lac+usc internal medicine residency survival guide 2013-2014
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LAC+USC INTERNAL MEDICINE RESIDENCY SURVIVAL GUIDE 2013-2014 1 2 THIS BOOK BELONGS TO: Dr. _________________________________________________ PGR: ________________________________________________ PHONE: _____________________________________________ EMAIL: ______________________________________________ CONTRIBUTING AUTHORS: Robert Drummond, M.D., Ph.D. Suneet Dullet, M.D. Beatrice Kenol, M.D. Arjun Makam, D.O. Alan Moazzam, M.D. Jackie Nneji, M.D., M.P.H. Ray Pillai, M.D. Mona Rezapour, M.D., M.H.S. Billy Sim, M.D. REVIEWING FACULTY: Donald Feinstein, M.D. Elaine Kaptein, M.D. Rod Mokhtari, M.D. Gina Rossetti, M.D. 3 SECTION 2 – BLS/ACLS 4 5 6 TABLE OF CONTENTS SECTION 1 – ACLS/BLS .................................................................................4 SECTION 2 – Phone Numbers/Consults/Voips .............................................4 SECTION 3 – THE WARDS ...........................................................................17 1. Tips For The Wards Team.........................................................17 2. Daily General Medicine Itinerary .............................................18 3. Admitting A Patient..................................................................18 4. Admit Orders............................................................................19 5. Daily Notes ...............................................................................22 SECTION 4 – COMMON ON-CALL/CROSS COVER SCENARIOS ....................25 1. Chest Pain ................................................................................25 2. Somnolence / Δ ms ..................................................................25 3. SOB ..........................................................................................25 4. Hypoglycemia...........................................................................26 5. Hyperglycemia .........................................................................26 6. Nausea / vomiting / diarrhea ...................................................26 7. Pain / insomnia / anxiety .........................................................27 8. HTN / hypertensive urgency ....................................................27 9. Hypotension .............................................................................27 10. Fever ........................................................................................28 SECTION 5 – PROCEDURES .......................................................................29 1. Imed consent ...........................................................................29 2. Central venous catheters (central lines)...................................29 3. Arterial lines .............................................................................35 4. External jugular line .................................................................37 5. Ultrasound-guided peripheral iv ..............................................38 6. Lumbar puncture .....................................................................40 7. Abdominal paracentesis ...........................................................42 8. Thoracentesis ...........................................................................45 SECTION 6 – COUNTY STUFF ......................................................................48 1. Locations in hospital ................................................................48 2. How to get stuff done ..............................................................48 a. Picc line ...........................................................................48 7 b. Stress test........................................................................48 c. TTE ..................................................................................48 d. PFT’S................................................................................49 e. EEG’S ...............................................................................49 f. Permacath/vascath .........................................................49 g. CT/MRI ............................................................................50 h. Pet scan ...........................................................................50 i. US ....................................................................................50 3. LAC+USC Radiology ...................................................................50 4. Frequent consults (and their requirements) .............................51 a. Ortho ...............................................................................51 b. Renal ...............................................................................51 c. Neuro ..............................................................................51 d. Heme...............................................................................51 e. Oncology .........................................................................51 f. Rad Onc ...........................................................................51 g. GI .....................................................................................51 h. Liver ................................................................................51 i. Urology............................................................................51 j. Speech and Swallow ........................................................51 5. Electrolyte Replacement ...........................................................52 6. Misc. county stuff ......................................................................54 a. How to TAR a patient ......................................................54 b. VNA .................................................................................54 c. Med Appliance ................................................................54 d. Special bed request .........................................................54 e. Isolation ..........................................................................55 SECTION 7 – BASICS OF PAIN MANAGEMENT ............................................56 SECTION 8 – TPN/TUBE FEEDS ...................................................................59 SECTION 9 – CRITICAL CARE/ ICU ..............................................................61 1. ICU On Call Intern Schedule ....................................................61 2. ICU Regular Day Schedule ........................................................61 3. Daily Considerations in the ICU ................................................61 4. Respiratory failure ...................................................................62 5. Types of supplemental oxygen.................................................63 8 6. Acute respiratory distress syndrome (ARDS) ...........................64 7. Supportive ventilation basic primer .........................................65 8. Sepsis .......................................................................................66 9. Shock........................................................................................67 10. Pressors....................................................................................68 SECTION 10 – CARDIOLOGY .......................................................................70 1. Differential diagnoses of chest pain .........................................70 2. Peripheral edema grading system ............................................72 3. JVP assessment ........................................................................72 4. Waveforms...............................................................................73 5. EKG...........................................................................................73 6. Acute coronary syndrome (ACS) ..............................................75 7. Post-cardiac cath pts ................................................................77 8. The new cardiomyopathy (CM) pt ...........................................78 9. Heart failure .............................................................................78 10. A-fib .........................................................................................80 11. HTN ..........................................................................................82 12. Hypertensive urgency/emergency ...........................................82 13. Syncope....................................................................................83 14. Brugada criteria (distinguish SVT from VT)...............................84 15. Valvular diseases ......................................................................85 SECTION 11 – ENDOCRINOLOGY ................................................................87 1. Insulin & Oral Antidiabetic Agents ...........................................87 2. Inpt Diabetes Management .....................................................87 3. DKA ..........................................................................................89 4. HHS ..........................................................................................90 5. Adrenal Insufficiency in Inpts ...................................................91 6. Thyroid Disorders .....................................................................92 7. Dyslipidemia.............................................................................95 SECTION 12 – INFECTIOUS DISEASES .........................................................98 1. Neutropenic Fever ..................................................................98 2. Fever of unknown origin ........................................................ 100 3. Endocarditis ........................................................................... 101 4. Community acquired MRSA ................................................... 105 5. Community acquired pneumonia (CAP) ................................. 106 9 6. HIV – new diagnosis ............................................................... 109 7. Reportable diseases ............................................................... 111 8. Bacteria classification ............................................................. 111 9. Fungi ...................................................................................... 113 SECTION 13 – GASTROENTEROLOGY/HEPATOLOGY ................................ 115 1. Diarrhea ................................................................................. 115 2. Clostridium difficile (Pseudomembranous) colitis .................. 118 3. Constipation ........................................................................... 119 4. GI Bleeding ............................................................................. 120 5. Helicobacter pylori ................................................................. 121 6. PPI use ................................................................................... 121 7. Colonoscopy Preparation ....................................................... 122 8. Inflammatory Bowel Diseases ................................................ 122 9. Acute Pancreatitis .................................................................. 124 10. Acute Hepatitis....................................................................... 126 11. Alcoholic Hepatitis ................................................................. 128 12. Acetaminophen Toxicity ........................................................ 129 13. Chronic (and Sub-acute) Hepatitis & ESLD ............................. 131 14. Liver Transplant ..................................................................... 132 15. Ascites & SBP ......................................................................... 133 16. Hepatorenal Syndrome .......................................................... 135 17. Cancer Screening ................................................................... 136 SECTION 14 – HEMATOLOGY/ONCOLOGY ............................................... 137 1. Anemia ................................................................................... 137 2. Hypercoagulability ................................................................. 142 3. DVT Prophylaxis .................................................................... 143 4. Anticoagulation in Pt w/ VTE.................................................. 144 5. Heparin Induced Thrombocytopenia ..................................... 147 6. Other Platelet Disorders ........................................................ 149 7. Hematological Malignancies ................................................. 151 8. Common Heme/Onc Emergencies ......................................... 159 SECTION 15 – NEPHROLOGY .................................................................... 162 1. Chronic Kidney Disease (CKD) ................................................ 162 2. Acute Kidney Injury (AKI) ....................................................... 164 3. Acid-Base Disorders ............................................................... 166 10 4. Hyponatremia & Hypernatremia............................................ 169 5. Hypokalemia & Hyperkalemia ................................................ 173 6. Management of Magnesium, Calcium, & Phosphorus ........... 176 7. Kidney Transplant – Pearls ..................................................... 177 SECTION 16 – NEUROLOGY & ADDICTION/WITHDRAWAL....................... 179 1. Bacterial Meningitis ............................................................... 179 2. Stroke (focal neurologic deficit) ............................................. 180 3. Alcohol Withdrawal ............................................................... 182 4. Opiate Withdrawal ................................................................. 182 5. Altered mental Status ............................................................ 183 6. Delerium ................................................................................ 183 7. Dementia ............................................................................... 186 8. Seizures .................................................................................. 187 SECTION 17 – PULMONARY ..................................................................... 189 1. Asthma ................................................................................... 189 2. COPD Exacerbations ............................................................... 192 3. ILD .......................................................................................... 192 4. Pulmonary Embolus ............................................................... 193 5. Pulmonary Hypertension ....................................................... 194 6. Pleural Effusion ...................................................................... 194 7. Pulmonary Edema .................................................................. 196 8. Cystic Fibrosis ......................................................................... 196 SECTION 18 – RHEUMATOLOGY .............................................................. 198 1. Systemic Lupus Erythematosis ............................................... 198 2. Rheumatoid Arthritis ............................................................. 202 3. Gout ....................................................................................... 203 4. Vasculitis ................................................................................ 204 5. Dermatomyositis/Polymyositis .............................................. 208 6. Scleroderma ........................................................................... 208 SECTION 19 – GENERAL PHARMACY ........................................................ 211 1. Steroid dosing ........................................................................ 211 2. Beta Blocker Dosing ............................................................... 211 3. ACE Inhibitor and ARB Dosing ................................................ 212 SECTION 20 – DISCHARGES ...................................................................... 213 1. Discharge Summary ............................................................... 213 11 2. Discharge Dictations .............................................................. 213 3. Transfer Discharge (Rancho los amigos, Oliver View, etc.) .... 214 4. AMA Discharge....................................................................... 214 SECTION 21 – HOW TO SURVIVE IN THE CLINICS ..................................... 215 1. Specialty Clinics ...................................................................... 216 2. Continuity clinic ..................................................................... 215 3. Galaxy .................................................................................... 216 4. Admissions from Clinic ........................................................... 216 SECTION 22 - END OF LIFE........................................................................ 217 1. DNR/DNI ................................................................................ 217 2. Comfort care .......................................................................... 217 3. Palliative care/Hospice Care .................................................. 219 4. Death exam ............................................................................ 219 SECTION 23 – MEDICAL INFORMATICS .................................................... 221 1. Affinity ................................................................................... 221 2. CCIS ........................................................................................ 221 3. Museweb ............................................................................... 221 4. PADI ....................................................................................... 221 5. QUANTIM............................................................................... 221 6. SYNAPSE ................................................................................. 221 7. RPS ......................................................................................... 221 8. Econsult ................................................................................. 221 9. Verinform ............................................................................... 221 SECTION 24 – OUTSIDE HOSPITAL PHONE NUMBERS .............................. 222 12 SECTION 2 – PHONE NUMBERS (Consults, VOIPS, etc.) IMPORTANT NUMBERS (Consults, VOIPS, etc) CARDIOLOGY Cards consult Stress Lab (Marci) Cath Recovery Echo sched Echo tech Echo Read EKG tech CARDS CONSULT VOIPS ID ID consult HIV clinic(5P21) TB Control Epidemiology PULMONARY Pulm consult Consult VOIP Bronch suite Resp therapy PIERRE (Induced sputum) PFT lab OTHER Endocrine Derm consult 13 226-4238 97468 95284,95783 97444 97445 97520 97466 A-93982 B-93983 226-3851 323-343-8258 226-7962 9-6645 GI GI & Liver Consult GI Recovery GI Lab GI fellow workroom ERCP Room GI Fellow VOIPS HEME/ONC Heme Consult Onc Consult Palliative Care Pain Management Rad Onc consult 226-7923 93995 9-4730 226-7492 9-1825 Onc clinic 4P1 91266 HD nurse VOIP OTHER Rheum Rheum VOIP EEG 442-2807 VOIP-93987 226-3375 RENAL Renal Consult Fellow VOIP 97974 95530 95530 92679 97275 A-93988, B-93989 226-6969 226-6395 9-8532 213-919-8545 9-5019 9-5023 OP appt 226-5177 226-7307 A 9-3996 B 9-3997 9-3243 226-7889 93998 9-7388 Derm pgr 213-717-2626 213-919-9578 Psych ED 9-7085 Neuro inpt VOIP Consult VOIP 9-4537 9-4536 Psych C+L answering machine 226-7975 SURGERY CONSULTS GEN SURGERY ACS Consults 9-7782 ACS A 919-8751 ACS C 919-8755 ACS B 919-8752 NON Trauma VOIP 9-7769 SICU VOIP/consult for PEG or TRACH 9-81717 CRS 9-7363 213-919-7363 6-7791 213-919-8581 9-7819 6-4981 213-919-7299 990-8574 213-919-0468 9-4198 93127 94198 HBS TMIS ”thoracic” CTS Surg Onc Plastics Tumor Breast Gyn-Onc OB Gyn ACS D 919-4529 OTHER SURGERY ENT Neurosurg Opthalmology Ortho consult pgr Ortho ID 97309 213-919-7000 9-7376 919-9254 213-919-3487 9-7227 Ortho ID pager 213-919-3487 Urology consult pgr Podiatry outpt only Vascular Vasc surg on call IR IR consult Aangio suite room 919-2156 FNA biopsy 94615 323-226-4172 9-5816 213-919-8750 94100 94099 RADIOLOGY radread.usc.edu CT reading room Days Approval aft 5pm Weekdays aft 5pm weekends Neuro reading room 14 91583 92798 92798 92798 94149 CT scheduling Inpt Outpt U/S scheduling U/S reading rm Xray Read 97202 92798 97207 94386 98063 MRI MRI MSK reading Xray 91289, 90, 91, 92, 93 96104 97234 Rads Attending 94395 Nuc Med Vasc Lab 97855 94618 Gold A Gold B Gold C Gold D Resident Rm 8A CCU MICU I MICU II MICU III 94013 94110 94150 94151 91385 93981 93984 93985 93986 MEDICINE TEAM VOIPS Med Consult Red A Red B Red C Red D White A White B White C White D 91644 94145 94146 94147 94148 94109 94153 94154 94155 ANCILLARY Inpt PHARMACY TPN Pharmacy 97641 96763 97438 PT/OT weekday 97437 weekend Speech Therapy 95096 95082 PICC PICC nurse 226 7516 323 409 4186 90779 Social Work Micro Lab Cytology 97012 94615 SCW in ER SCW main office Outpt PHARMACY 15 Admission Stuff UR Bed Control Nursing supervisor Sched Admit Discharge Stuff Discharge Waiting Unit 95001 95321 92965 Grace, UR 96412 91560 Patty Evans (supervisor) 93761 office, 97447 voip 96883 95253 Rancho Shirley Rancho liason Dr. Carpio Med Appliance On Call Chief Google Voice Ed Affairs 562-446-2347 91674 562-401-6085 95125 213 375 4455 VNA RN Dictation line 95090 888-201-8590 Pathology Chief’s Office 94606 323 226 7644 323 226 7556 Galaxy 323 226 2206 Wards Jail ................94568 2E .................96355 4AL ...............93929 4AH ..............93933 4BL ...............97490 4BH ..............94005 5A ................97391 5BL ...............98050 B5E ...............97882 5F .................97393 6A ................97730 6B .................97812 6C .................97225 6D ................97227 7A ................92592 7B .................94021 7C .................97312 7D ................97304 8A ................97651 8A Res Rm .....98652 CCU ..............97111, 97112, 97113 Ob.Gyn .........90504 NICU .............93264 PICU .............93883 16 SECTION 3 – THE WARDS 1. TIPS FOR THE WARD TEAM 1. Fill out/stamp request forms (U/S, CT, MRI, Nuclear Med, Stress test) and drop them off at 7:30 am or on Work rounds. 2. While one team member is presenting, someone else should take a blank order form and write down any orders the attending recommends then place it in the chart. 3. Write down all other post round tasks the attending recommends during rounds so that nothing gets missed during the afternoon. If the attending recommends a study (U/S, CT, etc.) fill out and stamp the appropriate form & gather the necessary info then submit them at the earliest opportunity. 4. Write PRN orders on nearly all of your patients: Tylenol 650 mg po/pr q4hr prn HA/Fever/Pain, Maalox 30cc po q6hr prn dyspepsia, MOM 30cc po q6hr prn constipation. Benadryl 25mg po qhs prn insomnia, Reglan 10mg IV/IM q6hr prn nausea (there is a check box for many of these on the Admission Orders set) Make sure you go through the PRN’s and make sure patients don’t have any contraindications (i.e. renal failure w/ MOM or elderly w/ Benadryl) 5. Record a pain score, list it as a separate problem, and treat it appropriately 6. Order an admit panel on most of your admissions: CBC w/ diff, BMP, Mg, Phos, LFTs, PT/INR, UA 7. Complete as much of the D/C summary as possible as you complete the H&P. 8. Know why each of your patients is still here and what you need to do to get them out of here. 9. Know which of your patients is sickest and make sure it is relayed to night float and med consult when appropriate. 10. Try to anticipate problems your patient may give the Night Float and warn them/sign out what you want done. 17 2. DAILY GENERAL MEDICINE ITINERARY 6-7am: Get Sign out from your Night Float and Pre Round/See New Patients 7-8am: Work rounds with Senior Resident 8-9am: Resident Morning Report Interns perform patient care/write notes 9-12 noon: Attending Rounds 12 – 1pm: Noon Conference/Lecture (Take lunch with you) 1-5:30pm: Patient care and Admissions 5:30pm: Sign Out to Senior Resident and Night Float 3. CHECKLIST FOR ADMITTING A PATIENT 1. You will receive a call from Med Consult, your Senior Resident, or Co-Intern that you have received a patient. Ask for the name, PF, and location. 2. Check to see if the patient is a bounce back , if so, notify your Senior Resident & Med Consult 3. Check Labs write the important ones on a lab sheet. 4. Check Affinity for Discharge Summaries and any Clinic Notes . Check Affinity, MUSEWEB, & Quantim EDM for old chart and any other useful information about the patient’s history. If you know the patient has been admitted before and Quantim doesn’t have the d/c summary, call Medical Records at 226-6221 for the old chart. 5. Check Synapse (to review) and Affinity (to read dictations) for any imaging done in ER or prior to admission. Briefly assess the patient (vital signs, brief exam) Look at the patient from across the room for general impression. Introduce yourself to the patient and/or family members and tell them you are going to briefly check on the patient. Mental Status: find out if the patient is AA&Ox4 (person, place, time, and situation) 18 Check Vital signs (Take the pulse for six seconds and multiply by 10) Count respirations for 15 seconds then multiply by 4 Get a pulse ox if you are worried at all about their respiratory status, consider an ABG Ask the nurse for the other vitals and for orthostatics Get a brief HPI, ask also if they have med allergies and their weight Assess whether the patient is critical, guarded, or stable. If they are not stable and not in the ICU , call your Senior resident or Med Consult (323) 409-1644 After Initial Assessment: Review ER sheet to see what was done and include a brief ER course in your H&P Go to the chart and write admit Orders (include your admit panel and prn’s). Medications will need to be written on the Medication Reconciliation Form (PADI). If the PADI form is not signed then pharmacy will not be able to dispense medications. Do full H&P (Template available on Chiefs’ Website) don’t be afraid to call the patient’s family, doctor, ER physician etc. for more info. Modify orders as necessary Start D/C Summary (If you are confident the patient will be discharged the next day, start prescriptions.) 4. ADMIT ORDERS: Usually, an admit order sheet will be available which contains a checklist of common admission items, if not, then use a physician order sheet and the following pneumonic: CAD VANDISMAL C- Condition: Stable, Guarded, Critical, etc. 19 A- Admit: Firm (Gold/White/Cardinal), Team (A,B,C,D) , Attending, Resident, Intern D- Diagnosis: CHF exacerbation, PNA, etc (this should be the admitting dx) V- Vitals: Usually “per routine” is sufficient (this is q 4 hours on the floor and q 1h in ICU) If particularly concerned about a patient you can initially check more frequently (ex: q 1 hour x 2, then q 4h) A- Allergies: PCN (anaphylaxis), Morphine (rash), etc. N- Nursing: Usually per routine unless special concerns (i.e. strict Is/Os, daily weights, dressing changes, seizure precautions, “O2 to keep Sat > 92%”, “foley to gravity”, etc.) D- Diet: Regular, ADA/Consistent Carbohydrate, 2gm Na, etc (see diet sheet on next page) I- IV Fluids: You can just write “SLIV” for saline lock which means the nurse periodically flushes the line and no standing IVF If the patient is not eating, does not have Renal Failure, Cirrhosis or CHF you can consider given maintenance fluids w/ ½ NS, consider D5 w/ ½ NS if patient is not diabetic One trick is to add 40 to their weight in kg and use that is your rate in cc/hr (ex: 70kg person would get 110cc/hr of IVF) If patient ETOH intoxication or withdrawal can give banana bag: 1mg Folate, 100mg Thiamine, 10cc MVI, 2gm MgSO4 in 1L NS at ~100cc/hr S- Studies: EKG, CXR,U/S, CT, MRI, etc. 20 M- Meds Make sure you fill out and sign the med reconciliation sheet (otherwise the patient will not get their meds) Check off PRN’s on the admission orders (Benadryl, MOM, etc.) but make sure they don’t have any contraindications Make sure you address PRN pain medications. All opioids have to be written “x 72 hours” or they will fall off after 1 day. You can write “x indefinite (cancer)” if the patient has a malignancy and it will stay on for the admission A- Activity: “as tolerated” unless you don’t want them getting out of bed in which case you and write “bed rest”, “bed rest with BRP (bathroom privileges)” if they are not a fall risk is also acceptable If you are worried they will not get out of bed and you want them to you can write “out of bed to chair tid” L- Labs: order CBC w/ diff, BMP, Mg, Phos, LFTs, PT/INR and UA on nearly everyone then add any more specific labs if labs were drawn a few hours ago (in ER or Clinic) no need to repeat until AM unless you need something specific if no labs were drawn in last few hours, everything should be sent GENERATING A GOOD DIFFERENTIAL: Here are three useful approaches: 1) Pathology: VINDICATE Vasculitis Infectious Neoplasm Degenerative (Aging) Iatrogenic (Procedures/Drugs) 21 Congenital Allergic/Autoimmune Trauma Environmental (Poisons/Chemicals) 2) Anatomy This works well with pain: RUQ pain: think of what anatomical structures are in the area or nearby: liver, gallbladder, colon, R kidney, stomach, pancreas, lower lobe of right lung, etc. 3) Pathophysiology This works well with things like acute anemia where based on pathophysiology it should be. 5. DAILY NOTE WRITING YOUR DAILY NOTE: Another useful mnemonic that can be used for writing a daily note is: CON ME LVN 1. Find the Chart 2. Look at the recent Orders 3. Look at the recent consult Notes 4. Check the nursing Medicine sheets (MAR) for the meds your patient is actually getting, or check PADI 5. Examine and interview the patient 6. Check for new Labs and to see which labs are still pending 7. Check the Vital signs 8. Talk with the Nurse or read the nursing assessment in affinity 9. Write your note DAILY NOTE TEMPLATE: Medicine (Red A, B, C, etc.) Progress Note Attending: Resident: Intern: ID: ex: 50 YO F w/ DM admitted for PNA 22 Problem List: (Keep this dynamic. Move things up or down on the list depending on what is most important.) 1- PNA 2. Strep Bacteremia 3. DM 4. HTN Meds: (keep this updated, check PADI daily and cross-reference with your signout, especially abx) Abx (date started, D#) Heart Meds Other Meds Prn Meds S: No overnight events. Pt remains febrile overnight O: VS: T, HR, RR, BP, O2 sat, Is/Os GEN HEENT PULM CV ABD EXT NEURO Results: (include important information, don’t copy and paste every lab and study the patient has had from the beginning of time. Only what’s relevant!) Labs: (CBC, CMP, etc) Micro: (any blood cultures, urine cultures, stool, etc…) Imaging: (any relevant imaging) 23 Assessment: (This is where you should put a good “one liner” that summarizes why the patient was admitted to the hospital and how the patient is doing.) Ex: 50 YO F w/ h/o DM admitted for PNA found to have strep bacteremia, now improving and afebrile x 24 hours. Plan: (Go through each problem daily and update. This is the most important part of your note. This is what consult services read and more importantly your attending will read and is an easy way to tell if an intern has a good understanding of his/her patient.) #PNA-improving -cont ceftriaxone and azithromycin, today day # …. -sputum culture negative -bcx positive for strep, see below # Strep Bacteremia -improving -on abx today day # -surveilance cultures negative -afebrile x 24 hours #Prophylaxis/FEN -PPI (yes or no) -DVT prophylaxis (leg squeezers, fragmin, etc. ) -Diet (ADA, 2 gram Na, etc.) 24 SECTION 4 – COMMON ON-CALL/CROSS COVER SCENARIOS 1. CHEST PAIN: • Order EKG & call floor for vital signs: BP, HR, O2 sat • Look at signout for underlying PMHx, reason for admission • Assess pt: Vital signs, physical exam (JVP, parasternal lift, gallops, rales, cool extremities), fluid status (check I/Os) • URGENT diagnoses: ACS, PE, dissection, PTX • Consider cardiac enzymes (STAT), CXR, consider urine tox (for cocaine) Other diagnoses: GERD, esophageal spasm, musculoskeletal, cocaine vasospasm, peri/myocarditis, anxiety attack, sickle VOC 2. SOMNOLENCE / Δ MS: • Review PMHx, Rx list & MAR for meds given in past 6 hrs • Check vitals, examine pt (including neuro), ABG, dexi • Trial of Narcan (0.2-0.4 mg IV) if suspicious for opioid overdose • If unresponsive: consider code +/- STAT head CT (non-contrast) • Consider CMP, Heme-8, urine tox, Ammonia, EKG, EEG 3. SOB: • Examine pt & vitals, most recent ABG, CXR, EKG, Volume/I&Os. Get new ABG, CXR, EKG. • DDx: Mucus plugging, COPD/asthma exacerbation, pulmonary edema, PE, pneumonia, ACS, ARDS, aspiration • Oxygen: Nasal cannula, facemask, non-rebreather NIPPV • Consider RT (for suction/nebs), IV Lasix, nebs (albuterol & ipratropium, standing) antibiotics, steroids, should pt be NPO? • Consider transfer to ICU or CCU (BiPap [for hypercarbia] or CPAP [for hypoxemia]) and notify MED consult 4. A-FIB W/ RVR: 25 • Examine pt, vitals, & EKG, then call MED consult. Patient will need ICU/CCU for telemetry as LAC+USC does not have a tele floor 5. HYPOGLYCEMIA: • Give ½ - 1 amp D50 (12.5-25 mg); if no IV access, consider glucagon IM and/or sublingual sugar • May repeat dexi on different machine & draw STAT glucose • Look at orders in chart: Hold standing insulin orders • Consider etiology: Mnemonic “Re-ExPLAIN” [Renal failure, Exogenous (insulin, oral antidiabetic agents, NPO, β-blockers, binge alcohol …), Pituitary (hypopituitarism), Liver failure, Adrenal crisis, Infection/Inflammation, Neoplasms (e.g. insulinoma,…) • Consider D5W gtt & checking Q2 FS 6. HYPERGLYCEMIA: • Give insulin; consider checking HCO3 & AG for possible DKA • May repeat dexi on different machine & draw STAT glucose • Evaluate Rx list for steroids, D5W gtt, (unlisted) carrier fluids w/dextrose (ex: Zosyn) — may need to call & ask pharmacy • Increase SSI; increase standing/baseline insulin; low-carb diet 7. NAUSEA / VOMITING / DIARRHEA: • N/V: Zofran 4-8 mg IV (or Zofran ODT) Compazine 5-10 mg IV, Reglan 10mg IV, Ativan 0.5mg SL, Dexamethasone 5mg. Give PO if pt tolerates. Promethazine 12.5 mg IV (higher doses can cause hallucinations) • Constipation: Ensure pt is on docusate / senna. PO: Miralax 17g, Lactulose 30g, Bisacodyl 10mg, Mg citrate 300 mL. PR: Bisacodyl (Dulcolax) 10mg, Fleet’s enema, SMOG (most potent). Never use enemas in immunosuppressed. • Diarrhea: consider c. diff stool antigen,stool ( WBC, ova) if C. diff (-) IVF & lytes. Stop bowel regimen. Lomotil 2.5 mg PO q4h, loperamide 2 mg PO q4h 26 8. PAIN / INSOMNIA / ANXIETY: see pain section for additional info and conversions • Pain: NSAIDs, Tylenol, Tramadol (non-opioid), Tylox, Norco (PO), Morphine (PO or IV), Dilaudid (PO or IV, but use as last resort), PCA. Avoid opioids in heroin users. If colicky(nephrolithiasis), Ketorolac works well. If pancreatitis, consider Dilaudid or Meperidine • Insomnia: Benadryl 25 mg PO/IV; Ativan 0.5mg PO qhs; Ambien 510 mg PO qhs; Trazodone 25mg PO qhs, Restoril 15mg Po Qhs prn • Anxiety: Ativan1mg PO/IV prn Agitation: LAC+USC Cocktail (Haldol 5mg IM+ Benadryl 25mg IM+ Ativan 1mg IM) 9. HTN / HYPERTENSIVE URGENCY: • Establish baseline & trends per vitals flowchart • Stop IV fluids unless necessary • Consider redosing meds (for example, one hour earlier) • Try oral meds first: Hydralazine 10 or 25 mg PO; Captopril 12.5 mg PO STAT; can give Nifedipine XL 30 or 60 mg PO, but caution w/ PRN nifedipine as this is long-lasting; Labetalol 100mg PO • If oral agents fail (after ~30 mins) – consider IV agents such as: Labetolol 20 mg IV push & then 2-6 mg/min IV gtt; Metoprolol 5 mg IV push x 3 (if not bradycardic); Nicardipine 5-15 mg/hr IV gtt. • YOU are required to do the IV push, nurses can not • CAUTION: Don’t drop BP precipitously – risk for STROKE! • Consider head CT if symptomatic w/ headache or Δ MS 10. HYPOTENSION: • Check bedside flowcharts to establish baseline, I/O’s • Review Rx list & nurse MAR for meds given in past 6h • Make sure pt is awake, recheck BP (use manual cuff if needed) • Examine pt to evaluate for shock (↓ UOP, cool extremities, ΔMS) as well JVP, pulsus paradoxus, rales 27 • Determine etiology: Hypovolemia (dehydration, blood loss), cardiogenic (CHF, pulm HTN, MI), obstructive (PE, tamponade), distributive (sepsis, anaphylaxis due to drugs) • Fluid challenge (500 cc to 1L bolus) – reassess HR, BP & UOP • Discuss code status & consent for blood transfusion, arterial line, central line if appropriate (& prior to pt developing Δ MS) • If hypotension persists: check for active ABO, PT/aPTT, H/H, cardiac enzymes, ABX, Cx, steroids, pressors 11. FEVER: • Obtain CXR, blood cultures x 2, U/A & Urine Cx; sputum Cx; OK not to repeat blood cultures if drawn w/in last 24 hours • Tylenol (one time dose so you know if persistently spiking) • Think outside the box: not always infectious etiology • Check signout: Need for broader abx coverage? Try to outline plan for NF if you expect your pt to have fever. 