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LAC+USC

INTERNAL MEDICINE
RESIDENCY SURVIVAL GUIDE
2013-2014

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THIS BOOK BELONGS TO:

Dr. _________________________________________________

PGR: ________________________________________________

PHONE: _____________________________________________

EMAIL: ______________________________________________

CONTRIBUTING AUTHORS:
Robert Drummond, M.D., Ph.D.
Suneet Dullet, M.D.
Beatrice Kenol, M.D.
Arjun Makam, D.O.
Alan Moazzam, M.D.
Jackie Nneji, M.D., M.P.H.
Ray Pillai, M.D.
Mona Rezapour, M.D., M.H.S.
Billy Sim, M.D.

REVIEWING FACULTY:
Donald Feinstein, M.D.
Elaine Kaptein, M.D.
Rod Mokhtari, M.D.
Gina Rossetti, M.D.

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SECTION 2 BLS/ACLS

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TABLE OF CONTENTS
SECTION 1 ACLS/BLS .................................................................................4
SECTION 2 Phone Numbers/Consults/Voips .............................................4
SECTION 3 THE WARDS ...........................................................................17
1. Tips For The Wards Team.........................................................17
2. Daily General Medicine Itinerary .............................................18
3. Admitting A Patient..................................................................18
4. Admit Orders............................................................................19
5. Daily Notes ...............................................................................22
SECTION 4 COMMON ON-CALL/CROSS COVER SCENARIOS ....................25
1. Chest Pain ................................................................................25
2. Somnolence / ms ..................................................................25
3. SOB ..........................................................................................25
4. Hypoglycemia...........................................................................26
5. Hyperglycemia .........................................................................26
6. Nausea / vomiting / diarrhea ...................................................26
7. Pain / insomnia / anxiety .........................................................27
8. HTN / hypertensive urgency ....................................................27
9. Hypotension .............................................................................27
10. Fever ........................................................................................28
SECTION 5 PROCEDURES .......................................................................29
1. Imed consent ...........................................................................29
2. Central venous catheters (central lines)...................................29
3. Arterial lines .............................................................................35
4. External jugular line .................................................................37
5. Ultrasound-guided peripheral iv ..............................................38
6. Lumbar puncture .....................................................................40
7. Abdominal paracentesis ...........................................................42
8. Thoracentesis ...........................................................................45
SECTION 6 COUNTY STUFF ......................................................................48
1. Locations in hospital ................................................................48
2. How to get stuff done ..............................................................48
a. Picc line ...........................................................................48

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b. Stress test........................................................................48
c. TTE ..................................................................................48
d. PFTS................................................................................49
e. EEGS ...............................................................................49
f. Permacath/vascath .........................................................49
g. CT/MRI ............................................................................50
h. Pet scan ...........................................................................50
i. US ....................................................................................50
3. LAC+USC Radiology ...................................................................50
4. Frequent consults (and their requirements) .............................51
a. Ortho ...............................................................................51
b. Renal ...............................................................................51
c. Neuro ..............................................................................51
d. Heme...............................................................................51
e. Oncology .........................................................................51
f. Rad Onc ...........................................................................51
g. GI .....................................................................................51
h. Liver ................................................................................51
i. Urology............................................................................51
j. Speech and Swallow ........................................................51
5. Electrolyte Replacement ...........................................................52
6. Misc. county stuff ......................................................................54
a. How to TAR a patient ......................................................54
b. VNA .................................................................................54
c. Med Appliance ................................................................54
d. Special bed request .........................................................54
e. Isolation ..........................................................................55
SECTION 7 BASICS OF PAIN MANAGEMENT ............................................56
SECTION 8 TPN/TUBE FEEDS ...................................................................59
SECTION 9 CRITICAL CARE/ ICU ..............................................................61
1. ICU On Call Intern Schedule ....................................................61
2. ICU Regular Day Schedule ........................................................61
3. Daily Considerations in the ICU ................................................61
4. Respiratory failure ...................................................................62
5. Types of supplemental oxygen.................................................63
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6. Acute respiratory distress syndrome (ARDS) ...........................64
7. Supportive ventilation basic primer .........................................65
8. Sepsis .......................................................................................66
9. Shock........................................................................................67
10. Pressors....................................................................................68
SECTION 10 CARDIOLOGY .......................................................................70
1. Differential diagnoses of chest pain .........................................70
2. Peripheral edema grading system ............................................72
3. JVP assessment ........................................................................72
4. Waveforms...............................................................................73
5. EKG...........................................................................................73
6. Acute coronary syndrome (ACS) ..............................................75
7. Post-cardiac cath pts ................................................................77
8. The new cardiomyopathy (CM) pt ...........................................78
9. Heart failure .............................................................................78
10. A-fib .........................................................................................80
11. HTN ..........................................................................................82
12. Hypertensive urgency/emergency ...........................................82
13. Syncope....................................................................................83
14. Brugada criteria (distinguish SVT from VT)...............................84
15. Valvular diseases ......................................................................85
SECTION 11 ENDOCRINOLOGY ................................................................87
1. Insulin & Oral Antidiabetic Agents ...........................................87
2. Inpt Diabetes Management .....................................................87
3. DKA ..........................................................................................89
4. HHS ..........................................................................................90
5. Adrenal Insufficiency in Inpts ...................................................91
6. Thyroid Disorders .....................................................................92
7. Dyslipidemia.............................................................................95
SECTION 12 INFECTIOUS DISEASES .........................................................98
1. Neutropenic Fever ..................................................................98
2. Fever of unknown origin ........................................................ 100
3. Endocarditis ........................................................................... 101
4. Community acquired MRSA ................................................... 105
5. Community acquired pneumonia (CAP) ................................. 106
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6. HIV new diagnosis ............................................................... 109
7. Reportable diseases ............................................................... 111
8. Bacteria classification ............................................................. 111
9. Fungi ...................................................................................... 113
SECTION 13 GASTROENTEROLOGY/HEPATOLOGY ................................ 115
1. Diarrhea ................................................................................. 115
2. Clostridium difficile (Pseudomembranous) colitis .................. 118
3. Constipation ........................................................................... 119
4. GI Bleeding ............................................................................. 120
5. Helicobacter pylori ................................................................. 121
6. PPI use ................................................................................... 121
7. Colonoscopy Preparation ....................................................... 122
8. Inflammatory Bowel Diseases ................................................ 122
9. Acute Pancreatitis .................................................................. 124
10. Acute Hepatitis....................................................................... 126
11. Alcoholic Hepatitis ................................................................. 128
12. Acetaminophen Toxicity ........................................................ 129
13. Chronic (and Sub-acute) Hepatitis & ESLD ............................. 131
14. Liver Transplant ..................................................................... 132
15. Ascites & SBP ......................................................................... 133
16. Hepatorenal Syndrome .......................................................... 135
17. Cancer Screening ................................................................... 136
SECTION 14 HEMATOLOGY/ONCOLOGY ............................................... 137
1. Anemia ................................................................................... 137
2. Hypercoagulability ................................................................. 142
3. DVT Prophylaxis .................................................................... 143
4. Anticoagulation in Pt w/ VTE.................................................. 144
5. Heparin Induced Thrombocytopenia ..................................... 147
6. Other Platelet Disorders ........................................................ 149
7. Hematological Malignancies ................................................. 151
8. Common Heme/Onc Emergencies ......................................... 159
SECTION 15 NEPHROLOGY .................................................................... 162
1. Chronic Kidney Disease (CKD) ................................................ 162
2. Acute Kidney Injury (AKI) ....................................................... 164
3. Acid-Base Disorders ............................................................... 166
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4. Hyponatremia & Hypernatremia............................................ 169
5. Hypokalemia & Hyperkalemia ................................................ 173
6. Management of Magnesium, Calcium, & Phosphorus ........... 176
7. Kidney Transplant Pearls ..................................................... 177
SECTION 16 NEUROLOGY & ADDICTION/WITHDRAWAL....................... 179
1. Bacterial Meningitis ............................................................... 179
2. Stroke (focal neurologic deficit) ............................................. 180
3. Alcohol Withdrawal ............................................................... 182
4. Opiate Withdrawal ................................................................. 182
5. Altered mental Status ............................................................ 183
6. Delerium ................................................................................ 183
7. Dementia ............................................................................... 186
8. Seizures .................................................................................. 187
SECTION 17 PULMONARY ..................................................................... 189
1. Asthma ................................................................................... 189
2. COPD Exacerbations ............................................................... 192
3. ILD .......................................................................................... 192
4. Pulmonary Embolus ............................................................... 193
5. Pulmonary Hypertension ....................................................... 194
6. Pleural Effusion ...................................................................... 194
7. Pulmonary Edema .................................................................. 196
8. Cystic Fibrosis ......................................................................... 196
SECTION 18 RHEUMATOLOGY .............................................................. 198
1. Systemic Lupus Erythematosis ............................................... 198
2. Rheumatoid Arthritis ............................................................. 202
3. Gout ....................................................................................... 203
4. Vasculitis ................................................................................ 204
5. Dermatomyositis/Polymyositis .............................................. 208
6. Scleroderma ........................................................................... 208
SECTION 19 GENERAL PHARMACY ........................................................ 211
1. Steroid dosing ........................................................................ 211
2. Beta Blocker Dosing ............................................................... 211
3. ACE Inhibitor and ARB Dosing ................................................ 212
SECTION 20 DISCHARGES ...................................................................... 213
1. Discharge Summary ............................................................... 213
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2. Discharge Dictations .............................................................. 213
3. Transfer Discharge (Rancho los amigos, Oliver View, etc.) .... 214
4. AMA Discharge....................................................................... 214
SECTION 21 HOW TO SURVIVE IN THE CLINICS ..................................... 215
1. Specialty Clinics ...................................................................... 216
2. Continuity clinic ..................................................................... 215
3. Galaxy .................................................................................... 216
4. Admissions from Clinic ........................................................... 216
SECTION 22 - END OF LIFE........................................................................ 217
1. DNR/DNI ................................................................................ 217
2. Comfort care .......................................................................... 217
3. Palliative care/Hospice Care .................................................. 219
4. Death exam ............................................................................ 219
SECTION 23 MEDICAL INFORMATICS .................................................... 221
1. Affinity ................................................................................... 221
2. CCIS ........................................................................................ 221
3. Museweb ............................................................................... 221
4. PADI ....................................................................................... 221
5. QUANTIM............................................................................... 221
6. SYNAPSE ................................................................................. 221
7. RPS ......................................................................................... 221
8. Econsult ................................................................................. 221
9. Verinform ............................................................................... 221
SECTION 24 OUTSIDE HOSPITAL PHONE NUMBERS .............................. 222

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SECTION 2 PHONE NUMBERS (Consults, VOIPS, etc.)

IMPORTANT NUMBERS (Consults, VOIPS, etc)


CARDIOLOGY GI
Cards consult 226-4238 GI & Liver Consult 97974
Stress Lab 97468 GI Recovery 95530
(Marci)
Cath Recovery 95284,95783 GI Lab 95530
Echo sched 97444 GI fellow workroom 92679
Echo tech 97445 ERCP Room 97275
Echo Read 97520 GI Fellow VOIPS A-93988,
EKG tech 97466 B-93989
CARDS CONSULT A-93982
VOIPS B-93983
ID HEME/ONC
ID consult 226-3851 Heme Consult 226-6969
HIV clinic(5P21) 323-343-8258 Onc Consult 226-6395
TB Control 226-7962 Palliative Care 9-8532
Epidemiology 9-6645 Pain Management 213-919-8545
PULMONARY Rad Onc consult 9-5019
9-5023 OP appt
Pulm consult 226-7923 Onc clinic 4P1 226-5177
Consult VOIP 93995
Bronch suite 9-4730 RENAL
Resp therapy 226-7492 Renal Consult 226-7307
PIERRE 9-1825 Fellow VOIP A 9-3996
(Induced sputum) B 9-3997
PFT lab 91266 HD nurse VOIP 9-3243
OTHER OTHER
Endocrine 442-2807 Rheum 226-7889
VOIP-93987 Rheum VOIP 93998
Derm consult 226-3375 EEG 9-7388

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Derm pgr 213-717-2626 Psych ED 9-7085
213-919-9578
Neuro inpt VOIP 9-4537 Psych C+L 226-7975
Consult VOIP 9-4536 answering machine
SURGERY CONSULTS
GEN SURGERY OTHER SURGERY
ACS Consults 9-7782 ENT 97309
213-919-7000
ACS A 919-8751 ACS B 919-8752 Neurosurg 9-7376
ACS C 919-8755 ACS D 919-4529 Opthalmology 919-9254
NON Trauma VOIP 9-7769 Ortho consult pgr 213-919-3487
SICU VOIP/consult 9-81717 Ortho ID 9-7227
for PEG or TRACH
CRS 9-7363 Ortho ID pager 213-919-3487
213-919-7363
HBS 6-7791 Urology consult pgr 919-2156
TMIS thoracic 213-919-8581 Podiatry outpt only 323-226-4172
CTS 9-7819 Vascular 9-5816
Surg Onc 6-4981 Vasc surg on call 213-919-8750
Plastics 213-919-7299 IR
Tumor Breast 990-8574 IR consult 94100
Gyn-Onc 213-919-0468 Aangio suite room 94099
9-4198
OB 93127 FNA biopsy 94615
Gyn 94198
RADIOLOGY radread.usc.edu
CT reading room CT scheduling
Days 91583 Inpt 97202
Approval aft 5pm 92798 Outpt 92798
Weekdays aft 5pm 92798 U/S scheduling 97207
weekends 92798 U/S reading rm 94386
Neuro reading 94149 Xray Read 98063
room

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MRI 91289, 90, 91, Rads Attending 94395
92, 93
MRI MSK reading 96104 Nuc Med 97855
Xray 97234 Vasc Lab 94618
MEDICINE TEAM VOIPS
Med Consult 91644
Red A 94145 Gold A 94013
Red B 94146 Gold B 94110
Red C 94147 Gold C 94150
Red D 94148 Gold D 94151
White A 94109 Resident Rm 8A 91385
White B 94153 CCU 93981
White C 94154 MICU I 93984
White D 94155 MICU II 93985
MICU III 93986
ANCILLARY
Inpt PHARMACY 97641 Admission Stuff
Outpt PHARMACY 96763 UR 95001
TPN Pharmacy 97438 Bed Control 95321
PT/OT Nursing supervisor 92965
weekday 97437 Sched Admit Grace, UR
96412
weekend 95096 Discharge Stuff
Speech Therapy 95082 Discharge Waiting 91560
Unit
PICC 226 7516
PICC nurse 323 409 4186 Social Work Patty Evans
90779 (supervisor)
93761 office,
97447 voip
Micro Lab 97012 SCW in ER 96883
Cytology 94615 SCW main office 95253
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Rancho Shirley 562-446-2347 VNA RN 95090
Rancho liason 91674 Dictation line 888-201-8590
Dr. Carpio 562-401-6085
Med Appliance 95125 Pathology 94606
On Call Chief 213 375 4455 Chiefs Office 323 226 7644
Google Voice
Ed Affairs 323 226 7556 Galaxy 323 226 2206

Wards
Jail ................94568
2E .................96355
4AL ...............93929
4AH ..............93933
4BL ...............97490
4BH ..............94005
5A ................97391
5BL ...............98050
B5E ...............97882
5F .................97393
6A ................97730
6B .................97812
6C .................97225
6D ................97227
7A ................92592
7B .................94021
7C .................97312
7D ................97304
8A ................97651

8A Res Rm .....98652
CCU ..............97111, 97112, 97113
Ob.Gyn .........90504
NICU .............93264
PICU .............93883

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SECTION 3 THE WARDS

1. TIPS FOR THE WARD TEAM


1. Fill out/stamp request forms (U/S, CT, MRI, Nuclear Med, Stress
test) and drop them off at 7:30 am or on Work rounds.
2. While one team member is presenting, someone else should
take a blank order form and write down any orders the
attending recommends then place it in the chart.
3. Write down all other post round tasks the attending
recommends during rounds so that nothing gets missed during
the afternoon. If the attending recommends a study (U/S, CT,
etc.) fill out and stamp the appropriate form & gather the
necessary info then submit them at the earliest opportunity.
4. Write PRN orders on nearly all of your patients: Tylenol 650 mg
po/pr q4hr prn HA/Fever/Pain, Maalox 30cc po q6hr prn
dyspepsia, MOM 30cc po q6hr prn constipation. Benadryl 25mg
po qhs prn insomnia, Reglan 10mg IV/IM q6hr prn nausea
(there is a check box for many of these on the Admission
Orders set) Make sure you go through the PRNs and make sure
patients dont have any contraindications (i.e. renal failure w/
MOM or elderly w/ Benadryl)
5. Record a pain score, list it as a separate problem, and treat it
appropriately
6. Order an admit panel on most of your admissions: CBC w/ diff,
BMP, Mg, Phos, LFTs, PT/INR, UA
7. Complete as much of the D/C summary as possible as you
complete the H&P.
8. Know why each of your patients is still here and what you need
to do to get them out of here.
9. Know which of your patients is sickest and make sure it is
relayed to night float and med consult when appropriate.
10. Try to anticipate problems your patient may give the Night
Float and warn them/sign out what you want done.

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2. DAILY GENERAL MEDICINE ITINERARY
6-7am: Get Sign out from your Night Float and Pre
Round/See New Patients
7-8am: Work rounds with Senior Resident
8-9am: Resident Morning Report Interns perform patient
care/write notes
9-12 noon: Attending Rounds
12 1pm: Noon Conference/Lecture (Take lunch with you)
1-5:30pm: Patient care and Admissions
5:30pm: Sign Out to Senior Resident and Night Float

3. CHECKLIST FOR ADMITTING A PATIENT


1. You will receive a call from Med Consult, your Senior Resident,
or Co-Intern that you have received a patient. Ask for the name,
PF, and location.
2. Check to see if the patient is a bounce back , if so, notify your
Senior Resident & Med Consult
3. Check Labs write the important ones on a lab sheet.
4. Check Affinity for Discharge Summaries and any Clinic Notes .
Check Affinity, MUSEWEB, & Quantim EDM for old chart and
any other useful information about the patients history. If you
know the patient has been admitted before and Quantim
doesnt have the d/c summary, call Medical Records at 226-6221
for the old chart.
5. Check Synapse (to review) and Affinity (to read dictations) for
any imaging done in ER or prior to admission.
Briefly assess the patient (vital signs, brief exam)
Look at the patient from across the room for general
impression.
Introduce yourself to the patient and/or family members and
tell them you are going to briefly check on the patient.
Mental Status: find out if the patient is AA&Ox4 (person, place,
time, and situation)

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Check Vital signs (Take the pulse for six seconds and multiply by
10)
Count respirations for 15 seconds then multiply by 4
Get a pulse ox if you are worried at all about their respiratory
status, consider an ABG
Ask the nurse for the other vitals and for orthostatics
Get a brief HPI, ask also if they have med allergies and their
weight
Assess whether the patient is critical, guarded, or stable. If they
are not stable and not in the ICU , call your Senior resident or
Med Consult (323) 409-1644

After Initial Assessment:


Review ER sheet to see what was done and include a brief ER
course in your H&P
Go to the chart and write admit Orders (include your admit
panel and prns).
Medications will need to be written on the Medication
Reconciliation Form (PADI). If the PADI form is not signed then
pharmacy will not be able to dispense medications.
Do full H&P (Template available on Chiefs Website) dont be
afraid to call the patients family, doctor, ER physician etc. for
more info. Modify orders as necessary
Start D/C Summary (If you are confident the patient will be
discharged the next day, start prescriptions.)

4. ADMIT ORDERS:
Usually, an admit order sheet will be available which contains a checklist
of common admission items, if not, then use a physician order sheet and
the following pneumonic: CAD VANDISMAL

C- Condition: Stable, Guarded, Critical, etc.

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A- Admit: Firm (Gold/White/Cardinal), Team (A,B,C,D) , Attending,
Resident, Intern

D- Diagnosis: CHF exacerbation, PNA, etc (this should be the


admitting dx)

V- Vitals: Usually per routine is sufficient (this is q 4 hours on the


floor and q 1h in ICU) If particularly concerned about a patient you
can initially check more frequently (ex: q 1 hour x 2, then q 4h)

A- Allergies: PCN (anaphylaxis), Morphine (rash), etc.

N- Nursing: Usually per routine unless special concerns (i.e. strict


Is/Os, daily weights, dressing changes, seizure precautions, O2 to
keep Sat > 92%, foley to gravity, etc.)

D- Diet: Regular, ADA/Consistent Carbohydrate, 2gm Na, etc (see


diet sheet on next page)

I- IV Fluids:
You can just write SLIV for saline lock which means the
nurse periodically flushes the line and no standing IVF
If the patient is not eating, does not have Renal Failure,
Cirrhosis or CHF you can consider given maintenance
fluids w/ NS, consider D5 w/ NS if patient is not
diabetic
One trick is to add 40 to their weight in kg and use that is
your rate in cc/hr (ex: 70kg person would get 110cc/hr of
IVF)
If patient ETOH intoxication or withdrawal can give
banana bag: 1mg Folate, 100mg Thiamine, 10cc MVI, 2gm
MgSO4 in 1L NS at ~100cc/hr

S- Studies: EKG, CXR,U/S, CT, MRI, etc.

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M- Meds
Make sure you fill out and sign the med reconciliation
sheet (otherwise the patient will not get their meds)
Check off PRNs on the admission orders (Benadryl, MOM,
etc.) but make sure they dont have any contraindications
Make sure you address PRN pain medications. All opioids
have to be written x 72 hours or they will fall off after 1
day. You can write x indefinite (cancer) if the patient
has a malignancy and it will stay on for the admission

A- Activity:
as tolerated unless you dont want them getting out of
bed in which case you and write bed rest,
bed rest with BRP (bathroom privileges) if they are not
a fall risk is also acceptable
If you are worried they will not get out of bed and you
want them to you can write out of bed to chair tid

L- Labs:
order CBC w/ diff, BMP, Mg, Phos, LFTs, PT/INR and UA on
nearly everyone then add any more specific labs
if labs were drawn a few hours ago (in ER or Clinic) no
need to repeat until AM unless you need something
specific
if no labs were drawn in last few hours, everything should
be sent

GENERATING A GOOD DIFFERENTIAL: Here are three useful approaches:


1) Pathology: VINDICATE
Vasculitis
Infectious
Neoplasm
Degenerative (Aging)
Iatrogenic (Procedures/Drugs)

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Congenital
Allergic/Autoimmune
Trauma
Environmental (Poisons/Chemicals)
2) Anatomy
This works well with pain: RUQ pain: think of what
anatomical structures are in the area or nearby:
liver, gallbladder, colon, R kidney, stomach,
pancreas, lower lobe of right lung, etc.
3) Pathophysiology
This works well with things like acute anemia where
based on pathophysiology it should be.

5. DAILY NOTE

WRITING YOUR DAILY NOTE: Another useful mnemonic that can be used
for writing a daily note is: CON ME LVN
1. Find the Chart
2. Look at the recent Orders
3. Look at the recent consult Notes
4. Check the nursing Medicine sheets (MAR) for the meds your patient
is actually getting, or check PADI
5. Examine and interview the patient
6. Check for new Labs and to see which labs are still pending
7. Check the Vital signs
8. Talk with the Nurse or read the nursing assessment in affinity
9. Write your note

DAILY NOTE TEMPLATE:


Medicine (Red A, B, C, etc.) Progress Note
Attending:
Resident:
Intern:

ID: ex: 50 YO F w/ DM admitted for PNA


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Problem List:
(Keep this dynamic. Move things up or down on the list depending on what
is most important.)
1- PNA
2. Strep Bacteremia
3. DM
4. HTN

Meds:
(keep this updated, check PADI daily and cross-reference with your signout,
especially abx)
Abx (date started, D#)
Heart Meds
Other Meds
Prn Meds

S: No overnight events. Pt remains febrile overnight

O:
VS: T, HR, RR, BP, O2 sat, Is/Os
GEN
HEENT
PULM
CV
ABD
EXT
NEURO

Results: (include important information, dont copy and paste every lab
and study the patient has had from the beginning of time. Only whats
relevant!)
Labs: (CBC, CMP, etc)
Micro: (any blood cultures, urine cultures, stool, etc)
Imaging: (any relevant imaging)
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Assessment: (This is where you should put a good one liner that
summarizes why the patient was admitted to the hospital and how the
patient is doing.)
Ex: 50 YO F w/ h/o DM admitted for PNA found to have strep bacteremia,
now improving and afebrile x 24 hours.

Plan: (Go through each problem daily and update. This is the most
important part of your note. This is what consult services read and more
importantly your attending will read and is an easy way to tell if an intern
has a good understanding of his/her patient.)

#PNA-improving
-cont ceftriaxone and azithromycin, today day # .
-sputum culture negative
-bcx positive for strep, see below

# Strep Bacteremia -improving


-on abx today day #
-surveilance cultures negative
-afebrile x 24 hours

#Prophylaxis/FEN
-PPI (yes or no)
-DVT prophylaxis (leg squeezers, fragmin, etc. )
-Diet (ADA, 2 gram Na, etc.)

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SECTION 4 COMMON ON-CALL/CROSS COVER
SCENARIOS

1. CHEST PAIN:
Order EKG & call floor for vital signs: BP, HR, O2 sat
Look at signout for underlying PMHx, reason for admission
Assess pt: Vital signs, physical exam (JVP, parasternal lift, gallops,
rales, cool extremities), fluid status (check I/Os)
URGENT diagnoses: ACS, PE, dissection, PTX
Consider cardiac enzymes (STAT), CXR, consider urine tox (for
cocaine)
Other diagnoses: GERD, esophageal spasm, musculoskeletal, cocaine
vasospasm, peri/myocarditis, anxiety attack, sickle VOC
2. SOMNOLENCE / MS:
Review PMHx, Rx list & MAR for meds given in past 6 hrs
Check vitals, examine pt (including neuro), ABG, dexi
Trial of Narcan (0.2-0.4 mg IV) if suspicious for opioid overdose
If unresponsive: consider code +/- STAT head CT (non-contrast)
Consider CMP, Heme-8, urine tox, Ammonia, EKG, EEG
3. SOB:
Examine pt & vitals, most recent ABG, CXR, EKG, Volume/I&Os. Get
new ABG, CXR, EKG.
DDx: Mucus plugging, COPD/asthma exacerbation, pulmonary
edema, PE, pneumonia, ACS, ARDS, aspiration
Oxygen: Nasal cannula, facemask, non-rebreather NIPPV
Consider RT (for suction/nebs), IV Lasix, nebs (albuterol &
ipratropium, standing) antibiotics, steroids, should pt be NPO?
Consider transfer to ICU or CCU (BiPap [for hypercarbia] or CPAP
[for hypoxemia]) and notify MED consult
4. A-FIB W/ RVR:

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Examine pt, vitals, & EKG, then call MED consult. Patient will need
ICU/CCU for telemetry as LAC+USC does not have a tele floor
5. HYPOGLYCEMIA:
Give - 1 amp D50 (12.5-25 mg); if no IV access, consider glucagon
IM and/or sublingual sugar
May repeat dexi on different machine & draw STAT glucose
Look at orders in chart: Hold standing insulin orders
Consider etiology: Mnemonic Re-ExPLAIN [Renal failure,
Exogenous (insulin, oral antidiabetic agents, NPO, -blockers, binge
alcohol ), Pituitary (hypopituitarism), Liver failure, Adrenal crisis,
Infection/Inflammation, Neoplasms (e.g. insulinoma,)
Consider D5W gtt & checking Q2 FS
6. HYPERGLYCEMIA:
Give insulin; consider checking HCO3 & AG for possible DKA
May repeat dexi on different machine & draw STAT glucose
Evaluate Rx list for steroids, D5W gtt, (unlisted) carrier fluids
w/dextrose (ex: Zosyn) may need to call & ask pharmacy
Increase SSI; increase standing/baseline insulin; low-carb diet
7. NAUSEA / VOMITING / DIARRHEA:
N/V: Zofran 4-8 mg IV (or Zofran ODT) Compazine 5-10 mg IV,
Reglan 10mg IV, Ativan 0.5mg SL, Dexamethasone 5mg. Give PO if pt
tolerates. Promethazine 12.5 mg IV (higher doses can cause
hallucinations)
Constipation: Ensure pt is on docusate / senna. PO: Miralax 17g,
Lactulose 30g, Bisacodyl 10mg, Mg citrate 300 mL. PR: Bisacodyl
(Dulcolax) 10mg, Fleets enema, SMOG (most potent). Never use
enemas in immunosuppressed.
Diarrhea: consider c. diff stool antigen,stool ( WBC, ova) if C. diff (-)
IVF & lytes. Stop bowel regimen. Lomotil 2.5 mg PO q4h, loperamide
2 mg PO q4h

26
8. PAIN / INSOMNIA / ANXIETY: see pain section for additional info and
conversions
Pain: NSAIDs, Tylenol, Tramadol (non-opioid), Tylox, Norco (PO),
Morphine (PO or IV), Dilaudid (PO or IV, but use as last resort), PCA.
Avoid opioids in heroin users. If colicky(nephrolithiasis), Ketorolac
works well. If pancreatitis, consider Dilaudid or Meperidine
Insomnia: Benadryl 25 mg PO/IV; Ativan 0.5mg PO qhs; Ambien 5-
10 mg PO qhs; Trazodone 25mg PO qhs, Restoril 15mg Po Qhs prn
Anxiety: Ativan1mg PO/IV prn
Agitation: LAC+USC Cocktail (Haldol 5mg IM+ Benadryl 25mg IM+
Ativan 1mg IM)
9. HTN / HYPERTENSIVE URGENCY:
Establish baseline & trends per vitals flowchart
Stop IV fluids unless necessary
Consider redosing meds (for example, one hour earlier)
Try oral meds first: Hydralazine 10 or 25 mg PO; Captopril 12.5 mg
PO STAT; can give Nifedipine XL 30 or 60 mg PO, but caution w/ PRN
nifedipine as this is long-lasting; Labetalol 100mg PO
If oral agents fail (after ~30 mins) consider IV agents such as:
Labetolol 20 mg IV push & then 2-6 mg/min IV gtt; Metoprolol 5 mg
IV push x 3 (if not bradycardic); Nicardipine 5-15 mg/hr IV gtt.
YOU are required to do the IV push, nurses can not
CAUTION: Dont drop BP precipitously risk for STROKE!
Consider head CT if symptomatic w/ headache or MS
10. HYPOTENSION:
Check bedside flowcharts to establish baseline, I/Os
Review Rx list & nurse MAR for meds given in past 6h
Make sure pt is awake, recheck BP (use manual cuff if needed)
Examine pt to evaluate for shock ( UOP, cool extremities, MS)
as well JVP, pulsus paradoxus, rales

27
Determine etiology: Hypovolemia (dehydration, blood loss),
cardiogenic (CHF, pulm HTN, MI), obstructive (PE, tamponade),
distributive (sepsis, anaphylaxis due to drugs)
Fluid challenge (500 cc to 1L bolus) reassess HR, BP & UOP
Discuss code status & consent for blood transfusion, arterial line,
central line if appropriate (& prior to pt developing MS)
If hypotension persists: check for active ABO, PT/aPTT, H/H, cardiac
enzymes, ABX, Cx, steroids, pressors
11. FEVER:
Obtain CXR, blood cultures x 2, U/A & Urine Cx; sputum Cx; OK not
to repeat blood cultures if drawn w/in last 24 hours
Tylenol (one time dose so you know if persistently spiking)
Think outside the box: not always infectious etiology
Check signout: Need for broader abx coverage? Try to outline plan
for NF if you expect your pt to have fever.

28
SECTION 5 PROCEDURES
(be sure to document in affinity AND verinform)

1. Imed consent found on the LAC+USC home page. Use this form to
obtain consent and dont forget to document all procedures (PICC line,
Central line, etc.) in BOTH affinity AND verinform

2. Central Venous Catheters (Central lines):


Indications: Lack of peripheral veins (h/o IVDU, chemo, thin eldery pts),
inability to cannulate peripheral veins, infusion of irritant substances,
infusion of potent drugs such as pressors (dopamine can be temporarily
delivered peripherally; all other pressors can be delivered peripherally but
theres risk of skin necrosis), infusion of parenteral nutrition (requires
dedicated port to minimize infection risk), rapid infusion (often via Cordis)
of blood products (ex: in setting of active GI bleeding), rapid replacement
of electrolytes, hemodynamic monitoring, temporary cardiac pacing.

Contraindications: No absolute contraindications. Apical emphysema or


bullae precludes infraclavicular or supraclavicular subclavian approaches,
carotid artery aneurysm or unclear vessel anatomy on ultrasound
precludes using internal jugular vein on the same side, presence of
thrombus precludes use of that vessel. If coagulopathy present, consider
reversing (w/FFP, vitamin K) to INR<1.4 & giving platelets to keep >50K.

Complications: Pneumothorax, hemothorax, infection, arterial puncture,


hematoma, venous thrombosis, air embolism, catheter embolus, thoracic
duct obstruction or injury (reduced w/ right side insertion), cathether
malposition, pleural effusion, nerve injury, cardiac arrythmias, myocardial
perforation & tamponade, pericardial effusion. Infection risk: Left
subclavian < Right subclavian < Right IJ < Left IJ <femoral

29
Equipment:
Central line kit (in general, choose triple lumen catheter [TLC] over
single)
Chlorehexadine; sterile saline flushes; mask, gown, bouffant cap (2);
scissors, gauze; lidocaine, site rite sleeve
Ultrasound
Sorbaview dressing
Sterile Gloves
Micropuncture kit

Preparation (general advice for all central lines):


1) Obtain qualified supervisor if you have not placed the required number
of supervised lines
2) Obtain assistant who will complete the required Central Line Checklist.
The assistant is expected to stop the procedure for any safety breach (e.g.,
sterile field contamination, incorrect positioning). In a true emergency,
checklist is not required.
3) (FOR SC & IJ LINES) Place pt in Trendelenburg & turn head away from
target vessel.
4) (FOR SC LINES) Roll a towel & place it between shoulder blades
5) Place blue chuck lining under pts shoulder & head to minimize blood
stains to bed (nursing will appreciate this).
6) (FOR IJ LINES) Identify IJ vein w/ US [ IJ vein is LATERAL to the carotid
artery & is compressible. Carotid artery is pulsating & noncompressible. ]
7) Scrub procedure site w/ chlorhexidine for 30 secs (2 mins if groin site).
Allow to air dry - this can take up to 2 mins.
8) Angle overhead telemetry monitor so you can visualize arrhythmias or
evidence of pt instability

30
9) Open Central Line kit & bundle kit, empty saline flushes into tray, open
items w/ non-sterile packaging & drop their sterile contents onto tray
(including ultrasound probe cover).
10) GET STERILE: Gown up w/ bouffant cap, mask, gown, & gloves.
11) Set up: Attach all 3 adapters to white & blue hubs. Draw up 5cc of
saline & flush white, blue, & brown ports (for TLC). You use the brown port
to thread the guidewire, so put the blue hub for this port piggy-backed
onto the blue hub of one of the other ports; this way the hub is easily
accessible on the field & not a stretch away.
12) Unsecure your guidewire; test your syringes, scalpel, & needle
13) Drape pt, leaving target area exposed.
14) Place equipment on pt or tray in the order you will need them.
15) Have someone help you put ultrasound probe cover on.
16) Order STAT CXR after IJ or subclavian to confirm placement.

A. Infraclavicular Subclavian Vein Approach:


1) Identify lateral margin of posterior belly of SCM muscles as it inserts
into clavicle by placing middle finger of your non-dominant hand on
sternal notch (medial end of clavicle) & thumb on lateral end of clavicle.
2) Visually divide length of clavicle into thirds.
3) Your needle insertion site is just lateral to middle 1/3 of clavicle & 1 cm
inferior to the clavicle.
4) Make a wheal w/ your anesthetic needle & advance needle medially &
superiorly towards the sternal notch. Keep the needle parallel to the floor
at all times. As you advance the needle, aspirate to make sure youre not
in a blood vessel & then inject lidocaine. Once you reach the periosteum,
inject most of the lidocaine along the surface of the periosteum.
5) Using your finder needle or actual needle, puncture the skin. Direct the
needle medially & superiorly towards the suprasternal notch. Keep
negative pressure by aspirating the syringe as you advance the needle.

