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Surviving Floor Call

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ELECTROLYTE REPLACEMENT

Potassium: 10 meq will raise K by 0.1


Cannot absorb more than 40-50 meq orally at one time
Max peripheral infusion is 10 meq/hr
Max central line infusion is 20 meq/hr
Oral replacement > IV replacement
Check and replace Mg!

Phosphorus:
Oral replacement
IV replacement – Kphos 30 mmol has ~ 40 meq K
Hypophosphatemia: Leads to weakness, bone pain, altered mental status. Caused by
chronic alcoholism, refeeding syndrome, TPN

Sodium:
Hyponatremia: Determine volume status
Hypovolemic (dehydration, vomiting, diarrhea, → 0.9 NS
Euvolemic → water restriction, Demeclocyline, tolvaptan (ADH antagonist)
Urine Na ↑ (>20), urine osmo ↑ (>200), serum osmo ↓
Hypervolemic → Diuretics
Correct serum Na by 8-12 in 24 hours and 18 in 48 hours (<0.5 meq/hr). You generally
only need to raise the serum sodium by about 5 to see symptomatic improvement
Use 3% NS if symptomatic hyponatremia. Must be in the ICU with central line to use this
Check urine sodium, urine osmolarity, serum osmolarity = 2x(Na+(BUN/2.8) + (blood
sugar/18))
Corrected Na (for ↑ glucose) = Na + (Glucose -5/3.5)
FYI: 0.9 NS = 153 meq Na
FYI: 3% saline = 513 meq

Magnesium:
1 mg IV raises Mg by 0.1
800 mg PO BID raises Mg by 0.4

Calcium:
Calcium chloride is 3x as bioavailable as calcium gluconate for replacement in
hypocalcemia
Hypercalcemia
Correct calcium (for ↓ albumin) = Ca + (0.8x (4-alb))
Due to increased resorption from bone, increased GI uptake or decreased renal excretion
(HCTZ), malignancy, hyperparathyroidism (↑ serum Ca, ↓ serum Phos), Paget’s, milk-alkali,
sarcoidosis
Stones, bones, groans and psychiatric overtones
Treatment: IVF, Lasix, bisphosphonates, Calcitonin

DIURETICS:
“BUN + Age = lasix dose”
Creatinine x2 = total daily lasix dose
1 mg Bumex IV = 20 mg Lasix IV = 40 mg Lasix PO
IV Lasix bolus = IV lasix infusion efficacy
Diuretics → contraction alkalosis (↓ Na, K, Cl, bicarb)

ANION GAP METABOLIC ACIDOSIS (MUDPILES)


Methanol (elevated osmol gap): Can cause vision loss. Treat with fomepizole or
ethanol or hemodialysis
Uremia
DKA (or alcoholic ketoacidosis which develops after the person stops drinking so serum
alcohol will be negative)
Paraldehyde
INH
Lactic Acidosis
Ethylene glycol/isopropyl alcohol (elevated osmol gap, presence of calcium oxalate
crystals in urine). Treat with fomepizole or ethanol
Salicylates

NON-ANION GAP METABOLIC ACIDOSIS (Hard-up)


May treat with bicarb
Hyperalimentation (TPN)
Acetazolamide
Renal Tubular Acidosis (RTA)
RTA type I (distal tubule) inability of distal tubule to secrete acid. Urine pH <
5.3, ↓ serum K (increased K excretion), ↓ serum bicarb
RTA Type II (proximal) inability of proximal tubule to reabsorb bicarb. Urine pH
> 5.3. ↓↓ serum bicarb. Associated with Fanconi’s syndrome.
RTA Type IV (hypo-aldosterone) decreased ammonia excretion. ↑ serum K
Diarrhea (loss of bicarb)
Ureteroenteric fistula
Pancreatic fistula

Indications for emergent hemodialysis (AEIOU


Metabolic acidosis
Electrolyte disturbance (↑↑K,)
Ingestion/drug overdose
Fluid overload
Uremia

SHOCK
Type Distributive Cardiogenic Obstructive Hypovolemic
Causes Sepsis ↓CO PE Hemorrhagic
Anaphylaxis MI, arrhythmia Tension Dehydration
Neurogenic pneumo
Tamponade
Skin Warm Cool Cool Cool
Pink Pale Pale Pale
Cardiac ↑ ↓↓ ↓ ↓
output
SVR ↓↓ ↑(initially) → normal → ↑ ↓
decreased
CVP ↓ ↑ ↑ ↓
HR ↑ NC or ↓ ↑ ↑
Treatment Antibiotics Oxygen Treat cause Fluids
Fluids Pressors Blood
Pressors IABP
Steroids

