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Moonlight Medicine
Adrian Paul J Rabe, MD, DPCP
8 Targets of Moonlight Medicine
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Infectious Disease
Cardiovascular Medicine
Pulmonary Medicine
Endocrinology
Gastroenterology
Poisons and Snakebites
Pain Medication
Electrolyte Correction
Infectious Disease
Infectious Disease
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URTI
Pneumonia
UTI
Dengue
Typhoid
Leptospirosis
Infectious Disease
URTI
URTI: Presentation
• Symptoms
– Cough, colds
– 3 to 5 days duration
• Signs
– Nasal discharge (clear or yellowish)
– Clear breath sounds
– No signs of sepsis
– Hemodynamically unstable
URTI: Order Sheet
• No labs necessary
• Medications
– Amoxicillin 500 mg TID or 1 g TID
– Clindamycin 300 mg QID for 5 days
– Azithromycin 250 mg OD x 5 days or 500 mg OD x 3
days or 1 g OD x 1 dose
– Avoid using broad-spectrum antibiotics
– Avoid prolonged regimens
• Advice
– Increased oral fluid intake (at least 2L/day)
URTI: Watch Out For…
• Persistence
– Fever should lyse within 24-48 hours
– Post-infectious cough occurs in 40% of patients
• Recurrence
– Consider allergic rhinitis – refer to an allergologist
• Seasonal pattern
• History of asthma or atopy
• Relation to exposure to allergens/certain settings (bedroom,
work)
– If also with weight loss, obstructive ssx, refer to ORL
Infectious Disease
Pneumonia
Pneumonia (CAP): Presentation
• Symptoms
– Cough with/without sputum production
– Fever
– Generalized weakness, anorexia
• Signs
– Crackles
– Decreased breath sounds
• Increased fremiti – consolidation/mass
• Decreased fremiti – pleural effusion
– Wheezing
CAP: Order Sheet
• Initial Diagnostics
– Chest X-ray
– CBC with platelet count
CAP: 2010 Guidelines
Does the patient have:
1. RR ≥ 30/min
2. PR ≥ 125/min
3. Temp ≥ 400C or ≤ 360C
4. SBP < 90 or DBP ≤ 60
5. Altered mental status, acute
6. Suspected aspiration
7. Unstable co-morbids
8. Chest X-ray: multilobar, pleural
effusion, abscess
No
Low Risk CAP
Yes
Moderate
Risk vs High
RIsk
Co-morbidities
• DM
• Active Malignancy
• Neurologic disease in evolution
• CHF Class II-IV
• Unstable CAD
• Renal failure on dialysis
• Uncompensated COPD
• Decompensated Liver Disease
CAP: 2010 Guidelines
Does the patient have:
1. Severe Sepsis
2. Septic Shock
3. Need for mechanical
Ventilation
No
Moderate
Risk CAP
Yes
High Risk CAP
CAP: Antibiotics
• Amoxicillin
• Extended macrolides
– Azithromycin
– Clarithromycin
• B-lactam/B-lactamase inhibitor combination
(oral)
– Co-amoxyclav
– Amoxicillin-sulbactam
– Sultamicillin
CAP: Antibiotics
• Oral second generation cephalosporin
– Cefaclor
– Cefuroxime axetil
• Oral third generation cephalosporin
– Cefdinir
– Cefixime
– Cefpodoxime proxetil
CAP: Antibiotics
• IV non-antipseudomonal B-lactam
– Co-amoxyclav
– Ampicillin-sulbactam
– Cefotiam
– Cefoxitin
– Cefuroxime
– Cefotaxime
– Ceftizoxime
– Ceftriaxone
– Ertapenem
CAP: Antibiotics
• Respiratory fluoroquinolones
– Levofloxacin
– Moxifloxacin
• Aminoglycosides
– Gentamicin
– Tobramycin
– Netilmicin
– Amikacin
CAP: Antibiotics
• IV antipseudomonal B-lactam
– Cefoperazone-sulbactam
– Piperacillin-tazobactam
– Ticarcillin-clavulanic acid
– Cefepime
– Cefpirome
– Imipinem-cilastin
– Meropenem
CAP: Low Risk
• Subsequent Diagnostics
– Sputum GS/CS optional
• Antibiotics
– Previously healthy
• Amoxicillin
• Extended macrolides
– Stable co-morbid condition (cover enteric G- bacilli)
• B-lactam/B-lactamase inhibitor
• 2nd generation oral cephalosporins +/- extended macrolide
• 3rd generation oral cephalosporin +/- extended macrolide
CAP: Moderate Risk (Admit)
• Subsequent Diagnostics
– Blood CS
– Sputum GS/CS
– Urine antigen for L. pneumophila
– Direct fluorescent Ab test for L. pneumophila
• Antibiotics
– IV non-antipseudomonal B-lactam + extended
macrolide
– IV non-antipseudomonal B-lactam + respiratory
fluoroquinolones
CAP: High Risk (ICU)
• Subsequent Diagnostics
– Blood CS
– Sputum GS/CS
– Urine antigen for L. pneumophila
– Direct fluorescent Ab test for L. pneumophila
– ABG
CAP: High Risk (ICU)
• Antibiotics – no risk for Pseudomonas aeruginosa
– Same as moderate risk
• Antibiotics – with risk for Pseudomonas
aeruginosa
– IV antipseudomonal B-lactam + IV extended
macrolide + aminoglycoside
– IV antipseudomonal B-lactam + IV Ciprofloxacin or
Levoflocacin (High dose)
CAP: Watch Out For
• Pleural effusion, Lung abscess
– Do thoracentesis
– Refer to TCVS for CTT if warranted
• Hemodynamic instability/Progressing sepsis
– Refer to Pulmo, IDS
• Hospital-acquired pneumonia
– Proper precautions in intubated patients
• Exacerbation of co-morbid diseases
CAP: Resolution
• For low-risk
– Follow-up after 3 to 5 days
• For moderate-/high-risk
– Step down when clinically improving
– Some infections (e.g. ESBL organisms) require a full
course via the IV route
• Chest X-ray findings
– May take up to 6 months to completely resolve
• Vaccination (including those with co-morbids)
– Pneumococcal: one time, then q5years
– Influenza: annually
Infectious Disease
Urinary Tract
Infection
Urinary Tract Infection
• Symptoms of Urethritis
– Acute dysuria, hematuria
– Frequency
– Pyuria
– Recent sexual partner change
• Symptoms of Cystitis
– Dysuria, Urgency
– Suprapubic pain
– Hematuria, foul-smelling urine, turbid urine
UTI: Presentation
• Symptoms of Acute Pyelonephritis
– Rapid development
– Fever, shaking chills
– Nausea, vomiting, abdominal pain
– Diarrhea
– Diabetes, immunosuppression
• Symptoms of catheter-related UTI
– Minimal symptoms
– Usually no fever
UTI: Presentation
• Signs of Urethritis
– Grossly purulent discharge expressed in genital tract
• Signs of Cystitis
– Suprapubic tenderness
– Fever
• Signs of Acute pyelonephritis
– Costoverterbal angle tenderness at side of involved
kidney
– Fever, signs of sepsis
UTI: Presentation
• Signs of catheter-related UTI
– Turbid/foul-smelling urine
– Purulent discharge
– Suprapubic tenderness
UTI 2004 Guidelines
• Does the patient have complicating risk factors?
