Download to read offline
Internal Medicine Moonlighting Slides IM
- 1. Diana Tamondong-Lachica, MD,FPCP Moonlight Internal Medicine
- 2. 8 Targets ofMoonlight Medicine Infectious Disease Cardiovascular Medicine Pulmonary Medicine Endocrinology Gastroenterology Poisons and Snakebites Pain Medication
- 3.
- 4.
- 5. URTI: Presentation Symptoms ¤ Cough,colds ¤ 3 to 5 days duration Signs ¤ Nasal discharge (clear or yellowish) ¤ Clear breath sounds ¤ No signs of sepsis ¤ Hemodynamically stable
- 6. URTI: Order Sheet Nolabs necessary Most URTI (even bacterial) resolve without antibiotic therapy Antibiotics only for ¤ Moderate symptoms that are not improving after 10 days ¤ Symptoms worsen after five to seven days ¤ Severe symptoms
- 7. URTI: Order Sheet Medications ¤Amoxicillin 500 mg TID ¤ Co-amoxyclav 625 mg BID (preferred if failed on Amoxicillin or if with severe symptoms) ¤ Azithromycin 250 mg OD x 5 days or 500 mg OD x 3 days or 1 g OD x 1 dose Advice ¤ Increased oral fluid intake (at least 2L/day)
- 8. URTI: Watch OutFor… Persistence ¤ Fever should lyse within 24-48 hours ¤ Post-infectious cough occurs in 40% of patients Recurrence ¤ Consider allergic rhinitis – may refer to an allergologist ■ Seasonal pattern ■ History of asthma or atopy ■ Relation to exposure to allergens/certain settings (bedroom, work) ¤ If also with weight loss, obstructive ssx, refer to ORL
- 9. URTI: Watch OutFor… Allergic Rhinitis ¤ If with weekly symptoms, and bothers sleep/work, must start Fluticasone furoate 2 puffs per nostril 2x a day for 4-6 weeks ¤ Exacerbations: Loratadine 10 mg at night ¤ Itching/Atopy: Cetirizine 10 mg OD ¤ Discharge: Oxymetazoline spray (may use only up to 3 days) ¤ Cough: Dextropmethophan+Phenylephrine ■ Tuseran Forte
- 10.
- 11. Pneumonia (CAP): Presentation Symptoms ¤Cough with/without sputum production ¤ Fever ¤ Generalized weakness, anorexia Signs ¤ Crackles ¤ Decreased breath sounds ■ Increased fremiti – consolidation/mass ■ Decreased fremiti – pleural effusion ¤ Wheezing
- 12. CAP: Order Sheet InitialDiagnostics ¤ Chest X-ray ¤ CBC with platelet count
- 13. CAP: 2016 Guidelines No Doesthe patient have: 1. RR ≥ 30/min 2. PR ≥ 125/min 3. Temp ≥ 400C or ≤ 360C 4. SBP < 90 or DBP ≤ 60 5. Altered mental status, acute 6. Suspected aspiration 7. Unstable co-morbids 8. Chest X-ray: multilobar, pleural effusion, abscess Low Risk CAP Moderate Risk vs High Risk Yes Co-morbidities • DM • Active Malignancy • Neurologic disease in evolution • CHF Class II-IV • Unstable CAD • Renal failure on dialysis • Uncompensated COPD • Decompensated Liver Disease
- 14. CAP: 2016 Guidelines No Doesthe patient have: 1. Severe Sepsis 2. Septic Shock 3. Need for mechanical Ventilation Moderate Risk CAP High Risk CAP Yes
- 15. CAP: Low Risk SubsequentDiagnostics ¤ Sputum GS/CS optional Antibiotics ¤ Previously healthy ■ Amoxicillin 1g TID ■ Azithromycin 500mg OD or Clarithromycin 500mg BID ¤ Stable co-morbid condition (cover enteric G- bacilli) ■ Co-amoxiclav 1g BID ■ Sultamicillin 750mg BID ■ Cefuroxime 500mg BID ■ +/- Azithromycin 500mg OD or Clarithromycin 500mg BID
- 16. CAP: Moderate Risk(Admit) Subsequent Diagnostics ¤ Blood CS ¤ Sputum GS/CS Antibiotics ¤ Ampicillin-Sulbactam 1.5g IV q6 ¤ Cefuroxime 1.5g IV q8 ¤ Ceftriaxone 2g IV OD ¤ PLUS any of the ff: ¤ Azithromycin 500mg OD PO ¤ Clarithromycin 500mg BID PO ¤ Levofloxacin 500mg OD PO ¤ Moxifloxacin 400mg OD PO
- 17. CAP: Moderate Risk(Admit) If aspiration is suspected ¤ Add Clindamycin 600mg IV q8 to regimens under Moderate risk ¤ Except for: • Ampicillin-Sulbactam 3g IV q6 • Moxifloxacin 400mg OD PO
- 18. CAP: High Risk(ICU) Subsequent Diagnostics ¤ Blood CS ¤ Sputum GS/CS ¤ Urine antigen for L. pneumophila ¤ Direct fluorescent Ab test for L. pneumophila ¤ ABG
- 19. CAP: High Risk(ICU) Antibiotics – no risk for Pseudomonas aeruginosa ¤ Same as moderate risk ¤ Ertapenem 1g IV OD Antibiotics – with risk for Pseudomonas aeruginosa ¤ Piptazo 4.5g IV q6 ¤ Cefepime 2g IV q8-12 ¤ Meropenem 1g IV q8 ¤ + Azithromycin 500mg IV OD + Gentamycin 3mg/kg OD or Amikacin 15mg/kg OD OR ¤ + Levofloxacin 750mg IV OD or Ciprofloxacin 400mg IV q8-12
- 20. CAP: High Risk(ICU) Pseudomonas aeruginosa ¤ Antibiotic use (at least 1 week in the past month) ¤ Malnutrition ¤ Steroid use (Prednisone 2.5 mg in the past week) If MRSA suspected, add any of the ff: ¤ Vancomycin 15mg/kg IV q8-12 ¤ Linezolid 600mg IV q12 ¤ Clindamycin 600mg IV q8
- 21. CAP: Watch OutFor Pleural effusion, Lung abscess ¤ Do thoracentesis ¤ Refer to TCVS for CTT if warranted Hemodynamic instability/Progressing sepsis ¤ Refer to Pulmo, IDS Hospital-acquired pneumonia ¤ Proper precautions in intubated patients Exacerbation of co-morbid diseases
- 22. CAP: Resolution For low-risk ¤Follow-up after 3 to 5 days For moderate-/high-risk ¤ Step down when clinically improving ¤ Some infections (e.g. ESBL organisms) require a full course via the IV route Chest X-ray findings ¤ May take up to 6 months to completely resolve Vaccination (including those with co-morbids) ¤ Pneumococcal: one time, then q5years ¤ Influenza: annually
- 23. INFECTIOUS DISEASE Urinary TractInfection
- 24. Urinary Tract Infection Symptomsof Urethritis ¤ Acute dysuria, hematuria ¤ Frequency ¤ Pyuria ¤ Recent sexual partner change Symptoms of Cystitis ¤ Dysuria, Urgency ¤ Suprapubic pain ¤ Hematuria, foul-smelling urine, turbid urine
- 25. UTI: Presentation Symptoms ofAcute Pyelonephritis ¤ Rapid development ¤ Fever, shaking chills ¤ Nausea, vomiting, abdominal pain ¤ Diarrhea ¤ Diabetes, immunosuppression Symptoms of catheter-related UTI ¤ Minimal symptoms ¤ Usually no fever
- 26. UTI: Presentation Signs ofUrethritis ¤ Grossly purulent discharge expressed in genital tract Signs of Cystitis ¤ Suprapubic tenderness ¤ Fever Signs of Acute pyelonephritis ¤ Costoverterbal angle tenderness at side of involved kidney ¤ Fever, signs of sepsis
- 27. UTI: Presentation Signs ofcatheter-related UTI ¤ Turbid/foul-smelling urine ¤ Purulent discharge ¤ Suprapubic tenderness
- 28. UTI 2004 Guidelines Doesthe patient have complicating risk factors? ¤ Anatomic abnormality ¤ Functional abnormality ¤ Recent UTI or Tract instrumentation (past 2 weeks) ¤ Renal disease/transplant ¤ Antibiotic use (Past 2 weeks) ¤ Immunosuppresion ¤ DM ¤ Catheter, indwelling/intermittent ¤ Hospital-acquired ¤ Symptoms for > 7 days AFRRAID CH7
- 29. UTI 2004 Guidelines UncomplicatedCystitis ¤ Medications (do 7 day regimen in males) ■ Cotrimoxazole 800/160 PO BID x 3 days ■ Ciprofloxacin 250 mg PO BID x 3 days ■ Ofloxacin 200 mg PO BID x 3 days ■ Norfloxacin 400 mg PO BID x 3 days ■ Nitrofurantoin 100 mg QID x 7 days ■ Cefuroxime 125-250 mg PO BID x 3-7 days ¤ Increase OFI ¤ No need for U/A or urine cultures except in males ¤ If unresolved after 7 days, consider as COMPLICATED
- 30. UTI 2004 Guidelines AcuteUncomplicated Pyelonephritis ¤ Urinalysis (expect increased WBC; bacteriuria not the defining parameter; WBC cast is pathognomonic) ¤ Urine GS/CS ¤ Outpatient treatment: ■ No signs and symptoms of sepsis ■ Non-pregnant ■ Likely to comply with treatment ■ Able to tolerate oral medications ■ Follow-up after 3-5 days
- 31. UTI 2004 Guidelines AcuteUncomplicated Pyelonephritis ¤ Empiric regimen should be started after culture is taken (Oral) ■ Ofloxacin 400 mg BID x 14 days ■ Ciprofloxacin 500 mg BID x 7-10 days ■ Levofloxacin 250 mg OD x 7-10 days ■ Cefixime 400 mg OD x 14 days ■ Cefuroxime 500 mg BID x 14 days ■ Co-amoxyclav 625 mg TID x 14 days (if GS is G+)
- 32. UTI 2004 Guidelines AcuteUncomplicated Pyelonephritis ¤ Empiric regimen should be started after culture is taken (IV, given until patient is afebrile) ■ Ceftriaxone 1-2 g IV OD ■ Ciprofloxacin 200-400 mg IV q12 ■ Levofloxacin 250-500 mg IV OD ■ Ampicillin-Sulbactam 1.5 g IV q6 (if GS is G+) ■ Piperacillin-Tazobactam 2.25-4.5 g IV q6-8 ¤ Post-treatment cultures are unnecessary
- 33. UTI 2004 Guidelines AcuteUncomplicated Pyelonephritis: WOF ¤ Fever after 72 hours of treatment, or recurrence of symptoms ■ Imaging studies (KUB-UTZ , KUB-IVP if Creatinine clearance acceptable) ■ Repeat urine culture ■ If without urologic abnormality, treatment duration is 2 weeks based on culture ■ If same organism between initial and repeat culture, treatment duration is 4-6 weeks
