Project: Ghana Emergency Medicine Collaborative
Document Title: General survey and patient care management
Author(s): Jere...
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Make Your Own A...
Pa#ent	
  care	
  management:	
  
Across	
  the	
  room	
  assessment	
  
Pain	
  management	
  
Basic	
  RSI	
  Protocol	...
“Across	
  the	
  Room”	
  
Primary	
  Assessment	
  
•  Consists	
  of	
  rapid	
  assessment	
  of:	
  
– A:	
  Airway:	...
Primary	
  Assessment	
  
•  Closer	
  assessment	
  of	
  A	
  (C-­‐spine)-­‐B-­‐C-­‐D	
  
•  Include	
  C-­‐spine	
  imm...
Secondary	
  Assessment	
  	
  	
  
•  Brief	
  assessment,	
  taking	
  about	
  90	
  seconds	
  to	
  
preform.	
  
– E...
“PEARLS”	
  of	
  pediatric	
  triage	
  
•  Treat	
  child	
  and	
  parent	
  as	
  one	
  pa#ent;	
  avoid	
  
separa#o...
“PEARLS”	
  of	
  geriatric	
  triage	
  
•  Do	
  not	
  assume	
  confusion	
  is	
  normal.	
  There	
  are	
  
many	
 ...
Red	
  Flags	
  of	
  Triage	
  
•  Airway	
  that	
  is	
  compromised	
  
•  Breathing	
  pagerns	
  that	
  result	
  i...
Red	
  flags	
  cont.	
  
•  Heart	
  rate	
  below	
  60	
  and	
  symptoma#c	
  or	
  
above	
  120	
  and	
  symptoma#c....
Pain	
  management	
  
•  Defini#ons	
  of	
  pain:	
  
– Pain	
  is	
  a	
  sensory	
  experience	
  associated	
  with	
 ...
Pain	
  management	
  
•  Ethical	
  issues	
  
– Use	
  of	
  placebos	
  
– Withholding	
  of	
  opioids	
  for	
  fear	...
Assessment	
  of	
  pain	
  
•  The	
  focused	
  survey	
  examines	
  the	
  chief	
  complaint	
  and	
  
is	
  done	
 ...
Pain	
  measurement	
  tools	
  
• 	
   Insert	
  photos	
  here	
  	
  
14	
  
Nonpharmacologic	
  pain	
  	
  
management	
  techniques	
  
•  Suppor&ve	
  environment:	
  give	
  explana#ons,	
  what...
Pharmacological	
  treatment	
  of	
  pain	
  
•  Non-­‐opioid	
  (for	
  mild	
  to	
  moderate	
  pain):	
  	
  
–  Para...
Pharmacological	
  treatment	
  of	
  pain	
  
(cont)	
  	
  
•  Adjunc#ve	
  medica#ons	
  
–  An#-­‐eme#cs:	
  
•  Pheno...
Expected	
  outcomes	
  
•  Monitor	
  pa#ent	
  response	
  
•  Record	
  all	
  per#nent	
  data:	
  
– Vital	
  signs,	...
Rapid	
  Sequence	
  Intuba#on	
  
•  Indica#ons:	
  Unconscious/Semi-­‐conscious	
  
pa#ent	
  that	
  require	
  airway	...
Contraindica#ons	
  and	
  alterna#ves	
  
•  Contraindica#ons:	
  
– Distorted	
  anatomy	
  
– Obstruc#on	
  
– Major	
 ...
Be	
  prepared	
  before	
  RSI	
  
•  Equipment	
  needed:	
  
– Appropriate	
  RN	
  and	
  intuba#onist	
  at	
  bedsid...
Brief	
  history 	
  	
  
•  Think	
  AMPLE	
  
– A:	
  Allergies	
  
– M:	
  Medica#ons	
  
– P:	
  Past	
  medical	
  hi...
Basic	
  RSI	
  Protocol	
  
•  Prepara#on	
  and	
  preoxygena#on	
  with	
  100%	
  oxygen	
  for	
  3	
  to	
  5	
  
mi...
General	
  RSI	
  Protocol	
  premedica#on	
  
•  Seda#on	
  
–  Preferred	
  medica#ons	
  
•  Etomidate:	
  0.2-­‐0.3	
 ...
Sellick	
  Maneuver	
  
•  Pressure	
  is	
  placed	
  with	
  the	
  index	
  finger	
  and	
  
thumb	
  over	
  the	
  cr...
Nursing	
  care	
  in	
  RSI	
  
•  Amer	
  muscle	
  paralysis	
  is	
  achieved	
  and	
  there	
  
are	
  no	
  fasicul...
Nursing	
  Care	
  in	
  RSI	
  
•  Observe	
  for	
  possible	
  skin	
  breakdown,	
  
pressure	
  points	
  at	
  body	...
Pa#ent	
  stabiliza#on	
  and	
  transport	
  
•  Trauma	
  categories	
  
– Pa#ents	
  should	
  be	
  taken	
  to	
  a	
...
Pa#ent	
  stabiliza#on	
  and	
  transport	
  