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AFRRAID CH7
Anatomic abnormality
Functional abnormality
Recent UTI or Tract instrumentation (past 2 weeks)
Renal disease/transplant
Antibiotic use (Past 2 weeks)
Immunosuppresion
DM
Catheter, indwelling/intermittent
Hospital-acquired
Symptoms for > 7 days
UTI 2004 Guidelines
• Uncomplicated Cystitis
– Medications (do 7 day regimen in males)
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Cotrimoxazole 800/160 PO BID x 3 days
Ciprofloxacin 250 mg PO BID x 3 days
Ofloxacin 200 mg PO BID x 3 days
Norfloxacin 400 mg PO BID x 3 days
Nitrofurantoin 100 mg QID x 7 days
Cefuroxime 125-250 mg PO BID x 3-7 days
– Increase OFI
– No need for U/A or urine cultures except in males
– If unresolved after 7 days, consider as COMPLICATED
UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis
– Urinalysis (expect increased WBC; bacteriuria not the
defining parameter; WBC cast is pathognomonic)
– Urine GS/CS
– Outpatient treatment:
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No signs and symptoms of sepsis
Non-pregnant
Likely to comply with treatment
Follow-up after 3-5 days
UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis
– Empiric regimen should be started after culture is
taken (Oral)
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Ofloxacin 400 mg BID x 14 days
Ciprofloxacin 500 mg BID x 7-10 days
Levofloxacin 250 mg OD x 7-10 days
Cefixime 400 mg OD x 14 days
Cefuroxime 500 mg BID x 14 days
Co-amoxyclav 625 mg TID x 14 days (if GS is G+)
UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis
– Empiric regimen should be started after culture is
taken (IV, given until patient is afebrile)
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Ceftriaxone 1-2 g IV OD
Ciprofloxacin 200-400 mg IV q12
Levofloxacin 250-500 mg IV OD
Ampicillin-Sulbactam 1.5 g IV q6 (if GS is G+)
Piperacillin-Tazobactam 2.25-4.5 g IV q6-8
– Post-treatment cultures are unnecessary
UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis: WOF
– Fever after 72 hours of treatment, or recurrence of
symptoms
• Imaging studies (KUB-UTZ , KUB-IVP if Creatinine
clearance acceptable)
• Repeat urine culture
• If without urologic abnormality, treatment duration is 2
weeks based on culture
• If same organism between initial and repeat culture,
treatment duration is 4-6 weeks
UTI 2004 Guidelines
• Asymptomatic bacteriuria
– Defined as ≥ 100,000 cfu in 2 consecutive midstream
urine specimens or 1 catheterized specimen
– Should screen for, and treat in
• Patients who will undergo GU manipulation or
instrumentation
• Post-renal transplant patients up to first 6 months
• DM with poor glycemic control, autonomic neuropathy or
azotemia
• All pregnant women
– Same antibiotics as acute uncomplicated cystitis
UTI 2004 Guidelines
• Recurrent UTI
– More 2x a year, with no urinary tract abnormalities
– May give prophylaxis (if symptoms are unacceptable)
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Post-coital (immediately after intercourse)
Daily for 6 to 12 months
Nitrofurantoin 100 mg at bedtime
Cotrimoxazole 200/40 mg at bedtime
Ciprofloxacin 125 mg at bedtime
Norfloxacin 200 mg at bedtime
Cefalexin 125 mg at bedtime
– Same antibiotics as acute uncomplicated cystitis, or may
also take 2 double strength Cotrimoxazole single dose as
soon as symptoms first appear
UTI 2004 Guidelines
• Complicated UTI
– Urine GS/CS
– Outpatient
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No signs of sepsis
Without marked debilitation
Inability to comply with treatment
Inability to maintain oral hydration/take oral medications
UTI 2004 Guidelines
• Complicated UTI
– Oral
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Ciprofloxacin 250 – 500 mg BID x 14 days
Norfloxacin 400 mg BID x 14 days
Ofloxacin 200 mg BID x 14 days
Levofloxacin 250 – 500 mg OD x 10-14 days
UTI 2004 Guidelines
• Complicated UTI
– Parenteral
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Ampicillin-sulbactam 1.5 – 3 g IV q6
Ceftazidime 1-2 g IV q8
Ceftriaxone 1-2 g IV OD
Imipenem-cilastin 250-500 mg IV q6-8
Piperacillin-Tazobactam 2.25 g IV q6
Ciprofloxacin 200-400 mg IV q12
Ofloxacin 200-400 mg IV q12
Levofloxacin 500 mg IV OD
– At least 7 to 14 days of therapy
UTI 2004 Guidelines
• Complicated UTI
– At least 7 to 14 days of therapy
– Urine culture should be repeated 1 to 2 weeks after
completion of medications
• If persistent, refer to urology/nephrology
– If no response, may do
• Plain KUB x-ray
• KUB-UTZ
• Helical CT scan
UTI 2004 Guidelines
• Catheter-associated UTI
– If asymptomatic, no need to treat, except if
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With bacterial agents with high-incidence bacteremia
With neutropenia
Pregnant
Will undergo urologic procedures/post-renal transplant
– Indwelling catheter should be removed
– Long-term indwelling catheters should be replaced
before treatment
UTI 2004 Guidelines
• Candiduria
– May treat if
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Symptomatic
Critically ill
Neutropenic
Will undergo urologic procedures/post-renal transplant
– Control diabetes (if present)
– Remove catheter, other urinary tract instruments (if
present)
UTI 2004 Guidelines
• Candiduria
– Cystitis
• Fluconazole 400 mg LD then 200 mg OD x 7-14 days
– Pyelonephritis
• Surgical drainage
• Fluconazole 6 mg/kg/day or Amphotericin B IV 0.6
mg/kg/day for 2 to 6 weeks
Infectious Disease
Dengue Fever
Dengue Fever: Presentation
• Symptoms
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Fever (Breakbone fever, saddleback fever)
Myalgia, retro-orbital pain (“trangkaso”)
Anorexia, nausea, vomiting
Cutaneous hypersensitivity
Epistaxis, petechiae, bleeding of pre-existing GI lesions
near the time of defervescence
– Sudden-onset to acute symptoms
• Signs
– Bleeding (petechiae on trunk, spreading face, extremities)
– Fever
Dengue Fever: Order Sheet
• Initial Diagnostics
– CBC with PC
• Leukopenia
• Thrombocytopenia
• Hemoconcentration
– Dengue IgM
– Crea, Na, K, AST, ALT
• Elevated AST more than ALT
Dengue Fever: Order Sheet
• Hydration
– Oral fluid intake
– Crystalloids: pNSS 1L x 60 or 80
– Colloids (for severe cases) or FFP
• Defervescence
– Paracetamol
– Tepid/Cold sponge bath
• Platelet replacement
– 1 unit of platelet concentrate per kg BW
– Serial platelet counts (q12 to daily)
Dengue Fever: WOF
• Continued hemorrhage
– Aggressive control of fever
– Platelet replacement
• Shock
– Lasts for only 1-2 days
– Intensive care may be necessary
Dengue Fever: Resolution
• 1 week course
• Discharge if
– Increasing trend of platelet count
– No bleeding
– No hemodynamic instability
• Advice regarding mosquito control
– Ablation of mosquito breeding grounds
– Mosquito nets rather than mosquito repellents
Infectious Disease
Typhoid Fever
Typhoid Fever: Presentation
• Symptoms
– Fever in past 1 to 2 weeks
– Abdominal pain (not always present)
– Headache, chills, cough, myalgia/arthalgia, diarrhea or
constipation
• Signs
– Relative bradycardia at the peak of fever
– Hepatosplenomegaly, abdominal tenderness
– Rose spots: faint, salmon-colored blanching rash
usually located on the trunk
Typhoid Fever: Order Sheet
• Diagnostics
– CBC with PC (leukocytosis, sometimes leukopenia,
neutropenia)
– Crea, Na, K, AST, ALT (slightly elevated LFTs)
– Blood CS (sensitivity 90% in first week)
– Bone marrow CS (even up to 5 days of theapy)
– Duodenal string test/culture
– Stool CS (positive in 3rd week if untreated)
• Admit if…
– Vomiting, diarrhea, abdominal distension
Typhoid Fever: Order Sheet
• Empirical treatment
– Ceftriaxone 1-2 g IV OD x 7-14 days
– Cefixime 400 mg PO BID x 7-14 days
– Azithromycin 1g PO OD x 5 days
• Multidrug resistant
– Ciprofloxacin 500 mg PO BID x 5-7 days
– Ciprofloxacin 400 mg IV q12 x 5-7 days
– Ceftriaxone 2-3 g IV OD x 7-14 days
– Azithromycin 1g PO OD x 5 days
Typhoid Fever: Order Sheet
• Critically ill (shock, obtundation)
– Add Dexamethasone 3 mg IV then 1 mg/kg q6 x 8
doses
– Admit to ICU
– Refer to IDS
– Repeat cultures if none were positive
Typhoid Fever: WOF
• Perforation/Obstruction
– Due to invasion of Peyer’s patches
– Refer to Surgery
• Continued fever
– Lack of susceptibility
– Consider another etiology
– Refer to an Infectious Disease specialist
Typhoid Fever: Resolution
• Defervescence in 1 week
• Return to normal values also in 1 week
Infectious Disease
Leptospirosis
Leptospirosis: Presentation
• Symptoms
– Wading in floodwater/exposure to mud
– Influenza-like illness: chills, headache, nausea,
vomiting, muscle pain (calves, back or abdomen)
– Fever, conjunctival suffusion/hemorrhage
– Hemoptysis
– Decreased urine output, tea-colored urine
– Overt jaundice
– Diarrhea