28 SECTION 5 – PROCEDURES (be sure to document in affinity AND verinform) 1. Imed consent – found on the LAC+USC home page. Use this form to obtain consent and don’t forget to document all procedures (PICC line, Central line, etc.) in BOTH affinity AND verinform 2. Central Venous Catheters (Central lines): Indications: Lack of peripheral veins (h/o IVDU, chemo, thin eldery pts), inability to cannulate peripheral veins, infusion of irritant substances, infusion of potent drugs such as pressors (dopamine can be temporarily delivered peripherally; all other pressors can be delivered peripherally but there’s risk of skin necrosis), infusion of parenteral nutrition (requires dedicated port to minimize infection risk), rapid infusion (often via Cordis) of blood products (ex: in setting of active GI bleeding), rapid replacement of electrolytes, hemodynamic monitoring, temporary cardiac pacing. Contraindications: No absolute contraindications. Apical emphysema or bullae precludes infraclavicular or supraclavicular subclavian approaches, carotid artery aneurysm or unclear vessel anatomy on ultrasound precludes using internal jugular vein on the same side, presence of thrombus precludes use of that vessel. If coagulopathy present, consider reversing (w/FFP, vitamin K) to INR<1.4 & giving platelets to keep >50K. Complications: Pneumothorax, hemothorax, infection, arterial puncture, hematoma, venous thrombosis, air embolism, catheter embolus, thoracic duct obstruction or injury (reduced w/ right side insertion), cathether malposition, pleural effusion, nerve injury, cardiac arrythmias, myocardial perforation & tamponade, pericardial effusion. Infection risk: Left subclavian < Right subclavian < Right IJ < Left IJ <femoral 29 Equipment: • Central line kit (in general, choose triple lumen catheter [TLC] over single) • Chlorehexadine; sterile saline flushes; mask, gown, bouffant cap (2); scissors, gauze; lidocaine, site rite sleeve • Ultrasound • Sorbaview dressing • Sterile Gloves • Micropuncture kit Preparation (general advice for all central lines): 1) Obtain qualified supervisor if you have not placed the required number of supervised lines 2) Obtain assistant who will complete the required Central Line Checklist. The assistant is expected to stop the procedure for any safety breach (e.g., sterile field contamination, incorrect positioning). In a true emergency, checklist is not required. 3) (FOR SC & IJ LINES) Place pt in Trendelenburg & turn head away from target vessel. 4) (FOR SC LINES) Roll a towel & place it between shoulder blades 5) Place blue chuck lining under pt’s shoulder & head to minimize blood stains to bed (nursing will appreciate this). 6) (FOR IJ LINES) Identify IJ vein w/ US [ IJ vein is LATERAL to the carotid artery & is compressible. Carotid artery is pulsating & noncompressible. ] 7) Scrub procedure site w/ chlorhexidine for 30 secs (2 mins if groin site). Allow to air dry - this can take up to 2 mins. 8) Angle overhead telemetry monitor so you can visualize arrhythmias or evidence of pt instability 30 9) Open Central Line kit & bundle kit, empty saline flushes into tray, open items w/ non-sterile packaging & drop their sterile contents onto tray (including ultrasound probe cover). 10) GET STERILE: Gown up w/ bouffant cap, mask, gown, & gloves. 11) Set up: Attach all 3 adapters to white & blue hubs. Draw up 5cc of saline & flush white, blue, & brown ports (for TLC). You use the brown port to thread the guidewire, so put the blue hub for this port piggy-backed onto the blue hub of one of the other ports; this way the hub is easily accessible on the field & not a stretch away. 12) Unsecure your guidewire; test your syringes, scalpel, & needle 13) Drape pt, leaving target area exposed. 14) Place equipment on pt or tray in the order you will need them. 15) Have someone help you put ultrasound probe cover on. 16) Order STAT CXR after IJ or subclavian to confirm placement. A. Infraclavicular Subclavian Vein Approach: 1) Identify lateral margin of posterior belly of SCM muscles as it inserts into clavicle by placing middle finger of your non-dominant hand on sternal notch (medial end of clavicle) & thumb on lateral end of clavicle. 2) Visually divide length of clavicle into thirds. 3) Your needle insertion site is just lateral to middle 1/3 of clavicle & 1 cm inferior to the clavicle. 4) Make a wheal w/ your anesthetic needle & advance needle medially & superiorly towards the sternal notch. Keep the needle parallel to the floor at all times. As you advance the needle, aspirate to make sure you’re not in a blood vessel & then inject lidocaine. Once you reach the periosteum, inject most of the lidocaine along the surface of the periosteum. 5) Using your finder needle or actual needle, puncture the skin. Direct the needle medially & superiorly towards the suprasternal notch. Keep negative pressure by aspirating the syringe as you advance the needle. 31 Advance the needle until it hits the clavicle & walk the needle vertically downward until you are able to pass the needle under the clavicle (keeping it parallel). As you pass the needle, point towards the suprasternal notch & you’ll hit the vein. 6) Check to make sure the blood is dark & not red/pulsatile. 7) Hold your position & gently unscrew the syringe. 8) Insert the guidewire & advance it through the needle. W/ your nondominant hand, take some gauze & hold it at the needle insertion site w/ your non-dominant 4th finger while your non-dominant index finger & thumb slide the needle out over the guidewire. Hold onto your guidewire w/ your dominant hand & then transition the guidewire to your nondominant index finger & thumb. Watch for ectopy on the cardiac monitor. 9) Once the needle has been withdrawn over the guidewire, use your nondominant index finger & thumb to hold the guidewire. REMEMBER to hold pressure at the needle insertion site w/ your 4th finger to minimize bleeding. 10) Use the scalpel to make a slight knick in the skin at the site of the wire. This will allow more easy entry for the dilator & catheter. 11) Insert the dilator over the wire, approximately 1-2cm into the skin. This is not to dilate the vessel, just the skin & subcutaneous tissue. Remove the dilator. 12) W/ your dominant hand, insert the catheter over the guidewire. As you advance the catheter, you will need to use your non-dominant index finger & thumb to w/draw the guidewire into the catheter. The guidewire will come out of the brown port. Once this occurs, hold onto the guidewire as it protrudes out of the brown port & advance the catheter to the desired position/depth. 13) In general, insert the catheter: a. 15 cm for a right sided subclavian b. 17 cm for the left sided subclavian. 32 14) Now you may let go of pressure at the needle insertion site. Using both hands, w/draw the guidewire into its plastic casing. 15) Check for function by aspirating each port w/ a half-filled saline syringe & flushing until the port is clear of blood. 16) Secure your line w/ the white hub. Remember to stitch one side of the white hub, then place the blue hub on top & sew both the white & blue hub to the skin. Don’t be too tight w/ your 1st knot so as to avoid skin necrosis. 17) If you hit the subclavian artery, remove the needle & hold pressure above & below the clavicle (pinch the clavicle). 18) After placing IJ or Subclavian line: a. To rule out arterial placement send blood gas to stat lab. b. Call for STAT CXR to confirm placement and r/o PTX. c. Write in chart, OK to use central line. [NEJM 2003;348:1123-33] Video at: http://content.nejm.org/cgi/content/full/348/12/1123/DC1 B. Internal Jugular Approach: 1) The safest method for all pts is to use the Site Rite to visualize the vein. The vein will be collapsible, whereas carotid artery is pulsatile & noncollapsable. It is preferable to find a site where the IJ is not directly above the carotid. 2) Make a wheal w/ your anesthetic needle & advance needle. Always aspirate before injecting any lidocaine. 3) W/ your finder needle or actual needle angled ~ 60º (almost same angle as your SiteRite probe) & towards the ipsilateral nipple, puncture the skin. Keep negative pressure by aspirating the syringe as your advance the needle. W/ the Site Rite, you should be able to see your needle as you advance it. Check to make sure the blood is dark & not red/pulsatile. 4) Hold your position & gently unscrew the syringe. 33 5) Insert the guidewire & advance it through the needle. W/ your nondominant hand, take some gauze & hold it at the needle insertion site w/ your non-dominant 4th finger while your non-dominant index finger & thumb slides the needle out over the guidewire. Hold onto your guidewire w/ your dominant hand & then transition the guidewire to your nondominant index finger & thumb. 6) Once the needle has been withdrawn over the guidewire, use your nondominant index finger & thumb to hold the guidewire. REMEMBER to hold pressure at the needle insertion site w/ your 4th finger to minimize bleeding. 7) Make a slight knick in the skin w/ the scalpel (insert in & out, w/ blade pointing away from wire, to avoid cutting wire). This will allow dilator/catheter to more easily enter skin. 8) Insert the dilator approximately 1-2 cm over the wire. You are not attempting to dilate the vessel, just the skin & subcutaneous tissue. Remove the dilator. 9) W/ your dominant hand, insert the catheter over the guidewire. As you advance the catheter, you will need to use your non-dominant index finger & thumb to withdraw the guidewire into the catheter. Hold onto the guidewire as it protrudes out of the brown port & advance the catheter to desired position. 10) In general (can adjust for height/size), insert the catheter: a. 16 cm for a right IJ b. 18 cm for a left IJ. 11) If you think you have hit the carotid, remove needle & hold pressure 510 mins or until bleeding stops, then follow-up to ensure no hematoma. No need for ultrasound unless you have inserted the dilator 12) IF PERFORMING W/O SITE RITE: Identify the triangle formed by the anterior & posterior bellies of the SCM muscle & the clavicle. Your insertion site is near the apex of this triangle. 34 13) Palpate the carotid artery in the triangle & retract it medially. 14) Insert the needle at a 45º angle to the skin into the triangle apex just lateral to the carotid pulsation, toward the ipsilateral nipple. 15) After placing IJ or Subclavian line: a. To rule out arterial placement send blood gas to stat lab. b. Call for STAT CXR to confirm placement and r/o PTX. c. Write in chart “Ok to use central line” [NEJM 2003;348:1123-33] Video at: http://content.nejm.org/cgi/content/full/348/12/1123/DC1 C. Helpful Femoral Vein Line Hints: • Identify the pulsation of the femoral artery & pull it laterally. • Needle insertion is just medial to the pulsation, 1 cm inferior to the inguinal ligament. Insert the catheter to the hub. • To rule out arterial placement, one of the following must be performed: transduce CVP, estimate CVP by fluid column, or send blood gas to stat lab. 3. Arterial Lines: A. Radial arterial line insertion (ICU, CCU) Equipment: • Basic tray, Arrow-ART line (get several just in case) • Suture (2.0 or 3.0), needle–driver, scissors (sterile) • Chlorhexidine scrub (1 or 2), blue chuck, +/- 1% or 2% lidocaine • Tape & arm board to stabilize/immobilize pt’s hand, +/- kerlex roll to help extend wrist • Sterile gloves, face shield, bouffant cap • Gauze • Sorbaview for dressing 35 • Ask nurse in advance to “set up for an A-line” Procedure: 1) Perform Allen’s test to assure collateral flow. Nml response < 7 secs. Inadequate collateral flow ≥ 14 secs. 2) Place blue chuck lining below arm. Use kerlex roll or rolled towel to place under the pt’s wrist to hyperextend the wrist & hand (may have to tape down their thumb to rail). Chloroprep wrist & get sterile, draping wrist w/ drape form basic tray. 3) Palpate the radial artery w/ 2 fingertips placed 2 cm apart. If unable to palpate, consider using a Doppler 4) Delineate a line between the fingertips, & insert the angiocatheter along this line at approximately a 45º angle from the skin. 5) Once you get a flash of blood in the needle hub, drop the angle & advance the guidewire until you cannot go further. If you notice resistance, re-angle (as far as 90º) or carefully reposition. 6) Slowly, in a twisting/pushing motion, advance the white catheter over the wire. 7) W/draw the guidewire, & leave the catheter in place. REMEMBER to quickly place your thumb over the white catheter once the guidewire is removed completely to prevent arterial blood from projecting across the room! 8) Attach the catheter to the transducer (nurse will often hand it to you). If good waveform, suture the catheter securely to the skin (around hub of art line). [NEJM 2006;354:e13] http://content.nejm.org/cgi/video/354/15/e13 B. Femoral arterial line insertion Equipment: • Single lumen central line kit 36 • Basic tray • Suture • Needle driver, scissors • Chlorhexidine (several) • Sterile gloves • Ask Nurse to “set up for an A-line” Procedure: 1) Identify the pulsation of the femoral artery. 2) This is your insertion site. Continue as if you were inserting a central line. Requires maximum barrier, including mask, sterile gloves, sterile gown & large sterile drape. 3) Attach catheter to the transducer & suture the site down. 4. External Jugular Line: Equipment: • IV start kits from Clean utility (EtOH swabs, gauze, tubing, flushes) • Chlorhexidine • Angiocath – several 18 or 20 gauges • Blue chuck lining Procedure: 1) EJ’s are all about prepping & positioning. It isn't a central line, so sterility isn’t required, but it’s important to keep the field clean & well lit. 2) Move bed away from wall, lock it, elevate it to its highest position, & then lower head down (Trendelenberg). Wait a few secs as external jugular vessels engorge. 3) Ask pt to turn their head all the way to 1 side & relax the neck muscles as much as possible. To engorge the vessels more (if pt awake), ask pt to bear down. 37 4) Divide the distance from jaw to above clavicle & work in the middle. Don’t go too far toward the lung as any error ruins the vessel for further attempts. 5) When the vessel is spotted, clean the field w/ a Chloraprep. Get the angiocath ready, get the tubing ready (flush w/ saline), leave the flush attached to the tubing (unless about to draw blood), have the Sorbaview ready, have the adherent tape ready, have gauze ready, make sure the pt is positioned on a chuck (clean bed after procedure). 6) Approach the vessel w/ the 18 gauge at a 45º angle. Hold the angiocath like a pencil between your thumb & forefinger. Advance using your fingers, not the whole hand. Holding the skin tight w/ the non-dominant hand, aim for the middle of the vessel, & pierce the skin & vessel w/ the needle. If you have blood return, lower the angle of the angiocath, & using the index finger of the hand holding the needle, advance the tubing over the needle into the vessel. Hub the tube. 7) Disconnect the angiocath from the assembly. Blood should spill out. Quickly grab the tubing & connect it to the hubbed angiocath tube. Flush & attempt to draw back blood. 8) Secure the tubing using the adherent tape in the IV starter kit, cover the EJ w/ the sorbaview, & clean up the remaining field. You have just obtained IV access! Now write for q6h 10cc saline or 6cc heparin flush. 5. Ultrasound-Guided Peripheral IV: Equipment: • IV start kits from Clean utility (EtOH swabs, gauze, tubing, flushes) • Sorbaview dressing • Clorhexidine (optional) • Arrow radial artery catheters (2-3) • SiteRite Ultrasound • Sterile ultrasound gel 38 • Blue Chucks Procedure: 1) The following method is designed to access deep peripheral veins not readily accessible by traditional means. The technique does not require complete sterility (sterile gowns & gloves are NOT required). 2) Raise the bed & position the pt such that you can comfortably view the supinated upper extremity both above & below the antecubital fossa. 3) Prep for the IV by connecting the tubing to the 10 cc saline syringe & flushing it. Open one of the arrow catheters. 4) Place a tourniquet on the proximal upper extremity & identify the veins & artery in the antecubital fossa via the ultrasound (the veins should compress, the artery pulsates). 5) Track the veins proximally & distally from the fossa w/ ultrasound & identify a site where the vein does not overly the artery. It is generally easier to place the IV distal to the fossa; however, proximal works as well. 6) When a suitable target vein has been found, clean the area w/ either EtOH or chlorhexidine. Apply sterile U/S gel once the site has been cleaned & confirm your position w/ the ultrasound. 7) Insert the catheter into the skin at a 70º angle. Use the SiteRite to guide your needle (you should be able to see the needle enter the vein). 8) Once you see the flash of venous blood, drop the angle of the arrow catheter to 30º. Unlike when placing an arterial line, do not advance the wire further than the length of the white catheter. 9) While holding the remainder of the catheter stable, advance the white catheter sheath w/ a gentle twisting motion. Remove the needle & wire once the catheter sheath is hubbed. Blood should spill out of the catheter once the wire/needle assembly is removed. Quickly connect the IV tubing to the catheter. You should be able to drawback & flush the IV. 39 10) Secure the tubing using the adherent tape in the IV starter kit, cover the PIV w/ the sorbaview, clean up the remaining field. You have just successfully placed an ultrasound-visualized, wire-guided deep peripheral IV! 6. Lumbar Puncture: Contraindications: • Evidence of uncal/cerebellar hernitation, markedly increased intracranial pressure, or obliteration of the 4th ventricle or basal cisterns. Usually cranial nerve abnormalities (blown pupil, papilledema) are hints. LP may be done in these pts if bacterial meningitis is strongly suspected. When in doubt & bacterial meningitis is suspected treat w/o LP. Do not wait for CT & reading! • Platelets <50,000, unless there is a pressing reason. For counts of <20,000, platelet transfusion is recommended prior to LP. • When the pt is anticoagulated, anticoagulation needs to be stopped & measures of anticoagulation must be nl for at least one hour prior to the procedure. Vitamin K or Protamine should be used in anticoagulated pts. If it must be done, use a 22 gauge spinal needle. • Back or spinal local infections as organisms can be introduced into the CSF. Equipment: • LP kit • Betadine or chlorhexidine (can use either) • Extra CSF tubes Minimal CSF volumes needed: Cell count & differential 1.0 cc Fungal cx/Crypto Ag 0.5 cc Oligoclonal bands 5.0 cc 40 Bacteriology Glucose Virology Mycobacteria/AFB Immuno/Meningitis Protein VDRL IgG Index (for MS) Cytopath (variable) 0.5 cc 0.3 cc 0.5 cc 5.0 cc 1.0 cc 0.4 cc 0.5 cc 0.5 cc ~3 cc You can often combine several of these tests together in one tube: e.g. tube #1 & tube #4 (1 cc each) for cell count & diff; tube #2 (1 cc) for protein/glucose; tube #3 (8 cc) for all of the microbiology which will later be distributed among the labs, except for VDRL which needs a separate tube. Always remember to collect 1-2 extra tubes for second thought tests & keep in fridge. Make sure all labs are ordered “STAT” so labels will print immediately. CSF for cytopath needs to be dropped off within an hour or so of the tap Procedure: 1) Position the pt either sitting on the edge of the bed leaning over a table (only if you do not need an opening pressure), or lying on their side in a tight fetal position. The key to a champagne LP is POSITIONING & a little bit of luck. 2) Palpate the superior edge of the iliac crests & create a line between it & the L4-L5 area. - When performing an LP on an overweight pt in whom the iliac crest cannot be identified, ask the pt “Put your hand on your hips.” This will be the level of the top of the iliac crest. No matter how obese, people always know where their hips are. 41 - The L4-5 interspace is a common location for osteophytic disease. It is also quite a small interspace. We often use the L3-4 space (just count one space above) which is usually larger & easier to get a needle in between the spinous process. 3) After prep (supplies, chlorhexidine to back, draping, etc.) & local anesthesia, insert the needle deeper, anesthetizing the periosteum. 4) Now, using spinal needle, advance between the spinous processes, angling towards the umbilicus. Keep the needle parallel to the floor at all times. Keep the bevel of the needle parallel to the fibers; if pt is upright, this means bevel to the side; if pt is lying on his/her side, this means bevel up toward the ceiling. 5) As you advance (usually a little more than 1/3 of the needle), w/draw the stylet periodically to check for spinal fluid. As you pass the dura, you will often feel a “pop”. video: http://content.nejm.org/cgi/video/355/13/e12/ 7. Abdominal Paracentesis: Contraindications: • Bleeding diathesis/anticoagulation. This must be considered a relative contraindication, since most pts w/ hepatic cirrhosis have an acquired coagulopathy. Consider using FFP and/or platelet transfusions if severe coagulopathy or DIC exists. • Pregnancy, especially sec or third trimester because of the danger of puncturing the uterus. • Known pneumoperitoneum Equipment: Diagnostic only: • 30 cc syringe • Basic Tray 42 • Lidocaine • Chlorhexidine • Red top, lavender or green top tube • Port-a-cult vial/tube Therapeutic: Either Caldwell (Paracentesis) needle Basic tray Lidocaine 10 or 20cc syringe Angio-cath tubing Lavender or green top tube Red top tube Or Thoracentesis Kit + Chlorhexidine Vacuum bottles/containers For all: Sterile gloves, face shields, nonsterile gowns Diagnostic +/- therapeutic paracentesis fluid should be sent for: (1) Cell count & differential (green top or lavender top, or tube from thora kit minimum 1 cc) (2) Gram stain & bacterial culture, as well as fungal & AFB when indicated (port-a-cult culture bottle/tube, or specimen cup) (3) Albumin (& send serum sample for albumin to calculate serumascites albumin gradient) (red top or tube from thora kit, min 1 cc) (4) Consider total protein, LDH, amylase (if you suspect pancreatitis), cholesterol (if you suspect chylous ascites) (red top or tube from thora kit) (5) Consider cytopath (any container, the more the better). 43 Procedure: 1) The lower quadrant approach is most often used. Place the pt in a supine position. If splenomegaly &/or hepatomegaly are present on physical exam, you should perform the paracentesis w/ ultrasound guidance. 2) Percuss to find the level of dullness to identify pocket of ascites. You can also send pt for an ultrasound mark, but be sure to tap as soon as possible, as ascites fluid moves. Perform paracentesis in same position pt was in when marked. 3) Locally anesthetize the skin w/ a wheal, then as you advance the needle, aspirate & inject lidocaine (particularly near peritoneum). 4) To decrease draining of fluid after removal of angiocath, you can elect to use the “Z” method in which you insert the Caldwell needle into the skin, then pull the skin caudally, then advance the needle until to you reach the ascitic fluid. REMEMBER TO KEEP NEGATIVE PRESSURE AS YOU ADVANCE THE NEEDLE. Sometimes you will need to make a small incision w/ scalpel to get the Caldwell needle through tough skin. 5) Insert the needle along the anterior axillary line, lateral to the rectus sheath (halfway between umbilicus & anterior superior iliac spine) or 1-2 cm below the level of percussed dullness. 6) Once needle is in the fluid pocket, attach the angio-cath tubing to the needle. 7) Insert the other end of the angio-cath into the vaccum bottles. *If the fluid stops draining, try spiking another bottle (sometimes the vacuum seal is depleted) or repositioning the needle. Video: http://content.nejm.org/cgi/video/355/19/e21/ Post-paracentesis albumin infusion: It is generally recommended, in large-volume paracentesis (i.e. ≥ 4L), to give 25cc of albumin (25% solution) for every 2L of ascitic fluid removed. 44 8. Thoracentesis: Indications: Fever w/ a pleural effusion (“Never let the sun set on an infected pleural effusion”); 1 cm thick effusion on US or lateral decubitus CXR w/o known cause; unilateral effusion in CHF exacerbation; effusions in CHF that don't resolve in 3 days w/ dieresis (75% of CHF effusions resolve w/in 48h of diuresis); poor oxygenation due to unresolving effusion(s). Equipment: Thoracentesis kit; Chlorhexidine; ABG syringe, Sterile gloves; face shield; gowns. (Thora kit tubes okay to send samples in instead of red, green & portacult) Pre-procedure imaging: Get a decub film (lie on the side of the effusion) to make sure it layers; also consider U/S to mark the tap Post-procedure imaging: chest Xray Laboratory tests: (1) Cell count & diff (2) Gram stain +/- culture (bacteriology, virology, mycology, AFB) (3) Glucose, protein*, LDH*, albumin, cholesterol, (if you suspect chylous effusion) (4) pH (draw in ABG syringe & place in ice) - walked to critical care lab ASAP (5) Cytopath, depending on your diagnostic concern (in any container: the more the better) *Send corresponding serum tests to calculate pleural fluid:serum ratios. Procedure: 1) View the CXR or thoracic CT so you know the area of interest. 45 2) Place the pt in a sitting position, leaning over a table. 3) Percuss out the effusion, noting the superior edge of dullness on the posterior chest wall. 4) Confirm w/ auscultation / Site Rite. 5) Sterilize the area & drape. 6) Insert the needle at the middle of the rib just below the superior edge of the dullness in the posterior axillary line. Aim for the SUPERIOR aspect of the rib (the neuro-vascular bundle runs under the rib). 7) Anesthetize the periosteum. Remember to aspirate as you inject. You will likely get pleural fluid while anesthetizing. 8) Exchange the needle for thoracentesis catheter, & proceed in the same manner. Remember to keep negative pressure in your syringe as you advance the needle. If you are performing a therapeutic tap, attach the syringe & bag to the tubing. Never use vacuum bottles for thoras. Obtain an opening pressure by removing the syringe & seeing at what vertical level the fluid stops dripping. Use constant pressure on the syringe to drain fluid, then push into the bag (it’s a one way valve.) Remember to estimate pleural pressure after every 4 syringes of fluid drained. Stop before -20 cm to avoid PTX & reexpansion pulm edema. 9) Tell the pt to hum as you remove the needle. Video: http://content.nejm.org/cgi/video/355/15/e16/ 9. Arthrocentesis: Indications: To determine the cause of an acute monoarthritis or polyarthritis and/or inject steroids if indicated. Contraindications: Overlying cellulitis; coagulopathy; prior knee surgery Equipment: Basic tray; Chlorhexidine scrub; 18 G needle; 20-60 cc Syringe; Lidocaine 46 Laboratory tests: (1) cell count & diff (green or lavender top), (2) gram stain +/- culture (bacteriology, virology, mycology, AFB) (port-acult or specimen cup) (3) Crystal analysis (& slides to look at it yourself) Procedure: 1) The knee may be tapped from either the medial or the lateral side. 2) Place pt in supine position. 3) Flex the knee slightly to an angle of 15 to 20 degrees. 4) Point of needle insertion is 1cm medial (or lateral) to the superior third of the patella, angling toward the intracondylar notch. 5) Anesthetize the area by placing a wheal of lidocaine in the epidermis, then anesthetize the deeper tissue. Remember to aspirate prior to injecting the lidocaine & direct the needle in the anticipated trajectory of the arthrocentesis needle. You may aspirate some synovial fluid w/ your anesthetizing needle (this is OK). If this happens, just w/draw your anesthetizing needle & exchange for an 18-gauge needle. 6) Using the 18-gauge needle, advance behind the patella & toward the intracondylar notch. AVOID “walking” the needle along the inferior surface of the patella (may damage the articular cartilage). REMEMBER to hold negative pressure in your syringe as you advance the needle. Remove as much fluid as possible (sometimes “milking” the effusion by compressing the suprapatellar region w/ the opposite hand may help). 7) This technique may also be used to inject steroids (triamcinolone / kenalog, vial is generally 10 ml of 40mg/ml -> inject 1 ml/knee) 8) An ACE bandage or knee immobilizer can help to reduce postprocedural swelling. Video: http://content.nejm.org/cgi/video/354/19/e19/ 47 SECTION 6 – COUNTY STUFF 1. Locations in hospital 2nd Floor – Cafeteria, 2E Psych ward, Discharge waiting unit, Conference Rooms A-D 3rd floor – Labor and Delivery 4th floor – MICU, CCU 5th floor – SICU 6th floor – Medicine Wards A-D 7th floor – Medicine Wards A-D 8th floor – Medicine Ward 8A, Medicine Resident Lounge, Pediatric Ward 8B ** Hallway between inpatient and clinic tower contains ancillary services on 3rd and 4th floor (4th floor - Stress Test, Echo Lab, Cardiac Cath Lab, GI procedures, Urology procedures, CT Scan, MRI) 2. How to get stuff done 48 Picc line –3 forms to be filled out: STAT CXR radiology form, PICC line form (check double lumen) and PICC line consent form (print from iMED CONSENT). Drop off in PICC room 4th floor Stress test – Fill out the stress test form & you can drop it off on the 4th floor to Marci (ext - 97468) TTE – Follow these steps and you can order the TTE on affinity by yourself: TTE Ordering in Affinity Change location to: “IM” -> Procedure menu > order processing > enter order Enter your name, hit enter through the tabs until a menu with orders comes up, TTE is one of the options, Select and hit Enter. Then enter the indication, Priority: ROUTINE, Another menu 49 for indication will come up, enter indication, Then enter out and sign with your SID number PFT’S – PFT’s & sleep study are on the same form. You can order it either inpatient or outpatient on the same form. Once you fill it out, go to the pulmonary lab on the 4th floor and give it to the secretary in the patient waiting area. EEG’S – You can either order this yourself on affinity (change location to A4E in affinity) or you can fill out the EEG form and fax it to the number that is at the top of the form. Permacath - Follow these steps to order the form yourself on affinity: Permacath Ordering in Affinity - > Change location to: “angio” or 3731 GH (space is important) Procedure menu > order processing > enter order..Enter your name, hit enter through the tabs until a menu with orders comes up > Go to MENU tab, and select ANGIO> Then MENU again and select D&T Vascular/Intervention> Hit ENTER Item #11 is Permcath> Select and hit Enter Then enter the indication > Priority: ROUTINE Another menu for indication will come up, enter indication Then enter out and sign with your SID number Permacath Ordering via Radiology Form to be placed in Chart: write “IR Permacath placement”, call IR at 94100 for approval VASCATH placement: Place Renal Consult for VASCATH placement or ask a nice renal or pulmonary fellow to place one (you must consent the patient yourself) CT/MRI - Fill out radiology form & stick it in the chart. Call radiology to approve/check on the status of the order in a few hours. PET scan – fill out the special PET CT form, sometimes found in the workroom, but also found on RPS website under clinic forms UltraSound – Fill out radiology form & stick it in the chart. Call radiology to approve/check on the status of the order in a few hours. 