•  Interhospital	
  transport	
  
– Each	
  hospital	
  should	
  have	
  a...
Pa#ent	
  stabiliza#on	
  and	
  transport	
  
•  Transfer	
  arrangements	
  	
  
– Responsibility	
  for	
  decision	
  ...
Pa#ent	
  stabiliza#on	
  and	
  transport	
  
communica#on	
  
•  Before	
  transfer	
  
–  Physician	
  to	
  physician	...
Pa#ent	
  stabiliza#on	
  and	
  transport	
  
•  Pa#ent	
  care	
  needs:	
  
–  Assure	
  patency	
  of	
  airway	
  
– ...
Medica#on	
  administra#on	
  
•  Caluculate	
  mL’s	
  per	
  hour	
  based	
  on	
  ug/kg/min	
  
	
  Rate=	
  ug	
  x	
...
A	
  math	
  problem	
  
•  Brevibloc	
  should	
  be	
  run	
  at	
  100U/kg/min.	
  Your	
  
pa#ent	
  weighs	
  198	
  ...
Answer	
  
•  Convert	
  pounds	
  to	
  KG:	
  198/2.2	
  =	
  90kg	
  
•  Determine	
  the	
  drug	
  concentra#on	
  of...
Another	
  math	
  problem	
  
•  Dopamine	
  is	
  infusing	
  in	
  a	
  210	
  pound	
  pan	
  at	
  
12mcg/kg/min.	
  ...
Answer	
  
•  Determine	
  weight	
  in	
  KG	
  210/2.2	
  =	
  95.5	
  kg	
  
•  Delivery	
  is	
  12mcg/kg	
  =	
  95.5...
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2014 gemc-nursing-lapham-general survey and patient care management

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This is a lecture by Dr. Jeremy Lapham from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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2014 gemc-nursing-lapham-general survey and patient care management