– Course progresses within 1 week, rarely 2 weeks
Leptospirosis: Presentation
• Signs
– Fever
– Conjunctival suffusion
– Jaundice and icterus
– Calf tenderness
– Decreased sensorium
Leptospirosis: Order Sheet
• Initial Diagnostics
– Lepto MAT/Dri-Dot
– Urine culture (positive at 2nd to 4th week, and for
several months after)
– Chest X-ray (check for pulmonary hemorrhage)
– BUN, Crea, Na, K, Cl, alb, Ca, Mg (check for acute
renal failure, electrolyte losses)
– Urinalysis (concentrated urine vs renal failure; picture
of UTI may confuse you)
– CBC with PC (anemia, leukocytosis)
– Stool CS (for patients with diarrhea)
Leptospirosis: Order Sheet
• Mild Leptospirosis
– Doxycycline 100 mg PO BID
– Ampicillin 500-750 mg PO QID
– Amoxicillin 500 mg PO QID
• Moderate/Severe Leptospirosis
– Penicillin G 1.5 M u IV QID
– Ampicillin 1 g IV QID
– Amoxicillin 1 g IV QID
– Ceftriaxone 1 g IV OD
– Erythromycin 500 mg IV QID
Leptospirosis: Order Sheet
• Hydration
– Based on urine output
– Replace electrolytes lost
• Transfusion
– Based on losses detected by CBC
• Control of hemoptysis
– Hydrocortisone 50 mg IV q6
– Tranexamic Acid 500 mg TID
Leptospirosis: WOF
• Weil’s syndrome
– Heralded by hemoptysis, renal failure, severe liver
dysfunction, or sepsis
– Refer to Infectious Disease specialist
– Refer to Renal service for early dialysis
– Transfer to ICU
Leptospirosis: WOF
• Jarisch-Herxheimer reaction
– Occurs in response to antimicrobial therapy, when
massive spirochete kill releases lipoproteins
– Simulates worsening of disease
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Fever, chills, myalgias, headache
Tachycardia, tachypnea
Increased WBC, neutrophils
Hypotension
– Supportive therapy
– Subsides after 12-24 hours without revision of meds
Leptospirosis: Resolution
• Jaundice to resolve in 2 to 4 weeks
• May discharge if
– Creatinine clearance is on upward trend
– Urine output at least 0.5 cc/kg/hr
– Electrolytes corrected
– Platelet/hemoglobin corrected
– No ongoing hemoptysis
• Prophylaxis
– Doxycycline 200 mg PO once a week if exposed
Cardiology
Cardiovascular Medicine
• Hypertension
• Angina
• Myocardial Infarction
Cardiology
Hypertension
Hypertension: Presentation
• Symptoms
– Frequently asymptomatic
– Aching nape/occipital area
– Symptoms of target organ damage
• Signs: Try to detect both cause and effect…
– Kidney disease: anemia, oliguria, sallow skin
– Cushing’s syndrome: obesity, striae, moon facies, etc
– Hyper/hypothyroidism
– Heart failure
Hypertension: Presentation
• Signs: Taking Blood Pressure
– Aneroid instrument vs mercury based instruments
– Seated quietly for 5 minutes (Quiet, private, with
comfortable room temperature)
– Bladder cuff is at least half of arm circumference
– Deflation is 2 mmHg/s
– Measure both arms, in supine, sitting and standing
positions (detects coarctation, orthostatic changes)
– Measure 1 leg at least once (take ABI)
Hypertension: Presentation
• Signs
– Palpate all possible pulses
– Cardiac examination is important
– Auscultate carotid and renal bruits
Hypertension: Classification
Classification
Normal
Prehypertension
Stage 1
Stage 2
Systolic,
mmHg
< 120
120-139
140-159
≥ 160
And
Or
Or
Or
Diastolic,
mmHg
< 80
80-89
90-99
≥ 100
Hypertension: Order Sheet
• Diagnostics
– Urinalysis (renal cause and complication)
– BUN, Crea, Na, K, Ca, alb (low K is clue for
aldosteronism and pheochromocytoma)
– FBS, Lipid profile (co-morbidities)
– CBC (anemia)
– ECG (LVH, other abnormalities)
Hypertension: Order Sheet
• Lifestyle changes
BEADS
– BMI < 25 kg/m2
– Exercise: Near-daily to daily aerobic activity
– Alcohol avoidance/moderation
– DASH diet: fruits, vegetables, low fat dairy, reduced
saturated and total fat
– Salt-restriction: NaCl < 6 g/d
Hypertension: Order Sheet
• Medications: Diuretics
– Examples
• Hydrochlorothiazide 12.5 – 25 mg OD-BID
• Furosemide 40-80 mg BID-TID
• Spironolactone 25-100 mg OD-BID
– Good for heart failure
– Caution in DM, gout, renal failure
– K reducer: furosemide, HCTZ
– K retainer: spironolactone
Hypertension: Order Sheet
• Medications: Beta blockers
– Examples
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Atenolol 25-100 mg OD
Metoprolol 25-100 mg OD-BID
Propranolol 40-160 mg BID (not cardioselective)
Carvedilol 12.5-50 mg BID (combined alpha and beta)
– Good for heart failure, angina, MI, tachycardia
– Caution in 2nd or 3rd degree AV block, asthma/COPD
Hypertension: Order Sheet
• Medications: ACE inhibitors
– Examples
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Captopril 25-200 mg BID-TID
Enalapril 5-20 mg OD
Lisinopril 10-40 mg OD
Ramipril 2.5-20 mg OD-BID
– Good for heart failure, MI, DM
– Caution in renal failure, hyperkalemia, renal artery
stenosis, pregnancy
– May cause cough, angioedema
Hypertension: Order Sheet
• Medications: Angiotensin receptor blockers
– Examples
• Losartan 25-100 mg OD-BID
• Valsartan 80-320 mg OD
• Candesartan 2-32 mg OD-BID
– Good for heart failure, MI, DM
– Caution in renal failure, hyperkalemia, renal artery
stenosis, pregnancy
– Used as second-line to ACE-inhibitors
Hypertension: Order Sheet
• Medications: Dihydropyridine CCBs
– Examples
• Amlodipine 5-10 mg OD
• Long-acting Nifedipine 30-60 mg OD
– Good for angina
– Caution in heart failure, 2nd or 3rd degree AV block
– Causes peripheral edema
Hypertension: Order Sheet
• Medications: Non-Dihydropyridine CCBs
– Examples
• Long-actingVerapamil 120-360 mg OD-BID
• Long-acting Diltiazem 180-420 mg OD
– Good for angina, MI, DM, tachycardia
– Caution in heart failure, 2nd or 3rd degree AV block
– Causes peripheral edema
Hypertension: Order Sheet
• Medications: Direct Vasodilators
– Examples
• ISMN 30-60 mg OD
• ISDN 5-10 mg BID-TID
• Hydralazine 25-100 mg BID-TID
– Nitrates good for angina, MI
– Nitrates cause hypotension, headache (must have at
least 8 hours a day drug free), and has reaction with
sildenafil
– Hydralazine should not be used in severe coronary
artery disease
Hypertension: Follow-up
• BP goal
– General: < 140/90
– Cardiac risk factors: < 130/80
– Albuminuria: < 125/75
• Adjustment
– Diuretics: daily to weekly (electrolyte imbalances)
– Beta-blockers: every 2 weeks
– ACE-inhibitors and ARBs: every 1 – 2 weeks
– CCBs: every 1 – 2 weeks
– Vasodilators: Every 1 – 2 weeks
Hypertension: WOF
• Secondary Hypertension
– CGN/Nephrotic syndrome/CKD: urinary findings,
edema
– Pheochromocytoma: sweating, palpitations, headache,
early target organ damage
– Primary aldosteronism: resistant to medications, low
K, weakness
– Connective Tissue Disease: pulse discrepancy,
systemic symptoms
– Refer to Renal/Endo/Rheuma
Hypertension: WOF
• Hypertensive Urgency vs Emergency
– Both require admission
– Emergency: presence of target organ damage
• Reduce blood pressure by 25% over minutes to 2 hours
• Parenteral agents
– Urgency: No target organ damage
• Reduce blood pressure over hours
• Oral agents
Hypertension: WOF
• Hypertensive Urgency vs Emergency
– Nitroprusside: 0.3 ug/kg/min, maximum at 10
ug/kg/min; discontinue if no response after 10
minutes
– Nitroglycerin drip: 5 ug/min, titrate at 5-10 ug/min at
3 to 5 minute intervals
• 10 mg/10mL or 50 mg/50 mL, diluted to 10 mg in 100 mL
– Nicardipine drip: 5 mg/h, titrate by 2.5 mg/h at 5-15
minute intervals, maximum at 15 mg/h
• 2 mg/2mL or 10 mg/10mL, diluted to 10-20 mg in 100 mL
Cardiology
Angina and the Acute
Coronary Syndromes
Angina: Presentation
• Symptoms
– Heaviness, pressure, squeezing, localized
retrosternally
– Crescendo vs decrescendo
– Radiates anywhere between the mandible and
umbilicus
– Related to exertion
• Signs
– High/low blood pressure, tachy/bradycardia
– Heart failure
Angina: Order Sheet
• Complete bed rest
• Oxygenation
– Target O2 saturation > 90%
– Nasal cannula vs face mask vs intubation
• Cardiac monitor
• Vital signs
• Ask about sildenafil use in past 24 hours
– Viagra, cialis, ambigra, adonix, erefil, neo-up
Angina: Order Sheet
• Give nitrates
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Nitroglycerin 0.3-0.6 mg, or via buccal spray
ISDN 5 mg sublingual
3 doses 5 minutes apart
If persistent, start Nitroglycerin drip
• 10 mg in 100 mL, start at 5 ug, and increased by 5-10 ug/min
• Titrated every 3 to 5 minutes until symptoms are relieved or
systolic arterial pressure falls to < 100 mmHg
– Good for pulmonary congestion
– Caution in: inferior wall/right-sided infarcts (hypotension)
Angina: Order Sheet
• Initial Diagnostics
– 12-lead ECG (within 10 minutes)
– 2D-echocardiogram
– Nuclear perfusion scan, cardiac MRI, cardiac PET
– BUN, Crea, Na, K, Ca, alb, Mg, AST
– Cardiac enzymes: Trop I/T > CKMB > CKtotal
– Urinalysis
– Chest X-ray
– PT/PTT
UAHR/NSTEMI/STEMI
• Loading Dose
– Aspirin 80 mg/tab 4 tabs chewed and swallowed