31
Advance the needle until it hits the clavicle & walk the needle vertically
downward until you are able to pass the needle under the clavicle
(keeping it parallel). As you pass the needle, point towards the
suprasternal notch & youll hit the vein.
6) Check to make sure the blood is dark & not red/pulsatile.
7) Hold your position & gently unscrew the syringe.
8) Insert the guidewire & advance it through the needle. W/ your
nondominant hand, take some gauze & hold it at the needle insertion site
w/ your non-dominant 4th finger while your non-dominant index finger &
thumb slide the needle out over the guidewire. Hold onto your guidewire
w/ your dominant hand & then transition the guidewire to your non-
dominant index finger & thumb. Watch for ectopy on the cardiac monitor.
9) Once the needle has been withdrawn over the guidewire, use your non-
dominant index finger & thumb to hold the guidewire. REMEMBER to hold
pressure at the needle insertion site w/ your 4th finger to minimize
bleeding.
10) Use the scalpel to make a slight knick in the skin at the site of the wire.
This will allow more easy entry for the dilator & catheter.
11) Insert the dilator over the wire, approximately 1-2cm into the skin.
This is not to dilate the vessel, just the skin & subcutaneous tissue.
Remove the dilator.
12) W/ your dominant hand, insert the catheter over the guidewire. As
you advance the catheter, you will need to use your non-dominant index
finger & thumb to w/draw the guidewire into the catheter. The guidewire
will come out of the brown port. Once this occurs, hold onto the guidewire
as it protrudes out of the brown port & advance the catheter to the
desired position/depth.
13) In general, insert the catheter:
a. 15 cm for a right sided subclavian
b. 17 cm for the left sided subclavian.

32
14) Now you may let go of pressure at the needle insertion site. Using
both hands, w/draw the guidewire into its plastic casing.
15) Check for function by aspirating each port w/ a half-filled saline syringe
& flushing until the port is clear of blood.
16) Secure your line w/ the white hub. Remember to stitch one side of the
white hub, then place the blue hub on top & sew both the white & blue
hub to the skin. Dont be too tight w/ your 1st knot so as to avoid skin
necrosis.
17) If you hit the subclavian artery, remove the needle & hold pressure
above & below the clavicle (pinch the clavicle).
18) After placing IJ or Subclavian line:
a. To rule out arterial placement send blood gas to stat lab.
b. Call for STAT CXR to confirm placement and r/o PTX.
c. Write in chart, OK to use central line.
[NEJM 2003;348:1123-33] Video at:
http://content.nejm.org/cgi/content/full/348/12/1123/DC1

B. Internal Jugular Approach:


1) The safest method for all pts is to use the Site Rite to visualize the vein.
The vein will be collapsible, whereas carotid artery is pulsatile & non-
collapsable. It is preferable to find a site where the IJ is not directly above
the carotid.
2) Make a wheal w/ your anesthetic needle & advance needle. Always
aspirate before injecting any lidocaine.
3) W/ your finder needle or actual needle angled ~ 60 (almost same angle
as your SiteRite probe) & towards the ipsilateral nipple, puncture the skin.
Keep negative pressure by aspirating the syringe as your advance the
needle. W/ the Site Rite, you should be able to see your needle as you
advance it. Check to make sure the blood is dark & not red/pulsatile.
4) Hold your position & gently unscrew the syringe.

33
5) Insert the guidewire & advance it through the needle. W/ your
nondominant hand, take some gauze & hold it at the needle insertion site
w/ your non-dominant 4th finger while your non-dominant index finger &
thumb slides the needle out over the guidewire. Hold onto your guidewire
w/ your dominant hand & then transition the guidewire to your non-
dominant index finger & thumb.
6) Once the needle has been withdrawn over the guidewire, use your non-
dominant index finger & thumb to hold the guidewire. REMEMBER to hold
pressure at the needle insertion site w/ your 4th finger to minimize
bleeding.
7) Make a slight knick in the skin w/ the scalpel (insert in & out, w/ blade
pointing away from wire, to avoid cutting wire). This will allow
dilator/catheter to more easily enter skin.
8) Insert the dilator approximately 1-2 cm over the wire. You are not
attempting to dilate the vessel, just the skin & subcutaneous tissue.
Remove the dilator.
9) W/ your dominant hand, insert the catheter over the guidewire. As you
advance the catheter, you will need to use your non-dominant index finger
& thumb to withdraw the guidewire into the catheter. Hold onto the
guidewire as it protrudes out of the brown port & advance the catheter to
desired position.
10) In general (can adjust for height/size), insert the catheter:
a. 16 cm for a right IJ
b. 18 cm for a left IJ.
11) If you think you have hit the carotid, remove needle & hold pressure 5-
10 mins or until bleeding stops, then follow-up to ensure no hematoma.
No need for ultrasound unless you have inserted the dilator
12) IF PERFORMING W/O SITE RITE: Identify the triangle formed by the
anterior & posterior bellies of the SCM muscle & the clavicle. Your
insertion site is near the apex of this triangle.

34
13) Palpate the carotid artery in the triangle & retract it medially.
14) Insert the needle at a 45 angle to the skin into the triangle apex just
lateral to the carotid pulsation, toward the ipsilateral nipple.
15) After placing IJ or Subclavian line:
a. To rule out arterial placement send blood gas to stat lab.
b. Call for STAT CXR to confirm placement and r/o PTX.
c. Write in chart Ok to use central line
[NEJM 2003;348:1123-33] Video at:
http://content.nejm.org/cgi/content/full/348/12/1123/DC1

C. Helpful Femoral Vein Line Hints:


Identify the pulsation of the femoral artery & pull it laterally.
Needle insertion is just medial to the pulsation, 1 cm inferior to the
inguinal ligament. Insert the catheter to the hub.
To rule out arterial placement, one of the following must be performed:
transduce CVP, estimate CVP by fluid column, or send blood gas to stat
lab.

3. Arterial Lines:
A. Radial arterial line insertion (ICU, CCU)

Equipment:
Basic tray, Arrow-ART line (get several just in case)
Suture (2.0 or 3.0), needledriver, scissors (sterile)
Chlorhexidine scrub (1 or 2), blue chuck, +/- 1% or 2% lidocaine
Tape & arm board to stabilize/immobilize pts hand, +/- kerlex roll to
help extend wrist
Sterile gloves, face shield, bouffant cap
Gauze
Sorbaview for dressing

35
Ask nurse in advance to set up for an A-line

Procedure:
1) Perform Allens test to assure collateral flow. Nml response < 7 secs.
Inadequate collateral flow 14 secs.
2) Place blue chuck lining below arm. Use kerlex roll or rolled towel to
place under the pts wrist to hyperextend the wrist & hand (may have to
tape down their thumb to rail). Chloroprep wrist & get sterile, draping
wrist w/ drape form basic tray.
3) Palpate the radial artery w/ 2 fingertips placed 2 cm apart. If unable to
palpate, consider using a Doppler
4) Delineate a line between the fingertips, & insert the angiocatheter
along this line at approximately a 45 angle from the skin.
5) Once you get a flash of blood in the needle hub, drop the angle &
advance the guidewire until you cannot go further. If you notice
resistance, re-angle (as far as 90) or carefully reposition.
6) Slowly, in a twisting/pushing motion, advance the white catheter over
the wire.
7) W/draw the guidewire, & leave the catheter in place. REMEMBER to
quickly place your thumb over the white catheter once the guidewire is
removed completely to prevent arterial blood from projecting across the
room!
8) Attach the catheter to the transducer (nurse will often hand it to you). If
good waveform, suture the catheter securely to the skin (around hub of
art line).
[NEJM 2006;354:e13] http://content.nejm.org/cgi/video/354/15/e13

B. Femoral arterial line insertion


Equipment:
Single lumen central line kit

36
Basic tray
Suture
Needle driver, scissors
Chlorhexidine (several)
Sterile gloves
Ask Nurse to set up for an A-line

Procedure:
1) Identify the pulsation of the femoral artery.
2) This is your insertion site. Continue as if you were inserting a central
line. Requires maximum barrier, including mask, sterile gloves, sterile
gown & large sterile drape.
3) Attach catheter to the transducer & suture the site down.

4. External Jugular Line:


Equipment:
IV start kits from Clean utility (EtOH swabs, gauze, tubing, flushes)
Chlorhexidine
Angiocath several 18 or 20 gauges
Blue chuck lining

Procedure:
1) EJs are all about prepping & positioning. It isn't a central line, so
sterility isnt required, but its important to keep the field clean & well lit.
2) Move bed away from wall, lock it, elevate it to its highest position, &
then lower head down (Trendelenberg). Wait a few secs as external
jugular vessels engorge.
3) Ask pt to turn their head all the way to 1 side & relax the neck muscles
as much as possible. To engorge the vessels more (if pt awake), ask pt to
bear down.

37
4) Divide the distance from jaw to above clavicle & work in the middle.
Dont go too far toward the lung as any error ruins the vessel for further
attempts.
5) When the vessel is spotted, clean the field w/ a Chloraprep. Get the
angiocath ready, get the tubing ready (flush w/ saline), leave the flush
attached to the tubing (unless about to draw blood), have the Sorbaview
ready, have the adherent tape ready, have gauze ready, make sure the pt
is positioned on a chuck (clean bed after procedure).
6) Approach the vessel w/ the 18 gauge at a 45 angle. Hold the angiocath
like a pencil between your thumb & forefinger. Advance using your
fingers, not the whole hand. Holding the skin tight w/ the non-dominant
hand, aim for the middle of the vessel, & pierce the skin & vessel w/ the
needle. If you have blood return, lower the angle of the angiocath, & using
the index finger of the hand holding the needle, advance the tubing over
the needle into the vessel. Hub the tube.
7) Disconnect the angiocath from the assembly. Blood should spill out.
Quickly grab the tubing & connect it to the hubbed angiocath tube. Flush
& attempt to draw back blood.
8) Secure the tubing using the adherent tape in the IV starter kit, cover the
EJ w/ the sorbaview, & clean up the remaining field. You have just
obtained IV access! Now write for q6h 10cc saline or 6cc heparin flush.

5. Ultrasound-Guided Peripheral IV:


Equipment:
IV start kits from Clean utility (EtOH swabs, gauze, tubing, flushes)
Sorbaview dressing
Clorhexidine (optional)
Arrow radial artery catheters (2-3)
SiteRite Ultrasound
Sterile ultrasound gel

38
Blue Chucks

Procedure:
1) The following method is designed to access deep peripheral veins not
readily accessible by traditional means. The technique does not require
complete sterility (sterile gowns & gloves are NOT required).
2) Raise the bed & position the pt such that you can comfortably view the
supinated upper extremity both above & below the antecubital fossa.
3) Prep for the IV by connecting the tubing to the 10 cc saline syringe &
flushing it. Open one of the arrow catheters.
4) Place a tourniquet on the proximal upper extremity & identify the veins
& artery in the antecubital fossa via the ultrasound (the veins should
compress, the artery pulsates).
5) Track the veins proximally & distally from the fossa w/ ultrasound &
identify a site where the vein does not overly the artery. It is generally
easier to place the IV distal to the fossa; however, proximal works as well.
6) When a suitable target vein has been found, clean the area w/ either
EtOH or chlorhexidine. Apply sterile U/S gel once the site has been cleaned
& confirm your position w/ the ultrasound.
7) Insert the catheter into the skin at a 70 angle. Use the SiteRite to guide
your needle (you should be able to see the needle enter the vein).
8) Once you see the flash of venous blood, drop the angle of the arrow
catheter to 30. Unlike when placing an arterial line, do not advance the
wire further than the length of the white catheter.
9) While holding the remainder of the catheter stable, advance the white
catheter sheath w/ a gentle twisting motion. Remove the needle & wire
once the catheter sheath is hubbed. Blood should spill out of the catheter
once the wire/needle assembly is removed. Quickly connect the IV tubing
to the catheter. You should be able to drawback & flush the IV.

39
10) Secure the tubing using the adherent tape in the IV starter kit, cover
the PIV w/ the sorbaview, clean up the remaining field. You have just
successfully placed an ultrasound-visualized, wire-guided deep peripheral
IV!

6. Lumbar Puncture:
Contraindications:
Evidence of uncal/cerebellar hernitation, markedly increased intracranial
pressure, or obliteration of the 4th ventricle or basal cisterns. Usually
cranial nerve abnormalities (blown pupil, papilledema) are hints. LP may
be done in these pts if bacterial meningitis is strongly suspected. When in
doubt & bacterial meningitis is suspected treat w/o LP. Do not wait for CT
& reading!
Platelets <50,000, unless there is a pressing reason. For counts of
<20,000, platelet transfusion is recommended prior to LP.
When the pt is anticoagulated, anticoagulation needs to be stopped &
measures of anticoagulation must be nl for at least one hour prior to the
procedure. Vitamin K or Protamine should be used in anticoagulated pts. If
it must be done, use a 22 gauge spinal needle.
Back or spinal local infections as organisms can be introduced into the
CSF.

Equipment:
LP kit
Betadine or chlorhexidine (can use either)
Extra CSF tubes
Minimal CSF volumes needed:
Cell count & differential 1.0 cc
Fungal cx/Crypto Ag 0.5 cc
Oligoclonal bands 5.0 cc

40
Bacteriology 0.5 cc
Glucose 0.3 cc
Virology 0.5 cc
Mycobacteria/AFB 5.0 cc
Immuno/Meningitis 1.0 cc
Protein 0.4 cc
VDRL 0.5 cc
IgG Index (for MS) 0.5 cc
Cytopath (variable) ~3 cc

You can often combine several of these tests together in one tube: e.g.
tube #1 & tube #4 (1 cc each) for cell count & diff; tube #2 (1 cc) for
protein/glucose; tube #3 (8 cc) for all of the microbiology which will later
be distributed among the labs, except for VDRL which needs a separate
tube. Always remember to collect 1-2 extra tubes for second thought tests
& keep in fridge. Make sure all labs are ordered STAT so labels will print
immediately. CSF for cytopath needs to be dropped off within an hour or
so of the tap

Procedure:
1) Position the pt either sitting on the edge of the bed leaning over a table
(only if you do not need an opening pressure), or lying on their side in a
tight fetal position. The key to a champagne LP is POSITIONING & a little
bit of luck.
2) Palpate the superior edge of the iliac crests & create a line between it &
the L4-L5 area. - When performing an LP on an overweight pt in whom the
iliac crest cannot be identified, ask the pt Put your hand on your hips.
This will be the level of the top of the iliac crest. No matter how obese,
people always know where their hips are.

41
- The L4-5 interspace is a common location for osteophytic disease. It is
also quite a small interspace. We often use the L3-4 space (just count one
space above) which is usually larger & easier to get a needle in between
the spinous process.
3) After prep (supplies, chlorhexidine to back, draping, etc.) & local
anesthesia, insert the needle deeper, anesthetizing the periosteum.
4) Now, using spinal needle, advance between the spinous processes,
angling towards the umbilicus. Keep the needle parallel to the floor at all
times. Keep the bevel of the needle parallel to the fibers; if pt is upright,
this means bevel to the side; if pt is lying on his/her side, this means bevel
up toward the ceiling.
5) As you advance (usually a little more than 1/3 of the needle), w/draw
the stylet periodically to check for spinal fluid. As you pass the dura, you
will often feel a pop.
video: http://content.nejm.org/cgi/video/355/13/e12/

7. Abdominal Paracentesis:
Contraindications:
Bleeding diathesis/anticoagulation. This must be considered a relative
contraindication, since most pts w/ hepatic cirrhosis have an acquired
coagulopathy. Consider using FFP and/or platelet transfusions if severe
coagulopathy or DIC exists.
Pregnancy, especially sec or third trimester because of the danger of
puncturing the uterus.
Known pneumoperitoneum

Equipment:
Diagnostic only:
30 cc syringe
Basic Tray

42
Lidocaine
Chlorhexidine
Red top, lavender or green top tube
Port-a-cult vial/tube
Therapeutic:
Either
Caldwell (Paracentesis) needle
Basic tray
Lidocaine
10 or 20cc syringe
Angio-cath tubing
Lavender or green top tube
Red top tube
Or
Thoracentesis Kit +
Chlorhexidine
Vacuum bottles/containers
For all:
Sterile gloves, face shields, nonsterile gowns

Diagnostic +/- therapeutic paracentesis fluid should be sent for:


(1) Cell count & differential (green top or lavender top, or tube from thora
kit minimum 1 cc)
(2) Gram stain & bacterial culture, as well as fungal & AFB when indicated
(port-a-cult culture bottle/tube, or specimen cup)
(3) Albumin (& send serum sample for albumin to calculate serumascites
albumin gradient) (red top or tube from thora kit, min 1 cc)
(4) Consider total protein, LDH, amylase (if you suspect pancreatitis),
cholesterol (if you suspect chylous ascites) (red top or tube from thora kit)
(5) Consider cytopath (any container, the more the better).

43
Procedure:
1) The lower quadrant approach is most often used. Place the pt in a
supine position. If splenomegaly &/or hepatomegaly are present on
physical exam, you should perform the paracentesis w/ ultrasound
guidance.
2) Percuss to find the level of dullness to identify pocket of ascites. You
can also send pt for an ultrasound mark, but be sure to tap as soon as
possible, as ascites fluid moves. Perform paracentesis in same position pt
was in when marked.
3) Locally anesthetize the skin w/ a wheal, then as you advance the
needle, aspirate & inject lidocaine (particularly near peritoneum).
4) To decrease draining of fluid after removal of angiocath, you can elect
to use the Z method in which you insert the Caldwell needle into the
skin, then pull the skin caudally, then advance the needle until to you
reach the ascitic fluid. REMEMBER TO KEEP NEGATIVE PRESSURE AS YOU
ADVANCE THE NEEDLE. Sometimes you will need to make a small incision
w/ scalpel to get the Caldwell needle through tough skin.
5) Insert the needle along the anterior axillary line, lateral to the rectus
sheath (halfway between umbilicus & anterior superior iliac spine) or 1-2
cm below the level of percussed dullness.
6) Once needle is in the fluid pocket, attach the angio-cath tubing to the
needle.
7) Insert the other end of the angio-cath into the vaccum bottles.
*If the fluid stops draining, try spiking another bottle (sometimes the
vacuum seal is depleted) or repositioning the needle.
Video: http://content.nejm.org/cgi/video/355/19/e21/
Post-paracentesis albumin infusion: It is generally recommended, in
large-volume paracentesis (i.e. 4L), to give 25cc of albumin (25%
solution) for every 2L of ascitic fluid removed.

44
8. Thoracentesis:
Indications: Fever w/ a pleural effusion (Never let the sun set on an
infected pleural effusion); 1 cm thick effusion on US or lateral decubitus
CXR w/o known cause; unilateral effusion in CHF exacerbation; effusions in
CHF that don't resolve in 3 days w/ dieresis (75% of CHF effusions resolve
w/in 48h of diuresis); poor oxygenation due to unresolving effusion(s).

Equipment:
Thoracentesis kit; Chlorhexidine; ABG syringe, Sterile gloves; face shield;
gowns. (Thora kit tubes okay to send samples in instead of red, green &
portacult)

Pre-procedure imaging: Get a decub film (lie on the side of the effusion)
to make sure it layers; also consider U/S to mark the tap

Post-procedure imaging: chest Xray


Laboratory tests:
(1) Cell count & diff
(2) Gram stain +/- culture (bacteriology, virology, mycology, AFB)
(3) Glucose, protein*, LDH*, albumin, cholesterol, (if you suspect chylous
effusion)
(4) pH (draw in ABG syringe & place in ice) - walked to critical care lab
ASAP
(5) Cytopath, depending on your diagnostic concern (in any container: the
more the better)
*Send corresponding serum tests to calculate pleural fluid:serum ratios.

Procedure:
1) View the CXR or thoracic CT so you know the area of interest.

45
2) Place the pt in a sitting position, leaning over a table.
3) Percuss out the effusion, noting the superior edge of dullness on the
posterior chest wall.
4) Confirm w/ auscultation / Site Rite.
5) Sterilize the area & drape.
6) Insert the needle at the middle of the rib just below the superior edge
of the dullness in the posterior axillary line. Aim for the SUPERIOR aspect
of the rib (the neuro-vascular bundle runs under the rib).
7) Anesthetize the periosteum. Remember to aspirate as you inject. You
will likely get pleural fluid while anesthetizing.
8) Exchange the needle for thoracentesis catheter, & proceed in the same
manner. Remember to keep negative pressure in your syringe as you
advance the needle. If you are performing a therapeutic tap, attach the
syringe & bag to the tubing. Never use vacuum bottles for thoras. Obtain
an opening pressure by removing the syringe & seeing at what vertical
level the fluid stops dripping. Use constant pressure on the syringe to
drain fluid, then push into the bag (its a one way valve.) Remember to
estimate pleural pressure after every 4 syringes of fluid drained. Stop
before -20 cm to avoid PTX & reexpansion pulm edema.
9) Tell the pt to hum as you remove the needle.
Video: http://content.nejm.org/cgi/video/355/15/e16/

9. Arthrocentesis:
Indications: To determine the cause of an acute monoarthritis or
polyarthritis and/or inject steroids if indicated.

Contraindications: Overlying cellulitis; coagulopathy; prior knee surgery

Equipment:
Basic tray; Chlorhexidine scrub; 18 G needle; 20-60 cc Syringe; Lidocaine

46
Laboratory tests:
(1) cell count & diff (green or lavender top),
(2) gram stain +/- culture (bacteriology, virology, mycology, AFB) (port-a-
cult or specimen cup)
(3) Crystal analysis (& slides to look at it yourself)

Procedure:
1) The knee may be tapped from either the medial or the lateral side.
2) Place pt in supine position.
3) Flex the knee slightly to an angle of 15 to 20 degrees.
4) Point of needle insertion is 1cm medial (or lateral) to the superior third
of the patella, angling toward the intracondylar notch.
5) Anesthetize the area by placing a wheal of lidocaine in the epidermis,
then anesthetize the deeper tissue. Remember to aspirate prior to
injecting the lidocaine & direct the needle in the anticipated trajectory of
the arthrocentesis needle. You may aspirate some synovial fluid w/ your
anesthetizing needle (this is OK). If this happens, just w/draw your
anesthetizing needle & exchange for an 18-gauge needle.
6) Using the 18-gauge needle, advance behind the patella & toward the
intracondylar notch. AVOID walking the needle along the inferior surface
of the patella (may damage the articular cartilage).
REMEMBER to hold negative pressure in your syringe as you advance the
needle. Remove as much fluid as possible (sometimes milking the
effusion by compressing the suprapatellar region w/ the opposite hand
may help).
7) This technique may also be used to inject steroids (triamcinolone /
kenalog, vial is generally 10 ml of 40mg/ml -> inject 1 ml/knee)
8) An ACE bandage or knee immobilizer can help to reduce postprocedural
swelling. Video: http://content.nejm.org/cgi/video/354/19/e19/

47
SECTION 6 COUNTY STUFF

1. Locations in hospital
2nd Floor Cafeteria, 2E Psych ward, Discharge waiting unit,
Conference Rooms A-D
3rd floor Labor and Delivery
4th floor MICU, CCU
5th floor SICU
6th floor Medicine Wards A-D
7th floor Medicine Wards A-D
8th floor Medicine Ward 8A, Medicine Resident Lounge, Pediatric
Ward 8B
** Hallway between inpatient and clinic tower contains ancillary
services on 3rd and 4th floor (4th floor - Stress Test, Echo Lab, Cardiac
Cath Lab, GI procedures, Urology procedures, CT Scan, MRI)
2. How to get stuff done
Picc line 3 forms to be filled out: STAT CXR radiology form,
PICC line form (check double lumen) and PICC line consent
form (print from iMED CONSENT). Drop off in PICC room 4th
floor
Stress test Fill out the stress test form & you can drop it off
on the 4th floor to Marci (ext - 97468)
TTE Follow these steps and you can order the TTE on affinity
by yourself:
TTE Ordering in Affinity Change location to: IM ->
Procedure menu > order processing > enter order Enter your
name, hit enter through the tabs until a menu with orders
comes up, TTE is one of the options, Select and hit Enter.
Then enter the indication, Priority: ROUTINE, Another menu

48
for indication will come up, enter indication, Then enter out
and sign with your SID number
PFTS PFTs & sleep study are on the same form. You can
order it either inpatient or outpatient on the same form. Once
you fill it out, go to the pulmonary lab on the 4th floor and give
it to the secretary in the patient waiting area.
EEGS You can either order this yourself on affinity (change
location to A4E in affinity) or you can fill out the EEG form and
fax it to the number that is at the top of the form.
Permacath - Follow these steps to order the form yourself on
affinity:
Permacath Ordering in Affinity - > Change location to:
angio or 3731 GH (space is important) Procedure
menu > order processing > enter order..Enter your
name, hit enter through the tabs until a menu with
orders comes up > Go to MENU tab, and select ANGIO>
Then MENU again and select D&T
Vascular/Intervention> Hit ENTER Item #11 is
Permcath> Select and hit Enter Then enter the
indication > Priority: ROUTINE Another menu for
indication will come up, enter indication Then enter
out and sign with your SID number
Permacath Ordering via Radiology Form to be placed
in Chart: write IR Permacath placement, call IR at
94100 for approval
VASCATH placement: Place Renal Consult for VASCATH
placement or ask a nice renal or pulmonary fellow to place one
(you must consent the patient yourself)

49
CT/MRI - Fill out radiology form & stick it in the chart. Call
radiology to approve/check on the status of the order in a few
hours.
PET scan fill out the special PET CT form, sometimes found in
the workroom, but also found on RPS website under clinic
forms
UltraSound Fill out radiology form & stick it in the chart. Call
radiology to approve/check on the status of the order in a few
hours.

3. LAC+USC Radiology (M-F, 9-5) www.trojanimaging.com

Chest Plain Radiology 323-409-6081


CT Body Protocoling & Procedure 323-409-1583
Resident
CT Abdomen 1 323-409-4395
CT Abdomen 2 323-409-1584
CT/MR Chest/Cardiac 1 323-409-4391
CT/MR Chest/Cardiac 2 323-409-4392
Emergency Radiology (ER) 323-409-2798
GI/GU Radiology 323-409-6084
Mammography/ Breast US 323-409-5167
MR Body 323-409-1293
MR Breast 323-409-1293
MSK Radiology (Bones) 323-409-6104
Neuroradiology (Brain, Spine) 323-409-4149
Neuroradiology (ENT) 323-409-4152
Neuroradiology (Small reading room) 323-409-3937
Nuclear Medicine 323-409-5857

50
Pediactric Radiology 323-409-6110
US general 323-409-4386
US Womens 323-409-6083

4. Frequent consults (and their reqs)


Ortho Have Xray ordered w/ prelim read preferably prior to
consult. For Osteomyelitis, have Xray and MRI ordered
Renal Order: UA w/ micro, urine eosinophils, Urine electrolytes
(UNa, UCr, U Urea) prior to Renal consult
Neuro perform thorough neuro exam, history of recent meds,
neuro Hx prior to neuro consult, recent scans
Heme Order peripheral smear, type and screen, CBC w. diff,
retic count before consulting heme.
Oncology You need to have a diagnosis of cancer before
consulting oncology. This is either imaging (4 phase CT of liver) or
tissue diagnosis (biopsy w/ pathology read). They will not see the
patient if the diagnosis is not established already.
Rad Onc usually consult in coordination with med onc for
potential radiation therapy after you have a tissue diagnosis
GI You need CBC, iron panel & acute bleeding before you can
consult GI. Consult GI team for: EGD, ERCP, or Colonoscopy.
Liver Have CMP, D. bili, platelets, PT/INR, and possible U/S or CT
of liver prior to Liver consult
Urology If suspect Renal cell carcinoma, or Prostate Cancer:
consult Urology. Or if patient has urethral problems or difficult
foley placement, consider urology consult.
Speech and Swallow Write the consult in the chart as follows:
speech therapy for speech and swallow evaluation.

51
5. Electrolyte replacement

HYPERKALEMIA
K (mEq/L) Treatment
> 6.5 Start w/ Insulin 10-20U IV w/ amp of D50
>5.2 w/ sxs: Ca gluconate 10% 10cc IVP over 2-3 min
w/ QRS widening or EKG changes, give Insulin 10-
20U IV w/ amp of D50
>5.2 w/o sxs: Kayexalate 25-50 PO qhr until BM, then
check STAT K
>4.0 Nothing

HYPOKALEMIA
PO options of K include KDUR or K elixir, IV is given as KCl
10 mEq of K should raise the serum K by 0.1
Can only do 10 mEq of K per hr on the floor (i.e.
Kdur40mEQ PO Q 4hrs)
If your patient is not eating, you need to replace the
approximately 60 mEq of K they will lose each day
K (mEq/L) Repletion
3.8-3.9 KDUR 20 mEq PO x1 or KCl 20mEq IV over 2 hrs
3.6-3.7 KDUR 40 mEq PO x1 or KCl IV over 4 hrs
3.4-3.5 KDUR 60 mEq PO x1 or KCl IV over 6 hrs
3.2-3.3 KDUR 40 mEq PO q4hrs x2doses or KCl 80 mEq IV
over 8hrs
3.0-3.1 KDUR 40 mEq PO q4hrs x3doses or KCl 80 mEq IV
over 8hrs
<3.0 KDUR 80 mEq IV over 8hrs then recheck K &

52
continue

HYPERMAGNESEMIA
Mg (mg/dL) Treatment
5.0-7.5 Ca Gluconate 1g IVP
1.9-4.9 Nothing

HYPOMAGNESEMIA
Mg (mg/dL) Repletion
1.6-1.9 Magnesium Sulfate 2g IV over 8hrs or Mg Oxide
400mg x7 tabs PO
1.2-1.4 Magnesium Sulfate 4g IV over 16 hrs or Mg Oxide
400mg x14 tabs PO

HYPERPHOSPHATEMIA
Mg (mg/dL) Treatment
>4.5 If Phos x Ca >65 -> amphojel 10cc PO TID w/ meals
If phos x Ca <65 -> CaCO3 650mg PO TID w/ meals
2.3-4.5 Nothing
**never combine amphojel and biCitra**

HYPOPHOSPHATEMIA
Phos (mg/dL) Repletion
1.0-2.5 K Phos or Na Phos 15 mmol x 8hrs
< 1.0 K Phos or Na Phos 30mmol over 16hrs

If all else fails, call pharmacy for any electrolyte replacement


questions (x97641)

53
6. Miscellaneous County
How to TAR a patient (Treatment Authorization Request)
There is a special form that needs to be filled out. For
hematology TARs and Oncology, the patients name, MRUN &
cancer dx needs to be written in a book that you can find in 7B.
In addition, you have to go to the patients ROR account and
put in a one or two sentence note about what the patient is
being TARd for. Your note should essentially meet criteria for
inpatient hospitalization, otherwise, the TAR wont be
approved.
You can also consider TAR a patient in other special situations.
For example: if a patient needs a PET scan prior to initiation of
chemotherapy, its Friday, and patient wont get the PET scan
until Tuesday, if there is no other treatment being done for
patient, you can D/C patient, and TAR for readmission on the
day of his scheduled PET scan. This opens a bed for 3 days, and
prevents the patient being admitted with no medical
treatment.
* note* If TARing a patient onto 7B for Heme, simply place the TAR
form in the plastic bag near the clerk. If TARing a patient for
any other service, TAR must be approved by Utilization Review,
Contact UR at ext. 96412
VNA You fill out the specific VNA form, have your attending sign
the form and drop it off on the 4th floor nursing office.
Med appliance There is actually a med appliance form in every unit
that you can fill out and get signed by a licensed physician. Call
Marcos 95125
Special bed request contact UR at 96412 for a special bed request
(i.e. inflatable bed, etc.)

54
Isolation- These are the types of isolation yon can order by writing it
in the patients chart:
Contact precaution: This type of precaution is for patients
who have infections with antibiotic-resistant organisms such
as VRE & MRSA. C. difficile is also included in this category.
These precautions are essentially to clean hands before and
after entering the room (with alcohol hand cleaner for most
infections and soap and water with C. difficile). It also
includes gloves and gowns.
Airborne precaution: These organisms can spread by drops
that are caused when patient coughs, sneezes, cries or talks.
These tiny drops can float for long distances in the air and
people without masks can breathe them in, so special air
control is needed to keep the organisms in the room. An
example is TB. You not only need the N95 masks but
negative pressure room.
Droplet precaution: These organisms can spread by droplets
caused when the patient sneezes, coughs, cries or talks.
These heavy droplets float just a short distance before
landing on things or people. Examples are influenza,
whooping cough, and meningitis. These require N95 masks
before entering the room.
Neutropenic precaution: These are for patient with ANC
below 1.0. And these precautions are essentially to protect
the patient. So we have to wear gloves, gowns and masks
(these masks dont have to be the N95 masks but just any
type of mask). If you put a patient on neutropenic
precautions, you should also put them on a neutropenic
diet.

55
SECTION 7 BASICS OF PAIN MANAGEMENT

World Health Organization 3-STEP LADDER


1 Mild 2 Moderate 3 Severe
ASA A/Codeine Morphine
Acetaminophen A/Hydrocodone Hydromorphone
NSAIDS A/Oxycodone Methadone
A/Dihydrocodeine Levorphanol
Tramadol Fentanyl
Oxycodone

Dosing:
- Dose once every half-life
PO/PR = 4 hrs
- Steady state after 5 half-lives
Breakthrough Pain Dosing
- Once every time to Cmax
PO/PR = q1hrs
SC/IM = q30mins
IV = q10-15mins

Changing Routes of Administration:

PO/PR IV/SC/IM Epidural Intrathecal


3 : 1 : 0.1 : 0.01

Transdermal Fentanyl
Morphine 50mg PO in 24hrs ~ Fentanyl 25mcg transdermal patch

56
Changing Analgesics

Oral/Rectal Dose Analgesic Parenteral IV/SC/M Dose


(mg) (mg)
150 Meperidine 50
150 Tramadol -
150 Codeine 50
15 Hydrocodone -
15 Morphine 5
10 Oxycodone -
3 Hydromorphone 1
2 Levorphanol 1
- Fentanyl 0.05

Direct Morphine-Methadone Conversion

24hr total dose of oral morphine Conversion oral morphine :


oral methadone
< 30 mg 2:1 (2mg morphine : 1mg
methadone)
31-99 mg 4:1
100mg-299 mg 8:1
300-499 mg 12:1
500-999 mg 15:1
>1000 mg 20:1
(*Fisch and Cleeland. Managing Cancer Pain in Skeel ed. Handbook of
Cancer Chemotherapy. 6th ed., Phil, Lippincott, 2003, p 663

57
Common Combination Pain Products

Combination Adjunct Narcotic PO Morphine


Product Equivalents
Tylenol # 3 Acetaminophen Codeine 30mg 3-4 mg
325mg
Norco Acetaminophen Hydrocodone 5 or 10mg
325mg 5mg or 10mg
Vicodin Acetaminophen Hydrocodone 5-6mg
500mg 5mg
Percocet Acetaminophen Oxycodone 7-8mg
325mg 5mg

**Note** at LAC+USC, there are limitations on standing orders for


Narcotics

All Narcotics orders, if unspecified, will fall off after 24 hrs


All schedule 2 non-combination medications (Morphine,
Dilaudid, Codeine) can be written for a maximum of 72hrs
PO combination medications (Norco, Vicodin, etc) can be
written for a maximum of 7 days
Patients with cancer can have orders written indefinitely

Example # 1: Norco 5/325mg PO Q4hr prn pain (x 7 days)


Example # 2: Morphine 4mg IV Q4hr prn pain (x 72hrs)
Example # 3: Dilaudid 2mg PO Q4hrs prn pain (Indefinite for cancer)

58
SECTION 8 TPN/TUBE FEEDS
1. Enteral Nutrition: (always preferable over parenteral nutrition)
a. Short Term: Via NasoGastric tube.
Ordering: Write NG tube order in chart, STAT CXR or KUB via
Radiology form to evaluate NG tube placement, after eval, write
okay to use NG Tube in the chart. Place nutrition consult by
writing nutrition consult in chart.
Duration: NG tubes cannot remain in place for over 2 weeks due to
risk of nasal cartilage necrosis.
Example of a basic initial order: Jevity 1cal via NGtube at rate of
30cc/hour. Increase rate by 20cc q2 hours until rate of 70cc/hour.
(hold if residuals >150cc). The rate can later be increased as
tolerated, and as recommended by the nutritionist.
Contraindications to NG tube placement: facial/skull fractures,
airwary compromise, esophageal varices, clotting disorders, and
history of gastric bypass surgery.

b. Longer Term: G-tube


Ordering: using radiology form, write: IR placed G-tube, check Body
Intervention, contact IR at 94100 for approval. or by the GI team
(consult GI for Percutaneous endoscopic gastrostomy (PEG)).
hile you wait for nutrition recommendations.
G-tube feeding orders: Can be either as boluses or continuously
via a pump, usually at nighttime.
Example of order for bolus: Jevity 1.5cal 2 cans via Gtube TID.
Flush with 50 cc H20 after each can
Example of order for continuous tube feeding: Jevity 1cal at
70cc/hour x 12 hours qhs

2. Parenteral nutrition:
Although it should not be routinely use in patients with normal GI
tracts, as there are many risks associated with parenteral nutrition
(including sepsis, fungemia), TPN may be recommended for patients

59
with bowel obstruction, severe gastroparesis or for complete bowel
rest in some cases of IBD.
Requirements:
TPN must be administered via a central line, so you will need
to order a PICC line for patients on the floor. (refer to PICC
order section)
The TPN orders must be submitted and faxed before 1PM
each day.
You can call the TPN pharmacy for help with selection of TPN
formula. Electrolytes in the fomula will have to be adjusted
daily, per TPN pharmacy recommendations.
o TPN cycling: it may be preferable to have TPN infusing for
only part of the day instead of 24 hours. For example, if
you want to have a patient receiving TPN only for 16 hours
of the day, you should contact the TPN services for
recommendations on daily cycling orders.
o TPN pharmacy x : (TPN form, Cycling orders)

3. Outpatient TPN
When medically cleared for discharge, patients who still need
parenteral nutrition can be discharged on TPN with Visiting nurse
services, after TPN formula, rates and cycling optimized as an inpatient.
Contact information:
Home Health-Carole Fernandez (213)919-6216 x93250
TPN Service-(323)226-7764

60
SECTION 9 CRITICAL CARE/ ICU

1. ICU On Call Intern Schedule (Nights)


2100: come in and meet with your resident.
You will do all the new admissions
Around 0200-0300: Electrolytes repletion (see repletion
section)
0600: Signout cross coverage/overnight events to your co
intern and co-residents coming in.