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: General survey and patient care management Author(s): Jeremy Lapham, 2014 (University of Michigan) License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 3. Pa#ent  care  management:   Across  the  room  assessment   Pain  management   Basic  RSI  Protocol   Pa#ent  stabiliza#on  and  transport   Medica#on  administra#on     3  
  4. 4. “Across  the  Room”   Primary  Assessment   •  Consists  of  rapid  assessment  of:   – A:  Airway:  Patent?   – B:  Breathing:  Efficient?   – C:  Circula#on:  Perfusing?   – D:  Deficits  in  neuro:  Awake?  Preform  and  AVPU   ra#ng.   4  
  5. 5. Primary  Assessment   •  Closer  assessment  of  A  (C-­‐spine)-­‐B-­‐C-­‐D   •  Include  C-­‐spine  immobiliza#on  if  any  chance   of  trauma.  If  unknown,  assume  trauma  and   place  C-­‐collar.   •  A  problem  with  airway  must  be  corrected   before  moving  on  to  breathing.  Breathing   must  be  corrected  before  moving  on  to   circula#on  etc.     5  
  6. 6. Secondary  Assessment       •  Brief  assessment,  taking  about  90  seconds  to   preform.   – E:  Exposure     – F:  Full  set  of  vital  signs.   – G:  give  comfort  measures;  get  gadgets  (foley,  NG,   pulse  ox,  etc).   – H:  Head  to  toe  inspec#on.   – I:  inspect  posterior  surface.   6  
  7. 7. “PEARLS”  of  pediatric  triage   •  Treat  child  and  parent  as  one  pa#ent;  avoid   separa#on.   •  Allow  child  to  make  as  many  decsions  as   possible  in  order  to  afford  him/her  some   control.   •  U#lize  play  therapy  if  possible.   •  Inform  the  child  of  what  will  happen,  do  not   give  false  reassurance.   •  Respect  the  privacy  of  the  child.   7  
  8. 8. “PEARLS”  of  geriatric  triage   •  Do  not  assume  confusion  is  normal.  There  are   many  condi#ons,  such  as  dehydra#on,  that  can   cause  confusion.   •  Don’t  dismiss  vague  complaints.  Elderly  will   some#mes  brush  over  some  problems  because   they  equate  them  with  “gedng  old”   •  Decreased  renal  perfusion  in  the  elderly  may   place  them  at  greater  risk  for  drug  toxicity.   •  When  tes#ng  skin  turgor,  test  on  the  lateral   cheek.  Loss  of  elas#city  may  be  confused  with   dehydra#on.   8  
  9. 9. Red  Flags  of  Triage   •  Airway  that  is  compromised   •  Breathing  pagerns  that  result  in  extreme   effort  (retrac#ons,  stridor,  lack  of  breath   sounds)   •  Circula#on  that  is  compromised  and  results  in   compromised  perfusion  (color  changes,   diaphoresis,  cool  extremi#es).     9  
  10. 10. Red  flags  cont.   •  Heart  rate  below  60  and  symptoma#c  or   above  120  and  symptoma#c.  Any  heart  rate   <40  and  >150.     •  Immune  compromised  pa#ents  with  a  fever.   •  Pregnant,  bleeding  pa#ent  with  c/o  pain  and   lightheadedness.   •  Acute  onset  of  tes#cular  pain.   •  Headache,  fever  and  change  in  mental  status.   10  
  11. 11. Pain  management   •  Defini#ons  of  pain:   – Pain  is  a  sensory  experience  associated  with   actual  and  poten#al  #ssue  damage  as  well  as   physiological  response  to  this  damage.   – Pain  is  whatever  the  person  experiencing  it   describes  it  to  be;  it  exists  when  the  person  says  it   does,  as  manifested  in  verbal  and  non-­‐verbal   behavior.     •  Emergency  Core  Curriculum,  5th  ed.  P537   11  
  12. 12. Pain  management   •  Ethical  issues   – Use  of  placebos   – Withholding  of  opioids  for  fear  of  addic#on.     – Withholding  of  opioids  for  fear  of  respiratory   depression.     12  
  13. 13. Assessment  of  pain   •  The  focused  survey  examines  the  chief  complaint  and   is  done  amer  the  primary  surveys  are  completed   •  Subjec#ve  Data:   –  Pain  scale   –  P-­‐Q-­‐R-­‐S-­‐T   –  Pain  relief  measures  agempted  at  home  (include  herbal/ tradi#onal/homeopathic,  etc).   •  Objec#ve   –  Inspec#on  of  the  area  of  pain  complaint   –  Palpa#on  and  ausculta#on  of  area  if  appropriate   –  Behavioral  responses  to  pain   13  
  14. 14. Pain  measurement  tools   •    Insert  photos  here     14  
  15. 15. Nonpharmacologic  pain     management  techniques   •  Suppor&ve  environment:  give  explana#ons,  what   to  expect  next,  realis#c  #me.   •  Posi&on  of  comfort:  includes  splin#ng,   immobiliza#on,  use  of  pillows,  towel  rolls.   •  Cutaneous  s&mula&on:  ice  to  fractures,  sprains.   Heat  to  muscle  spasms,  COOL  IS  THE  RULE  for   infiltrated  IV  sites.     •  Distrac&on  techniques:  music,  storytelling,   colouring  books,  etc,   •  Relaxa&on/breathing  techniques   15  