– Clopidogrel 75 mg/tab 4 tabs chewed and swallowed
– Metoprolol 5 mg IV q5 up to 15 mg (3 doses), then
followed in 1-2 hours by 25-50 mg PO q6
– Morphine 2-5 mg IV repeated q5-30 minutes
– Captopril 25 mg/tab ½ to 1 tab q8
– Heparinization
Angina: STEMI
• Decide whether to do PCI or not
– Referral center should be no more than 30 mins away
– Door-to-balloon time should be at most 90 mins
– Golden period: not more than 6h, may give 12h after
• Refer to CVS for thrombolysis
– Take informed consent
– Streptokinase 1.5 M u in pNSS to make 100 cc to
consume over 1 hour
– Pre-medication with Diphenhydramine 1 amp IV
– Can have hemorrhage, allergic reactions
Angina: STEMI
• Absolute contraindications to thrombolysis
– Cerebrovascular hemorrhage at any time
– Known structural cerebral vascular lesion (e.g. AVM)
– Non-hemorrhagic stroke/event in the past year
• Ischemic stroke within 3 months, except if within 3 hours
– Hypertension (SBP > 180, DBP > 110)
– Suspicion of aortic dissection
• Must do Chest/abdominal CT stat if suspected
– Active internal bleeding except menses
– Any known malignant neoplasm
– Significant closed head/facial trauma in past 3 months
Angina: STEMI
• Admit to ICU/CCU
UAHR/NSTEMI/STEMI
• Loading Dose
– Aspirin 80 mg/tab 4 tabs chewed and swallowed
– Clopidogrel 75 mg/tab 4 tabs chewed and swallowed
– Metoprolol 5 mg IV q5 up to 15 mg (3 doses), then
followed in 1-2 hours by 25-50 mg PO q6
– Morphine 2-5 mg IV repeated q5-30 minutes
– Captopril 25 mg/tab ½ to 1 tab q8
– Heparinization
UAHR/NSTEMI/STEMI
• Aspirin and Clopidogrel
– Part of antithrombotic therapy
– Maintenance
• Aspirin 80 mg/tab 1 tab OD (with a meal)
• Clopidogrel 75 mg/tab 1 tab OD
– WOF GI bleed, allergy to aspirin
UAHR/NSTEMI/STEMI
• Beta blockers
– Part of anti-ischemic therapy
– Maintenance
• Metoprolol 50 mg BID
– Target: HR 50-60 bpm
– Caution in hypotension, asthma, COPD. Severe
pulmonary edema
UAHR/NSTEMI/STEMI
• Calcium channel blockers
– Part of anti-ischemic therapy
– Used in patients with contraindication to beta
blockers
– Maintenance
• Long-actingVerapamil 120-360 mg OD-BID
• Long-acting Diltiazem 180-420 mg OD
– Target: HR 50-60 bpm, no chest pain
– Avoid rapid-release CCB (e.g. nifedipine)
– Caution in pulmonary edema, severe LV dysfunction,
hypotension, bradycardia, heart-block
UAHR/NSTEMI/STEMI
• Morphine
– Part of anti-ischemic therapy
– Maintenance
• None – PRN use only
– Target: no chest pain
– Caution in inferior wall/right ventricular infarction,
hypotension, respiratory depression, confusion,
obtundation
UAHR/NSTEMI/STEMI
• ACE-inhibitors
– Part of long-term cardiac therapy
– Maintenance
• Captopril 25 mg 1 tab q8
• Enalapril 5-20 mg OD
– Gradual increase as patient stabilizes
– Good for LV dysfunction, anterior wall MI
– Caution in hypotension, renal failure, hyperkalemia
UAHR/NSTEMI/STEMI
• Statins
– Part of long-term cardiac therapy
– Plaque stabilization
– Maintenance (@HS doses)
• Atorvastatin 10 mg, max 80 mg
• Rosuvastatin 10 mg, max 40 mg
• Simvastatin 20 mg, max 80 mg
– Gradual increase over a period of 2 months
– Good for dyslipidemia, MI
– Caution in liver disease, rhabdomyolysis
UAHR/NSTEMI/STEMI
• Heparin
– Part of anti-thrombotic therapy
– Types
• UFH 60 U LD, then 12U/kg/h target PTT 1.5-2.0x normal
• Enoxaparin 30 mg IV LD then 1 mg/kg SC q12 (OD if
creatinine clearance < 30 mL/min)
• Fondaparinux 2.5 mg SC OD
– If patient is unstable, has poor hemodynamic status, or
has risk of bleeding, age > 75 y/o, UFH is preferred
– PTT measurements should be done q6
– Duration is 2 to 5 days
UAHR/NSTEMI/STEMI
• Targets
– Activity (SUPERVISED)
•
•
•
•
•
•
First 12 hours: Bed rest
12-24 hours: Dangling legs/sitting in a chair
2nd-3rd day: Ambulation in room, go to shower
3rd day and beyond: 185 m (600 feet) at least 3x a day
Sexual activity: 2-4 weeks after event
Work: 1 month after event
UAHR/NSTEMI/STEMI
• Targets
– Diet
• First 4-12 hours: NPO
• If stable: Complex carbohydrates (50-55%), Fat < 30%, total
cholesterol < 200 mg/d, fiber rich
– Bowel care
• Stool softeners
• Bedside commode rather than bedpan
• Laxative
UAHR/NSTEMI/STEMI
• Targets
– Sedation
• Quiet, reassuring environment
• Diazepam 5 mg TID-QID
– Tight glycemic control
•
•
•
•
Insulin drip preferred in acute setting
Pre-prandial: 90-130 mg/dL (critical care: < 110)
Post-prandial: < 180 mg/dL (critical care: < 180)
Long-term: HbA1c < 7%
UAHR/NSTEMI/STEMI
• Targets
– Electrolyte
• Mg 1.0 mmol/L
•K
4.0-4.5 mmol/L
• Ca 2.12-2.52
– Discontinue O2
• May discontinue starting 6 hours after admission, if O2
saturation > 90%
Angina: Watch Out For…
• Arrhythmia
– Defibrillate with maximum dose available up to 3x
– Amiodarone 150 mg in 50 to 100 cc pNSS over 10
minutes, then drip 360 mg in D5W x 6 hours
– Refer to CVS
• Mechanical complications
– Wall rupture
– New-onset mitral regurgitation
– Pericarditis
– Refer to CVS/TCVS
Angina: Resolution
• Follow-up after 2 weeks
– for treadmill exercise test (if appropriate)
– Titration of medications
– Strengthen previous advice
Chronic Stable Angina
• Symptoms
– Same as acute angina
– Symptoms > 2 weeks
– No worsening, crescendo pattern over hours/weeks
– No increase in frequency
• Signs
– Hemodynamically stable
– Complete cardiovascular PE should be done
Chronic Stable Angina
• Diagnostics
– 12-L ECG
– Treadmill exercise test
– 2D-echo
– Crea, Na, K, Mg. Ca, alb
– Lipid profile, FBS
– Chest X-ray
Chronic Stable Angina
• Medications
– Anti-platelet
– Beta blocker
– ACE inhibitor
– Statin
Chronic Stable Angina
• Medications
– Anti-platelet
• Aspirin 80 mg OD
• Clopidogrel 75 mg OD if ASA-intolerant
– Beta blocker
• Atenolol 25-100 mg OD
• Metoprolol 50-100 mg OD-BID
• Carvedilol 6.25-50 mg BID
Chronic Stable Angina
• Medications
– ACE inhibitor
•
•
•
•
Captopril 25-200 mg BID-TID
Enalapril 5-20 mg OD
Lisinopril 10-40 mg OD
Ramipril 2.5-20 mg OD-BID
– Statin
• Atorvastatin 10 mg, max 80 mg @HS
• Rosuvastatin 10 mg, max 40 mg @HS
• Simvastatin 20 mg, max 80 mg @HS
Chronic Stable Angina
• If with high-risk features, or positive stress test,
advice coronary angiography with intervention
– Useless to do CA without intervention
– PCI vs CABG depends on clinical picture
– Refer to CVS in an institution with PCI/CABG
capability
Moonlight Medicine
Adrian Paul J Rabe, MD, DPCP
Pulmonology
Pulmonary Medicine
• Asthma
• COPD
Pulmonology
Asthma
Asthma: Presentation
• Symptoms
– Trigger
•
•
•
•
•
•
Allergen
URTI/Pneumonia
Beta blockers. Aspirin
Exercise. Cold air, hyperventilation, laughter
Occupational asthma (Mondays)
Stress
– Dyspnea, shortness of breath, chest tightness
• Night exacerbations
– Cough
– Younger age group
Asthma: Presentation
• Signs
– Tachypnea
– Tachycardia, hypertension
– Wheezing
– Absence of wheezing = severe
– Clubbing = uncontrolled
Asthma: Order Sheet
• Diagnostics
– ABG (hypercarbia, hypoxemia, alkalosis)
– Chest X-ray (rule out infection, other differentials)
– 12-L ECG (rule out cardiac causes of dyspnea
– CBC with PC (infection)
Asthma: Order Sheet
• Oxygenation
– O2 support
• Intubation if in impending/frank respiratory failure
• Short acting inhaled beta-agonists
– Salbutamol nebulization q5-15
– WOF tremors, palpitations
• Inhaled anti-cholinergics
– Ipatropium bromide nebulization q5-15
– WOF Dry mouth, decreased sputum production/dry
cough
Asthma: Order Sheet
• Glucocorticoids
– Hydrocortisone 50 mg IV q6 or 100 mg IV q8
– Budesonide nebule q8
– WOF Hoarseness, dysphonia, oral candidiasis, systemic
effects
• Aminophylline drip
– Mix as 1mg/mL
– LD 6 mg/kg over 20-30 minutes
– Maintenance at 1 mg/kg/hr (use lower dose in elderly, or
in nonsmokers)
– Hook to cardiac monitor
– WOF flushing, diarrhea, nausea, vomiting, arrhythmias
Asthma: Order Sheet
• If with status asthmaticus, admit to ICU
• Refer to anesthesia if previous measures don’t
work
– Propofol, Halothane
• Treat infection
– Most common is still viral URTI (supportive therapy)
– See CAP guidelines if with pneumonia
• Check if drug is the trigger
Asthma: Resolution
• Discharge
– No wheezing and tolerates room air
– No IV glucocorticoids
– Infection is treated
Asthma: Resolution
• Discharge Medications
– Home medications:
– Oral steroid with tapering schedule
• Prednisone at 0.5 -1 mg/kg/d in 2/3-1/3 dosing
– Combination inhaled corticosteroid with long-acting
inhaled beta-agonist
• Budesonide + Formoterol 160/4.5 or 80/4.5 ug 1-2 puffs BID
• Fluticasone + Salmeterol 500/50 or 250/50 or 100/50 1-2 puffs
BID
• Gargle after use
– Rescue doses of short acting inhaled beta-agonists
• Salbutamol neb PRN
Asthma: Outpatient Care
OCS
ICS
low dose
LABA
LABA
LABA
ICS
low dose
ICS
high dose
ICS
high dose
Short Acting Beta agonist
