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Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
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Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
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Lange Instant Access: Hospital Admissions Essential Evidence-Based Orders for Common Clinical Conditions Anil Patel, MD Family Medicine, Class of 2006 University of Pittsburgh Medical Center (UPMC)Pittsburgh, Pennsylvania New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange Instant Access: Hospital Admissions: Essential Evidence-Based Orders for Common Clinical Conditions Copyright © 2007 by The Mc Graw-Hill Companies, Inc. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. 1 2 3 4 5 6 7 8 9 0 DOC/DOC 0 9 8 7 6 ISBN-13: 978-0-07-148137-3 ISBN-10: 0-07-148137-0 This book was set in Times New Roman by Silverchair Science + Communications, Inc. The editors were Jim Shanahan and Maya Barahona. The production supervisor was Sherri Souffrance. Project management was performed by Silverchair Science + Communications, Inc. RR Donnelley was the printer and binder. This book is printed on acid-free paper. Cataloging-in-Publication data for this title is on file with the Library of Congress. Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drugtherapy are required. The authors and the publisher of this work havechecked with sources believed to be reliable in their efforts to provideinformation that is complete and generally in accord with the standardsaccepted at the time of publication. However, in view of the possibilityof human error or changes in medical sciences, neither the authors northe publisher nor any other party who has been involved in thepreparation or publication of this work warrants that the informationcontained herein is in every respect accurate or complete, and theydisclaim all responsibility for any errors or omissions or for the resultsobtained from use of the information contained in this work. Readers areencouraged to confirm the information contained herein with othersources. For example, and in particular, readers are advised to check theproduct information sheet included in the package of each drug theyplan to administer to be certain that the information contained in thiswork is accurate and that changes have not been made in therecommended dose or in the contraindications for administration. Thisrecommendation is of particular importance in connection with new orinfrequently used drugs. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
iii Contents Contributing Editors v Preface vii Acknowledgments ix GUIDE TABLES 1 1. CARDIOLOGY 21 2. ENDOCRINOLOGY 69 3. GASTROENTEROLOGY 89 4. HEMATOLOGY/ONCOLOGY 121 5. INFECTIOUS DISEASE 129 6. ELECTROLYTE DISTURBANCE AND NEPHROLOGY 183 7. NEUROLOGY 225 8. PULMONOLOGY 255 9. RHEUMATOLOGY 273 10. TOXICOLOGY 283 11. SYMPTOMS 331 12. SYMPTOM MANAGEMENT 349 Index 383 | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
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v Contributing Editors Sheila Alas, MD Chief Resident, Family Medicine UPMC, Pittsburgh, Pennsylvania Robert Barnabei, MD Inpatient Director & Clinical Instructor, Family Medicine UPMC, Pittsburgh, Pennsylvania David Garzarelli, MD Associate Program Director & Clinical Assistant Professor Family Medicine UPMC, Pittsburgh, Pennsylvania Vijay Karajala, MD Chief Resident, Internal Medicine UPMC, Pittsburgh, Pennsylvania Stasia Miaskiewicz, MD Program Director, Internal Medicine UPMC, Pittsburgh, Pennsylvania Gustavo Ortiz, MD Resident, PGY IV, Neurology Jackson Memorial Hospital, University of Miami, Miami, Florida Thomas Powell, MD Clinical Instructor, Nephrology UPMC, Pittsburgh, Pennsylvania | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
vi CONTRIBUTING EDITORS Joseph Secosky, MD Clinical Instructor, Cardiology UPMC, Pittsburgh, Pennsylvania Shripal Shrishrimal, MD Critical Care Fellow UPMC, Pittsburgh, Pennsylvania Phoebe Tobiano, MD Family Medicine, Class of 2006 UPMC, Pittsburgh, Pennsylvania Walton C. Toy, MD Rheumatology Fellow University of Arkansas Medical Sciences, Little Rock, Arkansas | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
vii Preface Writing hospital admissions orders is an important and fundamental responsibility of the hospital-based physician. Surprisingly, there arefew resources available to help interns and residents write the mostfocused and medically necessary admitting orders possible. Lange Instant Access: Hospital Admissions: Essential Evidence-Based Orders for Common Clinical Conditions focuses on medical conditions that hospital-based physicians commonly encounter. From cardiology to toxicology, admitting orders for dozens of diseases and disorders are presented in handy, easy-access tables. Thecontent of each table provides the reader with a snapshot of the mostimportant considerations for initial admissions as well as forimmediate follow-up and patient management. Lange Instant Access: Hospital Admissions includes evidence-based information, essential for today's learning and practice. All theinformation in the manual was acquired from respected references inthe medical literature, and the appropriate citations are includedthroughout the manual. This manual is a final product of 3 years of hard work, which was reviewed by some of the most recognized and respected physicians ininternal medicine, family medicine, and medicine subspecialties. Here is what some of my colleagues have to say about the manual: “The one and only complete and concise manual for commonly encountered admissions. ” “This is an excellent evidence-based book that eliminates carrying multiple books by having information at your fingertips like disposition of the patient, diagnostic studies, activity level of the patient, what to avoid, and finally the management of the patient's condition. ” “A good evidence-based admission reference guide for the interns and residents. ” “Useful for inpatient care as a thorough index when doing admissions and reviewing differential diagnosis. ” | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
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ix Acknowledgments I would like to dedicate Lange Instant Access: Hospital Admissions to my grandmother who had a lot of influence in my becoming aphysician. I would like to thank all the editors and contributors for their time and hard work devoted to this book. Without their efforts, this manualwould not be possible. I would especially like to thank my sweetheartfor her support. I also would like to thank Nina Tomaino, James Shanahan, Maya Barahona, and Melissa Jones and her team forworking very closely with me in making Lange Instant Access: Hospital Admissions a reality. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
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1 Guide Tables OUTLINE GT-1. Abbreviations 2 GT-2. MIVF 3GT-3. DVT Prophylaxis 4GT-4. GI Stress Ulcer Prophylaxis 6GT-5. Bilevel Positive Airway Pressure (BIPAP) Settings 6GT-6. Initial Ventilator Settings 7GT-7. Antibiotic Spectrum 9Figure GT-1. Dermatomal Map 19Figure GT-2. Vision Testing 20 | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
2 GUIDE TABLES TABLE GT-1: Abbreviations ? Clinical correlation required AAA Abdominal aortic aneurysm ABCs Airway, breathing, circulation ABG Arterial blood gasesac Before meals ACE Angiotensin-converting enzyme ACV Assist-control ventilation ADH Antidiuretic hormone AFB Acid-fast bacilli AIN Acute interstitial nephritis ALT Alanine aminotransferase ANA Antinuclear antibodies ANCA Antineutrophil cytoplasmic antibodies ARB Angiotensin receptor blockers ASA Acetylsalicylic acid (aspirin)5-ASA 5-Aminosalicylic acid AST Aspartate aminotransferase AV Atrioventricular AVM Arteriovenous malformation BGM Blood glucose monitor β -HCG β -Human chorionic gonadotropin BMP Basic metabolic profile (Na + , K + , CO 2 , Cl, BUN, Cr, glucose) BNP B-type natriuretic peptide BP Blood pressure BPH Benign prostatic hyperplasia BRP Bathroom privileges CBC Complete blood count (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 3 CHF Congestive heart failure CI Cardiac index CMP Complete metabolic profile (BMP + LFT)CMV Cytomegalovirus CNS Central nervous system CO Cardiac output COPD Chronic obstructive pulmonary disease CPK Creatine phosphokinase CRP C-reactive protein C&S Culture and sensitivity CT Computed tomography CVA Cerebrovascular accident Cx Culture CXR Chest x-ray DBP Diastolic blood pressure DIC Disseminated intravascular coagulation DM Diabetes mellitus DNR Do not resuscitate DVT Deep vein thrombosis Dx studies Diagnostic studies EBV Epstein-Barr virus ECG Electrocardiogram EEG Electroencephalogram EF Ejection fraction EGD Esophagogastroduodenoscopy ESR Erythrocyte sedimentation rate ETOH Alcohol (continued) TABLE GT-1: Abbreviations (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
