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TREATMENT OF HYPOKALEMIA THERAPEUTIC GOAL: To correct potassium deficit Minimize ongoing loss. To prevent life threatening complication. UNDER ECG MONITORING ORAL ROUTE (Safer) KCl – Ideal Choice K2CO3 and K+ citrate – ideal for RTA or Chronicdiarrhoea INTRAVENOUS CORRECTION For Severe Hypokalemia And In Those Unable To Take Anything Orally. Avoid I.V. K+ Till Urine Output Established. - Average Dose 60 –80 meq/day To Give 10meq/Hr Mix 25ml Of 15% Kcl (10ml Each) In 500ml of Isotonic Saline & Deliver 25 Drops/ Min (100ml / Hr) Available : 20meq/15ml solution or 8meq/ tablet Adverse effects: G.I. irritation so advice to take diluted or along with food Continue I.V. KCl as long as rhythm returns to normal then gradually taper and start to oral KCl. DON’Ts > 10 – 20meq/hr. > 80 meq/ltr through central vein > 240meq/day > 40meq/ltr through peripheral vein. Don’t add KCl in IsolyteM, or Dextrose fluid TREATMENT OF HYPERKALEMIA UNDER ECG MONITORING Antagonism of membrane effect of Hyperkalemia 10 – 20 ml of 10% Calcium gluconate given over 10 mts. (Does not K+ so plan definitive treatment) K+ Movement into Cells 1) Insulin & Glucose: 25 – 50 gm of I.V. Glucose with 10-20 units of regular insulin followed by 5% Dextrose 100ml/hr 2) NaHCO3 infusion 7.5% NaHCO3 3 amp. in 1 litre of normal saline Removal of K+ from Body 1. Loop and Thiazide diuretics 2. Cation exchange resins. Sodium Poly styrenesulphonate 25 – 50 gm mixed with 100ml of 20% Sorbitol. (can also be given as retention enema). 3. Hemodialysis (useful in severe metabolic acidosis) 3) - adrenergic agonists Most rapid and effective method Salbutamol nebulisation 20 mg in 4ml NS over 10 mts. Peritoneal dialysis only 15% – 20% as effective as Hemodialysis EMERGENCY TREATMENT OF HYPOGLYCEMIA HYPOGLYCEMIA AN ARTERIAL / CAPILLARY BLOOD GLUCOSE CONCENTRATION BELOW 3.0MMOL/L ((54MG%) No I.V. Access I.V. Access possible Inj. Glucagon 1mg i.m. (Avoided In Anorectic, Emaciated, Protracted Hypoglycemia, OHA induced hypoglycemia) 4 ampoules of 25% dextrose (25 gms of Glucose) Recovery anticipated in 10 mts If recovery delayed > 20 mts Recovery delayed > 5hrs Repeat 25 gm Glucose I.V. + 100mg hydrocortisone consider Cerebral edema Patient recovered I.V. Dexamethasone/ I.V. 20% Mannitol * In Insulin overdose / OHA overdose => Maintain blood sugar 90 – 180 mg% Glucose 80gms / hr given through Central Venous Line MANAGEMENT OF VARICEAL BLEEDING Vascular Access, Colloidal Fluids blood tranfusion (To maintain systolic BP > 90mmHg, Urine output > 40ml /hr, Hematocrit > 25 – 30%) Endoscopic therapy Pharmacotherapy 1. Octreotide Bandligation bolus 25 –100g Sclerotherapy followed by continuous infusion of 2550g/hr (continued for 48 –120 hrs) 2.Inj.Vasopressin 0.4 units/mt started and titrated upwards to control bleeding (not to exceed 1 unit / mt) used along with nitroglycerin 40g/mt to maintain systolic B.P. between 90-100mmHg. Shunt Surgery TIPSS (Transjugular intrahepatic portosystemic Stent – Shunt) Done if bleeding occurs after 2 or more endoscopic attempts Non-Shunting Surgery SUGIURA Operation Balloon Tamponade MANAGEMENT OF ANAPHYLAXIS Inj. Epinephrine 0.3 – 0.5mg (0.3 – 0.5 ml of 1 : 1000 solution) IM or SC (repeated at 20 min. intervals if necessary) Patients with major airway compromise or hypotension can be given Epinephrine sublingually or via E.T. tube Airway Management ET Intubation 100% oxygen therapy Volume expansion 500-100ml NS bolus followed by infusion titrate with B.P. and Urine output Inhaled agonists albuterol 0.5ml (2.5.mg) in 2.5ml NS Glucocorticoids (to prevent relapse of severe reactions) Methylpredinisolone 125 mg I.V. (or) Hydrocortisone 500mg I.V. Antihistamines (to relieve skin Symptoms) MANAGEMENT OF CEREBRAL MALARIA Maintain Airway, Breathing, two I.V. life line Quinine 20 mg/ Kg I.V. infusion in 10%D over 4 hrs followed by 10mg/Kg infusion over 2 – 8 hrs 8th hourly for 7 days (or) Artesunate 2.4 mg/kg I.V. or I.M. followed by 1.2 mg/kg at 12 & 24 hrs then daily once for 7 days (or) Artemether 3.2. mg/kg I.M. Stat followed by 1.6mg/ Kg/day for 7 days (If patient remains seriously ill or in ARF for > 2 days MAINTENANCE DOSE of Quinine should be reduced by 30 to 50%. No dose reduction for Arteminsinin derivatives.) Continuous infusion of 5% or 10% Dextrose (All patients on I.V. Quinine) Keep Temp < 38.50C with Paracetamol, Tepid Sponging If Hematocrit < 20% fresh whole blood or packed cell transfusion If ARF treat with Dialysis preferably Hemodialysis If Spontaneous bleeding give fresh blood and Inj. Vit. K 1 amp. I.V. If convulsions give Diazepam 0.15mg/kg I.V. or 0.5 mg/kg rectally with respiratory support. As soon as patient can take fluids, oral therapy should be substituted for parenteral treatment * Avoid: Steroids, Aspirin, NSAIDs, Heparin. MANAGEMENT OF RAT KILLER POISONS ZINC PHOSPHIDE & ALUMINIUM PHOSPHIDE Stomach wash with NaHCO3 Liquid Paraffin 30 ml thrice daily I.V. MgSO4 continuous infusion in NS 3 gm in first 3 hours then 6 gms in next 24 hours. Myocarditis treated with Hydrocortisone, Sorbitrate Oxygen, ventilatory support if needed WARFARIN AND ANTICOAGULANTS Gastric lavage with KMnO4 Inj. Vitamin K 10 mg I.M. Fresh blood and FFP if bleeding tendency Tablet Vitamin C 100mg thrice daily Iron supplementation
