medicine blue book

8/9/2019 Medicine Blue Book

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By Dr. W.T. Ong & Dr. A.L.R. Ong

Prepared bv Dr. Neo

TABLE OF CONTENTS AbbreviationsContributing Authors

Preface

Detailed Table of Contents

CardiologyPulmonologyGastroenterologyInfectious Diseases

NephrologyEndocrinologyRheumatologyNeurologyToxicologyNutrition

The Pregnant Patient with Medical ProblemsPreventive Medicine & Adult ImmunizationsFinal Pointers

Appendices All About DripsMore Drug Lists: Pain Relievers / Laxatives / AntidiarrhealsMore Drug Lists: Antiflatulence / Antipyretics / Hypnotics and SedativesIntravenous FluidsFormulasReferences



TABLE OF CONTENTS AbbreviationsContributing AuthorsPreface

Back to Main Table of Contents

Cardiology........ Willie T. Ong, M.D. Advanced Cardiac Life Support Acute Myocardial InfarctionThrombolytic Therapy in MIUnstable AnginaCongestive Heart FailureHypertensive EmergencySupraventricular Tachycardia

Atrial FibrillationPremature Ventricular Contractions & Ventricular TachycardiaPremature Atrial Contractions

Infective Endocarditis (Treatment)Infective Endocarditis (Prophylaxis)

Acute Rheumatic Fever Treatment & ProphylaxisCardio-Pulmonary ClearanceDyslipidemia with Lipid Lowering DrugsIndications for Permanent Pacemaker InsertionHypertensionList of Antihypertensives & Cardiac DrugsLow Molecular Weight Heparins for DVT and Unstable AnginaThe Cardiac Patient with Other Medical Disorders

Pulmonology........ Camilo C. Roa, Jr., M.D.

Bronchial AsthmaDrugs Used to Treat Asthma

Management of Chronic AsthmaManagement of Acute Exacerbations of Asthma: Home TreatmentManagement of Acute Exacerbations of Asthma: Hospital TreatmentChronic Obstructive Pulmonary DiseaseTuberculosis

Antituberculosis Drug ListPulmonary EmbolismHemoptysisPleural Effusion and Thoracentesis

AnaphylaxisPneumothoraxPneumonia

Gastroenterology ........ Virgilio P. Banez, MD.

Peptic Ulcer Disease & Acute GastritisUpper and Lower GI Bleeding

Anti-ulcer Drugs Hepatic Encephalopathy & Liver Cirrhosis

Abdominal ParacentesisViral Hepatitis

Acute CholecystitisBacterial Cholangitis and Biliary Sepsis

Acute Pancreatitis Acute Diarrhea with Mild Dehydration



Cholera with Severe Dehydration Acute Intestinal Obstruction

Infectious Diseases ........ Cecilia S. Montalban, M.D.

Clinically Useful Antibiotics Antibiotic Drug ListSystemic Viral Infection

Acute TonsillopharyngitisDengue Hemorrhagic Fever Typhoid Fever MalariaPrevention of Malaria in TravellersLeptospirosisSchistosomiasisSepsis and Septic ShockLower Urinary Tract InfectionPyelonephritisCellulitisMeningitis and EncephalitisTetanusOsteomyelitis

PeritonitisDiverticulitisPelvic Inflammatory DiseasePneumoniaInfective EndocarditisMumpsVaricella Zoster Empirical Antimicrobials for Out-Patient AdultsInitial Antimicrobials for Acutely Ill AdultsDrug of Choice for Microbial Pathogens

Nephrology...... Elizabeth S. Montemayor, MD.

Acute Renal FailureStrategy for Removing Excess FluidChronic Renal FailureHypokalemia HyperkalemiaHypocalcemiaHypercalcemiaHyponatremiaHypomagnesemiaHypermagnesemiaNephrolithiasisDialysisDosage Adjustment of Drugs in Renal Failure

Endocrinology........ Ruby T. Go, MD.

Approach to Type II Diabetes MellitusDiabetic Ketoacidosis / Hyperosmolar ComaThyroid StormHyperthyroidismHypothyroidism

Adrenal Insufficiency

Rheumatology........ Clemente M Amante,‘MD.OsteoarthritisGouty Arthritis



Rheumatoid ArthritisSystemic Lupus Erythematosus

Neurology ...... Carlos L. Chua, M.D.

Cerebral Infarction vs. Hemorrhage GuideIntracerebral HemorrhageSubarachnoid Hemorrhage

Cerebral ThrombosisCerebral EmbolismTransient Ischemic AttackStroke In EvolutionStroke in the YoungSeizures and EpilepsyBrain AbscessMyasthenia GravisParkinson's Disease

Alcohol Withdrawal Approach to Weakness

Toxicology...... Kenneth Hartigan-Go, MD.

Poisoning and Drug Overdose: General Guidelines

Acid Ingestion Alkaline Ingestion Amphetamine / Metamphetamines AnticoagulantsDiazepamDigitalis / DigoxinEthanolHydrocarbon / KeroseneIsoniazidNarcoticsOrganophosphatesParacetamolPhenothiazines / NeurolepticsSalicylate / AspirinTricyclic Anti-Depressants

Nutrition...... Nutritionist-Dietitians' Association of the Philippines

Recommended Diet by Organ SystemHigh Fiber DietLow Calorie DietHigh Calorie DietHigh Protein DietLow Protein DietLow Fat / Low Cholesterol DietLow Carbohydrate DietLow Sodium DietLow Potassium DietLow Uric Acid / Low Purine DietNutritional Management of Diabetics and Renal Patients

The Pregnant Patient with Medical Problems.Camilo C. Roa, Jr., M.D., Ruby T. Go, MD., Willie T.Ong, MD.

Pregnancy and HypertensionPregnancy and Cardiac DiseasePregnancy and AsthmaPregnancy and Thyroid DiseasePregnancy and Diabetes



Drugs Used in Pregnancy

Preventive Medicine & Adult Immunizations.Willie T. Ong, MD., Cecilia S. Montalban, MD.

Final Pointers . WillieT. Ong

Appendices

All About DripsMore Drug Lists: Pain Relievers / Laxatives / AntidiarrhealsMore Drug Lists: Antiflatulence / Antipyretics / Hypnotics and SedativesIntravenous FluidsFormulasReferences

Back to TopBack to Main Table of Contents



Abbreviations Back To Main PageBack to Detailed Table of Contents

=)

++/- ABG

Ac Ad Lib

AF AHA AMI

Amp AOG ARF

ARDS ASA

ASAP

ATSBIDBMBP

BpmBRPBUNBW

C&SCa

CADCap

CAPDCBC

CBGCBRCHFConc

COPDCPRCRFCRI

CSACVACVPCXR

DDAT

DBPDDxDIC

DKADM

DOCDTR

DxDVT

ECG/EKGEF

Cheaper drug option

Add or withWith or without Arterial bood gas Ante-cibum; before meals Ad libitum; as much as desired Atrial fibrillation American Heart Association Acute myocardial infarction Ampule(s) Age of gestation Acute renal failure Acute respiratory distress syndrome Aspirin or Acetylsalicylic acid As soon as possible

American Thoracic SocietyTwice-a-dayBowel movementBlood pressureBeats per minuteBathroom privilegesBlood urea nitrogen Body weightCulture and sensitivityCalciumCoronary artery diseaseCapsule(s)Chronic ambulatory peritoneal dialysisComplete blood count

Capillary blood glucoseComplete bed restCongestive heart failureConcentrationChronic obstructive pulmonary diseaseCardio-pulmonary resuscitationChronic renal failureChronic renal insufficiencyChronic stable anginaCerebrovascular accidentCentral venous pressureChest X-rayDayDiet as tolerated

Diastolic blood pressureDifferential diagnosisDisseminated intravascular coagulationDiabetie ketoacidosisDiabetes mellitusDrug of choiceDeep tendon reflexesDiagnosisDeep venous thrombosisElectrocardiogramEjection Fraaction



DMDOCDTR

DxDVT

ECG/EKGEF

e.g.EMD

ETFBS

G or gmGS

GttsH+HBT

HCO3HD

HDLHGT

HONCHPN

HRHr

HSIBW

IE

IHDI and OIMIUIV

IVPJK

KgL or lLDLLpm

LVLVH

McgMgMI

MinMilMR

MRIMS

MVPNa

NGTNH4NSS

NYHA

ODOGTT

OHAPAC

PcPDPE

PEFRPenPFTPO

Diabetes mellitusDrug of choiceDeep tendon reflexesDiagnosisDeep venous thrombosisElectrocardiogramEjection FraactionFor exampleElectromechanical dissociationEndotracheal tubeFasting blood sugar Gram(s)Gram stain

MacrodropsHydrogen ionsHepatobiliary tractBicarbonate ionsHemodialysisHigh density lipoproteinHemoglucotestHyperosmolar non-ketotic comaHypertensionHeart rateHour

At nightIdeal body weightInfective endocarditis

Ischemic heart diseaseInput and outputIntramuscular International unitsIntravenousIntravenous pushJoulesPotassiumKilogramLiter(s)Low density lipoproteinLiters per minute (Oxygen)Left ventricleLeft ventricular hypertrophy

MicrogramMagnesiumMyocardial infarctionMinute(s)MillionMitral regurgitationMagnetic resonance imagingMitral stenosisMitral valve prolapseSodiumNasogastric tube

Ammonium ionsNormal saline solutionNew York Heart Association

Once-a-dayOral glucose tolerance testOral hypoglycemic agentsPremature atrial contractionPost-cibum; after mealsPeritoneal dialysisPhysical examinationPeak expiratory flow ratePenicillinPulmonary function testPer orem; oral route



PcPDPE

PEFRPenPFTPOPPI

PRnPt. or Pts.

PTPTTPTU

PVCqQID

RAIURF

RHDRRRV

SBPSGOTSGPT

SLSnSp

SCSTATSuppSuspSVTSyr TabTC

TETTGTID

TMP-SMZTPAG

Tsp

2-D EchoTxu

ugtt or uggtsUO

UTZVSw/

w/oWPW

Wt

Post-cibum; after mealsPeritoneal dialysisPhysical examinationPeak expiratory flow ratePenicillinPulmonary function testPer orem; oral routePermanent pacemaker insertionProton pump inhibitor As neededPatient(s)Prothrombin timePartial thromboplastin timePropylthiouracil

Premature ventricular contractionEveryFour times-a-dayRadioactive iodine uptakeRheumatic fever Rheumatic heart diseaseRespiratory rateRight ventricleSystolic blood pressureSerum glutamic-oxaloacetic transaminaseSerum glutamic-pyruvic transaminaseSublingual; under the tongueScnsitivitySpecificity

SubcutaneousImmediatelySuppositorySuspensionSupraventriculat tachycardiaSyrupTablet(s)Total cholesterolTreadmill exercise testTriglycerideThree times-a-dayTrimethoprim-SulfamethoxazoleTotal protein and albuminTeaspoon(s)

Two-dimensional echocardiographyTreatmentUnitsMicrodrop (s)Urine outputUltrasoundVital signsWithWithoutWolff-Parkinson-White syndromeWeight

Back To Main PageBack to Detailed Table of Contents



Contributing AuthorsBack To Main Page

Back to Detailed Table of Contents

Clemente M. Amante, MD, FPCP, FPRAProfessor of Medicine, Section of Rheumatology, UP-PGH

VirgilioP. Banez, MD, FPCP, FPSG, FPSDEClinical Associate Professor of Medicine, Section of Gastroenterology, UP-PGH Carlos L. Chua, MD, FPNA

Associate Professor of Medicine, Section of Neurology, UP-PGH Kenneth Hartigan-Go, MD, FPCP, FPSECP, FPSCOT

Associate Professor, Department of Pharmacology, UP College of Medicine Clinical Associate Professor ofMedicine, Section of Toxicology, UP-PGH Ruby T.Go, MDClinical Associate Professor of Medicine, Section of Endocrinology, UP-PGH Cecilia S. Montalban, MD, FPCP, MSCTM

Associate Professor of Medicine, Section of Infectious Diseases, UP-PGH Elizabeth S. Montemayor, MD, FPCP, FPSN

Associate Professor, Department of Physiology, UP College of Medicine Clinical Associate Professor of Medicine,Section of Nephrology, UP-PGH Willie T. Ong, MD, MPH, FPCP, FPCCCardiologist, Manila Doctors Hospital and Makati Medical Center Camilo C. Roa, Jr., MD, FPCP, FPCCPProfessor, Department of Physiology, UP College of MedicineClinical Associate Professor of Medicine, Section of Pulmonary Medicine, UP-PGH




Preface to the Sixth Edition

The year 2005 marks the 10-year anniversary of the publication of the Medicine Blue Book. I wrote the draft duringmy intemship and completed the book my first year of residency at Manila Doctors Hospital. Even then, my utmostdesire in sharing this book is to assist the many struggling doctors and nursesin our different training institutions. Ihad seen how hard and how unrewarding. medical training can be. I hope the Blue Book can be your friend andcompanion at some point in your career.

One of the biggest problems afflicting our country right now is the high cost of healthcare. To address this, the

Blue Book contains several unique features: 1) effective drug options are listed whenever possible and noted with asmile =) icon, (2) priority laboratory exams to request are highlighted in bold, (3) the treatment regimens aregenerally listed according to importance, which means that crucial treatment strategies are listed first and supportivetreatments are listed last, (4) the dosages of drugs have been adjusted for the average Asian patient, and (5) onlytests and drugs available in our local setting are included.

This edition presents major revisions and updates in all chapters. The latest (local ones if available) have been

utilized. Again, myprofuse thanks to, Clemente Amante, Dr. Virgilio Banez, Dr. Carlos Chua, Dr. KennethHartigan-Go, Dr. Ruby Go, Dr. Cecilia Montalban, Dr. Elizabeth Montemayor and Camilo Roa Jr. for their selflessand untiring efforts in updating the text.

I am also greatly indebted to several people in my medical education: Dr. P. Ariniego, Medical Director at De La

Salle University Medical Center; , Dr. Nelson S. Abelardo, past Chair of the Department of Internal Medicine at

TheManila Doctors Hospital; and Dr. Rody G. Sy, former Head of the Section of Cardiology at UP-Philippine GeneralHospital.

Finally, I would like to thank my parents, Mr. Ong Yong and Mrs. Juanita Tan Ong, for their wholehearted supportin this endeavour. And to my wife, Anna for all her hard work in publishing this book. Above all, I humbly thank theLord God for His guidance and inspiration. I can accomplish nothing without Him but "I can do everything in Christwho strengthens me." Thank you for reading and may God bless us always.

Willie T. Ong




CardiologyWillie T. Ong, M.D.

Advanced Cardiac Life Support Acute Myocardial Infarction

Thrombolytic Therapy in MIUnstable AnginaCongestive Heart FailureHypertensive EmergencySupraventricular Tachycardia

Atrial FibrillationPremature Ventricular Contractions & Ventricular TachycardiaPremature Atrial ContractionsInfective Endocarditis (Treatment)Infective Endocarditis (Prophylaxis)

Acute Rheumatic Fever Treatment & ProphylaxisCardio-Pulmonary ClearanceDyslipidemia with Lipid Lowering DrugsIndications for Permanent Pacemaker Insertion

HypertensionList of Antihypertensives & Cardiac DrugsLow Molecular Weight Heparins for DVT and Unstable AnginaThe Cardiac Patient with Other Medical Disorders




PulmonologyCamilo C. Roa, Jr., M.D..

Bronchial AsthmaDrugs Used to Treat Asthma

Management of Chronic AsthmaManagement of Acute Exacerbations of Asthma: Home TreatmentManagement of Acute Exacerbations of Asthma: Hospital TreatmentChronic Obstructive Pulmonary DiseaseTuberculosis

Antituberculosis Drug ListPulmonary EmbolismHemoptysisPleural Effusion and Thoracentesis

AnaphylaxisPneumothoraxPneumonia




GastroenterologyVirgilio P. Banez, MD.

Peptic Ulcer Disease & Acute GastritisUpper and Lower GI Bleeding

Anti-ulcer Drugs Hepatic Encephalopathy & Liver Cirrhosis Abdominal ParacentesisViral Hepatitis

Acute CholecystitisBacterial Cholangitis and Biliary Sepsis

Acute Pancreatitis Acute Diarrhea with Mild DehydrationCholera with Severe Dehydration

Acute Intestinal Obstruction




Infectious DiseasesCecilia S. Montalban, M.D.

Clinically Useful Antibiotics Antibiotic Drug List

Systemic Viral Infection Acute TonsillopharyngitisDengue Hemorrhagic Fever Typhoid Fever MalariaPrevention of Malaria in TravellersLeptospirosisSchistosomiasisSepsis and Septic ShockLower Urinary Tract InfectionPyelonephritisCellulitisMeningitis and EncephalitisTetanus

OsteomyelitisPeritonitisDiverticulitisPelvic Inflammatory DiseasePneumoniaInfective EndocarditisMumpsVaricella Zoster Empirical Antimicrobials for Out-Patient AdultsInitial Antimicrobials for Acutely Ill AdultsDrug of Choice for Microbial Pathogens




NephrologyElizabeth S. Montemayor, MD.

Acute Renal FailureStrategy for Removing Excess FluidChronic Renal Failure

Hypokalemia HyperkalemiaHypocalcemiaHypercalcemiaHyponatremiaHypomagnesemiaHypermagnesemiaNephrolithiasisDialysisDosage Adjustment of Drugs in Renal Failure




EndocrinologyRuby T. Go, MD.

Approach to Type II Diabetes MellitusDiabetic Ketoacidosis / Hyperosmolar ComaThyroid Storm

HyperthyroidismHypothyroidism Adrenal Insufficiency




RheumatologyClemente M Amante,‘MD.

OsteoarthritisGouty Arthritis

Rheumatoid ArthritisSystemic Lupus Erythematosus




NeurologyCarlos L. Chua, M.D.

Cerebral Infarction vs. Hemorrhage GuideIntracerebral HemorrhageSubarachnoid Hemorrhage

Cerebral ThrombosisCerebral EmbolismTransient Ischemic AttackStroke In EvolutionStroke in the YoungSeizures and EpilepsyBrain AbscessMyasthenia GravisParkinson's Disease

Alcohol Withdrawal Approach to Weakness




ToxicologyKenneth Hartigan-Go, MD. Poisoning and Drug Overdose: General Guidelines

Acid Ingestion Alkaline Ingestion

Amphetamine / Metamphetamines AnticoagulantsDiazepamDigitalis / DigoxinEthanolHydrocarbon / KeroseneIsoniazidNarcoticsOrganophosphatesParacetamolPhenothiazines / NeurolepticsSalicylate / AspirinTricyclicAnti-Depressants




NutritionNutritionist-Dietitians' Association of the Philippines Recommended Diet by Organ SystemHigh Fiber DietLow Calorie Diet

High Calorie DietHigh Protein DietLow Protein DietLow Fat / Low Cholesterol DietLow Carbohydrate DietLow Sodium DietLow Potassium DietLow Uric Acid / Low Purine DietNutritional Management of Diabetics and Renal Patients




The Pregnant Patient with Medical ProblemsCamilo C. Roa, Jr., M.D., Ruby T. Go, MD., Willie T. Ong, MD.

Pregnancy and HypertensionPregnancy and Cardiac Disease

Pregnancy and AsthmaPregnancy and Thyroid DiseasePregnancy and DiabetesDrugs Used in Pregnancy




I am Dr. Neo. Aside from being trained with the knowledge and skills of western

medicine, I also have proclivities in unconventional software applications which lead me

to this work, the 6 th Edition of the Medicine Blue Book. The medicine Blue book has

been integral in our line of work. From med school, internship, moonlighting, crossconsultation beyond our specialties to treating our neighbours knocking at our doors

late at night with tummy cramps.

We doctors live underpaid and overworked conditions. With the MD to nursing phenomena, the medical diasporas, the mistrust of patients, threat from the government

and media of malpractice bills who know nothing of our line of work and passions. Weare one of the unsung heroes of our nation. As part of this brotherhood in white, with

blood and tears trailing our footsteps, this work is my tribute.

To my mentors, seniors, subordinates, your ultimate sacrifices did not go unnoticed. Tothe original authors of the book, I deeply apologize for lifting your whole work to be

shared to the medical force in their PDA, which is handier nowadays than bringingdifferent books and references. I hope you could consider it as my ultimate complement

and a gesturing of honouring you for choosing your work to be selflessly shared to ourother brothers and sisters-in-arms braving their training and practice without gain exceptfor the satisfaction that we have helped them. I hope you could also forgive my humility

which would seem to be cowardice represented by my anonymity.

Mabuhay tayong lahat.

Dr. NeoChristmas Day, 2004

Somewhere in the Greater Manila Area

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ADVANCED CARDIAC LIFE SUPPORTTo Cardiology Page

To Main Table of ContentsTo Detailed Table of Contents

Basic Principle: To sustain life, (1) blood must circulate and (2) blood must be oxygenated optimally.

General Guidelines: Take command. Obtain brief history.Identify and treat reversible cause:

5H’s: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyperkalemia or hypokalemia (othermetabolic problems), Hypothermia.5T’s: Tablets (drug overdose, accidents), Tamponade cardiac, Tension

pneumothorax, Thrombosis coronary (MI, Thrombosis pulmonary (embolism).

Step 1: Circulation.

Auscultate the precordial area for a heartbeat while palpating for the carotid pulse.If negative, start CPR.Note: Place bedboard. Do effective 4-5 cms sternal compressions.

Step 2: Oxygenate Optimally.

Is the patient cyanotic? Is the patient still breathing?If negative, check airway and do ambu bagging with 'tight' face mask.Note: Give 100% oxygen. Make sure ambu bag tube is connected to the oxygen tank. Suctionsecretions as needed. Hyperventilate initially.

Step 3: Treat the Cardiac Rhythm. Assess by cardiac monitor.

Done simultaneously:l. Insert IV line.2. Intubate patient if necessary (for asystole, electromechanical dissociation, bradyarrhythmia, orpersistently unstable rhythms).3. Get ABG's if with pulse (treat hypoxemia and acidosis).

I. Rhythm: Asystole (Silent Heart)

1. Continue CPR. Obtain IV access.

2. Epinephrine (1 mg/ampnle) 1-2 ampules IV stat q 3-5 minntes continuously until there isa cardiac rhythm or until CPR is stopped. May give epinephrine 1 mg ampule in 10 ml NSS

via ET tube q 3-5 minutes if no IV line is inserted yet.3. If unable to rule out fine ventricular fibrillation, defibrillate with 360 Joules.4. Atropine 1 mg IV; repeat q 3-5 min. Maximum of 3 mg.5. Consider external or transvenous pacing.6. Consider Bicarbonate 1 amp (1 meq/kg) if more than 15 minutes have elapsed since the hearthas stopped.

II. Rhythm: Ventricular Fibrillation or Pulse less Ventricular Tachycardia

l. Defibrillate with UNsynchronized 200 Joules stat, repeat with 300 Joules if unsuccessful, then

360 Joules.2. Continue CPR between defibrillations or until a defibrillator is available.3. If no conversion, give epineprhine 1 ampule prior to next defibrillation for cases of resistant or

fine ventricular fibrillation. Repeat q 3-5 minutes as needed.4. Continue Defibrillation until rhythm is converted to sinus.

5. Consider anti-arrhythmic drugs:a. Amiodarone 150-300 mg (1-2 ampules) slow IV in 10 minutes for resistant ventricular

fibrillation or ventricular tachycardia. Repeat dose if necessary.or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May repeat bolus 40 mg

(0.5 mg/kg) IV ofter 5 minutes. Maximum of 200 mg (3 mg/kg). If necessary, increase drip rate by1 mg/min to maximum of 4 mg/min. May give Lidocaine via ET tube plus 10 ml NSS.



6. For polymorphic ventricular tachycardia (torsade de pointes), give Magnesium Sulfate 1-2 gm IVdiluted in 100 ml DSW and given in 2 minutes.7. Consider Sodium Bicarbonate 1 amp slow IV.

III. Rhythm: Unstable Ventricular Tachycardia with Pulse

For presence of chest pain, dyspnea, MI, heart failure, or systolic BP < 90 mmHg:1. Cardiovert with synchronized 100, 200, 300 Joules. If patient is awake give Midazolam 2-5 mg

IV for sedation. May omit precordial thump.2. Consider anti-arrhythmic:

a. Amiodarone 150-300 mg (1-2 ampules) slow IV in 10 minutes. Repeat dose i f necessary.

or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May repeat bolus 40

mg (0.5 mg/kg) IV after 5 minutes. Maximum of 200 mg.3. If no conversion, cardiovert at synchronized 360 J, or if recurrent ventricular tachycardia,

cardiovert again starting at previously successful energy level, then after conversion, continuemedications.

IV. Rhythm: Stable Ventricular Tachycardia with Pulse

1. Precordial thump.2. Give anti-arrhythmic drugs:

a. Amiodarone 150 mg slow IV (1 ampule) in 10 minutes.or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May repeat bolus 40 mg

(0.5 mg/kg) 1V every 5 minutes until VT resolves. Maximum of 200 mg.3. If drugs fail, cardiovert with synchronized 100, 200 Joules.4. Treat accordingly if cardiac rhythm degenerates.

V. Rhythm: Bradycardia

A. For chest pain, dyspnea, drowsiness, heart failure, or systolic BP < 90 mm Hg:1. Atropine 0.5-1 mg IV stat. Maximum of 3 mg (0.04 mg/kg). May give via ET tube with 10

ml NSS.2. Continue CPR support if HR < 40 bpm.3. Consider external or transvenous pacing.

4. Consider Dopamine drip or Epinephrine drip as a temporizing measureB. For type II second degree dh third degree AV block, consider external or transvenous

pacing.C. If without symptoms, observe!

VI. Rhythm: Electromechanical Dissociation (EMD)

Definition: Sinus rhythm by cardiac monitor but without palpable pulses. No BP.Etiology: EMD can be secondary to inadequate fluid volume, pericardial tamponade, tensionpneumothorax, hypoxemia or acidosis. Less correctible causes include massive MI, prolongedischemia during resuscitation and pulmonary embolus.

1. Continue CPR

2. Correct primary problem (see etiology).3.. Epineprhine 1 mg IV q 3-5 min

4. Consider Bicarbonate 1 amp (44 meq) slow IV.

VI. Rhythm Successfully Converted to Sinus Rhythm:

1. If Systolic BP = 100 mm Hg:

Obtain laboratory exams: ABG, ECG (check for MI), CXRCBC, Na, K, RBS, Creatinine2 If Systolic BP =90 mm Hg:

i. Start Inotropics: Dopamine with or without Dobutamine.ii. Correct low volume, acidosis and hypoxemia.iii. Do ABG and other laboratory exams if feasible.

Advice



a. Adequate airway, ventilation, oxygenation, chest compression and defibrillation are more

important than initiating IV line and injecting medications.b. IV medications should be given by bolus with few exceptions. After each IV medicine, give 20-30

ml bolus of IV fluid and elevate the extremity.c. Do most of your interventions in the first 10 minutes of the CPR. Otherwise, the chance of

reviving the patient decreases markedly.

d. Lastly, treat the patient, not the cardiac monitor.

Source: Adapted from Guidelines 200O for Cardiopulmonary Resuscitation and EmergencyCardiovascular Care. Circulation, Vol. 102, No. 8, August 22, 2000.

To Cardiology PageTo Main Table of ContentsTo Detailed Table of Contents



ACUTE MYOCARDIAL INFARCTION

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To Detailed Table of Contents

Table 1-1. Molecular Markers in the Diagnosis of Acute Myocardial Infarction.

Tests Time to

DetectionPeak Duration Most

CommonSamplingSchedule

Troponin TSn = 94%Sp = 60%

3 -12 hours

24hours

5 -14 days

Once atleast 12hours afterchest pain

Troponia ISn = 95 %Sp = 90 %

3 - l2 hours

24hours

5 - 10days

Once atleast 12hours afterchest pain

CK-MB

3 - 12 hours

24hours

2-3 days

Every 12hours X 3;start at 6hours afterchest pain

Source: Modified from Braunwald, E.; Zipes D.P., Libby P..(Eds.) (2001). Heart Disease: A Textbook ofCardiovascular Medicine, (p.1l32) Philadelphiia: W.B. Saunders Company

Table 1-2 Killip Classification of AMI with Expected Hospital Mortality Rate.

KillipClass

Clinical Presentation ExpectedHospital

Mortality

I No signs of pulmonary or venouscongestion

0-5%

II Moderate heart failure or presence ofbibasal rales, S3 gallop, tachypeea, or signsof right heart failure including venous JVPand he hepatic congestion

10-20 %

III Severe heart failure, rales > 50% of the lungfields or pulmonary edema

35-45 %

IV Shock with systolic pressure < 90 mm Hgand evidence of peripheral vasoconstriction,peripheral cyanosis, mental confusion and

oliguria

85-95 %

Source: Forrester, J.S. et al (1976). Medical therapy of acute myocardial infarction by a applications ofhemodynamic subsets. NEJM, 295, 913-56.

Orders: Admit to ICUSample diagnosis: Acute MI, ST-elevation, anterior wall, Killips-l, day 1



Diet: Low salt, low fat dietVS: q 1 hour and record; Temp q 4 hour

Nursing I and 0 q shift. Complete bed rest with no bathroom privileges. High back rest. Limitvisitors. Anti-embolic stockings.

IVF: D5W 500 ml x 10 ml/hr Diagnostics: CK-MB , CPK-Total, Troponin T or Troponin I

ECG stat then repeat after 12-24 hours

Portable Chest X-ray, semi-sittingCBC with platelet count, Na, K, Ca, Mg, RBS, BUN, Creatinine, Urinalysis

Baseline PT, PTT (if contemplating anti-coagulation or thrombolytic therapy)

Lipid Profile

Therapeutics:

1. Initial ER Management (STAT):a. Oxygen at 2-4 liters/min via nasal cannula x 24 hours (especially if with heart failure or Oxygen

saturation < 90%)b. Nitrates: (defer for SBP < 90 mm Hg)

Nitrostat 0.4 mg SL up to 3 doses stat q 5min and PRN for chest pains then startIsosorbide Dinitrate (Isoket) Drip x 24-48 hours until chest pain subsides then shift toTransderm patch 5-10 mg OD to anterior chest wall

or Isosorbide mononitrate (Imdur) 60 mg OD AMor Isosorbide dinitrate (Isordil) 10-20 mg TID (6 am-12-6 pm)

c. Pain relief : Give adequate analgesia with Morphine 4 mg IV stat and PRN q 30 min up to 3

doses defer for SBP< 90 mm Hg (If with Inferior wall MI, give only 2-3 mg IV of Morphine becauseof risk of arrhythmia.)d. Aspirin 160-325 mg tab stat dose then 80 mg tab BID PC indefinitely

2. Consider Thrombolytic Therapy:

Indication: Patients presenting within the first 12 hours of chest pains with large anterior wallST-elevation MI or inferior wall MI with anterior wall(Vl-V3) reciprocal changes (see Thrombolytic Therapy in MI for full contraindications list)

3. Heparin:

Indication: For large anterior wall MI, atrial fibrillation, persistent chest pains, or presence of LVthrombus

a. Heparin 5000 units IV bolus then Heparin Drip: D5W 200 ml + Heparin 10,000 units at 14ugtts/min (700 units/hour) using an infusion set Check PTT q 12 hours with target PTT of 1.5-2Xthe control. Give Heparin for 2-5 days then overlap with Warfarin for 3 months if desired.

b. Low Molecular Weight Heparin: Enoxaparine (Clexane) 0.4 ml SC BID for 5 days.

4.Beta-blockers

Indication: All patients without contmindication to beta-blocker tharapy. Most beneficial in patientswith tachycardia anterior wall MI, hypertension, recurrent ischemic pain, atrial fibrillation. Avoid inpatients with moderate to severe CHF, wheezing, AV blocks and heart rate < 55 beats per minute.Start therapy early (<12 hours). Try to achieve a target HR of 55-60 bpm.

Metoprolol 50 mg 1/2 -1 tab q 8-12 hours or Esmolol 10-20 mg IV

Beta-blockers should be continued indefinitely in patients with no contraindication.5. ACE-inhibitors:

Indication: All patients with anterior wall MI Most beneficial for Killips II or higher, LV EF < 40,large anterior wall MI, clinical CHF, and with no contraindication to ace-inhibitors.

Captopril 25 mg 1/4 tab q 12 hr x 2 days then 1/2 q 12 hr, defer for SBP < 100 mm Hg. For BPspikes in hypertensive patients, may give Captopril 25 mg 1/2 -1 tab PO or SL.6. Consider Statins: Atorvastatin 20 mg tab OD or Simvastatin 20 mg tab OD HS

7. Diazepam 2-5 mg tab BID (especially for anxious patients)8. Duphalac 20-30 ml HS defer for LBM. Instruct patients not to strain9. Optional Meds: Antacids, H2-blockers.

Other Cardiac Meds:



1. Diuretics: Furosemide 40 mg tab or 20-40 mg IV stat dose for &ank CHF2. Lidocaine Drip: For high grade ventricular arrhythmias early post-MI3. Amiodarone PO or Drip: For persistent high-grade ventricular arrhythmias4. Avoid calcium-channel blockers:

a. Nifedipine.PO or SL is contraindicated in AMI or unstable anginab. Diltiazem, Verapamil: In patients with contraindication to beta-blocker therapy, verapamil ordiltiazem may be given for relief of ongoing ischemia or control of ventricular response in AF

in the absence of CHF, LV dysfunction, or AV blocks.5. Metabolic enhancers: (Not proven to be beneficial post-MI)

Co-Enzyme Q10 mg tab 1 tab TIDTrimetazidime (Vastael) 20 mg tab TID

For Non ST-elevation MI with No Congestion, Give

1. Metoprolol 50 mg 1/2 - 1 tab BID or 2. Diltiazem 30 mg BID-TID

For Non ST-elevation MI with Pulmonary Congestion, give

1. Ace-inhibitors (as above)2. Diuretics PRN

Avoid calcium-channel blockers in patients with heart failure.




THROMBOLYTlC THERAPY IN MI



A. Indications for Thrombolytic Therapy in MI:

1. Chest Pain consistent with AMI 2. ECG changes a. ST-segment elevation = 1mm in at least 2 contiguous limb leads or b. ST-segment elevation = 2 mm in et least 2 contiguous chest leads or c. New left bundle branch block

3. Time from chest pains to thrombolytic therapy: a. Less than 6 hours: most beneficial

b. 6-12 hours: lesser but still important benefits c. 12-24 hours: diminishing benefits but may still be useful in selected patients (e.g.those with ongoing chest pain)

B. Absolute Contraindications to Thrombolytie Therapy in MI: 1. Active internal bleeding (excluding menstruation) 2. Recent (within 2 weeks) invasive or surgical procedure 3. Suspected aortic dissection 4. Previous history of hemorrhagic cerebrovascular accident or subarachnoid hemorrhage 5. Recent head trauma or known intracranial neoplasm 6. Persistent BP = 200/120 mm Hg

C. Relative Contraindications to Thrombolytic Therapy in MI:

1. Known bleeding diathesis (severe thrombocytopenia, coagulopathies) or current use ofanticoagulants

2. Previous streptokinase treatment given for the past 6 to 9 months (in which case, give TPA) 3. BP= 180/100 mm Hg on at least 2 readings

4. Active peptic ulcer disease

5. History of thrombotic cerebrovascular accident6. Prolonged CPR of = 10 minutes or traumatic CPR

7. Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic condition 8. Pregnancy D. Treatment Regimen

1. ASA 325 mg tab now then OD 2. Diphenhydramine 50mg IV push 3. Hydrocortisone (Solucortef) 100-200 mg IV push 4. STREPTOKINASE 1.5 M IU in 90 ml D5W over 1 hour (100 ugtts/min) in a soluset Watch out

for hypotension and reperfusion arrhythmias. 5. PTT now and q 6 hours x 24 hours then q 12 hours. No IM injections or arterial punctures.

Watch IV sites for bleeding. 6. Optional (associated with increase bleeding risk): Heparin 5000 units IV bolus then 500-1000units/hr IV to maintain PTT at 1.5-2X the control.




UNSTABLE ANGINA


To Detailed Table of ContentsData:

A. Indications for Cardiac Catheterization and Possible Coronary Angioplasty (Available in UP-PGH,Philippine Heart Center, St. Luke’s & Chinese General Hospital)

1. Patients with persistent chest pains despite maximal medical therapy for 48 hours2. Patients with high-risk profile: Clinical heart failure, dynamic ST segment changes changes, S3gallop, hypotension, prolonged ongoing chest pain (= 20 minutes)

Orders:

Admit to ICU:Diet: Soft, low salt diet when stableVS: q 1 hour and record; Nursing: I and O q shiftIVF: D5 W 500 ml x KVODiagnostics:

ECG stat then repeat for persistent chest pains

CK-MB,CPK-TOTAL (to rule out AMI) twice q12 hours

Troponin T or I (positive in microinfarcts suggesting a poorer prognosis)

CBC, K, Creatinine, Baseline PT, PTT Portable Chest X-ray

Therapeutics:O2 at 2-4 lpm via nasal cannula1. Nitrates (same regimen as in Acute MI

2. Heparin for 5 days, if stable

Indications: For patients at high risk of complications - prolonged ongoing chest pains (>20 min),clinical heart failure, angina with hypotension or dynamic ST-T wave changes

a. Low Molecular Weight Heparins: Enoxaparin (Clexane) 0.4 ml (40 mg) SC BID (1 mg/kg

BID)or b. Regular Heparin: Heparin 5000 u IV bolus then Heparin Drip: D5W 200 ml+ Heparin

10,000 units at 14 ugtts/min (700 u/hr) using an infusion set Check PTT q 12 hours withtarget PTT of 1.5-2 X the control.

3. Aspirin 325 mg tab stat dose then ASA 80 mg 1 tab BID PC indefinitely or Clopidogrel (Plavix)

75 mg tab OD for patients unable to take ASA4. Metoprolol 50 mg 1/2 -1 tab q 8-12 hr (if no contraindications) and/or Diltiazem 30 mg tabBID-TID may be added in patients with persistent chest pains (watch out for bradycardia withMetoprolol).5. Other Meds

a. Morphine 4 mg IV stat for pain relief b. Diazepam 2-5 mg tab BID (especially for anxious patients)

6. Medical strategies for persistent chest pains (in patients without heart failure) a. Increase beta-blocker dosage b. Increase nitrates dosage (e.g. up to Imdur 60 mg tab BID or Isordil 40 mg tab QID)

c. Add Diltiazem PO to the above regimen




CONGESTIVE HEART FAILURE(For Systolic Heart Failure)



Data: Systolic vs. Diastolic Heart Failure:

1. Systolic Heart Failure: Markedly dilated left ventricle, low ejection fraction (problem with systolic LV

contraction phase). Treatment approach indicated below.2. Diastolic Heart Failure: Normal left ventricle size, usually concentrically hypertrophied, normal

ejection fraction (problem with diastolic LV relaxation phase and stiff LV). Treatment is different fromsystolic heart failure. Give beta-blockers and calcium-channel blockers.

Table 1-3. General Outline in the Management of Chronic Congestive Heart Failure Based on New

York Heart Association (NYHA) Functional Classification.

Management NYHAClass I

ClassII

ClassIII

ClassIV

Vaso-Dilators Ace-inhibitors or Angiotensin receptorantagonist

+ + + +

Lifestyle Changes:Restrict physical activityand restrict salt intake

- + + +

Low-doseBeta-blockers*

? + + ?

Diuretics**: Furosemideand Spiranolactone

- - + +

Digoxin - - + +

Dobutamine, Dopamine

and/or Nitroprusside

- - - +

Intraortic Balloon Pump And HeartTransplantation

- - - +

*Studies show that low-dose carvedilol, metoprolol or bisoprolol is a useful adjunct to conventionalregimen for CHF. However, dosages of ace-inhibitors and diuretics should first be maximized.** Diuretics may be given to achieve relief of edema and normalization of the jugular

Orders

Diet: NPO if dyspneic; Saft, low salt diiet when more stable (Na < 2 gm/day)Limit Total Fluid Intake to 1.0-1.2 liters/dayVS: q 1 hour and recordVS: q 1 hour and recordNursing: I and O q shif Nursing: I and O q shift strictly. Consider foley catheter insertion (hourly urine outputs),

Weigh patient daily. CBR with no batbroom privileges. High back rest. IVF: D5W 500ml X KVOor10ml/hr,

Diagnostics: CBC, Na, K, Ca, Mg, RBS, Creatinine, Urinalysis, ECG, Portable Chat X-ray semi-sitting,

2-D Echo with Doppler

Treatment Approach: Mnemonic 5 D's (Diet, Diuretics, vaso-Dilators, Digitalis, Dilatrend)



- Oxygen at 2-4 lpm via nasal cannula- For Acute Congestion: Stepwise approach -->Oxygen, Furosemide IV,Morphine IV as last resort- Correct precpitating factors: Arrhythmia, uncontrolled HPN, anemia, pulmonary infection,thyrotoxicosis, change inappropriate medications, emotional stress 1. Diuretics: (For acute CHF, fluid overload or edema)

a. Furosemide (Lasix) 20-40 mg IV then maintain on PO later, may double subsequent doses if

no urine output in 20-30 mins (e.g. give Lasix 40 mg IV then 80 mg IV after 30 minutes). If stillwithout urine output, start Lasix drip and consider stat peritoneal or hemodialysis for resistantcases

+ b. Spironolactone (Aldactone) 25 mg tab OD-TID for CHF class III to IV. 2. Vaso-Dilators:

a. Ace-inhibitors: First-line agents for chronic heart failure.Captopril 25 mg 1/2-1 tab q 6-12 hr. Maximum dose of Captopril 50 mg tab TIDor Enalapril 5-10 mg tab OD-BID, maximum dose of Enalapril 20 mg BID. Maximize doseof

ACE-inhibitors to achieve symptomatic relief of dyspnea. In patients with contraindication to ACE-inhibitors (e.g. acute renal failure), you may use Hydralazine 10-25 mg TID and ISDNgsordil) 10-20 mg TID.

b. Angiotensin receptor antagonists: Altemate drug if with ace-inhibitor cough; e.g. Losartan 50mg 1/2 -1 tab OD (maximum dose of Losartan 50 mg 1 tab BID).

3. Digitalis: Most beneficial in patients with atrial fibrillation. Digoxin 0.25-0.5 mg IV then complete

loading dose if needed or Digoxin (Lanoxin) 0.25 mg tab BID X 3 days then 1/2 - 1 tab ODthereafter.

4. Consider low dose beta-blockers for heart failure. Addition of Carvedilol (Dilatrend) 6.25 mg tab

BID. Watch out for hypotension and CHF within the first 4 hours after intake.

5. Other therapeutic options as indicated:a. Coemyme Q10 10 mg tab TID has some possible benefit.b. Nitrates: Transderm patch for 1 dose only if with no underlying CAD.c. ASA 80-160 mg PO OD as indicated.

6. Supportive Medications for CHF:a. If BP < 80 mm Hg, use Dopamine Drip or Norepinephrine (Levophed) Drip(if persistently hypotensive)b. If BP 90-100 mm Hg, use Dobutamine Dripc. If BP >= 110 mm Hg, use Nitroprusside Drip (Not Available)




HYPERTENSIVE URGENCY & EMERGENCY



Data: A. Hypertensive Urgency: No end organ damage; try oral medications first. Lower BP within 2-3 days.B. Hypertensive Emergency: Presence of changes in sensorium, papilledema, or heart failure. Use IVdrugs stat. Lower BP within 24 hours.

Orders

Admit to:Diet: NPO temporarily until stableVS: BP q 15 minutes till stableNursing: Complete bed rest without bathroom privilegesDiagnostics: CBC, Creatinine, K, ECG, Urinalysis, Chest X-ray, Fundoscopy

Therapeutics:

A. Per Orem or Sublingual Treatment:Mnemonic for anti-hypertensives that can be given sublingually: 3 C’s

1. Nifedipine (Calcibloc): 5-10 mg SL or PO (bite and swallow punctured capsule), repeat asneeded q 30 minutes, then 5-10 mg PO or SL q 6-8 hr . or Calcibloc OD 30 mg PO OD-BID.Maximum dose is 90 mg/day, contraindicated in patients with AMI or Unstable Angina.2. Captopril (Capoten): 25 mg 1/2 -1 tab SL or PO q 30 mins as needed.

3. Clonidine: 75 mcg tab SL or PO q hr (Maximum of 700 mcg)

B. Intravenous Treatment: See appendix section on IV drips

Mnemonic for anti-hypertensives that can be given intravenously: NAIC

1, Nicardipine IV: Duration of action: 3-6 hr

2. Hydralizine (Apresoline) IV: 5-10 mg IV q 3-6 hr (0.1-0.5 mg/kg/dose; maximum of 20 mg

per dose), or give 25-50 mg PO Qid. Duration of action: 3-6 hr.3. Isosorbide dinitrate IV (especially for patients with concomitant CAD)

4. Clonidine (Catapres) IV: May give 1 amp (150 mcg/I ml amp) SC, IM or IV with patient

supine.5. Nitroprusside IV (not available): 0.25-10 mcg/kg/min IV (50 mg in D5W 250ml), titrate todesired BP using an infusion set.




SUPRAVENTRICULAR TACHYCARDIA



Orders:

Diet: Full diet when stable (no coffee, tea or soft drinks)VS: q 1 hour, Hook to Cardiac Monitor Diagnostics: CBC, RBS, Na, K, Ca, Mg

CK-MB, Troponin T or I, BUN, Creatinine, MgT4 TSH Irmarepeat ECG after conversion to sinus rhythm

Chest X-ray, 2-D Echo when stable

Therapeutics:- Unilateral carotid massage (Check for carotid bruits first)- Attempt vagal maneuvers before drug therapy

A. Pharmacologic Therapy

l. If Systolic BP > 90 mm Hg, choose &om the following options:a. Calcium-channel blockers: Verapamil 2.5-10 mg IV over 2-3 minetes, wait 10-15

min before next dose (may give Calcium Gluconate 1 gram IV over 3-6 minutes prior toVerapamil); then 40 mg PO q 6 hours or Verapamil SR 240 mg 1/2-1 tab PO OD.Duration of action is 15 min. or Diltiazem (Ritemed Diltiazem C) ) 30-60 mg PO TIDb. Beta-Blockers: Esmolol 10-20 mg IV ). Duration of action is 9 minutes or Metoprolol

50 mg 1/2 tab PO stat dose then BIDc. Adenosine (Cardiovert) 6 mg/2 ml vial

i. Therapeutic indications:Initial dose: 3 mg given as a rapid IV bolus (over 2 seconds)Second dose: If first dose fails within 1-2 min, give 6 mg rapid IV bolusThird dose: If 2nd dose fails within 1-2 min, give 12 mg rapid IV bolusii. Precautions for use: Avoid in COPD and asthmatic patients, mild hypotension

occurs.2. If Systolic BP < 90 mm Hg or with heart failurea. Digoxin (Lanozin) 05 mg IV or PO, wait 2 hours before full effect of initial dose is

established then aliquots of 0.25 mg IV q 4-6 hours as needed (Losding dose of 1-1.25mg IV); thcn Digoxin 0.25 mg 1/2 - 1 tab OD. Contraindicated in patients with WPW in AF.Defer Lanoxin for HR < 60 bpm. Duration of action is 2 hours.

3. Adjuncts: Diazepam 2 mg tab BID B. Synchronized Cardioversion

- Ideally patient should be in NPO x 6 hr, digoxin level < 2.4 and K+ normal.1. Midazolam 2.5 mg IV until amnesic2. If stable, cardiovert with synchronized 25-50 J, increase by 50 J increments.3. If refractory to drug treatment or unstable (e.g. hypotensive or severe ischemia caused by thetachycardia), start with 75-100 J, then increase to 200 J if needed.




ATRIAL FIBRILLATION (AF)



Data:

A. Is the patient in acute AF (onset of less than 48 hours) or chronic AF?B. Treat the etiology of the AF, e.g. hypoxia, electrolyte imbalance (K, Ca, Mg), heart failure,severe ischemia, mitral stenosis, thyrotoxicosis, hypertension, chronic anxiety long disease, feveretc.

Orders:

Diet: Low salt diet when stableVS: q 1 hour, auscultate full minute heart rateNursing: Complete bed rest. Hook to cardiac monitor (if acute AF)Diagnostics: CBC, K, Ca, Mg, Creatinine, Digoxin assay, 2-D Echo with doppler , T3, T4 TSH Irma

Therapeutics: Treat the etiology or precipitating factor. Slow the ventricular rate with pharmacologic

therapy A. Acute AF with rapid ventricular response (HR > 100 bpm):

1. If Systolic BP = 90 mm Hg and not in heart failure:a. Verapamil 2.5-10 mg IV over 2-3 minutes, wait for 10-15 min. before next

dose then 40 mg PO q 6 hours or Verapamil SR 240 mg PO OD. Duration ofaction is 15 mins.or b. Metoprolol 50 mg 1/2-1 tab PO stat dose then BID

2. If Systolic BP < 90 mm Hg or with heart failure:a Digoxin (Lanoxin) 0.5 mg IV or PO, wait for 2 hours before full effect of initial

dose is established then aliquots of 0.25 mg IV q 4-6 hours as needed (Loadingdose of 1-1.25 mg IV); then Digoxin 0.25 mg 1/2 - 1 tab OD. Contraindicated inpatients with WPW in AF. Defer Digoxin for HR < 60 bpm.

3. Consider medical cardioversion for AF < 48 hours in onset. Consult the Cardiology BlueBook for indications and benefits of cardioversion.

B. Chronic AF:1. Same as above if with rapid heart rates2. For patients with high-risk for stroke (e.g. prior CVA, TIA, valvular heart disease, HPN,DM, CHF, LA size > 45 mm or CAD), anticoagulate with warlarin to attain a target protimeINR of 2-3.Loading dose: Warfarin (Coumadin) 5 mg tab PO X 2-3 days only. Recheck Protime on

the 3rd day. Usual maintenance dose: Warfarin (Coumadin) 2.5 mg I tab OD PO defer ifwith bleeding episodes.3. Astiplatelets if with contraindication to Warfarin: Aspirin 325 mg 1 tab PO OD after

mealsC. Synchronized Cardioversion: If medical therapy fails, or if with severe cardiovascular

compromise, may do synchronized cardioversion in extreme cases. Sedate patient first.




PREMATURE VENTRICULAR CONTRACTIONS & VENTRICULARTACHYCARDIA



A. In patients without heart disease (normal ECG, normal 2-D electrocardiography), PVC's have not beenshown to be associated with any increased morbidity or mortality. If with heart disease, we may need totreat the patient. Tailor treatment for each patient.B. Complications: Ventricular tachycardia, ventricular fibrillation, sudden cardiac deathC. Lown's Grading of PVC's:

GRADE:0 nonela < 30/hr < 1/min1b > 1/min2 > 30/hr 3 multiform, bigeminy, trigeminy

4a couplets4b salvos5 R on T phenomenon

D. Anti-Arrhythmic Drug Classes:

Class I (blocks sodium channels):IA - Quinidine, Procainamide, Disopyramide (SV 8c V)IB - Lidocaine, Phenytoin, Tocainide (V)IC - Flecainide (V)

Class II (Beta-blockers):Propranolol (SV & V)

Class III (blocks potassium channels): Amiodarone, Sotalol (SV k V)

Class IV (blocks calcium channels):

Verapamil (SV)

Legend: SV= drugs used to treat Supraventricular ArrhythmiasV= drugs used to treat Ventricular Arrhythmias

Orders:

Admit to:Diet: Soft diet when stableVS: q 1 hour, record number of PVC's per minuteNursing: Hook to cardiac monitor Diagnostics: CBC, Serum K, Ca, Mg, T3, T4, TSH, 24-48 hour Holter Monitoring or Loop Recorders

(check for episodes of ventricular tachycardia) ECG, 2-D Echo with doppler

Treatment Plan:1. Consider age of patient and the cardiac status. Most important considerations for admission andtreatment are the following:

a. Symptomatic patients with dyspnea, syncope, or dizzinessb. (+) Organic heart disease, especially post-myocardial infarctionc. low ejection &action of < 40%d. Lown's grading = 4a

2. Look for a possible secondary-etiology for PVC’s and treat this, e.g. CAD, thyroid diseases,acidosis, alkalosis, hypercaprea, hypoxia, hyperkalemia, hypokalemia, digitalis excess, mitral valve



prolapse, cardiomyopathy, or connective tissue disorders.

Therapeutics:1. Decrease precipitating factor, e.g. control anxiety and avoid alcohol, digitalis, caffeine coffee,softdrinks or tea.2. Treat the underlying cause, e.g. give nitrates for CAD, correct electrolyte imbalance etc.

3. Supportive: Oxygen, sedatives4. Treatment for PVC’s or Ventricular Tachycardia after correcting other factors:

a. Beta-blockers - empiric and cheap treatment (esp. for patients with MVP)

b. Lidocaine IV bolus and drip for acute episodes only.

c. if resistant, consider Amiodarone IV or PO: Amiodarone preparation: 150 mg/3 ml vial

IV loading dose: 500-1000 mg per 24 hr IV loading doses (5-10 mg/kg bodyweight per 24 hr)Example orders: Give 150 mg slow IV push over 10-30 minutes (with BP and HRmonitoring) followed by D5W 250 ml + 150-300 mg IV Amiodarone to run for 24hours. Supplemental doses of 150 mg IV over 10-30 minutes may be given forrecurrent arrhythmias especially hg the early phases of dosing OR

Oral Loading Dose: (10 mg/kg body weight per day for 2 weeks), Amiodarone 200

mg 1 tab PO TID for 2 weeks then maintenance of Amiodarone 200 mg 1 tab ODthereafter Amiodarone's side effects include hyperthyroidism, hypothyroidism, andinterstitial pulmonary fibrosis. Check thyroid function every 3-6 months

5. For ventricular tachycardia or cardiac arrest due to ventricular fibrillation, ImplantableCardioverter/Defibrillators (ICD) are proven to be beneficial in preventing sudden cardiac death.However, ICD’s are very expensive. Consult a cardiologist-electrophysciologist.




