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....2
...18
...33
......41
....53
...59
EKG-1).81
EKG-2 ()...106
EKG-3 ()....120
.144


CGMH R3

# -lactam

Penicillin

Cephalosporin

Carbapenem

Monobactam

@ -lactam
------------------------------------------------------------------------------------------------------------------------------------------

Penicillin
Natural Penicillin
1Penicillin G
# IV
# Group A StreptococcusSyphilisNeurosyphilis
#
@ Penicillin G 3,000,000U/vial
2Benzathine Penicillin
# IM
# Syphilis
#
@ Benzathine Penicillin G (IM) 240 IU/4ml/syringe
Staphylococcus Penicillinase Penicillin
1Penicillinase-resistant PenicillinOxacillin
2 -lactamase inhibitorAugmentin
Penicillinase-resistant Penicillin
1Oxacillin
# MSSA
# Penicillin
#
@ Oxacillin 1g/vial
2


1Oxacillin1G/PC1PC Q6H ~ 2PC Q6H
2CeftriaxoneRocephin1G/PC1PC Q12H
3Moxifloxacin400mg/PC1PC QD
4Clindamycin300mg/PC2PC Q8H
5Tigecycline50mg/PC1PC Q12H
6Linezolid600mg/PC1PC Q12H
2Methicillin
#
3Dicloxacillin
# Oxacillin
#
@ Dicloxacillin sodium 250mg/cap
Amino-Penicillin
1Ampicillin
# Streptococcus GNB
# Listeria Enterococcus
#
@ Ampicillin sodium 500mg/vial
@ Ampicillin 500mg/cap
2Amoxicillin
# Ampicillin
#
1
22g 1 hour before & after
#
@ Amoxicillin 500mg/cap
@ Amoxicillin 250mg/cap
3AugmentinAmoxicillin + Clavulanate
# -lactamase inhibitor MSSAEnterobacteriaceae
E. coliK.p.
#
#
@ Amoxicillin 1000mg + Clavulanic acid 200mg)/vial
@ Amoxicillin 500mg + Clavulanic acid 100mg)/vial
@ Clavulanic acid 125mg + Amoxicillin 875mg) 1Gm/tab
@ Curam 625mg/f.c. tab (Clavulanic acid 125mg + Amoxicillin 500mg)
3

4UnasynAmpicillin + Sulbactam
#
@ Ampicillin 1gm + Sulbactam 500mg)/vial
Carboxy-Penicillin
1Carbenicillin
2Ticarcillin
3TimentinTicarcillin + Clavulanate
# PseudomonasHAPStenotrophomonas
# Fluid overload
#
Ureido-Penicillin
1Piperacillin
2TazocinPiperacillin + Tazobactam
# PseudomonasHAP
#
@ Piperacillin sodium 2gm/vial
@ Piperacillin 2gm + Tazobactam 0.25gm)/vial (Pfizer)
@ PIPERACILLIN 2GM + TAZOBACTAM 0.25GM)/VIAL (Sandoz)
------------------------------------------------------------------------------------------------------------------------------------------

Cephalosporin

1Cefazolin
2Cefadroxil
# GPC + GNB PECKProtiusE. coliKlebsiella
# MSSA
# Staphylococcus Oxacillin Group A Streptococcus Penicillin
Cefazolin
#
@ Cefazolin sodium 1GM/vial
@ Cefazolin sodium 500mg/vial
@ Cefadroxil monohydrate 500mg/cap
Streptococcus
#
1Cefazolin + Clindamycin
2Penicillin + Clindamycin
# Clindamycin cover Streptococcus M protein
4


1Cefuroxime
# GPC + GNBPECK + HiMENH. influenzaeMoraxellaEnterobacterNeisseria
#
#
@ Cefuroxime 750mg/vial
@ Cefuroxime 250mg/tab
2Cefoxitin
# GPC + GNBPECK + HiMEN+ Bacteroid fragilis
#
#

1CeftriaxoneRocephin
# GPC + GNBPECK + HiMEN + S/SSalmonellaShigella
# BBB Metronidazole SBP
UrosepsisNeisseria gonorrhea
#
#
@ Ceftriaxone 1GM/vial
2CeftazidimeFortum
# GPC GNB Pseudomonas
# PseudomonasNeutropenic fever
#
@ Ceftazidime 1g/vial
@ Ceftazidime 500mg/vial
3Flomoxef
# Rocephin + Metronidazolecover
#
@ Flomoxef 1G/vial

1Cefepime
# GPC + GNB Rocephin Fortum
# PseudomonasNeutropenic fever
#
@ Cefepime 500mg/vial
5

E.coliK.p.
1AmpC -lactamase
# 1~3 Cephalosporin
# CephalosporinCarbapenem
2Extended-spectrum -lactamaseESBL
# Penicillin1~4 CephalosporinMonobactam
# Carbapenem
------------------------------------------------------------------------------------------------------------------------------------------

Carbapenem
1ImipenemTienam
# GPCGNBAmpC -lactamase ESBL
# Pseudomonas
# Seizure
#
@ Tienam (Imipenem 500mg + Cilastatin 500mg)/vial
Tienam Tazocin pneumonia Teicoplanin + Tazocin
Teicoplanin + Tienam
2Meropenem
#
# Pseudomonas
# BBB CNS
#
@ MEROPENEM TRIHYDRATE 500mg/vial (Meropenem Sandoz, SANDOZ)
@ Meropenem trihydrate 250mg/vial (Mepem, Dainippon)
3Doripenem
#
# Pseudomonas
#
@ Doripenem 250mg/vial
4Ertapenem
# PseudomonasAcinetobacter
# BTI
#
@ Ertapenem 1gm/vial
6

Carbapenem-resistant-Klebsiella pneumonia (CRKP)


# Carbapenem
# Colistin + Tigecycline (+/- Carbapenem)
Carbapenem synergic effect
------------------------------------------------------------------------------------------------------------------------------------------

Monobactam
1Aztreonam
# GNB Aminoglycoside
# Pseudomonas
#
------------------------------------------------------------------------------------------------------------------------------------------

Glycopeptides
1Vancomycin
# GPC
# MRSAARE (Ampicillin-resistant enterococcus)PRSP (Penicillin-resistant Streptococcus
pneumoniae)
# GPC GPC meningitisCONS
CONS CONS
# Red man syndrome
#
@ Vancomycin HCl 1GM/vial
@ Vancomycin HCl 500mg/vial
2Teicoplanin
# Loading dose2PC Q12H x 3 doses
# Maintain dose2PC QD
2PC QODClCr < 50 mL/min
2PC Q3DClCr < 20 mL/min, H/D, CAPD
#
@ Teicoplanin 200mg/vial
ORSA &
BBB

Lung

Soft tissue / Bone

Vancomycin

10%

20~30%

20~30%

Teicoplanin

<5%

50~60%

40~50%

Daptomycin

<10%

>60%

Linezolid

>40%

70~80%

>60%
7

------------------------------------------------------------------------------------------------------------------------------------------

Bacitracin
1Bacitracin-Neomycin
# Bacitracin for GPC
# Neomycin for GNB
#
@ Neomycin & Tyrothricin oint 10gm/tube
@ Neomycin & Tyrothricin oint 40gm/tube
Neomycin
# 4# Q6H
#
@ Neomycin sulfate 250mg/cap


50S
Macrolide
1Erythromycin
# GPCLegionellaChlamydiaMycoplasma H. influenzae
# Penicillin
#
@ Erythromycin 500mg/vial
@ Erythromycin 250mg/cap
2Clarithromycin
# GPCH. influenzae
# No-comorbidity CAP
#
@ Clarithromycin 500mg/fc tab
3Azithromycin
# GPCH. influenzae
# No-comorbidity CAP
# HIV MACMycobacterium avium complex
G(-)H.p.VibrioCampylobacter
# H.p.PPI + Amoxicillin + Clarithromycin
# Comorbidity CAP
- Augmentin + Clarithromycin
- Augmentin + Azithromycin
- Moxifloxacin
#
@ Azithromycin 250mg/tab
------------------------------------------------------------------------------------------------------------------------------------------

Lincosamide
1Clindamycin
# Erythromycin
# Metronidazole
# Pseudomembranous colitis
#
@ Clindamycin phosphate 300mg/2ml/pc
@ Clindamycin HCl 150mg/cap
9

------------------------------------------------------------------------------------------------------------------------------------------

Oxazolidinones
1Linezolid
# MRSAVRE
#
# MAOi SSRITriptanMeperidine serotonin syndrome
#
@ Linezolid 600mg/300ml/bag
@ Linezolid 600mg/tab
------------------------------------------------------------------------------------------------------------------------------------------

Chloramphenicol
1Chloramphenicol
# GPCGNB
# Gray baby syndrome
#
------------------------------------------------------------------------------------------------------------------------------------------

30S
Aminoglycoside
1Gentamicin
# GNB GPC
# Penicillin Cefazolin
#
# IrreversibleGentamicin > Tobramycin > Amikacin

#
@ Gentamicin sulfate 80mg/2ml/vial
@ Gentamicin 0.1% cream 15gm/tube
@ Gentamicin oph oint 0.3%, 5gm/tube
2Tobramycin
3Amikacin
# Mycobacterium Norcardia
#
@ Amikacin 500mg/vial
-----------------------------------------------------------------------------------------------------------------------------------------10

Tetracycline
1Tetracycline
# Q feverLyme disease
H.p.
#
#
@ Tetracycline HCl 250mg/cap
@ Tetracycline hcl 1% eye oint 5gm/tube
2Doxycycline
#
#
#
@ Doxycycline 100mg/cap
Orchitis& Epididymitis
# Rocephin + Doxycycline
#
- Rocephin 1PC Q12H Neisseria gonorrhoeae
- Doxycycline 1# BID Chlamydia
# Guideline 18~50 Sexual active
# E.coli Rocephin
Vibrio vulnificus
# Fortum + Doxycycline
#
- Fortum 2PC Q8H Vibrio vulnificus
- Doxycycline 1# BID Synergic effect
# Vancomycin cover GPC DC
------------------------------------------------------------------------------------------------------------------------------------------

Glycylcycline
1Tigecycline
# GPCGNB
# MDRABMDRKPCRKPMRSAVREPRSP Tetracycline
# Pseudomonas
# Tetracycline
#
@ Tigecycline 50mg/vial
11

MDRAB
# Colistin + Tigecycline
#
- Colistin 1PC Q12H
- Tigecycline 1PC Q12H
# Colistin
1IV1PC Q12H
2Inhalation1PC BID
# MDRAB Colistin + Tienam synergic effect

12


TMP/SMX
1Trimethoprim/Sulfamethoxazole
# BaktarBacideSeptrinSevatrim
#
# PJPNocardiosis
# Stenotrophomonas multophiliaCVPDouble lumenHickmanA-line
Baktar
#
@ Cotrimoxazole (SMZ 400mg + TMP 80mg)/5ml/amp
@ Cotrimoxazole (SMZ 400mg + TMP 80mg)/tab
------------------------------------------------------------------------------------------------------------------------------------------

Fluoroquinolone
# DNA
1Ciprofloxacin
# GNB
# PseudomonasSalmonella
#
@ Ciprofloxacin 2mg/ml, 50ml/bot
@ Ciprofloxacin HCl 250mg/fc tab
2Levofloxacin
# GNBGPC
#
#
@ Levofloxacin 500mg/100ml/bot
@ Levofloxacin 500mg/tab
3Moxifloxacin
# GNBGPC
#
# Pseudomonas
# UTI
#
@ Moxifloxacin 400mg/250ml/bot
@ Moxifloxacin 400mg/tab
13

4Gemifloxacin
# GNBGPC
# Moxifloxacin
#
@ Gemifloxacin 320mg/f.c. tab
Quinolone
GPC

GNB

Anaerobes

Pseudomonas

TB

Ciprofloxacin

+++

+++

Levofloxacin

+++

+++

++

Moxifloxacin

+++

+++

+++

Gemifloxacin

+++

+++

+++

------------------------------------------------------------------------------------------------------------------------------------------

Metronidazole
1Metronidazole
# DNA
# Bacteroides fragilisClostridium perfringensClostridium difficile
ProtozoaGiardiaEntamoiba histolyticaTrichomonas vaginalis
#
@ Metronidazole (IVF) 500mg/100ml/bot
------------------------------------------------------------------------------------------------------------------------------------------

Rifampin
1Rifampin
# DNA-dependent RNA polymerase
#
#
@ Rifampicin 300mg/cap
@ Rifampicin 150mg/cap

14

TB
# &

HIsoniazid (INAH)

300mg QD

Vit-B6Lupus-like syndrome

EEthambutol (EMB)

15~25mg/kg QD

Optic neuritis

RRifampin (RIF)

600mg QD

HypersensitivityFever
GI upset

ZPyrazinamide (PZA) 25mg/kg QD

>13

---------------------------------------------------------------------------------------------------------------------------------------#
@ HERZ x 2 months, then HER x 4 months (Total 6 months)
@ HRZ x 2 months, then HR x 4 months (Total 6 months)
Ethambutol Ethambutol
@ HR 9
---------------------------------------------------------------------------------------------------------------------------------------#

@ AKURIT-4 (Rif 150mg + INAH 75mg + EMB 275mg + PZA 400mg)/tabHERZ


@ Rifater (RIF 120mg + INAH 80mg + PZA 250mg)/tabHRZ
@ Rifinah 300 (Rif 300mg + INAH 150mg)/capHR
@ Rifinah 150 (Rif 150mg + INAH 100mg)/tabHR

@ Isoniazid 100mg/tabH
@ Ethambutol 400mg/tabE
@ Rifampicin 300mg/capR
@ Rifampicim 150mg/capR
@ Pyrazinamide 500mg/tabZ