- 34. UTI 2004 Guidelines Asymptomaticbacteriuria ¤ Defined as ≥ 100,000 cfu in 2 consecutive midstream urine specimens or 1 catheterized specimen ¤ Should screen for, and treat in ■ Patients who will undergo GU manipulation or instrumentation ■ Post-renal transplant patients up to first 6 months ■ DM with poor glycemic control, autonomic neuropathy or azotemia ■ All pregnant women ¤ Same antibiotics as acute uncomplicated cystitis
- 35. UTI 2004 Guidelines RecurrentUTI ¤ More 2x a year, with no urinary tract abnormalities ¤ May give prophylaxis (if symptoms are unacceptable) ■ Post-coital (immediately after intercourse) ■ Daily for 6 to 12 months ■ Nitrofurantoin 100 mg at bedtime ■ Cotrimoxazole 200/40 mg at bedtime ■ Ciprofloxacin 125 mg at bedtime ■ Norfloxacin 200 mg at bedtime ■ Cefalexin 125 mg at bedtime ¤ Same antibiotics as acute uncomplicated cystitis, or may also take 2 double strength Cotrimoxazole single dose as soon as symptoms first appear
- 36. UTI 2004 Guidelines ComplicatedUTI ¤ Urine GS/CS ¤ Outpatient ■ No signs of sepsis ■ Without marked debilitation ■ Ability to comply with treatment ■ Ability to maintain oral hydration/take oral medications
- 37. UTI 2004 Guidelines ComplicatedUTI ¤ Oral ■ Ciprofloxacin 250 – 500 mg BID x 14 days ■ Norfloxacin 400 mg BID x 14 days ■ Ofloxacin 200 mg BID x 14 days ■ Levofloxacin 250 – 500 mg OD x 10-14 days
- 38. UTI 2004 Guidelines ComplicatedUTI ¤ Parenteral ■ Ampicillin-sulbactam 1.5 – 3 g IV q6 ■ Ceftazidime 1-2 g IV q8 ■ Ceftriaxone 1-2 g IV OD ■ Imipenem-cilastin 250-500 mg IV q6-8 ■ Piperacillin-Tazobactam 2.25 g IV q6 ■ Ciprofloxacin 200-400 mg IV q12 ■ Ofloxacin 200-400 mg IV q12 ■ Levofloxacin 500 mg IV OD ¤ At least 7 to 14 days of therapy
- 39. UTI 2004 Guidelines ComplicatedUTI ¤ At least 7 to 14 days of therapy ¤ Urine culture should be repeated 1 to 2 weeks after completion of medications ■ If persistent, refer to urology/nephrology ¤ If no response, may do ■ Plain KUB x-ray ■ KUB-UTZ ■ Helical CT scan
- 40. UTI 2004 Guidelines Catheter-associatedUTI ¤ If asymptomatic, no need to treat, except if ■ With bacterial agents with high-incidence bacteremia ■ With neutropenia ■ Pregnant ■ Will undergo urologic procedures/post-renal transplant ¤ Indwelling catheter should be removed ¤ Long-term indwelling catheters should be replaced before treatment
- 41. UTI 2004 Guidelines Candiduria ¤May treat if ■ Symptomatic ■ Critically ill ■ Neutropenic ■ Will undergo urologic procedures/post-renal transplant ¤ Control diabetes (if present) ¤ Remove catheter, other urinary tract instruments (if present)
- 42. UTI 2004 Guidelines Candiduria ¤Cystitis ■ Fluconazole 400 mg LD then 200 mg OD x 7-14 days ¤ Pyelonephritis ■ Surgical drainage ■ Fluconazole 6 mg/kg/day or Amphotericin B IV 0.6 mg/kg/day for 2 to 6 weeks
- 43.
- 44. Dengue Fever: Presentation ProbableDengue ¤ Live in or travel to endemic area ¤ Fever and any 2 of the following: ■ Nausea and vomiting ■ Rash ■ Aches and Pains ■ Tourniquet test positive ■ Leukopenia ■ Any warning Sign ¤ Labs: when there are no signs of plasma leakage
- 45. Dengue Fever: Presentation WarningSigns ¤ Abdominal pain or tenderness ¤ Persistent vomiting ¤ Clinical fluid accumulation ¤ Mucosal bleed ¤ Lethargy, restlessness ¤ Liver enlargement > 2 cm ¤ Increase in hematocrit WITH decrease in platelet count
- 46. Dengue Fever: Presentation SevereDengue ¤ Severe plasma leakage leading to ■ Shock (Dengue Shock Syndrome) ■ Fluid accumulation with respiratory distress ¤ Severe bleeding (esp with use of ASA, Ibuprofen or corticosteroids) ¤ Severe organ involvement ■ Liver: AST or ALT > 1000 ■ CNS: Impaired consciousness ■ Heart and other organs
- 47. Dengue Fever: OrderSheet Initial Diagnostics ¤ CBC with PC ■ Leukopenia ■ Thrombocytopenia ■ Hemoconcentration ¤ Dengue IgM – esp if with unusual/atypical manifestations ¤ Dengue NS1 ¤ Crea, Na, K, AST, ALT ■ Elevated AST more than ALT ¤ Liver function: Protime, TB, DB, IB, albumin
- 48. Dengue Fever: OrderSheet Group A: May be sent Home ¤ Who: ■ Can tolerate oral fluids ■ UO every 6 hours ■ No warning signs ¤ ORS, fruit juice ¤ Paracetamol for high fever, TSB ¤ Possible follow-up if with complications
- 49. Dengue Fever: OrderSheet Group B: Admit ¤ Who: ■ Warning signs ■ Co-existing conditions (e.g. pregnancy, DM, extreme age) ¤ Hct before fluids ¤ Isotonic solution (pNSS, Ringer’s lactate) ■ 5-7 mL/kg/hr for 1 to 2 hours ■ 3-5 mL/kg/hr for 2 to 4 hours ■ For obese/overweight: use ideal body weight ■ May give oral fluids if tolerated
- 50. Dengue Fever: OrderSheet Group B: Admit ¤ If Hct remains the same/Clinical status stable ■ 2-3 mL/kg/hr for another 2 to 4 hours ¤ If Hct rises/Clinical status worsens ■ 5-10 mL/kg/hr for 1 to 2 hours ¤ Try to maintain UO 0.5 mL/kg/hr ¤ Fluids usually needed for only 24-48 hours ¤ Monitoring ■ VS q1-4, UO q4-6 then q6-12 if stable ■ Hematocrit after fluid then q6-12
- 51. Dengue Fever: WOF Transferto tertiary care if: ¤ Early presentation of shock (2nd or 3rd day) ¤ Severe plasma leakage or shock ¤ Undetectable pulse or BP ¤ Severe bleeding ¤ Fluid overload ¤ Organ impairment
- 52. Dengue Fever: OrderSheet Group C: Critical ¤ Who: ■ Severe plasma leakage ■ Severe hemorrhage ■ Severe organ impairment
- 53. Dengue Fever: OrderSheet Group C: Critical ¤ Monitoring ■ VS q15-30 until out of shock then q1-2 ■ Cardiac monitor ■ Pulse oximetry ¤ Arterial line if possible ■ BP ■ Blood extraction
- 54. Dengue Fever: OrderSheet Group C: Critical ¤ Bleeding ■ Avoid intramuscular injections ■ If mucosal, treat as minor bleeding – resuscitation as specified ¤ Major Bleeding ■ Prolonged/refractory shock ■ Renal/Liver failure or persistent metabolic acidosis ■ NSAID intake ■ Anticoagulant therapy ■ Preexisting PUD ■ Any form of trauma, including intramuscular injections
- 55. Dengue Fever: OrderSheet Group C: Critical ¤ Major Bleeding ■ Don’t wait for drop: Hct <0.3 in sepsis is NOT applicable ■ 5-10 mL/kg pRBC or 10-20 mL/kg of Whole Blood ■ Platelet concentrates or FFP DO NOT HELP! ■ May do only if pRBC and FWB does not work ■ Exacerbates fluid overload ■ NGT insertion must be done fully lubricated and with care
- 56. Dengue Fever: Resolution 1week course Discharge if ¤ Increasing trend of platelet count ¤ No bleeding ¤ No hemodynamic instability Advice regarding mosquito control ¤ Ablation of mosquito breeding grounds ¤ Mosquito nets rather than mosquito repellents
- 57.
- 58. Typhoid Fever: Presentation Symptoms ¤High grade fever in past 1 to 2 weeks ¤ Abdominal pain (not always present) ¤ Headache, chills, cough, myalgia/arthalgia, diarrhea or constipation Signs ¤ Relative bradycardia at the peak of fever ¤ Hepatosplenomegaly, abdominal tenderness ¤ Rose spots: faint, salmon-colored blanching rash usually located on the trunk
- 59. Typhoid Fever: OrderSheet Diagnostics ¤ CBC with PC (leukocytosis, sometimes leukopenia, neutropenia) ¤ Crea, Na, K, AST, ALT (slightly elevated LFTs) ¤ Blood CS (sensitivity 90% in first week) ¤ Bone marrow CS (even up to 5 days of threapy) ¤ Duodenal string test/culture ¤ Stool CS (positive in 3rd week if untreated) Admit if… ¤ Vomiting, diarrhea, abdominal distension
- 60. Typhoid Fever: OrderSheet Empirical treatment ¤ Ceftriaxone 1-2 g IV OD x 7-14 days ¤ Cefixime 400 mg PO BID x 7-14 days ¤ Azithromycin 1g PO OD x 5 days Multidrug resistant ¤ Ciprofloxacin 500 mg PO BID x 5-7 days ¤ Ciprofloxacin 400 mg IV q12 x 5-7 days ¤ Ceftriaxone 2-3 g IV OD x 7-14 days ¤ Azithromycin 1g PO OD x 5 days
- 61. Typhoid Fever: OrderSheet Critically ill (shock, obtundation) ¤ Add Dexamethasone 3 mg IV then 1 mg/kg q6 x 8 doses ¤ Admit to ICU ¤ Refer to IDS ¤ Repeat cultures if none were positive
- 62. Typhoid Fever: WOF Perforation/Obstruction ¤Due to invasion of Peyer’s patches ¤ Refer to Surgery Continued fever ¤ Lack of susceptibility ¤ Consider another etiology ¤ Refer to an Infectious Disease specialist
- 63. Typhoid Fever: Resolution Defervescencein 1 week Return to normal values also in 1 week
- 64.
