Medicine Blue Book

By Dr. W.T. Ong & Dr. A.L.R. Ong Prepared bv

Dr. Neo

TABLE OF CONTENTS Abbreviations Contributing Authors Preface Detailed Table of Contents Cardiology Pulmonology Gastroenterology Infectious Diseases

Nephrology Endocrinology Rheumatology Neurology Toxicology Nutrition The Pregnant Patient with Medical Problems

Preventive Medicine & Adult Immunizations Final Pointers Appendices All About Drips More Drug Lists: Pain Relievers / Laxatives / Antidiarrheals More Drug Lists: Antiflatulence / Antipyretics / Hypnotics and Sedatives Intravenous Fluids Formulas References

TABLE OF CONTENTS Abbreviations Contributing Authors Preface Back to Main Table of Contents Cardiology........ Willie T. Ong, M.D. Advanced Cardiac Life Support Acute Myocardial Infarction Thrombolytic Therapy in MI Unstable Angina Congestive Heart Failure Hypertensive Emergency Supraventricular Tachycardia Atrial Fibrillation Premature Ventricular Contractions & Ventricular Tachycardia Premature Atrial Contractions Infective Endocarditis (Treatment) Infective Endocarditis (Prophylaxis) Acute Rheumatic Fever Treatment & Prophylaxis Cardio-Pulmonary Clearance Dyslipidemia with Lipid Lowering Drugs Indications for Permanent Pacemaker Insertion Hypertension List of Antihypertensives & Cardiac Drugs Low Molecular Weight Heparins for DVT and Unstable Angina The Cardiac Patient with Other Medical Disorders Pulmonology........ Camilo C. Roa, Jr., M.D. Bronchial Asthma Drugs Used to Treat Asthma Management of Chronic Asthma Management of Acute Exacerbations of Asthma: Home Treatment Management of Acute Exacerbations of Asthma: Hospital Treatment Chronic Obstructive Pulmonary Disease Tuberculosis Antituberculosis Drug List Pulmonary Embolism Hemoptysis Pleural Effusion and Thoracentesis Anaphylaxis Pneumothorax Pneumonia Gastroenterology ........ Virgilio P. Banez, MD. Peptic Ulcer Disease & Acute Gastritis Upper and Lower GI Bleeding Anti-ulcer Drugs Hepatic Encephalopathy & Liver Cirrhosis Abdominal Paracentesis Viral Hepatitis Acute Cholecystitis Bacterial Cholangitis and Biliary Sepsis Acute Pancreatitis Acute Diarrhea with Mild Dehydration

Cholera with Severe Dehydration Acute Intestinal Obstruction Infectious Diseases ........ Cecilia S. Montalban, M.D. Clinically Useful Antibiotics Antibiotic Drug List Systemic Viral Infection Acute Tonsillopharyngitis Dengue Hemorrhagic Fever Typhoid Fever Malaria Prevention of Malaria in Travellers Leptospirosis Schistosomiasis Sepsis and Septic Shock Lower Urinary Tract Infection Pyelonephritis Cellulitis Meningitis and Encephalitis Tetanus Osteomyelitis Peritonitis Diverticulitis Pelvic Inflammatory Disease Pneumonia Infective Endocarditis Mumps Varicella Zoster Empirical Antimicrobials for Out-Patient Adults Initial Antimicrobials for Acutely Ill Adults Drug of Choice for Microbial Pathogens Nephrology...... Elizabeth S. Montemayor, MD. Acute Renal Failure Strategy for Removing Excess Fluid Chronic Renal Failure Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia Hyponatremia Hypomagnesemia Hypermagnesemia Nephrolithiasis Dialysis Dosage Adjustment of Drugs in Renal Failure Endocrinology........ Ruby T. Go, MD. Approach to Type II Diabetes Mellitus Diabetic Ketoacidosis / Hyperosmolar Coma Thyroid Storm Hyperthyroidism Hypothyroidism Adrenal Insufficiency Rheumatology........ Clemente M Amante,‘MD. Osteoarthritis Gouty Arthritis

Rheumatoid Arthritis Systemic Lupus Erythematosus Neurology ...... Carlos L. Chua, M.D. Cerebral Infarction vs. Hemorrhage Guide Intracerebral Hemorrhage Subarachnoid Hemorrhage Cerebral Thrombosis Cerebral Embolism Transient Ischemic Attack Stroke In Evolution Stroke in the Young Seizures and Epilepsy Brain Abscess Myasthenia Gravis Parkinson's Disease Alcohol Withdrawal Approach to Weakness Toxicology...... Kenneth Hartigan-Go, MD. Poisoning and Drug Overdose: General Guidelines Acid Ingestion Alkaline Ingestion Amphetamine / Metamphetamines Anticoagulants Diazepam Digitalis / Digoxin Ethanol Hydrocarbon / Kerosene Isoniazid Narcotics Organophosphates Paracetamol Phenothiazines / Neuroleptics Salicylate / Aspirin Tricyclic Anti-Depressants Nutrition...... Nutritionist-Dietitians' Association of the Philippines Recommended Diet by Organ System High Fiber Diet Low Calorie Diet High Calorie Diet High Protein Diet Low Protein Diet Low Fat / Low Cholesterol Diet Low Carbohydrate Diet Low Sodium Diet Low Potassium Diet Low Uric Acid / Low Purine Diet Nutritional Management of Diabetics and Renal Patients The Pregnant Patient with Medical Problems==.Camilo C. Roa, Jr., M.D., Ruby T. Go, MD., Willie T. Ong, MD. Pregnancy and Hypertension Pregnancy and Cardiac Disease Pregnancy and Asthma Pregnancy and Thyroid Disease Pregnancy and Diabetes

Drugs Used in Pregnancy Preventive Medicine & Adult Immunizations==.Willie T. Ong, MD., Cecilia S. Montalban, MD. Final Pointers =. WillieT. Ong Appendices All About Drips More Drug Lists: Pain Relievers / Laxatives / Antidiarrheals More Drug Lists: Antiflatulence / Antipyretics / Hypnotics and Sedatives Intravenous Fluids Formulas References Back to Top Back to Main Table of Contents

Abbreviations Back To Main Page Back to Detailed Table of Contents =) + +/ABG Ac Ad Lib AF AHA AMI Amp AOG ARF ARDS ASA ASAP ATS BID BM BP Bpm BRP BUN BW C&S Ca CAD Cap CAPD CBC CBG CBR CHF Conc COPD CPR CRF CRI CSA CVA CVP CXR D DAT DBP DDx DIC DKA DM DOC DTR Dx DVT ECG/EKG EF

Cheaper drug option Add or with With or without Arterial bood gas Ante-cibum; before meals Ad libitum; as much as desired Atrial fibrillation American Heart Association Acute myocardial infarction Ampule(s) Age of gestation Acute renal failure Acute respiratory distress syndrome Aspirin or Acetylsalicylic acid As soon as possible American Thoracic Society Twice-a-day Bowel movement Blood pressure Beats per minute Bathroom privileges Blood urea nitrogen Body weight Culture and sensitivity Calcium Coronary artery disease Capsule(s) Chronic ambulatory peritoneal dialysis Complete blood count Capillary blood glucose Complete bed rest Congestive heart failure Concentration Chronic obstructive pulmonary disease Cardio-pulmonary resuscitation Chronic renal failure Chronic renal insufficiency Chronic stable angina Cerebrovascular accident Central venous pressure Chest X-ray Day Diet as tolerated Diastolic blood pressure Differential diagnosis Disseminated intravascular coagulation Diabetie ketoacidosis Diabetes mellitus Drug of choice Deep tendon reflexes Diagnosis Deep venous thrombosis Electrocardiogram Ejection Fraaction

DM DOC DTR Dx DVT ECG/EKG EF e.g. EMD ET FBS G or gm GS Gtts H+ HBT HCO3 HD HDL HGT HONC HPN HR Hr HS IBW IE IHD I and O IM IU IV IVP J K Kg L or l LDL Lpm LV LVH Mcg Mg MI Min Mil MR MRI MS MVP Na NGT NH4 NSS NYHA OD OGTT OHA PAC Pc PD PE PEFR Pen PFT PO

Diabetes mellitus Drug of choice Deep tendon reflexes Diagnosis Deep venous thrombosis Electrocardiogram Ejection Fraaction For example Electromechanical dissociation Endotracheal tube Fasting blood sugar Gram(s) Gram stain Macrodrops Hydrogen ions Hepatobiliary tract Bicarbonate ions Hemodialysis High density lipoprotein Hemoglucotest Hyperosmolar non-ketotic coma Hypertension Heart rate Hour At night Ideal body weight Infective endocarditis Ischemic heart disease Input and output Intramuscular International units Intravenous Intravenous push Joules Potassium Kilogram Liter(s) Low density lipoprotein Liters per minute (Oxygen) Left ventricle Left ventricular hypertrophy Microgram Magnesium Myocardial infarction Minute(s) Million Mitral regurgitation Magnetic resonance imaging Mitral stenosis Mitral valve prolapse Sodium Nasogastric tube Ammonium ions Normal saline solution New York Heart Association Once-a-day Oral glucose tolerance test Oral hypoglycemic agents Premature atrial contraction Post-cibum; after meals Peritoneal dialysis Physical examination Peak expiratory flow rate Penicillin Pulmonary function test Per orem; oral route

Pc PD PE PEFR Pen PFT PO PPI PRn Pt. or Pts. PT PTT PTU PVC q QID RAIU RF RHD RR RV SBP SGOT SGPT SL Sn Sp SC STAT Supp Susp SVT Syr Tab TC TET TG TID TMP-SMZ TPAG Tsp 2-D Echo Tx u ugtt or uggts UO UTZ VS w/ w/o WPW Wt

Post-cibum; after meals Peritoneal dialysis Physical examination Peak expiratory flow rate Penicillin Pulmonary function test Per orem; oral route Permanent pacemaker insertion Proton pump inhibitor As needed Patient(s) Prothrombin time Partial thromboplastin time Propylthiouracil Premature ventricular contraction Every Four times-a-day Radioactive iodine uptake Rheumatic fever Rheumatic heart disease Respiratory rate Right ventricle Systolic blood pressure Serum glutamic-oxaloacetic transaminase Serum glutamic-pyruvic transaminase Sublingual; under the tongue Scnsitivity Specificity Subcutaneous Immediately Suppository Suspension Supraventriculat tachycardia Syrup Tablet(s) Total cholesterol Treadmill exercise test Triglyceride Three times-a-day Trimethoprim-Sulfamethoxazole Total protein and albumin Teaspoon(s) Two-dimensional echocardiography Treatment Units Microdrop (s) Urine output Ultrasound Vital signs With Without Wolff-Parkinson-White syndrome Weight

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Contributing Authors Back To Main Page Back to Detailed Table of Contents Clemente M. Amante, MD, FPCP, FPRA Professor of Medicine, Section of Rheumatology, UP-PGH VirgilioP. Banez, MD, FPCP, FPSG, FPSDE Clinical Associate Professor of Medicine, Section of Gastroenterology, UP-PGH Carlos L. Chua, MD, FPNA Associate Professor of Medicine, Section of Neurology, UP-PGH Kenneth Hartigan-Go, MD, FPCP, FPSECP, FPSCOT Associate Professor, Department of Pharmacology, UP College of Medicine Clinical Associate Professor of Medicine, Section of Toxicology, UP-PGH Ruby T.Go, MD Clinical Associate Professor of Medicine, Section of Endocrinology, UP-PGH Cecilia S. Montalban, MD, FPCP, MSCTM Associate Professor of Medicine, Section of Infectious Diseases, UP-PGH Elizabeth S. Montemayor, MD, FPCP, FPSN Associate Professor, Department of Physiology, UP College of Medicine Clinical Associate Professor of Medicine, Section of Nephrology, UP-PGH Willie T. Ong, MD, MPH, FPCP, FPCC Cardiologist, Manila Doctors Hospital and Makati Medical Center Camilo C. Roa, Jr., MD, FPCP, FPCCP Professor, Department of Physiology, UP College of Medicine Clinical Associate Professor of Medicine, Section of Pulmonary Medicine, UP-PGH

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Preface to the Sixth Edition The year 2005 marks the 10-year anniversary of the publication of the Medicine Blue Book. I wrote the draft during my intemship and completed the book my first year of residency at Manila Doctors Hospital. Even then, my utmost desire in sharing this book is to assist the many struggling doctors and nursesin our different training institutions. I had seen how hard and how unrewarding. medical training can be. I hope the Blue Book can be your friend and companion at some point in your career. One of the biggest problems afflicting our country right now is the high cost of healthcare. To address this, the Blue Book contains several unique features: 1) effective drug options are listed whenever possible and noted with a smile =) icon, (2) priority laboratory exams to request are highlighted in bold, (3) the treatment regimens are generally listed according to importance, which means that crucial treatment strategies are listed first and supportive treatments are listed last, (4) the dosages of drugs have been adjusted for the average Asian patient, and (5) only tests and drugs available in our local setting are included. This edition presents major revisions and updates in all chapters. The latest (local ones if available) have been utilized. Again, myprofuse thanks to, Clemente Amante, Dr. Virgilio Banez, Dr. Carlos Chua, Dr. Kenneth Hartigan-Go, Dr. Ruby Go, Dr. Cecilia Montalban, Dr. Elizabeth Montemayor and Camilo Roa Jr. for their selfless and untiring efforts in updating the text. I am also greatly indebted to several people in my medical education: Dr. P. Ariniego, Medical Director at De La Salle University Medical Center; , Dr. Nelson S. Abelardo, past Chair of the Department of Internal Medicine at TheManila Doctors Hospital; and Dr. Rody G. Sy, former Head of the Section of Cardiology at UP-Philippine General Hospital. Finally, I would like to thank my parents, Mr. Ong Yong and Mrs. Juanita Tan Ong, for their wholehearted support in this endeavour. And to my wife, Anna for all her hard work in publishing this book. Above all, I humbly thank the Lord God for His guidance and inspiration. I can accomplish nothing without Him but "I can do everything in Christ who strengthens me." Thank you for reading and may God bless us always. Willie T. Ong

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Cardiology Willie T. Ong, M.D. Advanced Cardiac Life Support Acute Myocardial Infarction Thrombolytic Therapy in MI Unstable Angina Congestive Heart Failure Hypertensive Emergency Supraventricular Tachycardia Atrial Fibrillation Premature Ventricular Contractions & Ventricular Tachycardia Premature Atrial Contractions Infective Endocarditis (Treatment) Infective Endocarditis (Prophylaxis) Acute Rheumatic Fever Treatment & Prophylaxis Cardio-Pulmonary Clearance Dyslipidemia with Lipid Lowering Drugs Indications for Permanent Pacemaker Insertion Hypertension List of Antihypertensives & Cardiac Drugs Low Molecular Weight Heparins for DVT and Unstable Angina The Cardiac Patient with Other Medical Disorders Back to Main Table of Contents

Pulmonology Camilo C. Roa, Jr., M.D.. Bronchial Asthma Drugs Used to Treat Asthma Management of Chronic Asthma Management of Acute Exacerbations of Asthma: Home Treatment Management of Acute Exacerbations of Asthma: Hospital Treatment Chronic Obstructive Pulmonary Disease Tuberculosis Antituberculosis Drug List Pulmonary Embolism Hemoptysis Pleural Effusion and Thoracentesis Anaphylaxis Pneumothorax Pneumonia Back to Main Table of Contents

Gastroenterology Virgilio P. Banez, MD. Peptic Ulcer Disease & Acute Gastritis Upper and Lower GI Bleeding Anti-ulcer Drugs Hepatic Encephalopathy & Liver Cirrhosis Abdominal Paracentesis Viral Hepatitis Acute Cholecystitis Bacterial Cholangitis and Biliary Sepsis Acute Pancreatitis Acute Diarrhea with Mild Dehydration Cholera with Severe Dehydration Acute Intestinal Obstruction Back to Main Table of Contents

Infectious Diseases Cecilia S. Montalban, M.D. Clinically Useful Antibiotics Antibiotic Drug List Systemic Viral Infection Acute Tonsillopharyngitis Dengue Hemorrhagic Fever Typhoid Fever Malaria Prevention of Malaria in Travellers Leptospirosis Schistosomiasis Sepsis and Septic Shock Lower Urinary Tract Infection Pyelonephritis Cellulitis Meningitis and Encephalitis Tetanus Osteomyelitis Peritonitis Diverticulitis Pelvic Inflammatory Disease Pneumonia Infective Endocarditis Mumps Varicella Zoster Empirical Antimicrobials for Out-Patient Adults Initial Antimicrobials for Acutely Ill Adults Drug of Choice for Microbial Pathogens Back to Main Table of Contents

Nephrology Elizabeth S. Montemayor, MD. Acute Renal Failure Strategy for Removing Excess Fluid Chronic Renal Failure Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia Hyponatremia Hypomagnesemia Hypermagnesemia Nephrolithiasis Dialysis Dosage Adjustment of Drugs in Renal Failure Back to Main Table of Contents

Endocrinology Ruby T. Go, MD. Approach to Type II Diabetes Mellitus Diabetic Ketoacidosis / Hyperosmolar Coma Thyroid Storm Hyperthyroidism Hypothyroidism Adrenal Insufficiency Back to Main Table of Contents

Rheumatology Clemente M Amante,‘MD. Osteoarthritis Gouty Arthritis Rheumatoid Arthritis Systemic Lupus Erythematosus Back to Main Table of Contents

Neurology Carlos L. Chua, M.D. Cerebral Infarction vs. Hemorrhage Guide Intracerebral Hemorrhage Subarachnoid Hemorrhage Cerebral Thrombosis Cerebral Embolism Transient Ischemic Attack Stroke In Evolution Stroke in the Young Seizures and Epilepsy Brain Abscess Myasthenia Gravis Parkinson's Disease Alcohol Withdrawal Approach to Weakness Back to Main Table of Contents

Toxicology Kenneth Hartigan-Go, MD. Poisoning and Drug Overdose: General Guidelines Acid Ingestion Alkaline Ingestion Amphetamine / Metamphetamines Anticoagulants Diazepam Digitalis / Digoxin Ethanol Hydrocarbon / Kerosene Isoniazid Narcotics Organophosphates Paracetamol Phenothiazines / Neuroleptics Salicylate / Aspirin TricyclicAnti-Depressants Back to Main Table of Contents

Nutrition Nutritionist-Dietitians' Association of the Philippines Recommended Diet by Organ System High Fiber Diet Low Calorie Diet High Calorie Diet High Protein Diet Low Protein Diet Low Fat / Low Cholesterol Diet Low Carbohydrate Diet Low Sodium Diet Low Potassium Diet Low Uric Acid / Low Purine Diet Nutritional Management of Diabetics and Renal Patients Back to Main Table of Contents

The Pregnant Patient with Medical Problems Camilo C. Roa, Jr., M.D., Ruby T. Go, MD., Willie T. Ong, MD. Pregnancy and Hypertension Pregnancy and Cardiac Disease Pregnancy and Asthma Pregnancy and Thyroid Disease Pregnancy and Diabetes Drugs Used in Pregnancy Back to Main Table of Contents

I am Dr. Neo. Aside from being trained with the knowledge and skills of western medicine, I also have proclivities in unconventional software applications which lead me to this work, the 6 th Edition of the Medicine Blue Book. The medicine Blue book has been integral in our line of work. From med school, internship, moonlighting, cross consultation beyond our specialties to treating our neighbours knocking at our doors late at night with tummy cramps. We doctors live underpaid and overworked conditions. With the MD to nursing phenomena, the medical diasporas, the mistrust of patients, threat from the government and media of malpractice bills who know nothing of our line of work and passions. We are one of the unsung heroes of our nation. As part of this brotherhood in white, with blood and tears trailing our footsteps, this work is my tribute. To my mentors, seniors, subordinates, your ultimate sacrifices did not go unnoticed. To the original authors of the book, I deeply apologize for lifting your whole work to be shared to the medical force in their PDA, which is handier nowadays than bringing different books and references. I hope you could consider it as my ultimate complement and a gesturing of honouring you for choosing your work to be selflessly shared to our other brothers and sisters-in-arms braving their training and practice without gain except for the satisfaction that we have helped them. I hope you could also forgive my humility which would seem to be cowardice represented by my anonymity. Mabuhay tayong lahat. Dr. Neo Christmas Day, 2004 Somewhere in the Greater Manila Area Back To Main Page

REFERENCES To Main Table of Contents To Detailed Table of Contents 1. Braunwald E, Fauci A, Kasper D, et al (Eds.), (2001). Harrison's Principles of Internal Medicine, 15th Edition. New York: McGraw-Hill Companies, Inc. 2. Braunwald E, Zipes D & Libby P (Eds.), (2001). Heart Disease: A Textbook of Cardiovascular Medicine, 6" Edition. Philadelphia: W.B. Saunders Company. 3. Burrow GN & Duffy TP (1999). Medical Complications During Pregnancy 5th Edition Philadelphia: W33. Saunders Company. 4. Ahya SN, Flood K & Paranjothi S (2001). WashingtonManual of Medical Therapeutics, 30th Edition. Philadelphia: Lippincott Williams & Wilkins. 5. Chan PD, Safani M & Cuchiarella MA (1995). Current Clinical Strategies, Outpatient Medicine. Singapore: Info Access & Distribution PTE Ltd. 6. Gilbert D, Moellering R & Sande M (Eds.), (2000). The Sanford Guide toAntimicrobial Therapy, 13th Edition. USA: Antimicrobial Therapy, Inc. 7. Kahn C, Weir G (1994). Joslin's Diabetes Mellitus, 13th Edition. Philadelphia: Lea & Febiger. 8. Ong WT & Patacsil GB (2004). Cardiology Blue Book 3rd Edition. Manila: A.L.W. Merchandise 9. Sibai BM (1996). Treatment of Hypertension in Pregnant Women: A Review Article. N Engl J Med, 335, 257-265. 10. Tanchoco CC, Cardino I, Jamorabo A, Panlilio L, Ruiz E, Ruiz V, Villaraza ME (1994). Nutritionist-Dietitians'Association of the Philippines (NDAP) Diet Manual 4th Edition. Manila: NDAP. 11. Tierney LM, McPhee SJ, Papadakis MA (2002). Current Medical Diagnosis and Treatment, 41st Edition. McGraw-Hill Companies, Inc. 12. Wayne Alexander R, Schlant R, et al (Eds.), (1998). Hurst's The Heart, 9th Edition. New York: McGraw-Hill Companies, Inc. 13. Wolfsthan SD (1989). Medical Perioperative Management. Connecticut: Appleton &Lange. 14. (2004). MIMS 99th Edition. Philippines: Medimedia International Group. To Main Table of Contents To Detailed Table of Contents

ADVANCED CARDIAC LIFE SUPPORT To Cardiology Page To Main Table of Contents To Detailed Table of Contents Basic Principle: To sustain life, (1) blood must circulate and (2) blood must be oxygenated optimally. General Guidelines: Take command. Obtain brief history. Identify and treat reversible cause: 5H’s: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyperkalemia or hypokalemia (other metabolic problems), Hypothermia. 5T’s: Tablets (drug overdose, accidents), Tamponade cardiac, Tension pneumothorax, Thrombosis coronary (MI, Thrombosis pulmonary (embolism). Step 1: Circulation. Auscultate the precordial area for a heartbeat while palpating for the carotid pulse. If negative, start CPR. Note: Place bedboard. Do effective 4-5 cms sternal compressions. Step 2: Oxygenate Optimally. Is the patient cyanotic? Is the patient still breathing? If negative, check airway and do ambu bagging with 'tight' face mask. Note: Give 100% oxygen. Make sure ambu bag tube is connected to the oxygen tank. Suction secretions as needed. Hyperventilate initially. Step 3: Treat the Cardiac Rhythm. Assess by cardiac monitor. Done simultaneously: l. Insert IV line. 2. Intubate patient if necessary (for asystole, electromechanical dissociation, bradyarrhythmia, or persistently unstable rhythms). 3. Get ABG's if with pulse (treat hypoxemia and acidosis). I. Rhythm: Asystole (Silent Heart) 1. Continue CPR. Obtain IV access. 2. Epinephrine (1 mg/ampnle) 1-2 ampules IV stat q 3-5 minntes continuously until there is a cardiac rhythm or until CPR is stopped. May give epinephrine 1 mg ampule in 10 ml NSS via ET tube q 3-5 minutes if no IV line is inserted yet. 3. If unable to rule out fine ventricular fibrillation, defibrillate with 360 Joules. 4. Atropine 1 mg IV; repeat q 3-5 min. Maximum of 3 mg. 5. Consider external or transvenous pacing. 6. Consider Bicarbonate 1 amp (1 meq/kg) if more than 15 minutes have elapsed since the heart has stopped. II. Rhythm: Ventricular Fibrillation or Pulse less Ventricular Tachycardia l. Defibrillate with UNsynchronized 200 Joules stat, repeat with 300 Joules if unsuccessful, then 360 Joules. 2. Continue CPR between defibrillations or until a defibrillator is available. 3. If no conversion, give epineprhine 1 ampule prior to next defibrillation for cases of resistant or fine ventricular fibrillation. Repeat q 3-5 minutes as needed. 4. Continue Defibrillation until rhythm is converted to sinus. 5. Consider anti-arrhythmic drugs: a. Amiodarone 150-300 mg (1-2 ampules) slow IV in 10 minutes for resistant ventricular fibrillation or ventricular tachycardia. Repeat dose if necessary. or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May repeat bolus 40 mg (0.5 mg/kg) IV ofter 5 minutes. Maximum of 200 mg (3 mg/kg). If necessary, increase drip rate by 1 mg/min to maximum of 4 mg/min. May give Lidocaine via ET tube plus 10 ml NSS.

6. For polymorphic ventricular tachycardia (torsade de pointes), give Magnesium Sulfate 1-2 gm IV diluted in 100 ml DSW and given in 2 minutes. 7. Consider Sodium Bicarbonate 1 amp slow IV. III. Rhythm: Unstable Ventricular Tachycardia with Pulse For presence of chest pain, dyspnea, MI, heart failure, or systolic BP < 90 mmHg: 1. Cardiovert with synchronized 100, 200, 300 Joules. If patient is awake give Midazolam 2-5 mg IV for sedation. May omit precordial thump. 2. Consider anti-arrhythmic: a. Amiodarone 150-300 mg (1-2 ampules) slow IV in 10 minutes. Repeat dose i f necessary. or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May repeat bolus 40 mg (0.5 mg/kg) IV after 5 minutes. Maximum of 200 mg. 3. If no conversion, cardiovert at synchronized 360 J, or if recurrent ventricular tachycardia, cardiovert again starting at previously successful energy level, then after conversion, continue medications. IV. Rhythm: Stable Ventricular Tachycardia with Pulse 1. Precordial thump. 2. Give anti-arrhythmic drugs: a. Amiodarone 150 mg slow IV (1 ampule) in 10 minutes. or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May repeat bolus 40 mg (0.5 mg/kg) 1V every 5 minutes until VT resolves. Maximum of 200 mg. 3. If drugs fail, cardiovert with synchronized 100, 200 Joules. 4. Treat accordingly if cardiac rhythm degenerates. V. Rhythm: Bradycardia A. For chest pain, dyspnea, drowsiness, heart failure, or systolic BP < 90 mm Hg: 1. Atropine 0.5-1 mg IV stat. Maximum of 3 mg (0.04 mg/kg). May give via ET tube with 10 ml NSS. 2. Continue CPR support if HR < 40 bpm. 3. Consider external or transvenous pacing. 4. Consider Dopamine drip or Epinephrine drip as a temporizing measure B. For type II second degree dh third degree AV block, consider external or transvenous pacing. C. If without symptoms, observe! VI. Rhythm: Electromechanical Dissociation (EMD) Definition: Sinus rhythm by cardiac monitor but without palpable pulses. No BP. Etiology: EMD can be secondary to inadequate fluid volume, pericardial tamponade, tension pneumothorax, hypoxemia or acidosis. Less correctible causes include massive MI, prolonged ischemia during resuscitation and pulmonary embolus. 1. Continue CPR 2. Correct primary problem (see etiology). 3.. Epineprhine 1 mg IV q 3-5 min 4. Consider Bicarbonate 1 amp (44 meq) slow IV. VI. Rhythm Successfully Converted to Sinus Rhythm: 1. If Systolic BP = 100 mm Hg: Obtain laboratory exams: ABG, ECG (check for MI), CXRCBC, Na, K, RBS, Creatinine 2 If Systolic BP =90 mm Hg: i. Start Inotropics: Dopamine with or without Dobutamine. ii. Correct low volume, acidosis and hypoxemia. iii. Do ABG and other laboratory exams if feasible. Advice

a. Adequate airway, ventilation, oxygenation, chest compression and defibrillation are more important than initiating IV line and injecting medications. b. IV medications should be given by bolus with few exceptions. After each IV medicine, give 20-30 ml bolus of IV fluid and elevate the extremity. c. Do most of your interventions in the first 10 minutes of the CPR. Otherwise, the chance of reviving the patient decreases markedly. d. Lastly, treat the patient, not the cardiac monitor. Source: Adapted from Guidelines 200O for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, Vol. 102, No. 8, August 22, 2000. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

ACUTE MYOCARDIAL INFARCTION To Cardiology Page To Main Table of Contents To Detailed Table of Contents Table 1-1. Molecular Markers in the Diagnosis of Acute Myocardial Infarction. Tests

Time to Detection

Peak

Duration

Troponin T Sn = 94% Sp = 60%

3 -12 hours

24 hours

5 -14 days

Troponia I Sn = 95 % Sp = 90 %

3 - l2 hours

24 hours

5 - 10 days

CK-MB

3 - 12 hours

24 hours

2-3 days

Most Common Sampling Schedule Once at least 12 hours after chest pain Once at least 12 hours after chest pain Every 12 hours X 3; start at 6 hours after chest pain

Source: Modified from Braunwald, E.; Zipes D.P., Libby P..(Eds.) (2001). Heart Disease: A Textbook of Cardiovascular Medicine, (p.1l32) Philadelphiia: W.B. Saunders Company

Table 1-2 Killip Classification of AMI with Expected Hospital Mortality Rate. Killip Class I II

III IV

Clinical Presentation

No signs of pulmonary or venous congestion Moderate heart failure or presence of bibasal rales, S3 gallop, tachypeea, or signs of right heart failure including venous JVP and he hepatic congestion Severe heart failure, rales > 50% of the lung fields or pulmonary edema Shock with systolic pressure < 90 mm Hg and evidence of peripheral vasoconstriction, peripheral cyanosis, mental confusion and oliguria

Expected Hospital Mortality 0-5% 10-20 %

35-45 % 85-95 %

Source: Forrester, J.S. et al (1976). Medical therapy of acute myocardial infarction by a applications of hemodynamic subsets. NEJM, 295, 913-56. Orders: Admit to ICU Sample diagnosis: Acute MI, ST-elevation, anterior wall, Killips-l, day 1

Diet: Low salt, low fat diet VS: q 1 hour and record; Temp q 4 hour Nursing I and 0 q shift. Complete bed rest with no bathroom privileges. High back rest. Limit visitors. Anti-embolic stockings. IVF: D5W 500 ml x 10 ml/hr Diagnostics: CK-MB, CPK-Total, Troponin T or Troponin I ECG stat then repeat after 12-24 hours Portable Chest X-ray, semi-sitting CBC with platelet count, Na, K, Ca, Mg, RBS, BUN, Creatinine, Urinalysis Baseline PT, PTT (if contemplating anti-coagulation or thrombolytic therapy) Lipid Profile Therapeutics: 1. Initial ER Management (STAT): a. Oxygen at 2-4 liters/min via nasal cannula x 24 hours (especially if with heart failure or Oxygen saturation < 90%) b. Nitrates: (defer for SBP < 90 mm Hg) Nitrostat 0.4 mg SL up to 3 doses stat q 5min and PRN for chest pains then start Isosorbide Dinitrate (Isoket) Drip x 24-48 hours until chest pain subsides then shift to Transderm patch 5-10 mg OD to anterior chest wall or Isosorbide mononitrate (Imdur) 60 mg OD AM or Isosorbide dinitrate (Isordil) 10-20 mg TID (6 am-12-6 pm) c. Pain relief: Give adequate analgesia with Morphine 4 mg IV stat and PRN q 30 min up to 3 doses defer for SBP< 90 mm Hg (If with Inferior wall MI, give only 2-3 mg IV of Morphine because of risk of arrhythmia.) d. Aspirin 160-325 mg tab stat dose then 80 mg tab BID PC indefinitely 2. Consider Thrombolytic Therapy: Indication: Patients presenting within the first 12 hours of chest pains with large anterior wall ST-elevation MI or inferior wall MI with anterior wall (Vl-V3) reciprocal changes (see Thrombolytic Therapy in MI for full contraindications list) 3. Heparin: Indication: For large anterior wall MI, atrial fibrillation, persistent chest pains, or presence of LV thrombus a. Heparin 5000 units IV bolus then Heparin Drip: D5W 200 ml + Heparin 10,000 units at 14 ugtts/min (700 units/hour) using an infusion set Check PTT q 12 hours with target PTT of 1.5-2X the control. Give Heparin for 2-5 days then overlap with Warfarin for 3 months if desired. b. Low Molecular Weight Heparin: Enoxaparine (Clexane) 0.4 ml SC BID for 5 days. 4.Beta-blockers Indication: All patients without contmindication to beta-blocker tharapy. Most beneficial in patients with tachycardia anterior wall MI, hypertension, recurrent ischemic pain, atrial fibrillation. Avoid in patients with moderate to severe CHF, wheezing, AV blocks and heart rate < 55 beats per minute. Start therapy early (20 min), clinical heart failure, angina with hypotension or dynamic ST-T wave changes a. Low Molecular Weight Heparins: Enoxaparin (Clexane) 0.4 ml (40 mg) SC BID (1 mg/kg BID) or b. Regular Heparin: Heparin 5000 u IV bolus then Heparin Drip: D5W 200 ml+ Heparin 10,000 units at 14 ugtts/min (700 u/hr) using an infusion set Check PTT q 12 hours with target PTT of 1.5-2 X the control. 3. Aspirin 325 mg tab stat dose then ASA 80 mg 1 tab BID PC indefinitely or Clopidogrel (Plavix) 75 mg tab OD for patients unable to take ASA 4. Metoprolol 50 mg 1/2 -1 tab q 8-12 hr (if no contraindications) and/or Diltiazem 30 mg tab BID-TID may be added in patients with persistent chest pains (watch out for bradycardia with Metoprolol). 5. Other Meds a. Morphine 4 mg IV stat for pain relief b. Diazepam 2-5 mg tab BID (especially for anxious patients) 6. Medical strategies for persistent chest pains (in patients without heart failure) a. Increase beta-blocker dosage b. Increase nitrates dosage (e.g. up to Imdur 60 mg tab BID or Isordil 40 mg tab QID) c. Add Diltiazem PO to the above regimen To Cardiology Page To Main Table of Contents To Detailed Table of Contents

CONGESTIVE HEART FAILURE (For Systolic Heart Failure) To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data: Systolic vs. Diastolic Heart Failure: 1. Systolic Heart Failure: Markedly dilated left ventricle, low ejection fraction (problem with systolic LV contraction phase). Treatment approach indicated below. 2. Diastolic Heart Failure: Normal left ventricle size, usually concentrically hypertrophied, normal ejection fraction (problem with diastolic LV relaxation phase and stiff LV). Treatment is different from systolic heart failure. Give beta-blockers and calcium-channel blockers. Table 1-3. General Outline in the Management of Chronic Congestive Heart Failure Based on New York Heart Association (NYHA) Functional Classification. Management Vaso-Dilators Ace-inhibitors or Angiotensin receptor antagonist Lifestyle Changes: Restrict physical activity and restrict salt intake Low-dose Beta-blockers* Diuretics**: Furosemide and Spiranolactone Digoxin Dobutamine, Dopamine and/or Nitroprusside Intraortic Balloon Pump And Heart Transplantation

NYHA Class I +

Class II +

Class III +

Class IV +

-

+

+

+

?

+

+

?

-

-

+

+

-

-

+ -

+ +

-

-

-

+

*Studies show that low-dose carvedilol, metoprolol or bisoprolol is a useful adjunct to conventional regimen for CHF. However, dosages of ace-inhibitors and diuretics should first be maximized. ** Diuretics may be given to achieve relief of edema and normalization of the jugular Orders Diet: NPO if dyspneic; Saft, low salt diiet when more stable (Na < 2 gm/day) Limit Total Fluid Intake to 1.0-1.2 liters/day VS: q 1 hour and recordVS: q 1 hour and record Nursing: I and O q shif Nursing: I and O q shift strictly. Consider foley catheter insertion (hourly urine outputs), Weigh patient daily. CBR with no batbroom privileges. High back rest. IVF: D5W 500ml X KVOor 10ml/hr, Diagnostics: CBC, Na, K, Ca, Mg, RBS, Creatinine, Urinalysis, ECG, Portable Chat X-ray semi-sitting, 2-D Echo with Doppler Treatment Approach: Mnemonic 5 D's (Diet, Diuretics, vaso-Dilators, Digitalis, Dilatrend)

- Oxygen at 2-4 lpm via nasal cannula - For Acute Congestion: Stepwise approach -->Oxygen, Furosemide IV,Morphine IV as last resort - Correct precpitating factors: Arrhythmia, uncontrolled HPN, anemia, pulmonary infection, thyrotoxicosis, change inappropriate medications, emotional stress 1. Diuretics: (For acute CHF, fluid overload or edema) a. Furosemide (Lasix) 20-40 mg IV then maintain on PO later, may double subsequent doses if no urine output in 20-30 mins (e.g. give Lasix 40 mg IV then 80 mg IV after 30 minutes). If still without urine output, start Lasix drip and consider stat peritoneal or hemodialysis for resistant cases + b. Spironolactone (Aldactone) 25 mg tab OD-TID for CHF class III to IV. 2. Vaso-Dilators: a. Ace-inhibitors: First-line agents for chronic heart failure. Captopril 25 mg 1/2-1 tab q 6-12 hr. Maximum dose of Captopril 50 mg tab TID or Enalapril 5-10 mg tab OD-BID, maximum dose of Enalapril 20 mg BID. Maximize doseof ACE-inhibitors to achieve symptomatic relief of dyspnea. In patients with contraindication to ACE-inhibitors (e.g. acute renal failure), you may use Hydralazine 10-25 mg TID and ISDN gsordil) 10-20 mg TID. b. Angiotensin receptor antagonists: Altemate drug if with ace-inhibitor cough; e.g. Losartan 50 mg 1/2 -1 tab OD (maximum dose of Losartan 50 mg 1 tab BID). 3. Digitalis: Most beneficial in patients with atrial fibrillation. Digoxin 0.25-0.5 mg IV then complete loading dose if needed or Digoxin (Lanoxin) 0.25 mg tab BID X 3 days then 1/2 - 1 tab OD thereafter. 4. Consider low dose beta-blockers for heart failure. Addition of Carvedilol (Dilatrend) 6.25 mg tab BID. Watch out for hypotension and CHF within the first 4 hours after intake. 5. Other therapeutic options as indicated: a. Coemyme Q10 10 mg tab TID has some possible benefit. b. Nitrates: Transderm patch for 1 dose only if with no underlying CAD. c. ASA 80-160 mg PO OD as indicated. 6. Supportive Medications for CHF: a. If BP < 80 mm Hg, use Dopamine Drip or Norepinephrine (Levophed) Drip (if persistently hypotensive) b. If BP 90-100 mm Hg, use Dobutamine Drip c. If BP >= 110 mm Hg, use Nitroprusside Drip (Not Available)

To Cardiology Page To Main Table of Contents To Detailed Table of Contents

HYPERTENSIVE URGENCY & EMERGENCY To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data: A. Hypertensive Urgency: No end organ damage; try oral medications first. Lower BP within 2-3 days. B. Hypertensive Emergency: Presence of changes in sensorium, papilledema, or heart failure. Use IV drugs stat. Lower BP within 24 hours. Orders Admit to: Diet: NPO temporarily until stable VS: BP q 15 minutes till stable Nursing: Complete bed rest without bathroom privileges Diagnostics: CBC, Creatinine, K, ECG, Urinalysis, Chest X-ray, Fundoscopy Therapeutics: A. Per Orem or Sublingual Treatment: Mnemonic for anti-hypertensives that can be given sublingually: 3 C’s 1. Nifedipine (Calcibloc): 5-10 mg SL or PO (bite and swallow punctured capsule), repeat as needed q 30 minutes, then 5-10 mg PO or SL q 6-8 hr . or Calcibloc OD 30 mg PO OD-BID. Maximum dose is 90 mg/day, contraindicated in patients with AMI or Unstable Angina. 2. Captopril (Capoten): 25 mg 1/2 -1 tab SL or PO q 30 mins as needed. 3. Clonidine: 75 mcg tab SL or PO q hr (Maximum of 700 mcg) B. Intravenous Treatment: See appendix section on IV drips Mnemonic for anti-hypertensives that can be given intravenously: NAIC 1, Nicardipine IV: Duration of action: 3-6 hr 2. Hydralizine (Apresoline) IV: 5-10 mg IV q 3-6 hr (0.1-0.5 mg/kg/dose; maximum of 20 mg per dose), or give 25-50 mg PO Qid. Duration of action: 3-6 hr. 3. Isosorbide dinitrate IV (especially for patients with concomitant CAD) 4. Clonidine (Catapres) IV: May give 1 amp (150 mcg/I ml amp) SC, IM or IV with patient supine. 5. Nitroprusside IV (not available): 0.25-10 mcg/kg/min IV (50 mg in D5W 250ml), titrate to desired BP using an infusion set. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

SUPRAVENTRICULAR TACHYCARDIA To Cardiology Page To Main Table of Contents To Detailed Table of Contents Orders: Diet: Full diet when stable (no coffee, tea or soft drinks) VS: q 1 hour, Hook to Cardiac Monitor Diagnostics: CBC, RBS, Na, K, Ca, Mg CK-MB, Troponin T or I, BUN, Creatinine, Mg T4 TSH Irma repeat ECG after conversion to sinus rhythm Chest X-ray, 2-D Echo when stable Therapeutics: - Unilateral carotid massage (Check for carotid bruits first) - Attempt vagal maneuvers before drug therapy A. Pharmacologic Therapy l. If Systolic BP > 90 mm Hg, choose &om the following options: a. Calcium-channel blockers: Verapamil 2.5-10 mg IV over 2-3 minetes, wait 10-15 min before next dose (may give Calcium Gluconate 1 gram IV over 3-6 minutes prior to Verapamil); then 40 mg PO q 6 hours or Verapamil SR 240 mg 1/2-1 tab PO OD. Duration of action is 15 min. or Diltiazem (Ritemed Diltiazem C) ) 30-60 mg PO TID b. Beta-Blockers: Esmolol 10-20 mg IV ). Duration of action is 9 minutes or Metoprolol 50 mg 1/2 tab PO stat dose then BID c. Adenosine (Cardiovert) 6 mg/2 ml vial i. Therapeutic indications: Initial dose: 3 mg given as a rapid IV bolus (over 2 seconds) Second dose: If first dose fails within 1-2 min, give 6 mg rapid IV bolus Third dose: If 2nd dose fails within 1-2 min, give 12 mg rapid IV bolus ii. Precautions for use: Avoid in COPD and asthmatic patients, mild hypotension occurs. 2. If Systolic BP < 90 mm Hg or with heart failure a. Digoxin (Lanozin) 05 mg IV or PO, wait 2 hours before full effect of initial dose is established then aliquots of 0.25 mg IV q 4-6 hours as needed (Losding dose of 1-1.25 mg IV); thcn Digoxin 0.25 mg 1/2 - 1 tab OD. Contraindicated in patients with WPW in AF. Defer Lanoxin for HR < 60 bpm. Duration of action is 2 hours. 3. Adjuncts: Diazepam 2 mg tab BID B. Synchronized Cardioversion - Ideally patient should be in NPO x 6 hr, digoxin level < 2.4 and K+ normal. 1. Midazolam 2.5 mg IV until amnesic 2. If stable, cardiovert with synchronized 25-50 J, increase by 50 J increments. 3. If refractory to drug treatment or unstable (e.g. hypotensive or severe ischemia caused by the tachycardia), start with 75-100 J, then increase to 200 J if needed. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