2. ICU Regular Day schedule


0600-0700: Pre-rounding
0700: Fellow rounds. Bedside rounds on all patients.
0900: Attending Rounds
Rounds end around 11: Get work done.
if youre post-call, then you leave after finishing your work, no
later then 1300.
If its a regular day, then get more work done and at 1800
Signout to Resident On Call.

3. Daily considerations in the ICU


Lines: now what lines you patient has and when each were placed
and need to be changed
Medications and Drips: Know all gtt with current rate/dose.
Comment on recent changes
Feeding: orally vs enterally vs parenterally
Analgesia & Sedation: usually with Fentanyl gtt for Analgesia and
Versed for Sedation
Excessive analgesia/sedation should be avoided.
Daily Sedation Holiday: (leads to shorter ICU stays)
VTE prophylaxis: sq Fragmin vs Heparin (if renal failure). SCDs
should definitely if anticoagulation is contraindicated. If patient is
on anticoagulation, SCDs may be ordered as well (depending on
fellows preference).
61
Stress ulcer/GI prophylaxis: refer to GI section or ICU book for PPI
guidelines
Other: I&Os, Urine output/24 hours and hourly, Bowel Movements
(know when your patients last bowel movement was and address
it if no bowel movements for 24-48hours) glucose control,
Restraints, Head of bed elevation, unless contraindicated , Family
discussions
Daily orders form:
Always order midnight labs, at least CBC with diff, BMP,
Mg, Phos daily. Usually also include PT/INR, PTT, LFTs.
Consider lactate and other labs as warranted.
Daily CXR at midnight if intubated or respiratory distress.
Repletion: When youre on overnight call, your job as the intern
includes repleting electrolytes as needed for all your teams
patients. Labs are drawn at midnight and results are usually up at
0200. See electrolyte repletion section, but with some caveats for
ICU as follows:
K: Normally, every 40 mEq of K given IV is in 500cc NS if given
peripherally, but can be concentrated if given through a central
line. You have to write an order to specify concentrate for central
line administration if you want to avoid giving too much fluids in
an already overloaded patient.
Mg: In the ICU, faster rate of infusion allowed, up to 1g over 1
hour.
Thiamine: Repletion should be considered in all patients with
starvation or alcohol withdrawal. Can be ordered as 100mg IV
q12h x 4 doses then 100mg PO/NGT daily.

4. Respiratory Failure:
Hypercarbia (PaCO2>45, pH <7.35)
1. CO2 production: fever, sepsis, seizures, high CHO load
in pt w/ underlying pulmonary disease
2. dead space: intrinsic lung disease (asthma, COPD,
CF, pulm fibrosis), chest wall disorders (scoliosis)
3. minute ventilation: Drug overdose, metabolic
62
derangements
(myxedema, hypokalemia), CNS disease (spinal cord lesions), PNS
disease (GBS, MG, ALS, botulism), muscle disease (myositis,
muscular dystrophy), chest wall disorders (scoliosis), upper airway
obstruction
Hypoxia (PaO2 < 60, SaO2 < 90)
1. FiO2: High altitude, tubing (of ventilator) not connected
(nl A-a gradient, can correct w/ increased FiO2)
2. Diffusion: COPD, parenchymal lung disease (can correct w/
increased FiO2)
3. V/Q mismatch: Large PE, PNA, atelectasis, asthma (high A-a
gradient, can correct w/ FiO2)
4. Hypoventilation (nl A-a gradient, can correct w/ FiO2)
5. Shunt: Severe ARDS, intracardiac, etc (high A-a gradient, cannot
correct w/ FiO2)

PAO2 - PaO2 gradient: (713 * FiO2) [(PaCO2/0.8) PaO2]


Nrml A-a gradient = (Age/4) + 4 (or use gradient = 0.43 * age)

- If A-a gradient is nrml & PaCO2 is high, then the cause of


hypoxia is likely hypoventilation.
- If A-a gradient is high, then the cause is shunt, V/Q mismatch or
DO2/VO2 (O2 Delivery/Consumption) imbalance such as
anemia, low cardiac output or hypermetabolism.
Treatment goal: correct hypoxemia
providing high FiO2
restoring lung volumes by recruiting more alveoli (with PEEP)

5. Types of Supplemental Oxygen:


Nasal cannula: 50 cc reservoir (nasopharynx/oropharynx), O2 flow 1-
6 L/min, FiO2 0.24-0.46. Each L/min roughly increases FiO2 by 0.04.
Oxygen face mask: 150-250 cc reservoir, O2 flow 5-10 L/min, FiO2
0.4-0.6.

63
Non-rebreather facemask: 750-1250 cc reservoir, O2 flow 5-10
L/min, FiO2 0.4-1. The reservoir bag is directly connected to the O2
delivery system & about 1/3 of the volume is depleted when pt
inhales.
Exhaled air leaves via a one-way valve in the mask which prevents
exhaled air from being re-breathed & room air from entering the
mask.
Non-invasive positive-pressure Ventilation: BiPAP vs. CPAP
Use CPAP (=IPAP) if primary problem is oxygenation (hypoxia)
Use BiPAP if primary problem is ventilation (hypercapnia)
The gradient between the IPAP (inspiratory) & EPAP
(expiratory) pressures controls the ventilation. If you increase
IPAP to improve oxygenation, remember to increase EPAP to
keep the gradient the same so as to keep ventilation constant.
BiPAP 10/5 is equivalent to Pressure Support Ventilation 5/5.

6. Acute respiratory distress syndrome (ARDS)


2011 Berlin Definition: divied into three categories based on degree
of hypoxemia
Mild (200 mm Hg < PaO2/FIO2 300 mm Hg)
Moderate (100 mm Hg < PaO2/FIO2 200 mm Hg)
Severe (PaO2/FIO2 100 mm Hg)
Causes: Most commonly sepsis and susbsequent inflammation
leading to increased permeability across basement membranes and
therefore edema in the airspace. This is later followed by
fibroproliferation (also contributing to decreased compliance and
leading to long term changes and decreased DLCO after ARDS
resolves in survivors)
Treatment: primarily supportive
Ventilator strategy for Treatment: with low tidal volumes
(between 4-6ml/kg) and PEEP (usually 5-10cm H20) to keep
alveoli open, goal is to keep PaO2>60mmHg without causing
ventilator associated lung injury
Keep fluid status for CVP goal of 4-6cm H20

64
Steroids use is controversial. May have benefit later in the
course but not at initial presentation, and probably only in
patient with high oxygen requirements and with no infection.
Steroids shown to INCREASE mortality in pt w/ sx >14 days.
(ARDSnet LaSRS LAZARUS trial NEJM 2006)

7. Supportive ventilation basic primer


Consider intubation for: resp acidosis (PaCO2 > 50mmHg, Ph
<7.3), hypoxemia (PaO2 <55 mmHg with fiO2 = 1.0), GCS </= 8,
hypotension (shock), ARDS (PaO2:FiO 2 < 200 mmHg)

1. Noninvasive Positive pressure ventilation


CPAP: continuous positive airway pressure
Patient initiates breaths and machine provides pressure
constantly
BiLevel positive airway pressure: Inspiratory PAP and Expiratory
PAP/PEEP
IPAP: Patient initiates breaths and machine provides pressure
at inspiration
EPAP: after breath initiated by patient, machine continues to
deliver some pressure, and this helps keep the alveoli open,
and thus improves recruitement of alveoli and decreases work
of breathing
Uses: Effective in treating decompensated COPD, status
asthmaticus

2. Invasive: intubation + mechanical ventilation


Indications for intubation:
o Respiratory failure/fatigue: Improve gas exchange,
increase oxygenation and ventilation Decrease work of
breathing
o Airway protection

Basic Modes:

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Volume A/C (assist control):
o Patient initiates breath, then machine provides a full set
volume
o Standard settings: PEEP 5, Vt 400-500cc (or 5cc/kg), RR
14, FiO2 40%
o Check ABGs and Watch for respiratory alkalosis from
hyperventilation, given patient will get full volume every
time a breath is initiated therefore tachypnea can lead
to staking and cause hyperventilation.
SIMV (synchronized intermitted mandatory ventilation) and
PEEP
o the patient is allowed to initiate breaths which trigger
the machine to provide a volume or pressure support,
but if the patient does not initiate a breath, the machine
will also provide a minimum set number of mandatory
breaths.
Pressure controlled
o Fixed pressure. Vt will vary depending on patients lungs
compliance. Therefore monitor Vt: can be too small in
poor compliance, which leads to poor ventilation.

** Consider Weaning trials to prepare for possible extubation, when


the underlying cause for intubation is starting to resolve.
Weaning parameters can be ordered and done by
Respiratory Tech.
You can also write for pressure support trials.
Example weaning order: When sedation off, change vent settings to
CPAP PS 7 PEEP 5 FiO2 30% titrate to spO2>93%. Revert to previous
vent settings if patient tires.

8. Sepsis
SIRS (systemic inflammatory Response syndrome) = 2 or more of
the following: T>38 or <36oC, HR >90, RR>20, WBC>12 or <4, or
bands >10%
Sepsis: SIRS + suspected source of infection
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Severe Sepsis: Sepsis + end organ damage
Septic Shock: Sepsis +hypotension <90/60 unresponsive to fluid
resuscitation
Management: patient should be in ICU setting, notify senior
resident and call med consult at 91644
Early goal directed therapy, Surviving Sepsis Campaign
Doing the following interventions within 6hours of presentation
has been shown to decrease mortality
IVF resuscitation with NS, target MAP >65mmHg
Obtain 2 sets of blood cultures, then start broad spectrum
antibiotics
Vasopressor: Norepinephrine preferred
Consider ICU admission, PA catheter and a-line
placements
LAC+USC protocol: The following must be done within the FIRST
hour of presentation
o IVF initiation at rate of 20mL/kg
o Lactate level
o 2 blood cultures before antibiotics
o broadspectrum antibiotics
Order set for standard antibiotic choices for:
o Unknown source: Vancomycin (for gram positives
including MRSA) , ceftriaxone for gram negatives (or
cefepime if risk of pseudomonas) and metronidazole
(for anareobes)
o CAPneumonia: Ceftriaxone and azithromycin
o Urosepsis: ceftriaxone or ciprofloxacin
o Abdominal infection: Zosyn
o Soft tissue infection: Zosyn

9. Shock:
Inadequate end-organ perfusion: UOP, perfusion (e.g., cool
extremities, cyanosis), MS, tissue hypoxia ( lactic acid)

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A. Cardiogenic/Pump Failure (myocardial dysfunction, usually due to
MI or decompensated CHF) CO & SVR
B. Obstructive/Mechanical defect (pericardial tamponade, acute PE,
ASD, valvular dysfunction, RV infarct) CO & SVR
C. Hypovolemic (hemorrhage or fluid loss) CO & SVR
D. Distributive (sepsis, anapphylatic, neurogenic, drugs, toxins, TSS,
myxedema coma, adrenal insufficiency, SIRS) CO & SVR

Management: depends on the type of shock


1. Differentiate between different etiologies.
Swan-Ganz Catheter: helps differentiate between septic vs
cardiogenic shock.
o Normal values:
Pulmonary Artery Mean Pressure (PCWP, Wedge):
8-12mm Hg (Estimate of the LA pressure)
Central Venous Pressure (CVP): 2-8mm Hg
Pulmonary Artery Systolic (PAS): 20-30mm Hg
o Before interpreting Swan-Ganz abnormal numbers, first
have the nurse double check and make sure that the
Swan is properly wedging (if there is any doubt in your
mind, you can always get a CXR and see where the Swan
is (it should look like its in the pulmonary artery)
10. Pressors:
Note: Adequate volume resuscitation is essential to minimize risk of
vasopressor-mediated splanchnic hypoperfusion.
**Norepinephrine is the first-line agent for septic shock.

Norepinephrine/Levophed: 1 effect predominates at low dose & 1


at higher dose. One randomized trial done suggested
norepinephrine better than dopamine at increasing BP in
hypotensive pts (91% vs 31%).

Epinephrine: 1, 2, & 1 agonist (used particularly in anaphylaxis).

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Adverse effects: arrhythmias & splanchnic blood flow.

Dopamine: Low dose stimulates dopamine receptorsrenal blood flow


& GFR; no benefit of low-dose dopamine on renal outcome [ANZICS,
Lancet 2000; 356: 2139]. Main side effect: tachyarrhythmias.

Phenylephrine: Pure vasoconstrictor. Useful in neurogenic &


anesthesia- induced hypotension. Also helpful when battling w/
tachycardia.

Vasopressin: Potent vasoconstrictor. Not to be substituted for


dopamine or norepinephrine as first-line agent in septic shock. Should
be added to first- line agent. Not titrated & used usually at 0.4 U/min.
Effective at improving MAP in vasopressor-resistant shock. Vasopressor
effects are preserved in setting of acidosis & hypoxemia.

*Dobutamine: 1 > 2. CO. Used specifically in cardiogenic shock.


Should not be used as vasopressor.

PRESSOR HR IONOTROPY SVR DOSE


Norepinephrine ++ ++ +++ 0.5-30 mcg/kg/min
Dopamine 0 + + 10-20 mcg/kg/min
Epinephrine +++ +++ ++ 1-20 mcg/kg/min
Phenylephrine ++ 0 +++ 1-200 mcg/kg/min
Vasopressin 0 0 ++ 0.2-0.4 units/min
*Dobutamine ++ +++ - 1-20 mcg/kg/min

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SECTION 10 CARDIOLOGY

1. Differential Diagnoses of Chest Pain:


A. Acute Coronary Syndrome (see below)
B. Musculoskeletal
Hx: Worsened pain w/ movement, deep breaths; recent trauma;
consider herpes zoster (pain in a dermatomal distribution).
Dx: Pain reproducible w/ palpation (does NOT exclude cardiac
cause).
Tx: Symptomatic (NSAIDs in costochondritis, lidocaine patch).
C. GERD/PUD/Esophageal spasm
Hx: Burning or cramping chest pain, burping, sour taste, worsened by
certain foods, pain worse w/ lying down, nocturnal cough,
asthma exacerbation, globus, dysphagia/odynophagia.
Dx: Clinical diagnosis, barium swallow (if odynophagia),
manometry, pH probe, consider H. pylori testing, endoscopy.
Tx: H2-blockers, PPIs, abx if H. pylori (+), lifestyle mod (e.g., no
late meals, avoid EtOH/caffeine/chocolate/mint, elevate head of bed).
D. Esophageal tears (Mallory-Weiss)
Hx: h/o emesis/dry heaves; may present w/hematemesis after
retching.
Dx: Clinical suspicion; can confirm w/ EGD.
Tx: Usually stops in 24-48 hrs w/ rest/conservative mgmt; may need
surgical repair if severe; if hematemesis, treat as upper GI bleed.
E. Pulmonary embolus
Hx: Virchow's triad: stasis (prolonged immobility); endothelial injury
(post-op); hypercoagulability (coagulation disorder, malignancy).
May present w/ pleuritic CP, dyspnea, tachypnea, tachycardia,
hemoptysis.
Dx: Hx of risk factors, Wells criteria, PE protocol CT w/ IV contrast,

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V/Q scan if contraindication to contrast (e.g., allergy, renal failure),
RV dilation on TTE or RAD, S1Q3T3 on EKG (if RV strain).
Tx: Anticoagulate (sooner is betterlower mortality. Empirically
start anticoagulation if high suspicion). If pt unstable w/RV strain
may need lytics or surgical/interventional tx.
F. Pneumothorax
Hx: h/o thoracic procedures, body habitus (e.g., tall, thin) for
spontaneous ptx, mechanical ventilation, severe
bronchospastic/obstructive lung disease, ipsilateral chest pain, usually
abrupt onset of SOB. Emphesema, Pul LAM, HIV/PJP, tension
Dx: CXR (tracheal deviation), breath sounds, hypotension.
Tx: 100% nonrebreather even if not hypoxic, chest tube if PTX
>15% (if tension PTX, needle decompression in 2nd IS at
midclavicular line).
G. Aortic dissection
Hx: h/o wt lifting/exertion, HTN, Marfanoid appearance, syphilis,
tearing chest pain radiating to the back.
Dx: BP discrepancy in one arm vs. other, AI murmur, mediastinal
widening on CXR, usually need TEE, CT or MRI.
Tx: Type A (involves ascending aorta)surgery; Type B medical
management (aggressive BP control w/ -blockers & nitrates)
H. Pericarditis
Etiology: 80-90% viral or idiopathic cause; also consider infectious,
neoplastic, CTD, radiation-induced, post-MI, post-pericardotomy,
uremia.
Hx: Severe, constant pain that localizes over anterior chest
w/radiation to back or either arm, worse w/inspiration, improved by
leaning forward.
Dx: Scratchy friction rub, best heard w/ pt leaning forward. EKG
has diffuse PR depression & concave upward ST elevation. Consider

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TTE (especially if considering tamponade).
Tx: ASA (esp. if recent MI), high-dose NSAID (ketorolac if CABG
or post-pericardiotomy), colchicine, prednisone 1.5 mg/kg qd x4wks
if severe.
I. Cardiac tamponade
Hx: Trauma/penetrating wound, pericarditis, post-MI
Dx: Beck's triad (distant heart sounds, JVD, hypotension), pulsus
paradoxus; EKG (low voltage, electrical alternans); CXR (large
cardiac silhouette); TTE (effusion, septal shift w/ inspiration).
Tx: Acutely: IV fluids; definitive tx is pericardiocentesis.
J. Acute chest/Sickle cell vasoocclussive crisis
Hx: h/o sickle cell disease, 2-3 days into VOC
Dx: CXR, pulse ox
Tx: Analgesics, IV fluids, O2 (see Heme section)

2. Peripheral Pitting Edema Assessment Scale


1+: 2mm depression, barely detectable impression when finger is
presssed into skin. Immediate rebound.
2+: Slight 4mm indentation. 15 seconds to rebound
3+: Deeper 6mm indentation. 15-30 seconds to rebound.
4+: > 30 seconds to rebound.

3. JVP assessment
On examination:
versus carotid pulse: JVP = biphasic, nonpalpable occludable, varies
w position.
JVD measurement to estimate CVP is done at 45degrees HOB, add 5
cm to level measured from sternal angle. Normal JVP 6-8 cm H20.
Hepatojugular Reflux: One can apply pressure to the abdomen to
test for HJR. If the pressure rises > 4 cmH20 AND stays elevated for >
10 secs, the HJR is +. This is consistent w/ a hypervolemic state.

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Kussmaul's sign: paradoxical increase JVP with inspiration. Sign of poor
filling of RV. DDx: constrictive pericarditis/restrictive cardiomyopathy,
pericardial effusion, severe right-sided heart failure.

4. Waveforms
An upgoing wave : RA contraction
The " x " descent follows the 'a' wave and corresponds to atrial
relaXation
C upgoing wave: RV Contraction causing the triCuspid valve to bulge
towards the RA.
X downward wave: atrial relaxation and tricuspid valve downward
going during systole
V upgoing wave : atrial filling
Y downward wave: opening of the tricuspid valve causing emptying
of JV and filling of ventricles

5. EKG
Use a consistent approach (rate, rhythm, axis, intervals, atrial
enlargement, hypertrophy, waveforms (q waves, ST/T wave changes,
R wave progression)
Overall: look at EKG, what jumps out at you?
Voltage: Is it standard or 12 standard? Look at the square shaped
waves at the leftmost side of the EKG.
Rate: QRSs in a line x 6
Rhythm: p before each QRS, look for heart block
Axis: look at I and aVF which represent simple vectors I=0 and
aVF=90 to assess the axis of the heart
Normal Axis:-30 to +90
LAD: axis beyond -30 degrees
RAD: axis beyond 90 degrees.
Intervals: check for a normal PR (120-200ms, i.e. 1 large box)
short PR-preexcitation of ventricles, delta waves (such as WPW)
QT interval (should be less than 12 of the RR interval)
Prolonged QT- see pocket medicine

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Leads: check to see if the patient is having a heart attack. For this
look for T wave inversions, ST elevations, or q-waves in any of the
following patterns. HI SAL
Waves: look at the P waves
LAA if wide >120ms notched P in II or biphasic p in V1 and >1mm
hump on the bottom
RAA if tall peaked p in II or biphasic p in V1 with larger hump
>1.5mm on top
QRS should be <120ms, for BBB QRS > 120 ms
o if V1 and V6 rabbit ears then LBBB
o if biphasic then RBBB
o for LVH S in V1 or V2 + R in V5 or V6 > 35
o for RVH R>S in V1 or Deep S in V6)
T wave for TWI, peaked T waves in hyperK.
R waves for Poor R wave Progression
Signs of Ischemia/Infarct: ST elevation/depression in contiguous
leads suggesting NSTEMI/STEMI
ST Depression: ischemia
ST Elevation:
Acute MI if upward convexity in contiguous leads.
If in all leads, think of perdicarditis.
DDx also includes many other causes such as Takotsubo,
Brugada syndrome, etc but your goal is not to miss an MI!
T wave inversions
Pathologic Q waves: if at least 1 box deep and 1 box wide. Indicates
necrosis or old MI
Coronary Artery Territories
Septal V1, V2 LAD territory
Inferior II, III, aVF RCA territory
Anterior V3, V4 - LAD territory
Lateral I, aVL left circumflex territory
Posterior V1, V2 (see lone ST depression which are really
elevations) left circumflex
Sgarbossa's criteria:

74
To detect MI on EKG in the setting of LBBB. 90% specificity of STEMI
(but only 36% sensitivity). If 3 points or more, diagnosis of MI.
ST elevation 1 mm in a lead with upward (concordant) QRS
complex - 5 points
ST depression 1 mm in lead V1, V2, or V3 - 3 points
ST elevation 5 mm in a lead with downward (discordant) QRS
complex - 2 points

6. Acute Coronary Syndrome (ACS):


Myocardial ischemia due to plaque rupture leading to coronary
thrombosis
Includes: Unstable angina, NSTEMI, & STEMI
1) Bottom Line: If youre unsure, the story is good & its safe to
anticoagulate, just heparinize
2) Review the EKG yourself, & make the differentiation between
NSTEMI & STEMI (ST elevations in at least 2 contiguous leads; 1
mm in limb leads or 2 mm in precordial leads; different criteria w/
LBBB 1 mm STE concordant w/ QRS, 5 mm STE discordant w/
QRS, or 1 mm STD in V1-3)
If STEMI: CALL EMERGENCY CARDS CONSULT/On CALL CARDS
FELLOW give ASA, start Heparin gtt (bolus 50 mg/kg, rate 12 mg/kg/hr),
This is a cath EMERGENCY (better outcomes w/ initial PCI vs.
thrombolysis). Note: pts thought to have high likelihood of
requiring CABG (likely left main or 3-vessel disease) should NOT
be given Plavix because it will delay surgery 5 days
If UA/NSTEMI: consider demand-side vs. supply-side ischemia,
Heparin & antiplatelet therapy (e.g., ASA, Plavix, GP IIb/IIIa
inhibitors).
3) Standards meds: Aspirin (4 chewable baby ASA; give Plavix if allergic to
ASA), -blockade (if HR/BP will tolerate), SL NTG for anginal pain,
high-dose statin, nasal canula oxygen, morphine prn pain. Consider
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Nitroglycerin gtt (Tridil) if CP not relieved, but watch out for
hypotension & nitro toxicity.
4) Caution: Avoid -blockers & nitrates if suspect inferior wall MI.
Cautiously consider -blockers if h/o cocaine use (Rangel 2010
Archives of Internal Medicine).
5) Anticoagulation in ACS: Use caution if prior bleeding hx. If the initial
management of ACS is a conservative approach & there are no
contraindications, consider LMWH (enoxaparin 1 mg/Kg SQ q12h).
Whenever possible, anticoagulation therapy should not be switched
from one drug to another. Avoid LMWH in pts w/ renal failure, but may
use on obese pts (1mg/kg). Consider Plavix [600 mg given mortality
benefits vs 300 mg (CURE trial)]. Consider addition of a GPIIb/IIIa
inhibitor in pts w/ TIMI score > 4, +troponins, Killip class >=III, or in pts
w/ CP even w/ heparin [NEJM 2001;345:494-502] [JACC 2008; 52(21)
:1693-1701]
6) Need cardiac monitor if admitting for r/o ACS, NO EXCEPTIONS, must
be in CCU for this.
7) Serial cardiac enzymes (CK/CK-MB/troponin q8h) & EKGs. Once
troponins have peaked, may check only CKs. Classic rule out is done
over 24hrs, but can be done in shorter time if cocaine CP.
8) Keep NPO in case of cath or stress test. Bedrest.
9) Calculate TIMI score (if ACS is leading dx), 1 point for each:
Age > 65
3 CAD risk factors (Tob, FHx, HTN, Hyperchol, DM)
Known coronary stenoses > 50%
Chronic ASA use
2 anginal episodes at rest
ST deviation 0.5 mm
Elevated cardiac markers
11) Killip Classification-categorizes pts w/ acute MI based on presence of

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CHF symptoms/LV dysfunction: I- no CHF symptoms; II- mild to
moderate CHF (rales, S3, JVD); III- overt pulmonary edema;
IVcardiogenic shock
30-Day mortality: I vs. II vs. III/IV (2.8% vs. 8.8% vs. 14.4%)
6-month mortality: I vs. II. vs. III/IV (5.0% vs 14.7% vs 23.0%)
[Am J Cardiol 1967;20,457-465] [JAMA 2003;290:2174-2181]

7. Post-cath checks
Usually 12 hrs post-cath by the on-call team.
Review the cath report in the chart: It will have results,
intervention and the diagram of the coronaries showing what
%age lesions were present.
Catheterizations can be Lt heart only (for CAD) versus Rt
heart only (for Pulm HTN/valvular disease) versus both
Check the distal dorsalis pedis pulses bilaterally
Check the femoral site for bleeding or hematomas
Review Hb and Cr 12 hours post-cath.1-2 Hb drop ok but check
q8h to make sure it plateaus.
Ask the patient about any pain or other complaints
Possible complications post-catheterization : Bleeding , Infection,
AV fistula (pulsatile mass and systolic bruit) order Doppler
ultrasound of femoral artery if suspected, and call the fellow if
confirmed. Arterial thrombosis (cold extremity, loss of pulses),
Retroperitoneal hematoma (order CT abdomen if suspected, and
call the fellow if confirmed or patient looks unstable, Emboli,
Contrast-induced renal failure. Just watch and hydrate (usually 3-5
days post-procedure), Arrhythmias, Arterial dissection/stent
thrombosis: chest pain post procedure.

** Patient may come out of the cath lab with a fem stop (pressure
device applied to the arterial closure site). These devices should never

77
be left in place over 6 hours due to risk of arterial thrombosis. The
patient should lie flat for 6 hours after removal.

8. The New Cardiomyopathy (CM) Pt:


Most common causes: Ischemic, HTN, Valvular, & Idiopathic
Types: Restrictive (amyloidosis, sarcoidosis, hemochromatosis, Wilsons)
Dilated (ischemic, Beriberi, Coxsackie B, Chagas, cocaine,
Doxorubicin, EtOH, familial, HIV, stress-induced, thyroid)
Hypertrophic IHSS, now called HOCM (genetic, etc.)
Dx: History, TTE, cardiac cath to r/o ischemia, HIV, ANA, TFTs

9. Heart Failure:
Can be systolic or HFpEF (i.e., signs & symptoms of HF in setting of nl
LV function (EF >50%) & absence of valvular disease)
Hx: Dyspnea, exercise tolerance, orthopnea, PND, peripheal edema, wt
gain, & abdominal discomfort (may include nausea/vomiting).
Quantify symptoms based on NYHA Classification scheme:
Class I: Symptoms at levels that would limit nl individuals
Class III: Symptoms w/ ordinary exertion.
Class III: Symptoms w/ less than ordinary exertion.
Class IV: Symptoms at rest.
Identify precipitant: Rx non-compliance; fluid/dietary indiscretions;
CAD event; HTN; PE; myocarditis; arrhythmia; infectious process; renal
failure; pulmonary disease; high outpit state e.g. anemia, hyperthyroidism,
AV fistula
Obtain cardiac hx, prior TTE, stress tests, & cath reports.
Exam: JVP, S3 or S4, murmurs, displaced/diffuse PMI, rales, pleural
effusion, sacral edema, hepatojugular reflux, pulsatile liver, ascites,
abdominal girth, LE edema.
Assess hemodynamics (congestion & perfusion)
Evidence of congestion (wet vs dry)
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Left-sided sx: Dyspnea at rest or early in exertion, orthopnea, PND
Right-sided sx: LE edema, abdominal fullness, bloating, anorexia
Evidence of low perfusion (cold vs warm)
Fatigue, somnolence, lethargy, anorexia, cool & pale extremities,
Weak pulses, narrow pulse pressure, decreased UOP, lactic
acidosis
Evidence of systolic HF: Cardiomegaly, LBBB, diffuse soft apical
impulse, tachycard, SBP < 90.
Evidence of nonsystolic HF: SBP >160, DBP> 100, LVH, S4
Workup: Heme-8, CMP, TSH, coags, cardiac enzymes, +/- pro-BNP
EKG: Ischemia, enlarged chambers, arrhythmia, pericarditis, new BBB
CXR: Vascular congestion, edema/effusion, Kerley B line, cardiomegaly
TTE (in new-onset HF), more useful when euvolemic
Tx:
Diurese w/ Lasix (IV is 2x as potent as PO). Note: Pt w/ low EF &
severe volume may require diuresis even if hypotensive (recall
Starling curve). BP will often improve w/ diuresis.
If Lasix not enough, double the dose (up to 240 mg); may add Diuril
or Metolazone (may not absorb b/o gut edema) 30 min before Lasix
dose.
Check bid lytes (goal K>3.5, Mg>1.5 unless arrhythmia K>4, Mg>2).
Restrict salt (<2g) & fluid intake (<1-2L), daily weights, strict I/O.
Assess response to therapy: Follow symptoms, O2 requirement,
daily weights, I/O, JVP, BUN, Cr, & bicarb w/ aggressive diuresis.
Afterload reduction w/ ACE Inh (can start w/ Captopril tid &
uptitrate), also good long-term survival benefits [CONSENSUS]
Long-term morbidity/mortality w/ -Blockers [MERIT].
Continue -Blockers if pt on prior to admission & extremities
not cold.
Do NOT start -Blockers during acute exacerbation

79
[OPTIMIZE-HF].
Improved morb/mort seen w/ nitrates/Hydralazine [v-HEFT-1] &
Spironolactone [RALES] (latter is reserved for severe symptomatic
HF).
Consider d/c CCBs w/ systolic dysfunction (some studies suggest
mort). W/ diastolic dysfunction, CCBs/BBs helpful in filling time.
Digoxin improves CHF symptoms, but not morbidity/mortality [DIG]
Consider inotropes (Dopamine, Dobutamine, Milrinone) if cold &
wet. Dobutamine better if: severe hypotension, renal failure, cost is an
issue. Milrinone is better if: pulmonary hypertension, need for -
blockade, severe tachycardia.

10. Atrial fibrillation:


Etiology: Mnemonic H PIRATES. Hypertension, Pulm disease,
Ischemia, Rheumatic heart disease, Accessory pathway,
Thyrotoxicosis, EtOH/Excess dig, Sick sinus syndrome
Dx: Irreg irreg pulse, hypotension, palpitations, CP, dizziness.
Tx:
Cardiac monitor if new onset A-fib
Start w/: Metoprolol 5 mg IV + 50 mg PO bid or Diltiazem 10-20
mg IV Push (over 2 min) + 30 mg PO QID.
If HR difficult to control: Diltiazem drip 5-15 mg/h, titrate to
HR<100.
If hypotensive or very bad systolic dysfx: Amiodarone 150 mg IV
over 10 min, then 1 mg/min IV x 6h, then 0.5 mg/min x 18h.
Studies show equivalence between rhythm control vs. rate control &
anticoagulation (AFFIRM, RACE) in pts w/ asymptomatic A-fib, so
this becomes a pt-specific decision.
Cardioversion: no need to anticoagulate if a-fib < 48h; otherwise,
anticoagulate for 4 wks before & 4 wks after cardioversion

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Chronic anticoagulation for paroxysmal or chronic a-fib: data now
supports use of CHA2DS2-VASc score, instead of CHADS2 score. (European
Heart Rhythm Association; Oct 31, 2010 & Pharmacotherapy. Odum et al,
2012)

Condition Points
C CHF 1
H HTN (>140/90 or on BP meds) 1
A2 Age >/= 75 2
D DM 1
S2 Stroke or prior TIA 2
V Vasc dz 1
A Age 65-74 1
Sc Sex category (female) 1

Score Risk Anticoagulation


0 Low None or ASA 75mg-325mg
PO Qday
1 Moderate PO Warfarin goal INR 2-3
or ASA 75-325mg
>/= 2 High PO Warfarin goal INR 2-3

Calculate HAS-BLED score for bleeding risk on oral anticoagulation in A


Fib. Give 1 point for each of the following: HTN (Systolic BP160mmHg);
Abnl renal fx; Abl liver fx; Age 65 years; Stroke in past; Bleeding; Labile
INRs; Taking other drugs as well; Alcohol intake at same time.
A HAS-BLED score 3 indicates 1-y bleed risk on AC which would be
sufficient to justify caution or more frequent evaluations.

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11. HTN:
Etiology: 95% of HTN is idiopathic (essential), but consider 2 causes
if age of onset <20 or >50.
Tx: Goal BP <140/90 or <130/80 in DM or CKD. General first-line
management is diet & exercise. Add pharmacotherapy if no improvement
over a few months.
First-line agents: HCTZ & ACEI (caution in AKI & CKD). New evidence for
dipyrimidine CCBs
ACCOMPLISH trial: CCBs are superior to diuretics when added to ACEi in
high risk patients

12. Hypertensive Urgency/Emergency:


Emergency implies evidence of end-organ damage: cardiac damage
(enzyme leak), renal damage (Cr, microscopic hematuria), stroke, MS,
hemorrhage on fundoscopic exam, flash pulmonary edema, shock liver.
Etiology: Exacerbations in our pt population are often the result of
medical noncompliance, dietary indiscretions, or missed HD (i.e volume
overload)
Dx: Check cardiac enzymes, CXR for pulmonary edema, UA for RBCs, head
CT if mental status/neurologic changes, etc.
Tx:
Note: Requires cardiac monitor. Pts on drips often need to be triaged
to CCU due to need for continuous BP monitoring and/or gtts.
Can start by giving prescribed PO medications (if missed dose) as well
as Nifedipine XL 30-60 mg (but caution as this is longer-acting),
Hydralazine 10-25 mg or Captopril 12.5 mg
Next, if needed, give IV push medications: Labetalol (start w/ 20mg IV
& can increase to 40mg 80mg IVP if necessary q10 min, up to 300
mg) or Metoprolol (start w/ 5mg IV q5 min, up to 15mg).
If IV pushes are inadequate, or if hypertensive emergency, use gtt:
Labetalol 2-6 mg/min (watch out for bradycardia) or Nicardipine 5-15
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mg/h (watch out for bradycardia) or Nitroprusside 0.3-10.0 mcg/Kg/min
(thiocyanate toxicity in CKD pts) or Enalaprilat (caution in AKI pts).
Transition to PO meds when controlled w/ IV.
- If hypertensive urgency, bring BP (MAP) down by 25% over hours.
- If hypertensive emergency, bring BP down by 25% in mins.
- Do not bring BP down too quickly as the pts cerebral vasculature
has shifted autoregulation (they will stroke); a goal SBP in the 160s
will maintain adequate perfusion to the brain.
- Most pts w/ hypertensive crises will have headaches as you decrease
their blood pressure (Remember: headaches can also be a prominent
side effect of nitrates).