Mild
intermittent
Mild
persistent
Moderate
persistent
Severe
persistent
Very Severe
persistent
Symptoms
≤2/week
3-6/week
Daily
Daily
Unremitting
Night
≤2/month
3-4/month
≥5/month
Frequently
Nightly
Asthma: Outpatient Care
• Smoking cessation
• Influenza vaccination annually
• Pneumococcal vaccination once then q5 years
Pulmonology
COPD
COPD: Presentation
• Symptoms
– Cough, sputum production, exertional dyspnea
– Smoking
– Decreased functional capacity
– Chronic symptoms
– Older age group
• Signs
– Wheezing
– Clubbing, cyanosis
– Barrel-chest
COPD: Presentation
• Diagnostics
– ABG (hypercarbia, hypoxemia)
– Chest X-ray (infection, chronic changes –
hyperinflation, fibrosis, cause of COPD)
– CBC with PC (infection)
– 12-L ECG (consider cardiac etiology)
COPD: Order Sheet
• Oxygenation
– O2 support
• Intubation if in impending/frank respiratory failure
• Short acting inhaled beta-agonists AND inhaled
anti-cholinergics
– Salbutamol nebulization q5-15
– Ipatropium bromide nebulization q5-15
• Methylxanthine
– Theophylline 10-15 mg/kg in 2 divided doses
– Comes in 100, 200, 300, 400, 450 mg
COPD: Order Sheet
• Glucocorticoids
– Hydrocortisone 50 mg IV q6 or 100 mg IV q8
– Budesonide nebule q8
– Shift to Prednisolone/Prednisone 30-40 mg to
complete 2 weeks
• Antibiotics
– Bronchiectasis with increased sputum production
– 2 weeks of antibiotics directed against pathogen
COPD: Resolution
• Complete smoking cessation
• Pulmonary Rehabilitation (Refer to Rehab)
• Lung volume reduction surgery in severe
emphysema
• Oxygen therapy
– Resting O2 sat < 88%
– O2 sat < 90% if with pulmo HTN, cor pulmonale
• Influenza vaccination annually
• Pneumococcal vaccine once then q5 years
COPD: WOF
• Cor Pulmonale
– Right heart enlargement on X-ray, ECG
– Prominent neck veins and peripheral edema
– Careful diuresis
• Furosemide 20-40 mg BID
• Spironolactone 25-100 mg OD-BID
Endocrinology
Endocrinology
• Diabetes Mellitus
• Thyroid Disease
Endocrinology
Diabetes Mellitus
DM: Presentation
• Symptoms
– Weight loss, unexplained
– Polyuria, polydipsia
– Frothy urine
– Decreased vision
– Poorly healing wounds, frequent infections
– Paresthesias, numbness
– Stroke, MI previously
– DKA: abdominal pain, nausea, vomiting, young
– HHS: poor appetite, increased sleeping time, elderly
DM: Presentation
• Signs
– Decreased sensation
– Non-healing wound
– Skin atrophy, Muscle atrophy
– Diabetic dermopathy (necrobiosis lipiodica
diabeticorum)
– Renal failure
– Retinopathy
– DKA: ketone breath, normal abdomen, tachycardic,
tachypneic
– HHS: obtundation, dehydration
DM Emergency: Order Sheet
• Diagnostics
– CBC with PC (infection, anemia)
– RBS, BUN, Crea, Na, K, Cl, Ca, alb, Mg, P (azotemia,
low albumin, electrolyte imbalances, anion gap)
– Plasma ketones if available
– ABG
– Chest X-ray (and X-ray of involved extremity if with nonhealing wound)
– Urinalysis with ketones
– 12-L ECG
– HBA1c (instead of FBS)
– CBG
DM Emergency: Order Sheet
• Computations
– Osmolality
• 2(Na + K) + BUN + RBS (in mmol/L)
• Normal is 276-290 mmol/L
– Anion gap
• Na – (Cl + HCO3)
• Normal is 10-12 mmol/L
DM Emergency: Order Sheet
Parameters
Blood Chem
ABG
Both
DKA
HHS
Glucose (mg/dL)
250-600
600-1200
Na
125-135
135-145
K
Normal to Inc
Normal
Mg
Normal
Normal
Cl
Normal
Normal
P
Dec
Normal
Crea
Slight Inc
Moderately Inc
Osmolality
300-320
330-380
Ketones
++++
+/-
HCO3
< 15 mEq/L
Normal to slightly dec
pH
6.8-7.3
> 7.3
pCO2
20-30
Normal
Anion gap
Inc
Normal to slightly Inc
DM Emergency: Order Sheet
• ICU admission
– If unstable
– pH < 7.00
– Decreased sensorium
• Refer to Endo
DM Emergency: Order Sheet
• Replace fluids
– 2-3 L pNSS over first 1-3 hours (10-15 mL/kg/h)
– 0.45% NSS at 150-300 mL/h
– D5 0.45%NSS at 100-200 mL/h if CBG ≤ 250 mg/dL
– WOF congestion, hyperchloremia
– HHS: if Na > 150, use 0.45% NSS at the onset
• Insulin
– Start only if K > 3.3
– 0.1-0.15 u/kg IV bolus
– 0.1 u/kg/h IV infusion, target CBG 150-250 mg/dL
• 20 or 100 units regular insulin in pNSS to make 100 cc in
soluset dripped via infusion pump (1cc = 1u if 100 u used)
DM Emergency: Order Sheet
• Assess precipitant
– Noncompliance/missed insulin dose
– Infection (UTI, pneumonia)
– Myocardial infarction
– Drugs
• CBG q1-2 hours
• Electrolytes and ABG q4 for first 24 hours
• NVS, I/O q1
DM Emergency: Order Sheet
• Correct potassium
– K < 5.5: 10 mEq/h
– K < 3.5: 40-80 mEq/h
• Correct acidosis only if pH < 7.0 after initial
hydration
– pH 6.9-7.0: 50 mEqs NaHCO3 + 10 mEqs KCl in
200 mL sterile water x 1h
– pH < 6.9: 100 mEqs NaHCO3 + 20 mEqs KCl in 400
mL sterile water x 2h
– Repeat ABG 2 hours after
– Repeat dose q2 hours until pH > 7.0
DM Emergency: Order Sheet
• Correct magnesium
– Target 0.8 to 1 mmol/L
– Each gram of Mg will increase Mg by 0.1 mmol/L
• 3g MgSO4 in D5W 250 cc x 12h = 0.3 additional Mg
DM Emergency: Order Sheet
• ICU admission
– If unstable
– pH < 7.00
– Decreased sensorium
• May apply hydration and insulin drip for
hyperglycemic states
• Refer to Endo
DM Emergency: Resolution
• Decrease insulin until 0.05-0.1 u/kg/h
• As soon as patient is awake and tolerates feeding,
may start patient on diet
• Overlap insulin with subcutaneous insulin
– Calculate insulin requirements from insulin drip used
in past 24 hours
DM Inpatient: Insulin Regimens
• NPH Insulin + Regular Insulin
– Total Insulin requirement: 0.5-1 u/kg BW
• 2/3 pre-breakfast: 2/3 NPH, 1/3 Regular Insulin
• 1/3 pre-supper: ½ NPH, ½ Regular Insulin
– pB = NPH pre-supper
– pL = Regular insulin pre-breakfast
– pS = NPH pre-breakfast
– HS = Regular insulin pre-supper
DM Inpatient: Insulin Regimens
• Glargine Insulin + Lispro Insulin
– Total insulin requirement: 0.5-1 u/kg BW
• Glargine (Basal) insulin: ½ of total, given at night
• Lispro insulin: other half given in 3 divided doses, 15
minutes before each meal
– pB = Basal insulin
– pL = Lispro insulin pre-breakfast
– pS = Lispro insulin pre-lunch
– HS = Lispro insulin pre-supper
DM Inpatient: Order Sheet
• Inpatient goals
– Pre-prandial 90-130 mg/dL
– Post-prandial < 180 mg/dL
• For thin, insulin sensitive patients
– Add 1 unit to errant insulin for every 50 mg/dL above
target
• For obese, insulin resistant patients
– Add 2 units to errant insulin for every 50 mg/dL
above target
DM Inpatient: WOF
• Nephropathy
– Refer to Renal if with decreasing urine output, low
creatinine clearance, for possible HD
• Ophthalmopathy/Retinopathy
– Refer to Ophtha
• Diabetic foot ulcer
– Refer to Ortho/TCVS
• Deterioration in sugar control
– See previous orders
– Refer to Endo
• Acute coronary event
DM Outpatient: Order Sheet
• Diagnostics:
– FBS, 2-hour post-prandial glucose
– Lipid profile
– HBA1c
DM Outpatient: Order Sheet
• Targets
– HBA1c < 7%
– Pre-prandial glucose (FBS) 90-130 mg/dL
– Post-prandial glucose (2h PPBS) < 180 mg/dL
– BP < 130/80 (< 125/75 for patients with renal
insufficiency)
– Lipid modification (order of decreasing priority)
• LDL < 100 mg/dL
• HDL > 40 mg/dL in males, > 50 in females
• TG < 150 mg/dL
DM Outpatient: Order Sheet
• Medications: Biguanides
– Dose
• Metformin 500 mg-1g OD, BID, TID
• Adjust every 2-3 weeks
– Goal effect
• Reduces HBA1c by 1-2%
• Reduces fasting plasma glucose
– Good: weight loss
– Caution: Renal insufficiency (Crea > 124 mmol/L),
lactic acidosis, GI effects
– Hold 24h prior to procedures, while critically ill
DM Outpatient: Order Sheet
• Medications: Sulfonylureas
– Dose
• Glimepiride 1-8 mg OD
• Glipizide 2.5-40 mg OD-BID
• Take shortly before meals
– Goal effect
• Reduces HBA1c by 1-2%
• Reduces fasting and post-prandial plasma glucose
– Caution: weight gain, hypoglycemia, renal
insufficiency (Crea > 124 mmol/L), liver disease
DM Outpatient: Order Sheet
• Medications: Thiazolidinediones
– Dose
• Pioglitazone 15-45 mg OD
• Rosiglitazone 1-4 mg OD-BID
– Goal effect
• Reduces HBA1c by 0.5-1.5%
• Reduces fasting and post-prandial plasma glucose
• Reduces insulin requirements
– Caution: weight gain but redistributes to peripheral
areas, hypoglycemia, renal insufficiency (Crea > 124
mmol/L), liver disease, edema, heart failure
DM Outpatient: Order Sheet
• Medications: DPP-IV inhibitors
– Dose
• Sitagliptin 50-100 mg OD
• Vildagliptin 50 mg OD-BID
– Goal effect
• Reduces HBA1c by 0.5-1.0%
• Reduces insulin requirements
– Good: does not cause weight gain, minimal
hypoglycemia
– Caution: Renal insufficiency (use 50 mg OD if Crea >
124 mmol/L), headache, diarrhea, URTI
DM Outpatient: Order Sheet
• Medications: Alpha-glucosidase inhibitors
– Dose
• Acarbose 25 mg with evening meal
• Maximize to 50 - 100 mg with every meal
– Goal effect
• Reduces HBA1c by 0.5-0.8%
• Reduces post-prandial plasma glucose
– Good: weight loss
– Caution: GI effects (diarrhea, flatulence, abdominal