- 65. Leptospirosis: Presentation Symptoms ¤ Wadingin floodwater/exposure to mud ¤ Influenza-like illness: chills, headache, nausea, vomiting, muscle pain (calves, back or abdomen) ¤ Fever, conjunctival suffusion/hemorrhage ¤ Hemoptysis ¤ Decreased urine output, tea-colored urine ¤ Overt jaundice ¤ Diarrhea ¤ Course progresses within 1 week, rarely 2 weeks
- 66. Leptospirosis: Presentation Signs ¤ Fever ¤Conjunctival suffusion ¤ Jaundice and icterus ¤ Calf tenderness ¤ Decreased sensorium
- 67. Leptospirosis: Order Sheet InitialDiagnostics ¤ Lepto MAT/Dri-Dot ¤ BUN, Crea, Na, K, Cl, alb, Ca, Mg (check for acute renal failure, electrolyte losses) ¤ Urinalysis (concentrated urine vs renal failure; picture of UTI may confuse you) ¤ CBC with PC (anemia, leukocytosis) ¤ Chest X-ray (check for pulmonary hemorrhage) ¤ Stool CS (for patients with diarrhea) ¤ Urine culture (positive at 2nd to 4th week, and for several months after)
- 68. Leptospirosis: Order Sheet MildLeptospirosis ¤ Doxycycline 100 mg PO BID ¤ Ampicillin 500-750 mg PO QID ¤ Amoxicillin 500 mg PO QID Moderate/Severe Leptospirosis ¤ Penicillin G 1.5 M u IV QID ¤ Ampicillin 1 g IV QID ¤ Amoxicillin 1 g IV QID ¤ Ceftriaxone 1 g IV OD ¤ Erythromycin 500 mg IV QID
- 69. Leptospirosis: Order Sheet Hydration ¤Based on urine output ¤ Replace electrolytes lost Transfusion ¤ Based on losses detected by CBC Control of hemoptysis ¤ Hydrocortisone 50 mg IV q6 ¤ Tranexamic Acid 500 mg TID
- 70. Leptospirosis: WOF Weil’s syndrome ¤Heralded by hemoptysis, renal failure, severe liver dysfunction, or sepsis ¤ Refer to Infectious Disease specialist ¤ Refer to Renal service for early dialysis ¤ Transfer to ICU
- 71. Leptospirosis: WOF Jarisch-Herxheimer reaction ¤Occurs in response to antimicrobial therapy, when massive spirochete kill releases lipoproteins ¤ Simulates worsening of disease ■ Fever, chills, myalgias, headache ■ Tachycardia, tachypnea ■ Increased WBC, neutrophils ■ Hypotension ¤ Supportive therapy ¤ Subsides after 12-24 hours without revision of meds
- 72. Leptospirosis: Resolution Jaundice toresolve in 2 to 4 weeks May discharge if ¤ Creatinine clearance is on upward trend ¤ Urine output at least 0.5 cc/kg/hr ¤ Electrolytes corrected ¤ Platelet/hemoglobin corrected ¤ No ongoing hemoptysis Prophylaxis ¤ Doxycycline 200 mg PO once a week if exposed
- 73.
- 74.
- 75.
- 76. Hypertension: Presentation Symptoms ¤ Frequentlyasymptomatic ¤ Aching nape/occipital area ¤ Symptoms of target organ damage Signs: Try to detect both cause and effect… ¤ Kidney disease: anemia, oliguria, sallow skin ¤ Cushing’s syndrome: obesity, striae, moon facies, etc ¤ Hyper/hypothyroidism ¤ Heart failure
- 77. Hypertension: Presentation Signs: TakingBlood Pressure ¤ Aneroid instrument vs mercury based instruments ¤ Seated quietly for 5 minutes (Quiet, private, with comfortable room temperature) ¤ Bladder cuff is at least half of arm circumference ¤ Deflation is 2 mmHg/s ¤ Measure both arms, in supine, sitting and standing positions (detects coarctation, orthostatic changes) ¤ Measure 1 leg at least once (take ABI)
- 78. Hypertension: Presentation Signs ¤ Palpateall possible pulses ¤ Cardiac examination is important ¤ Auscultate carotid and renal bruits
- 79. Hypertension: Classification (JNC7) Classification Systolic, mmHg Diastolic, mmHg Normal < 120 And < 80 Prehypertension 120-139 Or 80-89 Stage 1 140-159 Or 90-99 Stage 2 ≥ 160 Or ≥ 100
- 80. Hypertension: Order Sheet Diagnostics ¤Urinalysis (renal cause and complication) ¤ BUN, Crea, Na, K, Ca, alb (low K is clue for aldosteronism and pheochromocytoma) ¤ FBS, Lipid profile (co-morbidities) ¤ CBC (anemia) ¤ ECG (LVH, other abnormalities)
- 81. Hypertension: Order Sheet Lifestylechanges ¤ BMI < 25 kg/m2 ¤ Exercise: Near-daily to daily aerobic activity ¤ Alcohol avoidance/moderation ¤ DASH diet: fruits, vegetables, low fat dairy, reduced saturated and total fat ¤ Salt-restriction: NaCl < 6 g/d BEADS
- 82. First-line agents (JNC8)* Thiazide-type diuretic Calcium channel blocker (CCB) Angiotensin-converting enzyme inhibitor(ACEI) Angiotensin receptor blocker (ARB) *Including those with diabetes
- 83. Hypertension: Order Sheet Medications:Diuretics ¤ Examples ■ Hydrochlorothiazide 12.5 – 25 mg OD-BID ■ Furosemide 40-80 mg BID-TID ■ Spironolactone 25-100 mg OD-BID ¤ Good for heart failure ¤ Caution in DM, gout, renal failure ¤ K reducer: furosemide, HCTZ ¤ K retainer: spironolactone
- 84. Hypertension: Order Sheet Medications:Beta blockers ¤ Examples ■ Atenolol 25-100 mg OD ■ Metoprolol 25-100 mg OD-BID ■ Propranolol 40-160 mg BID (not cardioselective) ■ Carvedilol 12.5-50 mg BID (combined alpha and beta) ¤ Good for heart failure, angina, MI, tachycardia ¤ Caution in 2nd or 3rd degree AV block, asthma/COPD
- 85. Hypertension: Order Sheet Medications:ACE inhibitors ¤ Examples ■ Captopril 25-200 mg BID-TID ■ Enalapril 5-20 mg OD ■ Lisinopril 10-40 mg OD ■ Ramipril 2.5-20 mg OD-BID ¤ Good for heart failure, MI, DM ¤ Caution in renal failure, hyperkalemia, renal artery stenosis, pregnancy ¤ May cause cough, angioedema
- 86. Hypertension: Order Sheet Medications:Angiotensin receptor blockers ¤ Examples ■ Losartan 25-100 mg OD-BID ■ Valsartan 80-320 mg OD ■ Candesartan 2-32 mg OD-BID ¤ Good for heart failure, MI, DM ¤ Caution in renal failure, hyperkalemia, renal artery stenosis, pregnancy ¤ Used as second-line to ACE-inhibitors
- 87. Hypertension: Order Sheet Medications:Dihydropyridine CCBs ¤ Examples ■ Amlodipine 5-10 mg OD ■ Long-acting Nifedipine 30-60 mg OD ¤ Good for angina ¤ Caution in heart failure, 2nd or 3rd degree AV block ¤ Causes peripheral edema
- 88. Hypertension: Order Sheet Medications:Non-Dihydropyridine CCBs ¤ Examples ■ Long-actingVerapamil 120-360 mg OD-BID ■ Long-acting Diltiazem 180-420 mg OD ¤ Good for angina, MI, DM, tachycardia ¤ Caution in heart failure, 2nd or 3rd degree AV block ¤ Causes peripheral edema
- 89. Hypertension: Order Sheet Medications:Direct Vasodilators ¤ Examples ■ ISMN 30-60 mg OD ■ ISDN 5-10 mg BID-TID ■ Hydralazine 25-100 mg BID-TID ¤ Nitrates good for angina, MI ¤ Nitrates cause hypotension, headache (must have at least 8 hours a day drug free), and has reaction with sildenafil ¤ Hydralazine should not be used in severe coronary artery disease
- 90. BP Targets (JNC8) In the general population aged > 60 years ¤ Initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) > 150 mm Hg or diastolic blood pressure (DBP) > 90 mm Hg ¤ Target BP <150/90 mm Hg
- 91. BP Targets (JNC8) In the general population aged < 60 years, including those with CKD or diabetes: ¤ Initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) > 140 mm Hg or diastolic blood pressure (DBP) > 90 mm Hg ¤ Target BP <140/90 mm Hg
- 92. Hypertension: Follow-up Adjustment ¤ Diuretics:daily to weekly (electrolyte imbalances) ¤ Beta-blockers: every 2 weeks ¤ ACE-inhibitors and ARBs: every 1 – 2 weeks ¤ CCBs: every 1 – 2 weeks ¤ Vasodilators: Every 1 – 2 weeks
- 93. Hypertension: WOF Secondary Hypertension ¤CGN/Nephrotic syndrome/CKD: urinary findings, edema ¤ Pheochromocytoma: sweating, palpitations, headache, early target organ damage ¤ Primary aldosteronism: resistant to medications, low K, weakness ¤ Connective Tissue Disease: pulse discrepancy, systemic symptoms ¤ Refer to Renal/Endo/Rheuma
- 94. Hypertension: WOF Hypertensive Urgencyvs Emergency ¤ Both require admission ¤ Emergency: presence of target organ damage ■ Reduce blood pressure by 25% over minutes to 2 hours ■ Parenteral agents ¤ Urgency: No target organ damage ■ Reduce blood pressure over hours ■ Oral agents
- 95. Hypertension: WOF Hypertensive Urgencyvs Emergency ¤ Nitroprusside: 0.3 ug/kg/min, maximum at 10 ug/kg/ min; discontinue if no response after 10 minutes ¤ Nitroglycerin drip: 5 ug/min, titrate at 5-10 ug/min at 3 to 5 minute intervals ■ 10 mg/10mL or 50 mg/50 mL, diluted to 10 mg in 100 mL ¤ Nicardipine drip: 5 mg/h, titrate by 2.5 mg/h at 5-15 minute intervals, maximum at 15 mg/h ■ 2 mg/2mL or 10 mg/10mL, diluted to 10-20 mg in 100 mL