15


Penicillin
GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Penicillin G

0.5~4 million U Q4H

0.5~4 million U Q8H

0.5~4 million U Q12H

0.5~4 million U Q8H

Oxacillin

1~2g Q6H

1~2g Q6H

1~2g Q6H

1~2g Q6H

Ampicillin

250mg~2g Q6H

250mg~2g Q6~12H

250mg~2g Q12H~QD

Amoxicillin

200~500mg Q8H

200~500mg Q8~12H

200~500mg QD

Amoxicillin/Clavulanate

1g/0.2g Q8H

1g/0.2g Q12H

1g/0.2g QD

Ampicillin/Sulbactam

2g/1g Q6H

2g/1g Q8~12H

2g/1g QD

Piperacillin/Tazobactam

4g/0.5g Q6H

2g/0.25g Q6H

2g/0.25g Q8H

2g/0.25g Q6H

------------------------------------------------------------------------------------------------------------------------------------------

Cephalosporin
GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Cefazolin

1~2g Q8H

1~2g Q12H

1~2g QD~QOD

1~2g Q12H

Cefuroxime

0.75~1.5g Q8H

0.75~1.5g Q8~12H

0.75~1.5g QD

0.75~1.5g Q8~12H

Ceftriaxone

1g Q12H

1g Q12H

1g Q12H

1g Q12H

Ceftazidime

2g Q8~12H

2g Q12H~QD

2g QD~QOD

2g Q12H~QD

Flomoxef

1g Q8H

1g Q12H

1g QD

1g Q12H

Cefepime

2g Q8H

2g Q12H~QD

1g QD

2g Q12H~QD

------------------------------------------------------------------------------------------------------------------------------------------

Carbapenem
GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Imipenem

500mg Q6H

250mg Q6H

250mg Q12H

(Tienem)

(1PC Q6H)

(0.5PC Q6H)

(0.5PC Q12H)

Meropenem

1g Q8H

1g Q12H

0.5g QD

1g Q12H

Ertapenem

1g QD

0.5g QD

0.5g QD

Doripenem

500mg Q8H

250mg Q8~12H

------------------------------------------------------------------------------------------------------------------------------------------

Aminoglycoside
GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Gentamicin

1.7mg/kg Q8H

1.7mg/kg Q12H~QOD

1.7mg/kg QOD~Q3D

1.7mg/kg Q12H~QOD

Amikacin

7.5mg/kg QD

7.5mg/kg QD

7.5mg/kg Q3D

7.5mg/kg QD

16

------------------------------------------------------------------------------------------------------------------------------------------

Quinolone
GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Ciprofloxacin

400mg Q12H

400mg QD

400mg QD

Levofloxacin

750mg QD

750mg QOD

500mg QOD

Moxifloxacin

400mg QD

400mg QD

400mg QD

Gemifloxacin

320mg QD

160mg QD

160mg QD

------------------------------------------------------------------------------------------------------------------------------------------

Glycopeptide
GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Vancomycin

1g Q12H

1g QD

1g Q5D

Teicoplanin

400mg QD

400mg QOD

400mg Q3D

(Loading dose)

(400mg Q12H)

(400mg Q12H)

(400mg Q12H)

------------------------------------------------------------------------------------------------------------------------------------------

Anaerobic
GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Metronidazole

7.5mg/kg Q8H

7.5mg/kg Q12H

7.5mg/kg QD

7.5mg/kg Q12H

Clindamycin

600mg Q8H

600mg Q8H

600mg Q8H

600mg Q8H

------------------------------------------------------------------------------------------------------------------------------------------

GFR >50

GFR 10~50

GFR <10H/DP/D

CRRT

Daptomycin

4~6mg/kg QD

6mg/kg QQD

6mg/kg QOD

8mg/kg QOD

Linezolid

600mg Q12H

600mg Q12H

600mg Q12H

600mg Q12H

Tigecycline

50mg Q12H

50mg Q12H

50mg Q12H

50mg Q12H

(Loading dose)

(100mg STAT)

(100mg STAT)

(100mg STAT)

(100mg STAT)

Colistin

2PC Q12H

1PC Q12H

0.5PC Q12H

3.5PC Q12H

Baktar (TMP-SMX)

(>50kg) 3PC Q8H

(>50kg) 3PC Q12H

(>50kg) 3PC QD

(Cotrimoxazole)

(<50kg) 2PC Q8H

(<50kg) 2PC Q12H

(<50kg) 2PC QD

17


CGMH R3

SBP (mmHg)

DBP (mmHg)

Normal SBP

<120

<80

Pre-HTN

120~140

80~90

Stage 1 HTN

140~160

90~100

Stage 2 HTN

>160

>100

Isolated systolic HTN

>140

<90

=====================================================================================

Essential HTN95%
# 30~60
# 60 resistant arteriole
# 60
Isolated systolic HTN
Pulse pressure
# Isolated systolic HTN
-
-

------------------------------------------------------------------------------------------------------------------------------------------

Secondary HTN5%
# < 30 > 60
#
18

#
14%
a. 2%
- Atherosclerosis
- Fibromuscular dysplasia medial fibroplasia
- Bruit ACEi/ARB
-
- Captopril Renography
b. 2%
- DM nephropathyRenal cystPKDRenal tumor
20.5%
- HyperaldosteronismCushing syndromePheochromocytoma
30.2%
- renin volume expansion
-
# Obstructive sleep apneaPreeclampsiaEclampsia
ACEi/ARB

RAA system

19

=====================================================================================

AACEi/ARB
ACEi
#
1CaptoprilCapoten TID !
2EnalaprilSynbot
3FosinoprilFonosil
4LisinoprilZestril
5RamiprilTritace
# RAA system
#

@ Captopril 25mg/tab1# TID


4~6hr6.25mg TID50mg TID
@ Enalapril 5mg/tab1# QD5mg QD40mg QD
@ Enalapril 20mg/tab1# QD5mg QD40mg QD
@ Fosinopril sodium 10mg/tab1# QD
@ Ramipril 10mg/tab (Tritace, Sanofi)1# QD
ACEi + CCB
@ Amtrel (Amlodipine 5mg + Benazepril HCl 10mg)/tab
ARB
#
1LosartanCozaar
2ValsartanDiovan
3CandesartanBlopress
4IrbesartanAprovel
5TelmisartanMicardis
6OlmesartanOlmetec
# RAA system
# Both ACEi/ARB
1

2
a. preloadafterload
b. Post-MI remodeling
@ ARBValsartanCandesartan
#
20

@ Losartan potassium 50mg/tab1# QD


@ Valsartan 160mg/f.c tab1# QD
@ Candesartan 8mg/tab1# QD
@ Irbesartan 300mg/tab (Aprovel, Sanofi)1# QD
@ IRBESARTAN 300mg/tab (IRBESARTAN, Sandoz)1# QD
@ Telmisartan 80mg/tab1# QD
@ Olmesartan 20mg/tab1# QD
@ Azilsartan medoxomil 40mg/tab1# QD
ARB + Diuretics
@ Hyzaar (Losartan 100mg + HCTZ 12.5mg) tab1# QD
@ Co-Diovan (Valsartan 160mg + HCTZ 12.5mg) tab1# QD
@ Blopress Plus (Candesartan 16mg + HCTZ 12.5mg)/tab1# QD
@ Coaprovel (Irbesartan 300mg + HCTZ 12.5mg) f.c. tab1# QD
ARB + CCB
@ Exforge 5/160 tab (Amlodipine 5mg + Valsartan 160mg)1# QD
@ Telmisartan 80mg + Amlodipine 5mg)/tab1# QD
@ Sevikar 5/20 tab (Amlodipine 5mg + Olmesartan Medoxomil 20mg)1# QD
ARB + CCB + Diuretics
@ Exforge HCT (Amlodipine 5mg + Valsartan 160mg + HCTZ 12.5mg)/tab1# QD
@ SEVIKAR HCT (Amlodipine 5mg + Olmesartan 20mg + HCTZ 12.5mg)/tab1# QD
------------------------------------------------------------------------------------------------------------------------------------------

B-blocker
# 1 Renin 12
#
ISA (-)

ISA (+)

1 blocker

AtenololTenorminBisoprololMetoprolol

Acebutolol

Non-selective -blocker

PropranololInderalNadololTimolol

Pindolol

1 blocker + Non-selective -blocker

CarvedilolDilatrendLabetalolTrandate

# -blockerBisoprololMetoprololCarvedilol
# ISA (+)Intrinsic sympathetic activity
# ISA (-)
# Selective 1 blockerAtenololBisoprololMetoprolol
# PropranololInderal
1Rate control
2Hyperthyroidism
3Portal hypertension
21

# HR
#
1-blocker
2 Thiazide
3 CCBACEi Isolated systolic HTN
CCB > ACEi > -blocker
42 blockage effect claudication
5 -blocker
6
-blocker TCA tremorAtenolol
CNS tremor tremor Propranolol
#
1 blocker
@ Atenolol 100mg/tab1# QD
@ Bisoprolol hemifumarate 1.25mg/tab1# QD 1.25mg 10mg
@ Bisoprolol 5mg/tab (Concor, Merck)1# QD 1.25mg 10mg
@ BISOPROLOL FUMARATE 5mg/tab (Sinbisol,)1# QD 1.25mg
10mg
@ Metoprolol 25mg/tab1# QD
Non-selective -blocker
@ Propranolol 10mg/tab1# TID
1 blocker + Non-selective -blocker
@ Carvedilol 6.25mg/tab (Dilatrend, Roche)1# BID
@ CARVEDILOL 6.25mg/tab (Carvedilol HEXAL, Sandozs)1# BID
@ CARVEDILOL 25mg/tab (Carvedilol HEXAL, Sandozs)1# BID
@ Labetalol 200mg/tab1# BID
@ Labetalol HCl 25mg/5ml/ampfor Hypertensive Emergency
------------------------------------------------------------------------------------------------------------------------------------------

CCCB
#
DHP
1NifedipineAdalet TID ! 10mg/cap
2AmlodipineNorvasc
3FelodipinePlendil
4LercanidipineZanidip
5NicardipineNicarpine for Hypertensive Emergency!
Non-DHP
1DiltiazemHerbesser
2VerapamilIsoptin
22

#
1DHP >
DHP > Diltiazem > Verapamil
2Non-DHP Atrial fibrillation rate control
Verapamil > Diltiazem > DHP
#
1 ACEi-blocker CCB > ACEi > -blocker
2 Isolated systolic HTN Vasodilator
#
1ankle edema>
2 Non-DHP
Nifedipine Hypertensive
Urgency
Nifedipine
Amlodipine 3~4 Onset3~4 Peak7
Amlodipine
#
DHP
@ Nifedipine 10mg/cap1# TID BP
@ Nifedipine ex. release 30mg/tab (Adalat OROS, Bayer)1# QD
@ NIFEDIPINE slow release film-coated 30mg/tab ()1# QD
@ Amlodipine 5mg/tab (Norvasc, Pfizer)1# QD~BID 2# QD
@ AMLODIPINE 5mg/tab (Amlodipine, Sandoz, Sandoz)1# QD~BID 2# QD
@ Felodipine 5mg/tab1# QD~BID
@ FELODIPINE 5mg/tab (Stapin,)1# QD~BID
@ Lercanidipine 10mg/tab1# QD~BID 2# QD
@ Nicardipine HCl 10mg/10ml/amp ()for Hypertensive Emergency
Non-DHP
@ Diltiazem HCl 30mg/tab (Herbesser, Tanabe)1# TID
@ DILTIAZEM HCl 30mg/tab (Cartil,)1# TID
@ Diltiazem long acting 90mg/tab (Cardizem)1# QD
@ Verapamil HCl 40mg/tab1# TID~QID
@ Verapamil s.r 240mg/f.c tab oral1# QD
@ Verapamil HCl 5mg/2ml/amp
ACEi + CCB
@ Amtrel (Amlodipine 5mg + Benazepril HCl 10mg)/tab
ARB + CCB
@ Exforge 5/160 tab (Amlodipine 5mg + Valsartan 160mg)1# QD
@ Telmisartan 80mg + Amlodipine 5mg)/tab1# QD
@ Sevikar 5/20 tab (Amlodipine 5mg + Olmesartan Medoxomil 20mg)1# QD
23

------------------------------------------------------------------------------------------------------------------------------------------

DDiuretics
#

Acetazolamide
Amiloride
MannitolIICP

FurosemideLasix

ThiazideHCTZBehyd

AmilorideTriamterene
Spironolactone

Bumetanide
IndapamideNatrilix

Conivaptan
#

@ Furosemide 40mg/tab1# QD~BID


@ Furosemide 20mg/2ml/amp1PC QD~BIDSTAT for
@ Bumetanide 1mg/tab1# QD~BID
@ Bumetanide 0.25mg/ml, 2ml/amp1PC QD~BIDSTAT for
@ Indapamide 1.25mg/tab1# QD
@ Indapamide S.R 1.5mg/tab1# QD
@ BehydBenzyl Hydrochlorothiazide4mg/tab1# QD~BID
@ Spironolactone 25mg/tab1# QD
Diuretics + Diuretics
@ Amiloride 5mg + Hydrochlorothiazide 50mg/tab1# QD~BID
ARB + Diuretics
@ Hyzaar (Losartan 100mg + HCTZ 12.5mg) tab1# QD
@ Co-Diovan (Valsartan 160mg + HCTZ 12.5mg) tab1# QD
@ Blopress Plus (Candesartan 16mg + HCTZ 12.5mg)/tab1# QD
@ Coaprovel (Irbesartan 300mg + HCTZ 12.5mg) f.c. tab1# QD
ARB + CCB + Diuretics
@ Exforge HCT (Amlodipine 5mg + Valsartan 160mg + HCTZ 12.5mg)/tab1# QD
@ SEVIKAR HCT (Amlodipine 5mg + Olmesartan 20mg + HCTZ 12.5mg)/tab1# QD

24

25

#
FurosemideLasix

ThiazideHCTZBehyd
+

Na -K -2Cl

Na+-Cl-

Bartters syndrome

Gitelmans syndrome

26


Q1 Thiazide Nephrogenic DINDI?

A1+
exLasix Thiazide

NDI ADH Water diuresis


Thiazide Distal tubule NCC
+ Proximal tubule
Iso-osmotic ++
ADH

-------------------------------------------------------------------------------------------------------------------------------------Q2Lasix Thiazide ?