ATRIAL FIBRILLATION (AF) To Cardiology Page To Main Table of Contents To Detailed Table of Contents

Data: A. Is the patient in acute AF (onset of less than 48 hours) or chronic AF? B. Treat the etiology of the AF, e.g. hypoxia, electrolyte imbalance (K, Ca, Mg), heart failure, severe ischemia, mitral stenosis, thyrotoxicosis, hypertension, chronic anxiety long disease, fever etc. Orders: Diet: Low salt diet when stable VS: q 1 hour, auscultate full minute heart rate Nursing: Complete bed rest. Hook to cardiac monitor (if acute AF) Diagnostics: CBC, K, Ca, Mg, Creatinine, Digoxin assay, 2-D Echo with doppler, T3, T4 TSH Irma Therapeutics: Treat the etiology or precipitating factor. Slow the ventricular rate with pharmacologic therapy A. Acute AF with rapid ventricular response (HR > 100 bpm): 1. If Systolic BP = 90 mm Hg and not in heart failure: a. Verapamil 2.5-10 mg IV over 2-3 minutes, wait for 10-15 min. before next dose then 40 mg PO q 6 hours or Verapamil SR 240 mg PO OD. Duration of action is 15 mins. or b. Metoprolol 50 mg 1/2-1 tab PO stat dose then BID 2. If Systolic BP < 90 mm Hg or with heart failure: a Digoxin (Lanoxin) 0.5 mg IV or PO, wait for 2 hours before full effect of initial dose is established then aliquots of 0.25 mg IV q 4-6 hours as needed (Loading dose of 1-1.25 mg IV); then Digoxin 0.25 mg 1/2 - 1 tab OD. Contraindicated in patients with WPW in AF. Defer Digoxin for HR < 60 bpm. 3. Consider medical cardioversion for AF < 48 hours in onset. Consult the Cardiology Blue Book for indications and benefits of cardioversion. B. Chronic AF: 1. Same as above if with rapid heart rates 2. For patients with high-risk for stroke (e.g. prior CVA, TIA, valvular heart disease, HPN, DM, CHF, LA size > 45 mm or CAD), anticoagulate with warlarin to attain a target protime INR of 2-3. Loading dose: Warfarin (Coumadin) 5 mg tab PO X 2-3 days only. Recheck Protime on the 3rd day. Usual maintenance dose: Warfarin (Coumadin) 2.5 mg I tab OD PO defer if with bleeding episodes. 3. Astiplatelets if with contraindication to Warfarin: Aspirin 325 mg 1 tab PO OD after meals C. Synchronized Cardioversion: If medical therapy fails, or if with severe cardiovascular compromise, may do synchronized cardioversion in extreme cases. Sedate patient first. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

PREMATURE VENTRICULAR CONTRACTIONS & VENTRICULAR TACHYCARDIA To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data: A. In patients without heart disease (normal ECG, normal 2-D electrocardiography), PVC's have not been shown to be associated with any increased morbidity or mortality. If with heart disease, we may need to treat the patient. Tailor treatment for each patient. B. Complications: Ventricular tachycardia, ventricular fibrillation, sudden cardiac death C. Lown's Grading of PVC's: GRADE: 0 none la < 30/hr < 1/min 1b > 1/min 2 > 30/hr 3 multiform, bigeminy, trigeminy 4a couplets 4b salvos 5 R on T phenomenon D. Anti-Arrhythmic Drug Classes: Class I (blocks sodium channels): IA - Quinidine, Procainamide, Disopyramide (SV 8c V) IB - Lidocaine, Phenytoin, Tocainide (V) IC - Flecainide (V) Class II (Beta-blockers): Propranolol (SV & V) Class III (blocks potassium channels): Amiodarone, Sotalol (SV k V) Class IV (blocks calcium channels): Verapamil (SV) Legend: SV= drugs used to treat Supraventricular Arrhythmias V= drugs used to treat Ventricular Arrhythmias Orders: Admit to: Diet: Soft diet when stable VS: q 1 hour, record number of PVC's per minute Nursing: Hook to cardiac monitor Diagnostics: CBC, Serum K, Ca, Mg, T3, T4, TSH, 24-48 hour Holter Monitoring or Loop Recorders (check for episodes of ventricular tachycardia) ECG, 2-D Echo with doppler Treatment Plan: 1. Consider age of patient and the cardiac status. Most important considerations for admission and treatment are the following: a. Symptomatic patients with dyspnea, syncope, or dizziness b. (+) Organic heart disease, especially post-myocardial infarction c. low ejection &action of < 40% d. Lown's grading = 4a 2. Look for a possible secondary-etiology for PVC’s and treat this, e.g. CAD, thyroid diseases, acidosis, alkalosis, hypercaprea, hypoxia, hyperkalemia, hypokalemia, digitalis excess, mitral valve

prolapse, cardiomyopathy, or connective tissue disorders. Therapeutics: 1. Decrease precipitating factor, e.g. control anxiety and avoid alcohol, digitalis, caffeine coffee, softdrinks or tea. 2. Treat the underlying cause, e.g. give nitrates for CAD, correct electrolyte imbalance etc. 3. Supportive: Oxygen, sedatives 4. Treatment for PVC’s or Ventricular Tachycardia after correcting other factors: a. Beta-blockers - empiric and cheap treatment (esp. for patients with MVP) b. Lidocaine IV bolus and drip for acute episodes only. c. if resistant, consider Amiodarone IV or PO: Amiodarone preparation: 150 mg/3 ml vial IV loading dose: 500-1000 mg per 24 hr IV loading doses (5-10 mg/kg body weight per 24 hr) Example orders: Give 150 mg slow IV push over 10-30 minutes (with BP and HR monitoring) followed by D5W 250 ml + 150-300 mg IV Amiodarone to run for 24 hours. Supplemental doses of 150 mg IV over 10-30 minutes may be given for recurrent arrhythmias especially hg the early phases of dosing OR Oral Loading Dose: (10 mg/kg body weight per day for 2 weeks), Amiodarone 200 mg 1 tab PO TID for 2 weeks then maintenance of Amiodarone 200 mg 1 tab OD thereafter Amiodarone's side effects include hyperthyroidism, hypothyroidism, and interstitial pulmonary fibrosis. Check thyroid function every 3-6 months 5. For ventricular tachycardia or cardiac arrest due to ventricular fibrillation, Implantable Cardioverter/Defibrillators (ICD) are proven to be beneficial in preventing sudden cardiac death. However, ICD’s are very expensive. Consult a cardiologist-electrophysciologist. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

PREMATURE ATRIAL CONTRACTIONS To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data: PAC's are usually benign and can be found in 60% of normal adults. If patient is asymptomatic, treatment is usually not required. Orders: Diagnostics: CBC, K, Mg, T3, T4, TSH, 24-4S hours Holter monitoring if with symptoms (check for paroxysmal atrial fibrillation or supraventricular tachycardia), ECG, 2-D Echo Therapeutics: 1. Remove precipitating factors fever, anxiety, mitral valve prolapse, specific food (alcohol, tobacco, tea, coffee, or amphetamines) 2. If symptomatic and with palpitations: a. Sedatives: Diazepam 2 mg 1 tab OD HS and as needed. b. Beta-blockers: Metoprolol 50 mg 1/2-1 tab BID or c. Calcium-channel blockers: - Verapamil 40 mg 1 tab TID - Diltiazem 30 mg 1 tab BID-TID To Cardiology Page To Main Table of Contents To Detailed Table of Contents

INFECTIVE ENDOCARDITIS (Treatment) To Cardiology Page To Infectious Page To I.E. Prophylaxis To Main Table of Contents To Detailed Table of Contents Data Table 1-4 Two Traditional Classifications for Infective Endocarditis (IE) Acute Bacterial IE Pathogenic Organism

Staph aureus

Clinical Presentation Clinical Pathology Prognosis

High Fever, Acute course Normal cardiac valves Fatal in 6 weeks if untreated

Subacute Bacterial IE Strep. Viridans, Enterococci (less virulent) Low grade Fever, subacute course Damaged valves, (+) murmur Better prognosis

Table 1-5. Duke’s Diagnostic Criteria for Infective Endocarditis I. Criteria for Infective Endocarditis: A. Two major criteria or B. One major and three minor or C. Five minor criteria using definitions for these criteria as listed below D. Possible infective endocarditis: findings consistent with infective endocarditis that fall short of the criteria listed above II. Major Criteria A. Positive blood culture results for infective endocarditis. Typical microorganisms for infective endocarditis: Streptococci viridans, HACEK group, Strep. bovis, Staph. aureus, or enterococci recovered from two or more blood cultures. B. Either positive echocardiographic study result for infective endocarditis: Oscillating intracardiac mass, abscess or new dehiscence of prosthetic valve or newvalvular regurgitation OR Persistently positive blood culture results: microorganism consistent with IE recovered from one or more than 12 hrs apart. III. Major Criteria:(Mnemonic: PF-VIME) A. Predisposing heart condition or injected drug user B. Febrile syndrome C. Vascular phenomena: Arterial embolism, central nervous system hemorrhage, conjunctival hemorrhage, Janeway lesions. D. immunologic phenomena: Immune-complex glomerulonephritis, rheumatoid factor, false-positive VDRL test, Osler's nodes, or Roth spots E. Microbiologic evidence: Positive blood culture results but not positive for major criterion F. Echocardiogram: Suggestive of infective endocarditis but not positive for major criterion Source: Durack, D.T. (1998). Infective and non-infective endocarditis. In R. C. Schlant & R. Wayne Alexander (Eds.), Hurst's: The Heart (p. 2221). New York: McGraw-Hill Companies Inc. with permission Orders:

Admit to: Diet: DAT VS: q 4 hours, include temperature Diagnostics: For Acute bacterial eadocardltis: Blood C/8 (3X in 30 minutes): ideally before antibiotic treatment For Sabacute bacterial eadocarditis. Blood C/S 3X ia 6 hours CBC, Creatinine, Urinalysis (to check for complications) Rheumatoid Factor (positive if > 6 weeks of infective endocarditis) 2-D Echo with doppler(50-80%o sensitive except if with < 2 mm vegetations) Transesophageal Echocardiography (TEE) (90% sensitive) Therapeutics: A. Acute Bacterial Endocarditis Empiric Therapy paclading IV Drug Abuser): Target: Staphylococcus aureus 1. Nafcillin or Oxacillin 2 gm 1V q 4 hr or Vancomycin 500 mg IV q 6 hr ot 1 gm IV q 12 hr (1 gm in 250 ml D5W infused slowly over 1hr q 12 hr) X 4 weeks IV + 2. Gentamicin 100-200 mg IV (2 mg/kg), then 80 mg (1-1.5 mg/kg) IV q 8 hr X 3-5 days Note: Therapy can be changed once blood culture and sensitivity results are available B. Subacute Bacterial Endocarditis Empiric Therapy: Target: Strep. viridans, Enterococci 1. Penicillin G 2-4 mil units (12-24 million units/day) IV q 4 hr X 4 weeks IV or Ampicillin 2 gm (12 g/day) IV q 4 hr + 2. Gentamicin 80 mg (1-1.5 mg/kg) IV q 8 hr X 2 weeks IV Note: Choice between low dose or high dose Penicillin depends on the susceptibility of the microorganism and the clinical course of the patient. Use a higher dose for more toxic patients C.Clinical Course: 1. Defervescence after 3-7 days. 2. Repeat Blood C/S 2 and 4 weeks after the end of treatment to detect relapse. To Cardiology Page To Infectious Page To I.E. Prophylaxis To Main Table of Contents To Detailed Table of Contents

INFECTIVE ENDOCARDITID (PROPHYLAXIS) To Cardiology Page To Infectious Page To I.E. Treatment To Main Table of Contents To Detailed Table of Contents A. Cardiac Conditions Associated with Endocarditis: (prophylaxis recommended) 1. High-risk category: Prosthetic cardiac valves, previous bacterial endocarditis, cyanotic congenital heart disease, surgically constructed systemic-pulmonary shunts or conduits 2. Moderate-risk category: Rheumatic heart disease (acquired valvular dysfunction), mitral valve prolapse with valvar regurgitation and/or thickened leaflets, other congenital cardiac malformations (e.g. VSD, PDA, primum ASD, coarctation of the aorta and bicuspid aortic valve), hypertrophic cardiomyopathy. B. Prophylaxis for Dental, Oral, Upper Respiratory Tract or Eeophageal Procedures: 1. Oral: Amoxicillin 2 gm orally 1 hour before procedure, no need for a repeat 6 hours later; Children: 50 mg/kg orally 1 hour before procedure Penicillin allergy: Clindamycin 600 mg orally I hour before procedure or Cephalexin 2 gm orally 1 hour before procedure 2. Parenteral: Ampicillin 2 gm IM or IV 30 minutes before procedure C. Prophylaxis for Gastrointestinal and Genitourinary Procedures: 1. Parenteral: Ampicillin 2 gm IV plus Gentamicin 1.5 mg/kg IM or IV (not to exceed 80 mg) 30 min before procedure; followed by Ampicillin 1 gm IV 6 hours later Penicillin allergy:: Vancomycin 1 gm IV infused slowly over 1 hour + Gentamicin 1.5 mg/kg IM or IV (not to exceed 80 mg), 1 hour before pracedure Somer Adapted from the 1997 AHA Recommendations for Prevention of Bacterial Endocarditis To Cardiology Page To Infectious Page To I.E. Treatment To Main Table of Contents To Detailed Table of Contents

ACUTR RHEUMATIC FEVER 4 PROPHYLAXIS To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data Table 1-6. Jones Criteria for Acute Rheumatic Fever. Major Manifestations Mnemonic: CACES 1. Carditis* 2. Polyarthritis** 3. Chorea 4. Erythema marginatum 5. Subcutaneous nodules

Minor Manifestations

1. Clinical findings: Arthralgia Fever 2. Laboratory findings: Elevated acute phase reactants (Erythrocyte sedimentation rate, C-reactive protein) Prolonged PR interval

Supporting Evidence of Antecedent Group A Streptococcal Infection 1. Positive throat culture or rapid streptococcal antigen test 2. Elevated or rising streptococcal antibody titer

If supported by evidence of preceding group A Streptouccal infection (+) ASO titer, the presence of: A. Two major manifestations, or B. One major and two minor manifestations, indicates a high probability of acute Rheumatic Fever (RF), *1. Carditis: (1) new significant murmur usually mitral regurgitation or aortic regurgitation, (2) pericardial friction rubs or signs of pericardial effusion, (3) increase heart size, or (4) congestive heart failure ** 2. Arthritis: =2 joints and migratory type Orders: IVF: D5NM 1 liter X 24 hr Diagnostics: CBC, ASO (Anti-Streptolysin O test is always increased) ESR, C-Reactive Protein (weekly to monitor progress of treatment) Throat cultures for Streptococci ECG (check for prolonged PR interval) Chest X-ray, 2-D Ecbo with Doppler Therapeutics: - Bed rest to lessen joint pains. 1. Penicillin G IV or Ampicillin IV x 10 days to eradicate throat infection 2. For Arthritis only ASA alone at 75 mg/kg/day x 2 weeks followed by half the dose x 2-3 weeks, e.g. ASA 325 mg 3 tabs q 4 hr (maximum of 9 grams/day) for pain and fever, taper dose with clinical improvement. Joint pain usually decreases within 24 hours of initiation of aspirin treatment. 3. For Mild Carditis: ASA alone at 75 mg/kg/day x 6-8 weeks then taper gradually 4. For Moderate to Severe Carditis: a. Prednisone at 1-2 mg/kg/day x 2-3 weeks then taper e.g. Prednisone 5 mg 3 tabs q 6 hr (60-120 mg/day) + b. ASA 75 mg/kg/day x 6-8 weeks then wean gradually. Treat until ESR is normal. Taper steroids while giving ASA for 6-8 weeks to prevent rebound carditis. 5. Diazepam tablet PO if with chorea

6. Rheumatic Fever Prophylaxis: IM: 1.2 million units Penicillin 6 Benzathine IM every 3-4 weeks or PO: Penicillin V 250 mg cap BID or Erythromycin 250 mg cap BID 7. Duration of RF Prophylaxis: For rheumatic fever without carditis, give for 5 years or until 30 years old. For rheumatic fiver with mild carditis, give until 45 years old.For rheumatic fever with moderate to severe carditis, lifetime prophylaxis is recommended especially if there is increased risk for contracting streptococcal sore throat, i.e. patient lives in a crowded community or in close contact with children. Source: Adapted from Homer and Schulman, Journal of Rheumatology, 1995. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

CARDIO-PULMONARY CLEARANCE To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data Table 1-7. Modified Goldman's Classification: Cardiac Risk Stratification in Patients Undergoing Non-cardiac Surgery. Risk Factor

Points

1. History - Age > 70 years - MI within previous 6 months, unstable angina within 3 months or chronic stable angina with CCS (Canadian Cardiovascular Society) class III or IV angina 2. Physical Examination - S3 gallop or jugular vein distention, decompensated CHF - Severe aortic stenosis or mitral stenosis 3. Electrocardiogram - Rhythm other than sinus or PACs on last preoperative ECG - > 5 PVCs/min documented at an time before operation 4. General status - PO2 < 60 or PCO2 > 50 mmHg, K < 3.0 or HCO3 < 20 meq/I, BUN > 50 or Crea > 3.0 mg/dl, abnormal SGOT, signs of chronic liver disease, or patient bedridden from noncardiac causes 5. Operation - Intraperitoneal, intrathoracic, or aortic operation - Emergency Operation Total =

Goldman's Class

1. Class I: 2. Class II: 3. Class III: 4. Class IV:

0-5 points 6-12 points 13-25 points = 26

Low risk Intermediate risk Intermediate High risk

5 10

11 3

7 7

3

3 4 53

Incidence of Life-Threatening Complications 1-2 % 5-7% 16% 56%

Source: Modified from Goldman L, et al (1997). Multifactorial index of cardiac risk in noncardiac surgical. NEJM, 297 845. II. Diagnostics: A. Basic Exams: CBC, FBS, K, Creatinine, ECG, Chest X-ray PA-L B. Other Helpful Tests: Platelet count, PT, PTT, Urinalysis C. Optional Tests as Indicated: ABG, Total Bilirubin, Albumin, SGOT, 2-D Echo with doppler III. Treatment Approach: A. Correct anemia, poor nutritional status, hypovolemia, polycythemia, hypertension, electrolyte abnormality, cardiac arrhythmia, high blood sugar, pulmonary disease causing hypoxemia,

adrenal hyporesponse secondary to long-term steroid use. B. CP clearance and need for intraoperative monitoring. Three basic questions: 1. What is the medical status of the patient? a. What is the functional capacity of the patient? Can the patient climb at least two flights of stairs with ease? b. What is the patient's Goldman's Classification (Class I – IV)? Note: Low-risk patients to clear leave good functional capacity and are Goldman’s Class L 2. What is the operative procedure? a. High-risk surgery: Emergency major operation, aortic and other major peripheral vascular surgery, anticipated prolonged surgery with large blood loss. b. Intermediate risk surgery: Carotid endarterectomy, head and neck, intraperitoneal and intrathoracic, orthopedic, prostate surgery. c. Low-risk surgery: Breast, cataract, endoscopy, superficial procedures. 3. What type of anesthesia is to be used? From high-risk to low-risk: General anesthesia, spinal anesthesia, subarachnoid block, regional anesthesia, local anesthesia. C. Based on the answers above, we can now estimate the operative risk involved. Low-risk patients undergoing low-risk procedures have low operative risk. Conversely, high-risk patients undergoing high-risk procedures have high operative risk and need intraoperative monitoring. For other combinations of risk, the physician is advised to use his/her clinical judgment before clearing the patient. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

DYSLIPIDEMIA To Cardiology Page To Main Table of Contents To Detailed Table of Contents

A. Screening: In patients without coronary heart disease (CHD), the National Cholesterol Education Program (2001) recommends screening with a complete lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride) after a 12 hours fast for all adults > 20 years of age once every 5 years and as indicated. B. Positive Risk Factors (Add 1 point each): Age and gender (male > 45, female > 55 or premature menopause in women without estrogen replacement), current cigarette smoker (ten or more cigarettes per day), hypertension, family history of premature coronary artery disease (myocardial infarction or sudden cardiac death before age 55 in a male first degree relative and before age 65 in a female first degree relative), and low HDL cholesterol < 40 mg/dl. C. Negative Risk Factor: Subtract by 1 point if HDL > 60 mg/dl D. Normal Values: Ideal Lipid Profile - Total Cholesterol (TC) , 200mg/dl - HDL >=40 mg/dl - LDL 240 mg/dl (6.2 mmol/l)

= 160 mg/dl (4.1 mmol/l)

= 130mg/dl (3.4 mmol/I)

(+) CHD, DM or CHD risk e equivalents*

> 200 mg/dl (5.2 mmoVl)

= 130 mg/dl (3.4 mmol/l)

= 100 mg/dl** (2.6 mmol/I)

0-1 risk factors; No CHD

Start Drug Therapy (After 8-week trial of diet)

Treatment Goal LDL < 160mg/dl (4.1 mmol/1) < 130mg/dl (3.4 mmol/I) < 100 mg/dl (2.6 mmol/1)

Note: Conversion factor from mg/dl to mmol/l: multiply by 0.0259 * CHD risk equivalents comprise: (1) diabetes, (2) other clinical forms of atherosclerosis (symptomatic carotid artery disease, peripheral arterial disease, and abdominal aortic aneurysm), (3) multiple positive risk factors which includes consideration of the following - older age group, very high total cholesterol, low HDL, heavy cigarette smoker, and untreated and high blood pressure. ** In patients with CHD and LDL levels between 100-130 mg/dl, the physician should exercise clinical judgment in deciding whether to initiate drug therapy

Source: Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA Vol. 285 19:2486-97, May 16, 2001. F. Treatment Approach: 1. Goal o f treatment: Set treatment goal for target LDL 2. Start with Non-Pharmacologic Treatment: a. Diet therapy: Moderation in diet; increase intake of fish and vegetables. Diet for 8 weeks, then recheck Lipid Profile after 8 weeks. If repeat LDL values fall above the cut-off levels for starting drug treatment, initiate treatment with Statins. b. Aggressive coronary heart 'disease risk reduction: Smoking cessation, hypertension control, Aspirin treatment for documented coronary disease. c. Weight reduction if obese d. Increase physical activity (e.g. brisk walking, swimming) e. Consider stopping beta-blockers and thiazide diuretics f. Correct hyperglycemia (if diabetic) and replace thyroid hormones (if hypothyroid) 3.Drug treatment of choice: a. Type IIa: Increased LDL cholesterol and normal triglyceride (< 200 mg/dl): #1Statins, #2 Probucol, #3 Fibrates, #4 Nicotinic acid Type IIb: Increased cholesterol and increased triglyceride (200-400 mg/dl): #1 Statins or Fibrates, #2 Nicotinic acid c. Type IVL: Normal ch'olesterol but increased triglyceride: #1Fibrates, #2 Nicotinic acid, #3 Fish oil G. Available Lipid Lowering Agents 1. Statins as first-line drugs: (proven to prolong life with regular use) Atorvastatin (Lipitor) 10 mg, 20 mg, 40 mg, 80 mg tab: 10-80 mg tab OD HS Simvastatin (Vidastat =), Zocor) 10 mg, 20 mg, 40 mg: 5-40 mg/day, start with 5-10 mg OD HS. Pravastatin (Lipostat) 10 mg, 20 mg tab: 10-40 mg OD HS Fluvastatin (Lescol 40 mg, Lescol XL 80 mg tab): 1 tab OD HS 2.Fibrates Gemfibrozil (Reducel =), Lipigem =) 300 mg & 600 mg cap, Lopid O.D. 900 mg cap); 300-600 mg BID or Lopid O.D. 900 mg OD 3. Nicotinic Acid: Nicotinic Acid (generic) 50 mg, 100 mg tab: 50 mg OD then increase up to 100 mg TID 4. Others Oil gel capsule (Trianon Omegabloc) 1 cap TID To Cardiology Page To Main Table of Contents To Detailed Table of Contents

INDICATIONS FOR PERMANENT PACEMAKER INSERTION To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data There is general agreement that a permanent pacemaker should be implanted in the following conditions (Class I Indications): A. Complete Heart Block with l. (+) Symptoms due to the AV block (e.g. syncope, heart failure) 2. Asystole = 3 seconds by Holter monitoring even if without symptoms 3. HR < 40 bpm even without symptoms (any escape rhythm < 40 bpm) B. 2nd Degree AV block, permanent or intermittent, with symptomatic bradycardia C. Sinus node dysfunction with symptomatic bradycardia. In some patients this due to long-term essential drug therapy for which there are no acceptable alternatives e.g. digoxin for tachycardia-bradycardia syndrome. D. Carotid sinus stimulation causing recurrent syncope or asystole > 3 seconds in the absence of any medication that depresses the sinus node or AV conduction. Additional Data: 1. Patients should not be taking any drug that depresses the heart rate (i.e. digoxin, amiodarone, beta-blockers etc.). For example, digoxin needs 5 days to be completely excreted by the body, hence, we may opt to temporize the patient for 5 days even if he/she fulfills the above criteria. 2. The key clue in most of the above indications is the presence of symptoms. 3. Acute MI cases who develop bradyarryhthmias are usually treated with temporary internal pacing since the problem is reversible. Inferior wall MI is associated with edema of the AV node which usually resolves in 1- 2 weeks. 4. In poor patients who cannot afford permanent pacing, drug therapy with Bricanyl 2.5 mg tab BID-TID may be given with inconsistent results. In severe symptomatic cases, permanent pacing is the only alterative. The cheapest pacemaker available costs around Php 50,000. To Cardiology Page To Main Table of Contents To Detailed Table of Contents

HYPERTENSION To Cardiology Page To Main Table of Contents To Detailed Table of Contents Data: Seventh Join National Committee Classification: I. Hypertension category Normal Prehypertension Hypertension Stage 1 (mild) Hypertension Stage 2 (moderate-severe)

Systolic (mmHg) 80% predicted/ personal best - Sustained response for 4 hours ii. Management: - Continue regular broncho-dilator for 24-48 hours - Inhaled short-acting beta-2 agonist 2 puffs q 3-4 hr Alternative: Oral short-acting beta-2 agonist or theophylline 3Xday iii. Consultation: Contact Clinician within 48 hours for follow-up instructions b. INCOMPLETE RESPONSE i. Clinical Picture: (Moderate exacerbation) - PEF 60-80 % predicted/personal best ii. Management: ADD ORAL STEROID (1 mg/kg/day) - Continue beta-2 agonist and/or theophylline regularly iii. Consultation: Consult Clinician urgently for instructions c. POOR RESPONSE i. Clinical Picture: (Severe exacerbation) - PEF< 60% predicted/personal best ii. Management: ADD ORAL STEROID (1 mg/kg/day) - Repeat inhaled beta-2 agonist if available iii. Consultation: Immediate transport to hospital Emergency Department or nearest medical facility Note: Seek medical help immediately if the patient has the following: - Risk factors associated with asthma deaths: Current use of or recent withdrawal from systemic corticosteroids, hospitalization in the past year, ER visit for asthma in the' past year, prior intubation for asthma, psychiatric disease or non-compliance with asthma medication. - Manifestations of severe asthma exacerbation: Talks in words, agitation, drowsiness or confusion, paradoxical thoracoabdominal movement, cyanosis or pallor. To Pulmonology Page

To Main Table of Contents To Detailed Table of Contents

I. Management of Acute Exacerbation of Asthma: Hospital Care To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Orders: Diet: Regular diet when not dyspneic VS: Vital Signs q l hour, Call MD if HR > 120; RR > 30, O2 SAT < 90% Nursing: Peak flow rate pre and post bronchodilator treatment, 3 trials each and record the best only, BID-TID Connect to a pulse oximeter, Input & Output q shift; Moderate high back rest; Increase oral fluids IVF: D5NM 1 L X 12 hours; D5NR 1 L X 12 hours Diagnostics: Peak Expiratory Flow Rate BID (Pre- and post-nebulization) (get,the best of 3 good attempts) Chest X-ray portable (rule out pneumothorax & detect other problems) CBC, K, RBS, Creatinine, Sputum G/S, C/S (if with pneumonia by Chest X-ray) Consider ABG (if toxic-looking patient), ECG PFT (Pulmonary Function Test) to establish the diagnosis; = 15% increase in FEY following 2 pufls of beta 2-agonist (to be done when exacerbation is over and there is still uncertainty of diagnosis) Therapeutics: Mnemonic - NASA Oxygen at 2-6 1pm via nasal cannula Avoid or control trigger factors 1. Nebulization: Salbutamol (Ventolin) neb/inhaler q 3- hours (1 nebule/2-4puffs) or Ipratropium Br+ Salbutamol (Combivent) nebulization 1 vial q 6 hours or Ipratropium Br (Atrovent) 1 unit dose vial TIDED tachycardia) 2. Antibiotics - if with probable bacterial infection (fever, persistence, purulence, crackles) 3. Steroids a. Acute attack: Hydrocortisone (Solucortef) 250 mg IV stat then 100 mg IV q 4-6 hours X 4 doses or continuous if the condition warrants There is no role for inhaled steroids in the treatment of an acute attack. b. More stable: Start on oral steroids as soon as patients can safely swallow and taper off in 10-14 days i.

Prednisone 20 mg tab: I tab BID X 3 days then taper as follows: A.M. 1 1 1 1/2 Stop

3 P.M. 1 ½ 0 0

No. of Days X3 X3 X3 X3

or ii. Methylprednisolone (Medrol) 16 mg 1 tab BID X 3 days then taper. A.M. 1 1 1

3 P.M. 1 ½ 0

No. of Days X3 X3 X3

1/2 Stop

0

X3

iii. Inhaled Steroids - while not for acute attack, these drugs should be started early to have at least a 1 week overlap with the oral steroid. e.g. Salmeterol & Fluticasone (Seretide Diskus 250) 1 inhalation BID or Formoterol & Budesonide (Symbicort Turbuhaler) 1 inhalation BID 4. Aminophylline - only as an add on medication (if asthma is still not controlled) a. Acute Attack: not controlled by "N,A, &S ", give Aminophylline bolus at 5-6 mg/kg BW (if not maintained on theophyllines) then Aminophylline drip b. More stable: shift to Long-acting Theophylline e.g. Theodur 300 mg tab 1/2-1 tab BID or Unidur SR 400 mg, 600 mg 1/2-1 tab OD 5. If not controlled,by NASA (Nebulization, Antibiotics, Steroids and Aminophylline), consider intubation before respiratory fatigue sets in. 6. Optional medications: Antacids: Ranitidine 50 mg IV q 8 hours J. How to Use Your Diskus:

1. Open, 2. Slide, 3. Inhale, 4. Close 1. Open – hold the outer case in one hand then put other thumb on the thumbgrip. Push your thumb until you hear a click. 2. Slide – hold discus with the mouthpiece towards you. Slide the lever away until it clicks. 3. Inhale – put the mouthpiece to your lips. Breathe deeply. Remove discus from your mouth. Hold breath for 10 seconds. Breathe out slowly. 4. Close – put thumb in the thumbgrip and slide the thumbgrip back towards you until you hear a click. Your Discus is ready for use again. Wipe mouthpiece with dry tissue to clean. To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

CHRONIC OBSTRUCTIVE PULMONARY DISEASE To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Table 2-2. COPD Classification, Signs and Symptoms, and Treatment

A. Healthy Population 1. 2. 3.

S/Sx: none FEV1 as % predicted: Normal Tx: Smoking cessation for everyone

B. Mild COPD 1. S/Sx: Smoker’s cough, No abnormal signs, Little or no dyspnea - Mild symptoms 2. FEV1 as % predicted: = 80% 3. Tx: a. As needed Beta-2 Agonist e.g. Terbutaline Sulfate (Bricanyl Turbuhaler) 500 mcg/dose: 1 inhalation PRN q 2-6 hr (see for other drug options) b. Pulmonary rehabilitation C. Moderate COPD 1. S/Sx: Dyspnea on moderate exertion, Cough and moderate symptoms, continuous or intermittent 2. FEV1 as % predicted: 30-79 % 3. Tx: a. For intermittent symptoms: As needed Beta- 2 Agonists b. For continuous symptoms: Maintain on anticholinergics e.g. Tiotropium (Spiriva HandiHaler) inhalation of 1 capsule daily. c. If response is unsatisfactory add oral theophylline or long-acting B2-agonist d. Consider mucokinetic agent e. Pulmonary rehabilitation D. Severe COPD 1. S/Sx: - Dyspnea on mild exertion or at rest, Lung hyperinflation, Wheeze & cough 2. FEV1 as % predicted: < 30 % 3. Tx: a For continuous symptoms: Maintain on anticholinergies b. For frequent exacerbations (more than 4 times a year): Add inhaled steroids, e.g. Salmeterol & Fluticasone (Seretide Diskus 250) 1 inhalation BID c. Consider long - terms oxygen therapy at home Source: GOLD (2003) &Philippine Consensus on COPD Diagnosis and Management (1999) Diagnostics: CBC, serum Na, K, Chest X-ray, ABG, Sputum G/S, C/S Therapeutics: Similar to Asthma treatment {NASA - Nebulization, Antibiotics (if with infection), Steroids, Aminophylline} l. If hypercapneic, keep O2 low at 0.5-1.5 1pm via nasal cannula (so as not to depress patients respiratory drive). It is best to target O2 sat at 90-92 %. 2. Ipatropium Br & Salbutamol (Combivent) nebulization is more effective than Terbutaline or Salbutamol nebulization. Or if feasible give Tiotropium (Spiriva HandiHaler) inhalation of 1 capsule daily. 3. For acute exacerbations, give a course of intravenous or oral steroids. 4. Long term home oxygen therapy if patient hypoxemic or with cor pulmonale. 5. Treatment is symptomatic, only smoking cessation and home oxygen therapy have been shown to prolong life.

To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

PULMONARY TUBERCULOSIS To Pulmonology Page To Main Table of Contents To Detailed Table of Contents A. Symptoms: 1. Local symptoms: Cough, hemoptysis, chest pain, dyspnea 2. Constitutional symptoms: Fever, weight loss, chills, anorexia Note: Around 10 % (5-14 %) have no symptoms B. TB Concepts: 1. TB exposure 2. TB Infection: (+) Purified Protein Derivative (PPD) 3. TB Disease: (+) Target organ damage C. Indications of Active Disease: l. (+) AFB sputum smear (at least 2+) or (+) TB culture 2. (+) Symptoms: Constitutional symptoms are more reliable than local symptoms 3. Increase in chest x-ray infiltrates (usually apical) D. Indications of Inactive Disease: 1. Six months interval with no change in chest x-ray infiltrates and no constitutional symptoms 2. Preferably with history of completed TB therapy E. Indications of Favorable Disease Response: 1. Completion of prescribed treatment 2. Conversion to sputum smear and culture to negative 3. Resolution of constitutional symptoms 4. Resolution or improvement of local symptoms F. Table 2-2. American Thoracic Society (ATS) CLassification of PTB. Class

Exposure

Infections (+) PPD

Target Organ (+) CXR infiltrates

0 1 2 3 5

(-) (+) (+) (+) (+)

(-) (-) (+) (+) (+)

(-) (-) (-) (+) (+)

Indications of Active Disease (see C above) (-) (-) (-) (+) (+/-)

MDRTB(Multiple Drug Resistant Taberculosis) - suspect in PTB III patients who are still sputum smear or culture (+) despite 3 months of adequate treatment. Source: Maher D, Chavlet P, Spiaaci S, ct sl (1997). Treatment of Tuberculosis: Guidelines for National Programmes (Second Ed.). Geneva: World Health Organization G. TB Diagnostics Nursing precautions: Isolate patient in solo room if PTB Class III (active) Diagnostics: Chest X-ray PA-Lateral and Apicolordatic view Sputum AFB Smearin A.M. for 3 consecutive days Mycobacterium TB culture & sensitivity (PGH, Makati Medical Center) CBC, SGPT, SGOT, Alkaline Phosphatase H. Treatmeat Plan: l. ATS Class 0: No exposure, (-) PPD (e.g. Americans) Treatment: BCG in high prevalence area 2. ATS Class 1: (+) exposure, (-) PPD Treatment: If with recent exposure:

a. Give primary prophylaxis: HR for 4 months or HE for 6 months b. Repeat PPD in 2 months + if (+), treat as Class 2 U if (-), stop primary prophylaxis 3. ATS C1ass 2: TB Infection - (+) exposure, (+) PPD, (-) target organ TB lesion Note: 70% of adult Filipinos are (+) for PPD and are therefore naturally infected Treatment: a. If with recent PPD conversion, give primary prophylaxis HR for 4 months or HE for 6 months b. If not a recent PPD converter but currently exposed to a TB case, give primarily prophylaxis is as above c. If not a recent PPD converter 4 no family member has active TB, may not give primary prophylaxis 4. ATS Class 3: PTB active In the National TB Control Program, only Class III(Active) patients are targeted for treatment for financial reasons. For operational purposes ATS Class 3 patients are farther subidvided into WHO Category I, lI. and III. Table 2-3 Treatment Regimen for ATS Class 3 Patients (PTB Active) 1.

WHO Category I* a. TB patients: new smear-positive PTB; new smear negative PTB with extensive parenchymal involvement; new cases of severe forms of extra-pulmonary TB. b. Alternative TB Treatment Regimen i. Initial phase: 2HRZE (four drugs) ii. Continuation phase: 4HR

2.

WHO Category II a. TB patients: Sputum smear-positive: relapse; treatment after interruption b. Alternative TB Treatment Regimen i. Initial phase: 2HRZES and 1HRZE (Five drugs) ii. Continuation phase: 5HRE

3.

WHO Category III** a. TB patients: New smear-negative PTB (other than in Category 1) new less severe forms of extra-pulmonary TB. b. Alternative TB Treatment Regimen i. Initial phase: 2HRZ (three drugs) ii. Continuation phase: 4HR

* Give this regimen if with high bacterial load, cavitary lesions, AFB+4 smears, or high community resistance (e.g. NCR, Cebu, Davao, Zamboanga, Cavite, Pampanga). If with cavitary disease, give Streptomycin IM alternate days (60 doses) instead of Ethambutol ** May give this cheaper regimen for newly diagnosed TB and those cases found in low community resistance Source: Maher D, Chavlet P, & Spinaci S, et el (1997). Treatment of Tuberculosis: Guidelines for National Programmes (2nd Ed.. Geneva: World Health Organization. 5. ATS Class 4: Previous PTB disease (e.g. Chest X-ray with minimal infiltrates but no symptoms of active disease or previously treated PTB) Treatment Algorithm Has patient completed past treatment of PTB? — NO: Check old CXR if:

o

o

—

6 months stable CXR § If age 60 Just observe) § Repeat CXR after 3 months § If infiltrates increase or decrease, treat PTB as Class III.. If infiltrates are stable, stop treatment No previous CXR § Give 2HRZ/4HR § Repeat CXR after 2 months § If infiltrates increase or decrease, treat PTB as Class III.. If infiltrates are stable, stop treatment

YES: Observe and then Check old CXR if: o X-ray normal with normal or less infiltrates § Treat as PTB 3, 2HRZE/4HR (or 2HRZ/4HR) o X-ray the same , no changes § No treatment

6. ATS Class 5: PTB Suspect Treatment Plan: Check previous Chest x-ray Reclassify patient into Class III or Class IV in 2-3 months using sputum bacteriology or serial x-ray changes. 7. Multi-drug Resistant TB: Infection with strain of Mycobacterium tuberculosis which shows in-vitro resistance to at least Isoniazid and Rifampicin Treatment Plans: Use at least 4-5 drugs as hng as, a. Use at least 4-5 drugs as long as these include 2 drugs not previously taken. Do not add a single drug to a failing regimen to avoid resistance to the new drug. Consider continuing with H & R (most bactericidal) despite resistance, for example, if patient took HREZ X 6 months, may then add Streptomycin (first line drug) and Ofloxacin (second line drug. May discontinue either E or Z. b. Continue treatment for 18 months more from the time the patient’s sputum becomes AFB and culture negative. Get cultures to check sensitivity of TB organism. c. Consider Surgery for unilateral cavitary lesions in whom MDR-TB is established by the laboratory. Legend: H or INH honiazid R or RIF = Rifampicin Z or PZA Pyrazinamide E or EMB = Ethambutol S or STM Streptomycin I. Notes on Anti-TB Drug Intake: (Additional Treatment Plan for Active PTB) l. Instill in the patient’s mind the need to complete 6 months treatment. a. Since it is very difficult for patients to comply with multiple drug for the duration of at least six months, incomplete treatment not only decrease cure rate but also enhance development of resistance. It is ideal that treatment of TB should be done under direct supervision. “DOTS”Directly Observed Therapy Short Course requires actual observation during drug intake. There are now several DOTS centers in Manila to help doctors implement DOTS treatment even for private patients. Refer patients to Manila Doctors Hospital, PGH, Makati Medical Center and UST. b. Give all medications 1 hour before meals. It is ideal not to break the dose of the drug. c. If drugs are to be staggered because of side effects, make sure each drug component is still single dose. e.g. Rifampicin - before breakfast, EMB - before lunch, PZA - before supper d. Use only fixed dose combination, since most of these contain only 450 mg Rifampicin, add 150 mg Rifampicin if patient weighs > 60 kg or 130 lbs.

