Critical Care Medicine, Year 2000 Edition (Current Clinical by Michael Safani;Matthew Brenner

By Michael Safani;Matthew Brenner

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D. Thrombolysis 1. Unstable patients (systolic <90 mmHg) with proven pulmonary embolism require immediate clot lysis by thrombolytic therapy. 2. Tissue plasminogen activator (Activase) is recommended because it is the fastest-acting thrombolytic agent. 3. Contraindications to thrombolytics a. Absolute contraindications. Active bleeding, cerebrovascular accident or surgery within the past 2 months, intracranial neoplasms. b. Relative contraindications. Recent gastrointestinal bleeding, uncontrolled hypertension, recent trauma (cardiopulmonary resuscitation), pregnancy.

The dosage is 324 mg PO tid-qid. 3. Disopyramide (Norpace) has potent negative inotropic and anticholinergic properties. It is not recommended in older men because of urinary retention. 100-300 mg of the SR cap PO bid. C. Class Ic antiarrhythmic drugs 1. Flecainide and propafenone are associated with excess mortality in patients post MI, and they have significant proarrhythmic properties in patients with LV dysfunction. 2. Flecainide is highly effective for controlling atrial fibrillation with structurally normal hearts; 50-100 mg PO q12h; max 200 mg q12h.

Trimethoprim/Sulfamethoxazole (Septra DS) 160/800 mg PO bid. c. Amoxicillin/clavulanate (Augmentin) 500 mg PO tid [250, 500 mg]; stable against beta lactamases; gastrointestinal side effects (diarrhea) are common. d. Cefuroxime axetil (Ceftin), 250-500 mg PO bid; good activity against primary pathogens; stable against beta lactamase. e. Cefixime (Suprax), 200 mg PO bid or 400 mg PO qd; stable against beta lactamase, lacks Staphylococcus aureus coverage. f. Doxycycline (Vibramycin), 100 mg bid; not affected by betalactamase, S pneumoniae resistance in 10-20%.

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