- 96. CARDIOLOGY Angina and theAcute Coronary Syndromes
- 97. Angina: Presentation Symptoms ¤ Heaviness,pressure, squeezing, localized retrosternally ¤ Crescendo vs decrescendo ¤ Radiates anywhere between the mandible and umbilicus ¤ Related to exertion Signs ¤ High/low blood pressure, tachy/bradycardia ¤ Heart failure
- 98. Angina: Order Sheet Completebed rest Oxygenation ¤ Target O2 saturation > 90% ¤ Nasal cannula vs face mask vs intubation Cardiac monitor Vital signs Ask about sildenafil use in past 24 hours ¤ Viagra, cialis, ambigra, adonix, erefil, neo-up
- 99. Angina: Order Sheet Givenitrates ¤ Nitroglycerin 0.3-0.6 mg, or via buccal spray ¤ ISDN 5 mg sublingual ¤ 3 doses 5 minutes apart ¤ If persistent, start Nitroglycerin drip ■ 10 mg in 100 mL, start at 5 ug, and increased by 5-10 ug/min ■ Titrated every 3 to 5 minutes until symptoms are relieved or systolic arterial pressure falls to < 100 mmHg ¤ Good for pulmonary congestion ¤ Caution in: inferior wall/right-sided infarcts (hypotension)
- 100. Angina: Order Sheet InitialDiagnostics ¤ 12-lead ECG (within 10 minutes) ¤ 2D-echocardiogram ¤ BUN, Crea, Na, K, Ca, alb, Mg, AST ¤ Cardiac enzymes: Trop I/T > CKMB > CKtotal ¤ Urinalysis ¤ Chest X-ray ¤ PT/PTT ¤ Optional: Nuclear perfusion scan, cardiac MRI, cardiac PET
- 101. UAHR/NSTEMI/STEMI Loading Dose ¤ Aspirin80 mg/tab 4 tabs chewed and swallowed ¤ Clopidogrel 75 mg/tab 4 tabs chewed and swallowed ¤ Metoprolol 5 mg IV q5 up to 15 mg (3 doses), then followed in 1-2 hours by 25-50 mg PO q6 ¤ Morphine 2-5 mg IV repeated q5-30 minutes ¤ Captopril 25 mg/tab ½ to 1 tab q8 ¤ Heparinization (unfractionated heparin or low molecular weight heparin)
- 102. Angina: STEMI Decide whetherto do PCI or not ¤ Referral center should be no more than 30 mins away ¤ Door-to-balloon time should be at most 90 mins ¤ Golden period: not more than 6h, may give 12h after Refer to CVS for thrombolysis ¤ Take informed consent ¤ Streptokinase 1.5 M u in pNSS to make 100 cc to consume over 1 hour ¤ Pre-medication with Diphenhydramine 1 amp IV ¤ Can have hemorrhage, allergic reactions
- 103. Angina: STEMI Absolute contraindicationsto thrombolysis ¤ Cerebrovascular hemorrhage at any time ¤ Known structural cerebral vascular lesion (e.g. AVM) ¤ Non-hemorrhagic stroke/event in the past year ■ Ischemic stroke within 3 months, except if within 3 hours ¤ Hypertension (SBP > 180, DBP > 110) ¤ Suspicion of aortic dissection ■ Must do Chest/abdominal CT stat if suspected ¤ Active internal bleeding except menses ¤ Any known malignant neoplasm ¤ Significant closed head/facial trauma in past 3 months
- 104. Angina: STEMI Admit toICU/CCU
- 105. UAHR/NSTEMI/STEMI Loading Dose ¤ Aspirin80 mg/tab 4 tabs chewed and swallowed ¤ Clopidogrel 75 mg/tab 4 tabs chewed and swallowed ¤ Metoprolol 5 mg IV q5 up to 15 mg (3 doses), then followed in 1-2 hours by 25-50 mg PO q6 ¤ Morphine 2-5 mg IV repeated q5-30 minutes ¤ Captopril 25 mg/tab ½ to 1 tab q8 ¤ Heparinization
- 106. UAHR/NSTEMI/STEMI Aspirin and Clopidogrel ¤Part of antithrombotic therapy ¤ Maintenance ■ Aspirin 80 mg/tab 1 tab OD (with a meal) ■ Clopidogrel 75 mg/tab 1 tab OD ¤ WOF GI bleed, allergy to aspirin
- 107. UAHR/NSTEMI/STEMI Beta blockers ¤ Partof anti-ischemic therapy ¤ Maintenance ■ Metoprolol 50 mg BID ¤ Target: HR 50-60 bpm ¤ Caution in hypotension, asthma, COPD. Severe pulmonary edema
- 108. UAHR/NSTEMI/STEMI Calcium channel blockers ¤Part of anti-ischemic therapy ¤ Used in patients with contraindication to beta blockers ¤ Maintenance ■ Long-actingVerapamil 120-360 mg OD-BID ■ Long-acting Diltiazem 180-420 mg OD ¤ Target: HR 50-60 bpm, no chest pain ¤ Avoid rapid-release CCB (e.g. nifedipine) ¤ Caution in pulmonary edema, severe LV dysfunction, hypotension, bradycardia, heart-block
- 109. UAHR/NSTEMI/STEMI Morphine ¤ Part ofanti-ischemic therapy ¤ Maintenance ■ None – PRN use only ¤ Target: no chest pain ¤ Caution in inferior wall/right ventricular infarction, hypotension, respiratory depression, confusion, obtundation
- 110. UAHR/NSTEMI/STEMI ACE-inhibitors ¤ Part oflong-term cardiac therapy ¤ Maintenance ■ Captopril 25 mg 1 tab q8 ■ Enalapril 5-20 mg OD ¤ Gradual increase as patient stabilizes ¤ Good for LV dysfunction, anterior wall MI ¤ Caution in hypotension, renal failure, hyperkalemia
- 111. UAHR/NSTEMI/STEMI Statins ¤ Part oflong-term cardiac therapy ¤ Plaque stabilization ¤ Maintenance (@HS doses) ■ Atorvastatin 10 mg, max 80 mg ■ Rosuvastatin 10 mg, max 40 mg ■ Simvastatin 20 mg, max 80 mg ¤ Gradual increase over a period of 2 months ¤ Good for dyslipidemia, MI ¤ Caution in liver disease, rhabdomyolysis
- 112. UAHR/NSTEMI/STEMI Heparin ¤ Part ofanti-thrombotic therapy ¤ Types ■ UFH 60 U LD, then 12U/kg/h target PTT 1.5-2.0x normal ■ Enoxaparin 30 mg IV LD then 1 mg/kg SC q12 (OD if creatinine clearance < 30 mL/min) ■ Fondaparinux 2.5 mg SC OD ¤ If patient is unstable, has poor hemodynamic status, or has risk of bleeding, age > 75 y/o, UFH is preferred ¤ PTT measurements should be done q6 ¤ Duration is 2 to 5 days
- 113. UAHR/NSTEMI/STEMI Targets ¤ Activity (SUPERVISED) ■First 12 hours: Bed rest ■ 12-24 hours: Dangling legs/sitting in a chair ■ 2nd-3rd day: Ambulation in room, go to shower ■ 3rd day and beyond: 185 m (600 feet) at least 3x a day ■ Sexual activity: 2-4 weeks after event ■ Work: 1 month after event
- 114. UAHR/NSTEMI/STEMI Targets ¤ Diet ■ First4-12 hours: NPO ■ If stable: Complex carbohydrates (50-55%), Fat < 30%, total cholesterol < 200 mg/d, fiber rich ¤ Bowel care ■ Stool softeners ■ Bedside commode rather than bedpan ■ Laxative
- 115. UAHR/NSTEMI/STEMI Targets ¤ Sedation ■ Quiet,reassuring environment ■ Diazepam 5 mg TID-QID ¤ Tight glycemic control ■ Insulin drip preferred in acute setting ■ Pre-prandial: 90-130 mg/dL (critical care: < 110) ■ Post-prandial: < 180 mg/dL (critical care: < 180) ■ Long-term: HbA1c < 7%
- 116. UAHR/NSTEMI/STEMI Targets ¤ Electrolyte ■ Mg1.0 mmol/L ■ K 4.0-4.5 mmol/L ■ Ca 2.12-2.52 ¤ Discontinue O2 ■ May discontinue starting 6 hours after admission, if O2 saturation > 90%
- 117. Angina: Watch OutFor… Arrhythmia ¤ Defibrillate with maximum dose available up to 3x ¤ Amiodarone 150 mg in 50 to 100 cc pNSS over 10 minutes, then drip 360 mg in D5W x 6 hours ¤ Refer to CVS Mechanical complications ¤ Wall rupture ¤ New-onset mitral regurgitation ¤ Pericarditis ¤ Refer to CVS/TCVS
- 118. Angina: Resolution Follow-up after2 weeks ¤ For treadmill exercise test (if appropriate) ¤ Titration of medications ¤ Strengthen previous advice
- 119. Chronic Stable Angina Symptoms ¤Same as acute angina ¤ Symptoms > 2 weeks ¤ No worsening, crescendo pattern over hours/weeks ¤ No increase in frequency Signs ¤ Hemodynamically stable ¤ Complete cardiovascular PE should be done
- 120. Chronic Stable Angina Diagnostics ¤12-L ECG ¤ Treadmill exercise test ¤ 2D-echo ¤ Crea, Na, K, Mg. Ca, alb ¤ Lipid profile, FBS ¤ Chest X-ray
- 121. Chronic Stable Angina Medications ¤Anti-platelet ¤ Beta blocker ¤ ACE inhibitor ¤ Statin
- 122. Chronic Stable Angina Medications ¤Anti-platelet ■ Aspirin 80 mg OD ■ Clopidogrel 75 mg OD if ASA-intolerant ¤ Beta blocker ■ Atenolol 25-100 mg OD ■ Metoprolol 50-100 mg OD-BID ■ Carvedilol 6.25-50 mg BID
- 123. Chronic Stable Angina Medications ¤ACE inhibitor ■ Captopril 25-200 mg BID-TID ■ Enalapril 5-20 mg OD ■ Lisinopril 10-40 mg OD ■ Ramipril 2.5-20 mg OD-BID ¤ Statin ■ Atorvastatin 10 mg, max 80 mg @HS ■ Rosuvastatin 10 mg, max 40 mg @HS ■ Simvastatin 20 mg, max 80 mg @HS
- 124. Chronic Stable Angina Ifwith high-risk features, or positive stress test, advice coronary angiography with intervention ¤ Useless to do CA without intervention ¤ PCI vs CABG depends on clinical picture ¤ Refer to CVS in an institution with PCI/CABG capability
- 125.