  16. 16. Pharmacological  treatment  of  pain   •  Non-­‐opioid  (for  mild  to  moderate  pain):     –  Paracetamol  e.g.  Tylenol   –  NAIDS  e.g.  Buffrin   •  Opioid  administra#on  (for  moderate  to  severe  pain):   –  Morphine   –  Hydromorphone   –  Fentanyl   •  Seda#ve  administra#on  (for  allevia#on  of  anxiety,   seda#on  to  impair  memory,  induc#on  of  drowsiness):   –  Midazolam   –  Diazepam   –  Propofol  (hypno#c  seda#ve)   16  
  17. 17. Pharmacological  treatment  of  pain   (cont)     •  Adjunc#ve  medica#ons   –  An#-­‐eme#cs:   •  Phenothiazines:  prochlorperazine  maleate  (Compazine),   promethazine  HCL  (Phenergan),  chlorpromazine  HCL   (Thorazine).   –  Drugs  that  depress  the  vomi#ng  center  and  block   receptors  that  prevent  vomi#ng.   –  Produce  addi#ve  CNS  depression  when  used  with   opiods.   –  Pa#ents  should  be  monitored  for  poten#al  increase  in   orthosta#c  hypotension.     17  
  18. 18. Expected  outcomes   •  Monitor  pa#ent  response   •  Record  all  per#nent  data:   – Vital  signs,  pulse  ox   – Pain  scale  ra#ngs   – Physical  response  to  analgesics   •  Home  instruc#ons:   – Medica#on  administra#on   – Resources  (internet,  educa#on,  booklets,  etc)   – Necessary  referrals   18  
  19. 19. Rapid  Sequence  Intuba#on   •  Indica#ons:  Unconscious/Semi-­‐conscious   pa#ent  that  require  airway  control  and   protec#on.   – Severe  respiratory  distress   – Drug  overdose  with  respiratory  depression   – Status  asthma#cus   – Head  injuries  or  GCS  <8   – Unstable  cardiac  pa#ents  (CHF,  cardiogenic  shock)     19  
  20. 20. Contraindica#ons  and  alterna#ves   •  Contraindica#ons:   – Distorted  anatomy   – Obstruc#on   – Major  facial,  laryngeal  trauma   – Angioedema   •  Alterna#ves   – Agempts  may  be  made  to  intubate  a  pa#ent   nasally  who  is  a  wake,  using  only  seda#on.   20  
  21. 21. Be  prepared  before  RSI   •  Equipment  needed:   – Appropriate  RN  and  intuba#onist  at  bedside   – O2  source,  suc#on,  monitor,  B-­‐V-­‐M  device,   intuba#on  equipment,  pulse  oximetry   – Alterna#ve  airway  equipment  (laryngeal  mask   airway,  transtracheal  jet  ven#lia#on,   cricothyroidotomy  set)   – Pharmacologic  agents  (drawn  up  and  labeled  in   syringes).     21  
  22. 22. Brief  history     •  Think  AMPLE   – A:  Allergies   – M:  Medica#ons   – P:  Past  medical  history   – L:  Last  meal   – E:  Exis#ng  circumstances   22  
  23. 23. Basic  RSI  Protocol   •  Prepara#on  and  preoxygena#on  with  100%  oxygen  for  3  to  5   minutes  if  possible.   –  If  B-­‐V-­‐M  is  needed  to  preoxygenate,  then  use  the  Sellick  maneuver  to   prevent  gastric  disten#on   –  Discuss  possibility  of  adding  4%  lidocaine  to  aerolized  treatment  in   status  asthma#cus  if  awake  intuba#on  is  to  be  done   •  Premedicate:   –  Lidocaine  1mg/kg  IV  (prevents  ICP  rise)   –  Atropine  0.01mg/kg  IV  (minimum  dose:  0.1mg)  prevents  vagal   s#mula#on  of  bradycardia.   •  Administer  seda#ve  hypno#c   •  Try  to  limit  s#mula#on   •  Administer  neuromuscular  blocking  agent  to  produce  muscle   paralysis.     23  
  24. 24. General  RSI  Protocol  premedica#on   •  Seda#on   –  Preferred  medica#ons   •  Etomidate:  0.2-­‐0.3  mg/kg  IVP   •  Midazolam:  0.1  mg/kg  IVP   •  Ketamine:  1-­‐2mg/kg  IV   •  Propofol:  2mg/kg  (check  for  egg  allergy)   •  Muscle  relaxants/Paraly#c  agents   –  Succinylcholine  1-­‐1.5  mg/kg  IV,  2-­‐4mg/kg  IM  (use  with   cau#on  in  increased  ICP  and  intraocular  pressure)   –  Vecuronium  0.1mg/kg  IV  (1mg  is  defasicula#ng  dose,   but  not  for  eye  or  head  injuries)   –  Pancuronium  0.1  mg/kg  IV   24  
  25. 25. Sellick  Maneuver   •  Pressure  is  placed  with  the  index  finger  and   thumb  over  the  cricoid  car#lage     •  Insert  photo  here   25  
  26. 26. Nursing  care  in  RSI   •  Amer  muscle  paralysis  is  achieved  and  there   are  no  fasicula#ons,  the  pa#ent  is  intubated   while  u#lizing  the  Sellick  maneuver.   •  Confirm  placement  by  three  methods:   – Clinically:  ausculta#on  and  observa#on   – End  #dal  C02  detector   – CXR   •  Maintain  proper  body  temperature  (post-­‐ anesthesia  hypothermia  my  exist)   26  