2. If patient cannot complete treatment, better not to start treatment at all to avoid emergence of resistance (MDR-TB). 3. The allowance for non-compliance is two weeks maximum, otherwise the treatment regimen should be started all over again. 4. Follow-up patients monthly. During initiation of treatment make patients follow- up after a week to see if there are drug side effects. 5. If after 6 months, the patient is still symptomatic, continue treatment but do sputum AFB and culture and reassess if the patient has MDRTB or cured TB with bronchiectasis. 6. Post-treatmeat follow-up: If two years has elapsed and the patient is still asymptomatic, long-term cure is anticipated. Relapse occurs in 1-2 % of cases. J. Tuberculosis in Special situations: 1. Pregnancy: a. HRE X 9 months (Standard regimen for pregnant patients) b. Give 50 mg of Pyridoxine as vitamin supplements. c. Avoid PZA, especially in the first trimester, unless resistance to H and R is highly suspected. d. Avoid Streptomycin: May cause 8th cranial nerve fetal abnormality. e. Breastfeeding is allowed: Take drugs after breastfeeding; TB drugs do not have toxic effect on nursing newborns. 2. Uremia or end-stage renal disease a 2 HRZ / 6 HR (Safest regimen for renal disease) b. Give INH + RMF +/- Pyridoxine at the regular doses administered after dialysis. c. Ethambutol: Decrease dose to 8-10 mg/kg/day d. Pyrazinamide: Decrease dose to 12-20 mg/kg/day e. Avoid Streptomycin (nephrotoxic) 3. Liver Disease/ Drag-induced Hepatitis: a. Stop anti TB drugs if (1) (+) jaundice or (2) Liver function test (SGOT, SGPT) > 3X the normal values b. Slowly resume INH and Etlambutol during first week. Resume Rifampicin during the second week and then PZA 3 days after. 4. Diabetes Mellitus: Continue treatment for a minimum of 9 months 5. Elderly patients > 65 years: Give HR X 9 months 6. Extrapulmonary Tuberculosis: a. Same treatment regimen as pulmonary TB b. For Central Nervous System TB: i.Use H, R, Z because of good penetration to the CNS ii.EMB and STM penetrate inflamed meninges only. 7. PTB in Children (Primary Complex): a. mixed disease: INH 5mg/kg/day (max of 300mg) + RMP 10mg/kg/day (max of 600 mg) b. extensive disease: STM 10-18mg/kg/day (max of 750mg) or EMB 15-20 mg/kg/day – avoid in young children whose visual acuity cannot be monitored, PZA 20-30 mg/kg/day (no studies yet) To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

K. Anti-TB drugs available: First Line and Second Line Drugs To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Table 2-4 First Line Drugs for Tuberculosis 1. INH (H) Actions: Bacteriocidalintra/extra-cellular activity Dosage:5mg/kg/day, Adult dose = 300-400 mgPO Metabolism: Liver Side Effects:Hepatitis, safest in pregnancy Comments: Reintroduce INH gradually when liver enzymes are down, give slowly with Rifampicin 2. Rifampicin (R) Actions:Bacteriocidal intra/extra-cellular activity Dosage:10-20 mg/kg/day (child) Adult dose = 450-600 mg/day Metabolism: Liver Side Effects:Hepatitis, GI, haemolytic anemia, ARF, thrombocytopenia, nausea Comments: Increase metabolism of cortisone, coumadin, oral contraceptive, pheytoin 3. PZA (Z) Actions:Bacteriocidal at acidic pH, intracellular activity only Dosage: 20-30mg/kg/day Adult dose = 1500 mg/day Metabolism: Liver Side Effects: Most hepatotoxic Comments: Some patients tolerate lower dose gradually reintroduced 4. EMB (E) Actions:Bacteriostatic inra/extra-cellular activity Dosage: 15-20mg/kg/day Adult dose = 800-1000 mg/day PO Metabolism: Kidneys Side Effects: Optic Neuritis, (impaired color perception, dec. in visual acuity) Comments: Relatively safe in pregnancy 5. Streptomycin (S) Actions: Bacterostatic extra-cellular activity Dosage: 10-18mg/kg/day Adult dose = 1 gram IM Metabolism: Kidneys Side Effects: 8th nerve damage especially > 50 years old Note: Give all medications 1 hour pre-meals 2. Second Line Drugs for Tuberculosis a. Ciprofloxacin 500-1000 mg OD PO b. Ofloxacin 800 mg OD PO c. Terizidone (Terivalidin) 250 mg, 3 caps OD d. Amikacia 15 mg/kg IM/IV e. Cycloserine 15-20 mg/kg (1 gm) Note: The use of these drugs for MDRTB should be under the DOTS-Plus program (available at Makati Medical Center and Quezon Institute) to ensure that the patient gets a complete and free course of second line d Please avoid using them in your practice to minimize TB resistance.

ANTI-TUBERCULOSIS DRUG LIST: Note: The Department of Health TB pogrom provides Lee and complete course of anti-TB drugs. Refer patients to your local health centers.

1. Wyeth: Myrin-P Forte (4 TB Drugs in one tablet): Ethambutol 275 mg+ INH 75 mg + PZA 400 mg + Rifampicin 150 mg PO- Single daily dose: 40-54 kg, give 3 tabs; 55-70 kg, give 4 tabs, > /1 kg, give 5 tabs Myrin (3 TB Drugs in one tablet): Ethambutol 300 mg+ INH 75 mg+ Rifampicin 150 mg PO- Single daily dose: 40-49 kg, give 3 tabs; > 50 kg, give 4 tabs. 2. UAP: Quadpack (4 TB drugs): 3 Pyrina (Rifampicin 150 mg + PZA 500 mg+ INH 150 mg) cap, 3 Odetol (Ethambutol HCl 400 mg) PO- 1 pack daily as single dose for the first 2 months Tripack (3 TB drugs): 2 Etham (Ethambutol diHCI S00 mg + INH 200 mg + vit B6 20 mg) tab, 1 Median (Rifampicin 4SO my) cap PO- 1 pack daily as single dose for the next 4 months 3. Pascual Lab: Econokit (4 TB drugs): 1 Nyadin (INH 40 mg) tab, 1 Rifampicin 450 mg cap, 3 PZA 500 mg tab, 1 Ethionah (Ethambutol HC1 800 mg) tab PO- 1 pack daily as single dose for the first 2 months Econopack (3 TB drugs): 1 Nyadin (honicotinic acid hydrazide 400 mg) tab, 1 Rifampicin 450 mg cap, 3 PZA 500 mg tab PO- 1 pack daily as single dose for the first 2 months Continukit (Ethambutol HC1 800 mg, INH 400 mg, Rifampicin 450 mg) PO- 1 Rifampicin before breakfast, Ethambutol + INH after breakfast Continupack (2 TB drugs): 1 Nyadin (Isonicotinic acid hydrazide 400 mg) tab, 1 Rifampicin 450 mg cap PO- 1 cap & 1 tab in single intake preferably before breakfast for next 4 mos. To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

PULMONARY EMBOLISM To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Data: A. Predisposing actors: 1. Deep vein thrombosis as source: Carcinoma, CHF, recent pelvic and abdominal surgery, varicose veins, prolonged immobilization, pregnancy, estrogen intake 2. Tumor embolism from a gynecological or gastrointestinal source, e.g. liver cancer B. Signs and symptoms: Dyspnea, tachycardia, chest pain C. Diagnosis,of Pulmonary Embolism: 1. Clinical setting and high index of suspicion 2. Physical Exam: Increase JVP but clear hogs, loud Py2 3. ABG may show respiratory alkalosis, hypoxemia 4. ECG may show transient RAD, RBBB, S waves at precordial leads 5. V/Q Scan: Interpreted as normal, low, intermediate or high probability of PE 6. Pulmonary Angiography: Gold Standard for diagnosis D. Diagnosis of Deep Vein Thrombosis (as source of the emboli) 1. Duplex Ultrasound of the lower extremities (Non-invasive test) 2. Ascending Venography: Gold standard Note: In our local setting, pulmonary angiography and ascending venography are rarely done. A high index of suspicion and a compatible clinical setting already warrants treatment. Orders Admit to: VS: Vital signs q I hour; Bedrest without bathroom privileges IVF: D5NM I L x 24 hours Diagnostics: CBC, Chest X-ray, Serum K, Creatinine, Urinalysis ABG, ECG, PT and PTT baseline and monitor High-resolutiona CT-Scan or V/Q Scan D-Dimer (if negative, embolism is unlikely) Duplex Ultrasound of the lower extremities Therapeutics: 02 at 2-4 1pm by nasal cannula; anti-embolic stockings l. IV Heparin plus 5000 units then maintain at 500-1000:ulhr to maintain PTT at 1.5-2.5 X the control (for 7-10 days); check PTT q 12-24 hours or Low Molecular Weight Heparin 2. Overlap Heparin with Warfarin(Coumadin) 2.5 - 7.5 mg PO 3-4 days prior to stopping Heparin to maintain a PT INR or 2.0-3.0; Continue anticoagulation for 3 months or indefinitely depending on the persisterice of the predisposing factor 3. Other Treatment Options: a Inferior Vena Caval IVC) interruption or IVC filter insertion: For patients in whom anticoagulants are absolutely contraindicated b. Thrombolytic therapy: For acute massive embolism and hemodynamically unstable patients To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

HEMOPTYSIS To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Data A. Definition: Massive hemoptysis = 600 cc in 24 hours. Expanded definition includes those with associated asphyxiation even with blood loss < 600 cc/24 hours B. Etiology: Pulmonary tuberculosis, bronchiectasis, lung cancer, pneumonia, mitral stenosis, pulmonary edema, arterio-venous fistula C. Important Clinical Questions: l. Is this hemoptysis (from the lungs) or hematemesis (from the stomach)? 2. Is bleeding due to a breach in an anatomic barrier or due to a coagulopathy? 3. What is the approximate amount of blood loss? Look for tachycardia and orthostatic hypotension. 4. Is this a medical or a surgical problem? Orders: Admit to: ICU (for massive hemoptysis) Diet: NPO VS: Vital signs q 1 hour; Orthostatic BP and pulse 2X/day Nursing: Quantify all sputum and blood, suction PRN, hook to pulse oximeter Keep patient on a lateral decubitus position (on the side of the affected lung IVF: PNSS X 8 hours; Transfuse whole blood if needed Diagnostics: CBC, save blood for typing & cross matching, PT and PTT Chest X-ray PA, Lateral, ECG Therapeutics: Oxygen as needed 1. Plain NSS or plasma expanders while waiting for whole blood or packed RBC 2. If with coagulopathy, give Fresh Prozen Plasma or Cryoprecipitate 3. Tranexamic acid (Hemostan) 500 mg IV q 6-8 hours 4. Codeine (Codipront-N) 1 tbsp BID or Butamirate citrate (Sinecod) 1 tbsp QID 5. Address the bleeding site a Correlate PE with Chest x-ray to detect bleeding site b. Keep the bleeding lung down to keep bleeding contained in one lung c. Consider single lumen orotracheal intubation i. Left lung bleeding: Advance endotracheal tube far down to intubate right mainstem bronchus. ii. Right lung bleeding: Facilitated by right lateral decubitus position to shift the mediastinum rightward and along better access and view the left mainstem bronchus 6. Stat Bronchoscopy for persistent hemoptysis to localize bleed as a prelude to Surgery 7. Nebulization is contraindicated To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

PLEURAL EFFUSION & THORACENTESIS To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Usually due to pulmonary tuberculosis, lung cancer pneumonia, or congestive heart failure B. Pathophysiology: l. A structure is disrupted (esophagus, thoracic duct, blood vessel, bronchial tree) 2. Pleural abnormality with increase permeability, e.g. cancer or inflammation 3. Abnormal osmotic factors leading to transudative effusion, e.g. congestive heart failure, cirrhosis C. Category: Pus, exudate, transudate, chylous Orders: Admit to: IVF: D5W 500 cc X 40 cc/hr Diagnostics: CBC, Chest X-ray PA-L, ABG, ECG Diagnostic thoracoscopy (for difficult to diagnose effusion) Therapeutics: 1. Prepare the Following for Thoracentesis a. Secure consent b. Abbocath gauge #16, 5 sterile specimen bottles 1 liter sterile bottle, 50 cc syringe, 3 way stopcock, Xylocaine ampules c. Maximum drainage: 1-1.5 liters X 24 hours d. Usual site: 8th Intercostal space posterior axillary line 2. Post-Thoraoentesis Orders. a. Note for signs of respiratory distress b. Repeat CXR (PA, Lateral) after thoracentesis c. Serum LDH, TPAG Glucose simultaneously d. Send specimen Bottle 1: Cell count, Differential count Total Protein, LDH (5-10 ml EDTA) Bottle 2: AFB, Gram stain, C & S Bottle 3: Cytology eat Cell Block (obtain 200 cc of fluid or more to increase yield) 3. Diagnosis of Exudate using Light’s Criteria One or more of the ff a Pleural fluid Protein / Serum Protein ratio > 0.5 b. Pleural fluid LDH / Serum LDH ratio > 0.6 c. Plueral fluid LDH > 2/3 the upper limit of normal for serum LDH 4. Indications for Chest Tube Insertion: a. Gross pus on thoracentesis b. Presence of organisms on gram stain of the pleural fluid c. Pleural fluid glucose < 50 mg/dL d. Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

ANAPHYLAXIS To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Data: A. Identify precipitating factor or allergen B. Diagnosis is clinical, especially with history of allergen exposure. C. Stratify as to Severity: 1. Mild – skin manifestation only 2. Moderate to severe - presence of any of the following: (a) upper airway obstruction denoting laryngeal edema, (b) severe bronchospasm, or (c) cardiovascular dysfunction and/or hypotension Orders: Admit to: Diet: NPO temporarily VS: Vital signs q 1 hour Nursing: Input & Output; Elevate legs; Standby intubation set IVF: NSS X 6 hours- rapid fluid infusion Diagnostics: CBC, ABG, Urinalysis Skin testing, Radioallergosorbent Test (RAST) Portable Chest X-ray, lateral soft tissue neck x-rays ECG,Pulmonary Function Test Therapeutics: Oxygen at 6 lpm via nasal cannula or mask 1. For bronchospasm, give Bronchodilators: a. Terbutaline, 1 mg (1ml) in 2 ml NSS by nebulizer or Salbutamol (Ventolin) 0.5%, 0.5 ml in 2.5 ml NSS by nebulizer b. Epinephrine (1:1000) 0.2-0.5 ml SQ or IM q 20 min (for severe cases only) c. Aminophylline loading dose 4-6 mg/kg total body weight IV, then infuse 0.3-0.9 mg/kg ideal body weight/hour 2. For skin manifestations (urticaria and angioedema), give Antihistamines: Diphenhydramine (Benadryl) 25-100 mg IV, IM or PO q 2-4 hours 3. Corticosteroids: Hydrocortisone (Solucortef ) 200-250 mg IV then 100 mg q 4-6 hours IV steroids should be followed by PO steroids e.g. Prednisone) 4. For hypotension, give Pressors to maintain BP: (See Appendix on Drips) ] Noradrenaline (Levophed) IV or Dopamine IV 5. Consider Endotracheal Intubation for angioedema of the epiglottis and larynx (laryngospasm) causing upper airway,obstruction, severe bronchospasm, and stridor and excessive use of muslces of respiration.; 6. Premedication for radiocontrast or blood products in allergic patient: a. Prednisone 50 mg pO q 6 hours X 3 doses and b. Diphenhydramine 25-50 mg IM or 1V 1hour before procedure To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

PNEUMOTHORAX To Pulmonology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: 1. Spontaneous: a. Primary: Tall thin cigarette smoking adult b. Secondary: History of lung disease, e.g. tuberculosis, COPD 2. Traumatic: a. Non-iatrogenic b. Iatrogenic: Due to positive pressure ventilation, central venous catheterization, CPR, endotracheal intubation B. Differential Diagnoses: AMI, Pulmonary embolism, pneumonia, aortic dissection esophageal rupture etc. C. Signs Symptoms: 1. Sudden onset of chest pain and dyspnea 2. Ipsilateral expansion of the chest wall, decreased fremiti, hyperresonance 3. Tracheal deviation to contralateral side 4. Cyanosis, hypotension in severe cases Orders: Admit to: VS: Vital signs q 2 hours, Watch out for progressive dyspnea Diagnostics: CBC, ABG Chest X-ray PA expiratory film (check the visceral pleural line, absence of lung parenchymal markings between pleural line and chest wall, and mediastinal shift) Therapeutics: A. Medical l. Indications less than 15% pneumothorax and asymptomatic patient 2. Bed rest, Observe for 2 days 3. Repeat films q 24 hours 4. Oxygen at 2-6 1pm per nasal cannula 5. For Pain: Tramadol 50 mg q 8 hours lV or other analgesics PO B. Chest Tube Thoracostorny, (CTT) Indications: Greater than 15% pneumothorax and symptomatic patient C. Chemical Pleurodesis. Talc or Tetracycline Plurodesis Indications: (1) Recurrent pleural effusion, (2) rnalignant pleural effusions, (3) secondary pneumothorax including iatrogenic pneumothoraces and (4) patients with poor surgical risk D. Consider Video Assisted Thoracoscopy (VATS) for the following: l. Unexpanded lung for more than 5-7 days 2. Bilateral pneumothorax 3. Persistent air leak in the chest tube E. Consider Resectional Surgery as last resort To Pulmonology Page To Main Table of Contents To Detailed Table of Contents

PNEUMONIA To Pulmonology Page To Infectious Page To Main Table of Contents To Detailed Table of Contents A. Algorithm: Management-Oriented Risk Stratification of Community-Acquired Pneumonia (CAP) Immunocompetent Adults

Parameters

Minimal Risk CAP I Succeeding Parameters not Present

Low Risk CAP II Any of the ff: Diabetes mellitus Euplastic Disease Nuerologic Disease CHF, COPD Renal Insufficiency Chronic liver disease Alcoholism STABLE

Moderate Risk CAP III Any of the following: Age = 65 years RR = 30/min PR = 125/min Temp = 40 or = 35 C CXR: multilobular, pleural effusion, abscess progression of lesion Suspected aspiration Extrapulmonary evidence of sepsis

High Risk CAP IV Any of the following: Age = 65 years RR = 30/min PR = 125/min Temp = 40 or = 35 C CXR: multilobular, pleural effusion, abscess progression of lesion Suspected aspiration Extrapulmonary evidence of sepsis

NO Hypoxemia (PaO250) at room temp

Any of the ff: Shock or 1. signs of hyperperfusion: Hypotension Altered Mental State Urine Output 50 mmHG At room air

OR Any of the ff: Diabetes mellitus Euplastic Disease Nuerologic Disease CHF, COPD Renal Insuffeciancy Chronic liver disease Alcoholism UNSTABLE

Management

Outpatient

Outpatient

Ward Admission

ICU Admission

Sources 1. Task Force on CAP, Phil. Practice Guidelines Group in Infectious Disease (1998)-Community-Acquired Pneumonia: Clinical Practice Guideline (Volume l N. 2). Quezon City PPGG-ID Phil. Society for Microbiology and Infectious Diseases, with permission 2. American Thoracic Society: Guidelines for the Management of Adults with Community-Acquired Pneumonia. American Journal Respiratory Critical Care Medicine 163: 1730-1754, 2001.

B. Guidelines on Pneumonia Empiric Therapy: (Usual Recommended Dosages of Antibiotics in Adults, 50-60 Kg Body Weight, with Normal Liver and Renal Function) 1. CAP Category I: Minimal Risk CAP Common Organisms: 1- Strep. pnpneumoniae, 2- H. influenzae, 3- Respiratory viruses, 4- C. pneumoniae, 5- M. pneumoniae; Mortality rate at 1-5 % a. Amoxicillin 500 mg cap TID PO (standard regimen) b. Macrolides: Choice of i. Roxithromycin(Macrol, Rulid) 150 mg tab BID PO ii.Azithromycin 250 mg tab BID X 3 days iii.Erythromycin 500 mg cap QID PO (do not give if smoker because of the likelihood of H. influenza); 20% will develop gastric irritation 2. CAP Category II: Low Risk CAP Common Organisms 1- S. pneumoniae, 2- Respiratory viruses, 3- H. influenzae, 4- Aerobic gram negative bacilli, 5- S. aureus; Mortality at 1-5 % a. Choice of: i. Cefuroxime (Zinnat) 250-500 mg tab BID PO ii. Sultamicillin(Unasyn) 375-750 mg tab BID iii. Co-Amoxiclav (Augmentin) 375 mg tab TID or 625 mg tab BID PO b. Macrolides PO c. New Fluoroquinolones Alone PO (as nerve drug) Ex. Gatifloxacin (Tequin) 400 mg tab OD PO 3. CAP Category III: Moderate Risk CAP Common Organisms: 1- S. penumoniae, 2- H. influenae 3- Polymicrobial (including anaerobic bacteria/aspiration), 4- Aerobic gm-negative bacilli, 5- Legionella sp., 6- S. aureus, 7- C. pneumoniae, 8- Respiratory viruses; Mortality rate at 5-25 % a. Choice of: i. Cefuroxime (Zinacef) 750 mg q 8 hr IV ii. Ampicillin-Sulbactam (Unasyn) 750 mg-1.5 gm q 8 hr IV iii. Co-Amoxiclav (Augmeatin) 600 mg-1.2 gm q 8 hr IV + b. Erythromycin 500 mg - 1 gm q 6 hr IV or Azithromycin IV or c. New Fluoroquinolones Alone PO: (Cheaper option) Ex. Gatifloxacin (Tequin) 400 mg tab OD PO 4. CAP Category IV: High Risk CAP Common Organisms 1- S. pneumoniae, 2- Legionella sp., 3- Aerobic gram- negative bacilli, 4Pseudomonas aeruginosa, 5- S. aureus, 6-M. pneumoniae, 7-Respiratory viruses; Mortality rate at 50 % a. Choice of: Ceftazidime 1-2 gm q 8 hr IV or Piperacillin-Tazoobactam (Tazocin) 2.25 gm q 6-8 hr IV or Meropmem 500 mg q 8 br IV or Cefepime 1-2 gm q 12 hr IV + b. Erythromycin 500 mg - 1 gm q 6 hr lV or Azithromycin IV or Gatifloxacin (Tequin) 400 mg tab OD PO -/+ c. Choice of Aminoglycosides (for a few days for Pseudomonas coverage): Tobramycin 80 mg q 8 hr IV or Amikacin IV or Gentamicin IV C. Other Situations: 1. For Aspiration Pneumonia: a. Aspiration Pneumonia (community-acquired) Clindamycin 300-600 mg q 6-8 hr IV or Penicillin G 1-2 million units q 4 hr IV b. Aspiration Pneumonia (nosocomial) i. Piperacillin-Tazobactam (Tazocin) 2.25 gm q 6-8 hr IV or ii. Clindamycin 300-600 mg q 6-8 hr IV + Tobramycin 80 mg q 8 hr IV 2. Treatment Based on Typical and Atypical Clinical Presentation:

a. Typical Presentation: Fever, acute onset, pleuritic chest pain, lobar consolidation by x-ray, yellow copious phlegm, pleural effusion. Treatment: Beta-lactams (e.g. Co-amoxyclav) or Cephalosporins (e.g. Cefuroxime) b. Atypical Presentation: No fever, chronic, interstitial infiltrates by x-ray scanty white phlegm Treatment: Macrolides (e.g. Clarithromycin) 3. Cheaper Antibiotic Options: a. For CAP Category I and Category II: i. Amoxycillin PO for Typical Pneumonia ii. RoxithromycinPO for Atypical Pneumonia b. For CAP Category III: New Fluoroquinolones Alone PO Ex. Levofloxacin (Levox) 250-500 mg tab OD PO Orders: Diagnostics: CBC, Creatinine, Chest X-ray PA-L Sputum G/S and C/S, Sputum AFB 3X (for TB suspect) Therapeutics: l. Antibiotic regimen as listed above given for a maximum of 7-8 days only to minimize the emergence of resistance. 2. Berodual nebulization (10 gtts in 3 ml NSS) q 6 hours and prn 3. Switch Therapy: Intravenous antibiotic treatment may be shifted to or antibiotics after 48-72 hours if the following parameters are fulfilled: (a) there is less cough and resolution of respiratory distress (normalization of respiratory rate), (b) the temperature is normalizing, (c) the etiology is not a high risk (violent/resistant) pathogen, (d) there is no unstable co-morbid conditions or life-threatening complications, and (e) oral medications are tolerated. 4. For abundant secretions, may give Acetylcysteine (Fluimucil) 100 mg or 200 mg sachet dissolved in 1/2 glass H2O TID. Discontinue if patient has wheezing To Pulmonology Page To Infectious Page To Main Table of Contents To Detailed Table of Contents

PEPTIC ULCER DISEASE / ACUTE GASTRITIS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: Indications for Endoscopy: Recurrent epigastrc pain not responsive to H2 antagonist or PPI (Proton Pump Inhibitor), pain sufficient to wake the patient up, weight loss, anorexia, hematemesis, or melena. Orders Admit to: Diet: NPO, then regular diet VS: Vital signs q 4 hours, postural Blood Pressure (taken supine & sitting – especially if with bleeding) IVF: DER 1 liter X 12 hoprs; D5NM 1 liter X 12 hours Diagnostics: CBC, Amylase Na, K, Calcium Upper GI Series or Endoscopy with Clqtest (rapid urea' assay) ECG(for anemia-related ischemic changes) Ultrasound of Liver Hepato-biliary Tract and Paacreas (to rule out cholecystitis and pancreatitis) Therapeutics: 1. Diet: a. Avoid foods that stimulates acid secretion b. Stop smoking and alcohol c. Stop Aspirin, NSAIDS, Steroids. 2. Gastric Ulcer: a Do biopsy during endoscopy of gastric ulcer (to rule out Carcinoma) and do urease test. b. If urease test (-) treat with:, H2-blockers or Proton-pump inhibitors +/- Antacids for 6-8 weeks or H2-blockers or Proton-pump inhibitors +/- Sucralfate for 6-8 weeks c. If urease (+) or if H, pylori positive: give Eradication Treatment d. Repeat endoscopy or do Upper GI Series after 4-8 weeks of medical treatment: If there is no improvement, suspect malignancy. 3. Duodenal Ulcer: a. Usually not malignant but recurrent b. Do Helicobacter pylori testing. c. If urease test (-): Treat with H2-blockers +/- Sucralfate +/- Antacids or Proton-pump inhibitors for 4 weeks d. If urease test (+) or if H. pylori positive: give Eradication Treatment. e. If with frequent, recurrent or severe duodenal ulcer or if with duodenal ulcer complication: give maintenance dose of H2-blocker or proton-pump inhibitor (1/2 of daily dose) or recheck H. pylori eradication. If still urease (+), may give another eradication treatment. 4. Acute Gastritis: a. Withdraw offending agent if possible (e.g. alcoho1, NSAID, steroids) b. Give H2-blockers + antacids for 2 weeks or Sucralfate (Iselpin) 1 gram in 20 ml H2O QID 1 hour before meals and at bedtime 5. Helicobacter pylori Eradication Treatment: (positive urease test or H. pylori by histologic examination) a. Proton-Pump Inhibitor (PPI) to be given BID PO X 1 week + Amoxicillin 500 mg 2 caps BID X 1 week + Clarithromycin 500 mg 1 tab BID X 1 week

Note: For PPI, one may use any of the following: Esomeprazole 40 mg tablet Omeprazole 20 mg capsule Lansoprazole 30 mg capsule Pantoprazole 40 mg tablet Rabeprazole 10 mg tablet b. PPI to be given BID PO X 1 week (as above) + Metronidazole 500 mg 1 tab BID X 1 week + Clarithromycin 500 mg 1 tab BID X 1 week Additional note: One may continue PPI on a once a day dose for 3 more weeks for gastric or duodenal ulcers. 6. Symptomatic Medications a. Pain: Hyoscine-N-butylbromide (Buscopan) 1 amp IV q 6 hrs PRN or Ketorolac (Toradol) or Tramadol (Tramal) IV b. Vomiting: Metoclopromide (Plasil) 1 amp IV q 8 hrs PRN To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

GASTROINTESTINAL BLEEDING To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology of Upper Gastrointestinal Bleeding (UGIB): Peptic ulcer disease (duodenal & gastric), gastritis (stress, alcohol, drugs), esophagitis, duodenitis, esophageal varices, gastric or duodenal varies, Mallory-Weiss tear, angiodysplasia or telangiectasia, gastric or esophageal carcinoma, hemobilia, aortoduodenal fistula, bleeding diathesis leukemia, aplastic anemia, etc.) B. Etiology of Lower Gastrointestinal Bleeding (LGIB): Hemorrhoids, colonic diverticulum, colonic polyp, colonic cancer, angiodysplasia, amoebic colitis, inflammatory bowel disease (ulcerative colitis or Crohn’s disease), ischemic bowel disease, Meckel’s diverticulum, radiation proctocolitis, typhoid ileitis, bleeding diathesis leukemia, aplostic anemia, etc.) Orders: Admit to: Diet: NPO, stop alcohol, avoid NSAIDS and steroids VS: Vital signs q 1 hour and orthostatic BP q 4 hours Watch out for hypotension, tachycardia Nursing: Monitor I & O; Insert foley catheter to monitor mine output; Refer if urine output is < 30 cc/hr, or CVP < 4 or > 12 cm H2O; Record stool character and approximate amount. IVF: NSS or D5LR, or plasma expanders Prepare whole blood or packed RBC and/or fresh frozen plasma Two IV lines if needed; Transfuse blood. Consider CVP if vital signs are unstable ' Diagnostics: Place NGT (French 14 or 16), then consider lavage with NSS q 4 hours CBC with platelet count, Blood typing CT, BT, PT, PTT, Na, K, RBS, BUN, Crea Note: May have increased BUN/Creatinine ratio in cases of UGIB SGPT,SGOT, Alkaline Phosphatase, Total, Direct and Indirect Bilirubin ECG,Chest X-ray, Upright Abdomen, Urinalysis Gastroscopy with possible injection therapy, heater probe, hemoclip (for non variceal bleeding), sclerotherapy, cyanoacrylate injection, endoloop ligation or rubber band ligation (for variceal bleeding) Sigmoidoscopy or Colonoscopy (for lower GI Bleed) Angiography (can detect 0.5 cc/min bleeding) Technitium 99M RBC Scanning (can detect 0.1 cc/min bleeding) Therapeutics: O2 at 2-3 1pm by nasal cannula 1. H2-blockers or proton-pump inhibitors IV 2. Antacids: Maalox Plus 30 ml 1 hour after meals and at bedtime Maximum dose: Maalox 30 ml q 2 hours 3. Tranexamic acid (Hemostan, Cyclokapron) 500 mg IV push q 8 hours 4. For liver and coagulation problems (abnormal Protime): Aquamephyton 1 amp IV OD-BID May also give fish frozen plasma (4 units) 5. Sucralfate 1 gram 1 tab QID 6. Save two units of Fresh Whole Blood properly typed and cross-matched 7. Emergency treatment for variceal bleeding: Esophageal or fundal variceal bleeding a. Vasopressin (Pitressin) b. Somatostatin (Stilamin) 250 mcg 1V bolus then 250 mcg/hr IV infusion c. Octreotide (Sandostatin) 50-100 mcg IV bolus then 50 mcg/hr IV infusion d. Endoscopic sclerotherapy or cyanoacrylate injection e. Rubber band ligation or endoloop ligation f. Blakemore-Sengstaken tube insertion 8. Other treatments: a. After transfusion of 4 units of blood give Calcium gluconate (1 amp to be diluted in 30-50 cc D5W

given slow IV (not less than 30 min) b. Surgery: i. Shunting procedures; - Portocaval shunt - Mesocaval shunt - Distal splenorenal shunt (Warren Shunt) ii. Devascularization Procedures: - Hassab’s procedure - Suguira operation (transaortic paraesophageal devascularization, esophageal transection splenectomy, esophagogastric devascularization, pyloroplasty, vagotomy) To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

ANTI-ULCER DRUGS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents a. Antacids Al Hydroxide+ Mg Hydroxide (Maalox, ox TC, Maalox-Plus) suspension, tab PO - 2-4 tsp suspension or 1-2 tabs QID 20 min-1 hour after meals &at bedtime Al Hydroxide + Mg Hydroxide+ Mg Carbonate (Novaluzid) susp PO – 1 sachet 1 how after meals 4 at bedtime) Hydrotalcite+ Dicycloverine+ Simethiconee (Kremil-S) tab, susp PO - 2-4 tabs or 2-4 tsps q 4 hours, 1 hour & 3 hours after meals & at bedtime b. H2-blockers Cimetidine (Ritemed Cimetidine =) Tagamet) 200 mg tab, 400 mg tab, 800 mg tab, 100 mg/5 ml susp, 200 mg/2 ml, 300 mg/2 ml amp PO - 400 mg tab BID or 800 mg tab HS OD IV- 200 mg q 6 hours Note: Caution with Warfarin, Phenytoin, or Theophylline combination Ranitidine HCl (Raxide =) 150mg, Zantac) 75 mg tab, 150 mg tab, 300 mg tab, 150 mg/10 ml syrup, 50mg/2ml amp PO - 75-150 mg BID IV - 50 mg q 8 hr Famotidine (H2 Bloc, Pepcidine) 10 mg tab, 20 mg tab, 40 kg tab, 20 mg/2 ml amp PO - 20 mg BID or 40 mg OD IV - 20 mg q 12 hr Nizatidine (Axid) 150 mg cap, 300 mg cap, 100 mg/4 ml amp PO - 150 mg BID, 300 mg OD IV - 100 mg q 8 hr c. Proton Pump Inhibitors (PPI) Esomeprazole (Nexium) 20 mg tab, 40 mg tab PO-20-40mg OD Omeprazole (Losec) 10 mg cap, 20 mg cap, 40 mg vial PO-20mg cap OD IV - 40 mg q 12-24 hr (Note: Give the full 40mg 1V, since Omeprazole is unstable when already in suspension) Lansoprazole (Lanz. Prevacid, Promp, Suprecid),15 mg cap, 30 mg cap PO - 1 cap OD Pantoprazole (Pantoloc, Ulcepraz) 20 mg, 40 mg tab PO - 1 tab OD Rabeprazo1e (Pariet) 10 mg tab PO - 1 tab OD d. Cytopretectives Misoprostol 200 mcg, Diclofenac (Arthrotec) tab PO - 1 tab BID-QID Note: Use outer layer of the tablet only since core tablet contains Diclofenac. Misoprostol may discolor the stool black and may came abdominal cramps and diarrhea Sucralfate (Iselpin) 500 mg, 1 gram tab(for peptic ulcer disease or NSAID gastritis) PO- 500 mg - 1 gram in 20 ml water QID 1 hour before meals & at bedtime Note: Constipation may be observed as side-effect. Ranitidine / Bismuth Citrate (Pylorid) 400 mg tab PO- 1 tab BID

Note: Bismuth citrate may discolor the stool black. To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

HEPATIC ENCEPHALOPATHY/ LIVER CIRRHOSIS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: Types of cirrhosis: Alcoholic, biliary, cardiac, cryptogenic, post-necrotic, post-viral, metabolic, and miscellaneous causes Orders: Admit to: Diet: NPO temporarily; Total Cal = 1800 cal/day; 250-500 mg sodium/day; Protein intake 0-20 gm/day in 6 divided feedings if with hepatic encephalopathy, otherwise increase protein intake; fluid restriction to 1-1.5 l/day (if hyponatremia, Na < 130) VS: Neuro vital signs q 2 hours; I & 0 q shift Nursing: Stool charting q shift; Weigh OD in am, Measure abdominal girth OD (at level of umbilicus); Insert Foley catheter IVF: D10W X 16 hours or' D50.3 NaC1 X 24 hours; Keep patient on the dry side Diagnostics: CBC, Blood C&S, PT, SGPT, SGOT, Alkaline Phosphatase Total Protein, Albumin, Globulin, A:G Ratio Serum Ammonia (to differentiate from alcohol intoxication) Note: Serum ammonia may be elevated in only 50% of hepatic encephalopathy cases. BUN, Crea, Na, K, Urine Na (dehydration vs. hepatorenal syndrome) FBS, Urinalysis, CXR, ECG Ultrasound of Liver, Hepatobiliary Tract and Pancreas Liver Biopsy (to rule out carcinoma if ultrasound shows a hepatic nodule) Ascitic Fluid / Abdominal Paracentesis (for very tense ascites): Tube 1 - Protein, albumin, glucose, LDH Tube 2 - Cell count & differential Tube 3 - C&S, Gram stain, AFB, Fungal Tube 4 - Cytology Therapeutics: 1. Laxative: Duphalac (Lactulose) 30-60 ml TID to make 4-5 bowel movements per day. Fleet Enema if still without bowel movement. 2. If with hepatic encephalopathy: Aminoleban (branched chain amino acids) 500 cc IV q 12 hr (2 bottles/day): or Aminoleban or Falkamin 1 sachet in 180 ml water BID-TID PO 3. If with pedal edema and/or ascites: Furosemide (Lasix) 40 mg OD-BID PO or Furosemide 20 mg IV OD – TID or Spironolactone (Aldactone) 25 mg BID-QID 4. For Portal Hypertension: Propranolol 10 mg TlD, Isosorbide Dinitrate (Isordil) 20 mg 1 tab BID 5. Watch out for complications: a. Bleeding due to decrease in clotting factors (abnormal protime): i. Give 4-6 units of Fresh Frozen Plasma+ 1-2 doses of Vit. K preparation ii. Vit.,K Preparation: Phytomenadione (Aquamephyton) 1 amp IV (10 mg/ml amp) OD-BID; or Menadione (VCP Vitamin K, Vitakay) 10 mg 1 tab TID-QID PO b. Gastrointestinal bleeding (due to gastric erosions): Prophylactic H2-blockers, Antacids or Cytoprotective agents c. Infections: Consider prophylactic antibiotics with Metronidazole, Amoxicillin, or Cephalosporins d. Renal failure: Cautious fluid management with CVP insertion and monitoring. Consider albumin infusion & Low dose Dopamine and Furosemide drip e. Pulmonary infections and ARDS - intubation and PEEP f. Hepatic encephalopathy vs. cerebral edema: Do CT scan to differentiate i. Hepatic encephalopathy: Tx: Lactulose+ Aminoleban ii. Cerebral edema: Tx: Mannitol and hyperventilate, Steroids g. Hypoglycemia: Hypertonic Glucose D50-50 IV h. Cardiac arrhythmias i. Multiorgan failure

6. Other treatment options: a Multivitamins: Neurobion tab TID, Essentiale Forte 1 tab BID or Moriamin Forte 1 tab OD b. Pain reliever: Hyoscine-N-butylbromide (Buscopan) 1 amp IV q 6- 8 hr c. Neomycin Sulfate 0.5-1 gm PO q 6 hr X 7 days 7. Discontinue hepatotoxic drugs (anti-tuberculosis drugs, anticonvulsants etc.), Avoid Diazepam or Dilantin for seizures. To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

ABDOMINAL PARACENTESIS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Orders: l. Prepare the following: #1 Abbocath gauge 18, #1 20 cc syringe, #1 Venoset, #1 sterile bottle, #1 Xylocaine 2% #1 10 cc syringe w/ needle, #6 4x4 OS, Dressing Tray, Betadine antiseptic solution, #3 sterile vials, #2 sterile gloves size 7. 2. Abdominal paracentesis done about 3 cm. below the umbilicus, midline. 3. Submit the following: Vial 1 = Gram stain, AFB smear Vial 2 = Q/Q (Quantitative, Qualitative) Vial 3 = Culture 4 Sensitivity Optional: Total protein, amylase, LDH, glucose, etc. 4. Blood extraction for total protein, sugar and LDH To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

VIRAL HEPATITIS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: A. Epidemiology: 1. Hepatitis A and E: Incubation Period = 2 weeks - 2 months; Transmission = fecal-oral route 2. Hepatitis B, C and D: Incubation Period = 4 weeks - 6 months; Transmission = blood, sexual 3. Hepatitis G: Transfusion and hemodialysis related Serologic test: PCR (Polymerase Chain Reaction for Hepatitis G) B. Diagnosis: A clear distinction between Hepatitis A-E cannot be made solely on clinical grounds. The most accurate way to distinguish one from the other is by specific serologic testing (See Table 3-1). Table3-1 Simplified Diagnostic Approach in Patients Presenting with Acute Hepatitis Diagnostic Interpretation

Acute Hepatitis B Chronic Hepatitis Acute Hepatitis A superimposed on hepatitis B Acute Hepatitis A & B Acute Hepatitis A Acute Hepatitis A & B (HBsAg below detection threshold) Acute Hepatitis B (HBsAg below detection threshold) Test for Acute Hepatitis C (anti-HCV)

Serologic Tests of Patient’s Serum HbsAg IgM IgM AntiHAV anti-HBc + + + + + -

+ -

+ + +

+ +

-

-

+

-

-

-

Source: Dienstag, J. 8t Isselbacher, K (2001). Acute viral hepatitis. In E. Braunwald, A. Fauci, D. Kaspar et al (Eds.), Harrisom 's Principles of Internal Medicine (p. 1732). New York: McGraw-Hill with permission. C. Differential diagnoses: Alcoholic hepatitis (SGOT, SGPT usually < 400 iu), acute cholecystitis, common bile duct stone, pancreatic cancer, and right ventricular failure with passive congestion of the liver. D. Consider hospitalization in the following patients: Advanced age, serious underlying medical disorder, ascites, peripheral edema, symptoms of hepatic encephalopathy, decrease in protime activity, decrease albumin, hypoglycemia, high serum bilirubin, immunocompromised state and gastrointestinal b1eeding. Orders: Admit to: Diet: Initially clear liquid diet (if nauseated low fat (if with diarrhea) then high calorie, high carbohydrate diet. Restrict protein only if with signs of hepatic encephalopathy. VS: Vital signs q 4 hours Nursing: Hepatitis precautions IVF: D5NM 1 L X 12 hours; D5NR 1 L X 12 hours Diagnostics: Hepatitis B: HBsAg*, Anti-HBc IgM*, Anti HBs, HBe Ag, Anti-Hbe, HBV-DNA Hepatitis A: Anti-HAV IgM* Hepatitis C: Anti HCV, HCV-RNA

CBC, PT, Blood C/S, Amylase, Lipase, Urinalysis SGPT, SGOT (400-4000 iu and SGPT > SGOT) Alkaline Phosphatase, Total Bil, B1, B2 Ultrasound of Liver, Hepatobiliary Tract and Pancreas (to rule out malignancy and other diseases) *Tests part of short Hepatitis profile (see Table 3-1 on page 68) Therapeutics: 1. Supportive treatment: a Restricted physical activity b. Avoid hepatotoxic drugs 2. Optimal treatment (not evidence-based) a. Essentiale 1 cap TID or Jetepar 1 cap TID or b. Hepatofalk 1 tab, TID or Silyinarine 1 cap TID c. Supportive treatment: Multivitamins OD & H2-blockers d. Symptomatic meds: Pain relievers e. Anti-pruritic drugs or for sleep: Diphenhydramine HCl (Benadryl) or Hydroxyzine (Iterax) 10-25 mg BID-TID 3. Specific therapy:, a Considor Interferon for chronic Hepatitis B and C b. Lamivudine (a neucleoside analogue) is for chronic Hepatitis B given at 100 mg I tab OD X 1 year Note: Chronic Hepatic B with the following parameters – positive HbsAg, positive HbeAg, and elevated SGPT – has a good response rate to Interferon and Lamivudine treatment. 4. Prophylaxis: Hepatitis vaccination series (See section on vaccination) To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

ACUTE CHOLECYSTITIS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: A. Natural History of Gallstones: Asymptomatic (silent) gallstones need not be treated. Frequent biliary colic and stones > 2 cms are more likely to have complications requiring cholecystectomy. B. Etiology: - 90% associated with obstruction of the cystic duct by stone - 70% have bacterial inflammation: E. coli, Proteus vulgaris, Enterobacter, anaerobes - 95% secondary to gallbladder stones: Cholesterol and calcium bilirubinate C. Signs and symptoms: A biliary colic which progressively worsens with low grade fever and positive Murphy's sign with or without jaundice D. Course: - 75% will have remission in 2-7 days with medical therapy - 25% will develop complications requiring prompt surgery! - Of the 75% who will undergo remission, surgery is still recommended due to the high incidence of recurrence E. Complications: Empyema & hydrops, gangrene & perforation, fistula formation & gallstone ileus Orders: Admit to: Diet: NPO; Rest the gallbladder VS: Vital signs q 1-4 hours Nursing: I & O; Insert nasogastric tube IVF: D5NM X 8 hours +/- 20 meq KCl / Liter Diagnostics: CBC, Protime, Na, K, Ca, Blood CdhS, Urinalysis SGPT,SGOT, AlkaUae Phaephatase, Amylase(for differential diagnoses) Abdominal Ultrasound of the Liver, Hepatobiliary Tract and Pancreas Chest X-ray, ECG Therapeutics: A. Medical Treatment: 1. NPO, NGT, Fluid and Electrolytes 2. Pain reliever. Demerol 25-50 mg IV q 6 bolus (Drug of choice to relax the sphincter of Oddi), Do not give morphine. 3. Antibiotics: a. Ampicillin-Sutbactam (Unasyn) IV or Co-amoxyclav (Augmentin) IV (for uncomplicated'cases) b. Piperacillin-Tazobactam IV (for diabetic and debilitated patients to cover for gram negative sepsis Metronidazole IV B. Surgical Treatment (Open cholecystectomy or Laparoscopic cholecystectomy l. An emergency in those patients with complications 2. In those w/o complications, early surgery is recommended for stable patients To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