PREMATURE ATRIAL CONTRACTIONS



Data:PAC's are usually benign and can be found in 60% of normal adults. If patient is asymptomatic, treatmentis usually not required. Orders:

Diagnostics: CBC, K, Mg, T3, T4, TSH, 24-4S hours Holter monitoring if with symptoms (check for

paroxysmal atrial fibrillation or supraventricular tachycardia),ECG, 2-D Echo

Therapeutics:

1. Remove precipitating factors fever, anxiety, mitral valve prolapse, specific food (alcohol, tobacco,tea, coffee, or amphetamines)2. If symptomatic and with palpitations:

a. Sedatives: Diazepam 2 mg 1 tab OD HS and as needed.

b. Beta-blockers: Metoprolol 50 mg 1/2-1 tab BIDor c. Calcium-channel blockers:- Verapamil 40 mg 1 tab TID- Diltiazem 30 mg 1 tab BID-TID




INFECTIVE ENDOCARDITIS (Treatment)

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Data

Table 1-4 Two Traditional Classifications for Infective Endocarditis (IE)

Acute Bacterial IE Subacute BacterialIE

PathogenicOrganism

Staph aureus Strep. Viridans,Enterococci (lessvirulent)

ClinicalPresentation

High Fever, Acutecourse

Low grade Fever,subacute course

Clinical

Pathology

Normal cardiac valves Damaged valves,

(+) murmur Prognosis Fatal in 6 weeks if

untreatedBetter prognosis

Table 1-5. Duke’s Diagnostic Criteria for Infective Endocarditis

I. Criteria for Infective Endocarditis:

A. Two major criteria or B. One major and three minor or C. Five minor criteria using definitions for these criteria as listed belowD. Possible infective endocarditis: findings consistent with infective endocarditis that fall short ofthe criteria listed above

II. Major Criteria

A. Positive blood culture results for infective endocarditis. Typical microorganisms for infectiveendocarditis: Streptococci viridans, HACEK group, Strep. bovis, Staph. aureus, or enterococcirecovered from two or more blood cultures.B. Either positive echocardiographic study result for infective endocarditis: Oscillating intracardiacmass, abscess or new dehiscence of prosthetic valve or newvalvular regurgitation ORPersistently positive blood culture results: microorganism consistent with IE recovered from oneor more than 12 hrs apart.

III. Major Criteria:(Mnemonic: PF-VIME)

A. Predisposing heart condition or injected drug user B. Febrile syndromeC. Vascular phenomena: Arterial embolism, central nervous system hemorrhage, conjunctival

hemorrhage, Janeway lesions.D. immunologic phenomena: Immune-complex glomerulonephritis, rheumatoid factor,false-positive VDRL test, Osler's nodes, or Roth spotsE. Microbiologic evidence: Positive blood culture results but not positive for major criterionF. Echocardiogram: Suggestive of infective endocarditis but not positive for major criterion

Source: Durack, D.T. (1998). Infective and non-infective endocarditis. In R. C. Schlant & R. Wayne

Alexander (Eds.), Hurst's: The Heart (p. 2221). New York: McGraw-Hill Companies Inc. with permission Orders:



Admit to:Diet: DATVS: q 4 hours, include temperatureDiagnostics:

For Acute bacterial eadocardltis: Blood C/8 (3X in 30 minutes): ideally before antibiotic

treatmentFor Sabacute bacterial eadocarditis. Blood C/S 3X ia 6 hours

CBC, Creatinine, Urinalysis (to check for complications)Rheumatoid Factor (positive if > 6 weeks of infective endocarditis)2-D Echo with doppler (50-80%o sensitive except if with < 2 mm vegetations)

Transesophageal Echocardiography (TEE) (90% sensitive) Therapeutics:

A. Acute Bacterial Endocarditis Empiric Therapy paclading IV Drug Abuser):

Target: Staphylococcus aureus 1. Nafcillin or Oxacillin 2 gm 1V q 4 hr or Vancomycin 500 mg IV q 6 hr ot 1 gm IV q 12 hr (1 gm in 250 ml D5W infused slowly over 1hr q 12 hr) X 4 weeks IV + 2. Gentamicin 100-200 mg IV (2 mg/kg), then 80 mg (1-1.5 mg/kg) IV q 8 hr X 3-5days

Note: Therapy can be changed once blood culture and sensitivity results are available B. Subacute Bacterial Endocarditis Empiric Therapy:

Target: Strep. viridans, Enterococci 1. Penicillin G 2-4 mil units (12-24 million units/day) IV q 4 hr X 4 weeks IV or Ampicillin2 gm (12 g/day) IV q 4 hr + 2. Gentamicin 80 mg (1-1.5 mg/kg) IV q 8 hr X 2 weeks IV

Note: Choice between low dose or high dose Penicillin depends on the susceptibility of themicroorganism and the clinical course of the patient. Use a higher dose for more toxic patients

C.Clinical Course:

1. Defervescence after 3-7 days.2. Repeat Blood C/S 2 and 4 weeks after the end of treatment to detect relapse.

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INFECTIVE ENDOCARDITID (PROPHYLAXIS)

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A. Cardiac Conditions Associated with Endocarditis: (prophylaxis recommended)

1. High-risk category: Prosthetic cardiac valves, previous bacterial endocarditis, cyanotic congenital heart disease, surgically constructed systemic-pulmonary shunts or conduits2. Moderate-risk category: Rheumatic heart disease (acquired valvular dysfunction), mitral valveprolapse with valvar regurgitation and/or thickened leaflets, other congenital cardiacmalformations (e.g. VSD, PDA, primum ASD, coarctation of the aorta and bicuspid aortic valve),hypertrophic cardiomyopathy.

B. Prophylaxis for Dental, Oral, Upper Respiratory Tract or Eeophageal Procedures:

1. Oral: Amoxicillin 2 gm orally 1 hour before procedure, no need for a repeat 6 hours later;Children: 50 mg/kg orally 1 hour before procedure Penicillin allergy: Clindamycin 600 mg orally I hour before procedure or Cephalexin 2 gm orally1 hour before procedure2. Parenteral: Ampicillin 2 gm IM or IV 30 minutes before procedure

C. Prophylaxis for Gastrointestinal and Genitourinary Procedures:

1. Parenteral: Ampicillin 2 gm IV plus Gentamicin 1.5 mg/kg IM or IV (not to exceed 80 mg) 30min before procedure; followed by Ampicillin 1 gm IV 6 hours later Penicillin allergy:: Vancomycin 1 gm IV infused slowly over 1 hour + Gentamicin 1.5 mg/kg IM orIV (not to exceed 80 mg), 1 hour before pracedure

Somer Adapted from the 1997 AHA Recommendations for Prevention of Bacterial Endocarditis

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CARDIO-PULMONARY CLEARANCE



DataTable 1-7. Modified Goldman's Classification: Cardiac Risk Stratification in Patients UndergoingNon-cardiac Surgery.

Risk Factor

Points

1. History- Age > 70 years- MI within previous 6 months, unstable angina within 3months or chronic stable angina with CCS (CanadianCardiovascular Society) class III or IV angina

5

10

2. Physical Examination- S3 gallop or jugular vein distention, decompensatedCHF

- Severe aortic stenosis or mitral stenosis

11 3

3. Electrocardiogram- Rhythm other than sinus or PACs on last preoperativeECG- > 5 PVCs/min documented at an time beforeoperation

7 7

4. General status- PO2 < 60 or PCO2 > 50 mmHg, K < 3.0 or HCO3 <20 meq/I, BUN > 50 or Crea > 3.0 mg/dl, abnormalSGOT, signs of chronic liver disease, or patientbedridden from noncardiac causes

3

5. Operation- Intraperitoneal, intrathoracic, or aortic operation- Emergency Operation

34

Total = 53

Goldman's Class Incidence ofLife-Threatening

Complications

1. Class I:2. Class II:3. Class III:4. Class IV:

0-5 points6-12 points

13-25 points= 26

Low riskIntermediate risk

IntermediateHigh risk

1-2 %5-7%16%56%

Source: Modified from Goldman L, et al (1997). Multifactorial index of cardiac risk in noncardiac surgical.

NEJM, 297 845. II. Diagnostics:

A. Basic Exams: CBC, FBS, K, Creatinine, ECG, Chest X-ray PA-L

B. Other Helpful Tests: Platelet count, PT, PTT, UrinalysisC. Optional Tests as Indicated: ABG, Total Bilirubin, Albumin, SGOT, 2-D Echo with doppler

III. Treatment Approach:

A. Correct anemia, poor nutritional status, hypovolemia, polycythemia, hypertension, electrolyteabnormality, cardiac arrhythmia, high blood sugar, pulmonary disease causing hypoxemia,



adrenal hyporesponse secondary to long-term steroid use.

B. CP clearance and need for intraoperative monitoring. Three basic questions:1. What is the medical status of the patient?

a. What is the functional capacity of the patient? Can the patient climb at leasttwo flights of stairs with ease?b. What is the patient's Goldman's Classification (Class I – IV)?

Note: Low-risk patients to clear leave good functional capacity and are Goldman’s Class L2. What is the operative procedure?

a. High-risk surgery: Emergency major operation, aortic and other majorperipheral vascular surgery, anticipated prolonged surgery with large bloodloss.b. Intermediate risk surgery: Carotid endarterectomy, head and neck,intraperitoneal and intrathoracic, orthopedic, prostate surgery.c. Low-risk surgery: Breast, cataract, endoscopy, superficial procedures.

3. What type of anesthesia is to be used?

From high-risk to low-risk: General anesthesia, spinal anesthesia, subarachnoidblock, regional anesthesia, local anesthesia.

C. Based on the answers above, we can now estimate the operative risk involved. Low-risk

patients undergoing low-risk procedures have low operative risk. Conversely, high-risk patientsundergoing high-risk procedures have high operative risk and need intraoperative monitoring. Forother combinations of risk, the physician is advised to use his/her clinical judgment before clearingthe patient.




DYSLIPIDEMIATo Cardiology Page


A. Screening:In patients without coronary heart disease (CHD), the National Cholesterol Education Program(2001) recommends screening with a complete lipid profile (total cholesterol, LDL cholesterol,HDL cholesterol, and triglyceride) after a 12 hours fast for all adults > 20 years of age once every5 years and as indicated.

B. Positive Risk Factors (Add 1 point each):

Age and gender (male > 45, female > 55 or premature menopause in women without estrogenreplacement), current cigarette smoker (ten or more cigarettes per day), hypertension, familyhistory of premature coronary artery disease (myocardial infarction or sudden cardiac deathbefore age 55 in a male first degree relative and before age 65 in a female first degree relative),and low HDL cholesterol < 40 mg/dl.

C. Negative Risk Factor: Subtract by 1 point if HDL > 60 mg/dl

D. Normal Values: Ideal Lipid Profile

- Total Cholesterol (TC) , 200mg/dl- HDL >=40 mg/dl- LDL <130mg/dl- Triglycerides (TG) <200mg/dl

E. Recommended Treatment

Table 1-8. National Cholesterol Education Program (NCEP) Recommended Cut-off Treatment Levelsin Adults: Based on at Least Two Results Taken 8 Weeks Apart.

CardiacRisk

Category

Start Drug Therapy (After8-week trial of diet)

Start DietTherapy

Only

TreatmentGoal

Total Chol LDL LDL LDL

0-1 riskfactors; NoCHD

> 280 mg/dl(7.3 mmol/1)

= 190 mg/dl(4.9

mmol/l)

= 160mg/dl(4.1

mmol/l)

<160mg/dl

(4.1mmol/1)

2 or morerisk factors;No CHD

> 240 mg/dl(6.2 mmol/l)

= 160 mg/dl(4.1

mmol/l)

= 130mg/dl(3.4

mmol/I)

<130mg/dl

(3.4mmol/I)

(+) CHD,DM or CHDrisk e

equivalents*

> 200 mg/dl(5.2 mmoVl)

= 130 mg/dl(3.4

mmol/l)

= 100mg/dl** (2.6

mmol/I)

< 100mg/dl (2.6mmol/1)

Note: Conversion factor from mg/dl to mmol/l: multiply by 0.0259* CHD risk equivalents comprise: (1) diabetes, (2) other clinical forms of atherosclerosis (symptomaticcarotid artery disease, peripheral arterial disease, and abdominal aortic aneurysm), (3) multiple positiverisk factors which includes consideration of the following - older age group, very high total cholesterol, lowHDL, heavy cigarette smoker, and untreated and high blood pressure.** In patients with CHD and LDL levels between 100-130 mg/dl, the physician should exercise clinical

judgment in deciding whether to initiate drug therapy



Source: Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP)Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (AdultTreatment Panel III). JAMA Vol. 285 19:2486-97, May 16, 2001. F. Treatment Approach:

1. Goal o f treatment: Set treatment goal for target LDL

2. Start with Non-Pharmacologic Treatment:a. Diet therapy: Moderation in diet; increase intake of fish and vegetables. Diet for 8weeks, then recheck Lipid Profile after 8 weeks. If repeat LDL values fall above the cut-offlevels for starting drug treatment, initiate treatment with Statins.b. Aggressive coronary heart 'disease risk reduction: Smoking cessation, hypertensioncontrol, Aspirin treatment for documented coronary disease.c. Weight reduction if obesed. Increase physical activity (e.g. brisk walking, swimming)e. Consider stopping beta-blockers and thiazide diureticsf. Correct hyperglycemia (if diabetic) and replace thyroid hormones (if hypothyroid)

3.Drug treatment of choice:a. Type IIa: Increased LDL cholesterol and normal triglyceride (< 200 mg/dl):#1Statins, #2 Probucol, #3 Fibrates, #4 Nicotinic acidType IIb: Increased cholesterol and increased triglyceride (200-400 mg/dl):#1 Statins or Fibrates, #2 Nicotinic acidc. Type IVL: Normal ch'olesterol but increased triglyceride:#1Fibrates, #2 Nicotinic acid, #3 Fish oil

G. Available Lipid Lowering Agents

1. Statins as first-line drugs: (proven to prolong life with regular use)

Atorvastatin (Lipitor) 10 mg, 20 mg, 40 mg, 80 mg tab: 10-80 mg tab OD HSSimvastatin (Vidastat =), Zocor) 10 mg, 20 mg, 40 mg: 5-40 mg/day, start with 5-10 mg ODHS.Pravastatin (Lipostat) 10 mg, 20 mg tab: 10-40 mg OD HSFluvastatin (Lescol 40 mg, Lescol XL 80 mg tab): 1 tab OD HS

2.Fibrates

Gemfibrozil (Reducel =), Lipigem =) 300 mg & 600 mg cap, Lopid O.D. 900 mg

cap); 300-600 mg BID or Lopid O.D. 900 mg OD3. Nicotinic Acid:

Nicotinic Acid (generic) 50 mg, 100 mg tab: 50 mg OD then increase up to 100 mg TID4. Others

Oil gel capsule (Trianon Omegabloc) 1 cap TID




INDICATIONS FOR PERMANENT PACEMAKER INSERTION


To Detailed Table of ContentsData

There is general agreement that a permanent pacemaker should be implanted in the following conditions(Class I Indications):

A. Complete Heart Block with

l. (+) Symptoms due to the AV block (e.g. syncope, heart failure)2. Asystole = 3 seconds by Holter monitoring even if without symptoms3. HR < 40 bpm even without symptoms (any escape rhythm < 40 bpm)

B. 2nd Degree AV block, permanent or intermittent, with symptomatic bradycardia

C. Sinus node dysfunction with symptomatic bradycardia. In some patients this due to long-term

essential drug therapy for which there are no acceptable alternatives e.g. digoxin fortachycardia-bradycardia syndrome.D. Carotid sinus stimulation causing recurrent syncope or asystole > 3 seconds in the absence of anymedication that depresses the sinus node or AV conduction.

Additional Data:

1. Patients should not be taking any drug that depresses the heart rate (i.e. digoxin, amiodarone,beta-blockers etc.). For example, digoxin needs 5 days to be completely excreted by the body, hence, wemay opt to temporize the patient for 5 days even if he/she fulfills the above criteria.2. The key clue in most of the above indications is the presence of symptoms.3. Acute MI cases who develop bradyarryhthmias are usually treated with temporary internal pacing sincethe problem is reversible. Inferior wall MI is associated with edema of the AV node which usually resolvesin 1- 2 weeks.4. In poor patients who cannot afford permanent pacing, drug therapy with Bricanyl 2.5 mg tab BID-TIDmay be given with inconsistent results. In severe symptomatic cases, permanent pacing is the onlyalterative. The cheapest pacemaker available costs around Php 50,000.




HYPERTENSIONTo Cardiology Page


Data:

Seventh Join National Committee Classification:

I. Hypertension category Systolic

(mmHg)

Diastolic

(mmHg)

Normal <120 And <80Prehypertension 120-139 Or 80-89Hypertension Stage 1 (mild) 140-159 Or 90-99Hypertension Stage 2(moderate-severe)

= 160 Or = 100

Note: Take at least 2 readings on separate occasions to diagnose hypertension II. Recommendations for Follow-up Based on Initial Set Blood Pressure Measurements for Adults

InitialScreening

Systolic

BloodPressureDiastolic(mmHg)

Follow-up Recommended

<120 And <80 Recheck in 2 years120-139 Or 80-89 Advise healthy lifestyle and

recheck in 1 year 140-159 Or 90-99 Confirm hypertension in 2

months=160 Or =100 Evaluate or refer to source

of care within 1 month III. Recommended Laboratory Tests:

CBC Urinalysis, Potassium, FBS, Creatinine, Calcium, Total Cholesterol, HDL, LDL, TriglyceridesECG IV. Approach to Treatment

A. Rule out correctable and secondary causes of hypertension first.

Theseinclude drug-induced hypertension, thyroid or parathyroid disease, chronic disease,renovascular disease, coarctation of the aorta, primary aldosteronism, chronic steroidtherapy and Cushing’s syndrome, and pheochromocytoma.

B. Encourage Lifestyle Change for Essential Hypertension

1. Stop Smoking2. Lose weight if overweight. Maintain body mass index of 18.5 – 24.9 kg/m^2 for every10 kilogram of weight loss, BP drops by approximately 5-20 mm Hg.3. Reduce sodium intake (< 2 gm of sodium or approximately < 6 gm of sodium chloride).4. Healthy diet. Consume a diet rich in vegetables, fruits and low fat dairy products.

Reduce dietary saturated fat and cholesterol intake for overall cardiovascular health.Reducing fat intake also helps reduce calorie intake, which is important for control ofweight in type II diabetes5. Engage in regular aerobic exercise once BP is controlled. At least 30 minutes per day,most days of the week. Brisk walking is good exercise.6. Limit alcohol intake to less than 1 oz/day of ethanol (24 oz of beer, 8 oz of wine, or 2 ozof 80-proof whiskey)7. Maintain adequate dietary potassium, calcium and magnesium intake.

C. Choice of Antihypertensive Drags Based on Patient Characteristics. (List includes



compelling indications.)

1. Diabetic patients and those with chronic kidney disease: Use ace-inhibitors or

angiotensin II antagonists to delay diabetic nephropathy.2. Young patients:Use beta-blockers unless contraindicated.

3. Coronary artery disease patients: Use beta-blockers, calcium-antagonists. Avoid

hydralazine.4. Heart failure patients: Use ACE-inhibitors and/or diuretics. Generally avoid

beta-blockers and calcium-antagonists.5. Athletes: Avoid beta-blockers and diuretics.

6. Broncho-pulmonary disease patients: Use Verapamil and other calcium-antagonists.

Avoid beta-blockers.7. Peripheral vascular disease patients: Use calcium-antagonist (nifedipine),

vasodilators, or ace-inhibitors. Avoid beta-blockers.8. Dyslipidemic patients:Avoid beta-blockers and diuretics.

9. End-stage renal disease patients: Use calcium-antagonists, diuretics and

centrally-acting agents. Caution on ace-inhibitors.10. For stroke patients:Use ACE-inhibitors and/or diuretics.

11. Elderly patients: Use diuretics. Generally use lower dosages. Be wary of

pseudohypertension wherein the elevated BP is due to brachial artery atherosclerosis andnot hypertension per se.

D. Treatment Goal and Guide:

1. For hypertensive patients with diabetes or renal disease, the target BP is < 130/80 mm Hg. Forother patients without cardiovascular risk factors, the BP goal is < 140/90 mm Hg.2. JNC VII recommends the use of thiazide-type diuretics as first line treatment unlesswith contraindications. Two diuretics locally available are Aldazide given at 1/2 tablet a day andNatrilix. The most commonly used thiazide-type diuretic hydrochlorothiazide may soon beavailable.





DRUG LIST OF ANTI-HYPERTENSIVES & CARDIAC DRUGS:



ACE-Inhibitors Captopril (Capoten, Primace =)) 25 mg, 50 mg tab

PO 25-50 mg BID-TID; CHF: 6.25-50 mg TID; maximum dose of 150 mg/dayCilazapril (Vascace) 1 mg, 2.5 mg tab (Php 28/ tab)

PO 1/2 tab OD X 2 days then 1-2 tabs ODEnalapril (Hypace =), Renitec) 5 mg, 10 mg, 20 mg tab

PO 10-20 mg OD-BI; maximum dose of 40 mg/dayImidapril (Norten =), Vascor =)) 5 mg, 10 mg tab

PO 5-10 mg OD; maximum dose of 20 mg/dayLisinopril (Zestril) 5 mg, 10 mg, 20 mg tab

PO 10-20 mg/day; CHF-5-20 mg/dayPerindopril (Coversyl) 2 mg, 4 mg tab

PO 4mg/day OD-BID; CHF: 2-4 mg/day

Quinapril (Accupril) 5 mg, 10 mg, 20 mg tabPO 10-20 mg/day single or 2 divided doses; CHF dose: 5-10 mg OD

Ramipril (Tritace) 1.25 mg, 2.5 mg, 5 mg, 10 mg tabPO 1.25-2.5 mg OD-BID; maximum dose of 10 mg/day

Angiotensin II Antagonists (and diuretic combination)

Losartan (Cozaar, Lifezaar =)) 50 mg tab

PO 1/2 - 2 tabs ODLosartan & hydrochlorothiazide (Hyzaar) 50 mg/12.5 mg combination

PO1/2- 2 tabs OD in A.M. Ya - 2 tabs OD in A.M.Telmisartan (Micardis, Pritor) 40 mg, 80 mg tab

PO 40-80 mg tab OD in A.M.Telmisartan & Hydrochlorothiazide (Micardis Plus) 40/12.5 mg, 80/12.5 mg tab

PO 1 tab OD in A.M. 1 tab OD in A.M. Beta-Blockers

Atenolol (Therabloc =), Tenormin) 50 mg, 100 mg tab

PO- 50-100 mg PO ODBetaxolol (Kerlone) 10 mg, 20 mg tab

PO 10-20 mg tab ODBisoprolol Fumarate (Concore) 5 mg tab

PO 1 tab ODCarvedilol (Dilatrend) 6.25 mg, 25 mg tab

PO- 25-50 mg tab OD-BID; CHF dose: 3.125-12.5 mg BIDMetropolol Succinate (Betazok) 100 mg tab

PO 100-200 mg ODMetoprolol Tartrate (Neobloc =), Betaloc, Cardiosel) 50 mg, 100 mg tabPO 50-100 mg BID to TID

Nadolol (Corgard) 40 mg tabPO 40-80 mg/day

Pindolol (Visken) 5 mg tabPO 5-15 mg/day single dose

Propranolol HC1 (Inderal) 10 mg, 40 mg tabPO- 10-40 mg TID to QID



Calcium-Channel Antagonists

NifedipinePO- Calcibloc OD =) 30 mg tab OD; Odipin 40 mg 1/2 - 1 tsb ODPO- Adalat 1 Retard tab OD; Adalat 30 mg GITS tab OD-BIDPreferred maximum dose: 90 mg/dayNote: High-dose short acting Nifedipine has been associated with an increase in mortality.

Diltiazem HCl (Ritemed Diltiazem =), Dilzem, Diltelan, Tildiem) 30 mg tab, 60mg tab,90 mg SA tab, 180 mg SR tabPO 30-60 mg TID, SA tab BID, 1 SR tab ODVerapamil (Isoptin,Verelan) 40 mg tab, 80 mg tab, 180 mg SR tab, 240 mg SR tab

PO 40-80 mg tab TID, 240 mg SR caplet ODNimodipine (Nimotop) 30 mg tab, 10 mg/50 ml IV infusion

PO 1-2 tabs q 4-8 hourlyIV 1-2 mg/hr

Nicardipine HC1 (Cardepine) 10 mg tab, 20 mg tab, 40 mg SR cap, 2 mg/2 ml vial,10 mg/10ml vialPO- 10-40 mg tab TID or 1 SR cap BIDIV- 2-7 mg IV bolus or IV infusion

Amlodipine (Norvasc) 5 mg tab, 10 mg tabPO 2.5-10 mg OD; Maximum dose of 10 mg/day

Felodipine (Plendil ER) 2.5 mg tab, 5 mg tab, 10 mg ER tabPO 2.5-10 mg OD-BID

Manidipine (Minadil, Caldine) 10 mg tab, 20 mg tabPO 10-20 mg OD

Lacidipine (Lacipil) 2 mg tab, 4 mg tabPO 2-4 mg tab OD

Centrally Acting Drugs

Clonidine HCl (Catapres, Melzin) 75 mcg tab, 150 mcg tab, 150 mcg/ml amp,

2.5 mg TTS-1PO 75-150 mcg BID, maintenance of 0.3-1.2 mg/day, maximum of 2.4 mg/dayIV, OM, SC- 1 amp via SC, IM or IV routes for hypertensive crisis

Transdermal- TTS-1 One patch per weekMethyldopa (Aldomet, Dopetens, Meldopa, UL Methyldopa) 125 mg tab, 250 mg tab,500 mg tabPO 250-500 mg TID

Diuretics

Spiranolactone+Butizide (Aldazide =)) 25mg/2.5mg tab

PO 1/2-2 tabs/dayPreffered dose: 1/2 tab OD

Indapamide (Natrilix SR) 1.5 mg tabPO 1 tab OD

Bumetamide (Burinex) 1 mg tabPO 1 mg tab OD

Furosemide (Lasix) 40 mg tab, 20 mg/2 ml ampPO 1/2 tab OD-BIDIM, IV- 20-40 mg

Furosemide + Amiloride (Frumil) 40 mg/15 mg tabPO 1-2 tabs/day

Spironalactone (Aldactone) 25 mg tab, 50 mg tab, 100 mg tabPO 50-100 mg/day in single or divided doses

Hydrochlorothiazide: 25 mg tab or 1/2 tab ODPO 12.5 - 50 mg/dayPreferred dose: 12.5 mg or 1/2 tab OD



Not Available Note. For hypertension, lower doses of diuretics are preferred because of less side-effects such aselectrolyte abnormalities. If BP is still elevated, combine diuretics with other anti-hypertensives preferably

Ace-inhibitors.

Vasodilators Hydralazine HC1 (Apresoline) 10 mg tab, 25 mg tab, 50 mg tab, 20 mg amp

PO- 50-200 mg/day; 25 mg BID-TIDIV, IM- 5-10 mg slow IV q 3-6 hours; Maximum of 3.5 mg/kg/dayStarting dose: 25 mg BID

Prazosin HCl (Minipress) 1 mg tabPO- 0.5-2 mg OD-QIDStarting dose: 0.5 mg BID

Terazosin HCl (Hytrin) 1 mg tab, 2 mg tab, 5 mg tabPO 1-5 mg tab ODStarting dose: 1 mg at bedtime

=) Cheapest Anti-Hypertensives dt Cardiac Drugs (Mnemonic: ABCD)

I. Ace-inhibitors:

Enalapril (Hypace) 5 mg, 10 mg, 20 mg tabPO- 5-20 mg tab OD (Php 15.00 per 10 mg tab)or Imidapril (Norten, Vascor) 5 mg, 10 mg tabPO- 5-10 mg tab OD (Php 20.00 per 10 mg tab)

II. Angiotensin II Antagonists:

Losartan (Li fezaar) 50 mg tabPO- 1-2 tabs OD (Php 20.20 per 50 mg tab)

III. Beta-blockers:Metoprolol (Neobloc) 50 mg tab, 100 mg tab

PO- 1/2 - 1 tab BID (Php 8.00 per 100 mg tab) IV. Calcium-channel Antagonists:

Nifedipine (Calcibloc OD) 30 mg tabPO- 1 tab OD (Php 27.00 per 30 mg tab)

V. Diuretics:

Spironolactone+Butizide (Aldazide) 25mg/2.5mg tab PO- 1/2 tab OD (Php 9.50 per tab) Note: For poor patients with mild to moderate hypertension, use beta-blockers and/or low-dose diuretics.For severe hypertension, use calcium-channel antagonists. To Cardiology PageTo Main Table of Contents




LOW MOLECULAR WEIGHT HEPARINS: FOR DVT AND UNSTABLEANGINA


To Detailed Table of Contents Treatment Indications and Recommended Dosages:

1. Prevention of DVTfor General Surgery/ Orthopedic Surgery:

a. Dalteparin (Fragmin) 2500 IU SC ODor b. Enoxaparin (Clexane) 20 mg/0.2 ml SC ODor c. Nadroparin (Fraxiparine) 0.3-0.4 ml SC OD

Note: LMW Heparins may be started 12 hours after surgery if OK with thesurgeon. Heparin prophylaxis is continued until the patient is ambulatory.

2. Treatment for Deep Venous Thrombosis:

a. Dalteparin (Fragmin) 100 IU/kg SC BIDor b. Enoxaparin (Clexane) 1 mg/kg SC BID

or c. Nadroparin (Fraxiparine) 0.9 mg/kg SC BID (see recommended dosages below) 3. Treatment for Unstable Angina and Non Q-wave MI:

a. Enoxaparin (Clexane) 1 mg/kg SC BIDor b. Dalteparin (Fragmin) 100 IU/kg SC BID

Available Formulations of Low Molecular Weight (LMW) Heparins:

1. Dalteparin Sodium (Fragmin)

Formulation: 2500 IU10.2 ml or 5000IU/0.2 ml)Sample dosage for a 50 kg patient for treatment of Unstable Angina:5000 IU SC BID 2. Enoxaparine (Clexane)

Fonnulation: 40 mg/0.4 ml inj and 20 mg/0.2 ml injectionSample dosage for a 60 kg patient for tnatment of DVT:60 mg or 0.6 ml SC BID 3. Nadroparin Calcium (Fraxiparine)Formulation 0.3 ml and 0.4 ml (0.2 ml and 0.6 ml also available)3 1/2 hours half-life, activity up to 24 hours

Body Weight

<50 kg50-70 kg>70 kg

Treatment of DVT0.3-0.4 ml BID0.4-0.6 ml BID0.6-0.8 ml BID

SurgicalProphylaxis

0.2-0.3 ml OD0.3-0.4 ml OD0.4-0.6 ml OD

Note:1. Precautions: Bleeding disorders, hepatic insufficiency, first trimester of pregnancy.2. Technique: Right and left SC tissue at the anterolateral or posterolateral abdominalwall; inject vertically.

Source: Adapted from Weitz, J. (1997). Low-Molecular-Weight Heparins. NEJM 337, l 0, 691. To Cardiology PageTo Main Table of ContentsTo Detailed Table of Contents



THE CARDIAC PATIENT WITH OTHER MEDICAL DISORDERS



Cardiac (Hypertension, Congestive Heart Failure) 4 Renal Failure

1. The following drugs may be used for hypertension:a. Calcium-channel antagonistsb. Centrally-acting drugs

2. The following drugs may be used for congestive heart failure:a. Vasodilators:e.g. Prazosin (Minipres) 1 mg tab OD-TID

Apresoline 25 mg tab PO TIDb. Caution with Ace-inhibitors (increases potassium)

Cardiac (Coronary Artery Disease) & Gastrointestinal Bleeding

1. Mortality in patients with gastrointestinal bleeding is usually secondary to coronary arterydisease and not to the bleeding per se.2. The following drugs for coronary artery disease cannot be routinely given: Thrombolytics,heparin, warfarin or aspirin3. Correct anemia from the gastrointestinal bleeding (anemia aggravates CAD) Consider 4.Clopidogrel (Plavix) 75 mg tab OD or low dose Aspirin (Cor 30) at 30 mg OD

Cardiac (Hypertension) dt Diabetes Mellitus

1. Five Stages of Diabetic Nephropathy:

Stage 1: Hyperfiltration (increase GFR)Stage 2: Incipient stage (microalbuminuria)Stage 3: Overt stage (macroalbuminuria)

Stage 4: Azotemia (increase creatinine)Stage 5: End stage renal disease

2. Therapeutics:

a. Ace-inhibitors and Angiotensin II-antagonists are best for stages 1-3b. Calcium channel blockers am best for stages 4-5c. Beta-blockers cover up hypoglycemic symptoms and may also increase lipidsd. Diuretics can increase blood sugar and lipidsd. Diuretics can increase blood sugar andlipids

Cardiac (Atrial Fibrillation or Acute Myocardial Infarction) & Pneumonia

1.Caution with giving nebulization with beta-2 agonists as this may precipitate arrhythmias

2. May use saline nebulization or Ipratropium Bromide (Atrovent) nebulization




BRONCHIAL ASTHMATo Pulmonology Page


Data:

A. Definition: Asthma is a chronic inflammatory disorder of the airways in which many cells play a roleincluding mast cells, eosinophilia, T-lymphocytes and neutrophils In susceptible individuals, thisinflammation causes symptoms which are usually associated with widespread but variable airflowobstruction that is own reversible either spontaneously or with treatment, and causes an associatedincrease in airway responsiveness to a variety of stimuli.

B. New Classification of Asthma According to Severity:

1. Mild Intermittent Asthma2. Mild-Moderate Persistent Asthma3. Severe Persistent Asthma Table 2-1. New Chronic Asthma Severity Classification from Philippine Consensus from on the Diagnosis

and Management of Asthma (PCRDMA), 2004

Parameters

Chronic Asthma Severity

Mild

Intermittent

Mild-Moderate

Persistent

Severe

Persistent

Daytimesymptoms

Less thanweekly

Weekly Daily

Night Awakenings

Less thanmonthly

Monthly toweekly

Nightly

Rescue B2use

Less thanweekly

Weekly to daily Several daily

PEF or FEVl > 80%of

predicted

60-80% of

predicted

< 60% of

predicted

Treatmentneededcontrol

Occasional useof Beta-2agonists

Regular use ofinhaled

corticosteroidsand long-actingbeta-2 agonists

Usescombination of

inhaledcorticosteroids,

long-actingbeta-2 agonist

plus oral steroids.

Note: The previous classification of mild and moderate asthma have been combined into class sincetreatment is similar. C. Monitoring of Severity of Asthma

The use of the peak expiratory Sow meter is practical and is recommended for using both initialassessment and in monitoring the severity of asthma.

D. Treatment: Control of Triggers

Avoidance of triggers which includes irritant gases, weather changes, cold air, exercise, respiratoryinfections, certain foods, additives, drugs. These triggers cannot cause asthma to develop initiallybet can exacerbate estab1ished asthma.

E. Goal in the Pharmacologic Therapy of Asthma

The goal in the management of asthma is to achieve control. Control of asthma is defined as:



1. Minimal (ideally no) chronic symptoms, including nocturnal symptoms2. Minimal (infrequent) exacerbations3. Minimal need for pm beta-2 agonist, ideally none4. No limitations on activities, including exercise5. (Near) normal PEFR6. PEF variability < 20 %

7. Minimal (or no) adverse effects from treatment

To Pulmonology PageTo Main Table of ContentsTo Detailed Table of Contents



F. Drugs Used to Treat AsthmaTo Pulmonology Page


1. Controllers: Medications shown to be useful in achieving and keeping persistent asthma under control.

They are also called preventers. These include inflammatory agents, anti-allergic medications, andlong-acting bronchodilator

a. Corticosteroids (anti-inflammatory agents):i. Inhaled

Beclomethasone dipropionate (Bocloforte Melted Dose Inhaler) 250 mcg/inhalation: 2inhalations BlD-QIDBudesonide (Budecort Turbuhaler / Primavent Metered Dose Inhaler), 200-400 mcg/dose:400 mcg inhalation BID, max = 800 mcg/day

ii.Oral/SystemicPrednisone 5 mg tab (Decortisyl, DLI-Prednisone, USA tab Prednisone 40-60 mg initially thentaper Methylprednisolone (Medrol 4 mg, 16 mg ADT tab) 16 mg tab BID, then taper

b. Long-acting Broncbodilators:i.Long-acting beta-2 aganist

- Inhaled: Formoterol fumarate (Foradil Metered Dose Inhaler) 12 mcg/inhalation: 1inhalation BID- Oral / Systemic: Salbutamol (Ventolin Volmax 4 - 8 mg tab BID

ii. Long-acting Theophylline (Sustained formulation)Unidur SR 400 mg tab: 1 tab OD or K tab BlD may be increased by 200 mg increments q 3days, maximum = 900 mgNuelin SR 175 mg tab, 250 mg tab: 1 tab q 12 hoursBrondil 5R 100 mg 1-2caps q 12 hr; 200 mg and 300 mg 1 cap q 12 hr

c. Combined Corticosteroids and Long-acting Bronchodilators:

i Salmeterol & Fluticasone (Seretide Diskus 250) l inhalation BIDii.Formoterol & Budesonide (Symbiocort Turbohaler) 1 inhalation BID

Note: Combination may be better than inhaled steroids and bronchodilators taken separately. Thisallows for better asthma control at lower dosages.

d. Leukotriene Receptor Antagonists.i. MonteluekastNa (Singulair) 10 ing tab OD HSii. Zafirlukast(Acolate) 20 mg tab BIDIndication. May be used as an altenative drug for mild persistent and moderate persistent

asthma.

2. Relievers: Meditations that reverse airflow obstruction and quickly relieve its accompanying symptoms

such as cough, dyspnea, wheezing and chest tightness. These consist mainly of short-actingbronchodilators

a Short-acting Bronchodilators:

i Short-acting Beta-2 agonists

- Inhaled: Salbutamol (Ventolin I Asmalin / Libreatin Metered Dose Inbaler) 100mcg/inhalation: 1-2 inflation PRNTerbutaline Suite (Bricanyl Turbahaler) 500 mcg/dose: 1 inhalation PRN, maximum= 12 doses/dayTerbutaline Sulfate (Bricanyl Metered Dose Inhaler) 0.25 mg/dose: 1-2 puffs PRN,maximum = 12 doses/day

- Oral / Systemic: Salbutamol (Ventolin) 2 mg tab: 2 tabs TID-QID up to 4 tabs TID-QIDTerbutaline Sulfate (Bricanyl) 2.5 mg tab, 5 mg ER tab, 0.3 mg/ml syrup 2.5mg tab BID-TID, 5 mg tab BID, 2-3 tsp (10-15 ml) BID-TIDTerbutaline Sulfate 1.5 mg, Guiafenesin 66.65 mg (Bricanyl expectorant



syrup): 2-3 tsp (10-15 ml) BID-TIDii.Short-actingTheophylline (Regular Formulations)

Nuelin tab 3 tabs single dose initially then l tab q 6 hoursTheodur 200 mg, 300 mg tab: 150-300 mg tab q 12 hoursUSA Theophylline 200 mg 1 tab BID

b. Anti-cholinergic agents - Inhaed Ipratrapium bromide

Ipratropium bromide (Atrovent Metered Dose Inhaler) 20 mcg: 2 puffs TID-QID or q 4 hours,maximum = 12 puffs/day

c. Combined Anti-cholinergic and Short-acting Bete-2 agonists

Ipratropium Br 21 mcg, Salbutamol 120 mug (Combivent Metered Dose Inhaler ): 1-2 puffs

TID-QID, maximum 12 puffs/day

Note:1. For poor patients who cannot afford inhaler devices:

a Give oral beta2-agonists instead of inhaled beta2-agonistsb. Give oral corticosteroids instead of inhaled steroidsc. Use oral theophylline if needed

2. MDI’s are actually cheaper by the dose then most tablets!




- Oral steroid > 7.5 mg daily or alternate days

RELIEVER:- Inhaled short-acting beta-2 agonistnot to exceed 3 - 4 X/day- Add inhaled Ipratropium bromide

ALTERNATIVE RELIEVER:- Short-acting oral/ systemic bronchodilator (beta-2 agonist or theophylline)

Guide to Treatment Plan:

1. Patients should start treatment at the step most appropriate to the initial severity their condition. Arescue course of prednisone may be needed at any time and any step.2. When to Step up: If control is not achieved, consider step up. But first review patient medicationtechnique, compliance and environmental control.3. When to Step down: Review treatment every 3-6 months. If control is sustained for at least 3months, a gradual stepwise reduction in treatment may be started.




H. Management of Acute Exacerbations of Asthma: Home Treatment

To Pulmonology PageTo Main Table of Contents


1. ASSESS SEVERITY:Clinical features: cough, breathlessness, wheeze, chest tightness, use of accessory muscles andsuprasternal retractions PEF < 80% personal best or predicted (if available)

2. INITIAL TREATMENT:

Inhaled short-acting beta-2 agonist up to 3 treatments in 1 hour Alternative: Oral short-acting beta-2agonist and/or theophylline

3. Responses:

a. GOOD RESPONSEi. Clinical Picture:

(Mild Exacerbation): No symptoms within 1hr - PEF > 80% predicted/ personal best

- Sustained response for 4 hoursii. Management:- Continue regular broncho-dilator for 24-48 hours- Inhaled short-acting beta-2 agonist 2 puffs q 3-4 hr

Alternative: Oral short-acting beta-2 agonist or theophylline 3Xdayiii. Consultation: Contact Clinician within 48 hours for follow-up instructions

b. INCOMPLETE RESPONSE

i . Clinical Picture:(Moderate exacerbation)- PEF 60-80 % predicted/personal best

ii. Management: ADD ORAL STEROID (1 mg/kg/day)- Continue beta-2 agonist and/or theophylline regularly

iii. Consultation: Consult Clinician urgently for instructions

c. POOR RESPONSEi . Clinical Picture:

(Severe exacerbation)- PEF< 60% predicted/personal best

ii. Management: ADD ORAL STEROID(1 mg/kg/day)- Repeat inhaled beta-2 agonist if available

iii. Consultation: Immediate transport to hospital Emergency Department or nearest medicalfacility

Note: Seek medical help immediately if the patient has the following:- Risk factors associated with asthma deaths: Current use of or recent withdrawal from systemiccorticosteroids, hospitalization in the past year, ER visit for asthma in the' past year, prior intubation forasthma, psychiatric disease or non-compliance with asthma medication.- Manifestations of severe asthma exacerbation: Talks in words, agitation, drowsiness or confusion,paradoxical thoracoabdominal movement, cyanosis or pallor.

To Pulmonology Page



I. Management of Acute Exacerbation of Asthma: Hospital Care


To Detailed Table of ContentsOrders:

Diet: Regular diet when not dyspneicVS: Vital Signs q l hour, Call MD if HR > 120; RR > 30, O2 SAT < 90%Nursing: Peak flow rate pre and post bronchodilator treatment, 3 trials each and record the best only,BID-TIDConnect to a pulse oximeter, Input & Output q shift; Moderate high back rest; Increase oral fluidsIVF: D5NM 1 L X 12 hours; D5NR 1 L X 12 hoursDiagnostics:

Peak Expiratory Flow Rate BID (Pre- and post-nebulization) (get,the best of 3 good attempts)

Chest X-ray portable (rule out pneumothorax & detect other problems)

CBC, K, RBS, Creatinine, Sputum G/S, C/S (if with pneumonia by Chest X-ray)

Consider ABG (if toxic-looking patient), ECGPFT (Pulmonary Function Test) to establish the diagnosis; = 15% increase in FEY following 2pufls of beta 2-agonist (to be done when exacerbation is over and there is still uncertainty of

diagnosis)

Therapeutics: Mnemonic - NASA

Oxygen at 2-6 1pm via nasal cannula Avoid or control trigger factors

1. Nebulization:

Salbutamol (Ventolin) neb/inhaler q 3- hours (1 nebule/2-4puffs) or Ipratropium Br+ Salbutamol (Combivent) nebulization 1 vial q 6 hours or Ipratropium Br (Atrovent) 1 unit dose vial TIDED tachycardia)

2. Antibiotics - if with probable bacterial infection (fever, persistence, purulence, crackles)

3. Steroids

a. Acute attack: Hydrocortisone (Solucortef) 250 mg IV stat then 100 mg IV q 4-6 hours X 4 doses or

continuous if the condition warrants There is no role for inhaled steroids in the treatment of an acuteattack.b. More stable: Start on oral steroids as soon as patients can safely swallow and taper off in 10-14

days

i. Prednisone 20 mg tab: I tab BID X 3 days then taper as follows:

A.M. 3 P.M. No. of Days1 1 X31 ½ X31 0 X3

1/2 0 X3Stop

or ii. Methylprednisolone (Medrol) 16 mg 1 tab BID X 3 days then taper.

A.M. 3 P.M. No. of Days1 1 X31 ½ X31 0 X3



1/2 0 X3Stop

iii. Inhaled Steroids - while not for acute attack, these drugs should be started early to have atleast a 1 week overlap with the oral steroid. e.g. Salmeterol & Fluticasone (Seretide Diskus250) 1 inhalation BID or Formoterol & Budesonide (Symbicort Turbuhaler) 1 inhalation BID

4. Aminophylline - only as an add on medication (if asthma is still not controlled)a. Acute Attack: not controlled by "N,A, &S ", give Aminophylline bolus at 5-6 mg/kg BW (if not

maintained on theophyllines) then Aminophylline dripb. More stable: shift to Long-acting Theophylline e.g. Theodur 300 mg tab 1/2-1 tab BID or Unidur

SR 400 mg, 600 mg 1/2-1 tab OD

5. If not controlled,by NASA (Nebulization, Antibiotics, Steroids and Aminophylline), consider intubationbefore respiratory fatigue sets in.

6. Optional medications: Antacids: Ranitidine 50 mg IV q 8 hours

J. How to Use Your Diskus:

1. Open, 2. Slide, 3. Inhale, 4. Close

1. Open – hold the outer case in one hand then put other thumb on the thumbgrip. Push your thumbuntil you hear a click.

2. Slide – hold discus with the mouthpiece towards you. Slide the lever away until it clicks.3. Inhale – put the mouthpiece to your lips. Breathe deeply. Remove discus from your mouth. Hold

breath for 10 seconds. Breathe out slowly.4. Close – put thumb in the thumbgrip and slide the thumbgrip back towards you until you hear a

click. Your Discus is ready for use again. Wipe mouthpiece with dry tissue to clean.





CHRONIC OBSTRUCTIVE PULMONARY DISEASETo Pulmonology Page


Table 2-2. COPD Classification, Signs and Symptoms, and Treatment

A. Healthy Population1. S/Sx : none2. FEV1 as % predicted : Normal3. Tx: Smoking cessation for everyone

B. Mild COPD

1. S/Sx : Smoker’s cough, No abnormal signs, Little or no dyspnea - Mild symptoms2. FEV1 as % predicted : = 80%3. Tx:

a. As needed Beta-2 Agonist

e.g. Terbutaline Sulfate (Bricanyl Turbuhaler) 500 mcg/dose: 1 inhalation PRN q 2-6 hr (seefor other drug options)b. Pulmonary rehabilitation

C. Moderate COPD1. S/Sx : Dyspnea on moderate exertion, Cough and moderate symptoms, continuous orintermittent2. FEV1 as % predicted: 30-79 %3. Tx:

a. For intermittent symptoms: As needed Beta- 2 Agonists

b. For continuous symptoms: Maintain on anticholinergics e.g. Tiotropium (Spiriva

HandiHaler) inhalation of 1 capsule daily.c. If response is unsatisfactory add oral theophylline or long-acting B2-agonistd. Consider mucokinetic agente. Pulmonary rehabilitation

D. Severe COPD

1. S/Sx : - Dyspnea on mild exertion or at rest, Lung hyperinflation, Wheeze & cough2. FEV1 as % predicted: < 30 %3. Tx:

a For continuous symptoms: Maintain on anticholinergies

b. For frequent exacerbations (more than 4 times a year): Add inhaled steroids, e.g.Salmeterol & Fluticasone (Seretide Diskus 250) 1 inhalation BIDc. Consider long - terms oxygen therapy at home

Source: GOLD (2003) &Philippine Consensus on COPD Diagnosis and Management (1999)

Diagnostics: CBC, serum Na, K, Chest X-ray, ABG, Sputum G/S, C/S

Therapeutics: Similar to Asthma treatment {NASA - Nebulization, Antibiotics (if with infection), Steroids,

Aminophylline}

l. If hypercapneic, keep O2 low at 0.5-1.5 1pm via nasal cannula (so as not to depress patientsrespiratory drive). It is best to target O2 sat at 90-92 %.2. Ipatropium Br & Salbutamol (Combivent) nebulization is more effective than Terbutaline orSalbutamol nebulization. Or if feasible give Tiotropium(Spiriva HandiHaler) inhalation of 1 capsule daily.3. For acute exacerbations, give a course of intravenous or oral steroids.4. Long term home oxygen therapy if patient hypoxemic or with cor pulmonale.5. Treatment is symptomatic, only smoking cessation and home oxygen therapy have been shownto prolong life.



PULMONARY TUBERCULOSISTo Pulmonology Page


A. Symptoms:

1. Local symptoms: Cough, hemoptysis, chest pain, dyspnea2. Constitutional symptoms: Fever, weight loss, chills, anorexiaNote: Around 10 % (5-14 %) have no symptoms

B. TB Concepts:

1. TB exposure2. TB Infection: (+) Purified Protein Derivative (PPD)3. TB Disease: (+) Target organ damage

C. Indications of Active Disease:

l. (+) AFB sputum smear (at least 2+) or (+) TB culture2. (+) Symptoms: Constitutional symptoms are more reliable than local symptoms3. Increase in chest x-ray infiltrates (usually apical)

D. Indications of Inactive Disease:

1. Six months interval with no change in chest x-ray infiltrates and no constitutional symptoms2. Preferably with history of completed TB therapy

E. Indications of Favorable Disease Response:1. Completion of prescribed treatment2. Conversion to sputum smear and culture to negative3. Resolution of constitutional symptoms4. Resolution or improvement of local symptoms

F. Table 2-2. American Thoracic Society (ATS) CLassification of PTB.

Class Exposure Infections

(+) PPDTarget Organ

(+) CXRinfiltrates

Indicationsof ActiveDisease(see Cabove)

0 (-) (-) (-) (-)

1 (+) (-) (-) (-)2 (+) (+) (-) (-)3 (+) (+) (+) (+)5 (+) (+) (+) (+/-)

MDRTB(Multiple Drug Resistant Taberculosis) - suspect in PTB III patients who are still sputum smear or

culture (+) despite 3 months of adequate treatment. Source: Maher D, Chavlet P, Spiaaci S, ct sl (1997). Treatment of Tuberculosis: Guidelines for NationalProgrammes (Second Ed.). Geneva: World Health Organization G. TB Diagnostics

Nursing precautions: Isolate patient in solo room if PTB Class III (active)

Diagnostics: Chest X-ray PA-Lateral and Apicolordatic viewSputum AFB Smear in A.M. for 3 consecutive days

Mycobacterium TB culture & sensitivity (PGH, Makati Medical Center)CBC, SGPT, SGOT, Alkaline Phosphatase

H. Treatmeat Plan:

l. ATS Class 0: No exposure, (-) PPD (e.g. Americans)

Treatment: BCG in high prevalence area

2. ATS Class 1: (+) exposure, (-) PPD

Treatment: If with recent exposure:



a. Give primary prophylaxis:

HR for 4 months or HE for 6 months

b. Repeat PPD in 2 months + if (+), treat as Class 2U if (-), stop primary prophylaxis

3. ATS C1ass 2: TB Infection - (+) exposure, (+) PPD, (-) target organ TB lesion

Note: 70% of adult Filipinos are (+) for PPD and are therefore naturally infectedTreatment:

a. If with recent PPD conversion, give primary prophylaxis HR for 4 months or HE for 6monthsb. If not a recent PPD converter but currently exposed to a TB case, give primarily prophylaxisis as abovec. If not a recent PPD converter 4 no family member has active TB, may not give primaryprophylaxis

4. ATS Class 3: PTB active

In the National TB Control Program, only Class III(Active) patients are targeted for treatment forfinancial reasons. For operational purposes ATS Class 3 patients are farther subidvided into

WHO Category I, lI. and III.