Adequate Urine Output = 50 ml/kg/hr

BUN/Cr ratio: > 20 = pre-renal

Light’s Criteria
The fluid is an exudate if:
Pleural protein/serum protein > 0.5
Pleural LDH/serum LDH > 0/6
Pleural LDH > 67% normal

CARDIOLOGY TOPICS:
Digoxin loading: 500 mg IV → 6 hours later followed by 250 mg IV → 6 hours later 250 mg IV
followed by PO
Digoxin + ↑K (often in the setting of AKI) → emergent dialysis. Do NOT give calcium
gluconate (leads to stone heart)
Quick Tips to Decoding an EKG
LVH: Single lead R or S >25
R or S in any two leads > 35 (I like V3 and V5)
aVL > 11
Posterior MI: V1-V3 tall R waves
LAFB: Left axis, QRS 100-120 ms, deep S in II, III, aVF, tall R in aVL, I, V5-V6
PFB: Right axis, QRs 100-120 ms, tall R in II, III, aVF, deep S in aVL, I, V5-V6
RBBB: QRS > 120 ms, RSR’ in V1-V2, reciprocal changes in lateral leads
LBBB: QRS > 120 ms, RSR’ in V5-V6, broad notched R wave, may have ST depression or
TWI in lateral leads
RBBB + LAFB: QRS > 120 ms, LAD, RSR’ in V1-V2
RBBB + PFB: QRS > 120 ms, RAD, RSR’ in V1-V2

Types of Cardiac Stents


Bare Metal Stents (BMS): Requires dual anti-platelet therapy for 30 days
Drug Eluding Stents (DES): Requires dual anti-platelet therapy for 1 year unless
significant bleeding event occurs

Aortic Stenosis: Avoid afterload reduction (ACE inhibitors, hydralazine, Imdur). This will lead
to increased pressure gradient between the aorta and the LV leading to decreased profusion.

Stress Tests
Imaging (1)
Echocardiogram: Assesses wall motion, valvular abnormalities
Nuclear Perfusion: Radiotracer tagged RBC resting vs. stress images. Reversible defect
= ischemia. Fixed defect = infarction or interference
Stress (2)
Exercise: Best physiologic and functional assessment of cardiac ability, able to
see EKG changes
Adenosine/Lexiscan: Contraindicated if patient actively wheezing, caffeine
intake within 12 hours
Dobutamine (least preferred):
1+2 → exercise stress echo OR Lexiscan stress nuclear OR Dobutamine stress echo OR
exercise stress nuclear study

INSULIN
Basal Bolus
Weight kg x (0.3-0.7 depending on insulin sensitivity) = total daily dose (TDD)
TDD/2 = Lantus dose + total for three meals
Meals / 3 = total for each meal
Example: 100 kg female, insulin naïve
TDD: 100 x 0.3 = 30
30/2 = 15 for lantus and 15 for meals
15/3 = 5 units for each meal
Steroids: Increase serum WBC due to decreased WBC adherence to endothelial wall
Increase blood glucose due to increased liver gluconeogenesis and anti-insulin effects on
peripheral tissues

HEMATOLOGY -
DIFFERENTIATING ANEMIA
Microcytic (MCV < 80): Order iron studies, retic count, peripheral smear
Iron Deficiency: ↓ total iron, ↓ Ferritin, ↑ TIBC, ↑RDW
α,β Thalassemia: ↓HbA, normal RDW
Lead Poisoning: ↓heme, ↑ lead levels
Sideroblastic: ↑ total iron, ↑ Ferritin, ↑ TIBC, ringed sideroblasts (nucleated RBC with
iron deposits)
Sickle Cell: HbS
Hyperthyroidism
Macrocytic (MCV > 100): Order B12, folate levels, retic count, peripheral smear
Folate Deficiency: ↓ DNA production, hypersegmented PMNs, normal MMA, takes
months to develop
B12 Deficiency: hypersegmented PMNs, ↑MMA, takes years to develop. Consider
pernicious anemia (60s)
Acute leukemia
Reticulocytosis: ↑ retic count
Alcohol abuse
Myelodysplastic syndrome
Hypothyroid
Normocytic Anemia: Order iron studies, retic count, peripheral smear
Anemia of chronic disease: ↓ Iron, ↑ Ferritin, ↓ TIBC
Renal failure → ↓ EPO
Dilutional (pregnancy)
Aplastic Anemia: Parvo B19
Spherocytosis – defect in RBC membrane protein leading to hemolytic anemia
DIC/TTP/HUS

