesystemsofcarepolicystatement1.Dispatchedtohighestlevelofcareavailableintheshortestpossibletime2.Timebetweencallanddispatchofresponseteamlessthan90seconds3.EMSresponsetimelessthan8min4.On-scenetimelessthan15minbarringextenuatingcircumstances5.TraveltimeequivalenttotraumaoracuteMIcallsV.StrokesystemsofcareA.GoalsofcreatingstrokesystemsofcareincludestrokepreventioncommunitystrokeeducationoptimaluseofEMSeffectiveacuteandsubacutestrokemanagementrehabilitationandperformancereviewofstrokecaredelivery.B.Hospitalswiththecapacityandcommitmenttodeliveracutestrokecareintheemergencydepartmentandstrokeunitareessentialtoeffectivestrokecare.C.Transportingpatientstostrokecentersoptimizestheirchanceoftimelytherapyanddecreasesthemorbidityandmortalityassociatedwithstroke.VI.PrimarystrokecenterA.Establishedin2004byTheJointCommissionTJCcurrentlymorethan800primarystrokecentersexistB.Havededicatedandorganizedstrokeresourcesthatleadtoincreasedratesofintravenoust-PAadministrationincreasedlipidprofletestingimproveddeepveinthrombosisprophylaxisandbetterclinicaloutcomesVII.ComprehensivestrokecenterA.Criteriaestablishedin2011bytheAmericanStrokeAssociationB.Abilitytooffer247state-of-the-artcareonthefullspectrumofcerebrovasculardiseaseC.NeurocriticalcareunitsandinterventionalradiologyforcerebralinterventionsessentialD.CanbepartofahubandspokemodelofcaretomaximizestrokecareE.Evenpatientswithalargeinfarctbutoutsideinterventionwindowshouldbeadmittedtoaneurocriticalcareunitforcomplicationmanagement.ISCHEMICSTROKEI.EtiologyA.Causedbyathrombusthatoccludesabloodvesselintheheadorneck301.Progressionofsymptomsoverhourstodaysorcanbesudden2.PatientsoftenhaveahistoryofTIA3.Predisposingfactorsa.Atherosclerosisb.HypertensionHTNc.DMd.Hyperlipidemiae.Vasculitisf.Hypotensiong.Smokingh.Connectivetissuedisordersi.TraumatotheheadandneckB.Causedbyembolism251.Veryrapidonset2.HistoryofTIA3.Predisposingfactorsa.Atrialfbrillationb.Mitralstenosisandregurgitation 9CerebrovascularAccidentsBrainAttackCHAPTER1c.Endocarditisd.MitralvalveprolapseII.ClinicalmanifestationsdependingonthecerebralvesselinvolvedA.Middlecerebralartery1.Hemiplegiainvolvesupperextremityandfacemoreoftenthanlowerextremity2.Hemianesthesia3.Hemianopiablindnessofhalftheeldofvision4.Eyesmaydeviatetothesideofthelesion5.Aphasiaifdominanthemisphereisinvolved6.Neglectsyndrome7.Occlusionsofvariousbranchesofthemiddlecerebralarterymaycausedifferentndingsinvolvementoftheanteriordivisionmaycauseexpressiveaphasiaandinvolvementoftheposteriorbranchmayproducereceptiveaphasia.B.Anteriorcerebralartery1.Hemiplegialowerextremitymoreoftenthanupperextremity2.Primitivereexes3.Confusion4.Abulia5.Bilateralanteriorinfarctionmaycausebehavioralchangesanddisturbanceinmemory.C.Vertebralandbasilararteries1.DecreasedlevelofconsciousnessLOC2.Vertigo3.Dysphagia4.Diplopia5.Ipsilateralcranialnervendings6.ContralateralorbilateralsensoryandmotordecitsD.Deeppenetratingbranchesofmajorcerebralarterieslacunarinfarction1.Mostcommonlessthan5mmindiameter2.AssociatedwithpoorlycontrolledHTNordiabetes3.Contralateralpuremotororsensorydecits4.Ipsilateralataxiawithcruralpertainingtothelegorthighparesis5.DysarthriawithclumsinessofthehandIII.DiagnosticslaboratoryndingsA.CTscanoftheheadwithoutcontrastshouldbedoneinitially1.PreferabletoMRIintheacutestagetoruleoutcerebralhemorrhageasMRIisusuallynotasreadilyavailableespeciallyforpatientswhopresentwithstrokesymptomsandareonanticoagulationtherapyalsowillruleoutabscesstumorandSDH2.Appearsasanareaofdecreaseddensity3.Lacunarinfarctsappearassmallpunched-outhypodenseareas.4.InitialCTscanmaybenegativeandtheinfarctmaynotbevisibleforupto24hrB.Chestradiography1.Mayrevealcardiomegalyorvalvularcalcication2.Neoplasmmaysuggestmetastasisratherthanstrokeasthecauseofneurologicdecits3.Dilatedaortamayrevealaorticdissection.C.CBCsedimentationratebloodglucoseVDRLlipidproleINRPTTpriortoanticoagulationbloodureanitrogenserumcreatinineCrtoevaluaterenalfunctionbeforecontrastmediamaybegivenhomocysteineleveldrugscreenandbloodalcohollevelD.ElectrocardiogramECGifunrevealingmayplacepatientoncardiacmonitorHoltermonitorE.BloodculturesifendocarditisissuspectedF.EchocardiographywithbubblestudyG.TEEtodetectdysfunctionofleftatriumthrombus 