4 GUIDE TABLES FFP Fresh frozen plasma FHx Family history GBM Glomerular basement membrane GC Gonorrhea GERD Gastroesophageal reflux disease GFR Glomerular filtration rate GI Gastrointestinal GU Genitourinary H&H Hemoglobin and hematocrit HIDA Hepatobiliary iminodiacetic acid HIV Human immunodeficiency virus HSV Herpes simplex virus HTN Hypertension IBD Inflammatory bowel disease ID Infectious disease IHSS Idiopathic hypertrophic subaortic stenosis INR International normalized ratio I/O Intake and output JVD Jugular venous distention KOH Potassium hydroxide KUB Kidney, ureter, bladder LAD Left anterior descending LDH Lactate dehydrogenase LFT Liver function test (AST, ALT, Alk PO 4 , albumin, bilirubin) LP Lumbar puncture LR Lactated Ringer's (continued) TABLE GT-1: Abbreviations (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 5 MAT Multifocal atrial tachycardia MDI Metered-dose inhaler MI Myocardial infarction MIVF Maintenance IV fluid MRI Magnetic resonance imaging NC Nasal cannula NCV Nerve conduction velocity NPO Nothing by mouth NR No response NS Normal saline N/V Nausea/vomiting OOB Out of bedp-ANCA Perinuclear antineutrophil cytoplasmic antibodies PCI Percutaneous coronary intervention PCN Penicillin PE Pulmonary embolism PET Positron emission tomography PFT Pulmonary function testing PID Pelvic inflammatory disease PPD Purified protein derivative PPI Proton pump inhibitor PRBC Packed red blood cells PRN As needed, clinical correlation required PSA Prostate-specific antigen PT Prothrombin time PTH Parathyroid hormone PT/OT Physical therapy and occupational therapy (continued) TABLE GT-1: Abbreviations (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
6 GUIDE TABLES PTT Partial thromboplastin time PUD Pelvic ulcer disease RBC Red blood cellr/o Rule out RUQ Right upper quadrant SBP Systolic blood pressure SCD Sequential compression device SIMV Synchronized intermittent mandatory ventilation SLE Systemic lupus erythematosus SOB Shortness of breath SPEP Serum protein electrophoresis SSRI Selective serotonin reuptake inhibitor STD Sexually transmitted disease T 3 Thyronine T 4 Thyroxine TB Tuberculosis TCA Tricyclic antidepressant TCP Transcutaneous pacing TEE Transesophageal echocardiogram TG Triglyceride TIA Transient ischemic attack TIBC Total iron binding capacity TLC Total lymphocytic count TMP/SMX Trimethoprim/sulfamethoxazole TPN Total parenteral nutrition TSH Thyroid-stimulating hormone TTE Transthoracic echocardiogram (continued) TABLE GT-1: Abbreviations (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 7 TVP Transvenous pacing UA Urine analysis UC Ulcerative colitis Unit CCU/ICU/SICU/MICU/neuro-ICUUp ad lib As tolerated Urine R&M Urine random microscopy URI Upper respiratory infection US Ultrasound VDRL Venereal Disease Research Library VMA Vanillylmandelic acid V/Q scan Ventilation-perfusion scan WBC White blood cellwt Weight TABLE GT-2: MIVF First 10 kg of total body wt Use 100 m L/kg/day or 4 m L/kg/hr Second 10 kg of total body wt Use 50 m L/kg/day or 2 m L/kg/hr Above 20 kg of total body wt Use 20 m L/kg/day or 1 m L/kg/hr TABLE GT-1: Abbreviations (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
8 GUIDE TABLES TABLE GT-3: DVT Prophylaxis Mechanical Intermittent pneumatic compression or SCD Graduated elastic anti-embolism stockings Chemical Medical conditions Heparin: 5,000 unit SQ q12h Enoxaparin (Lovenox): 40 mg SQ once daily; if Cr Cl <30 m L/ min 30 mg SQ daily Dalteparin (Fragmin): 2,500 units SQ once daily Nadroparin:* 2,850 units SQ once daily General surgery in moderate-risk patient Heparin: 5,000 units SQ q12h Enoxaparin: 20 mg SQ 1-2 hrs before surgery and daily after surgery Dalteparin: 2,500 units SQ 1-2 hrs before surgery and daily after surgery Nadroparin:* 2,850 units SQ 2-4 hrs before surgery and daily after surgery Tinzaparin (Innohep): 3,500 units SQ 2 hrs before surgery and daily after surgery General surgery in high-risk patient Heparin: 5,000 unit SQ q8h or q12h Enoxaparin (Lovenox): 40 mg SQ 1-2 hrs before surgery and daily after surgery or 30 mg SQ q12h starting 8-12 hrs after surgery Dalteparin: 5,000 units SQ 8-12 hrs before surgery and daily after surgery Orthopedic surgery Heparin is not recommended (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 9 Enoxaparin: 30 mg SQ q12h starting 12-24 hrs after surgery or 40 mg SQ daily starting 10-12 hrs postsurgery Dalteparin: 5,000 units SQ 8-12 hrs before surgery, then daily starting 12-24 hrs after surgery or 2,500 units SQ 6-8 hrs after surgery, then 5,000 units SQ daily Nadroparin:* 38 units per kg SQ 12 hrs before surgery; 12 hrs after surgery; and once daily on postoperative days 1, 2, and 3; then ↑ to 57 units per kg SQ daily Tinzaparin: 75 units per kg SQ daily starting 12-24 hrs after surgery; or 4,500 units SQ 12 hrs before surgery and daily after surgery Major trauma Heparin: 5,000 unit SQ q8h Enoxaparin: 30 mg SQ every 12 hrs (for acute spinal cord injury) Enoxaparin: 30 mg SQ every 12 hrs starting 12-36 hrs after injury if the patient is hemodynamically stable *Not approved. TABLE GT-3: DVT Prophylaxis (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
10 GUIDE TABLES TABLE GT-4: GI Stress Ulcer Prophylaxis H 2 blockers or PPI for following conditions Mechanical ventilation >48 hrs >30% burn Coagulopathy Head trauma Shock Quadriplegia Severe sepsis Multiple organ failure American College of Gastroenterology guidelines for prevention of NSAID-induced ulcer for high-risk conditions Prior GI event Age >60 years High NSAID dose Steroid use Anticoagulation TABLE GT-5: Bilevel Positive Airway Pressure (BIPAP) Settings* Ventilation I (inspiratory positive airway pressure) Initial: 10-16 cm H 2 O E (expiratory positive airway pressure) Initial: 3-5 cm H 2 O O 2 (oxygenation) 4-10 L or 50-100% (Keep <6 L in COPD) RR (respiratory rate) Initial: 14-20 breaths per minute Note If CO 2 is high, ↑ I or ↑ RR If O 2 is low, ↑ E or ↑ O 2 *Use requires patient be alert and cooperative. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
11 TABLE GT-6: Initial Ventilator Settings Settings Normal Hypoxic Obstruction condition Restrictive lung condition Fi O 2 21-100% 100% 40-50% 40-50% Tidal volume 5-15 L/kg 6 m L/kg 5-7 m L/kg 5-7 m L/kg RR 12-16 mins 16-24 mins <24 mins 16-24 mins Mode ACV/SIMV ACV/SIMV ACV ACV/SIMVPositive end-expiratory pressure (PEEP)Minimal Variable PEEP-dependent Fi O 2 /O 2 saturation-dependent Complications with ventilatory support Barotrauma Pneumonia DVT Neuropathy Alveolar overdistention Atelectasis GI bleed Acute sinusitis Hypotension (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
12 Note Check CXR after placing patient on ventilator. Check ABG in 30 mins to 1 hr after any change in any parameters. Hypotension treat with IVF Give DVT and GI prophylaxis to all patients on a ventilator. DVT prophylaxis: heparin, 5,000 units SQ bid, or Lovenox, 40 mg SQ daily. GI prophylaxis: pantoprazole (Protonix), 40 mg IV daily (bid for GI bleeding)/famotidine (Pepcid), 20 mg IV bid. If ABG show high CO 2 tidal volume can be ↑ to blow off CO 2 or ↑ RR. PEEP is useful in hypoxic respiratory failure such as acute respiratory distress syndrome or cardiogenic pulmonary edema. Low levels of PEEP can be used in chronic obstructive pulmonary disease to keep airways open. Increasing PEEP decreases venous return to the heart and might lead to reductions in BP. High levels of tidal volume and PEEP might also predispose patients to barotraumas (vent-induced lung injury). TABLE GT-6: Initial Ventilator Settings (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
13 TABLE GT-7: Antibiotic Spectrum Gram-positive Gram-negative Atypical Anaerobe Pseudo-monas Methicillin-resistant Staphylo-coccus aureus (MSSA)Methicillin-susceptible S. aureus (MRSA) First-generation PCN +------Second-generation anti-staphylococcus PCN+-----+ Third-generation amino-PCN+±-±--± Fourth-generation anti-Pseudomonas PCN++-+ +-± First-generation cephalosporin+±----+ Second-generation cephalosporin+±-±--+ (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
14 Third-generation cephalosporin±+-± ±-± Fourth-generation cephalosporin+±-± +-± First-generation quinolones-+-----Second-generation quinolones-+±-±--Third-generation quinolones+++-+-+ Fourth-generation quinolones+++-±-+ Aminoglycoside-±----+ Macrolide + ± + ±--+Tetracycline ± ± + +-± ±Glycopeptide +--±-+ + (continued) TABLE GT-7: Antibiotic Spectrum (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
15 Carbapenems + +-+ ±-+ Ketolide +--±--+Miscellaneous Aztreonam-+--+--Daptomycin +----+ +Linezolid + ± ± ±-+ +Metronidazole---+---Antibiotic classifications PCNs First-generation Second-generation Third-generation Fourth-generation Benzathine PCN Dicloxacillin Amoxicillin Piperacillin PCN G benzathine and PCN G procaine (Bicillin C-R)Nafcillin Augmentin Piperacillin/tazobactam (Zosyn)Oxacillin Ampicillin PCN G Unasyn Timentin (continued) TABLE GT-7: Antibiotic Spectrum (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
16 PCN V Pivampicillin Procaine PCN Cephalosporins First-generation Second-generation Third-generation Fourth-generation Cefadroxil (Duricef) Cefaclor (Ceclor) Cefdinir (Omnicef) Cefepime (Maxipime)Cefazolin (Ancef) Cefotetan Cefditoren Cephalexin (Keflex) Cefoxitin Cefixime (Suprax) Cefprozil Cefoperazone Cefuroxime Claforan Loracarbef (Lorabid) Cefpodoxime Ceftazidime (Fortaz)Ceftizoxime Ceftriaxone (Rocephin) (continued) TABLE GT-7: Antibiotic Spectrum (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
17 Quinolones First-generation Second-generation Third-generation Fourth-generation Nalidixic acid (Neg Gram) Ciprofloxacin Levofloxacin (Levaquin) Gemifloxacin Enoxacin Moxifloxacin (Avelox) Lomefloxacin Norfloxacin Ofloxacin Aminoglycosides Macrolides Amikacin Azithromycin (Zithromax) Gentamicin Clarithromycin (Biaxin) Streptomycin Dirithromycin (Dynabac) Tobramycin Erythromycin Carbapenems Tetracyclines Ertapenem (Invanz) Doxycycline (Adoxa, Doryx, Monodox) Imipenem/cilastatin (Primaxin) Minocycline (continued)TABLE GT-7: Antibiotic Spectrum (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
18 Meropenem (Merrem) Tetracycline Glycopeptide Ketolide Vancomycin Telithromycin (Ketek) Medication peak and trough levels Medication Peak Trough Amikacin* 20-30 mcg/m L <10 mcg/m LGentamicin (Garamycin) 6-8 mcg/m L <2 mcg/m LStreptomycin 15-40 mcg/m L <5 mcg/m LVancomycin (Vancocin) 20-40 mcg/m L (usually not performed)5-15 mcg/m L (cellulitis) 10-20 mcg/m L (pneumonia/endocarditis) Note Check vancomycin trough level before third or fourth dose. Check gentamicin trough level before fourth dose. *With amikacin, obtain peak level 30 mins after a 30-min infusion; obtain trough level within 30 mins prior to next dose. TABLE GT-7: Antibiotic Spectrum (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 19 FIGURE GT-1: Dermatomal map. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