- 126.
- 127.
- 128. Asthma: Presentation Symptoms ¤ Trigger ■Allergen ■ URTI/Pneumonia ■ Beta blockers. Aspirin ■ Exercise. Cold air, hyperventilation, laughter ■ Occupational asthma (Mondays) ■ Stress ¤ Dyspnea, shortness of breath, chest tightness ■ Night exacerbations ¤ Cough ¤ Younger age group
- 129. Asthma: Presentation Signs ¤ Tachypnea ¤Tachycardia, hypertension ¤ Wheezing ¤ Absence of wheezing = severe ¤ Clubbing = uncontrolled
- 130. Asthma: Order Sheet Diagnostics ¤ABG (hypercarbia, hypoxemia, alkalosis) ¤ Chest X-ray (rule out infection, other differentials) ¤ 12-L ECG (rule out cardiac causes of dyspnea ¤ CBC with PC (infection)
- 131. Asthma: Order Sheet Oxygenation ¤O2 support ■ Intubation if in impending/frank respiratory failure Short acting inhaled beta-agonists ¤ Salbutamol nebulization q5-15 ¤ WOF tremors, palpitations Inhaled anti-cholinergics ¤ Ipatropium bromide nebulization q5-15 ¤ WOF Dry mouth, decreased sputum production/dry cough
- 132. Asthma: Order Sheet Glucocorticoids ¤Hydrocortisone 50 mg IV q6 or 100 mg IV q8 ¤ Budesonide nebule q8 ¤ WOF Hoarseness, dysphonia, oral candidiasis, systemic effects Aminophylline drip ¤ Mix as 1mg/mL ¤ LD 6 mg/kg over 20-30 minutes ¤ Maintenance at 1 mg/kg/hr (use lower dose in elderly, or in nonsmokers) ¤ Hook to cardiac monitor ¤ WOF flushing, diarrhea, nausea, vomiting, arrhythmias
- 133. Asthma: Order Sheet Ifwith status asthmaticus, admit to ICU Refer to anesthesia if previous measures don’t work ¤ Propofol, Halothane Treat infection ¤ Most common is still viral URTI (supportive therapy) ¤ See CAP guidelines if with pneumonia Check if drug is the trigger
- 134. Asthma: Resolution Discharge ¤ Nowheezing and tolerates room air ¤ No IV glucocorticoids ¤ Infection is treated
- 135. Asthma: Resolution Discharge Medications ¤Home medications: ¤ Oral steroid with tapering schedule ■ Prednisone at 0.5 -1 mg/kg/d in 2/3-1/3 dosing ¤ Combination inhaled corticosteroid with long-acting inhaled beta-agonist ■ Budesonide + Formoterol 160/4.5 or 80/4.5 ug 1-2 puffs BID ■ Fluticasone + Salmeterol 500/50 or 250/50 or 100/50 1-2 puffs BID ■ Gargle after use ¤ Rescue doses of short acting inhaled beta-agonists ■ Salbutamol neb PRN
- 136. Asthma: Outpatient Care ShortActing Beta agonist Mild intermittent Mild persistent Moderate persistent Severe persistent Very Severe persistent ICS low dose ICS low dose ICS high dose ICS high dose LABA LABA LABA OCS ≤2/week Symptoms Night ≤2/month 3-6/week 3-4/month Daily ≥5/month Daily Frequently Unremitting Nightly
- 137. Asthma: Outpatient Care Smokingcessation Influenza vaccination annually Pneumococcal vaccination once then q5 years
- 138.
- 139. COPD: Presentation Symptoms ¤ Cough,sputum production, exertional dyspnea ¤ Smoking ¤ Decreased functional capacity ¤ Chronic symptoms ¤ Older age group Signs ¤ Wheezing ¤ Clubbing, cyanosis ¤ Barrel-chest
- 140. COPD: Presentation Diagnostics ¤ ABG(hypercarbia, hypoxemia) ¤ Chest X-ray (infection, chronic changes – hyperinflation, fibrosis, cause of COPD) ¤ CBC with PC (infection) ¤ 12-L ECG (consider cardiac etiology)
- 141. COPD: Order Sheet Oxygenation ¤O2 support ■ Intubation if in impending/frank respiratory failure Short acting inhaled beta-agonists AND inhaled anti- cholinergics ¤ Salbutamol nebulization q5-15 ¤ Ipatropium bromide nebulization q5-15 Methylxanthine ¤ Theophylline 10-15 mg/kg in 2 divided doses ¤ Comes in 100, 200, 300, 400, 450 mg
- 142. COPD: Order Sheet Glucocorticoids ¤Hydrocortisone 50 mg IV q6 or 100 mg IV q8 ¤ Budesonide nebule q8 ¤ Shift to Prednisolone/Prednisone 30-40 mg to complete 2 weeks Antibiotics ¤ Bronchiectasis with increased sputum production ¤ 2 weeks of antibiotics directed against pathogen
- 143. COPD: Resolution Complete smokingcessation Pulmonary Rehabilitation (Refer to Rehab) Lung volume reduction surgery in severe emphysema Oxygen therapy ¤ Resting O2 sat < 88% ¤ O2 sat < 90% if with pulmo HTN, cor pulmonale Influenza vaccination annually Pneumococcal vaccine once then q5 years
- 144. COPD: WOF Cor Pulmonale ¤Right heart enlargement on X-ray, ECG ¤ Prominent neck veins and peripheral edema ¤ Careful diuresis ■ Furosemide 20-40 mg BID ■ Spironolactone 25-100 mg OD-BID
- 145.
- 146.
- 147.
- 148. DM: Presentation Symptoms ¤ Weightloss, unexplained ¤ Polyuria, polydipsia ¤ Frothy urine ¤ Decreased vision ¤ Poorly healing wounds, frequent infections ¤ Paresthesias, numbness ¤ Stroke, MI previously ¤ DKA: abdominal pain, nausea, vomiting, young ¤ HHS: poor appetite, increased sleeping time, elderly
- 149. DM: Presentation Signs ¤ Decreasedsensation ¤ Non-healing wound ¤ Skin atrophy, Muscle atrophy ¤ Diabetic dermopathy (necrobiosis lipiodica diabeticorum) ¤ Renal failure ¤ Retinopathy ¤ DKA: ketone breath, normal abdomen, tachycardic, tachypneic ¤ HHS: obtundation, dehydration
- 150. DM Emergency: OrderSheet Diagnostics ¤ CBC with PC (infection, anemia) ¤ RBS, BUN, Crea, Na, K, Cl, Ca, alb, Mg, P (azotemia, low albumin, electrolyte imbalances, anion gap) ¤ Plasma ketones if available ¤ ABG ¤ Chest X-ray (and X-ray of involved extremity if with non- healing wound) ¤ Urinalysis with ketones ¤ 12-L ECG ¤ HBA1c (instead of FBS) ¤ CBG
- 151. DM Emergency: OrderSheet Computations ¤ Osmolality ■ 2(Na + K) + BUN + RBS (in mmol/L) ■ Normal is 276-290 mmol/L ¤ Anion gap ■ Na – (Cl + HCO3) ■ Normal is 10-12 mmol/L
- 152. DM Emergency: OrderSheet Parameters DKA HHS Blood Chem Glucose (mg/dL) 250-600 600-1200 Na 125-135 135-145 K Normal to Inc Normal Mg Normal Normal Cl Normal Normal P Dec Normal Crea Slight Inc Moderately Inc Osmolality 300-320 330-380 Ketones ++++ +/- ABG HCO3 < 15 mEq/L Normal to slightly dec pH 6.8-7.3 > 7.3 pCO2 20-30 Normal Both Anion gap Inc Normal to slightly Inc
- 153. DM Emergency: OrderSheet ICU admission ¤ If unstable ¤ pH < 7.00 ¤ Decreased sensorium Refer to Endo
- 154. DM Emergency: OrderSheet Replace fluids ¤ 2-3 L pNSS over first 1-3 hours (10-15 mL/kg/h) ¤ 0.45% NSS at 150-300 mL/h ¤ D5 0.45%NSS at 100-200 mL/h if CBG ≤ 250 mg/dL ¤ WOF congestion, hyperchloremia ¤ HHS: if Na > 150, use 0.45% NSS at the onset Insulin ¤ Start only if K > 3.3 ¤ 0.1-0.15 u/kg IV bolus ¤ 0.1 u/kg/h IV infusion, target CBG 150-250 mg/dL ■ 20 or 100 units regular insulin in pNSS to make 100 cc in soluset dripped via infusion pump (1cc = 1u if 100 u used)
- 155. DM Emergency: OrderSheet Assess precipitant ¤ Noncompliance/missed insulin dose ¤ Infection (UTI, pneumonia) ¤ Myocardial infarction ¤ Drugs CBG q1-2 hours Electrolytes and ABG q4 for first 24 hours NVS, I/O q1
- 156. DM Emergency: OrderSheet Correct potassium ¤ K < 5.5: 10 mEq/h ¤ K < 3.5: 40-80 mEq/h Correct acidosis only if pH < 7.0 after initial hydration ¤ pH 6.9-7.0: 50 mEqs NaHCO3 + 10 mEqs KCl in 200 mL sterile water x 1h ¤ pH < 6.9: 100 mEqs NaHCO3 + 20 mEqs KCl in 400 mL sterile water x 2h ¤ Repeat ABG 2 hours after ¤ Repeat dose q2 hours until pH > 7.0
- 157. DM Emergency: OrderSheet Correct magnesium ¤ Target 0.8 to 1 mmol/L ¤ Each gram of Mg will increase Mg by 0.1 mmol/L ■ 3g MgSO4 in D5W 250 cc x 12h = 0.3 additional Mg
- 158. DM Emergency: OrderSheet ICU admission ¤ If unstable ¤ pH < 7.00 ¤ Decreased sensorium May apply hydration and insulin drip for hyperglycemic states Refer to Endo
- 159. DM Emergency: Resolution Decreaseinsulin until 0.05-0.1 u/kg/h As soon as patient is awake and tolerates feeding, may start patient on diet Overlap insulin with subcutaneous insulin ¤ Calculate insulin requirements from insulin drip used in past 24 hours
- 160. DM Inpatient: InsulinRegimens NPH Insulin + Regular Insulin Total Insulin = 0.5 to 1 u/kg Body Weight 2/3 total insulin 1/3 total insulin 2/3 NPH 1/3 Regular 1/2 NPH 1/2 Regular Sugar Pre-breakfast Pre-lunch Pre-supper Before sleeping Adjust Pre-supper NPH Pre-breakfast Regular Pre-breakfast NPH Pre-supper Regular