10SECTIONONEManagementofPatientsWithNeurologicDisordersH.CarotidduplexultrasonographyI.MRIMRADiffusion-weightedMRIismoresensitivethanconventionalMRIindetectingcerebralischemia.J.CTA1.Canprovideinformationregardingvascularanatomywiththree-dimensionalreconstructionrequirestheuseofcontactdye2.MayallowforrapidevaluationanddiagnosisinhospitalswithoutMRIcapability3.Canbeusedtoimagethecarotidarteriesinsteadofduplexultrasonographyandwillshowinternalcarotidarterystructure4.CTperfusioncanalsobeperformedaspartoftheCTAwhichcanprovideevidenceofsalvageabletissuepenumbraoranalreadycompletedinfarctandmayaffectthetreatmentplan.K.CerebralangiographycontinuestobethegoldstandardforcompleteevaluationofintracranialandextracranialvesselsL.LumbarpunctureLP1.Notalwaysnecessarybutmaybehelpfulifthecauseofstrokeisuncertain2.ObtainaCTscanfrsttoruleoutcerebralhemorrhageoranyexpandingmassthatcouldleadtoherniationifLPisperformedIV.ManagementA.Correcttreatmentdependsonacorrectdiagnosisofstroketypethereforeitisimperativethatdiagnostictestsbecompletedquickly.AreportfromtheNationalInstituteofNeurologicalDisordersandStrokeadvocatesthefollowinggoalswhicharebasedontimeofarrival1.Performaninitialemergencydepartmentevaluationwithin10min2.Notifythestroketeamorneurologistwithin15min3.StartaCTscanwithin25min4.ObtainaCTscaninterpretationwithin45min5.Administerthrombolyticsifappropriatewithin60min6.Transferthepatienttoaninpatientbedwithin3hrB.BPcontrol1.AcuteloweringofsystemicBPisnotrecommendedbecauseitmayleadtofurtherdamageintheischemicpenumbrainwhichautoregulationmaybedefectiveandmayclinicallyworsenthestroke.2.MostpatientswithacutecerebralinfarctionhaveanelevatedBPwhichusuallyreturnstobaselinewithin48hrwithoutanyspecialtreatment.3.BPcontrolmaybewarrantedhoweverinthefollowingconditionsa.SystolicBPSBPexceeds220mmHganddiastolicBPDBPexceeds120mmHgmalignanthypertensionb.Hypertensiveencephalopathyispresentc.Vitalorgansarecompromisedd.Aorticdissectione.Symptomaticcardiacdiseasef.Patientisreceivingt-PAtherapyi.SomeexpertsrecommenddecreasingBPinthosewhoarereceivingintravenousheparintherapyaswellalthoughthisisnotuniversallyaccepted.g.Inpatientswhoarecandidatesfort-PABPshouldbeloweredtoSBPlessthan185andDBPlessthan110priortot-PAadministration.Aftert-PAadministrationSBPshouldbemaintainedlessthan180andDBPlessthan105.4.WhenindicatedBPshouldbeloweredbyapproximately15andcloselywatchedforneurologicaldeteriorationrelatedtodecreasedperfusion. 11CerebrovascularAccidentsBrainAttackCHAPTER15.Thecurrent2013StrokeGuidelinesrecommendtheuseofeitherlabetalol1020mgIVpushover12mincanrepeatonceornicardipineintravenousdriptitratablefrom2.515mghrforBPmanagement.6.AnalternativeisesmololBrevibloc2.5grams250mlNSor2grams100mlNScontinuousinfusiontitratedtodesiredBPmaximumdoseshouldnotexceed300mcgkgmin.C.Anticoagulation1.Intravenousheparinhashistoricallybeenusedasatreatmentforacutestroke.Howeveritdoesnotreducetheseverityofastrokethathasoccurredandisnolongerroutinelyrecommended.Thedecisiontoevenconsidertheuseofheparinintheacutemanagementofstrokeshouldbedeterminedbyaneurologyexpert.2.Itmaybeusedinpatientswithstrokeinevolutionandinhypercoagulablestatesorinpatientswithveryhigh-riskorrecurrentemboli.3.Heparinmayincreasetheriskoftransformationfromischemicstroketohemorrhagicstrokeandthereforeisnotrecommendedformassivestroke.4.Noloadingdoseofheparinisrecommendedasthepotentialriskofhemorrhagictransformationishigh.Amaintenanceinfusionof12unitskghrmax1000unitshrcanbestarted.PTTshouldbe1.52.5patientsbaselinevalue.5.Heparinfollowedbywarfarin510mgdayPOisindicatedassecondarypreventioninsuspectedcerebralembolismresultingfromthefollowinga.Muralthrombusb.Mitralstenosisc.Atrialbrillationd.Mechanicalheartvalves6.Severalneweranticoagulantsarenowonthemarketandtargetedatstrokepreventionforpatientswithatrialbrillationorparoxysmalatrialbrillation.a.DabigatranPradaxaisadirectthrombininhibitor.Originallyusedtopreventthromboemboliceventsafterorthopedicprocedurestherandomizedevaluationoflong-termanticoagulationtherapyRE-LYstudydemonstratedthatdabigatranhadbenetcomparedwithwarfarinforpreventionofstrokeinpatientswithatrialbrillation.i.FoodandDrugAdministrationapprovedin2010at150mgBIDor75mgBIDinrenally-impairedpatientsb.ApixabanEliquisisafactorXainhibitoralsorecentlyapprovedforstrokepreventioninpatientswithatrialbrillation.Standarddoseis5mgBIDor2.5mgBIDforpatientsgreaterthan80yearsofagebodyweight60kgorlessorCrgreaterthan1.5mgdl.c.RivaroxabanXaroltoisafactorXainhibitorapprovedforstrokepreventioninpatientswithatrialbrillation.Standarddoseis20mgdailywitheveningmealforpatientswithcreatinineclearancegreaterthan50mlminor15mgdailywitheveningmealforpatientswithcreatinineclearance1550mlmin.AvoidusewhenCrCllessthan15mLmin.d.BecauseofthemechanismofactionoftheabovethreedrugsnoroutinelabdrawsofPTTorINRarenecessaryforongoingtreatmentandmayfacilitatebetterpatientcompliance.e.Ifacutehemorrhagedevelopsholdinganticoagulantsoruseofactivatedcharcoalmayreversebleeding.EmpiricfreshfrozenplasmafactorVIIorfactorIXcomplexmaybeattemptedinemergencysituations.f.Thedecisiontouseoneoftheneweranticoagulantsshouldbedeterminedafterathoroughdiscussionbetweentheneurologistcardiologistpatientandorfamilyhasoccurred.Therisksandbenetsshouldbecarefullyexamined. 12SECTIONONEManagementofPatientsWithNeurologicDisorders7.CTscanmaybenecessaryafter48hrtodeterminewhetheranyhemorrhaginghasoccurred.8.AnticoagulationiscontraindicatedifCTscanorLPsuggestscerebralhemorrhagetumorabscessSDHorepiduralhematoma.9.UsecautiouslyinpatientswithahistoryofGIbleedingbleedingtendenciessevereHTNoralargecerebralinfarct10.MaybeusedafteracompletedstrokeifembolizationisdeterminedtobethecauseD.Antiplatelettherapymaybeusedfornon-cardioembolicstrokepatientsnotduetovertebralorcarotiddissection.1.Aspirin81325mgdayPOa.Continuestobetheleastexpensiveandmostwidelyusedantiplateletmedication2.ClopidogrelPlavix75mgPOdaily3.Aggrenoxaspirin25mgimmediatereleaseanddipyridamole200mgextendedrelease1tabletBID1inthemorningand1atnighta.Approvedforstrokepreventionb.Studyhasshownthatthiscombinationmayreducestrokeby22comparedwithaspirintherapyaloneE.Mannitolandorhypertonicsalinecanbeusedforcerebraledemathatmayoccuronthesecondorthirdday.a.Mannitol0.251gramkgIVevery46hrmayhelpdecreaseelevatedintracranialpressureICPbyoverallosmoticdiuresis.Sideeffectscanincludeacutekidneyinjury.Serumosmolalityshouldbemonitored.b.Hypertonicsaline23.4canbeadministeredasanintravenouspushthroughacentrallineintheeventofanacutedecompensation.Standarddoseis30mlIVadministeredovergreaterthan30minsubsequentdosesdependentonICPc.Hypertonicsaline3canbeadministeredasanintravenousdriptomaintainahighersodiumlevelatthediscretionoftheintensivist.Standarddoseisinitialbolusof250300mlIVover60minfollowedbycontinuousinfusiontitratedtotreatmentgoalsincluding145155mEqLandserumosmolality310320mOsmL.Recommendcheckingsodiumlevelsevery6hrandadjustingdripPRN.F.Corticosteroidsareusedtoreducevasogeniccerebraledemarelatedtotumorburdenbutarenotrecommendedforcytotoxicedemafromstrokes.Hypertonicsolutionsareusedtoreducecytotoxicedemaassociatedwithcerebralinfarct.G.t-PAisnowbeingusedifappropriateconditionsaremetasthrombolytictherapyforacutestrokewhenthepatientisbroughtinwithin34.5hrafterthestroke.Thetraditionalwindowof3hrhasbeenexpandedto4.5hrwithcertaincriterialistedbelow.Suchconditionsincludethefollowing1.Availabilityofaphysicianwithappropriateexpertisetodiagnosethestroke2.24-hravailabilityofCTscanningtoassessforhemorrhage3.Capabilityoffacilitytomanageintracranialhemorrhageortransfertohigherlevelofcare4.Patientsmustseekhelpearlyandhaveawell-denedonsetofsymptoms.a.Commonlycalledlastknownwelltime5.Patientsconditionmustbecarefullyexaminedforcontraindicationssuchasthefollowinga.Previousandorcurrenthemorrhageb.Previousstrokeorheadtraumawithin3monthsc.Majorsurgerywithin14daysd.UrinaryorGIhemorrhagewithin24dayse.Seizureatstrokeonsetf.Arterialpunctureatnoncompressiblesitewithin7daysg.ElevatedPTTandPTlongerthan15seconds 