13. Syncope:
Etiology: Can be cardiac vs. non-cardiac (i.e., neuro/other). A majority
have no known etiology.
Cardiac: Arrhythmia (atrial or ventricular), valve disease (esp. AS), ACS,
systolic dysfx, HOCM, tamponade, aortic dissection, PE, pulmonary HTN
(cor pulmonale).
Non-cardiac: TIA/CVA, thromboembolism (from carotids, or paroxysmal
emboli from extremities), migraines, seizures, space occupying lesions in
the brain, vasovagal, hypovolemia, hypoglycemia, micturition syncope
(more common in men), preceding coughing spasm or bowel movement
(vagal), medication effects (i.e., -blockers, etc.), adrenal insufficiency.
Dx: Make sure it is syncopea true temporary loss of consciousness as
opposed to dizziness, vertigo, or presyncope.
Ask about prodrome.
Ask questions to assess if ictal or post-ictal state was present (aura,
witnessed seizing, incontinence, confusion, staring).
Assess volume status (orthostatics, skin turgor, oropharynx, etc.).
Consider CHF exacerbation or right-sided failure due to a large PE.

83
Listen for valvular murmurs, carotid & periph pulses (e.g. pulsus
parvus et tardus w/ AS), & bruits.
Check dexi.
EKG/cardiac monitor/enzymes to evaluate for cardiac causes.
Dry head CT to r/o any acute intracranial anomaly.
Consider TTE to evaluate mural thrombus & valve/systolic function
(w/ bubble study if want to r/o PFO), LE doppler to assess DVT
, head MRI/MRA, & EEG as indicated.
Consider checking cortisol for adrenal insufficiency.
Consider tilt-table testing for hypervagotonia.

14. Brugada Criteria (Distinguish SVT from VT):


Follow algorithm sequentially.
If yes to any criteria = VT. If all 4 criteria are absent, than dx is SVT w/
aberrancy (sens 97%, sp 99%).

CRITERIA Sens for VT Spec for VT


Absense of RS in ALL precordial leads 21% 100%
R to S>100ms in any precordial lead 66% 98%
A-V dissociation 82% 98%
Morph criteria for VT in V1-2 & V6 99% 97%

Morphological criteria for VT: [Circulation (1991)83:164959]


Primarily positive in V1 & in V1 & V6 (monophasic R or QR or RS
in V1 AND R to S ratio <1or QS or QR or monophasic R in V6)
Primarily negative in V1 & in V1 or V2 & V6 (R > 30msec in V1 or
V2 or >60 msec to nadir of S wave in V1 or V2 or notched S wave
in V1 or V2 AND QR or QS in V6)
Tx: Presence of structural heart disease or abnl EKG predict higher 1-y
mortality, requiring further evaluation & management of underlying

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pathology. [NEJM 2000;343:1856-62] [Circulation 2002;106:1606-1609]

15. Valvular Diseases:


A. Aortic Stenosis:
Etiology: calcific stenosis, bicuspid valve, rheumatic heart disease.

Stage/Severity Mean Gradient (mm Hg) AVA (cm2)


Nl 0 3.0-4.0
Mild <25 1.5-2.0
Moderate 25-40 1.0-1.5
Severe >40 <1.0

Hx: Angina (5-y mortality), syncope (3-y mortality), heart failure


(usually when AVA <1.0, 2-y mortality)
Tx:
1) Surgery when symptomatic, asymptomatic w/ AVA <0.6, or
asymptomatic moderate to severe AS undergoing CABG.
2) Medical Therapy gentle diuresis & BP control w/ ACE inh.
IABP sometimes required for stabilization & as a bridge to surgery.
*Note: AS is Pre-load dependent, so avoid venodilators (nitrates) &
negative inotropes (-blockers & CCBs)

B. Aortic Insufficiency:
Etiology: Rheumatic heart dz, endocarditis, HTN, Marfans, syphilis.
Hx: Pulmonary edema & hypotension (if acute).
Tx:
1) Surgery
2) Medical therapy
a) Stable AI vasodilators (nifedipine, ACE-I, hydralazine).
b) Acute decompensation afterload reduction w/ nitroprusside

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& inotropic support w/ dobutamine.
c) Vasoconstrictors & IABP contraindicated.

C. Mitral Regurgitation:
Etiology: Leaflet dysfxn (myxomatous degeneration, rheumatic heart
disease), ruptured chordae tendinae, papillary muscle dysfxn.
Hx: DOE, pulmonary edema, hypotension
Tx: Stable: afterload & preload reduction (diuretics/nitrates)
Unstable: dobutamine, nitroprusside. Consider IABP or surgery

D. Mitral Stenosis:
Etiology: Rheumatic heart disease & infiltrative disease
Hx: Pulmonary edema, dyspnea, A-fib & embolic events
Tx: Sodium restriction, gentle diuresis, blockade & anticoagulation.
Surgery or valvuloplasty if severe.

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SECTION 11: ENDOCRINE

1. Insulin and Oral Diabetic Medications

Type Onset Peak Duration Role in Management


Rapid-Acting
Humalog or lispro 15-30 min. 30-90 min. 3-5 hrs meals at the time of injn,
Novolog or aspart 10-20 min. 40-50 min. 3-5 hrs combine with long acting
Apidra or glulisine 20-30 min. 30-90 min. 1-2 hrs insulin

Short-Acting
Regular
Humulin/Novolin 30min-1hr 2-5 hrs 5-8 hrs covers meals w in 1/2-1hr
Velosulin 30 min.-1hr 2-3 hrs 2-3 hrs
(used in insulin pump)

Intermediate-Acting
NPH 1-2 hrs 4-12 hrs 18-24 hrs 1/2 day or overnight,
Lente 1-2 1/2 hrs 3-10 hrs 18-24 hrs combine with rapid or
short acting insulin
Long-Acting
Ultralente 30min-3 hrs 10-20 hrs 20-36 hrs full day coverage,
Lantus 1-1 hr no peak 20-24 hrs can combine w rapid
Levemir or detemir 1-2 hrs 6-8 hrs Up to 24 hrs or short acting insulin

Pre-Mixed*
Humulin 70/30 30 min. 2-4 hrs 14-24 hrs BID before meals
Novolin 70/30 30 min. 2-12 hrs Up to 24 hrs
Novolog 70/30 10-20 min. 1-4 hrs Up to 24 hrs
Humulin 50/50 30 min. 2-5 hrs 18-24 hrs
Humalog mix 75/25 15 min. 30min-2hrs 16-20 hrs

2. Inpatient Diabetes Management

How to Calculate Insulin Regimen


-usually NPH and Regular insulin
-0.6 units/kg in DM 2
-if insulin naive, consider using ISS and adjusting as needed or a lower
dose like 0.4 units/kg

87
-0.2 units/kg in DM1
-if in renal failure, calculate as above and then use half of the results as
insulin is renally excreted

AM Dose = 2/3 of total calculated insulin req (2/3 NPH and 1/3 Regular)
PM Dose = 1/3 of total calculated insulin req (1/2 NPH and 1/2 Regular)

When FASTING (i.e. NPO before procedure) give only 1/2 NPH and NO
regular *make sure you write this on the insulin form*

3. How to Adjust Insulin Regimen


-before breakfast blood sugar affected by evening NPH insulin the night
before
-before lunch blood sugar affected by morning R insulin
-before dinner blood sugar affected by morning NPH insulin
-bedtime blood sugar affected by evening R insulin

88
-if AM blood sugar is high, consider Somogyi phenomenon (rebound
elevated fs sugar in response to low early AM sugar level) and check 2 AM
blood sugar before adjustment of evening NPH dose

How to calculate a patients average blood sugar based on HbA1c:


((HbA1c-4) x 30) + 60

4. Glycemic Goals in the Hospital (AACE/ADA Guidelines 2009)

Patient Status Glycemic Goals mg/dL


Critically ill (exp. ICU, CCU) 140-180
Non critically ill
Preprandial <180
Maximum blood glucose <180

** AVOID HYPOGLYCEMIC EVENTS**

Signs of Hypoglycemia:
-Confusion, abnormal behavior or both, such as the inability to complete
routine tasks, Visual disturbances, such as double vision and blurred
vision, Palpitations, Anxiety, Sweating, Hunger, Tingling sensation around
the mouth, Seizures, Loss of consciousness

5. DKA
Etiology: Insulin non-compliance, infection, CVA, MI, severe illness,
surgery, pregnancy, steroids, thiazides, intoxication (EtOH, drugs).
More common in insulin-dependent DM (and HHS more common in
NIDDM).
Hx: N/v, abdominal pain, polyuria, polydipsia, dehydration, ketotic
breath, tachycardia, hypotension, MS, preceding infection.
Dx: Glucose>250, AG (>10), metabolic acidosis (pH< 7.3, bicarb <18),
ketosis (urine & serum), hypoPhos, hypoMg, pseudohypoNa (to correct,
add 1.6 to Na for every 100 in glucose above 100), hypoK or hyperK

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(usually total body hypoK even if labs show hyperK due to ion shift),
pre-renal ARF, hemoconcentration, leukocytosis.
Tx:
Assess ABCs (pts may be seriously volume down), CMP, PO4,
Mg, UA, serum ketones, serum osms, calculate AG, ABG
(correlate w/ VBG), EKG (ischemia), cultures (infection).
Insert 2 large bore IVs or central line, replete fluids w/ NS at rate
>125cc/h (up to 500 cc/h) +/- bolus & start regular insulin gtt at
0.1-0.2U/kg/h (+/- 10 unit Aspart bolus), titrating to dexis &
closure of anion gap. When dexi <250, change to D5 NS.
Continue insulin gtt until anion gap is closed AND bicarb >18.
Even if blood sugars are nl, keep gtt going until both of the
aforementioned are achieved.
When gap closes, give long acting insulin sub-q, & turn off
insulin gtt 1-2 h later.
Follow dexi q1h, BMP/Mg/PO4 q2-4h. Replete K, Mg, PO4.
Give 20-40mEq of K+/L fluid if the K+ is <4.5.
Only use IV bicarbonate [2 amps in 1L NS] if pH<7.0 or severe
hyperK
**Notes on DKA:
At LAC+USC, these are ICU patients, notify senior resident and med
consult at 91644 for ICU transfer and management
Dont just fix it, determine why it developed.
Dont drop serum osm by >3 mOsm/Kg/h; anything faster may lead
to cerebral edema.

6. HHS (HONK)
Hx: Usually in T2DM. Often overlaps/co-exists w/ DKA (& w/ similar
etiology). Develops slower than DKA. Neurological sx more common.
Mortality much higher than isolated DKA (10-50%).
Dx: BS > 600 (often > 1000), serum osms > 320, absence of severe
ketoacidosis (usually pH >7.3, bicarbonate usually >15)
Tx: Fluid, insulin, & electrolyte management are similar to DKA.
Initial fluid deficits are often higher (average 9L). When BS = 300,
switch to D5 NS & adjust insulin to maintain BS between 250-300
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until serum Osms go below 315 & mental status is nl.
Algorithm:

Hyperglycemic crises in adult patients with diabetes. Kitabchi et al


Diabetes Care. 2009

7. Adrenal Insufficiency Inpatient

Etiology
Primary: AI (Addisons Disease), Fungal, Sarcoidosis, AIDS not on HAART,
Amyloidosis, Mets, Hemorrhage, CAH

91
Secondary: Pituitary, Exogenous GCs, Post Corticosteroids,
Hypothalamic Disease
S/S: Skin Hyperpigmentation, Postural Hypotension and hemodynamic
instability, Muscle Wasting, Decreased body hair, Fever without a source,
Tachycardia, Muscle Weakness, Abdominal pain, n/v
Labs: Hyponatremia, Hyperkalemia, Hypoglycemia, Metabolic Acidosis,
Anemia, Eosinophilia, Pre-renal azotemia, Random Cortisol prior to
starting treatment (MICU), Blood, Urine, Sputum Cultures as indicated,
EKG, ACTH, Renin, Aldosterone, -Morning Cortisol (<5 highly suggestive)
then ACTH stimulation test (low dose or high dose test)
Diagnosis: Corticotropin stimulation tests
Low dose: Check baseline & 30 min cortisol level after administering
cosyntropin 1 mcg IV. Cortisol >18mcg/dl pre-stim or after 30min rules
out adrenal insufficiency (sens 95%, sp 96%).
High dose: Check baseline, 30 min & 60 min cortisol levels after
cosyntropin 250mcg IV. Relative insufficiency: 9 mcg/dl increase at
either 30 or 60 min.
Management: ABCs, IV Hydration
Tx w/ corticosteroids hydrocortisone 100 mg IV q 8 hrs is clinically
indicated in critically ill pts w/ signs of adrenal insufficiency.
Steroids in the MICU: Annane et al. [JAMA 2002] study survival
vs. Corticus [NEJM 2008] no effect on mortality.
Meta-analysis [Ann Intern Med 141:47, 2004] those w/ vasopressor
dependent shock for 2-72 h benefit from 5-7 days of physiologic
hydrocortisone followed by a 5-7 day-taper; no significant difference
between treating responders & non-responders.

8. Thyroid Disorders

A. Hypothyroidism
Types:
Subclinical Hypothyroidism: elevated TSH with normal fT4
Overt Hypothyroidism: elevated TSH and low fT4

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DDx: Hashimotos Thyroditis, Post partum Thyroiditis, Subacute
Thyroiditis, Graves disease (late stages), Iatrogenic: s/p thyroidectomy (2-
4 wks following total thyroidectomy), RAI therapy, external neck
irradiation, Iodine deficiency or excess
Drug induced (drugs used to treat hyperthyroidism: Lithium,
Amiodarone, Interferon alfa, oral tyrosine kinase inhibitors
Infiltrative Disease: Reidels thyroiditis, hemochromatosis, scleroderma,
leukemia, and cystinosis
Secondary Hypothyroidism: pituitary adenoma, postpartum pituitary
necrosis (Sheehan's syndrome), trauma, hypophysitis, nonpituitary
tumors such as craniopharyngiomas, infiltrative diseases, and
inactivating mutations in the gene for either TSH or the TSH receptor
Tertiary Hypothyroidism: any abnormality of the hypothalamus

Sx: weakness, depression, cold intolerance, weight gain, constipation,


menorrhagia in women, carpal tunnel syndrome
PE: delayed reflexes, bradycardia, myxedema
Dx:
-1st step: TSH
-if elevated, get fT4
-low fT4 (primary, start Levothyroxine replacement)
-normal fT4 (subclinical, re-checkin 1-3 months
-secondary or tertiary hypothyroidism low/normal/high TSH, low/normal
fT4 depending on the situation
-hyperlipidemia

Treatment: Levothyroxine 1.6 mcg/kg body weight per da. If patient is


older or has CAD/risk factors for CAD, can start at a lower dose first 25-50
mcg/day and then increase to complete dose as needed.
-Aim to keep TSH in normal range (0.5-5) and for resolution of symptoms.

B. Hyperthyroidism
DDx: Graves disease (most common), toxic multinodular goiter, toxic
thyroid adenoma

93
Other causes of elevated thyroid hormones: struma ovarii, postpartum
thyroiditis, Hashimotos thyroiditis, DeQuervains thyroiditis
Dx: FT4, TT3, TSH (Graves can have nl T4 but T3)
Sx: anxiety, weakness, tremor, palpitations, heat intolerance, increased
perspiration, weight loss despite a normal or increased appetite,
hyperdefecation, urinary frequency, oligomenorrhea or amenorrhea in
women, -gynecomastia and erectile dysfunction in men, unexplained
weight loss, new onset atrial fibrillation, myopathy, problems with glucose
control
PE: hyperactivity, lid lag, rapid speech, tremor, hyperreflexia, may have
AFib (irregularly irregular), exophthalmos and pretibial myxedema in
Graves disease
Labs: TSH, fT4, T3, Anti TPO Ab, Anti TSH receptor Ab
Treatment: Beta Blocker (decreases T4> T3 conversion) , Antithyroid
Medication (Methimazole, PTU) vs RAI ablation vs Surgery. Calcium
Supplementation
Acute Tx of thyroid storm: Propranolol 60-80 mg PO q4h; Methimazole
30 mg PO q6h (or PTU 250 mg PO q4h); Lugals iodine solution or
potassium iodide 10 gtt PO q8h; Hydrocortisone 100 mg IV q8h; Cooling
blanket.
Subclinical hyperthyroidism should be treated in pts w/ TSH persistently
<0.1, who are >65yo, postmenopausal, or have risk factors for
arrhythmias.

Additional info:
Overt Hyperthyroidism: low TSH, high T3 and/or T4
T3 toxicosis: low TSH, high T3 > T4
T4 toxicosis: low TSH, high T4 > T3
Amiodarone Induced: often T4 > T3
Subclinical: low TSH, normal T3 and T4
TSH induced (pituitary adenoma): normal/high TSH, high T3 and T4

C. Thyroid nodules
W/u (if being cost-effective) should be based on the TSH:

94
1. TSH low: Likely a hyperactive (benign) nodule, order thyroid
scintigraphy.
2. TSH high: Likely a cold nodule (w/ 15% risk of malignancy), thus
should pursue FNA.
3. TSH nl: Scintigraphy if nodule is small, vs. FNA if large (if large &
benign, should be active, & thus TSH should be low)

9. Dyslipidemia
(see AACE 2012 lipid guidelines for more information)

Screening:
-fasting lipid panel and in some cases CRP and Lp-PLA2
-all adults > 20 yrs age every 5 yrs
-all M 45-55 yrs and F 55-65 yrs at least every 1-2 yrs (more frequently if
other RFs present)
-if 0-1 CAD RFs at least yearly
-children > 2 yrs every 3-5 yrs if CAD RFs or FH of premature CAD or
dyslipidemia or are overweight or obese
-more frequently if FH of premature CAD or sudden death at < 55 yrs in
father or 1st degree M relative or < 65 yrs in mother or 1st degree F
relative
-annually screen all adult DM patients

Secondary Causes:
Total Cholesterol and LDL: Hypothyroidism, Nephrosis,
Dysgammaglobulinemia (systemic lupus erythematosus, multiple
myeloma) , Progestins or anabolic steroid treatment , Cholestatic diseases
of the liver due to abnormal lipoproteins as in PBC,Protease inhibitors for
treatment of HIV infection

Total Triglycerides and VLDL: CRF, DM2, Obesity, Excessive alcohol


intake, Hypothyroidism, Antihypertensive medications (thiazide diuretics
and b-adrenergic blocking agents), Corticosteroid therapy (or severe stress
that increases endogenous corticosteroids), Orally administered

95
estrogens, oral contraceptives, pregnancy, protease inhibitors for
treatment of HIV infection

When to Test in the Hospital:


-CAD, MI, Stroke, CAD equivalents (DM, PAD, Carotid Ds, Aortic Ds)
-Patient with RFs

Goals Based on Risk:

RISK RISK FACTOR LDL GOAL


category mg/dL
Very High Established or recent hospitalization for coronary, <70
carotid, PVD or DM + 1 or more additional RFs
High 2 RFs and 10-year risk >20% or CHD risk <100
equivalents, including diabetes with no other RFs
Moderately 2 risk factors and 10-year risk 10%-20 <130
high
Moderate 2 risk factors and 10-year risk <10% <130
Low 1 risk factor <160

RFs = high LDL, PCOS, cigarette smoking, HTN (BP 140/90 mm Hg or on


anti-hypertensive medication), low HDL(<40 mg/dL), FH of CAD (as
described above and age (men 45; women 55 years). Subtract 1 risk
factor if the person has high HDL (60 mg/dL)

Management: exercise, weight loss, smoking cessation, low fat diet


Elevated LDL
-drug of choice Statin (Simvastatin or Atorvastatin available at LAC)
-if admitted for ACS or stroke typically are aggressive (Simvastatin 80 mg
po qHS) although according to AACE using such high doses is no longer
recommended.
Elevated TG (>500)
-Fibrates (Fenofibrate, Gemfibrozil, etc.)
96
-adjunctive therapy with omega 3 fish oil pills
-Low HDL - exercise, weight loss, smoking cessation
-Other Agents less commonly used: Niacin, Bile Acid Sequestrants
(Cholestyramine), Cholesterol Absorption Inhibitors (Ezetimibe)

Side Effects:
Statins: LFT derangement (avoid statins in liver disease patients),myalgias,
muscle weakness, rhabdomyloysis, myopathy, Drug interactions (warfarin,
protease inhibitors, cyclosporine, CYP450)
Fibrates: Gemfibrozil may increase LDL, myopathy/rhabdomyolysis less
common than with statins, increased serum creatinine, Drug interaction
with warfarin
Niacin: skin flushing, pruritis, abdominal discomfort, may increase uric acid
Bile Acid Sequestrants: may increase TG, may decrease absorption of folic
acid and fat soluble vitamins
Cholesterol Absorption Agents: myopathy, rhabdomyolysis

97
SECTION 12: INFECTOUS DISEASES

1. Neutropenic Fever

Definitions
Neutropenic Fever
- T > 101 F at least once or T > 100.4 F for at least 1 hr) in a patient who is
neutropenic (ANC<500 or ANC expected to drop < 500 in the next 48 hrs)
Profound Neutropenia
-ANC<100
Functional Neutropenia
-hematologic malignancy results in qualitative defects of circulating
neutrophils (impaired phagocytosis and killing of pathogens)
-at risk of increased infection
-may have normal ANC

Risk Assessment
Low Risk: MASCC >21 (see Med Calc for MASCC)
-anticipated <7 day duration of neutropenia with no or few comorbidities
-may be treated with oral empiric therapy

High Risk: MASCC <21


-anticipated >7 days duration and profound neutropenia (ANC <100
cells/mm3 following cytotoxic chemotherapy) and/or significant medical
co-morbid conditions (ie. hypotension, oral/GI mucositis ,severe diarrhea,
IV catheter infection, pneumonia , new-onset abdominal pain, hepatic
insufficiency, renal insufficiency, or neurologic changes.
-admit to hospital for IV empiric therapy

Dx: Physical
- perform complete examination especially: skin , GI, Lungs, perineum
Labs: CBC w diff, BMP, LFTs, 2 sets of blood cultures (+ Cx from any
suspected sites of infection) Stool culture, O and P, C diff, U/a w/ micro + u
culture, LP and CSF examination if meningitis is suspected, Skin aspiration

98
or biopsy if any lesions are present, Sputum samples or BAL if patient has
cough or any respiratory s/s
Test for adenovirus, influenza, RSV, parainfluenza
Imaging: CXR (esp if patient has any respiratory s/s), CT head, sinuses,
abdomen, pelvis as indicated

Tx: High Risk Patients (the LAC+USC way)


-hospitalized for IV empiric antibiotics Add Abx every 48rs if still febrile
START w/ Cefepime 2 gm IV q 8 hrs (call ID pharm for approval code)
* if PCN Allergy: Aztreonam+ Vancomycin
* if unstable at Any TIME, add 2nd gram (-) coverage suck as
Amikacin
2nd + Vancomycin (if not already added )
3rd + Amikacin (if not already added )
4th + FLAGYL or switch cefepime to Imepenam
5th + Antifungal according to CXR and Dz being treated (micafungin,
fluconazole (Candida) , voriconazole (aspergillosis)
6th + Antiviral (valacyclovir or valgancyclovir), Oseltamivir if flu
season
7th Ambisome for Mucor/Rhizopus (sooner if indicated)

** note** Add Gram Positive Coverage(Vancomycin) for:


Hemodynamic instability , PNA on CXR ,(+) blood Cx for gram(+)
bacteria, Clinically suspected serious catheter-related infection,
severe mucositis, soft tissue infection at any site, colonization w/
MRSA, VRE, PRSP
**note** (If chills or rigors with infusion through catheter or cellulitis
around the catheter entry/exit site> remove catheters/lines and treat for
at least 14 days (longer if bacteremia persists)
For specific cultures:
- MRSA Add Vancomycin
-VRE Add Linezolid or Daptomycin
-ESBL Add Carbapenem
-KPC Early Tigecycline vs Polymyxin-Colistin

99
Duration of Therapy
-appropriate antibiotics should continue for at least the duration of
neutropenia (until ANC > 500 cells/mm3) or longer if clinically necessary
-If unexplained fever, continue until there are clear signs of marrow
recovery (ANC>500)
-If treatment course complete and all s/s of documented infection
resolved but still neutropenic can do oral FQ prophylaxis (Levofloxacin or
Ciprofloxacin) until marrow recovery
Note: Do not add/change antibiotics if temp is progressively
decreasing.
** No rectal exams, suppositories, or enemas in neutropenic pts due
to very high risk of infection. Also avoid NGT placement if possible**

2. Fever of Unknown Origin

Definitions:
1) Classic: Temp > 38.3 C (100.9 F) for > 3 weeks with evaluation of at least
3 outpatient visits or 3 days in hospital
(Common etiologies: infection, malignancy, collagen vascular ds)

2) Nosocomial: Temp > 38.3 C (100.9 F) and hospitalized for > 24 hrs but
no fever and not incubating on admission, evaluation for at least 3 days
(Common etiologies: C diff infection, drug induced, pulm embolism,
septic thrombophlebitis, sinusitis)

3) Neutropenic: Temp > 38.3 C (100.9 F), Neutrophil Count < 500, and
evaluation for at last 3 days
(Common etiologies: opportunistic bact infns, aspergillosis, candidiasis,
herpes)

4) HIV associated: Temp > 38.3 C (100.9 F), evaluated at least > 4 weeks
outpatient or >3 days inpatient, and HIV infection confirmed
(Common etiologies: CMV, MAC, PCP, drugs, Kaposis sarcoma, lymphoma)

100
Etiologies:
Infections: TB, Abscesses (Abdominal, Pelvic, Dental), Endocarditis,
Osteomyelitis, Sinusitis, CMV, EBV, HIV, Lyme disease, Prostatitis
Malignancies: Leukemia, Lymphoma, Metastatic Cancer, RCC, Colon
Cancer, Pancreatic Ca, Sarcomas, Hepatoma, MDS
Autoimmune: Adult Still's disease, PAN, PMR, Temporal arteritis, RA, IBD,
Reiter's syndrome, SLE, Vasculitides
Miscellaneous: Complications from cirrhosis, Factitious fever, Hepatitis
(alcoholic, granulomatous, or lupoid), DVT, Pulm Embolism, Sarcoidosis
Drugs: Allopurinol, Captopril, Cimetidine, Clofibrate, Erythromycin,
Heparin, Hydralazine, HCTZ, Isoniazid, Meperidine, MethylDopa,
Nifedipine, Nitrofurantoin, Penicillin, Phenytoin, Procainamide, Quinidine

Evaluation:
History: fever pattern, recent travel, exposure to pets/other animals, work
environment, sick contacts, family history (FMF), underlying conditions
(lymphoma, IBD, rheumatic disease), new medications
PE: thorough especially mucus membranes, skin, lymph nodes, chest,
abdomen, cardiac (new murmur), extremities (DVT)
Labs/Imaging: based on clues from history and physical examination
Preliminary Studies: CBC, BMP, LFTs, ESR, UA with micro, Urine Cultures,
Blood Cultures, CXR, Febrile Antibody Panel
Infections: US, CT A/P (abscess), sputum for AFB, HIV, EBV, CMV, ASO, TTE,
LP, Indium Labelled WBCs for occult infection, Tc 99, etc as indicated
Heme Malignancies: PBS, Electrophoresis, BM Bx
Nonheme Malignancies: CT, Mammogram, Endoscopy, Bone Scan, Gallium
Scan, MRI, Biopsies, PET, etc as indicated
AI: RF, ANA, Temporal Artery Bx, LN Bx
other tests as indicated

Management:
based on etiology

3. Infective Endocarditis
-suspected in patients with fever and a murmur
101
-esp patients with h/o IVDA or prosthetic valve
-acute = 3-10 days
-subacute = weeks-months

Etiologies:
Staph (esp MRSA, coagulase negative) in IVDA and prosthetic valves
Strep (esp viridans, if bovis then look for colon cancer)
Gram Negative Bacilli like culture negative HACEK: Haemophilus species
(Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus
paraphrophilus), Actinobacillus actinomycetemcomitans, Cardiobacterium
hominis, Eikenella corrodens, and Kingella species

Diagnosis: Dukes Criteria


2 major criteria or 1 major criteria and 3 minor criteria or 5 minor criteria
Major Criteria:
1) Blood Culture positive for IE
Typical organisms from 2 separate blood cultures: Strep viridans, Strep
bovis, HACEK, Staph aureus, or community acquired enterococci in the
absence of a primary focus or
Microorganisms consistent with IE from persistently positive blood
cultures defined as: at least 2 positive blood cultures drawn > 12 hrs apart
or all 3 or a majority of > 4 separate blood cultures or
Single positive blood culture for Coxiella burnetii or anti-phase 1 IgG Ab
titer > 1:800

2) Endocardial Involvement
Echo positive for IE (TEE for prosthetic valves, TTE for others) defined as:
oscillating intracardiac mass on valve or other supporting structures, in the
path of reguritant jets, or on implanted material in the absence of an
alternative anatomic explanation, or abscess, or new partial dehiscence of
prosthetic valve or new valvular regurgitation

Minor Criteria:
1) Predisposition, predisposing heart condition, or IVDA
2) Fever (temperature > 38 C)
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3) Vascular Phenomenon: major arterial emboli, septic pulmonary
infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival
hemorrhages, Janeway lesions
4) Immunological Phenomenon: glomerulonephritis, Oslers nodes,
Roths spots, and RF
5) Microbiological Evidence: positive blood culture but does not meet a
major criterion as noted above or serological evidence of active
infection with organism consistent with IE

History: IVDA, prosthetic valve, intracardiac device


PE: cardiac (murmur), fundus (Roths spots), extremities (Janeway lesions
and Oslers nodes)
Labs/Imaging: TTE, TEE, blood cultures x 3 from separate sites drawn at
least 1 hr apart, can repeat blood cultures and Echo if necessary

Management:
For full guidelines, see Circulation. Infective Endocarditis. AHA 2005.
Empiric Therapy: Vancomycin + Gentamicin/Tobramycin

Treatment:
Native Valve with Penicillin Susceptible Strep viridans or bovis:
Penicillin or Ceftriaxone alone x 4 wks or
Ceftriaxone/Penicillin + Gentamicin x 2 wks or
Vancomycin alone x 4 wks
Penicillin Resistant :
Penicillin/Ceftriaxone (4 wks) + Gentamicin (2 wks) or
Vancomcyin x 4 wks

Prosthetic Valve with Penicillin Susceptible Strep viridans or bovis:


Penicillin/Ceftriaxone (6 wks) +/- Gentamicin (2 wks) or
Vancomycin alone x 6 wks
Penicillin Resistant :
Penicillin/Ceftriaxone + Gentamicin (6 wks) or
Vancomycin alone x 6 wks
Native Valve with Oxacillin Sensitive Staph:
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Nafcillin/Oxacillin (6 wks) +/- Gentamicin (3-5 days) or
Cefazolin (6 wks) +/- Gentamicin (3-5 days) for penicillin allergic
patients
Oxacillin Resistant : Vancomycin x 6 wks
Prosthetic Valve with OSS:
Nafcillin (6 wks) + Rifampin (6 wks) + Gentamicin (2 wks)
--with ORS:
Vanc (6 wks) + Rifampin (6 wks) + Gentamicin (2 wks)
Native/Prosthetic Valve Enterococcal Infection:
Ampicillin/Penicillin + Gentamicin (4-6 wks) or
Vancomycin + Gentamicin (6 wks)
Gentamicin Resistance:
Ampicillin/Penicillin + Streptomycin (4-6 wks) or
Vancomycin + Streptomycin (6 wks)
Penicillin Resistance: Beta Lactamase producing:
Ampicillin/Vancomycin + Gentamicin (6 wks) or
Intrinsic Resistance:
Vancomycin + Gentamicin (6 wks)
Resistant to Penicillin/AG/Vancomycin:
Linezolid or
Quinupristin-Dalfopristin or
Imimpenem/Cilastatin + Ampicillin/Ceftriaxone + Ampicillin x 8 wks
Native/Prosthetic Valve HACEK infection:
Ceftriaxone/Ampicillin Sulbactam/Ciprofloxacin x 4 wks

Indications for Surgery:


CHF/ruptured valve or chordae tendinae
Prosthetic Valves
Fungal Endocarditis
Abscess
AV block
Recurrent emboli while on antibiotics

After Treatment: Get repeat blood cultures x 3, TTE, appropriate follow up


and physical examinations.
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Prophylaxis with Amoxicillin or Clindamycin/ Azithromycin/
Clarithromycin if:
Significant Cardiac Defect (prosthetic valve, previous endocarditis, cardiac
transplant recipient with valvulopathy, unrepaired cyanotic heart disease)
AND Risk of Bacteremia (dental work with blood, respiratory tract surgery
that produces bacteremia)

For further information, see the IDSA practice guidelines for Infective
Endocarditis.

4. Community Acquired MRSA

-All patients have a nasal swab done on arrival to the floor to check for
MRSA.
-If positive, contact precautions are started by Epidemiology.
-They enter a note in Affinity with recommendations of how to clear a
patient of MRSA.
-Recurrent MRSA: 2+ discrete MRSA infections in different sites over a 6
month period

Management of MRSA Infections:


Abscess/Furuncle/Carbuncle:
Incision and Drainage + Antibiotics if severe/extensive disease, s/s of
systemic illness, associated comorbidities/immunosuppression, extremes
of age, difficult to drain abscess completely, associated septic phlebitis, or
lack of response to I + D alone
Purulent Cellulitis:
Clindamycin/TMP-SMX/Doxycycline/Minocycline
Nonpurulent Cellulitis:
Cephalexin/Dicloxacillin/Clindamycin/Tetracycline/Linezolid/Amoxicillin+/-
TMP-SMX
Complicated Soft Tissue Infections:
Vancomycin/Linezolid/Daptomycin/Telavanacin/Clindamycin
Bacteremia: Vancomycin/Daptomycin
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Native Valve IE: Vancomycin/Daptomycin
Prosthetic Valve IE: Vancomycin + Gentamicin + Rifampin
Pneumonia: Vancomycin/Linezolid/Clindamycin
Osteomyelitis: Vancomycin/Daptomycin/Linezolid/Clindamycin/TMP-SMX
and Rifampin
Septic Arthritis: Vancomycin/Daptomycin/Linezolid/Clindamycin/TMP-
SMX
Meningitis: Vancomycin/Linezolid/TMP-SMX
Brain Abscess/Subdural Empyema/Spinal Epidural Abscess, Septic
Thrombosis or Cavernous or Dural Venous Sinus: Vancomycin/
Linezolid/TMP-SMX

For further information, please see the IDSA practice guidelines for MRSA
infections.

5. Community Acquired Pneumonia

CAP Definition: pneumonia (dyspnea, high fever, and often an abnormal


CXR) occurring before hospitalization or within 48 hrs of hospital
admission

HAP Definition: pneumonia after 48 hrs of hospital admission

VAP Definition: pneumonia within 48-72 hrs of being placed on a


ventilator

Healthcare Associated Pneumonia Definition: pneumonia in a patient in a


nursing home, HD center, or home health within the past 30 days or
hospitalization within the past 90 days

Etiology:
Strep pneumoniae - most common cause, including in HIV patients
H influenzae - COPD, smokers
Staph aureus - recent viral illness like influenza, Cystic Fibrosis pts, IVDA
Klebsiella pneumoniae - alcoholism, diabetes, currant jelly sputum
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Anaerobes - poor dentition, aspiration (alcoholics), foul smelling sputum
M. pneumoniae - young, healthy patients, may be a/w erythema
multiforme, dry cough, bullous myringits
C. pneumoniae - hoarseness of voice
Legionella - contaminated water sources such as air conditioning, GI or
CNS symptoms, hyponatremia, abnormal LFTs
C. psittaci - birds
C. burnetii - veterinarians, farmers
PCP now known as P. jirovecii - AIDS with CD4 < 200, elevated LDH
Atypical - mycoplasma, viruses, Coxiella, Pneumocystis, Chlamydia

Severity of Illness:

CURB-65 criteria: Confusion, Uremia (BUN>20), RR > 30, low BP (systolic <
90 or diastolic < 60), age > 65 years
Mortality: 0 (0.7%), 1 (2.1%), 2 (9.2%), 3 (14.5%), 4 (40%), 5 (57%)
If 0-1, treat as outpatient.
If 2, treat in wards.
If >3, often need to be treated in an ICU.