3. LAC+USC Radiology (M-F, 9-5) www.trojanimaging.com Chest – Plain Radiology CT Body Protocoling & Procedure Resident CT Abdomen 1 CT Abdomen 2 CT/MR Chest/Cardiac 1 CT/MR Chest/Cardiac 2 Emergency Radiology (ER) GI/GU Radiology Mammography/ Breast US MR Body MR Breast MSK Radiology (Bones) Neuroradiology (Brain, Spine) Neuroradiology (ENT) Neuroradiology (Small reading room) Nuclear Medicine 50 323-409-6081 323-409-1583 323-409-4395 323-409-1584 323-409-4391 323-409-4392 323-409-2798 323-409-6084 323-409-5167 323-409-1293 323-409-1293 323-409-6104 323-409-4149 323-409-4152 323-409-3937 323-409-5857 Pediactric Radiology US – general US – Women’s 323-409-6110 323-409-4386 323-409-6083 4. Frequent consults (and their reqs) 51 Ortho – Have Xray ordered w/ prelim read preferably prior to consult. For Osteomyelitis, have Xray and MRI ordered Renal – Order: UA w/ micro, urine eosinophils, Urine electrolytes (UNa, UCr, U Urea) prior to Renal consult Neuro – perform thorough neuro exam, history of recent meds, neuro Hx prior to neuro consult, recent scans Heme – Order peripheral smear, type and screen, CBC w. diff, retic count before consulting heme. Oncology – You need to have a diagnosis of cancer before consulting oncology. This is either imaging (4 phase CT of liver) or tissue diagnosis (biopsy w/ pathology read). They will not see the patient if the diagnosis is not established already. Rad Onc – usually consult in coordination with med onc for potential radiation therapy after you have a tissue diagnosis GI – You need CBC, iron panel & acute bleeding before you can consult GI. Consult GI team for: EGD, ERCP, or Colonoscopy. Liver – Have CMP, D. bili, platelets, PT/INR, and possible U/S or CT of liver prior to Liver consult Urology – If suspect Renal cell carcinoma, or Prostate Cancer: consult Urology. Or if patient has urethral problems or difficult foley placement, consider urology consult. Speech and Swallow – Write the consult in the chart as follows: speech therapy for speech and swallow evaluation. 5. Electrolyte replacement HYPERKALEMIA K (mEq/L) > 6.5 >5.2 >5.2 >4.0 Treatment Start w/ Insulin 10-20U IV w/ ½ amp of D50 w/ sx’s: Ca gluconate 10% 10cc IVP over 2-3 min w/ QRS widening or EKG changes, give Insulin 1020U IV w/ ½ amp of D50 w/o sx’s: Kayexalate 25-50 PO qhr until BM, then check STAT K Nothing HYPOKALEMIA PO options of K include KDUR or K elixir, IV is given as KCl 10 mEq of K should raise the serum K by 0.1 Can only do 10 mEq of K per hr on the floor (i.e. Kdur40mEQ PO Q 4hrs) If your patient is not eating, you need to replace the approximately 60 mEq of K they will lose each day K (mEq/L) Repletion 3.8-3.9 KDUR 20 mEq PO x1 or KCl 20mEq IV over 2 hrs 3.6-3.7 KDUR 40 mEq PO x1 or KCl IV over 4 hrs 3.4-3.5 KDUR 60 mEq PO x1 or KCl IV over 6 hrs 3.2-3.3 KDUR 40 mEq PO q4hrs x2doses or KCl 80 mEq IV over 8hrs 3.0-3.1 KDUR 40 mEq PO q4hrs x3doses or KCl 80 mEq IV over 8hrs <3.0 KDUR 80 mEq IV over 8hrs then recheck K & 52 continue HYPERMAGNESEMIA Mg (mg/dL) 5.0-7.5 1.9-4.9 HYPOMAGNESEMIA Mg (mg/dL) 1.6-1.9 1.2-1.4 Treatment Ca Gluconate 1g IVP Nothing Repletion Magnesium Sulfate 2g IV over 8hrs or Mg Oxide 400mg x7 tabs PO Magnesium Sulfate 4g IV over 16 hrs or Mg Oxide 400mg x14 tabs PO HYPERPHOSPHATEMIA Mg (mg/dL) Treatment >4.5 If Phos x Ca >65 -> amphojel 10cc PO TID w/ meals If phos x Ca <65 -> CaCO3 650mg PO TID w/ meals 2.3-4.5 Nothing **never combine amphojel and biCitra** HYPOPHOSPHATEMIA Phos (mg/dL) Repletion 1.0-2.5 K Phos or Na Phos 15 mmol x 8hrs < 1.0 K Phos or Na Phos 30mmol over 16hrs If all else fails, call pharmacy for any electrolyte replacement questions (x97641) 53 6. Miscellaneous County How to TAR a patient (Treatment Authorization Request) There is a special form that needs to be filled out. For hematology TARs and Oncology, the patient’s name, MRUN & cancer dx needs to be written in a book that you can find in 7B. In addition, you have to go to the patient’s ROR account and put in a one or two sentence note about what the patient is being TAR’d for. Your note should essentially meet criteria for inpatient hospitalization, otherwise, the TAR won’t be approved. You can also consider TAR a patient in other special situations. For example: if a patient needs a PET scan prior to initiation of chemotherapy, its Friday, and patient won’t get the PET scan until Tuesday, if there is no other treatment being done for patient, you can D/C patient, and TAR for readmission on the day of his scheduled PET scan. This opens a bed for 3 days, and prevents the patient being admitted with no medical treatment. * note* If TARing a patient onto 7B for Heme, simply place the TAR form in the plastic bag near the clerk. If TARing a patient for any other service, TAR must be approved by Utilization Review, Contact UR at ext. 96412 VNA – You fill out the specific VNA form, have your attending sign the form and drop it off on the 4th floor nursing office. Med appliance – There is actually a med appliance form in every unit that you can fill out and get signed by a licensed physician. Call Marcos 95125 Special bed request – contact UR at 96412 for a special bed request (i.e. inflatable bed, etc.) 54 Isolation- These are the types of isolation yon can order by writing it in the patient’s chart: Contact precaution: This type of precaution is for patients who have infections with antibiotic-resistant organisms such as VRE & MRSA. C. difficile is also included in this category. These precautions are essentially to clean hands before and after entering the room (with alcohol hand cleaner for most infections and soap and water with C. difficile). It also includes gloves and gowns. Airborne precaution: These organisms can spread by drops that are caused when patient coughs, sneezes, cries or talks. These tiny drops can float for long distances in the air and people without masks can breathe them in, so special air control is needed to keep the organisms in the room. An example is TB. You not only need the N95 masks but negative pressure room. Droplet precaution: These organisms can spread by droplets caused when the patient sneezes, coughs, cries or talks. These heavy droplets float just a short distance before landing on things or people. Examples are influenza, whooping cough, and meningitis. These require N95 masks before entering the room. Neutropenic precaution: These are for patient with ANC below 1.0. And these precautions are essentially to protect the patient. So we have to wear gloves, gowns and masks (these masks don’t have to be the N95 masks but just any type of mask). If you put a patient on neutropenic precautions, you should also put them on a neutropenic diet. 55 SECTION 7 – BASICS OF PAIN MANAGEMENT 1 Mild ASA Acetaminophen NSAIDS World Health Organization 3-STEP LADDER 2 Moderate 3 Severe A/Codeine Morphine A/Hydrocodone Hydromorphone A/Oxycodone Methadone A/Dihydrocodeine Levorphanol Tramadol Fentanyl Oxycodone Dosing: - Dose once every half-life PO/PR = 4 hrs - Steady state after 5 half-lives Breakthrough Pain Dosing - Once every time to Cmax PO/PR = q1hrs SC/IM = q30mins IV = q10-15mins Changing Routes of Administration: PO/PR 3 : IV/SC/IM 1 : Epidural 0.1 : Intrathecal 0.01 Transdermal Fentanyl Morphine 50mg PO in 24hrs ~ Fentanyl 25mcg transdermal patch 56 Changing Analgesics Oral/Rectal Dose (mg) 150 150 150 15 15 10 3 2 - Analgesic Meperidine Tramadol Codeine Hydrocodone Morphine Oxycodone Hydromorphone Levorphanol Fentanyl Parenteral IV/SC/M Dose (mg) 50 50 5 1 1 0.05 Direct Morphine-Methadone Conversion 24hr total dose of oral morphine Conversion oral morphine : oral methadone < 30 mg 2:1 (2mg morphine : 1mg methadone) 31-99 mg 4:1 100mg-299 mg 8:1 300-499 mg 12:1 500-999 mg 15:1 >1000 mg 20:1 (*Fisch and Cleeland. Managing Cancer Pain in Skeel ed. Handbook of Cancer Chemotherapy. 6th ed., Phil, Lippincott, 2003, p 663 57 Common Combination Pain Products Combination Product Tylenol # 3 Norco Vicodin Percocet Adjunct Narcotic PO Morphine Equivalents Acetaminophen 325mg Acetaminophen 325mg Acetaminophen 500mg Acetaminophen 325mg Codeine 30mg 3-4 mg Hydrocodone 5mg or 10mg Hydrocodone 5mg Oxycodone 5mg 5 or 10mg 5-6mg 7-8mg **Note** at LAC+USC, there are limitations on standing orders for Narcotics All Narcotics orders, if unspecified, will fall off after 24 hrs All schedule 2 non-combination medications (Morphine, Dilaudid, Codeine) can be written for a maximum of 72hrs PO combination medications (Norco, Vicodin, etc) can be written for a maximum of 7 days Patients with cancer can have orders written indefinitely Example # 1: Norco 5/325mg PO Q4hr prn pain (x 7 days) Example # 2: Morphine 4mg IV Q4hr prn pain (x 72hrs) Example # 3: Dilaudid 2mg PO Q4hrs prn pain (Indefinite for cancer) 58 SECTION 8 – TPN/TUBE FEEDS 1. Enteral Nutrition: (always preferable over parenteral nutrition) a. Short Term: Via NasoGastric tube. Ordering: Write NG tube order in chart, STAT CXR or KUB via Radiology form to evaluate NG tube placement, after eval, write “okay to use NG Tube” in the chart. Place nutrition consult by writing “nutrition consult” in chart. Duration: NG tubes cannot remain in place for over 2 weeks due to risk of nasal cartilage necrosis. Example of a basic initial order: “Jevity 1cal via NGtube at rate of 30cc/hour. Increase rate by 20cc q2 hours until rate of 70cc/hour. (hold if residuals >150cc)”. The rate can later be increased as tolerated, and as recommended by the nutritionist. Contraindications to NG tube placement: facial/skull fractures, airwary compromise, esophageal varices, clotting disorders, and history of gastric bypass surgery. b. Longer Term: G-tube Ordering: using radiology form, write: IR placed G-tube, check Body Intervention, contact IR at 94100 for approval. or by the GI team (consult GI for Percutaneous endoscopic gastrostomy (PEG)). hile you wait for nutrition recommendations. G-tube feeding orders: Can be either as boluses or continuously via a pump, usually at nighttime. Example of order for bolus: “Jevity 1.5cal 2 cans via Gtube TID. Flush with 50 cc H20 after each can” Example of order for continuous tube feeding: “Jevity 1cal at 70cc/hour x 12 hours qhs” 2. Parenteral nutrition: Although it should not be routinely use in patients with normal GI tracts, as there are many risks associated with parenteral nutrition (including sepsis, fungemia), TPN may be recommended for patients 59 with bowel obstruction, severe gastroparesis or for complete bowel rest in some cases of IBD. Requirements: TPN must be administered via a central line, so you will need to order a PICC line for patients on the floor. (refer to PICC order section) The TPN orders must be submitted and faxed before 1PM each day. You can call the TPN pharmacy for help with selection of TPN formula. Electrolytes in the fomula will have to be adjusted daily, per TPN pharmacy recommendations. o TPN cycling: it may be preferable to have TPN infusing for only part of the day instead of 24 hours. For example, if you want to have a patient receiving TPN only for 16 hours of the day, you should contact the TPN services for recommendations on daily cycling orders. o TPN pharmacy x : (TPN form, Cycling orders) 3. Outpatient TPN When medically cleared for discharge, patients who still need parenteral nutrition can be discharged on TPN with Visiting nurse services, after TPN formula, rates and cycling optimized as an inpatient. Contact information: Home Health-Carole Fernandez (213)919-6216 x93250 TPN Service-(323)226-7764 60 SECTION 9 – CRITICAL CARE/ ICU 1. ICU On Call Intern Schedule (Nights) 2100: come in and meet with your resident. You will do all the new admissions Around 0200-0300: Electrolytes repletion (see repletion section) 0600: Signout cross coverage/overnight events to your co intern and co-residents coming in. 2. ICU Regular Day schedule 0600-0700: Pre-rounding 0700: Fellow rounds. Bedside rounds on all patients. 0900: Attending Rounds Rounds end around 11: Get work done. if you’re post-call, then you leave after finishing your work, no later then 1300. If it’s a regular day, then get more work done and at 1800 Signout to Resident On Call. 3. Daily considerations in the ICU Lines: now what lines you patient has and when each were placed and need to be changed Medications and Drips: Know all gtt with current rate/dose. Comment on recent changes Feeding: orally vs enterally vs parenterally Analgesia & Sedation: usually with Fentanyl gtt for Analgesia and Versed for Sedation Excessive analgesia/sedation should be avoided. Daily Sedation Holiday: (leads to shorter ICU stays) VTE prophylaxis: sq Fragmin vs Heparin (if renal failure). SCDs should definitely if anticoagulation is contraindicated. If patient is on anticoagulation, SCDs may be ordered as well (depending on fellow’s preference). 61 Stress ulcer/GI prophylaxis: refer to GI section or ICU book for PPI guidelines Other: I&Os, Urine output/24 hours and hourly, Bowel Movements (know when your patient’s last bowel movement was and address it if no bowel movements for 24-48hours) glucose control, Restraints, Head of bed elevation, unless contraindicated , Family discussions Daily orders form: Always order midnight labs, at least CBC with diff, BMP, Mg, Phos daily. Usually also include PT/INR, PTT, LFTs. Consider lactate and other labs as warranted. Daily CXR at midnight if intubated or respiratory distress. Repletion: When you’re on overnight call, your job as the intern includes repleting electrolytes as needed for all your team’s patients. Labs are drawn at midnight and results are usually up at 0200. See electrolyte repletion section, but with some caveats for ICU as follows: K: Normally, every 40 mEq of K given IV is in 500cc NS if given peripherally, but can be concentrated if given through a central line. You have to write an order to specify “concentrate for central line administration” if you want to avoid giving too much fluids in an already overloaded patient. Mg: In the ICU, faster rate of infusion allowed, up to 1g over 1 hour. Thiamine: Repletion should be considered in all patients with starvation or alcohol withdrawal. Can be ordered as 100mg IV q12h x 4 doses then 100mg PO/NGT daily. 4. Respiratory Failure: Hypercarbia (PaCO2>45, pH <7.35) 1. ↑CO2 production: fever, sepsis, seizures, high CHO load in pt w/ underlying pulmonary disease 2. ↑dead space: intrinsic lung disease (asthma, COPD, CF, pulm fibrosis), chest wall disorders (scoliosis) 3. ↓minute ventilation: Drug overdose, metabolic 62 derangements (myxedema, hypokalemia), CNS disease (spinal cord lesions), PNS disease (GBS, MG, ALS, botulism), muscle disease (myositis, muscular dystrophy), chest wall disorders (scoliosis), upper airway obstruction Hypoxia (PaO2 < 60, SaO2 < 90) 1. ↓FiO2: High altitude, tubing (of ventilator) not connected (nl A-a gradient, can correct w/ increased FiO2) 2. ↓Diffusion: COPD, parenchymal lung disease (can correct w/ increased FiO2) 3. V/Q mismatch: Large PE, PNA, atelectasis, asthma (high A-a gradient, can correct w/ ↑FiO2) 4. Hypoventilation (nl A-a gradient, can correct w/ ↑FiO2) 5. Shunt: Severe ARDS, intracardiac, etc (high A-a gradient, cannot correct w/ ↑FiO2) PAO2 - PaO2 gradient: (713 * FiO2) – [(PaCO2/0.8) – PaO2] Nrml A-a gradient = (Age/4) + 4 (or use gradient = 0.43 * age) - If A-a gradient is nrml & PaCO2 is high, then the cause of hypoxia is likely hypoventilation. - If A-a gradient is high, then the cause is shunt, V/Q mismatch or DO2/VO2 (O2 Delivery/Consumption) imbalance such as anemia, low cardiac output or hypermetabolism. Treatment goal: correct hypoxemia providing high FiO2 restoring lung volumes by recruiting more alveoli (with PEEP) 5. Types of Supplemental Oxygen: Nasal cannula: 50 cc reservoir (nasopharynx/oropharynx), O2 flow 16 L/min, FiO2 0.24-0.46. Each L/min roughly increases FiO2 by 0.04. Oxygen face mask: 150-250 cc reservoir, O2 flow 5-10 L/min, FiO2 0.4-0.6. 63 Non-rebreather facemask: 750-1250 cc reservoir, O2 flow 5-10 L/min, FiO2 0.4-1. The reservoir bag is directly connected to the O2 delivery system & about 1/3 of the volume is depleted when pt inhales. Exhaled air leaves via a one-way valve in the mask which prevents exhaled air from being re-breathed & room air from entering the mask. Non-invasive positive-pressure Ventilation: BiPAP vs. CPAP Use CPAP (=IPAP) if primary problem is oxygenation (hypoxia) Use BiPAP if primary problem is ventilation (hypercapnia) The gradient between the IPAP (inspiratory) & EPAP (expiratory) pressures controls the ventilation. If you increase IPAP to improve oxygenation, remember to increase EPAP to keep the gradient the same so as to keep ventilation constant. BiPAP 10/5 is equivalent to Pressure Support Ventilation 5/5. 6. Acute respiratory distress syndrome (ARDS) 2011 Berlin Definition: divied into three categories based on degree of hypoxemia Mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg) Moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg) Severe (PaO2/FIO2 ≤ 100 mm Hg) Causes: Most commonly sepsis and susbsequent inflammation leading to increased permeability across basement membranes and therefore edema in the airspace. This is later followed by fibroproliferation (also contributing to decreased compliance and leading to long term changes and decreased DLCO after ARDS resolves in survivors) Treatment: primarily supportive Ventilator strategy for Treatment: with low tidal volumes (between 4-6ml/kg) and PEEP (usually 5-10cm H20) to keep alveoli open, goal is to keep PaO2>60mmHg without causing ventilator associated lung injury Keep fluid status for CVP goal of 4-6cm H20 64 Steroids use is controversial. May have benefit later in the course but not at initial presentation, and probably only in patient with high oxygen requirements and with no infection. Steroids shown to INCREASE mortality in pt w/ sx >14 days. (ARDSnet LaSRS “LAZARUS” trial NEJM 2006) 7. Supportive ventilation basic primer Consider intubation for: resp acidosis (PaCO2 > 50mmHg, Ph <7.3), hypoxemia (PaO2 <55 mmHg with fiO2 = 1.0), GCS </= 8, hypotension (shock), ARDS (PaO2:FiO 2 < 200 mmHg) 1. Noninvasive Positive pressure ventilation CPAP: continuous positive airway pressure Patient initiates breaths and machine provides pressure constantly BiLevel positive airway pressure: Inspiratory PAP and Expiratory PAP/PEEP IPAP: Patient initiates breaths and machine provides pressure at inspiration EPAP: after breath initiated by patient, machine continues to deliver some pressure, and this helps keep the alveoli open, and thus improves recruitement of alveoli and decreases work of breathing Uses: Effective in treating decompensated COPD, status asthmaticus 2. Invasive: intubation + mechanical ventilation Indications for intubation: o Respiratory failure/fatigue: Improve gas exchange, increase oxygenation and ventilation Decrease work of breathing o Airway protection Basic Modes: 65 Volume A/C (assist control): o Patient initiates breath, then machine provides a full set volume o Standard settings: PEEP 5, Vt 400-500cc (or 5cc/kg), RR 14, FiO2 40% o Check ABGs and Watch for respiratory alkalosis from hyperventilation, given patient will get full volume every time a breath is initiated therefore tachypnea can lead to staking and cause hyperventilation. SIMV (synchronized intermitted mandatory ventilation) and PEEP o the patient is allowed to initiate breaths which trigger the machine to provide a volume or pressure support, but if the patient does not initiate a breath, the machine will also provide a minimum set number of mandatory breaths. Pressure controlled o Fixed pressure. Vt will vary depending on patient’s lungs compliance. Therefore monitor Vt: can be too small in poor compliance, which leads to poor ventilation. ** Consider Weaning trials to prepare for possible extubation, when the underlying cause for intubation is starting to resolve. Weaning parameters can be ordered and done by Respiratory Tech. You can also write for pressure support trials. Example weaning order: “When sedation off, change vent settings to CPAP PS 7 PEEP 5 FiO2 30% titrate to spO2>93%. Revert to previous vent settings if patient tires.” 8. Sepsis SIRS (systemic inflammatory Response syndrome) = 2 or more of the following: T>38 or <36oC, HR >90, RR>20, WBC>12 or <4, or bands >10% Sepsis: SIRS + suspected source of infection 66 Severe Sepsis: Sepsis + end organ damage Septic Shock: Sepsis +hypotension <90/60 unresponsive to fluid resuscitation Management: patient should be in ICU setting, notify senior resident and call med consult at 91644 Early goal directed therapy, Surviving Sepsis Campaign Doing the following interventions within 6hours of presentation has been shown to decrease mortality IVF resuscitation with NS, target MAP >65mmHg Obtain 2 sets of blood cultures, then start broad spectrum antibiotics Vasopressor: Norepinephrine preferred Consider ICU admission, PA catheter and a-line placements LAC+USC protocol: The following must be done within the FIRST hour of presentation o IVF initiation at rate of 20mL/kg o Lactate level o 2 blood cultures before antibiotics o broadspectrum antibiotics Order set for standard antibiotic choices for: o Unknown source: Vancomycin (for gram positives including MRSA) , ceftriaxone for gram negatives (or cefepime if risk of pseudomonas) and metronidazole (for anareobes) o CAPneumonia: Ceftriaxone and azithromycin o Urosepsis: ceftriaxone or ciprofloxacin o Abdominal infection: Zosyn o Soft tissue infection: Zosyn 9. Shock: Inadequate end-organ perfusion: ↓ UOP, ↓ perfusion (e.g., cool extremities, cyanosis), ΔMS, tissue hypoxia (↑ lactic acid) 67 A. Cardiogenic/Pump Failure (myocardial dysfunction, usually due to MI or decompensated CHF) ↓CO & ↑SVR B. Obstructive/Mechanical defect (pericardial tamponade, acute PE, ASD, valvular dysfunction, RV infarct) ↓CO & ↑SVR C. Hypovolemic (hemorrhage or fluid loss) → ↓CO & ↑SVR D. Distributive (sepsis, anapphylatic, neurogenic, drugs, toxins, TSS, myxedema coma, adrenal insufficiency, SIRS) → ↑CO & ↓SVR Management: depends on the type of shock 1. Differentiate between different etiologies. Swan-Ganz Catheter: helps differentiate between septic vs cardiogenic shock. o Normal values: Pulmonary Artery Mean Pressure (PCWP, Wedge): 8-12mm Hg (Estimate of the LA pressure) Central Venous Pressure (CVP): 2-8mm Hg Pulmonary Artery Systolic (PAS): 20-30mm Hg o Before interpreting Swan-Ganz abnormal numbers, first have the nurse double check and make sure that the Swan is properly wedging (if there is any doubt in your mind, you can always get a CXR and see where the Swan is (it should look like it’s in the pulmonary artery) 10. Pressors: Note: Adequate volume resuscitation is essential to minimize risk of vasopressor-mediated splanchnic hypoperfusion. **Norepinephrine is the first-line agent for septic shock. Norepinephrine/Levophed: β1 effect predominates at low dose & α1 at higher dose. One randomized trial done suggested norepinephrine better than dopamine at increasing BP in hypotensive pts (91% vs 31%). Epinephrine: β1, β2, & α1 agonist (used particularly in anaphylaxis). 68 Adverse effects: arrhythmias & ↓splanchnic blood flow. Dopamine: Low dose stimulates dopamine receptors�↑renal blood flow & GFR; no benefit of low-dose dopamine on renal outcome [ANZICS, Lancet 2000; 356: 2139]. Main side effect: tachyarrhythmias. Phenylephrine: Pure vasoconstrictor. Useful in neurogenic & anesthesia- induced hypotension. Also helpful when battling w/ tachycardia. Vasopressin: Potent vasoconstrictor. Not to be substituted for dopamine or norepinephrine as first-line agent in septic shock. Should be added to first- line agent. Not titrated & used usually at 0.4 U/min. Effective at improving MAP in vasopressor-resistant shock. Vasopressor effects are preserved in setting of acidosis & hypoxemia. *Dobutamine: β1 > β2. ↑ CO. Used specifically in cardiogenic shock. Should not be used as vasopressor. PRESSOR Norepinephrine Dopamine Epinephrine Phenylephrine Vasopressin *Dobutamine 69 HR IONOTROPY SVR DOSE ++ 0 +++ ++ 0 ++ ++ + +++ 0 0 +++ +++ + ++ +++ ++ - 0.5-30 mcg/kg/min 10-20 mcg/kg/min 1-20 mcg/kg/min 1-200 mcg/kg/min 0.2-0.4 units/min 1-20 mcg/kg/min SECTION 10 – CARDIOLOGY 1. Differential Diagnoses of Chest Pain: A. Acute Coronary Syndrome (see below) B. Musculoskeletal Hx: Worsened pain w/ movement, deep breaths; recent trauma; consider herpes zoster (pain in a dermatomal distribution). Dx: Pain reproducible w/ palpation (does NOT exclude cardiac cause). Tx: Symptomatic (NSAIDs in costochondritis, lidocaine patch). C. GERD/PUD/Esophageal spasm Hx: Burning or cramping chest pain, burping, sour taste, worsened by certain foods, pain worse w/ lying down, nocturnal cough, asthma exacerbation, globus, dysphagia/odynophagia. Dx: Clinical diagnosis, barium swallow (if odynophagia), manometry, pH probe, consider H. pylori testing, endoscopy. Tx: H2-blockers, PPIs, abx if H. pylori (+), lifestyle mod (e.g., no late meals, avoid EtOH/caffeine/chocolate/mint, elevate head of bed). D. Esophageal tears (Mallory-Weiss) Hx: h/o emesis/dry heaves; may present w/hematemesis after retching. Dx: Clinical suspicion; can confirm w/ EGD. Tx: Usually stops in 24-48 hrs w/ rest/conservative mgmt; may need surgical repair if severe; if hematemesis, treat as upper GI bleed. E. Pulmonary embolus Hx: Virchow's triad: stasis (prolonged immobility); endothelial injury (post-op); hypercoagulability (coagulation disorder, malignancy). May present w/ pleuritic CP, dyspnea, tachypnea, tachycardia, hemoptysis. Dx: Hx of risk factors, Wells criteria, PE protocol CT w/ IV contrast, 70 V/Q scan if contraindication to contrast (e.g., allergy, renal failure), RV dilation on TTE or RAD, S1Q3T3 on EKG (if RV strain). Tx: Anticoagulate (sooner is better—lower mortality. Empirically start anticoagulation if high suspicion). If pt unstable w/RV strain— may need lytics or surgical/interventional tx. F. Pneumothorax Hx: h/o thoracic procedures, body habitus (e.g., tall, thin) for spontaneous ptx, mechanical ventilation, severe bronchospastic/obstructive lung disease, ipsilateral chest pain, usually abrupt onset of SOB. Dx: CXR (tracheal deviation), ↓ breath sounds, hypotension. Tx: 100% nonrebreather even if not hypoxic, chest tube if PTX >15% (if tension PTX, needle decompression in 2nd IS at midclavicular line). G. Aortic dissection Hx: h/o wt lifting/exertion, HTN, Marfanoid appearance, syphilis, “tearing” chest pain radiating to the back. Dx: BP discrepancy in one arm vs. other, AI murmur, mediastinal widening on CXR, usually need TEE, CT or MRI. Tx: Type A (involves ascending aorta)surgery; Type B�medical management (aggressive BP control w/ β-blockers & nitrates) H. Pericarditis Etiology: 80-90% viral or idiopathic cause; also consider infectious, neoplastic, CTD, radiation-induced, post-MI, post-pericardotomy, uremia. Hx: Severe, constant pain that localizes over anterior chest w/radiation to back or either arm, worse w/inspiration, improved by leaning forward. Dx: “Scratchy” friction rub, best heard w/ pt leaning forward. EKG has diffuse PR depression & concave upward ST elevation. Consider 71 TTE (especially if considering tamponade). Tx: ASA (esp. if recent MI), high-dose NSAID (ketorolac if CABG or post-pericardiotomy), colchicine, prednisone 1.5 mg/kg qd x4wks if severe. I. Cardiac tamponade Hx: Trauma/penetrating wound, pericarditis, post-MI Dx: Beck's triad (distant heart sounds, JVD, hypotension), pulsus paradoxus; EKG (low voltage, electrical alternans); CXR (large cardiac silhouette); TTE (effusion, septal shift w/ inspiration). Tx: Acutely: IV fluids; definitive tx is pericardiocentesis. J. Acute chest/Sickle cell vasoocclussive crisis Hx: h/o sickle cell disease, 2-3 days into VOC Dx: CXR, pulse ox Tx: Analgesics, IV fluids, O2 (see Heme section) 2. Peripheral Pitting Edema Assessment Scale 1+: 2mm depression, barely detectable impression when finger is presssed into skin. Immediate rebound. 2+: Slight 4mm indentation. 15 seconds to rebound 3+: Deeper 6mm indentation. 15-30 seconds to rebound. 4+: > 30 seconds to rebound. 3. JVP assessment On examination: versus carotid pulse: JVP = biphasic, nonpalpable occludable, varies w position. JVD measurement to estimate CVP is done at 45degrees HOB, add 5 cm to level measured from sternal angle. Normal JVP 6-8 cm H20. Hepatojugular Reflux: One can apply pressure to the abdomen to test for HJR. If the pressure rises > 4 cmH20 AND stays elevated for > 10 secs, the HJR is +. This is consistent w/ a hypervolemic state. 72 Kussmaul's sign: paradoxical increase JVP with inspiration. Sign of poor filling of RV. DDx: constrictive pericarditis/restrictive cardiomyopathy, pericardial effusion, severe right-sided heart failure. 4. Waveforms • An upgoing wave : RA contraction • The " x " descent follows the 'a' wave and corresponds to atrial relaXation • C upgoing wave: RV Contraction causing the triCuspid valve to bulge towards the RA. • X downward wave: atrial relaxation and tricuspid valve downward going during systole • V upgoing wave : atrial filling • Y downward wave: opening of the tricuspid valve causing emptying of JV and filling of ventricles 5. EKG Use a consistent approach (rate, rhythm, axis, intervals, atrial enlargement, hypertrophy, waveforms (q waves, ST/T wave changes, R wave progression) Overall: look at EKG, what jumps out at you? Voltage: Is it standard or 1⁄2 standard? Look at the square shaped waves at the leftmost side of the EKG. Rate: QRS’s in a line x 6 Rhythm: p before each QRS, look for heart block Axis: look at I and aVF which represent simple vectors I=0° and aVF=90° to assess the axis of the heart Normal Axis:-30 to +90 LAD: axis beyond -30 degrees RAD: axis beyond 90 degrees. Intervals: check for a normal PR (120-200ms, i.e. 1 large box) short PR-preexcitation of ventricles, delta waves (such as WPW) QT interval (should be less than 1⁄2 of the RR interval) Prolonged QT- see pocket medicine 73 Leads: check to see if the patient is having a heart attack. For this look for T wave inversions, ST elevations, or q-waves in any of the following patterns. “HI SAL” Waves: look at the P waves LAA if wide >120ms notched P in II or biphasic p in V1 and >1mm hump on the bottom RAA if tall peaked p in II or biphasic p in V1 with larger hump >1.5mm on top QRS should be <120ms, for BBB QRS > 120 ms o if V1 and V6 rabbit ears then LBBB o if biphasic then RBBB o for LVH S in V1 or V2 + R in V5 or V6 > 35 o for RVH R>S in V1 or Deep S in V6) T wave for TWI, peaked T waves in hyperK. R waves for Poor R wave Progression Signs of Ischemia/Infarct: ST elevation/depression in contiguous leads suggesting NSTEMI/STEMI ST Depression: ischemia ST Elevation: Acute MI if upward convexity in contiguous leads. If in all leads, think of perdicarditis. DDx also includes many other causes such as Takotsubo, Brugada syndrome, etc but your goal is not to miss an MI! T wave inversions Pathologic Q waves: if at least 1 box deep and 1 box wide. Indicates necrosis or old MI Coronary Artery Territories Septal V1, V2 – LAD territory Inferior II, III, aVF – RCA territory Anterior V3, V4 - LAD territory Lateral I, aVL – left circumflex territory Posterior V1, V2 (see lone ST depression which are really elevations) – left circumflex Sgarbossa's criteria: 74 To detect MI on EKG in the setting of LBBB. 90% specificity of STEMI (but only 36% sensitivity). If 3 points or more, diagnosis of MI. ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points ST depression ≥1 mm in lead V1, V2, or V3 - 3 points ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points 6. Acute Coronary Syndrome (ACS): Myocardial ischemia due to plaque rupture leading to coronary thrombosis Includes: Unstable angina, NSTEMI, & STEMI 1) Bottom Line: If you’re unsure, the story is good & it’s safe to anticoagulate, just heparinize 2) Review the EKG yourself, & make the differentiation between NSTEMI & STEMI (ST elevations in at least 2 contiguous leads; 1 mm in limb leads or 2 mm in precordial leads; different criteria w/ LBBB 1 mm STE concordant w/ QRS, 5 mm STE discordant w/ QRS, or 1 mm STD in V1-3) • If STEMI: CALL EMERGENCY CARDS CONSULT/On CALL CARDS FELLOW give ASA, start Heparin gtt (bolus 50 mg/kg, rate 12 mg/kg/hr), This is a cath EMERGENCY (better outcomes w/ initial PCI vs. thrombolysis). Note: pts thought to have high likelihood of requiring CABG (likely left main or 3-vessel disease) should NOT be given Plavix because it will delay surgery 5 days • If UA/NSTEMI: consider demand-side vs. supply-side ischemia, Heparin & antiplatelet therapy (e.g., ASA, Plavix, GP IIb/IIIa inhibitors). 3) Standards meds: Aspirin (4 chewable baby ASA; give Plavix if allergic to ASA), β-blockade (if HR/BP will tolerate), SL NTG for anginal pain, high-dose statin, nasal canula oxygen, morphine prn pain. Consider 75 Nitroglycerin gtt (Tridil) if CP not relieved, but watch out for hypotension & nitro toxicity. 4) Caution: Avoid β-blockers & nitrates if suspect inferior wall MI. Cautiously consider β-blockers if h/o cocaine use (Rangel 2010 Archives of Internal Medicine). 5) Anticoagulation in ACS: Use caution if prior bleeding hx. If the initial management of ACS is a conservative approach & there are no contraindications, consider LMWH (enoxaparin 1 mg/Kg SQ q12h). Whenever possible, anticoagulation therapy should not be switched from one drug to another. Avoid LMWH in pts w/ renal failure, but may use on obese pts (1mg/kg). Consider Plavix [600 mg given mortality benefits vs 300 mg (CURE trial)]. Consider addition of a GPIIb/IIIa inhibitor in pts w/ TIMI score > 4, +troponins, Killip class >=III, or in pts w/ CP even w/ heparin [NEJM 2001;345:494-502] [JACC 2008; 52(21) :1693-1701] 6) Need cardiac monitor if admitting for r/o ACS, NO EXCEPTIONS, must be in CCU for this. 7) Serial cardiac enzymes (CK/CK-MB/troponin q8h) & EKGs. Once troponins have peaked, may check only CKs. Classic “rule out” is done over 24hrs, but can be done in shorter time if cocaine CP. 8) Keep NPO in case of cath or stress test. Bedrest. 