- 161. DM Inpatient: InsulinRegimens Glargine Insulin + Lispro Insulin Total Insulin = 0.5 to 1 u/kg Body Weight 1/2 Total insulin 1/2 Total insulin 1/3 Lispro 1/3 Lispro 1/3 Lispro Glargine Sugar Pre-breakfast Pre-lunch Pre-supper Before sleeping Adjust Glargine Pre-breakfast Lispro Pre-lunch Lispro Pre-supper Lispro
- 162. DM Inpatient: OrderSheet Inpatient goals ¤ Pre-prandial 90-130 mg/dL ¤ Post-prandial < 180 mg/dL For thin, insulin sensitive patients ¤ Add 1 unit to errant insulin for every 50 mg/dL above target For obese, insulin resistant patients ¤ Add 2 units to errant insulin for every 50 mg/dL above target
- 163. DM Inpatient: WOF Nephropathy ¤Refer to Renal if with decreasing urine output, low creatinine clearance, for possible HD Ophthalmopathy/Retinopathy ¤ Refer to Ophtha Diabetic foot ulcer ¤ Refer to Ortho/TCVS Deterioration in sugar control ¤ See previous orders ¤ Refer to Endo Acute coronary event
- 164. DM Outpatient: OrderSheet Diagnostics: ¤ FBS, 2-hour post-prandial glucose ¤ Lipid profile ¤ HBA1c
- 165. DM Outpatient: OrderSheet Targets ¤ HBA1c < 7% ¤ Pre-prandial glucose (FBS) 70-130 mg/dL ¤ Post-prandial glucose (2h PPBS) < 180 mg/dL ¤ BP < 140/90 ¤ Lipid modification (order of decreasing priority) ■ LDL < 100 mg/dL ■ HDL > 40 mg/dL in males, > 50 in females ■ TG < 150 mg/dL
- 166. DM Outpatient: OrderSheet Medications: Biguanides ¤ Dose ■ Metformin 500 mg-1g OD, BID, TID (max 3g/day) ■ Adjust every 2-3 weeks ¤ Goal effect ■ Reduces HBA1c by 1-2% ■ Reduces fasting plasma glucose ¤ Good: weight loss ¤ Caution: Renal insufficiency (Crea > 124 mmol/L), lactic acidosis, GI effects ¤ Hold 24h prior to procedures, while critically ill
- 167. DM Outpatient: OrderSheet Medications: Sulfonylureas ¤ Dose ■ Glimepiride 1-8 mg OD ■ Glipizide 2.5-10 mg OD-BID ■ Take shortly before meals ¤ Goal effect ■ Reduces HBA1c by 1-2% ■ Reduces fasting and post-prandial plasma glucose ¤ Caution: weight gain, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease
- 168. DM Outpatient: OrderSheet Medications: Thiazolidinediones ¤ Dose ■ Pioglitazone 15-45 mg OD ■ Rosiglitazone 1-4 mg OD-BID ¤ Goal effect ■ Reduces HBA1c by 0.5-1.5% ■ Reduces fasting and post-prandial plasma glucose ■ Reduces insulin requirements ¤ Caution: weight gain but redistributes to peripheral areas, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease, edema, heart failure
- 169. DM Outpatient: OrderSheet Medications: DPP-IV inhibitors ¤ Dose ■ Sitagliptin 50-100 mg OD ■ Vildagliptin 50 mg OD-BID ¤ Goal effect ■ Reduces HBA1c by 0.5-1.0% ■ Reduces insulin requirements ¤ Good: does not cause weight gain, minimal hypoglycemia ¤ Caution: Renal insufficiency (use 50 mg OD if Crea > 124 mmol/L), headache, diarrhea, URTI
- 170. DM Outpatient: OrderSheet Medications: Alpha-glucosidase inhibitors ¤ Dose ■ Acarbose 25 mg with evening meal ■ Maximize to 50 - 100 mg with every meal ¤ Goal effect ■ Reduces HBA1c by 0.5-0.8% ■ Reduces post-prandial plasma glucose ¤ Good: weight loss ¤ Caution: GI effects (diarrhea, flatulence, abdominal distention), Renal insufficiency (Crea > 177 mmol/L)
- 171. DM Outpatient: OrderSheet Medications ¤ If 2 drugs aren’t sufficient, insulin is recommended ¤ Cost and compliance are of prime importance
- 172. DM Outpatient: OrderSheet Diet ¤ Fat 20-35% ■ Minimal saturated fat (<7%) ■ Minimal transfat ■ Decreased cholesterol (<200 mg/d) ■ At least 2 servings of fish (Omega-3 fatty acids) ¤ Carbohydrates 45-65% ■ Low glycemic index ■ Sucrose containing food with adjustments in meds/insulin ¤ Protein 10-35% ¤ High fiber
- 173. DM Outpatient: OrderSheet At least 150 minutes/week Monitor blood sugar before, during and after exercise ¤ CBG > 250 mg/dL, delay exercise ¤ CBG < 100 mg/dL, eat carbohydrate before exercise ¤ Pre-exercise insulin modification ■ Decrease dose ■ Inject into non-exercising muscle
- 174. DM Outpatient: Follow-up Homemonitoring of glucose HbA1c q3-6 months Medical nutrition therapy and education Eye examination annually Foot examination daily by patient, annually by MD Screening for albuminuria annually Lipid profile and Crea annually BP measurement q4 months
- 175.
- 176.
- 177. Hyperthyroidism: Presentation Symptoms ¤ Hyperactivity,irritability ¤ Heat intolerance, sweating ¤ Palpitations ¤ Weakness, weight loss, diarrhea ¤ Polyuria, oligomenorrhea Signs ¤ Tachycardia, sometimes atrial fibrillation ¤ Warm, moist skin ¤ Tremors, muscle weakness ¤ Anterior neck mass
- 178. Hyperthyroidism: Order Sheet Diagnostics ¤CBC with PC (infection) ¤ 12-L ECG (atrial fibrillation, tachycardia) ¤ Chest X-ray (rule out infection, cardiomegaly) ¤ Urinalysis (infection) ¤ Free T4 and TSH (high FT4, low TSH) ¤ Crea, Na, K (low K) ¤ Thyroid UTZ (especially if with nodule/s)
- 179. Hyperthyroidism: Order Sheet Burch-Wartofskyscoring ¤ Components ■ Temperature ■ CNS ■ GI ■ CVS: heart rate ■ CVS: heart failure ■ CVS: atrial fibrillation ■ Precipitant history ¤ Score ■ 25-44: impending storm ■ ≥45: storm
- 180. Hyperthyroidism: Order Sheet Therapeutics ¤Propylthiouracil 600 mg LD then 200-300 mg q6 ■ Orally/NGT ■ By rectum ¤ Saturated solution of Potassium Iodide (SSKI) 5 drops q6-8, 1 hour after every PTU dose
- 181. Hyperthyroidism: Order Sheet Therapeutics ¤Propranolol 40-60 mg PO q4 ■ If still no rate control: Verapamil 2.5-5 mg SIVP q15-30 minutes, maximum of 20 mg ■ Use digoxin rarely (decreased potency in hyperthyroidism) ¤ Glucocorticoids ■ Dexamethasone 2 mg IV q6 ■ Hydrocortisone 50 mg IV q6 ¤ Treat infection, fever aggressively ¤ Correct electrolytes
- 182. Hyperthyroidism: Order Sheet ICUadmission ¤ If stable, may admit to Ward Refer to Endo
- 183. Hyperthyroidism: Resolution Discharge ¤ TaperPTU to 200 mg TID ¤ Heart rate controlled with Propranolol BID ¤ Infection/precipitant treated
- 184. Hyperthyroidism: Out-patient Medication adjustment ¤Preferably Methimazole 20-30 mg OD ¤ Taper Propranolol until PRN Follow-up ¤ 2-4 weeks with repeat FT4 (same laboratory) ¤ Adjust methimazole based on FT4 ¤ TSH may be taken eventually to prove suppression Dietary avoidance ¤ Seafood ¤ Iodized salt
- 185. Hyperthyroidism: Out-patient 30 to50% achieve remission on medical treatment alone ¤ Usually after 12-18 months Definitive treatment: once euthyroid ¤ RAI ¤ Surgery ¤ Refer to Endo and GS/ORL
- 186. Hyperthyroidism: WOF Ophthalmopathy ¤ Steroids ■Prednisone 1 mg/kg in 2 divided doses ¤ Artificial tears ¤ Smoking cessation ¤ Refer to Ophtha
- 187. Hypothyroidism: Presentation Symptoms ¤ Weakness ¤Dry skin, hair loss, impaired healing ¤ Difficulty concentrating ¤ Weight gain, poor appetite ¤ Heart failure Signs ¤ Dry coarse skin, cool peripheral extremities ¤ Puffy face, hands and feet; alopecia ¤ Bradycardia ¤ Serous cavity effusions (pericardial, pleural, peritoneal) ¤ Hyporeflexia
- 188. Hypothyroidism: Order Sheet Diagnostics ¤Free T4, TSH (low FT4, High TSH) ¤ CBC with PC ¤ 12-L ECG (documentation of heart rate) ¤ Chest X-ray (enlarged heart, pleural effusion) ¤ Crea, Na, K (hypokalemia) ¤ Thyroid UTZ
- 189. Hypothyroidism: Order Sheet Diagnostics ¤Free T4, TSH (low FT4, High TSH) ¤ Anti-TPO ¤ CBC with PC ¤ 12-L ECG (documentation of heart rate) ¤ Chest X-ray (enlarged heart, pleural effusion) ¤ Crea, Na, K (hypokalemia) ¤ Thyroid UTZ
- 190. Hypothyroidism: Order Sheet Therapeutics ¤Levothyroxine 1.6 ug/kg BW in single dose before breakfast ¤ If missed dose: may take 2-3 doses of skipped tablets at once due to long half-life
- 191. Hypothyroidism: Follow-up Repeat TSHafter 2-4 weeks ¤ Use same laboratory ¤ Target lower half of TSH range
- 192.