20 GUIDE TABLES FIGURE GT-2: Near vision testing. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
21 1 Cardiology* *See Chapter 5 (Table 5-4) for discussion of endocarditis. OUTLINE 1-1. Chest Pain r/o Acute Coronary Syndrome (ACS)/MI 22 1-2. Acute Coronary Syndrome (ACS) 271-3. Acute MI (ST Elevation MI) 301-4. CHF 351-5. Hypertensive Emergency 391-6. Hypotension 441-7. Asystole 461-8. Bradycardia 481-9. Tachyarrhythmia 50 A. Atrial Fibrillation/Atrial Flutter 50 B. Supraventricular Tachycardia (SVT) (Narrow-Complex Tachycardia)52 C. Ventricular Tachycardia (VT) (Wide-Complex Tachycardia)55 D. Ventricular Fibrillation (V-Fib)/Unstable VT 57 E. WPW Syndrome (Short P-R, Narrow-Complex Tachycardia, Delta Wave)59 F. Torsades de Pointes 61 G. Pulseless Electric Activity 63 1-10. Aortic Dissection 65 | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
22 CARDIOLOGY TABLE 1-1: Diagnosis: Chest Pain r/o Acute Coronary Syndrome (ACS)/MI Disposition Unit/cardiac monitored bed Monitor Vitals Cardiac monitoring Diet NPO if procedure planned same day and after midnight if planned next day, ?1-to 2-g sodium diet Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs Troponin q8h × 3, CPK-MB q6h × 4, BMP, calcium, Mg, LFT, CBC, PT, PTT, INR, TSH, ?BNP Radiology and cardiac studies ECG, CXR (PA and lateral), ?ABG, ?abdominal CT If pulmonary embolism (PE) is suspected, spiral CT or V-Q scan, ?venous Doppler of lower extremities If aortic dissection suspected, chest CT, cardiac echo [TTE or TEE (preferred)] Special tests ?Myoglobin stat and q6h (high sensitivity but low specificity), lipid panel, ?toxicology screen Exercise stress test (see p. 26), homocysteine level in young patient Prophylaxis DVT Consults Cardiology (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 23 Nursing Call physician if patient reports of chest pain, stool guaiac Avoid Nitroglycerin (NTG) in patient using sildenafil (Viagra) Caffeine-containing products Pregnancy state: avoid ASA and ACERenal insufficiency or pregnancy: avoid spiral CT Management 1. NTG: 0. 4 mg SL × 3 q5min [check BP before giving NTG] if pain not responding to NTG and patient is in severe pain consider morphine, 2 mg IV q5min. Note: Hold NTG if SBP <90 2. Nitropaste, 1-1. 5 inches, or NTG patch, 0. 2 mg/hr q6-8h (off qhs)3. ASA: 325 mg crushed4. If chest pain continues despite NTG and morphine consider NTG drip NTG drip (mix 100 mg NTG in 500 m L D 5 W). Note: Hold if SBP <90, heart rate (HR) <60 Give 15-mcg bolus followed by 6 mcg/min (2 m L/hr) ↑ by 6 mcg/min q5min until patient is chest pain-free, SBP <100 (max: 200 mcg/min) 5. Consider enoxaparin (Lovenox): 1 mg/kg bid6. Metoprolol (Lopressor): 5 mg IV q2-3min × 3 doses, then 25 mg PO q6h; hold if pulse <60 or SBP <90 7. Lorazepam (Ativan): 1-2 mg PO tid-qid PRN for anxiety8. Consider statin if ↑ lipids: atorvastatin, 10 mg PO qhs, or simvastatin, 20 mg PO qhs, or pravastatin, 40 mg PO qhs 9. Acetaminophen (Tylenol): 325-650 mg q4-6h PRN for headache (continued) TABLE 1-1: Diagnosis: Chest Pain r/o Acute Coronary Syndrome (ACS)/MI (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
24 CARDIOLOGY Common etiologies of chest pain Emergent Nonemergent MI GERD PE Esophageal spasm CHF Peptic ulcer disease Aortic aneurysm Hiatal hernia Myocarditis/pericarditis Herpes zoster Tachyarrhythmia Mitral valve prolapse Pneumonia Costochondritis Pneumothorax Mastitis COPD exacerbation Thymoma Asthma exacerbation Lymphoma Esophageal rupture Anxiety Cholecystitis Psychoneurosis Bowel infarction Foreign body Pancreatitis Electrolyte abnormalities Diabetic ketoacidosis (continued) TABLE 1-1: Diagnosis: Chest Pain r/o Acute Coronary Syndrome (ACS)/MI (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 25 Thrombolysis in MI (TIMI) score for UA and non-ST-elevation MI and risk of cardiac events Criteria Score Risk of cardiac events in 14 days (TIMI 11B*) Age >65 1 Risk score Death/MI Death, MI, or urgent revascularization More than 3 coronary artery disease (CAD) risk factors (HTN, DM, smoker, ↑ cholesterol, FHx of CAD)1 0/1 3% 5% Known CAD (stenosis ≥ 50%)12 3 % 8% ASA use in past 7 days 1 3 5% 13% Recent severe angina ( ≤ 24 hrs)14 7 % 20% ↑ Cardiac markers 1 5 12% 26% ST ↑ ≥ 0. 5 mm 1 6/7 19% 41% *Entry criteria: UA/non-ST-elevation MI defined as ischemic pain at rest within 24 hrs with evidence of CAD (ST segment deviation or positive marker). (continued) TABLE 1-1: Diagnosis: Chest Pain r/o Acute Coronary Syndrome (ACS)/MI (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
26 CARDIOLOGY Stress test Exercise stress tests Imaging study dyes 1. Treadmill exercise stress test1. Cardiolite (technetium Tc-99m) 2. Adenosine Imaging should be performed approximately 1 hr after injecting the dye Contraindicated in patient with bronchospasm Long half-life 3. Dobutamine 2. Thallium Useful in patient with bronchospasm (e. g., COPD, asthma)Imaging should be performed immediately after injecting the dye Short half-life TABLE 1-1: Diagnosis: Chest Pain r/o Acute Coronary Syndrome (ACS)/MI (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 27 TABLE 1-2: Diagnosis: Acute Coronary Syndrome (ACS) Disposition Unit Monitor Vitals Cardiac monitoring Diet NPO if procedure planned same day and after midnight if planned next day, ?1-to 2-g sodium diet Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs Troponin q8h × 3, CPK-MB q6h × 3, BMP, calcium, Mg, PO 4 , LFT, CBC UA, PT/PTT/INR, fibrinogen, stool guaiac, fasting lipid panel, TSH Urine or serum β -HCG, ?drug toxicology screen (serum/urine) Radiology and cardiac studies CXR (PA and lateral), ECG, cardiac echo, exercise stress test Other tests ?Myoglobin stat and q6h (high sensitivity but low specificity) Homocystine level in young patient Prophylaxis DVT Consults Cardiology Nursing Call physician if patient reports of chest pain, stool guaiac Avoid Caffeine-containing products Patient using Viagra: avoid nitrates Pregnancy state: avoid ASA and ACE (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
28 CARDIOLOGY Management: ACS (non-ST-elevation MI, unstable angina) 1. NTG, 0. 4 mg SL × 3 q5min (check BP before giving NTG) if pain not responding to NTG and patient is in severe pain consider morphine, 2 mg IV q5min. Note: Hold NTG if SBP <90 or pulse <60 2. Nitropaste, 1 inch q8h, or NTG patch, 0. 2 mg/hr q12h (off qhs)3. ASA: 325 mg crushed × 1 PO, then ASA, 162 mg PO daily [if ASA allergy give clopidogrel (Plavix), 75 mg or 300 mg × 1 dose, then 75 mg PO daily] 4. Consider eptifibatide (Integrilin) IV, bolus of 180 mcg/kg (max: 22. 6 mg) over 1-2 mins followed by a continuous infusion of 2 mcg/kg/min (max: 15 mg/hr) up to 72 hrs or up to initiation of coronary artery bypass grafting, or tirofiban (Aggrastat), 0. 4 mcg/kg/min × 30 mins, then 0. 1 mcg/kg/min × 2-4 days, or abciximab (Reopro), 0. 25 mg/kg IV, then 0. 125 mcg/kg/min IV infusion × 12 hrs 5. Lopressor: 5 mg IV q2-3min × 3 doses, then 25 mg PO q6h (hold if SBP ≤90 or pulse <60); or atenolol, 5 mg IV, repeated in 5 mins followed by 50-100 mg PO daily; or esmolol, 500 mcg/kg over 1 min, then 50 mcg/kg/min infusion [titrate to pulse >60 bpm (max: 300 mcg/min)] 6. NTG drip (mix 100 mg NTG in 500 m L D 5W). Note: Hold if SBP <90, HR <60 Give 15-mcg bolus followed by 6 mcg/min (2 m L/hr)↑ by 6 mcg/min q5min until patient is chest pain-free, SBP <100 (max: 200 mcg/min) 7. Morphine: 2-4 mg IV push PRN for chest pain not relieved by NTG 8. Lisinopril: 2. 5-5 mg PO daily; titrate to 10-20 mg daily9. Tylenol: 325-650 mg q4-6h PRN for headache10. Lorazepam (Ativan): 1-2 mg PO tid-qid PRN for anxiety (continued)TABLE 1-2: Diagnosis: Acute Coronary Syndrome (ACS) (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 29 11. Docusate sodium (Colace): 100 mg PO bid for constipation 12. Dimenhydrinate, 25-50 mg IV over 2-5 mins q4-6h or 50 mg PO q4-5h for nausea, or ondansetron (Zofran), 2-4 mg IV q4h for N/V 13. Consider statin: atorvastatin, 10 mg PO qhs, or simvastatin, 40 mg PO qhs, or pravastatin, 40 mg PO qhs IIb/IIIa dosing for ACS and PCI Integrilin: bolus of 180 mcg/kg (max: 22. 6 mg) over 1-2 mins, then give 2 mcg/kg/min (max: 15 mg/hr); continue up to 18-24 hrs or until hospital discharge or Aggrastat:10 mcg/kg/min, then 0. 15 mcg/kg/min × 18-24 hrs or Abciximab (Reopro): 0. 25 mg/kg IV, then 0. 125 mcg/kg/min IV infusion × 12-18 hrs TABLE 1-2: Diagnosis: Acute Coronary Syndrome (ACS) (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
30 CARDIOLOGY TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) Disposition Unit Monitor Vitals Cardiac monitoring Diet NPO except medication (if possible cardiac catheterization) Cardiac diet (low sodium and low fat/low cholesterol) Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs Troponin q8h × 3, CPK-MB q6h × 3, CBC, BMP, calcium, Mg, PO4, LFT PT/INR/PTT, TSH, fasting lipid panel, UA, fibrinogen Radiology and cardiac studies CXR (PA and lateral), ECG in 12 hrs × 2, cardiac echo, ?cardiac catheterization Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) Urine or serum β-HCG, homocysteine level in young patient ?Drug toxicology screen (serum/urine) Prophylaxis ? Consults Cardiology Nursing Call physician if patient reports of chest pain, stool guaiac Avoid Patient using Viagra: avoid using NTG Pregnancy state: avoid ACE and ASA Management See Management: Acute MI; also see thrombolytic therapy criteria (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 31 FIGURE 1-1: ST elevation MI. TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) ECG Leads and Arterial Supply Associations ECG leads Blood vessel Area supplied V1-V4 LAD coronary artery Anterior V5-V6 Left circumflex Lateral I, a VL, V4-V6 Left circumflex Lateral II, III, and a VF RCA Inferior R/S ratio >1 in V1-V2 and reciprocal T inversion in V1Distal circumflex, posterior descending, or distal RCAPosterior I, a VL, V5, and V6 Diagonal branch of LAD coronary artery, marginal branch of left circumflex, left circumflex Anterolateral V1-V3 LAD coronary artery Anteroseptal Management: Acute MI 1. NTG: 0. 4 mg SL × 3 q5min (check BP before giving NTG) if pain not responding to NTG and patient is in severe pain consider morphine, 2 mg IV q5min (hold NTG if SBP <90) or 2. NTG ointment: 1-1. 5 inches, or NTG patch, 0. 2-0. 6 mg/hr q6-8h off qhs (hold NTG if SBP <90) or NTG drip (mix 100 mg NTG in 500 m L D 5W). Note: Hold if SBP <90, HR <60 (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