Chronology of Leukemia: ALL → AML (Auer rods) → CML (Philadelphia chromosome-


BCL-Abl) → CLL

Disseminated Intravascular Coagulation (DIC)


Hypercoagulable state → thrombosis → depletion of clotting factors → hemorrhage
Causes: Sepsis, placental abruption, crush injuries, heat stroke, burns
Labs: ↓↓ platelets, ↑PT/PTT, ↓ Fibrinogen (+d-dimer), schistocytes
Treatment: Treat underlying cause! Can give platelets, FFP but will be degraded

Thrombotic Thrombocytic Purpura (TTP)


FAT RN (need 3/5): Fever, anemia (hemolytic), thrombocytopenia, renal failure,
neurologic changes
Labs: ↓↓ platelets, PT/PTT normal!, schistocytes on peripheral smear
Treatment: Plasmaphoresis
Hypercoagulable State Workup
↓ Protein C, S
Factor V Leiden
Prothrombin mutation
Antiphospholipid, anti-cardiolipin antibodies
Anti-thrombin III deficiency
Malignancy
Tumor Lysis Syndrome: Common with acute leukemia and initiating treatment
↑K, ↑ uric acid, ↑ phos, ↓ Ca, ↑LDH
Prophylaxis: Allopurinol

Neutropenia: Absolute PMN count < 500 + fever = neutropenic fever. Must treat with broad
spectrum Antibiotics. If fever persists, consider anti-fungals
ANC = WBC x (Polys + Bands/100)
Bone Scan detects osteoBlastic activity only. Useful in detecting metabolically active sites
(inflammation, infection, malignancy.) Do not order when evaluating skeleton for multiple
myeloma or osteoporosis as these are predominately osteoClastic mechanisms. Order skeletal
survey (plain XR)

COMPLICATIONS of HYPOXIA (PaO2<60)


Anaerobic metabolism → ↑ lactic acid
Peripheral vasodilation
Pulmonary vasoconstriction → shunting
Fall off the Hb dissociation curve

CAUSES of UNCONSCIOUSNESS
AEIOU CHESS TIPPS
Alcohol, Epilepsy, insulin, overdose, uremia
Cardiac (MI), hypoxia, environmental (hypothermia), stroke, sepsis
Trauma, ingestion, psych, phenothiazine, salicylates

Common Hospital Admissions


CAP
Azithromycin + Rocephin OR Levaquin
Albuterol/Atrovent nebs
Oxygen – wean to maintain sats > 92%
Blood, respiratory cultures
Strep pneumonia or legionella antigen

HCAP
Hospitalized within the last 3 months, resident of nursing home
Need MRSA, anaerobic and double pseudomonal coverage
Example: Vancomycin + Cefepime + Levaquin
Treat the same as CAP
UTI
Is it really an UTI? WBC on microscopy?
Urine culture
Check for previous urine cultures and sensitivities
IV antibiotics – IV Rocephin is a good one to start with
IVF if needed
AKI?

Sepsis
Do they meet SIRS criteria (HR, RR, Temp, WBC)
IVF needed
Foley to monitor I/Os?
Blood/urine/respiratory cultures
Appropriate antibiotics
Lactic acid

Acute (on Chronic?) Renal Failure


Pre-renal: FENa <1% (kidneys try to reabsorb Na)
Renal: FENa >1% (tubular damage, unable to resorb Na) – most common cause is ATN
Discontinue NSAIDs, ACE/ARB and other nephrotoxins
Check UA, renal ultrasound to rule out infection and obstruction
IVF if indicated
Trend BMP
Foley to monitor I/Os?

Acute Respiratory Distress Syndrome (ARDS):


Acute
Bilateral infiltrates
PaO2/FiO2 ratio < 200
PCWP < 18 (not heart failure)
Causes: Trauma, burns, pancreatitis, sepsis, intubation, chemical inhalation
Treatment: Treat underlying source. Mechanical ventilation – Vt 3-5 cc/kg of ideal body
weight
Protein Calorie Malnutrition: Prealbumin > 20 = normal, 15-20 = suboptimal, 10-15 = mild, 5-
10 = moderate, <5 = severe