BACTERIAL CHOLANGITIS & BILIARY SEPSIS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: A. Definition: Bacterial cholangitis and biliry sepsis occur as a complication of common bile duct obstruction usually due to stones, ascaris, carcinoma or extrabiliary comression. B. Signs and symptoms”. In acute bacterial (suppurative) cholangitis, patients develop spiking fever, biliary colic pain and jaundice (Charcot's triad). Addition of hypotension and mental confusion constitutes Reynold's Pentad. Orders Admit to: Diet: NPO VS: Vital signs q 1 hour Nursing: I & O q shift; insert NGT IVF: D5NR 1 L X 6-8 hours; fast drip Plain NSS for sepsis or hypotension Diagnostics: CBC, Na, K, Blood C & S, PT, PTT, Amylase, Lipase, Alkaline Phosphatase, Total Bilirubin, B1, B2, Ultrasound of the Liver, hepatobiliary tract and pancreas (check common bile duct size to see if it is dilated, in which case there is obstruction), ERCP or MRCP (Magnetic Resonance Cholangio- Pancreatography), Chest X-ray, ECG Therapeutics: A. Surgical Treatment 1. Stat surgical referral for acute suppurative cholangitis presenting with Reynold’spentad requiring prompt surgical drainage. 2. Surgical operation: T- tube cheledochostomy, cholecystostomy, choledocholithotonyor biliary bypass surgery 3. Combination antibiotic treatment for yam negative sepsis B. Endoscopic Procedures 1. ERCP (Endoscopic Retrograde Cholangio Pancreatography)-duodenoscopy using side-viewing endoscope with instillation of contrast material into the biliary and pancreatic ductal system under fluoroscopic guidance. 2. EST (Endoscopic Sphincterotomy) or Endoscopic Papillotomy-ERCP with ablation of Sphincter of Oddi using sphinctcrotomeyor papillotome connected to a cautery machine. 3. Endoscopic Nasobiliary Drainage – ERCP with insertion of 6.SF nasobiliary catheter into the biliary system for decompression/drainage. 4. Endoscopic Biliary Stenting-ERCP with insertion of stents(5-15 cm 7-14 French in size) into the biliary system for decompression/drainage. C. PTBD (Percutaneous Tranhepatic Biliary Drainage) D. Medical Treatment 1, Start Antibiotics: a. Imipenem IV Ampicillin-Sulbactam (Unasyn) IV (single drug treatment) or b. Ampicillin IV, and Gentamicin IV and Metronidazole IV or c. Ceftazidime (Fortum) IV and Metronidazole IV 2. Pain reliever: Meperidine (Demerol) 25-50 mg IV q 6 hr. Avoid Morphine 3. Optional: H2-blockers IV To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

ACUTE PANCREATITIS To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Alcohol, gallstones metabolic factor, drugs, viral infecting, post-operative post-ERCP, blunt trauma B. Differential Diagnoses: Perforated viscus especially peptic ulcer, acute cholecystitis myocardial infarction, dissecting aortic aneurysm, pneumonia, diabetic ketoacidosis acute intestinal obstruction, mesenteric vascular occlusion C. Ranson's Prognastic Criteria (See Table 3-2) Table 3-2. Ranson’s Prognostic Criteria. 1. At admission or diagnosis a. Age > 55 years b. Leucocytosis > 16,000 per cubic millimeter c. Hyperglycemia >l l mmol/L (> 200 mg/dL) d. Serum LDH > 400 1U/L e. Serum AST > 250 1U/L 2. During initial 48 hours a. Fall in hematocrit by > 10% percent b Fluid deficit > 4000 ml c. Hypocolcemia < 1.9 mmol/L (< 8.0 mg/dL) d, Hypoxemia (PO2 < 60 mmHg) e. BUN rise > 1.8 mmol/L (> 5 mg/dL) after IV fluids f. Hypoalbuminemia < 32 g/L (< 3.2 g/dL) Note: >= 3 factors at time of admission (1) or during initial 48 hours (2). indicates an increased mortality rate. These patients need close monitoring in an ICU setting. Source:Greenberger, N. & Toskes (2001). Acute and Chronic Pancreatitis. In E Braunwald A. Fauci, D. Kaspar et al (Eds.), Harrison's Principles of Internal Medicine (p. 1795). New York: McGraw-Hill with permission. D. Local complications: Phlegmon Abscess (treatment is surgical drainage antibiotics Pseudocyst (treatment is surgery if = cms) Ascites and contiguous organ involvement E. Systemic complications: Acute respiratory distress syndrome pleural effusion cardiovascular, sepsis, diabetes mellitus, disseminated intravascular coagulation acute renal failure metabolic and central nervous System complications. Orders: Diet: NPO strictly, resume diet slowly after the 3rd-6th day if without pain VS: Vital signs q 2 hours including progress of abdominal pain Nursing: I & O; CBG monitoring; Place NGT if with ileus or vomiting IVF: D5NR 1 liter X 8 hours; D5NM 1 litre X 8 hours Diagnostics: CBC, platelet count, Na, K, Ca, Mg, BUN, CREA, TPAG Serum Amylase (1st to 4th day) - 3-fold Increase for diagnosis Lipase (1st-10th day) SGPT, SGOT, Alkaline Phosphatase, RBS, PT (if a heavy alcoholic)

Chest X-ray, ABG, ECG (Myocardial depressant fetor) Triglyceride, LDH, Total bilirubin, B1, B2. Plain Abdomen X-ray Supine & Upright (sentinel loop, colon cut-off sign and calcifications With chronic pancreatitis Ultrasound of Liver, Hepatobiliary Tract and Pancreas, then CT scan of the upper Abdomen, then ERCP (especially in gallstone-induced pancreatitis) Therapeutics: A. Medical: NPO, analgesics and IV fluids l. Insert nasogastric tube if with ileus 2. H2-blockers: Ranitidine (Zantac) 50 mg IV q 8 hours or proton pump inhibitor IV 3. Pain Relief: Meperidine HCl (Demerol) 25-50 mg IV q 6-8 hr, defer for BP < 100 4. Antibiotics for established infection or severe pancreatitis a. Cefoxitine or Ceftazidime IV +/ - Metronidazole IV or b. Ciprofloxacin IV or Imipenem IV 5. Low Calcium levels: Calcium Gluconate slow IV or incorporated in IVF 6. Total Parenteral Nutrition for malnutrition or prolonged NPO B. Surgical Open: 1. If with severe hemorrhage, necrotizing pancreatitis, pancreatic abscess or large pseudocyst(5-6 cms), do surgical drainage (Necrosectomy). This may have to be done repeatedly. 2. If associated with gallstone ileus, insert NOT to decompress bowel To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

ACUTE DIARRHEA WITH MILD DEHYDRATION To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet: BRAT (Banana, Rice, Apple, Tea) diet; no milk products VS: Vital signs q 4 hours & temp TID Nursing: I & O; Bowel Movement q shift & record (character, frequency and amount IVF: D5NSS 1 liter X 8 hours; D5NR 1 liter X 8 hours Diagnostics: CBC, Na, K, BUN, Crea, Urinalysis Fecalysis (check for leucocytes and parasites) Stool C & S using TCBS agar (for cholera suspect) Proctosigmoidoscopy Therapeutics: l. IV Fluids and ORS (Hydrite) 1-2 tabs in 150-200 ml water as desired 2. Use antibiotics for the following conditions: Febrile or gross blood in stool, toxic looking patient, elderly with concomitant illnesses (diabetic, on steroids etc.) or WBC > 16,000. a. If without vomiting: Give Ciprofloxacin 500 mg tab BID X 3-5 days or Norfloxacin 400 mg tab BID X 3-5 days or Co-trimoxazole forte tab BID X 3-5 days b. If with vomiting: Give IV antibiotics c. If Amebiasis suspect: Secnidazole (Flagentyl) 500 mg 2 tabs initially then 2 tabs within 4 hours. 3. Specific treatment a. If Shigella: Co-trimoxazole forte tab BID X 3 days b. If Salmonella or Campylobacter jejuni or ETEC Ciprofloxacin 500 mg tab BID X 5 days c. If Clostridium difficile. Metronidazole 500 mg tab TID X 10-14 days d. If Yersinia enterolitica Ciprofloxacin 500 mg tab BID X 3 doses e. If Giardia lamblia: Metronidazole 250 mg tab TID X 5 days 4. Symptomatic medications: a. Pain: Hyoscine-N-butylbromide(Buscopan) 1 tab TID or 1 amp IV q 6-8 hours Mebeverine HC1 (Duspatalin) 100 mg 1 tab TID-QID b. Vomiting. Metoclopromide (Plasil) l amp IV q 8 hours PRN c. Diarrhea: i. Racecadotril (Hidrasec) 100 mg cap: initially 1 cap OD then TID, maximum 4 caps ii. Loperamide (Lormide, Imodium) 2 caps initially then 1 capsule after each bowel movement, not to exceed 6 tabs per day. May give for 48 hours. If diarrhea does not improve then discontinue. Note: Avoid Loperamide in Amebiasis since it may prolong the course of illness. To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

CHOLERA / SEVERE DEHYDRATION To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet: BRAT (Banana rice, apple, tea) diet VS: Vital signs q 1 hour, postural BP, temp q 4 hours Nursing: Insert foley catheter I & O q hour Monitor bowel movement & record (character, frequency and amount) Cholera precautions IVF: DER 1 liter, Sent drip 300 cc then consume the remaining in 4 hours Replace volume per volume of Bowel movement. Diagnostics: CBC, Na, K, Cl, BUN, Crea ABG q 8-24 hours (if severely acidotic) Fecalysis, Stool C & S using TCBS (Thioglycolate Citrate Bile Salt) agar Urinalysis Therapeutics: 1. Adequate hydration: Insert CVP and monitor a. Hydrate patient using CVP and urine output as guide b. ORS (Hydrite) 2 tabs in 200 ml water as desired if without vomiting 2. Start antibiotics: a. Doxycycline 100 mg tab, give 3 tabs as singledose PO Note: Avoid in children < 8 years old or b. Co-trimoxazole (Bactrim) forte tab PO, 1 tab BID x 3 days or c. Ciprofloxacin (Ciprobay) 500 mg tab, give 2 tabs as single dose PO or d. Cipmfloxacin 200-400mg IV q 12 hours 3. Correct Electrolytes a Low Potassium: Kalium durule 1 durule TID-QID x 4 days or KCI incorporation with IV fluids b. Severe Acidosis: Sodium Bicarbonate IV push or drip 4. Racecadotril (Hidrasec) 100 mg 1 cap TID 5. Other treatment: Dopamine and/or Furosemide (Lasix) IV or drip to prevent renal failure To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

ACUTE INTESTINAL OBSTRUCTION To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: 1. Small intestine obstruction: Post-op adhesions and external hernias in 75%, intussusception 2. Large intestine obstruction: Carcinoma, sigmoid diverticulitis and volvulus in 90% 3. Adynamic Ileus; Any peritoneal insult, hematomas, post-operative ileus, ureteral calculus, hypokalemia, fractures ribs, pneumonia, sepsis, intestinal ischemia, gallstones, etc. B. Signs and Symptoms: 1. Small intestine mechanical obstruction: Colicky mid-abdominal pain, early vomiting 2. Large intestine mechanical obstruction: Colicky pain but lesser intensity, late vomiting, (+) history of recent alteration in bowel habits, usually (+) blood in stools 3. Adynamic ileus: No colicky pain, only discomfort from abdominal distention. Note: Complete obstruction - (+) obstipation Partial obstruction - diarrhea occasionally observed C. Complications: Strangulation and infection Orders Admit to: Diet: NPO VS: Vital signs q 1 hour, abdominal findings q 2 hours Nursing: I & O q shift, insert NGT IVF: D5NR 1 L X 8 hours + 20 meq KCl (adjusted according to Potassium levels) Diagnostics: CBC, Serum Na, K, Cl, BUN, Creatinine Abdominal X-ray supine & upright or lateral decubitus Chest X-ray CT Scan of the Abdomen Therapeutics: A. Complete obstruction of the small intestine or large intestine: 1. Stat surgical referral 2. NPO, Insert nasogastric tube B. Partial obstruction of small intestines or large intestines; adynamic ileus: 1. Medical management and observation 2. NPO, NGT and connect to bedside bottle or Gomco pump 3. Broad spectrum antibiotics if strangulation is suspected 4. Consider enema / high rectal tube 5. Pain: Ketorolac (Toradol) 15 mg IV q 4 hours. Avoid narcotics. 6. Other treatment: Metoclopromide (Plasil) IV and H2-blockers IV To Gastroenterology Page To Main Table of Contents To Detailed Table of Contents

CLINICALLY USEFUL ANTIBIOTICS To Infectious Page To Main Table of Contents To Detailed Table of Contents Table 4 -1 Clinically Useful Antibiotics. Drug

G (+) activity

G (-) activity

Anaerobic activity

+++

-

++

-

+ +

Specifically for Staph. aureus

-

+

Reserve drug and most active for S. aureus and Enterococcus. Give very slowly as IV infusion

++

++

-

++ ½

++ ½

++ ½

++

++

++ ½

Broad spectrum penicillin Good aerobic coverage Good anaerobic coverage

Natural Penicillins Penicillin

Penicillinase-Resistant Penicillin Oxacillin PO/IV ++ Flucloxacillin ++ Glycopeptide Vancomycin +++

Aminopenicillins: Amoxicillin PO Ampicillin IV Amox-Clavulanic Acid Ampi-Sulbactam

Penicillin with Anti-Psuedomonal Acitivity: Piperacillin/Tazobactam ++ ++ ½ +

Monobactams: Aztreonam

Comments

Narrow spectrum penicillins

Use as Reserve Drug for Pseudomonas

-

+++

-

Use as an alternate to the aminoglycosides in renal failure

Carabapenems: Imipenem-Cilastin Meropenem

+++

+++

+++

Use as Reserve Drug Gm (+) activity as good as Penicillin For Gm (-): May add Amikacin for synergism Anaerobic activity as good as Metronidazole

Ertapenem

++

+++

+

Very little activity against Pseudomonas

Macrolides: Erythromycin Azithromycin Clarithromycin Dirithromycin Tetracycline: Doxycycline Tetracycline

Aminoglycosides: Amikacin Gentamicin Tobramycin Netilmicin

++ ½

+½

+

++ ½

++

+½

+

++

+

For patients > 8 years old Tetracycline cheaper but given QID

+++

+++

-

With anti-Pseudomonas activity Amikacin with anti-TB action

First Generation Cephalosporins: Cephalexin PO ++ ½ + Cefazolin IV Second Generation Cephalosporins: Cefuroxime IV ++ ½ ++ Cefuroxime axetil PO ++ ½ ++ Cefoxitin ++ ++

+ + ++ ½

Third Generation Cephalosporins: Ceftriaxone ++ +++

++

May cause GI upset

-

Ceftazidime

Cefotaxime

Intravenous drug Oral drug Cephalosporin with best anaerobic coverage For multidrug resistant typhoid Ceftazidime is best for Pseudomonas Cefotaxime is best for meningitis

Fourth Generation Cephalosporin: Cefepime Cefpirome

Quinolones: Ciprofloxacin Norfloxacin Ofloxacin Fleroxacin

Levofloxacin Moxifloxacin Others:

+++

+++

+++

These should be reserved for the very resistant strains

+

+++

-

Used for multidrug resistant typhoid fever Ciprofloxacin is best for Pseudomonas Norfloxacin is good for severe UTI

++

+++

+

Moxifloxacin with better anaerobic activity

Co-trimoxazole Co-Trimazine Chloramphenicol

Clindamycin

Metronidazole

Rifampicin

++ ½

++ ½

-

++ ½

++ ½

++ ½

++

-

+++

-

-

++ ½

++

++

+

Drug of choice for uncomplicated Typhoid "Above diaphragm" anaerobes Good Gm (+) activity "Below diaphragm" anaerobes Used for pulmonary tuberculosis

- No activity against these microorganisms + Fair activity against these microorganisms ++ Good activity against these microorganisms +++ Excellent activity againts these microorganisms Additional Notes: 1. Drugs with Anti-Pseudomonas properties: Aminoglycosides (Tobramycin, Netilmicin, Amikacin, Gentamicin), Ceftazidime, Cefoperazone, Quinolones (Ciprofloxacin), Ticarcillin and Piperacillin, Monobactams (Aztreonam), Carbapenems (Meropenem), Fourth Generation Cephalosporins (Cefepime and Cefpirome) 2. Drugs with good anaerobic properties: Clindamycin, Metronidazole, Chloramphenicol, Cefoxitin, Meropenem, Ampicillin-Sulbactam, Amoxycillin- Clavulanic acid and high-dose Penicillin. 3. Drugs with good central nervous system penetration in meningitis: Ceftriaxone, Ceftazidime, Cefiuoxime, Cefotaxime, Ampicillin, Meropenem, Ampicillin-Sulbactam, Ciprofloxacin, Penicillin G and Vancomycin. Chloramphenicol and Co-trimoxazole have high diffusion to the cerebrospinal fluid even without meningitis. 4. Drugs safe for patients with liver disease: Aminoglycosides, Ampicillin, Amoxicillin, Cephalexin, Cefoxitin, Cefiaoxime, Ofloxacin, Penicillin G and Carbepenems. 5. Cephalosporins: a. Fourth Generation Cephalosporins have the same indications as Third Generation Cephalosporins and should remain as "reserved" drugs. b. The only two Third Generation Cephalosporins active against Pseudomonas are Ceftazidime and Cefoperarone. Cefoperazone may cause bleeding in predisposed patients. c. Cephalosporins that cross the blood-brain barrier. Ceftriaxone, Ceftazidime, Cefotaxime, Ceftizoxime. d. Cephalosporin with best anaerobioc coverage: Cefoxitin. Other Cephalosporins also have some anerobic properties. e. Cefuroxime axetil is given with meals. f. Cefazolin is the drug of choice only for surgical prophylaxis of abdominal operations and implant surgery. 6. Aminoglycosides a. Aminaglycosides are given q 8-12 hours in 30 minutes by slow IV or IM to avoid, possible neurornuscular paralysis. They must have loading doses, and should be given for < 7 days to

avoid nephrotoxicity. Creatinine is measured every 3 days. b. Amikacin: Expensive but it is the most potent and least nephrotoxic. Loading dose = 7.5 mg/kg, Maintenance dose = 15 mg/kg/day in 2 divided doses IM, IV c. Gentamicin, Tobramycin, Netilmycin, Loading dose = 2 mg/kg, Maintenance dose = 1.5 mg/kg/dosc q S hours IM, IV d. Gentamicin is the cheapest aminoglycoside. Spectinomycin is used for gonorrhea Streptomycin is used for PTB. 7. Macrolides a. Erythromycin is given with meals. If with GI upset, lower the dose. b. Azithromycin is given 1 hour before meals. 8. Rifampicin Aside &am anti-TB pmperties, Rifampicin naybe used synergistically with Oxacillin for S. aureus. Resistance may develop when Rifampicin is used alone. To Infectious Page To Main Table of Contents To Detailed Table of Contents

ANTIBIOTIC DRUG LIST To Infectious Page To Main Table of Contents To Detailed Table of Contents I A. Natural Penicillins: PO: Phenoxymethylpenicillin (Sumapen, Megapen, Pentacillin) 500 mg cap PO- 500 mg cap BID-TID PO IM: Pen G benzathine (Penadur 6-3-3) 600,000u; Pen G K 300,000 units; Pen G procaine 300,000 units/vial Note: Penicillin G is not given PO because of very poor oral absorption. IM: Benzathine Benzyl Penicillin (Penadur L-A) 1.2 or 2.4 million units/vial IV: Benzyl Penicillin Na (YSS Benzylpenicillin Na) 500,000 units, 1 mil& 5 mil units/vial B. Penicillinase-Resistant Penicillins (PRP): Cloxacillin Na (Orbenin, Prostaphlin-A) 250 mg cap, 500 mg cap PO- 500 mg cap q 6 hours PO Oxacillin Na (Prostaphlin) 250 mg/vial, 500 mg/vial, 1 gm/vial IV- 500 mg- 2 g q 6 hours IV (25-50 mg/kg/day, maximum = 8 gm/day), give by Soluset because it is too irritating Flucloxacillin (Stafloxin) 250 mg cap, 500 mg, 250 mg vial, 500 mg vial, 1 gm vial PO, 1M, IV- 250-500 mg q 6 hours PO, IM, IV C. Glycopeptide: Vancomycin HCl (Vancocin) 500 mg vial IV- 500 mg q 6 hourly IV or 1 gm q 12 hourly IV Note: To be given as slow IV infusion in 30 minutes to avoid adverse reactions. D. Oxazolidinones: New Class for aerobic gram-positive bacteria Linezolid (Zyvoz): PO or IV - 200 mg - 600 mg q 12 hr or q 24 hr E. Aminopenicillins: Amoxycillin PO/ Ampicillin IV Amoxicillin (Amoxil, Himox, Moxillin, Sumoxil, Wyamox) 250 mg, 500 mg cap PO- 500 mg cap TID PO Ampicllin (Amopen, Ampicin, Pensyn) 250 mg cap, 500 mg cap, 250 mg vial, 500 mg vial PO 250-500 mg cap TID-QID (not recommended orally bee. of poor absorption) IV, IM- 500 mg q 6 hr Bacampicillin HCl (Penglobe, Bacacil) 400 mg tab, 800 mg tab PO- 400 mg- 800 mg BID PO F. Beta-lactamase inhibitors: Amoxycillin- Clavulanic Acid; Co-Amoxiclav (Augmentin, Co-Amox) 375 mg tab, 625 mg tab, 1 gm tab, 300 mg vial, 600 mg vial, 12 gm vial PO- 375 mg TID or 625 mg – 1 gm BID IV- 600-1200 mg q 8 hours Ampicillin-Sulbactam: Sultamicillin (Unasyn) 375 mg tab, 750 mg tab, 375 mg vial, 750 mg vial PO- 375 mg 750 mg BID PO IM, IV- 750 mg – 1.5 gm q 8 hours IV G. Penicillins with Anti-Pseadomonas Activity: Piperacillin-Tazoobactam (Tazocin) 2.25 gm vial, 4.5 gm vial IV- 2.25 – 4.5 grams q 6-8 hours IV Ticarcillin Clavulanic Acid (Timentin): IV – 3.1 gm q 6 hours IV H. Monobactams: Aztreonam (Azactam) 500 mg vial, 1gm vial IV- 0.5-1 gram q 8-12 hours IV I. Carbapenem: Meropenem (Meronem) 500 mg vial, 1 gm vial IV- 500 mg - 1 gm q 8 hours IV

Imipenem-Cilastatin (Tienam) 500 mg vial IV- 250-500 mg q 6-8 hears slow IV push, maximum: 1 gm q 8 hours Note: To avoid seizures, give very slowly, preferably IV infusion. Ertapenem (Invanz =)) 1 gm vial IV- 1-2 gm IV OD infused over 30 min period IL Macrolides: Erythromycin (Erycin, Erythrocin, Ery-Max) 250 mg tab, 500 mg tab, 500 mg vial PO-250-500 mg TID-QID PO IV- 500 mg - 1 gm q 6 hr IV to be given very slowly by infusion Azithromycin (Zithromax) 250 mg cap, 500 mg film coated tab, 500 mg vial PO- 2 caps OD X 3 days IV- 500 mg IV OD very slow infusion to run for 45-60 minutes Clarithromycin (Klaricid) 250 mg tab, 500 mg tab, 500 mg OD . PO- 1-2 tabs BID Dirithromycin (Dynabac) 250 mg tabPO-2 tabs OD x 5 Roxithromycin (Macrol, Macrol OD, Rulid) 150 mg tab, 300 mg tab PO- 150 mg tab BID or 300 mg tab OD III Tetracyclines: #1 Doxycycline HCI (Vibramycin, Doxin) 100 mg cap PO- 2 cape initially Den 1 cap OD-BID maintenance Tetracycline (Ritemed Tetracycline) 250 mg cap PO- I cap QID Minocycline (Minocin) 50 mg cap, 100 mg cap PO- 200 mg initially then 100 mg cap BID Oxytetracycline (Terramycin) 250 mg cap, 500 mg cap PO- 1 cap QID IV. Aminoglycosides: #l Amikacin (Amikin, Amikacide) 100 mg vial, 250 mg vial, 500 mg vial IM, IV- Loading dose 7.5 mug, maintenance dose = 7.5 mg/kg q 12 hr or 5 mg/kg q 8 hr, e.g. 350 mg IV q 12 hours Gentamicin (Garamycin) 20 mg/ml vial, 80 mg/2 ml vial IM, IV- Loading dose = 2 mg/kg, maintenance dose 1.5 mg/kg/dose, e.g. 60-80 mg IV q 8 hours Tobramycin (Nebcin) 80 mg/2 ml vial, 1.2 gm powder IM, IV- Loading dose = 2 mg/kg, maintenance dose = 1.5 mg/kg/dose, e.g- 80 mg IV q hours Netilmycin (Nettomycin) 50 mg/2 ml vial, 100 mg/2 ml vial, 150 mg/1.5 ml amp IV- Loading dose 2 mg/kg, maintenance 1.5 mg/kg/dose, e.g. 150 mg IV q 12 hours or 300 mg IV OD V. Cephalosporins: First Generation Cephalosporins: Cephalexin PO end Cefazolin IV #1 Cephalexin (Ceporex, Forexin, Keflex) 250 mg cap, 500 mg cap, 1 gm caplet PO- 500 mg q 6 hours PO #1 Cefaxolin (Stancef, Faxilen) 500 mg vial, 1 gm vial IV-500 mg-1 gm q 8 hours IV Cefalotin (Keflin) 1gm vial IV- 500 mg-1 gm q 4-6 hours IV Second Generation Cephalosporins: #1 Cefuroxime axetil (Zinnat) 250 mg tab, 500 mg tab PO- UTI 250 mg BID; Respiratory infection 250-500 mg BID #1 Cefnroxime (Zinacef) 250 mg, 750 mg, 1.5 gm vial; EC Mono vial 750 mg & 1.5 gm IM, IV- 750 mg q 8 hours IV Cefoxitin Na (Mefoxin) 1pn vial IM, IV- 500 mg-2 gm q 6-8 hours IV Note: With very good activity against anaerobes Cefaclor (Ceclor) 375 mg CD ER tab, 750 mg CD ER tab; (Ritemed) 250 mg, 500 mg tab PO- 375-750 mg BID; 500 mg TID Cefprozil (Procef) 250 mg tab, 500 mg tab PO- 250 rng q 12 hr or 500 mg q 24 hr Cefotiam (Ceradolan) 200 mg tab, 500 mg vial, 1 gm vial

PO 1 tab TID IM, IV- 0.5-2 gm/day la 2-4 divided doses IV, IM Cefamandole (Mandol) 1 gm vial IV- 500 mg - 1 gm q 4-8 hourly IV Third Generation Cephalosporins: Ceftibuten (Cedax) 200 mg cap, 400 mg cap PO-200 mg BID Cefixime (Tergecef, Zefral) 100 mg cap, 200 mg cap PO- 100-200 mg BID PO #1 Ceftriaxone (Rocephin) IV – 250 mg vial, 500 mg vial, 1 gm vial+ 5 ml diluent IM, IV- 1-2 gm q 24 hr 1V #1 Ceftazidime (Fortum) 250 mg vial, 500 mg vial, 1 gm vial, 2 gm vial IM, 1V- 1-2 gm q 8 hours 1V #2 Cefotaxime (Claforan, Clavocef) 250 mg vial, 500 mg vial, 1gm vial IM, IV- 1-2 gm q 6-8 hr IV Cefoperazone (Cefobis) 500 mg vial, 1 gm vial IM, IV- 1-2 gm q 12 hours IV Ceftizoxime (Tergecin) 500 mg vial, 1 gm vial IM, 1V- 500 mg - 2 gm/day in 2-4 divided doses or 500 mg q 8 hours IV Fourth Generation Cephalosporins: Cefepime (Cepimax) 500 mg vial, 1 gm vial, 2 gm vial IM, IV- 1-2 gm q 12 hours IV Cefpirome (Cefrom) 1 gm vial 2 gm vial IV- 1-2 gm q 12 hours IV VL Quinolones: #1 Ciprofloxacin (Ciprobay) 250 mg tab, 500 mg tab; IV infusion: 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml PO- 250-ZSO mg tab BID IV- 100-400 mg IV q 12 hr C. Norfloxacin (Lexinor) 200 mg tab, 400 mg tab PO- 200-400 ag tab BID Fleroxacin (Requinol) 200 mg tab, 400 mg tab, 400 rng vial PO- 400 mg tab OD or IV infusion OD IV-400 mg q 24 hours IV Ofloxacin (Inoflox, Qinolon) 100 mg tab, 200 mg tab, 2@i mj/100 ml vial: PO- 100-200 mg BID-TID IV- 100-400 mg slow IV q 12 hr Pefloxacin (Peflacine) 400 mg tab, 400 mg/5 m1 vial PO- 1 tab BID IV- 400 mg vial diluted in 250 ml 5% glucose slow IV BID VII. New Fluoroquinolones: Levofloxacin (Floxel, Levox) 250 mg tab, 500 mg tab PO- 250 mg - 500 rng tab OD Gatifloxacin (Tequin) 400 mg tab, 10 mg/ml in 40 ml vial PO, IV infusion- 400 mg/day Moxifloxacin (Avelox) 40 mg tab PO - 1 tab OD VIII Other: Trimethoprim-Sulfa /Cotrimoxazole (Triglobe, Bactrim, Bacidal, Lidaprim, Microbid, Septrin) 400/80 mg-800/160 mg forte tab PO - 1 forte tab BID PO Chloramphenicol (Chloromycetin, Kemicetine) 250 mg cap, 500 mg cap, 1 gm vial Dose: 60 mg/kg/ day for Typhoid Fever PO- 500 mg QlD PO IV- 50-100 mg/kg/day in 4 divided doses or 500 mg q 6 IV or 1 gm q 8 hours IV Metronidazole (Anaerobia, Flagyl) 250 mg tab, 500 mg tab, 500 mg/100 ml vial PO-500-750 mg q 8 hours PO IV- 7.5 mg/kg/day QID or 500 mg q 8 hours IV Clindamycin (Dalacin C) 150 mg cap, 300 mg cap,40 vg amp PO- 150-450 mg cap q 6 hours IV- 10-25 mg/kg/day in 3-4 divided doses or 300-600 mg q 6-8 hours IV

To Infectious Page To Main Table of Contents To Detailed Table of Contents

SYSTEMIC VIRAL INFECTION To Infectious Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet: Regular VS: Vital signs q 4 hours Nursing: I & O q shift IVF: D5NM X 8 hours Diagnostics: CBC with platelet count, Tourniquet Test Throat Swab for gram stain, culture and sensitivity Urinalysis Therapeutics: 1. Supportive: Bed rest, increase oral fluid intake 2. Optional: If influenza is highly suspected a. Amantadine HCl (Symmetrel for Flu) 100 mg 1 tab BID for Influenza A only, or b. Oseltamivir (Tamiflu) 75 mg I cap BID x 5 days for Influenza A & C To Infectious Page To Main Table of Contents To Detailed Table of Contents

ACUTE TONSILLOPHARYNITIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Group A beta-hemolytic Streptococcus B. Complications: Rheumatic heart disease, rheumatic fever Orders: Admit to: Diet: Regular Nursing: IVF: D5NM X 8 hours Diagnostics: CBC, Throat swab gram stain and culture and sensitivity (if with exudate), ASO titer if complications are expected Therapeutics: l. Out-patient: Penicillin (Pentacillin) 500 mg tab PO TID-QID X 10 days or Amoxicillin 500 mg tab PO TID X 10 days or Azithromycin (Zithromax) 500 mg tab PO OD X 3 days only 2. In-patient Penicillin IV or Clindamycin (Dalacin) IV or Co-amoxiclav (Augmentin) IV or PO To Infectious Page To Main Table of Contents To Detailed Table of Contents

DENGUE HEMGRRHAGIC FEVER To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Dengue virus B. Transnission: Through bite of female Aedes aegypti mosquito C. Symptoms: 2-7 days of fever D. Complications:. Disseminated intravascular coagulation, pleural elusion, hemorrhage, epistaxis, melena, gum bleeding myocarditis, encephalitis hypotension, shock, acidosis, death E. Grading: Grade I: Fever (+) torniquet test, decease platelet, increase hemaocrit Grade II: Grade I symptoms+ spontaneous bleeding hemorrhage Grade III: Grade II symptoms+ thready pulse, decrease pulse pressure =20 mmHg, or hypotension Grade IV: Grade III symptoms+ profound shock, no blood pressure detected, no pulse Orders: Admit to: Diet: Avoid dark colored foods (for monitoring of melena) VS: Vital sings q 1- 4 hours and watch out for may signs of bleeding,temperature q 4 hr and in between if febrile or with chills Nursing: I & O q shift IVF: D5NM X 8 hours; D5NSS or D5LR for shock Diagnostics: CBC with platelet count PT, PTT Tourniquet test Dengue Serology if illness longer than 4 days Urinalysis, Chest X-ray (check for pneumonia, pleural effusion) Monitor: Platelet count +/- Hematocrit levels q 12-24 hours Therapeutics: A. Medical fragment 1. Supportive: Hydration 2. Optional medications: H2-blockers if with abdominal pain or gastrointestinal bleeding 3. Watch out for complications: a If there is a frank uncontrollable bleeding, fresh whole blood is indicated b. If PT, PTT is prolonged and with tbrombocytopenia, fresh frozen plasma transfusion is indicated. c. If there is disseminated intravascular coagulation platelet transfusion is indicated. Note: In the absence of bleeding, there is no need to administer platelet transfusion even if platelet count is low. B. Prevention l. Environmental: Get rid of mosquito breeding places 2. Vaccine: May be available in the near future To Infectious Page To Main Table of Contents To Detailed Table of Contents

TYPHOID & PARATYPHOID FEVER To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Salmonella typhi or Salmonella paratyphi B. Transmission: Ingestion of contaminated food or water; rarely from person to person transmission through fecal-oral route. C. Symptoms: High fever > 5 days, headache variable abdominal pain; severe cases may develop shock, delirium and stupor. D. Complications: Intestinal perforation, gastrointestinal haemorrhage end peritonitis may occur in the 3rd to 4th week of illness; rarely pancreatitis, hepatic and splenic abscesses, disseminated intravascular coagulation, myocarditis, meningitis. E. Typhi Dot Interpretation: IgM IgG l. (+) (-) - + Acute infection 2. (+) (+) - + Recent infection 3. (-) (+) - + Equivocal: Past infection or acute infection Orders: Diet: Regular VS: Vital signs q 4 hours including temp. Nursing: 1 & O q shift IVF: D5NM X 8 hours Diagnostics: CBC (normal WBC despite fever), platelet count , Tourniquet Test Typhi dot test (if illness is 4 days or longer) Malarial smear (Differential diagnosis) First Week of illness: Blood C/S Second Week of Illness: Urine G/S, C/S Third Week of illness: Stool CS Chest X-ray, Urinalysis Therapeutics: A. For uncomplicated cases, use Conventional Therapy: 1. Chlorampenical 3-4 gm per day PO m 4 divided doses X l4 days (50-100 mg/kg BW or 2. Co-Trimoxazole forte or double-strength tab BID PO X 14 days or 3. Amoxycillin 4-6 gm per day PO to 3 divided doses X 14 days B. For cases with complications, presence of severe symptoms, or clinical deterioration despite conventional therapy, use Empiric Therapy for Resistant Typhoid Fever: 1. Ceftriaxone (Rodephin) 3 gm infusion OD X 5-7 days Ceftriaxone may be used for pregnant women and children or 2. Fluoroquinolones: Ciprofloxacin (Ciprobay) 500 mg tab PO BID X 7-10 days or Ofloxaein gno5ec) 400 tag MPO DID X 7-104rys or Pefloxacin (Peflacine) 400 mg tab PO BID X 7-10 days To Infectious Page To Main Table of Contents To Detailed Table of Contents

MALARIA To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Malaria is the most important parasitic disease in humans. Plasmodium falciparum and P. vivum are common in the Philippines, East Asia, South America and Oceana, P. Ovale and P. malaria are common in Africa almost all deaths are caused by Plasmodium falciparum. B. Complications of severe Falciparum malaria: Cerebral malaria (coma, convulsions hypoglycemia, lactic acidosis, ARDS, acute renal failure anemia, jaundice, hemolysis heeloghemoglobinuria (rare blackwater fever), DIC and bleeding problems. Orders: Diet: Regular VS: Vital signs q 24 hours including temperature; Record temperature in between if febrile, or with chills Nursing: I & O q shift IVF: D5NM X 8 hours Diagnostics: CBC with platelet count (anemia low platelet, low to normal WBC) Malarial smear 3X (thick and thin smear) q 12 hours Malarial IFAT (Immunoflorescence Antibody Test serology) c/o RITM or UP College of Pubic Health (if smears are negative) Blood typing Blood Culture and sensitivity (to rule out Typhoid Fever) ESR, Urinalysis, Chest X-ray Monitor: BUN, Creatinine, RBS, PT, PTT, Liver Function Test Therapeutics: A. Species Not Chloroquine-Resistant 1. Chloroquine (Aralen) 250 mg: Give 4 tabs at zero hour, 2 tabs after 6th hour, 2 tabs on the 24th hour, and 2 tabs on the 48th hr (total of 10 tablets). Give after meals then 2. Primaquine 15 mg tab (to kill gametocytes upon discharge) Give 1 tab OD X 14 days for P. vivax or 3 tabs single dose for P. falciparum Note: Primaquine is not commercially available. It is given See by DOH. B. Species Chloroquine-Resistant: 1. Sulfadoxine 500 mg Pyrimethamine 25 mg (Fansidar) Give 3 tabs single dose or Quinine tablet 300-600 mg 1 tab TID for 7- 10 days (for P. falcifarum) C. For Severe Attache (P. falciparum) 1. Quinine Drip: Quinine 1 amp (10 mg of salt) in D5W 500 cc x 4 hours to be given q 8 hours IV.Shift quinine to oral tablets as soon as possible. Watch out for cardiac toxicity. and 2. Doxycycline 100 mg cap OD-BID (3 mg/kg/day) for 7 days. To Infectious Page To Main Table of Contents To Detailed Table of Contents

PREVENTION OF MALARIA IN TRAVELLERS To Infectious Page To Main Table of Contents To Detailed Table of Contents For Plasmodium falciparum, P. malariae, P. vivax, P. ovale: l. Areas with chloroquine-sensitive P. falciparum: a. Drug of choice: Chloroquine phosphate (Arden, Malarex) 250 mg 2 tabs once weekly on exactly the same day starting 2 weeks before entering endemic area, while there, and for 2 weeks after exposure. 2. Areas with chloroquine-resistant P. falciparum (Philippines, India, Africa China, South America etc.) a. Drug of choice: Mefloquine*(Lariam) 250 mg 1 tab once weekly starting one week before entering the endemic area, while there, and for 4 weeks after exposure. b. Alternative drug: Doxycycline* (Doxin, Vibramycin) 100 mg 1 cap 2 days prior to departure as test dose then 1 tab daily during exposure and for 4 weeks after exposure. c. Carry 3 tabs of Fansidar for self-teatment of febrile illness when medical treatment is not immediately available. * Avoid in children < 8 years old and pregnant women Anti-Malarial Drug List 1. ChloroquineSulfate (Aralen, Malarex) 250 mg tab 2 tabs on exactly the same day of each week 2. a. Sulfadoxine500 mg, Pyrimethamine 25 mg tab (Fansidar, Methamar) 3 tabs single dose b. Sulfametopyrazine 500 mg; Pyrimethamine 25 mg tab (Metakelfin) c. Mefloquine HCl 250 mg+ Sulfadoxine 500 mg+ Pyrimethamine 25 mg tab (Fancimef) 3. Halofantrine HCl (Halfan) 250 mg tab, 100mg/5ml susp 4. MefloquineHCI (Lariam) 250 mg tab, Prophylaxis: 1 tab once weekly To Infectious Page To Main Table of Contents To Detailed Table of Contents

LEPTOSPIROSIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Leptospires (spirochetes) B. Transmission: Exposure to rat urine, contaminated water and soil, or with a history of wading in floodwaters. Incubation period of 2 to 26 days (average of 7-13 days). C. Signs and Symptoms: 1. Leptospiromic phase (4-9 days): Leptospira in blood and CSF. Headache and fever heralds onset followed by calf pains, conjunctival suffusion, and jaundice (toxic-looking patient). 2. Immune Phase: Appearance of IgM Ab, decrease in fever. D. Complications: Hepatic and renal failure myocarditis, acute respiratory distress syndrome pneumonia, aseptic meningitis E. Differential Diagnoses: Hepatitis (increased SGOT, SGPT) typhoid fever, dengue fever, pneumonia, gastroenteritis Orders: Admit to: Diet: Regular VS: Vital signs q 2-4 hours including temp. Nursing: I & O q shift IVF: D5NM X 10 hours Diagnostics: CBC, Platelet count, PT, PTT CPK-total , Chest X-ray, Urinalysis BUN, Creatinine, RBS, K SGPT, SGOT, Alkaline Phosphatase, Total Bilirubin, Direct & Indirect Bilirubin Leptospiral Ab test c/o PGH MAT paired sera, MCAT rapid test Blood C/S, CSF culture, Urine C/S (after first week) Therapeutics: 1. For Moderate to Severe Cases: Penicillin 0 1.5-2 mil units q 4-6 hours X 7 days (best if started within four days of illness) 2. For Mild Cases: Doxycycline 100 mg PO BID X 7 days 2. Fluid and electrolyte replacement 3. Renal complications: a. Consider dialysis treatment for azotemia b. Dopamine drip at 1-2 mcg/kg/hour 4. Prophylaxis in Endemic Areas: Doxycycline 200 mg tab PO once per week To Infectious Page To Main Table of Contents To Detailed Table of Contents

SCHISTOSOMIASIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Schistosoma japonicum found in Southeast Asia, Philippines especially Leyte and Samar B. Pathophysiology: Exposure to freshwater in endemic area; ingestion of undercooked fish and crustaceans. Snail intermediate host is Oncomelania philippinensis. Parasite resides in the venules of the intestines, eggs are swept back mostly to the liver via the venous portal system. C. Signs and Symptoms: Two to six weeks from exposure, transient itching, swimmer's itch, Katayama fever, chills, headache, CNS symptoms; an increased worm load would result in increased Symptoms. D. Complications: Liver fibrosis, portal hypertension, presinusoidal hepato- splenomegaly, esophageal varices, cor pulmonale, pulmonary hypertension from worm emboli, glomerulonephritis, CNS lesions, multiple enhancing brain lesions mimicking brain tumors. Orders: Diagnostics: CBC (eosinophilia) COPT (serum), Kato-Katz (stool) Stool exam or rectal biopsy (positive eggs) Ultrasound of liver or wedge biopsy CT Scan of the head (if with neurologic symptoms) Therapeutics: Praziquantel 20 mg/kg TID PO with fo6d for 1 day only (available at DOH). Example: 650 mg tab, 1 1/2 tab TID for 3 doses only. To Infectious Page To Main Table of Contents To Detailed Table of Contents

SEPSIS & SPETIC SHOCK To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: 1. Gram (-) bacteria in 70% of cases; endotoxin present 2. Gram (+) bacteria in 15% of cases; from vascular catheter, burns, IV lines mechanical devices 3. Fungi etiology in 5% of cases; found in immunocompromised, neutropenic patients, or after antibiotic treatment B. Pathophysiology: 1. Endothelial injury, fluid extravasation with hypotension 2. Culprit cytokines, increase TNF alpha, Interleukin 1B and 8 Orders: Admit to: Diet: NPO temporarily VS: Vital signs q 1 hour Nursing: I & O q shift; consider pulse oximter insert NGT, CVP, Foley catheter IVF: Plain NSS 1 liter x 8 hours; D5NSS I liter x 8 hours Diagnostics: CBC with platelet count, PT, PTT, Fibrinogen degradation product Chest X-ray, ECG, RBS, ABG, Na, K, Mg, Ca, BUN, Creatinine Blood C/S 3X from different sites 1 hour apart Urinalysis, Urine C/S, Spatem G/S & C/S Cultureof wound, IV catheters, ascitic fluid, decubitus ulcers, pleural fluid Therapeutics: Oxygen at 2-5 1pm by nasal cannula or use face mask 1. Hemodynamic support: a. PNSS 1-2 L fast drip if hypotensive b. Inotropic support: Dopamine Drip, Norepinephrine Drip 2. Remove source of infection 3. Treat acidosis: Sodium bicarbonate for pH < 7.2 4. Treat disseminates intravascular coagulation: Heaprin low-dose 5. Empiric Antibiotics: Use appropriate antibiotics at right doses Note: Antibiotics may have to be changed depending on cultrure results after 2-3 days a. Non-immunocompromised adults i. Ceftriaxone (Rocephin) I-2 gm IV gq24 hr or Piperacillin-Tazobactam (Tazocin) 2.25 gm IV q 4-6 hr or Ceftazidime (Fortum) 1-2 gm IV q 8 hr or Meropenem (Meronem) 500 mg - 1 gm IV q 6-8 hr or Imipenem 500 mg - 1 gm IV q 6-8 hr ii. Gentamicin, Tobramycin or Amikacin IV iii. Clindamycin IV or Metronidazole 500 mg IV q 6 hr b. Nosocomial sepsis with IV catheter or IV drug abuse (S. aureus) i. Vancomycin 1 gm slow IV push in 30 minutes q 12 hr + ii. Gentamicin or Tobramycin IV c. Neutropenic patients (Neutrophiles < 500/cu mm) i. Ceftazidime 1-2 gm IV q 8 hr or Meropenem or Imipenem + ii. Tobramycin or Amikacin IV iii. Vancomycin 1 gm slows IV in 30 min q 12 hr (if with indwelling catheter) d. Candida Septicemia i. Amphotericin B IV or Fluconazole IV infusion

e. If Pseudomonas aeruginosa is suspected or for AIDS patients: i. Ceftazidime 1-2 gm IV q 8 hr or Meropenem or Imipenem + ii. Amikacin or Tobramycin IV To Infectious Page To Main Table of Contents To Detailed Table of Contents

LOWER URINARY TRACT INFECTION To Infectious Page To Main Table of Contents To Detailed Table of Contents Orders: IVF: D5NM 1, Liter X 8 hours Diagnostics: CBC, Urinalysis Urine G/S, C/S Therapeutics: A. Lower Urinary Tract Infection (Treat for 3-7 days) 1. Co-Trimaxazole (Bactrim Forte) 1 tab BID PO or Norfloxacin (Lexinor) 400 mg 1 tab BID or Ciprofloxacin (Ciprobay) 250-500 mg 1 tab BID or Cephalexin (Ceporex, Forexin) 500 mg 1 cap QID or Co-amoxiclav (Augmentin) 375 mg l tab TID PO or Nitrofurantoin (Macrodontin) 100 mg 1 cap QID PO or Amoxicillin 500 mg 1 tab TID (may be used in pregnancy) B. Complicated Catheter associated UTI: As per drugs used in severely ill septic pyelonephritis To Infectious Page To Main Table of Contents To Detailed Table of Contents

PYELONEPHRITIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet: Regular VS: Vital signs q 4 hours Nursing: I and O q shift IVF: D5NM 1 Liter X 8 hours Diagnostics: CBC, Blood Culture and sensitivity Urinalysis, Urine G/S, C/S RBS, BUN, Creatinine, Ultrasound of the kidneys Therapeutics: A. Moderately ill, non-septic pyelonephritis (Treat for 10-14 days PO) 1. Ciprofloxacin, Norfloxacin, Ofloxacin, Co-amoxiclav, Co-trimoxazole, or Cephalexin PO as per above dosages Lower UTI but given longer for 10-14 days B. Severely ill, septic pyelonephritis: (Treat with IV antibiotics until fever subsides, then use oral quinolone for 10-14 days) 1. Ampicillin 1 gm IV q 6 hr and Gentamicin 80 mg IV q 8 hr or 2. Ciprofloxacin (Ciprobay) 200-400mg IV q 12 hr or Ceftriaxone (Rocephin) 1-2 gm IV q 24 hr or Meropenem (Meronem) 500 mg - 1 gm IV q 6-8 hr C. Symptomatic medications: Pain relievers To Infectious Page To Main Table of Contents To Detailed Table of Contents

CELLULITlS To Infectious Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet: Regular; Increase fluids VS: Vital signs q 2 hours and record Nursing: I and O q shift; Keep affected extremity elevated IVF: D5NM 1 Liter X 8 hours Diagnostics: CBC, Blood culture and sensitivity Wound discharge gram stain, C/S Urinalysis Bone X-ray of cellulitis site (to rule out osteomyelitis) Therapeutics: A. Empiric Therapy l. Oxacillin (Prostaphlin) 2 gm IV q 4-6 hr (give by soluset because irritating) or Cefazolin (Stancef) l gm 1V q 8 hr or Penicillin 2 Mil units IV q 4-6 hr (only if high suspicion of Erysipelas) B. Immunosuppressed, Diabetic Patients or Ulcerated Lesions l. AmpicillintSulbacfam (Unasyn) Alone 1.5 gm IV q 8 hr or 2. Co-Amoxiclav (Augmentin) Alone 1.2 gm IV q 8 hr or 3. Oxacillin (Prostaphlin) 2g IV q 4-6 hr + If Septic, add: Gentamicin IV + Clindamycin IV/ PO or Metronidazole IV/PO C. Necrotizing Soft-Tissue Infection 1. Penicillin 4 Mil units IV q 4 hr 2. Gentamicin IV + 3. Clindamicin 1V D. Symptomatic Meditations: 1. Silva sulfadiazene cream 1% TID to affected area 2. Betadine solution for cleansing 3. Pain reliever as needed. E. Tetanus Management (depending on tetanus vaccination status of the patient) 1. Tetanus immune globulin 250 IV IM stat dose 2. Tetanus toxoid 1 dose IM now, then second dose after 1 month and third dose after 6 months.