32 CARDIOLOGY TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) Give 15-mcg bolus followed by 6 mcg/min (2 m L/hr) ↑ by 6 mcg/min q5min until patient is chest pain-free, SBP <100 (max: 200 mcg/min) 3. ASA, 325 mg crushed, then 162 mg EC PO daily ± Plavix, 75 mg or 300 mg × 1 dose, then 75 mg PO daily 4. Consider thrombolytic (alteplase or reteplase) if patient presents within 12 hrs (check stool guaiac) 5. Consider integrelin with ACS (non-Q-wave MI and unstable angina) or with planned PCI 6. Lopressor: 5 mg IV q2-3min × 3 doses, then 25 mg PO q6h (hold if SBP ≤90 or HR <60) or Atenolol: 5 mg IV, repeated in 5 mins followed by 50-100 mg PO daily (hold if SBP ≤90 or HR <60) or Esmolol: 500 mcg/kg over 1 min, then 50 mcg/kg/min infusion (hold if SBP ≤90 or HR <60) 7. Heparin drip: 80-100 unit/kg bolus, then 18-20 unit/kg or 1,000 unit/hr (check stool guaiac before r/o bleeding) Check PT/PTT, which should be 1. 5-2 times the control, and check 6 hrs after Patient can be started on Lovenox, mainly for unstable angina or non-Q-wave MI at 1 mg/kg SQ bid instead of heparin (adjust dose in renal failure: if Cr Cl <30 m L/min, use 1 mg/kg q24h) 8. Morphine: 2-4 mg IV push PRN for chest pain not relieved by NTG × 3 9. Consider ACE (lisinopril, 2. 5-5 mg PO daily; titrate to 10-20 mg daily) 10. Lorazepam (Ativan): 1-2 mg PO tid-qid PRN for anxiety11. Tylenol: 325-650 mg q4-6h PRN for headache12. Consider atorvastatin, 10 mg PO qhs, or simvastatin, 40 mg PO qhs, or pravastatin, 40 mg PO qhs (consider high-dose statin) (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 33 TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) 13. Colace, 100 mg PO bid for constipation 14. Dimenhydrinate, 25-50 mg IV over 2-5 mins q4-6h or 50 mg PO q4-5h for N/V, or Zofran, 2-4 mg IV q4h for N/V Note If heparin-induced thrombocytopenia present, consider argatroban, 2 mcg/kg/min IV continuous infusion Max 10 mcg/kg/min, adjust until steady-state a PTT is 1. 5-3 times baseline value Avoid using NTG in patients using Viagra and ACE and ASA in pregnant patients Patients with unstable angina should be started on Lovenox, 1 mg/ kg bid EF <40%, patient should be on ACE/ARB/hydralazine and nitrate Be cautious of starting heparin in patient with history of cancer due to risk of bleeding Criteria for fibrinolytic therapy Onset of symptoms ≤3 hrs can be given up to 12 hrs (most beneficial if given within 30 mins) ST segment ↑ of >1 mm in two or more contiguous ECG limb leads or A new left bundle branch block Absolute contraindications to fibrinolytic therapy Prior intracranial hemorrhage Documented structural cerebral vascular lesion (e. g., AVM) Documented intracranial malignant tumor (primary or metastatic) Ischemic stroke within 3 mos with exception of acute ischemic stroke within 3 hrs (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
34 CARDIOLOGY TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) Active bleeding or bleeding diathesis (does not include menses) Suspected aortic dissection Significant closed-head or facial trauma within 3 mos Relative contraindications to fibrinolytic therapy History of chronic, severe, poorly controlled HTN Severe uncontrolled HTN (SBP >180 or DBP >110) History of prior ischemic stroke >3 mos, dementia, or documented intracranial pathology Active peptic ulcer Pregnancy Traumatic or prolonged CPR (>10 mins) or major surgery within <3 weeks Recent internal bleeding (2-4 weeks) Noncompressible vascular punctures | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 35 TABLE 1-4: Diagnosis: CHF Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring (mainly K +) Diet Low salt (1-to 2-g) diet, cardiac diet, and fluid restriction 1,200-1,600 m L ?NPO Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs Troponin q8h × 3, CPK-MB q6h × 4, BNP, BMP Calcium, Mg, PO4, LFT, CBC, PT/PTT/ INR, fasting lipid panel, TSH level, UA Radiology and cardiac studies CXR (PA and lateral), ECG, cardiac echo, ?impedance cardiography Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) ?Serial BNP, iron studies Prophylaxis DVT Antiembolism stocking to control lower extremity edema Influenza (flu) and pneumococcal vaccine Consults Cardiology Nursing I/O, daily weight, head of bed and legs elevated, Foley catheter Stool guaiac (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
36 CARDIOLOGY Avoid NSAIDs, pseudoephedrine-containing products (i. e., nasal decongestants) Diastolic dysfunction: avoid vigorous diuresis to maintain CO Aortic stenosis: avoid ACE in severe aortic stenosis; use nitrates with precautions IHSS: avoid vigorous diuresis, digitalis, ACE, and hydralazine Avoid using ACE and ASA in pregnancy; consider avoiding NSAIDs, nasal decongestants Management 1. Loop diuretics If loop diuretics ineffective add metolazone (Zaroxolyn), 5-10 mg PO daily Spironolactone: add to poorly compensated cases [useful in New York class III-IV heart failure ( N Engl J Med 341, 10:709-717)] 2. KCl: 20-60 m Eq PO daily if patient on loop diuretic3. Nesiritide (Natrecor): useful in decompensated CHF and low EF Natrecor preparation: add 1. 5 mg in 250 m L D 5W dilution concentration: 6 mcg/m L Bolus: 2 mcg/kg; infusion rate: 0. 01 mcg/kg/min (contraindicated if SBP <100) or NTG: 5 mcg/min IV infusion, ↑ at rate of 5 mcg/min (hold if SBP <90) (50 mg in 250 m L D5W) 4. Morphine: 2-4 mg IV push PRN for anxiety5. ACE: check Cr Cl (see below) If ACE contraindicated consider ARB or hydralazine + isosorbide (continued)TABLE 1-4: Diagnosis: CHF (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 37 6. Digoxin: if patient has atrial fibrillation or severe CHF, or EF <30% start at 0. 5-1 mg IV/PO × 1 dose followed by 0. 25 mg IV × 2 doses, then 0. 125-0. 25 mg daily 7. β-Blocker: Hold if ↓ BP or ↓ pulse Most proven is carvedilol, 3. 125 mg PO bid × 2 weeks, then 6. 25 mg PO bid × 2 weeks or Bisoprolol (Zebeta): 5-20 mg/day [decreases all-cause mortality and morbidity in CIBIS-II study ( Lancet 1999, 352, 9-13)] Note: Be cautious of using β-blockers in patient with COPD. 8. Dopamine: 3-15 mcg/kg/min IV; titrate to CO >4, CI >2, SBP >90 (400 mg in 250 m L D5W 1,600 mcg/m L) or Dobutamine: 2. 5-10 mcg/kg/min IV; max: 14 mcg/kg/min (500 mg in 250 m L D5W 2 mcg/m L) or Milrinone: 0. 375 mcg/kg/min IV infusion; titrate to 0. 75 mcg/kg/ min (side effects: arrhythmia and hypotension) 9. ASA: 81 mg PO daily, or Plavix, 75 mg PO daily, if associated CAD 10. Warfarin (Coumadin): (5-10 mg to keep INR 2-3) if EF <30%11. Colace: 100 mg PO bid for constipation12. Dimenhydrinate: 25-50 mg IV over 2-5 mins q4-6h or 50 mg PO q4-5h for nausea, or Zofran, 2-4 mg IV q4h for N/V Commonly Used Medications in CHF Initial dose Max dose Loop diuretics Bumetanide 0. 5-1 mg daily-bid Titrate to achieve dry weight (up to 10 mg daily) Furosemide 20-60 mg daily-bid Titrate to achieve dry weight (up to 400 mg daily) (continued)TABLE 1-4: Diagnosis: CHF (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
38 CARDIOLOGY TABLE 1-4: Diagnosis: CHF (Continued) Initial dose Max dose Torsemide 10-20 mg daily-bid Titrate to achieve dry weight (up to 200 mg daily) ACE inhibitors Captopril 6. 25 mg tid 50 mg tid Enalapril 2. 5 mg bid 10-20 mg bid Fosinopril 5-10 mg daily 40 mg daily Lisinopril 2. 5-5 mg daily20-40 mg daily Quinapril 10 mg daily 40 mg bid Ramipril 1. 25-2. 5 mg daily10 mg daily β-Blockers Bisoprolol 1. 25 mg daily 10 mg daily Carvedilol 3. 125 mg bid 25 mg bid; if weight >85 kg 50 mg bid Metoprolol tartrate6. 25 mg bid 75 mg bid Metoprolol succinate12. 5-25 mg daily200 mg daily Digitalis glycosides Digoxin 0. 125-0. 25 mg daily0. 125-0. 25 mg daily Note: Monitor potassium when using loop diuretic and keep potassium >4. Source: From American Heart Association. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 39 TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) Disposition Cardiac-monitored bed/unit Monitor Vitals, BP check q30min, then q2-4h once BP is stable Cardiac monitoring Neuromonitoring Diet ?Clear liquids, ?heart healthy, ?low sodium Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs CBC, BMP, calcium, LFT, UA, urine R&M, TSH, troponin q8h × 3 CPK-MB q6h × 4, fasting lipid profile, drug toxicology screen (serum/urine), uric acid Radiology and cardiac studies?Myoglobin stat and then q6h (high sensitivity but low specificity) CXR (PA and lateral), ?cardiac echo (aortic aneurysm), ?head CT, ECG If intracranial hemorrhage is suspected head CT or LP If renal artery stenosis is suspected renal ultrasound, intraarterial angiography ?Impedance cardiography Special tests ?Catecholamine, ?24-hr catecholamine, ?24-hr urine metanephrine and VMA ?Renin level, ?aldosterone level, funduscopy Prophylaxis DVT (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