PORT Score:
See green book for more information.
Class 1 and 2: outpatient t/t
Class 3: observation or short hospitalization
Class 4/5: inpatient t/t

Severe CAP:
Minor Criteria: RR > 30, PaO2/FiO2 ratio < 250, multilobar infiltrates,
confusion/disorientation, BUN >20, WBC < 4000, Plt < 100,000, T < 36 C, or
Hypotension requiring aggressive fluid resuscitation
Major Criteria: Invasive Mech Ventilation, Septic Shock requiring pressors

Diagnosis:
History: recent travel, occupation, h/o influenza vaccine, h/o
pneumococcal vaccine, comorbidities, previous infections, etc.
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PE: RR, temperature, BP, pulmonary exam, mental status

Labs/Imaging/Procedures:
CBC - leukocytosis or leucopenia, CMP - elevated BUN, LFTs, Pulse Ox
severity, ABG severity, CXR, Sputum Gram Stain and Cx and AFB (if
suspected), Blood Cx, Legionella UAT, Pneumococcal UAT

Thoracentesis - if pleural effusion seen on CXR can get a lateral decubitus


XR to check for layering, empyema is exudative effusion with pH < 7.2
glucose < 60 and needs chest tube (Pulm or TMIS Consult) see Pulm
section re: Lights criteria

Lights Criteria: refer to pulm section

Management:
Outpatient:
1) No recent abx: Macrolide/Doxycycline
2) Recent Abx: Macrolide + High Dose Amox/Clav/2nd generation
Cephalosporin or Respiratory FQ alone (Levo, Gati, Moxi)

Hospitalized:
1) CAP: 3rd Gen Cephalosporin (Ceftriaxone) + Macrolide or Respiratory
FQ alone
2) CAP, ICU pt: 3rd Gen Cephalosporin/Amp-Sulbactam + Macrolide/FQ
3) Hospital Aqd and Risk of MDR organisms: antipseudomonal
PCN/Ceph/Carbapenem + FQ/(Gent + Azithro) + Vancomycin
4) Immunosuppressed: above + TMP-SMX +/- steroids
5) Aspiration: 3rd Gen Ceph/FQ +/- Clindamycin/Metronidazole
6) VAP: Antipseudomonal beta lactam + 2nd Antipseudomonal agent +
MRSA coverage

Empyema requires placement of a chest tube for drainage.


Specific treatment is based on organism and antibiotic sensitivities.

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Pneumococcal Vaccination for: everyone > 65 years age, chronic heart,
lung, liver, or kidney disease, functional/anatomic asplenia, heme
malignancy, immunosuppression (DM, alcoholic, CS, HIV/AIDS), CSF leak,
cochlear implant recipients

For additional information, please see IDSA practice guidelines for CAP.

6. Newly Diagnosed HIV


-Public Health notification
-Make sure all partners and children know that they could have HIV and
should be tested.
-Consider consulting ID if needed.

Labs to Obtain Upon Diagnosis:


-HIV ELISA and Western Blot
-CBC with Diff, CMP
-UA
-G-6-PD qualitative
-Hep Panel (Hep Bs Ag, Hep Bc Ab, Hep C Ab, Hep A Ab)
-RPR, if positive then FTA-ABS
-Fasting lipid profile
-Cellular immune profile (CD4-lymphocytes) x 2
-HIV-1 RNA load by PCR or branched-chain DNA x 2
-PPD, CXR PA and Lateral
-Toxoplasma gondii IgG Ab

Proper Use of HIV-Specific Laboratory Evaluations


HIV Viral Load
1. Possible acute retroviral syndrome to confirm diagnosis
2. Newly diagnosed HIV infection to establish baseline
3. Periodically to follow the course of HIV treatment (resistance)

HIV Resistance Assay


1. Prior to initiation of therapy when pre-existing antiretroviral drug
resistance is known or suspected - acute or chronic HIV infection.
109
2. During antiretroviral therapy after loss of virologic suppression (while
on antiretroviral drug therapy)

CD4-Lymphocyte Assay
1. Prior to initiation of therapy and periodically thereafter to evaluate the
indirect effects of virologic suppression and the need for opportunistic
infection antimicrobial prophylaxis.
2. At the time of intercurrent febrile illnesses to evaluate for the
possibility of opportunistic infection

Criteria for Initiation of Antiretroviral Therapy


1. Acute HIV infection or < 6 months since acute infection
2. Pregnancy in HIV-infected female
3. Any person with HIV infection who is ready to take antiretroviral
therapy
4. Symptomatic HIV or AIDS
5. HIV-infected partner in serodiscordant couple
4. Postexposure prophylaxis after body fluid exposure (healthcare
workers, emergency or disaster workers, rape victims and other
"voluntary" or involuntary sexual exposures)

Post Exposure Prophylaxis


-within 72 hours of exposure
-treatment for 28 days with 2-3 agents (Tenofovir + Emtricitabine +/-
Ritonavir)
-test for HIV as well as other blood borne infections and STDs
See NEJM 2009 article on post exposure prophylaxis for more information.

Opportunistic Infection Prophylaxis


CD4<250 = Coccidiodes, Fluconazole or Itraconazole
CD4<200 = P. jiroveci, TMP-SMX vs Dapsone vs Aerosolized Pentamidine
CD4<150 = Histoplasma if patient lives in endemic area, Itraconazole
CD4<100 = Toxoplasma, TMP-SMX vs Dapsone
CD4<50 = MAC, Azithromycin vs Clarithromycin

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7. Reportable Diseases
Please go to the following website for a list of reportable disease

http://www.cdph.ca.gov/HealthInfo/Documents/Reportable_Diseases_Co
nditions.pdf

8. Bacterial Classification

111
112
9. Fungi
Please see IDSA guidelines for the individual fungal infections to get
further information regarding treatment by organ involvement.

Aspergillus: affects lower resp tract, sinuses, skin by direct entry,-affects


CNS, CVS, other organs by hematogenous spread
Proven: histopathological documentation of infection (hyphae) + positive
culture from normally sterile site
Probable: host factors + s/s suggestive + microbiological evidence
Dx: culture, BAL, microscopic examination for hyphae, EIA test
Tx: Amphtericin B (Ambisome) or Voriconazole
Prophylaxis: See neutropenic fever section.

Candida: can affect any organ


-Risk Factors: broad spectrum antibacterial agents, use of central venous
catheters, parenteral nutrition, CRRT, neutropenia, implanted devices,
immunosuppresive agents
Dx: culture
Tx: usually Fluconazole, if oropharyngeal can use Clotrimazole or Nystatin
(call pharmacy for correct order)
Prophylaxis: See neutropenic fever section.

Coccidiodes: common to southern Arizona, central or southern California


(LA!), southern New Mexico, Texas
-can present as self limited CAP or more severe including extrapulmonaru
involvement
Dx: depending on organ involvement, can perform rapid test in serum
Tx: AMB vs Ketoconazole vs Fluconazole vs Itraconazole
Prophylaxis for solid organ transplant recipients and HIV patients with CD4
< 250 cells living in an endemic region -> use Fluconazole

Cryptococcus: Cryptococcus neoformans and gattii


Tx: HIV patient with meningoencephalitis = AMB + Flucytosine
-increased CSF pressure associated w increased morbidity and mortality

113
-Same for pulmonary disease and organ transplant patients with the
infection

Histoplasma: usually resolves within a month without therapy


-can affect lungs, heart, and causes of arthritis, arthralgia, and erythema
nodosum
Disseminated: does not improve within 3 wks, association with physical or
radiographic findings or lab evidence of extrapulmonary tissues
-May have hepatosplenomegaly, mucosal ulcers, skin lesions, GI
involvement, pancytopenia, elevated LFTs, increased LDH, increased
serum ferritin
Tx: indicated for moderate to severe pulmonary infections, CNS infections,
disseminated infections w/ Amphotericin B, Itraconazole
Prophylaxis = HIV patients with CD 4 < 150, use Itraconazole

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SECTION 13 GASTROENTEROLOGY/HEPATOLOGY

1. DIARRHEA
Acute Diarrhea(<4weeks)
History: Freq?, Blood?, Abd pain?, Duration?(about 1 week viral
and bacterial except C. diff), >1 week for parasitic, travel, food,
recent ABX, immunocompromised(CMV, MAI, Cryptosporidium,
Cyclospora, Isospora, Entamoeba histolytica)
Physical: Look for signs of volume depletion (VS, UOP, axillae, skin
turgor, MS) , Fever, abd tenderness, ileus, rash, appearance
(blood (inflammatory or invasive ulceration), mucus (IBS), or oil
(malabsorption))
Warning signs: sig pain(mesenteric ischemia), blood, pus, >6
stools/day, severe dehydration, immunosuppression, elderly,
duration >7d, hospital acquired
Labs: Stool cx, Blood cx, lytes, C. diff stool antigen(recent abx or
hospitalized), Stool O+P(if >10 days, travel to endemic areas,
exposure to unpurified water, outbreak, daycare, HIV+, MSM),
+stool ELISA(virus, crypto, giardia), serologies(E. histolytica), Stool
WBC not recommended as high false pos/neg
Imaging/EGD: CT/KUB if concern for toxic megacolon; flex sig/colo
if immunosuppressed or cx neg
TX: Generally self-limiting. Generally supportive if not severe, if
tolerating PO then oral rehydration is important, loperamide ok if
non-infectious or infectious w/treatment, IVF for severe
dehydration.
When to treat: abx rec for Shigella, cholera, C. diff, Giardia,
amebiasis, Salmonella if Pt > 50y old/ immunosupp./hospitalized
Empiric TX: Abx for non-hosp acquired inflammatory: 5-7 days
FQ
115
Consult considerations: GI(if initial workup negative), Endo(if
secretory), ID, Colorectal(toxic megacolon)

Chronic diarrhea(>4 weeks)


Etiologies
Meds (increased secretion, motility, cell death. inflammation, flora
changes, PPI, colchicine, abc, H2RA, SSRI, ARBs, NSAIDS, Chemo,
Caffeine
Osmotic: elevated stool osmol, no fecal fat, decreased with fasting
Lactose intolerance TX: lactose free diet, lactase supp.
Other: lactulose, laxatives, antacids, sorbitol, fructose
Malabsorption: elevated stool osmol, + fecal fat, decreased with
fasting
Celiac Dz:
S/S: Fe/Folate def anemia, osteoporosis, dermatitis
herpetiformis(pruritic papulovesicular), increased ALT/AST
Dx: IgA-tTG, Anti-endomysial Ab (more expensive, can resolve
after tx), Gold standard biopsy WITH response to diet.
Rx: Gluten free diet(if no reponse(noncompliance vs wrong dx).
Complications: 5% refractory, risk of T-cell lymphoma, sm. bowel
AC

Whipples Disease: infx w/ T. Whipplei


Cardinal Sxs: Abdominal pain, diarrhea, weight loss,
arthralgias(migratory)
disseminated dz with CNS/Cardiac sx/sx possible
Dx: Always r/o hyperthyroidism, connective tissue dz, IBS w/
migratory polyarthropathy, AIDS
Endoscopy with bx and PAS-positive macrophages is gold
standard

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Tx: (PCN streptomycin) or 3rd-gen ceph x 1014 d>> Bactrim for >
1 y, for disseminated dz reference current guidelines

Bacterial overgrowth: small intestinal bacteria from


incompetent/absent ileocecal valve, s/p RYGB, scleroderma,
diabetes, s/p vagotomy >> fat & CHO malabsorption.
Dx: 14C-xylose & H+ breath tests; Rx: cycled abx (eg, MNZ, FQ,
rifaximin)
Pancreatic insufficiency: most commonly from chronic pancreatitis or
pancreatic cancer
Decreased bile acids due to decreased synthesis (cirrhosis) or
cholestasis (PBC) >> malabsorption
Other: s/p short bowel resection (short bowel syndrome), Crohns
disease, chronic mesenteric ischemia, eosinophilic gastroenteritis,
intestinal lymphoma, tropical sprue, Laxative use, neoplasm,
decreased bile acid resorption s/p ileal resection/Chrons
lymphocytinc colitis, collagenous colitis(often a/w meds like NSAIDS)
Inflamatory: (+) Stool WBC or lactoferrin or calprotectin, (+) FOBT,
fever, abd pain). Causes: parasitic, CMV, TB. Radiation enteritis,
ischemic colitis, neoplasia(colon cancer/lymphoma)
Secretory: normal osmotic gap, no decrease in diarrhea w/ NPO, often
nocturnal.
Hormonal: VIP(VIPoma), Serotonin(carcinoid), thyroxine,
calcitonin(medullary cancer of thyroid), gastrin(Zollinger-ellison),
glucagon, substance P
Irritable bowel syndrome: Rx is symptom guided
Rome III criteria: recurrent abd pain >/= 3d/mo over 3 months plus
>/= 2 of the following: 1. improvement with defecation 2. onset
w/change of stool freq 3. onset w/change in form of stool

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2. Clostridium difficile Spectrum: Colonization to Fulminant
colitis
Manifestations:
Asx colonization (3% healthy adults/~20% in-PT on ABX)
Si/Sx: Acute watery diarrhea: poss. w/ blood, mucus, lower abd pain,
fever, classically very high WBC
Psuedomembranous colitis: In addition to above complaints,
pseudomembranes on scope and bowel wall thickening.
Fulminant Colitis (2-3%): toxic megacolon(colon dilatation >/=6cm
on KUB, colonic atony, systemic toxicity) and/or perf
Dx: Presence of bacteria: Many tests available, at LAC order C. diff
stool toxin or C. diff stool antigen and Illumigene LAMP
assay(newer than EIA/PCR) for C diff toxin is performed Se/Sn 95%,
~24hr turnaround,detects ToxinA+B+ and Toxin A+B-.
** If high suspicion with no diarrhea, ask nurse to mix sample with
water, as diarrhea may not always be present**
Flex sig if dx uncertain or no improvement with standard Tx
Tx: Everyone: Contact precautions,1:1 equipment, d/c abx if possible,
stop antimotility agents(unless on targeted ABX already)
Mild (<6 BM/d, temp <101F, WBC <15 k, no peritoneal sx or SIRS,
and age <65 y)
Rx: MNZ 500 mg PO tid x 1014 d; IV equal efficacy, use if poor PO or
ileus
Moderate (612 BM/d, temp 101103F, WBC 1525 k, visible LGIB,
or age >65 y)
Rx: vanco 125500 mg PO qid 1014 d; add MNZ 500 IV tid if not
improved by 48 h
Severe (>12 BM/d, temp >103F, WBC >25k, increased abd pain,
sepsis, or no bowel sounds)

118
Rx: vanco PO + MNZ IV; PR vancomycin available if ileus, though
avoid if evidence of toxic megacolon; ? tigecycline (CID
2009;48:1732);Ab CT, urgent surgery consult re: colectomy; consider
IVIG
If patient requires continuation of original ABX, continue c diff abx
for 7+ days after ABX cessation
Stool carriage can be positive 3-6 wk post tx and sx resolution, do not
re-treat

3. Constipation: common problem with many etiologies


Causes:
Functional: normal transit, slow transit, pelvic floor dysfunction,
constipation-predom IBS
Meds: opioids, anticholinergics (TCAs & antipsychotics), Fe, CCB,
diuretics, NSAIDs
Obstruction: cancer, stricture, rectocele, anal stenosis, extrinsic
compression
Metabolic/endo: DM, hypothyroid, uremia, preg, panhypopit,
porphyria, increased Ca, decreased K, decreased Mg
Neuro: Parkinsons, Hirschsprungs, amyloid, MS, spinal injury,
autonomic neuropathy
Dx: History/Physical w/ DRE, cbc, electrolytes, TSH. Colo for alarm
sxs: weight loss, +FOBT, fevers, FHx of IBD/colon cancer.
Sigmoidoscopy if no alarm sxs and <50yrs
Tx: Always write hold for diarrhea
1st Bulk laxatives, then Osmotics/Stimulants, then suppositories
/enemas
PPX for opiod use/extended bed rest
Bulk laxitives: Psyllium fiber 3.4g in 4-6oz h20/juice qdaily to QID
Osmotics: Monitor electrolytes while in use, caution with
CKD(mag/phos containing agents)

119
Miralax 17g in 4-8oz h20, Mag-citrate, lactulose 15-60cc qdaily to
QID
Stimulants: Senna 1-2 tab qdaily/BID; Biscodyl 5-15mg PO qdaily OR
10mg PR qdaily
Enemas: for refractory cases, tap water(500cc-1000cc), soapsuds,
mineral oil(fleets mineral oil),Lactulose(300ml lactulose in 700cc
h20/NS)

4. GI Bleeding (anywhere between mouth and anus)


UPPER: above ligament of Trietz,
UGIB>LGIB: N/V, hematemesis, coffee-ground emesis, epigastric
pain, vasovagal, melena, hematochezia(brisk bleed) UGIB DDX: PUD,
Varices, Gastritis/gastropathy/duodenitis,
Erosive esophagitis/ulcer, Mallory-Weiss tear, Vascular lesions,
neoplasm, OP bleed/epistaxis

LOWER: below ligament of Trietz


LGIB >UGIB: diarrhea, tenesmus, BRBPR, hematochezia
LGIB DDX: Diverticular disease (60% bleeds on right), neoplastic
disease, colitis (infectious, ischemic,radiation, IBD(UC>>CD),
angiodysplasia (More common ascending colon/cecum), anorectal,
vasculitis
Managment/Tx:
Assess severity: tachycardia(10%l loss),(+) orthostatics(20% loss),
shock(>30%loss)
IVF with NS or LR till normal VS, UOP, MS
Serial CBC(q6 or q8), can collect in pediatric tubes to minimize
iatrogenic blood loss
Transfuse to targ 25-30 HCT, FFP and Vit K to fix PT, plt>50k
Transfer to ICU if unstable with e/o end organ effect for intubation
and emergent endoscopy, consult GI immediately

120
If non-emergent with stable h/h,(+) FOBT, no melena /hematochezia,
no co-morbid dz, stable VS>>consult GI for outpatient EGD/Colo

5. Helicobacter pylori
Who to test: Patients with gastric MALT lymphoma, active peptic
ulcer disease, or a past history of documented peptic ulcer
Indications: Uninvestigated dyspepsia who are under the age of 55
years and have no "alarm features" (bleeding, anemia, early satiety,
unexplained weight loss, progressive dysphagia, odynophagia,
recurrent vomiting, family history of GI cancer, previous
esophagogastric malignancy)
Other indications: Immune thrombocytopenia, unexplained Fe def.
anemia, unexplained B12 def.
Dx: H Pylori stool antigen: has high Se/Sp, make sure to test after 2
weeks PPI free to minimize false neg, H2RA is ok to give in interm.
Serum Ab: Not recc. as it cant differentiate between current and past
infection. Biopsy proven on EGD.
Urea breath test: not routinely done at LAC
Tx:
Triple Tx (Clarith 500 bid + Amox 1 g bid OR MNZ 500mg BID + PPI
bid for 1014 d)
Quad Tx: (MNZ 250mg QID + TCN 375mg QID + Bismuth
subsalicylate 525mg QID + PPI bid (H. pylori resist to clarith or
amox allergy)
Confirm Eradication: with stool antigen a minimum of 4-6 weeks
after tx and off PPI

6. PPI use:
Always think about why you are starting PPI
Inpatient indications: continued tx of dyspepsia/GERD
Inpatient Stress ulcer prevention

121
Level 1: ventilated, coagulopathy, traumatic brain injury, major burns
Level 2: Multi-trauma, sepsis, Acute renal failure
Level 3: High dose steroids(>hydrocortisone 250mg or
equivalent/day)
Potential side effects: increased riskof- C. diff, CAP/HAP,
hypergastrinemia, gastric atrophy, chronic hypochlorhydria,
fractures, hypomagnesemia, iron/b12 malabs., plavix interaction

7. Colonoscopy Preparation
Start clear liquid diet till 6pm on night before, NPO after 6pm
and start Go-Lytley
Go-Lytley 4L, 8oz PO q10 minutes. Can expect first BM in about
1 hour after starting and loose BM 1-2 hours after finishing 4L.
If not clear, give additional 2L and cont to eval.

8. Inflammatory Bowel Diseases


Ulcerative colitis: inflammation of colonic mucosa
Si/Sx: Grossly bloody diarrhea, lower abd cramps, urgency, tenesmus

Severe colitis (15%): progresses over 1-2 weeks, dropping Hct,


elevated ESR, fever, hypotension, >6BM/d, distended abdomen
with absent bowel sounds

Extracolonic(>25%): erythema nodosum(inflamation of fat under


skin/tender nodules), pyoderma gangrenosum(necrotic ulcers),
aphthous ulcers, uveitis, episcleritis, thromboembolic events(esp
during flares), AIHA, seroneg arthritis, chronic hepatitis, cirrhosis,
PSC(increased risk of cholangio)
Dx: Colonscopy- granular, friable mucosaw/ diffuse ulceration,
pseudopolyps

122
Complications: Toxic Megacolon in 5%, treat with IV steroids and
broad-spectrum ABX, surgery if no improvement 48-72hrs(Consult
colo-rectal)
Tx: Acute flare- Consult GI
Mild disease (</=4BM/d w/o systemic tox): 5-ASA, PR if distal to
splenic flexure, PO if more extensive involvement: 2.4-4.8g/d
Moderate disease (</=6BM/d w/minimal systemic tox: PO
prednisone, IV prednisone for severe
Anti-TNF-alpha: for severe flare unresponsive to steroids
CsA (cyclosporine): severe flare: 2mg/kg infusion x 24h, check mag.,
avoid in low cholesterol due to decreased seizure thres.
Surgery: J pouch anal anastamosis, can dev. pouchitis(6%)>>tx
abx/probiotics

Crohns Dz: transmural inflammation of GI tract, skip lesions and can


involve any portion
"a fat granny and an old crone skipping down a cobblestone road
away from the TransAM wreck".

Sx/Sx: Mucus containing, not grossly bloody diarrhea, n/v, bloating.


Slowly progressive disease with abd pain, fevers, malaise, wt loss
Look for: Decreased albumin, elevated ESR/CRP, decreased HCT(due
to Fe,B12 def,folate def AND chronic inflamation)
Dx: EGD/Colo- non-friable lesions, cobblestoning, aphthous ulcers,
deep and long fissures, Micro-transmural inflammation with
mononuclear cell infiltrate, noncaseating granulomas(seen 25%),
fibrosis, ulcers fissures, rectal sparing
Complications: Perianal diseas(fissures,fistulas,abscesses), strictures,
fistulas, abscess

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Malabsorption sequelae 2/2 illeal diseases(gallstones, decrease fatty
acid absorption leading to Ca oxalate kidney stones, fat soluble vit
def)
Tx: Acute Flare - Consult GI
Abx: FQ/MNZ or amox/clav best for perianal disease
Steroids:
Mild disease (tolerating PO), can use budesonide w/ileal disease
(first pass metabolism limits systemic adverse effects).
Mod disease (wt loss, abd pain, nausea, anemia): PO Prednisone.
Severe disease (fever, obstruction, cachexia): IV pred 1mg/kg
Anti-TNF-alpha: Same indications as for UC although earlier use
may be better, Infliximab vs Adalimumab vs Certolizumab
Surgery: Diverting ileostomy, good for perianal disease

9. Acute Pancreatitis
Etiology: Gallstones (40%), Alcohol(30%), Drugs(furosemide,
thiazides, sulfa, DDI, asparaginase, estrogen, 6-MP/AZA, ACEI,
dapsone, 5-ASA, valproic acid), Obstructive, Metabolic(Hyper TG-
needs to be >1000 and usually~4500 and seen in familial hyperTG,
hypercalcemia), Infections, AI, Ischemia, Post ERCP(5% w/ sxs, 35-
70% asx with elevated amylase), Post trauma, Familial(PRSSI, CFTR,
SPINK I genes), scorpion sting
Si/Sx: abdominal pain +/- radiating to back, constant, some relief
leaning forward, N/V, abd ttp/guarding, decr. bowel sounds, +/-
palpable abd mass, +/- jaundice if biliary obs. Retroperitoneal
hemorrhage (Cullens-Periumbilical, Grey Turners-Flank). Fever,
tachycardia, hypotension, +/- shock
Dx Labs: Lipase more specific, amylase elevated x 3 ULN(not as sp as
lipase), ALT>3 x ULN suggests gallstone panc. Other: elevated wbc,
incr/decr HCT, incr BUN, decr Ca, incr Glc

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Imaging: KUB/CXR for sentinel loop air in small bowel in LUQ,
atelectasis, effusion Abd CT: Not required but TEST OF CHOICE.
Consider f/u CT w/IV contrast 3 days to eval for necrosis (avoid early
due to incr risk of necrosis with IV contrast)
Recommended for patients with Severe AP based on clinical criteria
or APACHE II score to determine if nec. panc. present.
Abd u/s: generally poor at viewing pancreas, however good at
assessing for biliary pathology(gallstones, BD dilitation)
MRI/MRCP: can detect necrosis, used to assess for stones and ductal
disruption
Tx: Supportive in mild cases, bowel rest generally enough
Fluids: be aggressive, in severe cases upwards of 10L/d may be
needed
Nutrition: PO better than TPNif NPO>7d; decr infectious compl.
and dz severity.
Analgesia: Meperidine difficult at LAC, morphine with theoretical
oddi spasm(has been used regularly anecdotally without
problems), Dilaudid a good option
ABX in severe panc: literature inconclusive regarding PPX as
mortality may not change, however ABX(carbapenems) should def
be started in patients with severe cases and e/o >30% necrotic
pancreas on CT
Surgery: infected necrosis nearly always requires debridement.
Improved out comes by delaying (if possible) surgery ~2 wks to
allow organization of necrosis. Cholecystectomy if gallstones (w/in
48 h if mild, o/w w/in 14 d
ERCP + sphincterotomy: in acute setting, reserved for severe
cholangitis/sepsis and T Bili>5(presumed obstructive).
Prognosis: Multiple scoring systems, calculators available on Qx
Calculate for iphone/android systems. These calculators are more

125
useful for triaging patients into categories of ICU requiring more
aggressive care vs patients that may not require this stratification
and subsequent monitoring for complications. Not routinely used for
stable cases. Calculators can also guide imaging in severe cases.
Complications:
Systemic: shock, ARDS, renalfailure, GI hemorrhage, DIC
Metabolic: hypocalcemia, hyperglycemia, hypertriglyceridemia
Acute fluid collection (3050%): seen early, no capsule, no Rx
required
Pseudocyst (1020%): fluid collection, persists for 46 wks,
encapsulated suggested by persistent pain & elevation of amylase
or lipase, or mass on exam most resolve spont.; if >6 cm or
persists >6 wks + pain >>endo/perc/surg drainage
Sterile pancreatic necrosis (20%): area of nonviable pancreatic
tissue
Infection (5% of all cases, 30% of severe): usually 2/2 enteric GNR
infected pancreatic necrosis: fever & c WBC not specific; FNA in
deteriorating Pt w/ necrosis (small risk of seeding sterile necrosis);
if gram stain/cx (+) >>abx + evacuation (percutaneously, followed
by surgical debridement after 4 wks
pancreatic abscess: circumscribed collection of pus (usually w/o
pancreatic tissue) treat with abx + drainage (CT-guided if
possible), usually seen >/=4 wks into course
Ascites or pleural effusion: occurs due to disrupted pancreatic
duct; consider early ERCP w/ stent across duct; can also occur
from draining pseudocyst

10. Acute Hepatitis (Viral)- If suspecting order Hepatitis panel,


ACUTE(includes Hep A IgM, Hep B surface Ag, Hep B Core Ag IgM,
Hep C virus Ab), TAT is 48 hours at LAC

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Hepatitis A(ssRNA, 30-45% of cases, no chronic carrier state)
Etiology: Fecal-oral, contaminated food, water, shellfish, day-care
Incub: 2-6 weeks
Sx: Diarrhea, decreased appetite, malaise, fever, n.v, RUQ pain,+/-
jaundice,rarely fulminant
Dx: Anti-Hep A IgM (+), Hep A IgG(+) with (-) IgM =Past exposure
Tx: supportive. Vaccinate people with chronic HBV, HCV or other
chronic liver dz
Post exposure ppx: age 1-40>>vaccinate,<1 or >40 or immunosupp
>> IgG

Hepatitis B (dsDNA, acute or chronic, 45% of cases)


Etiology: Blood, sexual, perninatal(vertical, very common in those
emigrated from Asia)
Incub: 6wk-6month(avg 12-14 wk)
Acute infxn: 70% sub-clinical, 30% jaundice, <1% fulminant
Chronic infxn: <5%(adult acquired), >90% (perninatal acquired); 40%
chronic carriers progress to cirrhosis, increased risk of cirrhosis with
concomiant infxn of other hepatitis viruses
Dx: Serologic and virologic tests
HBsAg: appears before sx; used to screen blood donors; persists >6
mo = chronic
HBV HBeAg: evidence of viral replication and incr. infectivity
IgM anti-HBc: first Ab to appear; indicates acute infection
Window period = HBsAg become (-), anti-HBs not yet (+), anti-HBc
only clue to infection
IgG anti-HBc: indicates previous (HBsAg (-)) or ongoing (HBsAg (+))
HBV infection
anti-HBe: indicates waning viral replication, decr. infectivity
anti-HBs: indicates resolution of acute disease & immunity (sole
marker after vac)

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HBV DNA: presence in serum correlates w/ active viral replication in
liver
Tx: for ACUTE: supportive, hospitalize for change in MS or elevated
INR(indications of possible acute liver failure and need for
transplant)

Hepatitis C (RNA, 10-30% of cases)


Etiology: Blood>>sexual, 20% w/o clear cause
Incub: 1-5 mos(avg 6-7wk)
Acute infxn: 80% subclinical, 10-30% symptomatic hepatitis w/
jaundice; fulminant rare, spontaneous resolution 30%
Chronic infxn: up to 80% progress to chronic, 20-30% women dev.
cirrhosis after 20 years, increased risk of cirrhosis in men, EtOH, HIV,
HCC in 2-5% cirrhosis
Extrahepatic syndromes: Cryoglobulinemia(this is not cold agglutinin
dz), porphyria cutanea tarda(blistering rash in sun exposed area),
MPGN, MGUS, IPF, NHL, DM
Serologic and virologic tests: Anti-HCV (ELISA): (+) in 6 wks, does not
= recovery or immunity; can be (-) after recovery
HCV RNA: (+) w/in 2 wks, marker of active infection
HCV RIBA: used to confirm (+) anti-HCV ELISA in Pts w/ undetectable
HCV RNA
HCV genotype (14): guides duration & predicts response to Rx
(genotype 2,3 > 1,4)
Diagnosis: acute hepatitis = (+) HCV RNA, +/- anti-HCV
resolved hepatitis = (-)HCV RNA, +/- anti-HCV
chronic hepatitis = (+)HCV RNA, (+) anti-HCV
Tx ACUTE: if no spont clearance at 812 wks, consider PEG-IFN-
alpha-2a/b x 1224 wks

11. Alcoholic Hepatitis: if high on the differential, Consult Liver


Etiology: GIB, chronic HBV, sepsis
Sx: can range from asx hepatomegaly(possible bruit) to
decompensation w/ascites, encephalopathy, and death. AST + ALT

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usually <300-500 w/ AST:ALT > 2:1, in part b/c concominant B6
deficiency(ALT can be normal); decr platelets, incr iron sat, incrd
Tbili, and INR indicate severe hepatitis
Note: patients can develop severe elevations in LFTs from alcoholic
cholestatic disease and will be seen in elevations of alk phos(THIS IS
NOT alcohol hepatitis)
Rx: Calculate Discriminant fxn(=4.6 x(PT-control[13.9 @ LAC] + Tb in
mg/dl), if >32 or encephalopathy>> methylprednisolone(does not
have to be metabolized by liver like prednisone) 32mg/d x 4 weeks
then 4-6 week taper
Pentoxifyline 400mg TID decreases mortality due to reduction in HRS
F/u: Lille model predicts nonresponse to steroids + mortality,
powered by change in Tbili from day 1>>7; non-responders have 6-
mo survival of 25% (http://www.lillemodel.com)

12. Acetaminophen Toxicity


Usually metabolized via glucuronidation and sulfation >>nontoxic
metabolites
OD usually >10g, which causes accessory CYPE2E1 hydroxilation
>>reactive electrophilic species that are scavenged by glutathione
until supply exhausted >>hepatotoxicity
CYP2E1 is induced by fasting and alcohol, so malnourished alcoholics
more predisposed to hepatoxicity by acetaminophen at lower doses
(2-6g)
May take 2-6 days to see liver dysfunction
Rx: NG lavage, activated charcoal w/in 4 hours, low threshold to start
even if serum acetaminophen level low/undetectable
NAC (n-acetylcysteine): can give up to 72 hours after ingestion, if
time of ingestion unknown or if chronic ingestion >4g/day

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PO NAC: Start 140mg/kg PO/NG x1 ASAP if <24h. Then 70mg/kg PO
q4h x 17 doses.
IV NAC: 150mg/kg over 1h>>50mg/kg over 4h>>100mg/kg over 16h;
risk of anaphylaxis; only use if unable to tolerate PO, GIB, pregnant,
fulminant liver failure
Rumack-Matthew nomogram - predicts risk of hepatoxicity based on
amount and time of ingestion

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13. Chronic (and Subacute) Hepatitis & ESLD
Hepatitis B:
Treat if: (1) HBeAg (+) w/ DNA >20,000 IU/mL & elevated ALT; (2)
HBeAg (-) w/ DNA >2,000 IU/mL & elevated ALT or liver bx
demonstrates stage >/= 2 fibrosis
PEG-IFN2a: best rate of HBeAg seroconversion at 1y(27%), low
tolerability limits use, in patients suffering depressive symptoms
while on therapy or those who could not tolerate due to depressive
SE, can start SSRI and re-try if patient willing
** Requires patients abstain from alcohol for at least 6 months prior
and during therapy** order baseline TSH

Tx: 1st line is entecavir or tenofovir; well-tolerated & low resistance,


HBeAg sero-conversion at 1 yr is 21%; seroconversion at 3 y for
entecavir is 39%; lamivudine 1530% resis at 1 y; telbivudine
increases CK & neuropathy; adefovir (add to lamivudine- resistant
Pts) nephrotoxic & resistance occurs, too)
Goal: if HBeAg (+) >> HBeAg (-), anti-HBe (-); if HBeAg (-) or
seroconversion>>indefinite
HIV/HBV coinfection: Rx w/ 2 drugs active against both HBV & HIV
DO NOT GIVE TENOFOVIR MONOTHERAPY IF HIV (+), thus order HIV
test in all Hepatitis patient when considering treatment
If inactive carrier scheduled to receive immunosuppresion
/chemotherapy >> Rx
Prevention: vaccinate high-risk Pts (3 doses 0, 1 & 6 mos)
Postexposure (risk infxn~30%)ppx: HBIG vaccine(if unvac. or known
non responder)

Hepatitis C:
Chronic: RNA (+), plus bx w/ either chronic hepatitis & fibrosis stage
>1 or compensated liver disease (in genotype 2 or 3, may proceed to
Rx w/o bx b/c high response rate)

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Drugs: PEG-IFN-alpha-2a + ribavirin. Goal is sustained virologic
response (SVR) = absence of viremia 24 wks after completion of Rx.
Protease inhibitors(telaprivir/boceprevir) in addition AKA Triple
therapy are not available at LAC, but are more effective
Genotypes 1 or 4: Rx 48 wks. If early vir resp (EVR) not achieved by
wk 12 (ie, RNA decr. <2 log) stop Rx, as EVR best predictor of lack of
SVR. If partial EVR (RNA decr. >/=2 log at 12 wks & undetectable at
24 wks), consider prolonging Rx to 72 wks. Overall SVR rate 5060%.
Genotypes 2 or 3: Rx 24 wks; SVR rate ~80%
Predictors of response: RNA <400k IU/mL, rapid vir resp (RNA at wk
4), cirrhosis, female, age <40 y, wt <75 kg, white/Hispanic, HIV, SNPs
in IL28B
Risks of Rx: flu-like sx, psych sx (if depressed can give SSRI), thyroid
dysfxn, marrow suppression (can give EPO & GCSF), hemolysis
(ribavirin), sexual dysfxn
Contraindication: decompensated cirrhosis, preg., severe
psychillness,active substance abuse, severe cardiac/pulm disease,
uncontrolled DM, seizure d/o, autoimmune disease
Vaccinate all chronic HCV patients against HBV and HAV if not
immune Post exposure (needle stick risk~3%)ppx: none;if HCV
RNA>>(+), consider Rx w/in 3mos

14. Liver Transplant


Not done at LAC-USC, however on occasion we have patients that
have that are s/p transplant.
When these patients come in, it is very important to contact the
transplant medicine physician managing the patient(often at an
outside institution) and discuss the case and current reason for
admission. Ensure med-list is accurate and most importantly
ensure all the medications are available through in-patient
pharmacy. If a certain transplant medication is not avaliable,
check to see if patient has this medication with them or have

132
them bring it from home and then write an order for: OK to
administer patients home medication XXXXX XX mg Qfrequency
Make sure medications that are given for in-patient indication do
not react with transplant medications
If patient pending surgery, stress dose steroids may be necessary,
can discuss with inpatient consult team or call outpatient
transplant medicine physician as steroid dose may have recently
changed, etc.