13CerebrovascularAccidentsBrainAttackCHAPTER1h.OralanticoagulantsorheparinwithelevatedPTTwithin48hri.Serumglucoselevellessthan50orgreaterthan400mgdlj.SBPgreaterthan185mmHgorDBPgreaterthan110mmHgk.Activeinternalbleedingwithin22days6.Additionalcriteriaforpatientswithinthe3-to4.5-hrwindowa.Inclusioni.Ischemicstrokecausingmeasurabledefcitii.Onsetofsymptomswithin34.5hriii.Agegreaterthan18yearsb.Exclusioni.Agegreaterthan80yearsii.SeverestrokeNationalInstitutesofHealthStrokeScalegreaterthan25iii.Takinganoralanticoagulantregardlessofinternationalnormalizedratioiv.Historyofbothdiabetesandpriorischemicstrokev.SBPgreaterthan185mmHgorDBPgreaterthan110mmHg7.Dose0.9mgkgmaximumdoseof90mggivenover60minwith10ofthecalculateddosegivenasaninitialbolusoveronemina.Admittostrokeunitb.Vitalsignsandneurochecksevery15minduringandfor2hrafteradministrationthenevery30minfor6hrthenhourlyuntil24hraftert-PAonsetH.SurgeryandCEAmaybeindicatedforthosewithhigh-gradeextracranialcarotidarterydiseasegreaterthan70ifnotathighriskI.RehabilitationshouldtakeamultidisciplinaryapproachJ.Additionaltreatmentoptions1.Mechanicalreperfusiona.Therearenumerousdevicesavailablethatareusedtomechanicallyretrieveaclotfromwithinacerebralartery.b.ExamplesincludetheMERCIdevicetheSolitairedevicetheTrevodeviceandthePenumbradevicec.Useislargelydeterminedbytheexperienceandexpertiseoftheuserandtheinstitution2.Combinedintra-arterialIAandintravenousthrombolysisa.TheInterventionalManagementofStokeIMSstudyevaluatedtheuseofIAt-PAinpatientswhoreceivedstandardintravenoust-PAbutdisplayedlittleornoimprovementbytheendofthet-PAadministration.b.TheinitialIMSandthenIMStrialtwoshowedgoodratesofrecanalizationoftheoccludedarterywithcomparablesafetydatatot-PAalonehowevertheIMStrialthreewasstoppedearlyforreportedfutility.Althoughthearterywasrecanalizedithasbeenreportedthatoveralloutcomeswerenotsignifcantlybetter.Furtherstudyiswarranted.HEMORRHAGICSTROKEI.DefnitionA.ConditionresultingfrombleedingintothesubarachnoidspaceorbrainparenchymaB.Accountsforapproximately14ofallcerebralinfarctionsII.EtiologyA.SAH1.Rupturedsaccularaneurysm852.ArteriovenousmalformationAVM83.CryptogenicB.ICH1.UsuallyassociatedwithHTN 14SECTIONONEManagementofPatientsWithNeurologicDisorders2.Predisposingfactorsa.HTNb.Useofanticoagulantsorthrombolyticsc.Useofillicitstreetdrugse.g.cocained.Heavyuseofalcohole.HematologicdisordersIII.ClinicalmanifestationsA.SAH1.Suddenheadacheofintenseseveritythatradiatesintotheposteriorneckregionandisworsenedbyneckandheadmovementsoftendescribedasathunderclapheadacheorworstheadacheofmylife2.GradingscalesstandardizedwaytodescribeSAHpatientsamongprovidersa.HuntandHessclassicationclinicalassessmenti.GradeIasymptomaticorslightheadacheii.GradeIImoderatetosevereheadachestiffnecknofocalsignsotherthancranialnervepalsyiii.GradeIIIdrowsymildfocaldecitorconfusioniv.GradeIVstuporhemiparesisv.GradeVdeepcomadecerebrationb.FishergradebasedonCTndingsi.GradeInoblooddetectedii.GradeIIdiffuseorverticallayerslessthan1mmthickiii.GradeIIIlocalizedclotandorverticallayer1mmormoreiv.GradeIVintracerebralorintraventricularclotwithdiffuseornoSAHB.ICH1.ElevationinBPoftentoveryhighlevels90ofpatients2.Headache403.Vomitingisanimportantdiagnosticsignparticularlyifthehemorrhageliesinthecerebralhemisphere49.4.Suddenonsetofneurologicdecitsthatcanrapidlyprogresstocomaordeathdependingonareainvolved505.Basalgangliahemorrhagea.Conjugatedeviationofeyestothesideofthelesionb.DecreasedLOCc.Contralateralhemiplegiad.Hemisensorydisturbance6.Thalamichemorrhagea.Downwarddeviationoftheeyeslookingatthenoseb.Pupilspinpointwithapositivereactionc.Comaiscommond.Flaccidquadriplegia7.Cerebellarhemorrhagea.Ipsilaterallateralconjugategazeparesisb.PupilsequalroundreactivetolightPERRLc.Inabilitytostandorwalkd.Facialweaknesse.Ataxiaofgaitlimbsortrunkf.VertigoanddysarthriaIV.DiagnosticslaboratoryndingsA.SAH1.CTscanoftheheadwillassistindifferentiatingbetweenanischemicandahemorrhagicstroke. 