\documentclass[10pt,a4paper]{article}

% Packages
\usepackage{fancyhdr}           % For header and footer
\usepackage{multicol}           % Allows multicols in tables
\usepackage{tabularx}           % Intelligent column widths
\usepackage{tabulary}           % Used in header and footer
\usepackage{hhline}             % Border under tables
\usepackage{graphicx}           % For images
\usepackage{xcolor}             % For hex colours
%\usepackage[utf8x]{inputenc}    % For unicode character support
\usepackage[T1]{fontenc}        % Without this we get weird character replacements
\usepackage{colortbl}           % For coloured tables
\usepackage{setspace}           % For line height
\usepackage{lastpage}           % Needed for total page number
\usepackage{seqsplit}           % Splits long words.
%\usepackage{opensans}          % Can't make this work so far. Shame. Would be lovely.
\usepackage[normalem]{ulem}     % For underlining links
% Most of the following are not required for the majority
% of cheat sheets but are needed for some symbol support.
\usepackage{amsmath}            % Symbols
\usepackage{MnSymbol}           % Symbols
\usepackage{wasysym}            % Symbols
%\usepackage[english,german,french,spanish,italian]{babel}              % Languages

% Document Info
\author{xkissmekatex (kissmekate)}
\pdfinfo{
  /Title (acnp-pulmonary.pdf)
  /Creator (Cheatography)
  /Author (xkissmekatex (kissmekate))
  /Subject (ACNP Pulmonary Cheat Sheet)
}

% Lengths and widths
\addtolength{\textwidth}{6cm}
\addtolength{\textheight}{-1cm}
\addtolength{\hoffset}{-3cm}
\addtolength{\voffset}{-2cm}
\setlength{\tabcolsep}{0.2cm} % Space between columns
\setlength{\headsep}{-12pt} % Reduce space between header and content
\setlength{\headheight}{85pt} % If less, LaTeX automatically increases it
\renewcommand{\footrulewidth}{0pt} % Remove footer line
\renewcommand{\headrulewidth}{0pt} % Remove header line
\renewcommand{\seqinsert}{\ifmmode\allowbreak\else\-\fi} % Hyphens in seqsplit
% This two commands together give roughly
% the right line height in the tables
\renewcommand{\arraystretch}{1.3}
\onehalfspacing

% Commands
\newcommand{\SetRowColor}[1]{\noalign{\gdef\RowColorName{#1}}\rowcolor{\RowColorName}} % Shortcut for row colour
\newcommand{\mymulticolumn}[3]{\multicolumn{#1}{>{\columncolor{\RowColorName}}#2}{#3}} % For coloured multi-cols
\newcolumntype{x}[1]{>{\raggedright}p{#1}} % New column types for ragged-right paragraph columns
\newcommand{\tn}{\tabularnewline} % Required as custom column type in use

% Font and Colours
\definecolor{HeadBackground}{HTML}{333333}
\definecolor{FootBackground}{HTML}{666666}
\definecolor{TextColor}{HTML}{333333}
\definecolor{DarkBackground}{HTML}{FF0DB6}
\definecolor{LightBackground}{HTML}{FFEFFA}
\renewcommand{\familydefault}{\sfdefault}
\color{TextColor}

% Header and Footer
\pagestyle{fancy}
\fancyhead{} % Set header to blank
\fancyfoot{} % Set footer to blank
\fancyhead[L]{
\noindent
\begin{multicols}{3}
\begin{tabulary}{5.8cm}{C}
    \SetRowColor{DarkBackground}
    \vspace{-7pt}
    {\parbox{\dimexpr\textwidth-2\fboxsep\relax}{\noindent
        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
    }
\end{tabulary}
\columnbreak
\begin{tabulary}{11cm}{L}
    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{ACNP Pulmonary Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{xkissmekatex (kissmekate)} via \textcolor{DarkBackground}{\uline{cheatography.com/33594/cs/10533/}}}
\end{tabulary}
\end{multicols}}