40 CARDIOLOGY Constipation and coughing prophylaxis to prevent intracranial bleeding Consults Cardiology, nephrology Nursing I/O, urine output, daily weights, stool guaiac Avoid ASA, Plavix, caffeine-containing products Management See Management: BP High BP Signs and Symptoms Life-threatening conditions Signs and symptoms Hypertensive encephalopathy Headache, blurry vision MI Chest pain (may not have chest pain in elderly/diabetes mellitus) Aortic dissection Back pain, chest pain Neurologic Sensory or motor loss, altered mental status Arterial thrombus Peripheral pulses Renal ↓ urine output Eclampsia in pregnancy Seizure, convulsions BP Classification Uncontrolled HTN Urgency Emergency BP >180/110 >180/110 >220/140Signs and symptoms Headache Severe headache Chest pain, SOB Anxiety SOB Dysarthria Asymptomatic Edema Altered consciousness (continued)TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 41 TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) (Continued) Uncontrolled HTN Urgency Emergency Encephalopathy Pulmonary edema CVACardiac ischemia Management: BP Dosage Onset Duration PO agents Clonidine 0. 1-0. 2 mg initially, then 0. 1 mg q1h up to 0. 830-60 mins6-8 hrs Captopril 12. 5-25 mg PO tid (may cause hypotension)15-30 mins4-6 hrs Labetalol 200-400 mg PO daily q2-3h30 mins-2 hrs2-12 hrs Prazosin 1-2 mg PO q1h 1-2h 8-12 hrs IV agents Nitroprusside Drip 50 mg in 250 m L D 5W; start at 3 mcg/ kg/min; max: 10 mcg/kg/min (check thiocyanate level)Seconds 3-5 mins Use caution when nitroprusside used >24 hrs, especially in renal failure (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
42 CARDIOLOGY TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) (Continued) Dosage Onset Duration Esmolol 5 g in 500 m L D5W, loading dose of 500 mcg/kg over 1 min, then 50-200 mcg/kg/min1-2 mins10-30 mins Trimethaphan 0. 5-5 mg/min (useful in aortic dissection)1-3 mins10 mins Nicardipine 5 mg/hr; ↑ by 1-2. 5 mg/hr q15min, max: 15 mg/hr1-5 mins3-6 hrs NTG 0. 25-5 mcg/kg/min; patient may develop tolerance2-5 mins3-5 mins Fenoldopam 0. 1-1. 6 mcg/mg/min; may protect renal function4-5 mins<10 mins Hydralazine 5-20 mg q20min IV (side effect: headache)10-30 mins2-6 hrs Labetalol Start at 20 mg 40 mg 60 mg 80 mg; repeat every 10-15 mins, max: up to 300 mg5-10 mins3-6 hrs Furosemide 10-80 mg (use in conjunction with vasodilator)15 mins 4 hrs Enalapril (Vasotec)1. 25-2. 5 mg q6h (max: 5 mg/24 hrs); may continue as PO15 mins >6 hrs (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 43 TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) (Continued) Dosage Onset Duration Caution: ↓ dose if Cr Cl <30, Cr >3, or renal stenosis Maintenance BP management Labetalol, 200-600 mg PO bid (max: 2,400 mg/day) Lopressor, 50-100 mg PO daily Hydralazine, 25-50 mg PO bid-qid Nicardipine, 30-60 mg PO bid (max: 120 mg/day) Note Labetalol not recommended for patients with asthma, COPD, CHF, heart block, bradycardia, cardiogenic shock Nitroprusside not recommended in pregnancy Hydralazine recommended in pregnancy CNS symptoms: avoid centrally acting medications, use β-blockers | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
44 CARDIOLOGY TABLE 1-6: Diagnosis: Hypotension Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet PRN Fluid Wide open initially (caution in patient with CHF) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium, Mg, PO4, LFT, amylase, lipase, TSH Troponin q8h × 3, CPK-MB q6h × 4, ABG Fibrin split product, fibrinogen, lactic acid Radiology and cardiac studies ECG, CXR (PA and lateral), abdominal x-ray (r/o obstruction), ?abdominal CT ?Pulmonary artery catheterization to determine etiology Special tests ?Myoglobin stat and then q6h ?Blood C&S, ?type and cross PRBC, serum/urine toxicology screen Serum/urine toxicology screen, ?cortisol level Prophylaxis DVT Consults Cardiology Nursing Trendelenburg position, stool guaiac, I/O, Foley catheter, low bed (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 45 Avoid Antihypertensive medications Management Epinephrine (Levophed): ACLS dosing range of 0. 5-30 mcg/min or mix 4 mg in 500 m L D5W Initially: 4 mcg/min = 30 m L/hr; usual range: 8-12 mcg/min Microgram to m L comparison according to mixture of 4 mg in 500 m L 4 mcg/min = 30 m L/hr6 mcg/min = 45 m L/hr8 mcg/min = 60 m L/hr10 mcg/min = 75 m L/hr Dopamine dosing: max: 50 mcg/kg/min; nonrenal property starts at >15 mcg/kg/min Premixed in D 5W 0. 8 mg/m L in 250 m L or 500 m L1. 6 mg/m L in 250 m L or 500 m L3. 2 mg/m L in 250 m LTABLE 1-6: Diagnosis: Hypotension (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
46 CARDIOLOGY TABLE 1-7: Diagnosis: Asystole Disposition ? Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock O 2 PRN Activity Bedrest Dx studies Labs CBC, BMP, Mg, PO4, PT/PTT/INR, LFT, ABG, serum toxicology screen, troponin q8h Radiology and cardiac studies CXR (PA and lateral), ECG Prophylaxis ? Consults Check code status Nursing Pulse oximetry Avoid ? Management See Management: Asystole (continued) FIGURE 1-2: Asystole. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 47 TABLE 1-7: Diagnosis: Asystole (Continued) Management: Asystole Check for code status before starting CPR Check ABCs Check pulse If no pulse, start CPR Check vitals Consider transcutaneous pacing Epinephrine, 1 mg IV q3-5min Atropine, 1 mg IV q3-5min (max: 0. 04 mg/kg) If asystole persists, consider withholding resuscitation Note: Always confirm asystole in two perpendicular leads. Also need to consider isoelectric V-fib. Source: From American Heart Association. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
48 CARDIOLOGY TABLE 1-8: Diagnosis: Bradycardia Disposition Unit Monitor Vitals Cardiac monitoring Diet ?NPO Fluid IVF (?wide open-?MIVF) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, TSH, troponin q8h × 3, CPM-MB q6h × 4 Radiology and cardiac studies CXR (PA and lateral), ECG, ?cardiac echo, event monitor, ?Holter monitor ?Electrophysiological study, ?exercise stress test Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) ?Troponin q8h, ?serum/urine toxicology screen, digoxin levels if patient already on digoxin Prophylaxis DVT Consults Cardiology Nursing Atropine at bedside Avoid β-Blockers, digoxin, amiodarone, clonidine, diltiazem, verapamil Note: Do not use lidocaine to treat escape slow wide complex rhythm Management See Management: Bradycardia (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 49 FIGURE 1-3: Bradycardia. TABLE 1-8: Diagnosis: Bradycardia (Continued) Management: Bradycardia Symptomatic Place patient in Trendelenburg position Atropine: 0. 5-1 mg IV push q3-5min (max: 0. 04 mg/kg) Then consider TCP If NR, dopamine, 5-20 mcg/kg/min If NR, epinephrine, 2-10 mcg/min If NR, isoproterenol, 2-10 mcg/min Asymptomatic If second-degree type II or third-degree heart block consider TCP or TVP For all other AV blocks or sinus node dysfunction have atropine at bedside When patient becomes symptomatic, follow above symptomatic protocol Source: From American Heart Association. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
50 CARDIOLOGY TACHYARRHYTHMIA TABLE 1-9A: Diagnosis: Atrial Fibrillation/Atrial Flutter Treatment for rate control Diltiazem (Cardizem): 20 mg IV over 2 mins, re-bolus in 15 mins, or Esmolol: 500 mcg/kg IV over 1 min, or Verapamil, 2. 5-5 mg IV initially then 5-10 mg IV, or Lopressor, 50 mg PO If low EF/low BP digoxin, 0. 5 mg IV bolus, then 0. 25 mg IV q2h until rate is controlled (max:1. 5 mg) Treatment for maintenance of sinus rhythm Procainamide, 2-6 mg/kg IV over 5 mins followed by 20-80 mcg/kg/min infusion (max: 2 g/day), or Amiodarone (for impaired ventricular function) or Ibutilide or Flecainide or Propafenone or Direct current cardioversion if medical therapy fails or patient is symptomatic Anticoagulation is recommended unless there is a contraindication Note Consider placing patient on Cardizem drip; start at 5 mg/hr titrate for rate control Consider anticoagulant with heparin and then Coumadin Urgent cardioversion: start heparin IV stat, then check TEE, then cardiovert within 24 hrs, then anticoagulate for 4 more weeks Delayed cardioversion: anticoagulate for at least 3 weeks (keep INR 2-3), then cardiovert, then anticoagulate for 4 more weeks | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 51 FIGURE 1-4: Atrial fibrillation. FIGURE 1-5: Atrial flutter. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
52 CARDIOLOGY TABLE 1-9B: Diagnosis: Supraventricular Tachycardia (SVT) (Narrow-Complex Tachycardia) Atrial tachycardia Atrial fibrillation/atrial flutter, MAT, sinus/inappropriate tachycardia, sinus nodal reentrant tachycardia, atrial tachycardia AV tachycardia AV nodal reentrant or AV reentrant tachycardia, junctional ectopic tachycardia, paroxysmal junctional tachycardia Disposition Unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, TSH, UA, troponin q8h × 3 CPK-MB q6h × 3 Radiology and cardiac studies CXR (PA and lateral), ECG, cardiac echo (TEE) Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) ?Serum/urine toxicology screen, digoxin levels if patient already on digoxin Prophylaxis DVT Consults Cardiology Nursing Stool guaiac (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 53 Avoid Caffeine-containing products Management See Management: SVT (Narrow-Complex Tachycardia) FIGURE 1-6: SVT. Management: SVT (Narrow-Complex Tachycardia) If patient is unstable cardiovert Vagal maneuver/carotid massage NR adenosine, 6 mg NR 12 mg NR 12 mg Cardizem, 15-20 mg (0. 25 mg/ kg) IV over 2 mins NR after 15 mins 20-25 mg over 2 mins Check the rhythm If junctional tachycardia (can be caused by digoxin or theophylline overdose) If normal EF β-blocker, calcium channel blocker, amiodarone If EF <40%, CHF amiodarone If multifocal atrial tachycardia (commonly seen in COPD patients) Correct hypoxemia first If normal EF β-blocker, calcium channel blocker, amiodarone If EF <40%, CHF amiodarone (continued)TABLE 1-9B: Diagnosis: Supraventricular Tachycardia (SVT) (Narrow-Complex Tachycardia) (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