A2Lasix NKCC2Thiazide NCC


ENaC ROMK
-------------------------------------------------------------------------------------------------------------------------------------Q3Lasix Thiazide ?
A3Lasix NKCC2 ROMK lumen positive Paracellular
Thiazide distal tubule TRPM6
-------------------------------------------------------------------------------------------------------------------------------------Q4Lasix ? Thiazide ?
A4Lasix NKCC2 ROMK lumen positive Paracellular
Thizaide NCC

-------------------------------------------------------------------------------------------------------------------------------------Q5Lasix Thiazide RAA system ?


A5Lasix macula densa Thick ascending limb NKCC2 macula densa
renin Thiazide distal tubule volume depletion proximal
tubule macula densa renin
-------------------------------------------------------------------------------------------------------------------------------------Q6Lasix Thiazide ?
A6Lasix urinary urate Thiazide urinary urate

-------------------------------------------------------------------------------------------------------------------------------------Q7 Thiazide Lasix hyponatremia?


A7Lasix Thick ascending limb NKCC2 medullary interstitium
medullary collecting duct
Thiazide medullary interstitium
collecting duct AQP2 hyponatremia
Lasix Thiazide
27

------------------------------------------------------------------------------------------------------------------------------------------

Vasodilator
#
1HydralazineApresoline
- NO
- tolerate ACEi/ARB
- Lupus syndrome 200mg
2MinoxidilLaniten
-
-
-
-
3Nitroprusside+
- NO
-
a. NTGSTAT
b. Isosorbide dinitrate (Isodil)TID~QID
c. Isosorbide-5-mononitrate (Imdur)QD HS
- Cyanide
4Fenoldopam
- D1 receptorD1 agonist vasodilatation
#
Hydralazine
@ HydrALAZINE HCl 10mg/tab1# TID~QID
@ HydrALAZINE HCl 50mg/tab1# TID~QID
@ Hydralazine HCl 20mg/ml/amp
Minoxidil
@ Minoxidil 10mg/tab1# QD 0.25#~0.5#
@ Minoxidil 5% Foaming solution 50mg/ml, 90ml/pc1660
Nitroprusside
@ NTG 0.6mg/tab, 25'S/package
@ NTG 5mg/10ml/ampfor Hypertensive Emergency
@ NTG tts 25mg/patch
@ Isosorbide dinitrate 10mg/tab (Isodil)1# TID~QID
@ Isosorbide-5-mononitrate cr 60mg/tab (Imdur, AstraZeneca)1# QD 1# HSfor PND
30mg 2# QD
@ ISOSORBIDE-5-MONONITRATE CR 60mg/tab (IBIMO,)1# QD 1# HSfor PND
30mg 2# QD
28

1-Blocker
#
1Terazosin
2Doxazosin
3Prazosin
4Tamsulosin BPH
#
# Postural hypotensionVasovagal syncope Risk factor
First dose phenomenon
#
@ Terazosin HCl 2mg/tab1# HS
@ Doxazosin XL 4mg/tab (Doxaben XL, Pfizer)1# HS
@ Tamsulosin D 0.2mg/tab (Astellas, Harnalidge)1# QD
@ TAMSULOSIN HCL SR O.D. 0.2mg/tab (Hanlosin,)1# QD
@ Tamsulosin prolonged release 0.4mg/tab1# QD
2-Agonist
#
1ClonidineCatapres
- Vasopressor Center 2 receptor NE
- Rebound hypertension
- = NEor 5-HT
2MethyldopaAldomet
- Methyldopa prodrug -methylnorepinephrine
Vasopressor Center 2 receptor NE
-
-
- = NEor 5-HT
#
@ Clonidine 75mcg/tab1# BID
@ Methyldopa 250mg/tab1# QID
Neuron Blocker
#
1Reserpine
- NE NE
- = NEor 5-HT
2Guanethidine
-
- = NEor 5-HT
29

=====================================================================================

# < 140/90 mmHg


# < 130/80 mmHg
# + < 125/75 mmHg
------------------------------------------------------------------------------------------------------------------------------------------

# Pre-HTNSBP120~140 mmHgDBP80~90 mmHg


BMI < 25Na < 3g/day
2 drinks/day in men; 1 drink/day in women 30
DASH

# Stage 1 HTNSBP140~160 mmHgDBP90~100 mmHg


Thiazide ACEi/ARBCCB
Cost effective-blocker
# Stage 2 HTNSBP>160 mmHgDBP>100 mmHg
A/B+C/D -blocker A+C/D
------------------------------------------------------------------------------------------------------------------------------------------

NICE Guideline

Step-1

< 55

> 55 or

C or D

Step-2

A+C or A+D

Step-3

A+C+D

Step-4

A+C+D+

30

------------------------------------------------------------------------------------------------------------------------------------------

#
#
#
#
#
#
#

ACEi/ARB
ACEi/ARB-blockerISA (-)
Isolated Systolic HTNCCBDHP DiureticsThiazide
-blockerCCBNon-DHP
DiureticsThiazide
-blocker
MethyldopaHydralazineLabetalolNifedipine

------------------------------------------------------------------------------------------------------------------------------------------

# ACEi/ARB
# ACEi/ARB
# -blocker2
#
#
#
#
#
#
#

-blocker2
-blocker2-agonistNeuron blocker
-blocker + Thiazide Diabetogenic potential
-blocker + Thiazide
DiureticsLasixThiazide
-blockerCCBNon-DHP
CCBNon-DHP

=====================================================================================

Hypertensive Emergency
#
#
# 220/140
mmHg
# NTG Labetalol 160/100 mmHg
#
1 220/130 mmHg
2 180/130 mmHg
3 185/110 mmHg
4SAHMAP 130 mmHg
5SBP 120 mmHg
31

------------------------------------------------------------------------------------------------------------------------------------------

Hypertensive Urgency
#
# SBP >180 mmHgDBP >120 mmHg
#

#
1
2 Nifedipine
Hypertensive emergency
1~2 160/100 mmHg
3
=====================================================================================

# ACEi/ARB
# Methyldopa
# HydralazineLabetalol Nifedipine

32


CGMH R3

OHA

QD

HbA1c

Sulfonylurea

Glimepiride

1.5

Glibenclamide

Gliclazide

QD~BID

Glipizide

GI

GI

Lipid profile

Lipid profile

Glinide

Repaglinide

1.5

Nateglinide

Mitiglinide
DPP-4

Incretin inhibitor

0.8

Biguanide

TID

Sitagliptin

Metformin

QD

TID

1.5

TZD

Rosiglitazone

1.0

Pioglitazone

QD

-glucosidase

inhibitor

0.7

Acarbose

TID

Pancreatic -cell

33

GI

------------------------------------------------------------------------------------------------------------------------------------------

Sulfonylurea
#
1GlimepirideAmarylQD
2GlibenclamideDiabetin, Euglucon, GlyburideQD
3GliclazideDiamicronQD~BID
4GlipizideMinidiabQD~BID
# -cell ATP-sensitive K+ channel
# HbA1C 1.5
# Days~Weeks
# Onset
#
1
Glinide
Glibenclamide active metabolites

2
#

@ Glimepiride 2mg/tab (Amaryl, Aventis)1# QD


@ GLIMEPIRIDE 2mg/tab (Nonin,)1# QD
@ Gliclazide MR 30mg/tab1# QD~BID
@ Gliclazide MR 60mg/tab1# QD~BID
@ Glipizide 5mg/tab1# QD~BID

@ Amaryl M tab (Glimepiride 2mg + Metformin 500mg)1# QD


@ Glimet tab (Glimepiride 2mg + Metformin 500mg)1# QD
------------------------------------------------------------------------------------------------------------------------------------------

MeglitinideGlinide
#
1RepaglinideNovonormTID
2NateglinideStatlixTID
3MitiglinideTID
#
#
#
#

-cell ATP-sensitive K+ channel


HbA1C 1.5
Days~Weeks

1
2
34

#
1
2
# Sulfonylurea Glinide
#
@ Repaglinide 1mg/tab (Novonorm, Novo Nordisk)1# TID
@ REPAGLINIDE 1mg/tab (Rovo,)1# TID
@ Mitiglinide 10mg/tab1# TID
------------------------------------------------------------------------------------------------------------------------------------------

DPP-4 Inhibitor
#
1SitagliptinJanuvia
2VildagliptinGalvus
3SaxagliptinOnglyza
4LinagliptinTrajenta
# Incretin GLP-1
GLP-1 DPP-4 GLP-1
Glucagon-like peptide-1GLP-1Dipeptidyl peptidase-4DPP-4
# HbA1C 0.8
# Days~Weeks
#
1Incretin
2Incretin
3Linagliptin
4PotencySaxagliptin > Linagliptin
# GFR > 50100mg/dGFR 25~5050mg/d
GFR < 2525mg/d
#

@ Sitagliptin 100mg/tab1# QD
@ Vildagliptin 50mg/tab1# BID
@ Saxagliptin 5mg/tab1# QD
@ Linagliptin 5mg/tab1# QD

@ Janumet (Sitagliptin 50mg + Metformin 500mg)1# BID


@ Galvus Met (Vildagliptin 50mg + Metformin 500mg)1# BID
@ Kombiglyze XR (Saxagliptin 5mg + Metformin 1000mg)1# QD
@ Trajenta Duo (Linagliptin 2.5mg + Metformin 850mg)/tab1# BID
-----------------------------------------------------------------------------------------------------------------------------------------35

Biguanide
#
1MetforminGlucophage
#
1
2 Metformin
# HbA1C 1.5
# Days~Weeks
#
1
2 Lipid profileUKPD
3
#
1
2
#
@ Metformin 500mg/tab1# TID
------------------------------------------------------------------------------------------------------------------------------------------

TZDGlitazone
#
1RosiglitazoneAvandia
2PioglitazoneActos
# PPAR-
GLUT-4
Peroxisome proliferative-activated receptor-PPAR-
# HbA1C 1.0
# Weeks~Months
#
1
2 Lipid profile
#
1
2 sodium retention
TZD
3 Rosiglitazone
4
5
6
36

@ Pioglitazone 30mg/tab (Actos, Takeda)1# QD


@ PIOGLITAZONE 30mg/tab (Glitis,)1# QD

@ ACTOSMET 15/850 (Pioglitazone 15mg + Metformin 850mg)/tab1# QD~BID


------------------------------------------------------------------------------------------------------------------------------------------

-glucosidase inhibitor
#
1AcarboseGlucobay
# -glucosidase
# HbA1C 0.7
#
#
1
2
-glucosidase
#
1
2
#
@ Acarbose 50mg/tab1# TID

37

------------------------------------------------------------------------------------------------------------------------------------------

OHA
#
1Sulfonylurea
2Biguanide TZD
3NPHDetemirGlargine
#
1Glinide
2 Incretin DPP-4 inhibitor
3-glucosidase inhibitor
4AspartLisproRI
#
1Sulfonylurea Glinide
2TZD
#
1Biguanide
2DPP-4 inhibitor
#
1Sulfonylurea
2Biguanide
3TZD
#
1Sulfonylurea
2DPP-4 inhibitor
3Biguanide
4-glucosidase inhibitor
------------------------------------------------------------------------------------------------------------------------------------------

OHA
1. OHA contraindication Metformin
1# BID~1# TID
2. 1# TID Sulfonylurea
3. DPP-4 inhibitor
4. TZD
Basal insulin
5. OHA Basal insulin
6. Metformin DPP-4 inhibitor Basal insulin
Glinide Acarbose
38

=====================================================================================

Insulin
# 0.5~1 U/kg/day2/3 1/3
-----------------------------------------------------------------------------------------------------------------------------------------

Onset

Peak

Duration

Rapid

AspartNovoRapid

3~4

LisproHumalog
GlulisineApidra
Short

RI

~1

2~3

3~6

Intermediate

NPH

1~4

6~10

10~16

Basal

DetemirLevemir

1~4

6~14

12~20

GlargineLantus

1~4

6~24

24

Rapid

Short
Intermediate
Basal

10

12

14

16

18

20

Rapid
1AspartNovoRapid
#
@ Insulin Aspart 100IU/ml, 3ml/pc TID HS
@ NovoMix 30 penfill 100U/ml, 3ml/pc30% Insulin Aspart + 70% Insulin Aspart Protamine
BID
@ NovoMix 50 penfill 100U/ml, 3ml/pc50% Insulin Aspart + 50% Insulin Aspart Protamine
BID
2LisproHumalog
#
@ Insulin Lispro 100IU/ml, 3ml/penfill TID HS
@ Humalog 100IU/ml, 3ml/penfill TID HS
@ Humalog Mix25 100IU/ml, 3ml/pen25% Insulin Lispro + 75% Insulin Lispro Protamine
BID
@ Humalog Mix50 100IU/ml, 3ml/pen50% Insulin Lispro + 50% Insulin Lispro Protamine
BID HS
39

3GlulisineApidra
#
@ Insulin GLULISINE (Apidra) 100IU/ml, 3ml/pen TID HS
------------------------------------------------------------------------------------------------------------------------------------------

Short
1Regular InsulinRI
# RI 1U 30
#
@ Regular HM insulin 100IU/ml, 10ml/vial TID HS
------------------------------------------------------------------------------------------------------------------------------------------

Intermediate
1Neutral Protamine HagedornNPHInsulin
# NPH 1U 20
#
@ NPH human insulin 100IU/ml, 10ml/vial BID HS HS
TID
------------------------------------------------------------------------------------------------------------------------------------------

Basal
1DetemirLevemir
#
@ Insulin detemir 300u/3ml/ HS TID
2GlargineLantus
#
@ Insulin glargine (Lantus) 100iu/ml, 3ml/pen HS TID
@ Insulin glargine 100iu/ml, 10ml/vial HS TID
------------------------------------------------------------------------------------------------------------------------------------------

1
- Basal insulin
2
- intensive insulin management
- AspartGlargine RINPH
3
-
4DKAHHS
40


CGMH R3

Hyponatremia

#
------------------------------------------------------------------------------------------------------------------------------------------

# Excess of water relative to sodium


1ADH
- AppropriateHypovolemiaHypervolemia with decreased EAV
- InappropriateSIADH
2ADH
- Primary polydipsia
- "Tea & Toast" and "Beer Potomania"
------------------------------------------------------------------------------------------------------------------------------------------

Plasma Osmolality
1Hypotonic
2Isotonic
3Hypertonic
# Osm (B)
Hypotonic Volume
1Hypovolemic
2Euvolemic
3Hypervolemic

# Na (B)Cr (B)Na (U)Cr (U)Osm (U)T4TSHCortisolAldosterone


------------------------------------------------------------------------------------------------------------------------------------------

Hypotonic Hyponatremia
#

41

Hypotonic hyponatremia
Hypovolemic

Euvolemic

Hypovolemic
Hyponatremia

UNa > 20

UNa < 10

FENa > 1%

FENa < 1%

Hypervolemic

Euvolemic
Hyponatremia

Uosm > 100

Uosm < 100

Hypervolemic
Hyponatremia

Uosm var.

