1...........................................

2.........(metabolic acidosis)

3...........................................

4.........(metabolic alkalosis)

5. .................................................

6. .....(respiratory acidosis)

7.......(respiratory alkalosis)

8............(mixed acid-base disorders)

.................................................................9

9.......................................
10

10........................ (hyponatremia)
11.................................................
12

12....................... (hypernatremia)
13

13.................................................
14

14..........................(hypokalemia)
15

11

15......................................
16

16.........................(hyperkalemia)
17

17......................................
18

18........................(hypocalcemia)
19

19......................................
20

20....................... (hypercalcemia)
21

21......................................
22

22.................................................
23

23................TCA (haldol or thorazin)

24

24.....................................Cocaine
25

25............. Inderal (calcium blocker)

26

26....................................Digitalis
27

27.................................... Narcotic
28

28.......................... Benzodiazepine
29

29.....(rapid sequence intubation, RSI)

30

30........(rapid sequence intubation, RSI)

31

31. Sexual Transmitted Disease (STD).33

32. Diarrhea35


(DOA)
AMIacute pulmonary edema

ACLS ACLS

87 7 1

1.

2. (metabolic acidosis)

: AG(Anion Gap)=Na+-(CI+CO2)

3.
1. With increased serum anion gap(>14 meq/liter)
(1)of endogenous origin
a. Renal failure: increased SUN, Creatinine, and phosphate
b. Acute tissue hypoxia, as with shock, convulsive seizures ,
pulmonary edema : increased serum lactate
c. Hepatic failure: abnormal liver function tests, increased
serum lactate
d. Uncontrolled diabetes: increased serum glucose and
acetone
(2)of exogenous origin, history
a. Ethanol (alcoholic ketoacidosis): increased serum acetone
b. Salicylates:increased serum salicylate, lactate
c. Methanol: measured serum osmolality >calculated
osmolality; increased serum formate, lactate
d. Ethylene glycol: measured serum osmolatity > calculated
osmolality; oxalate crystaluria; increased SUN later
e. Carbon monoxide: increased serum lactate, blood
carbonmonoxyhemoglobin
2.With normal serum anion gap(6-14 meq/liter)(hypochloremic
acidosis)
(1)of endogenous origin
a. Severe acute diarrhea or enteric fistula: history; serum K +
often < 3.5 meq/liter
b. Ureteroenteric anastomosis: history; AG sometimes
increased; serum K+ often <3.5 meq/liter
c. Type I RTA: history; urine pH 6.0 in the presence of
metabolic acidemia; serum K+ often < 3.5 mEq/liter
3

d. Type 4 RTA(hyporeninemic hypoaldosteronism): serum K +

often > 5.5 meq/liter; increased SUN; low plasma renin and
aldosterone
e. Addison disease (adrenocortical insufficiency): serum K +
usually > 5.5 meq/liter, low serum Na+, increased SUN; low
plasma cortisol and high ACTH; low plasma aldosterone
and high renin
(2)of exogenous origin
a. Acetazolamide: serum K+ often < 3.5 meq/liter
b. Hyporeninemic hypoaldosteronism (type 4 RTA)secondary
to NSAIDs: increased SUN; low plasma renin and
aldosterone; serum K+ often > 5.5 meq/liter
c. Cholestyramine: history
d. Sulphur: mildly increased serum sulphate; serum K + may be
5.5 meq/liter
e. Toluene: serum K+ often < 3.5 meq/liter, serum P low

4. (metabolic alkalosis)

5.
1.Primary loss of CI(with 2retention of bicarbonate):
hypochloremia
(1)Renal loss of CI
a. Diuretic therapy: urine [CI] may be < 15 meq/liter after
diuresis, but higher during diuresis
(2)Gastrointestinal loss of CI: urine CI< 15 meq/liter
a. Vomiting: history
b. Upper GI drainage
c. Chloride-losing diarrhea: history
2.Primary retention of bicarbonate-urine [CI] > 20 meq/liter
(1)Renal
a. Glucocorticoid therapy: history
b. Cushing syndrome: increased plasma cortisol
c. Primary hyperaldosteronism : increased plasma aldosterone
and suppressed renin
d. Bartter syndrome : increased plasma renin and aldosterone
e. Posthypercapnic alkalosis
(2)Gastrointestinal
a. Excess ingestion of absorbable alkali: serum calcium may
be elevated (milk-alkali syndrome)