To Infectious Page To Main Table of Contents To Detailed Table of Contents

MENINGITIS & ENCEPHALITIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet: Regular, fluid restriction if with increased intracranial pressure VS: Neurologic vital signs q 1 hour Nursing: Respiratory isolation, I & O q shift IVF: D5W 250 cc and keep vein open Diagnostics: CBC with platelet, Blood C/S, HSR, ABG Na, K, BUN, Creatinine, RBS, Urinalysis Viral studies if availabl0 (Coxsackie, Echo, mumps, EBV, HSV, CMV, arbovirus) Portable Chest X-ray, ECG CT Scan, MRI, EEG- if indicated Lumbar Puncture: CSF tube #1 - Total cell count RBC, WBC, Diff Count #2 - Protein, sugar #3 - G/S, C/S, AFB, Indian Ink #4- Sabouraud's Agar - Fungal meningitis #5 -TB Eliza Determination PGH #6 - CALAS (Cryptococcal Ag Latex Agglutination) c/o PGH Therapeutics for Meningitis: A. Meningitis Empiric Therapy for Age 9 months to 50 years old: 1. Ceftriaxone (Rocephin) 2 gm IV q 12 hr or Cefotaxime (Claforan) 1-2 gm IV q 6 hr or Ceftazidime (Fortum) 1-2 gm IV q 8 hr + 2. Vancomycin 1 gm slow IV push in 30 minutes q 12 h 3. Alternative for areas with low prevalence of drug-resistance S. pneumoniae: Penicillin G 4 million units IV q 4 hr or Chloramphenicol IV (if with Penicillin allergy) B. Empiric Therapy for patients > 50 years, Alcoholic, with Intake of Corticosteroids or Hematologic Malignancy or Other Debilitating Conditions: 1. Ampicillin 1-2 gm IV q 4 hr + 2. Vancomycin l gm slow IV push in 30 minutes q 12 hr + 3. Cefotaxime (Claforan) 1-2 gm IV q 6 hr or Ceftriaxone (Rocephin) 2 gm IV q 12 hr or Ceftazidime (Fortum) 1-2 gm IV q 8 hr C. Hospital-acquired Meningitis, Meninges after Head Trauma or Neurosurgery, Neutropenic Patients: 1. Meropenem (Meronem) alone 1-2 gm IV q 8 hr or 2. Vancomycin 1 gm slow IV push in 30 minutes q 12 hr + Ceftazidime (Fortum) 1-2 gm IV q 8 hr D. Therapy Based on Specific Etiologic Agent: 1. Streptocccus pneumoniae (Penicillin sensitive): Penicillin G 4 Mil wits IV q 4 hr 2. Staphylococcus aureus: Oxacillin 2 gm IV q 4-6 hr or Vancomycin 1 gm slow IV push in 30 minutes q 12 hr 3. Neisseria meningitides: (Penicillin sensitive): Penicillin G 4 Mil units IV q 4 hr 4. Haemophilus influenzae: Ceftriaxone (Rocephin) 2 gm IV q 12 hr or Cefotaxime (Claforan) l-2 gm IV q 4-6 hr 5.. Gram negative bacilli (not P; aeruginosa or Enterobacter cloacae): Cefotaxime (Claforan) 1 2 gm IV g 4-6 hr or Ceftriaxone (Rocephin) 2 gm IV q 12 hr or Ceftazidime (Fortum) 1-2 gm IV q 8 hr 6. Pseudomonas aeruginosa: Ceftazidime 1-2 gm IV q 8 hr, Meropenem 1-2 gm IV q 8 hr Note: For viral encephalitis no antibiotics are needed. E. Consider Dexamethasone Therapy: Dexamethasone 0.6 mg/kg per day in 4 divided doses for 2-4 days. e.g. Dexamethasone (Decadron) 8 mg IV initially, then 4 mg IV q 6 hr

Give the first dose of steroids 20 minutes before starting antibiotic therapy for best results. To Infectious Page To Main Table of Contents To Detailed Table of Contents

TETANUS To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Clostridium tetani, a gram-positive bacteria, produces tetanospasmin causing increased muscle tone and spasms. B. Transmission: Usually a non-immunized person develops a skin injury and comes into contact with infected soil. C. Symptoms: Diagnosis is clinical only. Symptoms initially include jaw stiffness (locked jaw) and dysphagia then followed by pain or stiffness in the neck, face (sardonic grin), shoulder, back and abdominal muscles. Hands and feet are relatively spared. Onset of symptoms may range from 3-14 days after the injury D. Complications: Severe cases may develop laryngeospasms, apnea autonomic dysfunction (hypertension, tachycardia, arrhythmia, high fever, profuse sweating), aspiration pneumonia, fractures, muscle rupture, rhabdomyolysis, deep venous thrombosis (DVT), pulmonary emboli and decubitus ulcers. Orders: Admit to single room. Diet: NPO temporarily VS: Neuro vital signs q 1 hour Nursing: I & 0 q shift, Seizure precautions Consider nasogastric tube insertion and nutritional support Avoid stimulation and bright lights; Keep room dark and quiet. Tongue guard; Watch out for respiratory depression; standby intubation set. IVF: D5NR 1 L X 10 hours Diagnostics: CBC, RBS Creatinine, K Wound G/S & C/S, Urinalysis Chest X-ray, ECG Therapeutics: 1. Give Anti-toxin: Human Tetanus Immunoglobulin Ig (Tetuman Berna, Tetaglobulin) 250 IU/amp, 4 amps IM 2. Give Tetanus toxoid 0.5 ml/amp, 1 amp IM now, then after 1 month, and after 6 months. 3. Start Antibiotics: Penicillin G 3-4 Mil units IV q 4 hr (18-24 Mil units per day) or Metronidazole 500 mg IV q 6 hr 4. For Muscle Spasms: Diazepam 2.5-5 mg IV q 6 hr or Diazepam drip: 10 mg in 100 ml D5W infuse in 2 hours q 8 hr (maximum of 60 my per day) 5. Supportive Therapy: a. Respiratory support, protection of the airway, IV hydration b. Prevent DVT, decubitus ulcers and GI bleeding; May give antacids per nasogastric tube c. Pain reliever. Ibuprofen 200 mg tab TID per NGT if needed d. Clean wound with hydrogen peroxide and Betadine To Infectious Page To Main Table of Contents To Detailed Table of Contents

OSTEOMYELITIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet: Regular VS: Vital signs q 4 hours Nursing: Keep involved extremity elevated IVF: D5NR 1 liter X 16hours Diagnostics: CSC, ESR, Blood culture and sensitivity Wound or tissue discharge G/S, C/S Urinalysis Chest X-ray Multiple x-ray views of involved bones Therapeutics: A. Adult Empiric Therapy (S. aureus, Gram-negative, Pseudomonas) l. Oxacillin (Prostaphlin) 2 gm IV q 4-6 hr or Cefazolin (Stancef) 2 IV q 8 hr or Vancomycin 1 gm slow IV push in 30 minutes q 12 hr (reserved drug for Oxacillin resistant S. aureus) 2. Ceftazidime (Fortum) 1-2 gm IVq 8 hr (if gram-negative bacilli on gram stain) B. Post Operative or Post Trauma (S. aureus, Gram-negative, Pseudomonas l. Oxacillin (Prostaphlin) 2 gm IV q 4-6 or Cefazolin (Stancef) 2 gm IV q 8 hr or Vancomycin 1 gm slow lV push in 30 minutes q 12 hr + 2. Ceftazidime (Fortum) 1-2 gm lV q 8 hr or Ciprofloxacin (Ciprobay) 500 mg PO BID C. Osteomyelitis with Decubitus Ulcer 1. Ciprofloxacin (Ciprobay) 200-400 mg IV q 12 hr + 2. Metronidazole 500 mg IV q 6 hr D. Symptomatic medications: Pain relievers To Infectious Page To Main Table of Contents To Detailed Table of Contents

PERITONITIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Orders: Admit to: Diet NPO VS: Vital signs q 1 hour Nursing: I & O q shift IVF: D5NSS + 20 meq KCl/L at 125 cc/hour Diagnostics: CBC, Na, K PT, PTT, Albumin LDH, Amylase, Lactate Urinalysis, Urine C/S X-ray of abdomen: plain film upright lateral decubitus Abdominal ultrasound Chest X-ray Abdominal Paracentesis: Vial #1 - Gram Stain, AFB smear Vial #2 - Q/Q (Quantitative/Qualitative) Vial #3 - Culture and sensitivity Optional: Total protein, amylase, LDH, glucose, etc. Therapeutics: A. Spontaneous Bacterial Peritonitis (nephrotic or cirrhotic) 1. Cefotaxime (Claforan) 1 gm IV q 6-8 hr or Piperacillin-Tazobactam (Tazocin) 2.25 gm IV q 6-8 hr or Ceftriaxone (Rocephin) 1 gm 1V q 24 hr or Ceftazidime (Fortum) 1 gm IV q 8 hr + 2. Ampicillin-Sulbactam (Unasyn) 750 mg IV q 8 hr B. Secondary Bacterial Peritonitis (from bowel perforation, ruptured appendix, or diverticula) 1. Meropenem (Meronem),alone:1 gm IV q 8 br or 2. Cefoxitin (Mefoxin) 1-2 gm IV q 8 hr + Gentamicin or Tobramycin IV (avoid in chronic renal failure) + Clindamycin 300 mg IV q 8 hr C. Renal Failure Patients with Peritonitis (associated with chronic ambulatory peritoneal dialysis) Target S. aureus 1. Ceftazidime (Fortum) 1-2 gm IV q 8 hr + Vancomycin 1 gm slow IV push in 30 minutes q 12 hr To Infectious Page To Main Table of Contents To Detailed Table of Contents

DIVERTICULITIS To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Incidence: Male > female elderly patient, left colon affected more than right colon due to higher intraluminal pressures B. Etiology: Inflammation of the diverticular sac due to gram-negative anaerobic bacteria C. Symptoms and Signs: Acute abdominal pain, nausea, vomiting fever, left lower abdominal tenderness and mass. D. Complications: Fistula formation, stricture of the colon with obstruction. E. Differential Diagnoses: Perforated colon carcinoma, appendicitis, Crohn's disease, ischemic colitis, gynecologic disorders. Orders: Admit to: Dict: NPO temporarily VS: Vital signs q 2 hr and record Nursing: I & O, place NGT if with signs of bowel obstruction or ileus IVF: D5NSS 1 L X 8 hours Diagnoses: CBC (inc WBC:), K, Blood C/S Amylase, Lipase, Urinalysis, Chest X-ray, EGG Plain abdominal x-ray upright and supine (to rule out perforation) CT Scan of the abdomen (to rule out abscess formation) Sigmoidoscopy & Barium Enema (after the acute phase is over because of danger of perforation) Therapeutics: 1. Bowel rest 2. Start antibiotics a Localized inflammatory response: i. Co-trimoxazole (Bactrim forte) 1 tab PO QID X 14 days or Ciprofloxacin (Ciprobay) 500 mg 1 tab PO BID X 14 days + ii. Metronidazole 500 mg 1 tab PO QID X 14 days or iii Co-amoxiclav Alone (Augmentin) 625 mg 1 tab PO TID X 14 days b. Patient systemically ill (Antibiotics should cover anaerobic and gram- negative bacteria): i. Cefoxitin (Mefoxin) 1-2 gm IV q 6 hr ii. Gentamicin or Tobramycin 1V + iii. Metronidazole 500 mg IV q 6 hr 3. Surgery referral to monitor complications (seen in 20-30% of cases): Abscess, fistula perforation, hemorrhage obstruction 4. Symptomatic medications a H2-blockers b. Pain relievers; Meperidine (Demerol) To Infectious Page To Main Table of Contents To Detailed Table of Contents

PELVIC INFLAMMATORY DISEASES To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Polymicrobial and sexually-transmitted infection of the upper genital tract. Neisseria gonorrhoeae and Chlamydia trachomatis commonly involved. B. Symptoms and Signs: Lower abdominal pain, fever, menstrual disturbance, cervical and vaginal discharge, lower abdominal adnexal and cervical motion tenderness, Some patients have mild symptoms only. C. Differential Diagnoses: Appendicitis, ectopic pregnancy, septic abortion, acute gastroenteritis, ovarian cysts and tumors, degeneration of a myoma. Orders: Admit to: Diet: NPO initially until cleared by Surgery and OB-Gynecology VS: Vital signs q 4 hours Nursing: I and O q shift IVF: D5NM 1 L X 8 hours Diagnostics: CBC, ESR, Gonococcal and Chlamydial Culture Urinalysis, Urine C/S Pelvic Ultrasound and/or Vaginal Ultrasound (check for pelvic masses and other differential diagnoses) VDRL, Pregnancy test Therapeutics: A. Outpatient Therapy (For patients with temperature < 38 C, WBC < 11,000, minimal evidence of peritonitis, active bowel sounds and able to tolerate oral feeding): 1. Ofloxacin 400 mg 1 tab BID PO X 14 days + Metronidazole 500 mg 1 tab BID PO X 14 days B. Inpatient Therapy: IV antibiotic regimens (2 options) are given for at least 48 hours after patient improves then continued oral antibiotics, Doxycycline 100 mg 1 tab BID PO, to complete therapy for 14 days. 1. Cefoxitin (Mefoxin) 1-2 gm IV g 6 hr + Doxycycline l00 mg 1 tab BID PO or 2. Clindamycin 300-600 mg IV q 8 hr + Gentamicin 80 mg IV q 8 hr C. Supportive Therapy: 1. Bed rest 2. Symptomatic medication: Pain relievers To Infectious Page To Main Table of Contents To Detailed Table of Contents

MUMPS To Infectious Page To Main Table of Contents To Detailed Table of Contents Data: A. Complications; Orchitis, aseptic meningitis or encephalitis, pancreatitis, myocarditis, thrombocytopenia, nephritis Orders: Admit to: Diet: Soft diet Diagnostics: CBC with platelet count Amylase, RBS, Creatinine Urinalysis Therapeutics: 1. Supportive treatment; a. Bed rest b. Paracetamol 500 mg tab PO as needed for fever >= 38º C and pain 2. For Orchitis a. May give antibiotics if with signs of bacterial infection Ciprofloxacin 500 mg tab BID PO x 10-14 days or Cephalexin 500 mg tab QID X 10-14 days b. Scrotal elevating and apply cold compress To Infectious Page To Main Table of Contents To Detailed Table of Contents

VARICELLA ZOSTER (CHICKEN POX) & HERPES ZOSTER (SHINGLES) To Infectious Page To Main Table of Contents To Detailed Table of Contents Data on Varicella Zoster: A. Incubation Period: 14-17 days B. Distribution: Rash erupts in trunk and face first. C. Complications: Bacterial superinfection cerebral ataxia after 2 days of no treatment, pneumonitis (20% of adult after 3-5 days), myocarditis, corneal lesions, nephritis, acute glomeruoephritis, hepatitis, bleeding, increase SGOT & SGPT Orders: Diagnostics for Varicella Zoster: CBC: Chest X-ray (to rule out pneumonia), Tzanck smear of skin lesions Therapeutics: A. For Varicella Zoster: l. Aciclovir (Zovirax) 800 mg 1 tab PO q 4 hr omitting the nighttime dose (5 doses/day) for 7 days (start within 24 hour of rash) 2. Isolate patient in a single room. B. For Herpes Zoster. 1. Valaciclovir (Valtrex) 500 mg tab, 2 tabs TID PO for 7 days (start within 3 days of rash) 2. For Herpes Zoster Ophthalmicus: Neosporin drips, 1 drop QID on affected eye. Refer to Eye Specialist. 3. Pain reliever for severe pain of herpes zoster 4. Optional: Neurobion 5000 mg I tab BID-TID PO To Infectious Page To Main Table of Contents To Detailed Table of Contents

Empirical Antimicrobials for Out-Patient Adults To Infectious Page To Main Table of Contents To Detailed Table of Contents Table 4-2. Examples of Empirical Choices of Oral Antimicrobials for Adult Outpatient Infections. Suspected Clinical Diagnosis Erysipelas, impetigo, cellulitis, ascending lymphangitis

Likely Etiologic Agent

Alternative Drug

Group A Streptococcus

Phenoxymethyl Erythromycin PO Penicillin (Pen) or PO or Cloxacillin Cephalexin PO X PO 7-10 days

Staph. aureus

Cloxacillin PO X Cephalexin 10 days PO X 7-10 days

Furuncle with surrounding cellulitis Pharyngitis

Drug of Choice

Group A Strep. (Beta hemolytic)

Phenoxymethyl (Pen) PO X 10 days Ampicillin PO X 10 days

Erythromycin PO X 10 days

Ciprofloxacin PO, TMP-SMZ Forte PO

Co-Amoxiclav PO

Strep.pneumoniae, Co-Amoxiclav H. influezae, PO, Cefuroxime Moraxella PO X 10 days catarrhalis S. pneumoniae, H. Co-Amoxiclav Amoxicillin PO, Acute sinusitis influenzae, M. PO, TMP-SMZ Forte catarrhalis Cefuroxime 250 PO X 10 days mg PO BID X 10 days Acute S. pneumoniae H. Clarithromycin TMP-SMZ bronchitis influenzae PO, Forte Erythmmycin PO PO x 10 days X 7 days Mixed Clindamycin PO Phenoxymethyl Aspiration oropharyngeal X 10-14 days Pen pneumoniae flora, inclu-- din PO x 10-14 anaeobes days Pneumoniae See Pulmo chapter Salmonella, Salmonella, Enteritis Shigella Shigella: Campylobacter, TMP-SMZ or Entamoeba Quinolones X 5 histolytica days Campylobacter. Ciprofloxacin X 5 d. E. hystolytica Metronidazole PO X 5-10 Otitis Media

Pyelonephritis or Cystitis

E. coli. K. pneumoniae, Proteus, S. saphrophyticus

Urethritis (associated with STD)

Pelvic Inflammatory Disease

Syphilis: Early SY (primary, secondary or latent of < 1 year's duration

Neisseria gonorrheae, Chlamydia trachomatis

Ceftriaxone 250 Azithromycin mg IM once for 1 gm PO once N. gonorrheae; for Doxycycline 100 C. trachomatis mg BlD X 7 days for C. trachomatis

N. gonorrheae, Ofloxacin 400 mg C. trachomatis, BID PO X 14 Anaerobes, Gm days and (-) rods Metronidazole 300 mg BID PO X 14 days Treponema pallidum

Ceflriaxone 250 mg IM followed by Doxycycline 100 mg BID PO X 14 days

Benzathine Pen Doxycycline PO G 2.4 mil units or Tetracycline IM once PO or Erythromycin PO X 15 days

Latent of > 1 year's duration or cardio-vascular SY

Benzathine Pen Doxycycline PO G 2.4 mil units or Tetracycline IM per week X 3 PO X 4 weeks weeks

Neurosyphilis

Aqueous Pen G Procaine Pen G 3-4 mil units q 4 2-4 million hr IV X 10-14 units/day IM+ days Probnecid 500 mg QID PO both X 10 days

To Infectious Page To Main Table of Contents To Detailed Table of Contents

Initial Antimicrobials for Acutely Ill Adults To Infectious Page To Main Table of Contents To Detailed Table of Contents Table 4-3. Examples of Initial IV Antimicrobial Therapy for Acutely Ill Hospitalized Adults Pending Identification of Causative Organism

Suspected Clinical Diagnosis

Likely Etiologic Agent

IV Drugs of Choice

Alternative Drugs

a. Meningitis, bacterial

Pneumococcus, Ceftriaxone 2 Cefotaxime 2 gm Meningococcus gm IV q 12 hr + IV q 6 hr or Ampicillin 2 gm Penicillin G 4 IV q 4 hr million units IV q 4 hr (thru soluset)

b. Meningitis, postoperative (or posttraumatic)

S. S. aureus, Vancomycin 1 Pen G 4 mil U IV gram gm IV q 12 hr + q 4 hr + negative Ceftazidime 2 Oxacillin 2 gm q bacteria, gm IV q 8 hr 4 hr + Amikacin Pseuddmonas 15 mg/kg/day (Pneumococcus, posttraumatic)

c. Brain abscess

Mixed anaerobes, Pneumococci, Streptococci

Ceftriaxone 2 Pen G 4 mil U IV gm IV q 12 hr or q 4 hr + Cefotaxime 2 gm Metronidazole IV q 6hr + 500 Metronidazole mg IVq 6 hr 500 m IV 6 hr

d. Pneumonia

See Pulmo chapter

e. . Septic thombophlebitis (e.g. IV tubing, IV shunts)

Staphylococcus, Oxacillin 2 gm IV Vancomycin 1 Gram-native q 4hr + gm IV q 12 hr + aerobic bacteria Gentamicin or Cefotaxime 2 gm Tobramycin or IV q 8-12 hr Amikacin IV

f. Osteomyelitis

g. Septic arthritis

S. aureus

S. aureus, N. gonorrheae

Oxacillin 2 gm IV Vancomycin 1 q 4 hr gm IV q 12hr Ceftriaxone 2 gm IV q 24 hr

Oxacillin 2 gm IV q 4 hr

h. Pyelonephritis B. coli Klebsiella, Ciprofloxacin Ceftriaxone 1-2 with flank Enterobacter, 200-400 mg IV q gm IV q 24 hr paain & fever Pseudomonas 12hr (recurrent UTI)

i. Suspected sepsis in neutropenic patient receiving cancer chemotherapy

j. Intraabdominal sepsis (e.g. post-oprative peritonitis cholecystitis)

S. aureus, Pseudomonas, Third or Fourth Ceftazidime 2 gm Klebsiella, E. coli Geaerahon IV-q 8 hr + Cephalosporins+ Vancamycin 1 Tobramycin or gm lV q 12 hr + Amikacin IV Tobramycin IV Meropenem or Imipenem 1 gm IV q 8 hr Gram-negative bacteria, Bacteroides, Anaerobic bacteria Streptococcus, Clostridia

To Infectious Page To Main Table of Contents To Detailed Table of Contents

Third Meropenem or Generation Imipenem 1 gm Cephalosporins+ IV q 8 hr gentamicin or Tobramycin or Amikacin IV+ Metronidazole 500 mg IV q 6 hr,

Drug of Choice for Microbial Pathogens To Infectious Page To Main Table of Contents To Detailed Table of Contents Table 4-4. Drugs of Choice for Suspected or Proved Microbial Pathogens. Etiologic Agent Moraxella catarrhalis (Branhamella)

Neisseriae gonorrheae (Gonococcus) Neisseria meningitides (Meningococcus)

Drug (s) of First Choice

Alternative Drugs

Co-Amoxiclav or oral Azithromycin, Clarithromycin, cephalosporins, Dirithromycin, Erythromycin, Trimethoprim-Sulfamethoxazole Doxycycline, Fluoroquinolones Ceftriaxone, Cefixime, Cefpodoxime

Ofloxacin, Spcctinomycin

Penicillin G

Ceftriaxone, Cefuroxime, Cefotaxime, Sulfonamide, Chloramphenicol

Gram-Positive Cocci: Pneumococcus (Strep. pneumoniae)

Penicillin G

Amoxicillin, Erythromycin, Cephalosporin, Vancomycin

Penicillin G or V (may add Gentamicin)

All beta-lactams, Erythromycin, Azithromycin, Dirithromycin, Clarithromycin

Penicillin G +/Aminoglycosides Vancomycin

Older Cephalosporins Vancomycin Trimethoprim-sulfamethoxazole

Staphylococcus, non-penicillinase producing

Penicillin G

Older Cephalosporins, Vancomycin

Staphylococcus, penicillinase producing

Penicillinase-resistant Penicillin: Nafciilin or Oxacillin IV, Dicloxacillin, Cloxacillin or Oxacillin PO

Vancomycin, Cephalosporin, Clindamycin, Co-Amoxiclav, Ampicillin-Sulbactam

Streptoooccus pyogenes, hemolytic groups A, B, C, G, F Strep. viridans Staphylococcus aureus, methicillin resistant Vancomycin

Strep. fecalis

Acinotobacter

Ampicillin+ Gentamicin Vancomycin+ Gentamicin Gram-Negative Rods: Imipenem, Meropenem, Fluoroquinolone+ Amikacin or Ceftazidime

Ampicillin-Sulbactarn

Bacteroides, oropharyngeal strain

Metronidazole

Clindamycin, Cefoxitin, Imipenem + Cilastatin, Meropenem, Ticarcillin

Bacteroides, gastrointestinal strains

Metronidazole

Cefoxitin, Chloramphenicol Clindamycin, Imipenem, Ampicillin-Sulbactam

Brucella

Doxycycline + Gentamicin or Streptomycin

Doxycycline + Rifampicin or TMP-SMZ+ Gentamicin Fluoroquinolone+ Rifampicin

Erythromycin

Clindamycin, Ciprofloxacin, Ofloxacin

Meropenem, Imipenem

Third Gen Cephalosporins, Aminoglycoside, Ciprofloxacin, Ofloxacin

Escherichia coli (sepsis)

Third Generation Cephalosporins

Ampicillin, TMP-SMZ, Ciprofloxacin, Imipenem, Aminoglycosides

Escherichia coli (first UTI)

Sulfonamide, TMP-SMZ

Ampicillin, Cephalexin, Ciprofloxacin, Oflooxacin

Haemophilus influenzae (meningitis, respiratory infection

Cefotaxime, Ceftriaxone

TMP-SMZ, Imipenem, Ampicillin, Chloramphenicol

Klebsiella pneumoniae

Third Generation Cephalosporins

Ciprofloxacin, Ofloxacin, Aminoglycoside

Legionella sp. (pneumonia)

Azithromycin, Ciprofloxacin

Erythromycin+ Rifampicin, Clarithromycin, TMP-SMZ

Yersinia pestis (plague)

Streptomycin,Gentamicin

Choramphenicol, Doxycycline

Proteus mirabilis

Ampicillin IV, Amoxici1lin PO

Third Gen Cephalosporins, Aminoglycosides, TMP-SMZ, Ciprofloxacin Ofloxacin

Proteus vulgaris and other species

Third Generation Cephalosporins, Ciprofloxacin Ofloxacin

Aminoglycoside, Imipenem, TMP-SMZ

Aminoglycoside+ anti-Pseudomonal Penicillin: Piperacillin-Tazobactam

Ceftazidime+/- Aminoglycoside, Imipenem, Meropenem, Ciprofloxacin

Pseudomonas pseudomallei

Ceftazidime

Chlaramphenicol, Tetracycline, TMP-SMZ, Co-Amoxiclav

Pseudomonas mallei

Streptomycin + Tetracycline

Chloramphenicol + Streptomycin

Campylobacter

Enterobacter

Pseudomonas aeroginosa

Salmonella typhi

Serratia, Providencia

Shigeilla Vibrio cholerae

TMP-SMZ, Chloramphenicol

Ceftriaxone, Ciprofloxacin, Ofloxacin

Third Gen Cephalosporins, Ciprofloxacin, Ofloxacin

TMP-SMZ, Aminoglycosides

TMP-SMZ, Ampicillin

Ciprofloxacin, Ofloxacin

Doxycycline, Ciprofloxacin Gram Positive Rods:

TMP-SMZ

Actinomyces

Penicillin G, Ampicillin

Doxycycline

Bacillus (e.g. Anthrax)

Penicillin G, Ciprofloxacin

Erythromycin, Doxycycline

Clostridium (e.g. gas gangrene, tetanus)

Penicillin G

Clindamycin, Metronidazole, Chloramphenicol

Corynebacterium diphtheriae

Erythromycin

Penicillin G, Clindamycin

Vancomycin Corynebacteriu jeikeium Listeria monocytogenes

Ciprofloxacin, Penicillin G + Gentamicin Ampicillin, TMP-SMZ

Ampicllin, Aminoglycoside

Acid-Fast Rods: Mycobacterium tuberculosis

INH+ Rifampicin PZA+ Ethamheol

Other antituberculous drugs

Mycobacterium leprae

Dapsone + Rifampicin +/Clofazamine

Minocycline, Ofloxacin

Myeobecterium kansasii

INH+ Rifampicin + Ethambutol

Ethionamide, Cycloserine

Amikacin + Doxycycline

Cefoxitin, Erythromycin Sulfonamide Minocycline, Imipenem

Mycobacterium fortuitum chelonei

TMP-SMZ Nocardia asteroides Borrelia burgdorferi (Lyme disease)

Spirochetes: Ceftriaxone, Cefuroxime, Doxycycline

High dose Penicillin G, Amoxicillin, Cefotaxime, Clarithromycin

Borrelia recurrentis Doxycycline

Erythromycin, Penicillin G

Leptospira

Penicillin G

Doxycycline

Treponema pallidum (syphilis)

Penicillin G

Doxycycline, Ceftriaxone

Treponema pertenue (yaws)

Penicillin G

Doxycycline

Azithromycin, Clarithromycjn, Erythromycin

Doxycycline

Doxycycline

Chloramphenicol

Chlamydia trachomatis

Doxycycline or Azithromycin

Ofloxacin or Erythromycin

Chlamydia pneumonia'

Doxycycline

Erythromycin, Clarithromycin, CiproQoxacin

Rickettsiae

Doxycycline

Chloramphenicol

Mycoplasms pneumoniae

Chlamydia psittaci

Notes: 1. Penicillin G is preferred for parenteral injection while Penicillin V is for oral administration. 2. Aminoglycosides: Gentamicin, Tobramycin, Amikacin, Netilmicin. To Infectious Page To Main Table of Contents To Detailed Table of Contents

Acute Renal Failure To Nephrology Page To Main Table of Contents To Detailed Table of Contents Algorithm 5-1. Management of Acute Renal Failure — — — — — —

Oliguria Rule out urinary obstruction ------ > Bladder catheter Ultrasound of Kidneys, Ureter, Urinary Bladder & Prostate Assure good renal flow ---- > Blood volume, Cardiac output, Dopamine? Dx: Renal Parenchymal disease (Confirm by urine electrolytes and clearance Diuretic trial (Furosemide 100-200 mg) o Polyuria (Dx: Some nephrons functional) § Continue diuretics § Expect Azotemia § Full nutrition § Intermittent hemodialysis as needed for solute clearance § Renal recovery § Dx: Some or all nephrons recovered o Oliguria: (Dx: No Nephrons functional) § Isolate renal failure — Full nutrition — Intermittent hemodialysis or peritoneal dialysis as needed for volume and solute control — Dx: Some or all nephrons recovered § Multiple Organ failure — Full nutrition — CAVH/CVVH for volume — CAVHD/CVVHD for solute control — Chronic Renal Failure o Dx: No nephron recovered § Chronic Dialysis o Dx: Some or all nephrons

Legend: CAVH: Continuous Arteriovenous Hemofiltration; CAVHD = Continuous Arteriovenous Hemodiafiltration; CVVH = Continuous Venovenous Hemofiltration; CVVHD = Continuous Venovenous Hemodiafiltration; PD = Peritoneal Dialysis Source: Bartlett, Robert (1996). Critical Care Physiology. Washington: Little, Brown and Co. Orders: VS: Check the volume status of patient: A. Intravascular volume. Check jugular venous pressure, postural blood pressure, heart rate and urine output B. Interstitial volume: Cheek skin turgor and oral mucosa Nursing: Weigh daily; Input and Output daily; Consider foley catheter and CVP insertion, No BP taking or IV &exertion on one arm IVF: NSS or DSNSS if with intravascular volume depletion, D5 0.3 NaCl if with intravascular & interstitial volume depletion Diagnostics: CBC, Blood typing, ABG Ca, K, Inorganic Phosphate, Na, Uric acid, PBS, RBS

BUN, Creatinine, Total Protein, albumin, Globulin Urinalysis, Ultrasound of both kidneys, ECG, Chest X ray Monitoring: Check BUN, Creatinine, K every 1-3 days Daily chest x-rays if necessary (check for congestion) Therapeutics: A. Fluid management: WHat is the volume status of the patient? 1. Normal volume: Fluid intake= urine output plus 300-500 ml/day Na intake= 2 gm/day 2. Volume overloaded: Fluid indake < urine output Na intake < 2 gm/day a. Try loop diuretics: Furosemide 40-100 mg IV push b. Consider Furosemide drip for 24-48 hours c. Consider dialysis 3. Volume depleted: a. Restore volume with isotonic saline or D5'0.3 NaC1, then prescribe fluid intake = urine output plus 300-500 ml/day and sodium intake = 2 gm/day 4. Consider CVP insertion if volume status is difficult to assess clinically 5. Consider Dopamine 1 amp 200 mg+ D5W 250 cc X 10 ugtts/min (0.5-2.0 mcg/kg/min) Note: In oliguric patients (< 400 ml/day) limit fluid intake to < 1 liter/day B. Diet / Nutritional Support:, 1. For weight maintenance: High caloric intake 35 kcal/kg/day Low protein: 1.0-1.2 gm/kg/day if pre-hemodialysis, 1.2-1.4 gm/kg/day if on hemodialysis NaCl < 2 gram/day, Phosphorous. 600-800 mg/day K =40 meq/day, Mg = none 2. Energy requirement (kcal/day) = Basal Metabolic Requirement (BMR) X 1.25 X Stress Factor Body Weight (Kg) 50 55 60

BMR (kcal) 1,300 1,400 1,500

Body Weight (Kg) 65 70 80

Nature of Illness Early starvation Post-operative (no complication) Long bone fracture Peritonitis Cancer Severe infection or multiple trauma Burns 10-30% 30-50% >50%

BMR (kcal/day) 1,600 1,700 1,800

Stress Factor 0.85-1.00 1.00-1.05 1.15-1.30 1.05-1.25 1.10-1.45 1.30-1.55 1.50 1.75 2.00

3. For weight gain Add 1,000 kcal/day for a gain of approximately 1 kg/week C. Electrolytes: 1, Hyperkalemia: See Hyperkalemia Chapter 2. Metabolic acidosis 3. Hypocalcemia: Does not require intervention if asymptomatic. CaCO3 if symptomatic or if NaHCO3 is being given. 4. Hyperphosphatemia: CaCO3 tab, Aluminum hydroxide 5. Hyperuricemia: No treatment unless with gout, e.g. Allopurinol 300 mg/day for 2 days tben 100

mg/day 6. Avoid magnesium-containing antacid salt substitute NSAIDS and other nephrotoxins. D. Adjust all drug dosages according to the Glomerular Filtration Rate E. Watch out for organ system involvement/complications: l. Infection - Urinaryt infection, pneumonia 2. Gastrointestinal Complications a. Gastrointestinal bleeding secondary to. peptic ulcer disease may contribute to incease urea and potassium load b. Ranitidine IV is effective in preventing gastrointestinal bledding c. Antacids: Aluminum hydroxide (Alu-tab) 600 mg 1-2 tab QID d. No magnesium-containing antacids 3. Cardiovascular complieations a Uremic pericarditis: a friction rub is an indication for dialysis treatment b. Coronary artery disease may worsen F. Indications for initiating hemodialysis 1. Failure of conservative management to relieve. a. Pulmonary congestion (unresponsive to high dose furosemide) b. Severe metabolic acidosis c. Severe hyperkamemia 2. BUN > 100mg/dl or Creatinine > 10 mg/dl Note: For acute renal failire it is nest to dialysis early To Nephrology Page To Main Table of Contents To Detailed Table of Contents

STRATEGY POR REMOVAL OF EXCESS FLUID To Nephrology Page To Main Table of Contents To Detailed Table of Contents Resistant edema or oliguric renal failure Salt restriction Step 1 Conventional dose o floop diuretic (e.g. Furosemide 40 mg IV bolus, Bumetanide 2mg IV) Step 2 High dose of loop diuretic by IV plus (e.g. Furosemide 20O mg IVg 6 hours) Step 3 IV, infusion,of loop diuretic (e.g. Furosemide 10-40mg/hr, Bumetanide 1-4mg/hr Step 4 High dose IV loop diuretic (as above) diluted in salt poor albumin administered over 30 minutes over 6 hours Or Thiazide diuretic (Hydrochlorothiazide or Metolazone) followed 30 minutes later by high doses of loop diuretic by IV bolus as above Step 5 Ultraflltration (as isolated procedure or with dialysis) Source: Lennon, A.M., Coleman. P. &Brady H. (2000). Management and Outcome of Acute Reral Failure. In R. Johnson and J. Feehally (Eds.). Comprehensive Clinical Nephrology (p. 19.4), Hadcourt Publishers To Nephrology Page To Main Table of Contents To Detailed Table of Contents

CHRONIC RENAL FAILURE To Nephrology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Chronic glomerulonephritis, chronic pyeloneyhritis, diabetes mellitus, polycystic kidney disease, renovascular disease, hypertension, drugs, etc. B. Chronic Renal Failure (CRF) Chw¿ristics: 1. Decrease glomerular filtration rate or increased creatinine for > 3 months 2. Small kidney size (< 10 cm) by ultrasound, increased echogenecity and poor corticomedullary differentiation 3. Anemia in the absent of blood loss C. Stages of Chronic Kidney Disease: Stage

Description

1

Kidney damage with normal or inc. GFR Kidney damage with mild dec. GFR Moderate dec GFR Severe dec. GFR Kidney failure