Table 2-3 Treatment Regimen for ATS Class 3 Patients (PTB Active)

1. WHO Category I*a. TB patients: new smear-positive PTB; new smear negative PTB with extensiveparenchymal involvement; new cases of severe forms of extra-pulmonary TB.b. Alternative TB Treatment Regimen

i. Initial phase: 2HRZE (four drugs)ii. Continuation phase: 4HR

2. WHO Category II

a. TB patients: Sputum smear-positive: relapse; treatment after interruptionb. Alternative TB Treatment Regimen

i. Initial phase: 2HRZES and 1HRZE (Five drugs)ii. Continuation phase: 5HRE

3. WHO Category III**

a. TB patients: New smear-negative PTB (other than in Category 1) new less severe formsof extra-pulmonary TB.b. Alternative TB Treatment Regimen

i. Initial phase: 2HRZ (three drugs)ii. Continuation phase: 4HR

* Give this regimen if with high bacterial load, cavitary lesions, AFB+4 smears, or high communityresistance (e.g. NCR, Cebu, Davao, Zamboanga, Cavite, Pampanga). If with cavitary disease, giveStreptomycin IM alternate days (60 doses) instead of Ethambutol** May give this cheaper regimen for newly diagnosed TB and those cases found in low communityresistance Source: Maher D, Chavlet P, & Spinaci S, et el (1997). Treatment of Tuberculosis: Guidelines for National

Programmes (2nd Ed.. Geneva: World Health Organization. 5. ATS Class 4: Previous PTB disease (e.g. Chest X-ray with minimal infiltrates but no symptoms ofactive disease or previously treated PTB)

Treatment Algorithm

Has patient completed past treatment of PTB?· NO: Check old CXR if:



o 6 months stable CXR§ If age <60:4HR or 6HE§ (If age >60 Just observe)§ Repeat CXR after 3 months§ If infiltrates increase or decrease, treat PTB as Class III.. If infiltrates are stable, stop

treatmento No previous CXR

§ Give 2HRZ/4HR§ Repeat CXR after 2 months§ If infiltrates increase or decrease, treat PTB as Class III.. If infiltrates are stable, stop

treatment

· YES: Observe and then Check old CXR if:o X-ray normal with normal or less infiltrates

§ Treat as PTB 3, 2HRZE/4HR (or 2HRZ/4HR)

o X-ray the same , no changes§ No treatment

6. ATS Class 5: PTB Suspect

Treatment Plan: Check previous Chest x-rayReclassify patient into Class III or Class IV in 2-3 months using sputum bacteriology or serial x-ray

changes.

7. Multi-drug Resistant TB: Infection with strain of Mycobacterium tuberculosis which shows in-vitroresistance to at least Isoniazid and Rifampicin

Treatment Plans: Use at least 4-5 drugs as hng as,

a. Use at least 4-5 drugs as long as these include 2 drugs not previously taken. Do not add a single

drug to a failing regimen to avoid resistance to the new drug. Consider continuing with H & R (mostbactericidal) despite resistance, for example, if patient took HREZ X 6 months, may then addStreptomycin (first line drug) and Ofloxacin (second line drug. May discontinue either E or Z.b. Continue treatment for 18 months more from the time the patient’s sputum becomes AFB andculture negative. Get cultures to check sensitivity of TB organism.c. Consider Surgery for unilateral cavitary lesions in whom MDR-TB is established by the

laboratory.

Legend: H or INH honiazidR or RIF = RifampicinZ or PZA PyrazinamideE or EMB = EthambutolS or STM Streptomycin

I. Notes on Anti-TB Drug Intake: (Additional Treatment Plan for Active PTB)

l. Instill in the patient’s mind the need to complete 6 months treatment.a. Since it is very difficult for patients to comply with multiple drug for the duration of at least six

months, incomplete treatment not only decrease cure rate but also enhance development ofresistance. It is ideal that treatment of TB should be done under direct supervision. “DOTS”-

Directly Observed Therapy Short Course requires actual observation during drug intake. Thereare now several DOTS centers in Manila to help doctors implement DOTS treatment even forprivate patients. Refer patients to Manila Doctors Hospital, PGH, Makati Medical Center andUST.

b. Give all medications 1 hour before meals. It is ideal not to break the dose of the drug.c. If drugs are to be staggered because of side effects, make sure each drug component is still

single dose.e.g. Rifampicin - before breakfast, EMB - before lunch, PZA - before supper

d. Use only fixed dose combination, since most of these contain only 450 mgRifampicin, add 150 mg Rifampicin if patient weighs > 60 kg or 130 lbs.



2. If patient cannot complete treatment, better not to start treatment at all to avoid emergence ofresistance (MDR-TB).3. The allowance for non-compliance is two weeks maximum, otherwise the treatment regimen shouldbe started all over again.4. Follow-up patients monthly. During initiation of treatment make patients follow- up after a week tosee if there are drug side effects.5. If after 6 months, the patient is still symptomatic, continue treatment but do sputum AFB and culture

and reassess if the patient has MDRTB or cured TB with bronchiectasis.6. Post-treatmeat follow-up: If two years has elapsed and the patient is still asymptomatic, long-term

cure is anticipated. Relapse occurs in 1-2 % of cases.

J. Tuberculosis in Special situations:

1. Pregnancy:

a. HRE X 9 months (Standard regimen for pregnant patients)

b. Give 50 mg of Pyridoxine as vitamin supplements.c. Avoid PZA, especially in the first trimester, unless resistance to H and R ishighly suspected.d. Avoid Streptomycin: May cause 8th cranial nerve fetal abnormality.e. Breastfeeding is allowed: Take drugs after breastfeeding; TB drugs do not have toxic effect on

nursing newborns.

2. Uremia or end-stage renal diseasea 2 HRZ / 6 HR (Safest regimen for renal disease)b. Give INH + RMF +/- Pyridoxine at the regular doses administered after dialysis.c. Ethambutol: Decrease dose to 8-10 mg/kg/dayd. Pyrazinamide: Decrease dose to 12-20 mg/kg/daye. Avoid Streptomycin (nephrotoxic)

3. Liver Disease/ Drag-induced Hepatitis:

a. Stop anti TB drugs if (1) (+) jaundice or (2) Liver function test (SGOT, SGPT) > 3X the normalvaluesb. Slowly resume INH and Etlambutol during first week. Resume Rifampicin during the second weekand then PZA 3 days after.

4. Diabetes Mellitus: Continue treatment for a minimum of 9 months

5. Elderly patients > 65 years: Give HR X 9 months

6. Extrapulmonary Tuberculosis:

a. Same treatment regimen as pulmonary TBb. For Central Nervous System TB:

i.Use H, R, Z because of good penetration to the CNSii.EMB and STM penetrate inflamed meninges only.

7. PTB in Children (Primary Complex):

a. mixed disease: INH 5mg/kg/day (max of 300mg) + RMP 10mg/kg/day (max of 600 mg)

b. extensive disease: STM 10-18mg/kg/day (max of 750mg) or EMB 15-20 mg/kg/day – avoid in

young children whose visual acuity cannot be monitored, PZA 20-30 mg/kg/day (no studies yet)




K. Anti-TB drugs available: First Line and Second Line Drugs



Table 2-4 First Line Drugs for Tuberculosis

1. INH (H)

Actions: Bacteriocidalintra/extra-cellular activityDosage:5mg/kg/day, Adult dose = 300-400 mgPOMetabolism: Liver Side Effects:Hepatitis, safest in pregnancy

Comments: Reintroduce INH gradually when liver enzymes are down, give slowly with Rifampicin 2. Rifampicin (R)

Actions:Bacteriocidal intra/extra-cellular activityDosage:10-20 mg/kg/day (child) Adult dose = 450-600 mg/dayMetabolism: Liver

Side Effects:Hepatitis, GI, haemolytic anemia, ARF, thrombocytopenia, nauseaComments: Increase metabolism of cortisone, coumadin, oral contraceptive, pheytoin

3. PZA (Z)

Actions:Bacteriocidal at acidic pH, intracellular activity onlyDosage: 20-30mg/kg/day Adult dose = 1500 mg/dayMetabolism: Liver Side Effects: Most hepatotoxic

Comments: Some patients tolerate lower dose gradually reintroduced4. EMB (E)

Actions:Bacteriostatic inra/extra-cellular activityDosage: 15-20mg/kg/day Adult dose = 800-1000 mg/day POMetabolism: KidneysSide Effects: Optic Neuritis, (impaired color perception, dec. in visual acuity)

Comments: Relatively safe in pregnancy5. Streptomycin (S)

Actions: Bacterostatic extra-cellular activityDosage: 10-18mg/kg/day Adult dose = 1 gram IMMetabolism: Kidneys

Side Effects: 8th nerve damage especially > 50 years old Note: Give all medications 1 hour pre-meals 2. Second Line Drugs for Tuberculosis

a. Ciprofloxacin 500-1000 mg OD POb. Ofloxacin 800 mg OD POc. Terizidone (Terivalidin) 250 mg, 3 caps ODd. Amikacia 15 mg/kg IM/IV

e. Cycloserine 15-20 mg/kg (1 gm)

Note: The use of these drugs for MDRTB should be under the DOTS-Plus program (available at MakatiMedical Center and Quezon Institute) to ensure that the patient gets a complete and free course of second line dPlease avoid using them in your practice to minimize TB resistance.

ANTI-TUBERCULOSIS DRUG LIST:

Note: The Department of Health TB pogrom provides Lee and complete course of anti-TB drugs. Referpatients to your local health centers.



1. Wyeth:Myrin-P Forte (4 TB Drugs in one tablet): Ethambutol 275 mg+ INH 75 mg + PZA 400 mg + Rifampicin150 mg

PO- Single daily dose: 40-54 kg, give 3 tabs; 55-70 kg, give 4 tabs, > /1 kg, give 5 tabsMyrin (3 TB Drugs in one tablet): Ethambutol 300 mg+ INH 75 mg+ Rifampicin 150 mg

PO- Single daily dose: 40-49 kg, give 3 tabs; > 50 kg, give 4 tabs.

2. UAP:Quadpack (4 TB drugs): 3 Pyrina (Rifampicin 150 mg + PZA 500 mg+ INH 150 mg) cap, 3 Odetol(Ethambutol HCl 400 mg)

PO- 1 pack daily as single dose for the first 2 monthsTripack (3 TB drugs): 2 Etham (Ethambutol diHCI S00 mg + INH 200 mg + vit B6 20 mg) tab, 1Median (Rifampicin 4SO my) cap

PO- 1 pack daily as single dose for the next 4 months

3. Pascual Lab:Econokit (4 TB drugs): 1 Nyadin (INH 40 mg) tab, 1 Rifampicin 450 mg cap, 3 PZA 500 mg tab, 1Ethionah (Ethambutol HC1 800 mg) tab

PO- 1 pack daily as single dose for the first 2 monthsEconopack (3 TB drugs): 1 Nyadin (honicotinic acid hydrazide 400 mg) tab, 1 Rifampicin 450 mgcap, 3 PZA 500 mg tab

PO- 1 pack daily as single dose for the first 2 monthsContinukit (Ethambutol HC1 800 mg, INH 400 mg, Rifampicin 450 mg)

PO- 1 Rifampicin before breakfast, Ethambutol + INH after breakfastContinupack (2 TB drugs): 1 Nyadin (Isonicotinic acid hydrazide 400 mg) tab, 1 Rifampicin 450 mgcap

PO- 1 cap & 1 tab in single intake preferably before breakfast for next 4 mos.




PULMONARY EMBOLISMTo Pulmonology Page


Data:

A. Predisposing actors:

1. Deep vein thrombosis as source: Carcinoma, CHF, recent pelvic and abdominal surgery, varicoseveins, prolonged immobilization, pregnancy, estrogen intake2. Tumor embolism from a gynecological or gastrointestinal source, e.g. liver cancer

B. Signs and symptoms: Dyspnea, tachycardia, chest painC. Diagnosis,of Pulmonary Embolism:

1. Clinical setting and high index of suspicion2. Physical Exam: Increase JVP but clear hogs, loud Py23. ABG may show respiratory alkalosis, hypoxemia4. ECG may show transient RAD, RBBB, S waves at precordial leads5. V/Q Scan: Interpreted as normal, low, intermediate or high probability of PE6. Pulmonary Angiography: Gold Standard for diagnosis

D. Diagnosis of Deep Vein Thrombosis (as source of the emboli)

1. Duplex Ultrasound of the lower extremities (Non-invasive test)2. Ascending Venography: Gold standard

Note: In our local setting, pulmonary angiography and ascending venography are rarely done. A highindex of suspicion and a compatible clinical setting already warrants treatment.

Orders

Admit to:VS: Vital signs q I hour; Bedrest without bathroom privilegesIVF: D5NM I L x 24 hoursDiagnostics: CBC, Chest X-ray, Serum K, Creatinine, Urinalysis

ABG, ECG, PT and PTT baseline and monitor

High-resolutiona CT-Scan or V/Q Scan

D-Dimer (if negative, embolism is unlikely)

Duplex Ultrasound of the lower extremitiesTherapeutics:

02 at 2-4 1pm by nasal cannula; anti-embolic stockings l. IV Heparin plus 5000 units then maintain at 500-1000:ulhr to maintain PTT at 1.5-2.5 X the control

(for 7-10 days); check PTT q 12-24 hours or Low Molecular Weight Heparin2. Overlap Heparin with Warfarin(Coumadin) 2.5 - 7.5 mg PO 3-4 days prior to stopping Heparin to

maintain a PT INR or 2.0-3.0; Continue anticoagulation for 3 months or indefinitely depending on thepersisterice of the predisposing factor 3. Other Treatment Options:

a Inferior Vena Caval IVC) interruption or IVC filter insertion: For patients in whom anticoagulantsare absolutely contraindicatedb. Thrombolytic therapy: For acute massive embolism and hemodynamically unstable patients

To Pulmonology Page




HEMOPTYSISTo Pulmonology Page


Data

A. Definition: Massive hemoptysis = 600 cc in 24 hours. Expanded definition includes those with

associated asphyxiation even with blood loss < 600 cc/24 hoursB. Etiology: Pulmonary tuberculosis, bronchiectasis, lung cancer, pneumonia, mitral stenosis, pulmonaryedema, arterio-venous fistulaC. Important Clinical Questions:

l. Is this hemoptysis (from the lungs) or hematemesis (from the stomach)?2. Is bleeding due to a breach in an anatomic barrier or due to a coagulopathy?3. What is the approximate amount of blood loss? Look for tachycardia andorthostatic hypotension.4. Is this a medical or a surgical problem?

Orders:

Admit to: ICU (for massive hemoptysis)Diet: NPOVS: Vital signs q 1 hour; Orthostatic BP and pulse 2X/day

Nursing: Quantify all sputum and blood, suction PRN, hook to pulse oximeter Keep patient on a lateral decubitus position (on the side of the affected lung

IVF: PNSS X 8 hours; Transfuse whole blood if neededDiagnostics: CBC, save blood for typing & cross matching, PT and PTT Chest X-ray PA, Lateral,

ECG

Therapeutics:

Oxygen as needed1. Plain NSS or plasma expanders while waiting for whole blood or packed RBC2. If with coagulopathy, give Fresh Prozen Plasma or Cryoprecipitate3. Tranexamic acid (Hemostan) 500 mg IV q 6-8 hours4. Codeine (Codipront-N) 1 tbsp BID or Butamirate citrate (Sinecod) 1 tbsp QID5. Address the bleeding site

a Correlate PE with Chest x-ray to detect bleeding site

b. Keep the bleeding lung down to keep bleeding contained in one lungc. Consider single lumen orotracheal intubation

i. Left lung bleeding: Advance endotracheal tube far down to intubate right mainstem bronchus.ii. Right lung bleeding: Facilitated by right lateral decubitus position to shift the mediastinumrightward and along better access and view the left mainstem bronchus

6. Stat Bronchoscopy for persistent hemoptysis to localize bleed as a prelude to Surgery

7. Nebulization is contraindicated




PLEURAL EFFUSION & THORACENTESIS



A. Etiology: Usually due to pulmonary tuberculosis, lung cancer pneumonia, or congestive heart failureB. Pathophysiology:

l. A structure is disrupted (esophagus, thoracic duct, blood vessel, bronchial tree)2. Pleural abnormality with increase permeability, e.g. cancer or inflammation3. Abnormal osmotic factors leading to transudative effusion, e.g. congestive heart failure, cirrhosis

C. Category: Pus, exudate, transudate, chylous Orders:

Admit to:IVF: D5W 500 cc X 40 cc/hr Diagnostics: CBC, Chest X-ray PA-L, ABG, ECG

Diagnostic thoracoscopy (for difficult to diagnose effusion)Therapeutics:

1. Prepare the Following for Thoracentesisa. Secure consentb. Abbocath gauge #16, 5 sterile specimen bottles 1 liter sterile bottle, 50 cc syringe, 3 waystopcock, Xylocaine ampulesc. Maximum drainage: 1-1.5 liters X 24 hoursd. Usual site: 8th Intercostal space posterior axillary line

2. Post-Thoraoentesis Orders.a. Note for signs of respiratory distressb. Repeat CXR (PA, Lateral) after thoracentesis

c. Serum LDH, TPAG Glucose simultaneously

d. Send specimenBottle 1: Cell count, Differential count Total Protein, LDH (5-10 ml EDTA)

Bottle 2: AFB, Gram stain, C & S

Bottle 3: Cytology eat Cell Block (obtain 200 cc of fluid or more to increase yield)

3. Diagnosis of Exudate using Light’s Criteria One or more of the ff a Pleural fluid Protein / Serum Protein ratio > 0.5b. Pleural fluid LDH / Serum LDH ratio > 0.6c. Plueral fluid LDH > 2/3 the upper limit of normal for serum LDH

4. Indications for Chest Tube Insertion:a. Gross pus on thoracentesisb. Presence of organisms on gram stain of the pleural fluidc. Pleural fluid glucose < 50 mg/dLd. Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH




ANAPHYLAXISTo Pulmonology Page


Data:

A. Identify precipitating factor or allergen

B. Diagnosis is clinical, especially with history of allergen exposure.C. Stratify as to Severity:1. Mild – skin manifestation only2. Moderate to severe - presence of any of the following: (a) upper airway obstruction denotinglaryngeal edema, (b) severe bronchospasm, or (c) cardiovascular dysfunction and/or hypotension

Orders:

Admit to:Diet: NPO temporarilyVS: Vital signs q 1 hour Nursing: Input & Output; Elevate legs; Standby intubation setIVF: NSS X 6 hours- rapid fluid infusionDiagnostics: CBC, ABG, Urinalysis

Skin testing, Radioallergosorbent Test (RAST)

Portable Chest X-ray, lateral soft tissue neck x-raysECG,Pulmonary Function Test

Therapeutics: Oxygen at 6 lpm via nasal cannula or mask1. For bronchospasm, give Bronchodilators:

a. Terbutaline, 1 mg (1ml) in 2 ml NSS by nebulizer or Salbutamol (Ventolin) 0.5%, 0.5 ml in 2.5ml NSS by nebulizer b. Epinephrine (1:1000) 0.2-0.5 ml SQ or IM q 20 min (for severe cases only)c. Aminophylline loading dose 4-6 mg/kg total body weight IV, then infuse 0.3-0.9 mg/kg idealbody weight/hour

2. For skin manifestations (urticaria and angioedema), give Antihistamines: Diphenhydramine(Benadryl) 25-100 mg IV, IM or PO q 2-4 hours3. Corticosteroids: Hydrocortisone (Solucortef ) 200-250 mg IV then 100 mg q 4-6 hours IV steroidsshould be followed by PO steroids e.g. Prednisone)4. For hypotension, give Pressors to maintain BP: (See Appendix on Drips) ] Noradrenaline(Levophed) IV or Dopamine IV5. Consider Endotracheal Intubation for angioedema of the epiglottis and larynx (laryngospasm)causing upper airway,obstruction, severe bronchospasm, and stridor and excessive use of muslcesof respiration.;6. Premedication for radiocontrast or blood products in allergic patient:

a. Prednisone 50 mg pO q 6 hours X 3 dosesand b. Diphenhydramine 25-50 mg IM or 1V 1hour before procedure




PNEUMOTHORAX



Data: A. Etiology:

1. Spontaneous:a. Primary: Tall thin cigarette smoking adultb. Secondary: History of lung disease, e.g. tuberculosis, COPD

2. Traumatic:a. Non-iatrogenicb. Iatrogenic: Due to positive pressure ventilation, central venous catheterization, CPR,endotracheal intubation

B. Differential Diagnoses: AMI, Pulmonary embolism, pneumonia, aortic dissection esophageal ruptureetc.C. Signs Symptoms:

1. Sudden onset of chest pain and dyspnea2. Ipsilateral expansion of the chest wall, decreased fremiti, hyperresonance

3. Tracheal deviation to contralateral side4. Cyanosis, hypotension in severe cases

Orders:

Admit to:VS: Vital signs q 2 hours, Watch out for progressive dyspneaDiagnostics:

CBC, ABG

Chest X-ray PA expiratory film (check the visceral pleural line, absence of lung parenchymal

markings between pleural line and chest wall, and mediastinal shift)Therapeutics:

A. Medical

l. Indications less than 15% pneumothorax and asymptomatic patient

2. Bed rest, Observe for 2 days3. Repeat films q 24 hours4. Oxygen at 2-6 1pm per nasal cannula5. For Pain: Tramadol 50 mg q 8 hours lV or other analgesics PO

B. Chest Tube Thoracostorny, (CTT)Indications: Greater than 15% pneumothorax and symptomatic patient

C. Chemical Pleurodesis. Talc or Tetracycline PlurodesisIndications: (1) Recurrent pleural effusion, (2) rnalignant pleural effusions, (3) secondarypneumothorax including iatrogenic pneumothoraces and (4) patients with poor surgical risk

D. Consider Video Assisted Thoracoscopy (VATS) for the following:l. Unexpanded lung for more than 5-7 days2. Bilateral pneumothorax3. Persistent air leak in the chest tube

E. Consider Resectional Surgery as last resort




PNEUMONIATo Pulmonology Page

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A. Algorithm: Management-Oriented Risk Stratification of Community-Acquired Pneumonia (CAP)Immunocompetent Adults

Minimal Risk

CAP I

Low Risk

CAP II

Moderate Risk

CAP III

High Risk

CAP IV

Parameters SucceedingParametersnot Present

Any of the ff:

Diabetes mellitusEuplasticDiseaseNuerologicDiseaseCHF, COPDRenalInsufficiencyChronic liverdisease

Alcoholism STABLE

Any of the

following:

Age = 65 yearsRR = 30/minPR = 125/minTemp = 40 or = 35CCXR: multilobular,pleural effusion,abscessprogression oflesionSuspectedaspirationExtrapulmonaryevidence of sepsis NO Hypoxemia

(PaO2<60)NO Acute

Hypercapnea(PCO2 >50) atroom temp

OR

Any of the ff:

Diabetes mellitusEuplastic DiseaseNuerologic DiseaseCHF, COPDRenal InsuffeciancyChronic liverdisease

Alcoholism UNSTABLE

Any of the

following:

Age = 65 yearsRR = 30/minPR = 125/minTemp = 40 or = 35CCXR: multilobular,pleural effusion,abscessprogression oflesionSuspectedaspirationExtrapulmonaryevidence of sepsis Any of the ff:

1. Shock orsigns of

hyperperfusion:Hypotension

Altered MentalState

Urine Output<30ml/hr

2. PaO2 < 60mmHG

Or acutehypercapnea(PaO2 > 50mmHG

At room air

Management Outpatient Outpatient Ward Admission ICU Admission

Sources1. Task Force on CAP, Phil. Practice Guidelines Group in Infectious Disease (1998)-Community-AcquiredPneumonia: Clinical Practice Guideline (Volume l N. 2). Quezon City PPGG-ID Phil. Society forMicrobiology and Infectious Diseases, with permission2. American Thoracic Society: Guidelines for the Management of Adults with Community-AcquiredPneumonia. American Journal Respiratory Critical Care Medicine 163: 1730-1754, 2001.



B. Guidelines on Pneumonia Empiric Therapy: (Usual Recommended Dosages of Antibiotics in Adults,50-60 Kg Body Weight, with Normal Liver and Renal Function)

1. CAP Category I: Minimal Risk CAP

Common Organisms: 1- Strep. pnpneumoniae, 2- H. influenzae, 3- Respiratory viruses, 4- C.pneumoniae, 5- M. pneumoniae; Mortality rate at 1-5 %

a. Amoxicillin 500 mg cap TID PO (standard regimen)b. Macrolides: Choice of

i. Roxithromycin(Macrol, Rulid) 150 mg tab BID POii. Azithromycin 250 mg tab BID X 3 daysiii.Erythromycin 500 mg cap QID PO (do not give if smoker because of the likelihood of H.

influenza); 20% will develop gastric irritation

2. CAP Category II: Low Risk CAP

Common Organisms 1- S. pneumoniae, 2- Respiratory viruses, 3- H. influenzae, 4- Aerobic gramnegative bacilli, 5- S. aureus; Mortality at 1-5%a. Choice of:

i. Cefuroxime (Zinnat) 250-500 mg tab BID POii. Sultamicillin(Unasyn) 375-750 mg tab BIDiii. Co-Amoxiclav (Augmentin) 375 mg tab TID or 625 mg tab BID PO

b. Macrolides POc. New Fluoroquinolones Alone PO (as nerve drug)Ex. Gatifloxacin (Tequin) 400 mg tab OD PO

3. CAP Category III: Moderate Risk CAP

Common Organisms: 1- S. penumoniae, 2- H. influenae 3- Polymicrobial(including anaerobic bacteria/aspiration), 4- Aerobic gm-negative bacilli, 5- Legionella sp., 6- S.

aureus, 7- C. pneumoniae, 8- Respiratory viruses; Mortality rate at 5-25 %a. Choice of:

i. Cefuroxime (Zinacef) 750 mg q 8 hr IVii. Ampicillin-Sulbactam (Unasyn) 750 mg-1.5 gm q 8 hr IViii. Co-Amoxiclav (Augmeatin) 600 mg-1.2 gm q 8 hr IV

+ b. Erythromycin 500 mg - 1 gm q 6 hr IV or Azithromycin IV

or c. New Fluoroquinolones Alone PO: (Cheaper option)Ex. Gatifloxacin (Tequin) 400 mg tab OD PO 4. CAP Category IV: High Risk CAP

Common Organisms 1- S. pneumoniae, 2- Legionella sp., 3- Aerobic gram- negative bacilli, 4-Pseudomonas aeruginosa, 5- S. aureus, 6-M. pneumoniae, 7-Respiratory viruses; Mortality rate at50 %a. Choice of: Ceftazidime 1-2 gm q 8 hr IV

or Piperacillin-Tazoobactam (Tazocin) 2.25 gm q 6-8 hr IVor Meropmem 500 mg q 8 br IV or Cefepime 1-2 gm q 12 hr IV

+ b. Erythromycin 500 mg - 1 gm q 6 hr lV or Azithromycin IVor Gatifloxacin (Tequin) 400 mg tab OD PO

-/+ c. Choice of Aminoglycosides (for a few days for Pseudomonas coverage):Tobramycin 80 mg q 8 hr IV or Amikacin IV or Gentamicin IV

C. Other Situations:

1. For Aspiration Pneumonia:a. Aspiration Pneumonia (community-acquired)Clindamycin 300-600 mg q 6-8 hr IV or Penicillin G 1-2 million units q 4 hr IVb. Aspiration Pneumonia (nosocomial)

i. Piperacillin-Tazobactam (Tazocin) 2.25 gm q 6-8 hr IVor ii. Clindamycin 300-600 mg q 6-8 hr IV + Tobramycin 80 mg q 8 hr IV

2. Treatment Based on Typical and Atypical Clinical Presentation:



a. Typical Presentation: Fever, acute onset, pleuritic chest pain, lobar consolidation by x-ray,yellow copious phlegm, pleural effusion.

Treatment: Beta-lactams (e.g. Co-amoxyclav) or Cephalosporins (e.g. Cefuroxime)b. Atypical Presentation: No fever, chronic, interstitial infiltrates by x-ray scanty white phlegm

Treatment: Macrolides (e.g. Clarithromycin)

3. Cheaper Antibiotic Options:

a. For CAP Category I and Category II:i. Amoxycillin PO for Typical Pneumoniaii. RoxithromycinPO for Atypical Pneumonia

b. For CAP Category III:

New Fluoroquinolones Alone POEx. Levofloxacin (Levox) 250-500 mg tab OD PO

Orders:

Diagnostics: CBC, Creatinine, Chest X-ray PA-L

Sputum G/S and C/S, Sputum AFB 3X (for TB suspect)

Therapeutics:l. Antibiotic regimen as listed above given for a maximum of 7-8 days only to minimize theemergence of resistance.

2. Berodual nebulization (10 gtts in 3 ml NSS) q 6 hours and prn3. Switch Therapy: Intravenous antibiotic treatment may be shifted to or antibiotics after 48-72

hours if the following parameters are fulfilled: (a) there is less cough and resolution of respiratorydistress (normalization of respiratory rate), (b) the temperature is normalizing, (c) the etiology is nota high risk (violent/resistant) pathogen, (d) there is no unstable co-morbid conditions orlife-threatening complications, and (e) oral medications are tolerated.4. For abundant secretions, may give Acetylcysteine (Fluimucil) 100 mg or 200 mg sachet dissolvedin 1/2 glass H2O TID. Discontinue if patient has wheezing

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PEPTIC ULCER DISEASE / ACUTE GASTRITIS

To Gastroenterology PageTo Main Table of Contents


Data:

Indications for Endoscopy: Recurrent epigastrc pain not responsive to H2 antagonist or PPI (Proton PumpInhibitor), pain sufficient to wake the patient up, weight loss, anorexia, hematemesis, or melena. Orders

Admit to:Diet: NPO, then regular dietVS: Vital signs q 4 hours, postural Blood Pressure (taken supine & sitting – especially if with bleeding)IVF: DER 1 liter X 12 hoprs; D5NM 1 liter X 12 hoursDiagnostics: CBC, Amylase Na, K, Calcium

Upper GI Series or Endoscopy with Clqtest (rapid urea' assay)

ECG(for anemia-related ischemic changes)

Ultrasound of Liver Hepato-biliary Tract and Paacreas (to rule out cholecystitis andpancreatitis)

Therapeutics: 1. Diet:

a. Avoid foods that stimulates acid secretionb. Stop smoking and alcoholc. Stop Aspirin, NSAIDS, Steroids.

2. Gastric Ulcer:

a Do biopsy during endoscopy of gastric ulcer (to rule out Carcinoma) and do urease test.b. If urease test (-) treat with:, H2-blockers or Proton-pump inhibitors +/- Antacids for 6-8 weeks orH2-blockers or Proton-pump inhibitors +/- Sucralfate for 6-8 weeksc. If urease (+) or if H, pylori positive: give Eradication Treatmentd. Repeat endoscopy or do Upper GI Series after 4-8 weeks of medical treatment: If there is noimprovement, suspect malignancy.

3. Duodenal Ulcer:

a. Usually not malignant but recurrentb. Do Helicobacter pylori testing.c. If urease test (-):

Treat with H2-blockers +/- Sucralfate +/- Antacids or Proton-pump inhibitors for 4 weeksd. If urease test (+) or if H. pylori positive: give Eradication Treatment.e. If with frequent, recurrent or severe duodenal ulcer or if with duodenal ulcer complication: givemaintenance dose of H2-blocker or proton-pump inhibitor (1/2 of daily dose) or recheck H. pylorieradication. If still urease (+), may give another eradication treatment.

4. Acute Gastritis:a. Withdraw offending agent if possible (e.g. alcoho1, NSAID, steroids)b. Give H2-blockers + antacids for 2 weeks or Sucralfate (Iselpin) 1 gram in 20 ml H2O QID 1 hourbefore meals and at bedtime

5. Helicobacter pylori Eradication Treatment: (positive urease test or H. pylori by histologic

examination)a. Proton-Pump Inhibitor (PPI) to be given BID PO X 1 week

+ Amoxicillin 500 mg 2 caps BID X 1 week+ Clarithromycin 500 mg 1 tab BID X 1 week



Note: For PPI, one may use any of the following:Esomeprazole 40 mg tabletOmeprazole 20 mg capsuleLansoprazole 30 mg capsulePantoprazole 40 mg tabletRabeprazole 10 mg tablet

b. PPI to be given BID PO X 1 week (as above)

+ Metronidazole 500 mg 1 tab BID X 1 week+ Clarithromycin 500 mg 1 tab BID X 1 week

Additional note: One may continue PPI on a once a day dose for 3 more weeks for gastric orduodenal ulcers.

6. Symptomatic Medications

a. Pain: Hyoscine-N-butylbromide (Buscopan) 1 amp IV q 6 hrs PRN or Ketorolac (Toradol) orTramadol (Tramal) IVb. Vomiting: Metoclopromide (Plasil) 1 amp IV q 8 hrs PRN





GASTROINTESTINAL BLEEDINGTo Gastroenterology PageTo Main Table of Contents


A. Etiology of Upper Gastrointestinal Bleeding (UGIB):

Peptic ulcer disease (duodenal & gastric), gastritis (stress, alcohol, drugs), esophagitis, duodenitis,esophageal varices, gastric or duodenal varies, Mallory-Weiss tear, angiodysplasia or telangiectasia,gastric or esophageal carcinoma, hemobilia, aortoduodenal fistula, bleeding diathesis leukemia, aplasticanemia, etc.)

B. Etiology of Lower Gastrointestinal Bleeding (LGIB):Hemorrhoids, colonic diverticulum, colonic polyp, colonic cancer, angiodysplasia, amoebic colitis,inflammatory bowel disease (ulcerative colitis or Crohn’s disease), ischemic bowel disease, Meckel’sdiverticulum, radiation proctocolitis, typhoid ileitis, bleeding diathesis leukemia, aplostic anemia, etc.)

Orders:

Admit to:Diet: NPO, stop alcohol, avoid NSAIDS and steroidsVS: Vital signs q 1 hour and orthostatic BP q 4 hours

Watch out for hypotension, tachycardia

Nursing: Monitor I & O; Insert foley catheter to monitor mine output; Refer if urine output is < 30 cc/hr, orCVP < 4 or > 12 cm H2O; Record stool character and approximate amount.IVF: NSS or D5LR, or plasma expanders

Prepare whole blood or packed RBC and/or fresh frozen plasmaTwo IV lines if needed; Transfuse blood.Consider CVP if vital signs are unstable '

Diagnostics: Place NGT (French 14 or 16), then consider lavage with NSS q 4 hoursCBC with platelet count, Blood typing

CT, BT, PT, PTT, Na, K, RBS, BUN, Crea

Note: May have increased BUN/Creatinine ratio in cases of UGIBSGPT,SGOT, Alkaline Phosphatase, Total, Direct and Indirect Bilirubin

ECG,Chest X-ray, Upright Abdomen, Urinalysis

Gastroscopy with possible injection therapy, heater probe, hemoclip (for non variceal

bleeding), sclerotherapy, cyanoacrylate injection, endoloop ligation or rubber bandligation (for variceal bleeding)

Sigmoidoscopy or Colonoscopy (for lower GI Bleed) Angiography (can detect 0.5 cc/min bleeding)Technitium 99M RBC Scanning (can detect 0.1 cc/min bleeding)

Therapeutics:O2 at 2-3 1pm by nasal cannula

1. H2-blockers or proton-pump inhibitors IV2. Antacids: Maalox Plus 30 ml 1 hour after meals and at bedtime

Maximum dose: Maalox 30 ml q 2 hours3. Tranexamic acid (Hemostan, Cyclokapron) 500 mg IV push q 8 hours4. For liver and coagulation problems (abnormal Protime): Aquamephyton 1 amp IV OD-BID

May also give fish frozen plasma (4 units)5. Sucralfate 1 gram 1 tab QID

6. Save two units of Fresh Whole Blood properly typed and cross-matched7. Emergency treatment for variceal bleeding: Esophageal or fundal variceal bleedinga. Vasopressin (Pitressin)b. Somatostatin (Stilamin) 250 mcg 1V bolus then 250 mcg/hr IV infusionc. Octreotide (Sandostatin) 50-100 mcg IV bolus then 50 mcg/hr IV infusiond. Endoscopic sclerotherapy or cyanoacrylate injectione. Rubber band ligation or endoloop ligationf. Blakemore-Sengstaken tube insertion

8. Other treatments:a. After transfusion of 4 units of blood give Calcium gluconate (1 amp to be diluted in 30-50 cc D5W



given slow IV (not less than 30 min)b. Surgery:

i. Shunting procedures;- Portocaval shunt- Mesocaval shunt- Distal splenorenal shunt (Warren Shunt)

ii. Devascularization Procedures:

- Hassab’s procedure- Suguira operation (transaortic paraesophageal devascularization, esophageal transectionsplenectomy, esophagogastric devascularization, pyloroplasty, vagotomy)

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ANTI-ULCER DRUGSTo Gastroenterology PageTo Main Table of Contents

To Detailed Table of Contents a. Antacids

Al Hydroxide+ Mg Hydroxide (Maalox, ox TC, Maalox-Plus) suspension, tabPO - 2-4 tsp suspension or 1-2 tabs QID 20 min-1 hour after meals &at bedtime Al Hydroxide + Mg Hydroxide+ Mg Carbonate (Novaluzid) susp

PO – 1 sachet 1 how after meals 4 at bedtime)Hydrotalcite+ Dicycloverine+ Simethiconee (Kremil-S) tab, susp

PO - 2-4 tabs or 2-4 tsps q 4 hours, 1 hour & 3 hours after meals & at bedtime

b. H2-blockers

Cimetidine (Ritemed Cimetidine =) Tagamet) 200 mg tab, 400 mg tab, 800 mg tab, 100 mg/5 ml susp,200 mg/2 ml, 300 mg/2 ml amp

PO - 400 mg tab BID or 800 mg tab HS ODIV- 200 mg q 6 hours

Note: Caution with Warfarin, Phenytoin, or Theophylline combination

Ranitidine HCl (Raxide =) 150mg, Zantac) 75 mg tab, 150 mg tab, 300 mg tab, 150 mg/10 ml syrup,50mg/2ml amp

PO - 75-150 mg BIDIV - 50 mg q 8 hr

Famotidine (H2 Bloc, Pepcidine) 10 mg tab, 20 mg tab, 40 kg tab, 20 mg/2 ml ampPO - 20 mg BID or 40 mg ODIV - 20 mg q 12 hr

Nizatidine (Axid) 150 mg cap, 300 mg cap, 100 mg/4 ml ampPO - 150 mg BID, 300 mg ODIV - 100 mg q 8 hr

c. Proton Pump Inhibitors (PPI)

Esomeprazole (Nexium) 20 mg tab, 40 mg tab

PO-20-40mg ODOmeprazole (Losec) 10 mg cap, 20 mg cap, 40 mg vial

PO-20mg cap ODIV - 40 mg q 12-24 hr (Note: Give the full 40mg 1V, since Omeprazole is unstable when already insuspension)

Lansoprazole (Lanz. Prevacid, Promp, Suprecid),15 mg cap, 30 mg capPO - 1 cap OD

Pantoprazole (Pantoloc, Ulcepraz) 20 mg, 40 mg tabPO - 1 tab OD

Rabeprazo1e (Pariet) 10 mg tabPO - 1 tab OD

d. Cytopretectives

Misoprostol 200 mcg, Diclofenac (Arthrotec) tab

PO - 1 tab BID-QIDNote: Use outer layer of the tablet only since core tablet contains Diclofenac.Misoprostol may discolor the stool black and may came abdominal cramps and diarrhea

Sucralfate (Iselpin) 500 mg, 1 gram tab(for peptic ulcer disease or NSAID gastritis)PO- 500 mg - 1 gram in 20 ml water QID 1 hour before meals & at bedtimeNote: Constipation may be observed as side-effect.

Ranitidine / Bismuth Citrate (Pylorid) 400 mg tabPO- 1 tab BID



Note: Bismuth citrate may discolor the stool black.




HEPATIC ENCEPHALOPATHY/ LIVER CIRRHOSIS



Data:Types of cirrhosis: Alcoholic, biliary, cardiac, cryptogenic, post-necrotic, post-viral, metabolic, andmiscellaneous causes

Orders:

Admit to:Diet: NPO temporarily; Total Cal = 1800 cal/day; 250-500 mg sodium/day; Protein intake 0-20 gm/day in 6divided feedings if with hepatic encephalopathy, otherwise increase protein intake; fluid restriction to 1-1.5l/day (if hyponatremia, Na < 130)VS: Neuro vital signs q 2 hours; I & 0 q shiftNursing: Stool charting q shift; Weigh OD in am, Measure abdominal girth OD (at level of umbilicus);

Insert Foley catheter IVF: D10W X 16 hours or' D50.3 NaC1 X 24 hours; Keep patient on the dry sideDiagnostics: CBC, Blood C&S, PT, SGPT, SGOT, Alkaline Phosphatase

Total Protein, Albumin, Globulin, A:G Ratio

Serum Ammonia (to differentiate from alcohol intoxication)

Note: Serum ammonia may be elevated in only 50% of hepatic encephalopathy cases.BUN, Crea, Na, K, Urine Na (dehydration vs. hepatorenal syndrome)

FBS, Urinalysis, CXR, ECGUltrasound of Liver, Hepatobiliary Tract and Pancreas

Liver Biopsy (to rule out carcinoma if ultrasound shows a hepatic nodule) Ascitic Fluid / Abdominal Paracentesis (for very tense ascites):

Tube 1 - Protein, albumin, glucose, LDHTube 2 - Cell count & differentialTube 3 - C&S, Gram stain, AFB, FungalTube 4 - Cytology

Therapeutics:

1. Laxative: Duphalac (Lactulose) 30-60 ml TID to make 4-5 bowel movements per day. Fleet Enema ifstill without bowel movement.2. If with hepatic encephalopathy: Aminoleban (branched chain amino acids) 500 cc IV q 12 hr (2bottles/day): or Aminoleban or Falkamin 1 sachet in 180 ml water BID-TID PO3. If with pedal edema and/or ascites: Furosemide (Lasix) 40 mg OD-BID PO or Furosemide 20 mg IV OD

– TID or Spironolactone (Aldactone) 25 mg BID-QID4. For Portal Hypertension: Propranolol 10 mg TlD, Isosorbide Dinitrate (Isordil) 20 mg 1 tab BID5. Watch out for complications:

a. Bleeding due to decrease in clotting factors (abnormal protime):i. Give 4-6 units of Fresh Frozen Plasma+ 1-2 doses of Vit. K preparationii. Vit.,K Preparation: Phytomenadione (Aquamephyton) 1 amp IV (10 mg/ml amp) OD-BID; orMenadione (VCP Vitamin K, Vitakay) 10 mg 1 tab TID-QID PO

b. Gastrointestinal bleeding (due to gastric erosions): Prophylactic H2-blockers, Antacids orCytoprotective agents

c. Infections: Consider prophylactic antibiotics with Metronidazole, Amoxicillin, or Cephalosporinsd. Renal failure: Cautious fluid management with CVP insertion and monitoring. Consider albumininfusion & Low dose Dopamine and Furosemide dripe. Pulmonary infections and ARDS - intubation and PEEPf. Hepatic encephalopathy vs. cerebral edema: Do CT scan to differentiate

i. Hepatic encephalopathy: Tx: Lactulose+ Aminolebanii. Cerebral edema: Tx: Mannitol and hyperventilate, Steroids

g. Hypoglycemia: Hypertonic Glucose D50-50 IVh. Cardiac arrhythmiasi. Multiorgan failure



6. Other treatment options:a Multivitamins: Neurobion tab TID, Essentiale Forte 1 tab BID or Moriamin Forte 1 tab ODb. Pain reliever: Hyoscine-N-butylbromide (Buscopan) 1 amp IV q 6- 8 hr c. Neomycin Sulfate 0.5-1gm PO q 6 hr X 7 days

7. Discontinue hepatotoxic drugs (anti-tuberculosis drugs, anticonvulsants etc.), Avoid Diazepam orDilantin for seizures.




ABDOMINAL PARACENTESISTo Gastroenterology PageTo Main Table of Contents

To Detailed Table of Contents Orders:

l. Prepare the following: #1 Abbocath gauge 18, #1 20 cc syringe, #1 Venoset, #1 sterile bottle, #1Xylocaine 2% #1 10 cc syringe w/ needle, #6 4x4 OS, Dressing Tray, Betadine antiseptic solution, #3sterile vials, #2 sterile gloves size 7.2. Abdominal paracentesis done about 3 cm. below the umbilicus, midline.3. Submit the following:

Vial 1 = Gram stain, AFB smear Vial 2 = Q/Q (Quantitative, Qualitative)Vial 3 = Culture 4 Sensitivity

Optional: Total protein, amylase, LDH, glucose, etc.4. Blood extraction for total protein, sugar and LDH





VIRAL HEPATITISTo Gastroenterology PageTo Main Table of Contents


A. Epidemiology:

1. Hepatitis A and E: Incubation Period = 2 weeks - 2 months; Transmission = fecal-oral route2. Hepatitis B, C and D: Incubation Period = 4 weeks - 6 months; Transmission = blood, sexual3. Hepatitis G: Transfusion and hemodialysis relatedSerologic test: PCR (Polymerase Chain Reaction for Hepatitis G)

B. Diagnosis: A clear distinction between Hepatitis A-E cannot be made solely on clinical grounds. Themost accurate way to distinguish one from the other is by specific serologic testing (See Table 3-1). Table3-1 Simplified Diagnostic Approach in Patients Presenting with Acute Hepatitis

DiagnosticInterpretation

Serologic Tests of Patient’sSerum

HbsAg IgM AntiHAV

IgManti-HBc

Acute Hepatitis B + - +

Chronic Hepatitis + - -

Acute Hepatitis Asuperimposed onhepatitis B

+ + -

Acute Hepatitis A & B + + +

Acute Hepatitis A - + -

Acute Hepatitis A & B(HBsAg belowdetection threshold)

- + +

Acute Hepatitis B(HBsAg belowdetection threshold)

- - +

Test for AcuteHepatitis C (anti-HCV) - - -

Source: Dienstag, J. 8t Isselbacher, K (2001). Acute viral hepatitis. In E. Braunwald, A. Fauci, D. Kaspar etal (Eds.), Harrisom 's Principles of Internal Medicine (p. 1732). New York: McGraw-Hill with permission.

C. Differential diagnoses: Alcoholic hepatitis (SGOT, SGPT usually < 400 iu), acute cholecystitis, commonbile duct stone, pancreatic cancer, and right ventricular failure with passive congestion of the liver. D. Consider hospitalization in the following patients: Advanced age, serious underlying medical disorder,ascites, peripheral edema, symptoms of hepatic encephalopathy, decrease in protime activity, decreasealbumin, hypoglycemia, high serum bilirubin, immunocompromised state and gastrointestinal b1eeding.

Orders: Admit to:Diet: Initially clear liquid diet (if nauseated low fat (if with diarrhea) then high calorie, high carbohydratediet. Restrict protein only if with signs of hepatic encephalopathy.VS: Vital signs q 4 hoursNursing: Hepatitis precautionsIVF: D5NM 1 L X 12 hours; D5NR 1 L X 12 hoursDiagnostics: Hepatitis B: HBsAg*, Anti-HBc IgM*, Anti HBs, HBe Ag, Anti-Hbe, HBV-DNA

Hepatitis A: Anti-HAV IgM*

Hepatitis C: Anti HCV, HCV-RNA



CBC, PT, Blood C/S, Amylase, Lipase, Urinalysis

SGPT, SGOT (400-4000 iu and SGPT > SGOT)

Alkaline Phosphatase, Total Bil, B1, B2

Ultrasound of Liver, Hepatobiliary Tract and Pancreas (to rule outmalignancy and other diseases)

*Tests part of short Hepatitis profile (see Table 3-1 on page 68)Therapeutics:1. Supportive treatment:

a Restricted physical activityb. Avoid hepatotoxic drugs

2. Optimal treatment (not evidence-based)a. Essentiale 1 cap TID or Jetepar 1 cap TIDor b. Hepatofalk 1 tab, TID or Silyinarine 1 cap TIDc. Supportive treatment: Multivitamins OD & H2-blockersd. Symptomatic meds: Pain relieverse. Anti-pruritic drugs or for sleep: Diphenhydramine HCl (Benadryl) or Hydroxyzine (Iterax) 10-25 mgBID-TID

3. Specific therapy:,a Considor Interferon for chronic Hepatitis B and Cb. Lamivudine (a neucleoside analogue) is for chronic Hepatitis B given at 100 mg I tab OD X 1 year

Note: Chronic Hepatic B with the following parameters – positive HbsAg, positive HbeAg, and elevatedSGPT – has a good response rate to Interferon and Lamivudine treatment.4. Prophylaxis:

Hepatitis vaccination series (See section on vaccination)




ACUTE CHOLECYSTITISTo Gastroenterology PageTo Main Table of Contents


A. Natural History of Gallstones:

Asymptomatic (silent) gallstones need not be treated. Frequent biliary colic and stones > 2 cms aremore likely to have complications requiring cholecystectomy.B. Etiology:

- 90% associated with obstruction of the cystic duct by stone- 70% have bacterial inflammation: E. coli, Proteus vulgaris, Enterobacter, anaerobes- 95% secondary to gallbladder stones: Cholesterol and calcium bilirubinate

C. Signs and symptoms: A biliary colic which progressively worsens with low grade fever and positiveMurphy's sign with or without jaundiceD. Course:

- 75% will have remission in 2-7 days with medical therapy- 25% will develop complications requiring prompt surgery!- Of the 75% who will undergo remission, surgery is still recommended due to the high incidence ofrecurrence

E. Complications:

Empyema & hydrops, gangrene & perforation, fistula formation & gallstone ileus

Orders:

Admit to:Diet: NPO; Rest the gallbladder VS: Vital signs q 1-4 hoursNursing: I & O; Insert nasogastric tubeIVF: D5NM X 8 hours +/- 20 meq KCl / Liter Diagnostics: CBC, Protime, Na, K, Ca, Blood CdhS, Urinalysis

SGPT,SGOT, AlkaUae Phaephatase, Amylase(for differential diagnoses)

Abdominal Ultrasound of the Liver, Hepatobiliary Tract and Pancreas

Chest X-ray, ECG

Therapeutics: A. Medical Treatment:

1. NPO, NGT, Fluid and Electrolytes2. Pain reliever. Demerol 25-50 mg IV q 6 bolus (Drug of choice to relax the sphincter of Oddi), Do notgive morphine.3. Antibiotics:a. Ampicillin-Sutbactam (Unasyn) IVor Co-amoxyclav (Augmentin) IV (for uncomplicated'cases)b. Piperacillin-Tazobactam IV (for diabetic and debilitated patients to cover for gram negative sepsisMetronidazole IV

B. Surgical Treatment (Open cholecystectomy or Laparoscopic cholecystectomy

l. An emergency in those patients with complications2. In those w/o complications, early surgery is recommended for stable patients




BACTERIAL CHOLANGITIS & BILIARY SEPSIS To Gastroenterology PageTo Main Table of Contents

To Detailed Table of Contents Data:

A. Definition: Bacterial cholangitis and biliry sepsis occur as a complication of common bile ductobstruction usually due to stones, ascaris, carcinoma or extrabiliary comression. B. Signs and symptoms”. In acute bacterial (suppurative) cholangitis, patients develop spiking fever, biliary

colic pain and jaundice (Charcot's triad). Addition of hypotension and mental confusion constitutesReynold's Pentad. Orders

Admit to:Diet: NPOVS: Vital signs q 1 hour Nursing: I & O q shift; insert NGTIVF: D5NR 1 L X 6-8 hours; fast drip Plain NSS for sepsis or hypotensionDiagnostics: CBC, Na, K, Blood C & S, PT, PTT, Amylase, Lipase, Alkaline

Phosphatase, Total Bilirubin, B1, B2, Ultrasound of the Liver, hepatobiliary tract andpancreas (check common bile duct size to see if it is dilated, in which case there is

obstruction), ERCP or MRCP (Magnetic Resonance Cholangio- Pancreatography), ChestX-ray, ECG

Therapeutics: A. Surgical Treatment

1. Stat surgical referral for acute suppurative cholangitis presenting withReynold’spentad requiring prompt surgical drainage.2. Surgical operation: T- tube cheledochostomy, cholecystostomy,choledocholithotonyor biliary bypass surgery3. Combination antibiotic treatment for yam negative sepsis

B. Endoscopic Procedures1. ERCP (Endoscopic Retrograde Cholangio Pancreatography)-duodenoscopy using side-viewingendoscope with instillation of contrast material into the biliary and pancreatic ductal system underfluoroscopic guidance.2. EST (Endoscopic Sphincterotomy) or Endoscopic Papillotomy-ERCP with ablation of Sphincterof Oddi using sphinctcrotomeyor papillotome connected to a cautery machine.3. Endoscopic Nasobiliary Drainage – ERCP with insertion of 6.SF nasobiliary catheter into thebiliary system for decompression/drainage.4. Endoscopic Biliary Stenting-ERCP with insertion of stents(5-15 cm 7-14 French in size) into thebiliary system for decompression/drainage.

C. PTBD (Percutaneous Tranhepatic Biliary Drainage)D. Medical Treatment

1, Start Antibiotics:a. Imipenem IV Ampicillin-Sulbactam (Unasyn) IV (single drug treatment)or b. Ampicillin IV, and Gentamicin IV and Metronidazole IVor c. Ceftazidime (Fortum) IV and Metronidazole IV

2. Pain reliever: Meperidine (Demerol) 25-50 mg IV q 6 hr. Avoid Morphine3. Optional: H2-blockers IV




ACUTE PANCREATITISTo Gastroenterology PageTo Main Table of Contents


Data:

A. Etiology: Alcohol, gallstones metabolic factor, drugs, viral infecting, post-operative post-ERCP,blunt trauma B. Differential Diagnoses: Perforated viscus especially peptic ulcer, acute cholecystitis myocardialinfarction, dissecting aortic aneurysm, pneumonia, diabetic ketoacidosis acute intestinal obstruction,mesenteric vascular occlusion C. Ranson's Prognastic Criteria (See Table 3-2)

Table 3-2. Ranson’s Prognostic Criteria.