UNa < 10

UNa > 20

FENa < 1%

FENa > 1%

Renal loss

Extra-renal

SIADH

Primary

Reset

C.H.F

Renal

Mineralocorticoid

loss

Hypothyroidism

Polydipsia

osmostat

Cirrhosis

failure

Glucocorticoid

Low salt

deficiency

Nephrosis

deficiency

@ FENa = (UNa/PNa) / (UCr/PCr)


Hypovolemic
# Renal lossUNa > 20FENa > 1%
1Diuretics
2Salt-wasting nephropathy
3Cerebral salt wasting
4Mineralocorticoid deficiency
# Extra-renal lossUNa < 10FENa < 1%
1GI lossVomitingDiarrhea
2Skin lossSweatingBurn
3Shift to third spacePancreatitis
Euvolemic
# SIADHADH UOsm > 100
1 MalignancyLung
BrainGIGULymphomaLeukemiaThymomaMesothelioma
2PulmonaryPneumoniaAsthmaCOPDPneumothoraxPressure ventilation
3CNSTraumaStrokeHemorrhageInfectionHydrocephalus
4DrugsAntipsychoticsAntidepressantChemotherapyVasopressinDDAVPMDMA
5MiscellaneousPainNauseaPost-operative status
42

# UOsm > 100


1Glucocorticoid deficiencyCo-secretion of ADH & CRH
2HypothyroidismDecreased cardiac output Increased ADH secretion
# Prinary polydipsiaUOsm < 100
# Low saltUOsm < 100
# Reset osmostat
Hypervolemic
# Congestive heart failureUNa < 10FENa < 1%
# Liver cirrhosisUNa < 10FENa < 1%
# Nephrotic syndromeUNa < 10FENa < 1%
# Renal failureUNa > 20FENa > 1%
------------------------------------------------------------------------------------------------------------------------------------------

Isotonic Hyponatremia
#
# HyperlipdemiaHyperproteinemiaMultiple myeloma
------------------------------------------------------------------------------------------------------------------------------------------

Hypertonic Hyponatremia
#
# 100 mg/dl 2.4 mEq/L
------------------------------------------------------------------------------------------------------------------------------------------

#
# Hypotonic hyponatremia
Hypervolemic
# Lasix
Hypovolemic
#
Euvolemic
#
1 Lasix
43

23% NaCl 24 10~12 mEq/L


Central pontine myelinolysis, CPM

@
[Na] per 1L infusate = ([Na] infusate - [Na] serum) / (TBW + 1)
TBW = BW x 0.6 x 0.5
= BW x 0.5 x 0.45
70 110 mEq/L 1L 3%NaCl
ANSTBW = 70 x 0.6 = 42
[Na] = (513 - 110) / (42 + 1) = 9.4 mEq/L

- 3% NaCl = 513 mEq/L


- 0.9% NaCl = 154 mEq/L
- 0.45% NaCl = 77 mEq/L
- 0.225% NaCl = 38 mEq/L
@
TBW x ( - ) = 0.513 x C.C. 3% NaCl
60 105 mEq/L 125 mEq/L 3% NaCl
ANS60 x 0.6 x (125 - 105) = 0.513 x X
X = 1403 c.c.
@ Central pontine myelinolysis
10~12 mEq/L 8 mEq/L60 x 0.6 x 8 = 0.513 x X
561 c.c. 3% NaCl 300 c.c. 3% NaCl
=====================================================================================

Hypernatremia

#
------------------------------------------------------------------------------------------------------------------------------------------

Hypervolemic
# HydrationD5W+
44

Euvolemic
# ADH
#
1Central diabetes insipidus
- ADH
- DDAVP 50%
- DDAVP
2Nephrogenic diabetes insipidus
- ADH
- DDAVP 10%
- Thiazide
Hypovolemic
# HydrationD5W
@

TBW x = (TBW + X) x
70 160 mEq/L 140 mEq/L
ANS70 x 0.6 x 160 = (70 x 0.6 + X) x 140
X=6L
@
10~12 mEq/L 8 mEq/L
ANS70 x 0.6 x 160 = (70 x 0.6 + X) x (160 - 8)
X = 2.2 L
------------------------------------------------------------------------------------------------------------------------------------------

Urine Osmolality
# Dehydration
#

Uosm

Renal loss free water

Complete DI

< 300

Partial DI

300~800

GI lossRemote diuretics

> 800

Extra-renal loss free water

45

------------------------------------------------------------------------------------------------------------------------------------------

Polyuria

Water diuresis
Uosm < 250

Primary polydipsia < 140

> 140

Solute diuresis
Uosm > 300

NG
Salt-wasting nephropathy

=====================================================================================

Hypokalemia

# 98% 2%

# 1 mmol/L 200~400 mmol/L


#
1Transcellular shift
2Extra-renal loss
3Renal loss
------------------------------------------------------------------------------------------------------------------------------------------

# Paralysis

------------------------------------------------------------------------------------------------------------------------------------------

# ST T U

46

------------------------------------------------------------------------------------------------------------------------------------------

Transcellular shift
# Insulin-agonistThyrotoxicosisTheophylline
Extra-renal loss Renal loss
# Extra-renal lossGI loss
- UK < 15 mEq/L
- UK < 25 mEq/day

Insulin
-agonist
Thyroxine

Digoxin

Theophylline

-blocker

- TTKG < 3
# Renal loss
- UK > 15 mEq/L
- UK > 30 mEq/day
- TTKG > 7
@ TTKG = (UK/PK) / (Uosm/Posm)
Transtubular K gradient

Alkalosis

Renal loss

Acidosis

Hypokalemia

Poor intake

Transcellular Shift

UK < 15 mEq/L

UK > 15 mEq/L

UK < 25 mEq/day

UK > 30 mEq/day

TTKG < 3

TTKG > 7

Extra-renal loss

Insulin
-agonist

Renal loss

GI loss

Thyrotoxicosis
Theophylline

Alkalosis

Diarrhea
Laxative abuse
Villous adenoma

Aldosterone

UCl < 20

UCl > 20

DKA

Vomiting

Diuretics

Type I RTA

NG tube

Bartters syndrome

Type II RTA
Amphotericin B

Aldosterone

1st hyperaldosteronism
- Conns syndrome
2nd hyperaldosteronism

Gitelmans syndrome
47

- Renal artery stenosis


- Renin-secreting tumor

Liddles syndrome
Apparent mineralocorticoid
Excess (AME)
Licorice

------------------------------------------------------------------------------------------------------------------------------------------

Transcellular shift
1 H+-K+
# Alkalosis K+
2Na+-K+ ATPase
# Insulin Na+-K+ ATPase Na+ K+
exDKA Insulin
# -agonist Na+-K+ ATPase Na+ K+
exAsthma COPD -agonist
# Thyrotoxicosis periodic paralysis, TPP
Na+-K+ ATPase Na+ K+
shift

3Ca DHP
# Hypokalemia periodic paralysis, HPP
shift
20
------------------------------------------------------------------------------------------------------------------------------------------

Extra-renal loss
#
- UK < 15 mEq/L
- UK < 25 mEq/day
- TTKG < 3
# DiarrheaLaxative abuseVillous adenoma
------------------------------------------------------------------------------------------------------------------------------------------

Renal loss
#
- UK > 15 mEq/L
- UK > 30 mEq/day
- TTKG > 7

48

# Aldosterone
1Primary hyperaldosteronismRenin Aldosterone
- Conn's syndrome
2Secondary hyperaldosteronismRenin Aldosterone
- Renal artery stenosis
- Renin-secreting tumor
# Aldosterone
1Liddle's syndrome Na Na K
2Apparent Mineralocorticoid ExcessAME
3Licorice

#
1DKA
2RTA type IDistalH+ Sjogren syndrome
3RTA type IIProximalHCO3- Multiple myeloma
4Amphotericin B
#
1LasixThiazide
2Bartter's syndrome
3Gitelman's syndrome
Bartters syndrome

Gitelmans syndrome
+

Na -K -2Cl Na+-Cl-
Lasix
Thiazide

Spironolactone
NSAID

Spironolactone
NSAID

------------------------------------------------------------------------------------------------------------------------------------------

#
1
2 Slow K
3 Potassium
49

=====================================================================================

Hyperkalemia

# Paralysis
------------------------------------------------------------------------------------------------------------------------------------------

#
- Diffuse peaked T waves
- PR prolong
- P wave
- QRS widening
- Sine wave pattern QRS T
- VF or PEA

Peaked T Wave

QRS widening

PR prolong
P Wave

Sine wave pattern

@ VF cardiac arrest
------------------------------------------------------------------------------------------------------------------------------------------

Transcellular shift
# -blockerDigoxin

# CKD
TTKG

50

Hyperkalemia
Transcellular Shift

-blocker
Digoxin
Acidosis

CKD

TTKG > 10

TTKG < 5

Aldosterone

Aldosterone

C.H.F
Cirrhosis

Aldosterone

Aldosterone

Fludrocortisone

Fludrocortisone

TTKG > 10

TTKG < 10

Renin

Spironolactone

Renin

Baktar
Calcineurin inhibitor
DM nephropathy

Addisons disease

NSAIDS

ACEi/ARB

-blocker

Heparin

Chronic interstitial nephritis

Ketoconazole

Cyclosporine
HIV

51

------------------------------------------------------------------------------------------------------------------------------------------

Transcellular shift
1H+-K+
# AcidosisH+K+
2Na+-K+ ATPase
# -blocker Na+-K+ ATPase
# Digoxin Na+-K+ ATPase
------------------------------------------------------------------------------------------------------------------------------------------

Calcium gluconate

Glucose + RI

15~30

Sodium bicarbonateJusomine 15~30

DiureticsLasixThiazide

30

2-agonist

30~90

Kalimate

1~2

Hemodialysis

52


CGMH R3

pH
# pH7.36~7.44HCO3-24PaCO240
# pH < 7.36
- HCO3- Metabolic Acidosis
- PaCO2 Respiratory Acidosis
# pH > 7.44
- HCO3- Metabolic Alkalosis
- PaCO2 Respiratory Alkalosis
# pH
- PaCO2 + HCO3- +
- PaCO2 + HCO3- +
- PaCO2HCO3- AG
------------------------------------------------------------------------------------------------------------------------------------------

1.25

0.75

0.1

0.2

0.3

0.4

# HCO3-
- PaCO2 = 1.25 x ( HCO3-)
- PaCO2 < 1.25 x ( HCO3-) +
- PaCO2 > 1.25 x ( HCO3-) +
HCO3- = 16 HCO3- = 8
- PaCO2 = 30 PaCO2 = 1.25 x ( HCO3-)
- PaCO2 > 30 PaCO2 < 1.25 x ( HCO3-) +
- PaCO2 < 30 PaCO2 > 1.25 x ( HCO3-) +

53

# PaCO2
- HCO3- < 0.1 x ( PaCO2) +
-

HCO3- = 0.1 x ( PaCO2)


HCO3- = 0.1~0.3 x ( PaCO2)
HCO3- = 0.3 x ( PaCO2)
HCO3- > 0.3 x ( PaCO2) +

PaCO2 = 50 PaCO2 = 10
- HCO3- < 25 HCO3- < 0.1 x ( PaCO2) +
- HCO3- = 25 HCO3- = 0.1 x ( PaCO2)
- HCO3- = 25~27 HCO3- = 0.1~0.3 x ( PaCO2)
- HCO3- = 27 HCO3- = 0.3 x ( PaCO2)
- HCO3- > 27 HCO3- > 0.3 x ( PaCO2) +

# HCO3-
- PaCO2 = 0.75 x ( HCO3-)
- PaCO2 < 0.75 x ( HCO3-) +
- PaCO2 > 0.75 x ( HCO3-) +
HCO3- = 32 HCO3- = 8
- PaCO2 = 46 PaCO2 = 0.75 x ( HCO3-)
- PaCO2 < 46 PaCO2 < 0.75 x ( HCO3-) +
- PaCO2 > 46 PaCO2 > 0.75 x ( HCO3-) +
# PaCO2
- HCO3- < 0.2 x ( PaCO2) +
- HCO3- = 0.2 x ( PaCO2)
- HCO3- = 0.2~0.4 x ( PaCO2)
- HCO3- = 0.4 x ( PaCO2)
- HCO3- > 0.4 x ( PaCO2) +
PaCO2 = 30 PaCO2 = 10
-

HCO3- > 22 HCO3- < 0.2 x ( PaCO2) +


HCO3- = 22 HCO3- = 0.2 x ( PaCO2)
HCO3- = 20~22 HCO3- = 0.2~0.4 x ( PaCO2)
HCO3- = 20 HCO3- = 0.4 x ( PaCO2)
HCO3- < 20 HCO3- > 0.4 x ( PaCO2) +
54

------------------------------------------------------------------------------------------------------------------------------------------

AG AG/ HCO3-
AGAnion Gap= [Na+] - ( [Cl-] + [HCO3-] )
#
+ = +
- = -
[Na+] - ( [Cl-] + [HCO3-] ) = ( [Albumin] + [] ) - ( [K+] + [Ca2+] + [Mg2+] )

[Na ]

( [Cl ] +

[HCO3 ]

( [Albumin] + [] )

2+

2+

( [K ] + [Ca ] + [Mg ] )