15. Ascites & SBP


Ascites: Calculate SAAG

Can order U/S for marking if bed-side U/S cannot locate or volume
is small. U/S can detect >100ml fluid.
Perform paracentesis in all new-onset ascites and consider in all
decompensated cirrhotics:

133
Routine: Cell count with diff + Gram stain, Culture, Albumin, Total
protein,
Other tests: fungal cx(prolonged hospital stay), AFB+ADA(r/o TB),
amylase(pancreatitis, gut perf), TG(chylous ascites), Cytology(if
suspect malginancy or peritoneal carcinomatosis), LDH, glucose,
CEA, Alk phos(perf)
Tx:
If 2/2 to portal HTN:
Decr. Na intake and start diuretics: Usually start Lasix and
Spironolactone in a 40mg:100mg ratio(least potassium
abnormalities with this ratio) once daily dosing, Can start lower
at 20mg/50mg if Cr a concern.
MAX: Lasix 160mg/Spironolactone 400mg.
Serial LVP (large volume paracentesis); albumin replacement
after large volume paracenteses if > 4-5 L are removed; 6-8 g/L
of albumin (25% concentration) should be given
Refractory cases may benefit from TIPS (Quality of life improvements
over serial LVP, however can increase HE but not an absolute CI to
procedure)
For non portal HTN: tx underlying cause
Bacterial Peritonitis: Presents with abd pain, fever, encephalopathy,
25% Asymptomatic

134
SBP/CNNA: seen in cirrhosis
Risk factors: AFTP<1g/dl, h/o SBP, current GIB (translocation)
Tx: cefotaxime 2gm IV q8h (oramox/clav) X 5d
If not improving can r/p para at 48 hrs, if PMN 25% less = Rx sucess
PPX: h/o SBP or AFTP<1.5 + Na<130, Cr >1.2 or Childs B
Can use Bactrim DS Qdaily, norflox not available at LAC
NNBA: often resolves w/o tx; Tx only if with symptoms or persistent
(+) cx
Secondary: abscess or perf
ascitic fluid TP >1 g/dL, glc <50 mg/dL, LDH >225 U, CEA >5, Alk phos
>240
Rx: 3rd gen cephalosporin + MNZ, urgent abd. imaging
Periotneal dialysis associated: Cloudy fluid, abd pain, fevers, nausea
Pathogens: 70% GPC, 30% GNR; Rx: vanc + gent(IV load then
administer directly through PD Cath)

16. Hepatorenal Syndrome


Vascular phenomenon with vasoconstriction in kidneys and
vasodilation in sphlancnic circulation that leads to progressive renal
insufficiency and azotemia (Cr> 1.5 or >1.5 x base) despite volume
challenge with Albumin 1mg/kg/d x 2 d and exclusion of other
causes (drugs, ATN, obstruction)
Type 1: doubling of the serum creatinine level to more than 2.5
mg/dl (221mol/liter) in less than 2 weeks; occurs in severe liver
failure
Type 2: is characterized by a stable or less rapidly progressive
course than in type 1.
Both a/w ascites (usually h/o refractory ascites), oliguria, UNa <10
mEq/L and decreased Na
Even if on furosemide, Urine Na <10 can still help as despite diuretics
urine Na is unexpectedly low
Etiology: GIB, over diuresis, infection, paracentesis, drugs
(aminoglycosides/NSAID)

135
Tx: octreotide(200mcg SC tid) + midodrine(12.5mg PO tid) + albumin
Mortality is high, higher for Type I vs. Type 2, if transplant possible
then kidney function returns generally as there is no intrinsic renal
pathology, however this is generally not an option for LAC patients
with few exceptions

17. Cancer Screening


Risk in UC ~2% at 10y,~8% at 20y,~18% at 30y. Similar for colonic CD,
except risk of small bowel cancer as well. Dysplasia best marker for
risk. Other risk factors include: PSC, (+)FHx, greater extent of disease,
stricture, & pseudopolyps.
Colo with random bx 8 years after dx, then q1-3 years based on risk
factors
If high grade dysplasia or dysplasia a/w mass>>colectomy,
Chemoprophylaxis: 5-ASA & ursodeoxycholic acid (if PSC) beneficial.

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SECTION 14: HEMATOLOGY/ONCOLOGY
for more in depth discussion, see Hematology Survival Guide

1. ANEMIA:
Hct < 36% in , < 40% in ; Fe-def most common cause
General workup: Ferritin, Iron Panel, B12, folate, retic count,
peripheral blood smear

Microcytic (MCV < 80):


Fe deficiency anemia: ferritin (<30 is 98% specific for Fe def [Am J
Clin Pathol 2001;115(1):112-118]; in cases of acute
infxn/inflammation, divide ferritin by 3 since it is an acute phase
reactant), % sat, TIBC, Transferrin, RDW . sTfR (Serum
Transferrin Receptor) concentration is in Fe-def anemia but not
ACD. Check fecal occult blood, consider colonoscopy to f/u on
positive FOBT and/or to r/o occult CA, EGD for occult UGIB.
Anemia of Chronic disease (ACD): ferritin, % sat, TIBC,
Transferrin.
Thalassemia: Normal iron studies, very low MCV (<70), Mentzner
Index MCV/RBC count <13, Hb electrophoresis w/ HbA2 in -thal &
normal in -thal, normal RDW
Sideroblastic anemia: Fe accumulates in mitochondria & not in
Heme. May be X-linked, idiopathic/myelodysplastic, or reversible
(lead, INH, Cu & Zn toxicity, EtOH). Typically microcytic. Iron studies
are a mixture between Fe-def & ACD (nl or Transferrin, TIBC &
Ferritin). Note: in EtOH-related sideroblastic anemia, there may be
RDW normocytic anemia b/o concomitant macrocytosis due to EtOH
itself +/- Vit deficiencies. May need BMBx.
Lead poisoning: Look for basophilic stippling on smear; H&P.

137
Normocytic (MCV 80 100):
blood loss, hemolysis, low producton. Initial workup should focus on
reticulocyte count, creatinine, hemolysis labs ( LDH,
haptoglobin, indirect Bili, (+) direct coombs), and blood smear.
Normal Reticulocyte count: Anemia of chronic dz: Esp. in renal
(burr cells), liver, thyroid disease
reticulocyte count + normal hemolysis labs: Hemorrhage,
Iron deficiency (mild to moderate, if severe, should be microcytic),
Mixed microcytic/macrocytic anemia, will see elevated RDW
High reticulocyte count with (+) hemolysis labs:
o G-6PD deficiency, sickle cell, autoimmune, druginduced,
microangiopathic (DIC, HUS, TTP, prosthetic valve, etc.),
PNH, hereditary spherocytosis, hypersplenism, or
infection (malaria, babesiosis).
** Note: To determine if retic count appropriate for degree of
anemia, calculate retic index:
Reticulocyte Index = Retic count x Hct/45
> 2% indicates increased destruction or loss of erythrocytes
< 2% indicates decreased production of erythrocytes

Additional causes of normocytic anemia:


Pancytopenias: Seen in systemic dz (EtOH, sepsis,
hypersplenism), aplastic anemia, MDS, leukemia, PNH,
myelofibrosis, metastatic solid tumors, etc. Consider PBS &
BMBx.
Pure red cell aplasia: Check parvovirus B19, BMBx
Sideroblastic anemia: See microcytic section.

Macrocytic (MCV > 100):

138
B12 deficiency: B12 (<200 = low, 200-300 = borderline, >300 =
nl), Methylmalonic acid (MMA) & homocysteine. May be
microcytic if severe
Folate deficiency: RBC folate, homocysteine, nl MMA
Other: Hydroxyurea, AZT (or other drugs), EtOH, EtOH-induced
sideroblastic anemia, liver disease, hypothyroidism, myelodysplasia.

Tx of nutritional deficiency anemia:


Vitamin B12:
1000 mcg SC/IM daily for 5 days, then 1000 mcg SC/IM weekly
for 5 wks then 1000 mcg SC/IM monthly for life. 1000 mcg PO
daily (only for chronic supplementation)
Folate: 1mg PO/SC/IM daily
Iron: Ferrous sulfate 325 mg TID or IV Iron Dextran
(http://www.globalrph.com/irondextran.htm)

Management of anemia of CKD:


All pts w/GFR<60 should be screened for anemia
Replete iron, folate & vit B12 deficiencies as indicated before
initiating EPO. Remember that folate deficiency may occur in pts on
hemodialysis, & that iron store can get depleted w/ EPO use.
Targets of iron therapy: Ferritin>200 ng/ml & Iron Sat >20% (for pts
on dialysis); Ferritin >100 ng/ml & Iron Sat >20% (for CKD pts not on
dialysis)
In dialysis pts, vitamin C combined w/ EPO can improve Hgb levels

Hemolytic Anemias:
Paroxysmal Nocturnal Hemoglobinuria: An acquired clonal stem cell
d/o; an inactivating somatic mutation of PIGA gene. inc RBC

139
sensitivity to complement, complement activation indirectly
stimulates plt aggregation and hypercoagulability
Si/Sx: hemolytic anemia and venous thrombosis (intra-abdominal,
cerebral), cytopenias
Dx: Flow cytometry: CD55 (DAF decay accelerating factor), CD59
(HRF homologous restriction factor)
Tx: Supportive care, allogenic HSCT, eculizumab (Ab that inactivates
terminal complement by binding C5 complement protein) If the pt
has large PNH clones (>50% of granulocytes affected), the
thrombotic risk is >40% and the pt should be txd with warfarin

G6PD Deficiency: X-linked metabolism defect susceptible to oxidative


damage
Triggers: Drugs (sulfa, antimalarials), infection, foods (fava beans)
Dx: Peripheral smear (Heinz bodies, bite cells), dec G6PD levels
Tx: stop offending drug, Tx underlying infection, PRBC transfusion if
necessary

Sickle Cell Anemia: Recessive beta-globin gene mutation (Val > Glu)
results in a structurally abnl Hb (HbS) that polymerizes under
conditions of low O2 tension.
Acute Pain/Vasoocclusive crisis: Caused by infection, thrombosis,
atelectasis, fat embolism
Dx/Symptoms: (Hb Electrophoresis diagnostic at birth )Hct,
reticulocyte count ( parvovirus B19 if retics), SOB, hypoxia, CP
infiltrates CXR, blood cx/UA/urine cx/NP aspirate/urine tox as
clinically indicated to eval for potential triggers; Check peripheral
smear for Sickle-shaped RBCs and Howell-Jolly bodies
Acute Tx: Analgesics (PCA frequently needed), IVF (200-250cc/hr,
but caution in pts w/ h/o pulm HTN), O2 via NC to keep sat >95%,

140
incentive spirometry (10x/hour), folate 1 mg PO daily, daily Hct &
retic count
Chronic Tx: Hydroxyurea (incr fetal Hb), folic acid, pneumococcal
vaccine, H flu vaccines, PCN
prophylaxis, manage all end organs that may become damaged
(eyes, heart, lungs, kidneys, bones), exchange or simple transfusions
+ deferoxamine (iron chelator)
**Acute chest syndrome**: New infiltrate on CXR, CP, fever, O2
requirement. Occurs, on average, 2.5 days after admission for VOC &
is potentially fatal. Precipitated by fat embolism or infxn (C.
pneumoniae, M. pneumoniae). Manage w/ abx (moxifloxacin), O2,
transfusion (exchange or simple), consult Heme [NEJM
2000;342:1855-65] [NEJM 1984;311:291-295]

Microangiopathic Hemolytic Anemia: Intra-arteriolar fibrin damages


RBCs leading to intravascular hemolysis (In TTP, there is no fibrin
deposition)
DDx: HUS, TTP, DIC
Dx: CBC , peripheral smear(schistocytes), PT/aPTT, fibrinogen
Si/Sx: FAT-RN Fever, Anemia, Thrombocytopenia, Renal Failure,
Neuro dysfunction (Seizures), or some combination of the above
HUS is divided into typical (90%) and atypical (10%) subtypes:
STEC-HUS or typical HUS: caused by shiga toxin, typically results in
renal failure
Atypical HUS: Renal failure with no diarrhea or shiga toxin
Tx: DO NOT give Abx, provide symptomatic and supportive
care. Plasma Exchange and Eculizamab have been shown to
help in patients with CNS involvement.

TTP : typically involves Neuro dysfunction

141
Tx: plasma exchange, eculizamab
DIC: due to trauma, shock, infection (sepsis), malignancy(APL), OB
complications
Dx: Increased , aPTT, Bleeding time, D-dimer, LDH decreased: plts,
haptoglobin,
Tx: treat underlying process, give FFP, cryoprecipitate to aintain
fibrinogen > 150, plts

2. Hypercoagulability:
Virchows Triad: Stasis, hypercoagulability, endothelial damage.
Causes:
Antithrombic activity: ATIII deficiency, Prot C or S deficiency
Prothrombotic activity: Congenital (Factor V Leiden [in caucasians])
& acquired APC resistance, Prothrombin 20210A, elevated factor VIII,
IX, XI, dysfibrinogenemia, hyperhomocysteinemia

Systemic disease: Antiphospholipid syndrome/SLE, IBD, malignancy,


hyperviscosity syndrome (polycythemia vera, etc.), PNH, CHF,
nephrotic syndrome, HIT-thrombosis syndrome, pregnancy

Situational risks: Surgery, immobility, HRT/OCPs, CV catheters w/u:


APCR, Factor V Leiden, Dilute Russel Viper Venom (increased w/
lupus anticoag), Anti-cardiolipin, Prothrombin 20210A,
homocysteine, Factor VIII, PT/PTT.
Dx: APC resistance screen, protrhombin PCR test, functional assays
for prot C and S, ATIII level, homocysteine level
*Prot C & S falsely on warfarin (C also falsely low w/ acute clot)
*ATIII falsely in pts on heparin or w/ acute clot

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HYPERCOAGUABLE STATES
Venous, Factor V Leiden: activated protein C resistance
Inherited Prothrombin mutation: G20210A > inc
prothrombin level
Prot C or S def: Coumadin-induced skin necrosis
risk
Antithrombin III def: may be heparin-resistant
Venous Stasis (immobilization, sx, CHF), malignancy,
acquired hormonal, nephritic syndrome
Venous/arterial, factor V Leiden + smoking
inherited Hyperhomocysteinemia: inherited or acquired
Dysfibrinogenemia
Venous/areteral Platelet defects (MPD,HIT,PNH), hyperviscosity
acquired (PCV, Waldenstroms, sickle cell, acute leukemia),
vessel wall defects (vasculitis, trauma, foreign
bodies), others (antiphospholipid syndrome, IBD)

3. DVT Prophylaxis:
A. Risk factors: (most important is ambulatory vs. not ambulatory)
Major: Age > 60 years, current active cancer (excluding non-
melanoma skin cancer), prior DVT/PE, stroke w/ residual paralysis in
past 3 months, paralysis, inherited or acquired thrombophilia, heart
failure NYHA III/IV, respiratory failure/COPD, acute infection/sepsis,
pregnancy or post-partum, obesity (BMI>30).
Minor: Central line, nephrotic Sd, IBD, estrogen or selective estrogen
receptor modulators.

B. Risk stratification:

143
Low risk: Anyone who is freely ambulatory. Tx: Keep active specify
ambulation plan (e.g. q shift)
Moderate Risk: NOT ambulatory w/ only 1 minor RF. Tx: Fragmin
5000K units SQ Q24hr
High Risk: NOT ambulatory w/ at least 1 major or 2 minor RFs. Tx:
Heparin 5000 units SQ q8h or Fragmin 5000K units SQ Q24hr
**All can be used +/- SCDs except when contraindicated below**

C. Contraindications:
Active bleeding, systemic anticoagulation, high risk of bleeding,
severe head trauma, elevated INR (1.5); therapeutic aPTT; platelets
<50K, pericarditis, active PUD, threatened abortion, recent TURP,
eye/brain/cord injury past 24 h.
*Heparins, but not all anticoagulants, are contraindicated if h/o HIT
SCDs: Dont use w/ arterial insufficiency, open wounds, or DVT in
area

4. Anticoagulation in Patients w/ VTE:


A. Heparin : (goal aPTT 65-100 seconds)
- Review baseline labs including aPTT, PT/INR, BMP, Heme-8
- Bolus should be strongly considered in pts w/ active thrombosis
Indications: Afib, DVT, PE, mechanical heart valve, mesenteric vein
thrombus, peripheral vascular disease, arterial thromboembolism
Initial dosing: follow Heparin sheet for bolus and initial infusion
rate, check APTT 6 hrs after initial rate, and every 6 hrs after rate
change per heparin sheet
Adjusting: see Heparin sheet

B. Warfarin :

144
Dont start until therapeutic on heparin since it reduces Prot C
before factors VII, IX, X, II
For pts on warfarin & UFH for tx of acute thrombosis, UFH (or UFH
followed by LMWH), should be continued for at least 5 days & INR
should be in the ordered goal range for at least 24 h before UFH (or
UFH followed by LMWH) is discontinued.
No loading dose - goal is to start w/ correct maintenance dose.
Start w/ 5 mg PO daily (or previous home dose) for most pts.
Allow 2-3 days for INR to begin to rise, follow anticoag recs daily
If there is an acute indication for AC, overlap w/ acute form of AC
until INR at goal. [Annals 1997; 126:133-136.]
Goal INR for VTE, A-fib, mechanical aortic valve: 2-3.
Goal INR for mechanical mitral valve, some recurrent VTE: 2.5-3.5.
Goal INR for some APS w/ recurrent TE: 3-4
After 6-month course, when deciding whether to continue
anticoagulation, may check d-dimer, & continue anticoagulation if
abnl. [Ann Intern Med 2008;149(7):481-90] [Williams Hematology
7th ed 2006, Ch 122]
Consider indefinite tx for pts w/ idiopathic DVT/PE or pts w/
continuing strong thrombophilic risk factors (APS, active cancer)

C. Anticoagulation in pts w/ HIT & renal failure: Argatroban. Use


Argatroban drip if isolated renal failure or bivalirudin if hepatic or
combined hepatic & renal failure.
Begin argatroban at 2 mcg/kg/min & check the first aPTT in 4 h w/
target aPTT ratio 1.5-3.0 [Ann Pharmacother 2003; 37:970-5, NEJM
2006;355:809-17].
For pts in ICU or w/ mild hepatic insufficiency, begin argatroban at
0.25-0.5 mcg/kg/min.

145
Monitor aPTT every 4 h until 2 consecutive aPTT values in the
therapeutic range, then check aPTT 12 h later, & if still therapeutic,
then at least daily.
Dose adjustments:
a) If argatroban subtherapeutic, gtt rate by 20% & recheck aPTT in
4h.
b) If supratherapeutic, gtt by 50% & recheck aPTT in 4h.
i. aPTT ratio is > 3.0, hold the infusion 30 mins.
ii. aPTT ratio > 4.0, hold 1 h before restarting at the lower rate.
c) After any dose adjustment, more frequent aPTT testing (ex: q4h)
until aPTT therapeutic X2, then 12h later, then at least daily.
Argatroban strongly influences INR during warfarin co-therapy, so
an INR of 4 must be achieved to ensure a therapeutic INR of 2 once
argatroban is discontinued.

D. Anticoagulation in pts w/ HIT & hepatic dysfunction: use


bivalirudin drip
Bivalirudin is enzymatical hydrolyzed in plasma & renally-cleared &
has a half life of 25 min in pts w/ nl renal function.
Initial infusion rate (nl renal function 60 ml/min): 0.15 mg/kg/h

Creatinine clearance Initial infusion rate


45-59 ml/min 0.1 mg/kg/hr
30-44 ml/min 0.075 mg/kg/hr
< 30 ml/min 0.05 mg/kg/hr
Hemodialysis or CVVHD 0.03 mg/kg/hr
Combined hepatic-renal failure 0.03 mg/kg/hr

Dose adjustments:

146
a) If bivalirudin subtherapeutic, gtt rate by 20% & recheck aPTT in
2h.
b) If supratherapeutic, gtt by 50% & recheck aPTT in 2h.
i. aPTT ratio is > 3.0, hold the infusion 30 mins.
ii. aPTT ratio > 4.0, hold 1 hour before restarting at the lower
rate.
c) After any dose adjustment, more frequent aPTT testing (ex: q2h)
until aPTT therapeutic X2, then 12h later, then at least daily.

5. Heparin Induced Thrombocytopenia:


A. Type I HIT:
Development of minimal thrombocytopenia during first few
days of IV heparin administration.
Resolves spontaneously despite continued heparin therapy.
Due to platelet aggregating properties of heparin; non-
imunologic, not severe.

B. Type II HIT:
Development of thrombocytopenia (typically 50% reduction) 4-
14 days after initiation of heparin (unless pt has prior
sensitization).
Associated w/ either large or small amounts of heparin by any
route.
Due to platelet antibodies; immunologic.
Test w/ PF4 HIT Ab & Serotonin Release Assay.
High risk of venous and/or arterial thrombosis unless heparin is
discontinued and alternative anti-thrombin agent is
administered (argatroban, etc.)

147
6-8 points = high probability of HIT, 4-5 points= intermediate
probability of HIT, < 4 points= low probability of HIT. (Lefkowitz.
Curr Hematol. 2003)
148
6. Other Platelet Disorders
Drug Induced Quinidine, abx, Sulfa drugs, glycopreotein
iib/iiia inhibitors (abciximab, etc.) Tx: stop offending
medication
ITP due to platelet associated IgG Abs. Dx of exclusion Tx:
Prednisone, splenectomy if unresponsive
Acquired disease Quantitative dysfunction 2/2 Liver dz, Renal
Dz, multiple myeloma, ASA Tx: Desmopressin to inc vWF, FFP or
cryo for bleeding.
H. Pylori unclear mechanism of plt dysfunction, however Tx of
H. Pylori shown to improve thrombocytopenia
Hereditary diseases
o Bernard Soulier: defect in Gp1, Type A (Gp1BA), Type B
(Gp1BB), Type C (Gp9)
o Glanzmanns thrombasthenia: defect in GpIIb/IIIa Tx: avoid
NSAIDS, ASA, give DDAVP, amicar, plt transfusions if severe
bleeding
o Von willebrands Dz: most common bleeding disorder, mimics
plt dysfunction (mucocutaneous bleeds) and hemophilia
(hemarthrosis) Dx: low vWF +/- abnrml vWF activity
(ristocetin cofactor activity) Tx: DDAVP if symptomatic

Platelet transfusion thresholds


< 90,000 prior to Neurosurgery
< 50,000 prior to general procedures
< 50,000 in symptomatic, bleeding patient
< 20,000 in febrile/neutropenic/septic
< 10,000 in asymptomatic patient

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Laboratory findings in various platelet and coagulation disorders
Bleeding
Condition PT aPTT Platelet count
time
Aspirin Unaffected Unaffected Prolonged Unaffected
Bernard-Soulier Decreased or
Unaffected Unaffected Prolonged
syndrome unaffected
C1INH deficiency Unaffected Shortened Unaffected Unaffected
Congenital
Prolonged Prolonged Prolonged Unaffected
afibrinogenemia
Disseminated
Prolonged Prolonged Prolonged Decreased
intravascular coagulation
Factor V deficiency Prolonged Prolonged Unaffected Unaffected
Factor X deficiency as
Prolonged Prolonged Unaffected Unaffected
seen in amyloid purpura
Factor XII deficiency Unaffected Prolonged Unaffected Unaffected
Glanzmann's
Unaffected Unaffected Prolonged Unaffected
thrombasthenia
Hemophilia Unaffected Prolonged Unaffected Unaffected
Liver failure, early Prolonged Unaffected Unaffected Unaffected
Liver failure, end-stage Prolonged Prolonged Prolonged Decreased
Thrombocytopenia Unaffected Unaffected Prolonged Decreased
Uremia Unaffected Unaffected Prolonged Unaffected
Normal or
Vitamin K deficiency or
Prolonged mildly Unaffected Unaffected
warfarin
prolonged
Von Willebrand disease Unaffected Prolonged Prolonged Unaffected

150
7. Hematological Malignancies
A. LEUKEMIA: malignant proliferation of hematopoietic cells.
Categorization is based on cellular origin and level of proliferation.
Acute: proliferation of minimally differentiated cells (myeloblasts,
lymphoblasts), defined as > 20% blasts in bone marrow (<20% blasts
defined as MDS)
Chronic: proliferation of more mature differentiated cells
(metamyelocytes/myelocytes, lymphocytes)

ACUTE LYMPHOCYTIC LEUKEMIA (ALL) most common in children, inc


incidence in Down Syndrome
Presentation: viral like prodrome, children may refuse to walk,
complain of bone pain, easy bruising on exam, pallor,
petechiae/purpura, echymosis, or bleeding
Dx: CXR, CBC, LP, peripheral smear, Bone Marrow Bx, Cytogenetics:
+TdT (terminal deoxynucleotidyl transferase: t(9:22) Philadelphia chr,
immunophenotype
Tx: NEW USC ALL chemotherapy regimen consists of Induction I and
II( Vincristine + Duanorubicin + Prednisone +/- PEG-A Aspariginase)
Consolidation I-VI (multiple agents), Maintenance (MTX, 6-MP)

ALL IMMUNOPHENOTYPES
Cell Type Surface Markers

Pre B cell + TDT, + CD19, variable CD10 and CD20

T Cell + TDT, acid phosphatase, - CD10, + T Cell Ag


(CD7)

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B Cell (burkitts) -TDT, + surface Ig

ACUTE MYELOLOGENOUS LEUKEMIA (AML) most cases occur in


adults, with incidence increasing with each decade of life. Prognosis
depends on: age > 60, MDS, and cytogenetics
Presentation: similar to ALL w/ anemia, fatigue, easy bruising,
leukemia cutis, petechiae/purpura, may also present w/ DIC, gingival
hyperplasia, CNS involvement, frequent infections
Dx: CBC, peripheral smear (+/- Auer rods, + granules), Cytochemistry
(+ myeloperoxidase or non specific esterase[NSE]) Bone marrow bx
w/ cytogenetics
Tx: Induction (7+3) Cytarabine D 1-7, Idarubicin D1-3 ;
Consolidation: <60y/o 3-4 cycles of HiDAC or SCT for intermediate or
hi risk pts; >60: intense chemotherapy or clinical trial
No CR or relapse: HiDAC or trial, SCT, salvage chemotherapy
FAB CLASSIFICATION OF AML
FAB Adult AML patients
Name
subtype (%)
M0 Undifferentiated acute myeloblastic leukemia 5%

M1 Acute myeloblastic leukemia with minimal 15%


maturation
M2 Acute myeloblastic leukemia with maturation 25%

M3 Acute promyelocytic leukemia (APL) (t15:17) 10%

M4 Acute myelomonocytic leukemia (CD14, 15) 20%

M4eos Acute myelomonocytic leukemia with eosinophilia 5%

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M5 Acute monocytic leukemia (++NSE) 10%

M6 Acute erythroid leukemia 5%

M7 Acute megakaryocytic leukemia (CD41) 5%

WHO SUBTYPES OF AML


Name Description

AML with translocations between chromosome 8


and 21 [t(8;21)] (ICD-O 9896/3); RUNX1/RUNX1T1
AML with inversions in chromosome 16 [inv(16)]
(ICD-O 9871/3); CBFB/MYH11
APL with translocations between chromosome 15
AML w/recurrent
and 17 [t(15;17)] (ICD-O 9866/3); RARA;PML
genetic
abnormalities AML with translocations in chromosomes 9 and
11 [t(9;11)]; MLLT3-MLL

Patients with AML in this category generally have a


high rate of remission and a better prognosis
compared to other types of AML.
This category includes patients who have had a prior
AML with myelodysplastic syndrome (MDS) or myeloproliferative
multilineage disease (MPD) that transforms into AML. This category
dysplasia of AML occurs most often in elderly patients and often
has a worse prognosis.
This category includes patients who have had prior
chemotherapy and/or radiation and subsequently
AML and MDS,
develop AML or MDS. These leukemias may be
therapy-related
characterized by specific chromosomal abnormalities,
and often carry a worse prognosis.
AML not Includes subtypes of AML that do not fall into the

153
otherwise above categories.
categorized
RISK STRATIFICATION OF AML

Risk 5-year Relapse


Abnormality
Category survival rate

Low
t(8;21), t(15;17), inv(16) 70% 33%
(CR 84%)
Normal, cKIT + t(8:21) +8, +21, +22,
Intermediate
del(7q), del(9q), Abnormal 11q23, all 48% 50%
(CR 76%)
other structural or numerical changes
-5, -7,5q-, 7q-, inv(3), t(6:9), t(9:22),
High
isolated FLT3-ITD mutation del(5q), 15% 78%
(CR 55%)
Abnormal 3q, Complex cytogenetics

ACUTE PROMYELOCYTIC LEUKEMIA (APL): t(15:17) M3 subtype of


AML. Can present with same symptoms of other AML (see above)
and DIC
Dx: CBC, peripheral smear, cytogenetics, Bone Marrow bx w/ PCR for
PML/RAR alpha.
Tx: Keep plts > 50, keep fibrinogen > 150 with cryo,
Induction: ATRA + Idarubicin
Consolidation : 3 cycles of anthracycline + ATRA for intermediate risk
patients + ARA C or Arsenic for high risk patients
Maintenance: ATRA or ATRA + 6MP/MTX
2nd line: Arsenic trioxide
3rd line: gemtuzumab, ozogamicin
**High WBC at Diagnosis correlates with risk for CNS disease

154
CHRONIC LYMPHOCYTIC LEUKEMIA (CLL): malignancy of mature
lymphocytic cells, typically age > 65.
Symptoms: usually an indolent disease, often diagnosed incidentally.
May present with lymphadenopathy, fatigue, hepatosplenomegaly.
Dx: peripheral smear (lymphocytosis, smudge cells, atypical
lymphoid cells); BM Bx : >30 small B-cells; Flow cytometry: extremely
low levels of surface Ig, +CD5, +CD19, +CD20, +CD23. Bone Marrow
Bx for confirmation
Prognosis: Good: 13q del, Poor: 17p del, 11q del, +12q, +CD38, +
Zap70, ++ beta2 microglobulin

Tx: no Tx for asymptomatic patients, simply observe.


** Note** may transform to intermediate or high grade lymphoma
(Richters transformation) at which point may Tx with splenectomy
+/- steroids
Decision to treat sometimes based on symptoms, progressive
marrow failure, AIHA/ITP refractory to steroids, progressive
lymphocytosis, massive hepato/splenomegaly or staging system such
as Rai and Binet system

CLL TREATMENT
1st line <70 yrs old FCR, FC, FR,PCR
1st line > 70 yrs old Chlorambucil +/- prednisone, CVP,
alemtuzumab, bendamustine,
rituxumab +/- fludarabine
Del 17p FCR, FR, CFAR, alemtuzumab
2nd line FC, FR, FCR, rituxumab, fludarabine,
pentostatin
Fludarabine, Cyclophosphamide, Rituximab, Pentostin

155
RAI CLINICAL STAGING SYSTEM
Risk group Stage Features Median
Survival
(months)
Low 0 Blood and marrow > 120
lymphocytosis
Intermediate I Lymphocytosis and 108
adenopathy
II Lymphocytosis w/ 94
splenomegaly or
hepatomegaly +/-
adenopathy
High III Lymphocytosis w/ anemia 60
(Hb <11g/dl)
IV Lymphocytosis w/ 60
thrombocytopenia
(<100K/uL platelets)

BINET STAGING SYSTEM


Stage

A No anemia, no thrombocytopenia, < 3 areas of lymph


involvement (Rai 0,I,II)
B No anemia, no thrombocytopenia, > 3 areas of lymph
involvement (Rai I,II)
C Anemia +/- thrombocytopenia, any # of areas of
involvement (Rai III, IV)

CHRONIC MYELOGENOUS LEUKEMIA (CML): malignancy of myeloid


cells seen in middle age. Can occur denovo or from

156
myeloproliferative disorders. Often stable, and then transforms into
acute leukemia(blast crisis). Also assoc. with prior radiation and
benzene exposure.
Si/Sx: typically indolent, may present w/ fatigue, fever, malaise, or
constitutional symptoms, blast crisis presents as bone pain, fever,
weight loss, splenomegaly
Dx: CBC shows leukocytosis w/ myeloid precursors, BM Bx w/
cytogenetics (Philadelpha chromosome t(9:11), BCR-AbL fusion gene
Tx: Chronic phase: imatinib, monitor w/ serial BCR-ABL transcript
levels, dasatinib, Nilotinib

B. Lymphoma: malignancy of monoclonal proliferation of cells from


lymphocyte lineage.
~90% B-cells, ~9% T cells, ~1% monocytes and NK cells

ANN ARBOR STAGING SYSTEM


I Single LN region
II > or = 2LN regions on same side of diaphragm
III LN regions on both sides of diaphragm
IV Disseminated involvement of one or more extralymphatic
organs
A= no Sx , B = B symptoms, X = bulky, E = single contiguous extranodal
site

Hodgkins: neoplastic Reed Sternberg cells, of B-cell origin. Assoc w/


EBV
Sx: Presents w/ cervical lymphadenopathy, spreads along
lymph nodes. B symptoms (night sweats, fevers, weight loss)
assoc. w/ bulky dz and worse prognosis

157
Dx: Lymph node Bx w/ cytogentics showing RS cells, BM Bx, CT
Ch/Abd/Pel
Staging: Ann Arbor system and presence of prognostic factors
Tx: ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine),
BEACOPP (bleomycin, etoposide, adriamycin,
cyclophosphamide, vincristine, procrabazine, prednisone),
ESHAP, stem cell transplant
Non-Hodgkins Lymphoma: neoplastic proliferation of b or T cells
classified as low, intermediate, or high grade on the basis of
histologic type. Includes Follicular lymphoma, gastric malt
lymphoma, splenic marginal zone lymphoma, mantle cell lymphoma,
Diffuse Large B Cell Lymphoma, Burkitts lymphoma, Peripheral T-cell
lymphoma.
Many are associated with infections: EBV (Burkitts lymphoma), HIV
(CNS lymphoma), HTLV (T-cell lymphoma), H.Pylori (gastric
MALToma)
Sx: similar to Hodgkins, including B symptoms.
Dx: LN Bx, BM Bx, LDH is prognostic factor
Tx: CHOP, R-CHOP (addition of Rituximab [anti-CD-20Ab] improves
outcome. See Heme Brain for various Tx regimen

C. Multiple Myeloma: malignant proliferation of plasma cells, often with


unbala nced excessive production of immunoglobulin heavy/light chains
Si/Sx: back pain, hypercalcemic symptmons (stones, groans, moans,
psychiatric overtones), pathologic fractures, fatigue, frequent
infections, pallor, fever, bone tenderness, lethargy.
Dx: UPEP (Bence Jones protein), SPEP (look for monoclonal Ig,
commonly IgG, >3g/dL), Bone Aspirate w/ >10% plasma cells,
skeletal survey will show punched out lytic lesions. LAP levels
are normal as lesions are lytic NOT blastic, B2 microglbulin,

158
DDx: Waldenstroms macroglobulinemia (IgM w/ cold agglutinins)
Tx: melphalan, prednisone, bortezomib +/- thalidomide, Stem cell
transplant for patient <60 in advanced stages of disease. Tx to
alleviate symptoms
Hypercalcemia hydration, glucocorticoids
Bone pain/destruction/fractures - bisphosphanates and
radiation
Renal Failure Hydration
Anemia erythropoietin
Infections - vaccinate

8. Common HEME/ONC Emergencies:


Blood Product Transfusion Risk & Reactions:
Noninfectious complications of blood transfusions (per unit): Fever
(1-4:100); Allergic rxn (1-4:100); Delayed hemolytic rxn (1:1,000);
Acute hemolytic rx (1:12,000); Fatal hemolytic rxn (1:100,000);
Anaphylactic rxn (1:150,000); Tx-related acute lung injury (1:5,000) If
any transfusion rxn occurs, stop transfusion, send remaining blood
product to blood bank for analysis along w/ a fresh sample of pts
blood. If mild rxn, ok for pt to receive subsequent transfusions after
w/u complete, but premedicate w/ acetaminophen 650 mg &
diphenhydramine IV 25-50 mg.