- 193.
- 194.
- 195. PUD: Presentation Symptoms ¤ PUD:Epigastric pain, usually at night ¤ Metallic/acid taste in the mouth ¤ Melena ¤ NSAID use ¤ Weight loss, early satiety, vomiting Signs ¤ Epigastric tenderness ¤ Epigastric mass ¤ Melena on DRE (uncommon)
- 196. PUD: Order Sheet Diagnostics ¤CBC with PC ¤ EGD with H. pylori biopsy ¤ Urea breath test ¤ FOBT ¤ Chest X-ray
- 197. PUD: Order Sheet Therapeutics(Active Bleeding) ¤ PPI drip ■ Omeprazole 80 mg IV bolus ■ Omeprazole 80 mg in pNSS to make 100 cc x 10 cc/h (8 mg/h) ¤ Immediate endoscopy
- 198. PUD: Order Sheet Therapeutics ¤Proton pump inhibitors – 2-week trial ■ Omeprazole 20 mg/d ■ Esomeprazole 20 mg/d ■ Lansoprazole 30 mg/d ■ Administer BEFORE a meal ■ Long-term: pneumonia, osteoporosis ¤ H2-receptor antagonists ■ Ranitidine 300 mg @HS ■ Famotidine 40 mg @HS
- 199. PUD: Order Sheet Therapeutics ¤Antacids ■ Usually for symptom relief ■ Aluminum hydroxide-Magnesium hydroxide ■ WOF nephrotoxicity
- 200. PUD: Order Sheet Therapeutics(H. pylori positive) ¤ OCA/OCM regimen ■ Omeprazole 20 mg BID ■ Clarithromycin 250-500 mg BID ■ Amoxicillin 1g BID or ■ Metronidazole 500 mg BID ¤ Refer to GI if no response
- 201. PUD: Resolution Follow-up after2-4 weeks ¤ Decision to continue PPI dependent on symptoms ¤ Gastric ulcers have risk for malignancy
- 202.
- 203. GERD: Presentation Symptoms ¤ Burningretrosternal chest pain worsening/precipitated by recumbency ¤ Regurgitation of sour material into mouth ¤ Cough ¤ Dysphagia Signs ¤ Obesity ¤ Usually normal abdominal PE
- 204. GERD: Order Sheet Diagnostics ¤Usually none needed ¤ EGD ¤ CBC with PC
- 205. GERD: Order Sheet Therapeutics ¤Proton-pump inhibitors ■ Omeprazole 20 mg/d ■ Esomeprazole 40 mg/d ■ Take 30 minutes before breakfast ¤ Weight reduction ¤ Elevation of head by 4-6 inches during recumbency ¤ Avoid ■ Smoking ■ Fatty food, large quantities of food/fluid ■ Alcohol, mint, orange juice ■ Calcium channel blockers
- 206.
- 207. Poisons and Snakebites GeneralPrinciples of Management Alcohol Toxicity and Withdrawal Silver Jewelry Cleaner Ingestion Organophosphate Ingestion Kerosene Ingestion Acid and Alkali Ingestion
- 208.
- 209. General Principles 1. EmergencyStabilization 2. Clinical Evaluation 3. Elimination of the poison 4. Excretion of absorbed substance 5. Administration of antidotes 6. Supportive Therapy and Observation 7. Disposition
- 210. General Principles 1. EmergencyStabilization ¤ Airway ¤ Breathing: Oxygenation and Ventilation ¤ Circulation: Inotropes ¤ Convulsion cessation ¤ Electrolyte/metabolic correction ¤ Coma
- 211. General Principles 2. ClinicalEvaluation ¤ History: ■ Time, Mode/Route ■ Circumstances prior ■ Pre-existing illnesses or co-morbidities ■ Home remedies/treatment given ¤ PE ■ Complete ■ Breath odor ■ Neurologic PE
- 212. General Principles 2. ClinicalEvaluation ¤ Laboratory Examinations ■ CBC with PC ■ Urinalysis ■ RBS, BUN, Creatinine, Na, K, Ca, alb, Mg ■ ABG ■ 12-L ECG ■ Bilirubins, PT, AST, ALT, Alk Phos ■ Chest X-ray (best if PA-upright) ■ Plain abdominal X-ray
- 213. General Principles 3. Eliminationof the poison ¤ External decontamination ■ Discard all clothing ■ Thorough bathing ■ Eye irrigation ■ Protective gear for personnel ¤ Empty stomach ■ Induction of emesis (if ingestion occurred within 1 hour) ■ Gastric Lavage (50-60 mL of tepid sterile water) ■ Don’t do in ingestion of caustics, kerosene! ■ Don’t do if patient is convulsing!
- 214. General Principles 3. Eliminationof the poison ¤ Limit GI absorption ■ Activated charcoal: 50-100 g in 200 mL H2O ■ Do multiple doses if with enterohepatic recirculation ■ Contraindicated in caustics ■ Follow with Na sulfate up to 2 doses, then soap sud enema for BM ¤ Demulcent agents ■ Raw egg albumin: whites of 8-12 eggs ¤ Cathartics ■ Na sulfate 15 g in 100 mL H2O ■ Contraindicated in caustics, easily absorbable chemicals, ileus, severe fluid and electrolyte imbalances
- 215. General Principles 4. Excretionof absorbed substances ¤ Forced diuresis ■ Mannitol 20% 1 mL/kg within 10 minutes then 2.5-5 mL/kg q6 x 8 doses ■ Must have good urine output ¤ Alkalinization (for weak acids) ■ NaHCO3 1mEq/kg/dose IV targeting urine pH > 7.5 ¤ Acidification (for weak bases) ■ Ascorbic Acid 1g IV q6 until urine pH ≤ 5.5 ¤ Dialysis
- 216. General Principles 5. Antidotes 6.Supportive Therapy ¤ Fluid replacement for losses ¤ Electrolyte correction ¤ Prevention of aspiration, decubitus ulcers ¤ Monitoring VS and I/O 7. Disposition ¤ ER vs Ward vs ICU ¤ Psychiatric evaluation ¤ Social evaluation
- 217.
- 218. Alcohol Intoxication Blood alcohol(mg/dL) ¤ mL ingested x % alcohol x 0.8 6 x kg BW Metabolism ¤ Non-alcoholic: 13 to 25 mg/dL per hour ¤ Alcoholic: 30 mg/dL per hour Estimated time of recovery ¤ Blood alcohol/metabolic rate
- 219. Alcohol Intoxication Blood Ethanol (mg/dL) SymptomsBrain affected < 50 Talkativeness, euphoria Frontal Lobe 50-100 Decreased inhibition/ increased confidence, emotional instability, slow Parietal Lobe 100-300 Ataxia, slurred speech , diplopia, decreased attention span Occipital Lobe Cerebellum 300-500 Visual impairment, severe ataxia, stupor Midbrain > 500 Respiratory Failure, coma Medulla
- 220. Alcohol Intoxication Category Specific% Ethanol Beer Lager 2-3% Pilsen 5-6% Strong 9-14% Wine Red/White 7-12% Fortified Wine Champagne 15-20% Distillates Whiskey, rye, rhum, bourbon, gin 40-50% Local distilled Lambanog, tuba 60-80% Hygiene Products Perfume/cologne 25-95% Mouth wash 15-25%
- 221. Alcohol Intoxication Local TermVolume Lapad 325 mL Bilog 325 mL Kwatro kantos 325 mL Long neck 750 mL Beer grande 1000 mL Beer (regular) 320 mL
- 222. Alcohol Intoxication History ¤ Amountingested ¤ With what substance PE ¤ Evidence of trauma ¤ Level of sensorium
- 223. Alcohol Intoxication: OrderSheet Labs ¤ Urine ketones ¤ CK MB, MM ¤ Amylase ¤ FOBT
- 224. Alcohol Intoxication: OrderSheet Therapeutics ¤ NPO ¤ Insert NGT ¤ IVF: D5 0.9 NaCl 1L x 8h Conscious Unconscious
- 225. Alcohol Intoxication: OrderSheet Therapeutics ¤ Thiamine 100 mg IM/IV ¤ D50-50 100 mL fast drip IV ¤ Refer to Psych ¤ Evaluate for withdrawal ¤ Observe for 6 hours ¤ Discharge on ■ Thiamine 50 mg TID OR ■ Vitamin B complex 1 tab TID ■ Folic Acid OD, Multivitamins OD Conscious
- 226. Alcohol Intoxication: OrderSheet Therapeutics ¤ Thiamine 100 mg IM/IV now then q8 ¤ D50-50 100 mL fast drip IV ¤ Refer to Neurology ¤ Observe for return of consciousness ■ Fully awake: Observe for 5-7 days, refer to Psychiatry ■ Partially awake: Work-up for decreased sensorium (NSS?) ■ Comatose: Naloxone 2 mg IV q2 minutes for a total of 10 mg; work-up for decreased sensorium, consider HD ¤ Same discharge plans Unconscious
- 227. Alcohol Withdrawal: Presentation Symptoms/Signs ¤Autonomic hyperactivity (sweating, tachycardia) ¤ Increased tremors ¤ Insomnia ¤ Nausea/vomiting ¤ Hallucinations/illusions ¤ Psychomotor agitation/anxiety ¤ Seizures
- 228. Alcohol Withdrawal: OrderSheet Therapeutics ¤ Diazepam 2.5-5mg q8 x 3 days then taper for next 2 days before discontinuation ¤ Vitamin B complex TID ¤ Folic Acid OD
- 229. Alcohol: Resolution Enrol inquitting program Advice moderation
- 230.