@ AG
@ Albumin mask
Corrected AG = Measured AG + (4 - Albumin) x 2.5
@ K+ Ca2+ Mg2+ AG
# AG = 10 2
# AG AG/ HCO3- HCO3- AG
- AG/ HCO3- = 1~2AG = HCO3- HCO3-
High AG
- AG/ HCO3- < 1AG < HCO3- HCO3- loss
High AG + Normal AG
- AG/ HCO3- > 2AG > HCO3- HCO3- gain
High AG +
AG = 20 AG = 10
- HCO3- = 14 HCO3- = 10 AG/ HCO3- = 1 High AG
- HCO3- = 4 HCO3- = 20 AG/ HCO3- < 1 High AG + Normal AG
- HCO3- = 20 HCO3- = 4 AG/ HCO3- > 2 High AG +
=====================================================================================

High AG
1KetoacidosisDKA
# Ketone Body (U)Blood Ketone Quantitative Test (B)
2Lactic AcidosisSepsis
# Lactate
55

3Uremia
# Creatinine
4MethanolEthanolEthylene glycolIsopropanol
# Osmolality gapOG > 10
5SalicylateParaldehyde
# Osmolality gapOG < 10
OGOsmolality Gap= Measured Osmoles - Calculated Osmoles
Calculated Osmole =2[Na-] + [Glucose]/18 + [BUN]/2.8
------------------------------------------------------------------------------------------------------------------------------------------

Normal AG
# UAGUrine Anion Gap
UAG = (UNa + UK) - UCl
#
+ = +
- = -

(UNa + UK) - UCl = - NH4+

# UAG < 0 NH4+ H+


GI loss HCO3- Type II RTA HCO3-
# UAG > 0 NH4+ H+
Type I RTAType IV RTA
# GI Loss HCO3-DiarrheaFistulaExternal pancreatic or small-bowel drainageUreterosigmoidostomy
- UAG < 0
# Renal Tubular AcidosisRTA
a. Type I RTADistal
- Sjogren syndrome H+
- UAG > 0 H+ NH4+
- Urine pH > 5.3
b. Type II RTAProximal
- Multiple Myeloma Acetazolamide
HCO3-
- UAG < 0
- FEHCO3- > 15% HCO3-
c. Type IV RTA
- Hypo-RAS Aldosterone
NH3
- UAG > 0 NH3 NH4+
- Urine pH < 5.3
56

=====================================================================================

# UCl < 20
1VomitingNG drainage H+ loss
@ H+Cl-K+HCO32Volume depletion RAA system
# UCl > 20
1HyperaldosteronismPrimarySecondary
2Bartter's syndromeGitelman's syndrome
=====================================================================================

1pH = 7.39HCO3- = 14PaCO2 = 24Na+ = 140K+ = 4.0Cl- = 106


pH
pH PaCO2 HCO3- +

AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 140 - ( 106 + 14 ) = 20
High AG
AG/ HCO3- = 10/10 = 1
High AG
High AG +
------------------------------------------------------------------------------------------------------------------------------------------

2pH = 7.30HCO3- = 18PaCO2 = 38Na+ = 140K+ = 4.0Cl- = 102


pH
pH < 7.36
HCO3-

PaCO2 < 1.25 x ( HCO3-)


+

AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 140 - ( 102 + 18 ) = 20
High AG
AG/ HCO3- = 10/6 = 1~2
High AG
High AG +
57

------------------------------------------------------------------------------------------------------------------------------------------

3pH = 7.42HCO3- = 42PaCO2 = 67Na+ = 140K+ = 3.5Cl- = 88


pH
pH PaCO2 HCO3- +

AG AG/ HCO3-

+
------------------------------------------------------------------------------------------------------------------------------------------

4pH = 7.42HCO3- = 25PaCO2 = 40Na+ = 140K+ = 3.0Cl- = 95


pH
pH PaCO2HCO3-

AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 140 - ( 95 + 25 ) = 20
High AG
AG/ HCO3- = 10/1 > 2
High AG +
High AG +
------------------------------------------------------------------------------------------------------------------------------------------

5pH = 7.20HCO3- = 10PaCO2 = 25Na+ = 135K+ = 3.0Cl- = 110


pH
pH < 7.36
HCO3-

PaCO2 < 1.25 x ( HCO3-)


+

AG AG/ HCO3-
AG = [Na+] - ( [Cl-] + [HCO3-] ) = 135 - ( 110 + 10 ) = 15
High AG
AG/ HCO3- = 5/14 < 1
High AG + Normal AG
High AG + Normal AG +

58


CGMH R3

Hemodialysis

- Arterial needle
- Arterial pressure monitor
- Blood pump
- Heparin syringe
- DialyzerHollow fiber AK
- Venous pressure monitor
- Air detector / clamp
- Venous needle

Blood Flow
Dialysate out

Heparin
Syringe
Blood Flow

Dialyzer
Blood
Pump

Dialysate in

Arterial
Pressure
Monitor

Venous
Pressure
Monitor
Air detector / Clamp

Blood Flow

Artery
AV Shunt
Vein

> 6 re-circulation
59

------------------------------------------------------------------------------------------------------------------------------------------

1Sign Permit
- H/D permit
- Double lumen catheter permit Double lumen
2Frequency
- QW135
- QW246
- QW15
- QW26
- ex: 7/6, 7/8, 7/10
#
3Vascular Access
1. AV Shunt

a. AV fistulaAVF
- brachial artery radial artery cephalic vein
- Venous arterialization
- CCr = 10~15 ml/min
Hickman
- 2~3
b. AV graftGortexAVG
-
- AVF
- 1
2. Hickman catheter

- Tunnel-cuffed catheterTCC
PERM catheter
- 1~3
- Internal jugular vein
-
3. Double lumen catheter
- Non-cuffed catheter
- 14
- Femoral vein
- Bedside

60

4Location
- AV ShuntForearm or Arm
- Hickman catheter Internal jugular vein Subclavian vein
- Double lumen catheter Femoral vein

5DialyzerHollow Fiber AK
# Dialyzer
- FB 170G
- FB 210U
#
# Disequilibrium syndrome

Brain edema

# Osm (B) = 2[Na+] + BUN/2.8 + Glu/18

#
- BUNCreatinineUric acid
- NaKCaPMg
- Pyrogen
- H+
- H2O
#
- RBCWBC
61

6Duration
- 2.5 hrs x 1, then 3.0 hrs x 2, then 4.0 hrs
- 4.0 hrs
# 4
# 2.5
7Dialysate

Na+

K+

Ca2+

Mg2+

Cl-

CH3COO-

HCO3-

Dextrose

No.16

103.00

2.0

3.5

109.5

3.0

100

No.100

100.00

2.0

2.5

0.75

105.25

2.0

200

No.110

103.00

2.0

3.0 1

109.0

3.0

200

Ca2+

Glucose

K+

No.8

3.5

200

2.0

No.9

2.5

100

2.0

No.10

3.0 0

2.0

No.11

3.0 100

2.0

#
-
-
-
# 2.0
7 KCl 3.0
8Blood flow
- 150 ml/min x 3, then 200~250 ml/min
- 200~250 ml/min
# Blood flow
9Dry weightDW
#
#
10UltrafiltrationUF
#
#
#
50 kg

53 kg

Dry weight

48

48

Ultrafiltration

62

11Heparin
#
1. Heparin none
- Heparin
2. Heparin drained out5000u AK
- Heparin normal saline
Heparin coating
- bleeding tendency
3. Heparin free5000u AK
- Heparin normal saline
Heparin
- bleeding tendency
-
4. Heparin loading/maintain
- Heparin
Loading dose20~30u/kgMaintain doseLoading dose
- Ex1000u/500u1500u/750u2000u/1000u
# Heparin 1 2 3 4
12Mannitol
- Mannitol 150ml IVF x 3 times
# Mannitol

13Blood transfusion
- Blood transfusion with voluven 250cc priming and during H/D
- Blood transfusion with SFP 2u priming and during H/D
# Colloid
Albumin

TetrastarchVoluven

SFP

FFP

# 250mlSFP FFP 2u 250mlVoluven 500ml


#
1. Priming Colloid
Colloid
2. During oncotic pressure

63

------------------------------------------------------------------------------------------------------------------------------------------

Modality
# Modality
1Intermittent hemodialysisIHD
2Continuous renal replacement therapyCRRT
3Sustained low efficiency dialysisSLED
#
# 24 CVVHCVVHDCAVHCAVHD
C ContinuousVV veno-venoAV arterio-veno
H HemofiltrationHD Hemodialysis
24

Blood flow 120~150 ml/min


Blood flow 200~250 ml/min
24

# Hybrid therapy
8 12 Blood flow
150~180 ml/min

------------------------------------------------------------------------------------------------------------------------------------------

135~155

132

H/D

0~4

P/D

2.5~3.5

2.5~3.5

3.5 2.5 3.0

0~0.20

1.5/2.5/4.0/25

P/D

25~40

Bicarbonate acetate

35~40

pH 5.2~5.6

64

------------------------------------------------------------------------------------------------------------------------------------------

Urea Reduction RateURR


# URR = [ (Pre-dialysis BUN - Post-dialysis BUN) / Pre-dialysis BUN ] x 100%
# URR > 65~70%
KT/Vd
#
- KClearance
- T
- Vd
# KT/Vd > 1.2
# URR 70% KT/Vd > 1.2
------------------------------------------------------------------------------------------------------------------------------------------

1Intradialytic hypotension
-
a. 100 mmHg
b. 100 mmHg 25%
-
a.
b.
c.
-
a.
b. 140 mEq/L 150 mEq/L
c. NO
d.
e. 1-agonistMidodrine
f.
2Dialysis-related amyloidosis
- 2-microglobulin carpal tunnel
syndromebone cystcervical pseudotumorarthropathy

65

=====================================================================================

Peritoneal Dialysis

#
# fluid overload

#
1
2
3
4
5
# Peritoneal equilibrium test

1High transporter

2Average transporter
3Low transporter
------------------------------------------------------------------------------------------------------------------------------------------

1
a. CAPD peritonitis
- Cloudy effluentAscites WBC > 100Neutrophil > 50%
- CONSStaphylococcus epidermidis GNB
- Cefazolin + FortumIP
b. Exit-site infection
- Less well-definedPainDischarge from exit site
- Staphylococcus aureus
2Encapsulating peritoneal sclerosis
-
- Ileus
- High peritoneal permeability state

- TPN
3
- 60~80%
4
-
66

CAPD peritonitis
Cefazolin
#
Loading dose1000 mg/each bag2Lx 8 hrs
Maintain dose250 mg/each bag2L
#
@ Cefazolin sodium 1GM/vial
@ Cefazolin sodium 500mg/vial
CeftazidimeFortum
#
Loading dose1000 mg/each bag2Lx 8 hrs
Maintain dose250 mg/each bag2L
#
@ Ceftazidime 1g/vial
@ Ceftazidime 500mg/vial
Loading Dose
(Per liter of dialysate)

Maintain Dose
(Per liter of dialysate)

500mg

125mg

Ceftazidime

500mg

125mg

Cefepime

500mg

125mg

Amoxicillin

250 to 500mg

50mg

Ampicillin

None

125mg

Oxacillin

None

125mg

Nafcillin

None

125mg

Penicillin G

50,000 units

25,000 units

Vancomycin

1g

25mg

Teicoplanin

400mg

20mg

Aztreonam

1g

250mg

Ciprofloxacin

50mg

25mg

Daptomycin

100mg

20mg

None

Oral: 200 to 300mg

Cephalosporins Cefazolin

Penicillins

Others

Linezolid

ONCE daily
Combinations

Unasyn

1g

100mg

Tienem

250mg

50mg

67

=====================================================================================

Acute Renal Failure

RIFLE

AKIN

KDIGO

RRisk

Cr > 50%7

Cr > 50%48

Cr > 50%7

Stage 1

U.O. < 0.5 ml/kg/hr for > 6 hrs

Cr > 0.3 mg/dL48 Cr > 0.3 mg/dL48


U.O. < 0.5 ml/kg/hr for > 6 hrs

U.O. < 0.5 ml/kg/hr for > 6 hrs

IInjury

Cr > 100%7

Cr > 100%48

Cr > 100%7

Stage 2

U.O. < 0.5 ml/kg/hr for > 12 hrs

U.O. < 0.5 ml/kg/hr for > 12 hrs

U.O. < 0.5 ml/kg/hr for > 12 hrs

FFailure

Cr > 200%7

Cr > 200%48

Cr > 200%7

Stage 3

U.O. < 0.3 ml/kg/hr for > 12 hrs

U.O. < 0.3 ml/kg/hr for > 12 hrs

U.O. < 0.3 ml/kg/hr for > 12 hrs

Anuria for > 12 hrs

Anuria for > 12 hrs

Anuria for > 12 hrs

LLoss

Need for RRT for > 4 weeks

EEnd-stage

Need for RRT for > 3 months

------------------------------------------------------------------------------------------------------------------------------------------

GFR
1Estimated GFRCockcroft-Gault formula140 - Agex BW / 72 x PCr x 0.85
2CCr = UCr x 24h / PCr x 1440
3MDRD-Simplify GFR
- 186 x PCr - 1.154 x Age - 0.203
- 186 x PCr - 1.154 x Age - 0.203 x 0.742
------------------------------------------------------------------------------------------------------------------------------------------

Pre-renal55%
#
#
-

Septic shock
Dehydration
Heart failure
Hepatorenal syndrome
NSAID ACEi/ARB GFR

68

Intrinsic renal40%
#
- RPGN
- ATN
- AIN

#
Diagnostic Index

Pre-renal

Intrinsic renal

Spot

FENa

<1

>1

urine

UNa

<20

>40

FEUrea

<35

>55

U/P Cr ratio

>40

<20

UOsm

>500

<350

Serum

BUN/Cr ratio

>20

10~15

U/A

Urine specific gravity

>1.020

~1.010

Urinary sediment

Transparent hyaline
casts

Pigmented granular muddy brown casts


RBC or proteintubular damage

# Pre-renal volume Na Urea


Osm (B) = 2 [Na+] + BUN/2.8 + Glu/18 Na Urea

# Intrinsic renal Na Urea


Post-renal5%
# Urinary obstruction
- Bladder neckBPHprostate cancerAnticholinergics
- UreterLymphadenopathyRetroperitoneal fibrosis
69

=====================================================================================