9) Calculate TIMI score (if ACS is leading dx), 1 point for each: • Age > 65 • ≥ 3 CAD risk factors (Tob, FHx, HTN, Hyperchol, DM) • Known coronary stenoses > 50% • Chronic ASA use • ≥ 2 anginal episodes at rest • ST deviation ≥ 0.5 mm • Elevated cardiac markers 11) Killip Classification-categorizes pts w/ acute MI based on presence of 76 CHF symptoms/LV dysfunction: I- no CHF symptoms; II- mild to moderate CHF (rales, S3, ↑JVD); III- overt pulmonary edema; IVcardiogenic shock 30-Day mortality: I vs. II vs. III/IV (2.8% vs. 8.8% vs. 14.4%) 6-month mortality: I vs. II. vs. III/IV (5.0% vs 14.7% vs 23.0%) [Am J Cardiol 1967;20,457-465] [JAMA 2003;290:2174-2181] 7. Post-cath checks Usually 12 hrs post-cath by the on-call team. Check the distal dorsalis pedis pulses bilaterally Ask the patient about any pain or other complaints Review the cath report in the chart: It will have results, intervention and the diagram of the coronaries showing what %age lesions were present. Catheterizations can be Lt heart only (for CAD) versus Rt heart only (for Pulm HTN/valvular disease) versus both Check the femoral site for bleeding or hematomas Review Hb and Cr 12 hours post-cath.1-2 Hb drop ok but check q8h to make sure it plateaus. Possible complications post-catheterization : Bleeding , Infection, AV fistula (pulsatile mass and systolic bruit) – order Doppler ultrasound of femoral artery if suspected, and call the fellow if confirmed. Arterial thrombosis (cold extremity, loss of pulses), Retroperitoneal hematoma (order CT abdomen if suspected, and call the fellow if confirmed or patient looks unstable, Emboli, Contrast-induced renal failure. Just watch and hydrate (usually 3-5 days post-procedure), Arrhythmias, Arterial dissection/stent thrombosis: chest pain post procedure. ** Patient may come out of the cath lab with a fem stop (pressure device applied to the arterial closure site). These devices should never 77 be left in place over 6 hours due to risk of arterial thrombosis. The patient should lie flat for 6 hours after removal. 8. The New Cardiomyopathy (CM) Pt: Most common causes: Ischemic, HTN, Valvular, & Idiopathic Types: Restrictive (amyloidosis, sarcoidosis, hemochromatosis, Wilson’s) Dilated (ischemic, Beriberi, Coxsackie B, Chagas, cocaine, Doxorubicin, EtOH, familial, HIV, stress-induced, thyroid) Hypertrophic IHSS, now called HOCM (genetic, etc.) Dx: History, TTE, cardiac cath to r/o ischemia, HIV, ANA, TFTs 9. Heart Failure: Can be systolic or HFpEF (i.e., signs & symptoms of HF in setting of nl LV function (EF >50%) & absence of valvular disease) Hx: Dyspnea, exercise tolerance, orthopnea, PND, peripheal edema, wt gain, & abdominal discomfort (may include nausea/vomiting). • Quantify symptoms based on NYHA Classification scheme: Class I: Symptoms at levels that would limit nl individuals Class III: Symptoms w/ ordinary exertion. Class III: Symptoms w/ less than ordinary exertion. Class IV: Symptoms at rest. • Identify precipitant: Rx non-compliance; fluid/dietary indiscretions; CAD event; HTN; PE; myocarditis; arrhythmia; infectious process; renal failure; pulmonary disease; high outpit state e.g. anemia, hyperthyroidism, AV fistula … • Obtain cardiac hx, prior TTE, stress tests, & cath reports. Exam: ↑ JVP, S3 or S4, murmurs, displaced/diffuse PMI, rales, pleural effusion, sacral edema, hepatojugular reflux, pulsatile liver, ascites, ↑abdominal girth, LE edema. Assess hemodynamics (congestion & perfusion) Evidence of congestion (wet vs dry) 78 • Left-sided sx: Dyspnea at rest or early in exertion, orthopnea, PND • Right-sided sx: LE edema, abdominal fullness, bloating, anorexia Evidence of low perfusion (cold vs warm) • Fatigue, somnolence, lethargy, anorexia, cool & pale extremities, • Weak pulses, narrow pulse pressure, decreased UOP, lactic acidosis Evidence of systolic HF: Cardiomegaly, LBBB, diffuse soft apical impulse, tachycard, SBP < 90. Evidence of nonsystolic HF: SBP >160, DBP> 100, LVH, S4 Workup: Heme-8, CMP, TSH, coags, cardiac enzymes, +/- pro-BNP EKG: Ischemia, enlarged chambers, arrhythmia, pericarditis, new BBB CXR: Vascular congestion, edema/effusion, Kerley B line, cardiomegaly TTE (in new-onset HF), more useful when euvolemic Tx: • Diurese w/ Lasix (IV is 2x as potent as PO). Note: Pt w/ low EF & severe volume ↑↑ may require diuresis even if hypotensive (recall Starling curve). BP will often improve w/ diuresis. • If Lasix not enough, double the dose (up to 240 mg); may add Diuril or Metolazone (may not absorb b/o gut edema) 30 min before Lasix dose. • Check bid lytes (goal K>3.5, Mg>1.5 unless arrhythmia K>4, Mg>2). • Restrict salt (<2g) & fluid intake (<1-2L), daily weights, strict I/O. • Assess response to therapy: Follow symptoms, O2 requirement, daily weights, I/O, JVP, BUN, Cr, & bicarb w/ aggressive diuresis. • Afterload reduction w/ ACE Inh (can start w/ Captopril tid & uptitrate), also good long-term survival benefits [CONSENSUS] • Long-term ↓ morbidity/mortality w/ β-Blockers [MERIT]. • Continue β-Blockers if pt on prior to admission & extremities not cold. • Do NOT start β-Blockers during acute exacerbation 79 [OPTIMIZE-HF]. • Improved morb/mort seen w/ nitrates/Hydralazine [v-HEFT-1] & Spironolactone [RALES] (latter is reserved for severe symptomatic HF). • Consider d/c CCBs w/ systolic dysfunction (some studies suggest ↑ mort). W/ diastolic dysfunction, CCBs/BBs helpful in ↑ filling time. • Digoxin improves CHF symptoms, but not morbidity/mortality [DIG] • Consider inotropes (Dopamine, Dobutamine, Milrinone) if cold & wet. Dobutamine better if: severe hypotension, renal failure, cost is an issue. Milrinone is better if: pulmonary hypertension, need for βblockade, severe tachycardia. 10. Atrial fibrillation: Etiology: Mnemonic “H PIRATES”. Hypertension, Pulm disease, Ischemia, Rheumatic heart disease, Accessory pathway, Thyrotoxicosis, EtOH/Excess dig, Sick sinus syndrome Dx: Irreg irreg pulse, hypotension, palpitations, CP, dizziness. Tx: • Cardiac monitor if new onset A-fib • Start w/: Metoprolol 5 mg IV + 50 mg PO bid or Diltiazem 10-20 mg IV Push (over 2 min) + 30 mg PO QID. • If HR difficult to control: Diltiazem drip 5-15 mg/h, titrate to HR<100. • If hypotensive or very bad systolic dysfx: Amiodarone 150 mg IV over 10 min, then 1 mg/min IV x 6h, then 0.5 mg/min x 18h. • Studies show equivalence between rhythm control vs. rate control & anticoagulation (AFFIRM, RACE) in pts w/ asymptomatic A-fib, so this becomes a pt-specific decision. • Cardioversion: no need to anticoagulate if a-fib < 48h; otherwise, anticoagulate for 4 wks before & 4 wks after cardioversion 80 Chronic anticoagulation for paroxysmal or chronic a-fib: data now supports use of CHA2DS2-VASc score, instead of CHADS2 score. (European Heart Rhythm Association; Oct 31, 2010 & Pharmacotherapy. Odum et al, 2012) C H A2 D S2 V A Sc Condition CHF HTN (>140/90 or on BP meds) Age >/= 75 DM Stroke or prior TIA Vasc dz Age 65-74 Sex category (female) Score 0 Risk Low 1 Moderate >/= 2 High Points 1 1 2 1 2 1 1 1 Anticoagulation None or ASA 75mg-325mg PO Qday PO Warfarin goal INR 2-3 or ASA 75-325mg PO Warfarin goal INR 2-3 Calculate “HAS-BLED score” for bleeding risk on oral anticoagulation in A Fib. Give 1 point for each of the following: HTN (Systolic BP≥160mmHg); Abnl renal fx; Abl liver fx; Age ≥ 65 years; Stroke in past; Bleeding; Labile INRs; Taking other drugs as well; Alcohol intake at same time. • A HAS-BLED score ≥3 indicates ↑ 1-y bleed risk on AC which would be sufficient to justify caution or more frequent evaluations. 81 11. HTN: Etiology: 95% of HTN is idiopathic (essential), but consider 2° causes if age of onset <20 or >50. Tx: Goal BP <140/90 or <130/80 in DM or CKD. General first-line management is diet & exercise. Add pharmacotherapy if no improvement over a few months. First-line agents: HCTZ & ACEI (caution in AKI & CKD). New evidence for dipyrimidine CCBs ACCOMPLISH trial: CCBs are superior to diuretics when added to ACEi in high risk patients 12. Hypertensive Urgency/Emergency: Emergency implies evidence of end-organ damage: cardiac damage (enzyme leak), renal damage (↑Cr, microscopic hematuria), stroke, ΔMS, hemorrhage on fundoscopic exam, flash pulmonary edema, shock liver. Etiology: Exacerbations in our pt population are often the result of medical noncompliance, dietary indiscretions, or missed HD (i.e volume overload) Dx: Check cardiac enzymes, CXR for pulmonary edema, UA for RBCs, head CT if mental status/neurologic changes, etc. Tx: • Note: Requires cardiac monitor. Pts on drips often need to be triaged to CCU due to need for continuous BP monitoring and/or gtts. • Can start by giving prescribed PO medications (if missed dose) as well as Nifedipine XL 30-60 mg (but caution as this is longer-acting), Hydralazine 10-25 mg or Captopril 12.5 mg • Next, if needed, give IV push medications: Labetalol (start w/ 20mg IV & can increase to 40mg – 80mg IVP if necessary q10 min, up to 300 mg) or Metoprolol (start w/ 5mg IV q5 min, up to 15mg). • If IV pushes are inadequate, or if hypertensive emergency, use gtt: Labetalol 2-6 mg/min (watch out for bradycardia) or Nicardipine 5-15 82 mg/h (watch out for bradycardia) or Nitroprusside 0.3-10.0 mcg/Kg/min (thiocyanate toxicity in CKD pts) or Enalaprilat (caution in AKI pts). • Transition to PO meds when controlled w/ IV. - If hypertensive urgency, bring BP (MAP) down by 25% over hours. - If hypertensive emergency, bring BP down by 25% in mins. - Do not bring BP down too quickly as the pt’s cerebral vasculature has shifted autoregulation (they will stroke); a goal SBP in the 160s will maintain adequate perfusion to the brain. - Most pts w/ hypertensive crises will have headaches as you decrease their blood pressure (Remember: headaches can also be a prominent side effect of nitrates). 13. Syncope: Etiology: Can be cardiac vs. non-cardiac (i.e., neuro/other). A majority have no known etiology. Cardiac: Arrhythmia (atrial or ventricular), valve disease (esp. AS), ACS, systolic dysfx, HOCM, tamponade, aortic dissection, PE, pulmonary HTN (cor pulmonale). Non-cardiac: TIA/CVA, thromboembolism (from carotids, or paroxysmal emboli from extremities), migraines, seizures, space occupying lesions in the brain, vasovagal, hypovolemia, hypoglycemia, micturition syncope (more common in men), preceding coughing spasm or bowel movement (vagal), medication effects (i.e., α-blockers, etc.), adrenal insufficiency. Dx: Make sure it is syncope—a true temporary loss of consciousness as opposed to dizziness, vertigo, or presyncope. • Ask about prodrome. • Ask questions to assess if ictal or post-ictal state was present (aura, witnessed seizing, incontinence, confusion, staring). • Assess volume status (orthostatics, skin turgor, oropharynx, etc.). Consider CHF exacerbation or right-sided failure due to a large PE. 83 • Listen for valvular murmurs, carotid & periph pulses (e.g. pulsus parvus et tardus w/ AS), & bruits. • Check dexi. • EKG/cardiac monitor/enzymes to evaluate for cardiac causes. • Dry head CT to r/o any acute intracranial anomaly. • Consider TTE to evaluate mural thrombus & valve/systolic function (w/ bubble study if want to r/o PFO), LE doppler to assess DVT , head MRI/MRA, & EEG as indicated. • Consider checking cortisol for adrenal insufficiency. • Consider tilt-table testing for hypervagotonia. 14. Brugada Criteria (Distinguish SVT from VT): Follow algorithm sequentially. If ‘yes’ to any criteria = VT. If all 4 criteria are absent, than dx is SVT w/ aberrancy (sens 97%, sp 99%). CRITERIA Absense of RS in ALL precordial leads R to S>100ms in any precordial lead A-V dissociation Morph criteria for VT in V1-2 & V6 Sens for VT 21% 66% 82% 99% Spec for VT 100% 98% 98% 97% Morphological criteria for VT: [Circulation (1991)83:1649–59] • Primarily positive in V1 & in V1 & V6 (monophasic R or QR or RS in V1 AND R to S ratio <1or QS or QR or monophasic R in V6) • Primarily negative in V1 & in V1 or V2 & V6 (R > 30msec in V1 or V2 or >60 msec to nadir of S wave in V1 or V2 or notched S wave in V1 or V2 AND QR or QS in V6) Tx: Presence of structural heart disease or abnl EKG predict higher 1-y mortality, requiring further evaluation & management of underlying 84 pathology. [NEJM 2000;343:1856-62] [Circulation 2002;106:1606-1609] 15. Valvular Diseases: A. Aortic Stenosis: Etiology: calcific stenosis, bicuspid valve, rheumatic heart disease. Stage/Severity Nl Mild Moderate Severe Mean Gradient (mm Hg) 0 <25 25-40 >40 AVA (cm2) 3.0-4.0 1.5-2.0 1.0-1.5 <1.0 Hx: Angina (5-y mortality), syncope (3-y mortality), heart failure (usually when AVA <1.0, 2-y mortality) Tx: 1) Surgery – when symptomatic, asymptomatic w/ AVA <0.6, or asymptomatic moderate to severe AS undergoing CABG. 2) Medical Therapy – gentle diuresis & BP control w/ ACE inh. IABP sometimes required for stabilization & as a bridge to surgery. *Note: AS is Pre-load dependent, so avoid venodilators (nitrates) & negative inotropes (β-blockers & CCBs) B. Aortic Insufficiency: Etiology: Rheumatic heart dz, endocarditis, HTN, Marfan’s, syphilis. Hx: Pulmonary edema & hypotension (if acute). Tx: 1) Surgery 2) Medical therapy a) Stable AI – vasodilators (nifedipine, ACE-I, hydralazine). b) Acute decompensation – afterload reduction w/ nitroprusside 85 & inotropic support w/ dobutamine. c) Vasoconstrictors & IABP contraindicated. C. Mitral Regurgitation: Etiology: Leaflet dysfxn (myxomatous degeneration, rheumatic heart disease), ruptured chordae tendinae, papillary muscle dysfxn. Hx: DOE, pulmonary edema, hypotension Tx: Stable: afterload & preload reduction (diuretics/nitrates) Unstable: dobutamine, nitroprusside. Consider IABP or surgery D. Mitral Stenosis: Etiology: Rheumatic heart disease & infiltrative disease Hx: Pulmonary edema, dyspnea, A-fib & embolic events Tx: Sodium restriction, gentle diuresis, β blockade & anticoagulation. Surgery or valvuloplasty if severe. 86 SECTION 11: ENDOCRINE 1. Insulin and Oral Diabetic Medications Type Rapid-Acting Onset Peak Duration Role in Management Humalog or lispro Novolog or aspart Apidra or glulisine 15-30 min. 10-20 min. 20-30 min. 30-90 min. 40-50 min. 30-90 min. 3-5 hrs 3-5 hrs 1-2½ hrs meals at the time of injn, combine with long acting insulin 30min-1hr 30 min.-1hr 2-5 hrs 2-3 hrs 5-8 hrs 2-3 hrs covers meals w in 1/2-1hr 1-2 hrs 1-2 1/2 hrs 4-12 hrs 3-10 hrs 18-24 hrs 18-24 hrs 1/2 day or overnight, combine with rapid or short acting insulin 30min-3 hrs 1-1½ hr 1-2 hrs 10-20 hrs no peak 6-8 hrs 20-36 hrs 20-24 hrs Up to 24 hrs full day coverage, can combine w rapid or short acting insulin 30 min. 2-12 hrs 10-20 min. 30 min. 15 min. 2-4 hrs Up to 24 hrs 1-4 hrs 2-5 hrs 30min-2½hrs 14-24 hrs BID before meals Short-Acting Regular Humulin/Novolin Velosulin (used in insulin pump) Intermediate-Acting NPH Lente Long-Acting Ultralente Lantus Levemir or detemir Pre-Mixed* Humulin 70/30 Novolin 70/30 30 min. Novolog 70/30 Humulin 50/50 Humalog mix 75/25 Up to 24 hrs 18-24 hrs 16-20 hrs 2. Inpatient Diabetes Management How to Calculate Insulin Regimen -usually NPH and Regular insulin -0.6 units/kg in DM 2 -if insulin naive, consider using ISS and adjusting as needed or a lower dose like 0.4 units/kg 87 -0.2 units/kg in DM1 -if in renal failure, calculate as above and then use half of the results as insulin is renally excreted AM Dose = 2/3 of total calculated insulin req (2/3 NPH and 1/3 Regular) PM Dose = 1/3 of total calculated insulin req (1/2 NPH and 1/2 Regular) When FASTING (i.e. NPO before procedure) give only 1/2 NPH and NO regular *make sure you write this on the insulin form* 3. How to Adjust Insulin Regimen -before breakfast blood sugar affected by evening NPH insulin the night before -before lunch blood sugar affected by morning R insulin -before dinner blood sugar affected by morning NPH insulin -bedtime blood sugar affected by evening R insulin 88 -if AM blood sugar is high, consider Somogyi phenomenon (rebound elevated fs sugar in response to low early AM sugar level) and check 2 AM blood sugar before adjustment of evening NPH dose How to calculate a patient’s average blood sugar based on HbA1c: ((HbA1c-4) x 30) + 60 4. Glycemic Goals in the Hospital (AACE/ADA Guidelines 2009) Patient Status Critically ill (exp. ICU, CCU) Glycemic Goals mg/dL 140-180 Non critically ill Preprandial <180 Maximum blood glucose <180 ** AVOID HYPOGLYCEMIC EVENTS** Signs of Hypoglycemia: -Confusion, abnormal behavior or both, such as the inability to complete routine tasks, Visual disturbances, such as double vision and blurred vision, Palpitations, Anxiety, Sweating, Hunger, Tingling sensation around the mouth, Seizures, Loss of consciousness 5. DKA Etiology: Insulin non-compliance, infection, CVA, MI, severe illness, surgery, pregnancy, steroids, thiazides, intoxication (EtOH, drugs). More common in insulin-dependent DM (and HHS more common in NIDDM). Hx: N/v, abdominal pain, polyuria, polydipsia, dehydration, ketotic breath, tachycardia, hypotension, Δ MS, preceding infection. Dx: Glucose>250, AG (>10), metabolic acidosis (pH< 7.3, bicarb <18), ketosis (urine & serum), hypoPhos, hypoMg, pseudohypoNa (to correct, add 1.6 to Na for every 100 in glucose above 100), hypoK or hyperK 89 (usually total body hypoK even if labs show hyperK due to ion shift), pre-renal ARF, hemoconcentration, leukocytosis. Tx: Assess ABCs (pts may be seriously volume down), CMP, PO4, Mg, UA, serum ketones, serum osms, calculate AG, ABG (correlate w/ VBG), EKG (ischemia), cultures (infection). Insert 2 large bore IVs or central line, replete fluids w/ NS at rate >125cc/h (up to 500 cc/h) +/- bolus & start regular insulin gtt at 0.1-0.2U/kg/h (+/- 10 unit Aspart bolus), titrating to dexis & closure of anion gap. When dexi <250, change to D5 ½NS. Continue insulin gtt until anion gap is closed AND bicarb >18. Even if blood sugars are nl, keep gtt going until both of the aforementioned are achieved. When gap closes, give long acting insulin sub-q, & turn off insulin gtt 1-2 h later. Follow dexi q1h, BMP/Mg/PO4 q2-4h. Replete K, Mg, PO4. Give 20-40mEq of K+/L fluid if the K+ is <4.5. Only use IV bicarbonate [2 amps in 1L NS] if pH<7.0 or severe hyperK **Notes on DKA: • At LAC+USC, these are ICU patients, notify senior resident and med consult at 91644 for ICU transfer and management • Don’t just fix it, determine why it developed. Don’t drop serum osm by >3 mOsm/Kg/h; anything faster may lead to cerebral edema. 6. HHS (HONK) Hx: Usually in T2DM. Often overlaps/co-exists w/ DKA (& w/ similar etiology). Develops slower than DKA. Neurological sx more common. Mortality much higher than isolated DKA (10-50%). Dx: BS > 600 (often > 1000), serum osms > 320, absence of severe ketoacidosis (usually pH >7.3, bicarbonate usually >15) Tx: Fluid, insulin, & electrolyte management are similar to DKA. Initial fluid deficits are often higher (average 9L). When BS = 300, switch to D5 ½NS & adjust insulin to maintain BS between 250-300 90 until serum Osms go below 315 & mental status is nl. Algorithm: Hyperglycemic crises in adult patients with diabetes. Kitabchi et al Diabetes Care. 2009 7. Adrenal Insufficiency Inpatient Etiology Primary: AI (Addison’s Disease), Fungal, Sarcoidosis, AIDS not on HAART, Amyloidosis, Mets, Hemorrhage, CAH 91 Secondary: Pituitary, Exogenous GC’s, Post Corticosteroids, Hypothalamic Disease S/S: Skin Hyperpigmentation, Postural Hypotension and hemodynamic instability, Muscle Wasting, Decreased body hair, Fever without a source, Tachycardia, Muscle Weakness, Abdominal pain, n/v Labs: Hyponatremia, Hyperkalemia, Hypoglycemia, Metabolic Acidosis, Anemia, Eosinophilia, Pre-renal azotemia, Random Cortisol prior to starting treatment (MICU), Blood, Urine, Sputum Cultures as indicated, EKG, ACTH, Renin, Aldosterone, -Morning Cortisol (<5 highly suggestive) then ACTH stimulation test (low dose or high dose test) Diagnosis: Corticotropin stimulation tests • Low dose: Check baseline & 30 min cortisol level after administering cosyntropin 1 mcg IV. Cortisol >18mcg/dl pre-stim or after 30min rules out adrenal insufficiency (sens 95%, sp 96%). • High dose: Check baseline, 30 min & 60 min cortisol levels after cosyntropin 250mcg IV. Relative insufficiency: ≤ 9 mcg/dl increase at either 30 or 60 min. Management: ABC’s, IV Hydration • Tx w/ corticosteroids hydrocortisone 100 mg IV q 8 hrs is clinically indicated in critically ill pts w/ signs of adrenal insufficiency. • Steroids in the MICU: Annane et al. [JAMA 2002] study → ↑ survival vs. Corticus [NEJM 2008] → no effect on mortality. • Meta-analysis [Ann Intern Med 141:47, 2004] → those w/ vasopressor dependent shock for 2-72 h benefit from 5-7 days of physiologic hydrocortisone followed by a 5-7 day-taper; no significant difference between treating responders & non-responders. 8. Thyroid Disorders A. Hypothyroidism Types: Subclinical Hypothyroidism: elevated TSH with normal fT4 Overt Hypothyroidism: elevated TSH and low fT4 92 DDx: Hashimoto’s Thyroditis, Post partum Thyroiditis, Subacute Thyroiditis, Grave’s disease (late stages), Iatrogenic: s/p thyroidectomy (24 wks following total thyroidectomy), RAI therapy, external neck irradiation, Iodine deficiency or excess • Drug induced (drugs used to treat hyperthyroidism: Lithium, Amiodarone, Interferon alfa, oral tyrosine kinase inhibitors • Infiltrative Disease: Reidel’s thyroiditis, hemochromatosis, scleroderma, leukemia, and cystinosis • Secondary Hypothyroidism: pituitary adenoma, postpartum pituitary necrosis (Sheehan's syndrome), trauma, hypophysitis, nonpituitary tumors such as craniopharyngiomas, infiltrative diseases, and inactivating mutations in the gene for either TSH or the TSH receptor • Tertiary Hypothyroidism: any abnormality of the hypothalamus Sx: weakness, depression, cold intolerance, weight gain, constipation, menorrhagia in women, carpal tunnel syndrome PE: delayed reflexes, bradycardia, myxedema Dx: -1st step: TSH -if elevated, get fT4 -low fT4 (primary, start Levothyroxine replacement) -normal fT4 (subclinical, re-checkin 1-3 months -secondary or tertiary hypothyroidism – low/normal/high TSH, low/normal fT4 depending on the situation -hyperlipidemia Treatment: Levothyroxine 1.6 mcg/kg body weight per da. If patient is older or has CAD/risk factors for CAD, can start at a lower dose first 25-50 mcg/day and then increase to complete dose as needed. -Aim to keep TSH in normal range (0.5-5) and for resolution of symptoms. B. Hyperthyroidism DDx: Graves’ disease (most common), toxic multinodular goiter, toxic thyroid adenoma 93 Other causes of elevated thyroid hormones: struma ovarii, postpartum thyroiditis, Hashimoto’s thyroiditis, DeQuervain’s thyroiditis Dx: ↑FT4, ↑TT3, ↓TSH (Graves can have nl T4 but ↑T3) Sx: anxiety, weakness, tremor, palpitations, heat intolerance, increased perspiration, weight loss despite a normal or increased appetite, hyperdefecation, urinary frequency, oligomenorrhea or amenorrhea in women, -gynecomastia and erectile dysfunction in men, unexplained weight loss, new onset atrial fibrillation, myopathy, problems with glucose control PE: hyperactivity, lid lag, rapid speech, tremor, hyperreflexia, may have AFib (irregularly irregular), exophthalmos and pretibial myxedema in Grave’s disease Labs: TSH, fT4, T3, Anti TPO Ab, Anti TSH receptor Ab Treatment: Beta Blocker (decreases T4> T3 conversion) , Antithyroid Medication (Methimazole, PTU) vs RAI ablation vs Surgery. Calcium Supplementation • Acute Tx of thyroid storm: Propranolol 60-80 mg PO q4h; Methimazole 30 mg PO q6h (or PTU 250 mg PO q4h); Lugal’s iodine solution or potassium iodide 10 gtt PO q8h; Hydrocortisone 100 mg IV q8h; Cooling blanket. • Subclinical hyperthyroidism should be treated in pts w/ TSH persistently <0.1, who are >65yo, postmenopausal, or have risk factors for arrhythmias. Additional info: Overt Hyperthyroidism: low TSH, high T3 and/or T4 T3 toxicosis: low TSH, high T3 > T4 T4 toxicosis: low TSH, high T4 > T3 Amiodarone Induced: often T4 > T3 Subclinical: low TSH, normal T3 and T4 TSH induced (pituitary adenoma): normal/high TSH, high T3 and T4 C. Thyroid nodules W/u (if being cost-effective) should be based on the TSH: 94 1. TSH low: Likely a hyperactive (benign) nodule, order thyroid scintigraphy. 2. TSH high: Likely a cold nodule (w/ ≈15% risk of malignancy), thus should pursue FNA. 3. TSH nl: Scintigraphy if nodule is small, vs. FNA if large (if large & benign, should be active, & thus TSH should be low) 9. Dyslipidemia (see AACE 2012 lipid guidelines for more information) Screening: -fasting lipid panel and in some cases CRP and Lp-PLA2 -all adults > 20 yrs age every 5 yrs -all M 45-55 yrs and F 55-65 yrs at least every 1-2 yrs (more frequently if other RFs present) -if 0-1 CAD RFs at least yearly -children > 2 yrs every 3-5 yrs if CAD RFs or FH of premature CAD or dyslipidemia or are overweight or obese -more frequently if FH of premature CAD or sudden death at < 55 yrs in father or 1st degree M relative or < 65 yrs in mother or 1st degree F relative -annually screen all adult DM patients Secondary Causes: ↑ Total Cholesterol and LDL: Hypothyroidism, Nephrosis, Dysgammaglobulinemia (systemic lupus erythematosus, multiple myeloma) , Progestins or anabolic steroid treatment , Cholestatic diseases of the liver due to abnormal lipoproteins as in PBC,Protease inhibitors for treatment of HIV infection ↑ Total Triglycerides and VLDL: CRF, DM2, Obesity, Excessive alcohol intake, Hypothyroidism, Antihypertensive medications (thiazide diuretics and b-adrenergic blocking agents), Corticosteroid therapy (or severe stress that increases endogenous corticosteroids), Orally administered 95 estrogens, oral contraceptives, pregnancy, protease inhibitors for treatment of HIV infection When to Test in the Hospital: -CAD, MI, Stroke, CAD equivalents (DM, PAD, Carotid Ds, Aortic Ds) -Patient with RFs Goals Based on Risk: RISK category RISK FACTOR LDL GOAL mg/dL Very High Established or recent hospitalization for coronary, carotid, PVD or DM + 1 or more additional RFs <70 High ≥2 RFs and 10-year risk >20% or CHD risk equivalents, including diabetes with no other RFs <100 Moderately high ≥2 risk factors and 10-year risk 10%-20 <130 Moderate ≥2 risk factors and 10-year risk <10% <130 Low ≤1 risk factor <160 RFs = high LDL, PCOS, cigarette smoking, HTN (BP ≥140/90 mm Hg or on anti-hypertensive medication), low HDL(<40 mg/dL), FH of CAD (as described above and age (men ≥45; women ≥55 years). Subtract 1 risk factor if the person has high HDL (≥60 mg/dL) Management: exercise, weight loss, smoking cessation, low fat diet Elevated LDL -drug of choice Statin (Simvastatin or Atorvastatin available at LAC) -if admitted for ACS or stroke typically are aggressive (Simvastatin 80 mg po qHS) although according to AACE using such high doses is no longer recommended. Elevated TG (>500) -Fibrates (Fenofibrate, Gemfibrozil, etc.) 96 -adjunctive therapy with omega 3 fish oil pills -Low HDL - exercise, weight loss, smoking cessation -Other Agents less commonly used: Niacin, Bile Acid Sequestrants (Cholestyramine), Cholesterol Absorption Inhibitors (Ezetimibe) Side Effects: Statins: LFT derangement (avoid statins in liver disease patients),myalgias, muscle weakness, rhabdomyloysis, myopathy, Drug interactions (warfarin, protease inhibitors, cyclosporine, CYP450) Fibrates: Gemfibrozil may increase LDL, myopathy/rhabdomyolysis less common than with statins, increased serum creatinine, Drug interaction with warfarin Niacin: skin flushing, pruritis, abdominal discomfort, may increase uric acid Bile Acid Sequestrants: may increase TG, may decrease absorption of folic acid and fat soluble vitamins Cholesterol Absorption Agents: myopathy, rhabdomyolysis 97 SECTION 12: INFECTOUS DISEASES 1. Neutropenic Fever Definitions Neutropenic Fever - T > 101 F at least once or T > 100.4 F for at least 1 hr) in a patient who is neutropenic (ANC<500 or ANC expected to drop < 500 in the next 48 hrs) Profound Neutropenia -ANC<100 Functional Neutropenia -hematologic malignancy results in qualitative defects of circulating neutrophils (impaired phagocytosis and killing of pathogens) -at risk of increased infection -may have normal ANC Risk Assessment Low Risk: MASCC >21 (see Med Calc for MASCC) -anticipated <7 day duration of neutropenia with no or few comorbidities -may be treated with oral empiric therapy High Risk: MASCC <21 -anticipated >7 days duration and profound neutropenia (ANC <100 cells/mm3 following cytotoxic chemotherapy) and/or significant medical co-morbid conditions (ie. hypotension, oral/GI mucositis ,severe diarrhea, IV catheter infection, pneumonia , new-onset abdominal pain, hepatic insufficiency, renal insufficiency, or neurologic changes. -admit to hospital for IV empiric therapy Dx: Physical - perform complete examination especially: skin , GI, Lungs, perineum Labs: CBC w diff, BMP, LFTs, 2 sets of blood cultures (+ Cx from any suspected sites of infection) Stool culture, O and P, C diff, U/a w/ micro + u culture, LP and CSF examination if meningitis is suspected, Skin aspiration 98 or biopsy if any lesions are present, Sputum samples or BAL if patient has cough or any respiratory s/s Test for adenovirus, influenza, RSV, parainfluenza Imaging: CXR (esp if patient has any respiratory s/s), CT head, sinuses, abdomen, pelvis as indicated Tx: High Risk Patients (the LAC+USC way) -hospitalized for IV empiric antibiotics Add Abx every 48rs if still febrile START w/ Cefepime 2 gm IV q 8 hrs (call ID pharm for approval code) * if PCN Allergy: Aztreonam+ Vancomycin * if unstable at Any TIME, add 2nd gram (-) coverage suck as Amikacin 2nd + Vancomycin (if not already added ) 3rd + Amikacin (if not already added ) 4th + FLAGYL or switch cefepime to Imepenam 5th + Antifungal according to CXR and Dz being treated (micafungin, fluconazole (Candida) , voriconazole (aspergillosis) 6th + Antiviral (valacyclovir or valgancyclovir), Oseltamivir if flu season 7th Ambisome for Mucor/Rhizopus (sooner if indicated) ** note** Add Gram Positive Coverage(Vancomycin) for: Hemodynamic instability , PNA on CXR ,(+) blood Cx for gram(+) bacteria, Clinically suspected serious catheter-related infection, severe mucositis, soft tissue infection at any site, colonization w/ MRSA, VRE, PRSP **note** (If chills or rigors with infusion through catheter or cellulitis around the catheter entry/exit site> remove catheters/lines and treat for at least 14 days (longer if bacteremia persists) For specific cultures: - MRSA – Add Vancomycin -VRE – Add Linezolid or Daptomycin -ESBL – Add Carbapenem -KPC – Early Tigecycline vs Polymyxin-Colistin 99 Duration of Therapy -appropriate antibiotics should continue for at least the duration of neutropenia (until ANC > 500 cells/mm3) or longer if clinically necessary -If unexplained fever, continue until there are clear signs of marrow recovery (ANC>500) -If treatment course complete and all s/s of documented infection resolved but still neutropenic can do oral FQ prophylaxis (Levofloxacin or Ciprofloxacin) until marrow recovery Note: Do not add/change antibiotics if temp is progressively decreasing. ** No rectal exams, suppositories, or enemas in neutropenic pts due to very high risk of infection. Also avoid NGT placement if possible** 2. Fever of Unknown Origin Definitions: 1) Classic: Temp > 38.3 C (100.9 F) for > 3 weeks with evaluation of at least 3 outpatient visits or 3 days in hospital (Common etiologies: infection, malignancy, collagen vascular ds) 2) Nosocomial: Temp > 38.3 C (100.9 F) and hospitalized for > 24 hrs but no fever and not incubating on admission, evaluation for at least 3 days (Common etiologies: C diff infection, drug induced, pulm embolism, septic thrombophlebitis, sinusitis) 3) Neutropenic: Temp > 38.3 C (100.9 F), Neutrophil Count < 500, and evaluation for at last 3 days (Common etiologies: opportunistic bact infns, aspergillosis, candidiasis, herpes) 4) HIV associated: Temp > 38.3 C (100.9 F), evaluated at least > 4 weeks outpatient or >3 days inpatient, and HIV infection confirmed (Common etiologies: CMV, MAC, PCP, drugs, Kaposi’s sarcoma, lymphoma) 100 Etiologies: Infections: TB, Abscesses (Abdominal, Pelvic, Dental), Endocarditis, Osteomyelitis, Sinusitis, CMV, EBV, HIV, Lyme disease, Prostatitis Malignancies: Leukemia, Lymphoma, Metastatic Cancer, RCC, Colon Cancer, Pancreatic Ca, Sarcomas, Hepatoma, MDS Autoimmune: Adult Still's disease, PAN, PMR, Temporal arteritis, RA, IBD, Reiter's syndrome, SLE, Vasculitides Miscellaneous: Complications from cirrhosis, Factitious fever, Hepatitis (alcoholic, granulomatous, or lupoid), DVT, Pulm Embolism, Sarcoidosis Drugs: Allopurinol, Captopril, Cimetidine, Clofibrate, Erythromycin, Heparin, Hydralazine, HCTZ, Isoniazid, Meperidine, MethylDopa, Nifedipine, Nitrofurantoin, Penicillin, Phenytoin, Procainamide, Quinidine Evaluation: History: fever pattern, recent travel, exposure to pets/other animals, work environment, sick contacts, family history (FMF), underlying conditions (lymphoma, IBD, rheumatic disease), new medications PE: thorough especially mucus membranes, skin, lymph nodes, chest, abdomen, cardiac (new murmur), extremities (DVT) Labs/Imaging: based on clues from history and physical examination Preliminary Studies: CBC, BMP, LFTs, ESR, UA with micro, Urine Cultures, Blood Cultures, CXR, Febrile Antibody Panel Infections: US, CT A/P (abscess), sputum for AFB, HIV, EBV, CMV, ASO, TTE, LP, Indium Labelled WBCs for occult infection, Tc 99, etc as indicated Heme Malignancies: PBS, Electrophoresis, BM Bx Nonheme Malignancies: CT, Mammogram, Endoscopy, Bone Scan, Gallium Scan, MRI, Biopsies, PET, etc as indicated AI: RF, ANA, Temporal Artery Bx, LN Bx other tests as indicated Management: based on etiology 3. Infective Endocarditis -suspected in patients with fever and a murmur 101 -esp patients with h/o IVDA or prosthetic valve -acute = 3-10 days -subacute = weeks-months Etiologies: Staph (esp MRSA, coagulase negative) in IVDA and prosthetic valves Strep (esp viridans, if bovis then look for colon cancer) Gram Negative Bacilli like culture negative HACEK: Haemophilus species (Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus), Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella species Diagnosis: Duke’s Criteria 2 major criteria or 1 major criteria and 3 minor criteria or 5 minor criteria Major Criteria: 1) Blood Culture positive for IE Typical organisms from 2 separate blood cultures: Strep viridans, Strep bovis, HACEK, Staph aureus, or community acquired enterococci in the absence of a primary focus or Microorganisms consistent with IE from persistently positive blood cultures defined as: at least 2 positive blood cultures drawn > 12 hrs apart or all 3 or a majority of > 4 separate blood cultures or Single positive blood culture for Coxiella burnetii or anti-phase 1 IgG Ab titer > 1:800 2) Endocardial Involvement Echo positive for IE (TEE for prosthetic valves, TTE for others) defined as: oscillating intracardiac mass on valve or other supporting structures, in the path of reguritant jets, or on implanted material in the absence of an alternative anatomic explanation, or abscess, or new partial dehiscence of prosthetic valve or new valvular regurgitation Minor Criteria: 1) Predisposition, predisposing heart condition, or IVDA 2) Fever (temperature > 38 C) 102 3) Vascular Phenomenon: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions 4) Immunological Phenomenon: glomerulonephritis, Osler’s nodes, Roth’s spots, and RF 5) Microbiological Evidence: positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with IE History: IVDA, prosthetic valve, intracardiac device PE: cardiac (murmur), fundus (Roth’s spots), extremities (Janeway lesions and Osler’s nodes) Labs/Imaging: TTE, TEE, blood cultures x 3 from separate sites drawn at least 1 hr apart, can repeat blood cultures and Echo if necessary Management: For full guidelines, see Circulation. Infective Endocarditis. AHA 2005. Empiric Therapy: Vancomycin + Gentamicin/Tobramycin Treatment: Native Valve with Penicillin Susceptible Strep viridans or bovis: Penicillin or Ceftriaxone alone x 4 wks or Ceftriaxone/Penicillin + Gentamicin x 2 wks or Vancomycin alone x 4 wks “ Penicillin Resistant “ : Penicillin/Ceftriaxone (4 wks) + Gentamicin (2 wks) or Vancomcyin x 4 wks Prosthetic Valve with Penicillin Susceptible Strep viridans or bovis: Penicillin/Ceftriaxone (6 wks) +/- Gentamicin (2 wks) or Vancomycin alone x 6 wks “ Penicillin Resistant “ : Penicillin/Ceftriaxone + Gentamicin (6 wks) or Vancomycin alone x 6 wks Native Valve with Oxacillin Sensitive Staph: 103 Nafcillin/Oxacillin (6 wks) +/- Gentamicin (3-5 days) or Cefazolin (6 wks) +/- Gentamicin (3-5 days) for penicillin allergic patients “ Oxacillin Resistant “ : Vancomycin x 6 wks Prosthetic Valve with OSS: Nafcillin (6 wks) + Rifampin (6 wks) + Gentamicin (2 wks) --with ORS: Vanc (6 wks) + Rifampin (6 wks) + Gentamicin (2 wks) Native/Prosthetic Valve Enterococcal Infection: Ampicillin/Penicillin + Gentamicin (4-6 wks) or Vancomycin + Gentamicin (6 wks) Gentamicin Resistance: Ampicillin/Penicillin + Streptomycin (4-6 wks) or Vancomycin + Streptomycin (6 wks) Penicillin Resistance: Beta Lactamase producing: Ampicillin/Vancomycin + Gentamicin (6 wks) or Intrinsic Resistance: Vancomycin + Gentamicin (6 wks) Resistant to Penicillin/AG/Vancomycin: Linezolid or Quinupristin-Dalfopristin or Imimpenem/Cilastatin + Ampicillin/Ceftriaxone + Ampicillin x 8 wks Native/Prosthetic Valve HACEK infection: Ceftriaxone/Ampicillin Sulbactam/Ciprofloxacin x 4 wks Indications for Surgery: CHF/ruptured valve or chordae tendinae Prosthetic Valves Fungal Endocarditis Abscess AV block Recurrent emboli while on antibiotics After Treatment: Get repeat blood cultures x 3, TTE, appropriate follow up and physical examinations. 