15CerebrovascularAccidentsBrainAttackCHAPTER1a.SensitivityofCTintherst3daysafterananeurysmalSAHisveryhighcloseto100.After57daystherateofanegativeCTscanincreasesandLPshouldbeconsidered.b.Aneurysmslessthan3mminsizeareunreliablydemonstratedonCTAc.DependingonsitesizeCTscanqualityandwhetherornotnecutswereobtainedaneurysmitselfmaybeseenin50ofcaseswhencontrastmaterialisgiven.2.LPifCTscanisunavailableornegativeandsuspicionishigha.Contraindicatedinanyexpandingmassbecauseitmaycauseherniationb.AfunduscopicexaminationmustbeperformedpriortotheproceduretoruleoutpapilledemaifnoCTavailablec.CerebrospinaluidCSFwillbeuniformlygrosslybloodyalthoughthismaynotoccurifthebleedissmall.InatrueSAHtheLPreveals103106RBCsmmd.Openingpressuremaybeelevatede.Xanthochromiaispresenti.YellowishdiscolorationofCSFproducedbybloodbreakdownproductsii.Xanthochromiaappearsnoearlierthan24hrafterbleedingoccursiii.CerebralangiographyaUsedtodeterminesourceofbleedpresenceofananeurysmandbestsourceoftreatmentmedicalorsurgicalbMaydemonstratevasospasmcShouldbeperformedafterthepatienthasbeenstabilized3.CTAisbenecialinpatientswhoaretoounstabletoundergocerebralangiographyorinanemergentsettingpriortosurgicalevacuationofclot.B.ICH1.CTscanwithoutcontrasta.Toconrmableedanddeterminethesizeandsiteb.MayrevealstructuralabnormalitiessuchasaneurysmsAVMsorbraintumorsthatmayhavecausedthebleedaswellascomplicationssuchasherniationintraventricularhemorrhageorhydrocephalus2.Cerebralangiographymaybeperformeda.TodeterminewhetherthesourceisananeurysmoranAVMb.Shouldbeconsideredforallpatientswithoutaclearcauseofhemorrhagewhoaresurgicalcandidatesparticularlyyoungnormotensivepatientswhoareclinicallystablec.Timingdependsonthepatientsclinicalstateandtheneurosurgeonsjudgmentabouttheurgencyofsurgeryifneeded3.MRIandMRAmaybeusefulfordetectingstructuralabnormalitiesi.e.AVMsandaneurysms.GradientrecalledechoMRImaybeusefulindetectinghemorrhage4.CTAmaybeusedtoallownoninvasiveimagingoflargeandmedium-sizedvessels5.CBCplateletcount6.Electrolytes7.ECG8.Chestx-ray9.Bleedingtime10.PTPTT11.Liverenzymes12.Renalstudies13.LPiscontraindicatedmaycauseherniationinthepresenceofalargehematomaV.ManagementA.SAH1.BasicABCsrstmanypatientsmayneedtobeintubatedifunabletoprotectairway 16SECTIONONEManagementofPatientsWithNeurologicDisorders2.ExternalventriculardrainEVDplacementifhydrocephalusseenonCTscanrelievingthepressurefromacutehydrocephalusmaydramaticallyimproveapatientsLOC3.Strictbedrestinaquietstress-freeenvironment4.Cardiacmonitoring5.Treatsymptomaticallyforheadacheoranxietyacetaminophenandorescalatingopiates.Avoiduseofnonsteroidalanti-inammatorydrugsduetobleedingrisk.6.Havethepatientavoidallformsofstrainingandexertion.7.OrderstoolsoftenersandlaxativesdocusateColace100200mgPONGtwiceaday8.Seizureprophylaxisa.Upto26ofpatientswithSAHwillexperienceseizuresb.Short-termseizureprophylaxisisusedtopreventseizuresintheacutelyillpatientandpreventspikesinBPandpossiblerebleedingoftheaneurysm.c.Commonlyusedmedicationsincludei.PhenytoinsodiumDilantin100mgIVevery8hrtitratetobloodlevel1020mcgmlfor7daysii.LevetiracetamKeppra500mgIVorPOtwiceadayfor7daysaAlternativetophenytointhereislimitedliteraturetosupportuseforthisindicationandisnotapprovedasmonotherapyforseizuresd.Ifthepatienthasaseizureduringtheacutephaseconsidercontinuingantiepileptictherapyforalongerduration.9.Acutehypertensioncancontributetoaneurysmre-ruptureandshouldbeaggressivelymanaged.a.MaintainSBPlessthan160mmHgb.Considerintravenoustitratablenicardipinedriporc.Labetalol10mgintravenouspushd.Hydralazine1020mgIVpushifpatienthasbradycardia10.Cerebraledemacanbereducedwithmannitolandorhypertonicsalinesolutions.a.Mannitol0.251gramkgIVevery46hrb.Saline3solutionloadingdoseof250300mlIVover60minutesfollowedbycontinuousinfusiontitratedtotreatmentgoalsincluding145155mEqLandserumosmolalityof310320mOsmLc.Saline23.4solution30mlIVadministratedover30minorlongersubsequentdosesdependentonICP11.Surgicalclippingorendovascularcoilingshouldbeperformedasearlyaspossible.Interventionalchoiceofaneurysmobliterationisdependentonthesizeandlocationoftheaneurysmthepatientsageandclinicalconditionandtheneurosurgeonsexperience.12.Coilembolizationandorstentplacementforrupturedaneurysmperformedbytrainedneurovascularsurgeonorneuroradiologist.a.Nonsurgicalprocedureinvolvingthethreadingoftinycoilsthroughamicrocatheterintotheaneurysmb.Maybeusedwhenbleedingisinadifcult-to-reachareaofthebrain13.Cerebralvasospasmsa.Vasospasmsoccurinapproximately30ofpatients.Itismostfrequentbetweendays7and10afteraneurysmruptureandusuallyresolvesafter21days.Itmaybeassociatedwiththepresenceofathickclotinthesubarachnoidspace.b.SymptomswhichincludeconfusiondecreasedLOClocalizingneurologicaldecitsheadacheandincreasedICPmayormaynotbepresent.Cerebralinfarctioncanoccurwithseverevasospasm 