54 CARDIOLOGY TABLE 1-9B: Diagnosis: Supraventricular Tachycardia (SVT) (Narrow-Complex Tachycardia) (Continued) If PSVT If normal EF β-blocker, calcium channel blocker, digoxin direct current cardioversion Also consider procainamide, amiodarone, or sotalol If EF <40% digoxin NR amiodarone NR diltiazem If unstable cardioversion Source: From American Heart Association. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 55 TABLE 1-9C: Diagnosis: Ventricular Tachycardia (VT) (Wide-Complex Tachycardia) Disposition Unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, TSH, UA Troponin q8h × 3, CPK-MB q6h × 3 Radiology and cardiac studies CXR (PA and lateral), ECG, ?cardiac echo Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) ?Serum/urine toxicology screen, signal-averaged ECG Prophylaxis DVT Consults Cardiology Nursing None Avoid β-Blocker, calcium channel blocker, digoxin, caffeine-containing products Management See Management: VT (Wide-Complex Tachycardia), Stable (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
56 CARDIOLOGY FIGURE 1-7: Ventricular tachycardia. TABLE 1-9C: Diagnosis: Ventricular Tachycardia (VT) (Wide-Complex Tachycardia) (Continued) Management: VT (Wide-Complex Tachycardia), Stable Monomorphic may consider synchronized cardioversion If EF <55% amiodarone, 150 mg IV/10 mins, or lidocaine, 0. 5-0. 75 mg/kg, then cardioversion If EF >55% procainamide load, 20 mg/min up to 17 mg/kg (1,000 mg), then infuse 1-4 mg/min (max: 17 mg/kg) or Procainamide, 100 mg IV over 5 mins q10min when effective; maintain IV rate at 2 mg/min Also consider sotalol, amiodarone, lidocaine Polymorphic search for electrolyte abnormality (K, Mg), drug toxicity, ischemia Normal QT: If EF <55% amiodarone, 150 mg IV/10 mins, or lidocaine, 0. 5-0. 75 mg/kg If EF >55% β-blocker, lidocaine, amiodarone, sotalol If NR synchronized cardioversion Prolonged QT (suggestive of torsades) Mg, overdrive pacing, isoproterenol, phenytoin, lidocaine Source: From American Heart Association. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 57 TABLE 1-9D: Diagnosis: Ventricular Fibrillation (V-Fib)/Unstable VT Disposition Unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, TSH, UA Troponin q8h × 3, CPK-MB q6h × 8 Radiology and cardiac studies CXR (PA and lateral), ECG, ?cardiac echo Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) ?Serum/urine toxicology screen, signal-averaged ECG Prophylaxis DVT Consults Cardiology Nursing ? Avoid Caffeine-containing products Management See Management: V-Fib/Unstable VT (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
58 CARDIOLOGY FIGURE 1-8: V-fib. TABLE 1-9D: Diagnosis: Ventricular Fibrillation (V-Fib)/Unstable VT (Continued) Management: V-Fib/Unstable VT Start CPR (consider placing patient on ventilator) Precordial thump if no defibrillator immediately available Shock 200 J NR shock 200-300 J and then 360 J If NR epinephrine, 1 mg IV q3-5min, or vasopressin, 40U IV × 1 dose If NR shock 360 J NR amiodarone, 300 mg IV, then give 150 mg in 3-5 mins (max: 2. 2 g IV/24 hrs) If NR shock 360 J lidocaine, 1-1. 5 mg/kg IV [may repeat in 3-5 mins (max: 3 mg/kg)] If NR shock 360 J magnesium sulfate, 1-2 g IV push over 2 mins (for hypomagnesemia/torsades de pointes) If NR shock 360 J procainamide, 30 mg/min or 100 mg IV q5min up to 17 mg/kg If NR shock 360 J HCO3, 1 m Eq/kg IV If NR shock 360 J Note: If patient has pacemaker, start shock at >200 J Source: From American Heart Association. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 59 TABLE 1-9E: Diagnosis: WPW Syndrome (Short P-R, Narrow-Complex Tachycardia, Delta Wave) Disposition Cardiac-monitored bed/unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, TSH, UA Troponin q8h × 3, CPK-MB q6h × 4 Radiology and cardiac studies CXR (PA and lateral), ECG, ?cardiac echo Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) ?Serum/urine toxicology screen, signal-averaged ECG Prophylaxis DVT Consults Cardiology Nursing ? Avoid Digoxin, β-blocker, calcium channel blocker, and adenosine; caffeine-containing products (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
60 CARDIOLOGY FIGURE 1-9: WPW syndrome. TABLE 1-9E: Diagnosis: WPW Syndrome (Short P-R, Narrow-Complex Tachycardia, Delta Wave) (Continued) Management Delta wave is-VE in V1, V2, and a VR; +VE in I, II, a VL, and a VF; and isoelectric in III Treatment if EF normal Direct current cardioversion or Amiodarone: 150 mg IV over 10 mins and repeat q10min, or Procainamide: load 20 mg/min up to 17 mg/kg (1,000 mg), then infuse 1-4 mg/min (max: 17 mg/kg) or Procainamide: 100 mg IV over 5 mins q10min; when WPW resolves, maintain IV rate at 2 mg/min Flecainide or Propafenone or Sotalol Treatment if EF <40% or CHFDirect current cardioversion or Amiodarone: 150 mg IV over 10 mins and repeat q10min Note If duration of WPW >48 hrs consider anticoagulation Urgent cardioversion: start heparin IV stat, then check TEE, then cardiovert within 24 hrs, then anticoagulate for 4 more weeks Delayed cardioversion: anticoagulate for at least 3 weeks (keep INR 2-3), then cardiovert, then anticoagulate for 4 more weeks Source: From American Heart Association. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 61 TABLE 1-9F: Diagnosis: Torsades de Pointes Disposition Cardiac-monitored bed/unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, TSH, UA Troponin q8h × 3, CPK-MB q6h × 4 Radiology and cardiac studies?Myoglobin stat and then q6h (high sensitivity but low specificity) CXR (PA and lateral), ECG, ?cardiac echo Special tests ?Serum/urine toxicology screen Prophylaxis DVT Consults Cardiology Nursing ? Avoid Amiodarone Ketoconazole Bepridil Moricizine Disopyramide Phenothiazine Haloperidol Procainamide Hypokalemia Sotalol Hypomagnesemia Tetracycline Ibutilide TCAs (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
62 CARDIOLOGY FIGURE 1-10: Torsades de pointes. TABLE 1-9F: Diagnosis: Torsades de Pointes (Continued) Management Polymorphic VT plus QT prolongation Magnesium sulfate: 1-4 g IV bolus over 5-15 mins, or Magnesium sulfate: 2-20 mg/min IV infusion; max: up to 48 hrs until QTc interval <440 msecs Isoproterenol: l2-20 mcg/min (2 mg in 500 m L D5W 4 mcg/m L) If medical treatment fails consider overdrive ventricular pacing or cardioversion | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 63 TABLE 1-9G: Diagnosis: Pulseless Electric Activity Disposition Cardiac-monitored bed/unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, TSH, UA, ?troponin q8h Troponin q8h × 3, CPK-MB q6h × 4 Radiology and cardiac studies CXR (PA and lateral), ECG, ?cardiac echo Special tests ?Myoglobin stat and then q6h (high sensitivity but low specificity) ?Serum/urine toxicology screen, signal-averaged ECG Prophylaxis ? Consults Cardiology Nursing DVT Avoid Hypothermia Management Assess patient, check pulses by Doppler Start CPR Search for probable etiology—6 H's and 6 T's Hypoxia Tension pneumothorax Hypovolemia Tamponade Hypothermia Thrombosis (PE) (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
64 CARDIOLOGY Hypo-or hyperkalemia Thrombosis (acute coronary syndrome) Hydrogen ion (acidosis)Trauma Tablets (drugs) Wide QRS: possible massive myocardial injury, hyperkalemia, hypoxia, hypothermia Wide QRS + slow heart: drug overdose (TCA, β-blockers, calcium channel blockers, digoxin) Narrow complex: consider hypovolemia, infection, PE, tamponade Specific causes and their treatments PE No pulse with CPR, no jugular venous distention (JVD)Management: thrombolytic/surgery Tension pneumothorax No pulse with CPR, JVD, tracheal deviation Treatment: needle thoracostomy Cardiac tamponade No pulse with CPR, JVD, narrow pulse before arrest Beck's triad (hypotension, JVD, distant heart sounds)Treatment: pericardiocentesis Hyperkalemia Check ECG (hyperacute T waves)Treatment: Ca Cl NR albuterol insulin + glucose NR sodium polystyrene (Kayexalate) If no etiology found consider the following: Epinephrine: 1 mg IV q3-5min NR atropine, 1 mg IV q3-5min (max: 0. 04 mg/kg) Source: From American Heart Association. TABLE 1-9G: Diagnosis: Pulseless Electric Activity (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 65 TABLE 1-10: Diagnosis: Aortic Dissection Disposition Unit Monitor Vitals Cardiac monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs CBC, BMP, PT/PTT/INR, troponin q8h, CPK-MB q6h Radiology and cardiac studies ECG, CXR (PA and lateral), CT, ?MRI Special tests TEE; if not available, then use TTE ?Aortogram, ?intravascular ultrasonography (can detect dissection even with-Ve TEE) ?Immunoassay for smooth muscle myosin heavy chain (highly sensitive in first 3 hrs) Prophylaxis ? Consults Cardiothoracic surgery, cardiology Nursing Stool guaiac (especially if history of abdominal surgery) Avoid Propranolol in patients with bronchoconstriction and sinus bradycardia Management See Management: Aortic Dissection Sufficient pain management required (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