2 3 4 5

GFR (ml/min/1.73^2) = 90 60-90 30-59 15-29 15 ml/min. 4. Prevent and correct the metabolic derangement and preserve the remaining renal function. Orders: Admit to: Diet: 35 Kcal/kg/day, low salt (2-4 gm sodium/day), low potassium (2-4 gm potassium/day, low phospate (600-800 mg phosphate/day), protein pre- hemodialysis or GFR < 2 ml/min is 0.6-0.75 gm/kg/day, protein on hemodialysis is >1.2 gm/kg/day, protein post-dialysis is >1.3 gm/kg/day VS: Vital signs q 1 hour with neurochecks refer for urine output < 20 cc/hour Nursing Weigh daily. Avoid magnesium-containing antacids, NSAIDS & otherNephrotoxin No BP:or IV line one arm IVF: Limit total fluid intake to 1-1.5 liters/day, depending on the urine output Diagnostics: Ultrasounsd of kidneys (Check for etiology or renal failure always rule out obstructive cause, check for small contracted kidneys, rule out renovascular disease) CBC(Anemia), K, Ca, TPAG, Inorganic phosphate, Lipid profile Monitor BUN & Creatinine, Urinialysis Nuclear GFR 24-hour urine collection for quantitative and endogenous creatinine clearance (if CRI/CRF disease

is stable) Therapeutics: 1. Fluid restriction For patients with congestive heart failure, hypertension, hyponatremia or excessive weight gain. 2. Acidosis: NaHCO3 grain X 1 tab TID aim for bicarbonate level of 24 umol.L for CRF patients. 3. Hyperkalcmia (see Hyperkakenia chapter) 4. Hypertension: Treat aggressively Use Ace-inhibitors or Angiotensin II antagonists if without contraindication. 5. Hyperphosphatemia: CaCO3 500 mg 1 tab TID to be given at the beginning of meals Maintain serum phosphorus at 4.5-6.0 mg/dl to prevent renal osteodystrophy 6. Anemia: a: Correct iron defficiency first. Give PO or IV iron if unable to achieve transferrin saturation at 25-35 % and Ferritin levels at 200-500 mg/ml. b. Erythropoietin 50-150 units/kg SC 1-3X/week to maintain hematocrit of 32-38. 7. Symptomatic Hyperuricemia Give Allopurinol 100 mg 1 tab OD 8. Hypocalcemia: Calcitriol (Rocaltrol) tab or CaCO3 tab TID 9. Vitamins Multivitamins tab OD, Vitamin C sparingly 10. Other Options: Ketoanalogues (Ketosteril) 600 mg 1-4 tabs TID Note: Adjust all drug dosages according to Glomerular Filtration Rate. To Nephrology Page To Main Table of Contents To Detailed Table of Contents

HYPOKALEMIA To Nephrology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Diarrhea, laxative abuse use diuretics vomiting, check for hypertension (hyperaldosteronism or glucocorticoid excess), renal tubular acidosis, polymyositis, hypokalemic peroidic paralysis. B. Principles of Management of Hypokalemia:, 1. The clinical context dictates the need for therapy of hypokalemia. Hypokelemia per se does not necessarily justify treatment with potassium supplements or potassium sparing diuretics. 2. Assess the etiology (redistribution versus deficit) of the hypokalemia. 3. Assess and correct acid-base balance and extracellular fluid volume abnormalities. 4. Assess the level of renal function 5. Assess and correct serum tonicity and serum magnesium, if needed. 6. Normokalemia or hypokamia in a context of metabolic acidosis or serum hypertonicity often indicates potassium deficits. 7. Potassium-sparing diuretics should not be used in patients at risk (patients with decreased renal function or patients receiving drugs impeding potassium homeostasis). 8. Only resistant hypokalmia justifies the use of two simultaneous treatment modalities of hypokalemia. 9. Assess the potential attribution of medications to hypokalemia and the underlying pathophysiology causative of hypokalemia and correct whenever possible. 10. Evaluate concurrent medications and/or existing clinical conditions that may aggravate the conscqueneps, of hypokalemia 11. Discontinue treatment of hypokaiemia whneever concentration is about 3.5-4.0 meq/l for fear of "overshoot" hyperkalemia or until a pattern of response is clearly established. 12. Whenever treating hypokalemia, follow the response to treatment by serial measurements of serum potassium concentration and if indicated, acid-base status. 13. The oral route of potassium replacement, using potassium chloride, is the safest and the preferred modality of treatment. The intravenous route of therapy should be reserved for extreme situations. C. Estimation of Potassium Deficit: 1. For a fall in serum potassium from 4.0 to 3,0 meq/l body potassium deficit is 200-3000 meq/70kg body weight 2. For serum potassium at 2.5 meq/L body deficit is 500 meq/70 kg body weight 3. For serum potassium at 2.0 meq/L body deficit is 700 meq/70 kg body weight Orders: Diagnostics: CBC, Serum K, repeat Serum K in 2-3 days Na, Ca, Mg, ABG Urine K, Urinalysis Therapeutics: 1. The oral route of administration is the safest and preferred mode of potassium replacement. Oral potassium should be given preferably as liquid with or after meals, or as tablet, which must be swallowed and not allowed to dissolve in the mouth; Dose depends on the clinical situation and the estimated deficit. e.g. Per Orem: Kalium durule 0.75gm (10 meq) TlD PO X 2-3 days or Oral KCl Solution 15-30 cc TID (1 gm KC1 = 14 meq K+) to be further diluted in oral feeding or water. Note: Each oral dose should not exceed 20-40 meq K+ 2. When potassium is provided by the intravenous route the use of peripheral vein is preferred over a

central route. The maximum rate at which potassium can be safely given into peripheral veins is usually 10-20 meq/hour. Higer rate maybe administeres if the clinical situation warrants more rapid correction of the hypokalemia. Usual concentration is 20-40 meq potassium in 1 liter of saline or dextrose solution. One must be aware of a decrement in serum potassium of about 0.2-1.4 meq/liter when potassium is administered glucose solute. e.g. Intravenous: Add 20-60 meq KCl in Plain NSS X 12 hours If potassium level is < 2 and (+) ECG abnormalities use glucose-free solution. When fluid restriction is necessary, up to 20 meq per 100 ml can be cautiously given over 1 hour via a microdrip. Higher concentrations of KCI may cause skin burns. 3. In the setting of severe hypokalemia, potassium can be delivered into the femoral vein with the tip of the catheter not in dose proximity to the heart The rate of administration should not exceed 60 meq/hour. To Nephrology Page To Main Table of Contents To Detailed Table of Contents

HYPERKALEMIA To Nephrology Page To Main Table of Contents To Detailed Table of Contents Data: General Approach to the Management of Severe Hyperkalemia A. Determination of severity 1. Serum potassium and the acuteness and rate of its rise 2. Clinics manifestatioas – ECG changes, cardiovascular, neuromuscular B. When possible, rapid determination of etiology 1. Inadequate renal excretion from renal failure with oliguria 2. Drugs that inhibit Renin-Angiotensin-Aldosterone system such as Beta-blockers, ACE-inhibitors, or NSAIDs C. Immediate discontinuation of all sources of potassium intake and agents that affect potassium homeostasis. D. Reversal of membreane abnormalities: Emergency treatment 1. Calcium gluconate 2. Hypertonic NaCl to yponatremic patients 3% NaCl or 50 ml sodium bicarbonate to 1 liter of NSS E. Redistribution of potassium from the extracellular space to the intrracellular space 1. Sodium bicarbonate IV 2. Insulin and glucose 3. Stimulation of Beta-2 adrenorcceptors (Salbutamol nebulization) F. External removal of potassium l. In stools: Cation exchange resin (Kayexelate or Sorbisterit) 2. In urine Increase urine flow rate and distal tubular delivery of sodium (loop diuretic: Furosemide IV bolus 70-80 mg) 3. By dialysis: Homodialysis or peritoneal dialysis Orders: Diagnostics: CBC Serum K, BUN, Creatinine, ECG-12 lead Therapeutics: A. Creatinine normal and not oliguric 1. Recheck serum potassium 2. Stop drugs which increase potassium (Beta-blockers ACE-inhibitors, NSAID) 3. Check other etiology of hyperkalemia B. Creatinlne increased and/or oliguria 1. Mild hyperkalemia (potassium level < 5.5 mmol/L): Restrict potassium intake; stop culprit drugs 2. Moderate hyperkalemia (potassium level = 5.5-6.5 mmo/L): a. Kayexelate or Sorbisterit 20 grams in 150 cc juice TID x 3 doses only (up to 4-5 doses/day) b. Diuretics: Furosemide 40-80 mg IV stat dose c. Optional: Beta -agonist (Salbutamol) nebulization 3. Severe hyperkalemia (potassium, level > 6.5 mmol.L) and/or (+) ECG changes: Mnemonic: G C S - Glucose, Calsium, gluconate & Sodium bicarbonate a. Calcium gluconate 10 ml 1 amp in 10% solution slow IV push in 5 minutes (at 2 ml/min) if with ECG changes. Repeat after 10 minutes if no improvement.. b. Glucose-Insulin: i. 50 ml of 50 % dextrose in water plus 10 units insulin in 2-5 minutes e.g. Mix D50-50 ml. + 10 units Humulin R slow IV stat then q 6 hours x 3 doges or ii. 500 ml of 10% dextrose 10 units insulin over 30-60 minutes (if volume overload is

not a problem) or iii. 1000 ml of 10% dextrose + 20 units insulin with one-third of the solution given in the first 30 minutes and the remainder over the subsequent 2-3 hours. Note: Method(a) can be repeated, if necessary, or can be followed by either (b) or (c). The latter 2 techniques lend themselves nicely to the additional maneuver of adding sodium bicarbonate (50-100 meq/L) to the dextrose solution. Potassium shift occurs in 30 minutes but benefits last for several hours. It is the best way to decrease potassium. c. Sodium Bicarbonate 1 amp slow IV push in 10 minutes Potassium shift occurs in < 15 minutes, with duration of 1-2 hours; this is the fastest way to decrease potassium. d. Beta-2 agonist :Albuterol (5 mg/ml) 20 mg by inhalation over 10 minutes. Onset of action is 15-30 minutes. 4. Prepare patient for dialysis if with renal failure or unresponsive to above measures. To Nephrology Page To Main Table of Contents To Detailed Table of Contents

HYPOCALCEMIA To Nephrology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Hypoalbuminemia, chronic renal failure, hypoparathyroidism (decreased PTH), acute hyperphosphatemia, hypermagnesemia, vitamin D defeciency, acute pancreatitis, sepsis, burns, multiple extracted blood transfusion Note: Fifty percent of ICU patients have calcium levels < 2.1 mmol/L (8.5 mg/dl but only 40% have decreased ionized calcium. To determine if true hypocalcemia is present add 0.8 mg/dl to serum calcium for every 1 gm/dl decrease of serum albumin below 4 gm/dl. B. Symptoms: Tetany, Trosseau's sign, Chvostek's sign, depression, lethargy, rarely seizures Orders VS: Vital signs q 1 hour, neurocheck q 4 hours Watch out for signs of tetany or abnormal mental status Nursing: Ambulate often Input and Output q shift; weigh daily; seizure precautions Diet: No salt added Diagnostics: CBC, serum Ca,Mg, TPAG, Creatinine, PTH (increased) Serum Phosphorus (decreased in Vitamiri0 deficiency) ECG(long QT), Urinalysis ABG Therapeutics: Treatment of Symptomatic Hypocalcemia: 1. Correct for hypoalbuminemia: A fall in serum albumin of 1 gm/dl is associated with a fall of 0.8 mg/dl in total calcium. For example: Present (total calcium = 8 mg/dl Present serum albumin 2.5 gm/dl Normal serum albumin = 4.0 gm/dl Correction = (4.0-2.5) x (0.8) = 1.2 Corrected total calcium = (8 +12) mg /dl = 9.2 mg/dl 2. Sodium gluconate 10% solution of 10ml/amp: 1-2 amp slow IV push (in 10-15 rninutes) with cardiac monitoring then incorporate 1 amp Calcium gluconate to present 1V fluids 3. Chronic treatment of hypocalcemia a. Calcium Carbonate (Calci--Aid, Calsan 500 kg 1 tab BID-TID b. Vitamin D3 supplements: Calcitriol 0.25 mcg cap OD-BID (Dose: 0.5-1..0 mcg/day) 4. Treat hypomagnesemia 5. Patients with severe or recurrent symptoms have a continuous infusion of dextrose solution containing an elemental calcium concentration of 15 mg/liter over 4-6 hours Note: Calcium + Sodium Bicarbonate are not compatible IV mixtures To Nephrology Page To Main Table of Contents To Detailed Table of Contents

HYPERCALCEMIA To Nephrology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology: Ninety percent me due to hyperthyroidism (increased PTH) or malignancy (normal PTH) B. Symptoms: Most own dehydrated, anorexia, nausea, vomiting, constipation, weakness, confusion to stupor C. Complications: Nephrolithiasis, obstructive renal failure Orders: Diet: Restrict calcium to 400 mg/day; Push oral fluids; 4-8 grams of salt pet day Diagnostics: CBC, Serum Ca, Na, Mg, Serum PTH levels TPAG, Creatinine Chest X-ray, ECG, Mammogram, Renal ultrasound Therapeutics: 1. Hydrate patient; Give 0.9% NSS at 150-600 cc/hour until no longer hypotensive; up to 1-4 Liters in 24 hours Note:, Severely hypercaloemic patients are almost always dehydrated. 2. Saline diuresis with 0.9% or 0.45% saline infused at 300-600 cc/hr to replace urine, loss 3. Consider Furosemide 20-40 mg IV q 8-12 hours after volume repletion. And if necessary. to prevent congestive heart failure, maintain urine output at 100-500 ml/hour. Avoid Thiazide diuretics. 4. Measure and replace serum sodium, potassium, magnesium 5. Other treatment options: a. For bone metastasis: Hydrocortisone 5 mg/kg IV q 8 hours then Prednisone 20-50 mg PO BID. Reduce dosage in 10 days as serum calcium decreases. b. Calcitonin salmon (Miacalcic) 50-100 iu SQ or IM OD-BID c. Biphosphonates (avoid in patients with renal failure) Pamidronate(Aredia) 30-90 mg/day given as a single 24-hour infusion for 3 days. To Nephrology Page To Main Table of Contents To Detailed Table of Contents

HYPONATREMIA To Nephrology Page To Main Table of Contents To Detailed Table of Contents Data: Algorithm 5-2. Clinical Approach to Hyponatremia — —

Decreased Na < 135 meq/liter Plasma Osmolality = [2(na)] + BUN(mmol/L) + Glucose(mmol/L) o Normal (280-295 mosm/kg H2O – check for hyperlipidemia (lipid profile) or hyperproteinemia as (TPAG) in multiple myeloma o High (>295 mosm.kg H2O) – etiology: check for hyperglycemia, mannitol treatment o Low (15) — Urine Na >20 mg/L o Renal Loss, RTA diuresis, Adrenal insufficiency, ketonuria o Tx: Isotonic Saline — Urine Na < 10 mg/L o 3rd space loss, GI loss o Tx: Isotonic Saline § B. Euvolemia (no edema) — Urine Na >20 mg/L o SIADH (lung, CNS dse., drugs), hypothyroidism, renal failure, Addison’s dse., stress, drugs — Urine Na 20 mg/L o ARF, CRF o Tx: Water restriction — Urine Na 126 mg/dl (7.0 mmol/L) on two separate occasions; b. Following ingestion of 75 gm of glucose: Blood sugar > 11.1 mmol/L (200 mg/dl) at 2 hours post-prandial and at least one other occasion. Note: Normal Fasting Blood Sugar is < 100 mg/dl (< 5.6 mmol/L) Impaired Fasting Glucose is 100-125 mg/dl (5.6 – 6.9 mmol/L) 4. Goals of Treatment: a. Hemoglobin A1C < 7% b. Fasting Blood Sugar between 5.0-7.2 mmol/L (90 -130 mg/dl) c. Peak post-prandial glucose < 10 mmol/L (180 mg/dl) 5. Diabetic Management: A. Non-pharmacologic (Step 1) 1. Diabetic Diet (see Nutrition chapter) Ideal Body Weight = [(Height in inches X 2.54) - 100] - 10% (if female) Ideal Body Weight X 35 cal/Kg = Total calories/day Sample: Total calories = 2000 cal/day 60% Carbohydrate: Total cal/day X 0.60 = 1200 cal /4 = 300gm carbo 220% Protein: Total cal/day X 0.20 = 400 cal / 4 = 100 gm protein 20% Fat: Total cal/day X 0.20 = 400 cal / 9 = 45 gm fat 2. Exercise regularly. 3. Weight reduction for overweight patients. B. Pharmacologic (Step 2): Oral Hypoglycemic Agents Sample Treatment for Type II Diabetes Mellitus Step 1: Non-pharmacologic treatmeat: Diet, exercise, weight reduction Step 2: Oral Hypoglycemic Agents a Start with Sulfonylareas: e.g. Start older patients with Glipizide (Minidiab) and younger patients with Glibenclamide Begin with low doses then maximize dose if blood glucose is uncontrolled Target FBS of = 140 mg/dl. Adjust dose every 2 - 4 weeks. -/+ b. Add Biguanides if still uncontrolled with Sulfonylureas: e.g. Metformin 500 mg tab TID

-/+ c. Add Alpha-glucosidase inhibitor if with post-prandial hyperglycemia: e.g. Acarbose (Glucobay) 50-100 mg tab TID w/ first mouthful of food. + d. Add Thiazolinediones (insulin Seasitizers): e.g. Rosiglitazone (Avandia ) 4 - 8 mg tab OD Step 3: Shift to Insulin treatment if still uncontrolled with oral hypoglycemic agents Table 6-2 Oral Hypoglyemic Agent: Types and Characteristics. OHA Type 1. SU a Glipizide (Minidiab) 2.5, 5 mg tab

Peak Level 1-3hr

Durations

Indication

Side Effects (SE)

15hr Short acting

Older Diabetics (Type 2)

Hypoglycemia

b. Gliclazide (Ritemed Gliclazide) 80 m tab

2hr

18hr Intermediate

Older Diabetics

Hypoglycemia

c. Glibenclamide(Hovid Glibenclamide (=), Euglucon d. Glimepiride(Solosa)1, 2, 3 mg tab e. Chlorpropamide (Diabinese) 250 mg tab

4hr

24hr Intermediate

Younger Diabetics

Hypoglycemia

2. Biguanides:Metformin (Neoform (=500 mg tab) (Gucophage 500, 850mg tab) 3.Alpha-glucosidase inhibitor: a. Acarbose (Glucobay) 50, 100 mg tab

24hr Intermediate 4hr

60hr Long-acting

Difficult to control diabetics, Patients with poor compliance Overweight patients with insulin resistance

Hypoglycemia, Steven-Johnson’s, Hyponatremia CI:Renal and Hepatic Failure

Post-prandial hyperglycemia

CI: Renal failure, liver dse. SE: Flatulence, diarrhea

Post-prandial hyperglycemia

Flatulence, diarrhea

24-30hr

Insulin resitance

3-4hr

Postprandial hyperglycemia, All type I diabetes

Increase liver enzymes, edema, weight gain Hypoglycemia CI: renal and Hepatic Failure

7-12hr

b.Voglibose (Basen) 200, 300 mcg

4. Thiazolidinediones: Rosiglitazone (Avandia) 5. Insulin secretagogues: Repaglinide (Novonorm)

Hypoglycemia

CI: Renal failure, liver disease, lactic acidosis

C. Insulin Treatment: 1. Types of Insulin: a. Short-acting: Humulin-R, Actrapid HM, Humalog (insulin analog) b. Intermediate-acting: Humulin-N Monotard HM, Protaphane HM c. Long-acting Humulin ultralente, Ultratard HM Table 6-3 Bioavailability of Insulin After SC Injection

Ave. Dose (mg/day) 2.25mg tab BID-TID 30 mins AC(before meals) Max:40mg/day 80 mg tab BID-TID with food Max:320mg/day 2.5-5 mg tab OD-BID with food Max:20mg/day 1,2,3 mg tab OD with food Max:8mg/day 250mg OD in a.m. with food Max:500 mg/day

Primary Mechanism Increase insulin secretion

500 mg tab TID; 850mg forte tab BID with food Max:3gm/day 50-100mg tab TID with first mouthful of food. Max:300 mg/day 200-300mcg tab TID Max:600 mcg/day 4-8mg tab OD Max: 8mg/day

Decrease hepatic glucose output

0.5-2 mg tab TID before meals Max: 6 mg/day

Increase insulin secretion Increase insulin secretion Increase Insulin secretion Decrease hepatic glucose output

Delay GI absorption of carbohydrates

Delay GI absorption of carbohydrates Increase insulin sensitivity Increase insulin secretion

Short-Acting (R) Intermediate (N) Long-Acting (L)

Onset 15 min.

Peak 2-4 hr

Duration 6-12hr

2-4 hr

8-12hr

18-24hr

4-6 hr

24-36hr

2. Three Different Insulin Regimens: a. Insulin Alone (currently accepted) Shift completely to Insulin after failure of maximal oral hypoglycemics i. Single-dose: Less optimal control of postprandial blood glucose but convenient for the patient (once-a-day injection) ii. Split-dose:Better control than single-dose e.g. Humulin 15 units N SC at 6 a.m. (2/3 as morning dose) Humulin 5 units N SC at 6 p.m. (1/3 as evening dose) iii. Split-mix: Better control than single-dose or split-dose e.g. Humulin N 14 units, Humulin R 6 units at 6 a.m. Humulin N 7 units, Humulin R 3 units at 6 p.m. b. BIDS (Bedtime Insulin and Daytime Sulfonylureas) Combined Insulin & Oral hypoglycemic agents e.g. Diamicron 80 mg 1 tab TID PO 30 minutes before meals Humulin N 10-20 units SC at night c. Insulin + Oral Hypoglycemic Agents: Add Insulin treatment on top of Oral hypoglycemic agents Choose any of the 3 regimens in No.1 (usually Single-dose or Split-dose) eg. Humulin N 20 units SC at 6 a.m. single-dose + Diamicron 80 mg I tab TID 30 minutes premeals 3. Blood Sugar Monitoring of Patients: a. Out-patient: Two hours post-prandial, FBS, Hgb A1C b. In-patient: CBG (Capillary Blood Glucose) monitoring CBG OD = 6 a.m. premeals or 2 hours post-prandial (after) lunch CBG BID = 6 a.m. - 6 p.m. premeals CBG TID = 6 a.m. - 12 noon - 6 p.m. premeals CBG QID = 6 a.m. - 12 noon - 6 p.m. - 12 midnight premeals 4. How to Calculate the Daily Insulin Requirement of an In-patient. Step 1: Use Insulin Sliding Scale for 1 day only to observe daily insulin requirement of the patient. CBG < 160 = no insulin CBG 160 - 200 = 4 units Humulin R SC CBG 200-300 = 6-10 units Humulin R SC CBG 300-400 = 10-14 units Humulin R SC CBG > 400 = call Attending Physician Step 2: Get total daily Insulin requirement to achieve reasonable control. e.g. 30 units needed for the day Step 3: For patients on oral diet give 2/3 of total daily Insulin requirement in the morning and 1/3 in the evening e.g. Humulin N 20 units SC at 6 a.m. + Humulin N 10 units SC at 6 p.m. Step 4: For patients on oral NGT feedings round the clock, give 1/2 of total daily dose at 6 a.m. and 1/2 at 6 p.m. e.g. Humulin N 15 units SC at 6 a.m. + Humulin N 15 units SC at 6 p.m. Note: Give additional short-acting insulin as rescue doses for CBG > 200 mg % 5. For Type I Diabetes Mellitus: Refer these patients to an Endocrinologist for strict insulin treatment.

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DIABETIC KETOACIDOSIS / HYPEROSMOLAR NON-KETOTIC COMA To Endocrinology Page To Main Table of Contents To Detailed Table of Contents Data: Clues to Diabetic Ketoacidosis (DKA) or Hyperosmolar Non-Ketotic Coma (HONC): l. Increase random blood sugar 2. Increase plasma osmolality > 320 mosm/L 3. Metabolic acidosis 4. Ketonemia: (+) ketones in DKA and (-) ketones in HONC Orders: Admit to: Diet: NPO temporarily VS: Vital signs q 1hour; Postural BP & pulse; Neurochecks q 4 hours Call MD if Urine Output < 30 cc/hour Nursing: I & O; Place foley catheter; Consider NGT and CVP; Oxygen at 2-5 lpm bynasal cannula or use face mask; Record all labs on flow sheet Diagnostics: CBC, Serum urine Ketones, Hgb A1C, ABG, CXR, ECG RBS, HGT q 1-4 hours initially, Na, K, Cl, Urinalysis BUN, Creatinine, Phosphate, Amylase (pancreatitis common in DKA) Compute serum osmolality: [2(Na)]+ Glucose (mmol/L) + BUN (mmol/L) Compute Anion Gap: Na - (Cl+ HCO3) Monitor: RBS, pH (normalizes) and anion gap (narrows) Therapeutics: Mnemonic - FIE (Fluids, Insulin, Electrolytes) 1. Fluid Replacemeat a. Correct the volume deficit. Frequent clinical assessment is needed. Consider bladder catherization and CVP insertion. Caution is indicated in treatment of the elderly, especially those with MI, CHF or renal insufficiency. b. IV Fluids: 0.5-5 liters NS over 1-7 hours, infuse at 400-1000 ml/hour until hemodynamically stable c. Maintenance fluids: D5 0.3NaC1 is appropriate at 100-200 ml/hour 2. Insulin Treatment a. Insulin Regular (Humulin R) 5-15 units (0.2 units/kg) IV or IM every hour until CBG decreases to 250 mg % or Use Insulin Drip at 2-10 units per hour till CBG =250 mg % Change to Insulin Sliding scale SC when ketones & anion gap are normal b. If CBG =250 mg%, may use D5R or D5NM at 100-250 cc/hour Keep Urine Output greater than 40 cc/hour 3. Electrolyte Management a. Potassium: Anticipate potassium deficit with insulin treatment b. If urine output is adequate, and Serum K < 5.8 meq/L add KC1 in concentration of 20-40 meq KC1 per liter of IVF c. Bicarbonate: for pH < 7.1, give Na Bicarbonate IV to correct ketoacidosis d. Phosphate: Check for hypophosphatemia To Endocrinology Page To Main Table of Contents To Detailed Table of Contents

THYROID STORM To Endocrinology Page To Main Table of Contents To Detailed Table of Contents Data: A. Signs and Symptoms: Irritability, delirium, coma, high fever, tachycardia, hypertension, sweating, restlessness, vomiting, diarhhea; older patients may present with less symptoms (apathetic thyrotoxicosis) B. Diagnostic Criteria for Thyroid Storm Table 6-4. Burch and Wartofsky’s Diagnostic Criteria for Thyroid Strom* Thermoregulatory Dysfunction Score Temperature 37.2-37.7C (99-99.9F) 5 37.8-38.2C (100-100.9F) 10 38.3-38.8C (101-101.9F) 15 38.9-39.3C (102-102.9F) 20 39.4-39.9C (103-103.9F) 25 >40C (=104.0 F) 30 Central Nervous System Effects Absent 0 Mild (Agitation) 10 Moderate 20 Delirium Psychosis Extreme Lethargy Severe (Seizure, Coma) 30 Gastrointestinal-Hepatic Dysfunction Absent 0 Moderate 10 Diarrhea Nausea/Vomitting Abdominal pain Severe (unexplained 20 jaundice) Cardiovascular Dysfunction Tachycardia (beats per minute) 99-109 5 110-119 10 120-129 15 130-139 20 = 140 25 Congestive Heart Failure Absent 0

Mild Pedal edema Moderate Bibasal rales Severe Pulmonary edema Atrial Fibrillation Absent Present Precipitant history Negative Positive

5 10 15

0 10 0 10

* In patients with severe thyrotoxicosis, points are assigned to the highest possible weighted description applicable in each category and scores totaled. When it is not possible to distinguish the effects of an intercurrent illness from those of the severe thyrotoxicosis per se, points are awarded such as to favor the diagnosis of storm and hence empiric therapy. A score of 45 or greater is highly suggestive of thyroid storm; a score of 25-44 is suggestive of impending storm, and a score below 25 is unlikely to re represent thyroid storm. Source: Burch, H.B. & Wartofsky, L. (1993). Life-threatening Thyrotoxicosis: Thyroid Storm.Endocrinol Metab Clin North Am, 22, 263-277. C. Complication: May exacerbate heart failiure and coronary artery disease D. Differential Diagnosis: Sepsis, hemorrhage, drug reaction E. Treatment: Identify and treat precipitating event, i.e. infection, surgery, amiodarone, anti-thyroid drug withdrawal, etc. Orders: Diet: No added salt VS: Vital signs q 1 hour Nursing: I & O; Seizure & aspiration precautions; Cooling measures for fever IVF: D5NM X 8-12 hours Diagnostics: Ultrasensittve TSH Irma (decreased), Free T4 (increased) CBC,Na, K, Urinalysis, Creatinine Chest X-ray, ECG Monitoring of treatment: Check Plasma T4 after 4 weeks. Decrease dose of PTU and iodine as plasma T4 normalizes. Therapeutics: 1. Propylthiouracil or PTU 50 mg tab: PO- 100-200 mg PO q 4-6 hours, maximum dose 1200 mg/day, usual maintenance dose 50 mg OD - BID Drug of Choice for (1) acute thyroid crisis because it also inhibits peripheral T4 to T3 conversion, and (2) pregnant patients. or Methimazole (Tapazole) 5 mg tab: PO- 10-20 mg every 6 hours, maintenance dose 5 mg OD-BID, maximum dose 120 mg/day Better drug for maintenance because of less agranulocytosis or Carbimazole (Neo-Mercazole) 5 mg tab, 20 mg tab: PO- 20-60 mg/day initially then maintenance at 5-15 mg/day 2. a. Propranolol (Inderal, Duranol) 10 mg tab, 40 mg tab PO- l0-40 mg TID - QID or Beta-blockers: Esmolol HCl (Brevibloc) IV or Verapamil 40-80 mg tab TID PO Adjust dose to prevent tachycardia, defer for HR < 60 bpm and BP < 100 mmHg. Caution in patients with moderate to severe heart failure. b. For Acute Atrial fibrillation: Digoxin 0.25-0.5 mg IV then PO Patients with thyrotoxicosis are relatively resistant to Digitalis, and may require higher loading doses.

3. Sodium iodine 1 gm IV q 8 hours or Iodone 1 tab TID or Potassium Iodine (Lugol's Solution) 2-5 gtts PO q 8 hours, given 1 hour after PTU (give for a few days only) 4. Consider Dexamethasone 2 mg IV or PO q 6 hours for urgent relief of thyrotoxicosis (increase glucocorticoid requirement in thyrotoxicosis & reduced adrenal reserve). 5. Treat concomitant diseases 6. Symptomatic medications: Paracetamol, Sedatives To Endocrinology Page To Main Table of Contents To Detailed Table of Contents

HYPERTHYROIDISM To Endocrinology Page To Main Table of Contents To Detailed Table of Contents Data: Etiology: grave's disease (common in young patients), toxic multinodular goiter (older petients), painless thyroiditis subacute thyroiditis Orders: Diagnostics: Ultrasensitive TSH Irma (decreased) Free T4(increased) or Total T4 Free T3 (increased) or Total T3 Thyroid Scan, RAIU (useful in cases of thyroiditis) Therapeutics: 1. Medical treatment: a Thionamides: i. Propylthiouracil or PTU (Philusa Propylthiouracil) 50 mg tab Dosage: 50-150 mg PO q 8 hr starting dose, max. dose 1200 mg/day ii. Methimazole (Tapazole) 5 mg tab Dosage: 10-20 mg PO q 8 hours, maximum dose: 60 mg/day iii. Carbimazole (Neo-Mercazole) 5 mg tab, 20 mg tab Dosage: 5-15 mg PO q 8 hours, maximum dose 60 mg/day Note: Larger doses may be initially required for control b. Beta-adrenergic antagonists and other drugs for treatment of palpitations, tremors, anxiety i. Propranolol (Inderal, Duranol) 10 mg tab, 40 mg tab: PO- 10-40 mg TID-QID or Beta-blockers: Esmolol HCl (Brevibloc) IV Adjust dose to prevent tachycardia, defer for HR < 60 and BP < 100 Caution in patients with heart failure or ii. Atenolol (Tenormin, Therabloc =)) 50-100 mg tab OD for better compliance or iii. Verapamil (Isoptin) 40-80 mg tab TID PO or iv. Digitalization with Digoxin for Acute AF 0.25-0.5 mg IV 2. Radioactive Iodine treatment 131-I 3. Subtotal thyroidectomy (patient must be euthyroid prior to surgery) 4. Symptomatic meds: a. Sedatives for anxiety b. Paracetamol PO for fever 5. Treatment plan: a. Patient follow up: Check T3 and T4 every 4-6 weeks. TSH is the last to normalize. If T4 is still increased, increase dose of thionamides. Taper dose once T4 is normal. b. Sore throat and fever may mean agranulocytosis (WBC < 500). Patients may die of this complication. Stop anti-thyroid drugs immediately. Other drug side effects include hepatitis, jaundice, vasculitis, drug-induced lupus. To Endocrinology Page To Main Table of Contents To Detailed Table of Contents

HYPOTHYROIDISM I MYXEDEMA COMA To Endocrinology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiology Primary Hypothyroidism in 90% , either Hashimoto's thyroiditis or iatrogenic hypathyroidism due to radioactive iodine treatment surgery or drugs, (e.g. amiodarone) B. Signs and Symptoms: Cold intolerance, menorrhagia, myalgia, slow deep tendon reflexes, dry skin, non-pitting edema, weight gain, somnolescence, constitpation C. Differential Diagnosis: Hypopituitarism, Down's syndrome, nephritis, nephritic syndrome Orders: Admit to: VS: Vital signs q 1 hour Nursing: I & O; Triple blankets for hypothermia; Seizure & aspiration precautions IVF: D5NM X 12 hours Diagnostks: TSH Irma (increased in primary hypothyroidism,TSH > 20 units/ml) Free T4(deceased) CBC, ceram Na (deceased), serum K, RBS Cholesterol, Triglycerides, Uric Acid, Cardiac Enzymes, SGOT, LDH (all inc. ) ECG(low voltage and inverted T waves) 2D-Echo with Doppler (30%develop pericardial effusion or heart failure) Therapeutics: A. Prinary Hypothyroidism 1. Levothyroxine Na (Euthyrox, Eltroxin, Thyrax Duotsb) 25 mcg, 50 mcg and 100 mcg tab. Dose: 25-150mcg/day a. Start usually with 25-50 mcg/day. Use lower dosages (12.5-25 mcg/day) for patients over 60 years and those with cardiac disease. Treatment is for life. b. Watch out for Adrenal Failure: Signs and symptoms are hypotension, nausea, vomiting after starting treatment. 2. Course: Symptoms improve in weeks. Wale out for heart failure from too aggressive therapy. 3. Plan: Increase dose by 25-50mcg every 4 weeks until patient is euthyroid. 4. Goal of treatment is to maintain plasma TSH in the normal range. Monitor Plasma TSH q 3-4 months. B. Secondary Hypothyroidism 1. Monitor serum T4 and other pituitary hormones. 2. Give steroid replacement first prior to L-thyroxine replacement. C. Emergency Therapy for Myxedema Coma Rarely needed unless patient has severe illness: hypoventilation, hypothermia, bradycadia, hypotension and hypoxia 1. L-thyroxine 50-100 mcg IV q 6-8 hours for 24 hours in emergency cases then shift PO 75-100 mcg PO once patient can tolerate oral intake. 2. Hydrocortisone 100 mg IV q 6-8 hours given prior thyroxine treatment To Endocrinology Page To Main Table of Contents To Detailed Table of Contents

ADRENAL INSUFFICIENCY To Endocrinology Page To Main Table of Contents To Detailed Table of Contents Data: A. Primary Adrenal Failure or Addison's disease (decrease cortisol, increase ACTH) 1. Progressive adrenocortical destruction of > 90% 2. Etiology: Autoimmune, tuberculosis, metastasis hemorrhage, AIDS, chronic granulomatous disease 3. Signs and Symptoms: Hyperpigmentation due to increase ACTH (only in primary adrenal failure) increase K, volume depletion, weight loss, anorexia B. Secondary Adreanal Failure (decrease cortisol. decrease ACTH) 1. Disorder of hypothalamus or pituitary, secondary to gucocorticoid withdrawal 2. Signs and Symptoms: Weakness, fatigue, anorexia, nausea, vomiting, weight loss, gastrointestinal complaints, increase sodium, orthostatic hypotension C. Adrenal Crisis l. Etiology: Steroid withdrawal; rarely, sepsis, drugs (Rifampicin, Phenytoin, Ketoconazole, Opiates), illness or surgery Algorithm for diagnosis: — —

— —

Suspected Adreanal Insufficiency Screening Test a) Plasma cortisol =15mcg/dl b) Plasma cortisol 30 min after 250 mcg Cosyntropin (Acth) IM or IV 20 mcg/dl) CBC, Serum Na (decreased), Cl (decreased), HCO3 (decreased) Serum K(increased), BUN, Creatinine CT Scan of the Adrenals Therapeutics: A. Adrenal Crisis Treatment: 1. Diagnosis is known a. Hydrocortisone 100 mg IV q 6 hours Decrease dose in several days and shift to Prednisone PO

b. D5 0.9 NSS Fast drip until hypotension is controlled 2. Diagnosis is not established a. Dexamethasone 5-10 mg IV stat b. D50.9 NSS fast drip for hypotension c. Do Cortrosyn Stimulation Test. Check serum cortisol after 30 minutes, then give Hydrocortisone 100 mg IV q 6 hours d. Look for and treat underlying illness that precipitated the crisis. B. Maintenance Treatment for Addison's disease: 1. Glucocorticoid: Prednisone (DLI Prednisone, Prednisone Organon) 5 mg tab: 2.5-7.5 mg PO after meals Increase dose or shift to IV dose during illness, injury, surgery or in the post-operative period 2. Mineralocorticoid: Flurocortisone 0.05 to 0.1 mg PO 3. Increase sodium intake to 4-6 gm/day To Endocrinology Page To Main Table of Contents To Detailed Table of Contents

OSTEOARTHRITIS To Rheumatology Page To Main Table of Contents To Detailed Table of Contents Data: A. Synonyms: Degenerative joint disease, Osteoarthrosis B. Types: 1. Primary or idiopathic osteoarthritis 2. Secondary osteoarthritis C. Common risk factors: Age, major joint trauma, repetitive stress, obesity D. Clinical features: Joint pain on motion, relieved by rest, stiffness after inactivity lasting less than 30 minutes. C. Common joints affected: Fingers (distal interphalangeal joints and proximal interphalangeal joints), big toe, hip, spine and knees F. Diagnosis: Clinical and radiological G. Treatment goal: Reduce pain, maintain mobility, and minimize disability Orders: Diagnostics: X-ray of the involved joint CBC,ESR (to rule out Rheumatoid Arthritis) Therapeutics: 1. Pain Relief: a. Paracetamol 500 mg tab TID-QID b. If Paracetamol is inadequate, may use NSAIDS PO but avoid in patients with renal insufficiency and peptic ulcer disease, e.g. Mefenamic Acid =) 500 mg 1 tab TID. c. For high-risk patients such as the elderly with gastritis or history of ulcer, use specific COX-2 inhibitors: Celecoxib (Celebrex) 100 mg cap BID d. Topical NSAIDS: Diclofenac (Voltaren) emulgel 1%, apply TID-QID e. Intra-articular steroids f. Intra-articular hyaluronic acid 2. Supportive Treatment: a. Weight reduction for obese patient b. Correct posture, support lumbar lordosis, use knee brace, use a cane at the contralateral side, use crutches or walkers, use corrective shoes for flat foot. c. Physical therapy - isometric exercises to srengthen muscle around the joints, usually the quadriceps and hamstring muscles. Avoid isotonic exercises. d. Heat application e. Orthopedic surgery with arthrotomy or total joint replacement - for failed medical management To Rheumatology Page To Main Table of Contents To Detailed Table of Contents

GOUTY ARTHRITIS To Rheumatology Page To Main Table of Contents To Detailed Table of Contents

Data: A. Gender Predisposition: Male, post-menopausal female B. Types: 1. Primary – familial history 2. Secondary – blood dyscrasias, lymphomas C. Stages of Gout: l. Asymptomatic Hyperuricemia 2. Acute Gouty Attack - attack peaks at the second to third day after the first symptom and subsides within 7-10 days 3. Interval or intercritical gout 4. Chronic tophaceous gout 5. Nepbrolithiasis D. Common Joints Involved: First metatarsophahngeal joint, ankle, knee, wrists, fingers and elbow E. Complications: Uric acid nephropathy renal insufficiency, tophi deposition Orders: Admit to: Diet: Low purine diet VS: q 4 hours Nursing: Apply ice bag during acute episode, support sheets over foot IVF: D5NM 1 L X 16 hours Diagnostics; CBC, BUN, Creatinine, Uric acid, ESR FBS, SGPT Urinalysis, 24 hour urine-collection for urinary uric acid and creatinine clearance Synovial flaid exam for analysis of crystals culture and sensitivity, gram stain, cell count, protein and glucose X-ray views of joint Therapeutics: l. Asymptomatic Hyperurecemia a. Dietary restrictions (See Nutrition chapter) b. Treat associated problems: Hypertension, hypercholesterolemia, diabetes, obesity c. No antihyperuricemics needed at this stage. Unnecessary treatment with Allopurinol may cause Steven-Johnson's Syndrome. 2. Acute Gouty Arthritis: a. Colchicine 2 tabs now then followed by 1 tab q 1 hour up to 6-8 tabs/day until there is pain relief, vomiting, diarrhea, or abdominal pain; then give maintenance Colchicine 1 tab TID for 2 days then BID; if not tolerated use NSAIDS b. NSAIDs: Indomethacin (Indocid) 25 mg 1 cap TID with meals or Diclofenac sodium (Voltaren Forte) 50 mg 1 tab TID x 3 days then BID until acute attack disappears or Ketorolac (Toradol) 1 amp IM or IV q 4-6 hours Note: Avoid NSAIDS if with renal insufficiency or ulcer c. If with history of peptic ulcer disease or bleeding, use COX2 inhibitor: i. Celecoxib (Celebrex) 200 mg cap OD X 5 days or Rofecoxib (Vioxx Forte) 50 mg tab OD + ii. Proton-pump inhibitor: Esomeprazole (Nexium) 20 mg 1 tab OD d. Other Options: i. Steroids PO: Methylprednisolone (Medrol) 16 mg 1 tab OD X 2 doses only and H2-blockers ii. Intraarticular injection of glucocorticoids iii. Patenteral (IM or IV) steroid for 1-2 days: Hydrocortisone (Solucortef) 100 mg q 8-12 hours X 2 doses or Dexamethasone (Decadron) 4 or 5 mg IM or IV 3 & 4. Intercritical or Chronic Gout:

a. Colchicine prophylaxis b. Not in acute phase: Allopurinol (Allurase =) 100 mg, 300 mg tab) 100 mg 1 tab OD X 2 weeks then increase to 300-600 mg daily depending on level of serum uric acid 5. Nephrolithiasis a. Alkalinize urine with sodium bicarbonate grain X 1 tab TID – QID or Potassium citrate (Acalka) 1,080 mg 1 tab BID-TID b. Increase fluid intake to at least 1.5 - 2 liters/day c. Allopurinol 300 mg 1-2 tabs OD To Rheumatology Page To Main Table of Contents To Detailed Table of Contents

RHEUMATOID ARTHRITIS To Rheumatology Page To Main Table of Contents To Detailed Table of Contents Data: Diagnosis: The American College of Rheumatology 1987 Revised Criteria for the Classificationa of Rheamatoid Arthritis: l. Guidelines for Classification a Four of seven criteria are reuired to classify a patient as having rheumatoid arthritis. (Sensitivity = 91-94% Specificity = 89%) b. Patients with two or more clinical diagnoses are not excluded. 2. Criteria* a. Morning stiffness: Stiffness in and around the joints lasting one hour before maximal improvement. b. Arthritis of three or more joint areas: At least three joint areas, observed by a physician simultaneously, have soft tissue swelling or joint effusion not just bony overgrowth. The 14 possible joint areas involved are right or left proximal inter-phalangeal, metacarpophalengeal, wrist, elbow, knee, ankle, and metatarsophalangeal joints. c. Arthritis of hand joints: Arthritis of wrist, metacarpophalangeal joint, or proximal interphalangeal joint. d. Symmetric arthritis: Simultaneous involvement of the same joint areas on both shies of the body. e. Rheumatoid nodules: Subcutaneous nodules over bony prominences, extensor surf' or juxtaarticular regions observed by a physician. f. Serum theumatoid factor: Demonstration of abnormal amounts of serum rheumatoid by any method for which the result has been positive in less than 5 percent of normal control subjects. g. Radiographic changes: changes: Typical changes of rheumatoid arthritis on posteroanterior hand and wrist radiographs which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints. * Criteria a-d must be present for at least 6 weeks. Criteria b-e must be observed by a physician. Source: Lipsky, P.E. (2001). Rheumatoid Arthritis. In E. Braunwald, A. Fauci, D. Kasper, et al (Eds.), Harrison's Principles of Internal Medicine (p. 1934). New York: McGraw-Hill, Inc., with permission.