  27. 27. Nursing  Care  in  RSI   •  Observe  for  possible  skin  breakdown,   pressure  points  at  body  prominences.   •  Morbidly  obese  pa#ents  need  to  be  turned  to   the  recovery  posi#on  or  sat  up  to  take   pressure  off  the  vena  cava  while  supine.   •  Placement  of  an  NG/OG  tube  to  decompress   the  stomach   •  Eye  lubrica#on  if  intuba#on  is  thought  to  be   for  an  extended  period  of  #me.     27  
  28. 28. Pa#ent  stabiliza#on  and  transport   •  Trauma  categories   – Pa#ents  should  be  taken  to  a  Level  One  Trauma   Center  are  iden#fied  by  the  American  College  of   Surgeons  according  to  injuries  and  mechanisms  of   injury.     – Non  trauma  categories:  follows  guidelines  put   forth  by  ins#tu#on  and  per#nent  governing   bodies.     28  
  29. 29. Pa#ent  stabiliza#on  and  transport   •  Interhospital  transport   – Each  hospital  should  have  a  formalized  plan  for   intra-­‐  and  inter-­‐hospital  transport  that  addresses   the  following  elements:  pretransport  coordina#on   and  communica#on,  transport  equipment,   accompanying  personnel,  monitoring  during  the   transport  and  documenta#on.  The  transport  plan   should  be  developed  by  a  mul#disciplinary  team   and  should  be  evaluated  and  refined  by  the   con#nuous  quality  improvement  process.     •  Am  J  Crit  Care,  1993  May;  2(3):  189-­‐95   29  
  30. 30. Pa#ent  stabiliza#on  and  transport   •  Transfer  arrangements     – Responsibility  for  decision  to  transfer   •  A&E  physician,  private  agending,  surgeon   – Responsibility  for  pa#ent  care  in  transit:   •  Referring  physician,  but  may  be  collabora#ve     – Mode  of  transporta#on   •  Dependent  upon  distance,  traffic,  pa#ent  condi#on   – Personnel  for  transport:     •  need  to  have  proper  educa#on,  training,  experience   compa#ble  with  the  pa#ent  acuity   30  
  31. 31. Pa#ent  stabiliza#on  and  transport   communica#on   •  Before  transfer   –  Physician  to  physician  report   –  Primary  nurse  to  receiving  charge  nurse  report   –  Report  to  transport  agency   –  Copies  of  all  documenta#on,  diagnos#cs  to  go  with  pt.     •  During  transport   –  Communica#on  to  referring  facility  of  any  changes  in   pa#ent  condi#on   •  Amer  transport   –  Follow  up  call  from  transfer  agency  to  referral  hospital   to  inform  personnel  of  the  outcome  of  the  transport   31  
  32. 32. Pa#ent  stabiliza#on  and  transport   •  Pa#ent  care  needs:   –  Assure  patency  of  airway   –  Assure  breathing  and  circulatory  support  accompanies   the  pa#ent   –  Splint  anything  that  might  be  broken   –  Control  bleeding  and  address  wound  care   –  Educate  pa#ent  and  family  of  transport  procedures   –  Assure  pain  relief  measures  are  available  for  the   pa#ent  in  transport   –  NGT/OGT  and  foley  if  applicable   32  
  33. 33. Medica#on  administra#on   •  Caluculate  mL’s  per  hour  based  on  ug/kg/min    Rate=  ug  x  kg  x  60  (minutes)            ug/mL   Calculate  the  conversion  of  pounds  to  kilograms    Lbs/2.2   33  
  34. 34. A  math  problem   •  Brevibloc  should  be  run  at  100U/kg/min.  Your   pa#ent  weighs  198  pounds.  Brevibloc  is  mixed   as  a  dilu#on  of  2500mg  Brevibloc  in  a  total  of   285ml  of  solu#on.  How  fast  should  it  be   infused?   34  
  35. 35. Answer   •  Convert  pounds  to  KG:  198/2.2  =  90kg   •  Determine  the  drug  concentra#on  of  1mL   –  2500mg/285  =  8.77mg/ml   •  Determine  the  number  of  mcg  in  8.77mg   –  8.77  x  1000  =  8770mcg/ml   •  Rate  =  ug  x  kg  x  60  (min)            ug/mL   =  (100  x  90  x  60)  /  8770   =540,000/8770  =  61.5  or  62ml/hr   35  
  36. 36. Another  math  problem   •  Dopamine  is  infusing  in  a  210  pound  pan  at   12mcg/kg/min.  How  many  mg/hr  will  this   pa#ent  receive?     36  
  37. 37. Answer   •  Determine  weight  in  KG  210/2.2  =  95.5  kg   •  Delivery  is  12mcg/kg  =  95.5  x  12  =  1146mcg/ min   •  Determine  hourly  drug  delivery   – 1146  mcg/min  x  60  =  68,760/hr   •  Determine  number  of  mg  from  mcg  (mcg/ 1000)   – 68,760/1000  =  68.760mg   37  

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