104 Prophylaxis with Amoxicillin or Clindamycin/ Azithromycin/ Clarithromycin if: Significant Cardiac Defect (prosthetic valve, previous endocarditis, cardiac transplant recipient with valvulopathy, unrepaired cyanotic heart disease) AND Risk of Bacteremia (dental work with blood, respiratory tract surgery that produces bacteremia) For further information, see the IDSA practice guidelines for Infective Endocarditis. 4. Community Acquired MRSA -All patients have a nasal swab done on arrival to the floor to check for MRSA. -If positive, contact precautions are started by Epidemiology. -They enter a note in Affinity with recommendations of how to clear a patient of MRSA. -Recurrent MRSA: 2+ discrete MRSA infections in different sites over a 6 month period Management of MRSA Infections: Abscess/Furuncle/Carbuncle: Incision and Drainage + Antibiotics if severe/extensive disease, s/s of systemic illness, associated comorbidities/immunosuppression, extremes of age, difficult to drain abscess completely, associated septic phlebitis, or lack of response to I + D alone Purulent Cellulitis: Clindamycin/TMP-SMX/Doxycycline/Minocycline Nonpurulent Cellulitis: Cephalexin/Dicloxacillin/Clindamycin/Tetracycline/Linezolid/Amoxicillin+/TMP-SMX Complicated Soft Tissue Infections: Vancomycin/Linezolid/Daptomycin/Telavanacin/Clindamycin Bacteremia: Vancomycin/Daptomycin 105 Native Valve IE: Vancomycin/Daptomycin Prosthetic Valve IE: Vancomycin + Gentamicin + Rifampin Pneumonia: Vancomycin/Linezolid/Clindamycin Osteomyelitis: Vancomycin/Daptomycin/Linezolid/Clindamycin/TMP-SMX and Rifampin Septic Arthritis: Vancomycin/Daptomycin/Linezolid/Clindamycin/TMPSMX Meningitis: Vancomycin/Linezolid/TMP-SMX Brain Abscess/Subdural Empyema/Spinal Epidural Abscess, Septic Thrombosis or Cavernous or Dural Venous Sinus: Vancomycin/ Linezolid/TMP-SMX For further information, please see the IDSA practice guidelines for MRSA infections. 5. Community Acquired Pneumonia CAP Definition: pneumonia (dyspnea, high fever, and often an abnormal CXR) occurring before hospitalization or within 48 hrs of hospital admission HAP Definition: pneumonia after 48 hrs of hospital admission VAP Definition: pneumonia within 48-72 hrs of being placed on a ventilator Healthcare Associated Pneumonia Definition: pneumonia in a patient in a nursing home, HD center, or home health within the past 30 days or hospitalization within the past 90 days Etiology: Strep pneumoniae - most common cause, including in HIV patients H influenzae - COPD, smokers Staph aureus - recent viral illness like influenza, Cystic Fibrosis pts, IVDA Klebsiella pneumoniae - alcoholism, diabetes, “currant jelly sputum” 106 Anaerobes - poor dentition, aspiration (alcoholics), foul smelling sputum M. pneumoniae - young, healthy patients, may be a/w erythema multiforme, dry cough, bullous myringits C. pneumoniae - hoarseness of voice Legionella - contaminated water sources such as air conditioning, GI or CNS symptoms, hyponatremia, abnormal LFTs C. psittaci - birds C. burnetii - veterinarians, farmers PCP now known as P. jirovecii - AIDS with CD4 < 200, elevated LDH Atypical - mycoplasma, viruses, Coxiella, Pneumocystis, Chlamydia Severity of Illness: CURB-65 criteria: Confusion, Uremia (BUN>20), RR > 30, low BP (systolic < 90 or diastolic < 60), age > 65 years Mortality: 0 (0.7%), 1 (2.1%), 2 (9.2%), 3 (14.5%), 4 (40%), 5 (57%) If 0-1, treat as outpatient. If 2, treat in wards. If >3, often need to be treated in an ICU. PORT Score: See green book for more information. Class 1 and 2: outpatient t/t Class 3: observation or short hospitalization Class 4/5: inpatient t/t Severe CAP: Minor Criteria: RR > 30, PaO2/FiO2 ratio < 250, multilobar infiltrates, confusion/disorientation, BUN >20, WBC < 4000, Plt < 100,000, T < 36 C, or Hypotension requiring aggressive fluid resuscitation Major Criteria: Invasive Mech Ventilation, Septic Shock requiring pressors Diagnosis: History: recent travel, occupation, h/o influenza vaccine, h/o pneumococcal vaccine, comorbidities, previous infections, etc. 107 PE: RR, temperature, BP, pulmonary exam, mental status Labs/Imaging/Procedures: CBC - leukocytosis or leucopenia, CMP - elevated BUN, LFTs, Pulse Ox – severity, ABG – severity, CXR, Sputum Gram Stain and Cx and AFB (if suspected), Blood Cx, Legionella UAT, Pneumococcal UAT Thoracentesis - if pleural effusion seen on CXR can get a lateral decubitus XR to check for layering, empyema is exudative effusion with pH < 7.2 glucose < 60 and needs chest tube (Pulm or TMIS Consult) see Pulm section re: Light’s criteria Light’s Criteria: refer to pulm section Management: Outpatient: 1) No recent abx: Macrolide/Doxycycline 2) Recent Abx: Macrolide + High Dose Amox/Clav/2nd generation Cephalosporin or Respiratory FQ alone (Levo, Gati, Moxi) Hospitalized: 1) CAP: 3rd Gen Cephalosporin (Ceftriaxone) + Macrolide or Respiratory FQ alone 2) CAP, ICU pt: 3rd Gen Cephalosporin/Amp-Sulbactam + Macrolide/FQ 3) Hospital Aqd and Risk of MDR organisms: antipseudomonal PCN/Ceph/Carbapenem + FQ/(Gent + Azithro) + Vancomycin 4) Immunosuppressed: above + TMP-SMX +/- steroids 5) Aspiration: 3rd Gen Ceph/FQ +/- Clindamycin/Metronidazole 6) VAP: Antipseudomonal beta lactam + 2nd Antipseudomonal agent + MRSA coverage Empyema requires placement of a chest tube for drainage. Specific treatment is based on organism and antibiotic sensitivities. 108 Pneumococcal Vaccination for: everyone > 65 years age, chronic heart, lung, liver, or kidney disease, functional/anatomic asplenia, heme malignancy, immunosuppression (DM, alcoholic, CS, HIV/AIDS), CSF leak, cochlear implant recipients For additional information, please see IDSA practice guidelines for CAP. 6. Newly Diagnosed HIV -Public Health notification -Make sure all partners and children know that they could have HIV and should be tested. -Consider consulting ID if needed. Labs to Obtain Upon Diagnosis: -HIV ELISA and Western Blot -CBC with Diff, CMP -UA -G-6-PD qualitative -Hep Panel (Hep Bs Ag, Hep Bc Ab, Hep C Ab, Hep A Ab) -RPR, if positive then FTA-ABS -Fasting lipid profile -Cellular immune profile (CD4-lymphocytes) x 2 -HIV-1 RNA load by PCR or branched-chain DNA x 2 -PPD, CXR PA and Lateral -Toxoplasma gondii IgG Ab Proper Use of HIV-Specific Laboratory Evaluations HIV Viral Load 1. Possible acute retroviral syndrome to confirm diagnosis 2. Newly diagnosed HIV infection to establish baseline 3. Periodically to follow the course of HIV treatment (resistance) HIV Resistance Assay 1. Prior to initiation of therapy when pre-existing antiretroviral drug resistance is known or suspected - acute or chronic HIV infection. 109 2. During antiretroviral therapy after loss of virologic suppression (while on antiretroviral drug therapy) CD4-Lymphocyte Assay 1. Prior to initiation of therapy and periodically thereafter to evaluate the indirect effects of virologic suppression and the need for opportunistic infection antimicrobial prophylaxis. 2. At the time of intercurrent febrile illnesses to evaluate for the possibility of opportunistic infection Criteria for Initiation of Antiretroviral Therapy 1. Acute HIV infection or < 6 months since acute infection 2. Pregnancy in HIV-infected female 3. Any person with HIV infection who is ready to take antiretroviral therapy 4. Symptomatic HIV or AIDS 5. HIV-infected partner in serodiscordant couple 4. Postexposure prophylaxis after body fluid exposure (healthcare workers, emergency or disaster workers, rape victims and other "voluntary" or involuntary sexual exposures) Post Exposure Prophylaxis -within 72 hours of exposure -treatment for 28 days with 2-3 agents (Tenofovir + Emtricitabine +/Ritonavir) -test for HIV as well as other blood borne infections and STDs See NEJM 2009 article on post exposure prophylaxis for more information. Opportunistic Infection Prophylaxis CD4<250 = Coccidiodes, Fluconazole or Itraconazole CD4<200 = P. jiroveci, TMP-SMX vs Dapsone vs Aerosolized Pentamidine CD4<150 = Histoplasma if patient lives in endemic area, Itraconazole CD4<100 = Toxoplasma, TMP-SMX vs Dapsone CD4<50 = MAC, Azithromycin vs Clarithromycin 110 7. Reportable Diseases Please go to the following website for a list of reportable disease http://www.cdph.ca.gov/HealthInfo/Documents/Reportable_Diseases_Co nditions.pdf 8. Bacterial Classification 111 112 9. Fungi Please see IDSA guidelines for the individual fungal infections to get further information regarding treatment by organ involvement. Aspergillus: affects lower resp tract, sinuses, skin by direct entry,-affects CNS, CVS, other organs by hematogenous spread Proven: histopathological documentation of infection (hyphae) + positive culture from normally sterile site Probable: host factors + s/s suggestive + microbiological evidence Dx: culture, BAL, microscopic examination for hyphae, EIA test Tx: Amphtericin B (Ambisome) or Voriconazole Prophylaxis: See neutropenic fever section. Candida: can affect any organ -Risk Factors: broad spectrum antibacterial agents, use of central venous catheters, parenteral nutrition, CRRT, neutropenia, implanted devices, immunosuppresive agents Dx: culture Tx: usually Fluconazole, if oropharyngeal can use Clotrimazole or Nystatin (call pharmacy for correct order) Prophylaxis: See neutropenic fever section. Coccidiodes: common to southern Arizona, central or southern California (LA!), southern New Mexico, Texas -can present as self limited CAP or more severe including extrapulmonaru involvement Dx: depending on organ involvement, can perform rapid test in serum Tx: AMB vs Ketoconazole vs Fluconazole vs Itraconazole Prophylaxis for solid organ transplant recipients and HIV patients with CD4 < 250 cells living in an endemic region -> use Fluconazole Cryptococcus: Cryptococcus neoformans and gattii Tx: HIV patient with meningoencephalitis = AMB + Flucytosine -increased CSF pressure associated w increased morbidity and mortality 113 -Same for pulmonary disease and organ transplant patients with the infection Histoplasma: usually resolves within a month without therapy -can affect lungs, heart, and causes of arthritis, arthralgia, and erythema nodosum Disseminated: does not improve within 3 wks, association with physical or radiographic findings or lab evidence of extrapulmonary tissues -May have hepatosplenomegaly, mucosal ulcers, skin lesions, GI involvement, pancytopenia, elevated LFTs, increased LDH, increased serum ferritin Tx: indicated for moderate to severe pulmonary infections, CNS infections, disseminated infections w/ Amphotericin B, Itraconazole Prophylaxis = HIV patients with CD 4 < 150, use Itraconazole 114 SECTION 13 – GASTROENTEROLOGY/HEPATOLOGY 1. DIARRHEA ● Acute Diarrhea(<4weeks) History: Freq?, Blood?, Abd pain?, Duration?(about 1 week viral and bacterial except C. diff), >1 week for parasitic, travel, food, recent ABX, immunocompromised(CMV, MAI, Cryptosporidium, Cyclospora, Isospora, Entamoeba histolytica) Physical: Look for signs of volume depletion (VS, UOP, axillae, skin turgor, MS) , Fever, abd tenderness, ileus, rash, appearance (blood (inflammatory or invasive ulceration), mucus (IBS), or oil (malabsorption)) Warning signs: sig pain(mesenteric ischemia), blood, pus, >6 stools/day, severe dehydration, immunosuppression, elderly, duration >7d, hospital acquired Labs: Stool cx, Blood cx, lytes, C. diff stool antigen(recent abx or hospitalized), Stool O+P(if >10 days, travel to endemic areas, exposure to unpurified water, outbreak, daycare, HIV+, MSM), +stool ELISA(virus, crypto, giardia), serologies(E. histolytica), Stool WBC not recommended as high false pos/neg Imaging/EGD: CT/KUB if concern for toxic megacolon; flex sig/colo if immunosuppressed or cx neg TX: Generally self-limiting. Generally supportive if not severe, if tolerating PO then oral rehydration is important, loperamide ok if non-infectious or infectious w/treatment, IVF for severe dehydration. When to treat: abx rec for Shigella, cholera, C. diff, Giardia, amebiasis, Salmonella if Pt > 50y old/ immunosupp./hospitalized ○ Empiric TX: Abx for non-hosp acquired inflammatory: 5-7 days FQ 115 ○ Consult considerations: GI(if initial workup negative), Endo(if secretory), ID, Colorectal(toxic megacolon) ● Chronic diarrhea(>4 weeks) Etiologies Meds (increased secretion, motility, cell death. inflammation, flora changes, PPI, colchicine, abc, H2RA, SSRI, ARBs, NSAIDS, Chemo, Caffeine Osmotic: elevated stool osmol, no fecal fat, decreased with fasting Lactose intolerance TX: lactose free diet, lactase supp. Other: lactulose, laxatives, antacids, sorbitol, fructose Malabsorption: elevated stool osmol, + fecal fat, decreased with fasting Celiac Dz: S/S: Fe/Folate def anemia, osteoporosis, dermatitis herpetiformis(pruritic papulovesicular), increased ALT/AST Dx: IgA-tTG, Anti-endomysial Ab (more expensive, can resolve after tx), Gold standard biopsy WITH response to diet. Rx: Gluten free diet(if no reponse(noncompliance vs wrong dx). Complications: 5% refractory, risk of T-cell lymphoma, sm. bowel AC Whipple’s Disease: infx w/ T. Whipplei Cardinal Sxs: Abdominal pain, diarrhea, weight loss, arthralgias(migratory) disseminated dz with CNS/Cardiac sx/sx possible Dx: Always r/o hyperthyroidism, connective tissue dz, IBS w/ migratory polyarthropathy, AIDS Endoscopy with bx and PAS-positive macrophages is gold standard 116 Tx: (PCN streptomycin) or 3rd-gen ceph x 10–14 d>> Bactrim for > 1 y, for disseminated dz reference current guidelines Bacterial overgrowth: small intestinal bacteria from incompetent/absent ileocecal valve, s/p RYGB, scleroderma, diabetes, s/p vagotomy >> fat & CHO malabsorption. Dx: 14C-xylose & H+ breath tests; Rx: cycled abx (eg, MNZ, FQ, rifaximin) Pancreatic insufficiency: most commonly from chronic pancreatitis or pancreatic cancer Decreased bile acids due to decreased synthesis (cirrhosis) or cholestasis (PBC) >> malabsorption Other: s/p short bowel resection (short bowel syndrome), Crohn’s disease, chronic mesenteric ischemia, eosinophilic gastroenteritis, intestinal lymphoma, tropical sprue, Laxative use, neoplasm, decreased bile acid resorption s/p ileal resection/Chron’s lymphocytinc colitis, collagenous colitis(often a/w meds like NSAIDS) Inflamatory: (+) Stool WBC or lactoferrin or calprotectin, (+) FOBT, fever, abd pain). Causes: parasitic, CMV, TB. Radiation enteritis, ischemic colitis, neoplasia(colon cancer/lymphoma) Secretory: normal osmotic gap, no decrease in diarrhea w/ NPO, often nocturnal. Hormonal: VIP(VIPoma), Serotonin(carcinoid), thyroxine, calcitonin(medullary cancer of thyroid), gastrin(Zollinger-ellison), glucagon, substance P Irritable bowel syndrome: Rx is symptom guided Rome III criteria: recurrent abd pain >/= 3d/mo over 3 months plus >/= 2 of the following: 1. improvement with defecation 2. onset w/change of stool freq 3. onset w/change in form of stool 117 2. Clostridium difficile Spectrum: Colonization to Fulminant colitis Manifestations: Asx colonization (3% healthy adults/~20% in-PT on ABX) Si/Sx: Acute watery diarrhea: poss. w/ blood, mucus, lower abd pain, fever, classically very high WBC Psuedomembranous colitis: In addition to above complaints, pseudomembranes on scope and bowel wall thickening. Fulminant Colitis (2-3%): toxic megacolon(colon dilatation >/=6cm on KUB, colonic atony, systemic toxicity) and/or perf Dx: Presence of bacteria: Many tests available, at LAC order “C. diff stool toxin or C. diff stool antigen” and Illumigene LAMP assay(newer than EIA/PCR) for C diff toxin is performed Se/Sn 95%, ~24hr turnaround,detects ToxinA+B+ and Toxin A+B-. ** If high suspicion with no diarrhea, ask nurse to mix sample with water, as diarrhea may not always be present** Flex sig if dx uncertain or no improvement with standard Tx Tx: Everyone: Contact precautions,1:1 equipment, d/c abx if possible, stop antimotility agents(unless on targeted ABX already) Mild (<6 BM/d, temp <101F, WBC <15 k, no peritoneal sx or SIRS, and age <65 y) Rx: MNZ 500 mg PO tid x 10–14 d; IV equal efficacy, use if poor PO or ileus Moderate (6–12 BM/d, temp 101–103F, WBC 15–25 k, visible LGIB, or age >65 y) Rx: vanco 125–500 mg PO qid 10–14 d; add MNZ 500 IV tid if not improved by 48 h Severe (>12 BM/d, temp >103F, WBC >25k, increased abd pain, sepsis, or no bowel sounds) 118 Rx: vanco PO + MNZ IV; PR vancomycin available if ileus, though avoid if evidence of toxic megacolon; ? tigecycline (CID 2009;48:1732);Ab CT, urgent surgery consult re: colectomy; consider IVIG If patient requires continuation of original ABX, continue c diff abx for 7+ days after ABX cessation Stool carriage can be positive 3-6 wk post tx and sx resolution, do not re-treat 3. Constipation: common problem with many etiologies Causes: Functional: normal transit, slow transit, pelvic floor dysfunction, constipation-predom IBS Meds: opioids, anticholinergics (TCAs & antipsychotics), Fe, CCB, diuretics, NSAIDs Obstruction: cancer, stricture, rectocele, anal stenosis, extrinsic compression Metabolic/endo: DM, hypothyroid, uremia, preg, panhypopit, porphyria, increased Ca, decreased K, decreased Mg Neuro: Parkinson’s, Hirschsprung’s, amyloid, MS, spinal injury, autonomic neuropathy Dx: History/Physical w/ DRE, cbc, electrolytes, TSH. Colo for alarm sxs: weight loss, +FOBT, fevers, FHx of IBD/colon cancer. Sigmoidoscopy if no alarm sxs and <50yrs Tx: Always write “hold for diarrhea” 1st Bulk laxatives, then Osmotics/Stimulants, then suppositories /enemas PPX for opiod use/extended bed rest Bulk laxitives: Psyllium fiber 3.4g in 4-6oz h20/juice qdaily to QID Osmotics: Monitor electrolytes while in use, caution with CKD(mag/phos containing agents) 119 Miralax 17g in 4-8oz h20, Mag-citrate, lactulose 15-60cc qdaily to QID Stimulants: Senna 1-2 tab qdaily/BID; Biscodyl 5-15mg PO qdaily OR 10mg PR qdaily Enemas: for refractory cases, tap water(500cc-1000cc), soapsuds, mineral oil(fleets mineral oil),Lactulose(300ml lactulose in 700cc h20/NS) 4. GI Bleeding (anywhere between mouth and anus) UPPER: above ligament of Trietz, UGIB>LGIB: N/V, hematemesis, coffee-ground emesis, epigastric pain, vasovagal, melena, hematochezia(brisk bleed) UGIB DDX: PUD, Varices, Gastritis/gastropathy/duodenitis, Erosive esophagitis/ulcer, Mallory-Weiss tear, Vascular lesions, neoplasm, OP bleed/epistaxis LOWER: below ligament of Trietz LGIB >UGIB: diarrhea, tenesmus, BRBPR, hematochezia LGIB DDX: Diverticular disease (60% bleeds on right), neoplastic disease, colitis (infectious, ischemic,radiation, IBD(UC>>CD), angiodysplasia (More common ascending colon/cecum), anorectal, vasculitis Managment/Tx: Assess severity: tachycardia(10%l loss),(+) orthostatics(20% loss), shock(>30%loss) IVF with NS or LR till normal VS, UOP, MS Serial CBC(q6 or q8), can collect in pediatric tubes to minimize iatrogenic blood loss Transfuse to targ 25-30 HCT, FFP and Vit K to fix PT, plt>50k Transfer to ICU if unstable with e/o end organ effect for intubation and emergent endoscopy, consult GI immediately 120 If non-emergent with stable h/h,(+) FOBT, no melena /hematochezia, no co-morbid dz, stable VS>>consult GI for outpatient EGD/Colo 5. Helicobacter pylori Who to test: Patients with gastric MALT lymphoma, active peptic ulcer disease, or a past history of documented peptic ulcer Indications: Uninvestigated dyspepsia who are under the age of 55 years and have no "alarm features" (bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting, family history of GI cancer, previous esophagogastric malignancy) Other indications: Immune thrombocytopenia, unexplained Fe def. anemia, unexplained B12 def. Dx: H Pylori stool antigen: has high Se/Sp, make sure to test after 2 weeks PPI free to minimize false neg, H2RA is ok to give in interm. Serum Ab: Not recc. as it cant differentiate between current and past infection. Biopsy proven on EGD. Urea breath test: not routinely done at LAC Tx: Triple Tx (Clarith 500 bid + Amox 1 g bid OR MNZ 500mg BID + PPI bid for 10–14 d) Quad Tx: (MNZ 250mg QID + TCN 375mg QID + Bismuth subsalicylate 525mg QID + PPI bid (H. pylori resist to clarith or amox allergy) Confirm Eradication: with stool antigen a minimum of 4-6 weeks after tx and off PPI 6. PPI use: Always think about why you are starting PPI Inpatient indications: continued tx of dyspepsia/GERD Inpatient Stress ulcer prevention 121 Level 1: ventilated, coagulopathy, traumatic brain injury, major burns Level 2: Multi-trauma, sepsis, Acute renal failure Level 3: High dose steroids(>hydrocortisone 250mg or equivalent/day) Potential side effects: increased riskof- C. diff, CAP/HAP, hypergastrinemia, gastric atrophy, chronic hypochlorhydria, fractures, hypomagnesemia, iron/b12 malabs., plavix interaction 7. Colonoscopy Preparation Start clear liquid diet till 6pm on night before, NPO after 6pm and start Go-Lytley Go-Lytley 4L, 8oz PO q10 minutes. Can expect first BM in about 1 hour after starting and loose BM 1-2 hours after finishing 4L. If not clear, give additional 2L and cont to eval. 8. Inflammatory Bowel Diseases Ulcerative colitis: inflammation of colonic mucosa Si/Sx: Grossly bloody diarrhea, lower abd cramps, urgency, tenesmus Severe colitis (15%): progresses over 1-2 weeks, dropping Hct, elevated ESR, fever, hypotension, >6BM/d, distended abdomen with absent bowel sounds Extracolonic(>25%): erythema nodosum(inflamation of fat under skin/tender nodules), pyoderma gangrenosum(necrotic ulcers), aphthous ulcers, uveitis, episcleritis, thromboembolic events(esp during flares), AIHA, seroneg arthritis, chronic hepatitis, cirrhosis, PSC(increased risk of cholangio) Dx: Colonscopy- granular, friable mucosaw/ diffuse ulceration, pseudopolyps 122 Complications: Toxic Megacolon in 5%, treat with IV steroids and broad-spectrum ABX, surgery if no improvement 48-72hrs(Consult colo-rectal) Tx: Acute flare- Consult GI Mild disease (</=4BM/d w/o systemic tox): 5-ASA, PR if distal to splenic flexure, PO if more extensive involvement: 2.4-4.8g/d Moderate disease (</=6BM/d w/minimal systemic tox: PO prednisone, IV prednisone for severe Anti-TNF-alpha: for severe flare unresponsive to steroids CsA (cyclosporine): severe flare: 2mg/kg infusion x 24h, check mag., avoid in low cholesterol due to decreased seizure thres. Surgery: J pouch anal anastamosis, can dev. pouchitis(6%)>>tx abx/probiotics Crohn’s Dz: transmural inflammation of GI tract, skip lesions and can involve any portion "a fat granny and an old crone skipping down a cobblestone road away from the TransAM wreck". Sx/Sx: Mucus containing, not grossly bloody diarrhea, n/v, bloating. Slowly progressive disease with abd pain, fevers, malaise, wt loss Look for: Decreased albumin, elevated ESR/CRP, decreased HCT(due to Fe,B12 def,folate def AND chronic inflamation) Dx: EGD/Colo- non-friable lesions, cobblestoning, aphthous ulcers, deep and long fissures, Micro-transmural inflammation with mononuclear cell infiltrate, noncaseating granulomas(seen 25%), fibrosis, ulcers fissures, rectal sparing Complications: Perianal diseas(fissures,fistulas,abscesses), strictures, fistulas, abscess 123 Malabsorption sequelae 2/2 illeal diseases(gallstones, decrease fatty acid absorption leading to Ca oxalate kidney stones, fat soluble vit def) Tx: Acute Flare - Consult GI Abx: FQ/MNZ or amox/clav best for perianal disease Steroids: Mild disease (tolerating PO), can use budesonide w/ileal disease (first pass metabolism limits systemic adverse effects). Mod disease (wt loss, abd pain, nausea, anemia): PO Prednisone. Severe disease (fever, obstruction, cachexia): IV pred 1mg/kg Anti-TNF-alpha: Same indications as for UC although earlier use may be better, Infliximab vs Adalimumab vs Certolizumab Surgery: Diverting ileostomy, good for perianal disease 9. Acute Pancreatitis Etiology: Gallstones (40%), Alcohol(30%), Drugs(furosemide, thiazides, sulfa, DDI, asparaginase, estrogen, 6-MP/AZA, ACEI, dapsone, 5-ASA, valproic acid), Obstructive, Metabolic(Hyper TGneeds to be >1000 and usually~4500 and seen in familial hyperTG, hypercalcemia), Infections, AI, Ischemia, Post ERCP(5% w/ sxs, 3570% asx with elevated amylase), Post trauma, Familial(PRSSI, CFTR, SPINK I genes), scorpion sting Si/Sx: abdominal pain +/- radiating to back, constant, some relief leaning forward, N/V, abd ttp/guarding, decr. bowel sounds, +/palpable abd mass, +/- jaundice if biliary obs. Retroperitoneal hemorrhage (Cullen’s-Periumbilical, Grey Turner’s-Flank). Fever, tachycardia, hypotension, +/- shock Dx Labs: Lipase more specific, amylase elevated x 3 ULN(not as sp as lipase), ALT>3 x ULN suggests gallstone panc. Other: elevated wbc, incr/decr HCT, incr BUN, decr Ca, incr Glc 124 Imaging: KUB/CXR for “sentinel loop” air in small bowel in LUQ, atelectasis, effusion Abd CT: Not required but TEST OF CHOICE. Consider f/u CT w/IV contrast 3 days to eval for necrosis (avoid early due to incr risk of necrosis with IV contrast) Recommended for patients with Severe AP based on clinical criteria or APACHE II score to determine if nec. panc. present. Abd u/s: generally poor at viewing pancreas, however good at assessing for biliary pathology(gallstones, BD dilitation) MRI/MRCP: can detect necrosis, used to assess for stones and ductal disruption Tx: Supportive in mild cases, bowel rest generally enough Fluids: be aggressive, in severe cases upwards of 10L/d may be needed Nutrition: PO better than TPNif NPO>7d; decr infectious compl. and dz severity. Analgesia: Meperidine difficult at LAC, morphine with theoretical oddi spasm(has been used regularly anecdotally without problems), Dilaudid a good option ABX in severe panc: literature inconclusive regarding PPX as mortality may not change, however ABX(carbapenems) should def be started in patients with severe cases and e/o >30% necrotic pancreas on CT Surgery: infected necrosis nearly always requires debridement. Improved out comes by delaying (if possible) surgery ~2 wks to allow organization of necrosis. Cholecystectomy if gallstones (w/in 48 h if mild, o/w w/in 14 d ERCP + sphincterotomy: in acute setting, reserved for severe cholangitis/sepsis and T Bili>5(presumed obstructive). Prognosis: Multiple scoring systems, calculators available on Qx Calculate for iphone/android systems. These calculators are more 125 useful for triaging patients into categories of ICU requiring more aggressive care vs patients that may not require this stratification and subsequent monitoring for complications. Not routinely used for stable cases. Calculators can also guide imaging in severe cases. Complications: Systemic: shock, ARDS, renalfailure, GI hemorrhage, DIC Metabolic: hypocalcemia, hyperglycemia, hypertriglyceridemia Acute fluid collection (30–50%): seen early, no capsule, no Rx required Pseudocyst (10–20%): fluid collection, persists for 4–6 wks, encapsulated suggested by persistent pain & elevation of amylase or lipase, or mass on exam most resolve spont.; if >6 cm or persists >6 wks + pain >>endo/perc/surg drainage Sterile pancreatic necrosis (20%): area of nonviable pancreatic tissue Infection (5% of all cases, 30% of severe): usually 2/2 enteric GNR infected pancreatic necrosis: fever & c WBC not specific; ∴ FNA in deteriorating Pt w/ necrosis (small risk of seeding sterile necrosis); if gram stain/cx (+) >>abx + evacuation (percutaneously, followed by surgical debridement after 4 wks pancreatic abscess: circumscribed collection of pus (usually w/o pancreatic tissue) treat with abx + drainage (CT-guided if possible), usually seen >/=4 wks into course Ascites or pleural effusion: occurs due to disrupted pancreatic duct; consider early ERCP w/ stent across duct; can also occur from draining pseudocyst 10. Acute Hepatitis (Viral)- If suspecting order “Hepatitis panel, ACUTE”(includes Hep A IgM, Hep B surface Ag, Hep B Core Ag IgM, Hep C virus Ab), TAT is 48 hours at LAC 126 Hepatitis A(ssRNA, 30-45% of cases, no chronic carrier state) Etiology: Fecal-oral, contaminated food, water, shellfish, day-care Incub: 2-6 weeks Sx: Diarrhea, decreased appetite, malaise, fever, n.v, RUQ pain,+/jaundice,rarely fulminant Dx: Anti-Hep A IgM (+), Hep A IgG(+) with (-) IgM =Past exposure Tx: supportive. Vaccinate people with chronic HBV, HCV or other chronic liver dz Post exposure ppx: age 1-40>>vaccinate,<1 or >40 or immunosupp >> IgG Hepatitis B (dsDNA, acute or chronic, 45% of cases) Etiology: Blood, sexual, perninatal(vertical, very common in those emigrated from Asia) Incub: 6wk-6month(avg 12-14 wk) Acute infxn: 70% sub-clinical, 30% jaundice, <1% fulminant Chronic infxn: <5%(adult acquired), >90% (perninatal acquired); 40% chronic carriers progress to cirrhosis, increased risk of cirrhosis with concomiant infxn of other hepatitis viruses Dx: Serologic and virologic tests HBsAg: appears before sx; used to screen blood donors; persists >6 mo = chronic HBV HBeAg: evidence of viral replication and incr. infectivity IgM anti-HBc: first Ab to appear; indicates acute infection Window period = HBsAg become (-), anti-HBs not yet (+), anti-HBc only clue to infection IgG anti-HBc: indicates previous (HBsAg (-)) or ongoing (HBsAg (+)) HBV infection anti-HBe: indicates waning viral replication, decr. infectivity anti-HBs: indicates resolution of acute disease & immunity (sole marker after vac) 127 HBV DNA: presence in serum correlates w/ active viral replication in liver Tx: for ACUTE: supportive, hospitalize for change in MS or elevated INR(indications of possible acute liver failure and need for transplant) Hepatitis C (RNA, 10-30% of cases) Etiology: Blood>>sexual, 20% w/o clear cause Incub: 1-5 mos(avg 6-7wk) Acute infxn: 80% subclinical, 10-30% symptomatic hepatitis w/ jaundice; fulminant rare, spontaneous resolution 30% Chronic infxn: up to 80% progress to chronic, 20-30% women dev. cirrhosis after 20 years, increased risk of cirrhosis in men, EtOH, HIV, HCC in 2-5% cirrhosis Extrahepatic syndromes: Cryoglobulinemia(this is not cold agglutinin dz), porphyria cutanea tarda(blistering rash in sun exposed area), MPGN, MGUS, IPF, NHL, DM Serologic and virologic tests: Anti-HCV (ELISA): (+) in 6 wks, does not = recovery or immunity; can be (-) after recovery HCV RNA: (+) w/in 2 wks, marker of active infection HCV RIBA: used to confirm (+) anti-HCV ELISA in Pts w/ undetectable HCV RNA HCV genotype (1–4): guides duration & predicts response to Rx (genotype 2,3 > 1,4) Diagnosis: acute hepatitis = (+) HCV RNA, +/- anti-HCV resolved hepatitis = (-)HCV RNA, +/- anti-HCV chronic hepatitis = (+)HCV RNA, (+) anti-HCV Tx ACUTE: if no spont clearance at 8–12 wks, consider PEG-IFNalpha-2a/b x 12–24 wks 11. Alcoholic Hepatitis: if high on the differential, Consult Liver Etiology: GIB, chronic HBV, sepsis Sx: can range from asx hepatomegaly(possible bruit) to decompensation w/ascites, encephalopathy, and death. AST + ALT 128 usually <300-500 w/ AST:ALT > 2:1, in part b/c concominant B6 deficiency(ALT can be normal); decr platelets, incr iron sat, incr’d Tbili, and INR indicate severe hepatitis Note: patients can develop severe elevations in LFTs from alcoholic cholestatic disease and will be seen in elevations of alk phos(THIS IS NOT alcohol hepatitis) Rx: Calculate Discriminant