1. At admission or diagnosisa. Age > 55 yearsb. Leucocytosis > 16,000 per cubic millimeter

c. Hyperglycemia >l l mmol/L (> 200 mg/dL)d. Serum LDH > 400 1U/Le. Serum AST > 250 1U/L

2. During initial 48 hoursa. Fall in hematocrit by > 10% percentb Fluid deficit > 4000 mlc. Hypocolcemia < 1.9 mmol/L (< 8.0 mg/dL)d, Hypoxemia (PO2 < 60 mmHg)e. BUN rise > 1.8 mmol/L (> 5 mg/dL) after IV fluidsf. Hypoalbuminemia < 32 g/L (< 3.2 g/dL)

Note: >= 3 factors at time of admission (1) or during initial 48 hours (2). indicates an increasedmortality rate. These patients need close monitoring in an ICU setting.

Source:Greenberger, N. & Toskes (2001). Acute and Chronic Pancreatitis. In E Braunwald A. Fauci, D.Kaspar et al (Eds.), Harrison's Principles of Internal Medicine (p. 1795). New York: McGraw-Hill withpermission.

D. Local complications:

Phlegmon Abscess (treatment is surgical drainage antibioticsPseudocyst (treatment is surgery if = cms)

Ascites and contiguous organ involvement

E. Systemic complications: Acute respiratory distress syndrome pleural effusion cardiovascular,sepsis, diabetes mellitus, disseminated intravascular coagulation acute renal failure metabolic andcentral nervous System complications.

Orders:

Diet: NPO strictly, resume diet slowly after the 3rd-6th day if without pain

VS: Vital signs q 2 hours including progress of abdominal painNursing: I & O; CBG monitoring; Place NGT if with ileus or vomitingIVF: D5NR 1 liter X 8 hours; D5NM 1 litre X 8 hoursDiagnostics: CBC, platelet count, Na, K, Ca, Mg, BUN, CREA, TPAG

Serum Amylase (1st to 4th day) - 3-fold Increase for diagnosis

Lipase (1st-10th day)SGPT, SGOT, Alkaline Phosphatase, RBS, PT (if a heavy alcoholic)



Chest X-ray, ABG, ECG (Myocardial depressant fetor)Triglyceride, LDH, Total bilirubin, B1, B2.

Plain Abdomen X-ray Supine & Upright (sentinel loop, colon cut-off sign and calcifications

With chronic pancreatitisUltrasound of Liver, Hepatobiliary Tract and Pancreas,

then CT scan of the upper Abdomen,then ERCP (especially in gallstone-induced pancreatitis)

Therapeutics:A. Medical: NPO, analgesics and IV fluids

l. Insert nasogastric tube if with ileus2. H2-blockers: Ranitidine (Zantac) 50 mg IV q 8 hours or proton pumpinhibitor IV3. Pain Relief: Meperidine HCl (Demerol) 25-50 mg IV q 6-8 hr, defer for BP < 1004. Antibiotics for established infection or severe pancreatitis

a. Cefoxitine or Ceftazidime IV+/ - Metronidazole IVor b. Ciprofloxacin IV or Imipenem IV

5. Low Calcium levels: Calcium Gluconate slow IV or incorporated in IVF6. Total Parenteral Nutrition for malnutrition or prolonged NPO

B. Surgical Open:

1. If with severe hemorrhage, necrotizing pancreatitis, pancreatic abscess or large pseudocyst(5-6cms), do surgical drainage (Necrosectomy). This may have to be done repeatedly.2. If associated with gallstone ileus, insert NOT to decompress bowel




ACUTE DIARRHEA WITH MILD DEHYDRATION



Orders:

Admit to:Diet: BRAT (Banana, Rice, Apple, Tea) diet; no milk productsVS: Vital signs q 4 hours & temp TIDNursing: I & O; Bowel Movement q shift & record (character, frequency and amountIVF: D5NSS 1 liter X 8 hours; D5NR 1 liter X 8 hoursDiagnostics: CBC, Na, K, BUN, Crea, Urinalysis

Fecalysis (check for leucocytes and parasites)

Stool C & S using TCBS agar (for cholera suspect)Proctosigmoidoscopy

Therapeutics:l. IV Fluids and ORS (Hydrite) 1-2 tabs in 150-200 ml water as desired2. Use antibiotics for the following conditions: Febrile or gross blood in stool, toxic looking patient,elderly with concomitant illnesses (diabetic, on steroids etc.) or WBC > 16,000.

a. If without vomiting: Give Ciprofloxacin 500 mg tab BID X 3-5 daysor Norfloxacin 400 mg tab BID X 3-5 daysor Co-trimoxazole forte tab BID X 3-5 daysb. If with vomiting: Give IV antibioticsc. If Amebiasis suspect: Secnidazole (Flagentyl) 500 mg 2 tabs initially then

2 tabs within 4 hours.3. Specific treatment

a. If Shigella: Co-trimoxazole forte tab BID X 3 daysb. If Salmonella or Campylobacter jejuni or ETECCiprofloxacin 500 mg tab BID X 5 daysc. If Clostridium difficile. Metronidazole 500 mg tab TID X 10-14 daysd. If Yersinia enterolitica Ciprofloxacin 500 mg tab BID X 3 dosese. If Giardia lamblia: Metronidazole 250 mg tab TID X 5 days

4. Symptomatic medications:a. Pain:Hyoscine-N-butylbromide(Buscopan) 1 tab TID or 1 amp IV q 6-8 hoursMebeverine HC1 (Duspatalin) 100 mg 1 tab TID-QIDb. Vomiting. Metoclopromide (Plasil) l amp IV q 8 hours PRNc. Diarrhea:

i. Racecadotril (Hidrasec) 100 mg cap: initially 1 cap OD then TID, maximum 4 capsii. Loperamide (Lormide, Imodium) 2 caps initially then 1 capsule after each bowelmovement, not to exceed 6 tabs per day. May give for 48 hours. If diarrhea does notimprove then discontinue.Note: Avoid Loperamide in Amebiasis since it may prolong the course of illness.

To Gastroenterology Page




CHOLERA / SEVERE DEHYDRATION



Admit to:Diet: BRAT (Banana rice, apple, tea) dietVS: Vital signs q 1 hour, postural BP, temp q 4 hoursNursing: Insert foley catheter I & O q hour

Monitor bowel movement & record (character, frequency and amount)Cholera precautions

IVF: DER 1 liter, Sent drip 300 cc then consume the remaining in 4 hours Replace volume per volume ofBowel movement.Diagnostics: CBC, Na, K, Cl, BUN, Crea

ABG q 8-24 hours (if severely acidotic)

Fecalysis, Stool C & S using TCBS (Thioglycolate Citrate Bile Salt) agar

UrinalysisTherapeutics:

1. Adequate hydration: Insert CVP and monitor

a. Hydrate patient using CVP and urine output as guideb. ORS (Hydrite) 2 tabs in 200 ml water as desired if without vomiting

2. Start antibiotics:a. Doxycycline 100 mg tab, give 3 tabs as singledose PONote: Avoid in children < 8 years oldor b. Co-trimoxazole (Bactrim) forte tab PO, 1 tab BID x 3 daysor c. Ciprofloxacin (Ciprobay) 500 mg tab, give 2 tabs as single dose POor d. Cipmfloxacin 200-400mg IV q 12 hours

3. Correct Electrolytesa Low Potassium: Kalium durule 1 durule TID-QID x 4 days or KCI incorporation with IV fluidsb. Severe Acidosis: Sodium Bicarbonate IV push or drip

4. Racecadotril (Hidrasec) 100 mg 1 cap TID5. Other treatment: Dopamine and/or Furosemide (Lasix) IV or drip to prevent renal failure




ACUTE INTESTINAL OBSTRUCTIONTo Gastroenterology PageTo Main Table of Contents


A. Etiology:

1. Small intestine obstruction: Post-op adhesions and external hernias in 75%, intussusception2. Large intestine obstruction: Carcinoma, sigmoid diverticulitis and volvulus in 90%3. Adynamic Ileus; Any peritoneal insult, hematomas, post-operative ileus, ureteral calculus,hypokalemia, fractures ribs, pneumonia, sepsis, intestinal ischemia, gallstones, etc.

B. Signs and Symptoms:

1. Small intestine mechanical obstruction: Colicky mid-abdominal pain, early vomiting2. Large intestine mechanical obstruction: Colicky pain but lesser intensity, late vomiting, (+) historyof recent alteration in bowel habits, usually (+) blood in stools3. Adynamic ileus: No colicky pain, only discomfort from abdominal distention.

Note: Complete obstruction - (+) obstipationPartial obstruction - diarrhea occasionally observed

C. Complications: Strangulation and infection

Orders Admit to:Diet: NPOVS: Vital signs q 1 hour, abdominal findings q 2 hoursNursing: I & O q shift, insert NGTIVF: D5NR 1 L X 8 hours + 20 meq KCl (adjusted according to Potassium levels)Diagnostics: CBC, Serum Na, K, Cl, BUN, Creatinine

Abdominal X-ray supine & upright or lateral decubitus

Chest X-ray

CT Scan of the AbdomenTherapeutics:

A. Complete obstruction of the small intestine or large intestine:1. Stat surgical referral2. NPO, Insert nasogastric tube

B. Partial obstruction of small intestines or large intestines; adynamic ileus:1. Medical management and observation2. NPO, NGT and connect to bedside bottle or Gomco pump3. Broad spectrum antibiotics if strangulation is suspected4. Consider enema / high rectal tube5. Pain: Ketorolac (Toradol) 15 mg IV q 4 hours. Avoid narcotics.6. Other treatment: Metoclopromide (Plasil) IV and H2-blockers IV




CLINICALLY USEFUL ANTIBIOTICS



Table 4 -1 Clinically Useful Antibiotics.

Drug G (+)activity

G (-)activity

Anaerobicactivity

Comments

Natural Penicillins

Penicillin +++ - ++ Narrow spectrumpenicillins

Penicillinase-Resistant Penicillin

Oxacillin PO/IV ++ - + Specifically forStaph. aureusFlucloxacillin ++ - +

Glycopeptide

Vancomycin +++ - + Reserve drug andmost active for S.

aureus andEnterococcus.Give very slowlyas IV infusion

Aminopenicillins:

Amoxicillin PO Ampicillin IV

++ ++ - Broad spectrumpenicillin

Amox-Clavulanic Acid

++ ½ ++ ½ ++ ½ Good aerobiccoverage

Ampi-Sulbactam ++ ++ ++ ½ Good anaerobiccoverage

Penicillin with Anti-Psuedomonal Acitivity:

Piperacillin/Tazobactam ++ ++ ½ + Use as ReserveDrug for

PseudomonasMonobactams:

Aztreonam - +++ - Use as analternate to theaminoglycosidesin renal failure

Carabapenems:

Imipenem-CilastinMeropenem

+++ +++ +++ Use as ReserveDrugGm (+) activity asgoodas PenicillinFor Gm (-): Mayadd

Amikacin forsynergism Anaerobic activityasgood asMetronidazole

Ertapenem ++ +++ + Very little activityagainstPseudomonas



Macrolides:

Erythromycin ++ ½ + ½ + May cause GIupset

AzithromycinClarithromycinDirithromycin

++ ½ ++ + ½

Tetracycline:

DoxycyclineTetracycline

+ ++ + For patients > 8years oldTetracyclinecheaper but givenQID

Aminoglycosides:

AmikacinGentamicinTobramycinNetilmicin

+++ +++ - Withanti-Pseudomonasactivity

Amikacin withanti-TB action

First Generation Cephalosporins:

Cephalexin PO

Cefazolin IV

++ ½ + -

Second Generation Cephalosporins:

Cefuroxime IV ++ ½ ++ + Intravenous drug

Cefuroxime axetil PO ++ ½ ++ + Oral drug

Cefoxitin ++ ++ ++ ½ Cephalosporinwith bestanaerobiccoverage

Third Generation Cephalosporins:

Ceftriaxone ++ +++ ++ For multidrugresistant typhoid

Ceftazidime Ceftazidime isbest forPseudomonas

Cefotaxime Cefotaxime is bestfor meningitis

Fourth Generation Cephalosporin:

CefepimeCefpirome

+++ +++ +++ These should bereserved for thevery resistantstrains

Quinolones:

CiprofloxacinNorfloxacinOfloxacinFleroxacin

+ +++ - Used for multidrugresistanttyphoid fever Ciprofloxacin isbest for PseudomonasNorfloxacin isgood for severe UTI

LevofloxacinMoxifloxacin

++ +++ + Moxifloxacin withbetter anaerobic activity

Others:



Co-trimoxazoleCo-Trimazine

++ ½ ++ ½ -

Chloramphenicol ++ ½ ++ ½ ++ ½ Drug of choice foruncomplicatedTyphoid

Clindamycin ++ - +++ "Abovediaphragm"

anaerobesGood Gm (+)activity

Metronidazole - - ++ ½ "Below diaphragm"anaerobes

Rifampicin ++ ++ + Used forpulmonarytuberculosis

- No activity against these microorganisms+ Fair activity against these microorganisms++ Good activity against these microorganisms+++ Excellent activity againts these microorganisms Additional Notes:

1. Drugs with Anti-Pseudomonas properties: Aminoglycosides (Tobramycin, Netilmicin, Amikacin,Gentamicin), Ceftazidime, Cefoperazone, Quinolones (Ciprofloxacin), Ticarcillin and Piperacillin,Monobactams (Aztreonam), Carbapenems (Meropenem), Fourth Generation Cephalosporins (Cefepimeand Cefpirome) 2. Drugs with good anaerobic properties: Clindamycin, Metronidazole, Chloramphenicol, Cefoxitin,Meropenem, Ampicillin-Sulbactam, Amoxycillin- Clavulanic acid and high-dose Penicillin.

3. Drugs with good central nervous system penetration in meningitis: Ceftriaxone, Ceftazidime,Cefiuoxime, Cefotaxime, Ampicillin, Meropenem, Ampicillin-Sulbactam, Ciprofloxacin, Penicillin G andVancomycin. Chloramphenicol and Co-trimoxazole have high diffusion to the cerebrospinal fluid evenwithout meningitis. 4. Drugs safe for patients with liver disease: Aminoglycosides, Ampicillin, Amoxicillin, Cephalexin,Cefoxitin, Cefiaoxime, Ofloxacin, Penicillin G and Carbepenems.

5. Cephalosporins:

a. Fourth Generation Cephalosporins have the same indications as Third GenerationCephalosporins and should remain as "reserved" drugs.b. The only two Third Generation Cephalosporins active against Pseudomonas are Ceftazidimeand Cefoperarone. Cefoperazone may cause bleeding in predisposed patients.c. Cephalosporins that cross the blood-brain barrier. Ceftriaxone, Ceftazidime, Cefotaxime,

Ceftizoxime.d. Cephalosporin with best anaerobioc coverage: Cefoxitin. Other Cephalosporins also have someanerobic properties.e. Cefuroxime axetil is given with meals.f. Cefazolin is the drug of choice only for surgical prophylaxis of abdominal operations and implantsurgery.

6. Aminoglycosides

a. Aminaglycosides are given q 8-12 hours in 30 minutes by slow IV or IM to avoid, possibleneurornuscular paralysis. They must have loading doses, and should be given for < 7 days to



avoid nephrotoxicity. Creatinine is measured every 3 days.b. Amikacin: Expensive but it is the most potent and least nephrotoxic. Loading dose = 7.5 mg/kg,Maintenance dose = 15 mg/kg/day in 2 divided doses IM, IVc. Gentamicin, Tobramycin, Netilmycin, Loading dose = 2 mg/kg, Maintenance dose = 1.5mg/kg/dosc q S hours IM, IVd. Gentamicin is the cheapest aminoglycoside. Spectinomycin is used for gonorrhea Streptomycinis used for PTB.

7. Macrolides

a. Erythromycin is given with meals. If with GI upset, lower the dose.b. Azithromycin is given 1 hour before meals.

8. Rifampicin

Aside &am anti-TB pmperties, Rifampicin naybe used synergistically with Oxacillin forS. aureus.Resistance may develop when Rifampicin is used alone.

To Infectious PageTo Main Table of ContentsTo Detailed Table of Contents



ANTIBIOTIC DRUG LISTTo Infectious Page


I A. Natural Penicillins:

PO: Phenoxymethylpenicillin (Sumapen, Megapen, Pentacillin) 500 mg cap PO-500 mg cap BID-TIDPO

IM: Pen G benzathine (Penadur 6-3-3) 600,000u; Pen G K 300,000 units; Pen G procaine 300,000units/vialNote: Penicillin G is not given PO because of very poor oral absorption.IM: Benzathine Benzyl Penicillin (Penadur L-A) 1.2 or 2.4 million units/vialIV: Benzyl Penicillin Na (YSS Benzylpenicillin Na) 500,000 units, 1 mil& 5 mil units/vial

B. Penicillinase-Resistant Penicillins (PRP):

Cloxacillin Na (Orbenin, Prostaphlin-A) 250 mg cap, 500 mg cap PO- 500 mg cap q 6 hours PO

Oxacillin Na (Prostaphlin) 250 mg/vial, 500 mg/vial, 1 gm/vial IV- 500 mg- 2 g q 6 hours IV (25-50

mg/kg/day, maximum = 8 gm/day), give by Soluset because it is too irritating

Flucloxacillin (Stafloxin) 250 mg cap, 500 mg, 250 mg vial, 500 mg vial, 1 gm vial PO, 1M, IV-250-500

mg q 6 hours PO, IM, IV

C. Glycopeptide:

Vancomycin HCl (Vancocin) 500 mg vial

IV- 500 mg q 6 hourly IV or 1 gm q 12 hourly IV

Note: To be given as slow IV infusion in 30 minutes to avoid adverse reactions.

D. Oxazolidinones: New Class for aerobic gram-positive bacteria Linezolid (Zyvoz): PO or IV - 200

mg - 600 mg q 12 hr or q 24 hr E. Aminopenicillins: Amoxycillin PO/ Ampicillin IV

Amoxicillin (Amoxil, Himox, Moxillin, Sumoxil, Wyamox) 250 mg, 500 mg cap PO- 500 mg cap TID PO

Ampicllin (Amopen, Ampicin, Pensyn) 250 mg cap, 500 mg cap, 250 mg vial, 500 mg vialPO 250-500 mg cap TID-QID (not recommended orally bee. of poor absorption)

IV, IM- 500 mg q 6 hr Bacampicillin HCl (Penglobe, Bacacil) 400 mg tab, 800 mg tab PO- 400 mg- 800 mg BID PO

F. Beta-lactamase inhibitors:

Amoxycillin- Clavulanic Acid; Co-Amoxiclav (Augmentin, Co-Amox) 375 mg tab, 625 mg tab, 1 gm tab,300 mg vial, 600 mg vial, 12 gm vial

PO- 375 mg TID or 625 mg – 1 gm BID

IV- 600-1200 mg q 8 hours

Ampicillin-Sulbactam: Sultamicillin (Unasyn) 375 mg tab, 750 mg tab, 375 mg vial, 750 mg vial

PO- 375 mg 750 mg BID PO

IM, IV- 750 mg – 1.5 gm q 8 hours IV

G. Penicillins with Anti-Pseadomonas Activity:Piperacillin-Tazoobactam (Tazocin) 2.25 gm vial, 4.5 gm vial IV- 2.25 – 4.5 grams q 6-8 hours IV

Ticarcillin Clavulanic Acid (Timentin): IV – 3.1 gm q 6 hours IV

H. Monobactams:

Aztreonam (Azactam) 500 mg vial, 1gm vial IV- 0.5-1 gram q 8-12 hours IV

I. Carbapenem:

Meropenem (Meronem) 500 mg vial, 1 gm vial IV- 500 mg - 1 gm q 8 hours IV



Imipenem-Cilastatin (Tienam) 500 mg vialIV- 250-500 mg q 6-8 hears slow IV push, maximum: 1 gm q 8 hoursNote: To avoid seizures, give very slowly, preferably IV infusion. Ertapenem (Invanz =)) 1 gmvialIV- 1-2 gm IV OD infused over 30 min period

IL Macrolides:

Erythromycin (Erycin, Erythrocin, Ery-Max) 250 mg tab, 500 mg tab, 500 mg vialPO-250-500 mg TID-QID POIV- 500 mg - 1 gm q 6 hr IV to be given very slowly by infusionAzithromycin (Zithromax) 250

mg cap, 500 mg film coated tab, 500 mg vialPO- 2 caps OD X 3 daysIV- 500 mg IV OD very slow infusion to run for 45-60 minutes Clarithromycin (Klaricid) 250 mg

tab, 500 mg tab, 500 mg OD .PO- 1-2 tabs BID

Dirithromycin (Dynabac) 250 mg tabPO-2 tabs OD x 5Roxithromycin (Macrol, Macrol OD, Rulid) 150 mg tab, 300 mg tab PO- 150 mg tab BID or 300 mg tabOD

III Tetracyclines:

#1 Doxycycline HCI (Vibramycin, Doxin) 100 mg cap PO- 2 cape initially Den 1 cap OD-BIDmaintenance Tetracycline (Ritemed Tetracycline) 250 mg cap PO- I cap QID

Minocycline (Minocin) 50 mg cap, 100 mg cap PO- 200 mg initially then 100 mg cap BIDOxytetracycline (Terramycin) 250 mg cap, 500 mg cap PO- 1 cap QID

IV. Aminoglycosides:

#l Amikacin (Amikin, Amikacide) 100 mg vial, 250 mg vial, 500 mg vial IM, IV- Loading dose 7.5 mug,

maintenance dose = 7.5 mg/kg q 12 hr or 5 mg/kg q 8 hr, e.g. 350 mg IV q 12 hours

Gentamicin (Garamycin) 20 mg/ml vial, 80 mg/2 ml vial IM, IV- Loading dose = 2 mg/kg, maintenance

dose 1.5 mg/kg/dose, e.g. 60-80 mg IV q 8 hours

Tobramycin (Nebcin) 80 mg/2 ml vial, 1.2 gm powder IM, IV- Loading dose = 2 mg/kg, maintenance

dose = 1.5 mg/kg/dose, e.g- 80 mg IV q hours

Netilmycin (Nettomycin) 50 mg/2 ml vial, 100 mg/2 ml vial, 150 mg/1.5 ml amp IV- Loading dose 2mg/kg, maintenance 1.5 mg/kg/dose, e.g. 150 mg IV q 12 hours or 300 mg IV OD

V. Cephalosporins:

First Generation Cephalosporins: Cephalexin PO end Cefazolin IV

#1 Cephalexin (Ceporex, Forexin, Keflex) 250 mg cap, 500 mg cap, 1 gm caplet PO- 500 mg q 6

hours PO

#1 Cefaxolin (Stancef, Faxilen) 500 mg vial, 1 gm vial IV-500 mg-1 gm q 8 hours IV

Cefalotin (Keflin) 1gm vial IV- 500 mg-1 gm q 4-6 hours IV

Second Generation Cephalosporins:

#1 Cefuroxime axetil (Zinnat) 250 mg tab, 500 mg tab PO- UTI 250 mg BID; Respiratory infection

250-500 mg BID#1 Cefnroxime (Zinacef) 250 mg, 750 mg, 1.5 gm vial; EC Mono vial 750 mg & 1.5 gm IM, IV- 750 mg q

8 hours IV

Cefoxitin Na (Mefoxin) 1pn vial

IM, IV- 500 mg-2 gm q 6-8 hours IV

Note: With very good activity against anaerobesCefaclor (Ceclor) 375 mg CD ER tab, 750 mg CD ER tab; (Ritemed) 250 mg, 500 mg tab PO- 375-750mg BID; 500 mg TIDCefprozil (Procef) 250 mg tab, 500 mg tab PO- 250 rng q 12 hr or 500 mg q 24 hr Cefotiam (Ceradolan) 200 mg tab, 500 mg vial, 1 gm vial



PO 1 tab TIDIM, IV- 0.5-2 gm/day la 2-4 divided doses IV, IM

Cefamandole (Mandol) 1 gm vial IV- 500 mg - 1 gm q 4-8 hourly IV Third Generation Cephalosporins:

Ceftibuten (Cedax) 200 mg cap, 400 mg cap PO-200 mg BID

Cefixime (Tergecef, Zefral) 100 mg cap, 200 mg cap PO- 100-200 mg BID PO#1 Ceftriaxone (Rocephin) IV – 250 mg vial, 500 mg vial, 1 gm vial+ 5 ml diluent IM, IV- 1-2 gm q 24 hr

1V

#1 Ceftazidime (Fortum) 250 mg vial, 500 mg vial, 1 gm vial, 2 gm vial IM, 1V- 1-2 gm q 8 hours 1V

#2 Cefotaxime (Claforan, Clavocef) 250 mg vial, 500 mg vial, 1gm vial IM, IV- 1-2 gm q 6-8 hr IV

Cefoperazone (Cefobis) 500 mg vial, 1 gm vial IM, IV- 1-2 gm q 12 hours IVCeftizoxime (Tergecin) 500 mg vial, 1 gm vial IM, 1V- 500 mg - 2 gm/day in 2-4 divided doses or 500 mgq 8 hours IV

Fourth Generation Cephalosporins:

Cefepime (Cepimax) 500 mg vial, 1 gm vial, 2 gm vial IM, IV- 1-2 gm q 12 hours IVCefpirome (Cefrom) 1 gm vial 2 gm vial IV- 1-2 gm q 12 hours IV

VL Quinolones:#1 Ciprofloxacin (Ciprobay) 250 mg tab, 500 mg tab; IV infusion: 100 mg/50 ml, 200 mg/100 ml, 400

mg/200 mlPO- 250-ZSO mg tab BIDIV- 100-400 mg IV q 12 hr

C. Norfloxacin (Lexinor) 200 mg tab, 400 mg tab PO- 200-400 ag tab BID

Fleroxacin (Requinol) 200 mg tab, 400 mg tab, 400 rng vialPO- 400 mg tab OD or IV infusion ODIV-400 mg q 24 hours IV

Ofloxacin (Inoflox, Qinolon) 100 mg tab, 200 mg tab, 2@i mj/100 ml vial:PO- 100-200 mg BID-TIDIV- 100-400 mg slow IV q 12 hr

Pefloxacin (Peflacine) 400 mg tab, 400 mg/5 m1 vialPO- 1 tab BIDIV- 400 mg vial diluted in 250 ml 5% glucose slow IV BID

VII. New Fluoroquinolones:

Levofloxacin (Floxel, Levox) 250 mg tab, 500 mg tab PO- 250 mg - 500 rng tab ODGatifloxacin (Tequin) 400 mg tab, 10 mg/ml in 40 ml vial PO, IV infusion- 400 mg/dayMoxifloxacin (Avelox) 40 mg tab PO - 1 tab OD

VIII Other:

Trimethoprim-Sulfa /Cotrimoxazole (Triglobe, Bactrim, Bacidal, Lidaprim, Microbid, Septrin) 400/80

mg-800/160 mg forte tab PO - 1 forte tab BID POChloramphenicol (Chloromycetin, Kemicetine) 250 mg cap, 500 mg cap, 1 gm vial

Dose: 60 mg/kg/ day for Typhoid Fever PO- 500 mg QlD PO

IV- 50-100 mg/kg/day in 4 divided doses or 500 mg q 6 IV or 1 gm q 8 hours IVMetronidazole (Anaerobia, Flagyl) 250 mg tab, 500 mg tab, 500 mg/100 ml vial

PO-500-750 mg q 8 hours PO

IV- 7.5 mg/kg/day QID or 500 mg q 8 hours IVClindamycin (Dalacin C) 150 mg cap, 300 mg cap,40 vg amp

PO- 150-450 mg cap q 6 hoursIV- 10-25 mg/kg/day in 3-4 divided doses or 300-600 mg q 6-8 hours IV



SYSTEMIC VIRAL INFECTION



Orders: Admit to:Diet: Regular VS: Vital signs q 4 hoursNursing: I & O q shiftIVF: D5NM X 8 hoursDiagnostics: CBC with platelet count, Tourniquet Test

Throat Swab for gram stain, culture and sensitivityUrinalysis

Therapeutics:1. Supportive: Bed rest, increase oral fluid intake2. Optional: If influenza is highly suspected

a. Amantadine HCl (Symmetrel for Flu) 100 mg 1 tab BID for Influenza A only,or b. Oseltamivir (Tamiflu) 75 mg I cap BID x 5 days for Influenza A & C




ACUTE TONSILLOPHARYNITISTo Infectious Page


Data:

A. Etiology: Group A beta-hemolytic StreptococcusB. Complications: Rheumatic heart disease, rheumatic fever Orders:

Admit to:Diet: Regular Nursing:IVF: D5NM X 8 hoursDiagnostics: CBC, Throat swab gram stain and culture and sensitivity (if with exudate), ASO titer if

complications are expectedTherapeutics:

l. Out-patient:Penicillin (Pentacillin) 500 mg tab PO TID-QID X 10 days

or Amoxicillin 500 mg tab PO TID X 10 days

or Azithromycin (Zithromax) 500 mg tab PO OD X 3 days only 2. In-patient

Penicillin IVor Clindamycin (Dalacin) IVor Co-amoxiclav (Augmentin) IV or PO




DENGUE HEMGRRHAGIC FEVERTo Infectious Page


Data:

A. Etiology: Dengue virusB. Transnission: Through bite of female Aedes aegypti mosquitoC. Symptoms: 2-7 days of fever D. Complications:. Disseminated intravascular coagulation, pleural elusion, hemorrhage, epistaxis,

melena, gum bleeding myocarditis, encephalitis hypotension, shock, acidosis, deathE. Grading:

Grade I: Fever (+) torniquet test, decease platelet, increase hemaocritGrade II: Grade I symptoms+ spontaneous bleeding hemorrhageGrade III: Grade II symptoms+ thready pulse, decrease pulse pressure =20 mmHg, or hypotensionGrade IV: Grade III symptoms+ profound shock, no blood pressure detected, no pulse

Orders:

Admit to:Diet: Avoid dark colored foods (for monitoring of melena)

VS: Vital sings q 1- 4 hours and watch out for may signs of bleeding,temperature q 4 hr and in between iffebrile or with chillsNursing: I & O q shiftIVF: D5NM X 8 hours; D5NSS or D5LR for shockDiagnostics: CBC with platelet count PT, PTT Tourniquet test

Dengue Serology if illness longer than 4 days

Urinalysis, Chest X-ray (check for pneumonia, pleural effusion)Monitor: Platelet count +/- Hematocrit levels q 12-24 hours

Therapeutics: A. Medical fragment

1. Supportive: Hydration2. Optional medications: H2-blockers if with abdominal pain or gastrointestinal bleeding3. Watch out for complications:

a If there is a frank uncontrollable bleeding, fresh whole blood is indicated

b. If PT, PTT is prolonged and with tbrombocytopenia, fresh frozen plasma transfusion isindicated.c. If there is disseminated intravascular coagulation platelet transfusion is indicated.Note: In the absence of bleeding, there is no need to administer platelet transfusion even ifplatelet count is low.

B. Preventionl. Environmental: Get rid of mosquito breeding places2. Vaccine: May be available in the near future




TYPHOID & PARATYPHOID FEVERTo Infectious Page


Data:

A. Etiology: Salmonella typhi or Salmonella paratyphiB. Transmission: Ingestion of contaminated food or water; rarely from person to person transmission

through fecal-oral route.C. Symptoms: High fever > 5 days, headache variable abdominal pain; severe cases may develop shock,

delirium and stupor.D. Complications: Intestinal perforation, gastrointestinal haemorrhage end peritonitis may occur in the 3rd

to 4th week of illness; rarely pancreatitis, hepatic and splenic abscesses, disseminated intravascularcoagulation, myocarditis, meningitis.

E. Typhi Dot Interpretation:

IgM IgGl. (+) (-) - + Acute infection2. (+) (+) - + Recent infection3. (-) (+) - + Equivocal: Past infection or acute infection

Orders:Diet: Regular VS: Vital signs q 4 hours including temp.Nursing: 1 & O q shiftIVF: D5NM X 8 hoursDiagnostics: CBC (normal WBC despite fever), platelet count , Tourniquet Test

Typhi dot test (if illness is 4 days or longer)

Malarial smear (Differential diagnosis)First Week of illness: Blood C/SSecond Week of Illness: Urine G/S, C/SThird Week of illness: Stool CSChest X-ray, Urinalysis

Therapeutics: A. For uncomplicated cases, use Conventional Therapy:

1. Chlorampenical 3-4 gm per day PO m 4 divided doses X l4 days (50-100 mg/kg BWor 2. Co-Trimoxazole forte or double-strength tab BID PO X 14 daysor 3. Amoxycillin 4-6 gm per day PO to 3 divided doses X 14 days

B. For cases with complications, presence of severe symptoms, or clinical deterioration despiteconventional therapy, use Empiric Therapy for Resistant Typhoid Fever:

1. Ceftriaxone (Rodephin) 3 gm infusion OD X 5-7 daysCeftriaxone may be used for pregnant women and childrenor 2. Fluoroquinolones:

Ciprofloxacin (Ciprobay) 500 mg tab PO BID X 7-10 daysor Ofloxaein gno5ec) 400 tag MPO DID X 7-104rysor Pefloxacin (Peflacine) 400 mg tab PO BID X 7-10 days




MALARIATo Infectious Page


Data:

A. Etiology: Malaria is the most important parasitic disease in humans. Plasmodium falciparum and P.vivum are common in the Philippines, East Asia, South America and Oceana, P. Ovale and P. malariaare common in Africa almost all deaths are caused by Plasmodium falciparum.B. Complications of severe Falciparum malaria: Cerebral malaria (coma, convulsions hypoglycemia, lactic

acidosis, ARDS, acute renal failure anemia, jaundice, hemolysis heeloghemoglobinuria (rare blackwaterfever), DIC and bleeding problems.

Orders:Diet: Regular VS: Vital signs q 24 hours including temperature; Record temperature in between if febrile, or with chillsNursing: I & O q shiftIVF: D5NM X 8 hoursDiagnostics: CBC with platelet count (anemia low platelet, low to normal WBC)

Malarial smear 3X (thick and thin smear) q 12 hours

Malarial IFAT (Immunoflorescence Antibody Test serology) c/o RITM or UP College of PubicHealth (if smears are negative)Blood typingBlood Culture and sensitivity (to rule out Typhoid Fever)ESR, Urinalysis, Chest X-rayMonitor: BUN, Creatinine, RBS, PT, PTT, Liver Function Test

Therapeutics:A. Species Not Chloroquine-Resistant

1. Chloroquine (Aralen) 250 mg: Give 4 tabs at zero hour, 2 tabs after 6th hour, 2 tabs on the 24thhour, and 2 tabs on the 48th hr (total of 10 tablets).Give after meals then2. Primaquine 15 mg tab (to kill gametocytes upon discharge) Give 1 tab OD X 14 days for P. vivaxor 3 tabs single dose for P. falciparumNote: Primaquine is not commercially available. It is given See by DOH.

B. Species Chloroquine-Resistant:1. Sulfadoxine 500 mg Pyrimethamine 25 mg (Fansidar) Give 3 tabs single dose or Quinine tablet300-600 mg 1 tab TID for 7- 10 days (for P. falcifarum)

C. For Severe Attache (P. falciparum)

1. Quinine Drip: Quinine 1 amp (10 mg of salt) in D5W 500 cc x 4 hours to be given q 8 hoursIV.Shift quinine to oral tablets as soon as possible. Watch out for cardiac toxicity.and2. Doxycycline 100 mg cap OD-BID (3 mg/kg/day) for 7 days.




PREVENTION OF MALARIA IN TRAVELLERS



For Plasmodium falciparum, P. malariae, P. vivax, P. ovale: l. Areas with chloroquine-sensitive P. falciparum:

a. Drug of choice: Chloroquine phosphate (Arden, Malarex) 250 mg 2 tabs once weekly on exactly

the same day starting 2 weeks before entering endemic area, while there, and for 2 weeks afterexposure.

2. Areas with chloroquine-resistant P. falciparum (Philippines, India, Africa China, South America etc.)a. Drug of choice: Mefloquine*(Lariam) 250 mg 1 tab once weekly starting one week before

entering the endemic area, while there, and for 4 weeks after exposure.b. Alternative drug: Doxycycline* (Doxin, Vibramycin) 100 mg 1 cap 2 days prior to departure as

test dose then 1 tab daily during exposure and for 4 weeks after exposure.c. Carry 3 tabs of Fansidar for self-teatment of febrile illness when medical treatment is not

immediately available.

* Avoid in children < 8 years old and pregnant women

Anti-Malarial Drug List

1. ChloroquineSulfate (Aralen, Malarex) 250 mg tab 2 tabs on exactly the same day of each week

2.a. Sulfadoxine500 mg, Pyrimethamine 25 mg tab (Fansidar, Methamar) 3 tabs single doseb. Sulfametopyrazine 500 mg; Pyrimethamine 25 mg tab (Metakelfin)c. Mefloquine HCl 250 mg+ Sulfadoxine 500 mg+ Pyrimethamine 25 mg tab (Fancimef)

3. Halofantrine HCl (Halfan) 250 mg tab, 100mg/5ml susp

4. MefloquineHCI (Lariam) 250 mg tab, Prophylaxis: 1 tab once weekly

To Infectious Page




LEPTOSPIROSISTo Infectious Page


Data:

A. Etiology: Leptospires (spirochetes)

B. Transmission: Exposure to rat urine, contaminated water and soil, or with a history of wading infloodwaters. Incubation period of 2 to 26 days (average of 7-13 days).C. Signs and Symptoms:

1. Leptospiromic phase (4-9 days): Leptospira in blood and CSF. Headache and fever heralds onsetfollowed by calf pains, conjunctival suffusion, and jaundice (toxic-looking patient).2. Immune Phase: Appearance of IgM Ab, decrease in fever.

D. Complications: Hepatic and renal failure myocarditis, acute respiratory distress syndrome pneumonia,aseptic meningitisE. Differential Diagnoses: Hepatitis (increased SGOT, SGPT) typhoid fever, dengue fever, pneumonia,gastroenteritis

Orders:

Admit to:Diet: Regular

VS: Vital signs q 2-4 hours including temp.Nursing: I & O q shiftIVF: D5NM X 10 hoursDiagnostics: CBC, Platelet count, PT, PTT

CPK-total , Chest X-ray, Urinalysis

BUN, Creatinine, RBS, K

SGPT, SGOT, Alkaline Phosphatase,

Total Bilirubin, Direct & Indirect BilirubinLeptospiral Ab test c/o PGH

MAT paired sera, MCAT rapid testBlood C/S, CSF culture, Urine C/S (after first week)

Therapeutics:1. For Moderate to Severe Cases: Penicillin 0 1.5-2 mil units q 4-6 hours X 7 days (best if started withinfour days of illness)2. For Mild Cases: Doxycycline 100 mg PO BID X 7 days2. Fluid and electrolyte replacement3. Renal complications:

a. Consider dialysis treatment for azotemiab. Dopamine drip at 1-2 mcg/kg/hour

4. Prophylaxis in Endemic Areas: Doxycycline 200 mg tab PO once per week




SCHISTOSOMIASISTo Infectious Page


Data:

A. Etiology: Schistosoma japonicum found in Southeast Asia, Philippines especially Leyte and Samar B. Pathophysiology: Exposure to freshwater in endemic area; ingestion of undercooked fish andcrustaceans.Snail intermediate host is Oncomelania philippinensis. Parasite resides in the venules of the intestines,eggs are swept back mostly to the liver via the venous portal system.

C. Signs and Symptoms: Two to six weeks from exposure, transient itching, swimmer's itch, Katayamafever, chills, headache, CNS symptoms; an increased worm load would result in increased Symptoms.

D. Complications: Liver fibrosis, portal hypertension, presinusoidal hepato- splenomegaly, esophagealvarices, cor pulmonale, pulmonary hypertension from worm emboli, glomerulonephritis, CNS lesions,multiple enhancing brain lesions mimicking brain tumors.

Orders:

Diagnostics: CBC (eosinophilia)

COPT (serum), Kato-Katz (stool)

Stool exam or rectal biopsy (positive eggs)Ultrasound of liver or wedge biopsyCT Scan of the head (if with neurologic symptoms)

Therapeutics:Praziquantel 20 mg/kg TID PO with fo6d for 1 day only (available at DOH).Example: 650 mg tab, 1 1/2 tab TID for 3 doses only.




SEPSIS & SPETIC SHOCK



Data:

A. Etiology:1. Gram (-) bacteria in 70% of cases; endotoxin present2. Gram (+) bacteria in 15% of cases; from vascular catheter, burns, IV lines mechanical devices3. Fungi etiology in 5% of cases; found in immunocompromised, neutropenic patients, or afterantibiotic treatment

B. Pathophysiology:1. Endothelial injury, fluid extravasation with hypotension2. Culprit cytokines, increase TNF alpha, Interleukin 1B and 8

Orders:

Admit to:Diet: NPO temporarily

VS: Vital signs q 1 hour Nursing: I & O q shift; consider pulse oximter insert NGT, CVP, Foley catheter IVF: Plain NSS 1 liter x 8 hours; D5NSS I liter x 8 hoursDiagnostics: CBC with platelet count, PT, PTT, Fibrinogen degradation product

Chest X-ray, ECG, RBS, ABG, Na, K, Mg, Ca, BUN, Creatinine

Blood C/S 3X from different sites 1 hour apart

Urinalysis, Urine C/S, Spatem G/S & C/S

Cultureof wound, IV catheters, ascitic fluid, decubitus ulcers, pleural fluid

Therapeutics:Oxygen at 2-5 1pm by nasal cannula or use face mask

1. Hemodynamic support:a. PNSS 1-2 L fast drip if hypotensiveb. Inotropic support: Dopamine Drip, Norepinephrine Drip

2. Remove source of infection3. Treat acidosis: Sodium bicarbonate for pH < 7.24. Treat disseminates intravascular coagulation: Heaprin low-dose5. Empiric Antibiotics: Use appropriate antibiotics at right dosesNote: Antibiotics may have to be changed depending on cultrure results after 2-3 days

a. Non-immunocompromised adultsi. Ceftriaxone (Rocephin) I-2 gm IV gq24 hr or Piperacillin-Tazobactam (Tazocin) 2.25 gm IV q 4-6 hr or Ceftazidime (Fortum) 1-2 gm IV q 8 hr or Meropenem (Meronem) 500 mg - 1 gm IV q 6-8 hr or Imipenem 500 mg - 1 gm IV q 6-8 hr ii. Gentamicin, Tobramycin or Amikacin IViii. Clindamycin IVor Metronidazole 500 mg IV q 6 hr

b. Nosocomial sepsis with IV catheter or IV drug abuse (S. aureus)i. Vancomycin 1 gm slow IV push in 30 minutes q 12 hr + ii. Gentamicin or Tobramycin IVc. Neutropenic patients (Neutrophiles < 500/cu mm)i. Ceftazidime 1-2 gm IV q 8 hr or Meropenem or Imipenem+ ii. Tobramycin or Amikacin IViii. Vancomycin 1 gm slows IV in 30 min q 12 hr (if with indwelling catheter)

d. Candida Septicemiai. Amphotericin B IV or Fluconazole IV infusion



e. If Pseudomonas aeruginosa is suspected or for AIDS patients:i. Ceftazidime 1-2 gm IV q 8 hr or Meropenem or Imipenem+ ii. Amikacin or Tobramycin IV

To Infectious Page




LOWER URINARY TRACT INFECTION


To Detailed Table of ContentsOrders: IVF: D5NM 1, Liter X 8 hours

Diagnostics: CBC, Urinalysis

Urine G/S, C/STherapeutics:

A. Lower Urinary Tract Infection (Treat for 3-7 days)1. Co-Trimaxazole (Bactrim Forte) 1 tab BID POor Norfloxacin (Lexinor) 400 mg 1 tab BIDor Ciprofloxacin (Ciprobay) 250-500 mg 1 tab BIDor Cephalexin (Ceporex, Forexin) 500 mg 1 cap QIDor Co-amoxiclav (Augmentin) 375 mg l tab TID POor Nitrofurantoin (Macrodontin) 100 mg 1 cap QID POor Amoxicillin 500 mg 1 tab TID (may be used in pregnancy)

B. Complicated Catheter associated UTI: As per drugs used in severely ill septic pyelonephritis




PYELONEPHRITISTo Infectious Page


Orders:

Admit to:

Diet: Regular VS: Vital signs q 4 hoursNursing: I and O q shiftIVF: D5NM 1 Liter X 8 hoursDiagnostics: CBC, Blood Culture and sensitivity

Urinalysis, Urine G/S, C/S

RBS, BUN, Creatinine, Ultrasound of the kidneys

Therapeutics: A. Moderately ill, non-septic pyelonephritis (Treat for 10-14 days PO)

1. Ciprofloxacin, Norfloxacin, Ofloxacin, Co-amoxiclav, Co-trimoxazole, or Cephalexin PO as per above dosages Lower UTI but given longer for 10-14 days

B. Severely ill, septic pyelonephritis: (Treat with IV antibiotics until fever subsides, then use oralquinolone for 10-14 days)

1. Ampicillin 1 gm IV q 6 hr and Gentamicin 80 mg IV q 8 hr

or 2. Ciprofloxacin (Ciprobay) 200-400mg IV q 12 hr or Ceftriaxone (Rocephin) 1-2 gm IV q 24hr or Meropenem (Meronem) 500 mg - 1 gm IV q 6-8 hr

C. Symptomatic medications: Pain relievers




CELLULITlSTo Infectious Page


Orders:

Admit to:Diet: Regular; Increase fluidsVS: Vital signs q 2 hours and recordNursing: I and O q shift; Keep affected extremity elevatedIVF: D5NM 1 Liter X 8 hoursDiagnostics: CBC, Blood culture and sensitivity

Wound discharge gram stain, C/S

UrinalysisBone X-ray of cellulitis site (to rule out osteomyelitis)

Therapeutics: A. Empiric Therapy

l. Oxacillin (Prostaphlin) 2 gm IV q 4-6 hr (give by soluset because irritating) or Cefazolin (Stancef) lgm 1V q 8 hr or Penicillin 2 Mil units IV q 4-6 hr (only if high suspicion of Erysipelas)

B. Immunosuppressed, Diabetic Patients or Ulcerated Lesions

l. AmpicillintSulbacfam (Unasyn) Alone 1.5 gm IV q 8 hr or 2. Co-Amoxiclav (Augmentin) Alone 1.2 gm IV q 8 hr or 3. Oxacillin (Prostaphlin) 2g IV q 4-6 hr + If Septic, add: Gentamicin IV+ Clindamycin IV/ PO or Metronidazole IV/PO

C. Necrotizing Soft-Tissue Infection1. Penicillin 4 Mil units IV q 4 hr 2. Gentamicin IV+ 3. Clindamicin 1V

D. Symptomatic Meditations:1. Silva sulfadiazene cream 1% TID to affected area2. Betadine solution for cleansing3. Pain reliever as needed.

E. Tetanus Management (depending on tetanus vaccination status of the patient)

1. Tetanus immune globulin 250 IV IM stat dose2. Tetanus toxoid 1 dose IM now, then second dose after 1 month and third dose after 6 months.




MENINGITIS & ENCEPHALITISTo Infectious Page


Orders:

Admit to:Diet: Regular, fluid restriction if with increased intracranial pressureVS: Neurologic vital signs q 1 hour Nursing: Respiratory isolation, I & O q shiftIVF: D5W 250 cc and keep vein openDiagnostics: CBC with platelet, Blood C/S, HSR, ABG

Na, K, BUN, Creatinine, RBS, Urinalysis

Viral studies if availabl0 (Coxsackie, Echo, mumps, EBV, HSV, CMV, arbovirus)Portable Chest X-ray, ECGCT Scan, MRI, EEG- if indicated

Lumbar Puncture:

CSF tube #1 - Total cell count RBC, WBC, Diff Count#2 - Protein, sugar

#3 - G/S, C/S, AFB, Indian Ink#4- Sabouraud's Agar - Fungal meningitis#5 -TB Eliza Determination PGH#6 - CALAS (Cryptococcal Ag Latex Agglutination) c/o PGH

Therapeutics for Meningitis:

A. Meningitis Empiric Therapy for Age 9 months to 50 years old:1. Ceftriaxone (Rocephin) 2 gm IV q 12 hr or Cefotaxime (Claforan) 1-2 gm IV q 6 hr or Ceftazidime(Fortum) 1-2 gm IV q 8 hr + 2. Vancomycin 1 gm slow IV push in 30 minutes q 12 h3. Alternative for areas with low prevalence of drug-resistance S. pneumoniae: Penicillin G 4 millionunits IV q 4 hr or Chloramphenicol IV (if with Penicillin allergy)

B. Empiric Therapy for patients > 50 years, Alcoholic, with Intake of Corticosteroids or HematologicMalignancy or Other Debilitating Conditions:

1. Ampicillin 1-2 gm IV q 4 hr + 2. Vancomycin l gm slow IV push in 30 minutes q 12 hr + 3. Cefotaxime (Claforan) 1-2 gm IV q 6 hr or Ceftriaxone (Rocephin) 2 gm IV q 12 hr orCeftazidime (Fortum) 1-2 gm IV q 8 hr

C. Hospital-acquired Meningitis, Meninges after Head Trauma or Neurosurgery, Neutropenic Patients:1. Meropenem (Meronem) alone 1-2 gm IV q 8 hr or 2. Vancomycin 1 gm slow IV push in 30 minutes q 12 hr

+ Ceftazidime (Fortum) 1-2 gm IV q 8 hr D. Therapy Based on Specific Etiologic Agent:

1. Streptocccus pneumoniae (Penicillin sensitive): Penicillin G 4 Mil wits IV q 4 hr 2. Staphylococcus aureus: Oxacillin 2 gm IV q 4-6 hr or Vancomycin 1 gm slow IV push in 30minutes q 12 hr 3. Neisseria meningitides: (Penicillin sensitive): Penicillin G 4 Mil units IV q 4 hr 4. Haemophilus influenzae: Ceftriaxone (Rocephin) 2 gm IV q 12 hr or Cefotaxime (Claforan) l-2 gm

IV q 4-6 hr 5.. Gram negative bacilli (not P; aeruginosa or Enterobacter cloacae): Cefotaxime (Claforan) 1 2 gmIV g 4-6 hr or Ceftriaxone (Rocephin) 2 gm IV q 12 hr or Ceftazidime (Fortum) 1-2 gm IV q 8 hr 6. Pseudomonas aeruginosa: Ceftazidime 1-2 gm IV q 8 hr, Meropenem 1-2 gm IV q 8 hr

Note: For viral encephalitis no antibiotics are needed.

E. Consider Dexamethasone Therapy:

Dexamethasone 0.6 mg/kg per day in 4 divided doses for 2-4 days. e.g. Dexamethasone(Decadron) 8 mg IV initially, then 4 mg IV q 6 hr



Give the first dose of steroids 20 minutes before starting antibiotic therapy for best results.




TETANUSTo Infectious Page


Data:

A. Etiology: Clostridium tetani, a gram-positive bacteria, produces tetanospasmin causing increasedmuscle tone and spasms.

B. Transmission: Usually a non-immunized person develops a skin injury and comes into contact withinfected soil.

C. Symptoms: Diagnosis is clinical only. Symptoms initially include jaw stiffness (locked jaw) anddysphagia then followed by pain or stiffness in the neck, face (sardonic grin), shoulder, back andabdominal muscles. Hands and feet are relatively spared. Onset of symptoms may range from 3-14days after the injury

D. Complications: Severe cases may develop laryngeospasms, apnea autonomic dysfunction(hypertension, tachycardia, arrhythmia, high fever, profuse sweating), aspiration pneumonia, fractures,muscle rupture, rhabdomyolysis, deep venous thrombosis (DVT), pulmonary emboli and decubitusulcers.

Orders:

Admit to single room.Diet: NPO temporarilyVS: Neuro vital signs q 1 hour Nursing: I & 0 q shift, Seizure precautions

Consider nasogastric tube insertion and nutritional support Avoid stimulation and bright lights; Keep room dark and quiet.Tongue guard; Watch out for respiratory depression; standby intubation set.