17CerebrovascularAccidentsBrainAttackCHAPTER1c.CalciumchannelblockersnimodipinemaybeusedtotreatcerebralbloodvesselspasmafterSAHfromrupturedaneurysms60mgPONGTevery4hrfor3weeks.Recentstudiesdemonstrateimprovedneurologicaloutcomesbyprocessesotherthanpreventinglargevesselnarrowing.d.IfsymptomaticvasospasmoccursthepatientisusuallytreatedwithIVFloading.TraditionaltripleHtherapyhasbeenmodiedtoeuvolemiamaintenanceandinducedhypertension.i.Aimforahematocritofapproximately30althoughoptimalhemoglobinlevelsarestilltobedeterminedii.Monitorcardiacoutputandcentralvenouspressureifnecessaryiii.ThegoalistooptimizethelowshearrateviscosityofthewholebloodandtoensurecerebralperfusionpressureCPPthatisadequatetorestoreregionalcerebralbloodfowinperusionareasbeyondthevasospasticvesselse.Treatmentislessriskyiftheaneurysmhasbeenclippedf.BalloonangioplastyorIAvasodilatorsmaybeusedforvasospasmsresistanttotheprecedingtreatmentsg.DailytranscranialDopplerultrasoundsshouldbeperformedtomonitorforvasospasm14.Rebleedinga.Rebleedingisunpredictablebutoftenoccursbetweendays2and19afterinitialruptureandisthoughttooriginatefrombrinolysisoftheclotatthesiteoftherupturedaneurysm.b.Fortypercentofpatientsrebleedandapproximatelyhalfoftheserebleedsarefatalthereforeeffortstosealoffananeurysmshouldbemadeassoonaspossible.c.Neurologicdeteriorationisgenerallyabruptd.ArepeatCTscanandoccasionallyarepeatLPisneededtoconrmrebleedinge.Theuseofantibrinolyticagentsaminocaproicacidtranexamicacidtopreventrebleedinganddecreasemortalityinpatientswithsubarachnoidhemorrhageiscontroversial.Useoftheseagentshasbeenassociatedwithanincreaseincerebralischemiaandnosignicantdecreasehasbeennotedinmortalityrateorindegreeofdisabilityamongsurvivors.f.Forpatientswithanunavoidabledelayinobliterationofaneurysmasignicantriskofrebleedingandnocompellingmedicalcontraindicationsshorttermlessthan72hrtherapywithtranexamicacidoraminocaproicacidisreasonabletoreducetheriskofeveryaneurysmrebleeding.15.Cerebralsaltwastinga.HyponatremiadevelopsafteraneurysmalSAHb.Excessivesecretionofnatriureticpeptidesthatcauseshyponatremiafromexcessivenatriuresisandvolumecontractionc.Crystalloiduidreplacementtomaintaineuvolemiad.Threepercentsalinesolutiontocorrecthyponatremiae.Considerudrocortisonetoaidincorrectionofhypovolemiaandhyponatremiaandtomaintaineuvolemia16.Fevera.MostcommonmedicalcomplicationinaneurysmalSAHb.Thepresenceoffeverthatisnoninfectiouscentralhasbeenassociatedwithseverityofinjuryamountofhemorrhageanddevelopmentofvasospasmc.Maybeamarkerofasystemicinammatorystated.Feveroftenassociatedwithworsecognitiveoutcomese.AggressivefevermanagementisrecommendedB.ICH 18SECTIONONEManagementofPatientsWithNeurologicDisorders1.Initialmanagementshouldbedirectedtowardthebasicairwaybreathingandcirculationandtowardfocalneurologicdecits.2.IntubationisindicatedforinsufcientventilationforhypoxiapartialpressureofoxygenPo2lessthan60mmHgorpartialpressureofcarbondioxidePco2greaterthan50mmHgandforobviousriskofaspiration.3.OxygenshouldbeadministeredtoallpatientswithpossibleICH4.ControlsevereHTNa.Shouldbeachievedthroughshort-actingagentslikenicardipinethataretitratableb.Thegoalistodecreasetheriskofongoingbleedingfromrupturedsmallarteriesandarterioles.c.OveraggressivetreatmentofHTNmaydecreaseCPPandthereforeworsenbraininjuryparticularlyinthesettingofincreasedintracranialpressure.d.HoweverrecentstudiesdemonstratethatSBPkeptabove140150mmHgwasassociatedwithmorethandoubletheriskofsubsequentdeathordependency.e.FurtherstudyisstillwarrantedbutcurrentevidencesuggeststhatacuteloweringofSBPto140mmHgisprobablysafe.f.PatientsshouldbecarefullymonitoredduringtheBPloweringphaseandifneurologicalexamdeterioratesconsiderincreasingtheBPgoaltoimprovecerebralperfusion5.CPPMeanarterialpressureMAP-ICPshouldbekeptat5070mmHg6.SomesuggestedmedicationsforelevatedBPincludethefollowinga.LabetalolTrandate510mgIVpushb.NicardipeneCardeneintravenoustitratabledrip2.515mghrc.EsmololBreviblocmaintenance50300mcgkgmin7.IfBPfallstolessthan90mmHgpressorsshouldbegivendopamine220mcgkgminphenylephrine0.55mcgkgmin50400mcgminepinephrine0.010.2mcgkgmin110mcgminornorepinephrineLevophed0.010.5mcgkgmin140mcgmin.8.MaintainICPatlessthan20mmHgandCPPatgreaterthan5070mmHga.Mannitolforcerebraledema0.251gramkgofa20solutiongivenintravenouslyevery46hri.Becauseofitsreboundphenomenonmannitolisrecommendedfor5daysorlessii.SerumosmolalityshouldbemeasuredBIDforthosereceivingosmotherapyandshouldbekeptatnogreaterthan320mOsmL.Watchrenalfunctioncarefullyanduidbalancestatus.b.Hypertonicsalinemayalsobeusedtotreatcerebraledemai.Threepercentsalineinfusionsmaybestartedwithsodiumchecksevery6hr.Administerloadingdoseof250300mlIVover60minutesfollowedbycontinuousinfusiontitratedtotreatmentgoals.Goalsodiumlevelsofupto145155mEqLandserumosmolalityof310320mOsmLareatthediscretionoftheintensivist.ii.Twenty-threepercentsalinemaybegiveninanacutelydecompensatingpatientasanemergencymeasuretotreatelevatedICP.Administeras30mlIVover30minorlongersubsequentdosesdependentonICP.c.Ventriculardrainforsecondaryhydrocephalusi.Useshouldnotexceed7daysbecauseofpossibleinfectiouscomplicationsii.Intravenousantibioticprophylaxismaybeusedifventricularcatheterisnon-antibioticcoatedd.IfhyperventilationisusedPCO2shouldbemaintainedat3035mmHge.Steroidsarenotrecommended9.Supportivemeasures 19CerebrovascularAccidentsBrainAttackCHAPTER1a.IVFsnormalsalineuidofchoicei.Excessiveadministrationcanworsencerebraledemaii.Goaliseuvolemia.iii.Fluidbalanceiscalculatedbymeasuringdailyurineproductionandadding500mlforinsensiblelossesplus300mlperdegreeinfebrilepatients.b.PhenytoinDilantin100mgevery8hrtitratetobloodlevel1020mcgmli.LevetiracetamKeppra500mgIVPOtwiceadayasanalternativetophenytoinc.Nutritionalsupportd.MaintainbodytemperaturewithacetaminophenTylenol650mgfortemperaturegreaterthan101.3F38.5Ce.Physicaltherapyf.Skincareturning10.Surgerya.Indicatedforpatientswithcerebellarhemorrhagegreaterthan3cmindiameterb.Indicatedforthosewithsurgicallyaccessiblecerebralhematomagenerallyextendingtowithinonecmofthecorticalsurfacec.Patientswithahemorrhagegreaterthan1cmfromthecorticalsurfaceorwithaGCSscoreof8orlesstendedtodoworsewithsurgicalremovalascomparedwithmedicalmanagement.d.MusttakeintoaccountageandoverallprognosiswhenconsideringasurgicalinterventionBIBLIOGRAPHYAdamsH.P.Jr.2009.Secondarypreventionofatherothromboticeventsafterischemicstroke.MayoClinicProceedings8414351.BedersonJ.B.ConnollyE.S.BatjerH.H.DaceyR.G.DionJ.E.DiringerM.N....RosenwasserR.H.2009.GuidelinesforthemanagementofaneurysmalsubarachnoidhemorrhageAstatementforhealthcareprofessionalsfromaspecialwritinggroupoftheStrokeCouncilAmericanHeartAssociation.Stroke4039941025.BroderickJ.P.2004.WilliamM.FeinberglectureStroketherapyintheyear2025Burdenbreakthroughandbarrierstoprogress.Stroke351205211.ConnollyE.S.RabinsteinA.A.CarhuapomaJ.R.DerdeynC.P.DionJ.HigashidaR.T....VespaP.2012.GuidelinesforthemanagementofaneurysmalsubarachnoidhemorrhageAguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociationAmericanStrokeAssociation.Stroke43617111737.DiringerM.N.ScalfaniM.T.ZazuliaA.R.VideenT.O.DharR.2011.Cerebralhemodynamicandmetaboliceffectsofequi-osmolardosesmannitoland23.4salineinpatientswithedemafollowinglargeischemicstroke.NeurocriticalCare1411117.EastonJ.D.SaverJ.L.AlbersG.W.AlbertsM.J.ChaturvediS.FeldmannE....SaccoR.L.2009.AHAASAscienticstatementDenitionandevaluationoftransientischemicattack.Stroke4022762293.ElliottJ.SmithM.2010.TheacutemanagementofintracerebralhemorrhageAclinicalreview.AnesthesiaAnalgesia110514191427.FerreroE.FerriM.ViazzoA.GaggianoA.FerreroM.MaggioD....NessiF.2010.EarlycarotidsurgeryinpatientsafteracuteischemicstrokeIsitsafeAretrospectiveanalysisinasinglecenterbetweenearlyanddelayeddeferredcarotidsurgeryon285patients.AnnalsofVascularSurgery247890899.FerriF.F.2010.Practicalguidetothecareofthemedicalpatient8thed..St.LouisMOMosby.FronteraJ.A.FernandezA.SchmidtJ.M.ClaassenJ.WartenbergK.E.BadjatiaN....MayerS.A.2009.Deningvasospasmaftersubarachnoidhemorrhage.WhatisthemostclinicallyrelevantdenitionStroke4019631968. 