Orders: Diagnostics: CBC, Rheumatoid Factor, ANA test (screening test) ESR, C-Reactive Protein (both with disease activity) Synovial Fluid Analysis (inflammatory arthritis) X-ray of affected joint Therapeutics: l. Empirical and palliative treatment a. Patient education b. orthotic "support" devices 2. Pharmacologic treatment a. ASA and other NSAIDS b. Low glucocorticoids: Prednisone 5 mg tab to be given at 2.5-7.5 mg/day Vary the dose dependirig on the disease activity c. For moderate to severe end/or sustained disease activity, may use the following: i. Disease-modyfying anti-rheumatic drugs: Gold anti-malarials methotrexate, Leflunomide (Arava) ii. Immunosuppressive therapy: Azathioprine, Cyclophosphamide, Cyclosporins

iii. Anti-TNF alpha therapy: Enbrel or Infliximab iv. Anti-interteukin therapy Note: At present, it is the consensus that combination therapy of NSAIDS, low dose steroids and disease modifying drugs including anti-cytokine therapy be started as early as possible especially with very active disease. Since each of these drugs is associated with considerable toxicity, it is best to refer these patients to a Rheumatologist To Rheumatology Page To Main Table of Contents To Detailed Table of Contents

SYSTEMIC LUPUS ERYTHEMATOSUS To Rheumatology Page To Main Table of Contents To Detailed Table of Contents Data: Diagnosis: The 1982 Criteria for Classification of Systemic Lupus Erythematosus (SLE) 1. Guidelines for Classification: a If four of therse criteria are present at any time during the course of the disease, a diagnosis of SLE can be made with a 98% specificity and 97% sensitivity b. Some patients may present with only one or two criteria but may have SLE. A high index of suspicion is needed for early diagnosis c. Differential Diagnoses: Rule out drug-induced lupus secondary to hydralazine, isoniazid, procainamide, chlorprenazine and other vasculitides. 2. Criteria Mnemonic - SOAP BRAIN MD a Malar rash: Fixed erythema flat or raised, over the malar eminences b. Discoid rash: Erythematous raised patches with adberent keratotic scaling and follicular plugging atrophic scarring may occur c. Serositis: Pleuritis or pericarditis documented by ECG, or rub, or evident of pericadial effusion d. Oral ulcers: Includes oral and nasopharyngeal ulcers, observed by physician e. Arthritis: Nonerosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling, or effusion f. Photosensitivity g. Hematoloicdisorder (Blood): Hemalytic anemia or leukopenia (less than 4000/uL> or lymphopenia (less than 1500/uL) or thrombocytopenia (less than 100,000/uL) in the absorb of offending drugs h. Renal disorder: Proteinuria greater than 0.5 gm/day or greater than 3+, or cellular casts i. Antinudearantibodies: An abnormal titer of ANAs by immunofluorescence or an equivalent assay at any point in time in theabsence of drugs known to induce ANAs j. Immunologic disorder: Positive LE cell preparation or anti-dsDNA or anti-Sm antibodies or false-positive VDRL k. Neurologic disorder: Seizures without other cause or psychosis without other cause Source: Hahn, B.H. (2001). Systemic Lupus Erythematosus. In E. Braunwald, A. Fauci, D. Kasper, et al (Eds.), Harrison's Principles of Internal Medicine (p. 1925). New York: McGraw-Hill, Inc., with permission. Orders: Admit to: Diet: Low salt diet VS: q 4 hours Nursing: Avoid sulfonamides, penicillins, diphenylhydantoin, hydralazine Diagnostics: CBC w/ platelet count, Creatinine, PT, PTT Bleeding time, Coombs test Chest X-ray Complete Lipid profile Indices of disease activity. Agti-ds DNA, C3 levels, ESR C-Reactive Proteins, Rheumatoid Factor (differential diagnosis) Urinalysis, 24-hour urine protein ANA(screening test if positive, request ANA panel) Anticardiolipin antibody (indicated for recurrent abortion or vena-arterial occlusive diseases) Therapeutics:

l. Arthritis, serositis, myalgia: NSAIDS, ASA, anti-malarials, low steroid steroid 2. For active severe SLE (CNS, renal, hematologic) a. Prednisone 5 mg tab: PO-40-60 mg/day, maintenance dose of 10-20 mg or Methylprednisolone (Solu-Cortef) Pulse therapy (MPPT) 500-1000mg 1 amp in D5W 500 cc X 6 hours X 3 doses/3days (if with severe SLE and with organ damage) b. Cyclophosphamide (Cytoxan) 2-3 mg/kg/day in divided doses or Cyclophosphamide IV Pulse therapy: D5W 500 cc + 500-1000 mg Cyclophosphamide X 6 hours Give Metoclopromide (Plasil) 2 tabs before Cyclophosphamide drip c. Azathioprine (Imuran) 2 mg/kg/day PO (immunosuppressants) Note: For active disabling SLE or with serious organ involvement, requiring Pulse therapy with methylprednisolone or immunosuppressive therapy, it is appropriate to refer to an Internist or Rheumatologist. 3. Other treatment: a. For photosensitivity: Sunscreens b. Skin lesions: Hydroxychloroquine sulfate (Plaquenil) 200 mg BID – needs eye check-up q 6 months + Betamethasone dipropionate (Diprolene) 0.05% ointment or Triamcinolone acetonide (Kenacott, Ledercort) 0.1% cream BID c. Thrombosis: Coumadin PO anti-coagulation or low molecular weight heparin d. Osteoporosis: Calcium 1500 mg + Vitamin D (Caltrate Plus) 1 tab OD or Alendronate Na (Fosamax) 10 mg 1 tab OD To Rheumatology Page To Main Table of Contents To Detailed Table of Contents

CEREBROVASCULAR ACCIDENT: INFARCTION VS. HEMORRHAGE To Neurology Page To Main Table of Contents To Detailed Table of Contents There are currently far available stroke scoring systems to differentiate supratentorial brain hemorrhage from infarction. All of these stroke scores have recently been validated at the UP-PGH Medical Center and the results show that the Siriraj Scoring and Allen Scoring have the highest sensitivity (80-85 %) and specificity (70-80 %). Our preference is the Siriraj Stroke Score (See Table 8-1) because of its simplicity. Note also that no scoring system is 100% accurate. Therefore, in case of doubt, do stat CT Scan. Table 8-1. Siriraj Stroke Score Variables 1.Consciousness

2. Vomiting 3. Headache within 2 hours 4. Diastolic Blood Pressure (DBP)

5. Atheroma markers (including diabetes, angina, & intermittent claudication)

Clinical features

Score

Alert Drowsy, Stupor Semicoma, coma No Yes No Yes Actual DBP in mmHg

0 2.5 5 0 2 0 2 DBP x 0.1

Sample patient* 0

2 2 90 mm Hg x 0.1 =9 points

None

0

One or More

3

3

-12 Total=

-12 +4

Constant

* Sample scoring for a hypothetical 50 year old male t with an acute shake syndrome. On consultation, he is alert and has complained of vomiting and headache after the onset of left-sided weakness. He has a history of diabetes mellitus and blood pessure is 150/90 mmHg. Based on this information, the patient’s stroke score per variable is given in the right-hand column. The total score is + 4, which is above the cut-off of 2 points, indicating a bable hemorrhagic stroke. Score Interpretation: = +2 = Most likely HEMORRHAGE - 1, 0 and+ 1 = Equivocal result (CT Scan recommended) = -2 = Most likely INFARCTION Source: Poungvarin, N. et al (1991). Siriraj Stroke Score and Validation Study to Distinguish Supratentorial Inlracerebral Hemorrhage from Infarction BMJ 302 1565-7.

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INTRACEREBRAL HEMORRHAGE To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: A. Hypertensive Bleed Signs Based on Location of Hemorrhage 1. Putamen: Depressed sensorium, contralateral hemianopsia, contralateral hemiparesis, pupils normal 2. Thalamus: Depressed sensorium, eyes deviated downwards, skew deviation, hemiparesis, pupils sluggish, deep conjugate gaze 3. Lobar: No coma, pupils normal, hemiparesis or hemisensory, (+) seizure 4. Pons: Early coma, pinpoint pupils, (-) doll‘s eye, quadripaesis, ocular bobbing ,(-) seizures 5. Cerebellar: Late coma, pupils small but teactive, ataxia gait, dizziness, vomiting B. Surgical Option: l. All cerebellar bleeds or infarcts > 15 ml needs a neurosurgical referral 2. All supratentorial bleed > 50 ml needs neurosurgieal evaluation Orders: Admit to: Diet: NPO VS: Neuro vital signs q 1 hour; Monitor pupil size and refer if =1mm difference Nursing: Input & Output q 4 hours & record; Insert NGT and foley catheter Moderate high back rest at 30 degrees Keep PCO2 between 25-29 mm Hg IVF: D5NSS 1 liter X 16 hours (if on NPO) D5NSS 1 liter X 30 cc/hr (once on oral feeding) Diagnostics: CT Scan stat CBC with platelet, Na, K, Creatinine, RBS ABG, Urinalysis, Lipid profile Chest X-ray,ECG Therapeutics: Oxygen at 2-3 lpm via nasal cannula 1. Mannitol 100 cc q 4 hours or 75 ml q 4-6 hours as side drip, Set drip 100-200 cc initially 2. H2-blockers or Proton pump inhibitors, e.g. Ranitidine 50 mg IV q 8 hours 3. Hypertension: a. In acute intracranial hemorrhage, gradual lowering of blood pressure is recommended b. Target BP of 150-160/90-100 mm Hg c. If SBP > 180 mm Hg, start Nicardepine drip 10-20 mg in 90 cc NSS. Start at 10 ugtts/min and then increase gradually. 4. Consider intubation with hyperventilation 5. Consider neurosurgical evaluation for large putaminal, lobar and cerebellar hematomas and for AV malformations. To Neurology Page To Main Table of Contents To Detailed Table of Contents

SUBARACHNOID HEMORRHAGE To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: Etiology: Usually due to ruptured aneurysm or ruptured arteriovenous malformation. Aneurysm is more common in the elderly while ruptured arteriovenous malformation is more common in the young and female population. Orders: Admit to: Diet NPO VS: Neuro vital signs q 1 hour; Monitor pupil size and refer if = 1 mm difference Nursing: CBR without toilet privileges; Keep room dark and quiet; No rectal exam IVF: D5NR 1 liter x 16 hours (if on NPO) D5NM 1 liter x 30 cc/hr (once on oral feeding) Diagnostics; CT Scan of the Head (if normal, may do MRI) Lumbar tap (check for blood and xanthochromia) provided there is no contraindication Cerebral Angiography: Four-vessel arteriography (The gold standard to determine the souse of bleeding) CBC with platelets, Na, K, RBS, Creatinine Therapeutics: Oxygen at 2-3 lpm via nasal cannula 1. Nimodipine (Nimotop) 30 mg 2 tabs PO q 4 hours per NGT X 21 days, must start as soon as possible Nimodipine drip 10 mg/50ml vial X 5-10 ugtts/min (1-2 mg/hr) X 6 vials (decreased incident of ischemic neurologic deficits) 2. Consider Dexamethasone (Oradexon) 5 mg IV q 6 hours 3. Consider Phenytoin IV load 18-20 mg/kg IV in plain NSS then Phenytoin 100 mg PO TID or Phenobarbital 60 mg 1 tab BID-TID 4. Laxative: Duphalac 30 ml at bedtime (to avoid straining and increase in ICP) 5. Stat referral to Neurosurgery for possible surgical clipping of aneurysm 6. Mannitol 20% 75-100 cc IV q 6 hours 7. Symptomatic Meditations a Consider sedatives and pain relievers b. H2 blockers IV (e.g. Ranitidine) c. Carbamazepine (Tegretol) 1/2 tab PRN for hiccups Avoid Motoclopamide (Plasil) baause of extrapyramidal reactions 8. Treatment of Complications: a. Rebleeding: 40/o mortality; intubate patient and decompress with Mannitol. Prevention is the key with adequate analgesia, control of hypertension, sedation, laxatives and early surgery, b. Vasospasm: Occurs within 4-14 days; majority progress to cerebral infarction. Treatment is with hypervolemic hcmodilution (3 liters of fluid per day) to decrease blood viscosity and maintain cerebral blood flow. Prevention with early Nimodipine PO. c. Hydrocephalus: Tube ventriculostomy / VP shunting To Neurology Page To Main Table of Contents To Detailed Table of Contents

CEREBRAL THROMBOSIS To Neurology Page To Main Table of Contents To Detailed Table of Contents Orders: Diagnostic: CT scan stat to rule out bleed (or after 16 hours from the onset of stroke to visualize infarct) ECG, Chest X-ray, CBC, PT, PTT, Na, K, Creatinine Lipid profile, RBS Therapeutics: Oxygen at 2-3 1pm via nasal cannula A. Anti-platelet Regimen: l. Aspirin 80-325 mg tab PO OD (still the drug of choice because cost- effective) or 2. Dipyridamole/Aspirin (Aggrenox) 200/25 mg 1 cap BID or 3. Clopidogrel (Plavix) 75 mg 1 tab OD or 4. Cilostazol (Pletaal) 50 mg 1 tab BID B. Neuroprotectants: 1. Citicoline(Somazine, Nicholin) 500 mg IV q 8-12 hr X 5 days, maximum of 2 gm/day); then continue with oral drops 100 mg or 1 ml BID 2. Piracetam (Nootropil) 12 gm IV initially then 3 gm IV q 6 hr X 5 days, then continue with oral preparation 1.2 gm tab BID. Contraindicated if with renal insufficiency. 3. Anti-edema treatment: Mannitol 100-150 cc q 4-6 hours for brain edema C. Other Treatment Options: 1. From 0-3 hours: Intravenous Tissue Plasminogen Activator (rt-PA) 2. From 3-6 hours: Intra-arterial Tissue Plasminogen Activator (rt-PA) To Neurology Page To Main Table of Contents To Detailed Table of Contents

CEREBRAL EMBOLISM To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: Etiology: Atrial fibrillation, acute MI, cardiac thrombus, carotid plaques Orders: Diagnostics: CT Scan stat to rule out bleed (or after 16 hours from the onset of stroke to visualize infarct) CBC,PT, PTT, Na, K, Creatinine, Lipid profile, RBS ECG, Chest X-ray, 2-D Echo (check for thrombus) Check Cardiac Enzymes: CPK-MB or Troponin I Therapeutics: 1. For cardioembolic infarcts, anti-coagulation with Heparin or Warfarin is the gold standard. Another option is LMW Heparin (e.g. Fraxiparine 0.4 cc SC BID for 10 days. Start within the first 24-48 hours). Target PTT of 1.5-2X the control for Heparin and target Protime INR of 2-3 for Warfarin. No need for monitoring with LMW heparin. 2. Aspirin =) 80-325 mg tab PO OD or Clopidogrel (Plavix) 75 mg 1 tab OD or Cilostazol (Pletaal) 50 mg I tab BID Note: These drugs itsy be used if Warfarin (Coumadin) is contraindicated. 3. Mannitol 75-100 cc IV q 6 hours may be given in anticipation of edema for large embolic infarcts 4. Consider seizure prophylaxis with Phenytoin (Dilantin) for large infarcts 5. Other Treatment Options: a. From 0-3 hours: Intravenous Tissue Plasminogen Activator (rt-PA) b. From 3-6 hours: Intra-arterial Tissue Plasminogen Activator (rt-PA) To Neurology Page To Main Table of Contents To Detailed Table of Contents

TRANSIENT ISCHEMIC ATTACK Orders: Admit for observation of neurologic deficits end work-up Diagnostics: CBC, Creatinine, Lipid profile, RBS, ECG, Chest X-ray Therapeutics: l. Aspirin 80-325 mg PO OD or Clopidogrel (Plavix) 75mg 1 tab OD or Cilostazol (Pletaal)50mg tab BID 2. Anticoagulation with Heparin for recurrent TIAs, crescendo type TIAs or stroke in evolution To Neurology Page To Main Table of Contents To Detailed Table of Contents

STROKE IN EVOLUTION Orders: Diagnostics: CT Scan, ECG, Chest X-ray CBC,PT, PTT, Na, K, Creatinine, Lipid profile, RBS Therapeutics: 1. Heparin bolus 5000 units IV then drip at 500-800 units/hour. Adjust to maintain PTT at 1.2-1.5 X the control. Check PTT q 12 hours. Start immediately in non-hemorrhagic, small to moderate size infarcts. 2. Overlap Warfarin with Heparin X 3 days. Warfarin 2.5 mg 1 tab OD until Protime INR of 2-3 is reached. Check Protime every 3 days until desired INR is reach' then monthly thereafter. To Neurology Page To Main Table of Contents To Detailed Table of Contents

STROKE IN THE YOUNG Orders: Diagnostics: VDRL, ESR, ANA, Protein C, Protein S, Antithrombin III assay Check for Metamphetamine abuse and Alcohol level Plasma Homocysteine levels (available at Makati Medical Center) CBC with Platelets, PT, PTT, Na, K, Creatinine, Lipid profile, RBS CT Scan, ECG, Chest X-ray Therapeutics: 1. Folic acid or Folate if homocysteine-related 2. Thiamine (Vitamin Bl) if alcohol-related To Neurology Page To Main Table of Contents To Detailed Table of Contents

SEIZURES & EPILEPSY To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: A. Definition: l. Epilepsy: Idiopathic. Two or more unprovoked seizures. 2. Status Epilepticus: Recurrent generalized convulsions at a freequency that does not allow consciousness to be regained in the interval between seizures or seizure of greater than 15 minutes duration. Mortality rate of 25%.Complications include epileptic encephalopathv & hypoxia B. Etiology Table 8-2.The Causes of Seizures. Neonates (< 1 Perinatal hypoxia and ischemia, Intracranial month) hemorrhage and trauma, Acute CNS infection, Metabolic disturbances (hypoglycemia, hypocalcemia, hypomagnesia, pyridoxine deficienc Infants and children (> 1 month and < 12 years) Adolescents (12-18 years) Young adults (18-35 years) Older Adults (> 35 years)

Febrile seizures, Genetic disorders (metabolic, degenerative, primary epilepsy syndromes), CNS infection, Developmental disorders, Trauma, Idiopathic Trauma, Genetic disorders, Infection, Brain tumor, Illicit drug use, Idiopathic Trauma, Alcohol withdrawal, Illicit drug use, Brain tumor, Idiopathic Brain tumor, Alcohol withdrawal, Metabolic disorders (uremia, hepatic failure, electrolyte abnormalities, hypoglycemia), Alzheimer’s disease and other degenerative CNS diseases, Idiopathic

Source: Loweinstein, D.H.: Seizures and Epilepsy. In Braunwald E, Fauci AS, Kasper D, et al (Eds.), (2001). Harrison's Principles of Internal Medicine (p. 23S8). New York: McGraw-Hill Companies Inc. C. Classification of Seizures: (based on the International Classification of Seizures) 1. Generalized Seizures: a. Tonic-clonic or Grand mal – Most common type of seizures b. Absence or Petit mal – sudden brief lapses of consciousness (seconds) usually beginning in childhood c. Others: Tonic, Atonic, & Myoclonic 2. Partial Seizures: a. Simple partial seizures - consciousness fully preserved during seizures b. Complex partial seizures – consciousness is impaired during seizures c. Partial seizure with secondary generalization 3. Unclassified Seizures Table 8-3 Commonly Used Anti-Epileptic Drugs Generic Name (Trade Name)

Indication

Dosage

Half-life

Drug Interactions

1. Phenytoin Na* (Dilantin) IV: 100 mg/ 2 ml amp PO: 3O mg, 100 mg cap Susp: 125 mg/5 m1,30mg/5ml

- Tonic-clonic (grand mal) - Focal-onset (Partial)

Loading dose: 24 hours 15-18 mg/kg/dose PO, IV Maintenance Dose900-400 mg/day PO, IV (Adult: 3-6 mg/kg/day given BID);(Child: 4-8 mg/kg/day given BID) 2. - Tonic-clonicAdult: 10-17 Carbamezapine* Focal-onset(Partial) 200-1200 hours (Tegretol) PO: mg/day 200 mg tab, SR Child: 15-35 200 mg tab, LA mg/kg/day 400 mg tab given BID-QID Syrup: 20mg/ml 3. Phenobarbital - Tonic-clonicLoading dose: 90 hours Na**(Luminal) Focal-onset(Partial) 15-18 mg/kg IV: 130 mg/ml given OD or Amp BID PO: 15 mg, 30 Maintenance mg, 60 mg, 90 dose: 60-180 mg tab mg/4q PO, IV (Adult 14mg/kg/day given q 12-24hr);(Child: 36 mg/kg/day given q 12-24 hr) 4. Valpoic acid*, - Tonic750-2000 15 hours ** (Depakene clonic mg/day given syrup, Epival -Absence BID tab) - Atypical initially 15 PO: 250mg/ Absence mg/kg/day; 5 ml syrup, -Myoclonic increasing 250 m tab - Focal weekly up to 60 onset mg/kg/day) 5. Clonazepam -Absence Adult: 1-12 24-48 (Rivotril) -Atypical mg/day given hours PO: 2 mg tab Absence OD-TID (0.1-02 -Myoclonic mg/kg) 6.Ethosuximide - Absence (petit 750-1250 60 hr (Zarontin) mal) mg/day 20-40 mg/kg 7. Lamotrigine - Focal onset 25-200 mg/day -25 hr (Lamictal) - Tonic-Clonic given -14 hr w/ PO: 50 mg tab, - Atypical absence BID PTN, CBZ, 100 mg glib, 5 - Myoclonic Max: 500 PHB mg dispersible mg/day - 59 hr tab w/VPA

8. Gabapentin - Focal-onset, 300-1200 (Neurontin) PO: AdjunctTreatment mg/day given 100 mg, 300 mg, TID-QID (up to 400 m 2400 mg/day if necessary & tolerated) 9. -Focal-onset 900-2400 pine (Trileptal) mg/day given PO: 300 mg, BID 6GO m tab

- Level t by INH, sulfonamides Level 4 by CBZ, PHB - Altered folate metabolism

- Level 4 by PTN, CBZ, PHB - Level l by erythromycin

- Level increased by VPA, PTN - Enhances metabolism of other drugs via liver enzyme induction

May precipitate absence status if given w/ clonazepam - Level decreased by PTN, CBZ, PHB - Level decreased by PTN, CBZ, PHB None

- Level decreased by PTN, CBZ, PHB - Levels decreased by VPA

5-9 hours None

10-17 hours

- Level decreased by PTN, CBZ, PHB

10. Topiramatc (Topamax) PO: 25 mg, 50 m 100 m tab

- Focal-onsetTonic-clonic

400 mg/day given BID

20-30 horns

- Level decreased by PTN, CBZ, PHB

Notes: * – blocks sodium du@mela **– GABA enhancing Abbreviations: PTN – Phenytoin, CBZ – Carbamazepine, VPA – Valproic Acid, INH – Isoniazid. PHB – phenobarbital. Orders: Admit to: Diet: NPO or DAT when no active seizures VS: Monitor vital signs q 1 how with neurochecks or any change in neurological status Nursing: RBS now and q 6 hours; Seizure precautions; Tongue guard IVF: D5NR 1 liter X 12 hours Diagnostics: CBC, Ca, Mg, Na, K, Creatinine, RBS, Serum ammonia, Chest X-ray CT Scan of the head (if with focal neurologic deficits or focal seizures) EEG with hyperventilation and photic stimulation Video EEG monitoring (to differentiate real seizures from pseudo-seizures) ECG by cardiac monitor throughout the administration of these drugs Therapeutics: Oxygen by face mask A. Status Epilepticus 1. Diazepam 02-0.3 mg/kg/dose then may repeat up to 3 doses until seizure stops, e.g. Diazepam 5-l0 mg IV q 30 min. or Lorazepam (Ativan) 2-4 mg slow IV, advantage: longer duration of action +/- 2. Phenytoin loading dose: 18 mg/kg in NSS IV at < 50 mg/min If still with seizures add 5 mg/kg for up to 2 doses or max. of 30 mg/kg +/- 3. If still with seizures, consider intubation. Fi02 at 100% and Add Phenobarbital (Luminal) 10-15 mg/kg IV at 50-75 mg/min lV until seizure stops. If seizures continuing, may add Pentobarbital. + /- 4. Anesthesia with Midazolam or Propofol a. Midazolam drip = (02 mg/kg loading dose then 0.1-0.4 mg/kg/hr maintenance dose) or b. Propofal (Diprivan) IV given by an anesthesiologist. B. Primary Generalized Tonic-Clonic (Grand Mal): 1. For Acute Attack: (depending on the severity and frequency of attacks) a. Phenytoin Na (Dilantin) 100 mg slow IV push q 8 hr or b. Phenytoin Na (Dilantin) 300 mg slow IV push q 4 hr with 10 cc plain NSS X 3 doses at 50 mg/min (loading dose of 900 mg or 15-18 mg/kg/dose) Note: May give full loading dose of Dilantin 1 gram in 30 minutes for recurrent seizures Watch out for hypotension and arrhythmias. 2. For Maintenance: a. Dilantin 100 mg 1 cap TID PO or b. Valproic Acid (Epival) 250 mg 1 tab TID or c. Carbamazepine (Tegretol) 200 mg 1 tab BID C. Focal-Onset (Partial) Seizure, including Secondary Generalized: 1. Carbamazepine (Tegretol) 2. Oxycarbazepine (Trileptal) 3. Phenytoin Na (Dilantin) 4. Valproic Acid (Epival) 5. Lamotrigine (Lamictal) D. Absence (Petit Mal): l. Ethosuximide 250-500 mg PO TID-QID 2. Valproic acid at 15 mg/kg/day E. Atypical Absence Myoclonic 1. Valproic acid 2. Clonazepam (Rivotril) 1/2- 2 tabs BID-QID F. Other Treatment Options:

1. Glucose 50 m) of 50% 1 vial IV 2. Thiamine (Vitamin B1) 50 mg IV in alcoholics 3. Pyridoxine (Vitamin B6) especially if seizure is due to INH G. Epilepsy Treatment Plan: 1. Use one drug until maximum dose is reached. (Monotherapy is advocated.) 2. If not controlled add a second drug and taper the dose of the first drug. 3. In some cases, two drugs are necessary to control seizures but there may be an increase in side effects. To Neurology Page To Main Table of Contents To Detailed Table of Contents

BRAIN ABSCESS To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: A. Etiologic Organism: Strep. nulleri, Staphylococcus (post-surgery), Bacteroides; pyogenic brain abscess are usually mixed infections gram positive, gram negative and anaerobes) B. Clinical Features: = 2 weeks of illness, presence of focus of infection, headache, fever, vomiting. Note that 50% of brain abscess do not present with fever. C. Common source of infection: Otitis media, sinusitis, dental infection, post-cranial surgery D. Four Stages of Brain Abscess: Stage 1 - Early cerebritis (Day 1-3) Stage 2 - Late cerebiitis (Day 4-9) Stage 3 - Early capsule formation (Day 10-13) Stage 4 - Late capsule formation (=Day 14), thickened capsule E. Differential diagnosis of CT scan appearance of brain abscess, Neoplasm, granuloma, hematoma, cerebral infarction, schistosomiasis, toxoplasmosis or lymphoma Oders: Diet: Osterized feeding 1800 cal, in 6 divide feedings; Insert NGT if with no gag reflex VS. Neuro vital signs q 2 hours and record, refer stat for pupil size difference= 2 mm Nursing: Input & Output q shift, insert Foley catheter IVF: D5NR 1 liter X 16 hours Diagnostics: CBC, CT scan or MRI (Gold Standard) Treatment: A. Surgical treatment: Aspiration or total excision of abscess Points for surgical treatment: (1) Abscess > 2.0 cm, (2) Accessible locate of abscess, (3) Abscess stage = 3 - do not aspirate in the cerebritis stage, (4) Unstable neurologic status B. Medical treatment: l. Empiric treatment a. Pen G IV 4 million units IV q 4 hours or Ceftriaxone 2 gm IV q 12 hours or Cefotaxime 2-3 gm IV q 6 hours and + b. Metronidazole 500 kg IV q 6 hours or PO or Chloramphenicol 1.0-1.5 gm IV q 6 hours 2. Treatment based on specific sites of infection: a. From otitis media (etio: Pseudomonas) Tx: Ceftazidime 2-3 gm IV q 8 hr b. Post-neurosurgery or post-traumatic (etiology: Staphylococcus) Tx: Vancomycin 500 mg IV q 6 hours + Ceftazidime IV 3. Mannitol if with signs of increased intracranial pressure 4. Steroids may be used to control vasogenic brain edema provided the patient is adequately covered with antibiotics C.Plan of medical treatment and follow-up 1. Give IV antibiotics for at least 4-6 weeks followed by pronged PO therapy of 24 months 2. Repeat CT Scan to check for regression or progression of abscess and to confirm the diagnosis To Neurology Page To Main Table of Contents To Detailed Table of Contents

MYASTHENIA GRAVIS To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: A. Pathophysiology: Autoimmune disease, decreased acetylcholine receptors to post-synaptic membranes. B. Differential Diagnosis: Lambert-Eaton Syndrome, hyperthyroidism, hypokalemia, Guillain- Barre syndrome C. Complications: 1. Respiratory depression 2. Myasthenic crisis a. Exacerbation with threats of respiratory failure b. Common dilemma: Cholinergic crisis (too much pyridostigmine) versus myasthenic crisis D. Treatment: Treat precipitating factor, e.g. infection, fluid management pulmonary physiotherapy, nebulization Orders: Diagnostics: 1. Repetitive Nerve Stimulation test (more than 15% decremental response is considered significant); Single Fiber EMG if RNS test is negative. 2. Edrophonium anticholinesterase test: 0.2 ml of 10 mg/ml (2 mg) IV (Check ptosis, handgrip, extra-ocular muscles) 3. Anti-acetylcholine receptor antibody assay (not available locally) Therapeutics: 1. Anticholinesterase: Pyridostigmine (Mestinon) 60mg tab: PO-30-60 mg q 4-8 hours, maximum 360 mg/day + Loperamide for diarrhea 2. Consider Prednisone 1-2 mg/kg/day for 4-8 weeks, then gradually taper if clinically stable + Antacids 3. Other treatment options: a Azathioprine (Imuran) or Cyclophosphamide (Cytoxan) b. Thymectomy: Thymoma present in 15% of myasthenia gravis patients c. Plasmapheresis d. IV Immunoglobulin therapy To Neurology Page To Main Table of Contents To Detailed Table of Contents

PARKINSON'S DISEASE & OTHER RELATED MUSCULAR DISORDERS To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: A. Classification l. Idiopathic (Primary): Parkingson's disease 2. Symptomatic (Secondary) a Drugs – neuroleptics b. Postencephalitic c. Toxins – manganese, CO, cyanide d. Vascular e. Brain Tumor f. Post-trauma – subdural hematoma 3. Parkinson-Plus Syndromes a. Progressive supranuclear palsy b, Multiple system atrophy i. Striatonigral degeneration ii. Shy-Drager syndrome iii. Olivapontocerebellar degeneration c. Dementia Syndromes i. Parkinson’s Dementia Complex ii. Normal pressure hydrocephalus d. Hereditary Disorders i. Wilson’s disease ii. Huntington disease iii. Hallervorden-Spatz disease B. Pathophysiology: Decrease pigmentation of substantia nigra; decrease production of dopamine that will bind with the dopamine receptors of the striatum (nigro-striatal pathway) C. Cardinal Features of Parkinsonism: Mnemonic TRAP 1. Tremor at rest 2. Rigidity 3. Akinesia – bradykinesia / hypokinesia 4. Posture – loss of postural reflexes, flexed posture of neck and trunk 5. Freezing (motor blocks) D. Definition of Terms: l. Athetosis – slow, writhing, continuous movements 2. Ballism – very large amplitude choreic movements, most frequently unilateral and is referred to as hemiballism 3. Chorea – involuntary, irregular, purposeless, non-rhythmic, abrupt, rapid, unsustained movements that flow from one body part to another. 4. Dystonia – twisting movements that tend to be sustained at the peak of movement, repetitive, progress to abnormal posture 5. Myoclonus – sudden brief, shock-like involuntary movements causal by muscular contractions 6. Tremors – To and So movement of a group of muscles with a fast and slow component in a repetitive manner, regular Orders: Diet: No caffeine Treatment: A. Non-pharmacologic treatment: Group support, exercises physical and speech therapy, education, nutrition, aids to daily living e.g. hand rails B. Pharmacologic Treatment: 1. Carbidopa + Levelopa (Sinemet) 25/100 mg tab, 25/250 mg tab

Half-life: 34 hours, Drug of Choice e.g. Sinemet 25/250 mg 1/2 tab BID; max of 8 tabs/day given BID-QID Start with the lowest dose then increase gradua1ly until reaching the desired clinical response. Ideally should be given before meals for better absorption if tolerable. If not tolerated (presence of nausea and vomiting), may be given after meal Not to be taken with vitamins because of drug interaction Side-effect: Dyskinesia is most common: This generally happens when too much dopamine is being taken 2. Monoamine Oxidase-B Inhibitor Selegyline (Jumex) 5 mg tab 1 1/2 tab BID (breakfast and lunch) Generally add-on therapy to Sinemet 3. Anti-cholinergic drugs Indication: for tremors a. Trihexyphenidyl HCl (Artane) 5 mg tab: 1/2 -1 tab OD-TID b. Biperiden (Akineton) 2 mg tab: 1/2 tab BID, maximum 16 mg/day c. Benztropine mesylate (Cogentin) 2 mg tab: 1/2-1 tab BID maximum 6 mg/day Side-effect: dryness of mouth 4. Dopamine-organist Drugs: Bromocriptine (Parlodel) 2.5 mg tab Give with Sinemet, add-on to Sinemet (treatment 2+3) Suggested dose:1/2 tab OD X 1 week then increase 1.25 mg/day every week Half-life = 3-6 hours Therapeutic response: 6-8 weeks 5. Others: Piribedil (Trivastal Retard 50) 50 mg 1 tab OD; may increase up to 3 tabs/day Particularly useful where tremors predominate To Neurology Page To Main Table of Contents To Detailed Table of Contents

ALCOHOL WITHDRWAL/DELIRIUM TREMENS To Neurology Page To Main Table of Contents To Detailed Table of Contents Data: A. Clinical Features: Background of chronic alcoholism, new onset of behavioral changes like restlessness, aggitation and exacerbation of tremors following alcohol withdrawal B. Differential Diagnosis:. 1. Acute confusional states: Seen in alcoholic intoxication or following heavy drinking among alcoholics 2. CNS infection/meningtis. Check meningeal signs to look for neck rigidity, Kernig's sign, Brudzinsky sign 3. Subdural Hematoma: Check head for contusions, hematomas or swelling. Do CT scan of the head if necessary 4. Hepatic encephalopathy: Check for palmar erythema, spider angiomatas. Observe for liver flaps or asterexis Orders: Admit to: Diet: Regular, push fluids VS: Vital signs q 4 hours, Call MD in case of increased agitation or change in neurological status IVP: D5NM X 12 hours Diagnostics: CBC, RBS, Serum Na, K, Ca, Creatinine Serum Ammonia, Amylase, SGOT, SGPT, Urinalysis, Ultrasound of the Abdomen, Chest X-ray, ECG Therapeutics: 1. Diazepam 5-20 mg PO or IV q 6-8 hours or Chlordiazepoxide (Librax) 1-2 tabs TID-QID, taper in 3-5 days 2. Haloperidol (Haldol) 1-5 mg PO TID or 2-5 mg IM IV q 4 hours for severe agitation 3. Neurobion 5000 1 tab TID or Neurobion I amp in 1 liter IVF 4. Symptomatic Medications: Metoclopromide (Plasil) 10 mg: 1 tab PO or 1 amp IV, IM q 6 hours or PRN Paracetamol for headache To Neurology Page To Main Table of Contents To Detailed Table of Contents

APPROACH TO WEAKNESS COMMON DIFFERENTIAL DIAGNOSIS To Neurology Page To Main Table of Contents To Detailed Table of Contents Differential Diagnosis

Diagnostic Tests

CVA, tumors, traums multiple sclerosis, lymphoma, etc.