distention), Renal insufficiency (Crea > 177 mmol/L)
DM Outpatient: Order Sheet
• Medications
– If 2 drugs aren’t sufficient, insulin is recommended
– Cost and compliance are of prime importance
DM Outpatient: Order Sheet
• Diet
– Fat 20-35%
•
•
•
•
Minimal saturated fat (<7%)
Minimal transfat
Decreased cholesterl (<200 mg/d)
At least 2 servings of fish (Omega-3 fatty acids)
– Carbohydrates 45-65%
• Low glycemic index
• Sucrose containing food with adjustments in meds/insulin
– Protein 10-35%
– High fiber
DM Outpatient: Order Sheet
• At least 150 minutes/week
• Monitor blood sugar before, during and after
exercise
– CBG > 250 mg/dL, delay exercise
– CBG < 100 mg/dL, eat carbohydrate before exercise
– Pre-exercise insulin modification
• Decrease dose
• Inject into non-exercising muscle
DM Outpatient: Follow-up
•
•
•
•
•
Home monitoring of glucose
HbA1c q3-6 months
Medical nutrition therapy and education
Eye examination annually
Foot examination daily by patient, annually by
MD
• Screening for albuminuria annually
• Lipid profile and Crea annually
• BP measurement q4 months
Endocrinology
Thyroid Disease
Thyroid Disease
• Hyperthyroidism
• Hypothyroidism
Hyperthyroidism: Presentation
• Symptoms
–
–
–
–
–
Hyperactivity, irritability
Heat intolerance, sweating
Palpitations
Weakness, weight loss, diarrhea
Polyuria, oligomenorrhea
• Signs
–
–
–
–
Tachycardia, sometimes atrial fibrillation
Warm, moist skin
Tremors, muscle weakness
Anterior neck mass
Hyperthyroidism: Order Sheet
• Diagnostics
– CBC with PC (infection)
– 12-L ECG (atrial fibrillation, tachycardia)
– Chest X-ray (rule out infection, cardiomegaly)
– Urinalysis (infection)
– Free T4 and TSH (high FT4, low TSH)
– Crea, Na, K (low K)
– Thyroid UTZ (especially if with nodule/s)
Hyperthyroidism: Order Sheet
• Burch-Wartofsky scoring
– Components
•
•
•
•
•
•
•
Temperature
CNS
GI
CVS: heart rate
CVS: heart failure
CVS: atrial fibrillation
Precipitant history
– Score
• 25-44: impending storm
• ≥45: storm
Hyperthyroidism: Order Sheet
• Therapeutics
– Propylthiouracil 600 mg LD then 200-300 mg q6
• Orally/NGT
• By rectum
– Saturated solution of Potassium Iodide (SSKI) 5
drops q6-8, 1 hour after every PTU dose
Hyperthyroidism: Order Sheet
• Therapeutics
– Propranolol 40-60 mg PO q4
• If still no rate control: Verapamil 2.5-5 mg SIVP q15-30
minutes, maximum of 20 mg
• Use digoxin rarely (decreased potency in hyperthyroidism)
– Glucocorticoids
• Dexamethasone 2 mg IV q6
• Hydrocortisone 50 mg IV q6
– Treat infection, fever aggressively
– Correct electrolytes
Hyperthyroidism: Order Sheet
• ICU admission
– If stable, may admit to Ward
• Refer to Endo
Hyperthyroidism: Resolution
• Discharge
– Taper PTU to 200 mg TID
– Heart rate controlled with Propranolol BID
– Infection/precipitant treated
Hyperthyroidism: Out-patient
• Medication adjustment
– Preferably Methimazole 30 mg OD
– Taper Propranolol until PRN
• Follow-up
– 2-4 weeks with repeat FT4 (same laboratory)
– Adjust methimazole based on FT4
– TSH may be taken eventually to prove suppression
• Dietary avoidance
– Seafood
– Iodized salt
Hyperthyroidism: Out-patient
• 30 to 50% achieve remission on medical
treatment alone
– Usually after 12-18 months
• Definitive treatment: once euthyroid
– RAI
– Surgery
– Refer to Endo and GS/ORL
Hyperthyroidism: WOF
• Ophthalmopathy
– Steroids
• Prednisone 1 mg/kg in 2 divided doses
– Artificial tears
– Refer to Ophtha
Hypothyroidism: Presentation
• Symptoms
–
–
–
–
–
Weakness
Dry skin, hair loss, impaired healing
Difficulty concentrating
Weight gain, poor appetite
Heart failure
• Signs
–
–
–
–
–
Dry coarse skin, cool peripheral extremities
Puffy face, hands and feet; alopecia
Bradycardia
Serous cavity effusions (pericardial, pleural, peritoneal)
Hyporeflexia
Hypothyroidism: Order Sheet
• Diagnostics
– Free T4, TSH (low FT4, High TSH)
– CBC with PC
– 12-L ECG (documentation of heart rate)
– Chest X-ray (enlarged heart, pleural effusion)
– Crea, Na, K (hypokalemia)
– Thyroid UTZ
Hypothyroidism: Order Sheet
• Diagnostics
– Free T4, TSH (low FT4, High TSH)
– Anti-TPO
– CBC with PC
– 12-L ECG (documentation of heart rate)
– Chest X-ray (enlarged heart, pleural effusion)
– Crea, Na, K (hypokalemia)
– Thyroid UTZ
Hypothyroidism: Order Sheet
• Therapeutics
– Levothyroxine 1.6 ug/kg BW in single dose before
breakfast
– If missed dose: may take 2-3 doses of skipped tablets
at once due to long half-life
Hypothyroidism: Follow-up
• Repeat TSH after 2-4 weeks
– Use same laboratory
– Target lower half of TSH range
Gastroenterology
Gastroenterology
• Peptic Ulcer Disease and GERD
• Approach to Jaundice
Gastroenterology
Peptic Ulcer
Disease
PUD: Presentation
• Symptoms
– PUD: Epigastric pain, usually at night
– Metallic/acid taste in the mouth
– Melena
– NSAID use
– Weight loss, early satiety, vomiting
• Signs
– Epigastric tenderness
– Epigastric mass
– Melena on DRE (uncommon)
PUD: Order Sheet
• Diagnostics
– CBC with PC
– EGD with H. pylori biopsy
– Urea breath test
– FOBT
– Chest X-ray
PUD: Order Sheet
• Therapeutics (Active Bleeding)
– PPI drip
• Omeprazole 80 mg IV bolus
• Omeprazole 80 mg in pNSS to make 100 cc x 10 cc/h (8
mg/h)
– Immediate endoscopy
PUD: Order Sheet
• Therapeutics
– Proton pump inhibitors
•
•
•
•
•
Omeprazole 20 mg/d
Esomeprazole 20 mg/d
Lansoprazole 30 mg/d
Administer BEFORE a meal
Long-term: pneumonia, osteoporosis
– H2-receptor antagonists
• Ranitidine 300 mg @HS
• Famotidine 40 mg @HS
PUD: Order Sheet
• Therapeutics
– Antacids
• Usually for symptom relief
• Aluminum hydroxide-Magnesium hydroxide
• WOF nephrotoxicity
PUD: Order Sheet
• Therapeutics (H. pylori positive)
– OCA/OCM regimen
•
•
•
•
Omeprazole 20 mg BID
Clarithromycin 250-500 mg BID
Amoxicillin 1g BID or
Metronidazole 500 mg BID
– Refer to GI if no response
PUD: Resolution
• Follow-up after 2-4 weeks
– Decision to continue PPI dependent on symptoms
– Gastric ulcers have risk for malignancy
Gastroenterology
GERD
GERD: Presentation
• Symptoms
– Burning retrosternal chest pain
worsening/precipitated by recumbency
– Regurgitation of sour material into mouth
– Cough
– Dysphagia
• Signs
– Obesity
– Usually normal abdominal PE
GERD: Order Sheet
• Diagnostics
– EGD
– CBC with PC
GERD: Order Sheet
• Therapeutics
– Proton-pump inhibitors
• Omeprazole 20 mg/d
• Esomeprazole 40 mg/d
• Take 30 minutes before breakfast
– Weight reduction
– Elevation of head by 4-6 inches during recumbency
– Avoid
•
•
•
•
Smoking
Fatty food, large quantities of food/fluid
Alcohol, mint, orange juice
Calcium channel blockers
Gastroenterology
Jaundice:
How to work it up
Jaundice: Work-up
• History
– Chronicity
– Medications
– Hospitalizations, blood transfusions
– Sexual history
– Drug intake
Jaundice: Work-up
• Diagnostics
– TB, DB, IB
– AST, ALT, Alkaline Phosphatase
– PT
– Albumin
– Hepatitis profile
– HBT-UTZ
– Coomb’s test
Jaundice: Work-up
Initial Work-up
Isolated elevation of
bilirubin
Bilirubin and other tests
elevated
Jaundice: Work-up
Isolated elevation of
bilirubin
Elevated DB
(DB > 15%)
Elevated IB
(DB < 15%)
Drugs
Hemolytic Disorders
Inherited disorders
Inherited disorders
Indirect Bilirubinemia
• Drugs
– History is diagnostic
– Rifampicin
• Hemolytic disorders
–
–
–
–
Precipitated by infection, or other illnesses
Enlarged spleen
Diagnosed by PBS, Coomb’s test
AST, LDH may be elevated
• Inherited Disorders
– Criggler-Najjar syndrome, Gilbert’s syndrome
– Present in childhood
Direct Bilirubinemia
• Inherited Disorders
– Dubin-Johnson syndrome
– Rotor syndrome
– Present in young to middle-aged
Jaundice: Work-up
Bilirubin and other tests
elevated
ALT/AST predominant
(Hepatocellular pattern)
Alk Phos predominant
(Cholestatic pattern)
Drugs
Viral Hepatitis
Autoimmune Hepatitis
Ultrasound
Hepatocellular Pattern
• Drugs
– Alcohol
– Paracetamol ingestion
– Other hepatotoxic drugs
• Viral Hepatitis
– Detectable by serology
• Autoimmune Hepatitis
– ANA positive in some cases
• May do liver biopsy if no diagnosis at this point
Jaundice: Work-up
Alk Phos predominant
(Cholestatic pattern)
Dilated Ducts on
Ultrasound
No Dilated Ducts on
Ultrasound
Extrahepatic
Intrahepatic
Extrahepatic Pattern
• Do CT scan or ERCP to assess cause of
obstruction
• Carcinoma
– Periampullary CA
– Gallbladder CA
– Cholangiocarcinoma
• Stone
– Filling defect
• Parasitic disease
Intrahepatic Pattern
• Viral Hepatitis
• Drugs
– Alcoholic Hepatitis
– Steroids
•
•
•
•
•
Cholestasis of Pregnancy
TPN
Sepsis
TB
Lymphoma
Poisons
Poisons and Snakebites
•
•
•
•
•
•
General Principles of Management
Alcohol Toxicity and Withdrawal
Silver Jewelry Cleaner Ingestion
Organophosphate Ingestion
Kerosene Ingestion
Acid and Alkali Ingestion
Poisons
General Principles
General Principles
1.