\fancyfoot[L]{ \footnotesize
\noindent
\begin{multicols}{3}
\begin{tabulary}{5.8cm}{LL}
  \SetRowColor{FootBackground}
  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}xkissmekatex (kissmekate) \\
  \uline{cheatography.com/kissmekate} \\
  \end{tabulary}
\vfill
\columnbreak
\begin{tabulary}{5.8cm}{L}
  \SetRowColor{FootBackground}
  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 14th January, 2017.\\
   Updated 16th January, 2017.\\
   Page {\thepage} of \pageref{LastPage}.
\end{tabulary}
\vfill
\columnbreak
\begin{tabulary}{5.8cm}{L}
  \SetRowColor{FootBackground}
  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Sponsor}}  \\
  \SetRowColor{white}
  \vspace{-5pt}
  %\includegraphics[width=48px,height=48px]{dave.jpeg}
  Measure your website readability!\\
  www.readability-score.com
\end{tabulary}
\end{multicols}}




\begin{document}
\raggedright
\raggedcolumns

% Set font size to small. Switch to any value
% from this page to resize cheat sheet text:
% www.emerson.emory.edu/services/latex/latex_169.html
\footnotesize % Small font.

\begin{multicols*}{3}

\begin{tabularx}{5.377cm}{x{2.04057 cm} x{2.93643 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Pulmonary Embolism}}  \tn
% Row 0
\SetRowColor{LightBackground}
Pathophysiology & • A thrombus in another area of the body {\bf{embolizes to the pulmonary vasculature via the RV and PA}}. \{\{nl\}\}• Blood flow distal to the embolus is obstructed, causing {\bf{increased PVR, PA pressure, and RV pressure}}. If severe, acute {\bf{cor pulmonale}} can occur. \{\{nl\}\}• Blood flow decreases in some areas, {\bf{dead space}} is created where there is {\bf{ventilation but no perfusion}}. \{\{nl\}\}• {\bf{Hypoxemia and hypercarbia}} occur and drive {\bf{tachypnea}}. \{\{nl\}\}If dead space is large, signs are more overt (SOB). PE and DVT are on a continuum. \tn 
% Row Count 24 (+ 24)
% Row 1
\SetRowColor{white}
Source & • Most PE arise from {\bf{thromboses of deep veins}} of lower extremities above the knee (iliofemoral DVT). \{\{nl\}\}• Can also arise from deep veins of pelvis. \{\{nl\}\}• Calf vein thrombi have a low incidence of embolizing to the lungs, but they can progress into the proximal veins and increase the risk of PE. \{\{nl\}\}• Upper extremity DVT is rare (seen in IVDU). \{\{nl\}\}• {\bf{Fat emboli}} from long bone fractures, amniotic fluid emboli during or after delivery, air emboli (trauma, lines), septic emboli (IVDU), schistosomiasis. \tn 
% Row Count 48 (+ 24)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{2.04057 cm} x{2.93643 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Pulmonary Embolism (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
Sympotms & • Not a reliable indicator of the presence of PE. \{\{nl\}\}• {\bf{Dyspnea (73\%), cough (37\%), pleuritic chest pain (65\%), hemoptysis (13\%)}}. \{\{nl\}\}• Only 1/3 of patients will have signs and symptoms of a DVT. \{\{nl\}\}• Syncope seen in large PE. \tn 
% Row Count 11 (+ 11)
% Row 3
\SetRowColor{white}
Signs & •  {\bf{Tachypnea}} (70\%), rales (51\%), {\bf{tachycardia}} (30\%), S4 (24\%), increased P2 (23\%).\{\{nl\}\}• Shock with rapid circulatory collapse in massive PE. \{\{nl\}\}• Others include low-grade fever, decreased breath sounds, and dullness on percussion. \tn 
% Row Count 22 (+ 11)
% Row 4
\SetRowColor{LightBackground}
Risk Factors for DVT and PE. & • Age\textgreater{}60, {\bf{malignancy}}, prior history, hereditary, {\bf{hyper coagulable states}}, prolonged immobilization, cardiac disease (esp. CHF). obesity, {\bf{nephrotic syndrome}}, major surgery (esp. pelvic or orthopedic), major trauma, pregnancy, and estrogen use. \tn 
% Row Count 34 (+ 12)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{2.04057 cm} x{2.93643 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Pulmonary Embolism (cont)}}  \tn
% Row 5
\SetRowColor{LightBackground}