Infectious complications of blood transfusions (per unit):


CMV: Common (caution if immunosuppressed); Hepatitis B: 1 in
205,000-488,000; Hepatitis C: 1 in 1,935,000; HIV: 1 in 2,135,000;
HTLV 1: in 2,993,000; Malaria: 1 in 4,000,000

159
Acute hemolytic rxn: classic triad of fever, hematuria,
abdominal/flank pain. Flush kidneys w/ IVF & diuretics. Fever: Treat
w/ acetaminophen.
Rigors: Meperidine 12.5-50 mg IVP q15min until relief. If
contraindicated, may consider tramadol (IV is Level IA EBM, but
often unavailable) [Anaesthesia 2009;64(2):141-6].
Rash/pruritis: Diphenhydramine, +/- H2- blockers & steroids.
Dyspnea: Consider TRALI vs. simple volume overload; check CXR,
consider IV furosemide, supportive oxygen. Treat TRALI like
ALI/ARDS, call MED CONSULT for ICU transfer
Anaphylaxis (severe urticaria, bronchospasm, laryngeal edema,
hypotension): Treat w/ epinephrine, IVF, & possibly MICU transfer
for airway visualization/intubation.
Febrile Neutropenia See ID Section for management

Back Pain + Cancer : think about cord compression, consider CT or MRI.


If pt has cord compression/focal neuro deficits, STAT consult to Rad Onc
and/or Neurosurg.
Tumor Lysis : Pt develops K, Phos, uric acid, LDH, Ca, & ARF.
(Check K, Cr, phosphate, UA, LDH anywhere from q4h to daily in pts
undergoing chemo for heme malignancies)
Give allopurinol, 600 load & 300 daily if tumor lysis is
anticipated
Give rasburicase if uric acid > 8
Always give nl saline, not bicarb. Never give phosphate feeds
the tumor.
DIC (Particularly in APL):
Check Heme-8, PT/PTT, D-dimer, fibrinogen q4h to daily in pts
undergoing chemo for hematologic malignancies

160
Give cryo if fibrinogen is downtrending (dont wait until less
than 150), keep fibrinogen >150
If patient has thrombosis instead of bleeding, consider starting
Heparin 10 units/kg/h (no bolus)

161
SECTION 15 NEPHROLOGY
1. Chronic Kidney Disease (CKD)
Defined as >/= 3 months of reduced GFR (<60) and/or kidney damage
(imaging/path/markers)
Can use MDRD equation to calculate estimate GFR, ensure no acute
changes in Cr before relying on the results of the equation
Etiologies: DM (45%), HTN/RAS (27%), glomerular (10%), interstitial
(5%), PKD (2%)

** Note ** Drops in creatinine in patients with advanced disease


may signify muscle loss due to chronic disease and NOT
improvement of renal fxn

Management: Consult in house if patient has any immediate indications


for dialysis or needs to be temporized pending initiation of dialysis
Diet: Low Na diet for HTN, Low K diet if hyperkalemic, Low phos
diet, strict control of blood sugar in DM
BP control: goal 130/80, can start with ACE inhibitor as effective in
DM and Non-DM. Ok if 25% DROP in GFR or 30% RISE in Cr. If more
than this, investigate other causes of drop/rise such as NSAID use,
hypovolemia, renal artery stenosis or another or uncompensated
heart failure. Can lower dose or stop medication if unable to
resolve and select another agent.
162
Other assoc. problems:
Metabolic acidosis: Sodium bicarb or citrate if HCO3<22, Bicitra 10-
30ml PO QID
Anemia: Goal Hgb 11-12, higher than this leads to more
complciations>>incr death, HTN, stroke, thrombotic events
No survival benefit for Hgb>9 via Epo if diabetic nephropathy
At LAC+USC, Darbopoeitin 0.45 mcg/kg q week, requires a form
that is available on most wards or is accessible in Intranet
home>>departments>>pharmacy>> pharmacy forms
Check a baseline iron panel + ferritin, keep transferrin sat >20%
Uremic bleeding: desmopressin(dDAVP) 0.3micro g/kg IV or 3
micro g/kg intranasally
Secondary hyperparathyroidism:
Increased phos, decreased calcium, decreased calcitriol >>
incr. PTH > renal osteodystrophy
CKD Stage correlates with target PTH level
Stage 3: 35-75 pg/ml
Stage 4: 70-110
Stage 5: 150-300
Phos binders: Renal consult recommended if planning to
use Amphojel
If phos <6mg/dl and calcium low: Phos-Lo 667mg 1-
2 tabs TID with meals
If phos and calcium high or phos >6mg/dL: Renagel
800mg 4-5 tabs TID with meals
If SEVERE high phos: Amphojel 5cc/600mg, 2.5-5cc
TID w/meals for NO LONGER than 3 DAYS

163
Calcitriol or paricalcitol if Ca-PO4 product <55, possible
mortality benefit for HD pts
Can use cincalcet if PTH remains elevated despite phos
binders and vit d analogue

2. Acute Kidney Injury (AKI): Abrupt increase in Cr in <48h of >/= 0.3


mg/dl OR Cr >/=50% OR UOP <0.5mL/kg/hr for >6h.
**note** Do not wait till creatinine is over ULN. Always trend Cr while
pts are in house as people with less muscle mass will have low baseline
Cr and often have AKI that goes unnoticed.
Dx: History/physical: recent procedures & meds; VS & vol status; s/s of
obstruction, vasc or systemic disorder; Ischemia (pre-renal & ATN)
accounts for >50% of in-hospital AKI Urine eval: I/O, UA w/micro, urine
osmol, electrolytes FENa = (Una/Pna) (Ucr/Pcr) * 100 < 1% >> pre-renal,
contrast, or GN; >2% >>ATN
When using diuretics, FENa becomes inaccurate, use FEurea instead.
FEurea = (Uurea/Purea) / (Ucr/Pcr)* 100; <35% >> pre-renal
Renal U/S: r/o obstruction and eval kidney size to estimate chronicity of
kidney disease
Serologies for glomerular disease: HIV, RPR, ANA, Anti-dsDNA, C3, C4,
Cryocrit, Hep B, HCV Ab, ANA, Anti-GBM

Three categories of AKI: Pre-renal, Intrinsic, Post-renal


A. Pre-Renal: Bland UA, hyaline casts, FEna<1%, BUN/Cr>20 Uosm
>500
Decreased Effective Arterial Volume: Hypovolemia, CHF, sepsis
Renal Vasoconstriction: NSAIDs, ACEI/ARB, Contrast, calcineurin
inhibitors, HRS, Hyper Ca
Large vessel: Renal artery stenosis (Bilat + ACEI), thrombosis,
embolism, dissection, vasculitis, compression
B. Intrinsic:

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Acute tubular necrosis (ATN): Granular muddy brown casts in
75%, +/- in AKI, +/- RBCs and protein from tubular damage, FEna
> 2% (except pigment and CIAKI), Uosm<350
Ischemia resulted from prerenal disease
Toxins: Drugs (Aminoglycosides, Amphotericin, cisplatin),
Pigments (Hb, myoglobin), Proteins (Ig light chains), Crystals (Uric
acid, Acyclovir, Methotrexate, indinavir, oral sodium phosphate)
Acute interstitial Nephritis (AIN): WBCs, WBC casts, +/- RBCs, (+)
urine eos in ABX, (+) lymphs in NSAIDs
Allergic: Beta-lactams, sulfa drugs, NSAIDs, PPIs
Infection: Pyelonephritis, legionella
Infiltrative: Sarcoid, lymphoma, leukemia
Autoimmune: Sjogrens, TINU syndrome, IgG 4, SLE
Small vessel: +/- RBCs, +urine eos in cholesterol emboli
Cholesterol, emboli, thrombotic,
microangiopathic(HUS/TTP, DIC, preeclampsia, APS,
malignant, HTN, scleroderma renal crisis)
Glomerulonephritis: Dysmorphic RBCs and RBC casts
C. Post-renal: Bland, +/- nondysmorphic RBCs if nephrolithiasis
Bladder neck: BPH, prostate cancer, neurogenic bladder, anti-
cholinergic meds
Ureteral (bilateral): malignancy, LAN, retroperitoneal fibrosis,
nephrolithiasis
Tx: treat underlying condition, avoid nephrotoxic drugs and ensure
renal dosing, correct volume status and electrolyte abnormalities,
Indications for emergent dialysis: AEIOU (Acidemia, Electrolyte
disorder: hyper K, hyper Ca, tumor lysis), Intoxication: methanol,
ethylene glycol, lithium, salicylates, Volume Overload (CHF), Uremia:
pericarditis, encephalopathy, bleeding

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3. Acid-Base Disorders
Acidemia: pH < 7.36, alkalemia: pH > 7.44

Metabolic Acidosis (pH < 7.40, HCO3 < 24)


1. Calculate Anion Gap: AG=Na-(Cl+HCO3), nl=122
2. Adjust for hypoalbuminemia: for each 1g/dl drop in albumin below 4,
correct AG by adding 2.5
3. Calculate Delta-Delta Gap HCO3=24-HCO3, AG=12-AG
HCO3 = AG -> pure AG metabolic acidosis
HCO3 > AG -> non-AG metabolic acidosis also present
HCO3 < AG -> metabolic alkalosis also present
4. Respiratory compensation:
Use Winters formula to calculate predicted PaCO2: =1.5[HCO3] + 8 2
If PaCO2 measured < PaCO2 predicted -> respiratory alkalosis
If PaCO2 measured > PaCO2 predicted -> respiratory acidosis

Anion Gap Acidosis Nrml Anion Gap Acidosis


Methanol Diarrhea
Uremia Ureteral diversion
Diabetic ketoacidosis RTA
Paraldehyde Hyperalimentation
Ischemia/Iron/INH Acetazolamide/Ammonium cl
Lactic Acidosis (Type A &B) Miscellaneous (Spirololactone,
EtOH, Ethylene Glycol, amphotericin B, Addisons Dz,
Salicyclates, Starvation NS IVF, Chloridorrhea,
posthypocapnia)

Workup for AG acidosis:


Calculate Osmolar Gap: OG = measured osmoles calculated osmoles;
Calculated osmoles = 2Na + glucose/18 +BUN/2.8 + EtOH/4.6
OG >10 suggests ingestion (ethanol, methanol, ethylene glycol, toluene,
mannitol, contrast dye); Check renal function, lactate, tox screen, ketones

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Workup for Nrml AG acidosis:
Calculate Urine AG: UAG = (UNa +UK) - UCl
Positive UAG: Type I & IV RTA, early renal failure, Ampho B
Negative UAG: GI causes, Type II RTA, dilutional acidosis, toluene
poisoning, exogenous acid)

Renal Tubular Acidosis


Distal/Type I: defective distal H+ secretion
Seen in severe acidosis, (+) UAG, UpH>5.3, FeHCO3<3%, decr serum K
Primary, AI (Sjogrens, RA), nephrocalcinosis, meds (Ampho, Li, Ifosfamide);
normally a/w decreased K; if with increased K>> sickle cell, obstruction,
SLE, renal transplant

Proximal/Type II: due to decreased proximal reabsorption of the HCO3


Seen in moderate acidosis, +/- UAG, UpH<5.3, FeHCO3>15%, decr serum K
Primary (Fanconis syndrome = decreased proximal reabsorption of HCO3,
PO4, gluc, amino acids), paraprotein (MM, amyloidosis), meds
(acetazolamide, heavy metals, ifosfamide), renal transplant, decr vit D,
NRTIs

Hypoaldosteronism/Type IV: Increased K >> Decreased NH3


synthesis/delivery >> decr urine acid carrying capacity
Seen in mild acidosis, (+) UAG, UpH<5.3, FeHCO3 <3%, incr serum K
Decr. Renin: DM nephropathy, NSAIDs, chronic interstitial nephritis, HIV
Normal Renin, decr Aldo synth: primary adrenal disorders, ACEI, ARBs,
heparin
Decr. Response to aldosterone: Meds- K sparing diuretics, TMP-SMX,
pentamidine, calcineurin inhibitors, tubulointerstitial disease: sickle cell,
SLE, amyloid, diabetes

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*Type III RTA=rare autosomal recessive Sd that behaves like a mixture of
Type I & II.
Tx: of severe acidosis (pH<7.2)
DKA: insulin & IVF; AKA: dextrose, IVF, replete K, Mg, Phos as needed
Lactic acidosis: treat causative condition and avoid vasoconstrictors
Renal failure: HD
Methanol & ethylene glycol: early fomepizole, vit B6 (eth glyc), folate
(methanol), HD
Alkali therapy: NaHCO3 (eg. 3 50-mmol amp in 1L D5W) to get serum
HCO3 >8 and pH >7.2(est. mmol of HCO3 needed as 8-[HCO3]serum x wt x
0.5)

Metabolic Alkalosis (pH > 7.40, HCO3 > 24)


Saline responsive etiologies require an initiating and maintaining
factors
Saline resistant etiologies develop from various causes
Initiating events
Loss of H+: from GI tract or kidneys
Exogenous alkali
Contraction alkalosis: diuresis>>excretion of HCO3-poor
fluid>>extracellular fluid contracts around fixed amount of HCO3>>
Increases HCO3 concentration
Post-hypercapnia induced renal retention of bicarb, once respiratory
problem corrected, can have transient alkalosis
Maintenance factors
Volume depletion leads to increased proximal resorption of NaHCO3
and increased Aldosterone
Increased aldosterone (Hyperaldosteronism) leads to Na reabsorption
in exchange for K+ and H+ excretion, increasing HCO3 retention

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Hypokalemia leads to transcellular K+/H+ exchange and an intracellular
acidosis in renal proximal tubule cells promote bicarb reabsorption and
ammoniagenesis
Workup
Check volume status and UrCl
If UrCl< 20mEq/L >> saline responsive
If UrCl> 20mEq/L >> saline resistant (unless on diurectics)
UrNa unreliable in alkalemia
If UrCl > 20 and volume status corrected, check BP

Tx: for severe alkalosis (pH > 7.6)


If volume depleted: d/c diuretics and correct deficit with isotonic
saline (If Cardiopulm dz prevents IVF, use KCL, Acetazolamide, HCl)
If NGT drainage that cannot be d/c: PPI
Hyperaldosteronism: treat underlying condition

4. Hyponatremia & Hypernatremia


A, Hyponatremia
Excess water relative to sodium, almost always incr ADH
Appropriate Incr ADH: Hypovolemia, hypervolemia with decr EAV

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Sometimes with decr ADH (appropriately suppressed), kidneys cannot
excrete excess water
Primary polydipsia: ingestion of massive amount of
H2O(>12L/day)
Tea +toast or Beer potomania: decreased daily solute and incr
free H20>> not enough solute to excrete H2O
Workup
Check Plasma osmols
o Hypotonic hyponatremia: most common; true excess of free
H2O relative to Na
Check volume status (VS, orthostatics, JVP, skin turgor, MM,
peripheral edema, BUN, Cr, uric acid

o Hypertonic hyponatremia: excess of another effective


osmol(glu,mannitol) that pulls H2O intravascularly, diluting
contents
Glucose correction: for every 100mg/dl gluc over 100mg/dl,
a drop of serum sodium of 2.4 is seen

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o Isotonic Hyponatremia: rare lab artifact from hyperlipidemia or
hyperproteinemia (Normal serum sodium conc with plasma sent
to ABG lab)
Urine osmols: limited use as often over 300, however
o Uosm <100 in primary polydipsia and decr solute intake
o Uosm>300 Almost always means NOT SIADH
o If euvolemic and elevated Uosm, think about
glucocorticoid insufficiency , hypothyroidism, and
hypopituitarism
Tx:
Asymptomatic: correct serum Na rate of </= 0.5mEq/L/h
Symptomatic: intial rapid correction (2 mEq/L/h for first 2-3 hrs)
Never increase Na more than 10-12 mEq/L/d to avoid osmotic
demylenation (spastic quadriplegia, dysarthria, dysphagia), especially if
hyponatremia is CHRONIC
IVF: Can use below equation to calculate initial change in serum
sodium per liter infusate, however this equation assumes that infusate
is not excreted (no natural loss of H20 or Na, which is almost never the
case)
o ([Na]infusate [Na]serum)/TBW +1
TBW = kgx0.6(man), x0.5(woman or old man), x0.45(old
woman)
o Remember: in SIADH, infused Na will be excreted and likely will
retain some of the free water, resulting in a DROP in serum
Na(usually if Uosm > infusate osm)
Hypovolemic hyponatremia: volume repletion with NS will remove
stimulus for ADH production and serum Na will correct
SIADH: free water restriction and treat underlying cause

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o Hypertonic saline if resistant to fluid restriction, check Na
frequently and use above equation to calculate estimated change
in serum Na
o Salt tabs if chronic and no CHF
o Aquaresis with vaptan drugs, non-forumulary at LAC, but are
vasopressin receptor antagonists allowing water to NOT be
resorbed
o Demeclocycline causes nephrogenic DI, drops UrOsm
o Furosemide impairs renal water retention give sodium to
maintain euvolemia as needed
Hypervolemic hyponatremia: free water and sodium restrict
o Loop diuretics and increase EAV(vasodilators to incr CO in CHF,
colloid infusion in cirrhosis)

B. Hypernatremia
All patients by definition are hypertonic, usually loss of
hypotonic fluid and impaired access to free water
Workup/etiology:

Check UrOsm, UrNa, volume status (VS, orthostatics, JVP, skin


turgor, MM, peripheral edema, BUN, Cr)

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UrOsm >700-800 >> extrarenal loss or Na overload; UrNa to
differentiate
o GI H2O loss: vomiting, NGT drainage, osmotic diarrhea,
fistula
o Insensible loss: fever, exercise, vent
o Na overload: hypertonic saline(fluids with sodium bicarb),
mineralcorticoid excess
UrOsm <700-800 >> Renal loss; differentiate DI vs diuresis
with UrOsm and Hx
o Diuresis: Osmotic(glc,mannitol,urea), loops
o DI: ADH deficiency(central) vs resistant(nephrogenic)
Central: hypothalamic/pituitary disease, idiopathic,
hypoxia, anorexia, EtOH
Nephrogenic: Congenital receptor dysfxn
Drugs: Li, amphotericin, demeclocycline, foscarnet,
cidofovir
Metabolic: hypercalcemia, severe hypokalemia, protein
malnutrition, congenital
Tubulointerstitial: postobstruction, recovery in ATN, PKD, sickle
cell, sjogrens, amyloid, pregnancy
Tx: Give access to H2O, replace free H2O deficit
Liters of H2O = ([Na] serum 140)/140 x TBW
Replace half over 24 hours (Rate of Na drop should not
exceed 0.5 mEq/L/h to avoid cerebral edema)
o In 70kg male, 125ml/h of free H2O will drop
[Na] by ~0.5 mEq/L/h
Na Overload: D5W + loop diuretic

5. Hypokalemia & Hyperkalemia


Hypokalemia (very common in-patient finding)

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Transcellular shifts: Alkalemia, insulin, catecholamines, hypokalemic

periodic paralysis, acute increase in hematopoiesis (megaloblastic


anemia treated with B12, AML crisis), hypothermia

Si/Sx: Nausea, vomiting, ileus, weakness, muscle cramps,


rhabdomyolysis, polyuria.
Imaging: EKG: U waves, +/- Increased QT interval, ventricular ectopy
(PVCs, VT, VF)
Workup: Rule out transcellular shifts (see above)
While 24hr urine is a good study, difficult to get done by nursing
Transtubular K+ gradiant(TTKG) : (UrK/PK) / (Urosm/Posm)
o UrK>30 mEq/d or >15 mEq/L or TTKG >7 >> renal loss
o UrK<25 mEq/d or <15 mEq/L or TTKG <3 >>extrarenal
loss
Tx: If true depletion and not a transcellular shift:
o A drop of 1 mEq is roughly equal to 200 mEq of TOTAL body
loss. Commonly 0.1 mEq/L drop in serum K warrants 10meq KCL
of repletion, for example, Serum K of 3.0 is repleted with
100mEq of KCL to get to 4.0 serum K. This method avoids over

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replacement, however more aggressive repletion can be used for
patients that may have continued losses(medications, npo, DKA)
o In a person with normal GI tract, PO repletion is AS good as IV.
o No dose difference for IV or PO. K-dur is a tablet while oral KCL is
a powder that needs to be mixed with water. K-dur is more
convenient for patient and nursing.
o Maximum hourly rate of repletion: 10meq per hour. For example
to give 80 mEq of K, you can order K-dur 40mEq PO q4 hours x
doses. OR you can write KCL 80mEq IV over 8 hours.
o Check Mg if K is resistant to repletion and replete Mg as needed.
o If you have a doubt of K status while repleting, RECHECK value in
PM and sign this out to your night float to follow up on. Caution
with renal failure or oliguria.

Hyperkalemia
Transcellular shifts: Acidemia, insulin def (DM), Beta-blockers, dig
intoxication, massive cellular necrosis (tumor lysis, rhabdo, ischem.
bowel, hemolysis), hyperkalemic periodic paralysis, succinylcholine
Any cause of decreased GFR in kidneys, acute or chronic
Normal GFR with decreased renal K excretion
Normal Aldo
o Decreased EAV and lower flow through kidneys: CHF,
cirrhosis
o Excessive K intake: in conjuction with impairment in K
excretion or transcellular shift

Hypoaldosteronism: same as etiologies of hypoaldo RTA (type IV)


o Decr renin: diabetic nephropathy, NSAIDs, chronic interstitial
nephritis, HIV normal renin, decr aldo synthesis: adrenal
disorders, ACEI, ARBs, heparin

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o Decr response to aldosterone
Meds: K-sparing diuretics,TMP-SMX, pentamidine, calcineurin
inhibitors
Tubulointerstitial Disease: sickle cell, SLE, amyloid, diabetes
Si/Sx: Weakness, nausea, parasthesias, palpitations
Imaging: ECG: peaked T waves, increased PR interval, increased QRS
width, loss of P wave, sine wave pattern, PEA/VF (ECG: low sensitivity,
cardiac arrest can be first electrical manifestation!)

Tx: Calcium gluconate not routinely given for peaked T-waves, later EKG
changes warrant closer monitoring and calcium gluconate administration

6. Management of Magnesium & Phosphorus

Magnesium
o Hypermag is rarely a life threatening problem
o Hypomag should be corrected in a hospitalized patient
o Repletion
IV Mg repletion is ideal for hospitalized patients
Goal for cardiac patients 2 or above
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Oral Mg formulations often will not be as well absorbed or
have GI complications(diarrhea)
Serum Mg represents extracellular Mg only and not the total
body magnesium, which is why aggressive repletion
generally is well tolerated.
When repleting Mg, give Magnesium Sulfate 1g over 4
hours. 2g over 8hrs, 4g over 16hours, etc.
In the ICU, use ICU electrolyte replacement sheet

Phosphorus
o Hyperphosphatemia: Please see management as in RF above
o Hypophosphatemia: Can give as KPhosph or NaPhosph.
o Each mmol of KPhosph IV = 1.5 mEq of K+
Dose of sodium or potassium phos is the same
o 15mmol IV over 8 hours, 30mmol IV over 12 hours
o Oral repletion is generally less effective and has very
frequent dosing
o Rectal enema fleets Phosphasoda enema

7. Kidney Transplant Pearls


o Not done at LAC-USC, however on occasion we have patients that
have that are s/p transplant.
o When these patients come in, it is very important to contact the
transplant medicine physician managing the patient (often at an
outside institution) and discuss the case and current reason for
admission. Ensure med list is accurate and that all the meds are
available through our in-patient pharmacy. If a certain transplant
medication is not avaliable, check to see if patient has this
medication with them or have them bring it from home and then
write an order for: OK to administer patients home medication
XXXXX XXmg Qfrequency.
o Ensure medications that are given for in-patient indication do not
react with transplant medications.
o If patient pending surgery, stress dose steroids may be necessary,
can discuss with inpatient consult team or call outpatient
177
transplant medicine physician as steroid dose may have recently
changed, etc.

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SECTION 16: NEUROLOGY & SUBSTANCE ABUSE

1. Bacterial Meningitis
Si/Sx: fevers, altered mental status, nuchal rigidity
Only 44% have all three
Can also have hypothermia, generalized headache, neuro
deficits, papilledema, seizures (Listeria), petechiae/palpable
purpura (N. meninigitidis)
Organisms: Neisseria meningitides, Strep Pneumo, Listeria
monocytogenes, Haemophilus influenza, Staph Aureus, Gram
negative rods
Indications for CT prior to LP:
o Immunocompromised state
o Hx of CNS disease (mass, stroke, infection)
o New onset seizure
o Papilledema
o Abnormal consciousness
o Focal neuro deficit
Relative contraindications to LP:
Raised ICP/mass
Thrombocytopenia
Spinal epidural abscess or cellulitis
LP orders:
Tube 1: cell count w/differential
Tube 2: Gram stain, culture
Tube 3: Protein, glucose
Tube 4: cell count w/differential
Can also order HSV, India ink, Crypto antigen, AFB etc.
depending on what you are looking for
+ LP results:
o Opening pressure > 20 mmHg
o Increased WBCs
o Protein > 50
o Glucose < 40

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Empiric Treatment
o Age 2 50: Vancomycin IV 15 mg/kg Q8-12H +
Ceftriaxone 2 gm IV Q12H, Start dexamethasone before
antibiotics
o Age > 50: Vancomycin + Ceftriaxone + Ampicillin 2 gm IV
Q4H
o Penetrating head trauma: Vancomycin + cefepime 2 gm IV Q8H
or ceftazidime or meropenem 2 gm IV Q8H (to cover
pseuodomonas)
o Immunocompromised: Vancomycin + Ampicillin + Cefepime or
Meropenem

2. Stroke
Types of Stroke: Ischemic (thrombotic), Ischemic (embolic)
Ischemic hypoperfusion
Etiology:
o Intracerebral hemorrhage
Usually in small arteries/arterioles
Forms a hematoma
Occurs over minutes to hours
Causes: hypertension, trauma, bleeding diathesis, amyloid
angiopathy, cocaine use
o Subarachnoid hemorrhage
Usually caused by rupture of arterial aneurysm
Sudden thunderclap headache
Loss of consciousness, seizure, nausea, vomiting, focal
neuro deficits
o TIA: transient neurologic dysfunction without infarction, usually
< 24 hours
Initial Tests:
o CT head w/o contrast to rule out hemorrhage
Good for diagnosing intracerebreal hemorrhage
May miss subarachnoid, if suspicious get an LP
o EKG
o Glucose
180
tPA eligibility
o Inclusion:
Ischemic stroke causing measurable neuro deficit
Onset < 4.5 hours before treatment
Age >= 18
o Exclusion:
Stroke or head trauma in past 3 months
Previous ICH
Intracranial neoplasm, AVM, aneurysm
Recent intracranial or intraspinal surgery
Arterial puncture at noncompressible site in past 7 days
SAH
SBP > 185 or DBP > 110
Glucose < 50
Active internal bleeding
Acute bleeding diasthesis
Platelet < 100,000
INR > 1.7 or PT > 15s
Heparin use within 48 hours or elevated aPTT
CT showing hemorrhage
Evidence of multilobar infarction > 33% of cerebral
hemisphere
Follow up Testing:
o CT or MR angiogram head and neck to evaluate
vasculature (Neurology usually orders MR angiogram)
o Cardiac monitoring for 24 hours to monitor for Afib
o Echo to evaluate for thrombus
o CBC, PT, PTT, INR, fasting lipids
o Swallow assessment (you can perform your own bedside
swallow with sips of water)
BP management
o Goal < 180/105 for 24 hours after thrombolytic
o Use labetalol or nicardapine as first line
antihypertensives
o Hemorrhagic stroke goal: SBP 140-150s
181
o Start statin to reduce recurrent stroke risk

3. Alcohol Withdrawal
Symptoms can begin within 6 to 12 hours of last drink
o Stage 1: agitation, anxiety, insomnia, restlessness, tremor,
diaphoresis, palpitations, hypertension, headache
o Stage 2: (24 to 72 hours after last drink): similar to stage 1,
more GI symptoms: nausea, vomiting, diarrhea
o Stage 3: (72 to 96 hours after last drink): autonomic
hyperactivity, fever, tachycardia, hypertension, agitation,
drenching sweats, halucinations, disorientation
o Death from head trauma, CV complications,
aspiration, fluid/electrolyte abnormalities
Withdrawal seizures usually occur within 24 to 48 hours
of last drink
Alcoholic hallucinosis (24 to 48 hours): visual, tactile, or
auditory hallucinations
Management: Alcohol withdrawal CAN KILL the patient.
Tx depends on severity of withdrawal, you can try the following
approaches
o Ativan 2 mg IV Q4H PRN only
o Scheduled Ativan + Ativan PRN
o Librium + Ativan PRN
o Be aware that Librium is long acting, cleared by the liver
(which can be impaired in alcoholics). When patients are
discharged, they may drink + have Librium lingering.
o Check the MAR to see how much Ativan is needed daily
o As many of these patients are found down or have falls be
sure to check for any trauma and order any imaging
depending on the injury.

4. Opiate Withdrawal
Signs and Symptoms: Dysphoria, Restlessness, Myalgias, Rhinorrhea

182
Lacrimation, Nausea/vomiting, Diarrhea, BMP/electrolytes
Management
o Unlike alcohol withdrawal, opiate withdrawal will Not kill the
patient
o Manage symptoms with PRN opioid and non-opioid pain
medications
o Uptodate recommends long acting opioids such as
methadone for withdrawal
o Typically at county we use PO and IV PRNs until symptoms
resolve
o Non opioid medications include: clonidine (0.1 mg PO Q1H if
monitored closely)

5. Altered Mental Status


Etiology: Mnemonic ABCD ATOMIC Airway, Breathing,
Circulation, Dextrose/Thiamine/Narcan, Alcohol, Trauma, Overdose,
Metabolic, Infection, Carbon monoxide
Drugs: Opiates, benzos, TCA, salicylates, EtOH, anti-cholinergics,
cocaine, anti-epileptics
Infxn (esp. intracerebral, sepsis): Bacterial, viral, cryptococcal, fungal
Ischemia: Low flow (MI, CVA, hypotension), trauma (CNS bleed,
subdural hematoma), acute psychosis (steroids, anti-cholinergics)
Metabolic: Hypoglycemia, uremia, hypercalcemia, hyponatremia,
hypoxia, hypercarbia, hyperammonemia, hypothyroidism
Other: Seizure or post-ictal, trauma, psychiatric (pseudoseizure)
Dx: Check pulse ox/ABG, dexi, CMP, heme 8, UTox, serum volatile
screen, NH3, EKG, LP, imaging (first dry head CT then MRI if
indicated), consider EEG.

6. Delirium
Delirium is defined as disturbance of consciousness, change in
cognition, or development of perception disturbance that is not
explained by dementia, that develops over hours to days
Tx: Identify & manage underlying cause(s):

183
Correct electrolytes (Ca, Mg, Na (aim for Na=140))
Reverse hypoxia, hypercarbia, Manage organ failure (kidney, liver,
hypotension), Suspect & treat infections
o Avoid restraints/lines/catheters, as feasible
o Ensure effective communication & reorientation
o Sitter/family re-direct & re-orient pt
o Calm speak softly, no TV, soothing music
o Give glasses/hearing aids back
o Improve sleep/wake cycle (haldol as sleep aid)
o Mobilize PT & OT orders
Last resort, consider short-term (usually 1 wk) haloperidol or
olanzapine (in people w/ conditions such as Parkinsons disease
or dementia w/ Lewy bodies, use antipsychotics w/ caution or
epilepsy not at all) (QT?; Sz Hx?)Can consider EEG for
nonconvulsive

184
185
7. Dementia

Ddx: (potentially reversible in bold): Alzheimers, multi-infarct


dementia,
AIDS dementia, Parkinsons w/ dementia, Picks disease, Lewy Body
Dementia, B12 deficiency, thyroid disease, depression, cerebral
vasculitis, medication side effects (analgesics, anti-cholinergic,
antihypertensive, psychotropic, sedative-hypnotic agents), NPH, tumor,
subdural hematoma, delirium.
Dx: MMSE, B12, RPR, TSH, head CT (consider MRI), HIV test

186
8. Seizures
Classification
o Generalized:
tonic clonic: tonic contractions of muscles with
intermittent clonic relaxation of muscles
absence: loss of consciousness without loss of muscle
tone
o Partial
Simple: focal findings without loss of consciousness
Complex: simple + impairment of consciousness
Causes: electrolytes, alcohol, brain mass, infection, trauma
Orders:
o CMP
o Can order alcohol, Utox if high suspicion
o EEG (EEG order sheet in medicine folder and needs to be
faxed)
o MRI brain
Management
o Treat underlying cause if first seizure
o Consult neurology, they will be the best source for
management of these patients
o Generalized Tonic clonic seizures: phenytoin, valproate,
Topamax, lamotrigine
o Absence: Ethosuximide
o Partial: carbamazepine, phenytoin, valproate, lamotrigine
Status Epilepticus
o > 10 minutes of continuous seizure activity or sequential seizures
without complete recovery
o This is a neurologic emergency and neuro should be consulted
o As with any emergency: check CAB, glucose, oxygen, make sure
patient has IV access Start with Ativan 4 mg IV and escalate, may
eventually need to be placed in a coma (See flowchart): Emerg Med
J2002;19:96-100 doi:10.1136/emj.19.2.96

187
188
SECTION 17: PULMONARY

1. Asthma
Hx: Ask about frequency of symptoms per week, Night symptoms
Medication compliance, # of hospitalizations and intubations
Exposures/medications: pets, carpets, aspirin
Dx: PFTs before and after bronchodilator
Many patients claim to have asthma but have never had PFTs!
Methacholine challenge test to rule out asthma
Exercise induced bronchospasm: decreases in FEV1 >=10% after
graded exercise
Management: Based on severity/classification of asthma (see
stepwise approach from NIH) In addition remove environmental
triggers
** Asthma is associated with GERD and treatment of these
conditions can help with uncontrolled asthma
Monitor Peak flow

Asthma Exacerbations
o Peak flow < 40% = severe, < 60%=moderate exacerbation
o CXR, ABG
o steroids x 7 10 days
o oxygen
o Albuterol nebulizers back to back, space out to Q4H
o Ipratropium not typically effective but can be tried

189
190
191
2. COPD
Emphysema: more severe, constant dyspnea
Chronic bronchitis: >3 mo/yr for > 2 yrs of productive cough,
intermittent dyspnea
Orders:
o CXR: look for hyperinflation, flattened diaphragms
o PFTs (if never done before) can show obstructive pattern
o ABG can show respiratory acidosis with metabolic acidosis
Chronic Treatment
o Oxygen improves mortality, indicated if PaO2 < 55, O2 sat
< 89%
o Ipratropium > albuterol inhalers
o Inhaled corticosteroids
o Smoking cessation
Acute Exacerbation Treatment
o Nebulizers: Ipratropium 0.5 mg + albuterol 2.5 mg HHN
Inhaled q4H ATC or PRN
o Steroids: methylprednisone IV vs prednisone PO (if
tolerating PO)
o Azithromycin: treat any underlying infection as well as
having anti-inflammatory effects
o Oxygen: NC vs NPPV

3. Interstitial Lung Disease


Dx: Hx of exposure, medications, or diseases that can result in ILD
Imaging: CXR, High resolution CT without contrast: reticular nodular
or ground glass pattern, PFTs: restrictive
Labs based on etiology of ILD
Sarcoidosis: ACE level
SLE: ANA
RA: rheumatoid factor, anti CCP
Goodpasteurs: antiGBM
HIV
Wegeners c-ANCA
ChurgStrauss: c or p ANCA
192
Microscopic polyangitis: p-ANCA
ABPA: aspergillus IgE
Bronchoscopy/BAL
Lung biopsy
Tx: depends on the cause of the ILD, and these patients should be
followed by chest clinic

4. Pulmonary Embolus
Risk factors: Virchows triad, Hereditary hypercoagulability: Protein
C/S deficiencies, Factor V leidin mutation, Antithombin, PT,
Plasminogen deficiency, Reduced mobility, Cancer, Advanced age,
Pregnancy, postpartum period
Signs: Dyspnea (73%), Pleuritic chest pain (66%), Cough (37%), Leg
swelling (28%), Leg pain (26%)
PE Symptoms: Tachpnea, Rales/crackles, Tachycardia, S4, Increased
P2, Fever
Dx: Calculate Well s score to determine probability of DVT (write
score on the CTPA order), D-dimer for low or intermediate
probability (will be required by radiology prior to CTPA), ABG, CXR:
Hamptons hump (wedge infarct), Westermark (prominent
pulmonary artery) EKG -> S1Q3T3 pattern. Sinus tachycardia , RV
strain
Imaging:
Echo to evaluate RV
V/Q scan are usually not diagnostic and end up intermediate
CT Angiogram of Chest (check order in affinity as these
routinely get mis-ordered
Regular chest CT
Chest Xray
Lower extremity US to evaluate for DVT
Tx:
In unstable patient with massive PE or select high risk
patients without hypotension:

193
Oxygen, Fluids, thrombolytics, embolectomy if not
responsive to previous treatment
In hemodynamically stable patients goal is prevent
thrombus extension with anticoagulation (LMWH > heparin)
Treatment duration is 3 6 months
Can treat longer if severe risk factors, VTE is idiopathic,
VTE is recurrent
IVC filter placement
Indications: contraindication to anticoagulation,
recurrent embolism

5. Pulmonary HTN
Definition: Mean PAP > 25 mmHg at rest or > 30 mmHg with exercise
or Systolic PAP > 40 mmHg
WHO Categories:
I: Pulmonary Arterial Hypertension: idiopathic PAH, collagen
vascular diseases, intracardiac shunts, portal hypertension, HIV
II: Left sided heart disease
III: Primary Lung Disease: COPD, ILD, Sleep apnea
IV: Chronic thromboembolic disease
V: miscellaneous etiology: inflammation, extrinsic compression,
mechanical obstruction
Si: Loud P2, Tricuspid regurgitation, RV heave, JVD, LE edema
Dx: EKG showing Right axis deviation, Echo, R heart cath
Tx: Anticoagulation for Group I and IV, goal INR=2, Oxygen for Group
III, Diuretics for fluid retention
o Endothelin antaognists: Bosentan, Ambrisentant, sitaxsentan
o Calcium channel blockers: nifedipine, amlodipine
o Prostanoids: Epoprestenol, Iloprost
o PDE inhibitors: Sildenafil
o Overall these patients can be very complicated/sick, make
sure they have good outpatient follow up

6. Pleural Effusion
Dx: Thoracentesis: Exudate vs Transudate: [NEJM 2002;346:1971-77]
194
Lights Criteria for Exudate Sensitivity Specificity
Fluid/serum LDH >0.6 86 84
Fluid/serum Prot >0.5 98 83
LDH>2/3 Upper limit normal 82 89
Chol >43 75 80
Chol >60 54 92
Fluid/Serum chol >0.3 89 81
Serum-Fluid Albumin 87 92

Exudate: Pneumonia/parapneumonic (25% of all effusions),


malignancy (15%), TB, PE (10%), collagen vascular disease,
pancreatitis, esophageal rupture
Transudate: CHF (40% of all effusions, 80% are bilateral),
hepatichydrothorax, constrictive pericarditis, nephrotic Sd, PE
(usually exudative), malignancy causing lymphatic obstruction,
myxedema, continuous ambulatory peritoneal dialysis (CAPD)
Hemorrhagic exudates (Hct effusion/Hct blood > 50%): TB, Tumor,
Trauma ("The 3 Ts").