Chronic Renal Failure

1
2
3 CKD
- DM nephropathy
- Amyloidosis
- Polykidney diseasePKD
- Renal vein thrombosis
-
------------------------------------------------------------------------------------------------------------------------------------------

CKD

120
0

Stage

GFR

Stage 1

>90

comorbid condition

Stage 2

60~90

Stage 3

30~60

Stage 4

15~30

renal replacement therapy

Stage 5

<15 or

Stage 5

15

Stage 1
Stage 4

90
Stage 2

30

Stage 3

60
------------------------------------------------------------------------------------------------------------------------------------------

CKD
1
2
3Chronic glomerulonephritisCGN
4Chronic interstitial nephritisCIN
------------------------------------------------------------------------------------------------------------------------------------------

24
# Nitrogen Nitrogen intake = Urinary nitrogen excretion
# Urinary nitrogen excretion = Urine urea nitrogen + Nonurea nitrogen
Nonurea nitrogen 30mg/kg/day Nitrogen Protein
6.25 Estimated protein intake = 6.25 (Urine urea nitrogen + Nonurea nitrogen)
5 g/day 1 g/day
# 60 Urine urea nitrogen = 8. 2 = 3.5 g/day
Estimated protein intake = 6.25 (8.2 + 1.8) = 62.5 g/day
70

------------------------------------------------------------------------------------------------------------------------------------------

CKD

# <40g/day<40mEq/day<3g/day

# EPO

# D2 D3
-
- SevelamerRenagelLanthanum
- PTH Oral ergocalciferolD2
- PTH CalcitriolD3

# Sodium bicarbonate CKD

# CKD ACEi/ARB
- DM < 130/80 mmHg
- DM + < 125/75 mmHg

# DM CCr<10ml/min DM CCr<15ml/min

1Folic acid
-
- 1# QD
2Vitamin B complexHi-Beston
-
- 1# QD~TID
3Calcium carbonate
-
-
- 1# TIDCC
- 2# TID AC CC
4EPO
-
a. Cr > 6
b. Hct<28<36
- 20000u 5000u QW 2000u TIW
5Sennoside
-
71

-------------------------------------------------------------------------------------------------------------------------------------CKD
CKD Hepatic encephalopathy
BUN Low protein diet HE
progressionGuidelineCKD 0.8 g/kg/dayCKD
Hyperkalemia CKD Fluid overload

DietLow protein 40g/dayLow K 40mEq/dayLow salt 3g/dayWater restriction 1500 ml/day


-------------------------------------------------------------------------------------------------------------------------------------
BUN Guideline
1.3 g/kg/day

DietLow protein 60g/day


-------------------------------------------------------------------------------------------------------------------------------------AKI
AKI CKD
-------------------------------------------------------------------------------------------------------------------------------------Fluid overload
I/O positive
fluid
DietLow salt 3g/dayWater restriction 1500ml/day1000ml/day
-------------------------------------------------------------------------------------------------------------------------------------

DietLow salt 3g/day


-------------------------------------------------------------------------------------------------------------------------------------
DM 30 kcal/kg
DietDM diet xxx kcal/day
-------------------------------------------------------------------------------------------------------------------------------------Compensated liver cirrhosis
compensated decompensatedCompensated
Albumin
Nutrition
GuidelineCompensated liver cirrhosisNutrition 35~40 kcal/dayProtein 1.2~1.5 g/kg/day
72

DietLow salt 3g/dayWater restriction 1500 ml/day


-------------------------------------------------------------------------------------------------------------------------------------Decompensated liver cirrhosis
Decompensated Hepatic encephalopathy HE progression
Urea Urea cycle Ammonia Hyperammonemia
HE
GuidelineDecompensated liver cirrhosisProtein 0.6 g/kg/day

Branched chain amino acidBACC


LeucineIsoleucine
Valine HE

DietLow protein 40g/dayLow salt 3g/dayWater restriction 1500 ml/day

-------------------------------------------------------------------------------------------------------------------------------------
DM 1ml 1
=

-------------------------------------------------------------------------------------------------------------------------------------
1ml 1
-------------------------------------------------------------------------------------------------------------------------------------&
1ml 2

-------------------------------------------------------------------------------------------------------------------------------------&

-------------------------------------------------------------------------------------------------------------------------------------
1ml 1
-------------------------------------------------------------------------------------------------------------------------------------
diet

73

=====================================================================================

Glomerular disease

1GlomerulonephritisGN
-
a. Acute GN
b. Rapid progressive GNRPGNCrescent formation
c. Chronic GN
- U/ADysmorphic RBCRBC castWBC cast
-
2Nephrotic syndrome
-
-
a. Proteinuria> 3.5 g/d
b. Hypoalbuminemia< 3.5 mg/dL
c. Edema
d. Hypercholesteralemia
e. Hypercoagulable status

24 ?
-5

Total protein (U) x 24 x 10 = 24


mg/dL

ml

g/day

Total protein (U) = 333mg/dL


24 = 1500ml
-5

24 = 333 x 1500 x 10 = 5g/day

------------------------------------------------------------------------------------------------------------------------------------------

Nephrotic Syndrome
Minimal Change DiseaseMCD
-
a. Lipoid nephrosis
b. Nil disease
- 80%
-
a. idiopathic
b. NSAIDRifampinHodgkins disease
-
a.
b. /
effacement/fusion of podocyte foot process
c. Heparan sulfate proteoglycan
Albumin
-
a. Prednisolone1mg/kg
b. CyclosporinCyclophosphamideMycophenolate mofetil
74

Membranous NephropathyMGN
-
- 30~50 = 21
-
a. idiopathic
b. HBVSLERALupus nephritis Class VNSAID

-
a. subepithelium
b. /spike & dome appearance
c.
Diabetic Nephropathy
- CKD
-

Stage 1

GFR 20~40%

Hyperfiltration stage
Stage 2
Silent stage

5~15

Stage 3

24 30~300 mg

Microalbuminuria stage
Incipient nephropathy

10

UACR30~300 mg/g

Stage 4

24 > 300 mg
15

GFR 10 ml/min
UACR> 300 mg/g

Gross proteinuria
Overt nephropathy

Stage 5
ESRD

7 25

-
a. Kimmelstiel-Wilson Nodular Sclerosis
b.
c. hyalinization
d.
75

-
a.
- DM < 130/80 mmHg
- DM + < 125/75 mmHg
b. ACEi/ARB
-

UACRUrine Albumin-Creatinine Ratio


# UACR = UAlb / UCr
mg/dLg/dL

# 1g Creatinine UACR = Albumin 24


# UACR30~300 mg/g Stage 3 DM nephropathyMicroalbuminuria
# UACR> 300 mg/g Stage 4 DM nephropathyGross proteinuria
Focal Segmental GlomerulosclerosisFSGS
-
a. idiopathic
b. HIVHeroin
-
------------------------------------------------------------------------------------------------------------------------------------------

Glomerulonephritis
Post-Streptococcal GlomerulonephritisPSGN
- 2~6
- A
- sub-epithelium
- ASLO (+)
- C3
- &
Goodpastures Syndrome
- 5~40 = 61
-
- Anti-GBM disease

Anti-GBM antibody

Goodpastures syndrome

Anti-GBM disease

- + Cyclophosphamide + Plasmapheresis
76

Hereditary Nephritis
- Alports syndrome
- Triad + +
Rapid Progressive GlomerulonephritisRPGN
- Crescentic glomerulonephritis
- Crescent formation
-

Type I

Goodpastures syndrome

Type II

Lupus nephritisPSGNH-S purpuraCryoglobulinemia

Type III

Pauci-immune
ANCA vasculitisWegeners granulomatosisMicroscopic polyarteritis nodosa
Churg-Strauss syndrome

------------------------------------------------------------------------------------------------------------------------------------------

+
Lupus Nephritis
- WHO
- Class Irare
- Class II20%mesengium
- Class III25%10~50%Focal GN
- Class IV40%>50%Diffuse GN
- Class V15%Secondary MGN
-
- Class IImesengium
- Class IIIIVsubendotheliumWire-loop
- Class Vsubepithelium
- ANA (+)Anti-dsDNA (+)
- C3

77

Membranoproliferative GlomerulonephritisMPGN
-
- Type I
- C3subendothelium
Tram-track
- C3C4
- Type II
- C3IntramembranousDense deposit
- C3C4
- C3 nephritic factor (+) = Auto-antibody to C3 convertase = C3 convertase
IgA IgA Nephropathy
- Burgers disease
-
- 1~3
- C3
-
- 1/3 20
Henoch-Schonlein H-S Purpura
- Anaphylactoid purpura
- IgA nephropathy + purpura
- C3
Cryoglobulinemia
- Cryoprecipitate (+)
- C3
- Anti-HCV Ab (+)
ANCA Vasculitis
- RPGN Type III
-

ANCA

ANCA (+)

Wegeners granulomatosis

80%

90%

c-ANCA

90%

Microscopic polyarteritis nodosa

90%

50%

p-ANCA

70%

Churg-Strauss syndrome

45%

70%

p-ANCA

50%

- + Cyclophosphamide +/- Plasmapheresis

78

=====================================================================================

Tubular disease
Acute Tubular NecrosisATN
-
a. Ischemia
-
b. Nephrotoxin
- NSAIDAminoglycosideCisplatinAmphotericinCyclosporin
-
- MyoglobinHemoglobin
- Ig light chainmultiple myeloma
- CCl4Chloroform
- HgPbAs
Contrast-Induced NephropathyCIN
-
-
a.
b.
c.
- 24 3~5 7~10
-
- non-ionic
- HydrationN/S half saline
- Acetylcysteine 2# BID
- Sodium bicarbonate
- MetforminNSAID

79

=====================================================================================

Interstitial disease
Acute Interstitial NephritisAIN
-
a. AllergySulfa drugs-lactamNSAIDPPI
b. InfectionAcute pyelonephritisLegionella
c. InfiltrativeLymphomaLeukemiaSarcoidosis
d. AutoimmuneSjogrens syndromeSLE
- TriadFever + Rash + Eosinophilia 5~10
- U/AWBC cast
Analgesic Nephropathy
- PhenacetinAspirin Caffeine
-
- Papillary necrosis
- Chronic interstitial nephritis
- Urothelial malignancy
Chinese Herbs Nephropathy
- Aristolochic acid
-
-
-

80

EKG-1
CGMH R3

Part-1

------------------------------------------------------------------------------------------------------------------------------------------

#
1Pacemaker cell
2Electrical conducting cell
3Myocardial cell

81

# Action potential

------------------------------------------------------------------------------------------------------------------------------------------

# 0.04 0.2
# 0.1 mV
mV

1.0 mV
0.5 mV
s
0.2

0.2

------------------------------------------------------------------------------------------------------------------------------------------

P
82

QRS

83

QRS
# Q
#
#
#
#

R
R'
S
QS

QRS

RS

RSR

QR

QS

# Segment
# Interval +

QRS
ST

PR

PR QRS
QT
84

------------------------------------------------------------------------------------------------------------------------------------------

#
#
#

------------------------------------------------------------------------------------------------------------------------------------------

#
#
#

85

------------------------------------------------------------------------------------------------------------------------------------------

# 0
# 60
# 120
# AVL -30
# AVR -150
# AVF 90

AVR

AVL

III

II

AVF

------------------------------------------------------------------------------------------------------------------------------------------

# V1
# V2
# V3 V2 V4
# V4
# V5 V4 V6
# V6

V6

V5
V4
V1

V2
86

V3

------------------------------------------------------------------------------------------------------------------------------------------

#
#
#
#

V1V2V3V4
IAVLV5V6
IIIIIAVF
AVR

------------------------------------------------------------------------------------------------------------------------------------------

P
#
# IAVLV5V6IIAVF
# IIIV1
# II P
# AVR P
# V2V3V4

PR
#
# 3~5 0.12~0.20
PR
#

PR

PR

87

Q
#
# IAVLV5V6
# IIIIIAVFV3V4

QRS
#
# IAVLV5V6IIIIIAVF R
# AVRV1 S
# R R wave progression V1 R V5 R V6
V5 Transition zone V3~V4

R wave progression
# CWR & CCWR
- CWRClockwise rotationTransition zone V5~V6
- CCWRCounter-clockwise rotationTransition zone V1~V2

88

QRS
#
# 1.5~2.5 0.06~0.1

QRS
ST
#

ST
T
#
# R T

R T
QT
#
# QT QT
# QT RR
# QT prolongQT interval > 50% RR interval
# QTc = QT /RR

QT
89

=====================================================================================

Part-2

#
AVF
- 90o

- 90o

180o

0o

180o

0o

90o

90o

AVF
#
QRS QRS
30 -150 AVF
30
- 90o
- 150o

180o

0o

30o

120o

90o

III
AVF

90

#
- Right axis deviationRAD90 ~180
- Left axis deviationLAD0 ~-90
- Extreme right axis deviationERAD-90 ~180
- 90o

LAD

ERAD
180o

0o

Normal
Axis

RAD

90o
#

------------------------------------------------------------------------------------------------------------------------------------------

RAE
# P IIIIIAVF 2.5
# P
#

Lead II

91

------------------------------------------------------------------------------------------------------------------------------------------

LAE
# P V1 1 1

Lead V1
------------------------------------------------------------------------------------------------------------------------------------------

RVH
#
- QRS
#
- V1 R S
- V6 S R

92

------------------------------------------------------------------------------------------------------------------------------------------

LVH
#
-V5 V6 R V1 V2 S 35
- V5 R 26
- V6 R 18
- V6 R V5 R
@
#
- AVL R 13
- AVF R 21
- R 14
- R S 25
@

93

------------------------------------------------------------------------------------------------------------------------------------------

# Secondary repolarization abnormalities


- ST
- T
#
# AVL

T
1
2
3RBBB & LBBB
4

94

=====================================================================================

Part-3
AV Block
First Degree AV Block
# PR 5

Second Degree AV Block


Mobitz Type IWenckebach Block
# PR P QRS

Mobitz Type II
# PR QRS

Third Degree AV Block


# AV Dissociation

95

------------------------------------------------------------------------------------------------------------------------------------------