fxn(=4.6 x(PT-control[13.9 @ LAC] + Tb in mg/dl), if >32 or encephalopathy>> methylprednisolone(does not have to be metabolized by liver like prednisone) 32mg/d x 4 weeks then 4-6 week taper Pentoxifyline 400mg TID decreases mortality due to reduction in HRS F/u: Lille model predicts nonresponse to steroids + mortality, powered by change in Tbili from day 1>>7; non-responders have 6mo survival of 25% (http://www.lillemodel.com) 12. Acetaminophen Toxicity Usually metabolized via glucuronidation and sulfation >>nontoxic metabolites OD usually >10g, which causes accessory CYPE2E1 hydroxilation >>reactive electrophilic species that are scavenged by glutathione until supply exhausted >>hepatotoxicity CYP2E1 is induced by fasting and alcohol, so malnourished alcoholics more predisposed to hepatoxicity by acetaminophen at lower doses (2-6g) May take 2-6 days to see liver dysfunction Rx: NG lavage, activated charcoal w/in 4 hours, low threshold to start even if serum acetaminophen level low/undetectable NAC (n-acetylcysteine): can give up to 72 hours after ingestion, if time of ingestion unknown or if chronic ingestion >4g/day 129 PO NAC: Start 140mg/kg PO/NG x1 ASAP if <24h. Then 70mg/kg PO q4h x 17 doses. IV NAC: 150mg/kg over 1h>>50mg/kg over 4h>>100mg/kg over 16h; risk of anaphylaxis; only use if unable to tolerate PO, GIB, pregnant, fulminant liver failure Rumack-Matthew nomogram - predicts risk of hepatoxicity based on amount and time of ingestion 130 13. Chronic (and Subacute) Hepatitis & ESLD Hepatitis B: Treat if: (1) HBeAg (+) w/ DNA >20,000 IU/mL & elevated ALT; (2) HBeAg (-) w/ DNA >2,000 IU/mL & elevated ALT or liver bx demonstrates stage >/= 2 fibrosis PEG-IFN2a: best rate of HBeAg seroconversion at 1y(27%), low tolerability limits use, in patients suffering depressive symptoms while on therapy or those who could not tolerate due to depressive SE, can start SSRI and re-try if patient willing ** Requires patients abstain from alcohol for at least 6 months prior and during therapy** order baseline TSH Tx: 1st line is entecavir or tenofovir; well-tolerated & low resistance, HBeAg sero-conversion at 1 yr is 21%; seroconversion at 3 y for entecavir is 39%; lamivudine 15–30% resis at 1 y; telbivudine increases CK & neuropathy; adefovir (add to lamivudine- resistant Pts) nephrotoxic & resistance occurs, too) Goal: if HBeAg (+) >> HBeAg (-), anti-HBe (-); if HBeAg (-) or ∅ seroconversion>>indefinite HIV/HBV coinfection: Rx w/ 2 drugs active against both HBV & HIV DO NOT GIVE TENOFOVIR MONOTHERAPY IF HIV (+), thus order HIV test in all Hepatitis patient when considering treatment If inactive carrier scheduled to receive immunosuppresion /chemotherapy >> Rx Prevention: vaccinate high-risk Pts (3 doses 0, 1 & 6 mos) Postexposure (risk infxn~30%)ppx: HBIG vaccine(if unvac. or known non responder) Hepatitis C: Chronic: RNA (+), plus bx w/ either chronic hepatitis & fibrosis stage >1 or compensated liver disease (in genotype 2 or 3, may proceed to Rx w/o bx b/c high response rate) 131 Drugs: PEG-IFN-alpha-2a + ribavirin. Goal is sustained virologic response (SVR) = absence of viremia 24 wks after completion of Rx. Protease inhibitors(telaprivir/boceprevir) in addition AKA Triple therapy are not available at LAC, but are more effective Genotypes 1 or 4: Rx 48 wks. If early vir resp (EVR) not achieved by wk 12 (ie, RNA decr. <2 log) stop Rx, as EVR best predictor of lack of SVR. If partial EVR (RNA decr. >/=2 log at 12 wks & undetectable at 24 wks), consider prolonging Rx to 72 wks. Overall SVR rate 50–60%. Genotypes 2 or 3: Rx 24 wks; SVR rate ~80% Predictors of response: RNA <400k IU/mL, rapid vir resp (RNA at wk 4), cirrhosis, female, age <40 y, wt <75 kg, white/Hispanic, HIV, SNPs in IL28B Risks of Rx: flu-like sx, psych sx (if depressed can give SSRI), thyroid dysfxn, marrow suppression (can give EPO & GCSF), hemolysis (ribavirin), sexual dysfxn Contraindication: decompensated cirrhosis, preg., severe psychillness,active substance abuse, severe cardiac/pulm disease, uncontrolled DM, seizure d/o, autoimmune disease Vaccinate all chronic HCV patients against HBV and HAV if not immune Post exposure (needle stick risk~3%)ppx: none;if HCV RNA>>(+), consider Rx w/in 3mos 14. Liver Transplant Not done at LAC-USC, however on occasion we have patients that have that are s/p transplant. When these patients come in, it is very important to contact the transplant medicine physician managing the patient(often at an outside institution) and discuss the case and current reason for admission. Ensure med-list is accurate and most importantly ensure all the medications are available through in-patient pharmacy. If a certain transplant medication is not avaliable, check to see if patient has this medication with them or have 132 them bring it from home and then write an order for: “OK to administer patient’s home medication XXXXX XX mg Qfrequency” Make sure medications that are given for in-patient indication do not react with transplant medications If patient pending surgery, stress dose steroids may be necessary, can discuss with inpatient consult team or call outpatient transplant medicine physician as steroid dose may have recently changed, etc. 15. Ascites & SBP Ascites: Calculate SAAG Can order U/S for marking if bed-side U/S cannot locate or volume is small. U/S can detect >100ml fluid. Perform paracentesis in all new-onset ascites and consider in all decompensated cirrhotics: 133 Routine: Cell count with diff + Gram stain, Culture, Albumin, Total protein, Other tests: fungal cx(prolonged hospital stay), AFB+ADA(r/o TB), amylase(pancreatitis, gut perf), TG(chylous ascites), Cytology(if suspect malginancy or peritoneal carcinomatosis), LDH, glucose, CEA, Alk phos(perf) Tx: If 2/2 to portal HTN: Decr. Na intake and start diuretics: Usually start Lasix and Spironolactone in a 40mg:100mg ratio(least potassium abnormalities with this ratio) once daily dosing, Can start lower at 20mg/50mg if Cr a concern. MAX: Lasix 160mg/Spironolactone 400mg. Serial LVP (large volume paracentesis); albumin replacement after large volume paracenteses if > 4-5 L are removed; 6-8 g/L of albumin (25% concentration) should be given Refractory cases may benefit from TIPS (Quality of life improvements over serial LVP, however can increase HE but not an absolute CI to procedure) For non portal HTN: tx underlying cause Bacterial Peritonitis: Presents with abd pain, fever, encephalopathy, 25% Asymptomatic 134 SBP/CNNA: seen in cirrhosis Risk factors: AFTP<1g/dl, h/o SBP, current GIB (translocation) Tx: cefotaxime 2gm IV q8h (oramox/clav) X 5d If not improving can r/p para at 48 hrs, if PMN 25% less = Rx sucess PPX: h/o SBP or AFTP<1.5 + Na<130, Cr >1.2 or Childs B Can use Bactrim DS Qdaily, norflox not available at LAC NNBA: often resolves w/o tx; Tx only if with symptoms or persistent (+) cx Secondary: abscess or perf ascitic fluid TP >1 g/dL, glc <50 mg/dL, LDH >225 U, CEA >5, Alk phos >240 Rx: 3rd gen cephalosporin + MNZ, urgent abd. imaging Periotneal dialysis associated: Cloudy fluid, abd pain, fevers, nausea Pathogens: 70% GPC, 30% GNR; Rx: vanc + gent(IV load then administer directly through PD Cath) 16. Hepatorenal Syndrome Vascular phenomenon with vasoconstriction in kidneys and vasodilation in sphlancnic circulation that leads to progressive renal insufficiency and azotemia (Cr> 1.5 or >1.5 x base) despite volume challenge with Albumin 1mg/kg/d x 2 d and exclusion of other causes (drugs, ATN, obstruction) Type 1: doubling of the serum creatinine level to more than 2.5 mg/dl (221μmol/liter) in less than 2 weeks; occurs in severe liver failure Type 2: is characterized by a stable or less rapidly progressive course than in type 1. Both a/w ascites (usually h/o refractory ascites), oliguria, UNa <10 mEq/L and decreased Na Even if on furosemide, Urine Na <10 can still help as despite diuretics urine Na is unexpectedly low Etiology: GIB, over diuresis, infection, paracentesis, drugs (aminoglycosides/NSAID) 135 Tx: octreotide(200mcg SC tid) + midodrine(12.5mg PO tid) + albumin Mortality is high, higher for Type I vs. Type 2, if transplant possible then kidney function returns generally as there is no intrinsic renal pathology, however this is generally not an option for LAC patients with few exceptions 17. Cancer Screening Risk in UC ~2% at 10y,~8% at 20y,~18% at 30y. Similar for colonic CD, except risk of small bowel cancer as well. Dysplasia best marker for risk. Other risk factors include: PSC, (+)FHx, greater extent of disease, stricture, & pseudopolyps. Colo with random bx 8 years after dx, then q1-3 years based on risk factors If high grade dysplasia or dysplasia a/w mass>>colectomy, Chemoprophylaxis: 5-ASA & ursodeoxycholic acid (if PSC) beneficial. 136 SECTION 14: HEMATOLOGY/ONCOLOGY for more in depth discussion, see Hematology Survival Guide 1. ANEMIA: Hct < 36% in ♀, < 40% in ♂; Fe-def most common cause General workup: Ferritin, Iron Panel, B12, folate, retic count, peripheral blood smear Microcytic (MCV < 80): • Fe deficiency anemia:↓ ferritin (<30 is 98% specific for Fe def [Am J Clin Pathol 2001;115(1):112-118]; in cases of acute infxn/inflammation, divide ferritin by 3 since it is an acute phase reactant), ↓ % sat, ↑ TIBC, ↑ Transferrin, ↑RDW . sTfR (Serum Transferrin Receptor) concentration is ↑ in Fe-def anemia but not ACD. Check fecal occult blood, consider colonoscopy to f/u on positive FOBT and/or to r/o occult CA, EGD for occult UGIB. • Anemia of Chronic disease (ACD): ↑ferritin, ↓ % sat, ↓ TIBC, ↓ Transferrin. • Thalassemia: Normal iron studies, very low MCV (<70), Mentzner Index MCV/RBC count <13, Hb electrophoresis w/ ↑HbA2 in β-thal & normal in α-thal, normal RDW • Sideroblastic anemia: Fe accumulates in mitochondria & not in Heme. May be X-linked, idiopathic/myelodysplastic, or reversible (lead, INH, Cu & Zn toxicity, EtOH). Typically microcytic. Iron studies are a mixture between Fe-def & ACD (nl or ↑ Transferrin, TIBC & Ferritin). Note: in EtOH-related sideroblastic anemia, there may be ↑ RDW normocytic anemia b/o concomitant macrocytosis due to EtOH itself +/- Vit deficiencies. May need BMBx. • Lead poisoning: Look for basophilic stippling on smear; H&P. 137 Normocytic (MCV 80 – 100): blood loss, hemolysis, low producton. Initial workup should focus on reticulocyte count, creatinine, hemolysis labs (↑ LDH, ↓ haptoglobin, ↑ indirect Bili, (+) direct coombs), and blood smear. Normal Reticulocyte count: Anemia of chronic dz: Esp. in renal (burr cells), liver, thyroid disease ↑ reticulocyte count + normal hemolysis labs: Hemorrhage, Iron deficiency (mild to moderate, if severe, should be microcytic), Mixed microcytic/macrocytic anemia, will see elevated RDW High reticulocyte count with (+) hemolysis labs: o G-6PD deficiency, sickle cell, autoimmune, druginduced, microangiopathic (DIC, HUS, TTP, prosthetic valve, etc.), PNH, hereditary spherocytosis, hypersplenism, or infection (malaria, babesiosis). ** Note: To determine if retic count appropriate for degree of anemia, calculate retic index: Reticulocyte Index = Retic count x Hct/45 > 2% indicates increased destruction or loss of erythrocytes < 2% indicates decreased production of erythrocytes Additional causes of normocytic anemia: Pancytopenias: Seen in systemic dz (EtOH, sepsis, hypersplenism), aplastic anemia, MDS, leukemia, PNH, myelofibrosis, metastatic solid tumors, etc. Consider PBS & BMBx. Pure red cell aplasia: Check parvovirus B19, BMBx Sideroblastic anemia: See microcytic section. Macrocytic (MCV > 100): 138 • B12 deficiency: ↓ B12 (<200 = low, 200-300 = borderline, >300 = nl), ↑ Methylmalonic acid (MMA) & ↑ homocysteine. May be microcytic if severe • Folate deficiency: ↓ RBC folate, ↑ homocysteine, nl MMA • Other: Hydroxyurea, AZT (or other drugs), EtOH, EtOH-induced sideroblastic anemia, liver disease, hypothyroidism, myelodysplasia. Tx of nutritional deficiency anemia: Vitamin B12: 1000 mcg SC/IM daily for 5 days, then 1000 mcg SC/IM weekly for 5 wks then 1000 mcg SC/IM monthly for life. 1000 mcg PO daily (only for chronic supplementation) Folate: 1mg PO/SC/IM daily Iron: Ferrous sulfate 325 mg TID or IV Iron Dextran (http://www.globalrph.com/irondextran.htm) Management of anemia of CKD: • All pts w/GFR<60 should be screened for anemia • Replete iron, folate & vit B12 deficiencies as indicated before initiating EPO. Remember that folate deficiency may occur in pts on hemodialysis, & that iron store can get depleted w/ EPO use. • Targets of iron therapy: Ferritin>200 ng/ml & Iron Sat >20% (for pts on dialysis); Ferritin >100 ng/ml & Iron Sat >20% (for CKD pts not on dialysis) • In dialysis pts, vitamin C combined w/ EPO can improve Hgb levels Hemolytic Anemias: Paroxysmal Nocturnal Hemoglobinuria: An acquired clonal stem cell d/o; an inactivating somatic mutation of PIGA gene. inc RBC 139 sensitivity to complement, complement activation indirectly stimulates plt aggregation and hypercoagulability Si/Sx: hemolytic anemia and venous thrombosis (intra-abdominal, cerebral), cytopenias Dx: Flow cytometry: CD55 (DAF decay accelerating factor), CD59 (HRF homologous restriction factor) Tx: Supportive care, allogenic HSCT, eculizumab (Ab that inactivates terminal complement by binding C5 complement protein) If the pt has large PNH clones (>50% of granulocytes affected), the thrombotic risk is >40% and the pt should be txd with warfarin G6PD Deficiency: X-linked metabolism defect susceptible to oxidative damage Triggers: Drugs (sulfa, antimalarials), infection, foods (fava beans) Dx: Peripheral smear (Heinz bodies, bite cells), dec G6PD levels Tx: stop offending drug, Tx underlying infection, PRBC transfusion if necessary Sickle Cell Anemia: Recessive beta-globin gene mutation (Val > Glu) results in a structurally abnl Hb (HbS) that polymerizes under conditions of low O2 tension. Acute Pain/Vasoocclusive crisis: Caused by infection, thrombosis, atelectasis, fat embolism Dx/Symptoms: (Hb Electrophoresis diagnostic at birth )↓Hct, ↑reticulocyte count (√ parvovirus B19 if ↓retics), SOB, hypoxia, CP infiltrates CXR, blood cx/UA/urine cx/NP aspirate/urine tox as clinically indicated to eval for potential triggers; Check peripheral smear for Sickle-shaped RBCs and Howell-Jolly bodies Acute Tx: Analgesics (PCA frequently needed), IVF (200-250cc/hr, but caution in pts w/ h/o pulm HTN), O2 via NC to keep sat >95%, 140 incentive spirometry (10x/hour), folate 1 mg PO daily, daily Hct & retic count Chronic Tx: Hydroxyurea (incr fetal Hb), folic acid, pneumococcal vaccine, H flu vaccines, PCN prophylaxis, manage all end organs that may become damaged (eyes, heart, lungs, kidneys, bones), exchange or simple transfusions + deferoxamine (iron chelator) **Acute chest syndrome**: New infiltrate on CXR, CP, fever, ↑O2 requirement. Occurs, on average, 2.5 days after admission for VOC & is potentially fatal. Precipitated by fat embolism or infxn (C. pneumoniae, M. pneumoniae). Manage w/ abx (moxifloxacin), O2, transfusion (exchange or simple), consult Heme [NEJM 2000;342:1855-65] [NEJM 1984;311:291-295] Microangiopathic Hemolytic Anemia: Intra-arteriolar fibrin damages RBC’s leading to intravascular hemolysis (In TTP, there is no fibrin deposition) DDx: HUS, TTP, DIC Dx: CBC , peripheral smear(schistocytes), PT/aPTT, fibrinogen Si/Sx: FAT-RN Fever, Anemia, Thrombocytopenia, Renal Failure, Neuro dysfunction (Seizures), or some combination of the above HUS is divided into typical (90%) and atypical (10%) subtypes: STEC-HUS or typical HUS: caused by shiga toxin, typically results in renal failure Atypical HUS: Renal failure with no diarrhea or shiga toxin Tx: DO NOT give Abx, provide symptomatic and supportive care. Plasma Exchange and Eculizamab have been shown to help in patients with CNS involvement. TTP : typically involves Neuro dysfunction 141 Tx: plasma exchange, eculizamab DIC: due to trauma, shock, infection (sepsis), malignancy(APL), OB complications Dx: Increased , aPTT, Bleeding time, D-dimer, LDH decreased: plts, haptoglobin, Tx: treat underlying process, give FFP, cryoprecipitate to aintain fibrinogen > 150, plts 2. Hypercoagulability: Virchow’s Triad: Stasis, hypercoagulability, endothelial damage. Causes: ↓Antithrombic activity: ATIII deficiency, Prot C or S deficiency ↑Prothrombotic activity: Congenital (Factor V Leiden [in caucasians]) & acquired APC resistance, Prothrombin 20210A, elevated factor VIII, IX, XI, dysfibrinogenemia, hyperhomocysteinemia Systemic disease: Antiphospholipid syndrome/SLE, IBD, malignancy, hyperviscosity syndrome (polycythemia vera, etc.), PNH, CHF, nephrotic syndrome, HIT-thrombosis syndrome, pregnancy Situational risks: Surgery, immobility, HRT/OCPs, CV catheters w/u: APCR, Factor V Leiden, Dilute Russel Viper Venom (increased w/ lupus anticoag), Anti-cardiolipin, Prothrombin 20210A, homocysteine, Factor VIII, PT/PTT. Dx: APC resistance screen, protrhombin PCR test, functional assays for prot C and S, ATIII level, homocysteine level *Prot C & S falsely ↓ on warfarin (C also falsely low w/ acute clot) *ATIII falsely ↓ in pts on heparin or w/ acute clot 142 Venous, Inherited Venous acquired Venous/arterial, inherited Venous/areteral acquired HYPERCOAGUABLE STATES Factor V Leiden: activated protein C resistance Prothrombin mutation: G20210A > inc prothrombin level Prot C or S def: Coumadin-induced skin necrosis risk Antithrombin III def: may be heparin-resistant Stasis (immobilization, sx, CHF), malignancy, hormonal, nephritic syndrome factor V Leiden + smoking Hyperhomocysteinemia: inherited or acquired Dysfibrinogenemia Platelet defects (MPD,HIT,PNH), hyperviscosity (PCV, Waldenstrom’s, sickle cell, acute leukemia), vessel wall defects (vasculitis, trauma, foreign bodies), others (antiphospholipid syndrome, IBD) 3. DVT Prophylaxis: A. Risk factors: (most important is ambulatory vs. not ambulatory) Major: Age > 60 years, current active cancer (excluding nonmelanoma skin cancer), prior DVT/PE, stroke w/ residual paralysis in past 3 months, paralysis, inherited or acquired thrombophilia, heart failure NYHA III/IV, respiratory failure/COPD, acute infection/sepsis, pregnancy or post-partum, obesity (BMI>30). Minor: Central line, nephrotic Sd, IBD, estrogen or selective estrogen receptor modulators. B. Risk stratification: 143 Low risk: Anyone who is freely ambulatory. Tx: Keep active – specify ambulation plan (e.g. “q shift”) Moderate Risk: NOT ambulatory w/ only 1 minor RF. Tx: Fragmin 5000K units SQ Q24hr High Risk: NOT ambulatory w/ at least 1 major or 2 minor RFs. Tx: Heparin 5000 units SQ q8h or Fragmin 5000K units SQ Q24hr **All can be used +/- SCD’s except when contraindicated below** C. Contraindications: Active bleeding, systemic anticoagulation, high risk of bleeding, severe head trauma, elevated INR (≥1.5); therapeutic aPTT; platelets <50K, pericarditis, active PUD, threatened abortion, recent TURP, eye/brain/cord injury past 24 h. *Heparins, but not all anticoagulants, are contraindicated if h/o HIT SCDs: Don’t use w/ arterial insufficiency, open wounds, or DVT in area 4. Anticoagulation in Patients w/ VTE: A. Heparin : (goal aPTT 65-100 seconds) - Review baseline labs including aPTT, PT/INR, BMP, Heme-8 - Bolus should be strongly considered in pts w/ active thrombosis • Indications: Afib, DVT, PE, mechanical heart valve, mesenteric vein thrombus, peripheral vascular disease, arterial thromboembolism • Initial dosing: follow Heparin sheet for bolus and initial infusion rate, check APTT 6 hrs after initial rate, and every 6 hrs after rate change per heparin sheet • Adjusting: see Heparin sheet B. Warfarin : 144 • Don’t start until therapeutic on heparin since it reduces Prot C before factors VII, IX, X, II • For pts on warfarin & UFH for tx of acute thrombosis, UFH (or UFH followed by LMWH), should be continued for at least 5 days & INR should be in the ordered goal range for at least 24 h before UFH (or UFH followed by LMWH) is discontinued. • No loading dose - goal is to start w/ correct maintenance dose. • Start w/ 5 mg PO daily (or previous home dose) for most pts. • Allow 2-3 days for INR to begin to rise, follow anticoag recs daily • If there is an acute indication for AC, overlap w/ acute form of AC until INR at goal. [Annals 1997; 126:133-136.] • Goal INR for VTE, A-fib, mechanical aortic valve: 2-3. • Goal INR for mechanical mitral valve, some recurrent VTE: 2.5-3.5. • Goal INR for some APS w/ recurrent TE: 3-4 • After 6-month course, when deciding whether to continue anticoagulation, may check d-dimer, & continue anticoagulation if abnl. [Ann Intern Med 2008;149(7):481-90] [Williams Hematology 7th ed 2006, Ch 122] • Consider indefinite tx for pts w/ idiopathic DVT/PE or pts w/ continuing strong thrombophilic risk factors (APS, active cancer) C. Anticoagulation in pts w/ HIT & renal failure: Argatroban. Use Argatroban drip if isolated renal failure or bivalirudin if hepatic or combined hepatic & renal failure. • Begin argatroban at 2 mcg/kg/min & check the first aPTT in 4 h w/ target aPTT ratio 1.5-3.0 [Ann Pharmacother 2003; 37:970-5, NEJM 2006;355:809-17]. • For pts in ICU or w/ mild hepatic insufficiency, begin argatroban at 0.25-0.5 mcg/kg/min. 145 • Monitor aPTT every 4 h until 2 consecutive aPTT values in the therapeutic range, then check aPTT 12 h later, & if still therapeutic, then at least daily. • Dose adjustments: a) If argatroban subtherapeutic, ↑ gtt rate by 20% & recheck aPTT in 4h. b) If supratherapeutic,↓ gtt by 50% & recheck aPTT in 4h. i. aPTT ratio is > 3.0, hold the infusion 30 mins. ii. aPTT ratio > 4.0, hold 1 h before restarting at the lower rate. c) After any dose adjustment, more frequent aPTT testing (ex: q4h) until aPTT therapeutic X2, then 12h later, then at least daily. • Argatroban strongly influences INR during warfarin co-therapy, so an INR of 4 must be achieved to ensure a therapeutic INR of 2 once argatroban is discontinued. D. Anticoagulation in pts w/ HIT & hepatic dysfunction: use bivalirudin drip • Bivalirudin is enzymatical hydrolyzed in plasma & renally-cleared & has a half life of 25 min in pts w/ nl renal function. • Initial infusion rate (nl renal function ≥60 ml/min): 0.15 mg/kg/h Creatinine clearance 45-59 ml/min 30-44 ml/min < 30 ml/min Hemodialysis or CVVHD Combined hepatic-renal failure • Dose adjustments: 146 Initial infusion rate 0.1 mg/kg/hr 0.075 mg/kg/hr 0.05 mg/kg/hr 0.03 mg/kg/hr 0.03 mg/kg/hr a) If bivalirudin subtherapeutic, ↑ gtt rate by 20% & recheck aPTT in 2h. b) If supratherapeutic, ↓ gtt by 50% & recheck aPTT in 2h. i. aPTT ratio is > 3.0, hold the infusion 30 mins. ii. aPTT ratio > 4.0, hold 1 hour before restarting at the lower rate. c) After any dose adjustment, more frequent aPTT testing (ex: q2h) until aPTT therapeutic X2, then 12h later, then at least daily. 5. Heparin Induced Thrombocytopenia: A. Type I HIT: Development of minimal thrombocytopenia during first few days of IV heparin administration. Resolves spontaneously despite continued heparin therapy. Due to platelet aggregating properties of heparin; nonimunologic, not severe. B. Type II HIT: Development of thrombocytopenia (typically 50% reduction) 414 days after initiation of heparin (unless pt has prior sensitization). Associated w/ either large or small amounts of heparin by any route. Due to platelet antibodies; immunologic. Test w/ PF4 HIT Ab & Serotonin Release Assay. High risk of venous and/or arterial thrombosis unless heparin is discontinued and alternative anti-thrombin agent is administered (argatroban, etc.) 147 6-8 points = high probability of HIT, 4-5 points= intermediate probability of HIT, < 4 points= low probability of HIT. (Lefkowitz. Curr Hematol. 2003) 148 6. Other Platelet Disorders Drug Induced – Quinidine, abx, Sulfa drugs, glycopreotein iib/iiia inhibitors (abciximab, etc.) Tx: stop offending medication ITP – due to platelet associated IgG Abs. Dx of exclusion Tx: Prednisone, splenectomy if unresponsive Acquired disease – Quantitative dysfunction 2/2 Liver dz, Renal Dz, multiple myeloma, ASA Tx: Desmopressin to inc vWF, FFP or cryo for bleeding. H. Pylori – unclear mechanism of plt dysfunction, however Tx of H. Pylori shown to improve thrombocytopenia Hereditary diseases – o Bernard Soulier: defect in Gp1, Type A (Gp1BA), Type B (Gp1BB), Type C (Gp9) o Glanzmann’s thrombasthenia: defect in GpIIb/IIIa Tx: avoid NSAIDS, ASA, give DDAVP, amicar, plt transfusions if severe bleeding o Von willebrand’s Dz: most common bleeding disorder, mimics plt dysfunction (mucocutaneous bleeds) and hemophilia (hemarthrosis) Dx: low vWF +/- abnrml vWF activity (ristocetin cofactor activity) Tx: DDAVP if symptomatic Platelet transfusion thresholds < 90,000 prior to Neurosurgery < 50,000 prior to general procedures < 50,000 in symptomatic, bleeding patient < 20,000 in febrile/neutropenic/septic < 10,000 in asymptomatic patient 149 Laboratory findings in various platelet and coagulation disorders Condition Aspirin PT aPTT Bleeding time Unaffected Unaffected Prolonged Unaffected Platelet count Bernard-Soulier syndrome Unaffected Unaffected Prolonged Decreased or unaffected C1INH deficiency Unaffected Shortened Unaffected Unaffected Congenital afibrinogenemia Prolonged Prolonged Prolonged Unaffected Disseminated intravascular coagulation Prolonged Prolonged Prolonged Decreased Factor V deficiency Prolonged Prolonged Unaffected Unaffected Factor X deficiency as seen in amyloid purpura Prolonged Prolonged Unaffected Unaffected Factor XII deficiency Unaffected Prolonged Unaffected Unaffected Glanzmann's thrombasthenia Unaffected Unaffected Prolonged Unaffected Hemophilia Unaffected Prolonged Unaffected Unaffected Liver failure, early Prolonged Unaffected Unaffected Unaffected Liver failure, end-stage Prolonged Prolonged Prolonged Decreased Thrombocytopenia Unaffected Unaffected Prolonged Decreased Uremia Unaffected Unaffected Prolonged Unaffected Vitamin K deficiency or warfarin Prolonged Normal or mildly prolonged Unaffected Unaffected Von Willebrand disease Unaffected Prolonged Prolonged Unaffected 150 7. Hematological Malignancies A. LEUKEMIA: malignant proliferation of hematopoietic cells. Categorization is based on cellular origin and level of proliferation. Acute: proliferation of minimally differentiated cells (myeloblasts, lymphoblasts), defined as > 20% blasts in bone marrow (<20% blasts defined as MDS) Chronic: proliferation of more mature differentiated cells (metamyelocytes/myelocytes, lymphocytes) ACUTE LYMPHOCYTIC LEUKEMIA (ALL) –most common in children, inc incidence in Down Syndrome Presentation: viral like prodrome, children may refuse to walk, complain of bone pain, easy bruising on exam, pallor, petechiae/purpura, echymosis, or bleeding Dx: CXR, CBC, LP, peripheral smear, Bone Marrow Bx, Cytogenetics: +TdT (terminal deoxynucleotidyl transferase: t(9:22) Philadelphia chr, immunophenotype Tx: NEW USC ALL chemotherapy regimen consists of Induction I and II( Vincristine + Duanorubicin + Prednisone +/- PEG-A Aspariginase) Consolidation I-VI (multiple agents), Maintenance (MTX, 6-MP) ALL IMMUNOPHENOTYPES Cell Type Surface Markers Pre B cell + TDT, + CD19, variable CD10 and CD20 T Cell + TDT, acid phosphatase, - CD10, + T Cell Ag (CD7) 151 B Cell (burkitt’s) -TDT, + surface Ig ACUTE MYELOLOGENOUS LEUKEMIA (AML) – most cases occur in adults, with incidence increasing with each decade of life. Prognosis depends on: age > 60, MDS, and cytogenetics Presentation: similar to ALL w/ anemia, fatigue, easy bruising, leukemia cutis, petechiae/purpura, may also present w/ DIC, gingival hyperplasia, CNS involvement, frequent infections Dx: CBC, peripheral smear (+/- Auer rods, + granules), Cytochemistry (+ myeloperoxidase or non specific esterase[NSE]) Bone marrow bx w/ cytogenetics Tx: Induction (7+3) Cytarabine D 1-7, Idarubicin D1-3 ; Consolidation: <60y/o 3-4 cycles of HiDAC or SCT for intermediate or hi risk pts; >60: intense chemotherapy or clinical trial No CR or relapse: HiDAC or trial, SCT, salvage chemotherapy FAB CLASSIFICATION OF AML FAB subtype Adult AML patients (%) Name M0 Undifferentiated acute myeloblastic leukemia 5% M1 Acute myeloblastic maturation 15% M2 Acute myeloblastic leukemia with maturation 25% M3 Acute promyelocytic leukemia (APL) (t15:17) 10% M4 Acute myelomonocytic leukemia (CD14, 15) 20% leukemia with minimal M4eos Acute myelomonocytic leukemia with eosinophilia 152 5% M5 Acute monocytic leukemia (++NSE) 10% M6 Acute erythroid leukemia 5% M7 Acute megakaryocytic leukemia (CD41) 5% WHO SUBTYPES OF AML Name Description AML with translocations between chromosome 8 and 21 [t(8;21)] (ICD-O 9896/3); RUNX1/RUNX1T1 AML with inversions in chromosome 16 [inv(16)] (ICD-O 9871/3); CBFB/MYH11 AML w/recurrent genetic abnormalities APL with translocations between chromosome 15 and 17 [t(15;17)] (ICD-O 9866/3); RARA;PML AML with translocations in chromosomes 9 and 11 [t(9;11)]; MLLT3-MLL Patients with AML in this category generally have a high rate of remission and a better prognosis compared to other types of AML. AML with multilineage dysplasia This category includes patients who have had a prior myelodysplastic syndrome (MDS) or myeloproliferative disease (MPD) that transforms into AML. This category of AML occurs most often in elderly patients and often has a worse prognosis. This category includes patients who have had prior chemotherapy and/or radiation and subsequently AML and MDS, develop AML or MDS. These leukemias may be therapy-related characterized by specific chromosomal abnormalities, and often carry a worse prognosis. AML not 153 Includes subtypes of AML that do not fall into the otherwise categorized above categories. RISK STRATIFICATION OF AML Risk Category Abnormality Low (CR 84%) t(8;21), t(15;17), inv(16) 5-year Relapse survival rate 70% 33% Normal, cKIT + t(8:21) +8, +21, +22, Intermediate del(7q), del(9q), Abnormal 11q23, all (CR 76%) other structural or numerical changes 48% 50% -5, -7,5q-, 7q-, inv(3), t(6:9), t(9:22), isolated FLT3-ITD mutation del(5q), Abnormal 3q, Complex cytogenetics 15% 78% High (CR 55%) ACUTE PROMYELOCYTIC LEUKEMIA (APL): t(15:17) M3 subtype of AML. Can present with same symptoms of other AML (see above) and DIC Dx: CBC, peripheral smear, cytogenetics, Bone Marrow bx w/ PCR for PML/RAR alpha. Tx: Keep plts > 50, keep fibrinogen > 150 with cryo, Induction: ATRA + Idarubicin Consolidation : 3 cycles of anthracycline + ATRA for intermediate risk patients + ARA C or Arsenic for high risk patients Maintenance: ATRA or ATRA + 6MP/MTX 2nd line: Arsenic trioxide 3rd line: gemtuzumab, ozogamicin **High WBC at Diagnosis correlates with risk for CNS disease 154 CHRONIC LYMPHOCYTIC LEUKEMIA (CLL): malignancy of mature lymphocytic cells, typically age > 65. Symptoms: usually an indolent disease, often diagnosed incidentally. May present with lymphadenopathy, fatigue, hepatosplenomegaly. Dx: peripheral smear (lymphocytosis, smudge cells, atypical lymphoid cells); BM Bx : >30 small B-cells; Flow cytometry: extremely low levels of surface Ig, +CD5, +CD19, +CD20, +CD23. Bone Marrow Bx for confirmation Prognosis: Good: 13q del, Poor: 17p del, 11q del, +12q, +CD38, + Zap70, ++ beta2 microglobulin Tx: no Tx for asymptomatic patients, simply observe. ** Note** may transform to intermediate or high grade lymphoma (Richter’s transformation) at which point may Tx with splenectomy +/- steroids Decision to treat sometimes based on symptoms, progressive marrow failure, AIHA/ITP refractory to steroids, progressive lymphocytosis, massive hepato/splenomegaly or staging system such as Rai and Binet system CLL TREATMENT 1st line <70 yrs old 1st line > 70 yrs old FCR, FC, FR,PCR Chlorambucil +/- prednisone, CVP, alemtuzumab, bendamustine, rituxumab +/- fludarabine Del 17p FCR, FR, CFAR, alemtuzumab 2nd line FC, FR, FCR, rituxumab, fludarabine, pentostatin Fludarabine, Cyclophosphamide, Rituximab, Pentostin 155 RAI CLINICAL STAGING SYSTEM Risk group Stage Low 0 Intermediate I II High III IV Features Blood and marrow lymphocytosis Lymphocytosis and adenopathy Lymphocytosis w/ splenomegaly or hepatomegaly +/adenopathy Lymphocytosis w/ anemia (Hb <11g/dl) Lymphocytosis w/ thrombocytopenia (<100K/uL platelets) Median Survival (months) > 120 108 94 60 60 BINET STAGING SYSTEM Stage A B C No anemia, no thrombocytopenia, < 3 areas of lymph involvement (Rai 0,I,II) No anemia, no thrombocytopenia, > 3 areas of lymph involvement (Rai I,II) Anemia +/- thrombocytopenia, any # of areas of involvement (Rai III, IV) CHRONIC MYELOGENOUS LEUKEMIA (CML): malignancy of myeloid cells seen in middle age. Can occur denovo or from 156 myeloproliferative disorders. Often stable, and then transforms into acute leukemia(blast crisis). Also assoc. with prior radiation and benzene exposure. Si/Sx: typically indolent, may present w/ fatigue, fever, malaise, or constitutional symptoms, blast crisis presents as bone pain, fever, weight loss, splenomegaly Dx: CBC shows leukocytosis w/ myeloid precursors, BM Bx w/ cytogenetics (Philadelpha chromosome t(9:11), BCR-AbL fusion gene Tx: Chronic phase: imatinib, monitor w/ serial BCR-ABL transcript levels, dasatinib, Nilotinib B. Lymphoma: malignancy of monoclonal proliferation of cells from lymphocyte lineage. ~90% B-cells, ~9% T cells, ~1% monocytes and NK cells ANN ARBOR STAGING SYSTEM I II III IV Single LN region > or = 2LN regions on same side of diaphragm LN regions on both sides of diaphragm Disseminated involvement of one or more extralymphatic organs A= no Sx , B = B symptoms, X = bulky, E = single contiguous extranodal site Hodgkins: neoplastic Reed Sternberg cells, of B-cell origin. Assoc w/ EBV Sx: Presents w/ cervical lymphadenopathy, spreads along lymph nodes. B symptoms (night sweats, fevers, weight loss) assoc. w/ bulky dz and worse prognosis 157 Dx: Lymph node Bx w/ cytogentics showing RS cells, BM Bx, CT Ch/Abd/Pel Staging: Ann Arbor system and presence of prognostic factors Tx: ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine), BEACOPP (bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, procrabazine, prednisone), ESHAP, stem cell transplant Non-Hodgkins Lymphoma: neoplastic proliferation of b or T cells classified as low, intermediate, or high grade on the basis of histologic type. Includes Follicular lymphoma, gastric malt lymphoma, splenic marginal zone lymphoma, mantle cell lymphoma, Diffuse Large B Cell Lymphoma, Burkitt’s lymphoma, Peripheral T-cell lymphoma. Many are associated with infections: EBV (Burkitt’s lymphoma), HIV (CNS lymphoma), HTLV (T-cell lymphoma), H.Pylori (gastric MALToma) Sx: similar to Hodgkins, including B symptoms. Dx: LN Bx, BM Bx, LDH is prognostic factor Tx: CHOP, R-CHOP (addition of Rituximab [anti-CD-20Ab] improves outcome. See Heme Brain for various Tx regimen C. Multiple Myeloma: malignant proliferation of plasma cells, often with unbala nced excessive production of immunoglobulin heavy/light chains Si/Sx: back pain, hypercalcemic symptmons (stones, groans, moans, psychiatric overtones), pathologic fractures, fatigue, frequent infections, pallor, fever, bone tenderness, lethargy. Dx: UPEP (Bence Jones protein), SPEP (look for monoclonal Ig, commonly IgG, >3g/dL), Bone Aspirate w/ >10% plasma cells, skeletal survey will show punched out lytic lesions. LAP levels are normal as lesions are lytic NOT blastic, B2 microglbulin, 158 DDx: Waldenstrom’s macroglobulinemia (IgM w/ cold agglutinins) Tx: melphalan, prednisone, bortezomib +/- thalidomide, Stem cell transplant for patient <60 in advanced stages of disease. Tx to alleviate symptoms Hypercalcemia – hydration, glucocorticoids Bone pain/destruction/fractures - bisphosphanates and radiation Renal Failure – Hydration Anemia – erythropoietin Infections - vaccinate 8. Common HEME/ONC Emergencies: Blood Product Transfusion Risk & Reactions: Noninfectious complications of blood transfusions (per unit): Fever (1-4:100); Allergic rxn (1-4:100); Delayed hemolytic rxn (1:1,000); Acute hemolytic rx (1:12,000); Fatal hemolytic rxn (1:100,000); Anaphylactic rxn (1:150,000); Tx-related acute lung injury (1:5,000) If any transfusion rxn occurs, stop transfusion, send remaining blood product to blood bank for analysis along w/ a fresh sample of pt’s blood. If mild rxn, ok for pt to receive subsequent transfusions after w/u complete, but premedicate w/ acetaminophen 650 mg & diphenhydramine IV 25-50 mg. Infectious complications of blood transfusions (per unit): CMV: Common (caution if immunosuppressed); Hepatitis B: 1 in 205,000-488,000; Hepatitis C: 1 in 1,935,000; HIV: 1 in 2,135,000; HTLV 1: in 2,993,000; Malaria: 1 in 4,000,000 159 Acute hemolytic rxn: classic triad of fever, hematuria, abdominal/flank pain. Flush kidneys w/ IVF & diuretics. Fever: Treat w/ acetaminophen. Rigors: Meperidine 12.5-50 mg IVP q15min until relief. If contraindicated, may consider tramadol (IV is Level IA EBM, but often unavailable) [Anaesthesia 2009;64(2):141-6]. Rash/pruritis: Diphenhydramine, +/- H2- blockers & steroids. Dyspnea: Consider TRALI vs. simple volume overload; check CXR, consider IV furosemide, supportive oxygen. Treat TRALI like ALI/ARDS, call MED CONSULT for ICU transfer Anaphylaxis (severe urticaria, bronchospasm, laryngeal edema, hypotension): Treat w/ epinephrine, IVF, & possibly MICU transfer for airway visualization/intubation. Febrile Neutropenia See ID Section for management Back Pain + Cancer : think about cord compression, consider CT or MRI. If pt has cord compression/focal neuro deficits, STAT consult to Rad Onc and/or Neurosurg. Tumor Lysis : Pt develops ↑K, ↑Phos, ↑uric acid, ↑LDH, ↓Ca, & ARF. (Check K, Cr, phosphate, UA, LDH anywhere from q4h to daily in pts undergoing chemo for heme malignancies) Give allopurinol, 600 load & 300 daily if tumor lysis is anticipated Give rasburicase if uric acid > 8 Always give nl saline, not bicarb. Never give phosphate – feeds the tumor. DIC (Particularly in APL): Check Heme-8, PT/PTT, D-dimer, fibrinogen q4h to daily in pts undergoing chemo for hematologic malignancies 160 Give cryo if fibrinogen is downtrending (don’t wait until less than 150), keep fibrinogen >150 If patient has thrombosis instead of bleeding, consider starting Heparin 10 units/kg/h (no bolus) 161 SECTION 15 – NEPHROLOGY 1. Chronic Kidney Disease (CKD) Defined as >/= 3 months of reduced GFR (<60) and/or kidney damage (imaging/path/markers) Can use MDRD equation to calculate estimate GFR, ensure no acute changes in Cr before relying on the results of the equation Etiologies: DM (45%), HTN/RAS (27%), glomerular (10%), interstitial (5%), PKD (2%) ** Note ** Drops in creatinine in patients with advanced disease may signify muscle loss due to chronic disease and NOT improvement of renal fxn Management: Consult in house if patient has any immediate indications for dialysis or needs to be temporized pending initiation of dialysis Diet: Low Na diet for HTN, Low K diet if hyperkalemic, Low phos diet, strict control of blood sugar in DM BP control: goal 130/80, can start with ACE inhibitor as effective in DM and Non-DM. Ok if 25% DROP in GFR or 30% RISE in Cr. If more than this, investigate other causes of drop/rise such as NSAID use, hypovolemia, renal artery stenosis or another or uncompensated heart failure. Can lower dose or stop medication if unable to resolve and select another agent. 