66 CARDIOLOGY FIGURE 1-11: Aortic dissection. TABLE 1-10: Diagnosis: Aortic Dissection (Continued) Aortic Dissection Classifications De Bakey classification Type I: originates in the ascending aorta, propagates at least to the aortic arch and often beyond it distally Type II: originates in and is confined to the ascending aorta Type III: originates in the descending aorta and extends distally down the aorta or, rarely, retrogrades into the aortic arch and ascending aorta Stanford classification Type A: all dissection involving the ascending aorta, regardless of the site of origin Type B: all dissection not involving ascending aorta Source: From Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies. Circulation 2003;108:628-635, with permission. (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 67 TABLE 1-10: Diagnosis: Aortic Dissection (Continued) Management: Aortic Dissection Consider surgery if following: Acute dissection of ascending aorta Acute dissection of descending aorta with: Signs of impending rupture (persisting pain, hypotension, left-sided hemothorax) Marfan syndrome Chronic dissection if aorta >5-6 cm in diameter or symptoms Acute BP management Propranolol, 0. 5-1 mg IV q3-5min, or metoprolol, 5 mg IV q5min (keep HR <70) Then nitroprusside 0. 3-10 mg/kg/min to keep SBP 100-120 mm Hg first line (If nitroprusside is continued for >48 hrs, then check thiocyanate level) or First line: labetalol: 10-20 mg IV bolus followed by 40-80 mg q10min or Second line: trimethaphan: 1-2 mg/min IV infusion or Third line: reserpine: 0. 5-2 mg IM q4-8h or Third line: methyldopa: 250-500 mg PO q6h (useful in pregnancy) Chronic BP management Metoprolol, 25-100 mg PO bid or atenolol, 50-100 mg PO daily plus (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
68 CARDIOLOGY Clonidine, 0. 1-0. 3 mg PO/patch daily, or hydralazine, 10-50 mg PO qid, or Amlodipine, 2. 5-10 mg PO daily, or enalapril, 2. 5-20 mg PO daily Pain management Morphine, 2-5 mg IV q3-4h or Meperidine, 50-100 mg IV/IM q4h PRN (caution in elderly due to risk of delirium) GFR 10-50 m L/min, 75% of normal dose at usual intervals GFR <10 m L/min, 50% of normal dose at usual intervals TABLE 1-10: Diagnosis: Aortic Dissection (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
69 2 Endocrinology OUTLINE 2-1. Adrenal Crisis 70 2-2. Diabetic Ketoacidosis (DKA) 732-3. Nonketotic Hyperosmolar Syndrome (NKHS) 772-4. Thyroid Storm (Thyrotoxicosis) 812-5. Myxedema Coma 842-6. Hyperparathyroidism and Severe Hypercalcemia 86 | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
70 ENDOCRINOLOGY TABLE 2-1: Diagnosis: Adrenal Crisis Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet Regular Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO 4 , LFT, TSH, T 3 and free T 4 , cortisol level Radiology and cardiac studies CXR (PA and lateral), ECG, CT of abdomen and head Special tests ?HIV testing, adrenocorticotropic (ACTH) stimulation test (see following page) Renin level, aldosterone level, ACTH level Metyrapone tests in suspected ACTH deficiency, 24-hr cortisol level PPD in high-risk population Prophylaxis DVT Consults Endocrinology Nursing ? Avoid K + and calcium supplements (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 71 Management 1. Hypotension with NS or D 5 NS (2-3 L): 500 m L/hr to wide open 2. Dexamethasone sodium phosphate, 4 mg IV, or hydrocortisone, 100 mg IV q6-8h, for first 24 hrs ( Note: Dexamethasone is preferred because it does not interfere with ACTH stimulation test) or 3. Fludrocortisone: 0. 1-0. 2 mg/day 4. Steroid dose should be adjusted during stress (infection, pregnancy, surgery) ACTH stimulation test 1. Obtain baseline serum cortisol and ACTH levels. 2. Administer 0. 25 mg of cosyntropin (synthetic ACTH) IV/IM. 3. Repeat cortisol levels every 30 mins and 6 hrs after ACTH administration (normal >18 mcg/d L). 4. Normal response is indicated when the cortisol level doubles in response to ACTH stimulation. 5. In adrenal insufficiency, serum cortisol levels fail to rise after ACTH administration. Signs and symptoms Nausea/vomiting/dehydration Anorexia weight loss Abdominal pain “acute abdomen”Unexplained fever Hyperpigmentation or vitiligo Weakness/malaise Constipation/diarrhea Syncope Vitals and lab evaluation Hypotension Unexplained hypoglycemia Hyponatremia Hyperkalemia (continued) TABLE 2-1: Diagnosis: Adrenal Crisis (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
72 ENDOCRINOLOGY Hypercalcemia Azotemia Eosinophilia ↑ TSH, and ↓ T 3 , T 4 ECG: peaked T waves CT of abdomen: calcification, enlargement, or hemorrhage of adrenal gland CT of head: destruction of pituitary/mass lesion TABLE 2-1: Diagnosis: Adrenal Crisis (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 73 TABLE 2-2: Diagnosis: Diabetic Ketoacidosis (DKA) Disposition Unit Monitor Vitals Cardiac monitoring Neuro check Electrolyte monitoring Diet NPO once stable start American Diabetes Association (ADA) diet, complex carbohydrate diet Fluid Caution in patient with CHF NS or 1 / 2 NS first liter should be given quickly (wide open) Then 500 m L-800 L/hr (correct fluid deficit), then start maintenance 150-500 m L/hr Change IVF to D 5 NS or D 5 1 / 2 NS once the glucose level 250-300 mg/d L O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs CBC with differential, BMP q2h × 2-3, then q4h until electrolyte stabilizes Calcium, Mg + , PO 4 , ABG, LFT, troponin q8h × 3, CPK-MB q6h × 4 β -Hydroxybutyrate (ketone), anion gap Fingerstick glucose q1h initially for first 3 hrs, then q2-4h for next 12 hrs UA, urine C&S, blood C&S, serum/urine ketone, serum osmolality (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
74 ENDOCRINOLOGY Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Calculate ∆ / ∆ , Hb A1 C , amylase, lipase, β -HCG, stool guaiac Prophylaxis DVT Consults Endocrinology, diabetic education Nursing Foley catheter, I/O, urine output, stool guaiac, monitor electrolytes Avoid Hypokalemia Management See Management: DKA Note As DKA is being treated, anion gap ↓ , but ketone can ↑ because the main ketone that is measured is acetoacetate, not β -hydroxybutyrate, and as DKA is being treated, β -hydroxybutyrate converts to acetoacetate. Calculation of Replacement of Total Body Water (TBW) Deficit 1. TBW in hypernatremia = Male: 0. 5 × wt (kg), Female: 0. 4 × wt (kg) 2. TBW in hyponatremia = Male: 0. 6 × wt (kg), Female: = 0. 5 × wt (kg) 3. Current TBW = TBW × (140/PNa+) 4. TBW deficit = TBW-current TBW 5. X = replacement fluid Na+ (m Eq)/154 6. Replacement volume (L) = TBW deficit × [1/(1-X)] Example 1. A 70-kg male with PNa+ of 160 m Eq/L 2. TBW = (0. 5 × 70 kg) = 35 L 3. Current TBW = [35 × (140/160)] = 30. 6 L (continued)TABLE 2-2: Diagnosis: Diabetic Ketoacidosis (DKA) (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 75 TABLE 2-2: Diagnosis: Diabetic Ketoacidosis (DKA) (Continued) 4. TBW deficit = (35-30. 6) = 4. 4 L 5. X = 75 (m Eq/L)/154 = 0. 496. Replacement volume (L) = 4. 4 L × [1/(1-0. 49)] = 8. 6 L (replace this deficit in 48-72 hrs) Note Correct sodium for hyperglycemia; for each 100 mg/d L ↑ of blood sugar above 200 mg/d L, Na + can ↓ 1. 6 m Eq Replacement: Give one-half in first 24 hrs and next half in next 48 hrs Isotonic fluid (NS) should be used initially when correcting TBW deficit and should be corrected slowly over 48-72 hrs The serum sodium should fall by no more than 0. 5 m Eq/L/hr (12 m Eq/day) N a+ concentration in IV fluids: NS = 154 m Eq/L, 1/2 NS = 75 m Eq/L Management: DKA 1. If K+ is <3. 3 replace K+ before giving insulin (ADA recommendation) 2. Initially: regular insulin, 0. 1-0. 2 U/kg IV followed by infusion of 0. 1 U/kg/hr IV Note: Infusion: 100 U in 500 m L NS (infusion rate of 50 m L/hr gives 10 U/hr) An appropriate response to insulin treatment is ↓ blood glucose of 50-75 mg/d L/hr 3. ↓ Insulin infusion rate to 2-3 U/hr when glucose level ↓ to 250-300 4. Stop insulin infusion when anion gap normalizes (10-15) and HCO3 is close to normal; give SQ insulin before stopping infusion (IV insulin half-life is only a few minutes) (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
76 ENDOCRINOLOGY TABLE 2-2: Diagnosis: Diabetic Ketoacidosis (DKA) (Continued) 5. K+: Potassium depletion should be expected with insulin treatment; if K+ <4 replace with IV boluses add 20-40 m Eq KCl to each liter of IVF change to K+ phosphate to prevent chloride overload (monitor K+ q2h) Vigorously replace K+ Peripheral IV: KCl, 10 m Eq/hr Central line: 20 m Eq/hr or nasogastric (NG) tube If PO tolerated, 40-80 m Eq If concurrent K + and PO4 depletion consider potassium phosphate, 20-40 m Eq 6. PO4: If PO4 <1 m Eq/L (ADA recommendation) give phosphorus, 2. 5-5 mg/kg in 500 m L over 6 hrs 7. Mg: Replacement is required only if severe hypomagnesemia or refractory hypokalemia Patients with ventricular arrhythmia treat with magnesium sulfate, 2. 5-5 g IV 8. HCO3: not required unless patient's p H ≤7 (ADA recommendation); treatment: add 50-100 m Eq HCO3 to each liter 9. Headache: acetaminophen (Tylenol), 325-650 mg PO q4-6h 10. Treat underlying etiology (e. g., infection, MI, noncompliance) Sample of Electrolyte Monitoring Table Time Blood sugar Na/K/ PO4Anion gap I/OCurrent treatment Plan | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 77 TABLE 2-3: Diagnosis: Nonketotic Hyperosmolar Syndrome (NKHS) Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitor Diet NPO once stable start ADA diet Fluid NS, 1-2 L over 1 hr (caution in patient with CHF) NS, 500 m L/hr until fluid deficit is corrected start maintenance 1/2 NS at 150-125 m L/hr IVF should be changed to D5NS or D5 1/2 NS when glucose level reaches 250-300 mg/d L O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs CBC with differential, BMP q2h × 2-3, then q4h until electrolyte stabilizes Calcium, LFT, Mg+, PO4, ABG, troponin Anion gap, β-hydroxybutyrate (ketone) Fingerstick glucose q1h initially for first 3 hrs, then q2-4h for next 12 hrs UA, urine and blood C&S, serum/urine ketones, serum osmolality Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Calculate ∆/∆, Hb A1C, stool guaiac, β-HCG, amylase, lipase Prophylaxis DVT Consults Endocrinology, diabetic education (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