Bundle Branch Block


RBBB
#
- QRS 0.12
- V1V2 RSR'
- V1V2 ST T
- IAVLV5V6 S

LBBB
#
- QRS 0.12
- IAVLV5V6 R
- IAVLV5V6 ST T
- V1V2 S

96

------------------------------------------------------------------------------------------------------------------------------------------

Hemiblock

#
- R
- S
-

#
- S
- R
-

97

------------------------------------------------------------------------------------------------------------------------------------------

Bifascicular Block
+
#
- QRS 0.12
- V1V2 RSR'
-
+
#
- QRS 0.12
- V1V2 RSR'
-
------------------------------------------------------------------------------------------------------------------------------------------

Blocks That Underachieve


Nonspecific Intraventricular Conduction Delay
#
- QRS 0.1
Incomplete Bundle Branch Block
#
- QRS 0.1~0.12
------------------------------------------------------------------------------------------------------------------------------------------

Pacemaker
#
-
- Mobitz type II
- Sick sinus syndrome
-
-

98

=====================================================================================

Part-4

# Accessory pathway
------------------------------------------------------------------------------------------------------------------------------------------

WPW Wolff-Parkinson-White Syndrome


# Kent Bundle
#
- PR 0.12
- QRS 0.1
- Delta
Slow
Pathway

Delta
Wave

Kent
Bundle
Fast
Pathway

------------------------------------------------------------------------------------------------------------------------------------------

LGL Lown-Ganong-Levine Syndrome


# James fiber
#
- PR 0.12
- QRS
- Delta

James
Fiber

99

------------------------------------------------------------------------------------------------------------------------------------------

# WPW PSVTAf
WPW + PSVT
#
1Orthodromic AVRT slow pathway Short RP interval QRS
2Antidromic AVRT fast pathway Long RP interval QRS VT

WPW + Af or AF
# Atrial fibrillationAf 20% WPW syndrome
# Atrial flutterAF 7% WPW syndrome
# 300
Vf

100

=====================================================================================

Part-5

# Diffuse peaked T waves


PR prolong P QRS widening T Sine wave pattern Vf or PEA
# Vf cardiac arrest
#

Evolutional EKG Change

Peaked T wave

PR prolong
P wave

QRS widening

Sine wave pattern

101


# ST T U
# U T U

U wave

# QT interval

# QT interval Torsades de pointes


# QT interval Torsades de pointes

------------------------------------------------------------------------------------------------------------------------------------------

#
-
- J waveJ Osborne wave ST
- Af

J wave
Osborne wave

102

------------------------------------------------------------------------------------------------------------------------------------------

1Therapeutic Level
# Digitalis Effect
# ST T

#
- ST

2Toxic Level
# Digitalis Intoxication
# ErythromycinTetracyclineVerapamilAmiodaroneSpironolactone

#
- Sinus arrestSinus exit block
-
- Paroxysmal Atrial Tachycardia, PAT
PVCAfAF
- PAT
21
QT
# QT
- Class Ia QuinidineProcanamideDisopyramide
- Class III AmiodaroneSotalolDofetilide
- Macrolide ErythromycinClarithromycinAzithromycin
- Quinolone CiprofloxacinLevofloxacinMoxifloxacinGemifloxacin
- TCACitalopramSSRI
- ThioridazineChlorpromazineHaloperidolPhenothiazine
- Arsenic trioxideTacrolimusIndapamide
Domperidone
# QT
# QT QTc 500ms2.5 QTc = QT /RR
103

------------------------------------------------------------------------------------------------------------------------------------------

Acute Pulmonary Embolism


#
- Non-specific ST-T change 50%
- Sinus tachycardia
- S1Q3T3 15~25%
- S
- Q
- T
- RBBB
- V1~V3 T
-

COPD
#
- Lung volume
- Lung volume
P
- R Poor R wave progression

104

------------------------------------------------------------------------------------------------------------------------------------------

Pericarditis
#
- ST T
- Pericardial effusion
- Pericardial effusion
Electrical alternans
QRS
#
- ST T
- T ST T ST

- Q
- PR
Hypertrophic Obstructive CardiomyopathyHOCM
#
- IAVLV5V6IIIIIAVFQ
Myocarditis
#
-
------------------------------------------------------------------------------------------------------------------------------------------

#
- T U
------------------------------------------------------------------------------------------------------------------------------------------

#
- Sinus bradycardia
- Mobitz type I
- Non-specific ST-T change ST T
-
- IRBBB
- Multifocal Atrial Tachycardia, MAT
105

EKG-2
CGMH R3

Part-6

------------------------------------------------------------------------------------------------------------------------------------------

(Angina

106

------------------------------------------------------------------------------------------------------------------------------------------

(Acute Coronary Syndrome

(NSTEMI& (STEMI

107

------------------------------------------------------------------------------------------------------------------------------------------

(
1
2
3
------------------------------------------------------------------------------------------------------------------------------------------

Onset

Peak

Decline

Troponin-I

4~6h

24h

7 days

CK-MB

4~6h

18h

2 days

Trop-I

CK-MB

6
108

------------------------------------------------------------------------------------------------------------------------------------------

(Evolutional EKG Change

T
# 0~4 T Peaked THyperacute TT
T
# T Ischemia
T T
# T
# Pseudo-normalization T T

109

T
1
2
3RBBB & LBBB
4

Non-specific ST-T change


- T
- T T R 1/10
ST
# ST Injury
# ST
# ST 3~4
# ST Early repolarization
J J point elevation
@
- ST T ST
-
@
- T ST
-

110

Q
# Q NecrosisQ
#
# Q 3~6
12 Primary PCI
# Q
# Q
1 Q
- IAVLV5V6IIIIIAVF Q
2 Q
- Q Pathologic Q wave Q Significant Q wave
-
- Q
- Q R
- AVR Q AVR Q

Reciprocal Change
#
- R Q
- ST T ST T
#

111

------------------------------------------------------------------------------------------------------------------------------------------

# RCA
# IIIIIAVF

112


# LCX
# IAVLV5V6

# LAD
# V1~V4
# V1~V4 ST elevationR
Q
# LAD

113


# RCA
#
# V1ST T R R > S
# RCA

------------------------------------------------------------------------------------------------------------------------------------------

- Reperfusion
Indication
# 30 ST Reciprocal change
# New LBBB

Thrombolytic Therapyt-PA

< 6
Door-to-Needle30

Primary PCI

< 12
Door-to-balloon90

Coronary revascularization

114


- t-PATissue plasminogen activator
- PCIPercutaneous coronary intervention
- CABGCoronary artery bypass graft
- PTCAPercutaneous transluminal coronary angioplasty
- BMSBare metal stent
- DESDrug-eluting stent
CABG PCI
- Left main disease
- 3VD + LVEF < 50%
- 2VD + LAD + LVEF < 50%
- DM
CATH
- STEMI
- NSTEMI with
- Hemodynamic unstable or cardiogenic shock
- Severe LV dysfunction
- VT/Vf
- Angina persisted despite medication treatment
- New MR or VSD
Killip Classification

Motality

Killip I

MI

0~5%

Killip II

MI + < 1/2 lung field crackles

10~20%

Killip III

MI + > 1/2 lung field crackles

35~45%

Killip IV

MI + Cardiogenic shock

60~80%

TIMI Risk Score

History

65

3 CAD

CADStenosis > 50%

7 Aspirin

ST

@ CATH
@ TIMI risk score unstable angina NSTEMI

115

------------------------------------------------------------------------------------------------------------------------------------------

ACS

Dual Anti-platelet TherapyDAPT


#
# cath stent
# 1+2 1+3
1Aspirin
- Loading300mg STAT
- Maintain dose100mg QD
2Clopidogrel
- Loading dose300mg STAT
- Maintain dose75mg QD
3Ticargrelor
- Loading dose90mg STAT
- Maintain dose90mg BID
#
@ Aspirin 100mg/cap
@ Clopidogrel 75mg/tab (Plavix, Sanofi)
@ Ticargrelor 90mg/tab
Heparinization
#
1Heparin
#
- Loading dose60u/kg
- Maintain dose12u/kg/hr
116

# Heparin line
- Heparin 25000u in N/S 500ml run 16 ml/hr, 2 ml/hr to keep APTT 1.5~2.0 66
- Heparin 25000u in N/S 500ml run 20 ml/hr, 2 ml/hr to keep APTT 1.5~2.0 83
- Heparin 25000u in N/S 500ml run 24 ml/hr, 2 ml/hr to keep APTT 1.5~2.0 100
# Check APTT Q6H Q12H QD
#
@ Heparin sodium 25000u/5ml/vial
2Enoxaparin
# 1mg/kg
#
- Q12H
- CCr 30~50 x 0.7Q12H
- CCr < 30 x 0.7QD
# > 65 x 0.7
# 80 60 CCr = 20 30mg QD
#
@ Enoxaparin sodium 6000iu/60mg/0.6ml (prefilled syringe)
Nitrite + -blocker CCBNon-DHP
#
1Nitrite
#
# NTG continued IV dripNTG line
# NTG line
- For run 3~6 ml/hr
- For run 10~20 ml/hr
#
@ NTG 0.6mg/tab, 25s/package
@ NTG 0.2mg/ml in 5% dextrose 250ml50mg/bot NTG line
0.2mg/ml
@ NTG 5mg/10ml/amp10PC in N/S 500ml0.1mg/ml
2-blocker
#
# Bisoprolol
#
@ Bisoprolol 5mg/tab (Concor, Merck)CAD 5mg
@ Bisoprolol hemifumarate 1.25mg/tab
CHF 1.25mg 5mg
117

3CCBNon-DHP
# Non-DHP CCB Diltiazem Non-Q infarction with good LV function
Verapamil
# STEMI Non-DHP CCB -blocker
#
@ Diltiazem HCl 30mg/tab (Herbesser, Tanabe)
@ Diltiazem long acting 90mg/tab (Cardizem)
Statin
#
#
@ Atovastatin 10mg/tab (Lipitor, Pfizer)
@ Atovastatin 40mg/tab (Lipitor, Pfizer)
@ Rosuvastatin 10mg/tab (Crestor, AstraZeneca)
@ Rosuvastatin 5mg/tab (Crestor, AstraZeneca)
@ SIMVASTATIN 40mg/tab (Simvahexal, Sandoz)
@ Pitavastatin 2mg/tab (Livalo,KOWA)
@ PITAVASTATIN 2mg/tab (Pitator,)
ACEi/ARB
# Remodeling
#
ACEi
@ Captopril 25mg/tab 4~6hr
@ Enalapril 5mg/tab
@ Enalapril 20mg/tab
@ Fosinopril sodium 10mg/tab
@ Ramipril 10mg/tab (Tritace, Sanofi)
ARB
@ Losartan potassium 50mg/tab
@ Valsartan 160mg/f.c tab
@ Candesartan 8mg/tab
@ Irbesartan 300mg/tab (Aprovel, Sanofi)
@ IRBESARTAN 300mg/tab (IRBESARTAN, Sandoz)
@ Telmisartan 80mg/tab
@ Olmesartan 20mg/tab
@ Azilsartan medoxomil 40mg/tab

118

------------------------------------------------------------------------------------------------------------------------------------------

Arrhythmia
1VT/Vf
- PrimaryIschemic induced
- SecondaryDue to CHF
2PVC
3AIVRAccelerated idioventricular rhythm
- reperfusion
4Supra-ventricular tachycardia
5AV block
Acute MR
# Due to papillary muscle dysfunction
Ventricular septal rupture
# Left-to-right shunt
Apical aneurysm formation
# ST

119

EKG-3
CGMH R3

Part-7

#
- 300 R
- 1500 R

# R 0.2 5 300
# R 0.4 2.5 150
#
- 100
- 75
- 60
- 50
------------------------------------------------------------------------------------------------------------------------------------------

Arrhythmia
# Normal sinus rhythm
#
# HIS DEBS

Hypoxia

COPD

Ischemia

Sympathetic stimulation

Drug

Electrolyte imbalance

Bradycardia

Sick sinus syndromeBrady-tachy syndrome

Stretch

120

------------------------------------------------------------------------------------------------------------------------------------------

1
2Ectopic Rhythm
3Reentrant Rhythm
4
5
------------------------------------------------------------------------------------------------------------------------------------------

Sinus Tachycardia
# HR > 100

Sinus Bradycardia
# HR < 60

Sinus Arrhythmia
#
-
-

121

Sinus Arrest
# Asystole
# Escape rhythm

P P

QRS
Sinus Exit Block
# Sinus arrest

Sinus exit block

Sinus arrest

122

------------------------------------------------------------------------------------------------------------------------------------------

Ectopic Rhythm
#
#

123

------------------------------------------------------------------------------------------------------------------------------------------

Reentrant Rhythm
# A B
# B
A
B B
# Reentry loop

# PSVTAF

AFast Pathway
BSlow Pathway

124

------------------------------------------------------------------------------------------------------------------------------------------

125

------------------------------------------------------------------------------------------------------------------------------------------

Supraventricular Arrhythmia
#
# QRS
Atrial Premature BeatPremature Atrial ContractionPAC
# P
#

Junctional Premature Beat


# P
#

126

Paroxysmal Supraventricular TachycardiaPSVT


#
150~250

Reentrant loopAVNRT
P IIIIIAVFV1V2
QRS T
# P
- Pseudo Rwave in V1V2
- Pseudo S wave in IIIIIAVF
#
1AVNRTAV nodal reentrant tachycardia AV node
2AVRTAV reentrant tachycardia
#
#
#
#

# AVNRT diffuse ST depression


- Typical AVNRTSlow-Fast type Slow pathwayShort RP interval
- Atypical AVNRTFast-Slow type Fast pathwayLong RP interval

127

# AVRT WPW syndrome


Reentrant loop AVNRT 200~300
- Orthodromic AVRT Slow pathway Short RP interval QRS
- Antidromic AVRT Fast pathway Long RP interval QRS VT

#
1Carotid Massage
- Carotid sinus

- EKG monitor
2Adenosine61212
- SA node AV node
-
- 6mg IV push3 N/S
- 3 12mg
- 3 12mg
3Unstable sign 50~100
4Radiofrequency Ablation
128