Atrial Fibrillation with RVR


New onset?
Check TSH, echocardiogram
Control rate!
Cardizem, Esmolol, Amiodarone, Digoxin
CHADS-Vasc score to assess anticoagulation needs
>2 → Coumadin/Lovenox/Heparin/Xarelto, Pradaxa or Eliquis
<2 → aspirin
Unstable → cardioversion
COPD Exacerbation
Albuterol and atrovent nebs
IV/PO steroids (Solu-medrol, Prednisone – attending preference)
Antibiotics – Azithromycin or Levaquin
Wean oxygen

PE/DVT
Cause? Hypercoagulable workup needed? Recent surgery? HRT? Recent
travel? History of blood clots?
Heparin/Lovenox/Xarelto – will need to bridge for Coumadin
Echocardiogram to assess right heart strain

Stroke/TIA (use stroke order set)


CT head without contrast to look for bleed
TPA if indicated within 3 hours (4.5 hours) if ischemic and indicated (consult neurology)
Stroke team (PT/OT/SLP/social work)
Check cardiac risk profile, HbA1C
Start statin (Lipitor), control blood sugars
If ischemic – do not treat hypertension to unless SBP > 220 or DBP > 110 → hydralazine
or Labetalol
If hemorrhagic – aggressive control of blood pressure
MRI brain without contrast
MRA neck and brain?
Carotid ultrasound?
Echocardiogram with agitated saline to rule out PFO/VSD
Bedside swallow evaluation – determines diet order

Decompensated Cirrhosis
Ammonia level – if elevated → lactulose titrated to 3-4 loose stools daily, Xifaxin
Fluid overloaded → Lasix: spironolactone 40:100, paracentesis, TIPS
Dehydrated → cautious fluid hydration
BMP, LFTs, CBC, paracentesis to rule out SBP
Only three things can cause ↑ LFTs > 1000 → toxicity (tylenol), shock liver, acute
hepatitis

Spontaneous Bacterial Peritonitis (SBP)


Paracentesis – fluid studies to look for SBP (>250 PMNs)
Gram negative rods (Klebsiella, E. Coli) or GPC (strep pneumo, enterococcus)
Alk phos and amylase to look for perforation
Replace Albumin 1.5 g/kg day 1 and 1g/kg day 3 after paracentesis
Serum Ascites albumin gradient (SAAG)
SAAG = serum albumin – ascites albumin
>1.1 → cirrhosis, right sided CHF
<1.1 → peritonitis, peritoneal carcinomatosis
Treatment: Cefotaxime (or Rocephin)
Upper GI Bleed (use order set)
Previous GI bleed? History of cirrhosis? On aspirin/plavix/NSAIDs?
2 large bore IVs, IVF
Type and screen and crossmatch RBC (order set)
Transfuse PRBC (# of units depends on Hb and severity of bleed)
IV Protonix 80 mg BID (or Protonix infusion)
Trend CBC q6h
H. pylori?
GI consult

Coumadin (or other causes of elevated INR) Coagulopathy


Stop Coumadin (or figure out why the INR is elevated)
IF BLEEDING or UNSTABLE - Vitamin K (PO better than IM) and FFP to reverse
Monitor for signs of bleeding

Tylenol Overdose
Determine amount and time
Toxicity = > 7.5g in single dose or >12g in 24 hours
Rapidly absorbed from GI tract – peak serum concentration within 4 hours (half life 2-4
hours)
Stage I (30 min – 24 hours) – nausea, vomiting, lethargy, labs NORMAL
Stage II (24-72 hours) - ↑ AST, ALT (can be >1000), ↑ PT/PTT, RUQ pain, AKI
Stage III (72-96 hours) – LFTs peak, jaundice, encephalopathy
Stage IV (recovery)
Monitor serum Tylenol concentrations
Rumack-Matthew nomogram
Treatment: Activated charcoal within 4 hours. IV Mucomyst (N-acetylcysteine) loading
dose of 150 mg/kg over 1 hour followed by 12.5 mg/kg/hr for 4 hours followed by 6.25 mg/kg/hr
for 16 hours
Trend LFTs, INR, PTT

DKA
Hyperglycemia + ketones + metabolic acidosis
Check BMP, Mg, Phos q4 hours and replace electrolytes aggressively
ABG needed?
Insulin gtt at 0.1 unit/kg/hr (do not start if K is < 3.3) → increase if blood sugar not
decreasing
REPLACE FLUIDS – volume depleted!! Start with 0.9NS → switch to 0.45NS/D5 when
glucose <250
Keep insulin drip going for at least 12 hours after the AG is closed. The gtt must be at
least 2 units/hr to effectively restore glycogen stores. This means you may need to increase the
D5 gtt to avoid hypoglycemia
Once the gap is closed for 12 hours, calculate the total amount of insulin used in 24 hours
(easy way is to take the last 6 hours and multiple by 4 or last 12 hours and multiple by 2). Take
the total amount of insulin required in 24 hours and multiple by 80%. Take this number and
divide by two to get your lantus dose and your total meal time dose. Divide your meal time dose
by 3 to get each meal requirement.
Give the Lantus 1-2 hours prior to stopping the insulin drip
Keep patient NPO until they feel like they want to eat
Check A1C