20SECTIONONEManagementofPatientsWithNeurologicDisordersFurieK.L.KasnerS.E.AdamsR.J.AlbersG.W.BushR.L.FaganS.C....WentworthD.2011.GuidelinesforthepreventionofstrokeinpatientswithstrokeortransientischemicattackAguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociationAmericanStrokeAssociation.Stroke421227276.HarriganM.R.RajneeshK.F.ArdeltA.A.FisherIIIW.S.2010.Short-termantifbrinolytictherapybeforeearlyaneurysmtreatmentinsubarachnoidhemorrhageEffectsonrehemorrhagecerebralischemiaandhydrocephalus.Neurosurgery674935940.JamiesonD.G.2009.Diagnosisofischemicstroke.TheAmericanJournalofMedicine1224S14S20.JauchE.C.SaverJ.L.AdamsH.P.Jr.BrunoA.ConnorsJ.J.DemaerschalkB.M....YonasH.2012.GuidelinesfortheearlymanagementofpatientswithacuteischemicstrokeAguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociationAmericanStrokeAssociation.Stroke443870947.KwonW.K.ParkD.H.ParkK.J.KangS.H.Lee.J.H.ChoT.H.ChungY.G.2014.Prognosticfactorsofclinicaloutcomeafterneuronavigation-assistedhematomadrainageinpatientswithspontaneousintracerebralhemorrhage.ClinicalNeurologyandNeurosurgery1238389.LansbergM.G.ODonnellM.J.KhatriP.LangE.S.Nguyen-HuynhM.N.SchwartzN.E....AkiE.A.2012.Antithromboticandthrombolytictherapyforischemicstroke.Chest1412Supple601Se636S.LuA.Y.AnsariS.A.NystrmK.V.DamisahE.C.AminH.P.MatoukC.C....BulsaraK.R.2014.Intra-arterialtreatmentofacuteischemicstrokeThecontinuedevolution.CurrentTreatmentOptionsinCardiovascularMedicine162110.MannoE.M.2010.Updateonintracerebralhemorrhage.CriticalCareNeurology183598610.Martinez-VilaE.SieiraP.I.2010.Currentstatusandperspectivesofneuroprotectioninischemicstroketreatment.CerebrovascularDiseases1116070.MlynashM.OlivotJ.M.TongD.C.LansbergM.G.EyngornI.KempS....AlbersG.W.2009.YieldofcombinedperfusionanddiffusionMRimaginginhemisphericTIA.Neurology721311271133.MorgensternL.B.HemphillJ.C.IIIAndersonC.BeckerK.BroderickJ.P.ConnollyE.S.Jr....TamargoR.J.2010.GuidelinesforthemanagementofspontaneousintracerebralhemorrhageAguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociationAmericanStrokeAssociation.Stroke41921082129.NationalInstituteofNeurologicalDisordersandStrokeNINDS.2004.StrokeHopethroughresearch.NIHPublicationNo.99-2222.Retrievedfromhttpwww.ninds.nih.govdisordersstrokedetail_stroke.htmOverviewofhemorrhagicstroke.2014.InR.S.PorterJ.L.KaplanEds.TheMerckManualHomeHealthHandbook.Retrievedfromhttpwww.merckmanuals.comhomebrain_spinal_cord_and_nerve_disordersstroke_cvaoverview_of_hemorrhagic_stroke.htmlPapadakisM.A.McPheeS.J.Eds.2014.Currentmedicaldiagnosisandtreatment53rded..NewYorkNYMcGrawHillEducation.SeevinckP.R.DeddensL.H.DijkhuizenR.M.2010.Magneticresonanceimagingofbrainangiogenesisafterstroke.Angiogenesis13101111.VijayaraghavanK.DeedwaniaP.2011.Renin-angiotensin-aldosteroneblockadeforcardiovasculardiseaseprevention.CardiologyClinics291137156. TextOverviewComprehensive900pagepracticetexttailoredtotheneedsofadult-gerontologyacutecarenursepraconersandalladvancedpraccenursesworkingwithacutelyillpaentsEvidence-basedtreatmentrecommendaonsanddiscussionsformorethan350ofthemostcommoncondionsexperiencedbyadult-gerontologypaentsCondionsareorganizedbybodysystemforquickreferencewhentreangpaentsEachcondionlistsdeningtermsincidencepredisposingfactorssubjecveandphysicalexaminaonndingsdiagnosctestsandmanagementstrategiestoprovidehelpeverystepofthewayCoveragealsoincludesdiscussionofbodysystemsnutrionalconsideraonsuidelectrolyteimbalancesshockandtraumaforacompletelookatpaentcareanddiagnosisInclusionofInternaonalStascalClassicaonofDiseasesICD-9andICD-10codesforeachcondionprovidedassupplementalmaterialintheappendixwww.NPcourses.com