IVF: D5NR 1 L X 10 hoursDiagnostics: CBC, RBS Creatinine, K

Wound G/S & C/S, Urinalysis

Chest X-ray, ECGTherapeutics:1. Give Anti-toxin: Human Tetanus Immunoglobulin Ig (Tetuman Berna, Tetaglobulin) 250 IU/amp, 4 ampsIM

2. Give Tetanus toxoid 0.5 ml/amp, 1 amp IM now, then after 1 month, and after 6 months.3. Start Antibiotics: Penicillin G 3-4 Mil units IV q 4 hr (18-24 Mil units per day) or Metronidazole 500 mg IVq 6 hr 4. For Muscle Spasms: Diazepam 2.5-5 mg IV q 6 hr or Diazepam drip: 10 mg in 100 ml D5W infuse in 2hours q 8 hr (maximum of 60 my per day)5. Supportive Therapy:

a. Respiratory support, protection of the airway, IV hydrationb. Prevent DVT, decubitus ulcers and GI bleeding; May give antacids per nasogastric tubec. Pain reliever. Ibuprofen 200 mg tab TID per NGT if neededd. Clean wound with hydrogen peroxide and Betadine




OSTEOMYELITISTo Infectious Page


Orders:

Admit to:Diet: Regular VS: Vital signs q 4 hoursNursing: Keep involved extremity elevatedIVF: D5NR 1 liter X 16hoursDiagnostics: CSC, ESR, Blood culture and sensitivity

Wound or tissue discharge G/S, C/S

UrinalysisChest X-rayMultiple x-ray views of involved bones

Therapeutics:

A. Adult Empiric Therapy (S. aureus, Gram-negative, Pseudomonas)l. Oxacillin (Prostaphlin) 2 gm IV q 4-6 hr

or Cefazolin (Stancef) 2 IV q 8 hr or Vancomycin 1 gm slow IV push in 30 minutes q 12 hr (reserved drug for Oxacillin resistant S. aureus)2. Ceftazidime (Fortum) 1-2 gm IVq 8 hr (if gram-negative bacilli on gram stain)

B. Post Operative or Post Trauma (S. aureus, Gram-negative, Pseudomonasl. Oxacillin (Prostaphlin) 2 gm IV q 4-6or Cefazolin (Stancef) 2 gm IV q 8 hr or Vancomycin 1 gm slow lV push in 30 minutes q 12 hr + 2. Ceftazidime (Fortum) 1-2 gm lV q 8 hr or Ciprofloxacin (Ciprobay) 500 mg PO BID

C. Osteomyelitis with Decubitus Ulcer 1. Ciprofloxacin (Ciprobay) 200-400 mg IV q 12 hr + 2. Metronidazole 500 mg IV q 6 hr

D. Symptomatic medications: Pain relievers




PERITONITISTo Infectious Page


Orders:

Admit to:

Diet NPOVS: Vital signs q 1 hour Nursing: I & O q shiftIVF: D5NSS + 20 meq KCl/L at 125 cc/hour Diagnostics: CBC, Na, K

PT, PTT, Albumin LDH, Amylase, LactateUrinalysis, Urine C/SX-ray of abdomen: plain film upright lateral decubitus

Abdominal ultrasoundChest X-ray

Abdominal Paracentesis:Vial #1 - Gram Stain, AFB smear Vial #2 - Q/Q (Quantitative/Qualitative)Vial #3 - Culture and sensitivity

Optional: Total protein, amylase, LDH, glucose, etc.Therapeutics:

A. Spontaneous Bacterial Peritonitis (nephrotic or cirrhotic)1. Cefotaxime (Claforan) 1 gm IV q 6-8 hr or Piperacillin-Tazobactam (Tazocin) 2.25 gm IV q 6-8 hr or Ceftriaxone (Rocephin) 1 gm 1V q 24 hr or Ceftazidime (Fortum) 1 gm IV q 8 hr + 2. Ampicillin-Sulbactam (Unasyn) 750 mg IV q 8 hr

B. Secondary Bacterial Peritonitis (from bowel perforation, ruptured appendix, or diverticula)1. Meropenem (Meronem),alone:1 gm IV q 8 br or 2. Cefoxitin (Mefoxin) 1-2 gm IV q 8 hr + Gentamicin or Tobramycin IV (avoid in chronic renal failure)+ Clindamycin 300 mg IV q 8 hr

C. Renal Failure Patients with Peritonitis (associated with chronic ambulatory peritoneal dialysis)

Target S. aureus1. Ceftazidime (Fortum) 1-2 gm IV q 8 hr + Vancomycin 1 gm slow IV push in 30 minutes q 12 hr




DIVERTICULITISTo Infectious Page


Data:

A. Incidence: Male > female elderly patient, left colon affected more than right colon due to higherintraluminal pressuresB. Etiology: Inflammation of the diverticular sac due to gram-negative anaerobic bacteriaC. Symptoms and Signs: Acute abdominal pain, nausea, vomiting fever, left lower abdominal tenderness

and mass.D. Complications: Fistula formation, stricture of the colon with obstruction.E. Differential Diagnoses: Perforated colon carcinoma, appendicitis, Crohn's disease, ischemic colitis,

gynecologic disorders. Orders:

Admit to:Dict: NPO temporarilyVS: Vital signs q 2 hr and recordNursing: I & O, place NGT if with signs of bowel obstruction or ileus

IVF: D5NSS 1 L X 8 hoursDiagnoses: CBC (inc WBC:), K, Blood C/S

Amylase, Lipase, Urinalysis, Chest X-ray, EGGPlain abdominal x-ray upright and supine (to rule out perforation)

CT Scan of the abdomen (to rule out abscess formation)Sigmoidoscopy & Barium Enema (after the acute phase is over because of danger ofperforation)

Therapeutics:1. Bowel rest2. Start antibiotics

a Localized inflammatory response:i. Co-trimoxazole (Bactrim forte) 1 tab PO QID X 14 daysor Ciprofloxacin (Ciprobay) 500 mg 1 tab PO BID X 14 days+ ii. Metronidazole 500 mg 1 tab PO QID X 14 days

or iii Co-amoxiclav Alone (Augmentin) 625 mg 1 tab PO TID X 14 daysb. Patient systemically ill (Antibiotics should cover anaerobic and gram- negative bacteria):

i. Cefoxitin (Mefoxin) 1-2 gm IV q 6 hr ii. Gentamicin or Tobramycin 1V+ iii. Metronidazole 500 mg IV q 6 hr

3. Surgery referral to monitor complications (seen in 20-30% of cases): Abscess, fistula perforation,hemorrhage obstruction4. Symptomatic medications

a H2-blockersb. Pain relievers; Meperidine (Demerol)




PELVIC INFLAMMATORY DISEASESTo Infectious Page


Data:

A. Etiology: Polymicrobial and sexually-transmitted infection of the upper genital tract.Neisseriagonorrhoeae and Chlamydia trachomatis commonly involved.B. Symptoms and Signs: Lower abdominal pain, fever, menstrual disturbance, cervical and vaginaldischarge, lower abdominal adnexal and cervical motion tenderness, Some patients have mild symptomsonly.C. Differential Diagnoses: Appendicitis, ectopic pregnancy, septic abortion, acute gastroenteritis, ovariancysts and tumors, degeneration of a myoma. Orders:

Admit to:Diet: NPO initially until cleared by Surgery and OB-GynecologyVS: Vital signs q 4 hoursNursing: I and O q shiftIVF: D5NM 1 L X 8 hours

Diagnostics: CBC, ESR, Gonococcal and Chlamydial CultureUrinalysis, Urine C/S

Pelvic Ultrasound and/or Vaginal Ultrasound (check for pelvic masses and other differentialdiagnoses)VDRL, Pregnancy test

Therapeutics: A. Outpatient Therapy (For patients with temperature < 38 C, WBC < 11,000, minimal evidence ofperitonitis, active bowel sounds and able to tolerate oral feeding):

1. Ofloxacin 400 mg 1 tab BID PO X 14 days + Metronidazole 500 mg 1 tab BID PO X 14 daysB. Inpatient Therapy: IV antibiotic regimens (2 options) are given for at least 48 hours after patientimproves then continued oral antibiotics, Doxycycline 100 mg 1 tab BID PO, to complete therapy for 14days.

1. Cefoxitin (Mefoxin) 1-2 gm IV g 6 hr + Doxycycline l00 mg 1 tab BID POor 2. Clindamycin 300-600 mg IV q 8 hr + Gentamicin 80 mg IV q 8 hr

C. Supportive Therapy:1. Bed rest2. Symptomatic medication: Pain relievers




MUMPSTo Infectious Page


Data:

A. Complications; Orchitis, aseptic meningitis or encephalitis, pancreatitis, myocarditis, thrombocytopenia,nephritis Orders:

Admit to:Diet: Soft dietDiagnostics: CBC with platelet count

Amylase, RBS, CreatinineUrinalysis

Therapeutics:1. Supportive treatment;

a. Bed restb. Paracetamol 500 mg tab PO as needed for fever >= 38º C and pain

2. For Orchitis

a. May give antibiotics if with signs of bacterial infectionCiprofloxacin 500 mg tab BID PO x 10-14 daysor Cephalexin 500 mg tab QID X 10-14 days

b. Scrotal elevating and apply cold compress




VARICELLA ZOSTER (CHICKEN POX) & HERPES ZOSTER(SHINGLES)

To Infectious Page


To Detailed Table of Contents Data on Varicella Zoster :

A. Incubation Period: 14-17 daysB. Distribution: Rash erupts in trunk and face first.C. Complications: Bacterial superinfection cerebral ataxia after 2 days of no treatment, pneumonitis (20%

of adult after 3-5 days), myocarditis, corneal lesions, nephritis, acute glomeruoephritis, hepatitis,bleeding, increase SGOT & SGPT

Orders:Diagnostics for Varicella Zoster: CBC: Chest X-ray (to rule out pneumonia), Tzanck smear of skin lesionsTherapeutics:

A. For Varicella Zoster:l. Aciclovir (Zovirax) 800 mg 1 tab PO q 4 hr omitting the nighttime dose (5 doses/day) for 7 days

(start within 24 hour of rash)2. Isolate patient in a single room.B. For Herpes Zoster.

1. Valaciclovir (Valtrex) 500 mg tab, 2 tabs TID PO for 7 days (start within 3 days of rash)2. For Herpes Zoster Ophthalmicus: Neosporin drips, 1 drop QID on affected eye. Refer to EyeSpecialist.3. Pain reliever for severe pain of herpes zoster 4. Optional: Neurobion 5000 mg I tab BID-TID PO




Empirical Antimicrobials for Out-Patient AdultsTo Infectious Page


Table 4-2. Examples of Empirical Choices of Oral Antimicrobials for Adult Outpatient Infections.

Suspected

ClinicalDiagnosis

Likely Etiologic Agent

Drug of Choice Alternative Drug

Erysipelas,impetigo,cellulitis,ascendinglymphangitis

Group AStreptococcus

PhenoxymethylPenicillin (Pen)PO or Cloxacillin

PO

Erythromycin POor

Cephalexin PO X7-10 days

Furuncle withsurroundingcellulitis

Staph. aureus Cloxacill in PO X10 days

CephalexinPO X 7-10 days

Pharyngitis

Group A Strep.

(Beta hemolytic)

Phenoxymethyl

(Pen) PO X 10days

Erythromycin

PO X 10 days

Otitis Media

Strep.pneumoniae,H. influezae,Moraxellacatarrhalis

Ampicillin PO X10 days

Co-AmoxiclavPO, CefuroximePO X 10 days

Acute sinusitis

S. pneumoniae, H.influenzae, M.

catarrhalis

Co-AmoxiclavPO,

Cefuroxime 250mg

PO BID X 10days

Amoxicillin PO,TMP-SMZ FortePO X 10 days

Acutebronchitis

S. pneumoniae H.influenzae

ClarithromycinPO,

Erythmmycin POX 7 days

TMP-SMZForte

PO x 10 days

Aspirationpneumoniae

Mixedoropharyngeal

flora, inclu-- dinanaeobes

Clindamycin POX 10-14 days

PhenoxymethylPen

PO x 10-14days

Pneumoniae See Pulmo chapter

Enteritis

Salmonella,Shigella

Campylobacter,Entamoebahistolytica

Salmonella,Shigella:

TMP-SMZ or Quinolones X 5

daysCampylobacter.Ciprofloxacin X

5 d.

E. hystolyticaMetronidazole

POX 5-10

Pyelonephritisor Cystitis

E. coli. K.

pneumoniae,Proteus, S.

saphrophyticus

Ciprofloxacin PO,TMP-SMZ Forte

PO

Co-Amoxiclav

PO



Urethritis(associatedwith STD)

Neisseria

gonorrheae,Chlamydiatrachomatis

Ceftriaxone 250mg IM once forN. gonorrheae;

Doxycycline 100mg BlD X 7days for C.

trachomatis

Azithromycin1 gm PO once

for C. trachomatis

PelvicInflammatoryDisease

N. gonorrheae,C. trachomatis,

Anaerobes, Gm(-) rods

Ofloxacin 400 mg

BID PO X 14days and

Metronidazole300 mg BID PO

X 14days

Ceflriaxone 250mg IM followedby Doxycycline100 mg BID PO

X 14 days

Syphilis: EarlySY (primary,secondary orlatent of <1 year's

duration

Treponema

pallidum

Benzathine PenG 2.4 mil units

IM once

Doxycycline POor Tetracycline

PO orErythromycin PO

X 15 days

Latent of > 1year's durationorcardio-vascularSY

Benzathine PenG 2.4 mil units

IM per week X 3weeks

Doxycycline POor TetracyclinePO X 4 weeks

Neurosyphilis

Aqueous Pen G

3-4 mil units q 4hr IV X 10-14

days

Procaine Pen G

2-4 millionunits/day IM+Probnecid 500

mg QID PO bothX 10 days




Initial Antimicrobials for Acutely Ill AdultsTo Infectious Page


Table 4-3. Examples of Initial IV Antimicrobial Therapy for Acutely Ill Hospitalized Adults Pending

Identification of Causative Organism

SuspectedClinical

Diagnosis

Likely Etiologic

Agent

IV Drugs of

Choice

Alternative Drugs

a. Meningitis,bacterial

Pneumococcus,Meningococcus

Ceftriaxone 2

gm IV q 12 hr + Ampicillin 2 gm

IV q 4 hr

Cefotaxime 2 gm

IV q 6 hr orPenicillin G 4

million units IV q4 hr (thru soluset)

b. Meningitis,

postoperative(or post-traumatic)

S. S. aureus,

gramnegativebacteria,

Pseuddmonas(Pneumococcus,

posttraumatic)

Vancomycin 1

gm IV q 12 hr +Ceftazidime 2gm IV q 8 hr

Pen G 4 mil U IV

q 4 hr +Oxacillin 2 gm q4 hr + Amikacin15 mg/kg/day

c. Brain

abscess

Mixed

anaerobes,Pneumococci,Streptococci

Ceftriaxone 2

gm IV q 12 hr orCefotaxime 2 gm

IV q 6hr +Metronidazole500 m IV 6 hr

Pen G 4 mil U IV

q 4 hr +Metronidazole

500mg IVq 6 hr

d. Pneumonia

See Pulmo chapter

e. . Septicthombo-phlebitis (e.g.IV tubing, IVshunts)

Staphylococcus,Gram-native

aerobic bacteria

Oxacillin 2 gm IVq 4hr +

Gentamicin orTobramycin or Amikacin IV

Vancomycin 1gm IV q 12 hr +

Cefotaxime 2 gmIV q 8-12 hr

f. Osteomyelitis

S. aureus

Oxacillin 2 gm IV

q 4 hr

Vancomycin 1gm IV q 12hr

g. Septic

arthritis

S. aureus, N.gonorrheae

Ceftriaxone 2gm IV q 24 hr

Oxacillin 2 gm IV

q 4 hr

h. Pyelonephritis

with flank

paain & fever (recurrent UTI)

B. coli Klebsiella,

Enterobacter,

Pseudomonas

Ciprofloxacin

200-400 mg IV q

12hr

Ceftriaxone 1-2gm IV q 24 hr



i. Suspectedsepsis inneutropenicpatient re-ceiving cancer chemotherapy

S. aureus,Pseudomonas,

Klebsiella, E. coli

Third or FourthGeaerahon

Cephalosporins+Tobramycin or Amikacin IV

Ceftazidime 2 gm

IV-q 8 hr +Vancamycin 1

gm lV q 12 hr +Tobramycin IVMeropenem orImipenem 1 gm

IVq 8 hr

j. Intra-

abdominalsepsis (e.g.post-oprativeperitonitischolecystitis)

Gram-negative

bacteria,Bacteroides, Anaerobic

bacteriaStreptococcus,

Clostridia

Third

GenerationCephalosporins+gentamicin orTobramycin or Amikacin IV+Metronidazole500 mg IV q 6

hr,

Meropenem orImipenem 1 gm

IV q 8 hr




Drug of Choice for Microbial Pathogens



Table 4-4. Drugs of Choice for Suspected or Proved Microbial Pathogens.

Etiologic Agent Drug (s) of First Choice Alternative Drugs

Moraxellacatarrhalis

(Branhamella)

Co-Amoxiclav or oral

cephalosporins,Trimethoprim-Sulfamethoxazole

Azithromycin, Clarithromycin,Dirithromycin, Erythromycin,

Doxycycline,Fluoroquinolones

Neisseriaegonorrheae

(Gonococcus)

Ceftriaxone, Cefixime,

Cefpodoxime

Ofloxacin, Spcctinomycin

Neisseria

meningitides(Meningococcus)

Penicillin G

Ceftriaxone, Cefuroxime,

Cefotaxime, Sulfonamide,Chloramphenicol

Gram-Positive Cocci:

Pneumococcus(Strep.pneumoniae)

Penicillin G

Amoxicillin, Erythromycin,Cephalosporin, Vancomycin

Streptoooccuspyogenes,hemolyticgroups A, B, C, G,F

Penicillin G or V (may add

Gentamicin)

All beta-lactams,

Erythromycin, Azithromycin,Dirithromycin, Clarithromycin

Strep. viridans

Penicillin G +/-

Aminoglycosides

Older Cephalosporins

Vancomycin Staphylococcusaureus, methicillinresistantVancomycin

Vancomycin Trimethoprim-sulfamethoxazole

Staphylococcus,non-penicillinaseproducing

Penicillin G

Older Cephalosporins,

Vancomycin

Staphylococcus,

penicillinaseproducing

Penicillinase-resistant

Penicillin: Nafciilin or OxacillinIV, Dicloxacillin, Cloxacillin or

Oxacillin PO

Vancomycin, Cephalosporin,Clindamycin, Co-Amoxiclav,

Ampicillin-Sulbactam

Strep. fecalis

Ampicillin+ Gentamicin

Vancomycin+ Gentamicin

Gram-Negative Rods:

Acinotobacter

Imipenem, Meropenem,

Fluoroquinolone+ Amikacin or Ceftazidime

Ampicillin-Sulbactarn



Bacteroides,oropharyngealstrain

Metronidazole

Clindamycin, Cefoxitin,Imipenem + Cilastatin,Meropenem, Ticarcillin

Bacteroides,gastrointestinal

strains

Metronidazole

Cefoxitin, Chloramphenicol

Clindamycin, Imipenem,

Ampicillin-Sulbactam Brucella

Doxycycline + Gentamicin orStreptomycin

Doxycycline + Rifampicin or

TMP-SMZ+ GentamicinFluoroquinolone+ Rifampicin

Campylobacter

Erythromycin

Clindamycin, Ciprofloxacin,Ofloxacin

Enterobacter

Meropenem, Imipenem

Third Gen Cephalosporins,

Aminoglycoside,Ciprofloxacin, Ofloxacin

Escherichia coli(sepsis)

Third GenerationCephalosporins

Ampicillin, TMP-SMZ,

Ciprofloxacin, Imipenem,

Aminoglycosides Escherichia coli

(first UTI)

Sulfonamide, TMP-SMZ

Ampicillin, Cephalexin,

Ciprofloxacin, Oflooxacin

Haemophilusinfluenzae

(meningitis,respiratoryinfection

Cefotaxime, Ceftriaxone

TMP-SMZ, Imipenem,

Ampicillin, Chloramphenicol

Klebsiellapneumoniae

Third GenerationCephalosporins

Ciprofloxacin, Ofloxacin,

Aminoglycoside

Legionella sp.(pneumonia)

Azithromycin, Ciprofloxacin

Erythromycin+ Rifampicin,Clarithromycin, TMP-SMZ

Yersinia pestis(plague)

Streptomycin,Gentamicin

Choramphenicol, Doxycycline

Proteus mirabilis

Ampicillin IV,

Amoxici1lin PO

Third Gen Cephalosporins,

Aminoglycosides, TMP-SMZ,Ciprofloxacin Ofloxacin

Proteus vulgarisand other species

Third GenerationCephalosporins,

Ciprofloxacin Ofloxacin

Aminoglycoside, Imipenem,

TMP-SMZ

Pseudomonasaeroginosa

Aminoglycoside+

anti-Pseudomonal Penicillin:Piperacillin-Tazobactam

Ceftazidime+/- Aminoglycoside,

Imipenem,Meropenem, Ciprofloxacin

Pseudomonas

pseudomallei

Ceftazidime

Chlaramphenicol, Tetracycline,

TMP-SMZ, Co-Amoxiclav

Pseudomonasmallei

Streptomycin + Tetracycline

Chloramphenicol +

Streptomycin



Salmonella typhi

TMP-SMZ,Chloramphenicol

Ceftriaxone, Ciprofloxacin,Ofloxacin

Serratia,Providencia

Third Gen

Cephalosporins,Ciprofloxacin, Ofloxacin

TMP-SMZ, Aminoglycosides

Shigeilla

TMP-SMZ, Ampicillin

Ciprofloxacin, Ofloxacin

Vibrio cholerae

Doxycycline, Ciprofloxacin

TMP-SMZ

Gram Positive Rods:

Actinomyces

Penicillin G, Ampicillin

Doxycycline

Bacillus (e.g.

Anthrax)

Penicillin G,Ciprofloxacin

Erythromycin, Doxycycline

Clostridium (e.g.gas gangrene,tetanus)

Penicillin G

Clindamycin, Metronidazole,

Chloramphenicol

Corynebacteriumdiphtheriae

Erythromycin

Penicillin G, Clindamycin

Corynebacteriu

jeikeium

VancomycinCiprofloxacin, Penicillin G +

Gentamicin

Listeria

monocytogenes

Ampicillin, TMP-SMZ

Ampicllin, Aminoglycoside

Acid-Fast Rods:

Mycobacteriumtuberculosis

INH+ Rifampicin PZA+

Ethamheol

Other antituberculous drugs

Mycobacteriumleprae

Dapsone + Rifampicin +/-Clofazamine

Minocycline, Ofloxacin

Myeobecteriumkansasii

INH+ Rifampicin +

Ethambutol

Ethionamide, Cycloserine

Mycobacterium

fortuitum chelonei

Amikacin + Doxycycline

Cefoxitin, Erythromycin

Sulfonamide

Nocardiaasteroides

TMP-SMZ

Minocycline, Imipenem

Spirochetes:

Borrelia burgdorferi(Lyme disease)

Ceftriaxone, Cefuroxime,Doxycycline

High dose Penicillin G,

Amoxicillin, Cefotaxime,Clarithromycin

Borrelia recurrentis Doxycycline

Erythromycin, Penicillin G

Leptospira

Penicillin G

Doxycycline

Treponemapallidum (syphilis)

Penicillin G

Doxycycline, Ceftriaxone



Treponema

pertenue (yaws)

Penicillin G

Doxycycline

Mycoplasms

pneumoniae

Azithromycin,Clarithromycjn,Erythromycin

Doxycycline

Chlamydia psittaci

Doxycycline

Chloramphenicol

Chlamydiatrachomatis

Doxycycline or Azithromycin

Ofloxacin or Erythromycin

Chlamydiapneumonia'

Doxycycline

Erythromycin, Clarithromycin,CiproQoxacin

Rickettsiae

Doxycycline

Chloramphenicol

Notes:1. Penicillin G is preferred for parenteral injection while Penicillin V is for oral administration.

2. Aminoglycosides: Gentamicin, Tobramycin, Amikacin, Netilmicin.




Acute Renal Failure

To Nephrology PageTo Main Table of Contents


Algorithm 5-1. Management of Acute Renal Failure · Oliguria· Rule out urinary obstruction ------ > Bladder catheter · Ultrasound of Kidneys, Ureter, Urinary Bladder & Prostate· Assure good renal flow ---- > Blood volume, Cardiac output, Dopamine?· Dx: Renal Parenchymal disease (Confirm by urine electrolytes and clearance

· Diuretic trial (Furosemide 100-200 mg)o Polyuria (Dx: Some nephrons functional)

§ Continue diuretics§ Expect Azotemia§ Full nutrition

§ Intermittent hemodialysis as needed for solute clearance§ Renal recovery§ Dx: Some or all nephrons recovered

o Oliguria: (Dx: No Nephrons functional)

§ Isolate renal failure· Full nutrition

· Intermittent hemodialysis or peritoneal dialysis as needed for volume andsolute control

· Dx: Some or all nephrons recovered

§ Multiple Organ failure· Full nutrition· CAVH/CVVH for volume· CAVHD/CVVHD for solute control· Chronic Renal Failure

o Dx: No nephron recovered§ Chronic Dialysiso Dx: Some or all nephrons

Legend:CAVH: Continuous Arteriovenous Hemofiltration; CAVHD = Continuous Arteriovenous Hemodiafiltration;CVVH = Continuous Venovenous Hemofiltration; CVVHD = Continuous Venovenous Hemodiafiltration; PD= Peritoneal Dialysis Source: Bartlett, Robert (1996). Critical Care Physiology. Washington: Little, Brown and Co. Orders:

VS: Check the volume status of patient:

A. Intravascular volume. Check jugular venous pressure, postural blood pressure, heart rate and urineoutputB. Interstitial volume: Cheek skin turgor and oral mucosa

Nursing: Weigh daily; Input and Output daily; Consider foley catheter and CVP insertion,No BP taking orIV &exertion on one armIVF: NSS or DSNSS if with intravascular volume depletion, D5 0.3 NaCl if with intravascular & interstitialvolume depletionDiagnostics: CBC, Blood typing, ABG

Ca, K, Inorganic Phosphate, Na, Uric acid, PBS, RBS



BUN, Creatinine, Total Protein, albumin, Globulin

Urinalysis, Ultrasound of both kidneys, ECG, Chest X ray

Monitoring: Check BUN, Creatinine, K every 1-3 daysDaily chest x-rays if necessary (check for congestion)

Therapeutics:

A. Fluid management: WHat is the volume status of the patient?1. Normal volume: Fluid intake= urine output plus 300-500 ml/day

Na intake= 2 gm/day2. Volume overloaded: Fluid indake < urine output

Na intake < 2 gm/daya. Try loop diuretics: Furosemide 40-100 mg IV pushb. Consider Furosemide drip for 24-48 hoursc. Consider dialysis

3. Volume depleted:a. Restore volume with isotonic saline or D5'0.3 NaC1, then prescribe fluid intake = urine outputplus 300-500 ml/day and sodium intake = 2 gm/day

4. Consider CVP insertion if volume status is difficult to assess clinically5. Consider Dopamine 1 amp 200 mg+ D5W 250 cc X 10 ugtts/min (0.5-2.0 mcg/kg/min)

Note: In oliguric patients (< 400 ml/day) limit fluid intake to < 1 liter/day

B. Diet / Nutritional Support:,1. For weight maintenance: High caloric intake 35 kcal/kg/day

Low protein: 1.0-1.2 gm/kg/day if pre-hemodialysis, 1.2-1.4 gm/kg/day if on hemodialysisNaCl < 2 gram/day, Phosphorous. 600-800 mg/dayK =40 meq/day, Mg = none

2. Energy requirement (kcal/day) = Basal Metabolic Requirement (BMR) X 1.25 X Stress Factor Body Weight

(Kg)BMR(kcal)

Body Weight(Kg)

BMR(kcal/day)

50 1,300 65 1,60055 1,400 70 1,70060 1,500 80 1,800

Nature of Illness Stress

Factor Early starvation 0.85-1.00Post-operative (nocomplication)

1.00-1.05

Long bone fracture 1.15-1.30Peritonitis 1.05-1.25Cancer 1.10-1.45Severe infection or multipletrauma

1.30-1.55

Burns 10-30% 1.50

30-50% 1.75>50% 2.00

3. For weight gain Add 1,000 kcal/day for a gain of approximately 1 kg/week

C. Electrolytes:1, Hyperkalemia: See Hyperkalemia Chapter 2. Metabolic acidosis3. Hypocalcemia: Does not require intervention if asymptomatic. CaCO3 if symptomatic or if NaHCO3is being given.4. Hyperphosphatemia: CaCO3 tab, Aluminum hydroxide5. Hyperuricemia: No treatment unless with gout, e.g. Allopurinol 300 mg/day for 2 days tben 100



mg/day6. Avoid magnesium-containing antacid salt substitute NSAIDS and other nephrotoxins.

D. Adjust all drug dosages according to the Glomerular Filtration Rate E. Watch out for organ system involvement/complications:

l. Infection - Urinaryt infection, pneumonia

2. Gastrointestinal Complicationsa. Gastrointestinal bleeding secondary to. peptic ulcer disease may contribute to incease urea andpotassium loadb. Ranitidine IV is effective in preventing gastrointestinal bleddingc. Antacids: Aluminum hydroxide (Alu-tab) 600 mg 1-2 tab QIDd. No magnesium-containing antacids

3. Cardiovascular complieationsa Uremic pericarditis: a friction rub is an indication for dialysis treatmentb. Coronary artery disease may worsen

F. Indications for initiating hemodialysis1. Failure of conservative management to relieve.

a. Pulmonary congestion (unresponsive to high dose furosemide)b. Severe metabolic acidosis

c. Severe hyperkamemia2. BUN > 100mg/dl or Creatinine > 10 mg/dl

Note: For acute renal failire it is nest to dialysis early

To Nephrology PageTo Main Table of ContentsTo Detailed Table of Contents



STRATEGY POR REMOVAL OF EXCESS FLUID



Resistant edema or oliguric renal failure Salt restriction Step 1

Conventional dose o floop diuretic (e.g. Furosemide 40 mg IV bolus, Bumetanide 2mg IV) Step 2

High dose of loop diuretic by IV plus (e.g. Furosemide 20O mg IVg 6 hours) Step 3

IV, infusion,of loop diuretic (e.g. Furosemide 10-40mg/hr, Bumetanide 1-4mg/hr Step 4

High dose IV loop diuretic (as above) diluted in salt poor albumin administered over 30 minutes over 6hours Or Thiazide diuretic (Hydrochlorothiazide or Metolazone) followed 30 minutes later by high doses of loopdiuretic by IV bolus as above Step 5Ultraflltration(as isolated procedure or with dialysis) Source: Lennon, A.M., Coleman. P. &Brady H. (2000). Management and Outcome of Acute Reral Failure.In R. Johnson and J. Feehally (Eds.). Comprehensive Clinical Nephrology (p. 19.4), Hadcourt Publishers




CHRONIC RENAL FAILURETo Nephrology Page


Data:

A. Etiology: Chronic glomerulonephritis, chronic pyeloneyhritis, diabetes mellitus, polycystic kidneydisease, renovascular disease, hypertension, drugs, etc.

B. Chronic Renal Failure (CRF) Chw¿ristics:

1. Decrease glomerular filtration rate or increased creatinine for > 3 months2. Small kidney size (< 10 cm) by ultrasound, increased echogenecity and poor corticomedullarydifferentiation3. Anemia in the absent of blood loss

C. Stages of Chronic Kidney Disease:

Stage Description GFR

(ml/min/1.73^2)

1 Kidney damage with normal or inc.GFR

= 90

2 Kidney damage with mild dec. GFR 60-903 Moderate dec GFR 30-594 Severe dec. GFR 15-295 Kidney failure <15 or dialysis

D. Management of Chronic Renal Failure

1. If the patient is on dialysis: Repeat hemodialysis for symptoms of congestive heart failure, severeacidosis, uremia, precardiits, hyperkalmia etc. Continue regular dialysis.2. If patient has not been previously dialyzed check for superimposed reversible factors. Thesefactors precipitated the acute renal failure on top of chronic renal failure or chronic renalinsufficiency

Superimposed reversible factors:

a. Decreased ineffective arterial blood volume (volume depletion, worsening congestiveheart failure)b. Hypertension / hypotensionc. Infectionsd. Urinary tract obstructione. Nephrotoxic agents

3. Conservative management of chronic kidney disease if GFR > 15 ml/min.4. Prevent and correct the metabolic derangement and preserve the remaining renal function.

Orders:

Admit to:Diet: 35 Kcal/kg/day, low salt (2-4 gm sodium/day), low potassium (2-4 gm potassium/day, low phospate(600-800 mg phosphate/day), protein pre- hemodialysis or GFR < 2 ml/min is 0.6-0.75 gm/kg/day, proteinon hemodialysis is >1.2 gm/kg/day, protein post-dialysis is >1.3 gm/kg/day

VS: Vital signs q 1 hour with neurochecks refer for urine output < 20 cc/hour Nursing Weigh daily. Avoid magnesium-containing antacids, NSAIDS & otherNephrotoxinNo BP:or IV lineone armIVF: Limit total fluid intake to 1-1.5 liters/day, depending on the urine outputDiagnostics:

Ultrasounsd of kidneys (Check for etiology or renal failure always rule out obstructive cause,

check for small contracted kidneys, rule out renovascular disease)CBC(Anemia), K, Ca, TPAG, Inorganic phosphate, Lipid profile

Monitor BUN & Creatinine, Urinialysis Nuclear GFR

24-hour urine collection for quantitative and endogenous creatinine clearance (if CRI/CRF disease



is stable)Therapeutics:1. Fluid restriction

For patients with congestive heart failure, hypertension, hyponatremia or excessive weight gain.2. Acidosis:

NaHCO3 grain X 1 tab TIDaim for bicarbonate level of 24 umol.L for CRF patients.

3. Hyperkalcmia (see Hyperkakenia chapter)4. Hypertension: Treat aggressively

Use Ace-inhibitors or Angiotensin II antagonists if without contraindication.5. Hyperphosphatemia:

CaCO3 500 mg 1 tab TID to be given at the beginning of mealsMaintain serum phosphorus at 4.5-6.0 mg/dl to prevent renal osteodystrophy

6. Anemia:a: Correct iron defficiency first. Give PO or IV iron if unable to achieve transferrin saturation at25-35 % and Ferritin levels at 200-500 mg/ml.b. Erythropoietin 50-150 units/kg SC 1-3X/week to maintain hematocrit of 32-38.

7. Symptomatic Hyperuricemia Give Allopurinol 100 mg 1 tab OD8. Hypocalcemia: Calcitriol (Rocaltrol) tab or CaCO3 tab TID9. Vitamins Multivitamins tab OD, Vitamin C sparingly10. Other Options: Ketoanalogues (Ketosteril) 600 mg 1-4 tabs TID

Note: Adjust all drug dosages according to Glomerular Filtration Rate.




HYPOKALEMIATo Nephrology Page


Data:

A. Etiology: Diarrhea, laxative abuse use diuretics vomiting, check for hypertension (hyperaldosteronism orglucocorticoid excess), renal tubular acidosis, polymyositis, hypokalemic peroidic paralysis. B. Principles of Management of Hypokalemia:,

1. The clinical context dictates the need for therapy of hypokalemia. Hypokelemia per se does notnecessarily justify treatment with potassium supplements or potassium sparing diuretics.2. Assess the etiology (redistribution versus deficit) of the hypokalemia.3. Assess and correct acid-base balance and extracellular fluid volume abnormalities.4. Assess the level of renal function5. Assess and correct serum tonicity and serum magnesium, if needed.6. Normokalemia or hypokamia in a context of metabolic acidosis or serum hypertonicity oftenindicates potassium deficits.7. Potassium-sparing diuretics should not be used in patients at risk (patients with decreased renalfunction or patients receiving drugs impeding potassium homeostasis).

8. Only resistant hypokalmia justifies the use of two simultaneous treatment modalities ofhypokalemia.9. Assess the potential attribution of medications to hypokalemia and the underlying pathophysiologycausative of hypokalemia and correct whenever possible.10. Evaluate concurrent medications and/or existing clinical conditions that may aggravate theconscqueneps, of hypokalemia11. Discontinue treatment of hypokaiemia whneever concentration is about 3.5-4.0 meq/l for fear of"overshoot" hyperkalemia or until a pattern of response is clearly established.12. Whenever treating hypokalemia, follow the response to treatment by serial measurements ofserum potassium concentration and if indicated, acid-base status.13. The oral route of potassium replacement, using potassium chloride, is the safest andthe preferred modality of treatment. The intravenous route of therapy should be reserved forextreme situations.

C. Estimation of Potassium Deficit:

1. For a fall in serum potassium from 4.0 to 3,0 meq/l body potassium deficit is 200-3000meq/70kg body weight

2. For serum potassium at 2.5 meq/L body deficit is 500 meq/70 kg body weight3. For serum potassium at 2.0 meq/L body deficit is 700 meq/70 kg body weight

Orders:

Diagnostics: CBC, Serum K, repeat Serum K in 2-3 days

Na, Ca, Mg, ABG

Urine K, Urinalysis

Therapeutics:

1. The oral route of administration is the safest and preferred mode of potassium replacement. Oralpotassium should be given preferably as liquid with or after meals, or as tablet, which must be swallowedand not allowed to dissolve in the mouth; Dose depends on the clinical situation and the estimated deficit.

e.g. Per Orem: Kalium durule 0.75gm (10 meq) TlD PO X 2-3 daysor Oral KCl Solution 15-30 cc TID (1 gm KC1 = 14 meq K+) to be further diluted in oral feeding or

water.Note: Each oral dose should not exceed 20-40 meq K+

2. When potassium is provided by the intravenous route the use of peripheral vein is preferred over a



central route. The maximum rate at which potassium can be safely given into peripheral veins is usually10-20 meq/hour. Higer rate maybe administeres if the clinical situation warrants more rapid correction ofthe hypokalemia. Usual concentration is 20-40 meq potassium in 1 liter of saline or dextrose solution. Onemust be aware of a decrement in serum potassium of about 0.2-1.4 meq/liter when potassium isadministered glucose solute.

e.g. Intravenous: Add 20-60 meq KCl in Plain NSS X 12 hours

If potassium level is < 2 and (+) ECG abnormalities use glucose-free solution. When fluidrestriction is necessary, up to 20 meq per 100 ml can be cautiously given over 1 hour via amicrodrip. Higher concentrations of KCI may cause skin burns.

3. In the setting of severe hypokalemia, potassium can be delivered into the femoral vein with the tip of the

catheter not in dose proximity to the heart The rate of administration should not exceed 60 meq/hour.




HYPERKALEMIATo Nephrology Page


Data:

General Approach to the Management of Severe Hyperkalemia A. Determination of severity

1. Serum potassium and the acuteness and rate of its rise2. Clinics manifestatioas – ECG changes, cardiovascular, neuromuscular

B. When possible, rapid determination of etiology

1. Inadequate renal excretion from renal failure with oliguria2. Drugs that inhibit Renin-Angiotensin-Aldosterone system such as Beta-blockers,

ACE-inhibitors, or NSAIDs

C. Immediate discontinuation of all sources of potassium intake and agents that affect potassiumhomeostasis.

D. Reversal of membreane abnormalities: Emergency treatment1. Calcium gluconate2. Hypertonic NaCl to yponatremic patients 3% NaCl or 50 ml sodium bicarbonate to 1 liter of NSS

E. Redistribution of potassium from the extracellular space to the intrracellular space

1. Sodium bicarbonate IV2. Insulin and glucose3. Stimulation of Beta-2 adrenorcceptors (Salbutamol nebulization)

F. External removal of potassium

l. In stools: Cation exchange resin (Kayexelate or Sorbisterit)2. In urine Increase urine flow rate and distal tubular delivery of sodium (loop diuretic: FurosemideIV bolus 70-80 mg)3. By dialysis: Homodialysis or peritoneal dialysis

Orders:

Diagnostics: CBC Serum K, BUN, Creatinine, ECG-12 lead Therapeutics:

A. Creatinine normal and not oliguric1. Recheck serum potassium2. Stop drugs which increase potassium (Beta-blockers ACE-inhibitors, NSAID)3. Check other etiology of hyperkalemia

B. Creatinlne increased and/or oliguria1. Mild hyperkalemia (potassium level < 5.5 mmol/L): Restrict potassium intake; stop culprit drugs2. Moderate hyperkalemia (potassium level = 5.5-6.5 mmo/L):

a. Kayexelate or Sorbisterit 20 grams in 150 cc juice TID x 3 doses only (up to 4-5 doses/day)

b. Diuretics: Furosemide 40-80 mg IV stat dosec. Optional: Beta -agonist (Salbutamol) nebulization

3. Severe hyperkalemia (potassium, level > 6.5 mmol.L) and/or (+) ECG changes: Mnemonic: G C S- Glucose, Calsium, gluconate & Sodium bicarbonate

a. Calcium gluconate 10 ml 1 amp in 10% solution slow IV push in 5 minutes (at 2 ml/min) ifwith ECG changes. Repeat after 10 minutes if no improvement..b. Glucose-Insulin:

i. 50 ml of 50 % dextrose in water plus 10 units insulin in 2-5 minutese.g. Mix D50-50 ml. + 10 units Humulin R slow IV stat then q 6 hours x 3 dogesor ii. 500 ml of 10% dextrose 10 units insulin over 30-60 minutes (if volume overload is



not a problem)or iii. 1000 ml of 10% dextrose + 20 units insulin with one-third of the solution given in thefirst 30 minutes and the remainder over the subsequent 2-3 hours.

Note: Method(a) can be repeated, if necessary, or can be followed by either (b) or (c). Thelatter 2 techniques lend themselves nicely to the additional maneuver of adding sodiumbicarbonate (50-100 meq/L) to the dextrose solution. Potassium shift occurs in 30 minutes

but benefits last for several hours. It is the best way to decrease potassium.

c. Sodium Bicarbonate 1 amp slow IV push in 10 minutes Potassium shift occurs in < 15minutes, with duration of 1-2 hours; this is the fastest way to decrease potassium.d. Beta-2 agonist :Albuterol (5 mg/ml) 20 mg by inhalation over 10 minutes. Onset of action is15-30 minutes.

4. Prepare patient for dialysis if with renal failure or unresponsive to above measures.




HYPOCALCEMIATo Nephrology Page


Data:

A. Etiology: Hypoalbuminemia, chronic renal failure, hypoparathyroidism (decreased PTH), acutehyperphosphatemia, hypermagnesemia, vitamin D defeciency, acute pancreatitis, sepsis, burns,multiple extracted blood transfusionNote: Fifty percent of ICU patients have calcium levels < 2.1 mmol/L (8.5 mg/dl but only 40% havedecreased ionized calcium. To determine if true hypocalcemia is present add 0.8 mg/dl to serumcalcium for every 1 gm/dl decrease of serum albumin below 4 gm/dl.

B. Symptoms: Tetany, Trosseau's sign, Chvostek's sign, depression, lethargy, rarely seizures Orders

VS: Vital signs q 1 hour, neurocheck q 4 hoursWatch out for signs of tetany or abnormal mental status

Nursing: Ambulate often Input and Output q shift; weigh daily; seizure precautionsDiet: No salt addedDiagnostics: CBC, serum Ca,Mg, TPAG, Creatinine, PTH (increased)

Serum Phosphorus (decreased in Vitamiri0 deficiency)ECG(long QT), Urinalysis ABG

Therapeutics:Treatment of Symptomatic Hypocalcemia:1. Correct for hypoalbuminemia: A fall in serum albumin of 1 gm/dl is associated with a fall of 0.8 mg/dl intotal calcium.For example: Present (total calcium = 8 mg/dl

Present serum albumin 2.5 gm/dlNormal serum albumin = 4.0 gm/dlCorrection = (4.0-2.5) x (0.8)

= 1.2Corrected total calcium = (8 +12) mg /dl

= 9.2 mg/dl2. Sodium gluconate 10% solution of 10ml/amp: 1-2 amp slow IV push (in 10-15 rninutes) with cardiacmonitoring then incorporate 1 amp Calcium gluconate to present 1V fluids3. Chronic treatment of hypocalcemia

a. Calcium Carbonate (Calci--Aid, Calsan 500 kg 1 tab BID-TIDb. Vitamin D3 supplements: Calcitriol 0.25 mcg cap OD-BID (Dose: 0.5-1..0 mcg/day)

4. Treat hypomagnesemia5. Patients with severe or recurrent symptoms have a continuous infusion of dextrose solution containingan elemental calcium concentration of 15 mg/liter over 4-6 hours Note: Calcium + Sodium Bicarbonate are not compatible IV mixtures




HYPERCALCEMIATo Nephrology Page


Data:

A. Etiology: Ninety percent me due to hyperthyroidism (increased PTH) or malignancy (normal PTH)B. Symptoms: Most own dehydrated, anorexia, nausea, vomiting, constipation, weakness, confusion tostupor C. Complications: Nephrolithiasis, obstructive renal failure Orders:

Diet: Restrict calcium to 400 mg/day; Push oral fluids; 4-8 grams of salt pet dayDiagnostics: CBC, Serum Ca, Na, Mg, Serum PTH levels

TPAG, Creatinine

Chest X-ray, ECG, Mammogram, Renal ultrasound

Therapeutics:1. Hydrate patient;

Give 0.9% NSS at 150-600 cc/hour until no longer hypotensive; up to 1-4 Liters in 24 hours

Note:, Severely hypercaloemic patients are almost always dehydrated.2. Saline diuresis with 0.9% or 0.45% saline infused at 300-600 cc/hr to replace urine, loss3. Consider Furosemide 20-40 mg IV q 8-12 hours after volume repletion. And if necessary. to preventcongestive heart failure, maintain urine output at 100-500 ml/hour. Avoid Thiazide diuretics.4. Measure and replace serum sodium, potassium, magnesium5. Other treatment options:

a. For bone metastasis: Hydrocortisone 5 mg/kg IV q 8 hours then Prednisone 20-50 mg PO BID.Reduce dosage in 10 days as serum calcium decreases.b. Calcitonin salmon (Miacalcic) 50-100 iu SQ or IM OD-BIDc. Biphosphonates (avoid in patients with renal failure)

Pamidronate(Aredia) 30-90 mg/day given as a single 24-hour infusion for 3 days.

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HYPONATREMIATo Nephrology Page


Data:

Algorithm 5-2. Clinical Approach to Hyponatremia

· Decreased Na < 135 meq/liter · Plasma Osmolality = [2(na)] + BUN(mmol/L) + Glucose(mmol/L)

o Normal (280-295 mosm/kg H2O – check for hyperlipidemia (lipid profile) or hyperproteinemiaas (TPAG) in multiple myeloma

o High (>295 mosm.kg H2O) – etiology: check for hyperglycemia, mannitol treatmento Low (<280) – assess ECF volume

§ A. Dec Total Body Water (Dry: BUN/Crea ratio >15)· Urine Na >20 mg/Lo Renal Loss, RTA diuresis, Adrenal insufficiency, ketonuriao Tx: Isotonic Saline· Urine Na < 10 mg/L

o 3rd space loss, GI losso Tx: Isotonic Saline

§ B. Euvolemia (no edema)· Urine Na >20 mg/Lo SIADH (lung, CNS dse., drugs), hypothyroidism, renal failure, Addison’s dse.,

stress, drugs· Urine Na <10 mg/Lo Polydipsia, water intoxication

§ Inc. Total body water, (+) edema· Urine Na >20 mg/Lo ARF, CRFo Tx: Water restriction· Urine Na <10 mg/Lo CHF, liver cirrhosis, nephritic syndromeo Tx: Water restriction

Note: SIADH-Syndrome of Inappropriate Antidiuretic Secretion, RTA-Renal Tubular Acidosis,ECF-Extracellular Fluid, Na-Sodium, BUN- Blood Urea Nitrogen, TPAG- Total Protein Albumin andGlobulin Source: Adapted from Singer, G. &, Breener, B. (2001). Fluid and Electrolyte Disturbances. In BraunwaldF Fauci A, Kasper D, et al (Eds.), Harrison's Principles of Internal Medicine (pp. 274-76). New York:McGraw-Hill, Inc., with permission. Orders:

Admit to:VS: Vital Signs q 2 hours, Check neurologic status, Call MD in case of seizure or any change in neurologicstatusNursing: Seizure precautions, weigh patient dailyDiagnostics: CBC, Serum Na, BUN, Creatinine

RBS( per every increase of 100 mg/dl serum glucose above 100 mg/dl serum sodium will

decease by 1.6 meq/liter)Urinalysis with specific gravity, Urine Na

Therapeutics:

A. DecreasedTotal Body Water (Hypovolemia)l. If volume depleted 0.9 NaCl (154 meq/L), calculate sodium deficit2. Calculate sodium deficit:

a. Target Sodium = 125-135 meq/L (130 meq/L)



b, Sodium deficit 0.6 X weight in Kg X (desired Na - actual Na)c. Correct at a rate not > 0.5 meq/liter/hour Give the patient 50% of calculated amount of sodium in the first 8 hours and the other 50% in inthe next 16 hours. or May also give NaCl l-2 tabs TID-QIO depending on the requirementd. Avoid sudden overcorrection because of the danger of CPM (Central Pontine Myelinosis)e. Use normal saline Do not give hypotonic fluids until serum sodium is more than 125 mg/L

3. Correct potassium deficit also

B. Euvolemia: (e.g. SIADH- Syndrome of Inappropriate Antidiuretic Secretion)1. Acute treatment for symptomatic patients (Na < 120 meq/L)

a. PNSS 1 L X 10 hours+ 20 meq/KClb. High salt of 8 gm NaCl/day for isotonic oral intake of 1 liter water (1 grn NaCl = 17 rneq ofsodium)c. Furosemide 20-40 mg PO or IV OD-BID

2. Chronic treatment: Restrict water to 1-1.2 L/day, Keep sodium levels > 120 meq/LC. Inc. Total Body Water (edematous states)

1. Restrict water according to loss (aim for negative balance)2. Salt restriction of 2 gm/day of sodium or less3. Consider diuresis with loop diuretics (Furosemide or Bumetanide)

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HYPOMAGNESEMIATo Nephrology Page


Data:

A. Etiology: Diarrhea, nasogastric tube insertion, pancreatitis, endocrine disorders hypercalcemia use ofloop diuretics, aminoglycosides, alcoholism, amphotericinB. Signs and Symptoms: Lethargy, tetany, weakness anorexia, nausea, vomiting cardiac arrhythmias

especially in patients on digoxin Orders:

Diet: Increase magnesium-containing foods, e.g. seeds, nuts, peas, beansVS: Vital signs q 2 hours; hold digoxinNursing: Monitor deep tendon reflexes (hyporeflexia suggests hypermagnesemia)Diagnostics: CBC, Serum Mg, Ca, K, Creatinine, Amylase, PTH .

ECG,Urine Mg (for those with unclear etiology)

Therapeutics:1. Treat the underlying cause

2. For symptomatic patients or serums Mg < 1 mg % give IV Mga. Day 1: Give 48.6 meq (6 grams) in 1 liter IV fluid over 4 hours followed by 2 liters (48.6 meq each)over the remaining 24 hoursb. Day 2-5: Give 48.6 meq (6 grams) over 24 hours dailyPreparation: MgSO4 250 mg/ml in 10 cc amp or 2.5 gm per 10 cc amp e.g. Give 1-2 gm MgSO4 IVover 15 minutes

3. Far asymptomatic or serum Mg between 1.1-1.4 mg/dl give oral Mga. Milk of Magnesia (13-15 meq/5 ml) 5 ml PO OD-QID




HYPERMAGNESEMIATo Nephrology Page


Data:

A. Etiology: Chronic renal failure, antacids intake, laxatives, IV magnesiumB. Signs and Symptoms: Nausea, weakness, paralysis, respiratory failure, decrease deep tendon reflexes,hypotension, bradycardia, hypocalcemia Orders:

VS: Vital signs q 2 hoursNursing: Input & Output q 2 hours; Check deep tendon reflexesDiagnostics: CBC Serum Mg, Calcium, Creatinine

ECG(check QRS > 0.14 m/sec or long QT)

Therapeutics:l. In patients without chronic renal failure: Saline diuresis with NSS at 100-200 cc/hr to promotemagnesium excretion2. Symptomatic patient with increased Mg levels:

a. Calcium gluconate 10% solution: 1-2 amps IV in 10-15 minutes

b. Furosemide 20-40 mg IV q 8 hoursc. Stat hemodialysis for Mg > 9.0 mg/dl




NEPHROLITHIASISTo Nephrology Page


Data:

A. Predisposing factors: (1) poor fluid intake, (2) exposure to hot and humid weather, and (3) diet high insalt,: protein and calciumB. Five types of stones: Clacium oxalate, calcium phosphate, struvite uric acid or cysteine stones.

Calcium stones are radiopaque and the most common (85%)C. Clinical Course: Stones less than 6 mm usually pass out spontaneously. Orders:

Admit to:Diet: Regular, low salt, low proteins intake preferred

Give 2-3 liters fluids/day (maintain urine output of 2000 ml/day)Restrict calcium to 400-600 mg/day (if absorptive hypercalciuria)

VS: Vital signs q 4 hours; call MD if urine output < 30 cc/hr Nursing: Strain all urine; Input & Output q shift, Consider foley catheter insertion if no urine output in 4hoursIVF: D5NM X 8 hours (3 liters/day)Diagnostics: CBC, BUN, Creatinine

Serum K, Calcium Uric acid, Phosphate

Urinalysis, Urine culture and sensitivity

Urine pH (pH < 5.5 = uric acid and cystine stones; pH > 7.5 = struvite)

KUB X-ray (Calcium stones are radiopaque; Uric acid and cysteine stones are

radioluscent)Ultrasound of the Kidneys and Bladder then KUB-IVP if BUN and Creatinine are normal

For recurrent stone-formers: 24-hour urine collection for volume, pH, calcium, uric acid,oxalate, phosphorous, and citrate excretionSend stones for X-ray Crystallography

Therapeutics:1. Pain Relievers: Meperidine (Demerol) 50-100 mg IM q 4 hours pm or Morphine or Acetaminophen

with codeine or Mefenamic Acid (Ponstan) 500 mg cap q 6 hours2. Antispasmodics: Hyoscine-N-butylbromide (Buscopan) 10 mg 1-2 tab 3-5 X/day3. Optional: Rowatinex 1-2 caps TID4. Refer to surgery if stones are > 10 mm in size or if there is severe pain unresponsive to medications,

fever, persistent nausea and vomiting, serious bleeding, ureteral dilatation or obstruction.

Prevention:l. Increase fluid intake to 8-12 glasses per day.