CT Scan or MRI of the head MRI if the spine Others: CBC, FBS, Na, K, Ca, ESR

Toxins, drugs, nutritional, alcoholic neuropathy, hereditary diseases

Good History and PE Drug and toxologic assays, heavy metal assay

Peripheral neuropathy

EMG (Electromyography) NCV (Nerve Conduction Velocity Studies) Nerve biopsy

Guillain-Barre Syndrome

EMG-NCV, Lumbar tap

Myasthenia gravis

History, PE RNS decremental response

Myasthenic syncope

RNS incremental response

Polymyositis, alcoholic myopathy, muscle disorders

CPK-total

Diabetes mellitus, hypokalemic periodic paralysis, renal tubular acidosis

FBS, HgbA1C, Na, K, Urine pH, ABG

Multiple sclerosis

History, PE, Visual Evoked Response, CSF-Ig G

Multiple myeloma

Serum Electeophoresis (definitive) Bence-Jones Protein, Serum Calcium

To Neurology Page To Main Table of Contents To Detailed Table of Contents

POISONING & DRUG OVERDOSE To Toxicology Page To Main Table of Contents To Detailed Table of Contents A. General Guidelines: 1. Maintain adequate airway, breathing and cardiac support. Patients who have ingested a large amount of tricyclic antidepressant may require intubation immediately even if mental status deterioration has not yet occurred. 2. If with mental status abnormalities (i.e. coma, stupor, drowsy), give 50 ml ampule of 50% (1-2 mUkg) dextrose, followed by Naloxone (Narcan) 2 mg IV, or endotracheally, and administer Thiamine 100 mg IV or IM. Naloxone may be repeated in boluses of 1-2 mg up to 4 mg IV. Obtain an immediate glucose level and administer glucose if the glucose is Rare Absent Present in 5.5mg/dl almost all cases 5. Absent Absent Present in Hemoconcentration, severe thrombocytopenia, disease liver dysfunction 6. LVH by EGG

May be present

Absent

Absent

*Defined as =1+ by dipstick testing on two occasions or = 300 mg in a 24-hour urine collection. Source: Sibai, B.M. (1996). Treatment of hypertension in pregnant women: A review article. N En 1 J Med, 335, 257-265. Orders: Admit to: Diet: Low salt, high calcium diet VS: q 1 hour with neurochecks Nursing: I & O Place foley catheter; Check deep tendon reflexes; Urine output, Complete bed rest IVF: D5NM X 12 hours Diagnostics: CBC with platelet count Blood typing, PT, PTT SGPT, SGOT, BUN, Creatinine, Uric acid Urinalysis, 24-how urine Albumin collection Therapeutics: Mneumonic 4 A's (Aldomet, Apresoline, Atenolol, Adalat) A. Gestational Hypertension - may be an early manifestation of pre-eclampsia - outcome generally is good without drug therapy B. Chronic Hypertension - use 4 A's (see below) No. 1-4 C. Pre-eclampsia - Target diastolic BP between 80-100 mmHg l. (Aldomet) Methyldopa 250-500 mg tab TID PO, maximum = 3 gm/day 2. (Apresoline) Hydralazine 5 mg slow IVP stat dose q 20 min up to 4 doses; Apresoline drip D5W 250 cc + 2 amps Apresoline (20 mg/amp) to run initially at 10-15 uggts/min then to titrate up to 60 ugtts/min or Apresoline 25-50 mg tab TID-QID PO; Maximum of 300 mg/day

If patient develops tachycardia, headache or nausea, shift to Nifedipine SL or PO 3. Atenolol (Tenormin) 50 mg tab OD PO 4. (Adalat) Nifedipine 5-10 mg PO or SL q 6-8 hours 5. For patients on NPO, use the following singly or in combination: a Nifedipine (Adalat) 5-10 mj SL q 6-8 hours Note: Watch out for hypotension with sublingual nifedipine, especially if the patient is also being given Magnesium sulfate. b. Hydralazine (Apresoline) drip: D5W 250 cc + 2 amps Apresoline (20 mg/amp) to run initially at 10-15 ugtts/min then to titrate up to 60 ugtts/min c. Clonidine (Catapres) drip: D5W 250 cc+ 2 amps Catapres (150 mg/amp) to run at 5-30 ugtts/min

To Pregnancy Page To Main Table of Contents To Detailed Table of Contents

PREGNANCY & CARDIAC DISEASE To Pregnancy Page To Main Table of Contents To Detailed Table of Contents Data: l. Avoid Dilantin, Warfarin ACE inhibitors and Angiotensin II antagonists. 2. Nearly all CVS drugs cross the placenta and are excreted in breast milk. 3. Most drugs should be avoided in the first trimenster inless the cardiac condition demands urgent treatment 4. Diuretics should not be in bipedal edema unless there is frank pulmonary congestion. Diuretics may decrease uterine blood flow Treatment Options: l. Inotropic agents - Digitalis is safe, Dopomine is reserved for life threatening situations only. 2. Vasodilators - Hydralazine is safe Use Nitrates as in the non-pregnant state Nitroprusside reserved for life threatening situations only. Avoid ACE inhibitors and Angiotensin II antagonitsts 3. Calcium-channel blockers - Verapamil and Nifedipine are relatively safe. 4. Beta-blockers - May be used for short period to time there are no alternatives. Side effect: intrauterine growth retardation, bradycardia 5. Anticoagulants/Antiplatelets - Warfarin conraindicated especially in the first trimester (20% teratogenic) Heparin SQ can be given, It does not cross the plaenta ASA and Dipyridamole can be given with slight increase in bleeding Safety to low omlecular weight heparins is still to be established To Pregnancy Page To Main Table of Contents To Detailed Table of Contents

PREGNANCY & ASTHMA Data: The course is relatively the same as in the non-pregnant patient. Treatment Options: 1. Beta 2- agonist PO or IV - inhibits uterine contractility 2. Steroids - (+) small risk of cleft palate formation in some animal but not proven in humans - placental insufficiency, prematurity and fetal death - neonatal adrenal insufficiency (?) - steroids may cause some intrauterine growth retardation. 3. Aminophylline / Theophylline - may inhibit uterine activity (?) - transient tachycardia in the baby 4. Cromolyn sodium - appears to be relatively safe in pregnancy 5. Status Asthmaticus - delivery by Caesarian section may improve asthma (anecdotal reports)

To Pregnancy Page To Main Table of Contents To Detailed Table of Contents

PREGNANCY & THYROID DISEASE To Pregnancy Page To Main Table of Contents To Detailed Table of Contents Data: Total T4 is increased because of increase in TBG (Thyroxin Binding Globulin) Orders: Diagnostics TSH Irma (best measure of thyroid function; normally , slightly decreased in first trimester) Therapeutics: 1. PTU Drug of choice for pregnant individuals Side effect: Neonatal hypothyroidism Total dose = 300 mg/day. If PTU dose > 300 mg/day consider subtotal thyroidectomy in the second trimester 2. Beta-blockers: e.g. Atenolol, Metroprolol May be given for a short period of time only 3. Surgery: Avoid surgery during the first trimester because of increase of spontaneous abortion Treatment Plan: 1. Monitor the patient's TSH and Free T4, keep Free T4 at the upper limit of normal. 2. Monitor the fetus for hypothyroidism or hyperthyroidism To Pregnancy Page To Main Table of Contents To Detailed Table of Contents

PREGNANCY & DIABETES MELLITUS To Pregnancy Page To Main Table of Contents To Detailed Table of Contents Data: A. Two Types of Diabetes in Pregnancy: 1. PregestationalDM (DM prior to pregnancy) Diagnosis: FBS > 126 mg/dl on 2 occasions or RBS > 200 mg/dl or 75 gm 2 hour OGIT > 200 mg/dl 2. Gestational DM a. Screening test (at 24-28 weeks usually or earlier): 50 gm 1 hour Oral Glucose Challenge of > 140 mg/dl b. If (+) screening test do Gold Standard For Gestational DM Diagnosis: 100 gm 3 hour Oral Glucose Tolerance test (OGTT) afbr an overnight fastof 8-14 hours Three-hour 100 gm OGTT Fasting 1 hour 2 hours 3 hours

National Diabetes Mellitus Data Group > 105 mg/d3 (53 mmol/L) > 190 mg/dl (10.6 mmolL) > 165 mg/dl (9.2 mmol/L) > 145 mgldl (8.1 mmol/L)

If two values are above normal then the patient is + Gestational DM. B. Complication: Birth defects, abortion, macrosomia, respiratory distress syndrome, stillbirth Treatment 1. Diabetic diet 2. Insulin treatment: Do not give oral hypoglycemic agents. These are contraindicated during pregnancy Sample Insulin Regimen: i.Humulin N (intermediate) or Humulin U (Ultralente - long acting ) OD in a.m. ii.Humulin N & R combination (intermediate & short acting) at 6 a.m. and 6 p.m. (2/3 of daily dosage to be given at 6 AM and 1/3 of daily dosage at 6 p.m.) Note: Aim for normal blood glucose (FBS =105 and Two-hour postprandial blood glucose of < 140 mg/dl. 3. Control diabetes at first 6 weeks AOG to prevent birth defects 4. Deliver baby ideally at 36-37 weeks AOG To Pregnancy Page To Main Table of Contents To Detailed Table of Contents

DRUGS USED IN PREGNANCY To Pregnancy Page To Main Table of Contents To Detailed Table of Contents Type

Safe to Use

Analgesics

Paracetamol

Anti-convulsants

Magnesium sulfate

Anti-depressants

Antidiabetic agents

Insulin

Antiemetics

Meclizine Metoclopromide

Anti-histamines

Chlorpheniramine

Antilipidemics

Antimicrobials

Anti-thrombotics

Amoxicillin Amphotericin B Ampicillin Ampicillin-sulbactam Cephalesporins Cotrimazole Co-amoxiclav Erythomycin Miconazole(topicai) Nitrofurantoin Nystatin Oxacillin Penicillin Piperacillin-Tazobactam Ticarcillin-clavulanic

Limited Info/Minimal Fetal Risk Diclofenac Ibuprofen Morphine Piroxicam

Fluoxetine Paroxetine Sertraline Acarbose Metfromin Diphenydrinate Odsnsetron Prochlorperazine Promethazine Brompheniramine Cetirizine Clemastine Diphenhydramine Fexofendine Hydroxyzine Loratadine Terfenadine Cholestyramine

Evidence of Fetal Risk Aspirin Codeine Indomethacin Tramadol Carbamazepine Clonazepam Ethosuximide Gabapentin Lamotrigine Amitriptyline Imipramine Venlafaxine Glipizide Glibendamide

Gemfibrozil

Acyclovir Azithomycm Aztreonam Chloramphenicol Clarithromycin Clindamycin Imipenan-cilastatin Metronidazole Vancomycin

Amikacin Co-trimoxazole Ethambutol Fluconazole Gentamicin Isoniazid Itraconazole Ketoconazole Miconazole (systemic) Pyrazinamide Rifampicin Tobramycin

Dalteparin Enoxaparin Heparin Ticlopidine

Aspirin

Avoid

Phenobarbital Phenytoin Valproic acid

Monoamine oxidase inhibitor

Fluvastatin Lovastatin Pravastatin Simvastatin Ciprofloxacin Doxycycline Norfloxacin Ofloxacin Tetracycline

Warfarin

Cardio-vascularDrugs

Atenolol Clonidine Digoxin Doxazosin Hydralazine Lidocaine Methyldopa Metoprolol Prazosin Propranolol Timolol Dextromethorphan

Cough & Cold Agents

Diuretics

Gastro-intestinalAgents

Antacids Attapulgite Kaolin-Pectin Loperamide Metoclopromide Psyliium

Respiratory Agents

Sedatives Thyroid Preparations

Levothyroxine Thyroid

Miscellaneous

Ferrous sulfate Potassium chloride

Cisapride H2-receptor antagonists Lansoprazole Omeprazole Simethicone Beclomethasone (inhalation) Cromolyn Ipratropium Salmeterol Theophylline Propofol Zolpidem

Allopurinol Chlorzoxazone Sumatriptan

Amlodipine Diltiazem Felodipine Nifedipine Nitrates Verapamil

ACE-inhibitors Losartan

Guiafenesin Phenylpropanolamine Pseudoephedrine Furosemide Spironolactone Amiloride Bumetsnide Misoprostol

Benzodiazepines Methimazole K iodide Propylthiouracil Azathioprine Cyclosporine Haloperidol Pentoxifylline

Pentobarbital Phenobarbital

Isotretinoin Lithium Quinine Tamoxifen

Source: Nauser T & McGraham M (1998). Pregnancy & Medical Therapeutics. In Carey C, Lee H & Woeltjc K (eds.). WashingtonManual of Medical Therapeutics, (534-537). Philadelphia: Lippincott Williams & Wilkins. To Pregnancy Page To Main Table of Contents To Detailed Table of Contents

PREVENTIVE MEDICINE & ADULT IMMUNIZATIONS To Main Table of Contents To Detailed Table of Contents Cancer Check-up and Screening Recommended Diagnostic test Immunization and Post-exposure Treatment Tetanus post-exposure treatment Hepatitis B post-exposure treatment Rabies post-exposure treatment

Guidelines for Routine Health Maintenance or "The Executive Check-up": Adapted from 1) The American College of Physicians expert recommendations for preventive care for asymptomatic, low-risk adults and 2) The American Cancer Society (1993) guidelines for the early detection of cancer hi people without symptoms. I. History, Physical Examination, Health Counselling: Every 2 years between ages 2MO, then yearly after age 40 A. History: 1. Pertinent Present History: Any symptoms 2. Review of Systems; Check also for depression, suicidal ideation, work-related stress 3. Past Medical History: Previous illness, operations, allergies; current drug intake 4. Immunization History: (See page 202) 5. Family History: Breast cancer, colon cancer, prostate cancer, hypertension, diabetes, ischemic heart disease, hyperlipidemia, alcoholism, mental illness, autoimmune disorders. 6. Personal and Social History: Occupational history, life style, smoking, alcohol, illicit drug use B. Physical Examination: 1. Blood pressure: Every 2 years after age 18 2. Weight: Every 2 years 3. Regional examination C. Health Counselling on: l. Breast self exam 2. Ill effects of cigarette smoking 3. Alcohol moderation 4. Aerobic exercise at least 3X per week for 30 minutes to 1 hour 5. Nutrition: Dietary moderation, less salt, less cholesterol and maintain ideal body weight 6. Advice against illicit drug use, high-risk sexual behavior, injury prevention, and dental care. II. Cancer Check-up and Screening (To Top) Check every 3 years between ages 20-40, then yearly after age 40 A. For Males and Females: l. Examination for cancers of the thyroid, lymph nodes, oral region, skin, testicles (males) and ovaries (females) 2. Digital rectal examination: Yearly after age 40 3. Stool for occult blood: Yearly after age 50 4. Sigmoidoscopy, preferably flexible: Every 5 years after age 50 B.For Males Only: 1. Digital prostate exam and serum prostate-specific antigen (PSA) in males; Optional: Digital prostate exam yearly and Serum PSA once after age 40. If either is abnormal, further examination by transrectal ultrasound and biopsy is indicated.

C. For Females Only: 1. Self breast exam: Monthly after 20 years old, especially in patients with a family history of breast cancer. 2. Clinical breast exam by the physician: Every 3 years between ages 20-40, then yearly after 40 years old. 3. Mammograms: Every 1-2 years (depending on risk of patient) between ages 50-75 years 4. Papanicolaou smear: Yearly until at least 3 consecutive satisfactory normal examinations, then every 3 years between ages 18-70. Optional if post-hysterectomy 5. Pelvic examination: Yearly after age 40 6. Endometrial tissue sampling: Women at high risk; at menaopause and thereafter at the discretion of the physician. High-risk women include those with a history of infertility, obesity, failure of ovulation, abnormal uterine bleeding, or unopposed Estrogen or Tamoxifen therapy. III. Recommended Diagnostic Tests: Patients are Divided into Those With and Without Cardiac Risk Factors. (To Top) A. Cardiac Risk Factors: 1. Age and gender (male > 45 years old, female > 55 years old or premature menopause in women without estrogen replacement) 2. Current cigarette smoker (ten or more cigarettes per day) 3. History of cerebrovascular disease, diabetes mellitus, or hypertension 4. Family history of premature coronary artery disease (myocardial infarction or sudden cardiac death before age 55 in a first degree relative) 5. Presence of peripheral vascular disease B. Examinations for Patients Negative for Cardiac Risk Factors: 1. History, Physical Examination every 2 years. 2. Fasting Blood Sugar, Creatinine, Uric Acid: Once after age 40 and as indicated 3. Complete lipid profile (total cholesterol, LDL. cholesterol, HDL cholesterol, and triglyceride) after a 12 hours fast for all adults >= 20 years once every 5 years 4. ECG 12-lead and Chest X-ray: Once after 40 for baseline (optional). This can be helpful when patients present later with cardiac or pulmonary disease C. Examinations for Patients Positive for Cardiac Risk Factors: 1. History, physical examination, blood pressure, and weight yearly. 2. Fasting Blood Sugar, Creatinine, Uric Acid: Once after age 40 then every 3 years or as indicated. 3. Complete lipid profile (total cholesterol LDL cholesterol HDL cholesterol, and triglyceride) after a 12 hours fast for all adults >= 20 years of age once every 3 years and as indicated. 4. ECG 12-lead and Chest X-ray: Once Once age 40 for baseline then as indicated only. 5. Treadmill Exercise Test: Indications: Adult patients with an intermediate pre-test probability for coronary artery disease (See Table 12-1) based on gender, age, and symptoms. Not indicated for the following: Routine executive check up, company clearance or travel clearance for patients with a low pre-test probability for coronary artery disease. Table 12-1. Pretest Probability of Coronary Artery Disease by Age, Gender, and Symptoms. Age

30-39

40-49

Gender

Atypical Angina Pectoris Intermediate

Non-anginal Chest Pain

Asymptomatic

Men

Typical Angina Pectoris Intermediate

Low

Women

Intermediate

Very low

Very low

Men Women

High Intermediate

Intermediate Low

Intermediate Very low

Very low Very low Low Very low

50-59

Men Women

High Intermediate

Intermediate Intermediate

Intermediate Low

60-69

Men Women

High High

Intermediate Intermediate

Intermediate Intermediate

Low Very low Low Low

Source: Adapted from Diamond, G. 4 Forrester, J. (1979). Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. NEJM, 300, 24, 1350-1358. IV. Immunization and Post-exposure Treatment: (To Top) A. Adult Immunizations: Table 12-2-Standard Adult Immunization (2004) Vaccine/Route 1. Pneumococcal Vaccine (For Streptococcus pneumoniae) *Inactivated vaccine *Intramuscular

2. Influenza Vaccine (Flu Vaccine) *Inactivated vaccine *Intramuscular

3. Hepatitis B Vaccine *Inactivated vaccine *Intramuscular

For Whom It Is recommended i. Persons > 50 years of age ii. Persons with chronic illness: Cardio-pulmo, diabetes, alcoholism, cirrhosis, CSF leaks iii. Immunocompromised conditions: Lymphoma, leukemia, CRF, nephritic syndrome, transplants, chemo/radiation therapy, HIV/AIDS, functional or anatomic asplenia i. Persons > 50 years of age ii. Persons with chronic illnesses: Pulmonary (asthma, COPD), cardiovascular (CHF), metabolic diseases, CRF iii. Immunosuppressed: H1V, transplant, chemo, cancer Health cane workers, caregivers Pregnant women i. Recommended for all adults particularly: - Immigrants from areas of high HbsAg endemicity - Hemodialysis patients, IV drug users, or homosexual males - Household contacts of HBV carrier - Recipients of blood products - Health care workers with frequent blood contacts

Schedule a. Pneumovax 0.5 ml IM once or b. Pneumo 23 prefilled syringe 0.5 ml IM once. Note: Booster dose after 5 years

a. Agrippal S1prefilled syringe 0.5 ml IM or b. Vaxigrip 0.5 ml IM Note: Give yearly preferably from February to June.

a Recomvax-B adult vial of 20 mcg or b. HB VAX II adult vial of 10 mcg(1 ml) or c. Engerix B adult 20 mcg/ml Give IM over deltoid region at 0, 1, and 6 months.

4. Tetanus/diphtheria toxoid (Adult Td) *Inactivated vaccine *Intramuscular

5. Varicella Vaccine ’Live attenuated vaccine *Subcutaneous

6. MMR Vaccine (Measles/Mumps/ Rubella) * Subcutaneous

i. All susceptible adults particularly: - Pregnant women - Health care workers

Dite Anatoxal Berna 0.5 ml IM. Note: For those without childhood immunization, give 3 doses at 0, 1 ,&4 6 months timing. Booster every 10 years

i. Recommended for all adults particularly: - Persons > 13 years old without history of Varicella infection or vaccination, especially health care workers teachers of young children, non-pregnant women of childbearing age, international travelers, military i. Recommended for all adults particularly: - All susceptible adolescent & adults without documented evidence of immunity, especially non-pregnant women of childbearing age Note, No adverse effect if a person immune to one or more is vaccinated

Okavax 0.5 ml SC < 13 years: 1 dose > 13 years: 2 doses (at least 1 month apart). Post-exposure prophylaxis given within 72 hrs. of exposure

a Trimovax 0.5 ml vial SC for 2 doses, give 1 month apart or b. M-M-R II 0.5 ml SC

Table 12-3 Special Immunization for Particular Health Care Workers Vaccine/Route

1. Typhoid Vaccine a. Oral-enteric-coated capsule; live attenuated Ty21a (Vivotif) b, Intramuscular -Vi capsular polysaccharide Ty 2 (Typhim Vi)

For Whom Recommend - Food handlers such as dietary personnel, cooks, waiters, servers, dieticians, nutritionists - Microbiology lab technicians - Persons with intimate exposure to a documented carrier

Schedule

PO: For primary and booster- 1 capsule each on days 0, 2, 4, one hr before a meal, with drink. Booster every 5 yrs. IM: For primary booster- single 0.5 ml IM dose on the deltoid. Booster every 2-3 years.

2. Rabies Vaccine (Active Vaccination) a. HDCV- Human Diploid Cell Vaccine b. PVRV- Purified Vero Cell Rabies Yaccine (Verorab) c. PDEV- Purified Duck Embryo Vaccine d. PCECVPurified Chick Embryo Cell Vaccine

- Health care workers in hospital that treat dog bites and rabies cases - Rabies research & diagnostic laboratory workers - Veterinarians and vet students - Field workers

Primary- series of 3 injections on days 0, 7, 21 or 28 IM on the deltoid: - HDCV 1.0 ml - PVRV 0.5 ml - PDEV 1.0 ml - PCECV 1.0 ml Intradermal (ID): - PVRV 0.1 ml - PDEV 0.2 ml - PCECV 0.2 ml Booster - single dose IM or ID every 2 years

Source: Adapted from Committee on Immunization, Philippine Society for Microbiology & Infectious Dses. (PSMID) R the Phil. Foundation for Vaccination (PFV) Standard Adult Immunization 2004. B. Tetanus post-exposure treatment (To Top) Table 12-4. Wound Classification Clinical Features Age of wound Configuration Depth Mechanism of injury Devitalized tissue Contaminants saliva, etc

Tetanus Prone

Non-Tetanus Prone

> 6 hours Stellate, avulsion > 1 cm

< 6 hours Linear

Missle, crush, burn Present

Sharp surface (knife, glass) Absent

Present

Absent

=1 cm

Table 12-5. Dirty Immunization Schedule. Tetanus-Prone Wound History of Tetanus Td 1,2 TIG immunization Unknown or < 3 doses Yes Yes 3 or more doses No No

Clean, Non-Tetanus Prone Wound Td TIG Yes No

No No

1 Td = Tetanus and Diphteria toxoids adsorbed (adult) TIG = Tetanus Immune Globulin (human) 2 Yes if wound > 24 hours old For children < 7 years, DPT (DT if pertussis vaccine contraindicated) For persons > 7 years, TD preferred to tetanus toxoid alone 3 Yes if > 5 years since last booster 4 Yes if > 10 years since last booster (from MMWR 39:37, 1990; MMWR (SS-2):15, 1997

C. Hepatitis B post-exposure treatment: (To Top) For percutaneous injury with blood or b1ood containing fluids (e.g. IV needle pricks from HbsAg positive patients) 1. For health care workers without vaccination: a Give Hepatitis B immune globulin / HBIG (Hepuman Berna) 4 ml IM within 96 hours of exposure. b. Start Hepatitis B vaccination series (see page 202) 2. For health care workers withvaccination: a Check HBs antibody titer. If a 10 IU/ml, no therapy. If < 10 1U/ml, give HBIG (Hepuman Bema) 4 ml IM and give booster dose of Hepatitis vaccine. D. Rabies post-exposure treatment: (To Top) Contact PGH, RITM or San Lazaro 1. Local wound treatment should be applied in all types of bite exposure. 2. Wounds should be immediately and thoroughly washed with soap and water preferably for 10 minutes. 3. Apply alcohol, tincture or aqueous solution of iodine or povidone iodine. 4. If possible, suturing of wounds should be avoided. However, if it is necessary, it should be done loosely and the anti-rabies immunoglobulin should be infiltrated around and into the wound before suturing. 5. Avoid applying ointment, cream or occlusive dressing to the bite site. Table 12-6. Guide for Rabies Post-ex sure Treatment. Category Type of contacts with suspect or confirmed rabid animal, or animal unavailable for observation I - Touching, petting, feeding of animals: Licks on intact skin, no open wound, no contact of animal saliva on mucous membrane, reliable history II

-

Nibbling of uncovered skin - Superficial scratch, abrasion - No break in skin, no bleeding - Licks on broken skin or healing wounds - Category I with unreliable history

III

-

Treatment

a. No vaccine needed b. Consider active vaccination in patient concerned about or is likely to have repeat exposure a. Vaccinate immediately (see Table 12-7) b. Stop treatment if animal remains healthy after 10-14 days, or if killed humanely and negative for rabies by lab exam

All head and neck exposure a. Vaccine + RIG Single or multiple immediately transdermal bites b. Stop treatment if animal - Licking of mucous remains healthy after membrane or contamination 10-14 days or if killed with saliva humanely and negative for rabies by lab exam

Table 12-7. Summary Schedule of Active Immunization for Rabies. Type of Regimen

Route*

Vaccine Type & Dose

Schedule**

Zagreb (2-1-1)

Intra-muscular

8 site ID Intra-dermal Regimen *** (8-0-4-0-1-1) 2 site 1D Intra-dermal regimen (2-2-2-0-1-1)

PVRV 0.5 ml PDEV 1.0 ml PCECV 1.0 ml PVRV 0.1 ml PDEV 0.2 ml PCECV 0.1 ml PVRV 0.1 ml PDEV 0.2 ml PCECV 0.2 ml

Day 0 = 2 doses Day 7 = 1 dose Day 21 = 1 dose Day 0 = 8 doses Day 7 = 4 doses Day 30 & 90 = 1 dose Day 0, 3 & 7 = 2 doses Day 30 & 90 = 1 dose

*The vaccines are given in the deltoid area of the arm. ** In giving anti-rabies vaccine, the first day when the first dose was given is considered as Day 0, regardless of the number of days interval between the biting incident and the day the vaccine was started. ***For the 8-site ID regimen, the 8 doses given on Day 0 may be given as follows: 2 on each deltoid, lower quadrants of the abdomen, lateral thigh and scapula.

Table 12-8. Dose and Preparation of Rabies Immune Globulin (RIG). Rabies Immune Globulin Equine Rabies Immune Globulin (ERIG) Human Rabies Immune Globulin (HRIG)

Preparation

Dose

Skin Test

1000iu/5ml vial

40 units/kg

Required

300 iu/2ml vial

20 units/kg

Not required

To Main Table of Contents To Detailed Table of Contents

FINAL POINTERS To Main Table of Contents To Detailed Table of Contents A.Important Differential Diagnoses for Common Complaints: Chief Complaint When a patient presents with ... 1. Dizziness 2. Headache a. frontal b. one-sided c. bilateral 3. Confusion / decreased sensorium

4. Chest pain 5. Dyspnea

6. Hypotension

7. Hypertension

8. Abdominal pain 9. Unexplained tachycardia

Differential Diagnoses Always Rule Out ... Cerebellar infarct, Transient ischemic attack Glaucoma (Acute Angle Glaucoma) Space occupying lesion, Arteriovenous malformation, Subdural hematoma Subarachnoid hemorrhage CNS Pathology (Meningitis, Encephalitis), Head trauma, Hypoglycemia, Drug intoxication, Infection, Sepsis, Hypotension, Hypoxemia, Hypercarbia, Hepatic encephalopathy, Uremia, Hyponatremia (check CBC, RBS, Na, Creatinine, O2, CO2, serum NH3) MI, Pulmonary embolism, Pneumothorax, Dissecting aortic aneurysm Acidosis (DKA, HONK), MI, CHF, Pulmonary embolism, Pneumothorax, Acute respiratory failure, Hypoglycemia Cardiogenic shock, Cardiac tamponade, Large MI, GI bleeding, Blood loss, Sepsis, Acidosis, Low albumin, Adrenal insufficiency, Pulmonary Embolism Hypertensive encephalopathy, CVA, Transient ischemic attack, Increased intracranial pressure Acute appendicitis, Superior mesenteric artery occlusion, Ruptured viscus Myocardial infarction, GI bleeding, Blood loss, Sepsis, Hyperthyroidism, Anxiety

B. When you are confronted with a problematic patient and you do not know what to do, remember this mnemonic: RACER – ER. R - RBS (Is this hypoglycemia, hyperglycemia?) A - ABG ( Hypoxia, Acidosis, Hypercarbia?) C - CBC ( Sepsis, Anemia?) E - ECG (MI,,Pulmonaryembolism) R - Radiology - CXR (Is this pneumothorax, CHF, pneumonia?)

E- Electrolytes - Na, K Ca (Electrolyte imbalance?) R - Renal function - BUN, CREA (Uremia?) To Main Table of Contents To Detailed Table of Contents

ALL ABOUT DRIPS To Main Table of Contents To Detailed Table of Contents

How to use the listed drip rates and equivalent dosages given: For example, the statement under number one for the daomine drip sees, “Drip of 2.5-10 mcg/kg/min is equivalent to 9-38 ugtts/min for a 50 kg patient.” This means that a dopamine drip of 2.5 mcg/kg/min is equivalent to giving 9 ugtts/min for a 50 kg patient while a dopamine drip of 10 mcg/kg/min is equivalent to 38 ugtts/min for a 50 kg patient. Using similar statements below as your guide, no tedious computations maybe necessary for the average patient. 1. Aminophylline Drip: D5W. 250 ml+ Aminophylline 250 mg/amp at 15-40 ugtts/min Maintenance Drip of 0.4-0.8 kg/kg/hr is equivalentto 20-40 ugtts/min for a 50 kg patient. Formula: ugtts/min= dose x BW LD = 5 mg/kg BW in 30 ml D5W in a soluset (if patient is not maintained on oral theophylline) Note: Maintenance infusion rate must be reduced to 0.2-0.3 mg/kg/hr for elderly patients, pregnant patients and those with CHF, liver disease or cor pulmonale 2. Amiodarone (Cordarone) Drip: Preparation: 150 mg/3 ml vial a IV Loading Dose: 5-10 mg/kgbody weightt/24 hour or 500-1000 mg in 24 hours Intravenous loading doses were given for an average of 4 days in clinical trials. Estimated maximum daily dose of 1000 rng/24 hours for Filipinos. Orders: Give 150 mg slow IV push over 10-30 minutes (with BP and HR monitoring) followed by D5W 250 ml+ 150 mg-300 mg IV Amiodarone to run for 24 hours. Supplemental doses of 150 mg IV over 10-30 mins may be given for recurrent arrhythmias especially during the early phases of dosing. No more than six additional boluses in any 24 hour period may be given. Or b. Oral loading dose: 10 kg/kg body weight per day for two weeks e.g. Amiodarone 200 mg 1 tab PO TID for 14 days Then maintenance of 200 mg 1 tab OD thereafter. Source: Adapted from Kowey, P., Marinchak, R., Rials, S. et al (1997). Intravenous amiodarone. JACC, 29, 6, 1190-8. 3. Clonidine (Catapres) Drip: Concentration=150 ug/m1 ampule D5W 250 ml+ Catapres 2 amps (150 mg/amp) at 5-30 ugtts/min 4. Clonidine/Hydralazine (Catapres/Apresoline) Drip: D5W 250 ml+ Apresoline 2 amps (20 mg/amp) + Catapres 2 amps (150 mg/amp) at 5-30 ugtts/min (Up to 60 ugtts/min) 5. Diazepam (Valium) Drip: D5W 100 ml+ Diazepam 10 mg q 6 hours (maximum= 60 mg/day) 6. Dobutamine Drip: D5W 250 ml + Dobutamine 250 mg/amp at 10-60 ugtts/min Drip of 2.5-20 mcg/kg/min is eguivalent to 80-60 ugtts/min for a 50 kg patient. Formula ugtts/min=(drip mcg x BW)/16.6 If with CHF, may use double dose: D5W 250 ml+ Dobutamine 500 mg (2 amps) at maximum rate of 30 ugtts/min 7. Dopamine Drip: D5W 250 ml+ Dopamine 200 mg/amp at 7-60 ugtts/min Drip of 2.5-10 mcg/kg/min is equivalent to 9-38 ugtts/min for a 50 kg patient. Formula: ugtts/min=(drip mcg x BW)/13.3 If with congestive heart failure (CHF), may use double dose: D5W 250 ml + Dopamine 400 mg (2

amps) at maximum rate of 30 ugtts/min 8. Dopamine-Lasix Drip: 75 ml of Dopamine Pre-mix (D5W 250 ml+ Dopamine 200 mg) + 25 ml of Lasix 250 mg in a soluset (Total of 100 ml) to run at 6-8 ugtts/min 9. Epinephrine Drip: D5W 250 ml + 1 amp (1 mg) Epinephrine at 15-150 ugtts/min Drip of 1-10 mcg/min is equivalent to 15-150 ugtts/min 10. Esmolol (Brevibloc) drip: Preparation: 100 mg/10 ml vial Concentration= 10 mg/ml Loading dose 0.5 mg or 500 mcg/kg/min e.g.: 50 kg = 25 mg or 2.5 ml slow IV in > 1 minute Maintenance dose= 25-200 mcg/kg/min; start at 50 mcg/kg/min over 4 min e.g.: 50 kg =2.5 mg/min or 150 mg/hr or 15 ml/hr = l5 ugtts/min 11. Furosemide (Lasix) Drip: D5W 250 ml + Lasix high dose 250 mg/amp at 5-30 ugtts/min Concentration= 1 mg/ml Drip of 5-30 ugtts/min is equivalent to 5-30 mg/hour 12. Heparin Drip: D5W 200 ml+ 10,000 units Heparin at 10-20 ugtts/min, use infusion pump Concentration= 50 units/ml Drip of 500 units-1000 units/hour is equivalent to l 0-20 ugtts/min Loading Dose= 3,000-5,000 units slow IV 13. Hydergine Drip: D5NM 1 liter + 6 amps Hydergine x 16-24 hours x 3 doses 14. Hydralazine(Apresoline) Drip: D5W 250 ml + Apresoline 2 amps (20mg/amp) at 5-30 ugtts/min (up to 60 ugtts/min) Maximum daily dose= 3.5 mg/kg body weight per 24 hours 15. Insulin Drip: PNSS 250 ml + 50 units Humulin-R Concentration= 0.2 units/ml Drip of 5-50 ugtts/min (or ml/hour) is equivalent to 1-10 units Humulin R/hour 16. Isosorbide Dinitrate (Isoket) Drip: a D5W 90 ml+ Isoket 10 mg in a soluset Drip of 10-50 ugtts/min is equivalent to 1-5 mg/hr. b. If with CHF, may use double dose: D5W 90 ml+ Isoket 20 mg in a soluset Drip of 5-25 ugtts/min is equivalent to 1-5 mg/hr or Glyceryl Trinitrate (Perlinganit) Drip: 1 mg/ml in 10 ml vials a. D5W 90 ml+ Perlinganit 10 mg (1 vial) in a soluset Drip of 10-50 ugtts/min is equivalent to 1-5 mg/hr b. If with CHF, may use double dose 90 ml D5W+ Perlinganit 20 mg (2 vials) Drip of 5-25 ugtts/min is equivalent to l-5 mg/hr 17. Lidocaine Drip: D5W 250 ml + Lidocaine 1 gm (pre-mix) at 15-60 ugtts/min Concentration = 4 mg/ml Drip of 15-60 ugtts/ml is equivalent to 1-4 mcg/min Formula: ugtts/min=dose x 15 Loading Dose (LD)= 1 mg/kg IV Note: Maintenance infusion rate must be reduced for patients with cardiac failure or hepatic dysfunction and for elderly patients.

18. Magnesiem Sulfate Drip: D5W 250 ml + 2 gm MgSO4 at 20 ml/hr Concentration: 250 mg/ml X 10 ml ampule = 2.5 gm/ampule 19. Mannitol-Furosemide Drip: a. Mannitol 250 ml + Furosemide 100 mg at 10 ugtts/min or b. Mannitol 36 ml + Furosemide 240 mg (24 ml) x 6 hours 20. Morphine Sulfate Drip: PNSS 50 ml+ 1 amp Morphine sulfate (16 mg/amp) at 6 ugtts/min (2mg/hr) As needed: May give 1-3 mg morphine suite SC prn 21. Nicardepine Drip: a. D5W 250 ml + Nicardepine 20 mg Concentration = 0.08 mg/ml Drip of 15-67 ugtts/min is equivalent to 1-5 mg/hr or b. D5W 90 ml+ Nicardepine 10 mg in soluset Concentration = 0.1 mg/ml . Drip of 10-50 ugtts/min is equivalent to 1-5 mg/hr Maximum dose = 15 mg/hr Note: The IV infusion site must be changed every 12 hours should a peripheral line be used. 22. Nimodipine (Nimotop) Drip: Concentration: 10 mg in 50 ml bottle Drip of 5-10 ugtts/min is equivalent to 1-2 mg/hour Note: Use larger veins and alternate IV site every 48 hours to avoid phlebitis. 23. Nitropruside (Nipride) Drip: D5W 250 ml + Nitroprusside 50 mg as side drip at 5-30 ugtts/min (usual dose) Concentration= 0.2 mgl/ml or 200 mcg/ml Drip of 0.5-8 mcg/kg/min is equivalent to 8-120 ugtts/min for a 50 kg patient Formula: ugtts/min (dose x BW kg)/3.3 Note: Taper within 3 days to avoid thiocyanate toxicity. Cover infusion set and IV line with aluminum foil or carbon paper. 24. Noradrenaline(Levophed) Drip: 2 mg Noradrenaline in 2 ml ampule D5W 250 ml+ 1 amp Levophed at 15-60 ugtts/min Concentration= 8 mcg of Noradrenaline per ml Drip of 2-8 mcg Noradrenaline/min is equivalent to 15-60 ugtts/min 25. Pentoxifylline (Trental) Drip: a D5W 250-500 ml + 1 amp Trental 300 mg x 6 hours for 1 dose then PO Trental 400 mg 1 tab TID b. D5W 500 ml + 3 amps Trental (900 mg) x 24 hours 26. Sodium Bicarbonate Drip: D5W 250 ml + NaHCO3 1 amp (8.4%-50ml vial) X 12-24 hours (or at 20-40 ugtts/min) 27. Somatostatin (Stilamia) Drip: Give 250 mcg slow IV then a. D5W 500 ml + 3 mg Somatostatin at 42 ml/hr (250 mcg/hr) or b. D5W 250 ml + 3 mg Somatostatin (Stilamm) at 21 ml/hr (250 mcg/hr) until GI bleeding has stopped or up to 5 days 28. Streptokinase (Streptase, Kabikinase) Drip: Streptokinase 1.5 million units + Dy5 90 ml at 100 ml/hr (1 hour running rate)

29. Terbutaline (Bricanyl) Drip: D5W 250 ml + 5 amps Bricanyl at 10-30 ugtts/min

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MORE DRUG LIST To Main Table of Contents To Detailed Table of Contents PAIN RELIEVERS a. Paracetamol *Paracetamoll (Tempra, Alvedon, Biogesic, Aeknil) 500 m forte tab, 150 mg/2 ml amp PO- 1 tab q 4 hr IV, IM- 1 amp q 4 hr b. NSAIDS Aspic (Coaxal, Regular Medicol, United Home Aspirin) 325 mg tab, 500 mg tab PO- 1 tab q 4 hr Mefenamic Acid (Ponstan, Dolfenal, Gardan) 250 mg cap, 500 mg cap PO- 1 cap TID *Ibuprofen (Advil, Brufen) 200 mg tab, 400 mg tab, 600 mg tab PO- 1 tab q 6 hr Diclofenac Na (Voltaren, Neo-Pyrazon) 25 mg tab, 50 mg forte tab, 75 mg SR tab, 100 mg SR tab, 75 mg/3 ml amp PO- 75-150 mg/day in 2-3 divided doses IM- 1-2 amps/day Indomethacin (Indocid) 25 mg cap PO- 1 cap BID-TID Ketoprofen (Orudis EC/IM/IV) 100 mg EC tab, 50 mg/2 ml IM amp, 100 mg IV vial PO- 1 tab BID post cibum IM- 50-100 mg IM 1V- 100-300 mg daily Ketorolac Trometamol (Toradol) 30 mg/ml amp IM, IV- 10-30 mg q 4-6 hours Naproxen Ma (Flanax) 275 mg tab, 550 mg forte tab PO- 1 tab q 8 hr *Meloxicam (Mobic) 7.5 mg tab, 15 mg tab, 15 mg/1.5 ml amp PO, IV-7.5-15 mg/day Piroxicam (Feldene) 10 mg cap, 20 mg cap, 20 mg Flash tab, ointment PO- 1-2 caps OD-BID Tenoxicam (Tilcotil) 20 mg tab, 20 mg vial PO- 1 tab OD IM, IV- 1 vial/day c. Selective inhibitors of Cyclooxygenase (Cox-2) *Celecoxib (Celebrex, Coxid) 100 mg cap, 200 mg cap PO- 100 mg cap BID *more expensive but with less GI irritation d. Opiates Pethidine HCl (Demerol) 100 mg/2 ml amp, 50 mg X 30 ml vial IM, K- 50-150 mg q 3-4 hr Morphine Sulfate (Hizon Morphine Suite) 10 mg tab, 20 mg tab, 30 mg tab, 10 mg/ml amp, 15 mg/ml amp. PO- 10-40 mg QID IM- 10 mg/70 kg body weight IV- 1-4 mg slow 1V (for myocardial infarction patients) Nalbuphine HCl (Nubain) 10 mg/ml vial SC, IM, IV- 0.15-0.20 mg/kg BW or 5-10 mg q 3-6 hr Tramadol (Tramal) 50 mg cap,100 mg retard tab, 50 mg/ml amp, 100 mg/2 ml amp

PO, IM, IV, SC- 50-100 mg q 6-8 hr maximum= 400 mg/day LAXATIVES Bisacodyl (Dulcolax) 5 mg tab, 10 mg suppository PO-1-2 tabs HS Per Rectum- one 10 mg suppository Lactulose (Duphalac) PO-1-2 tbsp HS Mg(OH)2 (Phillips Milk of Magnesia) 311 mg tab, 425 mg/5 ml syrup PO- 2-4 tabs, 2-4 tbsp in 1/2 glass of H2O Na Picosulfate (Laxoberal) 5 mg tab, 1 mg/ml syrup PO- 1-2 tsp or tab HS Psyllium Hydrophilic Mucilloid (Metamucil) 5.9 gm sachet PO- 1 sachet/glass of watar OD-TID Standardized Senna Concentrate (Senokot) 187 mg tab, 0.337 mg/3 gm granules PO- 2 tabs OD - 4 tabs BID, 1-2 tsp granules BlD ANTIDIARRHEALS Attapulgite (Polymagma, Diatabs) 600 mg tab, 600 mg/5 ml susp PO- 2 tabs or tsp initially then after each LBM, max =16 tabs/day or 90 ml/day Loperamide HCl (Imodium, Lormide) 2 mg cap PO- 2 caps initially then 1 cap after each LBM, maximum = 6caps/day Nifuroxazide (Ercefuryl) 200 mg cap PO- 1 cap QID Paromomycin (Humagel) 150 mg cap, susp PO- 1-2 caps or tbsp q 3-5 hr Diphenoxylate HCl+ Atropine (Lomotil) tab PO-2 tabs TID-QID

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MORE DRUG LIST To Main Table of Contents To Detailed Table of Contents ANTIFLATUNETS/FOR GAS Activated Dimethicone (Disflatyl) 40 mg tab PO- 1-2 tab chewed after meals Pancreatin+Dimethicone (Pankreoflat) 80 mg tab PO- 1-2 tab with meals ANTISPASMODICS Hyoscine-N-butylbromide (Buscopan) 10 mg tab, 20 mg amp PO - 1-2 tabs TID-QID IV, IM, SC- 1-2 amps Mebeverine HCl (Duspatalin) 100 mg tab PO- 1 tab TID-QID Pinaverium Br (Eldicet) 50 mg tab PO- 1-2 tabs TID with meals ANTIPYRETICS Temp < 37.8 C Tepid sponge bath Temp > 37.8 C = Paracetamol 325-500 mg tab PO q 4 hr Temp > 38.5 C Paracetamol 500 mg tab PO q 4 hr or Aeknil 1 amp IV q 4 hr HYPNOTICS, SEDATIVES, TRANQUILISERS Alprazolam (Xanor) 250 mcg tab, 500 mcg tab, 1 mg tab PO- 250-500 mcg OD-TID Bromazepam (Lexotan) 1.5 mg tab PO- 1-2 tabs OD-TID Clorazepate Dipotassium (Tranxene) 5 mg cap, 10 mg cap PO- 5-10 mg cap HS Diazepam (Valium, Trazeparn, Anxionil) 2 mg tab, 5 mg tab, 10 mg tab, 10 mg/2 ml amp PO-2-5 mg OD- TID IV, IM- 2-5 mg q 3-4 hr *Diphenhydramine HCl (Benadryl) 25 mg cap, 50 mg cap, 50 mg/ml vial PO-25-50 mg BID IM, IV- 10-50 mg in 4 divided doses Flurazepam Dihydrochloride (Dalmane) 15 mg cap PO- 1/2- 1 cap HS Haloperidol (Haldol) 2 mg tab, 5 mg tab, 10 mg tab, 50 mg/ml amp (Serenace) 0.5 mg tab, 1.5 mg tab, 5 mg tab, 20 mg tab, 5mg/ml amp PO- 10-15 mg/day or 2-5 mg BID-TID IM- 10-30 mg Midazolam (Dormicum) 15 mg tab, 5 mg/ml amp, 5 mg/5 ml amp, 15 mg/3 ml amp PO- 1/2 -1 tab HS IV, IM- 0.07-0.1 mg/kg/BW or 2.5-5 mg Zolpidem (Stilnox) 10 mg tab PO- 1/2-I tab HS *Safest sedative for elderly patients To Main Table of Contents To Detailed Table of Contents

INTRAVENOUS FLUIDS IV Solutions D5W D10W 0.9 NSS/PNSS D5LR NM NR D5 0.9 NaCl D5NMK

Glucose 50g/L 100g/L

50g/L 50g/L

Na

Cl

154

154

130 40 140 154 40

109 40 98 154 40

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K

4 13 5 30

Ca

HCO3

3

28

FORMULAS To Main Table of Contents To Detailed Table of Contents A. Anion Gap = Na - (Cl + HCO3) B. Arterial Blood Gas Computation: l. Metabolic Acidosis: dec pCO2 = (1.5X delta HCO4)+8 + or - 2mmHg 2. Metabolic Alkalosis: inc. pCO2= (0.9X delta HCO3)+9 + or - 2mmHg 3. Respiratory Acidosis (Acute): delta HCO3 = delta pCO2 x (1/10) + or - 3meqlL 4. Respiratory Acidosis (Chronic) delta HCO3 = delta PCO2 x (3/10) + or - 4 meq/L 5. Respiratory Alkalosis (Acute): deltaHCO3 = deltaPCO2 x (2/10) but not < 18 meq/L 6. Respiratory Alkalosis (Chronic): delta HCO3 = delta pCO2 x (4/10) but not 30.0 E. Cardiac Output = Heart Rate X Stroke Volume F. Corrected Serum Calcium (mg/dl) = measured Ca in mg/dl + 0.8 X(4 – albumin in g/dl) G. Estimated Creatinine Clearance (ml/min) = [(140-age) X weight in Kg]/ 72 (males, 85 in females) X serum Cr (mg/dl) H. Ideal Body Weight: a. Female: 100 pounds+ (5 pounds per inch over 5 feet) b. Male: 106 pounds + (6 pounds per inch over 5 feet) I. Mean Arterial Pressure (MAP) = [Systolic BP+ (2 X Diasto1ic BP)]/3 Normal Value: 70-100 mm Hg J.Normal Creatinine Clearance = 100-125 ml/min (males), 85-105 (females) K. Plasma osmolality (mosm/L) = [2 (Na+ K)] + BUN (mmol/L) + RBS (mmol/L) Normal Value: 280-300 mosm/L

L. Sodium (Na) deficit (mEq) = 0.6 X (wt. kg) X [desired (Na) - actual (Na)] M. Temperature Conversion: a Degree Fahrenheit to Degree Celsius: C = (F – 32) x 5/9 b. Degree Celsius to Degree Fahrenheit: F = (C x 9/5) + 32 To Main Table of Contents To Detailed Table of Contents

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