2.
3.
4.
5.
6.
7.
Emergency Stabilization
Clinical Evaluation
Elimination of the poison
Excretion of absorbed substance
Administration of antidotes
Supportive Therapy and Observation
Disposition
General Principles
1. Emergency Stabilization
– Airway
– Breathing: Oxygenation and Ventilation
– Circulation: Inotropes
– Convulsion cessation
– Electrolyte/metabolic correction
– Coma
General Principles
2. Clinical Evaluation
– History:
•
•
•
•
Time, Mode/Route
Circumstances prior
Pre-existing illnesses or co-morbidities
Home remedies/treatment given
– PE
• Complete
• Breath odor
• Neurologic PE
General Principles
2. Clinical Evaluation
– Laboratory Examinations
•
•
•
•
•
•
•
•
CBC with PC
Urinalysis
RBS, BUN, Creatinine, Na, K, Ca, alb, Mg
ABG
12-L ECG
Bilirubins, PT, AST, ALT, Alk Phos
Chest X-ray (best if PA-upright)
Plain abdominal X-ray
General Principles
3. Elimination of the poison
– External decontamination
•
•
•
•
Discard all clothing
Thorough bathing
Eye irrigation
Protective gear for personnel
– Empty stomach
• Induction of emesis (if ingestion occurred within 1 hour)
• Gastric Lavage (50-60 mL of tepid sterile water)
– Don’t do in ingestion of caustics, kerosene!
– Don’t do if patient is convulsing!
General Principles
3. Elimination of the poison
– Limit GI absorption
•
•
•
•
Activated charcoal: 50-100 g in 200 mL H2O
Do multiple doses if with enterohepatic recirculation
Contraindicated in caustics
Follow with Na sulfate up to 2 doses, then soap sud enema for
BM
– Demulcent agents
• Raw egg albumin: whites of 8-12 eggs
– Cathartics
• Na sulfate 15 g in 100 mL H2O
• Contraindicated in caustics, easily absorbable chemicals, ileus,
severe fluid and electrolyte imbalances
General Principles
4. Excretion of absorbed substances
– Forced diuresis
• Mannitol 20% 1 mL/kg within 10 minutes then 2.5-5 mL/kg
q6 x 8 doses
• Must have good urine output
– Alkalinization (for weak acids)
• NaHCO3 1mEq/kg/dose IV targeting urine pH > 7.5
– Acidification (for weak bases)
• Ascorbic Acid 1g IV q6 until urine pH ≤ 5.5
– Dialysis
General Principles
5. Antidotes
6. Supportive Therapy
–
–
–
–
Fluid replacement for losses
Electrolyte correction
Prevention of aspiration, decubitus ulcers
Monitorin VS and I/O
7. Disposition
– ER vs Ward vs ICU
– Psychiatric evaluation
– Social evaluation
Poisons
Alcohol
Alcohol Intoxication
Blood Ethanol
(mg/dL)
< 50
50-100
100-300
300-500
> 500
Symptoms
Brain affected
Talkativeness, euphoria
Decreased inhibition/increased
confidence, emotional instability,
slow reaction
Ataxia, slurred speech , diplopia,
decreased attention span
Visual impairment, severe ataxia,
stupor
Respiratory Failure, coma
Frontal Lobe
Parietal Lobe
Occipital Lobe
Cerebellum
Midbrain
Medulla
Alcohol Intoxication
Category
Beer
Wine
Fortified Wine
Distillates
Local distilled
Hygiene Products
Specific
Lager
Pilsen
Strong
Red/White
Champagne
Whiskey, rye,
rhum, bourbon, gin
Lambanog, tuba
Perfume/cologne
Mouth wash
% Ethanol
2-3%
5-6%
9-14%
7-12%
15-20%
40-50%
60-80%
25-95%
15-25%
Alcohol Intoxication
Local Term
Lapad
Bilog
Volume
325 mL
325 mL
Kwatro kantos
Long neck
Beer grande
Beer (regular)
325 mL
750 mL
1000 mL
320 mL
Alcohol Intoxication
• Blood alcohol (mg/dL)
– mL ingested x % alcohol x 0.8
6 x kg BW
• Metabolism
– Non-alcoholic: 13 to 25 mg/dL per hour
– Alcoholic: 30 mg/dL per hour
• Estimated time of recovery
– Blood alcohol/metabolic rate
Alcohol Intoxication
• History
– Amount ingested
– With what substance
• PE
– Evidence of trauma
– Level of sensorium
Alcohol Intoxication: Order Sheet
• Labs
– Urine ketones
– CK MB, MM
– Amylase
– FOBT
Alcohol Intoxication: Order Sheet
• Therapeutics
– NPO
– Insert NGT
– IVF: D5 0.9 NaCl 1L x 8h
Conscious
Unconscious
Alcohol Intoxication: Order Sheet
• Therapeutics
– Thiamine 100 mg IM/IV
– D50-50 100 mL fast drip IV
– Refer to Psych
– Evaluate for withdrawal
– Observe for 6 hours
– Discharge on
• Thiamine 50 mg TID OR
• Vitamin B complex 1 tab TID
• Folic Acid OD, Multivitamins OD
Conscious
Alcohol Intoxication: Order Sheet
• Therapeutics
Unconscious
– Thiamine 100 mg IM/IV now then q8
– D50-50 100 mL fast drip IV
– Refer to Neurology
– Observe for return of consciousness
• Fully awake: Observe for 5-7 days, refer to Psychiatry
• Partially awake: Work-up for decreased sensorium (NSS?)
• Comatose: Naloxone 2 mg IV q2 minutes for a total of 10
mg; work-up for decreased sensorium, consider HD
– Same discharge plans
Alcohol Withdrawal: Presentation
• Symptoms/Signs
– Autonomic hyperactivity (sweating, tachycardia)
– Increased tremors
– Insomnia
– Nausea/vomiting
– Hallucinations/illusions
– Psychomotor agitation/anxiety
– Seizures
Alcohol Withdrawal: Order Sheet
• Therapeutics
– Diazepam 2.5-5mg q8 x 3 days then taper for next 2
days before discontinuation
– Vitamin B complex TID
– Folic Acid OD
Alcohol: Resolution
• Enrol in quitting program
• Advice moderation
Poisons
Paracetamol
Paracetamol: Presentation
• Toxic dose if 150-300 mg/kg
• Symptoms vary based on time after exposure
– 0-24 hours: asymptomatic, nausea, vomiting
– 24-36 hours: asymptomatic, upper abdominal pain
– 36-72 hours: onset of liver/renal failure
– 72-120 hours: jaundice, bleeding, liver/renal failure
Paracetamol
• History
– Time, mode
– Intake of other substances/meds
– Co-morbidities
• PE
– Heart, liver, kidneys
– Neurologic examination
Paracetamol: Order Sheet
• Diagnostics
– Serum paracetamol
– AST, ALT, PT
Paracetamol: Order Sheet
Volume ingested?