Chylothorax (TG >110): thoracic duct damage due to trauma,


malignancy, Lymphangiomyomatosis.

Other: Post-CABG, Dresslers Sd, uremia, post-radiation, asbestos


exposure, drug-induced, Meigs Syndrome, yellow nail syndrome

Complicated versus uncomplicated: complicated if positive gram


stain or pH <7.2 or glucose < 60. Usually requires drainage.

Indications for thora: Fever w/ a pleural effusion; 1 cm thick effusion

195
on US or lateral decubitus CXR w/o known cause; unilateral effusion
in CHF exacerbation; effusions in CHF that don't resolve in 3 days w/
diuresis (75% of CHF effusions resolve w/in 48h of diuresis); poor
oxygenation due to unresolving effusion(s).

7. Pulmonary Edema
Management:
UNLOAD ME : Upright posture, Nitrates/Nitroprusside, Lasix,
Oxygen, Albuterol /ipatropium, Dopamaine/dobutamine,
Morphine, Electric cardioversion

LMNOP Lasix, Morphine, Nitrates, Oxygen, Positioning

8. Cystic Fibrosis
5% of CF pts are diagnosed after age 16
Autosomal recessive inheritance. >1000 mutations can lead to CFTR
channel dysfxn.
Clinical manifestations:
Chronic Sinopulmonary Disease, chronic cough/sputum;
persistent infection w/ characteristic pathogens (e.g
Pseudomonas); airflow obstruction; chronic chest radiographic
abnormalities; sinus disease; nasal polyps.
GI & nutritional abnormalities: pancreatic insufficiency;
meconium ileus; D istal Intestinal Obstruction (DIOS); focal
biliary or multilobar cirrhosis
Obstructive azoospermia; congenital bil absence of Vas
Deferens, Diabetes; osteoporosis
Burkholderia Cepacia: Aerobic very resistant GNR (Bactrim,
Meropenem). 8 genomovars: Type III associated w/ poor
outcomes. Transmissible between pts! 3 foot rule for all CF
pts. Pts w/ Cepacia seen separately.
Dx: sweat chloride; known CF Mutations on both alleles; bioelectric
abnormalities in nasal epithelium in vivo
Tx:

196
Infection: Anti-pseudomonal antibiotics. Tobra 10 mg/kg/day
(with normal renal function). Accurate peak & trough levels are
important! BID dosing: Peak 20-30, Trough < 0.5. Levels from central
lines & implanted ports are inaccurate. Once good levels established,
only need to check q5 days unless changed in dose or change in renal
function.

Obstruction: Airway Clearance (Chest percussion, flutter valve,


high frequency oscillatory vest); Dornase Alpha 2.5 mg nebulized BID,
2 agonists

Inflammation: inhaled & oral steroids, Ibuprofen, ?azithromycin


PFTs at least q3mos w/ aggressive intervention for declines
Regular prevention w/ chest PT BID; TOBI 300 mg nebulized BID
(q.o. month); Dornase Alpha; Serevent, Flovent

Nutrition: pancreatic enzymes (1000-2000 lipase units/kg/meal;


Ultrase MT 20, Pancrease MT 20, & Creon 20 contain 20,000 lipase
units/capsule. DO NOT use generic pancrealipase); high fat, high salt
diets; caloric supplements; fat soluble vitamins (ADEKs); Megestrol
(Megace) or Marinol. Treat CF-induced diabetes w/ insulin NOT oral
agents.

197
SECTION 18 RHEUMATOLOGY

1. Systemic Lupus Erythematosis

Common Serology labs

Disease Association Sensitivity Specificity


Antibody
(Sensitivity)

Drug-induced lupus 95% 80%


Anti-histone
SLE

Anti-ds DNA SLE 57% 97%


Anti-Sm SLE 24-30% 96-98%
Anti-Ro/SS-A Sjgren's syndrome 50-60%
SLE 40-50%
Anti-La/SS-B Sjgren's syndrome 40-50%
SLE 15%
Anti-RNP MCTD 71-100% 84-100%
Anti-Scl-70 Systemic sclerosis 20% 100% for
ANCA Wegeners 70-90% diffuse
Anti-CCP granulomatosis
Rheumatoid arthritis 30-60% 95-98%
Diagnostic criteria for SLE
4 or more of the following during course of disease:
95% specificity, 75% sensitivity

Mucocutaneous
1. Rash with UV exposure
2. Malar rash
3. Oral and nasopharyngeal ulcers
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4. Discoid rash (scaly, round patches

Organ System
5. Arthritis (symmetric, nonerosive, 2 or more joints)
6. Serositis (pleuritis or pericarditis)
7. Renal (proteinuria >0.5g daily or any cellular casts)
8. Blood changes (hemolytic anemia, leucopenia, lymphopenia
thrombocytopenia)
9. Neuropsychiatric (seizures or psychosis)

Lab values
10. Positive ANA (99% sensitive, not specific)
11. Anti-dsDNA (sensitivity 75-100%), Anti-Sm, or antiphosholipid
antibodies

Drugs that cause Lupus: Hydralazine, Isoniazid, Procainamide,


Methyldopa, Quinidine, Chlorpranimide

Symptoms by organ system:


Constitutional: Fatigue, myalgia, weight change, fever
MSK/Skin: Arthritis, rashes, Raynaud phenomenon
Pulmonary: Pleurisy, pleural effusion, pneumonitis, interstitial lung disease
Cardiovascular: Pericarditis, Libman-Sacks endocarditis, myocarditis, CAD
Neurologic: Depression, cognitive deficits, delirium, psychosis, seizures,
headaches, peripheral neuropathies, movement disorders, cranial
neuropathies, myelitis, meninigitis.
Eye: Keratoconjuntivitis, episcleritis, scleritis, anterior uveitis
Hematologic: Leukopenia, anemia, thrombocytopenia, thrombophilia,
thromboembolic events

Useful Lab Tests:


Basics: CBC w/ diff, CMP, CK, ESR/CRP, Urinalysis
Serologic: ANA, anti-dsDNA Ab, Anti-Smith Ab, C3, C4

General treatments of lupus:


199
NSAIDS: Used for the treatment of joint pain, fever, headache, serositis

Antimalarials- Very effective for skin, joint, and constitutional symptoms


and for the prevention of clinical relapse. Survival benefit with odds ratio
of death of 0.13.

Glucocorticoids: Used for SLE with organ system involvement and for
acute flares. Solumedrol IV 1g daily can be used for acute lupus flares,
particularly for renal and CNS involvement. If clinically stable can start
Prednisone 1-2mg/kg per day and then tapered on an outpatient basis.

Immunosuppresants: Methotrexate, cyclophosphamide, azathioprine,


mycophenolate, and rituximab. Generally used in addition to steroids for
SLE with organ system involvement, in patients refractory to steroids, or to
lessen steroid dose.

Acute SLE problems/emergencies by organ system:


SLE flares=high DS DNA Ab, low C3/C4

PULMONARY
Acute pneumonitis (1-12% of SLE)
Presentation: Fever, cough +/- hemoptysis, pleurisy, dyspnea,
pulmonary infiltrates on x-ray, hypoxia, basilar rales, pleural effusion
(in 50 percent), serum anti-DNA antibodies, and no apparent
infection
Dx: CT w/ ground glass infiltrates or honey combing fibrosis. BAL
with lymphocytosis or granulocytosis
Tx: Prednisone 1mg/kg/day or Solumedrol 1g IV x3 days

Diffuse alveolar hemorrhage (rare)


Presentation: Acutely ill with dyspnea, hemoptysis, cough, +/-
anemia
Dx: CXR with alveolar bibasilar infiltrates. BAL with bloody fluid and
hemosiderin laden macrophages
Tx: Solumedrol 0.5-2g IV, Cyclophophamide, intubation, antibiotics
200
NEUROLOGIC
Psychosis: (5% of SLE patients)
Presentation: Disordered and bizarre thinking with delusions and
hallucinations, fluctuating delirium.
Tx: Antipsychotics acutely. Prednisone 1-2mg/kg PO daily. Can add
Cyclophophamide or Azathioprine.

Stroke (up to 20% of SLE patients)


Presentation: Strokes in SLE typically more severe with 77% suffering
with NIH stroke scale >6. Risk of death from stroke doubled
compared to non-SLE stroke in observational studies.
Dx: Antiphospholipid antibody positive, C3 and C4 levels low, Anti-DS
DNA levels high in addition to normal stroke workup.
Tx: If patient has had a stroke and has moderate/high APL antibody
levels then should start Warfarin with goal INR 2-3. If APL without
stroke or low levels of APL then ASA 81 mg daily.

Seizure (10-20% of SLE patients)


Presentation: Both generalized and partial seizures can occur. Often
in younger, newer onset SLE.
Dx: Associated with anti-50 kDa, anti-Sm, and APL. EEG and other
standard seizure work up.
Tx: Antimalarials decrease incidence of seizures. Antiepileptic drugs
as per typical seizure treatment.

RENAL
Lupus Nephritis
Presentation: Renal failure, nephritic syndrome.
Dx: Elevated creatinine, UA w/ micro with protein, casts. +anti DS
DNA titers, low C3 and C4 levels. Elevated protein/creatinine ratio.
Kidney biopsy for staging to determine treatment.
Tx: Depends on type of lupus nephritis seen on biopsy. If indicated
by biopsy use Methylprednisone 0.5-1gm IV qdaily for short course
along with Mycophenolate or cyclophosphamide. ACE inhibitors for
201
sclerodermal renal crisis, proteinuria. Aggressive hypertension
management. Consult Endocrine service.

2. Rheumatoid Arthritis

Diagnostic criteria for RA ( 6/10 points)


Number and site of involved joints
1. 2 to 10 large joints (from among shoulders, elbows,
hips, knees, and ankles) = 1 point
2. 1 to 3 small joints (from among the
metacarpophalangeal joints, proximal
interphalangeal joints, second through fifth
metatarsophalangeal joints, thumb interphalangeal
joints, and wrists) = 2 points
3. 4 to 10 small joints = 3 points
4. Greater than 10 joints (including at least 1 small
joint) = 5 points
Serological abnormality: Rheumatoid Factor or Anti-
citrullinated peptide/protein antibody
1. Low positive (above the upper limit of normal, ULN)
= 2 points
2. High positive (greater than three times the ULN) = 3
points
Elevated acute phase response: ESR or C-reactive
protein= 1 point
Symptom duration at least six weeks = 1 point
Labs:
Basic: CBC, CRP/ESR, Uric Acid, Urinalysis
Serologic: ANA, RF, Anti-citrullinated peptide/protein antibody
Imaging: Xrays hand/wrist/feet
Tx:
Mild RA: NSAID + hydroxychloroquine vs sulfasalazine
Moderate RA: NSAID or steroid + methotrexate

202
Resistant (to methotrexate) RA: Methotrexate + TNF
inhibitor/hydroxychloroquine/sulfasalazine

3. Gout

Definition: Inflammatory arthritis induced by deposition of


monosodium urate crystals
Predisposing factors: Alcohol, fatty diet, thiazide, loop diuretics, low
dose aspirin
Clinical features:
Pain, redness, swelling
80 percent of initial attacks involve a single joint, most often at the base
of the great toe (podagra) or knee
Elevated ESR, CRP, leukocytes, fever
Uric Acid levels 6.8 consistent, not diagnostic. Normal uric acid in 12-
43% with acute gout
Dx: Check Synovial fluid for:
Needle shaped, negatively birefrigent crystals under polarized
light (Sensitivity 85%, specificity 100%
WBC 3,000-50,000 (>50% PMNs)
Negative gram stain/culture
Tx:
Acute gout
NSAIDS - Naproxen 500mg PO BID
Colchicine 1.2 mg PO, with 0.6mg PO one hour later. Low dose
regimen leads to less GI toxicity. Dose reduction in
hepatic/renal insufficiency.
Steroids (If unable to take NSAIDS or colchicine, ex. RF)
If Systemic - Prednisone 30-50mg/day x 2 days, then taper
over 1 week
Chronic Gout
Allopurinol 100mg PO daily and titrate up (usually 300mg
daily)

203
** do NOT use Allopurinol for acute gout, as this will exacerbate
attack
Cochicine 0.6mg PO daily, can increase to 0.6mg PO BID
Probenicid 250mg PO BID and titrate up

4. Vasculitis
Definition: Inflammatory leukocytes in vessel walls with reactive damage.
Vessel damage leads to bleeding and downstream ischemia and necrosis

CLASSIFICATION BY VESSEL SIZE


Small vessel Medium Vessel Large vessel
Churg Strauss Polyarteritis nodosa Takayasus arteritis
Granulomatosis w/ CNS vasculitis Giant Cell arteritis
polyangiitis (Wegeners)
Henoch-Schonlen
Cryoglobulinemia
vasculitis
Hypersensitivity
vasculitis
Microscopic polyangiitis
Connective tissue
disorders
Vasculitis 2/2 viral infxn

Large vessel:

Takayasus arteritis
Presents with fatigue, malaise, syncope, headaches, abdominal
pain, arthralgias, chest pain, dyspnea, hemoptysis, angina.
ACR criteria: 3/6 positive- Sensitivity 90.5%, Specificity 98%
1. Age <40
2. Claudication of extremities
3. Decreased pulsation of one or both brachial arteries
4. Difference of at least 10mmHg in each arm

204
5. Bruit over one or both subclavian arteries or abdominal
aorta
6. Arteriogrpahic narrowing or occlusion of aorta, its
primary branches, or large arteries in the proximal upper
or lower extremities no due to other cause

Labs findings: Normochromic, normocytic anemia. WBC normal.


Elevated ESR, CRP. NegativeANA, ANCA, anti DS-DNA, APL.
MRI/CT/angiography w/ narrowing of large vessels.

Giant cell arteritis


Presents with fever, fatigue, weight loss, temporal headache, jaw
claudication (most specific history finding), amaurosis fugax
(transient monocular vision loss).
ACR criteria: 3/5 positive- Sensitivity 94%, Specificity 91%
1. Age >50
2. Localized headache of new onset
3. Tenderness or decreased pulse of the temporal artery
4. Erythrocyte sedimentation rate (ESR) greater than 50
5. Biopsy revealing a necrotizing arteritis with a
predominance of mononuclear cells or a granulomatous
process with multinucleated giant cells
Labs findings: Decreased albumin. AST/ALT elevation. Elevated ESR,
Elevated CRP.

Medium Vessel:

Polyarteritis nodosa
Associated with Hepatitis B, Hepatitis C, hairy cell leukemia.
ACR criteria: 3/10 with documented vasculitis-Sensitivity 82%,
Specificity 87%
1. Otherwise unexplained weight loss >4 kg
2. Livedo reticularis
3. Testicular pain or tenderness

205
4. Myalgias (excluding that of the shoulder and hip girdle),
weakness, or polyneuropathy
5. Mononeuropathy or polyneuropathy
6. New onset diastolic blood pressure >90 mmHg
7. Elevated levels of serum blood urea nitrogen (>40 mg/dL
or 14.3 mmol/L) or creatinine (>1.5 mg/dL or 132
mcmol/L)
8. Evidence of hepatitis B virus infection via serum antibody
or antigen serology
9. Characteristic arteriographic abnormalities not resulting
from noninflammatory disease processes
10. A biopsy of medium- or small-sized artery containing
polymorphonuclear cells

Labs findings: Normochromic, normocytic anemia. WBC normal.


Elevated ESR, CRP. Negative ANA, ANCA, anti DS-DNA, APL.
MRI/CT/angiography w/ narrowing of large vessels.

Small vessel:

Churg-Strauss (Eosinophilic granulomatosis with polyangiitis)-


Presents with asthma, eosinophilia, upper airway disease, skin
disease
ACR criteria: 4/6 positive- Sensitivity: 85%, Specificity of 99.7
1. Asthma (a history of wheezing or the finding of diffuse
high pitched wheezes on expiration)
2. Greater than 10 percent eosinophils on the differential
leukocyte count
3. Mononeuropathy (including multiplex) or polyneuropathy
4. Migratory or transient pulmonary opacities detected
radiographically
5. Paranasal sinus abnormality
6. Biopsy containing a blood vessel showing the
accumulation of eosinophils in extravascular areas

206
Lab findings: Eosinophilia (5,000-9,000 eosinophils), P-ANCA positive
(70-75%), BAL with eosinophils, CXR transient patchy opacities.

Wegeners disease (Granulomatosis with polyangiitis):


Granulomatous inflammation of upper and lower respiratory tracts
and glomerulonephritis
ACR Criteria: 2/4 positive- Sensitivity 88%, Specificity 92%
1. Nasal or oral inflammation (painful or painless oral ulcers
or purulent or bloody nasal discharge)
2. Abnormal chest radiograph showing nodules, fixed
infiltrates, or cavities
3. Abnormal urinary sediment (microscopic hematuria with
or without red cell casts)
4. Granulomatous inflammation on biopsy of an artery or
perivascular area
Labs findings: C-ANCA positive, UA w/ hematuria and proteinuria

Hypersenstivity Vasculitis
Drug induced vasculitis and serum sickness
ACR Criteria: 2/4 positive- Sensitivity 88%, Specificity 92%
1. Age >16
2. Use of possible offending drug in temporal relation to
symptoms
3. Palpable purpura
4. Maculopapular rash
5. Biopsy of a lesion showing neutrophils around an
arteriole/venule

Cryoglobulinemic vasculitis
Immunoglobulins precipitate in the cold and dissolve on warming
Associated with Hepatitis C
Small vessel inflammation results from deposition of
immunoglobulins and complement in the vessel wall
Type 1: Monoclonal immunoglobulin (IgM or IgG)

207
Type 2: Monoclonal IgM with activity against polyclonal
IgG
Type 3: Polyclonal IgM with activity against polyclonal IgG

5. Dermatomyositis/polymyositis
Immune mediated muscle injury
Dx: Symmetric proximal muscle weakness
Typical skin findings:
Gottrons sign (erythematous, scaly rash symmetrically
over MCP/IP joints
Heliotrope rash
Shawl sign and V sign (erythematous heliotrope over
chest/shoulders/back)
Nailbed changeds
Mechanics hands (roughening and cracking of skin of
hands)
Labs: Elevated serum muscle enzymes ( CK, LDH, AST, ALT, Aldolase)
Others: Myopathic changes on EMG. Muscle or Skin biopsy.
Malignancy: 5-7x incidence of malignancy vs normal population,
Associated with ovarian, lung, cervix, pancreas, bladder, stomach
malignancies
Tx: Steroids, Immunosuppression

6. Scleroderma
Presentation: Diffuse, thickened skin

DIFFUSE CUTANEOUS SCLERODERMA SYSTEMIC SYMPTOMS

Diffuse Early (<3 years after


Late (>3 years after onset)
cutaneous onset)
Constitutional Fatigue and weight loss Minimal, weight gain typical
Vascular Raynaud's often relatively Raynaud's more severe,

208
mild more telangiectasia
Rapid progression
Cutaneous Stable or regression
involving arms, trunk, face
Prominent arthralgia,
Flexion contractures and
stiffness, myalgia, muscle
Musculoskeletal deformities, joint/muscle
weakness, tendon friction
symptoms less prominent
rubs
More pronounced
symptoms, midgut and
Gastrointestinal Dysphagia, heartburn
anorectal complications
more common
Maximum risk for Reduced risk of new
myocarditis, pericardial involvement but progression
Cardiopulmonary
effusion, intersitital of existing established
pulmonary fibrosis visceral fibrosis
Maximum risk period for Renal crisis less frequent,
Renal
scleroderma after 5 years uncommon after 5 years

LIMITED CUTANEOUS SCLERODERMA SYMPTOMS

Limited Early (<10 years


Late (>10 years after onset)
cutaneous after onset)
Only secondary to visceral
Constitutional None
complications
Raynaud's
typically severe Raynaud's persists, often causing
Vascular
and longstanding digital ulceration or gangrene
telangiectasia
Cutaneous Mild sclerosis with Stable, calcinosis more prominent

209
little progression
on trunk, face
Occasional joint
Musculoskeletal Mild flexion contractures
stiffness
More pronounced symptoms,
Dysphagia,
Gastrointestinal midgut and anorectal complications
heartburn
more common
Lung fibrosis may develop, but often
progresses slowly, Anti-SCL-70
predicts increased risk of severe
Usually no
Cardiopulmonary fibrosis. Maximum risk for
involvement
developing isolated pulmonary
hypertension and secondary right
ventricular failure.
Rarely involved, anti-RNA
Renal No involvement polymerase predicts increased risk
of renal involvement.

210
SECTION 19: PHARMACY

1. Steroid Dosing
NAME Gluco. Mineralo. T 1/2 in
Potency potency hours
Hydrocortisone 1 1 8
Cortisone acetate 0.8 0.8 PO 8, IM 18
Prednisone 4 0.8 16-36
Prednisolone 4 0.8 16-36
Methylprednisolone 5 0.5 18-40
Dexamethasone 30 0 36-54
Betamethasone 28 0 36-54
Triamcinolone 5 0 12-36
Fludrocosrtisone 15 200 -
Deoxycorticosterone 0 20 -
Aldosterone 0.3 200-1000 -

2. Beta Blocker Dosing


Drug Dose B-1 Selective Once Daily
Equivalence Dosing
Acebutolol 200mg Yes Yes
Atenolol 50mg Yes Yes
Bisoprolol 10mg Yes Yes
Carvedilol 50mg No No
Labetalol 200mg No No
Metoprolol 100mg Yes Yes (SR)
Nadolol 80mg No Yes
Oxprenolol 80mg No No
Pindolol 7.5mg No Yes
Propranolol 80mg No Yes (LA)

211
Sotalol 80mg No No
Timolol 10mg No No

3. Ace Inhibitor and ARB Dosing

DRUG DOSE EQUIVALENCE


Captopril 12.5 mg tid
Enalapril 5 mg daily
Ramipril 2.5 mg daily
Lisinopril 10 mg daily
Quinapril 10 mg daily
Fosinopril 10 mg daily
Cilazapril 2.5 mg daily
Benazepril 10 mg daily
Perindopril 2 mg daily
Trandolapril 1 mg daily

DRUG DOSE EQUIVALENCE


Irbesartan 150mg
Valsartan 80mg
Losartan 50mg
Telmisartan 40mg
Candesartan 8mg

** For any questions regarding medications and dosing, call inpatient


pharmacy at x9-7641 and ask for your ward pharmacist (7B, 7C, etc).

212
SECTION 20 - DISCHARGES

1. Discharge Summary
When a patient is discharged from the hospital, you must
include in his/her chart a paper discharge form (available in
English or Spanish) which can be found in the resident work
rooms on each ward. Be sure to include all relevant information
including discharge medications and f/u appts.
Place prescriptions in the front of the chart, remember that it
takes approx. 4-5 hours for prescriptions to be filled, so if you
anticipate an AM discharge, either ask the clerk to drop them
off the night before, or drop them off yourself in at the
outpatient pharmacy before you leave.

2. Discharge Dictations

Call: 1-888-201-8590
Enter your physician ID number, then #. (i.e. 1144XX#)
Enter work type 10 for discharge summary, then #.
Enter medical record number, then #.

Important things that should be in a Discharge Dictation:

First and Last name (spelled out) of patient and Attending


Date of Admission
Date of Discharge
Discharge Diagnosis (If multiple, enter major diagnosis first)
Summary of Hospital Course including:
Diagnostic Imaging (CT Chest, Brain, MRI, etc)
Procedures w/ results (EGD, colonoscopy, LP, etc)
Consults (Neurosurgery, GI, Liver, etc)
Condition at Discharge
Discharge Medications
Discharge Follow Up appointments
213
3. Transfer Discharges
Sometimes, you may need to transfer a patient to another
hospital or to a long term care or rehab facility.
In these scenarios be sure to:
1. Attach the normal paper discharge summary.
2. Include a typed Transfer/Discharge Summary similar to
what you would write if you were transferring to a
different ward in the hospital (Including any MICU
course, WARDS course, CCU course, etc).
3. Attach the 3 part, multi colored, duplicate transfer
form available on each ward (ask the ward clerk).
4. Write COPY CHART in MR orders section of chart.
5. Be sure to contact Rancho liason, or transfer MD (if
necessary) at other hospital.

4. Against Medical Advice (AMA) Discharge


When a patient expresses the desire to leave AMA:
Call your senior resident and tell them patient wants to LAMA.
ALWAYS try to convince the patient to stay and receive
appropriate medical care. Explain the severity of the patients
illness, the necessity of the treatment, and the specific dangers
(including death if applicable) of LAMA.
If patient has capacity, and can repeat the dangers of leaving
AMA, then have patient sign the AMA form. If patient refuses to
sign the AMA form, have another MD or nurse sign the form as a
witness.
Document in affinity your conversation with the patient and be
sure to include everything written above, especially the possibility
of death if patient leaves AMA.
Complete a paper Discharge Summary and place it in his chart and
write patient leaving AMA on the D/C summary.
Call the dictation line and dictate the patients hospital course,
and that patient left AMA.

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SECTION 21 HOW TO SURVIVE IN THE CLINICS
1. Specialty Clinics
o Hudson
Clinic code to document patient encounter on Affinity:
H223C
2829 S. Grand Ave., Los Angeles, CA 90007
o Roybal
Clinic code to document patient encounter on Affinity:
R1096C
245 S. Fetterly Ave., Los Angeles, CA 90022
o VA Downtown
351 E. Temple St., Los Angeles, CA 90012
o El Monte
Clinic code to document patient encounter on Affinity:
E222C
10953 Ramona Blvd., El Monte, CA 91731
o Rand-Schrader (5P21; HIV/AIDS clinic)
1300 N. Mission Road, Los Angeles, CA 90033
2. Continuity Clinic located in Outpatient Department building
(OPD)
1:00-1:30pm: didactic ambulatory curriculum session
o Each week, one resident is assigned to present a 1-page
summary of the designated clinic article to the group
o Each resident will be expected to have read the article and
cases for each clinic session.
o Be cognizant of your assigned day for clinic presentation
(available on Amion)
1:30-5:00p: direct patient care
o Document each patient visit in Affinity
Affinity clinic code: varies
Translation machines are available in the clinic or
may call the Health Care Interpreter Network at (323)
226-3600 (code: 201609).

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Social Workers are available in the clinics as well.
All male house officers must be chaperoned by a
female medical assistant or nurse when performing
breast, pelvic, genital or rectal exams on female
patients. Document the name of the chaperone in the
chart.
Document Routine Health Mainteance (RHM) at the
end of each. Examples include: urging cessation of
smoking, updating vaccinations, performing Pap
smears, breast examinations, digital prostate
examinations, and colon cancer screening.
o Review each patient visit with an attending
physician.
o All clinic notes must be co-signed by an
attending

3. Galaxy (only for clinic 4P61)


o A system created for closer follow-up on labs and
diagnostic studies. Information is reviewed by Galaxy on-
call resident who calls patients directly to review results
and adjust care plans, when appropriate.
o Page the on-call Galaxy resident (available on Amion) to
setup for a particular patient who needs closer follow-up.

4. Admissions from Clinic


o Stable patients requiring hospitalizationclinic attending
must approve all recommendations for hospitalization.
Once approved, call Utilization Review (UR) at (323) 226-
2212 to inform them of the admission. Inform the
Medicine Consult resident of the impending admission by
paging the service beeper (213) 919-9218. The two star
Emergency Department resident must be contacted for
acceptance of any clinic patient referred directly to the
Emergency Department.
o Emergency situationsCall a code blue and notify your
attending and charge nurse. Start ACLS protocol.

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SECTION 22 - END OF LIFE
1. DNR/DNI
o Do Not Resuscitate (DNR):do not do CPR: its use is not
intended to indicate that any other therapeutics are to be
withheld or limited
o Do Not Intubate (DNI): in the event of cardiopulmonary
failure, patient does not desire mechanical ventilation
o Generally, patients should be both DNR and DNI or full code.
o In patients with capacity: address and document DNR/DNI
code status in patients medical record.
o In patients without capacity: determine if a surrogate is
available. Surrogate should act in accordance with patients
desires or in the best interest of the patient, if patients
wishes are unknown. Document code status to that effect in
patients medical record.
o In patients without capacity and surrogate: decisions
should be based on medical judgment and what is believed
to be in the best interest of the patient. In the event that
there is conflict among members of the health care team,
consultation with the Ethics Resource Committee may be
solicited.
o An order to forgo CPR must be written and signed by a
licensed physician in the order sheet in the patients medical
record. Write Do Not Do CPR. Unacceptable terms include
DNR, No ACLS, and No BCLS.

2. Comfort care
o The focus of care should be to optimize patient comfort and to
allow a peaceful death in the presence of family and friends.
o Consider carefully what medications and procedures the
patient is receiving and whether or not they are necessary (i.e.

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does the benefit in the short term justify the burden or
disruption in a dying patient?)
o You may choose to use available comfort care order sets found
under Departments > Palliative Care on intranet page.
o Recommendations:
General Care- Private room with 24 hour visitation
*STOP nonessential medications.
*STOP unnecessary labs, needle sticks, radiographs, etc.
Oral Care- Lip balm/ water q4hrs ATC dry lips/ mouth
Eye Care- Artificial tears 2 drops to eyes q4hrs PRN dry
eyes
Fever- Acetaminophen 650mg PO/PR q4hrs PRN T > 101 F
Nausea- Metocloperamide 10mg q6hrs IV/PO q6hrs ATC
Bowel regimen- Bisacodyl 10mg supp PRN no BM x 48hrs
Agitated Delirium- Haloperidol 1mg SL q8hrs PRN
agitation
Seizures- Lorazepam 2mg IV q4hrs PRN seizure > 5 min
Pain or Dyspnea- Reassess frequently. Titrate to symptom
relief.
If patient opioid nave, consider
o Morphine sulfate 5mg PO q4hrs ATC or
o Morphine sulfate 2mg IV q4hrs ATC or
o Morphine sulfate 1mg/hr IV continuous
infusion
If patient previously on opioid for symptoms, titrate
starting from current dose and adjust based on
patient needs
Labored breathing/ Anxiety- Lorazepam 0.5mg
IV q4hrs PRN
*Use opioids as 1st line treatment and
Lorazepam as adjunct
Excessive secretions- Glycopyrrolate 0.4mg
IV/SL q4hrs ATC

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3. Palliative Care/ Hospice Care
Palliative care Hospice care
Palliate symptoms Palliate symptoms
Anyone is eligible Terminal illness
Not necessarily end of life care Only end of life care; Prognosis
<6 months if illness runs
expected course
Able to continue with curative No further curative therapies;
treatment Focus on comfort

When to consult Palliative Care (consult line: 9-8532; location:


5G100)
o Team/patient/family needs help with complex decision
making
o Goals of care clarification
o Code status discussions
o Frequent visits to the emergency department or admissions
to the hospital for same diagnosis
o Prolonged length of stay without evidence of improvement
or poor prognosis
o Unacceptable symptom distress (i.e. pain, dyspnea, nausea,
etc.)
o Uncontrolled psychological or spiritual issues at end of life
o Provide family support
o Provide information and resources to patients/family
o Determine hospice eligibility

4. Death Exam
o Death pronouncement is the official time of death so do not
delay unnecessarily once called by nursing staff.

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o If family is present, introduce yourself, offer a sympathetic
statement, and explain your role (i.e.: I am Dr. . I am very sorry
for your loss. I am here to examine yourand pronounce
his/her death.
o If family is absent, call the next-of-kin to deliver the message.
o Confirmation of death:
First, confirm identity of patient with hospital tag
Note general appearance of the body, lack of respiratory
effort, unresponsiveness to verbal and noxious stimuli,
fixed and dilated pupils, absence of carotid pulse, and
absence of heart and breath sounds on auscultation
Pronounce the time of death
o Complete Death Certificate:
Usually Nursing staff contacts One Legacy who deals with
organ donation issues
Document Death Note on Affinity essentially stating your
exam findings
Dictate the discharge summary of the hospital course

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SECTION 23 MEDICAL INFORMATICS
Amion: Online Scheduling System; available at www.amion.com
(login: uscim)
Affinity: Electronic Medical Records System. Daily Notes (H and P,
consult notes, procedures)
CCIS: Electronic Medical Records System for ICU and CCU
(Progress Notes [NOT H and P], View Current medications)
E-signout: Electronic Patient Handoff System; available at
www.uscnorris.com/esignout
Museweb: Electronic EKG Records System
PADI: Electronic Pharmacy System. Used in the clinics to
electronically prescribe medications under the license of
supervising physician. Used in the inpatient setting to view
current medications and prescribed outpatient medications.
QUANTIM: Portal to assess Department of Emergency Medicine
documentations and to view delinquencies (i.e.: review/sign
dictated discharge summaries).
SYNAPSE: Electronic Radiology Information System to assess
diagnostic imaging
RPS (Referral Processing System): Electronic Referral System
used to initiate referral to specialist
E-consult: Recently adopted, more efficient Electronic Referral
System for specialty referrals (Note: Not all specialties have
switched to E-consult, therefore, will still need to use RPS for
those specialties not listed under the E-consult login page)
VERINFORM: visit the USC Internal Medicine Residency Data
Management Website (VERINFORM) to update duty hours,
complete/view evaluations, and to document all procedures:
https://rm.verinform.com/lac

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SECTION 24 LOCAL OUTSIDE HOSPITAL NUMBERS

HOSPITAL MAIN # MED RECORDS MED REC fax#


Cal Hospital Med Ctr 213- 748-2411 213- 742-5470 213- 742-5669
Cedars Sinai 310-423-3277 310- 423-2259 310- 423-0113
White Memorial 323-268-5000 Main, then x 1012 323- 881-8755
Good Samaritan 213- 977-2121 213- 977-2115 213- 977-2106
Harbor-UCLA 310- 222-2345 310- 222-2061 310- 782-1796
Hollywood Presbyterian 213- 413-3000 323- 913-4960 323- 666-2939
Olive View-UCLA 818- 364-1555 818- 364-4124 818- 364-3518
Ronald Regan-UCLA 310- 267-9119 310- 825-6021 310- 825-3356
UCLA Med Ctr, Santa Monica 310- 319-4000 310- 825-6021 310- 825-3356

** When requesting patient information from medical records


offices through RELASE OF INFORMATION AUTHORIZATION
FORM, please be sure to include point of contact name, phone
number (team VOIP or pager), and fax number.

** If patient is unable to provide signature, please have family


member or MD sign the form, and write patient unable to sign on
the medical release form.

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