PSVT
PSVT Reentrant loop
1AVNRT loop AV node
2AVRT loop WPW syndrome
AVNRT AVRTloop slow pathway fast
pathway
--------------------------------------------------------------------------------------------------------------------------------------AVNRT
AVNRT slow pathway fast pathway QRS loop
P loop
P
slow pathway QRS RP intervalQRS
P fast pathway QRS
RP interval
--------------------------------------------------------------------------------------------------------------------------------------AVRT
AVRT slow pathway QRS
fast
pathway VT QRS
P
RP interval AVNRT slow pathway
loop P RP interval
fast pathway
loop P RP interval

129

Atrial FlutterAF
# IIIIIAVF
#
#
#
#
#
#
#

250~350
P
Af
AV Block 21
Carotid Massage 31 51
Rate controlAnticoagulant Af
Unstable sign 50~100

41 Atrial Flutter

Carotid massage 31 51
Carotid massage

130

Attial FibrillationAf
#
# 350~500 AF

#
Irregularly irregular
#
- P P
- QRS
# Carotid Massage

131

Af
1Thromboembolic prevention
- CHADS2 score
- CCongestive heart failure1
- HHypertension1
- AAge > 751
- DDM1
- S2Prior stroke or TIA2
@
- 0 Low risk Aspirin
- 1~2 Moderate risk Aspirin or Warfarin Prior stroke or TIA Warfarin
- 3~6 High risk Warfarin
- CHADS2-VAS score
- risk factorVascular disease1 Age 65~741
Female sex1
- Age > 75 2
- low risk group

- ACC/AHA 2006 Guideline


- Aspirin
- <75
- Warfarin
- >75
- >65 DMCADCHF
-
EF<35
2Rate control
- -blockerPropranolol
Non-DHP CCBDiltiazemVerapamil
- Digoxin
- Propranolol Non-DHP CCB Digoxin
- AfRVR + Amiodarone Digoxin -blocker CCB
3Rhythm control
- Unstable sign 200 120~200
- Af < 48
- Af > 48 Warfarin INR 2~3 3
Warfarin 4
- IcIII
- IcPropafenoneFlecainidefor HTN
- IIISotalolfor
- IIIAmiodaroneDofetilidefor
- Paroxysmal Af
- Persistent Af
132

Multifocal Atrial TachycardiaMAT


#
# 100~200 100
# Wandering atrial pacemaker
# COPD Theophylline

# Carotid Massage
#
- P
- PR
-
# Rate control-blocker Non-DHP CCB

133

Paroxysmal Atrial TachycardiaPAT


#
#
#
#
#
#

100~200

EKG sinus tachycardia


PATPVC
Carotid Massage

134

------------------------------------------------------------------------------------------------------------------------------------------

Ventricular Arrhythmia
#
# QRS
Premature Ventricular ContractionPVC
#
# PVC
#
1Periodic PVC
2Bigeminy PVC
3Trigeminy PVC
4Triplet PVC

Periodic PVC (

Bigeminy (21

Trigeminy (31

Triplet (
135

# PVC VTVf
- PVC
- PVC
- PVC
- R on T PVC T VT
- PVC

Ventricular TachycardiaVT
# PVC
# 120~200
#
1VT associated with structural heart disease
- VT
- Peri-infarctScar reentry monomorphic VT
- Ischemic polymorphic VTVf
- CardiomyopathyArrhythmogenic right ventricular dysplasiaARVD VT
2VT in the absence of structural heart disease
- Brugada syndromeLong-QT syndrome
polymorphic VT
- idiopathic VT right ventricular outflow tractRVOT
LVOT VTfascicular VT

136

#
1 VTMonomorphic VT
- Unstable sign 100
- Amiodarone
- Amiodarone
- Loading dose150mg IVF run 10 mins
- Maintain dose1 mg/min x 6 hrs, then 0.5 mg/min
- Amiodarone
- Loading dose1PC in D5W 50cc run 10 mins
- Maintain dose6PC in D5W 500cc run 33 ml/hr x 6 hrs, then 17 ml/hr
- VTLidocaineIV MexiletinePO
- VTBidirectional VTPhenytoinIV
2 VTPolymorphic VT
- Unstable sign 360 120~200
- Amiodarone
3 VTPulseless VT
- CPR + ACLS 360 120~200

Monomorphic VT

Polymorphic VT
Ventricular FibrillationVf
#
#
- CPR + ACLS 360 120~200

137

VT & SVT

1. wide QRS tachycardia 80% VT


2. wide QRS tachycardia 95% VT
---------------------------------------------------------------------------------------------------------------------------------------

Brugada algorithm
( Precordial lead V1~V6
YES ( Q

1. RS ?

VT

NO ( RS

2. RS ?

> 0.1 (

VT

< 0.1 (
3. AV dissociation?

YES

VT

NO

4. QRS
( VT
RBBB configuration

LBBB configuration

QRS > 0.14s

QRS > 0.16s

V1

V6

(QRS regular Favor VT


138

Capture beat Fusion beat ( Favor VT

Capture beat
(

Fusion beat
(

IAVF ( Favor VT
Favor VT

( Apex VT

( Base VT

139

Accelerated Idioventricular RhythmAIVR


# P QRS
# 50~100 50 Idioventricular Rhythm
#

Torsades De Pointes
# VT QT PVC T
R on T
# VT QRS VT
# MgSO4 1~2g in 5~60

------------------------------------------------------------------------------------------------------------------------------------------

+ Aberrant conduction
# QRS
+ Aberrant conduction
#
- QRSSVT with aberrant conduction
- QRSAf with aberrant conduction

140

141

=====================================================================================

Part-8 ACLS

142

------------------------------------------------------------------------------------------------------------------------------------------

Tachycardia

------------------------------------------------------------------------------------------------------------------------------------------

Bradycardia

143


CGMH R3

Part-1
Anatomy

-
-
-
-
144

(Mitral stenosis X

Mitral Stenosis

Normal

CXR Findings in Mitral stenosis


- LA enlargement (LA border enlargedCarinal angle > 90oDouble contour
- Pulmonary congestion (Butterfly patternBat wingCephalization
- RVH (Boot-shaped
- RA enlargement (RA border enlarged

------------------------------------------------------------------------------------------------------------------------------------------

MCL

2
3
4

PV
AV

RA

PV
AV
MV
TV
RV

LA

3
4

LV

5
MV

TV

6
7

145

------------------------------------------------------------------------------------------------------------------------------------------

Jugular Venous Wave

A
V
C

Y descent

X descent

X descent

Y descent

146

Cannon A Wave

Giant A Wave
V
C

C-V Wave

Y descent

Deep Y descent

X descent

Giant A Wave

Cannon A Wave

C-V Wave

Deep Y descent

(TR

147

------------------------------------------------------------------------------------------------------------------------------------------

Arterial Pulse
Hypokinetic Pulse
# Shock
#
Hyperkinetic Pulse
# AR
#

#
- Bounding pulse
- Water-hammer pulse
- Collapsing pulse
- Corrigans pulse
- Aortic run off
Pulsus Parvus et Tardus
# AS
#

Pulsus Bisferiens
# HOCM (Hypertrophic obstructive cardiomyopathy
# HOCM ( muscle hypertrophy
(

148

Pulsus Alternans (
#
#

Bigeminal Pulse
# PVC
# PVC (

Pulsus Paradoxicus (
# Cardiac tamponade
# Cardiac tamponade ( 10 mmHg
( 10 mmHg
#
- (VR
-
Cardiac tamponade
- (

-
Cardiac tamponade Pulsus paradoxicus
AS & HOCM Valsalva maneuver
Valsalva maneuver venous return LV
1ASmurmur
2HOCMmurmur

149

Valsalva maneuver
Valsalva maneuver venous return ?
venous return
venous return
vena cava chest wall
SVCIVCRARV

transmural pressure
venous return

LA LV filling Frank-Starling Lawstroke volume


cardiac output
Valsalva maneuver venous return LV Valsalva
maneuver rib cage
venous return LV Frank-Starling Lawstroke volume
cardiac output Aorta aortic pressure Phase I

aortic pressure cardiac output Phase II


aortic
pressure Phase III
venous return cardiac output
aortic pressure Phase IV
Heart rate
baroreceptor reflex

Valsalva maneuver venous return LV HOCM


murmur AS murmur

150

------------------------------------------------------------------------------------------------------------------------------------------

PMI
# MCL Localize 2~3 cm
# BriefTappingNot forceful
# Early systole
PMI in LV Pressure Overload
# MCL Localize 2~3 cm
# Pulpable S4
# Sustained thrust during systole
PMI in LV Volume Overload
# Diffuse 3~5 cm
# Pulpable S3
# Hyperdynamic with quick thrust followed by retraction
------------------------------------------------------------------------------------------------------------------------------------------

Left Parasternal Heave or Lift


# RV
# outward lift Heave
1RV Pressure Overload PSTOFIPH
2RV Volume Overload ASDPRTR
3Severe MR
4Single Ventricle
------------------------------------------------------------------------------------------------------------------------------------------

Heart Sound

151

S1

MV TV

Apex
MV

AV PV

S2

AVPV

S3

Rapid Ventricular Filling

AR

Volume Overload

MR

LV compliance

VSD

Hyperdynamic Heart
@
@ M mode E
S4

Atrial Contraction

LVH

Pressure Overload

LV compliance
@ M mode A
Aortic Election Click

Valvular AS

Apex

Aortic root dilatation

MV
AV

Pulmonic Ejection Click

Valvular PS

PV

Mid-systolic Click

Apex
MV

Opening Snap

MV

Apex

MS

MV

RHD

# S2 A2P2
#
- VR A2P2
- LVA2P2
Wide Splitting S2
# Pulmonary Valve
# ASDPSCRBBBType ALeftpre-excitation
@ MR Wide Splitting S2 Aortic Valve
Paradoxical Splitting S2
# Aortic Valve
# AnginaSevere ASCLBBBType BRightpre-excitation
152

153

------------------------------------------------------------------------------------------------------------------------------------------

Heart Murmur

Systolic Murmur

Systolic Ejection Murmur

ASPS

Pan-systolic MurmurHolosystolic Murmur

MRTRVSD

Diastolic Murmur

Early Diastolic MurmurDiastolic Blowing Murmur

ARPR

Mid-Diastolic MurmurDiastolic Rumbling Murmur

MSTS
AR Austin flint murmur
MSTS

Late Diastolic Murmur

Continuous Murmur

Continuous Murmur

PDA

154

=====================================================================================

Part-2
2D Mode ( Cardiac Window

Para-Sternal Approach
Para-sternal long axis view

Para-sternal short axis view

Apical Approach
Apical four chamber view

Apical long axis view

155

Sub-Costal Approach
Subcostal short axis view

Sagittal bicaval view

Supra-Sternal Approach

Long Axis View

Short Axis View

------------------------------------------------------------------------------------------------------------------------------------------

M mode

156

------------------------------------------------------------------------------------------------------------------------------------------

Y.C.Chen 2012.02.23
157

=====================================================================================

Part-3
Mitral StenosisMS

1 MRMV orifice fish mouth


2
3SLERA
4Severe mitral annular calcification

4~6 cm2

Mild

1.5~2.0 cm2

Moderate

1.0~1.5 cm2

Severe

< 1.0 cm2

1Mid-diastolic rumbling murmur

1Opening SnapOS

@ MS S2 OS MV
2S1
@ MS S1 MV

#
- -blockerNon-DHP CCB
- Warfarin
1MS with Af
2MS with prior embolic event
3MS with left atrial thrombus
- MS
# Percutaneous mitral balloon valvotomyPMBV
- Moderate to severe MSMVA < 1.5 cm2 PMBVClass I
- LA thrombusModerate to severe MREcho score > 8
# Mitral valve replacementMVR
- PASP > 60 mmHg MVRClass IIa
158

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Mitral RegurgitationMR

1 MR posteromedial papillary muscle


2 MROrganic Myxomatous degeneration
3 MRFunctional DCM

1Pansystolic murmurAxilla

1 S1ARMR
2Wide Splitting S2

#
- Acute MR afterload IV Nitroprusside IABP
- Organic MR ACEi/ARB-blocker
- Functional MR ACEi/ARB-blocker
#
- Severe MRRegurgitation >50%
- + LVEF > 30% / LVESD < 55mm Class I
- + LVEF < 60% / LVESD > 40mm Class I
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Mitral Valve ProlapseMVP

1Marfan syndromeEhlers-Danlos syndromeOsteogenesis imperfecta


2

- Myxomatous degenerationAcid mucopolysaccharidosis

1Mid-systolic Click

12D-EchoSystolic archingDiastolic domingHelmet-shapedBowing


2M mode BucklingHammock

#
- -blocker
159

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Aortic StenosisAS

1/Degenerative/Calcified 70~90
2/Congenital/Bicuspid 60~80
3 AS+AR 30~50

3~4 cm2

Mild

1.5~2.0 cm2

Moderate

1.0~1.5 cm2

Severe

< 1.0 cm2

1Systolic ejection murmurHarsh crescendo-decrescendo


Bilateral carotid

2Gallavardin phenomenon
@ MR

1Pulsus Parvus et Tardus

2Paradoxical Splitting S2

# TriadHeart failurSyncopeAngina

#
- DigoxinDiuretics
- Vasodilator-blocker
#
- Severe ASAVA < 1 cm2Vmax > 4 m/sMean pressure gradient > 40 mmHg
- Class I
- + LVEF < 50% Class I

160

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Aortic RegurgitationAR

1Valvular 2/31/3
2Root

1High-pitchedDiastolic blowing murmur


- Valvular AR
- Root AR

@
2Austin flint murmurLow-pitchedMid-diastolic rumbling murmur

@ MS AR anterior leaflet of mitral valve

1 S1ARMR
2Hyperkinetic pulseBounding pulseWater-hammer pulseCollapsing pulse
Corrigans pulseAortic run off
3De Mussets sign Pulse Head bobbing
4Quinckes sign Pulsating capillary in nail bed, alternating flushing and paling
5Traubes sign Pistal-shot sound over femoral artery
6Duroziezs sign To-and-fro murmur

#
- VasodilatorACEi/ARBCCB
#
- Severe ARRegurgitation >50%
- Class I
- + LVEF < 50% Class I
- + LVEDD > 75mm Class IIa

161