162 Other assoc. problems: Metabolic acidosis: Sodium bicarb or citrate if HCO3<22, Bicitra 1030ml PO QID Anemia: Goal Hgb 11-12, higher than this leads to more complciations>>incr death, HTN, stroke, thrombotic events ○ No survival benefit for Hgb>9 via Epo if diabetic nephropathy ○ At LAC+USC, Darbopoeitin 0.45 mcg/kg q week, requires a form that is available on most wards or is accessible in Intranet home>>departments>>pharmacy>> pharmacy forms ○ Check a baseline iron panel + ferritin, keep transferrin sat >20% ○ Uremic bleeding: desmopressin(dDAVP) 0.3micro g/kg IV or 3 micro g/kg intranasally Secondary hyperparathyroidism: ● Increased phos, decreased calcium, decreased calcitriol >> incr. PTH > renal osteodystrophy ● CKD Stage correlates with target PTH level ○ ○ ○ ● 163 Stage 3: 35-75 pg/ml Stage 4: 70-110 Stage 5: 150-300 Phos binders: Renal consult recommended if planning to use Amphojel ○ If phos <6mg/dl and calcium low: Phos-Lo 667mg 12 tabs TID with meals ○ If phos and calcium high or phos >6mg/dL: Renagel 800mg 4-5 tabs TID with meals ○ If SEVERE high phos: Amphojel 5cc/600mg, 2.5-5cc TID w/meals for NO LONGER than 3 DAYS ● Calcitriol or paricalcitol if Ca-PO4 product <55, possible mortality benefit for HD pts ● Can use cincalcet if PTH remains elevated despite phos binders and vit d analogue 2. Acute Kidney Injury (AKI): Abrupt increase in Cr in <48h of >/= 0.3 mg/dl OR Cr >/=50% OR UOP <0.5mL/kg/hr for >6h. **note** Do not wait till creatinine is over ULN. Always trend Cr while pts are in house as people with less muscle mass will have low baseline Cr and often have AKI that goes unnoticed. Dx: History/physical: recent procedures & meds; VS & vol status; s/s of obstruction, vasc or systemic disorder; Ischemia (pre-renal & ATN) accounts for >50% of in-hospital AKI Urine eval: I/O, UA w/micro, urine osmol, electrolytes FENa = (Una/Pna) (Ucr/Pcr) * 100 < 1% >> pre-renal, contrast, or GN; >2% >>ATN When using diuretics, FENa becomes inaccurate, use FEurea instead. FEurea = (Uurea/Purea) / (Ucr/Pcr)* 100; <35% >> pre-renal Renal U/S: r/o obstruction and eval kidney size to estimate chronicity of kidney disease Serologies for glomerular disease: HIV, RPR, ANA, Anti-dsDNA, C3, C4, Cryocrit, Hep B, HCV Ab, ANA, Anti-GBM Three categories of AKI: Pre-renal, Intrinsic, Post-renal A. Pre-Renal: Bland UA, hyaline casts, FEna<1%, BUN/Cr>20 Uosm >500 Decreased Effective Arterial Volume: Hypovolemia, CHF, sepsis Renal Vasoconstriction: NSAIDs, ACEI/ARB, Contrast, calcineurin inhibitors, HRS, Hyper Ca Large vessel: Renal artery stenosis (Bilat + ACEI), thrombosis, embolism, dissection, vasculitis, compression B. Intrinsic: 164 Acute tubular necrosis (ATN): Granular muddy brown casts in 75%, +/- in AKI, +/- RBCs and protein from tubular damage, FEna > 2% (except pigment and CIAKI), Uosm<350 Ischemia resulted from prerenal disease Toxins: Drugs (Aminoglycosides, Amphotericin, cisplatin), Pigments (Hb, myoglobin), Proteins (Ig light chains), Crystals (Uric acid, Acyclovir, Methotrexate, indinavir, oral sodium phosphate) Acute interstitial Nephritis (AIN): WBCs, WBC casts, +/- RBCs, (+) urine eos in ABX, (+) lymphs in NSAIDs Allergic: Beta-lactams, sulfa drugs, NSAIDs, PPIs Infection: Pyelonephritis, legionella Infiltrative: Sarcoid, lymphoma, leukemia Autoimmune: Sjogrens, TINU syndrome, IgG 4, SLE Small vessel: +/- RBCs, +urine eos in cholesterol emboli Cholesterol, emboli, thrombotic, microangiopathic(HUS/TTP, DIC, preeclampsia, APS, malignant, HTN, scleroderma renal crisis) Glomerulonephritis: Dysmorphic RBCs and RBC casts C. Post-renal: Bland, +/- nondysmorphic RBCs if nephrolithiasis Bladder neck: BPH, prostate cancer, neurogenic bladder, anticholinergic meds Ureteral (bilateral): malignancy, LAN, retroperitoneal fibrosis, nephrolithiasis Tx: treat underlying condition, avoid nephrotoxic drugs and ensure renal dosing, correct volume status and electrolyte abnormalities, Indications for emergent dialysis: AEIOU (Acidemia, Electrolyte disorder: hyper K, hyper Ca, tumor lysis), Intoxication: methanol, ethylene glycol, lithium, salicylates, Volume Overload (CHF), Uremia: pericarditis, encephalopathy, bleeding 165 3. Acid-Base Disorders Acidemia: pH < 7.36, alkalemia: pH > 7.44 Metabolic Acidosis (pH < 7.40, HCO3 < 24) 1. Calculate Anion Gap: AG=Na-(Cl+HCO3), nl=12±2 2. Adjust for hypoalbuminemia: for each 1g/dl drop in albumin below 4, correct AG by adding 2.5 3. Calculate Delta-Delta Gap � ΔHCO3=24-HCO3, ΔAG=12-AG ΔHCO3 = ΔAG -> pure AG metabolic acidosis ΔHCO3 > ΔAG -> non-AG metabolic acidosis also present ΔHCO3 < ΔAG -> metabolic alkalosis also present 4. Respiratory compensation: Use Winter’s formula to calculate predicted PaCO2: =1.5[HCO3] + 8 ± 2 If PaCO2 measured < PaCO2 predicted -> respiratory alkalosis If PaCO2 measured > PaCO2 predicted -> respiratory acidosis Anion Gap Acidosis Methanol Uremia Diabetic ketoacidosis Paraldehyde Ischemia/Iron/INH Lactic Acidosis (Type A &B) EtOH, Ethylene Glycol, Salicyclates, Starvation Nrml Anion Gap Acidosis Diarrhea Ureteral diversion RTA Hyperalimentation Acetazolamide/Ammonium cl Miscellaneous (Spirololactone, amphotericin B, Addison’s Dz, NS IVF, Chloridorrhea, posthypocapnia) Workup for AG acidosis: • Calculate Osmolar Gap: OG = measured osmoles – calculated osmoles; Calculated osmoles = 2Na + glucose/18 +BUN/2.8 + EtOH/4.6 • OG >10 suggests ingestion (ethanol, methanol, ethylene glycol, toluene, mannitol, contrast dye); Check renal function, lactate, tox screen, ketones 166 Workup for Nrml AG acidosis: • Calculate Urine AG: UAG = (UNa +UK) - UCl • Positive UAG: Type I & IV RTA, early renal failure, Ampho B • Negative UAG: GI causes, Type II RTA, dilutional acidosis, toluene poisoning, exogenous acid) Renal Tubular Acidosis Distal/Type I: defective distal H+ secretion Seen in severe acidosis, (+) UAG, UpH>5.3, FeHCO3<3%, decr serum K Primary, AI (Sjogrens, RA), nephrocalcinosis, meds (Ampho, Li, Ifosfamide); normally a/w decreased K; if with increased K>> sickle cell, obstruction, SLE, renal transplant Proximal/Type II: due to decreased proximal reabsorption of the HCO3 Seen in moderate acidosis, +/- UAG, UpH<5.3, FeHCO3>15%, decr serum K Primary (Fanconi’s syndrome = decreased proximal reabsorption of HCO3, PO4, gluc, amino acids), paraprotein (MM, amyloidosis), meds (acetazolamide, heavy metals, ifosfamide), renal transplant, decr vit D, NRTIs Hypoaldosteronism/Type IV: Increased K >> Decreased NH3 synthesis/delivery >> decr urine acid carrying capacity Seen in mild acidosis, (+) UAG, UpH<5.3, FeHCO3 <3%, incr serum K Decr. Renin: DM nephropathy, NSAIDs, chronic interstitial nephritis, HIV Normal Renin, decr Aldo synth: primary adrenal disorders, ACEI, ARBs, heparin Decr. Response to aldosterone: Meds- K sparing diuretics, TMP-SMX, pentamidine, calcineurin inhibitors, tubulointerstitial disease: sickle cell, SLE, amyloid, diabetes 167 *Type III RTA=rare autosomal recessive Sd that behaves like a mixture of Type I & II. Tx: of severe acidosis (pH<7.2) DKA: insulin & IVF; AKA: dextrose, IVF, replete K, Mg, Phos as needed Lactic acidosis: treat causative condition and avoid vasoconstrictors Renal failure: HD Methanol & ethylene glycol: early fomepizole, vit B6 (eth glyc), folate (methanol), HD Alkali therapy: NaHCO3 (eg. 3 50-mmol amp in 1L D5W) to get serum HCO3 >8 and pH >7.2(est. mmol of HCO3 needed as 8-[HCO3]serum x wt x 0.5) Metabolic Alkalosis (pH > 7.40, HCO3 > 24) • Saline responsive etiologies require an initiating and maintaining factors • Saline resistant etiologies develop from various causes Initiating events Loss of H+: from GI tract or kidneys Exogenous alkali Contraction alkalosis: diuresis>>excretion of HCO3-poor fluid>>extracellular fluid contracts around fixed amount of HCO3>> Increases HCO3 concentration Post-hypercapnia induced renal retention of bicarb, once respiratory problem corrected, can have transient alkalosis Maintenance factors Volume depletion leads to increased proximal resorption of NaHCO3 and increased Aldosterone Increased aldosterone (Hyperaldosteronism) leads to Na reabsorption in exchange for K+ and H+ excretion, increasing HCO3 retention 168 Hypokalemia leads to transcellular K+/H+ exchange and an intracellular acidosis in renal proximal tubule cells promote bicarb reabsorption and ammoniagenesis Workup Check volume status and UrCl If UrCl< 20mEq/L >> saline responsive If UrCl> 20mEq/L >> saline resistant (unless on diurectics) UrNa unreliable in alkalemia If UrCl > 20 and volume status corrected, check BP Tx: for severe alkalosis (pH > 7.6) If volume depleted: d/c diuretics and correct deficit with isotonic saline (If Cardiopulm dz prevents IVF, use KCL, Acetazolamide, HCl) If NGT drainage that cannot be d/c: PPI Hyperaldosteronism: treat underlying condition 4. Hyponatremia & Hypernatremia A, Hyponatremia Excess water relative to sodium, almost always incr ADH Appropriate Incr ADH: Hypovolemia, hypervolemia with decr EAV 169 Sometimes with decr ADH (appropriately suppressed), kidneys cannot excrete excess water Primary polydipsia: ingestion of massive amount of H2O(>12L/day) Tea +toast or Beer potomania: decreased daily solute and incr free H20>> not enough solute to excrete H2O Workup Check Plasma osmols o Hypotonic hyponatremia: most common; true excess of free H2O relative to Na Check volume status (VS, orthostatics, JVP, skin turgor, MM, peripheral edema, BUN, Cr, uric acid o 170 Hypertonic hyponatremia: excess of another effective osmol(glu,mannitol) that pulls H2O intravascularly, diluting contents Glucose correction: for every 100mg/dl gluc over 100mg/dl, a drop of serum sodium of 2.4 is seen o Isotonic Hyponatremia: rare lab artifact from hyperlipidemia or hyperproteinemia (Normal serum sodium conc with plasma sent to ABG lab) Urine osmols: limited use as often over 300, however o Uosm <100 in primary polydipsia and decr solute intake o Uosm>300 Almost always means NOT SIADH o If euvolemic and elevated Uosm, think about glucocorticoid insufficiency , hypothyroidism, and hypopituitarism Tx: Asymptomatic: correct serum Na rate of </= 0.5mEq/L/h Symptomatic: intial rapid correction (2 mEq/L/h for first 2-3 hrs) Never increase Na more than 10-12 mEq/L/d to avoid osmotic demylenation (spastic quadriplegia, dysarthria, dysphagia), especially if hyponatremia is CHRONIC IVF: Can use below equation to calculate initial change in serum sodium per liter infusate, however this equation assumes that infusate is not excreted (no natural loss of H20 or Na, which is almost never the case) o ([Na]infusate – [Na]serum)/TBW +1 TBW = kgx0.6(man), x0.5(woman or old man), x0.45(old woman) o Remember: in SIADH, infused Na will be excreted and likely will retain some of the free water, resulting in a DROP in serum Na(usually if Uosm > infusate osm) Hypovolemic hyponatremia: volume repletion with NS will remove stimulus for ADH production and serum Na will correct SIADH: free water restriction and treat underlying cause 171 o Hypertonic saline if resistant to fluid restriction, check Na frequently and use above equation to calculate estimated change in serum Na o Salt tabs if chronic and no CHF o Aquaresis with “vaptan” drugs, non-forumulary at LAC, but are vasopressin receptor antagonists allowing water to NOT be resorbed o Demeclocycline causes nephrogenic DI, drops UrOsm o Furosemide impairs renal water retention – give sodium to maintain euvolemia as needed Hypervolemic hyponatremia: free water and sodium restrict o Loop diuretics and increase EAV(vasodilators to incr CO in CHF, colloid infusion in cirrhosis) B. Hypernatremia All patients by definition are hypertonic, usually loss of hypotonic fluid and impaired access to free water Workup/etiology: Check UrOsm, UrNa, volume status (VS, orthostatics, JVP, skin turgor, MM, peripheral edema, BUN, Cr) 172 UrOsm >700-800 >> extrarenal loss or Na overload; UrNa to differentiate o GI H2O loss: vomiting, NGT drainage, osmotic diarrhea, fistula o Insensible loss: fever, exercise, vent o Na overload: hypertonic saline(fluids with sodium bicarb), mineralcorticoid excess UrOsm <700-800 >> Renal loss; differentiate DI vs diuresis with UrOsm and Hx o Diuresis: Osmotic(glc,mannitol,urea), loops o DI: ADH deficiency(central) vs resistant(nephrogenic) Central: hypothalamic/pituitary disease, idiopathic, hypoxia, anorexia, EtOH Nephrogenic: Congenital receptor dysfxn Drugs: Li, amphotericin, demeclocycline, foscarnet, cidofovir Metabolic: hypercalcemia, severe hypokalemia, protein malnutrition, congenital Tubulointerstitial: postobstruction, recovery in ATN, PKD, sickle cell, sjogrens, amyloid, pregnancy Tx: Give access to H2O, replace free H2O deficit Liters of H2O = ([Na] serum – 140)/140 x TBW Replace half over 24 hours (Rate of Na drop should not exceed 0.5 mEq/L/h to avoid cerebral edema) o In 70kg male, 125ml/h of free H2O will drop [Na] by ~0.5 mEq/L/h Na Overload: D5W + loop diuretic 5. Hypokalemia & Hyperkalemia Hypokalemia (very common in-patient finding) 173 Transcellular shifts: Alkalemia, insulin, catecholamines, hypokalemic periodic paralysis, acute increase in hematopoiesis (megaloblastic anemia treated with B12, AML crisis), hypothermia Si/Sx: Nausea, vomiting, ileus, weakness, muscle cramps, rhabdomyolysis, polyuria. Imaging: EKG: U waves, +/- Increased QT interval, ventricular ectopy (PVCs, VT, VF) Workup: Rule out transcellular shifts (see above) While 24hr urine is a good study, difficult to get done by nursing Transtubular K+ gradiant(TTKG) : (UrK/PK) / (Urosm/Posm) o UrK>30 mEq/d or >15 mEq/L or TTKG >7 >> renal loss o UrK<25 mEq/d or <15 mEq/L or TTKG <3 >>extrarenal loss Tx: If true depletion and not a transcellular shift: o A drop of 1 mEq is roughly equal to 200 mEq of TOTAL body loss. Commonly 0.1 mEq/L drop in serum K warrants 10meq KCL of repletion, for example, Serum K of 3.0 is repleted with 100mEq of KCL to get to 4.0 serum K. This method avoids over 174 o o o o o replacement, however more aggressive repletion can be used for patients that may have continued losses(medications, npo, DKA) In a person with normal GI tract, PO repletion is AS good as IV. No dose difference for IV or PO. K-dur is a tablet while oral KCL is a powder that needs to be mixed with water. K-dur is more convenient for patient and nursing. Maximum hourly rate of repletion: 10meq per hour. For example to give 80 mEq of K, you can order K-dur 40mEq PO q4 hours x doses. OR you can write KCL 80mEq IV over 8 hours. Check Mg if K is resistant to repletion and replete Mg as needed. If you have a doubt of K status while repleting, RECHECK value in PM and sign this out to your night float to follow up on. Caution with renal failure or oliguria. Hyperkalemia Transcellular shifts: Acidemia, insulin def (DM), Beta-blockers, dig intoxication, massive cellular necrosis (tumor lysis, rhabdo, ischem. bowel, hemolysis), hyperkalemic periodic paralysis, succinylcholine Any cause of decreased GFR in kidneys, acute or chronic Normal GFR with decreased renal K excretion Normal Aldo o Decreased EAV and lower flow through kidneys: CHF, cirrhosis o Excessive K intake: in conjuction with impairment in K excretion or transcellular shift Hypoaldosteronism: same as etiologies of hypoaldo RTA (type IV) o Decr renin: diabetic nephropathy, NSAIDs, chronic interstitial nephritis, HIV normal renin, decr aldo synthesis: adrenal disorders, ACEI, ARBs, heparin 175 o Decr response to aldosterone Meds: K-sparing diuretics,TMP-SMX, pentamidine, calcineurin inhibitors Tubulointerstitial Disease: sickle cell, SLE, amyloid, diabetes Si/Sx: Weakness, nausea, parasthesias, palpitations Imaging: ECG: peaked T waves, increased PR interval, increased QRS width, loss of P wave, sine wave pattern, PEA/VF (ECG: low sensitivity, cardiac arrest can be first electrical manifestation!) Tx: Calcium gluconate not routinely given for peaked T-waves, later EKG changes warrant closer monitoring and calcium gluconate administration 6. Management of Magnesium & Phosphorus Magnesium o Hypermag is rarely a life threatening problem o Hypomag should be corrected in a hospitalized patient o Repletion IV Mg repletion is ideal for hospitalized patients Goal for cardiac patients 2 or above 176 Oral Mg formulations often will not be as well absorbed or have GI complications(diarrhea) Serum Mg represents extracellular Mg only and not the total body magnesium, which is why aggressive repletion generally is well tolerated. When repleting Mg, give Magnesium Sulfate 1g over 4 hours. 2g over 8hrs, 4g over 16hours, etc. In the ICU, use ICU electrolyte replacement sheet Phosphorus o Hyperphosphatemia: Please see management as in RF above o Hypophosphatemia: Can give as KPhosph or NaPhosph. o Each mmol of KPhosph IV = 1.5 mEq of K+ Dose of sodium or potassium phos is the same o 15mmol IV over 8 hours, 30mmol IV over 12 hours o Oral repletion is generally less effective and has very frequent dosing o Rectal enema – fleets Phosphasoda enema 7. Kidney Transplant – Pearls o o o o 177 Not done at LAC-USC, however on occasion we have patients that have that are s/p transplant. When these patients come in, it is very important to contact the transplant medicine physician managing the patient (often at an outside institution) and discuss the case and current reason for admission. Ensure med list is accurate and that all the meds are available through our in-patient pharmacy. If a certain transplant medication is not avaliable, check to see if patient has this medication with them or have them bring it from home and then write an order for: “OK to administer patient’s home medication XXXXX XXmg Qfrequency.” Ensure medications that are given for in-patient indication do not react with transplant medications. If patient pending surgery, stress dose steroids may be necessary, can discuss with inpatient consult team or call outpatient transplant medicine physician as steroid dose may have recently changed, etc. 178 SECTION 16: NEUROLOGY & SUBSTANCE ABUSE 1. Bacterial Meningitis Si/Sx: fevers, altered mental status, nuchal rigidity Only 44% have all three Can also have hypothermia, generalized headache, neuro deficits, papilledema, seizures (Listeria), petechiae/palpable purpura (N. meninigitidis) Organisms: Neisseria meningitides, Strep Pneumo, Listeria monocytogenes, Haemophilus influenza, Staph Aureus, Gram negative rods Indications for CT prior to LP: o Immunocompromised state o Hx of CNS disease (mass, stroke, infection) o New onset seizure o Papilledema o Abnormal consciousness o Focal neuro deficit Relative contraindications to LP: Raised ICP/mass Thrombocytopenia Spinal epidural abscess or cellulitis LP orders: Tube 1: cell count w/differential Tube 2: Gram stain, culture Tube 3: Protein, glucose Tube 4: cell count w/differential Can also order HSV, India ink, Crypto antigen, AFB etc. depending on what you are looking for + LP results: o Opening pressure > 20 mmHg o Increased WBCs o Protein > 50 o Glucose < 40 179 Empiric Treatment o Age 2 – 50: Vancomycin IV 15 mg/kg Q8-12H + Ceftriaxone 2 gm IV Q12H, Start dexamethasone before antibiotics o Age > 50: Vancomycin + Ceftriaxone + Ampicillin 2 gm IV Q4H o Penetrating head trauma: Vancomycin + cefepime 2 gm IV Q8H or ceftazidime or meropenem 2 gm IV Q8H (to cover pseuodomonas) o Immunocompromised: Vancomycin + Ampicillin + Cefepime or Meropenem 2. Stroke Types of Stroke: Ischemic (thrombotic), Ischemic (embolic) Ischemic hypoperfusion Etiology: o Intracerebral hemorrhage Usually in small arteries/arterioles Forms a hematoma Occurs over minutes to hours Causes: hypertension, trauma, bleeding diathesis, amyloid angiopathy, cocaine use o Subarachnoid hemorrhage Usually caused by rupture of arterial aneurysm Sudden thunderclap headache Loss of consciousness, seizure, nausea, vomiting, focal neuro deficits o TIA: transient neurologic dysfunction without infarction, usually < 24 hours Initial Tests: o CT head w/o contrast to rule out hemorrhage Good for diagnosing intracerebreal hemorrhage May miss subarachnoid, if suspicious get an LP o EKG o Glucose 180 tPA eligibility o Inclusion: Ischemic stroke causing measurable neuro deficit Onset < 4.5 hours before treatment Age >= 18 o Exclusion: Stroke or head trauma in past 3 months Previous ICH Intracranial neoplasm, AVM, aneurysm Recent intracranial or intraspinal surgery Arterial puncture at noncompressible site in past 7 days SAH SBP > 185 or DBP > 110 Glucose < 50 Active internal bleeding Acute bleeding diasthesis Platelet < 100,000 INR > 1.7 or PT > 15s Heparin use within 48 hours or elevated aPTT CT showing hemorrhage Evidence of multilobar infarction > 33% of cerebral hemisphere Follow up Testing: o CT or MR angiogram head and neck to evaluate vasculature (Neurology usually orders MR angiogram) o Cardiac monitoring for 24 hours to monitor for Afib o Echo to evaluate for thrombus o CBC, PT, PTT, INR, fasting lipids o Swallow assessment (you can perform your own bedside swallow with sips of water) BP management o Goal < 180/105 for 24 hours after thrombolytic o Use labetalol or nicardapine as first line antihypertensives o Hemorrhagic stroke goal: SBP 140-150s 181 o Start statin to reduce recurrent stroke risk 3. Alcohol Withdrawal Symptoms can begin within 6 to 12 hours of last drink o Stage 1: agitation, anxiety, insomnia, restlessness, tremor, diaphoresis, palpitations, hypertension, headache o Stage 2: (24 to 72 hours after last drink): similar to stage 1, more GI symptoms: nausea, vomiting, diarrhea o Stage 3: (72 to 96 hours after last drink): autonomic hyperactivity, fever, tachycardia, hypertension, agitation, drenching sweats, halucinations, disorientation o Death from head trauma, CV complications, aspiration, fluid/electrolyte abnormalities Withdrawal seizures usually occur within 24 to 48 hours of last drink Alcoholic hallucinosis (24 to 48 hours): visual, tactile, or auditory hallucinations Management: Alcohol withdrawal CAN KILL the patient. Tx depends on severity of withdrawal, you can try the following approaches o Ativan 2 mg IV Q4H PRN only o Scheduled Ativan + Ativan PRN o Librium + Ativan PRN o Be aware that Librium is long acting, cleared by the liver (which can be impaired in alcoholics). When patients are discharged, they may drink + have Librium lingering. o Check the MAR to see how much Ativan is needed daily o As many of these patients are found down or have falls be sure to check for any trauma and order any imaging depending on the injury. 4. Opiate Withdrawal Signs and Symptoms: Dysphoria, Restlessness, Myalgias, Rhinorrhea 182 Lacrimation, Nausea/vomiting, Diarrhea, BMP/electrolytes Management o Unlike alcohol withdrawal, opiate withdrawal will Not kill the patient o Manage symptoms with PRN opioid and non-opioid pain medications o Uptodate recommends long acting opioids such as methadone for withdrawal o Typically at county we use PO and IV PRNs until symptoms resolve o Non opioid medications include: clonidine (0.1 mg PO Q1H if monitored closely) 5. Altered Mental Status Etiology: Mnemonic – “ABCD ATOMIC” Airway, Breathing, Circulation, Dextrose/Thiamine/Narcan, Alcohol, Trauma, Overdose, Metabolic, Infection, Carbon monoxide Drugs: Opiates, benzos, TCA, salicylates, EtOH, anti-cholinergics, cocaine, anti-epileptics Infxn (esp. intracerebral, sepsis): Bacterial, viral, cryptococcal, fungal Ischemia: Low flow (MI, CVA, hypotension), trauma (CNS bleed, subdural hematoma), acute psychosis (steroids, anti-cholinergics) Metabolic: Hypoglycemia, uremia, hypercalcemia, hyponatremia, hypoxia, hypercarbia, hyperammonemia, hypothyroidism Other: Seizure or post-ictal, trauma, psychiatric (pseudoseizure) Dx: Check pulse ox/ABG, dexi, CMP, heme 8, UTox, serum volatile screen, NH3, EKG, LP, imaging (first dry head CT then MRI if indicated), consider EEG. 6. Delirium Delirium is defined as disturbance of consciousness, change in cognition, or development of perception disturbance that is not explained by dementia, that develops over hours to days Tx: Identify & manage underlying cause(s): 183 Correct electrolytes (Ca, Mg, Na (aim for Na=140)) Reverse hypoxia, hypercarbia, Manage organ failure (kidney, liver, hypotension), Suspect & treat infections o Avoid restraints/lines/catheters, as feasible o Ensure effective communication & reorientation o Sitter/family re-direct & re-orient pt o Calm → speak softly, no TV, soothing music o Give glasses/hearing aids back o Improve sleep/wake cycle (haldol as sleep aid) o Mobilize → PT & OT orders Last resort, consider short-term (usually ≤1 wk) haloperidol or olanzapine (in people w/ conditions such as Parkinson’s disease or dementia w/ Lewy bodies, use antipsychotics w/ caution or epilepsy not at all) (↑QT?; Sz Hx?)Can consider EEG for nonconvulsive 184 185 7. Dementia Ddx: (potentially reversible in bold): Alzheimer’s, multi-infarct dementia, AIDS dementia, Parkinson’s w/ dementia, Picks disease, Lewy Body Dementia, B12 deficiency, thyroid disease, depression, cerebral vasculitis, medication side effects (analgesics, anti-cholinergic, antihypertensive, psychotropic, sedative-hypnotic agents), NPH, tumor, subdural hematoma, delirium. Dx: MMSE, B12, RPR, TSH, head CT (consider MRI), HIV test 186 8. Seizures Classification o Generalized: tonic clonic: tonic contractions of muscles with intermittent clonic relaxation of muscles absence: loss of consciousness without loss of muscle tone o Partial Simple: focal findings without loss of consciousness Complex: simple + impairment of consciousness Causes: electrolytes, alcohol, brain mass, infection, trauma Orders: o CMP o Can order alcohol, Utox if high suspicion o EEG (EEG order sheet in medicine folder and needs to be faxed) o MRI brain Management o Treat underlying cause if first seizure o Consult neurology, they will be the best source for management of these patients o Generalized Tonic clonic seizures: phenytoin, valproate, Topamax, lamotrigine o Absence: Ethosuximide o Partial: carbamazepine, phenytoin, valproate, lamotrigine Status Epilepticus o > 10 minutes of continuous seizure activity or sequential seizures without complete recovery o This is a neurologic emergency and neuro should be consulted o As with any emergency: check CAB, glucose, oxygen, make sure patient has IV access Start with Ativan 4 mg IV and escalate, may eventually need to be placed in a coma (See flowchart): Emerg Med J2002;19:96-100 doi:10.1136/emj.19.2.96 187 188 SECTION 17: PULMONARY 1. Asthma Hx: Ask about frequency of symptoms per week, Night symptoms Medication compliance, # of hospitalizations and intubations Exposures/medications: pets, carpets, aspirin Dx: PFTs before and after bronchodilator Many patients claim to have asthma but have never had PFTs! Methacholine challenge test to rule out asthma Exercise induced bronchospasm: decreases in FEV1 >=10% after graded exercise Management: Based on severity/classification of asthma (see stepwise approach from NIH) In addition remove environmental triggers ** Asthma is associated with GERD and treatment of these conditions can help with uncontrolled asthma Monitor Peak flow Asthma Exacerbations o Peak flow < 40% = severe, < 60%=moderate exacerbation o CXR, ABG o steroids x 7 – 10 days o oxygen o Albuterol nebulizers back to back, space out to Q4H o Ipratropium not typically effective but can be tried 189 190 191 2. COPD Emphysema: more severe, constant dyspnea Chronic bronchitis: >3 mo/yr for > 2 yrs of productive cough, intermittent dyspnea Orders: o CXR: look for hyperinflation, flattened diaphragms o PFTs (if never done before) can show obstructive pattern o ABG can show respiratory acidosis with metabolic acidosis Chronic Treatment o Oxygen improves mortality, indicated if PaO2 < 55, O2 sat < 89% o Ipratropium > albuterol inhalers o Inhaled corticosteroids o Smoking cessation Acute Exacerbation Treatment o Nebulizers: Ipratropium 0.5 mg + albuterol 2.5 mg HHN Inhaled q4H ATC or PRN o Steroids: methylprednisone IV vs prednisone PO (if tolerating PO) o Azithromycin: treat any underlying infection as well as having anti-inflammatory effects o Oxygen: NC vs NPPV 3. Interstitial Lung Disease Dx: Hx of exposure, medications, or diseases that can result in ILD Imaging: CXR, High resolution CT without contrast: reticular nodular or ground glass pattern, PFTs: restrictive Labs based on etiology of ILD Sarcoidosis: ACE level SLE: ANA RA: rheumatoid factor, anti CCP Goodpasteurs: antiGBM HIV Wegeners’ c-ANCA ChurgStrauss: c or p ANCA 192 Microscopic polyangitis: p-ANCA ABPA: aspergillus IgE Bronchoscopy/BAL Lung biopsy Tx: depends on the cause of the ILD, and these patients should be followed by chest clinic 4. Pulmonary Embolus Risk factors: Virchows triad, Hereditary hypercoagulability: Protein C/S deficiencies, Factor V leidin mutation, Antithombin, PT, Plasminogen deficiency, Reduced mobility, Cancer, Advanced age, Pregnancy, postpartum period Signs: Dyspnea (73%), Pleuritic chest pain (66%), Cough (37%), Leg swelling (28%), Leg pain (26%) PE Symptoms: Tachpnea, Rales/crackles, Tachycardia, S4, Increased P2, Fever Dx: Calculate Well’ s score to determine probability of DVT (write score on the CTPA order), D-dimer for low or intermediate probability (will be required by radiology prior to CTPA), ABG, CXR: Hampton’s hump (wedge infarct), Westermark (prominent pulmonary artery) EKG -> S1Q3T3 pattern. Sinus tachycardia , RV strain Imaging: Echo to evaluate RV V/Q scan are usually not diagnostic and end up intermediate CT Angiogram of Chest (check order in affinity as these routinely get mis-ordered Regular chest CT Chest Xray Lower extremity US to evaluate for DVT Tx: In unstable patient with massive PE or select high risk patients without hypotension: 193 Oxygen, Fluids, thrombolytics, embolectomy if not responsive to previous treatment In hemodynamically stable patient’s goal is prevent thrombus extension with anticoagulation (LMWH > heparin) Treatment duration is 3 – 6 months Can treat longer if severe risk factors, VTE is idiopathic, VTE is recurrent IVC filter placement Indications: contraindication to anticoagulation, recurrent embolism 5. Pulmonary HTN Definition: Mean PAP > 25 mmHg at rest or > 30 mmHg with exercise or Systolic PAP > 40 mmHg WHO Categories: I: Pulmonary Arterial Hypertension: idiopathic PAH, collagen vascular diseases, intracardiac shunts, portal hypertension, HIV II: Left sided heart disease III: Primary Lung Disease: COPD, ILD, Sleep apnea IV: Chronic thromboembolic disease V: miscellaneous etiology: inflammation, extrinsic compression, mechanical obstruction Si: Loud P2, Tricuspid regurgitation, RV heave, JVD, LE edema Dx: EKG showing Right axis deviation, Echo, R heart cath Tx: Anticoagulation for Group I and IV, goal INR=2, Oxygen for Group III, Diuretics for fluid retention o Endothelin antaognists: Bosentan, Ambrisentant, sitaxsentan o Calcium channel blockers: nifedipine, amlodipine o Prostanoids: Epoprestenol, Iloprost o PDE inhibitors: Sildenafil o Overall these patient’s can be very complicated/sick, make sure they have good outpatient follow up 6. Pleural Effusion Dx: Thoracentesis: Exudate vs Transudate: [NEJM 2002;346:1971-77] 194 Light’s Criteria for Exudate Sensitivity Specificity Fluid/serum LDH >0.6 86 84 Fluid/serum Prot >0.5 98 83 LDH>2/3 Upper limit normal 82 89 Chol >43 75 80 Chol >60 54 92 Fluid/Serum chol >0.3 89 81 Serum-Fluid Albumin 87 92 Exudate: Pneumonia/parapneumonic (25% of all effusions), malignancy (15%), TB, PE (10%), collagen vascular disease, pancreatitis, esophageal rupture Transudate: CHF (40% of all effusions, 80% are bilateral), hepatichydrothorax, constrictive pericarditis, nephrotic Sd, PE (usually exudative), malignancy causing lymphatic obstruction, myxedema, continuous ambulatory peritoneal dialysis (CAPD) Hemorrhagic exudates (Hct effusion/Hct blood > 50%): TB, Tumor, Trauma ("The 3 Ts"). Chylothorax (TG >110): thoracic duct damage due to trauma, malignancy, Lymphangiomyomatosis. Other: Post-CABG, Dressler’s Sd, uremia, post-radiation, asbestos exposure, drug-induced, Meig’s Syndrome, yellow nail syndrome Complicated versus uncomplicated: complicated if positive gram stain or pH <7.2 or glucose < 60. Usually requires drainage. Indications for thora: Fever w/ a pleural effusion; 1 cm thick effusion 195 on US or lateral decubitus CXR w/o known cause; unilateral effusion in CHF exacerbation; effusions in CHF that don't resolve in 3 days w/ diuresis (75% of CHF effusions resolve w/in 48h of diuresis); poor oxygenation due to unresolving effusion(s). 