6. (respiratory acidosis)

7. (respiratory alkalosis)

8. (mixed acid-base disorders)

10

10. (hyponatremia)
: mS osm=measured serum osmolality
cS osm=calculated serum osmolality
= 2 Na+ + glucose/18 + SUN/2.8

11

11.
1.Measurement artifact
(1)Hyperlipedemia
(2)Hyperproteinemia, as with macroglobulinemia or myeloma
2.Shift of water from cells to ECF, as with marked hyperglycemia
3.Increased total body water
(1)With normal total body Na+
a. Syndrome of inappropriate ADH secretion (SIADH)
(a)Drugs, such as chlopropamide, haldol
(b)Lung diseases, such as pneumonia, TB
(c)Ectopic vasopressin secretion, especially with lung
tumors
(d)CNS disease, such as meningitis
b. Compulsive water drinking
c. Hypothyroidism
(2)With increased total body Na+- edematous states
a. Chronic heart failure
b. Chronic liver disease
c. Chronic renal disease, especially nephrotic syndrome
d. Hypoalbuminemia
4.Decreased total body Na+
(1)Gastrointestinal losses owing to vomiting, diarrhea, drainage
(2)Renal losses
a. Diuretic drugs, especially thiazides
b. Mineralocorticoid, deficiency
c. Salt-wasting nephropathies
(3)Skin losses- sweating, with replacement just by water

12

12. (hypernatremia)

13

13.
1.Increased total body Na+ (rare in adults)
(1)Intravenous administration of hyperosmolar NaCI or NaHCO 3
solution
(2)Drinking sea water ([Na+] nearly 500 mmol/L)
2.Decreased total body water
(1)Excess renal losses
a. Osmotic diuresis owing, for example, to severe glycosuria
b. Diabetes insipidus
(a)Central- vasopressin deficiency owing to posterior
pituitary disease (tumor, granuloma, idiopathic)
(b)Nephrogenic- congenital- evident from infancy acquiredLi+ toxicity, K+ depletion, hypercalcemia
(2)Decreased intake- deficient thirst owing to impaired
osmoreceptor function

14

14. (hypokalemia)

15

15.
1.Inadequate K+ intake- often a contributing factor but seldom a
sufficient cause in the absence of increased K+ losses
2.K+ shift from ECF to cells
(1)Alkalemia, especially caused by acute respiratory alkalosis
(2)Insulin
(3)Hypokalemic (familial)periodic paralysis
3.Increased losses
(1)Gastrointestinal- from diarrhea, drainage, vomiting ( in the
last, mainly from kaliuresis)
(2)Renal
a. Diuretic drugs- thiazides and loop diuretics
b. Mineralocorticoid therapy
(a)Glucocorticoid therapy
(b)Hyperaldosteronism caused by adrenal adenoma
(c)Cushing syndrome
c. Mg++ deficiency
d. Type 1 renal tubular acidosis

Hint: DKA, digitalis intoxication, periodic paralysis

1.K:3-3.5 100 meq, K:2.5-3 200 meq
2.Rate:1/2 amp in 1 bt/hr, DKA 1 amp in 2 bt/hr, 60
meq/hr in severe DKA

16

16. (hyperkalemia)

17

17.
1.Measurement artifact due to in vitro leakage of K + from leukocyte
(with marked leukocytosis)or platelets (with marked
thrombocytosis)
2.K+ shift from cells to ECF
(1)Metabolic acidemia
(2)Hyperosmolarity, as with severe hyperglycemia
(3)Insulin deficiency
(4)Severe tissue damage, as with tumor lysis or rhabdomyolysis
3.Excess K+ intake- uncommon, except when associated with
decreased renal excretion
4.Decreased renal excretion
(1)Renal failure, especially acute, and particularly if associated
with major tissue damage (eg: tumor lysis or rhabdomyolysis)
(2)Antikaliuretic drugs
a. Diuretics- spironolactone, triamterene, amiloride
b. NSAID
c. ACE inhibitors
d. Angiotensin receptor blocking drugs
(3)Hypoaldosteronism
a. Hyporeninemic (ie, type 4 renal tubular acidosis)
b. Adrenocortical insufficiency (Addison disease)