Chest pain (use order set)


Typical or atypical
History of CAD? Previous stress tests, echocardiograms, caths, CABG?
Aspirin, morphine, oxygen, nitro
Check cardiac risk profile, HbA1C
Trend troponin x3
Stress test? Can the patient exercise?
Telemetry monitor
Risk factors: Smoking, HTN, DM, HLD, CKD, family history male < 55, female <65
first MI, age > 55 female, > 45 male, PVD, OSA

ACS/acute MI
Remember MONAβHCG
Morphine, Oxygen, Nitrates, Aspirin
β-blocker (Metoprolol 5 mg x3 doses q5 min)
Heparin/Lovenox
Clopidigrel/Effient (anti-platelet)
Integrilin (GIIb/IIIa blocker)
Trend troponin x3

Acute (on Chronic) Heart Failure (use order set)


History of systolic or diastolic heart failure? Previous echocardiograms? History of
CAD?
JVD? S3?
Diuretics (Lasix, bumex)
Preload/Afterload reduction (nitro, vasotec)
Foley to monitor I/Os
Echocardiogram
Daily weights, low sodium diet
If acute – hold beta blocker
Will need to address starting ACE inhibitor, spironolactone and beta blocker upon
discharge

Pancreatitis
Cause: Gallstones, alcohol, hyperlipidemia, meds (lasix, GLP-1), scorpion sting, ERCP,
etc
Trend lipase, get CT abdomen to check for necrosis/pseudocyst
Treatment: NPO strict, IVF, Pain control
Ranson’s Criteria

Osteomyelitis
Hematogenous vs. Direct inoculation vs. Contiguous
Cover for staph aureus, anaerobes, pseudomonas (diabetics), coag negative staph →
vancomycin, Levaquin, Cefepime, Zosyn etc
Imaging: XR (acute infection may not show up), MRI, bone scan
Labs: ESR, CRP, CBC

Encephalopathy (Altered mental status)


Cause? Metabolic, drug induced, dehydration, sepsis
Check patient specific labs
IVF if needed

Drug Overdose/Suicide Attempt/Alcohol Intoxication


Consult social work – social work cannot talk to the patient unless blood alcohol level <
0.08 – repeat alcohol levels as needed
Banana bag (type in banana bag in orders) – use 0.9NS, 1L, daily, MVI, folic acid 1 mg,
thiamine 100 mg – or you can use a daily MVI, thiamine and folic acid PO
Serax PO and Ativan IV for withdrawal
Sitter at bedside, suicide precautions
Depending on drug ingestion – treatment specific to that drug

Hypertensive Emergency:
Hypertension with evidence of end organ failure (chest pain, pulmonary edema, AKI,
altered mental status)
Decrease blood pressure by 25% of presenting blood pressure (should be <180 systolic, <
110 diastolic) within minutes-hours
Drugs: Nitroprusside (<24 hours due to risk of cyanide poisoning), nitroglycerine,
Nicardipine, Labetalol

Hypertensive Urgency:
Elevated blood pressure (generally > 180 systolic) without end organ damage
Decrease blood pressure over days

Hypercalcemia
Cause - Cancer? Tums? HCTZ? Hyperparathyroidism?
Treat with IVF first
May use Lasix, bisphosphonates and calcitonin

Drug G+ MSSA MRSA G+ VRE G– P.A. Anaerobe Intra- Uses


Strep CoNS E.C. Rods cellular
Nafcillin
PCN
Amox
Amp +gent
Augmentin
Unasyn
Timentin
Zosyn
Keflex
Ancef
Cefotetan
Cefuroxime
Cross
CTX
BBB
Ceftaz
Cefepime
Ceftaroline X
Clinda
Doxy
Cipro X X
Levaquin
Avelox
Azithro
Gent Synergy
Tobra
Aztreonam
Ertapenem
Imipenem Some
Doripenem
Cross
Meropenem
BBB
Vanco
Linezolid
Dapto
Tigecycline
Bactrim
Flagyl
Rifampin synergy

Levaquin – can lower seizure threshold, needs to be renally dosed