Prognosis & • PE is usually clinically silent. \{\{nl\}\}• Recurrences are common, which can lead to {\bf{chronic pulmonary HTN and chronic cor pulmonale}}. \{\{nl\}\}• When undiagnosed, mortality approaches 30\%. \{\{nl\}\}• When PE is diagnosed, mortality is 10\% in first 60 minutes. Of those who survive initial event, 30\% will die of recurrent PE if untreated. \{\{nl\}\}• Most are recurrent in the first few hours. \{\{nl\}\}• Treatment with {\bf{anticoagulation}} decreases mortality to 2-8\%. \tn 
% Row Count 21 (+ 21)
% Row 6
\SetRowColor{white}
Diagnosis & • If suspected PE, stabilize with {\bf{IVF and O2}}. \{\{nl\}• \}If PE is likely, {\bf{start anticoagulation before diagnostic tests}}. \{\{nl\}\}• If PE is unlikely, get testing first. \{\{nl\}\}• If the patient has contraindications to anticoagulation, get testing first and then {\bf{consider IVC filter}}. \tn 
% Row Count 34 (+ 13)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Testing}}  \tn
% Row 0
\SetRowColor{LightBackground}
D-Dimer & • {\bf{Specific fibrin degradation product}} whose levels can be elevated in PE or DVT. \{\{nl\}\}• Sensitive (90-98\%). \{\{nl\}\}• If results are normal and clinical suspicion is low, PE is very unlikely. \{\{nl\}\}• {\bf{Specificity is low}}, as it can be {\bf{elevated in MI, CHF, pneumonia, and postop}}. \{\{nl\}\}• Any cause of clot or increased bleeding can elevate D-Dimer. \tn 
% Row Count 16 (+ 16)
% Row 1
\SetRowColor{white}
Venous Duplex Ultrasound & • If positive, {\bf{treat with IV heparin}}. \{\{nl\}\}• False positives will lead to anticoagulation in patients without PE. \{\{nl\}\}• If negative, the test is of very little value and the patient may still have a PE (up to 50\% of patients with PE). \tn 
% Row Count 27 (+ 11)
% Row 2
\SetRowColor{LightBackground}
Echocardiogram & • {\bf{Acute massive PE }}is accompanied by {\bf{RV dilation and failure due to RV outflow obstruction and increased PVR}}. \{\{nl\}\}• The {\bf{dilated RV pushes the septum towards the LV}}, causing further {\bf{decrease in LV preload and CO}}. \{\{nl\}\}• This shows up as  {\bf{dilated RV cavity and hypokinesis of the RV free wall}} with sparing of the apex ({\bf{McConnell's sign}}). \tn 
% Row Count 43 (+ 16)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Testing (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
Helical CT & • {\bf{\textgreater{}90\% sensitivity and good specificity}}. \{\{nl\}\}• Can visualize very small clots (\textgreater{}2mm). Can miss clots in small sub segmental vessels. \{\{nl\}\}• {\bf{Test of choice}}. \{\{nl\}\}• If negative and high clinical probability of PE, there is a 5\% incidence of PE. \{\{nl\}\}• Contraindicated in patients with renal insufficiency because of {\bf{IV contrast.}} \tn 
% Row Count 15 (+ 15)
% Row 4
\SetRowColor{white}
CXR & • Usually normal. {\bf{Atelectasis or pleural effusion}} may be present. \{\{nl\}\}• Mainly useful to exclude competing diagnoses. \{\{nl\}\}• Hampton's hump or Westermark's sign are rarely present \tn 
% Row Count 23 (+ 8)
% Row 5
\SetRowColor{LightBackground}
V/Q Scan & • Important when there is a contraindication to helical CT. \{\{nl\}\}• Results can either be normal, low-probability, \seqsplit{intermediate-probability}, or high-probability. \{\{nl\}\}• A normal V/Q scan rules out PE and no further testing is needed. \{\{nl\}\}• A high probability scan is {\bf{very sensitive for PE}} and indicates treatment with heparin. \{\{nl\}\}• If low or intermediate probability, clinical suspicion determines next step. \{\{nl\}\}• If high, pulmonary angiography is indicated. \tn 
% Row Count 44 (+ 21)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Testing (cont)}}  \tn
% Row 6
\SetRowColor{LightBackground}
Arterial Blood Gas & • Not diagnostic. \{\{nl\}\}• {\bf{PaO2 and PaCO2 are low}} (latter due to hyperventilation) and {\bf{pH is high}}. \{\{nl\}\}• {\bf{Typically respiratory alkalosis}}. \{\{nl\}\}• {\bf{The A-a gradient is usually elevated}}. A normal A-a gradient makes PE less likely but does not exclude it. \tn 
% Row Count 12 (+ 12)
% Row 7
\SetRowColor{white}
Pulmonary Angiography & • {\bf{Gold standard}}. Definitively diagnoses or excludes PE. \{\{nl\}\}• But the test is invasive. {\bf{Contrast is injected into the PE branch after percutaneous catherization of the femoral vein}}. \{\{nl\}\}• Consider when noninvasive testing is equivocal and risk of anticoagulation is high, or if the patient is unstable and embolectomy may be required. Rarely performed due to 0.5\% mortality. \tn 