Hint: uremia, HD, drugs etc

1.Sod bicarb 1 meq/kg
2.Mild (5-6)- lasix, keyexelate
3.Mod (6-7)- D50W 2 amp + RI 10U
4.Severe (>7)- cal gluconate or cal chloride, HD

18

18 (hypocalcemia)
: Pi: serum inorganic phosphate

19

19.
1.Low serum protein-bound calcium owing to hypoproteinemia
(especially hypoalbuminemia)
(1)Gastrointestinal malabsorption or protein leak
(2)Nephrotic syndrome
(3)Hepatic cirrhosis
2.Low serum ionized Ca++
(1)With hyperphosphatemia
a. Renal failure
b. Major tissue damage- tumor lysis, rhabdomyolysis
c. Hypoparathyroidism
(a)Postsurgical
(b)Idiopathic
(c)Pseudohypoparathyroidism
(2)Hypomagnesemia, especially in malnourished ethanol abusers
(3)Vitamin D deficiency- seldom a cause of severe hypocalcemia
in adults except in hypoalbuminemia
(4)"Hungry bone syndrome"- bone repair after parathyroid
adenomectomy
(5)In acutely severely ill patients (ICU hypocalcemia)

Hint: alcoholic, malnutrition, ac pancreatitis

1. 10% calcium chloride 10 ml (100 mg)over 10-20 min
2. Total: 1 gm over 6-12 hrs

20

20. (hypercalcemia)
: SPEP: serum protein electrophoresis
PTH-r-P: parathyroid hormone related protein
Pi: serum inorganic phosphate

21

21.
1.High serum albumin due to hyperproteinemia- seldom causes
serum calcium much above 11 mg/dl
(1)Tourniquet stasis
(2)Thiazide diuretic therapy
(3)Multiple myeloma ( a very uncommon cause of the
hypercalcemia in this disorder)
2. High serum ionized Ca++
(1)Increased bone dissolution
a. Hyperparathyroidism
b. Tumor, especially lung, kidney, (increased
PTHrP[parathyroid hormone related protein] secretion)
c. Bone metastasis, especially from breast or prostate cancer
d. Multiple myeloma, and perhaps other tumor, with increased
OAF (osteoclast activating factor)secretion
e. Hyperthyroidism
(2)Increased gastrointestinal absorption of calcium
a. Increased vitamin D
(a)Excessive intake
(b)Granulomatous disease- sarcoid, TB (with increased
1,25-dihydroxy-D)
(c)Lymphoma (increased 1,25-dihydroxy-D)
b. Milk-alkali syndrome (excess intake of CaCO 3)
(3)Decreased renal excretion- familial hypocalciuric
hypercalcemia (FHH)
(4)Decreased bone formation despite continuing dissolution, as in
bedfast patients with extensive Paget disease

Hint: metastatic breast cancer, estrogen

1.N/S bolus, lasix 40-100 meq (1 meq/kg, every 2-4 hrs),
2.Calcitonin, hydrocortisone, indomethacin, mithramycin,
diphosphonate ,
3.Other associate hypokalemia and hypomagnesemia

22

22.
Hint: Seizure, alcoholic, malnutrition, pancreatitis,
low K or Ca, arrhythmia
1. MgSO4 1-2 gm over 5-10 min. 4-6 gm over the next 24 hrs
2. If cardiac arrest: MgSO4 1-2 gm IV push

23

23. TCA (haldol or thorazin)

1.Sod bicar 1-5 meq/kg over 1-2 min, then drip
2.Hyperventilation
3.Target: PH:7.5, BP normal, QRS<100 msec
4.If QT prolonged or Torsade de pointes: MgSO4 1-2 gm bolus or
over 1-5 min
5.If still low BP: norepinephrine, epinephrine, high dose dopamine
6.Procainamide should be avoided

24

24. Cocaine
1.MONA, Benzodiazepine, MgSO4
2.Beta blocker should be avoided
3.Lidocaine
4.Epinephrine 5-10 min , high dose
5.Propranolol 3-5 mg/every 5 min for refractory VT/VF is
acceptable
6.Labetalol 5-20 mg if VF/VT persisted