7. Pulmonary Edema Management: “UNLOAD ME” : Upright posture, Nitrates/Nitroprusside, Lasix, Oxygen, Albuterol /ipatropium, Dopamaine/dobutamine, Morphine, Electric cardioversion “LMNOP” Lasix, Morphine, Nitrates, Oxygen, Positioning 8. Cystic Fibrosis 5% of CF pts are diagnosed after age 16 Autosomal recessive inheritance. >1000 mutations can lead to CFTR channel dysfxn. Clinical manifestations: Chronic Sinopulmonary Disease, chronic cough/sputum; persistent infection w/ characteristic pathogens (e.g Pseudomonas); airflow obstruction; chronic chest radiographic abnormalities; sinus disease; nasal polyps. GI & nutritional abnormalities: pancreatic insufficiency; meconium ileus; D istal Intestinal Obstruction (DIOS); focal biliary or multilobar cirrhosis Obstructive azoospermia; congenital bil absence of Vas Deferens, Diabetes; osteoporosis Burkholderia Cepacia: Aerobic very resistant GNR (Bactrim, Meropenem). 8 genomovars: Type III associated w/ poor outcomes. Transmissible between pts! “3 foot rule” for all CF pts. Pts w/ Cepacia seen separately. Dx: ↑ sweat chloride; known CF Mutations on both alleles; bioelectric abnormalities in nasal epithelium in vivo Tx: 196 Infection: Anti-pseudomonal antibiotics. Tobra 10 mg/kg/day (with normal renal function). Accurate peak & trough levels are important! BID dosing: Peak 20-30, Trough < 0.5. Levels from central lines & implanted ports are inaccurate. Once good levels established, only need to check q5 days unless changed in dose or change in renal function. Obstruction: Airway Clearance (Chest percussion, flutter valve, high frequency oscillatory vest); Dornase Alpha 2.5 mg nebulized BID, β2 agonists Inflammation: inhaled & oral steroids, Ibuprofen, ?azithromycin PFTs at least q3mos w/ aggressive intervention for declines Regular prevention w/ chest PT BID; TOBI 300 mg nebulized BID (q.o. month); Dornase Alpha; Serevent, Flovent Nutrition: pancreatic enzymes (1000-2000 lipase units/kg/meal; Ultrase MT 20, Pancrease MT 20, & Creon 20 contain 20,000 lipase units/capsule. DO NOT use generic pancrealipase); high fat, high salt diets; caloric supplements; fat soluble vitamins (ADEKs); Megestrol (Megace) or Marinol. Treat CF-induced diabetes w/ insulin NOT oral agents. 197 SECTION 18 – RHEUMATOLOGY 1. Systemic Lupus Erythematosis Common Serology labs Antibody Disease Association (Sensitivity) Sensitivity Specificity Drug-induced lupus 95% 80% 57% 24-30% 50-60% 40-50% 40-50% 15% 71-100% 20% 70-90% 30-60% 97% 96-98% Anti-histone SLE Anti-ds DNA Anti-Sm Anti-Ro/SS-A Anti-La/SS-B Anti-RNP Anti-Scl-70 ANCA Anti-CCP SLE SLE Sjögren's syndrome SLE Sjögren's syndrome SLE MCTD Systemic sclerosis Wegener’s granulomatosis Rheumatoid arthritis Diagnostic criteria for SLE 4 or more of the following during course of disease: 95% specificity, 75% sensitivity Mucocutaneous 1. Rash with UV exposure 2. Malar rash 3. Oral and nasopharyngeal ulcers 198 84-100% 100% for diffuse 95-98% 4. Discoid rash (scaly, round patches Organ System 5. Arthritis (symmetric, nonerosive, 2 or more joints) 6. Serositis (pleuritis or pericarditis) 7. Renal (proteinuria >0.5g daily or any cellular casts) 8. Blood changes (hemolytic anemia, leucopenia, lymphopenia thrombocytopenia) 9. Neuropsychiatric (seizures or psychosis) Lab values 10. Positive ANA (99% sensitive, not specific) 11. Anti-dsDNA (sensitivity 75-100%), Anti-Sm, or antiphosholipid antibodies Drugs that cause Lupus: Hydralazine, Isoniazid, Procainamide, Methyldopa, Quinidine, Chlorpranimide Symptoms by organ system: Constitutional: Fatigue, myalgia, weight change, fever MSK/Skin: Arthritis, rashes, Raynaud phenomenon Pulmonary: Pleurisy, pleural effusion, pneumonitis, interstitial lung disease Cardiovascular: Pericarditis, Libman-Sacks endocarditis, myocarditis, CAD Neurologic: Depression, cognitive deficits, delirium, psychosis, seizures, headaches, peripheral neuropathies, movement disorders, cranial neuropathies, myelitis, meninigitis. Eye: Keratoconjuntivitis, episcleritis, scleritis, anterior uveitis Hematologic: Leukopenia, anemia, thrombocytopenia, thrombophilia, thromboembolic events Useful Lab Tests: Basics: CBC w/ diff, CMP, CK, ESR/CRP, Urinalysis Serologic: ANA, anti-dsDNA Ab, Anti-Smith Ab, C3, C4 General treatments of lupus: 199 NSAIDS: Used for the treatment of joint pain, fever, headache, serositis Antimalarials- Very effective for skin, joint, and constitutional symptoms and for the prevention of clinical relapse. Survival benefit with odds ratio of death of 0.13. Glucocorticoids: Used for SLE with organ system involvement and for acute flares. Solumedrol IV 1g daily can be used for acute lupus flares, particularly for renal and CNS involvement. If clinically stable can start Prednisone 1-2mg/kg per day and then tapered on an outpatient basis. Immunosuppresants: Methotrexate, cyclophosphamide, azathioprine, mycophenolate, and rituximab. Generally used in addition to steroids for SLE with organ system involvement, in patients refractory to steroids, or to lessen steroid dose. Acute SLE problems/emergencies by organ system: SLE flares=high DS DNA Ab, low C3/C4 PULMONARY Acute pneumonitis (1-12% of SLE) Presentation: Fever, cough +/- hemoptysis, pleurisy, dyspnea, pulmonary infiltrates on x-ray, hypoxia, basilar rales, pleural effusion (in 50 percent), serum anti-DNA antibodies, and no apparent infection Dx: CT w/ ground glass infiltrates or honey combing fibrosis. BAL with lymphocytosis or granulocytosis Tx: Prednisone 1mg/kg/day or Solumedrol 1g IV x3 days Diffuse alveolar hemorrhage (rare) Presentation: Acutely ill with dyspnea, hemoptysis, cough, +/anemia Dx: CXR with alveolar bibasilar infiltrates. BAL with bloody fluid and hemosiderin laden macrophages Tx: Solumedrol 0.5-2g IV, Cyclophophamide, intubation, antibiotics 200 NEUROLOGIC Psychosis: (5% of SLE patients) Presentation: Disordered and bizarre thinking with delusions and hallucinations, fluctuating delirium. Tx: Antipsychotics acutely. Prednisone 1-2mg/kg PO daily. Can add Cyclophophamide or Azathioprine. Stroke (up to 20% of SLE patients) Presentation: Strokes in SLE typically more severe with 77% suffering with NIH stroke scale >6. Risk of death from stroke doubled compared to non-SLE stroke in observational studies. Dx: Antiphospholipid antibody positive, C3 and C4 levels low, Anti-DS DNA levels high in addition to normal stroke workup. Tx: If patient has had a stroke and has moderate/high APL antibody levels then should start Warfarin with goal INR 2-3. If APL without stroke or low levels of APL then ASA 81 mg daily. Seizure (10-20% of SLE patients) Presentation: Both generalized and partial seizures can occur. Often in younger, newer onset SLE. Dx: Associated with anti-50 kDa, anti-Sm, and APL. EEG and other standard seizure work up. Tx: Antimalarials decrease incidence of seizures. Antiepileptic drugs as per typical seizure treatment. RENAL Lupus Nephritis Presentation: Renal failure, nephritic syndrome. Dx: Elevated creatinine, UA w/ micro with protein, casts. +anti DS DNA titers, low C3 and C4 levels. Elevated protein/creatinine ratio. Kidney biopsy for staging to determine treatment. Tx: Depends on type of lupus nephritis seen on biopsy. If indicated by biopsy use Methylprednisone 0.5-1gm IV qdaily for short course along with Mycophenolate or cyclophosphamide. ACE inhibitors for 201 sclerodermal renal crisis, proteinuria. Aggressive hypertension management. Consult Endocrine service. 2. Rheumatoid Arthritis Diagnostic criteria for RA (≥ 6/10 points) Number and site of involved joints 1. 2 to 10 large joints (from among shoulders, elbows, hips, knees, and ankles) = 1 point 2. 1 to 3 small joints (from among the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists) = 2 points 3. 4 to 10 small joints = 3 points 4. Greater than 10 joints (including at least 1 small joint) = 5 points Serological abnormality: Rheumatoid Factor or Anticitrullinated peptide/protein antibody 1. Low positive (above the upper limit of normal, ULN) = 2 points 2. High positive (greater than three times the ULN) = 3 points Elevated acute phase response: ESR or C-reactive protein= 1 point Symptom duration at least six weeks = 1 point Labs: Basic: CBC, CRP/ESR, Uric Acid, Urinalysis Serologic: ANA, RF, Anti-citrullinated peptide/protein antibody Imaging: Xrays hand/wrist/feet Tx: Mild RA: NSAID + hydroxychloroquine vs sulfasalazine Moderate RA: NSAID or steroid + methotrexate 202 Resistant (to methotrexate) RA: Methotrexate + TNF inhibitor/hydroxychloroquine/sulfasalazine 3. Gout Definition: Inflammatory arthritis induced by deposition of monosodium urate crystals Predisposing factors: Alcohol, fatty diet, thiazide, loop diuretics, low dose aspirin Clinical features: Pain, redness, swelling 80 percent of initial attacks involve a single joint, most often at the base of the great toe (podagra) or knee Elevated ESR, CRP, leukocytes, fever Uric Acid levels ≥ 6.8 consistent, not diagnostic. Normal uric acid in 1243% with acute gout Dx: Check Synovial fluid for: Needle shaped, negatively birefrigent crystals under polarized light (Sensitivity 85%, specificity 100% WBC 3,000-50,000 (>50% PMNs) Negative gram stain/culture Tx: Acute gout NSAIDS - Naproxen 500mg PO BID Colchicine 1.2 mg PO, with 0.6mg PO one hour later. Low dose regimen leads to less GI toxicity. Dose reduction in hepatic/renal insufficiency. Steroids (If unable to take NSAIDS or colchicine, ex. RF) If Systemic - Prednisone 30-50mg/day x 2 days, then taper over 1 week Chronic Gout Allopurinol 100mg PO daily and titrate up (usually 300mg daily) 203 ** do NOT use Allopurinol for acute gout, as this will exacerbate attack Cochicine 0.6mg PO daily, can increase to 0.6mg PO BID Probenicid 250mg PO BID and titrate up 4. Vasculitis Definition: Inflammatory leukocytes in vessel walls with reactive damage. Vessel damage leads to bleeding and downstream ischemia and necrosis CLASSIFICATION BY VESSEL SIZE Small vessel Medium Vessel Large vessel Churg Strauss Polyarteritis nodosa Takayasu’s arteritis Granulomatosis w/ CNS vasculitis Giant Cell arteritis polyangiitis (Wegeners) Henoch-Schonlen Cryoglobulinemia vasculitis Hypersensitivity vasculitis Microscopic polyangiitis Connective tissue disorders Vasculitis 2/2 viral infxn Large vessel: Takayasu’s arteritis Presents with fatigue, malaise, syncope, headaches, abdominal pain, arthralgias, chest pain, dyspnea, hemoptysis, angina. ACR criteria: 3/6 positive- Sensitivity 90.5%, Specificity 98% 1. Age <40 2. Claudication of extremities 3. Decreased pulsation of one or both brachial arteries 4. Difference of at least 10mmHg in each arm 204 5. 6. Bruit over one or both subclavian arteries or abdominal aorta Arteriogrpahic narrowing or occlusion of aorta, its primary branches, or large arteries in the proximal upper or lower extremities no due to other cause Labs findings: Normochromic, normocytic anemia. WBC normal. Elevated ESR, CRP. NegativeANA, ANCA, anti DS-DNA, APL. MRI/CT/angiography w/ narrowing of large vessels. Giant cell arteritis Presents with fever, fatigue, weight loss, temporal headache, jaw claudication (most specific history finding), amaurosis fugax (transient monocular vision loss). ACR criteria: 3/5 positive- Sensitivity 94%, Specificity 91% 1. Age >50 2. Localized headache of new onset 3. Tenderness or decreased pulse of the temporal artery 4. Erythrocyte sedimentation rate (ESR) greater than 50 5. Biopsy revealing a necrotizing arteritis with a predominance of mononuclear cells or a granulomatous process with multinucleated giant cells Labs findings: Decreased albumin. AST/ALT elevation. Elevated ESR, Elevated CRP. Medium Vessel: Polyarteritis nodosa Associated with Hepatitis B, Hepatitis C, hairy cell leukemia. ACR criteria: 3/10 with documented vasculitis-Sensitivity 82%, Specificity 87% 1. Otherwise unexplained weight loss >4 kg 2. Livedo reticularis 3. Testicular pain or tenderness 205 4. Myalgias (excluding that of the shoulder and hip girdle), weakness, or polyneuropathy 5. Mononeuropathy or polyneuropathy 6. New onset diastolic blood pressure >90 mmHg 7. Elevated levels of serum blood urea nitrogen (>40 mg/dL or 14.3 mmol/L) or creatinine (>1.5 mg/dL or 132 mcmol/L) 8. Evidence of hepatitis B virus infection via serum antibody or antigen serology 9. Characteristic arteriographic abnormalities not resulting from noninflammatory disease processes 10. A biopsy of medium- or small-sized artery containing polymorphonuclear cells Labs findings: Normochromic, normocytic anemia. WBC normal. Elevated ESR, CRP. Negative ANA, ANCA, anti DS-DNA, APL. MRI/CT/angiography w/ narrowing of large vessels. Small vessel: Churg-Strauss (Eosinophilic granulomatosis with polyangiitis)Presents with asthma, eosinophilia, upper airway disease, skin disease ACR criteria: 4/6 positive- Sensitivity: 85%, Specificity of 99.7 1. Asthma (a history of wheezing or the finding of diffuse high pitched wheezes on expiration) 2. Greater than 10 percent eosinophils on the differential leukocyte count 3. Mononeuropathy (including multiplex) or polyneuropathy 4. Migratory or transient pulmonary opacities detected radiographically 5. Paranasal sinus abnormality 6. Biopsy containing a blood vessel showing the accumulation of eosinophils in extravascular areas 206 Lab findings: Eosinophilia (5,000-9,000 eosinophils), P-ANCA positive (70-75%), BAL with eosinophils, CXR transient patchy opacities. Wegener’s disease (Granulomatosis with polyangiitis): Granulomatous inflammation of upper and lower respiratory tracts and glomerulonephritis ACR Criteria: 2/4 positive- Sensitivity 88%, Specificity 92% 1. Nasal or oral inflammation (painful or painless oral ulcers or purulent or bloody nasal discharge) 2. Abnormal chest radiograph showing nodules, fixed infiltrates, or cavities 3. Abnormal urinary sediment (microscopic hematuria with or without red cell casts) 4. Granulomatous inflammation on biopsy of an artery or perivascular area Labs findings: C-ANCA positive, UA w/ hematuria and proteinuria Hypersenstivity Vasculitis Drug induced vasculitis and serum sickness ACR Criteria: 2/4 positive- Sensitivity 88%, Specificity 92% 1. Age >16 2. Use of possible offending drug in temporal relation to symptoms 3. Palpable purpura 4. Maculopapular rash 5. Biopsy of a lesion showing neutrophils around an arteriole/venule Cryoglobulinemic vasculitis Immunoglobulins precipitate in the cold and dissolve on warming Associated with Hepatitis C Small vessel inflammation results from deposition of immunoglobulins and complement in the vessel wall 207 Type 1: Monoclonal immunoglobulin (IgM or IgG) Type 2: Monoclonal IgM with activity against polyclonal IgG Type 3: Polyclonal IgM with activity against polyclonal IgG 5. Dermatomyositis/polymyositis Immune mediated muscle injury Dx: Symmetric proximal muscle weakness Typical skin findings: Gottron’s sign (erythematous, scaly rash symmetrically over MCP/IP joints Heliotrope rash Nailbed changeds Shawl sign and V sign (erythematous heliotrope over chest/shoulders/back) Mechanic’s hands (roughening and cracking of skin of hands) Labs: Elevated serum muscle enzymes ( CK, LDH, AST, ALT, Aldolase) Others: Myopathic changes on EMG. Muscle or Skin biopsy. Malignancy: 5-7x incidence of malignancy vs normal population, Associated with ovarian, lung, cervix, pancreas, bladder, stomach malignancies Tx: Steroids, Immunosuppression 6. Scleroderma Presentation: Diffuse, thickened skin DIFFUSE CUTANEOUS SCLERODERMA SYSTEMIC SYMPTOMS Diffuse cutaneous Early (<3 years after onset) Late (>3 years after onset) Constitutional Fatigue and weight loss Minimal, weight gain typical Vascular Raynaud's often relatively Raynaud's more severe, 208 mild more telangiectasia Rapid progression Stable or regression involving arms, trunk, face Cutaneous Prominent arthralgia, Flexion contractures and stiffness, myalgia, muscle Musculoskeletal deformities, joint/muscle weakness, tendon friction symptoms less prominent rubs Gastrointestinal Dysphagia, heartburn Maximum risk for myocarditis, pericardial Cardiopulmonary effusion, intersitital pulmonary fibrosis More pronounced symptoms, midgut and anorectal complications more common Reduced risk of new involvement but progression of existing established visceral fibrosis Maximum risk period for Renal crisis less frequent, scleroderma after 5 years uncommon after 5 years Renal LIMITED CUTANEOUS SCLERODERMA SYMPTOMS Limited cutaneous Early (<10 years after onset) Late (>10 years after onset) Constitutional None Only secondary to visceral complications Vascular Raynaud's typically severe and longstanding telangiectasia Raynaud's persists, often causing digital ulceration or gangrene Cutaneous Mild sclerosis with Stable, calcinosis more prominent 209 little progression on trunk, face Musculoskeletal Occasional joint stiffness Mild flexion contractures Gastrointestinal Dysphagia, heartburn More pronounced symptoms, midgut and anorectal complications more common Cardiopulmonary Usually no involvement Lung fibrosis may develop, but often progresses slowly, Anti-SCL-70 predicts increased risk of severe fibrosis. Maximum risk for developing isolated pulmonary hypertension and secondary right ventricular failure. Renal No involvement Rarely involved, anti-RNA polymerase predicts increased risk of renal involvement. 210 SECTION 19: PHARMACY 1. Steroid Dosing NAME Gluco. Potency Mineralo. potency T 1/2 in hours Hydrocortisone 1 1 8 Cortisone acetate 0.8 0.8 PO 8, IM 18 Prednisone 4 0.8 16-36 Prednisolone 4 0.8 16-36 Methylprednisolone 5 0.5 18-40 Dexamethasone 30 0 36-54 Betamethasone 28 0 36-54 Triamcinolone 5 0 12-36 Fludrocosrtisone 15 200 - Deoxycorticosterone 0 20 - Aldosterone 0.3 200-1000 - 2. Beta Blocker Dosing Dose Equivalence B-1 Selective Acebutolol 200mg Yes Once Daily Dosing Yes Atenolol 50mg Yes Yes Bisoprolol 10mg Yes Carvedilol 50mg No Yes No Labetalol 200mg No Metoprolol Nadolol 100mg Yes 80mg No Oxprenolol 80mg No No Pindolol 7.5mg No Yes Propranolol 80mg No Yes (LA) Drug 211 No Yes (SR) Yes Sotalol 80mg No No Timolol 10mg No No 3. Ace Inhibitor and ARB Dosing DRUG DOSE EQUIVALENCE Captopril 12.5 mg tid Enalapril 5 mg daily Ramipril 2.5 mg daily Lisinopril 10 mg daily Quinapril 10 mg daily Fosinopril 10 mg daily Cilazapril 2.5 mg daily Benazepril 10 mg daily Perindopril 2 mg daily Trandolapril 1 mg daily DRUG DOSE EQUIVALENCE Irbesartan Valsartan Losartan Telmisartan Candesartan 150mg 80mg 50mg 40mg 8mg ** For any questions regarding medications and dosing, call inpatient pharmacy at x9-7641 and ask for your ward pharmacist (7B, 7C, etc). 212 SECTION 20 - DISCHARGES 1. Discharge Summary When a patient is discharged from the hospital, you must include in his/her chart a paper discharge form (available in English or Spanish) which can be found in the resident work rooms on each ward. Be sure to include all relevant information including discharge medications and f/u appts. Place prescriptions in the front of the chart, remember that it takes approx. 4-5 hours for prescriptions to be filled, so if you anticipate an AM discharge, either ask the clerk to drop them off the night before, or drop them off yourself in at the outpatient pharmacy before you leave. 2. Discharge Dictations Call: 1-888-201-8590 Enter your physician ID number, then #. (i.e. 1144XX#) Enter work type 10 for discharge summary, then #. Enter medical record number, then #. Important things that should be in a Discharge Dictation: 213 First and Last name (spelled out) of patient and Attending Date of Admission Date of Discharge Discharge Diagnosis (If multiple, enter major diagnosis first) Summary of Hospital Course including: Diagnostic Imaging (CT Chest, Brain, MRI, etc) Procedures w/ results (EGD, colonoscopy, LP, etc) Consults (Neurosurgery, GI, Liver, etc) Condition at Discharge Discharge Medications Discharge Follow Up appointments 3. Transfer Discharges Sometimes, you may need to transfer a patient to another hospital or to a long term care or rehab facility. In these scenarios be sure to: 1. Attach the normal paper discharge summary. 2. Include a typed Transfer/Discharge Summary similar to what you would write if you were transferring to a different ward in the hospital (Including any MICU course, WARDS course, CCU course, etc). 3. Attach the 3 part, multi colored, duplicate transfer form available on each ward (ask the ward clerk). 4. Write COPY CHART in MR orders section of chart. 5. Be sure to contact Rancho liason, or transfer MD (if necessary) at other hospital. 4. Against Medical Advice (AMA) Discharge When a patient expresses the desire to leave AMA: Call your senior resident and tell them patient wants to LAMA. ALWAYS try to convince the patient to stay and receive appropriate medical care. Explain the severity of the patient’s illness, the necessity of the treatment, and the specific dangers (including death if applicable) of LAMA. If patient has capacity, and can repeat the dangers of leaving AMA, then have patient sign the AMA form. If patient refuses to sign the AMA form, have another MD or nurse sign the form as a witness. Document in affinity your conversation with the patient and be sure to include everything written above, especially the possibility of death if patient leaves AMA. Complete a paper Discharge Summary and place it in his chart and write patient leaving AMA on the D/C summary. Call the dictation line and dictate the patient’s hospital course, and that patient left AMA. 214 SECTION 21 – HOW TO SURVIVE IN THE CLINICS 1. Specialty Clinics o Hudson Clinic code to document patient encounter on Affinity: H223C 2829 S. Grand Ave., Los Angeles, CA 90007 o Roybal Clinic code to document patient encounter on Affinity: R1096C 245 S. Fetterly Ave., Los Angeles, CA 90022 o VA Downtown 351 E. Temple St., Los Angeles, CA 90012 o El Monte Clinic code to document patient encounter on Affinity: E222C 10953 Ramona Blvd., El Monte, CA 91731 o Rand-Schrader (5P21; HIV/AIDS clinic) 1300 N. Mission Road, Los Angeles, CA 90033 2. Continuity Clinic –located in Outpatient Department building (OPD) 1:00-1:30pm: didactic ambulatory curriculum session o Each week, one resident is assigned to present a 1-page summary of the designated clinic article to the group o Each resident will be expected to have read the article and cases for each clinic session. o Be cognizant of your assigned day for clinic presentation (available on Amion) 1:30-5:00p: direct patient care o Document each patient visit in Affinity Affinity clinic code: varies Translation machines are available in the clinic or may call the Health Care Interpreter Network at (323) 226-3600 (code: 201609). 215 Social Workers are available in the clinics as well. All male house officers must be chaperoned by a female medical assistant or nurse when performing breast, pelvic, genital or rectal exams on female patients. Document the name of the chaperone in the chart. Document Routine Health Mainteance (RHM) at the end of each. Examples include: urging cessation of smoking, updating vaccinations, performing Pap smears, breast examinations, digital prostate examinations, and colon cancer screening. o Review each patient visit with an attending physician. o All clinic notes must be co-signed by an attending 3. Galaxy (only for clinic 4P61) o o A system created for closer follow-up on labs and diagnostic studies. Information is reviewed by Galaxy oncall resident who calls patients directly to review results and adjust care plans, when appropriate. Page the on-call Galaxy resident (available on Amion) to setup for a particular patient who needs closer follow-up. 4. Admissions from Clinic o o 216 Stable patients requiring hospitalization—clinic attending must approve all recommendations for hospitalization. Once approved, call Utilization Review (UR) at (323) 2262212 to inform them of the admission. Inform the Medicine Consult resident of the impending admission by paging the service beeper (213) 919-9218. The “two star” Emergency Department resident must be contacted for acceptance of any clinic patient referred directly to the Emergency Department. Emergency situations—Call a code blue and notify your attending and charge nurse. Start ACLS protocol. SECTION 22 - END OF LIFE 1. DNR/DNI o o o o o o o Do Not Resuscitate (DNR):“do not do CPR”: its use is not intended to indicate that any other therapeutics are to be withheld or limited Do Not Intubate (DNI): in the event of cardiopulmonary failure, patient does not desire mechanical ventilation Generally, patients should be both DNR and DNI or full code. In patients with capacity: address and document DNR/DNI code status in patient’s medical record. In patients without capacity: determine if a surrogate is available. Surrogate should act in accordance with patient’s desires or in the best interest of the patient, if patient’s wishes are unknown. Document code status to that effect in patient’s medical record. In patients without capacity and surrogate: decisions should be based on medical judgment and what is believed to be in the best interest of the patient. In the event that there is conflict among members of the health care team, consultation with the Ethics Resource Committee may be solicited. An order to forgo CPR must be written and signed by a licensed physician in the order sheet in the patient’s medical record. Write “Do Not Do CPR.” Unacceptable terms include DNR, No ACLS, and No BCLS. 2. Comfort care o The focus of care should be to optimize patient comfort and to allow a peaceful death in the presence of family and friends. o Consider carefully what medications and procedures the patient is receiving and whether or not they are necessary (i.e. 217 does the benefit in the short term justify the burden or disruption in a dying patient?) o You may choose to use available comfort care order sets found under Departments > Palliative Care on intranet page. o Recommendations: General Care- Private room with 24 hour visitation *STOP nonessential medications. *STOP unnecessary labs, needle sticks, radiographs, etc. Oral Care- Lip balm/ water q4hrs ATC dry lips/ mouth Eye Care- Artificial tears 2 drops to eyes q4hrs PRN dry eyes Fever- Acetaminophen 650mg PO/PR q4hrs PRN T > 101 F Nausea- Metocloperamide 10mg q6hrs IV/PO q6hrs ATC Bowel regimen- Bisacodyl 10mg supp PRN no BM x 48hrs Agitated Delirium- Haloperidol 1mg SL q8hrs PRN agitation Seizures- Lorazepam 2mg IV q4hrs PRN seizure > 5 min Pain or Dyspnea- Reassess frequently. Titrate to symptom relief. If patient opioid naïve, consider o Morphine sulfate 5mg PO q4hrs ATC or o Morphine sulfate 2mg IV q4hrs ATC or o Morphine sulfate 1mg/hr IV continuous infusion If patient previously on opioid for symptoms, titrate starting from current dose and adjust based on patient needs Labored breathing/ Anxiety- Lorazepam 0.5mg IV q4hrs PRN *Use opioids as 1st line treatment and Lorazepam as adjunct Excessive secretions- Glycopyrrolate 0.4mg IV/SL q4hrs ATC 218 3. Palliative Care/ Hospice Care Palliative care Palliate symptoms Anyone is eligible Not necessarily end of life care Able to continue with curative treatment Hospice care Palliate symptoms Terminal illness Only end of life care; Prognosis <6 months if illness runs expected course No further curative therapies; Focus on comfort When to consult Palliative Care (consult line: 9-8532; location: 5G100) o Team/patient/family needs help with complex decision making o Goals of care clarification o Code status discussions o Frequent visits to the emergency department or admissions to the hospital for same diagnosis o Prolonged length of stay without evidence of improvement or poor prognosis o Unacceptable symptom distress (i.e. pain, dyspnea, nausea, etc.) o Uncontrolled psychological or spiritual issues at end of life o Provide family support o Provide information and resources to patients/family o Determine hospice eligibility 4. Death Exam o Death pronouncement is the official time of death so do not delay unnecessarily once called by nursing staff. 219 o If family is present, introduce yourself, offer a sympathetic statement, and explain your role (i.e.: I am Dr. …. I am very sorry for your loss. I am here to examine your…and pronounce his/her death.” o If family is absent, call the next-of-kin to deliver the message. o Confirmation of death: First, confirm identity of patient with hospital tag Note general appearance of the body, lack of respiratory effort, unresponsiveness to verbal and noxious stimuli, fixed and dilated pupils, absence of carotid pulse, and absence of heart and breath sounds on auscultation Pronounce the time of death o Complete Death Certificate: Usually Nursing staff contacts One Legacy who deals with organ donation issues Document Death Note on Affinity essentially stating your exam findings Dictate the discharge summary of the hospital course 220 SECTION 23 – MEDICAL INFORMATICS 221 Amion: Online Scheduling System; available at www.amion.com (login: uscim) Affinity: Electronic Medical Records System. Daily Notes (H and P, consult notes, procedures) CCIS: Electronic Medical Records System for ICU and CCU (Progress Notes [NOT H and P], View Current medications) E-signout: Electronic Patient Handoff System; available at www.uscnorris.com/esignout Museweb: Electronic EKG Records System PADI: Electronic Pharmacy System. Used in the clinics to electronically prescribe medications under the license of supervising physician. Used in the inpatient setting to view current medications and prescribed outpatient medications. QUANTIM: Portal to assess Department of Emergency Medicine documentations and to view delinquencies (i.e.: review/sign dictated discharge summaries). SYNAPSE: Electronic Radiology Information System to assess diagnostic imaging RPS (Referral Processing System): Electronic Referral System used to initiate referral to specialist E-consult: Recently adopted, more efficient Electronic Referral System for specialty referrals (Note: Not all specialties have switched to E-consult, therefore, will still need to use RPS for those specialties not listed under the E-consult login page) VERINFORM: visit the USC Internal Medicine Residency Data Management Website (VERINFORM) to update duty hours, complete/view evaluations, and to document all procedures: https://rm.verinform.com/lac SECTION 24 – LOCAL OUTSIDE HOSPITAL NUMBERS HOSPITAL Cal Hospital Med Ctr Cedars Sinai White Memorial Good Samaritan Harbor-UCLA Hollywood Presbyterian Olive View-UCLA Ronald Regan-UCLA UCLA Med Ctr, Santa Monica MAIN # 213- 748-2411 310-423-3277 323-268-5000 213- 977-2121 310- 222-2345 213- 413-3000 818- 364-1555 310- 267-9119 310- 319-4000 MED RECORDS 213- 742-5470 310- 423-2259 Main, then x 1012 213- 977-2115 310- 222-2061 323- 913-4960 818- 364-4124 310- 825-6021 310- 825-6021 MED REC fax# 213- 742-5669 310- 423-0113 323- 881-8755 213- 977-2106 310- 782-1796 323- 666-2939 818- 364-3518 310- 825-3356 310- 825-3356 ** When requesting patient information from medical records offices through RELASE OF INFORMATION AUTHORIZATION FORM, please be sure to include point of contact name, phone number (team VOIP or pager), and fax number. ** If patient is unable to provide signature, please have family member or MD sign the form, and write patient unable to sign on the medical release form. 222 223 224 225 226