DIALYSISTo Nephrology Page


A. Dialysis Indications: When to start dialysis

1. Subjective symptoms of uremia2. Creatinine clearance of 10 ml/min for non diabetics or 10-20 ml/min for diabetics3. Pulmonary edema, severe hypekalemia or metabolic acidosis

B. Absolute Contraindications to Dialysis:1. Hemodialysis: No vascular access possible2. Peritoneal Dialysis:

a.. Loss of peritoneal function producing inadequate clearanceb. Adhesions blocking dialysis flowc. Surgically uncorrectable abdominal herniad. Abdominal wall stomae. Diaphragmatic fluid leakf. Inability to perform exchanges

C. Acute Hemodialysis (HD) Prescriptions

1. Session length: 2 hours‘(or post hemodialysis BUN of approximately 70% of pre- hemodialysis

BUN)2. Blood flow rate: 200 ml/min3. Dialysis solution: Bicarbonate dialysis4. Fluid removal orders: Remove 2.2 liters at a comstant rate (May do initial fluid ultrafiltration forpulmonary congestion or pulmonary edema5. Anticoaguhtion orders:

a. Routine heparin prescription: 2000 units initially then heprain infusion into the arterial line at1000 units per hour b. Heparin free prescription:

i. Heparin rinse: Rinse dialyzer Wth NSS 1 liter plus 3000 units heparin then flush withunheparinized saline or patient’s bloodii. High blood flow rate: 250-300 million if tolerated. Periodic saline rinse: 100-250 salinewhile occluding the blood inlet line every 15-30 minutes. Adjust the ultrafiltration wee toremove the excess fluid.

c. Low molecular weight heparins6. Common complications during dialysis

a Hypotensioni. Place patient in Trendelenberg positionii. Saline bolus (100 cc or more) through the venous blood line or 10-20 cc hypertonic salinebolusiii. Reduce ultrafiltration rate to zeroiv. Oxygen inhalation if necessary

b. Muscle crampsi. Usually occurs in association with hypotension (Give above measures)ii. Hypertonic saline or hypertonic glucose bolus

D. Acute Peritoneal Dialysis (PD) Prescription:

1. Check abdomen for abdominal masses & previous surgeries. Opt for open insertion if the above

are present2,.; Procedure for Insertion of the Catheter.

a The stylocatheter is to be inserted within 1 cm below the umbilicus at the midline.b. Properly disinfect the skin, especially the umbilicusc. Inject local anesthesia (Xylocaine 2%) up to the peritoneal fasciad. Stab skin with a scalpel blade no. 11 then insert catheter together with the stylet undercontrolled pressuree. Entryinto the peritoneum is made when a “give’” is felt. Withdraw the stylet for a few millimetersand direct the blunt catheter into the right lower quadrant.f. Connect the catheter to the administration set.



3. Peritoneal Dialysis Ordersa. Use 1.5 % dialyzing solution (Inpersol); may use 2.5 % or 4.25 % for poor drainageb. Use 1 liter for the first few exchanges then shift to 1.5 to 2.0 liters if toleratedc. One exchange time usually involves the following:

Infusion time = 5-10 minutesDwell time = 20-30 minutesDrain time = maximum of 30 minutes

d. For fluid removal, use a more hypertonic solution, e.g. 4.5% dialyzing solutione. For solute removal, use a larger volume of dialyzing solutionf. For poor drainage, try the following maneuvers:

i. Change position of the patientii. Incorporate heparin 500-1000 units per liter of dialyzing solution if without bleedingproblemsiii. Use a hypertonic solutioniv. If above maneuvers fail, reinsert catheter

g. Oral potassium supplements if serum potassium is < 4 meq/L.h. Shift to Tenckhoff catheter after 72 hours, if kidney failure is not reversible.i. Record fluid balance accurately in a separate sheet.

To Nephrology Page




DOSAGE ADJUSTMENTS OF DRUGS IN RENAL FAILURE


To Detailed Table of ContentsNote:

R= Renal; HD= Hemodialysis; PD=Peritoneal Dialysis; H=Hepatic; N=None; A=should be avoided;?=uncertain status Drug Route of

Elimination Adjusted Dosing Interval (hr) or Dose % for

GFR (ml/min)Supplement After

Dialysis

>50 10-50 <10

Aminoglycosides

Amikacin R 12 12-18 24-48 HD,PD

Gentamicin R 8-12 12 24-48 HD,PD

Netilmicin R 8-12 12 24-48 HD,PD

Tobramycin R 8-12 12 24-48 HD,PD

Streptomycin 24 24-72 72-96 HD,PD

Penicillins

Amoxicillin 8 8-12 24 HD,PD

Co-Amoxiclav R,H 8 8-12 12-24 HD

Ampicillin R,H 6 6-12 12-24 HD

Oxacillin R,H N N N N

Penicillin G R,H N 75% 20-50% HD

Piperacllin-Tazobactam R,H 6 8 12 HD

Macrolides

Clarithromycin R,H N 75% 50-75% N

Erythromycin H N N 50-75% N

Cephalosporins

Cefamandole R 6 6-8 8-12 HD

Cefalotin R 6 6-8 12 HD,PD

Cefazolin R 8 12 24-48 HD

Cefepime R 12 24 25%q24h HD

Cefixime R 12-24 75% 50% N

Cefoperazone H N N N N

Cefotaxime R,H 8-12 12-24 24 HD

Cefoxitin R 8 8-12 24-48 HD

Cefprozil R 12 16 24 HD

Ceftazidime R 8-12 24-48 48-72 HD

Ceftibuten R 24 50% 25% HD

Ceftizoxime R 8-12 36-48 48-72 HD

Ceftriaxone R,H N N 24 N

Cefuroxime R 8 8-12 24 HD

Cephalexin R 6 6 8-12 HD,PD

Cephradine R 6 50%Q6h 25%q8-12h HD,PD

Fluoroquinolones

Ciprofloxacin R N 12-24 24 N

Gatifloxacin 400mgq24h 200mgq24h 200mg

q24h

HD,PD

Levofloxacin R 8-12 24 48 N

Lomefloxacine R N 75% 50% N

Norfloxacin R N 12-24 A N

Ofloxacin R N 12-24 24 N

Sparfloxacin R N 50% q48h 50%q48h ?

Carbapenem Antibiotics

Imipenem R N 50% 25% HD

Meropenem R 8 50%q12h 50%q24h HD

Other Antibiotic Agents



Azithromycin H N N N N

Aztreonam R N 50-75% 25% HD,PD

Chloramphenicol R,H N N N N

Clindamycin H N N N N

Doxycycline R,H 12 12-18 18-24 N

Metronidazole R,H N N 50% HD

Minocycline H N N N N

Sulfamethoxazole ' R,H 12 18 24 HDTetraacycline R,H 12 12-24 24 N

Trimethorpim R,H 12 18 24 HD

Vancomycin (IV) R 24-72 72-240 4-7 days N

Antifungal Agents

Amphotericin B N 24 24 24-48 N

Fluconazole R,H 24 24-48 48-72 HD

Flucytosine R 12 24 24-48 HD,PD

Itraconazole H,R N N 50% N

Ketoconazole H N N N N

Miconazole H N N N N

Terbinafine R,H N ? ? ?

Antimycobacterial Agents

Ethambutol R 24 24-36 48 HD,PD

Isoniazid H,R N N N HD,PD

Pyrazinamide H,R 24 24 24 HD,PD

Rifampicin H 24 24-48 48 N,PD

Antiviral Agent

Acyclovir (IV) R 6-8 24 48 HD

Acyclovir (PO) R N 12-24 24 HD

Amantidine R 24-48 48-72 7 days N

Gangcyclovir R 12 24 3X/week HD

Indinavir RH,R 8 ? ? ?

Lamivudine R 12 24 33%q24hr ?

Nelfinavir H N N N ?

Valacyclovir R 8 12-24 50%q24h HD

Zalcitabine R 8 12 24 ?

Zidovudine H 8 or 12 8 or 12 8 HD

NSAIDS

Acetaminophen H 4 6 8 HD

Aspirin H,R 4 4-6 A HD

Diclofenac H N N N N

Ibuprofen H N N N N

Indomethacin H,R N N N N

Ketoprofen H N N N N

Ketorolac (IM) H,R N N 50% N

Naproxen H N N N N

Nebumetone H N N N N

Piroxicam H N N N N

Sulindac H,R N N 50% N

Tramadol H,R N 12 12 N

Opiod Analgesic Drug

Codeine H N 75% 50% N

Meperidine H N 75% 50% N

Morphine H N 75% 50% N

Antihypertensive Drug

Clonidine R N N N N

Doxazosin H N N N N

Hydralaine (PO) H 8 8 8-16 N

Losartan H N N N N

Methyldopa R,H 8 8-12 12-24 HD,PD



Prazosin H,R N N N N

Terazosin R N N N N

Valsartan R,H N N ? ?

Angiotensin-Converting Enzyme Inhibitors

Benazepril H,R N 75% 50% N

Captopril R,H N N 50% HD

Enalapiil R N 75% 50% HD

Fosinopril H N N N NLisinipril R N 50% 25% HD

Moexipril R,H N 50% 50% ?

Quinapril H,R N 75% 50% N

Ramipril R,H N 50% 50% HD

Trandolarpil R,H N 25-50% A N

Beta-Andrenergic Antagonist

Atenolol R N 50% 25% HD

Betaxolol H,R N N 50% N

Carvedilol H N N N N

Metoprolol H N N N HD

Niadolol R N 50% 25% HD

Pindolol R,H N N N ?

Propranolol H N N N N

Calcium Channel Antagonist

Amlodipine H N N N N

Diltiazem H N N N N

Felodipine H N N N N

Isradipine H N N N N

Nicardipine H N N N N

Nifedipine H N N N N

Verapamil H N N 50-75% N

Diuretics

Acetazolamide R 6 12 A

Bumetanide R,H N N N

Furosemide R N N N

Indapamide H N N N

Spiranolactone R 6-12 12-24 A

Thiazide R N N A

Antiarrhythmic Drug

Adenosine N N N N

Amiodarone H N N N N

Digoxin R 24 36 48 N

Flecainide R,H N 50% 50% N

Lidocaine H,R N N N N

Propafenone H N N 50-75% N

Quinidine H N N N HD,PD

Sotalol R N 30% 15% N

Sedative Drugs

Alprazolam H N N N N

Chlordiazepoxide H N N 50% N

Diazepam H N N N N

Lorazepam H N N N N

Midazolam H N N 50% N

Zolpidem H N ? ? N

Antidepressant Drugs

Amitriptyline H N N N N

Fluoxetine H N N N N

Imipramine H N N N N

Nortriptyline H N N N N

Paroxetine H N ? ? ?



Sertraline H ? ? ? ?

Venflaxine H N 75% 50% N

Other Psychoactive Drug

Chlorpromazine H N N N N

Haloperidol H N N N N

Lithium R N 50-75% 25-50% HD, PD

Anticonvulsant Drugs

Carbamezapine H,R N N 75% NEthosuximide H,R N N 75% HD

Phenobarbital H,R N N 12-16 HD,PD

Phenytoin H N N N N

Primidone H,R 8 8-12 12-24 HD

Valproic acid H N N 75% N

Gastrointestinal Drugs

Cimetidine R 6 8 12 N

Cisapride H N N N N

Famotidine R,H N N 50% ?

Metoclopromide R,H N 75% 50% N

Misoprostol R N N N N

Nizatidine H N 24 48 N

Omeprazole H N N N ?

Ranitidine R N 18-24 24 HD

Sucralfate N N N N N

Antilipidemic Drugs

Cholestyramine N N N N N

Clofibrate H 6-12 12-24 24-48 N

Fluvastatin H N N ? N

Gemfibrozil R,H N 50% 25% N

Lovastatin H N N N N

Pravastatin R,H N N 50% N

Simvastatin H N N 50% N

Hypoglycemic Drugs

Chlorpropamide ? 24-36 A A N

Glipizide H,R N N N N

Glibenclamide H,R N A A N

Insulin H N 75% 50% N

Metformin R A A A N

Troglitazone H,R N N N ?

Anticoagulant Drugs

Dalteparin R N N N N

Enoxaparin R N N N N

Heparin H N N N N

Warfarin H N N N N

Other Drugs

Alendronate R N A A ?

Allopurinol R N 50% 10-25% ?

Colchicine (PO) R,H N N 50% N

Dipyridamole H N N N ?

Finasteride H,R N N N N

Glucocorticoids H N N N ?

Nitrates H N N N N

Pentoxifylline H N N N N

Terbutaline H,R N 50% A ?

Theophylline H N N N HD,PD

Ticlopidine H N N N ?

Antihistamines

Cetirizine H,R N 50% 50% ?

Fexofenadine H,R N 24 24 ?



Note:

R= Renal; HD= Hemodialysis; PD=Peritoneal Dialysis; H=Hepatic; N=None; A=should be avoided;?=uncertain status Sources:

Gilbert, DN, Moellering, RC & Sande, MA (2000). The Sanford Guide to Anrimicrobial Therapy. VT,USA:Antimicrobial Therapy, Inc.Catey, CF, Lee HH & Woeltje, KF (Eds.). (1998). The Washington Manual of Medical Therapeutics.Philadelphia:Lippincott Williams & Wilkins.




APPROACH TO TYPE II DIABETES

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1. Etiology a. Insulin resistance

b. Decreased insulin secretion2. Pathophysiology

Table 6-1 Pathophysiology of Diabetes Mellitus

FBS 2-hour-postprandial

InsulinResistance

InsulinSecretion

Treatment

Phase1

Normal NormalOGTT

Increased Increased None

Phase2

Normal Increased MarkedlyIncreased

Increased Diet,Glucosidase

inhibitor,Metformin

Phase3

Increased Increased Increased Decreased Oralhypoglycemics

3. Diagnosis of Diabetes: Based on 2004 ADA Recommendation

a. FBS > 126 mg/dl (7.0 mmol/L) on two separate occasions;b. Following ingestion of 75 gm of glucose: Blood sugar > 11.1 mmol/L (200 mg/dl) at 2 hourspost-prandial and at least one other occasion.Note: Normal Fasting Blood Sugar is < 100 mg/dl (< 5.6 mmol/L)Impaired Fasting Glucose is 100-125 mg/dl (5.6 – 6.9 mmol/L)

4. Goals of Treatment:

a. Hemoglobin A1C < 7%b. Fasting Blood Sugar between 5.0-7.2 mmol/L (90 -130 mg/dl)

c. Peak post-prandial glucose < 10 mmol/L (180 mg/dl)5. Diabetic Management:

A. Non-pharmacologic (Step 1)1. Diabetic Diet (see Nutrition chapter)

Ideal Body Weight = [(Height in inches X 2.54) - 100] - 10% (if female)Ideal Body Weight X 35 cal/Kg = Total calories/daySample: Total calories = 2000 cal/day60% Carbohydrate: Total cal/day X 0.60 = 1200 cal /4 = 300gm carbo220% Protein: Total cal/day X 0.20 = 400 cal / 4 = 100 gm protein20% Fat: Total cal/day X 0.20 = 400 cal / 9 = 45 gm fat

2. Exercise regularly.3. Weight reduction for overweight patients.

B. Pharmacologic (Step 2): Oral Hypoglycemic Agents

Sample Treatment for Type II Diabetes Mellitus

Step 1: Non-pharmacologic treatmeat: Diet, exercise, weight reduction

Step 2: Oral Hypoglycemic Agents

a Start with Sulfonylareas:e.g. Start older patients with Glipizide (Minidiab) and younger patients with GlibenclamideBegin with low doses then maximize dose if blood glucose is uncontrolled Target FBS of =140 mg/dl. Adjust dose every 2 - 4 weeks.

-/+ b. Add Biguanides if still uncontrolled with Sulfonylureas: e.g. Metformin 500 mg tab TID



-/+ c. Add Alpha-glucosidase inhibitor if with post-prandial hyperglycemia: e.g. Acarbose

(Glucobay) 50-100 mg tab TID w/ first mouthful of food.+ d. Add Thiazolinediones (insulin Seasitizers): e.g. Rosiglitazone (Avandia ) 4 - 8 mg tab OD

Step 3: Shift to Insulin treatment if still uncontrolled with oral hypoglycemic agents

Table 6-2 Oral Hypoglyemic Agent: Types and Characteristics.

OHA Type Peak

LevelDurations Indication Side Effects (SE) Ave. Dose

(mg/day)Primary

Mechanism

1. SUa Glipizide (Minidiab)2.5, 5 mg tab

1-3hr 15hr Short acting

Older Diabetics(Type 2)

Hypoglycemia 2.25mg tabBID-TID 30

mins AC(beforemeals)

Max:40mg/day

Increaseinsulin

secretion

b. Gliclazide (RitemedGliclazide) 80 m tab

2hr 18hr Intermediate

Older Diabetics Hypoglycemia 80 mg tabBID-TID with

foodMax:320mg/day

Increaseinsulin

secretion

c.Glibenclamide(HovidGlibenclamide (=),

Euglucon

4hr 24hr Intermediate

YoungerDiabetics

Hypoglycemia 2.5-5 mg tabOD-BID with

food

Max:20mg/day

Increaseinsulin

secretion

d.Glimepiride(Solosa)1,2, 3 mg tab

24hr Intermediate

Hypoglycemia 1,2,3 mg tabOD with foodMax:8mg/day

IncreaseInsulin

secretion

e. Chlorpropamide(Diabinese) 250 mgtab

4hr 60hr Long-acting

Difficult tocontrol

diabetics,Patients with

poorcompliance

Hypoglycemia,Steven-Johnson’s,

HyponatremiaCI:Renal andHepatic Failure

250mg OD ina.m. with food

Max:500mg/day

Decreasehepaticglucoseoutput

2.Biguanides:Metformin(Neoform (=500 mgtab) (Gucophage 500,850mg tab)

7-12hr Overweightpatients with

insulinresistance

CI: Renal failure,liver disease,lactic acidosis

500 mg tabTID; 850mgforte tab BID

with foodMax:3gm/day

Decreasehepaticglucoseoutput

3.Alpha-glucosidase

inhibitor: a. Acarbose(Glucobay) 50, 100mg tab

Post-prandial

hyperglycemia

CI: Renal failure,

liver dse.SE: Flatulence,diarrhea

50-100mg tab

TID with firstmouthful offood.

Max:300mg/day

Delay GI

absorption ofcarbohydrates

b.Voglibose (Basen)200, 300 mcg

Post-prandialhyperglycemia

Flatulence,diarrhea

200-300mcgtab TID

Max:600mcg/day

Delay GIabsorption ofcarbohydrates

4. Thiazolidinediones:Rosiglitazone(Avandia)

24-30hr Insulinresitance

Increase liverenzymes, edema,

weight gain

4-8mg tab ODMax: 8mg/day

Increaseinsulin

sensitivity

5. Insulinsecretagogues:Repaglinide(Novonorm)

3-4hr Postprandialhyperglycemia,

All type Idiabetes

HypoglycemiaCI: renal and

Hepatic Failure

0.5-2 mg tabTID before

mealsMax: 6 mg/day

Increaseinsulin

secretion

C. Insulin Treatment:

1. Types of Insulin:a. Short-acting: Humulin-R, Actrapid HM, Humalog (insulin analog)b. Intermediate-acting: Humulin-N Monotard HM, Protaphane HMc. Long-acting Humulin ultralente, Ultratard HM

Table 6-3 Bioavailability of Insulin After SC Injection



Onset Peak Duration

Short-Acting(R)

15 min. 2-4 hr 6-12hr

Intermediate(N)

2-4 hr 8-12hr 18-24hr

Long-Acting (L) 4-6 hr 24-36hr

2. Three Different Insulin Regimens:

a. Insulin Alone (currently accepted)Shift completely to Insulin after failure of maximal oral hypoglycemics

i. Single-dose: Less optimal control of postprandial blood glucose but convenient for the patient

(once-a-day injection)ii. Split-dose:Better control than single-dose e.g. Humulin 15 units N SC at 6 a.m. (2/3 as morning

dose) Humulin 5 units N SC at 6 p.m. (1/3 as evening dose)iii. Split-mix: Better control than single-dose or split-dose e.g. Humulin N 14 units, Humulin R 6

units at 6 a.m. Humulin N 7 units, Humulin R 3 units at 6 p.m. b. BIDS (Bedtime Insulin and Daytime Sulfonylureas)

Combined Insulin & Oral hypoglycemic agentse.g. Diamicron 80 mg 1 tab TID PO 30 minutes before mealsHumulin N 10-20 units SC at night

c. Insulin + Oral Hypoglycemic Agents:

Add Insulin treatment on top of Oral hypoglycemic agentsChoose any of the 3 regimens in No.1 (usually Single-dose or Split-dose)eg. Humulin N 20 units SC at 6 a.m. single-dose+ Diamicron 80 mg I tab TID 30 minutes premeals

3. Blood Sugar Monitoring of Patients:

a. Out-patient: Two hours post-prandial, FBS, Hgb A1Cb. In-patient: CBG (Capillary Blood Glucose) monitoring

CBG OD = 6 a.m. premeals or 2 hours post-prandial (after) lunchCBG BID = 6 a.m. - 6 p.m. premealsCBG TID = 6 a.m. - 12 noon - 6 p.m. premealsCBG QID = 6 a.m. - 12 noon - 6 p.m. - 12 midnight premeals

4. How to Calculate the Daily Insulin Requirement of an In-patient.

Step 1: Use Insulin Sliding Scale for 1 day only to observe daily insulin requirement of the patient.CBG < 160 = no insulinCBG 160 - 200 = 4 units Humulin R SCCBG 200-300 = 6-10 units Humulin R SCCBG 300-400 = 10-14 units Humulin R SCCBG > 400 = call Attending Physician

Step 2: Get total daily Insulin requirement to achieve reasonable control. e.g. 30 units needed for theday

Step 3: For patients on oral diet give 2/3 of total daily Insulin requirement in the morning and 1/3 in theevening

e.g. Humulin N 20 units SC at 6 a.m. + Humulin N 10 units SC at 6 p.m.Step 4: For patients on oral NGT feedings round the clock, give 1/2 of total daily dose at 6 a.m. and1/2 at 6 p.m.

e.g. Humulin N 15 units SC at 6 a.m. + Humulin N 15 units SC at 6 p.m.Note: Give additional short-acting insulin as rescue doses for CBG > 200 mg %

5. For Type I Diabetes Mellitus: Refer these patients to an Endocrinologist for strict insulin treatment.



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DIABETIC KETOACIDOSIS / HYPEROSMOLAR NON-KETOTIC COMA



Clues to Diabetic Ketoacidosis (DKA) or Hyperosmolar Non-Ketotic Coma (HONC):l. Increase random blood sugar 2. Increase plasma osmolality > 320 mosm/L3. Metabolic acidosis4. Ketonemia: (+) ketones in DKA and (-) ketones in HONC

Orders:

Admit to:Diet: NPO temporarilyVS: Vital signs q 1hour; Postural BP & pulse; Neurochecks q 4 hours Call MD if Urine Output < 30 cc/hour Nursing: I & O; Place foley catheter; Consider NGT and CVP; Oxygen at 2-5 lpm bynasal cannula or useface mask; Record all labs on flow sheet Diagnostics: CBC, Serum urine Ketones, Hgb A1C, ABG, CXR, ECG

RBS, HGT q 1-4 hours initially, Na, K, Cl, Urinalysis

BUN, Creatinine, Phosphate, Amylase (pancreatitis common in DKA)

Compute serum osmolality: [2(Na)]+ Glucose (mmol/L) + BUN (mmol/L)

Compute Anion Gap: Na - (Cl+ HCO3)Monitor: RBS, pH (normalizes) and anion gap (narrows)

Therapeutics: Mnemonic - FIE (Fluids, Insulin, Electrolytes)

1. Fluid Replacemeat

a. Correct the volume deficit. Frequent clinical assessment is needed.Consider bladder catherization and CVP insertion. Caution is indicated in treatment of the elderly,especially those with MI, CHF or renal insufficiency.b. IV Fluids: 0.5-5 liters NS over 1-7 hours, infuse at 400-1000 ml/hour until hemodynamically stablec. Maintenance fluids: D5 0.3NaC1 is appropriate at 100-200 ml/hour

2. Insulin Treatment

a. Insulin Regular (Humulin R) 5-15 units (0.2 units/kg) IV or IM every hour until CBG decreases to250 mg % or Use Insulin Drip at 2-10 units per hour till CBG =250 mg %Change to Insulin Sliding scale SC when ketones & anion gap are normalb. If CBG =250 mg%, may use D5R or D5NM at 100-250 cc/hour Keep Urine Output greater than 40 cc/hour

3. Electrolyte Management

a. Potassium: Anticipate potassium deficit with insulin treatmentb. If urine output is adequate, and Serum K < 5.8 meq/L add KC1 in concentration of 20-40 meqKC1 per liter of IVFc. Bicarbonate: for pH < 7.1, give Na Bicarbonate IV to correct ketoacidosisd. Phosphate: Check for hypophosphatemia




THYROID STORM



Data: A. Signs and Symptoms: Irritability, delirium, coma, high fever, tachycardia, hypertension, sweating,restlessness, vomiting, diarhhea; older patients may present with less symptoms (apathetic thyrotoxicosis) B. Diagnostic Criteria for Thyroid Storm Table 6-4. Burch and Wartofsky’s Diagnostic Criteria for Thyroid Strom*

Thermoregulatory Dysfunction

Score

Temperature

37.2-37.7C (99-99.9F) 5

37.8-38.2C (100-100.9F) 10

38.3-38.8C (101-101.9F) 15

38.9-39.3C (102-102.9F) 20

39.4-39.9C (103-103.9F) 25

>40C (=104.0 F) 30

Central Nervous System Effects

Absent 0

Mild (Agitation) 10

Moderate 20

Delirium

Psychosis

Extreme Lethargy

Severe (Seizure, Coma) 30

Gastrointestinal-Hepatic

Dysfunction

Absent 0

Moderate 10

Diarrhea

Nausea/Vomitting

Abdominal pain

Severe (unexplained jaundice)

20

Cardiovascular Dysfunction

Tachycardia (beats perminute)

99-109 5

110-119 10

120-129 15

130-139 20

= 140 25

Congestive Heart Failure

Absent 0



Mild 5

Pedal edema

Moderate 10

Bibasal rales

Severe 15

Pulmonary edema

Atrial Fibrillation Absent 0

Present 10

Precipitant history

Negative 0

Positive 10

* In patients with severe thyrotoxicosis, points are assigned to the highest possible weighted descriptionapplicable in each category and scores totaled. When it is not possible to distinguish the effects of anintercurrent illness from those of the severe thyrotoxicosis per se, points are awarded such as to favor thediagnosis of storm and hence empiric therapy. A score of 45 or greater is highly suggestive of thyroidstorm; a score of 25-44 is suggestive of impending storm, and a score below 25 is unlikely to re representthyroid storm. Source: Burch, H.B. & Wartofsky, L. (1993). Life-threatening Thyrotoxicosis: Thyroid Storm.EndocrinolMetab Clin North Am, 22, 263-277. C. Complication: May exacerbate heart failiure and coronary artery diseaseD. Differential Diagnosis: Sepsis, hemorrhage, drug reactionE. Treatment: Identify and treat precipitating event, i.e. infection, surgery, amiodarone, anti-thyroid drug

withdrawal, etc. Orders:

Diet: No added saltVS: Vital signs q 1 hour Nursing: I & O; Seizure & aspiration precautions; Cooling measures for fever

IVF: D5NM X 8-12 hoursDiagnostics: Ultrasensittve TSH Irma (decreased), Free T4 (increased)

CBC,Na, K, Urinalysis, Creatinine

Chest X-ray, ECG

Monitoring of treatment: Check Plasma T4 after 4 weeks. Decrease dose of PTU and iodine as plasma T4 normalizes.

Therapeutics:1. Propylthiouracil or PTU 50 mg tab: PO- 100-200 mg PO q 4-6 hours, maximum dose 1200 mg/day,

usual maintenance dose 50 mg OD - BIDDrug of Choice for (1) acute thyroid crisis because it also inhibits peripheral T4 to T3 conversion, and (2)

pregnant patients.or Methimazole (Tapazole) 5 mg tab: PO- 10-20 mg every 6 hours, maintenance dose 5 mg OD-BID,

maximum dose 120 mg/dayBetter drug for maintenance because of less agranulocytosis

or Carbimazole (Neo-Mercazole) 5 mg tab, 20 mg tab: PO- 20-60 mg/day initially then maintenance at5-15 mg/day

2.a. Propranolol (Inderal, Duranol) 10 mg tab, 40 mg tab PO- l0-40 mg TID - QID

or Beta-blockers: Esmolol HCl (Brevibloc) IVor Verapamil 40-80 mg tab TID PO

Adjust dose to prevent tachycardia, defer for HR < 60 bpm and BP < 100 mmHg.Caution in patients with moderate to severe heart failure.b. For Acute Atrial fibrillation: Digoxin 0.25-0.5 mg IV then POPatients with thyrotoxicosis are relatively resistant to Digitalis, and may require higher loading doses.



3. Sodium iodine 1 gm IV q 8 hours or Iodone 1 tab TID

or Potassium Iodine (Lugol's Solution) 2-5 gtts PO q 8 hours, given 1 hour after PTU (give for a few daysonly)

4. Consider Dexamethasone 2 mg IV or PO q 6 hours for urgent relief of thyrotoxicosis (increaseglucocorticoid requirement in thyrotoxicosis & reduced adrenal reserve).

5. Treat concomitant diseases6. Symptomatic medications: Paracetamol, Sedatives




HYPERTHYROIDISMTo Endocrinology Page


Data:Etiology: grave's disease (common in young patients), toxic multinodular goiter (older petients), painlessthyroiditis subacute thyroiditis

Orders:

Diagnostics: Ultrasensitive TSH Irma (decreased)

Free T4(increased) or Total T4

Free T3 (increased) or Total T3Thyroid Scan, RAIU (useful in cases of thyroiditis)

Therapeutics:1. Medical treatment:

a Thionamides:i. Propylthiouracil or PTU (Philusa Propylthiouracil) 50 mg tab

Dosage: 50-150 mg PO q 8 hr starting dose, max. dose 1200 mg/day

ii. Methimazole (Tapazole) 5 mg tabDosage: 10-20 mg PO q 8 hours, maximum dose: 60 mg/day

iii. Carbimazole (Neo-Mercazole) 5 mg tab, 20 mg tabDosage: 5-15 mg PO q 8 hours, maximum dose 60 mg/dayNote: Larger doses may be initially required for control

b. Beta-adrenergic antagonists and other drugs for treatment of palpitations, tremors, anxietyi. Propranolol (Inderal, Duranol) 10 mg tab, 40 mg tab: PO- 10-40 mg TID-QID

or Beta-blockers: Esmolol HCl (Brevibloc) IV Adjust dose to prevent tachycardia, defer for HR < 60 and BP < 100Caution in patients with heart failure

or ii. Atenolol (Tenormin, Therabloc =)) 50-100 mg tab OD for better complianceor iii. Verapamil (Isoptin) 40-80 mg tab TID POor iv. Digitalization with Digoxin for Acute AF 0.25-0.5 mg IV

2. Radioactive Iodine treatment 131-I

3. Subtotal thyroidectomy (patient must be euthyroid prior to surgery)4. Symptomatic meds:

a. Sedatives for anxietyb. Paracetamol PO for fever

5. Treatment plan:a. Patient follow up: Check T3 and T4 every 4-6 weeks. TSH is the last to normalize. If T4 is stillincreased, increase dose of thionamides. Taper dose once T4 is normal.b. Sore throat and fever may mean agranulocytosis (WBC < 500). Patients may die of thiscomplication. Stop anti-thyroid drugs immediately. Other drug side effects include hepatitis, jaundice, vasculitis, drug-induced lupus.




HYPOTHYROIDISM I MYXEDEMA COMA



Data:

A. Etiology Primary Hypothyroidism in 90% , either Hashimoto's thyroiditis or iatrogenic hypathyroidismdue to radioactive iodine treatment surgery or drugs, (e.g. amiodarone)

B. Signs and Symptoms: Cold intolerance, menorrhagia, myalgia, slow deep tendon reflexes, dry skin,non-pitting edema, weight gain, somnolescence, constitpation

C. Differential Diagnosis: Hypopituitarism, Down's syndrome, nephritis, nephritic syndrome Orders:

Admit to:VS: Vital signs q 1 hour Nursing: I & O; Triple blankets for hypothermia; Seizure & aspiration precautionsIVF: D5NM X 12 hoursDiagnostks: TSH Irma (increased in primary hypothyroidism,TSH > 20 units/ml)

Free T4(deceased)CBC, ceram Na (deceased), serum K, RBS

Cholesterol, Triglycerides, Uric Acid, Cardiac Enzymes, SGOT, LDH (all inc. )ECG(low voltage and inverted T waves)

2D-Echo with Doppler (30%develop pericardial effusion or heart failure)

Therapeutics:A. Prinary Hypothyroidism

1. Levothyroxine Na (Euthyrox, Eltroxin, Thyrax Duotsb) 25 mcg, 50 mcg and 100 mcg tab. Dose:25-150mcg/day

a. Start usually with 25-50 mcg/day. Use lower dosages (12.5-25 mcg/day) for patients over 60years and those with cardiac disease. Treatment is for life.b. Watch out for Adrenal Failure: Signs and symptoms are hypotension, nausea, vomiting afterstarting treatment.

2. Course: Symptoms improve in weeks. Wale out for heart failure from too aggressive therapy.3. Plan: Increase dose by 25-50mcg every 4 weeks until patient is euthyroid.4. Goal of treatment is to maintain plasma TSH in the normal range. Monitor Plasma TSH q 3-4months.

B. Secondary Hypothyroidism

1. Monitor serum T4 and other pituitary hormones.2. Give steroid replacement first prior to L-thyroxine replacement.

C. Emergency Therapy for Myxedema Coma

Rarely needed unless patient has severe illness: hypoventilation, hypothermia, bradycadia, hypotensionand hypoxia

1. L-thyroxine 50-100 mcg IV q 6-8 hours for 24 hours in emergency cases then shift PO 75-100 mcgPO once patient can tolerate oral intake.2. Hydrocortisone 100 mg IV q 6-8 hours given prior thyroxine treatment




ADRENAL INSUFFICIENCY



A. Primary Adrenal Failure or Addison's disease (decrease cortisol, increase ACTH)1. Progressive adrenocortical destruction of > 90%2. Etiology: Autoimmune, tuberculosis, metastasis hemorrhage, AIDS, chronic granulomatousdisease3. Signs and Symptoms: Hyperpigmentation due to increase ACTH (only in primary adrenal failure)increase K, volume depletion, weight loss, anorexia

B. Secondary Adreanal Failure (decrease cortisol. decrease ACTH)1. Disorder of hypothalamus or pituitary, secondary to gucocorticoid withdrawal2. Signs and Symptoms: Weakness, fatigue, anorexia, nausea, vomiting, weight loss,gastrointestinal complaints, increase sodium, orthostatic hypotension

C. Adrenal Crisisl. Etiology: Steroid withdrawal; rarely, sepsis, drugs (Rifampicin, Phenytoin, Ketoconazole, Opiates),illness or surgery

Algorithm for diagnosis: · Suspected Adreanal Insufficiency· Screening Test

a) Plasma cortisol =15mcg/dlb) Plasma cortisol 30 min after 250 mcgCosyntropin (Acth) IM or IV <18mcg/dl

· Decrease Cortisol(Possible Adreanl Insufficientcy)Primary vs. Secondary

· Check Plasma ACTHo ACTH Increased

Primary Adrenal Insufficiency/ Addison’s Disease

(+) pigmentationo ACTH Decreased or Normal

Secondary Adreanl Insufficency-central cause (hypothalamic or Pituitary)- steroid ingestion and withdrawal- normal patient

Orders:

Diagnostics: Plasma Cortisol level

Plasma ACTH level

Short Cosyntropin (Cortrosyn / ACTH) Stimulation Test:Give 250 mcg IV with determination of Plasma Cortisol after 30 minutes(Normal Value: Serum Cortisol > 20 mcg/dl)

CBC, Serum Na (decreased), Cl (decreased), HCO3 (decreased)

Serum K(increased), BUN, Creatinine

CT Scan of the Adrenals

Therapeutics:A. Adrenal Crisis Treatment:

1. Diagnosis is knowna. Hydrocortisone 100 mg IV q 6 hoursDecrease dose in several days and shift to Prednisone PO



b. D5 0.9 NSS Fast drip until hypotension is controlled2. Diagnosis is not established

a. Dexamethasone 5-10 mg IV statb. D50.9 NSS fast drip for hypotensionc. Do Cortrosyn Stimulation Test. Check serum cortisol after 30 minutes, then give Hydrocortisone100 mg IV q 6 hoursd. Look for and treat underlying illness that precipitated the crisis.

B. Maintenance Treatment for Addison's disease:1. Glucocorticoid: Prednisone (DLI Prednisone, Prednisone Organon) 5 mg tab: 2.5-7.5 mg PO aftermealsIncrease dose or shift to IV dose during illness, injury, surgery or in the post-operative period2. Mineralocorticoid: Flurocortisone 0.05 to 0.1 mg PO3. Increase sodium intake to 4-6 gm/day




OSTEOARTHRITISTo Rheumatology Page


Data:

A. Synonyms: Degenerative joint disease, Osteoarthrosis

B. Types: 1. Primary or idiopathic osteoarthritis2. Secondary osteoarthritisC. Common risk factors: Age, major joint trauma, repetitive stress, obesityD. Clinical features: Joint pain on motion, relieved by rest, stiffness after inactivity lasting less than 30

minutes.C. Common joints affected: Fingers (distal interphalangeal joints and proximal interphalangeal joints), big

toe, hip, spine and kneesF. Diagnosis: Clinical and radiologicalG. Treatment goal: Reduce pain, maintain mobility, and minimize disability Orders:

Diagnostics: X-ray of the involved joint

CBC,ESR (to rule out Rheumatoid Arthritis)

Therapeutics:

1. Pain Relief:a. Paracetamol 500 mg tab TID-QIDb. If Paracetamol is inadequate, may use NSAIDS PO but avoid in patients with renal insufficiency

and peptic ulcer disease, e.g. Mefenamic Acid =) 500 mg 1 tab TID.c. For high-risk patients such as the elderly with gastritis or history of ulcer, use specific COX-2

inhibitors: Celecoxib (Celebrex) 100 mg cap BIDd. Topical NSAIDS: Diclofenac (Voltaren) emulgel 1%, apply TID-QIDe. Intra-articular steroidsf. Intra-articular hyaluronic acid

2. Supportive Treatment:

a. Weight reduction for obese patientb. Correct posture, support lumbar lordosis, use knee brace, use a cane at the contralateral side,use crutches or walkers, use corrective shoes for flat foot.c. Physical therapy - isometric exercises to srengthen muscle around the joints, usually thequadriceps and hamstring muscles. Avoid isotonic exercises.d. Heat applicatione. Orthopedic surgery with arthrotomy or total joint replacement - for failed medical management

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GOUTY ARTHRITISTo Rheumatology Page


Data: A. Gender Predisposition: Male, post-menopausal femaleB. Types:

1. Primary – familial history2. Secondary – blood dyscrasias, lymphomas

C. Stages of Gout:l. Asymptomatic Hyperuricemia2. Acute Gouty Attack - attack peaks at the second to third day after the first symptom and subsideswithin 7-10 days3. Interval or intercritical gout4. Chronic tophaceous gout5. Nepbrolithiasis

D. Common Joints Involved: First metatarsophahngeal joint, ankle, knee, wrists, fingers and elbowE. Complications: Uric acid nephropathy renal insufficiency, tophi deposition

Orders:

Admit to:Diet: Low purine dietVS: q 4 hoursNursing: Apply ice bag during acute episode, support sheets over footIVF: D5NM 1 L X 16 hoursDiagnostics; CBC, BUN, Creatinine, Uric acid, ESR FBS, SGPT

Urinalysis, 24 hour urine-collection for urinary uric acid and creatinine clearance

Synovial flaid exam for analysis of crystals culture and sensitivity, gram stain, cell count,

protein and glucoseX-ray views of joint

Therapeutics:l. Asymptomatic Hyperurecemia

a. Dietary restrictions (See Nutrition chapter)b. Treat associated problems: Hypertension, hypercholesterolemia, diabetes, obesityc. No antihyperuricemics needed at this stage. Unnecessary treatment with Allopurinol may causeSteven-Johnson's Syndrome.

2. Acute Gouty Arthritis:

a. Colchicine 2 tabs now then followed by 1 tab q 1 hour up to 6-8 tabs/day until there is pain relief,vomiting, diarrhea, or abdominal pain; then give maintenance Colchicine 1 tab TID for 2 days thenBID; if not tolerated use NSAIDS

b. NSAIDs: Indomethacin (Indocid) 25 mg 1 cap TID with meals or Diclofenac sodium (Voltaren Forte)50 mg 1 tab TID x 3 days then BID until acute attack disappears or Ketorolac (Toradol) 1 amp IMor IV q 4-6 hours

Note: Avoid NSAIDS if with renal insufficiency or ulcer c. If with history of peptic ulcer disease or bleeding, use COX2 inhibitor:

i. Celecoxib (Celebrex) 200 mg cap OD X 5 days or Rofecoxib (Vioxx Forte) 50 mg tab OD+ ii. Proton-pump inhibitor: Esomeprazole (Nexium) 20 mg 1 tab ODd. Other Options:

i. Steroids PO: Methylprednisolone (Medrol) 16 mg 1 tab OD X 2 doses only and H2-blockersii. Intraarticular injection of glucocorticoidsiii. Patenteral (IM or IV) steroid for 1-2 days: Hydrocortisone (Solucortef) 100 mg q 8-12 hoursX 2 dosesor Dexamethasone (Decadron) 4 or 5 mg IM or IV

3 & 4. Intercritical or Chronic Gout:



a. Colchicine prophylaxisb. Not in acute phase: Allopurinol (Allurase =) 100 mg, 300 mg tab) 100 mg 1 tab OD X 2 weeks thenincrease to 300-600 mg daily depending on level of serum uric acid

5. Nephrolithiasis

a. Alkalinize urine with sodium bicarbonate grain X 1 tab TID – QID or Potassium citrate (Acalka)1,080 mg 1 tab BID-TIDb. Increase fluid intake to at least 1.5 - 2 liters/dayc. Allopurinol 300 mg 1-2 tabs OD




RHEUMATOID ARTHRITISTo Rheumatology Page


Data:

Diagnosis: The American College of Rheumatology 1987 Revised Criteria for the Classificationa ofRheamatoid Arthritis:

l. Guidelines for Classification

a Four of seven criteria are reuired to classify a patient as having rheumatoid arthritis. (Sensitivity

= 91-94% Specificity = 89%)b. Patients with two or more clinical diagnoses are not excluded.

2. Criteria*a. Morning stiffness: Stiffness in and around the joints lasting one hour before maximal

improvement.b. Arthritis of three or more joint areas: At least three joint areas, observed by a physician

simultaneously, have soft tissue swelling or joint effusion not just bony overgrowth. The 14possible joint areas involved are right or left proximal inter-phalangeal, metacarpophalengeal,

wrist, elbow, knee, ankle, and metatarsophalangeal joints.c. Arthritis of hand joints: Arthritis of wrist, metacarpophalangeal joint, or proximal interphalangeal

joint.d. Symmetric arthritis: Simultaneous involvement of the same joint areas on both shies of the

body.e. Rheumatoid nodules: Subcutaneous nodules over bony prominences, extensor surf' or

juxtaarticular regions observed by a physician.f. Serum theumatoid factor : Demonstration of abnormal amounts of serum rheumatoid by any

method for which the result has been positive in less than 5 percent of normal control subjects.g. Radiographic changes: changes: Typical changes of rheumatoid arthritis on posteroanterior

hand and wrist radiographs which must include erosions or unequivocal bony decalcificationlocalized in or most marked adjacent to the involved joints.

* Criteria a-d must be present for at least 6 weeks. Criteria b-e must be observed by a physician.

Source: Lipsky, P.E. (2001). Rheumatoid Arthritis. In E. Braunwald, A. Fauci, D. Kasper, et al (Eds.),Harrison's Principles of Internal Medicine (p. 1934). New York: McGraw-Hill, Inc., with permission.

Orders:

Diagnostics: CBC, Rheumatoid Factor, ANA test (screening test)

ESR, C-Reactive Protein (both with disease activity)

Synovial Fluid Analysis (inflammatory arthritis)X-ray of affected joint

Therapeutics:l. Empirical and palliative treatment

a. Patient educationb. orthotic "support" devices

2. Pharmacologic treatmenta. ASA and other NSAIDSb. Low glucocorticoids: Prednisone 5 mg tab to be given at 2.5-7.5 mg/day

Vary the dose dependirig on the disease activityc. For moderate to severe end/or sustained disease activity, may use the following:

i. Disease-modyfying anti-rheumatic drugs: Gold anti-malarials methotrexate, Leflunomide(Arava)ii. Immunosuppressive therapy: Azathioprine, Cyclophosphamide, Cyclosporins



iii. Anti-TNF alpha therapy: Enbrel or Infliximabiv. Anti-interteukin therapy

Note: At present, it is the consensus that combination therapy of NSAIDS, low dose steroids anddisease modifying drugs including anti-cytokine therapy be started as early as possible especiallywith very active disease. Since each of these drugs is associated with considerable toxicity, it is bestto refer these patients to a Rheumatologist




SYSTEMIC LUPUS ERYTHEMATOSUS

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Data:Diagnosis: The 1982 Criteria for Classification of Systemic Lupus Erythematosus

(SLE)

1. Guidelines for Classification:a If four of therse criteria are present at any time during the course of the disease, a diagnosis ofSLE can be made with a 98% specificity and 97% sensitivityb. Some patients may present with only one or two criteria but may have SLE. A high index ofsuspicion is needed for early diagnosisc. Differential Diagnoses: Rule out drug-induced lupus secondary to hydralazine, isoniazid,procainamide, chlorprenazine and other vasculitides.

2. Criteria Mnemonic - SOAP BRAIN MD

a Malar rash: Fixed erythema flat or raised, over the malar eminences

b. Discoid rash: Erythematous raised patches with adberent keratotic scaling and follicular plugging

atrophic scarring may occur c. Serositis: Pleuritis or pericarditis documented by ECG, or rub, or evident of pericadial effusion

d. Oral ulcers: Includes oral and nasopharyngeal ulcers, observed by physician

e. Arthritis: Nonerosive arthritis involving two or more peripheral joints, characterized by

tenderness, swelling, or effusionf. Photosensitivity

g. Hematoloicdisorder (Blood): Hemalytic anemia or leukopenia (less than 4000/uL> or

lymphopenia (less than 1500/uL) or thrombocytopenia (less than 100,000/uL) in the absorb ofoffending drugs

h. Renal disorder : Proteinuria greater than 0.5 gm/day or greater than 3+, or cellular castsi. Antinudearantibodies: An abnormal titer of ANAs by immunofluorescence or an equivalent assay

at any point in time in theabsence of drugs known to induce ANAs j. Immunologic disorder: Positive LE cell preparation or anti-dsDNA or anti-Sm antibodies or

false-positive VDRLk. Neurologic disorder : Seizures without other cause or psychosis without

other cause

Source: Hahn, B.H. (2001). Systemic Lupus Erythematosus. In E. Braunwald, A. Fauci, D. Kasper, et al(Eds.), Harrison's Principles of Internal Medicine (p. 1925). New York: McGraw-Hill, Inc., with permission. Orders:

Admit to:Diet: Low salt dietVS: q 4 hoursNursing: Avoid sulfonamides, penicillins, diphenylhydantoin, hydralazineDiagnostics: CBC w/ platelet count, Creatinine, PT, PTT Bleeding time, Coombs test

Chest X-ray

Complete Lipid profile

Indices of disease activity. Agti-ds DNA, C3 levels, ESRC-Reactive Proteins, Rheumatoid Factor (differential diagnosis)

Urinalysis, 24-hour urine protein

ANA(screening test if positive, request ANA panel)

Anticardiolipin antibody (indicated for recurrent abortion or vena-arterialocclusive diseases)

Therapeutics:



l. Arthritis, serositis, myalgia: NSAIDS, ASA, anti-malarials, low steroid steroid2. For active severe SLE (CNS, renal, hematologic)

a. Prednisone 5 mg tab: PO-40-60 mg/day, maintenance dose of 10-20 mgor Methylprednisolone (Solu-Cortef) Pulse therapy (MPPT) 500-1000mg1 amp in D5W 500 cc X 6 hours X 3 doses/3days (if with severe SLE and with organ damage)

b. Cyclophosphamide (Cytoxan) 2-3 mg/kg/day in divided doses or Cyclophosphamide IV Pulsetherapy:

D5W 500 cc + 500-1000 mg Cyclophosphamide X 6 hoursGive Metoclopromide (Plasil) 2 tabs before Cyclophosphamide drip

c. Azathioprine (Imuran) 2 mg/kg/day PO (immunosuppressants)Note: For active disabling SLE or with serious organ involvement, requiring Pulse therapy with

methylprednisolone or immunosuppressive therapy, it is appropriate to refer to an Internist orRheumatologist.

3. Other treatment:a. For photosensitivity: Sunscreensb. Skin lesions: Hydroxychloroquine sulfate (Plaquenil) 200 mg BID – needs eye check-up q 6months

+ Betamethasone dipropionate (Diprolene) 0.05% ointmentor Triamcinolone acetonide (Kenacott, Ledercort) 0.1% cream BID

c. Thrombosis: Coumadin PO anti-coagulation or low molecular weight heparind. Osteoporosis: Calcium 1500 mg + Vitamin D (Caltrate Plus) 1 tab OD or Alendronate Na(Fosamax) 10 mg 1 tab OD




CEREBROVASCULAR ACCIDENT: INFARCTION VS. HEMORRHAGE

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There are currently far available stroke scoring systems to differentiate supratentorial brainhemorrhage from infarction. All of these stroke scores have recently been validated at the UP-PGHMedical Center and the results show that the Siriraj Scoring and Allen Scoring have the highest sensitivity(80-85 %) and specificity (70-80 %). Our preference is the Siriraj Stroke Score (See Table 8-1) becauseof its simplicity. Note also that no scoring system is 100% accurate. Therefore, in case of doubt, do statCT Scan.

Table 8-1. Siriraj Stroke Score

Variables Clinical features Score Sample patient*

1.Consciousness Alert 0 0

Drowsy, Stupor 2.5 Semicoma,coma

5

2. Vomiting No 0

Yes 2 2

3. Headachewithin 2 hours

No 0

Yes 2 2

4. Diastolic BloodPressure (DBP)

Actual DBP inmmHg

DBP x

0.1

90 mmHg x 0.1

= 9points

5. Atheromamarkers (includingdiabetes, angina,& intermittentclaudication)

None 0

One or More 3 3

Constant -12 -12

Total= +4

* Sample scoring for a hypothetical 50 year old male t with an acute shake syndrome. On consultation, he is alertand has complained of vomiting and headache after the onset of left-sided weakness. He has a history of diabetesmellitus and blood pessure is 150/90 mmHg. Based on this information, the patient’s stroke score per variable is given in the right-hand column. The total score is+ 4, which is above the cut-off of 2 points, indicating a bable hemorrhagic stroke.

Score Interpretation:

= +2 = Most likely HEMORRHAGE- 1, 0 and+ 1 = Equivocal result (CT Scan recommended)= -2 = Most likely INFARCTION

Source: Poungvarin, N. et al (1991). Siriraj Stroke Score and Validation Study to Distinguish SupratentorialInlracerebral Hemorrhage from Infarction BMJ 302 1565-7.

To Neurology PageTo Main Table of ContentsTo Detailed Table of Contents



INTRACEREBRAL HEMORRHAGETo Neurology Page


Data:

A. Hypertensive Bleed Signs Based on Location of Hemorrhage

1. Putamen: Depressed sensorium, contralateral hemianopsia, contralateral hemiparesis, pupilsnormal2. Thalamus: Depressed sensorium, eyes deviated downwards, skew deviation, hemiparesis,pupils sluggish, deep conjugate gaze3. Lobar: No coma, pupils normal, hemiparesis or hemisensory, (+) seizure4. Pons: Early coma, pinpoint pupils, (-) doll‘s eye, quadripaesis, ocular bobbing ,(-) seizures5. Cerebellar: Late coma, pupils small but teactive, ataxia gait, dizziness, vomiting

B. Surgical Option:

l. All cerebellar bleeds or infarcts > 15 ml needs a neurosurgical referral2. All supratentorial bleed > 50 ml needs neurosurgieal evaluation

Orders:

Admit to:Diet: NPO

VS: Neuro vital signs q 1 hour; Monitor pupil size and refer if =1mm differenceNursing: Input & Output q 4 hours & record; Insert NGT and foley catheter

Moderate high back rest at 30 degreesKeep PCO2 between 25-29 mm Hg

IVF: D5NSS 1 liter X 16 hours (if on NPO)D5NSS 1 liter X 30 cc/hr (once on oral feeding)

Diagnostics: CT Scan stat

CBC with platelet, Na, K, Creatinine, RBS

ABG, Urinalysis, Lipid profile

Chest X-ray,ECG

Therapeutics:Oxygen at 2-3 lpm via nasal cannula

1. Mannitol 100 cc q 4 hours or 75 ml q 4-6 hours as side drip, Set drip 100-200 cc initially2. H2-blockers or Proton pump inhibitors, e.g. Ranitidine 50 mg IV q 8 hours3. Hypertension:

a. In acute intracranial hemorrhage, gradual lowering of blood pressure is recommendedb. Target BP of 150-160/90-100 mm Hgc. If SBP > 180 mm Hg, start Nicardepine drip 10-20 mg in 90 cc NSS. Start at 10 ugtts/min andthen increase gradually.

