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Moonlight Medicine

Adrian Paul J Rabe, MD, DPCP

8 Targets of Moonlight Medicine


Infectious Disease Cardiovascular Medicine Pulmonary Medicine Endocrinology Gastroenterology Poisons and Snakebites Pain Medication Electrolyte Correction

Infectious Disease

Infectious Disease
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

Yes

Moderate Risk vs High RIsk

No

Low Risk CAP

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

Yes

High Risk CAP

No

Moderate 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?
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

AFRRAID CH7

UTI 2004 Guidelines


Uncomplicated Cystitis
Medications (do 7 day regimen in males)

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:

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)

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)

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)

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

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

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

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

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

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
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 Peyers 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
Weils 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

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 Cushings 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 Diastolic, mmHg < 80 80-89 90-99 100

And Or Or Or

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
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

BEADS

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

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

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
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 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 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 dont 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 LABA ICS low dose ICS low dose LABA ICS high dose LABA ICS high dose

Short Acting Beta agonist


Mild intermittent Symptoms Night 2/week 2/month Mild persistent 3-6/week 3-4/month Moderate persistent Daily 5/month Severe persistent Daily Frequently Very Severe persistent Unremitting 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 Glucose (mg/dL) DKA 250-600 HHS 600-1200

Na
K Mg Blood Chem Cl P Crea Osmolality Ketones HCO3 ABG Both pH pCO2 Anion gap

125-135
Normal to Inc Normal Normal Dec Slight Inc 300-320 ++++ < 15 mEq/L 6.8-7.3 20-30 Inc

135-145
Normal Normal Normal Normal Moderately Inc 330-380 +/Normal to slightly dec > 7.3 Normal 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: NPH, 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: 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 arent 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
Tachycardia, sometimes atrial fibrillation Warm, moist skin Tremors, muscle weakness Anterior neck mass

Signs

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
Dry coarse skin, cool peripheral extremities Puffy face, hands and feet; alopecia Bradycardia Serous cavity effusions (pericardial, pleural, peritoneal) Hyporeflexia

Signs

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 Coombs 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, Coombs test AST, LDH may be elevated

Inherited Disorders
Criggler-Najjar syndrome, Gilberts 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)
Dont do in ingestion of caustics, kerosene! Dont 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 Talkativeness, euphoria Decreased inhibition/increased confidence, emotional instability, slow reaction Ataxia, slurred speech , diplopia, decreased attention span Brain affected Frontal Lobe Parietal Lobe Occipital Lobe Cerebellum Midbrain Medulla

Visual impairment, severe ataxia, stupor Respiratory Failure, coma

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 Kwatro kantos Long neck Beer grande Beer (regular) Volume 325 mL 325 mL 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

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

150 mg/kg

(+) SSx

(-) SSx
Observe for 72h

(+) SSx or AST, ALT or PT abn

(+) 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


Insert NGT Lavage with Activated Charcoal

> 60 mL or unknown

Na Sulfate (BM) Clean anal area with petroleum jelly

Insert NGT Lavage with water

Kerosene: Order Sheet


Sensorial Change Pneumonia Toxic substances

Observe for 1224 hours


Refer to Psych Discharge

Observe for 3 days

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
Admit Observe for 48 h Liquid diet for 48h H2 blockers PO/IV Demulcent, antacids or sucralfate

Grade 2a/b
Admit to ICU NPO IV hydration, TPN H2 blockers IV Repeat EGD 24-48h

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

No

Perforation, Necrosis?

Psych Referral Discharge Ff-up with GS/GI

Yes
Laparotomy

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


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 Extent First degree

Endoscopy

First degree
Admit Observe for 48 h Liquid diet for 48h Demulcent, antacids

Second degree
Admit to ICU NPO IV hydration, TPN Hydrocortisone 100 mg IV q6 H2 blockers IV Sucralfate Repeat EGD 24-48h

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

Psych Referral Discharge Ff-up with GS/GI Laparotomy

No
Yes

Perforation?

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