% Row Count 29 (+ 17)
% Row 8
\SetRowColor{LightBackground}
Rules Out PE & Normal or low-probability V/Q scan or helical scan and low clinical suspicion, negative pulmonary angiogram (definite), and negative D-Dimer with low suspicion \tn 
% Row Count 36 (+ 7)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Testing (cont)}}  \tn
% Row 9
\SetRowColor{LightBackground}
Wells Criteria & Symptoms and signs of DVT (3 points), alternative diagnosis less likely than PE (3 points), HR\textgreater{}100 (1.5 points), immobilization \textgreater{}3 days or surgery in last 4wks (1.5 points), previous DVT or PE (1.5 points), hemoptysis (1 point) and malignancy (1 point). If \textgreater{}4, PE is likely. \tn 
% Row Count 12 (+ 12)
% Row 10
\SetRowColor{white}
Indications for Treatment & intraluminal defects in central, segmental or lobular PAs on helical CT (or high probability with a scan) and clinical suspicion, DVT diagnosed with clinical suspicion, and positive pulmonary angiogram (definitively proves PE). \tn 
% Row Count 22 (+ 10)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{x{1.64241 cm} x{3.33459 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Treatment}}  \tn
% Row 0
\SetRowColor{LightBackground}
Oxygen Therapy & • To correct {\bf{hypoxemia}}. \{\{nl\}\}• Severe hypoxemia or respiratory failure requires intubation and mechanical ventilation. \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
Heparin & • Either unfractionated or LMWH (enoxaparin) to prevent recurrence. \{\{nl\}\}• Prevents further clot formation but {\bf{does not lyse existing emboli or diminish thrombus size}}. \{\{nl\}\}• Start immediately based clinical suspicion. Do not wait for studies if high. \{\{nl\}\}• Give one bolus, followed by infusion for 5-10days. \{\{nl\}\}• Goal aPTT of 1.5-2.5x normal. \{\{nl\}\}• Acts by {\bf{promoting antithrombin III}}. \{\{nl\}\}• Contraindications include active bleeding, uncontrolled HTN, recent stroke, and HIT. \{\{nl\}\}• LMWH has less complications but NOT used in ESRD. \tn 
% Row Count 27 (+ 22)
% Row 2
\SetRowColor{LightBackground}
Warfarin & • For long-term treatment. {\bf{Can start with heparin on day 1}}. \{\{nl\}\}• Goal INR is 2-3. Continue for 3-6 months depending on risk factors. \{\{nl\}\}• Some patients with significant risk for recurrence (malignancy, hyper coagulable state) should receive lifelong therapy. \tn 
% Row Count 38 (+ 11)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{1.64241 cm} x{3.33459 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Treatment (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
Thrombolytic Therapy & • Streptokinase, TPA. \{\{nl\}\}• {\bf{Speed up lysis of clots}}. \{\{nl\}\}• Does not improve mortality rates. \{\{nl\}\}• Should be considered for use in patients with {\bf{massive PE}} who are {\bf{unstable}}, and patients with {\bf{evidence of RHF.}} \tn 
% Row Count 10 (+ 10)
% Row 4
\SetRowColor{white}
IVC Filter & • Have not been proven to reduce mortality. \{\{nl\}\}• Patients are at a higher risk of recurrent DVT but lower risk of recurrent PE. \{\{nl\}\}• Complications include filter migration or misplacement, filter erosion and perforation of IVC, and IVC obstruction due to filter thrombosis. \{\{nl\}\}• Indicated for patients with contraindications to anticoagulation, complication of current anticoagulation, failure of adequate anticoagulation evidence by recurrence, and low pulmonary reserve (high risk of death due to PE). \tn 
% Row Count 30 (+ 20)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{1.64241 cm} x{3.33459 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Treatment (cont)}}  \tn
% Row 5
\SetRowColor{LightBackground}
NOACs & Fondaparinox is an injectable factor Xa inhibitor. Rivaroxaban is an oral factor Xa inhibitor. Neither can be used in severe CKD (GFR\textless{}30). Epixaban is approved for use in CKD. \tn 
% Row Count 7 (+ 7)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

\end{document}