25

25. Inderal (calcium blocker)

1.Saline bolus 500-1000 ml, atropine 0.5-1.0 mg,
2.Epi 2-100 ug/min for hypotension,
3.Glucagon 1-5 mg over 1 min,
4.Dopamine 10-20 ug/kg/min, cal chloride 5-20 ml, TCP
5.If above fail: dobutamine, norepinephrine, isoproterenol
6.Cardiopulmonary bypass or IABP if needed

26

26. Digitalis
1.For chronic: volume replacement, K and Mg replacement
2.For acute: Digibind (Fab)
3.If cardioversion is needed: use low dose energy (25-50 J)

27

27. Narcotic
1.Standard ACLS protocol
2.Naloxone 2 mg/ 2-5 min up to 10 mg
3. naloxone half life 15-45 min. 15-45
min

28

28. Benzodiazepin
e
1.Anexate 0.2 mg over 60 sec/ every 1 min, up to 1 mg
2.Suspect benzodiazepine overdose
(1)Anexate 0.2 mg over 30 sec, if no response in 30 sec
(2)Anexate 0.3 mg over 30 sec, if no response in 30 sec
(3)Anexate 0.5 mg over 30 sec/ every 1 min, up to 3 mg
(4)If 5 mg given in 5 min, still no response
(5)It is not a case of benzodiazepine overdose

29

29. (RSI)

30

30. (RSI)
SOAP ME

1.S: suction
2.O: oxygenation
3.A: airway support
4.P: premedication
(1)atropine: in all age of children, 0.02mg/kg
(2)lidocaine: prevent increased ICP, 1 mg/kg, so, if concern ICP,
then giving
(3)defasculating step
a. Pavulon (pancuronium)- 0.01 mg/kg
b. vencuronium- 0.01 mg/kg
c. rocuronium- 0.06-0.12 mg/kg
(4)sedatives: to induce unconscious
a. thiopental- myocardial depressant, but good in head trauma,
be careful in hypotension
b. ketamine- bronchodilating effect, good in bronchial asthma
may increase ICP and IOP, 2 mg/kg
c. benzodiazepine- dose for RSI higher than normal dose for
sedation
midazolan: 0.05-0.1 mg/kg
Fantanyl: 2-5 mcg/kg
5.ME: monitoring equipments- EKG monitor, Pulse oximeter
monitoring
6.Cricoid pressure
7.Paralysis; neuromuscular blocking agent
(1)succinylcholine- dose: 1-1.5 mg/kg, but in infant: 2.0 mg /kg
side effect: increased ICP, IOP, intragastric pressure
31

bradycardia, tachycardia, hyperkalemia fasciculation- prevent

with small dose of non-depolarizing agent
(2)vencuronium- 0.2-0.3 mg/kg
(3)pancuronium (Pavulon)- 0.1 mg/kg
(4)rocuronium- 0.6-1.2 mg/kg
8.Intubate
9.Confirm the position

31. Sexual Transmitted Disease(STD)

32

1. Genital ulcer
(1). Chancroid: caused Hemophilus ducreyi
Dx: one or more painful genital ulcer,tender inguinal
lymphadenopathy
1) azithromycin 1gm po only
2) ceftriaxone 250 mg im only
3).ciprofloxine 500 mg po bid x 3 D
4).erythromycin 500 mg qid x 7 D
(2). Herpes simplex
1). acyclovir 400 mg po tid x 7-10 D
2). famciclovir 250 mg po tid x 7-10 D
3). valacyclovir 1 gm po bid x 7-10 D
(3). Syphilis: painless chancre
1): Benzathine penicillin G 2.4 million im only
2): doxycylcine 100 mg po bid x 14 D, if allergic to penicilline
2. Cervicitis and urethritis: mucopurulent discharge
(1). Chlamydia: 1). azithromycin 1gm po only
2). doxycycline 100 mg po bid x 7 D
3). erythromycin 500 mg po qid x 7 D
(2). Gonorrhea: 1). cefixime 400 mg po only
2). ceftriaxone 125 mg im only
3). ciprofloxacin 500 mg po only
4) ofloxacin 400 mg po only
3. Vaginitis:
(1). Bacteria vaginitis: overgrowth of normal vaginal
flora with anaerobes
Dx: white discharge, clue cell, vaginal pH>4.5 &
positive whiff test, STD ? multiple sex partners
In nonpregnant women
33