Known
< 150
mg/kg
Observe
for 24h
(+) SSx or
AST, ALT
or PT abn
≥ 150
mg/kg
Unknown
N-acetylcysteine
Test dose: 0.1 mL in
0.9 mL NSS IV
Diphenhydramine 1
mg/kg prior to
phases
Phase 1: 150 mg/kg in
200 mL D5W x 1h
Phase 2: 50 mg/kg in
500 mL D5W x 4h
Phase 3: 100 mg/kg in
1L D5W x 16h
(+) SSx
(-) SSx
Observe
for 72h
(+) SSx or
AST, ALT
or PT abn
Paracetamol: Order Sheet
Normalization after 72
hours
Discharge
Paracetamol: WOF
• Acute Renal Failure
– IVF hydration
– Refer to Renal for possible Dialysis
• Bleeding
– Vitamin K 10 mg IV up to q6
– Target PT > 60% activity
• Hepatic insufficiency
– Vitamin B complex
– Vitamin K
• Electrolyte abnormalities
– Hypoglycemia, acidosis, hypokalemia, hypocalcemia
Poisons
Silver Jewelry
Cleaner
Silver Jewelry Cleaner
• Active compound is cyanide-derived
• Binds to cytochrome oxidase enzymes, inhibiting
cellular respiration
SJC: Order Sheet
• Diagnostics
– ABG
– Serum cyanide
– CBC with PC
• Anticipatory Care
– ICU admission
– Close monitoring
– Treatment for co-ingestants (e.g. alcohol)
SJC: Order Sheet
• Therapeutics
– Oxygenation
• High flow
• Prophylactic intubation esp if with decreased sensorium
– Na nitrite 300 mg SIVP (over 5 minutes)
• Vasodilator, displaces cyanide, producing methemoglobin
• Causes hypotension
– Na thiosulfate 12.5 g (50 mL of a 25% solution) SIVP
(over 10 minutes)
• Speeds the displacement of cyanide by providing sulfur for
binding
SJC: WOF
• Decreased sensorium
– Aspiration precautions
– Prophylactic intubation if warranted
• Seizures
– Diazepam
– Increased oxygen delivery
• Hypoxic encephalopathy
– Rapidly reversible if antidote given early
– If still not reversed, need prognostication by Neuro
Poisons
Kerosene
Kerosene
• History
– Time
– Amount
– Mucous membrane irritation
– CNS depression, seizures
• PE
– Lung findings: crackles, respiratory distress
– Arrhythmia, tachycardia
– Sensorial changes
Kerosene: Order Sheet
• Diagnostics
– Chest X-ray (6 hours post-ingestion)
– ABG
Volume ingested?
≤ 60 mL
≤ 60 mL +
other toxic
substance
> 60 mL or
unknown
Kerosene: Order Sheet
Volume ingested?
≤ 60 mL
≤ 60 mL +
other toxic
substance
> 60 mL or
unknown
• Na Sulfate
• (BM)
• Clean anal area with
petroleum jelly
• Insert NGT
• Lavage with
Activated
Charcoal
• Insert NGT
• Lavage with
water
Kerosene: Order Sheet
Sensorial Change
Pneumonia
Toxic substances
Observe for 1224 hours
Observe for 3
days
• Refer to
Psych
• Discharge
Supportive
Care
Kerosene: WOF
• Pneumonia
– Penicillin G 200,000 u/kg/d in 6 divided doses
– Clindamycin 300 mg PO/IV q6
– Metronidazole 500 mg PO/IV q6
• Gastritis
– Al-hydoxide-Mg-hydroxide 30 mL q6
• Prolonged PT
– Vitamin K 10 mg OD
• Seizures
– Diazepam 2.5-5 mg SIVP
– Refer to Neuro
Poisons
Acids
Acids
• Causes coagulation necrosis which forms eschars
– Damage is self-limiting
• Eventual stenosis of viscus
Acids: Order Sheet
• Diagnostics
– Cross-matching
– Urine hemoglobin
– Chest X-ray upright, plain abdomen
– Emergency EGD
Acids: Order Sheet
• Therapeutics
– Copious amounts of water to decontaminate
externally
– NPO
– IVF: D5NSS 1L x 8h
– Meperidine 25-50 mg IM
– Famotidine 20 mg IV q12
– Concentrated acids: Enhance excretion with Mannitol
• Test dose: 1 mL/kg within 10 mins
• If with good urine output: 2.5-5.0 mL/kg q6 x 8 doses
• Discontinue mannitol if with poor urine output x 2h
Acids: Order Sheet
Grade
Findings
0
Normal
1
Edema, hyperemia of mucosa
2A Friability, blisters, hemorrhages, erosions, whitish
membranes, exudates, superficial ulcerations
2B
2A + deep discrete or circumferential ulceration
3A Small scattered areas of multiple ulcerations and
areas of necrosis
3B
Extensive necrosis
Endoscopy
Grade 0-1
Grade 2a/b
Admit
Observe for 48 h
Liquid diet for 48h
H2 blockers PO/IV
Demulcent, antacids
or sucralfate
Admit to ICU
NPO
IV hydration, TPN
H2 blockers IV
Repeat EGD 24-48h
No
Psych Referral
Discharge
Ff-up with GS/GI
Perforation,
Necrosis?
Yes
Laparotomy
Grade 3a/b
Admit to ICU
NPO
IV hydration/TPN
H2 blockers IV
Hydrocortisone 100
mg IV q6 for
shock
Meperidine
Antibiotics (anarobes,
Gram negatives)
Repeat EGD 24-48h
Acids: WOF
• Acute abdomen
– Surgery
– Lifelong vitamin B12 if gastrectomy done
• Shock
– Fluids, antibiotics as appropriate
• Upper airway obstruction
– Tracheostomy
– Hydrocortisone 100 mg IV q6
• Upper GI Bleed
– Blood transfusion, surgery
Poisons
Alkali
Alkali
• Causes liquefaction necrosis
– Damage spreads, and may continue for days
Alkali: Order Sheet
• Diagnostics
– Cross-matching
– Urine hemoglobin
– Chest X-ray upright, plain abdomen
– Emergency EGD
Alkali: Order Sheet
• Therapeutics
– Copious amounts of water to decontaminate
externally
– NPO
– IVF: D5NSS 1L x 8h
– Meperidine 25-50 mg IM
– Famotidine 20 mg IV q12
Alkali: Order Sheet
Extent
First degree
Findings
Superficial mucosal hyperemia, mucosal
edema, superficial sloughing
Second degree Deeper tissue damage, transmucosal (all
layers of the esophagus), with exudages,
erosions
Third degree Through the esophagus and into the
periesophageal tissues (mediastinum ,
pleura or peritoneum), deep ulcerations,
black coagulum
Endoscopy
First degree
Second degree
Admit
Observe for 48 h
Liquid diet for 48h
Demulcent, antacids
Psych Referral
Discharge
Ff-up with GS/GI
No
Admit to ICU
NPO
IV hydration, TPN
Hydrocortisone 100
mg IV q6
H2 blockers IV
Sucralfate
Repeat EGD 24-48h
Yes
Laparotomy
Perforation?
Third degree
Admit to ICU
NPO
IV hydration/TPN
H2 blockers IV
Hydrocortisone 100
mg IV q6 for
shock
Meperidine
Antibiotics (anarobes,
Gram negatives)
Repeat EGD 24-48h
Alkali: WOF
• Acute abdomen
– Surgery
– Lifelong vitamin B12 if gastrectomy done
• Shock
– Hypovolemic/Septic: Fluids, antibiotics as appropriate
– Neurogenic: Mepedirine 1 mg/kg/dose IV
• Upper airway obstruction (Glottic edema)
– Tracheostomy
– Hydrocortisone 100 mg IV q6
• Upper GI Bleed
– Blood transfusion, surgery
National Poison Control
and Management Center
(02) 554-8400 loc 2311
(02) 524-1078
0922-896-1541
Pain Pharmacopeia
Pain Medication
• Most common complaint
• Best treatment: address the cause
Pain Pharmacopeia
NSAIDs
Pain Medication: NSAIDs
•
•
•
•
•
•
ASA 80-160 mg PO OD
Paracetamol 500-650 mg PO up to q4
Ibuprofen 400 mg PO up to q4
Naproxen 250-500 mg up to q12
Ketorolac 15-60 mg IM/IV up to q4
Celecoxib 100-200 mg PO up to q12
Pain Medication: NSAIDs
• Advantages
– Deals well with inflammatory pain (muscle and joint pain,
malaise from infection, etc)
– Absorbed well from the GI tract
• Disadvantages
–
–
–
–
GI irritation (except paracetamol)
Peptic ulcer
Nephropathy
Increases blood pressure
• Selectivity for COX-2
– Decreases GI symptoms
– Increases cardiovascular risk
Pain Pharmacopeia
Narcotics
Pain Medication: Narcotics
• Morphine 60 mg PO up to q4
• Tramadol 50-100 mg PO up to q4
Pain Medication: Narcotics
• Advantages
– Broadest efficacy
– Very rapid especially if IV
• Disadvantages
– Nausea and vomiting
– Constipation
– Sedation
– Respiratory depression
Pain Pharmacopeia
Anti-depressants
Pain Medication: Anti-depressants
•
•
•
•
•
Duloxetine 30-60 mg/d
Desipramine 50-300 mg/d
Imipramine 75-400 mg/d
Amitriptyline 25-300 mg/d
Doxepin 75-400 mg/d
Pain Medication: Anti-depressants
• Advantages
– Very useful for chronic pain
•
•
•
•
•
•
Post-herpetic neuralgia
Diabetic neuropathy
Tension headache
Migraine
Rheumatoid arthritis
Cancer
– More rapid onset of relief
Pain Medication: Anti-depressants
• Disadvantages
– Significant number of side effects
•
•
•
•
Orthostatic hypotension
Heart block/conduction delay
Constipation
Urinary retention
Pain Pharmacopeia
Anti-convulsants
Pain medication: Anti-convulsants
•
•
•
•
•
Phenytoin 300 mg @ HS
Carbamazepine 200-300 mg up to q6
Clonazepam 1mg up to q6
Gabapentin 600-1200 mg up to q8
Pregabalin 150-600 mg up to BID
Pain medication: Anti-convulsants
• Advantages
– Effective for neuropathic pain (e.g. trigeminal
neuralgia, DM nephropathy)
• Disadvantages
– Hepatic toxicity
– Dizziness
– GI symptoms
– Heart conduction disturbances
Electrolytes