4. Consider intubation with hyperventilation

5. Consider neurosurgical evaluation for large putaminal, lobar and cerebellar hematomas and for AVmalformations.




SUBARACHNOID HEMORRHAGETo Neurology Page


Data:

Etiology: Usually due to ruptured aneurysm or ruptured arteriovenous malformation. Aneurysm is morecommon in the elderly while ruptured arteriovenous malformation is more common in the young andfemale population. Orders:

Admit to: Diet NPOVS: Neuro vital signs q 1 hour; Monitor pupil size and refer if = 1 mm differenceNursing: CBR without toilet privileges; Keep room dark and quiet; No rectal examIVF: D5NR 1 liter x 16 hours (if on NPO)

D5NM 1 liter x 30 cc/hr (once on oral feeding)Diagnostics; CT Scan of the Head (if normal, may do MRI)

Lumbar tap (check for blood and xanthochromia) provided there is no contraindicationCerebral Angiography: Four-vessel arteriography (The gold standard to determine the souseof bleeding)CBC with platelets, Na, K, RBS, Creatinine

Therapeutics:

Oxygen at 2-3 lpm via nasal cannula1. Nimodipine (Nimotop) 30 mg 2 tabs PO q 4 hours per NGT X 21 days, must start as soon as

possibleNimodipine drip 10 mg/50ml vial X 5-10 ugtts/min (1-2 mg/hr) X 6 vials(decreased incident of ischemic neurologic deficits)2. Consider Dexamethasone (Oradexon) 5 mg IV q 6 hours3. Consider Phenytoin IV load 18-20 mg/kg IV in plain NSS then Phenytoin 100 mg PO TID or

Phenobarbital 60 mg 1 tab BID-TID4. Laxative: Duphalac 30 ml at bedtime (to avoid straining and increase in ICP)5. Stat referral to Neurosurgery for possible surgical clipping of aneurysm

6. Mannitol 20% 75-100 cc IV q 6 hours7. Symptomatic Meditationsa Consider sedatives and pain relieversb. H2 blockers IV (e.g. Ranitidine)c. Carbamazepine (Tegretol) 1/2 tab PRN for hiccups

Avoid Motoclopamide (Plasil) baause of extrapyramidal reactions8. Treatment of Complications:

a. Rebleeding: 40/o mortality; intubate patient and decompress with Mannitol. Prevention isthe key with adequate analgesia, control of hypertension, sedation, laxatives and earlysurgery,

b. Vasospasm: Occurs within 4-14 days; majority progress to cerebral infarction. Treatment iswith hypervolemic hcmodilution (3 liters of fluid per day) to decrease blood viscosity andmaintain cerebral blood flow. Prevention with early Nimodipine PO.

c. Hydrocephalus: Tube ventriculostomy / VP shunting




CEREBRAL THROMBOSISTo Neurology Page


Orders:

Diagnostic: CT scan stat to rule out bleed (or after 16 hours from the onset of stroke to visualize infarct)ECG, Chest X-ray, CBC, PT, PTT, Na, K, Creatinine Lipid profile, RBS

Therapeutics: Oxygen at 2-3 1pm via nasal cannula A. Anti-platelet Regimen:

l. Aspirin 80-325 mg tab PO OD (still the drug of choice because cost- effective)or 2. Dipyridamole/Aspirin (Aggrenox) 200/25 mg 1 cap BIDor 3. Clopidogrel (Plavix) 75 mg 1 tab ODor 4. Cilostazol (Pletaal) 50 mg 1 tab BID

B. Neuroprotectants:1. Citicoline(Somazine, Nicholin) 500 mg IV q 8-12 hr X 5 days, maximum of 2 gm/day); then

continue with oral drops 100 mg or 1 ml BID2. Piracetam (Nootropil) 12 gm IV initially then 3 gm IV q 6 hr X 5 days, then continue with oral

preparation 1.2 gm tab BID. Contraindicated if with renal insufficiency.3. Anti-edema treatment: Mannitol 100-150 cc q 4-6 hours for brain edema

C. Other Treatment Options:1. From 0-3 hours: Intravenous Tissue Plasminogen Activator (rt-PA)2. From 3-6 hours: Intra-arterial Tissue Plasminogen Activator (rt-PA)




TRANSIENT ISCHEMIC ATTACK

Orders:

Admit for observation of neurologic deficits end work-upDiagnostics: CBC, Creatinine, Lipid profile, RBS, ECG, Chest X-ray

Therapeutics:

l. Aspirin 80-325 mg PO ODor Clopidogrel (Plavix) 75mg 1 tab ODor Cilostazol (Pletaal)50mg tab BID

2. Anticoagulation with Heparin for recurrent TIAs, crescendo type TIAs or stroke in evolution




STROKE IN EVOLUTION

Orders:

Diagnostics: CT Scan, ECG, Chest X-ray

CBC,PT, PTT, Na, K, Creatinine, Lipid profile, RBS

Therapeutics:

1. Heparin bolus 5000 units IV then drip at 500-800 units/hour. Adjust to maintain PTT at 1.2-1.5 X thecontrol. Check PTT q 12 hours. Start immediately in non-hemorrhagic, small to moderate size infarcts.

2. Overlap Warfarin with Heparin X 3 days. Warfarin 2.5 mg 1 tab OD until Protime INR of 2-3 is reached.

Check Protime every 3 days until desired INR is reach' then monthly thereafter.




STROKE IN THE YOUNG

Orders:

Diagnostics: VDRL, ESR, ANA, Protein C, Protein S, Antithrombin III assayCheck for Metamphetamine abuse and Alcohol levelPlasma Homocysteine levels (available at Makati Medical Center)

CBC with Platelets, PT, PTT, Na, K, Creatinine, Lipid profile, RBSCT Scan, ECG, Chest X-ray

Therapeutics:1. Folic acid or Folate if homocysteine-related2. Thiamine (Vitamin Bl) if alcohol-related




SEIZURES & EPILEPSYTo Neurology Page


Data:

A. Definition:

l. Epilepsy: Idiopathic. Two or more unprovoked seizures.2. Status Epilepticus: Recurrent generalized convulsions at a freequency that does not allowconsciousness to be regained in the interval between seizures or seizure of greater than 15 minutesduration.

Mortality rate of 25%.Complications include epileptic encephalopathv & hypoxia

B. EtiologyTable 8-2.The Causes of Seizures.

Neonates (< 1month)

Perinatal hypoxia and ischemia, Intracranialhemorrhage and trauma, Acute CNS infection,Metabolic disturbances (hypoglycemia,hypocalcemia, hypomagnesia, pyridoxine deficienc

Infants andchildren (> 1month and <12 years)

Febrile seizures, Genetic disorders (metabolic,degenerative, primary epilepsy syndromes), CNSinfection, Developmental disorders, Trauma,Idiopathic

Adolescents(12-18 years)

Trauma, Genetic disorders, Infection, Brain tumor,Illicit drug use, Idiopathic

Young adults(18-35 years)

Trauma, Alcohol withdrawal, Illicit drug use, Braintumor, Idiopathic

Older Adults (>35 years)

Brain tumor, Alcohol withdrawal, Metabolicdisorders (uremia, hepatic failure, electrolyteabnormalities, hypoglycemia), Alzheimer’s diseaseand other degenerative CNS diseases, Idiopathic

Source: Loweinstein, D.H.: Seizures and Epilepsy. In Braunwald E, Fauci AS, Kasper D, et al (Eds.),(2001). Harrison's Principles of Internal Medicine (p. 23S8). New York: McGraw-Hill Companies Inc. C. Classification of Seizures: (based on the International Classification of Seizures)

1. Generalized Seizures:a. Tonic-clonic or Grand mal – Most common type of seizuresb. Absence or Petit mal – sudden brief lapses of consciousness (seconds) usually beginning inchildhoodc. Others: Tonic, Atonic, & Myoclonic

2. Partial Seizures:a. Simple partial seizures - consciousness fully preserved during seizuresb. Complex partial seizures – consciousness is impaired during seizuresc. Partial seizure with secondary generalization

3. Unclassified Seizures

Table 8-3 Commonly Used Anti-Epileptic Drugs

Generic Name(Trade Name)

Indication

Dosage

Half-life

Drug Interactions



1. Phenytoin Na*(Dilantin) IV: 100mg/ 2 ml ampPO: 3O mg,100 mg cap

Susp: 125 mg/5m1,30mg/5ml

- Tonic-clonic(grand mal)

- Focal-onset(Partial)

Loading dose:15-18mg/kg/dosePO, IVMaintenanceDose900-400mg/day PO, IV(Adult: 3-6mg/kg/daygivenBID);(Child: 4-8mg/kg/daygiven BID)

24 hours

- Level t by INH,sulfonamides -Level 4 by CBZ,PHB- Altered folatemetabolism

2.Carbamezapine*(Tegretol) PO:200 mg tab, SR200 mg tab, LA400 mg tabSyrup: 20mg/ml

- Tonic-clonic-Focal-onset(Partial)

Adult:200-1200mg/day

Child: 15-35mg/kg/daygiven BID-QID

10-17hours

- Level 4 by PTN,CBZ, PHB- Level l byerythromycin

3. PhenobarbitalNa**(Luminal)IV: 130 mg/ml

Amp

PO: 15 mg, 30mg, 60 mg, 90mg tab

- Tonic-clonic-Focal-onset(Partial)

Loading dose:15-18 mg/kggiven OD orBID

Maintenancedose: 60-180mg/4q PO, IV(Adult14mg/kg/daygiven q12-24hr);(Child:36 mg/kg/daygiven q 12-24hr)

90 hours - Level increasedby VPA, PTN- Enhancesmetabolism of

other drugs vialiver enzymeinduction

4. Valpoic acid*,** (Depakenesyrup, Epivaltab)PO: 250mg/

5 ml syrup,250 m tab

- Tonic-clonic

-Absence- Atypical Absence

-Myoclonic- Focal

onset

750-2000mg/day givenBIDinitially 15mg/kg/day;increasingweekly up to 60

mg/kg/day)

15 hoursMay precipitateabsence status ifgiven w/clonazepam - Leveldecreased by

PTN, CBZ, PHB

5. Clonazepam(Rivotril)PO: 2 mg tab

-Absence-Atypical Absence

-Myoclonic

Adult: 1-12mg/day givenOD-TID (0.1-02mg/kg)

24-48hours

- Leveldecreased byPTN, CBZ, PHB

6.Ethosuximide(Zarontin)

- Absence (petitmal)

750-1250mg/day 20-40mg/kg

60 hr None

7. Lamotrigine(Lamictal)PO: 50 mg tab,100 mg glib, 5mg dispersibletab

- Focal onset- Tonic-Clonic

- Atypical absence- Myoclonic

25-200 mg/daygivenBIDMax: 500mg/day

-25 hr -14 hr w/PTN, CBZ,PHB- 59 hrw/VPA


- Levelsdecreased by

VPA

8. Gabapentin(Neurontin) PO:100 mg, 300 mg,400 m

- Focal-onset, AdjunctTreatment

300-1200mg/day givenTID-QID (up to2400 mg/day ifnecessary &tolerated)

5-9 hours None

9.pine (Trileptal)PO: 300 mg,6GO m tab

-Focal-onset 900-2400mg/day givenBID

10-17hours




10. Topiramatc(Topamax) PO:25 mg, 50 m 100m tab

- Focal-onset-Tonic-clonic

400 mg/daygiven BID

20-30horns


Notes:* – blocks sodium du@mela

**– GABA enhancing Abbreviations: PTN – Phenytoin, CBZ – Carbamazepine, VPA – Valproic Acid, INH – Isoniazid. PHB –phenobarbital.

Orders:

Admit to:Diet: NPO or DAT when no active seizuresVS: Monitor vital signs q 1 how with neurochecks or any change in neurological statusNursing: RBS now and q 6 hours; Seizure precautions; Tongue guardIVF: D5NR 1 liter X 12 hoursDiagnostics: CBC, Ca, Mg, Na, K, Creatinine, RBS, Serum ammonia, Chest X-ray

CT Scan of the head (if with focal neurologic deficits or focal seizures)EEG with hyperventilation and photic stimulationVideo EEG monitoring (to differentiate real seizures from pseudo-seizures)

ECG by cardiac monitor throughout the administration of these drugs

Therapeutics: Oxygen by face maskA. Status Epilepticus

1. Diazepam 02-0.3 mg/kg/dose then may repeat up to 3 doses until seizure stops, e.g. Diazepam5-l0 mg IV q 30 min. or Lorazepam (Ativan) 2-4 mg slow IV, advantage: longer duration of action

+/- 2. Phenytoin loading dose: 18 mg/kg in NSS IV at < 50 mg/min If still with seizures add 5 mg/kgfor up to 2 doses or max. of 30 mg/kg

+/- 3. If still with seizures, consider intubation. Fi02 at 100% and Add Phenobarbital (Luminal) 10-15mg/kg IV at 50-75 mg/min lV until seizure stops. If seizures continuing, may add Pentobarbital.

+ /- 4. Anesthesia with Midazolam or Propofola. Midazolam drip = (02 mg/kg loading dose then 0.1-0.4 mg/kg/hr maintenance dose)or b. Propofal (Diprivan) IV given by an anesthesiologist.

B. Primary Generalized Tonic-Clonic (Grand Mal):

1. For Acute Attack: (depending on the severity and frequency of attacks)a. Phenytoin Na (Dilantin) 100 mg slow IV push q 8 hr

or b. Phenytoin Na (Dilantin) 300 mg slow IV push q 4 hr with 10 cc plain NSS X 3 doses at 50mg/min (loading dose of 900 mg or 15-18 mg/kg/dose)Note: May give full loading dose of Dilantin 1 gram in 30 minutes for recurrent seizures Watchout for hypotension and arrhythmias.

2. For Maintenance:a. Dilantin 100 mg 1 cap TID POor b. Valproic Acid (Epival) 250 mg 1 tab TIDor c. Carbamazepine (Tegretol) 200 mg 1 tab BID

C. Focal-Onset (Partial) Seizure, including Secondary Generalized:

1. Carbamazepine (Tegretol)2. Oxycarbazepine (Trileptal)

3. Phenytoin Na (Dilantin)4. Valproic Acid (Epival)5. Lamotrigine (Lamictal)

D. Absence (Petit Mal):

l. Ethosuximide 250-500 mg PO TID-QID2. Valproic acid at 15 mg/kg/day

E. Atypical Absence Myoclonic

1. Valproic acid2. Clonazepam (Rivotril) 1/2- 2 tabs BID-QID

F. Other Treatment Options:



1. Glucose 50 m) of 50% 1 vial IV2. Thiamine (Vitamin B1) 50 mg IV in alcoholics3. Pyridoxine (Vitamin B6) especially if seizure is due to INH

G. Epilepsy Treatment Plan:

1. Use one drug until maximum dose is reached. (Monotherapy is advocated.)2. If not controlled add a second drug and taper the dose of the first drug.3. In some cases, two drugs are necessary to control seizures but there may be an increase in side

effects.




BRAIN ABSCESSTo Neurology Page


Data:

A. Etiologic Organism: Strep. nulleri, Staphylococcus (post-surgery), Bacteroides; pyogenic brain abscessare usually mixed infections gram positive, gram negative and anaerobes)

B. Clinical Features: = 2 weeks of illness, presence of focus of infection, headache, fever, vomiting. Notethat 50% of brain abscess do not present with fever.

C. Common source of infection: Otitis media, sinusitis, dental infection, post-cranial surgeryD. Four Stages of Brain Abscess:

Stage 1 - Early cerebritis (Day 1-3)Stage 2 - Late cerebiitis (Day 4-9)Stage 3 - Early capsule formation (Day 10-13)Stage 4 - Late capsule formation (=Day 14), thickened capsule

E. Differential diagnosis of CT scan appearance of brain abscess, Neoplasm, granuloma, hematoma,cerebral infarction, schistosomiasis, toxoplasmosis or lymphoma

Oders:

Diet: Osterized feeding 1800 cal, in 6 divide feedings; Insert NGT if with no gag reflexVS. Neuro vital signs q 2 hours and record, refer stat for pupil size difference= 2 mmNursing: Input & Output q shift, insert Foley catheter IVF: D5NR 1 liter X 16 hoursDiagnostics: CBC, CT scan or MRI (Gold Standard)

Treatment: A. Surgical treatment: Aspiration or total excision of abscess

Points for surgical treatment: (1) Abscess > 2.0 cm, (2) Accessible locate of abscess, (3) Abscessstage = 3 - do not aspirate in the cerebritis stage, (4) Unstable neurologic status

B. Medical treatment:

l. Empiric treatmenta. Pen G IV 4 million units IV q 4 hours or Ceftriaxone 2 gm IV q 12 hours or Cefotaxime 2-3gm IV q 6 hours and+ b. Metronidazole 500 kg IV q 6 hours or PO or Chloramphenicol 1.0-1.5 gm IV q 6 hours

2. Treatment based on specific sites of infection:a. From otitis media (etio: Pseudomonas) Tx: Ceftazidime 2-3 gm IV q 8 hr b. Post-neurosurgery or post-traumatic (etiology: Staphylococcus)Tx: Vancomycin 500 mg IV q 6 hours + Ceftazidime IV

3. Mannitol if with signs of increased intracranial pressure4. Steroids may be used to control vasogenic brain edema provided the patient is adequatelycovered with antibiotics

C.Plan of medical treatment and follow-up

1. Give IV antibiotics for at least 4-6 weeks followed by pronged PO therapy of 24 months2. Repeat CT Scan to check for regression or progression of abscess and to confirm the diagnosis

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MYASTHENIA GRAVISTo Neurology Page


Data:

A. Pathophysiology: Autoimmune disease, decreased acetylcholine receptors to post-synapticmembranes.B. Differential Diagnosis: Lambert-Eaton Syndrome, hyperthyroidism, hypokalemia, Guillain- BarresyndromeC. Complications:

1. Respiratory depression2. Myasthenic crisis

a. Exacerbation with threats of respiratory failureb. Common dilemma: Cholinergic crisis (too much pyridostigmine) versus myasthenic crisis

D. Treatment: Treat precipitating factor, e.g. infection, fluid management pulmonary physiotherapy,nebulization

Orders:

Diagnostics:1. Repetitive Nerve Stimulation test (more than 15% decremental response is consideredsignificant); Single Fiber EMG if RNS test is negative.2. Edrophonium anticholinesterase test: 0.2 ml of 10 mg/ml (2 mg) IV (Check ptosis, handgrip,extra-ocular muscles)3. Anti-acetylcholine receptor antibody assay (not available locally)

Therapeutics:1. Anticholinesterase: Pyridostigmine (Mestinon) 60mg tab: PO-30-60 mg q 4-8 hours, maximum360 mg/day

+ Loperamide for diarrhea2. Consider Prednisone 1-2 mg/kg/day for 4-8 weeks, then gradually taper if clinically stable

+ Antacids3. Other treatment options:

a Azathioprine (Imuran) or Cyclophosphamide (Cytoxan)b. Thymectomy: Thymoma present in 15% of myasthenia gravis patients

c. Plasmapheresisd. IV Immunoglobulin therapy




PARKINSON'S DISEASE& OTHER RELATED MUSCULAR DISORDERS

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Data: A. Classification

l. Idiopathic (Primary): Parkingson's disease2. Symptomatic (Secondary)

a Drugs – neurolepticsb. Postencephaliticc. Toxins – manganese, CO, cyanided. Vascular e. Brain Tumor f. Post-trauma – subdural hematoma

3. Parkinson-Plus Syndromesa. Progressive supranuclear palsyb, Multiple system atrophy

i. Striatonigral degeneration

ii. Shy-Drager syndromeiii. Olivapontocerebellar degeneration

c. Dementia Syndromesi. Parkinson’s Dementia Complexii. Normal pressure hydrocephalus

d. Hereditary Disordersi. Wilson’s diseaseii. Huntington diseaseiii. Hallervorden-Spatz disease

B. Pathophysiology: Decrease pigmentation of substantia nigra; decrease production of dopamine that willbind with the dopamine receptors of the striatum (nigro-striatal pathway)C. Cardinal Features of Parkinsonism: Mnemonic TRAP

1. Tremor at rest2. Rigidity3. Akinesia – bradykinesia / hypokinesia4. Posture – loss of postural reflexes, flexed posture of neck and trunk5. Freezing (motor blocks)

D. Definition of Terms:l. Athetosis – slow, writhing, continuous movements2. Ballism – very large amplitude choreic movements, most frequently unilateral and is referred to ashemiballism3. Chorea – involuntary, irregular, purposeless, non-rhythmic, abrupt, rapid, unsustainedmovements that flow from one body part to another.4. Dystonia – twisting movements that tend to be sustained at the peak of movement, repetitive,progress to abnormal posture5. Myoclonus – sudden brief, shock-like involuntary movements causalby muscular contractions6. Tremors – To and So movement of a group of muscles with a fastand slow component in a repetitive manner, regular

Orders:

Diet: No caffeineTreatment:

A. Non-pharmacologic treatment: Group support, exercises physical and speech therapy, education,nutrition, aids to daily living e.g. hand railsB. Pharmacologic Treatment:

1. Carbidopa + Levelopa (Sinemet) 25/100 mg tab, 25/250 mg tab



Half-life: 34 hours, Drug of Choicee.g. Sinemet 25/250 mg 1/2 tab BID; max of 8 tabs/day given BID-QIDStart with the lowest dose then increase gradua1ly until reaching the desired clinical response.Ideally should be given before meals for better absorption if tolerable. If not tolerated(presence of nausea and vomiting), may be given after mealNot to be taken with vitamins because of drug interactionSide-effect: Dyskinesia is most common: This generally happens when too much dopamine is

being taken2. Monoamine Oxidase-B Inhibitor

Selegyline (Jumex) 5 mg tab 1 1/2 tab BID (breakfast and lunch)

Generally add-on therapy to Sinemet3. Anti-cholinergic drugs

Indication: for tremorsa. Trihexyphenidyl HCl (Artane) 5 mg tab: 1/2 -1 tab OD-TIDb. Biperiden (Akineton) 2 mg tab: 1/2 tab BID, maximum 16 mg/dayc. Benztropine mesylate (Cogentin) 2 mg tab: 1/2-1 tab BID maximum 6 mg/day

Side-effect: dryness of mouth4. Dopamine-organist Drugs:

Bromocriptine (Parlodel) 2.5 mg tab

Give with Sinemet, add-on to Sinemet (treatment 2+3)

Suggested dose:1/2 tab OD X 1 week then increase 1.25 mg/day every weekHalf-life = 3-6 hoursTherapeutic response: 6-8 weeks

5. Others:Piribedil (Trivastal Retard 50) 50 mg 1 tab OD; may increase up to 3 tabs/dayParticularly useful where tremors predominate




ALCOHOL WITHDRWAL/DELIRIUM TREMENS

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Data:

A. Clinical Features: Background of chronic alcoholism, new onset of behavioral changes likerestlessness, aggitation and exacerbation of tremors following alcohol withdrawal

B. Differential Diagnosis:.1. Acute confusional states: Seen in alcoholic intoxication or following heavy drinking among

alcoholics2. CNS infection/meningtis. Check meningeal signs to look for neck rigidity, Kernig's sign,

Brudzinsky sign3. Subdural Hematoma: Check head for contusions, hematomas or swelling. Do CT scan of the

head if necessary4. Hepatic encephalopathy: Check for palmar erythema, spider angiomatas. Observe for liver flaps

or asterexis

Orders: Admit to:Diet: Regular, push fluidsVS: Vital signs q 4 hours, Call MD in case of increased agitation or change in neurological statusIVP: D5NM X 12 hoursDiagnostics: CBC, RBS, Serum Na, K, Ca, Creatinine

Serum Ammonia, Amylase, SGOT, SGPT, Urinalysis,Ultrasound of the Abdomen, Chest X-ray, ECG

Therapeutics:1. Diazepam 5-20 mg PO or IV q 6-8 hours

or Chlordiazepoxide (Librax) 1-2 tabs TID-QID, taper in 3-5 days2. Haloperidol (Haldol) 1-5 mg PO TID or 2-5 mg IM IV q 4 hours for severe agitation3. Neurobion 5000 1 tab TID or Neurobion I amp in 1 liter IVF4. Symptomatic Medications:

Metoclopromide (Plasil) 10 mg: 1 tab PO or 1 amp IV, IM q 6 hours or PRNParacetamol for headache




recirculation kinetics. Note that activated charcoal may cause constipation or fecal impaction.c. Activated charcoal is not effective for alkalis, cyanide, mineral acids, ferrous sulfate and

petroleum ingestion.4. Cathartics (Sodium sulfate)

a. Contraindicated in infants, acid and alkali ingestion, patients who will receive an oralantidote, adynamic ileus severe diarrhea, abdominal trauma, surgery, suspected intestinalobstruction, severe elctrolyte loss or dehydration. Magnesium sulfate cathartics are

contraindicated in renal 5ailufailure. Sodium sulfate is contraindicated in hypertension andheart failure.

b. Sodium sulfate 15-30 grams (or 250 mg/kg) in 100 ml water given 30 minutes aper theactivated charcoal. If still without bowel movement within one hour, may repeat procedure.

5. Forced Diuresis

Warning: Forced diuresis should only be attempted in treatment centers that can monitor hydrationand electrolyte status of patients.

a. Forced Diuresis: Maintain urinary flow rate of 5-7 ml/kg/hr by infusing normal saline andintermittent boluses of Furosemide 20 mg IV doses. Alternatively, use mannitol 20-100 gm IV,maximum 300 gm Monitor electrolytes and state of hydration.

b. Forced Alkaline Diuresis: May be useful for phenobarbital, mephobarbital, primidone,

salicylates, lithium, isoniazid. Adult dose: Sodium bicarbonate 1-2 amp IV followed bycontinuous IV infusion of 1-2 ampules (50-100 mEq) of sodium bicarbonate in 1 liter of

0.25-0.45 and normal saline at 250-500 ml/hr the first 1-2 hours. Maintain the urine pH of7.3-9.0. Add additional 0.45% normal saline and intermittent doses of Furosemide 20 mg IV.Increase urine output to 2-3 ml/kg/hour.

6. Miscellaneous Antidotes

a Extrapyramidal reactions to Pheaothiazines or Metoclopromide

Diphenhydramine 25-50 mg IV or IM q 6 hours X 4 doses; followed by 25- 50 mg IVor PO q 6hours for 24-72 hours PRN.b. Benzodiazepine overdose (e.g. Diazepam, Midazolam, Lorazepam)

Flumazenil 0.5 mg/5 ml ampule: 0.2 mg IV q 5-15 minutes until the patient wakes up er until 1 mgis reached. Consider gastric emptying, activated charcoal. Administer cathartic and conservativesupportive therapy.

C. Guidelines for Nurses:

1. When antidotes are ordered, it is meant to be given immediately or at least reasonably within thehour in some cases. They are not given when it is the next convenient dosing period for thenurses (i.e. TID, q 6 hours)

2. Always check with the Pharmacy for the available antidote or the Poison Center before asking thepatient to purchase these at outside pharmacy outlets because these special drugs may not becommercially available. Inform the doctor at once when it is known that these drugs are notavailable. Some special antidotes are available in the PGH Central Block Pharmacy telephoneNo. 521-8450 local 3163). Examples are N-acetylcysteine, N-acetyl penicillamine and succimer.These may be requested for use by the hospital in need but should satisfy two requirements: (a)the attending physician shouid sign a waiver freeing PGH of any liabilities from the use of suchantidotes and, (b) a toxicology consultant is preferably invited to co-manage the case.

3. For collection of specimens, see Table 9-1.

Table 9.1 Available Tests and the Specimen Required for Determination.

Test Sample Required Special Instructions

RBCcholinesterase

5 ml heparinized

Freshly collected bloodsample; place in iceimmediately after collectionand during transport to thelab



Salicylate

2 m1 serum

Collect 5 ml blood in a plaintube

Methanol

Plasma

Collect 5 ml blood withanticoagulant (citrate oroxalate except heparin and

EDTA); place in ice Ethanol

Serum

Collect 5 ml blood in a plaintube

Paracetamol

Serum/urine

Collect 5 ml blood in a plaintube or 10 ml freshly voidedurine

Mercury

10 ml heparinizedblood50 ml aliquot of 24hour urine

Collect 10 ml blood inheparinized tube Collect 24 hr urine (e.g. 8Wam-8:00 am the 0llowiegday, mix well and submit 50

ml aliquot Isoniazid

5 ml serum or 10ml urine

Collect 10 ml blood in plaintube or 10 mlFreshly voided urine

Coproporphyrin

200 ml aliquot of24 how urinesample

Place 10 ml sodiumcarbonate to the collectionbottle, collect s 24 hr urine,mix well and submit 200 mlaliquot

Phenobarbital

Serum

Collect 5 ml blood in plaintube

Amphetamine /Metamphetemine

Urine

Collect freshly voided urine

Phenothiazine

10 ml urine

Collect freshly voided urine

Paraquat / Diquat 10 ml urineCollect freshly voided urine

Quinidine /Quinine

10 ml urineCollect fleshly voided urine

Para-nitrophenol 15 ml urineCollect freshly voided urine

Methemoglobin/Sulfhemoglobin

5 ml heparinizedblood

Collect 5 ml blood inheparinized test tube

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ALKALI INGESTION

Diet: NPONursing: Monitor BP, HR, abdomen for guarding & tendernessDiagnostics: Serial CBC, Cross-matching; Monitor electrolytes

Upright CXR & Abdominal films (check for perforation, pneumoperitoneum)

Therapeutics:1.. Immediately rinse the oral cavity copiously with cold water. Protect airway, and administer

oxygen and fluids if appropriate; antibiotics if evidence of esophageal injury is present.2. Esophagoscopy and gastroscopy should be performed immediately if there is drooling, stridor

or painful swallowing; otherwise it may be deferred for 12-24 hours. Hydrocortisone dose IV isrecommended for deep or circumferential burns with tapering of dose over three weeks.

3. Emesis, neutralizing agents, gastric lavage, cathartics and charcoal are all contraindicated.




AMPHETAMINE / METAMPHETAMINE TOXICTIY

Admit to:Diagnostics: CBC with platelet, PT, PTT, RBS, BUN, Creatinine, Na, K, CPK-total

Urine amphetamine level, Urinalysis, ABGTherapeutics:

l. Activated charcoal and cathartics. Emesis has no role.2. Further elimination with:

a. Mannitol 20% 50-100 ml q 6 hoursb. Acidification of urine with Vitamin C at 1 gram q 6 hours provided CPK total is normal

3. Watch out for complications:a. Seizures: Diazepam 5-10 mg IV up to 20 mg followed by loading dose of Phenytoin 18 mg/kg inNSS IVb. Psychosis or agitation: Chlorpromazine or Haloperidol (may also reduce hypertension),Diazepam IVc. Hypertensive crisis: Alpha-blocking agents or Beta-blockersd. Arrhythmias: Propranolol or Lidocaine

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ANTICOAGULANT OVERDOSE Orders:

Admit to:Diagnostics: CBC with platelet count PT, PTT CreatinineTherapeutics:

A. Heparin1. Give Protamine sulfate at 1 mg IV for every 50 - 100 units of heparin infused in the preceeding2 hours; dilute in 25-50 ml IV fluid over 10 minutes

B. Warfarin

1. Perform gastric lavage and give activated charcoal if recently ingested2. Give Vitamin K 5-10 mg IV or SC q 8-12 hours3. Give fresh frozen plasma 2-6 units for severe bleeding




DIAZEPAM OVERDOSE Orders:

Admit to:Nursing: I & O; Pulse oximeter; Aspiration and seizure precautions; Monitor BP and respirationDiagnostics: CBC, RBS ABG

CXR, ECG Cardiac monitoring, Pulse oximetryTherapeutics: Support BP and respiration1. Place NOT, and do gastric lavage

Protect airway with endotracheal tube2. Instill 50-100 gram charcoal, followed by repeated doses of 20-25 gm via NGT q 4-6 hour 3. Cathartics4. Flumazenil 200 mcg IV q 5-15 minutes until patient wakes up or a total of 1mg is reached. Note: Flumazenil may precipitate withdrawal seizure on chronic users of diazepam. Watch out forhypotension, CNS, respiratory depression and withdrawal syndrome (agitation, seizures, restlessness,insomnia).

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DIGITALIS/DIGOXIN OVERDOSETo Toxicology Page


Data:

Digitalis Induced arrhythmias: Isolated PVC's; second degree block (Wenckebach); third degree block,

paroxysmal atrial tachycardia with block; or slow, regularized atrial fibrillation. Orders:

Admit to:Nursing: Insert a reliable IV line, placeNGT and do gastric lavageDiagnostics: Digitalis assay, CBC, Ca, K, Mg

CXR, ECG, Cardiac monitoring needed

Therapeutics:l. Discontinue digitalis preparations, correct hypokalemia, hypomagnesemia, or hypercalcemia. Administercharcoal slay every 4-6 hours, and cathartics.

Replete fluids and electrolytcs. Dialysis may be needed if with persistent hyperkalemia.2. Symptomatic sinus node depression and low-degree AV block.

Atropine 0.5 mg IV q 5 min, maximum of 3 mg3. Bradycardia: If hemodynamic compromise occurs, may require artificial pacing.

4. Serious ventricular arrythmiasLidocaine 75-100 mg (1 mg/kg) IV over 5 min or use Phenytoin IVNote: Defibrillation may be dangerous for the patient.




ETHANOL TOXICITY

Orders:

Admit to:Nursing: I & O, Consider placing NGT followed by gastric lavage if patient is seen early after alcoholintake.

Diagnostics: CBC, RBS, Ca, Mg, Phosphate, Creatinine, ABGSerum ethanol level, serum lipase, amylase

Urinalysis, ECGTherapeutics:1. Maintain adequate airway, ventilation, circulation, and administer oxygen2. Thiamine 100 mg IV or IM q 8 hours, followed by Glucose 25-50 g IV3. Seizures:

Diazepam or Phenytoin IVNote: Watch out for signs and symptoms of ethanol withdrawal, in whichcase diazepam is indicated. Also, check for signs and symptoms of subduralhematoma.





ISONIAZID OVERDOSE

Orders:

Admit to:Nursing: I & O; Insert foley catheter IVF: D5NM 1 liter x 8 hours

Diagnostics: CBC, WBC (Leukocytosis)ABG(Metabolic acidosis)

K(Hypokalemia)

RBS(Hypoglycemia); Toxicology Screen

CPK-Total (Rhabdomyolysis)

Therapeutics:1. Place NGT and do gastric lavage till clean. Administer Activated charcoal2. Antidote: Pyridoxine HCl (Vit B6) 1 gm/10 ml given gram per gram basis

Example: Ingestion of 10 tabs INH 400 mg requires 4 grams of Pyridoxine HCl IV3. Seizures: Diazepam 5 mg IV for active seizure4. Metabolic acidosis: If pH < 7.15-7.20, administer sodium bicarbonate IV infusion to correct acidosis

early.5. Consider Mannitol 20% 100 ml now then 75 ml q 6 hours




NARCOTIC OVERDOSE(Pethidine, Morphine, Heroin Nalbuphine)



Admit to:Nursiag: Place NGT and do gastric lavage (if narcotic is orally ingested)Diagnostics: CBC, RNS, Na, K, Creatinine

CK-MB, CPK-Total ABG, UrinalysisCXREGG, consider Cardiac Monitoring and Pulse Oximeter

Therapeutics:1. Maintain airway, ventilation, and circulation2. Naloxone 2.0 mg q 5 minutes initially via IV, IM, SC, endotracheally or continuous IV until patient’ssensorium end respiratory pattern improves.

Naloxene is preferable to be given as IV push in regular intervals.Maintenance dosage: 0.4 - 0.8 IV push as needed q 10-15 minutes to maintain respiration. Notehowever, that in cases of acute narcotic overdose on top of chronic use, withdrawal seizures

may be precipitated.3. Activated charcoal if (+) bowel sounds and cathartics

Observe for signs of pneumonia, infection, hypoxia, and rhabdomyolysis4. Watch out for complications:

a. Seizures due to accumulation of Norpethidine (a metabolite of pethidine): Give Diazepamand Phenytoin IVb.. Pulmonary edema: Give oxygen, furosemide, positive pressure ventilationc. Hypotension: May use fluid resuscitation and dopamine




ORGANOPHOSPHATE POISONING(Insecticides/Pesticides)



Orders:

Admit to:Nursing: NPO; I & O; Insert foley catheter Diagnostics: CBC, Na, K, RBS, BUN, Creatnine CBO q 12 hours

SGOT, SGPT, Amylase, PT, ABG

RBC Cholinesterase (5 ml heparinized blood sent to Department of Pharmacology Lab, 3rd

Floor, UP College of MedicineUrinalysis (if output is reddish check for MyoglobinCXR, ECG

Therapeutics:1. Decontamination

a. External decontaminationHave the patient rinse gently with alkaline soap or baking soda (10 gm in 100 ml Water)

Change clothes and wash patient with soap using gloveb. Internal decontamination

Insert NGT and do gastric lavage with activated charcoal 200 gm in 200- 500 ml water 2. Activated charcoal 1 gm/kg PO then sodium sulfate 15-30 grams in water after 30 minutes. Repeat

sodium sulfate after one hour if still no bowel movement.3. Antidote: Atropine Sulfate 0.01-0.05 kg/kg IV q 5 minutes or 1mg IV usually

Maintain the following parameters: Dry mucosa, HR > 60 bpm (target HR of around 100 bpm),hypoactive bowel sounds, pupils > 4 mm; watch out for Atropine toxicity such as temperature > 39C, absence of sweating, psychosis and restlessness.

4. Seizures: Diazepam 5 mg IV q 8 hours, Consider Phenytoin IV5. D50-50 glucose 1 ampule q 6 hours6. Mannitol at 1 ml/kg IV in 10 minutes as test dose, If with good urine output, give 2.5-5 ml/kg q 6 hours

x 8 doses7. If with arrhythmia, do not give beta-blockers or Lidocaine; may give calcium-channel antagonists or

Phenytoin instead.8. Avoid the following drugs: Furosemide, beta-blockers, sulfa-containing drugs and aminoglycosides.9. Correct acidosis with sodium bicarbonate




PARACETAMOL OVERDOSAGE



Admit to:Diet: NPO during initial treatment of gastric lavage, then may resume diet if patient is conscious and

coherent.VS: Neuro vital signs q 1 hour Nursing: I & O; Aspiration and seizure precautions; Place NGT then lavage with water IVF: D5NS X 8 hoursDiagnostics: CBC with platelet

RBS, BUN, Creatinine, SGPT, SGOT, PT, PTT, Amylase

Alkaline Phosphatase (daily for at least 3 days), Urinalysis

Serum Paracetamol Ccncentration (Note time of blood extraction and timeof Paracetamolingestion)

Therapeutics:1. Nasogastric tube2. Activated Charcoal 30-100 gram doses, remove via NGT suction prior to oral acetyleystein

antidote.3. Sodium sulfate4. IV Antidote: N-acetylcysteine (Hidonac) 200 mg/ml injection

Available commercially and at PGH Central Block Pharmacy (Tel. No. 521-8456 local 3163).a. Dosage and administration: An initial dose of 150 mg/kg body weight of N-acetylcystine is

infused in 200 ml 5% dextrose IV over 15 minutes, followed by an IV infusion of 50 kg/kg in500 ml 5% dextrose over the next 4 hours, then 100 kg/kg in 1 liter 5% dextrose over thenext 16 hours. (This gives a total dose of 300 mg/kg in 20 hours.)

b. N-acetylcysteine is very effective in preventing Paracetamol-induced hepato-toxicity whenadministered during the first 8 hours after a paracetamol overdose. When administeredafter the first 8 hours, the protective effect diminishes progressively as theoverdose-treatment interval increases. However, clinical experience indicates that N-acetylcysteine can still be of benefit when administered after 24 hours in patients at risk of

severe liver damage. In general, for patients presenting later than 24 hours after aparacetamol overdose, guidance should be sought from PGH Poison Control Center.c. Treatment nomogram (See Figure 9-1): Plasma paracetamol concentration in relation to

time after the overdose is commonly used to determine whether a patient is at risk ofhepatotoxicity and should therefore receive treatment with an antidote such asN-acetylcysteine.

Figure 9-1 Plasma Paracetamol (Acetaminophen) Concentration in Relation to Time after Overdosage as

a Guide to Prognosis.



Source: Adapted from Smilkstein MJ, Knapp GL, Kully KW, et al (1988), Efficacy of oral N-Acetylcystein inthe treatment of acetaminophen overdose: Analysis of the National Multicenter Study.N Engl J Med : 1557,1988




PHENOTHIAZINE /NEUROLEPTIC OVERDOSE



Admit to:Diagnostics: ECG, Toxicology Screen, specifically Forrest test

Abdominal X-ray may show pill concretions

Therapeutics:l. Insert NGT2. Activated charcoal initially 1gm/kg then 0.5 gm/kg q 4-6 hours for 2 days3. Treat Complications:

a Cardiac arrhythmias: Give Lidocaine IVb. Seizures: Diazepam IVc. Nueroleptic malignant syndrome (associated with hyperthermia, autonomic dysfunction, muscular

rigidity and coma states): Dantrolene if indicatedParanormal and cooling measuresNote: Do not give Aspirin

d. Acute Dystonic Reactions or Extrapyramidal Reactions:

i. Hold anti-psychotic medsii. Diphenhydramine 25-50mg IV or IM q 6 hours X 4 doses, followed by 25-50 mg IV or PO q

6 hours for 24-72 bwrs PRNiii. Biperiden 2 mg tab: 1 tab TID




SALICYLATE OVERDOSE(ASPIRIN)



Admit to:Diagnostics: CBC, Blood culture and sensitivity, Ff, FFT (48 bouts post-ingestion

SGPT, SGOT, Alkaline Phosphatase (48 hours post-ingestion)RBS, Na, K, Cl, BUN, Creatinine, ABG

Urinalysis Stool exam with occult blood

ECG, CXRTherapeutics:

1. Stabilize respiratory and cardiac functions. Avoid diluting gastric contents Since this may increasegastric absorption.2. Nasogastric tube3. Activated Charcoal: 1 gm/kg body weight q 5 hours for 2 days4. Sodium sulfate 15-30 grams in 100 ml H2O orally or per NGT with every other doses of activatedcharcoal to prevent charcoal constipation or fecal impaction5. Glucose and KCl should be infuse with othet fluids

Treatment Plan:l. If with dehydration and kypokalemia (due to vomiting), manage with vigorous fluid and electrolytereplacetnent. Cerebral edema can best be avoided by using hypertonic rehydration solutions.2. Elimination Measures:

a Alkaline diuresis to maintain urinary pH at approximately 8.0 by giving sodium bicarbonate IV [100mEq of sodium bicarbonate (2 amps) in 1 liter of D%W at 10-15 ml/kg/hr]. Monitor urine output,urine pH and serum K, and increase alkalinization at a tate of 2-3X maintenance rate fluidrequirement if the patient is dehydrated, until urine flow is adequate. Follow arterial pH closely toavoid excess systemic alkalinization. Watch closely for signs of fluid overload.

b. Hemodialysis is indicated for initial salicylate level > 160 ml/dl or when 6-hour level is > 130 mg/dl orwhen profound acidosis (pH < 7.1); or when there is renal failure, severe CNS dysfunction;pulmonary edema or deterioration despite supportive therapy.

c. Other treatments:i. Acidemia: IV Sodium Bicarbonateii. Seizures: IV diazepamiii. Pulmonary edema: Treat with high concentrations of oxygen, furo-semide and positive

end-expiratory pressure ventilationiv. Cerebral edema: Treat with hyperventilation and osmotic diuresis with Mannitol




TRICYCLIC ANTIDEPRESSANT OVERDOSETo Toxicology Page


Orders:

Admit to:

Nursing: I & O; Pulse oximeter; Aspiration and seizure precautionsDiagnostics: CBC, Na, K, Mg, Creatinine, ABG

CXR, ECG, Cardiac Monitoring

Therapeutics:1. Place NGT and do gastric lavage

Protect airway with endotracheal tubeInstill 50-100 grams (1gram/kg body weight) charcoal, followed by repeated doses of 25 grams(0,5 gram/kg body weight) via NGT q 4-6 hours for 2 daysSodium sulfate 15-30 grams

2. Serious cardiac toxicity:Treat with alkalinization; goal of treatment is to achieve arterial pH of 7.5

Administer sodium bicarbonate, 50-160 mEq (1-2 ampules) IV in 10 min; followed by infusion of 2ampules of bicarbonate in 1 liter of D5W at 50 ml/hour . Mechanical ventilation andhyperventilation may be required to maintain PCO2 25-30 mmHg, pH > 7.45. Avoid excessive

systemic alkalosis.3. Indications for alkalinization:

Significant acidosis, bradycardia, arrhythmias, interventricular conduction abnormalities (QRS >100 msec or heart block), hypotension, abnormalities of mental status or seizures.

4. Seizures:IV Lorazepam or Diazepam followed by Phenytoin

5. Symptomatic bradycardia:If refractory to alkalinization, treat with Atropine or Terbutaline infusion and consider pacemaker.

6. Ventricular tachycardia or fibrillation:If refractory to alkalinization, treat with Lidocaine, loading dose 50-100 mg (1-2 mg/kg), then infuse2-4 mg/min IV

7. Supraventricular arrhythmias: LidocaineIf refractory to alkalinizatien, or if hypotension, heart failure, MI occurs, consider DC cardioversion.

8. Hypotension: Hydrate with normal saline, treat with Norepinephrine




Recommended Diet by Organ System

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Disorders Recommended Diet

Gastritis Low-fiber, bland

Peptic ulcer Bland

Vomiting Fluid and electrolyte replacement

Constipation High-fiber, increased fluids

Diarrhea Liquid, low-fiber, regular, fluidelectrolyte replacement

Cirrhosis w/hepaticInsufficiency orencephalopathy

Protein-restricts sodium-restricted,fluid-restricted

Stable cirrhoticpatients

Normal protein

Gallbladderdisease

Low-fat, calorie-restricted, regular

Hepatitis Regular, high-calorie, high-protein

Pancreatitis Low-fat, regular, small, frequentfeeding, tube feeding or totalparenteral nutrition

Hyperlipidemias Fat-controlled, calorie-restricted

Hypertension,heart failure,coronary arterydisease

Low-sodium, calorie-restricted,faulted

Acute renaldiscase

Protein-restricted, high-calorie,fluid-controlled, sodium-controlled,potassium-controlled

Chronic muddisease

Protein-restricted low-sodium,fluid-restricted,potassium-restricted,phosphorus-restricted

Kidney stones Increased fluid intake,calcium-controlled low oxalate

Nephroticsyndrome

Sodium-restricted, high-calorie,high protein potassium-restricted

Chronic obstructivepulmonary disease

Soft, high-calorie low-carbohydrate,high-fat small frequent feedings

Underweight,tuberculosis,cancer

High-calorie high-protein

Food sensitivities Elimination of offending substance

Obesity,overweight

Calorie-restricted, high-fiber

Stroke Mechanical soft, regular, or tubefeeding

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High Fiber Diet

Food Group Allowed

Vegetables Leafy, legumes (dried beans,peas etc.)

Fruits Ripe papaya, dried prunes,raisins, mangoes

Rice orsubstitute

Pinipig, oats, corn, whole wheator rye bread breakfast cereals,bran and fiber




Low Calorie DietTo Nutrition Page


1. Indication: Obesity; overweight cardiac, hypertensive arthritic or diabetic individuals; hypothyroidism;

prolonged bed rest or in elderly patients.2. Calories are reduced by limiting carbohydrates and fats while keeping protein at the normal level of 1.1

gm or more per kg body weight per day. However, very low calorie diets, 1200 kcal or less, requirevitamin and mineral supplementation.

Nutritionist-Dietitians' Association of the Phillppiaes (NDAP)

formula for normal calorie: calories/kg body weight/day

Activity level* Male Female

In bed butmobile

35 30

Light 40 35

Moderate 45 40Heavy 50

*Examples of activity levels:Sedentary - secretary, clerk, typist, administrator, bank teller Light - teacher, nurse, student, physician, lab. technician, house with maidsModerate - housewife w/o maid, vendor, mechanic, jeepney and car driver Heavy - farmer, laborer, cargador, miner, fisherman, heavy equipment operator

Food Group Allowed Restricted

Vegetable All None

Fruit All, fresh canned in

water only

Candied canned

syrupMeat orsubstitute

Boiled, broiled,baked: lean beef,pork, chicken, fish,eggs; skim milk,cheese, beans, &legumes

With excessive fator fried orprocessed with oil,cream, whole milkcheese

Fat None Gravies, sauces,cream, nuts,coconut, saladdressings

Sugar andsweets,dessert

Gulaman, gelatinwith littlesugar

Jam, jelly,marmalade, syrup,candy, honey,chocolate bars

Beverage Calamansi, coffee,tea with artificialsweetener, "diet"carbonatedbeverages inmoderation

Regular,carbonated & alcohol drinks, milkshakes, maltedmilk

Soup Fat-freemeat,chicken,orfish broths

Cream soups



Miscellaneous Spices, condimentsw/o sugar

"Snack foods" e.g.popcorn, snackchips





High Calorie Diet 1. Indication: Underweight, hypercatabolic conditions like hyperthyroidism, injury, burns, fever and

infections2. Just reverse the above regimen for low calorie diet. Increase intake of foods in the right column

(restricted group for low calorie diet). Increase necks.




Low Protein DietTo Nutrition Page


1. Indication: Acute glomerulonephritis with impaired renal function, chronic renal failure with impairedrenal function without hypertension, advanced liver disease . with hepatic insufficiency orencephalopathy

2. This diet provides about 30g of protein per day This is achieved with a liberal use of carbohydrates,and

fat. Cereals beans and nuts used in limited amounts. The diet is low in vitamin B and iron.

3. Low-protein = 0.6 gm/kg BW/day

Normal-protein = 1.1 gm/kg BWHigh-protein = 1.5 gm/kg BW


Vegetable All except legumes Legumes

Fruit All

Meat or

substitute

All except nuts, seeds

and beans in allowedamounts

Fat Cooking fats, butter,margarine, salad oilsand dressings

Coconuts,other nuts

Sugar andSweets

All None

Dessert Plain arrow roots orcornstarch andpuddings, nata decoco, tatamis na bao,kondol, sago, kaong,kamoteng kahoy

Those withmilk, eggs,nuts cerealse.g. icecream,bibingka,

cookies,custard, etc.

Miscellaneous Sotanghon, saucesthickened w/cornstarch only,herbs and spices inmoderation




Low Fat / Low Cholesterol DietTo Nutrition Page


aIndication:

i. Low fat – Weight reduction, cholecystitis, cholelithiasis, atherosclerosis, portal cirrhosis,hepatitis, pancreatitis, sprue, fat malabsorptionii. Low cholesterol - hypercholesterolemia, coronary artery disease, adults with family history ofheart disease (as primary preventive measure)

b. Low At provides no more than 15% of total ovaries or about 1800 kcal and 30 grams fat. Sinceabsorption of fat-soluble vitamins is impaired when fat intake is low, supplementation of the diet withthese vitamins, especially vitamin A, is desirable.

c. Low cholesterol diet regulates both the amount and type of fat. It is planned to provide 15-25% of thetotal calories of fat. Dietary cholesterol is kept at less than 300 mg/day.


Vegetable All, cooked w/oadded fat

Fried, buttered, creamed

Milk Whole or evaporatedcow’s milk inmoderation, skim ornon-fat milk

Carabao's milk,condensed milk

Rice orsubstitute

All cereals, roots,tubers; macaroni,sphaghetti pan-de-sal

Mami, miqui, breads withadded fats eg. croissants,muffins, pancakes, sweetills, biscuits

Meat, fish orsubstitute

Lean, w/o skin andfat, boiled, broiled orbaked, egg cookedin any way exceptfried skim milk

Fried canned in oil,processed canned orfrozen meats, drippingsfrom meat, internalorgans, fried eggs,sausages, lobster, shrimpheads,oyster, clam, crab

(aligui) cream cheese,whole milk nuts

Fat None Cream, butter, oil, saladdressings mayonnaise,gravies, chicharon

Desserts Gelatin, fruits ices,angel cake

Pies and pastries,chocolate




Low Carbohydrate DietTo Nutrition Page


1.. Indication: Chronic obstructive pulmonary disease, dumping syndrome

2. Provides no more than 50% of total calories, diet is higher in fat and protein than the normal diet


Vegetables Starchy vegetables

Milks Unsweetened Condensed,chocolate, cocoa

Rice orsubstitute

All

Meat orsubstitute

All except beans Beans and beanproducts

Sweets None All

Desserts Gelatin,artificialsweeteners

All

Beverages Coffee, tea w/osugar

Carbonated knon-carbonated

Soups Clear broths Thickened w/ flour orcornstarch

Miscellaneous Spices andcondiments w/osugar

Sweet pickles,catsup, gravies,popcorn




Low Sodium DietTo Nutrition Page


1. Indication: Congestive heart failure with edema, hypertension, liver disease with ascites,

glomerulonephritis, nephritic syndrome, acute and chronic renal failure2. Regular diet of 2800 to 6000 mg sodium or 7-15 grams of table salt. No salt is used in the preparationand service of meals


Soups Plain broths w/osalt

Canned soups, bouilloncubes and meatextracts

Protein-richfoods

One egg per dayonly

Canned, salted, cured,processed meat,smoked, fish poultry;cheese, peanut butter

Vegetables All fresh Spinach, kinchay,

mustard, beetsFats Unsalted fats,

butter ormargarine

Commercial saladdressing, salted nuts,chicharon, snack chips

Miscellaneous Commercial sauces andseasonings; bagoong,patis, soy sauce, tausi




Low Potassium DietTo Nutrition Page


1. Indication: Hyperkalemia, acute and chronic renal disease

2. This is a diet in which the potassium content is reduced to about 1.0 to 1.8 grams (25 to 46 rnEq) perday. The usual diet contains about 2 to 6 grams (51.3 to 153.6 mEq) daily, coming mainly fromvegetables, cereals, fruits meat, fish and poultry. Vitamins A and C are likely to be low and must beprovided in the form of supplements. The diet should be used for limited periods as a supplement tomedical therapy.