78 ENDOCRINOLOGY Nursing Foley, I/O, urine output hourly (maintain 50 m L/hr) Avoid Hypokalemia Management See Management: Nonketotic Hyperosmolar Syndrome Calculation of Replacement of Total Body Water (TBW) Deficit 1. TBW in hypernatremia = Male: 0. 5 × wt (kg), Female: 0. 4 × wt (kg) 2. Current TBW = TBW × (140/PNa+) 3. TBW deficit = TBW-current TBW 4. X = Replacement fluid Na+ (m Eq)/154 5. Replacement volume (L) = TBW deficit × [1/(1-X)] Example 1. A 70-kg male with PNa+ of 160 m Eq/L 2. TBW = (0. 5 × 70 kg) = 35 L 3. Current TBW = [35 × (140/160)] = 30. 6 L 4. TBW deficit = (35-30. 6) = 4. 4 L5. X = 75 (m Eq/L)/154 = 0. 496. Replacement volume (L) = 4. 4 L × [1/(1-0. 49)] = 8. 6 L (replace deficit in 48-72 hrs) Note Replacement: Give one-half in first 24 hrs and next half in next 48 hrs. Isotonic fluid (NS) should be used initially when correcting TBW deficit and should be corrected slowly over 48-72 hrs. The serum sodium should fall by no more than 0. 5 m Eq/L/hr (12 m Eq/day). (continued)TABLE 2-3: Diagnosis: Nonketotic Hyperosmolar Syndrome (NKHS) (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 79 TABLE 2-3: Diagnosis: Nonketotic Hyperosmolar Syndrome (NKHS) (Continued) N a+ concentration in IV fluids: NS = 154 m Eq/L, 1/2 NS = 75 m Eq/L. Management: Nonketotic Hyperosmolar Syndrome 1. Fluid replacement and electrolyte replacement essential Note: If K+ <3. 3 replace K+ before giving insulin 2. Calculate serum osmolarity: (2 × Na+) + (BUN/2. 8) + (glucose/18) 3. NS 1-1. 5 L/hr initially, then change to 1/2 NS at 500 m L/hr 4. Regular insulin, 0. 1-0. 2 U, should be given initially in severe hyperglycemia (>600) then Infusion: 0. 05-0. 1 U/kg/hr (50 U of regular insulin in 500 m L of NS at 50 m L/hr gives 5 U/hr) 5. When glucose reaches 250-300 mg/d L ↓ infusion rate to 1-2 U/hr and change IVF to D5 1/2 NS 6. After stopping infusion place patient on sliding scale and regular insulin SQ 7. K+: Potassium depletion should be expected with insulin treatment; if K+ <4 replace with IV boluses add 20-40 m Eq KCl to each liter of IVF change to K+ phosphate to prevent chloride overload (monitor K+ q2h) Vigorously replace K+ Peripheral IV: KCl, 10 m Eq/hr Central line: 20 m Eq/hr or NG tube If PO tolerated, 40-80 m Eq If concurrent K + and PO4 depletion consider potassium phosphate, 20-40 m Eq 8. PO4: If PO4 <1 m Eq/L phosphorus, 2. 5-5 mg/kg in 500 m L over 6 hrs (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
80 ENDOCRINOLOGY TABLE 2-3: Diagnosis: Nonketotic Hyperosmolar Syndrome (NKHS) (Continued) 9. Mg: Replacement is required only if severe hypomagnesemia or refractory hypokalemia Patients with ventricular arrhythmia treat with magnesium sulfate, 2. 5-5 g IV 10. HCO3: not required unless patient's p H ≤7; treatment: add 50-100 m Eq HCO3 to each liter 11. Headache: Tylenol, 325-650 mg PO q4-6h12. Treat underlying etiology (e. g., infection, MI, noncompliance) Sample of Electrolyte Monitoring Table Time Blood sugar Na/K/ PO 4Anion gap I/OCurrent treatment Plan | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 81 TABLE 2-4: Diagnosis: Thyroid Storm (Thyrotoxicosis) Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs Stat total T4 (primary turnaround), BMP, calcium, Mg, PO4, TSH, free T4, total T3 CBC with differential, β-HCG in females, blood and urine C&S, CPK (r/o rhabdomyolysis), LFT Radiology studies CXR (PA and lateral), ECG, ?thyroid scan, ?US of thyroid Special tests ?Serum and urine toxicology screen, ?ETOH level, ?troponin, ?radioiodine uptake ?Nuclear thyroid scintigraphy 123I [cannot perform nuclear scan after saturated solution of potassium iodide (SSKI)] Prophylaxis DVT Consults Endocrinology Nursing ? Avoid ASA (displaces T 4 from thyroid-binding globulin, thus raising T4 level) β-Blocker in bronchoconstriction Anticoagulation activity may be ↑ by propylthiouracil (PTU) Management See Management: Thyroid Storm (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
82 ENDOCRINOLOGY TABLE 2-4: Diagnosis: Thyroid Storm (Thyrotoxicosis) (Continued) Diagnostic Criteria for Thyroid Storm Signs and symptoms Score Signs and symptoms Score Tachycardia CNS 99-109 5 Mild agitation 10110-119 10 Moderate delirium 20120-129 15 Moderate psychosis20 130-139 20 Extreme lethargy 20 >140 25 Severe seizure/coma 30 Temperature CHF 99-99. 9 5 Mild pedal edema 5100-100. 9 10 Moderate bibasilar rales10 101-101. 9 15 Severe pulmonary edema15 102-102. 9 20 Atrial fibrillation 10 103-103. 9 25 Precipitant history>104 30 Negative 0 GI Positive 10 Moderate nausea/ vomiting/diarrhea, abdominal pain10 Severe unexplained jaundice20 <25, storm is unlikely; 25-44 supports the diagnosis of storm, ≥45 highly suggestive of storm. Source: From Burch HB, Wartofsky L. Life-threatening thyrotoxicosis: thyroid storm. Endocrinol Metab Clin North Am 1993;22:263, with permission. (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 83 TABLE 2-4: Diagnosis: Thyroid Storm (Thyrotoxicosis) (Continued) Management: Thyroid Storm Adjust dosing of PTU and methimazole in pregnancy ( ↓ dose) PTU: 300-600 mg PO/NG bolus, then 150-300 mg PO/NG q6h (Preferred in elderly, cardiac disease, and pregnant and lactating females) or Methimazole (Tapazole): 80-100 mg PO/PR/NG bolus, then 30 mg q8h Saturated solution of potassium iodide: 5 drops PO q6-8h × 24-72 hrs, or Sodium iodine: 250 mg IV q6h, or Lugol's solution: 10 drops added to IVF q8h Propranolol: 80-120 mg PO q4-6h or 1 mg/min for 2-10 mins (blocks T4 and T3) or Esmolol: 5g in 500 m L D5W, loading dose of 500 mcg/kg over 1 min, then 50-200 mcg/kg/min Dexamethasone: 2 mg IV q6-8h, or hydrocortisone, 100 mg IV q6-8h Tylenol: 325-650 mg PO q6h PRN for fever CHF and atrial fibrillation: Manage with digoxin 131Iodine and surgery reserved until patient is euthyroid Note: Administer PTU or methimazole 1 hr before giving iodide to prevent oxidation of iodide to iodine. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
84 ENDOCRINOLOGY TABLE 2-5: Diagnosis: Myxedema Coma Disposition Unit Monitor Vitals (hypothermia) Cardiac monitoring Electrolyte monitoring (hyponatremia, hypoglycemia) Diet High bulk diet (to prevent constipation) Fluid IV hydration essential (caution in patient with CHF) O 2 ≥2 L O2 via NC; keep O2 saturation >92%; respiratory support essential Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium, Mg, PO4 level, TSH, free T4, total T3, T4, LFT β-HCG in females, ABG, CPK, blood and urine C&S, lipid profile Cortisol level before and after cosyntropin (Cortrosyn) administration (r/o adrenal insufficiency) Radiology studies CXR (PA and lateral), ECG, ?head CT (r/o CVA) Special tests Troponin q8h × 3, CPK-MB q6h × 3, ?radioiodine uptake Prophylaxis DVT Consults Endocrinology Nursing ? Avoid β-Blocker, antihypertensives, narcotics can ↑ T 4, sedatives (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 85 Management Prevent heat loss: Cover the patient but avoid external rewarming to prevent vascular collapse Respiratory support Thyroxine: 200-400 mcg IV followed by 50-100 mcg daily Triiodothyronine: 5-20 mcg IV followed by 2. 5-10 mcg IV q8h Hydrocortisone: 100 mg IV q8h; give before thyroid replacement Note: Sudden change in metabolic rate after treatment may precipitate ACS in these patients; consider anticoagulation in patients at high risk or in patients with prior atrial fibrillation. TABLE 2-5: Diagnosis: Myxedema Coma (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
86 ENDOCRINOLOGY TABLE 2-6: Diagnosis: Hyperparathyroidism and Severe Hypercalcemia Disposition Medical floor/unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet Limit calcium to 1,200-1,500 mg/day and vitamin D to 400 IU/day Fluid IVF hydration essential before diuresis O 2 PRN Activity As tolerated Dx studies Labs CBC, BMP, Mg, PO4, ionized calcium, albumin, LFT, parathyroid hormone (PTH) Radiology and cardiac studies ECG, CXR (PA and lateral) ?CT of neck with and without contrast, immunoassay for intact PTH ?Sestamibi scan for neck, ?thallium technetium scan of neck (to localize lesion) Special tests Amylase, lipase, PTH, i PTH assay 24-hr urine calcium, ?calcitriol?PTH-like protein (associated with solid malignancy), PTHr P Prophylaxis ? Consults Endocrinology, ?nephrology Avoid Thiazide diuretic, calcium-containing products Management See Management: Hyperparathyroidism and Hypercalcemia (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 87 TABLE 2-6: Diagnosis: Hyperparathyroidism and Severe Hypercalcemia (Continued) Hyperparathyroidism Signs and symptoms Hypercalcemia Nephrolithiasis Anemia Bone disease Hypophosphatemia Proximal/distal renal tubular acidosis Hypomagnesemia ↑ Calcitriol production Hyperuricemia Muscle weakness Weakness and fatigue ↑ Gastrin production peptic ulcer Constipation Nephrogenic diabetes insipidus Pancreatitis Corneal calcium deposition Shortening of Q-T interval CNS dysfunction PTH inhibits proximal tubular bicarbonate reabsorption mild metabolic acidosis. Management: Hyperparathyroidism and Severe Hypercalcemia Treat hypercalcemia (also see Chapter 6) IVF: NS at 200-300 m L/hr adjust to maintain the urinary output to 100-150 m L/hr followed by furosemide (Lasix) diuretics Zoledronic acid: 4 mg IV over 15 mins Calcitonin: 4 IU/kg q12h if NS and Lasix not effective Pamidronate: 60-90 mg IV over 4 hr q24h (if serum calcium >3. 5 mg/d L) Etidronate, 7. 5 mg/kg/24 hr IV daily × 3 days, or alendronate, 5-10 mg PO qd or 70 mg PO weekly Prednisone: 20 mg PO bid-tid (continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
88 ENDOCRINOLOGY TABLE 2-6: Diagnosis: Hyperparathyroidism and Severe Hypercalcemia (Continued) Gallium nitrate: 200 mg IV continuous infusion for 5 days (side effect: nephrotoxicity), not commonly used Dialysis Treat underlying etiology | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
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