- 231. Paracetamol: Presentation Toxic doseif 150-300 mg/kg Symptoms vary based on time after exposure ¤ 0-24 hours: asymptomatic, nausea, vomiting ¤ 24-36 hours: asymptomatic, upper abdominal pain ¤ 36-72 hours: onset of liver/renal failure ¤ 72-120 hours: jaundice, bleeding, liver/renal failure
- 232. Paracetamol History ¤ Time, mode ¤Intake of other substances/meds ¤ Co-morbidities PE ¤ Heart, liver, kidneys ¤ Neurologic examination
- 233. Paracetamol: Order Sheet Diagnostics ¤Serum paracetamol ¤ AST, ALT, PT
- 234. Paracetamol: Order Sheet Known <150 mg/kg Volume ingested? N-acetylcysteine Test dose: 0.1 mL in 0.9 mL NSS IV Diphenhydramine 1 mg/kg prior to phases Phase 1: 150 mg/kg in 200 mL D5W x 1h Phase 2: 50 mg/kg in 500 mL D5W x 4h Phase 3: 100 mg/kg in 1L D5W x 16h Observe for 24h Unknown ≥ 150 mg/kg (+) SSx (-) SSx Observe for 72h (+) SSx or AST, ALT or PT abn (+) SSx or AST, ALT or PT abn
- 235. Paracetamol: Order Sheet Normalizationafter 72 hours Discharge
- 236. Paracetamol: WOF Acute RenalFailure ¤ IVF hydration ¤ Refer to Renal for possible Dialysis Bleeding ¤ Vitamin K 10 mg IV up to q6 ¤ Target PT > 60% activity Hepatic insufficiency ¤ Vitamin B complex ¤ Vitamin K Electrolyte abnormalities ¤ Hypoglycemia, acidosis, hypokalemia, hypocalcemia
- 237.
- 238. Silver Jewelry Cleaner Activecompound is cyanide-derived Binds to cytochrome oxidase enzymes, inhibiting cellular respiration
- 239. SJC: Order Sheet Diagnostics ¤ABG ¤ Serum cyanide ¤ CBC with PC Anticipatory Care ¤ ICU admission ¤ Close monitoring ¤ Treatment for co-ingestants (e.g. alcohol)
- 240. SJC: Order Sheet Therapeutics ¤Oxygenation ■ High flow ■ Prophylactic intubation esp if with decreased sensorium ¤ Na nitrite 300 mg SIVP (over 5 minutes) ■ Vasodilator, displaces cyanide, producing methemoglobin ■ Causes hypotension ¤ Na thiosulfate 12.5 g (50 mL of a 25% solution) SIVP (over 10 minutes) ■ Speeds the displacement of cyanide by providing sulfur for binding
- 241. SJC: WOF Decreased sensorium ¤Aspiration precautions ¤ Prophylactic intubation if warranted Seizures ¤ Diazepam ¤ Increased oxygen delivery Hypoxic encephalopathy ¤ Rapidly reversible if antidote given early ¤ If still not reversed, need prognostication by Neuro
- 242.
- 243. Kerosene History ¤ Time ¤ Amount ¤Mucous membrane irritation ¤ CNS depression, seizures PE ¤ Lung findings: crackles, respiratory distress ¤ Arrhythmia, tachycardia ¤ Sensorial changes
- 244. Kerosene: Order Sheet Diagnostics ¤Chest X-ray (6 hours post-ingestion) ¤ ABG ≤ 60 mL ≤ 60 mL + other toxic substance > 60 mL or unknown Volume ingested?
- 245. Kerosene: Order Sheet ≤60 mL ≤ 60 mL + other toxic substance > 60 mL or unknown Volume ingested? • Insert NGT • Lavage with Activated Charcoal • Insert NGT • Lavage with water • Na Sulfate(BM) • Clean anal area with petroleum jelly
- 246. Kerosene: Order Sheet Observefor 12-24 hours Observe for 3 days Sensorial Change Pneumonia Toxic substances • Refer to Psych • Discharge Supportive Care
- 247. Kerosene: WOF Pneumonia ¤ PenicillinG 200,000 u/kg/d in 6 divided doses ¤ Clindamycin 300 mg PO/IV q6 ¤ Metronidazole 500 mg PO/IV q6 Gastritis ¤ Al-hydoxide-Mg-hydroxide 30 mL q6 Prolonged PT ¤ Vitamin K 10 mg OD Seizures ¤ Diazepam 2.5-5 mg SIVP ¤ Refer to Neuro
- 248.
- 249. Acids Causes coagulation necrosiswhich forms eschars ¤ Damage is self-limiting Eventual stenosis of viscus
- 250. Acids: Order Sheet Diagnostics ¤Cross-matching ¤ Urine hemoglobin ¤ Chest X-ray upright, plain abdomen ¤ Emergency EGD
- 251. Acids: Order Sheet Therapeutics ¤Copious amounts of water to decontaminate externally ¤ NPO ¤ IVF: D5NSS 1L x 8h ¤ Meperidine 25-50 mg IM ¤ Famotidine 20 mg IV q12 ¤ Concentrated acids: Enhance excretion with Mannitol ■ Test dose: 1 mL/kg within 10 mins ■ If with good urine output: 2.5-5.0 mL/kg q6 x 8 doses ■ Discontinue mannitol if with poor urine output x 2h
- 252. Acids: Order Sheet GradeFindings 0 Normal 1 Edema, hyperemia of mucosa 2A Friability, blisters, hemorrhages, erosions, whitish membranes, exudates, superficial ulcerations 2B 2A + deep discrete or circumferential ulceration 3A Small scattered areas of multiple ulcerations and areas of necrosis 3B Extensive necrosis
- 253. Grade 0-1 Grade2a/b Grade 3a/b Endoscopy Admit to ICU NPO IV hydration, TPN H2 blockers IV Repeat EGD 24-48h Admit to ICU NPO IV hydration/TPN H2 blockers IV Hydrocortisone 100 mg IV q6 for shock Meperidine Antibiotics (anarobes, Gram negatives) Repeat EGD 24-48h Admit Observe for 48 h Liquid diet for 48h H2 blockers PO/IV Demulcent, antacids or sucralfate Psych Referral Discharge Ff-up with GS/GI Perforation, Necrosis? Laparotomy Yes No
- 254. Acids: WOF Acute abdomen ¤Surgery ¤ Lifelong vitamin B12 if gastrectomy done Shock ¤ Fluids, antibiotics as appropriate Upper airway obstruction ¤ Tracheostomy ¤ Hydrocortisone 100 mg IV q6 Upper GI Bleed ¤ Blood transfusion, surgery
- 255.
- 256. Alkali Causes liquefaction necrosis ¤Damage spreads, and may continue for days
- 257. Alkali: Order Sheet Diagnostics ¤Cross-matching ¤ Urine hemoglobin ¤ Chest X-ray upright, plain abdomen ¤ Emergency EGD
- 258. Alkali: Order Sheet Therapeutics ¤Copious amounts of water to decontaminate externally ¤ NPO ¤ IVF: D5NSS 1L x 8h ¤ Meperidine 25-50 mg IM ¤ Famotidine 20 mg IV q12
- 259. Alkali: Order Sheet ExtentFindings First degree Superficial mucosal hyperemia, mucosal edema, superficial sloughing Second degree Deeper tissue damage, transmucosal (all layers of the esophagus), with exudates, erosions Third degree Through the esophagus and into the periesophageal tissues (mediastinum , pleura or peritoneum), deep ulcerations, black coagulum
- 260. First degree Second degree Third degree Endoscopy Admitto ICU NPO IV hydration, TPN Hydrocortisone 100 mg IV q6 H2 blockers IV Sucralfate Repeat EGD 24-48h Admit to ICU NPO IV hydration/TPN H2 blockers IV Hydrocortisone 100 mg IV q6 for shock Meperidine Antibiotics (anarobes, Gram negatives) Repeat EGD 24-48h Admit Observe for 48 h Liquid diet for 48h Demulcent, antacids Psych Referral Discharge Ff-up with GS/GI Perforation? Laparotomy Yes No
- 261. Alkali: WOF Acute abdomen ¤Surgery ¤ Lifelong vitamin B12 if gastrectomy done Shock ¤ Hypovolemic/Septic: Fluids, antibiotics as appropriate ¤ Neurogenic: Mepedirine 1 mg/kg/dose IV Upper airway obstruction (Glottic edema) ¤ Tracheostomy ¤ Hydrocortisone 100 mg IV q6 Upper GI Bleed ¤ Blood transfusion, surgery
- 262. NATIONAL POISON CONTROL ANDMANAGEMENT CENTER (02) 554-8400 loc 2311 (02) 524-1078 0922-896-1541
- 263.
- 264. Pain Medication Most commoncomplaint Best treatment: address the cause
- 265.
- 266. Pain Medication: NSAIDs ASA80-160 mg PO OD Paracetamol 500-650 mg PO up to q4 Ibuprofen 400 mg PO up to q4 Naproxen 250-500 mg up to q12 Ketorolac 15-60 mg IM/IV up to q4 Celecoxib 100-200 mg PO up to q12
- 267. Pain Medication: NSAIDs Advantages ¤Deals well with inflammatory pain (muscle and joint pain, malaise from infection, etc) ¤ Absorbed well from the GI tract Disadvantages ¤ GI irritation (except paracetamol) ¤ Peptic ulcer ¤ Nephropathy ¤ Increases blood pressure Selectivity for COX-2 ¤ Decreases GI symptoms ¤ Increases cardiovascular risk
- 268.
- 269. Pain Medication: Narcotics Tramadol50-100 mg PO up to q4 Morphine 60 mg PO up to q4 ¤ need S2
- 270. Pain Medication: Narcotics Advantages ¤Broadest efficacy ¤ Very rapid especially if IV Disadvantages ¤ Nausea and vomiting ¤ Constipation ¤ Sedation ¤ Respiratory depression
- 271.
- 272. Pain medication: Anti-convulsants Phenytoin300 mg @ HS Carbamazepine 200-300 mg up to q6 Clonazepam 1mg up to q6 Gabapentin 600-1200 mg up to q8 Pregabalin 150-600 mg up to BID
- 273. Pain medication: Anti-convulsants Advantages ¤Effective for neuropathic pain (e.g. trigeminal neuralgia, DM nephropathy) Disadvantages ¤ Hepatic toxicity ¤ Dizziness ¤ GI symptoms ¤ Heart conduction disturbances
- 274.