Food Group

Vegetable

Allowed Restricted

Fruit Patola, tomato,ampalaya,cabbage, sitaw (inallowed amounts

Cauliflower, celery,mushroom,.squash, all leafyvegetables

Meat orsubstitute

Fresh pineapple (inallowed amounts)

Apple, latundan,orange, papaya,

lanzones, melon,santol

Fat Alimango,alimasag, oysters,frank-furters,sausages, tokwa,beans, cottagecheeses, sardines

Miscellaneous Butter, margarine,mayonnaise, skimmilk

Coconut milk,avocado, peanutbutter

White sugar, plaingelatin, vinegar,garlic, ginger,vanilla, mustard

Catsup, cream oftartar, yeast, brownsugar, panotsa




Low Uric Acid / Low Purine Diet:To Nutrition Page


1. Indication: Hyperurecemia (high uric acid levels), gout

2. Low purine diet is about 120-150 mg/day whereas regular diet contains as much as 600 to 1000mg/day. Diet should be relatively high in carbohydrate and low in fat since since carbohydrates havebeen shown to favor uric acid excretion while fats tend to favor retention. A liberal intake of fluids ishelpful in eliminating excess uric acid and in minimizing calculi formation.


Vegetable All except thoserestricted

Asparagus, cauliflower,mushroom, spinach

Rice orsubstitute

Rice, cereals Oatmeal, whole wheatand whole grain cereals

Meat orsubstitute

Milk, cheese, meatin

allowed amountsonly

Mussels, meat extracts,brain, internal organs,

beans, lentils, legumes,sordines, tunsoy, tamban,mackerel (alumahan,hasa-hasa, tanigui),anchovies (dilis,bagoong), tahong

Beverages

Milk, tea, coffee Alcoholic beverages

Miscellaneous Gelatin, fruits

Gravies (sarsa), meatextracts, patis, yeast,nuts




Nutritional Management of Diabetics and Renal Patients


To Detailed Table of Contents1. Nutritional management of Diabetes Mellitus:

a. Total calories - sufficient to maintain reasonable weight in adults, or meet increased needs ofchildren, adolescents, pregnant and lactating women and individuals recovering from catabolic illness.

b. Caloric distributionCarbohydrates: 50-70%Protein: 10-20%Fat: 20-30%

c. If obesity and weight loss are the primary issues, use the lower fat levels (20-25%) of total calories.d. Cholesterol - limit to 300 mg/day or lesse. Carbohydrates and sweeteners

Non-nutritive sweeteners: Aspartame may be used in moderationDietary fiber: Aim for about 20 grams/day or more. Excessive amounts are not necessary.It is best to limit the use of sucrose and sucrose containing foods.

f. Sodium - limit to about 3000 mg/day; less for people with hypertension or renal complicationsg. Alcohol - moderate amounts may be allowed, contingent on good metabolic control

h. Vitamin and mineral supplements - not usually necessary, but may be given to individuals on reducedcalorie diets (1000 kcal/day or less)

2. Nutritional Management of Chronic Reaal Insufficientcy (CRI)

a. The diet for chronic renal inefficiency is also called predialysisdiet . The diet is restricted in two majornutrients: protein and phosphorus. Restrictions in sodium, postassium, fluid and calories are basedon individual needs. Because of restrictions in certain foods, the diet is deficient in calsium, iron,Vitamin B12 and zinc. The diet.aims to reduce the workload of the diseased kidney(s) by reducing theurea, uric acid, creatinine and eleetrolytes (especially phosphates) that must be excreted andpostpone the need for dialysis.

b.

DietaryModifications

Recommendation

Protein (gm/kgIBW)

0.6-0.8*

Energy (kcal/kgIBW)

Normal weight: 35kcal/kg IBWObese: 20-30Underweight orcatabolic: 50

Phosphorus(mg/kg. IBW)

8-12

Sodium (mg/day). 1000-3000**

Potassium, Fluid,Calcium

Typically not restricted

Fiber 20-25 gm/day

*The upper limit of, this range is preferred for patients with diabetes or malnutrition. For nephroticsyndrome, allow 0.8-1,0 g/kg IBW.**Additional sodium, may be required with salt-losing nephropathies

3. Nutritional Management of Chronic Renal Failure (CRF):

a. The diet for CRF is designed to meet nutritional requirements minimize uremic complications,maintain acceptable blood chemistries, blood pressure and fluid status, The diet is used for patients



with CRF requiring hemodialysis or peritoneal dialysis treatments.

b.

Dietary

Modifications

Hemodialysis Peritoneal Dialysis

Protein(gm/kg/IBW)

1.1-1.4; at least60%high biologicvalue

1.2-1.51.2-1.3 for maintenance1.5 far repletion1.2 for reduction or ifwith diabetes

Energy (kcal/kgIBW)

30-35 for wt.maintenance25-30 for wt.reduction40-50 for weightgain

25-30 far maintenance35-50 for repletion20-25 for reduction35 if with diabetes

Phosphorus < 17 meq orapproximately800-1200 mg/d

(keep serumlevelmax of 4-6 mg/100ml)

< or approximately at1200 mg/day

Sodium

2000-3000mg/day

Individualized based onblood pressure & weight

Potassium 40 mg/kg IBW orapprox 50-80meq/day(1250-2000mg/day)

General1y unrestrictedwithCAPD and CCPD

Fluid 500-700 ml/dayplus dailyurine output orapprox.

700-1500 ml/day

CAPED & CCPD,approx.2000-3000 ml/daybased on daily weight

fluctuations and bloodpressure

Fat Limit cholesterolto < 300 mg/day;

emphasizepoly-unsaturated

fats

4. Food Selection Guide for Renal Patients:

Food

Group

Allowed Restricted

Vegetable All fresh in

allowed amountsPickled vegetables, saltfermented vegetables likeburong mustasa, kimchi,sauerkraut, canned andfrozen vegetables



Fruit All except thosein avoided list, inallowed amounts

Maraschino cherries,candies fruits,dried fruits

Milk Evaporated,whole in allowedamounts

Commercial foods madewith milk, condensedmilk, sherbet, cocoa,chocolate, malted milk:

Rice Rice, bread,bihon, macaroni,spaghetti, corn,all of theirproducts inallowed amounts

Commercially prepareddesserts and pastries;snack chips; cereal orcrackers with bakingsoda, salt or other sodiumcompounds; whole wheatgrain, breads andcereals, mami, mike,misua, instant noodles

Source: Adapted from Tanchoco CC, Cardino I, Jamorabo A, Panlilio I Ruiz E, Ruiz V, Villaraza ME(1994). Nutritionist-Dietitians' Association Of The Phillipines (NDAP) Diet Manual (4th Ed.),withpermission.




PREGANANCY & HYPERTENSIONTo Pregnancy Page


Data:

Table 11-1. Hypertensive Disorders of Pregnancy.

Clinical Finding Chronic

HypertensionGestationalHypertension

Preeclampsia

1. Time of onset ofhypertension

< 20 weeks ofgestation

Usually inthirdtrimester

= 20 weeks ofgestation

2. Degree of:hypertension

Mild or severe Mild Mild or severe

3. Proteinuria* Absent Absent Usuallypresent

4. Serum urate >5.5mg/dl

Rare Absent Present inalmost allcases

5.Hemoconcentration,thrombocytopenia,liver dysfunction

Absent Absent Present inseveredisease

6. LVH by EGG May bepresent

Absent Absent

*Defined as =1+ by dipstick testing on two occasions or = 300 mg in a 24-hour urine collection. Source: Sibai, B.M. (1996). Treatment of hypertension in pregnant women: A review article. N En 1 J Med,335, 257-265.

Orders: Admit to:Diet: Low salt, high calcium dietVS: q 1 hour with neurochecksNursing: I & O Place foley catheter; Check deep tendon reflexes; Urine output, Complete bed restIVF: D5NM X 12 hoursDiagnostics: CBC with platelet count Blood typing, PT, PTT

SGPT, SGOT, BUN, Creatinine, Uric acid

Urinalysis, 24-how urine Albumin collection

Therapeutics: Mneumonic 4 A's (Aldomet, Apresoline, Atenolol, Adalat)

A. Gestational Hypertension

- may be an early manifestation of pre-eclampsia- outcome generally is good without drug therapy

B. Chronic Hypertension

- use 4 A's (see below) No. 1-4C. Pre-eclampsia

- Target diastolic BP between 80-100 mmHgl. (Aldomet) Methyldopa 250-500 mg tab TID PO, maximum = 3 gm/day

2. (Apresoline) Hydralazine 5 mg slow IVP stat dose q 20 min up to 4 doses; Apresoline drip D5W

250 cc + 2 amps Apresoline (20 mg/amp) to run initially at 10-15 uggts/min then to titrate up to 60ugtts/min or Apresoline 25-50 mg tab TID-QID PO; Maximum of 300 mg/day



If patient develops tachycardia, headache or nausea, shift to Nifedipine SL or PO3. Atenolol (Tenormin) 50 mg tab OD PO

4. (Adalat) Nifedipine 5-10 mg PO or SL q 6-8 hours

5. For patients on NPO, use the following singly or in combination:a Nifedipine (Adalat) 5-10 mj SL q 6-8 hoursNote: Watch out for hypotension with sublingual nifedipine, especially if the patient is alsobeing given Magnesium sulfate.b. Hydralazine (Apresoline) drip: D5W 250 cc + 2 amps Apresoline (20 mg/amp) to runinitially at 10-15 ugtts/min then to titrate up to 60 ugtts/minc. Clonidine (Catapres) drip: D5W 250 cc+ 2 amps Catapres (150 mg/amp) to run at 5-30ugtts/min

To Pregnancy PageTo Main Table of ContentsTo Detailed Table of Contents



PREGNANCY & CARDIAC DISEASETo Pregnancy Page


Data:

l. Avoid Dilantin, Warfarin ACE inhibitors and Angiotensin II antagonists.2. Nearly all CVS drugs cross the placenta and are excreted in breast milk.3. Most drugs should be avoided in the first trimenster inless the cardiac condition demands urgenttreatment4. Diuretics should not be in bipedal edema unless there is frank pulmonary congestion. Diuretics maydecrease uterine blood flow

Treatment Options:l. Inotropic agents - Digitalis is safe, Dopomine is reserved for life threatening situations only.

2. Vasodilators - Hydralazine is safe

Use Nitrates as in the non-pregnant state

Nitroprusside reserved for life threatening situations only. Avoid ACE inhibitors and Angiotensin II antagonitsts

3. Calcium-channel blockers - Verapamil and Nifedipine are relatively safe.

4. Beta-blockers - May be used for short period to time there are no alternatives.Side effect: intrauterine growth retardation, bradycardia

5. Anticoagulants/Antiplatelets - Warfarin conraindicated especially in the first trimester (20% teratogenic)Heparin SQ can be given, It does not cross the plaenta

ASA and Dipyridamole can be given with slight increase in bleeding

Safety to low omlecular weight heparins is still to be established




PREGNANCY & ASTHMA Data:

The course is relatively the same as in the non-pregnant patient.Treatment Options:1. Beta 2- agonist PO or IV - inhibits uterine contractility

2. Steroids - (+) small risk of cleft palate formation in some animal but not proven in humans- placental insufficiency, prematurity and fetal death- neonatal adrenal insufficiency (?)- steroids may cause some intrauterine growth retardation.

3. Aminophylline / Theophylline - may inhibit uterine activity (?)- transient tachycardia in the baby

4. Cromolyn sodium - appears to be relatively safe in pregnancy5. Status Asthmaticus - delivery by Caesarian section may improve asthma

(anecdotal reports)




PREGNANCY & THYROID DISEASETo Pregnancy Page


Data:

Total T4 is increased because of increase in TBG (Thyroxin Binding Globulin)

Orders:Diagnostics TSH Irma (best measure of thyroid function; normally , slightly decreased in first trimester)

Therapeutics:1. PTU

Drug of choice for pregnant individualsSide effect: Neonatal hypothyroidismTotal dose = 300 mg/day. If PTU dose > 300 mg/day consider subtotal thyroidectomy in thesecond trimester

2. Beta-blockers:

e.g. Atenolol, MetroprololMay be given for a short period of time only

3. Surgery:

Avoid surgery during the first trimester because of increase of spontaneous abortion Treatment Plan:

1. Monitor the patient's TSH and Free T4, keep Free T4 at the upper limit of normal.2. Monitor the fetus for hypothyroidism or hyperthyroidism




PREGNANCY & DIABETES MELLITUSTo Pregnancy Page


Data:

A. Two Types of Diabetes in Pregnancy:1. PregestationalDM (DM prior to pregnancy)

Diagnosis: FBS > 126 mg/dl on 2 occasions or RBS > 200 mg/dl or 75 gm 2 hour OGIT > 200 mg/dl

2. Gestational DM

a. Screening test (at 24-28 weeks usually or earlier): 50 gm 1 hour Oral Glucose Challenge of >140 mg/dl

b. If (+) screening test do Gold Standard For Gestational DM Diagnosis: 100 gm 3 hour Oral

Glucose Tolerance test (OGTT) afbr an overnight fastof 8-14 hours

Three-hour 100gm OGTT

National Diabetes MellitusData Group

Fasting > 105 mg/d3 (53 mmol/L)

1 hour > 190 mg/dl (10.6 mmolL)

2 hours > 165 mg/dl (9.2 mmol/L)

3 hours > 145 mgldl (8.1 mmol/L)

If two values are above normal then the patient is + Gestational DM.

B. Complication: Birth defects, abortion, macrosomia, respiratory distress syndrome, stillbirth

Treatment

1. Diabetic diet2. Insulin treatment:

Do not give oral hypoglycemic agents. These are contraindicated during pregnancySample Insulin Regimen:

i.Humulin N (intermediate) or Humulin U (Ultralente - long acting ) OD in a.m.ii.Humulin N & R combination (intermediate & short acting) at 6 a.m. and 6 p.m.

(2/3 of daily dosage to be given at 6 AM and 1/3 of daily dosage at 6 p.m.)Note: Aim for normal blood glucose (FBS =105 and Two-hour postprandial blood

glucose of < 140 mg/dl.3. Control diabetes at first 6 weeks AOG to prevent birth defects4. Deliver baby ideally at 36-37 weeks AOG




DRUGS USED IN PREGNANCYTo Pregnancy Page


Type Safe to Use Limited

Info/Minimal FetalRisk

Evidence of Fetal

Risk

Avoid

Analgesics Paracetamol DiclofenacIbuprofenMorphinePiroxicam

AspirinCodeineIndomethacinTramadol

Anti-convulsants Magnesium sulfate CarbamazepineClonazepamEthosuximideGabapentinLamotrigine

PhenobarbitalPhenytoinValproic acid

Anti-depressants FluoxetineParoxetineSertraline

AmitriptylineImipramineVenlafaxine

Monoamineoxidaseinhibitor

Antidiabetic agents Insulin Acarbose

Metfromin

Glipizide

Glibendamide

Antiemetics MeclizineMetoclopromide

DiphenydrinateOdsnsetronProchlorperazinePromethazine

Anti-histamines Chlorpheniramine BrompheniramineCetirizineClemastineDiphenhydramineFexofendineHydroxyzineLoratadineTerfenadine

Antilipidemics Cholestyramine Gemfibrozil FluvastatinLovastatinPravastatinSimvastatin

Antimicrobials Amoxicillin Amphotericin B Ampicillin Ampicillin-sulbactamCephalesporinsCotrimazoleCo-amoxiclavErythomycinMiconazole(topicai)NitrofurantoinNystatinOxacillinPenicillinPiperacillin-TazobactamTicarcillin-clavulanic

Acyclovir Azithomycm AztreonamChloramphenicolClarithromycinClindamycinImipenan-cilastatinMetronidazoleVancomycin

AmikacinCo-trimoxazoleEthambutolFluconazoleGentamicinIsoniazidItraconazoleKetoconazoleMiconazole(systemic)PyrazinamideRifampicinTobramycin

CiprofloxacinDoxycyclineNorfloxacinOfloxacinTetracycline

Anti-thrombotics DalteparinEnoxaparinHeparinTiclopidine

Aspirin Warfarin



Cardio-vascularDrugs Atenolol ClonidineDigoxin DoxazosinHydralazineLidocaineMethyldopaMetoprololPrazosinPropranololTimolol

AmlodipineDiltiazemFelodipineNifedipineNitratesVerapamil

ACE-inhibitorsLosartan

Cough & Cold Agents Dextromethorphan GuiafenesinPhenylpropanolaminePseudoephedrine

Diuretics FurosemideSpironolactone

AmilorideBumetsnide

Gastro-intestinalAgents Antacids AttapulgiteKaolin-PectinLoperamideMetoclopromidePsyliium

CisaprideH2-receptorantagonistsLansoprazoleOmeprazoleSimethicone

Misoprostol

Respiratory Agents Beclomethasone(inhalation)CromolynIpratropiumSalmeterolTheophylline

Sedatives PropofolZolpidem

Benzodiazepines PentobarbitalPhenobarbital

ThyroidPreparations

LevothyroxineThyroid

MethimazoleK iodidePropylthiouracil

Miscellaneous Ferrous sulfatePotassium chloride

AllopurinolChlorzoxazoneSumatriptan

AzathioprineCyclosporineHaloperidolPentoxifylline

IsotretinoinLithiumQuinineTamoxifen

Source: Nauser T & McGraham M (1998). Pregnancy & Medical Therapeutics. In Carey C, Lee H &Woeltjc K (eds.). WashingtonManual of Medical Therapeutics, (534-537). Philadelphia: Lippincott Williams& Wilkins.




PREVENTIVE MEDICINE & ADULT IMMUNIZATIONS


Cancer Check-up and ScreeningRecommended Diagnostic testImmunization and Post-exposure Treatment

Tetanus post-exposure treatment Hepatitis B post-exposure treatment Rabies post-exposure treatment

Guidelines for Routine Health Maintenance or "The Executive Check-up":

Adapted from 1) The American College of Physicians expert recommendations for preventive care forasymptomatic, low-risk adults and 2) The American Cancer Society (1993) guidelines for the earlydetection of cancer hi people without symptoms. I. History, Physical Examination, Health Counselling: Every 2 years between ages 2MO, then yearly afterage 40

A. History:

1. Pertinent Present History: Any symptoms2. Review of Systems; Check also for depression, suicidal ideation, work-related stress3. Past Medical History: Previous illness, operations, allergies; current drug intake4. Immunization History: (See page 202)5. Family History: Breast cancer, colon cancer, prostate cancer, hypertension, diabetes, ischemic

heart disease, hyperlipidemia, alcoholism, mental illness, autoimmune disorders.6. Personal and Social History: Occupational history, life style, smoking, alcohol, illicit drug use

B. Physical Examination:

1. Blood pressure: Every 2 years after age 182. Weight: Every 2 years3. Regional examination

C. Health Counselling on:

l. Breast self exam2. Ill effects of cigarette smoking3. Alcohol moderation4. Aerobic exercise at least 3X per week for 30 minutes to 1 hour 5. Nutrition: Dietary moderation, less salt, less cholesterol and maintain ideal body weight6. Advice against illicit drug use, high-risk sexual behavior, injury prevention, and dental care.

II. Cancer Check-up and Screening (To Top)

Check every 3 years between ages 20-40, then yearly after age 40

A. For Males and Females:

l. Examination for cancers of the thyroid, lymph nodes, oral region, skin, testicles (males) and ovaries(females)2. Digital rectal examination: Yearly after age 403. Stool for occult blood: Yearly after age 504. Sigmoidoscopy, preferably flexible: Every 5 years after age 50

B.For Males Only:

1. Digital prostate exam and serum prostate-specific antigen (PSA) in males; Optional: Digitalprostate exam yearly and Serum PSA once after age 40. If either is abnormal, further examinationby transrectal ultrasound and biopsy is indicated.



C. For Females Only:

1. Self breast exam: Monthly after 20 years old, especially in patients with a family history of breastcancer.

2. Clinical breast exam by the physician: Every 3 years between ages 20-40, then yearly after 40years old.

3. Mammograms: Every 1-2 years (depending on risk of patient) between ages 50-75 years

4. Papanicolaou smear: Yearly until at least 3 consecutive satisfactory normal examinations, thenevery 3 years between ages 18-70. Optional if post-hysterectomy

5. Pelvic examination: Yearly after age 406. Endometrial tissue sampling: Women at high risk; at menaopause and thereafter at the discretion

of the physician. High-risk women include those with a history of infertility, obesity, failure ofovulation, abnormal uterine bleeding, or unopposed Estrogen or Tamoxifen therapy.

III. Recommended Diagnostic Tests: Patients are Divided into Those With and Without Cardiac Risk

Factors.(To Top)

A. Cardiac Risk Factors:1. Age and gender (male > 45 years old, female > 55 years old or premature menopause in women

without estrogen replacement)2. Current cigarette smoker (ten or more cigarettes per day)3. History of cerebrovascular disease, diabetes mellitus, or hypertension4. Family history of premature coronary artery disease (myocardial infarction or sudden cardiac

death before age 55 in a first degree relative)5. Presence of peripheral vascular disease

B. Examinations for Patients Negative for Cardiac Risk Factors:

1. History, Physical Examination every 2 years.2. Fasting Blood Sugar, Creatinine, Uric Acid: Once after age 40 and as indicated3. Complete lipid profile (total cholesterol, LDL. cholesterol, HDL cholesterol, and triglyceride) after a

12 hours fast for all adults >= 20 years once every 5 years4. ECG 12-lead and Chest X-ray: Once after 40 for baseline (optional). This can be helpful when

patients present later with cardiac or pulmonary disease C. Examinations for Patients Positive for Cardiac Risk Factors:

1. History, physical examination, blood pressure, and weight yearly.2. Fasting Blood Sugar, Creatinine, Uric Acid: Once after age 40 then every 3 years or as indicated.3. Complete lipid profile (total cholesterol LDL cholesterol HDL cholesterol, and triglyceride) after a

12 hours fast for all adults >= 20 years of age once every 3 years and as indicated.4. ECG 12-lead and Chest X-ray: Once Once age 40 for baseline then as indicated only.5. Treadmill Exercise Test:Indications: Adult patients with an intermediate pre-test probability for coronary artery disease (See

Table 12-1) based on gender, age, and symptoms. Not indicated for the following: Routineexecutive check up, company clearance or travel clearance for patients with a low pre-testprobability for coronary artery disease.

Table 12-1. Pretest Probability of Coronary Artery Disease by Age, Gender, and Symptoms.

Age Gender Typical AnginaPectoris

Atypical AnginaPectoris

Non-anginalChest Pain Asymp-tomatic

30-39 Men Intermediate Intermediate Low Verylow

Women Intermediate Very low Very low Verylow

40-49 Men High Intermediate Intermediate Low

Women Intermediate Low Very low Verylow




Women Intermediate Intermediate Low Verylow


Women High Intermediate Intermediate Low

Source: Adapted from Diamond, G. 4 Forrester, J. (1979). Analysis of probability as an aid in the clinicaldiagnosis of coronary artery disease. NEJM, 300, 24, 1350-1358.

IV. Immunization and Post-exposure Treatment: (To Top)

A. Adult Immunizations:

Table 12-2-Standard Adult Immunization (2004)

Vaccine/Route For Whom It Is

recommended Schedule

1. PneumococcalVaccine (ForStreptococcuspneumoniae)

*Inactivated vaccine*Intramuscular

i. Persons > 50 years ofageii. Persons with chronicillness: Cardio-pulmo,

diabetes, alcoholism,cirrhosis, CSF leaksiii. Immunocompromisedconditions: Lymphoma,leukemia, CRF, nephriticsyndrome, transplants,chemo/radiation therapy,HIV/AIDS, functional oranatomic asplenia

a. Pneumovax 0.5ml IM onceor b. Pneumo 23

prefilled syringe 0.5ml IM once.Note: Booster doseafter 5 years

2. Influenza Vaccine(Flu Vaccine)


i. Persons > 50 years ofageii. Persons with chronicillnesses: Pulmonary(asthma, COPD),cardiovascular (CHF),

metabolic diseases, CRFiii. Immunosuppressed:H1V, transplant, chemo,cancer Health cane workers,caregivers Pregnantwomen

a. AgrippalS1prefilled syringe0.5 ml IM or b. Vaxigrip 0.5 mlIMNote: Give yearly

preferably fromFebruary to June.

3. Hepatitis BVaccine


i. Recommended for alladultsparticularly:- Immigrants from areas ofhigh HbsAg endemicity- Hemodialysis patients, IVdrug users, or homosexualmales

- Household contacts ofHBV carrier - Recipients of bloodproducts- Health care workers withfrequent blood contacts

a Recomvax-Badult vial of 20 mcgor b. HB VAX II adultvial of 10 mcg(1 ml)or c. Engerix B adult20 mcg/ml Give IM

over deltoid region at 0,1, and 6 months.



4. Tetanus/diphtheriatoxoid (Adult Td)


i. All susceptible adultsparticularly: - Pregnantwomen- Health care workers

Dite Anatoxal Berna0.5 ml IM. Note: Forthose withoutchildhoodimmunization, give3 doses at 0, 1 ,&46 months timing.Booster every 10years

5. Varicella Vaccine’Live attenuatedvaccine*Subcutaneous

i. Recommended for alladults particularly:- Persons > 13 years oldwithout history of Varicellainfection or vaccination,especially health careworkers teachers of youngchildren, non-pregnantwomen of childbearing age,international travelers,military

Okavax 0.5 ml SC <13 years: 1 dose >13 years: 2 doses(at least 1 monthapart).Post-exposureprophylaxis givenwithin 72 hrs. ofexposure

6. MMR Vaccine(Measles/Mumps/

Rubella)* Subcutaneous

i. Recommended for alladults particularly:

- All susceptible adolescent& adults withoutdocumented evidence ofimmunity, especiallynon-pregnant women ofchildbearing ageNote, No adverse effect if aperson immune to one ormore is vaccinated

a Trimovax 0.5

ml vial SC for 2doses, give 1month apart or

b. M-M-R II 0.5ml SC

Table 12-3 Special Immunization for Particular Health Care Workers

Vaccine/Route For WhomRecommend

Schedule

1. Typhoid Vaccinea.

Oral-enteric-coatedcapsule; liveattenuatedTy21a (Vivotif)

b, Intramuscular -VicapsularpolysaccharideTy 2 (TyphimVi)

- Food handlerssuch as dietarypersonnel, cooks,waiters, servers,dieticians,nutritionists- Microbiology lab

technicians- Persons withintimate exposureto a documentedcarrier

PO: For primaryand booster- 1capsule each ondays 0, 2, 4, one hrbefore a meal, withdrink. Boosterevery 5 yrs.IM: For primarybooster- single 0.5ml IM dose on thedeltoid. Boosterevery 2-3 years.



2. Rabies Vaccine(ActiveVaccination)a. HDCV- HumanDiploid CellVaccineb. PVRV- PurifiedVero Cell RabiesYaccine (Verorab)c. PDEV- PurifiedDuck EmbryoVaccined. PCECV-Purified ChickEmbryo CellVaccine

- Health careworkers inhospital thattreat dog bitesand rabiescases

- Rabies research& diagnosticlaboratoryworkers

- Veterinarians andvet students

- Field workers

Primary- series of 3injections on days0, 7, 21 or 28IM on the deltoid:- HDCV 1.0 ml- PVRV 0.5 ml- PDEV 1.0 ml- PCECV 1.0 mlIntradermal (ID):- PVRV 0.1 ml- PDEV 0.2 ml- PCECV 0.2 mlBooster - singledose IMor ID every 2 years

Source: Adapted from Committee on Immunization, Philippine Society for Microbiology & Infectious Dses.(PSMID) R the Phil. Foundation for Vaccination (PFV)Standard Adult Immunization 2004.

B. Tetanus post-exposure treatment (To Top)Table 12-4. Wound Classification

ClinicalFeatures

Tetanus Prone Non-Tetanus Prone

Age of wound > 6 hours < 6 hours

Configuration

Stellate,avulsion

Linear

Depth > 1 cm =1 cm

Mechanism ofinjury

Missle, crush,burn

Sharp surface (knife,glass)

Devitalizedtissue

Present Absent

Contaminantssaliva, etc

Present Absent

Table 12-5.

Immunization Schedule.

DirtyTetanus-Prone

Wound

Clean,Non-TetanusProne Wound

History of Tetanusimmunization

Td 1,2 TIG Td TIG

Unknown or < 3 doses Yes Yes Yes No

3 or more doses No No No No

1 Td = Tetanus and Diphteria toxoids adsorbed (adult)

TIG = Tetanus Immune Globulin (human)2 Yes if wound > 24 hours old

For children < 7 years, DPT (DT if pertussis vaccine contraindicated)For persons > 7 years, TD preferred to tetanus toxoid alone

3 Yes if > 5 years since last booster 4 Yes if > 10 years since last booster

(from MMWR 39:37, 1990; MMWR (SS-2):15, 1997



C. Hepatitis B post-exposure treatment: (To Top) For percutaneous injury with blood or b1ood

containing fluids (e.g. IV needle pricks from HbsAg positive patients)1. For health care workers without vaccination:

a Give Hepatitis B immune globulin / HBIG (Hepuman Berna) 4 ml IM within 96 hours of exposure.b. Start Hepatitis B vaccination series (see page 202)

2. For health care workers withvaccination:a Check HBs antibody titer.

If a 10 IU/ml, no therapy.If < 10 1U/ml, give HBIG (Hepuman Bema) 4 ml IM and give booster dose of Hepatitis vaccine.

D. Rabies post-exposure treatment: (To Top) Contact PGH, RITM or San Lazaro

1. Local wound treatment should be applied in all types of bite exposure.2. Wounds should be immediately and thoroughly washed with soap and water preferably for 10

minutes.3. Apply alcohol, tincture or aqueous solution of iodine or povidone iodine.4. If possible, suturing of wounds should be avoided. However, if it is necessary, it should be done

loosely and the anti-rabies immunoglobulin should be infiltrated around and into the wound beforesuturing.

5. Avoid applying ointment, cream or occlusive dressing to the bite site.

Table 12-6. Guide for Rabies Post-ex sure Treatment.

Category Type of contacts with suspect

or confirmed rabid animal, oranimal unavailable for

observation

Treatment

I - Touching, petting, feeding ofanimals: Licks on intact skin,no open wound, no contact ofanimal saliva on mucousmembrane, reliable history

a. No vaccine neededb. Consider activevaccination in patientconcerned about or islikely to have repeatexposure

II - Nibbling of uncovered skin- Superficial scratch,abrasion- No break in skin, nobleeding- Licks on broken skin orhealing

wounds- Category I with unreliable

history

a. Vaccinate immediately(see Table 12-7)b. Stop treatment if animalremains healthy after10-14 days, or if killedhumanely and negative forrabies by lab exam

III - All head and neck exposure- Single or multiple

transdermal bites- Licking of mucous

membrane or contaminationwith saliva

a. Vaccine + RIGimmediatelyb. Stop treatment if animalremains healthy after10-14 days or if killedhumanely and negative for

rabies by lab exam

Table 12-7. Summary Schedule of Active Immunization for Rabies.

Type ofRegimen

Route* VaccineType & Dose

Schedule**



Zagreb(2-1-1)

Intra-muscular

PVRV 0.5 ml Day 0 = 2 dosesDay 7 = 1 doseDay 21 = 1 dose

PDEV 1.0 ml

PCECV 1.0ml

8 site IDRegimen ***(8-0-4-0-1-1)

Intra-dermal PVRV 0.1 ml Day 0 = 8 dosesDay 7 = 4 dosesDay 30 & 90 = 1

dose

PDEV 0.2 ml

PCECV 0.1ml

2 site 1Dregimen(2-2-2-0-1-1)

Intra-dermal PVRV 0.1 ml Day 0, 3 & 7 = 2 dosesDay 30 & 90 = 1dose

PDEV 0.2 ml

PCECV 0.2ml

*The vaccines are given in the deltoid area of the arm.** In giving anti-rabies vaccine, the first day when the first dose was given is considered as Day 0,regardless of the number of days interval between the biting incident and the day the vaccine was started.***For the 8-site ID regimen, the 8 doses given on Day 0 may be given as follows: 2 on each deltoid, lowerquadrants of the abdomen, lateral thigh and scapula.

Table 12-8. Dose and Preparation of Rabies Immune Globulin (RIG).

Rabies ImmuneGlobulin

Preparation Dose Skin Test

Equine RabiesImmune Globulin(ERIG)

1000iu/5mlvial

40units/kg

Required

Human RabiesImmune Globulin(HRIG)

300 iu/2mlvial

20units/kg

Notrequired




FINAL POINTERSTo Main Table of Contents


A.Important Differential Diagnoses for Common Complaints:

Chief Complaint Differential DiagnosesWhen a patient

presents with ... Always Rule Out ...

1. Dizziness Cerebellar infarct, Transient ischemicattack

2. Headachea. frontal Glaucoma (Acute Angle Glaucoma)b.one-sided

Space occupying lesion, Arteriovenousmalformation, Subdural hematoma

c. bilateral Subarachnoid hemorrhage3. Confusion /decreasedsensorium

CNS Pathology (Meningitis,Encephalitis),Head trauma, Hypoglycemia, Drug

intoxication,Infection, Sepsis, Hypotension,

Hypoxemia,Hypercarbia, Hepatic encephalopathy,

Uremia,Hyponatremia (check CBC, RBS, Na,Creatinine, O2, CO2, serum NH3)

4. Chest pain MI, Pulmonary embolism, Pneumothorax,Dissecting aortic aneurysm

5. Dyspnea Acidosis (DKA, HONK), MI, CHF,Pulmonaryembolism, Pneumothorax, Acuterespiratoryfailure, Hypoglycemia

6. Hypotension Cardiogenic shock, Cardiac tamponade,LargeMI, GI bleeding, Blood loss, Sepsis,

Acidosis,Low albumin, Adrenal insufficiency,PulmonaryEmbolism

7. Hypertension Hypertensive encephalopathy, CVA,Transientischemic attack, Increased intracranialpressure

8. Abdominal pain Acute appendicitis, Superior mesentericartery occlusion, Ruptured viscus

9. Unexplainedtachycardia

Myocardial infarction, GI bleeding, Bloodloss,Sepsis, Hyperthyroidism, Anxiety

B. When you are confronted with a problematic patient and you do not know what to do, remember thismnemonic: RACER – ER.

R - RBS (Is this hypoglycemia, hyperglycemia?)

A - ABG ( Hypoxia, Acidosis, Hypercarbia?)

C - CBC ( Sepsis, Anemia?)

E - ECG (MI,,Pulmonaryembolism)

R - Radiology - CXR (Is this pneumothorax, CHF, pneumonia?)



E- Electrolytes - Na, K Ca (Electrolyte imbalance?)

R - Renal function - BUN, CREA (Uremia?)




ALL ABOUT DRIPSTo Main Table of Contents


How to use the listed drip rates and equivalent dosages given: For example, the statement under number one for the daomine drip sees, “Drip of 2.5-10mcg/kg/min is equivalent to 9-38 ugtts/min for a 50 kg patient.” This means that a dopamine drip of 2.5mcg/kg/min is equivalent to giving 9 ugtts/min for a 50 kg patient while a dopamine drip of 10 mcg/kg/minis equivalent to 38 ugtts/min for a 50 kg patient. Using similar statements below as your guide, no tediouscomputations maybe necessary for the average patient. 1. Aminophylline Drip: D5W. 250 ml+ Aminophylline 250 mg/amp at 15-40 ugtts/min

Maintenance Drip of 0.4-0.8 kg/kg/hr is equivalent to 20-40 ugtts/min for a 50 kg patient.Formula: ugtts/min= dose x BWLD = 5 mg/kg BW in 30 ml D5W in a soluset (if patient is not maintained on oral theophylline)

Note: Maintenance infusion rate must be reduced to 0.2-0.3 mg/kg/hr for elderly patients,pregnant patients and those with CHF, liver disease or cor pulmonale

2. Amiodarone (Cordarone) Drip:Preparation: 150 mg/3 ml viala IV Loading Dose: 5-10 mg/kgbody weightt/24 hour or 500-1000 mg in 24 hours

Intravenous loading doses were given for an average of 4 days in clinical trials.Estimated maximum daily dose of 1000 rng/24 hours for Filipinos.

Orders: Give 150 mg slow IV push over 10-30 minutes (with BP and HR monitoring)followed by D5W 250 ml+ 150 mg-300 mg IV Amiodarone to run for 24 hours. Supplemental dosesof 150 mg IV over 10-30 mins may be given for recurrent arrhythmias especially during the earlyphases of dosing. No more than six additional boluses in any 24 hour period may be given.

Or b. Oral loading dose: 10 kg/kg body weight per day for two weeks

e.g. Amiodarone 200 mg 1 tab PO TID for 14 daysThen maintenance of 200 mg 1 tab OD thereafter.Source: Adapted from Kowey, P., Marinchak, R., Rials, S. et al (1997).

Intravenous amiodarone. JACC, 29, 6, 1190-8.

3. Clonidine (Catapres) Drip:

Concentration=150 ug/m1 ampuleD5W 250 ml+ Catapres 2 amps (150 mg/amp) at 5-30 ugtts/min

4. Clonidine/Hydralazine (Catapres/Apresoline) Drip:

D5W 250 ml+ Apresoline 2 amps (20 mg/amp) + Catapres 2 amps (150 mg/amp) at 5-30ugtts/min (Up to 60 ugtts/min)

5. Diazepam (Valium) Drip:

D5W 100 ml+ Diazepam 10 mg q 6 hours (maximum= 60 mg/day)

6. Dobutamine Drip: D5W 250 ml + Dobutamine 250 mg/amp at 10-60 ugtts/min

Drip of 2.5-20 mcg/kg/min is eguivalent to 80-60 ugtts/min for a 50 kg patient.Formula ugtts/min=(drip mcg x BW)/16.6If with CHF, may use double dose: D5W 250 ml+ Dobutamine 500 mg (2 amps) at maximum rateof 30 ugtts/min

7. Dopamine Drip: D5W 250 ml+ Dopamine 200 mg/amp at 7-60 ugtts/min

Drip of 2.5-10 mcg/kg/min is equivalent to 9-38 ugtts/min for a 50 kg patient.Formula: ugtts/min=(drip mcg x BW)/13.3If with congestive heart failure (CHF), may use double dose: D5W 250 ml + Dopamine 400 mg (2



amps) at maximum rate of 30 ugtts/min

8. Dopamine-Lasix Drip:

75 ml of Dopamine Pre-mix (D5W 250 ml+ Dopamine 200 mg) + 25 ml of Lasix 250 mg in asoluset (Total of 100 ml) to run at 6-8 ugtts/min

9. Epinephrine Drip: D5W 250 ml + 1 amp (1 mg) Epinephrine at 15-150 ugtts/min

Drip of 1-10 mcg/min is equivalent to 15-150 ugtts/min

10. Esmolol (Brevibloc) drip:

Preparation: 100 mg/10 ml vialConcentration= 10 mg/mlLoading dose 0.5 mg or 500 mcg/kg/min

e.g.: 50 kg = 25 mg or 2.5 ml slow IV in > 1 minuteMaintenance dose= 25-200 mcg/kg/min; start at 50 mcg/kg/min over 4 min

e.g.: 50 kg =2.5 mg/min or 150 mg/hr or 15 ml/hr = l5 ugtts/min

11. Furosemide (Lasix) Drip:

D5W 250 ml + Lasix high dose 250 mg/amp at 5-30 ugtts/minConcentration= 1 mg/ml

Drip of 5-30 ugtts/min is equivalent to 5-30 mg/hour 12. Heparin Drip:

D5W 200 ml+ 10,000 units Heparin at 10-20 ugtts/min, use infusion pumpConcentration= 50 units/mlDrip of 500 units-1000 units/hour is equivalent to l 0-20 ugtts/minLoading Dose= 3,000-5,000 units slow IV

13. Hydergine Drip: D5NM 1 liter + 6 amps Hydergine x 16-24 hours x 3 doses

14. Hydralazine(Apresoline) Drip:

D5W 250 ml + Apresoline 2 amps (20mg/amp) at 5-30 ugtts/min (up to 60 ugtts/min)Maximum daily dose= 3.5 mg/kg body weight per 24 hours

15. Insulin Drip: PNSS 250 ml + 50 units Humulin-RConcentration= 0.2 units/mlDrip of 5-50 ugtts/min (or ml/hour) is equivalent to 1-10 units Humulin R/hour

16. Isosorbide Dinitrate (Isoket) Drip:

a D5W 90 ml+ Isoket 10 mg in a solusetDrip of 10-50 ugtts/min is equivalent to 1-5 mg/hr.

b. If with CHF, may use double dose: D5W 90 ml+ Isoket 20 mg in a solusetDrip of 5-25 ugtts/min is equivalent to 1-5 mg/hr

or Glyceryl Trinitrate (Perlinganit) Drip: 1 mg/ml in 10 ml vials

a. D5W 90 ml+ Perlinganit 10 mg (1 vial) in a solusetDrip of 10-50 ugtts/min is equivalent to 1-5 mg/hr

b. If with CHF, may use double dose 90 ml D5W+ Perlinganit 20 mg (2 vials)Drip of 5-25 ugtts/min is equivalent to l-5 mg/hr

17. Lidocaine Drip: D5W 250 ml + Lidocaine 1 gm (pre-mix) at 15-60 ugtts/min

Concentration = 4 mg/mlDrip of 15-60 ugtts/ml is equivalent to 1-4 mcg/minFormula: ugtts/min=dose x 15Loading Dose (LD)= 1 mg/kg IVNote: Maintenance infusion rate must be reduced for patients with cardiac failureor hepatic dysfunction and for elderly patients.



18. Magnesiem Sulfate Drip: D5W 250 ml + 2 gm MgSO4 at 20 ml/hr

Concentration: 250 mg/ml X 10 ml ampule = 2.5 gm/ampule

19. Mannitol-Furosemide Drip:

a. Mannitol 250 ml + Furosemide 100 mg at 10 ugtts/min or b. Mannitol 36 ml + Furosemide 240 mg (24 ml) x 6 hours

20. Morphine Sulfate Drip:

PNSS 50 ml+ 1 amp Morphine sulfate (16 mg/amp) at 6 ugtts/min (2mg/hr) As needed: May give 1-3 mg morphine suite SC prn

21. Nicardepine Drip:

a. D5W 250 ml + Nicardepine 20 mgConcentration = 0.08 mg/mlDrip of 15-67 ugtts/min is equivalent to 1-5 mg/hr

or b. D5W 90 ml+ Nicardepine 10 mg in solusetConcentration = 0.1 mg/ml .Drip of 10-50 ugtts/min is equivalent to 1-5 mg/hr Maximum dose = 15 mg/hr

Note: The IV infusion site must be changed every 12 hours should a peripheral line beused.

22. Nimodipine (Nimotop) Drip:

Concentration: 10 mg in 50 ml bottleDrip of 5-10 ugtts/min is equivalent to 1-2 mg/hour Note: Use larger veins and alternate IV site every 48 hours to avoid phlebitis.

23. Nitropruside (Nipride) Drip: D5W 250 ml + Nitroprusside 50 mg as side drip at 5-30 ugtts/min (usual

dose)Concentration= 0.2 mgl/ml or 200 mcg/mlDrip of 0.5-8 mcg/kg/min is equivalent to 8-120 ugtts/min for a 50 kg patientFormula: ugtts/min (dose x BW kg)/3.3Note: Taper within 3 days to avoid thiocyanate toxicity. Cover infusion set and IV line with

aluminum foil or carbon paper.

24. Noradrenaline(Levophed) Drip: 2 mg Noradrenaline in 2 ml ampule

D5W 250 ml+ 1 amp Levophed at 15-60 ugtts/minConcentration= 8 mcg of Noradrenaline per mlDrip of 2-8 mcg Noradrenaline/min is equivalent to 15-60 ugtts/min

25. Pentoxifylline (Trental) Drip:

a D5W 250-500 ml + 1 amp Trental 300 mg x 6 hours for 1 dose then POTrental 400 mg 1 tab TID

b. D5W 500 ml + 3 amps Trental (900 mg) x 24 hours

26. Sodium Bicarbonate Drip:

D5W 250 ml + NaHCO3 1 amp (8.4%-50ml vial) X 12-24 hours (or at 20-40 ugtts/min)

27. Somatostatin (Stilamia) Drip:

Give 250 mcg slow IV thena. D5W 500 ml + 3 mg Somatostatin at 42 ml/hr (250 mcg/hr)or b. D5W 250 ml + 3 mg Somatostatin (Stilamm) at 21 ml/hr (250 mcg/hr) until GI bleeding has

stopped or up to 5 days

28. Streptokinase (Streptase, Kabikinase) Drip:

Streptokinase 1.5 million units + Dy5 90 ml at 100 ml/hr (1 hour running rate)



29. Terbutaline (Bricanyl) Drip: D5W 250 ml + 5 amps Bricanyl at 10-30 ugtts/min




MORE DRUG LISTTo Main Table of Contents

To Detailed Table of Contents PAIN RELIEVERS

a. Paracetamol*Paracetamoll (Tempra, Alvedon, Biogesic, Aeknil) 500 m forte tab, 150 mg/2 ml amp

PO- 1 tab q 4 hr IV, IM- 1 amp q 4 hr

b. NSAIDS

Aspic (Coaxal, Regular Medicol, United Home Aspirin) 325 mg tab, 500 mg tabPO- 1 tab q 4 hr

Mefenamic Acid (Ponstan, Dolfenal, Gardan) 250 mg cap, 500 mg capPO- 1 cap TID

*Ibuprofen (Advil, Brufen) 200 mg tab, 400 mg tab, 600 mg tabPO- 1 tab q 6 hr

Diclofenac Na (Voltaren, Neo-Pyrazon) 25 mg tab, 50 mg forte tab, 75 mg SR tab,100 mg SR tab, 75 mg/3 ml amp

PO- 75-150 mg/day in 2-3 divided dosesIM- 1-2 amps/day

Indomethacin (Indocid) 25 mg capPO- 1 cap BID-TID

Ketoprofen (Orudis EC/IM/IV) 100 mg EC tab, 50 mg/2 ml IM amp, 100 mg IV vialPO- 1 tab BID post cibumIM- 50-100 mg IM1V- 100-300 mg daily

Ketorolac Trometamol (Toradol) 30 mg/ml ampIM, IV- 10-30 mg q 4-6 hours

Naproxen Ma (Flanax) 275 mg tab, 550 mg forte tabPO- 1 tab q 8 hr

*Meloxicam (Mobic) 7.5 mg tab, 15 mg tab, 15 mg/1.5 ml ampPO, IV-7.5-15 mg/day

Piroxicam (Feldene) 10 mg cap, 20 mg cap, 20 mg Flash tab, ointmentPO- 1-2 caps OD-BID

Tenoxicam (Tilcotil) 20 mg tab, 20 mg vialPO- 1 tab ODIM, IV- 1 vial/day

c. Selective inhibitors of Cyclooxygenase (Cox-2)

*Celecoxib (Celebrex, Coxid) 100 mg cap, 200 mg capPO- 100 mg cap BID

*more expensive but with less GI irritation d. Opiates

Pethidine HCl (Demerol) 100 mg/2 ml amp, 50 mg X 30 ml vialIM, K- 50-150 mg q 3-4 hr

Morphine Sulfate (Hizon Morphine Suite) 10 mg tab, 20 mg tab, 30 mg tab,10 mg/ml amp, 15 mg/ml amp.PO- 10-40 mg QIDIM- 10 mg/70 kg body weightIV- 1-4 mg slow 1V (for myocardial infarction patients)

Nalbuphine HCl (Nubain) 10 mg/ml vialSC, IM, IV- 0.15-0.20 mg/kg BW or 5-10 mg q 3-6 hr

Tramadol (Tramal) 50 mg cap,100 mg retard tab, 50 mg/ml amp, 100 mg/2 ml amp



MORE DRUG LISTTo Main Table of Contents

To Detailed Table of ContentsANTIFLATUNETS/FOR GAS

Activated Dimethicone (Disflatyl) 40 mg tab

PO- 1-2 tab chewed after mealsPancreatin+Dimethicone (Pankreoflat) 80 mg tab

PO- 1-2 tab with meals

ANTISPASMODICS

Hyoscine-N-butylbromide (Buscopan) 10 mg tab, 20 mg ampPO - 1-2 tabs TID-QIDIV, IM, SC- 1-2 amps

Mebeverine HCl (Duspatalin) 100 mg tabPO- 1 tab TID-QID

Pinaverium Br (Eldicet) 50 mg tabPO- 1-2 tabs TID with meals

ANTIPYRETICS

Temp < 37.8 C Tepid sponge bathTemp > 37.8 C = Paracetamol 325-500 mg tab PO q 4 hr Temp > 38.5 C Paracetamol 500 mg tab PO q 4 hr or Aeknil 1 amp IV q 4 hr

HYPNOTICS, SEDATIVES, TRANQUILISERS

Alprazolam (Xanor) 250 mcg tab, 500 mcg tab, 1 mg tabPO- 250-500 mcg OD-TID

Bromazepam (Lexotan) 1.5 mg tabPO- 1-2 tabs OD-TID

Clorazepate Dipotassium (Tranxene) 5 mg cap, 10 mg capPO- 5-10 mg cap HS

Diazepam (Valium, Trazeparn, Anxionil) 2 mg tab, 5 mg tab, 10 mg tab, 10 mg/2 ml ampPO-2-5 mg OD- TIDIV, IM- 2-5 mg q 3-4 hr

*Diphenhydramine HCl (Benadryl) 25 mg cap, 50 mg cap, 50 mg/ml vialPO-25-50 mg BIDIM, IV- 10-50 mg in 4 divided doses

Flurazepam Dihydrochloride (Dalmane) 15 mg capPO- 1/2- 1 cap HS

Haloperidol (Haldol) 2 mg tab, 5 mg tab, 10 mg tab, 50 mg/ml amp(Serenace) 0.5 mg tab, 1.5 mg tab, 5 mg tab, 20 mg tab, 5mg/ml ampPO- 10-15 mg/day or 2-5 mg BID-TIDIM- 10-30 mg

Midazolam (Dormicum) 15 mg tab, 5 mg/ml amp, 5 mg/5 ml amp, 15 mg/3 ml ampPO- 1/2 -1 tab HS

IV, IM- 0.07-0.1 mg/kg/BW or 2.5-5 mgZolpidem (Stilnox) 10 mg tabPO- 1/2-I tab HS

*Safest sedative for elderly patients




INTRAVENOUS FLUIDS

IV Solutions Glucose Na Cl K Ca HCO3

D5W 50g/L

D10W 100g/L

0.9NSS/PNSS 154 154

D5LR 130 109 4 3 28

NM 40 40 13

NR 140 98 5

D5 0.9 NaCl 50g/L 154 154

D5NMK 50g/L 40 40 30




FORMULASTo Main Table of Contents


A. Anion Gap = Na - (Cl + HCO3)

B. Arterial Blood Gas Computation:

l. Metabolic Acidosis:dec pCO2 = (1.5X delta HCO4)+8 + or - 2mmHg

2. Metabolic Alkalosis:

inc. pCO2= (0.9X delta HCO3)+9 + or - 2mmHg

3. Respiratory Acidosis (Acute):delta HCO3 = delta pCO2 x (1/10) + or - 3meqlL

4. Respiratory Acidosis (Chronic)delta HCO3 = delta PCO2 x (3/10) + or - 4 meq/L

5. Respiratory Alkalosis (Acute):

d eltaHCO3 = deltaPCO2 x (2/10) but not < 18 meq/L

6. Respiratory Alkalosis (Chronic):delta HCO3 = delta pCO2 x (4/10) but not <14 meq/L

Note: delta means change in levels of CO2 or HCO3

C. Bicarbonate deficit =

(Body Wt in kg) (0.4) X [desired(HCO3) - measured (HCO3)]Note: Give only half of the computed deficit

D. Body Mass Index =Weight in Kg / (Height in meters)

Interpretation:Underweight < 18.5Normal weight = 18.5-24.9Overweight = 25.0-29.9Obese > 30.0

E. Cardiac Output = Heart Rate X Stroke Volume

F. Corrected Serum Calcium (mg/dl) = measured Ca in mg/dl + 0.8 X(4 – albumin in g/dl)

G. Estimated Creatinine Clearance (ml/min) =

[(140-age) X weight in Kg]/ 72 (males, 85 in females) X serum Cr (mg/dl)

H. Ideal Body Weight:

a. Female: 100 pounds+ (5 pounds per inch over 5 feet)b. Male: 106 pounds + (6 pounds per inch over 5 feet)

I. Mean Arterial Pressure (MAP) = [Systolic BP+ (2 X Diasto1ic BP)]/3

Normal Value: 70-100 mm Hg

J.Normal Creatinine Clearance = 100-125 ml/min (males), 85-105 (females)

K. Plasma osmolality (mosm/L) = [2 (Na+ K)] + BUN (mmol/L) + RBS (mmol/L)

Normal Value: 280-300 mosm/L



L. Sodium (Na) deficit (mEq) = 0.6 X (wt. kg) X [desired (Na) - actual (Na)]

M. Temperature Conversion:

a Degree Fahrenheit to Degree Celsius: C = (F – 32) x 5/9b. Degree Celsius to Degree Fahrenheit: F = (C x 9/5) + 32




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The blue book

2013 Blue Book

2012 Blue Book

Blue Book Current