1). metronidazole 500 mg po bid x 7 D

2). clindamycin cream 2% (5 gm)
3). metr-gel 0.75% (5 gm intravaginally bid x 5 D)
In pregnant women: in early second trimester
1). metronidazole 250 mg po bid x 7 D
2). clindamycin 300 mg po bidcream 2% (5 gm)
3). metronidazole 2 gm po only
(2). Trichomoniasis vaginitis: caused by protozoa
Dx: malodorous, yellow green discharge, vulval irritation
1). metronidazole 2 gm po only
4. Pelvic Inflammatory Disease (PID): most caused by
Gonorrhea & Chlamydia. No need hospitalization
except: pregnancy, TOA, severe illness or high fever, failure
of OPD treatment, noncompliance, surgical condition
can not be exclude, immunodeficiency
Dx: low abd tender, adnexal tender, cervical motion tender
1). ofloxacin 400 mg po bid x 14 D + metr 500 mg po bid x 14 D
2). doxycyc- 100 mg po bid x 14 D + ceftriaxone 250 mg im only
3). doxycycline 100 mg po bid x 14 D + cefoxitine 2 gm +
probenecid 1 gm po only
4). doxycycline 100 mg po bid x 14 D + any third generation
cephalosporin (cefitzoxime or cefotaxime)

32. Diarrhea
34

Causes: infectious, non-infectious, virus, radiation induced,

parasite
Infectious: mainly in colon, frequent, small-volume stool, fever,
systemic and toxic sign, tenesmus, blood or pus in the stool, but
absence of stool leukocyte does not rule-out a bacterial cause,
stool OB test is useful, an alternative to fecal leukocyte.
Non-infectious: frequent, large-vol stool, mainly in small intestine
Infectious colitis
1. Shigella: fecal-oral, contaminated food or water
Dx: fever, abd pain, copious watery diarrhea that become
bloody, abdominal tender, especially in LLQ, seizure
common in children, toxic megacolon, Reiters
syndrome, hemolytic-uremic syndrome
Tx: self-limited, antibiotic shorten the duration
2. Salmonella
1). Non-typhoidal: contaminated water or food- poultry, meat,
milk, eggs
Dx: headache, fever, malaise, nausea, vomiting, abdominal
pain, followed by diarrhea, stool may or may not be bloody
Tx: self-limited, anti discouraged, except immunosuppression
2). Typhous:
Dx: typhoid fever, flu-like, paradoxical brady, rose spot,
hepatosplenomegaly, mental cloudy, seizure, bloody stool,
perforation
Tx: should always be treated with antibiotics
3. Campylobacter: contaminated water or food
Dx: watery to bloody, mucoid diarrhea, fever, abd pain,
tenesmus, toxic megacolon, Reiters syndrome,
cholecyctitis, pancreatitis,
35

Tx: self-limited, but antibiotics in toxic or prolonged course

4. E.coli: important cause of outbreaks of bloody diarrhea and is
more likely to affect individuals at the extremes of age
Route: undercooked ground beef, or other foods, via person to
person contact
Dx: history of bloody diarrhea, visibly bloody stool, no reported
fever, abdominal tenderness, leukocytosis, hemolytic uremic
syndrome, thrombotic thrombocytopenic purpura, toxic
megacolon
Tx: anti depend on the causative agent, some yes, some no
5. Clostridium difficile: antibiotic-associated colitis
Route: linked with cephalosporin, ampicillin, clindamycin,
usually 4-9 D after initiation of antibiotics, can be passed
person to person
Dx: semi-formed stool, greenish-colored, or bloody and mucoid,
toxic, fever, abd pain, and tenderness, bloody diarrhea,
leukocytosis, hypoalbuminemia, pseudomembranes found
by colonscope shock, cecal perforation, profound
hemorrhage
Tx: DC the offending antibiotic,
metro- or vanco: depend on the severity of the disease
Antibiotic therapy: fluoroquinolones, except C. difficile group

36